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Parcel 038-1113-10-000 12/04/2006 02:21
PAGE 1 OF 1
F 1
Alt. Parcel 28.31.18.47964 038 - TOWN OF STAR PRAIRIE
Current ' X! ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current CO-Owner
O - KEHREN, RICKY G & JACQUIE A
RICKY G & JACQUIE A KEHREN
1084 192ND AVE
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 1084 192ND AVE
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 2.160 Plat: N/A-NOT AVAILABLE
SEC 28 T31 N R1 8W 2.16A IN NE SE LOT 4 OF Block/Condo Bldg:
CSM IN VOL III PAGE 835
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
28-31 N-1 8W
Notes: Parcel History:
Date Doc # Vol/Page Type
10/30/2000 632595 1554/353 WD
04/30/1999 602297 1423/50 QC
04/07/1999 600881 1417/151 WD
07/23/1997 734/104
2006 SUMMARY Bill Fair Market Value: Assessed with:
175623 161,600
Valuations: Last Changed: 10/05/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.160 32,800 110,000 142,800 NO
Totals for 2006:
General Property 2.160 32,800 110,000 142,800
Woodland 0.000 0 0
Totals for 2005:
General Property 2.160 32,800 110,000 142,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 126
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
• 1 y •
y
-e
4VO
SC CROIX COUNTY ~4fts ~9J9
g pp _ SURVEYOR'S RECORD *0841 G, Fogy
84 ID.
CERTIFIED SURVEY MAP
UNPLATTED LANDS I I
S89°53 E I I
S 89°53'E 663.00 I
I
363.00 300.00
90 1 66 II
I I
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3 cm 2 w 1 ; zi
o 2.68 ACRES 2.42 ACRES Q~
u-
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t0 w _ Z 11-
(n fD e 0co J I -OD Q I ~i
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zi SE-NE-SE Z o°~ I z
-~I t w z 11 -
o I
~S N 89°5&W 300.58 ~
~j 176.30 124.28 R=80 1 z
I N89°53 W 220.62 I c!) I
130.23 90.39 co
zi ~U " \ M ° j I 1
1 w I
o~
Z o ' / -o ~ ~I 1 N
o O JII ~ 1
66 b
2.16 ACRES Q
~ cc I I
1.52 ACRES a UJ` I
M m F-I I I
NORTHERLY w w NORTHERLY Qt I
RIGHT-OF-WAY LINE -,n o RIGHT-OF-WAY LINE JI 6
I l I
sm 00' oc 0Z. 1 I g I
N89°53 W 330.00 z N8 W z 89°a3W 267.00
-cD ' N89-53'W 6 .00 663.00 97.18
CENTERLINE OF EXISTING TOWN ROAD q a f,
1.77 POINT OF
UNPLATTED LANDS ~u>tNUr~ BEGINNING
SCALE IN' FEET ~rGp1 yb -
EAST LINE OF
/ySE I/4 SECTION 2E
ALTER I SE CORNER
o IOU 20o APPROVAL OF THIS MINOR SUBDIVISIO rGREG0
Y = SECTION 28
_ DOES NOT MEAN APPRnvei C R
. i
• AS BUILT SANITARY SYSTEM REPORT
TOWNSHIP 5tu' r t3 t SEC. T N, R W
{1. ADDRESS k~9,Lt~.l ~.if,~t w►ryy~, ~'c,, ST. CROIX COUNTY, WISCONSIN.
DIVISION 7 , LOT__~_ LOT SIZE '
PLAN VIEW
-Distances b dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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III i i ( I ~
Indicate Nantn Annaw
:'TIC TANK(S)MFGR.CONCRETE STEEL S ca.te / yC r
NO. of rings on cover Depth DRY WELL
'1_-NCHES NO. of width length area
j no. of lines width= length area
depth to top of pipe
;:.ELATE
.t.: RATE AREA REQUIRED 2 ' O AREA AS BUILT
;claimer: The inspection of this system by St. Croix County does not imply complete
,.iDliance with State Administrative Codes. There are other areas that it is not possible
inspect at this point of construction. St. Croix County assumes no liability for
.tem operation. However, if failure is noted the County wi make every effort to
:;ermine cause of failure. .
ASES AND OILS SHOULD NOT BE DISPOSED THROUGH.>THi ' SYST .
