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Parcel 026-1113-70-000 09/22/2005 10:37 AM
PAGE 1 OF 1
Alt. Parcel M 3.30.18.652 026 - TOWN OF RICHMOND
Current X_j 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
O - JACOBSON, JOHN H
JOHN H JACOBSON
1218 172ND AVE
NEW RICHMOND WI 54017
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 1218 172ND AVE
SC 3962 NEW RICHMOND
SP 8020 UPPER WILLOW REHAB DIST
SP 1700 WITC
Legal Description: Acres: 1.100 Plat: 2021-GREEN ACRES ADD
SEC 3 T30N R18W LAND BETWEEN LOTS 4 & 5 Block/Condo Bldg: LOT PARK
IN PLAT OF GREEN ACRES PLATTED AS PUBLIC
PARK Tract(s): (Sec-Twn-Rng 401/4 1601/4)
03-30N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
05/29/2003 723431 2256/476 TI
07/23/1997 733/446
07/23/1997 721/138
07/23/1997 678/629
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 06/20/2002
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.100 28,400 130,700 159,100 NO
Totals for 2005:
General Property 1.100 28,400 130,700 159,100
Woodland 0.000 0 0
Totals for 2004:
General Property 1.100 28,400 130,700 159,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 126
Specials:
User Special Code Category Amount
Special Assessments Special
Charges Delinquent Charges
Total 0.00 0.00 0.00
w
Form-STC- 104
AS BUILT SANITARY SYSTEM REPORT
OWNER ~Jl~'Sts,c TOWNSHIP SEC. T N-R~W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I1HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I
7, ~V
7c/, - 9l0
7- S,7
a ~
I
I
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point:
Proposed slope at site: ,
SEPTIC TANK: Manufacturer: J
Liquid Capacity:
Number of rings used: Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front, Side, 0 Rear, /fly feet
From nearest property line Front,OSide,~Rear, O 2 feet
Number of feet from: well , building: ~d
(Include this information of the above plot plan)( 2 'reference dimensions to septic tank)
SEE REVERSE SIDE
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: J~ Length:- , Number of Lines: Area Built:_
Fill depth to top of pipe: 26 it
Number of feet from nearest property line: Front, O Side, Rear,O Pt.
Number of feet from well:/ /
Number of feet from building: ~.S
(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:
r~
Dated. C)-Plumber on job:
License Number :
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS
P.O. BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
BUREAU OF PLUMBING
MADISON, WI*53707
•
XFX1 CONVENTIONAL ❑ALTERNATIVE State Plan I.D. Number:
Holding Tank El In-Ground Pressure El Mound ( If assigned)
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTI N AT
John Jacobsen 704 N. Knowles Ave. New Richmond 540 7
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT EL CST REF. PT. ELEV.:
SW SW Section 3 T30N-R18W Town of Richmond Green Acres
Name of Plumber: IMP/MPRSW No. County: Sanitary Permit Number:
Cal Powers Jr. 1563 St. Croix 88436
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: T NK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
YES ❑ NO
BEDDING: VENT DIA.: VENTMATL.: HIGH WATER DYES ❑NO
ALARM'. NUMBER F I ROAD: PROPERTY WELL: BUILDING: JVENT FRESH
~J LINE: AIR INLET
FEET FROM
YES UNO H DYES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIOUID CAPACITY. PUMP MODEL: PUMP/SIPHON MANUFACTURER'. WARNING LABEL LOCKING COVER _
PROVIDED: PROVIDED
DYES ❑NO DYES ❑NO DYES ❑NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING IVENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET'
PUMP ON AND OFF) DYES ❑NO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO.OF DISTR. PIPE SPACING COVER INSIDE DIA SPITS LIQUID
DIMENSIONS ~Z TRENCHES / kN
G PIT DEPTH
GRAVEL DEPTH FILL DEPTH JDISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: UMBER OF PROPERTY WELLTO FRESH
BELOW PI PESABOVE COVERELE INLET EL V. END: IR INLET
FEET FROM LINE o~ j~ / T
NEAREST-1 v V V b
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 TEXTURE PERMANENT MARKERS OBSERVATION WELLS
DYES ❑NO DYES ❑NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL. SODDED. SEEDED MULCHED
CENTER'. EDGES.
