HomeMy WebLinkAbout004-1045-95-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 46d4c ~0
ADDRESS '2 t-(-y (-j (Y
SUBDIVISION CSM# LOT
SECTION T NCO N-R W, Town of 4 C
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
r
~ c o k S~ a t~
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
t ,
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK,,/ PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Me C~ w-e S L` 0 Liquid Capacity: 3 ~ U v
,r
Setback from: Welly' House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
I
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: 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 INSTALLATI
PLUMBER ON JOB: r~ 4.4
LICENSE NUMBER: e/ 6
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and'Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI Rig o..
HAMPTON, EMILY X
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding C 3 St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeratio NA Dist. Pipe
Holding >50 ~ Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Ma er Dema
Model Number GP
TDH Li Friction System TDH Ft
oss ad
Forc a i n Length Dia. Fi Dist. To Well
IL ABSORPTION SYSTEM
BED / Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS N 1 N
S P / L BLDG L LAKE/STREAM LEACHING manufacturer:
SETBACK ±!~a CHAMBER
INFORMATION Type O Mo a Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spa Vent To Air Intake
Length Dia. Length Dia. Spacing
COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/ Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)'
LOCATION: CADY.20.28.15W, SW, NW, CTH NN
CZ)e
Plan revision required? ❑ Yes e-9-0-
Use other side for additional information. 7
SBD-6710 (R 05/91) Date Inspectors Signature Cert. No.
1
ADDITIONAL COMMENTS AND SKETCH s
SANITARY PERMIT NUMBER:
' Safety and Buildings Division
111111 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 Coun o
than 8 112 x 11 inches in size. ~ 7~-
• See reverse side for instructions for completing this application State Sanitary Permit Number
`r~ 7l0
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State PI I. mb~e/~
CJ
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION 3 !
Property Owner Name Property Location
L s'tcl1/4 K 01/4, S 6? T 2 f, N, R b-_E (or) W
Propert Owner's ailing Address Lot Number Block Number
6/ C=N 'NN
City, State / / / e zip Code ?Phone Number Subdivision Name or CSM Number
~ >
E] y Nearest Road
II. TYPE OF BU gING: (check one) El State Owned It P-T
Public 1 or 2 Family Dwelling - No. of bedrooms 0 vown of G Q C ~ -N
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 [-j Apartment/ Condo 00bl - G `~5 ?5-
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 / Mote[ 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. C% Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 rut. Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 D 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 Capacity
gallons Total # of Prefab. Site Fiber- Exper
INFORMATION Gallons Tanks Manufacturers Name Concrete con- Steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank 3000 f dl.J ❑ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility f r installa ' the onsite sewage system shown on the attached plans.
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Business Name: (PrintZ Plumb sSignature- ( ps) /MPRSW No.: Phone Number:
Plumber's Address (Street, City, Sta , F/C?Ode): ' i
ru c, Ve 1161" IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate s e Issuing Agent Sign
pproved ❑ Owner Given Initial Surcharge Fee) 7
Adverse Determination
X. ONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Division, Owner, Plumber
i
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1
x.
INSTRUCTIONS
9
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 existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Cer-:plete for all septic, pump/siphon and
holding tanks for this systern. Check experimental approval only if tanks receive ?xperimental prodJct approval from
DILHR.
Vill. Pesponsib hty statement. Installing plumber is to fill in game, license number with appro-)nate orefix (e.g. MP, etc.),
and phone number. Plumber must sic,n application form -
lX_ Couw.y ' Department Use Only.
X.. Coun.y /Department Use Only.
.,31!r:,',5 r : Sr7 dl ter than 1X 1 1 I`ChLS S_1 ed t ) lrnty The plans must
t'_? scale or'01i rrF,i 1,nc tanks}, septic
Dump or siphon
he 1-JAling served,
voluni
,Au rg information.
+ GROUNDWATER SURCHARGE
tij i !Ins odfcd ht_- C`eatlon of surcharges (fees) for _i nu~~. er cat r ated p!.:i l c `.vhi(h Can
e~f ct r, ord
! nrC t':+ouq h-'-se ~•urcharges are used far monitoring grog! ndvva'e c)nl,tmaLi cr; i~)vestigations
a~~ J establis'~r;;_~ of standards.
