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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER re-I)v Y) ir• u +
ADDRESS 1 t7 f ed 17~P r~7 y
SUBDIVISION CSM# LOT # V
SECTION~T N-R W, Town of
ST. CROIX COUNTY, WISCONSIN
>'r~
Awl)
PLAN VIEW q~
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM j ov
.7` ~D
ti
i t
°D .~rb ARROW f
l
Provide setback and elevation information on rev re se of this form
Provide 2 dimensions to center of septic tank manhole cover.
i
J
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK-•/ PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: -Q' S~ Liquid Capacity:
Setback from: Well House ci Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: ~ Length 5- Number of trenches
Distance & Direction to nearest prop.`` line:
__L7r`
6
Setback from: well: 9_ House Other'
ELEVATIONS
Building Sewer ST Inlet ST outlet
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: I ` ,u y'~~l.(J,
~-t
LICENSE NUMBER:
r
INSPECTOR: 3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and quman Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 21 Rq64
Pe tkiAld~G s NWRY/BRENDA ❑ City ❑ Village [A Town of: State Plan ID No.:
U1L,1111VY
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA 7 !I i~rf'
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Z Benchmark 6 6
9/j
Dosi n
r' ` r
Aeration Bldg. Sewer (
~
Holding St11A Inlet
T BACK INFORMATION St/gf outlet p'g` r r
Vent
TANK TO P/ L WELL BLDG. AirIto ntake ROAD Dt Inlet
Septic NA Dt Bottom
53 i
Dosing Headers S
Aeration Dist. Pipe
' II
Holdi Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manu Dema
Model Number GPM
TDH Lift Fricti Syesatem TDH Ft
FQf In Length Dia. Fi Dist. To Well
SOIL ABSORPTION SYSTEM
TRENCH Width ' Length r No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~S DIME
SYSTEM TO P/ L BLDG WELL LAKE L Manuf r:
SETBACK
INFORMATION Type O no-, r i pd `1 OR UNIT Model Number:
System:~larrr.C- 75
DISTRIBUTION SYSTEM
Header / Manif0d Distribution Pipe(s) , x Hole Size x Hole Spacing Vent To Air Intake
Length ~ Dia. Length Dia. ~ Spacing -Z!~_
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade S
Depth Over n Depth Over xx Depth Of -7 xx seeded/ Sodded xx Mulched
a~BJ-! Trench Center S /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: Warren 5.29. 8W,,SW NW, Lot 2, 103rd Stre
,
Plan revision required? ❑ Yes ❑ No q
Use other side for additional information. 17 1/al 9 T
SBD-6710(R 05/91) Date Inspector's Signature Cert. No.
~I SANITARY PERMIT APPLICATION
_ In accord with ILHR 83.05, Wis. Adm. Code cou~lry
01LHR
/ STATE SANITARY PERM T #
-Attach complete plans (to the county copy only) for the system, on paper not less than o?18'o cV
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.
PROPE OWNER PROPERTY LOCATION
o~ c.-u S4f '/4 /vW,/a, S S~ T N, R E (or)
PROPERTY OW 'S MAILING ADDRESS LOT # BLOCK #
/C 7-A sl- e;2 1
CITY, STATE ZIP CODE PHONE NUMBER CSM NUMBER
s Q. 215-) 4X 113 0 31 o a /3
II. TYPE OF BUILDING: (Check one) El State Owned 0 VILLLAGE : a),41-9R z°1 NE I E 3
❑ Public Ell or 2 Fam. Dwelling-# of bedrooms ~ SPALOR L
111. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo `7 l
2 ❑ Assembly Hall 60 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 120 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. Q 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 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 N 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
250 7 D b r 1.rt-5"Feet .0-5-Feet
VII. TANK CAPACITY Site
INFORMATION in allons Total # of Manufacturer's Prefab. Fiber- Exper.
New lExisting Gallons Tanks Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank / - 5r% w F1 1 11 - El
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.
Plumber's Name (Print): Plumber's Signature: (No tamps) MP/MPRSW No.: Business Phone Number:
Plumber's Address (Street, City, Sta , Zip Code): _
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sa iry Permit ee (~SurchargerFeee) water ~e ssue Issuing A ntSi ure (No §kftp_V
pproved ❑ Owner Given Initial <//d(~ / ~f
Adverse Determination ! 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 sahlit&ey permit m„y be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisco,nsir Administrative Code will be applicable.
