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HomeMy WebLinkAbout038-1057-20-000 v o ~ o ~ ° I a•°i °o, I N O 69 O 6q of o o 0 ti ~ I 0 I w I o L ao r- 0 coots I g y o I a y co O z y p O V m> ,.p > a 2 w O` Oj C G. a W 'o-o CL ~€g I Yrn o CL w aU € N :2~maci I U~ Z t N ,p O C 8_0 a c Z p•0) {L C 2 C N p, lL C N O 3 003 a) y L C •p m n O Q C vw•$ I E ¢ w I M I M 3 I a I z I H z O I O d ' a co z a co I I o v E Z~ c I c a r > > r_ c I c o v~ I CD z c E I c E ~w N d r++U cu N d N .C N m t O a O c O Q z m z I z m z N ° c ~ ti d ~ t o d c I cco ° of L ip E C N > _ U 2 a a' U CL CL co M > N d N h •O N d r~ N Y O° o rG rG ra n c ~G rG rm m ° c U) (a U) E 4 m a n o v z ,t333 = c 12333 c wN ' 'N aaa I ~ CLCLCL zo IL 3 N 9 IZ Z U) co co rn 0 U) J U 1 a) rn } c rn rn } !e ~l j M N I Q N N N °p Q o 0 = O L ir, ~n O L 'a O E O O N N m y O 9 m y O) d CD r_ 4) I N =I N a ~ w r- 4m Q (n N 7 Q fn Q O N N N y H oo m 0 E y `O m y o c c E v rn rO c°~ 1 H m-2 c I m o c n 0) °o v N 0 fp 0 N 440 In CCO• N O c co y I O 0 0 C 7 N N O- d H -0 Z 14) IA y L L :3 •O S5 r ICI M ;z 0) Y 7 O a) O S N F- F- C CD C, to 0 r U) r- N Z m= H I Q a O 2 2 t6 L Z N :9 ~9 .rt CA • O # E I v~ 4) a I a • rrww 'co a as ° 14) A tia~ oaCi 13U) N V 0 Parcel 038-1057-20-000 12/01/2006 11:03 AM PAGE 1 OF 1 Alt. Parcel 14.31.18.244B 038 - TOWN OF STAR PRAIRIE Current X, ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner COLLEEN M JOHNSON O - JOHNSON, COLLEEN M 1297 220TH AVE NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 1297 220TH AVE SC 3962 NEW RICHMOND SP 1700 WITC Legal Description: Acres: 1.520 Plat: N/A-NOT AVAILABLE SEC 14 T31N R1 8W 1.52A IN NE NE LOT 1 Block/Condo Bldg: CSM 3/674 EZ-UT-1226/259 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 14-31 N-1 8W Notes: Parcel History: Date Doc # Vol/Page Type 01/11/2005 784697 2729/331 WD 07/23/1997 1078/322 WD 07/23/1997 912/191 2006 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/13/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.520 28,600 144,700 173,300 NO Totals for 2006: General Property 1.520 28,600 144,700 173,300 Woodland 0.000 0 0 Totals for 2005: General Property 1.520 28,600 144,700 173,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 110 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 R; ;3 512 oEr, cl,urY CERTIFIED SURVEY MAP NE CORNER SECTION 14 N 1/4 CORNER T31 Nt R18W TOWN ROAD z2o~1~, po~9o S 89 06'E 297.00 0: off` ~ P01 NT OF ' BEGINNING M 0 5,80UTHERLY RIGHT- F-WAY LINE M01 19 S 890 06 E 264.00 ' ova 33 06, v w 2 APPROVAL OF THIS MINOR SUBDIVISION I o i o t= DOES NOT MEAN APPROVAL FOR ~ 0 V) (0 w BUILDING S,Tc OR SEPTIC SYoTEM, i o o REFER TO H62.20. V I z k6 w p I G> =-:14 ZI N I W W- I Z cO I W JI 0) 2.02 ACRES INCLUDING ROAD RIGHT-OF-WAY a) } N~ r6 1.60 ACRES EXCLUDING 11 11 6 a o LL o N APPROVED CIJ o I a) mzui pl O IVY ~ = I = -1 w Z Z N a W a; All G 2 3 7978 o~ =1 Cn Y awm dl Z I 5: ').XC;U tY' p Cr z, ZI ~I CJ p : icd51V_ PARKS PLANNING F- AND Zo..4ING COMMITTEE 3 ~I NE-NE 1 ~-s~ 199. 40 90 2 6 4.00' - 33.g0' Z N 890 06' W 297.00' pi UNPLATTED LANDS I SCALE IN FEET 60' 0 60' 120' LEGEND County Section Corner monument, Berntsen Cap • 1" iron pipe found `--`E I/4 CORNE O 1" x 24" iron pipe w6ighing 1.63 lbs./lineal ft. set ,y P K NAIL FOUL, This instrument drafted by Scott B. Lohman F/ ~ D 491 a 1978 Via Volume 3 Page 6711°'1~•64`h'' s 8 y • Parcel 038-1057-10-000 12/01/2006 10:58 AM PAGE 1 OF 1 Alt. Parcel 14.31.18.244A 038 - TOWN OF STAR PRAIRIE Current XST. 