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. ST. CROIX COUNTY ZONING n�
G UCI ARTMCNT , ° !\
AS BUILT SANITARY REPORT
1 ff
Owner t1 i s ST r
Address
City /State GyA counmr
-'` ZONING OFFICE
,. � /�axr !� A • AA N �
Legal Description:
Lot �q,— Block — Subdivision/CSM # V a 1 /Z op 32
'�+ N '�+ 5F ,Sec. A 1 T AN-R - Town of K' g n ic.�t ihnir PIN # OAg –/d 6,2 -26
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer LLc-lz -e r Size STS /cyo / Setback from: House Well P/L
Pump manufacturer Model
Alarm location
(HOLD ONLY)
Setbacks: ern road Vent to fresh air intake Water Line
Meter location
Alarm location
SOIL ABSORPTION SYSTEM:
Type of system: Go K vat, 4 _,, 1 Width -- Length —6 Number of Trenches
Setback from: House I56 Well 1 7c)' P/L 3 Vent to fresh air intake f
ELEVATIONS
Description of benchmark �� _ A ¢ s �'� - Elevation Id do'
'
Description of alternate benchmark Elevation
Building Sewer 7 6, 11 ST/HT Inlet ST Outlet TA /,37 PC Inlet --��
PC Bottom ✓`� Header/Manifold 23- " Top of ST/PC Manhole Cover
Distribution Lines ( ) 9 3 c% ( ) ( )
Bottom of System ( ) y,z . O- ( ) ( )
Final Grade
Date of installation 7 17 Permit number 31 -4� ej State plan number -----------
Plumber's signatur License number )9�4te 313 // oO
Inspector
Complete plot plan a
NOTICE: Please provide the following:
• A plan view sketch showing everything within 100 feet of the system.
• Two horizontal reference points to center of septic tank manhole cover.
• Show alternate benchmark, if applicable.
PLAN VIEW
7 eg Ckj 4</a *1 lit -�.' I -f V4 1
�elx4r 1600 s�joi, Taw
/31K
yz' te
Go v�
!]/ vl i�GKbYn a j 5 3 dreaL
ate,.
INDICATE NORTH ARROW
. Wisconsin Qepartment of Commerce Count
PRIVATE SEWAGE S
Safety and Buildings Division
INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 315880
Permit Holder's Name: ❑ Cit [] Villa e Town of: State Plan ID No.:
DAVIS, JOHN B. KINNICKINNIC
CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.:
I� 022- 1062 -20 -000
too
TANK INFORMATION ELEVATI N DA A A9800268
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Uc Benchm r Z �°7 �0�• lOe=s
Dosi ng
Aeration Bldg. Sewer •7& Cr
Holding t% Inlet - g
TANK SETBACK INFORMATION t Outlet 37 5i.f
TANK TO P/ L WELL BLDG. A ir ir I to ntake ROAD Dt Inlet
A
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade 7.0 75. -(o
Manufacturer Dem d
Model Number GPM
TDH Lift Friction System DH Ft
oss Forcemain Length H Dist. To well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of renches PIT No. Of Pits Inside Dia. Liquid D h
DIMENSION DIMENSION N
SETBACK
SYSTEM TO P /L BLDG WELL LAKE/ STREAM LEACHING Manufactur INFORMATION Type HAMBER Model Nu er. .�•�
System:. b 11� O IT f
DISTRIBUTION SYSTEM A 1 07k C 0
[ Header / Maryfold W Distribution Pipe(s) rr --� x Hole Size x Hole Spacing Vent To Air Intake
Length l c Dia. Length7Y Dia. 3_4 Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Bed /Trench Edges opsoi ❑Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: KINNICKINNIC 21.28.18.P334B,NW,SE 1162 RIVER DRIVE
wt4z Sid
Plan revision r quired? ❑ Yes X Use other side for additional infor n. " O A
SBD -6710 (R.3/97) Date N Inspector's Si ture f i e ' rt. N
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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1*6 �nsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 2 01 0 Box7969gton Ave
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size. S -
• See reverse side for instructions for completing this application State Sanitary Permit Number
y ou p rovide maybe used b other overnment agency p rograms !� `
The information pr application
y p y y 9 y p g ❑Check if revision to pre
[Privacy Law, s. 15.04 (1) (m)]. / 1 �C � kimer —Dr! State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Pro Owner N e Propert Location
VC)V_N" p o,v S J( Nv�(1 /4 9E 1/4,S Q 1 T aS , N, R 1$ E (ode
