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Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Laborand Human Relations INSPECTION REPORT ST. CROIX
S&fety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
PefirTkIlderd~p~,~: ❑ City ❑ Village Town of: State Plan o.:
Hudcon
CST BM Elev.: l , Insp. BM Elev.: BM Description:
Parcel Tax No.:
TANK INFORMATION ELEVATION DATA 7/ _S
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic e~ ~aS Benchmark lGb,
Dosing Aeration Bldg. Sewer 7 O '
Holding /Of. Inlet
TANK SETBACK INFORMATION St/,ff Outlet
5, s. sF
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake IV(
Septic NA Dt Bottom
Dosing NA Headed „p 93 /,p ,
Aeration NA Dist. Pipe
3,G.'~ `
Holdi,pq-'fT Bot. System
/3' PI o '
PUMP/ SIPHON INFORMATION Final Grade
C~i
Manufacturer Demand -/J`AS'
a
Model Number GPM
TDH Lift Fric Sys
Flea
Force main ength Did. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Lengt d/ No. Of Trenches PIT No. Of Pits Inside Dia. uid Depth
DIMENSIONS DIMEN
SYSTEM TO P/L BLDG WELL LAKE/STREAM LE Manufacturer:
SETBACK
INFORMATION TypeO rir, CH BER Model Number:
System: -Lrti,cS /SSA, OR UNIT
DISTRIBUTION SYSTEM
Header Distribution Pipe(s) x rHQIe Size x Hole ng Vent To Air Inta
Length Dia. LL Length. Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At- ae Systems On
Depth Over Depth Over xx Deptth xx Seeded/ Sodded xx Mulched
Q~W/Trench Center Trench Edges Tops~l ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.),-/45 1~~t l
LOCATION: Hudson.10.29.19W, SE, NE, Lot 5, Zephyr Lane
f
Plan revision required? ❑ Yes allq`o
Use other side for additional information. o?
SBD-6710 (R 05/91) Date Inspector's Signat re Cert UNo
SANITARY PERMIT 51L • Cron` COUNTY
713ILHR TRANSFER/RENEWAL UNIFORM PERMIT #
(PLB 67-T)
PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER:
PROPERTY LOCATION: CITY:
VILLAGE:
' '/4 F '/4,S o ,T,,2 N,R If E (or) TOWN OF: ML WSo,rJ
LO /N --UMBER: BLOCK NUMBER: SUBDIVISION NAME: ,t NEAREST ROAD, LAKE , OR LANDMARK:
A
PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO:
NAME: SIGNATURE: NAME: PHONE NUMBER:
k, T er I L✓i[li~l~ 5~~~~-a-Gfet
ADDRESS: v , PHONE NUMBER: ADDRESS:
ec- 5- 41.E sotJ
~ls
/VV~~ tt!!
I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this
property.
15
PLUMBER'S SIGNATU E: TPRI S PLU B R NAME (IF CHAED):
PLUMBER'S ADDRESS: PREVIOUS P MBER'S ADDRESS:
MP MPRSW NUMBER: PHONE NUMBER: MP/T~ MSVPNUMBER: PHONE NUMBER:
pis ► 3~~ -3/~ l ( ►
IGNATU E OF 1 DATE APPROVED: DISTRIBUTION: Original - County
/ p Copy - Bureau of Plumbing
zC0 < Copy - Owner
DILHR-SBD-6399 (R. 5/82) Copy - Plumber
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Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water Systems
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size. " C O f
• See reverse side for instructions for completing this application State Sanitary Permit Num er
-2 737
The information you provide may be used by other government agency programs ❑ Check it r vision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION
Property Owner Name r Property Location
SE 1/4 v4, S 16 T cZ , N, R
Property Owner's Mailing Address Lot Number Block Number
:Z9 ;Ln 40,214519,0,e, e # It)
Cit , State z,p Code Phone Number Subdivision Name or CSM Number
r M
1(6a-) Y-41-46b u ha
II. T P F BUILDING: (check one) ❑ State Owned 1f ]Nearest Road
it , Public 1 or 2 Family Dwelling - No. of bedrooms ` Town of Z 09A
Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) - e
1 E] Apartment/ Condo 0~Ic- /QD ? ~ ' Q
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. R, New 2. ❑ Replacement 3- ❑ Replacement of 4. ❑ Reconnection of 5- ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued- Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 JRSeepage 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- Fina ra e
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
6 00 75-6 e. g , g 9s? o.~. Feet fol. Feet
VII. TANK Ca
in aclt
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 oF44o 6P@-Tawk O - e ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
PI mber's Name: (Print) r r's Ig ture: o S a ps) rPJAAPR6V#-4O.: Business Phone Number:
PI mber's Address (Street, City, State, Zip Code):
0 ril 5 t / li iz
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing Agent nature o St ps)
Approved E] Owner Given initial Surcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS j
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite-sewage systems must be properly rri. gQUined. The septic tank(s) must be pumped by a licensed pumper whenevef
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. I
To be complete and accurate this sarutary 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 1/2 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 contamination investigations
and establishment of standards.
