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HomeMy WebLinkAbout020-1326-10-000 t STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS-` 14 r ( ~9 SUBDIVISION / CSM# LOT ~^1 SECTION / Z T 2~ N-R ""y Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ss o t1( it ,1 NATE ' ~ ~ 4 II ri i Z ~o G A c. TKtY((' 1 !V EI ovs~ r. \ 0 ~`Y f R ~wEtl 45''± E ~I F _ /IS of II-? .c, ~a cJE L ~ Y INDICATE NORTH ARROW A Y Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. i BENCHMARK: ! GD- AT t n 2 A(FvL ALTERNATE BM: ~o/°~ NE Cyr nkt f!D : { / S 7 8 I G 7 7 i SEPTIC TAN / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Uj ~V r F Liquid Capacity: O Setback from: Well r ' tc~ House other q9 JV F~~rt~E2 6~ Novsv. Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length &pO Number of trenches Distance & Direction to nearest prop, line: 3 S' , 76 !~!m ia~ t C ~f Setback from: well: (oO_ House_ ~ Other - p~ L 1 7. ELEVATIONS f Building Sewer _ ST Inlet: 1,76 :.,c39,%SST outlet: PC inlet PC bottom Pump Off Header/Manifold Bottom of system_ 8 j. •Z S~ 15'- Existing Grade I. / 3 Final grade 9• ~ / p DATE OF INSTALLATION:: PLUMBER ON JOB: LICENSE NUMBER: - o U CJ INSPECTOR: 3/93:jt ,wisconsiwDepartment of Industry, PRIVATE SEWAGE SYSTEM County: - abor and Human Relations S INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.:, GENERAL INFORMATION 299013 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: MILLER SAM HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: Iddl-7 /Do ` oLe a _t, TANK INFORMATION ELEVATION DATA A9700331 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ° Benchmark /D J , Dosing Aeration Bldg. Sewer Holding St / Ht Inlet 0,0 '9 q, TANK SETBACK INFORMATION St/ Ht Outlet q,5' Verit ir Ito ntake ROAD Dt Inlet TANK TO P / L WELL BLDG. A Septic >lv 3 NA Dt Bottom Dosing NA Header/Man. /d,O7.` 94•~Q /8' 9 Aeration NA Dist. Pipe 9 97:8?' Holding Bot. System 2v' q17. ys' , ' PUMP/ SIPHON INFORMATION Final Grade Z1.3 i~, o /,67 Manufacturer Demand /6 3, 3 Model Number GPM TDH Lift Lricti n System TDH Ft mead Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width , Length No. O Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 60 DIMEN I N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION Type Of 41~ . Model Numer: System: (0 6 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 c Bed/ Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 12.29.19,SE,NW 838 MOON BEAM WEERT LOT 64 Plan revision required? ❑ Yes 42f No Use other side for additional information. l / I C/ ul /fl 1z. SBD-6710 (R 05/91) Date 6i pector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: x Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. 06onsin In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County 5/ than 81/2 x 11 inches in size. , 4 _ C re) • See reverse side for instructions for completing this application State Sanitary Permit Number' The information you provide may be used by other government agency programs Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. Q,38 Aooy) Beam State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property Owner Name Property Location k LLF. E_ 1/4 X1/4, S Z T , N, R E Pro rty Owne.f Mailing Address Lot Number Block Number Q si City, State Zi C de Pho a Number Subdivision Name or CSM Number 0 Q& i(M) Z14 I -r*A(At L 0 GC- :2 II. TYPE BUILDING: (check one) ❑ State Owned ❑ Ity Nearest Road ❑ Village JU -5 40~ , f 114 A y Public 1 or 2 Family Dwelling - No. of bedrooms Town OF `E !Y IGY III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) /0. aq . /9 . /Lo 93 ! 