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042-1053-40-100
a o a) i o 3: ci ti ~ O o~ O O o ~ w 0 1 N N ~ I I h I v z° c Li o 3 ~ I ~ Q v Z y W o z a m I rn C*4 U o c O z Z v ~ ~ - p O Z O Z c (A F- T E -o I C ~ a) M O N O) y y m O C: O d L O L) c -0 L) O Z m z N 16 I z C V Cl) t0 E O N t0 N a C. w Q Cl) YU~ D D IL N 0 CO) U) U) E Z N> NO 7 O .U O o r 5 a u It z •aa ~ a (mil N ~ N 11a 7 O N m- U 0) rn rn cf) 0) ~~l a' N T 0 O O O N E T 1 C O 0 = N C', O ml y O It a d a in o " O 1 O O O CO C y O O n E co a 04 CD O o M 3 CA En V d °o °o O D. co 'O N N CJ) F- C O O 7F- N of m w 00 • CV 0 p rn R >>(C O > 0- co O Z c g Cn w T v~ d (0 ~ a I 3 a L a m d • e~ Q. E 2 c c r A c0 ~IL 2 ~0U)t) A Parcel 042-1053-40-100 05/24/20 P05 10:29 AGE 1 OF n1 Alt. Parcel 19.29.18.303A-10 042 - TOWN OF WARREN Current X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner * POLEN, GARY P & RHONDA M GARY P & RHONDA M POLEN 967 80TH AVE ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 967 80TH AVE SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 7.670 Plat: N/A-NOT AVAILABLE SEC 19 T29N R18W PT SW SE BEING LOT 2 Block/Condo Bldg: CSM 11/3041 7.67AC EZ-U-1204/465 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 19-29N-18W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 1157/183 WD 2005 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/22/2001 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 7.670 55,200 184,000 239,200 NO Totals for 2005: General Property 7.670 55,200 184,000 239,200 Woodland 0.000 0 0 Totals for 2004: General Property 7.670 55,200 184,000 239,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 523 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ti 3 4 L REC ve s sTC - ioa ;y J U L 1 8 1996 AS BUILT SANITARY SYSTEM REPORT S7 CF40X COUNTY ZONINGOFFICE OWNER-. ~/?,f ?,LFli \ 00 ADDRESS /~,gD rDS~ SUBDIVISION / CSM# LOT # SECTION J~T ,2!?N- ~W, Town of ST. CROIX COUNTY, WIS NSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF YSTEM 0 1 IC 7 ~ z ' / ~ 4t Get ~t~~~G T/Mrc INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. r BENCHMARK: ~O OF ~/.~2'L - 1i1+~! El?2H i /1/~ L= L-.t l+~£ f~:JGF ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: wE,Ext Liquid Capacity: 00 Setback from: WellHouse Other Pump: Model# Float seperation ons/cycle: Al cation -:SOIL ABSORPTION SYSTEM # ( ,'2 Width: S' Length #2 T6' Number of trenches z Distance & Direction to nearest prop. line: 1?' Setback from: well: /Ups Housed Other eC^f)(( ELEVATIOIS v/ fi ~ p-)A Building Sewer ~uG ST Inlet . lO/. P6 ST outlet /o 7-1,-' PC inlet PC bottom Pump Off # ~ /aD~a ~ p d" Q6 Header/Manifold Bottom of system 6i 9,el Existing Graded/, © z, y Final gradeVIyo.z. y DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER:-, INSPECTOR: l-~fiLr 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: ST; CROIX Labor and Human Relations INSPECTION REPORT ' Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION t'4~3ir'sG fYim, ❑ City ❑ Village W Town of: State Plan ID No.: t'1,>~N AK P ~31, g CST B.M Elev.: Insp. BM Elev.: BM Description: 7~, Parcel Tax No.: AgAnnin7d TANK INFORMATION ELEVATION DATA gd1d ZTYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / Benchmark (o, /S /G8 Dosing Q , id O. ~fl 05, Aeration Bldg. Sewer Holding St/ ~X Inlet TANK SETBACK