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09/29/2005 03:23 PM
Parcel 042-1017-10-100 PAGE 1 OF 1
Alt. Parcel 7.29.18.101 E 042 - TOWN OF WARREN
ST. CROIX COUNTY, WISCONSIN
Current X 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 - GOIN, JAMES HERBERT & MARILYN
JAMES HERBERT & MARILYN GOIN
943 107TH AVE
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 943 107TH AVE
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 3.550 Plat: N/A-NOT AVAILABLE
SEC 7 T29N R18W PT NE NW BEING LOT 1 CSM Block/Condo Bldg:
6/1658 1.89AC & PARC DESC COM NW COR SD
CSM;TH S 00'W 338.01 FT; TH S 89'W Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
214.25'; TH N 00' E 338.01 FT; TH N 88' E 07-29N-18W
214.25FT TO POB
Notes: Parcel History:
Date Doc # Vol/Page Type
10/22/1998 589582 1368/140 WD
07/23/1997 746/77
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/19/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.550 44,200 147,300 191,500 NO
Totals for 2005:
General Property 3.550 44,200 147,300 191,5000
Woodland 0.000 0
Totals for 2004:
General Property 3.550 44,200 147,300 191,5000
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 204
Specials:
User Special Code Category Amount
Special Assessments Special Charges 00 Delinquent Charges
00
Total 0.00
Form - S T C - 104
emu., -
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP R^ r~ SEC. T ~N-R~W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•I.HR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
&M PROPER7 Y iNE
y0`
/3'1~ QC'.
o vL~- V'/
/~ES~ge,vcF
r13'
Aeopfl?rY Lau E
Stale
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used ~i~~NE/r~ ( Cv~tifR«<
Elevation of vertical reference point: 00 Proposed slope at site:
SEPTIC TANK: Manufacturer: (.J 1S EK Liquid Capacity: -COG 6-7A-
Number of rings used: Tank manhole cover elevation: S 7/
Tank Inlet Elevation: Tank Outlet Elevation:
9~y
Number of feet from nearest Road: Front 10 Side 0 Rear, l Sl feet
.From nearest property line -'Front 10 Side,ear, O 3 feet
Number of feet from: well building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER .
Manufacturer: Liquid Capacity:
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: g 1~_ .91O Trench:
Width: Len the ~/O Number of Lines: Area Built: 9V sy
----------r-
Fill depth to top of pipe: 44?
Number of feet from nearest property line: Front, O Side, aRear,oirt
.
Num
ber 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, Q Ft.
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 :
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
BUREAU OF PLUMBING
P.O. BOX 7969
MADISON,-WI 53707 State Plan I.D. Number.
XU CONVENTIONAL O ALTERNATIVE (If assigned)
❑ Holding Tank O In-Ground Pressure O Mound
INSPECTION DATE.
NAME OF PE RMIT HOLDER! JADDRESS OF PERMIT HOLDER: p
.~Cs~
Go in 54023 ~17 i6
James Rt. 1, Roberts, WI 90
REF. PT. ELEV.: CST REF. PT. ELEV..
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN.
NE NW, Section 7, T29N-R18W, Town of Warren
MP/MPRSW Nn.. Cnunty. Sanitary Permit Number.
Name of Plumber: 837 79
Gary Zappa 3300 St. Croix
SEPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY. TANK INLET ELEV.. TANK OUTLET FILE V.. WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED.
RYES ❑NO DYES ENO
I NUMBER OF ROAD PROPERTY WELL BUILDING IVEN TO1111H
BEDDING: fENT DIA.: VENT MATL HIGH WATER AIR INLET.
LIN y
C~ ALARM FEET FROM
DYES :jN:O t r DYES NO NEAREST 1 G.
DOSING CHAMBER:
MANUFACTURER BEDDING: Z7EP UMP M(1DEL PUM P; SIPHON MANUF A(;TIIHEH ROVIIDEDLABEL PROVIDED OVER
DYES DDYES ONO DYES DNO
ONTROLS OPERATIONAL NUMBER OF PROPERTY WELL BUILDING JVENTTOFRESH
AIR NL TGALLONS PER CYCLE: FEET FROM LINE
(DIFFERENCE BETWEEN YES ❑NO NEAREST-~
PUMPONANDO FF) ~FI JI)IAMFrEli naATERIALANDMARKwG
SOI L ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE
or excavation. (if soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.) CONVENTIONAL SYSTEM: LIQUID
BED/TRENCH WIDTH LENGTH NO OF DISTH PIPE SPACING COVER 'NSIUL OIA =PITS DEPTH-
TRENCHES M IAL PIT
DIMENSIONS
B VEN
V H.4V CL i?EF'1 rl FILL DEPTH DI STR PIPE DISTH PIPE DISTR. PIPE MATERIAL NO DIS NUMBER OF PROPERTY 'WE -L L UILDING. T TO FRESH
AIR LET
BE LOW PI S AB vE COVER EL EV.INLff ELEV END n PIPES FEET FROM LINE E 2 ~S 3 INLET
'L 017r I °l 7. 2~ 2 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 ❑NO
PEHMANF NI MARKERS OBSERVATION W` LLS
SOIL COVER TBxruRE
DYES ONO DYES ONO
SEEDED MULCHED
DEPTH OVER TRENCH BED DEPTH OV FH TRENCH BED 70[PTH S(11)uFD
CENTER EDGES D DYES ❑ NO
YES. [:]NO DYES DNO
PRESSURIZED DISTRIBUTION SYSTEM:
W FILL DEPTH ABOVE COVER
LATEHAL SPACING GRAVEL DEPTH BELOWPIPF
BED/TRENCH DIMENSIONS
MANIFOLD PUMP DISTR. PIPE MANIFOLD MATERIAL P PESISTH DiSAT R. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
IDTH. LENGTH E~,NIFFD
ELEV.. ELEV. ELEV.
