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ST. CROIX COUNTY ZONING OFFICE
Y E
Hudson, WI 54016
911 4th Street IFF11,
Telephone - (715)386-46 The St. Croix Co. Zoning Office offers the servic water inspection to Lending Institution, Realty private individuals.
COMPLETION OF THIS FORM IS ESSENTIAL SO THAT THE PROPERTY CAN BE
LOCATED.
Please provide the following information, enclose appropriate fee
made payable to ST. CROIX CO. ZONING, and mail, along with form
to the above address. Testing will be done as soon as possible
after fee and form are received.
WATER TESTING FEE:$ 25.00
(For nitrates and coliform bacteria) FEE:$175.00
WATER TESTING
(VOC'S) $ 25.00 - /
SEPTIC SYSTEM INSPECTI FEE: --b~
PROPERTY OWNERS NAME:
PROPERTY OWNERS ADDRESS : jA12 9d NA- a CITY : C` /Y? 4/1±t6 Legal Description1/4, -S 1/4, Sec. T _d W,
Town ofSE7-.r Lot No.l~ 7, `i ,Subdivision
FIRE NO. / 13 LOCK BOX NO. 4 C~
Color of house ~ F Realty sign? / Firm:
PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP, i.e., COPY OF PLAT
BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained.
Firm or individual requesting services:
Telephone No.- 5'3 J-j
REPORT TO BE SENT TO:
7 tj J- S c>
CLOSING DA
Signature: 11
ST. CROIX COUNTY
xn.,
Ov.
WISCONSIN
rw,*
ZONING OFFICE
J r
ST. CROIX COUNTY COURTHOUSE
911 FOURTH STREET • HUDSON, WI 54016
_ (715) 386-4680
- - -
Sept. 25, 1991
George M. VanderVeer
720 72nd St.
Somerset, WI 54025
Dear Mr. VanderVeer:
An inspection of the septic system which serves your home was
conducted on Sept. 18, 1991. At the time of this inspection the
sanitary system appeared to be functioning property. It did,
however, have sewage effluent ponding within the drainfield.
This condition indicates that the system has begun to seal ("plug
up") and as there was no excavation of the drainfield, the degree
of sealing is very difficult to determine. Because of this, the
length of time the system will continue to function properly is
impossible to predict and depends a great deal upon the personal
habits of the household.
I strongly recommend that the septic tank be pumped at a minimum
of once every three years, every two years would be preferable.
If I can be of any further assistance in clarifying this matte
please feel free to contact me at this office between the hours
to 5:00 P.M. Monday - Friday.
o KK--.-Thompson
incees Assistant Zoning Administrator
cj
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNE rj, e TOWNSHIP Scpyria_A SEC. ply T _31 W
ADDRESS OS (c CSC-S)f ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE 3 ?S `FAO
PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
—1P71---- h
)2.8
‘.) G
\ c9
v,(4/
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point usecggb
Elevation of vertical reference point: /Q O ' Proposed slope at site: 7/d
SEPTIC TANK: Manufacturer: l ce<S Liquid Capacity: /0 p C yeti
Number of rings used: d Tank manhole cover elevation: 9 7: (7
Tank Inlet Elevation: '`3,6''17 Tank Outlet Elevation: 9,!:�, S' 2
Number of feet from nearest Road: Front,QSide0 Rear, O �(� feet
From nearest property line : Front,O Side,Rear,O 70 '
/� feet
Number of feet from: well /VQ �itJ�i'� , building: /
(Include this information of the above plot plan) ( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
a �
i
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear,Q Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan) .
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: J ( Length: 66 Number of Lines: / Area Built:33C7 4*
Fill depth to top of pipe: L-7( "
Number of feet from nearest property line: Front, O Side, ® Rear,O Ft .(� p /
Number of feet from well: 1)0 00-e.iL-C �Y
Number of feet from building:
(Include distances on plot plan). /
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box() or distribution box O been used on any of the above soil
absorbtion sytems? (Check one) .
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, (I)Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: - 2o--Y7 Plumber on job 1W,e
License Number: C 2 2_ 2._.
