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Parcel #: 042-1018-95-200 09/29/2005 08:37 AM
PAGE 1OF1
Alt. Parcel#: 7.29.18.11 OF 042-TOWN OF WARREN
Current ,_Xj 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
PATRICK G&AMY R DREWS O-DREWS, PATRICK G&AMY R
973 105TH AVE
ROBERTS WI 54023
Districts: SC=School SP=Special Property Address(es): '=Primary
Type Dist# Description `973 105TH AVE
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 1.000 Plat: N/A-NOT AVAILABLE
SEC 7 T29N R1 8W NW SE 1 A LOT 1 CSM Block/Condo Bldg:
7/2034 NOW BECOMES LOT 1 CSM 7/2041
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
07-29N-18W
Notes: Parcel History:
Date Doc# Vol/Page Type
02/08/2005 786956 2745/31 WD
05/01/2003 719652 2226/441 TI
06/22/1987 782/607
501200 2226/444 W
2005 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/19/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.000 25,000 160,800 185,800 NO
Totals for 2005:
General Property 1.000 25,000 160,800 185,800
Woodland 0.000 0 0
Totals for 2004:
General Property 1.000 25,000 160,800 185,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 112
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
1�4 �\
cs
o CERTIFIED SURVEY MAP
MAP NO_ 1859
NW 1/4 SE 1/4 AND NE 1/4 SW 1/4
SECTION 7, T29 N - R 18 W WARREN TOWNSHIP
Z r
w T. CROIX COU N TY WISCONSIN
� z
0 o HN BOUGHTON, OWNER ROBERTS WISCONSIN
� U �
>- N c z ---i— BEARINGS ARE ASSUMED AND REFEREMCED TO THE
z I- - " EAST — WEST ONE QUARTER LINE, SECTION 7
:=D) cn
z UNPLATTED LANDS
o a
BEARING N89049� 13°W- -
w N 00°42'01 E 1/I6TH LINE.
s.
796.26 k,, LEGEND
M - 26'960 90°04 C` o o—_- -EXISTING IRON BARS, 11/8'DIA.
o I X 24 IRON PIPE, SET
LOT rn N WT. 1.68 LB. PER L.F.
Oi rN 6 M t� 0 300' 600' 900'
LU m s•s 1�.- 1 1
1
z w
25 °°i o SCALE: I'= 300
-0 0 0
2 p0 W N AREA, LOT 1: 313,9.14 SQ.FT E, 14.00' Q' r- ° 7 206 ACRES
Ki CD • - EXISTING I' IRON BARS Z
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m• - - - -
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°2s., 1"' N00°38'47"E 33'-1-4', -33' OD
48.11 N
6 -�- o_ _��_ NOTE: AN EXIST. 35' EASEMENT PLUS AN
Rec. S 00 37 00 W a ,
,;6 o s° I O ADDITIONAL 13.11 FOR A 48.11'EASEMENT
`\� 66' d,M 3s' it BY WRITIN DOCUMENT. VOL.786 P249
`°' a� UNPLATTED LAND z
3. �0®460®"wol/
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MARTIN E.
LV
VORSEN
a
679 J 1302
+—COUNTY WEST I/4 COR. S\ HUDSON MONUMENT, EXIST. J FNNFSS „® Wis. �rr�
ACCESS / EASEMENT STATEMENT e\D ���-qA1 •SU VZ j C-,
As owner of the above described access - ®��� Ta®oeasement, this is for the expressed use , 4
of the 7.206 acre parcel of land described.
If future parcels are to be served by this access, , REV. 5/20'87 REV.7/6/'87
a roadway will be constructed to meet APPROVALS 8/5/'87
S C oix county roadway,standards.
Volumed,; 7 -Page 1859
--COUNTY Su'u eywes <0-ty
CERTIFIED SURVEY MAP MAP NO.
