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U; 2 7 7 7 P 3 8 9 KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX GO., wI
Document Number Document Title RECEIVED FOR RECORD
04/05/2005 09:15AM
St. Croix County AFFIDAVIT
Occupancy Affidavit EXEMPT #
REC FEE: 11.00
TRANS FEE:
COPY FEE:
f6~a o o dQ r i /y CC FEE:
Name - (Owner) Typed or printed PAGES: 1
being duly sworn, states, under oath, that:
1. He/she is the owner/part owner of the following parcel of land located in St.
Croix county, Wisconsin, recorded in Volume 98'S Page 59-9- Document
Numbergb St. Croix County Register of Deeds Office: Record; Area
Name and Return Address
A parcel of land located in the A' 4 of thoY6 V4 of Section TA'' ~p
T__ N - R / 7 W, Town of _ OYq 1P7,-VZQA1 L) St. Croix
County, Wisconsin, being duly described as follows (include lot no. and
/f.1 <
subdivision/CSM or detailed legal description):
Se✓C. /0 7"2q',Al R17 W ?A/E11Yff 1V0,eTH y2/. Sr a A- 6 -r 310 3 ' 01C A(F/.Si-% Parcel Identification Number (PIN)
As owner of the above described property, I acknowledge that the septic system serving this residence is sized for a
bedroom home, or a design flow of gpd. The design flow is calculated by assuming 150 gpd for 2
individuals per bedroom. There are currently,--?, occupants living in this residence; occupants are permitted
based on the design flow. Therefore the septic system serving this residence is code compliant. However, I
understand that if there are intentions to exceed the number of permitted occupants, the system will need to be
modified to accomodate any increased wastewater flows and/or contaminant loads. I also acknowledge that I will make
this information available to any future parties interested in purchasing this property.
Dated this _L day of A At r L -7,cnf9 5
* * Tedd 0 Drenth
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) _ STATE OF WISCONSIN )
)ss.
authenitcated this day of _ St. Croix County. )
20P the came before me this I s tday of April
the above named
k Tariri n nrgnth
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, _ to me krwwm to be the person(s) who executed the foregoing
authorized by § 706.06, Wis. Slats.) instru ent and acknowledge a same.
THIS INSTRUMENT WAS DRAFTED BY
RA
Gam:' . J. Rasmussen
'cj DT • b41c,'$tate of Wisconsin
(Signatures may be authenticated or acknowledged. Both arenot f e ' mission is permanent. If not, state expiration date:
.My r
necessary.) A R IVota Pubic -Sa2® 0s Wsconsh
"THIS PAGE IS PART OF M - NOT VEN" '
This tnJl w"wdon nwst be completed by se bnWer ' fi and!?M ryrequired). Otherh/ormaUon suds as the
gnvdkV douses, leagal descrlptlort, etc. may be placed on this brat rq(r- or may be plaoed on addluoeW pages or the
doosrnent bf2tc use ofttrls cover page adds one page to ytwrdocumentpnd 12.00 to the recorubw fee. Wisconsin Statutes. 59.517.
RECEIVED
ST. CROIX COUNTY ZONING OFFICE APR 0 5 2005
ST. CROIX COUNTY
CERTIFICATION STATEMENT ZONING OFFICE
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have ins ected the septic tank presently serving the
441
/0 y (o 0
ST. 2 9, /7, /S'7,4 residence located at:
'/4, SE 1/4, Section Town2N, Range I -7 W, Town
of HA-pi IJ-D St. Croix County Wisconsin. Upon
M o
inspection, I certify that I have found the tank(s), to the best of my
knowledge, will conform to the requirements of Comm. 84.25, and it (they)
appear(s) to be fiinctioning properly.
1_ ,
Most recent date of service
Did flow back occur from absorption system? Yes No-L,,Z
(if no, skip next line.)