DYES UNO DYES ❑NO DYES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH. NO.OF LATERAL SPEGRAVEL PTH BELOW PIPE FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE ERIAL: N0. DIST R. T
R. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.'. ELEV.: DIA.: ELEV.'. PIPES :
ELE
VATION AND
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
DYES ❑NO DYES ❑NO
COMMENTS: PERMANENT MARKERS: OBSE YATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
LINE:
FEET FROM
~r DYES ❑NO DYES ❑NO NEAREST
-7
.
7 ~ f
1
k
Sketch System on Retain in count file for audit.
Reverse Side. y
SIGNATURE: TITLE.
DILHR SBD 6710 (R. 01/82)
~ILHR SANITARY PERMIT APPLICATION COUNTY
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.Q. NUMBER
81/4 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
N, R E (or&
PROPER TY O N 'S MAILING A DRESS LOT NUMBER BLOCK N MBER SU DIVISION NAM
CI Y, ST
A I _T T ZIP CODE PHONE NUMBER CITY VILLAGE NEAREST OAD, KE OR LANDMARK
11. TYPE OF BUILDING OR USE SERVED: 70-e,011
Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify):
111. PURPOSE OF APPLICATION: (Check only one in ##1. Check 2,3 or 4, if applicable)
1. a. Vp 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 r~O~F SYSTEM: (Check only one in ##1 and only one in ##2)
1. a. UPI 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. ❑ See a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per in REQUIRED (Square Feet): PROPOSED (S2uare Feet):
Feet Private ❑ Joint ❑ Public
VI. TANK CAPACITY Site
in allons 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 ❑ ❑ ❑ ❑
Lift Pump Tank/Si hon Chamber ❑ ❑ ❑ ❑ ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
Plu ber's Name (Print): l PI ber's Signa ure: No Stam ) MP/MPRSW No.: Business Phone Number:
N `
,_5 Plum W's Address ( treet, City, te, Zip Code): Name of Designer:
I. SOIL TEST INFORMATION
Certif' d S 'I Tester (C ) Name [Phone ST #
S'
CST' ADDRESS ( reet, city, State Zip Code) Number:
i
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature (No Stamps)
Approved Surcharge Fee
❑ Owner Given Initial
Adverse Determination `rfF/O 0
a
X. COMMENTS/REASONS FOR DISAPPROVAL:
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; 'usuelly'every 2 to 3 years;
6. If you have questions concerning your pr;vat- sewage syste t, 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 'tie legal descr=:p,tio:r where the system is to be
installed;
ll. Type of building or use served: I` 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 8'h 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 Groundwater
included the creation of surcharges (fees) for a number of regulated practices which Wiscor~ in's
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water thaf buried treasure A
is used in your building is returned to the groundwater through your soil absorption o 1
system or the disposal site used by your holding tank pumper.
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Rsources. These funds are used for nnc or ng ground- rr t
water, groundwater contamination in estigdi; xns and esta. Zlishm~ rrt t,f sttanda _Is. Groindsrrater,
it's worth protecting.
SBD-6398 (R.03/86)
1
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
Location of Property' Section , T ~o N - R W
Township
Mailing Address 7 /
Subdivision Name Lot Number ,
Previous Owner of Property 'fJ
Total Size of Parcel
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 211 and Page Number as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warranty Deed
2. Land Contract
3.• Other recordings filed with the Register of Deeds Office
In addition, a certified survey, if available, would be helpful so as to avoid delays
of the reviewing process. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
PROPERTV OWNER CERTIFICATION
I (We) eexU6y that aft 6tatement6 on th.ia 6o4m ahe true to the bebt o6 my (oun)
knoweedge; that I (we) am (cute) the ownen(a) o6 the pnopenty de6cA bed in thiA
in6o4mati,on 6onm, by vi tue o6 a wa&A.anty deed neeon ed in the 066ice o6 the
County RegiAten o6 Deedb u Document No. ; and that I (we)
pneeent,ty own the pnopobed site bon the aewage poa 4ystem (on I (we) have
obtained an easement, to nun with the above decAi.bed pnopenty, bon the
conatnucti.on o6 eaid eystem, and the acme has been duty %eco&ded in the 066ice
o6 the County Reg-ieten. o6 Deeds, as Document No. )
S GNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
X~111 S r
DATE SIGNED DATE SIGNED
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WISrONSIN REAL ESTATE TRANSFER RETURN Wisconsin Department of Revenue
G.^.ANTOR: ' GRANTEE:
Name Julio., 1 sc sY ,.SiE Name ► ~c-ilin it, t : eA
Social Security Number Social Security Number
j Full Address New address if property transferred was residence Full Address
104 174. Atiowlt:e Avez.me
tc: L.iuhti,;t W 54017
Is grantor related to grantee? Relationship includes,
marriage, blood relative, , partner, lessee-lessor, ❑ Yes` ❑ No Name and address to which tax bills should be sent if not the same as above
i
co-owner, parent corporation or joint owner.
