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AS BUILT SANITARY SYSTEM REPORT°
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OWNER
ADDRESS ~ P7
zz -Z.)
T
SUBDIVISION / CSM# LOT #
SECTION TQN-4,_~W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAVI VIE
SHOW EVERYTHING WITH 0 FEET OF SYSTEM
p
p 77,
f e
A
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:?
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer:
Liquid Capacity: __/f
Setback from: Well-- - House 23- Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length T- ` Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: ':1,1e House ~27"_ Other
ELEVATIONS
Building Sewer ST Inlet; 9/ ST outlet 2.j v
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system Existing Grade ; ;7S- Final grade
7 -
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR: 4eu
1-4
3/93:jt
i
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
La5brand Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village a Town of: State PIA o.:
GOSSELIN, LAURENCE X
CST BM Elev.: Insp. BM Elev.: BM Description: ST. Parcel Tax No.:
TANK INFORMATION . ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark goo, "
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet Y"
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
irl
Septic >oL 7/,/ V3 ' ),m r NA Dt Bottom
Dosing NA Header/ Man. 6,3q 3-l0 1
Aeration NA Dist. Pipe 9,t/V g3157
Holding Bot. System 9, 3 9d, 7 3
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand 97, y8
Model Number GPM
TDH Lift Lrict' System TDH Ft
Head
Forcemain L th Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO -P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION Type Of G "71~ fj OR UNIT Moe Number:
System:
DISTRIBUTION SYSTEM
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
xx Depth Of xx Seeded/ Sodded xx Mulched
Depth Over Depth Over
Bed /Trench Center Bed/ Trench Edges Topsoil E] Yes ❑ No E] Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: ST, JOSEPH.24.30.20W, NEB,, LOT 2, 23RD STREET
3 Z/
Plan revision required? ❑ Yes [~/No / r
Use other side for additional information. OS `~jr rz.f1. (o
SBD-6710 (R 05/91) Date I ped is Si ature Cert. No.
Safety and Buildings Division
r^~~i~C1•in SANITARY PERMIT APPLICATION Bureau of Building Water System!
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 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
a~~S., q
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION
Prope y Owner Name Property Location
114 1/4, S T , N,(or
Property Owner's Mailing Address of Number Block Number
4Y,' t Zip Code Phone Number Subdivision Name or CSM Number
PE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road
E] Public 1 or 2 Family Dwelling - No. of bedrooms ~ E] Toan of
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
0,30 /OD
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandiser 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. pr Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank OnlyExisting 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 t4 Seepage Bed 21 ❑ Mound 30E] Specify Type 41 ❑ Holding Tank
12E] Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43E] 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 ./'nch) Elevation
t eet
91-
VII. TANK i Can alloacitns Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existin strutted
Tanks Tanks
Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for i stallation of the onsite sewage system shown on the attached plans.
Plumb is Na e: (PCfnt Plumb rs Si r r (No a ypl IMP/MPRSWNo.: Business Phone Number:
qi
tubers dress (Street ity, St Zip C
r
/ O / .a`
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved f itary Permit Fee (includes Groundwater Date Issue Iss ng Agent Signature (No Stamps)
#Approved E] T Surcharge Fee)
Owner Given Initial V
Adverse Determination
X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SHD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety & 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.
lk 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 wi .h 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 suf.;-iitied to the county The plans must
inL!ucie the following: A) plot plan, drawn to scale or with complete dimension., locati :;n of ho ding tank(s), septic
tanks? or other treat rent tanks; building sewers; vvelk,; water mains/water ser ce; strum > :;nci lakes; pump or siphon
tanks, distribution boxes; so"! absorption systems; replacement system areas; and the !o:, tio,- . { the building served
B) horizonial and vertical eiev,,lion reference points; C1 complete specification,, for pur.-ps ar,:c controls; dose volume;
elevation differences; friction loss, pump performance curve; pump moae! ;wd, : arnp in - u,f _._'urer, D} cross section
of the soil absorption system if required by the (ounty; E) soil test data on a 1 1, S form; a ,d } al' 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.
