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HomeMy WebLinkAbout020-1330-50-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner 0 �- Address "723 ) k!5 City /State Legal Description: Lot Block Subdivision/CSM # '/. ScL /. Nom Sec. 33 , T jQN -RAW, Town of `' PIN # Q SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION Tank manufacturer � Size ST/PC / / && Setback from: House 1,?W Well ;aA PIL f Gr Pump manufacturer — Model )t 5 Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location ib SOIL ABSORPTION SYSTEM Type of system: Width Length 75 Number of Trenches Setback from: House �S G / Well t hoc i P/L VP / Vent to fresh air intake ELEVATIONS Description of benchmark PV C- / -� Elevation !dG Description of alternate benchmark Elevation � r Building Sewer 5 ` yd ST/HT Inlet J ST Outlet 9`, y; ( PC Inlet r PC Bottom , C) Header/Manifold l �� Top of ST/PC Manhole Cover S. 30 1 Distribution Lines O b A Bottom of System Final Grade { ) ( ) { ) Date of installation AR/— Permit numbe t� �� �{ �, _`3C State plan number /9 0 - 7 , 2 r Plumber's signature License number ���' 7 Date / a / a / Inspector G;f� NA 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 N h� l CAL i . co INDICATE NORTH ARROW i Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM . Safety and Buildings Division CountyST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary3Plrmiti`8: Personal information you provice may be used for secondary purposes [Privacy Leg, s.15. (1 )(m)). 466 1117 u G' , 1f", e ' DEAN Eh ftkWllage ❑ Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel T�x4 _ 3 0 - 50 -000 too - � D� ( Z 1�UC % TANK INFORMATION ELEVATION DATA A9800509 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic y�,� � ��-- 6lyp Benchm r .S �S j Dosin (p7 f!0 �'l -�.�M Jo3��� y.yy Gf? 5l Aeration - - - -_ Bldg. Sewer St /inlet TANK SETBACK INFORMATION St/ Ht Outlet — TANK TO P / L WELL BLDG. Air I to ntake ROAD Dt Inlet Air JD3.& Septic 1 S� A� A �� j()/ NA Dt Bottom 103 1.571, ?! -0 & Dosing +, Yl1 �-- p✓� J�0 NA Hea der/ man. p S 317- Jp /. &� Aeration �— NA Dist. Pipe 05.E �. la /• Holding, - Bot. System VSO y•SO JaI PUMP/ SIPHON INFORMATION X11 yk Final Grade Manufacturer u Demand 92- ? a ) jp /. 3, y D7 Model Number gpD� °&PM 5 Vn Jp356 g•5 S TDH 1 , Lift 13 ,(p iction Sy Ste m2 S TDHj�, t Forcemain Length Dia. H ) r Dist. To Well SOI ABSORPTION SYSTEM BED RENCH Width / Length i No. Of Trenches PI No. Of Pits Inside Dia. Liquid Depth N 1 N S DIMEN IONS _ SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING INFORMATION Type Of , CRAM M Z iN er: System Z S (Z O NIT DISTRIBUTION SYSTEM Header /Manifold ^ Distribution Pipe( x Hole Size x Hole Spacing Vent To Air Intake Length 7__ Dia. ^ t Length Dia. � ' Spacing �- 1/ .1 3(, r SOIL COVER O' 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 191 Bed/ Trench Edges lZ 9 Topsoil Yes ❑ No 0-Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) S,Z /` LOCATION: HUDS N 23.29.19,SW,NW 728 W,ALDROFF FARM RD— EVERGREEN LOT - - a , 5`� Vo` W `q IA. gyp" f I Fc4f �G1 f _ w A pro vi � G. Plan revision re fired? ❑ es g) No Use other side for additional information. ,27 ®/ SBD -6710 R Date inspector's Sig ture .3/97 Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue N P O Box 7302 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County ,� t than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitar �umbe�r y P Personal information you provide may be used for secondary purposes Check if revision t o p revious ap 7A [Privacy Law, s. 15.04 (1) (m)]. � p pp D W O 1C./ r0/T AWYi♦ pW , State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION d7 Pro rty Owner Name Property Location O S /a /a, S T O� [ , N, R W Pro ert lock N Owner's Mailing Add ss Lot Number Bumber City, 5 Zip Code Phone Number Subdivision Name or CSM Number C IS> 5VS l - .s(. E II. PE F BUILDING: (check one) State Owned ❑ It Nearest Ro d ❑ Village Public 1 or 2 Famil Dwellin - No. of bedrooms Town OF III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) a3 ;kq - /9. 