Property Owner's Mailing Address Lot Number Block Number
L 4 1 5 k ak `>oXc. ---
City, State Zip Code 77 M one Number Subdivision Name or CSM Number
vvh� �c�x ►.o�Y.�,c'ti1N -1�o bta) Ia53- 9 CLSM V i P LQ O
11. TYPE OF BUILDING: (check one) ❑ State Owned O it Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms �� Town OF U1 \C- _0 we_ yv ic
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 [] Apartment/Condo - /• 99. / O p . 34
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. ❑ New 2. X Replacement 3. ❑ Replacement of 4, ❑ Reconnection of 5. ❑ Repair of an
System System Tank Only Existing System - --------- Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench `3idh�kv\or 22 ❑ In- Ground Pressure I 42 ❑Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
5c) "T"50 (sq. ft.) Proposed (sq. ft.) (Gals/da A ft.) (Min. /inch) Ele vation
" T " 50 , Q a — I -® Feet U.C)Feet
VII. TANK Cap acity in gallo Total # Of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con Steel glass Plastic App
New Existin strutted
Tanksl Tanks
Septic T cHplriiag -dank 1(�o t�Q� G\ 5` �'x El 1:1 1:1 1-1
Lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ 1 ❑ 1 ❑ ❑
VI11. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility f or installation of the onsite sewage system shown on the attach plans.
Plumber's Name: (Print) PI e s Si nat re: Stamps) MP /MPR511V No.: Business Phone Number:
R ut cJ. r � 1b LA15
Plumber's Address (Street, City, State, Zip Code):
N8a y5 _'&t 2cvcr
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitar Permit Fe (includes Groundwater D ate I ssued Issuing A nt kfffS re (No Stamps)
Approved ❑ Surcharge Fee) Cf
Owner Given Initial
v Adverse Determination - 7 6
X. CONDIT O SO
F AP ROVAL / REASONS FO ISAPPROVAL: S S
Lws�a i� .
�14 s � �1� vt l -e' Cass 44"4
seDmnvLiv 6) '_ e fDISTRIBUTION: Original to County, One copy To: Safety8 awldingsOiwision,Owner,fkrwber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608- 266 -3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing lumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),
P Y 9P P
address and phone number. Plumber must sign application form.
IX. County/ Department Use Only.
X. County / Department Use Only.
Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
----------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations
Division of Safety 8 Buildings in accord with ILHR 83.05; Wis. Adm. Code
COUNTY
Attach complete site an on S�• G�CII X
mpl plan paper not less than 8112 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road. >J ZZ L O 6 Z Z,b
APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION lRftD Y
PROPERTY OWNER: \ PROPERTY LOCATION
� c t'\ GOtff -LeT "W 1/4 SE 1 /4,S Z 1 T Z ,N,R l E (ork
PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
4312 v1-i b2 . Z I - C S Vo_ VZ N 3Z(30
CITY, STATE ZIP CODE PHONE NUMBER []CITY ❑VILLAGE ®TOWN NEAREST ROAD
w `(� '�i- TW yq Hfv ss too (61Z) 6S3 _ozz -9 tuNN 1e k-[KAu to I Czwe'?_ `Dl�_kue
[ j New Construction Use [>I Residential / Number of bedrooms [) Addition to existing building
P4 Replacement [) Public or commercial describe
Code derived daily flow L1 S 0 gpd Recommended design loading rate • S bed, gpd/ft - � trench, gpd/9
Absorption area required 01 bed, ft 1 S O trench, ft Maximum design loading rate S bed, gpd/ft • b trench, gpd/ft
Recommended infiltration surface elevation(s) q Z O It (as referred to site plan benchmark)
Additional design / site considerations SEE NoY tr w'a ry G Z
Parent material i' q_ns`f OV�fl1V Flood plain elevation, if applicable b 6 • S It }60 a .
S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem W S ❑u ®S ❑U OS ❑U I u s ❑u 50S ❑ U ❑ S EU
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITrer&
: .. .<
1 o.-VZ %\-t v-- 3(. 1 s u ►n cS z • s . 6
Ground
elev.
q •0 ft.
Depth to
limiting
,>l
Remarks:
Boring #
m V�- a Z� • s
k : Z \2 -1oS tu4�z-S1L - o sC�
Ground
elev.
