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Parcel 026-1049-95-000 02/15/2006 09:03 AM
PAGE 1 OF 1
Alt. Parcel 17.30.18.255 026 - TOWN OF RICHMOND
Current Xl' 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
O - KRAMER, DAVID A
DAVID A KRAMER
1551 100TH ST
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description ' 1551 100TH ST
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 17 T30N R1 8W 40A NE SW Block/Condo Bldg:
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
17-30N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 846/47
07/23/1997 824/404
2005 SUMMARY Bill Fair Market Value: Assessed with:
95696 236,500
Valuations: Last Changed: 06/30/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.000 13,500 97,500 111,000 NO
UNDEVELOPED G5 2.000 2,700 0 2,700 NO
PRODUCTIVE FORST LANDS G6 37.000 89,100 0 89,100 NO
Totals for 2005:
General Property 40.000 105,300 97,500 202,800
Woodland 0.000 0 0
Totals for 2004:
General Property 40.000 105,300 97,500 202,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 210
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
R
STC - 104 '
AS BUILT SANITARY SYSTEM REPO
x
OWNER S1 C;+
ADDRESS ` f QQ
t ~ ` 4
SUBDIVISION / CSM# LOT #
SECTION )_T3_N-R ► $ W, Town of c.~ ~nor~/
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~ou,p
q 23~ _ __Qwe`'
Cr~
ii
l~
y INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
%GVld It BENCHMARK: % rah ~i~rJ 5 . u: l 1 4 c,(, L l U u, 2Q,
` I Y
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: W -C,45 Liquid Capacity: /pG(>
Setback from: Well S~ House ~Other
Pump: Manufacturer Zol),, Model# s3 Size
Float seperation to Gallons/cycle: I
Alarm Location
SOIL ABSORPTION SYSTEM
Width: S Length l0() Number of trenches /
Distance & Direction to nearest prop. line: /So W
Setback from: well: House 170'1
i0 '1 Other
ELEVATIONS
Building Sewer ST Inlet ~S 46 ST outlet ,
PC inlet !"I PC bottom 81 7 Pump Off 5__2.7G
Header/Manifold Bottom of system
Existing Grade 69,G Final grade
DATE OF INSTALLATION:`'' 1
PLUMBER ON JOB: o crP /
LICENSE NUMBER: V-(05 3-1-
INSPECTOR:
3/93:jt
LWC"XpA;ar rtWVWjgy,17. 30.18. ATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
199895
Permit Holder's Name:
❑ City ❑ Village k Town of: State Pla
n ID No.:
IRICMOND
v.: Insp. BM Elev.: BM Description: Parcel Tax No.: Q -1049-9
26
--000
TANK INFORMATION ELEVATION DATA A9300300
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic tl J, 9 x
Benchmark ioo
106,
Dosing
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet 8S d 2-
rit
TANK TO P/ L WELL BLDG. Aier
Intake ROAD Dt Inlet
la•o9 k5/7
Septic 7aJS ' aw, NA Dt Bottom /5,5 76
Dosing NA Header/ Man. 617, Sy
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number 3 tia GPM
TDH Lift ya 0 Friction Systtem1iA TDH I`AI Ft
Forcemain Length I I ~ Dia. 1)1; Dist. Towell'7
SOIL ABSORPTION SYSTEM
BED/TRENCH Width / Length i No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN I N ~dO / DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O CHAMBER Model Number:
System: `1 /rjU ~Zv dad /i 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 E] No ❑ Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: RICHMOND 17.30.18.255
a
{fit ,1 ~C + f i ti~,. e•
Plan revision required? ❑ Yes E~ No i
Use other side for additional information. Q.0
SBD-6710(R 05/91) Date I `pe r' Signature Cert No.