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 - DUBOIS, MARY MARY DUBOIS C - ANDERSON W, J, T, & JOHN ANDERSON W, J, T, & JOHN,ET AL C - ANDERSON, WILLIAM R 1584 95TH ST C - ANDERSON, THOMAS NEW RICHMOND WI 54017 C - ANDERSON, JOHN CASEY C - ANDERSON, JAMES Districts: SC = School SP = Special -ft6pe Addross(e * = Primary Type Dist # Description * 2184 CTY RD C SC 3962 NEW RICHMOND d~ SP 1700 WITC Legal Description: Acres: 37.980 Plat: N/A-NOT AVAILABLE SEC 14 T31N R1 8W NE NE EXC 2.02A IN CSM Block/Condo Bldg: 3/674 EZ-UT-1226/261 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 14-31 N-1 8W Notes: Parcel History: Date Doc # Vol/Page Type 01/12/2004 751332 2490/140 TI 03/22/1999 599830 1412/311 QC 05/21/1996 543969 1179/63 TI 2006 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 10/05/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 25,000 98,600 123,600 NO AGRICULTURAL G4 35.200 6,600 0 6,600 NO UNDEVELOPED G5 0.780 100 0 100 NO Totals for 2006: General Property 37.980 31,700 98,600 130,300 Woodland 0.000 0 0 Totals for 2005: General Property 37.980 31,700 98,600 130,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 v FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT ~t OWNER ~ Lf rr,`/:` .~s 'z L% TOWNSHIP f:rz ~f z /k.'ll~ SECTION ✓ = T N-R I LS W ADDRESS? ST. CROIX COUNTY, WISCONSIN I SUBDIVISION LOT ~I ,SLOT SIZE _ PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYPTE wf/1 t f P • c• i ~C 12 ~ l S e4 INDICATE NORTH ARROW BENCHMARK: Elevation and description: , Alternate benchmark SEPTIC TANK:Manufacturer: Liquid Cap. Rings used: Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side , Rear Ft. From nearest prop. line:Front Side, Rear Ft. No. of feet from: Well Building: (Include this information in the above plot plan) (2 reference dimensions to septic tan)O) SEE REVERSE SIDE I AAA :rte A r PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front_, Side_, Rear-Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed:- Trench: Seepage Pit: Width:__Z,2_Length___{;- -2 Number of Lines: Area Built a Exist. Grade Elev. ~J Proposed Final Grade Elev. Fill depth to top of pipe: Z PTO. feet from nearest prop. line:Front , Side, Rear Ft."-,-)V i No. feet from well:_ 0 No. feet from building HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front , Side , Rear Ft. No. feet from: Well building , nearest road_ Alarm Manufacturer: INSPECTOR: DATE : PLUMBER ON JOB : 9rJGS5'.~,~ LICENSE NUMBER: /S s 6/90:cj DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR A9 100 /3SA TY & BUILDING LABOR & NUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION 4 ) State Plan I.D. Number: Ap4~Q}SOy.9V'976 C . 14 T31- R18 ' 1V 4 N Town of Star Prai e CONVE TIONAL El ALTERATIVE (If assigned) Co. Rd. C Holding Tank ❑ In-Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Margie Anderson R59A New Richmond Wi BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST''EmmF. PT. ELIE . 1100, - 0 Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Calvin Powers Jr. 1563 St. Croix 149054 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK QUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDE PROVIDED: S .n iC. J~Q ES ❑ NO ❑ YES 2nMF BEDDING: I VENT MATL.: HIGH WATER UMBER OF ROAD: PROPERT) WELL: BUILDING: VENT TO FRESH /f ALARM: ) 14 FEET FROM LINE• ( I AIR INLET- E:1 YES O ❑ YES ~14111) ~ NEAREST 06 a !H~ DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO ONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: BER OF PROPERTY WELL: BUILDING: VENT TO FRESH DIFFERENCE BETWEEN FEET LINE: I PUMP ON AND OFF ❑ YES ❑ NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIA MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue. CONVENTIONAL SYSTE (o 3,6 BED/TRENCH WIDTH: L NO.OF DISTR. IPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID . TRENCHES: MATERIAL : PIT nFPTH' DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. IPE DISTR. PIPE MATERIAL: O. I R. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PJPEgSr: f, ABOVE EAR ELEV. INL Tr: ELEV. END: PIP S: FEET FROM LINE: f y' ~ AIR INLET: p 1~ NEAREST e2Q 7/J0 19. >A0 MOUND SYSTE :,3, ' Mound site plowe perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and ff rows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW '71 ❑ 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 TR /BED DEPTHS OF TOPSOIL: AMES SEEDED: MULCHED: CENTER: EDGES: ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRI TION SYSTEM: BED/TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BEL PIPE: FILL DEPTH ABOVE COV TRENCHES: DIMENSIONS ANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE 15111-STRIBUTION PIPE MATERIAL & MARKING: ELEVATION AN LEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTIO HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMAT N APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTV WELL: BUILDING: COM ENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST Sketch System on etain in county file for audit. Reverse Side. SIGN URE: TITLE: SBD-6710 (R. 06/88) L ZP&HR SANITARY PERMIT APPLICATION couNT/Y~L In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than / 2f 8% x 11 inches in size. ❑ check i#revis (Z ions application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPEfff OWNER PROPERTY LOCATION CL V- i ) it ' o•~ Z t/a %4, S T , N, R 0(Or)i0 PROPERTY OWNES MAILING ADDRE§S LOT # BLOCK lc~ CITY, STA E ZIP CODE PHONE NUMBER SUBDIVISION NAME 0 CSM NUMBER . TYPE OF BUILDING: (Check one CITY NEAREST~ROAD 11 ) ❑ State Owned VILLAGE ❑ Public LO 1 or 2 Fam. Dwelling- # of bedrooms -3 AR EL TAX NUM R( ) III. BUILDING USE: (If building type is public, check all that apply) Q~ 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.E1 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 ra Seepage Bed 21 El Mound 30 El Specify Type 41 El 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 Feet pFeet 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 or Holdin Tank A0,60 o Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plum er's ame (Pri • - Plumber's Signatu Sta ps) MP/MPRSW No.: Business Phone Number: 4j"j ;cj Ve ,e 3 4 - s~ Plum s Addr ss Str t, City, Stat ip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S itary Permit Fee (includes Groan water Date Issued jissuing A nt Signature No S p Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-M (formerly Pib-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 wile 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. 11. 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 (8.11/88) l m. ' APPLICATIOH FOR BAHITART PERHIT 9TC-100 Thla appllcatlon form Is to be conplntad In full and signed by the cvntr(t) of the property being developed, hay Inadoquacles will only result In dtlays of the piirnlt letuancg, -Should this davelopment be Intended for t o ale by owner/contractor,(epec houoe), thcn a second form should be r a t a I A t d and coxpleted vhan Lila property is sold and submitted to t h I a a L L I c a vith the ■Pproprlate decd rtcordlnq. Ovntt of property _ M&V, t.,p *a,CQ- r-aa Location of property x_1/4 1/1, Bectlon T-,31_,)1-R_&_V T o vn s h l p_ zAzee Hailing ■ddtess _ PO -A. Address of site Q vwe_, lubdlvl■lon nasta_ • Lot number e P r I Y I a u A avner of property Total size of parcel e Date parcel vas created / Je Act all cornets and lot llna■ ldentlflable7 Ye■ No Is this pro patty being developed for resale (spar hauls)? yes Yo1vMand Page Number = as recorded