HomeMy WebLinkAbout018-1059-10-100
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 1--a/r'
ADDRESS ZqS Ige
SUBDIVISION / CSM# Ue~ lh LOT # 3
&jV,1110#ECTION ,26 Ta? N-R/7 W, Town of TTa-/yMernc(
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
4-r W -d . &1e
f 3~8. sf~'
9b'
/90 `-~S~ . p 'k0? I e
,e
~ ZB'o~'~l "~(STat 3o3S~ enrage.
Ail. C . ,
V)
3 -
INDICATE NORTH ARROtq
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to cent=er of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
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 ST Inlet.' ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUtIBER ON JOB:
LICENSE NUMBER:
INSPECTOR:
3/93:jt
' LQisAU(Mp;artUW9NA,y26. 29.17.
Labor and Human Relations W$/6►TE SEME SYSTEM County: Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: 199975
Permit Holder's Name: ❑ City ❑ Village IR Town of: State Plan ID No.:
CST BM E ev.: Insp. BM Elev.: BM Description: Parcel Tax No.: Oj 4/
a's
018-1059 10-100
TANK INFORMATION ELEVATION DATA A9400007
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic £ Benchmark
Dosing
Aeration Bldg. Sewer
Holdi St /6)0 Inlet L
TANK SETBACK INFORMATION St/)(f Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom PS -~7
Dosing NA Header/
Aeration NA Dist. Pipe I? VIPHolding' ° Bot. System
PUMP / INFORMATION Final Grade
Manufacturer Demand h n, 21-
Model Number GPM
1 Loss Friction Syetem TDH Ft
TDH Lift
~ FFii
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHIN Man rer:
SETBACK
INFORMATION Type O tz CHAMBER"
~s Model Number:
System: e-dwillA /r IT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: HAMMOND 26.29.17.403A,190TH,LOT 3
l~
Plan revision required? Q-Yes ❑ No
Use other side for additional information. 4
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No
f
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
>oy
Icf
2$ 1
3r„
a / t ;
3d
e ,
16
SANITARY PERMIT APPLICATION
. _7DI'L.HR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than R check 7s.
8% x 11 inches in size. U Check if revision 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
, ~ r a^ T 7!~ S T/'_'? , N, R / 7 If (or we
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
j A1,4
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
NEAREST ROAD
II. TYPE OF BUILDING: (Check one
) CITY VILLAGE C
❑ State Owned
Z / QQWN OF:
❑ Public Z 1 or 2 Fam. Dwelling-# of bedrooms :~L PARCEL TAX NUMBER( S)
III. BUILDING USE: (If building type is public, check all that apply) r
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
40 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. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 511 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 M Seepage Bed 21 ❑ Mound 30 El Specify Type 41 El 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 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 1 ELEVATION
Jl
7 Feet l5' u Feet
VII. TANK CAPACITY Site
in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks Concrete structed glass App.
Tanks Tanks
Septic Tank or Holdin Tank y- F-1 1
Lift Pump Tank/Si hon Chamber inn'? o ,
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name// (Print)` y Plumber's~Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date ssue Issuing A nt Sign re (No S ps
Approved ❑ Owner Given Initial Surcharge Fee) Q~
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 & 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:
1. Property owner's name and rnailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one 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 it tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with comple e 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 absorptior: 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 (ifferences; 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-6398 (R.11/88)
~W nGr
SJ' -See. ,ZG
/v Pe , je-
~95z C; y" Rol, J-
13o%~w ~ ~ Gc~,' • syooz fi
7is-G8~-297 7 NWAI' IIVi) y
-l,z9N 9 l70
Z4 5Ac'" '-esp
A 4. ,'Ote d
/Vek. B, M,
is o •o ' F%rr7~' Step
0 ~ 3
H Z
o s
1 h
0 3
o
hg's bene,ti mar) Y-emoveol (~a r ade De~✓e- LJay
~
30~ z 8~ Z p•M.
B. /m, /00.0 =TP o~ I~
31 ,C3/act P,Pe ~ 23
~YG s x/600
131- 99.95 tel. co~,6o at 72.
BZ- 99,33
A~fe rna/e 18"
Q 3 - 99.0 ~ I I
I3y-99.3e 90.