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969 BUREAU OF PLUMBING
MADISON, WI 53707 State Plan I.D. Number:
NE14j E5414, S24,T31N-R19W CONVENTIONAL ❑ALTERNATIVE (If assigned)
Town of Somerset ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
72th Street
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE:
George VanDabur Uakd Route 1, Box 21, Osceola, WI 54020 3d'67,'C)o 94,04
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: MP/MPRSW No. County Sanitary Permit Number:
William Pfannes 6222 St. Croix 99035
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY. TANK INLET ELE V . . TANK OUTLET ELEV.: WARNING LABEL IL OCKING COVER
P WARNING PROVIDED:
YES ❑NO ❑YES VNO
BEDDING: VENT DIA.: IVENTMATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILOING:1 NT TO FRESH
L~ ALARM FEET FROM -70 LINE T I Ir1AI INLET.
❑YES NO 1 ( ❑YES O NEAREST I V
DOSING &AMBER:
MANUFACTURER. JBEDDING: LIQUID CAPACITY. PUMP MODEL PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERAT ZONAL: NUMBER OF PROPERTY WELL. BUILDING. I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET:
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing ENCTH DIAMETER MATERIAL AND MARKING
or excavation. (if soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH LENGTH NO. OF DISTR. PIPE SPACING. COVER INSIDE CIA.. #PITS. ILIQUID
BED/TRENCH THE NCHES MATERIAL: PIT DEPTH
DIMENSIONS
GRAVEL DEPTH FILL DEPTH JDISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. D R. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW P P - ABOVE COVER. ELEVq INLET ELEV. END ^ T PIPES. FEET FROM LINE> J~ AIR INLET.
~~(l f. L NEAREST---s
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS.
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED. MU LCHED.
CENTER. EDGES.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH. NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER:
BED/TRENCH TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. JDISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING.
ELEV.: ELEV.. DIA.. ELEV.: PIPES: DIA.:
ELEVATION AND
DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL
PLANS:
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF L NE:ERTV I WELL: BUILDING:
FEET FROM
❑YES ❑NO 2 ❑YES ❑NO NEAREST
Sketch System on R ain in county file for audit.
1
Reverse Side. TITLE:
SIGNATURE -
Zoning Admin'
DILHR SBD 6710 (R. 01/82)
or
C~ILHR SANITARY PERMIT APPLICATION COUP
In accord with ILHR 83.05, Wis. Adm. Code J
. o STATE SANITARY PERMIT #
9 9o3Ls-
-Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER
8% x 11 inches in size.
-See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES O NO
PROPERTY OWNER PROPERTY LOCATION
0 /a T3~ , N, R E (or
R ER OWNER' MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
6X ;9L I
CITY, STATE ZIP CODE PHONE NUMBER CITY dr NEAREST ROP)), LAKE 09 LA'N15MARK
❑ VILLAGE : P 756f
5 &L II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family C~?, OR ❑ Public (Specify):
III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable)
1. a. ,New b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2)
1. a. Conventional b. ❑ Alternative C. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. ❑ seepage Bed b. See a e Trench c. ❑ Seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): gip,
r " ' 1 3 3 0 90, e';?_ Feet Private ❑ Joint 1-1 Public
VI. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank Q e ❑ ❑ L1
_-Ki- Lift Pump Tank/Si hon Chamber 1 Li VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name (Print): lumber's Signature: ( m s) MP/MPR9tl1rIVtS.: Business Phone Number:
A_
(71-57) - 2
Addres (Street, City, State, Zip Tod-e): Name of Designer:
tPer's
w
r
Vlll. SOIL TEST INFORMATION
Certified Soil Tester (CST) Nam CST #
VU r
lf~
CST's ADDRESS (Street, State, ip Code) Phone Number:
A)IJ 6 (,A- s'
❑ El r,;t-
IX. C TY/DEPARTMENT US ONLY
Disapproved Sanitary Permit Fee Groundwater Date Issuin Agent Signature (No Stamps)
charge Fee
,Approved ❑ Owner Given initial
Lit
Adverse Determination /Do . D~ ~10'15,00 6 -87 /,J
X. C MMENTS/REASONS FOR DISAPPROVAL: kS6"
SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUffION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
1. This sanitary permit is valid for two (2) years;
2. Your sanitary permit may be renewed before the expiration date, and at the 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 grmit issuing authority. A new permit r+ay be needed
if there is a change in your building plans, system locution, estimated wastewater flow (nurr ter of bed-
rooms. etc.), depth of system, or type of system;
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. Private sewage systems must be properly maintained~-The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owners name and mailing address. Provide the legal description where the syster-i is to be
installed;
II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement. reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons l be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank mat-,t ial. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experiments! apf ^:)val only if
tanks received experimental product approval from DILHR;
VII. Responsibility statement: Installing plumber is to fill in name, license number with appropri~.te prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8',/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, `ccation of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/hater service;
streams and lakes; dosing or pumping chambers; distribution boxes; soil absorption system,; 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.
