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HomeMy WebLinkAbout020-1308-90-000 ST. CROIX COUNTY TONING DEPART t �. MCNT , AS BUILT SANI'T'ARY REPORT � Owner {Zc G(ux N A. o R S G eJ Address 3 "' City /State W9 S q �► Leg Description: I t Block Subdrvision/CSM # _ ��- e_Psa,Nfi 'y. ' /,S ,Sec , T N -R W, Town of Wap _ro PIN # U.7L — 130 = -4o�Uad SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: ? Tank manufacturer jz-4- 5 Size ST/PC Setback from: House 1L W el l, P/L 3' Pump manufacturer Model �' Alarm location (HO ANUS ONLY) Setbacks: Service road Vent to fires take Water Line Meter location Alarm location SOIL' ABSORPTION SYSTEM: Type of system d kC4fL 1 Width 3 - Length ? S Number of Trenches _ Setback from: House Well 23 P/L 4' Vent to fresh air intake ELEVATIONS Description of benchmark _ U p p � U � ��"�' r ` � Elevation Description of alternate benchmark Elevation Building ewer Q q o g ST/HT Inlet 1` U , 3 � ST Outlet • � � - � / PC Inlet -_' PC Bottom- Header/Manifold 7 Top of ST/PC Manhole Cover 11.7 5 Distribution Lines Bottom of System Final Grade Date of installation 7 A7/ ?)p ermit number 33 State plan number Plumber's signature V 11 License number �aa` IU Date Inspector Compltle plot plan K NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW 1 400 5b� cis, oc N ? I 3 k�S ICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: IX Personal information you provice may be used for secondary purposes [Privacy Law s.15.04 (1)(m)]. 338888 Perrryit l�9 ftiJ�Jaft � GREGG L . ❑ CitW �e Town of: State Plan ID No.: uu1v11�tC�V1V U1V �- CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No -: I I d'0 - $ E A 020- 1308 -90 -000 TANK INFORMATION U ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic 1200 Benchmark `f35_ pf, Dosing fi( /, Is,M 4.44 /01.94 Aeration Bldg. Sewer S 3 6 1g', 99 Holding St /Ht Inlet (D� 8,31 TANK SETBACK INFORMATION St/ Ht Outlet (,•ZL 8 O TANK TO P / L WELL BLDG. Air I to ntake ROAD Dt Inlet Air Septic ( ' 8 — NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe •� �'s qd . Holding Bot. System S— PUMP / SIP INFORMATION Final Grade CZ 4,8'7 Manufac rer Demand Model Number M TDH Lift L oss e tem TDH Ft Forcemain Length Dia. Dist. SOIL ABSORPTION SYSTEM 10STr RENCH3 Width Length we. �hes PIT No. Of Pits Inside Dia. Liquid Depth DI EN t -N - 'x DIMEN I N SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING Manufctur SETBACK _ CHAMBER INFORMATION Type O Q i M el Number: 77 System: I tJ 7 7 OR UNIT P DISTRIBUTION SYSTEM Header/ nifolcl Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. l Length Dia. Spacing 7 7� SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over 78ed th Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 16.29.19.1548,SW,SE 938 WAXON LN— PLEASANT VIEW LOT 9 Plan revision required? ❑ Yes (1,No - Use other side for additional information. 03 Z 00 �� SBD -6710 (R.3/97) pC,.ttor's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ° :w e � i } _ ° € e .. �. a° ° ° a °; . e� a w i s s e ; t i e......,.. c °... ,.,. . . . . . . J � 4 € f € 3 t ( a s w i 8 a e ° � 1 a s , { .� t t t � t € ( .,.. I Y x { € ...«.. ..,<. ,.ems.. .... bA _ e e. d � IL cons i n Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code p merce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application state sanitary Permit Number 3__5 F 1 3 y The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]- ` State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Pro y Owner Nam Property Location U)1 /4 5t 1/4, S /& T , N, R 47 E (or) W Property O 's Mailing Address Lot Number Block Number `/ R u 9 City Sta a Zip Code Phone Number Subdivisi me or CSM Numbe V II. TYPE B IL ING: (check one) ❑ State Owned ❑ 't� Neare M YOW ❑ vil age Public 1 or 2 Family Dwelling - No. of bedrooms own of 5 III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 vl - Iq , l5 - 1 ❑ Apartment/ Condo 01A ^ 13Q ? 