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Parcel 042-1087-70-000 01/29/2007 04:37 PM
PAGE 1 OF 1
Alt. Parcel 31.29.18.486C 042 - TOWN OF WARREN
Current X 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 - VONDRISKA, GEORGE J & EMILY J
GEORGE J & EMILY J VONDRISKA
924 CTY RD N
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description * 924 CTY RD N
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 11.050 Plat: N/A-NOT AVAILABLE
SEC 31 T29N R18W 11.05AC THAT PT SW 1/4 Block/Condo Bldg:
SW1/4 LYING S OF CO RD N AS IN 635/638
667/310 EXC P486E Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
31-29N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 1142/481 WD
07/23/1997 8 3L435-
07/23/1997 8 4 5~ C-TevynGt,L,ti
07/23/1997
2006 SUMMARY Bill M Fair Market Value: Assess -With:
149808 370,200
Valuations: Last Changed: 10/22/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 11.050 66,500 203,600 270,100 NO
Totals for 2006:
General Property 11.050 66,500 203,600 270,100
Woodland 0.000 0 0
Totals for 2005:
General Property 11.050 66,500 203,600 270,100
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 124
Specials:
User Special Code Category Amount
018-RECYCLING SPECIAL ASSESSMENT 15.00
Special Assessments Special Charges Delinquent Charges
Total 15.00 0.00 0.00
Form- S T C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SEC. T e~ ' N-R /rS W
ADDRESS 4 ST. CROIX COUNTY, WISCONSIN
y
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of I1H.R 83
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I
S ~ ~ if ~ ~ Yo
t 1o i ~ p~,,rsr
.
> S /rrv s-
717 79 '
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used>
Elevation of vertical reference point: ~l Proposed slope at site:
SEPTIC TANK: Manufacturer: Z'Y,/7 Liquid Capacity: 1
Number of rings used: Z Tank manhole cover elevation:
Tank Inlet Elevation: ~ Tank Outlet Elevation: Number of feet from nearest Road: Front,O Sidel DRear, O ~
5-e feet
From nearest property line Front, 0Side, 0Rear, 0 71 S( 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: L-C eyi If Liquid Capacity:
Pump Model: Pump/Siphon Manufacturer: 2-~/,5 3 Pump Size
Elevation of inlet: Bottom of tank elevation:
r Pump off switch elevation: r1 p / Gallons per cycle: 2-
Alarm Manufacturer: Z1,1Z/ 4. Alarm Switch Type:
Number of feet from nearest property line: Front, O Side, 0-Rear, Ft.`
Number of feet from well: > s~
Number of feet from building: 2 `
(Include distances on plot plan). ^
SOIL ABSORPTION SYSTEM
Bed: S ~ Trench:
Width: e Length: Number of Lines: ~ Area Built: ~TZ
Fill depth to top of pipe:
Number of feet from nearest property line: Front, O Side, (D' Rear, 0 Ft
Number of feet from well: SC^~
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, O 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
LA BOX 7969 PRIVATE SEWAGE SYSTEMS DIVISION
MADISON, WI 53707 BUREAU OF PLUMBING
[IjEONVENTIONAL ❑ALTERNATIVE StatePlanl.D.Numb-
(lf assn ned)
L:1 Holding Tank ❑ In-Ground Pressure ❑ Mound ~ 3, _j _ ; _4()
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE.
Steve Germain Highway "N", Roberts, WI
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV
SW SW, Section 31, T29N-R18W, Town of Warren
Name of Plumber. M"m PR SW No.. Count
y Sanitary Permit Number:
David B. Fogerty 3289 St. Croix 64873
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. EVATL LIQUID CAPACITYTANK INLET ELEVTANK OUTLET ELEVWARNING LABEL LOCKING COVER
PROVIDEDPROVIDEDES NO LIYES LINO
BEDDING: =NO,- EHIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILDING. ALARMFEET FROM LINE IVENTTOFRESH
AIR INLET.
