HomeMy WebLinkAbout038-1198-40-000 Safety and Buildings Division County oo e
201 W. Washington Ave., P.O. Box 7162 /X
SCOOSIII Madison, WI 53707 - 7162 Sanitary Permit Number (to be fill ' by Co.)
Department of Commerce (608) 266 - 3151 �ad ��
State Plan I.D. Number
Sanitary Permit Application
A
In accord with Comm 83.21, Wis. Adm. Code, personal information you provid A
may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Address /different than mailing address)
I. Application Information - Please Print All Information /331 � 1" " ' j "
Property Owner's Na a , , _ °) 4 Parcel # o Block #
Property Owne ' Mailing Address ) " ` Property Location
,✓� - 7 �/ A �
City, State Zip Code P�¢rte Number lY-
J � 4 - ..,a__J 3� / (cir oo;. T N; IY // E
II. Type of Building (check all that apply) / S
or 2 Family Dwelling - Number of Bedrooms �T.,.�AG�� Subd' vision Name CSM Number
❑ Public /Commercial - Describe Use �' tel. )� ,p
❑ State Owned - Describe Use : ❑City_❑Villageownship of i
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
❑ List Previous Permit Number and Date Issued
B. ❑ Permit Renewal mit Revision Change of ❑ Permit Transfer to New
Before Expiration Plumber Owner y a O /' / 3 12-61
W. Type of POWTS System: (Check all that apply)
- Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter
❑ Constructed Wetland ❑ Pressurized In- round ❑ Holding Tank El Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter a hing Chamber ❑ Drip Line ❑ Gravel-les§ Pipe Other (explain)
V. Dispersal/Treatment Area Information: Z2 B fkvi r'
Design Flow (gpd) Desiyp4oil Application gpdsf) Dispersal Area Required (so Dispersal Area Proposed (t) jlSystem Elevatio
PEEP& V3
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site S•.eel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks /
Septic or Holding Tank
Aerobic Treatment Unit
Dosing Chamber
VIL Responsibility Statement- I, the undersigned, as a responsibility for installation of the POWTS shown on the attached plans.
Plumber's Na me (Print) Plumber's Si A MP /MPRS Nu er Business Phone Number
Plumber's Addre ss (Street, City, State, Zip
V VC ount Department Use Onl
Approved ❑ Disapproved Sanitary Permit Fee neludes Groundwater Date Issued suing Age t Signature ( ps)
Surcharge Fee) t fD�
' ❑ Owner Given Reason for Denial
IX. Conditions of Approval /Reasons for Disapproval
,Q. ;Q � ate- 0 U
Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size
vnn Lino /rl ni inn\
OT PLAN
PROJECT P.C. Collova Bldrs. Inc A SS P.O. Box 489 Somerset Wi 54025
NE ' 1/4 NW , 1/4s
/ 4 S 13 /J�'N a 18 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE3 /18/03 BEDROOM 3
CONVENTIONAL XXX IN -GRO PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1 000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chamber 22
BENCHMARK V.R.P. Top of steel fence post ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
216th Ave �2
STEM ELEVATION 95.3/96.0
Vent Plans Designed Using
Conventional Powts
> 6„ Standard Biodiffuser Manual Version 2.0
of Cover Leaching Chamber
with 31.1 ft2 of Area
6' Lon
g
11"
34" Grade at System Elevation
Pro 3 operty Line
Bedroom
House 35'
30' 70'
5 _
65' 60'
35'
B.M.
B -3
70'
2 -3' X 69' Cells with >3' Spacing
y y
Vents B -2
0'
I
i
Property Line
240 Property Line
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County �� �
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 0�
Please print all information. ew by D �7
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owne Property Location l
r Go . Lot ' 114 14 T l N R E r)
Property r s Mailing Address Lof j# BI # Suba. Name or CSM#
city State Zip Code Phone Number City El Village Town Nearest Road
W 1 �a (
Pf New Construction Ll Residential / Number of bedrooms Code derived design flow rate ) GPD
❑ Replacement ❑ Public - - Describe:
Parent material L/c� Flood Plain elevation if applicable ft.