SAFETY & BUILDINGS DIVISION
State i
Department of Indus man Relations
May 19, 1995 A,r fe^„" 6 Rose Street
rosse WI 54603
40. ;
WEGERER SOIL TESTING
421 N MAIN STREET
PO BOX 74
RIVER FALLS WI 54022
RE: PLAN S95-40389 FEE RECEIVED: 60.00
HAMPTON, EMILY
SW,NW,20,28,15W
TOWN OF CADY COUNTY OF ST CROIX
HOLDING TANK
The Department has reviewed the above-referenced submittal.
Conditional approval is hereby granted for the system plan submittal. All
noted items must be corrected. The review and approval of the system is based
on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin
Administrative Code, and is contingent upon compliance with any stipulations
shown on the plans. This system has not been reviewed for the code
requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin
Administrative Code.
This plan submittal approval will expire two years from the approval date, or
if a sanitary permit is obtained, plan approval will expire on the day the
initial sanitary permit expires. The licensed plumber responsible for this
installation shall keep one set of plans with the Department's stamp of
approval at the construction site. The installer shall notify the appropriate
inspector when inspections can be made.
All permits required by the city, village, township or county shall be
obtained prior to installation.
Inquiries should be directed to me at the number listed below. Please refer
to the plan number shown above.
Sincerely,
r
Dennis Sorenson
Plan Reviewer
Section of Private Sewage
(608) 785-9336
SBDA-7887 (R. 10/84)
r
HOLDING TANK Page of 2
For
A Z Bedroom residence S95-40389
SW- NW i ZO T Z'8 N R 1 S W
,
A ED IN THE OF THE 4 OF SECTION
LOC T 4
TOWN OF C1~b~( , SZ'• C.v-x.)LX COUNTY, VTISCCNSIN.
INDEX
PAGE 1 of 3 TITLE SHEET
PAGE 2 of 3 PLOT PLAN
PAGE 3 of 3 HOLDING TANK SECTION
PREPARED FOR
61 c'rN N a ftcr t rte'
s~~fuG \jkLU y, cal s4-)6-7 MAY - a
♦ww-
SAFETY i BUGS. DIV.
PREPARED BY
WEC-sEiREF;Z E3 Q I L TF-=E T I N(
AND ~~~tQO!®
I7EE3 I Ism S►EFRV' I CE
F.O. BOX 74 421 N. MAIN ST. , •°'°~«V''••®°~°
RIVER FALLS. NI 54022 r'• ti
ARTHUR 1. g
715'425'01115 0 W _,!E,ER t r
Z G-St5 R
p o HISWONTH, ~
! i WIS. JnJ w
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Naow
~ ~3,1g9s
JOB NO. 5 ' 4 _
r PLOT PLAN Page Z of 3
Scale
895-49389
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. o ~.e)t-k ST►AuG wt~
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. ~``)tl STAG 'T'1't'y.Jk.~
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895 -40389
HOLDING TANK CROSS-SECTION
Approved Weather Proof
Vent Cap Junction Box
/Approved Locking Manhole Cover
4" C•I•---~ With Warning Label Attached
Vent Pipe
Minimum 12"
Final Grade
4" Minimum
Approved Joint
18" Minimum
Water Tight '
Seal
High Water
Alarm Switch
SPECIFICATIONS - - _ - - ~
TANK New L"' Existing Approved Join
Manufacturer: M~Dw~, N C'~ xt°ST" w/ C.I. Pipe
Blind C.I. Tank Size: 3 pop Gallons Extending 3"
Plug Onto Solid So
ALARM Manufacturer: S•3'. SV~ (oR nvc ~~P~
Model Number: ~ p \ \~A
Switch Type : t o
NUMBER OF BEDROOMS:
GALLONS PER DAY: 3 O
3" of Bedding Under Tank
~ll 7 f 1 { i it
HOLDING TANK SERVICING CONTRACT
Contact Date
This contract is made between the
I
Holding Tank Owner(s) Name(s) and Pumper's Name
I
Emily Hampton I ~E~✓~i
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:)
Part ofSection 20.
_ T2$N _RLSW_ Town o.f---C-ady-3 St -Croix --C-o-u-nty--) _Wt c-on-sin
a s r e c o r _e i n .y4-lum-e_._-4-2 y . _-p-a-g e -l
(See.attached description~_____ - -
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 St . Croix
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 servicing the holding tank(s). The owner agrees to maintain the all-weather access
of 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 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 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 on which the holding tank was serviced;
f. The volumes in gallons 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 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 changes to this service contract or a copy of a new service contract with the municipality
and the County named above within ten (10) business days from the date of change to this service contract.