ELEVATION AND
DISTRIBUTION COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
INFORMATION HOLE SIZE HOLE SPACING Cll.V - PLANS
OYES ONO DYES ❑NO
MBER OF PROPERTY WELL: BUILDING:
NU
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: LINE:
FEET FROM
DYES ❑NO DYES ❑NO NEAR_ETST-_
1
Sketch System on Retain in county file for audit.
Reverse Side. SIGNATURE TITLE'
4
DILHR SBD 6710 (R. 01/82)
wlsconsln APPLICATION FOR SANITARY PERMIT ,I, al ILHR (PLB 67) UNIFORM SANITARY PERMIT #
DEPRRTR1EnT OF 7
InOU5TR4, LRBOR-6 HUTRn gELRTIOns /
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 81/2x 11 inches in size.
-See reverse side for instructions for completing this application. PLEASE PRINT
[PR OPERTY OWNER MAILING ADDRESS
PR PERTY LOCATION'
000-1
N, R E (or W TOWN OF:
1/4/4, S T ,
MER SUBDIV SIGN NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER JnM~: r N ~
LOT NUMBER BLOCK !B,
' l -
TYPE OF BUILDING OR USE SERVED y
X 1 or 2 Family Number of Bedrooms: Public (Specify):
THIS PERMIT IS FOR A:
New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Seepage Bed ❑ Seepage Trench ❑ Seepage Pit ❑ Holding Tank
System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy
❑ Existing, For Which A Previous Permit Is On File, Permit # issued
❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions.
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity `r
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE T S BLOCK: ❑ Mound ❑ In-Ground Pressure
Total #of Prefab. Site Steel Fiberglass Plastic
Gallons Tanks Concrete Constructed
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
91.6 60 9 Private ❑ Joint ❑ Public
1, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signature: NMP/I~$,$Ip(,No.: Phone Number:
2AAqAa,a - 7~ Plumber's Address: Name of Designer:
Z
V 'y
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
~f}O J~~ ❑ Owner Given Initial
eason for Disapproval: Approved Adverse Determination
Alternate course(s) of Action Available:
DILHR-SBO-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
1
INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398
To be complete and accurate the permit application must include: +
1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in
a city, village or town);
2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant,
etc.) ;
3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks.
4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of
square feet to be installed;
5. Complete the section on water supply;
6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi-
fication, place your license number in the space provided and sign the permit in the signature block;
7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the
permit;
8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation.
Failure to comply will void the sanitary permit.
9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable.
10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system,
depth of the system, type of system.
11. All revisions to this permit must be approved by the permit issuing authority.
12. A complete plan including a plot plan, drawn to scale or with complete dimensions.
13. Horizontal and vertical elevation reference points that are permanent and clearly shown.
14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s)
to system, building sewer and vent observation pipe(s).
15. The permit issuing agent may require a cross section drawing of the effluent disposal system.
TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems
must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning
your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin.
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 James H. and Marilyn B. Goin
Location of Property NE NW '4, Section 7 T 29 N - R 18 W
Township Warren
Mailing Address Rt. 1
Roberts, Wi. 54023
Subdivision Name
Lot Number
Previous Owner of Property Glenn Francis
Total Size of Parcel 1.89 acres
Date Parcel was Created June 3, 1986
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for resale (spec house) ? Yes X No
Volume 6 and Page Number 1658 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.
PROPERTy OWNER CERTIFICATION
I (We) ceJtti6y that aU ~statements on thi.6 6ovn ahe tAue to the best of my (oun)
know.2edge; that I (we) am (one) the ownen(.s) o6 the pnopehty dacl bed in thin
kn6o~unati.on bonm, by viAtue o6 a wannanty deed hecohded in the O~6ice ob the
County RegisteA o6 Deeds a/s Document No. 412876 ; and that 1 (we)
pu,sentey own the pnopo~sed site bon the sewage pots system (oh. I (we) have
obtained an eo-6 emen t, to kun with the above dez cAibed pnopelcty, {o& the
con,stAuction of said system, and the same has been duty neeonded in the 066ice
ob the County Reg.usten. o6 Deeds, as Document No. ) .
r
GNATURE OF OWNER SIGNATURE F CO-OWNER (IF APPLICABLE)
6-5-86 6-5-86
DATE SIGNED DATE SIGNED
H
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STC - 105 r
a
SEPTIC TANK MAINTENANCE AGREEMENT Ho
St. Croix County z
d
a
H
OWNER/BUYER JAmes H and Marilyn B. Goin
ROUTE/BOX NUMBER Route 1 Fire Number
.CITY/STATE Roberts, Wi. ZIP 54023
PROPERTY LOCATION: NE 3L, NW ;4, Section 7 , T2_N, R__.l_a_W,
Town of Warren , St. Croix County,
Subdivision , Lot number
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes. Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a licensed septic tank pumper. What you put into
the system can affect the function of the septic tank as a treat-
ment stage in the waste disposal system.