INFORMATION St/ Outlet 2,99(' /CTD. y3' TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic -j3 NA Dt Bottom J. /06. ai Dosing NA Header / Man. k~w NA Dist. Pipe Holdin9 Bot. System 7.l ~ O/ PUMP SIPHON INFORMATION Final Grade li,yp Ma acturer Demand M C*Xl- Model Number M TDH Lift riction ea TDH F L Forc ain Length Dia. Dist. Tc well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length , No. Of renches PIT No. Of Pits Insi uid Depth DIMENSIONS S S DIME I G Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION TypeO .C.4r , CHAMBER Mo e System:-&-cnoZ5 : o~ j~ OR UNIT DISTRIBUTION SYSTEM Header / Pdd „ Distribution Pip s) Hole Size x Hole Spacing Vent To Air Intake I/ v Length Dia. `i Length 13 Dia. Spacing O SOIL COVER x Pressure Systems Only xx Mound Or At-Gr ys s Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodde xx Mulched Bed /Trench Center/ Bed /Trench Edges Topsoil ❑ Yes ❑ No No COMMENTS: (Include code discrepancies, persons present, etc.) *AS LOCATION: WARREN... 9,.9.,28W., SW, SE, 80T^ H ~A'VE Ll p y,~ n o -p Can c4_-l 4 C/ ems', 0 TIV-0 CI& y4c_ Plan revision required? ❑ Yes [g- Use other side for additional information. Q 5~' 1,9 1 SBD-6710 (R 05/91) te Inspector's Signatu a Cert No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: U - Safety and Buildings Division (EiSANITARY PERMIT APPLICATION Bureau of Building Water Systems ■7R 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. K • See reverse side for instructions for completing this application State Sanitary Permit Number ! "I I / iF The information you provide may be used by other government agency programs Check if revision to^ evi uS appfication (Privacy Law, s. 15.04 (1) (m)]: State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location ! > T N, R E (or~w_ I rll,,1/4 . 1/4,S Property Owne~s Mailing Address Lot Number - Block Number City State Zip Code Phone Number _ Subdivision Name or CSM Number II. TYPE . F BUILDING: (check one) ` ❑ State Owned o v ty Nearest Rojo llage ❑ Public 1 or 2 Family Dwelling - No. of bedrooms Town OF III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. [n New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 110 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 J(Seepage Trench 7, 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: %<nde-S i ~~,~,9'c~~ 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. SysfX Kiev. 7. Final Grade Required (q. ft.) Proposed (sq. ft. (Gals/day/sq. ft.) (Min./inch) Elevation ~ - _ /Id p oz , 7 p.r r! Feet Feet VII. TANK Capacity Site M gallons Total, # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper INFORMATION New Existi Gallons Tanks Concrete strutted glass App. n Tanks Tanks J El 1:1 ❑ ❑ 0 ❑ Septic Tank or Holding Tank Lift Pump Tank /Siphon Chamber ❑ ❑ I El 1- 1:1 E] 11 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility or i st Ion o t e onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plum s n"a r ps) ftAP/MPRSW NO.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Slgnat (No Stamps) Surcharge Fee) Approved Owner Given initial 1 t!r Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or exisJng 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 t)refix (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 8 112 x 11 inches must be submitted to the cour;ty. 