if yes, explain how related
Grantor is 0 Individual ❑ Partnership ❑ Corporation ❑ Other Grantee is
Individual ❑ Partnership ❑Corporation ❑ Other
Telephone: Grantor ( ) Telephone: Grantee ( )
I PART I - PROPERTY TRANSFERRED PART II - PHYSICAL DESCRIPTION AND INTENDED USE
Check proper box and enter name of municipality and county 1. Kind of Property 2. Principal IntendedUse
❑ City ❑ Village 0 Town I; ~'i:_n+`-1+.?
a. R Land Only a. ❑ Residential d. ❑ Agricultural
I County ❑ New Construction b. ❑ Commercial e. M Recreational
Street address of property transferred. Include road name and /or fire number. ❑ Building Previously Used c. ❑ Industrial f. ❑ Other
❑ Solar Design 3. Land Area and Type Estimated
❑ Earth Sheltered Home a. Lot size 17 6 x
Legal Description (Fill in complete legal description in space below or if metes ❑ Condominium b. Total Acres ❑
and bounds description attach 4 copies of it as shown on the instrument of ❑ Time Share 1. Tillable Acres ❑
conveyance. If certified survey map number is used in description list town, b. Residential Units, if any 2. W.T.L. Acres ❑
range, section and acres.) Tax Parcel Number
❑ One Family 3. F.C. Acres ❑
Lot No. Blk No. Section Town Range ❑ 2 and 3 units 4. Managed F.L. ❑
Plat Name
~ ❑ 4 or more units c. Ft. of Water Frontage
❑
i
i PART III - FINANCE Is Agricultural property transferred? Yes No If yes complete Financial Terms (PE-500 Supplement) on last page
PART IV -TRANSFER (One answer is mandatory for questions 1-4, 5a or b must be completed, questions 6, 7 & 8 as apply)
1. ❑ Sale 2. E3 Gift 3. ❑ Exchange 4. ❑ Other transfer (Explain)
5. Ownership interest transferred a. El Full b. ❑ Other (Explain)
6. ❑ Deed in satisfaction of land contract - What was the date of the original land contract?
7. Amount of mortgage assumed by grantee? $ 1 1 0 . • :i 8. Does the grantor retain any of the following rights: ❑ Life estate ❑ Easement
PART V - ENERGY Is this property subject to the Rental Weatherization Standards, ILHR 67? ❑ YES 0 NO If NO, enter Exclusion Code from
instructions f NOTE: If YES attach the appropriate DILHR Transfer Authorization form (Cert of Compliance Stipulation or Waiver) to be recorded
if PART VI - COMPUTATION OF FEE OR STATEMENT OF EXEMPTION (See instructions)
1. Total value of REAL ESTATE transferred (purchase price, etc. rounded to next even hundred). Include real estate exempt from
local property tax (Solar, wind, M&E etc.), but exclude personal property $ y
2. Value of personal property transferred but excluded from line 1 $
3. Value of property exempt from local property tax included on line 1 $
i
i 4. TRANSFER EXEMPTION NUMBER if exempt for Reasons 1-16 (see instructions) Sec. 77.25. ( # t3 )
Y cents p $ tYtG
r 5. Fee - thin per one hundred dollars of value (line 1 times.003) Make check payable to Register of Deeds
PART VII - CERTIFICATION
j The transfer must be reported regardless of the grantor's state of residence. Information on this return will be used to administer Wisconsin's Income and Fran-
chise Tax Laws, Real Estate Transfer Laws, Rental Unit Energy Efficiency Laws and General Property Tax Laws.
