HomeMy WebLinkAbout030-1053-95-100St. Croix County I
Detail Sanitary Information
Computer #:
030-1053-95-100
Parcel #:
23.30.19.198b10
Municipality:
St. Joseph, Town of
Owner:
Low, John R. & Randy 1452
State Permit:
233463 Issued: 01
County Permit:
0 Installed: 01
St. Croix County Planning and Zoning - Cb t _4
Monday, September 12, 1011 of 3:I7:26 PM
Detail Sanitary Information � 1 3 (/" �/ Page 1 of I
Computer #: 030-1053-95-100 Sub/Plat: NA Section:
Parcel #: 23.30.19.198b10 Lot: 6 TNIRNG: T30N R19W
Municipality: St. Joseph, Town of CSM: Vol. 17 Pg. 4450 114 114: Govt Lot 3
Owner: Low, John R. & Randy 145� Run New Richmond, WI 54017
State Permit: 233463 Issued: 06/1411995 POWTS Dispersal: Non -Pressurized In -ground Permit: Re rent
County Permit: 0 Installed: 06/15/1995 POWTS Detail: Bed - Seepage Bedrooms 1 WI Fund:
POWTS Pretreatment: NA
Notes Notes
Issuer/Inspector AS Built Issuer/Inspector As Built Plumber Other Requirements
Jim Thompson Yes Jim Thompson Yes Zappa This cabin for seasonal use - maintenance
Tom Nelson Signed Tom Nelson Signed Off: No inspections will be done at a longer interval
than three years.
Maintenance Main Notification
Scheduled Pump Date Pw :c eduIed P m D Pum Notification
6/15/1998 6/15/1998 /n 04/2012006
67 412007 6/15/2007 IYi P� i�IGjr G
7/4/2013
Additional Notes Money Owed
Formerly lots 1 8 2 of CSM 5/1246, nka 6. Found $0.00
as -built attached to another permit, but Tom took
elevation shots on 2nd tank installed downstream
from the mg ou e n ga Ion lift
chzmBFr-Ta-nT-s-Ro-w-n-on--pT6rpMw-WO-Mnature
or further completion of inspection report, but he
did write down rod readings for final inspection on
back of permit paperwork (deed) see BOA files
formerly lots 1 & 2 of CSM 511346 notecard filed
with p�erml it � J"Af �
{U ew
Za// — oz*m f ?
, ai) *>
Ck
Wisconsin Department of Industry,
Labor and liyman Relations
Safgty and Buildings Division
GENERAL INFORMATION
PRIVATE SEWAGE SYSTEM
INSPECTION REPORT
(ATTACH TO PERMIT)
PpsrQltHold Pfihwe: ❑ City ❑ Village Town of;
CSIIT++BBIM Elev VYiI1 Insp BM Elev : BM Description:
(00,0 00.0 5P I'kilL ; K s�'q n vcsf
ELEVATION DATA
IANK INt*UKMAIIUN
TYPE
MANUFACTURER
CAPACITY
Septic
W4 t5 4L&
l p0D
Dosin
J570gae It
Aeration
If
Holding 7
TANK SETBACK INFORMATION,�eL Ar-ikii c t
TANKTO
P/L
WELL
BLDG.
Vent to
Au Intake
ROAD
Septic
NA
Dosing
NA
Aeration
NA
Holding
PUMP / SIPHON INFORMATION
Manufacturer I 13s
Model Number., ,I 4;;<7 W —
PM
TDHF`Lift , • 1Frictio System A TDH'/S•S3Ft Loss
For<emain ength f Dia. to Dist To Well
SIMABSORPTIO SYSTEM
County:
ST. CROIX
Sanitary Permit No.:
State Plan o
Parcel Tax No:
STATION
HI
FS
ELEV.
Benchmark
79
77
100
Bldg. Sewer
(o 2p
St/Ht Inlet
td
�SL'
..
St/ Ht Outlet
/•f fil
S 7
Dt Inlet
1
Dt Bo m
2
2'� Z
Header / Man.
