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Parcel #: 032-1090-60-110 02/12/2007 12:48 PM
PAGE 1 OF 1
Alt. Parcel#: 33.31.19.432B-10
Current X 032-TOWN OF SOMERSET
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
TIMOTHY J JOHNSON 0-JOHNSON, TIMOTHY J
1842 45TH ST
SOMERSET WI 54025
Districts: SC= School SP=Special Property Address(es): •=Primary
Type Dist# Description 1842 45TH ST
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 5.010 Plat: N/A-NOT AVAILABLE
SEC 33 T31 N R1 9W PT NE SW LOT 2 C.S.M. Block/Condo Bldg:
8/2161 5.01 AC
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
33-31N-19W
Notes: Parcel History:
Date Doc# Vol/Page Type
07/23/1997 1049/77 TI
07/23/1997 855/11
2007 SUMMARY Bill#: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/05/2006
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.010 58,000 124,100 182,100 NO
Totals for 2007:
General Property 5.010 58,000 124,100 182,100
Woodland 0.000 0 0
Totals for 2006:
General Property 5.010 58,000 124,100 182,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch#: 143
Specials:
User Special Code Category g ry Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00
0.00
m
FILED
OCT 051989&-
JAMES O'CONNELL
Register of Deeds
4�:2141 SL Croix CO.,ffil
CERTIFIED SURVEY MAP
LOCATED IN THE NE 1/4 OF THE SW 1/4 1 SECTION 33 , T31N , R19W ,
-5-QME-�SETI ST. CROIX COUNTY , WISCONSIN.
OWNED BY:
CHRISTOPHER a PAM BRUNELL
R T. 2
SCIMERSET, W) 54025
NOTE: THIS MAP IS A SUBDIVISION OF LOT I
OF THE CERTIFIED SURVEY MAP RECORDED IN
VOLUME 4 OF CERTIFIED SURVEYS, PAGE 1166.
rn
R T I F I rr ) IV/ r.- V qVA A r, V• It I_ L I
w . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
O 2
WEST LINE SE- NW
U j.-
vz I:
EXISTING
CENTER OF SEC. 33,
66' WIDE ROADWAY EASEMENT T31N , R19W
. 33.
2 N89.3000- -W W QUARTER LINE
(R.R. SPK. FOUND).
1324.55'
S890 30' 00" E 3 2 4. IT 0 SECTION LINE)
1291 .53'
S89*30'00"E 12 91.6 1' 33.0
40 CORNER
o
0 at a,
to existing ng house eI
cn cy 00
M
w 0) N
z U,
existing dri
7- (O I
01 LOT 1 31 33,
CD 569. 30' 00" E 666. 95'
15.03� ACRES I
0 m (654,731 SO. FT.) v 635-66' w
to In 13.3 AC. EXC. R.O.W. 31.29' 1 :
cn (579,541 SO. FT.)
)241
LOT 2
Z, 0 m (V z
5.0 IL ACRES
(218,216 S0. FT.) p to
to e,
4.30 AC. EXC. R.O.W. • N
(187,479 SO. FT.)
O N89-30' 00" W 665. 18' 627.85' 29.56' 3.416'
W m 666. 13'
656. 54'-- --
N89030' 00" W 13 22.67 (To SECTION LINE) 626.98'
EXISTING
66' WIDE ROADWAY EASEMENT
Z r
E FR 11-1 F I Lc C) S Ul R V LE Y A4 A I'D v L
p A
cli -
C\j f.
lir -4
0
WEST LINE NE . SW SI/4 COR. SEC. 33 ,T-31N,
R19W (COUNTY suRvEyows cj
MONUMENT FOUND).
o R RECORDED AS
CIO
cn Z)
-- IV.—
Lu 0 s SET I"x 24" IRON PIPE WEIGHING ()
1.13 Les. PER LINEAL FOOT.
JAMES M.
WEBER
11 1`-0 • IRON PIPE FOUND
S
Uj
U.(6 N SPRING VALLEY
LI
�09 WIS.
W(6 SCALE 200' 711"
W z 0<w ....w;.
