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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS MADISON, WI 53707
(H63.09(1) & Chapter 145.045)
. NO. SUBDIVISION NAME:
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.: BLK :
~4 22 /T30 N/R191(or)W St. Joseph 2 /a Bass lake North
COUNTY: OWNER'S E: MAILING ADDRESS:
St. Croix Richard Stout 11353 Awautkee Trl., Hudson, Wi. 54016
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER OLATION TESTS:
I EiResidence 3 n/a UNew ❑Replace 4-26-92 4-26-92
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILLHOLDINGTANK: RECOMMENDED SYSTEM: (optional)
CAS ❑U i~iS ❑U ® S ❑U El S RU ❑ S GUj conventional split level trench
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
deciaml' PROFILE DESCRIPTIONS a-e 34 BxB
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-1 7.17 107.95 none >7,17 .92, 10yr3/2, 1., .92, 7.5yr3/4, l.s., 5.33,-
10 5 4 co. s.
2 7.00 107.95 none >7.00 •58, 10yr3/2, 1., 1.67, 7.5yr3/4, l.s., 4.75-
6- 1 4/4 co.s.
3 6.92 106.35 none >6.92 .67, 10yr3/2, 1., .42, 10yr4/3, sil., 1.00, 7.5yr
B- 3/4, l.s. 4.83, 10yr4/4, co. s.
104.55 .75, 10yr3/3, 1., .67, 10yr4/3, sil, 1.17, 7.5yr /4-
B-4 6.42 none >6.42
104.30 .75, 10yr3/2, 1., 1.25, 7.5yr3/4, l.s., 4.50,-
B-5 6.50 none >6.50
B-
d' PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER I AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERI0132 PERIOD PER INCH
P-1 3.50 none 3 6 6 6 <3
P-2 3.50 none 3 6 6 6 <3
P- 3.50 none 3 6 6 6 <3
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. 104.55=u per trench
SYSTEM ELEVATION 102.85= lower trench
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
Gary L. Steel 4-26-92
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
1554 200th. Ave. New Richmond Wi. 54017 22 8 1715ZZ4b_-fM0
CST SIG T E:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R. 02/82) -OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
1 ,omplete an:; accurate soil test, your report must include;
I e ;al d ion;
2. 7' a section must clearly indicate whether t'lis is a residence or commercial project;
3. MAXIMUM number of bedrooms or commercial use planned;
4, Is this a new or, replacement systein;
5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
0. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. V'-.KE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A
ate sheet: may be used if desired;
. s.. e your benchmark and vertical elevation reference point are clearly shown, and are permanent;
e appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp-
1L'. i r sn (such as flood plain, elevation) does riot apply, place N.A. in the appropriate box;
1 1 . S. ? and place your current address and your certification rlunaber;
12. Me legible copies acid distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
< and Textures Other Symbols
st - St-.,- (over 10") BR - Bedrock
cob Cobble (3 - 10") SS - Sandstone
gr - Gravel (under 3") LS - Limestone
Ix s S HGW - H h GrouI`- +
cz ``--id Pere - F I 'ion Rat,
reed = E and W - I!
fs - I and Bldg I ding
Is - Loamy Sand , Greater Than
"sl Sandy Loam < L- ; Than
'I - Loarn Bn -
0 Silt Loan) BI
si - Silt Gy - Gi:y
~I - Clay Loam Y Yellow
Sandy Clay Loarn R - Red
Silty Clay Loam mot - Mottles
Sandy Clay wl - vvitli
sic - Silty Glay fff - few, fine, faint
c - Clay CC; - conimorl, coarse
pi - Peat rnm Many, medium
rn Muck d distinct
p prominent
Noll L - Nigh ter level,
Six general snil~lextures sl v ater
for liquid waste disposal BM - Be.,,,,...1- ,
VRP - Vertic Reference Point
TO THE OWNER:
)0 rest report is the first step in securir a -y init. The count or tl )ep. -tment may request
-;-n of this soil test in the field fariot, ;ice. A c - ~for the private
system and a permit application mu the apf.._,. y in order to
ob` a a permit. The sanitary permit mus posted prior to V f + )y t action.
