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Parcel 040-1111-50-100 06/03/2005 09:40 AM
PAGE 1 OF 1
Alt. Parcel 29.28.19.4526 040 - TOWN OF TROY
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): Current Owner
CERNOHOUS, GENE M
GENE M CERNOHOUS
184 CARLSON LA
RIVER FALLS WI 54022
Districts: SC School SP =Special Property Address(es): Primary
Type Dist # Description ' 184 CARLSON LA
SC 4893 SCH D OF RIVER FALLS
SP 0100 CHIP VALLEY VOTECH
Legal Description: Acres: 2.500 Plat: N/A-NOT AVAILABLE
SEC 29 T28N R19W NE NW LOT 1 OF C.S.M. Block/Condo Bldg:
5/1499
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
29-28N-19W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1074/145 TI
07/23/1997 704/246
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/21/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.500 54,500 146,800 201,300 NO
Totals for 2005:
General Property 2.500 54,500 146,800 201,300
Woodland 0.000 0 0
Totals for 2004:
General Property 2.500 54,500 146,800 201,300
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 205
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
' Form- STC_
AS BUILT SANITARY SYSTEM REPORT
_N-RZ~_W
OWNER TOWNSHIP o SEC. _ T JqA
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of ILHR 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
' /ZF.SSn) NGE
,
loco Ga~c
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used Z'T 00'k"r2
Elevation of vertical reference point: _2a22' 0o Proposed slope at site: cJ
SEPTIC TANK: Manufacturer: Liquid Capacity: 90a Q,4,
Number of rings used: NvNg Tank manhole cover elevation:
Tank Inlet Elevation: Tank Outlet Elevation:
Number of feet from nearest Road: Front, Side,O Rear, O O✓6~L 11Z7L) feet
.From nearest property line Front,0Side,fI'lRear,0 1r;7J feet
Number of feet from: well4 , building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
t „
PUMP CHAMBER
Manufacturer: Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: Pump Size
Elevation of inlet: Bottom of tank elevation:
f
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: Length: Number of Lines:_ Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, O Rear,( Pt.`s
Number of feet from well:
Number of feet from building:
i
(Include distances on plot plan).
SEEPAGE PIT
Size: Number of pits: Diameter:
Liquid depth: Bottom of seepage pit elevation:
Area Built:
_q
Has either a drop box O or distribution box O been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity:
Number of rings used: Elevation of bottom of tank:
Elevation of inlet:
Number of feet from nearest property line: Front, O Side, O Rear, 0Ft.
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: 3J Plumber on job:
r
License Number: )
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAf•7 RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX -.9;9 BUREAU OF PLUMBING
MADISON JI 53707
CONVENTIONAL ❑ALTERNATIVE state Plan I.D. Number
I
❑ Holding Tank ❑ In-Ground Pressure ❑ Mound lf assigned )
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER: INSPECTION TE
Gene M. Cetnohouz R. R. 3, Box 60A, Rive/'L 1-atb, W1 Q.A.
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: [ST REF. PT. ELEV.
NE% NW! , Section 29, T28N-R19W, Town of Tnoy - Lot#1
Name of Plumber. MP/MPRSW No. County Sanitary Permit Number_
Gate Za a 3300 St. cuix 58934
SEPTIC TANK/HOLDING TANK:
MANUFACTUR LIQUID CAPACITY. TANK INLET ELE V.. TANK OUTLET ELEV.: WARNING LABEL LOCK( G CO R
PR VI ED'. PROV D
Y /
Y LAY S ❑NO
BEDDING ES ❑NO
: IVENT DIA.: VENT MATE HIGH WATER NUMBER OF ROAD: ]PROPERTY WBU ILDING(VENT TO FRESH
ALRM FEET FROM
Y LINEAIR INLETES ES ❑NO NEAREST 7
DOSING CHAMBER:
MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL PUMP/$I 7N 7ACTUR111 WARNING LABEL LOCKING COVER
PROVIDED. PROVIDED:
❑YES ❑NO ❑YES ❑NO ❑YES ❑NO
GALLONS PER CYCLE: PUMP AND CON TROL$ OPERATIONAL NUMBER OF PROPERTY WELL BUILDING I VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) ❑YES ❑N NEAREST 31111.
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FNGTH IIIIAMIT111 MATERIAL AND MARKING
or excavation. 1 if soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH NO OF DISTR PIPE SPACING COVEN INSIDE CIA -PITS LIQUID
TRENCJ~' / 10A PIT DEPTH.