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill Groundwater '
included the creation of surcharges (fees) for a number of regulated practices which Wisconsin's
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried (reasure
is used in your building is returned to the groundwater through your soil absorption o
system or the disposal site used by your holding tank pumper.
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398 (R.03/86)
APPLICATION FOR SANITARY PERMIT
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 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 & G C1 R6G /2 " • Vi9'U2 11c Q
/ 1 , T 3 / W
Location of Property �V /;;�-. �S �.�) �, Section N-R
Township 5 0/11eR SL % •
Mailing Address /l r W ! /1 ox J c'0 2 `a c`JVFS6'7"- l j,SC , S 1/ c,j
•
•
Address of Site , 8/'J')� i\
..�
•
Subdivision Name
. Lot Number
Previous Owner of property /3E)R3LIL r/ C jR (Jt 6 j�
Total Size of Parcel }?,C) Ac:Rc S
Date Parcel was Created
Are all corners and lot lines identifiable? � :/ Yes No
Is this property being developed for resale (spec house) ? Yes ` ..' No
Volume cj and Page Number 1 61 (1 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
I (We) ceAti.6y .that al statements on this 6oAm aAe tAue .to .the best o6 my (ouh)
hmowtedge; .that I (we) am (ane) the owne/t(e ) o6 .the pnopen.ty descAi.bed .in .this
.in6onma.ti.on 6onm, by vJ., tue o6 a waAAanty deed rteconded .in the 066iee o6 .the
County Reg•us.ten o6 Veeds as Vocument No. it (Pt2r) ; and that I (We) pnesentey
own the proposed 6.Lte bon .the sewage disposat system (on. I (we) have obtained an
easement, .to nun with .the above de.schi,bed pnopenty, bon .the eonb•ttucti.on o6 said
dye.t€m, and .the tame ha.a been duty n'conded .i.n the 066Lce o6 .the County Reg•cs.ten o6
Deeds, ab Document No.
•
SIGNATURE)OF OWNER �1 ( 1
SIGNATURE OF CO-OWNER (IF APPLICABLE)
n V/
DATE SIGNED DATE SIGNED
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED I OR RECORDING DATA
WARRANTY DEED
426630'
.I 81PAGE 199 IZEG45TERS OFFICE
' - ST. CROiX CO., WIS.
` Burdette D. Krueger and Mariellen Krueger, Qw;'~, ;bt• Reoord Nits 5th_
husband and wife, as joint tenants d0yOrf June 1927
10:45 A
_ 04
conveys and warrants to George M. Vander Veer and
Karen J. Vander Veer, husband and wife as - Iovofrl:~
D~Ne
marital property with rights of survivorship
RETURN TO
the following described real estate in S t. C r o i x County,
State of Wisconsin:
Tax Parcel No:
The land herein referred to is sitpated in the County of St. Croix, State of
Wisconsin and is described as follows:
Part of N112 of SW1/4 of Section 24-31-19 described as follows: Commencing at
the W1/4 corner of said Section 24; thence S87°57'05"F.. (assumed bearing,)
923.77' along the N line of said SW1/4 to the point of beginning; thence
S87°57'05"E. 224.61 feet; thence S0025138"E 31.52': thence Sly 124.92' along
the W'ly right-of-way line of an existing private road on a 228.32' radius
curve concave E'ly whose chord bears S16°06'04"E 123.37'. thence S31°46'30"F
114.46' along said W'ly right-of-way line; thence SE'ly 130.87' along tile SWIly
right-of-way line of said existing private road on a 300.62' radius curve
concave NE'ly whose chord bears S44°14'47"E 129.84': thence S56°43'04"E 97.13'
along said SW'ly right-of-way line; thence SE'ly 60.82' along said SW'ly
right-of-way line on a 266.00' radius curve concave NE'ly whose chord bears
S63°16'06"E 60.69'; thence N87°30'16"W 561.05': thence N2°10'16"E 404.85' to
the point of beginning.
