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Home My WebLink About008-1078-30-150 r - 1323 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations Attach complete site plan on paper not less than 8' %x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference pant (BM), direction and p� I.D percent slope, scale or dimemsions, north d distance to nearest road. °°��' 008- 1078 -30 -100 Please pri ``\� " " IN, r �:, Reviewed By Date Personal information you provide mtiQVSffia for seco* y pu s( , s. 15.04 (1) (m)). Property Owner Property Location Harold Stark _ Govt. Lot SE 1/4 SW 1/4 S 27 T 28 N R 16 W `�r Property Owner's Mailing Add s f_n ^''; t Lot # Block # Subd. Name or CSM# �J — 2438 10th Avenue r�9.c,�•" _� 2 CSM Vo��?; Pg.q / City ip Code ;� City j Village in Town Nearest Road Baldwin 027 w 715 -69* Eau Galle 10Th Avenue New Construction Use: R �/ roams 3 Code derived design flow rate 450 GPD Replacement _j Public or commercial - Describe. Parent material Glacial outwash Flood plain elevation, if applicable na General comments and recommendations: Install bull -run valve to allow future use of hydrollically failed system. Existing system elev. _ 95.20', replacement system elev. = 93.50'. ❑ Boring 1 Boring # 0.1 Pit Grand surface elev. 97.55' ft. Depth to limiting factor > 107" in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft= 1 0 -18 10yr3/2 none sil 2fsbk ds as 2f 0.5 0.8 2 18 -23 10yr5 /4 none sil .2fsbk ds cs 2f,lm 0.5 0.8 3 23 -35 10yr4/4 none sl Osg dsh cw if 0.5 0.9 4 35 -41 7.5yr none gr. Is Osg di cw if 0.7 1.2 5 41 -107 10yr6 /4 none s & gr Osg di - - 0.7 1.2 H #4 & 5 contain 10% cobbles. Coarse fragments comprise less than 35% of horizons. F il Boring # A Boring id Pit Ground Surface elev. 97.71 ft. Depth to limiting factor >1 10" in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft= 1 0 -13 10yr3/2 none sil 2fsbk ds as 21' 0.5 0.8 2 13 -19 10yr5/4 none sil 2fsbk ds cs 21' 0.5 3 19 -27 10yr4 /4 none sl Osg dsh cw if 0.5 0.9 4 27 -36 7.5yr4/6 none gr. Is Osg dl cw if 0.7 1.2 5 36 -110 10yr6/4 none s & gr Osg dl - - 0.7 H #4 & 5 contain es and stones. Coarse fragments comprise less than 35% of horizons. Effluent #1 = BOD 5> 30 < 220 and TSS >30 < 50 mg/L Effluent #2 = BOD <S mg/L and TSS -00 mg/L CST Name (Please Print) Sign re: CST Number James K. Thompson = 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number Osceola, WI 54020 10/16/00 715- 248 -7767 r property owner Harold Stark Parcel ID # 008 - 1078 -30 -100 Page 2 of 3 M Boring # Boring Pit Ground Surface elev. 100.92 ft Depth to limiting factor > 93" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GR *Eff#1 *Eff#2 1 0 -12 10yr3 /3 none sil 2fsb ds as 2f,lm 0.5 0.8 2 12 -16 10yr4 /4 none sil 2msbk ds cs 2f,im 0.5 0.8 3 16-24 10yr5 /4 none sil 2msbk dsh cw if 0.5 0.8 4 24 -31 10yr4 /6 none sl 2msbk dsh cw - 0.5 0.9 5 31 -75 10yr4/4 non gr. sl lcsbk dh gw - 0.4 0.6 6 75 -93 10yr4/4 none gr. sl Om dh - - 0.3 0.5 Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots ' *Eff#1 *Eff#2 F —I� # Pd Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots I GP ' *Eff#1 *Eff#2 " Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD <30 mg/L and TSS <30 mWL The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608- 264 -8777. SESO, Sec.27, 'Tb. of A-6 o _" % Gbscr a- 0,, b! I V 5 ale: 1 . 13. .� %oPofa,r Crmdir�uner Con d&?ser,pac(. E/ee s 3 beolroor►, P-111, res;der�ce B3 ■ ont,�.l a : T� off' ✓¢n Co. wil - �, ,,o Assumed a ✓. _ /oo.�: az X. /2 X d U ■ j /oo fo CeU.. 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O _ ° 0 Ta I 0 — I N no 3 o CON o o 0 m 3 � o co n o 0 0 CD o to o W o o b m m m as , m En O rsa O ., to o o g o g O n O L O a N Cc 0 0 / Col se c — _ z z- z g / o 00 / ° $ % § $ 2 § . 9; 0 . 7 k e _ � 2 Q C �� m� » E E ca -N ° / 0 / % .. �; k = o o §� 0 _ �; $ $ ED ƒ § § § n r ■ C 0 0 0 2 .. k CO §) �; / § § 7 I 2 � � E ■ _ . � 2 � � CD § � & � .. � § 2 0 0 { ƒ . � _ ■ � � D « � E � E i � 2 ■ S: $ 0 � z E c N m m w CD \ § =0' > k ' 2 % ._ k § \ g ± § §B 777/ a OGEE ERA` § #K 7 a � )/( � ) i m�a W �I§ k §J % Ee < \ AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP ,iraU &Alle SEC . 27 TZ8N -R/�W ADDRESS ST. CROIX COUNTY, WISCONSIN. SUBDIVISION LOT LOT SIZE 4rreS PLAN VIEW Distances and dimensions to meet requirements of H63 _ W EV ERYTHING WITHIN 100 FEET OF SYSTEM F. /I FJ I M r" �Q J I I di a e o th Arrow JT SC L . BENCHMARK: (Permanent reference Point) Describe: j,,spect on /% /e oo % 2 Elevation of vertical reference point: p�' Slope at site: o SEPTIC TANK: Manufacturer: 41ee ks Liquid Capacity:_ DD Number of rings on cover oV e Tank- manhole cover elevation Tank Inlet Elevation: ZZ Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set f or a cyc a gallons; total capacity of distribution lines gallon: size of pump head; gallon per minute horsepower branT name of pump and model number ; Type of warning device HOLDING TANK:. Manufacturer Number of gallons Rlovntinn of o nnvdr o 'I PORT Of INSPECTION - INDIVIDUAL SLWAGL SYSTI.M Sakti. tali Vv 1( m< t stato, sep?4 . AM I T o w n.,5 h t. Choi x County Lot ub di v,i o n -i'l I C I ANK Sr c g a f 1, o nz Numbe.4 o6 compaktments ti I , ( P I ( ' c ( P r om: W v e f B ti i f di Yi g 12 H.i,qhwa toA CiIMVING CHAMBER -1 o n,6 Pump Mana4de-tivieA — Made(' Numb HOLDING TANK Number o6 Compaii:tme.nt,6________ Pu mp e rs A?-a.Am Sys- tern • 1)(,5tance 64om Wetf guitding__ 12% .6,fope_ ____ Highwate-4 A6SOWPTION SITE Ttionch 1 ) ta ki 0 c it, o m : We ff 0 8(44 1 f d 4, t 2 -' 4 e o e, ti 4' g h w a t c li S-0 AW:011 SITE DIMENSIONS (V((1(h (16 tite y1ch t Rvqii.i�ivd ali.ea A ll 0 I c k i , i th o{ ea . tr i n e .— t Depth o6 rack be'eow ti,i'e J7 i Ntirnbol( oA Xi . ice ;21 Depth oA novh, oven ti-fv o to f e. v Yi C-In gth oA 0 L) 6t Depth o( tife befow i � � I t, - jiLad AV L)(,ti (ance betwee.n fine.6 6 t �kopv o6 pelt 100 At 'Totae ab6oAption ake.a_ S 6t Type o6 Covey: Papers ei�i Atitaw I ' l f D I M F NS I ON-S N(imbe, o6 p.i.46 Gravel alliou P,( t,5 I/ CA oii (6 Idv di amete,�i At Depth below infet — -- ---- --- 7 A d v4 t Io-tl4e ab6oll.ption aqva A ncquihed State and County State Permit # QpJ . P L B 6 Permit A lication County Permit # PP 57�; Ro%X for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # r A. OWNER OF PROPERTY Mailing Address: Wt�l lAwt l�a�v� /�/t��c p ig, L I S o B. LOCATION: _ E /a ' /a, Section cZZ, TaY' N, RZJ& E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Towns �u a5 4k k e C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family X Duplex No. of Bedrooms 7Wg No. of Persons 6A- A t D. SEPTIC TANK CAPACITY /OOd Total gallons No. of tanks O/✓el HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete f Poured -in -Place Steel Fiberglass Other (specify) New Installation X Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New ___x_— Replacement Alternate (Specify) Seepage Trench: No. of L,,i9�e,a��l Ft. Width Depth Tile depth (to No. of Trenches Seepage Bed: _X _ Length �Width /A ' Depth 2o " Tile depth (top No. of Line '7 10 Seepage Pit: Inside diame er Liquid Depth No. of Seepage Pits Percent slope of land - a o Distance from critical slope WATER SUPPLY: Private IX Joint ❑ Community ❑ Municipal ❑ Owners name as listed o n EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Certified Tester, NAME So e. d f C.S.T. # "- 6V 4 and other information obtained from OtAJAJ e (owner /builder). Plumber's Signature MP/ 'r- q- ?9 Phone # 7/5� 69 'X-337J Plumber's Address �• PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. i E 1 . � ry s e m € € E E € 4 L_ _.. c ° a € E € 3 L r Eif' i15 Rev. 9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT -0F HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 LOCATION: ✓� ' /4,' /o, Section (or) W Township or.AeipeFitY �i9y CaGA /�G Lot No. , Block No. County 1 u Ivlsion me Owner's /Buyers Name: 601111/Ar» Mel k /�e, Mailing Address: 4.2 Z- . E /Y964. -0 406 `f �>�- AWL, 1_71^ ) TYPE OF OCCUPANCY: Residence No. of Bedrooms °� COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS �— oZ — _ PERCOLATION TESTS ` � — A ?Z g SOIL MAP SHEET 9J� NAME OF SOIL MAP UNIT J� /-4 J,-/ -74A e. PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN /IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P / to ?J_- i P- lI ,Less v µ a. 91f j:jqAfj P- !