General comments
and recommendati
mendations:
Bon # Bonng
Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
=
j'
--
® Boring #
7E] Boling ,
Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Muns Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = BOD > 30 1 220 mg/L and TSS >30 < 150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) a CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evalua ion Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 5;0 -r— -� 3 715 - 246 -4516
f
Property Owner _ Parcel ID # Page of
Boring # ❑ Boring
®
r 2 f Pit Ground surface elev� ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
� 1 Of l'� S
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/_ ' Effluent #2 = BOD < 30 mg/_ 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.
se o- 83 30 (e.eroo)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
420747 0
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)J.
Permit Holder's Name: City Village X Township Parcel Tax No:
P.C. Collova Builders, Inc. I Star Prairie Township 038- 1198 -40 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
00-6 t� W ae". "�S -�t¢, 13.31.18.1048
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic � Gv Benchmark 5 d "no U
Dosing l V - --- AI M QY>, D l�DI� J 3 �v� S
Aeration Bldg. Sewer
Holding SVHt Inlet (/ 3
TANK SETBACK INFORMATION St/Ht outlet /
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic t / i Dt Boo
Dosing TJ V Header/Mar
Aeration P Pipe o I c
Holding Bot. Syste
Final Grad
PUMP /SIPHON INFORMATION 7 ?
- I j
Manufacturer Demand St Cover
GPM 1 7 ,5 d -
Model b
TDH Lift n Loss System Head TDH t
Forcem ' Length Dia.
SOIL ABSORPTION SYSTEM C
BED/TRENCH Width Length I No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS Is �/
SETBACK SYSTEM TO / P/L BL WELL LAKE /STREAM EACHING Manuf r @r: . r/
INFORMATION CHAMBER OR
Typ f System: V / / UNIT
f Model Number.
DISTRIBUTION SYSTEM el
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Inta eO bP
1, Pipe(s) / G/ t' > y
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
0 Yes [2 No a Yes [] No
COMMENTS: Include code discre encies persons present, etc. Inspection #1: / 4(J /b Inspection #2:
Location: 1339 216th Ave New Richmond, WI 54017 NE 1/4 NW 1/4 13 T31N R18W Pine Acres Lot 5 Parcel No: 13.31.18.1048
1.) Alt BM Description = 3 I .�_ _ � h J, n , - / -4 __apj Gtr
3 �� Gtr /CIIQ/1rJ_J�.
2.) Bldg sewer length = ) 6
Ste`
- amount of cover =>
Plan revision Required? q � J Yes [� No
Use other side for additional information. 12
SBD -6710 (R.3/97) Date Ins e ctor's Signature Cert. No.
,Sky Est-.
J
safety and Buildings tImsm county r
201 W. Washington Ave., P.O. Box 7082 J f C D l
Madison, WI 53707 — 7082 Saoituy Permit — Number to be tilled in by Co.)
� o s (608) 261 -6546 �o? Q 7
Department of Commerce
Sanitary Permit Applic n App safe Plan I.D. Number
In accord with Comm 8321, Wis. Adm, Code, Msond A
MW be used > w sewodmj' pagan c Privary . slS. - V lz ® pmject Address cif diffeaha than mai>ift address)
L App>ication Information - Please Print Alt Wormation MAR 1 9 2003' l 3 3 9 .2 t (o '40e- JV
Pvo Ow
( ? � ST. CRUX CUUN7 Y 8
property Owner Mailing Address �( n Property Locati
/
city7g&Fe Zip Code Phone Number v, 4Lk2v, Section
LA-,) " I R2��E�g-
II. Type ofBuBding (tom all that apply)
Name C 1Qunber
Famr7y Dwelling- Nrmtber of Bedrooms
❑State Owned - DesaibeUm �' �� ( DCm5! DVill
III. Type 9frerinift {Cgedlt euly out box on Use A. Complete line B if applicable) 0 '38 — l L g + q D — dp0
A. X"w Sy0m, ❑ R System ❑ Tre mmatoldiog Tamp Rq&-U emt Only ❑ Otber MoW{Sce4on to Exis ft System
B. ❑ Permit Rmewai D Permit Revision ❑ amp of ❑ PamitrramBr to New List R°V1Om Permit Number and Date Wood
Before lemon Ptmmber owner
Iv efPOw - Cheat s� c�
- pressurized k4round D Mound> 24 im ofsuilable soil D Maud <aa io of suitable soil ❑ M Grade O SW& Pass Sand F*w D
C ueted Wa land ❑ Ptr mhW Iu -Grmmd ❑ Holding Talc ❑ Peat Ricer D Aerobic Tnestmeat Unit ❑ Remculadng Sand "i ter ❑
