HomeMy WebLinkAbout030-1071-30-000 (2)sTc 10 4
AS BUILT SANITARY SYSTEI{ REPORT
OWNER
ADDRESS -l?,qn E(nz -1rr.
,/-^, {rrn-,n^,-,),a-/677
suBDrvrsroN / csM#I.OT #
sEcrro[e21:'.T.-5a_N -RJ L w,Town of -</, -(rr.r/
sT. cRorx couNTY, wIScoNSrN
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover-
CL*,,t
Nht'A
Nxtr)
/ "*a't*I
€*<,\
PLAN VTEW
SHOW EVERYTHING WITHTN 1OO FEET OF SYSTEM
uillB,*
i4'-\$
N
{\
{d:
TNDICATE NORTH ARROW
t
BENCHI(ARK:l/n D ln.o')J.,
SEPTIC IANK ,/ PU!{P CEAUBER
l.tanufacturer: /" ).r;z'<
EOI,DING TAIIX RT(ATION
acity:
S ize
Setback from: weII /-rC' House other
Punp : Manufacturer Model #
Float seperation_ Gallons/cycle:
Alarm Location
, SOII, ABSORPTION AYATEU
width:Len Nunber of trenches
Distance & Direction to nearest prop. line:
setback from: weII: House other
"o*rrlQ'_"rr.,
q_<.'7 sT Tnletc44a__:Uu2_ST outlet.rr- -
5'24.8 7
Building Sewer
PC inlet Pc bottom Pump off
stemHeader,/Mani fold_ Botton of sy
Existing crade Final grade
DATE OF INSTALI,ATION:
PLUI,TBER ON JOB:
LICENSE NUMBER:
TNSPECTOR:
3/93 2jt
ALTERI{ATE Bt.{:
rS,eAS,I 9}[ i,.,.frT,'" *I&f; $,eH 2 6' 30' lRrrffffkt\&Atft' I9fr frtr'Labor apd Human Relations
" Safety and Burldrngs Divisron INSPECTION REPORT
(ATTACH TO PERMTT)GENERAL INFORMATION
TANK INFORMATION ELEVATION DATA
TANK SETBACK INFORMATION
PUMP / SIPHON INFORMATION
SOIL ABSORPTION SYSTEM
FROG
A9300081
Permit o e s Name ownvVa9e
CST BM Elev.://), a
lnsp BM Elev BM Description
/rLr
rm-rtnaaty
State Plan lD No'- -
ParcelTax No.:
o?n-1 07 1 -?n-nnn
TYPE IVIANU FACTU RER CAPACITY
Septic
T
Q)etKs (
Dosing
Aeration
Holding
STATION BS F5 E LEV
Benchmark '4,o2'
/
L///
Bldg. Sewer
f, m tntet
/t n outtet x
DFffi -r4
Dt Bottom
Header / Man
Dist. Pipe
Bot System
Final Grade
Y,
76,27
TAN K TO Ptt WELL BLDG Vent to
Arr lntake ROAD
Septia NA
Dosing NA
Aeration ___NA
Holding 6'/o a 7
Manufacturer Demand
GPMlVlodel Number
TDH Lift Friction
Loss
Svstem
Head TDFh.-- Ft
Forcemain Length Dia Drst. To Well
BED / TRENCH
DIMENSIONS
Wrdth Length No. Of Trenches PIT No Of Prts
DIMENSIONS
lnsrde Dra Liquid Depth
SETBACK
INFORMATION
SYSTEM TO PIL BLDG WELL LEACH INLAKE /
CHAMBER
OR UNIT
Ma n ufacturer
Type Of 7System:ffT 5za Model
DISTRIBUTION SYSTEM
x Pressure Systems Only xx Mound Or
COMMENTST (lnclude code discrepancies, persons present, etc.)
LOCATION: ST. JOSEPH 26 .30 . 1 9 .253M, NW, NE, LOT
t7- // i'/'
Plan revision required? [ Yes
Use other side for additional informati
(
ems Only
2L,, FROG POND LANE
-/r r.*Ll /., , , , -1. {.
l
er / Man
Dra'
H o
Length Dia
utron PrDstrt e rze Vent To Arr lnta exHoexHoe Spacing
I Yes
ched
.-
xx Seeded / Sodded-
fl Yes n No
Depth Over
Bed / Trench Center
Depth Over
Bed / Trench Edges
xx Depth Of
Topsorl
E 2s
sBD-6710 (R 0s/91) _y lnspector's Srgnature Cert No
)I )
L.(l- )
104 A a1
4tl (
HI
Z at/ =
s.4s qs,'
(
(./<7 7
a /
'z((.)s
/n t3lz >)5'
so/<
SOIL COVER
/a)
I
dr,
&up,(/ out"
/tr
--
DILHFI SANITARY PERMIT APPLICATION
ln accord with ILHR &1.05, Wis. Adm. Code
-Attach complete plans (to the county copy only) for the system, on paper not tess than8l{x 11 inches in size.
