HomeMy WebLinkAbout032-1033-80-000
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Parcel 032-1033-80-000 04/10/2006 03:14
PAGE 1 OF 1
F 1
Alt. Parcel 12.31.19.1638 032 - TOWN OF SOMERSET
ST. CROIX COUNTY, WISCONSIN
Current
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
O - GEIGER, JOY S
JOY S GEIGER
2252 80TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 2252 80TH ST
SC 3962 NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 3.000 Plat: N/A-NOT AVAILABLE
SEC 12 T31N R1 9W 3A IN NE SE E 56' OF S Block/Condo Bldg:
234' OF SE NE
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
12-31N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1153/550 TI
07/23/1997 573/486
2006 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/23/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.000 48,000 94,900 142,900 NO
Totals for 2006:
General Property 3.000 48,000 94,900 142,900
Woodland 0.000 0 0
Totals for 2005:
General Property 3.000 48,000 94,900 142,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 134
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP- `~i;,s~ rS~% SEC. T /_N, RKW
P.O. ADDRESS st z ST. CROIX COUNTY, WISCONSIN
~~°fi
SUBDIVISION LOT LOT SIZE
r~ -PLAN VIEW
U Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100FEET OF SYSTEM
_ Il 7j ~
4
V
SEPTIC- TANK (S)_ MFGR.~ CONCRETE 4--- STEEL
N0: of rings on cover° Depth DRY WELL
TRENCHES No. of width engtn area
BED no. of lines width length .y~ area
71
dept to top of pipe
AGGREGATE -/y-1
PERK RATE AREA REQUIRED AREA AS BUILT DISCLAIMER: The inspection of this system by St, Croix County does not imply
complete compliance with State Administrative Codes_ There are other areas
that it is not possible to inspect a1- this point of construction. St. Croix
County assumes no liability for sys* m operation. However, if failure is
noted the County will make every of rt to determine cause of failure.
GREASES AND OILS SHOULD NOT BE DIS- )ED THROUGH T SYYSTEM.
1--
• • 'CTO
. l
DATED ` LUMBER ON JOB
LICENSE f
. o. Rol
l
�4
/ �
I . .
• S REPORT OF IfSPrCTION--INDIVIDUAL SEWAGE DISPOSAL SYSTEI i
•
i l S sitar Permit Jd
y `�/
4-''•- ate Septic 7
•
��A'.IE 1 k-euit-- TOWNSHIP i
• t. Croix County
SE?'TIC TA'?I(
Size /,- .r gallons . 'lumber of Compartments .
Distance From: Well ( ft. 127 or greater slope /EJ' it
. Building ' ft. Wetlands 0 f
Righwater 7.trj ft.
r '
DISPOSAL SYSTE.1 Tile Field or Seepage Fit(s)
5 (Distance From: . Well 70 n ft. 127 or greater slope ft
,� q 2 Building S`i ft. Wetlands f
IELD �-
Highwater f t, •
Total length of lines 1 f2 ft. Number of lines . Length of
each line ' (` ft. Distance between lines (:. ft. Width of the
trench 'L ft. Total absorption area / ( ) :).- sq. ft. Depth
of rock below tile / 2-- in. Depth of rock over tile '- in. Cover
over.rock , _ >-u . Depth of tile below grade in. Slope of
trench - in per 100) ft. Depth to Bedrock /CY) ft. Depth to
ground wateriiul -
ft.
•
PITS
Number of pits . O i e ianeter ft. Depth below inlet
ft. Gravel aroun es no. .Total absorption area
sq. ft.
Square feet of seepage trench bottom area required
.
Square feet of seepa . pit pea required
Inspected' -�K4-4
'•' Title : = // /---
Approved Date 197 .
Rejected Date 197 •
• .6 , .
