HomeMy WebLinkAbout161-1022-40-000
i
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Wwr A~~ l G I~C El. = ` I C
Mailing Address ~j ~A,4 Ar~ K)
Property Address U .LS- 56 ~ :T-- y
(Verification required from Planning & Zoning Department for new construction.)
City/State Jf p~ ;,~-~o btj Parcel Identification Number / ~P yo ~-Y)
LEGAL DESCRIPTION /
Property Location /a 1 1/a Sec. f3. T 21 NR 20 W,.Tt~wftr ofE/`" - U d
,
Subdivision Plat: &Alk kbt~ AT~~," , Lot li/ , Z, 3
Certified Survey Map # , Volume , Page #
Q
Warranty Deed # Z (before 2007)Volume , Page #
Spec house ❑ yes no Lot lines identifiable yes ❑ no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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 a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm,383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms
SIGNATURE OF LICANT(S) DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 09/07)
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County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
pV In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT
O~ Personal information you provide may be used for secondaryurpoges ST. CROIX COUNTY GOVERNMENT CENTER
t~ G~~.4 (Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road
Hudson, WI 54016-7710
(715)386-4680 Fax (715)386-4686
Attach complete plans for the system on paper not less than 8-171 inc size.
- f ary Permit # ❑ Check if revision to previous application
pLA);IWNG & ZO ~
1. Application Information - Please Print all Information Location:
Property Owner Name n S~ 1/4! U 1/4, Sec 1
0 3
/~1 L E~.~~ ~ ~ ~r✓ ~ Z N, 20 R E(or W
Property Owner's Mailing Address Lot Number Block Number
Y /r o f ! Z ~ CC/
City, State Zip Code Phone Numer u division Name or CSM Nu ber
LA ~fl D .
II T of Building: (check one) ~K I, fq,671b,1..o =ity illage ❑Town of
1 or 2 Family Dwelling - No. of Bedrooms:
❑ Public/Commercial (describe use): `y
❑ State-owned Nearest Road
11. Type of Permit: (Check only orle ' box on line A. Check box on line B if applicable) Gf./ osv
Parcel Tax Number(s)
A) 1Repair Reconnection ❑Non-plumbing 4. ❑ Rejuvenation
Sanitation (1;+ !e j'(1
l1f
o 1, n Weld ~ lm c~ Permit m~r Date Issued Statnitary Permit was previously issued S 7 a
B) qa'
IV. Ty of POWT System: (Check all that apply)
Non-pressurized In-ground ❑ Mound ? 24 in. suitable soil ❑ Mound 24 in. suitable soil ❑ Mound A+0
❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line
❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other
❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating
V. Dispersal/Treatment Area Information: E. 7 1 _55 Ti 77 A',x 116 S ~A &_~3
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
6 Tank ZO Proposed (Gals./daylsq.ft.) (Min.fnch) ~ I~ Elevation
00 192 q-t, tz~--
VI. (Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- 111 Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
/ Z / 2- S-0 E3
-~Z) U17
El 1:1 El
❑ ❑ Li ❑ ❑
VII. Responsibility Statement
I, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/instailation of non-plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the installation of non-plumbing sanitation system.
Plumber's Name (print) Plumber's Si ture (no ps): MP/MPRS No. Business Phone Number
Plumbe Address (Street, City, State, Zip Code
Vill. County Use Only
Disapproved Sani ary Permit Fee D to Issued uing Ag t Sig ature tamps)
Approved Owner Given Initial Adverse 2'ZS ~O / 0 / 211
Determination /
IX. Cond'tions of Approval/Reasons for Disapproval: -
~ 4 za_
S ~
y ~ yc S
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF EXISTING SEPTIC TANK(S)
This is to certify that I have inspected the existing septic and/or dose tank
presently serving the followX-AWAD esidence: I
(Street address) 63 q Ra /y located
at: 5 '/4, S C '/4, Section 13 TownRange 20 W,
10rrof i or- , oU DS, St. Croix County
~ Wisconsin.
Upon inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of Comm. 84.25, and it (they)
appear(s) to be functioning properly.
Most recent date of inspection or service
Did flow back occur from absorption system? Yes No~,✓
(if no, skip next line.)
