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AS BUILT SANITARY SYSTEM REPORT
OWNER ,~,v~ L ►n
3
ADDRESS
,PnLv)-s IX)is
SUBDIVISION / CSM Una /p LOT Z
SECTION
_T 21 N-RW, Town of 1, 141yy'°n
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
l ~,r
•
u~`
e
I
PIK 1)
77
~O-
~fA o4
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK' ~r`O'n ( TO
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: G~cc~S Liquid Capacity: ldvo
Setback from: Well 115 House other
Pump: Manufacturer /Z/ /I Model # Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: S Length S7 Number of trenches
Distance & Direction to nearest prop, line: ?i'
Setback from: well: ILD House Other
ELEVATIONS
Building Sewer ST Inlet. ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: /U~ 3l -r6
PLUMBER ON JOB:
LICENSE NUMBER: '611'f5
INSPECTOR: 1j,
3 / 9 3 : j t
Wistor`isin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
262358
Permit Holder's Name: ❑ City ❑ Village [A Town of: State Plan ID No.:
WARREN
CST BM Elev.: BM Description: Parcel Tax No.:
/0. C~ 17Z- 611 a /'--tv,-¢ /DY. A9600168
TANK INFORMATION ELEVATION DATA 2013 1
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 5 lC) Benchmark'.
Dosing - 1c) eb Pi
Aeration Bldg. Sewer
Holding St/}Wt Inlet
9 6,
TANKS TBACK INFORMATION St/ t Outlet ' 17
Vent
TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet
Septic LS / 72S ,;4V NA Dt Bottom
Dosing NA Header / Man. ~
33 Aeration NA Dist. Pipe
Holdin Bot. System ~Z
PUMP/ SIPHON INFORMATION Final Grade
0.4k,6 p E 104, 91- 7'
Manufacturer Demand
E&, Af ;2
Model Number GPM &,,Y
6.
oss
s Mead Ft ~r -3i
TDH Li Los
Force ain Length Dia. H Dist.Towell
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS S DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEAC~MBER cturer:
SETBACK
INFORMATION Type Of 7a,-, Mode Number:
System: "'5a ~j~ / T OR UNIT
DISTRIBUTION SYSTEM
Header / 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 Syste
Depth Over Depth Over xx Depth Of Seeded / Sodded xx Mulched
Bed /Trench Center Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: WARREN.20. 9.18W, NEO, Soo,-110TH S
/ ' ~ "C . ESC" +r~'" .C~,%i~ 5. G~.~ G~~✓12t; ~f .'l~~•
Plan revision required? ❑ Yes to j /
Use other side for additional information. L/0
SBD-6710 (R 05/91) Date Inspector's Siqn ure Cert No
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau Building Water System:
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less Coun `
than 8 112 x 11 inches in size. /
• See reverse side for instructions for completing this application State aniRtarryyQPermit Number
The information you provide may be used by other government agency programs ❑ Check it reisiog P-15ou Iicarion
lPrivacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFOR ATION
Prope Owne Name _ Property Location
1 /4 5~e 1/4, S T Z,f , N, R J r (orQ
Propert Owner's Mailing Address Lot Number Block Num
o
City, ate Zip Code Phone Number Subdivision Name or CSM Number
Ot? ( > C3.01 ✓a1 !b If' 1
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ ltly Nearest Road
❑ Public 1 or 2 Family Dwelling - No. of bedrooms 3 ~ rowan OF l,_rre-,ft_ ~1os~
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo Z - 0 57 ^ 7 V
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. p'New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only ______________Existing System Existing --ystem
_
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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12gSeepage 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
v l a4 7a 7 ~5 Feet 140,!%0 Feet
VII. TANK Capacity Total # Of Prefab. Site
App
INFORMATION in g Gallons Tanks Manufacturer's Name Concrete Con- Steel Fiberglass- Plastic Exper.
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank -9 ❑ ❑ ❑ ❑ ❑
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-
Plum ' rs Name: (Print) Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
772
I^,,.: I S..1941
9941 Plumber' Address (Street, City, State, Zip Code):
a'-t3 t~"~ t~'
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved XS itary Permit Fee (Includes Groundwater ate Issued Issuin Agent Signa re (No Stamps)
Approved ❑ Owner Given Initial /P
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to Counly, One copy To: Safety & Buildings Division, 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 systern, 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 Dvvelling.
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, re<:onne<tion, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information Provide all information requested for numbers I through 7.