.1 It .�
Depth to
limiting
factor
2 0N1N
Remarks:
TName: Please Print Phone.
Arthur L. We erer 715 -425 -0
egerer Soil Testing & De sign Service -P.O. Box 74 River Falls,WI 54022
Signature: �� ` Date: CST Number:
ELY �q- °J� M00576
PROPERTY OWNER SOIL DESCRIPTION REPORT Page'? - o f
PARCEL I.D.# DZZ 60
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourclary Roots GPD /ft
In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ITrench
3 z — �S l�h M
Z �t -3S .. Lo`1� X116 - 1 S �csblz M v`F►- �w - s .6
Grounds 3 3S_�t9 WS1L
elev.
0 1a 1 ft.
Depth to
limiting
factor
Remarks:
Boring #
�. M M 00 c - E!ece. 3 ' x S' I-v t:
�Z Utiv O G
131
S � �J ML
Ground Q �- ! JV . 1
elev. "1Zy e
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(R.05/92)
PLOT PLAN Pa 3 of 3
SCALE 1 "= �O '
ex goo
15 D 2tur � ,: a)
i
7 0 �
O 9
�u-j
m e
Grp -uh�� S�D� � 6 `-' � _� �wi � z - � . Wu • 3' oN 9��'1�ow�
3
I 3�
l
k
O j
D
, A
I
X 1162
t ( )
� 715 423-0 69 14 00576
CST Signature Date Signed Telephone No. CST #
Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of 3
Labor and Human Relations —
DMsion ofSafety &Buildings in accord with ILHR 83.05; Wi Adm: Code
COUNTY 'T
. S, C7R-o1 X
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but
not limited to vertical and horizontal reference point (BR, direction and % of'slope, scale or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION MMV4 D
PROPERTY OWNER: PROPERTY LOCATION
�nH N �?, . "vg t SR , (1OftteT NW 1/4 5E 1/4,S 2l T Z13 ,N,R I t E
PROPERTY OWNER':S MAILING ADDRESS LOT # I BLOCK # SUBD. NAME OR CSM #
11Z VAS DR. Z — CSM UoL \Z 1 32.60
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ®TOWN NEAREST ROAD
w IImZ yq )-7iV SS wo (btz) 653.-(3Z-z_9 1tt►JN Ze to I 1ZweR `DR.1U0_
(] New Construction Use [)q Residential I Number of bedrooms 3 [ ] Addifign to existing building
P4 Replacement [ ] Public or commercial describe
Code derived d aily flow y S 0 gpd Recommended design loading rate ` S bed, gpd/ft' ` �O try, gpdjft
Absorption area required 01 0 O bed, ft2 - 15 O trench, ft2 , Maximum design bading rate ' S bed, gpd1ft ` b trench, gpol(t
Recommended infiltration surface elevation(s) a 'Z • 0 It (as referred to site plan benchmark)
Additional design / site considerations 5Q1E 1 101 Gh3 \ PSG - Z .
Parent material Rood plain elevation, if aWicable 8 6• S It }�o p_L
S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT-GRADE S�Y W FILL HOLDM TANK
U= Unsuitable for sys WS ❑ U ®S ❑ U ® S ❑ U W S ❑ U 5n S ❑ U ❑ S 6
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rertdi
\,o V_ 3 L Z 1 s u rn u`Qh c s z • s, b
Ground
elev.
q .o ft
Depth to
limiting
factor
4
Remarks:
Boring #
1
Wa
Ground ' A
.r,
elev. {-
-,
Depth t0 sr c
2 MtV
t ? LDS
El
Remarks:
TName— Please Print Arthur L. We erer Phone' 715- 425 -0165
egerer Soil Testing & Design Service -P.O. Box 74 River Falls,WI 54022
Signature: /�.� � Date: 6 1 n_ arg CST Nwnb
0 0 5 7 6
PROPERTY OWNER 'tz�1PcV1 S SOIL DESCRIPTION REPORT Page' Z of 3
PARCEL I.D. DZZ.._ I 6z &0
Depth Dominant Color Mottles Structure GPD /ft
Boring # Horii6n Texture Consistence Bouiday Roots Bed Tn3r�ch
.. In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
l,
k, Q. �i Z �2 -3S .. Lb �'► tZ ! S cs b 1t
Grounds 3 3S —ll9 10`-tI -S 1L O 33
elev.
