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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
Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI
TIMM, DOROTHY X
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/ L WELL BLDG. Airl to ntake ROAD Dt Inlet
Air l
Septic NA Dt Bottom
Dosing NA Header/ Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
ead
Loss I
Forcemain Length Dia. Fi Dist. To wen
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type Of Moe Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/Tr nchCenter Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ady.4.28.15W, NW, SE, State Highway 128
p //1 n
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
L
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water systemi
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 Croix
than 8 112 x 11 inches in size. • • See reverse side for instructions for completing this application State sanitary Permit Number
c' 13-
The information you provide may be used by other government agency programs ❑ Check if revision to prevt us application
►Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name Property Location
W114 E 1/4, S T41 , N, R s E (o W
Pro rty Owner's ailing Address Lot Number Block Number
5 W.
W
,311
City, State Zip Code Phone Number Subdivision Name or CSM Number
S oa ( >
II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road
❑ Village ~~ff
Public 1 or 2 Family Dwelling - No. of bedrooms - Town OF Q4 17
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Num er(s)
d6~-)00
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. ;W Reconnection of 5. ❑ Repair of an
------System --------System Tank OnlyExisting System Existing System
B) 5q A Sanitary Permit was previously issued- Permit Number Date Issued w /
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
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 Feet
VII. TANK Ca
in gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existin structed
Tanks Tanks
Septic Tank or Holding Tank I pufS7 ffggFjr ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume respo_ sibility for ins a ftn of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plu er's Signat (No Sta s) MP/MPRSW No.: Business Phone Number:
lumber's Address (Street, City, Zip
,S AV enmo L 7
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (IncludesGroundwater ate Issue Issuing A nt Si nature Sta ps)
Approved El Owner Given Initial 0/ p~ j~rchargeFee)
Adverse Determination /
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SOD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS r
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 locat 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 8 112 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 F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the_ctQation 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.
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S8~)- 40397
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HOLDING TANK CROSS-SECTION
Approved Weather Proof
Vent Cap Junction Box
/Approved Locking Manhole Cover
11
4 C'I• With Warning Label Attached
Vent Pipe
Minimum 12 And Padlock
✓Final Grade
4" Minimum
✓ Approved Joint '
18" Minimum
4ater Tight i
)eal High Water '
SPECIFICATIONS Alarm Switch
lApproved TANK New XExisting Manu a'cturer: , 7 Joint
w/ C.I. Pipe
91ind C.I. Tank Size:~,1-) Gallons Extending 3'
lug ALARM Manufacturer: Onto Solid Soi:
Model Number:
Switch Type
NUMBER OF BEDROOMS:
GALLONS PER DAY:
3" of Bedding Under Tank
Owner's Name:
Address:
Legal Discr~p oit n: /l,~
Townshi /Munici alit`
County: n~
r
PLUMBER/DESIGNER
Signature:/-
umber,.
License Nate:
D
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:PARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
IIu~RY DIVISION
\BOR JIMAAND PERCOLATION TESTS (115) P.O. eox 7767
JN RELATIONS MADISON, WI 53707
(H63.090) & Chapter 145.045)
)CATION: SECTION: TOWNSHIP/MUNICIP LITY: LOT N ,:BLK. O: SUBDIVISION NAME:
N CE 1/66 /T.99N/R JSE (or)AUNTY: OWN'ER'S/BUYER'S NAM AILIN DR SS: /
E DATES OBSERVATIONS MADE
NO. BE l : COMM EffUA-CDESCR ON: I"Hut-I t: UESCRIPTIO S: PERCOLATION
S'
~esidence -3 / All + ew L~d'Replace y
\TING: S- Site suitable for system U- Site unsuitable for system
DENT NAB: MOUND: IN•GR~OUND- R U ~ M-1N-FILLHOLDINGTANK: RECOMMENDED SYSTEM: (optional)
S 201 S ~ S 25 S 210 U r],J~ U
Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
Eder s.H63.09(5)(b), indicate: A Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
)RING TOTAL DEPTH TO G R UNDWATER-RIC'rtE-S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
)MF3ER DEPTH4AI. ELEVATION OBSERVED EST. H TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
17 E/ S."I I
~.v' R SC 1~'A,c,Cp ~G7 Ho
S 81 i ~D b
9q S~ p s s' s.1
ors Ts. D
: II Sr ` r.
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PERCOLATION TESTS
rEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
JMBER INCHES AFTERSWELLING INTERVAL-MIN, p PER INCH
)T PLANT Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori
tal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
and slope.
YSTEM ELEVATION - - - -
CC
41 le.
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11
11 1• t-
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I N
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the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
iministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief,
M (print): TESTS WER COMP ETTED ON:
le [A ie Q c. 7 0
ESS- CERTIF ATIO NUMBER: PHONE NUMBER (optional):
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STRIBUTION: Original and one copy to Local Authority, Prohcrty Owner and Soil Tester.
