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HomeMy WebLinkAbout012-1010-50-000 h 03 60 N ~ I! c I a 0. 0 b O N ~ I d •O I ~ I 0) A I Zt o I v I z O Z O C C U. C EO I O Q V I M CD z w z o it g € z m U)i ! a m o I o z c d `z :!t ° c z E z v Cl) N c O .C N lU I ydy y y ~ C I a _ O O z m z O !I'n z N ° o y c E c N N _ > I co m a R b U c ,n a v a m o n o e c a „ .0 N o Ev~rmrvrr> j o ,moo z> 3 3 a s z o IL CL CL IL z I n y U) J c) rn rn } I _ O LO ~ ~ M ~ ago N O O N E I C O r p a p ml C d N I M 'p Q } CD f6 CO 0 rn O N N C 00 3 d a c `O E °o co ~ ~ a"i d a~ v nom. I T'O Ir pQj C ~ N C C1 ~ 'O N N V O M. C C. C N G~ y m ) N) y e- N W W c0 I A a ! O C ~ 4) 'ryV) ~ N M = y CD O 2:3 O O U • O M W ! LL N O z E U') v~ `m j € a xt a C a i E ` 'c c ~1 A c0 ao jo;aici ~ STC - 10 4 3 AS BUILT SANITARY-,FYSTEM REPORT RECEIVED ti OWNER RO-qex- 4., NOV'O "t IJJ }p~p7 4ADDRESS ST CMX SUBDIVISION / CSM# W~ ak..~ 0 laA,, LOT # SECTION T .30 N-R-O-W, Town o f A" Y- i n 4 t r` k& ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 3 qb q~ IV~ s < ~r e ~el INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: 4 o , ALTERNATE BM: A r f G/l L.s7" ~ r h ~ SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manu ctu r:_~ Liquid Capacity: Setback from: Well House 4LS t Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: 1s Lengthy Number of trenches_ Distance & Direction to nearest prop, line: a7 e-"oSetback from: well: House_ Other ELEVATIONS Building Sewer ST Inlet:-Z<( ST outlet: `09 PC inlet PC bottom Pump Off Header/Manifold Bottom of system q(p,~ Existing Grade-21. Final grade /co,j DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: 7S ~o~ INSPECTOR: F16W f je1/' 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor agdHuman Relations INSPECTION REPORT ST. CROIX .Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 299009 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: FERGUSON, ROGER ERIN PRAIRIE CST BM Elev.: Insp. BM Elev.: BM Description: L Parcel Tax -1010-50-000 JO~ o at~lq ; 0 -C 0122- O TANK INFORMATION ELEVATION DATA A9700327 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic yJ, go l Do O Benchma q q lD~9y /DU Dosing Aeration Bldg. Sewer Yl0. Holding St/ Ht Inlet 9Ff 100.0t TANK SETBACK INFORMATION St/ Ht Outlet 5•~3` q ' Vent TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet Air Septic +.5-0 -I'100 5-S NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe 1,19 7•,y 97, ' o f Holding Bot. System Zo °PG.771 PUMP/ SIPHON INFORMATION Final Grade `l 2-L /-00.77" Manufacturer Demand a -o /00. 3 Model Number GPM °`LotL~ Z • (03 E~2 If TDH Lift Friction S stem TDH Ft Forcemain Length ia. Dist. To Well SOIL ABSORPTION SY TEM QFS~ MD.fT /I BENCH Width Length No-6tTTFn fees PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I N 12 7 DIMENSIONS LEACHING Manu actu r: SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM INFORMATION Type O CHAMBER Mode er: Syste .mlew- A 3e> `4'60 100 OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length 72 Dia. Y Spacing lS/ -ter 72- SOIL COVER x Pressure Systems Only x M and Or At-Grade Systems Only Depth Over Depth Over xx pth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges T it ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc. LOCATION: ERIN PRAIRIE 03.30.17.39A 1763 CNTY RD "T" LOT 1 Plan revision required? ❑ Yes ❑ No / Use other side for additional information. 