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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER joy? i' C C' n 1 S
ADDRESS -Z90 57`
~
~91e- n W oo , C/ /v Z4-)l
SUBDIVISION / CSM# LOT #
SECTION__y_TZq N-R_,15 W, Town of . 1r~ re
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
_~ePaC~
r 10w I ~
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
f
I
BENCHMARK: /t'Je f a P,'P e 01
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: I'Se-I Liquid Capacity: 750
Setback from: Well 70 J House Other
Pump: Manufacturer (go~.4 /0 Model# Lc~ GSA/ILSize 1~3 Ali
Float seperation Gallons/cycle: Lox
Alarm Location ,y~ 7 ~^a ,'lP r SOIL ABSORPTION SYSTEM
Width: 31 Length _11g_ Number of trenches f
Distance & Direction to nearest prop. line: --5 fo
Setback from: well: 7O House 2"V I
Other
ELEVATIONS
Building Sewer ST Inlet pro / ST outlet 9~~s
PC inlet 99.5 PC bottom 5,2'5 Pump Off 9K,Z
Header/Manifold /03,_37 Bottom of system /0 7. 7
Existing Grade-,/0&,7 Final grade /09,g/7
DATE OF INSTALLATION: Y-25-
PLUMBER ON JOB: 7Z~ca k Z-f~~, Sc7yl
LICENSE NUMBER:
INSPECTOR: r ~'yy~yypspyti
3/93:jt
(poke 74fils
BOLDT'S PLUMBING & HEATING, INC.
820 MAIN STREET BALDWIN, WISCONSIN 54002
(715) 684-3378 FAX (715) 684.3144
No .
mil
yo.
Am sG IS
3d
0 o y,
Sox 750
t . ~
Combo ~qy~~ ~
9y~ i
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yVisconsimDepartmentof industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
GENERAL (ATTACH TO PERMIT) Sanitary Permit No-:
~dINFORMATION
P ANNI9s er sJ (SANtCE P ❑ City Village Town of: State Plan o.: S
Qj: JX ut E]
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 4c ~..,a
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark'
) / i
Dosing
5~
Aeration- Bldg. Sewer
Holding St/~Pf Inlet
TANK-SETBACK INFORMATION St/ Outlet
TANK TO P/ L WELL BLDG. Ae ntake ROAD Dt Inlet
Septic S~ NA Dt Bottom
Dosing r0 r i/ ~~s' NA Man.
Aeration NA Dist. Pipe
Bot. System !s 3 w 2
PUMP/ SNFORMATION Final Grade
Manufacturer errand 7~,
Model Number 6 3
S GP
TDH Lift 03 Friction cff Systems4Z TDH VFt Head
Forcemain Length Dia.,,-) Dist. To Well
SOIL ABSORPTION SYSTEM
BED Width Length No. Of Trenches PIT No. Of Pits Inside Dia. h
DIMENSIONS r DIMEN
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Maqgatturer
-
SETBACK
INFORMATION Type O to CHAMBE 4 O Model Number: I) 1114 System: C% 12
Q
DISTRIBUTION SYSTEM
l eader/ Mani o Distribution Pipe(s) x Hole Size, x Hole Spacing Vent To Air Intake
Length Dia. Length 921 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
9r/ Trench Center -Bd /Trench Edges / ;e;;> Topsoil es ❑ No Et-YE-s ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Sprlpgfl 1d. 4.29.15W, NW, SW, 290th Street
117
0~
Plan revision required? es ❑ No
Use other side for additional information. ?I,, 9 t~ 9
SBD-6710 (R 05191) Date §Z~Irispe_ctor's Signatu a Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
DiLHR SANITARY PERMIT APPLICATION
1::In accord with ILHR 83.05, Wis. Adm. Code COUNTY
`51 (/7f' /
O lX
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than Q t 07 I ~
8% x 11 inches in size. ❑Check If revision t previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. S9~f- /j/a
PROPERTY OWNER PROPERTY LOCATION
G'41Ce_ %a Sa.)%,S TZ9,N,R I (or /W
PROPERTY OWN~~MAILI /l~ ADDRF~SS ~ LOT BLOCK # I~~
CITY, STATE / ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
G'/cn woad'C' 5-'1013 1(71_!!r)2.1s,-Y9P3
