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ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
p N M N N N N p■ ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
i
03-7- to-7-
May May 22, 1995,~i) /l"Ib
Lyle and Marie Klink
772 210th Avenue
Somerset, Wisconsin 54025
RE: Water Inspection Results for Residence located at
772 210th Avenue, Somerset, Wisconsin
Dear Mr. and Mrs. Klink:
Enclosed is the original test results from Commercial Testing
Laboratory, Inc. for water inspection of the above property. If
you have any questions with regard to said report, please let me
know.
;nce- ely,
K. Thompson
Asssant Zoning Administrator
St. Croix County, Wisconsin
mz
Enclosure
COMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 5227
FAX - 715 - 962 - 4030
ST. CROIX COUNTY ZONING OFFICE REPORT NO.: 84225/01 PAGE i
ST.CROIX CTY GOV.CTR REPORT DATE: 5/17/95
1101 CARMICHAEL ROAD DATE RECEIVED: 5/1.1/95
HUDSON, WI 54016
ATTN'. THOMAS C. NELSON
OWNER: Lyle 6 Marie Klink
LOCATION'. 772 210th Ave., Somerset
COLLECTOR. Jim Thompson
DATE COLLECTED: 5-10-95 7 8
TIME COLLECTED: 1'.34pm 9
~O
SOURCE OF SAMPLE2
DATE ANALYZEDtS'#11-95~
TIME ANAi.YZED.2.00pm r-
COLIFORM,MFCC'. 0 /100 ml
F ti~
INTERPRETATION'. Bacteriologically SAFE Z
NITRATE-N: 5 ppm
Above 10 ppm exceeds the recommended Public
Dr i *J D9 Water Standard.
Coliform Bacteria/100 ml
Nitrate-Nitrogen, mg/L
LAB TECHNICIAN*# Pam Gane
WI Approved Lab No. 1.9
OFAM0EPEN,
J~ `90
O
t Means "LESS THAN" Detecfable Level. Approved by:
OO
PROFESSIONAL LABORATORY SERVICES SINCE 1952
(q-q5
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
Y p M N p p p p .~..d ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
May 11, 1995
Mr. Lyle & Marie Klink
772 210th Ave.
Somerset, WI 54025
Dear Mr. & Mrs. Klink:
At your request, I conducted an inspection of the septic system
serving your residence on May 10, 1995. This property is located
at the above address in somerset Township, St. Croix Co. WI. A
water sample was taken at the same time and submitted for analysis
of bacterial and nitrate contamination. The results will be
forwarded to you as soon as we receive them.
Per Mr. Klink's statement, this septic system was installed
approximately 26 years ago. Our records do not date back to the
time this system was installed, so it is impossible to determine
exactly what the system consists of or how many square feet of
drainage area there may be. It appears that it is a below grade
gravity fed drainfield which is located north west of the house.
Most septic systems consist of a septic tank which traps the solids
and greases from the sewage stream and then allows the remaining
sewage effluent (liquid) to drain into a subsurface drainage area.
Once the liquid reaches this point it seeps away by percolating
through the soil surrounding the system. Failure results when the
soil surrounding the system becomes plugged with microscopic
bacteria and sludge, which form a clogging mat. As time goes on,
this clogging mat becomes progressively thicker, allowing less and
less liquid to seep away from the system. When this clogging
becomes severe enough, liquid sewage is trapped in the drainage
area, a condition known as ponding, and results in backup of sewage
into the structure or the discharge of sewage to the ground
surface.
Although there were no obvious signs of clogging or of system
failure, the system's advanced age gives reason to be concerned
about the systems ability to function properly in the future.
Because of this, I cannot guarantee or warrant that this system
will function properly in the future. Typically, a septic system
of this type must be replaced by the time it reaches this age.
As this was a surface inspection of said system and did not involve
any excavating, chemical analysis or direct observation of the
systems components, there may be hidden defects in the system not
discoverable by this inspection.
In an effort to prolong the system's life as long as possible, I
recommend that steps be taken to minimize the wastewater flow from
the house which enters the system. For example, repair any leaking
water fixtures and/or replace them with water conserving fixtures,
reduce time spent in the shower, wash clothes and dishes only when
there is a full load, use a washing machine with a suds saver
feature, etc. I would also recommend that you have the septic tank
pumped at a minimum of once every three years.
