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110
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
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ADDRESS
SUBDIVISION CSM# (e " A,, 116 4 ~ LOT ~
SECTIONT N-R_4~W, Town of /C ry~'l~ l C!. CC
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
/x'610P
Y '
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INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions: to center of septic tank manhole cover.
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Wisconsin Depdrtmentof Industry, PRIVATE SEWAGE SYSTEM County:
Lacier and I$umanrRelations INSPECTION REPORT ST. CROIX
Safety aRd Buildwogs Division
(ATTACH TO PERMIT) Sanitary Permit No.:
. GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village Town of: State P
DANIEL, EDDIE & GLENDA XQ
KINNICKiNNic no
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel ax o.:
TANK INFORMATION ELEVATION DATA f-1 w,A Inn
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark /oo
Dosing /430.
Aeration Bldg. Sewer
Holding St/ Ht Inlet 1a,6 ~oS,S S~
TANK SETBACK INFORMATION St/ Ht Outlet / ~5
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake l3./6 /D~/`~PS
Septic ~5v ' a5 ~a5 NA Dt Bottom /12022r
Dosing yas' j >aS" ~dC NA Header/Man.
Aeration NA Dist. Pipe J45- 114_33
Holding Bot. System S,/7
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer 1 Demand lam. //U, / S
Model Number lt/i GPM JJ%}~~..rz/ g /p 1-75
TDH Lift Friction System TDH Ft
i Loss Head
Forcemain Length Dia. Dist. To Well~S~
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3, i~r DIMENSIONS
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manu acturer:
SETBACK
INFORMATION Type O /7QL> Mode Number:
System: Y 7e1_1tsr-9 /$,S l owo y 5U' CHAMBER N~ OR UNIT
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) it x Hole Size x Hole Spacing Vent To Air Intake
1 ' , S acin 1/,/ I//g
Length Dia. a Length - Dia. p g 7 56
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Q Depth Over ~11 Q xx Depth Of xx Seeded /_Sedde-6- xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil (0 - 1311yes ❑ No [/Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: KI/NNICKINNIC 8.28.18.120C,SW,NE,LOT 10, SLEEPY HOLLOW DR.
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. 'y la~ t?y 3!
SBD-6710 (R 05/91) Date t Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH •
SANITARY PERMIT NUMBER:
SANITARY PERMIT APPLICATION COON
l~'~'~Ifra Fi In accord with ILHR 83.05, Wis. Adm. Code C_o ti--A
STATE SANITARY PERMIT #
=Attach complete plans (to the county copy only) for the system, on paper not less than o2 l 8isQ~
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. `741- 1-105 23
PROPERTY r.0 NER PROPERTY LOCATION
E4 C
Y., S TC/a, N, R E (o Kw
PROPERTY OWNER'S MAILI AD ESS LOT # BLOCK J,
,7 7
CI SATE ' ZIP CODE PHONE NUMBER SUBDIVI ION NAME OR BER
s~, tee r Z1 N ~e~ Y6 2Syr''
II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLLLAGE " 1 ( B ST ROAD ^f'
GG~ ~J
lhll► l Molf
❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms PA ELTAXNUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo l(
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 80 Mobile Home Park 12 ❑ Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
I
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. f4 New 2.E] Replacement 3. ❑ 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 RMound 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
/n REQUIRED (sq. ft.) PROPOSED/(sq. ft.) (Gals/day/sq. ft.) (Min.//inch) ✓ ELEVATION
~oq LI ~N~ v J Feet Feet
(,E
VII. TANK CAPACITY Site
in alIons 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 1_2b0 P(~QS
Lift Pump Tank/Si hon Chamber 55) 1 r t`
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown o ched plans.
Plumber's Name (Print : Plu er ignature: (No St$mps) MP PRSW Business Phone Number:
Plumber's Address (Street, City tate, Zip Code): , F
20 Ca Avg
IX. LINTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued suing Ag t Signatur tam )
y4,ot Surcharge Fee) y /
Approved ❑ Owner Given initial r2A 5 j,
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08193) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
II
INSTRUCTIONS E;
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),bo 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.