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 2%~s/~/~~1 ¢s
ADDRESS 4
SUBDIVISION / CSM# LOT
SECTION-j7:2_T_.~N-R_2_q'_W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW VER
32
u
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t~ ss
INDICATE NORTH ARR W
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
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/ QGdt~ ~~-~,r~ - ~P9F9~A f~~~~~✓.a~ ~Jy/ -
BENCHMARK:,, A~~~,~b l~v)
a
ALTERNATE BM•
U
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: S Liquid Capacity:
Setback from: Well House f Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
t
Alarm Location
SOIL ABSORPTION SYSTEM
Width: 42- Length Number of trenches
Distance & Direction to nearest prop. line:~74
Setback from: well: House Other
ELEVATIONS
a1
Building Sewer ST Inlet; ST outlet
n„
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: LICENSE NUMBER:
INSPECTOR: 3/93:jt
1AX- s n partAIiitof4,q§ ' 22. 3A. WkAVESE*Gk%S S~t&forth Ba County:
Labor and Human Relations INSPECTION REPORT
IT- CIZOIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
;GENERAL INFORMATION
Permit Holder's Name: ❑ City ❑ Village lk Town of: State Plan ID No.:
St. LTQ&Qph
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/D /00~ 5e~!~ 5.lci
TANK INFORMATION ELEVATION DATA A9400092
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark a /00,
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet /0 S-
TANK SETBACK INFORMATION St/Ht Outlet /v-7,
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic do NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System /D W
PUMP/ SIPHON INFORMATION Final Grade ~f f O
S lI "~I
Manufacturer Demand S) r~~-/`r~; rn
Model Number GPM
TDH Lift Friction Syesatem TDH Ft
oss
Forcemain I I Length HDi H Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Lengt No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN I N DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM
INFORMATION Type 0 7 . CHAMBER Model Number:
y j "IUD ~tJ//~ ~f/ OR UNIT
System: ?
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENT Include code discrepanci s, p" , s present, etc.)
LOCATION. J&se h.22.30.19u, NE, Lot 2, North Bay Road
-74
Pla~revision required? ❑ Yes ❑ No , r h
Use other side for additional information.
SBD-6710 (R 05/91) Date Ins"pedor's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
t
SANITARY PERMIT APPLICATION
LDILR In accord with ILHR 83.05, Wis. Adm. Code COUNTY
y STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ O1Q~6
8% X 11 inches in size. Check if revision to ft'lous 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
% T , N, R (or
PROPERTY OWN R'S MAILING A DRESS LOT # BLOCK #
)
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVI ION NAME OR CSM NU ER
II. TYPE OF BUILDING: (Check one) CITY NEA EST ROA
❑ State Owned ❑ VILLAGE
Public ,JZ 1 or 2 Fam. Dwelling-# of bedrooms- PARCEL AX UM ER(
❑ .
III. BUILDING USE: (If building type is public, check all that apply) 0
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 80 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.E] Replacement 3. ❑ Replacement of 4.0 Reconnection of 5.0 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 12. 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
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 Holdin Tank
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for install ion of the onsite sewa a system shown on the attached plans.
Plumber' Nam (Pring: Plumbs 's gn re: N mps) MP/MPRSW No.: Business Phone Number:
Plum 's Address (Street, City, State, Zip C de):
i l
-75 /
IX. COUNTY/DEP RTMENT USE ONLY
❑ Disapproved San4qry Permit Fee (includes Groundwater Date Issue Issuing Agent s)
Approved ❑ Owner Given Initial C)o Surcharge Fee)
Adve Determin lion
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. R s nitary,permit is valid for two (2) years. `
2. Yo-6P Sanitary permit may be renewed before the expiration date, and at the time of renev,al 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 require a Sanitary Permit Transfer/Renewal For+n (Sl 6;399) to be
submitted to the county prior to installation.
