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HomeMy WebLinkAbout020-1056-00-200 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY IN BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O: BOX 7969 BUREAU OF PLUMBING MADISON,-WI 53707 ®CONVENTIONAL DALTERNATIVE State Plan l.D.Number: D Holding Tank ❑ In-Ground Pressure D Mound [If assigned) NAME OF PERTIT4W6d JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Arthur Windolff Route 1, Hudson, WI 54016 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN'. REF. PT. ELEV.: CST REF. PT. ELEV.-. SW4 SW4i Section 21, T29N-R19W, Town of Hudson Name of Plumber: MP/MPRSW No. Counly Sanitary Permit Number: Calvin Powers Jr. I1563 St. Croix 69617 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY'. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. DYES ❑NO DYES ONO BEDDING: VENT DIA.: VENT MAT( HIGH WATER NUMBER OF ROAD: PROPERTY IWELL: BUILDING: VENT TO FRESH ALARM FEET FROM LINE. AIR INLET'. DYES ❑NO DYES ❑NO NEAREST _ 311. DOSING CHAMBER: MANUFACTURER. BEDDING'. LIQUID CAPACITY PUMP MODEL IP11MP,SIPH0N MANIA ACTIIREH IV, ARNING LABEL LOCKING COVER PROVIDED'. PROVIDED: DYES ❑NO DYES ❑NO DYES ❑NO GALLONS PER CYCLE: 7ND CONTROLS OPERATIONAL NUMBER OF PROPERTY JWELL BUILDING JVENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) DYES ❑NO NEAREST III SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing - JOIAMF TEH MATE HIAE AND MAHKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE MAIN the soil is dry enough to continua.) CONVENTIONAL SYSTEM: WIDTH LENGTH IN001 IDISTH PIPE SPACING COVER 1111111L DIA 'PITS LIQUID BED/TRENCH THENCHES MATERIAL: PIT DEPTH. DIMENSIONS GRAVEL DEPTH FILL DEPTH UISTH PIPE DISTH PIPE DISTR. PIPE MATERIAL NO DISTH NUMBER OF `PROPERTY WELL. =ENT TO FRESH BELOW PIPES ABOVE COVER EI EVWL1 ELEV END EET FROM INEIR INLET'. 1 I F NEAREST--~► MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- DYES NO meets the criteria for medium sand. TIONS MEASURED. ❑ SOIL COVER TEXTURE 1PIRMANI NT MARKF RS F1111SERVATION WELLS _ DYES ❑NO DYES ❑NO DEPTH OVER TRENCH BED DEPTH OVER THENCH 11111 TOPSOIL SODDED SEEDED MULCHED CENTER EDGES ['""C' DYES. ❑NO DYES ❑NO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH TRENCHES LATERAL SPACING GRAVEL DEPTH HE LOW PIPF FILL DEPTH ABOVE COVER DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTH DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV.. DIA. ELEV. PIPES DIA: ELEVATION AND DISTRIBUTION INFORMATION 'TOLE SIZE HOLE SPACING DRILLED CQHHECT LV COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANTS DYES ❑NO DYES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM LINE: DYES ❑NO DYES ❑NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. TITLEDILHR SBD 6710 (R.01/82) r~N~_ wisconStn APPLICATION FOR SANITARY PERMIT -~'40&0;4 ♦DILHR COUNTY (PLB 67) UNIFORM SANITARY PERMIT # ~ OEPRRTTEI-IT OF - Ir10USTRV,LRBOR&HUTRf1 RELRT101-IS 4 ~J f /7 -Attach complete rilans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'/2x 11 inches in size. 11 -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRE S qd I !'Ar~Fkur W d i~v ar w1 C, PROPERTY LOCATION 5 W1/45 "/4, S , TICI N, R 19 It (or) W T OWN OF V o 44k'L /4- LOT NUMBER BLOCK NUMBER ISUBDIVISIJ)N NAME NEAREST ROAD, r TATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED X 1 or 2 Family Number of Bedrooms: ❑ Public (Specify): THIS PERMIT IS FOR A: Z New System ❑ Tank Replacement ❑ Repair El Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. ,N Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity /000 Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: G Wg a 6 c:. IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): 1 6 15- ( /s Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of P)umber (Print Signat MPRSW No.: Phone Number: CaIUir7 U pc~ 1 S (_)/5-)2_Y6 )~er's Address: Name of Designer: S / ~~.w L~ r~► c~ ~v cs C~ 5~ ~ COUNTY/ DEPARTMENT USE ONLY Signature of Issuing Agent: Fee: Date: ❑ Disapproved ~~-oQ ,+~G p~ ❑ Owner Given Initial Approved Adverse Determination Reason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber 1 INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 To be complete and accurate the permit application must include: r 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. APPLICATION FOR SANITARY PERMIT ST 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 e ~Ai LY1 J, FF Location of Property It cw 1%, Section Z I , T N - R C W Township 4 u 7, o n Mailing Address L/ 0 Subdivision Name pra pOS G`,S,1T7, Lot Number 2 ` a Previous Owner of Property Total Size of Parcel 2-, A S Date Parcel was Created n o u l-,aUcz Are all corners and lot lines identifiable?_ Yes No Is this property being developed for resale (spec house) ? h Yes No Volume and Page Number as recorded with the Register of Deeds _ INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: -W9rrgnty Deed 2. Land Contract 3.• Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. PROPERTV OWNER CERTIFICATION I (We) eenti.by that att statements on this bonm aae tAu.e to the best ob my (out) k.nowtedge; that I (we) am ( cute) the owner (6) o6 the pnopexty des eh i.bed in thiA inbonmati,on bonm, by viAtue ob a warranty deed recorded in the Obbice ob the County RegiAten. ob Deeds a6 Document No. ; and that I (we) pnes entt y own the proposed 6i to bon the sewage pod system (on I (we) have obtained an easement, to hun with the above de6en.ibed pKopexty, bon the eonstnucti.on ob said system, and the same has been duty neeoaded in the Obb.iee ob the County Reg.e6teK ob Deeds, as Document No. ) . SIGNATU OF OWNER gym/ SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED DOCUMENT 1144. OTAT& BAN OF q ISCONO W 9099 1 !t ~aaa~.anes nra i' 1' ^t TTei• aMACC Rasl[R-$= iOR DICCORoj*jQ DATA VOL' it I Charles W Ernst $ ! ? r REGISTER:; OF~eg This Deed. a . ST. cRO Ix Co. wJ& . Rm"d for Re=d th _ 2nd- (lay of_ Jn! ig 76 ~ r Grantor conveys and warrants to........ Arthmr... Grantm_. t for a valuable cons iders,lion..Of....$1. O.D...and... other ....&ood....andL...... i.alNiab.le....c.o,n.i-.t.^derat-ion RHT'V RPtl 40 the following described real estate in St..,...CZ?A0 X....... County, Tri County raving's & Loan Ass sn State of Wisconsin: -lax Key r.............................. All that part of the Southwest quarter (SW;.,) This is ...nPn.... homestcad property. of the Southwest quarter (SW%) of Section 21, Township 29 North, Range 19 West, lying southerly of the centerline of State Trunk highway 111211, prior to the relocation of said centerline. The parcel described above lies North of present County Trunk Highway non f Exception to warranties: Existing highway right-of-way. Executed at........HudsonA ,Wis,cpn..? this.2nd f_Ja uary. to3.6 . SIGNED AND SFAt.