R Synthetic Mafia Pilsen Chamber ❑ tine ❑ Gmv&las ❑ Otber
v. ttHeut Area I ' a: 1310
Desiga Flow (gpd) Design Soil Application > Ater Requirod (s� C ✓ !/
VT Tank Info in TOW amber Mangy t'tdab Site Fiber Plastid
Galleon Gallons ofUaits ��� ,�J _� a� Catuete Constructed Glass
WW r- /� Y
Tads Tads
septic ar Wft Tack
Ilacbic THIN" Unit
VII. Respensibft Sbftmmt - 1, the raspomsi68ity far imam of the POW share ow the attiel" plains.
PbrmbePs Name (Print) Pbmbar's
rtQ B Phone '
r,z.lLr1/ Vi i./.
plumber's w'd&ess (Strax, City, Stater. Terµ )
use Only sanitary Permit Fee (iachrdes Groundwater tanned )
❑ DisMauv StschsrgeFa) "t - c d 3 3
❑ Owner Giver Reason far Denial 0
IX. Conditions of ApprovaUResseos for Disttpprovt
W
� I
E�� ,
Athei phn (ss tier sy ply) tar tits a papa lea tMaaltlZ s 11 itreMs b arse
SBD -6398 M 08/02)
OT PLAN
PROJECT P.C. Conova Bldrs. Inc j/T/R ADDR sS P.O. Box 489 Somerset Wi 54025
NE 1/4 NW 1/4S 13 18 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 3 BEDROOM 3
CONVENTIONAL XXX IN-GP64D PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFO TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambe 222
BENCHMARK V.R.P. Top of 2" Pipe ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE O WELL +H.R.P. Same as Benchmark
216th Ave SYSTEM ELEVATION 94.4'
j ent Plans Designed Using
/ Conventional Powts
Standard Biodiffuser✓ Manual Version 2.0
Leaching Chamber
with 31.1 ft2 of Area
3 Grade at System Elevation
Pro 3
Bedroom
House
30'
T
50'
B -1 B -3
60'
lVents !30)1 Vents
PIJB-2 2 -3' X 69' Cells with >3' Spacing
60'
B -5 B -4
5 '
Alt. B.M.
M. #1 240' Property Line
I
OT PLAN
PROJECT P.C. Coilova Bldrs. Inc ADDR SS P.O. Box 489 Somerset Wi 54025
NE 1/4 NW 114S 13 /)DPRESSU SSURE N/R 18 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE BEDROOM
S /18/03 3
CONVENTIONAL X)oC IN -G CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambe C 22
/
BENCHMARK V.R.P. Top of 2" Pipe ASSUME ELEVATION 100' Filter Zabel A -100 /
❑ BOREHOLE O WELL *H. R. P. Same as Benchmark
216th Ave SYSTEM ELEVATION 94.4'
Vent Plans Designed Using
/ Conventional Powts
>6"
Standard Biodiffuser✓ Manual Version 2.0
of Cover Leaching Chamber
with 31.1 ft2 of Area
6' Long 11 "
34" Grade at System Elevation
Pro 3
Bedroom
House
30'
T
50'
B -1 B -3
60'
10' Vents
Vents
jo 30' B -2
0 ' 2-3' X 69' Cells with >3' Spacing
B -5 60' B -4
5 '
Alt. B.M.
ts B.M. #1 240' Property Line
WIKc nsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of.
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Attach complete site plan on paper not less than 8' /z x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference -pa0t Blob direction and
percent slope, scale or dimemsions, north arrow, and location' -ands distance to nearest road.
Parcel I.D.#
APPLICANT INFORMATION - Please print all ormafiok Pendzn
Personal information you provide may be used for secondary purplbEq;( 4VaW Laws 15.04 (1) (m)). evie y . Date !
Properly Owner P rty Location
Lakes & Hills Development Govt.Lot _ 1/4 NW 1/4, 13 T 31 N,R 18 ❑W❑
Property Owner's Mailing Address Lot Block # Subd. Name or CSM# - —
° x �� �: , z 3 ❑ - -- - _ -- P ine Acres
' C ity ., State Zip Code Phone(diiirteer City illage Nown Nearest Road
�tJl1 I f C c d,c ,�, /U Y D S� Y� '�� 216 TH. Ave.
