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W sconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
LaborandHumanlIelations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
P q;h is ne: HENRY ❑ City ❑ Village Town of: State P n
t: ,
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
i
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
/C0, I
Septic i Benchmark
SQ /v Z DO
Dosing
Aeration- Bldg. Sewer
Holdi St / I w Inlet ,CGS ' j'7
TANK SETBACK INFORMATION St/ FX Outlet
TANK TO P/ L WELL BLDG. Ae Intake ROAD Dt Inlet
Septic 33 NA Dt Bottom
Dosing b~~n NA Header/Man.
Aeration NA Dist. Pipe a q~+ ~`r
Holding Bot. System
PUMP / SI"INFORMATION Final Grade
Manufacturer Demand a _ • D
Model Number GPM
OF~
TDH Lift Friction System,, ~TDH Ft 1/0-
Loss 4
Hea
Forcemain Length Dia. Dist. To Well Cr a/
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT Of Pits Inside Dia. Li
DIMENSIONS DIMENSIONS
LEACHING r
SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM -
INFORMATION Type 0 P CHAMBER del Number.
t9,' System: OR UNIT
hill DISTRIBUTION SYSTEM
l1'n 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 /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Hammond.24.29.17W, SE, SW, #ighway 12 West
~3 Y
~2 41,
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:
o I
-9
a
DILHR SANITARY PERMIT APPLICATION
~....a. In accord with ILHR 83.05, Wis. Adm. Code COUNTY r o JX
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 a y~ O v
8% x 11 inches in size. check r ision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. 5 - O 7
PROPERTY OWNER PROPERTY LOCATION
S,C Y4 5GJ%4, S Z41 T 29 N, R / 7 11(O W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
e~; 7S- _T Aw
Zo_3,T tiw 17 1114
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
J l9 01. l 2L ° I
II. TYPE OF BUILDING: (Check One CITY NEAR ST ROAD
❑ State Owned VILLAGE f z. Lf~£
22 OF. Gtm poo
❑ Public R 1 or 2 Fam. Dwelling- # of bedrooms sZ PARCEL TAX NUM ER
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo D 1
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 in line A. Check line B if applicable)
A) 1. ❑ New 2. 0 Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 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 30 ❑ Specify Type 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 LJ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 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) ~-7 ELEVATION
Ef ~j® 37~ .3 /1W "?q,07 Feet O/•67Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New P-xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holdin Tank O - 40 S f F1 F1
Lift Pump Tank/Si hon Chamber A 750,
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) P PRSW No.: Business Phone Number:
747
T__>0 le- Z7 7 IS ) 4FAI 379'
Plumber's Address (Street, City, State, Zip Code):
zo /Y,)Q ,'r.., is-f', /r ub ' ``fODZ~
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater a essue Issuing Agent Signature (No Stamps) _
Surcharge Fee)
Approved ❑ Owner Given Initial D 1
/0 Adverse Determintion a(~ CY
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
r
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 wik 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.
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'h 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 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)
SAFETY & BUILDINGS DIVISION
State of Wisconsin
Department of Industry, Labor and Human Relations
June 16, 1995 2226 Rose Street
La Crosse WI 54603
BOLDTS PLUMBING
820 MAIN ST
BALDWIN WI 54002
RE: PLAN S95-40467 FEE RECEIVED: 180.00
SCHELLHAAS, HENRY
SE,SW,24,29,17W
TOWN OF HAMMOND COUNTY OF ST CROIX
MOUND SYSTEM
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.
incerely,
D nis S
s
Plan Reviewer
Section of Private Sewage
(608) 785-9336
SBDA•7997(8.10/94)
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895-40467
Cross Section Of A Mound Using A Trench For. The Absorption Area
AST",C-33 _ H
-Med4m Sand Fi11 -J1 ° F 6" Topsoil
3 E D
Plowed Layer
Trench Of h" - 2h" Aggregate,
6" Below Pipe, Covered With D /0 Ft.
Straw, Marsh Hay Or.Synthetic Fabric
E / /L Ft. G /U Ft.
F 75 Ft. H AI Ft.
is .plan Of u~rd_U' Trench For The Absorption Area
Force Main
Distribution Pipe
Permanent Markers Observation Pipe
A o
W
B K
j~
\
Trench Of - 22" Aggregate
I
L -
A °t. I 9-5 Ft. K /o Ft. W 21 Ft.
B 9 L Ft. J r7•5 Ft. L 1141 Ft.