%LJ IN PRESENCE OF Ry ,en (SiihL) - 'i . CHARLES W. ERNST N/A F,11 ICI. Signatures of Charles. ...W......Erns.t,....a/_k/a...Charles .Worthingt on. Erns t, authcn i[a,t^,l d"% day of ) WILLIA J. RADQSEVIC11 Tolr \9cn iu; 4.irc l;ar ! \\';s"„n. n 'r ft^h<r f'.;: I~TA'I t' 01' WISCON'sl V tt 1 _ Count the ah•+Ir namnl t<, mr kn^,,An l-r ~h. I-: uh,t rsi~. un _ ~ 1 ~ THIS INSTRUMENT WAS OPAFTEO 8Y .William. J. Radosevich The use of witnesses i+ nl.ta Names of pcmms signin,l; in an} capacity shiwld he tlp cd or IKintr.l below tlirir .i; natures ~ 4 li 11i+1"Ae\+ 1 ~ '-3 C)" ED tiov o ST. CROIX CCUNT1' un2latted l,nd__owned_bY_R!2t!er- Gh1PREYSE'd51Vk PARK] PLAHMNG z + o dVZ ZOHI, G COMATTEc c 1 0 c~ NO04811211W 1+86.38, cn I o N -i c] cn - r i - t r,) 453.3L" 33 - O c_) to - .ca r- - ^v t~ o rte) r *i (~l fV (t, N ~J C.J o N N • -I G _ CJ C.) N O N N n o / \ (P N (D N I to rt rl- vi _ C,3 C) r,i rrl • to . :a U O W n To ICJ 'S- ' L) 4) 1,-1 Ira' IIr M tru I•-' \ \ ICl Ilv N00048112W 486.87' IC • Ir]. t 453.87' 331 i-r 70' 70' I N r N U, r-- ,C~. - 1:] to - U N ICY J O I Y ~ D S ~ r- --t O C7 / ~ ~ _ t:: ~ o- -r rn N00°4811L"4J 471.16' / " ` 436.05' _ 3 5 . I 1 / v c.) x C,- c tc) -G m o N c.> o w r~ - c'> ct] m 0 In :Ia :O O p /il ' 1 ~ rt rt ~ in to c;) 651 6i cn rc I ~ c ~ N c~ ~ cn c o° v f~ 1 c-) -a CJ r1 CIO cn r- C:) 0 CV7 / O CJ r CT <n V J c'] cn c= FT I f, I r / m I 3 rn rn ~j M -o r _ r•~ o in _ ~ a rn y ~ m c lFJ 1-t l;0 . H V-_ G 7 rn -v cL, 'o 4-1 r,l r kEFCi~[iI ICED TO THE r UST ST G7 3. y t T m GG'rg,In,.uGJ ~ U r._ (,l) / LI1~E OF T(I ! 1 7'1 nJ U 1r .D TO OCr aR or8Itc iJcn r7 Z 0~ 1 ~r, ti H ~i 9 ST C- 105 r r 9 H SEPTIC TANK MAINTENANCE AGREEMENT 0 St. Croix County z ` c7 OWNER/BUYER ROUTE/BOX NUMBERV Fire Number CITY/STATE zip PROPERTY LOCATION:S(,J~4, 5L--Jk, Section, T:),g N, R~W, Town of (juckay, St.. Croix County, . Subdivision lpr`f°-5 Lot number Improper use dnd maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists 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 treat- ment 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 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), 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. 0 Z I/WE, the undersigned, have read the above requirements and agree N to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ro ment 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 f DATE 7 - -2 S-sCS St. Croix County Zoning Office P.O. Box 98• Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above addres . V E o 0 0= 0 . C U) 00 OD. C c!) 0 fa ui o al 'a > > y 3 c ca C'3 3 om m v oc cc E O C cv O C N U V1 C O O i y F. Q Cl U to O w O ey C 0 u~ N C O O M C 0 0 cc cc 0 4) a 3°'30=- °~a O" r W oca J «-=0. c~v o _ to c Q ~ c N 0) 0 w O C P2 Q 'o - 0 0 E U O~ 3 Z 4) U 0 0U)c m Q C ~-cv~ ~=cv a Q 3 ai cod F- cn all N Z cn M- 0 cn c ac~, 0c~a~c rny° al O ;o° ~UCO 'C - O i CD tv- a mo o:: o 0.0 0) N O 0 U 0 0qt ca N¢ c Q aa`'0~ 0 v.. M- h C 0 c 0 O O C O C R1 cc1 ~ ` M I V OC E C O) Z .s (_n C= O 7 O E ~ O C C= O C C I O cv o 0 w C6 CM O 0 O O U u rn c D a~ E vs mi I - I y~ y 0 CL cc ~ C' O cv ` 3 U 0 t7 c O b co CC o Y~ 0 0 3 0 0 (D a ado •~r0 13 c 0 00ca 4~0 z co w 0 0.0 C o U U ~Y N 3 co C O i i O C N CU `O > L O E c v m> H:: 3 m m° c x N ~ O DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS N INDUSTRY, DIVISION LABOR NDLATIONS PERCOLATION TESTS (115) -•.!?.0. BOX 7969 HUk4AN (H63.09(1) & Chapter 145.045) 1 53707 LOCATION: SECTION: TOWNSHIP/ LOT NO.: BLK. N kAW: t9 Town of Hudson 3 ropo. sw 14sw1 `21 /T 29 N/R 19 for 66 1 COUNTY: OWNER'S NAME: MAILING