HomeMy WebLinkAbout006-1005-60-100 27 1
ST. CROIX COUNTY ZONING DEPARTMENT',
AS BUILT SANITARY REPORT
r
Owner a r l� C'/�' r i 7 1
Property Address 1'' 3 9 $ ✓ -, ST CROIX
C 0UNTY
City /State .S
r ZQNING:'"�I�t�E
Legal Description:
g P -;
Lot .. Block — Subdivision/C M # 9
lVjtfP '/a ul' /o Sec T N � W Town T PIN # /O�
3.3I • 11-:37-1-A
SEPTIC TANK -- DOSE CHAMBE -- HOLDING TANK INFORMATIO
Tank manufacturer Size ST/PW Setback from: House Well/ P/L /G�
Pump manufacturer Model
Alarm location .--
(HOLDING TANKS ONLY) i
Setbacks: Service road e::Q Vent to fresh air intake Water Line T"
Meter location ;"L-S;
Alarm location
SOIL ABSORPTION SYSTEM
Type of system: th Number of Trenches
Setback from: Hous esh air intake
ELEVATIONS
Description of benchmark � ,��� Elevation
Description of alternate benchmark Elevation,' . O
Ar
Building Sewer 9� 0 2 ST/HT Inlet 9 S ST Outlet D PC Inlet . 9�
PC Bottom — op er
Distribution Lines ( ) O
Bottom of System
Final Grade ) () ( )
,
Date of install'ation /., /9y Per it number tale plan number
l
Plumber's signature License number Datey//_
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
2'
c�
J�
Cr
INDICATE NORTH ARRO
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
s'
J�
o
P"
INDICATE NORTH ARRO
�O
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County
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)]. 320276
irniUiolcl Marne ❑City ❑ Village Town of: State Plan ID No.:
CST BKMKEIev.: AKL BBB Insp. BM Elev.: M Description: }[j,Oj Parcel Tax No.:
® 100 19,40 006 - 1005 -60 -100
NJ
TANK INFORMATION ELEVATION DATA A9800466
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic ..,._�- •�-• -- Benchmark 10D
Dosing
E Bldg. Sewer (2On 4t H Inlet Y
TANK SETBACK INFORMATION *'/ t Outlet
TANK TO P/ L WELL BLDG. Vent
Intake ROAD
Septic NA Dt Bottom
Dosing �, NA Header / Man.
Aeration °__. NA Dist. Pipe
oldin 451> 2S'�' Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer ,� Demand
Model Number
TDH Lift ,, L riction vs£em TDH Ft ead oss
Forcemai �tength• " ..,• Dia. FFff Dist. Toweu
SOIL ABSORPTION SYSTEM
9 ry Liquid Depth
BED /TRENCH Width Len No. Of Trenches PIT No. Of Pits Inside Dia.
SYSTEM TO P/ L BLJ�a "1NELL LAK EN 1 Manufactury
DIMEN I N DIM
SETBACK
E /STREAM LEACHING rer:
INFORMATION Type Of CHAMBER-" Model Number:
System: OR 11NIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spo.cir+g Vent To Air Intake
Length Dia- Length Dia "'Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Gr
y y de S Only
[ Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched
ed /Trench Center Bed /Trench Edges Topsoil El Yes ❑ No ED] Yes E] No
COMMENTS: (Include code discrepancies, persons present,etc.) -,
LOCATION: CYLON 3.31.16,NE,NW 2394 235TH STREET – LOT 1
�I (_ 1 01 - 7 ICIO
Plan revision required? ❑ Yes No !�
Use other side for additional information. (( 7r) D SC, /r-S
SBD -6710 (R.3/97) Date Inspector's Signature Cert. No
ADDITIONAL COMMENTS AND SKETCH A
SANITARY PERMIT NUMBER:
E
Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 E. Washington Ave.
Viscons 7 In accord with ILHR 83.05, Wis. Adm. Code P.O. P O. Bo 96 9
Department of Commerce Madison, WI W707 -7969
• Attach complete plans (to the county copy only) for the system, on paper not less County t
than 81/2 x 11 inches in size..