Approximate volume or length of time: gallons minutes
Tank Capacity:
Construction: Prefab Concrete _Z Steel Other
Manufacturer (if known): " r4
Age of Tank (if known):.
Permit number (if known) q2 5
(Licen ignature) (Print Warne)
(Title) (License Number) M PR
(Date)
Form to be completed by licensed plumber (Dept of Commerce Chapter 5
and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin
Administrative Code)
Rev. 9/2008
8012832
Tx:4009828
926982
STATE BAR OF WISCONSIN FORM 1 - 2000
BETH PABST
Document Number WARRANTY DEED REGISTER OF DEEDS
ST. CROIX CO., WI
THIS DEED, made between SuDon, LLC, a Wisconsin limited liability RECEIVED FOR RECORD
company, Grantor, and Bernard M. Drevnick and Michele A. Drevnick, 11/16/2010 12.47 PM
husband and wife as survivorship marital property, Grantee. EXEMPT NA
Grantor, for a valuable consideration, conveys to Grantee the following REC FEE: 30.00
described real estate in St. Croix County, State of Wisconsin (the TRANS FEE: 1530.00
"Property"): PAGES: 3
SEE ATTACHED EXHIBIT A
Recording Area
Name and Return Address:
Land Title, Inc.
1900 Silver Lake Road, Suite 200
New Brighton, MN 55112 3
Together with all appurtenant rights, title and interests. 161-1022-40-000; 161-1021-10-000; 161-1059-
90-000; 161-1059-80-000
Parcel Identification Number (PIN)
This is not homestead property.
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except
Roadways, Easements, Restrictions, and Rights of Way of record
Dated this tc of October, 2010
SuDon,LLC
* Susan A. Solsvi , Member * Donna M. Shaffer, Member
*
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF 0611roo )
COUNTY. ss.
authenticated this Personally came before me this a 0 day of
~(1IZjQ[ -V1 the above named Donna M.
Shaffer, Member of SuDon, LLC, a Wisconsin limited liability
*
TITLE: MEMBER STATE BAR OF WISCONSIN company, to me known to be the person(s) who executed the
foregoing instrument an ac owledged the same.
(If not,
authorized by § 706.06, Wis. Stats.) L
THIS INSTRUMENT WAS DRAFTED BY
Notary Public, State of _ C"10
rCi~
My commission is permane
Larry Mountain, Attorney, 1900 Silver Lake Rd #200, New ARIA S_ GOYDEN )
Brighton, MN 55112 NOTARY PUBLIC
(Signatures may be authenticated or acknowledged. Both arc not necessary.) STATE OF COLORADO
*Names of persons signing in any capacity must be typed or printed below their signature
My Commission Expires 03/14/2012
1 of 3 WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1-2000
State of Wi S CAC1 Ste.
County of. '`.J - &L
This instrument was acknowledged before me on 0 1 ci
Date
~ gc.b s,
Name(s) of Person(s)
y J, N s.
J:•o-i A R y.
Sign: a of Notary Public A U 6\-N0 p
TF OF
Title (or Military Personnel) , CC,, ' stnmpiseol
5~1
2 of 3
EXHIBIT A
Part of Lots 1, 2, and 3, Block 1, part of Lot 3, Block 6, and part of Lake Avenue, now vacated, all in the
Plat of Lakeside, now a pail of the Village of North Hudson, St. Croix County, Wisconsin, described as
follows:
Commencing at the Southeast corner of Section 14, Township 29 North, Range 20 West, in the Village of
North Hudson; Thence N00°58'26" E along the east line of the SE 1/4 of Section 14 a distance of 1535.00
feet; thence N89°01'34"W a distance of 33.00 feet to the west right of way of Galahad Road; thence,
along said right of way, N00°58'26"E a distance of 198.79 feet to the point of beginning, from which a
3/8 iron rod in concrete bears S89°08'00"E a distance of 0.21 feet; thence N89108'00"W a distance of
442.38 feet to a 3/8 iron rod in concrete at a mcander line, established for this survey, on the easterly
shore of Lake St. Croix; thence, along said meander line, N02002'36"E a distance of 9.88 feet to the
south line of the north 10 feet of above said Lots; thence, along last said south line, S89°05'43"E a
distance 442.20 feet to the west right of way of Galahad Road; thence, along said right of way, S00°
58'26"E a distance of 9.58 feet to the point of beginning. Together with all lands lying between the
above described meander line and the shore of Lake St. Croix on a line bearing N89°08'00"W from the
beginning of said meander line and bearing N89°05'43"W from the end of said meander line.