❑YES ❑YES LINO NEAREST ilk j
DOSING CHAMBER: n
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER
Pf OVl ED PROVIDFtS
V,~~,"it ❑YES NO (J U ES LINO ❑ iESr/U NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL BUILDING VENT TO FRIES
(DIFFERENCE BETWEEN FEET FROM LINE IAIR INLET
PUMP ON AND OFF) YES LINO NEAREST J7 ~.t// J31
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing Nr,rH DIAMErER J MATERIAL AND MARKING
or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
the soil is dry enough to continue.) MAIN
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH. LENGTH IN OF DISTR. PIPE SPACING. COVER INSIDE DIA zP
DIMENSIONS TRENCHES MATERIAL PIT unulD
y DEPTH:
GRAVEL DEPTH FILL DEPTH DISTR. PIPF DISTH PIPE DISTR. PIPE MATERIAL. NO. DISTR.}y NUMBER OF PROPERTY WELL. BUILDING: VENT TO FRESH
BELOW PIPFS ABOVE COVER FLEV INLET ELEV. END 7 PIPES. FEET FROM LINE. AIR II~L~.
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-
❑YES NO meets the criteria for medium sand. TIONS MEASURED.
LI
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
❑YES LINO ❑YES LINO
DEPTH OVER IRENCH'PLO DEPTH OVER TRENCH; BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES.
❑YES LINO ❑YES LINO ❑YES LINO
PRESSURIZED DISTRIBUTION SYSTEM:
BE WIDTH LENGTH TRENCHES LATERAL SPACING GRAVEL DEPTH BELOW PIPF FILL DEPTH ABOVE COVER
.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. DISTH DIST
ELEVATION AND R. PIPE DISTRIBUTION PIPE MATERIAL & MARKING
ELEV.. ELEV.. DIA. ELEV.. PIPES. DD II A.:
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
PLANS
❑YES LINO ❑YES LINO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER 3F PROPERTY WELL TDING.
FEET FROM LINE:
❑YES LINO ❑YES LINO NEAREST
J/ ~ t
J1{ r P _ _ y ..r
Sketch System on n county file for audit.
Reverse Side.
SIGN TITLE.
DILHR SBD 6710 (R. 01/82)`-~
Wisconsin 10 APPLICATION FOR SANITARY PERMIT
D I L H R r 11'r COUNTY
A OEnRRTmenTOV (PLB 67~ UNIFORM SANITARY PERMIT #
In OUSTR V, LR90R 6 HUTRn RELRTIOnS I`A/
-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
PROP
PROPE TY OWNE MAILING ADDRESS
PROPERTY LOC TION ITY:
VILLAGE:
1/4 1/4, S T, N, R /,V E (or W TOWN OF> W r /e
LOT NUMBER BLOCK NUMBER SUBDIVISION NAME ]NEAREST ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER
TYPE OF BUILDING OR USE SERVED /I~~
i1 or 2 Family Number of Bedrooms. mod` ❑ Public (Specify): CJ C 6 THIS PERMIT IS FOR A:
A! New System ❑ Tank Replacement ❑ Repair
❑ Replacement Soil Absorption System ❑ Revision ❑ Privy
❑ Alternate System F-1 Reconnection ❑ Petition for Modification
IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK.
El~ 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
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
Gallons Tanks Concrete Constructed Steel Fiberglass Plastic
Septic Tank Capacity
Lift Pump/Siphon Chamber
Manufacturer:
PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY:
(Minutes per inch): REQUIRED (Square Feet): PROPOSED ISquare Feet):
S- Z Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
N of Plumber (Print): natu _ MP/MPRSW No.: Phone Number:
9 ) 'Tr"L
Plume Addr ss: ame of Designer:
r
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing Agent: F e: Date:
❑ Disapproved
!I G"~ L~ Owner Given Initial
Approved r Adverse Determination
Reason for Disapproval:
i
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.
:lzst be fout and ror r:~.eted before sul? : i::: Form - S T C 100
67 to county :n, office.
Owner of Prope rt V (
Location of Pro ert ` 1~ C 'fU P Y 1. 1~1L Sec~ion_ I T N R W
Township,~L~_.~ - ( ( I!v~YV G( ~~V L ~_C` i Z`I~~j Jul
Mailing Address; I F)cx_
n o L,
Subdivision Name
Lot Number
Previous Owner of Property L~^~
Total Size of Parcel Ll~~.>Ci (n -/en
y f '
Date Parcel Was Created
Are all corners identifiable? Yes No
Include with this application one of the following:
,-Certified Survey Map
Deed
.Land Contract, or
.Other I:egal Document which describes the property
PROPERTY OWNER CERTIFICATION
I (We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in this
information form, by virtue of a warranty deed reco ed in the Office of the
County Register of Deeds as Document No. -:Z}_ ; and that I (we)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been duly recorded in the Office
of the County Register of Deeds, as Document No.
SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED T-
I
WISCONSIN REAL ESTATE TRANSFER RETURN Wisconsin Department of Revenue
GRANTOR: GRANTEE:
f . Name - STATE U&NX OF FAMEM Name STEV,M- B. GERMi4 N & ISM K. GERMAIN
Social Security Number (Voluntary) I I I I Social Security Number (Voluntary)
Full Addre s New address if property transferred was residence Full Address
ki Wrest Boulevard Rt. #2, corner of Domfty Road ~ BMy. N
A R0b*rt8, WI 54023 Roberts, NI 54023
Is grantor related to grantee? Relationship includes, 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. ❑ Yes "No
Grantee is Individual ❑ Partnershi ❑ Cor oration ❑ Other
f Telephone: Grantor ( ) 749 3 Telephone: Grantee ( ) -
PART I - PROPERTY TRANSFERRED
Check proper box and enter name of municipality and county Street address of property transferred include road name and/or fire number.
❑ City ❑ Village ❑ Town of: Corner of Highway N and Soundry rtoa l
County of: St. Croix Roberts, Wisconsin 54023
Legal Description (Fill in complete legal description in space below or if metes and bounds description attach 3 copies of it as shown on the instrument of
conveyance. If certified survey map number is used in description list town, range, section and acres.)
Lot No........... Blk No........... SecLion......381 Town ......2~Range ...19Plat Narne...-
Property Parcel Number ......................l.................................................
That Part Of the SRI Of the It lying South of County Road *NO in Section 31, Township
29 Northip Rane 18 festf and also the North 30 40res of the 16* of the MWIS of Section 6*
Township 28 ftrth, Range 18 West, except that part thereof desocibed in Vol. 485, -page
443, Doo. APO. 310825, Register of Deeds' Office, St. Croix County, Wisconsin.
PART II - PHYSICAL DESCRIPTION AND INTENDED USE
1. Kind of Property b. Residential Units, if any 2. Principal Intended Use 3. Land Area and Type Estimated
a. Land Only ❑ One Family a. ❑ Residential d. ❑ Agricultural a. Lot size x ❑
❑ New Construction ❑ 2 and 3 units b. ❑ Commercial e. ❑ Recreational b. Total Acres ❑
❑ Building Previously Used ❑ 4 or more units c. ❑ Industrial f. Other (Explain) 1. Tillable Acres
❑ Solar Design c. ❑ Rental Pole Shed. Silo and bern 2. W.T.L. Acres
❑ Earth Sheltered Home 3. F.C. Acres
❑ Condominium C. Ft. of Water Frontage ❑
PART III - TRANSFER (Answer as many as apply)
1. ❑ Sale 2. ❑ Gift 3. ❑ Exchange 4. ❑ Deed in satisfaction of land contract - What was the date of the original land contract?
5. " Other transfers (Explain below) 6. Ownership interest transferred ❑ Full ❑ Other (Explain below) 7. What is the amount of mortgage assumed
by grantee? $ 8. Does the grantor retain any of the following rights: ❑ Life estate ❑ Easement []:None
E aro Contract
PART IV - COMPUTATION OF FEE OR STATEMENT OF EXEMPTION 55,W0.00
1. Total value of REAL ESTATE transferred (purchase price, etc. rounded to next even hundred. Do not include personal property) $
2. Value of personal property transferred but excluded from line 1 . . . . . . . . . . . . . . . . . . . . . $
3. Value of tax exempt property (solar, wind, waste treatment, mfg. M&E, other) included in line 1 $
4. TRANSFER EXEMPTION NUMBER if exempt for Reasons 1-13 (see instruction).. . . Sec. 77.25. L i
5. Fee - thirty cents per one hundred dollars of value (line 1 times .003) (Make check payable to Register of Deeds) $ ZxeWt
PART V -CERTIFICATION
The transfer must be reported regardless of the Grantor's state of residence. Information on this return will be used to administer Wisconsin Income and Franchise
Tax Laws. Disclosure of the social security number is voluntary.
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
9/31/84 Ronald R. Stowt, Presidmet
SIGN
HERE Signature of Grantee or Agent Dli7e31/84 Prja or TypeL.enis Name] x. 1n
Document No. Vol. (Reel) Page (Image) Date Recorded Date and Kind of Conveyance
LEAVE
THIS Parcel Number 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
PE-500 (R. 11-81)
School District No. PROPERTY OWNERS COPY
IN s.~`w~3aaH'
A complete return is required for all conveyances of passage of ownership interests in real estate except easements, wills or leases. (Upon completion, submit ,
all Arts of this form intact to the Register of Deeds with the instrument of conveyance. If a fee is due snake check payable to Register of Heeds,
RANTOR: Usually the former owner of the property. (Seller if property transferred by sale,)
GRANTEE. The new ownec.of the pfoperty (the purchases when property transferred by sale).