License Q~
Signed: ~o~ cLc o-~ Number: Alf 6669 Date: .5 /5~
S Pale z~T y
Distribution Pipe Detail For Two Lateral Network
Holes Located On Bottom
Are Equally Spaced PVC Force 'lain End Cap
2
-f
fY l X ~I ~ PVC Distribution Pipe
P P
X
* Last Hole Should Be Next To End Cap T
P ~.5 Ft. Hole Diameter_ Inch
X_ Inches Lateral Diameter Inch(es)
Y 44 q_ Inches Force Main Diameter z, Inches
Of Holes/Pipe
Invert Elevation Of Laterals Ft.
Signed: License Number:
r: +
Date: -'5 -l5 - 95
~r PAr.f 1;F~
PUtl*%P CHAMP,:-'R CROSS SEC'!OIJ AMC, =°[CIFIC/710"!S
VCMT CAP S9,5-404.67
Y"C. Z. VEUT PIPE
-fr7 WEATHERPROOF APPROVED LOCAIMG
25' ^ROM DOOR. JUNCTIOAJ BOX MAWHOLE COVER
WWCOW OR FRESH I2"MIU.
AIR INTAKE
GRADE
Y"'41U.
18" .
CONDUIT Na1J
IB"MIAI, -V .4
\
1
1
IhILET PROVIDE I
A7ft1,dLFI`T SEAL I I I I V
i I
I
APPROVED JOINT A I APPROVED 161
W
/C.1. PIPE f I III WIC.I. PIPE
EXTENDIMCs 3' I I ( EXTEUD111G
ALARM
OkIT0 SOLID SOIL 6 I II OMTO SOLID S
• I 1
C r I I Oki
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ELEV. 9 F7
PUMP - OFF
0
M COUCKETE BLOCK
RISER EXIT PERMITTED ONLY IF TAUK MAIJUFACTURER HAS SUCH APPROVAL
SEPTIC E 5PEC, IFI.CAT] IOUS
DOSE
TAIJKS MAMUFACTURER: &).a, 'S IJUMBER OF DOSES: PER DA!
TANK SIZE: - D GALLONS DOSE VOLUME
/ ' 30 GALLOK
ALARM MAMUFACTURER: 5-,] E-/eC-11'✓O INCLUDIKIG 6ACXFLOW: 12C~
MODEL k1U1A6EK: A1.9 CAPACITIES: A= 34 IWCFIES OR 439 '4L-GALLOk:
SWITCH TYPE: /~~^GL! y' g = z INCHES OR 45'86 GALLCk
PUMP MAMUFACTURER: UAU~O~ C = 12 INCHES OR 12(7'3 GALLOI.
MODEL MUMBEK' - e-2,6-0 3,11 D = /Z INCHES OR 16r5'16 GALLOK
SWITCH TYPE: G✓' ay- MOTE: PUMP AMD ALARM ARE TO BE
MIMIMUM DISCHARGE RATE 'o-/ GPM, INSTALLED ON 5EPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEIU PUMP OFF ARID DISTRI15UTIOM PIPE.. -L- FEET
+ MINIMUM NETWORK SUPPL H PRESSURTTEE/ . , , , , , , . 2.5-~ FEET
+ 50 FEET OF FORCE MAIM ~
X 'S F/pp rtFRICTIOU FACTOR..-7- FEET
TOTAL DyIJAMIC HEAD Z 7 FEET
IMTERAJAL. DIMEIJS10AIt OF TAUK: LEA]GTH F' _-,WIDTH ;LIQUID DEPTH 50%
91GIJE D: - , l~ LICEMSE IJUMBER. •
- DATE.
SU
Ce
C U, Wes PUM'..',., ,s -P,
467
9 5
MODEL 388,5
25 00 SEE -314~ Solid
WE/5H
° 70
20 WE10H
J
F 60
WE07H
15
WE05H
40
10 30 WE03M
WE031
20
5
10
0 0
0 10 20 40 50 60 70 80 90 100 110 120 GPM
I I j
0 10 20 30 m'/h
CAPACITY
@E GOULDS PUMPS. INC.
SBNECA FALLS WW YOW 13ae
METERS FEET
,20 - 1 -T ; -MODEL 3885
35 SIZE 3I4" Solids
110 WE15HH
I
100 '
30
90
25 80
i
I
Q 70 i
= 20
J I
60 i
0
WEOSHH
50
15
i
40
10 30
20
5
10 - -
0 0 I
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
L - - ----I - I -
0 10 20 30 m'/h
Cs.IACITY
01985 Goulds Pumps. Inc Effective July, 1985
0 S-~$-9~ JYIP6~iZ`7 C3885
(J .L h In accord with Ih ; " dm. Code
e
COONTY
Attach.complate site plan on paper not loss than 8 1/2 x 11 inches In size. Plan must include, but S f ro
~
not United to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D.