Bs o
135 - 99.20 Ire a
93
Elio Ril a B3
N~iv Beo~ elev. / /
9/-1 7'
1~rawr, 73y ; F'om lllS,rv 3,M,
Al p 64 Z9
csr
/v - 20 - 9 3 / Sca ~e / 'f0 l
PAGE OF
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
VEIJT CAP
4"C.I. VENT PIPE
WEATHER PROOF APPROVED LOCKING
25' FROM DOOR, JUNCTIOU BOX MANHOLE COVER
~
WINDOW OR FRESH 12"MIU.
AIR INTAKE
GRADE I
I 'i" MIIJ.
I 18" ml Ki. kl~ CONDUIT--
INLET PROVIDE I
AIRTIGHT SEAL I I i I
I I I
APPROVED JOINT A I I (I APPROVED JOINTS
W/C.•I. PIPE I III W/C.I. PIPE
EXTENDIM& 3' I II ALARM EXTEMDING 3'
OUTO SOLID SOIL B I i I ONTO SOLID SOIL
I
I I o1J
~ .I I
ELEV. FT.
PUMP -
OFF
r
D
CONCRETE BLOCK ~
RISER EXIT PERMIIT•ED OIJLy IF TAUK MANUFACTURER HAS SUCH APPROVAL
SEPTIC E SPECIFI.CAT`IOMS
DOSE
TANKS MANUFACTURER: WMBER OF DOSES: 4 PER DAa
TANK SIZE: GALLONS DOSE VOLUME ?
ALARM MAMUFACTURER: INCLUDING 6ACKFLOW: 12S I, l_ GALLONS
MODEL NUMBER: f CAPACITIES: AINCAE5 OR-:~ GALLONS
SWITCH TYPE: Af Y L'cY''~ g= INCHES OR` GALLONS
PUMP MANUFACTURER: C ,INCHES ORS ?J GALLOIJS
MODEL NUMBER: << )1;~. D= INCHES ORS" GALLOIJS
SWITCH TYPE: MOTE: PUMP AWD ALARM ARE TO BE
MINIMUM DISCHARGE RATE-GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF ARID DISTRIBUTION PIPE.. FEET
+ MIIJIMUM NETWORK SUPPLY PKtSSUKE~. _ , . . . _ . . , . 2.5 FEET
+ FEET OF FORCE MAIN X ~~F/ /f
loo FL FRICTION FACTOR_ _ f . FEET
TOTAL DYNAMIC HEAD FEET
IUTERNAL DIMEWSIONI; OF TANK: LEIJGTH VO" ;WIDTH .;LIQUID DEPTH
3 1 G U E D:-l LICEMSE UUMBER: 14FI`y Z n/ DATE: A~2 - 17)11
Submersible Effluent
.
Performance .
Curves
Pumps
METERS FEET
- 90 MODEL 3885
25 SIZE 3/4' Solids
__Hd I I I
WE15H
° 70,-
X 20 WE10H
J
H 60
-WE07H
i-
15 50
NE05H
dZ N,
40
10 30 WE03M
20
5
10
0 0 9_~H
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
I I I 1
0 10 20 30 m'/h
CAPACITY
uGMLDS PUMPS. INC.
SS ECA FALLS NEW YCCx 13148
METERS FEET
120 MODEL 3885
SIZE 3/4" Solids
110 WE15HH
100
30
90
I
25 80
i
70
S 20
60
0
OSH
50 WE H
15
40
10 30
20
5
10
0 0
_Lj
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
L 1 I
0 10 20 30 m'/h
CAPACITY
01985 Goulds Pumps. Inc. Effective July, 1985
C3885
509'729
CERTIFIED SURVEY MAP
Located in part of the NA of the NWa of Section 26, T29N, R17W
Town of Hammond, St. Croix County, Wisconsin; being Lot 1 o'
Certified Survey map recorded in volume 8, Page 2271 at t
St. Croix County Register of Deeds office. S RLED
NOV 3 01993#
JAMo°
Doe&
PA&W
INW Corner of SLCf*QL,WI
Section 26 nL_Al -IIr-rL~L I n n I
L'N -L__r11 V410S
~ J unty Section Monument - - -
Aluminum Cap Found
North line of the NW} of Section 26
U. S. H I GHWAY 11 12 11 M N89o30' 4311E
M ~ ~L-
N890 3014311E --388.541
A 5.99' 192.55' V
cc 3C 6rF, 2264.35'
- 63 ti9 1~~ N8905614911E 261.72'
N} Corner of
\ ti; 3 ,3\ SScC C / U-)
GVp ~/y~"' Section 26
F--I r~t ~9~ CK Railroad Spike Found
AT wI I 66, ~a.~ ray~(!d7~~a,e~d.I~eEe
1~1 o W_ wI - ....LOT 3
1 0 M
V F-- I I m
t0 N -
01 2.65 Acres Inc. R/W rn N
-0 0 ~ 115,336 Sq. Ft. Inc. R/W M co _
V 11* 2 N M
„ d QI I N IN 2.33 Acres Exc. R/W
o ~I c N 101,383 Sq. Ft. Exc. R/W I