/ N o rr it '' v SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- a if 7 - ,v S. err, ' a e• i „ B- 2 2 n _ # 1/ �� 0 4t, r B_ a if v ,/ it 4 6 r B— /r U B_ 02 Q� li V PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy '(o Indicate scale or distances. Give horizontal and vertical reference points. lVicate slope. Ole we 3 E m T R .. Y I - �� I�_P N Vil 3. _ ! V ' 4 .'V f� r f or R a * + + + CL � t dsQ It o�p� � � N + '1 D �fi Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County Safety and Buildings Division St. Croix INSPECTION REPORT GENERAL INFORMAKION (ATTACH TO PERMIT) Sanitary"MTtlNo.: Personal information you'provice may be used for secondary purposes [Privacy Law, s 5.04 (1)(m)). Permit Holder's Name: ❑City ❑ Vi a e o of: State Plan ID No.: Stark, Harold LIZ (%1ievTo V _ CST BM Elev.:. Insp. B Elev.: BM Description:l S S Parcel Td6 95'1b78 - 30-100 TANK INFORMATION ELEVATION DATA -211 7j, 16 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 2 - Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St /Ht Outlet TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt Inlet Air Septic 10D� y�. --(�3� NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe y io3r .$D Holdin Bot. System PUMP / SIPHON INFORMATION Final Grade Man cturer Demand t cover Model Num GPM y�(e,i � ca. �� , (�� %,oZ r TDH Li Fir 'on System TD Ft L oss Forcemain Length Dia. H Dist. To Well SOIL AB RPTION SYSTEW TRENCH Wi tFp Len th No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DI (109 .4 2 DIM ENSION S SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING � Manu acturer: SETBACK INFORMATION Typeo < < CHAMBER ]F;o_ mber: System: 0� " I3a 13� OR UNIT ac: DISTRIBUTION S)6S JEM may Se- Header/ M4nifo Dia. Distribution Pipes) x Hole Size x Hole Spacing Vent To Air Intake rr / Length Ot Lengt Dia. Spacing 0'0 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed/Tr nch Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: 019 /oZ '// Inspection #2: 44 Location: 2438 10th Avenue, Baldwin, W1 54002 (SE 1/4 SW 1/4 27 T28N R1 6W) - 292816412B -Lot 2 x� 1.) Alt BM Description =NIA ¢ 2.) Bldg sewer length= ACV" - amount of cover r Plan revision required? ❑ Yes SdNo Use other side for additional information. DS SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.2 1, Wis. Adm. Code 201 W Washington Ave. v�SC0/1S See reverse side for instructions for completing this application PO Box 7 Personal information you provide may be used for secondary purposes Madison, W1 53707 -7302 Department of Commerce [Privacy Law, s. 15.04(1)(m)) (Submit completed form to county if not state owned. Attach com lete plans (to the county copy only) for the system, on paper not l ess than 8 -1/2 x 11 in ches in size. County Statc Sanitary Permit Number ❑ Check if revision to previous application State Plan 1. D. Number � C t-o / X I. Application Information - Please Print all Information Location: Property Owner Name Property Location L� o /6 / d l! /Q ✓� .51 1 /4 -T&)1/4, S TZd ,N, R IS or W Property Owner's Mailing Address Lot Number Block Number -;� ,? e zw City, State Zip Code Phone Number Subdivision Name r C umber ( 715 1 1f ?e-3V,3 J l. Q z 7 it II ype of Buil tng: (check one) ` t2 j�, � r� �� ❑ City g 1 or 2 Family Dwelling - No. of Bedrooms: �. j , i ❑Villa e 13 Public /Commercial (describe use): ,' ;:�� ,li9"fown of Ll GQl/e- ❑ State -owned r III Type of Permit: (Check only one box on line A. Check b R o, line B if app icable) , Nearest Road - A) 1. ❑ New System eplacemont 3. ❑ Replacejnent(ef i iV a. ? c Parcel Tax Number(s) System TankC'1(tF `; R(Yixistin S e OOQ /07830- /00 B) Permi r rUUN'V 3, Z j / Date Issued A Sanitary Permit was previously issued I zONiNG OFFICE Z / 3 IV Type of POWT System: (Check all that apply) _ _ . = °• i ®'Non- pressurized In- ground ❑ Mound , d�1 d Filter ❑Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank L_-= -E7 Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V Dispersal/Treatment Area Information: Z2 1 C e-6 I. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. Percolat' n Rate 6. System Elevation 7. Final Grade Required 3 -7S Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) Elevation 710 a d ry , z AIX 7rs'5✓ VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks ❑ ❑ ❑ ❑ ❑ VII Responsibility Statement I, the undersigned, assume res on ibility for installation of the POWTS shown on the attached plans. Plumber's Name (print) Plumber's Signature (no stamps): MP/MPRS No. Business Phone Number a I C L. NuOtso �z0�5'3' 7 /1=� �7 Plumber's Address (Street, City, State, Zip Code) ]� �� d am/ 11 D7 1�Q ! �L!/ r � Y� � t VIII County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) Approved ❑ Owner Given Initial Adverse Surcharge Fee) Determination �Z h A OCJ I.X. Conditions of Approval /Reasons for Disapproval: u"R . w./ va /t,e oN(y si�cdl �'or a 2 `aQ� la nan, �c CcS�c��or s(wrf per C' c,j a j f =vrt fo cx fer`� �c a{' p�or oseeQ s�/ SBD -6398 (R. 07/00) ,. EOLDTS PLBG & HTG Fax : 715 - 684 -3144 Nov 06 1 00 16:58 P02 �. 3oF3 �•^e /d SE,..,r f,�af. 2y3f IVAF vt. ■.50:1 ob�ser'✓a6�a► s Est, act .17, 'PI • •F Pt Ark u k ' g //, N sue. /� :�� • E/'�' + �' I . 8 • _ : o p or 4:r coyW: &."er t.nds.�,ti- pas E'kr, _ �,��Y 3 bedrnpn, rc5idsnce B3 � ,o' e.nc.� Tp of ✓cn� eQ�. a1 ZS • : .s y r � c >.o. �rle / NG Ao y U* ).Sol /ESE.t /a► 4� �..Ekf � � ,Z�n t/v�s at3irLd�uSr�, q Z,2 -Arr /cr0,16 wr- A,�p / esaypQc.; 'Oell f " obscrVo�'a� 47- o 3 00 BpLDTS PLBG & HTG Fax 715- 684 -3144 Nov 06 '00 16:58 P01 R OLDT's VL 1 �vx�iu i PLUNGING a HEATING IK. "Serving You For 40 Years" 820 Main Street Baldwin, WI 54002 (715)684 -3378 Fax(716)694 -3144 Fax Transmission Date: - - OHO TO: Cr a Y w RE: Q . o I� 4r:L Phone: FAX # Z S OU From - �4 lie, 4 Including this page, there are ?—.-- pages in this transfer: MESSAGE: WreG Lday Vq lV � Q signed: /�4 1323 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Sal & Site Evaluations County Attach complete site plan on paper not less than 8'% x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. 