C3 DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
STATEISIT R PERMi #
-Attach complete plans (to the county copy only) for the system, on paper not less than 8f x 11 inches in size. C re si eviousapplication
-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
r a~ WE Y4 Sko %a, S 1 ~ T 3d AR R 16 E Or) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
t 42 4 5 7`• ►V /4- nr
CITY, ATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
San, S401~ 71s .s/40 iv
L-i
CITY NEAREST ROAD
II. TYPE OF BUILDING: Check one
( ) State Owned
21 VILLAGE ~Q
/rsoa 1 CyQ yh 5~
OF:
❑ Public Z&1 or 2 Fam. Dwelling-# of bedrooms -2w-. PARCEL NUMBER(S)
III. BUILDING USE: (If building type is public, check all that apply) t 308 ?,55- )A i_ I, _ '
1 El Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 80 Mobile Home Park 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. XNew 2. ❑ Replacement 3. ❑ Replacement of 4.E1 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 3 'Soo 0.6 2 9L . 3 9 Feet 14. 3-Feet
VII. TANK CAPACITY Site
in gallons Total # of Prefab. Fiber- Exper.
INFORMATION New P-xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holdin Tank C10 loco 7 e A h c
Lift Pump Tan goo SOU L.,
Vllll. 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/M o.: Business Phone Number:
~o.r ~ Imo. 45e '15- 47S QI7J_
Plumber's Address (Street, City, State, Zip Code):
D4 S Le* Fell S W .54oz-
IX. C NTY/DEPARTMENT USE ONLY
❑ Disapproved Sani Permit Fee (includes Groundwater Date Issued issuing Agen ig re (No mps
proved El Owner Given Initial ~ Surcharge Fee)
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety it Buildings Division, Owner, Plumber
INSTRUCTIONS >
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by, a.licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
It. 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)
SEPTIC TANK MAINTENANCE AGREEMENT ~
St. Croix County
• a
OWNER/BUYER rt
ROUTE/BOX NUMBER Fire Number S--S- I
r
CITY/STATE IP rt
PROPERTY LOCATION:Section, T=N, R_= W,
Town of 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 licens'ed' 's'ept'ic tank pumper. What you put into
the system can affect the .unction o_ t e septic tank as a treat-
ment stage in the waste disposal system.
St. Croix County residents may be eligible to recieve 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 's't'erns agree to keep their system properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a mater 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.
H
I/WE, the undersigned have read the above requirements and agree 0
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, asset by the Wisconsin Depart- w
ment of Natural Resources. Certification form must be completed •d
and returned to the St. Croix County Zo g Office within 30 days
of the three year expiration date.
SIGNED
DATE °
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
1-
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 zesale by
owner/conttactot,(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.
Ownet of property • cz~.rti~2
Location of property =_l/4, Section k T __Z.4.N-R_L1.-Y
Township
Mailing address
Address of site
Subdivision name
Lot number
Previous owner of property
Total also of parcel n~
Date parcel was created
Are all corners and lot lines Identifiable? X an No
Is this property being developed for resale (spec house)? as No
volume K„and Page Number as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THS FOLLOWING:
A WARRANTY DEED which Includes a DOCUMENT NUMSSR, VOLUME AND PAOS 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 Certlfled Survey Map, the Cettifled Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described In