7 7 1❑ Apartment/ Condo ®IZ.. 6• t G 10 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. ❑ Reconnection of 5. ❑ Repair of an System System Tank OnlyExisting 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 121A 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 S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) r Elevation Q -750 co Feet / O 2, meet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank r 6?_ LS ❑ ❑ ❑ ❑ ❑ 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) Plumber's Signature: (No Stamps) MP/MPRSW No.: Business=Phone Num er: Plumber's Ac dress (Street, City, State, Zip Code): 10`70 J'l4 ~ d Vo .S 1 I 4P IX COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Age t Signat re (NoStam 14 roved Surcharge Fee) pp ❑ Owner Given Initial /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 x 1. A sanitary permit is valid for two O 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 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. •M fia LtT toe, f el ,fir- 4 A , L-l""- vi 1, i 1 \L f, Y ~ t ( F { 4 ZU 5 0 b I~ ww n 1 1 ' L1. _ I I d.: 0 Yr ~ Z i _ -F a: • w 0. ,1 I o w I m 44 t ° Z in Safety and Buildings Division ~~iLA■~1 SANITARY PERMIT APPLICATION Bureau of Building Water Systems 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 than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location s di /71 /L S£ 1/4 U A/4, S Z T 2 , N, R E (orI W Pro erty Owner's Mailing Address Lot Number Block Number 1City, State Zip Code Phone Number Subdivision Name or CSM Number 1115-VOI± 1(3 8,(. ) Z. 7-4 WAIR" 2 i ~ AC II. TYPE O BUILDING: (check one) ❑ State Owned ityage Nearest Road ❑ Vill E] Public 1 or 2 Family Dwelling -No. of bedrooms 3 Town OF vDSet4 moo /V 4T eA 1 L III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) c72c~-/+3 2~-/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. ❑ Reconnection of 5. ❑ Repair of an 7 System --------System Tank OnlyExisting 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 12MSeepage 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 •S d 'S& 40o O •8 98~ cn Feet a 2, Feet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper_ INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ 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) Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: /kif, 10.4 ' S_a Sao b~~9 Plumber's Address (Street, City, State, Zip Code): v,!T 9.. eJ ,6 Ieo 4o l4 v O Sc~ ) O / IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved San tary Permit Fee (Includes Groundwater ate Issued Issuing A ent Sign ture (No S ps) A roved ~~Surcharge fee) pp E] Owner Given Initial Adverse Determination z ~ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) 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 maybe 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, 608-266-3815. 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 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 8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or wii:h 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. 5 A n7 /')1 /L ~f~c 7/4,riI/F7 y r2 1 1) < F /-o7 c✓ g 3 $ !rlooN BE m Sys?E F/,- 98,ov, TAoLO-/3t~-/o/y/-`APO ~,oies_o3Soc5 5 c AL E ~ tl, ~ tOd,Op~ ~tT S s p~-zv qo' ! o d i ! (p0 -v c ~ m I N ~ rn ! f X02 2,-41 ' I i 13 3 i AjoTE' LuT TQ BE MADE ouER (Y7' fi S~ST9/0• 4,o LoT~~S ~r ~ y (03 Lc37- L14 N0 o° 2,b0 ~4L G; ~S 24 ~ a 3 2 ' z~ Asa Q U Sc ASE o v , Q ~ ~ v 2 ys ~ ~ ~ E ! I 4160 Al ~t4 #1 IRO 14 ~ M, ~ N I o m L4 rn I o j I , 41 CTI j .D ~ ~ + + IR n 41, I ~ Z , 11 I -u 1 I m I N I `z I Z I - Q L4 a - z~O µ Fn ~ m ~ O 0 0 z ~ t,j -i o r^ LA Gox Wisconsin -0epartment of Industry, SOIL AND SITE EVALUATION REPORT Page of 'Labor and'.fluman Relabons DiLision of gafety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 kit3c size. Plan must include, but S not limited to vertical and horizontal reference point M y diAdti n of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and disxdnce to,nearest oIti APPLICANT INFORMATION-PLEASElNT A ATf>1? r EVIEWED BY DATE PROPERTY OWNER: PERTY LOCATION Q .