EH 115
• • • WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH,BUREAU OF ENVIRONMENTAL HEALTH
•
' P.O. BOX 309
I • - MADISON,WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
S£- OILY.,Section ��..,,T- IN, R Gi
LOCATION: ' '�s�c � E (or) Township or Municipality S �IC'/�'S �./
Lot No. , Block No. Mtk /�/IAJOR, County S 7, C,C'e7/�
/ Sub ivi ' n Name A A •74
Owner's Name: S t a#Lc1 T / !S c?i- /
1` �-Mailing Address: 1 k)1cc I, rr,Oki<:l L'1, C
TYPE OF OCCUPANCY: Residence x No. of Bedrooms 3 Other
EFFLUENT DISPOSAL SYSTEM: NEW ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS 3 !`S - 2'j----- PERCOLATION TESTS 3 -4- 7,
SOIL MAP SHEET 3•'/ 1 SOIL TYPE L/ L/ 5 i4i') j'i ri-c;c, /LT L C1r¢ys--7
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN/IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P 3( _
5if ri9 ill 3 ecyi rg 1 E-) 3 0. 1 I y Yo
P=z 3 1 , ( g /26 2 c. 0L //y 1 3o
P_3 3.4r / ( , I n 0 3 I 39
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
a ► 6 > 3'6. o-YTS b-- .40 5 L. Q-9( 5-4-
Z I / Y74 o-1`T.S, Y-7v ' S, <:' . .-.9G 54
R 3 r I )76 .0-frTS• (- .�[2 5 � -2D n $ -
1 t I 7 g4, 6-r7$,g- 6 0 5A b 0 - 94. 5.4-
R-
s' > 94 l5-if-T_ S lr' .2 a 5 41 S> ' s'L .
6 t / >76 ®-8-7 s, t-o 5
0 ‘ a -76 Sc
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the location and square feet of suit ble areas. Indicate number of square feet of absorption area
needed for building type and occupancy. // .25 Indicate scale
or distances. Give horizontal and vertical reference points. dicate slope. y� I Z / 2 g L
v
r S t'
.i
Nit iiil tom
attounim
•mruu uu4414m5,lior aauRau• ■onium U
1 1 -NI ei iii
pliooki i , , 4,,, Ili II 1111 ,
1 rill 1 00, Ai!
i d L 40 liotto N
ll MIMI 1
r P �� 111111111111 ■Ad A t ilk 11111, 1E1 11ii i ii
oil mik 1
a r 1 iau.ii11 sr.
I,the undersigned,hereby certify that the soil tests reported on this form were made by me in accord wit the procedures
and methods specified in the Wisconsin Administrative Code,and that the data recorded and location of test holes are correct
to the best of my k wledge and beli .
Name (print) 4 a Certification No. 5 ^_5_31 /
Address .4/.i ..4 �a— �'i o 1 7
Name of installer if known rA.. .}
3ei,.....t..„w322/
CST Signature
COPY A—LOCAL AUTHORITY
P L •i-ril 1 ' State and County State Permit #
Permit Application County P it
for Private Domestic Sewage Systems Count
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address: .
57�k,�.c>Q ra t N.e Lo- RR '!t�`' -,-,-.0 w a.a...e.,
B. LOCATION: .„$g '/4 /Ve 1/4, Section /2., T 3 / N, R (? E (or) COY,) Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village _r
Township 5oi r''S'
. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms 3 No. of Persons ei
D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YESA---NO # of Bathrooms_L
Automatic WasherX YES NO arther (specify)
E. SEPTIC TANK CAPACITY /COO Total gallons No. of tanks /
*Holding tank capacity Total gallons No. of tanks
New Installation x Addition Replacement Prefab Concrete
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) Lj0 2)..16 3) 3 y Total Absorb Area / I Z S sq. ft.
New k Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Iiepth No. of Trenches_
2 Seepage Bed: Length �'-//Width 1 ' Depth 3(.'" Tile Depth 2.&a ' No. of Lines Z
Seepage Pit: Inside diameter`r Liquid Depth Tile Size
11 "
Percent slope of land 2 2e 5' Distance from critical slope
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified Soil Testp5 �^
NAME CL 9L () 11-, l'O U., r r.s C.S.T. # ) ---ci i and other information
obtained from Olx.i .e 1 ( caner builder). _/ _
Plumber's Signature �. MP j - 15 b 3 Phone #2y6 —s'i35
Plumber's Address t 3 f1 4 -- i c4,me -ccf V✓.S C
J
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well). it I
tl°ite-^ ,____.",.. '--6*'.
