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HomeMy WebLinkAbout038-1029-95-000 4 O d O 01 C d O fJ (D CD •^ CD CD ID m # CD ` 3 ID Cn z ;o F z o W - 0 Cn -1 2 z cn 7 cf) o o C7 ;� O O N "J O N 0 , O N N 0 - ' V p V W `� i -• Ln v cn N N M Z Z a V N N C us (0, of � I(D N CO p T N CL w Sll N ^t \ 1 \ O O C c'> N 0 ; 7 p_ O CD C (b 3 N CP (3 N O� W 0 H N A f0 VI V1 W p O 0 to C (n C (0 p .7 CD z 0 D C a o O v C 01 a N d N Lt° CD N CL Z c 07 = c C/) N r , , c c c coffin m _ C5 L j A CD a- Z ' O w 0 00 � N CD o o y C e �1 ^' 6 o z 0 0 0 3 z 0 0 0 p . ? ° _ o 0 ° w a _ aQ N �• O � ' (1 � N Z - c c a c N N N p D o v ° c v v ° CO e v v v o O SD N N Ul `< CD N A !� m C7 d '6 (P O w a A a = A c m= m o y o y N V L V . 3 CD N 3 CL CL Z rr Z .. O D CD O O D W O O o � � m m ° m m • N N N En CD ° CD Co $ h� O a N p N CL :3 CD a 3 z CD 0 z CD :3 0 2 O Ch C 0 y C j n n 7 n p z "� N C1 N O- j G 7 Z J W m CL a , z 0 3 0 3 a _. C/) p " O m N CD A W "O W CD (> CD n g0 Q y 3 CL CD CD O O Q 7 CD 3 a � CD K C7 x ° �o y r 0 T N O ' 0 T n 7 Sy C C 7 fD v (= O O O CCU z Q �_ N� Z O O. O d t O O - d O !Z 3 N � 7 CD = N N < m a �m o n 5� - X c 0 p J p O C1 L (a 3 CD CD S N N CD 7 cn ao m m z a `G N a S O p _p p o3 N CO CO 'p j ti O N O � O S ' I O - a o m < D o0 a o m o m 0 Cl 0 CL '.DER �ES T05�1NSHIP _� %�/ , S c.�- �• , ST. CROIX COUNTY, WISC;_N IN. T N, R '36IVISION -, LOT o�,- LOT SIZE PLAN VIEW Q 3 lOa -Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM / P0 Alc/f - \ \a ► 666 \' G1 ' � �� � � �__� `, .''`� �� I n • -• j + r s ` r 7' s I. .TIC TANK(S) ec&- MFGR. . CONCRETE STEEL NO. of rings on cover Depth �'� 'NCHES N0. of p DRY WELL width length area ? no. of line width lengt area depth to top of pipe 33REGATE /Y / iY - _:iC RATE AREA REQUIRED 'AREA' AS BUILT >: 7� � ;claimer: The inspection of this system by St. Croix County does not imply complete j valiance with State Administrative'Codes. There are other areas that it is not possible iinspect at this point of construction. St. Croix County assumes no liability for _tem operation. However, if failure is noted the County will make every effort to ermine cause of failure. ' ASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. _ ' /( /�� Nc DATED 7 y • �� (; PLUMBER ON JOB LICENSE NUMBER . z REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM Sanita &y Petm.ix _ Sate Septic / NAME � r-�- Townbh.Lp Cno.ix County _ Location /1/ C: - SC Section SEPTIC TANK 1 Size 10 gaCtona . Num6ob o6 Companmenxs Vibxanee F&om: We.ttt Viz. 12$ ox g&eaxet b,tope Bu.i.td.ing W et.tanda 6#. H.ighwateA it. DISPOSAL SYSTEM Via#anee FAom: We.tt t it. 12$ of gteate& a.tope -� S . Bu.i.td.ing 3 C) _ it. Wettanda d F t. • H.ighwaxet fix. FIELD DIMENSIONS: Width o6 t&ench 2 it. Depth o6 Aoek be.tow .t-i..te .in. Length o6 each tine it. Depth o6 tack oven ti..te Z .i n. Numb a6 t.i.nea �'- Depth o6.ite below grade ZY .in. Tota.t teng.th of Q.ine.6 it. S.tope o6 tteneh in pen 100 it. Di4tanee between tined %," t. Depth to bedrock Tota.t abzotbtion area jt Depth to gtoundwateA 11 Requited area it2 Type of Cove &-�l Pap en o Straw PIT DIMENSIONS: Numbe& o6 pits G&ave.t around p.it.6 yea no O Outside d.iame Depth below .in.tet it. r � Tota.t abaoAb on at ea it 2 . o 2 . �v A&ea &equ.i &ed - it 2 rn INSPECD BY TIT APPROVED L•/ , DATE 19 7� REJECTED , DATE 197. E H ,115 Rev. 9/78 A REPORT ON SOIL BORINGS AND PERCOLATION TESTS WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES P.O. BOX 309, MADISON, WISCONSIN 53701 LOCATION: C %4, Section . 7 T2_N,R&:&(or ownsh' or Manitipaiitr- V f4?