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PUMP CHAMBER «+►
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size ,
Elevation of inlet: Bottom of tank elevation:
Pump off switch elevation: Gallons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, O Rear,0 Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: DL Trench:
Width: / 2 Lenith: ��� Number of Lines:J„-cr Area Built
Fill depth to top of pipe: 0715 "
Number of feet from nearest property line: Front, O Side, Rear,O Ft . rO ,
Number of feet from well:
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, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: / Plumber on job:
License Number: /i1j, 45 d'
3/84:m3
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER -S T� "/ .. TOWNSHIPa'��, <_ SEC. ° T N-R % W
ADDRESS �!� `. y,R/ ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE V_-
PLAN VIEW
Distances and dimensions to meet requirements of I•I,HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
i
J
i
i`
J
7 J
�41
� - INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used S'�...: •g / /j""
rte.
Elevation of vertical reference point: 1a,-Y, � ° _ Proposed slope at site: G i
SEPTIC TANK: Manufacturer: L�/d.; �._� Liquid Capacity:
Number of rings used: C Tank manhole cover elevation:
Tank Inlet Elevation:-LM—HA Tank Outlet Elevation: g R.lp
Number of feet from nearest Road: Front 10 Side 0 Rear, O /rjQ" feet
From nearest- property line Front 10 Side,O Rear,O feet
Number of feet from: well �� , building: l4
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O.,BOX 7969 BUREAU OF PLUMBING
MJDISON W`1 37 07
SE3a, SW1�;S N,%28N—R19W CONVENTIONAL 1:1 ALTERNATIVE State Plan I.D.Number:
Town of Troy ❑ (If assigned)
❑ ❑
Holding Tank In-Ground Pressure Mound
091=44 W
NAME OF PERMIT HOLDER: ADDRFSS OF PERMIT Hot DER INSPECTI N A E:
Roger E. .Mor7ris: Route 2-, Hudson, WI 54016 � � f
BENCH M RK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PL ELEV..
r,
Name of Plumber: MP/MPRSW No.-. County Sanitary Permit Number:
William Schuma er 6382 St. Croix T 96003
SEPTIC TANK/HOLDING TANK:
MANUFAC R: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
� � I — D, /� /�� P O IDES: PROVIDED
(7/ YES ❑NO ❑YES E
BEDDING: VENT DIA.: VENT MAT HIGH WATER NUMBER CIF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM. FEET FROM. /CIO LINE: ^/ �� Id AIR INLET FiA]YES NO ❑YES NO NEAREST !% `//y
DOSING CHAMBER:
MANUFACTURER: r-
ING DD : LIQUID CAPACITY PUMP M PUMP/SIPHON MANUFACTURER. WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
YES ❑NO OYES ❑NO OYES ONO
GALLONS PER CYCLE: PUMP AND C R ERATIONAL NUMBER OF IPROPERTY IWELL ILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET:
PUMP ON AND OFF) ❑ e El NO NEAREST;
SOIL ABSORPTION SYSTEM.Check the soil moisture at the qePA f plowing FORCE L vGTH ]DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construct ion'shalI cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
"WIDTH LENGTH NO.OF DISTR.PIPE SPACING. COVER INSIDE DIA.. #PITS. ILIQUID
F}E13lT1iENCH / / TRENCHES M TERIA L: PIT DEPTH:
=�'iI1111E111'.k��3N5 J/ l/Gi's _
GRAVEL DEPTH "FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATERIAL. NO ST UMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH FEET FROM BELOW PIPES ABOVE COVER ELEV.INLET.ELEV END PIP S. LINfE AIf�NLET:
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 crit is for medium sand. TIONS MEASURED.