1 1 E] Apartment /Condo 6�D y 330— '6 _ 0O � 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. /DP 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 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 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION S YSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (s q- ft.) Proposed sq. ft.) (Gals/day /sq. ft.) (Min. /inch) �. Elevation Feet Feet aclt VII TANK in Ca allo g Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks eptic Tank r Holding Tank / coo 000 El El 0 11 11 Lift Pum Tank i hon Chamber ❑ ❑ 1 ❑ 1 ❑ 1 ❑ ONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite se_ age system shown on the attached plans. Plumber's Name: (Print) r Plumber' ignat PRSW No.: Business Phone Number: ZKV 36 8 -6 Plu e s dress Street, City, State, Zip Cod Ci � no IX. COUNTY / DEPART ENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued suing Agen ignature (No Stamps) pproved []Owner Fee) Owner Given Initial � � ov � L � Adverse Determination T X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R .11I97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber Safety and Buildings a 2226 ROSE ST LA CROSSE WI 54603 -1905 ,sconsi Tommy G. Thompson, Governor Philip Edw. Albert, Acting Secretary Department of Commerce October 09, 1998 CUST ID No.267341 ATTIC PO WTS INSPECTOR WEGERER SOIL TESTING & DESIGN ZONING OFFICE 421 N MAIN ST ST CROIX COUNTY PO BOX 74 1101 CARMICHAEL RD RIVER FALLS WI 54022 \ �, HUDSON WI 54016 RE: CONDITIONAL APPR041 Identification Numbers APPROVAL EXPIRES: 10/09/2 01 Transaction ID No. 180727 Site ID No. 161428 SITE: ST c RGtr, Please refer to both identification numbers Site ID: 161428 \ �'I� rr �( above, in all correspondence with the \ FF St Croix County, Town of Hudson\ ->, ag en cy SW1 /4, NW1 /4, S23, T29N, R19W Evergreen Estates Subdivision - Lot 5 Richard La Casse FOR: Description: Mound Object Type: POWT System Regulated Object ID No.: 428886 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The following conditions shall be met during construction or installation and prior to occupancy or use: • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(d), Wis. Stats. 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. Sincerely, q, DATE RECEIVED 09/30/1998 FEE REQUIRED $ 180.00 erard M. Swim FEE RECEIVED $ 180.00 POWTS Plan Reviewer - Integrated Services BALANCE DUE $ 0.00 (608)785-9348, Mon - Fri, 7:15 AM - 4:00 PM jswim@commerce.state.wi.us • Page 1 of 6 V MOUND SYSTEM FOR A BEDROOM RESIDENCE LOCATED IN THE S W 1 /4 OF THE t-JW 1/4 OF SECTION Z3 ,T N, R_ 11 W, TOWN OF VAAJp s o NJ , ST- CRpUC COUNTY, WISCONSIN.. I-OT T.S - -- - - - - -- AE INDEX S SFp 3 0 �O PAGE 2 of 6 PLOTEPL S HEET gF�TV & B�0 '998 PAGE 3 of 6 PLAN VIEW -CROSS SECTION., GS 0111 PAGE 4 of 6 DISTRIBUTION PIPE LAYOUT PAGE 5 of 6 PUMPING CHAMBER PAGE 6 of 6 PUMP PERFORMANCE CURVE PREPARED FOR L A c1A9sE cvsTZSVI-1 vi m �Z.Z.p ORkw�o� L�vE �1vOSO1�, wi S4otb PREPARED BY WECEE;tEFt E3 C3 = L TEST I N1(3 � AND. DES = (31M SEFt�1 = CE C .�.NS /y P.O. BOI 74 421 K. KAIK ST. nRnaua L. RIVED. HALLS. M1 54022 WE GEREN D-915 p 0 '�N j. 115 - 4255-0165 tLLSWORTK P. Coll 1'0 U iii S I ti l� R9 J � l � t JOB NO. PLOT PLAN Page Z of 6 Scale 1 "= S 6 W, < < PVe p1P� r i r trL "s i ' - 1 � 1 1. 