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STC - 10 4aT
AS BUILT SANITARY SYSTEM REPORT
!
OWNER corms. ,1 r
ADDRESS ~fl 4d2~ ' x, d 1
SUBDIVISION / CSM# ,'irt! ~,~a711 LOT #
SECTION /.5- T 1 N-R l~¢ W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
9a
0
s~ ~Z
SS S
INDICATE NORT ARROW
Provide setback and elevation information on reverse of th s form.
3
Provide 2 dimensions to center of septic tank manhole over.
IZ2
A
f
BENCHMARK:
~,o
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: 1~)~~,~!S Liquid Capacity: %QQQ_
Setback from: Well House -Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: House Other
ELEVATIONS
Building Sewer /42, - ST Inlet: j,:~92 ST outlet: /D,' 7
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system 100,"9
Existing Grade Final grade
DATE OF INSTALLATION: -
ti
PLUMBER ON JOB: - /
LICENSE NUMBER:
INSPECTOR:
,n, -
3/93:jt
Wisconsin D_qpartmentof 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 268640
319
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
GERMAIN, MIKE STAR PRAIRIE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
16l), ram, /G~ • a
TANK INFORMATION ELEVATION DATA A9600335 /v 2 y'6
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
DOsin
Aeration Bldg. Sewer .2
r7~ py sd
Holding St! Inlet 3,0
" TANK SETBACK INFORMATION St/ Outlet 3, 25 /o9,aS
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic /v;~7 NA Dt Bottom
Dosing NA Header-
Aeration A Dist. Pipe d,73 CJ /$7'
Hol Bot. System /Op (a
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand'' c S' ' /
Model Number M
TDH Lift F on System
Forcemai ength Dia. H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width/ Length~ / No. Of Tenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS / DIMEN
SYSTEM TO P/ L BLDG WELL LAKE / STREAM L Manufacturer:
SETBACK AMBEfI
INFORMATION TypeO new 4 i Mode Number:
System: 1SF S }1 OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x x Hole Spacing Vent To Air Intake
Length Dia- 7 Length '53 Dia. 41- Spacin
SOIL COVER x Pressure Systems Only xx Mound Or At-Gra ystems 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: STAR PRAIRIE.15.31.18W, NW, SW, 112TH AVE
Qe
Plan revision required? ❑ Yes No
Use other side for additional information. R~~
SBD-6710 (R 05/91) Date Inspector's Signatur Cert. No.
ADDITIONAL COMMENTS AND SKETCH r
SANITARY PERMIT NUMBER:
Safety and Buildings Division
L.p`riR SANITARY PERMIT APPLICATION Bureau of Building Water Systems
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 San'tar Per it yber
The information you provide may be used by other government agency programs E] Check it revisioon to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Propert Zer Na Property Location
r 1 /4 1/4, S T , N, R Oor~
Property Owner's Mailing Ad ess Lot Number Block Numb
f ifs 1L~
11x2,2 zz
Cit State Zip Code Phone Number Subdivision Na a CSM umber
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ tit Nearest Road
To n
E] Public 1 or 2 Family Dwelling - No. of bedrooms El
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) O
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. jA 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
11 M 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,/inch) Elevation
,J Feet ,~2 Feet TANK Ca acit
VII• in gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic AppN w Exist in strutted
Tanks Tanks
Septic Tank or Holding Tank -r l r r EJ El R El El-
lift Pump Tank /Siphon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the ndersigned, assume responsibility for in allat4on "e onsite sewage system shown on the attached plans.
Plu er' 7am (P Plu ts) MP/MPRSW No.: Business Phone Number:
`
3,1
Plu ber' Address treet, ity, Stat Zip COCA:
IX. COUNTY / 13EPARTMENT USE ONLY
E] Disapproved Sani ry Permit Fee (Includes Groundwater Date Issue Is uing Agent Signature (No Stamps)
Surcharge Fee)
X Approved ❑ Owner Given Initial
Adverse Determination
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD-6398 (R. 0S/94) DISTRIBUTION: Original W County. One copy To: Safety & Builclings Divi ion, 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.
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.
"O;v 20910
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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.
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)).