-See reverse side for instructions for completing this application.
I. APPLICAI{T INFORMATION - PLEASE PRII{T ALt IilFORTATION.
cou
application
STATE PLAN I.D. NUMBER
S? ? - 34nexr
PROPFBTIOWNER-{J)t-.€,),,,/PROPERW LOCATION
t )il% I r Yr,SJl T <o, N, R lq dOr@
PROPERTY S LOT#3t
ZIPCODE
,\y'ot 7
PHONE NUMBER()CSM NUMBER
,\','*rail( AA0
SU
OSc-/C7 _?A\) \-/
6
7II
trtrtrtr
NEAREST
trtr
lll. BUILDING USE: (lf building type is public, check allthat apply)
Other: Specify
ll. TYPE OF BUILDING: (Check one)State Owned
10
11
12
13
Medical Facility/Nursing Home
Merchandise: Sales/Repairs
Mobile Home Park
Office/Factory
1 E AouOondo
2 Z Assemblv Hall
3 I Campground
4 ll Church/School
s E Hotet/Motet
Outdoor Recreational Facil ity
RestauranUBar/Dining
Service Station/Car Wash
E prOti. B', or 2Fam.Dwellinffi of bedroo ^, 2
lV. TYPE OF PERillT: (Check only one in line A. Check line B if applicable)
A) 1.E u"* 2. E Replacement 3.System System
B) E n Sanitary Permit was previousty issued. Permit #
4.tr 5.
Date lssued
Repair of an
Existing System
Reconnection of
Existing System
Replacement of
Tank Only
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution
42
43
trtr Holding Tank
Vault Privy
Experimental
30 E Specify Type11
12
13
14
trtr
Seepage Bed
Seepage Trench
Seepage Pit
System-ln-Fill
21
22
Mound
ln-Ground
Pressure
7. FINAL GRADE
ELEVATION
Feet
6. SYSTEM ELEV
Feet
VI. ABSORPTION SYSTEM INFORMATION:
4. LOADING RATE
(Gals/daylsq. ft.)
5. PERC. RATE
(Min./inch)2. ABSORP. AREA
REQUIRED (sq.ft.)3. ABSORP. AREA
PROPOSED (sq. ft.)
CAPACITY
in qallons Prelab.Fiber-
glass Plastic Exper
App
VI!. TANK
INFORTIATION New
Tanks
Existino
Tanks-
Total
Gallons #otTanks Manufacturer's Name
Site
Con-
structed
Steel
Seotic Tank or Holdino Tank ?*n 3u,t tEr{s 8
Lift Pump TanUSiphon Chamber f
V!II. RESPONSIBILITY STATEiIENT
l, the undersigned, assume responsibility for installafion of the onsite sewage system shown on the attached plans.
MP/MPRSW No.:PIPlumbCr's Name (Printl: t#- / OP")^,,//
Business Phone Number
( ze t1y'p-"3?/
{t R"* /n{) , e4rt-> (I,l
Pium6€iSAddress GtffiCI-tt,
Irx. GoI,I{TY/DEPARTMENT USE ONLY
Mr*,.o Adverse Determination
f] olsapproved
l--l Owner Given lnitial Surcharge Fee)
Perm
-St-'
sYry/(**P
X. CONOITIOilS OF APPROVAL/REASONS FOR DISAPPROVAL:,;7E5ffr'!
SBD€398 (formerly Plb47) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Salety & Buitdings Division, Owner, Plumber
"/"?rtr
PERMIT
to
ctw:-
Yit**q=,i sJ ln*,rt/
BLOCK #
II l-t L]
\
z
-i
I
I
I
fr.t "tQ
HOLDING TANK CROSS-SECTIOTIa
l{eather Prrof
a
1ater Tlght
Orner's ]lame:
Address:
Legal
Townsh
County
Junctlon Box
Approvedr'
Yent Cap
\Appr.oved Locki ng l{anhol e Cover
l{i th tlarnl ng Label Attached
Pe
4' C.I.