0
100' 200' 400 U vo
CA 0 081114100
S %
Wm to
SHEET I OF 2 JAMES M. WEBER, S- 1804
DATED
88 - 213
THIS INSTRUMENT DRAFTED By 014tent IVI.Amow
VOLUME 8 PAGE 2161
F
Fo rm. - S T C - 104
AS BUILT SANITARY SYSTE11 REPORT
OWNER �r /^ TOWNSHIP SEC. 3 T,L/ N-R W
ADDRESS _jlY�j Yf�> �_ ST. CROIX COUNTY, WISCONSIN
SoairB�fl7', �_ S"',fo�5
SUBDIVISION LOT ' LOT SIZE 4a/
PLAN VIEW
Distances and dimensions to meet requirements of I1HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
Ott
J
jz c l� qY � INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference pint used
Elevation of vertical reference point: Proposed slope at site: 3 �t2
SEPTIC TANK: Manufacturer: 66 ,e A f Liquid Capacity: /.>®�
s used:
Number of rings 5-- Tank manhole cover elevation: !fGw,D
Tank Inlet Elevation: C�/� ? Tank Outlet Elevation:
Number of feet from nearest Road: Front 10 Side o Rear, 0 ;;, 200 feet
From nearest property line ' Front 10 Side,&ear,0 > IeO � feet
Number of feet from: well 1>S0 � bul .fling: J?,
(Include this information c ii,, :above plot pJ an)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
f
PUMP CHAMBER
Manufacturer: tf/{c�S Liquid Capacity: �BU
" Pump Model: Pump/Siphon Manufacturer: Pump Size—
Elevation of inlet: '911. 3 Bottom of tank elevation: �� 9
Pump off switch elevation: & Gallons per cycle:
Alarm Manufacturer: de-L Alarm Switch Type: -a
Number of feet from nearest property line: Front, O Side, / Rear,Q Ft?AVII
Number of feet from well: 70
Number of feet from building: O
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: y Trench:
Width: Len$th:___j Number of Lines: 3 Area Built:b 3�
Fill depth to top of pipe: y2
Number of feet from nearest property line: Front, O Side, O Rear,O Pt .' �
Number of feet from well: > i00
Number of feet from building:
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, 0 Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: r Plumber on job:
License Number:
3/84:mj
V
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDING
LABOR&HUMAN RELATIONS DIVISION
P.O'BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES&APPLICATION
r IS �I. l 707 State Plan I.D.Number NnJJ 4 t ec . 33 T31-R19 (Ifassigned)
n of Somerset Ln 2 ❑ CONVENTIONAL ❑ ALTERATIVE
h St . u Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Q�
Tim Johnson 1844 45th ST. Somerset WI 54017 �a U
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FRO PLAN: REF.PT.ELEV.: CST REF.PT.ELEV:
QQ 0
Name of Plumber: MP/MPRSW o.: County: Sanitary Permit Number:
ID4Lvid Fogerty 3289 St . Croix 1
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
91 �f PR0 DED: PROVIDED:
( �0 0 �`'(fr�"l 1q, "S ES ❑NO ❑YES-ffl NO
BEDDING: VENT DIA.: V�NTt.: HIGH WATER NUMBER OF ROAD: PROPERT WELL: BUILDING: VENT TO FRESH
)I /1 1 ALARM: FEET FROM �0� LI>Ei 0 O � �� � � AIR INLET:
❑YES NO 1 L ❑YES ❑NO NEAREST----b.
DOSING CHAMBER:
MANUFACTURER: BEDDING. LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
E]YES' Q NO d 0 e ' C ❑"�ES ❑NO -❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE: O > � �� AIR INLET:
PUMP ON AND OFF 2fYES ❑NO NEAREST `
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: 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 SYSTEM:
WIDT LE GTH: NO.OF DISTR.PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID
BED/TRENCH TRENCHES: M ERIAL: PIT DEPTFJ:_-
DIMENSIONS /
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIP MATER L: NO.D NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: AB O COVER, ELEV.INLET: ELEV.END: PIPE FEET FROM LINE, f AIR INLET:
1 r CIS. NEAREST----01'
M UND 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 I TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
[--]YES ❑NO ❑YES ❑NO
EIEVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
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: DIA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑YES ❑NO ❑YES ❑NO
PERMANENT RK RS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
:
COMMENT e FEET FROM LINE.
LYES ❑NO ❑YES ❑NO NEAREST—�
f`
t
i
-- ��
Sketch System on Retain in county file for audit.
