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Parcel #: 181- 1025 -50 -100 12/30/2005 11:35 AM
PAGE 1 OF 1
Alt. Parcel #: 03.30.19.91G 181 - VILLAGE OF SOMERSET
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 - RDJ PROPERTIES LLC
RDJ PROPERTIES LLC C - %ROREBECK DANIEL
%ROREBECK DANIEL
1355 AWATUKEE TR
HUDSON Wl 54016
Districts: SC = School SP = Special Property Address(es): ' = Primary
Type Dist # Description
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 5.020 Plat: 1099 -CSM 04/1099
SEC 3 T30N R19W LOT 1 OF CSM 4/1099 Block/Condo Bldg:
5.02AC
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
03- 30N -19W
Notes: Parcel History:
Date Doc # Vol /Page Type
04/15/2004 759686 2549/063 QC
02/05/2002 670322 1830/420 WD
2005 SUMMARY Bill #: Fair Market Value: Assessed with:
80925 199,600
Valuations: Last Changed: 09/01/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 5.020 45,000 120,100 165,100 NO
Totals for 2005:
General Property 5.020 45,000 120,100 165,100
Woodland 0.000 0 0
Totals for 2004:
General Property 5.020 45,000 120,100 165,100
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
Parcel #: 181- 1024 -90 -200 12/30/2005 11:35 AM
PAGE 1 OF 1
Alt. Parcel #: 03.30.19.91A -20 181 - VILLAGE OF SOMERSET
Current X1 ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner
THOMAS J &THELMA FORREST O - FORREST, THOMAS J & THELMA
7135 TYLER RD
SIREN WI 54872
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description
SC 5432 SCH D OF SOMERSET
SP 1700 WITC
Legal Description: Acres: 0.190 Plat: 2992 -CSM 11/2992
SEC 3 T30N R1 9W PT OL 91 BEING OUTLOT 2 Block/Condo Bldg:
CSM 11/2992 .19 ACRE
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
03- 30N -19W
Notes: Parcel History:
Date Doc # Vol /Page Type
2005 SUMMARY Bill #: Fair Market Value: Assessed with:
80919 1,500
Valuations: Last Changed: 08/27/2001
Description Class Acres Land Improve Total State Reason
UNDEVELOPED G5 0.190 1,200 0 1,200 NO
Totals for 2005:
General Property 0.190 1,200 0 1,200
Woodland 0.000 0 0
Totals for 2004:
General Property 0.190 1,200 0 1,200
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
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 24
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City X Village Township Parcel Tax No: - 7 Forrest, Tom Village of Somerset 180 - 1025 -50 -100
CST BM Elev: Insp. BM Elev: BM Description:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
n Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG IWELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number:
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size Tole Spacing Vent to Air Intake
Pipe(s)
Length_ Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth of 1 xx Seeded /Sodded T Mulched L __
Bed/Trench Center Bedrrrench Edges Topsoil Yes No Yes No
❑
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 490 Forrest Drive Somerset, WI 54025 (SE 1/4 NW 114 3 T30N R19W) NA Lot 1 Parcel No: 03.30.19.91G
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
i
Plan revision Required? [is] Yes [a No
Use other side for additional information.
Date Insepctor's Signature Cart. No.
SBD -6710 (R.3/97)
County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN
�v In accord with 15.04 St. Croix County Sanitary Ordinance ZONING OFFICE
Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road
Hudson, WI 54016 -7710
(715)386 -4680 Fax(715)386 -4686
Attach complete plans for the system on paper not less than 8 -1/2 x 11 inches in size.