Yent Pi Flnal Grade
SPEC I FICATIotIS
72' l{i nimum
3'ofB Under Tank
Exl stl ngr:
n/')
4' illnfmum
l8'l,linimum
rcved Joi nt
H c.I. Pi e
)ea I
p
3llExtendi ng
Onto Solid Soi
Bottr Tanks Typical of Each 0ther
D
rp
ta
scr on:p
/lrlun c
TANK llew V
.manuEffiit
Tank Size:
UI(o
na,ullF
,4.'\./
iva(I
ons
ESIGN ALART{ Manufacturer:
ilodel lltrnber:
Swi tch Type aa
NUMBER OF BEDROOI'IS :_,2
Slgnature:
Ll cense r: -<3
Approved Jol nt 6
4T c Ia a
t,
Hl gh llater
Al arn Swl tch
Bllnd C.I.
Pl ug
A
Date:{-.E ?e
I
GALL0NS PER DAY: ?rln
oa
Wisconsin Department of lndustrv.Labor arid Human Relations PRIVATE SEWAGE SYSTEM
REVIEW APPLICATION
Safety and Buildings Division
Bureau of Building Water Systems
Jlayward Office209 W 1st Street
Rt 8, Box 8072
Hayward, Wl 54843
Phone (7t 5) 634-4804
Fax (71 5) 634-51 50
La Crosse Off ice
2226 Rose Street
La Crorse, Wt 54603
Phone (608) 785-9334
Fax (608) 785-9330
Madison Office
201 E. Washington Ave.
P.O. 8ox 7969
Madrson, Wl 53707
Phone (608) 267-51 l9
Fax (608) 26t-0592
Shawano Office
1053A E. Green Bay Street
P.O. Box 434
Shawano, Wt 54,l6G
Phone (71 5) 524-3626
Fax (7'15) 524-3633
Waukesha Office
401 Pilot Court. Suite CWaukesha, Wl 53189
Phone (ale) 546-6666
Fax (414) 548-8614
INSTRUCTIONS:To save time, schedule your review with one of the offices listed above prior to submittat. Fill in all applicable data and submit thisform together with fees and plans/information. your subm ittal must be received at least one workin g day prior to the appointment at the off icewhere your review was scheduled. please call any of the listed off ices if you need help filling out the form or have questions on what information toSubmit. PLEASE PRINT VERY CLEARLY.A sample of a completed form is on the reverse side for1. APPOIN TMENT INFO
your reference.
RMANON.rf ou have schedu led an a rntment fill rn the informationAppointment Date uested below to save time:
Plan tdent
IJ2. PROJ ECT INFORMATION lf this revrew is a revision or extension to yOur existrngprovide that number here:plan identification num
Reviewer Name
Locat
LOT t4
3. APPLICATION FOR
System Type (check one):Syrtem Type t (include new and existing tanks)
Up To 1,500 gallon septic tank
1,501 - 2,500 gallon septic tank
2,501 - 5,000 gallon septic tank
5,00'l - 9,000 gallon septic tank
9,001 -l 5,000 gailon septic tankOver t 5,000 gallon septic tank
ber,
4. FEE COMPUTATIONS
Up To 1,000 gallon dose chamber
1,001 - 2,000 gallon dose chamber
2,001 - 4,000 gailon dose chamber
4,001 - 8,000 gallon dose chamber
8,001 -t 2,000 gallon dose chamberOver t2,000gallon dose chamber
Up To 5,000 gallon hotding tank
5,001 -t0,000gallon holding tankOver 10,000 gallon holding tank
County
T
tranuutr
A
H
M
N
P
o
FEE SUBMITTED
Building Type (check one):
D tr Dwelling, lor2FamilyP fl pubtic Buitdings fJ State-owned Buitding
1110.00
$ 120.00
$ 160.00
3 200.00
$ 300.00
t s00.00
$ 70.00
$ 80.00
s 100.00
$ 120.00
t 140.00
t 160.00
$ 60.00
3100.00
$ 1s0.00
t 300 00
$ 60.00
3 100 00
$ 225.00
$ 225.00
t 75.00
t 6000
Code Derived Daily Flow
-
_ gpd
