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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER~~ ld ~PS~'
ADDRESS
SUBDIVISION / CSM# U / ~b~► ar57 LOT # -2-
SECTION - ? T-~)_N-R_Z W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
vr'~,dax
2 ~
s ue, t . / 7/
d1 ~.$~►~w-s 5X 5'f3
xme INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
i
i
BENCHMARK: y p~,rte OIL Gt~~,S~ ~dl~GircR
ALTERNATE BM: J
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
If Manufacturer: lJ is Cf Liquid Capacity: ZIA~>
Setback from: Well 135~ House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches Z
Distance---&-D-irEction-to-wear-est-propli-ne:- --.'9Z-
Setback from: well: 171 House 7 5 ' 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: y
PLUMBER ON JOB:, m•C~ti,.~-~---
LICENSE NUMBER: /~~~5" jo7ay'
INSPECTOR:
3/93:jt
Wiscortsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
LaVor and,H u man Relations INSPECTION REPORT ST. CROIX
S,pfety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION lis
PeJnj H Ider~~aQte p ❑ City ❑ Village R Town of: State Plan ID No.:
S IV CST BM Elev.: 1VA Insp. BM Elev.: BM Description: -.qTAR PRAIRIE Parcel Tax No.~
j0D /O0, `~1
A44001 90
TANK INFORMATION ` ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark &01
Dosing QU
Aeration Bldg. Sewer
Holding St/Ht Inlet 97,/3
TANK SETBACK INFORMATION St/ Ht Outlet 7.b q(_ j to
Verit
ir Ito ntake ROAD Dt Inlet
TANK TO P/ L WELL BLDG. A
Air
Septic > SO' S 3q / y qo NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe Ia,SY 3,(4~
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade G11r,.3
Manufacturer Demand
i r
Model Number GPM
TDH Lift Fri ion System TDH Ft
Forcemain Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length f No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS S~ -2- DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK CHAMBER
INFORMATION TypeO Model Number:
System: j cr," Jr d 117S I j7/ OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia- I Length Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over N Depth Over < xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes El No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LCCgATION: STAR PRAIRIE.29.31.18W,NE,SE,LOTi 192ND AVE.
'.1 t 7 7'~
Plan'14 sion'r~quired? [ es [:1 No !C f
Use other side for additional information. c: "'Pfo
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
`DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
o
14~~.
STATE 'SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 ecf
8% x 11 inches in size. ir vlsi 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 WNER / PROPERTY LOCATION
aL '/4 _9C' '/4, S .2_/ T 1, N, R (or fo
PROPERXY OWNER'S MAILING ADD ESS LOT # BLOCK #
CI TATE ZIP CODE PHONE NUMBE SUBDIVISION NAME OR CS NUMBER 2
Z 75
II. TYPE OF BUILDING: (Check one CITY NE EST ROAD
❑ State Owned ❑ VILLAGEde lee
1771 =N QF:
NUMBER )
❑ Public A 1 or 2 Fam. Dwelling-# of bedrooms ~ PARCEL T
111. BUILDING USE: (If building type is public, check all that apply) ~?~8 r t jC1 _ 16~
1 ❑ Apt/Condo u
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
50 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. P9 New 2.E] 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 300 Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 ❑ In-Ground 420 Pit Privy
13 1~ Seepage Pit Pressure 43 ❑ Vault Privy
1140 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) ELEV TION
. -a ---r ' 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
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
PI bar's Name (Print): Plumber's ignature: (aSta s) MP/MP RR W Nn_-: Business Phone Number:
Ce 1 i r,~ 3~ ~'7z 5&1 A-V
Plumber Address (Street, City, State, Zip ode): l
dW 02
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater [Date Issued Is uin Agent Signature (No mpsj -
l~ Surcharge Fee)
Approved ❑ Owner Given initial
~f~
Adverse Determination `
66
X. CONDITIONS OF APPROVAL/REAS NS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/86) 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 relleHal 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 (Star) 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
ll. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
Ill. 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 cn 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 13% 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
Wis;onsin 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 f
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
PROPER OWNER: PROPERTY LOCATION
n GOVT. LOT 1/4 1__ 1/4,S N,R e(or
PROPERTY OWNER':S MAILING ADDRESS LOT # BLO # SUBD. NAME OR CSM #
.N a ['-:2 W/6, I
CITY STATE ZIP CODE PHONE NUMBER ❑CITY VILLA E ®fOWN NEAREST ROAD
I
pC] New Construction Use jX] Residential / Number of bedrooms [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow gpd Recommended design loading rate gybed, gpd/ft2-.d--trench, gpd/ft2
Absorption area required bed, ft2 5-Z& trench, ft2 Maximum design loading rate _.__bed, gpd/1`1!2_,~trench, gpd/ft2
Recommended infiltration surface elevation(s) ZZ- ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material azz~
Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem [ZS OU JZS ❑ U RS ❑ U ®S ❑ U ❑ S ®U ❑ S 01)
SOIL DESCRIPTION REPORT4
Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
7T 0_5
Ground
elev.