• et0I .�
icy:7 — , —
_ asmoo°, , a: I
o
,J°°
cutt,
rAA)
Do Not Write in Space elow - OR DEPARTMENT USE ONLY
t� O
Date of Application � 0/7 � ees Paid: State /(?, � 0 Con a� (` '� Date � /7,
Permit Issueda3 eeted ( ate)! 7 Issuing Agent Nam .))%
Inspection Yes No Valid# Date Rec'd
1. county (whi e copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 6/1/76
PLE167
i, ; State and County State Permit #
1 �� Permit Application County Permit #
for Private Domestic Sewage Systems County Sy
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing
71Addressr
� 7 t-z,' V112* / � (. 4)Fs 6 _(,sr/0 ` 0 , , � a/4 iiiii)--iJd
B. LOCATION: i '/4 '/4, Section , T...� N, R '' E- (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township Sarre y'ecc->
C TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family —Duplex No. of Bedrooms _ No. of Persons
D. TYPE OF APPLIANCES: Dishwasher 1 YES NO Food Waste Grinder YES L—NO # of BathroomsL
Automatic Washer L/YES NO Other (specify)
E. SEPTIC TANK CAPACITY /O-t12, Total gallons No. of tanks
*Holding tank capacity Total gallons No. of tanks
New Installation L— Addition Replacement Prefab Concrete e_ --
*Poured in Place Steel Other (specify)
F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) go 2) .3 3) 34/Total Absorb Area //...`5" sq. ft.
New 4----Addition Replacement *Fill System
Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches
Seepage Bed: Length 950 Width / ' Depth .36,"- Tile Depth ,T6 '' No. of Lines 2--
Seepage Pit: Inside diameter Liquid Depth Tile Size ' "
Percent slope of land %p Distance from critical slope
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Certified,�+ Soil Tester,
NAME < ,t4 L t , rt.! 1 VD u9 ,,s C.S.T. # j;— 5,3/ and other information
obtained from y�1J t,a � e _ke• . (owner/builder).
Plumber's Signature 4 �:..j,C, / . 4--,..--- > MP/MPRSW# /Z '> ‘/ Phone #;1-iL- / 2 ,5
Plumber's Address
/1..`), ."�-ri'1.c; - -G.-4. r. .( /tom:-i
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with
H62.20, including well).
17g
,,, /
, /j.„/11-"4"."-. ( ..."
Do Not Write in Space to FOR DEPARTMENT USE ONLY
Date of Application es Paid: State Count D i
Permit Issued/ ejootc date) 7 _Issuing Agent Name
Inspection Yes No Valid# Date Rec'd
1. county (w to copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy)
Revised Date 6/1/76
i
4 f
-td yy/
E A S E M E N T
THIS INDENTURE, Made and entered into this 9th day of June,
1978, by and between VERNE R. NELSON and DORIS H. NELSON, husband
and wife, hereinafter called GRANTORS, and ROBERT J. GEIGER and
JOY S. GEIGER, husband and wife, hereinafter called GRANTEES;
WHEREAS, the GRANTORS and GRANTEES are the owners of adjoining
lands in Section Twelve (12), Township Thirty-one (31) North, of
Range Nineteen (19) West, St. Croix County, Wisconsin; and,
WHEREAS, GRANTEES herein purchased their real estate from STUART
A. NELSON and SANDRA NELSON, husband and wife, in April of 1978; and,
WHEREAS, the said STUART A. NELSON had applied for a sanitary
permit for the property sold to the said GRANTORS prior to said sale;
.and,
WHEREAS, it is necessary to extend the drainfield for said
sanitary system to meet the St. Croix County Zoning requirements;
NOW, THEREFORE, the GRANTORS, in consideration of the sum of
One Dollar ($1.00) and other valuable consideration, hereby grant
unto the GRANTEES, their heirs and assigns, forever, the right to
construct, maintain, and keep in repair a drainfield for a septic
system over and across the following described property:
9
A parcel of land located in Section Twelve (12), Township
Thirty-one (31) North, of Range Nineteen (19) West, more
particularly described as follows: Commencing at a point
234 feet North of the Southeast corner of the Southeast
Quarter of the Southeast Quarter (SEh of SEh); thence
West 180 feet; thence North 48 feet; thence East 180 feet;
thence South 48 feet to the Point of Beginning, St. Croix
County, Wisconsin.