4- +1 !1
ego aa / I /•~-'r m r-I LL/-I L
H ..~i o m Lo : L.li I I rn i \~I
t N Cl) R L o = -25.83' S89o08'00°W 390.16' C>
ar o
co e ca O N a 364.33' ."LL
U';I
LJI )0191(
N O
CSI d O O
cI 3 o .,I
_ LOT 4 =>I
CD o ST. Cr m cot>wy
CMataoa PiR
L.L;I °o °o 1.79 Acres Inc. R/W o
78,126 Sq. Ft. Inc. R/W I Z"inglkMd
I
I 33' 33'I 1.67 Acres Exc. R/W
~I ( 72,960 Sq. Ft. Exc. R/14
i1 25.84' 365.311 V vat
of
*T''``'' S8900810011W 391.15' apor"ddot*
Scale in Feet "w-vd duo lbe
i 'In Ir-)l r",% n it
% 0 50 100 200
' c Ob a°. LEGEND
't`om. t.~ t;~..~ Section Corner Found
a~• i,,',~ ■ 111 Iron Pipe Found - D.O.T. Monument
W} Corner of O 111 x 2411 Iron Pipe Set, weighing
Section 26 1.68 lbs. per linear foot.
OWNER 2" Iron Pipe Found • 1" Iron Pipe Found
Ken Peterson • • • • • • • • • • • • • • • 100' Roadway Setback Line
1958 C.T.H. "J"
Baldwin, WI 54002 VOLUME 10 PAGE 2714
This instrument drafted by Michael Erickson Proj. No. 93-61
I
SURVEYOR'S CERTIFICATE
I, Allen C. Nyhagen, registered Wisconsin Land Surveyor, hereby
certify that by..the direction of Ken Peterson, I have surveyed,
mapped and described the land parcel which is represented by this
Certified Survey Map; that the exterior boundary of the land
parcel surveyed and mapped is described as follows: .
A parcel of land located in part of the NW1/4 of the NW1/4 of
Section 26, T29N, R17W, Town of Hammond, St. Croix County,
Wisconsin; being Lot 1 of Certified Survey Map recorded in Volume
8, Page 2271 at the St. Croix County Register of Deeds office;
further described as follows:
Commencing at the NW corner;of said'-section 26; thence
N89030'43"E, along the north line of the NW1/4 of said section,
195.99 feet to'the point of beginning; thence continuing
N89030'43"E, along said north line, 192.55 feet; thence
S00019'33"E, along the west line of Lot 2 of said Certified
Survey Map recorded in Volume 8, Page 2271, 519.23 feet; thence
S89o08'00"W, along the south line of Lot 1 of said Certified
Survey Map, 391.15 feet to the west line of the NW1/4 of said
section; thence N00002'25"W, along said west line of the NW1/4,
425.35 feet; thence N63023'26"E, 219.12 feet to the point of
beginning.
Above described parcel is subject'to: right-of-way of U.S.
Highway "12", right-of-way for town road (190th Street), and all
easements of record.
I, also certify that this Certified Survey Map is a correct
representation to scale of the exterior boundary surveyed and
described; that I have fully complied with the current provisions
of Chapter 236.34 of the Wisconsin Statutes and the Land
Subdivision Ordinance of the County of St. Croix in surveying and
mapping same.
r
Each parcel shown on this map (Plat) is subject to State and County
Laws, rules and regulations (i.e., wetlands, minimum lot size, access
to parcels, etc.) Before purchasing or developing any parcel contact
the St. Croix County Zoning Office £or advice.
VOLUME 10 PAGE 2714
n
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER
/ - T
ROUTE/BOX NUMBER'
FIRE NO. j9s8.
