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-Parcel 192-1030-30-000 10/11/2006 11:37 AM
PAGE 1 OF 1
Alt.'Parcel 36.29.16.300D 192 - VILLAGE OF WOODVILLE
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 - LARSON, WARREN G
WARREN G LARSON
400 SQUIRRELS RUN
WOODVILLE WI 54028
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description " 400 SQUIRRELS RUN
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 5.920 Plat: N/A-NOT AVAILABLE
SEC 36 T29N R16W PART OL 69 5.92A LOT 4 Block/Condo Bldg:
OF CERT SURVEY MAP IN VOL III PAGE 798
ORD 681/139 Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4)
36-29N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
10/24/2005 810177 2914/369 QC
07/23/1997 718/395
07/23/1997 681/139
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/31/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 30,000 162,900 192,900 NO
PRODUCTIVE FORST LANDS G6 3.920 10,200 0 10,200 NO
Totals for 2006:
General Property 5.920 40,200 162,900 203,1000
Woodland 0.000 0
Totals for 2005:
General Property 5.920 40,200 162,900 203,1000
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 502
Specials:
User Special Code Category Amount
Special Assessments Special Charges 00 Delinquent Charges
00
Total 0.00
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Parcel 192-1030-30-000 10/03/2005 11:47 AM
PAGE 1OF1
Alt. Parcel 35.29.16.300D 192 - VILLAGE OF WOODVILLE
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
0 - LARSON, WARREN,& BRENDA LIGHTNER
WARREN,& BRENDA LIGHTNER LARSON
400 SQUIRRELS RUN
WOODVILLE WI 54028
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description * 400 SQUIRRELS RUN
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 5.920 Plat: N/A-NOT AVAILABLE
PART OL 69 5.92A LOT 4 OF CERT SURVEY Block/Condo Bldg:
MAP IN VOL III PAGE 798 ORD 681/139
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
35-29N-16W
Notes: Parcel History:
Date Doc # Vol/Page Type
07/23/1997 718/395
07/23/1997 681/139
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/31/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.000 30,000 162,900 192,900 NO
PRODUCTIVE FORST LANC G6 3.920 10,200 0 10,200 NO
Totals for 2005:
General Property 5.920 40,200 162,900 203,1000
Woodland 0.000 0
Totals for 2004:
General Property 5.920 40,200 162,900 203,1000
Woodland 0.000 0
Lottery Credit: Claim Count: 1 Certification Date: Batch 502
Specials:
User Special Code Category Amount
Special Assessments Special Charges 00 Delinquent Charges
00
Total 0.00
r Form - S T C - 104
AS BUILT SANITARY SYS'T'EM R'EPOR'T /
r
K S P i 'T'OWN SHIP vpo t SEC . T' .c 1` N-R L W
OWNER
. Z 1. ~ 3csa~
ADDRESS f _ ST. CROIX COUNTY, WISCONSIN
3('~-30--w~"
1.~' / LOT LOT SIZE
SUBDIVISION - f
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
\ r `r
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevation of vertical reference point: Proposed slope at site:
SEPTIC TF,.NK: M~ nui:acturer:Me_~~_~ _Licluid Capacity:
Number of r- ngs used: Tank manhole rover elevation:
Tank Inlet e levation; Tank Outlet Elevation:
Numbe; of fe et l_ rom nearest Road: Front> k/ 'Side o Rear, 3 fe e t
>
feet
K' I
From t car,,5l property :Line Front,0Side, Ir TZear,
Numbe: of feet from: well building:
(Include this information of the above plot plan) ( 2 reference d men sign s i tMo septic tank)
SEE REIRSF, S`,
a'
PUMP CHAMBER
Manufacture-r: 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, Ft.
Number of feet from well:
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORBTION SYSTEM
Bed:
Trench:
Width: t~ Length: (p Number of Lines:
Area Built: x.
Fill depth to top of pipe:
Number of Beet from nearest property line: Front,
o Side, O Rear, O Ft,
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 of seepage pit elevation:
Area Built:
Has either a drop box 0 or distribution box 0 been used on any of the above soil
absorbtion sytems? (Check one).
HOLDING TANK
Manufacturer.: Capacity:
Number of rings used: hIevaci.-n of bottoi;, Lal.ic:
Elevation of, inlet:
Number of feet from nearest property line: Front, O Side, O Rear, Ft.
O
Number of feet from well:
Number of feet from building:
Number of feet from nearest road:
Alarm Manufacturer:
Inspector:
f
Dated: _ Plumber on job:
i~
v
License Number:
3/84:mj
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, Side, O Rear, 0 Ft.
Number of feet from well:
Number of feet from building:
(Include d.jstances on plot plan).