`INS°ECTOR
DATED PLU;LBER ON JOB
LICENSE NUMBER j _
.r
z
' REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM
San.itaA y PeAm.i
State SPp.t.cc,/L. _
~ el St. Croix County
NAME Z e Township 'Alt"
Location S~ S-7 Section
SEPTIC TANK
/ I
Size ~ gattons. Number of Compantmenxs f
Diztance FAOm: Wett 12% on gneateA ztope it
Bu.itd.ing it. Wettandb ~ .
H.ighwaten it.
DISPOSAL SYSTEM
D.ibtance FAOm: WeQ.Z L~ 12% on gneateA ztope it.
Bu.itd.ing i it. Wettands r Ft.
H.ighwateA - it.
FIELD DIMENSIONS:
Width o6 trench it. Depth o6 no ck b etow t ite l in.
Length o6 each tine it. Depth a6 Aock oven Cite Z in.
C NumbeA a6 tines - Depth ob tite below gnade9- 4-.in.
1-
Totat tength o6 .2inez/ U it. Sta pe o j tnench in pen 100 it.
D.iatance between tines L 6x. Depth to bedrock 6 •
IT j;. Totat ab4oAbtion atcea /f - ~ 2 Depth to groundwater ~ •
j Requited area it2 Type o4 Coven: ~ Papn Straw
PIT DIMENSIONS:
Numbers o6 •t/s GAavet around pitzs yes no
Outside di meted 4t Depth below .inlet ~ •
2
' z
Totat abs4b. - o n a ea it y
AAea n q" iAed it2
INSPECTED By WN-Y-- TITLE
APPROVED DATE 19 74.
_ Y
REJECTED , DATE 197
ER 115 Rev. 9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION:_<Z_%,.'5LL'/a, Sectior>..'2 aTs3JN,R,94 (or) W, Township or Municipality S7"- A 64j,06
County
Lot No. , Block No.
--Subdivision Name
Owner's/Buyers Name: 7-rr27 E "Air P
Mailing Address: C
TYPE OF OCCUPANCY: Residence-No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW~REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS 8' a Z -7 / PERCOLATION TESTS mss- 701
SOIL MAP SHEET NAME OF SOIL MAP UNIT T w
PERCOLATION TESTS
TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- DEPTH CHARACTER SOIL SINCE HOLE HOLE AFTE INTERVAL
MIN/IN
INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
BER 7
P- la_ Q
3 3
P- Aj~ddd
AID AM
P- p li 1 / 3
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
TEXTURE, MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- 7 9
B-
B- G
B- _ ?16 --NIL
B-
-
7 42
B-6 ;>916 10-e- A
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the lorapon and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy .Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
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7
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6 `AFL 3 s F _
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State and County State Permit #
PLO 67 ~ Permit Application County Permit #
for Private Domestic Sewage Systems County
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY c Mailing Address:
'7-LOCATION: _'/4 Section, M:2;jLN, R (or) W Lot# City
Subdivision Name, nearest road, lake eo landmark Blk# Village
Township -'~rc 7h
C. TYPE OF OCCUPANCY: *Commercial *Industrial *Other (specify) *Variance
Single family Duplex No. of Bedrooms No. of Persons
D. SEPTIC TANK CAPACITY Total gallons No. of tanks
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured-in-Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate ' Total Absorb Area sq. ft.
New A Replacement Alternate (Specify)
Seepage Trench: No. of 1-ineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: Length C -Width_-ZDepth Q Tile depth (top)e-No. of Lines
Seepage Pit: Inside di meter Liquid Depth No. of Seepage Pits
Percent slope of land ~ Distance from critical slope
WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared
by the Cer ' ied . Soil T s ,
NAME pt C n C.S.T. # -5-5 '5,l and other information
obtained from w~+ (owner/builder).