11. 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) fora 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.
I
I
SBD-6398 (R.11/88)
`Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations
t',ivision of Safety Buildings in accord with ILHR 83.05, Wis. Adm. Code
' COUNTY
ST G~or X,
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION' REVIE DATE
PROPERTY OWNER: PROPERTY L N v - ri` q
FDD/E a 6:1,FVJ0+ GOVT. LOT ' 1/4 A/ 114,0 p ,R E (or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # B ' SUBO. N R #
h'D !3 ,4 v G~FN~s • /v _ 5!;? /7o Of~i 7-«.v
CITY STATE ZIP CODE PHONE NUMBER ❑CITY ❑VI N ROAD
/ uDso,~ lv~s. 55~0~~ (115) aft -IV3 ~ , 411-0 4t;
[ New Construction Use (Residential / Number of bedrooms y :Aditior>)t e i wilding
j j Replacement Public or commercial describe
Code derived daily flow (D o O god Recommended design loading rate • y bed, gpolft2 • S trench, gpd/ft2
Absorption area required 5"00 bed, ft2 d ° trench, 112 Maximum design loading rate • S bed, gpd/ft2 • & trench, gpd/ft2
Recommended infiltration surface elevation(s) • P A ..3 ft (as referred to site plan benchmark)
Additional design/ site considerations SrT&=_ $017•y/31,F_ 4,v Y {aR lfo y vo T rA,G- S yS T-,-,,
Parent material Scf 95' 5AAJT44 . 1fv1ACC1Jr rO Flood plain elevation, if applicable ti'p' • It
6rvo - 6,'L7- E-A0/-ffwr HOLDI
TMK
S = Suitable for system CONVENTIONAL M~OUyr~ IN-GROUND_PRE DIRE AT- S DE U ❑ SYSTEM ILL ❑ S ~
U = Unsuitable fors stem ❑ S DT I Crl'S ❑ U ❑ S Ldiy_ SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell tOu. Sz. Cont. Color Gr. Sz. Sh. Bed ranch
,<a w~ 4 O-5 /o yg 3/Z S. / 2,a+t , shK Mkt ufk c5 3-F s
A z 3 o R y z,, sbk vf R C 5 3f .5 Co
;e ~a....... S - I y /
Ground 6 13 - 4 7.5 Y R s 2~ s b k rm-f R, 15 2- f s ~
elev.
ID'f, 6 ft. 7.S yR P3 =NA~D) S U, rw► , 9R GAy6t . 2-
. 3
Depth to s vie 5/&' tv", Q ,t
limiting Y R P G /1N v -F i et op N P
factor S yR 5
g,55
Remarks: S.~e Rc, (ot,.~
Boring #
2 Z Q• /a yR 3/y St` 1 z.~► sbK ,t,,.f R e s 3 f . S .
~ ,<:.:xn<.:;, 11_1,(, '1•S ~,R `//Ce 51 1,n..,, '54K .w,f R S .2•F • S • C.
Ground
elev. C Zt'o-So -7•5YR 9R a Ayc~ a •G . ` • 3
/01710 ft. y.
F It 24-SO 2.5 Y k s S P C_ I nM D'~
Depth to
limiting
factor „ RIZINAU]
S JeA_ (3 e, I 04c)
Remarks:
CST Name: Please Print R 0 f3ER T t4 L-13 R i O Wr Phone: _71S-3e6- 819Q s
Address: (e S 5 0 r -P- p. t 1- j q- 13 c S rM j- Y P2._.
Signature: 0 S O A_~ "0 ( S , S Date: CST Number:
N b rt t C f~D/C'~ 'Zd.t>,S w E'>i °E"
This test site NOT APPROVED
for a conventional septic system.