ADDRESS: St. croix Arthur Windolff Rt. 1, Hudson, Wi. 54016 yC s r6mj USE DATES OBSE DNS ADE ; NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DE kF/TNS: PERCO STS: ®Residence 3 ®New ❑Replace 11124 RATING: S= Site suitable for system U= Site unsuitable for system CONVENT((I~~ON~AL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) E]S L_.JU ES ❑U S ❑U ❑ S ❑U ❑ S ❑ll conventional If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: N/A I Floodplain, indicate Floodplain elevation: N/A PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPrH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 6.91 106.2 None 6.9 1.71 Bn,sl, 1.21 Bn ls, 41 Bn med s B_ 2 6.1 111.6 None 6.1 11 Bn sl, 0.91 Sil, 2.71 Bn, med s, Cobb, 1.51 med s, cobb. B_ 3 71 109.4 None 71 21 Bn sl, 1.8 med s, 1.71 Bn, s,Gr,cobb, 1.51 Bn CC,S. B 4 6.91 105.9 None 6.9 11 Bn sl, 0.91 sil, 3.01 med S, 2.01 cc S, Gr,Cobb. B- 5 7.7 108.0 None 7.7 11 sl 1.2 1 31 med s 2.51 S Gr. B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. P RIOD 1 PERT 02 PER1003 PER INCH P- 1 3.21 no 31 3 P_ 4 2.9 no 31 3 3 3 1 P- 5 41 no 31 3 3 3 1 P-- P- P PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION_ 103.0 ( i LEGEND 1 - _ horidg hole III perkJoI, Sl al-el =--l L 1„ o+1- 3~ T (elev. perk I Q I- #3;107.0 0 ❑ ) ~ _ - pri ary; 15.. _ Aftern ara ~I I I areaate I t N I i f i 421 I 50 > r 135l.I ! 581 SW corner lot 3 i ( 1 i B.M. _ 1,90.00 516......91 1" ironlpro"erty pipe 470 1" S $9°-11'-48".W I L__ I, the undersigned, hereby certify that the soil tests reported on this form were made by mein 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: Allen C. Nyhagen 11/12/84 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 108 Walnut St. Hudson Wi. 54016 4 386-2007 CST/S;I~~GNA~~TURE CiC .C.G7~.s1 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - A r~ ~ /l~ c,U ► n ~ v 1, r r~ ~1 1 C-1 U S~+ O/T~ W 1 S'-fin PAGE OF roSS ~0-C~1Uf1 G SY5 0n1 C 5w yy s w%y A-a,-Z1 T 29Ny,C Icy w 14- CIS 0 .11) Fresh Air Inlols And Observation Pipe .Approved Vent Cap Minimum 12" Above Final al Grade 20- 42" Above Pipe _ 4" Cost Iron To Final Grade Vent Pipe Marts Hay Or Synthetic Covering win 2" Aggregate Over Pipe Distribution - Tee pipe 0 0 0 0 6" Aggregofe o Perforated Pipe Below Beneath Pipe o -Cooing Terminating At Bottom of System i P~p~oSen ~t~k~ 1grH~l{ , " (eJ•.7 ton 5 0 SOIL FILL DISTRIBUTIOVI PIPE APPROVED S'jAITI-IETIC COVER o e ~'-MATERIAI- OR 9" OF STRAW 2.0FOGRE66AIE c OR (~ARSN HAy OF 1Z -2i/2 AGGREGATE E6 LEV. OF~3 FTQ.. E DIS-rRiSUTI1JA1 PIPE TO BE AT LEAST 2-2- IUCHES BELOW ORIGIIJAL GRADE AQU AT LEAST20 IKJCHES BUT AIO MORE THAKI 42 INCHES BELOW FILIAL GRADE /'MAXIMUM DEPTH of F-XeAVAT160 FKOM OWANAL 6KAK WILL BE -LL_ IUCHES MINIMUM ®EPT'M OF FACAVATIOW FROM 0~161114AL GRADE WILL BE 31- INCHES SIGIJED: LIC EW SE UUMBE R: I S ~c S Z ' DATE: 110 I A r ur (O o do/ FF g n I~ed'SiLe- l2!K EI'3 sQrT, 9nk loop >ooc~7 j Sc a / ~/0 M '5W ~oRneR 0 G7 e. 1 - 5- C~/vi r► P©~e~'~ J IZ ri.P~sw Ifs ~L v iosy 142. ' X35' S~3 Sou L s~ STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Sn~,y ~r,,d ADDRESS SUBDIVISION / CSM# Jae „hams LOZ,, SECTION T N-R W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VI %10 SHOW EVERYTHING WITHIN FEET OF SYSTEM I ~s law f 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:_,~11 Liquid Capacity: old Setback from: Well /6g&" House Other Pump: Manufacturer Modelt Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length ,5-7 Number of trenches Distance & Direction to nearest prop. line: ~?n Setback from: well: 6,-T; 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: PLUMBER ON JOB: LICENSE NUMBER: 'J! INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and 5yildings Division CEANERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI BONNGARD, STAN & JULIE X CST BM Elev.: Insp. BM Elev.