DIMENSIONS
GRAVEL DEPTH FILL DEPTH ISTR PIPE DISTR PIPE DISTR. PIPE MATERIAL NO. DI NUMBER OF PROPERTY WELL. BUILDING. ~ERESH
BFLOW PIPEABOVE COVER LEVINLET ELEVEND PIPEI
"7 Z FEET FROM ~ Y 777
L NEAREST LINE
-s
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.
❑YES ❑NO
SOIL COVER TEXTURE PER ENT ARKERS OBSERVATION WELLS
❑ ES ❑NO ❑YES ❑NO
DEPTH OVER TRENCHBED DEPTH OVER TRENCH. BED DEPTH OF TOPSOIL SOD ED SEEDED MULCHED
CENTER EDGES
YES ❑YES ❑NO ❑YES ❑NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH LENGTH NO.OF LATERAL $PACI G G AV PTN BEL W PIPE FILL DEPTH ABOVE COVER
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR,'PIP NIF D MATER IA IN O. DISTR [STR P IPE DIS rR BUTION PIPE MATERIAL & MARKING
ELEVELEV.DIAELE V f PIPESA.'.
ELEVATION AND r
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECT LrW COV R MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
I U PLANS
❑YES ❑NO ❑YES ❑NO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WE S: NUMBER OF PROPERTY WELL BUILDING
( FEET FROM LINE
' E Z ❑ YES ❑ NO ❑ YES ❑ NO NEAREST
U
Z
L ~J 7 • / I
Sketch System on n in county fi e for audit.~j G
Reverse Side.
SIGN TI LE:
D I L H R S B D 6710 (R. 01/82)
i'
wlsconsln APPLICATION FOR SANITARY PERMIT
'r DILHR COUNTY
oERRRrmEnT OF (PLB 67)
UNIFORM SANITARY PERMIT #
~ InOUSTRV,IRBOR6HUTRn REIRTlOnS l`9iff
-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 MAILING ADDRESS
PR PERTY LOCATION;
1/4 '!,6`1/4, S TV, N, R E (o 6W) TOWN
F:
ZIA
LOT NUMBER BLOCK NUMBER SUBDIVISION NAM NEAREST ROAD, l/AKE OR LANDMARK ]STATE PLAN I.D. NUMBER
s r'I'?
TYPE OF BUILDING OR USE SERVED CAVI&
&r 2 Family Number of Bedrooms: Public Specify): `f
THIS PERMIT IS FOR A:
X 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 X 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 VUV x S
Lift Pump Tank/Siphon Chamber
Holding Tank capacity
Manufacturer:
IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS 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):
bQQ. o U Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber (Print): Signature: AAP/MPRSW No.: Phone Number:
/L b ( ;/IS) Jeg-LSD
Plumber' Address: Name of Designer:
COUNTY/ DEPARTMENT USE ONLY
Signature of Issuing Agent: Fee: Date: ❑ Disapproved
~ ,rr ~J(7 7 ~j ❑ Owner Given Initial
2& a ~l L~CiLJ 1 Y<S Approved Adverse Determination
Reason for Disapproval:
Alternate course(s) of Action Available:
DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber
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
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 r~Ii,t,_ leej-. r~ A'1• C le fZ 1-1 litt Ck
Location of Property_ CU Section, T
0N - R W
17-
Township (7
Mailing Address
`R F:~ ~r
Subdivision Name
Lot Number
Previous Owner of Property k11jZfZL)i q ef, 1~ t, I~
Total Size of Parcel
Date Parcel was Created f J
Are all corners and lot lines identifiable? x Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume 10 ~ 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER CERTIFICATION
I (We) ee/t i6y that aU statements on .th,vs 6onm ane tAue to the best 06 my (ouh.)
knowledge; that I (we) am (ane) the owneA(h) o6 the pAopefcty dauLibed in th.ih
!.vi ~oAmati.ovn Bohm, by v4Atue o~ a waAAan,ty deQd. Aeeondod in the. 066ice o6 the
county Reg-i steA o ~ Deed6 " Document No. 'f Y 1 and that I (we)
p4aentty own the puposed /site 6oA the sewage posat system (oA 1 (we) have
obtained an e"ement, to Aun with the above d"cAbed p)Lopetcty, 6oA the
eon,stAucti.on o6 said .6ystem, and the .same has been duly AeeoAded in the 066ice
o4 the County Regii teA of Deeda, as Document No.
