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HomeMy WebLinkAbout020-1221-10-000 K¥ 7 7 2 $ m� j2 22 \ t @ © § K : 0 / . & § � � G � � 2 / $ ? ] ƒ ƒ 7 LL \f 0 \\ n ) r a % " \ z' § - k » § IL M V N a m ) B 2 2 \ k k CD � k k ± E 2 E \ I c $ N \ § = E _ $ e : k CD a )� CD §G� + f § k D < k e? < / § > . .. .. k % k j t / \ k k k ° ° ƒ a§ ( �CLM c �� 0 0 2 E f � 0 o k 2 E k \\ m ] ' co 2 U) k CL 2 K K K 7 C a a 2 § 2 2 a §k 2 j 2 o k i ƒ co k k , } § § t j k § \ US © ® - 0 � ® § ca (n : o o /\ 7 c 7 = 0 2 1 . .. Lo 0 7 $ E < » e .2 < @ § » © 4) a ° k § %f� _ k (n I o� :U) c �— a ] § It 3 @ § ƒ % 2 j)c )/ c_ )\ SO) -0 .- ■ _ § ' / R ` % 2 § o § \ }\ Q o ) / \ § 2 0 / ] 2 \ 2 $ g § a a E L » " IL ' k a § k a § co� / 3 a o� J 0 2 0 r Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER �� Yh; ��Q_ }� TOWNSHIP ° SEC. / 7 T 1_2' N -R ADDRESS to # 7 $ Z ST. CROIX COUNTY, WISCONSIN / /s a h W Z- 7' 1 SUBDIVISION - P&, f. y; C_") Flies JZ_L Z 3 LOT SIZE o ©Z c a.✓ s PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM p Sy s rtQ - wi t IV. �iYC C��� �o � a.. V��[L� m � 5 10 � L 3 �. w A � Lol z Z. I2 2 Sy f I ABM I s Q Z4 X ;Z 32. t t # t t mot$ N I A INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used C-o" r ©q k5u" / 2z_ Elevation of vertical reference point: pbo•o Proposed slope at site: % 1 SEPTIC TANK: Manufacturer: (,)c- Liquid Capacity: �f Number of rings used: 7/ Tank manhole cover elevation: •�Z� Tank Inlet Elevation: Tank Outlet Elevation: Z -- Number of feet from nearest Road: Front ,O Side, Rear, O �� S feet From nearest-property line Front,OSide,ORear,Q } feet Number of feet from: well L� _, building: �© (Include this information of the above plat plan)( 2 reference dimensions to septic tank) i+T•T Tr!TTT`T (•T ^TTi^ _, PUMP CHAMBER i Manufacturer: fl Liquid Capacity: Pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, © Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: �ifn Trench: Width: Length: 3 Number of Lines: Area Bui1t: Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, ( Rear,O Ft� ? Number of feet from well: :z r4 w Number of feet from building: it 2� (Include distances on plot plan). SEEPAGE PIT r Size: / f/T 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 absorbtion sytems? (Check one). HOLDING 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, 0Ft. Number of feet from well: Number of feet from building Number of feet from nearest road: Alarm Manufacturer: Inspector:- Dated: Plumber on j ob: License Number: 3/84:mj • DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION c P.O. BOX 7969 ON -SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION N MADISO, WI 53707 Sfn S , Sec. I7,T29 -R19 L 1 StaePlanI. Number: Town of Hudson �C��VENTIONAL El ALTERATIVE ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound Wa rt-- NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: T m litiscin, WT 9401 'Rn3c 9R2 I BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM LAN: REF. PT. ELEV.: CST FIEF. PT. ELEV.: Name of Plumber: MP /MPRSW No.: County: Sanitary Permit Number: SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCK COVER ��� / r ' a / -I 2• PROVID ❑ NO PROVDED: 9� /,3 / BEDDING: VENT DIA.: VENT MATL.: HIGH WATE l/ NUMBER OF ✓ ROAD: PROPERTY W BUILDING: VENT TO FRESH cf ALARM: FEET FROM LINE: AIR IN �¢ET'r ❑ YES NO C� o NEAREST �� S 4" 12 C� DOSING CHAMBER: MANUFACTURER: I BEDDING: LIQUID CAPACITY: I PUMPMODEL: PUM ON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO I ❑ YES ❑ NO GALLONS PER CYCLE: P NUMBER OF PROPERTY I WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN LINE: AIR INLET: PUMP ON AND OFF ) YES ❑ NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moistueCa the depth of plowing FORCE LENGTH: DIAMETER: I MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED /TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID /� �� I TRENCHES: 1 �r MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE I DISTR. PIPE I DISTR. PIPE MATERIAL: N ISTR. NUMBER OF PROPERTY WEL . BUILDING: VENT TO FRESH BELOW PIPES: ABO OVER: ELEV. INLET: ELEV. p END- n PIPES: LINE: AIR INLET: 