Should have any questions or concerns that I can clarify for you,
please feel free to contact me at this office between the hours of
8:0 am.- 5:00 pm., Monday - Friday.
Since ely~,
ames K. Thompson
Assistant Zoning Administrator
cc: file
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
11 t r r r p r • ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmich '
r_-~- Hudson, WI :C
(715) 80",
SEPTIC INSPECTION / WATER TEST REQUEST
Please specify desired test(s) & remit appropriate Ewe' ith
application. Outside water lines are often turned off` 't Nc.r.
-w
winter months, making access to the home necessary:, P,16ase ma P,
arrangements with this office to insure that entry carf /be` ga
❑ Water (VOC's) $185.00 Septic $50.00
f~ Water (Nitrate & Bacteria) 45.00 0 Nitrate & Bacteria
retest $15.00
Owner: L V~ ar,'e / t ; n K Requested by:
Address:/7a 4/01h Aye- Address : 77a - to *h A et-
SorrlerSe4- W ZIP .Cg6g5- Sb/YIe/'Se+ W1. ZIP-.5-q0d5-
Telephone W: (7_aj_ay7-_q7/- Telephone NQ: (ZL,!~) 0y7_ 3 -7
/S
Property address (Fire W & Street) : 77a - o? 101 h AVc,
Location: Sec. 13 , T31t_N, R14w W, Town of So"krsr- -
Realty firm: Lock Box Combo: Closin Date: un n .145 So01
/~s ,8~+~ rSel1's h; s p lace . He has
t I+ S ted already
TO BE COMPLETED BY PROPERTY OWNER
PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS
Water sample tap location: A;tChea S; ,l K
Is the dwelling currently occupied? 19 Yes ❑ No
If vacant, date last occupied:_
Age of septic system: (o ~ju Septic tank last pumped by: We s .'d a at e/Previous Owner's Name(s) . VC 'leuJ r'n Q
Have any of the following been observed?
❑Y ❑N Slow drainage from house.
❑Y ON Sewage Back-up into dwelling.
OY ❑N Sewage discharge to ground surface or road ditch.
OY ON Foul odors.
Other comments relative to system operation:
I certify that the above information is complete and true to the
best of my knowledge.
OWNERS SIGNATURE: DATE:_95-
~a40L
At
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
R60-K reyQp4sed S,eu?,_i' EX,,t, Norfih
. .A
IN t~ s dt ~t~ jO rA ; h L hu~et of
F.e1d NOrth weS~erly d ;I'ec .an
~cSep+; -ton k
TO BE COMPLETED BY INSPECTION AGENCY
System design &/or permit on file? ❑Yes ONO
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: 9;r low grd OAt-Grd ❑Mound
Approx. size X ity ❑Dos OPressurized
Ft .2 Umed OTrench & ry Well
OHolding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES ❑Other ❑Unknown
Septic tank ~
Setbacks: OHouse a/OWell 4~<OProp. lineCX-)LlOther
Do e tank
WOLetbacks: OHouse ❑Well ❑Prop. line 00ther
ocking cover OWarning label ❑Pump/Floats
OAlarm ❑Elec. wiring
Soil Absorption System
Setbacks: ❑House OWell OProp. line C her oGe~ _ _!~~[00 ❑Pond ing : ODischarge : IJp,S
General rpm ante 7 = -
NSPECTORS SKETCH OF SYSTEM LOCATION
Id
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Inspector j
Title
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS ZZ,9 ~
SUBDIVISION / CSM# LOT #
SECTION _T N-R ,Lg W, Town of ~ EJ
S CROIX COUNTY, WISCONSIN
9 PLAN VIEW
eHEV
NG WITHIN 100 FEET OF SYSTEM
a8
I
IN ICATE NORTH ARROW
Provide setback and ele ation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
r
I
BENCHMARK'
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION 0/91 Manufacturer: Liquid Capacity: Setback from: Well~i House :!s Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: -Length- Number of trenches
Sf~
Distance & Direction to nearest prop. line:
Setback from: well:,:,,,2(- House Other
ELEVATIONS
act/~~`• ~S i~ -
Sewer ST Inlet: q~, 1 ST outlet: S
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: _
LICENSE NUMBER:
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 284193
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
GILKERSON, RICHARD SOMERSET
CST BM Elev.: I Insp. B/M' Elev.: , BM Description: Parcel Tax No.:
-.2X
TANK INFORMATION ELEVATION DATA I' VAJ
TYPE MANUFACTURER pCAPACITY STATION BS HI FS ELEV.