96 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 _ ' New 2 E] Replacement 3. ❑ Replacement of 4_ E] Reconnection of 5. ❑ Repair of an ___'_'_`_ System ________ System____ _________ Tank _____ ly______________ Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding nk 120Seepage Trench 22 ❑ In- Ground Pressure Lp J 3 t � 7 � I 4 ❑ Pit Privy E] 13 Seepage Pit ❑ Vault Privy 14 ❑ System -In -Fill roc f VI. ABSORPTION SYSTEM INFOR ATIO : 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade /� Requir (sq. ft.) Pro ose_dSsq. ft.) (Gals/d /sq. ft.) (Mi nch) Elevation O O . V 5 V _ �p S 0 Feet 160 •f Feet VII. TANK Capacit in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete st C on ed Steel glass Plastic App Tanks Tanks epticTank kh7fdTr g 1 n`k ca ❑ ❑ ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 1 ❑ 1 ❑ ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plu ber's Signature: (No St am s) MP /MPRSW No.: Business Phone Number: V ti Plumber's Add ress (Street, City, State, Zip Code): IX. COUNTY/ DEPARTMENT USE ONLY [] Disap p roved Sanitar Permit Fee (includes Groundwater � I ij ate Issued Issuing A nt Signature (No Stamps) Sanitary �pproved ❑Owner Given Initial _ ur,hargeFee) ',4 Adverse Determination � 1 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: �/ be>,/vaow � 3��•�t — t��.o -� P lv>z S �/� /fir � c� ox `����s�' seD -sass (R.1 liss) D,snMtrrtoa: orb to county. onie copy To: safet a auadings Division. owner, rkomber INSTRUCTIONS 1 _ A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every '2 to 3 years. 6. It you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3151. To be complete and accurate this sanitary permit application must include: L Property owner's nacre and mailing address. Provide the °egal description and parcel tax numbers) 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. 111. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. Vil. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing 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 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. ,w...... r r.... LIZ 0 1 f3 tz��,o e s r- Q � N _ �o a� s 2uty P l s �� Cortueg � L - t v - Go. o ®= (3 fh tf a _ -f �S RAN �) e - 9q• 8�` No{p.- UP Bea '�I,aN S ( Y s -ew, Note : Ad p(.Q �u�S IS AKA �p�fiQll e 63 a iRt� c�•t S a3 IU ` � 4 80D ROOM 3x�S' n� es D �orh aob lci P p y t ��� 9 y' 35` 30 ar+, y f INpI Gal, 61M fu N a- U C C en E G Lo crj (D ® ' U E �I- = C 0 ~ E E `O O _ X O1 CN W N co j„ V � to T ca T3 to +�. M cl r i 3� �� ° ° o C O Z a� 3 a� °- (a cx p Eo -p cc 70 co CL c CL -- 3 CU I J,.. iJ a N � j L cc,) (� J �l.l , i .. Ir � _ 3 0 � Q, z x v° J LL O Z to N O m rvv °v ° ° °�I.- - -' a • • • • to � I Wi sconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 ' D„rision of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code F.nvimnmental Ry Design Attach complete site plan on paper not less than 8'h x 11 inches in size. Plan must County - include, but not limited to: vertical and horizontal reference point (BM), direction and S Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel LD.