II. TYPE OF BUILDING: (Check one) ❑ State Owned 0
0 ITY 77 VILLAGE .S NEAREST ROAD
10 rr~ ,Z 90
❑ Public Z 1 or 2 Fam. Dwelling-# of bedrooms 3 AR LTAx MBE
III. BUILDING USE: (If building type is public, check all that apply) ®3 , _ _ c~s U00
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 120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1jrXil New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5-E] 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 El Specify Type 41 El Holding Tank
12 El Seepage Trench 22 In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
140 System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3, ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
: 5 Q -37-5 -3 74 •S AIA /07 Feet 10~, S Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New F_xlsting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank so 10.50 e i sc rs
Lift Pump Tank/Si hon Chamber. 750 - 754 CnYn O
Vill. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
GSS~-S37
Plumber's Address (Street, City, State, Zip Code):
~ f e+~
~ ~Ckr'ri- a c-J /'Y\- A ~~OC/
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sa ry Permit Fee (Includes Groundwater a e issued Issuing Agent Signatur s)
r-6- Tp
L(kApproved ❑ Owner Given Initial ago C~-= urcharge Fee)
Adverse D r nation go
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS -
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted,to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
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) 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)
I
SAFETY & BUILDINGS DMSION
State of Wisconsin
Department of Industry, Labor and Human Relations
June 16, 1994 209 West First Street
Route 8, Box 8072
Hayward WI 54843
BOLDTS PLUMBING
820 MAIN ST
BALDWIN WI 54002
RE: PLAN S94-20340 FEE RECEIVED: 180.00
ANNIS, JANICE
NW.SW,4,29,15W
TOWN OF SPRINGFIELD 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,
eroy G. J nsky
Wastewate Specialist Senio
Section of Private Sewage
(715) 726-2544 Friday's
4347R/ 1
seams ia, owu
Cross Section Of A Mound Using A Trench For The Absorption Area
4-;sTn C 34Fi H
Med#tmf- San
I 0 F 6" Topso i 1
3 E
Trench Of 'Z- 2~" Aggregate, Plowed Layer
OA if RI&W SPLiM aDvOtrW lfth D A0 Ft.
Straw Marsh Hay On/ ynthetic Fabric
ol{ionaC. c~ E Ft. -f 6 .O Ft.
F
N Ft. .
A
APPRO"17E)
1 Q
DEPARTMENT OF INDUSTRY LABOR AND HUMAN RELAIIONS
DIVISION OF SAFETY AND BUILDINGS
Er tad Using A Trench For The Absorption Area
Force Main
Distribution Pipe i
Markers Observation Pipe
W A ~Permannent \ B K -
I Trench Of - 2z" Aggregate
L
A Ft. K /Z Ft. W 3o,5 Ft.
B Ft. J Ft, L Ft.
Signed: AlUtP4- License
Plumber: Date:
S94-20340
Distribution Pipe Detail For Two Lateral Network
Holes Located On Bottom
Are Equally Spaced PVC Force Main End Cap 2
fX'rTX I PVC Distribution Pipe
P P
X
* Last Hole Should Be Next To End Cap T
P Ft. Hole Diameter Inch
X_ Inches Lateral Diameter Z Inch(es)
Y Inches Force Main Diameter Inches
# Of Holes/Pipe
Invert Elevation Of Laterals 107 Ft.
Signed: License Number: /44 p "Z I?
Date: 122111AIF cF:VVAGE SYSTEM
Conditioaia[Lv
APPROV"
DEPARTMENT OF INDUSTRY LABOR-AND HUMAN RELAI IONS
DIVISION OF SAFETY AND BUILDINGS
4&I-SE t- C ESP OENC
S94-20340,
PAGF: CF A/
PUMP CHAMBER CROSS SECTION AMD SPECIFICATIOUS
VENT CAP
4"C.-I. VENT PIPE
WEATHER PROOF APPROVED LOCKING
' JUNCTION BOX MAWHOLE COVER
5 FROM DOOR, I'
WINDOW OR FRESH - 12"MIU.
AIR INTAKE I
GRADE I
I 4"MIN.