this Information form, by virtue of a warranty deed recorded In the Office of
the County Register of Deeds as Document No. 4 ~ 9"71 2 t and that t (we)
presently own the proposed site for the sewage disposal system (Of I (we) have
obtained an easement, to tun with the above described property, for the
conatruc~-1~ n of Id system, and the same has been duly recorded In the office
Of the~o n!y gieter of Deeds, as Document No. h1a1"Z 1
S gnalute of owner Signature of co-owner (If Applicable)
-7 1176
ate of 119hatuto Date of Signature
1 3
EPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
JDUSTRY, DIVISION
4BOR BOX LIMAN REDLATIONS PERCOLATION TESTS (11J) MADISON W 53707
(H63.090) & Chapter 145.045)
OCAT ON: SECTION: OWNSHIP UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME:
N1 E 1145814 ► 7 /T 3o N i (or) W N
OUNTY: OWNER'S U ER' AM • MAILING ADDRESS:
DAVID ;7, C R014 KRAME ,A?4 r 37 0 i
3E DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
gResidence NA KNew ❑ Replace
ATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: S STEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
[K"S ❑U IBS ❑U ®S ❑U ❑S ZU []S ZU I TASNCN SX(
Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
nder s.H63.09(5)(b), indicate: CLASS I Floodplain, indicate Floodplain elevation: NA
PROFILE DESCRIPTIONS
ORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
UMBER DEPTH IN, OBSERVED EST. IGHES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
0-5" QI SL Gy 3. 5L 14.24" Ran 51- wlrh Sr
8 oo. 89 NONE 88 2q-32 RB« 5 r 32- R$., r
Q p Q 0-8" 41 SL 11" 6p On 5L 19.20 9. b . w r 1,
4 2 V ~0 q8.74 I+~ONr > 86 28-40 Rah 58r 9o-86 3r
O-s" (315L 5-18" &Y 13n SL 18 25 5L w.T1 sr
.3 q 0 qq. 0 NONE > 70 25-3G A8r 5jr 3G- 40 gr
~q QQQ 0-9 131 61.4-12 &Y(3. SL ►2-~~ RBn SL w.-►l 9r
3 B V ~~.95 NONE > SQ 2a-EQ RRn SS•r 32-SS 3r
q0 _ QD 0-3 1315[ 3-/6. Gy&,SL 118 51, wif; 3r
9 7.(y N 0IV J= a4-30 ae. s, ,r 3o-QO r
3-
PERCOLATION TESTS
TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
IUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RI D 2 PERIOD PER INCH
► q 0 5 V
2 44° No e- 10 5`a' S'l 8
3 461, rv 0 rv e 10
~n 5 `j' S 8
OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hon-
,tal 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
land slope.
YSTEM ELEVATION 916,34
I
I _ I i
i- I I I I TP_
- I
I -
I II i ~ .p
~REA ~ >z I
' P21 I I
o~ i I i► I ; , I
{ I
I
i
I
Irori C1.14
pak reF I.___ i I
I I a5 0 MC114
I
i ss14 _ELL_1.9_
10
the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Iministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
4ME (print : TESTS WERE COMPLETED ON:
Yi C 9-?1 -8e
DDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
1042- 5. 'Mat;, 577 tvc, Faih Lji'5 -54.,Z2- '?IS-425- Z11 -5
CST SI~NATURE:
STRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
LHR-SBD-6395 (R. 02/82) -OVER -
p~..e 3 ~ ~ 3
N F-
~ W
H LL
W
115
34
- 110 -
ITY
32 -10VE 5-
30 100 -
95
28
90
28 85
EFFLUENT 24 80 MODELI
and Q 75-.MODEL- 189
DEWATER/NG = 22 70 165
V 20 65'
s"A
Z 18 60
55 _
16 50 MODEL
O 163 MODEL
F- 14 45 188
12 40_
35 -
10 MODEL
30 137, 139 MODEL
185
8
25
6 20- I MODEL
MODEL 161
15
11 I 4 97
lo
2 GDEL
5 55,
57,59
0
GALLONS 10 2 30 40 50 60 70 80 90 100 110
LITERS 0 110 160 240 320 400
FLOW PER MINUTE
z o
so awn+w
• PAGE 2- OF
PUMP CHAMBER CROSS SECTION AKID SPECIFICATIONS'
VENT CAP
40C.I. VENT PIPC WCATHEK PROOF APPROVED LOCKIN&
JUUCTIOW DOX MAWHOLE COVER
2S' FROM DOOR, It•MIIJ.
WINDOW OR FRESH I
AIR INTAKE 4 2 .9;
GRADE I y MIN.
l0' MIIJ. .