5. Onsite sew;ige systems r:iust be properly-mainkai-sed. The tank(s) n,~;:;s be aa• r~i~e#.-, a !''cert~ed -
pumper ~,r,,er,ever necessary, usually every 2 to 3 years.
6. If you ha,.le questions concerning your onsite, sewage system, contact your local code ;tr~n +:triGt.'t~tor 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 a,ld parcai tax n,:mber(s) of
where the system is to be installed
Il. Type of building being served. Check only one and complete of bedrooms f t or 2 Family hIwelling.
III. Building u.;e. 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 replacernent, reconnection, or
repair.
V. Type of sy:;tem. 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 t<'il,rs, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Gorn rate 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 5% 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; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems, rei k+,ament system
areas; and they location of the building served; B) horizontal and vertical elevation reference •)cints;
C) complete specifications for pumps and controls; close volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorrejon system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
- -
GROUNDWATEWSURCHARGE -
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a numl~er of
regulated practices which can effect groundwater.
The monies colle=cted.through these surcharges area ' sec for "lo io; ing grc. rrdw tt:=r, cr't
water contain nation inves igations and-'establishment of standards.
SBD-6398 (R.11/88)
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jEPARTMENT OF
SAFETY & BUILDINGS
INDUSTRY, REPORT ON SOIL BORINGS AND DIVISION
LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969
HUMAN RELATIONS 1 J MADISON, WI 53707
(1-163.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
~/4 ,1/4 22 /T 30 N/11191(or) VII St. Joseph 2 /a Bass Jake North
COUNTY: OWNER'S E: MAILING ADDRESS:
St. Croix Richard Stout 1353 Awautkee Trl., Hudson, Wi. 54016
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: ]COMMERCIAL DESCRIPTIO PROFILE DESCRIPTIONS : O A O TESTS:
FaFc R esidence 3 n/a ZjNew ❑Replace
4-26-92
4-26-92
RATING: S= Site suitable for system U= Site unsuitable for system
CONV STI NIL: MOUND: I M-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
S ❑U GS DU ®S ❑U ❑ S RU ❑ S GU conventional split level trench
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.H63.09(5)(b1, indicate: Il/a Floodplain, indicate Floodplain elevation: n/a
deciaml' PROFILE DESCRIPTIONS a e 34 BxB
BORING TOTAL P H TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH HICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH} ELEVATION OBSERVED ES HES TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.)
B 1 7.17 107.95 none >7,17 .92, 10yr3/2, 1., .92, 7.5yr3/4, l.s., 5.33,-
07.95 4 co. s.
B 2 7.00 107.95 none >7.00 •58, 10yr3/2, 1., 1.67, 7.5yr3/4, l.s., 4.75-
10 r4/4 co.s.
B 3 6.92 106.35 none >6.92 .67, 10yr3/2, 1., .42, 10yr4/3, sil., 1.00, 7.5yr
3/4, l.s. 4.83, 10yr4/4, co. s.
BA 6.42 104.55 none >6.42 •75, 10yr3/3, 1., .67, 10yr4/3, sil, 1.17, 7.5yr4/4-
B'S 6.50 104.30 none >6.50 •75, 10yr3/2., 1., 1.25, 7.5yr3/4, l.s., 4,50,-
B-
d ' PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER I WWrgS AFTERSWELLING INTERVAL-MIN. PER INCH
P.1 3.50 none 3 6 6 6 <3
P.2 3.50 none 3 6 6 6 <3
P.3 3.50 none 3 6 6 6 <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. 104.55=upper trench
SYSTEM ELEVATION 102.85= lower trench
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I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print : TESTS WERE COMPLETED ON:
Cary L. Steel 4-26-92
'ODRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional),.
200th. Ave., N_ ew Richmon(L- 14i. 50017 22 8 171St246-6200
CST SI T E: a r
J: Origin,,' and one copy to local A: h, y Owner and Soil Tester.