3 of 3
AFFIDAVIT OF CORRECTION I IIIIIIIIIIIIIIIIIIIII
IIIIIII
1I
Document Number 8 0 2 1 5 9 4
Tx:4015734
Pursuant to s.236.295 (1) (a), Wisconsin Statutes, I Ty R. Dodge, Registered 932785
Land Surveyor, S-2484, hereby certify that I prepared a property description BETH PABST
used in a certain Quit Claim Deed recorded at the St. Croix County Register of REGISTER OF DEEDS
Deed's Office as document No. 926981, located in the Village of North ST. CROIX CO., WI
Hudson, and that said description is shown on page 3 of said document as RECEIVED FOR RECORD
Exhibit A and contains an error on lines 3 and 8 of the last paragraph of the 02/24/2011 12:27 PM
description, noted as follows: EXEMPT
...the west right of way of Galahad Road; thence, along said right of way, REC FEE: 30.00
N00°58'26"E a distance of 198.79 feet to the point of... PAGES: 1
Together with all lands lying between the above described meander lien..
That the shown items should be corrected to read:
Name and Return Address
...the west right of way of Galahad Road; thence, along said right of way, Ty R. Dodge
N00°58'26"E a distance of 180.20 feet to the point of... S&N Land Surveying, Inc.
2920 Enloe Street
Hudson, WI 54016
Together with all lands lying between the above described meander line..
161-1022-40-000
Parcel Identification Number (PIN)
IA,SCONS,
TY R.
Ty R e S-2484 9 DODGE
Dat this Z -3 R° day of f e6 P"0-~'? 52011. 1 S-24I34
1 G rrAR LAKE, r
W,
State of Wisconsin, f
*4+
St. Croix County. } ~V
Personally came before me, this l day of 1 , 2011 the
above na ed Ty R. Dodge to me known to be the person who executed the foregoing instrument and acknowledge the
same. \
~ CiV~ J . ate, ~
►1
~P \p~~ 1 14
Notary Public, State of Wiscon 'n
Commission Expiration Date MOLLI J. y'
~ ~ HAN~EN
FOFWIS
Kghrt►~`''~
DR AFTLI) R. DODti-r- ' S~rN LM'p SURv`*r-6
This information must be completed by submitter: document title name & return address, and PIN (if required). Other information such as the granting
clauses, legal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document. bvRDA 2/99
Note: Use of this cover page adds one page to your document and $2.00 to the recording fee Wisconsin Statutes, 59.43 (2m)
1 of 1
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Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER 45eJ6„37iJ 1rt~/FaT~,eti.lpT e - r SEC. ZT Z9 N-R 20
ADDRESS j -39 C A c,a rJA4 Rv AJ. ST. CROIX COUNTY, WISCONSIN /
~ r s/k
SUBDIVISION ~rCL SIGt LOT I 2 3 LOT SIZE
Blo46~1
PLAN VIEW
Distances and dimensions to meet requirements of ILHR, 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
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INDICATE NORTH ARRO
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BENCHMARK: Describe the vertical reference point used 6,22ZL AZE
Elevation of vertical reference point: /DD,p D Proposed slope at site:
.