- I
la MIN. PRIVATE SEV1~`401TYSTE
INLET I
Arm P ROVED EAL i III
APPROVED JolIJ7 DEPARTMENT OF INDUSTRY' LABOR AND HUMAN RELAI IONS I i 1 ( APPROVED JOIWTS
w/c.z. PIPE DIVISION OF SAFETY AND BUILDINGS I III W(C.I. PIPE
EXTENDING 3' I II ALARM EXTENDIMG 3'
ONTO SOLID SOIL I i I ONTO SOLID SOIL
e~JtE CO SPON N E
I ow
c
ELEV. -5'0 FT. PUMP-~
OFF
PROPERLY A L TANKS..
ILHR 83.1 )(C WAC CONCRETE BLOCK
ANCHOR TANK AE
CAES SARY ILHR t3.~lq&
`E IT" &MITfED DULY IF TAA1K MAULIFACTURE.R HAS SUCH APPROVAL
SEPTIC E 5PEC. IFI'CATIOUS
DOSE -
TANKS MANUFACTURER: GCLe*Seyi5 NUMBER OF DOSES: PER DAM
TANK SIZE: 260 GALLOWS DOSE VOLUME ~
ALARM . MANUFACTURER: IAICLUDING 6ACKFLOW: GALLONS
MODEL NUMBER: - CAPACITIES: A=~~ 5 IA1CRES O fit'. GALLOfJS
r
SWITCH TYPE: 11krCury B= 2 INC ES OR 6'3Z, GAJJ~LONS
PUMP MANUFACTURER: L~0N I~ Q-46 C UILHE5 0R, .Mlk A'L~ 0Uto
MODEL NUMBER: 3~$5 Eo3i~L. D=-/L INCHES OR S"7 g GALLONS
SWITCH T`JPE: AleY-curt' MOTE: PUMP A1JD ALARM ARE TO BE
MINIMUM DISCHARGE RATE ~8'ag GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. 12 FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . . . . 2.5 FEET
o .G
♦ T
FE .Z Z 2 'L
ET OF FORCE MAIN X F RICTIo D 1J FACT
loo~zF OR._ FEET
TOTAL 0. %JAMIC. HEAD = I` FER94 _ 2 p 3 4 0
INTERNAL DIMEMSIOMS OF TANK: LENGTH ;WIDTH $3~~ ;LIQUID DEPTH
31GK3E0:02~' LICENSE NUMBER: /~1~GGZ9 5--~~'_
DATE:
Submersible Effluent
P'erf®rmance
Curves Pumps oT q
METERS FEET
MODEL 3885
25 80 SIZE 3/a" Solids
wE,5H
70
X 20 wE1oH
J
H 60
0 WE07H
50
15
40 WEOSH
10 30 WE
WE031
20
5
10
0 0
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
i i t
0 10 20 30 m3/h
CAPACITY
~GOULDS PUMPS, INC.
S9ECA FAuS tew Nx owe
METERS FEET
120 MODEL 3885
35 SIZE 3/4" Solids
110 WE15HH
100
30 '
90
25 80
i
Q 70
W
Z 20
J
H 60
0
WEOSH
H
50
t5
40
10 30
20 -As
5
10
0 0
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
i i i
0 10 20 30 m3/h
CAPACITY
01985 Goulds Pumps, Inc. S94-2034E+ July, 1985
C3885
JvIL. kA 1vu pI1 C (Z V*A LUA1IUf4 titYUti I
D(( 1 L H R in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1 inches in size. Plan must include, but X
not limited to vertical and horizontal reference i-M e ' n and % or slope, scale or PARCELI-D. N
dimensioned north arrow and location a s
roa
r® <!rf
REVIEWED BY DATE
APPLICANT INFORMATION-PLEA E IN Al_,,,NFORf ,ill N
PROPERTYONNER s`` c3+ PROPERTY LOCATION
GOVT. LOT .t 1 114 i''014,S T N.R /g («o
PROPERTY (7NNER'S MAILING ADDRE LOT !r/ BLOCK N SU80. NAME OR CSM t
CITY, STATE J ~ZIP PHONE ❑CITY ❑VILLAGE QTOWN/ NEAREST ROAD
jlr,ve~V,~,.>i~,/` //r~G.,~?/~5 _~..'r•,'.tiri~ ,C_/~/ Z'~/-~ A/r/
A New Construction Use [A Residential TT4rAbe[.nLbedrooms ~
j) Replacement ( J Public or commercial describe
Code derived daily flow gpd Recommended design loading rate - `E bed, gpd/ft2 - 5 trench, gpw
Absorption area required 3,3 /J• U bed, ft2 3'750 trench,112 Maximum design loading rate • 5 bed, gpd/ft2 •6 trench, gpolft2