1,r) 97 I I Fi47~1 SBD-6710 (R 05/91) Date Inspector Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH y SANITARY PERMIT NUMBER: - SANITARY PERMIT APPLICATION 20 eE and Buildings Division P.O. Box 7969 %'LconWn In accord with I LHR 83.05, Wis. Adm. Code Department of Commerce Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. ST , C - e • !C • See reverse side for instructions for completing this application State Sanitary Permit N ber The information you provide may be used b other government agency Ov Y Y Y programs ❑ Ch k if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Prope Owner Name Property Location SQ1/4 A W 1/4, S 3 T 30 , N, R 17 4111111(or) W Property (Kvner's Mailing A ress Lot Number Block Number City,,State Zip Code Phone Number Subdivision Name or CSM N ber 41042 t,3.c s SAO if ( 7/5-) &#A - ftjy o 11. TYPE F BUILDING:, (check one) ❑ State Owned ❑ itNearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms --3 Town OF ►~4 1'4ltiyfr T 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs ll ❑ 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 ANew 2. E] Replacement 3. ❑ Replacement of 4. E] Reconnection of 5. E] 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 SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade t~ Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) q Elevation 7SD v'D `~rQD $ ah" ~~+rl Feet / Feet VII. TANK Cap city gallons Total # of Prefab. Site Fiber- Exper. INFORMATION g Manufacturer Manufacturer's Name Con- steel glass Plastic App Gallons Tanks Concrete New Existing structed Tanks Tanks Septic Tank or Holding Tank f 1 (Q4,q~~ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Na" (Print) Plumber's Sign tur • (N Stamps) /MPRSW No.: Business Phone Number: 4l , ~o "A-L-V4,3 l SG ~t S'-BSI L St3.S' co I Plumber's Ac dress (Street, Cit State, Zip Code): 194ld~ pe,J Gc) d IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (InciudesGroundwater at Issued Issuing Agent Signature (No Stamps) Approved Surcharge Fee) ❑ Owner Given Initial 41 Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R.11/96) DISTRIBUTION: original to county. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS r 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration (late, and at a 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 properly maintained. The septic tank(s) must be pumped by a 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 and Buildings Division, 608-266-3151. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. 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 online A. Complete line E, 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 for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/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. VIII. 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 8 1/2 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; wells; 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 sizing 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 contamination investigations and establishment of standards. I I IR 1i l Al 1 SW- t I 1 - , - } + - - ~ , _ ! - t -1 - ; - _ _ , _ ! ; _ _ Imo. h ► t:1 ~`l►`'~_- t-- ' T I 6 i` I I I I I I ( 07 bot&l t16, AO - I I I ~ ~ i II 1~ - - I --j. i~ L I I I I I , j ~ I , i //~fLI l 1 T I I II - - 1 i I I I I I I t i 1 i i , i I i I I ' i I 1 I I ~ I l I I i I 1 . 