DYES ONO
SOIL COVER TEXTURE: PERMANENT MARKERS OBSERVATION WELLS
EYES ENO OYES 0 N
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPT F TO SOIL. �, SODDED SEEDED. MULCHED:
CENTER EDGES ". ❑YES ❑NO
❑YES ❑NO EYES ONO
PRESSURIZED DISTRIBUTION SYSTEM:
`.WIDTH. LENGTH. NO.OF LA FAIL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER
EtYiRENCt) TRENCHES
E R
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL. NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING:
ELEV.: ELEV: CIA.. ELEV.. PIPES: DI A.:
011"t AT°ION�N�
T Nt°°d HOLE SIZE HOLE SPACING. DRILLED CORRECTLY. COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED
FkHMATTN, PLANS
YES
El NO ❑YES
NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF LRnOE ERTV WELL: BUILDING:
❑YES ❑NO —]YES ❑NO NEA1 --
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURES � \ TITLE
DILHR SBD 6710 (R.01/82) . Zoning Adminis trator
SANITARY PERMIT &T at) i � COUNTY
'ZIVILHR TRANSFER/RENEWAL UNIFORM PERMIT 4#
(PLB 67-T) y 10 W3
PERMIT RENEWAL DATE: PERMIT TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D.NUMBER:
j �7 C9 —Icc_ 9 -7
PROPERTY LOCATION: CITY:
VILLAGE: rk
1= '/o S&3 '/o,S 19,T N,R 19 E (or TowN o /
LOT NUMBER: BLOCK NUMBER: SUBDIVISION NAME: NEAREST ROAD, LAKE OR LANDMARK:
Lj
PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO:
NAME: SIGN TUBE: N ME: PHONE NUMBER:
'T a ET'r_PS '� 0 9��' �, ty-)Ioc,c,,s
ADDRESS: D
fo� � r \ ��� ', � I PHONE NUMBER: �
S ' ,� C�-e 0I �0
I, the undersigned, hereby assume responsibility for installation of the private sewage system that has previously been approved for this
property.
PL/UMPER'S_SIGNATURE: PREVIOUS PLUMBER'S NAME (IF CHANGED):
PLUMBER'S ADDRESS: PREVIOUS PLUMBER'S ADDRESS:
M / PRSW NUMBER: PHONE NUMBER: MP/MPRSW NUMBER: PHONE NUMBER:
( 9d;�;!) 3/d l I ( )
SIGN TURE OF ISSUING AGEN DATE APPROVED: DISTRIBUTION: Original-County
9 /J r,> Copy-Bureau of Plumbing
• / Copy-Owner
DILHR-SBD-6399 (R. 5/82) Copy-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;
I1. 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:
III. 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'/2 x11 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 04#.
included the creation of surcharges (fees)for a number, of regulated practices whioh•- Wisco iCt`S e
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water tha` buried Tea5ttrB
is used in your building is returned t�,) the groundwater through your soil absorption o
system or the disposal site used by your holding tank pumper.
a
ThL monies coiie..tec through these surcharges ar,. credited to th., groundwater fund adminis
I
9 9 9
t, Resources.n n r � ground-
water,b .the Department . f Natural R_source.l. These funds are used for mon torin rour d
Y p 99
f
water, groundwater contamination investigations and establishmert of standards. Groundwater,
;t's worth protecting.