L14R•SBD-6395 (R. 02/82) - OVER -
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
t a,
Location of property-N-O1/4 C 1/4, Section T N-R W
Township C y Mailing address 14- cu LJASa w, ~-Zva-17
Address of siteS'3 {f w V /Z? ICJ i, / a-n0, tcJ /k r-
Subdivision name Lot no.
Other homes on property? L-- Yes No
Previous owner of property
Total size of property S3 6- (Z- 2 e S
Total size of parcel S 3
Date parcel was created
Are all corners and lot lines identifiable? k----Yes No
Is this property being developed for (spec house) ? Yes L---No
Volume and Page Number 3 zc) 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. 4-ILI7 7 5_2 , 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.
Z 0 r~ `
Signature of Applicant Co-Applicant
Dat-of tiign ture Date of Signature
Form-STC- 104
AS BUILT SANITARY SYSTEM DEPORT
1
OWNER _ TOWNSHIP SEC. f T _2&N-RZ_~LW
ADDRESS /7 ol ST. C1(01X COUNTY, 141SCONSIN
Lsd
SUBDIVISION LOr LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•LHR 83
SHOW EVERYJ'11t14G WITHIN 100 FEET OF SYSTEM
t
G /
i Z_7
-43
I INDICATE NORTH ARROW
BENCHMARK: Describe the vertic.nl reference rni.nt used
Elevation of vertical reference point: le ~ Proposed slope at site: 1~70_
SEPT,rC TANK: Manufacturer: 1.J-,uJd Capacity:
Number of rings used: Tank mnnhul.e cover elevation:
Tank Inlet Elevation: Tank OuL.l..?. Llevation: •
Number of feet from nearr i 1;-•,id: Front,"'_;;70Rear, O feet
.From nearest pYc.,,,c.i ; ine Frnnt:, 1 1c,,ORear,0 feet
Ntm,her of f~n~- fY~n r.v.l l t... r t t
PUMP/HAMBER
i
Manufacturer: Liquid Capacity:
' Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front. O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL BSORPTION SYSTEM
Bed: Trench:
Width: Length: Number of Lines: Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear, 0 It
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SEE AGE PIT
Size: Number of pits: Diameter: -
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: i Capacity: _ 36
Number of rings used: Elevation of bottom of tank:
Elevation of inlet: Number of feet from nearest property line: Front, Side, O Rear, 0Ft.0
Number of feet from well% 1//G5
/
Number of feet from building: o )4402 Z' 127
Number of feet from nearest road:
Alarm Manufacturer: -J L- Z- C-7 22 1cf)
Inspector:n '"~ZsoJ
Dated'. D l4 O _ Plumber on job: License Number:
/Yl~ ~C 1
3/84:mj
DEPARTMENT OF INDUSTRY. INSPECTION REPORT FOR SAFETY & BUILDING
LABGri & HUMAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON, WI 53707 State Plan I.D Number
NW 4 , SE 4 , Sec . 4 . T28-R15 ❑ CONVENTIONAL ❑ ALTERATIVE lifassigned)
Town 11of Cady ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
OF PEr"If~ OLDER ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Dorothy Timm Rt.l Wilson Wi
BENCH MARK.permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.. CST REF. PT. ELEV.:
Name of Plurnber. MP/MPRSW No.'. County: Sanitary Permit Number.
6219 St. Croix 13 48
-Lyle Meyers
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
_ PR IDED P, 19VIDED:
a vv~D `4 _ CC YES ❑ NO L1J YES F-1 NO
BEDDING VENT DIAL VENT MA L., HIGH WATER NUMBER OF ROAD' PROPERTY WELL: 771LDING: VENT TO FRESH
ALARM: FEET FROM f LINE, AIR I ET:
YES ❑ NO ❑ YES ❑ NO NEAREST U ; ~ f
DOSING CHAMBER:
MANUFACTURER: BEDDING. LIQUID GAPACIll PUMP MODEL: PUMP/SIPHON MANUFACTURER ARVIN OVIDEDG LOOVIDED OVER
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
FRESH
GALLONS PER CYCLE: P AND CONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING: AI INLET
(DIFFERENCE BETWEEN FEET FROM LINE:
PUMP ON AND OFF PUM E] YES ❑ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH METER: MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until AIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO OF DISTR. PIPE SPACIN COVER INSI DIA.. PITS: LIQUID
BED/TRENCH TRENCHES MATERIAL PIT DEPTH
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL O DISTR. NUMBER OF, ROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER. ELEV. INLET: ELEV. END: IPES: FEET FROM LINE: AIR INLET:
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to Check the tex re of he fill materia for 1PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound syste s to m ke certain th t it N REVERSE SIDE. SHOW
❑ YES ❑ NO meets the cri eria for medium sa ELEVATIONS MEASURED.
SOIL COVER TEXTURE PER NENT MARK S: OBSERVATION WELLS,
❑ YES NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TO SOIL: 7'y EEDEDMULCHEDCENTEREDGESS ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH: LENGTH: NO OF LATE L SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO. DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.: ELEV.' DIA. ELEV.. PIPES- DIA.