1 1 I I 1 I I t ~ i ~ 1 ~ I I I r ~ ~ ~ 1 r I I i I f i ~ I 1 i- I - ~ I ~ I I I ' j' I I I I I I{ I I! ' ~ _ _ _ II I j I - ` - I 1 I ~ I I 1 I ~ ~ ~ I ~ ' i 1 I - I i ~ i I I ~ 1 I , j . i ~ ~ I I - ~ I I I I I I I I I t - - - .17 I I I V l ~ ' ~ ' --I 1 j E _ ~!t1_ ~ _ I ~ - 1 i ~ -•--f ~ 1 I O'l I I I ~ { I a ~ r- - I I I I I I -a - I I I I ~ ~ I i I I ~ ~ I I ' 1 66, i ; I I I ~ I I ~ - I; I I II I t' t I I ' i- I I I I _ . r-- I - I ~ ~ ill I I ~ - - - i - ~ - - - - I I ~ ~ I I ~ I I ~ ; I f I I I I ' I 1 I I I I I I -I I i - I I I I ; I I I I I , I , , - 1 I ; I I I I I ~ I i ~ I I I I I f 1 i ~ { ; I I , I I I t ; , _ _ _I i _ i I i 1 ; ; I I' r i I ! I I _ ~ I 7 ; I I ' I L I I_ _ ~ 1-. f 4 1 I I II F- 4- I I I I I i l j~ I t I I l i I I I f I T- { ~fLr ys °'y • 33g 5. C7r-~^~- PAGE OF Nr~ Jec~lon O~ Sy51'cr►1 U-0 Fresh Air Well; And Observation Pipe Approved Vent Cap mllntmum 12' Above Final Grade 20- 42' Above Pipe _4' Co s,1 Iron To Flnot Grade Vent PIPS marsh May Ot Synlhelk Covering I ula. 2' Agpreg'ols Over Plpe DliPIP:1lon o 0 0 0 - Tea a pipe 6' Aggregate o Perlorated Plpe 0410w Bene oIA Plpe o Coupilny Terminallag At Bottom Of System t7 / Pru(~vseD ~'I~~~I: ``9rr%c1< ~~cJ .T son • .SOIL FILL DISTKI5UTIOU PIPE APPROVED G~U'J CTIC COVER cs op. 4" OF STRAW 2" o A~GRt:GATE ; OK MARSU NA`j- 1 10 ) 0F- ?_-21/Z AGGFCEGATE. ELEV. 0F.~ FEET_ DIS-rRI5'JTI0Q PIPE TO 51: AT LEAST _ay IN•CHE-S BELOW ORIGIIJAL GRADE AIJU AT LEASTLO 11JCHES BUT..l,10 MOKC TRAM 42 MIMS 13ELOW FINAL GRADE MIMUM WN OF EXCAVAT100 FROM .0,16WAI (RADF.WILL BE IIJCHES JAIKIMUlM 9EPrj{ of EACAVATImN 'FROM. OlkI4IaAL GROE WILL BE 3G INCHES SIGIJED: LIC CU SE UUMBE R' DATE: "I~ _ / 7 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS 1 / MADISON, WI 53707 (H63.0911) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/1~tbtr LOT NO.: J BLK. NO, SUBDIVISION NAME: SW 14W 1/4 3 /T30 N/R.7xfQor) W Erin Prarie 1 n /,q Willow RiverView COUNTY: OWNER'S 9NAME: MAILING ADDRESS: St. Croix David B. Olson R.R.0, New Richmond, Wi. 54017 USE DATES OBSERVATIONS MADE ®Residence NO. BEDRMS.: COMMERCIAL DESCRIPTION: R~Vew ❑Replace (PROFILE DES RIPTIONS: PERCOLATION TESTS: 3 n/a 4_4_88 n /a RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) QS DU &S❑U )gS ~U ❑ S 1U ❑ S @9 conventional If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate: C1aSS 2 Floodplain, indicate Floodplain elevation: n/a PROFILE DESCRIPTIONS page 29 SHC2 BORING DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 6.84 100.11 none >6.84 .75bl.1. 1.17bn.sil. 1.42bn.s.l. 3.50bn.c.s.&gr. B- 2 7.08 100.40 none >7.08 1.00bl.1. 1.00bn.sil. 1.25bn.s.1. 3.83bn.c.s.&gr. B. 3 6.83 100.12 none >6.83 1.00b1.1. ,75bn.sil. .83bn.s.l. 4.25bn.c.s.&gr. B_ 4 6.67 99.83 none >6.67 .75bl.1. 1.00bn.sil. 1.00bn.s.l. 3.92bn.c.s.&gr. B- 5 6.75 99.68 none >6.75 1.00bl.1. .42bn.sil. .58bn.s.1. 4.75bn.c.s.