008- 1078 -30 -100 Please print all information. B Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Harold S Govt. Lot SE 1/4 SW 1/ S 27 T 28 N R 16 W Property aili Owners Mng Address Lot # Block # Subd. Name or CSM# 2438_ 1 Avenue 2 CSM Vol. ?, Pg. ? City State Zip Code Phone Number _ City Ij Village Y Town Nearest Road Baldwin WI 1 54002 715 - 698 -3533 Eau Galle I 10Th Avenue I New Construction Use: t/ Residential / Number of bedrooms 3 Code derived design flaw rate 450 GPD e Replacement Lj Public or commercial - Describe: Parent material Glacial outwash _ Flood plain elevation, if applicable na General comments and recommendations: Install bull -run valve to allow future use of hydrollically failed system. Existing system elev. _ 95.20', replacement system elev. = 93.50'. a Boring # Boring .✓ Pit Ground Surface slew. 97.55' ft. Depth to limiting factor >107" - in. Soil Application Rate Horizon Depth Dominant Color I Redox Description Texture Structure Consistence Boundary Roots GPDIft= _ - -- - _ _ _ ---r ✓ i 0 -18 • '� 10yr3 non sil ✓0.8 _ 2fsbk ds as 2f 0. 5 , -- - - -, -_ 2 18 -23 1 n one sil 2fsbk ds �cs 2f,lm 0.5 ✓I 0.8✓ _: 3 23-35 10yr4/4 ! none sl Osg d cw if 0.5 0.9 - -- -- - - -- 4 - ` - -- —.I — { - - -- -- - -- I— 4 35 -41 • 7.5yr4/ none gr. . s Osg d 1.2 l I cw 1f 0.7 ,� — 5 1 , 10yr6 /4 none s & gr j Os dl - - 0.7 ,/ 1.2 ', H #4 & 5 contain 10 cobbles. Coarse fragments comprise less 35% horizons. Fil Boring # Boring ✓J Pit Ground surface slew. — 97.71 ft. Depth to limiting factor >110" - in. Soil Application Rate Horizon Depth I Dominant Color Redox Description Texture Structure Consistence Boundary Roots _ GPD /ft' i 1 -13 10yr3 /2 none sil 2fsbk ds as 2f 0.5 �; — 0.8 - -- 2 13 -19 10yr 5/4 none sll 2 fsbk ds cs 2f 0.5 ✓ , 3 19 - 27• I 10yr4 /4� none sl Osg dsh cw if 0.5 0.9 rt 7.5yr4/6 _ none gr. is Osg dl cw if 0.7 1.2 / 4 27 -36 _ _ -- - - 36 -110 •_ -- - / , z 5 10yr6 none s & gr Osg dl 0.7 -- H #4 & 5 contain es and stones. Coarse fragments comprise less n 35° o horizons. ' Effluent #1 = BOD 5 > 30 < 220 and TSS >30 < 50 mg/L Effluent #2 = BOD <30 mg/L and TSS <30 mg/L CST Name (Please Print) Sign re: CST Number Jame K. Thom son = 3602 Address A.C.E. Soil &Site Evaluations Date Evaluation Conducted Telephone Number Osceola, WI 54020 10/16/00 715- 248 -7767 Property Owner Harold Stark Parcel ID # 008 - 1078 -30 -100 Page 2 of 3 a Bo Boring # ring Pit Ground Surface elev. _ 100 .92 __ ft. Depth to limiting factor > 93" in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 'Eff# 6PDIft EfW 1 j 0 -12 10yr3 /3 none sil 2fsbk ds as 2f,im 0.5 0_8j 2 12 -16.1 10yr4 /4 none sil 2msbk ds cs 2f,im 0.5 - �I 0.8 3 1 16 -24 10yr5 /4 n one sil 2msbk dsh -Fcw if 0.5 j 0.8 / 4 24-31 I 10yr4/6 11 none sl — 2msb dsh cw - 0.5 +_ 5 rt 31 - 75 ' 1 0yr4 /4 none gr. sl lcsbk I gw 0.4 0.6 6 75 -9 3 •' 10yr4 /4 none gr. sl O m — dh —_ 0.3 0.5 ✓ Boring # Boring ft. ❑ Depth to limiting factor in. Soil lication Rate Pit Ground Surface elev. _ - -- _ -- APP H6 Dominant Color Redox Description I Texture Structure Consistence Boundary Roots «E GPDI Eff#2 i ❑ Boring # Boring n, Depth to limiting factor in. Soil Application Rate 21 Pit Ground Surface elev. — Horizon i Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 'Eff#1 Eff#2 i i ----------- - -- -- I _ ' Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L " Effluent #2 = BOD <30 mg/L and TSS <30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 264 -8777. �. 3a3 SESc.�� 5ec.•Z7, �. of /��$ Fain / /f, � • GbiJc IJ y CJ�• on 1 .: %op or air Cr/noli /i me-r- 3 beolroorn �f`Jau7A'� I'CSioterlt�. I o.qz a ma : or iltn ea?. Ass efev . _ 82 x. a x0o 71 • 3oil abs O E..E /!q!..i 5eofiC h �/ ,Z trenc.�es at 3 X68RSu5, z2 F5E • eleer, at oaE /e� v 9G. Coo . :77n F` /f�a � d S.dew.•ne/i� /eau( c- ls:- .„!•mss• e� aca(t Crec.� I ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/B _ � �J Mailing Address o? U 1 L in ! n 5 q c Z Property Address y _ � 5 900'L (Verification required from Planning artment for new construction) CitylState Cll mil_ parcel Identification Number LEGAL DESCRIPTION Property Location S E %., S W y,, Sec. N -R I t W, Town of Eau C' (C, Subdivision 1�1 i� Lot # Certified Survey Map # �� g J �� Volume /e , Page it z 7 Warranty Deed #/ F Volume Pag # 7 Spec house ❑yes (moo Lot lines identifiable 0 yes ❑ no S YSTEM -MAINTENANCE Improper use and maintenance of your septic systemcould result is its premat=faflure to handle wastes. Propermakftnance consists of pumping art the septic tank every three years or sooner, if needed licensed You Pet item by a , pamper. What r>xbo the can affect .the function of the septic tank as a treatment stage fa the waste diisposal.system. The property owner agrees to submit to St Croac Zoning Department i .certification form. signed by the owner. and by a P ]o Y nPltt rest<ictedphsaiberor a Iicensedprmrpervuifymgthat (1) the on-site wastewaterdisposal system is is proper operating condition and/or (2) after inspection, and pumping Cif nexessary), the septic. taak is Less than 1/3 fa of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards 6 fortis, h=in,'as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin.. Cmoi ration stating that Your septic system has beta maintained must be completed and returned to the St C roix.County Zoning Office within 30 days.of the three year c lion date. SI 'LURE OF PUCANT / U'/ O U DATE OWNER. CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described a ve, by virtue of a warranty deed recorded in .Register of Deeds Office. It 1 SlVgA MRE - F APPLICANT DATE « « « « «« Any information that is rnis- rcpreseutcd may result in the sanitary permit being revoked by the Zoning Department. « « « « «« «• Include wlth this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the S�R7 residence located at: s�� 1/ $� y. Sec. Z7 T 28 N, R W, Town of K � l/ , St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Z( if Did flow back occur from absorption system. Yes No no p ski next line. Approximate volume or D length of time: gallons minutes Capacity: /OUp ate Construction: fab Concrete v Steel Other Manufacturer (if known) Age of Tank (if known) : � ZZ4 (Signature) / (Name) Please Print (Title) (License Number) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle) . Name �a e /�/1�1C.SDY� -� Signature MP /MPRS Z 0 8 1461PAra 67 6 1 1 5Q8 KATHLEEN H. WALSH Document Number WARRANTY DEED ST. CROIX WI RECEIVED FOR RECORD Donald W. Larson and Jill L. Larson, f /k/a Jill L. Sorum 10 - 1999 6:00 AM husband and wife conveys and warrants to Harald D. Stark YARRAWTY DEED and Jan M. Stark, husband and wife, holding as survivorship EXEMPT I marital property, the following described real estate in St. CERT COPY FEE: COPY FEE: Croix County State of Wisconsin: TRANSFER FEE: 465.00 RECORDING FEE: 10.00 PAGES: 1 Recording Area Name and Return Address 6t CRW VALLEY TIRE KRWM NIL PO BOX 750 109 N. MIAM St RIVER FALLLVA 64022 008 - 1078 -30 -100 (Parcel Identification Number) Part of the Southeast Quarter of the Southwest Quarter (SE '/4 of SW %) of Section Twenty - seven (27), Township Twenty -eight (28) North, Range Sixteen (16) West, Town of Eau Galle, St. Croix County, Wisconsin, more particularly described as Lot Two (2) of Certified Survey Maps filed November 24, 1993, in Volume 10, Page 2711, as Document No. 509582, office of the Register