HomeMy WebLinkAbout040-1229-70-000 4
ST. CROIX COUNTY ZONING DEPARTIyI + NT �..
AS BUILT SANITARY REPORT
Owner
Property Ad4xpss ao L rte e.6
City /State =
Block B
Legal escl n:
Lot ��- Block -' SubdivisionlCSM # ( 2/ *V
N4 1 /4 SW 1 /4, Sec. /j , T - ' -R L5 W, Town of v PIN # /9 Y D -/ 31- - 7 -o
SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION:
Tank manufacturer LU t4=6 Q r' Size ST/PC 7 �etback from: House ga Well 0-k 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: fI trc Width -3 Length g Number of Trenches -.3
Setback from: House a $ o Well W P/L c2o Vent to fresh air intake a D
7
ELEVATIONS
Description of benchmark `fi Elevation 5
Description of alternate benchmark "�' Elevation
Building Sewer ST/HT Inlet °f ST Outlet FES 7 a PC Inlet —~
PC Bottom "` Header/Manifold 19N. 3,' Top of ST/PC Manhole Cover 9.2.
3
Distribution Lines(/) $kq k (xi (3) `
Bottom of System V
Final Grade Q)
Date of installation/v/ er ' number State plan number
n /)
Plumber's signature License number Date � / 97
Inspector
Complete plot plan or
s
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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KATE NORTH ARR
1
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count
Croix
Safety and Buildings Division
INSPECTION REPORT y
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)]. 344554
Permit Holder's Name: ❑ City ❑ Village Town of State Plan ID No.:
Bye, C.M. Town of Troy
CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.:
�C/ � --- ce 040 - 1229 -70 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Z�Q Benchmark di
Alt. BM .
D A 113
/0 f
Aeration Bldg. Sewer _ to(
Hol g Ht Inlet
TANK SETBACK INFORMATION �t/ Ht Outlet d . q 0Z2. S
TANK TO P/ L WELL BLDG. vent to ROAD
Air }r�t3ke
Septic �lo�` AJ A NA
D
Header/ Man.
Aeration NA Dist. Pipe
Hol Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer e d St cover 4 Z /0 Z(,
Model Number GP t7
gM �r rP /s & /ter 1 9Op� �
TDH LiftLriction System TDH TP 1 - . a D
Force in Length Dia. Fi t. To well TPI - I , 1023_ Zan r
-I
SOILABSO PTION SYSTEM 13 rs Ca h
BED / EN Width r Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIME N 3 P Z 5 -3 DIMENSION
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEA Manufa turer:
SETBACK \ ��0✓
INFORMATION Type7 P Model umber:
System: eehv 1 AI IT 5
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
r� L � (� J � /
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 1 ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: to /i� /99 Inspection #2: /
Location: 335 Soo Line Road, River Falls, WI (NEIA, SW 1/4, Section 16 T28N -R19W) - 16.28.19.1127
2 9' 0 ; , 6 e we r 4A !& 4 4 l6 " ��„�. 9411, A* � m�
& ,�� Lauer
C Alf 3 M 1= 4&p o
Q ULr. Cdr tyf4sk, /'S
deyamlC V`&ICS dt- 6lek�
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. ro
SBD -6710 (R.3/97) Da a Inspector's ature Cert No.
ADDITIONAL COMMENTS AND SKETCH `
SANITARY PERMIT NUMBER:
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Vi sconsin Safety and Buildings Division
SANITARY PERMIT APPLICATION
201 s x Washington Avenue
Department of Commerce In accord with tLHR 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 81/2 x 11 inches in size. S
• See reverse side for instructions for completing this application State Sanitar Wumber
Personal information you provide may be used for secondary purposes [I Check if revision to previous a y cation
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N
Property O r Nam Property Location
F 1 /4 54 3 1/4,5 1(0 T , N, R 1 916r) W
P erty Owne 's Mailing Address Lot Num er Block Number
State Zip Code T one Number Sub ivision Name or CS Number
s Lti.f- S O )
II. TYPE OF BUILDING: (check one) ❑ State Owned o Cit Nearest Road
Public 1 or 2 Family Dwelling - No. of bedrooms ° V own oF t *..Q R alt
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment / Condo v
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. 0 New 2 ❑ Replacement 3. ❑ Replacement of 4 ❑ Reconnection of 5. ❑ Repair of an
______Syrstem ________ 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 [ Tank
12 eepage Trench 22 In- Ground Pressure 42 ❑ Pit Privy
13 S ❑ Seepage Pit C 3 � 3 )e I 43 ❑ Vault Privy
14E] System-In-Fill ///A /��Gw rj Irt
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) t Elevation
(000 1 /.Rob b6 go Pe 1 Feet 9k& Feet
VII. TANK i Ca acft llons
n 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
eptic an ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ I ❑ I ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plu ber's Name: (Print) P ber's Si atu : ( o Stamps) MP /MPRSW No.: Business Phone Number:
ears a
_37 71S cZV(oo 91
Plumb NSP dd s (Street, C Stat ip Cod
\1 to gi
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater at ued ssIssuin g nt Signature (No Stamps)
Surcharge Fee) / , [Ap proved []Owner Given Initial p�S o� �
Adverse Determination IUD
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 gyestions 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.