:'r' •1:;~ i~
This is not homestead property.
(is) (is not)
Exception to Warranties:
,
Dated this 30th day of May 19 87
EAL) (SEAL)
. Burdette D. Krueger Mariellen Krueger
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
SS.
St. Croix County.
authenticated this day of '19- _ Personally came before me this 30th day of
May 119 87 the above named
Burdette D. Krueqer and
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L N U M O E R
ABSTRACT OF TITLE
';~;o the following described `deal Estate situated in
!;1I ST. CROIX COUNTY, WISCONSIN
ICI
Part of N/2 of SW/4 of Section 24-31-19 described as follows: Commencing
{ at the W'/4 corner of said Section 24; thence S87057'05"E (assumed bearing)
923.77' along the N line of said S6"/4 to the point of beginning; thence
S87057105"E, 224.61 feet; thence S0°25'38"E 31.52'; thence Sly 124.92'
i! along the Wly right-of-way line of an existing private road on a 228.32'
radius curve concave Ely whose chord bears S16006104"E 123.371; thence
S31°46'30"E 114.46' along said Wly right-of-way line; thence SEIy 130.87'
along the SWIy right-of-way line of said existing private road on a 300.62
radius curve concave NEIy whose chord bears S4401414711E 129.841; thence
" S56043104"E 97.13' along said SWIy right-of-way line; thence SEIy 60.82'
along said SWIy right-of-way line on a 266.00' radius curve concave NEIy
whose chord bears S63016106"E 60.69'; thence N87°30'16"W 561.051; thence
14; N2°10'16"E 404.85' to the point of beginning.
Subject to an easement for existing town road on the N 31.5' more or
less of the said parcel. Contains 3.03 Acres including town road right-
of-way and 2.87 acres excluding town road right-of-way.
(Continued by direction from December 6, 1904, @ 8:00 A.M. for NE'H of SW'l+
of Section 24-31-19; from July 8, 1908, @ 8:00 A.M. for E 17 acres of NW/4
of SW% of Section 24-31-19; and from March 22, 1916 „ @ 8:00 A.M. for NWY.
of SW% EXCEPT E 17 acres thereof and EXCEPT 1 acre in the NW corner thereof;
EXCEPT Entries 1-3 inclusive, which are made a part hereof).
jl.
ill
PREPARED FOR
Doar, Drill & Skow
Attorneys at Law
New Richmond, WI 54017
ST. CROIX COUNTY ABSTRACT CO.
Hudson, Wisconsin
a
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ST C- 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT
0
St. Croix County Z
OWNE /BUYER &~C'~r~C4'~'
m
ROUTE/BOX NUMBER r Box )A(0 2- Fire Number
CITY/STATE S~-- / LA./ - zip ,S yCUc~ s
PROPERTY LOCATION: W ~ ' S ~4, Section-T .31 N, R9-W,
Town of St. Croix County,
Subdivision Lot number -3
I
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment 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 systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary)., the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. H
0
I/WE, the undersigned, have read the above requirements and agree Lnn
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- v
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year expiration date.
SIGNED r a~3
DATE
Q ~y
St. Croix County Zoning Office
P. 0. Box 98
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
EPARTMEN-I OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS .
JF USTR`i!! ______ 4!.VISION
ABOR P.O. BOX 7969 AND T PERCOLATION TESTS (115) MADISON,WI 537Q7
UMAN RELATIONS
• (ILHR 83.09(1) & Chapter 145)
°CATION: SECT( N: -TOWNSHIP�MUNICIPALITY: LOT NO.:IBLK.NO.�SUBDIVISION NAME:
Nc.1/S )1/I •7Ii3iN/R�9E (or = `� �L�� �t- S' �� - 1--
t1. c•inEl. 5 - __.--
lO1UNTY: OWNER'S/BUYER'S NAME MAILING ADDRESS
K0�r�S faeyf� NQi46ec,2 lo . '_�ldgk/ 1L r2i V �_ '_'Sc yt-'40
SE _ DATES OBSERVATIONS MADE
NO.BEDRMS.' COMMERCIAL. DESCRIPTION PnOFIL€D SCRIPTIUNS: PERCOLATION TESTS:
AResidence z /A- iNew L]Replace - I .o tSiet-Z
cv0 Ja� 12
ATING:S=Site suitable for system U=Site unsuitable for system
ONVENTIONAL: MOUND. IN-GROUND-PRESSURE: SY STEM IN FII LrnE
OLDING TANK:RECOMMENDED SYSTEM:(optional)
51( s uu n s r 1u I x sn�u 1 IS Rills 1u 0,,,_.rA/,,,-, 4/ u/Nr'1, 7,Pi a5Af 116,.�it«uNlAP-
TQt"'"k? 1,�) ,P
DESIG 7Yii- -- — r�fi ihi.:,i=,;,_ Ls g,4.4.a,,;,:v Bt1os ,S vs 7,•
DESIGN RATE: any port on of the tested area is in the
t Percolation Tests are NOT required If /
,nder s ILHf;83 09(5)(bl,indicate. /11/ _ Floodplain, indicate Floodplain elevation:
_ PROFILE DESCRIPTIONS
tGRING TOTAlf T TNfl�1AT-S-R IN-CW[4; CHARACTFR OF SOIL. WITH THICKNESS,COLOR, TEXTURE, AND DEPTH
(UMBER D OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV_ON BACK.) I
3- I S;/ 7' 9v A.•0,, L C.�7.1i'\* E c.Ts . 1' ii, .1 &'L;I'A �Cj 8 .1 I83; (Tits .3,4 '
3 Z �'' `�y,7� �t'vrv'E. �_�r 5 LT •cyst �?,o,,By1. 1.6%sN s gv►t y j t,TB,r�"i �s f
, —Y
:rs.v'1; Cy 8wL i 4
3- G. 3 ' %,41,,? if/,z, (C,$` ,-- 4.Ts w /=2.' B,vts gi41Ji ..?..,.'
cT 7, BN4./,5' BA, , 8 1 4 T Ba.s 49-1 /..5$'
[� / p c 2 V'I sd Cr
a- (l t ` /6.LT' LL CAL k �?�i,(>7 0`� 3J 1 T e Q.v 1 s Brtn,6 R. cl
8-s 91 } � ,f'ai.t_. �i/ 3' .10 2.)" c, is-- /✓ BHgL !, 0' LTBasd,f 3'5.e'. IT Brs a,De
B (o S3' '& .' _._.i�'cieq:- 1, < �,1d/ .-, 4Ta .6JF •Z. a,6 ' IT8 L .)S� [�Rrs� /•S� •
DFcET PERCOLATION TESTS ,(revs w/►-2 t'8a Ls A„,,,l$ I • Zi''
TEST @�- H WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER AFTER SWELLING INTERVAL.-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
P- Z .5,8.3 4' 4 z _ C C.
P-- 3,33T 4 ._..3- -- -- i A ___ //ppr Ia 7
P.
. t i
P- — _.—_
LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hot•
tntal and vertical elevation reference points an 1st w t eir c tit on,the plot plan. Show the surface elevation at all borings and the direction and percent
t land slope. b . bt. VC3, i
;Y T. ELEVATION_ �8 y_-- -__ 9a,611 4.
N�
.•1r�, w' J I'
.CP.\ F _r .1�•r"; v• cei,...:1 - t
N (cr c. -` tJ {<0
/ f
-.7,---' 1 <I'. -.v-c>3/ / 7 r ' -, •sji. : • :.
•
j •
�' ' 0.
rN .,14 .i-- _Y� —Y,Fti
--4 era � -- 4 s `' ^ 1 - — ,\ — — — ��.�,
-c ,..;3 I c- r �Ic-sQ ,O, ,mac,
r \ •U 4 -*, ,�pp�;C. ,Feeto
I, the undersigned, tipieby certify that the soil tests reported on this form were made by me in accord wi a procedures and methods specified in to Wisconsin
Adm nistrative Code,and that the data recorded and the location at the tests are correct to the best o y knowledge and belief.