PART OF THE NW 1/4 SE 1/4 , SECTION 79 T 29 N - R 18 W
TOWNSHIP OF WARREN ST. CROIX COUNTY WISCONSIN
OWNER: JOHN BOUGHTON ROBERTS WISCONSIN
SURVEYOR: M.E. HALVORSEN HUDSON WISCONSIN
MARCH 23, 1981
FORTY LINE S 89°48'00" E_
NORTH LINE 1168.10' O
1900 o'b
�S 0�
2 I 9 w
NW 1/4 SE 1/4 °o rn 19.83 ACRES ± N o
SEC. v w �
0 0 INC. 3 ' RIGHT OF WAY 4
.5� ocn 2 o0
-Z
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° Oo �1
P.0.8. �O O
R/W --p A�-_ �► 434.00" O� _c $ i
2 0
R/w rnm
I" IRON BAR `�_F8_902,3$'00 E _. " rT�'-6.—.00--uu
$ 725.46' OS•
w w 0 00 N 890 23'00" W
z 10 m
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454.40' I" IRON PIPE
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�-COUNTY SURVEY MONUMENT
SOUTH 1/4 CORNER, SEC.7
BEARINGS ARE ASSUMED AND
ARE REFERENCED TO THE
NORTH-SOUTH QUARTER LINE.
- LEGEND -
�— — — — EXIST. 3/4 " ROUND IRON BARS M
—__- EXIST. 1 1/8" ROUND IRON BARS �0 ��.� w
O— — 3/4"X 24" ROUND IRON BAR SET.
WT. 1.50 LB. PER LIN. FT. MARTIN E.
HALVORSEN
a S-1302 i
0 300' 600' 900' ® HUDSON, j
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SCALE : 1"= 300' <
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"_ CERTIFIED SURVEY MAP
°_2 cv
t �a
PART OF THE NW 1/4 SE 1/4
W� SECTION 71 T29N, R18W WARREN TOWNSHIP oc
' ST. CROIX COUNTY WISCONSIN
OWNERt RICHARD SCHULTZ ROBERTS,WISCONSIN
�. JARe is�' `
o1 Deeds
Z l/NPLATTED LANDS
o
N00 42 0/ E
58754 �_—
ot
°
Pole N00010'47"E 190.35 . � -LEGEND
4. --€—Q-
N )(--EXISTING A" IRON BAR
0 I+ousts h 9 I •—EXISTING I" IRON PIPE
�
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3 Lor l
on
ih � ti I
N
o tr
j m ap SCALE 1" 100'
Z OD
to
ui LOO ao o so too
S01°I7'33"W
° 185.40 ( E-
46 > BEARINGS ARE REFRENCED TO THE W 1/4 LINE
O z SEC. T AS ASSUMED N99°49'13"W
AREA
LOT 1 2 47,851 Sq.it./I.10 Ac.
it
CO
r I UNPLATTE�_LANO
FREDRICK W.
\� "
NNFSS \ _ NANN
HF ENGA
Ey S•1953
R 1N00DpURY
1W 1/4:COR. SEC.7 �, '%, U1 N
([XIaTINQ COUNTY MONUMCMT) \ �� V �� �'°�,,1
\ y3fI1S1(1`ti`L
P
OCT 28W8
ST.CROIX coumy
COMI'REHE 2W pARn pIjq ;
AND ZONING COR+Ru1rLtF
VOLUME 7 PAGE 2041
' S1' `/
p//off
44225'7-
11" CERTIFIED SURVEY MAP OF Q01'
0 wz ? Lt Q
PART OF THE NW 1/4 SE 1/4 '' x '
2 ��Jlti�u�J
W�
SECTION 71 T 29 NI R 18W WARREN TOWNSHIP J �'``" S
ST. CROIX COUNTY WISCONSIN 4►
OWNERS RICHARD SCHULTZ ROBERTS,WISCONSIN
-� FOR MORTGAGE PURPOSES ONLY--
a.
2 UNPLATTED LANDS
PqB NO0042'01"E 208.72' N00042'01",F L/NE
58754 ---
1": 7 a
y� r`
i a LOT / N I LEG ND
4.
v 3 I H )(--EXISTING I1'" IRON BAR
io IlousE M I
*--EXISTING I" IRON PIPE
o►
v
Os OM I NOTE:
Z
OD Z N THIS SURVEY IS FOR MORTGAGE
PURPOSES ONLY. ANY SALE OR
SUBDIVISION Of THESE LOTS MUST
FIRST COMPLY WITH ST. CROIX CO.
500042 01 W 208.72 09 SUBDIVISION ORDINANCES.