# -- APPLICANT INFORMATION - Please , pm t . lt..idfonnation. Rev B D to LIZA_ Personal intormawn you provide may he used for rposes (Prnracy Law s; 1 (1) (m)). Property Owner `� rj Pro rty Location Gunderson, QEeg Govt. Lot - SW 1/4 SE 1/4 S 16 T 29 N,R 19 W Property Owner's Mailing Address = 3 Lot # I Block # I Subd. Name or CSM# 750 G Sandhill Pt. Rd N -' 9 ' - ' Pleasant View City State Zi Phone¢dp,f U City [Village Town Nearest Road Hudson VVI 54 ZU'AG0FFfCE Hudson CTH A New Construction Use: Z Resi ' I T pf bdroorns 3 ❑Addition to existing building 1 Replacement !_! Public or c _desedbe Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpdtif .8 trench, gpd/W Absorption area required 643 bed, ft' 563 trench, f? Maximum design loading rate .7 bed, gpd/frz .8 tr ench, gpdW Recommended infiltration surface elevation(s) 96.50 ft (as referred to site plan benchmar Additional design / site consideration System to beinstalled below restrictive horizons P arent material c Over Glacial Outwash Flood pWn elevation, N applicable Na ft S= Suitable for system I Conventional Mound In -Ground Pressure i AT -Grade System in Fill i Holding Tank U= Unsuitable for system 1 2 s ❑ u r, s z u I n s n_ u o s z u I o s � G I r, s u ^ SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/f" Boringf# Horizon in. Munsell Qu. Sz. Cont. Color Texture ± Gr. Sz. Sh. �Consistenc� Boundary Roots I Bed Trench 1 1 0 -6 10yr3 /2 - sil I 2msbk mfr cs 2f .5 .6 I I I I I I I I 2 i 6 - 16 10yr4/4 - sil i Imsbk mfr i cs if .4 .5 Ground 3 1 16 -281 10yr4/6 - 1 sit 1 Imsbk 1 mfi 1 cs I - .2 .3 99 .8.5 ft 4 28 -39 10yr4/4 I c2d5yr5 /8 I sit I ltsbk mfi I cs .3 Depth to 5 39 -10tX 10yr5 - cs Osg ml - i - .7 .8 limiting S This soils report is an addition to a report that was conducted by Bob tllbrecht on 5/21/94 factor ' 100 ot 49 - I I I I I Remarks: 12 inch rule applies to horizon 4 Elevation 96.60 1 1 0 -6 10yr3/2 I - sil I 2msbk I mfr i es 2f .5 .6 2 I 6 -13 10yr4/4 - ? sil Imsbk mfr cs if .2 .3 Ground 3 ( 13 -27 10yr4/6 - sil lmsbk mfi cs - .2 ; .3 elev i i I I i i i `•8 ft 4 2 ?36 }Oyr4 /4 c2d5yr518 i sil mfj I cs - .2 .3 Depth to 5 j 36-1001 10yr5 /4 I - I cs I Osg I ml I - I - I 7 8 limiting factor i i i >100 Remarks: _ 12 " _rule applies to horizon 4 elevation 96.80' CST Name (Please Print) Signature: Telephone No. Thomas C. Nelson 715- 246 -2454 Address Environmental By Dcsign Data CST Number Ref # 1432 120(h Street, New Richmond, Wl 54017 3/1/99 227387 210 PROPERTY OWNER: (runderson, (ke SOIL DESCRIPTION REPORT ; 210 ; Page 2 of 3 PARCEL WA Environmental By Desi Depth i Dominant Color i Mottles Structure i i i GPD/f� Horizon! in. I Munsell ! Qu. 5z. Cant Color ! Texture ! Gr Sz Sh ICansistence! Boundary ! Roots I Bed ` Trench I I I I I I 3 1 0 -6 10yr3/2 - A 2msbk mfr cs 2f .5 .6 I I 1 1 I 1 1 I ! 6 -11 I 10yT4/4 I - I sit ! 1 msbk I mfr I cs I 1 f I ^ .3 Ground II elev 3 111 -23 10yr4/6 I - I A I imsbk I mfi I cs 1 - 1 .2 .3 ' 1 4 i 23 -32 i 10yr4/4 i c2d5yr5 /8 sit lfsbk i mfi i cs i - i .2 - .3 Depth to 5 1 32 -100 1 10yr514 1 - ( cs I osg 1 m1 I - 1 - ? S limiting i o i factor .98 I I I I I I I I I I Remarks: 12" rule applies to horizon 4 Elevation 97.04' i I I i I i i i Ground elev I I I I I I I Depth t o limiting factor I I I I I I I I I i i i i i i i Remarks: ............... . ! I I I I ! Ground elegy Depth to I l I I L I 4 I I limiting factor I I I I I I I I { I 1 1 I 1 I f Remarks: i i i i i I i i I Ground elev I I I I I I I I Depth to I I I I I I I I I limiting factor I f I i i i i i i I i Remarks: i ENV iRONAERTAL 1 1432 120' STREET, NEW RICHMOND, WISCONSIN 715 -246 -2454 Tom Nelson Certified Sail Tester 227387 -- Registered Sanitarian SR00713 GREGG GUNDERSON — Lot SW '/, , S FI /d SRCTTON 1 T 29 N, R 19 W Hudson Township, St. Croix