2KI ft. A1101 .5
Depth to
limiting
factor
Remarks:
Boring #
z4 A
Ground -
elev.
ft.
I r1/
Depth to
limiting *F F
factor
4 "
Remarks:
CST Name:-Please Print 1 Phone:
Address: 1 r.,
Signature: Date: a
PROPERTY OWNER-2 l SOIL DESCRIPTION REPORT Pageof`
PARCEL I.D. # `
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trerch
6
hti
eiii
Ground
Z21 Z
elev.
ft. -
Depth to
limiting
factor
>/C~n
Remarks:
Boring #
Z'U
Ground
y
elev. Pq ~7~ -1 1's
~zft.
Depth to
limiting
factor
> 99,
Remarks:
Boring #
AIZ
Ground d
elev.
t ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
inDepartmentofIndustry, SOIL AND SITE EVALUATION REPORT Page Of
and Human Relations
of safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
TY Attac
h complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but EL I.D. #
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
F
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION EWED BY DATE
PROPS WNER: PROPERTY LOCATION
7 GOVT. LOT J~r 1/4 11/4,. N,R (or( 1
PROP-EflTY OWNER':S MAILING ADDRESS LOT # BL # SUBD. NAME OR CSM #
.up
I- Me? I I
CITY STATE ZIP CO E PHONE NUMBER ❑CITY IL E ®f OWN NEAREST ROAD
pCj New Construction Use (XJ Residential / Number of bedrooms (J Addition to existing building
j I Replacement j Public or commercial describe
Code derived daily flow :&4-_ gpd Recommended design loading rate 7 ed, gpolft2_,~trench, gpd/ft2
Absorption area required ~ -!V-? bed, ft2.s1.~ trench, ft2 Maximum design loading rate _._Z_bed, gpd/ft2_,g_trench, gpd/ft2
Recommended infiltration surface elevation(s) 9- ft (as referred to site plan benchmark)
Additional design / site considerations
Parent material Flood plain elevation, if applicable ft
tU. itable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
suit able for s stem i0S ❑ U 10 S ❑ U [ZS ❑ U ®S ❑ U ❑ S 1Z ❑ S O U
SOIL DESCRIPTION REPORT "a
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Baxtdar y Roots GPD/ft
in. Munsell Ou. Sz. Cont. Color GrA . Viz. Sh. Bed Thr&
Q- -9 IA- YAO A1214
law
Ground R g" W141 A11,14
elev. ft
_ _ €
7. 19_tzy.~ to 4*1
2
E
limiting
factor €
Remarks:
Boring #
€
J
Ground
elev.
21., 1 fL
Depth to
limiting
factor
Remarks:
CST Name: Please Print Phone:
ress:
Signature: Date: CST Number:
r
65 delivery of the accepted offer to Buyer on or before 4Q' cq6 NdoN /U91, 1 1" /xy v utnerwwe rl11b U11 V 1
66 Is void and all earnest money shall be promptly returned to Buyer. 14
67 This transactioh is to be close .the office of Buyer's mortgagee or at the office of
.68. ,on or before Z ~`U~E .77~~ , 19 or at such other time and place as may be agreed in writing.
,69 Legal possession of property shall be delivered to Buy r on date f closing.
70 It is understood the property is now occupied'by CAA/
71 under (oral lease) (written lease), which.terms are:
72
73 Occupancy of - L/f CAA/ y- c_A410 shall be given to Buyer on t r~S
74 If Seller is permitted to occupy property after closing, Seller shall prepay occupancy charge of $ per day, which 10,
75 (shall) (shall not) be refundable based on actual occupancy.
76 The sum of $ shall be withheld from the purchase price to be escrowed with _40
77 /1 1
.78 to guarantee delivery of occupancy to Buyer AND FOR NO OTHER PURPOSE, which sum upon Seller's failure to deliver
79 occupancy shall be paid to Buyer as liquidated damages or returned to Seller if occupancy is delivered to Buyer on the agreed date.
.rYOWNPR J SOIL DESCRIPTION REPORT Page of
LD. #
r ,
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BaxtcJary Roots GPD/ft
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed react
i
Ground
elev.
,e5.3 ft -
Depth to =
umitlng
factor .
Remarks:
Boring #
i
MNMW~ f-1- ej? A,
mom as
d~ 1
Ground x A, Ad
,
elev. _
fc.