:/J,r/ �•
Reverse Side. l '6 SIGNATURE: TIT
SBD-6710(R.06/88) AA I
C�ILHR SANITARY PERMIT APPLICATION !07
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
8%x 11 inches in size. El Ch�Irevfs3ion 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
!z. f k '/a 5C, '/4,S T 3/ , N, fR T E(or�
P PERTY OW R'S MAILING ADDRESS LOT# BLOCK#
CITY,STATE ZIP CODE PHONE NUMBER Ocw--
1o,okfWW-k c o 56 c/S-2- d7
11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD
�L ❑State Owned ❑ VILLAGE* y�
❑ Public L�1 or 2 Fam. Dwelling–#of bedrooms TAX NU ER(S)
111. BUILDING USE: (If building type is public,check all that apply) L/ 6
1 ❑ Apt/Condo J
2 El Assembly Hall 6 Medical Facility/Nursing Home 10 El 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. ENew 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
41 ❑ Holdin Tank
11 [1�Seepage Bed 21 El Mound 30 ❑ Specify Type Holding
Tank
❑ 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 12.ABSORP.AREA 3.ABSORP.AREA 4. LOADING RATE 5. PERC.RATE 6. SYSTEM ELEV. 17. FINAL GRADE
REQUIRED(sq.ft.) PROPOSED(sq.ft.) (Gals/day/sq.ft.) (Min./inch) ELEVATION
S� — v 3 , yr /0/, 7 Feet ,0 S �Feet
CAPACITY Site
VII. TANK in allons Total #of Prefab. Fiber- Exper.
INFORMATION New !sting Gallons Tanks Manufacturer's Name structed
oncret Con- Steel glass Plastic App
Tanks Tanks
Se tic Tank or Holdin Tank "ce — P e✓ '
�
Lift Pump Tank/Siphon Chamber &A01 c c r
VIII. RESPONSIBILITY STATEMENT
1,the undersigned,assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name(Print): Plumber's Signature:(No Stamps) IOfP/MPRSW No.: Business Phone Number:
lumber's Add as( tree,City,State,Zip Code):
r" W o1
IX. COUNTVIDEPAKTMENT USE ONLY Issuin Agent Signature(No Stamps)
❑ Disapproved Sanitary Permit Fee(Includes Groundwater a e slue
� Surcharge Fee)
Approved El owner Given Initial
D rmin tf on
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.11/88) DISTRIBUTION: Original to County,One Copy To:Safety&Buildings Division,Owner,Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new
criteria in the Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be
submitted to the county prior to installation.
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed
pumper whenever necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the
State of Wisconsin, Safety & Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete##of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of
tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all
septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers;wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398(R.11/88)
• 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 7 jm j- /Vo4r" 4 TONw 50/V
Location of property AIZ-_i/4 s X1/4, Section 33
Township -5,o d2€R i
Mailing address 1 -g- g g 4Ls S T, So SST w/, S ozs
Address of site 1 &4 Z 9-5-Z �7 7 wl, s-¢aas'
Subdivision name
Lot number
h,/S?O EQ 76PR A, 0NFL4
Previous owner of property 01 i9, ��vw ELL
Total size of parcel _ S
Date parcel was created I
Are all corners and lot lines identifiable? ✓ Yea No
Is this property being developed for resale (spec house)? Yes f/ No
Volume and Page Number 'Z16 I as recorded with the Register of Deeds.
-------------------------------------------------------------------------------
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PACE NUMBER, and
the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if
available, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Certified Survey Map, the Certified Survey
Map shall also be required.
---------------------------------------------------------7---------------------
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. $5'-Z �j 7g ; and that I (We)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Regislar of eeds, as Document No. ) .
Signature of Owner Signatu of Co-Owner (If Applicable)
Date of signature Date of Signature
-- --^ACT 25 '89 13:57 RIV VAL ABSTRACT 3867664AAAAAAAA .2/2
f� J
DOCUMENT NO. STATE BAR OF 'WISCONSIN FORM 1-19821, THIS SPACE RESERVED FOR RECORDING OATH f
WARRANTY DEED I
.f r IE
4528'74
I. REGISTER'S OFFICE
This Deed, made between _Chrstopher__Todcl__Alne],} •an,�i, 5T. CROIX CO., W1
:A:::Brunell.:f. Pamela-A: Boerumt husband and_ i
• Reed for Record
i
f .............•---•------._............................................ _..... ...._.__.. .. .., Grantor, I� Ot
I
and..,i�axwa..I,_c..Johnsonanlinremarried _widow and T 10 989
imothy I .30 OCT 2 51 A. M
J�..J4�lnsoH�..as aoint tenant............................ ......... ...
�.... •-•-••---•-•••----•----------------------•-------••---•-----•---------------•-••----• V RegisterofDe
. ...................................................................*.-._.. Grantee, (j
W�tneSSeth, That the said Grantor, for a valuable consideration......
.... •....
••---•.......................................-••..........._..... __- ---•'i
conveys to Grantee the following described real estate in ............. RervaN To f
County, State of Wisconsin:
..'o
` Part of the Northeast Quarter of the Southwest Quarter Tax Parcel No: .................................