11. 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 specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must
include the following: A) plot plan, drawn to scale or with complete. dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E)" soil test data on a 115 form; arrd 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 Wisconsin Department of Industry SOIL AND SITE E V A L U A N REPORT Page \ of 3
Labor and Human Relations
INvision of Safety & Buildings in accord with ILHR 8 W4_' 00 •
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches 'n 4�' Para r stcapTmdii:46 iude, 4 buf
not limited to vertical and horizontal reference point (BM), directiorans� % of `e or PARCEL I.D. #
dimensioned, north arrow, and location and distance to nearest r
APPLICANT INFORMATION - PLEASE PRINT ALL INFO MATIM -) 1. - REVI , 7 j TE/
4 17 PROPERTY OWNER: , 's PROPJt1^f L/kT{OI'e
1 /4,S It T Z8 ,N,R 1 E( W
PROPERTY OWNER':S MAILING ADDRESS lK;# UBD. NAME OR CSM #
l O N . At f� S T , r 1 6 L.0\ LT \1 S'M 41 � ft t) j ON
CITY, STATE ZIP CODE PHONE NUMBER ['CITY []VILLAGE MOWN NEAREST ROAD
R.tuevL LL5 S OLZ (7157 X125- 81 61 p SOD LI" t.-wito
New Construction UsejA Residential /Number of bedrooms L { [) AdditiQrt to ebsting building
[) Replacement [ I Public or commercial describe
Code derived daily flow 6"ZOO gpd Recommended design loading rate __ — bed, gp(W 0.5 trench, gpd1ft
Absorption area required — - bed, ft trench, ft Ma)amum design loading rate — 9 - J- - bed, gpolfl 0 - S trench. gpd*
Recommended infiltration surface elevation(s) sw ►.aoTt- ol�j 1 - ft (as referred to site plan bendanA)
Additional design/ site considerations 3 �Z - kl S' Y- 80' LMJ 6
Parent material sty t M e%ft -0ytM ALL o tjil�VL aihu _ Rood plain elevation if applicable N •A • ft
S = ystem MOtkdD IN- GROUND PRESSURE AT -GRADE SYSTEM IN 111. HOLDING TANK
U or S tem ®$ ❑ U ® $ ❑ U ®$ ❑ t I� S ❑ U ❑ S 2 U ❑ S o U
SOIL DESCRIPTION REPORT
Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouifty Hoots GPD /ft
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmnch
p_p, Lp�Q 31Z - S 11 Z , �Ia l wt M'FH cS - 0.5 0.6
1
Z 8 -23 ►O `1R � - sf f Z�sbk >nfa ew - O.S 0.6
Ground 3 23 - - ).Sva 3/y — s lit sbk w �4, cs — o.q 1 0-S
elev. So -63 7. S 1 R y/6 �' g o S 9 w� — o. S o. 6
4 �9•o ft. ` 1
Depth to 5 & 4 to 1 R y/ � � o S9 S €o.
limiting
factor
Remarks:
Boring #
a -8 l0�(R 312 S) } Z�Sd1r wt'F'►- c3
1 3 -ill
Z g -ZY toytz 31 sll z�sbk w►�>
3 zY -qo - ) -Syn vy — S, lrn 5bvr es - o.�/ o•S
Ground
elev. LL4 3 _)•S `1R Y16 cs S 5 S 10. (,
9 $1.3 ft
Depth to
limiting
factor
Remarks:
T Name - Please Print Phone:
Arthur L. tde erer 715- 425 -0165
Ad dress: Soil Testing & Design Service -P.O. Box 74 River Fa11s,WI 54022
Sgnature: Date: CST Number:
G q 9S M00576
PROPERTY OWNER B`t t�! — Z Ct Q �-rZ SOIL DESCRIPTION REPORT Page of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Ba x6y Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
o_lZ o.s o• 6
tz - 3D 104p-- 3! s 1 f Z'Mh Yn i- etU 0,-S 0.
Ground 3 O -$S l•SyR 31y CSbvr 0- y 0•S
elev.
ct 3 epa� U 01= v Ws
Depth to
limiting
factor
? as
Remarks:
Boring # i
0 -11 SO cS - o. S, 0.6
y z ►► p totic� 3)L sf'I Zisb4 o•S 0 -6
3 3$ 1.vi v.- )ly S1 10-3 bk m. f - _ 0•y jo.S
Ground
elev.
9 85.9 ft.