~7~1~1 MILLE, to 4 LOT S~ 114 NW 1/4,SI2 T '29 N.R j 7 E (or) W PROPERTY 0 ER':S MAILI ADDRESS L,!V # BLOCK # SUBD. NAME OR CSM # C'Qut' (N ZNA Q N Td J,ANNLk *01 CfUSTATE ~ ` f,1 ZIP ODE N CITY ❑V LLAGE OWN NEAREST ROAD ~J S40 J b~~ T c New Construction Use [ ] Residential / Number droottis Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 1Uench, ft2 Maximum design loading rate -Q _bed, gpd/1`1:20trench, gpd/ft2 Recommended infiltration surface elevation(s) Qrt TinC,t 3 0~3~ ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft 7 Y TEM IN FILL HOLDING TANK S = Suitable for system NVENTIONAL M UND I kGROUND PRESSURE T-GRADE U= Unsuitable for system S❑ U S El U PUS ❑ U I(S ❑ U S❑ U [3 S Iftru SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ;L s m CS 6.4- D RE, _26 .SY2 4 /4 /~S SCa rf~ w 102 Ground p- /CaA d SG 7 e v L4 ft. Depth to limiting factor > 7, ~a Remarks: Boring # lo-9 /ovg3 - L I ste_ rho- J a 8, 19-a 1PYk 4/4 Z - bK AF tc~ I~ 0~2 0.3,' Ground elev. $ D 4/a S S~ 4.7 16.8 ft. Depth to limiting f ct~ or ? 9.60 Remarks: CST Name: Please Print Phone: L(QGO !AQ Y ~ Sod -77 0 Address: Signature, U~~ Date: CST Number-.;;~g4 7~42 PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z, of .3 PARCEL I.D. # 1sT 64 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPO/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed nench ,n-/6 oe.3 / - L % At Sb;K A r w 7 7 ,4 S /0C YP- - S i L 1 ri sbz w - 16-2 3 Ground 1Q X-/61 AA , ? Mg SG 03 NC elev. lta ft. Depth to limiting factor >400 2 Remarks: Boring # _ L bhs~r, 0, 6's -33 '7sy 4 _ MS SG r;n Cw - D 7 C5. Ground $ 33 l6yle 3 /h5 S4 7 d 7 elev. x , 6 ft. Depth to limiting factor >,a ZS Remarks: Boring # A -J ~v.e 3 J - L 1 m sbK 13 16-31 aY4 4 - S ~L M sbK A,~ 6w - 0.2 6. O a ~ Ground $ 7, YR 4/3 M5 SG rn r- Li /o3 6 ft. 8 /6y9 4 3 M:5 SG rh 7 _ d 0 ,8 Depth to limiting factor y V .K3 Remarks: Boring # h~ x Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) . y 7 J 1s L ~ ~ ~ D D. / 1 p r- 3 rvi x ~aa p rp l / c4l W d \ m ~ 1 r' n 3 60 _ 7 w LA IV <s S (A x Elio a w 1 SECOND ADDITION TO TANNEY MIDGE SPECIAL ADDITION' LOCATED IN PART OF THE SWI/4 OF THE NWI/4, PART OF THE SEI/4 OF THE NWI/4, FART OF THE NEI/4 OF THE SWI/4, AND PART OF THE NWI/4 OF THE SWI/4, ALL IN SECTION 12, T29N, R19W, TOWN OF HUDSON, ST CROIX COUNTY, WISCONSIN; INCLUDING ALL OF LOT 40 OF THE FIRST ADD. TO TANNEY RIDGE SPECIAL ADD. I a, .x3.90a. `lam IM,e '4'02"w a,.~ x,125b g 4" S48 T 0.\ \ + i e .r\ YR ~ r 39 LOT 67 LOT 64 LOT 63 LOT 62~, -sa b OtG~~ w n r, er,,. ,o rr ? • ^ „r, r.a ' r~ e ni r.i wr n..r a 4~~. Z LOT 65 LOT 66 s \ ~R , >u r, LOT 44 - ! I a xx \ 36 ty ~-BEAM i~G•+~ar-~ sx5 LOT 45 - ao It ✓ s ~a LOT 59 LOT 60' LOT 61 LOT 46 so r,. 589*24,02_w 74.W SLOT 47 psi LOT 58 : x ; W w LOT I { o , ` ~o xrob~ev.'< ur,~].., x,x. k,1rl' l' ~ `I LoT 57 l E4EN0 \ m aa,aee ae r ~r iu...ar so rr. LOT 49.4 LOT 56 8 LOT 50 LOT 55 31 'fix„ ~ ~ ,..