//: f BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA / y TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 11,dweS ~eCIxSZG Benchmark A / S 1 /693,S7'. Bldg. Sewer 3. 167, I Ing St/11et~ DES 7_1~ TANK SETBACK INFORMATION St/.Outlet TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet Air I Septic 44 NA Dt Bottom Ir Dosing NA Header_ 03 Aeration A Dist. Pipe 03 ing Bot. System ,0/ PUMP/ SIPHON INFORMATION Final Grade 0 L27 Man Demand Cc 1072 11 Model Number GPM TDH Lift Fri System Ft ss eacl~1_ . --T cemain Length Dia. Ff Dist. To Well 771 E: SOIL ABSORPTION SYSTEM BED/TRENCH Width Length i No. Of Trenches PIT No. Of Pits Inside Dia. uid Depth DIMENSIONS DIMEN I SYSTEM TO P/L BLDG WELL LAKE/STREAM LEAC M acturer: SETBACK INFORMATION TypeO xc,. _30!5, / CHAMB Model Num er. System /Jo~v Ce, , IT DISTRIBUTION SYSTEM Header 1 -3 Distribution Pipe(s) „ i x Hole Size x Spacing Vent To Air Intake Length Dia. Length Dia. ~'Z Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only` . o i Depth Over ,I Depth Over xx Depth Of Px S odded xx Mulched ROPTrench Center ~9-~ /Trench Edges c~ - ~ Topsoil ❑ Yes ❑ No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) A`' i&~--E'~ - LOCATION: Hudson.21 29.19W~ SW SW Lot 3, jacobs Lane Use Plan revision required? ❑ Yes 9-9-0-- other side for additional information. SBD-6710 (R 05/91) Date Inspector's ignature Cert. No. ADDITIONAL COMMENTS AND SKETCH _ SANITARY PERMIT NUMBER: . . SANITARY PERMIT APPLICATION co. ` v'■~-■'■~■ In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 45 8% x 11 inches in size. ❑ 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 -0 Jak ; e ~ %_Ta/4, S t T.V , N, R E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Aef y CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER C sn o II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned ❑ VILLAGE : C r OL TOWN OF: &jj4y RCEL TAX NUMBER( ) ❑ Public R1 or 2 Fam. Dwelling-# of bedrooms ~ PA 111. BUILDING USE: (If building type is public, check all that apply) n /0 2 0 1 ❑ Apt/Condo d~ 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. R1 New 2. ❑ Replacement 3.E1 Replacement of 4.0 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 9 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 Yy REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Q t Feet Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank X F-1 Lift Pump Tank/Si hon Chamber El - Ll El 171 1 [1 El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. PRSW No.: Business Phone Number. Plumber's Name (Print): Plumber's Signature: (No Stamps) Mill Plumber's Address (Street, City, State, Zip Code): s~ .Sri r IX. COUNTYIDEPARTMEN USE ONLY ❑ Disapproved SFitary Permit Fee (includes Groundwater Date Issued I ui g Agent Sign ure (No Stamps) Approved El Owner Given Initial Surcharge Fee) Adverse Determination /0 1 ~6 X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) 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. 