Plumber's Signature MP/MPRSW# Phone #
Plumber's Address F t'
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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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 268690
Permit Holder's Name: ❑ City ❑ Villag Town of: State Plan ID No.:
ERGER, MARTIN STAR PRAIRIE
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA A960039
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction a~stemE TDH Ft
Forcemain I I Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMEN I N
LEACHING
SETBACK Manufacturer:
SYSTEM TO P / L BLDG WELL LAKE/STREAM CHAMBER
Mode Number:
INFORMATION Type Of
OR UNIT
System:
DISTRIBUTION SYSTEM
[Header / Manifold Distribution Pipe(s) Hole Size HSt To Air Intake
gth Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: STAR PRAIRIE.28.31.18W, NE, SE, 192ND AVENUE
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 t
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION Busafetyreau o oand ff BuiluildiinWater Systems
gWater 201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, Wl 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8112 x 11 inches in size. <;I- 01 /0- x
• See reverse side for instructions for completing this application State tarn Permit Number
The information you provide may be used by other government agency programs ❑ Check it revision to previous previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Prope Owner Name Property Location
/4 1/4, S T'3J , N, R/ ;~57E (or)o
Property Owner's Mailing Addrest' Lot Nu ber Block Number
1110 &</ i9
City, State Zip Code Phone Number Subdivis n Na or CSM Number
U, Uci ~S3`S !r~ 3
II. TYPE BUILDING: (check one) ❑ State Owned ❑ City Near%t Road/~
.I~
❑ Village /
Public 1 or 2 Family Dwelling - No_ of bedrooms ~Z J~r Town OFD ' / ~o~-
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. A Repair of an
System SystemTank OnlyExisting 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„3 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
® 7V XD Feet Q,6/ Feet
VII. TANK in gallons Total # of Prefab. Site Fiber- Exper
INFORMATION Gallons Tanks Manufacturer's Name Concrete con St eel glass App.
New Exist in structed
Tanks Tanks
Septic Tank or Holding Tank CC> ~f{G ~/'f/~j El ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I e ndersigned, assume responsi ilit f r installation of the onsite sewage system shown on the attached plans.
PFarmbees Name: (Print) r' na re: (No Stamps) MP/MPRSW No.: Business Phone Number:
-21 V-
Plumber's Address (Str e , Cif State, Zip Code)
IX. COUNTY / DEPARTMENT USE ONLY
T ❑ Disapproved Sa itary Permit Fee (Includes Groundwater ate Issued Issuing Ag nt S' natur (N am
Surcharge Fee)
oved ❑Owner Given Initial cc
Adverse Determination /!o ,
X. CONDIT O OF APPROVAL ZREASO S FO ISAPPROYAL:
~~47 eta'
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS `
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit 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.
0
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 smallerthan 8 112 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
taroks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations Page of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code
yAttach 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 C
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 Dateir -7.
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
r h O C`C Y" Govt. Lot N E 1/4 cJ 1/4,S a 9 T 3 N,B ~i, E (or)~
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM-# ~04
1D%4_ 19 rv ( y cs M Q s.. '3 s
City State Zip Code Phone Number
~ ❑ City ❑ Village ® Town Nearest Road
❑ New Construction Use: 9Residential / Number of bedrooms_ Addition to existing building
❑ Replacement Public or commercial - Describe:
Code derived daily flow yso gpd Recommended design loading rate
bed, gpd/ft2 i trench, gpd/112
Absorption area required 91;> o bed, ft2 r5C>L trench, ft2 Maximum design loading rate . S bed, gpd/ft2~trench, gpd/ft2
Recommended infiltration surface elevations) 97.33 ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material Saa f' E ~ V Sb h-r e_ C r., e v w t aw` i I lood 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 [A S ❑ U 54s ❑ U ® S ❑ U 59 S ❑ U ❑ S 54 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
b$ 3 Si 1.. F sbkk mFr a s F . 3
a -I sl Si L- F PL fv\ of A.
.
Ground ~j _3 K'ftsle S► L ?m k. 411~'r w 1 F
elev. • '
Depth to Jr Y2 3~ S -S Y+'11-. - . 7 ; ,
limiting
factor ;
_O in.
Remarks: 16"
Boring #
A Sj L"_ a_
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
CST Name (Please Print) Signatu a Telephone No.
r 5~4rk ~L37u 5-.;?VG-35c38'
Address Date CST Number
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page - of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Structure 2
9 Texture Consistence Boundary Roots
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
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBDW-8330 (R. 08/95)
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CERTIFIED SURVEY MAP
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14 APPROVAL OF THIS MINOR SUBDMSIO
SECTION
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ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently serving
the residence located at: 4, Set/,
Sec. T_3/ 'yq/ R_Z_&_W, Town of ,S r , /e 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 Cf- /,?ri
Did flow back occur from absorption system? Yes No4 (if no, skip next
line.
