HomeMy WebLinkAbout040-1148-10-000
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L~,%~C(!AT1AN: TROY 13.28.20.576)
-WisconsinDepartmentofIndustry, PRIVATE SEWAGE SYSTEM County:
Labor a n Human Relations INSPECTION REPORT ST. CROIX
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 199817
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
ItEITER, LEO, FREDERIC & MARY TROY
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/C»I 0~i...) e c~ . 040-1148-10-000
TANK INFORMATION ELEVATION DATA A9300218
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark boa . /06.
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet 7,97
Vent
TANKTO P/L WELL BLDG. Airito ntake ROAD Dt Inlet
Septic NA Dt Bottom
Dosing NA. Header / Man. 7V
Aeration NA Dist. Pipe fj g~ q~ol
Holding Bot. System 83 q , 0
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Fi Dist. To Well
7-
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS q DIMENSIONS
LEACHING Manu adurer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM
INFORMATION Type O /U CHAMBER Mode Number:
System: ~ `7 OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) i x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length -fts 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 p~reeet, etc.)
LOCATION: TROY 3.28.20.57E • ~j
I ~
Plan revision required?' ❑ Yes ❑ No
Use other side for additional information. 6
SBD-6710(R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
1 a
SANITARY PERMIT NUMBER: +
E
y
i
a g
DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code COUNTY
t Croix
STATE 4re"112to7mvious RY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ i 8% x 11 inches in size. SA
if 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 SE %4, S 13 T 28, N, R 20 W
Fred & Mary RL--iter NW PROPERTY OWNER'S MAILING ADDRESS LOT # _____jEO #
553 Count Road N 12
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
Hudson, WI 54016 715 386-9829
NEAREST ROAD
II. TYPE OF BUILDING: (Check one) ❑ State Owned
❑ Public ❑ 1 or 2 Fam. Dwelling of bedrooms 4 PARCEL TAX NUMBER(S)
III. BUILDING USE: (If building type is public, check all 7;;9 040-1148-1000
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. ❑ 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
600 857 857 .7 93.15 Feet 96.60 Feet
VII. TANK CAPACITY Site
in allons Total # of Prefab. Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Se tic Tank
M~_.J2~ Ej 1 0 0 Ej Ej. F-I
VIII. RESPONSIBILITY STATEMENT _T
I, the undersigned, assume responsibi ' Installation of the onsite sewage'3yst_em awn on the attached plans.
Plumber's Name (Print): P b's n t e: o mps) MP Business Phone Number:
- 4
715 ) 425
Paul C.J. Steiner G~~ 780
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Perm Fee (Includes Groundwater a ssue Is i Agent Sin re (No tamps)
_Surcharge Fee)
Approved ❑ Owner Given Initial 3
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renehal 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.
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'f 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; (lose 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)
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Ub Qr and Human Rphtioms
Division of Salety 6 Buildings in accord with ILHR 83.0`.'. WIS. Adm. Code - -
S-L Croix
Attach complete site plan on paper not less than B 1/2 x 11 inches in site. Plan must inciud., but PARCEL I D t
not limited to vertical and horizontal reference point (BM), direction and Y. of si. pe, scale or 040-~ 148-1000
dimensioned, north arrow, and location and distance to nearest road, REyltarED BY DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
PROPERTY OWNER: F:iQPLF1TY LCCATION
Fred S t Reiter GOYP.LOT N11 W SE 111,5 13 T 28 ~N.R 20 'w
PROPERTY OWNER':S MAILING ADDRESS LOT a BLOCK a 51.180. NAME OR GSM a
553 Count Road N 12
CITY, STATE ZIP CODE PHONE NUMBER I~J~+f~:{xt✓ `~k•~ &OWN NEAREST ROAD
Nart
Hudson WT 54016 (715) 386-9829 -h Cgvc% road
;Kj New Construction Use (}j Residential I Number of bedrooms (j Addition to existing building
(j Replacement (j Public or commercial describe
Code derived daily flow 600 _ gpd Recommended design loading tale 7 bed, gpd1ft2_, 8 _Ueneh, gpdrUZ
2
Absorption area required ~ bed, ft2 _750_ trench, h2 Maximum design loading rate ~_ped, gpd/ft2 _R _-bench, gpdm
Rcxmmended infiltration surface elevation(s) 93.15 ft (as referred to site plan benchmark)
Additional design/ site considerations Use a 10' x 100' Bed rg„2 Trenches 5' 5'
Parent material Flood plain elevation, if appricible _ It
S = Strilable for system CONVEM104AL POUND KGROUNO PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U Unsu;lable fors stem IDS O U ® S. O U ®S O U IRS O U 0S o u us b au
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/Il
Doring A Horizon in. Munsell - Ou. Sz. Cool Color Texture Gr. Sz. Sh. Consistonce Dojxby Pools Bed Trtxtiit
~
-in=4
"1 0-9 10YR 2/1 None sit 2 m sbk mfr as 2f .5
2 9-22 10YR 3/4 None sl 1 m sbk mfr as 1f .5 .6
Ground 3 22-31 10YR 5/6 None is 1 m sbk • • mfr as .7 .8
elev.
