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Form - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER r1m4f Z L%/V TOWNSHIP // r �' "'L= f SEC. T N-R W
ADDRESS /j, ST. CROIX COUNTY, WISCONSIN .
Aj
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•LHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
f'TG'LiSG�
r r �
iI
r �
r
r �
r
Sc� Tip i- INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used L %[sr+
Elevation of vertical reference point: /Q X7, (7 Proposed slope at site: _y,
SEPTIC TANK: Manufacturer: Liquid Capacity: /'1t'3
Number of rings used: _� Tank manhole cover elevation: 9 ,
Tank Inlet Elevation: " � ! Tank Outlet Elevation:
Number of feet from nearest Road: Front,O Side IQ Rear, O feet
C
OFrom nearest property line Front,O Side, Rear,O pQ ` feet
Number of feet from: well , building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: Liquid Capacity:
P Model: Pump/Siphon Manufacturer: Pump Size
Elevation f inlet: Bottom of t elevation:
Pump off switch vation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from near prope line: Front, O Side, O Rear,Q Ft.
ber of feet from well:
Number of feet from building:
nclude distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: X _ Trench:
Width: f Length: j Number of Lines: 3 Area Built
Fill depth to top of pipe: _ /E(lrMA , z 30
Number of feet from nearest property line: Front, O Side, ( Rear,O Ft . f-
Number of feet from well: YY
Number of feet from building: 0
(Include distances on plot plan). .
EPAGE PIT
ze: Number of pits: Diameter:
Liqui epth: Bottom of seepage pit elevation:
Area Built:
Has either a drop box or distribution box O been use n any of the above soil
absorbtion sytems? (Check on
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation o bottom of tank:
Elevation of inlet:
Number of feet fr nearest property line: Front, ide, O Rear, O Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
i
Dated: -Q�-X _ Plumber on job:
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RE4ATIONSr PRIVATE SEWAGE SYSTEMS DIVISION
6.0.BOX y969 BUREAU OF PLUMBING
MADISON,WI 53707
SE%,NE%,S5,T29N-R19w MCONVENTIONAL ❑ALTERNATIVE FStale Plan l.D.Number:
(If assigned)
Town o4 St. Joseph ❑Holding Tank ❑ In-Ground Pressure ❑Mound
48th Stue a 030- /0 If - 3&—(:::I� • -7-74
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER' INSPECTION DATE: �y 2
Machaet Long oute 2,-Hudson, wI 54016 l 2�a g u'E
LEV
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.E ..
44 7- / /-)5 Ida �� �i�lr Tv-
Name of Plumber MP/MPRSW No County Sanitary Permit Number:
Donavan Schmitt 3205 St. Ctoax 112689
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. ILIQUID CAPACITY. TANK INLET ELE V.: TANK OUTLET ELEV._ WARNING PROVIDED OVER
DYES ONO DYES ONO
BEDDING. VENT CIA.. VENT MATIL HIGH WATER NUMBER ROAD: PROPERTY WELL. BUILDING. VENT TO FRESH
JALARM LINE. AIR INLET
FEET FRO
❑YES ONO DYES ON N
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL PROVIDED OVER
PROVIDED'.
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP Al D CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH
LINE AIR INLET
(DIFFERENCE BETWEEN FEET FROM
PUMP ON AND OFF) DYES ❑NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL A"°MARKING
FORCE
or excavation. (If soil can be rolled into a wire,construction shall cease until
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH: LENGTH. NO.OF DISTR.PIPE SPACING COVER IN:iIUE DIA rf PITS LIQUID
BED/TRENCH TRENCHES MATERIAL: PIT DEPT"
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR PIPE DISTR.PIPE DISTR.PIPE MATERIAL. NO DISTR NUMBER OF PROPERTY
7777 V NT TO FRESH
BELOW PIPES ABOVE COVER ELEV INLET ELEV.END' PIPES FEET FROM LINE AIR INLET
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA-
meets the criteria for medium sand. TIONS MEASURED.