❑ New Construction ❑ Use: Residential I Number of bedrooms 3 ❑Addition to existing building -
❑ Replacement ❑ Public or commercial describe
Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpdM 8 trench, gpd/ftz
Absorption area required 643 bed, ft' 562 trench, ff Maximum design loading rate .7 bed, gpd/ft .8 tr ench, gpolftz
Recommended infiltration surface elevation(s) 93.5 ft (as referred to site plan benchmark)
Additional design I site considerations
Parent material - - - - -- Flood plain elevation, if applicable - -- --- ft
S= Suitable for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank
U= Unsuitable for system ❑ S Cl u ®S 11 U ❑ s ❑ U Z S❑ U ❑ S U ❑ S❑ U
SOIL DESCRIPTION REPORT
Horizon Depth Dominant Color Mottles Texture Structure Consistent Boundary Roots GPD/ft
Boring# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
1 1 0 -10 l 0YR3 /3 ------- - - - - -- 1 1 msbk mvfr as if .4 .5
2 10 - 19 10Y /3 ---------- - - - - -- 1 lmsbk mv g lvf .4 .5
Ground 3 19 -31 10YR4 --- --------- - - - - - - C l l msbk mfr as - - -- .2 .3
elev
97.9 ft 4 31 -61 7.SYR4/4 ------------ - - - - -- c osg ml cw
---- .7 8
5 61 -94 I OYR5 /6 ------------ - - - - -- s osg ml - -- - - -- .7 8
Depth to - -- - - _ - - - -- — - -
limiting q , v L4 2 ti &
factor
>94"
Remarks: _ �� Sa �_c� •! ? _ - - _ --
2 1 0 -10 l OYR3 /3 ------------ - - - - -- 1 1 msbk mvfr as i f 4 .5
------------- 1 lmsbk mv fr
2 10 - 19 1 OYR4 /3 - - - -- g'v lvf .4 .5
Ground 3 19 10YR4 /4 --------------- Cl lmsbk mfr as - - -- 2 3
elev — — -
97.9 ft 4 32 -57 7.5YR4/4 ------------ - - - - -- cs } osg ml cw - - -- .7 .8
Depth t0 5 57 -95 10YR /6 ---- - - - - -- s osg m
- -- - - -- 7 .8
limiting « y
factor 0 T - -
>95
Remarks: . - --
CST Name (Please Print) S' nature: Telephone No.
Jacque Hawki _ _ y 7& - J Y y,
Ad ress t1 Date CST Number Ref #
i f Qu 6 u C (N j �S3 4/12/00 426
i
PROPERTY OWNER: Lakes & Hills Development SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D.# Pcndin8 _
Depth Dominant Color I Mottles Structure nsistence Bound Roots GPD/fl2
Horizon in Munsell Qu. Sz. Cont. Color I Texture Gr. Sz. Sh.
Bed :Trench
1 0 -9 10YR3 /3 - - - - -- 1 lmsbk mvfr as if .4 .5
2 9 -17 10YR4/3 ------------------ I lmsb mvfr gw lvf .4 .5
Ground I
elev 3 17 -30 10YR4/4 ------------ - - - - -- cl I lmsbk mfr as - - -- .2 3 ---
97.9 ft. 4 30 -59 7.SYR4/4 ------------ - - - - -- cs osg gw - --- 7
.8
Depth to - - -- - - -- .7 .8
p 5 59 - 10YR5 /6 ------------ - - - - -- s � osg � m1
limiting - — t
`!