GSM SCALE I" • 1001
il_
W Ioo :o o so loo
v BEARINGS ARE REFRENCED TO THE E—W 1/4 LINE
Z SEC.? AS ASSUMED N89°49'IeW
2
_ — — AREA
s�
csM LOT 1 = 43,562 Sq.ft./ 1.00 Ac.
NNFSSF \� ��ttltllWilly,
Pop
W 1/4 COR. SEC.? \ .'` `•• i
(EXISTINS' COUNTY MONUMENT) FREDRiCK W., .
\ !
*= NANNENOA s'k
S-1958 '
WOODBURY
MN
"D Ns U av t"O
fl
d/Jfflltt�l
Vol. 7 Page 2034 w
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: ✓ Trench:
Width: '40F I— Length: 5/j Number of Lines: Area Built: �!'li
Fill depth to top of pipe: �,2 'Pt
Number of feet from nearest property line: Front, O Side, O Rear, Ft . ¢/
Number of feet from well: > 15'
i
Number of feet from building:
(Include distances on plot plan). leal--y
SEEPAGE PIT 100, 7
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, OFt.
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: 3d�
3/84:mj
F
Form - S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER CIC SC, lir Z'Z TOWNSHIP 6,&O RejV SEC. _7 T 2f_N-R IS W
ADDRESS Gy N yr, ST. CROIX COUNTY, WISCONSIN
6�t, �1y j
SUBDIVISION LOT LOT SIZE / 1
PLAN VIEW
Distances and dimensions to meet requirements of I114R 83
Gc�C
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM f,1
y, . 9,
l -
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used 7- 0 �i. AIZ �_
Elevation of vertical reference p oint: /aD� � Propos/ed slope dt rt .
site:
SEPTIC TANK: Manufacturer: Liquid Capacity: e'.*"
Number of rings used: �_ Tank manhole cover elevation: �j,
Tank Inlet Elevation:_p_8,5- Tank Outlet Elevation: _ Q g, p _
Number of feet from nearest Road:
Front 1 Side � Rear O > Sip feet
From neare8t-property line ' Front 10 Side,O Rear,O SD feet
Number of feet from: well > SD building: _
(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
MADISON,WI 53707
NWT, SE,, S7,T29N—R18W IiCONVENTIONAL ❑ALTERNATIVE State Plan ID.Number:
(lf assigneAl
Town of Warren ❑Holding Tank ❑ In-Ground Pressure ❑Mound
Hennessey Drive
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DAT
Richard Schultz Hennessey Drive, Roberts, WI 54023 /0,/L5- S>7
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.-.
Name of Plumber: MP/MPRSW No County: Sanitary Permit Number:
Dave Fogerty i 3289 1St. Croix 99041
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
DYES ONO DYES ❑NO
BEDDING: VENT of VENT MATLL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING. VENT TO FRESH
ALARM. FEET FROM LINE: AIR INLET:
DYES ONO DYES 1:1 NO NEAREST '
DOSING CHAMBER:
MANUFACTURER. BEDDING: LIQUID CAPACITY. PUMP MODEL. JPUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑YES ❑NO DYES ONO OYES ONO
GALLONS PER CYCLE: 7ND CONTROLS OPERATIONAL. NUMBER'.OF PROPERTY WELL: BUILDING:JVENTTOFRESH'
(DIFFERENCE BETWEEN FEET FRAM LINE AIR INLET:
PUMP ON AND OFF) DYES ❑NO NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
WIDTH: LENGTH. NO.OF DISTR.PIPE SPACING. COVER .INSIDE DIA.'. *PITS. LIQUID
eBB,OXI"�ElCH `. TRENCHES. MATERIAL: PIT DEPTH:
3114fENEtS
GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE JDISTR.PIPE MATERIAL: NO.DISTR NIUMBER',OF PROPERTY WELL: BUILDING: VENTTO 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.
DYES ONO
SOIL COVER ITFXTURE PERMANENT MARKERS: OBSERVATION WELLS
1:1 YES 1:1 NO ❑YES 1:1 NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED. MULCHED.
CENTER. EDGES.
❑YES E:1 NO 1:1 YES ONO ❑YES 1:1 NO
PRESSURIZED DISTRIBUTION SYSTEM:
a��r
WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
p :
EOATARMC14 TRENCHES:
i MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL: NO.DISTR. DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING.
