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030-2036-30-400
% 0 2 0 k \ ) o r 9 K } 0 f 0 \ ; [ _ 0 % 7 c $ J m . 7 / 2 % § 0 % gCj z 2 } ) ] [ c CL LL LL j\ 0C § § # a \ a # / J ■ � 7 • 7 z . CD 2 � ` 0 0 "t k V A / � I a m 0 0 0 z % t c £ © � - t z z e E 2 e E 2 m r 3 2 CD .� Ix ix a. b ƒ � 2 � 0 , 0 \ m 0 \ § k k § D k .. z z - : C 2 4 c lot co �t \ �� CLM �/ \@ & 0 2 2 m 2 0 . Z n k \ � k 6\ o . � 20 a a a z �� a 2 a R k > 2 2 @ @ o j \ \ j 2 �j \ \ t i� $ o E ) o o ] 2 a ƒ D C a 2 ± U z 2 $ .6 � J ¥ m m �© .6 2 # z ■ % k ■ I ) E _ $ E o e « o ° Zo ° ./ c c 8 a@ k o f o a- 8 8 £ ; o ; c = 6 �: . . E .e%R� 2 g§ 0 a / I 12 5 c n c 2 § g .2 = . t z z = 2j CD to s = c - �/\ k ; m a§ E E` 7 2§ a 9 c 7 g am/ R 0 2 3 6 0 A �« g o z/ z z / 2 .. .. � 2 m �2 §� 2 l L: IL » IL » § e c a§ c a§ Con k 0 a 2 0 2 v � - - — - - -- Form -STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER V /, L✓A,Ot�.✓ TOWNSHIP Sy �/ps�,oy SEC. �� T O N -R W ADDRESS p80f� /y�„�ps -� �D, ST. CROIX COUNTY, WISCONSIN S T'it .4 - IAI SUBDIVISION LOT LOT SIZE 10c�rs PLAN VIEW �-- �_ TN6fI i�✓ �4a.K Yo.ys /.vSO�cTiu•✓ Distances and dimensions to meet requirements of I1.HR, 83 S/✓�d j SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM p8S d��A fia✓ GA `7' ' gg l' no C a r •� rr Jr � ooal INDICATE NORTH ARROW /JOT rort p BENCHMARK: Describe the vertical reference point used r Sr i ,o. GoAar^ of /0 Elevation of vertical reference point: Proposed slope at site: SEPTIC TANK: Manufacturer: Ae/-0v�sT6� Liquid Capacity: /DOD 6itS. Number of rings used: _�_ Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front,0 Side , Rear. yao feet From nearest property line Front 1 0 Side 1 0 Rear,0 _ Z feet Number of feet from: well >�O , building: 47 (Include this information of the above plot plan)( 2 reference dimensions to septic tank) 1� S REVE RSE SIDE i PUMP CHAMBER Manufacturer: iquid Capacity: 7S0 r .0". /P Q�i'ic P Pump Model: tL- �.?S�`l/ Pump /Si�iwn Manufacturer: y � P um p Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: oo Lour Number of feet from nearest property line: Front, O Side, O Rear, i Number of feet from well: >SO i Number of feet from building: ,3 (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: 8 Length: `! Number of Lines: Z. Area Built: Fill depth to top of pipe: Ntuher of feet from nearest property line: Front, O Side, ® Rear,0 Pt. Number of feet from well: /.Sb Number of feet from building: (Include distances on plot plaia). „ SEEPQcGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbbtion sytems? (Check one). H0LD+ TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: from building: Alarm iacturer: Inspector: Dated: /S_ Plumber on job: License Number: 3/84:mj.. i ` SANITARY PERMIT APPLICATION COUNTY T DILHR In accord with ILHR 83.05, Wis. Adm. Code 57 STATE SANITARY PERMIT ## —Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8Y x 11 inches in size. „ Q a —See reverse side for instructions for completing this application. PETITION I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION FOR VARIANCE ❑ YES CKNO PROPERTY OWNER PROPERTY LOCATION `�/--- o !' iI[ a11✓ Se % ,SE '/4, S Tao , N, R X i (or PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME OIL 0.40 Af CITY, STATE ZIP CODE PHONE NUMBER ET eiw NEAREST ROAD,4:AKIS OR LANDMARK z - S.S08.2 3f- A E0 TOWN E . lar�r «vii II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family -j OR ❑ Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. ® New b. ❑ Replacement c. ❑ Replacement of d._❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit ## Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner /building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. Conventional b. ❑ Alternative C. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. DO Mound f. ❑ IGP In -Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. X Seepage Bed b. ❑ Seepage Trench c. ❑ Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): i A/ 37� ,37� 5' 0 Feet Private ❑Joint Public VI. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or4eldin /000 A200 / awnr a n- cw,sr' ® ❑ Lift Pump TankW4pfien Gen+ber 7sO _ .s0 �� it © 1 ❑ ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Si ture: No Stamp ) MP /NNo.: Business Phone Number: �11f w T 6L,C ;�.w/ / Plumber's Address (Street, City, State, Zip Code): Name of Des'gner: l - - xro Y.z a 4"'A 4).T- VIII. SOIL TES INFORMATION Certified S7 1,_e1'1t 1 1f ter(CST)Name CST ## .40 G S m?G CST's ADDRESS (Street, City, State, Zip Code) Phone Number: A6, ! 01— �"— IX. COUNTY/15EPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate l iss ' g Agent Signature (No Stamps) gee S rcharge Fee Approved Owner Given Initial \\ r �� - _ _ p �j� �I Adverse Determination � OK���O X. COMMENTS /REASONS FOR DISAPPROVAL: �caI,, fo, SBD -6398 (formerly Plb -67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This sanitary permit is valid for two (2) years; 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable; 3. Alt revisions to this permit must be approved by the permit issuing authority. A new permit'may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608 -266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description where the system is to be installed; ll. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1 -6; VI. Tank information: Fill in the capacity of every new and /or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift /siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; dosing or pumping chambers; 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. ------------------------------------------------------------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of-over 2years of steady negotiation and public debate. The groundwater bill Ground a�•' included the creation of surcharges (fees) for a number of regulated practices which Wiscon�in;'S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried Treasure' e is used in your building is returned to the groundwater through your soil absorption u system or the disposal site used by your holding tank pumper. 'so The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- 1 water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD -6398 (R.03/86) n Ai // ✓/J It • 090 'YJN ✓O / � . -c s v b N W c» N L► u. Z tiJ _ p h �i 1� � v � •tY' j d v �� •, 4 �' v <t a ! � z � o o v P4 O M a ',x ti . � 3 o � .. �' H a U ° H H H � � h �► � � �Q � i . W a p O O W C H N & v a� b ! ` Cd }a d $4 s� p a N u l Q W V � N k r � N v P4 ? y E-1 a 06. 0 a E W Fa-4 3 P4 v z H U 0 V4 Or .I., s~ s~ (D « 1 GC 1 1 I a O Z H = = z cH��at�i Aaowww� 00 P E- 4 1 WHO.. G e- p ` H O O P4 s ca w - x � a at >C }+ ,� << �� ,�, +� ' J 4 ,. � �` ` s �'� r. � M '• • .. ♦��,�•�� -, w 0 o w a 2 H W to H d W C a N � 0 a 0 r=4 Ui - o V o �►�- `v w tN E-1 d w N o Cl a� v o z _ a N H d m n q � M U v q � o V2 � H K O � � « w o O H z a w « H H H q W W w W W U U a H 0 a Ri (Yi • H .cy' 1 1 1 1 1 . P4 w 3:cn, -A A W w - rS �t :� e£ of F • ' • irY y^� 1 • :,: 4 A Rrr M oNO 0N0 I 3m0 d r� T 7! o p X p N o °� 0 0 u O ° 0) I A w `C • CD COD a CCD A N CD 3 CD 0 01 ! p 4 N 0 - 4 y W 7 C = CD CD j y N Q 0 N N C7 CD 7 Co N =i a O O W 1 0 0-0 m cD 3 to p o > >(D w 0 y 3 y ° o �' C J y � J yO O r� cn z D a Q, l U) D a m M CD cc D co a n l m cfl CD rn a n 3 a IW ° ° a IW ° ° r - lo t O N N O 0 a A O W O �1 0. O co O CD < O OD 000 N K cr lr 3 V N O O c n W Cn0 1 3 c towD d r M C O fD r D 00 O 7 CD IUD CD Vj ? O = m A N 0 !� CD •• O •• CD N 3 °' N CD CL z N O D O I �i O D D tD c c C 0 CL I 0 I c � c n 3 n 3 o C o CD rn A rn • m .'0 A Z R j 47 oo oov mop CD CD eo z CL c °o cn 3 B m o H � w z i a I w m D D m OD ? o n o co m c m c CD o a I o o a ' N z N N � Co 0 co 0 co a m i m CD N n o o b O CD A la CD N I d0 v A p O Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count y Safety and Buildings Division INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)l. 353193 Permit Holder's Name: ❑ City ❑ Village ❑xTown of: State Plan ID No.: Waalen Timoth I Town of S t. Joseph CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 030 - 2036 -30 -200 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet Ar Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand