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030-2035-95-300
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix � Safety and Building Division INSPECTION REPORT Sanitary Permit No: 515254 0 CV4ERAL 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: Coerber, Ross W. I St. Joseph, Town of 030 - 2035 -95 -300 CST BM Elev: Insp. BM Elev: BM Description: _ Section/Town /Range /Map No: /p0 �j f G5 I 24.30.20.473A20 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER i CAPACITY STATION BS HI FS ELEV. Septic I r Benchmark 0.38 q7.4C Alt. BM 3 • � Z q, � 7 ` T Bldg. Sewer a 50 - n Holding U St/Ht Inlet 1 _ 1V TANK SETBACK INFORMATION St/Ht Outlet 98 � 7 - 3 TANK TO 4 2L WELL BLDG. Vent to Air Intake ROAD BW=il t Septic / Dt B tt m P': (L.,, 7 50' . lO � ) � ` / Header /Man. '7. � Sd - Z Aeration G/JO�I�, Dist. Pipe 7 15 6.02 Holding Bot. System b 815 -oz (3k Final G de PUMP /SIPHON INFORMATION W 3 '73 . - 7'Z - Manufacturer Demand St Cover GPM efa ✓► r' 3. ) Z g S Model Nu TDH L Friction Loss System H DH Ft Forcemain Length Dia. I Dist. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length / No. Of Tr PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Qgpth DIMENSIONS 3i l revt e" �' SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: /+ , I I INFORMATION CHAMBER OR � V7a Type f System; x k too J� ! UNIT Model Number : DISTRIBUTION SYSTEM 2a�- /�d - /�y / �/ •- 5(� Header /Manifold j Distribution t; Pipe(s) \ ` \ ` 3!'. f f Leng Dia Length \ Dia Spacing a .-- SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only 9 Depth Over Ri Depth Over xx Depth of xx Seeded /Sod ed xx Mulched Bed/Trench Center /1 Bed/Trench Edges Topsoil -- I es N No Yes ® No Y COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 291 Arbor Hills Drive Houlton, WI 54082 (NE 1/4 SE 1/4 24 TON R20W) Arbor ill sLot 3 No: 24.30.20.473A20 " ro 1.) Alt BM Description = F'l.�c� 6 �^- �+Jl,. dz 42k, buy j 2.) Bldg sewer length = I - amount of cover = X� S�'i •� 4we Plan revision Required? Yes V(No Use other side for additional information. SBD - 6710 (R.3/97) Date F . Cert. No. P r commerce.Wi.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 St. Croix sc n s n Madison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.) t r i Department of Commerce Z5 Sa�hitary Permit Application -- _`. stat Transaction Number Nk In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate`gbverumental Project Address (if different than mailing address) unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are 7f' submitted to the Department of Commerce. Personal information you provide may be used for secondary Same Z / purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. , / ,�� I. Application Information — Please Print All Information 1 S Property Owner's NameO Parcel # / 030- 2035 -95 -300 Ross W. Coerber Property Owner's Mailing Address - . Property Location A1 14 Za �T GRQI NWT 0 291 Arbor Hills Drive F1G� Govt. Lot I City, State Zip Code P NE ' /,, SE Yd, Section 24 (circle one) Hudson, WI. 54016 715 - 549 - 6558 T 30 N; R 20 E or W IL Type of Building (check all that apply) Lot # El I or 2 Family Dwelling — Number of Bedrooms 3 O Subdivision Name Block # Plat of Arbor Hills ❑ Public /Commercial — Describe Use mod. Na ❑ City of ❑ State Owned — Describe Use CSM Number , / 9 El Village of Na V z61 ❑ Town of St. Joseph III. Type of Permit: (Check nl one box online A. Complete line B if applicabl �( A ' ❑ New System Re lacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) Y n1 P Y g p Y g Y ( P ) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner ld- IV. T of PdWTS S stem /Com onent/Device: Check all that a 1 In a on- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Information: 56 Infiltrator "Q-4" standard chambers & 8 endca s, Wieser Concrete filter canister w/ Pol Lok PL -525 effluent filter Design Flow (gpd Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Pro pos (sf) System Elevation 450 gpd /' 0.40 gpd/sq. ft. V-11- 1125 sq. ft. .11, 1,143.20 sq. ft. 89.00' / VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units ° o o New Tanks Existing Tanks I� . c Y Y A W Oa OG SZ a. U &n yr w Q 0. Septic or Holding Tank Na 1 0 1,000 1 Weeks Co crete X Dosing Chamber Na Na 1 Na Na VII. Responsibility Statement- I, the unde igned, assu a responsibility for i lion of the POWTS shown on the attached plans. Plumber's Name (Print) a tu a MP/MPRS Number Business Phone Number James K. Thompson i MPRS 30021 715) 248 -7767 Plumber's Address (Street, City, State, Zip Cod 340 Paulson Lake Lane, Osceola, WI 54020 VIII. County/Department Use Onl Approved ❑ Disa roved El Permit Fee Date d Issuing nt Signatur r e1A Lit Reason for Denial $ / 7, , IX. Conditiylq r f #%K& easons for Disapproval 1. Swic taMt, efpt i►.nt f+lt@r and d'is�a»iiiirnusf.�lt aisrvlfcea " /i�,aftnalned 69 per mahageht►erA plan provided by plumber. 2. All setback requirements must t,� mamtamed Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x 11 inches in size SBD -6398 (R. 02/09) Valid thru 02/11 1 eda/ua- F, / o. •E b � tt o - �2g�iU �.%e 1 4J4a , 6'or, r 0. � br O'co n n t I l 7/09/92 ♦ Ex••s4J�F yraafe .291 U /,o6 3, c s+h ✓eC.9, R� �sr9, r��yv sE Sew. zs, r. JoK, ,P zow, rm. ofsE axph, sE - cr Otx (2o., cc)/. a : A Il lab / ; ,ies arc > /co • f-rcm , & csf.ed a -- Fa. PrcposF�oC;s/oIKS&Ice/ /. /o rb /r N;(Is LLriVL ,e, (q) r-kcs Q,1: 'o -s!" wadded �Q/e� fvbc sB9.�1 _i`r'e eccv �92.s/' i 1 t � `� pi ✓tnion i �. E /C ✓. [i4- o"'ve -t r ndeit A5Jr(AMed eW. = /Ct%O 9va' � EXiS'Etr7 wcedec� `; 3 n, & dence - P. 2, {/✓ 5 1 o'ee nntll 7 /oy /9z ♦ Ex.'s�1� rook [.l e6 ScR /e. / = vo ,Qoss u). Cn..r b c r (� �9 1,4rhof 44 / /5,4-: -v / S 2, /.o 3, Gs ni ✓e(. 9 ,p 2. 0 a2., - rn, c rSh -JbSVA,, 3E - cro�x Co U) tt PSI. X030 - .