IT IS FURTHER UNDERSTOOD that the GRANTORS herein, their heirs
and assigns, hereby retain the use of the surface of the above
described land, provided, however, that such use does not interfere
. - - - - . . I iL - t -3 .7-_ 2 _G. -.1,4 -A Af%na nnf [-At]CP
w
STATE OF WISCONSIN )
Dunn ) SS.
$""X COUNTY )
Personally came before me this _Sth_day of June, 1978, the
above named VERNE R. NELSON and DORIS H. NELSON, husband and
wife, to me known to be the persons who executed the foregoing
instrument, and acknowledged the same.
Notary Public
E3EX County, Wisconsin
My Comm. Expires: 911 Q/78
This Instrument Drafted By:
Reinstra & Van Dyk, S.C.
New Richmond, WI 54017
•k
2+
LY
E A S E M E N T
THIS INDENTURE, Made and entered into this 9th day of June,
1978, by and between ROBERT J. GEIGER and JOY S. GEIGER, husband
and wife, hereinafter called GRANTORS, and VERNE R. NELSON and
DORIS H. NELSON, husband and wife, hereinafter called GRANTEES;
WHEREAS, the GRANTORS and GRANTEES are the owners of adjoining
lands in Section Twelve (12), Township Thirty-one (31) North, of
Range Nineteen (.19) West, St. Croix County, Wisconsin; and,
WHEREAS, the GRANTORS, in consideration of One Dollar ($1.00)
and other valuable consideration, hereby grant unto the GRANTEES
an easement for the purpose of ingress and egress over the
following described land:
A parcel of land located in Section Twelve (12), Township
Thirty-one (31) North, of Range Nineteen (19) West, more
particularly described as follows: Commencing at a point
222 feet North of the Southeast corner of the Southeast
Quarter of the Southeast Quarter (SEh of SEC); thence
West 200 feet; thence North 12 feet; thence East 200 feet;
thence South 12 feet to the Point of Beginning, St. Croix
Count*, Wisconsin.
TO HAVE AND TO HOLD the easement or right of way hereby granted
forever unto the GRANTEES, their heirs and assigns as appurtenant
to the said land of the GRANTEES.
IN WITNESS WHEREOF, the GRANTORS have hereunto set their hands
and seals the day and year first above wri n.
• (SEAL)
o rt J. G err
Jill 11 At
11 Aah (SEAL)
09
y . Geig
STATE OF WISCONSIN )
D ) SS.
SWOL lUMUL COUNTY )
Personally came before me this 9th day of June, 1978, the
Ahnira nAMPd ROBERT J. GEIGER and JOY S. GEIGER, to me known to be
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
i.aboranr.HumanRelations
INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 284200
Permit Holder's Name: ❑ City ❑ village Town of: State Plan ID No.:
GEIGER, JOY SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
oss H
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P /L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION TypeO CHAMBER Mode Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET.12.31.19W, NE, SE, 80TH STREET
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
ADDITIONAL COMMENTS AND SKETCH
A
SANITARY PERMIT NUMBER:
Ali ~"`~Drs Safety o and Building Water Division Systems
SANITARY PERMIT APPLICATION Bureau
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 112 x 11 inches in size. . r_1 ~
• See reverse side for instructions for completing this application State Sanitary Per it Number
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
(Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Prop _rty Owner Name Property Location
"..'fj d 4,, - 1/4~ e. 1/4, S 1,~2 T N, R E (orYg
Property Owner's Mail g Addless Lot Number Block Number
V
City, State / Zip Code Phone Number Subdivision Name or CSM Number
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City :jjNeaestpad
❑ VIl e Public 1 or 2 Famil Dwellin - No. of bedrooms Town OF ~
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel / Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5 Repair of an
System System Tank Only Existing System ~-Existing System
B) ❑ A Sanitary Permit was previously issued- Permit Number Date Issued
V, TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
110 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
1.2 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
.S U I/ Required(. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
~ c, /Feet Feet TANK O VII_ Capacity
INFORMATION in gallons Total # Of Pr
New Existing efab. Site Fiber Exper.