3D ?98(8.03/86)
DIL R SANITARY PERMIT APPLICATION COUNT C i ?Di
In accord with ILHR 83.05,Wis.Adm.Code
STAT�SANITARY PERMIT#
—Attach complete 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 IfKS) NO
PROPERTY OWNER PROPERTY LOCATION
4Fdl,, S /07 T,;?-F-, IV, R / E(or
PROPERTY OWNER'S MAff ING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
5''' � � � .✓ — � Q,VILLAGE: �----
II. TYPE OF BUILDING OR USE SERVED: O'VO—1o7
Number of Bedrooms if 1 or 2 Family 2 OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in##1. Check##2,3 or 4,if applicable)
I
1. a. ILI-New 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. &onventional b. ❑Alternative c. ❑ Experimental
2. a. ❑System- b. ❑ Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP
In-Fill Tank
V. ABSORPTION SYSTEM INFORMATION: (Check one)
1. a. [N Seepage Bed b. ❑seepage Trench c. ❑ See a e 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):
7 I:r'
,l / � Feet -Private El Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total ##of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank or Holding Tank 1)c
Lift Pump Tank/Siphon Chamber ❑ I Lj Lj ❑ I Li
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Plumber's Name(Print): / Plumber's Signature:(No Stamps) P PRSW No.: Business Phone Number:
Plumber's Address(Street,City,State,Zip Code): Name of Designer:
Vlll. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#
3.2
CST's ADDRESS(Street,City,State,ffp Ci5der Phone Number:
L
7
IX. COUNTY/DEPARTMENT USE ONLY
p� ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
Lpl Approved ❑ Owner Given Initial S �harrge Fee /� /� )
Adverse Determination `41w'� ^-' vU `'�/�^� ` � / " ) . � 0
X. CO MENTS/RE ONS FOR DISAPPROVAL:
fah � iby 7Xc>rins ASV
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
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 ZO 12eU-
Location of Property S� Spiv , Section 119 , T N-R W
Township
Mailing Address / �,�s o„/ u. y r%l
Address of Site _R;2- ��� S'di✓ �e �c�
Subdivision Name
. Lot Number
e
Previous Owner of Property
Total Size of Parcels
Date Parcel was Created
Are all corners and lot lines identifiable? Yea No
Is this property being developed for resale (spec house) ?1 Yes No
Volume /, and Page Number 1,2 as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
I
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
I ((ve) CcAti6y that atC z ta.temewtA on this ahe hue to .the bent o 6 my (ouh)
hnowtedge; .that I (we) am (ahe) -the ownen(h foAm
06 the pnopeJrty duchi.bed in .thiA
.in6okmati.on 6onm, by viAtue 06 a waAAan.ty deed neconded in the 066ice o6 the
Count RepAteA o6 Veedh ah Voeument No. � 5-; and that I (We) pnehenttty
awn .the phopoeed site bon the sewage d"posa.Z hy�s em (on. I (we) have obtained an
ea.hement, to nun with the above deachibed pnopehty, OIL the eon,atnucti.on o6 eaid
eya.tem, and the dame hae ,b"n duty neconded in the 066.ice o6 the County Reg,i.eteA o6
Vttd6, as Poeme.n t No. 47`2- 71,'Z Ste) .
SIGNATURE OI? OWN R SIGNATURE 0 CO- WNER (IF APPLICABLE)
DATE SI D DATE SIGNED
DCCUMVff NO. MATR "R Of WUK*XM YOM 1—M I**OEM sunnow P"=woo*am
WARRMY ono
#&IMTM
ST.COM=6 was
This Deed. =a&
........... .. ..........................................................
..................................................... M"to Mori M% .
..Ri c aur-4-91Lmus... ....LialLAM................................
.....................................................................................................
...................................................
.............
........WAAD.U14-jod..Visa...an...§UrY1.YQr.ahU..JA4r.1tA1.....
............. .................................................................................
........................................
Witn:::* t, That the said Onater. fSr a T8111"0011111111dwstim......
........Q.r4At.Qr........................................I.................................. .......
conveys to Grantee the following described real estate is ......at......Qx.Q .......
County, State of Wiscesgia:
Lot 1, Certified Survey Map filed Taz Faced No:
September 269 1980, in Volume 4, Page
993, Document No. 366634.
TOGETHER WITH a 66 '.foo!t easement for ingress and egress as
shown on said Certified Survey Map.,
Also, together with a permanent easement as described in Vol.
567, Page 208, Doc. No. 345657•
tin 0
is not
This ...._ .. ........ beemetead property.
6W(Wi;;i)
Together
apd Singular do bereditumeate and appurtenances tbareunto belonging;
MAnse 0
And..........................................................................................................................................................
warrants that the title is good. hmWeas" in too simple and free and clear of encumbrances except
easements, restrictions and rights-of-way of record, if any.
and will warrant and defend the
Datedthis .....................Z6....................... day of ............?.%.y.................................................I
........(SEAL) ... ..... ..............