Indicate whether or not grantor and grantee are related by blood, marriage, lessee-lessor, co-owner, parent corporation or joint owner.
Enter the name and address to which tax bills are to be sent.
PART I - PROPERTY TRANSFERRED Enter the name of the county and the municipality in which the transferred property is located and check whether it
is a city, village; or town, Enter the street address of the property transferred. If rural property, give the fire number if knows.
The legal description is the legally accepted statement which identifies the location and boundaries of this property and can be found on the instrument of can•
veyance (deed, etc.). Enter the full legal description or attach three copies of the legal description as it appears on the instrument of conveyance to the front of
this form. Also enter the town, range and section in which property is lucatedx Enter the property parcel number opposite the space provided. The number can
most readily be obtained from the property tax bill at the time taxes are ascertained for proration purposes.
PART 11 -PHYSICAL DESCRIPTION ADD INTENDED USE F PROPERTY"
Item la: Check all boxes that best describe property. One box mast be checked.
Item 1b. Check only one box. (If "Land Only" is checked in l.a. omit this item,}
Item lc: Check if property is to be rented. If non-rental leave blank.
Item 2: Check only one box which best describes intended use, If (2a) is checked answer (lb). If (f.) is checked please explain.
Item 3a: Enter lot size. If unknown, enter estimated size and check box.
Item 3b: Enter total acres, if unknown, enter estimated total acreage and check box,
Item 3bl: Enter number of tillable acres, if none leave blank.
Item 3b2: Enter number of acres under woodland tax contract, if none leave blank.
Item 31x3: Enter number of acres under forest crop contract, if none leave blank,
Item 3c: Enter number of feet of water frontage. If unknown, enter estimated footage and check box. If none leave blank.
Note: Owners of forest cropland are required bylaw to notify the Depaartrner: t of Natural Resources of transfer of ownershr°cr,
PART Ill - TRANSFER Check the appropriate boxes (1 through B) to show how the property was acquired, i.e., by Sale, rift, or Exchange and what property
interests were retained or transferred. If is checked L.C. date must be entered. If Other (5 or 6) is checked, please explain in space provided. In (7) show the
amount of mortgage assumed by the buyer, if none leave blank.
PART IV - COMPUTATION OF FEE On Line 1 enter the full actual consideration plaid or to be paid (rounded to tlae next even hundred) for Real Estate inclu-
ding the amount of any lien or liens thereon. DO NOT include consideration for personal property such as household furniture, farm machinery, boats, etc. in
case of a Gift, nominal consideration or Exchange of property, enter the estimated current fair market value (the price which could ordinarily be obtained for
the property at a sale in an open market between a willing buyer and willing seller).
On Line 1 if the value does not end in even hundreds (Le. $11,520) for computational purposes round to next even hundred (l.e., $11,600).
On Line 2 shove the value of personal property purchased but excluded from Line 1.
On Line 3 show the value of real estate included in Line 1 but exempt from property tax.
Can Line 4 enter Transfer Exemption Number (1-13) it this transfer is exempt. See Exemptions Below. Also, if this is an original land contract (no fee is imposed)
enter the words "Original L.C." on this line and state value on line 1. Also state valise on line 1 for Exemption No. B.
On line 5 enter the amount of fee if none of the exemptions apply to the transfer. The fee is based upon a rate of 300 per 100 on Line 1. Pees for deeds exe-
cuted in fulfillment of an original land contract dated: Prior to Dec. 17, 1971 No Fee
Dec. 17, 1971 - Aug. 31, 1961 101 per 100
Sept. 1, 1931 or thereafter 30 per100
PART tl - CERTIFICATION The transfer must fee reported regardless of the grantor's state of residence. Informations on this return will he used to administer
Wisconsin income tax laws, disclosure of social security number is voluntary.
SECTION 77.25 - EXEMPTIONS FRO,10 FEE The fees imposed by this subchapter do not apply to a conveyance:
(1) Prior to the effective date of this subchapter (October 1, 1969).
(2) To the United States or to this state or to any instrumentality, agency or, subdivision of either.
(3) Which, executed for norninal, inadequate, or no consideration, confirms, corrects or reforms a conveyance previously recorded.
(4) On sale for delinquent taxes or assessments.
u) Cn partition'.