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Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3
Labor a TV Hurnan.Relations
Divisi--A of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
CrOI x
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
C-->ervL° Ke. GedfitOr SIG 114 NE 1/4,S 10 T 2.9 N,R 10~ t) W
PROPERTY OWNER':S MAILING DDRE LOT # BLOCK # ;OWN ED. NAME OR CSM #
920 fa4S1( e. c, SA 20g 5 - CITY, STATE IP CODE PHONE NUMBER ❑CITY ❑VILLAGE NEAREST ROAD
Co CoYOVe RA Q S501(o (bl2) y59 ~Ig ~ 14ud,-SO Ze r
New Construction Use DC1 Residential / Number of bedrooms. y [ J Addition to existing building
j J Replacement [ J Public or commercial describe
Code derived daily flow 60C) gpd Recommended design loading rate 0 , to bed, gpdM2 0 .'7 trench, gpd/ft2
Absorption area required X58 bed, ft2 _7tr-0 trench, ft2 Maximum design loading rate 0, -7 bed, gpd/ft2 0,8 trench, gpdm2
Recommended infiltration surface elevation(s) -40 b,e d 6krmi, r\ed ft (as referred to site plan benchmark)
Additional design/ site considerations sySltm-Ao be_Lr~s -t1Yd_~~~r~ o~ 4 Yavfj
Parent material Flood plain elevation, if applicable /U ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem 0S ❑ U >d s❑ U 9S ❑ U El S 21U E] S 0 u1:
❑ S RU
SOIL DESCRIPTION REPORT erdy-nck. - 0 Dq-0'5-q--'S re r
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trend)
»f I 0- o 2-.11 sr1 1 fab m-Pr aS c2 .2 I ,3
-7.5 Y 3/i 5,11 Z m O.,b M'Fr CS fl 0-5- 0 ro
Ground 3 I9-31 1o Y 3/ _ s•2 m5bK rn-dr- C.S I , 5 0,
elev. m F
q4.-7 ft. y 31-3 ~q__ ►~y6 ~/1 5•i [ 2 nr\5_ K m-Fy- C5- N(~ I\J
sare1
Depth to 5 37-145 D K -3/3 raV'tl ry\l 0.9J
l0,8
imiting factor b 4s--7q to Yr2 5/ 5 ►?,1 - 0~ 7 0~
Remarks: Apr%zon 4 2- Kas S008e r 3 Somt SdrA
Boring #
- 5,11 1 fabK MTY- as (22 0,Z 0, 3
o w
7
<:.....x:. k#' 2 I5--24 7 5 yK 3/Z si) 2 moLb ,r C S F I aS d. (O
3 24- 36 10 3/ _ 5 1 ~r G~ S ! d
Groufld ! Gm
elev. - 36-41 y+c 10 ie-4& it a °/t 5,1 2ms6m4v- GS Ule, Alm
g~ft. 5
Depth to S' 41 (G3 ,o . 3/a rauc1 W - 0.
li
miting _ o S 0 w.l 0► y
tactor
Remarks: Y) Zon -R-I m150 Z f
CST N Please Pint + Phone: J , IS
J
p
nsa2 t'VI )Nye. A W1 5 Do
e r Date: 1O_ 0~ q CST Number:
r
PLOT PLAN Page Z of Z
f►~
Property Owner ErKc, ~e.,e N_
Legend. Legal Description Lo}5tyY,l~cty-}~ BM = ~~rw
SE %40~+K,LhelhiSta, `0,-r29tit,Rl9
Town, o~ I~Ud60r>> SA. Cro ik Co,~ WibcOr,SIyt
= soil boring w/backho(
z~ p h y r t-a~rc
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d
E4 4~.7 ~ G
TH14 is art aold-fiti 0v, An
rtpor.} c0m01-C+#-d o9-OS-9S
Cour~~ on Si-}c : 10-03-95
~ ~ ' ,Born ~ ( p~iscDrt~-'iv~utd -
~ ~ Sys { cry -4d .bc. to ca# eo! -Fos-
F~ 9~6' So~tr~d o~ lob
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Signed CST
Date I0-03-95
Wsconsiy~Oepartment of Industry,
Labor and'HuMan Relations SOIL AND ` L U A T I O N REPORT Page I of 3
E.&AMon oFSafety & Buildings in accord ILHR 83 05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper notless than 8 1/2 x 11 ches in size. Plan must include, but `Jf . Cro r X
