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HomeMy WebLinkAbout020-1075-10-700St. Croix County Planning and Zoning Wednesday, September 06, 2006 at 4:5I:14PM Detail Sanitary Information Page I of I Computer #: 020-1075-10-700 Sub/Plat: NA Section: 27 Parcel #: 27.29.19.302H Lot: 2 TWRNG: T29N R19W Municipality: Hudson. Town of CSM: Vol. 10 Pg. 2729 114 114: NE 1/4 SW 1/4 Owner: Richmar Industries 642 Brakke Driv son, WI 54016 Stale Pe it: 299179 Issued: 111251 1997 WTS Dispersal: Non -Pressurized In -ground Permit: New County rmit: 0 Installed: 12/06/1997 WTS Detail: Bed -Seepage Bedrooms: 0 WI Fund: POWTS Pretreatment: NA otes Issuer s Built Plumber Other Requirements Additional Notes Money Owed Not determined Yes Bird, Shaun $0.00 Jim Thompson Signed Off No Maintenance Scheduled Purn Date Pumped 1st Notification 2nd Notification 3rd Notification 12/5/2000 04/20/2006 f 6/6/2005 04/20/2006 Richmar Industries NE4,S114, Sec.27 P.O. Box 38S T29N-R191V, Town Somerset, WI S402S Hudson Lot 2 Brakke Road Address of Site: 644 Brakke Drive Permit No.: 199985 2-11/94 Gary Zappa New System - Trench St. Croix County Planning and Zoning Thursday, May 17, 2W at 8:57:49 AM Detail Sanitary Information Pare I of Computer!!: 020-1075-10-1,06-- Sub/Plat: NA Section: 27 Parcel #: 27.29.19.302H / Lot: 2 LD'' a3 TNMNG: T29N R19W Municipality: Hudson, Town of CSM: Vol. 10 Pg. 2729 1/4 114: NE 1/4 SW 114 Owner: Richmar Industries LLP 64 644 Bra Drive Hudson. WI 54016 State Permit: 199985 Issued: 02/11/1994 POWTS Dispersal: Non -Pressurized In -ground Permit: New County Permit: 0 Installs 03/23/1994 POWTS Detail: Trench - Seepage Bedrooms: 0 WI Fund: POWTS Pretreatment: NA Notes Issuer/Inspector As Built Plumber Other Requirements Mary Jenkins Yes Zappa, Gary Jim Thompson Siyned Off Yes Maintenance Scheduled Pumo Date Pumped 1st Notification 2nd Notification 3rd Notification 2/11/1997 3/23/1997 Owner: Richmar Industries LLP & 644 Brakke State Permit: 299179 Issue 11/25/1997 County Permit: 0 Ins led: 12/06/1997 Nutes IssuerlInscector As Built Not determined Yes Jim Thompson Signed Off No Additional Notes Money Owed 5117/07 located a missing permit for a 2nd $0.00 building/POWTS on this lot. Town of Hudson has a record from building permit for the sanitary permit number and date. File with 1997 permit for same lot n`ve'19uiIsorj, WI 54016 OWTS Dispersal: Non -Pressurized In -ground Permit: New OWTS Detail: Bed - Seepage Bedrooms: 0 WI Fund: POWTS Pretreatment: NA 0,y dvt) L=!i Plumber Other Requirements Additional Notes Money Owed Bird. Shaun proposed split into lots 3 8 4 as of 2007. see also $0.00 1994 permit filed with this one for 2 buildings on same lot Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 6/6/2005 8/1/2006 04/20/2006 8/1/2009 52G IJ� LA 3 STc - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 1, Ire4 �iES ADDRESS lob 3 CsM 221wljv SUBDIVISION / CSM# / LOT #�_ SECTION TQ$j N-R/c7 W, Town of 1{,wp5o.,/ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Pfoozer'I AlAi 47 /V 6. I a Co?A/ E� 41"J'r E«V. = /oo.00" 7fhf y/0 SE.UEr 41.. E i5"ropit 45[Iri4r-T.wKAN40 Sc,Iyo Au C1,CAAJ0 .,1r,j54 eeriov PlAf Z—ir l A .�co Af'riarPr It* —4EV<< �.sr 3Nrewv w4fAdArt io.?" �pp�SEo /�.'lu.rli.voug Pnkllov& /esA 7✓1 f `!�I Nfw 7 � AQA� OiN& INDICATE ARROW /V e) Sei}G f Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: �P Or / „�.