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Form - S T C - 104
BUILT SANITARY SYSTEM REPORT
v~
O
OWNER TOWNSHIP SEC. T N-R 17 W
ADDRESS - ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I•IHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
~ ~ eI
750
~
Oat '70
f I ►i11~T
>~~rP V I I I !
I I I i '
~ ~ ~ I V I I I
'/V0
r
INDICATE NORTH ARROW
y
IL
BENCHMARK: Describe the vertical reference point used
~c~Ke. fat
Elevation of vertical reference ^ t' A;'t'
point: Proposed slope at site: /n
SEPTIC TANK: Manufacturer: Liquid Capacity:
s
Number of rings used: lflol?e_ Tank manhole cover elevation: le~tO -Y Y'
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front 10 Side, Rear, O 85 feet
. From nearest property line Front,0Side10Rear,0 Cfeet
Number of feet from: well building:
i
(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: Bot om o t nk elevation:
Pump off switch elevation: G to s per cycle:
Alarm Manufacturer: a Switch Type:
Number of feet from nearest prope y lin 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: Ive S Trench:-//O
lo,
/C~ f a
Width: Length: f% Number of Lines: 25 Area Built:
Fill depth to top of pipe:f o
Number of feet from nearest property line: Front, O Side, ® Rear,0 Pt. D
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 s e pit elevation:
Area Built:
Has either a drop box O or distrib tion box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: AL Cap -ty:
Number of rings used: 1 ation f ottom 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: <oY _ Plumber on job: License Number:
3/84:mj
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bot om o t nk elevation:
Pump off switch elevation: A G to s per cycle:
Alarm Manufacturer: a Switch Type:
Number of feet from nearest prope y lin Front, O Side, O Rear Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM /
Bed:e Trench: ~O
Width: Length: Number of Lines: -6' Area Built:/O y 47
Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, ® Rear,O Ft. 0
Number of feet from well: 4O02
Number of feet from building: /16
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom s e pit elevation:
Area Built:
Has either a drop box O or distrib tion bo~ O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Cap ty:
Number of rings used: _//~l ation f ottom of tank:
Elevation of inlet:
I/ /
Number of feet from nearest/Property ne: 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: k/)al?
License Number:
3/84:mj
DEPF.RTMENT Of INDUSTRY, INSPECTION REPORT FOR
LABOR & HUMAN RELATIONS SAFETY & BUILDINGS
P:p. BOX i969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON.VVI. 53}07 BUREAU OF PLUMBING
L~'C.'UNVENTIONAL ❑ALTERNATIVE State Plan l.D.Number
:
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound (If-igned)
NAME OF PERMIT HOLDER: ADDq ESS OF PERMIT HOLDEq
Richard Gorton R. R. 1, Hammond, WI INSPE I NDATE:
BENCH MARK (Permanent reference Point) DESCRIBE IF DIFFERENT FROM PLAN ~
NE SW, Section 16, T29N-R17W, Town of Hammond REF. PT. ELEV.: V.: CST REF PT. ELEV.
Name of Plumber
MP/MPRSW No.: County: Sanitary Permit Number:
Dale E. Hudson 6629 St. Croix 64889
SEPTIC TANK/HOLDING TANK:
MANUFACTURER:
LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL
LOCKING CO ER
P 0 "DED: PROV
BEDDING: VENTD VENT MATL.. HIGH WATER L{JYES ❑NO J ❑NO
ALARM. NUMBER OF ROAD: PROPERTY WELL: BUILD IN TO FRESH
❑YES p FEET FROM LINE: I IR INLET
❑YES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER. BEDDING. LIQUID CAPACITY. PUMP MODEL: PUMP/SIPHON MANUFACTURER.