of Deeds for St. Croix County, Wisconsin, TOGETHER WITH AND SUBJECT TO 10 " Ave. right of way and a 66 foot wide common driveway easement as shown on said Certified Survey Map. Exception to warranties: all easements and restrictions of record. This is homestead property. Dated this /V day of a �E'P. 1999. + -gon Id W. L rson i rson AUTHENTICATION ACKNOWLEDGMENT Signature(s A t,- iSei+J STATE OF WISCONSIN / ST. CROIX COUNTY J 1 �� f Q IlPit� Personally came before me this day of 1999, the above named Donald W. Larson and Jill L. Larson, authenticated this S V day of / !y 9 f/k/a Jill L. Sorum, to me known to be the person(s) who executed the foregoing instrument and acknowledge the same. signature type or print name signature TITLE: MEMBER STATE BAR OF WISCONSIN type or print name (If not, Notary Public St. Croix County, Wisconsin. authorized by §706.06, Wis. State.) My commission is permanent. (If not, state expiration date: ) THIS INSTRUMENT WAS DRAFTED BY Thomas A. McCormack - Names of persons signing in any capacity should be typed or Baldwin. WI 54002 printed belay their signatures. hf—d- Prof —ionab Company Fwd du Loa. Wiacon 800 - 6552021 ti FILED ` 8 NOV 2 41993► 2 JAMES O'CONNEI.L 509582 L LC j Co D eeds CERTIFIED SURVEY MAP v' THE SE 1/4 OF SW 1/4 OF SECTION 27, T 28N, R 16 W, TOWN OF EAU 6ALLE, ST. CROIX COUNTY, WISCONSIN. PREPARED FOR: NANCY GEHRIG NI 14 CORNER SEC. 27 (FOUND COUNTY MON.) UNPLATTED LANDS " . N. LINE SE -SW� 16' b O: { N 89° 36 X 25 "E 1327.64' � 750.69' 576.95' 8' e . I— N 'r SHED : D BARN :v w 0 & `" LOT I W w w --— (A O Z 20.81 ACRES n 19.34 ACRES 1+1` to (906,275 SO. FT.) o (842, 260 SO. Fr) 19.96 AC. EXC. EASEMENTS i 18.41 AC. EXC. EASEMENTS a, :C ro m (869,421 SO. FT.) 2 (802,097 SO FT.) 'z " :r m � m , r :p S86.08'50 "E S86'08'50 "E m w 33.00' 33.00' �O IA 33' " ,D 33'-+q I 66' WIDE COMMON D z I DRIVEWAY EASEMENT EXISTING SEPTIC .0 • v w . III: WELLZ.p CA hI h IC " .1 Sul c / F CREEK POND ` - ° I W �o / .j 2 IM ? BUILDING SETBACK LINE o S 89 57" W I al 1325.72' o o p od o N89.33'5T' 1325.68. — — 580.62_ M i _ _ — 678_92- — �s•33.06' {3e 609.25' .....33.09 r 33.06' S89 5 7 "W 1 325.68 S LINE SE - SW SW CORNER SEC. 2 10 T H AVE SI 14 CORNER SEC. 27 (FOUND COUNTY MON.) ....... " "•'•' (FOUND COUNTY MON.) i I _�,�� {3fS89iDIr�s_ k < �c X L DESCRIPTION The SE 1/4 of the SW 1/4 of Section 27, T 28 N, R 16 W, Town of Eau Galle, St.Croix County, Wisconsin, more fully described as follows: Beginning at the S 1/4 corner of said Section 27: Thence S 89 "W, along the south line of the SE 1/4 of the SW 1/4 a distance of 1325.68' to the southwest corner thereof; Thence N 3 "W, along the west line of the SE 1/4 of the SW 1/4 a distance of 1320.91' to the northwest corner thereof; Thence N 89 "E, along the north line of the SE 1/4 of the SW 1/4 a distance of 1327.64' to the northeast corner thereof; Thence S 3 "E, along the east line of the SE 1/4 of the SW 1/4 a distance of 1319.84' to the S 1/4 corner of Section 27 and the point of beginning. Contains 40.15 acres subject to 10th Avenue right of way and a 66' wide common drive way easement. Also subject to any and all additional easements, right -of -ways, restrictions or conveyances of record. Note: Parcel shown on this map is subject to State and County Laws, 2ules and Regulations (i.e. wetlands, minimum lot size, access to parcel, etc.). Before purchasing or developing any parcel contact the St. Croix County Zoning Office for advice. SURVEYOR'S CERTIFICATE I, James M. Weber, registered land surveyor, hereby certify: That in full compliance with the provisions of Chapter 236.34 of the Wisconsin Statutes and the provisions of the St.Croix County Subdivision Ordinance and under the direction of Nancy Gehrig, owner, I have surveyed, divided and mapped the above described parcel of land and that this map is a correct representation thereof. Dated this e day of .e ,1993. JAMES M. James M. Weber S - 1804 v WENN -M NELSEN -WEBER LAID SURVEYING s - 1804 SPRING VALLEY 1 W IS. J'j Q w SHEET 2 OF 2 A, '•`�••M..,.••.' ,.,� �° �LHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # Attach completT plans (to the county copy only) for the system, on paper not less than ] 8% x 11 inches in size. El / ' i 9 �� Check f 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. PROPERTY OWNER PROPERTY LOCATION _t7on ' eOrSo�^- / V 7 / _ 1 //_ 5 0_ 5,C Y4 5 1VY4,S 27 TZ ?,N,R /� lf(or W PROPERTY OWNER'S MAILING ADDRE LOT # BLOCK # I,F S (n , -� Ave> mS u Z CITY, STATE A � ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER St. �r ea i•1 550 j 4 136 �33� CITY /� NEAREST ROAD 11. TYPE OF BUILDING (Check one ❑State Owned O l7et TOWN OF: VILLAGE : 45 l '45r ve ❑ Public 0 1 or 2 Fam. Dwelling -# of bedrooms _9;� PARCEL TAX NUMBER( 111. BUILDING USE: (If building type is public, check all that apply) oo $ _ / p7 8 , 3 O 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ Restaurant/Bar /Dining 4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash 5 ❑ Hotel /Motel 9 ❑ Office /Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. S 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 ❑ 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 2. ABSORP. AREA 3, ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) ELEVATION —300 t 7 G /0 1?0 3 95. L Feet 97• Z Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass Plastic App Tanks T anks structed Se tic Tank or Holdin Tank 000 e;va I C ,2e e It' F1 Lift Pump Tank/Siphon 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 Stamps) MP /MPRSW No.: M ness Phone Number. 17 a le uG✓so rte. � a,� e �6 Z9 G�y 70 Plumber's Address (Street, City, State, Zip Code): O I.S 57 i �Q /C�Wl►� (i( /i '. AZ B IX. COUNTY /DEPARTMENT US NLY ❑ Disapproved Sanitary Permit � (I ncl ud es Surarge Fee) Water [13 Approved Owner Given Initial /2 I ssued o3 Issuing Agent Signature (No Stamps) ❑ / j/ 7 Adverse Determination / l9 X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: i D-6398 former) Plb-67 R. 11/88 DISTRIBUTION: Original to County, SB (formerly )( ) 9 One Copy To: Safety & Buildings Division, Owner, Plumber PLOT P LAN Page z of Z SCALE 1 "= Flo ' w�'u �xtS'tv�+ I p T& j 7 so, %4 . --- es } �� 4esL I 4w ?r�� I ��, Yo P �.. Wo•o 1 ti $oT�jM o Y 9`� f 'A d &L q7- I � _ N1 f 1-I eaVV-eS - r Ltw L o f - S Zoo' �- tmsT o r g• 1 a P. C13- Z 1 ( 715 ) 4L M005_ 7b _ CST Signature Date Signed Telephone No. CST # � f a d �2 _ u L � 3 Q _ �Q0 I 0 en IL 0 2113 cr � J - L a Ca- � � o NIN ccd C W o T �- K� O° �� '� •�" KFE t z NO h No 1 Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of Z Labor and Human Relations `Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY - � S T • CLZC1 l X Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: N YpVQy G" `Z lG PROPERTY LOCATION S 0 '' ZU - (�FR GOVT. LOT S NZ 1/4 S W 1/4,S Z-_ T 7 - 6 ,N,R 16 E (ore PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # I SUBD. NAME OR CSM # 1$ZS LiI. C . SOvy Z — csm CITY, STATE ZIP CODE PHONE NUMBER ❑CITY []VILLAGE ®TOWN NEAREST ROAD s`r A )LI N SS0%j3 L,l -633$ v Clp►_- Lel 1 110 - M "t [ ] New Construction Use aQ Residential / Number of bedrooms Z [ ) Addikn to existing building [ I Replacement [ j Public or commercial describe Code derived daily flow 300 gpd Recommended design loading rate -- bed, gpd/ft - trench, gpN Absorption area required L) Z 9 bed, ft trench, ft Maximum design loading rate 9 , 7 bed, gP W ftench, gPcw Recommended infiltration surface elevation(s) 15LL S`Dw G 9 S- Z ' ft (as referred to site plan benchmark) Additional design/ site considerations 'E L9Tfw G X2.' Y - y u' Ts e1tb C q 8 o to ' � Parent material s N+'s\ `i a v Ml h S o} Flood plain elevation, it applicable ft S = Suitable for system CONVENTIONAL MOUND IN•GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK U= U nsubtle for stem Cad S O U IRS O U I� S O U [B S❑ U ®S O U OS rRI I SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mom Texture Structure Cortsistem Bwxl3y Roots GPD /ft in. Munsell Qu. Sz. Cart. Color Gr. Sz. Sh. Bed Toich 1 3 tiZLtv?