Recommended infiltration surface elevation(s) _ 05 . U _it (as referred to site plan benchmark)
Additional design / site considerations
Parent material i / Q A p rr+ Se 0~'✓rJ Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND MROUNDPRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors tem ❑ S MU ❑ S ❑ U ❑ S Pau CAS U ❑ S jo U ❑ S B U
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Botxxjay Roots GPD/ft
in. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. Bed Tr>
Q S • Jr' 1 to
I D • 42 !e L S/ ~m S4 M
< M,, Z 7-3 7,S Xe S p-'; Cw L~ -'1 -5
Ground 3 3- 7 5 s y C Z. 7•S' Sc f rn s "'w'
' `f I Jr
elev.
Depth to
limiting
factor
Remark's:
Boring # /
_ / 0-5 /oYR 3`~ S/L✓rjj~ /rl7 r 0S Z1'1
C y€s Z 3-1?
5 3 / Zms In-F cw
Ground CS /~'1'rr GW y ' elev. 31 - 7,5 511 C -L 75 Yk 7 8 SG l 2,,, A /n-~ • y
,
Depth to - - - -
limiling
factor
- -
31
I
Remarks:
CST Name:-Please Print Phone:
Address: -
Signature'
f ~ / Date_ CST Number:
Boring # Horizo Depth Dominant Color Mottles Structure GPD
in. Munsell Texture Consistence Bo~rxiay Roots 17
C+u. Sz. ConL Color Gr. Sz. Sh• Bed fircnj
2tvjl< Q -5 ~6
Ground -3 ZI-38 7..5
elev. 7m s r C w • y
/ L-tt~ -
io'~ ft. `i! 38-5 7• YR6 9 C '7
z, , , yR 7 SC Sk ~
r
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
tt.
Depth to
limiting
factor
Remarks:
Boring #
3y
Ground
elev.
K.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
tt.
Depth to
limiting
factor
T -
Remarks:
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER. cI IC,- Arr. 5
MAILING ADDRESS
PROPERTY ADDRESS IIS 5 Z' S-71`.
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 1'3
PROPERTY LOCATION All Z) 1/4, SW 1/4, Section 7 T N-R W
TOWN OF ST. CROIX COUNTY,,,//WI
SUBDIVISION X/w LOT NUMBER N
CERTIFIED SURVEY MAP _9 VOLUME , PAGE , LOT NUMBER /v
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 a iration date.
SIGNED:
DATE: U Lq9/ 9 q
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 U el M;"' ,'S 1n12." S
Location of property ,t/W 1/4 Sc,d 1/4, Section TZ? N-R 15 W
Township r_I Mailing address 2909 c-n,,, J>d. 26
aleh 00 c jW.)i~.
Address of site
subdivision name Lot no.
Other homes on property? Yes No
Previous owner of property
Total size of property
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for (spec house) ? Yes ___,,~'_No
Volume and Page Number as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner (s) of the
property described in this information form,. by virtue of a
warranty deed recorded in 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.
Sig ture of Applicant Co-Applicant
\z~\ C~ 1\
Date of Signature Date of Signature
STa-!-E P>R OF W'~CC)N`IN FORM 1
WAriri4:`TTY Dk iD~" N ~,.a
Lloyd Pnnis and Teanette Ennis, ~REGISTUS OFINCE
rt~is [~eeti, l,.a,i. i- "'e:' ST. CROIX CO., WIS.
his wife, Recd. for ReoxJ tNS.____28
Granter
dcry of ;1a o . A.D. 19 00
;,,11 ElA~n Annis and Janice mnis, his wife. as at 3 ;00 P , M.
joint *.enants, _ ~ ~
Grantee, j!