St cover Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSI SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of CHAMBER model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over 7Bed) h Over xx Depth Of 7C) x Seeded /Sodded xx Mulched Bed /Trench Center Tren ch Edges Topsoil Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 1416 County Road V, Hudson, WI (SE1 /4, SE1 /4, Section 24 T30N -R20W) - 24.30.20.476C 1.) Alt BM Description= 2.) Bldg sewer length= - amount of cover = Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. i ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: S 3 � f t i e 3 t t _ _ { s i3s, Y i EgE _. _ ,.. —_. ........ _ — . i r i { .,, „.„„..e.. � .. �.,..m�. �.N E _ ,.,.,„. ... -.. ,,.w ...«- t '�......... ., y t,e... ....a..�.� y.,....n..e ....„�.,..„ r m.....,j. .«. ... e. m..e......; i .. ,......�.a.,. .. ........_.,__ mm ,.U.w......._w,m.... ,.�.. n.,.e �...... �.,__m.m ..a„,„„�,�_..,„,.,,�, na...wb..,..�,.e..,� .... ........ .®.„s.... e.m.....��....,._. �.,... �....,,. �.. m. �....... 5...... m.._ s_.. �.. m. �.....,( ?(. de. �.,........... �.... e...-: .....,...���- ..,...,..�.,.�.. -. SANITARY PERMIT APPLICATION 201E �; Washin Viswnsin P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on n County than 8 112 x 11 inches in size. r �- • See reverse side for instructions for completing this applicatio \J State,Sanitary Permit Nu y ou p rovide may be used b other g overnment agency ro ra t �r � The information application Y P Y Y 9 9 Y P 9 S, 1 '" "' ;`-" ❑Ghecktif rev evlous (cation (Privacy Law, s. 15.04 (1) (m)]. StatFPion I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL NF6 R�'TIbA srr) Property Owner Name �0 Pr i6tion -G r. S �G4J 1 /4, S l.._ T N, R Zo E (or) ID Property Owne Mailing A dress �y ` / 9t Block Number City, St a Zip Code Phone Number i Idn Jam br Number �, 1160 -1 1 (71 , �"25'42-623\J. - 7 �'� 19 y II. TYPE B IL ING: (check one) ❑ State Owned ❑ it Nearest Road on Public 1 or 2 Family Dwelling - No. of bedrooms :_ g v illage Town OF S , S . f C, 11 1U. t/ 111. BUILDING (If building type is public, check all that apply) Oarcel Tax Number(s) 1 ❑ Apartment/ Condo 6 3O — ;? G - 3d -L O 0 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) ,e 17—A A) 1 • ❑ New 2_ ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5, pair of an ______System -------- System ------------- Tank Only Existing System E teem - B) E] A Sanitary Permit was previously issued. Permit Number d i"! 7: � 4: Date IsS11.10ld „ �/• V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 AMound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 2 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 E] 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 S� Requited (ss}�ft.) Proposed ��.) (Gals/da� . ft.) (Mir �) Elevation 12, V d Feet Feet Capacity VII. TANK in Ca gallo Total # Of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con Steel glass App. New Existing structed Tanks Tanks Septic Tank Holding Tank /dam / ^ Er ❑ ❑ ❑ ❑ ❑ um nk /Siphon Chamber `js(, / ❑ ❑ ❑ ❑ ❑ VITUR ESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. s Name: (Print) Signature: (No Stamps) Business Phone Number: e nl ly) cl r 'YYt C., T< Z,/ dress (Street, City, State, Zip Code): IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fe (Includes Groundwater ate ssue Issuing Age t igna re o Stamps) P(Approved [02 Given Initial Surcharge Fee) erse Determination X. CONDITIONS OF APPROVAL/ RE SONS FO DISAPPROVAL: � • �6 � r� � �� .rot, SBD -6398 (R.11/96) 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. 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. 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 oroduct 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 severs; 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. f 1 Wisconsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 Pivision of Safety and Buildings in accord with Comm 83.05, W is. Adm. Code A.C.E. Soil &Site Evaluations Attach complete site plan on paper not less than 8 x 11 inches in size. Plan must County Include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.