3. All revisions to this per nit must be approved by the permit issuing authority.
4. Changes in ownersh;p , r plumber requires a Sanitary Permit TransferiRenewal Form (SE?: 63-09) to be
submitted to the ;r:.rsty prior to installation.
5. - Onsite sewage s t-rns must be property maintained. The s,,-, is tank(s) must be pu: I , d : y licensed
pumper whenever nece ;sary, usually, every 2 to 3 years.
6. If you have questions cc_ncerning your gnsite sewage system, contact your local code administrator or the
State of Wisconsin, SafE ty_& 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 sewed. Check only one and complete of bedrooms if 1 or 2 Family )welling.
III. Building use. If building t` pe is Public, check all appropriate boxes that apply.
IV. Type of ne mit. Check only one in line A. Complete line B if permit is for tank replacement, i°econnection, or
repair.
V. Type of system. Check aparopriat:e box depending on system type.
VI. Absorpt''ron system information. Provide all information requested in ##1_7
Vli. Tank irtrrmation. Fill in tl.e capacity of every new aid/or existi•i to;ll{. ':'st the total L rnber of
tanks am roanufacturer's name. Indicate prefab or cite constructed and lank material Ct.!mPle1e for all
septic. pwrnp/siphon and-i-iolding tanks for this system. Check ex.zN ,rr;er;;al approval on k, if '.anks received
expeyin r ' pioduct app oval from DII_'iR
VIII >~?sp 1 ax tlivy statementr nstallirg plumber is to fill in name, li. ?sse nu'riber with astir Q!P,iz:,~ rdrefi.K (e.g.
.M.P, ate:. , address and ph )ne nur^ber. Plumber must sign application fci-m.
IX. Courity./Cepdrtment Use C nly.
X. County/,Department Use Cnly.
Completf, pl-,ns and spec `icition-z not smaller than 131/2 x 11 inches mutt be submitterJ tc. t[w. county. The
ians r=~~.~i ~nciude the fol owing: plot plan, drawn to scale or. with conple;e dimen_k a"is, +~rc atii~n of
hcld:nr septic tar ,(s) or other trea°ment tan<s: building dc.i water w a ^ter service;
streams nd fakes, purn[? )r slph~:i tar+, :,listribution boxes; soo +C''- o; .,i{ 1 syslemr; ;e!- fi 4i- ^nleot system
areas,' of the b l~r ti(, i,L,r11; 3) h0'IZOnta) and Verr!Lta' Ir.ti::;tir`r r"ef" !)d' i.~ It ;
C) complete specificat'.onr for purr: rs and controls; dose volume; ei6vato,ii; siflerences: ti :,furl loss; pump
performance curve; pump model grid Frump manufacturer; D) cross section of the soil ab;:orpa ion 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 inciud, ~d the creation of surcharges (fees) for a numb,::r 0
regulated prac,.C es 4Y" C,h r'.ar -ftect groundw^t
The mon e, c-J! orted th, e;igh 1 xt;e su? char gat, Flft. ?e , foC PTO?i d%n
water cor•%rT.-W,-itiY)n in v--. Je -)t s and ostaFs ishc tsar
SBD-6398 (R.11/88)
r
pZ-o-r f Z-
/V,,
1
J
C1 I
p~
n1 -100,00 0,•N' 13-3
X3141 IzT t
0 6 7A"~ ~d
~ J ~ L ~O L 1
I
I
I
"j
~ I I
I
10
d3 ,b7 w AA ii
3/1
I}A;
ORA
rA&C OF
1
CIA:
Froth Ali I111e16 And Obeervdlion Pipe
Approve$ Yang Cap
Mlnla~ye~ W Abe.e -
final Grate
20 - a2v Above Pope _ 4" Cell Item
Te Final Grade Vonl Pope
Mash Nef Or S/ntheok Covering
min 2' Aggregate
Over Pope
Oletrlbellon
pipe e o o e Tee
6v Aloes of: s
Reneelb Plp Palerelel Pipe Below
o ~Cwpllne Tarnllnellne At
Bellenl Of 51e1en1
~~ru(%~~sc D rl~e.l
tool Sm/vl',
SOIL FILL
DISTIt18UTIOf.1 PIPE
. APPROVED SyNTMETIC COVER
/MATERIPAL OR q" OF STRAW
2"0F/4GGRf:GATE OR MARSU NAIJ
ELF V, OF J EE-r-. a 4..