SEPTIC TANK: Manufacturer: (J/ES ER Liquid Capacity: taco ~4
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side, Rear, 3C~ 7 feet
From nearest property line Front 10 Side,aRear, O 33r feet
Number of feet from: well ,Q , building: 16
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: Trench:
Width: Length: y(o~ Number of Lines: 3 Area Built: o„{
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, e<ear,0 Pt
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
i
Dated: t Plumber on job:
License Number : //'/LJ i'~o C7
3/84:mj
Parcel 161-1022-40-000 06/27/2006 10:45 AM
' PAGE 1 OF 1
Alt. Parcel 13.29.20.413.414.415A 161 - VILLAGE OF NORTH HUDSON
Current ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
SUDON LLC O - SUDON LLC
628 4TH ST N
HUDSON WI 54016
Districts: SC = School SP = Special =
Property Address(es): Primary
Type Dist # Description * 539 GALAHAD RD N
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 0.000 Plat: 02/35-LAKESIDE ADDN 1910
LOTS 1, 2, BLK 6 ALSO S 40' OF LOT 3 BLK Block/Condo Bldg:
6 LAKESIDE ADD VIL NH INCLUDES PARCELS
161-1021-10 (P383A)/1059-90 (52513) & Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
161-1059-80 (525A) 13-29N-20W
Notes: Parcel History:
Date Doc # Vol/Page Type
08/06/2004 770930 2632/547 QC
08/06/2004 770929 2632/544 TI
03/11/2003 712737 2167/63 TI
01/03/2003 704493 2099/540 CC
M.0
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 05/19/2005
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 0.000 376,300 196,000 572,300 NO
Totals for 2006:
General Property 0.000 376,300 196,000 572,300
Woodland 0.000 0 0
Totals for 2005:
General Property 0.000 376,300 196,000 572,300
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: 10/04/2005 Batch 05-28
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Abstract of Title
and y ..~.v,
P 1;'-A- T
Descriptions as in
Deed Book : 298 page 235
at_=:No.129.
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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.7. BOX 7*9 BUREAU OF PLUMBING
MADISON, WI 07 I2
MADISON S14 ,T29N-R20W (CONVENTIONAL ❑ALTERNATIVE State PgnnIiD. Number: (If Village North Hudson Holding Tank ❑ In-Ground Pressure El Mound
NAME OF PERMIT HOLDER: DRESS OF PERMIT HOLDER: INSPECTION DATE:
Quentin Wentlandt 7539 Galahad Road North, Hudson, WI 54016 1-) -0c
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: MPIMPRSW No.: County: Sanitary Permit Number:
Gary Zappa 3300 St. Croix 92548
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: JLIQUIP~~~ggqCITY: TANK INLET ELEV.: TANK OUTLET ELEV. WARNING LABEL LOCKING COVER
/P ODED: PROVIDED:
u J D YES ❑NO ❑YES NO
BEDDING: VENT D A.: IVENTM7L.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: IVENT TO FRESH
C JALARM FEET FROM 7 LINE ! / AIR INLET.
❑YES O ❑YES NO NEAREST J 3 ~l/ (CIS
DOSING CHAMBER:
MANUFACTURER: MY-ING L IQUID CAPACITY. PUMP MODELPUMP/SIPHON MNUFACTURERWARNING LABEL LOCKING COVER
PROVIDEDPROVIDED:
ES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL' BUILDING: VENTTOFRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) ❑YES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moistureat the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
WIDTH./// ILENLT JNO.OF DISTR. PIPE SPACING'. COVER INSIDE DIA. #PITS LIQUID
BED/TRENCH / y TRENCH S PIT DEPTH
DIMENSIONS l l/~ ll^/•
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. O TR. NUMSEROF PROPERTY WELL. BUILDING. V NT
t TO FRESH
BELOW PIP ABOV R'. ELEV.INL,ET E EV.D~ PIPES FEET FROM LINE AIR~gL~T
is. Y '222 NEAREST-i 12 2 2 2 / GG
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES ❑NO ❑YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED SEEDED MULCHED
CENTER: EDGES'.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH. TRENCHES: LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
DIMENSIONS
MANIFOLD PUMP, MANIFOLD DISTR. PIPE MANIFOLD MATERIAL'. NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEV.: ELEV.: CIA ELEV.: PIPES DIA.:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES ❑NO COVER ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
LoltJl FEET FROM LINE:
❑YES O ❑YES ❑NO NEAREST
I ? I i
1V
Sketch System on
ain in co ty file for audit.
Reverse Side.
SIGN TITLE.
DILHR SBD 6710 (R. 01/82) Zoning Administrator
®ILHF-~ SANITARY PERMIT APPLICATION COUNTY
In accord with ILHR 83.05, Wis. Adm. Code C a X
STATE SANITARY PERMIT
9
-Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER
8% x 11 inches in size.