9�.9-3 r ,Z•O`/ ' S�• c� 3 NEAREST �� Ie� (� r J Cup v ? • t�� MOUND SYSTEM: Mound site plowed p ndicular to Check the texture o fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown ope: mound syste o make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets t riteria for medium sand. ELEVATIONS MEASURED. SOIL COVER I TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH /BED DNCH / BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: ED ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTR SYSTEM: BED /TRENCH WIDTH: LENGTH LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENC DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFO RIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRE COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION PPROVED PLANS YES ❑ NO I ❑ YES ❑ NO PERMANENT M RS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS FEET FROM LINE: ❑ YES E] NO ❑_Y El NO NEAREST � �,� � ) ��� m t:.ci� / �,�,w,•,� �"' �'� i U� *�irrl % ��j. C'G,��T�Gu� -l�, . 40 Sketch System on Retain in county file for audit. Reverse Side. IGNATUR TITLE: SBD -6710 (R. 06/88) ILHR SANITARY PERMIT APPLICATION • In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ❑ Check if revision to previous application —See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. AP PLICAN T INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION SCL Al A Ni S GJY4 YE Y4, S � - J T 7-9, N, R / g E (or)(E> PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # .8,c 3* Z 7 L z� CITY, STATE ZIP CODE PHONE NUMBER SU IVISION NAME OR CSM NUMBER O. 3 Z& V i e tJl� 5's Check one) CITY NEAREST ROAD Ili. TYPE OF BUILDING ( ) ❑State Owned VILLAGE : pp n L cf t v� ✓t C.l' E] Public 1 or 2 Fam. Dwelling -# of bedrooms PARC TAX MB R( ) 111. BUILDING USE: (If building type is public, check all that apply) Z 4? ! Z 3 1 ❑ Apt/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 ❑ Office /Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. E New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # — Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 NeepageTrench eepage Bed 21 El Mound 30 El SpecifyType 41 El Holding Tank 12 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 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) 472-?e'0 ELEVATION - ' S G 7 V Q. 3 Feet 9510 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank �C7 az Lift Pump Tank/Siphon Chamber El H I F1 VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (N Stamps) MP /MPRSW No.: Business Phone Number: D o uy(6s f �`� a/1 �+ ooir T "'I P y 3 Y 2S� 7 ) 3 Plumber's Address (Street, City, State, Zip Code): J �4 4 A ( e ,4^,0 n 4 W 1 9 0l 7 IX. COUNTY /DEPARTMENT USE ONLY L] Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) 'Approved ❑ Surcharge Fee) Owner Given Initial / /�.-. Adverse D &rmination 3 6C1 X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: i SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber a'�v� �lot U SS P U A I TE - �6 s V. = 9a,y . 3119 /Vt a( 90 B . M•' N ° W. �or�o r dF cowc �d't•� 93 AS A� r R sa- 100.0 O I i 13or ' ,— ,�� -"� i d �t is S (,T..s'�' B�1f.,� E \V • _ °i Z.tio - � 1 y�� =�a� Z � � ii � /V�tn�. 7" kd 1�xdw ova,✓ -�� � BI 1Mvva_ "f Liar. SL �' of co %/e ✓. Z B O I-t G g' k _ oc/ 0 t1ns- s y s"rt at� p �$ XN8 z�l'x32' tt ..tea Sa { � �._.__ f � o � I Z Z ,Q v. 1 �� � �, '� i S P tom r (l4a✓' dj ( Wks✓ 0� Lo w .0 o � i 7� / . ♦ `J tt o va. v SC7 To - ( - Iti s p + ; c A. o� w y t W N I 1 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUSTRY,*' DIVISION 1 C HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707 (ILHR 83.09(1) & Chapter 145) LOCATION: , , SECTION: TOWNSHIP /Mlif�fft"LMy- OT NO. BLK. NO.: S BDIVISION NAME: s6 r`7 /T7_9 N/R iq b or W ,� �� - a fter V1 Fw COUNTY: U A S 'Spr CPO ) SO M 46 7 3 IR8QQ USE DATES 013SERVATIONS MADE NO. BEDRMS : COMMERCIAL DESCRI TION: PROFILE DESCRIPTION COLATION TES S: Residence ' ` WNew OReplace ��$ � 199 '' - X 951 Vl �It_s�G�'jI`. Ca �j� C C�1LS 8�B 11u�L�NQ�T RATING: S- Site suitable for system U.