~rgr. FB-T TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PER ROD 3 PER INCH P- P- P-See design rate P-_ P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 96.90 i ~ i E s ~ e I: 2 'j )6W) 47 l z / ~r 17 ~bt ►3, - ; E= _ _ MAY t 2 t~88 INSTRUCTIONS FOR COMPLETING FORM 11 - SRI - To be a complete and accurate soil test, your reiaort. must include; 1. Complete legal description; 2. The use section must Cl I c whe this is a or commercial I 3, MAXIMUM number ,ns or corer use plane h. this a nr~- or replay tt suit- it ig boxes. A IS SUITABLE FOR A HOLDING TANK ONLY IF ALL YSTEMS !LED OUT I- ~:ED ON SO! _ `ONDITIONS; G e o4vn here for uiritin ~'escriptions and c, --n1 plot plan; 7. .ately locating y{ ;;,cations. D-rruing w ferred. A rr i; Kcal elevatior point ar own, Imanent; 9 to dates, names, es, flood plain data, per = it exemp- 10 era, elevation} n, t apply, . in ghs e box; 11. > a~' ss an<` tificat 12 required. ALL SOIL TEE ._!ST NTH THE Lt /WTHORITY V%1, YS OF COMPLETION, TIONS FOR CERTIFIE ~ L TESL`-; Textures C St - 1,P) Lied; roi:7 10"1 - Sandstone gr - der 3") L : estone _ HC Ci P Mat" n - 87 Rn 13*si. 131 k C; s - _ G y Y _ L-)am R L in Clay •v% sis - Clay - '4 Po i ri t 'VIIYt'rF ' { V-ki bl/ UI AQ0 LI- V-1 11111 I1J JVV 4V0 1 I'lL'u1 J1L'1\ Vl L1:GL Y JUG 433597 I- i ~ it• a 6 4b t:O1° 52 5 4 It 1Z ~ west line of the NN w, zn 00 rn r A o ~ - J Q1 C. THTIT" m rP ° . -i ti - - = w n cn O (U -11 C., M 11W C) ~m - - 66.03' y rn P. t:zl s 3 G) Co cn ty n . ~ 0 w rr c Li 0 U1 z N Ln ° rO le O F{ rll F-, Bearings are referenced to the t7 A) U) I P tl N. N _ west line of the NO assumed to bear N01o5215411E. N O Fh o • G~ N ~ w m CO ° o ° n 2 ril x a.- G) n N O :rk- r d o small tract a X 0 v x F•{~ a v n n F Sol.05215411W O C: (D Iv.- c 'n .`TC rn ~ L7 II 307.50' rF r: C, C n.. n o 0 r- r•- , cn c0 O I O - F. LO r to a co 0 O !7 rn J7 O O ~-3 rn rn ~ j x U .J tr' I ~ - ~ r L7 O r :J I f- ~ T n'1 F•' C 4t I O _ r- w ~ N W N N cn FJ w ~ u' G, J 0o LD CO N m N I Ln x~. 3 CI) 0 N rb !t ° w I~ Ln p1 t u CY) v ♦ n o x o T f irr w CD rZ v - ~f Ln J S ~ A N on CO v ~.n A~ Sll 1 © l7 n ~ IV 1'J 0) W V ~ 1 J l 1 w C-1 C m dd 2 I 4-1 ~-I U4/ Ll/ 21 f IWO 11-V4 kAA 110 060 4U61 lCir,b1J1L'tUl LGL'uJ , i • r a SURVEYOR'S CERTIFICATE I, Allen C. Nyhagen, registered Wisconsin Land Surveyor, do hereby certify that by the direction of David Olson, I have surveyed, described and mapped the land parcel which is represented by this Certified Survey Leap; that the exterior boundary of the land parcel surveyed and mapped is described as follows: i A'. parc,V.L; of land. located in -.part of the SW]of the NW4 of Section 3, T30N, R17W, Town of yrin.Prairie, St. Croix County, Wisconsin; further described as follows: Commencing at the Wk corner of said Section 3; thence NOlo52'S4"E along the west line of said NA, 204,55 feet; thence S89050'14"E 49.52 feet to the easterly right- of-way of C.T,H "T" and the point of beginning of this description; thence continuing S8905'0'14"E along the northerly right-of-way of the Soo Line Railroad, 921.36 feet; thence N05015'09"E 542.26 feet; thence S76020'15"W' 697.85 feet; thence S01052'54"W 307,:=50 feet; thence N89050'14"W 280.62 feet to said-easterly right-of--way of C.T.H "T"; thence S01052'54"W along said right- of way, 6;,6.03.