G ~
low- o ~jY~ c oT ~tc t =,eC/40
6
y7 ~ Wtl~ 6f~
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page -/-of
Labw and Human Relations
Divfsibo 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 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
PROP RTY OWNER: PROPERTY LOCATION
S GOVT. LOT 114 1/4.S T - N,R X(0
PROPERTY OWNER':S MAILIIP~DDRE S LOT # BLOC # SUBD. NAME OR CSM #
7 r-2
CITY ATE ZIP CODE PHONE NUMBER EICITYi LLAGE OWN NEAREST RO~J~ j
[ ] New Construction Use N Residential/ Number of bedrooms [ ] Addition to existing building
bQ Replacement [ ] Public or commercial describe
Code derived daily flow ~Q gpd Recommended design loading rate __,~bed, gpd/ft21 trench, gpd/ft2
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate _,_7 bed, gpd/ft2=trench, gpd/ft2
Recommended infiltration surface elevation(s) 7'~I- ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material _ Flood plain elevation, if applicable ft 'V '14 S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM
IN FILL HOLDING TANK
U= Unsuitable fors stem ® S ❑ U Im S❑ U 7JES❑ U 121 S❑ U ❑ S O U ❑ S O U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Bwxky Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Copt. Color Gr. Sz. Sh. Bed Trench
All ~a
Ground
elev.
Depth to
limiting
factor
~ 9C
Remarks:
Boring #
7 19
Ground
elev.
. 1Z) 5Z ft.
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Phone: fE2
Address:
Signature: 1 Date: CST Number:
,ge
PROPERTY OWNER - SOIL DESCRIPTION REPORT Page-2of-
PARCEL I.D. # '
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Co Color Gr. Sz. Sh. Bed Trench
yJ::{%:iiirvf
4vyi•::: i:•i:?:v}
...tit4
Ground
elev.
Depth to
limiting
factor
~-2c-
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
FT
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
4
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
joss,
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V
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30 ~W SyS~fXa
4OW
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InisboritanDepaMrentofIndustry, SOIL AND SITE EVALUATION REPORT Page / of .�
* , kii,and Human Relatbns
of Safety 3 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 inches in size. Plan must include,but Th ) - ,,,,
not limited to vertical and horizontal reference point(BM),direction and%of slope,scale or PARCEL I.D.I
dimensioned,north arrow,and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROP RTY OWNER: PROPERTY LOCATION
.4i.1es',,etr.4" gASSs'1`w/ GOVT.LOT 4/4 1/4n// 1I4,�y,/T ?p, ,N,R__, 4(or.
PROPERTY OWNER:S MAILII ADDRE LOT ft BLLO`CK I SUED.NAME
OR/,CSM I
CITY,'�f ��7jj ���1 v,�c ZIP ODE PHONE NUMBER �C�v, DXLAGEI OWN NEAREST RO
>5'.9,/4.1 u.lr _ryfsR2 ( ) ?� is - —2?' s
( J New Construction Use,J>Q Residential/Number of bedrooms ? I J Addition to existing building
pd Replacement I ] Public or commercial describe
Code derived daily flow_-54-0 gpd Recommended design loading rate , 7 bed,gpd/ft2 - ? trench,gpd/ft2
Absorption area required C-Y bed,tt2 s 5—<;',3 trench,ft2 Ma,Njmum design loading rate , 7 bed,gpd/ft2 . ' trench,gpd/ft2
Recommended infiltration surface elevation(s) 9 7;1 ' ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material - O_ t..' - , 9 �r Flood plain elevation,if applicable a ft
S=Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U=Unsuitable for system IDS ❑U ®S ❑u OS O u OS ❑U ❑S Mu ❑S Jil U
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color Mottles Texture Structure GPD/ft2
Consistence Boirtby Roots
in. Munsell // flu.Sz. A ..L, L rColor Gr. Sz. Sh. Bed Tn3nd1
alia
I 0�7/ /A 5t�_r.�? /Y ,/ o s 4,.. e I_ y
.-v *&1- I / ,/? ,A' �s , I/ I 9,‘.,- a?..,, 7 .0
Ground 3 ._-V 7a /,X'C/1 A <- (9.11 y /,/ — /if . 7 -
Depth to
limiting
factor
>9C
Remarks:
Boring#
/ o-i' //,,P-�� A �di "--, / Qc . . 7 .,-f
MI ,a /% /nSe 1s % -'7/ 3'.) ,a?,,p 7 .9
Ground
,_- - /05P`�i // s �'J.y,s5 / ry t . 7
-/ .a 9 sle'$4 ,,4 S (9.,-� f-, / - _ . 7 .A.