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 s`akes'- pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of 'he 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 B~lkig g.o water contamination inve~tigat ons and establishment of standards. Job Number Name Date CAVE Y PLUMAUMV jaMM6 pork oSW ftftlbor Rod 54023 ~'~N~~' pie 749-365fs 7i{EwcM~s, i 'rX 4 r r ~ 49 e 4 = /oo•o TO/ f T = /l zoo ~p c= c,E v a~ - p~, o i G WAO ~'K ld ark -1, -acs i i I i Dave Fogerty Plumbing 4 SEWER SYSTEMS & PERK TESTING FOGERTY HEIGHTS ROAD ROBERTS, WISCO SIN 54023 (715) 749-3656 uc: ± - t,r rye - //;/4*v, p5, 0, /770 Tye r t~ 99, y 2 /C /J. s/oP~ , T .t Safety and Buildings Division 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 8112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs E] Check if re'vislon f0 evi6u>lap. [cation [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location D j-k 1/4, S T 2 , N, R E (or Property Own is Mailing Address Lot Number Z Block Number "R P y /Z 14_10_14 )I f z City, State Zip Code Phone Number Subdivision Name or ber m O.2 c y6) q_VXS II. TYPE F BUILDING: (check one) E] State Owned ❑ Nearest Roaslr ❑ VII age Public 1 or 2 Family Dwelling - No. of bedrooms Town OF jW#* AO c III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment / Condo O o 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 erchandise: 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 1V. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. 0 New 2. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an -----System ________System_____________TankOnly 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 JZ 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 Feet 99. Dv 9-A o Feet VII. TANK Capacity site in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION Gallons Tanks Concrete glass App. New Existin structed Tanks Tanks Septic Tank or Holding Tank ae)t* ❑ ❑ El 11 Lift Pump Tank /Siphon Chamber VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation oft onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Sta s) /MPRSW No.: Business Phone Number: r v Plumber's Ad ress (Street, City, State, Z Code): O .`L3 IX. C UNTY / D PARTMENT SE ONLY ❑ Disapproved Sanj 4ry Permit Fee (Includes Groundwater ate Issue Issuing Agent Signat (No Staraps) Approved (fir J10 Surcharge Fee) ❑ Owner Given Initial6 Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05194) - DISTRIBUTION: Original to County, One copy To: Safety a Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained- The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I_ 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. Vtl. 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 8 112 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 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 Q- all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act.410 included the creation of surcharges (fees) fora number of regulated practices which Eah effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards, j~c/r~ y PlJ?G L PE )c T Etrz►ve y},,c 3mk /~o, pogltfz'Tlj ►,ir ~~1e23 2Y9-34 -ev i { i N qY3 W6Sf ~~~PEJ~TUE. ~tJo wEU- -/oilll~rv~ ~JeO»~ FARM /f-re, A c T ~ O f~ y *r s- X ~ /2x 72 ~ #3 X C/V ~RNr}r ) ~M~t 3 s~ 3 l~LF / '"=30 Ll = QM~ 2" (~S.ti1 GfFF~CJZ7 Trot, Tot' oP ~urirL~ .aSS ~M