ELEV.. ELEV.. DIA.. ELE V.. PIPES: DIA.:
EL VA rlON AN
0400I�iIA ,J_,l HOLE SIZE HOLE SPACING: DRILLED CORRECTLY. COVER MATERIAL. VERTICAL LIFT CORRESPONDS TO APPROVED
17OR1iii PLANS.
DYES ONO ❑YES El NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER h1,^ PROPERTY WELL: BUILDING:
FEET FFIQiUI+ , LINE:
DYES ❑NO ❑YES ❑NO �iEA
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE: TITLE:
Zoning Administrator
DILHR SBD 6710(R.01/82)
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;
ll. 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;
Ill. 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 13% 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; close 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 intc 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 Groundy�atet
inciuded the creation of surcharges (fees) for a number of regulated practices which Wiscon`
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reeastlr
is used it your building is returned tc; the groundwater through your soil absorption u
system or the disposal site used by your holding tank pumper.
0
T I fe �,iomes codected through these _,rcharges are c:recited to th.� groundwater fund admnnis.-
tv,(ed by 'he Department of Natural F-sources These funds are used for rnonitoring ground- t
ter, gr-)undwa!er coat=�minaticn in, estigatirns and es'ablishment of standard: Groundw ;-! _.. __.._._.w
worth, protecting.
,398 iR.03/86)
�iLHI� SANITARY PERMIT APPLICATION COUNTY /
In accord with ILHR 83.05,Wis.Adm. Code
ST TE SANITARY PERMIT#
9�p v
—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 N NO
PROPERTY OWNER PROPERTY LOCATION
Richard Schultz '/4 %4, S 7 Tqq N, R E(or)
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
Hennessey Drive ------- --------- ---------------------
CITY,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,61%IQ G A h1QI �"-
Roberts WI 54023 49 3164 O VILLAGE
II. TYPE OF BUILDING OR USE SERVED: /24/l.C.- A,0 . d�r� — lolk 9S'lad
Number of Bedrooms if 1 or 2 Family 4 OR ❑ Public(Specify):
III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable)
1. a. 0 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. ®Conventional 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. Seepage Bed b. ❑seepage Trench c. ❑seepage Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 15.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):
8 820 828 100.72 Feet Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in gallons Total ##of Manufacturer's Name Prefab. Fiber- plastic Exper.
Con- Steel
INFORMATION New xisting Gallons Tanks Concrete strutted glass App.
Tanks Tanks
Septic Tank or Holding Tank ❑
Lift Pump Tank/Siphon Chamber I I ❑ I ❑ ❑
VII. RESPONSIBILITY STATEMENT
I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans.
Dave FnciprEy Q900 Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number:
749 3656
Plumber's A dress Street,City,State,Zip Code): Name of Designer:
Fogerty H ts. Rd. Roberts WI 54023 D. B. Foaerty
VIII. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#
Dave Fogerty
CST's ADDRESS(Street,City,State,Zip Code) Phone Number:
Focfertv Hcfts. Rd. Roberts WI 54023 749 365
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater I ISSUIn q Agent Signature(No Stamps)
„Approved ❑ Owner Given Initial �haCrge Fee r
Adverse Determination QUry• 1 .
X. C , MMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
APPLICATION FOR SANITARY PERMIT
S T C - 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 n y
Location of Property /V k.; 14 S 14, Section , T-;�7 N-R W
Township (} tz n_e of
Mailing Address 30 Y`"o A / 10,`10 ,`S j6 A)
/Z& Lej-�i ceJ r` 1TV0 L �
Address of Site .g -e
Subdivision Name
Lot Number
Previous Owner of Property I -d
Total Size of parcel 7. z- Q^ciz�
Date Parcel was Created �--
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number (ire - as recorded with the Register of Deeds.