See explanation. G
/3 A,vp S OF vie y/
s.4,✓p . jklf, GG.s yliS• y 5~9.t.9l~ /fir/E7IP s
stlt'A-s IIA!7- 11116-WV I,;1C y 7b
~SGvE/l 4, Gt>~ T covGY'/-iou S
17104 t' 204J ,~G G~~'7TE5 S~vt32~-
~~12~'cn'a,v ?d N~,P.~-~~ L polvv lv~~D
PROPERTY OWNER ~LSOIL DESCRIPTION REPORT Page of'
PARCEL I.D. # LO t /O - S/E&~y rl ucSCJ •
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BoundlW Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
3 0.16 /oyk 3/Z - 5d 2.. row'. Sb,C 'PAUf0. CS 3 5 .G
r x 42_ /0 -.16 toff- 31y sr l z.5h %4p- Os ~f . s .G
Ground 26 -3G /0 vP 13, C, b k /w~'F 12 C S 3'F" . S
elev. _
ft. (3z wy OYp- y 51 1,f, IFA -fA e s , . y .s
Depth to ,
limiting
factor A-7-5 Z
SSS
Remarks:
Boring #
>...,..:.I ~ z
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
'-x
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring 4
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Con 0~7A/O ACMM
L. o7 I C~
.1 c). A C4A
J
6C ALE- : I = YO
8 z = /3/~~~NaE P~'rs
9,~goE FIEw►r~.~,s
A ~ti,P .POaC
8670 /3E0 . ~
E ~~'vf no~3 - 11!. 70 j
110
- /3M SeT - T0 f
of
N&W r To LIf
Lo V'N" 400047
s
167 3y- ~lEU~Tio,~ c
This test site NOT APPROVED
for a conventional septic system.
'e$ expl natt'on
r
ELEVATIDU S
~~v OvT
srA 3 ~D g
IfOMES rre- f
$ y S TE ICI I E UAT1tW W td<. i
1 r
i
i
~avct E ~f~ • C'L.
of
Slev. it
t;5
~b
a
`75o~a~ fab.v g. do a.~ PUC.
pkNYl P~Pc Heats l.ar,e
v
z
~.~t
ditto!~ ;
COT,
oe st
wu~
Or; e
0
C 1 jj
K~I CTWk4p.
~0t.lee Pa.
Page
Or
Straw Marsh Hay,
Synthetic Covering
Distribution Pipe
Medium Sand
Topsoil
3 ( E a D
3 ~
slopes
0/0
A%d Of - 2 %2 Force Main Plowed
Aggregate Layer
D i Ft.
Cross Section Of A Mound System Using E Ft.
F IS Ft.
A Bed For The Absorption Area
G I . o Ft.
A Ft. H i.5-Ft.
Signed: B Ft.
License Number: ~a3 f K Ft.
(U a 3 L- Ft.
Date:
_ Ft.
Alternate Position Ft.
of
Force Main W Ft.
L
Observe-lion Pipe-,,.,
g K
j
I° --1--
W
~.Distributl 2
Pie ova
p ,t ~J,BO4 No so~~fi►gse 9ate
I 1N~S ~ s~PEtY
ObservatilW- yob arm drs
SEA C
Plan View Of Mound Using A Bed For The Absorption Area
I
1 1
Page _ Of
Perforated Pipe Wall
'2 ^
End View
Per/orated
End Cap PVC Pipe
p\ee
o Holes Located On Bottom,
Are Equally Spaced
• R
Q m°''n
PVC
Manifold Pipe
Alternate Position Of
Distribution Force Main
Pipe
Last Hole Should Be
Next To End Cop •
End Cop..,) Distribution Pipe Layout P 3 ~ Ft.
R
S
Xl Inches
Y 0 Inches
Signed: Hole Diameter Inch
Lateral Inch(es)
License Number:
Manifold Inches
Date : Ply. Force Main e7 Inches
"It
# of holes/pipe S
Invert Elevation of Laterals "Ft.
'51'a
-
of 110 0ti Sig"
S~~ G
PAGE OF
PUMP CHAMBER CROSS SECTION ARID SPECIFICATIOAIS
VENT CAP
N°C.I. VENT PIPE
WEATHER PROOF APPROVED LOCKING
JULICTIOU BOX MAWHOLE COVER
2' 25' FROM DOOR,
WINDOW OR FRESH 12"M111.
