HomeMy WebLinkAbout032-2092-40-000
~L o (1) O
o c I I
~ I
h
O
N
N
N
rn c
(L N
~ r
O
'o
Q C I
a)
_N
o z = d
N
-CE
LL O J 0)
3 a °o
Q H
M
a3i I
w E
rn z
z = p
z d
N Cl) z a m
0
O z !t c
z a ° o
tO H m N z
_ E
v ~ M I
NN
C (0 N
N O
a N L
O O O w
Z m z Z
c
N
z C: I
N
E
~i Y d - Y
m ° , d c 0
a) O d `c co co C.
` o
E
Q, ^ ~ m, frA frA frA U
I~J 10333 a~ Zo
• a a a
g
N - M Lo
to J U rn rn }
o N M - 0 N
O U
~ O CO E
'O
> o~ c d
Q 'o N y ~ ~
in m `t } cn o
o =
O N M H
O O M CO r y C N U E Lo co
r" O~ y O O
CL C
V O = N Z: :c
p
40. 0) O 0 O co U 0 .0.. N M
K 0.0 N M « d N H c (D (O 00
=^)l N E cp E 0 U
O
• O i~r O N U) FO- N O Z c Cn
~ II
QOD R € a
n ` a
• a d ;2 d
~`Iv E ` c
-1 A V a 2 1 8 U) U
.w
STC - 104 ft r,
AS BUILT SANITARY SYSTEM REPORT
1 S;r~~, f Gs
~~9 ti
OWNER
1
ADDRESS tit
SUBDIVISION / CSM# LOT
SECTION= T ZZ_N-R_ W, Town of
f
ST. CROIX COUN Y ISCONSIN
PLAN VIEW
SHOW E ERYTHING'IWITHIN 100 FEET OF SYSTEM
eye
.~o t l
12
I ND 1 CATF tJOR SAI 0l '
I
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic Lank manhole (-'over .
BENCHMARK:
e~/sE~'/o
r-Y
ALTERNATE BM:Cyl/
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length_ Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well:,- House Other
ELEVATIONS
Building Sewer l y Z ST Inlet. L / ST outlet
PC inlet PC bottom Pump Off
Header/Manifold C/7 9!Z Bottom of system
Existinq GradeT,~Vl_9 Final grade
DATE OF INSTALLATION: G S
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR: /AV2
3/93:)t
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION
Pv ilPilder6M. ❑ City E] Village C1 Town of: State Plan 076
CSllTBBIVI Elev.: Insp. BM Elev.: BM Description: , X Parcel Tax No.:
TANK INFORMATION ELEVATION DATA 3G/9
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark ? <;
Dosing
Aeration Bldg. Sewer' X77,
Holdi St/,o Inlet /a 33
TANK SETBACK INFORMATION St/,,t Outlet o- ' 3.dd ' ld ~l
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake ^
Septic ~sa7. NA Dt Bottom
Dosing NA Header /
Aeration A Dist. Pipe 9 3'Z
Holdin Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manllfasturer Demand
Model Number
TDH Lift F In System
TDH Ft~
oss -Head
Forcemain Length Did. Dist. To Well
SOIL ABSORPTION SYSTEM
BED rrFOKR- Width Length q No. Of Trenches PIT No. Of Pits Inside i Depth
DIMENSIONS ?6 DIMENSIONS
cturer:
Manufacturer: SYSTEM TO P/ L BLDG WELL LAKE / STREAM " I-EA G
INFORMATION Type O ::r C jH16-Moe um er:
System: R UDISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size T x Hole Spacing Vent To Air Intake
Length _ Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-G a Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/Tre enter Bed/ Tce+iEdges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Somerset.24.31.19W NW NE 205th Avenue
9
7
~f
g
Plan revision required? ❑ Yes 040
Use other side for additional information. 21, __1 P~F 19 1
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
SANITARY PERMIT APPLICATION BureauSafetyanofdBBuiuildi ng Waater teri
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 ..5j
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
A33 4r70
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
Prope Owner Name Property Location
1/4 1/4, S T , N, R ~(or)S
Property Owner's Mailing Address Lot Number Block NumbeL
Cit tate Zip Code Phone Number Subdivision Name pr CSJVI Number S,f
( )
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road
Village
Public 1 or 2 Family Dwelling - No. of bedrooms ~ ❑ Town OF
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
032 - -Icqa' -Lk -06 O
1 ❑ Apartment/ Condo
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. ru New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an
System System Tank TankOnly- ___________-_Existing System _________Existinq 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
1 1JM 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 ❑ 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/lay/sq. ft.) (Min./inch) Elevation
Feet Feet
VII. TANK Ca
in galloacitn s Total # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
New Existing 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.