ELEVATION AND :
DISTRIBUTION HOLE SIZE. HOLE SPACING: DRILLED CORRECTLY. COVER MATERIAL VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL BUILDING:
COMMENTS: FEET FROM LINE
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
Rf;a oe_ m +44e_~cr audit
Sketch System on r I -
Reverse Side SIGNATURE p r nrLE;
SBD-6710 (R. 06/88) Z4
-
$89-40397
rvU, 846PACE,8
Document No. TTl epec. --.d for literal" dal
449788 HOLDING TANK AGREEMENT REGISTERS OFFICE
Agr«m.ntDa , WI
This agreement is made Deh+ean the ST. CROIX CO.
County or Local Governmental Unit IHiding Ta~k(slOwn.rlsl Recd for Record
Cady Township IDorothy Timm
St.Croix County i at j UL1191989
(Called MurwcipaNfy be/owl i
M
We acknowledge that application is being made for the installation of (a) holding ~ w
tank(s) on the following property. (Provide legal lane! description:) a,&-
Thp uF sE of Section 4 ':;2ownshi 28N., • Re9lsfer of Deeds
Hange 15W. north of the Freeway
R.hum To
- - - - - - - - - - - - - - - - - - - - - - - - - - - - -
ur thm continued we of the existing premises requires that a holding tank De installed on the property for the purpose Of proper containment Of
sewage. :Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under
Ch: ILHR 83. Wis. Adm. Code. Or Ch. 145. Slats. .D,~,wf At
' As an Indut7einNtt to the County of S t~ rrn.i x i/aliillK to issue a sanitary permit for the above described property.
we egret to the following:
-1;" Owrtir_igmes to conform to all applicable requirements of Ch. ILHR V. 'His. Adm. Code relating to holding tanks. It the owner fads to have the
`holding tank properly serviced In respor:se to orders issued by the municipality to prevent or abate a nuisance as described in as. 146.13 and
146a4: Slats: tM"municipality may enter upon the property and service the tank or cause to have the tank serviced and'charoe the owner by
placing the'dwgis:On the. tax bill as a special assessment for current services rendered. The charges will M assessed as prescribed by
2.'OwnK agues b paY ail etiirges-and costs incurred by the municipality for inspection. pumping. hauling or otherwise servicing and maintaining
the Holding tank inalich imanner as to prevent or abate any nuisance or health hazard caused by the holding !ank. The municipality shall noy(ly
the OwrN Of any costs-wflleh ttall.be paid by the owner within thirty (30) days from the date of notice. In tha event the owner does not
oosts within thirty(30)'day4, 1!N owner specifically agrees that all of the costa and charges may be placed on the tax roll as aasses
ment.lor.the abatement of nuisance, and the tax shalt be collected as provided by law.
3. The owner, except as provK so by s. 146.20 (30) (d). Slats.. agrees to contract with a person who is :icensed unte Ch. NR 113. Wis. Adm: Coda to x
have the holding tank serviced, and to tile a copy'of in* contract or the owner's registration with the municipality and with the county. The owner
further aquas to file a copy of any changes to the servfcs contract or a copy of a new service contract with the municipality a, d the county within
tan (10) business days from the date of change to the service contract.
4. The owner agrees to contract with a person licensed under Ch. NR 113. Wis. Adm. Coee «rO shall submit to the municipality and to the county a - - "
report In accord with $IL HA 81.18 (4) (a) 2.. Wis. Adm. Code for the servicing on a vtfniannuat oasis. In the case of registration under
a. 146-16'(3) (d). State:; y» owner shall submit the report to the municipality and the coun:f.
5. This agreement will remaln in effect only until the local governmental unit responsible for the regulation of private sewage systems certi!ies that
the propertyb served by either a municipal sewer or a soil absorption system that comblie i with Ch. ILHR 83. Wis. Adm. Code. in addition.:n,s
agreement may be cancelled by executing and recording said certification w,th reference tD this agreement in such manner which witl permit
the existence of the certification to be determined by reference to the property
6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of in* owner The owner shall submit the agreement to
the iagister u7 S.sus a.u! .N.*.kgcvG,.:ynt saali be rec.,. Le : Ly the revuier c! _ reds . wai permit t!,a axis;avice o~ G.... y eami;--
to be determined by reference to the property where the holding tank is installed
O(' w0-0611111 NamNal /tPru+U - I Ow~raQrts) Signa~tureells)
0 [1 Y' ~A y -r1 f-h M Vret4 Subscribed and Sworn to before me on this date.
Mu 1041 Official Name (Print) - I Mun,c,paf Official Signature ! Notary PubbC"
1 I 4/commission expires:
.~►^nadenP Alen I
Mun al Official Tale iPrmt) k. j o2 I
~/mar (
Subscribed and sworn to before me on this date: RYASE NM: This agteat>a1t shall be bull and void if both sigflti--
i Rnzes are not notarized individually of together at
- the see tine.