Owner(s) Name(s) (Print) I Owner's Signature(s)
cam'
Emily Hampton I___Subscribed and sworn to before me on this date:
Pumper's Name (Print) I Pu is Sign re Notary Publi(
My commission expires:
sr,~~j I 5~ lqq Cr
Pumper's e/giisstration Number
SOD-7574 (R. 09188) This instrument was drafted by the State of Wisconsin Department
of Industry, Labor and Human Relations
r
South Half of Northwest Quarter of Northwest Quarter (S2 of NW-4 of NW-14)
and the Southwest Quarter of the Northwest Quarter (SW4 of NW4) of
Section Twenty (20), Township Twenty-eight (28) North, Range Fifteen
(15) West, St.Croix County, Wisconsin, except the following:
Commencing 430 feet West of the Southeast corner of the Southwest
Quarter of the Northwest Quarter (SW4 of NW4) of Section Twenty,
Township Twenty-eight (28) North, Range Fifteen (15) West; thence
East 430 feet; thence North 350 feet; thence West 150 feet; thence
in a Southwesterly direction to the place of beginning.
Wisconsin Departm5nto~'~iL0y, HOLDING TANK AGREEMENT Bureau o oand ff Buildings Safety and Wat Water Systems
tabor and Human Relations 111. IPA,E This space reserved for recording data
•Docutnent No /Plan Identification No. This agreement is made between the
governmental unit and holding tank
reement Date owner(s)
s
g SE CRO+X
C/
or Local Governmental Unit Holding Tank Owner(s)
Cou
Y
Town of Cady Emily Hampton MAY 1 1995
called Munici ali below at 10.30 A._
We acknowledge that application is being made for the installation of (a) holding '
{
tank(s) on the following property: (Provide legal land description)
Regtatcr ft
Part of Section 20,T28N,R15W, Town of Cady, Yes''''
4~Do
St.Croix Count Wisconsin as recorded in Volume 412,
page 518. Return To
(See attached description)
or that continued use of the existing premises requires that a holding tank be 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, Stats.
As an inducement to the County of S t .Croix to issue a sanitary permit for the above described property, we agree to do the following:
1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the
holding tank properly serviced in response to orders issued by the municipality to prevent or abate a human health hazard as described in s. 254.59,
Stats., the municipality may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing
the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Stats.
2. The owner agrees, pursuant to s. ILHR 83.18 (10), Wis. Adm. Code, to have installed in a new building or new structure a water meter approved by
the County and State. The water meter shall be installed by a plumber authorized by the State to conduct such installations, with said installation
complying with State regulations and manufacturers specifications. The owner agrees to be financially responsible for the purchase, installation,
maintenance, and repair of the water meter, and agrees to allow the municipality to enter the above described property on a regular basis to read
and/or inspect the water meter.
I
Owner agrees to pay all charges and cost incurred by the municipality for inspection, pumping, hauling, or otherwise servicing and maintaining the
holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. The municipality shall notify the owner
of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within
thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of
a human health hazard, and the tax shall be collected as provided by law.
4. The owner, except as provided by s. 146.20 (3) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have
the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality. The owner further agrees to file a copy
of any changes to the service contract, or a copy of a new service contract, with the municipality within ten (10) business days from the date of
change to the service contract.
5. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit to the municipality on a semiannual basis a
report in accordance with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code, for the servicing of the holding tank. In the case of registration under s. 146.20 (3)
(d), Stats., the owner shall submit the report to the municipality. The municipality may enter upon the property to investigate the condition of the
holding tank when pumping reports and meter readings may indicate that the holding tank is not being properly maintained.
6. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the
property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, 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 will permit the
existence of the certification to be determined by reference to the property.
7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit the agreement to the
register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be
determined by reference to the property where the holding tank is installed.
Owner(s) Name(s) - Print Notrized Owner(s) Signature(s)
Emily Hampton 14 Subs T d. LvAr~tobefore me on this date:
A -P-
Notary Public
P U P IERCE CO.
micipal Official Name - Print Municipal Offical Signature XP
N ~sbnexptfei~t•
13 (2 /V
Municipal Official Title - Print .0111 9
To 49 C- k C,
The information you provide may be used by other government agency programs [Privacy Law, s. 15.04 (1)(m')•!,,
SRD-6123 (R 04/94)
VOL 1119PPA)I7
South Half of Northwest Quarter of Northwest Quarter (S2 of NW4 of NW-4)
and the Southwest Quarter of the Northwest Quarter (SW4 of NW4) of
Section Twenty (20), Township Twenty-eight (28) North, Range Fifteen
(15) West, St.Croix County, Wisconsin, except the following:
Commencing 430 feet West of the Southeast corner of the Southwest
Quarter of the Northwest Quarter (SW4 of NW4) of Section Twenty,
Township Twenty-eight (28) North, Range Fifteen (15) West; thence
East 430 feet; thence North 350 feet; thence West 150 feet; thence
in a Southwesterly direction to the place of beginning.
i„ 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 m / f t o k~
.Location of property 1/4 CJ/~l/4, Section 2U IT -&N-R l S~ W
Township ad y Mailing address 2 ( C n (Y
Address of site
Subdivision name Lot no.