County Sanitary Permit # ❑ Check if rev ' Rr 19 plication
1. Application Information - Please Print all Information Location: r
Property Owner Name 1/4� W1 /4, Sec
d
1 T N,W R j 9 E (or W
Property Owner's Mailing Address tT Lot Num1 er Block Number
` 0!. ' 'r
ity, State Zip Code Ph r ;! t Subdivision Name or CSM Number
1
11 Type of Building: (check one) 2 amity illage Town of
J9 1 or 2 Family Dwelling - No. of Bedrooms: 3
❑ Public/Commercial (describe use): rru r ��
❑ State -owned Nearest Road
II. Type of Permit: (Check only one box on line A. Check box on line B if applicable) t - r ' J � >
Parcel Tax Number(s)
A) 1.❑ Repair 2. ❑ Reconnection 3. ❑Non- plumbing CkRejuvenation
Sanitation Zw
Permit Number Date Issued
B)
❑ State Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
Non - pressurized In- ground ❑ Mound ❑ Sand Filter constructed Wetland
Pressurized in- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other
. Dispersal/Treatment Area information: . Sa
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. t6il Applicati Rat 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed (Gals. /day /sq.ft.) ( Min.Anch ) Elevation
( 4,50 9. 9/33 gg .yZ-
1. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing
Gallons Tanks Concrete structed glass
Tanks Tanks
❑ ❑ 1 ❑ 1 ❑
❑ ❑ ❑ ❑ ❑
11. Responsibility Statement
I, the undersigned, assume responsibility for repair/ reconnenction /rejuvenationAnstaliation of non - plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair o e i I of non - plumbing sanitation system.
Plumber's Name (print) nature (no stamps): Business Phone Number
ors 7r- ZS/6 S�k
Plumber's Address (Street, City, State, Zip Cod
111. County Use Only
Disapproved Sanitary Permit Fee Date Issued Issuing Agent Signature (No stamps)
3 ?�_Approved Owner Given Initial Adverse
Determination rT
IX. Conditions of Approval /Reasons for Disapproval:
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
5�
Attach complete site plan on paper not Less than 8 1/2 x 11 inches in size. Plan must County t
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. Q
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 10;Z5- 50 - 00
Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Govt. Lot 1/4 1/4 S 3 T 3a N Rig E (or W
Property Owner's Mailin Address Lot # Block # Subd. Name or CSM#
35 T r
City State Zip Code Phone Number ❑ City aVillage 'own Nearest Road
6 i(`G I k ( S) 9 -ns V II it q ,C 0F Some r F 0rrp -s e;j
❑ New Construction Use: E Residential / Number of bedrooms �� Code derived design flow rate Ys 40 GPD
%Repleemmmt kuuewt ,%❑ Public or commercial - Describe:
Parent material ` �1 A. e- 0 - 1 D +.a W G. S Flood Plain elevation if applicable ft.
General comments ` �t'RF,5151v " .�" i� 5G_ %. I Y. � i S rZ� �Gy�.I'.S �' {& 3ct. 1;$u�
and recommendations: v
was t bo t w, a F v Gv t f : G • ' '�,r V.. was (a. s i- '> V w. ,P Au 9-
p c. I 5 Y 3 119.
F-)] Boring # Bori
❑ Pit Ground surface elev. � f ft. Depth to limiting factor y Gsa in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2
SL
F-1 Boring # F1 Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in�.-- -- •- �.,,,
.Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ' A *Eff#1 *Eff#2 IL I
t —Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 _< 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L
C Name (Please Print Signature CST Number
fp a s 17 Y t
Address a .� y� S+, to Evaluation Conducted Telephone Number
.5f y.,58�
SBD -8330 (R07 /00)
a ,
.. r
Property Owner Parcel ID # Page of
F-1 Boring # E] Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
7
F-1 Boring # F1 Boring
Pit Boring
Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608- 264 -8777.
SBD -8330 (R.07 /00)
,
see -• , " t Poiw
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ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently serving
the m �offts - r residence located at : Y.,
Sec. T R Town of St. Croix
County, Wisconsin. Upon inspection, I certify that I have found the tank and
baffles to be in good condition, and it appears to be functioning properly.
Last time serviced
Did flow back occur from absorption system? Yes No (if no, skip next
line.
Approximate volume or length of time: /�j d gallons `minutes
Capacity: /noo
Construction: Prefab Concrete Steel Other
Manufacturer (if known) :
Age of Tank (if known):
(Signature )// (Name) Please Print
(Title) (License Number)
(Date)
Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or
licensed disposer (NR 113 Wisconsin Administrative Code)
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
- -
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank condition, I
certify that the tank, to the best of my knowledge, will conform to the
requirements of ILHR 83, Wis. Adm. Code (except or inspection opening over
outlet baffle) .