factor -
>95 - I -
Remarks:
1 I 0 -11 10YR - ----------- - - - - -- 1 lm sbk mvfr as if 4 .5
2 11 -19 10YR4 /4 ------ - - - - -- 1 l m sb k mvfr gw I lvf .4 .5
Ground
elev 3 19 -29 10YR4/6 ------------- -- cl lmsbk mfr as - - -- 2 .3
- -I --
97.9 ft. 4 29 -59 7.5YR4/4 I ------------ - - - - -- cs osg ml gw ---- .7 .8
Depth to 5 59 -95 10YR5/6 ----- ------- - - - - -- s osg ml - - -- - - -- 7 8
limiting -
factor
>95 - + -
Remarks:
5 1 0 -9 10YR3/3 -- ---------- - - - - -- 1 I lmsbk mvfr as if .4 .5
—
2 9 - 18 10YR4 / ------------ - - - - -- 1 1 msbk �- mvfr - gw lvf .4 .5
Ground ____ 2 .3
3 18 -29 10YR4/6 ------------ - - - - -- Cl 1 msbk mfr as
elev 97.9 ft. 4 29 -59
7.SYR4/4 ------------ - - - - -- C4 os ml cw - - -- 7 8
Depth to 5 59 -93 10YR5 /6 I ------------ - - - - -- I s I osg ml - - -- - - -- .7 .8
limiting -
factor
>93 - - � - -- - -- ±-- -- — -� --
Remarks
Ground
elev
Depth to - --- � - - - - -- --- - --�-- - --} - --
limiting —
factor �—
I I
Remarks: ____
IT a
i
y
rl
CA
2
"1-
r �
2 �I
f �
1
c
d
C � M
e
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
Contingency Plan
1. If system fails, determine cause of failure, use alternate area and install new system or
install system at a lower elevation.
2. Replace any other failing components as needed.
Plumber: Shaun Bird 715 - 246 -4516
St. Croix County Zoning 715 - 386 -4680
Pumper Tom Mondor 715- 246 -5148
Shaun Bird #226900
r
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
• AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer P. C. Collova Builders, Inc.
Mailing Address P O Box 489 Somerset, WI 54025
Property Address a` �
rrll ,, __
(Verificati required from Planning Department for new construction)
City/State Vt��: R �C�`IVYIc�" � (ANT-- Identification Number 03, — 11 q ' 1 1D az
LEGAL DESCRIPTION
Property Location %,, 0 /,, sec, 1 _ T:�LN -RW, Town of
Subdivision Lot # S �j
Certified Survey Map # . Volume , Page #
Warranty Deed # Volume . Page # Z y f/[2
Spec house Dyes ❑ no Lot lines identifiable 0- ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its prematureafailure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
masterplumber, journeyman plumber, restrictcdplumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
7 of a t4rec year a iration date.
d 3 166 16 - 3
SIGNATURE OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
property described above, by virtue of warran eed recorded in Register of Deeds Office. 04 -3 /!d
SIGNATURE OF APPLICANT DATE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
r
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
12/16/02 MON 11:55 FAX 715 388 4887 REGISTER OF DEEDS 10003
U. 1871P 025
Purchaser promises to pay when due all taxes and asatecoments laviod an the Propert y or upon Vendol"s inierast
"i(1, it and to deliver to Vendor on damdnd receipts showing such paynneat.
Purchaser shalt keep the improvements on the Property insured ayy ninst Ioss or dmllaRc Occasioned by tin:, ex.
%added coverage perils and such other hmal'ds as Vendor may require, without CO- inlluran4e, tbrough insurers approved
by Vendor, in the sum of $ NIA ' but V01191Ot Shall not require coverage in an amount more
than the ba]atsUC owed undZi fit s Contract. era aver she Piey the inaurttn0o premiums wlxrt due. The pOIICle9 shall
contain The es gu ard elmnse is favor of Inc Vendors iRTdrOSr ol d, hitless Vendor Otherwise Rama in writing, the gri¢irml
ofall policies eavoriap. the Pmperry shall bu depegited with Vander. Purchaser shall promptly give notice of toss to
insurance compthtius and Vendor, Unless Purchucr Sold Vt=W otherwise aCtoo in writing, insurance proeeads sliall
be aPPlied To t0sLOration Or repair of the property damaged, paroviclad the Vendor deems the restoration or repair to po
econamlcally fua2ibic.
Purehamirr eovenanTa not to ousmnit waste nor allOw WILAS to be 001TIMILted on die Pt'Opurty. IQ keep like Property
in good tenantable COn411101 and repair, to keep the Property free (coin liana aupsrior t0 Tito lion of this C;OMAUL, and
to comply with all laws, Wdiaa710001 and regulations aranxing the Property.