Notary PubhC I _ -
My commission expires: I
tl !5- .
1' -
5 a--2.0 i ~-AR
8
' ►.7 (7 a~ r ~ tI tj ~ `7
HOLDING TANK SERVICING CONTRACT
convect ate
This contract is made between the
_
Holding Tank O.,ner(s) Name(s) _ _ _ - - _ and Pumps is Name - - - - - _ - - - - - ! _ - - _ - - _
I
We acknowledge the installation.ot (a) holdi tank(s) on the followip property: (Provide lega description:)
1. The owner agrees to file a .copy of this contract with, the local governmental unit hereinafter called the "municipality". which has
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b). Wis. Adm. Code and
with the County of DUNN
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to, permit the pumper to have access and to
enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weattier access
road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay
the pilmper'for all charges Incurred In servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b). Wis.
Adm. Code. and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees
to include the following Ih the semiannual report:
a. The name and address of the person responsible for servicing the holding tank:
b. The name of the owner of the holding tank.
c. -..The location of the property on which the holding tank is installed:
d. The sanitary permit itumber issued for the holding tank:
e. The dates .on which,the holding lank was serviced:
1. The volumesln gallohfbf the contents pumped from the holding tank for each servicing:
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain In effect until the owner or pumper terminates this contract. In the event of a change in This contract.
the owner agrees"to file a copy of any.enanges to this service contract or a copy of a new service contract with the municipality
and the County nsetedabova within ten (10) business days from the date of change to this serv?cs contract.
0w1eraJ Name(s) (Print) I Owner's signature(s)
DuPrRY f M/1 - ( Q -t/YVliyt.J Subscribed and rn to before me on s 33tie: s
Pumper Name P4-16V Pumper'a Si atute - - lntary~u01,c
commission expi
7rn /TT/ESTi94
Pumper'& Regs a t
Subscribed and sworn to belore me on this date: ~
I
. Notary ubl,C
My commission expires:
PLEASE NM: This agreamt shall be nil) and
void if both signatures a a)e not
rotmrizad together at the mw
time or individually.
.
7N16 SPACE RESERVED FOR RECORDING DATA
DOCUMENT NO. I STATE BAR OF WISCONSIN FORM 3 - 1982
1
QUIT CLAIM DEED
447759 i 401 ki 320
=
- REGISTER°S OFFICE
f by his ST. CROIX CO., W!
Lavern L. Timm, husband of Dorothy Timm,
. Recd for Record
Attarniry_-in--Fact.,_.Dorothy---- L_...T.imm_,._a/.-k/a.Aorothy---•-
...-----.Tiroro............... MAY 111989
quit-claims to _-Rorothy..bmm...... w.Zfe...o._L,a.Ver11 of 8:30 A. M
it
Reglater of Deeds
- - .I
the following described real estate in ..S.t_....C.r.O.1.X County, ;
State of Wisconsin: RETURN 70
Northeast Quarter of Southeast Quarter of Section 4,
Town 28, Range 15 West, except that property described
in that certain .ward of Damages of the State Highway I
Commission of Wisconsin, recorded August 26, 1957 in Tax Parcel No:
Vol. 344, page 205, as Instrument No.251652, Register of
I'
Deeds Office for St. Croix County, Wisconsin, and also excepting ll
that property as described in that certain Warranty Deed dated July 28, 1961 :I
and recorded August 29, 1961 in Vol. 379, page 635, Instrument No. 266528,
Register of Deeds Office, St. Croix County, Wisconsin, {
ie
Also,
South One-half of Northwest Quarter of Southeast Quarter of Section 4, Town 28,
Range 15, except that part lying northerly of Interstate Highway 94.
i
Also,
That part of following described property lying north of U.S. Interstate Highway
94: South Half of Northwest Quarter of Southeast Quarter and Northeast Quarter
of Southeast Quarter of Section 4, Town 28 North, Range 15 West.
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This . is
1-- homestead property.
(is) (is not) 89
May. - 19...
Dated this 1St day of
( S E AL) ~a-44A! fi, ..c.!~u_- . %{r:t3 .G.ul.1< )
Timm" by his .
Attorney ~act, Dorothy L. Timm
. . . . . . (SEAL) (SEAL)
"
AUTHENTICATION ACKNOWLEDGMENT 14''
of Lavern L. Timm
. Sign STATE OF WISCONSIN
`J.
in-Fact, broth _1
authenti t day of_.. I~Y 19-89 Personally came before me this ................day of ,
19-------. the above named
obert_.R Gav.i_c__.........
TITLE: MEMBER STATE BAR OF WISCONSIN ij
(If not,
authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the
foregoing instrument and acknowledge the same. ~
THIS INSTRUMENT WAS DRAFTED BY II
Robert R. Gavi c
- s
Spr.Tn.g--V3-1.lEy_,..hlI__54.7.f')_7-----------------.._.... Notary Public . County, Wis.
i'
(Signatures may be authenticated or isckno«•ledi;ed. Both My Commission is permanent. (If not, state expiration
~I
are not necessary.) date : . . 19....._..) ~I
•
I~
•Natnes of persons signing in any capacity sbou'.d be typed or printed below thr'.r signatures.
