HomeMy WebLinkAbout030-2031-40-000 ST. CROIX COUNTY ZONING DEPARTMENT
AS BUILT SANITARY REPORT
Owner ) �,
Property Addres4 9 Q nt N 6
City /State : 54 ,
Legal Description:
Lot Block Subdivision/CSM #
1 /a N /4, Sec. Z1.3. TAN -R W, Town of PIN # CO 3-, X� _r
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION
Tank manufacturer W U^'— Size ST/PC Setback from: House -5 5 Well 0A, P/L
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: 1 Width _ Length ? S Number of Trenches
Setback from: House &Y" Well � P/L - 9 6 Vent to fresh air intake 94
ELEVATIONS
Description of benchmark Elevation /tz
Description of alternate benchmark Elevation
Building Sewer ST/HT Inlet
9 4' S ST Outlet PC Inlet � - - '
PC Bottom T _ Header/Manifold 7 .23 Top of ST/PC Manhole Cover
Distribution Lines
Bottom of System
Final Grade () 9 6-y
() 5 9 ( )
Date of installation R 6?_/ ermit number 3 � State plan number
Plumber's si nature License number Date 9 /,?F/ 9 9
Inspector `
Complete plot plan
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
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INDICATE NORTH ARROW
Wisconsin department of Commerce PRIVATE SEWAGE SYSTEM County:
t
Safety anti Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: ST, CRC IX
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 338844
Permit Holder's Name: ❑ City ❑ Village IN Town of: State Plan ID No.:
PLOURDE, LAWRENCE ST. JOSEPH
CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.:
lcJO.c�� C*. &" n►. e,r- 0a►,r -CW 030- 2031 -40 -000
TANK INFORMATION ELEVA ION DATA A9900110
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ( Benchmark 7
Dosing B S va .S8
Aeration Bldg. Sewer
Holding St /Ht Inlet 1Y 9 .S
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD
`�!/ Air Intake
Septic > ,300 '!C S5 NA
Dosing NA Header / Man.
Aeration NA Dist. Pipe , ( sy
Holding Bot. System
7.
PUMP / SIPHON INFORMATION Final Grade 5_1 GG Z.
Manu er D 5 � 4
Model Number GPM
TDH I Lift Fricti ye t
Forcemain ength Dia. H Dist. To well
sotr' AB - SORPTION SYSTEM jZ j, ," J,
BfiD NCH Width Le h No. f enches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 DIMENSION
Manu c
er:
r a t u
SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING 1
INFORMATION Type of CHAMBER M el Numbe
System: G�.J 7 M 61 OR UNIT _ Li
DISTRIBUTION SYSTEM
Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia Length pacing
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.)
LOCA ION: ST. JOSEPH 3.30.20.447,SW,NE 1467 ANDERSON SCOUT CAMP RD
Plan revision required ❑Yes No 1 12 2Z . f '
Use other side for add tional information.
SBD -6710 (R.3/97) Date Inspector's Signature Cert No
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Safety and Buildings Division
Vi s�onsin SANITARY PERMIT APPLICATION 201 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, onO C ount
than 8112 x 11 inches in size.
i nitary Permit Number
• See reverse side for instructions for completing this applicati > • .
Personal information you provide may be used for secondary purposes i,ect 'revision to previous application
[Privacy Law, s. 15.04 (1) (m)]- tat FIa I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL II a RMA10&, / `
Prop rtyOwnerName r ation �.
h v4, S' �' T 3 , N, R E (or)®
Property Owner's Mailing Address ryumber Block Number
/ , • 1
i t y, St to Zip Code Phone Number Sub SM Number
. YP OF BUILDING: (check one) ❑ State Owned it Nearest Road
Village
Public 1 or 2 Family Dwelling - No. of bedrooms own OF Co
111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 3 Z 4 , qY' t
1 F1 Apartment/ Condo 03/ — — d ° °
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. ❑ Replacement 3. E] Replacement of 4_ E] Reconnectionof 5 ❑ Repair of an
- _____System ____ __System _______ ______ Tank Only________ - _____ Existing System ________ Exis --- System
B) A Sanitary Permit was previously issued. Permit Number Date Issued Z
V. TYPO OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
120 Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit `� 43 ❑ Vault Privy
14 ❑ System -In -Fill 1
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2- Absorp. Area 13. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
equired (sq. ft.) 1 (sq. ft.) Gals/day /sq. ft.) (Min. /inch) E vation
S D w 63 .� s 4. ? 9 eet G Feet
Capacit
VII. TANK in Ca allo Total # of r Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Exist in structed
Tanks Tanks
tic Tan r p�� -S ❑ ❑ ❑ ❑ ❑
tift Rue.. hamber I ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plum er's Name: (Prin PI er's Sig at (No Stamps) MP /MPRSW No.: Business Phone Number: CJ U po ^3 S3 7 71s O 5!
