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County Sanitary Permit Application ST.CROIX COUNTY WISCONSIN
�q In accord with Chapert 12 St.Croix County Sanitary Ordinance PLANNING&ZONING DEPARTMENT
` tonal information you provide may be used for secondary purposes ST.CROIX COUNTY GOVERNMENT CENTER
�i4 r `�, - •( [Privacy Law.S.15.04(1)(m)] 1101 Carmichael Road
t r
Hudson WI 54016-7710
Q Q (715)386-4680 Fax(715)386-4686
'Attach complete plans forthAgeill 5T1"R3p2r flu!'lumthan B-1/2 x 11 inches in size.
J(J1;?Ajn-ty Sanitary Permit# ❑ Check us application
2-Q 1
I. Application in oration-Please Print all information Location:
Property Owner Name '
1 114 ,1/4,Sec
d C O r r e N, R (or)W
Property Owne s Mailing Address Lot Number Block Number
City,State Zip Code Phone Numer Subdivision Name or CSM Number
CA_), A 4C rl GtJt �Ye� 7 ��n e Z:
ll Type of Building: (check one) (amity ❑Village I,STown of
❑ 1 or 2 Family Dwelling-No.of Bedrooms: /
❑ Public/Commercial(describe use): Q S�
❑ State-owned Nearest Road
II.Type of Permit: (Check only one box on line A. Check box on line B if applicable) CC2 7X ,}�v�+
Parcel Tax Number(s)
A) 1.0 Repair 12.El Reconnection 3.MNOn-p/Nn-plumbing 4.E]Rejuvenation fJ® � �4fA'
Sanitation KJ
B) Permit Number Date Issued❑ State Sanitary Permit was previously issued
IV.Type of POWT System: (Check all that apply)
❑ Non-pressurized In-ground ❑ Mound? 24 in.suitable soil ❑ Mound<_24 in.suitable soil ❑ Mound A+0
❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line
❑ Pressurized In-ground �olding Tank qC,.JL}- W;; ❑ Single Pass ❑ Other
❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating
V.Dispersal/Treatment Area information:
1.Design Flow(gpd) 2.Dispersal Area 3.Dispersal Area 4.Soil Application Rate 5.Percolation Rate 6.System Elevation 7.Final Grade
Required Proposed (Gals./day/sq.ft.) (Min./inch) Elevation
VI. Tank information Capaicty in Gallons Total #of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks 3
Zb ; 0 ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
VII.Responsibility Statement
1,the undersigned,assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the installation of non-plumbing sanitation system.
Plumber's Name(print) Plumber's Signature(no stamps): MPIMPRS No. Business Phone Number
fit/
Plumber's Address(Street,City,State,Zip Code)
VIII.County Pse Only
DD= Permit Fee Date Issued Issuin gent Sign r stamp
Approved Owner Given I '' N
Set n Ie
IX.Cond►'ons of Approval/Reasons for Disapproval: raJ� t
Vao(-� r.�� M06 -- bL �, 6
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II— C ix• Building Permits
I LLr.0 Site Plan Form
iX,
(See reverse for check list and sample)
1810 Crest View Drive, Suite#1 C
Hudson, WI 54016
715-377-2152
b O Ave.
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Name and Property Address: je— _e.
I certify that the above Site Plan is a true representation of this lot and accurately shows all dimensions, easements,and
proposed and existing structures on said lot. Any deviation from this approved Site Plan may void the Permit
Signature of Owner/Builder or Contractor: Date:
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ConCBETE V. N0. 3
�n Z SEPTIC MANUAL W3716 US HWY 10 MAIDEN ROCK, WI 54750 DATE: JANUARY 2012 DATE:. 3 20 12 POST-POUR:
° REVISED ,IAN. 2012 800-325-8456 FILE: V020-dR
Il llllllllflllllllllllllll ll 111
State Bar of Wisconsin Form 1-2003 8 1 3 4 2 3 5
WARRANTY DEED Tx:4108524
973679
Document Number Document Name BETH PABST
REGISTER OF DEEDS
ST. CROIX CO., WI
THIS DEED,made between Daniel P.O'Neill,Mary S.Amundsen,Thomas O. 02/20/2013 3:59 PM
O'Neill,Timothy H.O'Neill and Nancy Kathleen O'Neill EXEMPT#: NA
REC FEE: 30.00
("Grantor,"whether one or more),and Joseph B.Borntreger and Wilma A. TRANS FEE: 900.00
Borntreger PAGES: 2
("Grantee,"whether one or more).
Grantor for a valuable consideration,conveys to Grantee the following described real Recording Area
estate,together with the rents,profits,fixtures and other appurtenant interests, in Name and Return Address
St.Croix County,State of Wisconsin("Property")(if more space is David J.Estreen
needed,please attach addendum): 304 Locust St.