(S) Pursuant to mergers of corporations,
(7) By a subsidiary corporations to its parent for no consideration, nominal consideration or in sole consideration or cancellation, surrender or transfer of
capital stock between parent and subsidiary corporation.
(3) Between husband and wife or parent and child for nominal or no consideration.
~,9) Between agent and principal or trustee and beneficiary without actual consideration,
9) Solely in order to provide or release security for a debt or obligation except as required by s. 77.22(2)(b).
l10 By will, descent or survivorshlp.
ix, Pursuant to or in lieu of condemnation.
n>s N
~ H
G
In
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S T C - 105 r
H
SEPTIC 'TANK MA1NTLNANCL ACkEEMLNT r+
' o
SC Croix CUL1l1Ly
/ C7
y
OWNER/ 13UYER__~ _-A-A rn 1 t
It0WIT/HUX NUMBF,R 1;ire Num1) r
C I T Y/ ST AT E1r' n V J C---- - 1. 11',1
t
t , L~,t,~
PROP 'RTY 1 UCA`T'1(1N : -=r;, ~ 1 5Jc t i ll 1-- ' 1- ` _N , K ! W
1t 11 >
~ nr
't'own of St . Croix County,
Subdivision _ LoL number
Improper use aad maintenance of your s4pt>_c system could result in
its premature failure to handle wastes. Proper maintenance con-
si6L"6 of pumping Uut the septic Lank every LIII'ce years or suuuer,
if needed, by a licensed sc1,.Lfc tack imml+er. What you put into
the sybrenl affe-t of the sear i tank as a treat-
ment stage in Lhe wash; disposal
St. Croix Cooney residents wad be eligible Lo receive a grallL 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, mill the requirement that
owners of all new _~S_tems agree Lo keep choir systems properly
Ilia iLILUined.
The property Uwner agree:; Lo submit Lo St. Croix Cuuuty Zoning a
certification form, siguud by the uwner and by a master plumber,
journeyman plumber, restricted plumber or a licensed pumper veri-
fying that (1) tike oil- Site wastewater disposal system is in proper
uperatiog cundiLiuu and (2) after inspo(-Limi and pumping; (iA 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. y
0
E
I/WL, the undersigned, have read the above requirements and agree
to maintail► file private sewage disposal sysLeul ill accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- a
ulent of Natural Resources. Certification form must be completed
and returned to the St. Croix CountyZunii►g Office within 30 days
Of the three year expiratit+ll date.;
SIGNLll..c-~t~
D ATE
St. Croix Cuuuty Zoning Office
P.O. fox 98
Ilammur d, W1 54015
715-7~ 6-2239 or 715-425-8363
Sign, date and return to above address.
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PAGE OF
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
VCWT CAP
4"C. I. VENT PIPE
WCATHEK PROOF APPROVED LOCKING
JUNCTION BOX MANHOLC COVER
- 25' FRCM DOOR, frl
WINCOW OR FRESH I2 MIIJ.
AIR INTAKE
I
GRADE
I y"MIN.
19"~iMfLi N.
CONDUIT -
18"MIN.
PROVIDE 11l
AIRTIGHT SEAL I I
I I I
APPP.O'✓EC JOINT A I III APPROVED JOINTS
W/C.I. PIPE I III W/C.I, PIPE
EXTENCII,JC. 3' I II EXTENDING 3'
ONTO SOLID SC!.. ALARM
B i I I ONTO SOLID SOIL III
I ON
c I I
I
k PUMP..... --j OFF
D
CONCRETE BLOCK
RISER EXIT PERMITTED ONLY IF TANK MANUFACTURCR HAS SUCH APPROVAL
SPEC,IFICATIOMS
SEPTIC AND
DOSE TANKS MANUFACTURER: a~? NUMBER OF DOSES: Z PER DAB
TANK 'dIZE: GALLONS DOSE VOLUME
ALARM MANUFACTURER: BACKFLOW: 7 y GALLONS
MODEL NUMBER: ~2
CAPACITIES: A= INCHES OR 37. GALLONS
SWITCH TYPE: --~1
B = ~ INCHES OR 3's GALLO►JS
PUMP MANUFACTURER: C - INCHES OR GALLONS
MODEL NUMBER: s - vv D - -f_ INCHES OR 1 3 7 &ALLOMG
SWITCH TYPE: NOTE: PUMP AND ALARM ARE TO BE
PUMP DISCHARC&E RATE -,21 GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFEKENC[ BI<7e'YJEEAI PUMP OFF AND DISTRIBUTIOM PIPE.. ~ FEET
+ MIIJIMUM NETWORK SUPPLY PRESSURE , , . , , • , • 2.5 FEET 7.03
+ FEET OF FORCE MAIN X _ F%oFT.FRICTION FACTOR.. FEET
!l = TOTAL DYNAMIC HEAD FEET
INTERNAL DIPIE.W51OW4 OF TANK: LENGTH = ;WIDTH "o ;LIQUID DEPTH
SIGUED LICE(`1SE "UMBER* ~Z ~}f
DATE:
-117-
Halt.