_'5jy St I a i's bk W, c-S — o,S u.6 Ground 3 1 3Z-40 1 b`2'2 316 -` S Z F 5bk hhUf - - o,S o•6 elev. Q S•S ft. O 's yy d•$ Depth to limitin factor )le ft aC� i •�f �; ' F v Remarks: Boring # L t ? OIZ xJoT SUl S Cpwt1�L�( wt �)c 1S /vG D1�t` �tIZ �� Ground S ut S S U 1 L OF � S • 2 13 elev. R U U 1= � (S �u G s S 1 s ft Depth to A-i 1, la 1 LE� - I t l' L=0 b t? limiting facto S T y'f C l er Rs, e a t i t Z R t� & Z4 ",' - 4b0W i s to - 77 Remarks: T Name.- -Please Print Phone: Arthur L. We erer 715- 425 -0165 egerer Soil Testi & Design Service -P.O. Box 74 River Falls,WI 54022 Signature: Date: CST Number: 3- 1- 7 - 7 Ll- 0 t3 M00576 PLOT PLAN Pa - 7 of Z SCALE 1 "= 4 ' I o ` ego ��l • — > SO I moo ti o �--- - 10 o A I \�►c►..h Yv P �.. Wo.p I ti� So�l�lM O Y D� \ &L q Z fyi I � D Ltw of 1 S Zoo' A -- A p 3S m ` a Av ct 3- Z`77 (715 4 5 - C1 h5 M00576 CST Signature Date Signed Telephone No. CST # PLOT PLAN Pa z of - z— SCALE 1 "= y,r ' � - krxts ` sAj G `D to u o' Bl R et s4 -L � 40' !vPb &. a.z D n I N sST Low of P. t L) - 3s 9 3- Z ( 715 ) 423-0165 M 00576 CST Signature Date Signed Telephone No. CST # : Rev. 9/78 Evil 4tEPORT-ON SOIL BORINGS AND PERCOLATION TESTS t WISCONSIN DEPARTMENT OF-HEALTH AND SOCIAL SERVICES P.O. $0 309, MADISON; WISCONSIN 63701 LOCrATIPN /4, /., Section 16 D (or) W Township or-MuniciQaRly- Lot''Nv._,,Block No.. County Su IvIsIon me Owner's /Buyers'.Name: �'t.J/ i ) A10 c tJiw/ �e• Mailind'Add.ress: /a?7.2 /Y�tl �i!t >.C.�.`t f�;f `� `if `rlul., /..ti ✓� TYPtOF- CIMUPANCY. 'sidence X No. of Bedrooms `COMMERCIAL EFFIWENT!U]SP.OSAL SYSTEM:- NEW x REPLACEMENT ALTERNATE SYSTEM OTHER DATE$`OBSERV,ATIONS JAADE; SOIL,BORINGS �' d, F " ! PERCOLATION TESTS - 2 SO] .LMAP,'SME1T 9 NAME OF SOIL MAP UNIT PERCOLATION TESTS TEST DEPTH CHARACTER SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHE RATE NUM' R': INCHES THICKNESSRN INCHES SINCE HOLE HOLE AFTE INTERVAL M N% N BE 1ST WETTED 'SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P 5 'LM A�t ' R O ez J L n1 ff 7P P— H 9 v cal P SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBE.., ;.L TEXTURE, MOTTLING AND DEPTH TO BEDROCK NCM.ES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES S 7a �► T 5 . 9 8 G ^5 9 /, / 87- �G TS a �� e a PLQJ ., E te�.ercolation.tests, soil;borsholea aindsuitable,Sol I areas.) Indi.aate.on, the - pla -the loc lion and square feet of suitable areas. In,q%4 �pf 40 . fe�t,:bf pbsorptLgn prep. needgdfor.ouilditrgwty and'oeeu n �� ,Indicate scale or distances. Give` izA . " "p !nd?.:vertica!'`ieference poi I dicate slope. E 1 I ?► o 1 Y "� K � I 1 Or / V 4 . A ll' 6 r { Y {t 1 , ' r I State, and County State Permit # .. 67 County Permit # Permit Application for Private Domestic Sewage Systems County "DENOTES STATE APPROVAL REQUIRED Date :Approval.. Received from State . if Required.. State . Plan I.D. # A. OWNER. OF PROPERTY Mailing Address: l..tJi / /� ra rvt t /i✓/t' /c. B. LOCATION: '/ '/4, Section T_ N, R E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township A� C. TYPE OF OCCUPANCY Commercia _Industrial Other (specify) Variance Single family X Duplex No. of Bedrooms a No. of Persons 6^j D. SEPTIC TANK CAPACITY /00- Total gallons No. of tanks U/✓ HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured -in -Place Steel Fiberglass Other (specify) New Installation X Replacement Lift Pump Tan or Siphon C Total gallons Prefab concrete Poured- in•Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New— — Replacement Alternate .(Specify) Seepage Trench: No. of L!iqeal Ft. Width Depth Tile depth (top) s No. of Trench Seepage _X _LengthWidth..__Depth Tile: depth (top �`�, No. of Line ��`� Seepage Pit: Inside diame r Liquid. Depth No. of Seepage Pits Percent slope of land o Distance from critical slope 11 WATER SUPPLY Private Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 1.15 if other than present owner: I., the., undersigned, do hereby certify that the information I have reported is in accord with Section . H62.20, Wisconsin iAdmin'istrative Code, and that I -have sized the effluent . disposal system from the EH -115 prepared by the Certified Tester, Soi NAME C.S.T. # ��$�5/ and other information obtained ..from (owner/builder), Plumber's„ Signature MP/MPWGW s ", Phone # ,Plumber's. address i PLAN .VIEW: Provide sketch below of system•(include direction of slope and all distances in with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. I , is he x c� v A x 0 *, p V R UN * � (p n 1 a o a� Z � Lh u o i kA rk p N a�a� o'er co a A + A � E 2 V9jQ bTjMli6,tW, NJk1E 27.28.1 jRI j'E tffAGEjYjtjNf H AVE. County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan ID No.: EAU GATIR M E ev.: Insp. B Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9200451 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM F TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia DIMENSION . Liquid Depth D IMENSIONS SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Center Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: EAU GALLE 27.28.16.412,SE,SW,LOT 2,10TH AVE. Plan revision required? ❑ Yes ❑ No Use other side for additional information. I I F_ SBD -6710 (R 05/91) Date Inspector's Signature Cert. No. DILH SANITARY PERMIT APPLICATION COUNTY R In accord with ILHR 83.05, Wis. Adm. Code �� .. ►-o�X STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 0�9 �/ 8% x 11 inches in size. El Check revision to previous application - See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER y� / / PROPERTY LOCATION .Do Za r - s -O. J i o Yur? s,C '/4 5 4t Y4, S 7 T Z , N, R /�, If (or ow PROPERTY OWNER'S MAILING ADDRE LOT # BLOCK # zzz S ,��" Ave > �- N� CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Sf C'r X ca M ✓l • 5503 y36 X338 II. TYPE OF BUILDING (Check one CITY NEAREST ROAD El State Owned ❑ VILLAGE �Qu V / ' a e_ ` ❑ Public 0 1 or 2 Fam. Dwelling -�# of bedrooms �' PARCE A NUM ER() �+ 111. BUILDING USE: (If building type is public, check all that apply) Do $ ifJ �•, 3 O 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ Restaurant/Bar /Dining 4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash 5 ❑ Hotel /Motel 9 ❑ Office /Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. g 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 ❑ 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 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) ELEVATION -300 4 A10 ,?Q 3 95- L Feet 97 Z- Feet VII. TANK CAPACITY Site INFORMATION in allons