F lma~a ~ pN FENL E ~NF_ . k = % o,er~vG Iv = /oT c oKAAE )Z 0 ^ lIzvo ~iqc S.T. EcEd 9y y ~vF f ~ OF 3 MXCAS SC*LE / =moo A~'cvjwF 1W.o'~ o,v GrN~ F,E'IvcF. go 9--vg yeo~ss,~ ~rTE CoQ~E,2 ~,~s7riirF r7~' X 177, X 3J' ~t 3 ~ i¢CT6/CN~TI= DANE 6OQEM PLLgMNQ Uc ensed Perk Tester 6 Plumber 03233 WV,ts Road 340 Phone 749-3636 L< ~o«w 0 i 4 vN= -1 a 1 00 0i1Zc sq- ti v N or Wsgonsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of Labor and Human Relations Division'of safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but ARCEf.d not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or J c=~ dimensioned, north arrow, and location and distance to nearest road. " REVIEWED 8Y:; 'i TE APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION G ; PROPERTY LOCATION PROPERTY OWNER: ~ . GOVT. LOT SG~J 1/4 %t/4,S- ~T ' ;•.N, E (o& It ; PROPERTY WNER':S MAILING ADDRESS LOT # LOCK # SUBD. , 9[~.CSM # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE F]TOWN EARES AD z 3 ( ) 8'- o S z'' 1gvE. [ j New Construction Use[/] Residential/ Number of bedrooms Addition to existing building j I Replacement [ I Public or commercial describe Code derived daily flow jkO gpd Recommended design loading rate 7 bed, gpd/ft2 . y trench, gpd/ft2 Absorption area required fSY bed, ft2 7-5-V_ trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design I site considerations 3 ' ce ©N rt~r2- LGSZy~ - EC1~ iow Parent material 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 s stem jd So U El S m U ®S ❑ U El S ❑ U ❑ S IZ U ❑ S O U SOIL DESCRIPTION REPORT Boring # Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft f2- in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends • Ground -Z sc AAA 4A 94A 2F elev. 8 '?0T ft. j - - S Depth to 7-51 ? limiting _ _ . 7 8 factor j 7- p v_ 7Ae 4A Remarks:. 91K 70 6:R 4 d 3 G Boring # ~ z GG ~ . °S w: 2 - c Sffit AO FR c5 z ttn/ .3 C_ M VYSZ Ground elev. Depth limiting factor Remarks: 3 ri D ~o 6: C CST Name:-Please Print Phone: 740=1,404 Address. : 20 Wl S Signature: Date: CST Number: o 2 3 PROPERTYOWNER_ G•OL,f/ SOIL DESCRIPTION REPORT Page ?_ot"3 y PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bou rd3y Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench NK ; • p_a _3 ~L z es .s Ground Z (p _ p /0 VIZ .5 C 3M elev. - 3 S ..2 .3 7- ft. 0 S ?•.S- G f14 v - . D. o Depth to /0 ZZ limiting -S S fit L factor Remarks: 03 4%:j~ 3o7u g Boring # l d-~ 3 2 c L s v Ground SG © 5 6- /Yl L S . O . p elev. ft. 3 -90 0- S o sG L - Depth to limiting factor Remarks: 2 -510 e-- L • ro r E Boring # 15- Z0_ L 24A SA& Ground Z _ - S C L S . O . O elev. ~p ft. 3 3 - .S O L - - ? Depth to limiting factor Remarks: 1 3 Cm Boring # Ground elev. ft Licensed Test r 6 Plumber Fo Heigh S Road Depth to ROBE , WISCO IN 5402 749- limiting one factor / a / Remarks: SBD-8330(8.05/92) 7~ L f ~ OF 3 XCAGS Sc~GE / ~ xo ~ ~ _ ~ r ~~c RTn/ TRH., o~ N~ ~SStfafE 1W,OO,a 4Z'Nf fEJvcE. ~i~0 ~f Y3' = 4p-r eoRAPEA T,pw~D, P,?opnfEp s;tT,E -vf,*Ee ?,W&I-F r X ~~exwl*Ry 14 ~ 3!' X dt 1 At MANATE If ' X40 #V X - 3g DAVE FOGGY PLUMNG Uc ensed Perk Tester 6 Pkm'd r #3233 t:R!:0 R08EW, WHM NISI Phone 749-365~~ ~OLE•1'v s' d'~ ~o6S vys~nnsin Department of Industry. SOIL AND SITE EVALUATION REPORT Page of Libor and Human Relations Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY ' . _ ' Attach complete site plan on paper not less than B 1/2 x 11 inches in size. Plan must include, but ' - not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL 1D.* dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY ii14TE PROPERTY OWNER: PROPERTY LOCATION GOVT. LOT .5W 1/4 1/4,S . ; t• . N,R. E (orev PROPERTY WNER':S MAILING ADDRESS LOT # BLOCK # SUBD~-NAIyIE OA CSM # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ❑I OWN NEARESTRAD (/I New Construction Use [ A Residential /Number of bedrooms _ ( ] Addition to existing building Replacement [ I Public or commercial describe Code derived daily flow j OW gpd Recommended design loading rate ~ 7 ed, gpd/ft2 . Y trench, gpd/ft2 Absorption area required bed, ft2 7S trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations 3' Ctrl ew ti /fwXS 122 - ,razw 70- W' Q'P5 fq,TLLTop Parent material Flood plain elevation, if applicable It E S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK ❑ S ❑ U O S U U= Unsuitable fors stem 0S ❑ U ❑ S ❑ U OS ❑ U ❑ S OU7' SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench Ground Z Z 7 - SC S V S 2F .2 .3 elev. 4~ ft. ,3 L s ~ s 7 .8 Depth is 7-S2 0 - 71~1 -5 G limiting - • ] g factor > o o _ ZZ!K Remarks: 7 6;e Clop 3 GC ley Boring # z 3 s c s z- Ground elev. q _gy _ 7 S 04Sr- M - • f! Depth to limiting factor Remarks: 3 v-' X70 C CST Name:-Please Print Phone .A46/rrpl) e. RF EJf ry - y~-36 S6 Address: '2 E Wl S Signature: / Dare CST Number. PROPERTYOWNER G• ~pL~,f/ SOIL DESCRIPTION REPORT Page z of. ? PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh.Y Roots Bed rerxh 'M VEY= -Y pY~``-~ O- o - 3 ~L z cs S elev. . ou nd Z !o - o - >,M ltfF:,Z S .2 3 ft. .O Depth to limiting •S S /yr L factor o S Remarks: 1 3070 6,-el, # I'lan "RGround 72 5 c © M L S . O , p elev. 3 2 -9o D s o sG - • ? Depth to limiting factor Remarks: r r ~i4 E Boring # O - 3 1- SC 2 4d I/ 3M Q1.8' Ground Z _ O- S C s L S O O elev. 3 3 _ S lp~ ft. O ~ L - - 7 . ~ Depth to - limiting factor Remarks: 1 b`G 3 CO Boring # 0e,0 -,4J 2- 1;ivj-1Z- :gAA Ground elev. Licensed erk Test r & Plumber q5.Z ft. 89 Fo Heigh s Road Depth to ROSE t~ , WISCO IN 5402 -104 limiting one factor Remarks: l~vE f ~ OF 3 XCAG5 SSA-LE' / =xo ' 1J C'A,CRfi~ TRRF, 0 O,c iV ~3S~atF ~cx~.v'~ oV Lr,,vZ FEIvcrE. X 6'0 ,Y„tJ~1 ~ ?11 rg yy3 • = DoT CORwIFA cfiw~ .~~v = 9y. y ' FED fdu. e 13eiva7m N ~F- S.tTrE i7 X P,~~,~Ry 177, n dt 1 40 ~ y K 1 DAVE FOGERTY 6PLUMBING aA -7// 7 UCensed P er & Plumber 3S- _ 63~ I ~Foo9~e_~Ry gttl Ro ad R08ERTS. Wl lN 540 Phone 749-3656 ~i~' y ~0«w STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNEIL MAILING ADDRESS PROPERTY ADDRESS G 7 60 (location of septic system) lease obtain om the Planning Dept. CITY/STATE - 12.4,r>1- PROPERTY LOCATION -C&cj 1/4, 1/4, Section T_24_t_N-R_/j0_W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP VOLUME A__, PAGE O c , 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 Fee year ex ' tion dat . DATE: -qL<4 19 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. Owner of property PO L A',V Location of property_j0;&2_1/4_SE 1/4, Section Te_~N-R_Zj5E_W Township F_Aj Mailing address fly" ,420, 1~-Zg4e Address of site a7 1 vGr- /?odxr cuT . /D Subdivision name - - Lot no. 2 Other homes on property? Yes ✓ No Previous owner of property Total size of property 44 4 Total size of parcel 14 7 "/Zw Date parcel was created jael Are all corners and lot lines identifiable? L,- Yes No Is this property being developed for (spec house)? Yes t,,INo Volume 14-r-7 and Page Number /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 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) know-ledge 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. ~~8 29 3 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. .