WARNING LABEL LOCKING COVER
❑YES ❑NQ PROVIDED: PROVIDED:
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. ❑ YES ❑ NO ❑ YES ❑ NO
(DIFFERENCE BETWEEN NUMBER OF PROPERTY, WELL euILOINC VENT FRESH
PUMP ON AND OFF) FEET FROM LINE' AIR INLET
:
SOIL ABSORPTION SYSTEM. Check the soil moisture at the❑d pth of plowing ❑ NO NEAREST
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE DIAMETER MATERIAL AND MAgKINc
the soil is dry enough to continue.) MAIN
CONVENTIONAL YSTEM:
BED/TRENCH WIDTH: LENGT NO. OF DISTR PIPE SPACING COVER
DIMENSIONS TRENCHES INSIDE DIA tt PITS.
04 IAL: PLS. LIQUID
DEPTH:
GRAVEL DEPTH FILL DEPTH DI STR .PIPE DISTR. PIPE JOIST q. PIPE MATERIAL N ISTR.
BELOW PIP ECOVER- ELE V. ~tET. ELEV. END: NUMBER pF PROPERTY WELL: eUILDING~ VENT TO FRESH
/'rYI t°" P s- FEET FROM LINE: ,~r AIR INLET:
MOUND SYSTEM:
Mound site plowed per endicUlar 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-
❑YES ❑NO meets the criteria for medium sand. TIONS MEASURED.
SOIL COVER rexrugE
PERMANENT MARKERS. OBSERVATION WELLS.
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH ❑YES ❑NO ❑YES ❑NO
CENTER EDGES: OF TOPSOIL. SODDED.
YES ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE
TRENCHES: FILL DEPTH ABOVE COVER:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV. ELEV.. DIA.. ELEV.: PIPES: DIA.:
[DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY
COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS.
COMMENTS: ❑YES ❑NO ❑YES ❑NO
PERMANENT MARKERS: OBSERVATION WELLS:
NUMBA F PROPERTY WELL: BUILDING:
FEET M LINE:
YES N ❑YES ❑NO NEAGoy"'
5"
Sketch System on
Reverse Side. Ret~i_," ottn-ty file for audit.
[SIG-NATURE
TITLE
DILHR SBD 6710 (R. 01/82)
w5consin ~ APPLICATION FOR SANITARY PERMIT
HR (P 6 COUNTY
IL
OEPRRTTT~rIT I L-6
ino STRV.LCMC &HUmgnRELRT10ns UNIFORM SANITARY PERMIT i
-Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8/2x 11 inches in size,
-See reverse side for instructions for completing this application. PLEASE PRINT
PROPERTY OWNER
R
MAILING ADDRESS
PROPERTY LOCATfON 6Ff
A~Z 1/4 .5Lv'i /4 S , T,;7? N, R /'7 (or) TOWN F:
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
1 ~U • GtJJt 7
TYPE OF BUILDING OR USE SERVED 0/
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
i~ Alternate System ` ❑ Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
Seepage Bed ❑ Seepage Trench ❑ Seepage Pit F1 Holding Tank
System-ln-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
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity
Litt Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer. 2, e P- 7<s
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: Mound El In-Ground Pressure
Total #of Prefab. Site
Gallons Tanks Concre Constructed Steel Fiberglass Plastic
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
ERCOLATION RATE ABSORPTION AREA ABSORPTION AREA VI/ATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet):
5 (7 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: MP/MPRSW No.: Phone Number:
1117~well~e) X7
Plumber's Address: Name of Designer:
/ 4~~Z J
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: G
J J ❑ Disapproved
' {y L~ Owner Given In
r kG Approved term
Reason for Disapproval: - Adverse D ,'nat non
Alternate course(s) of Action Available;
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
F
'INDUSTRY;- of REPORT ON SOIL BORINGS AND SAFETY &
INflIJS DIVISI~.