Total ## of Prefab. Fiber- Exp New istin Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdina Tank A00 11 0 lie e is Lift Pump Tank/Siphon Chamber L1 - 0 _L I El VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP /MPRSW No.: Business Phone Number: 17ale Z- c✓sor� �a C' 262 .5- 6d'y - 337 Plumber's Address (Street, City, State, Zip Code): se B0 i s b . d IX. COUNTY /DEPARTMENT US NLY Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Approved ❑Owner Given Initial j` _ QO Surcharge Fee) Adverse Determination / lD 01 IAV�8 X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608 -266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County /Department Use Only. X. County /Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD -6398 (R.11/88) r PLOT PLAN Pa z of z- SCALE 1 "= 4Z ' w QxtS'tvu G I > SO' 8NO ��10 14o . •c,----- 3 0 d 3 t2 0 B 1 s 1 ►2 l �lo � S�"R C � V �h►T �� .l.00.0 &L q 4 1 2 4# O N�rsr Ltcv L of Xct - 3 `( hc tz k N Q P 3 s +r,, ra X13- Z:1- �z ( 715 ) 42 -0169 1400576 CST Signature Date Signed Telephone No. CST # Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page ) of z- Labor and Human Relations Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY s T• C�ZC1 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 PRgERTY OWNER: tV P" Aj Gy 6 (FIA (Z I& PROPERTY LOCATION L S 6 k) — a3 U ` - t �R 1' � 1 GOVT. LOT SST 1/4 5 W 1 /4,S Z1 T ,N,R 11, E (or } PROPERTY OWNER -S MAILING ADDRESS LOT TT BLOCK # SUBD. NAME OR CSM #! 1$ Z S Q U `f\vT" C S0'.'" _ -- CS M CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE R9TOWN NEAREST ROAD s`r -0_utK d HN) SSa%ca (bfZ) L436 -6338 [ ] New Construction Use pQ Residential / Number of bedrooms Z [ ] Addtkn to eAsting building j ] Replacement [ ] Public or commercial describe Code derived daffy flow 300 gpd Recommended design loading rate -- bed, gpd/ft - trench, gpol(t Absorption area required y Z9 bed, ft trench, ft Ma'dmum design loading rate o • `? bed, gpd/(l trench, gpd/(t Recommended infiWaticn surface elevation(s) FULLS Dw 6 9 S- ft (as referred to site plan bendtrttarlo Additional design/ site considerations IE G t2.' X y la t et, C q8(3 t � Parent material s p5s�4 Flood plain elevation, if applicable It S = Suitable for system C0NVWn0NAl MOUND N0ROUND PRESSURE AT4RADE SYSTEM IN FILL l IOLDNJG TANK U= Unsuitable for W S O U IRS ❑ U ®S ❑ U 19S ❑ U U S ❑ U ❑ S IffU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure Cormistence GPD /ft Boring # Horizon in. Munsell Qu. Sz Coin Odor Texture Gr. Sz. Sh. BMnd3y Roots Bed TMndh man U o- to 10`ttZ 31Z - Si Z Sbh V�f tr Q-S - o• S o•b Z 1o_'I Z Lt IL - 5 'ft- c - S Ground 3 SZ -40 tb`12 316 IE hT CS _ o o•� elev. g 8•S ft. 1 4 4D- It3i f 3 - 1:.0•$ Depth to limiting factor Remarks: Boring # Sot. S ejl) 1� 1_'( W t; )c 1 w G O L)J� 7 Ground S""4% 1 S U 1 L t'} OF 1 S r • Z ra elev. R11 U 1= (S 'PA-) 6 S 1 s ft. Depth to EO N Z Q D" M o i( I limiting factor S 1 - " Tmwr Un "(Z N 13 ' IZ cci r` Co Z IS I R N I Eiv r 6y79 Remarks: CS T Name:—Please Print Arthur L. We erer Phone.. 715- 425 -0165 Add ress: Soil Testing & Design Service -P.O. Box 74 River Falls,WI 54022 Signature: Date: CST Number: M00576 5CO /c /CY - Il e Z� qO , r— septre '�'anT Not so a h1s Sys�crn w as deS.,�neo� a 2 Le ol, 3 fie Comes a� Q _ t ' A --77�� Own ers ; D OY% �g rsow �V') S or ur'} 17 �awv� By: AlP6e. 1�a�o1w ►�.�,� 1,�� , �yoOL CsT 3413 //Z9 - 9 3 /o rA ✓e STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER �\ S O �1.1 r� �(� n �C1 I a r\ ROUTE /BOX NUMBER 0 4Y, FIRE NO. CITY /STAT d L ZIP -- _3 V O D PROPERTY LOCATION: 5E 1/4 � — � V 1/4, Section �_ , T v 1 N, R W, Town of Ck_�_. �'�Q: (7 , St. Croix County, Subdivision p)t� , Lot No. 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 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 $3000 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 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. Certification form will be sent approximately 30 days prior to three year expiration. 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 Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zonin Office within 30 days of the three year expiration date. SIGNED j yl DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386 -4680 Sign, Date, and Return to above address 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. ------------------------- ---------------------------------II-,-f----/--------------- Owner of property L - � C� Location of property 1/9 S (,.) 1/4, Section 2_ , Township _-C s- lain C� ' Mailing address 'Address of site jC'`v�C Subdivision name A Lot number Q� Previous owner of property V►1C 1 C" �~ I Total size of parcel 3 Date parcel was created I Are all corners and lot lines identifiable? _ X Yes No Is this property being developed for resale (spec house)? Yes X No Volume hSLInd 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 ' 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 d-eed recorded in the Office of the County Register of Deeds as Document No. - ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recor in the Office of �County_yregi? ter of Deeds, as Document No ,� DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2 — 1982 1 599785 . `� VR 1052PAGE 236 REGISTER'S OFFICE Nancy Gehrig, a single person - -• . ST. CROIX CO., WI 1 ------------ ----- - - - - -- - -- - - - -- ----- ------------- -------------------- --- Rec'd for Record ` .. .._...,. _.. ...... ......... d - - -w. -- Larson aad - Jil- 1-- L ------- - - - -- i t DEC - -1 1993 I• conveys and warrants to Donal 8.:.30 � a. SO r u m . '. -_as . j oin . tenant -s - and -- not -- as - -- tenants - - -- ! at M in common - - - - -- ...... - ---------------------------------------- Register of Deeds - -- - - -- -- ----- - - - - -- --- - ----- I - .._...- .....------ .---------- .--------------------------------- ---- RETURN TO i �i .... .... ...... ............... .. . ... .. ........... .. . ......................................----------------- .. ----------------- .--------- .------ .._...- __.... - -.... the following described real estate in ............. 9. CXQ-3X ......... _.- .County, - State of Wisconsin: Tax Parcel No: .............................. Part of the Southeast Quarter of Southwest Quarter (SE4 of SA) of Section Twenty -Seven (27), Township Twenty -Eight North (T28N), Range Sixteen West (R16W) more particularly described as Lot _2 of Certified Survey Map, filed No4ember 24, , 19 93 , Vol. 10 of CSM, Page 2711 Document No. 509582 Office of the Register of Deeds for St. Croix County, Wisconsin. I Arr� I� I This .......... . is not . .. . . homestead property. xPW (is not) Exception to warranties: p Easements and restrictions of record. !I Dated this .- - 1 - -..... day of - �/ �. � ------------ -- -- - -- --- 19 �+ - 7G_ e iC��—�� - - - - - -- - (SEAL) G.��`~j�. -- - -... _ . (SEAL) Nanc hrig - - -- - -- ----- - - - - -- -- - - - - -- - - - - - -- ------ - - - - -- -- (SEAL) (SEAL) II II - ..... - --- - H AUTHENTICATION ACKNOWLEDGMENT I� Signature (s) ------------------------------------------------------------ STATE OF WISCONSIN ss. --------------------------------------------------------- - - - - -- St. Croix ---- - -- - -- County. /3 • �3 P ILB 6 7 State and County State Permit # Permit Application County Permit # for Private Domestic Sewage Systems County "DENOTES STATE APPROVAL REQUIRED Date Approval. Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: B. LOCATION: ' / 4 ' /., Section - T_ N, R_ E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township r C. TYPE OF OCCUPANCY: Commercial_ Industrial `Other (specify) Variance Single family X Duplex No. of Bedrooms % No. of Persons D. SEPTIC TANK CAPACITY /0 00 Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured -in -Place Steel Fiberglass Other (specify) New Installation x Replacement Lift Pu Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify) E, EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft. New — _Replacement Alternate (Specify) Seepage Trench: No. of Li �aI Ft. Width Depth Tile depth (top No. of Trencl ps Seepage Bed: — _Length Width /-Z Depth _Tile depth (top `/ No. of Line 2 1 / Seepage Pit: Inside diame r Liquid Depth No. of Seepage Pits Percent slope of land -- � Yo Distance from critical slope =• WATER SUPPLY: Private E�T Joint ❑ Community ❑ Municipal ❑ Owners name as li o E H 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Certified Tester, Soi NAME e o f C.S.T. and other information obtained from 011 , A (owner /builder). Plumber's Signature o-E MP /MPN$W* ' r -`/ "f Phone # Plumber's Address 1_ 14 4,d, PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. , - I i , 5 Rev. 9/78 ;....� REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 LOCATION: �� i/a, �lt l+ /� p /., Section 0; T; N,R�5 (or) W, Townshi or.Municipality Lot No. Block No. County IVIS O me Owner's /Buyers Name: �'�� 111 Mailing Address is 7,Z / )/u w ,/ % /4t i "`� '} 'f f' f) 4i . �':✓ d TYPE OF OCCUPANCY;. :A' idence x No. of Bedrooms � COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS (MADE: SOIL BORINGS ��` 7 � PERCOLATION TESTS SOIL MAP SHEET tx �3 NAME OF SOIL MAP UNIT PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM• I THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN /IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 / 5 - S S,L.rn , P — r6 � ` R . to (J ' '� ; P— a 9" - P _ /, p r , ' v C - c i SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES OBSERVED ESTIMATED HIGHEST TEXTURE, MOTTLING AND DEPTH TO BEDROCK IF OBSERVED IN INCHES B— 7 . 2 5 F ii 6 ,L /YI e;401 a a s_ C/ • , Y" J T�2 >� °15 3, B- '7a B- 1 PLAN VIEW (Locate,percolation tests, soil bore holes and suitable soil areas.) Indicate,on the plan the location and square feet of suitable areas. Indicate numbgr of square feet of absorption area needed, for building-type and occupancy �U .Indicate scale or distances. Give horizontal and vertical reference poi Wdicate slope. Art I . I � lib FJ �� '� k �- • l I K L1 , cL•�I I � �; -►E ' �E •;.... 01 4 1 i N r ; � , - r t - , � i. 4 ti ' f r J 2 � * 3 Q � J * � � IL u o i ¢j o + V a 77 �7 0' i L 0 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: -Labor and H Relations Safety and Buildings INSPECTION REPORT ngs Division ST. CRt3lzs, (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 216 8 5 v7 Permit Holder's Name: ❑City ❑ Village Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9200461 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P / L WELL BLDG. Air Intake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. If Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: EAU GALLE. u i . v8 l 6- r SE, a ! 1.40TH AVE Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R 05/91) Date Inspector's Signature Cert. No. Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water System: 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. 5 , • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check" it revision o previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name / Property Location eta r^,d j i ,CL?Y'$O�'`� 545 5 1/4, S Z7 T,? I , N, R/4 4 {or W Property Owner's Mailing A ddress Lot Number Block Number �� Cit , Stat Zip Code Phone Nu / m /� ber s Subdivision Name or CSM Number R I�W i w �� yPO� ( 7 /.J ) 6 7 — u77 t � / � g II. TYPE OF BUILDING: (check one) ❑ State Owned [] Cit ,,�� / Nearest Road Public 1 or 2 Famil DwelIin - No. of bedrooms o Town of LQt! 6pf�P✓ D ✓G - III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment /Condo 00 9 — /07 - ? -3D" X00 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 5 ❑ Hotel / Motel 9 ❑ Office /Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4_X of 5_ E] Repair of an System System Tank Only System - --------- Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11,KSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation �� O ® G /QSS / Feet Feet VII Capacit TANK in gallo Total # of r Prefab. site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank or Holding Tank r R ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ 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 Stamps) MP /MPRSW NO.: Business Phone Number: a> l 66 7/5' - 49194 - ? $ Plumber's Address (Street, City, State, Zip Code) Q l� W t ✓�� IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved anitary Permit Fee (includes Groundwater ate Issued i ng Agent Signature (No Stamp) Approved ❑ Surcharge Fee) Owner Given Initial Adverse Determination /U X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 05194) 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 a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4_ Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems m' ust be properly maintained. These tic tanks m 9 Y must be pumped p p Y p () b a licensed Y pumper whenever p p necessary, usual) ever 2 to 3 e Y Y Y rs. Y, a 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 - 3815. = To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use_ If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County / Department Use Only. Complete plans and specifications not smaller than 8 1/2 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; pump or siphon tanks; distribution boxes; soil absorption systems; replacement s stem areas and the location p Y of the building served; ed; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; doe 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 contamination investigations and establishment of standards. z8 x36 c ' Sale / -'�o a�a9c 2 Beol ZS x A69 Af / ''// me. w L Alfe.rnafel SD 5�.�. 27 T No. s e. 3 fi No L �rc�wN B r • Own Gov" aw.-,j j;// �Q�SOw �p 6� 2Y38 /oSAvG. X98- 3o -'19 7-9- /a Ave , W=onsin Department of Industry. SOIL AND SITE EVALUATION REPORT Page 1 of 2 - Labor and Human Relations Division of safety & Buitdngs in accord with ILHR 83.05, Wis. Adm. Code COUNTY %'r - C_Ctz I.x Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BW), direction and % of slope, scale or PARCEL 1.D. x dimensioned, north arrow, and location and distanoe to nearest road. APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION REVEWEDBY DATE PR&ERTY OWNER: iv tqQ G G Ili �,o�, PROPERTY LOCATION V- o k1 - - S , u GOVT. LOT %Z U4 S W 1/4,S Z T Zs ,N,R 16 E (WO PROPERTY OWNER'S MAILING ADDRESS LOT BLOCK i I swn. NAME OR CSM # I $ Z, S Q u vvr . Sow Z I — " CS M CITY, STATE DP CODE PHONE NUMBER OCITY CMU AGE ®TOWN NEAREST ROAD % ( QZM Q FIN S wa ( 61 y 3 6 - 3 3 $ (S LO `r* A-je (J New Construction Use P4 Residential / Number of bedrooms Z [ ] AdMQn b e*ft building j ] Replacement (J Public or commercial describe Code derived daily flow 300 gpd Recornrr ended design loading rale -- — bed, gPN try gpdffil Absorption area regked L4 Z9 bed, ft trench, it Ma*w design Wng mle - 2 . 