Other homes on property? Yes o \
Previous owner of property Q Dl~ d N
Total size 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 (spec house) ? Yes No
Volume d/[ and Page Number l 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. -;Z ~(-3 k3 , 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.
Signature of Applicant Co-Applicant
Date of Signature Date of Signature
i
DOCUMENT NO. l R QUIT CLAIM DEED
VOL ) 3 STATE OF WISCONSIN-FORM 13 41
4/ THIS SPACE RESERVED FOR RECORDING DATA
2'799®6
i
THIS INDENTURE, Made by_ Leon E. Hampton, a single man, REGISTERS OF r IG:c.
_ ST. CROIX CO.. W:b.
_ Recd for Record this- 3.0-t-h_
grantor of St. Croix _ --County, Wisconsin, hereby quit-claims day of_ Anifil__ ~1.O.19_6'r
to _ -Emily Hampton, my niece, at1 If M
f
Register of eeds
_-grantee RETURN TO
of St. Croix County, Wisconsin, for the sum of
One Dollar ($1.00), other valuable consideration and
natural love and affection, _
the following tract of land in St. Croix _ County, State of Wisconsin;
South Half of Northwest Quarter of Northwest Quarter (S',, of NW4 of NIV4)
and the Southwest Quarter of the Nol.~thwest Quarter (SWj of NW;i) of Sec- ~
tion Twenty (20), Township Twenty-eight (28) North, of Range fifteen
(15) West, St. Croix County, Wisconsin, except the following: Connenc-
ing 430 feet Nest of Southeast corner of Southwest Quarter of Northwest
Quarter (SW4 of NWu) of Section Twenty (20), Township Twenty-ei-ght (28)
North, of Range Fifteen (15) West; thence Last 430 feet; thence North
! 350 feet; thence West 150 feet; thence in a Southwesterly direction to
the place of beginning.
f III I
it
II The consideration is less than ;100 anti no revenue is required.
I
N~
1E7 ' IN WITNESS WHEREOF, the said grantor ha S _ hereunto set his -hand. -and seal - this.. 28t1h
day of _ April A. D., 19 65
t ~ III
SIGNED AND SEALED IN PRESENCE OF C 7~ Z (SEAL)
Leon I:. I ampton
((J I
J- (SEAL)
Harold D. Olson
I
Mary Jo Hovland, R. N. (SEAL)
I~
M. Waller
SPATE OF WISCONSIN, 1
} ss.
St . Croix _ _ _ County.
, 65
day of April A. D., 19
Personally came before me, this 28th
the above named Leon _E_ _ Hampton, a single man,
to me known to be the person -who executed the foregoing instrument and acknowledged the same.
II /S
. OAS
,.,1,
I Harold D. Olson
L
?FAL
_ County, Wis.
. Croix_..
This instrument drafted by NotaryPublic _ St
-Harold D._ _Olson, _.Atty. ' My Commission(Fxpitrs) (Is) permanent
(Sectlon S9.St (1) of the Wisconsin Statutes proafdge tli~s~~ell`lnetrtimonts to be recorded shall hero plainly Printed or typewritten [hereon the
names of the grantors, grantees, witnesses end
QUIT CLAIM DEED-STATE OF WISCONSIN. FORM NO. 13 H. L, MILLER Eo.. MILWAUKEE
I
W E C EFZC E F E3 Q 11_ T F= T I IV G F.O. 801 74 421 N. MAIN ST.
