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ws Qr.zin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
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 8 1/2 x 11 in~5~e. Plan must include, but St. Croix
PARCEL I.D. #
not limited to vertical and horizontal reference point (BM £ ~C0enct ° ptslope, scale or
dimensioned, north arrow, and location and distance; niif road`' 030-2005-30
APPLICANT INFORMATION-PLEASE PRIN,,,T qf~,L INFORMATION` REVIE Y DATE
s =r
PROPERTY OWNER: PR TY LOCATION
Gerald P. Deborah A. Schoutij - G0 T NE 1/4 SE 1/4,S 33 T 30 N,R 19 fir) W
PROPERTY OWNER -S MA!IING ADDRESS ; 0; BLOCK # SUBD. NAME OR CSM #
589 125th. ve. + ja na na
CITY, STATE ZIP C ONE NUMBER ❑VILLAGE DOWN NEAREST ROAD
Hu n, WI. 54016 (71, 54.9-68f8 St . Joseph 125th. Ave.
New Constructi Use Residential / Number of bedrtlo -2 . 3 [ [ Addition to existing building
jx[ Replacement [ ] Public or commercial describe
C aily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 - 8 trench, gpd/ft2
Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 - 8 trench, gpd/112
Recommended infiltration surface elevation(s) 95.25' ft (as referred to site plan benchmark)
Additional design / site considerations n
Parent material outwash Flood plain elevation, if applicable na It
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem El S ❑ U LAS ❑ U EIS ❑ U [3s ❑ U ❑ S ®U ❑ S ~MU
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence) Roots GPD/ft
in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed Tm-nch
1 _ 1 0-13 10yr3/3 none 1 2msbk mfr 9w 2m .5 .6
ft~ 2 13-29 10yr4/4 none sil lfsbk mfr gw if .2 .3
Ground 3 29-39 7.5yr4/4 none sl 2mgr mfr gw na .5 .6
0 1
115 ft 4 39-84 7.5yr4/6 none S Osg ml na na .7 .8
Depth to
limiting
factor
+84"
Remarks:
Boring # 1 0-10 10yr3/3 none 1 2msbk mfr gw 2m .5 .6
2 2 10-19 10yr4/4 none sicl 2msbk mfr gw if .4 .5
U
3 19-25 7.5yr4/4 none sl 2mgr mvfr gw na .5 .6
Ground
elev. 4 25-80 7.5yr4/6 none S Osg ml na na .7 .8
96.95 ft.
Depth to
limiting
factor
+80"
Remarks:
CST Name:-Please Print Gary L. Steel Phone: 715-246-6200
Address: 1554 200th. Ave., Ne -Richmond, 1. 540-.17 10-13-9 cstm 02298
Signature: Date: CST Number:
i
PROPERTY OWNER Gerald Schouten SOIL DESCRIPTION REPORT Page _2. of 3
PARCEL I.D. # 030-2005-30
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Du. Sz. Cont Color I Gr. Sz. Sh.
Bed iTrench
1 0-8 10yr3/3 none 1 2msbk mfr gw if .5 .6
'3
2 8-20 10yr4/4 none sicl 2msbk mfr gw if .4 1 .5
Ground 3 20-36 7.5yr4/4 none sl 2mgr mvfr gw na .5 .6
elev.
98.25 ft 4 36-96 7.5yr4/6 none S Osg ml na na .7 ~.8
c
Depth to
limiting
factor
+96"
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Miii:
::::}iiti•%i iJiii
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev. j
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Gerlad P. Schouten 1554 200th Ave.
CSTM2298 NE4SE4 S33-T30N-R19w New Richmond, WI 54017
MP¢RSW 3254 town of St. Joseph (715) 246-6200
N
1"=40'
B1.= top of sw corner of concrete base of outside step C el. 100'
015
1
/431
rQ~~
"'73 ' - ~ ~I2~
I Z °7p
Cc)~
Gary L. Steel
10-13-95
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER GQVAld ~ t O-Qbofeg,~ A. Sc.~OUfiPN
ADDRESS 581 L~5+~ Ad
P\), Ds d N Wal S C..