(' (NE-k of SW-,-,) of Section 33, Township 31 North, Range 19 [Jest
described as follows: Lot 2 of the Certified Survey Map recorded
in Volume 8 of Certified Survey Maps, Page 2161, �!
I � i
� r
This ........?:$..not___•,__. homestead property'.
(ie not) I'
Together with all and singular the hereditaments and appurtenances thereunto belonging;
wnd..!~hzxszaghex..xs?d�..kx nalX..aad_.�a�leli .:�l,... 1 utt l,�,... lk/A--f amt IA..A,...AgPu.V.ql............
warrants that the title is good, indefensible in fee simple and free and clear of encumbrances except
subject to easements, covenants and restrictions of record
and will warrant and defend the same.
i Dated
�l this ......... .$ h.............................. day of October
.................................................. 19.8 ....
:1 ...........•..........................•....--••--.....---••---... ...(SEAT,)
E CHRISTOPHER TODD BRUNELL
...........................................•-•.......•-•-•........ *
� �Q
....._..-•----------------•-•---•-•---••----•........................(SEAL) --.._(SEAL}
• .................................................................. PAMELA A....B...... ............................ i t
I, AVT>tI]SNTICATION ACKNOWLEDGMENT i!
IIrf Signature(s) ............................................................ STATE OF WISCONSIN '!
i •........ ...................... . ........................................... ss. i►
..........Sir...-C rO ix..........County.
authenticated this ........day of........................... 10...... Personally came before me this .......1$t hds,y of
- --. ... Q.9 t oh e.r...................... 19.$9... the above named I;
Chxi >:aghQr__Tszsld_.�xunell;..arl� ------------------
P.amtr�a..A. �xllnP.lX..................................
TITLE: MEMBER STATE BAR OF WISCONSIN *...*
--------------------------•------------------•------------•-----•-------•-.....
(if
not. ...........................................
authorized by ¢ 108.08, Wis. Stats.)
.... � •-••---------------•--••--•----------. --•-------••-----------•- i';mg
known to be the persons............ who executed the
Notary.Public foregoing instrument and acknowledge a same. f
p State o in I
THIS INSTRUMENT WAS DRAPTH BY �W1SCOnS /���
..Heywood &_Carl,.by Samuel R. Car_ i_ - -...Carrel McD � �.............................
aniel
...�:Ot,Box•229,..Hudson:..WI 5401.6 `........................S't-. -Cza7 x--------------•.................
.........- •-•-••-------•------ Notary PLiblie ..........................................County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration �
+' are not necesaasy.)
date
19 ,i
�I ONames of tlarsons sicning in any capacity should be typed or printed below their siynawres. i�
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER / /t�� /�,Ftii,q -T-o ^11/50 IV
ROUTE/BOX NUMBER—] F-9::9 9 7H S T FIRE NO. 7'4Z-
CITY/STATE So w1E�2sc-:T w 1 ZIP S�g o ZS
PROPERTY LOCATION: A/,6-7 1/4 5 W 1/4, Section , T Sj N, R_LJ_W,
Town of Sov�,r �S� T , St. Croix County,
Subdivision , Lot No. Z
Improper use and maintenance of your septic system could result in its premature
failure to handle wastes. Proper maintenance consists of pumping out the septic
tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER.
What you put into the system can affect the function of the septic tank as a
treatment stage in the waste disposal system.
St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of
$3000 of the cost of replacement of a failing system, which was in operation
prior to July 1, 1978. St. Croix County accepted this program in August of
1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their
systems properly maintained.
The property owner agrees to submit to St. Croix County Zoning a certification
form, signed by the owner and by a master plumber, journeyman plumber,
restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and (2) after
inspection and pumping (if necessary), the septic tank is less than 1/3 full of
sludge and scum. Certification form will be sent approximately 30 days prior to
three year expiration.
I/WE, the undersigned, have read the above requirements and agree to maintain
the private sewage disposal system in accordance with the standards set forth,
herein, as set by the Wisconsin Department of Natural Resources. Certification
form must be completed and returned to the St.Croix Co y Zoning Office within
30 days of the three year expiration date.
SIGNED
DATE
St. Croix County Zoning Office
P.O. Box 98
Hammond, WI 54015
(715) 796-2239 or (715) 425-8363
Sign, Date, and Return to above address
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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(print): TESTS WERE COMPLETED ON:
Ucensed Pork Test Mar plumber
ADDRESS: 1tOBER r WISCONSIN 5023 CERTIFICATI N NUMBER: PHONE NUMBER(optional):
pho" 7"56
CST SIG URE: r
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
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