not limited 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
PROPERTY OWNER: PROPERTY LOCATION
Gene 21 Ke -G WT--LET` S' 1/4 /39 1/4,S 10 T 29 N,R 19 6(Qr)'W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM #
7 q2O kor+sla4e Av,-. 4Z01? S - 3.trKh4r~-
CITY, STATE ZIP CODE PHONE NUMBER QCITY QVILLAGE TOWN NEAREST ROAD
Co+ e GM-Je MN S50) (o (bjZ) L15q- I4 y0 dc.:-or- Ze Syr Lan-2
New Construction Use DQ Residential / Number of bedrooms [ j Addition to existing building
(j Replacement [ j Public or commercial describe
Code derived daily flow' 600 gpd Recommended design loading rate bed, gpd/ft2 0,_ trench, gpd/ft2
Absorption area required bed, ft2 ZO trench, ft2 Maximum design loading rate 01.1 bed, gpd/ft2 ®Lq trench, gpd/ft2
Recommended infiltration surface elevation(s) 4o be d t_4 rrri, n,- d ft (as referred to site plan benchmark)
Additional design / site considerations sys+em 4o tre `tnrta6 fJ '.n tay e.C ON sand ( !a-MVP,(
Parent material Flood plain elevation, if applicable nl fi It
S = Suitable for system CONVENTIONAL 7' MOUND IN-GROUND PRESSURE AT-GRADE 7S-YSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem faS O U lSI S O U 15S ❑ U ❑ S tgU 4i S EI U [IS RU
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
-w .s t - s; I I o.~K m ~-~r cts 2 Z 3
Z t4-2g 7-s 312- - s~ 1 ► a.b m ~r c s 0. Z- 3
eS
Ground 3 7-S-35• lb YR3J4 st► 2 sbK rn-Ir
elev.
95.96ft J0YP_ 3 Ib lvli rox 4 si l Zmsbl: M+1 o.i
Depth to 5 y6-45 Io v i2,+/~ sand to - - 0.7 ' 0
limiting sroueJ
factor
>C
Remarks:
Boring #
€ 1 -15 2.s/) s'f t~obK Moir a
0 m CZ 0 2- .3
I
Z- Z x•33 to K b s• ► fa_bK _S
C_ 0, Z 0.3
3 -4 f0 1' r t EroYeu S~1 LmsbK fm~', CS r
Grout
elev. ,f - -
46-V 10 Yr-'-11r, carat f' r M1
~ltt -I ho
sroujf Depth to
~ .limiting
factor
Remarks: [
I " Name'r-Pl se Printl Phone:
o . E-}p !'f S'~2l-''~ 15 268' - ~I R t 5'
Addr
't1i'1 1s, Ave, .4 2x LI001 _
Signature Date: CST Number:
PRUVERHUWNER SOIL UESCRIP'TIUN REPOR'll Page, ~-of
PARCEL I.D. a1
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouxfery Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
3 1 0- i 5 YK 2.S/ ► - SO t ) ('ab ~rnY as C2 3
h
2- 13-20 312- 5iI nn q cs F-/ 0,Z 0,3
Ground 3 3 m %bK mf'r C
elev.
%.3 ft. y - Z io Y 31Io YK6 l0 4 ~rI 2msbK m~'~ c i I N12 rlP~
Depth to S 2-4 b V 10, 4 sari. 4 0 5 ~A - -
limiting el a.? 0.~
factor
Remarks: 1-brkwn Z has some vo-u e-I ; Narizor, has snme card YauA P rnix cd r
Boring #
I p-t3 5Y 2.5 5 1 I -F abK v~J cl' CZ
►3-25 o y 3I 41 I 2rn--bK My 'r- -F S 0.(o
Ground 3 26-357 5-1 R 3 io O iCi 10Y44 A, :511 Zrrtsb K m-Pr G ~I ti K
elev. 35- Io L4G arc. C~ m 1 - 0 .'7 ; O,S~
%A ft
3ra'~I
Depth to
limiting
factor
Remarks: Pori-zon Z has wn^e graveA
Boring #
1 -rz ~Y z,S - I dab mVfr a.s c 0, 2-1 ,
-2(o 5
10 vv VC l 0 rrml i_ I 0, 0.$
1,53 a
Ground 3 -3~ l o 4 Me io Yf-(- 14 e S'11 I 4~0lb K mfr c vi -0 N
elev. ~_qp y s S
i
a5g5ft.
sraue.t
Depth to
limiting
factor
?g~~r
Remarks: de r'.Zort 3 has sor-,ecarol
Boring #
I ~
Ground
elev.