Depth to
limiting
factor `
Remarks:
Boring # p. S 1 a 6
,ti..:�..:' 1 o -LO 10`12 3l Z S l 2. �$b `^'� CS
vO - 0`1 R 3 ! (, S1 o • .6
Groun S 1 csDk vw�f�. _ 0 -y IU.S
Groun _
elev. 3 Lo pU OIL '7• S L i V14 4
9 g3•y ft.
Depth to
limiting '
factor
i
Remarks:
Boring #
j
Ground '
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
r -
Page of
PLOT PLAN
3 3
SCALE I"= ----
f— y9 / 6 °
3V�.
NOTE: House to be at least ti
25' from trenches. well to
be at least 50' from trenches. 64 6 �eH'
0
a
N NOTE TO INSTALLER:
Place trenches maximum 36" deep at the upslope edge.
m Trenches to be minimum 20" deep at the downslope edge.
Determine trench elevations at the time of construction.
Qoi 61
- %!L• 0 1 S6.6'2' cN
f 1 �'� LRav PLPt
LSl. °►� � q
s.► — 14 °! etgBS-
0
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6 6
1- 1L`i'L'Riuh'1'E '11t�el�y ' I
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9y -302. 6z
d, 1- 3 0 -95 ( 715 ) 4�5 -n�h5 _ N00576
CST Signature Date Signed Telephone No. CST #
1(Visconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page \ of 3
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but ST. c.kz - o 1 X
PARCEL I.D. #
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
E fJ 1��T1JIJ \ S S 0 L Z Geff. 1/4 SLAJ 1 14,S I t T Z8 ,N,R 1 E( W
PROPERTY OWNER' MAILING ADDRESS LOT i BLOCK # SUBD. NAME OR CSM #
-- I l0 N . M-h Prtw 3 T'. 6 Z — GLpV t?1Z STtYT)O►J �'tDlJ1770N
CITY, STATE ZIP CODE PHONE NUMBER (]CITY X11 ILLAGE ®f OWN NEAREST ROAD
Lvlstz. S w
S oLZ.. (7151 I-I a- 8 ► 61 p Y ] Soio LUJE D
R emu. � I
New Construction Use.M Residential /Number of bedrooms [ ] Addikn io epsfing building
I 1 Replacement I ] Public or commercial describe
Code derived daily now 61zio gpd Recommended design loading rate — bed, gpolft ° • 5 trends, gpolft
Absorption area required — bed, 11 ` USD trench, ft Ma)amum design loading rate o . �l bed, gpf:W o . S trench, 9Pdfit
Recommended 3 referred fitfiltratian surface � r�o�' ou ?+t$ � ft (as refe plan benctrnark)
elevaton( s s
Additional design/ site considerations RS Mill ffke0 3 1 T1t1!w e-" 3 — S' x- 80' t 6
Parent material SiM tM49vT -OUQ)t _'NLA_ ouQR ovtw*-SN Flood plain elevation, it applicable N -IN . ft
$ = Sllltable for System COPNENTIONAL MOUND N- GROUND MESSURE AT -GRADE SYSTEM N FILL HOLDNG TANK
U= Unstittable for tern ® S 11 U ® S ❑ U I� S❑ U gi S ❑ U [Is o U [IS 0 U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Sere Consis Bmrd3y GPD /ft
Boring # Horizon in. Munsell Clu. Sz. Cont Color Gr. Sz. Sh. Roots Bed tench
p -� 1D`1 312 - sil Z'FSb►c wl CS - o_s 0-6
cu
Z 8 - ►0 'I 2 31 y - S i Z�s bk et - o• s o_6
Ground 3 Z3 SO -- ).S`f2 9 — S lwt Sbk V C_S — o. S
elev. y so_63 -). S y 2 y/L - `�' g O S 9 �„� C.S - o. s o. b
R '4-10 ft
Depth to 5 63- 6 t I R_ v/ o s9 w► I - o s o. fa
limiting
factor 6'
Remarks: �!
Boring # W1 `f 9- 312 T 1
Z
3 7- q -(10 1 - )-S l ip 3 ly — s 1wi wtujF, �S - o. o •S
Ground
elev. L yb -8 3 - )•S `fR Y14 S 1 (,
9 $1.3 It
Depth to
limiting
factor
$ 3"
Remarks:
T Name.— Please Print Arthur L. We erer Phone: 715-425-0165
egerer Soil Testing & Design Service -P.O. Box 74 River Fa11s,WI 54022
Sgnature: Date: CST Number:
G u! -3OZ 6Z )- 30 - 9S M00576
PROPERTY OWNER B`it — 3 CWQ L -rt SOIL DESCRIPTION REPORT Page Z•of
PARCEL I.D. #
Depth Dominant Color Mottles Structure GPD /ft
Boring # Horizo:n Texture Consistence Bo�xxlary Roots
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
4: - SI Z Sb 0-S - o.S o- L
>' Z ti .3D _ s 1 2'F'sbh », I cw . 0-S a (,
Ground 3 O -8S 1- vim 31y S cS It, k tin a•`/ o•S
elev.