-9, (R. 02/8)) - OVF;3
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NO,. NdIN M►/1 0►1111111gM Pit$
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1DISTa15Uy10U PIPt •'irV OC AT 4CA>ZT _ 1
AUV AT. LCA4T;® IA9CHGL OUT 1.10 MOKC THAN `42EIWr.►iCi C OW FINAL. C 1110C
I'."'MU'A OF-PT.11.0F EXCAVAT1,00 FXOM 0KI61NA1. 6KAV9 WILL,. BE
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STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER M i, ed t -c Van A SS -e.
MAILING ADDRESS /00, Box (oV SOM*rs,_-T W) S'102s
PROPERTY ADDRESS LOT a B L PJ
(location of septic system) Please obtain from the Planning Dept.
CTTY/STATE ST. %c. Jcs r
PROPERTY LOCATION Of 1/4, N L 1/4, Section D-1 T_3_Q _N-R 14 W
TOWN OF S7• 7o~eseP~. ST. CROIX COUNTY, WI
SUBDIVISION RhSS LA Ke POOrT k LOT NUMBER
CERTIFIEDSURVEY MAP V,)\.h , VOLUME 1079, PAGE-) qrb , LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1)
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three jeej i tion date.
SIGNED:
DATE: y ° 2s - y y
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
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 B2 iattLe VA roASSpr
Location of property_MF; 1/4 Mr-_ 1/4, Section 2-'2T 3a N-R 19 it W
Township <7", ,Toe. Mailingaddress P.o_ 6ox (vL~
Address of site (,Oaf Subdivision name _Igo-<6 L-Aky Norl Lot no.
Other homes on property? Yes No
Previous owner of property 5TO,,,~-r
Total size of property 3.44 &tA,
Total size of parcel x &09,-)b 3 60 a.C4*-
Date parcel was created ctq~
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes No
Volume 16'7!S' 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 Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for the
construction of said system, and the same has been duly recorded in
the office of the County Register of Deeds as Document No.
Signature of Applicant Co-Applicant
9-QS -Q V
Date of Signature Date of Signature
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
U57115
11. 107 )PAGE 198
~ ~ r ~,...ta y>,..? it ...~u'+,~' ~~tlT-YeI~•~
ST. CRCIX CO." 1N1
Rbed for n6variI
Richard O Stout and Jan P- Stout, - -
husband and wife survivorship marital APR 2 2 1994 ;
property, 1245. P
conveys and warrants to Michelle M. Vanassp
ertdlDle~;ls
RETURN TO
the following described real estate in qt . Croix County, i
State of Wisconsin:
Lot #2, Plat of Bass Lake North, Town Tax Parcel No:
of St. Joseph.
is not
This homestead property.
(is) (is not)
Exception to Warranties: easements, restrictions and right-of-ways of
record, if any.
Dated this 22nd day of April 119 94
(SEAL) (SEAL)
Richard O. Stout Janet P. Stout
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
ss.
St - Croix County.
authenticated this day of 19 Personally came before me this 22nd day of
April , 19_9 the above named
Richard O Stout and TanPf- P
Stout
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person ~cyh a y
authorized by § 706.06, Wis. Stats.) foregoing instrument and acknowledge tbeOS~tu Public
THIS INSTRUMl~NT W t'. JFTED BY IIVV tout I 'orate Uj
w
H1.ids", WI 54016 Notary Public County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.)
date: 6,2 , 194:4.)
Names of persons signing in any capacity should be typed or printed below their signatures SB2 NTF 0021
WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms, P.O. Box 10208, Green Bay, WI 54307-02D'
Form No.2 - 1982
oA
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UNPLATTED ANDS
COUNTY TRUNK HIGHWAY 8 1z, WEST LINE Of THE NEIH OF THE NEI/• OF SECTION 22
S'43'44'E 560.63' TO THE PUBLIC r
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EAST LINE OF THE NEW. OF SECTION 22
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BE ARINGS ARE REFERENCED TO THE NORTH LINE Of THE
{\.e \ NEI14 OF SECTION 22. ASSUMED TO GEAR S@9-55'13 -W.
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