ft. rifV,
Depth to
limiting N I )~I )'~!',h
factor I li;t
Remarks:
SBD-8330(R.05/92)
Page 3 of .3
PLOT PLAN
Z *1 r 9YQ55
Property Owner EiKC,C~corge Legend: Legal Description Lo -S, GurKVae-4-, BM oF,nel~I tncepo~ sawi-1,
1&t co^phe-r
S~~y off-e AjE%y, Sect-'soh ~O •r29A1,t~,f9ti. aSsuwA-ed I00.01
'Tow, of ffadsoh) s+, Crt4x (20t f 4yj WAscons1 v~
0 = soil boring w/backhoe
1~J ILF11Q r{$ s-c-l-loue'c ~y~lern~
Zip hyr LartE
i
❑taz
EL 46.fo' p 131
/ t:t.45.85! ~ QDr
P o x
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IV,
F1.46.3
L0GAT10N 5 KE-10*
Q SS 814 EL95A5/ Elq~1 i
i ' I Zephyr l.or
i J
Signed CST
M03707
Date 5-er. -,S `ct9S
j
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
MAILING ADDRESS '71,. O 4~ai
PROPERTY ADDRESS l _~t k ^ 4 h
(location of septic system) Pl ase obtain from the Planning ept.
CITY/STATE
G~
PROPERTY LOCATION r= 1/4, IV F 1/4, Section ~D T M~ N-RW
TOWN OF CTU~ S[rr\ ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP , 0 U1 ,z-AGF,:: LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year expiratio date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property "('h€, U. F 'L~'e
Location of property SC- 1/4 _1/4, Section t(! T qq N-R ~ W
Township cA 5ay, Mailingaddress '1011(] 14fe,(A _-11p A,,
'~/^1
Jj} /y~~ ~ c .7 la am'5nlj
V„~✓V GT .
I I
Address of site 7 e b1 ` (v4111(~
Subdivision name - 6k fyhg jp 544 -i'V' Lot no. _
Other homes on property? Yes~_No
Previous owner of property Q AL
t.~
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
Vol 1I143
ume l and Page Number 43 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 6n Uqffice of the County Register of
Deeds as Document No. 3 and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
d
Signat re, f AP', ant Co-Applicant
Date of Signature Date of Si nature
9
j STATE BAR OF WISCONSIN FORM 1 - 1982
534669 ~ WARRANTY DEED ~
DOCUMENT NO. voi. 11400 PAGE 14 REGISTER'S OFFICE
ST. CROIX CO., WI
Rai d for Record
This Deed, made between Dale G. Wucher
and Sandra S. Wucher, husband and wife OCT 6 1996
09 f. said Dale G. Wucher a/k/a Dale George Wucher
"-0 , Grantor, 8t 8: 30 A.M
and Eugene J. Eike and Jodi M. Eike, husband and 4'.sU"A. OA&
wife as survivorship marital property _ Register of Deeds
2 said Eugene J. Eike a/k/a Gene J. Eike
D 21 _ Grantee, 0ftni~ qlt c~ ti~-t~
"i THIS SPACE RESERVED FOR RECORDING DATA
= Witnesseth, That the said Grantor, for a valuable consideration
Cn NAME AND RETURN ADDRESS
i D conveys to Grantee the following described real estate in St. Croix Heywood & Cari, S. C.
• tU Zj County, State of Wisconsin:
204 Locust Street
W- Hudson, WI 54016
I C -J Lot 5, Burkhardt Station, Town of Hudson, St. Croix
County, Wisconsin _
.71 C
(Parcel Identification Number)
i
+t '
4 Ya
This is not homestead property.
( (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And - Grantor
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
easements, covenants and restrictions of record, if any
and will warrant and defend the same.
Dated this 5th day of October 19 -
(SEAL) w•~ (SEAL)
* * a/k/a Dale George Wucher
(SEAL) 42"'2(SEAL)
Sanarn S Wucher
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
SS.
St. Croix County.
authenticated this _ day of 19 Personally came before me this 30th day of
September , 19-5- the above named
nalP G WurhPr and Sandra S_ WurhPr
* Hnghand S Wife
TITLE: MEMBER STATE BAR OF WISCONSIN said Dale G. Wucher a/k/a Dale George Witcher
(If not, _
authorized by §706.06, Wis. Stats.) to me known to be the persons who executed the
it P;eg t nstrument and ac nowle e t same.
THIS INSTRUMENT WAS DRAFTED BY
Heywood & Cari, S.C.-by Walter Hodynsky J ne Terke sen
204 Locust St. Hudson, WI 54016 Not Public St. Croix County, Wis.
(Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date:
I
~necessary.) May 9 , 19__99-_.)
'i
E TERKELSEN
*Namcs ut persons signing in any capacity should be typed or printed below their signatures. `10tdry Public
WARRANTY DEED STATE BAR OF CISCONS17NS tG ofWisconsin Wis nsin Legal Blank Co.Inc.
FORM No. I Milwaukee. Wis.
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