pIST~J,A!;TI ~A1 rtrr. TO, At AT LEIkST `3"6 k9L4ES $,C,L0w co; IGIA4A~ G tA,O~
M,rl11U A>y L,EAS t Lt) 1!J,C}{ ~.3,UT Alp /10f+IC xflAla 4L IIAICEa IQE.LOWFdJ~11/?yl
MNc. Pip rii OF EXCAVAT1,00 FROM .ar~i~W~►~ 6X140 WILL es: `~,~o lucl~.Es
/1i IN ll~a g,Er rN or EXC>IU/1TImfJ IoM 01kI41,WkL Cjg4,9,E WILL. eC INCHES
I
SIGAIEO: -
LIGEAISE ~IUMBER: ~ %
DATE
llo
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page X of
Labor and Human Relations
Divisionoof Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
' ST', G2.U lX.
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
C~t'cCz ( fl/ ~R~~D A SOU Ll Iv GOVT. LOT SW 1/4 NW 1/4,S S T Z-9 N,R LB E (olE V~
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR GSM If
\,0I6 8'" ST. - - usto csm
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ®fOWN NEAREST ROAD
~'IvpSp1V, !')l S4 O 16 (-)I S) 3 $6- \13 -t' 1.v 1'c~Z.ZE'ty tio-~) V` ST.
( New Construction Use [kj Residential / Number of bedrooms 14 [ ] AdditiQn to existing building
j j Replacement [ ] Public or commercial describe
Code derived daily flow 6~o gpd Recommended design loading rate - bed, gpd/0 D • 6 trench, gpd/ft2
Absorption area required SS 6 bed, ft2 S o trench, ft2 Maximum design loading rate ° I bed, gpd/ft2 0• b trench, gpd/ft2
Recommended infiltration surface elevation(s) s I;M Nom W nt~G E 3 ft (as referred to site plan benchmark)
Additional design / site considerations Z `Tfz~vctf~S- ~C'.t{ S' ~ I wl' t-W G f'11z ZLQCOMw1
Parent material S"~`-t ovlwhS bl Flood plain elevation, if applicable °l Z $ ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for s stem DUS ❑ U [as OU ®S ❑ U 0S ❑ U WS ❑ U ❑ S RrU
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
h i. yti:\h `L:i
o- slb wi v cS - i, 0.5
Y><-<<<;<:<' Z zL-Flo to `~I 2 X16 - S o SI ~,,,1 eS - o o
Ground 3 40 7S to `LIZ L1~6 _ S o s 9 M 1 _ o -l o. `d
elev.
x{8.3 ft.
Depth to ; moo 1AJ GS 1, y 4 S R ti Qh t__, St 1 s 1 a~" Yi t 5 u ~(-_rM L f
limiting p0-f IS OF bv" M(YrrLk) / wrvs SV_ryv T-
factor
-7
Remarks:
Boring #
o_t3 tioH~ 3t3 - S) e5'07 ynQi6 CS o S
3 u3 ~y tokm vllI
Ground ,
elev.
~t~ • S ft.
Depth to
limiting
factor
> 7 SI" '
Remarks:
CST Name:-Please Print Phone:
Arthur L. We erer 715-425-0165
ergerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signature: q3 - z.15 Date: do-tS - a3 CST Number: M00576
PROPERTY OWNER ~uy Llt~l SOIL DESCRIPTION REPORT Page Z of ' 3
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounclaty Roots ~aPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerxh
I o- l0 10 2 3 l 3 - s \ sb12 M y c S b- V O- S
Z lb-~z. l~ `t-2 31b S O g~ vn \ eS - o. v•
Ground 3 Z _~S 1 u `t LZ 4r - S c~ S g t) o• v. $
elev.
ot 6. ~f ft.
Depth to
limiting
factor
.7
Remarks:
Baring #
S) 1 CSI, ~^n v c S - a ~ o . S
Z 1l-SS ~o `t~z 316 - S O S°t ern, CS _ o,~ o,g
vvj{i.
3 Ss -7~l ~O ~tlz S/!6 - S o s g tM 1 - o. o, g
Ground
elev.
98. ~ ft.