We declare under penalty of law, that this return (Including any accompanying schedule) has been examined by us and to the best of our knowledge and
! belief it is true correct and complete.
Signature of Grantor or Agent Date Print or Type Agent's Name
SIGN
HERE Signature of Grantee or Agent Date Print or Type Agent's Name
If Signed By Agent Agent Address Phone
Document No. Vol. (Reel) Page (Image) Date Recorded Date and Kind of Conveyance Conv. Code
LEAVE `
Parcel Number
THIS 19 19 Code: County Tax District Assm't Dist
AREA L L
` BLANK I I 1 Office 2 Field 3 Use 4 Reject
A B C D E F T T Ratio Consideration
School District No.
PE-500 (R. 11-85)
PROPERTY OWNERS COPY
g NOTICE OFA,SSESSMENT Town, Village, or City of: 026-1113-70
In accordance with Section 70.365 of the Wisconsin Statutes, you are TOWN OF RICHMOND
hereby notified of your assessment for the current year 19 86 on the Parcel No.: 3.30.18.652
property described. IF YOU WISH TO CONTEST THIS ASSESSMENT, Legal Description or Property Address:
SEETHE REVERSE SIDE.
O 1. Land improvements/Higher Land Use SEC 3 T30N R 18W LAND BETWEEN
8eawnED 2. Change due to revaluation LOTS 4 & 5 IN PLAT OF GREEN
For C13.Newconstruction/remodeling/additions ACRES PLATTED AS PUBLIC PARK
Change 4. Correction of Error _
5. Assessment of Omitted Property
ED 6. No Change ,
7. Other-
YEAR LAND BUILDINGS TOTAL
JOHN H AND JANICE G JACOBSON 1986 4000 4000
704 N KNOWLES AVE
NEW RICHMOND, WI 54017 1985 1500, 1500°
Total Dollar Assessment Increase $ °r
Board of Assessors Date (if applicable): Q
OARD OF REVIEW AUG 25 1986 LOAM TO 4PM Board of Review Date: 8_25_8 M
0:
For Additional Information Call: 715-386-6146 d
T OF _ REPORT ON SOIL BORINGS AND SAFETY & BUILDING;
INDUSTRY,
DIVISION
LABOR AND PERCOLATION TESTS (1151 P.O. BOX 7969
HUMAN RELATIONS \ J MADISON, WI 53707
~ (H63.090) & Chapter 145.045)
LOCATION: SECTION: T rOTNO.:BLK.N SUBDIVISION NAME:
(J w'/4 /T? o N/R (80 (or) W ~r
COUNTY: OWN R'S MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COM7~~& ESCRIP TI7~_ PROFILE DESCRIPTIONS: PER OLATION TESTS:
QqResidence Aew❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system d
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FIL OLDING TAN : RECO ME ED SYS M:(optif6nal)
S ❑U S ❑I ❑ S ❑ $ C-D
4tz
If Percolation Tests are NOT required DESIGN RATE: any portion of the tested area is in the
under s.H63.09(5)(b), indicate: SS [Floodplain, indicate Floodplain elevation: j
P eFIL SCRIPTIONS
De-c- Pr f
BORING TOTAL DEPTH TO GROUNDWATER CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B- j SO. 'M 0 0 O. _ / 2, 2 - -,7 5
B-2
10 c39,3 - 2, / 3 - ,o
_
B-3 !9. 7 ti _ 2, `7 60, 3 da z I, pr 2,
B- S_ 0 , 2- All
C3 O o - - 2.O ' Z. o -2. d
B-
PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER I 5 AFTER/+SWELLING INTERVAL-MIN. P-E~R OD 7 PERIOD2 PERIOD PER INCH
P_ 0 /0 , / Z 2-
P_ 2 41 ON _/0 / t
P- A) nAte 6 2- 4~5 1 1 y,
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 `
LAL
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IN
0 ~-a~r
r\ i ~ r [ I ~ d P ~ ~ I
~ _ I e ~ ( E I I E 1 3 i E
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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
and that the data recorded and the location of the tests are correct to the best of myg6nowledge and belief.
1 TESTS WERE COMPLETED ON:
CERTIFICATION NUMBER: PHONE NUMBER (optional):
i'>'1 O ~ L S~ V ~ Z
CST GNATURE:
.ie copy to Local Authority, Property Owner and Soil Tester.