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% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) 06 s o~ e Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 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 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 PROPERTY OWNER: PROPERTY LOCATION 1 GOVT. LOTS 1/4 S 0 1/4,S ZJ T Zr'f N,R I cj $,(or) W PROPERTY 0 R':S MA. ADDRE LOT # BLOCK # SUED. NAME OR CSM # l Cl STAT ZIP CODE PHONE NUMBER CITY VILLAGE 6gOWN N EST ROAD S I ~O Q~rJ) `~Z8 New Construction Use Residential / Number of bedrooms 3 [ J Addition to existing building [ ] Replacement [ J Public or commercial describe Code derived daily flow 4-50 gpd Recommended design loading rate _:Z_bed, gpd/ftZ_, Ltrench, gpd/It2 Absorption area required 4i bed, 112 & - I trench, ft2 Ma>nmum design loading rate 1 bed, gpd/ft22trench, gpolft2 Recommended infiltration surface elevation(s) z 5 ft (as referred to site plan benchmark) Additional design / site consi=44c,44 ozS Parent material Flood plain elevation, if applicable ft S = Suitable for system ZONAL MOUND IN• ROUND PRESSURE AT- RADE SYSTEM INILL HOLDING TANK U= Unsuitable for system COS SS D U D S D S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trert~ Z, p Z7 D pty-1 .5 se PH Co LD l i- 5- Ground 3 75t4l b 910 ~'1 ff i 7 -I -N /oI -ft Depth to limiting factor Remarks: Boring # td .2 5,0,e Ground '7z 7 5 6 d S 1 ~=ft. Depth to limiting -1~factor Remarks: CST Name:-Please Print Z. Phone: /I ^zd~ _ ~~o Address: Z r JL` / L S4fl 7 Al A10-.4 1z17,0'x C~t~ Signature: Date: T Number: Z 16- -7- j PROPERTYOWNER R00,2105AA11 SOIL DESCRIPTION REPORT Page z of PARCEL I.D. # Boring # Horizon Depth I Dominant Color I Mottles (Texture ( Structure Consistence Bandary Roots GPD/ft in Munsell Ou. Sz. Cont Color Gr. Sz. Sh. ( Bed ITrerxh 0 t L :5/ IQ m,,4 1 CO 2 I Ground 37-7V -7 . 5.2 # b M LA OVA r 7 . elev2 5 ' Depth to limiting factor y- 'I Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. 1 ft. Depth to limiting factor i Remarks: SBD-8330(R.05/92) STEEL'S SOIL SERVICE Gary L. Steel .57~F./V1,L QL JlC o fJN Red. 1554 200th Ave. CSTM2298 New Richmond, WI 54017 M PRSW 3254 s ,q 5.)Yi S z 1--¢- z9 N - p (715) 246-6200 vi p.9 X13 ~ / 5°70 ~9, f3' REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS iN1GNT OF DIVISION TRY, P.O. BOX 7969 OR AND PERCOLATION TESTS (115) MADISON, WI 53707 ,MAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: E TION TOWNSHIP/ LOT NO.: BLK- NO.: SUBDIVISION NAME: 1 1 Town of Hudson 3 Proposed C.S.•M. sw sw 21 /T 29 N/R 19 (or COUNTY: OWNER'S NAME: MAILIN ADDR SS: St. croix Arthur Windolff Rt. 1, Hudson, Wi. 54016 ffT ERVATIONS MADE USE A N ESTS: NO. R AL D S RIPTION: Replace 11/12/84 L®Residence 3 ®Naw RATING: S- Site suitable for system U° Site unsuitable for system CONVENTIONAL: MOUND: IN•GROUNI 1 11 1 UR.: S STEM-IN•FILL HOLDING TANK: RECOMMENDED SYSI EM: (optional) D S a1~ 7S [111 0 S ElU E S Du ~ S ~U conventional if Percolation Tests are NOT required DESIGN RATE: If any portion of t~tested area is in the N/A N/A Floodplain, indicaplain elevation: under s.H63,09(5)(b), indicate: PROFILE DESCRIPTIONS BORING TOTAL ELEVATION PTH T R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED S TI? - HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 6.91 106.2 None 6.9 1.7' Bn,sl, 1.2' Bn Is, 4' Bn med s B. 2 6.1 111.6 None 6.1 11 Bn sl, 0.9' Sil, 2.71 Bn, med s, Cobb, 1.51 med s, cobb. B 3 7' 109.4 None 2' Bn sl, 1.8 med s, 1.7' Bn, s,Gr,cobb, 1.5' Bn CC,S. 13- 4 6.91 105.9 None 6.9 1' Bn