Depth to
limiting
factor
Remarks:
Boring #
0-t2 to~~Z313 - S~ 1cS~~c `MV-~~„ ~S - o•~( o•S
r: 8 2 ti-zl low 2 3/L - s) \ C-Sbk YAQiF - e S o•y ` o, s
3 zt-37 l~`1,2 31.6 S b S~ w, ~ cs ~ o• ~ o. 8
Ground
elev. y 3~ S t u `t 2 `116 - S O s 9 ~^n 1 - o• u, g
R~ -7 ft.
Depth to
limiting
factor
S`4
Remarks:
Boring #
NrY.~;.< ~ o- ~ 1 tioK2 313 - s) l c sb~c m ~S - o,y' o. s
`9\z 1I-iZ 31L - s1 1~sbk ~s _ o.y o.s
3 Zz-Y8 loktz 31~ S oS~ r'1 CS o.$
Ground
el vo Z v/6 - S O S CS Depth to
limiting
facto Y y Ll -1-1-1
Remarks:
SBD-8330(8.05/92)
PLOT PLAN Page 3 of 3
SCALE 1"= ~-lO
t=e►.~ c.e
C w~-Z Cu wE It,- t SsT- So' F=%Om `T'~C. f{' 5,
~ w
t
o ~
Pu C PIPE w / LR`(N (.bave-L ~
1jI • rn
of
L
o I #~.suIT"Lk, RMk!h Fo1L lNlT11)l..
~ o l
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BY~ _ e R4.-L' 0,1 S"ttLCH 31Y4 b) S
f N-vc PtPN w/LATN
•
tJaT'E ~b 11L1S~C ~2~
lUS't+~t 1. Z `T}t~vCtt~S - LPtCN 'V Y- 7 S' LOAJG C S'Xcoo' RQcOx-jyj t-~YT l Lms-r -
6` t~Ph'2T W1 ~'t x l wl UVA 36" DM> ffT -ME Ul'S LA 3'P' E LT. GEC IN 1`111 Q `T'tG SI LT,?% PrR~1A
`1ZN'1 tti F RCN C v 7z4 ~uS I37' Me OF ep)v S`TlzuC17ULJ.
g3_22S
1o-1S- °t3 (715 ) 4 .5-ni hs M00576
CST Signature Date Signed Telephone No. CST #
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
• COUNTY
ST. CGZU isC
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but PARCEL 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.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
6011 11 MA-A> BZQ)13D A QDU Ll N GOVT. LOT SW 1/4 NW 1/4,S S T Z-9 N,R 1% E (olq~g
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SLUM. NAME OR CSM #
~pt6 8'" ST. - - C~R~iPOS~ c.SM
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ®fOWN NEAREST RQAD
v~S01V, L-it S4 41 6 ()l5) 3$6-`V3,t5 1,v N.ZErfv ti03~ ST.
New Construction Use [Scj Residential I Number of bedrooms L4 [ ] AddifiQn to existing building
[ ] Replacement [ ] Public or commercial describe
Code derived daily flow 600 gpd Recommended design loading rate - bed, gpddt2 D • trench, gpolft2
Absorption area required aS8 bed, ft2 1 S o trench, ft2 Maximum design loading rate o "1 bed, gpd/(t2 L, $ trench, gpo1ft2
Recommended infiltration surface elevation(s) SEC NoTe W pkG E 3 ft (as referred to site plan benchmark)
Additional design/ site considerations Z `CSZ~►~.tfQS ~_r<C,N S , Y- too, Lw f^, fly i w►"t+"f E~/t~EQ
Parent material SK>~~`-f ovlwhS lot Flood plain elevation, if applicable °L Z $ It
S = Suitable for system CONVENTIONAL MOUND lN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable for stem 0S ❑ U EWS ❑ U Ems 0U S❑ U MS ❑ U ❑ S R U
SOIL DESCRIPTION REPORT
Depth Dominant Color Motlles Texture Structure Cortsisbence Bouncl<ry Roots GPD/ft
Boring # Horizon in Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ranch
1 0-zI l'z' `1 313 - s I cS blt, wi v CS _ t v o" S
4
.c R
` Z ZL-yo to ~2 316 s o•~ o• 6
Ground 3 0_7S to `LIZ V/6 S s 9 M 1 _ 0 1 0.8
elev.
g8.3 ft
Depth to t.~e pp uGS ),y S -N2r~v stil s1 P\" vid S U" Lfr/A,'s
limiting p`f h ot~`fjt of by" u >~to'tT~-►'~ ~^~RS s~v
factors "
Remarks:
Boring #
o- ~3 LO `1 R 3! 3 S) e 5lbvc rn i t 1, ~S o 4 o S
3 Z 13-y3 1042 3/6 - S b S9 m) es - o. o'~
rvt 1 - o.~ o.I~
3 u3 mLm VA' - S o v)
Ground
elev.