Depth to
limiting
factor
Remarks:
CST Name:—Please Print I..1(2.(3 Phone:
Address:
- S�' �. ` , . 5 .e gordrr-�iE AD a -� CST Number:
PROPEMY OWN ER„../Aee, arc s-,12-./.,v SOIL DESCRIPTION REPORT Pagec.A2 of s-?
PARCEL I.D.# • e: ' t
Depth Dominant Color S olor Mottles Structure GP Dift2
Boring# Horizon . Texture Consistence Barclay Roots
Bed T
/
in. Munsell Qu. z.,7 C Gr. Sz. Sh. rench
,c:;)--A? /0)e:EZ2 4 4zsda /
. . •>7 4-?? let' "5/ Ad Is ,L11,1- . ,,, /
3 i c ,A.-, • -
Ground ...??..-s--/ zio x,/,/././
4/4 - - /...2/ sii ?
31• 1/ 5-7Xse4/
/ — — •7 -S
Depth to
limiting
factor
Remarks:
Boring#
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring#
49Mj
• §
Imo
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring#
Ground
•
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
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CERTIFIED SURVEY MAP
Located in part of the NE4 of the NW'44 and in part of the SE4 of the NW4f all in
Section 24, T30N, R20W, Town of St. Joseph, St. Croix County, Wisconsin; being
Lot 1 of Certified Survey Map recorded in Volume 7, Page 2072 at the St. Croix
County Register of Deeds office.
NW Corner of Ni Corner of
Section 24 North line of the NWi Section 24
S89°53'00"W S8905310011W
130
C,wiHLL 1300.85' s
.851 I° I
_
°o A rT LOT AREAS o y
I o o TR/-A I
C1 N Including R/W Excluding R/W s
C`J I N S89053' 0011W Lot 2 289+091 Sq. Ft. 223,363 Sq. Ft. o
200.00' 6.64 Acres 5.13 Acres 4J •0
L I 32.76'.'1/ Lot 3 146,806 Sq. Ft. 132,859 Sq. Ft. N
24
se'I \ vyx 3.37 Acres 3.05 Acres w :
d o 0
I 100, 1 d
= LO
J I v~ \`7 a LO
W C)
~°j , OWNER W +
Co
Larry Gosselin C o C_
M
1497 23rd Street
IWO Houlton, WI 54082 co ; -4 41
:!)I 31.90': r
. I _f4 BARN SHED
3C C
n cv q201
6' Sao ❑
4 rn N ✓
f`- I 4-
r s
(III LEII. N 3 SHED N82°46'10"W
QC)
'I --I LLJ 258.06' ❑ /
IL
❑ GARAGE
/ !gQ{390"n c
~L Cl~ I o OJ o HOUSE SO. a a
1 I 1 FO o ~4,~ 1 t
2 so
1 ~J I I .rl 0 ~O V~ 4 A far
L01 (01 I]!I 00 [TRAILER HOUSE..'