SUBDIVISION / CSM# YV A LOT # NA
SECTION 33 T30 N-R/9 W, Town of S~ JUSQ(7~
ST. CROIX COUNTY, WISCONSIN
I
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Y8, 7 ,
s~PTtr.°
Tt. ay-
~doo 9~1
7'
9a,
N
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
• To oS 5W Cait Ne 0 f CoNCR-tte gas d T
ALTERNATE BM: Own ! De Sfiq 10 0. U
US ED fix) SI I N9 SEPTIC TANK
PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: ~j A
Liquid Capacity: j0d0 qfl
Setback from: Well O fox Soy
House o~ Other
Pump: Manufacturer
Model#Size ----1
Float seperation Gallons/cycle:
Alarm Location
SOIL/ ABSORPTION SYSTEM
Width: Ia 7
Length Number of L- r
Distance & Direction to nearest prop, line: 31
Setback from: well: av_ K SO House
9 4 • S UrhocQ q(o d5 Other
9(Q ,~7 Np ELEVATIONS
Building Sewer
ST Inlet; ^/p ST outlet 97. 79
PC inlet PC bottom
Pump Off
Header/Manifold Bottom of system
Existing Grade 9-,55
Final
grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
Qt•1/1" rl4Ad~~
LICENSE NUMBER: 3'-lay
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labornn~ Human Relations INSPECTION REPORT ST. CROIX
Safety and BLildings,Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: 91
Per Holder's Name: ❑ City ❑ Village a Town o : State PI
SCHOUTEN, GERALD/DEBORAH X
CST BM Elev.: Insp. BM E v.: BM D cription: seph Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 5 Benchmark C')
Dosing r ; 1
Aera ' Bldg. Sewer a-t r `7
H O+Ct Ing St/A Inlet any.,,
TANK SETBACK INFORMATION St/ Outlet L Z// 9 J
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header
Aeration A Dist. Pipe
i
Holdi Bot. System S i S, aS
PUMP/ SIPHON INFORMATION Final Grade
M#nUfar-tafe --D and
Model Number GP
TDH Lift F ' Ion System TDH Ft
Ford Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width i Length'/ i No. Of Trenches PI No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS /0 S'1~ DIMENSION
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHIN anufacturer:
SETBACK
INFORMATION TypeO , 02 a<< CHA R Mode Number:
System: loess `76 10 F~ 7~- OR NIT
DISTRIBUTION SYSTEM
Header PibFarrifeFd• Distribution Pipe(s) x Hole Size x Hole Spacing Air Intake
/ cfi
Length. Dia. Length -57 Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade I
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.) .)F AS ~cM•~ `
LOCATION: St. Joseph. 33.30.1jW, NE SE, 125th Avenue
GJ.PJ1Y~oC.~ ~ P~"~ ,Q'`f'i~ ~.c,~ti~ tam /•LC~-2~~~.a~io
Plan revision required? ❑ Yes Q-141-6
Use other side for additional information. 1// 1071i6t
SBD 6710 (R 05/91) Date Inspector's Signat re Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
j
i
I, _
i SANITARY PERMIT APPLICATION BureaSafetyu o oand ff Building System!
ding Water 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. 45/
0 See reverse side for instructions for completing this application State Sanitary Permit Number
a 419777
The information you provide may be used by other government agency programs ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Pro erty Owner Name Property Location oraA A161/4 S-,~- 1/4, S 3 T N, R E ( DW
Property Owner's Mailing Address Lot NumbeNr Block N
~a ,9
City, Sta a Zip CoL~dJ~~6aPhone Number Subdivision Name or CS/~ IJ er
11. TYPE F BUILDIN : (check one) ❑ State Owned ❑ !ty Nearest Road
❑ Vllfage
Public 1 or 2 Family Dwelling- No. of bedrooms Town OF
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment / Condo 030 _a 0011__w
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining
4 ❑ Church / School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel / Motel 9 ❑ Office / Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. ❑ New 2. 'a Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an
Existmq System
System _ -System Tank TankOnly ______________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 Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 E] Y n-F'
11
S stem-I 1
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
Req V8 q. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min./inch) Elevation
ISV 8 95.~5Feet 79•5Feet
VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank or Holding Tank /0()o ~A ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: (No tamps) ro P/MPRSW No.: Business Phone Number:
.3,z,,~) 7'/2- 386 - 5lOdZ)
Plumber's Addre s (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved San ary Permit Fee (includes Groundwater aIssuing Age t Si ture Sta s)
Approved ❑ Surcharge Fee)
Owner Given Initial 1 11i6 / S-~
Adverse Determination
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD•6398 (R. 05194) - DISTRIBUTION: Original to County, One copy To: Safety s 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 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 t 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.)1,_
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 b the count ; E) soil test data on a 115 form and F) all sizing i
by Y, ) so ) nformation.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for anumber of regulated practices which can
effect groundwater.