# APPLICANT INFORMATION - Please print all information. — 2U — 30 Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). R Y Date zR Property Owner Property Location Timothy R. & Traci L. Wa tlen Govt. Lot SE 1/4 SE 1/4 S 24 T 30 N,R 20 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1416 Co. Rd. V 1 CSM Vol. 7, Pg. 1998 City State Zip Code PhoneNumber L] City Village MTown Nearest Road Saint Joseph WI 54082 715 -549 -6073 St.Joseph County Road V ❑ New Construction Use: Residential / Number of bedrooms 3 ❑Addition to existing building Z Replacement Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate •5 bed, gpd/ft trench, gpd/ft Basal area required 900 bed, ft trench, f1 Maximum design loading rate .5 bed, gpd/ft trench, gpd/ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Soil evaluation conducted for Terra Lift rejuvination of existing hydrolically failed mound system. Parent material Glacial till. Flood plain elevation, 9 a livable NA ft S= Suitable for system Conventional Mound in Pressure AT - Grade System in Fill Holding Tank U= Unsuitable for system EIS ® U M S❑ U El N U El S® U [IS N U ❑ S® U SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Structure GPD/ft in Munsell Qu. Sz. Cont. Color Texture Structure Gr. Sz Boundary Roots Bed Trench 1 Ground elev Depth to limiting See attached sheet for discusion of system evaluation. factor Remarks: CST Name (Please Print) Signatur . / Telephone No. James K Thompson 715- 248 -7767 Address A.C.E. Soil & Site Evaluations Date CST Number Ref # 340 Paulson Lake Lane, Osceola, W1 54020 7/24/99 3602 1076 9 I 70 (ro ` lo t r • \' }�NfNG 1 � p lt7 � SOIL AND SITE EVALUATION 1076 Page 2 of 3 PROPERTY OMMIffR: Timothy R &Traci L. Wallen PARCEL `E11 A.C.E. Soil & Site Evaluations REPORT MEMO This evaluation has been conducted to determine the suitability of an existing hydrolically failed mound system for Terra -lift rejuvenation. Two sites were dug by hand into the mound to determine the suitability of the fill used during the original construction of the system and the extent of the system failure. The sand fill used during the construction of the mound is a "pit run" loamy sand / sand material with a matrix color of 10yr4 /4. This material met the codes in place at the time the system was constructed, but does not appear to conform to ASTM C33 standards as required by current sanitary code, WI. Administrative Code Comm. 83.23(3)(b)l. Effluent is seeping into the sand beneath the gravel bed, but at an obviously reduced rate. A bacterial bio-mat has formed at the interface of the sand fill and the gravel bed resulting in effluent seeping through the sidewall of the mound and surfacing above the bed. No bio -mat was observed at the sand /soil interface, indicating that the permiability restriction is isolated to the sand /gravel interface. There are two options to consider. The more extreme option is to remove the existing sand fell and rebuild the mound with screened and washed sand that meets the ASTM C33 standard. The second option is to proceed with the Terra -lift process in spite the limitations of the existing sand material. Given the length of time that the system has functioned properly and the absence of a bacterial bio -mat at the sand /soil inerface, it is the opinion of this inspector that the sand material in place, althoug not conforming to the ASTM standard, is not sufficiently substandard to justify removal and replacement. I • tv r z CA p oo 2 . .. .o o tA z oo I V u � W ro r ., :4K • rt -s a , ^ rn gem T � N �A Cl) 0 m � "V ,y r..• O Ph rn CY z ••t: v� v -a. nn '1 F y Qo �• fOnivr2 0�0 ' 0 nv 41, �v i �rxC-,Hwa ernbb 0 0 r k » c, 1 Ili 1 114 H C+ C++ C++ C++ C+ C+ c 0 H H z o a cn a m UN -LN � � o z • y v . - I Cf. 1 Z 0 d b � � o f b o .0 1 bo r h z ' A• 'd� 1 u cD h l m p I O r ° T m t z c o m = I w d - ( 1 c pv 04 K + 1 'd N N N (D 1 m q d PC t H I z `I 4,0Gec� 43932` aV e 76 c°J c.•. --i Cn cO 3 Q r n O T 0 • O O rt CO W. O O N ' c Co o ( p (� - o r• a, a Cn N v w - o - �� If- UL'��+L? z a T rn m =3 III rn �. 