-See reverse side for instructions for completing this application. PETITION r5y 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES NO
PROPERTY OWNER PROPERTY LOCATION
T ri 'J5 '/a `sue '/4,S T ,N,R Q E(or)W
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER JBLOCK NU ER SUBDIVISION NAME
CITY NEAREST ROAD, LAKE OR LA DMARK
77
CITY, STATE ZIP CODE PHONE NUMBER
VILLAGE :
e< goo,
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify):
Ill. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable)
1. a. ❑ New b. X Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy.
IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2)
1. a. 9 Conventional b. ❑ Alternative C. ❑ Experimental
2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. X Seepage Bed b. E1 Seepage Trench c. ❑ Seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
-,~o "I t' "P 77, 40 Feet ® Private ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank or Holding Tank AcJ
d- El ~ h P 1 " ❑ 1-1 ❑ ❑
Lift Pump Tank/Si hon Chamber El 1 1 1:1
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signature: (No Stamps) *W/MPRSW No.: Business Phone Number:
J av 5
A I.- Z-6- poo, ~ - 9- Plumbe ' Address ( t, City, State, Zip Code): Name of Designer:
J ~
Vlll. SOIL TEST INFORMATION IV 4V
Certified Soil Tester (CST) Name CST
ST's ADDRES treet, Ci y, State, Zip CodeV L/ Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps)
Approved ❑ Owner Given Initial CSrjcharge Fee
,&j ~ L$
Adverse Determination Id d - • L'J0 ~vr
X. CO ENTS/REASONS FOR DISAPPROVAL:
IX C141 /J CI
y
SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
1. This 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. A new permit may be needed
if there is a change in your building plans, system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewace system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 608-266-381:5.
To be complete and accurate this sanitary permit application must include:
1. Property owners name and mailing address. Provide the legal description where the system is to be
installed;
II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
III. Purpose of application: Check only one in ##1. Complete #$2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in ##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. 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. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
Complete plans and specifications not smaller than 8'/2 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; dosing or pumping chambers; 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.
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the
result of over 2 years of steady negotiation and public debate. The groundwater bill Groundwater
included the creation of surcharges (fees) for a number of regulated practices which Wiscon~Sin's a
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that, r~
buried ti easure
is used in your building is returned tc. the groundwater through your soil absorption a
system or the disposal site used by your holding tank pumper. w\_,
The monies collected through these surcharges are cre&.ed to the groundwater fund adminis-
tered, by the Department of Natural Resources. These funds are used for monitoring ground:
water, groundwater contaminatio- in\ estigat:'ons and est~ blis?+m._-nt of standards. Groundwatt
's worth protec',?ng
;;31'a-.6398 i9.03i36;
APPLICATION FOR SANITARY PERMIT
STC - 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
Location of Property , Sectionnl , T N-R W
Township I I A G O F ! I' D Pi-tT ~ZU O E D Al
Mailing Address (s I LA- If A a A ~
/gyp Rt /f U Q SO
N
Address of Site ~ 3q_ r t~ L 14 b LQ Al l
.Subdivision Name
Lot Number
"Previous Owner of Property
Total Size of Parcel
Date Parcel was Created C g~19
Are all corners and lot lines identifiable? No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number NZ 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 refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
i
PROPERTY OWNER CERTIFICATION
I (We) centi6y that at statement on thi.6 bonm alr.e true to the but o6 my (oun)
knowledge; that I (we) am (ane) the owner(s) ob the pnopenty descA bed in this
.in6onmati,on 6o4m, by viAtue o6 a waAAanty deed tecotded in the 066ice o6 the
County Reg.i,6.ten o6 Deedsas Document No. p Z ; and that I (We) pneeentey
own the pnoposed site 6on the s ewa9a dig os s s em (or t (we) have obtained an
easement, to nun with the above dedcA bed pnopenty, bon the constnucti.on o6 said
system, and the same ha6 en duty keco&ded in the 046ice o6 the County Reg" ten o6
Veed6, a.6 Document No. WO 02 12-
SIGNATURE Old OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
DEED RECORD VOL. 307 e ~6
WARRANTY DEED. STATE OF WISCONSIN-FORM No. 9
240120 1 This Indenture, Madeby Lloyd S. Gilbert and Lucille Gilbert, his wife
' grantor S , of St. Croix County, Wisconsin, hereby conveyxand w:,
Quentin W. Wentlandt and Lorraine A. 4entlandt, husband and wife, as joint tenants
grantees of St. Croix County, Wigan
thesum of Tnelve Thousahd Eight Hundred and no/100 ($12,800.00) Dollars
the following tract of land in St. Croix County, State of Wisconsin:
Lots 1, 2 and 3, except the North 10 feet of said Lot 3, in Block 6; and Lots 1, 2 and 3, Block "1"
North 10 feet of said lots, all in the Plat of Lakeside, now a part of the Village of North Hudson.