0 ►8.o ft. ,
Depth to
limiting
factor j
4
f
Remarks:
Boring #
�. Z c -e 3 x S' LW 1 4
Ground ° L� S Q ti1V L IA/C. 1 i
elev. e,
ft v
Depth to
Ilmlting . , .
factor .
i
,
Remarks:
Boring #
i
i
i
,
Ground '
,
elev.
ft.
Depth to
limiting i
factor
t-A
Remarks:
Boring # j
,
Ground ,
• eiev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
PLOT ELAN Pa 3 of 3
SCALE" 1 "=
r�uh� p
• � z O �'�- `d 6 s
et qy
s.l
'►S' D �2.6u� .
1S
,
7% 3' b:2
\ S�4`riC- tie- +1'i�u� 1�1v1�1v��
ON wsx mm OF
GWrR�/tGE Stp, N 6 �' � „� — 2z . We • 3� an► 9�`�'ra� -1
of �juSF r1D1wG .
X
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i
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Ic ( 715 ) 14 00576
CST Signature Date Signed Telephone No. CST #
S T C - 105
SFTI WTANK MAINTEINANCT AGRI-I'ME.NT
S(. Croix Courtly
(MINF I I?/ I l I I YFI I Z b4it5
----------
MAILING ADDRESS
PROPENTN' Aimimss A 13-0 c 67
(location of septic system) Please obtain from the V111111611" Dept.
CITY/STATE,
__ _4- _____. '- C� I?
PIZ OPE WIN LOCATION 1/4, 1/4, Section N-R \V
FO WN Of ST. UIMIX cmw•y \Vl
S11111DIVISION LOT NUMBEAt
NIAV VOLUME
___, PACE 1j) r r4UNIBE.R
Imptoper use and maintenance of your septic systent could result in its ptemature failure to liaiidlc
wa Proper maillictialice cons of pu mping out the septic tank every three years or sooner, if needed
by licensed septic lank pumper. What You [)it( Into the system can affect the function of the septic tank
Is I tle:11111rilt stage in the waste disposal system.
St Croix comity residents may be eligible to receive a grant for a maxim of 60% of the cost
of replacement of 1 failing system, which was in operation prior to July 1, 1918. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
'I he property owner agrees to submit to St. Croix Zoning a cer torn,, sig
lie(] by tile owner
and by a lilitcl phillibel, jotimeyman plumber, restricted plumber or n licensed pumper verifying Illat M
the on sitr wastewater disposal Sys(cill is in proper operating condition mid ()) after inspection and
pulliplill" (if necessary), fit(,. septic tank is less titan 1/3 full of sludge and scuts
I/We, the undersigned have lead the above requirements and agree (o mainumi the private Sewage
dispo.;,11 -'yclelll in iccoldalice with the s(andards set rot herein, as sci by the Wiscollsiti DNR
I I 1 loll stating that your septic his been maintained must be completed and wilittled t the St Croix
County hming Officer willmi 30 days or the three car expiration dale
Sl( - PNE'D:
;l ('1flix Comity 7.0111til"
(iovvillim-111 Ccfile(
1101 ('mmit Road
lhid V,'I 511016
W
K
S T C — 100
` I
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 sold and submitted to this office with the
appropriate deed recording.
Owner of property 1% I Re V - Jc &bAyis', S � L "S < ��W (S
Location of property W 1 /fY NW 1/4, Section ,T N -R W
Township Mailing address t i 6 z
Address of site t! `z QwC(Z ) (2cuv' ` Q, ��,y Ve3 Ca5 LOt - ,"T.w cJZ
Subdivision name Lot no. Z
Other homes on property? Yes v- No
Previous owner of property ,l
Total size of property Zq 4caC,y t
Total size of parcel Z3 , w� �a�n� s
Date parcel was created ,
Are all corners and lot lines identifiable? V — Yes No
Is this property being developed for (spec house)? Yes x, No
Volume and Page Number as recorded with the Register
of Deeds. ' 1 rc� - 3 (3 & -- p L o wy Lo C tAv sIt"ti
-------------------------------------------------------------------
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. 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 Certified Survey Map
shall also be required.