�o3S= 9s 3� du,: A From �Lsttd a.rP_4.. P�oposecl d;sPcrsa/ c, //. A b or P lb s Lori x- �ui(y�fy[nc��s ctf 3 Wooded 'x s8'ua' / � y r BoC�rn oFS,d�na /aei Y's f�r✓1 .'�'�� ll ecr�39 .2.51! Bred. ,!v be = 89.E i' 9yt� o i ' i o pan .Sa.-Ace � r YI ✓ erwon � �` i ; � VQa ✓C q � i n✓ot ` ° ,arcs co.,crec �� \ �•/ isEu'�a/ � To ���, /. Ile �� EXiS'EinV � br u.sl� a6' � �es,dencL r awn y . � Conventional POWTS Index & Tilte Sheet Project Name: Coerber 3 bedroom Replacement Conventional POWTS i Owners Name: Ross W. Coerber Owner's adress: 291 Arbor Hills Road, Hudson, WI 54016 Site address: Same Project Location: Subdivision: Lot 3, Plat of Arbor Hills Legal Description: NEt /4 Kim, Sec. 24, T.30N., R. 20W., Town of St. Joseph, St. Croix Co., W I. Parcel ID #: 030 - 2035 -95 -300 I Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Dispersal Cell Sizing Calcualtions Page 4 System Cross Section Page 5 System Management Plan Page 6 Filter Specifications Page 7 Treatment & /or Filter Tank Cross Section Page 8 Parcel map Page 9 Septic Tank Maintenance Agreement Page 10 Certification for Utilization of existing septic tank Page 11 Waranty Deed Attachments: Soil Evaluaiton Report Mater Plumber Restricted Service: James K. Thompson, Dept. of Comm. Credential #30021 Signature: Date: Page 1 Of 11 Design pursuant to In- Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD- 10705 -P (N.01 /91) DISPERSAL CELL SIZING CALCULATIONS 1. Q bedrooms)(] 00 gallons estimated flow)(1.5 design factor) = 450.00 Gpd design flow 2. Infiltrative capacity of native soil = 0.4 gpd/sq. ft. 3. Absorption area required: 1,125.00 sq. ft. 4. Absorption area as proposed: 1,143.20 sq. ft. (56 chambers total) Infiltrator "Quick 4" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4" end cap (pair) = 5.80 sq.ft, EISA 1,125.00 sq. ft. — (4 pair endcaps)(5.80) = 1,101.80 sq. ft. 1,101.80 sq. ft. /20.00 = 55.09 chambers required Number of trenches: 4 na, 14 chambers per trench Trench width: 2.83' Trench length: 58.00' Trench spacing: 8.00' on center Total system area w/ 5' trench spacing: 27.00'x 58.00' 5,0er",Sa / FT �rlo Sca ^ 0 � q V42,16 4 f pteEonPoit rnsp�cb�N °mot v El ` K f N l O r 1 --pe V O O h Pg. 3 of l 1 wo d J i F �h , i x � W O > 2 i v ■vim � � � � � JJ .� d r■ 3 - - ^� ems: a Li w P > 1FA!r■ Q T Q won D 4 ' —r W ■ 0 �in a .. .r■ Q ' °'■'■ O ■ saw al®■ a J 8 a , r �+ -_ 6F I o N Al - o � f Conventional Septic System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shalt be maintained in accordance with component manual SBD- 10705 -P (N.01/01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with bottom of tank to be S 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. i Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October- March) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a two - year /1 -year schedule by use of diversion valve. Effluent to be diverted from new dispersal cell to old cell at 4 year anniversary of new system installation. Old cell to be utilized for a 1 year period. Afterwards, effluent dispersal to be alternated between cells on schedule to allow use of new cell for two years and old cell for 1 year. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to the installing lumber, Jim Thompson at (715) p Y gP 248 -7767 or the St Croix County Zoning Department at (715) 3864680. . SoF /l EFFLUENT FILTERS POLYNOX "The PL -525 has 525 linear feet of 1/16" slots. It has an automatic shut off ball. When the filter is removed for cleanin the ball will A" "" Accepts PVC g, accessibility < — _• extension handle float up and temporarily shut off the system so the effluent won't leave the tank. No other 52 line., feet filter on the market can make that claim!" ol, liltratlon sluts - Rated for over —° 10.000 GPD Accepts 4" & 6" SCHO. 40 Pipe n f - Gas deflector ! ._e Automatic shut -off ball when tilt., Is removed "The PL -122 has over 122 linear feet of 1/16" slots. Rated for 1500 gallons per day, and < Handl „2 "PVC Handle can be manifolded together with other PL- Alarm Switch 122's to double or triple the GPD. It has an 122 Linear ft. automatic shut off ball that stops flow when — ' of1/16inch Filter Slots the filter cartridge is removed for cleaning. Comes complete with it's own housing, no Filter Housing gluing of tee or pipe and no extra parts to with 3 &4" Pipe Adapter buy. Gas Deflector Automatic Shut -Off Ball When Filter is Removed From Tank Order # Model # Description List Price PK -525 PL -525 Effluent Filter System 203.50 PK -122 PL -122 Effluent Filter System 62.50 6 -10 Cl 133HS311A 99 - vg - 5Z� - 008 SOOZ 'NVr 'n36 8002 ),8vnNVf :31V0 OSLK VA ')4008 N301VW 'OIAMH sn 91LfM iynNVVI OI1d3S �\ 1MS:Ae NMV84 313U91100 = o 31Vo 'ON A3'8 1 313'M llt/130 �i31SINbO 6311U Ln \ a ~ } Z_ O U� _J Q Q Q J W W O (f) L +I ry F- < Q r- W� W W ry p Q U O L w z Z O IY C W Q U O C) U N J W Q W � W M I) W f N Q _J r r _J U 0 Q av w N � Y W O W O 2 Z @ L) L £ J �. a J 0 Q Q. 1 W N W J a_ NIW „S l W \ p p :M ~ Z o Q W = r U J �* J a W U J Z M Z Z w01 9 nN 1L� m p N �Q I U J0: iD O Qw Z Z I W Lo J ZWJ I �I of Q QZW Q ?r W N w 00� QQN 0_ W UU n W n. N Q „�£b ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify hat I have in the existing s and/or s an y p g p o do t presently serving the followin g residence: (Street address) 291 ,�r,�or- ,g- 1/s kOoao/ located at: 4 c — 1 /4, S ,5 '/4, Section .2- , Town 3o Range . W, Town of 5f . - tascpl- , 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) appear(s) to be functioning properly. Most recent date of inspection or service s/o & //y - -r Did flow back occur from absorption system? Yes k No (if no, skip next line.) Approximate volume or length of time: gallons " minutes Tank Capacity: 6m Construction: Prefab oncrete Steel Other Manufacturer (if known): eL)g4 Coicre- e Tank (if known): _ 16 vea' -'s ermit n amber (if known) .2O89z/ rcensed Plumber Signature) (Print Name) (Title) (License Number)' MPRS (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 �. 