AIR INTAKE I
GRADE I
I ti"MIN.
18" M I AI.
CONDUIT
INLET PROVIDE I
' AIRTIGHT SEAL
t
APPROVED JOIN
W/C.I. PIPE T A' ~w I I W/C.IVP PEO►WTS
A
EXTENDING 3'-°"~s3~7 I III EXTENDING 3'
ALARM ONTO SOLID SOIL
OWTO SOLID SOIL h ~:A
B t,. ~p30 1,'. fi~lORg i I
IC,(-I. "LS gap u z5 I I ow
25
LLEV. 22--._ 1NaVS ~Y, pN I I
~IS►OH 8 _ _ 1
FT--O-
OFF
PUMP E CONCRETE BLOCK
RISER EXIT PERMITTED ONLY IF TAWK MANUFACTURER HAS SUCH APPROVAL.
SEPTIC f SPEC.IFI'CATIOAIS
005E M
TANKS MAWUFACT URER. f• 1i~~Q~ 91'e~ u St I.WMBER OF DOSES: PER D"
TANK SIZE: ZSO GALLONS DOSE VOLUME I12•Sty•)
ALARM MANUFACTURER: ^f aAk (41-At INCLUDING BACKFLOW: I ~r L GALLONS
GALLONS
MODEL NUMBER: u A CAPACITIES: A= Z ` INCHES OR L L
SWITCH TYPE: 14 ~ 5= Z- INCHES OR 3y 88 GALLONS
~~q~Z
PUMP MANUFACTURER: I: n %.I ep C =8INCHES OR 139 5 GALLOWS
MODEL NUMBER: - Li t 03 L D=-I1INCHES OR X209. GALLOWS
SWITCH TYPE: 1-4 f) 1 NOTE: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARGE RATE 3 _GP(A INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEELI PUMP OFF AND 013TRIBUTIOIJ PIPE.. o FEET 11•`I`~
+ MINIMUM NETWORK SUPPLY PRESSURE . . 2.5 FEET
♦ 9"S FEET OF FORCE MAIN X 3A y 6 FYO nFRICTIOW FACTOR. .-L FEET
TOTAL DYNAMIC. HEAD = I1. FEET
• / I I I~ 1~
IIJTERNAL EIJSIOMS OF TANK: LENGTH 10 ? 11 ;WIDTH - I .;LIQUID DEPTH
~ 1 n
91GIJED: LtCE1JSE DUMBER: Y17? 1 DATE: " /
r
r
joN 2 y X994
/V.
SAFETY & BUILDINGS DIVISION
.
State of Wisconsin
Department of Industry, Labor and Human Relations
June 27, 1994 2226 Rose Street
La Crosse WI 54603
WANG EXCAVATING
THOMAS WANG
W9672 770 AVE
RIVER FALLS WI 54022
RE: PLAN S94-40593 FEE RECEIVED: 180.00
DANIEL, EDDIE & GLENDA
SW,NE,8,28,18W
TOWN OF KINNICKINNIC COUNTY OF ST CROIX
MOUND SYSTEM
The Department has reviewed the above-referenced submittal.
Conditional approval is hereby granted for the system plan submittal. All
noted items must be corrected. The review and approval of the system is based
on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin
Administrative Code, and is contingent upon compliance with any stipulations
shown on the plans. This system has not been reviewed for the code
requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin
Administrative Code.
This plan submittal approval will expire two years from the approval date, or
if a sanitary permit is obtained, plan approval will expire on the day the
initial sanitary permit expires. The licensed plumber responsible for this
installation shall keep one set of plans with the Department's stamp of
approval at the construction site. The installer shall notify the appropriate
inspector when inspections can be made.
All permits required by the city, village, township or county shall be
obtained prior to installation.
Inquiries should be directed to me at the number listed below. Please refer
to the plan number shown above.