sl, 0.9' sil, 3.0' med S, 2.0' cc S, Gr,Cobb. B- 5 7.7 108.0 None 7.7 11 sl 1.2 1, 3' med s 2.51 S Gr. B- PERCOLATION TESTS LEVEL-INCH TEST DEPTH. WATER IN HOLE TEST TIME DROP IN P WATRIER D 2 ES P R RATE R MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. P P. 1 3.21 no 3' 3 3 1 P. 4 2.9 no 3' 3 3 3 P_ 5 41 no 31 3 3 _P- P- P PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 103.0 LEGEND boring hole i a erk hoe i - - - a i ~ , II I i I i i O i 1 50.E ' J o 7 v \ l v 2. I.I ` III C~ elev. perk, a~ 3 I #31107.0 O ~ ma 15 I' Alternate. prt a r . tN area ry y I I ea 13 -1__ o I 1 421 50' 135' 58' SW corner lot 3 y y u. x Y v 1 B.M. _.100.00 I 516 S:890_111_4811 W I 111 iron; property pipe 470.12 91 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, TESTS WERE COMPLETED ON: NAME (print): Allen C. Nyhagen 11/12/84 CERTIFICATION NUMBER: PHONE NUMBER(optional): ADDRESS: _ 108 Walnut St. Hudson Wi. 54016 CST SIGN564. ATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. "I uo con.azor IR (12/87) -OVER - .i r,, , Sw ~ ~ a p19w ZpWN pE ~ ~ p~~~P ~ ~ 1R 9N ~ S ESw1~~10N20.Z2 , of tW pE SE,G ~n, ~~~•~~c . GP~EO E, tRE S ~lIWISGpNS1N. Yo J E ~I~+ p1,~ CppN~ ~ O~WZN~p~~E 6 C~~~d~~~~ cRv~`l r1Pe SZ • GRp aR~~ , Z • ~ko, NG lE~ S~ ~~o°S°N' w ~G~N~ ~ PZQE' S~ZGWI ~~zN ~~~1F L~ i~°N•Ft. d6 _ 6 9E R ~n o q~~gG~. ~ ~ O 1 • VE Opt P SG SLOG E p 3 ~ Q,tQg~ ~Y, ~ ~ ~ \ © Gp5 E R~V~P p S pB~~I ~ a ~ i ~ ~ = ~ ~ 14y,25~` -BOO ~ \ d s ` `A 3R~32, ~ ~ \ Sy 7 ~~3~~ f \ y v p~+ ~ ~\3~• 92 ~ ~ ry 3 , • ~ s ~p6 9 acr s W , N ~ ~ \ G ZN6 RIW s EXG~ , 9 sQ•{~• \ 3 s4•{t.IEXC~pO ~ ~3,~1 acr G RIW ~ : 1p 5 lacre5 E~.l ~NC~-pOTNG RIW o ING`OOZN ~6~~g~ 1 1N6 RIW pr's Z,1~'99acre ~ y 9~ 9,34acce ~ G~OOZN6 RIW ` x 5~6• ~ 2 ~1 f ~ •l Z~ o •3p2cre ~ c 2p0 a 2.69 9p6,1~~ ~ p avV" 1~ - ~ 1~ ae"W RIW G • ~ :~v S9o1 ~ by o ~ S 999 " Vp,~ 1pp y ~Gj.R. 2~,.p0~ o ~yZa ~ 011 4~"W WE'S~1I 4NR ' / o ~ ~ ► ~ ~ ~ i _ ~ : 9 W Z~fl ~ v Sa `~9"W S a 00~ r other ~ . ` 0 9 w' O~~.y o 1 ~ ~2~as"• s ~ ~ ~ ~~SW GORNE 2~ u~ ~ ?~t ~ A : , ~ ~ S2G~~pl1 4 P'~ NaZ~ STC-105 J SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MAILING ADDRESS l~L~~,a~n,~ ~.c . ~"`/D/~v PROPERTY ADDRESS (location of sep system) Please obtain from the Planning Dept. CITY/STATE . PROPERTY LOCATION ~ 1/4, y yV 1/4, Section c~ U T~_N-R~_W TOWN OF ~ ~~~.r~-n~ ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIEDSURVEYMAP ,VOLUME~,PAGE ~,~~S,LOTNUMBER~_ 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 lrnun 4{.nir eve4Am r.rnnarw maintainPr~  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 date. SIGNED: Gzi DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 u,...a 0~`N~Q 4C ~ 1 WS `~10~ ~ON~~~N c C ~N~ /~pN~ ~ Ng9 _ Q, ~PGOes / ~k V~ d` ~A~ d~ ~ ~ yG` ~~r s~ o~ .o~ G~~ A ~ f ~ r` ~ ~~~fi ~ y ~ b s ~ ~ d ~a ~y~ ~ ~ ~ /r~ n - V V ~ (~~/9 V+ • 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 d- Location of property'<(- 1/ SU) /4, Section T N-R W Township -ku. jzQ'~ Mailing address Address of site subdivision name 1-6--5j7 Lot no. Other homes on property? Yes_~No Previous owner of property Total size of property Q Total size of parcel 2AJZIQ-,l Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes ✓ No Volume /0 and Page Number/555 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 POS675q 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. Sign re of Applicant C Applicant 'Z/ a -za - 94 D e f signature Date of Signature - - DOCUMENT