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE :
PROPERTYANNER PROPERTYLOCATION
e r S e 1 h as GOVT. LOT sZ 111 S4'114SZZ7 T 2 N.R 7 W
PROPE TYOr W R"S MAILIdG ADDRESS LNOT 8 71 G BLOCK SU80. NAME OR CSM I
CITY, STATE ' ZIP CODE PHONE NUMBER []CRY []VILLAGE ~1 OwN NEAREST ROAD
6~y-3M a T Nw Z 60
(j New Cm*uc5on Use pq Residential / Number of bedrooms
Replacement ( j Public or commercial describe
Code derived daily flow ySC~ gpd Recormended design loading rate • 2 bed, gpd/ft2 -3 trench. gpd/lt2
Absorption area required -37J bed, ft2 .3r7 ~ trench, ft2 Maximum design loading rate • 5 bed. gpd/ft2L(p trendL gPd/ft2
Recommended infiltration surface elevation(s) 98.07 It (as referred to site plan benchmark)
Additional design / site considerations
Parent maleital ,'0 a be- v Flood plain elevation, if applicable fl
S - Suitable for system ooNVENrlocfAt m ocxdo NCA90U OPRESSURE AT•GRADE SYSTEM N FU HOLIMG TANK
U= Unsuitable V system OS j3U
T JR S❑ U ❑ s JO'U ❑ S a U ❑ S ou El S u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Modes Texture Structure Consistence Bajbay Roots GPD/ft
in. Munsetl Qu. a ConL Color Gr. Sz. Sh. Bed Tmnct
7.5%R YL A& e si l cif'- Gs -2 .3
Non a Sl" A' ~ 5 6 i < ~r C . Z~' ' S • G
Ground .3 2/-3z. 7,5>R1:-V,1 /vo✓) e S'd z ~5 m r C W
• 5 + ~O
elev.
97- 9' IL 3z 39 715 y lZ -L C 2 0/ 7,5 YA Y W-A S • 5 .
Depth to
limiting
h-dor
i I
T__
Remark's: j~j- t✓ / n' n 5 c5. 0~5 o n o r '
Boring #
0-/0 7'5 YR -f/.?- N e s; S G a s z '21-3
C1 Z /0-/9 Mort t s ' .Z f s~ r~ r•
Ground 3 19-7-9 17, 5 YA 4/y No r2 f, s 2 rY, s ~'k r» G , G
9- 57n 29,36 '7.5 YR ~'7/7_
C o4 75 Yg-'* • 6
Depth to AN 2 1995
limiting cD ST
(actor __O0W
Z8, -
s ~
Remarks: Sa.-„ tr
CST Name:-Please Primal /P Z7, Phono:
ua~so -
Address: 7/.5 3-?, E
SignalWC Date: CST Number:
Boring # fiorizo Depth Dominant Color MONO Structure GP(/ (111
in. Munsell Texture Consistence Bouiday Roots
Qu. Sz. Cont Color Gr. Sz. Sh. Bed :Tarn
13 / 0-9 '7- 5 he s L o.~ 5; ,n S h M a s z • Z • 3
Z 9-25 '7'5Y~y/Y Sd M7FV• Cra
Grprnd 3 ~5-90 7 , jHo, /~rl~. 25r,J elev.
7JZ1t`1b-i~9 '7.5 C 2 i 7-5 YR !Yg
S 2 s~ C t~ :5 1,4
Depth to jq_
smiting
factor
T®sf - .
3t
Remark's: Sd c41eQ k ~U .Cerma/2 feat sonC~ /oho. /VOV^
Boring #
131
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
FO z
Ground
elev.
fl.