H CMiUarCorrpry® STATE DAtt OF AiscoNsiN Stock
e µ • o „ FORM No. 3 - 1982 Io. 13003
Form- S T C - 104
AS BULLT SANITARY SYSTEM REPORT
OWNEk TOWNSHIP SEC. T - N-R rW
ADDRESS ST. C1tOIX COUlIT'i, WISCONSIN
GSo ~.J 6 S
SUBDIVISION ~J LOT N l~ LOT SIZE '.L~.
PLAN VIEW
Distances and dimensions to mect requirements of I•LHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i 64'~ti
1~ K
D t Lt`s°~ DID t
ICA
Gpd-
s
Cp I
av
R`
C 6D
ti
I ~
L/ INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point:-Proposed slope at site:
8977 TANK: Manufacturer: _ Llgol d Capacity:
Number of rings used: Tank mnnhul.e cover elevation: 1(}0'7
Tank Inlet Elevation: Tank OullcL Llevation: '
Number of feet from nears i. Te-ad: Front,0 S0 Rear, O feet
.From nearest-propci- y.Ine Front,CoRear,O feet
Number of feet front: we-11 bu(.td (nr:
t
PUM""ER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Site
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, C )Side, o Rear, O Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL BSORPTIOH SYSTEM
Bed: Trench:
Width: Length: Number of Lines: Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear,O Tt.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SEE AGE PIT
Size: Number of pits: Diameter: ,
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer:Capacity:4C)
~7
Number of rings used: Elevation of bottom of tank: •
Elevation of inlet: i
Number of feet from nearest property line: Front, Side, O Rear, 0Fte"
Number of feet from well: G -r-- Number of feet from building: o~ r
Number of feet from nearest road:
Alarm Manufacturer: .Z/ L-2 1_(b
y,
Inspector:
Dated: Ao Plumber on job: ~1' • T ~°2~
License Number:
3/84:mj
• SAFETY & BUILDING
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR
DIVISION
LABM & HUMAN RELATIONS
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON, WI 53707 State Plan I.D. Number:
NW 4, SE 47 Sec. 4. T28-R15 ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of Cady ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
INXWY05F PE OLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Dorothy Timm Rt. 1 Wilson Wi
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: =6;19 No.: County: Sanitary Permit Number:
Lyle Me ~yyers St. Croix 13
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
q~ PR IDED: PR IDED:
-0-0 04 `4f YES ❑ NO YES ❑ NO
BEDDING: VENT DIAy VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINf ~J AIR I ET'
YES ❑ NO ❑ YES ❑ NO NEAREST U L
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING OVER
PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
RESH
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VER INLET:
(DIFFERENCE BETWEEN FEET FROM LINE:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST 110-
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: METER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until AIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH: LENGTH: NO. OF DISTR. PIPE SPACIN COVER ERIAL: INSI DIA.: # PITS: I ID
BED/TRENCH TRENCHES: PIT DEPTH,
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL O. DISTR. NUMBER OF ROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: IPES: FEET FROM INE: AIR INLET:
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to Check the tex re of he fill materia for PRQVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound syste, s to m ke certain th t it N REVERSE SIDE. SHOW
❑ YES ❑ NO meets the cr' eria for medium sa ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PER NENT MARK S: OBSERVATION WELLS;
❑ YES NO ❑ YES ❑ NO
HED:
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TO SOIL: y D: EEDED: MULC
CENTER: EDGES:
Y Y'S ❑ NO ❑ YES [__1 NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: TNO.OF RENCHES: LATE L SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
ELEVATION AND
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
Re or audit.
Sketch System on
Reverse Side. SIGNATURE: TITL
SBD-6710 (R. 06/88)
17DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code 72,
~ s.w.svs
~ .aar,w,ua
STATE SANITARY PERMIT ~T
-Attach complete plans (to the county copy only) for the system, on paper not less than I
8% x 11 inches in size. ❑ C eck if revision to previou application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
S T2_8', N, R E (Ora
PROPERTY OWNER'S MA ICING ADDRESS LOT # BLOCK #
eY
CITY STATE ZIP CODE PHONE NUMBER SUBDIVISION k)RCSMNUMBER
13 CITY
VILLAGE : NEAREST ROAD
II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑
S
❑ Public 1 or 2 Fam. Dwelling of bedrooms PARCEL TAX NUMBER(5)
III. BUILDING USE: (if building type is public, check all that apply)
1 ❑ Apt/Condo C• r-J
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 120 Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1.0 New 2. Replacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 300 Specify Type 41 Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
140 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 Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
t Con- Steel glass Plastic App
INFORMATION New lExisting Gallons Tanks Manufacturer's Name oncre structed
Tanks Tanks
Septic Tank or Holdin Tank A) Lift Pump Tank/Si hon Chamber 0 [j IF-J El
Vllll. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans.