• See reverse side for instructions for completing this application State sanitary Permit Number
y ou p rovide may be used b other g overnment agency programs 32(ev.2'Z
y p y y g g y p g ❑Check if revision to prev application
The information on
[Privacy Law, s. 15.04 (1) (m)].
State Plan I.D. Number
I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N /
Property Owner Name Property Location
;_ ( + C_ OL, C z 1 /4p,.� j 1/4, S T 3/ , N. R /.� E (or
Property Owner's Mailing Address of Nu b Block Number
City, State _ Zip Code Phone Number Subdivision Name umber ,/
cxw �r Lx) t� C ) �T
11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Lag Nearest Road
❑ VI I e i� Public 1 or 2 Famil Dwellin - No. of bedroom do of 1 -2 7P l�'t
III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Num er(s)
1 ❑ Apartment/ Condo �
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 Q 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. ❑ Replacement of 4. E] Reconnection of 5_ C] Repair of an
System System Tank Only Existing System -------- Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41�&Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
3 Q 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.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation
/ I t_/" * Feet /V Feet
acit
VII. TANK in Cap llo s Total # of Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Existing structed
Tanks Tanks
Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber' gn re: (No Sta MP /MPRSW No.: Business Phone Number:
Plumber's Address (StreL-C-2222.4L Code):
IX. COUNTY/ DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps)
A roved Surcharge Fee)
IM Approved ❑ Owner Given Initial Oo
Adverse Determinati U() on �� E cc y/olm
X CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL:
SBD -6399 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety & Builings Division, Owner, Plumber
l
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:
L 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.
Ili. 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; and F) all sizing inform'atiorr.
----------------------------------------------------------------------------------------------------
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.
i
I
. Safety and Buildings
15837 USH 63
HAYWARD WI 54843 -8107
'sconsin Tommy G. Thompson, Governor
Department Of Commerce Philip Edw. Albert, Acting Secretary
September 22, 1998
SHAUN R BIRD CUST ID No. 226900
896 68 AVE
AMERY WI 54001
RE: CONDITIONAL APPROVAL
APPROVAL EXPIRES: 09/22/2000 Identification Numbers
Transaction ID No. 148225
SITE: ST CROIX COUNTY, TOWN OF CYLON Site ID No. 160549
NE 1/4, NW 1/4, S3, T3 IN, RI 6W Please refer to both identification numbers,
EARL & BARB CARR RESIDENCE I above, in all correspondence with the agency.
FOR: DESCRIPTION: REPLACEMENT HOLDING TANK
OBJECT TYPE: POWTS REGULATED OBJECT ID NO.: 426079
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements.
A copy of the approved plans, specifications and this letter shall be on -site during construction and open to
inspection by authorized representatives of the Department, which may include local inspectors. All permits
required by the state or the local municipality shall be obtained prior to commencement of
construction /installation/operation.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
I
Sincerely,
DATE RECEIVED 09/17/1998
FEE REQUIRED $ 60.00
eroy G. sky, Was water Sp list FEE RECEIVED $ 60.00
Field Op tions Bureau BALANCE DUE $ 0.00
(715)726 -2544 Voice
(715)726 -2549 Fax
1jansky@commerce.state.wi.us
I
PLOT PLAN
PROJECT Earl and Barb Carr ADDRESS 2394 235th St. Clear Lake Wi 54005
NE' 1/4 NW #' 1/4S 3 /T 31 N/R 6 W Cylon COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 9 BEDROOM 3
CONVENTIONAL IN-Gi66ND PRESSURE CONVENTIONAL LIFT HOLDING TANK XXX
MOUND SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE 2 -1200 LOAD RATE ABSORPTION AREA # of chambers
IL BENCHMARK V.R.P. Base of Siding ASSUME ELEVATION 100'
❑ BOREHOLE O WELL *H. R. P. Same as Benchmark
SYSTEM ELEVATION none
Alternate Benchmark Base of Well Building @ 99.0 P.O.W.T.S.
ditionally
APPROVED
DEPARTMENT OF COMMERCE
DIVI ION OF SAFETY AND BUILDINGS
S E RRE NDE E
Pro ert ine
Driveway 0' 10'
-4
75'
N
W
Alt.