SOIL ABSORBTION 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, O Ft.
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 of seepage pit elevation:
Area Built:
Has either a drop box O or distribution box a been used on any of the above soil
absorbtion sytems? (Check one),
HOLDING TANK +
Manufacturer: Capacity:
Number of rings used: EievaLIC- of bottou, [aLlk:
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: ~
(J
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 79Cv. BUREAU OF PLUMBING
MADISON, WI 53747 [IdVONVENTIONAL ❑ALTER NATIVE state PI-ID. Number
Ilf assigned)
1-1 Holding Tank E] In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DATE.
Warren Larson Squirrel's Run Road, Woodville, WI 6-al-P11 -3--00
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.. CST REF PT. ELEV.
SW NW, Section 36, T27N-R16W, Lot#4, Village of Woodville
Name of Plumber- jM1,MPRSW No.. Coumy. Sanitary Permit Number.
Stephen Aaby 5184 St. Croix 49509
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY. TAfffyyy KKK INLET ELE V.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER
- ; / /J /5-C P WI ED. PROVIDED-
f1VI`oI- &rVI v YES ENO DYES ENO
ILDIN VENT TO FRESH
ROPERT WELLBU
BEDDING. VENT DIA.. VENT MAT L'. fGLAHRM WATER NUMBER OF ROAD1 PJ
FEET FROM LINE: + AIR INLET
DYES NO C I( EYES LINO INEAREST7~ Z- L DOSING C AMBER:
MANUFACTURER BEDDING. LIQUID CAPACITY PUMP MODEL JPUMP,IIIHON MANUFACTURER WARNING LABEL LOCKING COVER
P ED: PROVIDED'.
EYES ENO /1111 1 ROMES LINO YES ENO
ILDING I VENT TO FRESH
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER O HOPFHTY WEL
(DIFFERENCE BETWEEN FEET FR LINE L AIR INLET
PUMP ON AND OFF) DYES ONO NEARES
R I A L AND M ARKIN
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing JLI iAMET G;
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:
WIDTH LENGTH NO. OF DISTR. PIPE SPACIN(; COVEg.. UE DIA #PITS LIQUID
BED/TRENCH TRENCHES MA IAL: IT DEPTH
OIN
DIMENSIONS
PR ERTY WELL BUILDING'. VENT TO FRESH
GRAVEL DEPTH FILL DEPTH DISTR. PIPF DISTR. PIPE DISTR. PIPE MATERIAL: NO ISTH. N BER
BELOW PIPES ABOVE COVER IL EV INLE f EV EN -7 PIP S LIN AIR INLET
1 1 F T FROM y a 50
11 W~ J/ Z C N AR E ST--► C-v
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
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 ENO
SOIL COVER TEXTURE PERMANENT MARKERS OBSERVATION WELLS
DYES ENO LJYES NO
DEPTH OVER THE NCH'BED DEPTH OVER TRENCH; BED UEPTH OF TOPSOIL SODDED S ED MULCHED.
CENTER EDGES '
DYES ENO YE NO DYES NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH. NO.OF LATERAL SPACING. IGRAVELDEPTIIBELOWTPFIWPI. FILL DEPTH ABOVE COVER.
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO. D R. JD~STRPIP DISTRIBUTION PIPE MATERIAL & MARKING
ELEVATION AND ELEVELEVDIAELEVPIPE DA.'.
DISTRIBUl ION
INFORMATION BOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL pLA NSVERTICAL LIFT CORRESPONDS TO APPROVED
DYES ENO DYES ENO
COMMENTS: PERMANENT MARKERS: JOBSERVATION WELLS: NUMBER OF PROPERTY WELL. BUILDING.