with the Reglstat of Deeds. INCLUDE VIT11 THIn APPLICATION TIM FOLLOwIM A VAARXNTT DQID which Includes a DOCUHIHT HUH©¢R, VOLLMI AND PAOt NUHaiR, and the ©rkL Or T119. RBOISTER 07 DRSDtl. In addition, a c a r t I L I A d survey, it available, would be helpful so as to avoid delays of the reviewing process. It the deed description references to a CettlLled Survey Hip, the Cattlfled lurvey Hap shall also be required, PROPERTY OVUER CERTIYICATION I(Va) eartlty that ■ll statements on thla form are true to the best of my out knovltdgel that I (we) em (ere) the owner(s) of the property descrlbtd In t h I a Information form, by virtue of a warrant dam cP ad In the office of the county Rtglstet of Deeds as Document I(o. prtstntIy own the Proposed alto for the newage sposal a sLen) and that I (ve) obtalntd an easement, to run with the above described proparty,(vIar htha consttuctlon of sold syatem, and the same ham been duly recorded In the ofllce of the County Re stet of Doads, as Document Ho. 1. algnatur of owner Egnatute oL co-owner (IL Applicable) - / -7 - l Date of slgnatura Data of llgnature HGMil roonipw, DOCUMENT NO. STATE BAR OF WISCONSIN-FORM 2 5 '798 vol 581 wct-356 WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA Willard A. Anderson and Patricia Anderson, REGISTERS OFFICE husban an wi e, as point tenants ST. CROIX CO., WIS. Recd, for Record this conveys and warrants to Thomas Anderson and Margie A. day of SeRt. A.D. 19.4 Anderson husband and wife as Joint at tenants ► M. eglsfe► of l)ee s RETURN TO i the following described real estate in__ St. aoi x County, u State of Wisconsin: k Lot One (1) of the Certified Survey Map recorded in the St. Croix County Register of Tax Key No. Deeds office on August 30, 1978 in Volume 3 of Certified Survey.Maps on Page 674 being a part of the Northeast .quarter of the Northeast quarter • (NE4 of NEk) of Section Fourteen (14), Township Thirty-one (31) North, Range Eighteen (18) West. This conveyance is between parent and child for no consideration. l FEF E VMP This is not homestead property. (is) (is not) Exception to warranties: Dated this 18th day of September 78 19 . (SEAL) (SEAL) Willard A. Anderson (SEAL) Q...~- (SEAL) Patricia Anderson AUTHENTICATION ACKNOWLEDGMENT Sept*h%er s authenticated tl1i 18th aay of STATE OF WISCONSIN 19 N/A as. County. Personally came before me, this N/A day of * G. E. Norman N/A TITLE: MEMBER STATE BAR OF WISCONSIN the above named (If-not;----------------------=---- N/A anthvrt-ter~ tip $ T06:fM,-Wis.-3tats: jThis instrument was drafted by DOAR, DRILL, NORMAN, BAKKE, & to me known to be the person...- who executed the fore- New Richmond, Wisconsin 54017 going instrument and acknowledged the same. (Signatures may be authenticated or acknowledged. Both are not necessary.) Notary Public County, Wis. My Commission is permanent. (If not, state expiration date: , 19 WARRANTY DEED-STATE BAR OF WISCONSIN, FORM NO. 2-1977 _ SEPTIC TANK MAINTENANCE'AGREEHENT w St. Croix County ~ OWNER/BUYER 4'r r s" 0 ROUTE/BOX NUMBER Fire Number e ~ CITY/STATE (N t~l ZIP 5; 0 PROPERTY LOCATION:,Aef k, Section TILN, R _W, _ZS Town of St. Croix Coun y, Subdivision Lot number C-6 4? v ance of your septic system could r cAlt i Improper use and maintenance its premature failure to handle wastes.' Prooer maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licen's'ed* 's,e tic tank pumper. What you put into the system can a ect the .unct on 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, whi.c 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 .sys't'ems 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), ;-he