tr Check tf Reptacing Existing System Experimental System (additional one time fee)Revrsions To Approved plan
D Petition For Variance
Petition For Variance: Setback
Site Evaluation
Plumbing
Revision
tr Groundwater Monitoring Groundwater Monitoring - per Site
Site Evaluation in Lieu of
(other than a proposed subdivision)
Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring t 60.00
Subtotal:
MAKE ALL CHECKS PAYABLE To: SAFETY AND BUIL
Priority Review: Enter same amount as Subtotal
DINGS DIVISION
5. SUBMITTT NG PARTY INFORMATIONTele No. (inc ude area code & extension)
o.&et ress Or .O.8ox City, T or Vill rp
HC ,O:
,; "o
,o3n
I Aerobic or prepack aged treatment system fees are ca lculated based on equl valent stze septic tanks and2 Revision fees are not applicable to temporary holding tanks or extensioni to existing approvalsNOTE: Fees are purs
I city fl virruse [t rown or
Com N
sBD-6748 (R.03A3)
uant to Wis. Adm. Code, Chapter ILHR 2, and are subject to change annually
dose chamberr
Pe
OVER+
At-Grade
Holding Tank
Mound
Non-Pressu rized I n-G roU rtd (Convcnttonat)
Pressurized ln-Ground
D
Total Fee:
ffi ?NMAIE SCWAGE SYSIEMraritw rrtuc ltof E'E]tr:f
i:ITT,'E::]alL-at -rl.(.a.s t{ttar.tral tt r.ri,rtr0 t!.lll L.ontr lltt,ttcr 0al tar-3t It,ItrO,,.,l0!I,
t:mtO. aa rlt ralt^l G,t..arr.-r
tlmo.
'.laai.iortltrclrt-Olt',.lf,tl
al E(qri,ba.(,ra-a,s tlta!:r'rll.,lcarrx.rr.ri4 r Laliro.Oltl3'.{aa,..Oltlarattl0
alll[xtrott: torhe.t aa.trr..fr dra.olardt ..drt-...a rr*.ra. ve ta.t.i.t.rarti.-it alr.rt rLa r.-aa..tCa.ba.,lt ..rFl
i.otta-La.ar.trurra..rd. ra.ataar.aaaa.rait artalr.Lraa.i-nL.ad-t ad.rrsr.l||a.t?c..rtn .!anriaottr.{a.tFlr.d t.Slriair.l'.i t.{a.-..r.c.*rih..-cr totd.a.An appolntment to have a submttial
J
a s ltt
EIrYl
r.:-
.lrtll rta 6.a.it
o
t
ra2ad,
c*r.tt..o.1r. teo ;
Cldta.tLa.tt-r!tt--
-I,.F-
a- Li-rLt-!-raL-.
Ffi
!'!a..lt'. I f.fa.
1!r. t lot.trtli.a.r
Ln-rtoa.' fi.tb,
taia.. rq yx,!E: t6..r
G....a..rr aa..!.o.ha - a.. tr
GJr"n.
revlered should be madehave to present a subml
. You do notttal tn persoo. :-
l,laklng an appolntment ulll go muchqulcker lf you complete
L
lu :|:1
Ozo,.rl.c,
:T]
,lo
lnglven to you rfter the
I nforaatloo ne
ldenttfl caa revl s lon
part I rlll be
5 of thls forn prlor to
parts 2, 3 and
cal I lng. The
t-eppol ntment ls
aa
a
I
o
btc
rJor -tlot -
id .................cr ..-...-..,......-.
i..l ..................
alla-tt:.!ar..-t:o0tDoatoo
t.1,tar
l'or
f,Ot -tC/D$ln f.frr rdOt. x!Ee.ac. rtda.t! r.
?6
-IAD-
Renember to record an exlsfl ng plan
tlon number lf subrnltilor extenslon.forlllor-t-
:.Il.a.ot.
,'TaI,olraoar,0oaraoitor
Itr. 1Ot L.ida.tr.- ........_....... t aoo
Systen Type, Bulldtng Type
and Systen Repl acenentcorpleted yhen subml ttl
. Dally flor ,;ust al I be ;".i
trrI....... _a plan for a i1
SYstem Typs :'
tem Type :
!-0loo
trtaSrrt-lttt I
prlvate seragels not llsted,after 'other.,,
sysfil I ln
lf
Sys
i-IEFI
tri.. ...... -...--...... 3 t1O
o t aoo ...... .
t-.1 ......... ?8O
At 6t/r
itrte that .Conventtonal" systen_ ls
"llon-pres sur l zed In-ground."