Dist. Pipe
Bot. System
/%
Final Grade
0
h1
40V
(b Mn
04-J
44 '
20L(
BED / RENCH
DIMENSIONSI
Width/6,
Lengt S �r
No Of Trenches
PIT
No Of Pits
Inside Dia
Liquid Depth
SYSTEM TO
P/ L I
BLDG
WEL
LAKE TREAM
LEACHING
Manufacturer:
SETBACK
INFORMATION
CHAMBER
T pe �1
z/
r
r
/
r
200
Moe Number:
System{ o"V•
12-7
OR UNIT
DISTRIBUTION SYSTEM So ^
I
Header l Main old
Distribution Pipe(s)
x Hole Sae
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: St. Joseph.23.30.19W, Gov't Lot 3. Lot 1, Ridge Run
��- ��- °� mac✓, ��
Lor-
Plan revision required[]Yes []No
�d h
Use other side for additional information.
SBD-6710(R 05/91) Date Inspector's Signature
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
It
-� CANIITADV DCRSAIT ADDI If_ATIAN
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT N
-Attach complete plans (to the county copy only) for the system, on paper not less than
oc '3 -3 4�o 3
8'% x 11 inches in size.
❑ Check 9revision to previous 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
J---).Vk/ ,/pc,) Cam;.. 4
3 % %, S a3 T 30, IN, R /`t' E or
PROPERTY OWNER'S MAILING ADDRESS
LOT ff
BLOCK 0
/4/5"g ICni4rnE /f CAAJ
/
CITY. STATE I
ZIP CODE
PHONE NUMBER
SUBDIVISION NAME OR CSM NUMBER
EW I K�IMoN� GJ,
Svc,"7
IA. TYPE OF BUILDING: (Check one) CITY NEAREST ROA
State Owned VILLAGESron
TOWN 9: ,�sc/N rI �4GE un/
❑ Public 1 or 2 Fam. Dwelling-# of bedrooms L TAX NUMBEH(5)
Ill. BUILDING USE: (If building type is public, check all that apply) -
1 ❑ Apt/Condo
2 El AssemblyHall 6 ❑ Medical Facility/Nursing Home 10 ❑Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranVBar/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. JgReplacement 3. ❑ Replacement of 4. ElReconnection 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 30 ❑ SpecityType 41 ❑ Holding Tank
12 ❑ Seepage Trench 22 ❑ 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 16.SYSTEMELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gala/day/sq. ft.) (Min./inch) ELEVATION
ISO 300s?.Fr %/�sq.�r. • �(e 45'3. S5' Feet moo' Feet
VIL TANK
INFORMATION
CAPACITY
in gallons
Total
Gallons
III of
Tanks
N
Manufacturer's Name
Prefab.
Concrete
Site
Con-
Steel
Fiber-
glass
Plastic
er-
App.
p
New
isti
Tanks
Tanks
structed
Septic Tank or HoldingTank
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.
Plumber's Name (Print):
Plumber' (No Stamps)
MPIMPRSW No.:
Business Phone Number:
o�
7n&to:
1�� S 33t9S
r/5 3��— Aso
Plumber's Address (Street City, State, Zip e).
ry �T
W. COUNTY/DEPARTMENT USE ONLY
LiDisapproved
San)ory Permit Fee (Includes Groundwater
a
owing nt ture Stam
Approved
❑ Owner Given Initial
Surcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County. One Copy To: Safety 8 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:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
If. 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; 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-6M (R.11188)
96
84
72
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SECT. 100 TAB Effluent Pumps PG 101
DATE
January 1, 1986
r U M � •
MODEL SEVH- aw SESH- .iW 10w 20w
RATED HP 0.4 t 0.6 1 1.0 1 2.0
SOLID SIZE 3/4 BLADE 2 SPEED 34450 RPM
VOLTAGE * ; 60Hz 1 PH
M mom,
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■■■■■m1■■■■■■i
■■■■■"I■■■■■■1
■■■■■s1■■■■■■i
80 100
USGPM
* SEVH-4W: 115V or 230V, 208V
SESH-5W: 115/230V, 208V
SESH-10W and SESH-20W: 230V only
120 140
ABS PUMP hr. 140 Pond View Drive Meriden, Connecticut 06450
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PLOT B CROSS SECTION PLANS
ZAPPA BROS. EXCAVATING INC
PLUMBING UNIT ..