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LO V
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le,
. fi I I I ~ J~a i `c ~
CSI \ i rfXNE of the NW ,,rr~~
ty
PPROED
~J) I ❑ _1/ SE} of the NWj M tl
> I a
CSI LEGEND
19 Aluminum County Section Monument Found 1dY 2 '94 N
\ ❑
• 1" Iron Pipe Found m
S'F . CROEX COUN:rY
/ 0 1" x 24" Iron Pipe Set, weighing 1.68 lbs. pumij iliro4di4 piaw&
/ x Masonry Nail Set in Concrete Surface Zoning and
/ Pa-+: s Committer
• • , • • • • • • . • • • Roadway Setback Line
{f not recorded
within 30 days-of
approval date
approval sheM We
m4 & vem
`ALE IN FEET 2
N
200 400 VOLUME 10 PAGE 2753
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31KOIJ HHO S , HOAHAUnS
CERTIFIED SURVEY MAP
Located in part of the NE'-4 of the NW'-4 and in part of the SE'-4 of the NW'-ti, all in
Section 24, T30N, R20W, Town of St. Joseph, St. Croix County, Wisconsin; being
Lot 1 of Certified Survey Map recorded in Volume 7, Page 2072 at the St. Croix
County Register of Deeds office.
NW Corner of N} Corner of
Section 24 North line of the NWI Section 24
S8905310011W i S89o53'004
130 I HL 1300.85'
4t N
A LOT AREAS
o T~ ~-r I
r-I ool ~rcH~~
o o I Including R/W Excluding R/W s-t
C`J I h S89053100 "W 289,091 Sq. Ft. 223,363 Sq. Ft. o
Lot 2
N
200.001 \C % 6.64 Acres 5.13 Acres 4J
L7 I 16724'
146,806 Sq. Ft. 132,859 Sq. Ft. d
LL I L32.76' 7 Lot 3 w t" a
3.37 Acres 3.05 Acres L. 4.
1 6 6' ~x cF ° o
J I loo'
C- 3Z M
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U 1 0o 4(nINER A s
41 En
~v Larry 6osselsn r_ o W
CV) M 6s ;P' ~ L7Sl 1497 23rd Street cc r
• I
41
Houlton, WI 54082 CO
31.901. . o
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~ I \ J S E'4 of 1 1 1 i= i i. 7,
Q) I LEGEND
Aluminum County Section Monument Found
• 1" Iron Pipe Found o
J / o 1" x 24" Iron Pipe Set, weighing 1.68 lbs. per linear foot U
x Masonry Nail Set in Concrete Surface
Roadway Setback Line U-
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pug paAanans Naepunoq a0Tas4x9 sq; ;o aleas o; uoT4e4u9s9ad9a
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;o ;utod aq; o; ;aa; 00.OOZ `uoT;oas pies ;o ;/TMN age 30
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'uoT;oas pTes ;0 V/TMN aq; ;o Quit glaou aq; buote '14„00,£948S
aouaq; :tZ uot;oaS ptes ;o aauaoo i,/TN 8q4 ;g buTouaww00
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'4S aq4 ;e ZLOZ abed 'L awnloA uT papaooaa dew AananS pat;T4290
;o T 401 butaq !utsuoosTM 'A;unoo xtoa0 *IS 'gdasor •4s ;o uMoy
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UT pug i,/TMN 9q4 3o V/T3N aq; ;o ;agd uT pa;eool pust ;o IQoaed v
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31V0I J I1830 S , HOAZAHnS
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNE DYER S,S+ L cs c s L /
MAILING ADDRESS 2- 3 S /~U C,L'T6 V W 3-40 k2-
13 RO P ERTY ADDRESS 2- 3 `-A v U L ro A.) J L/ l 54c) k 2-
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE D Ci 2- 'T D N k/
PROPERTY LOCATION 1/4, -IV 1/4, Section S T 3 o N-R 2 a W
'OWN OF ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER 2-
CERTIFIED SURVEY MAP V VOLUME$ PAGE!I'IS'",-LOT NUMBER Z
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 property 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.
UWe, 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 expiration date.