4
Depth to
limiting
fa cto r 7S`�
i
Remarks:
Boring # 1 0 -11 i��Q 3 1Z si 1 Z �sdh w,-f�. O
Il ZO 31L St I Z o•S io -6
0 . �o.S
Ground
elev.
9 83. 0 1 ft.
Depth to
limiting
fac tor YJ
Remarks:
Boring # i
o -LO t�� 2 3l2 S1 Z `� �n `�'�., CS o• S i al
-�,I to4R j IL si ( 3�shk 4ntr cw -- 0- S i
3
Ground 3.1-80 3 [ - S 1 cSDk v w _ 0. 0.S
9 "y ft. 3 OZ nJS rQ00tkfr3 OP I— S411. 4 L/l
Depth to
limiting
factor
8o•i
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
r - �
Pa ge e 3 of 3
. PLOT PLAN g —
SCALE
49 6 ° i
6Z
' X
NOTE: House to be at least y'" s y S Ct8
25' from trenches. Well to
be at least 50' from trenches. 64 63 met°
CIO
O
0
o NOTE TO INSTALLER:
0 Place trenches maximum 36"-deep at the upslope edge.
0 Trenches to be minimum 20" deep at the downslope edge.
Determine trench elevations at the time of construction.
loT 6
8 ►-t - cam., qSb -64' olv
eL a-14 °- a
S.1 o
8.4
l l ( I 3 qT S'X $o k4k)G
3 kT S'
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co+vYo�tiz LPL. 486 °-
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trL. Ll�' c, 1 /03. e-q
►-flT
6q
0,,t� gU -3oz_ 6z
d 1— 3 O — �1S (715 ) 425 - 01 F,5 1400576
r Telephone No. CST #
I CST Signature Date Signed P
1
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP RM ERTIFI ATI N F
C C 0 0
Owner/Buyer
Mailing Address lo 6o � � ,j I q�tt� U 54
Property Address \, To zlt? e
(Verification required from Planning Department for new construction)
City /State & Vt)C ;5 Parcel Identification Number N -0
LEGAL DESCRIPTION
Property Location �'/4, S �5 ' /4, Sec. – L� — , T 8 N -R W, Town of ' 0
Subdivision /ova 4 A2 dd;� e— Lot # .
Certified Survey Map # . Volume . Page #
Warranty Deed # (l1��O(F , Volume , Page # g�
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.
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 t your septic syst as 4beenintained must be completed and returned to the St. Croix County Zoning Office within 30
days a three ear ex rati
G ATURE O 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.
SIGNATURE OF6<PPLYtANT 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
< JUN -30 -99 11:05AM FROM -BYE, GOPF i ROHDE, LTD. + T -500 P.02/04 F -145
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WARRANT
Document Number:
Rewm Address: C. M. Bye
PO box 187
River Falls, WI 54022
Parwi I.D. Number MINI: 040 - 1229.70
This good, made between Dennis R. and Sandra C. Schultz Revocable Trust,
Dennis R. Schultz and Sandra C. Schultz, Trustees both with full power of sale or
encumbrancing, Grantor, and C. M. Bye, Grantee,
Witnssseth, That the said Grantor, fo a valuable consideration , conveys to
Grantee the following described real estate in St. raix County, State of Wisconsin:
An undivided one -half interest in Lot 6 , Glover Station 4`° Addition to
the Town of Troy.
This is not homestead property.
Together with all and singular the her ditaments and appurtenances thereunto
belonging:
And Dennis R. Schultz and Sandra C. Schultz warrants that the title is good,
indefeasible in fee simple and free and clear of encumbrances except easements and restrictions
of record and will warrant and defend the same.
.� Dated this - -_. day of - �1 1999.
Dennis R. Schultz laridra C. Schultz
ACKNOWLEDGMENT
I
DRAFTED BY: STATE OF WISCONSIN?
ss.
C. M. Bye, Attorney at Law ST. �ROIX COUNTY
River Falls, Wisconsin
Persnaily came before me This M
199 , the above named Dennis R. ,>$`g#}ti•I`anaD M
Sand , m C. Schultz, to me known t4 44i the #r;&n *4 s
who mucuted the foregoing Instrument ; a�
ackn wledge the e. �.=• �.,.�� °,_
jy a
Public, St. Croix County, Wis.
c mmission is expires:
i
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BGR Bye, Gaff
TRIAL LAWYERS & RQhdc, Ltd.
258 Riverside Dnve • P.Q. Box 167 • River Falls, W1 34022 Ph: 715. 425 -2161 • Fax: 715 -425 -7413
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