Plumber's Address (Street, City State, Zip Co e):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued ng Agent Signature (No.Stamps)
Approved []Owner Given Initial Surcharge Fee)
Adverse Determination` Zh
X. CONDITIONS OF APPROVAL / REASqNS FOR DISAPPROVAL:
1 q J�j
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 may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed 'pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, -$08- 266 -3151.
To be complete and accurate this sanitary permit application must include:
I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit_ Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
VIII. Responsibility statement. Installing 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'specificationsnot smaller than.81 /2 x 11 inches mustbe submitted tolhe 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 mainstwater 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.
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*6 onsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
P O Box 7302
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,_ 1 �O<
than 81/2 x 11 inches in size. �
• See reverse side for instructions for completing this application State Sanitary Permit Numbe
33y g�
Personal information you provide may be used for secondary purposes E] Check if revision to pr cous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATI N INFORMATION -PLEASE PRINT ALL INF RMATION
Property Owner Name Property Location
0 Lj 41 SW " NS S 1 /4, S ,3 T 3C) N, R E (or)e
Property Owner's Mailing Add ess Lot Number Block N mber
City, tate Zip Code Phone Number Subdivision Name or CSM Number
t ( )
11 11. TYPE OF ILDING: (check one) ❑ State Owned ❑ Cit Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms ° Tow OF S @�
III BUILDING SE: (If building type is public, check all that apply) arcel Tax Number(s) 2'!j - 'Z,p, '7
1 ❑ Apartment/ Condo ---10
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. t New 2. ❑ Replacement 3, E] Replacement of 4_ E] Reconnection of 5_ C] Repair of an
__System -------- System ------------- Tank Only______________ Existing System ________ ExfstfngSystem
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 � FQI Seepage Bed 21 [] Mound 30 [] Specify Type 41 []Holding Tank
12 Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System -In -Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Pro _p
(sq. ft.) (Gals/da /sq. ft.) (Min. /inch) Q p Elevation
` D 60 1� i3 0 ?1 ?Fee t / Z Feet
VII. TANK cap acit in all0 S Total # Of Prefab. Site Fiber- Exper.
INFORMATION Ne Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App
w Existin strutted
Tanks Tanks
Septic Tank or Holding Tank O `UO � `P rS ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber I I I ❑ ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for ins Ilation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Pr Ptu be 's Sig atu o Stamps) MP /MPRSW No.: Business Phone Number:
0,�� Co W ors �3 7 - 7/5 -a S1,25
Plu ber's Address (Street, City, Stat Zip Code)
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved S it Permit Fee (Includes Groundwater ate slue Issuing Ag t S'
Surcharge Fee)
Approved E] Owner Given initial
!71
Adverse Determination G'!;X
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 may be renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608- 266 -3151.
To be complete and accurate this sanitary permit application must include:
1. 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.
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 Bif permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
V1. 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 must sign application form.
IX. County/ Department Use Only.
X. County/ Department Use Only.
Complete plans and specifications not smaller than 81/2 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.
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.•1. i Appro.le Vsnl'C o
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finel .6f at. �.
20. 42' Above Pipe 4' Cad Iron
To final Ofo$., Vanl PIP$
_ ►tarn 110/ Of SrnlMlk Ce..i
Utn 2'Agptapalo •.
Ow Pipe
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o �"Ca.ptlno T.�tnlnoltna AI
oollom 01 s1
SOIL FILL.
OISTK►BUTt01.1 PIPE APPROVED swPAETIC COVCR
OR 9" of s
2" OF AGGRE6AlE ---�� ter; =� ; - OR �•1ARSN HAy
AGGRCGATr, pwU �• �'.
