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HomeMy WebLinkAbout020-1313-20-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER z12& L- ADDRESS ,i2®G SUBDIVISION / CSM# LOT # Z SECTION 2 2 T_f N-R_,ZfW, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW k VERYTHING WITHIN 100 FEET OF SYSTEM Briuvwv 14y INS ref L 414 /"S~; fw ~~t CONNfY I S W tp►"Ntr 70 X27 ~ ~d war! y~~ ~ f~'~t d INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ,rr .e /Od. ALTERNATE BM:~,~~ SEPTIC TANK PUMP -GHAMB-BR Manufacturer: Liquid Capacity: Ad0 e-3 Setback from: Well House ,p' Other Pump: Manufacturer Model Size Float seperation Gallon Alarm Location SOIL ABSORPTION SYSTEM Width: /Y Length ,S'O J Number of trenches e s Distance & Direction to nearest prop. line: Setback from: well:Z!ake House 2,7 Other. ,/V l ? mod' ELEVATIONS Building Sewer f'.?. /,r ST Inlet: f'.P.0 0/ ST outlet: P.A .Pz. PC inlet PC bottom Pump Off Header/Manifold Q.~.~ Bottom of system p/, 7 Existing Grade Final grade PZ,p ' DATE OF INSTALLATION: w l P PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor an'dHuman Relations INSPECTION REPORT ST. CROIX safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 284282 Permit Holder's Name: ❑ City ❑ Village 'X] Town of: State Plan ID No.: DELTA CONSTRUCTION HUDSON CST BM Elev.: T Insp. BM Elev.: BM Description: Parcel Tax No.: 020-1313-20-000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. 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 oss mead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION TypeO CHAMBER Mode 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: HUDSON.22.29.19W,SW,NE 874 ROSS ROAD LOT 2 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 i SANITARY PERMIT NUMBER: I Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. Wisconsin P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. p•,-E • See reverse side for instructions for completing this application State Sanitary Permit Number .Z ryaJ'_ 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)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location ;,Y C8 Gd 114,AIA 1/4, S 2_2.. T ~z , N, R E (or)d Property Owner's Maillg Addres Lot Numb Block Number s City, S ate Zip Code Phone Number Subdi 'si n Name or CSM Number aal II. TYPE BUILDING: (check one) ❑ State Owned tyy Nearest Road E;EE] ilage Public 1 or 2 Famil Dwellin - No_ of bedrooms VVr on OF 1 III. BUILDING USE: (If building type is public, check all that apply) arcel Tax Number(s) 1 ❑ Apartment/ Condo /3/3- )-G 7 • S8 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outd or 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. W 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 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit /-C vi*Sl`ort 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 4~4V I 'R sd , Feet Feet TANK Capacity VII. FORMATION in gallonTotal # of Manufacturer's Name Prefab. Site Steel Fiber- Plastic Exper. New Exist- Gallons Tanks Concrete strutted glass App. Tanks Tanks Septic Tank or Holding Tank 20,~- ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume re nsibility for installation of th o site sewage system shown on the attached plans. PI ber's Name: (Print) Plumber' ignature: ( ) 1'dfPlfDlf RSW No.: Business Phone Number: PI is Ac dress (Street, Cit , State, Code): o .l' O.Z 3 IX. COUNT / D PART E T USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate slue Issuing Agent Signature (No Stamps) ❑ Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-8398 (A 11198) 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. Ill. 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 8 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.an`d,spedfications 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 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. F+OQERTY PLUMBING DAVE FOCEM PLUMBING DATE: -3~zG~°f 7 Lken Perk Tester & Plumber ~#e3~2y33 #13 Heighu Rood JOB PT: S'/ 9 ROS'EOR , V011HSI36N 54023 Phone 749.56 JOB SP. 3gi-ii6G ScsGE / yo ~ std RSS/~rr~E / R9. i'J x n rlor LUf X = ~oYr~ I 1 ~ s T, u o wscc - > Y~d~ so fia,, x ~ I p j,/, ~~/e, adz 1~ L At Y I x x Est L.