COWDUIT
PROVIDE I
IAILE T ~ AIRTIGHT SEAL I I I ~ ~
I III v
APPROVED JOINT A I I (I APPROVED JORITS
W/C.T. PIPE I III W/C.I. PIPE
EXTENDING 3' I II ALARM EXTENDINf. 3'
ONTO $0610 %OIL I I I ONTO SOLIo 6011
e I I
i I ON
c I 1
I
LLCV.51 Q6-7 FT. PUMP --i
~ OIi
0
S 1 CONCRETE DLOCK
13200p, Awito
RISER EXIT PERMITTED OWL1 IF TANK MANUFACTURER HAS SUCH APPROVAL. ING
SEPTIC 5 PE C I F I GAT10KI S
DOSE Lw~ ee I1 S NUMBER OF Doss: PER CM
W6S TA p1A►IUFACTURCR:
TANK WZE: 800 GALLOWS DOSE VOLUME I 1)
'3
ALAR MAIJUFACTURLR: Irl CC FOR INCLUDIW6 BACKPLOW: 6ALLONs
MODEL WUMBCK: 01 U CAPACITIES: A= a0 INCHES OR l GALLONS
SWITCH TyPL: M..~ . V e. 5z -.7-INCMcs OR 3~• 4 G66LOWS
PUMP MANUFACTURER: Z 0e, Utk c, =_1.Q_INCHES OR I !3 GALLONS
MODEL NUMBER: ft J- 63 D- J1 INCHES Olt 2119-4 GALLON6
SWITCH TYPE' M~vCwr;4 MOTE: PUMP AWD ALARM ARE TO OE
MINIMUM DISCHARGE RATE -GPM IN5TALLE0 ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE OETWEEM PUMP OFF ALID.DISTRIDUTIOW PIPE.. 10,14 FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . FLET
+ „445 FEET OF FORCE MAIN X -212YofLFRICT101J FACTOft.. FEET
TOTAL DtIWAMIL HEAD = FEET
r!
IWTERNAL DIMENSIOW' OF TAWK: LEW(,TH -E0-"J-;WIDTH .;LIQUID DEPTH 4
2
- 1 8. 30A
0
SIGNED: LICENSE NUMBER: 3 3 8 DATE; 9 0
r
Fresh Air Inlets And Observation Pipe 100Q--- Approved Vent Cap
r
Minimum 12" Above
Final Grade 20 - 42" Above Pipe 4" Cast Iron _ I ~~i:P.Zt/II Y .
Q .
To Final Grade Vent Pipe N1Q1Q53~7
- - Synthetic Covering
MIA. 2" Aggregate
Over Pipe
Distribution - Tee
pipe -Lo--0 0 0 0
6" Aggregate 0
Beneath Pipe
o EL. 9 Q, 39
YVOr~~` 4O Acre. Qp,"lrcl
1320 T-
a1 6YMde the "bast of 24
clerk Trcc- 4fs-,** el, Top
ldo.oo'
.Ss~ t
ai a2
P1 - -
V4 ~ >•cplae~rw.~
~I ~ Rrta i
c o P 63 100/
M - (o"
197-
pq 65
e,, 3 145 i
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DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LPBOR & HeJMAN RELATIONS DIVISION
.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
M ISON yv1 5 707 State Plan I.D. Number:
NW ,ST 4 , , ec . 17 , T30-R18 ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of Richmond
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound
00th St.
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
David Kramer 142 3rd St. Hudson WI 54016
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
Carl P Heise 3378 St. Croix 128709
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CA TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVDED:
{ ❑ YES ❑ NO ❑ YES ❑ NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET:
❑ YES ❑ NO ❑ S O NEAREST 10
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: VODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET:
PUMP ON AND OFF ` ❑ YES ❑ NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil i-Akre at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wirNAstruction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTE
WIDTH: LENGT NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
BED/TRENCH y~ TRENCHES: MATERIAL: PIT DEPTH:
DIMENSIONS 9
GRAVEL DEPTH FILL DEPTH DI `PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. LET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET:
NEAREST 1111-
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST----*
Retain in county file for audit.
Sketch System on
Reverse Side. SIGNATURE: TITLE:
SBD-6710 (R. 06/88)
- SANITARY PERMIT APPLICATION
rlJ DILNA In accord with ILHR 83.05, Wis. Adm. Code Cou
STATE SANITARY PERMIT
#
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ~a 6 0
8% x 11 inches in size. Check If revision to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
a, j a, e r t/aS j Y4, S) T-1 N, R t e 1r(or) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
4 24 f,t S T.