Property ner Property Location
' Govt. Lot 1/4 1/4,S 15
- T N,R E (or V1/J
Prope Owner's Mailing Address Lot # Bloc Subd. Name or CSM#
z
City Sta Zip Code Phone Number Neare Road
( ❑ City Villa 21 Town
New Construction Use: R1 Residential / Number of bedrooms Addition to existing building
❑ Replacement / ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate ~~7 bed, gpd/fit trench, gpd/ft2
Absorption area required bed, ft2-S~.~..-trench, ft2 Maximum design loading rate ~Zbed, gpd/ft2_,g_trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material a 6. 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 [Z S ❑ U ® S ❑ U ®S ❑ U [ S ❑ U ❑ S U ❑ S Z 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
0
Ground
elev. 7
Depth to
limiting
factor
Remarks:
Boring #
_Z'
Al 151
elev.
Depth to
limiting
factor
19$_in. Remarks:
CST Name le a Pri ~ Signature Telephone No.
Address Date CST Number
C ~
' SOIL DESCRIPTION REPORT
PROPERTY OWNER pages of
PARCEL I.D.#
Horizon Depth Dominant Color Mottles Structure 2
Boring # Texture Consistence Boundary Roots
in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. Bed , Trench
Zak-
Ground 3 -
elev.
Depth to
limiting
factor
Remarks:
Boring # _
3 7'
Ground
elev. ,
Depth to
limiting
factor
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 # s
Ground
elev.
Depth to
limiting
factor
>,&2 in. Remarks:
Boring #
Ground
elev.
ft. '
Depth to
limiting
factor
in. Remarks:
SBDW-8330 (R. 08/95)
- a/ 7s44/ lp6j
19, Al
:
i
}
33~ ,
abor and nd Human Department Relations Industry,
L SOIL AND SITE EVALUATION REPORT Page % of 3
Labor
Division of Safety & Buildings in accord with ILHR 83.05, rAd NTI
t,15T: C_ R01, K
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan not limited to verti
cal and horizontal reference point (BM), direction and % of slP dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATIONREVIE
BY DATE
PROPERTY OWNER: P TY LOCbTdON
.
'L"'.
~l'Gh,4,9D 577-o U 7- G f u
O .W lhlj j- 1/4, N,R E (oo
PROPERTY OWNER':S MAILING ADDRESS - LOT K M 1f
i 3S3 /f w,4 T 0 eAE:s= TSP. kV
A
CITY, STATE ZIP CODE PHONE NUMBER REST ROAD
ttu So,,..) lots. syolco cc
(~r5)s4q-0731 t
rYli'Y
[I,f ew Construction Use [ 4-fiesidential I Number of btsdrooms 3 +o q Addition to existing building
[ [ Replacement [ ] Public or commercial describe
Code derived daily flow god Recommended design loading rate bed, gpd/tt2 trench, gpo1f<2
Absorption area required bed, 112 75 9 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2Ftre ch, gpd/1112
Recommended infiltration surface elevation(s) S4W } .3 It (as referred to site plan benchmark)
Additional design / site cons rations
Parent material 5'CS I i OAIA Al i;F- 0,7" Flood plain elevation, if applicable ft
S =Suitable for system CONWIO L M ❑ U IN•G ❑ D U ESSURE AT-G EE U SYYSTW-1N FILL HOLDING _tJ
U=Unsuitable for s ste cg's U CC'S U O S
M El
SOIL DESCRIPTION REPORT IVIle = N07/ ,Pc~oH/~L~ NEED
Boring # Horizon Depth Dominant Color Mottles Texture Structure Roots GPD/ft
In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ten h
o fo ye J/3 s1/ 2 -f shk- /W v-FR s s . 6.
z -/s /o ye 3/~/ of j- he *4-F,e s s 6,
Ground . 3 3 /D f`k ljsr, ~ GS - ? . oo
elev.
gs. 20 ft. D /O
Depth to
limiting i
factor
Remarks:
Boring #
- /ovi? 3/3 2-f she- S <3f • s G
Z
071M-.:
~ G
L - /0 y/2 3/t( D 1+5 he •wt f cs .37
Ground
elev. 01
Depth to
limiting
factor ii
Remarks:
CST Name:-Please Print R d Q IER T 2t L 13 R IBC l' Phone. 7167--38& _ S / S JC
Address: 7 - CsrA 1. V L?.7-
Signature: Ulbricht s Date: CST Number:
n..... Jlnnfa
L !
PROPERTYOWNER P#?-4"P fz~~T SOIL DESCRIPTION REPORT P Z 3
1 age of
PARCEL I.D. T iE ! 11E~ $~.t1 f~
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourifty Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed nnch
die s Xf s
Ground l ID yl~ • s. S ~7
elev.