1 s o�p of - Nvj&j chi .a s\ 86`oF z �r S � �4 lob s • 1 1 � t Bo mb NOTES 1. Elevations shown are existing ground elevations unless otherwise noted. 2. Install permanent markers at end of each lateral. ( Z required) 3. Install 4" observation pipes with approved caps. ( - Z required) 4. Septic tank to be' MOASO gallon capacity manufactured by '1'11, k1L''6TZ\2!y LTV e . 5. Bench Mark y� 6. Divert surface water around mound to prevent ponding at the uphill side. Page 3 Of 6 Approved Synthetic covering T.IZ - r ► c Na Distribution' Pipe Medium Sand Topsoil H F G Elev. fro • j' 3 1 � E. D- ........... b 8 % Slope Force Main Plowed Trench of i " -2 2" Aggregate From Pump Layer (undisturbed D Z.o Ft. Soil E *\ •y Ft. Cross Section Of A Mound System Using F e-g Ft. I Trench For The Absorption Area G N.a Ft. A S Ft. H I• S Ft. 6 -- )S Ft. I \S Ft. Linear Loading Rate= 6 " GPD/LN FT Design Loading Rate= 0.3 GPD /SQ FT Ft. K Ft. L q Ft. 8l torn to Positi i - ..� r -., 6 i �� ,�,t W Z1 Ft. L Force K Main_ W Distribution Trench Of Pipe Aggregate I Observation Permanent-/ Pipes Markers (Anchor securely) Mound Using I Trench For Absorption Area Page Of -- 6 Perforated Pipe Detail 0 End View Perforated End Cop.) �`ey PVC Pipe s Install Permanent at end of each lateral Holes Located On Bottom, Are Equany Spaced Q End Cop - P f-1 * PVC Face Main OistrtDution Pipe Lost Hole Should Be Next To End Cap Distribution Pipe Layout P 3 y.S Ft. X 3 Inches Y 3 � Inches Hole Diameter 11 y Inch Lateral 1 Inches) Manifold Inches Force Main " 2 Inches # of holes /pipe \ 113\-5 Invert Elevation of Laterals Ft. Place lst hole 1 ` 64 from tee with succeeding holes at 36� intervals. Last hole to be next to the end cap. ' Combination Septdc;Tank and PUMP CHAMBER CROSS SECTIOU AMD SPECIFICATIOUS' PAGE S OF -VEIJT CAP WEATHER PROOF JUIJCTIOIJ BOX H VEUT PIPET APPROVED LOCKING _ 0. - - - - -- MA►JHOLE COVER - _.10 FROM DOOR. wA(tf.IIWG L146EL.. :iimDow OR FRESH AJK IIJTAKE cw+aulr s b hI>•X ,6"M�W. GR.lS I H� MIIJ. I / 18' KIIJ. 18 "KIN. �� ---- - - - - -- 4 IJJt0 - nW 4tPt ' r PROVIDE I - - - -- IAILE T AIRTIGHT SEAL • BgFFT_�.S � I I I v APPROVED JOIWT A I I I APPROVED JOIIJTF W /C. PIPE Olt Tank construction I III w /c.z. �IPEP�� I I I I ALARM shall comply with "I I ILHIR ;3.15 and 33.20 o I I I I ou G I l ab.6� I CLCV. f T PUMP,, - -� OFF 0 COClCRETE BLOCK 3" APPRcovFa 7 X- RISER EXIT PERMIITCD OIJLtI IF TAIJ MAIJUFACTURER HAS SUCH APPROVAL gED01N4 SEPTIC f SPEGIFICATIOIJS DOSE y.��Iw�� W V NUMBER OF DOSES: PER DA4 TAIJK MANUFACTURE TANK SIZE: `OUO AEC) GALLOWS DOSE VOLUME l ALARM MAIJUFACTUILER: S.S. ELzt r12-0 INCLUDIIJG 6ACKFLOW: GALLONS MODEL ►JUMBER: �0, Hw CAPACITIES: A= �� IAICHES OK 3010 GALLOAI5 SWITCH TVK: B= Z IUCHWOR 3 � G( LLOU5 PUMP MANUFACTURER: C�oUI_DS G= 1D IUCHES OR "D GALLOWS MODEL NUMBER: D= a IMCHES OR GALLOWS SWITCH TYPE' MOTE: PUMP AND ALARM AR TO bE 6 MIMIMUM DISCHARGE RATE �' GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFEREWCE DETWEEU PUMP OFF AWO..DI5TRIBUTIOW PIPE.. ��' FEET + MINIMUM NETWORK SUPPLY PRESSURE . ; . . . .. .. 2.511 FEET b F T. Z.b� + LAS FEET O F FORCE MA X �OfLFRICT101J FACTOR_. FEET - - TOTAL Dy1JAMIG HEAD = b ' S FEET Pump chamber DIAMETER 38 l IIJTERWAL. DIMEIJSIOIJt OF TANK: LENGTH ;WIDTH ;LIQUID DEPTH • BOTTOM AREA 231= — GAL /INCH AS PER MANUFACTURER = 11.0 GAL /INCH Goulds Submersible Effluent pum { 4 EP _. 