10 2209 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page I of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations Attach complete site plan on paper not less than 8'% x 11 inches in size. PI stn St. Croix include, but not limited to: vertical and horizontal reference point (BM), di nci<' j percent slope, scale or dimemsions, north arrow, and location and distance� County ares Parcel LD. � ,���``'� -.- 030 - 2035 - 95-300 Please print all information. � ° ,�„�„ Review By Date Personal information you provide may be used for secondary purposes (Priv 5.04 (1) (m)). at Property Owner roperty Location Ross W. Coerber G vt. Lot NE 1/4 SE //4 S 24 T 30 N R 20 W Property Owner's Mailing Address L # Block # Subd. Name or CSM# Q� i 291 Arbor Hills Dr. 3 Plat Of Arbor Hills City State Zip ode P Numb8604� 1G , City J Village � Town Nearest Road Hudson i WI 54 6 W9 lii O1 St.Joseph Arbor Hills Dr. 64 4klkz�� New Construction Use: tol Reside umber of bedrooms 3 Code derived design flow rate 450 GPD tj Replacement J Public or commercial - Describe: Parent material Glacial Till Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for conventional POWTS dispersal cell wit 91pd /sq.ft. /day loading rate. Proposed trench elevations to be 89.00'. Borin g # - I Boring NJ Pit Ground Surface elev. 91.49 ft. Depth to limiting factor >84 11 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fe in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0 -7 1Oyr3 /2 none I 2fgr mvfr as 3fmc 0.6 0.8 none i 2 7-20 10 r4/3 sl 2fsbk mvfr cs 2fmc 0.6 1.0 Y 3 20 -26 7.5yr4/6 none scl 2fsbk mvfr gw 1fmc 0.4 0.6 4 26-46 7.5yr4/4 none sl 2msbk mvfr gw 1fmc 0.6 1.0 5 46 -60 7.5yr4/4 none sl 1msbk mvfr gw 1fm 0.4 0.7 6 60 -84 7.5yr4/4 none sl lcsbk mfr - 1fm 0.4 0.7 �I Fil Boring # Boring J 3 601 Pit Ground Surface elev. 92.63 ft. Depth to Limiting factor > 114" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfN in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -5 1Oyr3/2 none I 2fgr mvfr as 2fmc 0.6 0.8 2 5 -24 1Oyr4/4 none $I 2fsbk mvfr cs 2fmc 0.6 1.0 3 24 -38 7.5yr4/4 none sl 2fsbk mvfr cw 1fmc 0.6 1.0 4 38 -50 7.5yr4/6 none Is Osg ml gw 1fm 0.7 1.6 5 50-100 1Oyr4/6 none s Osg ml as 11fm 0.7 1.6 6 100 -114 7.5yr4/4 none sl 1 csbk mfr - - 0.4 0.7 Effluent #1 = BOD 5 > 30 < 220 mg /L nd TSS >30 <) 150 iing/d Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L CST Name (Please Print) I Signa re: CST Number James K. Thompson s..._ 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 4/28/2010 715 - 248 -7767 I _ Property Owner Ross W. Coerber Parcel ID # 030 - 2035 -95 -300 Page 2 of 3 3 Boring # J Boring 001 Pit Ground Surface elev. 91.88 ft. Depth to limiting factor >88" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -6 10yr3/2 none I 2fgr mvfr as 3fmc 0.6 1 0.8 2 6-24 10yr4/3 none sl 2fsbk mvfr cs 2fmc 0.6 1.0 3 24-42 7.5yr4/4 none sl 2fsbk mvfr gw 1fmc 0.6 1.0 4 42 -66 7.5yr4/4 none sl 2msbk mvfr gw 1fmc 0.6 1.0 5 66 -76 7.5yr4/4 none sl 1msbk mvfr gw 1fm 0.4 0.7 6 76 -88 7.5yr4/4 none sl 1csbk mfr - 1fm 0.4 0.7 � d 1 F—I Boring # --� Boring 3 J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots = in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Etf#1 *Eff#2 ❑ Boring # J Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GP in. Munsell Qu, Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg /L * Effluent #2 = BOD s 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) A.C.E. Soil & Site Evaluations • 1 O 'Con At It 7/o9�9Z • �!'CL4 I-jZP " -Scale- ,Qa-s u). e, -6cr (� 91.4F'dwr /,/, • / /,s O //oc�.C�Eoi1, cJ /, S�l08Z, /-o 3, C.s ro ✓e(. ,P z 0cv,, Tn. ofS�,tosC/oh� SE • C -roi�c Co c.c� /. 74 030 - 9z35 P'.S --30 ou¢_: 4 d /ct /, - ,es are- > /cc)' �'rcr» f�Sted arf4. A L wac�dc.d 0cC�6om o Fs, d,�� �� ��' , �,�' etch• ?92.s /,' i . o pan , ` \ O! i ', �X/.7fJrYf cvev�'s 10a7Cre u `ai !� % E/ed, at s nJe/t: of \J •xd i�?6/,C/ 62 % EXi.S 6'i1y b��ctl� ape'- '� ieea,dence. \ \ P�. 3W3 STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER /3o_Ss MAILING ADDRESS ri PROPERTY ADDRESS Ille l ' , le" i l' ' (location of septic system) Please obtain from the Planning Dept. CITY /STATE l�c���✓ Gt/i SCditJS' //V ay PROPERTY LOCATION 1/4, 1/4, Section N -R � W TOWN OF e ST. CROIX COUNTY, WI SUBDIVISION A/Zt30/Z /Y// LL S LOT NUMBER `S CERTIFIEDSURVEY MAP q , VOLUME / , PAGE o? S /9 � LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. 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. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and r me to the St. Croix County Zoning Officer within 30 days of the three y expi tion da e. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11193 OOCUME'NT NO, j nu:; t.rncts rrccLiwcu 1 11CCORUIIIU onrn WARRANTY DEED H STATE BAR OF WISCONSIN .00RDI '2-1982 - 51348 SAM E. MILLER, a single person, Grantor < �.. - - - - - - -- - - - --- --- - - - - -- - - - - -- - -- - -- -- - ---- ....._ -- - - .. - -- - - - -- - -- - -- - . -- ---------- FEB 2 8 1994 conveys and warrants to .. W COERBER a sin le erson , ....- - - -- -' - - - -- ...___.�....--- --- ...g..... -p � -- - - -_. � .. _ .. 1.0:45 A. i Grantee _ „___- Rq — — — -- •- - - - -• . ...... ........... — — — It f ��tlr0lAi s!$ ------- ------ — — ------•---- - -------- ----- ------- ------ --. - --'-- .. ............._._.........------------- ._•___........ .......................... .... ..- _ ------ .......... ..... ..._.. I. RETURN TO the following described real estate in ............... County, State of Wisconsin: Tax Parcel No- - -- ---- ---- -_- __ ----------- Part of NE of SEA of Section 24, Township 30 North, Range 20 West, St. Croix County, Wisconsin described as follows: Lot 3 of Certified Survey Map filed August 6, 1992 in Volume 9, Page 2519 as Document Number 486842. TOGETHER WITH and SUBJECT TO reservations, restrictions and easements and rights -of -way of record, if any. ;r This ------ .