CITY/STATE fc%ZIP
PROPERTY LOCATION: I.Iz V1/4 4//t,) 1/4, Section , T N, R_2_W1
Town of c~/11rJ , St. Croix County,
Subdivision a~ -~5_0y'7-Q 9 , Lot No.
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 a 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
$3000 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
systems properly maintained.
The property owner agrees to submit to St. Croix County Zoning a certification
form, signed by the owner and by a master 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. Certification form will be sent approximately 30 days prior to
three year expiration.
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 Department of Natural Resources. Certification
form must be completed and returned to the St.Croix County Zoning Office within
30 days of the three year expiration date.
SIGNED -
DATE
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
` APPLICATION FOR SANITARY PERMIT
S T C - 100
This application form is to be completed in full and signed by the owner(s) of
the property being developed. Any inadequacies will only result in delays of
the permit issuance. Should this development be intended for resale by
owner/contractor,(spec house), .then a second form should be retained and
completed when the property is sold and submitted to this office. with the
appropriate deed recording.
-Owner of property
Location of property 1/9 AlrLl" 1/4, Section T N-R ~ W
Township _orrirr~r,~
Mailing address
'Address of site
Subdivision name 5 M a71,~ , 597
Lot number 3
Previous owner of property
Total size of parcel ~✓~r-~~,Date parcel was created
Are all corners and lot lines identifiable? _,_'~_Yes No
Is this property being developed for resale (spec house)? Yes - No
Volume -and Page Number l_ ~ 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
Hap shall also be required.
--------------------7---------------------
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, -510 j-1
presently own the proposed site for the sewage disposal system;(ordIt(we)I have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of t7enty Register of Deeds, as Document No.
) .
Signat r of Owner Signature of Co-Owner (If Applicable)
bate of Signature
Date of Signature
DOCUMENT NO. WARRANTY DEED
THIS SPACE RESERVED /OR R[CORDING DATA
5,.0258 STATE BAR OF WISCONSIN FORM 2-1982
- - O vot 1054PAGE211
REGISTER'S OFFICE
Kenneth- C... •Peterson•• and• Louise E, Peterson, ST. CROIX CO., WI I
I husband and wife, hoidin~ as survivorship Rec'd1~nrReco~
y•_-_- ~j
. marital-• Qropert - - '
• DEC- 9 1993
and warrants to ..Ldrry..I.. Peterson... and Karen at 11:UO
Ate...Pete-rsgn~--hbnd..-~n~l w,f~ n s«~•-~'Pr'r.,lt-al/GIJAL
surviyorsh. g•••• a y
...Pr.operty................................ A 10 to Of Deeds
I
RETURN TO
the following described real estate in St_....Cro jx.....------ County,
State of Wisconsin:
T1 x Parcel No:
Part of the Northwest Quarter of the Northwest Quarter (NWk of NWk)
of Section Twenty-six (26), Township Twenty-nine North (T2.9N), Range i
Seventeen (R17W), more particularly described as Lot Three (3) of i
Certified Survey Maps recorded in Vol. 10, Page 2714, as r:)cument 1
No. 509729 filed November 30, 1993, being a part of Lot One (1)
of Certified Survey Maps recorded in Vol. 8, Page 2271.
i
_ I
STAN : M
bO
I
This 19._ nOt..........-- homestead property.
J4 (is not)
Exception to warranties: Easements and restrictions of record.
Dated this day of ecember
19.93...
.........................................•------.........•---(SEAL)
. . . (SEAL)
•
• Kenneth C. Peterson
..................•-•--•-........._..-•------•-----••--------..(SEAL) ~ ^Q_._....._.
(SEAL)
Louise E. Peterson
AUTHRNTICATION ACBNOWLEDOMBNT
Signature(s) STATE OF WISCONSIN
suthenticst .this -------------County.
day of-------------------------- 119 Personally came before me this
?ft--I.daq of
- • j?gCember............ • 19--93- the above named
.Kenneth C. Peterson and
Louise E. Peterson
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by ?08.08, is. Stata.) for
to me known to be the person $_.____~1:~who ezecd
ute ' e
THIS INSTRUMENT WAS DRAFTED BY g instrument And acknowl~ 7-the same..
Thomas A. McCormack
.........-Baldwin~..~=...54002-------------•----._.....•.. a.--- :~~r~. ~tJ,.l.::..........
s
- Notary Public
(Signatures may be authenticated or acknowledged. Both My Commission is pepanen . (If • s, }eCOUnty, Wis.
are not necessa ezpir lion
date: .
'Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANT! DEED aTATN BAR OF WMCOT7
Snli Wisconsin Legal Blank Co., IRD. If
ILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
,
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than I
8% x 11 inches in size. ~/J Check if revision o 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
- Y4 '/a, S T , N, R (o W
PROPERTY OWN 'S MAILING ADDRESS LOT # BLOCK #
/t/X
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
130 acs L - 77
ii. TYPE OF BUILDING: (Check one CITY
El State Owned O VILLAGE Y ~'!/rJOr NEAREST ROAD
r-I ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms-~ AR EL TAX NUM ER( )
III. BUILDING USE: (If building type is public, check all that apply) O 3/4 ! i G 5 116
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
30 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 in line A. Check line B if applicable)
A) 1..4 New 2. ❑ Replacement 3.0 Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - 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 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 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 10 ELEVATION
Q /U L N q/, t! !7 Feet , Feet
CAPACITY
VII. TANK in allons Total of Prefab. Site Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank f"
Lift Pump Tank/Si hon 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's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
Ar, k 1, E/,~!Fl Z (21--5
Plumber's Address (Street, City, State, Zip Code):
' IX. COUNTY/DEPARTMENT USE ONLY
Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
P 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 & 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:
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.
ll. 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, !ocation of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; pvelis; water mains ,.eater service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absornt~on 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; elevati;n ,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 mc)mtoring groundwater, ground-
water contamination investigations and establishment of standards.
i
SBD-6398 (R.11/88)
wY~G.r ;
Safe Sec. ,zG
~95z Cty, T
715- G -N-,2 9 7 r7 ivc~/y /~llil%
-/',z 9N 170
Al,
/Y 0 Z ~.~nI~Q O.rb UY ~I'fI
,i aWJ I~ r of 00 n
OI, Dm e6 a ~a~
~I j ~ ~ nA AID
qq y e o acY G .~v
`l P~,fo.ofeC4 1
New B, M,
io0.o' c ,rrf Step
O 3
~ N z
vvi n
0 3
VQrQ G 1Jr~~/e ~a/
tips 6enc,ti /Y»arl~ -drnovepl
30'
/00,0 ~ = off, o f P", [
3
131acK I°,PC a 23
In 5x/ooo
B1- 99.95 comdo sl a2
(3z- 99/33
AMeo rncr/e 418
Q3 - 99.0 90,
13 y' 99 ~3 L•
135 - 99•Zo Ire a 1.3
a~~ ~B3
JVEuJ Bed r/ev. ~
91,'Y7~ /
~~QW n : F~on, 111 8,M,
Al P a6 z
Cs r
/o - 20- 93 / Scale
~wY 12
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY5~
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than
8% x 11 inches in size. ❑ check f r visiiooonn 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
14~ <3 r' • • / f~' G'7-Soi~"~ /t l c) '/4 N, r. S .2-6 T e_q , N, R / 7 9 (or W
PROPERTY OWNER' MAILING ADDS LOT # BLOCK #
/i 57-g c/✓~
CITY, STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
5'09?Zq
3
(71 J o?1 'Z? 7 I
II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD
) El State Owned p V
4QWN OF: ILLAGE s'
P
❑ Public M 1 or 2 Fam. Dwelling-# of bedrooms ~ PARCEL AX NUMBER(S)
III. BUILDING USE: (If building type is public, check Z11 that apply)} /6 9 jn lpo
1 ❑ Apt/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 in line A. Check line B if applicable)
A) 1. 3 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 9 Seepage Bed 21 ❑ Mound 300 Specify Type 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 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
7..5 Q /O'7 Z fly ~t~ .7 /v,141 /71K 7 Feet 4?, /7 'Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New F-xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank 5P 1-1 50 f /f/; c ovP T Pe(fst
Lift Pump Tank/Si hon 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's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
DnI(' llZ~
Plumber's Address (Street, City, State, Zip Code):
~r/!iiY'f' ~_3<!//~L U✓ f~ /I~i `~'~(~/i~
F Z6
IX. C NTY/DEPARTME USE ONLY
❑ Disapproved San' ry Permit Fee (Includes Groundwater ate ssue Issuing ent Sign lure (No mps
0~Approved F] Owner Given Initial Surcharge Fee)
Adverse ~9/~
Determination GU
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
t[ 1
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:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one 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.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8'f 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 ele~v_rtion 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.