- Site unsuitable for system -' O�� T�� • I M OUN D�� • ❑� IN -G � O� • rY$T � I��L � S G�K: RECOMMENDED SYSTEM: ptional) �/�1 d l 8 k36 If Percolation Tests are NOT required DESIGN RATE: Q If any portion of the tested area is in the under s. ILHR 83.09(5) (b), indicate: C L Floodplain, indicate Floodplain elevation: NA Iv. C_ -r PROFILE DESCRIPTIONS BORING TOTAL P H T R UNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH*, ELEVATION OBSERVED TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 043 49.41 N > 0,133 13"eLcrs 37 "$QN s 8 " ge") er Z2 , $P" ei5 B- Z . p.S� 99.$ /eon, > /D•SS /6 sz-rs z�� 5, Q.vCs�GR /9' B- 3 p,@3 42 Ncuv > /0. 24 ''gcs 0 5 F "BaN /o�13a,�S� B )• d0 03. o > J l .oa Z /'& X75 s B .9'& 03.2 NONC > 1� 4' � 9" eR..0 - 5 B- Dtc�c'1 PERCOLATION TESTS TEST DEPTH , WATER IN HOLE TEST TIME D WA LEVEL-INCHES RATE MINUTES NUMBER S AFTER SWELLING INTERVAL -MIN. PERIOD I PE PERIQQ3 PER INCH P_ 1 .16 t,,6ME 1 Ct9..5;6 3 > > > �t < 3 P_ Z .so t 99.96 3 > > > Z < P- 3 40 ,a -00 >z > >z < P_ P- JATIOri �eRG P- PLOT PLAN: Show locations of percolation tests, so' gs and the dimensions of suitable reas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points show their location on the plot plan. Show the s ce elevation at all borings and the direction and percent of land slope. Z O SYSTEM ELEVATION. 92,4 to' �lcsr� o _ _ i i t- a; c a Ilk t N I L w ELi v � N ! - t I _.. - �._. _� IF Ir. is LJ- t co 1 y'+T1z � 9i'� 1 S Tip A �N� 6 N _ ..___. _. us t ► V k so' ro - TNt s t Pr►C 4 QYaQ I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified i the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief, ON t:.o : r YT NAM print): TESTS WERE COMPLETED ON: Ma 11&>' �N ) SoN S� `�i lNc FIr$2 0 14>e Y '2l l 9 ADDRESS: CERTIFICATION NUMBER: PHONE N MBER(optional): CST SIGNA URE: _1� �1� DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR•SBD -6395 (R, 10/83) — OVER — APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and 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 f12,/&ZA✓ Location of property S W 1/4 S 1/4, Section ,/ 7 , T Township - Mailing address x Address of site c,< Jk� t �aa� Subdivision name p r /c Lot number / Z 3 Previous owner of property / ✓ /o �Q �� Total size of parcel . Date parcel was created Are all corners and lot lines identifiable? as N o Is this property being developed for resale (spec house) ?Yes No Volume YS and Page Number y,75-/ as recorded with the Register of Deeds. ------------------------------------------ - ------------ ----------------- ------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A VARRANTY 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 references to a Certified Survey Map, the Certified Survey Map shall also be required. ------------------------------------------------------------------------------- PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. o_'7 Z o - 7 - ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Registe of Deeds, as Document No. Z9 7 z o 7 ). Signature of Owner Signature of Co -Owner (If Applicable) 9 9 Date of Signature Date of Signature L STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER Sg .*.2 /�/iy /4-✓ - - ROUTE /BOX NUMBER ,-or �'` Z d Z- FIRE NO. CITY /STATE ZIP — 're1021-6 PROPERTY LOCATION: S w 1/9 S 1/9, Section 7 T _:!�f N, R _Zg_-& I li Town of St. Croix County, Subdivision Lot No. /Z 3 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 SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 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. to St. Croix Count The property owner agrees to submit Y Zoning 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 (2) after Inspection and pumping (if necessary), 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. I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department 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. �a SIGNED DATE o[ ^ a U St. Croix County Zoning Office. St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386 -4680 Sign, Date, and Return to above address PARK VI ESTATES FQURT-f ADD1T14N � A , ,RAt SU'MMSIO LOCATED IN'THE lC*SWA a NWbh - kW,SECnCN 17, T29N•, R19 N., TOWN CF ». HU)SSCN.. ST. CROX COUNT WSC ,4'V,S'1N w j t'P t 1. may• / C=TI71CATE OT TOWTitZt/iSUM STATE O WI3CCNS" 1ST. 60m cOGiH:Y I', 8ewsl)r A. 3oltoion.. peters ttae daffy elected. qusiilfad'aad sctiat ?trey Tsaasuser I of the Town o! Ffuteoa, do hereby certify that in aceovda.00a rotorda is my office, these are Do unpaid tress or eela ne i aseessrnes as o, iaolai«i la the Plat of Park Vies se Zetatas Fourth Ad&Hon. .. _ . oa any land S y te Beverly V.J Town Treasurer l TOWN BOARD AZSOLUTION ` RESOLVED, that the Alert of Psrk View Estates 'Fourth Addition In the Town of i Hudson, Darrel E. 'd'art and Bove A. Wert, nwnere, is hereby approved by the III 'rows 8 zd iJ / . r a • 'proved own b sman D, tgnad owe t..tatrmrn I t aarobv eorNfy that the lorrgoin.l la a copy of is roeulutton adopted by the Town I Board of the Town of Hudson. i D /to Town Clerk OWNERS' CeRTIFICATE OF DEDICATION As owners, we hereby certify that we caused the land described on thi: Plat to be survy,d, !l Ad•d, mapped and dodieated es ro?ro.ented on this Plat.. W • 4140 certify t`iet ;his Flat le required by S. 236.10 or S. 236.12 to be submitted to tine following for i :tpprovsl or objoctlon. Depertmert t,t Development j bepartment of Industry. Labor and Human Rolatione, Town of Hudson. City of Hodaoa and St. Croix County. I' W;T t =SS the load and real of sold owners this _. t day of • .. j1 In breeonce of: --//A {• t i aU rte! . err• Yt t �dLLN/ i _ J ! 1 flsysrly A. Wer( I . STATE OF WISCONSIy) S3 I ST. CROIX COUNTY ) I Personally came before me this " .lay at _ // .+. / • •• the above mmo•i Darrel C. Wert and Beverly A, Wert, to Ins itnown. to be the persons w`to executed the foregoing instrument &awl acknowledged the sarne. 1 Notary Public y!,' :, .. • „�, , Wisconsin My commission expires I /9� )• i r • j rN�� bier' tech, ?fotary Atblit I - :CERTIFICATE OF TOWN CLERK' i i STATt OF WISCONSIN) 1 )S' { ST: CROIX COUNTY ) I. Alta lbrne. being the duly appointed, qualilled and acting Town Clerk of the j 'Town of Zh-dson. do hereby te,� i!y that copies of this Plat were forwarded ere required by %..'.36, 12 on the day of B , 1984, and that within the 20•day limit eat Fy e. 136. (3) (no object! ns to the plat have boon (lied) (1U Jhjsct!n• 1 to •ha F)At have been mer), Data HitX porno, Town Clerk . x JAMES E. RUSCH SURVEYING & MAPPING HUDSON, WISCONSIN 7111! thlTtlW NT CRAFTED 81 e . c � ` t i _ t • ��rttl � "rt4 ✓'d ti�� i t� . ! L t ti 'r '. ILA , C4 �d ( ld�4 1', P � U ud e � AITE 1z "V 3N9 /VkT f d t cowc C�'� row a� ROL, 1 2 Z- 100.0 0 T �_o'� d �c is S (T. t'r B� \V • _ �i z. o va,✓ Z � � I, I � � Y � v1A0. ✓ y S y StG (�. W �� �� � a v0._ �z P� ( to ba e- S o `F>^ i S N o fir; l I 0 N i Alto OU 0 v '�° tea_ o Jc ✓` ou Sad �G.o-gcL rt ✓ ,, s y s74ir. , 1'Xa2' a i ` ' P I d j i Wks-✓ �i� Lvw�cS 00.1 Or i I 73 O Va-Y W � vi -----_---- -- y y i s I I i 1 7. 0 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner �=' S� r� Property Address S �N • ✓ - I I? R - �— City /State e2il COUNTY L�NINGOFFICE Legal Description: Lot 2 Block Subdivision/CSM # �U/ IqL t/4 J�Y t /4, Sec. /1 T4N -R/'l W, Town PIN # & a • /22/ - /O SEPTIC TANK -- DOSE CHAMBER -- =TANK INFORMATION: Tank manufacturer Pft'WF CD - Size IT/PC 1 4 0 V Setback from: House ��' Well s50 P/L /Co Pump manufacturer Model S Alarm location - 4ZS -7336 (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM �le' Width ` Length Number of Trenches Z Type of system: gt h Setback from: House We11 P/L 2 Vent to fresh air intake ELEVATIONS OCAS f3vW0,.w 6te of 57P4 Itj S�Z.� Description of benchmark Elevation Description of alternate benchmark 70' A af= 46.11° Elevation Ex I'S TiN6-- N�� New �'3�� Building Sewer ST/IJW Inlet ST Outlet PC Inlet ` PC Bottom S 0- 1 3 ' . Header/Manifol� /o/ 33 Top of ST/PC Manhole Cover Go 4 Distribution Lines ( ) ( ) Bottom of System ( ( ) ( ) Final Grade () () ( ) 3202 ? N Date of installation / / Permit number State plan number Plumber's signature License number Date Inspector (/Y6 !N Complete plot plan � private & Associates private Sewage Consultants OR 655 O'Neil Rd. Hudson, Wis• 54016 rte ? Z N Sp o IA NA N � w o o � y o o � y L A Al ul� KK Wisconsin Departaiient of Commerce Y' Safety and Buildings Division PRIVATE SEWAGE SYSTEM Count ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitarDnt�,§ , Personal information you provice may be used for secondary purposes [Privacy L s.15.04 (1)(m)]. :ii LL // ttii Permit Holder's Name: a Cit Village Town of: State Plan ID No.: BUCHANAN, EDWARD & LYNN AU8 N CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel TMV ;1221 10-000 TANK INFORMATION ELEVATION DATA A9800469 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark a. Dosing ' U. Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Veritto TANK TO P/ L WELL BLDG. Ai Intake ROAD Dt Inlet Septic fin NA Dt Bottom / 7, O,> Dosing NA Header / Man. . y Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft H ead Forcemai - n Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH width Len h No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 z I DIMENSI SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of vt;r CHAMBER Model Number: System: , a ;e /�; : -° / C' , ,a 1 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 Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) 7 3� LOCATION: HUDSON 17.29.19.1222,NE,SW 457 JENSEN LANE,? 3 /� f' ~ Plan revision required? ❑ Yes ❑ No (� Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert No. A isConsl n Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. 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 paper not less County C than 8112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check if re Xo. t o pr"evl Nu � Eppiication [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Propert y O ner Na a Property Location r L wN 1/4 5W 1/4, S /? T � , N, R /f E (or) W roperty Owner's Mailing Ad���� G � Lot Number `L Block Number 'T �' City, State ZI Code Pho a Number Subdivision Name or CSM Number ow .V eta/ Cv c I > 9 2, rz- p 1454v 45'5 .4f>A.' eo.,.> II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms g V own OF ff !/JT eel Lyv 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) d - . 1221 • /O 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 ❑ 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 g Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ,______System 1 %.System Tank Only Existing System Existing System B) ❑ ASanitary Permit was previously issued. Permit Number 3 ,rY3 Z Date Issued Z' �' V. TYPE OF SYSTEM: (Check only one) y, 7 revs is 4,4&4L 3 rSfWs &e 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 13 Seepage Pit f ff G,.�I��j��/ /Dw�' 43 Q Vault Privy 14 ❑ System -In -Fill d(C�ESS {� 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 ? C O Re wired (sq. ft.) Pro osed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) e Elevation J I re �- 1D �� Feet l�y� Feet Capacit VII. TANK in Ca allon g Total # of Prefab. Site Fiber Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con steel glass Plastic App New Existin � JA2 strutted T nks Tanks epticTd 75.0 I nv 175.6 ❑ ❑ ❑ ❑ El i urrtp Ta 4V /65 ❑ I ❑ I ❑ 1 ❑ ❑ RESPONSIBILITY STATEMENT 2 paw I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Pr nt) Plumber's Signat e: (No Sta s) MP /MPRSW No.: Business Phone Number: RoB�7 �l���i7 -22- 4 3 7 s /S' - Plumber's Address (Street, City, State, Zip Code): 5 .� I .AlQ lL l llmpsolj S e r'.0! 4 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) I \ / j Approved ❑ Surcharge Fee) 9 30 9 6 Owner Given Initial 6tS / (,i„O,l/• Adverse Determination /� ' t X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -63M (R.11/96) DISTRIBUTION: original to county. one copy To: safety & Buildings Division. owner. Plumber d444 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the SIP � LY � residence located at: /t s 1/4, Sec. , T l ( N, R_2�f W, Town of _ D Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. �� Last time serviced Did flow back occur from absorption system? Yes LNo (if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: /0 Construction: Prefab Concrete Steel Other Manufacurer (if known) : Age of Tank ( if known) : lr1'�e-2 IF (Signature) Associate (Name) Please Print Ulbrich t wage consultants 