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 owners) of the
property described in this information form, by virtue of a
warranty deed recorded in the office of the County Register of
Deeds as Document No. C/ 5 "o a �2 , and that I (we) presently
own the proposed site for the sewage disposal system or I (we)
obtained an easement, to run 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.
9/L
S' nature of Appli ant Co- Applicant
Date ofTignature Date of Signature
Jr
DOCUMENT NO. WARMAM DIED 4 1mr-00041441 "TA
STATE BAR Or WISCONSIN FOAM 2—"
45062 ' ;t , . SM E 1611 ICAPER'S OFFIrE
SL CROIX CO., w
Reed for Record
........ ................................... .......... ....... ....... .................................. 0%;T 101989
....... ...................................................... ..................................... 0 11:30 A. M
..... ................. .. ................... I ...... ..........................................
conveys and warrants to ...John.- Bradford - .Davis, - ir a-m=iel.-
. Ivan, . • taking- title. -with. - sole. rights - -of. marub- 4A-&-.and ......
control ----------------------------- .................... ...............................................
.............. --- -- ...... ........ I-- � ......................... ....
.............................................................. ......... ............... ..........
...... . ... .................................................. - .......................................... wRUww To
... .... ................................................................. .......... I ..........................
........ .. ..................................... ................................... .
the following described real estate in .� ........O ... ........................
State of Wisconsin:
Tax me: ..............................
The west 1/2 of Northwest 1/4 of the Southeast 1/4 and
the West 660 feet of South 534.8 feet of Southwest 1/4
of the Northeast 1/4;
AILI in Section 21-28-18 St. Croix County,, Wisconsin-
*,-
s �goso
FEE
This --- iS Mt ............ homestead property.
(id (is not)
Exception to warranties: Easements, restrictions and rights of way of record.
Dated this ......... 19J
day of
---- - -- ... ... ........ (SEAL)
------- ---l- ASEAL)
a Timothy M. TroLlan__ ......
. ...... ------- --- ------- ...... .......... .... ... .. .. . ...' .. .1 -- - ..
................. ..................
.--- (SEAL) . ... . ..... I . .. ... (SEAL)
.... .. .. ....................... ... . ...... . .
AUTHENTICATION ACKNOWLZDGMZNT
.. "
A STATE OF WISCONSIN
as.
I>
0 -1r..%.jF --- -------------------------------------------
,, t* * tiPitdaw Zh-6-4y of.tx-TC- 19-8-9. Personally came before =e this ................ day of
.......... ..... ....
------- ------- . 19-89- the above named
. ................ .................. --------
- ---------------------------------------- -
• ii�p- -M--TrIlan -
o
--------- -------------------- ....... ------ -------------- --------------- ..................................
- �nff B �ii - �i BAR ........... I .......
M --- E M ----- E - R ' S " A ' T ... ... '' OF WIStUNSVN ............................ ............ .......
(if not .................... -- --------------- -------- ------ ---- ... ... . ....... -••- -------- -------------- - ------------- -- --- - ............
authorized by 1706.06. Wis. State.) to me known to be the person ..... .... who executed the
foregoing instriment and acknowledge the same.
THIS INSTRUMENT WAS DA4FTED BY
Owc-n Kuchevar Attorney at law ........
.............. .. . .... ...... ... I ......
219 North Main, River Falls, W1 54022
.................... ................................... - ..................... Notary Public County, Wis.
(Signatures may be authenticated or acknowledged. Bou. My Commission is pvrrvianerat. (If not, state expiration
are not necessary.) date: .. .. ..... 19
oN &aaft of pmng signing in any cspa,ity a huutd be typed ,, p,,nl.d b,l— th--i,
STATE PAR OF
FOX" NO 2 — 1752 Stock No. 13002
CERTIFIED SURVEY MAP
V:: LOCATED IN THE SW 1/4 OF THE NE 1/4 AND IN THE NW 1/4 OF THE SE 1/4 OF SECTION 21, T28N,
RISW, TOWN OF KINNICKINNIC, ST.CROIX CO., WI.
N 1/4 CORNER OF —� PREPARED FOR JOHN B. DAVIS, JR.