Gallons Tanks Manufacturer's Name Concrete stCon- Steel glass Plastic App
rutted
Tanks Tanks
Septic Tank or Holding Tank ~C /~plr1 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumb Si ure:,lo Stamps) MP/MPRSW No.: Business Phone Number:
i
Z/s
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing Agent Si re o mps)
roved 0-0 Surcharge Fee)
pp ❑ Owner Given Initial /So
Adverse Determination ( U
X CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever,
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
Il. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material- Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations Page I of
Division of Safety and Buildings in accordance with s. IL is. Adm. Code
Jj
Attach complete site plan on paper not less than 8 1/2 x 11 inches in si P must J. ty
include, but not limited to: vertical and horizontal reference point (BM on andw ~n c, s t
percent slope, scale or dimensions, north arrow, and location and di to n -j~ P D. #
APPLICANT INFORMATION - Please print all infor " n. 1996 a 3 a _ 13
Re ' w d by Date
Personal information you provide may be used for secondary purposes (Privacy 15.04 (1)gif,)PROUx
Property Owner Pr
o 6 e-1 'q efr . Lot 4 5 9 1/4,S l a T 3 I N,R I q E (or)(2>
Property Owne s Mailing Address !1'8Subd. Name or CSM#
a a S
City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
Ghw.t~nc~ W t. S Vo 1,7 ( 715 )ayb-3919 v30 ae-'r tr % CA- D
❑ New Construction Use: ® Residential /Number of bedrooms 3 Addition to existing building
❑ Replacement L CA ❑ Public or commercial - Describe:
Code derived daily flow 4 S0 gpd Recommended design loading rate .Lbed, gpd/ft2 • S trench, gpd/ft2
Absorption area required II aIS bed, ft2 Q00 trench, ft2 Maximum design loading rate _ bed, gpd/ft2 . trench, gpd/ft2
Recommended infiltration surface elevation(s) Q 5. 1 ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material j 5~C Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system [5tS ❑ U I Xs ❑ U t4 S ❑ U JRS ❑ U ❑ S U ❑ S %I U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
L I F 6 r rhFr 5 aF . 3
a 1-a oYa~ CL in m Fr CW I .5
Ground -S oYR 15 ° C ms by, "Fr c.w 'VP ,
elev.
.g
97- D-(P-ft. y •70 y/ 5 0 - L c.w - .7
Depth to ,
limiting
factor
9;L in.
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
CST Name (Please Print) Signature Telephone No.
To n Y1 A 54C.rYL 7)5--~4 V -3
Address Date CST Number
syoQio
PROPERTY OWNER SOIL DESCRIPTION REPORT
Page of
PARCEL I.D.# ,
Boring # Horizon Depth Dominant Color Mottles T Structure 2
in. Munsell Qu. Sz. Cont. Color 'Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
Ground
elev.
ft. ,
Depth to
limiting
factor
in.
Remarks:
Boring #
Ground
elev.
ft. ,
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft. -
Depth to
limiting
factor
in.
Remarks:
SBDW-8330 (R. 08/95)
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER s.~
MAILING ADDRESS 27-,5-2-
ADDRESS
PROPERTY
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE l~L i~ ~ = ['i i
PROPERTY LOCATION ZV - 1/4, Jl 1/4, Section Tai N-R;1 W
TOWN OF ` ,ter !s=aw ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP -9 VOLUME PAGE ,LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum ;of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978: St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration date.