Plumber's Name (Print): Plumber's Sign re: (No tamps) 4rAP PRSW No.: Business Phone Number:
le- r~'l e 25G` / 9 wl 3-2Qie
Plum lifer's Address (Street, City State, Zip Cod
R 042 16? - Z--
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial / ~ / d6 Surcharge Fee)
Avers Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) 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 the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the 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 & 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 in 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 in #1-7.
VII. Tank information. Fill in the capacity of every new and/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.
Vill. 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% 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; those 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, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
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► {--4397
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NSITE SEWAGE S`f STEtt1
U'!'AfzTML ti i 0!: Lr; 30R AND hiJPtiflAiV RELATIONS ~ , .
r
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- HOLDING TANK CROSS-SECTION `
Approved Weather Proof
Vent Cap
Junction
Box „
Approved Locking Manhole Cover
4!~ C•I• With Warning Label Attached
Vent Pipe And Padlock
Minimum 12"
Final Grade
4" Minimum
f Approved Joint
18" Minimum
4ater Tight-'
~
)eal High Water
Alarm Switch ~
SPECIFICATIONS ,
TANK New Existing Approved Joint
Manu acturer: ryl / rcJ~,rr, rte, -r-
w/ C.I. Pipe
Blind C.I. Tank Size: 20 al ons Extending 31
'lug ALARM Manufacturer: Onto Solid Soil
Model Number:-
Switch Type
NUMBER OF BEDROOMS:
GALLONS PER DAY:
3" of Bedding Under Tank
Owner's Name:
Address:
Legal Discrtption: _ t,L, .y ccJ
Township/Municipality: `
County:
PLUMBER/DESIGNER 1J ` r a.9 SEVV G S~ 8 f
Si nature:
9
License Nu e
Date:
/,n 7
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A:i,: 'c' AND HUMAN R__Li~TIONS
SBUIL, ' S
:PARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
II11f~Y, DIVISION
\BOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 7969
JMAN RELATIONS
N WI 3707
JMA
(1-163.090) & Chapter 145.045)
)CATION: f}~ SECTION: n TOWNSHIP/MUNICIP LITY: LOT N,:BLK O: SUBDIVISIONNAME:
of , 44 '/451% Ta9N/R 1.5E (or
)UNTY: OWNERWBUYER'S NAM : AILIN DR SS:
/ e
;E DATES OBSERVATIONS MADE
FRLTLATIONTEST
NO. BE . COMMERCIAE DESCRIPTION: DESCRIPTIONS:
~ S:
Residence NM ew Lfdi~eplace ~I
v
\TING: S- Site suitable for system U- Site unsuitable for system
)NVENT A MOUND: IN-GROUND U : S M-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM-(optional)
S DS 2T DS Lam' OSa EeSOU s
Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
,der s.1-163.09(51(b), indicate: A Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
)RING TOTAL P H TO R UNDWATER4NCH S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
)MBER DEPTI-11011, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) +
14
R SCE c~' ~-G7 he
t' S e -Z t / D artj d
11 - L10'-
' 3W "A
s. Ts rS ~,y1,p J y..~.r
s,
d7
a L-~
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
JMBER INCHES AFTERSWELLING INTERVAL-MIN. PER INCH
YN 14
N4 L/
- I
3T PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori
tal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
and slope.
YSTEM ELEVATIONt~
Y ~•t.1
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the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Iministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
~M (print : TESTS WER COMP ETED ON:
/ If /9
2 Jot c' ) 7
ESS: CERTIF ATIO NUMBER: PHONE NUMBER(optional):
O
CS TS NA RE:
c
!G
STRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
LIIR-SBD-6395 (R. 02/82) - OVER -
~
$89-40397
'C. 846 PAGE 218
Document No. This space maerred for record" dam -
44978Q HOLDING TANK AGREEMENT REGISTERS OFFICE
Agreement Oats , a7 `OV This agreement is made ber+een me S, C,ROIX Co., WI
Countyor Local Governmental Unit I Holding Tank($) Owner(s) Recd for Record
Cady-Township (Dorothy Timm
St. Croix County i J U L 191989
Called arrnedpe --I I C1 0:4 f
We acknowledge that application is being made for the installation of (a) holding T
tank(s) on the following property. (Provide regal land, description:) a C~ay
TnP NE-SE of Section 4 Townahi 28N. v Register of Deeds
Hinnge 15W. north of the Freeway
ffeturn To
- - - - - - - - - - - - - - - - - - - - - - - - - - - - -
or thm c,onbnued useof the existing premises requires that a holding tank be rnstalleo on the property for the Purpose of proper containment of _
sewage. -.Also. the property cannot now be served by a municipal sewer. or any other type of private sewage system as permitted under
Ch: ICHR 83. Wis. Adm..Code. or Ch. 145. Stats.