Septic G A&,-,\s ~tr1C` • t9 GEC Benchmark ~ /Ge.4
Dosing
Aeration Bldg. Sewer
Hold' St/Ht inlet (,4
TANK SETBACK INFORMATION St/ Ht Outlet S,G~ 9~.Ca
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic c~Q ) d~ fi'r' ji f`" NA Dt Bottom
Dosing NA HeaderAgRaw:
i
Aeration A Dist. Pipe 7.90
Holdtfig S, /7
Bot. System Y"
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand 751+•7 /
Model Number GPM
TDH Li, Friction System TDH Ft
Loss Forcemain Length Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length,,, No. Of Trenches PIT No. Of Pits Inside Di uid Depth
DIMENSIONS DllE
LEA Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM
INFORMATION Type O C BER Moe Number
f
c 01-~ -OR UNIT
DISTRIBUTION SYSTEM
HeaderwhhUORF&T Distribution Pipe(s) / x Hole Size x Hole Spacin Vent To Air Intake
Length Dia. Y Length Dia. Spacing C9
SOIL COVER x Pressure Systems Only xx Mound Or A ade Systems On
Depth Over Depth Over xx Depth Of xx Seeded / Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No E] Yes ❑ N.
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET.13.31.19W, SW, SE, 210TH/AVE
Plan revision required? ❑ Yes ❑ No p
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
I
Safety and Buildings Division
~•p~'■~i i SANITARY PERMIT APPLICATION Bureau of Building Water System!
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.
• See reverse side for instructions for completing this application State Sanitary Permit Number
,,2 Fglgj
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 Owner Na Property Location
1i4 1/4, S / T , N. R (or
Property Owner's Mailing Address Lot Number Block umber
City tate Zip Code Phone Number Subdivision Name or CSM Number
( )
Jj~
II. TYPE F BUILDING: (check one) ❑ State Owned It Nearest Road/
E] village
Public 1 or 2 Family Dwelling - No. of bedrooms fQr Town OF
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) p
1 ❑ Apartment/ Condo ® 7 70
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. jR 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
11 Eg Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ 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
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min. nch) Elevation
Feet Feet
VII. TANK Capacity
gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existin structed
Tanks Tanks
Septic Tank or Holding Tank xn 1 1,6w 14n ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the ndersigned, assume responsibility for inst lation of onsite sewage system shown on the attached plans.
Plum r' Name- (Prin Plumber s Si tur (N mps MP/MPRSW No.: Business Phone Number:
Plu ber's Addres; (St eet, Ci, State, Z Code)
G R'"j' r-1
11 11A
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sani ry Perm' Fee (Includes Groundwater ate Issue Issuing Ag nt Sign ture (N a S)
CAp'y proved ❑Surcharge Fee)
Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL / RE SONS FO DIS PPROVAL:
SBD-6398 (R. 05194) 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 may be 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.
II. 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 a!i 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.
/;j
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certi y that I ,have inspected the septic tank presently
serving the residence located at:
_1/4,_1/4, Sec.T,_7LN, Town of
Upon inspection, I certify that I have found the
tank and baffles to be in good condition, and it appears to be
functioning properly.
Lasttime serviced
Did flow back occur from absorption system? Yes No (if no, skip
next line)
Approximate volume or length of time: gallons minutes
Capacity:
Construction: Prefab Concrete Steel Other
Manufacurer (if known):
Age of Tank (if known):
(Signature) (Name) Please Print
(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 certify 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).