SI ATURE OF OWN SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
y My
S T C - 105 r
y
H
SEPTIC TANK MAINTENANCE AGREEMENT
0
St. Croix County z
d
OWNER BUYER c=V1C Jt`(• yiGtIC LC`~:,
ROUTE/BOX NUMBER RFD 3GX _Iq Fire Number
CITY/ST ATE_"R~ k-1: ei2 , <s-~ _-ZIP----- - 5,/G2-
PROPERTY LOCATION: ~4, Section '1' ;>4N, R_ f W,
Town of St. Croix County,
Subdivision Lot number
I
Improper use dnd 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
three year expiration. ti
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, as set by the Wisconsin Depart- v
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.
S I G N E D
DATE C7 -'•5
St. Croix County Zoning Office
P.O. Box 98,
Hammond, WI 54015
715-796-22'49 or 715-425-8363
Sign, date and return to above address.
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N ( REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
10 DIVISION
AAN RELATIONS PERCOLATION TESTS (115)
(H63.09(1) & Chapter 145.045) MADISOON, W 53;0
-
~I OCATION: SECTION: . TOWNS HIP/MIJP}+O}PAE TY.- LOT NO.: BLK. NO.: SUBDIVISION NAME:
~svat/ 1/ -9 /Tzt,N/R t9 E PR~pos c.s. rte.
COUNTY: OWNER'S/BtiY-ER'S NAME: MAILING ADDRESS:
USE DATES OBSERVATIONS MADE
NO. BEDRMS.: COMMERCIAL DESCRIPTION: O New DESCRIPTIONS: PER OLATION TESTS:
NResidence ~f~1New ❑Replace v D - zS- a
o----- - g y t y
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK RECOMMENDED SYSTEM:loptional)
~SU~ ❑S ~U ~S ❑U ❑S ~u ❑SU Z TRS-H s'x.16o'
[underrcs.1-63.09(5)(b), olation Tests are NOT required DESIGN RATE: Iport on of the tested area is in the
N A
indicate: dplain, indicate Floodplain elevation:
F
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-Ifle WEE CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH I ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B l 6.0 -~~•S 1J1e bnoT~ 0.9' ~1\cg,~ 1S Ts
6_0 V. Z RT L/• 3 '
l._. T S 1.5' l Is ; 3. y' 13n S I w/
B- ' J ~1 z It 76.0 SL\GIZTLuf ~F"~D S
\•z' U01c~3,~ LTS; 4•y'_ByIS' o 5'13n 'S
B 3 e 1 g . 3' 7 6. 1
B 7 ~.O $ 3. S 7 ~,o' ~tGn7t Y DSO S
11D\zBn LTs~ 53n SC 3 L/ 8n S1 w/
B- 5 7.b' fig, bl r.• ~.p ' Sl (GNTL4 D1_-1S= $R1~SJS J' 'Z F_~ >7 c I'
hAuT Z' VD1zSh I_T-S; y. o' s,';; o' Bn 1s ,
B- ~'3 -1 y~c>>JL .A 5.9 ' 1• ~ ' n S1 s lGr-~y i`3~5~ -r~~ 'v 2Y a os~ P 6.0
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD 2 PERIOD 3 PER INCH
P_ i z l~ 0 3 o S/a S,% s%3 y S
P- Z 2Y tIJO 3 0 3/ 31V 3/y 1,/ 0
P_ fit/ )'JO 3 t7 ~/s -788 37
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 horn
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.
QQ 81•t 3 -78.6' S~l~ S~~2~c`t SrivwS 1.`1tif~~'ct~
SYSTEM ELEVATION rao•o' ) -1 • z' Ctio~ T~tP lcf\
.tea - ~ - ,li -~E
LI/~eS 1 of ae . Z9 ; ~'r-~; ? - ~csv 9? , t c>r~ s~~ ► C=
'o I )),j p 11. Ja ~c T12
C(-OT ~,n,eS~ to
7 . ?,v tE L C,
_ LZTJ ST S& 11~E eif-_ 5tt~
- - -P
_ PZ 6' S T 1 - - - - - - - - - -
- 1
~Z
- + - -i
7
t I
j f 0
I I f
SCR ~L = 60' ~CCi=PT s s ~~wN sc , V)
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin
Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
NAME (print): TESTS WERE COMPLETED ON:
I z~V~C L. L-7z - -zS-`a`/
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
iZTV y--x, --Z6 ~LLEL.JJ`i=T4 1,u) 54'x!1 S~~ ls_vz S-13/6v
- - CST SIG ATUR
DISTRIBUTION: Or ,inal and one copy to Local Authority, Property Owner and Soil Tester.
P11rir,-SBD-6395(R 0 2182) - OVER -
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