:Assn inducement to thiscounty of -$t a Crni Y - R to issue a sanitary permit for the above described property:
we agree to the w1owing: .
1 CNVQ?r agree' 10 conlOthi to all applicable requirements of Ch. ILHR 63. Wis. Adm. Code relating to holding tanks. lithe owner fads fo have the
`holding lank ptoperly serviced in response to orders issued by the municipality to prevent or abate a nuisance as, deecribed In as. 146:13 and
146AC8tata -tHe'municipality may enter u on the and service the tank or cause to have the tank serviced and'Char a the owner b
P property 0 r
pfaeing the'd►arges onthe,tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed' by
a: 68.60. Slats -
agrees to Pay tit dtarges'and costs incurred by the municipality for inspection. (wmping• hauling or otherwise servicing and maintaining
2 owner
theAoldng'tank in S"h a manner as to. prevent or abate any nuisance or health hazard caused by the holding lank. The municipality _a ibi
r
the OwiW Of any Costawf)feh 014i(be paid by the owner within thirty (30) days from the date of notice. In the event the owner dt>ls~nOt nr; uye
- costa w0dn"thirty"(36)day'„ ttls_Owner specifically agrees that all of the costs and charges may be placed on the tax roll aaa 3.:u 45sess- -
_
'ment.foc the abatement of a'nuisance. and the tax shalt be collected as provided bylaw.
3: The owner. except as provK w by s. 146.20 (30) (d). Slats.. agrees to contract with a person who is 5consed unese Ch. NR 113. Wis. Adm Codi to
have the holding tank "Aiced,and to file a copy.'of the contractor the owners registration with the municipality and.with the county; The oidner
further' agrees to'flle s copy of oily changes io the service,contractor a copy of anew service contract with the municipality a,d the.cou" within
ton (10) bueina" days Insrn in* date of change to the service contract.
4. The owfleragrees to contract with a person licensed under Ch. NR 113. Wis. Adm. Coee 'e no shall submit to the municipality and to the county a: -
report -in accord _with a 11.1-11 11,93.18 (4) (a) 2.. Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under -
a..146Z (3).!d), Stalsgthe owner shall submit the report to the municipality and the county.
5 Thls agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certi!fes Inat
the property w served by elther a municipal sewer or a soil absorption system that comphe~ with Ch. II.HR 6?. Wis. Adm. Code. In addition. this. -
agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which wdt perms
the existence of tha certification to be determined by reference to the property.
6. This agreement shall be trending upon Ufa owner. the heirs of the owner and assignees of the owner The owner shall .submit the agreement to -
the register qt lesda ah.:." agr.eL:-tnt. si.aliae rec.,: Ga:: i:r the reyete• C' _ cede ; ...•,ra...~ _E• w.C per-•t tha existence o' tr..
to be determined by reference to the property where the holding tank is installed
Owner(s) Name(s) (Print) - - I Ois) Signature(s) r - -
n r f'~ f j:L -4w0-4 Subscribed and sworn to before me on this date:
l
57
MU lpal Oalc_lal Name(Print) I Municipal Official Signature Notary 'u....
ni1 I y commission expires:
munni I ofrrdaI Ties lP mt) ,J p~ f
Subscribed and sworn to before me on this date: RYAS'E NM: This agreanast shall be ==y oboth atgrsa-
tetras are rot notarized ofr tngedw at
the s®e title.
I
• Notary Pubf•c I ;a:'~•~••. _
My commission expires: •`~4 L. "~Y"'e.,yw~,
lC
Q~.
U
HOLDING TANK SERVICING CONTRACT
Convect Date - -
This contract is made between the
-
Nol0ingtankOvn•r(s►iGm•(p - - - - - - and I Pumper'sName - - - - - - - - - - - - - - - - - - -
- -
I
`Tim r~ C Sfly~,~ .~c,Pll/cF
We acknowledge the installation of (a) holdi tank(s) on the followiq property. (Provide lega description:)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1. Ths owner agrees to file a .copy of this contract with, the local governmental unit hereinafter called the "municipality". which has
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
with the County of DUNN
2. The owner agrees tohave'the holding tank(s) serviced by the pumper and guarantees to, permit the pumper to have access and to
ante{ upon the property for.the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access
road or drive so .that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay
the pumper for alt charges Incurred In servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b). Wis.
Adm.- Code. and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees
to Include the following In'the semiannual report:
a.' The name and address of the person responsible for servicing the holding tank:
b.' The name of the owner of the holding tank;
C. The location of the property on which the holding tank is installed:
d. ` The sanitary permit number Issued for the holding tank:
e. The dates onwhich.the holding lank was serviced:
I. The volumes In 9a11ons of the contents pumped from the holding tank for each servicing:
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will rimain in effect until the owner or pumper terminates this contract. In the event of a change in this contract.
the owner agrees'- to file a copy of any.cnanges to this service contract or a copy of a new service contract with the municipality
and the County naatedatoovi withinton (10) business days.rom the date of change to this service contract.