50' B -5 70' 3 B.M.
75
Existing 3 Garage 1 Well ' ,
34' Bedroom 26 B.M. 15 80'
Old System to be House 32' B -3
pumped and buried 15' 26' 8
5' T 0 0 New Service Road
to be installed <25' from tanks
T
F Seperation between tanks T -2
Tanks are to be properly bedded
and provided with lockdown covers
145 with approved warning labels
B -1 r
148225
15'
360' Property Line
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` Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page of
Bureah of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 1Rc $ s►ze. �i}st, County
include, but not limited to: vertical and horizontal refs n it (BM). e
percent slope, scale or dimensions, north arrow, an nand earBSt bad. Parcel I.D. #
APPLICANT INFORMATION - Please p ' all i►im#tin Revie by Date
Personal information you provide may be used for seconds + gttr�►oses (PnQtry . IBM (1) (} )) �
Property Owner ti pN IN'3 jr � +C Prope.f ocation
, �� ,•, ' 04% t A/ 1/4"/4,S T ,N,R E (orYe
Property Owner's Mailing Address �. '� ? + o Block# Subd. Name or CSM#
f a
City State Zip Code Phone Number ❑ Cit <<fown Nearest Road
ty ❑ Villa G
❑ New Construction use: Residential /Number of bedrooms Addition to existing building
%Replacement ❑ Public or commercial - Describe:
Code derived daily flow J60 gpd Recommended design loading rate & P. bed, gpd/ft A — trench, gpd/ft
Absorption area required ,e_ bed, ft ft Maximum design loading rate, 2 bed, gpd/ft trench, gpd/ft
Recommended infiltration surface eievation(s) ft (as referred to site plan benchmark)
Additional design/site considerations
Parent material Flood plain elevation, if applicable lv lk ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
u= unsuitable for system ❑ S u ❑ s K u ❑ s g u ❑ s _E� u ❑ s R u Os ❑ u
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr._Sz. Sh. Bed , Trench
/y am
Ground
elev.
Depth to
limiting
fa or
Min.
Remarks:
Boring #
O _• / yrbJZ j � _ h� ll� N ii� 1 � 6'•
Ground
e
Depth to
limiting
factor
/<�__in. Remarks:
CST 7 (Please Print gnature Telephone No.
Address Date CST Number
PROPERTY OWNKIR �(a/�/z� SOIL DESCRIPTION REPORT
Page of : l
g �—
PARCEL I.D.#
Boring Horizon Depth Dominant Color Mottles Structure 2
g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
13 Bed ,Trench
Ground
elev.
fL
9
Depth to
limiting
factor
1:5 in.
Remarks:
Boring #
El
Ground
7 levy . �
Depth to
limiting
�agtor
''�7 in.
Remarks:
Horizon Depth Dominant Color Mottles Structure PD�2
Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # --
-!Z 1, 3
Lj I y�6 Z Al A AIA .
Ground
Depth to
limiting
factor
/ � - -' n ' Remarks:
Boring #
Ground
elev.
- ft.
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
Soil Test Plot Plan
Project Name Earl and Barb Carr Byron Bird JD - --- )
.
Address 2394 235th St. ,
Clear Lake Wi 540 CSTM #220515
Lot 1 Subdivision ---- - ---- -- Date 9/11/98
NE 1 /4 1/4S T 31 N/R 16 W TownshipCylon
Boring Q Well PL Property Line County ST. CROIX
IL BM or VRP Assume Elevation 100 ft.Base of Siding
System Elevation none *H R p Sa as Benchmark
Alternate Benchmark Base of Well Building @ 99.0
Property Line
ay 0 , 10'
Driveway -4
75'
N
W
Ch
Alt.