Remember to record your telephone
ha-beo.ri r..ol Lroac.qr.ra-.r4.6..t t .oO
I^ttaltcHStttrAv tra ro 3artiw AxD ]'ItOtxGt quid loLliaa:...,..number. lt ls theyour address fron use to recal Ita flle. Plansour da, 3?5- ,l lo to the subnlttlng party.po go* 7ti 3 (rf B! 1...t o.,..a|..r.t,r.t.ri..irrn6 t ..r...t.4.r.d tx.d !. n -.r.d r'i.ai.t .rt..iddq..t9 t n. rd.iit .r....ir.rrr..& br..rF.rt .rr..l.n lor.r-e .rt,n l
floq ! rr.3. fl ro or,
C.Ac.L. 19E;ll
B
. SvsL."r, Co.r,Aq.v
rcII: aaar..a t .r.rrl aaS. ..i (.ia.(l.aa.r
lDarrc al,ttl
lxl l. ..{ xa rlFr to
3 are returned
HOLDING TANK AGREEMENT
Docufiqnl No.
Agrccmcnl Otlr
Thls agreement ls made between the
Thlr rpecr rlrlrvrd lor rccordlng drtr
for the purpose ol proper containment ol
ate sewage system as permitted under
County or Locrl Govcrnmcntal Unlt lHoldSr O<ott Gun ry I A5r-Tr5epx fi'@Ns*iP I '
lng Trnk(r) Ownrr(r)
o Ba-r /< I 0,fr{2a$
B e k.cs rt
We acknowledge that application ls being made lor the lnstallatlon of (a) holdlng
tank(s) on the lollowlng property, (Provlde legal land description:)/38o t?Ro&f"n, teN€ -Pgeecu 26,go,/?. )53m
,14o.2(, fJor*r Rtgal pRrCt/
As an lnducemenl to lhe County ol
ws sgree to the lollowlng:
Sf. Goty ro rssue a sanirary r.,,fi,"qrH#.urarli r5rr,,r,
l. Own6r letalt lo conrorm to all appllcabl€ roqulremsnls ol Ch. ILHR 83, wis, Adm. Cods rsls ng lo holding tank3. ll ths ownor tsits to havs thaholdlng tsnk proporly 3€rvlced ln rosponso lo ordsrs lssued by lhs munlclpallly lo provent or abale a nuliance as descrlbsd in ss. .146.13 and146.14. Sl.ls. tha munlclpalily m8y- ant€r upon ths prop€rly and sarylc€ tho tank oi cause to hav6 tho tank ssrvlcod
"no "rrirg" th" o*n"ibiplsclng lhe chugea on ihe lsx blll as ! sp6clal aslo33meni lor curr€nt servlces rendered. Th6 chrrgs! wlll b6 as3ossed ai prescriueo uy3. 66.60, Strt!.
2. ownsr tltao! lo ply ellcharge! lndco3tl lncurrod.by tho munlc-lpallly lor lnlpectlon, pumping. haullng or otherwlss tervlclno and mainlainingthe holdlng tank ln such a mannlr_a! lo Ptsvsnt or lbato any nuliancs or heslth hazard cauiedoy ttre h;lding lank. rle muntcipettty stralinotit!ths ownsr ol lny cosls whlch lhall bs pald by.lhe_ownor wlthln thirty (30) days lrom lhe date ol no cs. ln th; €v6nt ths owner ioei not pay tn6co!13 wllhln lhi,ly (30) day3, lhs owner specilicslly agree3 thal sll ol tho co;ls .nd charges m8y b€ ptacsd on lhs tax roll !s a rpeciat issesrmont lor lhe abal6monl ol a nulsance, and lhe tar shall be colleclsd !s p,ovid€d by law.
3. Tho ownli, srcept es provlded by 3. 116,20 (30) (d), sl8t3., agrsss to contract wlth a person who ls llcensed undor ch. NR 113, wis. Adm. code lohavo tho holding lank ssrvlcad rnd to lllo a copy ol lho contrect or the ownsr's rogtsrra on wlttt ttre municipality and wlttr urg -rriv. Ti" o*^"ilutthsr agre33 to tile ! copy ol any chango3 to the 3srvico contract or a copy ol a new sorylce contract wilh ihs municipality 8no rrre iounry wirrrint€n (t0) buslnass dlys lrom tho drle ot chango to lho sorvlc6 contract.
4 Tho ownor lgtos! to conlrlct with s pe,son llcensod under ch. N R 113. wls. Adm. code who shalt submit to tho muntclpslily 8nd to tho county sraport ln rccord wllh !. ILHB 83.18 (4) (a) 2,, wlr. Adm. coda tor the lo/vtctne on e remtannuai uartr. tn the oma ol ragirtretion undlrl. 110.20 (3) (dl, Stat!., th. owner shr submtt thc rupo to tho munlclps ly and ttri county.