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
I (We) centti.by that a t statements on thi6 bo,%m ane true to the beast ob my (ouA)
knowledge; that I (we) am (au) the owne�x(.fl ob the pnopenty de�scAibed in this
inbonmati.on botm, by viA tue ob a wannanty deed neco)Lded in the Obbice ob the
County Regihten ob Deeds as Document No. � , and that I (we) ptaentty
own the pupoaed site bon the sewage di�sposat zyztp (on I (we) have obtained an
easement, to nun with the above descA bed ptopenty, bon the constnucti.on ob said
zyatem, and the same has been duty %econded in the Obb<ice ob the County Reg-usten ob
Deeds, as Document No. T ) . 4 q ODa'D
dLq— — �� ;0, 44611�
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPL LE)
'2 V ") 1
DATE SIGNED DATE SIGNED
II. .DOCUMENT NO. ( THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED I,
STATE BAR OF WISCONSIN FORM 2—1882
429020
O 2�
I .. _. 70$PAGE ... RrGISTERS OFFICL �I
ST. CROIX CO., W IS.
Reed, for Record Hlis 11 t 11
....-.•.�Q�i:rl--H..•.I3oucPubon--and,-,Ruth.-E..•.-Boughton.,..-••---•••••• ,
uar}d and wife, - day
h sb of Au>y. A.D. 19 87 !
(I ....... ........ •---...........--• .... .---. ............ ................................................ t� 9:20 A II
...III ".'#
conveys and warrants to .-Ri.Ch.ard... . ...$.Ch??.ltZ...4.1'?5....................
.........Lilli--an...R.._..Schultz,....husband..and..wif.e.................. Iw Q D•wI
.........surv.Lvor.s hip...mar i.tal..pr-ope r.ty-.,.................................
................................................................................................................. I
.............•---.............................................I.........
i
........................................................._...........;--••,----•-•-•---.............. ..._....... , RETURN TO
• .............................................
. ........................................................ . _........ ... ................................. _.......____..__. .. ..
the following described real estate in ....St.. CrOlX............................County, i
State of_ Wisconsin:
Tax Parcel No:
' I
A one (1) acre parcel of property located in
the Northwest (NW) corner of the property described
as follows: Lot 1 of Certified Survey Map dated i
April 20, 1987 and recorded at the Register of
Deeds office for St. Croix County on August 6, 1987 in
Volume 7 , Page 1859, as Document Number 428908 . it
Ii
This Deed is given in partial satisfaction of that !
certain Land Contract dated June 8 , 1987 and recorded
at the Register of Deeds office for St. Croix County
on June 22, 1987 in Volume 782, Page 607 , as Document
Number 427240.
00
FEE
is not
not).. .. homestead property.
This ........... .. . . ..
i
Exception to warranties:
I �
Subject to easements, reservations and restrictions of record.
I �.
Dated this .........10th All U.St........................................... 19.$.7....
............................... day of .............._g..
i
fH.-----•..............................................................(SEAL) . . . .... ............... ... _ ........(SEAL.)
................•---•----•--.....--•---•-••--...-•-......------... ' -- JOIiN BOU 'HTON i
_... ................
O-
.............................. (SEAL) / ��..... --- ..(sEAt.)
SEAL ..._..G.........
------•........................•----•---•-•-----------............ • . .-RUTI....E-_...BOUGHTON........-:--............
i!
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) ----Of,_JAh11--1i.....Boiagh-ton........... STATE OF WISCONSIN
I
........ ........................
ss.
......................................County.
authenticated this 1JOL -d !y of guSt........... 19.8-7. Personally came before me this ................day of
........................................... 19........ the above named i
'•• --..S.TEPHEN_.J..-JDUNLAR..-------•...._. ................. II
TITLE: MEMBER STATE BAR OF WISCONSIN
..........--•-•-----•.......................•--•--•-•---•.......................
............................................................
to me known to be the person ............ who executed the
foregoing instrument and\,tcknowledge the same.
II THIS INSTRUMENT WAS DRAFTED BY I;
STEPHEN..J J. DUNLAP --•-•.....................•----.............._.._......-•---•---------------- .
••--•---- ........... .........
IIUdSOn, W1SCOriSln Notary Public ..County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent.(If not, state expiration
are not necessary.) date:
I I
*Names of persons signing'in any capacity should be typed or
I printtvl below their siYnatures.
