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(D a EL IL L CL • m a a~ m y d d c rr`1~V E _ w 3= Y I 0 U) 0 U) • AS BUILT SANITARY SYSTEM REPORT w~NER a::~4~ loij TOWNSHIP EC. TN, R /.~W :O.'ADDRES3'` ST. CROIX COUNTY, WISCONS N. °~BDIVISION LOT LOT SIZE PLAN VIEW .Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1PTIC TANK(S)_ MFGR. CONCRETE STEEL NO. of rings on cover Depth DRY WELL 'ENCHES NO. ofwidth ,:~F- length____ef~ area D D no. of lines width length area depth toD of pipe GREGATE RK RATE AREA REQUIRED 7 5 AREA AS BUILT y asciaimer: The inspection of this system by St. Croix County does not imply complete mpliance.with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no liability for ,stem operation. However, if failure is noted the County will make every effort to termine cause of failure. :EASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYST `INSPECTOR DATED IV /7/1~' PLUMBER ON JOB LICENSE NUMBER I " 'REPORT Or I1]SPECTION--I:dDIVIDUAL SEWAGE DISPOSAL SYSTEM Sanitary Pernit A<~ State Septic n z T61•1I1SHIP St. Croi;; Csunty SEPTIC TAM" Size gallons. `umber of Compartments Distance From: Tell ~ft. 12% or greater slope it Building' % ft. Wetlands f: Iiighwater ft. DISPOSAL SYSTE.1 iTile Field or Seepage Pit(s) Distance From: Well ft. 12%.or greater slope i ft Building ft. Wetlands f 7. FIELD Hiphwater ft. Total length of lines /(Q ft. Number of lines Length of each line €t. Distance between lines/" ft. Width of the 1~0 trench eft. Total absorption area sq• ft. Depth o£ rock below rile _LL-in. Depth of rock over tile in. Cover -nver.rock. Depth of tile below grade in. slope of trench in ner 100 ft. Depth to Bedrock ft. Depth to ground water ft. PITS . :lumber of pits 0 sid diame r ft. Depth below inlet ft. Gravel a-roun j it • s no, Total absorption area sq . ft. .Square feet of seepage trench bottom area required Square feet of Aeepage nit a ea required A'A Inspected by: t" al~~t Approved Date 197 -rL • Re i er_t-P_ ~ _ EH 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 0, M = !REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: Sectior~~., T&N, RL~ (or( Township or Ma~ty (1, 1,=n into d Lot No. , olleeel~-Nac -,/~}Gr~5 Subdivision Name County fp .r Owner's Name: G /CL C l Mailing Address: TYPE OF OCCUPANCY: Residence y No. of Bedrooms -3 Other EFFLUENT DISPOSAL SYSTEM: NEW V ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS ER OL TION TESTS SOIL MAP SHEET SOIL TYPE A It 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 AFTER INTERVAL MIN/IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MI P ' d 0 7 * 3Q ty7lI P- a 3y e or ~/AA I X16 SCI P3 ore le, D44-q aq- dl 1 d I SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) Bj- PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and 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 slo Vo' f tN I-EE PLB6.7 State and County State Permit # Permit Application County Perm' • for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: r) UACX-d ' ,'t B. LOCAT ON: ` jyV V Y4, Section T,--~C N, R~ E (or) (W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village ~,Aved Township Lie-" W"--c'J C. PE OF OCCUP CY: Commercial *Industrial *Other (specify) *Variance Single family L/- Duplex No. of Bedrooms No. of Persons D. TYPE OF APPLIANCES: Dishwasher ✓YES NO Food Waste Grinder YES iNO # of Bathrooms-- Automatic Washer ✓YES NO Other (specify) E. SEPTIC TANK CAPACITY Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation ✓ Addition _ Replacement _ Prefab Concrete t/ *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1)-~a 2)~3) _,,?,/Total Absorb Area sq. ft. VOW Newer Addition Replacement *Fill System IV Seepage Trench: No. Lin,. Feet /44p Width Depth Tile Depth t`n No. of Trenches Seepage Bed: Length Width Depth Tile Depth No. of Lines Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land Distance from critical slope 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 Ce ified Soil Tester, NAME ,,,In C Le rerl'Z- C.S.T. # J5 - /Sc- 2 and other information obtained fro (owner/builder). / Plumber's Signature' 'ZL MP/MPRSW# Phone #fo~~~,p Plumber's Address PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with including well). 