~ l3z' ~ ~ gO I I I r i ~ A.3r1 ZJ l Ross /cc Safety and Buildings Division !:t■Lr■~1' SANITARY PERMIT APPLICATION Bureau of Building Water system: 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 8112 x 11 inches in size. s--rZrgQC • See reverse side for instructions for completing this application State Sanitary Permit Number a Ss~2 8-1 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 L; /r/ Sw 114 Ap114, S Z2_ TA , N, R E (orer Property Owner's Meiling Address Lot Number Block Number O 2 2- - City, State Zip Code Phone Number Subdivision Name order etJ W~ v 6 ( y II. TYPE OIF BUILDING: (check one) ❑ State Owned City Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms Town OF o 0 III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 020 - /3/ -Afl 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. m New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 1 1 0 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 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation 6Wi -7 2. / Feet Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex per. INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App strutted Tanks Tanks Septic Tank or Holding Tank 240 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of Ole onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumb is Si natur o Sta s) 1111PIMPRSW No.: Business Phone Number: Ty ZYE -_74S-4 P um er's Address (Street, City, State ip Code): fir- C-a= zze xj IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing gent Signature (No St s roved Surcharge Fee) pp ❑ Owner Given Initial` j~ 30~7 Adverse Determination C~ X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SOD-6398 (R. 05194) 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 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'dim'ensions, 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-numberof regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. r DAVE FOGERTy PLUMMNG : DATE- f7 Licensed Perk Tester & Plumber 0p53233 63289 JOB S^! 9 ROBEI~'fS, WISCO"M 554023 Phone 749-3656 3Ql-//6G SasRGE / . yo . ha i ~ ~Pll D Y' ~'Ll~ r ?t/ xt 1 gSSti~/E /R9.'V K I ~(o"caf X '6or:'p-I n O = i /e z 1~xn <c~v= 9~•/ ~ Y y ec Y _ y~ , x Y, f/SE iI ~I I O I 757 Q ~2 ~1 ~ ~ Ross .~u! out I I i i n Anm A 1 a a*, ~R. w` ~ a h~ 1 • ~ r SOG li'4 CE 916.68' i , I 595.48' w `1 C 6'\ tL ~ I - U re) 1 ~~y\ a N u p I 616' (J Ul) 0) w N cD I - C\j 00 On IOG O N W rn Z N Q 0 Q N L. LL. 0 IO t- W O ir 0 rr (n I N i Z _ 6 6' W Lu ~ W C a 0 0) co NUJ °06 tD a ~1 O M M 37 E~ I (o W LL G J 1. i ~ N03 42'22 W g~ ' cc z - 150'. 145. 37 S03°42'22 E © Sp i 1 -_pp' 145;00' N OO I wi t U)I 133' 1 3' 100' . ID N { tD 1~1 i ( M : LL i - i / LL ti C W" o N 4 Q Q Q (n U- Z 2 W i I I ~ ~ ~ X e ~ W N I I O 1f V w a ¢ J Cr 1 N •7 I ~ n! I r_ o N Cp Q rh c y~ C\~ ~ \ \ Ilk 264.68 2:5.12 I NO0° 16'35"W 500.00' ` 4:11 ~ ' ~ p( ~ ~ _ ~ • 5.6 ~ =°i ~ 506'20 Uu . 1 a - . . M b' ~ H I O U. i L Z ' 1 g ~ ~ CY k) m c) W ~ i w O ~1 a 1 ( a of W In 1 o O f Q co U) 0 M ~pI O W O N Q W ~ t w 1 LEI ~1 - XN 1 0 h 00 L): ,n W m1 Z n < 00 0 o i a z ~ t 1 i i to er zl 500.00 170.64' 202.84 • ~ i DAVE FOMM PLUMWNG Ucensod Pork r Plumber FoY Hem Rid ROBE IV 7S NIN 5402 Phone - p~c~.¢ la.vST Lo7 ~.1 Al',ext sc.~tE ~ yo Q *7 = Tod of iyrrrL Ar B.as~ of IAaRe c 7-A ESQ 4jTaw.r / O o Zj = %o ~ o f .