SIGNED:, Lit "9L
J
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
r only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property
Location of property ~'j 1/4 Sf-1/4, Section /Z ,T_, LN-RAW
Township CMailing address
Address of site.,
Subdivision name Lot no.
Other homes on property? Yes-.4'-" No
Previous owner of property
Total size of property
Total size of parcel I-S ~~42
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes No
Volume and Page Number as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner (s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
i ature o 'App icant Co-Applicant
Datex'of Signature Date of Signature
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently serving
the %,~~residence located at:
Sec. /Z T RAW, Town of Sa,St. Croix
County, Wisconsin. Upon inspection, I certify that I have found the tank and
baffles to be in good condition, and it appears to be functioning properly.
Last time serviced
Did flow back occur from absorption system? Yes.,- No (if no, skip next
line.
Approximate volume or length of time: L7 gallons minutes
Capacity: ~~ro
Construction: Prefab Concrete- Steel Other
Manufacturer (if known):
Age of Tank (if known):
7r
(Signa ure) (Name) Please 15r-int
(Title) (License Number)
(Date)
Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or
licensed disposer (NR 113 Wisconsin Administrative Code) ,
- - - - - - - - - - - - - - - - - - - - - - - - - - -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank condition, I
ce~rtify that the tank, to the best of my knowledge, will conform to the
requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over
outlet baffle).
i
Name
s Signature
MP/MPRS
537536 V6. y1153PA,_ 50p , . .
TERMINATION OF DECEDENT'S PROPERTY INTEREST
• Joint Tenancy or Life Estate Termination ]s. 867.045] or
• Summary Confirmation Of Interest in Property s. 867.046]
Decedenrs Name
a'
Robert J. Gei er
Address of Decedent at Dace a Deae, stare P C; STEM`S 017j,10
City zo
1 to
at~ 2252 80th Street New Richmond, WI 5 017
F ST CR~'~X CO., %A
Doe d l F.. d f r Rcco.-d
October 29, 1995 270
` -18-7047 DEC 18 1995
Presentation of Death Certbncate
r.'
K i Crory that I have viewed a CwWW copy a the deeedenrs dea+h certificate. f't 9:30 A.
This Inter" In real estate is Unnirgted under
a~
document with rre ReqWer o Deeds
he estaNishing joint tenancy deed ) t ~ a 8swe. '(You must to wtw prov~e a copy 4 in me county whare the real
Recorcim9 Me is M as pars. 867.045, 867.046.
_s 867-046 which IN
Pertains to t~
property (1 real property of a decedent specified in a marital BAKKE NORMAN,. S . C agraament prop rt the deed and alsso to (2) survivorship ma itai property.
(you must provide a P. 0. Box 50
esubashing scavworshipnrardalpropery-) New Richmond, WI 54017
P►on of real Property tax bull.
fts" "'IM ft ~cunrent a copy of trre real
Pr9)lmh tax dill Jon each parcel for the raar i -Vd al* preceding decedents dear.
Wftwftdm of deed *$UbfthkV Joint tenancy a wvlvorship marital pry
This deed is found in vokaneyrm 573
Pa9m#dbe 486 a, (da,+dtaaei► peoords x Deeds
Description of the real estate.
Mcknde ony the eA*r* of avner_,4W (or Mender or
Oxachy Th the same as on the deed, a attached to in land at the ilwae dtfre decedenrs deaft if the extent olland is
description d the COPY Old* deedirisy be desc tw the rear estate
property is as follows Ornate sPece a needed, attachpeges)
A parcel of land located in Section Twleve (12
Township Thirty-one
(31) North, Range Nineteen (19) West, more ca descri
as follows: Commencing at the Southeast Corner1ofltheySoutheastd
quarter of the Northeast Quarter (SEi
(12)5 thence proceedin liasterly a distance ofo560afe Section Twelve
right angles in a Northerly direction a distance of 234~feetncthence
at right an les in n 8 sterly direction, a distance of 560 feeh
thencat r~ght angles in a Southerly direction; a distance of 234
feet to the point of beginning) containinq 3 acres, more or less.