...........................................................
• • ............Elchard-Cherrty ....................
.....................................................................(SEAL) . ....................................................................MAL)
• .................................................................. • ..................................................................
AUTNZNTICATION ACKNOWLNDGMXNT
Signatu"(4) STATZ OF WISCONSIN
............................26........................................... ......................................
antben ted ............. U-17 Personally cam before aw this
..
-,ee ......... ........................................ .I le...........—...tM ebme 200M
.......... ......................... ................................................ . .
Kristinag�� ...�4.n..d..e...e..n..
..... ... .....................................................
-*- --- ---------_
TITLE: MEMBER STATE MR OF
WISCONSIN .......................................................
(If Uok..................................................:......... ........................................................................
authorized by 1 906.06.WiL Stets.) to me known to be the persoa ............ who smearI , the
foregoing instrument and aclawwledge the wMe,
THIS INSTRUMZNT WAS CMAFT90 By
Kristin Og land Lundeen ...............................................................................
.........A.,.f 5ifiiFi **uw...—*--------*-*** ...............................................................................
................................................................................ Notary Public ..........................................CMAtT,'WU
(Signature may be autimUcated •
or admowledgod. Both my Commission is Permanent.(If not. state amba"M
are not n*ceuary.) date: ........................................................Ile.........
•X&MM of pff"M&6aj&g in S"e&&wjW qpboom be tro"w pAMM Glow t►ak*16MMUM".
WASAAM" DSiD sAa-gr wommum
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DESCRIPTION
A parcej of land located in the SE-1/4 of the SIV1 14 of Section 19 , T28N , R19IV ,
Town of Troy described as follows : Commencing at 'the S1 /4 corner of said
Section 19 ; thence NO ° 13 ' 50"L' (true bearing) 1305 . 30 ' along the East line
of said SIV1 14 ; thence N89° 38 ' IV 660 . 00 ' along the North line of said SE1/4
of the SIV1 14 to the point of beginning ; thence S0 ° 13 ' 50"IV 330 . 00 ' ; therrce
S89038113 S89°38 ' 581 . 93 ' ; thence S0055152"E 322 . 81 ' along the Westerly right-of-way 1
' line of present County Trunk highway "F" ; thence N89°42 ' IV 1221 . 10 ' along
the South line- of the N1 12 of said SEI/4 of the SW1 14 ; thence NO ° 10130"IV
654 . 171 ; ' tlience S890381E 637 . 26 ' along said North line of the SEl/4 of the
SIV1 14 to the point of beginning .
Contains 13 . 87 acres , more or less .
I certify that the above description and map are correct and that I have
fully complied with the provisions of Sec . 236 . 34 of the Wisconsin Statutes
and Section 5 . 4 . 2 of the St . Croix Coun Zoning Ordinance .
Date : October 19 , 1979 . � .
Zevised Date: February 27, 1980. Francis •11 . Ogden S- 88.2 Job No . 1196
Ogden Engineering Co .
SGOI�S����'', River � Falls , Wisconsin 54022
'FRANCIS H.
OGDEN = I hereby certify that this map has been approved
5.882 = by the Town Board .
RIVER FALLS.