5' Thl! lgt"mrnl wlll remlln ln cllrqt only unul lhe local govornm€ntal unll .esporulble lor the roguta on ol prtvat€ sewrg! lystems cortiti€s thatthq properly lr sorved by slthsr a muolclpal sowor or a-ioll rblorptlon syst€m thal complles witi ctr. tLiR'gs, wis. tarn. cods. tn sddition. thi3a9to'm'nl mly be cancellsd bv srecullng and rscordlng sald cortlllcation wtth r"r-ui"" iourit "greiilnr ln such manner-*r,"r, ,iii plr.nithr orlrtanca ol tha coT lc! on to ba datsrminsd by role;onco to tho property.
S Thl! agreomonl lhall b9 blndlnc up9n the own€r, the h€lrs ol lhg ownsr and assignees 0l the owner. Tho ownsr shall submit the agreemenl tolhB tlglttor ol dooda lnd tho agroement shall be rocordsd by the r6elster ol deedi in e manner whictr wiit-permit tne extst6nca ol the agr€smentto b. detrrmhsd by r6ter.oc. to tho proporty wh6rs tho hotding tani lr tnstafled.
Owner(r) Name(sf (Printl
FuA€Kt K. -t
l)s w xs tr
C44o, C
)Signalure(s)
Mu al
) Bre*
7 Subscribed and sworn to belore me on this date:lll s
A-rf,
My commissi Car
"flfd
Gfanfotary Pubric
Publlc
Municlpal Ollicial Name (Print)
'ro(r)u 0F sT.(rosEPl+
re tl
Municipal Olliclal Tltlc (Prlnt)t*d Cl4&t ZZ7 trt\)isconsin
S8O-0123 (8. t0/85) Thls tnstrument was drafled by the Slats ol Wisconsln Oeparlmenl ol lnduslry, Labor and Human Relat ns, Bureau ot Plumbing.
Coniracl Oala
HOLDING TANK SERVICING CONTRACT
This contract is made between thev/a Az/r)
Holding Tank Owner(s) Name(s)
Q /?Ra L J.OBT Rr K6€N-T-s4 Pumper's Name
Po* Ev't
LI a9T€
{-t qtt to
m'GfirC Tt1 c '
and
we acknowledge the lnslallation of (a) holding tank(s) on the lollowing property: (Provlde legal description:)
/ 3to l:ao6 ,u*o Lo*g furz"et tJo. JG. 30. t7. isei:., -ar.' i-s'":! R rqq., ptz- eL ,/ tTgrS4 0ZB 5
?il !"';; ii i"n'o*,-1,,{.,r'ro*i.o".g s^ !Jr*rr.,-!s sz>e-c- r
5z,,f,iyfE""i?EfuWg2r!fl:L"i":^7*,;i.i?i"7!{.€-A.:t;{;fll€^t L€ Al 6t"€- 7t 7H€ p Nr o F g€el/i./l.t^to.
1. The owner agrees to lile a copy oflhis contract *ith tha local governmenlal unit hereinatler called the "municlpality", which has
signed thE pumping agreement required in Ch. |LHB 83.18 (4) (b), Wis. Adm. Code and
with the County ol 5'n an,oTx
2. The owner agress to have the holding tank(s) serviced by lhe pumper and guarantees to permit the pumper lo have access and to
enler upon the properly lor the purpose ot servicing lhe holding tank(s). The owner agrees to maintain lhe all-weather access
road or drive so that the pumper can service lhe holding tank(s) with the pumping equipment. The owner turther agrees to pay
the pumper lor all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit lo th€ municipalily which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis.
Adm. Code, and to the county, a rePort lor the servicing ol the holding tank(s) on a semiannual basis. The pumper lurther agrees
to include the lollowing in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;b. The name ol the owner of lhe holding tank;c. The location ol the property on which the holding tank is installed:d. The sanitary permit nrrmber issued for the holding tank;e. The dates on which the holding tank was serviced:l. The volumes in gallons of tlre contents pumped lrom the holding tank lor each servicing;g. The disposal sites to which lhe contenls lrom the holding tank were delivered.
4. This agreement will remain in ellect unlil lhe owner or pumper terminates lhis conlract. ln the event of a change in this contract.
lhe owner agr€es to lile a copy ol any changes to this service contract or a copy ot a new service cohtract with the municipality
and the County named above wilhin len ( 10) business days lrom the date o, change to this service contragl.