County, Wisconsin Page 3 s 0 N 3 1 ° o 1� Sloe, a Qt�1 �- SCALE 1" =40 Tom Nelson BM 1. TOP OF IRON PIPE SE LOT CORNER ELEV. 100' BM 2. TOP OF IRON PIPE ELEV. 99.80' V"ruln Deparome ations nt of Industry SOIL AND SITE EVALUATION REPO Page of 3 el Labor and Human R Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. ft dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION 04,41 -- W h X Dill GOVT. LOT OESr' -• 1/4,S l(o T 2 9 N.R. 1 E (ai PROPERTY OWNERS MAILING ADDRESS LOT tr BLOCK I SUBD. NAME OR CSM # . .5q or • 'RE) . A P I6•kSANT UtEw CITY, STATE ZIP CODE PHONE NUMBER 171CITY QVILLAGE OWN NEAREST ROAD opsoz 4>1S. SS/o /C. (7/5) X6.35/38 cry. RP + ( -I'New Construction Use ( Residential / Number of bedrooms 3 40 y f I Addition to existing building j) Replacement ySo- (J Public or commercial describe Code derived daily flow &cv gpd Recommended design loading rate . 5 bed, gpd/It Uertch, gptiV Absorption area required bed, ft trench, 11 Maximum design loading rate'? bed, gpd/ft Uertdt, gpol(r Recommended infiltration surface elevation(s) 5.ac- . 3 `� �• S ft (as referred to site plan benchmark) Additional design/ site considerations u S e "(• AJ ok.c -9 Parent material -TCS -T,? 'PA L-07 Sf . Flood plain elevation, it applicable It $ = Suitable for System CON-VENTIONAL MOUND IN GROUND PRESSURE AT -GRADE SYSTEM W MMOING T AW, If U= Unsuitable fors stem R' O U ❑ S 2� 2 11 U ❑ S B O S 91T I IDS SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botnd3y Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed lToxh 1 1 140-20 /,* YR Y11 t f shdt 4 R C 55 ( I 0 - 4o /O f (23 /2- $t 2; 7 S be S CS 2 non Ground 3 /O Y,e y Le ^ Si /, l f sk /►•n f i a '- 1 -f . LC , S /0/.J-ft /0 vp y` S Sr' / l -F s!� ,w• / ' a,r' i . �t • S Depth to 6 ' C/� lo ysP Sl - C . $ • Q S d X r • d limiting factor �a Remarks: 12-" R v t E A PIP 1 i £D - }-o t+o P- A3 . Boring # ( 0.1 Io YR z eB6- w C c ! sr'r'. ! f C.5 z co Z I7 -32. /o V2 313 s� �. �, �f' '�"`� 1Z S 1 J - . `{ •S Ground elev 31- fo YA 316 � S nM nn,A a.0 �- : - 7 . o O /0 2 •� ft Depth to tft�> 3 A--�Tti PV A-)' c6..5 i" vouS' ( 40 10" /p limiting B o 1=- J d (e 51y hoj,+ 1P I' /. A00 i a,r .4-( . S factor Remarks: _ I l " R io - 4 - oho CST Name: - Please Print Ro s e a r 2l L IB R 1 C h r Phone: 7 ? 18 5 Tess: ( SS ©' Nei L 'Rp. t(- U 0,so ,v Gv l S. 5 y o r !a cS Th 2. 4 8 L Signature: r �Z��l� W CA , A I � Date: � CST Number: APPS ,_ N O 7E 7 'this test site . ��. nYetntio�� s8 8 for hex" c i s F l��yt S c i4 u ,� o p tco 5 T' T f o ? E�4 D 't t'o�S E g Elo w o � > l� 2 � I'f LEo R &977'. t1cfi t U li St' L . %A VAJAJ r',J ( A G ORIGINAL Polerro,5 OF Te:�s7T a-t-� . S -rem 5 ko b L " 0T C3 F i &3 012 PROPERTYOWNER 1/�RN w �XO^� SOIL DESCRIPTION REPORT Page? of PARCEL L04 tl / Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouckxry Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. I Bed Twnch 1 0 • �l /o y2 3/1 A :577 !, f; gx- nom► 77 � S 37 � /" 5 F 51 Ground . 35 /D YA f Sl e d A CS �- . S _ to e J51 Depth to limiting factor Remarks: _ Boring # 1 0- 16 fie 31 Si�, 2 Sit n� f,� C S 3 • S J, _j M -2f �' fib• i Ground -3 2 3 /° ��� sit /f -4W -,I Cs j 5 v g ft Depth to smiting factor f/ , Remarks: Boring # 1 0-16 /o% 31-1— �---- S'i/ / 7 , :41 - CS 3 f ' •-5 Ground • , ' elev. y .z- y /a`,e 3K. s / .�,, g',2 s j •� /Q Z''° t ` goy s/y •s �, S ,� . � 1 . 0 Depth to Nmiting 7 fac tor Remarks: U /-2 'Gc.'r.