`M
HUMA NfsltE SELATIONS 1 PERCOLATION TESTS (115) BOX 7969 (H63.090) & Chapter 145.045) MADISON, W1 53707
LOCATIO StC ION TOWNS Hi1 LOT NO":BLK. NO.: SUBRIVISION NAME:
~ / 16 /T,29N/1'/ 71 (or
C. UNTY. OWNERS UYER'S' AM MAILING ADDRESS: A114
* r
47
d0i t /~f
U E _ DATES OBSERVATIONS MADE
NO. B DRM1AS : C M ER AL DES 1 TIO L5New S ATION T STS:
Residence
A~A ❑Replace
_ ,2 - F5 05' _ . 3 -5,
RATING: S= Site suitable for system U- Site unsuitable for system
ONVEN I AL: MOUND: IN-UHOUND-FRESSURE. $ M-IN-FILLHQLDING TANK: RECOMMENDED SYSTEM:/ ptional)
~s ❑U 1:1s [2u as ®u as au as Fe u cC~
If Percolation Tests are NOT required DESIGN RATE: LFloodplain, an
y portion the tested area is the '
under s.H63.09(5)Yb1, indicate: indicate Fioodplaro elevation:
PROFILE DESCRIPTIONS `
BORING TOTAL P H' GROUNDWATER-4-N- HES CHARA TER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH'
NUMBER DEPTH IN, ELEVATION OBS RVE H ST TO BEDROCK IF OBSERVER (SEE ABBRV. ON BACK.)
B_ ,t
/ s cl,
El- 3 10, 51
r
43 30 o' n .5-
B-
B_
s-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WA 'ER LEVEL-INCHES RATE MINUTES
NUMBER +fI&W6 AFTERSWELLING INTERVAL-MIN. Ri nt P Rlea2 P PER INCH
P- .3 y2 o a / f
A j fQ y j„ /gam.
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
. s
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r z `
F
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,
I t 1
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r
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,
,
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e 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
'nistrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. '
(print): TESTS WERE COMPLETED ON:
-D 2-
SS: e S_, 3 - 85
CST
CERTIFICATION NUMBER: PHONE NUMBER (optional):
CST SIGNAJURE:
/C~(.(:'4. ~;..7. /Aft-"'te'e •~i-6'~.--'•
10N: Original and one copy to Local Authority, Property Owner and Soil Tester.
395 (R. 02/82) - OVER -
G rte'.
No ap
r
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V tl ~ ~ VQQT ~.!'1
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10-
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0\ CERTIFIED SURVEY MAP
DUANE L. LEWIS AND LORNA D. LEWIS, ROGER M. DANIELS AND ESTHER C. DANIELS
N Part of the Nor west 1/4 of the Southeast 1/4 and the Northeast 1/4 of the Southeast
1/4 of Section 1 , Township 29 North, Range 17 West, Town of Hammond, St. Croix
r County, Wiscons .
K UNPLATTED LANDS
eI c C.rN." a Q - - - - b L _ _ -
W S00.36'37W 2639.68' ^E LINE SE I/4
n
b l of O 0 414.84
Q _ _ _ n a
IL N 'N S00• 6'57'r 414.38'
ti
N o o Z o M
a a
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O M ~ O I O D 0 y V rA LL
p b I O D N rc N
h d .
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7 h U 0! C N W C n n H N b
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1y dY Z • d;""" d o N J O O N d
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a
to •
m 0 Z z rc o
dl h I o m m
OI Q v y W
Z d 41 Q y H
QI 493.00 411.35. O W tq
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J X S 00.36' 57 W-j906.35' WI _ I
al em
1. ~o* \90 Q NS y~~~/ N Q I " ~
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m: W M U _ : M a 'L 0 Q o
S 71 ° m
a a W m W
m 3 ~ ~ ~T ER FALL J J y
wisc
03 U
LAND
assists
W
Laurence W e
. Murphy
a
v a Registered Land Surveyor
W
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W
y u 3
a W
N 1L 2
W O 0O W
~ N V h 2
N J
Q o a;
avnn W
O m " R n
O n 00 • 16 02 "W 330.05'
in ku
.,l co N 2 N X
a
\ m fill
n C
y