- 4 # 9 " � Lot No. , Block No. County u division Name Owner's /Buyers Name: Xgf 5 g l��' B ox Jog ,F A A_ 0-AikI t Mailin Address: TYPE OF OCCUPANCY: Residence X No. of Bedrooms 3 COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW X REPLACEMENT ALTERNATE SYSTEM OTHE DATES OBSERVATIONS MADE: SOIL BORINGS - 79 PERCOLATION TESTS SOIL MAP SHEET 3 F F /f NAME OF SOIL MAP UNIT PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTE INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P Z o� I t► f� 1 `i / " 4 / 3 P-3 e2 C 3 1 P_ SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B_ & o CQ G B C � SL d b- Sc- 7 - l B- B- B- PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the Ian the loc ion a d square feet of suitable areas. Indicate number of square feet of absorption area needed for building,type and occupancy Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope Al / I O �T4 € € I 4 ..P..1i2 PLB 6 State and County State Permit # V Q 7 Permit Application County Permit # 90 —ITY for Private Domestic Sewage Systems County * DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROP RTY Mailing Address: B. LOC TIO A[ y ,(� ya, Section T ZZ N, R-LA E (or) IN Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township C. TYPE OF OCCUPANCY: Commercial * Industrial * Other (specify) Variance Single family Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete Poured -in -Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify) E. EFFLUEN DISPOSAL Alternate (Specif SYSTEM: Percolation Rate Total Absorb Area New Re lacement sq. ft. y) Seepage Trench: No. of Lin al Ft. Width Depth Tile depth top)_ No. of Trenches Seepage Bed: Length i Width 2X--Depth _ Tile depth (top) --No. of Lines - -3 Seepage Pit: Inside dia rete_r Liquid Depth No. of Seepage Pits Percent slope of land — J _ C Distance from critical slope 32-e e WATER SUPPLY: Private X Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Certi ied S it Tester, NAME 6 (z / G C.S.T. # —5 S ;,,1 j!/ and other information obtained from (owner/builder). T Plumber's Signature MP /MPRSW# G+ Phone # �i 3 Z Plumber's Address .---�— PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. C G i m e s. e ° d 3� c Xi e mm A t E r — V 1 {= 0 al ° o N - r FILED �` o - N N m CD Z D A C) AUG 191980 < z v - m 0 2 JAMES 0 CONNELL 'PA Q c O o 0 R1QIaIr of Deeds fi Z 00 d el 81. Croix Cownty, V 't m N O O O Wisconsin Z p ` z Ci O _ ` D 0 S 00 46'- 21" E ( m 655.22' ° ^� 0 605.22' a ; 0 50.00 OD O t o O m 0 D \ � O N rn rn C o m \ fT oo -1 �n '; •A to a ' - i D D 0 N ._ - m - r m Z OD C ��� Z' C C - v 0 BEARINGS ARE REFERENCED 4 TO THE EAST LINE OF THE m l � l SE 1/4 OF SEC. 7 l'� C m g z _ (ASSUMED N 00° - 47' -43 "W) -4 SOD° -47'- 01" E y co w N w - 327.56' ° - M w f 0 \ .A : A r W y to 0 L" 0 L11 N y Z Z OD m Z A 00 0 n 9 60 ` N r C tD 0 !p N m 4 0 0 0 O In y Q OD Z 2 0 Le o c0 �= 0 m to OD (b m w 0 00 pQl111St8ryN� G . �' m 0 Ot dNS` ti 0 ,0. w v ALLEN C. - Parcel #: 038 - 1029 -95 -000 12/27/2005 12:17 PM PAGE 1 OF 1 Alt. Parcel M 7.31.18.139B 038 - TOWN OF STAR PRAIRIE Current XI ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner TERRY J & KIMBERLY A PALMER O - PALMER, TERRY J & KIMBERLY A 2246 90TH ST NEW RICHMOND WI 54017 Districts: SC = School SP = Special Property Address(es): • = Primary Type Dist # Description * 2246 90TH ST SC 3962 NEW RICHMOND SP 1700 WITC Legal Description: Acres: 4.950 Plat: N/A -NOT AVAILABLE SEC 7 T31 N RI 8W 4.95A IN NE SE LOT 2 OF Block/Condo Bldg: CSM IN VOL IV PAGE 971 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 07 -31 N-1 8W Notes: Parcel History: Date Doc # Vol /Page Type 07/23/1997 1248/481 WD 07/23/1997 859/77 07/23/1997 608/95 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 118765 224,800 Valuations: Last Changed: 10113/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.950 46,800 174,100 220,900 NO Totals for 2005: General Property 4.950 46,800 174,100 220,900 Woodland 0.000 0 0 Totals for 2004: General Property 4.950 46,800 174,100 220,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 120 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Count ST. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryJ16171" Personal information you provice may be used for secondary purposes [Privacy La%X s.15.04 (1)(m)). Permit PALMER, S N1�Eky �S VOMAtim of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: 71 5M Description: Parcel Tialg- 1029-9 - 000 TANK INFORMATION ELEVATION DATA A9800148 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Air to i ntake ROAD Dt Inlet ir Septic NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss H ead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION DIMEN I N SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type O mod Number: System: 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.) LOCATION: STAR PRAIRIE 7.31.18.139B,NE,SE 2246 90TH STREET Plan revision required? ❑ Yes ❑ No (� Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert No. Safety and Buildings Building W SANITARY PERMIT APPLICATION y Bureau of Buildin Water S 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm- Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County X than 8 112 x 11 inches in size. O • See reverse side for instructions for completing this application State Sanitary Permit Number -3 d The information you provide may be used by other government agency programs ❑ Check it r Ision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Propertysltiierrer Na Property Location X114 1/4,S —,7 Tom/ ,N, R/ (o W Property Own is Mailing Address 5G Lot N r - Block Number a 90 City, State /} Zip Code Phone Number Su Ion Name or CSM (dumber 4LA 77 11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit -- -- — earest Road ❑ Village ❑ Public 1 or 2 Family Dwelling - No. of bedrooms p �_ jZ Town OF 51 III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 7 2 1 q � 8 1 171 Apartment/ Condo e— a /dZ9 – ' 9 d® 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) /�V hOilr A) 1 E] New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ epair 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 1 ,LtSeepage Bed 21 E] Mound 30 E] Specify Type 41 ❑ Holding Tank 12 ETSeepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 94 8 Feet 97• �j Feet Capacity VII. TANK in g allo ns Site Total # of Prefab. Fiber- Exper- INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass .Plastic App New Existing strutted Tanks Tanks Septic Tank'erflUITffI`1T r ra k j / ❑ ❑ ❑ ❑. ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ I ❑ ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumbe " ig to e No Stamps) MP /MPRSW No.: Business Phone Number: '� tuber's Address (Street, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater J/ 4 Issued Is Agent Signature (No Stamps) )%Approved [:]Owner Given Initial ��jj Surcharge fee) Adverse Determination ] 0 / f� X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SHD -6398 (R. 05/94) DISTRIBUTION: Original to Coiu,ty, One nipy To:. Safety & Buildings Dive ion, Owner, Plumber Wd man w idw NOME NEW No 0 m NNE ON MEMEN ONE -no MON =i■�■ =■ No MEN E MEMO 0 No mosums mom NEON om IMMMMs MEN ME SOMEONE ME 0 ME mom ON ON ON NEED MUM ■ 0 NONE No Ohl" 0 No ME m mom NONE No Emom mom NEI mom MORE ON � �N mom ■ IN N NE 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 j .P�� !�, ,.L residence located at: Sec. :2 _ , T _ N, R Town of St. Croix County, Wisconsin. 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 a Did flow back occur from absorption system? Yes No A (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: , /dr� D Construction: Prefab Concrete Steel Other Manufacturer (if known): Age of Tank (if known) : -. (Signature) f (Name) Pleas rint �i ti 00Q_ 12) < 9' (Title) (License Number) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin 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) . ? Name ,/�/2i3 /r,a n� Signature �"1T MP /MPRS -qg s Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page I of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and .