SECTION 21. (COUNTY•
MONUMENT FOUND). S
$Ic; UNPLATTED LANDS
$�N �6 KINNICKINNIC
N b• R 1 VER
POSITION FALLS S 87 41 l "E 660.53
IN RIVER. NO 324 4 NOTE BEARINGS ARE
IRON PIPE SET. i� 373.6 y 286. 93 y REFERENCED TO THE N -S
QUARTER LINE. (ASSUMED
o BEARING).
io LOT 1 $ O
4.80 ACRES g ".
L
d Z09, 122 $0. FT. n�
}
a p W
S 87 ° 41' 51 "E
7 307. 55'
66.0.5' POND ��
d E -W QUARTER SECT ION L 1 NE
.I G -
tn W� 66' cn:
o_p 2 garage o:
tm ac
yUu fuse a
w o $ LOT 2 is
23.45 ACR S ►°
ti w rn W I, 021, 378 Sa FT. t: 3
Q ro `3 20.95 AC. E C. RiW a �-
o 912, 485 SO FT. a
w � to
I I $
66' ,
driveway
I
. oo. I. HWY. S TB AC .
....._ ................. /N w
• 664.26 ... f ....
M $S87 ° 52'4 'E
Qf
1 I N 87 ° 55 , Ol "W 664. 36'
SOUTH L I NE OF THE NW - SE I
- ,UNPLATTED • LANDS
S l-'4 CORNER OF SECTION
21. ! 1 ' IRON PIPE FOUND).
JAMES NA. •�^���
• " I' IRON PIPE FOUND. WEBER
0 + SET / X 24' IRON PIPE ` � 1804
WEIGHING 1. 13LBS PER L INEAR.FOOT. 8PRJNQ VgLLEY
300 0 300 0 J� wls. ,�,
600 900 � �,,.•�p� ° .
G — �'•'sal R RAPHIC SC ALE FEET a��
96 -133 THIS INSTRUMENT DRAFTED By JIM WEBER S I OF 2 JAMES M. WEBER S =1804 NELSEN-sE ,AND SURVEYING
DATED 5CC -��'c •
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
119
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 Village X Township Parcel Tax No:
Davis Family Farm /Revocable Trust I Kinnickinnic, Town of 022- 1062 -20 -000
CST BM Elev: Insp. BM Elev: BM Description: Section /Town /Range /Map No
21.28.18.3448
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
SUHt 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
TDH Lift 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 jBLDG IWELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size i x
Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems On
Depth Over Depth Over xx Depth of 1 xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil ±,1 Yes No t, � Yes l aF No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: / / Inspection #2: / !
Location: 1162 River Drive River Falls, WI 54022 (NW 1/4 SE 1/4 21 T28N R18W) NA Lot 2 Parcel No: 21.28.18.344B
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? ; Yes No
Use other side for additional information.
Date Insepctor's Signature Cert. No.
SBD -6710 (R.3/97)
ST CRO� c OUNTY
4
PLANNING & ZONING
EROSION & SEDIMENT CONTROL PLAN
Site location: 1162 River Drive, Lot 2, Town of Kinnickinnic
Owner(s): Davis Family Farm Irrevocable Trust
Parcel ID #21,28.18.3348
Code Administration
715 386 - 4680 Under St. Croix County Zoning Code 17.70(3)(b) 5: "The (Zoning) Administrator may
attach reasonable erosion prevention conditions to a permit approved for issuance." In
Land Information addition, Wisconsin Uniform Dwelling Code Comm. 21.125 requires the building permit
Planning applicant and /or landowner to follow erosion control procedures and maintain them until
715- 386 -4674 the site has been stabilized (Uniform Dwelling Code Comm 21 is available on -line at:
www. commerce. state. wi .us /SB /SB- DivCodesListing.html)
Real Property
715- 386 -4677 The Owner of the above parcel is responsible for notification of all contractors performing
construction activities on this site that an Erosion & Sediment Control Plan is in effect and the
Recycling following activities will be required in order to maintain compliance with the plan:
715- 386 -4675
1. Maintain existing vegetation wherever possible to minimize erosion and sediment
movement. The primary source for construction site runoff will be the house foundation
excavation, driveway, well drilling, and soil stockpiled until final grading and stabilization is
complete. Septic system installation adds to temporary disturbance, but establishing cover
on exposed soils will prevent erosion. Apply seed and mulch as recommended in #4 below.
2. Install construction entrance before any excavation begins!! Construction equipment
and vehicles must utilize a stabilized driveway access off public road for heavy equipment;
this includes cement trucks, well drillers, and other contractor's vehicles that require access
to the property during construction. Avoid muddy, rutted conditions that may allow
contaminated runoff to reach waterways and /or drainage ditches. Property owner must
repair damage to ditches resulting from multiple access points and sediment tracked on
public roadways must be removed at the end of each workday.
