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HomeMy WebLinkAbout026-1111-60-000 \ // } ) � o / 0 4 4 � � I � 2 / � % } � £ \ E < m_ ) � § % 0 z' 0 z / § % / ) j a ■ / § z § 2 ) t z J $ \ co D 0 \ E $ .� ƒ - / § 3 ) Q t z) z a $ k .. k > \ � 2 � ca n � § k J ( \ ) k ■ m } ƒ j { » n g k & & } S .;E 0 0 0 t - & )_ J - § \ § ° �\ { Cl) 5 ) » © : 3 \ 2 , � � k \ $ = S E C14 c o ®/ S J 8 8 § e G = & ) § C \ / ) / § 'n / k \ / § - w 0 0 Cl) 0 2 f§ )\ � t � ® � � a « E 0 » / E)) ka§ IL / � a 2 o 3 o ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner I twx L-9,M �P� Property Address S/ City /State Al tc N 41 Legal Description: Lot ?w4 Block Subdivision/CSM # 0 I.-. - &d IV '/4 5 ' /a, Sec. , T 3 0 N -R Y W, Town of PIN # 02k- 66 SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC Ow l Setback from: House VO Well 60 P2 17 Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: Q. Width 1, 9 - Length Number of Trenches Setback from: House 19 0 Well oV P/L �_ Vent to fresh air intake ELEVATIONS Description of benchmark (l S N � �-n Elevation Description of alternate benchmark Elevation Building Sewer ST/HT Inlet ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover 8 i Distribution Lines Bottom of System O '73. O ( ) Final Grade g9�s Date of installation 5 /a7'/ Permit number .33 State plan number i Plumber's signature License number ;Q6.5- Date S L� / g Inspector - Complete plot plan •�' i NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW 7 l� i r Pd �- .S INDICATE NORTH ARROW Parcel #: 026- 1111 -60 -000 04/29/2005 08:38 AM PAGE 1 OF 1 Alt. Parcel #: 4.30.18.632B 026 - TOWN OF RICHMOND Current X', ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): " = Current Owner * NORDQUIST, DARLA DARLA NORDQUIST FEHLAN THOMAS FEHLAN THOMAS 1751 MARGARET ST NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): ` = Primary Type Dist # Description * 1751 MARGARET ST SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 0.600 Plat: 2573- VIEBROCK'S RIVER VALLEY VIEW SEC 4 T30N R1 8W PT LOT 33 LYING S OF Block/Condo Bldg: LOT 33 FOLLOWING LN: COM ON W LN LOT 33 41.28' NE OF SW COR TH SWLY TO A PT ON SE LN Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) LOT 34 10' SW OF NE COR LOT 34 ASSESSED 04- 30N -18W WITH P633A & P51A -10 AS DESC IN 877/221 Notes: Parcel History: Date Doc # Vol /Page Type 10/13/1997 566786 1269/578 WD 09/03/1997 1261/473 QC 07/23/1997 1152/441 WD 07/23/1997 437/393 2004 SUMMARY Bill M Fair Market Value: Assessed with: 20530 169,300 Valuations: Last Changed: 06/20/2002 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.200 41,400 112,200 153,600 NO Totals for 2004: General Property 2.200 41,400 112,200 153,600 Woodland 0.000 0 0 Totals for 2003: General Property 2.200 41,400 112,200 153,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 307 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel #: 026- 1111 -70 -000 04/29/2005 08:37 AM PA GE 1 OF 1 Alt. Parcel #: 4.30.18.633A 026 - TOWN OF RICHMOND Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): = Current Owner " NORDQUIST, DARLA DARLA NORDQUIST FEHLEN THOMAS FEHLEN THOMAS 1751 MARGARET ST NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 0.000 Plat: 2573- VIEBROCK'S RIVER VALLEY VIEW SEC 4 T30N R18W PT OF LOT 34 OF Block/Condo Bldg: LOT 34 VIEBROCK'S RIVER VALLEY VIEW ADD: COM 41.28' NE OF SW COR LOT 33 SWLY TO SW Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) COR SD LOT TH ALG NWLY SIDE LOT 34 FOR 04- 30N -18W 59.45' TH SELY TO SE COR LOT 34 TH ALG SELY LN LOT 34 TO A PT 10' FROM NE COR more Notes: Parcel History: Date Doc # Vol /Page Type 10/13/1997 566786 1269/578 WD 09/03/1997 1261/473 QC 07/23/1997 1152/441 WD 07/23/1997 437/393 2004 