Approximate volume or length of time: gallons minutes
Capacity: J0®0
Construction: Prefab Concrete X Steel Other
Manufacturer (if known):
Age of Tank (if known):
2at (N e 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
ce'r'tify that the tank, to the best of my knowledge, will conform to the
requirements of ILHR 83, Wis. Adm. Code (except for i pection opening over
outlet baffle).
Name =./-21- Signature
9' MP/MPRS ~
. 1'
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 9!- ~~is9 r2!`!L2 ~e~+; er
MAILING ADDRESS 10,k`l 1?-2s2c1 A-c /l/e ur /Pct KuagcQ
PROPERTY ADDRESS 10k5/ /F-2#,P ke. le-,w X L4 Ago't'* t Lets.SYd / 7
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE A'e w /P c lair ried &)-z- <S'"% ~'1
PROPERTY LOCATION 6 1/4, -5,6 1/4, Section T 3 N-R_18 W
TOWN OF Slur Pea• r,, e ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER_
CERTIFIEDSURVEY MAP , VOLUME 3 , PAGE LOT NUMBER 7
3S'8c~1s /
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 - 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.
Ownerof property,
Location of property //,E 1/4_T,,5 1/4, Section oT3/ N-R~W
Township Mailing address fo4Cy /9a .yo A,4c
AOe cu ~,e `i sl2v~c~ . G.ls .S"yc~ i ~
Address of site /-01!Z Subdivision name A/-"/f- Lot no.
other homes on property? Yes No
Previous owner of property Ta opes 14lo e
Total size of property A ,4eNes
Total size of parcel
Date parcel was created 1.9 2,9
Are all corners and lot lines identifiable? Yes X No
Is this property being developed for (spec house)? Yes ___X No
Volume 97 and Page Number as recorded with the Register
of Deed .-7~ °23
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. sue`?,W,/ 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.
Si nature of Appl' ant Co-Applicant
A p-
Date of Sig ature Date of Siqnature
• E.,,ED FOR RECn R~IKG DATA
HIS SPA:E RE^.
'J~' T
y, OOCtpjCNT NO. WARRANTY DEED
STATE BAR OF WISCONSt~' FOK9i 2 -1982
`409,4 `734MAO& ltGlSitR5 C)FtICE
'TROIX Co., WIS
. r ~.-cord thisb
Moe.. and. Sandra M. Moe, as husband &.wife
dames F Re fI March A.D• 1916
.
230 ti
Martin. J.• .Beryzr..and..._ - ~Z
.011%e%4 un,i %c.,rrants to . a.
o;
Annette K. Berger., as trusband wi fe
...County,
the following described reu! estate in
. q'az Parcel No:
5tate of Wisconsin:
Part of the NEB of the SEA of 2B-31-18 described in as follows:
Volume 3,
i_ot 4 of the Certified Survey p fil
as Document 1358851.
Certified Survey Maps, page 835,
rights of ingress and egress
town road th
r with and subject to non-exclusive roadway
h to 80 feet in width fified Surve the existing y Map Said
Togethe is
over t e roadway 66 costs to
provides access toll 44 lots e~roadway. Any maintenance
shown on said map is lt d equally by the owners of all 4 loLsoprivate roadway are to be s and maintenance obligations Said access rights on purchaser's
heirs,
said Certified Survey binding up
are covenants running with the land,
successors and assigns.
i -70
A
F-
is homestead property.
This
(is) (is not)
Easements of record
Fxccptiin to warrantie
86
19
March
5th day of
Iratcll this
('t•AI,I Moe
James R.
(Sj:ALi L ~
Sandra M. Moe
i ACKNOWLEnCTMENT
AUTHENTICATION
STATE OF 1VIaC0NSIN
.
Signature (s) . C r 0 Count
~ o
r - . 19....-. Yer'unall~• carne before me this day .
authenticated this day' of Mar :h 19..a~.. the aLoye narwd
.Me
James. R....M.oe. anal Sandra M... o
.
- TITLE: NIFNII1FR STATI• BAR OF «•►5( oNnlN
~yho excreted the
i
R ([f trot.. to we know'rt to hv t 'he I,rr-on c
foic,oing in~run;+..rt ur,! ark no .Iclltc [1,c >:u
j a.uthor,zed by § 70').01% Wts. •St;tt.+J