&0 it.
1
Depth to
limiting I
factor
Remarks:
Boring # 10-// /O YX 3/2-- D/r.K 2,,,.., ,sLj,e AA- Y' S 3 j . r!i
2- 2-31o y4 3/2 S,~Il In, 7OCZ 1-74 57
Ground: 3 L3 0 /o Y y • s O s ~,r? .
elev.
Depth to i
Nmiting
factor
Remarks:
Boring # ,
0-/2- io yiP 3/3 - 11044f 2, w A4A ~s zf
5 I . G
Ak 40 1- ~-1a /o ~iP 3/ o fe 5-
3 YX lS CS .7 ~ . v
,,.elev. S-~ 1, -7. fl
Depth to i
limiting ?
factor
Remarks:
Boring #
t
Ground
elev.
ft.
Depth to
Hmiting
factor
L.o T y,
,,o
• = ,QACwAOpe P'i'ts
~M sEr; rop ~f
/00,0 1
a
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3 r7
7
7S By
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VJiscdnsin Deparbn6nt
Rel of Industry,
L~a SOIL AND SITE EVALUATION REPORT Page / of 3
• ~ `db~'F +luman Relations
IRM91on or Safety A 13tAkNngs in accord with ILHR 83.05, Wis. Adm. Code
CO
sr. CR 0 rx
Attach complete site plan on paper not less than 81/2 x 11 inches in size, Plan must include, but
not limited to vertical and horizontal reference point (OM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, And location and distance to nearest road,
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
t
PROPERTY OWNER: PROPERTY LOCATION
Ql'c h A R?) 577-o u 7- GOVT. LOT NW 1/4 JrU) t/4,S 1_15r T 3/ N,R E (oo
PROPERTY OWN R':S MAILING ADDRESS LOT # BLOCK 1 SUBD. NAME OR CSM t
/ 3 3 /f W4 7-0 I~EZ= T.P. #3 I E lIvre
CITY, STATE CIS, ZIP CODE PHONE NUMBER IlY ILLAGE N NEAREST ROAD
if v 500 syof(o (7/5)541?"(,731 57- PR/4tRlrc CC
14<ew Construction Use 14-Nsidentlal I Number of b6drooms 3 +0 4 (J Addition, to existing building
Replacement Public or commercial describe
Code derived daffy flow y °ov gpd Recommended design loading rate bed, gpd/112 Wench, gpolft2
Absorption area required o o bed, ft2 7~'y trench, 112 Maximum design loading rate • 7 bed, gpolft2 trerldt, gpdh2
Recommended infiltration outface etevatlon(s) SEA t~q .3 ft (as referred to site plan benchmarq
Additional design / site oon ations
Parent material 5'CS I 1 IJ,yA'A, ~ 'Flood plain elevation, If applicable ft
S - Suitable for System ~O UL T m-oL,"' Ej U N .GRPKD ❑ U PRESSURE AT-GRADE SYS FLL 7HOLD
T
U =Unsuitable Ior system
U p U ❑S
IRS I
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Texture Structure Roots GPD/ft
In. Munsell Qu. Sz. Cont Cola Gr. Sz. Sh. Bed
TbIch
0-6 fo Yi2 J/3 /Y 2-f Ihk 40(rfj2 s t s . G
z -/S o ye 3/ - si/ Zf Sble .*,fe S . s
Ground . 3 3 /0 ~~ri S~jrC~ MOftv GS 7 .00
~S. io tt. /p , S. D S OQ
Depth to
limiting
factor
LL 1. 11 1 -J. I
Remarks:
Boring
0-9 / o yI? 3/3 0 Z-f she S ~f . s ~ • G
Z 2- ~0 y/Z O Zfsd& f cs . s • G
Ground 3 /d s S 7
elev.
7 ~ y0 K.
Depth to
limiting
factor a
Remarks:
T Name:-Please Print R O g IER r V L(3 R I'C k r Phone. 715= 36&
_ S 5
Address:
Spnahxe: r
rivals tit a Associates Sewage Consultants Date: CST Number:
P
CHI r VWNEA ^IPI~ Sfr~ e~ T -
SOIL DESCRIpTi~ `
PAgcEL I.b. l f ON REPQpT
- ~/VET 8~-.vf> - -
Boring 0 Horizon DePth Dominant Color WIN.