Depth to =
limiting
factor
> gq
Remarks:
Boring #
i
i
/ I
E At Z
~ i
Ground
elev. _ _ `
Ice ft. `
Depth to
Qmiting
factor
Z~L I
Remarks:
Boring #
I
lwmlm
i
Ground
elev.
ft.
Depth to
umiting
factor
Remarks:
SBD-8330(R.06192)
65 delivery of the accepted offer to Buyer on or before 4Q66 "40/v /UMW ► ,-17y uu =a= wi-mQ a 110 U„G,
66 is void and all earnest money shall be promptly returned to Buyer.
67 This transaction is to be close a e office of Buyer's mortgagee or at the office of pezem,4 .TN 4UosoA✓
.68. on or before ;T U&jE _,19 or at such other time and place as may be agreed in writing.
69 Legal possession of property shall be delivered to Buy r on date f closing.
70 It is understood the property is now occupied'by -4 /ur e- 41,1
71 under (oral lease) (written lease), which.terms are:
72
73 Occupancy of L/,AC qA/ r ~-,A /VLJ shall be given to Buyer on _S' aST/v v
74 If Seller is permitted to occupy property after closing, Seller shall prepay occupancy charge of $ per day, which
75 (shall) (shall not) be refund le based on actual occupancy.
76 The sum of $ shall be withheld from the purchase price to be escrowed with
77
78 to guarantee delivery of occupancy to Buyer AND FOR NO OTHER PURPOSE, which sum upon Seller's failure to deliver
79 occupancy shall be paid to Buyer as liquidated damages or returned to Seller if occupancy is delivered to Buyer on the agreed date.
. . . . . . .
X88. ✓ °~9 ~Y,~ ~~,..s~'/~~;sr>= 9, ~l~kl. . . . . .
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65 delivery of the accepted offer to Buyer on or before Lie Nell A11,-199* Otherwise this offer
66 is void and all earnest money shall be promptly returned to Buyer.
67 This transaction is to be close a office of Buyer's mortgagee or at the office of
.68, on or before z aM.4 , 19 or at such other time and place as may be agreed in writing.
69 Legal possession of property shall be delivered ~to Buy r on date f closing.
AJT
70 It is understood the property is now occupied'b
71 under (oral lease) (written lease), which.terms are:
72
73 Occupancy of yACati * A 4,,d shall be given to Buyer on ~t c7ST/~
74 If Seller is permitted to occupy property after closing, Seller shall prepay occupancy charge of $ per day, which
75 (shall) (shall not) be refund le based on actual occupancy.
76 The sum of $ shall be withheld from the purchase price to be escrowed with
77
78 to guarantee delivery of occupancy to Buyer AND FOR NO OTHER PURPOSE, which sum upon Seller's failure to deliver
79 occupancy shall be paid to Buyer as liquidated damages or returned to Seller if occupancy is delivered to Buyer on the agreed date.
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TIMM EXCAVATING 2
Route 1 BOX 192 SHEET NO. OF
WILSON, WISCONSIN 54027 CALCULATED BY ^ - l'kl"-- DATE
(715) 772-3214 (715) 386-5443
MPRS #3224 WI MPCA #696 MN CHECKED BY DATE
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PRODUCT 205-I /Ar6W.EF`/Inc.. Groton. Mass 0147: 'o Order PHONE TOLL FREE 1-8DD-225-M
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CERTIFIED SURVEY MAP
Located in.-part of .the NEh of the SEh- of Section 29, T31N, R18W, Town
of'Star Prairie, St. Croix county, Wisconsin.
SCALE. IN. FEET
50
NORTH LINE OF THE NE 1/4 OF THE SE I _ / E I/4 CORNER OF
N89°03'29 'IE 661.C'0i 29
.T4 7 76 IS1.35
~ EXI8TIN6 /ENCELINE SECTION
OWN
\ ~J
RICHARD C. HAOLEYB
\ ARLUE L. HADLEY
d' . ' t SHED 1409 COULEE ROAD
h QE'Pl~E o HUDSON,WI64016
330a 0' ~
89°30 "
erc. M G71
i I
!all.
1 d' mod'
O
QD d W~ d
' nh \ M W
w - ~l
O'
1
Z
0 LOT 3 ~ I o
'1
2
LOT
~ ~
zi ~o a; INC. R/W: co INC. R/W: _71
13.11 Acres $
t1' I, 6.89 Acres co
O w
i 300,328 Sq. Ft. W 571,083 Sq. Ft.
P• ~)1 'EXC. R/W: ~ EXC. R/W:
O = N
Z 6.63 Acres 12.,.P9 Acres
288,780 Sq. Ft. C 561,324 Sq. Ft. J
1
;ti_. _ (JI N 0 SEPTIC
~ N FIOIIBE
NWW47144"W i~ . • • 661, 36' N
330;78`.' 330.58' .
