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Form - S T C - 104
..r
f AS BUILT SANITARY SYSTEM REPORT
OWNER l TOWNSHIP
_eSEC. T ..cYN-R W
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of H 63
SHOW EVERYTHING WITHIN 100 FEE`i ur' SYSTEM
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T. -7 1V W e
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rt) INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used P
Elevation of vertical reference point: rf"~~Y
Proposed slope at site:
SEPTIC TANK: Manufacturer: ' Liquid Capacity:
Number Df rings used: Tank manhole cover elevation:
A/7`'-Tank Inlet Elevation:
Tank Outlet Elevation: Number of feet from nearest Road: Front,O Side, Rear, O feet
From nearest property line Front, 0Side, (D Rear, 0 feet
Number of feet from: well 2 `7 building: 7
(include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE RI~VF16E SIDF
t
PUMP CHAMBER
Manufacturer: L Liquid Capacity: ,106
Pump Model: Pump/Siphon Manufacturer: ✓~=~'L Pump Size
e-
Elevation of inlet: _ Fr;e Bottom of tank elevation: Pump off switch elevation:.- Gallons per cycle:
Alarm Manufacturer:?t,t, Alarm Switch Type:
Number of feet from nearest property line: Front, ( Side, O Rear, Ft•~_
Number of feet from well:% A
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Bed: i/ 'french:
Width: Length: sl/ Number of Liners: „S Area Built:
Fill depth to top of pipe:
Number of feet from nearest property line: Front, 10Side, O Rear, O Ft.
Number of feet from well: (tf~ t
Number of feet from building:
(Include distances on plot plan). ~t,~/ ~h
SEEPAGE PIT ~~ek
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, 0 Side,,0 Rear, O Ft.
Number of feet from well: \
i
Number of feet from building:
Number of feet from nearest road:
Alarm ranufacturer:
Inspector: _r
L
Dated: Plumber on job:
License Number:
3/84:mj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS
LAI#OR & HUMAN RELA?,IONS PRIVATE SEWAGE SYSTEMS DIVISION
P.O. BOX 7969
BUREAU OF PLUMBING
MADISON,,V.(l,537(,
UCONVENTIONAL ❑ALTERNATIVE State Pla nned)
lD.Number.
(If assig
❑ Holding Tank El In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER. ADDRESS OF PERMIT HOLDER. INSPECTION DATE.
JeAAy AggvL R. R. 1, Box 106, Hammond, WT
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV.
SE% SF%, SEction 5, T29N-R18G1, Town vj WaC tAen
Name of Plumber. MP/MPRSW No.. County Sanitary Permit Number.
Dave Fogerty 3289 St. Ctoix 49479
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. . LIQUI CAPACITY TANK INLET ELEV JTELEVARN.ING LABEL JLOCKING OVER
XVIDEDPROVID
~ YES LINO ❑ E ~:N.
BEDDING. VEA3r D,f VENTMA L_ HIGH WATER NUMBER OF ROAD. PROPERTY WELL: JBUILDINAI,: E
SH
tALARFEET FROM LINe IVENTTO
nIR INL
❑YES LINO ❑YES LINO NEAREST
DOSING CHAMBER:
MANUFACT ER BEDDING. LIQUID CAPACITY PUMP MODEL PUMP/SIPHON MAN"UFtiAC C1R WARNING LABEL LOCKING COVER
L V r/ ❑YES N O YES LINO YES LINO
GALLONS PER CYCLE: PUMP AND CON T HOES OPERATIONAL NUMBER OF PROPE TV III, W LL BUI ING_ VENT TO FRESH
(DIFFERENCE BETWEEN - FEET FROM LINE IAEr
PUMP ON AND OFF) YES LINO NEAREST
SOIL ABSORPTION SYSTEM. Check the soil moisture at the epth of plowing LENGTH / JDIAMITIR MATERIAL AND MAR LNG
or excavation. (If soil can be rolled into a wire, construction shall cease until MAINE Lf 3 ,
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH LENGTH NO. OF IDISTR PIPE SP LING C V JINSIDE DIA. -PITS LIQUID
TRENCHES f~f AL' PIT DEPTH
DIMENSIONS .
GRAVEL. DEPTH FILL DEPTH DISTR. PIPE pISTR. PIPE DISTR. PIPE MATERIAL : O. D rR. NUMBER OF PROPERTY LL. BUILDING
: VEN TO FRE H
BELOW PIPES AHOVE/COVER ELEV. INt.F f ELEEVr. END. PIPE
LINE., AIF NLET:
FEET FROM
NEAREST-
MOUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill Taterial for PROVIDE DIAGRAM OFSYSTEM
and furrows thrown upslope: mound systems to make certain that it ON REVSE SIDE. SHOW ELEVA-
❑YES LINO meets the criteria for medium sand. TIONS~ EASURED.