Name Signature
MP /MPRS
- V01.
f �G -___-
Dowpreat _ KATHLEEN N. _ WALSH
p REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
07 -27 -2001 1:00 PM
AFFIDAVIT
EXEMPT D
CERT.COPY FEE:
COPY FEE: 6.00
TRANSFER FEE:
RECORDING FEE: 12.00
PAGES: 2
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oowr � I t mq► VWW on Wdid&W ptin otdw
Salutes, $9.43(2m) WRDA20"
ve►_ ...U� PAGE 581 ST. CROIX COUNTY
WISCONSIN - - --
- ZONING OFFICE
r r r N r r i ST. CROIX COUNTY GOVERNMENT CENTER
. ;. 1101 Carmichael Road
Hudson, WI 54016 -7710
(715) 386 -4680
AFFIDAVIT OF SYSTEM REJUVENATION
Property Owner: Iff
Address:
`7/3� e�or� S. Y, tl/
Day time phone:( 7 �
?� y 3 6y
Parcel
Legal Description of property: 5A ; �L� 4, Sec._,
R.W., Tn. of
St. Croix County, WI
As owner of the above described property, I acknowledge that the
septic system serving this residence (is /is not) undersized by
current code. standards. I understand that the issuance of a
sanitary permit to allow the attempted rejuvenation of the septic
system does not imply that the system meets current code sizing
requirements, nor does it imply that the proposed procedure will be
successful. I also acknowledge that I will make this information
available to any future parties interested in purchasing this .
property.
Signature:
Date: _
A 5/97
o rwisco l) 0
• s .,
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREBMBNT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer e�7—
Mailing Address 7/3S '' r# S, �"'+ 1 -J , S y 7�
property Address � Y(� � afr� st' �l �; r e_. e rte° r S fi Ad
(Verification required from Planning Department for new construction)
City/State 1
Parcel Identification Number
LEGAL DES IP'1'ION
V4 r /4, Sec. T W, Town of , `L' rye; ° / TT"
Property Location � F. /4, t�.1.. � O N -R -c ..-� �--
Lot #
Subdivision
Pa e # 169 -9
Certified Survey Map # �7 _qq , Volume __.__ II
Warranty Deed # , Volume , Pago #
Spec house ❑ yes k7 no Lot lines identifiable 10 yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
septic consists of pumping
out the s tic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
mastorplumber, journeymanplumber, restrictedplumber or a licensed pumper verifying that (1) the ou -site a rastewaterdisposal system
is is proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce m and the Department of Natural Resources, State of Wiscons�Certifi 3
stating that your septic system has beds maintained must be completed and returned to the St. Croix County Zoning
days of a three year date.
__._... ?
DATE
SIGNATUItJ OF APPLICANT
OWNER CERTIFICA'T`ION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
DATE
SIGNATURE OF APPLICANT
« « « « «« Any information that is mis- mpresmted may result m the sanitary permit being revoked by the Zoning DepwIMMIL
« « « « ««
« Include with this application. a stamped warranty deed from the Regishx of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
06/20/01 09:17 FIRST AMERICAN BAW SIREN -+ 246 7867 NO.002 D02
Part of Lot 91A of t Outlet Plat of the VillaM of Somerset, beinC a mart of the
Southeast One quarter (St*) of the Northwest One Quarter (NWT) of Segtion Three (3),
Township Thirty (30) North, Range Nineteen (19) West, Village of Somerset, St. Croix
County, Wisconsin described in Volume of Certified Eu_x -vey Maps on page 1999
as Certified Survey No. 1099
ST. CROIX COUNTY
CERTIFIED SURVEY MAP
MAP PFA ^8 AIE 1EFF*36NCEr TO THE SCALE IN FEET
EAST LINE: 0%' '"'aE N. 4. 1/4 0- SZC-
T I O N 3, T -30 - 3 -10 -W, ASSUMED , ao o � o'
BEARING -N -00 30' 52 " -W.
0 =1 1/4 ".IRON PIPE, 24
MIN.WEIGHT■I.13L9S. PER
LINEAL FOOT. SET
*:,I 6/9 24" IRON' PIPE FOUND.