P b is St mps) MP/MPRSW No.: Business Phone Number:
Plumber' Zam(Pn
2
I
too I
/I I ZP
Plu be-r's Address (Street, City, State Zip Code):
JJ
IX. COUNTY / DEPARTMENT SE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signature (No Stamps)
yAppricived Surcharge fee) ❑ Owner Given Initial f7J
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
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 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 isto 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 throuoh
VIl. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons nur,!)f r of tanks and
manufacturer's nan^2, indicate prefab or site constructed and tank material. Complete fr; r ilr septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks re:_~riveo experimental product approval from
DILHR
VIII- Responsibility statement. Installing plumber is to fill in lame, 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.
cations not sma. ; - = .gin ? 1/2 x 1 1 inches r-;i tied t -inty The plans must
plot Alan, drawn l,- sc:e or wi LIi COinpl~+'.' G :ll' lo,.. ( Idlng :ank(S), septic
n'. jl,k bjiidin IL Je :ter pump or siphon
Sr~ -iIacemenc syst-rr ±ne LuiIding served;
dose volume;
u v la` CrcSS
r c, ;nformatiorl.
-
GROUNDWATER SURCH/`,R E
1933 Val,..ri'lsli' lrla i;{~F' j thE- c_-eatior' C rClia rg PS ( ) `(t~ t ill ' e d ac, which -an
of fect. gi oundwa!..-
1)~tlt_5iJ ~Clk,d thrciug h 1.;lose_."Wil;'gesafeused fC.i r,)(WlC'-.r ~,rnlirvestigations
at-A establishment of standards-
YA)
i
~ o tIs
au
!Gd s'
I ~ I
a ~ r
/ aw',
~.es ,i ,dam,
PAGE OF
CrC) Sec~lon C) /i Uen ~y
~w/.G
l 7,fe
Fresh Air Intels And Observation Pipe
Approved Vonl Cap
Minimum 12" Above
Final Grade
20- 42' Above Pipe _ 4' Cool Iron
To Final Grade Venl Pipe
Muth May Or SynlMlk Covuinq
win. 2' Aggregals
Over Pipe
Olelribullon - Tee
PIPe 0 0 0 0 0
6o 4ath PIP o Perforated Pipe Solo•
B neath PIP.
e
0 -Coupling Terminollna AI
U0110. Of Sytlem /42
Pro ~oSe(~ ~I~kI (qr~.~l<
l o rli", z
SOIL FILL
DISTRIBUTIO" PIPE
APPROVED S4jK -IETIC COVER
° •`-PIATERIAI OR 9 OF STRAW
2" OF AGGR EGATE //`\\OR MARSH NAy
° to or- 12-ZI/Z AGGREGATE ~•~8
t-LEV.OF>FEET
DIbTRIgIJTIOTJ PIPE TO BE AT LEAST IIJCHES BELOW ORIGIAJAL GRADE
AUL) AT LEAS-1-40 ITJCHES BUT KIO MORE THAT) H2 IFICNES BELOW FIIJAL GRADE.