Sincerely,
.yard Swim
Plan Reviewer
Section of Private Sewage
(608) 785-9348
4512R/ 1
sen-sail ~s. uireu
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. /Croix County
OWNER/BUYER~ P CJ l ~i ICl l? f
i"I ~ C'
MAILING ADDRESS y/n l`f ~d & I
PROPERTY ADDRESS 7 rP 9 L
(location of septic system) Pleaseo tain from the Planning Dept.
CITY/STATE a i 11 /l c A .
PROPERTY LOCATION 5ZAJ 1/4, 1/4, Section a T N-R AF- W
TOWN OF / 411nG~ /0 ST. CROIX COUNTY, WI
SUBDIVISION Lo d A G LOT NUMBER IQ Lf CERTIFIED SURVEY MAP , VOLUME _8 , PAGE , LOT NUMBER lb
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 date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
r, 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 T--41'r / ~ /e,0- ~4 1,6,
Location of prop Kn' ty~1/4, SectionT~N-R~W
Township , yi' Mailing address
Address of site V s~FF c' O
Subdivision name CS Lot no.I O
Other homes on property? Yes No
Previous owner of property e ~ ell Total size of property 2Z) 4
Total size of parcel ,W 4.
Date parcel was created p'2'5
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes No
Volume ln'~ and Page Number /a 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 th ffice 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.
-70 7
Signature of Applicant Co-Applicant
'7z):A y
Date ofdgnature Date of Signature
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1988 TNIS Er,.Ce RraERVED FOR RECORDING DATA
WARRANTY DEED
510487
, . 105✓
y. 'Pty Fast R'S OFFICE
This Deed, made between Robert. .Richter,.-a/_k/.a........... OIX Co., WI
Rabert.R.._Richter, for Record
Grantor, 4 1993 ;
and-.---Eddie--W -.Daniel--and-G.lenda-G.--Daniel,,--lwsband------------ :50 - F.M
and.wi-fe......------•-•---
eti.,1 Q~
Grantee, rofon* IF,
Witnesseth, That the said Grantor, for a valuable consideration
ji conveys to Grantee the following described real estate in $t., crpi_X___..._.. - RETURN To tl
County, State of Wisconsin:
Tax Parcel No:...................................
Part of SEl/4 of NW1/4 and part of SW1/4 of NEl/4 of Section 8-28-18,
described as follows: Lot 10 of Certified Survey Map filed March 22, 1991,
in Vol. 118", page 2338.
TMMIE t with the right of ingress and egress over the road righ, of way
as shown as Outlot "1" of Certified Survey Map filed March 22, 1991, in
Vol. "811, page 2329.
!eR
FES
I~, E
i
j This ..not------ homestead property.
X145 is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And....... Robert.Richter- .a/V-a.Robert--K-.Richter
warrants that the title is good, indefeasible in fee simple end free and clear of encumbrances except
easements, restrictions and rights-of-way of record, if any;
- ~ and will warrant and defend the same.
I Dated this ---------•-•---•------•+-0---------------•-- day of _Becembier. 19-93--.
I
1
ii (SEAL) - ~C (SEAL)
I
Robert Richter, a/k/a Robert K.
- er--------------- .
~ticht
-------•----•-•-----•--•-----•----__...•••-•-•-----••----•----•-•---.(SEAL) ........(SEAL)
•
I
i
I
i) AUTHNNTICATION ACSNO W LBEIGMENT
Signature (a) STATE OF WISCONSIN
i
nty
St.---Croix------------ Con
authentic If this --------day of-------------------------- 19------ Personally came before m• this 1_!!..... day of
i
December - 19•_•.)3. the above named
lI Bobezt-Richte>, a/k/a
Robert __K_ RichJ~ Connors------------
TITLE: MEMBER STATE BAR OF WISCONSIN NOW-7-PAMC
(If not
authorized by § 706.06. Wis. Stats.) '~y~e ~O
to me known to be the perltl9'"..•..._ who executed the
1 f ing instru nd acknow ge the same.