❑YES 1-1 NO -----------
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES ❑NO 1:1 YES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED M LCHED
CENTER EDGES.
❑YES ONO ❑YES ❑NO ❑YES. ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH- LENGTH. NO.OF LATERAL SPACING (TRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKINI,
ELEV. ELEV.. DIA. ELEV. PIPES
ELEVATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
DYES ❑NO DYES ❑NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING
FEET FROM LINE:
DYES E:1 NO —]YES NO NEAREST
i
Sketch System on Retain in county file for audit.
Reverse Side. SIGNATURE. TITLE
Zoning Admani s t atotc
DILHR SBD 6710(R.01/82) i
COL R SANITARY PERMIT APPLICATION °It.
In accord with ILHR 83.05,Wis.Adm.Code
�. STATE SANITARY PERMIT##
i / 13 G r2
Attach cbmpdete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER
8%x 11 inches in size.
—See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ® NO
PROPERTY OWNER PROPERTY LOCATION
'/a '/a, S " T,27, N, R Zf E(06P
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER IBLOCKNUMBER SUBDIVISION NAME
I
CITY,S ATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
cle gT=4 ( 9 TOWN OF:XX a&L".a
VILLAGE : 97-w ,
D
II. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. XNew b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e.❑ Repair of an
System System Septic Tank Only an Existing System Existing System
2. ❑ A Sanitary Permit was previously issued. Permit# Date Issued
3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements.
4, ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. -
IV. TYPE OF SYSTEM: (Check only one in#1 and only one in#2)
1. a. Conventional b. ❑Alternative C. ❑ Experimental
2. a. ❑System- b. ❑ Holding C.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tan k
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. MSeepage Bed b. ❑See a e Trench c. ❑ seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):
Q , Feet Private []Joint ❑ Public
VI. TANK CAPACITY Site
in ga ons Total #of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank ` ❑ I El —S- 1
Lift Pump Tank/Siphon Chamber ❑ Li I El
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name(Print): Plum s Signature.(No Stamps) MPAPRSW No. Business Phone Number:
�.J
P umber's Address( reet, ity,State,Zip Code l- Name of Designer:
r
S
V ll. SOIL TEST INFOIRMATION
Certified SSoiI Tester(CST)Name CST##
A127_
CST's ADDRESS(Street,City,State,Zip Code) Phone Number:
r 3
L p -
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sa try Permit Fee Groundwater ate Iss ' g Agent Signature(No Stamps)
lqApproved ❑ Owner Given Initial M S charge Fee Q�
Adverse Determination �[24`w ZAP 7—"7
X. COMMENTS/REASONS FOR DISAPPROVAL:
wak ale
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT
APPLICATION
TO THE APPLICANT:
1. This 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. A new permit may be needed
if there is a change in your building plans,-system location, estimated wastewater flow (number of bed-
rooms, etc.), depth of system, or type of system;
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. Private sewage•systems must be properly-maintained.,The septic tank(s) should be pumped by a Licensed
pumper whenever necessary, usually every 2 to 3 years;
6. If you have questions concerning your private sewage system, contact your local code administrator or the
State of Wisconsin, Bureau of Plumbing, 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 where the system is to be
installed;
II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment; 30 seat
restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling;
111. Purpose of application: Check only one in ##1. Complete##2 if permit is for tank replacement, reconnection or
repair;
IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project
is in conjunction with University of Wisconsin;
V. Absorption system information: Provide all information requested in##1-6;
VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed,
number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete
for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if
tanks received experimental product approval from DILHR;
VII. 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. Fill in designer name if
applicable;
VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number.
IX. County/Department Use Only;
X. Comment area for use by county or resaon given when application is disapproved.
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; dosing or pumping chambers; 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.