-.--,.-I--- 321.65'
33E0.7_4'___
30.74 89 112"W
S8716'12 _W 66_ L~
iY? NQ AVFJNUE ~ TH LINE OF ETHANE I/4 OF THE SE I/4
LAN
C.S.K IN
I V.
. _D_ _I? 34 ~,eo 0
LEGEN , I GS
O
"0 1" IRON PIPE FOUND1 et
Fr p I" x 24" IRON PIPE SET WEIGHING MYH g,
1.78 LOS. PER LINEAR' FOOT ~ 25
100 FOOT ROADWAY SETBACK LINE Z
WATER'S EDGE HUDSON,~
MARSH AREA +WIS.
ALUMINUM COUNTY SECTION MONUMENT FOUND
THIS lNSTIWMENTCRaIrTTEDeIr AUCNAEI. ERICL~~Opd, 5U dl ISE CORNER OF
SECTION 29
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER is- a- Ness
MAILING ADDRESS ~~ly /%'a ti~ {G~✓ ~i
PROPERTY ADDRESS
(location of septic system) Please obtain/ from the Planning Dept.
CITY/STATE
/~GU
PROPERTY LOCATION 1/4, 3L 1/4, Section F , T_-L/ N-R. W
TOWN OF ST. CROIX COUNTY, WI
SUBDIVISION _ LOT NUMBER
CERTIFIEDSURVEY MAP_'~(" VOLUME 1 b ,PAGE -2LOT 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 year expiration date.
SIGNED:
DATE: j 9y
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
8 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 &7 J-es 2
Location of property _1/41/4, Section a-Lq,T_Z/ N-R_ZiE_W
Township r pr "4 rr e, Ma~ ing address
ft #:;~,w/ 11ue lzleli)
L L
Address of site Anmj-
Subdivision name C81W Lot no.
Other homes on property? Yes__,X_No
Previous owner of property
Total size of property
Total size of parcel , F-9
Date parcel was created
Are all corners and lot lines identifiable? es No
Is this property being developed for (spec house) ? Yes _No
Volume -Jog 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 he office of the County Register of
Deeds as Document No. 7P 76' , 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.
'Ax'o~a
Signature of A licant Co-Applicant
9v 5- 3/ 9
Date of Si nature Date of Signature
, -
DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2-1982
ffifleag ASS
-
V~~~
Ri~h,~zd.. C..-Hadle_y_.alad. _Ar.1.ue . L.-. Hadley,.-husband.-- _ _ riec~d ~,r ReaaM
and. -wife,
JUN 1994
conveys and warrants to Donald A. Jess _a-nd 'Ma -.i- ynR. Jess t c:.t 1:45 P. ~
~
.
L
RETURN TO
the following described real estate in St. CrO* County,
State of Wisconsin: c
Tax Parcel No:.. .'3~~_P/1~:..1~~ 00
Part of the NEl/4 of SE1/4 of Section 29, Township 31 North, Range 18 West,
St. Croix County, Wisconsin, described as follows: Lot 2 of Certified Survey
Map filed May 11, 1994, in Vol. "10", page 2757, Doc. No. 516553.
ALSO all that part of Lot 3 of Certified Survey Map filed May 11, 1994, in
Vol. "10", page 2757, Doc. No. 516553 lying South of the Apple River and Wly
of the extension of the East line of said Lot 2.
t_70
This 1S not
homestead property.
CiM(is not)
Exception to warranties: Easements, restrictions and rights-of-way of record,
if any.
Dated this - - day of
- 19---94...
- - - (SEAL)
4C - ? r'' - (SEAL)
Richard C. -Hadley
(SEAL) - _
- - (SEAL)
* Arlue L. Hadley
* - - .
AUTHENTICATION ACKNOWLEDGMENT
i
Signature(s) _.R chard__C_.__Ha~lley,--_-_-___ STATE OF WISCONSIN
Arlue L. Hadle Y P
ss.
y ' - ---------County.
authenticated this __...day of_________________ 19---- .4 ~ Personally came before me hi _~!-S~__day of
L`~` 19 the above named
~J
Kristina 0 land STRA[VD -
TITLE: MEMBER STATE BAR OF WISC rrv~
(If not, -Azwls N
authorized by § 706.06, Wis. Stats.)
to me known to be the person who executed the
forego' g instrument and a cnowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Kristina O gland
~ &nbArtL, S~-_ ran
Attorney at Law
Notary Public - ~l~-ik-------County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.)
date: - `mil r _ - ~-----------------19-----••-• - 04 *Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.
_ FORM No. 2 - 1982 Milwaukee Wiscnnsin - - _ _ J