Jo�N
PRONJECT
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SP.Kf /AI S,6M AUSr NO
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FRESH AIR INLET AND OBSERVATION PIPE
APPROVED VENT CAP
MAXIMUM 12'
ABOVE FINAL GRADE
MAXIMUM OF 42' ABOVE
PIPE TO FINAL GRADE
MARSH MAY OR SYNTHETIC COVERING F- l
MINIMUM 4' AGGREGATE
OVER PIPE
DISTRIBUTION PIPE
ELEVATION BED G' AGGREGATE •
BOTTOM PER SOIL BENEATH PIPE
3 Essa •
FT. —�
4' CAST IRON VENT PIPE
SIGNED:
LICENSE: 339s
DATE: G ' % — SS -
TEE
SOIL TESTING BY:
1-�rf0U,Ty' JoAyscw
PERFORATED PIPE BELOW
COUPLING TERMINATING
AT BOTTOM OF SYSTEM
witsconsin Department of Industry, SOIL AND SITE EVALUATION REPORT
Labor and Human Relation.
Dihsion of Safety 6 Buldnas '- ----
Page / of 3
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
PARCEL I.D. 0
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION
REVIEWED BY DATE
P OPERTY OWNER:
a k 0h ip LWGOVT.
PROPERTY LOCATION p
LOT 24 3 1/4 1/4.S Z3 T 30 ,N,R 17 E (or) W
PROPERTY OWNERS MAILING ADDRESS
8L
LOT tT
BLOCK •
SUB . NAME O CSM rf
P,
Z z o �c, A
L- s i,46
C?SJ4TTEu ZIP CODE PHONE NUMBER
[-]CITY[]VILLAGENEAREST
ROAD
L
[ [ Nov Construction Used('[ Residential / Number of bedrooms U.jY, (] Addition to existing building
K Replacement [ I Pudic or commercial describe
Code derived daffy flow gpd Recommended design loading rate . _ bed, gpoltt2,&_trench, gpo1ft2
Absorption area required bed, It2 trench, ft2 Maximum design loading rate — bed, gpd/112O, Itrench, gpdM1
Recommended infiltration surface elevation(s) " (as referred to site plan benchmark)
Additional design / site considerations TR llN c+J(s -ro BE I-ae;r m -)-H e 4640 U".I L
Parent material Flood plain elevation, if applicable It
$ = SU1lable 10r System
U= Unsuitable for stem
l�(TIONAL
S❑ U
D
dJ S❑ U
W GROUND PRESSURE
S❑ U
AT -GRADE
❑ S 1� U
SYSTEM N FILL
❑ S 11
HOLDING T
❑ S U
Boring #
13
Ground
elev.
Depth to
limiting
>lb.
Boring #
IN
ZIs
Ground
�O.
Depth to
limiting
factor
SOIL DESCRIPTION REPORT
Horizon
Depth
in.
Dominant Color
Munsell
Mottles
Qu. Sz. Cont Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Bourbafy
Roots
GPD/ft
Bed
Tienic l
Q-IS
3
SL
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Remarks:
Remarks:
-Please Print
sort
Phone:
Spnaturra;�JA �j �� \c�Y'Y� Date: p� CST Number:.3A,,4 I
PROPERTYOWNER RUbDLP LOW SOIL DESCRIPTION REPORT Page of
PAMMIAP
Boring #
13
Ground
elev.
ft.
Depth to
smiling
factor
Boring #
13
Ground
Alm,
01ft.
to
M"
factor
Boring #
13
Ground
Depth to
limiting
factor
Boring #
13
Ground
elev.
tt.