~'3g393 0 Sig ature of Applicant Co-Applicant 6 53823. ~ ~ CERTIFIED SURVEY MAP LOCATED IN THE SW 1/4 OF THE SE 1/4 AND IN THE SE 1/4 OF THE SE 1/4 OF SEdTION 19, T29N, R18W, TOWN OF WARREN, ST. CROIX CO., WI. NOTE; BEARINGS ARE PREPARED FOR FLORENCE POLEN REFERENCED TO THE SOUTH LINE OF THE SE 114. z (RECORD BEARING). UNPLATTED LANDS I APPROX. EAST LINE OF THE O SOT SW-SE EVE, s a0°o~ zo E % w x.03, /9 w 339, p3, \ o s 80°07 2O E w 62. cn 30 I 3 7. I FENCE X M ® \ X .N I 15' M tn; Z HOUSE IN S 07034'59'W o F 269.77' z n LOT 2 p; 7.67 ACRES S SHEq I GARAG ( 333, 943 SO. FT.) o IIL~~~ F- . 7.41 AC. EXC. R/W Q' : (322,754 SO. FT.) A a: cn Z. O W BARN • N o: LOT 3 co : 6.23 ACRES I to Q: (271,328 SO. FT. ) . 3 .J. 5.97 AC. EXC. R/W (260,014 SO. FT.) I N O W O Z: FENCE X I X 701.20' 27 ;16 334.00' 00' 282. 4I' 1304. 79' S89°44 10"E L 1~ -X-N 89°44' 10"W 616.41'_X_X_X3O_ N89 44'100W S 114 CORNER OF SEC. SOUTH LINE OF THE SE 114 FENCE SE CORNER OF SEC. 19. 19. (COUNTY MONUMENT (COUNTY MONUMENT FOUND). UNPLATTED LANDS FOUND). NOTE: THIS MAP IS A SUBDIVISION OF LOT I OF THE C.S.M. REC. IN VOL. 7, PAGE 2063. :1RR:~\Tti" DEED W, r DO.~JNIENT NO Florence Polen, a/k/a Florence K. JAN 1 0 1996 Polen, individually and as the 9:15 A. surviving joint tenant of Nelson Polen, a/k/a Nelson V. Polen con+ec: and Isarrants to Gary P. Polen and Rhonda M. Polen, husband and wife as survivors',--.in marital prooerty- AIA i{y, n f1 .iF is Hunh It. twin, Attornev at Law C:WTN LAW PERM, S.C. St. Croix 430 Second Street the (ollo,+,.:g describe real estate in Count. Stale of Wisconsin: P.O. BOX 106 Hudson, WI 54016 Part of 042-1053-40 A parcel of land in the SW 1/4 of the SE 1/4 ,Parcel l,lent,t,,;,t,t,n Nurtherl of Section 19, Township 29 North, nanne 18 West, in the Town of Warren, described as follows: Lot 2 of a Cert~f'.ed Survev Map dited November 7, 1995 and recorded January 5, 1996 in Volume 11 of Certified Survev Maps, at Page 3041, as Document Number 533231, in the office of the Reaister of Deeds for St. Croix Countv, Wisconsin. x TRA J§EER 4 This ia_homotead propert%. i (is not) Exception to µarranties: TOGETHER WITH AND SUBJECT TO any other easements, covenants, reservations or restrictions of record, if anv, but this shall not be deemed to extend any such other recorded encumbrances beyond the term established by law therfor. 9th Jay-'f Januarv I9 96. Dated this (SEAtt z, L4 I:' r (SF \L) • Florence Polen ` t ' (SEAL) ISF.,\L1 AUTHENTICATION ACKNOWLEDGMENT Signature(s) Florence- Polen, a/k/a STATE OF WISCONSIN r _ r ~ t day of - ^ anuary .19 96 Per.unallc came hc(orc me this ,Ic+~ al Flo4MAMBER aulhethis -is -.K -Po en-- - - - - Count%. 19 the those named . Gwin - - TITLSTATE BAR OF WISCONSIN N/A- - (if not. - - aulhorited by §706.06. Wis Stats.) to me kno+,n to be the person ,sho executed the E....•n„m,. ~-trument and 3:k110+0:19e the game.