septic,.tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. y 0 I/WE, the undersigned have read the above requirements and agree 0 to maintain the private sewage disposal system in accordance with the standards net forth, herein, as.set by the Wisconsin Depart- s ment of Natural Resources. Certification form must be completed .d' and returned to the St. Croix County Zoning Office within 30 days of the three year expiration.date. SIGNED DATE - / 7 St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND P.O. BOX 7969 PERCOLATION TESTS (115) MADISON WI 3707 HUMAN RELATIONS p d (ILHR 83.09(1) & Chapter 145) LOCATION: ' SECTION: NCR L (or *TOWNSHIP/M ITY: LOT N BLK- NO.JSUBDIVSION NAME: COU T OWNER'S/BUYER'S NAME: A IIVIIL-ING ADDRESS: v,;fi o,w R '/2:0_'4 MA ofn USE DATES OBSERVATIONS MADE X Residence BE MS.: COMMERCI L DESCRIPTION: ~PROFILE DESCRIPTIONS: PER OLATION TESI~JResidence Il RATING: S= Site suitable for system U= Site unsuitable for system rONVENTIONAL: MOUND: IN_ -GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED S STEM-(optional) [zs If Percolation Tests are NOT required DESIG RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: '_2 Sje PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF IL WI ICKN ESS, OLOR, TUBE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- Al- r. T 8S 2 - rjgjk 3 B- leis 9,0 Alds 0/9 911 9 A14" '7,1910 B- 9/1 B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT 2 PERIOD,? PER INCH P- _ P- P_ 9 P- P- P PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal 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 of land slope. SYSTEM ELEVATION E rLi 9sTM OfJ 'a ! .S ~0~ - E ; E s 3 b~ i N c E E . ~ Pa- 34' 34 r 7 T- 3 , y}} 3 GG R.,J,E I, 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 Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME rint : TESTS WERE COMPLETED ON: .0 1J..) 129~A2,62- r _-L' s-- ? - W A as: CERTIFICATION NUMBER: PHONE NUMBER (optional): s'S~S 01 PI, UiRE: : DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - "-TRUC.TIONS FOR COMPLETING FORM 115 - S O- 6355 To be , ~I accurate soil yr ui, report mus include: C ascription; 2, The u, ; r°lust clear, ,indicate whether this is <sidence or commercial 1310jert; 3, MAXI giber of b ores COrnnIT)OrCi>aI ginned; 4. Is thi< P", cerr~ s, t 5. Compl t3t:knt, SITE I.. ` 'ABLE FOR A HOLDING TANK ONLY IF ALL OTHI-.,x RULED O ; F BASED CONDITIONS; 6PLEAS :wic_rras sl :D°. r for a:ae descriptions c, d completing the plot plan, 7, ',,A; n;r locating ~a locations. scale is preferred. A p ; m are clearl- si~own, and are permanent; vai:ic,, 5 C c'xi's aces, names, A& od plain data, percolation test exemp- 10. If : r c ~i UdtiGrt} ci~as ° pl, - % N.A. in appio pr-iate box; 11. Sign i, c. -r c "s a=ad y(-:Ir m number; 12. Make 1:,;;bl€: ~ a tl distriL requhed. ALL L' ~L TESTS MUST a_? FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS Of- COMPLE. T,' RRREVIATIONS FOR CERTIFIED SOIL TES E- Soil Soil Separates ,ac Textures Other Symbols st - Stc: i BR Bedrock cob - C 10") SS Sandstone gr Gri_ =der 3") 1 Lirntsto s f liclh t cs cc ~ci reed s It" fs - F~ Is Le, ~l Siv,dy scl t L.; rr, ;ic; Itj;% Loam to tI("s sc; - rfiyClay vv;` - with sic: S-I'y Clay - few, fine, faint pi Man"', t-q cf <fistirtc?: prrar t c High T six V V. erence Pont TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. ~ t 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 y A eL.hJp. & ram. residence located at: _&6~_1/4, 1/4, Sec._J T_V N, R__ZS _W, Town of 'oVg~-,/eUpon 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 I k- 71 Did flow back occur from absorption system? Yes/( No (if no, skip next line) Approximate volume