Depth to
limiting
factor
mom
ffi-TAPIMM
Remarks:
Remarks:
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Remarks:
Remarks:
SODeMO(R.05/92)
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER---J09,ol koLo
ADDRESS /5/SS Aoae -PHN
AJE� #f�CHIPIOA40 Se/V,rJ /
SUBDIVISION / CSM# 5- / 3 Y� LOT #
SECTION a3 T 30 N-R /9 W, Town of S-r Josco/+
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
7S0 fp+r&-. 5EP7.0 A,sT L,4.tM11df 019N.np F4&V. - 413 V6'
-7" C<vSFo Cut ��,soL .tr o.d JJeP rc'e" I 4"A1
rt1f0uC,+r 01?JeL- Ay 14feA 4-1,N. -1a"C�v,0'
� " PVC Sc lI DVO �pc6 IHA,,,j / 9sr ' Ao.J L
q -ro 40f*Al ,k K Pr ew rhdfP
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S�Pr,G T�f�+K
�cc J)f1 UE ,MY
INDICATE NORTH ARE
AJn Sc.4t£
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
Svl ye .mil
C" u As
I i EJ. =,0000
BENCHMARK: S.cn/ Asr �<<v. 10(3,0"'3
ALTERNATE BM: SPor oN wouQ NEXT TO 4J0e/? OF /QES.Loe.vcf
f4ed. y9.0G'
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity: ?s0 (p,41- /000eogc•
Setback from: Well So' House 5�Other
Pump: Manufacturer AeS Model# SfSr/-SwSize
Float seperation •90'
Alarm Location .gyp" A ouE
Gallons/cycle: /92.'78 G-z!5
aAj Ste-., , rc tJ
SOIL ABSORPTION SYSTEM
Width: /G ' Length 59' Number of trenches
Distance & Direction to nearest prop. line: -,u7.4
Setback from: well: /4-0' House i00' Other J?5
ELEVATIONS
.7G"
COA P.46E '
Building Sewer 4G.ag ST Inlet. ST outlet gy SS
PC inlet PC bottom y"?• /2 Pump Off 0
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: Cc✓J
LICENSE NUMBER: ,KjD,PS 3395
INSPECTOR:
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ST. CROIX COUNTY CERTIFIED SURVEY MAP
LOCATED IN PARTS OF GOVERNMENT LOTS 2 81 3 OF SECTION 23,
T 30 N, R 19 W. TOWN OF ST. JOSEPH, ST. CROIX COUNTY,
W ISCONSIN. s ��
SCALE: ONE INCH EQUALS ONE HUNDRED FEET
100' 0 100' 200' 300,
N
W + E
S TRACTS
REL05T385-
L-AND AREA
TO HIGH WATER l2O
143 - �j N 85° 2S 27" E. 241.45'
BASS
LAKE COP
CD0
CDO
01 LOT
/ m 95,026 SO. FT. (2. IS
in
m
K
In
N
3
ID
n
to
Q
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— 1.5
LEGEND
O I"X 24" IRON PIPE SET WEIGHING 1.68 LBS./LIN. FT.
° 3/4;' IRON PIPE FOUND
• 3/4"IRON RE -BAR FOUND
o 1/2" IRON PIPE FOUND
E 1-1/4" IRON PIPE FOUND
-- +�— EXISTING BARBED-WIRE FENCE
• �-0— EXISTING WOODEN FENCE
THE SOUTH LINE OF GOVERNMENT LOT 3 IS ASSUMED
TO BEAR N. 890 48' 58" W.
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o3ciano W.23'.27"E z
EX/S r/NG HOUSE
v x sruv6
OUrRUILO/N6
UNPL A TTEO_ L AN05
S 890 48' 58" E. 400.72
LOT 2
299,351 SO. FT (6.87 ACRES)
TO MEANDER LINE
101,647 SO FT ( 2.33 ACRES)
;� THE SOUTH L/NC OF GOVERNMENT LOT 3
v) N 18°-04=47"E /
r
/
W TO EDGE OF LAKE
I
r+i
N. 890 48' 58" W. 515.08' f
EwSrrN6 HOUSE
ro
°
87 54' 36" W. 160.81' 1
�— S. I° 59' 08" E. 32.10'
0
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UNP4AI I�� L.4/VjJS
tIn
N
NO
3
h� EXIST/MS 64RA6£
o
PRIVATE ROAD EASEMENT FROM PROPERTY TO TOWN ROAD (12 MILE!)
00
VOL. 300, PAGE 547, NO RECORDED WIDTH
I VOL. 295, PAGE 547, 33' WIDTH
138�'
Z� N. 89° 48' 58" W. 261.56'1:1
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SECT/ON 23
COUNTY MON(
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER 2 Z�. a
MAILING ADDRESS fr lz v r_ IZu N - /(ire
PROPERTY ADDRESS / 5')-6 IZ 1 :3) AffM M ► ! . eO -
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE
PROPERTY LOCATION Lo 7 JK, .3 �f�, Section �3 T .� � N-RAW
TOWN OF S r . r= r " , ST. CROIX COUNTY, WI
SUBDIVISION
LOT NUMBER
CERTIFIEDSURVEY MAP , VOLUME=f , PAGELOT 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 maximµm 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 d returned to the St. Croix
County Zoning Officer within 30 days of the three year expiration
SIGNED: " N Lv w
c+. R rc e r r}rr0 (V- rsy �e rz
DATE: Tz A m y u o .-. r:* L� v
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016
11/93
8 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.