MAXIMUM MN OF F-XCAVAT100 FROM OKI&YJAL 6KAoF- WILL BE ~ 11JCHE5
M1141MUM 0q OF EXCAVATIO" FROM. C*161WAL GRAPE WILL BE INCHES
SIGIJED:
LICEU5E DUMBER:
a DATE:
'DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
` P.O. BOX 7
LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707
707
HUMAN RELATIONS
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: TTY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
NW 1/4 NE 1/4 24 /T31 N/R 19fxor) W Somerset 1 2` Hansens Turtle Lake Hi is
COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS:
St. CRoix Mike Rutledge Box 44, Star Pratie, Wi. 54026
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: PER OLATION TESTS:
(residence 2-3 n/a ~vew ❑Replace 8-28-92 n/a
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
BS ❑ U HS ❑ U ® S❑ U ❑ S ❑ S CCU conventioanl trench
DESIGN RATE:
If Percolation Tests are NOT required DES If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: class 2 Floodplain, indicate Floodplain elevation: n/a
PROFILE DESCRIPTIONS a 10 CoC2
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL T THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- 1 84 100.35 none >84 0-12, 10yr4/3, sl.; 12-36, 10yr , si
36-84, 7.5yr 4/6, ls.
0-12, 10yr 3, L.; U-27, , si Z/-56,-
B 2 gp 99.43 none >80 7,5yr4/6, co.s.; 56-65 5yr4/4, sl.
50
8-24, si -
7.5yr /4
B 3 84 101.95 none >84 s.;~50-56,5yr4/4,sl.;56-84, 7.5yr4/6, ls.
103.45 0-9, 10yr4/3, l.; 9-36, 10yr5/4, sil.; 36-53, 7.5 r-
B- 4 84 none >84 4 4 s.•53-63 5 r4 4 sl.• 63-84 7.5 4 4 ls.
B- 5 84 102.95 none X84 0-11, 10yr4/3, L.; 11-35, 10yr5/4,sil.; 35-59, 7. yr
414, 1 .s -
strateified in 6" bands
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER PER INCH
P-
P-
P- s de desigLi rate
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indica a or dis ibe NA the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elev i t al4tiyipgs and TR2 directs percent
of land slope. 98.45=upper trench m f~? 9 199, ro
qq,
SYSTEM ELEVATION 97.70=middle trench S T C
e
}
owed- trench
,
E
ING
19
t ,
,
N
, r a
,
E
c.J ClC/`~4 l E V- ~p
j
J`
E
-
a
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
Gary L. Steel 8-28-92
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
1554 200th. Ave., New Richmond, Wi. 54017 2298 + 7 5- 6-6200
CST SIGNA ~
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 10/83) OVER -
I"110 a'CTIONIF "'OR COMPLETING Fir i 5 - SRO - S
To be a co :c,cur,je yon msti mi
1. C;omplet on;
The rase early ;hether this 1s a residence or con n, J,
1 MAX IINIU mrriercixal use planned;
4. Is this a n6v ,
3. Complete the s:, \ SITE IS SUITABLE FOR A HOLDING TAN Y IF ALL
OTHER SYSTF' BASED ON SOIL CONDITIONS;
S. PLEASE use the 'e for writing profile descriptions at cr erg the plot plan;
7. 1#ti1IAKE A U 3I locating your test Iocatacans. C de is preherred. A
saraar- shrar r
S, Make sure y ~ and reference point are clearl sl . o< :ad are permanent;
9. C axes as rrfes, addresses, flood plain ,n test exemp-
tion,
10. If the Mik) ~I ood plain, elevation) does riot apply, placr N e ~.i aprooriate box;
11_ Sign the low, ~rar c urent ad{ Tess axi your certification rau L
12. Make c. d distribute as required. ALL SOIL TEST. FILED WITH THE
LOCAL UTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIE SOIL TESTERS
Snail Separates and Textures Other Symbols
st - Stone (over 10"i BR Bedrock;
cob Cobble (3 - 10") SS - San€' ne,
gr Gravel (under 3") L.S Lin
us - Sand kIGW F. 1 ' j
c;s `"o;g> se Saud Perc I rc
reeds k~ .lit.m ,nd iel
9s - E3Edg B I
L
Ba -
S1t L, jam, BI - E ;;k
Gy G V
A S `
scl Loarrr R
sicl S'I C: t,.-:rn rraot -
sc = Sandy C }n,;`
sic; Silty Clay ff( - sae, faint
cc - an, coarse
P' Mrn y, mediUrn
rrr :'.SCE (
p prominent
HVVL High wa, I
surfae ' ,
1 e BM - Bench N'
VRP Vet ,al I rce Point
TO THE OWNER:'
This soil test report is the first step in securing a sanitary permit. The county or the Department may request
verification of this soil test in the field prior to permit issuance. A complete set of plans for the private
sewage system and a permit application must he submitted to the appropriate local authority in order to
obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction.