O? nsrfs) Name(d) (Prins ( Owner's Signaturew
Y f /rill I Q /f .t.l2- "t /l'✓l/LvJ Subscribed and rn to before me on p s gate:
Pumper's Name
/ 'r / r/09 7,'d 0 I ommission ezpir
Pumpeisnpis + -
Subscribed and sworn to before me on this date: y
a
Notary Public
My commission expires:
PLEASE NJIE: This agreemnt shall be mill and
void ih both signatta~es arae not
not mized together at the
time or individually.
H
z
H
STC - 105 r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
a
y- H
OWNER/BUYER ~pra '~y 1 1I'Ytry1
ROUTE/BOX NUMBER Z r 1 74(UV /gy S OX Fire Number-?Z/6
.CITY/STATE j~~ r Sn A/ ~+SC, ZIP Lj /~Uc7
PROPERTY LOCATION•(41, Section , T _N, R _W,
Town of GL~ , St. Croix County,
Subdivision Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you pit into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. yo
E
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
r,
the standards set forth, herein, as set by the Wisconsin Depart- ro
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office within 30 days
of the three year,expiration date.
SIGNED (J /
DATE 7Z Z7/ L
St. Croix County Zoning Office
P.O. Box 98=
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
APPLICATION FOR SANITARY PERMIT
STC - 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 O Y 0
Location of Property r.; / .J4, Section , T~N-R~ W
Township
Mailing Address Y 13o )r 3 4
L! I s o A/0 (A-) l`s A 40a ~
Address of Site (A
IS a
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes Z,--No
- Volume and Page Number _32-a as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A ,Warranty Deed which includes a Document number, volume and page number, and the
Seal of the Register of Deeds. In addition, a certified survey, if available, would be
helpful so as to avoid delays of the reviewing process. If the deed description refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTy OWNER CERTIFICATION
I (we) ceAti6y that att .6taxement6 on this Bohm cute xnue to the bust o6 my (oun)
knowledge; that 1 (we) am (cute) the ownen(,s) o6 the pnopenty descAibed in this
.in6oxmat.ion Bohm, by vi tue o6 a waAAanty deed neconded in the 066.ice o6 the
County Regi6teA o6 Deed6 ab Document No. and that I (We) pnuentty
own the pnaposed site bon the sewage dispo~at tem•(on I (we) have obtained an
eabement, to nun with the above dedchibed pnopeh ty, 6ot the conbtnuction ob s aid
.6ybxem, and the dame hays been duty )Leconded in the 046ice ob the County Reg.usten 06
Deeds, as Document No. C) .
SIGNATURE OF WNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
Lf-Z-I
SIGNED DATE SIGNED
• ' •
+ RtttRV(O /OR RXCOROING DATA
DOCUMENT No. STATE BAR OF WISCONSIN FORM 3-11W THIS t!'ACt
QUIT CLAIM DEED
447759 !I IIF. 940faPA,E320
i; REGISTER'S OFFICE
LaVern L. Timm, husband of Dorothy Timm, by his ST. CROIX Ca. WI
Recd for Record
Attor__ney.-in..Fact.,.. Dorothy
..........zftaco MAY 111989
quit-ciaims to Darathy..Z.imm.,....wife..o.f .LaV.ern _L...T.imm....... at 8:30 A. M
Q RbOkW of D"ds
the foUowins described real estate in S.t....Croi.X County.
State of Wisconsin: *LTVA' TO
Northeast Quarter of Southeast Quarter of Section 4,
Town 28, Range 15 West, except that property described
in that certain Award of Damages of the State Highway
Colm►ission of Wisconsin, recorded August 26, 1957 in Tax Parcel No:
Vol. 344, page 205, as Instrument No.251652, Register of
Deeds Office for St. Croix County, Wisconsin, and also excepting
that property as described in that certain Warranty Deed dated July 28, 1961
and recorded August 29. 1961 in Vol. 379, page 635, Instrument No. 266528,
Register of Deeds Office, St. Croix County, Wisconsin,
Also,
South One-half of Northwest Quarter of Southeast Quarter of Section 4, Town 28,
Range 15, except that part lying northerly of Interstate Highway 94.
Also,
That part of following described property lying north of U.S. Interstate Highway
94: South Half of Northwest Quarter of Southeast Quarter and Northeast Quarter
of Southeast Quarter of Section 4, Town 28 North, Range 15 West.
P~
This i....... homestead property.
(is) (is not)
Dated this lat day or Play , l9 89
(SEAL) O a 104--+.r t..w- ~Yq [ c4r~t1iC, T, AL
• LaVern L. Timm by-his
Attorney in Fact, Dorothy L. Timm
(SEAL) .(SEAL)
At1TNXMTICATION ACENO W LEDOURNT
of Lavern L. Timm
Sign STATE OF WISCONSIN
.y, in Facts orothy L. Timm
County.
a ..day of.. may 19..8 I ~.rAOnnlly came before me this .....day of
- - - - _r 19 the Rbov-s named