Hudson,WI 54016
See Exhibit A lc Awl 1�'-b-So)U ,QLs
CCU-_M%-V-CW 004-1008-50-000 1 Cb 4-1 cm-916-WO
Parcel Identification Number(PIN)
This IS NOT homestead property.
(is)(is not)
Grantor warrants that the title to the Property is good,indefeasible,in fee simple and free and clear of encumbrances except:
Easements,restrictions and right-of-way of record,if any.
Dated / / G
*Nancy Vtb1 n O' e' (SEAL)
/ (SEAL) / (SEAL)
* Dan' I P.O' ll ' *Thomas O.O'
(SEAL)
*Mary ridsen * y H.O'Neill
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF
ss.
authenticated on COUNTY)
Personally came before me on
* e above-named�Q�(p� �' en 1
TITLE:MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person(s) who executed the oregoingg Ne'U
authorized by Wis.Stat. §706.06) instrument and acknowled PA e same.
THIS INSTRUMENT DRAFTED B Mgjppfy SCHMITZ*
Attorney David J. Estreen Untm Plablic Notary Pu ic,State of
304 Locust St.Hudson,WI 54016 $110 of ftconsiflMy Comm ion(is pe anent)(expires:
(Si c i. loth are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATION TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
WARRANTY DEED 02003 STA'L'E BAR OF WISCONSIN FORM NO.1-2003
jTdIlpamc below signatures. INFO-PROTM Legal Forms•(800)655-2027-infoproWms.com
i
I
LEGAL DESCRIPTION
EXHIBIT A
The East Half of the Northwest Quarter(E 1/2 of NW 114)of Section Four(4),Township Twenty-eight(28)North
of Range Fifteen(15)West, St.Croix County,Wisconsin,excepting therefrom the following described parcel:
Beginning at the Northeast corner of said East Half of the Northwest Quarter(E 1/2 of NW 1/4) of Section Four
(4),Township Twenty-eight(28) North, Range Fifteen(15)West,thence West 335 feet parallel to the South line
of said East Half of the Northwest Quarter(E 1/2 of NW 114),thence South 950 feet,thence East 335 feet,
thence North 950 feet to the place of beginning.
AND ALSO
The Northeast Quarter of the Southwest Quarter(NE 1/4 of SW 1/4)of Section Four(4),Township Twenty-eight
(28)North, Range Fifteen (15)West, St. Croix County,Wisconsin, lying North of Interstate Highway.
I
(12-4385S.P F D/12-43855135)
PJ�F2ereated with pdfFactory trial version www.pdffactory.com
8260936
Document Number Document Title TX:4213298
St. Croix County 1002538
BETH PABST
Non-Plumbing Sanitation Affidavit REGISTER OF DEEDS
ST. CROIX CO., WI
C1ej5,gu'Nfr- RECEIVED FOR RECORD
Name'—(Owner) Typel or printed 10/06/2014 12:57 PM
being duly sworn,states,under oath,that: EXEMPT #:
REC FEE: 30.00
He/she is the owner of th e following ollowin parcel of land located in St. PAGES: 1
Croix County,Wisconsin,recorded in Volume " Page ---
Document Numberq`3(,ZgSt. Croix County Register of Deeds Office: Recordin Area
Name and Return Address
A parcel of land located in part of the 'fAof the([(/'/ of Section Josr�/1 !3%yo►°v►7're�e r
T_�� N—RAW, Town of , St. Croix ay.75, (,OYh /eve
County, Wisconsin,being duly described as follows (include lot no.
�so�i !�f/, 5Y'o� 7
and subdivision/CSM or detailed legal description): - -
tG � GAG P41 () Parcel IdentificationNumber(PIN)
`V(,1. A new structure on this lot will be used as a habitable dwelling,but will contain no plumbing for potable water and/or
wastewater. Occupants of said structure utilize a vault privy for disposal of human waste,which was authorized by a non-
plumbing sanitation permit in compliance with Sections 12.A. l.g and 12.3a.2 of the county sanitary ordinance.
2. No plumbing may be installed in the premises served by the non-plumbing sanitation device until a sanitary permit has
been obtained for installation of a code-compliant POWTS.
3. The contents of the vault shall be disposed in accordance with NR 1 l 3,Wis.Adm.Code.
4. This agreement shall be binding on the owner,their heirs,assignees and/or land contract purchaser.
I also acknowledge that I will disclose this information to any parties interested in purchasing this property in the future.
Dated this :2 _day of t�GT a a
i
�al It R &V a7`✓fa Q R
*
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
)ss.