. AND RIVER. FALLS. MI 54022
I7► E S I G Rf !S3E Ft V= C E 115-425-0165
ATTN:Y"L ~Iv~;~ S`plV DATE
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SUBJECT:
WE ARE ENCLOSING THE FOLLOWING ITEMS:
NO. OF
COPIES DESCRIPTION
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SENT TO YOU FOR THE FOLLOWING REASONS:
❑ FOR APPROVAL ❑ APPROVED AS SUBMITTED ❑ INFORMATION DESIRED
[>~FOR YOUR USE ❑ APPROVED AS NOTED ❑ RETURN COPIES
❑ NOT APPROVED ❑ FOR REVIEW AND COMMENT
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DESIGN SERVICE
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of Z
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM)„ and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and ch a a be) y, I. 4 s _ 015
APPLICANT INFORMATION-PLEASE P REVIEWED BY DATE
PROPERTY OWNER: 40 PERTY LOCATION fJW lU w RNp
S w 1/4 M W 1/4,S ZU T 1,16 N,R 5 E (we
y~ k'cl[ 1r~j\ V-1
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PROPERTY OWNER'.S MAILING ADDRESS una f, BLOCK # SUBD. NAME OR CSM #
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CITY, STATE zip CO BE []VILLAGE RrOWN NEAREST ROAD
S"iNvi fu G \)Wtlf( w[ S4 C, R 't c`N " N N
[ [ New Construction Use [ Residential [ ] AddiiQn to e)dsdq building
wmme '
D4 Replacement [ I Public or
Code derived daily flow 35o gpd Recommended design loading rate - bed, gpd/ft2 trench, gpolft2
Absorption area required - bed, ft2 - trench, ft2 Ma)dmum design loading rate - bed, gpolft2 - trench, gpo1ft2
Recommended infiltration surface elevation(s) N It (as referred to site plan benchmark)
Additional design / site considerations \-%,i l fu 6 hz~ IN
Parent material S L S frD lfl WT O u M l.I.- Rood plain elevation, if applicable M . ft
S = Suitable for System CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for system ❑ S 19 U ❑ S ®U ❑ S ®U ❑ S [OU ❑ S ®U ®S ❑ U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bound3y Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trends
Z 8 -Zg \,,o `-t. kz S 13 S `tQ s 1~ S [ o~-t wt'F~ - -
Ground
elev.
Depth to
limiting
fact r,~
Remarks:
Boring #
1~ = °l tryb1Z)t'70 It-t- 13o1L! A) G g y~LU w L
lh7L(~ W !v ~D S
+
Ground
elev.
It
Depth to
limiting
factor
Remarks:
CST Name.--Please Print Arthur L. We erer phone. 715-425-0165
egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signature:. S 48 Date: CST Number:
tpRu l3 Lq 95 M00576
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION RE-PORT Page 1 of 7-
Labor and Human Relations
Division of Safety & Buikings in accord with ILHR 83.05, Wis. Adm. Code
' COUNTY
s`r . caZ-c~~X
Attach complete site plan on paper not less than 8112 x 11 inches in size. Plan must include, but PARCEL I.D.
not limited to vertical and horizontal reference point (13M), direction and % of slope, scale or O I. y~ ~1 S- 9 5
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATIONS , rv W R ova
"1 Q4 "Wgo vw 60kg. LA; S by 1/4 Mk) 1/4,S Z% T 116 N,R \!S E (or W
PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
Z61 C "NN" - -
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE [.MOWN NEAREST ROAD
S~WwG vYKl f M S\4-)6~ (>>s)~72_ ~[Stg (1,R~`C y" MN b
[ ] New Construdon Use[ Jq~ Residential /Number of bedrooms Z [ J Addtkn to existing building
JA Replacement [ J Public or commercial describe
Code derived daily flow 3DO gpd Recommended design loading rate - bed, gpo1ft2 trench, gpd/ft2
Absorption area required - bed, tt2 - _ trench, 112 Ma)dmum design loading rate - bed, gpd/ft2 trench, gpd1ft2
Recommended infiltration surface elevation(s) ty - tN - 11 (as referred to site plan benchmark)
Additional design / site considerations `Z`/Ct h n
Parent material S S eb l-nW-r o u M " f') t_k. Flood plain elevation, R applicable M - N , It
rUZNAWable e for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN IU HOLDING TANK
S ®U MS ❑ U
for stem ❑ S IRU ❑ S ®U ❑ S ®U 1:1 S U 1:1
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ierxh
vz!~'-\ L_ 3 LZ Zm51oVL r~'Fh e
i 1 Opt v„L.~~ - -
Z 8 $ ~ti kZ S 13 SIB 'T
Ground
elev.
-A,ft
Depth to
limiting
fac Lt
Remarks:
Boring #
= °t R'b~t'f~~ fit- ~oN G St_u w L
f~-,c 1 w No SD S€
Ground +
elev.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Arthur L. We erer Phone: 715-425-0165
egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Sgnature: q S -~8 Date: CST Number:
OP Pt ~3 Lg95 M00576
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