50 B -5 70' 32' B.M.
Existing 3 Garage 26 , Well 75'
34' Bedroom B.M. 5 80'
House 32 B -3
15'
26' 8
5'
T 0 ,
145' �B -2
0
b
c�
B -1 C"
c�
15'
360' Property Line
HOLDING TANK SERVICING CONTRACT
Contract Date
This contract is made between the
Holding Tank Owner(s) Name(s) and I Pumper's Name
I /
S a n�Q f3 l r : - Ca..,rr-
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:)
2 3 9 y Z 3 57+k s-f-
Sec 3 T3ii R )bI- PT Nom. IVW
Q td--t I a- es 9J Z y 9
Ac
1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality ", which has
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
with the County of
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to
enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all- weather access
road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay
the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis.
Adm. Code, and to the county, a report for, the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees
to include the following in the semiannual report:
' a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. location of the property on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain In effect until the owner gr pumper terminates this contract. In the event of a change in this contract,
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality
and the County named above within ten (10) business days from the date of change to this service contract.
Owner Name(s) (Print). I0 er's Si na re(s +
� i
CO - Q— Subscribed and sworn to before me on this date:
I
Pumper's Name (Print) I Pumper's Signature
N otary Public
- My commission expires: Z G
Pumper's Registration Number
$ DIANE B. W. tLU"H t
Notary Public
s8D - 7574 (R. 09/8 This instrument was drafted by the State of Wisconsin Department 911ft Of Wamx" I.
of Industry, Labor and Human Relations
C y VOL 1060PACE`386 `
5878�r 8 HOLDING TANK AGREEMENT
This agreement is made between the government
(Document Number) unit & holding tank owners (s
Holding Tank Owners: REG�"VR -- 0 - PFICE
J. Ca r~r ST. CR CO., WI
Rec'i for RevorO
Agreement Date: Township: C Y L DAI SEP 9 9 1998
We acknowledge that application is being made for the installation of (a) holding tank(s) on
the following property: (Provide legal land description. Use extra sheet of paper if more
space is needed.) Z 3 c y 2 3 S S " h
Ra tenor of 4oedto
Sec 3 7 31V R 16 W PT NF NW
(fie %n L od l m�' C -5 7 M 9 zq-4 Ztt
Name & Return Address: _
or that continued use of the existing premises requires that a holding tank be installed on the S.,4
property for the purpose of proper containment of sewage. Also, the property cannot now be Z 3 1 y Z35
served by a municipal sewer, or any other type of private sewage system as permitted under �e l,Jr Yom
Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Stats.
As an inducement to the County of4M to issue a sanitary permit for the above described --- _— ----------------- _____— --- ----------------
property, we agree to do the following: arcel ID Number' 6 - - leo
1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code
relating to holding tanks. If the owner fails to have the holding tank properly serviced in
response to orders issued by the governmental unit to prevent or abate a human health hazard as described in s. 254.59, Stats., the governmental
unit may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on
the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Stats.
2. The owner agrees, pursuant to s. ILHR 83.18(10), Wis. Adm. Code, to have a water meter installed in a new building or new structure. The
water meter shall be installed by a plumber authorized by the State to conduct such installations, with said installation complying with State
i+igulations and manufacturers specifications. The owner agrees to be finally responsible for the purchase, installation, maintenance, and repair
of the water meter, and agrees to allow the governmental unit to enter the above described property on a regular basis to read and /or inspect the
water meter.
3. Owner-agrees to pay all charges and cost incurred by the governmental unit for inspection, pumping, hauling, or otherwise servicing and
maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. The governmental
unit shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner
does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a
special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law.
4. The owner, except as provided by s. 146.20(3)(d), Stats., agrees to contract with a person who is licensed under Ch.NR 113, Wis Adm. Code,
to have the holding tank serviced and to file a copy of the contract or the owner's registration with the governmental unit. The owner further
agrees to file a copy of any changes to the service contact, or a copy of a new service contract, with the governmental unit within ten (10)
business days from the date of change to the service contract.