VII. Tank information. Fill in the capacity of every new/or existing tank, list the tota' gallons, ')i,,rnti. r of tanks and
manufacturer's name, indicate prefab or site constructed and tank material C,, - ple'e Ofl ptic, rump/siphon and
holding tanks for this system. Check experimental approval only if tanks receivec experro ,prod,.ict approval from
DILHR
VIII. Responsibility statement. Installing plumber is to fill in name, license number w, 1) apprw),- a:F Urefi;, (e.g. MP, etc.),
address and Phone number. Plumber must sign application form.
IX. County/ Deparunent Use Only
X. County / Department Use Only.
_ R >
r-;lle, _ _ ,tic, ticatis r .-:a th,ar: L .1:. x ;ty he plans must
,;;lot J;an _cale or v1,th cc - iclin; t;~nk(w), septic
s, 4 rv pump, or'lip`- n
s o p r t ;ilding se ved:;
~lt r:
nforrn
GROUNDWATER SURCHARGE
'1983 ~s.: > ?sin Act_ 4101 in:~luded the creation of surcharges (lees) t-)r a number of reC),laced pr it, which can
effect groundw,ater_
Th _ car es c0 i, i_hese ~ urc'r_arges a~e used for monitoring ;raund~~r~~. ~ inve~-_iDations
and estab' ~,n st~r1-ard~_
r JOB /l Q K G / {l Cl GC
TIMM EXCAVATING SHEET NO. of Z
Route 1 Box 192 T /
WILSON, WISCONSIN 54027 CALCULATED BY DATE
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 205-1 Inc, Groton, Mass. 01471, To Order PHONE TOLL FREE 1-8*225-M
` TIMM EXCAVATING SHEET NO. Z of -
Route 1 Box 192
WILSON, WISCONSIN 54027 CALCULATED By DATE
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
SCALE
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PRODUCT 205-1 Inc, Groton, Mass.01471. To Order PHONE TOLL FREE I-8W225-6380
,4OVEA.1Pv. j To oiei &1V,+1 TES 7- or- <0 '/1- yy DC~J-v-w~st//cam ~iy,~yL 7,9,0, 'S .
Wisconsin Department of Industry, SOIL AND SITE EVALUATION
Labor and Human Relations 12 Page of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. 0~
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must C11,r,*,',,' i'~
&MX '~~A
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. s t
"1;1. D. } '
Pli~
APPLICANT INFORMATION - Please print all Information. R . by Date
Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Mlh`(t.; G'FFIC:E
i
Property Owner ,a v yeR Property Location •
~',E 4NAI+ AAJ_ leeSVr G iiVD,q h/G. Govt. Lot iVF, 1/4 S ~ 4~ N,R E (org)
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
6/5 lrkj=_ C v ST • 1_
City State Zip Code Phone Number , ~ Nearest Road
/jvpSo-~ W/. 5y ol/a (7/5 ) 391- ///y/ ❑ City Village L~ Town / O 6 -
Ua New Construction Use: 911 esidential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
r 'VIR x Nor
/Q bed, gpd/ft2 • 7 trench, gpd/ft2
Code derived daily flow y7 gpd R5,(0A AjevP,-_ Aecommended design loading rate Al
Absorption area required _bed, ft2 j ' trench, ft2 Maximum design loading rate bed, gpd/fi • IF trench, gpd/ft2
Recommended infiltration surface elevation(s) SLOE 4 3 It (as referred to site plan benchmark)
Additional design/site conside tions *&SE GO.✓G wz D/ P4 -"a le*)e P/,5
Parent material 13 0,418,e4 ~7s dUTI.Ilff Flood plain elevation, if applicable N~ ft
S = Suitable for system Conventional Mound In-Ground Pressure SAT-Grade System in Fill Holding Tank
U = Unsuitable for system 9 ❑ U ~'br El U U 2-S El I 1 [~'Sl ❑ U El S 14
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
Cp / a -/o lo ,e 2./2- S./ 2 f sbk Im f R 5 ~f . s .
2- 1104f I /OYX -1/;I-
Ground If, il /o 5!; al,511 G i -7
elev.
-41-110 5 S 7: 69
/oo •~ft.
Depth to
limiting
factor
In.
Remarks:
Boring # / k Z/Z 511 24 5hk' ,w -fR 9,5 /,ve • 57
'
~Fl
3 33-90 0 5 . 5• O S 7
Ground
elev.
160. LKIJ
Depth to
limiting
fa for
7 4?In. Remarks:
CST Name (Please Print) Signature Telephone No.
IRo Q ewr Z4 I c 61- 7/S 3 - b04 ~,5-
Address Date CST Number
~G•~!!T G~NJ~/~i~I/ SOIL DESCRIPTION REPORT ? ` .3
PROPERTY OWNER Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Structure 2
Texture ConsikBoundary
Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench
S./ 2-F 56,E i ,-F/,- . S ; .a
2- 2
Ground • O
elev.