•
Also that part of Lake Avenue, new vacated, described as follows-. Connencing at a point on the ,est
of Block 1 in the Plat of Lakeside, which point is 160 feet South of the Northwest corner of said bl
• thence '4est 50 feet to the East line of Block 6 in said plat; thence South to the Southeast corner c
Block 6; thence East 50 feet to the Southwest corner of Block 1; thence Borth to the Place of her-inr.
Also all of First Avenue, also known as First Street in said plat of Lakeside, which adjoins said
1 and 6 and vacated Lake Avenue on the South.
Also the North ld feet of Outlot "84" of the Assessor's Plat of the Village of North Hudson.
(5614.30)
(Can. )
j
i
I
• IN WITNESS WHEREOF, the said grantor s ha ve hereunto set their hands and seal S this 26th.
May . A. D., 19 54
Signed and Seated in Presence of Lloyd S. Gilbert
Lloyd S. Gilbert
Harold 7lalbrandt
• Harold W"albrandt Lucille Gilbert
Robert L. Bauer Lucille Gilbert
Robert L. Bauer
STATE OF WISCONSIN,
St. Croix county. las,
Personally came before me, this 26th. day of May • A. D.
the above named Lloyd :i. Gilbert and Lucille Gilbert, his wife,
to me known to be the person S who ezecuted the foregoing instrument and acknowledged the same.
i
Received for Record this 27th. day of Harold Nalbrandt
Harold
May A. D., 19 54 , at 2:45 o'clock P.M. Walbrandt
Notary Public, St. Croix Coup
(S GAL)
David Hope Register of Deeds.
nay Commission expires May 4 • A. D.
Deputy.
i .
' H
z
tn
H
• a
8TC-105 r
a
,.j
SEPTIC TANK MAINTENANCE AGREEMENT Ho
St. Croix County z
d
a i
OWNER/BUYER V !1~ 'r / Al I r~ ~I E Al 7.1, A' /YD'r M
ROUTE/BOX NUMBER 5 39- r,~LµNk-0 R&A0 Fire Number
.CITY/STATE NvRT)4 /'duo sov Wt ZIP S'q6 1 G
PROPERTY LOCATION: 4, Section, TN, R 20 w,
Town of N p R -r FF rI O D S 6/d, St. Croix County,
Subdivision Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you pdt into
the system can affect the function of the septic tank as a treat-
ment 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 systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
three year expiration. y
0
E
I/WE, the undersigned, have read the above requirements and agree z„
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- v
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Offkpe within 30 days
of the three year expiration date.
SIGNED
DATE
St. Croix County Zoning Office
P.O. Box 98,
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
DEPARTMENT OF REPORT ON SOIL L7VRINGS AND SAFETY & BUILDINGS
NDUSTRY, DIVISION
ABC►Fi AND P.O. BOX 7969
IUM,AN RELATIONS PERCOLATION TESTS (115) MADISON, W153707
(H63.09(1F& Chapter 145.045)
-OCATION! SECTION: TOWNSHIP UNICIPALIT OT NO.: BLK. NO.: SUBDIVISIO NAME:
S 1 1/44 4 /T=_~ NIRZ04 (dr) w ,t-LA6, L 37 l kTl< l~ubso LM err, s 1
BOUNTY: OW UY 'S AME: MA IN ADDRESS:
r r
f C_ eU ►X C rV? 1 h+ n 53"? G Al/4 /J A k'i~ F. u~u lLjsa N ! 4o i6
SE DATES OBSERVATIONS MADE
_ NO. BEDRMIS.: COMMERCIAL DESCRIPTION: i I IFERCOLATION TESTS
OResidance ❑New 'Replace AP*►L. ze, r%7 DESCRIPTIONS: A?k,L z is
N
eEiL~ ( I'"r- 57
ATINO: S- Site suitable for system U- Site unsuitable for system
N I : MOUND: IN-GROUN -IN-F LL OLDING TANK: RE//1COMMENDED SYSTEM optional)
S ❑V ❑S QU - S ❑U [_],S U ❑S U 0614VEn/r/oNil~
f Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
order s.H63.09(6)(b), indicate: CLtdSS Floodplain, indicate Floodplain elevation: Ni"t
fl'z. t- PROFILE DESCRIPTIONS
tORING
TOT 12.LeIll AL T R UND ATER INCHES C ARACTER O SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
IUNIBER DEPTH -M. ELEVATION OBSE V D TO BEDROCK IF OBSERVED ISEE ABBRV. ON BACK.)