------- is not homestead property. (is) (is not) Exception to warranties: llated this _..._... - - - - - - - -- -- -- -- -- - -. day of ---- - - - - - -- - ebruary - -- - -- (SEAL) VF�:.�l”' °.G� -� -- -------- __ (SEAL) it _ - -- - -- - - - -- - -- - -- SAM E. MILLER - - ....... _._ ...._.. ' ............... ..............,.,.. (SEAL) .(SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature (s) - -_ -_ STATE OF WISCONSIN i t SS. - ----- - ----- - --•- -- ---- - - - - -- �f C ----County. oul 00 HueIg Ie60-1 uisuooSiM rubNudblln Mu Hva �yv L� uenu o�tvvnavin •saanjuuBis ataga molaq pa;uud ao padAj aq pinogs sipuduo hue ut SutuZjs suosaad jo satuum. 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X w 7 m n Z� m —a 1 90,£Sp£ON rl z > 0 / m C r $ M rt C OP lA S v C7 -a r E,. 0) :S ua C C,) ", > T En F - ct (D C ;7 0 m U) CA O O� � ABC' 0 -D 0 0 o NE} of the SE} of Section: 24, T30 R20W m �� rr�cg$g� CD � 0 0 c2 NWJ of the SW} of Section 19, T30N, R19W ° y O, {p - O 0 cD O O :3 N co d v d 1f A , i N r) ,� N c'z A SHEET 3 OF 3 SHEETS VOLUME 9 PAGE 2519 y n co) 0 c7(A 3 - 0 n c fir :E c o > > 0 0 5 V 7! a • ID ID � FF Ml .� (A O N (7 CO N O " • 5 m d u o w CO 3 m c°Dc m w Q CD ,O„ 1:2 -i m H W N N 0 O N C- `Al N v C 7 j Cl) O O '- O O w G < I �' CD O ( � a � 3 N � I 3 3 K ( O O C A Co O 0 N O O CD'f ...� < � O -1 CT N C—D 7 7 o N 0 N w U, N D ' N NI j o O O o CD z D W a ? cj y W a I "C _ _ CD O O p n o N CD ' 0 2 < ca N A w c A= N ,O„ c ° c ( 3 M A.AO 000— 000 °Y !tl O Z l � r • N co ; c < w D 0) :r 3 co 0 j v o T C 0 N G G O O CD CD 1 m 0) 7 CD CD N Cn N O1 O N E d N Z N w tD �i Z O Z (D 0 O D CD a Q D a U) m m m m �• C CD f0 N CD fp N c CD (D C CD fD w a a O. 3 7 3 7 Z CD (D f/1 O N O O A Z c a j Z � N m CD CD 0 CL 06 z o a Cl) y Z y Z < CD m CA w I I D o a N CL cc CC CD a G 7 d C N C CD 3 N c m CD a ° ao o a y m @ CD y =+ �, : CD I co 0 —' C ° N o a 0 m T a I CD 7. 1 � O fD N N — N I I 0 {n O � 0 I a X A O I O A CD CD hq ,CJ�D O Q O ~ ~ Parcel #: 030 - 2035 -95 -300 10/05/2006 04:35 PM PAGE 1 OF 1 Alt. Parcel M 24.30.20.473A -20 030 - TOWN OF SAINT JOSEPH 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 ROSS W COERBER O - COERBER, ROSS W 291 ARBOR HILLS DR HOULTON WI 54082 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description ` 291 ARBOR HILLS DR SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 3.010 Plat: N/A -NOT AVAILABLE SEC 24 T30N R20W PT NE SE BEING LOT 3 OF Block/Condo Bldg: CSM 9/2519 3.01 ACRES Tract(s): (Sec- Twn -Rng 401/4 1601/4) 24- 30N -20W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 1181/175 WD 07/23/1997 1179/481 SD 07/23/1997 1066/399 WD 07/23/1997 969/209 WD 2006 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/09/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.010 73,100 194,400 267,500 NO Totals for 2006: General Property 3.010 73,100 194,400 267,500 Woodland 0.000 0 0 Totals for 2005: General Property 3.010 73,100 194,400 267,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 221 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER _4.S Lie e ADDRESS E ---D91 SUBDIVISION / CSM# - - LOT # �_ SECTION _ N - R , ,,,� W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM G Sb wF'� �KJawfy INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. I I BENCHMARK: ALTERNATE BM: i SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Wel House Other Pump: Manufacturer Model# Size Float seperation Gallons /cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length !�Tn Number of trenches Distance & Direction to nearest prop. line: Setback from: well: S3 House �� , _ Other ELEVATIONS Building Sewer ST Inlet 7 ST outlet PC inlet PC bottom Pump Off Header /Manifold 9�S_5 Bottom of system Existing Grade �� b Final grade DATE OF INSTALLATION: I PLUMBER ON JOB: LICENSE NUMBER: _ _DS INSPECTOR: 3/93:jt W o ss aleez"Cle ,Ili �� s�' �� s;� � > ✓� , LJ S'y08.2 �S I /8 ii �/ousi= h.2.. g� t L t e �+`par��+,t o1�tr��r�? 430 'VA� 'SEW/1►GE�YS�t l Hi M County: Laborand Human Relations INSPECTION REPORT Safety and Buildings Division ST. CROIX s- (ATTACH TO PERMIT) Sanitary Permit No.: 'GENERAL INF 08921 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: St. Josenh ev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9400042 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic GI%�.1�_s J p �) Benchmark Dosing Aeration Bldg. Sewer Holding St /Ht Inlet j (�(, - TANK SETBACK INFORMATION St/ Ht Outlet qt s�,b TANK TO P / L WELL BLDG. Air i to ntake ROAD Dt Inlet Air Septic 7d�� - �,/ ®[ /z NA Dt Bottom Dosing NA Header /Man. Aeration NA Dist. Pipe Holding Bot. System &„g 3 57, S- 0 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand j ] �J �r 7/ Model Number GPM TDH Lift Friction Syesatem TDH Ft Forcemain Length Dia. IHf Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trerl> hes PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS `� ' /� DIMENSI N SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer: INFORMATION Type O CHAMBER Model Number: System: __61P Mo t OR UNIT DISTRIBUTION SYSTEM Header / Manifold I Distribution Pipe(s) g I x Hole Size x Hole Spacing Vent To Air Intake Len Dia- I Lengt Di a. S p acin SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over 1 Depth Over n xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center 3� Bed /Trench Edges r� `� Topsoil ❑ Yes ❑ No ❑ Yes ❑ No O,MMENTS: (Include code discrepancies, persons present, etc.) LOCATION: St. Joseph.2j. NE, SE, Lot 3, Arbor Hill Drive �,�,r ... art J Plan revision required? 