~w" , L j LOT 54 r LOT 51 t j ,e ,4 r • LOT 52 Ir LOT 53 „ I • „ SHEET I OF 3 SHEETS I 8 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 J a / 09// 4'4F"e--- Location of propertyS L`: 1/41/4 , Section 1 z , T24N-R_ Township V 0 A-n o xl' Mailing address - pUUS©Al W/ SsJ~ 6 Address of site _ $ do IV / t: r7 /!c 1-0,14Q Subdivision name 1-4NNC r/ & ijn,0,C - Lot no. _ Other homes on property? Yes No Previous owner of property e 4-- Total size of property ;?too f~ Total size of parcel 2,0c9 .~1 C--- Date parcel was created _ 0/- ' - 9 3 Are all corners and lot lines identifiable? C Yes No Is this property being developed for (spec house)? Yes No Volume ! and Page Number `f Sv 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. -s0 , 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. i atu of Applicant Co-Applicant -Zt - ` I Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER _!S& In l LC E7 k MAILING ADDRESS -Z-- PROPERTY ADDRESS S 3 S /j1D~/\( 1 (location of septic system) Please obtain from the Planning Dept. CITY/STATE y S 4 A! ► d7 Co PROPERTY LOCATIONS 1/4,A/ Q/ 1/4, Section 1 T_2f N-R Z W TOWN OF U n SD ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER - CERTIFIED SURVEY MAP S S/P 3 S, VOLUME 1° , PAGE? r , 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 expiration date. SIGNED: _ 1 DATE: 2- St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 r DOCUMENT NO. STATE BA F WISCONSI ~0RX 1-1903 *"1s'.•4cs "ef4"19D FOR "eCO"o1"O owre ARRANTY 0 0 ' 504855 YOL 103i cE 455 CIST.4'$ oFt-. This Deed~1. , made between %in 'N CO., Randall W. S nan and Patricia E. S nan, 1 " . Y.. X...........- ^ec'd }br Record 'c husband...and.. wi fe Grantor, ! SEP T 1993 and... Sam.E.....Mil:ter!............n..le...Person.......•-••-------------•--•---- ~t 10:45 - A.-M L Grantee, Witnesseth That the said Grantor fQr a valuable consideration...... Randall W.'Synan and Patrlcia Et. SynanCro as*°"" .o ix conveys to Grantee the following described real estate in S County, State of Wisconsin: U Tai Past Ne " The SE1/4 of NE1/4 of Section 11; the SKI/4 of NW1/4, the N1/2 of SW1/4, and the South 53 rods (874.5 feet) of the SE1/4 of NW1/4 except the East 74 feet thereof, all in Section 12; all in Y~ Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin. FF~ AND ' A parcel of land located in part of the NE1/4 of SE1/4 of Secti ntn 11, Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin further described as follows: Commencing at the E1/4 corner of said Section 11; thence S89 30200"W, along the North line of the SE1/4 of said Section, 1212.32 feet to the point ' of .,eginning; thence continuing S89 30100"W, along said North line, 66.00 feet; thence S00 281030E, 500.00 feet; thence N89 30100"E, along the North line of Certified Survey Map filed in Vol. "30, Page 722, 38.08 feet; thence N00 11'33"W, 150.00 feet; thence N03 58134"E, 351.07 feet to the point of beginning. This A-.JXkQ-t homestead property. r (is) (is not) Together with all and singular the hereditaments and appurtenances tiuereunto belonging; And.....Raziaa.xl...FT.~.... ynai}.. and_•Patr_icia.. E-...Synan warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights-of-way of record, if any. and will warrant and defend the same. . 19..9.. i Dated this day of ....Ali$LtS...................................... . c ..(SEAL) MA&iI4O!i.t✓ . ...........................(SEAL) ' Randall W. SYnan Patricia E. Synan (SEAL) (SEAL) 'J ; • AUTHIIINTICATION ACSNOWLSDOURNT Sl ture a STATE OF WISCONSIN i ---~......t-,.... St. Croix j authenticated this day of..... » 19 .»...p»~..-.py~case bdm me '_•.......day of •1 f August ~ 19........ the above named iI . - Randall fol. 3xrian, i ( TITLE: MEMBER STATE BAR OF WISCONSIN S nan - - » - (If not, authorised ' b 7 4 708.00. Wis State ) to me known to be the person 1..... Nom: he I I eoatj/Jt