:.:
: ,7 )TESTWEREC-- "'� ,ffICATION NUMBER: PH NE N BER(optionel):
T CST SIGNATURE:''
c.
I
ION: Original and one copy to Lorl A.s,tjyority Propery Owl and Soil Tester-G:;0' il't 10 131) i/ ,��yy OVER •-
.f' C
-pQclr?e O04 dQ far
E. , Sw/ say, TV 121Gzj
330 ~
E'xrefa~- 6k))iere 01 nAen 6 orn^~d°
A)
grn /O°
r- Wisc(Wsin 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 284195
Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.:
VANDERVEER, GEORGE 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
Vent
TANKTO P/L WELL BLDG. Airito ntake ROAD Dt Inlet
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 Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION Type O CHAMBER Model 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 Fxx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: SOMERSET.24.31.19W, NW, SW, 205TH AVE
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
SANITARY PERMIT NUMBER:
s'
Division
Safety o and Building Water Systems
v.=`■■■~ SANITARY PERMIT APPLICATION Bur 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
r than 8 112 x 11 inches in size. C
• 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 ii revisi n to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Ow er Name Property Location
/
f ~4nC d AC19- AJLU4 S a T N, R /g E (or)gProperty Owner's Ma ing Address_ / aJ7 Lot Number Block Number _
7
City, Sta e . Zip Code Phone Numb r Subdivision Name or CSM Number
'1~ - j.6, "ZI L_
_Ia • w1 02 ~ a ~
II. TYPE F BUILDING: (check one) ❑ State Owned p City Nearest Roa*f
p Village X105 Nr -
❑ Public 1 or 2 Family Dwelling - No. of bedroo Town of O~
III. BUILDING USE: (If building type is public, check all that app y) Parcel Tax Number(s)
1 ❑ Apartment /Condo 6 3 a + 1 aG.' -30
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_______ 2Existing System Existing System
B) A Sanitary Permit was previously issued. Permit Number V 7 Date Issue o
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 [A Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12X 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
vation
fa Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Q Ele
I-ZE
'30 ~ 7 y d Feet , 6 eet TANK Capacity
VII. in gallons Total # of Prefab. Site Fiber- Exper
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existin strutted
Tanks Tanks
Septic Tank or Holding Tank /deco e) ❑ ❑ ❑ ❑ ❑
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'ss5ame: (Print) Plu r' S tur : (No Stamps) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street City, State, Zip Code .
075 / ' Gi
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved San ry Permit Fee (includes Groundwater Date Issue I sung Agent Sig ture (No S mps
A roved At o surcharge fee) O
App ❑ Owner Given Initial ✓At
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SRO-6398 (R. 05194) DISTRIBUTION: Original ro Cnuray, One copy To: Sarety 8 Puil,lings Div,aon, Owner, Plumbzr
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 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.
WiscorAii Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations Page-A- of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code
County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in s'
include, but not limited to: vertical and horizontal reference point (13 on and , ~ S 1 rO 1
percent slope, scale or dimensions, north arrow, and location and s ) to n@ rR t i6ad. - el I.D. #
ei + ~ Ps
a.~a3a- 6-3b
APPLICANT INFORMATION - Please print all inf wed by Date
agy w s 15,@4 (1) (m)). ' R
Personal information you provide may be used for secondary purposes
Pi
Pr//o~~perty Owner' 3 Location
L7 G p t' Gr GC ~f o '~a~tl :1: /4 5 W 1/4,S a 4 T 31 N,R I q E (or) ID
Property Ovvrt rs Mailing Address J tft . ;Bll~c Subd. Name or CSM#
ao 1W4 51.
City State Zip Code Phone Number El City ❑ Village Town Nearest Road
w.e~ ~'r W~L S`to~ (715 -531 No-~`~+1 So~.er st 65t~' Qve..