6 (Title) Hudson, S� (License Nu%er (Date) F orm to be completed by licensed plumber (s.145., nsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR -83, Wis. Adm Code (except for inspection opening over outlet baffle). zz l�3�s' Name Signature MP /MPRS Ulbricht 6 Ass e consultants 5/88 povate Sewag 865 O Nell Rd. Hudson, Wis. 54018 ULBRICHT & ASSOCIATES CO. 655 O'Neil Road - Hudson, WI 54016 Reg. Designers of Engineering Systems 715- 386 -8185 Private Sewage Consultants PROJECT INDEX D I LH R Plan I . D . # N/ _ -` - -- -- - __. Date Owner N d�F - YVtl �,v(�/ Phone ,3 ��• P2 f Z Address y5 7 Legal Description ANN 020 /22 �� 07 - -4_ PAervr �s r,} � N� iy s� i� see-..-7 T-L 0. Iy Town of v County C.S.T. • �tT F -ZG'7s Installer '? t7 1 - 22 4 , 7 5 7 Local Authority/ Supervision r PROJECT DESCRIPTION 1Pq ?2F>?-f )E�W /f--v 9 1�e ;YS C /tWO ��5�,4 -cam 3 �'� �X rsT•' -v�- �S�?�1` 7`��. 76 6e 2 tJz�'P 7 • 3 ';y 01-S Pg .1 PLOT PLAN VIEWS -0 Q Pg.2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEWS =' HU09 M.1W DOSING CHAMBER CROSS SECTION c �'j .3 }, `%F_ E',� �•�` VV r ........ E PUMP PERFORMANCE SPECS �y � 'hi design for installation is based entirely on measurement lad scape conditions (slopes etc.) and soi s, elevations, T't�e accura y of his specs, as re 1 suitabiliL•y provided by CS1M of the CS ported, shall remain the sole res n t po sibility Any use of this POWTS design by any licensed plumber, or any 4 related unlicensed arties or persons P p s (excavaters, laborers) shall not be construed as an assn r,, assum ption o (y' f responsibility b P P Y Y the designer for the workmanshi placement, p, construction, p , substitution or selection of any components not specified, or any assumptions by the plumt that any unspecified components are state approved or proper, or the effects of poor judgement if working under adverse damaging weather conditions (wet /frozen soils) by any such parties or persons. d -,v a N3 y w . � o •� n � ; t 1 Iw N _ � o SP 1 i t � 1 ha rp m J " � I C COD , � O p n ' O y Iff r "z_ �iNi S QED Z wra7kf7 Y 1 - . / r CRa SS S c TIoA) r� i9Pf A&,6P I V . T c4,,,oO Iff j I/M N wt- 1 J� 7 L A Ve R4 riitD 7' V &VI S � Tim y r PUMP CHAMBER CROSS SECTION AA1D SPECIFICATIONS VEDT CAP 4 "C.I. VENT PIPE —7 APPROVED LOCKIM& WEAT E N R PROOF r MANHOLE COVER _T I P_ FROM DOOR, JUAICTION BOX 4 N� NSE1 WIIJDOW OR FRESH 12 "MIU. / ���� / j AIR INTAKE I � (,rIT /O Al GRADE I 4 "MIN. U I I CONDUIT -- _- _- _ - -_ -_ � /6 f7' oAv \ ` �-O IF I PROVIDE - -- _,_.�.. AIRTIGHT SEAL APPROVED JOIN A (DA�'`C I I APPROVED JOINTS \\//C.3:. PIPE I� "1 nN lV� I III W /C•I• PIPE EXTENDING 3' 0� n I II ALARM EXTENDIAIG 3' OMTO SOLID SOIL B 1 v 3 I I( I OUTO SOLID SOIL rIp I I O N ELEV. FT Pump- _.J I � OFF Z/SE ,j Ore D � .l 5 ' ` �.. /yOiPE eF 40 Ariod �� D01� � I ��� BLOCK Silrvl� RIStR EXIT PERMITTED OUL9 IF TANK MAWUFACTURER HAS SUCH APPROVAL SEPTIC E S P E C I F I I OU S DOSE /G / / ���STE/�iV TANKS MAIJ UFACTURER: �jt2�` ,+s;i WMBER O pOS£S: PER DAS TAUK SIZE: /0_� GALLOUS DOSE VOLUME $,O n ALARM MAAIUFACTURER: �'V INCLUDING BAGKFLOW: GALLONS ` MODEL DUMBER: CAPACITIES: A= 2.0 IMC11ES OR GALLONS SWITCH TYPE: "7/� tl i lOI ( B 2 "�IMC14ES OR 5 GALLOUS PUMP MAMUFACTURER: �ZO ��lEi C = Q _0 - INCHES OR 22-0 GALLOUS • „ MODEL MUMBER: ��-(14w [r , d D= 7. Z INCHES OR 2 - 3 0 GALLOMS 5WI7CH T9PE: // MOTE: PUMP AMD ALARM ARE TO BE MINIMUM DISCHARGE RATE _.3 GPM r INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEIJ PUMP OFF AUD DISTRIBUTIOM PIPE.. FEET 1'ANk SPEC - S • + � M II U II MUM UETWORK SUPPLY PRESSUR / . . . . . . . . . . . 6.5- FLET - cAG�. + /� FEET OF CORCE MAIM X r F lo Ft FRICTIOU FAC FEET /, '� C = TOTAL DYNAMIC HEAD L FEET J INTERNAL DIMENSIONS OF TAUK: LEUGTH ;WIDTH `" • ;LIGIUID DEPTH " T 7 7 7 , 7 - t02 10 •�f� It -t S Of HEAD CApq�iN C �0 — MODEL "911" 3 7 /e b I/4 e 4 3/e a 2 s— 1 b , I 3 se 15 O } + - �J 10 s / /le 2 s 1 1/2 -II 1/2 NPT 0 U.S. CALLt]NS 10 20 LITERS /0 50 so 70 0 160 2 e0 Row PER MINUTE TOTµ DY1rA4x; HIAWLOW PIII1, UTI IlrtuENT AH0 DEWAttWHO HEAD CA►ACIIY 12 UNITarMIN FEET YETE►is QAL{ Irlls 0 1.52 T! 2 to 3.05 In zit Is 4.141, +/ 110 + 20 s t0 25 OS Lack v atw x 3 5/16 CONSULT FACTORY FOR SPECIAL APPLIC 6 Electrical alternators, for duplex systems, are avallable and AT are supplied with an alarm. * Mercury float switches are available for controllin O.,Mechanlcal alternators, for duplex systems, are with or a three phase systems. 9 single and without available alarm switches. Double 1 back mercury float switches are avai p ggy labia for variable level long cycle controls. Standard all mode - Welght 38 Ibe - 1/, H 1. udegroltloatopereted2 SELECTION DUIDE iA series 2. single Piggyback tnechartica) switch, no extsrnal Model V Ite.ph ��• �Conlrol selec 11 o n 0 p G9yback mercury boy Switch or doubt• CO ^Nol rWuind M90 q4. • elm lox •witch• peter to FMo17I. PJOyback mercury, boal 11S 1 ub 6 I or ; Du lax 3. Machanlcal alternator t0-0072 or 10_0013. 1. Bee fM0712, for correct "w" of EU�alAparnalor, "E•p�� 230 I Auto S. Mercury sensor f►pa1 switch / fla0 230 1 Non 3 1 or 1 s 7 _ duple (3) or ( Ibal system, 00023 used y a con dol ulhrator .fxeih• 2 or.R fl ti 3 or 1 tt e 0_ f Aw ; Nl hpie "J Pak ".lunetlorr box. for yd �x w duplex operatbn 10 4002• connecllon or caked In sim• 7. Two 112) hole "J Pak ", Tor water Ohl cone . -_ , . For Mlortlo n on addtlbnel 2aIM sW � F 0.!; Atus PecA .1t �FMOeI�a w py Mu^ l+o�ee; I�„�AntI Ny�� AE ket.11alloa of CAUTION eonu II „e Butn' FltOtsT; a.w n „pr.. Crowd ttox Ir.J Ik•n• 460 1. � rod 6. � 0 4 wkl^i eAo,W w r•••nt Nellon•l floe hs lA• •cast b C d. oAo NE • •Acatd be do" by s 1» IoxowW In.r,a. N•sak Ad (OINAf, 1 n en1 IM C ooup•tl•n•1 s•bly e For unusual conditions a res ERV POWEpED DESIGN y factor A fjngineered Into the desi n of o 'eI - -T-- ---, .__ g .ry Zoeller pump. ` MAR TQ . P-0- OOK 16347 O 10ViTYII9,? 40756-0317 Manulacluiers ol. , . L ,1 iNIP 10. 3 ?80 06 Milers lark take 1�; KY IO216 n Q pS (502) 778 -2131 • fAV tS02) Ill -3621 l/A / c� ,��,�E /9.�9 Wisconsin Department of Industry SOIL AND SITE EVALUATION Page of 3 Labor and Human Relations Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County Include, but not limited to: vertical and horizontal reference point (BM), direction and ST• i�eo/ K_ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # d 2 d - X22 - APPLICANT INFORMATION - Please print aU information. 7wed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). c Property Owner ^^d Property Location Y� V r Govt. Lot N� 1/4 Sw i /4,S 7 T 0 ,N,R E (oro Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# '1S•7 �'��5�A L� • /23 'p4k' mew �sr� ' City State Zip Code Phone Number L/ -7 ET T Nearest Road L-� �J K//• Sy06�o ( ?1S)3Q l'�71/ ❑City V'Ia��IJ Town �'��S'L�.r� 4/1) ❑ New Construction Use: A Residential / Number of bedrooms S Addition to existin building X Replacement ❑ Public or commercial - Describe: !y' IS4 7 OfS 7` - -P .. 1 Z O -Ff f Code derived daily flow 759 gpd Recommended design loading rate bed, gpd /ft trench, gpd /ft Absorption area required bed, ft2 Y3& trench, ft Maximum design loading rate bed, gpd/ff? trench, gpd/11 Recommended infiltration surface elevation(s) .S n ft (as referred to site plan benchma)Ic���,e considerations / /P l✓! /"U•y S7 ev �1,s Additional design /site co n s Parent material 10E'S'.S' OZJ!�;LO S1fVDY Flood plain elevation, if applicable r� ft S = Suitable for system �Conve vial �M-,ou In G� - round essure �A,T Gra S Holding Tank U = Unsuitable for system Ud5 ❑ U t� s El U Ps El U Ly'S LJ U U El SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /11:2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench D�(v :5 /fS CS /7 ;.S •V M y G Z Ground D o 6 d elev. p 7 7 Depth to limiting factor , 7 1/ // Remarks: Boring # SL 13 S 3 /O /Z Yl L 2,+S k_ 1)" -fl( rS • S ; .6 /o ,Q ylCe / dM, g S . Z . 3 Ground ZO 514k — elev. Depth to limiting factor 7 in. Remarks: CST Name (Please Print) DQ ep- 4 1?1C- Signature Telephone No eft S. V6 Address Private Sewage Consultants Date �+ CST Number 655 O'Neil Rd. � �1 , 10 1 , 5 . /�I . Go1��S e� ; ' 1 'evfM , J oy- Y 3.3� �. �x Sys1�-r Dw � had M At I A0,AA- �- /. PROPERTY OWNER SOIL DESCRIPTION REPORT Page y of .3 PARCEL I.D.