or length of time: c,Mp, gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacurer (if known): Age of Ta ( if known) : - ups ' ~u~U~~►~~~rs w (Signature) (Name) Please Print (Title) (License Number) zz (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 ope ng over outlet baffle). Name Signature /MPRS 5/88 wl~ SV rr~it~ir J c Aqz,)" sj ,C3c0 S,CP~~e ~1J/r • /~s~~~ /OGd~~s~ i '61"Jcti ~~y uses/,~ yl~i°~~r.J >s'G 3 I / mo l ~us i r- „ 0 I ~ y0 " , G. e,2 07 PAGE OF I~ - CrvZS S~c~100 A 3rt~ Sy c! On flesh All Inlets And Ob►elvallon Plpe 1 App/ovld Veal Cap LAWonu,w 12* Above final G1ede 20. 42' Above Pip' _4" Cool Icon To flaol Glade Veal Plpe _W/eh liar 01 Slnlhelk Coveting MIA 2' Agg/egols 0vb pipe 0141116 *1194 Pipe 0 00 Beno alh Pipe Tee + ge o 1`e110lalee Pipe below ' o ~Cevpllno Twnlheling Al Balloon, Of 311418M o~C Pin.-I Pau D 5 / T-l'o- ' ton 2': 22~ SOIL FILL: DISTRIBUTIOM PIPE APPROVED S41PIETIC COVER YEFF "e''1'1ATERIM- OR 9" OF STRAW 2"OFhGGRE6A1E / OR MARSH HAy G 1;'0PAGGREGATE ELEV. OF FEET-- DIST1115UTIOW PIPE TU BC AT LEAS-r WCHES BELOW ORIGIMAL GRADE AWU AT LCASTLO IUCHCS BUT LIO MORC THAI) tit IMCRES BELOW FINAL GRADE J MXIMUM W N OF EXCAVATIO0 F'KOM OR16WJAL WK WILL BE ~ INCHES PUNIMUM OEM of EACA%/AT10" r-A,0^ 0,4~k6IWAL (,3RADF- WILL BE, ~L INCHES SIGIJE.D: _Z_ QIJ LICCWSC IJUMBEII: DATE. 91 T T o - r rv~Y1 --plR\i LjSjT~~ NTE 3>r2 , TOtrINSHIP~)~ y SEC. / T ~ N. R~W 0. ADDRESS ST. CROIX COUNTY, WISCON ' ' 3DIVISION LOT LOT PLAN VIEW -Distances & dimensions to me requirem s of Hb2.2O SHOW VERYTHING WITHIN 100 ET OF SYSTEM , ,~q gyp, _ - " L . s oe `TIC TANK(S) MFGR. CONCRETE,- STEEL N of rings on cover Depth DRY WELL -NCHES NO. of width length area no. of lines width/2 ; length = area depth//to op of pipe 3REGATE - y ii Sh,~ .K RATE AREA REQUIRED <,_/r AREA AS BUILT X ✓T~ :claimer: The inspection of this system by St. Croix County does not imply complete /:pliance with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no liability for tem operation. However, if failure is noted the County will make every effort to :.ermine cause of failure. ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. INSPECTO DATED?~~,,f PLUMBER JOB LICENSE NUMBER Z REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM San.itaxy Pexmit- Staxe Sept.i NAME Towndhi St. Cxo.ix County Lacaion a oJZP, SecZiav~ TJIN,R/~/G! SEPTIC TANK A ~ Size Z --gattonA. Numbex 96 Compaxtmentz Diztanee Fnom: Wett 12% on gxeatex Ztope it Bu.itd,ing it. Wettands ~ . H.ighwatex it. DISPOSAL SYSTEM D.ietanee Fxom: Wett 12% an gxeatex z Cope jx. Bu.itd.ing it. Wettands Ft. H.ighwatex it. FIELD DIMENSIONS: Width o6 tkench it. Depth o6 xock betow t.ite-Z -9--in. Length of each tine it. Depth ab xock oven t.ite 2-- .in. Numbe,% ob tines "2- Depth of t.ite below gxade f" in. Totat .length o j t inez GZ it. Stope o j txench in pen 100 it. D.ia#anee between tined__L_jt. Depth to bedxock ~ . Totat aba oxbt.ion axea:Z2_U 6t2 Depth to gtoundwatet it. Requited axea it 2 PIT DIMENSIONS: Numbex of pits Gxavet axound pits yeas no Outside d.iametex Depth below inlet it. 2 Totat, abboxbtion ly Y it A Axea %equingd ' 6t2 rn INSPECTED BY z--~'7 TITLE APPROVED , DATE . 