Name Signature MP/MPRS
5/88
7 re~4rd 4,4es6lj
7 ~ 214 am E. . ,
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations Page of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County
/
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Parcel I.D. #
APPLICANT INFORMATION - Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Prope Owner Property Location
Govt. Lot 1/4 114,S T N,R E/(or
Pro erty Owner's Mailing Address Lot # Block# Subd. Name or CSM#
ZZ-2 &4 /VY
Ci State Zip Code Phone Number ❑ City ❑ Village [Z Town Nearest Road
11,01 1 .j ( 1 is - f/
❑ New Construction Use: (2 Residential / Number of bedrooms Addition to existing building
0 Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate ,,gybed, gpd/ft2-1-~-/_trench, gpd/ft2
Absorption area required bed, ft2,ZCtren h, ft 2 Maximum design loading rate _ Ly5bed, gpd/ft2 trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design/site considerations _ o
Parent material 'Z Flood plain elevation, if applicable iV s ft
IF = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
= Unsuitable for system ® S ❑ U ® S ❑ U LZ S ❑ U ®s ❑ U ❑ s U ❑ S W U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2
in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
/ Bed Trench
Alz
b L
Ground
elev. G
ft. -
Depth to
limiting
factor
,,V7 in.
Remarks:
Boring #
S L
L A/IJ =211
.4.114
G
3 / S'
_
Ground -41 Z
elev.
Depth to
limiting
factor
> in. Remarks:
CST Name (P ase P int) Signature I Telephone No.
Address Date CST Number
SOIL DESCRIPTION REPORT
PROPERTY OWNER ' Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench
__5 / r4 S
s
Ground
elev. S~
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 ~J
MAILING ADDRESS ~y
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION _S"is1 1/4, -'5Z_ 1/4, Section ,L 2 T 9j~/ N-R G' W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP , 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 treattnent 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.
Tlie property owner agrees to submit to St. Croix Zonittg n certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (I )
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.
UWe, 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: Z-1
DATE: 101-3~Zg
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
V • v i v V
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
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 J
Location of property. -Tz:,) 1/4_1/4, Section _ jl~ ,T_,.?4N-RqW
Township~~,,, f Mailingaddress_ t5~'e_`Aldl
Address of site _
Subdivision name "11,4- Lot no.
other homes on property? Yes No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? _Yes -
Volume and Page Number as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMDER, VOLUME AND PAGE
NUMBER AND THE SEAI, 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 dead 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 n:; Document No.
40 t e of~ ~licant Co-Applican
Dc+tc of Sig aturc Date of S gna ure
]'~OJ1G WARRAN I1' D-# D
DOCUMLNT NU '
-lE'.~:= = i19 REGISTER'S OFFICE
Michaei..7. Germain and ;'.icht I le M. Germain. 'husband ST. CROIX CTY., WI
- - - - - Rcc'd f;;r Foccrd
and wife, - _ - - - ~
- - - - - - MAR 6 1996
- - - - - - - _f 1 . .AM
am it> and ttarant1 to -Richard L. ('ilkerson and ~isD._
- r3~4JK.
Gilkerson, husband and w1fe~_
of Deeds
- - - Tr S SPACE RESERVED FOR RE,;ORD,NG 0 /1►TA
NAME ANC ?CT ::FN ACDRESS '
r
the followin .lescnbed real estate in _ St. Croix _ County, f~
State of Wisconsin:
FARCE ]EN r7,-F Te-/rT-,N NUM9EF
Part of SW1/4 of SE1/4 of Section 13, TcAnship 31 North, Range 19 North, St. Croix
County, Wisconsin, described as follows: Lot 4 of Certified Survey Map filed
March 1, 1996, in Val. 11, Page 3065, Loc. No. 540285.
EXCEPT that part deeded to the Town of -orlerset for Town Road purposes.
$XJEER
This is not homestead proper
X)= (is not)
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
t
Dated this Y7~ day of March A D . 19_ %
(SEAL)
(SEAL) -iin
wt M. t Ge
'Michael "J. Germain Michelle
(SEAL) (SEAL)
rzt AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Michael J. Germain, State of Wisconsin,
ss.
Michelle M. Germain County
authenticated this !5 t4-' day of March 19 96 Personally came before me this day of
19 , the above named
Kristina Og and _
TITLE: MEMBER STATE BAR OF WISCONSIN - -
(If not, - -