00 rr N c F c x rn rt N .yk C r. _ - r 1 ' ���I.� i�; N CD CC/) H - r, C7 '] CL LL�� ► '7 CD I--• o I c N o to x N N �� , •• �-.•• -1 r'• rn ('> (P Co o O 7 F 7 'O CD •L CD - 3 rt W. V N v _ JAMES O'CONNE!•L 3 � °' to � d .-• 7 CD x •O M .I- M 7 CL n Tl o = t7 ReOister of Deeds C/) tD d c o m �-- -) — o St, Crok CI VA E O C Cr o \�t�3 en w n rt o m a - o �D CL N GL E CD 11 Cr M ID CAI n o W• o E m �C rt o In o CD rl-• 3 .•• rt s rt r• r 0 0 1 C N o t/1 r• to x N o B earings are referenced to the N r 6 east line of SEJ of Section 24 rn assumed to bear N00 0 38 1 20 "E. o Cn M C-) unplatted lands — owned by ,ottter5 0 C) N r. west line of the SEA of the SEi CD C--) S00 11 W 662.06' w 0 331.03' 202.71' 128.32' C) i z cn o z }� CD M z CD N O t 7y Ln N ao L 3 V O F N N F t0 m o rn rn o IC � x I c 1 7 1'O N I'O Cn F IfD Co N - N 1 n 1 CL to n to 1 CD I O O to N 1 CL O I �•-• N o 1 �-r 1 0 _ rt rt rt rn IW n I CL r+ �• I Ca. O I In Cn_ I N C m ~ ti S00 20 "W Im ~ C" rt Im 0 0 330.72' s a I v' ~ n n ~ I CT Cn I`< N - -� r• I� n o 0 1 ` D „ CD 7, Ci m i o C) I rt Cn rt (n rn `� Cn N o 1 Co 1� X Co C) Z to I •7 I N r- C7 O V rt I to C= 1- N S -1 -4 D C) C) C M n C7 C V Co N W N n S S M d C CD C ) : O. O Cn .7 O 0 O O 7 CL .TJ N Cry t0 to ') rt r• C c rr rr o r m o n o o cn '* *� t p cn rt a -- Q cn CD O F N C, 7C) g m U3 La all LD O rl fi,:a V7 M M O ,.y Co r - N W N -' F n F}J 3r .h �y .4i• - 0 0 o r v �Pi G .�� i1 '..� rY `'• W o - w < F It C2 T N Q1 n N ,t `yy� y y `4 m rn m ,... c f� tD S00038' 20 "W...... - ' `�fi�G+��.i9t8Ct .v• "�� �v 330.41' o 660.75' 93.43' 236.95' 330.38' ti N00038'20 "E 30.38' N N r n ` N00 "E 660.76' _� --4 CA m n - _� y O w m ^ - r 0 east line of the SE} o o ) In z rt n .• o /1111P/ RC �. •� N 7 N F �. O N S. F �< VOLUME 7 PACE 199£3 9 I CROCK -CouIGrr /W+aMEAaaaa�wr a DMONNO OMMR W ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer m + h I WC c..1 '2 r t Mailing Address 4 i L C o . - 116- Property Address (Verification required from Planning Department for new construction) City/State 14%. A a ri it, . (,J Parcel Identification Number 3 G — �- y 3 �, - 3 0 - Z 0 a LEGAL DESCRIPTION Property Location S E 1 /4, St 1 /4, Sec. '2 T 3 o N -R Q W, Town of CA Subdivision . Lot # Certified Survey Map # , Volume 11 -J age # '1 Warranty Deed # q3 (�� , Volume NO Page # �. Spec house ❑ yes ❑ no 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. Uwe, 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 a year xpiration date. ra/ , 9 SIGN TURF 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 pro ++ described a e, by virtue of a warranty deed recorded in Register of Deeds Office. f o SIGNATURE 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 OOCUMCHT NO. STATE BAR OF WISMNfliN FORM ,--IOU •Mrs sacs asesevsa Fos aseaa4we am• ouiY cuia� DEED 439�LZ � ,-�-. - p♦ i� BOOK 016 f'A�E 451 . REGISTER'S OFFICE .....ftrb!! a.. �? :.. #r�l t#��!t��Q�.... 4,..N 1A9 ............... 010.. %" { .................................................................................. ............................... bed lot► R�caa1 I 421 walma es � ini o f li y........ ..�iaaleri::and::Traa ert JUL 14 t .... husband ,and , wife.. as..R...e?�ntA ............... ............. 41 • ��s' AM ilia following described real estate in ...... ..6t.....Crolx ................. Cotiunt state of Wisconsin: IIl1YgN �o Lot One (1) of Certified Survey Map recorded in ( `' Volume 7, Page 1998 of Certified Survey Maps, It being a part of the North one -half (Nh) of the �! Southeast Quarter of the Southeast Quarter ' (SE% of SEk) of Section 24, Township 30 North, Ran4bi Parcel No: .............................. � 20 West, St. Croix County, Wisconsin. i �1 II � I rXFNrPT i 1 l 11 1 it This ..A.5 .AlJt........... homestead property. i (is) (is not) Datedthis .... .........t..Y. /............... ......... day of .......... ...... ......... .............................., 19..88... (SEAL) ....a..�... (SEAL) Ij • Barbara J. Christianson ............................. ........ ............................... (SEAL) .................................. ............................... (SEAL) I • ... ............................... • . ....... .... ........ ........................... ........-- ...... AUTSBNTICATION ACKNOWLEDGMENT Signature($) ............................. ............................... STATE OF W*9C01g9[1r �I ................................................. ............................... ......... ....County i authenticated this ........day of ........................... 19...... Fera ly came before me this .. /..Y.f ....day of ............. 19.88.. the above named I) .......................... .� ................... ..............-...---- • -..... Barba a Christianson, a single .... ....... ..... .................................................. .... ... • ....Per:. Vin... I TITLE: MEMBER STATE BAR OF WISCONSIN (If not ...........: .......... .. Stut ......................... ................................................. ............................... ( authorised by � ?06.06. Wis. State.) t� to me known to be the person who executed the foregoing instrument and acknowledge the same. (� 1 TH14 1NSiRUMFNT WAS onAFTro Ely JamesF. Lammers . ............................... ... .......... ........... .................... I1 1 3'5" Igor Tiwes£erri" "avenue ' " " " " " " " "... j.,�..... 9 f: t1MMEM ..... ... i Stillwater, ... MN..5S. 082 ......................... . . .• Notary P tic ......... NOW V ft�t- +w:9EAOTN%. ( (Signatures MAY he authenticated or ncknow-ledged. Both M� G' mission is per 1 T �' r are not necessary.) =3m o•^ s dale ............................................. 19.........) 1. PLIMP CHAMBER CROSS SEC AND SPECIFICATIONS VENT CAP H VENT PIPE • WEATHER PROOF APPROVED LOCKING . . _T JUNCTION BOX MANHOLE COVER 25' FROM DOOR, 12 "MID. WINAO.W OR FRESH I :�..: I.JTAKE _ GRADE I `I "mim. I B" m1m. CONDUIT � -- ---- - - - - -- 18 "/KIN. 4 �` l INLE PROVIDE T I 9 ��? y � / A AIRTIGHT SEAL UALARM c - APPROVED J01WTS APPROVED JOINT W /C.I. PIPE W/C.I. PIPE 2 Q! EXTENDING 3` EXTENDING 3 (�1 ONTO SOLID SOIL O NTO SOLID SOIL g p - k`�� 0 � s I I o • C O, . f19p �� I � Q v __J ELEV. FT. PUMP D -� OFF 0'. G � ~• c 2 2 J' ON ETE BLOCK .0 CR • O RISER EXIT PERMITTED OIJL IF TAN MANUFACTURER HAS SUCHP SEPTIC F SPE IFI DOSE _? Ic. PER DAB TANKS 7�'1ANUFACTURER: �/�1Tlw.y illusr NUMBER.OF DOSES: TANK SIZE: l mesa : GALLONS DOSE VOLUME _ S 7- LcTno INCLUDING BACKFLOW: S GALLONS ALARM MANUFACTURER: MODCL NUMBER: ' CAPACITIES: A= ?/.5.IMCHES=0R GALLONS SWITCH TYPE' / / '�� "� s' �iGO'r ��.lisc.y / 9 B– — INCHES OR ..-!TV,_5' GALLONS PUMP MANUFACTURER: h`l'�On��ssrwG I /'� C= 9 INCHES OR GALLONS MODEL NUMBER: - s�✓aS/N/ D= INCHES OR 7 GALLONS: SWITCH TYPE' �6'/lCawy �LowJ' Ss�isc'ti' MOTE: PUMP AND ALARM ARE TO BE MINIMUM DISCHARGE RATE ads GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. E FEET .1- MINIMUM NETWORK SUPPLY PRESSURE .. . . .. . . . . 2 . 5 FEET `� FT.00 p�FRICTIOIJ 70R.. "� FEET .{- ,�Q ._ FEET OF FORCE MAIN X FAC f� —� TOTAL DYNAMIC HEAD = W 5 ' FEET INTERNAL DIMENSIONS OF TAUK: LENGTH L 70 ;WIDTH L' ii ;LIQUID DEPTH SIGNED:. '�� LICENSE DUMBER: DATE:�B • V i two a M CD Bill F N o 13 > wr _ U J W w D � O I � W I L C ' b y V .V � 3 • N V �- L cb d Cn ' N r•-i CC I I z � b Z 4 w a uj -P ILI \o' W c � C I 3 >, c� C ul 0 U1 N 1.0 > o ow Q\ o `,.., w ` to t o .a a A w W z a ° o �+ IN o ca — — o I � � 4--- -- H o � » z N E-4 W U rn o z » z a w H E-4 H W W W W W W C) 0 a H 0 0 a;c z tiH • C H II w�� A H ti a r ..a. H z y a STC - 105 a H SEPTIC TANK MAINTENANCE AGREEMENT Ho St. Croix County z d a OWNER /BUYER H �i �Y1D �l �� � � �1 t� ROUTE /BOX NUMBER I� D m eriJ el , Fire Number CITY / STATE � Wo + ✓ ► I inn ZIP �)60�5 Z PROPERTY LOCATION: k, 14, Section, TSQN, R _0__ Town of St. Croix County, Subdivision Lot numbe . I Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con - sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank.is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 0 E I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- ro ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office P.0. Box 98 Hammond, WI 