STATE BAR OF WISCONSIN
KC MYnaI Curymrryo FORM No. 2— 1982 - Stock No. 13002
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' -CERTIFIED SURVEY MAP MAP N0_„__
PART OF THE NW 1/4 SE 1/4 SECTION 71 T_29 N — R 18 W
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TOWNSHIP OF WARREN ST. CROIX COUNTY WISCONSIN
a OWNER : JOHN BOUGHTON ROBEFTS '�1SC0l�JS1IV
SURVEYOR: M.E. HALVORSEN HUDSON WISCONSIN
MARCH 23, 1981
N
FORTY LINE
S 890 48'00° E
NORTH LINE 9 1168.10' 1p
p 0sf 09
Lo
2 O
19.83 ACRES ± ti o
NW 1/4 SE 1/4 0 —
w° n� INC. 33 RIGHT OF WAY ;4 cn
SEC. 7 -� w z 00
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P 0.EI �0 4 3 4.00•• Of o
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w -000
R/W 2.300
�� R/W - _-_c , „ — } � - $ 725.46 o
�/ R 9 88 23 00 E J 66.00
y 1 IRON BAR --- - 593.20 ----W w °OC N 890 2300" W
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I" IRON BAR-► N 89° 2.3,05"w _I" IRON PIPE
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f.-- COUNTY SURVEY MONUMENT
SOUTH 1/4 CCRNER, SEC.7
TT BEARINGS ARE ASSUMED AND
ARE REFERENCED TO THE
NORTH-SOUTH QUARTER LINE.
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— L E G E N D — ,NOtt��ot�oojN��
•— — -- — EXIST. 3/4" ROUND IRON BARS
G— — -- EXIST. 1 1/8, ROUND IRON BARS �► v' ��
0- - -- 3/4"X 24" ROUND IRON BAR SET. ,��} MARTIN E.
WT. 1.50 LB. PER LIN. FT. ' ; HALVORSEN
Z S-1302
0 300 600 900 ` HUDSON, if
S WIS. �.
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SCALE : 1"- 300' +ye�e NO RJE;,�•
(OVER)
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STC - 105 9
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SEPTIC TANK MAINTENANCE AGREEMENT o
St . Croix County z
d
9
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OWNER/BUYERPc �ew / ((;AJ c_,L —
ROUTE/BOX NUMBER A.)2 .k,– v Fire Number
,CITY/STATE a$� c ZIP S TU 23
PROPERTY LOCATION: N(J 66 ;4, Section 7 T N , R /?W,
Town of CA2 cZARe of St . Croix County,
Subdivision Lot number
I
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 m_ y 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 H
three year expiration. o
E
z
I/WE, the undersigned , have read the above requirements and agree
to maintain the private sewage disposal system in accordance with 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 .
SIGNED 4J�klj.
DATE
St. Croix County Zoning Office
P.O. -Box 984-
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address .
INSTRUCTIONS FOR COMPLETING FORM 115- SR® - 6395
To be a complete and accurate soil test,your report must include;
1. Complete legal description;
2. The use section must clearly indicate whether this is a residence or commercial project;
3. MAXIMUM number of bedrooms or commercial use planned;
4, Is this a new or replacement systern;
5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL
OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing profile descriptions anal completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A
separate sheet may be used if desired;
S. Make sure your benchmark and vertical elevation reference point are clearly shown,and are permanent;
0, Complete all appropriate boxes as to dates,names,addresses,flood plain data, percolation test exemp-
tion, if appropriate;
10. If the information (such as flood plain,elevation) does not apply, place N.A.in the appropriate box;
11. Sign the form and place your current address and your certification number;
12. Make legible copies and distribute as requirOd. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st — Stone (over 10") BR — Bedrock
cob Cobble (3- 10„) SS Sandstone
gr. Gravel (under 3") LS Limestone
*s _ Sand HGW — Nigh Groundwater
cs - Coarse Sand Perc — Percolation Rate
mod s — Medium Sarid W Well
fs Fine Sand Bldg - Building
Is -- Loarny Sand Greater Than
*sl - Sandy Loam < Less Than
I — Loam Bra - Brown
*sil - Silt Loan" B1 - Black
si Silt Gy — Gray