St.Croix County. )
authenticated this day of Personally came before me this day of 0
e':�n I L4 the above named
to me known to be
TITLE: MEMBER STATE BAR OF WISCONSIN the person(s)who executed_thet•foregoing�nstrument and acknowledge the
(If not, same.
authorized by§706.06,Wis.Stats.) �~
TMS INSTRUMENT WAS DRAFTED BY t`'"• * ! Fl.
M.
Notary Public,Stat i 6 c f isconsta '�',
(Signatures may be authenticated or acknowledged. Both are not My Commission is'p 'ne£ ;l not,s te.a3�ptration date:
necessary.) Date:
12- .
"THIS PAGE IS PART OF THIS LEGAL DOCUMENT—DO NOT REMOVE"
This information must be completed by submitter: document title,name&return address.and PIN(if required). Other information such as the granting
clauses,leagal description,etc.maybe placed on this first page of the document or maybe placed on additional pages of the document.Note: Use of/his
cover page adds one o e to your document and$2.00 to the recording fee. Wisconsin Statutes,59.43.
St. Croix County 102 38 Page 1 of 1
State of Wisconsin,Department of Natural Resources Farmer Non-Commercial Septage
Farmer Certification
PO Box 7921 Operator Certification Application
Madison WI 53707-7921 Form 3400-194 (2/08)
Notice: Use of this form is required if you wish to receive a Farmer Septage Operator Certification. The certification in required under s.281.17(3),
Wis.Stats.Personal information collected is used for program administration and enforcement.Wisconsin's open records law requires the department
to provide most information to requesters[s.19.31 to 19.39,Wis.Stats.].
Department Use Only—Operator Number
Applicant Information
Name j� County
C Sr ca r k
Address t Work Telephone Number Home Telephone Number
ze- G.. c 41d/y1=_
City IState IP Code E-mail Address(optional)
f/Q
C�1r �r 5' � '7
Septage Land Application Information
Septage Holding Tank Size Estimated Pumping Frequency otal Agricultural Production Acres
Existing Cover Crop on Proposed Application Site (Note: Land must remain in active agricultur I production.)
Do you have sufficient acreage that meets the requirements of ch. NR 113, Wis.Admin. Code? ®Yes ❑No
Do you plan to land apply septage in the winter? ❑Yes 0 No
Is the proposed site acceptable for winter application based on the following requirements? I�Yes E]FV
No
1. Slope must be less than or equal to 2%.
2. Waste application cannot exceed 10,000 gallons per acre per winter.
3. Waste cannot be applied within 750 feet of surface water or wetlands.
4. Waste cannot be applied in a floodplain.
How will pathogen and vector control requirements be met? (select one)
F1 Direct injection ❑Incorporate within 6 hours ®Elevate pH to 12 for 30 minutes before application
Do you have a vehicle or farm implement capable of uniform waste application? ❑Yes ❑No W;11 plo vide—
Do you need to drive on a public roadway to access the proposed application site? ❑Yes ,®No
Required Attachments-Provide 2 copies of each (Contact your County Conservationist if necessary)
1. Aerial photo showing the septage tank and proposed application site.
2. A map showing the farm and proposed application site and property boundary.
3. Soil survey map for the proposed application site.
Operator Certification
By signing this form, I certify that the information provided is correct and I have received and understand the requirements of NR 113,
Wis.Admin. Code.
Operator. ignature Date Signed
Mail is cor6pleted application to: ate of Wisconsin
Department of Natural Resources
Farmer Certification
PO Box 7921
Madison WI 53707-7921
�G
Pursuant to ss.299.07 and 299.08,Wis. Stats., a social security number is REQUIRED when applying for a WDNR license or
certification.The number may not be disclosed to anyone except the Wisconsin Department of Workforce Development or the
Department of Revenue for child support and tax purposes. THE SOCIAL SECURITY NUMBER WILL NOT BE RETAINED IN,THE
PAPER RECORDS.
Social Security Number of Operator
State of Wisconsin
DEPARTMENT OF NATURAL RESOURCES Scott Walker, Governor
101 S.Webster Street Cathy Stepp,Secretary
Box 7921 Telephone 608-266-2621
Madison Wl 53707-7921 FAX 608-267-3579 wsc
TTY Access via relay-711 Derr aeateau R�souAs
Farmer Non-Commercial Septage Operator Certification
Dear Applicant:
Wisconsin Act 347 was signed into law on April 29,2006 to allow farmers the ability to land apply their own
holding tank waste unto owned or leased parcels. The intent of the Act was to eliminate misuse of the exemption
under previous law which was done primarily by non-farmers who were not actually eligible for the exemption. It
was not the intent to penalize true farmers operating in compliance with the terms of the exemption. The
Department is not opposed to allowing true farmers the ability to land apply their waste in an environmentally
sound manner. This Act created an application process and now defines who is eligible for the exemption:true
farmers generating their own waste who have a minimum of 40 acres of land in active agricultural production.