AUG .9
L' + y
a 198
�* '•y 44.4 L
+r 1 :`� _. •. byµ $y N, _ COINER O W TTE
aRaSr,�:��P +�'e':. Ot 6 S. E 0^ Tam N. W
' Ox SECTION 3-
I 0 T' IRON PIPE
LO olA- OU mL(r PLAT O I INPLICE
VILL.AgE 0=' SOMERSET ( EXISTING
1
t �
a W
N N
N-67 °62'31"• E 86.0 p a
400-00 a - O
1
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. o a
tiT 101A y /1J e o 0
UNFLATTED
r Y i fj�f� m o
UTLOT "A "FRAM E _ ui
HOUSE
o
LO I '-0 4
:ILLAGI°a m ( 5.02 ACRES)
g a
POLSHED e
%)MERSEY
m a
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tw • ; A /.
ate. • rc. _ -
�aa , + 1 470.46'
S "ti9 06 $ 'W 470.46
E
SOUTH LIWE OF S.B. 1A OF N.W.IA4 OF SECTION 3• SrQoS. g �L' r_ COI E 3
UNPLA'L7'ED —LANDS ssA -' 3T_ -Na_
i9-
_ Volume 4 P age 1099 ,/�
06/20/01 09:17 FIRST AMERICAN BANK SIREN d 246 7867 NO.002 PW
SURVEYOR'S CERTIFICATE
STATE OF WISCONSIN 35 Continued
COUNT;. OF DUNN SS
I, LEE F. VILLENEM, REGISTERED LAND SURVEYOR hereby certify that I have surveyed, divided
and mapped part of Outlot 91A of the Outlot Plat of the Village of Somerset, being a part
of the Southeast One quarter (SEA) of the Northwest One Quarter (NWJ) of Section Three (3),
Township Thirty (30) 'North, Range Nineteen (19) West, Village of Somerset, St. Croix County,
Wisconsin described as follows:
Commencing at the Southeast corner of Section Three (3), Township Thirty (30) North, Ran,e
Nineteen (19) West, Town of Somerset, St. Croix County, Wisconsin;
thence on an assumed behring of North 46 0 17' 38" West, 3662.99 feet to the Southeast
corner of the Southeast One Quarter (M*) of the Northwest One Quarter (MW of said
Section Three (3) for the point of beginning of the parcel here -in described;
thence South 88 08' 52" West along the South line of said Southeast One Quarter
(S *) of Northwest One Quarter (NWT), 470.46 feet to the Northeasterly right -of -way line 0 . r
the Soo Line Railroad:
thence North 45 0 57' 29" West along said right -of -way line 97.4 feet:
thence North 00 30' 52" blest, 366.45 feet;
thence North 87 52' 51" East, 400.00 feet;
thence South 00 30' 5"!" East, 184.10 feet;
thence North 87 52' 51" East, 140.00 feet to the East line of said Southeast One
!-( Quarter (SEJ) of Northwest One Quarter (NWt);
thence South OO 30' 52" East along said East line 274.88 feet to the point of
beginning.
Containing 5.02 acres
,
I certify that I have made such survey and map at the direction of Tom Forrest, owner of
said land and that such map is a correct representation to sale of the boundaries of
the land surveyed. X have fully complied with the provisions of Chapter 236.34 of the
Wisconsin Statutes and all provision of the St. Croix County Sub - division Ordinance and
Village of Somerset Sub - division Ordinance in surveying, dividing and mapping the same.
LEE F. vn=1EUVE RLS #0984
March 19, 1981
Certified Surrey No.
St. Croix County, Wisconsin.
3- 4 f .
Volume 4 Page 1099
11
Z°8U55
EXECUTOR'S DEED
TO ALL TO WHOM THESE PRESENTS SHALL COME
I, William F. Bergeron, of the City of Stillwater,
in the County of Washington, State of Minnesota, Executor
of the Estate of William A.Bergeron, deceased, late of
St. Croix County, Wisconsin, send Greeting:
WHEREAS, William A. Bergeron entered into a contract
with Thomas J. Forrest on January 10, 1970 to sell to said
Thomas J. Forrest and Thelma A. Forrest, his wife, the real
estate hereinafter described;
AND, WHEREAS, said William A. Bergeron died testate
on February 16, 1970 and I have been appointed Executor of
his estate,and,
WHEREAS, by the terms of testator's will this Executor
was empowered to sell real property without order of the court;
AND, WHEREAS, all the conditions of said contract have
been fully performed and the purchase money has been fully
paid according to the terms thereof;
NOW, THEREFORE, KNOW YE, That I, the said William F.