Owner(s) Name(s) (Print)
lio a€ rr K
CaEoL J
Brrur*n
Baprs il
Owlrer Signature(s)
Ur4-rZ ,B"rr-*2,
Subscribed and sworn lo belore me on this date:
?-,=r
My commi SS ion expires:
Pumoer's Name {Print)
Poaxrs Liqw'cl t^Jnsk illg* lno I Prrnrpcr's Signatu
?
Pumper's Begislralion Number
/ 0*7 <.
This instrument was dralled by the State of wisconsin Department
ol lndustry, Labor and Human Relations, Bureau ol Plumbing.
sBD.7s74 (N. r r/85)
U rC
s T c 105
SEPTIC TANK MAINTENANCE AGREEMENTSt. Croix County
ot^lN ER/BUY E eRr Axo Be u €sHL
ADDRESS oG Pa u> Lu FIRE NUMBE 139o
CITY/STAT ilct^t R,,*tmoND t0T.zt 5q o t'7
PROPERTY LOCATION: N t,,L/4 , N {T/4 , SECTION '6 , T-.3.Q-N-R_/ q_W
TOWN OP 9T, J, s tl st. croLx County,
LOT NUMBER .t L .
F rngs {
SUBDI VI S ION 61-.</nd .L
Improper use and maintenance of your septic system couldresult in its premature failure to handle wastei. propermaintenance consists of pumping out the septic tank every threeyears or sooner, i f needed by a licensed seplic tank p,r*p.t'. Whatyou put into the system can af f ect the f unct,ion of thA =lpii" tankas a treatment stage in the waste disposal system.St. Croix County residents may be eligiUfe to receive a grantfor a maximum of 6ot of the cost of re-pfacement of a tallingsystem, which was in^ operation prior to .ruf y 1, Lgzg . st,. croixcoun!y accepted this program in August of 1980, with therequirement that owners of all new syitems .gr.L to keep theirsystem properly maintained.
. . Tf. Ploperty owner agrees to submit to st. croix zoning acert'i f ication 'f orm, signed . by the owner and by a mater plumber,jouf neyman plumber , restricted plurnber or a I i;;;;;d= -pumper
verifying that ( 1 ). the on-site wastewater disposal system'i= inproper operating condition and (2) after inspection and'pumping (iinecessary ) , the septic tank is less than i/l full of sfuaqe andscum. '
T /we, the undersigned have reacl the above requirements andagree to maintain the private sewage disposal system in accordancewith the standards set forth, herein, as set by the wisconsin DNR.certif ication stating that, your septic has bee-n maintil;;d ;ust becompleted and returned to the st. -crolx co. zonJ.ng of f Lcer within3 o days of the three year exprration date . - ----':
SIGNED | (4^J
St. Croix co. Zoning Office911 4th St.Hudson, WI 54016
DATE:q
sTc-100
This application form_ 1: t: be completed in fuII and signed bylthe - owner ( s ) of the property
- reing'deteioft .- ;y'iroi'"rq',1'u"i.,wlll only result rn ieli_ys 6r ilin'pJrmrt r..u.n"n. , Should thrsdevelopment be iirtended for ,"="f'"-Uv ownerr/cohtractor, (spechouse), then'a second_ form sho,rd be rdtained and compreted ,,henthe propertv' is sord .and rruritt"a- tii-tiir-'Jrr"#r^;'iH the
Owner of property K €2r k kruo O ,ENXSH
Location of ' property /{N L/4 NF t/q , Section Ab , f 30 N_R /7 W
Township )*.
Mailing address / zt'4,
/ar-&771-,.\ gg/ I b
Address of site 3go Fazt/Oz-YL9-J DSubdivision name t no./
other homes on property?v es lz' No
Previous own€r of property rnAp Jq L4 L L€E SullNso t../
Total size of parcel b
Date parcel .was created e-sLs
Are all corners and rot rines ldentlflabte? _yes o
rs thls property perng deveroped f or ( spec house ) ?_yes / xo
:;tBI:-? 9 ?-.r',a pase Number qq aB recorded wtth the Resisrer
INCLUDE WITII THIS APPLICATION THE FOLLOWING:A WARRANTY DEED which incrudes a DocultENT NITHBBR, voLUHE AlrD pAGENUHBEIT & TtlE SEAL Of' TIIE REGISTER Of' DEEDS. ,In addition, acertified survey, if availabre, wourd be ;;r;;;r' so as to avoidderays of the revi.e.w-!ng process. rf tha deed descriptionreferences to a certifted 3urvey Map, the certlfled tG;;y Hapshall also be required , - ^- -Y- u-- |
PROPERTY OWNE,R CERTIFICATION
at aII statements on thls for(w
besthe
war
Dee
own
obttherec
No.