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: Description Class Acres Land Improve Total State Reason Totals for 2004: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2003: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel #: 026- 1014 -80 -110 04/29/2005 08:41 AM PAGE 7 OF 1 Alt. Parcel #: 04.30.18.51A -10 026 - TOWN OF RICHMOND Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): = Current Owner NORDQUIST, DARLA DARLA NORDQUIST FEHLEN THOMAS FEHLEN THOMAS 1751 MARGARET ST NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description SC 3962 NEW RICHMOND SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 0.000 Plat: N/A -NOT AVAILABLE SEC 4 T30N R18W PT N1/2 SE1/4 DESC AS Block/Condo Bldg: COMM SE COR LOT 36 OF VIEBROCK'S RIVER VALLEY VIEW ADD'N; TH N 16 DEG E 148.77' Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) TO POB; TH DUE E TO WILY R/W OF CTY TK A; 04- 30N -18W TH NLY ALG R/W TO A POINT DUE E OF NE COR LOT 34;TH DUE W TO NE COR LOT 34; TH more Notes: Parcel History: Date Doc # Vol /Page Type 10/18/1997 566786 1269/578 WD 08/03/1997 1261/473 QC 07/23/1997 1152/441 WD 07/23/1997 877/221 2004 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: Description Class Acres Land Improve Total State Reason Totals for 2004: General Property 0.000 0 0 0 Woodland 0.000 0 0 Totals for 2003: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y: Count Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST CRO X Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 338925 Permit Holder's Name: I ❑ City ❑ Village Town of: State Plan ID No.: NORDQUIST, DARLA /FEHLEN, TOMI RICHMOND CST BM Elev.:- Insp. BM Elev.: BM Description: 1 7 026-1014-80-110 Tax No.: 01O d /' K 1.r�" j .. l ti✓ ,..a TANK INFORMATION ELEVATION DATA A99001$0 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ° Benchmark M9,311 A) Dosing Aeration Bldg. Sewer I Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet irl Septic 1 9 , 6 o 2 s NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System / 93j PUMP/ SIPHON INFORMATION Final Grade Manufacturer 6emand Model Number GPM i TDH Lift Friction ystem TDH Ft oss Forcemain Length Dia. H Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS /-- 47` •� 1 DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION TypeOt CHAMBER Model Number: System: l� p ' /Q 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: RICHMOND 04.30.18.51A- 10,NE,SE 1751 MARGARET STREET Plan revision required? E] Yes ['No Use other side for additional information- SBD -6710 (R.3/97) Date ks $ctor's Signature Cert No. L _ ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: { x E a E i i t e f # e a a w i L a ..�... { f w., e a a { x . 3 { i ..mom..,. .. ,: -..P. ....� ,.,....� ,.e..n.. ... {... ,m..e.., ,- .. ,. ,.. w. _ . _.» ...... m, � f t } 3 m. m. ,..., mm .. ...} mmd . .......... ..s n-- .., m... { ,.. ...,. ! m.� n f { E E ' _« i . w e.. w� .... ,,. emu. .e m.mK ... _. a<.. ,..,µ_.x ..,.»,.... ._ .„a. r 1 � ... �., .... �. ,.. m , i 7 i f £ f { Safety and Buildings Division NVisconsi SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. a t • See reverse side for instructions for completing this application state sanitary Permit Nu ber 33 ? r l 2 1 � Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Ow Name P 0 !y Location t .19 1/4,S T N,R E(o W al 14444 30 Property Owner's Mailing Address Lot Numb Block Number City, State U Zip Code Phone Number Subdivis on Name or C Number 11. TYPE OF BUILDING: (check one) ❑ State Owne It Neare Road p Village Public 1 or 2 Family Dwelling - No. of bedrooms Town of III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 07-11io -1 CIA - 8o I1, O 1 [] Apartment / Condo 4-so- 1 — 1 p -- 