0(Yes ❑ No I L: Use other side for additional information. SBD -6710 (R 05/91) Date U Inspector's Signature Cert. No. r SANITARY PERMIT APPLICATION OILHR COUNTY In accord with ILHR 83.05, Wis. Adm. Code STATE SA ITA P # —Attach complete plans (to the county copy only) for the system, on paper not less than ' Q C l 2— 8% X 11 inches in size. 1-1 Check if revision to previous application —See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. PROP TY OWNER PROPERTY LOCATION N, or PROPERTY OWNER'S MAILING D ESS LOT # BLOCK # CITY, AT ZIP CO E PHONE NUMBER SUBDIVISION ME OR CSM BER II. TYPE OF BUILDING CITY : (Check one N REST RDA ❑ State Owned VILLAGE - ❑ -# Public 0 1 or 2 Fam. Dwellin of bedrooms -� x N III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 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 in line A. Check line B if applicable) A) 1. 0 New 2. ❑ 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 ## _ 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 El HoldingTank 12 rD El Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /'nch) ELEVATION 7 Feet Feet CAPACITY VII. TANK Site INFORMATION in allons Total # of Prefab. Fiber- Exper. New istin Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdina Tank O Lift Pump Tank/Siphon Chamber Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installatio of the onsite sewage system shown on the attached plans. Plumb 's Nam (Pr ):. Plumber. Sig tur �(7ta� MP/MPRSW No.: Business Phone Number: umber' Addr (Street, City, Stfite, Zip Cod ): IX. COUNTYiDEPA TMENT USE ONLY ry Disapproved Sanitary Permit Fee (Includes Groundwater D a e sue Issuing Agent e m Approved ❑ Owner Given Initial d G Surcharge Fee) 3 l - Adverse Determination �� X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS ., 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must 3e approved by the permi` ;,,suing authority. 4. Changes: ;r, :.1w iership or plumber requires a Sanitary Form !,8BD 6399) tc to su' >, `, lo prior to im ,tallation. 5 . ifeust bE- +_rig 'P'- ' rf!a he iC tan-. = -t be ;`: o d.by a licens }d r-ei,essary, usually every 2 to 3 years. 6. If you save. Questions concerning yu r onsite sewage syste ,, contact your local code - , -Irfiinistrafor Cr the - state cl Wisconsin, Safety & Buildings Division, 608- 266 -3R To be complete and accurate this sanitary permit application must irlc'.ude: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the F;vstem is to be installed. II. Type of building being served. Check only one and compieto # of bedreoms 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 in line A. Complete line S if permJ is for tarn replacement, reconnection, or . repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1 - -7 VII. Tank information. Fill in the capacity of every new and /or exiting tank, list the total gal :ons, number o' tanks and manufacturer's name. indicate prefab or site constructed anc tank material. Complete for al . septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks rece :ved experimental product approval from DILHR. VIN. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (o.g. MP, etc.), 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'% 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 <.Ilk-va °ion rMerence points; C) complete specifications for pumps and controls; dose volume; elevation cJfferences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the so l 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 Gurcharges (fees) for a nurllr,�r of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitor ng gro : ac , -eater. _i ound- water- contamination investigations and establishment A standards. - i SBD -6398 (R.11/88) � ;s o` v7� r , .6 3s i r i`' PA6C or ro 80 4 V e16940 11 x It IMN'fl��• Vwu ►y ' r . ' !M___l�INi 0. fr•uytlt �i••w111• �•�;'', • • • ! • r 0• jyttMq•U •,r � r • .c • fl•Nl�d {�� ' • �-• Too ` ' ' f•w.q� Iqo • • ►alw•r•o IIp YN•• w • �CwMlw� T «wIn.IM! AI 4061941 of gp$$* Pro u s e. to Fins-1 grhcl-c Mt, FILL' ®IA PIPE APPRO'IED S 19piCTIC COVC 2 "OF AGGRJ6 6AIs •-� IUTZR OR V OF $TItA%. OR MARs1• NAy ELEV. OF a FE Y._•.. • , "aPi -t'� � ^rt '� //� ,,,• DISTR►pyTIVIJ P1rt,T() pC AT 4CAiT -, 'wCHCS SCLOW ORwisiAl, •trt1►OE AUt! AT LCAiTtO IWCHLZ OUT LIO MORC THAN yZ 11 4C t1LLOW fINAI CItAOC I XUwM "PT11,0F F-XcAVATIOP FROM OK16VAL 6RADA WIL1. eC - _ IWCHCS tV?(1MVM OEF n1 OF EXCA FAO^ 1 4111 �► AL CjRnDjL wlt.t. 8C 1! gIG1.IC0. . LIGCWSC LjUjA OgTC i • / K'•tf not•n t)f OJ'1 r• OI In0u11rT, "'. >vi and human Rtlaltont 11 V 11 Ut bt mt 1 Iv, t t1{ 1 1✓rt t (Attach Soil Profile location Map • To Scale • On A Stperett Signet! Sheet) '0 40• �'� 1. b; •ol {v gulf."L Il e rWYy /, � • , % 5 S ._ / _ C.t • ' Ne tO.Vt I W I Mb V K1 : p b { tee a y ►c*w 1 "./ Cdlrflr n ^- M t I OaOM 0 r a a r / Iw nt.Ititt.;te,< It , r R lOT ' • CS4l ` � _# _ _�� BLOCK " lu801v1 1 � OH % Morton d. M1� _ alllaCl Oroln DOmtn•nl color MQttlrl SlruUuff In Mvn� ltll T onl I r Ttlt r _Luna r htNuAll f agar leas ^1 o t ;44, e. Gr, I. h n t l n Ro h•wt11 Qr0 ICY = Jl _ 2L.11 - ? ., r � — f l� 3 MOr.len O•eln Oorntna M • lot 1{ r Or S h. n l Ifn A 1 o n r hmtnel ►laen leaew/ O►o►a n Owu ir•ntli 0•a Icy . _LL� / 1 . • - f7 - At Color .1 In Motllet Slrv <Wr1 ' Murr ell — 1. of r 1 a ++�. r Gr 1 h n I n ^ 1 n0a llr^rOp luew/000•o n, 11•KA 6•d 'I cy a jj -, 0. r.i J . ,� I Morton Orotn Oornmenl Coto, In Moltl•1 Mvn ell M . Color 1 ,, r 1lrutivle j Or h n l n R o l 1 n Umluwe Iatlarl lwsw•O1ptq e , 1 Orolri tr•Ke M•1 ilev .r 7 (} . nor,ton Oroln �Oomrnanl Color In M n ell Molllf - SIIUtIV /e i on . I r 1 t f r h llrttfnnl fatlta► laewt0►Oa n n i n R %% =ICY 10 nda Owtn 1rtKn / Al * Addrltonal Ilemarltt: PECOMML•NDED SYSTEM TYPE: t I ' Olnf f Site f ellulf l: I y �• S �Icm i n c ICV Y E il10n 9 v • 614 signed I l l CST HI►m1 (P(kll) Cllr $1410 zip 1 • .t .•, c I j t l i ;. i{ 1 i f l l i l l l i ��i , I P N _ I I i _ I � !. 1' '.1�c� 7'•U.�., 1 •: ,.� / ' I I i� I __ I I I I I I I{ I { , ( i _ i -- : -- •` ��y.. �l�,, -1 � -, -� I _ I - i i `• ``'i I _i I I I I I ( I �_�' � ' I I I _ TT ; I t, - •,•1 �� - ' 11.', !i fi i1 ►1111 i - - - , if .