DECIARATtp[t t, we declare that this docaxrent is, to the nest of my (out) lurowladQe am beW.
with the en!~" and Arrtations d the Wtsconsirr Statutes. more s needed a hp`s and a and is in tnha. blame and Address d Pers..xr Fteceivirp gal~or>ship yo peoedent
Joy S. Geiger eQVaar¢ed) Dace
2252 80th Street Surviving
Spouse i ti I /..y, yS1
AUTHEN wAT10N orACKNOWLEDGEMENT
'"*iD0Mer1*rT P8r=W"w*ft-b0ab rreon(da" December 1995
This document was
dnl4ed by Owint or type name bebw) gDr+aeae d rwtary or oerar vsr+
Timothy J. auhorixedbarlrtrrtiebran°~
Scott, Atty 1017850 bftve'a. N.K70 +n
BAKKE
11111,1[j) 11 ii!
New Richmond, WI 54017o"YDe"m1e Rat ~n r vka_ or wamf
8tareaW%op *kC0,Vdr St. Croix
of D-ft Assocy'an Form Hr.„o ut nre No t a r Pub) i c
y --Dnecan**ee;on6#es 2-7-99
~y -s
REGISTERS OFFIC
ST. CROIX CO., W I.S.
Recd. for Record Hvs 1 h
day of Sept. A.b. 19 78
at 12: 0 M.
E A S E M E N T ar °'i .aa.
THIS INDENTURE, Made and entered into this 9th day of June,
1978, by and between VERNE R. NELSON and DORIS H. NELSON, husband
and wife, hereinafter called GRANTORS, and ROBERT J. GEIGER and
c:
JOY S. GEIGER, husband and wife, hereinafter called GRANTEES;
WHEREAS, the GRANTORS and GRANTEES are the owners of adjoining
'.`rands in Section Twelve (12), Township Thirty-one (31) North, of
Range Nineteen (19) West, St. Croix County, Wisconsin; and,
.
41,
WHEREAS, GRANTEES herein purchased their real estate from STUART
A. NELSON and SANDRA NELSON, husband and wife, in April of 1978; and,
WHEREAS, the said STUART A. NELSON had applied for a sanitary
permit for the property sold to the said GRANTORS prior to said sale;
and,
WHEREAS, it is necessary to extend the drainfield for said
sanitary system to meet the St. Croix County Zoning requirements;
NOW, THEREFORE, the GRANTORS, in consideration of the sum of
;'One"Dollar"..($1.00) and other valuable consideration, hereby grant
.`:unto the GRANTEES, their heirs and assigns, forever, the right to
".;;".construct, maintain, and keep in repair a drainfield for a septic
system over and across the following described property:
A parcel of land located in Section Twelve (12), Township
Thirty-one (31) North, of Range Nineteen (19) West, more
particularly described as follows: Commencing at a point
234 feet North of the Southeast corner of the Southeast
Quarter of the Northeast Quarter. (SE; of NR 2,) ; thence
West 180 feet; thence North 48 feet; thence East 180 feet;.
thence South 48 feet to the Point of Beginning, St. Croix
County, Wisconsin.
IT IS FURTHER UNDERSTOOD that.the GRANTORS herein, their heirs
i.„
nd;.assigns,,, hereby retain the use of the surface of the above
r1PRCYihAd land. provided. however, that such use does not interfere
i
1 a
i
STATE OF WISCONSIN )
Dunn ) SS.
Y1=, COUNTY )
Personally came before me this 9th day of June,.1978, the
above named VERNE R. NELSON and DORIS H. NELSON, husband and '
wife, to me known to be the persons who executed the foregoing
instrument, and acknowledged the same.
unn. Notary Public-
MEXXMfX1# County, Wisconsin=
My Comm. Expires: 9/10/7~
i
This Instrument Drafted By:
Reinstra & Van Dyk, S.C.
` New Richmond,.WI''54017
~'y l..i S ..,j,sr + i-r k•,,-'f~q y f_TS",''C
-00
+1
1 •
7.
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