Depth to
limiting
factor
Remarks:
Boring #
L'all-I
Ground
elev. t L
n
Depth to
limiting
factor
Remarks:
jj L-411 t i 1 1 in accord with It i`fii+F.''~ Wis. Adm. Code
` ..~..w.::a~nK> aRrsad COUNTY
• Attach.complelo site plan on paper not less than a 12 x 11 in;,hes in size. Plan must include, twt '
not Ginned to vertical and horizontal reference point (Ghl), direction and % of slope, scale or PARCEL 1.0.1
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
FROPERTYOWNER PROPERTYLOCATION
e r GOVT. LOT 5F t/l 5ZDVM.SZZ~ T 2 AR 7 8 (a W
FROPEM YOW (RD'S LWL UG ADDRESS LOT Jr BLOCK I SUBO. NAW OR CSM t
. -Z0<3 b /Line/ - / Zi /Vi4
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE JMTOWN NEAREST ROAD
13Q~~w/iti L,J~'• 5" 20Z (745) 6gy-39q c~M onl w
[ J New Construction Use Residential / Number of bedrooms
Replacement [ J Public or commercial describe
Code derived dally flow 50 gpd R de loading rate • 2 bed, gpd/ft2 •3 trench, gpolft2
Absorplioh area required -371 bed, ft2 37 5 trench, 0 um design baling rate • 5 bed, gpd4t2_~_trer>ch, gpd/ft2
Recommended Infiltration surface elevation(s) "o it (as referred to site plan benchmark)
Additional design / site considerations
Parent material /o o r>7 v Flood plain elev46on, if applicable A44 ft
S = Suitable for system o0NYMT10tM MOUND INGROUNOPRESSURE ATGPAOE SYSTt3(14 FILL F HaOM TANK ' q
U= Unsuitabte forsystem C1 S j3U jM S ❑ U [I S 'ou ❑ S ,OU ❑ S tl ❑ S "au
SOIL DESCRIPTION REPORT
GPD/fl
Boring # Horizon Depth Dominant Color Mottles Texture Structure
Consistence
in. Munsell Qu. Cont. Color Gr. Sz. Sh. BaxxJay Roots Bed Trer~fi
7,5 %R /L None s; l ~i>r G s - 2 .3
7 2 '7-.5YRy~y None s, 'l m Y c. Z~ •5 •G
Ground 3 21-3Z.75 -YR: y y Ivor)e zz S /n-~r CW • 5 •
elev.
97--Y-'fL Y 3Z-39 7 -5 c 2 d 75 YA 79 w~S s • 5 • ~
Depth to
!'uniting
3~ II
Remark's: a CA' / men q r ohs o n
Boring #
o -/0 7'5yR 3/z Al rl je sS rr~ Q S Z • Z ~ •.3
Z Z io-/9 '7.5y`~/`f None .Zfsd r~ w •5 -r?
Ground 3 8 5 YA 4/y No 4 e, s Z r>7 s m 4, G 5 to
elev. ' 281--V. `7"5YR ~'7/Z_
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Address: 8Zy
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CERTIFIED SURVEY NO. 291
Part of the SEq of the SW-1-4 of Section 24, T29N, T17W, Town of Hammond
County of St. Croix, State of Wisconsin
335126
UNPLATTED LANDS LEGEND
• 3/4"x 24' ROUND IRON R00
WEIGHING 1.502 LBS/L.F.
i.-X-x-x-X EAST -x-[-363.00'X-x-x-X-x w
' z
'000 00 o
00' 00 I . y M
O.k 00 A0 c. 3H
2 r-1 0• 0as
• _ L J 0 Z• I-WF-
Q'« °a r , f n Q• W>0
JAI N 1 EXISTING N J• X3Z
L _ BUILDINGS I M • 06
Y
t mom
.I---J I
1 1 LQT I o o
0 r j 1 117,430 S0. FT. o W:
hW, ;x C I I 2.7 ACRESa N
Q:I L_J i F-; SCALE
I"= loo'
Z.+ Z x 0 Z; 100 50 25 0 100
O
190' - EXISTING S 1/4 -SEC 2
090 OS UTH LINE OF THE SW 1/4 -SEC 24, T29N, R17W 0 trwn' T29N, RI7W
0452.78' WEST rp
U. S. WEST H`A/v 363.00' IA
UNPLATTED LANDS
I, Leon R. Herrick, registered land surveyor hereby certify:
That I have surveyed, divided, and mapped a part of the SE-4 of the
SW-14 of Section 24, T29N, R17W, Town of Hammond, County of St. Croix, State
of Wisconsin, more particularly described as follows:
Commencing at the Sq corner of said Section 24, thence W 452.78
feet to the..point of beginning;
Thence continuing W 363.00 feet;
Thence N 323.50 feet;
Thence E 363.00 feet;
Thence S 323.50 feet to the -point of beginning.
Said parcel contains 117,430 square feet more or less (2.7 acres
That I have made such survey, land division and plat by the direction
of Gordon Palmer.
That such plat is a correct representation of all exterior boundaries
of the land surveyed and the subdivision thereof made.
That I have fully complied with the provisions of Chapter 236 of the
Wisconsin Statutes and the subdivision regulations of the County of St. Croix,
and the Town of Hammond in surveying, dividing and mapping the same.
1976
Dated this day of zz:a~yE
2;L - - q
335126 APPROVED
ST. CROIX COUNTY
COMPREHENSIVE PARKS PLANNING
p- SCON AND ZONING COMMITTEE
o*`
LEON R. AUG 1 9 1916
HERRICK
MENOMONiE.