❑ New Construction Use: Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow 3DV gpd Recommended design loading rate _ bed, gpd/fF a trench, gpd/ft2
Absorption area required ya q bed, f:2 -375 trench, ft2 Maximum design loading rate . -bed, gpd/ft2_ &-g-trench, gpd/ft2
Recommended infiltration surface elevation(s) _l Jam' . la ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material Qm T6 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 ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ U ❑ S ❑ 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
1 -l a 1 3 F51- 1 F 6r rn VF a s a F y. 5
2- Id` - Y/5L Fsbk. w~✓ w F 5
Ground 5. SKRy~y Stor -S L.
wxm elev.
I of R y/3 5 L - - . 8
Depth to
limiting
factor
c f o2 tl
Remarks:
Boring #
J'L
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
CST Name (Please Print) Signature Telephone No.
1'ar / ~g - 5$$
Address Date CST Number
a7 to oo -t-0.. r 1' /`mot - M- 40 11
s oa 4•
w-T
PROPERTY OWNER SOIL DESCRIPTION REPORT '
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
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
'n. Remarks:
Boring #
Ground
elev.
ft. ,
Depth to
limiting
factor
in.
Remarks:
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wiscopsip Department of Industry, SOIL AND SITE EVALUATION
Labor ahd Human Relations Page -A- of
Eftsion of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code
X
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 6,Y1
C r'D 1
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. #
6'3'A-
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)).
Property Owner Property Location
O r C tr Gfr.r Govt. Lot N W 1/4 5 W 1/4,s a y T 3' N,R I I E (or) l~
Property Own is Mailing Address Lot # Block# Subd. Name or CSM#
ao a
City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road
W-t S4vu (-I 1S );t 4 7 -532 N° a~►~ 5o~•c~siL r aSt~' 4\)e.. .
❑ New Construction Use: ® Residential / Number of bedrooms Addition to existing building
❑ Replacement Public or commercial - Describe:
Code derived daily flow 100gpd -f Recommended design loading rate . bed, gpd/ft2 trench, gpd/ft2
Absorption area required y a q bed, ft2 3 ! 5 trench, ft 2 Maximum design loading rate _-.1-bed, gpd/ft2 e a trench, gpd/ft2
Recommended infiltration surface elevation(s) 9 5 • I e( ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material I rn G7 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 ❑ S ❑ u ❑ S ❑ u ❑ s ❑ u ❑ S ❑ u ❑ s ❑ U ❑ s ❑ U
SOIL DESCRIPTION REPORT
Boring # 4orizon Depth Dominant Color Mottles Structure GPD/ft2
9 Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
l ! -la t 3 L J F G r rn VF a S I F y. 5
Y/ 5>^ FSbk t",✓ F w F .y S
Ground 5- 5~ R y y 5 t 6r - S L r .,3 I V F J: 8
elev.
Depth to
limiting
factor
Remarks:
Boring #
04 0-
Ground
elev.
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IVISION
FPAIyfMENI OF REPORT ON SOIL BORINGS AND D
IVISION Mt B
DIVISI
dC3USTRY,
ABOR AND PERCOLATION TEST'S (115) MADISOP.O. BOX N W 53707
OMAN RELATIONS
(ILHR 83.09(1) & Chapter 145)
0CA~Fl 0N: 5ECT1 N: TOWNSHIP~"MUNICIPALITY L07 NO.:BLK. NO.: SUBDIVISION NAME:
Nc.'/ SCd'/ ~ /T N/R /9 E (Or - 'N =,'f _1)
OUNTY: OWNER'S BUYER'S NAME MAILING ADDRESS:
SE DATES OBSERVATIONS MADE
NO.BEDRMS. COMMERCIAL bt'sc tIPTIUN P~OFIL~B TPTI N A TESTS:
O
AResidnnce /V/A- Vi New [-]Replace
ATING: S= Site suitable for system U- Site unsuitable for system
ONVENTIONAl i MOUNDC E: SY, 7FM I'SYSTEM:(ooptional) ( o u I~ V jU JIN-GROUND-PRESSOR
04-
E V EJ' IV _l a$ 0 U~ CV ~I V 0.d, 11-:W41 U/,-:A 7'//-1- 150 l /OfJi~K'FR
7" m.' P.. LS L3h6j .iVS7
I Percolation 'tests are NOT required DESIGN RATE: If any port,on of the tested area is in the
tiler tLH) 83.09(5)(W, indicate. Floodpl.iin, indicate Floodplain elevation:
~rrC PROFILE DESCRIPTIONS
a7RING TG`tAl CHARnr TFR Ot SOI1. WITH THICKNESS, COLOR, TEXTURE, AIJO DEPTH
(UMBER D OBSERVED. EST. HIG11Esr TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