e) certify th rm are true to thet of my (our)knowledge that I we )am ( are ) the owner (s) ofproperty dbscribed In thls Inf ormatLon form , by vLrtue of aranty deed recorded n e ffice of the Co unty Register ofds as Document No.a , and that I (we) presentlythe proposed site f or the sewage dlsposal system or I (we)ained an easement, t o run the above descr lbed property,forconstruction of sald system, and the Bame has been dul Yord4ba4ed ln g4the offlce of, County RegLster o!deede as Docunen t
Oo,r-.<lLrtuL
S 9na ure o app
:
Co-appI ica t
3i 44q 7Dateof Signature
icant
Date of Signature
I
/4o {
Doc.uME|rr No WARRANTY DEED
STATE BAR OF WISCONSIN FORM 2_TE8246?98? i,, S83,^,r gg
Lyle C. Swanson, a single per5on ald Mar11 W. Juhl, asingle person
convels and r'arrante to . Robert K,...Benish..and C.aro.l..J.. .Ben.i sh,
husband and wife as mar.'ital property rith righLs.of . ...survivorship . .
txts ltacf ilsfivto 701 lEcoro'No oAr^
Part of Government Lot "4" and part of Nlll of NI,II of Section 26-30-19 describedas follows: Conunencing at the NE corner of the Nl.{l^of NEI of Section 26-30-19;^thence W 628 feet, thence S 259.5 feet; thence i 43"30'8,484 feet; thgnce S 50uE396 feet to the po'int of beginning; thence S 50"E 66 feet; thence S 54"t{ aboutl15 feet to the E shore qf Bass Lake; thence Ntlly along the E shoqe of Bass Laketo a point which is S 54"1{ of the point of beginningi thence N 54"E to the pointof beginning. The above described property is also known as Lot 2l on James and
Edna Simon's Hill Addition to Bass Lake.
TOGETHER I.JITH easements as described in Vo1."838", Page 555, Document No. 447194.
IRANSEEBs_l3lL0
the tollowing described """f ".r"t" i" . 9! 1 CiOl i
State of Wisconsin:
Th is is(is) (is not)
homestead prop€rty
Exception to *'arrantics
Easements and restrictions of record, if
Dated this. 4th day of ........
(SEAL)
(sEAL)
AUTIIENTICATION
Sig'nature (s)
authenticated this .,-.-...day of . -. - --. - ---,-.. -....-..--., 19..-. -.
TITLE: MEMBER STATE BAR OF WISCONSIN
(lf
by S 706.06, \f,is. Statr.)
THIS INSTRUMENT 'J\/AS DRAFTEO EY
.. County,
Tar Parcel No:
a
C. Swanson
AC KN Ovr' LE DG ME NT
STATE OF WISCONSIN
s5.
REGISTER'S OFFICE
sr. cRolx co., wt
Rec'd for Record
CCr 0 s 1990
M?#a
( SEAL )
(SEAL,
--.1!h .....a"v ot
the above naned
FE
any.
0ctober
. -. ...S.t.- Croitc.........-..County.
Personall!' carne before me thigOctober 'o 90
to me knorn to be the person -----.---... who executed the
foregoing instrument and acknowledge the same.
t.lilliam J. Radosevich, Attorney at Law <- )'**n. Ct 3 )*l,oe.r--.
502 Second St., Hudson, bll 54016
(Signatures may be suthenticated or acknowledged. Bothate not necessary,)
rs permanlnt. iri "ot, .i"i!"lliT;"I*;
{Jtf A, }r&S0tl re .)ImrY futtshtt ot livbonsn
lr, oflunisIm grJx16 Q -/? -R3
Notary Public ...Ml' Commission
date : .. . . . .. . . . . .. - .
'Nu€ of D.tuB rlanlDg itr.by c.p.city lhould bG typ.d or printed belos th.ir !i8iDrtur6.
WAR8,r.X-I'T DEED STATE BA8 O' W'TSCONSI:YI'ORM llo. t- 1982
'silconlin LCd Blon\ t',' lr,rll,,$aIr6. lVir.
90,, 19,