! 0.
_ E bf .E~ F CONN[R OF sf r/w Of s[
Cf :f[IrON 3.,T lr x,R II YI lrx Jf/1, 0
T___~_~~___-IT•!i O!'R- AS t.r U~'~I r4V •ra~ x !'1 ~ \
N er•TOf arse PUBLIC r ti$' +a uoo••1 ~liooi 9 °=1 Sso _ TREET
--'`7i~ °0 3 aoo 00 .,..od a°o eoa pD reso~ ~ tecoa
8
el. lii. 0° Y.°d $66 t°t n i' SErd~ ~.+,5 •b.. f
° ,ett l ~a~~~?'~ i
~~3000 ^8 ^ Ln✓• 4lSH C4GiV h `~G wL
r~
t'+y~'R' • V f R P,yl \ I
^'g N8 ryR
2 I : -HIr±W b•~
I $ s d
II i1C 170,300 by ll 141,000!0 . f,
2 3 4 5 w
-~r• '•r•oo° 1 ':Y~ k +~1' ~8 130,331p. ff. 133, 951 q. ft. 13I,39914 It 133,931 p11
r+s•lr..r ° ''4,. 4t4'. I i i A tt r..
'p
08 J
1+i r 4 M 111 y ,0 f' f, ,P ••°•.1
•1 ! -0_ + )e..Ir r 3.00 feOW F -
e" • /82.730 vS ff `i1's° • wI)•ef W w r:. xe) Jr .oo
tes I ~ w. . Y 171,001 vq. Ir. I
'
°
APPROXIMATE HIGH WATER ELEV.-8600r 4
APPROXIMATE LOW WATER ELEV•BSS.J fx j0 rr a•
APPROXIMATE WATER ELEV.r 860.0 ( °N q'
(APRIL, 19611 3.'yy`•Y~'F's'N 4E54,050r
1 ALL EIEV ON US GS- MEAN SEA ° UI
LEVEL DATUM •P 7
\\a
159,600.q. If. N mi
v CL
sas'0r st ~ `\r=° k `~.r ~y. _ yam` , xeerorW'w
t ~ )ooo
.A tP t'IS •1r '
i
~ E•v. i 8 i
°'+a~°p0s ,t Q. Iyc 8 8 _ 3t5
- 'r'rr. a • 119.600 9. I
Iwt• `
M1
1~ , ~ ///W •ev~r• I
9
171.001 rq II I
G / T I.DT Ntl I
p\\ ~ CERTIFIED SURVEY MAP OI
f
Doc
c f.::1' .'~.1
159, GOO sQ. Ir
r,
~l l y r r
10
140,031 eq H.
N. I-II O1
APPROXIMATE HIGH WATER ELEV. • 8600
APROXIMATE LOW WATER ELEV. r838.! l~ r •r'4• U
P
APPROXIMATE WATER ELEV.•B6QO
(APRIL. 1981) :pw I' .g m
ALL ELEV. ON DATUM. G. 5., MEAN •AP\-
~SEA LEVEL DATUM. 131,830 vq. Ir 0.
. Iiil \ . o W - sr•oJw
II I~ ° r0°rr
TURTLE j 0
~ "~ppp---~-. I I r~l .--:.ELL'•J !0/ xsl•. s'!a'R . -r.2-_
I° r°=°iY F°fFO1~ LAKE' 0p0• °x ixE o. rxF xrn.xc lns[aze.nnx..e.n R.