27 197 REJECTED DATE 197_ f EH 1'15 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 • MADISON, WISCONSIN 53701 REPORT ON SOIL BORINGS AND PERCOLATION TESTS{-~ LOCATION:'/a /N, R 1d Er(or) W, Township or Mvi iv*sUlY~ S 7 ~'}r I Section r , T n Lot No. , Block No. bdi ion Name County ~ ' -P., vi Owner's Name: t' L ►°L~ I S - iD Mailing Address: ,r X c7 te*rn I I% L TYPE OF OCCUPANCY: Residence No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW 4' ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS rIi 107S P STS z`~'/ ~9~ YPE SOIL MAP SHEET ,3 SOIL T PERCOLATION TESTS TEST DEPTH HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE CHARACTER OF SOIL NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN BER P_ 571 _5 61- 2- aq+f1 P-Z SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) B- z z Z s 21 7-21 7 72-" B- 7_7 I/ Z 1,4- 72 .2 A,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 number of s uare feet of absorption area needed for building type and occupancy. 14b IFJndicate scale or distances. Give horizontal and vertical reference points. Indicate slope. r ' ItN z - 2 tic S' 1, 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 Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. Name (print) -&_h/ C fic j~tion No. Add ress Name of installer if known CST Signature COPY A -LOCAL AUTHORITY State and County State Permit PLB.67 Permit Application County Permit # a County for Private Domestic Sewage Systems *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: tAN" + L-yNo4,% 53, 51v:nc _'/a Section /L Jj N, R 15 f(or) W Lot# City _ B. LOCATION:A)ja Subdivision Name, nearest road, lake or landmark Blk# Village r Ji Township tFr s 0%- 14 C. TYPE OF OCCU NCY: *Com rcial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms No. of Persons~-3_ D. TYPE OF APPLIANCES: Dishwasher !/YES NO Food Waste Grinder-YES 4NIT * of Bathrooms--L Automatic Washer i:-YES NO Other (specify) E. SEPTIC TANK CAPACITY /,00 e) Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation L""- Addition Replacement _ Prefab Concrete 1 *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 2) 3) 4' Total Absorb Area sq. ft. New_✓Addition Replacement *Fill System Seepage Trench: No. Lin. Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length,,,' Width J Z-0 Depth ~11 Tile Depth 7 i9t-1' No. of Lines ~i Tile Size Seepage Pit: Inside diameter Liquid Depth Percent slope of land Distance from critical slope 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 Cert 4iied Soil Tester, NAME 1 / C.S.T. # 2 7, 7B and other information obtained from ner builder). Plumber's Signature MP/MPRSW# >D S Phone # A v ` - sy x y Plumber's Address PLAN VIEW: Provide sketch be ow of system (include direction of slope and all distances in accord with H62.20, including well). o 16'` (~~7 4Q _ Al 10 fZT1 Not Write in Spa elow DEPARTMENT U E ON Do c Date of Application Fees Paid: State 1 o y ate oY /o Permit Issued/Bed (date) Issuing Agent Na X~ -7 Inspection Ye~No Valid* D Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76 P1 `y" WISCONSIN DEPARTMENT OF HEALTH & SOCIAL SERVICES Division of Health Section of Plumbing & Fire Protection Systems .may INSPECTION REPORT Name of Premises WE '1--l E li4 `x, I~! 7' ~r.tj lk-(j treet City County { Master Plumber Ksc W k4 o ~k-1 Address Journeyman Plumber Address Owner -r\,(V1 ta Pk►.c~evso,, Address o,•, .-1 1~li►r.r LIST PARAGRAPH VIOLATED. CHECK BOX LOCATED IN FRONT OF W.A.C. VIOLATED. ( )H62.01 (.)H62.09 ( )H62.17 ( )H62.02 ( )H62.10 ( )H62.18 INSPECTION CHECK APPROPRIATE BOX ( )H62.03 ( )H62.11 ( )H62.19 O BUILDING.SEWER O WATER DISTRIBUTION ('SEWAGE DISPOSAL ( )H62..04 ( )H62.12 ( )H62.20 O WATER SERVICE ( ) DRAIN WASTE & VENT ( )H62.05 ( )H62.13 ( )H62.21 ( ) BUILDING DRAIN O FIXTURES, FINISH INSPECTION ( )H62.06 ( )H62.14 ( )H62.22 Approximate number of fixtures ( )H62.07 ( )H62.15 ( )H62.23 ( )H62.08 ( )H62.16 ( )H62.24 TYPE OF BLDG. ("'f PRIVATE ( ) PUBLIC OCCUPANCY 3 BRIEF, FACTUAL COMMENTS: ~ J y ( ) SEE ATTACHED DISCUSSED WITH PLUMBER ( Yes O No SIGNATURE (Voluntary) ti.'_4 DATE OF INSPECTIONS 2 ° S IGNATURE OF &I'P y a