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Ut'C )r PERCOLATION TESTS Z;ra,,s h+7~_211g,v LS e3~+r•~s 1 'P.3'
EST %M HS' IN HOLE TEST TIME DR IN WATER LEVEL-INCHES RATE MINUTES
NUMBER %MHS AFTERSW_ELLING tNTERVAL.-MIN. pFRi_ D' 1 ptRioo P PER INCH A 00
P.Z 8' 4z G C' .43
P- .3.3 - - - - - L -3 .67
P
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L P how locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what art the horl-
,ntal an vertical elevation reference points toQjI st~wtw t air /c8~trt onfthe plot plan. Show the surface elevation at all borings and the direction and percent
I land slope, 4t-
;SEMELEVATION .-_-9a,~ -
4e-
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 1~:,p~,.~ r/a,~~~✓ residence located at:
~ ,
~ /
1 542
Sec. ZZ, T-,I/ _N, R-qW, Town of 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 /e; -05>-:zG
Did flow back occur from absorption system? Yes No (if no, skip next
line.
Approximate volume or length of time: gallons minutes
Capacity: /Qzrl
Construction: Prefab Concrete- Steel Other
Manufacturer (if known) :
Age of Tank (if known) :
(Signature) ~j (Name) Please Pr'
(Tithe) (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 s2~S Signature
MP/MPRS c
r 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
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. ~144 D/Q^,gt2ti,
Location of property L
Township, Mailing address
Address of site
Subdivision name 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 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.
r2'c X30
S'gnatur of Applicant Co-Applicant
Date of Signature Date of Signature
t
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
y✓c UG~er~l~
MAILING ADDRESS
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
/ltpd
CITY/STATE
PROPERTY LOCATION, 1/4, Section T_j,/ _N-R / 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 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 piration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVEL DR RECORDING DATA
WARRANTY DEED
4h63U Ji. I ~
01PA,,[ 199 REGISTERS OFFICE
Burdette D. Krueger and Mariellen Krueger, ST. cROrx co., wrs.
husband and wife, as joint tenants R-, d. ffor Reoord his-5th
dUy of June A.D. 1987
10:45 A
conveys and warrants to _ George M. Vander Veer and
Karen J. Vander Veer, husband and wife as -
marital DrODerty with rights of survivors ip 1er9fD~e"
RETURN TO
the following described real estate in St. Croix County,
State of Wisconsin:
Tax Parcel No:
The land herein referred to is situated in Lhc County of St. Croix. State of
Wisconsin and is descr2bed as follows:
Part of N1/2 of SW1/4 of Section 24-31-19 described as follows: Commencing at
the W1/4 corner of said Section 24: thence S87°57'05"E (assumed bearingi
923.77' along the N line of said SW1/4 to the point. of beginning; thence
S87°57'05"E. 224.61 feet; thence SO°25'38"E 31.52': thence Sly 124.92' along
the W'ly right-of-way line of an existing private road on a 228.32' radius
curve concave E'ly whose chord bears S16°06'04"E 123.37': thence S31°46'30"F
114.46' along said W'ly right-of-way line; thence SE'ly 130.87' along; the SW'ly
right-of-way line of said existing private road on a 300.62' radius curve
concave NE'ly whose chord bears S44°14'47"E 129.84: thence S56°43'04"E 97.13'
along said SW'ly right-of-way line; thence SE'ly 60.82' along said SW'Iy
right-of-way line an a 266.00' radius curve concave NE'ly whose chord bears
S63°16'06"E 60.69': thence N87°30'16"W 561.05': thence N2°10'16"E 404.85' to
the point of beginning.
:"r' `l ~t daft
This i s not homestead property. (is) (is not)
Exception to Warranties:
Dated this h day of May 19 87
EAL) (SEAL)
. Burdette D. Krueger Mariellen Krueger
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
SS.
St. Croix county.
authenticated this day of 19. _ Personally came before me this 30th day of
May 19 87 the above named
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