CITY, ST?TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE OF BUILDING: (Check one) CITY ff NEAREST RkOAD
❑ State Owned ❑ VILLAGE Rich /r7Lry0~ 1od f S~
TAX NUMBER(S)
❑ Public ~1 or 2 Fam. Dwelling-# of bedrooms ~ PARCEL =W QF:
III. BUILDING USE: (If building type is public, check all that apply) I 3o 1 zss-
1 ❑ Apt/Condo I
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 El Merchandise: Sales/Repairs 11 El Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. X New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 9 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
130 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) C~ ELEVATION
450 q 2 Q Feet f,.75Feet 19 VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank oo 00 1-1 LR_ Q I D
Lift Pump Tan OO 00 WC,'CkS
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) o.: Business Phone Number:
Loci 3. 7t5 5-Z 75
Cap p. jq elst
Plumber's Address (Street, City, State, Zip Code):
to 4 't S, t4 ck, I u ei 611 l r "s 5' a
IX. COtVJN TY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued issuing ent Signatur (No Sta
Approved ❑ Owner Given Initial Surcharge Fee)
Advers Determi nationi
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
--7
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years. ,
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
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.
Vlll. 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 it a
required by the county; E) soil test data on a 115 form; and F) all siring 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)
Fresh Air Inlets And Observation Pipe -=G T
~ or
~~j--- Approved Vent Cap t-1f
Minimum 12' Above
Final Grade
~i-lI~SaN_..tiTf ..~4
20- 42 Above Pipe 4' Cast Iron
►'G S 1 ~t:7.lt/II .Y .
To Final Grade Vent Pipe
Synthetic Covering
min. 2' Aggregate
Over PP lps
Distribution - Tee
Pipe 0 0 0 0 0
6' Aggregate o
Beneath PI Pipe
r 4, ~/P
o 4
J~
NOri~ qO 9Gre. Qa+C~~
13 2 o r
Q~' V2QZ~R~ t tror.. n.;~~
a~ ~YadEi rve- babL o4 24 v
os.k 'Tree- 4s-sW„,e *I. 7u('
a p 160 .00
~t
j rcpl.cc
i Aran
o `o I 92; 63 ' i0o/
14 7 a- - i1
pq _3~' - 6 _ _65
' o.c. Mo.w
J
2zo' 2901 ° 800 C.-\ p. ~ clnu 6"
i o 1 oo0C4d1 Scr-I;c
J! / O
I
PACrE -2- OF 3
PUMP CHAMBER CROSS SECTIOIJ AMD SPECIFICATIOAIS
VENT CAP
-7 4"C.I. VENT PIPE WEATHEK PROOF APPROVED LOCKING
.IUUCTION DOX MANHOLE COVER
25' FROM DOOR, 1Z•MIU.
wINDOW OR FRESH I
AIR INTAKE 4 2 A I
GRADE I `I" MIN.
I
le• Mlu.
CONDUIT
WAIN. \
11~ _
PROVIDE I
INLE T ~ AIRTIGHT SEAL
I I v
APPROVED JOINT A I 1 1 APPROVED JOIN
W/C.Z. PIPE I III W/C.I. PIPE
CXTCNDIW4 3' I II ALARM CXTENDIN6 3'
ONTO 501.10 SOIL I I ( ONTO SOLID i0
e I I
i ON
C I I
LLCV.SZSe, FT. PUMP--~ -_J
~ OFF
D
S 9 COWCRETE BLOCK
3" APPR
RISER EXIT PCRMIITED ONLY IF TAIJK MAWUFACTURCR HAS SUCH APPROVAL. gEpplK
SEPTIC E 5PEC.IFIC. AT10K.1S
DOSE
It S
TANKS MANUFACTURER: C NUMBER OF DOSES: PLR DAy
TANK SIZE: g~ 6 GALLONS DOSE VOLUME
ALAftlrl MAIJUFACTURGR: CCt~?r IIJCLUDII46 OACKFLOW: 'L3278 GALLON!
11
-
MODEL NUMBER: DL U CAPACITIES: A= 20 IWCHE5 OR 364 CALLOW:
SWITCH TyPL: N~ cy CL V,/ 8 a ?-_IWCMEt OR G( LLON:
PUMP MAIJUFACTURCR: Z of IItk C.10 - IWC.HES OR CALLOW
MODEL NUMBER: N- S3 D- 11 INCHES OR 218. 9 GALLON
SWITCH T`JPE: M~~twy: MOTE: PUMP AMD ALARM ARE TO BE
MINIMUM DISCHARGE RATE 2 GPM INSTALLED ON 5EPARATE CIRCUITS
VERTICAL DIFFERENCE DETWILIJ PUMP Off A1JO.015TRIbUTIOM PIPC.. 10,14 FEET
t MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . PM FLET
+ ~4S FEET OF FORCE MAW X --2i_FYoFT.FRICTIOU FACTOR.. 67_ FEET
TOTAL DtIWAMIC HEAD = ILZI FEET
1 99
INTERNAL DIMLW51OWt OF TANK: LENGTH WV ;WIDTH r LIQUID DEPTH
f' 2 9 p'
I = i8 1
r~„ < . LICE115E NUM6ER: 3 3 DATE:--"
I SIG LIE D:
I
gape- G ~ 3
cc w
W W
F- U.