54015 715- 796 -2239 or 715 - 425 -8363 Sign, date and return to above address. ST. CROIX COUNTY WISCONSIN ZONING OFFICE 796 -2239 (HAMMOND) 'i 425 -8363 (RIVER FALLS) HAMMOND, WI 54015 May 6, 1988 i Division of Safety and Building Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 Dear Sir: An on site investigation for the Timothy Waalen property, located at the SE 1/4 of the SE 1/4 of Section 24, T30N -R20W, Town of St. Joseph, St. Croix County, revealed suitable soils at a depth of 26 inches, below which seasonable high ground water was noted. This site should be suitable for a mound system. Should you have any questions, please feel free to contact this office. Sincerely, Thomas C. Nelson Zoning Administrator TCN /rc Y DOCUMENT NO. STATE IIAlt OF WISCONSIN F01thl 3-1982 '11114 SPACE RESERVED YOn RECORDING DAIA QUIT CLAIM DEED 439412 1 L� 80oK 816 cc?? PACE 451 I REGISTER'S OFFICE I B ST. CROIX • -- .. arbara J. Christianson,,,, a,, ,sng�,e..geXSgfi ............... Co., , i ( I "' Rec'd for Record II . ..................... ..... ..... . .............. ` "R.' Wa and Traci . .. L. Waa . JUL . 1 4 988 quit - claims to ........................................... ......................... - - -•• � y s M I' husband and wife as • ,joint._t.Qr tts, -. 8 A at ............::::::......:::::::::.&.............................................. ............................... Register of Deeds the followin.• described real estate in ....... ...St....CrpjN ................. County, State of Wisconsin Rf.'IUIIN ,o ' I� Lot One (1) of Certified Survey Map recorded in I, II Volume 7, Page 1998 of Certified Survey Maps, being a part of the North one -half (N]�) of the Southeast Quarter of the Southeast Quarter (SE4 of SE4) of Section 24, Township 30 North, RanWLyx P arcel No .............................. 20 West, St. Croix County, Wisconsin. I� l l I 1 vk'EWT I Ii l: i I I. 1 I � I I I i l� This ... i.P..f?4t........... homestead property. (is) (is not) Datedthis ............ ....................... day of ................. .. ........... .............................., 19..88... 1 1 r 1 ............(SEAL) ....... ...... ..�� ���..(SEAL) • ....................... ............................... Barbara J. Christianson f I ..... ....................................... ....I....................(SEAL) ................................... ............................... SLAL • .................................. ............................... • .................................. ............................... AUTHENTICATION ACKNOWLEDGMENT i Signature(s) ............................. ............................... STATE OF W,L•,+eOi M -- II .....................................•---------.. ...--- ..._..................... authenticated this ........ day of ........................... 19...... Per5wHqly came before me this ........ day of II -- •--- • ..........: ..................... 19.88.. the above named ............................................. ..................... .......... Barba a Christianson, a single ... ............................... ............. • .... ....Per..on TITLE: MEMBER STATE BAit OF WISCONSIN � (If not. .. �I Stat ................................................. ............................... I authorized by § 7UU.U6, Wis. Stuts.) to the known to be the person ............ who executed the I foregouig instrument ttnd acknowledge the some. THIS INS "rRUMF.NT WAS OnArTFO BY James F. Lammers ........................... ..... . . . ................................ . . /l: Ii 1835 Nor£hwesterii ;venue •...... . ✓.•.... /d�fES,f:-LAMMERS Stillw.ater, N ............. ...MN..55. 082 .............................. 1 Ilic NOTARY N"—IW A4TN \ `} otary f , 11 (Sipn:ltnres may be authenticated or uc{cnuwledE;ed. Beth Aly unission is perft>; . n 1JIY - ' 6M TONt4WNT.<� ;ir:ition I' are not necessary.) o II dstte: ............................ . ................ 