°t•-) • S It
Depth to
limiting
f~t~ SI'
Remarks:
T Name:-Please Print Phone. 715-425-0165
Arthur L. We erer
egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signature: C)3 _ ZZ 5 Date: CST Number: M00576
PROPERTY OWNER Gov ~~t~l SOIL DESCRIPTION REPORT Page? of 3
PARCEL I.D. #
Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
M in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed n~ch
6 1 0-10 ~oy2 3~3 s` t csblz )'AU GS - o•Y o•S
S o g°f~ eS - p•7 0•~
Ground 3 Z_~5 1u `ttZ ~f!6 - S o 3 S 1 o• 7 0,
elev.
or 6, ~ ft.
Depth to
limiting
factor
77 s„
Remarks:
Boring #
-tl 1o`-t~ 3 13 - S) l CSl~ticv~~ cS - ay o,S
13 Z LL-SS ~o `t1Z 316 _
S O S9 'M ~S o-1 n,p
3 SS -7Y 16 -1v- y!6 - S O Sg ~ 1 - o• 7 ` 0.g
Ground
elev.
98, ~ ft.
Depth to
limiting
factor
Remarks:
Boring #
=~h.:..;.< o- ~Z ~o~~Z 313 - s 1 C-Sb~c rnvi~, ~g - o• y n• S
8 Z ~Z-Zl do `'t R 31L S k `A u
3 Z1-37 l~`1,2 31~, S b Sg w~ ~ CS ~ 0•'7 v• 8
Ground
elev. y S l U ~t 2 y16 S O s _ `
R~ ft. 9 rn\ o ~u,~
Depth to
limiting
factor
Remarks:
Boring #
0-11 tioK2 313 - s) 1 gb~c w uif - o, S
9 Z l-Z 2. to`t2 3!L - s cSbtiZ vin U` -5 _ o•4/ 0,5
3 zz_~8 1o~tz 31~ S o sq ~S - o•~ o. g
Ground
elev. y (!e--) 'f lb `12 VJ6 - S o s 9
~0 . n ft. ' o, f3
Depth to
limiting
factor 14 y
Remarks:
SBD-8330(R.05/92)
PLOT PLAN Page 3 of 3
SCALE 1"= yO '
C w~-Z L 't% we- wr ~-6,NsT- So Y~z UV-t `tul le l+~ s.l
s
t
~ >L
~ I
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PQ C RIPE w/ Lft 7 1:@slD
• N
01
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I
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fit 96 V tt q'1 s e~ 48 l
BFJ, ~R9.7-1 Nv S"I~VLGM 3111` D1A-
f IvC PIPt w/c-FjTN
•
tied __lb - C~ sl't~CCt=c2~
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CST Signature Date Signed Telephone No. CST #
f.
FILED
e NOV2 91993+x•
509706 JAMES O'CONNELL
L Heplster of aeede
8t crobc Co., WI
C ER T T F I ED S UR V E Y M
Located in the SW 1 /4 of the NW 1 /4 of Section 5, T29 N, R 18W , Town
of Warren, St. Cj-c)ix Co•anty, Wisconsin,
1
U%pL ATTED -LANDS P0g
N 89' 45' 43" 8 449.42' 1 S 89° 43'x3 "w
i i2 .-....•--363.72' 193.34
c, North line.., of the. SW 1/4 of the NW 114'
34.58' p 1
4 14 E14,
CY)
0)
w , \00 ,1
J1 / r1 1 L07
2 , 1 ,0
~ lf7
o '•227 061 Sq. Ft. (5.213 a.cred) 11 1
cn !'Including right-of-way.
21 1 .582 Sq. Ft. (4, 857 acres)'. 9~+
Excluding right-of-way.