OIndicates 1"x 24" iron pipe weighing 1.13 lbs./ lin. ft* set. 3
7 ` QI
2 3 W
W F•
J Q
• to N J
x IL
N/S I14 LINE 0 'k O
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2
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-x - N 00 • 0510811W 13 03.01 ' y
x
m
Dated: 19 September 1984 UNPLAT TED LANDS
Vol. QA-r" Page /!-g( SHEET I0F2
Certified Survey Maps
St. Croix County,'Wisconsin
APPLICATION FOR SANITARY PERMIT
ST 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/contractpr,("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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
r e e- rA
Owner of Property W
Location of Property It, Section AC , T 2q N - P. / 7 W
Township i/Q kn ,'-n o n j
Mailing Address 4i~ p u r e /3 69 fC j 2
Subdivision Name
Lot Number ,
Previous Owner of Property p~
Total Size of Parcel S$", C{ C Z S
Date Parcel was Created _Alo V, 9 L/
Are all corners and lot lines identifiable? = Yes No
Is this property being developed for resale (spec house) ? Yes - No
Volume 7 p~~ and Page Number I 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 _ 4kL eeAti.6 y .that a tt .6 to temen to on #h i a 6oAm a ,%e t&ue to the beat o6 my ,(ogg&1
hnoweedge; that 1 (dug) am jg"I the owne lAl o6 the pnopeAty deAc4ibed in #hiA
.in6o4mati,on 6oAm, by viAtue o6 a wmAa.nty deed neconded in the 066.ice o6 the
County RegiA ten. o6 Deeds " Document No. 7 75,'S' and that I we
pnea enemy own the pnopoa ed A to bon th.e a ewage poa a ya.tem (on I have
obtained an easement, to hu.n with the above ded en i.bed paopen ty, bon the
conbthuation o6 aaid a p tem, and the name has been duty neconded in the 066.ice
o6 the County Reg-i a.ten o6 Deeds, ab Document No. 3 7 ~3 35`1.
SIGNATURE OF WNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
WAL ESTATt TRANSFER RETURN Wisconsin 0 artroent of Revenue
4A NT GRANTEE:
me X. axe Roar C. Dario s Name RicMr4 J. and aria A. Corton _T
$ctual Security Number I Social Security Number
" `4e5s, New address if property transferred was residence Full Address
Rouba 1, .11M 1?2
Ramon
-do WX
441
fit " dated to grantee? relationship tncludcs, Yes' No Name and address to which tax bills should be sent if not the samt_ as above
a „ ood relative, partner, lessee-lessor,
parent corporation or ioint owner.
`trf stow related
Gkantor is {Individual ❑ Partnershh ❑ Corporation ❑ Other Grantee is
91 Individual F3 Partnership El Coi poration ❑ Other
n. Grantor ( Tele hone: Grante
irac -proper box and enter name of miuiir il, ,lit y and county Street address of property transferred include road name and/or fire number-
Hasnond
Vihage ;c Town
Sty. Croix
c 'County
AA~ga Description (Fill in complete le I description in space below or if metes and.bounds description attach 3 copies of it as shown on the instrument of
~"1 l 1Hi ~y arm i# #+y~rrtSe6ant% t t er, rangy s it and aci )
otNo. Blk No. Section lawn K trig( Plat None
propeVt,Parc -
of Number - -
"W" I S-" to right 0_ way of St. Croix Count Tr=3s
+ r th1 $astarly ,p qrt o nl thereof.. TOGSTIOR wife and Stsm" to
~tbsar aasessents. covenants, r"Orvations and restrictions of record, tr aay.
YSICAL DESCRIPTION AND INTENDED USE
bs „ r b R idef-04 Units, it Principal Intended Use 3.
~-y Land, e ~O,and Type Estimated
a Z IM a,' Residential d ❑
t LJ Agricultural a. to 4* x
New Construction 2 and'3 units
h. Commerc,iat' e. ❑ Recreational h.
I Building Prevlousl y Used Jotal Acres ❑
Building y El 4 or mare units c. ❑ Industrial f, El other (Explain) I. ___Tillable Acres ❑
❑ Solar Design c.