Approximate volume or ngth of time: gallons minutes
Capacity:
Construction: Prefa Concrete _ Steel Other
Manufacturer (if known):
Age of Tank (if known):
(Licensed Plumber Si ture) (Print Name)
(Title) (License Number) MP/MPRS
I
I
C9" _
(Date)
Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes)
or licensed disposer (NR 113 Wisconsin Administrative Code)
1
Wisconsin Department of Health and Sooial. Services
Plb..#67 370 Division of Health
SEPTIC TANK PERMIT APPLICATION
TYPE or USE BLACK INK
A. OW;?ER OF PROPERTY
Name Address (Street, City, Zip Code)
COU?IT1'vJ ' ~i~~~
B. LOCATION OF PR0?ERTY WHERE SYS-= WILL BE CONSTRUCTED ALTERED OR EXTENDED
Check One:
CITY VILLAGE LEGAL DESCRIPTION
TO'+d lSHIP Ef 7 1J~
C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? .~.1. YES NO PERMIT NL2SBER
D. SEPTIC TANK CAPACITY Gallons NEW INSTALLATION REPLACEMENT ADDITION
MATERIALS: Prefab Concrete Poured in Place Steel Other
NUM3ER OF Tk;KS TO BE INSTALLED: 0`3-
E. TYPE OF OCCUPANC i
Check Ore: One or Two Family Residence Commercial Industrial Other
Specify)
Number of Persons to be Acco.T odated Number of Bedrooms
F. APPLIANCES, ETC: Food Waste Grinder YES A- NO Automatic Clothes Washer YI:S NO
Dishwasher YES NO Autoratio Potato Peeler YES_4_ NO
Other (Specify)
G. KAST`aR Pl P:BZR ?D%Klli,': INSTALLATION
Name: Address: 1 License Number:
-l" W11" Z
i /
Signature of Appiic:ant: Kp RSW
Address:
H. (T be Completed by Issuing Agent)
Date of Application 7 J Fee Paid
Permit Issued (date 7 u~'7 Permit Number
Agent (Name) Zv'- . tyl Fors L",-//
Torn, Village, City, County, etc.
(Specify)
Note: The application cannot be considered for filing until all of the above questions are answered and the
fee paid. Agents will fom and application, the fee of $1.00 for each septic tank and the third copy
of the permit (canar.r) to the Division of Health. Checks and money orders should be wade payable tr
the Division of Health.
Do not write in space below - FOR DEPARTMENT USE ONLY
1. DATE RECEIVED f I ACCEPTED BY RETURNED
(Initials) (Date) 5 Corr~eg. )
FEE RECEIVED _ ✓ _ VALID. No. --7 ~1 ' PERMIT M0.
es or No
REVIEWED BY APPROVED DATE
(Initials) (yes or No
COMPLETE 071 MR SIDE
y
SEPTIC TANK PERMIT NO.
' R E P O R T O N S O I L P E R C O L A T I O N T E S T
A N D S O I L B O R I N G S
TO
DIVISION OF HEALTH - PLU-Ml21v 57,0716N
P.O.Box 309, IMisou, Wis. $3701
Pursuant to H 62.20, Wis. Administrativo Code
P E R C O L A T I O N T E S T
Test Depth Cha:acteP of Soil Hours Water Teat Time Drop inn Watar Level 7nciies utes
Fa11
Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last Ec'oolnch
1st Witted GVOE2 4/t in Minutes Last Period Last Period Period Example
p - 0 36" 7o Soil 101+ ClaV 26~+ 25 Yea or No 30 1 2 1 2 1 2 60
l ~r7 ~JC-~ aC 4)0 'Y o Y3 ~J!
J
RECORD DATA FROM MINIMUM OF 3 TEST HOLES
Compute size of absorption area in accord with H 62.20 Wis. Administrative Code.
S O I L B O R I N G S- Mint-um 36" Belci proposed Absorption Syst*m
Boring Total Depth Depth to round Vt" Depth_ to Bedrock
Number Inohes Cbserved $stir-%ted Observad E3ti^::6tad Character of Soil with Thickness in Inches
Example
B - 0 72" r 72" Black Top Soil 12"; Clay 1811• Sand 18111 Gravel 24"
J. J~y i /r 1 9i~>L~ L
7 z
RECORD DATA FROM MINE-11--M OF 3 BOR-7 HOT FS
Yps OF OCCUPANCYs
R SIDENCEs Number of Bedrooms 5 OTHER: (Specify) Number of Persons
FOOD WASTE GRINDER: Yes - No Dishwashers Yes No Automatic Clothes Washars Yes No
EFFLUENT DISPOSAL SYSTEM: NEW EXTENSION ADDITION REPLACE ENT
Tile Size No.Lin.Feet LL Trench Width _ Depth_ Number of Lines
Seepage Bed: Length Width Depth Tile Size No. Lines
Seepage Pits Inside Diameter Liquid Depth
I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under ray super-
vision in accord with the procedures and method specified in Chapter H :.2.20 (13), Wisconsin Administrative Co-e, and
that the data recorded and location of test holes are correct to the best of my knowledge and belief.
NAME It1 .C.L~ t ~ Cif L TITLE L/) C1~~t~E~ -
Type or Print
REGISTRATION NO or MASTER PLUMBER LICENSE NO. 77f 7
ADDRESS .4 l?I /n y~ /L~ l~ / `e
DATE Z) SIGNATURE
do