't X ~ ko~5~. 3 i3~ r'~ I a~ 7 f f . Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 299074 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: BEST, GLADYS GLENWOOD CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 016-1054-30-000 TANK INFORMATION ELEVATION DATA 1 ' TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing J Bldg. Sewer Aeration Holding St/ Ht Inlet -1 TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake 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 Loss ead F Forcemain Length Dia. Fi Dist. To Weil SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS LEACHING Manu acturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM INFORMATION TypeO CHAMBER Model 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: GLENWOOD ~`r.30.15.380A,SW,SW 1435 320TH STREET Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: !I v shinlgton Ave sion SANITARY PERMIT APPLICATION 201eE. W and D Visconsin Department of Commerce 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 than 8 1/2 x 11 inches in size. 0 / • See reverse side for instructions for completing this application State Sanitary Permit Number ❑ Check if revision to pre sous application The information you provide may be used by other government agency programs 90~ (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name~ Property 4&I Location 5 T , N, R ((77 Oj Property Owner's Mailing ddress Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number G we da I O ( 7/-S') 11. TYPE F BUILDING: (check one) ❑ State Owned City Nearest Road Village Public [I 1 or 2 Family Dwelling - No. of bedrooms _,2- Town OF Gteivw0o S7` 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) L1157 /0/- 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT:.(Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. X Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate_ 6. System Elev. 7. Final Grade Req fired sq. ft.) Propo ed ft.) (Gals/day/sq. ft.) (Min./inch) CC~~ t7 Elevation ~'O / Feet Feet Capacity TANK Ca in allos Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank ODD /d GfJ f ❑ ❑ ❑ ❑ ❑ 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 Name: (Print) Plum 's Signature:: o Stamps) MP/Iii No.: Business Phone Number: Plum er's A(dress (Street, City, State, Zip~C de o o d /V " v/ 3 / w IX. COUNTY/ DEPARTMENT S ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing ent Sig ture (No am ) (Approved Owner Given initial 60 Surcharge Fee) q Adverse Determination / , 7 X. CONDITIONS OF APP OVAL / E ONS F R DISAP RRO~VA11L:, SOD-6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & 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 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 on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on systeTri 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. o Le w o .2 f F t--- ~ - it - v RIM o~ o. - - 14 o ---1- - F- F- Witconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must Count include, but not limited to: vertical and horizontal reference point (BM), direction and O percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location O Govt. Lot W 1/4s',4/ 1/4,S;, T3a ,N,R 3W) W Property Own s Mailing Address Lot # Block# Subd. Name or CSM# 0 '74- - - City State Zip Code Phone Number Nearest Road kjo d 6;t -y 1 ~ O/.7 ( /,o- )c2 &r ❑ City ❑ Village Town New Construction Use: Residential / Number of bedrooms 2 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 4Lf-'67 gpd Recommended design loading rate --e~bed, gpd/ft2____:~trench, gpd/ft2 Absorption area required bed, ft2 9,00 trench,, f7t2 Maximum design loading rate bed, gpd/ft2_4 _f _trench, gpd/ft2 Recommended infiltration