9E UIL 4 31-40 10YR 6/4 None s 0 - s ml as .7 1.8
Depth to 5 40-99 10YR 713 None scrr 0- s ml 7 8
limiting j
factor
one
Remarks: System below 42"
I
Boring # '
1 0-15 10YR 2/1 None sil 2 m sbk mfr as 2f .5!, .6
1 .6
2 15-28 10YR 3/4 None sl 1 m sbk. mfr as 1f .5 1
3 28-4 10YR 5/6 Pion is 1 m sbk mfr as .7 .8
Ground '
elev. 4 40-4 10YR 6/4 None ScTr 0 - s ml as .7 .8
97.89 IL
5 48-9 10YR 7/3 None scrr 0 - s ml .7 .8
Depth to
limiting
factor
None_
Remarks:
CST Name:-Please Print Phone' 715 425-5544
Steiner Plumbing & Electric.-Inc.
Mdress:
Signature: Date: CST Number:
C Jul 221993 3074
: FM & MW RETIFR SOIL AND SITE EVALUATICN err
ARCEL I.D.
Structure Roots GPD/lt.
Depth Dominant Color ttles Texture Cr, Sz. Sh. Cons~temce lacundbry Bed TMrOh
oring # Horizon In. Munsell Ou. Sz. Cont. Cow
1 0-12 10YR 2 1 n
3'f 0YR 3/4 None sl 1 m sbk mfr as 1f .5 .6
:r:.. `w 2 12-21 1
None is 1 m sbk mfr as .7 .8
Ground 3 21-28 10YR 5/6
elev. ml as 7 ` 8
96.65 4 28-42 10YR 6/4 None s 0 - s
Depth to 5 42-99 1 {
limiting
factor i
None I
Remarks:
Boring #
1 0-12 10YR 2/1 None sil 2 m
2 12-24 10YR 3/4 None sl 1 m sbk mf
3 24-36 10YR 5/6 None is 1 m sbk mfr as .7: .8
i
Ground ---7 .8
elev. 4 36-46 10YR 6/4 None s 0 - s ml as
-
92E.5G ft • 7 ` • g
5 46-98 10YR 7/3 None -
Depth to
limiting
factor
None
Remarks:
Boring # 2
1 0-12 10YR 211 None si }
1.:.: _
S`
mfr
5 2 12-27 10YR 3 4 None sl 1 i
3 27-32 10YR 5/6 None is 1 m s
Ground
elev. 4 32-45 10YR 6/4 None s 0 - scr -M1
96 --M ft 7
5 45-10 10YR 7 3
Depth to
smiting -
factor
None_
Remarks:
Boring #
r"
r
Ground
elev.
ft.
Depth 10
limiting
factor
Remarks:
rnn r~~~t .05>r321
o= =noun': t, 5 U 11. 1•1 r i UJ I l l: L" 'i 1 L ~J ! 1 I t V 1 1= 1
Labor and Human Rolatiom
Division of Sal sty a Wkfirgs in accord with ILHR 83.01.': Wis. Adm. Code
.