3. Do not allow contaminated runoff to be directed onto neighboring property or into
surface water conveyances. Create temporary diversions graded ALONG CONTOUR
between excavated areas and any potential receiving waters (this includes driveway & road
ditches) by routing contaminated runoff into vegetated buffer areas on owner's property.
(Refer to specification sheet for temporary diversions available from county).
The owner of record during site construction will be responsible for compliance with state and
county code requirements as specified in this Erosion & Sediment Control Plan. Please feel free
to contact me with questions regarding erosion & sediment control product installation.
PLAN PREPARED BY: RYAN YARRINGTON, ZONING TECHNICIAN #683475
Owner acknowledgement of ESC Plan requirements:
_/_/2007
(Please sign and return original ESC form to Planning & Zoning Dept. A copy is attached to the owner's permit and
maintenance agreement, which is given to the plumber at time of permit issuance.)
ST. CROIX COUNTY GOVERNMENT CENTER
1 10 1 CARM/CHAEL ROAD. HUDSON, W1 54016 715 386 - 4686 FAA
County Sanitary Permit Application 71VED TY WISCONSIN
In accord with Chapert 12 St. Croix County Sanitary Ordinance & ZONIN ARTMENT
Personal information you provide may be used for seconds NTY GOVERNMENT CENTER
Roa
[Privacy Law. S. 15.04(1)(m)] R EC on, 0167710
680 Fa x (715)386 -4686
Attach complete plans for the system on paper not lesi than U&Tx fi i ize.
County Sanitary Permit # El Check if revision to pre ious application
08 9 ST. CR01
1. Application Information - Please Print all Information Location:
Property Owner Name /n '^ W 1/4 SC 1/4, Sec
' Z
V � AX r! l� L (F Off$ ^ Z, 1? N, t R /? E (or
Property Owner's Mailing Address Lot N Block Number
City, State Zip Code Phone Numer Sub ' or CSM Number
l US A c�5 '5 `fo Z �- V b z/ Z 3 2 6
II T pe of Building: (check one) 6K f Mity ❑Village ®Town of
1 or 2 Family Dwelling - No. of Bedrooms: t' 1�
❑ Public /Commercial (describe use): � �`�"� I /✓i✓/ C q C
❑ State -owned Nearest Road
II. Type of Permit: (Check only one box on line A. Check box on line B if applicable) ( U ✓�
Parcel Tax Number(s)
A) 1 Repair 12.IL–Reconnection 3. ❑Non - plumbing 4. ❑ Rejuvenation ZZO • om
Sanitation , 33
B) Permit Number Date Issued
State Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
12' Non - pressurized in- ground ❑ Mound >_ 24 in. suitable soil ❑ Mound :5 24 in. suitable soil ❑ Mound A +0
❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Other
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating
Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade
`50 Required � Proposed (Gals. /day /sq.ft.) � (Min. /inch) �� O/ Elev�ayti�on^
p TJ
I. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic
New Existing Gallons Tanks Concrete structed glass
Tanks Tanks
14 r65 CZ0"_4 A!r ❑ 1 ❑ 1 ❑ ❑
VII. Responsibility Statement
I, the undersigned, assume responsibility for repair / reconnenction /rejuvenation/installation of non - plumbing for the POWTS shown on the attached plans. A
license is not required for terralift repair or the installation of non - plumbing sanitation system.
Plumber's Name me (print) lumber's Signature (no stamps): Z P / No. Business Phone Number
° 6 �— 3— 4sta
Plum s Address (Street, City, State, Zip Code)
III. Coun Use Oni 17
sapproved Sanitary Permit Fee Date Issued Issuing nt Signat e (
j Approved n Adverse C OO ID1,3/6 7
PD!eermEnation J
IX. Conditions of Approval /Reasons for Disapproval:
lo.l�.
SYSTEM OWNER:
1. Septic tank, effluent filter and 4„
dispersal cell must all be services / maintained 5a
as per management plan provided by plumber.
2. AN sddmk requirements must be maintained 11 /
as per applicable code / ordinances. p IN � .
l o fi Plem
�b ►1 �Q
N. e
Orr. Trrnck
5y3T 72. 0
/oov�al I;C Tan f%
BoWo jBM
�m �
cs � s i'd ,. ,) oti slrc f � 71
/•
160-0' —(�.