In. Munsell Qu. Sz. Cont. Cobr Texture t ucture ar QpD/ft
3 p-~ /D 3 ~~Y Roots Bed
z
Ground
Zy /o ~►-fe --ts /f s . G
elev.
m~td~ to
Factor ,
>f
Remarks:
Boring #
y/e
z 2 2-3 shy ~iP 5 3 . f" , G
s~~ fe s Ale
Ground 3 3 D /D 1~ y . S~
elev.
Dh to
Img
laclor .
Remarks:
Boring #
o-,z AP yp 3/3
Z ~-la /o ° /off'' ~ ~ c.~ YR 3 2-f
. s . G
Ground 3 -L /p S/?e L' l . S
elev.
it.
. S.
s 7
Depth to
KmiNng
f v w
Remarks:
Boring # Ground
elev.
)epth to
uniting
9Clor
Remarks: .
o4z
• ,
L-OT 93
X70'
5~•4~ : / = 30
19M sir; ror ~f Pty- ~I-tv•
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS G
/ /ate
PROPERTY ADDRESS c ' 1 ~~ctr~
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE y-yC1kA-"
PROPERTY LOCATION ►J 10 1/4, S 1/4, Section , T N-R W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION ILI LOT NUMBER -
CERTIFIED SURVEY MAP , VOLUME Q9 , 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:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
• S T C - loo
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
Location of property NW 1/4 5'J 1/4, Section ,T N-R W
Township Mailing address P. QVV 3'70
Address of site ~OoZ.
Subdivision name Lot no.3 _
Other homes on proper y? Yes -No
- qT
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created j996,
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes No
volume 11gq and Page Number 01 S' 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. 'r5(413j(4q 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.
Si4aturee of Applicant Co-Applicant
4 241
34 42 228
LOT 43 LOT .41 300
LOT 40 LOT 282 39
- LOT
T
909
0 907 906 905 co 89
M 48i
LOT
-IMF
8 894-
/s7- -4 - _ _ IiE,Q N
OT 38
904
LOT 2
0
N 893
2 3 &____848_"' 4
LOT 37 339.84'
903
845 $46 0 84jT 34x.21' `LOT 30
0
N 894
310.62'
a 5
a
N 849 I LOT 36 26547'
200 ' 208' 222 1
254.24 378.63 I 263.24 902 LOT 31
i OD 895
LOT 2 ti LOT 3 N
.56
v L_ 10, _ PAG E N 2937 K 6 i LOT 3 5 '
2600C 269'D M 8.50 - I 901 898 89E
s2i;18' LOT
'.81' 351. '
1256 5 66'
1 aLO T 33
p.
851 LOT 34
N 7 a
900 899
389. 0,
a3,''~\ 8512 - AVE -
270 D A -
R
sE
v4 S w 114 0 9 13 14 N 15
' VOL 1199, PAC0 01 /0,00 j'"-
549144
STATE BAR OF WISCONSIN FORM 1 - 1982
WARRANTY DEED
DOCUMENT NO. ,M
REGISTER'S OFFICE
ST. CROIX CO., WI
This Deed, made between Rec'dforRecord
R!GhaEd 0. Stems SEP 6 1996
Grantor,
and Michael J. Germain and Michelle M. Germain, at 8:30 AM
husband and wife, %-KA l,,,,, -R J ,4k.
Register of Deeds
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration
Richard O. Stout
conveys to Grantee the following described real estate in St- Croix THIS SPACE RESERVED FOR RECORDING DATA
County State of Wisconsin: NAMEDRETU N ADDRESS
Lot 43, Plat of Apple River Bend First
Addition, Town of Star Prairie, St. ~O• &V` (A
Croix County, Wisconsin.
_SyGtcr
(~SS 118/ -yo
PARCEL IDENTIFICATION NUMBER
F N , * i i oa j ,aa)-
TRANSFER
FEE
i'
I
This is not
homestead property.
(is) (is not)
,i
Together with al and s'ngular the hereditaments and appurtenances thereunto belonging;
And RM'arc~ O. Stout
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except j
easements, restrictions, rights-of-way and covenants of record,
if any.
ii
and will warrant and defend the same. ij
Dated this day of August '30 19 96
r (SEAL) (SEAL) II
* Richard O. Stout
(SEAL) (SEAL)
* *
i.
~i
AUTHENTICATION ACKNOWLEDGMENT
I
Signature(s) State of Wisconsin, j
I
St. Croix SS.
County.
.7.,.. ,.r , n n...._,....,.11.. L..f__.. .L:.. A . -