Anach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must inclu8:.. but St CYoiae: 922nt pARCEt. I 0 t.. ,
not limited to vertical and horizontal reference point (BM), direction and % of sL pe, scale or 040_1148-1000
dimensioned, north arrow. and location and distance to nearest toad. REVIEWED BY GATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
PROPERTY OWNER: P:iOPERTY LCCATIOy
Fred & t!Ra Reiter GOVT. LOT MI 114 SE 1/4,S 13128- •N•R 20 )ftri-w
PROPERTYOWNER':S MAILING ADDRESS LOT I BLOCK s SURD. NAME OR CSM !
553 hunt Road N 12
NEAREST STATE ZIP CODE PHONE NUMBER - " '~(xD..`I W4-; U UWN NEAREST ROAD
Hudson WI 54016 (715)386-9829
QC) New Construction, Use Residential I Number of bedrooms 4_ (j Addition to existing building .
I 1 Replacement (J Public or commercial describe
.
Code dcrved daily kW 600 , gpd Recommended design loading tale -7 bed, gpd42 t _.$_trench. god/111
Absorpson area reored:_ bed. 112 _ trench. h2 Maximum design loading rate _,7 bed. gpd/lt2_ .R trenrh. gpd4t2
Rowmmended infiltration surface eteval'=on(s) 93.15 - 4 (as referred to-site plan benchmark)
Addition!design/sr'leconsiderations Use a 10-' x 100' lied or 2 Trenches 5' x 5'
Parent material ` Flood plain elevation, if applicable A
s Suitable for system. CONVFI~K L IN-GROUNO PRESSURE AT-GRADE MTEM w TILL HOLDING TANK
I -I
U. Unsuitable for rem IRIS O U ®S O U as O U as O U CIS O U O S O U
SOIL DESCRIPTION REPORT
• GPD/ll 'I
Boring N Horizon Depth Dominant Color Mottles Texture Structure Consistence &rcby faoot-S in. Munsell - OU. Sz. Cont. Color Gr. Sz. Sh. Bed
Tmrdi
•0-9 .1OYR 2/1 None sil 2 m sbk mfr as 2f .5 .6
M1M~; , 5
..,r.,.r..t 2 9=22 -10YR 3/4 None sl 1 m sbk mfr as 1f .6
Ground :--3, ' . 2241_ 10YR 5/6 None is 1' m sbk - • mfr as 7 .8
qLOfL - : A' 31-40 10YR 6/4 . None s 0 _ s ml - - as .7 1 .8
Depth to 5. 40=99- 16YR 7/3 None s 0 _ ml 7 8
facto ,
nnP .
Remarks: System below 42"
I.
Boring #I '
1 0-15 10YR 2/1 None sil 2 m sbk mfr as 2f .5 ! .6
.2.a 2 15=2 10YR 3/4 None. sl 1 m sbk rnfr' as 1f -.5 ; .6
3 28-4 10YR 5/6 t`Tone is 1 m sbk mfr as .7 .8
Ground
elev. 4 40-4 10YR 6/4 None s 0 - s ml as .7 .8
97.89 1L
.5 48-9 10YR 7/3 None scTr 0 - s ml •7 .8
Depth to
limiting
factor
None
Remarks:
CST Name.-Roast Print Phone:
Steiner Plumbing & Electric, Inc. (715)425-5544
Mdress:
Dale: CST Number:
Sgnatwc / T..,.. 11 1001 'x074
GIER: FID & MW REMx SOJ_. hcvv sitE ENALi,ALVIGN
t.
Re EL I.D. l
Structure Roots GPD/tt
Oepth Oominant Color Motes Texture Cons>c!"~~ Bed Tr
)ring A Horizon In. Mansell . Ou. Sz. Cont. color Gr. Sz. Sh.
'M¢PY 1 0-12 10YR 2/1 n
3' 0YR 3/4 None sl 1 m sbk mfr as 1f .5 .6
w 2 12-21 1
1 as .7 as
is m sbk mfr
round 3 21-28 10YR 5/6 None
PV. 0 - s ml as 7 8
5 4 28-42 10YR 6/4 None s y
.7 ' .8
None-
-
)eplh to 5 42-99 1
Iclor
None
Remarks:
Lorin ' .