Bergeron, in my capacity of Executor aforesaid, by virtue of
the power and authority in me vested as aforesaid, and in
consideration of the sum of Six Thousand Five Hundred Dollars
to me in hand paid by the said Thomas J. Forrest and Thelma
A. Forrest, the receipt whereof is hereby acknowledged, do
hereby grant, bargain, sell and convey unto the said Thomas
J. Forrest and Thelma A. Forrest, husband and wife, as joint
tenants, grantees, their heirs and assigns, all of the follow-
ing described real estate in the County of St. Croix, State of
Wisconsin, to -wit:
Outlots "90" and 11 91" of the Assessor's Plat of the
Village of Somerset except that part conveyed to
Clarence and Marcella Emerson in 11 390 11 , page 263,
and except that part of Outlot "90" (being part of
Southeast Quarter of Northwest Quarter (SEJNWJ) of
Section 3, Township 30, Range 19) lying Wly of County
Trunk Highway "I" and Nly of the Railroad right -of-
way and except that part of Outlot 11 91" (being art
of Southeast Quarter of Northwest Quarter (SEtNWI)
of Section 3, Township 31, Range 19) lying Sally of
railroad right -of -way.
TO HAVE AND TO HOLD the above bargained real estate
to the said grantees, their heirs and assigns, FOREVER.
IN WITNESS WHEREOF, I, the said William F. Bergeron,
as Executor aforesaid, have hereunto set my hand and seal
th10 day of March, 1970.
SIGNED AND SEALED IN ,
PRESENCE OF: .�. �,fosLi (SEAL)
8
Executor of the Estate of
HugK F. Gwin William A. Bergeron, Deceased.
ar ara . Ba neman iTiSFER
FEE
s�BK 460 PACE 67 r
eooK 460 68
STATE OF WISCONSIN)
) ss
ST. CROIX COUNTY )
On this ZG �%ay of March, 1970, before me personally
appeared William known to me to be the Executor
of the estate of William A. Bergeron, deceased, late of
St. Croix County, Wisconsin, mentioned in the within conveyance,
and acknowledged that he executed the same as such Executor,
freely and voluntarily, for the uses and purposes therein
expressed.
j
,,,• „ • ,,; :; ": Tru F. Gwin, Notary Public
G , St. Croix County, Wisconsin
41 ,,� My Commission is Permanent
Il k. IS INSTRUMENT DRAFTED BY
Hugh F. Gwin
OFFICE
g '7 CO., Wis..
Marc1?__._A.D.19_10
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• AS BUILT SANITARY SYSTEM REPORT
I ER Z TOWNSHIP SEC. T N, R W
,O. ADDRESS , ST. CROIX COUNTY, WISCONSIN.
.'3DIVISION
LOT LOT SIZE'-
PLAN VIEW
-Distances & dimensions to meet requirements of H62.20
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
I-T� I . I
Se
A
i
a
L L
S C L � ^�
'TIC TANK(S) 1 MFGR. / XS CONCRETE STEEL
NO. of rings on cover C? Depth DRY WELL
rT NCHES NO. of width length area
no. of line width length G are
depth to top of pipe
GUI GATE 3 � & zy,AA �
RATE AREA REQUIRED AREA AS BUILT YJ
I+Stiaimer: The inspection of this system by St. Croix County does not imply complete
;aVliance.with State Administrative Codes. There are other areas that it is not possible
iQ inspect at this point of construction. St. Croix County assumes no liability for
IStem operation. However, if failure is noted the County will make every effort to
Ei� ermine cause of failure.
iGASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. .+r
- 'INSPECTOR- -_
DATED ,2 — 72 PLUMBER ON JOB
LICENSE NUMBER
f
R &PORT INSPECTION INDIVIDUAL SEWAGE SYSTEM
Sanitary Penm.it -26"'
State Septic /,Z %77
) it "
NAME Tawnbh.ip �_��.� St. CAO.ix County
Locat.iore �—f�� �' �� Section —
SEPTIC TANK -
Size Z aVV gattons. Numbers of Compahtmen
" 11,
ViAtance FAom: Wet O fit. 12$ oh gneateA s.iope it
Bu.itd.ing .3 s 6t. Wettand.6
H.ighwateA - it.