Depth to
limiting
factor
' fin.
Remarks:
Boring #
Ground
elev.
ft
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 # ;
Ground
elev.
n.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to `
Yp
limiting
factor
in. Remarks:
SBDW-8330 (R. 08/95)
I
• N
~ ~ nm
N
14
9 ~ ~ m
rn .
2 YO 0 H
m
i ~ o N
II r / r
' VVIeconsin Industry,
and Fluman Relations SOIL AND SITE EVALUATION REPORT
labor P 3
age _ Of
DWilion of Safety & Buildings in accOt th ILHR 83.05, Wis. Adm. Code
- COUNTY
1~, ST c,P~/'X
Attach complete site plan on paper not less x 11 i e. Plan must include, but
not limited to vertical and horizontal refer int (BM), ection d of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location tango n t Dad. r'
APPLICANT INFORMATION-PIE PRINT A REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
I)gRyt.
GOVT. LOT kE 1/4 SE 1/4.S20 T N,R [ E (a) W
PROPERTY OWNER':S MAILING ADDRESS i
(l 2 f!o O 'f L•. h V E LOT # BLOCK # SUBD. NAME OR CSM #
2- C- SM 0CVj0 /.V 6-
CITY, STATE ZIP CODE 0 []CITY []VILLAGE FAFOWN NEAREST OAD
Rot3EQrs W I. 5yai3 ( SG2. AR^OEw //O sr,
[ New Construction Use [ Or Residential / Number of bedrooms 3 1 v [ [ Addition to exissdng building
j I Replacement [ I Public or commercial describe
Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpolft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate • _1 bed. gpd/ft2 • S trench, gpd/ft2
Recommended infiltration surface elevation(s) 5-~- 0 . 3 ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material sG5 $9 - 13,vR&,4.4. °OT _ 6-1,4c.,iF1 Flood plain elevation, if applicable N It
OU7' Allot SYSTElit IN FILL S = Suitable for system [Ers rr11 U Mouya U IN= G~pHN[]D U ESSURE nT c~F►oE[] U 21- U p S~L~'tT
U =Unsuitable for system S ❑ U GK'S L•J$
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft
Texture Consistence Botnctary Roots Bed rer>~
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
f O- /o rR 2-12. o, A L T 7iA- m%T R 35 z f . S
Z -Lo /o yie 31- 5/ /f' 56,E /W f p cs
y •S
Ground j 7•5 Y k 311s /41 ,e We e S , • 7
elev. .PAve//
ut• • y 75 YX y 6s
l 5/7
Depth to /
9
factor
Remarks:
Boring #
f o /o yie 21-2- /oAM z cs if s . G
rum lo yle /7C X
Ground 3 7. S %2 31S /.t~► d f? es -2
elev. y 3 S"i 7 S y `I/ - 9~9v~i d S e S • 7
- Zzft
Depth to
limiting
factor ,
Remarks:
CST Name: Please Print P. 0 (3 E R r ?A L(3 k; C ITT' Phone: 3 J06 _
Address: 5S O'Aje ( DP. 1+VPS oa W I. 5~011o
CS r1tv -X yFZ.
PROPERTY OWNER O~~y/ v Nis SOIL DESCRIPTION REPORT Page Z of
-
PARCEL I.D. # /-D T --:Fr 2-
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell (lu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Y Roots
Bed Trench
3 I o -i /o R 2/2_ 10,4,,j Z -FSJe~fe cs z-F 5
Z /y 2 .1 / yk 31y S./ z t She M, f R cs ! S G
Ground 7 - Y 7'S yt? 31s CS • -7 o0
elev.
Depth to
limiting
factor
i
Remarks:
Boring # Y/2 10,4,y L -F S6k 441 7' ie CS . $
z 11-17 /o y) 3,y
3 117-2-7 /o Y e V s/ 17' SAf M, fie CS . ~ . S
Ground
elev. -96 y
Depth to
limiting
factor
Remarks:
Boring #
o-iZ /o yre 2/Z X401
a s Zf N
Z7 7syie31/s df cs , _,6.
Ground 140
elev. fl 7 - S yiP y s. a, s -
A0 y s/ C S D, ~.e - - ?
Depth to
limiting
i factor
72-
Remarks:
Boring #
Ell
Ground
elev.
ft.
Depth to
fimiting
factor
tit.~ar,c.