The monies collected through "these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
R B,L 7
PLOTA M 1) RO S S S I-
_U Mm
N A M E L ~ J f ~ , c h _ .N..A.M T 1 doumee_5010 C 1 0 nl v . _1c E N S
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~i3 Via. IaxSy lea CWwr, of Cowe'eQ1e epse
a4fi.Slpa S`re~ ~~QV.= Ivb,v
S 10PQ = Bb, e5
}
FRI:SII i:11 ItdL[:TS- -,A_ND 0BSEIIVATfIoi I I.P1;
CROSS SECTION
Approved Vent Cap
Minimum 12" Ahovc ~)Npl ~ez~~e
-Final C;r.~ije___~ _ 9q•sS
1 ,
Ya
Above Pipe Cast Iron
Vent Pipe
To Final Gradr-
Marsh Hay Or Synthetic Covcriny
Min. 2" Ayyr.c(,J'.l1 I
Over Pipe
DisLribution,_ Tee j
Pipe I
Aggregate Per-fora Led Pipe nciota
95 a~ ~D)~~M cnth Pipe .-.-Coupling Terminating* r
~l ed... . RoL•tom. of System...
i rT
Wisconsin Department of Industry. SOIL AND SITE EVALUATION REPORT Pave 1 of '
Labor and Human Relations
Division of Sa" & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 4/2 x 11 inches in size. Plan must include, but St. Croix
not limited to vertical and horizontal reference point (IBM), direction and % of slope, scale or PARCEL I.D. *
dimensioned, north arrow, and location and distance to nearest road. 030-2005-30
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPER OWNER: PROPERTY LOCATION
Gerald P. & Deborah A. Schouten GOVT: LOT NE t/a SE 110 33 T 30 N,R 19 14r) w
PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK a SUED. NAME OR CSM #
589 125th. Ave. na na na
CITY, STATE ZIP CODE PHONE NUMBER QCITY MVILLAGE OWN NEAREST ROAD
Hudson, WI. 54016 (715) 549-6888 St. Joseph 125th. Ave.
(J New Construction Use Residential / Number of bedrooms 3 (J Addition to em b% building
j3q Replacement [ J Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading ram .7 bed, gp W . 8 M MM, gpd/ft2
Absorption area required 643 bed, h2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 -8 french, gpd(t2
Recommended infilbation surface elevabon(s1 95.25' ft (as referred to site plan benchmark)
Additional design I site considerations
Parent material outwash Flood plain elevation, if applicable na ft
F uitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
nsuitable for system { MS 13U CAS ❑ U us o u 13S ❑ U 0S ®U ❑ S -1sm U
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color Mottles Texture Structure ConsistencelBmlldary Roots GPD/ft
in. Munselt Qu. Sz. Cont Color Gr. Sz. Sh. Bed IEr-
1 0-13 10yr3/3 none 1 2msbk mfr gw 2m .5 .6
1
42 13-29 10yr4/4 none sil lfsbk mfr 9W if .2 1.3
Ground 3 129-39 7.5yr4/4 none sl 2mgr mfr 9W na .5 .6
97.e65ft 4 39-84 7.5yr4/6 none S Osg m1 na na .7 :.8
Depth to
limiting
factor
+84"
Remarks:
Boring # 1 0-10 10yr3/3 none 1 2msbk mfr gW 2m .5 .6
I
2 2 10-19 10yr4/4 none sicl 2msbk mfr 9W if .4 .5
k
3 19-25 7.5yr4/4 none sl 2mgr mvfr gW na .5 .6
Ground
elev. 4 25-80 7.5yr4/6 none S Osg ml na na .7 `.8
96.95 ft,
Depth to
limiting
factor
+80"
Remarks:
T Name:--Please Prat Gary L. Steel Phone: 715-246-6200
Address: 1554 200th. Ave., Ne -,Richmond, W1.540-j7 10-13-95 cstm 02298
e:--.. M.... rVT ~I. ~L...