.3 13�cQra�
Ho &-�
wr-U
t L Y
Q
� 1✓�[ � /AD ..
i L k - r -e
or Jo h n DOLvI s �r
0 2 6 yS/
i
U. 2681P 160 - 7 - 7 »8a
KATHLEEN H. WALSH
STATE BAR OF WISCONSIN FORM 3 - 2000 REGISTER OF DEEDS
Document Number Q UIT CLAIM DEED ST. CROIX CO.. WI
l�
RECEIVED FOR RECORD
This Deed, made between John Bradford Davis, Jr., a married man 10/22/2004 10: 00AN
with sole rights of management and control of the property described
herein Grantor, and Lincoln S. Davis and Susan D. Flvgare. in their capacity 6iUI T CLA I Il DEED
as designated Trustees of the 2004 Davis Family Farm Irrevocable Trust
!cE- 1 16
Grantee. REC FEE: 11.00
Grantor quit claims to Grantee the following described real estate in St. TRANS FEE:
Croix County, State of Wisconsin (if more space is needed, please attach COPY
addendum): PAGES: 1
LOTS ON)t'; (1) AND TWO (2) OF CERTIFIED SURVEY MAP IN
VOLUME J'WELVE (12) OF CERTIFIED SURVEY MAPS, PAGE 3260,
AS DOCU ENT NUMBER 559802, FILED IN ST. CROIX COUNTY
REGISTE OF DEEDS OFFICE ON MAY 23,1997, BEING LOCATED
IN THE S UTHWEST QUARTER OF THE NORTHEAST QUARTER
(SW 114 OP NE 1/4) AND IN THE NORTHWEST QUARTER OF THE Recording Area
SOUTHEAST QUARTER (NW 1/4 OF SE 1/4) OF SECTION TWENTY
ONE (21), TOWNSHIP TWENTY EIGHT (28) NORTH, RANGE Name and Return Address
EIGHTEEX (18) WEST, TOWN OF KINNICKINNIC. Subject to River Gwen Kuchevar
Drive right of way. Rodli, Beskar, Boles & Krueger, S.C.
P. O. Boa 138
River Falls, WI 54022
022 - 1059 -50- 000 :022- 1062 - 20-000
Together with all appurtenant rights, title and interests. Parcel Identification Number (PIN)
is is not homestead property.
Dated this C5CA day of September. 2004 (is) (is not)
* *Jo Wb radfor avls, Jr.
• s
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) John Bradford Davis, Jr. STATE OF )
,�....�..,...... ) ss.
County )
tOn>!iLai$li ttiiS`•av of September
4 2004
C/_
/ Personally came before me this day of
(�E
_ .. • `�"� i the above named
e
n K evat
TI� : �lRTATE BAR OF WISCONSIN
to me known to be the persons) who executed the foregoing
authorized by &706.06. Wis. Stats.) instrument and acknowledged the same.
THIS INSTRUMENT WAS DRAFTED BY
Gwen Kuch�var - Attornev at Law
River Falls, WI 54022 Notary Public. State of
My Commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or aclotowledged. Both are not necessary.) )
• Names of persons signing in any capacity must be typed or printed below their signature. INFO -PRO (800 )655 -2021 wwwJnfoprofams.cam
STATE BAR OF WISCONSIN
QUIT CLAIM DEED FORM No. 3 - 2000
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
p1-Vl 1 �L L/ ,4/t /99� ` Uo cAter V i t e 4 sidence located at:
A) Uj 1 /4, 5 Section - 2-1 Range 8 W, Town
Of t A) of ( c fc 4A)AI St. Croix County Wisconsin. Upon
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)
a ear to be functionin properly.
PP (s ) g . p P Y
Most recent date of service _ Z O
Did flow back occur from absorption system? Yes No,
(if no, skip next line.) r
Approximate volume or length of time: gallons minutes
Capacity: 0�
Construction: Prefab Concrete Steel Other
Manufacturer (if known):
Age of Tank (if known):
9 Vs2. S
(Licensed Plum &r Signature) (Print ame)
'z- 6� 5eY 7
(Title) (License Number) MP/MPRS
(Date)
Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes)
or licensed disposer (NR 113 Wisconsin Administrative Code)