`_75' SETBACK FROM NORMAL HIGHWATER \ U~ \
10
\ N z
C)Wnad by: David 8z 17onnR\-0
985 Cty. Rd. \
ichmond, s \ -O x
44 New R
o a-
x ram 0, 0 0
%
.y ~ N
W, !1 4b4 61 N W
.
x: Q, -)s L a 41 A.53# a 3~ g~
~S ~N w aye • ~ W
' 1 08 5 3~,• 02 z
f U o x m.-A- PROVED
U
G ER o1F1 ~ ~0?? W
C1:tt)QlC OGHITJI'Y
WARVEY G. -OmPrehenslye Raw*
JOHNSON Zoning and
S-18$,9 SCALE IN FEET PWJ1cJCarWTV''jhW00'
HUDSO , b 1
'Gr W IS
' 0' 2 5' 50' 100' if naAAcordw 300'
'I090,4144,61*
9 09„,4114,.1 4` Wj'Wn 30 days of
;d1 SUFt0 approval date
approval.- 691b@3.69 ,
Section cornez• monument N 89° 54 4t E 5216-24"'
E1 /4 Cor,
(Berntsen cap fnd.) :OD1 /4 Cor,
0 1"x 24" iron pipe weighing 1,68 Sec. 5 Sec. 5
lbs. / lin, ft, set, T29N,R18W
• 1" iron pipe found.
Fence Bearings referenced to the E-W 1/4 sec.
wetlands line of Section 5, assumed N89°54'41'.'E.
waters edge
VOLUME 10 PACE 2713
493-2234
Drafted by: JVC;
CURVE DATA TABLE
Curve Radius Central Arc Chord Chord Tangents
No. Ankle L ength Length
1 5139, 101 2°0912,1" 193,44' S160 27116E 193.43' S17°31'58"E
S 15°22134"E
2 870,081 8°59118 136.50' S19°52'13"E 136.36' $15°22134"E
SZ4°21'52 "E
3 656.001 5"Z9'0.1 62,791 S2 1°37'20"E 62,771 S24°2115Z"E
S1 8°52'48"E
4 5106. 101 2" 16120 202,501 $16 30144"E 202,481 S17°38'54"E
S15°22134"E
5 903.08' 8°59118" 141 , 67' S19 52113"E 141. 531 S15022'34"E
S24°21'52 "E
6 623.00' 4°57'12. 53,861 S21°53'16"E 53,84' S240211521'E
S1902414011E
DESCRIPT1:0N
A parcel of land located in the Southwest quartet of the Northwest
quarter of Section 5, Township 29 North, Mange 18 West, Town of
Warren, St,Croix County, Wisconsin, described as follows;
Commencing; at tho Wost quarter corner of Section 5; thence North
89 degrees 54 rninult!s 41 seconds ]vast -Ea03.69 feet along the East
West quarter secti~on line ; thence North 00 degrees 00 minutes 42
seconds West 1300.?-3 feet; thence South 89 degrees 45 minutes 43
seconds West 193,34 is-,:t to the Point of Beginning; thence Southeasterly
193.44 feet along the arc of ar-5139. 10 foot radius curve concave to
the South-west whose. chord bears South 16 degrees 27 minutes 16
seconds East 193.43 feet; thence Switheasterly 136.50 feet along the
arc of a 870, OR foot radius curve concave to the Northeast whose
chord bears South 19 degrees 52 minutes 13 seconds East 136,36
feet; thence South 24 degrees 21 minutes 52 seconds East 73,68 feet;
thence Southeasterly 62. 79 feet along the arc of a 656.00 foot radius
curve concave to tht• Southwest whose chord bears South 21 degrees
37 minutes 20 seconcls Fast 62.77 feet; thence South 81 degrees 02
minutes 28 secon.-Is West 498. 14 feet; thence North 12 degrees 16
minutes 21 seconrls West 526,99 feet; thence North 89 degrees 45
minutes 43 seconds Fast 449.42 feet to the Point of BEginning,
containing 227, 061 square fact (5.213 acres) more or less, and
being subject t.n All (en5t-ments, restrictions and covenants of
record,
I, Harvey C',, Johnson, registered Wisconsin Land Surveyor, hereby
certify that by the direction of Gary and Brenda Poulin, I have surveyed,
described and mapp(.d the above described parcel; that such plat is a
true and correct reproAontation of the exterior boundaries of the land
surveyed and that I }1;, vn Bally complied with the provisions of Section
236.34 of the Wisconsin Statutes, the St, Croix County Subdivision
Ordinance and the. Town of Warren Subdivision Ordinance to the best
of my professional )mowledge, understanding and belief,
V
Ilarvey G. ,Iv on S- 18 9 9
r
Johnson Surveying, Tnr. 216 Meadow >i VO North Hudson, Wi, 54016 VVIS
WIS
OF:NERAL S'T'A''FMt"NT /~O9 '+,,..."..r
0 40
U'JS
Each parcel shown on this N1161 00le
map is subject. to State and County laws, rules and regulations (i.e.,
wetlands, minimum lot size, access to parcel, etc,) Before
purchasing or d.►vPloping any parcel contact the St.Croix County
Zoning Office for advice. VOLUME 10 PAGE 2713
~1
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 Gary and Brenda Poulin
Location of property SW 1/4 NW 1/4, Section 5 T 29 N-R 18 W
Township Warren Mailing address 1174 103rd St. New Richmond,
WI 54017
Address of site 1174 103rd Sty New Richmond, WI 54017
Subdivision name Lot no.