[gyp r( ,per .o p
.41 3 .1:' -71
orv > /19LL':,J"~- 79 "&N M`~- 17"'RD$R4 MS
S2~""PPN MS
3-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP WATER LEVEL-INCHES RAE MINUTES
JUMBER INCHES AFTER SWELLING INTERVAL-MIN. ERIQD t; _P RIO PeRIOD3 PER INCH
4 s / oN 99.11 3 1> 'Z > 7 .E
P- Z 4 , ZG
h. .ZO a $.FsO
n -
t_OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
ontal 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
r•; land slope.
` YSTEM ELEVATION 94.6a f I
zz '
- SS
la- l
A p.z 3 Iss
N
'1t" ~'>T (:e,a i>L ~ 'DLO i0
37 ~t - _PC < SC AL>¢
I ~ l'~ 2U
1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with this procedures and niviliods 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:
I-~AeJr~ l )t_ rlNSc,r l _ ~SG►~ Su~J6YlN~, ~NL _ APleZ8, 1997
ADDRE -S CERTIFICATION NUMBER: PHONE NUMBER (optional):
~C7~; Silo/6 3~t~~ FsU
- CST SI NATUHE -
!MSTRIBUTION: Oriyutal.rridone (:ol+y to Loral Authoiity, Piotieiiy Ownvi and Soil Iestei.
0ILHR-SRD-6395 (R. 01/R?) M/Ftt
L
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
DIVISION
NpUSTRY, P.O. BOX 7969
.ABOR AND PERCOLATION TESTS (115) MADISON, W153707
IUMtaN RELATIONS (1-163.090M Chapter 145.045)
A 10 S C ION: y ° TOWNSHIP UNICIPik OT NO.t BLK. NO.: SUBDIVISION AME:
S t t . /TN/R (dr) W ItL►9G, z tit GtRT1i ~ ~ ~b as - s
A LING DDR
,OUNTY: OWN S BUYER'S AME: V SS:
//UDsQ N W W Ft154016
-1 is J' > 1){ < rv r a re e h~A i 53y l~ 't L a N k Nom l~(
SE DATES OBSERVATIONS MADE
NO. B DRMS.: COMMERCIAL DE RIPTION: RTPTIONS: IPER :1
rOResidence ~ - ❑New Replace A IL z~ /95s7 Ar~2t~ It /9K
157 I~uRv~~
ATING: S- Site suitable for system Um Site unsuitable for system
N N I A MOUND: IN GROUND -IN-F LL OLDING TANK: RECOMMENDED SYSTEM optional)
S CCU 0S QU ' S OU DS U ❑S U 0
1 Percolation Tests are NOT requirad DESIGN RATE: II any portion of the tested area is in the
ruder s.H63.09(6) (b), indicate: L,4SS I I Floodplain, indicate Floodpfain elevation;
PROFILE DESCRIPTIONS
"CORING TOTAL DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
JUMBER DEPTH-lfif ELEVATION OBS RV D HIGHEST EST. TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
3-
.47- 99.-z' /1(c"lt >8•tiz ll'F'~ L a'TS ao"13eN?d'tS''~izfl~
'3- 9% ,7 N3 NtL > a y z- 11"ALL'a77_ 79''8et4 M"-- 17"Rh19RtJ M5
' r~1,L ?"Yl rg MS 5 'f~h$~rl M~
r -3„ _
PERCOLATION TESTS
Tor-
DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
DUMBER INCHES AFTERSWELLING INTERVAL-MIN. RIOD_1_.- __PEsiiOD2 _ PER INCH
q .5 / or~J 89.11. Z - > Z
' P- -Z q .zG X 7 ~ 2
Z6
sa 3
n_
,
' t.OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
ontal 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
,•i land slope.