- --` I 1 I- I I I I 1 I 4 �- , -- I I � fit i I'' - - - r- , — i I 4 i I I i . l _.i_ ! i � i! I � 11 I I I► I ( -I 1 1 1 i f r ° C) L� z C F - C, �C) H M I N VOL 8 /- 2 1 / I S00 11 W 650.641 _ r V / �1 IC) a 100/ �o I(r r, ~ O O • N f9 3 3/ I 7 � �a ^ w m 1 _ y ?90 o l< ry- o ti «- w J (N o r-- 0 0 I cn z w C, — Ct.1',N0 IG7 c c 0 0 t'f• O V N ...... • �O �� Ca O $. rt I LC r w ry + / ® y -n rt rn O r t. P. 10 z w 31180 �£g ©, m 0 b 0 t r m -n i 4 � sy i�� Cl ft (D 1680►£S £ON i M tij do � / m Z r• n N• N � � i C Y Cn la, b 0" N H rt (D < 0 rya fn ` �, n N 7 m 0 Z O (D En - < Co 0 0 ,0 NE} of the SEJ of Section: 24, T30N R20W � m, 10J ���� (D 0) 0 0 c2 NWJ of the SW} of Section 19, T30N, R19W y a N (D O n r �� r m O O ! C d► rn r ,a. r v '�� O. ! r) a s rn y O / .II r a tr z rt ( D SHEET 3 OF 3 SHEETS VOLUME 9 PAGE 25 I DOCUMC`_NT NO, WARRANTY DEED "imq srnc.r. Iq'r4rnrvcu VnR vrer_01(Wnc uAiA STATE BAR OF WISCONSIN .i" ORM '2-1982 • 513485 SAM E. MILLER, a single person, Grantor -- --------------------------------------- ... ......... --- --- --- - - – -- f f 1• � f II I --- - -- -- - - -- - -- - - --- - - - - -- - - _ ----------- -- - ........ -- - - -- - - -- ! FEB 2 $,, 1994 conveys and warrants to ROSS W. COERBER, a single person, 10 A: Grantee .. - -- .... . - -- - - - -- - - -- ----••----•---------------•-------------------------------- •------- - - - - -- ---------------- - - - - -- RisterollSEl�d3 - .... - - " -- ..-- • - - - -- - •---- •--- •• - - - -- ---- ------ ----- - -_ - -- ........ • - -- - - -- _ � RETURN TO . ..........................------------------------------------ .------------ . the following described real estate in --__._- _ St...- CSO1X------------ -- - - - -- _County, State of Wisconsin: Tax Parcel No: .............. .--------------- Part of NEB of SEA of Section 24, Township 30 North, Range 20 West, St. Croix County, Wisconsin described as follows: Lot 3 of Certified Survey Map filed August 6, 1992 in Volume 9, Page 2519 as Document Number 486842. TOGETHER WITH and SUBJECT TO reservations, restrictions and easements and rights -of -way of record, if any. This ___ _ is not _ homestead property. (is) (is not) Exception to warranties: llated this _ - - -- - 1 J- ------------------- day of .- -- -- -- -- - -Febr - -- - --- --- -- - - - - -- -- --- -- 19--94 _. s �, - - - - - - -- -(SEAL) - --- -- - --- ----- - -- - - - -- ----------------------- _(SEAL) SAM E. MILLER r .....(SEAL) ............. .. ............. (SEAL) ---- -- ---- I AUTHENTIGATION ACKNOWLEDGMENT Signature(s) --- -- - - - --- --------- ------- --------- -- - - -- STATE OF WISCONSIN ,I ss. ------------------------------------------------------------- •---- . - - - - -- ST . CROIX - •--- --- ------ ----- --- ---- --- -- - - -- County. authenticated this ........ day of ........................... 19 ------ Personally came before me this __as�__day of - - - -- February- -- --------- - - - - - -- 19__9A.. the above named --------------- • - - - - -- - •------------ - - - - -- ------------- ••• -• -- i --•---•--------- •---- ••------- •---- - - - - -- -•-•-----•---------------------------- Sam E. Miller TITLE: MEMBER STATE BAR OF WISCONSI � - -- ----------- --------------- ---- •--- _• -' - - -- ..... (If not, ...... authorized by § 706.06, Wis. Stats.) r" known to be the person ------------ who executed the No my I- 'ng instrument and acknowledge the same. r THIS INSTRUMENT WAS DRAFTED BY Attorne -- -Barr C. Lundeen �, ......... .... . . . . .. .. ........ _------- - - - - -- --- - - - - -- . y �'..• .. L j") tj C chard F. Prokash MUDGE, PORTER & LUNDEEN, S.0 110 -- _Sec--nd Street Iludson_ .. G N. St -. Cro_ix__- _- _ - -___ -Count Wis. 3I -� y Public Y, g ! (Signatures may be authenticated or acknowle �, "tiq� , Commission is permanent. If not tire not necessary.) ' . ^date: January__19 _ --- state expiration 19.97 ) *Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. t FORM No. 2 — 1982 Milwaukee, W S T c - in This application form is to be completed in full, and signed by the ovnicr(s) of the property being developed. Any inadequacies will only result in delays of the permit issua this development be intended for resale by owner/ ontractor, Douse), 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 /lass Location of property 61/4 .SE 1/4, Section P T N -R W .Township 573' Ts Mailing address r Address of site a?9/ 4 21,30X Subdivision name 14913OR x4a Lot no. 1 . other homes on property? yes X No Previous owner of property - 5A, , - f Total size of parcel AC r�[ Date parcel was created _ xuqus'r ', AY 4 Are all corners and lot lines identifiable? _ Yes No Is this property being developed for (spec house)? Yes ,X No Volume / and Page Number as recorded, with the Register of Deeds. ------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARILMITY DLED which includes a DOCUHEHT NURBER, VOLUME AND PAGF. 11UHUI,R & THE SEAL OF THE I EGISTLI 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 referencoa to a eortified survey Map, the certified survey Nap shall also be required. PROPERTY OWNER CERTIFICATION I(wc) certify that all statements on this form are true to the best .of ny (our) knowledge that I (we) am (are) the owner(s) 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 11o. 'S/f1 9' 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 t s ' orde;l�e of• ce of County Register of deeds as Document nature of'ap i.cant Co-applicant t Da Eel - a — f - M g ture Date of S gnature STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER /loss C'aER$ MAILING ADDRESS '- 0 U9'_� WO PROPERTY ADDRESS Xfi 661i� }/ /LCS (location of septic system) Please obtain from the Planning Dept. CITY /STATE _ et Eevv i6-d6A.S 1/V - ay PROPERTY LOCATION �_ 114, S 114, Section T ..3D N -R o9 W TOWN OF l �oN ST. CROIX COUNTY, WI SUBDIVISION f7 2�CiO12 �Yi LL S' LOT NUMBER � 3 CERTIFUD SURVEY MAP , VOLUME I , PAGE , 9S 7 9 , LOT NUMBER 5 -a Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. 