Al-
❑ Rental
~artC15he1teFecJ Home ~ W.T.L. Acres
o q n# 3. F.C. Acres El
` ma~-~yy fAncwer as many as apply) c Ft, of Water Frontage
❑
Sale 2. LJ Gift 3. ❑ Exchange 4-T❑ Other transfer (Explain)
S Ownership, interest transferred ❑ Full ❑ Other (Explain)
,II o ~ofhandiontract-W t
t as the date of the original land contract(
PART IV -COMPUTATION OF FEE OR STATEMENT OF EXEMPTIONS the r torrtain an or the fo!(owin ri hts:. Life estate Easement
❑
kE
~ ieaF t ,u~ ~
I s r a S TATf transferred (pur aserdee;'etc. rounded to next even hundred. Do not include personal property) $ 5 4.2 010
r"k~alle' otersrrRal*o(~erty transferred but e ATWO from line l
i Value of tax exempt property (solar, wind, waste treatment, mfg. M&E, other) included in line 1
4. TRANSFER EXEMPTION NUMBER of exempt for Reasons 1-13 (see instruction) $
5. Fe Sec 77.25.
Fee chi cents one hundred dollars of value (line 1 times .003) Make check a able to Re isles of Deeds 64.70
PART V - O TIFICA N
$ _ I
Th~ transfer must be reported regardless of the Grantor's state of residence. Information on this return will be used to administer Wisconsin income and Fran
diftxe Tax Laws and the Wisconsin Real Estate Transfer Law.
k declare utrue nder pe correct nal an cofoatllaw,ete. that this return (Including any ac
.
'tttf it is companying schedule) has been examined by us and to the best of our knowledge and I
Signatu Grantor or Ahern
* r t " Date Print of Type gent' 11 s' lame
R Sign t Age DaI Zj~w
" Prink of Type Agent's Name
`nt ss`
Phone
D" Y0, vol. (Reef) Page (Image) TDale Recorded Date and Kind of Conveyance
L10w
Pat'eel Nu K
Y z: 19 19 Code: County [ax Distract Assm't Dist
%ildL~+
S L etr _
A B C, p F E I I _ 1 Office 2 Field 3 Use 4 Reject
T T Ratio Consideration j
P (R x$41
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STC - 105 r
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SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
A Q may/ i H
OWNER/BUYER r_ A Q r c) , /2/Gl I~ f ~ Go r~"o ~
ROUTE/BOX NUMBER IQO a nP L od p Z / 7 Fire Number F_7
DD ~//0
P__-
CITY/ STATE /~Q /~✓/~a? Q_n~/,8 C Z I
PROPERTY LOCATION: Section , TO?g N, R /7 W,
Town of ll/!Z/ylC~l7G~ $ t. Croix County,
Subdivision A14 Lot number A14
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 II
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. 'A
0
E
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
H
the standards set forth, herein, as set by the Wisconsin Depart- ra
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
21
SIGNED G v
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.
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tq ST. CROIX COUNTY ZONING OFFIC
SID. St. Croix County Courthou
911 4th Street 91
Hudson, WI 54016 vz o
Telephone - (715)386- 680%~~
The St. Croix County Zoning Office offers the service of septic
and water inspections to Lending Institutions, Realty Firms, and
private individuals.
^=mpletion of this form is essential so that the nroRerty can be
located.
Please provide the following information, enclose appropriate
fee made payable to St. Croix County Zoning Office, and mail,
along with form to the above address. Testing will be done as
soon as possible after fee and form are received.
WATER TESTING----------------------------FEE: $ 25.00
(For nitrates and coliform bacteria)
WATER TESTING FEE: $175.00
(For VOC'S)
SEPTIC SYSTEM INSPECTION-----------------FEE: $25.00
(Determines if system is properly functioning at time of
inspection)
Property owner's name
Property owner's address
Legal Description-T,'--' 1/4 of the 1/4 of Section //0 T,21_N-R/7
Town of~~A-rv Lot Number Subdivision Name
rum mtnffiza QA~ U= BOX NUMBER 7
Color of house 14 Tka Realty sign by house? I so, list firm:
PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP,i.e,COPY OF PLAT BOOK,
WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained.