Vendor agrees that in ease the purchase prloo with interest mn4 other monays anal] bu rutty paid and all eondilions
shall be fully perrOntica At the times and in the manner above specified, Vondnr will on demand, ummuts and deliver to
the Purchaser, a Warranty Dead, in fee simple, or the Property free and clear of3ii lions and encumbrances, except
tin lien etiourtlitr created by the not or default of Piorchasar, and except^ _ sale ,
raafrialtonr an
r hrs -0t, Or of repOrd
Purchaser 60. that time is of doe esscn" and Cc) In the event oft dcFsuli in the payinenl of any principal or
itltcldat which continues for a period uP days fallowing the pp *qifood dote date or (b) in the event ofa default In
perRlrmnnCe Of any other obligation of Pitrehnser which continues for a period or days ratldwing written notice
tboraaf by Vendor (delivered pw'sonally er mailed by ceru1100 stall), then the entlreowsjRBGdni; balance under this contraut
shall become Immediatoly duo &net payable to full, at Vendor's option and without notiva (which Purahaser 1lteaby
wudvoe), and Vendor shall oleo litvu the roltowing rignta sad reinadics (subject to any lirnilOUans provided by law) in
addition to those provided by law or in equity; (1) Vendor may, at hit Option, terminate this uontmct and PurehasoNs
rights, title and interest hk the Property and recover the Properly back thmttgh strim rurcolosure with any equity of
redemption to be conditioned upon Purohaeeei fUll payment ei'ihe entire outolU balance, with interest thereon twin
olio data of dotault at the rate in effort on such data and other amOur a due hereunder (In which event all amounts proviousiy
paid by Purchaser shall be tierfbdtcd sot liquide"d damages for failure to fulfill this C ontract and as rental for the
Property If purchaser rails to redeem) or III) Veadof MAY sue fbr specific perforthanes orthis Contract to eompol
immediate and full payment of the entire outstanding belancs, with interest thcroon at the rata in effect an me date Of
default and other amolims dtie I lereun d: r, I n which event the Property shall be auctioned at judicial aide and Pusuhaxar
iball be liable for any deflo(on4y; or OdO Vendor may sue at law f or the entire unpnid purchase price or any portion
therent, Or (IV) Vendor May declare this Contract s1, art end and remove this Contract as a cloud on title in a qurei_tftle
action if The equitable interest orpurchsm is Insip and (v) Vendor may have Purcha ejected from possasslon
of and Property and have a receiver appointed to collect any rents, issues Or profits during the pondenoy Of any avtiOA
under (I), (ii) pr (iv) above. Notwithstanding any oral or written statements or actions of Vendor, an CICCIlotl orally
Of the foregoing remedies shstl odly be binding upon Vendor if and when pursued in lilfaattoa and oil goals e114 expan2ux
inoluding, reasonable attorneys fbas of Vendor incurred to enforce any remedy hereunder (whether abauea 01' AOT) TO the
e%toat not prohibited by law and expenses of title avidence shall he added to principal and paid by Dural-Amer, oa In-
curred, and shall be included in any judgtpont.
Upon tllo oOntmOnaoment or during the rmndsn4y of any action of foreclosure of rills Contract, Purchaser consents
to the apO0t1111nOr11 Of a raeelvcr or the Property, includinh hornostuad interest, to collect the rents, Issuos, uruJ pruliti or
the property dur ing the pendency orsuch action, and suoh rents, iasuas and profits when so collected skull be hew and
noshed as the uourt shall direct.
Purohescr shall not transfer, sell Cr Convoy any 1080A Or equilabla interest in rho Property (by assignment or any
orPurchisnar rights ender this Conttmot or by u ption, long-term lease or in any Other way) without the prior written
consent of Vendor unless either the Outstanding balance payable under this C1onn'a0t is rtrxt paid in full or Oct interest
acnvoyod is a pp lod ge Or assignmunt or Purchasaes interest under this Contract solely as security for on indebtedness of
Purchaser. In t11O event OFany such laimifer, sale or conveyance without Vcad(Wm written consent, the entire outstandinS
bulancz payable under this Convect shall beoomu immcdiaWly due and payable In full, in Yeedor's option without nuUcu.