<1 - OVER -
i C T -R COMPLETING FORM 115 µ SIBID -
To 3 A test, y,.-,.o. vepor must 4-hl e:
a r .
2. T.
1 MA. _I se
4. Is th' n;
5. Cc A -'-E IS SUITA3L A HOLDING TANK ONLY IF ALL
U... _ IT ~'Pn ON SOIL w _o NS•
d. PL _ citing profit ~~-is and com Ing the ~ I;
7. M, g your test prof A
Id
10. If )ropriate box;
11. S6
12, gyn. _ TE-S 'S -E FILED WITH THE
IONS FOR ERTIFIE6 ~ 7
L In
pi
Hf
To THE OJAINIER:
i
Ste<;, irise
42 4/145- - '
. -~SE,C 98..E
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STC - 105 r'
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SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County 0
z
a
I H
OWNER/BUYER
~,~~ry.,~i,~
ROUTE/BOX NUMBER_ Fire Number
CITY /STATE _2 I P
PROPERTY LOCATION 1-4, 4, Section T_N, RW,
Town of St. Croix County,
Subdivision S 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 sootier,
if needed, by a licensed septic tank uunl)er. 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~ 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 'honing 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. H
0
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, ~is set by the Wisconsin'Depart- ro
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-
DATE St. Croix County Zoning Office
P.O. iox 913
Hammo`id, W~ 54015
715-746-22:19 or 715-425-8363
Sign, date and return to above address.
WISCONSIN REAL ESTATE TRANSFER RETURN Wisconsin Department of Revenue
GRANTQR: GRANTEE:
me : % • 'Tt6t ry . 81riC .Z!)1~! .T . ~,C?J£'TC all Name Julio K. Jacohon
Social Security Number Social Security Number
L
Full Address - New address if property transferred was residence Full Address
Poute 4 704 No.th Knowles Ave.
New Richmond, IN1 54017 Now Fi.chriond, V1 54017
Is grantor related to grantee? Relationship includes, ❑ Yes' No Name and address to which tax bills should be sent if not the same as above
marriage, blood relative, partner, lessee-lessor,
co-owner, parent corporation or joint owner.
'If yes, explain how related
Grantor is [3Lindividual ❑ Partnership ❑ Corporation ❑ Other Grantee is 0 Individual ❑ Partnership ❑ Corporation ❑ Other
Telephone: Grantor ( ) j j - 2!;43 Telephone: Grantee 4 * ) A' s - A153
PART I - PROPERTY TRANSFERRED PART If - PHYSICAL DESCRIPTION AND INTENDED USE
Check proper box and enter name of municipality and county 1. Kind of Property 2. Principal IntendedUse
❑ City ❑ Village W Town D = t ~1--are
7Z(.7. a. [Land Only a. ❑ Residential d. ❑ Agricultural
County S t• ("_ro I X ❑ New Construction b. ❑ Commercial e.
R1 Recreational
Street address of property transferred. Include road name and /or fire number. ❑ Building Previously Used c. E1 Industrial f. ❑ Other
Route 4 ❑ Solar Design 3. Land Area and Type Estimated
{ -ter ❑ Earth Sheltered Home a. Lot size 76 x 2 7 4 12
Legal Description (Fill in complete legal description in space below or if metes ❑ Condominium b. Total Acres ❑
and bounds description attach 4 copies of it as shown on the instrument of ❑ Time Share 1. Tillable Acres ❑
conveyance. If certified survey map number is used in description list town, b. Residential Units, if any 2. W.T.L. Acres ❑
range, section and acres.) Tax Parcel Number ❑ One Family 3. F.C. Acres ❑
Lot No. Blk No. Section Town Range ❑ 2 and 3 units 4. Managed F.L. ❑
p1,1- K!"n- n 4 or more units c. Ft. of Water Frontage ❑
PART 111- FINANCE Is Agricultural property transferred? Yes No If yes complete Financial Terms (PE 500 Supplement) on last page
PART IV - TRANSFER (One answer is mandatory for questions 1-4, 5a or b must be completed, questions 6, 7 & 8 as apply)
1. ❑ Sale 2. ❑ Gift 3. ❑ Exchange 4. U~ Other transfer (Explain) k.r)rZ c ction Ve_ ee'.