THIS INSTRUMENT WAS DRAFTED BY ~I
_ - i~
yXlStina_ Qglalld-----•-------•---•-----------••
Alice Joy Co rs
Attorney--at--TAN---------------------------------------- Notary Public County,
~t ~r Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is perm ent not, state expiration
I~
are not necessary.) _ n
date: 19.1.'-'1•)
*Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Leal Blank Co. Inc
FORM No. 1 - 1992 Milwaukee, Wis.
MAR2
21,991.- 1
CERTIFIED SURVEY MAP t~
LOCATED IN THE SW1/4 OF THE NE1/4, THE NW1/4 OF THE NE.I 4,'TaE 4
OF THE NE1/4 AND THE SE1/4 OF THE NE1/4 OF SECTION 8,.,-k.28N, R18W,
TOWN OF KINNICKINNIC, ST. CROIX COUNTY, WISCONSIN
NOTE: OUTLOT 1 IS A ROAD RIGHT-OF-WAY
ra o 3 AND EXEMPT FROM THE REVIEW REQUIREMENTS
H o V OF THE ST. CROIX COUNTY SUBDIVISION
w w .D ORDINANCE.
w °
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z
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4ZIND
1 42nd 6Ave. ~O,-------`V 1887.53' T28N, R18W
3 I c719,238 S.F.±S88°16'01 W 4568.73'
00
00 Hz 0.442 AC. ± UNPLATTED LANDS
O1 I E-z C.S.M. LOT 1
`4,`f H 0 VOL. 4, PG_ 1159/ SCALE IN FEET
00N I P14 PQ
-
Of 300' 600'
THIS INSTRUMENT DRAFTED BY JAMES T. SWANSON
Vol. 8 Page 2329
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w
r CERTIFIED SURVEY MAP
LOCATED IN THE SE1/4 OF THE NW1/4 AND THE SW1/4 OF THE NE1/4 OF SECTION 8, T28N, R18W,
f TOWN OF KINNICKINNIC, ST. CROIX COUNTY, WISCONSIN
C.S.M. LOT 1
4 OUTLOT 1 ' P6)-t- r _ - - 5 166' I
2 3 SO°17'00"W 51 .00' 6 --j
_ - I
S28°13100E 7
50.001 I I -41M
S24053'0211 W 10041 F+Iv'+
110.10' iii a0 ~ I
zP11Iw
C14 4
N82°34'30"W Nt UI~
I
95T. 5r,
N0°23'56"E 705.04' 0
g3,3i
I
o WEST LINE OF THE SW1/4 OF THE NE1/4 I
UNPLATTED LANDS 1 66'
I
NORTHERLY RIGHT-OF-WAY LINE
LEGEND
ST. CROIX COUNTY SECTION CORNER
MONUMENT, FOUND.
• 1" IRON PIPE, FOUND.
aq 1"x24" IRON PIPE WEIGHING
1.681/LINEAL FOOT, SET.
01 `V
1.0
a I +1 N
I ° 0 OWNER AND SUBDIVIDER
Robert Richter
vl No o °o ~ ~I 1152 Riverside Dr. N.
W 3 -4 a o ~-i I Hudson, Wisconsin 54016
z 00 00 _ N r~ C all
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00 °
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00 00
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3
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`r' 00 w 00 ASSUMED BEARINGS REFERENCED TO THE
M ~ ° -4 U NORTH LINE OF THE NW1/4 OF SECTION 8
00 z Ln ow I-q WHICH BEARS S88°34'57"W
00 H rn z
cn a Cl) H z
H
x
~ H C7
C4 a PQ
o
z N0003'50"W 409.80'
NOTE: THIS MAP IS EXEMPT FROM
N88°15'55"E TOWNSHIP AND COUNTY REVIEW
S0°34'11"W 1832.76' 25.93' BECAUSE THIS LOT EXCEEDS 20
N WEST LINE OF THE NE1/4 OF THE NW1/4 ACRES IN SIZE.
r, cv AND THE WEST LINE OF THE SE1/4 OF THE NW1/4
i° oo UNPLATTED LANDS
NW CORNER
SECTION 8 This instrument drafted by James T. Swanson.
T28N, R18W
Vol. 8 Page 2338