Vendor shall mal(C all payments when due under any mortpttge outstanding against tht: Property an the date Of
Wit Contract (except for any mertgago granted by Purchaser) o1' under any ante secured thereby, provided Purchaser
maker timely payment of the amounts then due under this Convael_ Ture hascr may make any such paymonts directly to
the Mortgagoo it vendor Roils to do so and all payments to made by Purchaser shall be 0MIC1 yrW pAytilen 11 mad: Un
this Contract,
Vendor cony waive any defeait without waivins any other aubsequant or prior default Of teur011940r.
All terms or this Contract Ahnit be bindlnE upOLl And InUeO TO the benents of the heirs, legal reprosoniai Ives.
cucceaaorm and assigns of Vendor and Purchaser, (1f not an ownot urthe Property the apouao of Vondor nor a valuable
consideration joins heroin to rgleaae hOmestand rights in the auDim 1 roperty and fa rtes to join in the execution Of the
dead TO be mada in fulfillment hareef,)
Dated 1,1112 day or April 2002
Lakes & H ��r � Tg In _ (SUAW
Ne lsua Pre sddea! P.
. , �•,,, •_ Ven C. eJlava, Preside _1'urcha5cr
_(SEAL) — _,_..._�......._....�.._,. (SSAL)
e Vendor t _ _ .. .Purchaser
AUTHEN'BCATION ACKNOWLEDGMENT
3ignature� �, aa&Hilb.lne" a Minsesotm Corporation, STATE OF WISCONSIN
Ri[h��rdtbi'al E . stead. P, C, Cglb Bai ld ers, Inc., ) 55.
— COUNTY)
�1th4mkbsied th13 Wiy of April 2opj Perwlealiy cams before me this __ diy Or
t .... �� —... .�...,..�...� the above named
. strS _.....�.. — ...._
TI16'l BAR .
OF WISOONSIN Inc known to be the person(s) who exe uied the ILrcgoina
'� I j e,•" • instrunamt and seknuwftdgc the yams
authorlxe by Q7 06: WIs. lus.)
TICS INSTRUMUNT WAS PRAFT&n PY .—
AtthracyKristluOabtd Notarypubiio (uunly, W1.40011616 Iludacn, Wl 54016 _
(Sij"Murss may be Whenlicoled or ackNiiulcilgd. Both are flat My Cumaniariem is permancnl, (il'reel, st sxpirhlipn data:
Names ofilelsons signing In any ttarRclty Amid be typed or ptlnud below 117411' SILnalunx,
I. rWnCON111ACT- ledld eermdCerserete- Thee6aretWkeemesPara Nt. 11.1043 inrormatianProtess 'anataCempe,ty,Fanodu Lac, W1 aM N-2021
12/16/02 MON 11:35 FAX 715 386 4687 REGISTER OF DEEDS 2002
U 167 1 P 024 �3
3'rATi: HAROP ttfISCONSTN PORbI I1 • 1012 f. 7
t f t
LAND CONTRACT s is B. VAL
i
or
ndividual and Csrporat, S?. CE!f]Il(�. am
` (TO It U31:12 FOR ALL TRANSACTIONS WHERE 0YLA ° VI
STS, 0o01EPINAKIDANDW071M R.NCM4CONSUNSA RECEIVED F( $J Qp�
oertrrtu Yaarber SACT10T1SI
64 -11 -2602 9135 All
CONTRACT. by and between Lakes & Hills, lac., a Minns4ota E1� Maw
Co rp or odion, •. 3.
TRAANS Me �23 .40
("Vendor", whether one or mare) and P. G Gaiiovn Ballde Inc 0657' W; Fir.: PAT31:5 t 2
(" Purchaser", whether one or more). Vendor sells and agrees to convoy to Address
Nenip a nd ' d Mo
Purchaser, upon the prompt and full performance ofthis contract by Parehamr, Ret
the following property, together with tho rants, prof ta, finwros and other KRISTINA 0GLAND
appurtenant interests (ell called the "Propotty ), in SL Croix A TORNEY AT LAW County. $tats of Wisaonsint - P.O. BOX 359
H UD SON, VA 54018
01 93 -IO-000
Late 2, 4, 49 a 53, ne Acres, Sr Croix County, Wisconsin.
This is toot homestead property.