Firm or individual requesting services:
Telephone Number
REPORT TO BE SENT T
Closing date )4tAAU j&/. 41,P9'
S gna u
ST. CROIX COUNTY
4- ~Y-0-
WISCONSIN
ZONING OFFICE
A N N N N N r~~~i ST. CROIX COUNTY GOVERN Ott
1101 Carmichaelr
x- - Hudson, WI 54Q 6a. /10 s'
(715) 386-° O
SEPTIC INSPECTION / WATER TEST REQUEST FORM Eft N j
Please specify desired test(s) & remit appropriate fee wftfftr_
application. Outside water lines are often turned off°x r.~-
winter months, making access to the home necessary. PleasL-.-m
arrangements with this office to insure that entry can be gained.
❑ Water (VOC's) $185.0 ❑ Septic $50.00
Water (Nitrate & Bacteria) 45.00 ❑ Nitrate & Bacteria
retest `~$15. 00 ~j
Owner: V GA ' ,,1► I aCG Ot J Requested by: 1 / I ►JA
Address: E3 (o Le, 7 Address: S1
+~AVKMOnG4 L-A ZIP 5yo1z Sd✓l W ZIP SYD/
Telephone N4: (-11.5 ) 7,7 (o- 5 Telephone N4: /(-15 ) 345(0- 3 (o
Property address (Fire W & Street) : c13& 1 nn,0. RBI • T /
Location: Sec. , TN, R W, Town of ✓v~.ohA
Realty firm: Lock Box Combo: Closing Date:A5,4P
018- 1031Q 030-000 /4,.29. 17.25'3Gr
TO BE COMPLETED BY PROPERTY OWNER
PROVIDE A SKETCH OF HOUSE & SEPTIC SYSTEM ON REVERSE OF THIS FORMS
Water sample tap location:
Is the dwelling currently occupied? ❑ Yes 0 No
If vacant, date last occupied:
Age of septic system:
Septic tank last pumped by: Date:
Previous Owner's Name(s):
Have any of the following been observed?
❑Y ❑N Slow drainage from house.
❑Y ❑N Sewage Back-up into dwelling.
❑Y ❑N Sewage discharge to ground surface or road ditch.
❑Y ❑N Foul odors.
Other comments relative to system operation:
I certify that the above information is complete and true to the
best of my knowledge.
OWNERS SIGNATURE: DATE:
1/94
I
i
OWNERS DRAWING OF HOUSE & SEPTIC SYSTEM LOCATION
IN
TO BE COMPLETED BY INSPECTION AGENCY
System design &/or permit on file? []Yes ❑No
Soil series per SCS Soil Survey: sheet #
Type of soil absorption system: OBelow grd ❑At-Grd []Mound
Approx. size 'X OGravity ODose []Pressurized
Ft.2 []Bed OTrench []Dry Well
OHolding Tank ❑Outfall pipe
OBSERVED DEFICIENCIES []Other []Unknown
Septic tank
Setbacks: []House []Well []Prop. line []Other
Dose tank
Setbacks: []House []Well []Prop. line []Other
[]Locking cover []Warning label []Pump /Floats
[]Alarm []Elec. wiring
Soil Absorption System
Setbacks: []House []Well []Prop. line []Other
OPonding: []Discharge:
General comments:
INSPECTORS SKETCH OF SYSTEM LOCATION
N
Inspector
Title
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
p x a~ u Ron", ST. CROIX COUNTY GOVERNMENT CENTER
1101 Carmichael Road
r'r Hudson, WI 540 1 6-771 0
- (715) 386-4680
a
I
November 13, 1996
Mid-America Bank
Attn: Jill
600 2nd Street
Hudson, WI 54016
RE: WATER TEST RESULTS FOR JAY & RENE MARCOTT PROPERTY LOCATED AT
936 COUNTY ROAD T, HAMMOND, WI 54015
Dear Jill:
Enclosed, please find the original water test results for the above
referenced property. We apologize for not getting these results to
you sooner and for any inconvenience this may have caused.
If you have any questions or if we can be of further assistance,
please give our office a call.
S ncerely, „ J
Mary J. Jenkins
Assistant Zoning Administrator
St. Croix County, Wisconsin
db
Enc.
COMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800-969-5227
FAX - 715-962-4030
ST. CROIX COUNTY ZONING OFFICE REPORT NO.! 27512/01 PAGE 1
ST.CROIX CTY.GOV.CTR REPORT DATE: 10/15/96
1101 CARMICHAEL ROAD DATE RECEIVED: 10/09/96
HUDSON, WI 54016
ATTNI THOMAS Co NELSON
OWNER: Jay b Rene Marcott
LOCATION: 936 C.T.H. "T", Hammond
COLLECTORS M. Jenkins w
DATE COLLECTED: 10-08-96
TIME COLL.ECTED*# 1000ae'
SOURCE OF SAMPLE: Kitchen tap
DATE ANALYZED:10-9-95
TIME ANALYZED# 2100pas
COLIFORM,MFCCS 0 /100 al
INTERPRETATIONS Bacteriologically SAFE
I
NITRATE-N*# 5.4 ppm
Above 10 ppm exceeds the recommended Public
Drinking Water Standard.
Coliform Bacteria/100 mt
Nitrate-Nitrogen, mg/t
LAB TECHNICIAN: Pain Gane
WI Approved Lab No. 19 -
t Means "LESS THAI!" Detectable Level Approved by
PROFESSIONAL LABORATORY SERVICES SINCE 1952
-vb
ST. CROIX COUNTY ZONING OFFIC
St. Croix County Courthou
911 4th Street
Hudson, WI 54016
Awl
Telephone - (715)386- 680 1
The St. Croix County Zoning office offers the service of septic
and water inspections to Lending Institutions, Realty Firms, and
private individuals.
ComRletion of this form is essential so that the property can be
located.
Please provide the following information, enclose appropriate
fee made payable to St. Croix County Zoning Office, and mail,
along with form to the above address. Testing will be done as
soon as possible after fee and form are received.
WATER TESTING----------------------------FEE: $ 25.00_
(For nitrates and coliform bacteria)
WATER TESTING FEE: $175.00
(For VOC'S)
SEPTIC SYSTEM INSPECTION-----------------FEE: $25.00
(Determines if system is properly functioning at time of
inspection)
Property owner's name
Property owner's address
Legal Descriptions 1/4 of the 1/4 of Section, TN-R/7
Town of Lot Number 2- Subdivision Name
FIRE NUMB= !22i~ UZZ BOX NUMB= )IJ ~51( 4 7_
Color of house - Realty sign by house? F I so, list firm:
PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP,i.e,COPY OF PLAT BOOK,
WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET.
Testing of residential water requires a sample that is fresh. If
the home is vacant, and has been so for some time, the water line
must be purged by running the water for several hours before the
test can be conducted.
WINTER TESTING: Many times water lines are turned off, or sill
cocks are turned off, making access to the home necessary. If
this is the case, please make proper arrangements with this
office to ensure time when entry may be gained.
Firm or individual requesting services:
Telephone Number
REPORT TO BE SENT TO:
Closing date
S gnature
COMMERCIAL TESTING LABORATORY, INC.
514 Main Street, P.O. Box 526
Colfax, Wisconsin 54730
715-962-3121
800 - 962 - 8378 (WI)
800 - 962 - 5227
ST. CROIX ZONING REPORT NO.* 31470/41
ST. CROIX COUNTY PAGE 1
REPORT DATES 7/19/89
COURTHOUSE DATE RECEIVED: 7/18/89
HUDSON, WI 54016
ATTNS THOMAS C. NELSON
30L~
OWNERS g*oxx 49, 7, .1
LOCATIONS , Hammond, WI
COLLECTORS Mary Jenkins - St. Croix County Courthouse
SOURCE OF SAMPLES Bathroom Sink Faucet
COLIFORMS 240 /100 ml
INTERPRETATIONS Bacteriotogicatty UNSAFE
NITRATE-NS 9 ppm
Under 10 ppe is safe for human consumption.
COLIFORM + NITRATE
LAB TECHNICIANS Pam Gane
L
WI Approved Lab No. 19
F,\NDEVFNpE t° y a~
P
V y
< Means "LESS THAN" Detectable Level Approved by'#
o PROFESSIONAL LABORATORY SERVICES SINCE 1952
I