5. The owner agrees to contract with a person licensed under Ch.NR 113, Wis. Adm. Code, who shall submit to the governmental unit and the
county on a semiannual basis a report in accordance with s.ILHR 83.18(4)(a)2., Wis Adm. Code, for the servicing of the holding tank. In the
case of registration under s. 146.20(3)(d), Stats., the owner shall submit the report to the governmental unit and the county. The governmental
unit or county may enter upon the property to investigate the condition of the holding tank when pumping reports and meter readings may
indicate that the holding tank is not being properly maintained.
6. This agreement will remain in effect only until the governmental unit responsible for the regulation of private sewage systems certifies that the
property is served by either a municipal sewer or a soil absorption system that complies with Ch.ILHR 83, Wis. Adm. Code. In addition, this
agreement may be canceled by executing and recording said certification with reference to this agreement in such manner which will permit the
existence of the certification to be determined by reference to the property.
7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit the agreement to
the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement
to be determined by reference to the property where the holding tank is installed.
O wner(s) name(s) - Please Print Governmental Unit Official Name - Please Print Subscribed and sworn to before me on this date:
1 AKbAra .5 -e u AoP /1
Notarized Owner(s) Signature(s) Govemmental Unit Official Title lease Print Not Public
Gl Q J r P -e J S a 'k / �t
_ ��/!ti
Governmental Unit Official Signature y commission expir 3 - "-" 7 RT
910:96 c:lwp5Norms1h1.agr (Drafted by Zoning Admin) Persoraf information you provide may he used for secondary purposed (Privacy Uw. j40W4 A)j0
&AM of w isaortoirt
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer
Mailing Address �,�� �� /S�•
Property Address
(Verification required from Planning Department for new construction)
City /State Parcel Identification Number
LEGAL DESCRIPTION
Property Locatio � /,, /4, Sec. ��N - Town of
Subdivision Lot # r--
Certified Survey Map # 7� �d , Volume , Page #�� _.
Warranty Deed # : e16 ,Volume ,Page #
Spec house ❑ yes,�rno Lot lines identifiable ;3 ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
AI
SIGNA OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNAIURE OF APPLICANT DA E
* * * * * * 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
State Bay of Wisconsin Form 2 1982
%'ARRANTY DEED
DOCUMENT NO 11N �PA�E�1� R= uJlcr{J vrri.t_. �..
ST. CROix CTY., Wl
Floc a If Rte
Delwin E. Amondson, also known as Delwin Eugene_
Amondson, a single person JUL 8 1.996
9:15 A�
con%e)s and Warrant. to Earl J. Carr and Barbara J. Smith,
as joint tenants in common ,
N=Mi. �N , F'' W, .1i'I: "I .
the I' Blow ing deacnhed real estate in St. Croix
('ounts. State of Wisconsin.
006 - 1005 -60 -100
iParcel Identification Number)
Part of NE 1/4 of NW 1/4 of Section 3- 31 -16, described as follows: Lot 1 of
Certified Survey Map filed March 19, 1992 in Vol. "9 ", page 2 =159, Doc. No.
480684; St. Croix County, Wisconsin.
$ TR NgER
FEE
This is homestead property
tis) Its nt,u
Fcccp-tion t- % %arranties Subject to all easements, restrictions and covenants of record.
Dated thi 5th dai, of July l / 96
4
f�t�/�jPAI.) S f \ 1 t
Delwi�mondson "L
ISFAI,! Sl 11
AC r11ENTICAT10N ACKN0NkTEDG.%tEN'r
Stenaturet,) STAIU OF N'ISCO \SI\ f
(
authenii,mcd this due „f . 19 ;
Prr- .•n.tlle came h•h Fite this u of
�
• V ly �.` the ah,,.c Fiat -)ed
[fiLI.: \1F \1RFRS1,\i1 R \ROF\%'IS('OtiSI\
! it n„t.
ao,u)rurl
,
aulh ,riled hl ?371)6 Oh. \\'i Stals.l to File L.1' r '+e tl
, mn tr(.{+yr" � �j� �,h„ rer.ub;d !hr
.) ,tFNf . "SAS DRav icp Hv � * * ' ,�
REINSTRA & VAN DYK, S.C.