5. Ownership interest transferred a. El Full b. ❑ Other (Explain)
6. ❑ Deed in satisfaction of land contract - What was the date of the original land contract?
7. Amount of mortgage assumed by grantee? $ 8 Does the grantor retain any of the following rights: ❑ Life estate El Easement
PART V - ENERGY Is this property subject to the Rental Weatherization Standards, ILHR 67? ❑ YES N NO If NO, enter Exclusion Code from
instructions1 NOTE: If YES attach the appropriate DILHR Transfer Authorization form (Cert. of Compliance Stipulation or Waiver) to be recorded
PART VI - COMPUTATION OF FEE OR STATEMENT OF EXEMPTION (See instructions)
1. Total value of REAL ESTATE transferred (purchase price, etc. rounded to next even hundred). Include real estate exempt from
local property tax (Solar, wind, M&E etc.), but exclude personal property
2. Value of personal property transferred but excluded from line 1 .....:...................a........................................... $ _
3. Value of property exempt from local property tax included on line 1 $
4. TRANSFER EXEMPTION NUMBER if exempt for Reasons 1-16 (see instructions) Sec. 77.25. ( t )
5. Fee - thirty cents per one hundred dollars of value (line 1 times .003) Make check payable to Register of Deeds `s
PART VII CERTIFICATION j
The transfer must be reported regardless of the grantor's state of residence. Information on this return will be used to administer Wisconsin's Income and Fran-
chise Tax Laws, Real Estate Transfer Laws, Rental Unit Energy Efficiency Laws and General Property Tax Laws.
We declare under penalty of law, that this return (Including any accompanying schedule) has been examined by us and to the best of our knowledge and
belief it is true correct and complete.
Signature of Grantor or Agent Date Print or Type Agent's Name
SIGN /6
HERE Signature of Grantee or Agent Date Print or Type Agent's Name
ZI /€q6 Judith A. Remir.qton, Atty.
if Si ned By Agent Agent Address Phone
I`a0 Welt rJ.]Cst Street TMI~E. Richntond, =11 54017 (715 )24C-3422
Document No. Vol. (Reel) Page (Image) Date Recorded Date and Kind of Conveyance Conv. Code I
LEAVE 409684 733 445 313/86 2/25/86
'1? 1
THIS Parcel Number 19 19 Code: County Tax District Assm't Dist
AREA L L
BLANK I 1 1 Office 2 Field 3 Use 4 Reject
A B C D E 1 F T T Ratio Consideration
School District No.
PE-500 (R. 11-85)
PROPERTY OWNERS COPY I
Jo. ~,j
PAGE OF
ti S S S t~ c t o n o a I~ f l~ S S t e
y ~
Fresh Air Inlets And Observation pipe
Approved vent Cap
Minimum 12" Above
FIRM Grade
20 - 42" Above Pipe _ 4" Cod Iron
To Final Grade vent Pipe
Marts Hay Of synthetic Cove(in
Min 2" Aggregate
Over Pipe
Distribution
Pipe 0 0 a -Too
6" Aggregate
sense Pertoreied Plpe ealzw
lit Plps o
o - Coupling Terminating At
Bottom Of system
PruPoSep ~Inal
v(`9rh~1<
tJwT ton \
SOIL FILL
DISTKIBUT10"..1 PIPE
APPROVED S4MIETIC COVER
2~~A`GRE4ATE ~_MATERlAl- OR 9" OF STRAW
/yOR MARSH HAy
e
(e OF 12-2i/2 AGGREGATE X,
T.LEV. OF4L FEET,
i
DIS'T"1115UTIOW PIPE TU BE AT LEAST _-3Q_ WCHES BELOW ORIGINAL GRADE
A1JU AT LEASTZ0 INCHES BUT 1.10 MORE THAN 42 INCHES BELOW FINAL GRADE
MAXIMUM DEPTH OF EXCAVATI60 FROM ORIGINAL 6KADE WILL BE INCHES
/MAXMUM Wrr of EXCAVATION MoM1*141WAL (39aV€ WILL BE i. INCHES
L~
SIGiJEO:
LICEIJS£ IJUMBER:
' DATE
110 J