SOIL COVER TEXTURE PMARKERS BSERVATION WELLS
>t10
DEPTH OVER TRENCH:BED DEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED YESr` SEEDE ❑YES MULCHED LINO
CENTER EDGES.
❑YES LINO ' ❑YES LINO ❑YES LINO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH LENGTH. NO. OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER
BED/TRENCH TRENCHES.
d'
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
❑YES NO ❑YES LINO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE
❑YES LINO ES LINO NEAREST
~v 41
Sketch System on }et tr1 county file for audit.
Reverse Side. f V
SIGNATURE - TI TEE.
D I L H R S B D 6710 (R. 01/82)
LABOR AND PERCOLATION,. TESTS (11,5) MADISP.O. BOX 7969
ON W1 3707
HUMAN RELATIONS
M63.0901'& Chapter 145.045)
LOCATION: SECTION: WNSHIP/MUNICIPALI'T LOT NO.: BLK. NO.: SUBDIVISION NAME:
V 1/4, -,7 /T~ N/Rig E ( « _
C'0 NTY: ' . OWNER'S BUYER'S NAME: MAILING ADDRESS:
` O/
USE DATES OBSERVATI NS MADE
NO.BEDRMS.: 1COMMERCIAL DESCRIPTION: (PROFILE DE RIPTIONS: ER LATION TESTS:
[ErResidence 3 New ❑Replace
RATING: S= Site suitable for system U= Site unsuitable for system
ONVENTIONAL: MOUND: IN-GROUNDPRESSORE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
c~s❑U 2SElUos❑uIosau EIS BU
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: - I Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
-Z nrr _ c
ORING TOTAL ELEVATION -.OEP-rH TOG UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND Df-PTH
NUMBER DEPTH IN, OBSERVED EST. 1 HES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
off f
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B-
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71-- 1-1 7 r A rr I M ' ,
B- 7
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G .0 91.r,
-7 r ,7. PERCO A ION T STS 15,
TEST DEPTH WATER IN HOLE TEST TIME DROP N WATER LEVEL-INC S RATE MINUTES
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD P__RI PER INCH
P- /D s z-
P-
P- O
P-
P- 2 0
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
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I, the undersigned, hereby certify that the soil tests reported on this form were made by mein 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,
E (print : TESTS WERE COMPLETED ON:
S; CERTIFICATION NUMBER: PNONE UMBER (optional):
II -
DEPARTMENT OF APPLICATION SAFETY & BUILDINGS
INDUSTRY, FOR SANITARY DIVISION
LABOR AND PERMIT P.O. BOX 7969
HUMAN RELATIOCJS (PLB 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. A legible reproduction of the soil test report or the owner's copy must be
included.
Property Owner: Mailing Address:
Prope y Locati n: l City, Village Townshi' • C unty:
t/a Ste" t/aS /T NCRi E (or'~~ e- !r .
Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number:
(If assigned)
TYPE OF BUILDING
Number of
❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms:
5"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 y
HOLDING TANK CAPACITY
LIFT PUMP TANK/SIPHON CHAMBER
MANUFACTURER:
EFFLUENT DISPOSAL SYSTEM
PERCOLATION RATE ABSORPTION AREA
(Minutes per inch): PROPOSED (Square feet): 11 New ❑ Replacement ❑ Experimental Q Seepage Bed ❑ Seepage Pit
1:1 Alternative (specify) El Seepage Trench
7 Z c
Water Supply: Owner's Name as Listed on Soil Test Report (If other than present owner):
ED' Private ❑ Joint ❑ Public
I, the undersigned, hereby assume responsibility for installation of the priv to sewage system shown on the attached plans.
Na a of Plumber: Si re. M PRSW Phone Number:
PlumFer's Addr ss: I' Nan7-1Desi9ner:_
COUNTY/DEPARTMENT USE ONLY
iof Issuing oApt: 0,~a Date: APPROVED Sanitary JPermit ~Number:
v ' Ja ❑ DISAPPROVED! / 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 (R.07/81)
_Z
-
APPLICATION FOR SANITARY PERMIT
S `1 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/contractez,("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 4!!