()6) (is not)
Purchaser agrees to purchase the Proparty and to pay to Vendar at place Vendor directs
tiro sum ors 1073000 imric following, manner; (a)
at the execuliOrt or This Contract: and (b) the bo once r; "$ 97 600.00 . -„ , to with intere%t * stn data
hereof on the balanes Outstanding from tines to time at the raw o 10 % percent per annum
umil paid in full, as follows; Vendor shelf relam the above lots epos payment as follows: l,ot 3 for !pSCW.uo; 1.ot 4 far Szd,600.00t
Lns49 for 326,900.00 and Lot53 for 527,900,00. Intermit shall not aeerue until 6 meetbs after the oblong of this Cantreci 7M111
down peymcat on this Costrset shall be it credit to the last lot rela,ued.
Provided, however, the enrlre outstanding balance shall bs paid in Aill on or haron: flit _ oth day of
Nell -"" 2003_ (the maturity dials). Following airy default in pay call, Interest shell accrue w the rata or per annual on the 6nL1ru amaant
In dvt4ult (which shall include, without limltatioo, delinquent interest and uric'4 uceeleeation or maturity, the entire
principal balance),
Purchaser, Weito excused by Vendor, agrees to pay monthly to Vendor amounts suPiicket to pay reesanably nnticl-
patcd annual texts, speeiel asstresmanIV, tiro and required insuranea promWina when due. To the extent received by V endo..
Vendor agrees to apply payments to theseobligUiOns when due. Such amounts rwelved by the Vendor for poyrrknl of
taxes, assesstnctrts and insurance wilt be deposited into an eacn,rw fund orteustae account, but aha11 not hear Interest
unless otherwise roqu!red try law.
Payments shall be applied first to interest on the unpaid balance at the rate speciliud and then to principal. Any
amount may be prepaid without premium or the upon principal at any rant: after day ortloling _,_ - .__ , 7tXX )
In the overt a'r am� prepayment, that: eomract shall not be treated as in Uatault witkt respect to payment sn lon
as the unpaid balance of pr Oaipal, and irtterwt (ants in such m
case aaoruin iMersat from month to onth %all hip irsaw
as unpaid principal) is less than dta armor that acted indebtedness woufd have been had the morally payments been
made as Prot specified above; provtpad that monthl pa msrain %hall be continued in the event. of erad,t of any proceeds
of insurance the condemnation. the condemned premises being theri:aiter excluded heretYon,
Porchanur mistas that Purchaser is satiatlod with the tills n ; shown by the title evidence submitted to Purchaser
for examination except: Pint asortgage to Sanders Martgtge Company, LLC
Purohnsor agrees Le pay the cost of futura ti tic evidence. Iftida evidence Is In the fbrn nI'an atistract, it shi r
be mlaincd by Vendor until the toil puraftase pries is paid.
Purehaacr shall be entitled to take possession of the Property oil platy of elesing. - XICX?CX
Crass tout one,
LAND MhlTWACT- Iadividual and Sucre itsr of wluossia
Cdrpsrste Perm No. 11 . 1932
rvaimmaia 4,ot6mitwiss company. Femt Cu Lat.'61 890.455,2021
Dated this 1_L day of /KeUY . 2000 L
Z • x
� ao
------------ - - - - -- MATCH LINE — SEE SHEET 2 OF
33 —C42— C43
1 — C73 _ C77
33
0 )501 54
60.
.
t.
67,766 sq.ft. y 55
C79A 1.56 acres 65,437 sq.ft.
1.502 acres
9
S *2 £
4 ry
27 1,29'
e
52 (:5 °� n N . 56 I
0 W ry� 100 —L
65,892 sq.ft. g a 68,507 sq.ft. 65,530 sq.ft.
1.51 acres 1.57 acres 1.504 acres 3
?ryM jp 8
2" iron pipe found
245.77' 227.27 363.61'
� South line of NW 1/4
af Sec. 13, T31N, R 18
11 12 13 _14_
'ICE TO ALL UTILITY COMPANIES: SURVEYOR:
_at Corner Monumentation (ALL UTILITY COMPANIES SHALL MAINTAIN Todd M. Hendershott
.NCE FROM ALL LOT CORNERS AND BENDS IN THE RIGHT —OF —WAY) Metro Land Surveying do Engineering
tion being disturbed will be subject to remonumentation fees. 332 County Road "D"
Little Canada, MN 55117
t