`S'YSTEM ELE"TION 4.~a
atra~t~ ~i~eue.wr~v i
22 '
w
s s
( p_~. B 3 rss i4c
It < SCALE
I J
I I
LINe
eou
1, the undersigned, hereby certify that the soil tests reported on this form we m made by file fit accord with the procedures and methoids specified in fhrr Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the hest of my knowledge and belief.
NA E print TESTS WERE COMPLETED ON
140JE ~ulltdre.r'~ P~su~SuQJEr~N~, ~NC_ - APPIi.Z 190
ADDRE • CEIi11F1CAfION NUMBER: PHONE NUMB ER(opti<maU:
r/
o 16
SIGNATHlif.
!ASTRIBUTION: or igutal and one ropy to Loral Author dly, I'r open ty Owner and Soil festw.
:)ILHR-SRI)-639f; IR 021821 f 1VEI'
NonTN Pnvl~fiaTY LS.vE pD / L
Noll- = l~ES7 /iLOPERTY LS..iE 21' O✓E2 .
ro eir /,~LutF Zz>vr 3o, 9S"' r~ Exrsn~~ 2ESZo,wc O~la7 "Qrvo Ci2D11
' 1402A,S
- lvorP= EFFLue..T Lr,.,E f,~GT2o..i
(7 "Jo :3y /'vc X o z 3s)
Tb AZ X,,VJ444A-rEO b%2TIV
~~~N~' `~'?NItKNES y X ~,pNEETS
GAAA6E 6r Clalr,0 CELL Sn/SNtA7'X N
/2Z vE t _/q Y
eXXST="t 49
CxLsTS~6 bic=v6v ~oY //t0TEGT"
E-3o Lx=.sTZivb 11 Nor., F-- blo ' SYsTr>"►
D 6pL
/ZkSTlJk"r/GE JE%TXQ TA N QI fLoP~ VSLL-G F_ OF
3d Ise , ~ O //v, 1ve4rnro,,.
73
J'T. CaD=x. CO,
0 ° s,
6
12
6 , vENT
V%Q 7 0
31
EAST
ExrsrlNc,
4
' °~L XIS TMN G FAX LJE,3 CAIIA Pwoo--Ary
SF-PTZC, l Arrv1L yb LzNc
ArvO 01LY kIEL L
AID JAL L X T JJ ~ ~
CILA"VLA/l MAT&IMAt
/Lf9 .f U9 Ll=
LXi.&-r=" b 111k1A7-EfL .1'9-zv2CE
So LfTJJ /OROPE2TY L2n/E 71~ slY rxE Irv Ai a GA LNN/J YJ RD
,ELs✓. = loo, oo
ILOTE- ,SWT4 PRo/°F2TY D>WIV Lt- i-v,51.L TS OVEm 76 F'n,om /o^orD PGo ;0RASNFSI=L0
FRESH AIR INLET AND OBSERVATION PIPE
- APPROVED VENT CAP
MAX IMlJM 12"
ABOYE FINAL GRADE
4" CAST IRON VENT P i PE
Mt4XIMlJM OF 42" ABOVE
PIPE TO FINAL GRADE /
SIGNED:." , ~,.,5~✓
MARSH HAY OR SYNTHETIC COVERING LICENSE.-
'/~J - .~dlJ
IMUM 2" AGGREGATE DATE: ,l~OVER P I PE
MIN 9/'
-
~4- L
PIPE
SOIL TESTING BY:
TEE
46
ELEYATiON BED 6" AGGREGATE •
BOTTOM PER SOIL BENEATH PIPE PERFORATED PIPE BELOW
TEST IS ` COUPLING TERMINATING
'99"'16 FT. AT BOTTOM OF SYSTEM