I
GROUNDWATEiR 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-6398 (R.11/88)
S;te Sec' 'ZG
L a ~ ~ y >°e~G rro
~9sz qty, Rol, J-
13a/o/~, ~ h, ~ syooz
.2977
Nc~/y /~ltJ/'y
-;~'Z 9N 9170
5~4 c reS
wu ie wp`b` • o °i
•N~ra~Ql~ ~ a04 oyd o
41// t+
Perf orO~eol
v
N
0n 4. N
0 ~
O
Z
17~~~e Ljay
13,x1, - /oo-o~ =T~ o~ lye„
.Cilac P,Pe 23
/y~o8al.
BI- 99.95 810 0 B2
BZ- 99'33"
A~ferna~e `IS
133 - 99.0 '
90,
!3 y - 99 ,3 z•~ ~o
as
C35 _ 99•Zo Art A o\.
Byp R
0 83
,Z-
/
:D 4r a
144 p
Csr 3#13
to 20 - 93 '/o
h'wy- /z
DII.HR ANIJ al l t-tVALUAI IUN HtI VH t
in accord with iLHR 83 05, Wis Adm. Code
COUNTY,
• Attach;oomj5f4te ante pl•ari on paper not lasmthan 8. t/2 x 11 inche s1n size. Plan must.indude, but
,
not limited to 4adcal and horizonlat reference - - - _ _ PARCELIA. 0 -r--
pant (13 M) dreclion and % of slope, scale or
dmensioned. north arrow, and location and distance to nearest road.
APPLICANTINFORMATION-PLEASE PRINT ALL INFORMATION REVIEWE08Y GATE .
PROPERTY OWNER : PROPERTY LOCATION
l CQ r~ O GOVT. LOT I/4 /1)e 14S 2e T N.R 17 # (or) w
PROPERTY _ EWS MAILING ADDRESS LOT R BLOCK # SUED. NAME OR CSM S
CITY, STATE C ZIP CODE PH7ONE NUMBER '7 7 []CITY []VILLAGE MOWN J NEAREST ROAD
lvz_ PI New Construction Use K1 Residential / Number of bedrooms
l 1 Replacement ( ) Public or commercial desabe
Code derived daily now 750 gpd Recommended design loading rate bed, gpd1ft2 trench, gpd/tt2
Absorption area required O 77 bed. n2 5 u trench, tt2 Maximum design loading rate bed. gpdM2=trench. gpd/ft2
Recommended infiltration surface elevation(s) 91f 7 It (as referred to site plan benchmark)
Additional design / site considerations
Parent malertaf Flood plain elevation, N applicable /iyX' It
S = Su lme (or system COW-efltONAL MOUND NG OUNOPRESSURE AT-GRADE SYSTEM N FILL HOLDING TANK
U= Unsuitable forsystem OS ❑ U 0S ❑ U .®S ❑ U S❑ U ❑ S .®U ❑ S au
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color MOWS Texture Structure consistence Bourdary Roots GPD/ft
in. Munsell Ciu. Sz. Cont Color Gr. Sz. Sh. Bed Trerd
qtr-
,y
Ground -U-57
elev. r y°rr, t~; ir1
15 it. 57--0/
Depth to 5 l- ~9 io Y /i, 005,r_ C - rr, I d
limiting
factor
9
Remarks:
Boring #
AIA
5' T
Ground
elev.
52 6,
h ~ny rnc~~s •7 ° b
m
limiting
factor - Remarks-
CST Name:-Please Print' Phone:
Address: -
Signature:
Date: CST Number:/
Boring # Horizo Depth Dominant Color Mottles Structure ;app-~ljr
..g . _ in. Munsetl Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Baaidary Roots
Bed ,T.
Ground ~Z.. /lam Y o
elev.
A? U
~(lu'~~ I O
Cow r s I a rJ
Depthngto "Y'
r~
d
factor
Remark's:
Boring #
i /~L{Zf
Ground `5 $3-~1 /may ~lsY r C Ste'
elev.
q9 3~ fL
Depth to
limiting
actor
Remarks:
Boring #
pi leg
. FF57
Ground Sy-~l /D Y/~ 1 C r~5' O G. S~ ~'7 •8
elev.
91!!2 ft.
Depth to
limiting
fac
pr
I
Remarks:
Boring #
Ground
elev.
ll.
Depth to
6miti
ng
factor 1
Remarks: