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HomeMy WebLinkAbout014-1033-80-000 I �..,....... 9 ,/ �. r ST. CROIX COUNTY ZONING DEPARTME AS BUILT SANITARY REPORT Owner r° �"',. . ry r 4 �t.:�9 i _[�� i c�G� ��' P1 I �le"7 R Address — gA u,—.� U+ � : �r c,4p � 1 9� ..•! „ Cp X City/State >�RekA SMl n1G►S zQti�NCoF�C� /` Legal Description: Lot Block Subdivision/CSM # UbL► 1 "7 Rw4 r '/4 '/+ , Sec. 1 ,TAN -Ry5W, Town of i PST PIN # 014-0 L SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer KAtJ Size ST/PC / Setback from: House Well r �21� PR- Pump manufacturer — Model -- Alarm location (HOLDING TANKS ONLY) r r Setbacks: Service road Vent to fresh air intake Water Line 60 Meter location M. A . Alarm location 1. jJ B A SC;M i� 1 ,11- SOIL ABSORPTION SYSTEM: Type of system: Width Length Number of Trenches Setback from: House Well P/L Vent to fresh air intake ELEVATIONS Description of benchmark BMorn QF• StD;Ajq Cf.) Qf,5 • 510e: Elevation Description of alternate benchmark Elevation C-- 1 9 4 5 Building ewer 1 ' g ST/HT Inlet ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover Distribution Lines ( ) O ( ) Bottom of System( ) O ( ) Final Grade ( ) ( ) ( ) Date of installation mit num r 3C' _ State plan number _7{004 Plumber's signature License number 22:564 Date 4 Inspector — 90( - > complete plot plan O' i NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW wou- i� N INDICATE NORTH ARROW i I a Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count' Safety and Buildings Division §T . CROIX • INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar §P� 1119.: Personal information you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. S 3 0 Permit MCOLLOUG EL Ej&Ei� E] Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel 3114 1033-80-000 t w tsC� I f3+. e- 71 C� 1 Y114 TANK INFORMATION EVATION DATA A9800112 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark 10 I / loo Dosing 1' Aeration Bldg. Sewer o I �fr 2 St A�Pnlet �{p}ti� f0 2'l.� TANK SETBACK INFORMATION St/ Ht Outlet 4 TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet irl � Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe old 7S 53 S b Bot. System PUMP / SIPHON INFORMATION Final Grade Manufacturer Pemand Model Number GPM TDH Lift Fri Ion System TDH Ft os Forcemain Length Di H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside_ Dia. Liquid Depth DIMEN SIONS DIMENSION SYSTE ACHING Manufacturer: SETBACK INFORMATION Type O CH a Number: S OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distributi x Hole Size x Spacing Vent To Air Intake Length Dia. Length SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over eded /Sodded xx Mulched Bed /Trench Center Bed /Trench E Topsoil I ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) LOCATION: FOREST 15.31.15.240A,SE,SE 2132 CTY RD P Plan revision req fired? ❑ Yes 5� No Use other side for additional information. r 1 6 SBD -6710 (R.3/97) Date Inspector's Signature ert. 1 s ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: u ' I VOL 1318 PACE 6 8 Document Number/Plan I.D. No. HOLDING TANK AGREEMENT 578051. This agreement is made between the government unit and holding tank owner ( s). 1 GK MICE Name and Return Address REGIS mP lr m CepLt - OvG { A � o � R Coosa" wI X0 fi3 e,pv v� 11 +>5 w trZl� APR 2 8 1998 W R.e Ic.r� -5 P rz.l (a G- A f2 z-4, - 3 i Parcei identifier number (PIN) ?agreement Date 0 t 4 1 a33 5o I 4/ �'9 'C �+- [� 1 { Re tw of Oe9* Governmental Unit Holding Tank Owner(s) We acknowledge that application is being made for the installation of (a) holding•tank(s) on the following propeM!gProvide legal land description. Use reverse side if additional space is needed) CROi or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 143, Stars. As an inducement to the Cw Zrl or ST CkC 1 to issue a sanitary permit for the above described property, we agree to do the following: 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 rank 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 regulations 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 governmen =l unit for inspection, pumpi.^.g, hauling, or otherwise -seer -cat; 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. 1. The owner, except as provided by s. 146.20 (3) (d), Stars., 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 contract, 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. i. 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. = 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 S. This agreement will remain in effect only until the governmental unit responsible for the regulation of private sewage systems terrines 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. Ownerns) Name(s) - Please Print r L eotl\ overnmental Unit Ot6ciai Name - Please Print Subscribed ana swots to before me on this date: IYIu. MC C©L4,00 ,41 LI 5o v\ M 9 % c' Notarized Owner(s) Signaturets) Governmental Unit Official de - Please Print J Notary Public ^^ 1 Gov mmental Unit fficial Signature My j 1111 1 Drafted (� by �� /� R-t �L S.1 Personal infaimation you provide may be used C PY@4� J 1,LA w iii* xinll• Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. Vliconsin In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. �5 Cyolix • See reverse side for instructions for completing this application State Sanitary Permit Number 3c>_7738 The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Num r I. APPLICATION INFORM - PLEASE PRINT ALL INF RMATI a ,q2 Property Owner Name 5 ope ation MM mCQ�.- �.r3�.'tn 4� /4 1/4,S (f5 T 3 , N, R 1!5Kr) W Property Owner's Mailing Address Lot Number Block Num City, State Zip Code Phone Number Subdivision Name or CS_ M Number � Ito 7 474 I?Z1� �>' uW W_ fiZX ( 1 )ZS3- = . TYPE F BUILDING: (check one) E] State Owned 11 t -� Nearest Road [] VII age 69-L"5T Public 1 or 2 Family Dwelling y: � - No. of bedrooms �_ Town OF CIO 634 �P III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) o 14-- io m U �S 1 S 1 ❑ Apartment/ Condo 2 [] Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor R creational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales / Repairs 11 ❑ Restaurant / Bar/ Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ' ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 ❑ New 2. 1K Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5, ❑ Repair of an System System Tank Only 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 g( Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -ln -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 4-5o Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq_ ft.) (Min. /inch) Elevation ---- Feet Feet Capacit VII. TANK in Ca allons Total # of Prefab. Site Fiber- Ex p er. INFORMATION gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic A p p New Exist in s Tanks Tanks olden Tank �(�� N ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I 1 ❑ 1 ❑ ❑ ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibjl't y for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) PI mbe 's Sig u s) VANMPRSW No.: 6(5)U51 usiness Phone Number: o tJ Rtz i OCF, 2 - — 3Q2-0 Plumber's Address (Street, City, State, Zip Code): 14-11 V5"-A T wrwo IX. COUNTY / DEPAR TMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Issuin c Agent Signature (No Stamps) A roved ( pp ❑ Owner Given Initial Eg0 Surcharge Fee) � /cx� � oig C Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBO.6M (A 11/96) DISTRIBUTION: Original to County, One copy To: Safety E Buildings Division, Owner, Plumber II INSTRUCTIONS y i 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 instailatior ;. 5. Onsite sewage systems must be properly ma9taine `'(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 application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is tote 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. p Y q g 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 tanks or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. RESIDENTIAL AND SMALL COMMERCIAL CONCRETE HOLDING TANK DESIGN ,:irrrafe 7'arrk Option INDEX AND TITLE SHEET Project MEL MCOLLOUGH Owner MEL MCOLLOUGH Address 167 BEAVER VIEW ROAD EUREKA SPRINGS AR 72831 (501) 253 -5087 Legal Description lftq&Sl5 Township FOREST County ST CROIX Subdivision Name Lot No. Parcel ID Number 014 - 1033 -80 Plan ID Number P'O'W.T S. INDEX AND TITLE SHEET PAGE ONE Conditionally HOLDING TANK SPECIFICATIONS PAGE TWO SITE PLAN APPROVED HOLDING TANK AGREEMENT PAGE FOUR DEPARTMENT Of ERCE Of SAFE? ILDINGS SEE CORRESPONDEN Designer RQNFRIEDEaL Signature t Phone No. (715) 637 -3020 License Number 226564 Date 4/8/98 SBD-10463 -E (N.05196) Page 1 of 4 ' 76042 r HOLDING TANK SPECIFICATIONS Single Tarrlr, Option 0 ple/e Red Boxes Or ?fy In - p ounds Metric If one- or two - family, number of bedrooms = 3 AndlOr....Non- residential flow per day = gpd or 0 Lpd Minimum holding tank volume required = 2000.0 gal or 7570 L i Holding tank capacity proposed 2800 gal or 9462.5 ] L Manufacturer SKAW Alarm manufacturer IS J ELECTRO Alarm model number 1 101 Depth from inlet invert to service alarm = 12.0 in or 30.5 cm Liquid depth of tank below inlet invert = 50.0 in or 127.0 cm HOLDING TANK CROSS SECTION manhole cover with locking device and finished junction �i warning label vent cap 12" (30 cm) min. grade box —� 4• /10 cm1 min. vent pipe conduit 18" (48 cm) Electrical as per NEC 300. _ 12.0 in. or building sewer 30.5 cm service inlet blind plug alarm on to seal outlet Manhole and vent 38.0 in. or may be reversed. 96.5 cm 3 in. (8 cm) bedding under tank. Tank anchored as necessary to negate buoyant forces. Note: All tank joints, and joints between tank openings and piping are sealed water tight. Project: MEL MCOLLOUGH Plan I.D.: Page 2 of 4 HOLDING TANK SITE PLAN Project: MEL MCOLLOUGH Legal Description: Nt OAS15T31N R15W N Subdivision Name: Scale: 1: V =40' Plan I.D.: Lot No.: L W Gf Yp ��'su� -AtLA 1 F P—W �3ARN 3>�n Rm I 1rl Y • 11/15+ O LDRIVe J Page 3 of 4 5 9MD o 13rn 'BeoLN Mpe K. SL. 1cx) - , f)0 11 O C. >~ 1C) ►��, 0 s.6). cp�� CORREC114N NEEDED HT, Now IN C% TAU r- J 5G0 50.t• v KAQ SEE CORRESPONDERM Safety and Buildings 15837 USH 63 m HAYWARD WI 54843 -8107 Nvisconsin Tommy G. Thompson, Governor Department of Commerce William J. McCoshen, secretary April 15, 1998 RON E FRIEDELL 1419 13TH AVE BARRON WI 54812 RE: CONDITIONAL APPROVAL Transaction ID No. 76042 APPROVAL EXPIRES: 04/15/2000 SITE: Site ID: 6109 ST CROIX County, Town of FOREST �C,$i' 101/4, J11/4, S15, T3 IN, R15W MEL MC OLLOUGH FOR: Description: HOLDING TANK, RESIDENTIAL, 450 GPD Object Type: POWT System Regulated Object ID No.: 14786 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes listed in the regarding line above. 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. • Abandon failing system per COMM 83.03(2). • Maintain well set backs per COMM 83.18(7)(a)1. 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. When making an inquiry or submitting additional information, please refer to Transaction ID No. in the regarding line. Sincerely, DATE RECEIVED 04/14/1998 to FEE REQUIRED $ 60.00 PATRICIA SHANDORF , POWTS PLAN REVIEWER FEE RECEIVED $ 60.00 Integrated Services BALANCE DUE $ 0.00 (715)634-4870, M -F 7:45 AM - 4:30 PM PSHANDORF @COMMERCE.STATE. W I.US Wi-Nonsin Department of Commerce SOIL AND SITE EVALUATION Divisionof Safety and Buildings Page ( of Bureau of Integrated Services in accordanceF#R 09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 i es) ize. PI ust County include, but not limited to: vertical and horizontal reference p nt j9M), di .J �,, ` f clr�t percent slope, scale or dimensions, north arrow, and location 4ini1 distancc ✓ 1 Parcel I.D. # i 4�r C) 14 -- APPLICANT INFORMATION - Please print all i. `#09 f ` ; j .R 'ewed-by Date q :�a . Y Personal infomiat'an you provide may be used for secondary pu (f'ri-cy Law, scMSM4 t1� (m)). ;'-• -. � Property Owner M P l idoft L M F i iJ 1 t G OWav C*H` _GovE Cgt' 1/4 � 'E 1/4,S rj T 3 1 ,N,R W Property Owner's Mailing Address `L Block# Subd. Name or CSM# V OL I A 0'7 City M City ❑ V Town ate Zip Code Phone Number Nearest Road ❑ � A =- (5ol ) Z 55 -5 Co A t. � ❑ New Construction Use: ® Residential / Number of bedrooms �� Addition to existing building —° ® Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate — bed, gpd* = french, gpd* Absorption area required bed, ft trench, It Maximum design loading rate bed, gpd/(tz � trench, gpolft Recommended infiltration surface elevations) ft (as referred to site plan benchmark) Additional design/site considerations H o � i 1J G. TAI-) i. R i✓cc.)M m eN f)w Parent material U tJ 1<0 iot I "plain elevation, if applicable . A r ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ❑ S® U ❑ S® U ❑ S KU CIS O U El Do u NS El u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 C3 1 in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 0 '75`l% 3 2 — S i 1 2 m a bK I 5 g R 5 .• (o 2 -11 10YR. 4- z,s�� G2 S srnab M — ,5 ' .k, Ground 11- 2,5Y,i' 3 I'lt sc , 1 N,qb 1< m i — , 2. ; . 3 el ?v q � Depth to limiting factor �in. Remarks: Boring # 1 0 -8 ?.5-tt2.3 2 5 t 1 Zm bK- m i 9 2. 7.. - 21 5 2.5yz C-1- 51c.l am m t 5 ► . 4 ; �5 3 i- 2.5 2.� p " D C3c sCi tmobk i gs r ' • 3 Ground 4- - 1 .5`frz. 5 to 1.5 C 3C, 5 5r,1 a Sci 5 i m ( •`�- ' ' 3 R elgv. i Depth to limiting factor _901n. Remarks: X' 11XR- SP50 10 c> `p 3 Ca CST Name (Please Print) Signature Telephone No. R =*J TRi(✓ifrt_L, U�A � I _ a t 5 3 - 1 - Address i4lq � J �' 1 5k�0 154-0t?, Date � u.0 ,qg CST Number I mC ut PROPERTY OWNER MEW L DESCRIPTION REPORT t-4 W ��t.� Page 2- of •- 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 Bed ,Trench 2 I ll -11 I0Y,2 51 Z oyrn4$ 5ZZ 511 Zm f nn ss � (JP; . 2. Ground -3 C - 2 n,o. bk i elev. j j Depth to limiting factor in. Remarks: Boring # 1 0- `7,5 31 2- — 511 2t b Im I S5 2A 65 ' 2 tl loYf2 5 2 0 Cad s►c.► i►ry abir, Tnj 1 .4 ;.5 Ground elpv. p Depth to limiting factor -U_in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ? Z 5 2 - on o�hk I M 2 1 13 - A IoYR,S .41. czA Si ci 2rna6K 1 Ground elev. if a5L- 7. Jft. Depth to limiting factor - L5L -in. Remarks: - rYIS Fe9 —#MCn WAS uAMn 1)06 Boring # 13 Ground elev. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) 1'© LA.) a FC) R -e!:"T -- 51 Cho NOT Td Sc.A-AP, j 1 0 - ? , s r pu3�•� BB C> P--M l�iciJ ° YAP-I> N ousB. &. Y �A� 3 X r Zt~34. � 5011TOM aF 5ioxNC„ 0 #3 C-DZ.+JZ r HOLDING TANK SERVICING CONTRACT Contract Date _ — — — — — This contract is made between the — — - - — — — — — — — — — — — — — Hotding Tank Owner(s) Name(s) and Pumper's Name I nn>✓� mGc�t��� � NbR��y ANT. — We acknowledge the Instflation of (a) holding tank(s) on the following property: (Provide legal description:) St ( G 15 � �Zl �jl.j `r0L,2, U01 Y, GOO OT I 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 1� CF z t x 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. It HR 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. The 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; I. 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 or 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(et) Names) (Print) I Owner's Signature(s) met.. M C OL"D c, I Wh j V )fi Subscribed and sworn to before me on this date: _Mn VT O f �l� Olrl 4 Pumper's Name (Print) I Pumper's Signature �� � o ary u c I M ommission ex e ' OOOTA }- �d' A Z 4 / I -.®__ -f - 4 Pumper's negistration Number P BLI C ' y� De artmen�� W SBD -7574 (a_ 09/88) This Instrument was drafted by the State of Wisconsin p of Industry, Labor and Human Relations a • VOL 131.h PAGE 46 Document Numbe r/Plan I.D. No. HOLDING TANK AGREEMENT 578051. This agreement is made between the government unit and hoidino tank owner sl. ' Name and Return address REGIST'�E " O — FFICF hx Reco R� MCOL'Lt�0 /�,�;� �T, CRQIX C d WI 'faf ro Ito? i3 �v t V\ w tZ,� APR 2 8 1998 �: a Parcel idenutier number (PIN) agreement Date � � g �.}� J 1 0 14- — i X33 C I 7 � a ter lef+� Da(.R�J Governmental Unit -T �,€ 'F Holding Tank Ownegs) We acknowledge that application is being made for the installation of (a) holding-tank(s) on the following property Provide legal land description. Use reverse side if additional space is needed) ro 5Iff-c- 1 5 T -i R 16 w or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. UM 83, Wis. Adm. Code, or Ch. i +6, Scats. ?is an inducement to the C W. TrY f7F' ST C 01 to issue a sanitary permit for the above described property, we agree to do the following: 1. Owner agrees to conform to all applicable requirements of Ch. MER 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. 254.39, Scats., the governmental unit may enter upon the property and service the rank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax hill 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 regulations 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 cc pay all charges and cost incurred by the governmental unit for inspection, pumping, hai l ng, 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. 1. 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 contract, 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. S. 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 .HR on a semiannual basis a report in accordance with s. I1 83.18 (4)%) 2.. Wis. Aden. Code. for the servicing of the holding tank. In the case of registration under s. 146.20 (3) (d), State., 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 S. This agreement will remain in effect only until the governmental unit responsible for the regulation of onvare sewage systems certifies that the propert 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. ;. 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 he determined by reference to the property where the holding tank is installed. Ownetts) Namets) - Please Print Governmental Umt Official Name - Please Print Subscribed ana sworn to before me on this (late: Notarized Owncns) Signatnre[sl Governmental Unit Official do - Please Pnn[ Notary Public l � Gov mmcntal Unit Official Signature MY y Drafted by Pe au infom,azwn you provide =y be used 1 pytposa (Pnvxlt.Law r,* )(mll u�.e...� 5 - g��± OF W,sCO� • ' ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer MU —V i M m C,C�C,f�t1 Mailing Address 11PI beipauR V RoAD GyRF 5P -W(AS AR - T Z.4o 3I Property Address 0- 1 - 5 - L cf t FD (Verification required from Planning Department for new construction) City /State EMee -AL.Q i Parcel Identification Number 0 14 1 �® I LEGAL DESCRIPTION Property Location ' /,, %,, Sec. 15 . T 31 N -R 5 W, Town of Subdivision , Lot # Certified Survey Map # . Volume . Page # Warranty Deed # 5'2 -4 15 t I . Volume 110-1 . Page # 4- 19 Spec house ❑ yes PQ no Lot lines identifiable JA yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result is its prematurafailure 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 a to submit to St Croix Zoning Department a certification fomr, signed by the owner. and by a i;na � masterplumber, journeymanplumber, restrictedplumberor a licensedpumperverifying that (1) the on -site wastewaterdisposal 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 of the year expira . n date. ILI -A��z I SIGNATURE 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 owners) of e property described above 7bvirtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICKW 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 I __ STATE BAR OF WISCONSIN FORM 3 — 19101 524812 ;1 a rA2- .011 MECASM office Richard 0. Rosen and Helen L. wife and Li.her h 10:00 A ............................................................................. . . . . . ........................... ........... ............. ........... ................................... . .. . . ... . . ......................... ......................... . ................................................... . . . . ................... . River ......... .................... . . . . ... . ..... ....................... . .. . . ............................... L:=Falls, WI 022� WFA except the Was-, 38 rods of the Rhat 66 rods of the Scaith 35 rods thereof, All in T31N-Rl5W. FEE This deed is given in fulfillment of a certain Land Contract between the parties hereto dated June 1, 1985, recorded June 4, 1985 in Vol. 713, page 319 as Doc. No. 402423. V0 (is 111100 Exception to warranties: Ebdsting higbways, easements and riglIits of way of record. Signabm(s) STATE OF WISCONSIN to me known to be the Pe fore"lng instrument and ow TmIS INSTRUMENT WAS VRArrZ0 BY wi Legal Blank Co. Inc. ^~- .. --__ DX - -