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Owner of property V u D o � P H E , 1.ee / imm a e�. r-- ., n. -- s
Location of property 4T3 ] # i t , Section Z 3 , TAN-R L 5—w
Township's Mailingaddress J2�,�
Address of site
subdivision name Lot no.
Other homes on property? Yes '� No
Previous owner of property 12 Pf
Total size of property 'Z , 3 3
Total size of parcel
Date parcel was created 5 y
Are all corners and lot lines identifiable? ✓ Yes No
Is this property being developed for (spec house)? Yes ✓ No
Volume 2:J and Page Number c',' as recorded with the Register
of Deeds.
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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 Hap
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. , 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.
Wnature of Applicant Co -Applicant
Jo,_N Z.
- - 3 1 -S
Date of Signature Date of Signature
Parcel #: 030-1053-95-100 03130/2005 12:16 PM
PAGE 1 OF 1
Alt. Parcel #: 23.30.19.198B-10 030 - TOWN OF SAINT JOSEPH
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address:
Owner(s): ' = Current Owner
' LOW, JOHN R
JOHN R LOW
RAILSBACK RANDY
RAILSBACK RANDY
3406 SE 18TH PL
CAPE CORAL FL 33904
Districts: SC = School SP = Special
Property Address(es): ' = Primary
Type Dist # Description
' 1452 RIDGE RUN
SC 3962 NEW RICHMOND
SP 8040 BASS LAKE REHAB DIST
SP 1700 WITC
1(�
Legal Description: Acres: 6.003
Plat: 1628-CSM 17-4450 030103
SEC 23 T30N R19W PRT GL 3 FKA PT LOTS 1
Block/Condo Bldg: LOT 06
& 2 CSM 5/1346 NKA CSM 17-4450 LOT 6
(6.003AC)
Tract(s): (Sec-Twn-Rng 401/4 160114)
23-30N-19W
Notes:
Parcel History:
Date Doc # Voupage Type
06/12/2003 725621 2274/032 AGREE
01/31/2003 707745 17/4450 CSM
07/23/1997 786196
2004 SUMMARY Bill #: Fair Market Value: Assessed with:
5177 341,500
Valuations:
Description Class
RESIDENTIAL G1
Totals for 2004:
General Property
Woodland
Last Changed: 07/08/2004
Acres Land Improve Total State Reason
6.000 255,800 80,200 336,000 NO
6.000 255,800 80,200 336,000
0.000 0 0
Lottery Credit: Claim count: 0 Certification Date: Batch #:
Specials:
User Special Code
040-OTHER ASSM'T
Category
SPECIAL ASSESSMENT
Amount
284.43
Special Assessments Special Chargaas Delinquent Chargas
Total 284.43 U 00
Parcel #: 030-1053-95-000 D6/27/2D05 04:41 PM
PAGE 1 OF 1
Alt. Parcel #: 23.30.19.198B 030 - TOWN OF SAINT JOSEPH
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address:
Owner(s): ' = Current Owner
JOHN R LOW
' LOW, JOHN R
3406 SE 18TH PL
CAPE CORAL FL 33904
Districts: SC = School SP = Special
Property Address(es):
' = Primary
Type Dist # Description
SC 3962 NEW RICHMOND
SP 8040 BASS LAKE REHAB DIST
SP 1700 WITC
Legal Description: Acres:
0.000
Plat: 0324-CSM 0511346
SEC 23 T30N R19W PT GL 2&3 LOT 1 OF CSM
Block/Condo Bldg: LOT 01
5/1346 NKA PT CSM 17-4450
Tract(s): (Sec-Twn-Rng
401/4 1601/4)
23-30N-19W
Notes:
Parcel History:
Date Doc #
Vol/Page Type
01/31/2003 707745
17/4450 CSM
07/23/1997
1218/35 QC
07/23/1997
7671388
2005 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last changed: 04/12/2004
Description Class Acres Land Improve Total State Reason
Totals for 2005:
General Property
0.000
0 0 0
Woodland
0.000
0 0
Totals for 2004:
General Property
0.000
0 0 0
Woodland
0.000
0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch #:
Specials:
User Special Code
Category
Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 AO 0.00