GROUNDWATER SURCHARGE
On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more
commonly known as the groundwater protection law. This change in statutes was the
result.of over 2 years of steady negotiation and public debate. The groundwater bill Ground
included the creation of surcharges (fees) for a number of regulated practices which Wisco
e.
i
can effect groundwater. The surcharge took effect on Jul 1 1984. All of the water that
9 9 Y
buried reasure
is used in your building is returned to the groundwater through your soil absorption
o I
system or the disposal site used by your holding tank pumper.
' a
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398(R.03/86)
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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
e o Property
Owner f P p e rty
Location of Property JS4�' Section -:S , Te-, N-R 1'7 W
Township
!tailing Address
Address of Site
Sub v son me
LcT, Xu"er
Previous Owner of Property �f� / jUCr( j�S
Total Size of Parcel /y i9G%ES
Date Parcel was Created
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for resale (spec house) ? Yes _� No
Volume and Page Number 16-y as recorded with the Register of Deeds..
7�
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Warranty Deed which includes a Document number, volume and page number, and the
Seal of the Register of Deeds. In addition, a certified survey, if available, would be
helpful so as to avoid delays of the reviewing process. If the deed description refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
T (toe) cuW6y that att s•tatemen" on tW foram alte tAue to the but 06 my (owe)
hnc�wtedge; that i (we) am (cute) .the ownen(�s i o6 the pnopenty duCAi.bed in .thie
.in6onmati.on 6onm, by viAtue o6 a waAAanty deed 4eeonded in the 066.tee 06 the
Co mu Xy RegiAte�t o6 De¢dhass Document No. _ '7 and that I (We) pneeentCy
aun the p1toposed 6 to bon the �Sewage dv_POA byes •em• (on I (we) have obtained an
ea.ee"ent, to stun with the above de ckibed phopehty, 6oh the eon,dttAuc.Uon o6 6ai.d
system, and the dame hae been duty keeoaded to the 066tee o6 the County Reg•ie.ten o6
Veedd, ae Voewnent No. ) ,
SIGNATURE 01 OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
�!i9- 9e
DATE SIGNED DATE SIGNED
r
�1 ,...
s - @
36
411677
CERTIFIED SURVEY MAP
LOCATED IN THE SE 1/4 OF THE NE 1/4 OF SECTION 5 , T29N , R19W, TOWN OF
EPH , ST. CROIX COUNTY , WISCONSIN . MNID BY: DAN BAUM
RT 2
FILED RIVNIt FALLS, :l'I•
')SEE' Slil,;lsT 2 OF 2 FOR D[SCRIPTIO1P* 5/,U 22
MAY 8 1986 CULTIVATED
ABU OIQ !.r O=SET I"x 24"IRON PIPE WEIGHING 1.13 LOS. FIELD
I%tft«, PER LINEAL FOOT. spike
at 0,04 )rt ( 0 -- 1" IRON PIPE FOUND. in oak 6g15 J9
0 IS .0 N P L A T T E D LANDS fence spikf
0 in • . In elm
0 0 ' i T829SQP.>t. .. . . . . . . . .
w_ u I 22' S 8 9°39'49"E 660.35' 35'
VF-2
Z u- I 627.3 " ' -
�^° 1 33,0 _ + NORTH LINE OF THE
u- I � -+-t � ExISTING 471 SE I/4 - NE I/4 .
a (E•eh�e 1i FOUND 1"IRON PIPE AND SET
Z IT BELOW EXISTING GROUND.
z w 133' 33 (SEE TIES IN ENLARGEMENT) .
ILI 4-
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Q00,o Lo`���
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LU 01
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lw o t0 I' 10.0 ACR
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10. 01 ACRES
I' (436, 067 SO.FT.)
CO' z 9.12 AC.T0 R.O.W.
Id•: I (397, 416 SO.FT.)
W 1/4 CORNER OF SEC. 133' 331 E 1/4 CORNER OF SEC.