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. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and r me to the St. Croix County Zoning Officer within 30 days of the three y expi tion da e. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson WI 54016 11193 I 0 LQ g4T,;QVpartrt§,%rofhT9§VH 24.30.20 E �WAT S`((S RD. V bounty: Labor a Human Relations INSPECTION REPORT Safety a Buildings Division ST. CROIX ' (ATTACH TO PERMIT) Sanitary Permit No- 'GENERAL4NFORMATION 193354 Permit Holder's Name: ❑ City ❑ Village [R Town of: State Plan ID No.: ST. JOSEPH CST BM El&.: Insp. BM Elev.: BM Description: Parcel Tax No.: 030 - 2035 -95 -300 TANK INFORMATION ELEVATION DATA A9300014 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet irl Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss m ead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: SETBACK INFORMATION Type of CHAMBER Model Number. System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake 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 xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH 24.30.20,NE,SE, LOT 3, CO. RD. V A ql 4 rbly Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ` II -- SANITARY PERMIT APPLICATION � 0ILHR _a.,..�.,.v. In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # – Attache complete plans (to the county copy only) for the system, on paper not less than ❑�- 8% x 11 inches in size. Ch if evis revio application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION �Y4 %,S T O ,N,R b E(or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOC Z K # o x .# Z8Z ___? CITY, ST ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER aUs WX 9 II. TYPE OF BUILDING (Check one) El state Owned VILLAGE : NEAREST ROAD s r. A c ®. R�d(- v ❑ Public ipj 1 or 2 Fam. Dwelling -# of bedrooms :L R EL TAX N ) 111. BUILDING USE: (if building type is public, check T11 that apply) 1 ❑ Apt/Condo J 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 in line A. Check line B if applicable) A) 1. M New 2. El Replacement 3. ❑ Replacement of 4. El Reconnection of 5. El Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # — 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 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 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 REQUIRED (sq. ft.) PR POSED (sq. ft.) (Gals /day /sq. ft.) (Min./inch) J ELEVATION �SD �on 7Z ...1- T est Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdina Tank OOO f ten/ Lift Pump Tank/Siphon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): / Plumber's Signal re: (No Stamps) MP /MPRSW No.: Business Phone Number: Do k / S fro7�cc"t Plumber's Address (Street, City, State, Zip Code): D / IX. C TY /DEPARTMENT USE ONLY [] Disapproved Sanitary Permit Fee (Includes Groundwater D I ssued F1 Issuing A nt Signa No S m Ap Owner Given Initial Y proved # /� Fee) ❑ f � r� Adverse X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS . 11— A sanitary permit is valid for two (2) years. ` 26 Your-sanitary permit may be renewed before the expiration date, and at the 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 & Buildings Division, 608 -266 -3815. 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. Ill. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in 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 in ##1 -7. VII. Tank information. Fill in the capacity of every new and /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 plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), 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% 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, ground- water contamination investigations and establishment of standards. SBD -6398 (R.11/88) f S oa m m 11 t r A r 6 N o s t CA 3 co A -k e f rs" sf` � / � s� � /. = /oo ' Al a goy, tS _ �� QP Il 33� a S V N . I �h L„o i { t i I } 4 } ` Y N L� I 90 d ,Z6 \ 70 � d �J "W�O Su/) I u� KiN r... V rl c U Q4 ,p ! I' f I T m 0 1 � I t '1{ ` w (' rri Y I � � II c �o r 1i i i CD cr, trJ / CD / H 1J l z CD Ir o fV p U V IN V ��u L U G f V L 1 I ° S0 0 0 37 1 50 11 W 650.64 IE• ' / I V � / r / �1 Icr - I y � 0 0 • rt O p O ICJ 9, ,o Aj • I_� o 0 • r W \ r O r— !A En z t" IG� on G (t :9 N 0 ' rt to ti o m Ud y'n • A`C O f) I-- w of o -n '-1 0 G 0 `�• f+ I Q0 r w N .+ ( ® O 1 0 1 C•C w .•' 1 IF fA SL a c 'T' CD �� (D En :J O � n 0 1 F ? o rt i- I C) z W r 311801£So£OS (n 0 sy � rt -n k w �r m O rt (D 100'OOT wO �i�.V n z �r — Mn801£5o£ON r G tTJ -- n to / , � r•i, t ' :J id z 4`1'' e4- 0 d co to t c c NE} of the SE} of Section. 24, T30 N, R20W � i. ?7LC '�4 a ((D W CD ° NWJ of the SWJ of Section 19, T30N, R19W y 01 (D / (D 0 0 :5 f Lu 0 ( / CD > 0 �� $ 0 a I y 5 9 > ^ Lop a ¢ z rt -•u 1 (D VOLUME 9 PAGE 2519.1; SHEET 3 OF 3 SHEETS H ; M. III n L• 8 1 r 21 ° AIUNI S00 650.64 r - J 100, �O PQ CD s w OOy C-2 ? e O o f I ` IF- 0 co w i � Q to v d N W y h. • A'r O 0 ( �i '_ ....... 0 " (D r• r W N rt A 4 3ao0 n rn 00 n w rt 0 - 1 r - s-3 ►-h rt n 100 CON - n nj`r K A'Y' 0 d . / M / �* .�.'0 Cn f'h rt C rt (D rn O cn o N NEi of the SE4 of Section.24, T30 R20W \:' ( N 0 6 °= NW} of the SW} of Section 19, T30N, 19W `.�. y O, (D 4 ' o - 12 £ n rt rt O O 0 (n ~' E N (D C AC' (D CZ) ` w r f z rt - (� �..� 4 0 7 / SHEET 3 OF 3 SHEETS l __ SSHSHS E 30 T SH3HS M - 18 'ON •Coed jaae>IssIB uejj Aq pa;leip ;uawnjlslft sigj , 6LSZ SOU 6 zwn10A hZ not ;Dag 00z_ 001 09 o ,, .' � }o .1auJo0 3S S3H3 i�II 3'I'dOS = 111�iI� N � � N vA 7 ►+ W N r+ uAu 'H'1'0 M/a ° �EEi �� - 10A iii 61 hST 11So88S 3u6hs8 o68N 1 v I bZ uoi409S ®100' S IE 3 {3S a4 �o {3N a4� �o auti y;noS MiMiSTo6£N �Bn 196'82 a, 1to'IZ -�� egpegs;jenojWs 1E9'LZ _ 1LE ZZ /y� e3eP IeAOXS& • , \ ®100' S O� ,To sAup 0S tgknm Mu6h 18 068S PePjOl'� -� ul 1..Zri "MU-1w0 s*sed p ` pue 6u{uueld a Bsuayex#ulc.