39 .0 86'
rs
a,
13M
-rol o~ S vA've yoR's
l " X ~4- r ,vE
L o T 6,04N eg .
gyp' ~/3s
d ~ X33
S U 6r6 E ST Eta s y s T c~
t~uhT~'o~S ~~o , O
T # Z o
so • c, b r- 3 5-1, yi
6
CERTIFIED SURVEY MAP
R is W, 7cwr, O' Wsrran, St. Croix County, Wisconsin. -
h
UNPLArrED LANDS q
O Indicates 1" x 24" iron pipe weighing o 13
N 89 /4' 46"E 38-9.00, CO
1.13 lbs./lin. ft. set.
O
O ~ ~ 1 I i 2
CA
o L'a ` r q
Owner's Address: ~I N L O T Z
1126 80TH AVE. y W 2.232 ACRES o I N
Roberts, WI 54023 QI OI o 97,242 so. Fr. , h W
Z o
J 2.01 9 ACRES EXC. ROAD N
QI , N N ,
2 J ~ _ R. O.tW.:.
00 87,951 S0. FTI I I I O o
2 • so, t r.
3.5 51. 4J.' I 37.3 j O j
O
N 89_' /4' 46 "E 3189.00': W
P~1% ° h W
o
O ~ y~ N 89. 14 46 "E 389. 0 b b H
399 _ _ . _ _ -351. 19' 1 7.8 o Q
P A I~ 2
A -
3
5 LOT-3
I -WON N h QI
S 85 • 06' 134. 41• I ti q I 1u 4)
O 2. 873 ACRES O ~
N /Z5, 247 So. Fr. I • N m N !u
\ N \ "1 m O ~ I
` N M 2.59Z ACRES EXC. ROAD O 3
M R.O. W. I O j Q
M //z. 900 so. Fr. o I Q J
DI o ~ „ I 2 o O Z
I I 2 2
Q q LOT 5' N89 14'46"E 389.00' I O
M O
O 330.10' V 8.9
W 5.354 ACRES Q
•
53, 531
I O Z53,212 SO. FT. O
W D 5. 236 ACRES EXC. TOWN ROAD Q L O T 4 i Q 2
LU O R.0 W. AND JOINT DRIVEWAY y I v ~j MI
~I EASEMENT 2 2.244 ACRES O ~1I I
O I
228, 083 S0. FT, rt 97, 733 SO. Fr. ~j
Q O 2.0,'7 ACRES EXC. ROAO R.O.W. N
JI 2 87, 872 S0. Fr. I
Z 389.00' I`r' O
,I 443.00' 349.23' i 9.7
S 89 14 46 "W 832.00'
O
i q UNPLA TIED LANDS h
~ N Q' W
ti y
h ~ s `O 2
Q N p SE 6OR. SEC. 20, 7'29 N, R18 W,
J
/COUN rY SURVEYOR'S MON_ i
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER t LrL
MAILING ADDRESS .C5 ~ryC t,Jc~~ Lti!
PROPERTY ADDRESS
(location of septic system) Please obtain from the Planning Dept.
l c tz , U/LP
CITY/STATE '41&50^1
PROPERTY LOCATION N le_- 1/4, S ~ 1/4, Section :R0 T .2? N-R A3 W
TOWN OF PCA,~ :s ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP , VOLUMEr~, PAGE X87 , LOT NUMBER 2
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 tnis 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: Z/ -96
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 YSV7- t t~~W,4 Z='V614H4-.
Location of property &C- 1/41/4 , Section ;,)0 , T N-R__Lk_W
Township 60eqgjLEi✓ Mailing address fS~S /~i✓EwOa
i4/aJs0,✓ ".Z"- -5110/!a
Address of site 6,2 /p ST;
Subdivision name CS Yk- A) a,5 7v Lot no.
Other homes on property? /601 -Yes___>C No
Previous owner of property A"wZyr.- - A4&'r -Ta'V- =5
Total size of property gM= _-2, 023
Total size of parcel
Date parcel was created 4mm1-- 'Zpa
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? Yes --.,g -No
Volume and Page Number
c7mvpqpy as recorded with the Register
of Deeds]/91 41~
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. 5*yy o , 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.
Ala~
Signature of Applicant Co-Applicant
7 44P
Date of Signature Date of Signature
`'rrr/
FILED
JAN 2 5 1995 ►
KATHLEEN H. WALSH
52542 Rt. Croix O., W1 iQ
ti St. Croix Co., WI
II
CERTIFIED SURVEY MAP
DARYL JONES'-dtal.
Part of the SE 1/4 of the SE 1/4. and the NE 1/4 of the SE 1/4 of Section 20, T 29 N,
R 18 W, Town of Warren,'"St: Croix County, Wisconsin. N
h
UNPLATTED LANDS a
O Indicates 1" x 24.11 iron pipe weighing o 3
N 89 • /4' 46 "E 389. 00 ' ~ ~b
1.13 15s./lin.*ft. set.