`S T D percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # a - # d a9 - 95 - 0000 APPLICANT INFORMATION - Please print all information. Revi by Date Personal information you provide may be used for secondary purposes (Privacy law, s. 15.04 (1) (m)). _ Property Owner Property Location Govt. Lot P E1/4 s 1/4,S 7 T 31 N,R r 8 E (ore Property Owner Mailing Address Lot # Block# Subd. Name or CSM# a n 7 D `\ S & a M 3 (-5 8 y8 P. 9 City State Zip Code Phone Number Nearest Road ❑ City ❑Village �+ Town Nt w �_i cLtonh I Wti 6Y0I ( -3178 -h-.1 Pr.. 4,-. tIN 5 ❑ New Construction Use: C4 Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow J© gpd Recommended design loading rate . 5 bed, gpd/fF a trench, gpd/ft Absorptio area required �� bed, ft 7 5 t ft 11 g _ bed, gpd/ft (0 trench, gpd/ft pr Re +end infiltration surface elevation(s) 9 W . rench, Maximum design loadin g rate S 9 f ft (as referred to site plan benchmark) Additional design /site considerations v Parent material Q L 1 C, Flood plain elevation, if applicable 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 ❑ u ®S ❑ u ❑ S U ❑ S W u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell 06. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench + C Ground R`t �., a m 5 b M T r G I Depth to P -351 K V S L -;� In sb 4 MTV' 1 rS , 1I10 limiting -�p s'�R t;t v- S factor PO in. Remarks: Boring # R 11 Ground elev. Depth to limiting T C factor in. Remarks: `^ CST Name (Please Print) Signature Ife No. �` n 't' r ( _G Address Date CST Number go OR A ffi, WOMEN MENEM N N No pEN ME MENEM boom 0 mmm M WE sum - MOMEEM a Mom NOME EME ME nn No ME ME MENEM Mom ME 9 ME ., N 4 �� 1 ME L STC -105 SEPTIC TANK MAINTENANCE AGREEMENT �St. Croix County OWNER/BUYER MAILING ADDRESS PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY /STATE �L 4) A �l i 41-1.1 l.Lyi PROPERTY LOCATION QG, ,r- 1 /4, 1/4, Section 7 T _-Jj _ N -RZ,6 TOWN OF _ S�—�� �Q ,rte, ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP 3 M , VVOLUME C/, PAGE 9.21 , LOT NUMBER O> 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 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 60% 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 mater 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 County Zoning Officer within 30 days of the three Z'piration t SIGNED: / DATE: 6 14 ve t C �� St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 • S T C - 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 Location of property _ 1 /4 1/4, Section T_3LN -R W Township o�,� Mailing address Address of site Subdivision name Lot no. Other homes on property? Yes _,.A�' No Previous owner of property Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec ho us ) ? Yes No Volume fly S and Page Number k�L— as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY 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 owners) 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. and that I (we) presently own the proposed site for the sewage disposal system or I (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 the County Register of Deeds as Document No. S6 /GX3 4 iat e of Applicant Co- Applicant LAG � Date Of Signature Date of Signature t I •SC.y -i O oCroi m 0 �' c �, N m v 70 Ca a o "= rn 980 Z m o Z NNELL O c eed! f -A mfy, V q t^ CD m ro O O M g v w ;u D 0 S 00 46'- 21" E M 655.22' ° N 0 605.22' 5000 .O o w �n Z to 0 m O� `y O D \ � C N r a m n o m M OD -4 cn D D 0 � N _ 0 t M ti - m T1 X Z CD Z M 0 v Z BEARINGS ARE REFERENCED Z O TO THE EAST LINE OF THE m SE 1/4 OF SEC. 7 f1 C Z (4SSUMED N 0 D - 47' •43• 'W) - 4 S 00° -47'- OI" E OD w N w ro 327.56' ° r m O w -� --< W CD - r O / .p P r O W w y tp 0 � Z - ( y .� OD DD N c r > 7 N g :U V m — N Jr _ 0 X 9� O1 ' N r C (1 GD ' r .•► m (n m 1% o v- 0 0 v a ' - OD � co z z O o t0 t o m c t M ,� to � � pin c„ w N -� ` ��gaNlStBryp� i CL