g sil 2 m Mfr
1 0-12 10YR 2/1 Time i
sl 1 m sbk mf
2
12-24 1`OYR 3/4 ' None-
A,,.,q
47.1 .8
3 24=36 1OYR 5/6 None is 1 m sbk mfr as i
.71 Ground ml as
elev. 4 36=46 "'1OYR'6/4' None s
95,56 fEl .7 ; .8
5 46-98 10YR.7/3 None s
Depth 10
limiting
factor
None-
Remarks: 9
Boring. - M
t 2
si
0=12 10YR 2 1 None
:
5t` 2 12-27 10YR 314 None sl 1
3 !27-32 v10YR 5/6 None is 1
Ground
elev. 4 32-45 10YR 6/4 None scrr 0 s -
5 7 8
9fi-7. ft
5 45-1100, 1 7 3 -
Depth to
limiting
factor
Nom
Remarks:
Boring
13
I
Ground
elev.
IL
Depth to
Gmifing
factor
Remarks:
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~Gt ~L Il CQ P P
ADDRESS J'i-3
lt)
SUBDIVISION / CSM# LOT
1
SECTION T-2& N-R ,2 W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
.Z4
0 Bole
S<Gl(~/O~ gm
Fle~. /00 INDICATE NORTH ARROW
•7 ~
Provide setback and elevation in ormation on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
f ORY r.J. 985-A
M.•Yn,. C..n...n II .11
Stock No. F26273
7
50 CERTIFIED SURVEY t.-IAP
t.'JC:ATEL' IN G0VE:RN%1!.:N f L01 3, SECTION 13, T28N, R20VI
LAKE ST. CROIX
C-1 I
UL x-1983
00
OOMMILL
1+ 41
1 ° I NQ:v41 1064, tii
NORMAL WATER'S l
r.
. 2
EDGE 0 9
6/25/82 010
Z
pER Cn
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2 o'
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IM
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m f7 I CO
to I T l~
v 7 O o I r
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O
I r <1..{ CO tD Y - I7
M v,l r j I Ln n tV w I U
V1 -7: n I V1
• Co I+ I
a, C2 NOTE. Found Fence Post
- 0 1 , w
o r r / in 2. 40' North of Line at
this Point.
N O l_, w
.t. -
m - s. -NOTE. Found' "
l 1 ton
D F, Rod 2.66' North of Line
n (A A
c, n Z' + at
this Point.
r- m
r.~ ; _n - m
7Cl l!1 i
14-
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IN c) h, vi
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-rt I
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vo VI
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- - - s~. y APPROVED
I
j o \O, iv JUL 1~ 1983
`c I Si. CROIX COt1viY
v2 \ to r COS'.PREHCNSIY: PnF.K5 F AYMUG
F+v AND 20:1IN3 COMWITH
ASSUMED BEARING REGERENCED TO
THE PLAT OF BOMAR HEIGHTS
.10 FIRST ADDITION. /POINT OF BEGINNING
lis instrument drafted by
-nes T. Swanson. C, TOWN ROAD S89°!10'35"W
- 1417.19'
S0057'03"E 12.621-- E1/4 CORNER
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/ BUYER r eQ' Y L { C ` 10.f- 14- e-4- o
ROUTE/BOX NUMBER 'S 4 9' AJD CQU~ 114 Fire dumber g a
Cl
j ZIP (_~q o A(_ rt
CITY/ STATE ktvo-5 D 1 ~J
IMPORTANT: BE SURE THIS DESCRIPTION COVERS YOUR PROPERT) , Section T a D N, R_g I-W ,
of St. Croix County,
V&(s , ►all
t; ivision o Lot number-
tenance of your septic system could result in
its premature failure to handle wastes. Prover maintenance con-
sists 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 a ect the .unct on o, the septic tank as a treat-
ment-stage in the waste disposal system.
o
St. Croix County residents ,may oe clj6~- - _ t s
a maximum of 60% of the cost.of replacement of a failing County,
whLC was in operation prior to July 1, 1978. St. Croix accepted this program in August of 1980, with the requirement that
owners of all new sys'Cems agree to keep their system properly
maintained.
Zoning b lum
The property owner agrees to.submit to St. Croix County Zonb ,
certification form, signed by the owner and by a mater p
journeyman plumber, restricted plumber or.a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and -M-after inspection and pumping (if nec-
less than 1/3
essary), the septic~ill kbe is
Certification form
three year-expiration.