# IZ3 c S T�-re-5 J� Boris # Horizon Depth Dominant Color Mottles Structure 2 Boring Texture Consistence Boundary Roots IIFI`M in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3 0• o z — /s 7V Z / 3 i6 rz 300 SQL ��s ,� � S . Z ; •3 Ground elev. Depth to limiting factor Remarks: Boring # Ground elev. ft. , Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring #. , Y � r Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. , Depth to limiting factor in. Remarks: SBDW -8330 (R. 08/95) M � 1 s� r� CAJ w n R � Y - C� TP L go G b W �amo = ` N o- r � - ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM r Owner/Buyer L YNit 13 UGAi +il 3g� • �Z 1�' 2— Mailing Address Z 15 - 7 Z,"- /-/Y- y VV Property Address `/ U �SOl LfJ -5. svo/ 6 (Verification required from Planning Department for new construction) City /State Parcel Identification Number LEGAL DESCRIPTION Q Property Location /V9 '/4, SW '/4, Sec. f , T ` N -R 9 W, Town of i �S T Subdivision S Pi �U �W 'STS Lot # Z 3 Certified Survey Map # , Volume , Page # Warranty Deed # �( , Volume , Page # S�— Spec house ❑ yes 0 no Lot lines identifiable Ery' ❑ 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 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 se t' y e has b9oh maintained must be completed and returned ttoo� the ..,St. Croix County Zoning Office within 30 days of thre ra ion A IAIURE OF APPLICA �6 � ��� DATE OWNER CERTIFICATION I (we) certify that all statements Lts are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the p perry described above, by virtue oeed recorded in Register of Deeds Office. /2 SI A 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 /O STATE BAR OF WISCONSIN FORM 2 - 1982 5616.7) WARRANTY DEED DOCUMENT NO. !+ t ^ - -- - -- -- - - - -- -- - -- _ - - - - -- -- VOL�248 m: a52 Thiomas L mi is Perillr nd Diane Ast AEG45TCRS ❑t-FI a— Li Perillo, ST. CRON CTY. W) As his wife iah ttiitl+. ►'K 1991 conveys and warrants to David Ani nnrtT Van Gelder a nd - .lo Anne Van Gelder husband and wife. as {� 10:30 A M survivorship marita �prooerty - w,._ R WAA i HYptsW of Deeds ""S SPACE RESERVEJ FOR NEGORDING DATA NAaE 41MB RETURN ADDRESS the following described real estate in St. Croi X , t ottr, : �. State of Wisconsin: i i; ;r ij ;t 0213 -- 1221 -10 PAFkCe tTENTWICATION NUMBER I, I, I' I ! Lot 123, Park View Estates Fif th Addition in the Taal^ of RiAson r i ''. �► ER This is homestc-.d property. (is)+ Exceptiontowarratnies: Ex isting highways, easements and rights cmf ra of record. I Dated this c;)7 day of June (SEAL) b � (SEAL) -- (SEAL) G� (SEAL) • • Di ane T .i Ada Perri 11 Q AUTHENTICATION AC-92NOWLEDGMENT Signature(s) State of W ss. C.U. authenticated this day of .19 Personally carat bwiow me this e _ day of Jtgt , 19-9_, the above named Thomas Perillo and Diane_ Linda_ Perillo., Intend qnd wife TITLE. MEMBER STATE BAR OF WISCONSIN -- (If not, ����� X — authorized by §706 -06, Wis. Stats.) ��Q� toIn to be 'z.Y ?mson Who executed the foregoing acicnowArdge the / THIS INSTRUMENT WAS ORAFTED BY r1 Attorney David J . - _ G _ 304 Locus t S t • . - 4I1 tS�j. County, Wis. (Signatures may be authenticated or acknowledged B.xh are not��eip �M ' �lRt� issic )ern anent.- (I nt.., state explr.:ion date: necessary) • Narnes of perr signing in any capacity should by tl•pcd or pnnted bt" tber. stgnaturts. WARRY \TY DEED SrAEE Form No. o. 2 — 1982 51\ N'uur's" Mn --a'J� Inc rm . — 19e2 Bearints referenced to the South line . of the SKI/4 of Section 17. assumed R 399 i • I N N 17• UNPLATTED LANQS N T OD t '�'tp. Cn � I �$— N ' >a 00 to o a �' � • �/ a `� I 0) do / I f to ^! J N // ^p I� Im I 1��'a1' N a' i 1p 1 - - - - - - - -• - - - - - - N " �Q• �. i0011�C 3100.M' E T W E R Y R QA _• ! R_QAR g „ - - -- N N00 03' 0. � 1• 108.00 " � N J - a' N I M.7 00 14 *2 `— I I T — I I c . w r m z 3M 60 r 0 00 114']0 C — �, = m J a O I r O r 2 g M 900 14'70r� n, I a ' ( 0 �. I " � - u I ! c� . — w '' of I N u o *C N � _ I � n I 3 N r. 00 111' m it I� I :- w I 1 •• •- Isi I =' I D T 0 to 300.31 ' I r _I 6 s 0 rn ! 00 i1'JO L U) — ' i O I = s S o I 4 N LCO —rs _ ( NO MOO;- XO g I t 7