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. F Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an - - - - -- System - - - - - -- System --- ---- - - - - -- Tank Only ------ - - - - -- Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit X 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. /inch) Elevation Sa A l•7 93. Feet , J Feet VII. TANK Ca acft in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Existing structed T nks Tanks Septic T o o Ing Tank ODD ❑ ❑ ❑ ❑ ❑ L ift Pump Tank /Siphon Chamber I I ❑ I ❑ I ❑ I ❑ ❑ 1 ❑ Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for i tion of the onsite sewage system shown on the attached plans. Plu ber's Name: (Pri PI ber's Sign ture: ( Stam s) MP /MPRSW No.: Business Phone Number: S a V G S Plumber's Address (Street, tit , State, Zip Code): IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing ent Signature (No Stamps) []Approved E] Owner Given Initial Surcharge Fee) Adverse Determination a-� /7 � X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) 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 maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4_ Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608- 266 -3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed: IL Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber mustsign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plansand specifications not smaller th6n.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 Foss; 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. T �e hL -e, w lU O_ S� ff) o, Va r Sit • U ►w.b r k tzuw Y �I.QAZ ..5FiEa a OcAv" a- y , n �z Ir - C (�U S S JY 1 S a a r = f� e"or JQ iC11hnCYM'1 S'yo �Y sp s r 3 au Itic� r fresh Alt Inlot► And Observation PIDe (�{_ �1�(( n f ._\.1• VR-A— LJ"�I.u.i i F� Appre Vent Cop f�tiT 3� •,� Nlntmwn 12•AOOro 11 ►Ino1 Clads VV 0A 20' 42' Above Plpf —4* C°el Iron To ►IAO1 Credo— Vent Ptpo Mash Ilex Or SrnlMlk Co.rr , • Lln 2' Appropoto O.er Ptpe J — DI III IDvtlon ' Pipe --Toe i C A AOQ pips Poll 01 PI ' OeneoU Itpo ° p 'o below o `C.,Vlnp Tuminolinp At Oellom 01 Srotem P rp�nSe D �I�e -` gri.clt SOIL FILL D►S7IZIBU7IO1.1 PIPE A PPP ovED SjgpAurlc covcR ••• �11�Tl:RIAt• OR J" of sTaAw 2" of J�GGRCG1liE —�� =r ;,' -' "" OR MARSH HA`j a OPlt -2 AGGItCGATE DIS"I"RIi5u - now PIPE 7(j INC. AT LEAST _ INCHES BELOW ORIGIIJAL GR AQU AT LEAST LO IIJCHES BUT 1.10 MORC THAW 42 IUCII£S BELOW FINAL GRADE MAXIMUM OaVrvi OF F- )KAVATIOP FXOM ORI&WAL 69ADR WILL BE '', IucHES 'rJKItAV pEp ni of EACAVATImN r-P � GR4Dk BE, WILL B IN CHE S SIGIJCD: LIGCIJSC 11UMBER: DATE 110 _ Div ision f Department Safety and Buildings Commerce Pa Di SOIL AND SITE EVALUATION g � Division of a of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County , include, but not limited to: vertical and horizontal reference point (BM), direction and st . r O \X percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 0" - /J 11- � 0 - 00b APPLICANT INFORMATION - Please print all information. Reviewed b Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). r Prope Owner Property Location Govt. Lot 06 1/4 5e114,S T 31 ,N,R l g *or) W Property Owner's Mailing Address' Lot # I Block# I Subd. Name or CSM# JC .3& City State Zi ode Phone Number Nearest Road ❑ City ❑� llage Town ❑ New Construction Use: Residential / Number of bedrooms Addition to existing building X Replacement ❑ Public or commercial - Describe: �f Code derived daily flow 'V_50 gpd Recommended design loading rate bed, gpd /ft . o trench, gpd /ft Absorption area required G!q bed, ft SO trench, ft2 Maximum design loading rate bed, gpd /ft I Y trench, gpd /ft Recommended infiltration surface elevation(s) go ft (as referred to site plan benchmark) Additional design /site considerations Parent material Q 14 CLS I Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Pill Holding Tank U = Unsuitable for system 41 S ❑ U (AS ❑ U ® S ❑ U ❑ S U ❑ S RL U ❑ S 29 U SOIL DESCRIPTION REPORT Q Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft in. Munsell Ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench . 5 1 k O- 4 /0 5 Ground 139 AD M S 3 elev. eft. 5 , g Depth to limiting factor - HI > in. Remarks: Boring # .....:.................... .3 1' / r Ground t7 sAg f 1 ' $ '- elev. Depth to jW limiting factor >94 in. Remarks: CST Name (Please Prin Signature Telephone No. 71 r Address Address V Date CST Number / Zks 5 -Il aa s.? 7 PROPERTY OWNER 1 D� Fe�\&V - SOIL DESCRIPTION REPORT Page —c2— of a. PARCEL I.D.# C�e16 /II� �O"� t7J Boring Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed .Trench ra Ground 3 7' 0 r S f ! ' 1 7 :. G e elev. ft: -s� o Depth to limiting fac r 'Win. Remarks: Boring # i3 Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # i3 Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) Tam, f. P ht 175!4 �' V C�, �w U )41A ldgAJ3 w4 R►e- hVV►OV►A 1 sy o17' oat - ,itt r6o-pO° A / Vil C, b �o- ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the TOvvl� E2 U4, %- residence located at: _ 1 /4, .5r _ 1/4, Sec. T_36 N, R /a W, Town of " knznj Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? Yes NoA(if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacurer (if known) : ----• '��1� Age of Tank 'f known): abrri a 4.1 A�o W --J4 V'-C' (Signature) (Name) Please Print & e-s- z z O 5 3 7 (Title) (License Number) 5'J* (Date). Form to be completed by licensed plumber (s.14.5.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) -- — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR -83, W' Adm. Code (except for inspection opepn 'g over outlet baffle). Name �Q�pt#1 �� Signature � trtr� S 5/88 i ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Mailing Address 1 Qr sc�o�7 Property Address Sc (�4._, (Verification required from Planning Department for new construction) City /State Parcel Identification Number C),a to — (I 1 , ( Q LEGAL DESCRIPTION Property Location A E '/4, V4, Sec. , T N -R 3c) W, Town of LA-) Subdivision r D S t V Ct �� `-� cv , Lot # 7 ? Certified Survey Map # , Volume , Page # Warranty Deed # -$& liv7� �o , Volume / , Page # s 7� Spec house ❑ es no P Y � Lot lines identifiable yes ❑ no SYSTEM MAINTENANCE 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 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 master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal 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 34 days of the three year expiration date. �GNAJjJRE 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 ` the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. 4 XJU OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.****** ** 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 , [� Yet SIAIf It (T Wl;t hfJtilN It ) IM 2 - 1 WAKIZAN I Y UI I DOCUMFNr NO James M. Hebert, a /k /a James Michael IjEGIS; r r`'5. OF FICE Hebert, a single person - 5T, Gfipix CQ„ WI OCT 13 1997 r,,,., vs and Harraats 10 - - D arla _- Nord st- -and Thomas­. - _ — Fehlea ____.___---- - - - - -. _.--- _. —__ -- 9:15 A.M Re later of Dee=ia r I; THIS SOACF RE�EHJED _R DATA Nnt1E AN0 RETURN ADDHESS tI„ ., n „",,!! �e,�r,I�d «,I ��..�,,, !!, - -- �t _ .Croix. - - -- -- Attorney's Ti e of Still. k ' (ountt', S�atc.,l iV'i;n;mm i t"atEr 1835 NorthwC-Stern Avenue ^ti!iwater. MN 55082 026 -1 1 1 1 -60 0 -1 1 1 1 -70 (See Attached Exhibit "A ") 3s1 __lam _ hur;r - .;red r!rl Easements, restrictions and rights -of -way of record, if any. ( , - -- L, of September 97 Jame M. Hebert, a /k /a James Michael Hebert nt IlfrV r1( AFION ACKN0 \VLPUGNIFNF 0 James - -M. _11ebFtrt,_a /k. /a_ -_- cite of ��i,;Consin, James-Michael - Hebert - _ - - - ,,'' � Sept.L"-.mbe ID _9.7 - -- ('ir : - .,na h•'Inir nr !his _. Ala }'� Kristina OgLand r Attorne7 Kr i -it i na Ogla Ht:dsnt ?, 9 40? 