0 3871 EP05 APPLICATIONS • Fasteners: 300 series • Fully submerged high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. • dry without damage to heat transfer. ■ Motor Cover: Thermo las- • Holmes systems components. tic cover with integral handle Av for automatic and • Farms Motor: and float switch attachment • • EPO4 Single phase: 0.4 HP, manual operation. Automatic points. Heavy duty sump 115 or 230 V, 60 e: 0.4 0 models include Mechanical p ts' • Water transfer Float Switch assembled and ■ Power Cable: Severe duty • Dewatering RPM, built in overload with rated oil and water resistant. automatic reset. preset at the factory. • EP05 Single phase: 0.5 HP, ■ Bearings: *Upper and lower SPECIFICATIONS FEATURES heavy duty ball bearing 115 V, 60 Hz, 1550 RPM, construction. Pump:'EPO4 built in overload with ■ EPO4 Impeller: The • Solids handling capability: automatic reset. plastic Semi -open design 1 /4 " maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. SP' Canadian Standards Association •Total heads: up to 24 feet. with three prong grounding a size: NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo - • Dischar g plastic enclosed design for (CSA listed model numbers • Mechanical seal: carbon- length, 16/3 SJTW with end in 'F or AC'.) rotary/ceramic- stationary, three prong grounding plug improved performance. BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 104 °F (40 °C) continuous superior strength and 140 °F (60 °C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. 10 , • Capable of running -- -� - -- - j� dry without damage to s 30 components. -- - -- - ►scP��n Pump: EP05 8 - 2 Fr = -- • Solids handling capability: 0 25 3 /4" maximum. w 7 • Capacities: up to 60 GPM. s 20 • Total heads: up to 31 feet. • Discharge size: 1'/�" NPT. z 5 - - - -- -- - - - • Mechanical seal: carbon- 0 15 BUNA /N el sto ers.nary 4 ----- - - -- —{- EPOS • Temperature: F 3 10` ! 104 °F (40 °C) continuous EP O4 — _ _ -_ -_ 140 °F (60 °C) intermittent. 2 - - - -_ -- i 0 00 10 20 30 40 50 GPM 0 2 4 6 8 10 12 m CAPACITY ©1995 Goulds Pumps, Inc. Effective May, 1995 R9R71 Wisconsin Department of Industry, ry, Labor and Human Relations SOIL AND SITE EVALUATION Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 112 x 11 Inches In size. Plan must Count Include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road, parcel I.D. # PEA.)DIN G---- APPLICANT INFORMATION - Please print all Information. Reviewed by Date Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location c� q fIVR136 1 -41VP Co/° 0 Govt. Lot SW 1 /4 NW 1/4,S 2 T 2- ` ,N,R / / E (or WE Property Owner's Mailing Address E S T Lot # Block# Subd. Name or CSM# 3 NiNNi = soT sI h�l� c. G - . 5 �1/ERCr�PEC•V EST�4-TE5 City State Zip Code Phone Number Nearest Road //IV/. /2 5r. Pfku L N iN� 5 5101 (� i � ZZZ - 59 55 ❑ iu p visage Town ar�C k��Y /e V ps New Construction Use: Residential / Number of bedrooms - L4 Addition to existing building ❑ Replacement kSv - El Public or commercial - Describe: Code derived daily now 69 gpd Recommended design loading rate ' bed, gpolit ' S trench, gpd/fl Absorption area required SOV bed, ft s bD trench, ft2 Maximum design g 7 , gpd/(l • - trench, gpd/ft ` n loadin rate Recommended Infiltration surface elevations) SEA P i ' 3 ft (as referred to site plan benchmark) Additional design /site con ations''T� Svc T�7� hoL -cs 7 - Y,, 4 6 -- 7 - Y,, 4 6 -- SYX 7 . Parent material 5C1_3 8 /" / � /l /0 r ' Flood plain elevation, If applicable I {t S = Suitable for system I Conventional Mound In- Ground �P-ressssure AT-Grade , System In Fill Holding Tank U = Unsuitable for system ❑ S � ❑ IdS U El EJ S u r] S L�' U I ❑ S F-� l ❑ S Q-6 SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/tt2 In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench I.._ o-7 /0 YR .313 ---- Gosh if5IJ4 4,, � 6!1- />� �{ ; - S Ground 3 2y 3 /O Yie S /Z ?. Z 3 elev. , /e 5-15-ft. 3 ?