Location of Property <-v~, ~4, Section g , T ? N W
Township
Mailing Address 4 ( ~ lG( !1 ~y9~t~ 3~a w ye /S
Sub-division i.risi°Jn Na:M;:
Lot Number
•r
a f
Previous Owner of Property r_e
.~zpi `LG~ ~G
Total Size of Parcel
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes y/ No
Volume -59 and Page Numbers-- 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
pROPERT V /)FINN CERTIFICATION
I (We) eeAt. 6y that aU statements on this bow ane -tAue to the beat o6 my (ouic.)
k.nowtedge; '.that I (W~~) am (a)101 ttin n04100/( (h) o6 the pnope&tU de6c4 bed in 'this
in6onmat%on 6oun, by vi4tue o6, a waAAanty deed in -the 066ice o6 the
County Regizten o6 Deeds as Document No.? 2 S y ; and that I (we)
pnesenay oan the paopoaed site bon the sewage poa system (o& I (we) have
obtained an easement, to 4aw with .the above desuubed pnopeaty, bon the
eonstAucti.ori. 06 said a y.6 tem, and the same has been duly -tu'.canded -i.n the 066ice
o6 .the County Regis-ten o6 Deeds, as Document No.
IGNA URE OF ER SIGNATURE OF CO-OWNER (IF APPLICABLE)
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E SI NED DATE SIGNED
7
t';•a~'I'11•'I I':I~ III~Vt~:'r I~'Irll'
Part of the Southeast 1/4 of the Southeast 1/1 of Section Township 29 North,
Range 18 West., Town of Warren, St. Croix County, Wisconsin.
o Indicates I" x 24" iron pipe stake weit;:liu~ 1.15 lhs/1't. set..
• Indicates 1' pi pe found. n
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APPROVED
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~~~a~~nunl'lu►unu~~~~~
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I P 19 1979 .!L
o
{ JA MIS L. -
I ~ S1. CdOIX COUNTY
CO,n►.tEMENSrVE PARKS PLANNING r`V ~I'I 4 J ' f MURPHY •1f
AND ZONING COMMIME O\ c S 4 2
ooh u = t
klVLtt FALLS, r~0
APPROVAI OF THIS MINOR SUBDIVISION 'l v' J J'J WISC. 44v
DOLS NOT MLAN APPJtOVAL FO i J FiQ ' va
f~ S
BUILDING SATE OR SEPTIC SYSTEM; LAND
REFER TO H62.20.
Vol. J'r,f~r
(:vrt.ifi•td .;ur\\.~ > ; ;I , I / )rrfnrrn I.. a f,t,y
.:1 . f,('f)f X i;•ilul"t~,r'•, t..rr~~.r•,,,I:,I r~ , i .•~.I:IIn•!'r•~1 I .Ifni .;ilf'V,':/tif'
CZ7 =--j
1
s..~y 1 I,r •Ir I•I I.1 Ir.n „r I1r yr r •Ir i
PAl>E OF
` PLIMP fIihMt~lK CHL)_~ `1CTI0IJ AFIU '~VLCIFICAl-101 "
r.r.r+rtiiataatdtil.a~uaw.r++■~aolml~+~*~+i~'~'~rl~rns ~ - -
1 C 1 vLfJl" PIPC
WLATHLI( YKOOF APPROvEO LOCKING.
JUWCTIOIJ 00)( MANH(1LC COVLK
` ,n FNOr\ UUUR.
wiIJL,0W UK FRCSH 12 MID.
AIR I&I FAKL
GKADC
I
18'M I U.
COIJDU17--
PROVIDE I
IAII 4 I ~ AIKTI(.HT SEAL I I i I
I i
APPN.O'!k0 JOINT A I III APPROVED JDIWTS
W/LI. VI PG. I III W/C.TL. PIPE
LIITENDIMG 3' I (I ALARM EYTEWOINL 3'
OWTO b0l 10 SC;: I I ONTO 501-ID COIL
d I I
I I oN
G I 1
I
PUMP OFF
0 -
COkICRETL CLOCK
K15r I EXIT PERMI?IrED ONLY IF TA1JK MAWUFACTURLR HAS SUCH APPROVAL
~PCC.IFICAT10KAS
bLPTIC AND
pp5 MAWUFACTUQEIZ: WUMbLK Of OOSES: PLK DA.y
TAWK ~IIC:. GALLONS an ~y DOSE VOLUME 1/-5d
LAK MAUUFACTURFRR: OACKfLOW Y/ GALLONS
MODEL. WUMbLK'. CAPACITIES: A = f INCHES OR ~~Yf GALLONS
SWITCH TUPL: I'D = ' u INCHES OR GALLOWS
1'uMN /'\AWUFACTURER: INLHES OR GALLOWS
iV
MODEL WUMEER: ,l~'1 D~ INLHESOR r'eee/ALLOW6
SWITCH TbpE: MOTE: PUMP AND ALARM ARC TO oL
PUMP DISGHAkf g: RATC PM IN5TALLED ON %EPARATE CIRCUITS
VLKTICAL DIFFE LLMGS GtOWLLIJ PUMP Off AWD PISTftibUTIL)w PIPC.. FEET
+ MIWIMUM NETWORK SUPPLY PRf66uKc . . . . . . . . . . • 2.5 FLET
+ Lug Q _ FEET OF FORCE MAIN X f/Ip01I[FRICTIOW FALTOK__-k1~ FEET
l I~~ TOTAL ~JWAMIC HEAD 17 FLET
r L~~u r~ ~ < < y
IWTLKLIAL. plf-lLW i0W'fi Of TAWK: L_LK46,TH iWdDTH Q i LIQUID OLPT H("
~IGIJEG: " L IZE.WSE NUMIALKI. s 2 4 UATL
-111-
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PAGE OF
PUMP CHAMBER CRO55 SECTION AND `;PCC.IFICA"T"IONS
VCWT CAP
'i°C.I. VENT PIPE
WEATHER PROOF APPROI/ED LOCKING
JUNCTION BOX MANHOLE COVER
:5' FROM DOOR,
WINCOW OR FRESH 112 MIU. I
AIR INTAKE
(:BADE
I 'i° MIN.