SIGNED: a'-o -
DA'1'1::~
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 100 & os'SZ4IV
TAI- No 4536-2-034 Go,16d
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 LAW ~ 1~ C 0 3'3 .L Location of property r ~ 1/4~/ X1/4, Section _S 2 TAO N-R Ikl
7,u W
Township S % - \SDS,t P# Mailing address 2- 3 S r -
Addressofsite 2.3 sT /)0V2_7-6N IWf 5-
Subdivision name - Lot no. 2,
other homes on property? Yes_ ✓ No
Previous owner of property ~S/sC CL u A/~~ o i~
Total size of property A CAF
_S_
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? _ _Yes ~ No
Volume and Page Number 3A a::; recorded with the Register_
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be }helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. 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.
e
S.iyna re of Applicant Co-Applicant
Date of Signature Date of Signature
T - - THIS MAGI R[ftRV[O 1011 R[GOROINO DATA ii
i DOCUMENT NO. i WARRANTY DEED
II
STATE BAR OF WISCONSIN FORM 2-1982
865PAGE S2
' u: - CC CC
45644' I,
REGiSR~S OFFICE
ST. CRO)X CO., W1
hen L. Sko lund and Vernell A. Skoglund . j!i Rete~ for Rllterd'
.step
MAR 07 IJ90
M i
I!I 8:30 A.
conveys and warrants to ..Laurence•.P..-Gosselin•-and•_.....
...J-...Gasael.in.,...hushhts ofasurg vorshi i al
with ri P..-......
ii.
-
11
-
R[TYRN TO
II
j'
the following described real estate in ........_St...._G. .-1)C•-• ...............County. II
State of Wisconsin: Ii
Ta: Parcel No:
A parcel of land located in part of the Northeast Quarter of~theo }`h~ ?s~l4~~c~ (NEJ
_ of NW}) and the Southeast Quarter of the Northwest Quart ( }
Twenty-four (24), Township Thirty (30) North, of Range T+aenty (20) West, Town of St.
Joseph, further described as follows: Commencing at the North Quarter (N}) corner of said Section 24; thence South 89° 53' 00" West, 1300.85 feet along the North
line of
t
I' said Northwest Quarter (NW}); thence South 00° 08' 48" West, 200.00 feet along the West of line this of the East description; Half of thence said continuing Northwest
Quarter (E} of NW}) to the point of beginning
South 00° 08' 48" West, 1224.95 feet along said
West line of the East Half of the Northwest Quarter (E} of I.W}); thence North 43* 20'
46" East, 904.00 feet along the centerline of S.T.H. "35" and "64"; thence North 36°
18' 42" West, 704.81 feet; thence South 89° 53' 00" West, 200.00 feet to the point of
andobeginning. Above described parcel is subject to right of way for S.T.H. "35" and "64"
and for the town road as shown on this map, and subject to all other easements of .
record.
This conveyance is given in satisfaction of that certain land contract between ,the
parties, dated March 11, 1989, recorded March 13, 1989 in Vol. "835", page
Document No. 446092.
This ._..ls-..nOt__•-...... homestead property.
(is) (is not)
Exception to warranties:
4k
-5th Mar-ch------------- -----19._90
Date this _ -
- day of - -
- (SEAL) (SEAL)
Vernell A. Skoglund
r
; (SEAL) (SEAL)
Ste hen L S,to lund '
p
bAUTHENTICATION ACKNOWLEDGMENT
4
Signature(s) Vernell-- STATE OF WISCONSIN
i Stephen L koglund
County.
oaths th' S y o!_--March 1990- Personally came before me this day of
1 19 the above named
f.
S tt R. Needham
TITLE: ER STATE BAR OF WISCONSIN
(If not,
•
- •te.) . to me known to be the person who executed the
authorized by $ 706.06, W-- - - . - -Sta-
foregoing instrument and acknowledge the same.
w THIS INSTRUMENT WAS DRAFTED BY -
.
Reinstra,._yan__Dy_k..&._ Needhamr•.- S . C12
-
201 South Knowles Avenue, Box 7 ' county, Wis.
.
NeLl_•Bichmond ,.._hII_-'- 54017 • --My aCommission is permanent. (If not, state expiration
(Signatures may be authenticated or acknowledged. Both date: 19...._
are not necessary.)
Ii *Nams of persons signing in any capacity should be typed or printed below their signatures.
Stock No. 13002
STATB BAR OF WISCONSIN
FORM No. 2- 1982