0
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, as set by the Wisconsin Depart-
ment of Natural Resources. Certification vOfficetwithinm30edays
and returned to the St. Croix Cou y Zoning
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.
• APPLICATION FOR SANITARY PERMIT
STC-100
This application form Is to be completed In full and signed by the owner(s) of
the pcopecty being developed. Any inadequacies will only result in delays of
the permit Issuance. -Should this development be intended got resale by
owner/contract ac,(spec house), then a second form should be retalned and
completed when the property is sold and submitted to this office with the
appropriate deed recording.
I ~i I
Owner of property e e C- G la / 1~chl Te{^
Location of Qcoparty" 3 - Section 1.. T...N•M~.Y
Township In Q +
Mallln9 address o ~ ~e__,
l'~ y~ S o vl 1,cJ I ~ O/
• Address of site
Subdivision nas►e r e cn -
Let number
Previous owner of property , ~o b e y- e.VV S
Total size of parcel I 3 Fo ct- c- r e 6 .
e Date Parcel was created "iL)_~_Ll (~1 3
__Jle
Are all cornets and lot lines ldentIllableT as
Is this property being developed tot resale tepee house)? as
Volume and Page Mumber ~ as recorded with the Register of Deeds.
-------•-F=y
S7
INCLUDE WITH THIS APPLICATION TUR FOLLOWINCt
A WARRANTY DRRD which Includes a DOCUMLNT NUMBRR, VOLUMB AND PAcz NUMgZR, and
the SRAL OF THR RBOISTBR OF D8RD8. In addition, a cartltied survey, it
available, would be helpful so as to avoid delays of the reviewing process. It
the deed description references to a Certified Survey Map, the Certltled Survey
Map shall also be required.
7---------------------
PROPRRTY OWNER CERTIFICATION
I(Ve) certify that all statements on this form are true to the best of my (out)
knowledge] that I (we) am (ate) the owner(s) of the property described In
thls Information form, by virtue of a warrant ee t corded In the Office of
the county Register of Deeds as Document No. L~ V~~• I and that I (vol
presently own the proposed alto for the sewage disposal system (of I (we) have
obtained an easement, to run with the above descrlbed property, toe the
conattuctlon of sold system, and the same has been my recorded In the office
of the county Register o eeds, as Document No.
45
! gn lure of owner Signature of o-ownee i Appiieabiel
at of gnature Date of Signature
DEED 1.\t
ACQUIT\CLAIM 0 SIN F0
r REGISTER'S OFFICE
4J~%S' % x. SJ~PA~~ 5 ST. CROIX CO., WI
" Recd for Record
-.l~~rjorie H. Ahrens, a single woman
a~ OCT 2 41989
10:00 A M
L. Reiter, /n
quit-cta!m~ to Frederic A. Reiter and Mary_
husband and wife Register of0eeds
$C . Croix County.
,tl':.. •'ltle•~t rC;II estate to - Re-' +iv 'J
the
Mate of
Part of Government Lot "3" of Section 13, Township 28
Julyfollows:
North, ianoe 20 West described
intVol. "5". Page 1311.
of Certified Survey Map filed 12, 1983 -
Tax Parcel \o:........ -
-
TOGETHER WITH and SUBJECT TO easements, reservations,
restrictions and rights-of-way of record, if any.
-Ihri. ~r Lb
FE'S
The purpose of this deed is to convey to grantee any right, title or interest that
grantor has in this property including the interest or title she acquired by
virtue of an assignment of lacontract recorded on April 28, 1986 in Vol. 737,
Page 588 as Document Number 41211.
is not o:':<r., a+1 prr.ncrt}.
T~.=
in89
30th iay August
'F.:\ l•' V maYjorie 11 Ahrens
tcc:ALr
ACKN0W L0DGNIENT
AUTHENTICATION OREGON
T \T 1. of K }CX i _ I
.
- ~ n
all. awe. h(-orc, m~ tn:;
R9 bm yi
i - •.a
autt:^r.ticatel tlr.> day' n,`' . 19 \ugust tFc
~0
rt
TIT1. F: \ti:}tl:F:P. STATE I:AR
HEYWOOD and CARI Oregon
by Samuel R. Carl
P.O. Box 229, Hudson, W1 54016