118" MIU.
CONDUIT
16"MIN,
IN11..1_ T PROVIDE
I -
'T AIRTIGHT E I I V
I I
APFR.OVEC JOIN A- III APPROVED JOINTS
W/C.I. PIPE. I III W/C.I. PIPE
EXTENDING. 3' I II ALARM EXTENDING 3'
ONTO 501.110 SC B I ONTO SOLID SOIL
I I
C ON
I I
I
OFF
b~ U
O
CONCRETE BLOCK
RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS SUCH APPROVAL
SPEC.IFICATIOMS
SEPTIC AND ss
DOSE TANKS MANUFACTURER: NUMBER OF DOSES: _-PER DAy
TAIJK LIZE GALLONS (4t DOSE VOLUME
ALARM MANUFACTURER: r1r BACKFLOW. _f= GALLONS
fr / ~It s~ vo/, yu/.
MODEL DUMBER: CAPACITIES: A=INCHES OR GALLONS
SWITCH TYPE: /l~•'' Z INCHES OR r
_ B = 6ALLOAJS
PUMP MANUFACTURER: l c+ Ff c C - lie WLHES OR GALLOWS
MODEL NUMBER: D= e INCHES OR ALLONS
SWITCH TYPE: _h~ar~s~
~Z.. NOTE: PUMP AN ALARM ARE TO DE
PUMP DISCHAR(.E KATC GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE BTi;7 IGCAJ PUMP OFF AUD 0I5TRIBUTIOM PIPE.. 17 FEET
+ MyIAJI~MUM NETWORK SUPPLY PRE55URE . . , , • . , , • , 2•5 FEET J
7.?L~ FEET OF FORCE MAIN X FT. ~I
Ja o Fr.FRICTIO►J FACTOR.. FEET
TOTALfO tJQAMIL MEAD = FEET
IMTERILIAL. DIMILI ISIOMi OF TAWK: LENGTH ;w4DTH ;LIQUID DE TH
91GNE4: C ~z" LICEIJSE AJUMBER: DATE:
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D.1-1-H.R.
Leroy Jansky O.W.S.wisconsin Department of industry,
PLB-1 INSPECTION REPORT ' ~'f- `W1154729 Sa fetyb&rBui 1 diingsRDi vi s i on
1 ` 15) 723-8786 Bureau of Plumbing
Name o remises Dl~1~ P I an T>7--No:
t County Sanitary Permit #
as er, um er Firm Name A-ddress
`.csT Address
Owner- Address
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Y__.... _ .._.2 2.7 n.Y 1Aa-rt1h AT 1`i rt_:.P'.T..~~ ~4`tl`►s1
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9
~t wFv~ r" aan~F~ TAE ~s tic>,r~~, (21 ~,~f.~~rs31+E Wv=si cry.
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Discussed with Signature
( )See Attached.
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Parcel 042-1013-70-000 05/12/2006 03:01 PM
PAGE 1 OF 1
Alt. Parcel 05.29.18.80E 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
JOHN J AGGER O - AGGER, JOHN J
1090 110TH AVE
ROBERTS WI 54023
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 2.550 Plat: 0865-CSM 03/0865
SEC 5 T29N R18W PT SE SE BEING CSM 3/865 Block/Condo Bldg: LOT 3
LOT 3 2.55AC ASM'T INC 042-1013-50
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
05-29N-18W SE SE
Notes: Parcel History:
Date Doc # Vol/Page Type
09/15/2003 739917 2409/64 QC
07/23/1997 605/226
2006 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/19/2001
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.910 36,400 131,600 168,000 NO
Totals for 2006:
General Property 4.910 36,400 131,600 168,000
Woodland 0.000 0 0
Totals for 2005:
General Property 4.910 36,400 131,600 168,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00