5 , T29N, R19W. (000NTY 1 5,T29N , R19W.(000NTY
SURVEYOR'S MONUMENT I O SURVEYOR'S MONUMENT
FOUND.) I 0 FOUND).
N89°37'08"W 636.27' M_
39�—B 2' ' 0— — — — — — — — —"'L M — 661.18
"E 115 TH. N89°37'08"w 661. 18 AV E. M N89°3 oe'w
0
E - W QUARTER SECTION LINE
� r
r •y •�
~ `:r SCALE 1 = 200 '
w :NE13ER z 0101
1G04 x 0 ' 100' 200' 400'
SPRING; VALLEY I
e \ f tiw
..�r� ,;ttc; •, <<;; SHEET I OF 2 .
•i•t3 �^'"'� 04 Ta t►v.219 A 1, THIS INSTRUMENT DRAFTED 9Y J•%- --
� f tt
DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1988 THII •RACK 1140614V40 #OR RECORDING DATA
IpXARr TY DEED
43254G Ivor /.77PA r
635
-- - WISTEWS OFFICE
This Donna M. Heir, Constance A. ST. WX CO., WI
ke�ahe�dtbe Bauer Ret'd for Record
Bec er an
••.............................•-------•--•-•---------•-----------------•----.........•-•--••-•------------••--- NOV.......................................•---........------•--......-•----------....---•-••-----..._, Grantor, NOU 01987
and...__.Michael_R,..Long.................................... Of I/.30 A
------ `100 4
.........•--•--......--•....... , Grantee, ' Of09�
Witnesseth, That the said Grantor, for a_valuable consideration------
........---------•---•--...----•....................•-•-•------•--.....--•---......................-•----------
St. CrolX RETURN TO
conveys to Grantee the following described real estate in .................................. H__ywood,Cari and Murray
County, State of Wisconsin: i P.O.Box 229, Hudson, Wis.
Part of the SE4 of the NEk of Sec. 5, T29N, R19W _
described as Lot 1 of Certified Survey Map filed May 8,
1986, 'in Vol. .6 of C.S.M. ,, page 1648, Document 411677, Tax Parcel No:
MANS
$
j pia) (ia not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
4
And...Donna_M.-_Heir,-_Constance A. Becker and Daniel R. Bauer
... •-------------•-------•-------------•---------------------•---...--•-------•-
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements of
record, if any, and provided further that the warranties do not apply to that part of
maP•id lot which lies North of the "Existing Occupation (fenceline)" as shown on said
and will warrant and defend the same.
Dated this �? ------ day of ..........��y-......................................................
, 19.87.
- SEAL) ; l?-!... --..VIS4 L...........(SEAL)
* Constance A. -Becker . Donna M. Heir
•---•---••------ •------•--•----..._..--•-----...------•. nn ............... ------------------
AL) (lam_. --- -- ..` SEAL)
{ r
1 A. LADYS-- OTZ------ ------------- ' AaDi�l..?,�.. u x.................. -
M MINNESOTA
unty
AUTHENTICAT N ACKNOWLEDGMENT
of Daniel R-..-Bauer STATE OF �
Signatures)
._• - - ---- - - .- -
..................... ......• •••....._..............••--•-....-••-•-----••• Oran a as- -
:Z S.� -)x 7 8..: County.—
1-.. - authentic this .....__. a o ------------------
--------- Personally came before me this ................day of
...... ---------- --•-- - ------- ................................... --------------------------------------- 19.$�:_. the above•naTapd
J n D. Heywood .................... - ......... ._.. ......OFFICIAL SEAL i. �;�
Q PfE}FAiZ�C�t!•B E �Ai�FF?RdV�R j• -• =
- ----- -- ---
TITLE: MEMBER STATE BAR OF WISCONSIN `' �► :.;�, 4
(If not, ••--- -----••--••-••----...-•-- ,>`� OR�'Jf� - p 4t
authorized by $ 706.06, Wis. Stats.)
r CC.4NTV-•-------
m n to�ecFlly' lAN 22, 198$,z,� *
f 'rVgTi g 1 s men an nowl�ei�ge t ,,sa
THIS INSTRUMENT WAS DRAFTED BY 'r� i ' GA���'M
John D. Heywood, HEYWOOD
- .CARL & MURRAY. �r�t�ttlit°
----------------- ........................................................