T D H HEAD CAPACITY CURVE
w
2
TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE
3O EFFLUENT AND DEWATERING
SERIES 53-55-57-59 97 137-139 183 165
M LTRS LTRS LTRS LTRS LTRS
28 1.52 163 248 394 231 231
EFFLUENT AND DEWATERING 3.05 129 216 300 231 231
4.57 72 163 242 227 227
26 \ 6.10 104 136 223 227
♦ SEWAGE AND DEWATERING
\ 7.62 30 _ 216 223
9.14 206 220
24 ♦ 1219 172 2.06-
\L 15.24 125 191
18.29 57 161
22 \ 21.34 114
24.38 53
MODEL\\ MODEL Lock Valve: 19' 24.5' 26' 66' 87'
20 16'.3 \ 165 TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE
` SEWAGE AND DEWATERING
` SERIES 267 268 282 284 293
18 M LTRS LTRS LTRS LTRS LTRS
v 1.52 408 386 492 681
\ 3.05 227 273 360 598
\ '>1J 4.57 76 163 238 511
1 6 \ 20. 6 10 30 125 401
\ - -
25',] 7.62 288
\ "3Q
14 9.14 163 292
1067 227
\
12.19 174 )
1 13.72 106 J
12 15.24 45
1 M O D E L Lock Valve: 18' 21' 26' 35' 53'
10 293
MODELS
8 137 139
6 MODEL rk- 284
4 MODEL MODEL
282
268 \ ~
2 MODELS
53, 55, MODEL MODEL
57,59 97 267
LITERS 80 160 240 320 400 480 560 640 650
FLOW PER MINUTE
3280 Old Millers Lane Manufacturers of. . .
P.O. Box 16347
Kentucky
O (502)177882 31 lucky 40216 `QL/.4L/rY PUMPS SiYCE /9.39
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DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, cc DIVISION BOX HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707
(H63.090) & Chapter 145.045)
LOCATION: SECTION: OWNS HIP :LOT NO.:BLK. NO.: SUBDIVISION NAME:
s- W /4 - . I /V7 N/R/10 ! (or A, e, rkYJ G&44 IF
COUNTY: OWNER'S/BUYER'S NAME: JMAILING ADDRESS:
Cro, eV e_ 6 e~-m 4e O*ai_ dx a 9y -SOMPXS•z~ (.t-~i Yc~.Z
USE DATES OBSERVATIONS ADE
NO. BEDRMS.: 7RCIAL ESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence XNew ❑Replace
So"Y MAP i6 x D ,2 / Q 9 ~J
RATING: S= Site suitable for system U= Site unsuitable for system & /ek
CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
XS ❑U ®S ❑U [KS ❑U ❑ S KU ❑ S ®U Cvu le'xs
If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the
under s.H63.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PR FI E DESCRIPTIONS
BORING TOTAL♦ DEPTH TO GROUNDWATER44&HtS CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH.ifC: ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
~I /•3gn! / r. x;3/3., s~ r
B- . Y,()'- 7 C~ ' n gn S v r. .S ~n /s r
h on A (a .44 5, P4-. on /J;
10' yq~C)
B
lax~~ /.3117 Y. 4 7 Cs
/a
B-
PERCOLATION TESTS
TEST DEPTH* WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
44S AFTERSWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PERIOD3 PERINCH
P- o G 0 ' /40
P_ Y.Ye
A/C Q
P- -3 -3 - 3
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. D2 (f-Z• _ 71. 1,00,11 1 68,7/ -4 16'11 i/~ty
.~9r•
SYSTEM ELEVATION 9y ef+ IS
LPL, c /mo, o' v
7',e- /efo 1e4(A5 f5111
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1 T P /OCR ~ ` f•~ ~i:-ref C,~ifY GAG _
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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:
A Aej!$ t CIIJ S seoto, Je- 02 ~l _ef
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional):
-01 CST , TUR :
v
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
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