1a - bed. . — trench, WW Recommended k0kalim surface elevations) LRL Sn N G 9S' ft (as relerred lo site plan bendtmarlo Additional design / sile aonsider�ttions i2 - riN 6 1L `y y d' g eVv C X18 o a Parent material s Mv'z�-4 tYv 1' -JNaN} Rood plain elevation, ti applicable it S = SUltable for sysl rn CONvBriT mk MOUNO N SOM PRESSUM AT-MW SYSTEM N FILL HOLM TANK u =U ae0 sisimn QS ❑u [$s ❑u I ®S ❑u cgs ❑u ®s ❑u OS Iffu SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Moines Texture Structure Corts;slartoe Bourtday Roofs GPD/ft in. Munsell 01 Sz. Coat Color Gr. Sz. Sh. Bed Tiench Z % 1R JIY - St I Z`15�h wt'ft- C- Ground 3 S2 -40 f5bk wt v fl- CS _ e, S elev. 9 8 .S n y LI0.�g 1gYR3/6 - S g6v. O 39 IV, \ Depth to r ins factor Remarks: Boring # �° �uRtn/G tsL, W � t OR�Ut1T Lai Sk� L Ground S �L S 1 S U P, L OF T S - 2 Q elev. �� TDK 01= C I S Av G 13 1 s 1 rLw kniting n I ` �Lt v - C tzs, e� factor S1 t �o B R - F phi t' �y 9 °,� — u8oa" tS tzwlb END Remarks: CST Name:-- Please Print Phone: Arthur L. We erer 715- 425 -0165 ess: egerer Soil Testing & Design Service -P.O. Box 74 River Falls WI 54022 g , Sgnate: Date: CST Number: 3- Z L[- 1.'7 -. M00576 PLOT P LAN Page Z of Z SCALE 1 "= 4 ' „ate �x�s'Iw 6 - �- > l y _ v2 o B.l �Z• �--- 10 b 3 � 40' SL'P`RC Vbvr Bor'mvn 0 P 9M cL q7- _ m i test Lvv e o f �9 - 3 k{ VVCtt_e . 1 -4 �fMCQJ_ PI x a. 3 g rn \ 'N �3 3- Z`?7 71 M O0576 CST Signature Date Signed Telephone No. CST # /? QA a-�� N loo- l p 1 m d �0 A Q) f � � t" A t )k tT � n �* O IZ I�RoPeR /A e o l� E 1 *, , �. Rev. 9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 LOCATI€ N S % k, Section _L ,T�&N,RItt (or) W Township or MunaiPaiIfy LotNo. , .Block No. County s iv me Owner's /Bows - Name: L'�iii4 ./Ira Z4JIAI e. Mailing Addnsss: 7-Z /1)r� t. Y'�� ,�.� �t r � f. =` �S� r �►, /� . ��,✓ TYPE OROCCUPANCY.. BesOence X No. of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS SOIL BORINGS S � �? - 9 / PERCOLATION TESTS -�" � ? - k/ SOIL MAP SHEET 95 NAME OF SOIL MAP UNIT 5-1 A SRf ffil' PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTEF INTERVAL MIN /IN BER / / 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 y p- 36 ,r n 'A „ 5 f�cv,4 r -,LPG$ (J C7 P_ p n /d SOIL BORING TESTS TEST TOTALDEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER,, INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES > G 7'5 9 ... , Af 8- >' -T"5 r PLAN- VIEW 11;.'ocate;percolation tests, soil bore holes and suitable soil areas.) Indicate,on the pla the 1 � on.aad,sgnare.feet of.suitableareas. lndical Rol c rsf square feet of absor tion area needed. for buildin .. P g type and occupancy , Indicate scale -or distances. Give horizontal and vertical reference poin!s�ricate slope. I , 3 l � � A 1 0 41wr ♦ . 1. le Aj „ f STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix ( County OWNER/BUYER MAILING ADDRESS 2 3 S /d /✓Y�. PROPERTY ADDRESS L�3Q ICA'Gl n Lei (location of septic syste ) Please obtain from the Planning Dept. CITY /STATE 130 �- PROPERTY LOCATION 5 1/4, SW 1/4, Section 27 , T 23 N R 1 6 W TOWN OF 'CUc u 90 ST. CROIX COUNTY, WI SUBDIVISION AM LOT NUMBER AM CERTIFIED SURVEY MAP , VOLUME IZ?, PAGE 2- 7.41, LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 09/15/94 13:53 $ COUN CLERK Z002/002 y 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 C? d (J" // ZOY— ©'"J Location of property S 1/4 5CO 1/4, Section 2 , T 2- E* N -R Township ZQ u 00//6 Mailing address _tea 1 01 w )' , 6, .211 . Address of site -if 3'? e, _ 7 1 - subdivision name Lot no. Z other homes on property? Yes X No Previous owner of property Total size of property 20 re5 Total size of parcel Date parcel was created Are all corners and lot lines identifiable? _Yes No is this property being developed for (spec house) ? Yes ,k" No volume lo f; and Page Number Z36 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 CERTIFYCATION 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($) 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. .5097 5 , 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. iL Si nature o Applicant 41caJn 7/9 Zq Date of Signature Date of bi4Aature • ~ DOCUMENT NO. WARRANTY HEED THIS 3,ACE rESERVED IiOR RECONDIND DATA STATE BAR OF WISCONSL`` FORM 2 -1982 509'785 ' REGISTERS OFFICE Nancy Gehrig, a single person .. - - - -- - - -------- - - - - -- --- - - - --- ;T. CR OIX C0.. 1111 -- ------ ---- -- - --------------------------- ..._......... Rec'd for Record .. - - -•- - - -- --- - - -- - - - -•- - - - -- - - .. .... _ _ ...... . . .......... ................... DEC 1 1993 con inrcommon joint Dtenanta,. and not - as • i! 8t 30 -A. M ............................................ ....__.......I---- - - - - -- ......................... - -------------- - - ---- ...................... -- .................... . ------- -......................... ........................ ....... •---- • - -••- ..._ .------------ .------------ - - - -- - - - - - -- - •- • - - - - -- 1 i i .. ... ............ ............... ................ ...................................... RETURN TO I� Q -- I the following described real estate in 19t _a_. .r9.1_a -_.___ - - - -_- County, ` = -- — — -- - - - - -- -- �) State of Wisconsin: Tax Parcel No: .............................. Part of the Southeast Quarter of Southwest Quarter (SE1 of SWk) of Section Twenty -Seven (27), Township Twenty - -Eight North (T28N), i Range Sixteen : Est (R16W) more particularly described as Lot of Certified Survey Map, filed November 24, , 19 93, Vol. 10 of CSM, Page 2711 Document No. 509582 Office of the Register of Deeds 4 for St. Croix County, Wisconsin. ii tRANSFEh , i FHB i t o i This ------- is --- __-- n t homestead property. j � X4W (is not) ;i Exception to warranties: Easements and restrictions of record. j Dated this ----- -- --- ----- ----- - --_-- day of -------------------- . 124f/"- ... 19._.. . - ...--••--...(SEAL) - -- -!��--�., (SEAL) 1 _....7 Nanc Gehrig ....(SEAL) - -- - – (SEAL) s AUTHENTICATION ACKNOWLEDGMENT I� j Signature(s) ____ STATE OF WISCONSIN ----- -- -- -- St. Croix •-- County. I i t authent' Aed this -------- day oL-- ______ ____ ________ _1 ------ Pe rs onally came before me this ..�.�_...day of �t �- _- •- - •-. °•.• -- - ------------ • 19C�_ the above named - -- - - - - -- ----- - - - -_- -- - - - - -- -- - - - - -- ----------------- - - - - -- Nancy Gehr g - - -- ------ • --------- - - - - -- ------------------ •............•• - - -•- '--------------------•----------•---------------------------------- •---- - - - - -- ------------------ •-- •-- •-- •------ •---- • - - - -- ---- ••......•-- •---- •---- ........ TITLE: MEMBER STATE BAR OF WISCONSIN (If not, ..................... authorizedb -- ..................................................... •.. - •---................ y $ 706.06, Wis. Stats.) to me known to be the person ............ who executed the faft-going inst nt and sck t i THIS INSTRUMENT WAS DRAFTED BY � _ 1 Thomas A. McCormack /� •�) •nww�MM