DISC ILIBtJTIU1J PIPE TV BE AT LEAS-( IfJCHES BELOW ORIGIMAL GRADE
AUU AT LCAS'T t0 INCHCL OUT 1,10 MORC 'THAI) 1 12 Mr-IIES OCLOW FIAIAL G RAO C
MXUMwM DXQ•t<{ OF F-X FKoM OR16WAL 6RAVR WILL. BC ate_ IWC.HES
t INIIA M 0Epnl OF EACAVATION r C ,1 , 1 6WAL rjR49k WILL »C Mr_
SIGUCO:
LIG kJUMBEII:
DATE
' WisconsirrDepartment of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page / of 3
Bureau of Integrated Services in accordance with s: Ly# -84,09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches/tn srze Rust
. Plan / County
include,but not limited to: vertical and horizontal reference point'(Btvl),direFfioni?ig,. C-;.AN C) r o 'i y
percent slope,scale or dimensions,north arrow,and location aald dithance ,(1° r i ad. Parcel I.D.# n
f
03o — 9O3/ - iyo - oco
APPLICANT INFORMATION - Please print all intor'rnatil�t� 4
®rJ." Reviewed byDate
Personal information you provide may be used for secondary purposes(Irivaey Law,s. 15.04 O1fm 1
s �P.V
Pro erty Ownera ii.L.,, t-p N.Q..9._ Pio Lt.r-il D___, P4mpo+ty Lo>ation
p Govt.Lot of 1/4N E 1/4,S T N,R ao E or W
Property Owner's Mailing Address Lot# ; Block# Subd. Name or CSM#f-
<<
City State Zip Code Phone Number I�if Nearest Road
El City El Village rg Town
Sl‘: o -,, I m I Ssa a,i ( ) S-t . Nin-c. :fL-- 14- ' er sccAfi Rc1
RI'
New Construction Use: Residential/Number of bedrooms J Addition to existing building
�{
Replacement CI Public or commercial-Describe:
Code derived daily flow -Jr(7 gpd Recommended design loading rate t 5 bed,gpd/ft2 %(' trench,gpd/ft2
Absorption area required 90Z) bed,ft2 75° trench,ft2 Maximum design loading rate , s bed,gpd/ft2 'to trench,gpd/ft2
,f
Recommended infiltration surface elevation(s) d,9 _ft(as referred to site plan benchmark)
Additional design/site considerations pal v,,.es
Parent material 04 u CA S )'\ Flood plain elevation,if applicable t/}- ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system Al S El u Ws 0 U X S ❑ U ❑ S U ❑ S V U ❑ S ...pC U
SOIL DESCRIPTION REPORT A yV-}, tro
Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2
Texture Consistence Boundary Roots
in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. Bed Trench
or,8 iy 3/ 5,/ 7c slk mi-r q3 Q F ,5 ;' (..
5'37 /a y°P /.% _` 5,/ 3 s b k- tm 5-, Q s l C , S ' '6
GroGround 3 37'9 /0 r y6 5i/ 02in 5b( m�rr c L)
eft. y a mr fb Sy9 gf ill - — ,
Depth to 95-41, -
limiting t `_
factor
14, in. •e. . ,..
Remarks:
Boring #
l 0-7 A2yr '//1- — 5' i ..,1m5bk irvS- 6.5 r ,5 , ,I.
50 /o (dlb 5/I ;, rnsbk m$ r ck5 /C-- ,5" 4.
j SO76 toy r j/a -cci-,ci Oess3 I - — , 7
Ground
elev.
ft.
Depth to
limiting ,
factor
.�% in. Remarks:
CST/Name (Please Print){'\ Signature Telephone No.
Address Date CST Number
PROPERTY OWNER '� A+�- ►►"2Nc�F? urc SOIL DESCRIPTION REPORT a a,
Page of 3
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. I Munsell Qu. Sz. Cont. Color C /l Gr r. . ►� Sz. S Bed ,Trench
o
_y9 c .2mSb
Ground �—
elev. `� r
q7, ft.
Depth to
limiting
factor
J'in. '
Remarks:
Boring #
S A, m ci S a ' � ,•
Ground
&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 #
.5 oL $- a21 D r
Ground S J vnf l
elev.
95� -eft•
Depth to
limiting '3&"
fact r -7 l
Remarks:
Boring #
[3
Ground
elev.
ft.
Depth to
limiting
factor '
in.
Remarks:
SBD -8330 (R. 07/96)
I
-
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer ' n i o t-Q h CQ, o u r C6 4
Mailing Address !—e 1! e ,( /f,(/(�'(e "_ V �SZI
Property Address Ik � O S D i! �
(Ver fication required from Planning Department for new construction)
City /State Parcel Identification Number 030 — a03 / S/4
LEGAL DESCRIPTION
Property Location 5 W '' /a, N ' /a, Sec. T 3 O N -R., Town of S� zo Se p1 .