6 , r i uat 1.269PA1 EXHIBIT "A" PA RCEL I Part of Lots 33 and 34 of Viebrock'9 River Valley View Addition in the Town of Richmond, St. Croix County, Wisconsin described As follows: Commence on west Line of said Lot 33, 41.28 feet NEly of SW corner of said Lot 33; thence Sally to SW corner of said Lot 33; thence SWly on Nr71y line of said Lot 34, 59.45 feet; thence SEly to SP corner of said Lot 34; thence NEly on SFIy line of said Lot 34 to a point to fee, from NE corner of said Lot 34; thence NWly tc Place of AAglnrii.ng. P ARCE L _I A part. of tho N 1/2 o SF. 1,4 of Section 4, Township 30 North, Range 19 West, St. Croix 9 A4, Wisconsin described as follows: Commencinq at the SE corner of Lot 36 of Viebrock's River Valle 3L w Addition to t,'-.e Town of is mon ; thence 15 "07'E 148.77 feet to the Point of Beginnin parcel to be described; thence due Pant to the Wly right of way of County Trunk Highway "A" As currently laid and travAled; thence Nly, along said right of way, t a point which is due Rasa- of the NE corner of t 34 of -1i eebr.ock' s River Valley view Addition thence c mjer Pt*^r",r5 t'�e : — cS f n ZT� Lot 34 of said Addition; thence S39 "50'W 141.75 PPP, ;o Lhre ^IE corner of Lct 15 of said Addition; thence S16 50.0 feet to the Pcinn of Beginning. �i.1b1PCt To an eaSC'.Tnnri in favor of W --' -am J. Fr �F_'C °, his succP.SSOrS and assigns, over thA Wly 30 feet of the a!- ciescrit-ed property, for p.urpoF of ingress and egress. 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Z - R2 t WARRANT)' DEED EXHIBIT "A" Apr PARCEL I Part of Lots 33 and 34 of Viebrock's River Valley View Addition in the Town of Richmond; St. Croix-County, Wisconsin described as follows: Commence on West line of said Lot 33, 41.28 feet NEly of SW corner of said Lot 33; thence SWly to Sw corner of said Lot 33 thence Sally on Nally line of said Lot 34, 59.45 feet; thence SEly to SE corner of said Lot 34; thence NEly on My line of said Lot 34 to a point 10 feet from NE corner of said Lot 34; thence NWly to Place of Beginning. PARCEL II A part of the N 1/2 of SE 1/4 of Section-4, Township 30 North, ;Range 18 West, St. Croix County, Wisconsin described as follows: Commencing at the SE corner of of 36 of Viebrock's River Valley View Addition to the Town of Richmond; thence N16 148.77 feet to the Point of Beginning of the parcel to be described; thence due East to the Wly right of way of County Trunk Highway " A " as currently laid and traveled; thence Nly, along said right of way, to a point which is due East of the NE corner of Lot 34 of Viebrock's River valley view Addition; thence due west to the NE corner of Lot 34 of said Addition; thence S39 141.75 feet to the NE corner of Lot 35 of said Addition; thence S16 50.0 feet to the Point of Beginning_ Subject To an easement in favor of William J. Preece, his heirs, successors and assigns, over the Wly 30 feet of the above described property, for purposes of ingress and egress. P 19 , the above named • K 0g +r TITLE: MEMBER STATE BAR OF WISCONSIN (if not, authorized by §706.06, Wis. Stars.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Og Hu d so n, WI 54016 Notary Public, County, Wis. (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date: necessary.) 19 ) • Names of petsons signing in any capacity should by typed or printed below their signatures. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. �I l WARRANTY DEED i;onn No. 2 -1982 Mihen km, Win