*cl — Clay Loam Y Yellow
srcl — Sandy Clay Loarn R — Red
sicl - Silty Clay Loam mot — Mottles
se Sandy Clay wt' - with
sic - Silty Clay fff few,fine, faint
"°c Clay cc - common, coarse
pt -- Peat mm — Many, medium
fit Mack d --- distinct
la — prominent
HWl_ -- High water level,
Six general soil textures surface water
for liquid waste disposal BM Bench Mark
VRP — Vertical Reference Point
TO THE OWNER:
This soil test report is the first step in seecrrirag a s nitary perrsait.The county or the Department may request
ver;fication of this soil test ill the field prior, to permit issuance. A complete set of plans or the private
wvja,e systern and a permit: application must lse subraaitted to lvmiy'lu�j04ty Jr,i Ordr"'? to
gal=taln a p€'rntit. The sanitary perrrait must be Obtained arld p osted 4f j)or,tcs,mii}soot Ci ariy.consti:ugtion'
i” <
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY,INDUS DIVISION
HUMAN AND PERCOLATION TESTS (115) MADISON,BOX
WI 3707
`HUMAN RELATIONS
(H63.090) &Chapter 145.045)
LOCATION: SECTION: OWNSHIP/ LOT NO.:BLK.NO.: SUBDIVISION NAME:
w '/a s a /T' 9 N/R E ( ---
COUNTY: OWNER'S MAILING ADDRESS:
0 2v r
USE DATES OBSERVATIONS MADE
r��
NO.BEDRMS,: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PER OLATION TESTS:
axesidence �..._ FXN ew ❑Replace
Yf
RATING:S=Site suitable for system U=Site unsuitable for system
CONVEcN I1UNAL: ]� IN-GROUND-PRESSURE: SYSTEM-IN-FILL H(OL�DIING TANK:RECOMMENDED SYSTEM:(optional)
CIS ❑U IMOUND:
LJJ ❑U � ❑U ❑U LJJ ❑Y
[::0:6�n Tests are NOT required DESIGN RATE: I If an —
y portion of the tested area is in the
09(5)(b),ind icate: �— Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
B-
B-
B-
B-
B-
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERT D 2 PERIOD3 PERIOD PER INCH
P-
P-
P-
P
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION moo_ 72-
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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): UMBING TESTS WERE COMPLETED ON:
Licensed Perk Tester 6 Plumber C 7
ADDRESS: CERTIFI AT ON NUMBER: PHONE NUMBER(optional):
F erty N011thts Road
ROSE WIS NSIN 54023
Phone 74"656 c S I G
DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, DIVISION
HUMAN DLATIONS PERCOLATION TESTS (115) MADISON WI 53707
RE
(H63.090)&Chapter 145.045)
LOCATION: SECTION: TOWNSHIP/ I8+Pt�ttT'V: LOT NO.:BLK.NO.: SUBDI VISION NAME:
>�s / /T fN/R/F E ( G� _ _
COUNTY: OWNER'S BU"ERz6-PMekFE: MAILIN ADDRE S:
sT I
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USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COMM R A DE RIPTION: (PRO I S: TESTS:
�esidence 3 ..►---- O'New ❑Replace
RATING:S=Site suitable for system U=Site unsuitable for system
ONVENTIONAL: M(O�U]N�D: IN-GROUNDPRESSURE: S STEM-IN-FILL HOLDING TANK:RECOMMENDED SYSTEM:(optional)
C►�S ❑U I J DU CAS DU I CgS DU I CC'S OU I ' F2.
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b),indicate: �--� �/ Floodplain,indicate Floodplain elevation:
PROFILE DESCRIPTIONS
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.)
B,
B- 2. 75- 7 6 — / 7 Y 9
B- .3 /,7 i s S, 9( = c 7
B_
9I /6p. 7j 7 yC ✓C5. f !r� �/
J— CS tv/ v
B'
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD PER INCH
P
P-
P-
P-
P-
P_
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope.
SYSTEM ELEVATION
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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.
NA (print): TEST5 WERE COMPLETED ON:
r y
ADDRE�4 � CER FI ATION NUMBER: PHONE NUMBER(optional):
3
CST SIG
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DISTRIBUTION: Original and one copy to Local Authority,Property Owner and Soil Tester.
DILHR-SBD-6395 (R.02/82) —OVER —
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DAVE FOGERTY PLUMBING
Licensed Perk Tester & Plumber
#3233 03289
Foggerty Heights Road
ROBERTS, WISCONSIN 54023 1 �.
Phone 749-3656
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