Subdivision , Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # ,Volume _ ,Page # _Q
Spec house ❑ yes no Lot lines identifiable 7 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
masterplumber, 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 30
days ' e three year ex irat' n ate.
IR
SIGNATURE OF PLICANT 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 pr rty described above, a of a warranty deed recorded in Register of Deeds Office.
SIGNATURE OF AP CANT 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
boGUMEN4 No. STATE BAR OF WISCONSIN FOGY 1 —flit TM1e MACR ""*VIM MR *SCOMINe DATA
WMRANTr D990
464789
D W •Bura ct�_- and_ - -_- REGISTER' OFFICE
This Deed, made between . ._... �. CQQIX CO, �
NanC_r A_.._. u s. cY�,... b�uabalad. ..and..rai.fe..as-- ,�oiaL - - - - -- Reed for R
... tenant-s.- and..not...a13_..t.enanta.-in ...common- .---- .------- _ - -_._.
........................................... . .............................................. 9 Grantor, D ECI 019M
and... ..Lawrence....L...Plourde__and. Arlene- .A.. -- Plourde,_ d 11:20 As M
husband and .wife, .As. ..jaint... tenants ............... •••-- - - - - -• 0
..................... --- ----- ....................................... . ...................... Graatee, AtpNltrof0��dt
Witnesseth That the said Grantor, for A valuable consideration - -_ -__
. -- -• .._ . .._ ....... . ... .. .. . . .... .... ....... .. ...
conveys to Grantee the . following described real estate in _..St..._.Croi7c- RKTURN To
County, State of Wisconsin:
Southwest Quarter of the Northeast Quarter Tax Parcel No ...................................
($Wt of NEB) of Section Twenty -three (23), Township
Thirty (30) North Range Twenty (20) West.
This Warranty Deed is being conveyed to satisfy Land Contract
dated November 14, 1985.
+�
FM
This ------- 1$__.n0t------- homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And- -- --- -- -••--
warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except
and will warrant and defend the same,
Dated this - - - -- ------ 5th --- --- --------- day of ---------- - November-------- - - - - --
19_.9Q_ -.
�
- -- -- -
---------- -- ---------------- ---= •------ - - -- --- - - --- (SEAL) -- - ..RiYV►'u�_..:1!1.. -- � - -- - __ (SEAL)
' -- - - - - -- ........... - a --- ennisW. -1311r$ch-----------
li
- ----- ------- ------- -- -- -- - -• - -- ----- -- --- -- -- -- - -.... (SEAL) - -- /� � "� � CL�,+CG .- - - - ---- --(SEAL) i
x
- - -- ----- - - - - -- ----- --- - -- - - - - -- ---- •----- • --------------- Nancy_ - ----- ul:sckt ---------------------------
AUTHBNTICATION ACSNOWLEDOMBNT
Signature(s) -------------•----------- --------- --_• ........... .-......... STATE OF WISCONSIN I
i
-- -- - ------ - - - . . IX - -- ......... County
authenticated this ........ day of ---------------- ___•------- 19 ._..__ Personally came before me this .. -g�� ....dif /st i
- - -- November . - - __ -- 19.4Q_: the,bove fi&.4'
..................... ---• .................... I------------- ---•-- -- -- ----• ---- J !!
Dennis__S±I.___Bursch__ and • .
:NarVy AJ_
' - - - -- ---- - - - - -- - - -- Bursch
TITLE: MEMBER STATE BAR OF WISCONSIN ,^
------------ ---- --------- •--•-- ---- --• -_- -- - ----• r
(If not, - -- -- --•--- 4
authorized by 706,06, Wis. Stats.)
qeg�o S.
be the person _____.__.. who ezecul�rt�te
f ment Jf. d acknowledge) the a ......
B THIS INSTRUMENT W AS DRAFTED Y � •l.t•L.-... . ............._..
............... ... ..... M._..Wagner- - - - -- ---------- _ - - - - -- . - - --
... -_ ...... --- •- .._....---- - - -- -- - - - - -• --- --- --- ------ N– ..St...- C.roiX . --- ---....County, Wis.
(Signatures may he authenticated or acknowledged, Both M is permanent. (If not, state expiration
are not necessary.) date: _- 09113._ .. ...... _... - -_- ---- -- ----- --- 1912....)
*Nara s of persons signing in any opacity shou!d be :opal or print.l bel— their sigaat.,rrs-
WARRANTY DEED STATE. BAR OF WISCONSIN Wig ,nain Legal Black Co. Inc-
FORM No. 1 — 1932 Mil — -ke, Wis.