FEET FROM LINE:
( x,15 I DYES ENO OYES ENO NEAREST
L~ ~cl a /y. ~j S
os
G L5 a S~ ,SSG
01
Z d
C'1 y
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE. ~ TITLE
DILHR SBD 6710 (R. 01/82)
UFPARTMENT,OF
N
DUS'F Y,' REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
I~iUUS-R C DIVISION
_ABOR AN - P.O. BOX 76
HUMAN -RELATIONS PERCOLATION TESTS (115) MADISON WI 53707
(H63.09(1) & Chapter 145.045)
OCATION:' SECTION: TOWNSHIP/MUNICIPALITY: L-OT N .:BL-K. NO.: SUBDIVISION NAME:
~ ~k. ~~'Gc%.~~~u~Ll
COUNTY: /BUYER'S NAME: MAILING ADDRESS:
G ale n L it s Z,v_ _O_ y t_ r Gy
DATES OBSERVATIONS MADE _
NO. EDRMS.: COMMERCIAL DESCRIPTION' T~ PROFILE DESCRIPTIONS: PE~CSLAT(ON TESTS:
Residence !k r!]iNew ❑Replace
zq-
BATING: S= Site suitable for system U= Site unsuitable for system ! `f
A ~TI~~ . MOUND: IN-G~ND-P URE: SY❑S-T-EM-IN_FILL HOLDING TANK: RECOMMENDED SYSTEM: (opt~nal)
S US XUTo S XU x 6 j?,
II Percolation Tests are NOT re uired DESIGN RATE:
Q If any portion of the tested area is in the All
under s.H63.09(5)(b), indicate:
Floodplain, indicate Floodplain elevation:
&e~5 jq
PROFILE DESCRIPTIONS
c)RING TOTAL PTH TO GR UNDWAT%INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
JuMBER DEPTH IN, ELEVATION OBSERVED ES . GHE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B 6 9
. 6"
J• ~ ~ ,S 1 ~ ~ 'i ~ , ~ / ~ ~j ~ ivy ~ ~%l
; 7f,6
Al., Al S
49 ' t s L S'
7-5
_ k
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 3 PER INCH
7 /P
P-
LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
untal 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
I land slope.
SYSTEM ELEVATION -
i
1
I ,
I i
i
i ,
,
I
I
{
,
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
Viministrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief.
,JAME (pnntT TESTS WERE COMPLETED ON:
1DDRESS: CERTIFICATION NUMBER: PHONE NUMBER (opt ional).
-1--
CST SIGNATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
,1I 1113 SBD-6395 (R. 02/82) OVI-H
EH 115, Rev. 9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
P.O. BOX 309, MADISON, WISCONSIN 53701
LOCATION: 7 L, %,eyLc Section LL JL-IN,R-L&L-E-4w) W, TewRSbip-or Municipality 1,- 2 + - L L o
Lot No. , Block No. C'ri Fi i= t7 <"y ( ( r Y NO 7~i i County A
Subdivision ame
Owner's/Buy rs Name: IV T I 4 iii 4.
y
Mailing Address: / L,~Z 4)4111 /v L h-y~d
TYPE OF OCCUPANCY: Residence-)( No. of Bedrooms COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW x REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS/ PERCOLATION TESTS %l '7- Z-4
SOIL MAP SFiEET_ OF SOIL MAP UNIT 5/4/V L/' • , IV Ak,
PERCOLATION TESTS
TEST DEP1H CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES
NUM- RATE
INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL
I BER _ 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN
P- 1 '7Lr See bore hole data rp,rc) .3 ; e Y C 3
Z; / i Q r
P-3
z J y _
P 1
P- {
,1 (I It
P t
R -;Install drainfield at >s inches. SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
B- y4- Z
l C{ f VC /V t. 2C
B-3 Zi
B-L
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the location and 1uare feet*of suitable areas.
Indicate number of square feet of absorption area needed for building type and occupancy 7~t, i Indicate scale or distances.
Give horizontal and vertical reference points. Indicate slope.
.I
Notes: i
1-Red flags at bore I
I ,
holes 1, 2, & 3 indicate
14: 7-A4
location of primary (
fr~~ia
disposal site.
%s
s s 11•... 1
` s - >lope
2-Elevation reference I z' Qtat 34./,o fe
point is r* - -
I `ALT ; N
3-Measurement for sketch
were obtained by pacing. I r vT
I
4-Estimate sq. ft. suitable i G ,~ti~r«c
soi 1 area for each of primary
no~ _ I I ~ c'L rZf F w
and alternate disposal site.
5-Bottom of Perc holes are at elevation PR~irzry'`«~~
4' . L
1, the undersigend, 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 location of test holes are correct to the best of my
knowledge and belief.
Name (print) Gordon N Wing Certification No. 55-541
Address 3508 Nimitz Street, Eau Claire, WI 54701
.Name of installer if known
CST Signature.,
Copy A -Local Authority
DEPARTMENT OF APPLICATION SAFETY & BUILDINGS.
INDUSTRY, FOR SANITARY DIVISION
LABOR AND 1 PERMIT P.O. BOX 7969
HUMAN RELATIONS' (PL13 67) MADISON, WI 53707
Attach plans for the system on paper not less than 8'/2 x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal
and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter
H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master
Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be
included.
Property Owner: Mailing Address:
Property Loca`t'ion: G"VI Village or 7: County
C t/a(~r<1N'4S rP ~T~► NCR ` 4__-_(or LVt e_ L" KO; X
Lot Nu ber: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Num r:
eol) 1,e
i Uf assigned)
u • r r
TYPE OF BUILDING CJ
~ Number of
❑ Public* El Variance* ❑ Other (specify)* / / Bedrooms:
~$<1 or 2 Family *State Approval Required.
TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW REPLACE- OTHER
GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify)
SEPTIC TANK CAPACITY
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER: A4j0jU_)a)&M
Y1C.
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet . +J New ❑ Re ement 1:1 Experimental Seepage Bed ❑ Seepage Pit
649 _15 ternative (specify) ❑ Seepage Trench
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans.
Name of Plumber: Sign atur /i MP/MPar&W No.: Phone Number:
~Sf-e . hey) L. o-b (Ts)
Plumber' Address:
ame of Designer:
du ~ Ile- LAJ-r 40 Rff r J-I L /0-6
COUNTY/DEPARTMENT USE ONLY
Signature of Issuing A ent: Fee: Date: APPROVED Sanitary Permit Number:
A"ZtZ,/ 12 1613--^c qSO
❑ DISAPPROVED A l /
Reason for Disapproval: ~
Alternate course(s) of Action Available:
Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in-
stallation. Failure to comply will void the sanitary permit.
DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber
DILHR-SBD-6398 (N.03/81)
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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
Kold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property
Location of Property ~~SW ,34 K )W 4, section 10 T al N - R L
Township Mai 1 ing Address ji9
Subdivision Name U
Lot Number
Previous Owner of Property
Total Size of Parcel
Date Parcel- was Created
~ I
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume__- and Page NumberQ 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 '_ha 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 0W%R CERTIFICATION
I (W& eenti6y that a4k atatements on this fonm aAe thue to the best of my (out)
Knowtedge; that I (we) am (cure) the owner(s) of the pnopetty dactibed in this
tn{format%on foam, by v ntue of i wa& anty deed teeotded in the Office of the
County RegA;ter of Deeds as Document No. _ and that I (we)
pneseatty own the proposed site {dot the sewage diopo6a2 system (ot I (we) have
obtained an easement, to tun with the above descatibed ptopunly, lot the
Consthuction"o4 said system, ani the same has been duly tecotded in the Office
06 the County RegAM of "Deeds, a6 Document No.
SIGNATUR)E,OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
` Wisconsin Department of industry,
PLB-1 INSPECTION REPORT Labor & Human Relations
Safety & Buildings Division
Bureau of Plumbing
Name o Promises Date an No.
Street - oun y Sanitary Permit -T
master Plumber Firm ame dress
Journeyman Plumber, Address
Owner Address
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Discussed with Signature
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( )See Attached. ~ 1~- ~ v.,
DILHR-SBD-6192 (R.10/82) Signature o is um ing_ n= i e` as e p""TS
Inspector Local Inspector Plumber or Responsible Party l/ C_`0 ner
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51:PT iC TANK MAINTLNANCL AGREEMENT
St. Croix County
y
O W N E R /BUY 1: R v_ a-C
ROUTE/BOX NUMB LIt Dire Number
CITY/STATE ~ rC4~~l Zlf_ ~
PROPERTY LOCATION ection 70 rN, R
V~GGt~q~ w° LC x
St. Croix County,
S u b d 1 v L s i o it Lot l t u m b e r
luip,ropov llec `alld milintenanct'. of your septic System could result in
iLS premature lailure to haudlc wastes. Proper maLilteuance con-
sists of pumping out the septic tank every three years or sooner,
if needed, by a lice_n_sed suLLic tank punier. What you put intu
Lhe system can affect the function of Lhe septic tank as a LreaL -
ment sLage l-ll Lite w.aSLL~ U1t.~` vstem.
St. Croix County residents ula~y be eligible to receive a grant for
it Max_imum of 60% of the cost of replacement of a failing; systeul,
which was in operatiou prior to July 1, 1978. St. Croix County
accepted this program in August of. 1980, with the reyuiremeut that
owners of al -L new systems to keep their systems properly
a rce
g
ilia iutained.
The property owner ag,tccs Lo submit Lo St. Croix County l.unlilg; 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 irnspection and pumping (if Lice-
essary), the septic Itauk is less than 1/3 full of sludge and scum.
Certification form will be sent approximately 30 days prior Lo
three year expiration. °
I/W1, Lite undersigned, have read the above requirements acid agree ui,
to maintain the private sewage disposal system ill accordance with
Lite standards set forth, herein, as set by Lite Wisconsin Depart-
Merit of Natural Resources. Certification form must be completed
and returned to the St. Croix County Zoning Office wi.thIn 30 days
ui tilt' three year expiratii~rn date.
S I G N ED
c -
D AT t. ) t~ -
St. Croix County Zoning Office
P.0. [10x 910
Itammo ~d, W 54015
715-7)6-2239 or 715-425-8363
Sign, date and return to above address•