Other homes on property? Yes x No
Previous owner of property Rayever Fams, Inc.
Total size of property 2 bedroom now, 4 bedroom later 1090 sq. ft.
Total size of parcel 5 acres
Date parcel was created recorded CSM Nov. 29, 1993
Are all corners and lot lines identifiable? x Yes No
Is this property being developed for (spec housed ? Yes x No
Volume 10 and Page Number 2713 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.516791 , 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.
~ S
Si n r o Applicant ~ -Applica t
Date of Signature Date of Signature
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER Gary and Brenda Doulin
MAILING ADDRESS 1174 103rd St. New Richmond, WI 54017
PROPERTY ADDRESS 1174 101 r d St- N4.,Ric-
(location of septic system) Please obtain from the Planning Dept.
CITY/STATE New Richmond, WI
PROPERTY LOCATION SW 1/4, NW 1/4, Section 5 , T 29 N-R 18 W
TOWN OF Warren , ST. CROIX COUNTY, WI
SUBDIVISION LOT NUMBER
CERTIFIED SURVEY MAP 5 0 9 7 0 6 , VOLUME 10 , PAGE 2 713 , LOT NUMBER 2
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 xpiration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
~I J DOCUMENT No. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA
STATE BAR OF WISCONSIN FORM 2-1982
~
516791 Yo! 1078PAGt C- 07
Rayever Farms, Inc., a Wisconsin Corporation, lkn r:.,•,.
.
MAY 19 1994
.
' 8:45 A.,
conveys and warrants to Gary_-P. Poulin and Brenda J..FouIin,
husband_.and..wife.----•-•----•--•---. •
►e ::;r u
- ~.o.~...~..,~
RETURN TOO S LZ L H-
- Brenda Poulin C/o Heritage itl
. 502 Tul ren a e
the following described real estate in ..._$t. -CrO1X .........County,
State of Wisconsin:
Tax Parcel No:
Part of the SW 1/4 of the NW 1/4 of Section 5, Township 29 North, Range 18 West,
Town of Warren, St. Croix County, Wisconsin, described as follows: Lot 2 of
the Certified Survey Map filed November 29, 1993, as Document No. 509706 in
Volume 10 of Certified Survey Maps, Page 2713.
This .S__nOt........ homestead property.
(is not)
Easements, restrictions and rights-of-way of record, if any.
Exception to warranties: It is hereby understood and agreed that Grantee's interest in
the above-described property is subject to all applicable terms and rerservations of
rights contained in the Farmland Preservation Agreement No. 008021, recorded in the St.
CE92e, tgQs Register of Deeds office in Vol. 708, page 100, as Doc. No. 400541.
this [9'N^ day of May, 1994. Rayever Farms, Inc.
- (SEAL) Bya. (SEAL)
(SEAL) ..Py.: ---.(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
bm v~ ~-io( • ~stt~
Signature(s) _______________________STATE OF WISCONSIN
ss.
c{iL~ May this ,Jf__..______May 19...94 Personally came before me this ________________day of
- 14~1 , 19 the above named
Kristina gand
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stats.) - -
to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Kristina O gland
Attorney at Law
Notary Public County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date: 19.........
)
,Names of persons signing in any capacity should be typed or printed below their signatures.