NO. ' ; STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 1 50865'7 VOL 104 I PAGE 389 _ _ 1I This Deed, made between _ Douglas R Zilz REGISTER'S OFFICE $I. CROIX Co., W+ Rx'd for Record Grantor, NOV 0 91993 and--------- Stanley_ M. Bonngard and Juliette M. Bonngard. al 8-15 AA husband and wife as survivorship marital property Grantee ~pitNt Of DeNIa ! eth, That the said Grantor, for a v$luable cpnsideration-Q _ e Witness dollar and oter good and valuable consideration 1 : • RETURN TO conveys to Grantee the following described real estate in .....St. Croix ro County, State of Wisconsin: I Tag Parcel No- i' i' Part of SW4 of SW4 of Section 21-29-19 more particularly described as Lot 3 of Certified Survey Map filed July 30, 1985 in Volume 11611, page 1555 as Document No. H 403919. I rl 1 N's ~J FEE i 1 is not This homestead property. ( (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And.... Douglas R. Zilz I' warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and reservations, if any, of record I i and will warrant and defend the same. Dated this day of ---------Novem-•------------ 19._93... r ~I --------------------------•--.....---•-------------------------------(SEAL) . (SEAL) Dou 1 s R. Zilz ---•----g I (SEAL) (SEAL) is AUTHENTICATION ACKNOWLEDGMENT it I STATE OF WISCONSIN Signature (s) j SS. i - ST. CROIX y County. i authenticated this _--_----day of------------ - 19------ NoveMDer all came before' 19_ the above named - D4vzI@L.~ - R,- Z i 1 - * TITLE: MEMBER STATE BAR OF WISCONSIN • (If not, authorized by § 706.06, Wis. Stats.) to me known to be the person . who execi{ted the foregoing instrument and acknowledge''the same. : i THIS INSTRUMENT WAS DRAFTED BY Zilz and Estreen N II P~t): Box"35 * Kathleen M. Bennett " i• Hudson WI __54016--------------------------------------- St. Croix ' Notary Public fo~lnty, Wis. i (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (if not, state expiration are not necessary.) it date- 19--------•) •NaInes of persons signing in any capacity should be typed or printed below their signatures. ; STATE BAR OF WISCONSIN c' n~ N.C.Mille,CompeM11y11 _ FORM No. 1- 1982 Stock NO. 13001 n~NNILL '4039.9 APPROVED NOV 7 1984 C"i ST. CROIT(; COUNTY unelatted_lands owned by_platter_ ° C"i C. c cn r 'OMPREHEN31VE PARKS PLANNING ? r ZONING COMMITTEE ;K :c o -c o W I o N x m N00048112"W m z n C"i .381 ° 31- 4 ~ x CA 486 3.3' n c m -453.381 a o o co z 3 ao o x o co m m r z z v o o z m co try t- I N~ CO Y N r N O r O O 2` ,L c" V u+ t0 _ w ab to • . 6 i _ W W Z Z. d O N i- Q N ff ~O N N ao N r N • C! N • N rh et OD r a m v I--+ 1 - 0 0 0 co ~J O 00 I o -y1 O Z X r r O r O _ b o 00 M o o 1 a z I - IrT ~ o O kr ~ _ = I 11to~i kr to N00048112"W 486.871 30 o- 453.871 T331 10 j ~ 10- M-+ - p 701 701. 1 VA %t owD IN 1W N r N r F ~ 1W . r O O. V cn O N . K b t0 O O - W N ( 1 lo- O K N N d ql .6 p O k'r tO et et fV 17' O kC ~O o-+ v v _ ~ ~ r r :4 ~ ar _ N0004811211W 471.161 C, r 0 x 436.051 / / ° ~c 35.11 )K n M P4 W >c zn co C, r .y r O G W W O N / r I M C1 O t0 H n 01 Z 2 7 Z 7 H r O A N G7 A N O / y N a N C') T \ ••H O Z • .-r m / Z n x x a O 651 V \ S~ N x z 'v Ae / M ' Cr) V~o S C-1 me AIL, 0 -n C) M o. ° f•) N C r m z /~0 • Q c m C Do Xn F. (T m m r N M 0o r / ota = d M ~ x a a m z ? z I a rn c a N 3 y ca ca ca c T C, m m rro m r T m o v x / o BEARINGS REFERENCED TO THE WEST G~ C N r LINE OF THE SW 1/4 ASSUMED TO BEAR N00058143'P A m at at ft. n O Volume 6 Page 1555