W
11
34
110-
'0"h/TY 5
32 -10IE 5-
30 100 -
95
28
90
26 85
EFFLUENT 24 80
MODEL
N
and Q 75 MODEL 189
DEWATERING = 22 70 165
V 20
~ --65--'-
Z 18 60
}
55 _
J
16 50 MODEL
O 163 MODEL
F- 14 45 188
12 40_
35 -
10 MODEL
30 MODEL
137, 139 185
8
25-
6 20- I MODEL
I
15 __MODEL 161
1 I is 21 4 .97
10
MODEL
2
L
5 5Q 55,
57, 59
0
GALLONS 10 2 ) 30 40 50 60 70 80 90 100 110
LITERS 0 0 160 240 320 400
FLOW PER MINUTE
s
L..il....Nla~ckt
a.................. ....asra~pe~..~s..si~a~l.e..maa~ Rr
} ;;t
....4aMu
Witas"eth, That the a.M Vie, flea a Va1WN as.aNa.ttiii»
{i ee.via to oraabe do foliowiag datalbed "d Iowa In .ft&..!Cm1i(. forw " z
County. stab of W, - -naia:
i4 • ~b.mr.~.wlRarsw~+riree r
f Tas Poll
"o Northeast 1 /4 of the Soudmest 1/4 of Sacdon 17, Towaddp 30 Nottly
By accephuxe of this deed, GrwAm and dWr aifooseem and afidpM, yR!~ 10
fouowify; restrictive ~oveamb as to the use of to pt+oparq►'
,u
1. The property wiH a* be wed for resid=W wad apiaditW,purpaa.
2 No business enterprise dual be conducted on the properly swept a, mg tek; c
incidental to its reidenW and apiar Uld trse. ~ <
3. The shill be no CoQlfnwdal rai ft or brafidinS Of dop tee tee p+t> I• ~w r
`f Grantees agree no awe than 3 dop shag be rapt ao d~ pelopol'q►
aon~operatioaal hidNOr;
4. There shall be no darap of unused or
i't
on the premises Which are tat used at Is" oo a tlwotMl{tw/isi. `
III
' This .i&..nQt bomeseld d Property.
(is) (is not)
TagetbW witb all wad singular tie beraditaments and appurtmawn ansa to kkaslosi
And GYantOY
wanwft that the tide h, +„od. indefeasible in fee simple and free sod clear of ansumbfiOiM e> ..INUA p E
coning ordinances and easements of record
and will warrant and defend the Same.
Dated this ~/7" day of qmly................................., 1l r ,,1 "yp
..........(SEAL) ..(SItAL)
Lore erk•
I!, .
a/k/a Lrrain. A. Merkt
.................................(SEAL) ..........................................(iT)iAL)
.F,
• •
AUTHSNTICATION ACSNOWLSIDOfrIBUT
Sicnatureol) .of..Lor.>:a.ine..Merkt..a/.k; a... STATE OF WISCONSIN
Lorraine A. Merkt a.
......................................County.
II, authenticated this /rjd..dar nf J1 day
19.8 Personally came before me this
.019 the above named
. . .
•...53.....Fr w..iiA~ni€1f1
TITLE: MEMBER STATE BAR OF WISCONSIN
X_
7 ~ K 'AlCAR to me known to be the person who executed the
foregoing instrument and acknowledge the name.
THIS INSTRUMENT WAS DRAFTED BY
Bakke....No="...&..~S.ahumas~her..... SA C . .
1200 Heritage Drive •
New-4RLch=nde..IAT1.....540.17 Notary Public . ..............County. Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (if not, state expiration
are not necessary.) date: 19.........)