19.........) ji �1 ENTIOF p SAFETY & BUILDINGS EPARTM AN D 1 REP ORT ON SOIL BO RINGS D 4 ERCOLATION TESTS (115 P.O. BOX 3707 ABOR AND MADISON, WI 53707 UMAN RELATIONS I, (ILHR 83.09(1) &Chapter 145) -T ,1 TOW HIP /b6� LOT NO.:BLK. .: SUBDIVISION / NAME: '/4 - �� /T30N / for W / /�I� -11) UNTY: OW UY R'S NAME: e LN DRESS: y Rog DATES OBSERVAT ONS MADE SE pR FIL I S: LA ION TESTS: . NO.BEDR COMM R IAL DESCRIPTION: (�� esidence w ❑ Replace r _) Y L TING: S= Site suitable for system U_ =_ _Site unsuitable for system QN NTrrOUN . �� l G� SYSTEM - IN - FI OLDING TAN ECOMMENDED SYSTEM. (optional) DESI If an portion of the tested area is in / /j f Percolation Tests are NOT required N RATE: � I y p the / /�- // rider s. ILHR 83,09(5)(b), indicate: Floodplain, indicate Floodp elevation: G SS PROFILE DESCRIPTIONS ORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH UMBER DEPTH IN, ELEVATION OBSERVE HE TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) (` ) ` cu � j u _3 qQ &,22U `30 PERCOLATION TESTS DEPTH W HOLE T ST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES ER WG_L 44U aVAL N. R OD 1 RE RI O D I - r P . P OT PLAN: Show locations of percolation tests, soil )oTmgs and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- ntal and vertical elevation reference points anO'show their location on the plot plan. Show the surface elevation at all borings and the direction and percent land slope. S YSTEM ELEVATION ., .. .. r ' 4 I 7o p . f J � the undersigned here rtify that'1l�ye so �,t s reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin ministrative , and t the data r rd the location of the tests are correct to the best of my knowledge and belief. I AM print : o TESTS WERE D ON: /L S DDR SS: ^ CERTIFICATION NUMBER: JPHQNE NUMBER optional): CST G ATU6li E: I k{1 Lq uthority, Property Owner and Soil Tester. ISTRIBUTION: l rigindl a d one copy iLitR -SfsD .6395 (R. 10! �l OVER — APPLICATION FOR SANITARY PERMIT STC - 100 This application form i PP s to be co mpleted i n full an i d signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, ( "spec house "), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of Property Location of Property 14 �j ;4, Section 24 , T -3 O N -R 2O W Township 5 Mailing Address . r Address of Site Subdivision Name Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? Yes No . Is this property being developed for resale (spec house) ? Yes No Volume and Page Number `'� as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A Warranty Deed which includes a Document number volume and page number and the Seal of the Register of Deeds In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description refer- ences to a Certified Survey Map the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATIO I (We) cektiby that att statements on this bokm cute tkue to the but ab my (oun) knowledge; that I (we) am fake) the ownek(s o the pkopeAty described in this inbokmation Jokm, by vi tue ob a wa&4anty deed kecokded in the 066ice as the County Reg-is.ten 0 Deeds as Document No. q /,- and that I (We) pkesentey own the pka pos ed s.cte bok the s ewag e d i,s pod s ys em (ak I (we) have obtained an easement, to kun with the above debckbed pkopWq, ban the constkucti.on ob said system, and the same has been duty ecokded in the 0 ' y e .cce a the Count Re -cs bb b ten o Deeds, as Document No. y g b 1. SIGNATURE OF OWNER SIGNATURE OF CO -OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED o f 0 3 °i c a • q . '0 B m 1 o w — cn Z (n � --I O -+ cn N O 3 O N Z 3 m Z K H n s O O f/) O Vt y n Oa O O c O '� N A W `C • • O p 0 �* m =r 3 3 c N �y ° O. "" N m N t0 fD CD O ^ y to N! O O N v W C N j W 7 A C N N = O O NO W O N N - O d o 0 � I a 61 0 O f0 3 O O W ° O ° o m o m e m n o° N O 0 '�', o m 7 O 0• 3 E * o y y h H l O L7 0 m m to Z D A a rn l ? cn D ¢ rn CD = D W a n m c= y n a ( I a o o 3 0 °° 3 O 7 CD --4 V t A A 0 l�1i � � O O co o co(o 00 O. o 000 a n r N to to < co 00 < ! 3 c N � • SD 0 % o m hi o A o Z z f' ° =' D o D D o 0 p m � O ° =r rn O _0 CD m m m m A z 7 cn --1 N ao� oo� mo C C A Z ° o °o X cn N p w — W CD O D x a m a o v CL � o N CO 00 0 ' m w C CD m c Z a N o a a, oZ CD F c < CD _+ c 0 �. b I � I s CD o I I m < ti C o m o o o o a iJ CD m aro p o O C o i ° O i