Fees, certification exams, and other requirements are waived.However, at a minimum you must meet the
following requirements of chapter NR 113 Wis.Adm. Code:
1. The holding tank must be located on the same parcel of land where the septage will be land applied.
Parcel of land means that it is contiguous, although it can be divided by a road or railroad track, and under
the same ownership interest.
2. You must own or lease at least a 40 acre contiguous parcel of land which is in use for agricultural
purposes.
3. Sufficient land must be included in the 40 acre parcel which meets the department requirements(see
below)for land application and which can adequately receive the projected volume of wastewater.
4. You must comply with all applicable statutes and rules in removing and land applying the wastewater.
5. Keep records of when you pump,how much is pumped,where it is applied, and how it is applied.
6. You must report all pumping activity to your County when requested.Failure to report may result in a
suspended or revoked certification.
Minimum land application and other requirements which you will need to satisfy include the following site
restrictions(please see Chapter NR 113,Wis.Adm. Code for more detail as this is not an exhaustive list):
• At least 3 feet of depth to groundwater or bedrock
• Soil permeability of no greater than 6 inches per hour in the top three feet of soil
• At least 250 feet of separation to a private well and 1000 feet to a public well
• At least 250 feet of separation to a home or business with approval(500 feet without approval)Note this
distance may be reduced further if the septage is injected or incorporated
• At least 1000 feet from a rural school or health care facility
• Slope must be less than 6%if surface applied or 12%if injected or incorporated(less than 2%if frozen or
snow covered)
• At least 200 feet from any surface water, including wetlands or sinkholes(may be reduced if injected or
incorporated)—750 feet if frozen or snow covered
• No more than 3,000 gallons per week may be applied to the same parcel of land(no more than 10,000
total gallons per acre on frozen or snow covered ground).
• You must report each pumping event to your County according to their requirements
• The holding tank waste must either be injected, incorporated (disced or plowed under within 6 hours), or
hydrated lime must be added to it to raise the pH to 12 and held there for 30 minutes.
• There is a 30 day restriction for animal grazing or public access to the field.
d nrmi.gov
wisconsin.gov Naturally 1 , ISCONSIN Pnraedw
Recycb0
Paper
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• You must have a watertight implement which can pump your tank and land apply it in a uniform pattern.
You should not need to drive on a public roadway other than to cross one, in order to access your field.
The above requirements are to protect the public health and environment and include federal as well as state
regulations.
Complete and submit form 3400-194 Farmer Non-Commercial Septage Operator Certificate along with a plat
map,soil survey map with soil type shown, and an aerial photo. These maps are available from your County
Conservationist.On each map, outline the field to which you will apply the waste clearly marking the area which
meets the above requirements.Note on the aerial photo the location of any homes or drinking wells and the
location of the holding tank.
If you meet the above requirements you will be approved for this certification and you will be able to pump and
land apply your own holding tank waste on your approved agricultural land.
To get your questions answered about this certification by emailing the Farmer Certification Program at
DNROpCertSeptage @wisconsin.gov
To apply, submit the application and required maps to your local DNR office.
Coordinator Name Iffm r aAEV.341011
South Central Region Columbia, Crawford, Dane, Dodge,
Horicon Service Center Stephen Warmer
N7725 Highway 28 924-387-7570 Grant, Green, Iowa, Jefferson;
Horicon WL 53032 Lafayette, Richland, Rock, Sauk
Southeast Region Kenosha, Milwaukee, ozaukee,
2340 N Dr Martin.Luther King Jr Kimberly Thomas-Britt Racine, Sheboygan, walworth,
Dr 414-263-8635 Washington, Waukesha
Milwaukee W1 53212
Brown, Calumet,Door,Fond du Lac,
Northeast Region Heidi Schmitt Green Lake, Kewaunee, Manitowoc,
2984 Shawano Ave Marquez Marinette,Marquette,Menominee,
Green Bay WI 54313 920-562-5145 Oconto, Outagamie,Shawano,
Waupaca, Waushara, Winnebago,
West Central Region Adams, Buffalo, Chippewa, Clark,
Black River Falls Office Jeanne Calhoun Dunn,Eau Claire, Jackson,Juneau,
910 Highway 54 E 715-284-1462 LaCrosse, Marathon, Monroe, Pepin,
Black River Falls WI 54615 Pierce, Portage, St. Croix,
Trempealeau, Vernon, Wood
Ashland, Barron, £ayfield, Bumett,
Northern Region Douglas, Florence, Forest, Iron,
875 S 4th Ave Alison Conniff Douglas, Lincoln,Oneida,Polk, Price,
Park Falls W1 54552 715-762-1361 Rusk, Sawyer,Taylor,Vilas,
Washburn