DISPOSAL SYSTEM .
ViAtance FAom: W et d l it. 12% on greaten a.iope fit.
Bu.itd.ing G G it. Wettands �— Ft.
• H.ighwaten �.
FIELD DIMENSIONS:
Width oj thench 1� fix. Depth a ` below tc ie .in.
Length o6 each tine it. Depth o6 Aock oven t.ite i n.
Numbers-o6 tine-6 Depth o6 t.ite below grade 2 .in
Totat, Length o6 tines j it. Stope o6 trench - in pex 100 it.
D.iatance between t ine.6 ",t. Depth to b edto cfz fit.
Totat abs oAbt.ion area = 6t 2 Depth to gnoundwat fit.
-- Requ.iAed aAea it2 Type o6 Coven: rape& n Straw
PIT DIMENSIONS:
Numbers o6 pit-6 GAavet around pits yes no
Outside d.iameteA I Depth below .inlet St.
1 2
Totat ab d oAbt.ion aA.�va �t
Area %equi,%ed it2
INSPECTEDY- �� `�.- TITLE
APPROVED .� `,� , DATE 2 i w 197 `% \
REJECTED , DATE 197
i
5 Rev. 9/78
REPORT ON SOIL BORINGS AND PERCOLATION TESTS [
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVIC f ��FI�rF[l
P.O. BOX 309, MADISON, WISCONSIN 53701 �i �� IS 979
ZOW 6
LOCATION � X 11 1" Section , �' e N,_ (or�ownship <r
N f
Lot No. , Block No. County
Subdivision Name
Owner's/Buyers Name: e- 5 7`
Mailing Address:
TYPE OF OCCUPANCY: Residence No. of Bedrooms -� COMMERCIAL
EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEMENT ALTERNATE SYSTEM OTHER
DATES OBSERVATIONS MADE: SOIL BORINGS A) PERCOLATION C - TESTS —' -2
SOIL MAP SHEET NAME OF SOIL MAP UNIT CO' - r11
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHE RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE BOLE AFTER INTERVAL MIN /IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
P-
P-
P-
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR,
TEXTURE, MOTTLING AND DEPTH TO BEDROCK
NUMBER INCHES
OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES
/
B_ 4
(� r
B- A ,e- s , ,4 r -S-y %S
PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the " pl an the location and square feet of suitable areas.
Indicate number of square feet of absorption area needed for building type and occup�an !S Cod` II dicate scale or istances.
Give horizontal and vertical reference points. Indicate slope. �i� = ry��2_ "re, ,S�S7 n •1— �P�e „„
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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) 4 ` y :S�nD Certification No.
Address 6 LG � S a
,Name of installer if known
L
Copy A —Local Authority CST Signature
State and County State Permit
P 'r Permit Ap County Pq4it
for Private Domestic Sewage Systems Count
*DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
T�.4s
� a rP��sr"
B. LOCATION: ; S� '/ W %, Section _jr , T,� N, R/ E (or) ilW Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village 5d1�'DD� &P 7
Township
C. TYPE OF OCCUPANCY: Commercial * Industrial * Other (specify) Variance
Single family X Duplex No. of Bedrooms No. of Person
D. SEPTIC TANK CAPACITY Total gallons No. of tanks t
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concret Poured -in -Place Steel Fiberglass Other (specify)
New Installation _ Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate T Total Absorb Area sq. ft.
New Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Trenches
Seepage Bed: 2C Length 36 Width. Zt Depth S1 "' Tile depth (top) No. of Line 3
Seepage Pit: Inside diameter Liquid Depth No. of Seepage Pits
Percent slope of land 6 —& 2a Distance from critical slope
WATER SUPPLY: Private X Joint ❑ Community El Municipal ❑
Owners name as listed o n EH 1 15 if othe than present owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared
by the Certified Soil Tester,
NAME aayw /S C /,3/ dpi SD C.S. —j" — j"j and other information
obtained from {� , J owner bui
Plumber's Signature MP /MPRSW# Phone #
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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Do Not Write in Space Below F R COUNTY AND STATE DEPARTMEN USE ONLY
Date of Application (a Fees Paid: State �J t r!R' C Q Date / O
Permit Issued d (date) 7 Issuing Agent Name
Inspection YeNo State Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78