I 6.7
~ 332.26 ' 2
h I ~ N h
Owner's Address: WI N LOT 2 O
1126 80TH AVE. y W 2.232 ACRES I O I O N
I
Roberts, WI 54023 QI Z o 97, 242 So. FT. 1 N
J . 2.019 ACRES EXC. ROAD I N 1j ;
I
J R.O. W. I f, y
2 00 87, 93/ SO. FT. i I I al OJ v
2 33/. 4/' 1 373 j a j
P~~ N 89 • /4' 46 "E 3189.'00'i O O 4i `
I e
tt L/ 61 N 89• l4' 46 "E 389. O `O 'o O
399 3 3 1. / 9' 1 7.8 Q Q
P/ ~ I h I ~ Z
P~ A I M
~ ~1 / a m z Q
3 I . W v
~'S LOT 3 1 m• I "
aR ~ WO M N h OI
h, OI Q
S 85 • 06' /6" O 2. 873 ACRES I N g N W W LU
E /34. 4/'
N /23, 247 S0. Fr. I 0
N ` M 0 O
N M 2.592 ACRES EXC. ROAO O O QI
R.O. W. I O 00 I
M //2, 900 SO. FT. I O 4i
O I 2 0
e h o Q 2
OI o
Z L Q T 5 N 8 9• /4' 46 "E 389.00' I I a
JIM 00 330. /O' b B.9 O
W 3.354 ACRES O I~ m ~33, 33
O 0 233, 2/2 SO. FT. O 1 y W 6 6'~
4JI 5. 236 ACRES EXC. TOWN ROAD 00 O T •Q I OQ J M
O R.O.W. ANO JOINT DRIVEWAY N
O 2 M 2.244 ACRES i M M ( I~i~ 2
~I O EASEMENT 97,733 SO. FT. I h v
O 228, 083 SO. FT, h
Q N 2.0/7 ACRES EXC. ROAD R.O.W.N N
J 87, 872 SO. FT.
~ I o
389.00' I~_~ ~9.7 ,
Zt
J 443.00' 349.23' 1 I )
S 89 1 4' 4 6" W 832. 00' p
W a UNPLA TTED LANDS h
q q W _.ii'4•e
? N N v 4
o iu b 2
Q N SE COR. SEC. 20, T29N, R/8 W,
J f ,EI ! 1
W V O /COUNTY SURVEYOR'S MON.J :f.•;i..-j
Z y o This instrument drafted by hyi
~ Laurence W. Murphy ~~~~`3`~~SG.~N`S~i~~~j~
0 0 0
.Y ~
t
~~ISCC>\>I~ 1 r?R`.:. -
STATE BAR OF
1~ 'f+D WARRANTY DIED
DOCUMENT NO. ~ 110
'l
Holly Jones h
APR 1 199
"t 10:00
coR.rys .,Rd war ants to Kent T. Lindahl an (1 L1IIIT L t -3 11 , . -,~~t~t
husband and wife. - ;
_-__--_.-.._.._-_._.-_'F.j '.l"-C .:ash -
--EQUITY•TYTLE SERVICES
the following described real estate in St. Croix 400 SOUTH E-ECOND STREET
State of Wisconsin: HUDSON, W154016
~Ai,CEL CC`J F C~Tiv ~~`.'Bca
Part of the SEi/4 SE1/4 and the NE1/4 =E1/4, Sec. 20-T29N-R1'1d
described as follows: Lot 2 of Cert~ i ee Survey Map recorded in
Pge Vol. 10 of Certified Survey Maps.' lbtlCt~er with a 40 foot easement
for ingress and egress over and across tie North 40 feet of Lot 5
of said Certified Survey Map lying adjacent to and directly South
of Lot 2.
T h?'WER
This- is not homestead property.
XX(XX (is not)
Exception to warranties: Easements, restrictions ar:a ri -hts-of-way of record,
if any.
Dated this 28th day of `(arch , A D., 19-_96
.
(SEAL) (SEAL)
-
. Holly A. Jones
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
State of Wisconsin,
Signature(s) >c
St. Croix co~ray
authenticated this day of -19- arne before me this 2Rth day of
;arch 19 96, the alikwe r,anied
'cI1)z A JonEC
TITLE: MEMBER STATE BAR OF WISCONSIN ~
(If riot,
authorized by §706.06, Wis. Stats.l :o :^r be the P,•r n wh., e\ccwcd the f0regoang
lhg6me