� PA sfr VC. Ao-r (oF3vEq E<z ✓. = 1oo.c7v, ALTERNATE BM: 6Ui[ 0/�/ro riw,SA foaC E SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: L JiE 5E& Liquid Capacity: Setback from: Well fS' House G" Other Pump: Manufacturer A/A Model# AIA Size /V/4 Float seperation AIA Gallons/cycle: &IA Alarm Location �/ SOIL ABSORPTION SYSTEM Width: s Length O' 2Z: Number of trenches / Distance & Direction to nearest prop. line: f,�' eiyw6✓.rs" Setback from: well: /0,;F' House P? ' Other Building Sewer ELEVATIONS ST Inlet %%-GS� ST outlet �P.qa- PC inlet PC bottom IVA Pump Off AIA Header/Manifold % . }ff ' Bottom of system %C..Z,e, Existing Grade /0/. .�'S' Final grade /00. Sc' DATE OF INSTALLATION: �/ 3�2 �fz PLUMBER ON JOB: 17le = LICENSE NUMBER: INSPECTOR: 3/93:jt ��Poq A�005. Zuc, LAGATs�1 rt Ai6i,stW , 29 r 19W . PVIVAIS? SEW*G? Slfjrff6le Id. Labor and Human Relations INSPECTION REPORT Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Permit Holder's Name: ❑ City ❑ Village Town of: CST BIWE�v :� nsp E ev : BM Description: UU, dd. �d TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic �- S Dosi Aeration Holdin TANK SETBACK INFORMATION TANKTO P/L WELL BLDG. Ventto Au Intake ROAD Septic Ql (o jjA_ NA Dosing NA Aeration NA Holding PUMP / SIPHON INFORMATION Manuf cturer Demand Model Number GPM TDH Lift Friction S s Ft Forcemain Dla. Dist To Well SOIL ARSORPTION SYSTEM ELEVATION DATA ounty: S Sanitary ermit F State Plan D No.: Parcel Tax No A94DUO14 STATION BS HI FS ELEV. Benchmark 1-7�1.' le-j . Gb Bldg. Sewer St/JpWlnlet O ' St/lllfbutlet r Dt Inlet Dt Bottom Headerfh&i%, P Fr'p 9 ?0 Dist. Pipe a. z' i �� 38' 3Y' / /o. S' Bot. System 0. �0. Z Final Grade „ S. d7 /O/, .9 BED/TRENCH Widths i n A 7 No. Of riches No Of Pits Inside Dia. Liquid Depth DIME SIONS O, 7 SYSTEM TO P / L BLDG WELL LAKE / STREAM RING Manu a SETBACK INFORMATION TyPe 4 System: Cen'bM 6 /7 OR UNIT nICT0I11111TInFd CVCTFM I leader I Distribution Pipe s x HOT— o a Sue x Hole S aun Vent To Au Intake „ Length � Di Length / Dia Spaung SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ ed xx Mulched ,� Y10.LTrench Center , - �Z ench Edges 3p - y2 Topsoil s ❑ No ❑ Ves ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.27,29,19W, NE, SW, Lot 2, Brakke Rd. Plan revision required? []Yes Q_�Iti o Use other side for additional information. SBD-6710(R 0"1) Date x� Z inspector's Signat6re Cert No � ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 07tz'—.. a_ SANITARY PERMIT APPLICATION 1J I.�ILMK In accord with ILHR 83.05, Wis. Adm. Code C0,7` G . _- ` STATE SANITARY PERMIT # —Attach complete plans (to the county copy only) for the system, on paper not less than cl� 8% x 11 inches in size. ❑ l prevIou* application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION '/ /., S % T 9, N, R EfDrQo PR RTY OWNER'S MAILING ADDRESS LOT # BLOCK # ITY, STATE T I ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER ❑ State Owned L3 VILLAGE NEAREST ROAD 11. TYPE OF BUILDING: (Check one) I RF4 izez cAczPublic ❑ 1 or 2 Fam. Dwelling-# of bedrooms ) III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranUBar/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. X 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ® Seepage Trench 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 15.PERC.RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION r % n _ 9 Feet Feet VII. TANK INFORMATION CAPACITY in gallons Total # of Tanks Manufacturer's Name Prefab. Concreteglass Site Con- Steel Fiber- plastic Exper. App. New Tanksanks PlatingGallons structed Septic Tank or Holdina Tank T — r Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) Mr/MPRSW No.: Business Phone Number: - s ?O c,) S _ n Plumber's Address (Street, City, State, Zip Code): - s IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sajry Permit Fee (Includes Groundwater Surcharge Fee) Dale IssuedIssuing Agent Signature ( bumps) Id Approved ❑ Owner Given Initial Adverse X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly PItr87) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety 6 Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be property maintained. The septic tank(s) must be pumped b9 8 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 & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. If. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in 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 in ##1-7. VII. Tank information. Fill in the capacity of every new and/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. Vill. 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 812 X 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; welts; 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 sing 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) /�/(#1?A-f &5rf s S 9 4 40040 �oPOsEO ` OA✓ENT/I)NAC ��1 vIrY *j<<r / Oc.�tilof �/� ,O Sall t4,4. SS/0/4 Sr C /� f o/X �U4"ry OBE -J�j Tz r- P,14E Ae f a Sp/ rE f (AN A44-f 3 A&5oepricw AQEA (leov SEcr/aAj )AGE V J/-e/NG SPEC/F/(AT/vNS A4.7i mle. CoNrf/4o-ce : - 41,04 &eo i Znl c . ,j/S Sixril Sr /V uaSov G�li 5yu/b 71s- 3S'4 - a9sa So/[ 0-vA4 A-r1oAj JJ E 4u - �JPVFYJUJWSOA) �f5/Gvi4 F �tAc..,� FEB 0210 SAFM i MM- OW JKP�S 339s 111144 '5�� J44J. z29 , i4q,g/ 2vkuA t aroee OIA EEO G5" KECEtAEC This approval does not lnctude revievi , of y��E��y L 1Ne S 4 40040 nny in upstream of the septicth tank. See section determine whether plan submittal Code to' approval is required for that plumbing. Ar A/ f. (u7 e'�oPNEf 6,,4tV.= /Oaco' - /5GS 6.4t- StPTit -r4A)K AVD S,-„rs/O P✓c ��OoSfD GUe�c �uc.47�oa� SL ��E14NCXaT/�NS�ECT/p1J PP! L,�iT�I A��PuVU� �/,P TG/�T �,�, ' I; —�CVCL D/STiPO�aTi�,t/ /tC/Q�EIP Tc A!L TiQcNfr!ff 1 —VeA/'T Ar Eni/j Door EA[t/ IfNl// T , k7r. ' .4/07 �.� GAO DoSfo f-7EA hJofC: PjPfoQAiyD 9,Ak /N TENr,r C /5 - - - J• T rfF SDI 35 so3y �Vc BccAusE of 6; E.rwif So/c OvEe ?/pENcrf 5.4o�/A/4, GIP To .e r -r Oxo�cRrr AlAar. PII� MusT aE �a� o t-&bCtXb ASTM CZ7-Zg AS M� �,, pX/NG� �iFEA PRIVATE SEWAGE SY8TEM � TA'atk tV1iR 94.30-4 onditionally AROVED 7 0rrd Pv�E,Pr�/ /•� £ — °� UMA iAFE7T 1NINpINiiE 710Mi fts r �iPo PE Y �iirvF QQ am NDENCE U,fAKKC /fOAO ,4u <,ofLC S/TE f"(o/Al //TGL 1+✓z1s45 Yo -LV -�r/-Lj 'ey 77ly 31 -2na w6E 1 Njl :see rlv�Ivg� � ,rt' •/�3r3 0�� //�r�� ��v N�i1nS� 1sO h �sd PAO �Ivi��n°� 7r1�N1 Nis // I , rvo►1-»� SS�1/J Y� � Ivn/1d o5 009000 A313 3045)NslrviJ r 7*1 S%S/ ���n17f�jn nvl iv� )r�e� : 0 V 0 OV V6 S s�ylsh0 56 Es pvw �JrrNl�ijr �� -9' bs 4 9 / % : C7Vfrk",,( ` G -7 9 _ o5 " co hs ooc,7y - x OE rr� 51 S •/ ajr5ovcl y 0 511V I o.741nd-7�( 056 054 Q 0 / OS k el vo-�? or )r 09 yv0»v:P �L,vx/� Ovrp frly�or 6'onj 0 s3�,sordu�� 05 WWV rv'011dJ05?V 3r/s �rt4 we)wliviW sr�v�ja d/ao f � s-74-ts n y OVOOV V68 Wisconsin Department ofIndustry, SOIL AND SITE EVALUATION REPORT Labor hnd Human Relations Division of Safety & Buildings Page I of �.... Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or COUNTY -CS-r Cgo I X PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION REVIEWED BY DATE P PERTY OWNER: IC14 An R /N SUS t RI ES PROPERTY LOCATION q GOVT. LOT Z 1/41/4,Sa7T Zj ,N,R I / E (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER ( ) ❑CITY ILLAGE EVOWN �aSc�N NEAREST ROAD S TH 12_ Nero Construction Use [ ] Residential / Number of bedrooms [ ] Addition to existing building I ] Replacement [;1(J Public or commercial describe Code derived daily flow gpd Recommended design loading rate (3, S bed, gpd/R2 0 (- trench, gpCV t2 Absorption area required bed, ft2 trench, 112 Maximum design loading rate O . S bed, gpd/112 O . L trench, gpd4t2 Recommended infiltration surface slevation(s) A - It (as referred to site plan benchmark) Additional design / site considerations $ Parent material Flood plain elevation, if applicable ft $ _ $Ultable fOr System Unsuitable for stem ENTnONAL $ ❑ U ND $ ❑ U IN• ROUND PRESSURE $ ❑ U AT -GRADE S ❑ U Y TEM IN RLL S ❑ U HOLDING TANK ❑ $ qu Boring # r Ground elev. i6koi ft Depth to limiting Wtor > /&-St Boring # Z Ground elev. /o4 5G It Depth lo limiting factor SOIL DESCRIPTION REPORT Horizon Depth in. Dominant Color Munsell Mottles Qu. Sz. Cant Color Texture Structure Gr. Sz. Sh. Consistence Borxiary Roots GPD/ft Bed lTrench 9-1 S, L 1 tili car Mkt C I o.z 0.3 - -Sol 16 yfe3 4 _ S r -11 /oy,2S 4 5F r I c I p S p.6 fli-ln 16YR 4 — 5 M r I I 0.7 0,6 "'q•, IDYk 4f 4- O F /In�r Ck Remark4- Sw 81ft4ZIlJZt}- X !%kIZr`w JS INieV-SPc)PSc& W,TNrn/ �2Tu�c��'q No2f�rJs 4 0-13 foyk J — 1 sbK rn r C O a5 r32� �oY23 Z S,C 1 s6K �r C 1 OZ o3 7 (IN'S Eg a YP — s ,� �, I 1 0-'7 O.% lotI£ 414. —vrs O.V19C rS" a I 6.5 0.4 Remarki,SoU N LAS7 t5eAIPJC, — IZa4 iN, SPez NOQI-zn,uS CST Name:—Please,Print 4RAY ')6gNsoe-j Phone: 6 6Z-0 Address: F O v(hsoN I S16 / 1- Signatur Date: 12 2 - 9 3 CST Number: ,/ 4 (zewufte"es :s5ljBweu *P�oV,aUa-731 Ni V.4-cZV-7A--U:)-LNl 41-1 WZ)-.J.QN V( -2ryj-?Ivu 0: A S4 Y SO LO So bo A. 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Oil SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations February 4, 1994 ZAPPA BROTHERS 7156STN HUDSON WI 54016 2226 Rose Street La Crosse WI 54603 RE: PLAN S94-40040 FEE RECEIVED: 120.00 RICHMAR INDUSTRIES NE,SW,27,29919W TOWN OF HUDSON COUNTY OF ST CROIX NON -PRESSURIZED IN -GROUND SYSTEM The Department has reviewed the above -referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be made. All permits required by the city, village, township or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Sincerely, rard Swim Plan Reviewer Section of Private Sewage (608) 785-9348 3015R/ 1 ax04MxtiM61MI, S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUY ADDRESS / On( FIRE NUMBER _ W CITY/STATE q PROPERTY LOCCATION:,,A&�_1/4.4�PV 1/4, SECTION ` 2_, TOWN OF_//YU�_fnn� , St. Croix County, SUBDIVISION LOT NUMBER 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 6o% 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 system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification*form, signed by the owner and by a matey 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. 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 DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix Co. Zoning fficer within 30 days of the three year expiration SIGNED: Ir ;��� DATE: y � -- ` 9 St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 S T C - l00 This application form is to be completed in full and signed by jhe owner(s) of t)le property being developed. Any inadequacies will only result ,n 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 Z ,e,nls /w�� Location of property„ i` 1/4 Lam/ 1/4, Section / -., TAN-R_W Township Mailing address Address of site la Subdivision name_ 27caZ1,,y) Lot no, Other homes on property? ________yes_1L_No Previous owner of property Total size of parcel Date parcel -wag created Are all corners and lot lines identifiable? )ZI—Yes No Is this property peing developed for (spec house)?_Yes No Volume LC , and Page Number 2129 Of Deeds. as recorded with the Register INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & 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 awner(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. ti,,�1,4 and that I (we) own the proposed site for the sewage disposal systemorreI (we obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of County Register of deeds as Document No. l signature a lieant Co -applicant — 2— Date of Signature Date of Signature