St. Croix.County residents may be eligible to receive a grant for
a maximum of 60% of the cost of replacement of a failing system,
which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that
owners of all new systems agree to keep their systems properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and (2) after inspection and pumping (if nec-
essary), the septic 'tank is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior to
H
three year expiration. H
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- '0
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.
r
SIGNED
DATE 6/ /86
St. Croix County Zoning Office
P.O. Box 98f
Hammond, WI 54015
715-7.96-2239 or 715-425-8363
Sign, date and return to above address.
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
DIVISION
INDUSTRY P.O. BOX 7969
' LABOR AND PERCOLATION TESTS (115) MADISON, Wt 53707
HUMAN RELATIONS (1-163.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHI Y: dT NO.: 'MILNO.: SUBDIVISION N M :
Nf- '/4NU/ 7 /T-a N/Riait 4e~r,F1F-'&! = AV6MAP
COUNTY: ER'S N WE: LING ADORES
fit ~i
si& LeMA- :ST A[Akrk /j(jdsn+v Ljj • 4
S-i-C~a~ Jai~f~s (~oinl
USE DATES OBSERVATIONS MADE
Residence )rNew ❑Replace 4. $ 1 _ to Z
RATING. Sm Site sultabia for system U- She unsultWe for system
L T NK: RECOMMENDED SYSTEM:(optional)
EM-IN -
N S U S C lI I~ S C.JU S U Q U CI'QNV. $erD - 0, K38►
If Percolation Teat are NOT required la SRAT~' TW ST If any portion of the tested area is in the '
under s.H63.a8(51(b), indicate: N. t„R.~ MfIMI Jy Fioodplain, indicate Fioodpiain elevation:
PROFILE DESCRIPTIONS
&ORING L 1 H A R IL 1 THICKNESS, C LOR, TEXTURE, AND DEPTH
AMER ELEVATION TO BEDROCK IF OBSERVED {SEE ABBRV. ON BACK.)
► 1-20'& L; /.'7S' w Lik b7b QM MED 4o,3nTo
B. $110 ~Z , 4.0 0,%Ja 3t7-
S w ff R-oMtnr. / S • l,~a0 /~Q$IY S ~
1.O6 ~c.L ; Z•I' $rJ LS• a. 2o' bit
B- T 1~ O f l.3S $N MCA S.- 1.4 ,~BBt~/ Ado t t•I,o iW Mom S
11-3 ► 0)4'.6! t4o"15 4,+ 7~~r /,Ot7' 9LL,• 7•i ~ kN 5 r ~ Z 'SN'y, W, MST
1
0 qtr M &S' ` &qVs
2.20~$Nr±.' l*30$N L 5 j 4J0$L ~ s GEMEnITf ~
B-4 7,60 89,94- ~A*tiJ6 7?►0 0t
B. 9"50 lot, 67. N o"i6 : 7 9, 510' b~ $N L , o -so -ISK I-VS, Z.ro'cTi9f4 I'F'S 13.46 DK
'S CdAf4 litia O IT $N N7rA 15'tA.Ja'Dr-
iit~ trtts>~► ~ ~ i n1 ~ i~,sG,.~+' ¢tota'CS~ flA~i $r,l'S~ o.StY ~e~5t
B. ~ o>`I Ev
PERCOLATION TESTS - "COTE: N V M e- o ON 5
w t 1•N JKC4KwJ "
DEPTH, WATRINHOLE TIME DROF1N WATER LEVEL-INCHES RA MINUTES
NUMBER AFTER SWELLING INT RVAL-MIN. PER INCH
P. 01.4! L. ISM
.tim -
t1 t
P. toots's
P-
PLOT PLAN: Show locations of percolation testa, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori
zontai 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. R,G 4 v! 4 4 o o QS
SYSTEM ELEVATION !~G . z o
4900 . %t... '.iR4 L a _Z40, LAI Lj~ S w 6 0- 1-r .9N #I It .Tri Nt'A SI
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! + ; /►Z o' M 4S:W bm-ISacC t~oti '14,5;
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L 70
1, the undersigned, hereby osrtify that the soil tests reported on this form were ands 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 ray knowledge and belief.
A print : T COMPLETED ON:
tAV'S - G► z..
ADDRESS: CERTIFICATION NUMB ER: PHON NUMBERloptionai)'
fl a/v o 6 to I S) 3B6 Q-
auR.
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SOO-6395 (R. 02/82) OVER -
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