� Boring # L i Ground —'— elev. it Depth to limiting factor Remarks: can OOOA /O ACMM 1 d Jr 3 w � � N W 5 Y STEM APeA -- co N • o W a o r o 0 -i - 00 -0 0 `o `F D. w o m ° Q Rk Q " n r L VI W \ L C `I 0 O rn 0 ST CROIX COUNTY • SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer o ¢ l r • i1; i�,� r �,��� LT Mailing Address ,elf i�1 Snit J � Property Address— 0 Ja V , ,i ,q,il a AXU�� (Verification required from Planning Department for new construction) /� City/State J d.SQ A J Parcel Identification Number Kl�,O 1,366 LEGAL- DESCRIPTION Property Location , 5'aJ %4, S ,�F %4, Sec. _ j(a, Tic. N R W, Town of Subdivision Nn n n ;a Lot # Certified Survey Map # _yo,, Volume . Page # Warranty- Deed # x'8'7 9.5".� Volume 136 0 . Page # ' Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑. no S MNANCE bvwpauwaadmaiateoaa,oeofymwptic couldr+ emhinitspnmat= faaureto ,baadlewastmPmpernmb*naaoe Cwsiscs of pumping out the septic tank every throe years or soone4 if Hooded by st licensed pumper. What yon put into do system can affect the fimah'oa of the septic tank - as. a treatment stage in the waste disposal system. The property owner agrees to sabmit to St. Croix Zoning Department a certification foam, signed by the owner. and by a =sW p1un9w4joarney=nplumbcr, restrictedphunbaoralicensedpaoVerverifYing that ( 1) die on- site;wasteanrterdisposaisystem is in proper operating condition and/or (2) after won and pumping.(if necessary), the septic-tank is less than 1/3 full of sludge. Vwe, the und=igned have read the above requirements and agree to maintain the private sewage disposal system with tha standards set forth, hacin, as set by due Department of Commerce and the Department of Natural Resou sta ' 69 y our septic urns; state of Wisconsin, Cerhficatioa system has beta maintained must be completed and reteuned to the St. Croix County Zoning Office within 30 f the d= irati date. SIGMA 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 it by ' of a warranty deed recorded in Register of Deeds Office. '� SIG F APPLICANT DATE s• « « «« Any information. that is mis- represented may result in the sanitary permit being revoked by the Zoning Depar :rt. *' «••' • Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey a if ref Y P reference is made is the warranty tl' d red STATE BAR OF WISCONSIN FORM 2 - 1982 it WARRANTY DEED DOCUMENT NO. Daniel R. Shaha and Karen A. Solverson, n REGIS'f E''� �iCE 1 � husband and wife, ST, QR0)X M, W1 ;� �44d tMf �h�9rd SE j conveys and warrants to Grew L Gunderson, a sincfle person C): D D I Re aster Af gsdiF i Ij l THIS SPACE RESERVED FOR RECORDING DATA `I NAME AND RETURN ADDRESS the following described real estate in St. Croix County State of Wisconsin: i EAGLE VALLEY BANK, N.A. i 1301 Coulee Rd., Unit 2 Hudson, Wl 54016 020- 1308 -90 PARCEL IDENTIFICATION NUMBER ( II Lot 9, Pleasant View in the Town of Hudson, St. Croix County, Wisconsin. I TRANSFER j FEE i I I 11. ( 4 This is homestead property. (is) XIOM Exception to warranties: Easements, restrictions and rights -of -way of record, if any. li Dated this 17th day of Se A.D., 19 98 �I it (SEAL) (SEAL) Dana 1 R. 4Sha (SEAL) (SEAL) I } Karen A. olverson I � AUTHENTICATION ACKNOWLEDGMENT j( State of Wisconsin, j � Signature(s) ss �I - Vernon County. �� c � � � I • I NORTHLIMg $TqTION.,jI I I fs'12S 7 [0 fS.6fN ° - W o - _" Ae 1 N ^^ - : r 10 "' ° I'o ° 11 W,6M pb ^y, ♦ n ! . 0 4 e I ^ r _ ♦ /,0 ♦ ♦ O F ' � / 1. h / 16'S2f 7 LS fS.61N // •��, <ti i ,�, io is :�. / —07 / • e rr-- -- SB'119 1 •, • N- i o .r a .o r r / / • fl, `• \ \ ` O` • .. C j F O e : 1 ro .,w�.i •o �T a � Mme \ ��Jpl�l O �, •I .1 0 uj 111 Ill ; N : I ' - N •\ i m b \ W r„ I I ` � ■ Y .� . Y \ \ I C J & I w j 0 . 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