PROPERTY OWNER Gerald Schouten SOIL DESCRIPTION REPORT Page 2, of'3
PARCEL I.D. 030-2005-30
Depth Dominant Color Mottles: Texture Structure Consistence ear>r~ry Roots GPD/ft
Boring # Horizon in. Munsell tau. Sz. Cori Color Gr. Sz. Sh. Bed ITS ich
PURI r 1 0-8 10yr3/3 none 1 2msbk mfr gw if .5 .6
3
sz 2 8-20 10yr4/4 none sicl 2msbk mfr gun if .4 1.5
Ground 3 20-36 7.5yr4/4 none sl 2mgr mvfr 9w na .5 .6
98 M ft 4 36-96 7.5yr4/6 none S Osg ml na na .7 !.8
DepM to
limiting
faC 96«
Remarks:
Boring #
Ground
elev.
ft: '
NO to
limiting
lam
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev. 1
it.
to
Inviting
factor
Onw+w N.n• -
w
TEEL1
S S SOIL SERVICE
Gary L. Steel Gerlad P. Schouten 1554 200th Ave.
GSTM2298 NEkSE4 S33-T30N-R19w New Richmond, Wf 54017
MPRSW 3254 town of St. Joseph (715) 246-6200
N
1"=40'
EM.= top of sw corner of concrete base of outside step C el. 100'
o''r kxo
1.x.3 ' ~ Gcf`
6,3 10'
.?3 ' ~y•2 '?2f
1 2 °7o
100 Cie -
Gary L. Steel
10-13-95
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
A
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I11 have inspected the septic tank presently
serving the _LCf-s,1debOKr~~ Sc~~U~eN residence located at:
1/4, 'Sf- 1/4, Sec. 33 , T 36 N, R 19 W, Town of
Upon Inspection, I certify that I have found the
tank and baff'les".'to be in good condition, and it appears to be
functioning properly.
Last time serviced (0d.
16 o9 s
Did flow back occur from absorption system? Yes No (if no, skip
next line)
Approximate volume or length of time: gallons minutes
Capacity: ) Old 0 gA)
Construction: Prefab Concrete Steel Other
Manufacurer (if known): rJ]2~'
Age of Tank (if known) :
(Signa ure) (Name) Please Print
(Title) (License Number)
(Date)
Form to be completed by licensed plumber (x.145.06, Wisconsin Statutes)
or Licensed Disposer (NR 113 Wisconsin Administrative Code)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR-83, Wis. Adm. Code (except for
inspection opening over outlet baffle).
Name -.~1►~'~ 660r-ereK Signature QVIrl
MP/MPRS ~
5/88
' LA 1 A. V V
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 era Ad c ~ 0.. " D Y0. rT • 6q+en
J G 1ti.
Location of property /VE1/4,61/4, Section 33 -R 9 W
Township sS1- S Mailingaddress S6? Ids- f~✓
tp
ad6o yo l b
Address of site _6-8 9
Subdivision name Lot no. IV4
other homes on property? Yes X_No
L
Previous owner of property M n j~, -a s=r' oCi /Yl Q m `~~T
Total size of property Appre ~ ~i -,cc s
Total size of parcel PPS tc X o, r-, ( e .S
Date parcel was created
Are all corners and lot lines identifiable? __Yes No
Is this property being developed for (spec house)? Yes __X_No
Volume 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.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this corm 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. O _ and that I (we) presently`
own the proposed site ~f-o-i'- h ~s wage 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 Cow-Applicant
Date of Signature Date o . S i gz~~: ure
C - 105
Sl,' IC TANK M,AINTENANCF, AGRF,ENIEh I'
St. Croix t'ounty
.
OWNERIIWYE,R ~4Te ---~ebD~Q~._...
MAILING ADDRESS
PROPER"]')' ADDRESS
(location of septic systenn) Please obtain from the 1'1~!nninf; Dept.