-?3 io Y/e y /6c Gt , r. 10V12 4/L POCXeTS OF / 1 f� Depth to limiting factor Remarks: Boring # F2_ If,,X ft,14t oF <_ 0 - 5 10 YA 3/3 — 4a g f l fSAe /141 y5e C S / f 7 Ground v oM ( -7 S/c elev. +1A 70 _ o ft. /o S! 5 Z- Zee S S 5 � t o 51 Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. R O B E R 1-- 7.4 L [312 i C T t,�- 7/.� 396 Address Date CST Number Asso ciates /� - /b - r l CST.y z yeZ Private Sewage Consultants 655 O'Neil Rd. Hudson, Wis. 54016 ORI GMAL 4, PROPERTY OWNER 7 — SOIL DESCRIPTION REPORT page Z of 3 PARCEL I.D.lt � 1 S �(� E � C) �� sr�r c S Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 Cont. Color Gr, Sz. Sh In. Munsell Qu. Sz. ry . Bed ,Trench 3 �4,q / A." die 0-5 � � �( • S Ground 3 elev. 'y /O /tJD•b3 ft. -7.5 SL /7Cs io G/ ij fi Depth to Y4 limiting factor Remarks: Boring # Ground elev. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots O In. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor In. Remarks: SBDW -8330 (R. 08/95) I P ' C • 1 7 �--- -- d n o Qs � e 0 t ° o y 4 � � • 7 N O w � w o c W � 0 r b fi U� y� Z a J . a ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Dag �rr'o Mailing Address In r anaa, •O v $p Property Address C� (Verification requited from Planning delArtment for new construction) City/State ALA I Parcel Identification Number o - L — Z13UQ -'5-0 -&00 LEGAL DESCRIPTION Property Location (� '/,, y,, Sec. 2.3� T 21N -R-4t-W, Town of Subdivision `�' ..cs a �i of # J � Volume age # a Warranty Deed # �56 , . Volume f 3 6 7 _, Page # Spec house O yes H no Lot lines identifiable yes O 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, restrictedplumberor a licensedpumper 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. 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. /��'�` lb p 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 owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. IGNATURE O 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 COL 1167 PAGE 162 P� 5 8 9505 STATE BAR OF WISCONSIN FORM 2 — 1982 WARRANTY DEED DOCUMENT NO. .. ............. _- ........ j LaCasse Custom Homes, Inc., a Wisconsin Corporation RE S RE R — OFFICE ST. CROIX CO., WI FZol Inr Rcsord OCT 2 0 1998 conveys and warrants to Dean A SagStek -ter and Dawn M- ` K Q SargstPtter, hush and wi fP, Re stow of Roads THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St Croix County, State of Wisconsin: EAGLE `!GALLEY BANK, N.A. 1301 Coulee Rd., Unit 2 Hudson, WI 54016 6ao- 1 3'3q- ,50-000 PARCEL IDENTIFICATION NUMBER I Lot 5, Evergreen Estates in the Town of Hudson, St. Croix County, Wisconsin. I I I TRANSFER as i' E �i I This is not homestead property. i (is not) Exception to warranties: Ea sements, restrictions and rights -of -way of record, if any. Dated this day of October A.D., 19 98 LaCa e C stom Homes, Inc. i� (SEAL) BY U ��0� (SEAL) Richard W. LaCasse, President (SEAL) (SEAL) i AUTHENTICATION ACKNOWLEDGMENT State of Wisconsin, Signature(s) J G� , �4 � �• • �' �-K s St. Croix - County authenticated this day of = , 19 Personally came before me this aU day of = nY,Pr 19 the above named �''* • U V�\� a44P tom Hn mPS, T13(- , ham--- - S ' • SG �iCharrd W LaCasse, President, TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized b §706.06, Wis. Stats.) Y to me known to be the person who executed the foregoing 5Notar t and a e the same. THIS INSTRUMENT WAS DRAFTED BY ` r Attorney Kri stina Qa and �, r ,�, Q L� n 1'1 I. h Hudson, WI 54016 blic, _ C � 4i __ County, Wis. (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date: necessary.) Names of persons signing in any capacity should by typed or printed below their signatures. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc li Milwaukee, Wis. 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