surface elevation(s) / d f Z' & M_ft (as referred to site plan benchmark) Additional design/site considerations O F S ~l 4 Jr'V S7B/~/ Parent material e q-4 A l' l A L t z L L Flood plain elevation, if applicable It S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system IXS ❑ U As ❑ u ®S ❑ U ® S ❑ U ❑ S IN U ❑ S LV u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground elev. 9..7 ft Depth to limiting factor XZJ-in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: CST Name" (Please ePrint)) Signature Telephone No. 0&=.zds (9' r Address Date CST Number is o/ 9 /76 w ~7a 6;1 eh• v zlc /'7` k, SOIL DESCRIPTION REPORT PROPERTY OWNER Page Of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Structure 2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground elev. ft. Depth to limiting factor in. ' Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) m o - ~ ~ - f I I - - 1 v it 1` I - _ - P4- 1 - - _ - i 11 - - Y - I +i] 1 r ! r i i f ! I i r , I I ~ ~ I I ~ ~ I ~ I ~ I I ' I I I i i ---I I. i _ r L~ I i _ i - - 17- ~ I IF-T I j ~ I I - ST. CROIX COUNTY WISCONSIN ZONING OFFICE 1 M N II N N ■ ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 AFFIDAVIT OF SYSTEM REJUVENATION Property owner: ~91AOI V,S X?e S'114 Address: 0,4 e~co0 d ci7`~~yoi ~ Day time phone: (,7/ 3 7) d?~~-yy 9~ Parcel I. D. # O//- &EI Legal Description of property: ; $W sec.,2~f T.2N. , R. ~ W. , Tn. of G~EN~vOO al , St. Croix County, WI As owner of the above described property, I acknowledge that the septic system serving this residence (is/ Wit) undersized by current code standards. I understand that the issuance of a sanitary permit to allow the attempted rejuvenation of the septic system does not imply that the system meets current code sizing requirements, nor does it imply that the proposed procedure will be successful. I also acknowledge that I will make this information available to any future parties interested in purchasing this property. signature: Date:_ 21,131 2 5/97 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 residence located at: Gam;,41 S ction T2 a_N, R_f~` W, Town of 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: IfZJ7- Did flow back occur from absorption system? Yes X No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: ~4~'a 4/jL Construction: Prefab Concrete X Steel Other Manufacturer: (If known) : Age of Tank (If known): e. 1"rh (Signature) (Name) Please print p.Z,(.( mbeg Ali 'Es d (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 Signature P/~ '5-~6 O ok, R. R. No. 6 x Menomonie. Wis. 54751 8 urvevar.% . E~.ctroni5'~isbnai Meswdng (715) - 235 - 3656 PLAT OF:; SURVEY tL FN : AM E:," . Mr, . _Loul s Goetkln D Glenwood Citq', Wiac. 54,013 SHEET 1 of 2 IrkV It $ W , DESCRIPTION: See Sheet 2' of 2 ru a D~ A y 7 A F A 77 4' F 0,15 - •p x74 'J"'`~Z{ r ~ Y ~ ' G~2 5 Q' t 2. \ y' .-ity 1 4 t~ o h I& N t ~+J o O ' ~f. 1. • :e M LEGEND'. N FEET 0 - Iron Pipe, i`A_ ; y ~ P.0.8. Point of BObi6 -7-6 MOB P. I vl S T C - loo 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 G~ /}~S/ •S C~eS Location of property.57~1/401/4, Section ,T,&_N-R_Z!r W Township ALP tt/rc~ D p~ Mailing address 0,4 /f r¢ ~'~~vwood 1~v Zvi .Syo/3 Address of site. G/ /o;~/- e%V6cva a C/ G~ /~Y Lri/.S<fo%~ Subdivision name Lot no. Other homes on property? Yes XNo 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 house)? Yes _X_No Volume .sd gland 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 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 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. p 7 , and that I (we) presently YZ own the proposed site f 6r 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 ffice of the County Register of Deeds as Document No. the 10 Signature of Applicant Co-Applicant Date Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/MWW e2/ldV MAILING ADDRESS Jr0 O/! Sf' PROPERTY ADDRESS d fi7 , .S (location of septic system) Please obtain from the