-j,
Wis. f e Date
U R
LEGEND
(tb SECTION CORNER MONUMENT FOUND , BERNTSEN CAP
® 1" IRON PIPE WEIGHING 1 . 68H/LINEAL FOOT, FOUND
O 1" x 24" IRON , PIPE WEIGHING 1 . 68# /LINEAL FOOT, SET
x EXISTING FENCE LINE
CURVE DATA TABLE
RVE NO. LOT NO. RADIUS WORD BEARING CIIORD LL•NG11I CENTRAL ANGLE
2 80.00' N23 019'41"E 147.32' 225 055 '22"
3 80.00' N38 007 '39"IV 125. 23' 103000142"
4 80.001 . N74 050102"L• 140.55 ' 1.22 054140"
')URVEYED FOR OWNERS
,IC:K CHERRY AND STEVE PETERSON Steven L . Peterson
727 Mc KNIGHT ROAD Richard A . Cherry
ORTII ST. PAUL , MINNESOTA SS109 Gregory K . fled
2727-McKnight Road
I'E : THIS CERTIFI1D SURVEY HAP REPLACES N . St . Paul , Minn . 55109
TIFF CERTIFIED SURVEY MAP RI:CORDL•U
Mr . F, Mrs . Richard Jackson
NV—OLUME 2 , PA7CE 556 , DOCUMENT 1424 Hallam# 346822 . Mahtomedi , Minnesota 55115
,ICY OF 11IE SI'. CROIX COUNTY MUIRMENSIVL• PARKS PLANNING AND ZONING COI MI'IT'EE
roadway—s}iowm oil ti—lis map is a private 'roadway. Any mai.ntemince costs of the private road-
, after its approval by the Zoning Administrator as a standard road, shall be shared p;t"o-rat
is iristtZVrtent draCtcd by Robert K. Krisak. by the adjoining property owners. Shotiltl the
• . roadway be urken over by a rnuniciprr 1 i ey as
a public road, mainten.nnce costs thereafter
would be a public expense.
w
Vol urne 993
H
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ST C - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT Ho
St . Croix County z
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OWNER/BUYER �e Eger m.s rr r_�
ROUTE/BOX NUMBER �� Cp ,� ..�So,-�-f Fire Number
CITY/STATE /ya�SC,✓ G`� *T ZIP � � lC
PROPERTY LOCATION : _1Z, Section , T o27 N , R �� W,
i
Town of lre t St . Croix County ,
Subdivision Gs 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 If
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. Ho
I/WE, the undersigned , have read the above requirements and agree c~n
to maintain the private sewage disposal system in accordance with x
H
the standards set forth , herein , as set by the Wisconsin Depart- 'v
ment of Natural Resources . Certification form must be completed
and returned to the St . Croix County 'boning 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 .
APPLICATION FOR SANITARY PERMIT
STC - 100
i
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 fora should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.,
- -- - - - - - - - - - -
Owner of Property ::5 C&U
I.ucat tun of Property — ,... J k, Section , T N - R W
Tuwusliip �Y,f ,/
M.►11 ing Address c=�7-y-+yl
Subdivision Name
Lot Number ,
Previous Owner of Property
'1'utal Size of Parcel
U:ete Parcel was Created
Arc all corners and lot lines identifiable? ;_ Yes No
Lb Lids property being developed for resale (spec house) ? �_ you _ No
Vulw�€ 7 and Page Number ,�.�• as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
1, Land Contract
J. Other recordings filed with the Register of Deeds Office
In addition, a certified survey, if available, would be helpful so as to avoid delays
,)I the reviewing process. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
PROPERTY OWNER CERTIFICATION
1 (we) ee ti.6y that aU ata.temen.ta on thiA. 6ohm ane t4ue to the beat o6 my luuA)
ItnuwIedge; boat I (we) am (ane) the owneA(a) o6 the pnopen,ty deaeAibed in .t;"
016u4mati.un 6u4m, by vi4tue o6 a wax4anty deed neco,%ded in .the .O66ice o6 tj►e
Cuuri t y RegiAteA 06 Deeds as Document No. IF ; and that I (we)
pheae t,Uy own .the.pkoposed .bite bon the a i-i peaaweyarem lun I (we) have
ub.tai.►►ed an eaa em-ent,__�to hun with the above deaeh.i.hed pa.openty, bon the
eu►tetAucti.un o6 aai.d system, and the aame has been day %econded in the 066.ice
U4 -Die Co Reg4'A 06 Deeda,. as Document No.