' Rpidar o1 Dred~-v
ti~'ltT1E5St'th, "Chat the s'tid Grantor. for a valuable consideration
{~p ~y~ other pod andvaluable .consideration, R
one Dollar (`71.00) and RETUNIM1 ?J
cone: to grantee the following ier riled real estate in St..-CroiX-
Countt. 'State of w isconsln
Tax Key No...
st Quarter (NW 1/4) and the North Half (N 1/2) of
2 of the 111ortlx~re~ Section Four (4) , 'i'~~p ~''1eri~'-Nine (29)
Zhe West Half (W 1t )
the Southwest Quarter. (SNI 1/4) ,
Nr rth, Rancpe Fifteen (15) West.
d Contract Dated October 1, 1973, Recorded
'This Deed is given irI Satisfaction of a Lan661 as ant 320122, at the Register
January 10, 197, in Volume "507", orl PaSe
of Deed's Office for St. Croix COunty.
T;SFER
S ZO
FEE
This 1S homestead property.
(is) (is not) urtenances thereunto belalgiug:
To4ether w.7'L ail a:• } sing''lueanette dig s, his wrfer- -
T
.end Lloyt Anns- and
•.sarrant? that the title is good, indcfeasible in fee simple and free anti 1tieSf,e cumany:,e, except
recorded protective covenants, ease~ts, and util~
;,n.l wilt warrant and defend the same. 1933U:
-
`icy of
I~:Ked this _ G~
Gi l l c~ YU~J (SEAT.)
(SEAL)
Lloyd A finis
- SEAL)
_ (SEAL)
Annis
« ' anette... - - - -
ACKNOW LEDCLMENT
AUTHENTICATION
day of STATE OF WISCONSIN
>ignatures authenticated 'this - Do n ~ ss.
19 1 County.
- h_ day of
Pe ovally came before me, this Lloyd j~ ay of
_ - ~K the above named
and Jeanette Annis,. his wife,
TITI.E: '•IEN113F:R F,TATF; BAR GF WISCONSIN
r
;l! It,_.. i~;. IV'i Uri, wi4 jtat5.
ersonS who axecuted t!.e
..F rsb av. . ne row to b~ Che p con „e t'r exe
- .y ;'R :v(: r:t .r.ns Uc< ;ores' ii!i`, atru vie: aa,!
Robert F. Wall ; ;1 ! ' ~11t"~
522 Second Street
41I 5401b F~q1 t 1i. Fischer
Htxlson, ut!t'„ Wt
p~ ¢HL hSll)ll,~ 1]un .t. r :.kr%rt wl
Prir~xnC:S t. 1 (t uot.
•,t ; ~r_k , ~•rd Rath ~l -C'p~!~ru~ "~r` p- e
i' ,oaf i•;_ ~ ,
ut:', dec..-:.;t~.;., date:
1 b.• wx tw it r!Rnat,,-
•Vat, r i,: j. rair~ a.,.• .s Pa, .tY aF "ill h ~ t_: t_.,; prn•:,,• 1t. 1 a 1; . i
STATF. BAA OF WISCONSIN N w':,. . 1•..71'
W1AflAS:7 CE,".D - FORM No.1 - 1877 -
t~4 Y' ,"c G Se c.
z 909 C-ty, -D D
G/cn wnoo/ C,' sate T Csrm 3y13
f '
zGs- 90,3
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QI-/o6.yG
13Z
53-103.0
No.
CR p
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Ac{es
Ufa I
PRIVATE SEWAGE SYSTI'M
ond[fionc~~~r~
ence APPROVED`
ABO AND HUMAN RELAIIM
CE imntlvTRY DIVISION OF SAF TY AND BUILDINGS-
EE OR *ON D CE 3 B~P~.kS N~c .
~I
{ 4 /35
Q
Len CATF- Ida t.-D
ALON(s TftE la5`~ 1 T:zsox 750 -gal,
Ct~iv~u2 LrNa Coen bInal"ion
lv 0 001 n-
` G% _
a -
y 55 ~
4
5 ,S94$ 2034
BI Q- 'S 7' 8 .5
Fence a, M, ~ii'JG