Planning Dept. CITY/STATE G~ E tSILrJ D D a✓ /~c/ V PROPERTY LOCATION SA/ 1/4, YW 1/4, Section, T2_N-R W TOWN OF G~ P/S/tti D O d ST. CROIX COUNTY, WI SUBDIVISION 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 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 year a piration date. SIGNED: DATE: 2A-;;,,3 / z "7 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 DOCUMENT NO. STATE BAR OF WISCONSIN-FO1,01 a r 37Q~ © QUIT CLAIM DEED ' ~~THIS SPACE RESERVED FO RDING DATA VOL 568 'Pa rE 2_0.8 Claribel Misslin REGISTERS OFFICE BY THIS DEED, ST. CROIX CO r# VMS Grantor-, Roc'd. for Record Mris_ 17th quit-claims to Gladys Best day of Jain. A.D. 19 78 o 2:00 P. , M. One and no/100ths ($1.00) 10 Grantee for a valuable consideration DOllC Register cf Deeds the following described real estate in St_ 'Croix County, State of Wisconsin: H RETURN TO Richard P. Rivard Glenwood City, A 54013 Tax Key H This is not homestead property. Part of the Southeast Quarter (SEl4) of the Southeast Quarter (SEl-4), of Section 23, Township 30 North, Range 15 West and part of the Southwest Quarter (SWk) of the Southwest Quarter (SW%) of Section 24, Township 30 North, Range 15 West, described as follows: Commencing at the Northwest corner of the Southwest Quarter (SA) of the Southwest Quarter Mk) of Section 24, Township 30 North, Range 15 West for a point of beginning of the parcel herein described: thence on an assumed bearing of South 84° W,09" East, along the North line of the Southwest Quarter (SA) of the Southwest Quarter (SWk) of said Section 24, 182.91 feet to an iron pipe; thence South 09° 38' 27" West, 376.85 feet to an iron pipe; thence North 72° 40' 08" West, 104.39 feet to an iron pipe on the West line of said Southwest Quarter Mk) of Southwest Quarter M%); thence continuing North 720 40' 08" West, 218,.54 feet to the center line of the town road; thence along a curved center line concave to the Northwest to a point in the center line of said township road, said curved center line having a chord bearing of North 21° 56' 47" East, and a chord distance of 316.17 feet; thence South 84° 58' 09" East; along the North line of said Southwest Quarter (SWk) of Southwest Quarter (SA-,), 90.80 feet to the point of beginning. Containing 2.4 acres. Executed at GlenwOO(l City, Wisconsin _ this 5th day of January '1978 SIGNED AND SEALED IN PRESENCE OF j,r~1').1.~ SF EP, (SEAL) Claribel Misslin (SEAL) (SEAL) (SEAL) Signatures of Claribel Misslin ' i 77. authenticated this 5th day of Janu 19. Richard P. Rivard Title: Member State Bar of Wisconsin or Other Party Authorized under Sec. 706.06 viz. 2ND STORY FINISHED BY OTHERS Iy 17 SHED DORMER u. C) I _ fir C OPEN TO I~ I p BEDROOM #3 BELOW I ( BEDROOM 02 ' m rn C ;I r ~ N C7 0 o N 4 m O~ A rn - I m 10 o ;I, • F0 0 DINING i KITCHEN I ? IOOYW Ia OPEN TO i c.w 2ND FLOOR BEDROOM $1 i i ur LIVING ROOM i .a _ I ST. CROIX COUNTY WISCONSII4 _ ZONING OFFICE N NNNNf ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 - (715) 386-4680 AFFIDAVIT OF RE-CONNECTION Property Owner: • Address : O/ 17 Day time phone : (265-) Parcel I. D. # o/p/_ Legal Description of property:'/. Sec., T.N. R. Z,f W. , Tn. of G~ e~t~w • St. Croix County, WI As owner of the above described property, I acknowledge that the septic system serving this proposed ,3 bedroom residence is undersized by current code standards, but otherwise meets all requirements of State Statutes, Wisconsin Administrative Code and St. Croix County Zoning Ordinances. I understand that the issuance of a sanitary permit to allow the re-connection of the existing system does not imply that the system will function properly after it is placed in service. I also acknowledge that I will inform any future parties interested in purchasing this property that this permit was issued for the re- connection of an existing septic system and not for the installation of a new system. Si~~~ / T 111 Signature: _ ;,y7 Date: Z1NGpFFICE ,C()