•Nam ss .t passes winning in any capacity dwuld be typed or printed blow dwir simnswre.
wwsal►xrt Darn .TATS Of VINWXM wwonds lama 1116ek cs.
t t~ 1Ni ee66 ' ; ~
EPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
JDUS DU3T"riV, 1 C DIVISION
N
AROR AND PERCOLATION TESTS (115) MADISON WI 969
UMAN,RELATIONS
(H63.090) & Chapter 145.045)
O CATION: S I ECT-U'. OWNSHIP MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME:
t E '/4 Sg14 17 /T,301 X (or) YV N
OUNTY: OWNER' U ER' AM • MAI N ADDRESS:
1404 r T 0 I 1
'E DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: [K New NS: PERCOLATION TESTS:
gResidence [KNew ❑Replace 2Q 8 A
ATING: S= Site suitable for system U- Site unsuitable for system '1
:)NVENTI NAL: MOUND: IN-GROUND R UIE: SYSTEM-IN-Fl LL HOLDING TANK: RECOMMENDED SYSTEM: (optional)
Z S ❑U zS ❑U zS ❑U EIS ®U EIS ®U 1 TR6hCN SX(
Percolation Tests are NOT required DESIGN RATE: FFloodplain, any portion of the tested area is in the
nder s.H63.09(5)(b), indicate: ~'L~ SS indicate Floodplain elevation: NA
PROFILE DESCRIPTIONS
ORING TOTAL -DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
UMBER DEPTH IN, ELEVATION OBSERVED EST.HIQ HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
I_ 0-5" GI SL 5-14 "Gy 13m SL )4.24." RG" SL t.,~rA sr
8 ~0, $4 NON - 7 88 24-32 Al& 5 r 32- f3s" r
Q O-8" 1 SL 8-►4" fay fan 5l 14'28 P wcr sv
i 2 86 98.7 NONr5 > 810 28-40 ROn 53r 90-86 3,
O-s" O! SL Gy On SL 18-25 n SL tir,T t, s r
3 9 0 q9. Q NONE o
> 7 0 25-3G 9 8n 5 j r 36- 90 9r
QQ 0-9 1131 SL 4-12 Gy(3,,S[yL 12-~~ Ri3n SL w,~1 gr
8 6 Q I 1Q,9 NO NF_ > VQ .?-~a R13n S.T r 32-SS I -
97• NO nt~ QO 0-3 (31-5L 3-/G CvySoSL /(0-~4 A8~. SL wctL gr
'4-30 9,13v, s v- 30-40 r
3-
PERCOLATION TESTS
TEST DEPTH. WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
(UMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD PER1002 P R PER INCH
I 9 11 0 5 4 4 2
Z 49„ 1vo e 0 54' 7P "
8
3 46 rvoN (a" 5 S
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-
ital 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
land slope.
YSTEM ELEVATION 9~.34
j
A~l
. - I i
! e r I I _I
_ _ TN
_ r i.. _...r.- f
.._1. - - -
j ' H
24" dk re
00-54,102
the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Iministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
>ME (print : TESTS WERE COMPLETED ON:
Yi 9- 21 -8e
DDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
1042 S. Matti ST tvc~ dal "s 5dP2~ 14 ')15-425-21?s
ST SIGNATURE:
STRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
LHR-SBD-6395 (R. 02/82) - OVER -
I
I
it
I
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
ICI i
OWNER/BUYER
ROUTE/BOX NUMBER 1 HZ-4 L ez n~_~~. FIRE NO. \-575~ V
CITY/STATE ZIP <z)\ e.,
PROPERTY LOCATION: _~1/4 'SW /4, Section , T~N, R~M_W,
Town of .nmN , St. Croix County,
Subdivision _ , rof 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 syst m, which was in operation
prior to July 1, 1978. St. Croix County accepte this program in August of
1980, with the requirement that owners of ALL NEW iYSTEMS agree to keep their
systems properly maintained.
The property owner agrees to submit to St. Croix Co my Zoning a certification
form, signed by the owner and by a master pl mber, journeyman plumber,
restricted plumber or a licensed pumper verify ng that (1) the on-site
wastewater disposal system is in proper operatin condition and (2) after
inspection and pumping (if necessary), the septic t nk is less than 1/3 full of
sludge and scum. Certification form will be sent ap roximately 30 days prior to
three year expiration.
I/WE, the undersigned, have read the above require ents and agree to maintain
the private sewage disposal system in accordance wi h 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 Zoning Office within
30 days of the three year expiration date.
SIGNED
DATE 1~ I 1 1~
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
II
+ 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 _ ~ e"S:Sn
Location of property _tLF,_1/4 _'-e%W 1/9, Section
Township
Mailing address
Address of site
Subdivision name
i
Lot number
Previous owner of property
Total size of parcel 2 Ass
Date parcel was created `j I lam' $9
Are all corners and lot lines identifiable? es No
Is this property being developed for resale (spec house)? as No
Volume and Page Number 2' - as recorded with the Register of Deeds.
_INCLUDE WITH THIS APPLICATION THE FOLLOWING:
VARRAXTY__IlBEIr which Includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and
the SBAL OF THE REGISTER OF DEEDS. In addition, __a__ certified survey] if
available, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Certified Survey Map, the Certified Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in
this information form, by virtue of a warranty deed recorded in the Office of
the County Register of Deeds as Document No. ',A~Aa -?t P_ ; 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
construe o of said system, and the same has been duly recorded in the Office
of the o ty R 1s r of Deeds, as Document No. H%4:2-7)-_:>
lie
Signature of Owner Signature of Co-Owner (If Applicable)
Date of Signature Date of Signature
v.
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1 - 1982 THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
449712 Svc►. ~4 6PAsE 47 REGISTER'S OFFICE
This Deed, made between Lorraine__Merk... a/k/a ST. CROIX CO., WI
Lorraine---A Kerkt---------------------------------•- Recd for Record
Grantor, JUL 17 1~09
- .
and- _'-David_A-•---Kramer-,---a---sing_Le..man---------------- o 10:3 AM
Registerof Deed
Grantee,
Witnesseth, That the said Grantor, for a valuable consideration
RETURN TO
conveys to Grantee the following described real estate in .S_ts.._Cr-oiX...........
County, State of Wisconsin:
Tax Parcel No-
The Northeast 1/4 of the Southwest 1/4 of Section 17, Township 30 North, Range 18 West.
By acceptance of this deed, Grantees and their successors and assigns, agree to the
following restrictive covenants as to the use of the property:
1. The property will only be used for residential and agricultural purposes.
2. No business enterprise shall be conducted on the property except as may be
incidental to its residential and agricultural use.
3. There shall be no commercial raising or breeding of dogs on the property.
Grantees agree no more than 3 dogs shall be kept on the property as pets.
4. • There shall be no storage of unused or non-operational vehicles or machinery
on the premises which are not used at least on a seasonal basis.
-S zv r&~
This _is_._rmt homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And-----Grantor------
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except municipal
zoning ordinances and easements of record
and will warrant and defend the same.
Dated this /T-'--•------------------------ day of "ly
x oLt..2c~rc~__ a (SEAL) (SEAL)
Lorraine Merkt
a/k/a Lorraine A. Merkt
(SEAL) ---•--------------------------•--------•------...-•-•---------------(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature0j) .of-_Lorxaine.-Meru::~ __.a/-k/.a._- STATE OF WISCONSIN
Lorraine A. Merkt SS.
--------------------------------------County.
:authenticated this ~_-day ouly_-_---____-, 19.89_ Personally came before .me this ................day of
1 19........ the above named
--C~------------
-
G•,:__E,___Norman
TITLE: MEMBER STATE BAR OF WISCONSIN
? 3MiKX~l--~---y-u-------'-------------------------- -
~7YXi to me known to be the person who executed the
foregoing instrument.and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Bakke,---Norm,ln_._&__ Schumacher,-_- S . C,
1200 Heritage Drive
-New--- Richmond,- W1-----540.17 Notary Public -.-----.-------------...------------------County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (if not, state expiration
are not necessary.) date: 19
*Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Leval Blank Co. Inc.
FORM No. 1 - 1982 Milwaukee. Wis.