-feet to the.point of beginning. Together with and subject to a 66 foot wide Private Road Easement as shown on this map and subject to all other easements of record: That this Certified Survey Map is a correct representation to scale of the exterior boundary surveyed and described; that I have fully complied with the current provisions of Chapter 236.34 of the Wisconsin Statutes and the Land Subdivision Ordinance of the County of St. Croix in surveying and'mapping same. r r~LLE~S fi„ GEN ~s 5-J 3fl?' N6.,tb 02- r~ r Allen C. Nyhage J U `•4 VOLUME 7 PAGE 2004 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERBUYER MAILING ADDRESS' PROPERTY ADDRESS to ` (location of septic system) lease obtain from the Planning Dept. CITY/STATE ~iaG t,✓. PROPERTY LOCATION ,5 W 1/4, AIU) 1/4, Section s T_3 6N-R___LZ_W , TOWN OF r i +n `Qh G 1 r ST. CROIX COUNTY, WI p ~ SUBDIVISION t j ~~tr~ tC t s¢.r U 1~ LOT NUMBER CERTIFIED SURVEY MAP , VOLUME PAGE , 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 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 GO% 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 year expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 ' 11/93 4 • 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 housej, 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_ R 0q.&61- r► K S p I' `11 Location of propertySW _1/4 N _1/4, Section _,j,T 30 N-RAW Township_~ r~ h R, ow- ow- Mailing address RA ar Address of site L7(.3 Subdivision name ( _~1..•+~i Rs.,u O VA,.> Lot no. Other homes on property? _Yes No Previous owner of property-- Da,%,: A y h Total size of property S, Sri c re.«s Total size of parcel Date parcel was created re Are allcorners.and lot lines identifiable? Yes No. Is this property being. developed for' ('spec house).? Yes _,AC No volume /rya and Page Number 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 avid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER.CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner (s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as,Document No. 5S.%. 5 , 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. Si tur pplicant Co- licant Date of Signature Date of Sig at e 55968) STATE BAR Of WISCONSIN P : bYV 2 - 1982 WARRANTY DEED p ' DOCUMENT NO. R~ TZ^'3 C7..:E B. David Olson and Judith C Olson. husband and wife S Gi0iX C3, V4 1" ro to ibalal MAY, 2i 1997 conveys and warrants to Roger A. FerStson and Jessica L 11 :30 A M FergygOn. hijahand and ratfo as aurvivnrship im-1-11 o j-k Property - f sgasr of Gam INIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS 2 a. r. the following described real estate in St. Croix County, State of Wisconsin: F/✓Q Part of SW 1/4 of NW 1,4 of Section 3-30-17 described as follows: Lot 1 of Certified Survey Map filed July, 28, 1988 in Vol. "7", page 2004, Doc. No. 439897. 012-1010-50` i' PARCEL IDENTIFICATION NUMBER It. A4PFER i i This is not homestead property (is not) Exception to warranties: Subject to all easements, restrictions and covenants of record. Dated tfys 19th day of _ may AD. I9--9L7_. . (SEAL)<< : (SEAL) • B. David Olson Judith C. Olson - (SEAL) (SEAL) x AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, St Croix County authentica,ed this day of 19_ Personally came before the this =9th day of May 19 97 . the above named B. David Olson b Judith C. Olson TITLE: MEMBER STATE BAR OF WISCONSIN ~F (If not. r4fts- authorized by §706.06, Wis. Stats-) to me known to be the person 8 ~ tf erne. uted iieT1QJrWg tnst e t and acknowled the si ~ _ ' THIS INSTRUMENT WAS DRAFTED BY =/Z- REINSTRA b VAN DYR, ;,.C. 4 Coe -281 San James G. Hee~ New Richmond, Wisconsin 54017 ,y pUhl;c St -Croi Cuunta-Vris.