201 South Knowles Avenue }�d' •
New Richmond, Wisconsin 54017
\ ir'. P W" � �.tIY� '. `f � L,. f i .,u )•� \, r
�tcr;nur.s ma, h. aurhrnui:urJ ..r ar6noi IrJrcJ Rath are not \ts t, rn fnctt /1f- R� M'Itr reprrau. n J i!,
Of 16
Ne R R 1115} 1 1) �1 e1 }KeR Ut Ui�t i) \.1♦ .,
OR %1 2 VINZ
FILED
MAR 191992
2 JAMES O'CONNEIL 9
Register Dt Deeds
480684 ` �"�" Co" VIA o
CERTIFIED SURVEY MAP N
Located in part of the NE1 of the NW of Section 3, T31N, R16W,
Town of Cylon, St. Croix County, Wisconsin.
OWNER LEGEND
Delwin Amondson Found St. Croix County Aluminum
Rt. 2 Box 21 monument.
Clear Lake, Wi. 54005 X No monument found. Set Nail from
found ties of record.
NOTE: this lot is being created Set 1" x 24" Iron Pipe weighing
for the purposes of farm- 0 1.68 LBS. per linear foot.
land consolidation.
SCALE I = 100 N 1/4 CORNER
SEC.3 -31-16
0 50 100 200
Bearings are referenced to the
North & S one - quarter line U N P L A T T E D LANDS rn m
assumed IV to bear NORTH. N �
rn:0
0.)R 7V L EAST 360.00' mP
Z / 327.00' 3 of IC
IC 119122 3.00 is IZ
k2l. :BUILDING �� = 1 u
I�
L O T I SETBACK N O
Ir
yes yrtatasf��� II— L� I •�— loop � O m 1�
I�OI COON 1� C D
' tt[151V8 2 ? 0
0 0ACRES )TOTAL SEPTI CENT = iS = �m
• { I N 79, 134 S0. FT. ) N m) ID
( ' ' f. ,� k; Cwnrnit�l EX. R/W _ S 1.817 ACRES ) N 1 (n O' ti r ; a 0 1 xrdCO ,/ Y90f SHED rt�sd i
O 1 N Z D
I ' IZ
`�v 'i1�`3 ❑•WELL
Ab 0 to `' av io r �" I IWR 0 0 1 0
- 9n'�+.......•.''' in �,�' be - - -- DRIVEWAY - ---
327.00
33.00'- _•, x
W EST 360.00 6'
UNPLATTED LANDS
OD
SURVEYOR'S CERTIFICATE This instrument was drafted by D.J.Z.
S I/4 CORNER '
I Ronald F. Johnson, a Registered Wisconsin Land Surveyor, SEC. 3-31-16
do hereby certify that I have surveyed and mapped a parcel of
land located in part of the NE; of the NW4 of Section 3, T31N, R16W, Town of Cylon,
St. Croix County, Wisconsin; described as follows:
Commencing at the N; corner of said section 3; thence SOUTH 262.27 feet along the north
and south one - quarter line of said Section 3 to the Point of Beginning; thence
continuing SOUTH 242.00 feet along said north and south one - quarter line; thence WEST
360.00 feet; thence NORTH 242.00 feet; thence EAST 360.00 feet to the point of beginning.
Containing 87,120 square feet (2.000 acres). Subject to Town Road right -of -way as
shown on this map and also subject to all easements, restrictions and covenants of
record.
I further certify that this map is a correct representation to scale of the exterior
boundaries surveyed and described; that I have fully complied with the current provisions
of Chapter 236.34 of the Wisconsin Statutes and the subdivision regulations of the
Town of Cylon and the County of St. Croix in surveying and mapping same.
Ronald F. ohnson R.L.S. No. 1186 Date
Ron Johnson Land Surveying GENERAL NOTICE (required by County)
P.O. Box 194 Each parcel shown on this map is subject to state
Amery, Wi. 54001 and county laws, rules and regulations (i.e.,
Tele. (715) 268 -2601 wetlands, minimum lot size, access to parcel,
etc.) Before purchasing or developing any parcel
contact the St. Croix Co. Zoning office for
advice.
Vol. 9 Page 2459