4
- r ' V - mac: ,R t ~!'t'f.P •T! `t1T a'
\ M , ro.o sa
+
~9 •6`76 ~q ff.'
1xA oe if°LOO, v
o v1 • I PRIVATE POND P+• • 0!+r ~ 'y'w
APPROXIMATE WATER ELEV BG00 e•
Abd
(APRIL,1981) l.-_.___~
OUTLOT I a°°°
y f .3 I32,02i stfff. Il
tp -
wv.Iv
2u ;b ._xse•0I'le'R-lbaea- -I~..
a'h .0- LINE Cf TRf 14-111
.e Q 1` I
Y w de'~P~• `t
~ I afFq ~
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Z
MAILING ADDRESSi/ q ho- C. "-r 6 6)j to
v
PROPERTY ADDRESS
r
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE WT
1T
n' A
PROPERTY LOCATION I V 1/4, N 1/4, Section ° TT_N-R I~ W
TOWN ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER I
CERTIFIED SURVEY 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 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 expiration dat .
SIGNED: -C
DATE: ll
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
STC - loo
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only s of the permit issuance. Should this
result in delay
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 S'4 - 01-I M 4 `(P
Location of property YJI.t) 1/4 06 1/4, Section Z , T 3 N-R__I~ W
Township Mailing address
t LO h It 13 a 711^4 r„ f
Address of site
Subdivision name rx,sf t no.
Other homes on property? Yes ✓ No
Previous owner of property m:~ fL erlor~-
r
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? i/ Yes No
Is this property being developed for (spec house) ? Yes V' 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 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 t~1:3 office of the County Register of
Deeds as Document No. rj2 1b , 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.
Sing a e of Applicant Co-Applicant
60l
Onto of S i cannt-t17 " natp cif qi onatiira
. 52988'7
State Bar of Wisconsin Form 2 - 1982
• WARRANTY DEED
• DOCUMENT NO. VOL tj~a'`~~~ y - '
Michael G Rutledge, a single person. JUN 7 1995
i {
12:15 P. '
Daniel E. Tate and Tcnni a T.
conveys an warrants to r
Pate Living 'irus£
THIS SPACE RESERVED FOR RECORDING DATA
NAME ANrD' RETURN ADDRESS /
x-~,/0110
h~ ~X ~ WW -
4 T 7 e Clu
the following described real estate in St erni x (Ij,&•Cj, Pc aL Vd-C WL k/
County, State of Wisconsin: 5511 Q
(Parcel Identification Number)
i
Lot 1, Block rr2rr, Hansen Is Turtle Lake Hills First Addition in the Town
of Somerset, St. Croix County, Wisconsin.
~I t ~ 7S
~I
'I
This is not homestead property.
- - i
(is not)
Exception to warranties: Easements, restrictions and rights-of-way of record,
if any.
_ day of May 19 95.
Dated this
e n ~I
(SEAL)
(SEAL)
Michael G Rutledge
~I
(SEAL)
(SEAL)
I q
j
ACKNOWLEDGMENT
AUTHENTICATION
STATE OF WISCONSIN
Signature(s) SS.
County.
17 day of
Personally came before me this
authenticated this day of t9-
May 19_95- the above named
Mir•hael L-Rutledg a cin&le-Prspn,---
TITLE: MEMBER STATE BAR OF WISCONSIN -
(If not, me known o be the person who executed the
authorized by §706.06, Wis. Stats.) Connie M. GUIIiXSO rcgoing i tr ment and acknowled a ~e sa e.
Notary Public - % Sow---
THIS INSTRUMENT WAS DRAFTED BY State of Wisconsim----- - IK is ina_4gland- Connie M. Gullixson
Notary Public St • CrO1X County. Wis.
_ _ Attoa~ Law - -
(Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date:
- 12'14--- - • 19.47 . )
necessary.) ~
'Names A pe-n-igmng in any capacity should be typed or printed below their signatures.
STATE. BAR OF wISC'ONSIN Wisconsin Legal Blank Co.. Int.
WARRANTY DEED r..t`~..4va ,i FORM No. 2 - 1982