Q
T
wl& APPROVAL OF THIS MINOR SU3DIVISION
~
ass* aSuVol. 1 Page 291 DOES NOT MEAN APPROVAL FOR SEPTIC
SYSTE-M. REFER TO H62.20
t
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNERIBUYER
MAILING ADDRESS Zod
PROPERTY ADDRESS ~Saf;'q °
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE e' .5 ZIZ90 Z_
PROPERTY LOCATION S 1/4, SLJ 1/4, Section T 2 9 N-R )7 W
TOWN OF ,n-1 rn z~ ✓1 Cat ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER /vim
CERTIFIED SURVEY MAP AlAf VOLUME j PAGE 29 , LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system-
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
I
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement-that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
LAVe, 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. Cron
County Zoning Officer within 30 days of the three year expiration date
SIGNED
DATL Z_~fS - -
Si. Cron County Zoning Office
Govcrnmcm Center
1 101 Cann chacl {load
Hudson. W1 51016 t I;y;
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,/ yy ~G1?C ~i~Qs
Location of property S - 1/4 57,J 1/4, Section ,T_Z3N-R 7 ~W
Township Mailing address o3 w /Z [d
BQ/dLL~l~fh. rah _7~~eoZ-
Address of site -a rime,
Subdivision name 41d,4 Lot no. 111A
Other homes on property? Yes No
Previous owner of property G'~rc ors. 7"'allr2ev-
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? _ X Yes No
Is this property being developed for (spec house) ? Yes ,.Y No
Volume ?4/0 and Page Number 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.
II
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. , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Si na e o Applicant Co-Applicant
~-22 rS
Date of Signature Date of Signature
y
DOCUMENT NO. WARRANTY DEED THIS 51ACL R[a[avaO ro" RECOROINO OATH
1 I STATE BAIL OF WISCONSIN FORM 3-1995!
f 44'76'72 f ~
REGISTER'S OFFICE
'
Gordon ~
. E.....Palme.. ._and..Rosette.. D. Palmeri
St CROM CO., Mn
~ Reed for Record I
husband and wife as jo n., tenants I
I MAY 0 8 1989
1989
10:00 AM f
conveys and warrants to a~£nr'y...3chelxldds.2..sT.Cx...and.---
Sha r on...K..... S ch>zlhaa s.,_.. husband. ..an d.. w i f e,
fI bald.inq..aa__nurvivorzhip..mat.ital...prop-arty dOwde I
I
- -
R[TURN TO
the following described real estate in St.....Crolx............. County, State of Wisconsin:
Tax Parcel No:
Part of the Southeast Quarter of Southwest Quarter (SEk of SWk)
of Section Twenty-Four (24), Township Twenty-Nine North (T29N),
Range Seventeen West (R17W), described as follows: Lot One (1)
of Certified Survey Map filed August 30, 1976 in Vol 111",
Page 291.
TRANSFER
a In2.0 O
FEE
This 13 homestead property.
(is) jNXY *
Exception to warranties: Easements and restrictions of record.
Dated this - I-r- day of 19..89..
----.--(SEAL) ✓ . - (SEAL)
Gordon E.- -Par
------------••--•-•-----------(SEAL) _.Q-Q.Q¢.•. . (SEAL)
' ' - Ro.se.tte---D.... Palmer.
AUTERNTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
St. Croix County. 53.
- I
.
authenticated this day of........................... 19...... Personally came before me this 5.tb diy of
14................... 1989 the above named
Gordon E. Palmer and
Rosette..D....Palmer....
TITLE: MEMBER STATE BAR OF WISCONSIN)
(If not, -
authorized b
y 706.08. Wis. Stats,J ,
• ~•~j, to me known to be the person s........... who executed the
A 1t y: foregoing instrument and ack a the same.
THIS INSTRUMENT WAS DRAFTED QYQ :
Thomas A. McCormack
:...Pi1e~-
P ' - - - ~flf50.ti--......
.
Baldwin, WI 54002
' Notary Public -.S.t.._.C.roiX .County, Wis.
.
(Signatures may be authenticated or aekneg47 eg Hy Commission is permanent. (If not, state expiration
are not necessary.) F B04
date.
y-~s - , 199
"Names of persous signing in any capacity should be typed or printed blow their -i[nau-.
WARIIANTT DEED STATE BAR OF WISCONSIN R'i+•or.+in L.xai ItlwA I',, Inr
FORM ?Jo_ 2 - 1'182 6'n.