P.O.-.Box 229_=_ Hudson;:Wisconsin 54016 Orange --_---_County, CA
Notary Public ------------ V
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.)
kn _- Please see Acknowledgment on z�r averse°��d�:-------""'•-----------°"--- 19---------
*Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Lelral Blank Co. Inc.
FORM No. 1—1982 Milwaukee, Wis.
HOW 802 PACE 434
DOCUMENT NO. STATE -BAR OF WISCONSIN FORM 3-1982 THIS SPACE RESERVED FOR RECORDING DATA
QUIT CLAIM DEED REGISTER'S OFFICE
�c Q' ST. CROM CO-t w1
Reed for R000td
.Constance A. Becker, a resident of Orange County, Feb. 5, 1988
...................
_ California 8:30 AM
----------------------------------------------------------•--------•---------------------------------------------
quit-claims to _Michael R._ Long,---•---- ...................................................
•-----•- ----- ---------------------------- -------- ---------------------- ------------------------ ----
-•--•--------------------------•--------- -----------------------.....------------------------------------------.
the following described real estate in ____St.__Croix---------------------_- County,
State of Wisconsin: RETURN TO
Hood, Cari & Murray
Part of the SEA of the NEB of Sec. 5, T29N, R19W P.O. Box 229, Hudson, WI
l _
described as Lot 1 of Certified Survey Map filed May 8'
Tax Parcel No- ------------------------------
i
FEE
EXEC .
This deed is given for a nominal consideration only to confirm a conveyance....,-. ..,,.-_.-- ,,. _
previously recorded. And it is not subject to payment of. the Wisconsin
Real_Estate Transfer Fee.
..µ
The' i ul `fee "and trans a ret�lti P��rd reported ant9"paidt
the deed from the above named grantor and others to the above named grantee .recorded
in Vol. 797, page 635A, Doc. 432546.
This ----i$_.no.t............ homestead property.
:*%* (is not)
Dated this k=1�------.-_. day of .............- December..... 19_.$7...
-----•---------•--•-••-------••-----•-•-------•-------- ---•----•--- SEAL '.r- JBI'.:!+�.C� ems',
• ( ) � -l ...(SEAL)
* -----••-----•------------•.....................••-----••--•••--•• * Co1?�.tanCe. A,. Becker.._
-----•-------•--•----- •--•--•-•----•-------•--••------------- ------(SEAL) ------- ............................................................(SEAL)
.............. ...................................................
AUTHENTICATION ACKNOWLEDGMENT
- ------ STATE OF CALIFO'RNI'A
a .. 0(`('ICI4L SEAL x --------------------------County.
. .......PHYLLIS A F'I\tX N Personally came before me this ..9__-_...•_._day of
NOTARY PUBLIC-"CALIF04A
I' I2e�eWbeX.................... 1931_. the above named
r a'
- Or73,fU6E-C(191V11'
-- ----- ----
?BY czmm. c�pires APR 12, 199] -D- - ---- -_A.-_Becker-------------
+.-s cal -- -
,,:•' ................................................................................
(If no£, �------------------------------- ------- -----------------------------•-------------
-------•-•-•-----. ----------------------------•--
authorized by § 706.06, Wis. State.) to me known to be the person..................
erson ____.,g__.._.. who executed the
foregoing instrument and
l acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY llis A. Pankin
John D. Heywood, Heywood, Cari & Murray r
---------- --------
-- -------------•----------. -------- ,_ 1 �
P.O. Box 229 Hudson WI 54016
•-•-- --- •-- '- ---------------------
-
--
- -----------•----------'--------------'----------------------------------- Notary P is ----- -Oran County.CA.