CI"I'1'IS"1'A"T 1?,(,~~~ J~~1 5
- - - _ _fL~ - - - _ -
r
PROPERTY LOCATION' ~G 1/4,-_SE 1/4, Section .33---' 1 iV_ --w
'TOWN OF ,5T, JO,$ e, P ~A - S"f . (AiOix C N"1'1', \v1
SUBDIVISION A11A - LO1' 1VUMBEI2 N~
CERTIFIEDSURVEY MAP , VOLUME , PAGE , 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 I, 1978. St. Croix Count),
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 sct by the Wisconsin DNR
Certification stating that your septic has been maintained must he completed and returned to the St Croix
County /.oning Officer within 30 day: of the three year I iration da
/ -
DAII
I Croix County Zonillf" OlficC
( ;ov(.rnnicnt Ccntcr
I10I Carnnchacl I:oad
Hudson, AV'I ),1010 l l/`~;
DO~JCUMENT NO. STATE BAR OF WISCONSIN-.'ORM 2
THIS SPACE RESERVED FO RECORDING DATA
- ,3.I 73~p VOLJ 646 =A:` WARRANTDEED
REGISTEIRS OFFICE
M~.c.ha.e~.. K_.__ Maus.C._.a_nd...Kare.g..R Maust•: . ST. CROIX CO., WI6.
a ...a.s._his..wAJ.e.... nd---in.._her. own... ight Recd, for Record Rtis 29th
Lat4:115 April A.D. 19 82
conveys and warrants to ..G-erald__-P._. Schouten. and
...Deb.ar.ah...A.-..Sc.ho.ute.n.,...h.us-b.an.d..Z.nd...x_i e P M.
_ p~,t. or tt..a•
RETURN TO Fed Land Bk. Assn.
.
- Highway 35 N
_ the ic'I-iwmg described real estate in .....ti.....C.LQJ..X ......................County, River Falls, WI 54022
State of W`'R. nsin:
Tax Key No .
Part of the NE4SEJ described as follows:
Commencing at the SE corner of the NE4SE4, thence W.
467.37 feet to an iron pipe hereinafter known as the
place of beginning, thence continuing W. 50 feet to
_ an iron pipe, thence N. 9 degrees 0' W. for 1305
feet to an iron pipe on the S. right of way of
County Trunk "E", thence SE'ly along said right of
way 300 feet to an iron pipe, thence S'ly 1233.9
feet to the place of beginning,
Sec. 33-T30N-R19W.
~.ArYSF ~
This ...-..ls-._.------------- homestead property.
(is) tix man
Exception to warranties- Existing highways, easements, rights of
way and restrictions of record.
Dated this - .Y!-... day of 19$2---•
(SEAL) 1,66,4 Q - K7~ ---(SEAL)
- ' • ..Mi-ch_ae.1...K,__iNau-st
•---(SEAL) ....-•-----(SEAL)
Ka-.e-[!..R....-MAU
AUTHENTICATION ACKNOWLEDGMENT
Signatures authenticated this day of STATE OF WISC N&W
19........ Pennsylvania M s=.
------------------------------County. ~f
I----•-••------------- /PQersonally name before me, this day of
(7 ~oz---------- the above named
• .
•
. BAIT OF WISCONSIS .Mi-chael_-K•.--Maust,_-and---aren
TITLE . : MEM . BER . STATE .
Maust, husband aqd w~.f~~ ~l y,
(If not,
authorized by § 706.06, Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BY to me known to be the person 5=.;-.bwhog~ ecutM the
'oregoing instrument and ackro4'4 the sa}fde.
Attorne -David J. Estreen s
y i
- - - r..
Pinn.
.
Votary Public ~'`~`Z•'-h..:,tioue!y, Wis.
(Si natures may be authenticated or acknowledged. Both NO Commission is ermanent. (If not, state expiration
a are not necessary.)
date: --LI-Y7400<1. . /J.
ROSEMARY . 13~is...1
WILSON. NOTARY PUBLIC
SOUTH MIDDLETON TWP.. CUMBERLAND COUNTY
' •Namea of penons °wning in any capacity should he typed or printwi hel- their signature.. MY COMMISSION EXPIRES MARCH I5. 1966
McMef, Pennsylvania Association of Notaries
STATE BAR OF WISCONSIN Wi-r.in t-I R:enk Co. Inc.
PORM N ~ WISCONSIN
WARRANTY DEED MH-k- Wig. (Jnb3a2K)