* 6 1 A-MOO WHO IS. o � 36. `9 (a`v rt O' ® 101 T 3 A _ y N O O m ° ° ° c nn uu #4- o C M V3nOG7C�t�V easy ysueW ` � - �r� �, °> ° F- o \� N O y v CD s c Dull joeg4aS AeMpeoa 12 a auTTDaua j 6ut4scx3 r , o' to Ln 0 o N • 4004 ,ieaull r y+ CD y led - sqi 89 6 ut4 610 n 1 `�Z� \ �� �� 1 3as ad ld uo�I 11hZ x u1 O o �)\ rt m O ` 0 co puno j adid uoJI 111 • C \ ` ` (D puno j adid uoJI 11Z • ° o s .\ w av punoj 3uawnuoN `��S\ ` Q H rt N e ° u0133aS A4unoo wnuFwnid ,)N\ P /t N AT hZ uot439 S lr 30 d0uJo0 13 N h 9i0hS IM 'uospnH 4 Pic SZTT (D fD uat 3jagob 1 �� bisz /d uic,? UarIMO u Fly 0 ,�,3..5'F�L • uTsuoosTM 'AqunoO N d XT010 -qS 'gdasor -4S 3o uMOy aq-4 UT TTa - J NO. ; £,L '6T not - 4oaS 3o hMS aqq 3 °fMS aqq PUP CMS 9 3 NMN aqq .3o q zed u pus TMOZU 'HOSS 'VZ u o z40 9 9 3o NHS 994 3o PHN aqq 3o gavd ui paieooq N M, ddW A3Adns G3IJUM y im "C" /o Sp6oQ N\ 10 IS,6D v7d - P ih oog .s6 s p 2 898 ll3U0,0 S3wvr c S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER ADDRESS Z9'L_ FIRE NUMBER �z CITY /STATE ZIP A0 /4 PROPERTY LOCATION: 3/4 � 1/4 , SECTION , T _3a N - R: Z : TOWN OF �� s.� -,d�- , St. Croix County, SUBDIVISION Zo.✓ %� /f , LOT NUMBER -_ Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. 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. The property owner agrees to submit to St. Croix Zoning a certification 'form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1), the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and SCUM. I /We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix Co. Zoning Officer within 30 days of the three year expiration date. SIGNED DATE: St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 K'•+(nn+.n Of ovit -001 01 Iroultrr. La hut" an Atli I,onl �VILUC�V11If �IV1111�I V1 %I (Attach Soil Profile Location Ma To Scill • On A Se irate. Signed Sheet) ` 9c• . • -� W; , \ . sue• ►apt got, I vy. 0a r f cuwwrr wo uv aff tOWN M0 Kt 4000 •1 CaLr 1 V- ✓y lilt 1.0+0 0 a BCAWC, t^ ru►Meww�l� R ,� CSur LOT ) BLOCK ,' % sult01VIs10N sC rear IllKat/ U • % nor ton Oto1h 0o Color MQnlff Slru<lurf In Munitll ..Cone Co! r ifU r Car. UPI Fade.. Laengt;PO •f n. r t. h, C n 111 n ! Ito 1 n 1.r 00I 110nCh 0.0 _7 Mot -Ion Otolh Oom.nanl Color Moll,Rl StrutlWf In Mvnlen Llrtrtlel tiller) L.a0ng000%a n on . Ipr T ! ► G►, S h, onu IM R H ton r OROU NMI% n Elev a - S t l d • Orlon OROth !om Want Color Mottles Structure In Munt 1.0 010 1eri re Gr, Un+IVnq ►eclair lauongGPOaQ n. t. % hh. n i t n Roo 1 nd/ Door% er•ntn fs.e Elev �U Al r (j , 1 Mor ton Depth Oom.nant C01or Mottltt jlrvtivrt f In Mun NI Unrunq i461011 Lea"GPb►a n .Color 1 f rtur0 Gr It. Sh . C omi llitmice R oll 89y rid ary Depth 1,0 0. f Elev : / • 7 Morton Ofolh OOrn rnAntColor Mo1111f In M n ell C ant. Co lor T c r 1. Structvrf Lln.unq taxed Lo•engOPpa,o n Gr h, n + nt R to n /r Depot, TrtntW d.a Elev • ^ < C S a _ - _: , -4 r 2 ma /1 ^,�� �-• (, ^� r Additional Afn+frltl: � RECOMMENDED SYSTEM TYPE: I — Olntt S+tf ltaWlll: I Sycicm Elcvation '• ^ +t1. lgnf ft► ill01INo. Clr • fill CST Nano (Print) ly 6tN• Tip , L �i I ,� � I i i I I � I I I t I i� - - -- :77 T I i t '4 V .0 L t -------- 7 000 - , i l I I! ! i I I� I I I I I 1 1 I' i -- - _��i i{ I i i i i I t FT I it I I 1 1 1 11 i I '�� I - { I -' - -- 77' FT i - FT T T717 s ' STC -100 This application form is to be completed in full and signed b he owners of the � owner( s) property being developed. Any inadequacies will only result in delays of the permit issua ,should this development be intended for resale by owner /contractor,(spec house) , then 1a 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 Se,h, Location of propertyZ/-4-1/4 54 1/4, Section ?�, Ted N-Rlg Township �-- Mailing address Zox 2�2- 11e. t�So i k/� �e �o Address of site Subdivision name _i�o�' /�� / /,S Lot no. - Other homes on property? _yes _ No Previous owner of property Total size of parcel _ D 1 f, C Date parcel -was created _ 7- & _ /7z_ Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ?,)( Yes No Volume and Page Number a0? as recorded with the Register of Deeds. --------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & 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 owner(s) 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. V jfr_r _ , 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 County Register of deeds as Document No. _5/8'gSG3 . Signature of applicant Co- applicant Date of Signature Date of Signature DocuMBNT rte. S'PATIC BAR OF WIStkGN9ttk WAR RAWn' DE ,? 488563 Th is Deed, us& 68twm . -!N'iFi.t..L.N. _ and.. ... ... ....... f� �M r.:f7ff "ilk ut ( i sit. Or "tor: ! G am . fL A _ .................. . ~._ ..... .. . ... . ...« .... . . «..... ...... .....................:i. . . .. .... . t#t..,....set .R cb..se c tos .... ..... .... .. .... . „JT3.s d�rratioa... ......... ....... .......... - ........__....._._._....__..... ._.._..................._..- i _ Gon"ys to (;r"%4 Bw ha wksdefarom real estate in ,.._8t._ amix........_..,_ :E A Wk ry (" Coonv. . o! iY: { 0) Bar ' - a A pesc a ter , � ttq, 1/4 cat the '�(:ft U IA of Section 24 . i�&2k4 described 4s U f It :! e+t' do On -tined savey ft filed is the Off 'Loa al: the 11e, 'fi►t D�* ad kost 6, 1992 in Vo 9: , PKw 2519 Tox , i4 deed in Pali P of a Land tbrgt�ac +° 4.A ;- :?a ,'s ¢'0:t r* ,.,. x 'tryBAor j ali - aa s la gd oz e 1 tL eredz$sawe:Tts and a parteaata.xs M 4t�1 4k [ndeieatsthis in fee simple and fret Rn3 clear of *j . qC nicerd f if aW, and the Protective _ sjvtC?r� 1r'. t At is Vbl. 86 PW 4M 4W W.! 483. _ .+tF rye [ 11w and' Wo$ tke $AWOL ' Dead j � .�,,..a.,+..,aa. •�-• • • -• - -- day of •--- - - -- -- - - -------- ,. 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