(Signatures may be authenticated or acknowledged. Both My Commission is perman .(If not, state expiration
are not necessary.)
date: .ArP91L......IZ
QUIT CLAIM DEED STATE BAR OP WTRCONSIN wisconein Legal Blank Co. Inc.
FORNI '. . , ;A J' I Milwaukee. Wis.
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SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
d
a
OWNER/BUYER / /L'f//I L 4/t,/Z,
ROUTE/BOX NUMBER // 7 S Sp Fire Number
CITY/STATE ZIP '_5C-/O/6
PROPERTY LOCATION : S,,,i� IVY ' Section �5 T ,--2 'F N , R /� W,
Town of ST t�CVS�r�� 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 licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St . Croix. County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1 , 1978 . St . Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their 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 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 . yo
I/WE, the undersigned , have read the above requirements and agree N
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- d
ment 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 . 9
SIGNED �C �
DATE f
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 .
DEP MENT OF REPORT ON SOIL BORINGS AND SAFETY&BUILDINGS
I ' UST,RY, DIVISION I
LABOR AND 1 P.O. BOX 7969
HUMAN RELATIONS PERCOLATION TESTS (115) MADISON,WI 53707
(H63.0911)& Chapter 145.045) j
LOCATION: ECTION: N UNICIPALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME:
SE43a% '14
COUNTY: OWNER'S UYER'S NAME: MAILING ADDRESS:
ST•caZ u vc ►� 'BaV RF Z 2,I U Em F., LL'S
DATES OBSERVATIONS MADE
USE (PROF D �IIONS: ESTS:
NO.BEDRMS : COMMER AL DESCRIPTION:
®,Residence - �, �. WNew ❑Replace 3 _ _ 8 _ 84i
RATING:S-Site suitable for system U=Site unsuitable for system
ONVE NAL: MOUND: IN-GROUND ESSU M-IN-FILL OLDING TANK:RECOMMENDED SYSTEM:(optional)
LAS E DU ®S I ❑S SU Z ��-,.� h es - efl s 'x ►��'
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)Ib),indicate: N'A• Floodplain,indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-Ifd*i*F!S' CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH ti>4 ELEVATION OBSERVED F-sT-TI-GHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
\•O' BnSi I TS; Z-'-1 'B►► s i
B- 1 (o•6' 96-C) `
2.2' 1.3 ' S1,2.Z'
B- Z 6.5' qs.o' t1 6•S
B-
it 1. 1 ' , o• q ' F3nSl : t -S ' ah Si
B- 4 G-lam' °l 6.6 �I > 6.6 Z Z. 3 I
B- C; � •$l a4 .0 t( 6•� ' 0•9' EsnSiD Ts;
1.�' 3nsi 1•I�QrIS�;3•)�1�n s
B- it
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PE RI_Q_1_ PERIOD2 PER INCH
P_ 1 3L 1.» 3D \ 1 30
ale to� 3� t /-z-
P- Z /
P- 3 36 No 30 l-11% 1-'�8 1 8
P' - 3 b'I -�
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 q ow their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope. 1Z1� REPI.I\cl'1�7.�T �hd�
SO 8v�2-hC�11iROT— SAl1'RE
® 'n \
SYSTEM ELEVATION 9 Z-It
1
11
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qF SYSr ..
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`S Q. O - � Sc11LE O = 60' tKc�"p_r hS S}4 t4"" S C C
SE - NCIy
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 the location of the tests are correct to the best of my knowledge and belief.
NAME(print : TESTS WERE COMPLETED ON:
Qcz'�tv2 �. w �G If-£3— $6
ADDRESS: Q:T LI 80X, -2-L to CERTIFICATION NUMBER: IPHONE NUMBER(optional):
��LSwoRTli ► s�ol 576 ►S—u2S—o16
CST SIGNATU E:
DISTRIBUTION:Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395(R.02/82) —OVER —
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