IL;N RE RF OW 9-K- SIGNATURE OF CO-OWNER (IF APPLICABLE)
U 1'E S NED DATE SIGNE'U
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parcel of land located in the St of tM
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• SEPTIC TANK NAINTENA CE ACKEFMEN'r o
St . Craig goat
U
y
UWNEk/BUYEK ,�s�Y°LJ /�� ✓ `�''
KOUTE/BOX NUMBER ld�S L��C��r�7`n _.. = ___Fire Number
•
C ITY/STATE _G 11'
rKUPEKTY LOCATION : S� �G. �'� 14, Section.__ , T___;2 N , N / "W '
Town of P St . Croix County ,
Sub4$vision . Lot uumber�__.
• I
improper use, and maintenance of your septic byst. iu could result in
its premature failure to handle wastes . Proper u►aintenanCe con-
sibts ui pumping out the septic tank every t1irce years ur buunvr , I
it needed . by a licensed sus tic tank pu!M r . What yC)u put into
the system can affect the function o"f- t4w septic tank as a treat -
taunt stage in the waste disposal system.
St . Croix County residents !ay be eligible to receive a grant for
a waximum of 60X of the cost of replacement of a failing SysLetu,
which was in operation priv.c . _--- -St . Cruix C.►unty
accepted this program in August' of 198U, with the requirc:wcnt that
owners of all new systems agree to keep their systems properly
maintained. •"" '_°
J
The pruperty owner agrees to submit to SL . Croix County 'Zoning a
certification form, signed by Lite owner and by a tnaater plumber ,
journeyman plumber, restricted plumber or a licensed pumper veri -
fying that (1) the on•pite wastewater disposal syattem is in proper
uperating condition and (2) after inspection and puuipii►g ( it nec -
essary) , the septic 'tank is less than 1/ 3 full of sludge and scum .
Certification form will be sent approximately 30 days prlur to
H
three year expiration. 0
>e
I/WE, the undersigned, have read the above requirements and agree In
to maintain the private sewage disposal system in accordance with
the standards set Forth, herein, as set by the Wisconsin Depart- 'u
ment of Natural Resources. Certification form must be completed
and returned to the St. Croix CQIIU �Y Zoning Of l;:e withi 0 days
of the three year expiration date .
SIGN D
DATE
St . Croix County Zoning Office
P.O. Box 98
Hammond , WI 54015
715-796-2739 or 715-425-8363
Sign , date and return to above address ,
DEPARTMENT OF REPORT ON SOIL BORINGND SAFETY& BUILDINGS
INDU�;TRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
(H63.090)& Chapter 145.045)
LOCATION: ECTION: TOWNS HIP/#Mb tefP*i-FY: LOT NO.:BLK.NQ: SUBDIVISION NAME:
�/w1/ i lDil N/R E ( Y� i
COUNTY: OWNER'S a4*Efi'9-N*rf tE: (LING ADDRESS:
USE DATES O SERVATIONS MADE j
NO.BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE NS: PERCOLATION TESTS:
r�y'
LJResidence Ea'l�l
3 ew ❑
Replace S /o ' 8F
RATING:S=Site suitable for system U=Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND S STEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional)
cg's ❑u EIS c 2S ❑u DS ou 12-S EN
y m 7
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s.1463.09(5)(b),indicate: — Floodplain,indicate Floodplain elevation: /W/¢-
PROFILE DESCRIPTIONS ./ ? _ ,� e
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST,HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV,ON BACK,)
i
B- z 63 9. > 3 S'8,lr Is .,''A7 N Aee w Z= e e6
B- 3 r c . A > X5 5� /.2 � S S ' e w
B- `/ 7.7
+y nts S ' tt c E
B-
PERCOLATION TESTS
rPUTrE DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
INCHES AFTER SWELLING INTERVAL-MIN. PERT D 1 PERT D 2 P PER INCH
P- S G _T
p_ I I A 5r/). 2- 4. IX/-
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
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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 OMPLETED ON:
—ADDRESS: CERTIFICATION NUMBER: PHONE NUMB Ell(optional):
w r U3 2— S-�f 1 3't 3,?' t 7
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR,SBD-6395 (R.02/82) —OVER —
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