~/IS X47 BASE Of Ts G, ~ n K ~ = BoBrv~ sal ~Z ~ e = ~ovv~ GoT ~ofNE~, l~ N W 17 v #3 f3~~ I AS i DATE 26 • si 9 JOB Joe OP. A OAS ~4~ L i4 illf a IM -W'^tr s ui- I I _ I i i } i j j } I 1 1 i i MGM Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Pa g of Labor and Human Relations g Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but ' C not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. ,10 - ,3 3 D APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION EG p k ,Z'Q GOVT. LOT 1/4 1/4,S ETC N,R E (o~ PROPERTY OWNERMAILING ADDRESS LOT # BLOCK # SUBD. NAME OR-efti # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ❑fOWN NEAREST ROAD S ~2 ( ) 8 -~/6 z New Construction Use V] Residential / Number of bedrooms Addition to existing building Replacement [ I Public or commercial describe Code derived daily flow &10 gpd Recommended design loading rate _7 ed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 ;7_5-0 trench, ft2 Maximum design loading rate _7_bed, gpd/ft2__,y _trench, gpd/ft2 Recommended infiltration surface elevation(s) 01:1; zT__92./ ' ft (as referred to site plan benchmark) Additional design /site considerations J "4e& 47- G0Q'T E.Vy. Parent material' - Flood plain elevation, if applicable ft S = Suitable for system ' CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem m S ❑ U OS ❑ U JOS ❑ U ❑ S O U ❑ S ~ U ❑ S o U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourtlary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench . 3 f.. z - m - SrG m SB fi <S Ground 3 -42 z •s - S O G L - , 7 , I /,r /11 elev. 92,P- ft. .S->` D ML i •7 Depth to - limiting factor Remarks: Boring # 42 2 3~ - L S K vF p3"~ 3 -76 .S- 6f L Ground eIft. Y 74-/v - o Sd-' - P Depth to limiting , factor Remarks: 6"Xlo° o~ DLS CST Name: Please Print Phone: Address: e ~ v~ Z w o2 3 Signature: Date: ` CST umber: 7 PROPERTY OWNER )&PY- C~J T SOIL DESCRIPTION REPORT Page Z ofd % PARCEL I.D. # Depth Dominant Color Mottles Texture Structure Consistence Roots GPD/ft Boring # Horizon in Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Boundary Bed. Trench is xi~ 16, - Ground Z .S- df" Cs /F elev. Depth to limiting factor Remarks: Boring # Z S ..S' \ fiv... IF 7 13 Z.3 -M A9 - 41A, k-;/6C L Ground elev. 6-e .7 ft. Depth to limiting factor Remarks: 3 / ,3 = U O Lc~' ~O Boring # . 9-1 vv. S- S !YI f X G F V-3 - 3.3 o - -s a rh FiZ s . o Ground C S O .S L S elev. 4/ r5 -,$'0 - vy/v .5 -0 Depth to - S A S /kl L - 7 limiting factor Remarks: Boring # tiff.:: 't4; .y • _ Ground JOB PT:. elev. ft. JOB SP:, Depth to limiting factor Remarks: S13D-8330(8.05/92) S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property Location of property _$f,) 1/41/4 , Section 2 L , T,?y N-R_Zf_W Township dt,4 7 Mailingaddress-.7joG ,Z.lkexll Address of site A%sl C-.V.V /L Subdivision name Lot no. Other homes on property? Yes No Previous owner of property zlldN,E Total size of property Total size of parcel Date parcel was created i',,57- Are all corners and lot lines identifiable? _J/ Yes No Is this property being developed for (spec house)? Yes __V' No Volume and Page Number -V;51 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. 50,f 3 , 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. S3~ o a3 Si natu f Applicant Co-Applicant Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERR yr.~j~sr ~rs~t~rc~J/r( _ MAILING ADDRESS S-4 Z_61~, wa- PROPERTY ADDRESS f7'1 I?c,ss cvr S9'y/4 (location of septic system) Please o tain from the tanning Dept. CITY/STATE PROPERTY LOCATION fi:d 1/4, VC 1/4, Section .Z 2 T_ay _N-R_Zf_W TOWN OF &yAS2f , c ST. CROIX COUNTY, WI SUBDIVISION , We g;i /QG~s~v LOT NUMBER 2 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 expiratioT date SIGNED: DATE: - St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 n 1155PA,< <.1f Loy AS2 • WARRANTY DEED DCCUMENT NO. rnis :p.- R---d For ,--ding r -A THIS DFED made between DELTA CONSTRUCTION JAN 2 1996 COMPANY, a Minnesota corporation a/k/a DELTA CONSTRUCTION, Grantor and DELTA CONS L RUCTION, 10:10 A. ht INC., a Wisconsin corporation, Grantee, Witnesseth, That the said Grantor, conveys to Grantee the following described real estate in St. Croix County, State of Wisccnsin: ~ C is ~ ^k1 • ' :t LoC2-,/3, 4, 5, 6 and 8, Pheasant Rust Addition to the Town of Hudson, St. (--,,ix County, Wisconsin. F EXEMPT- This is not homestead property. TOGETHER WITH and SUBJECT TO reservations, restrictions, easements and rights-of-way of record, if any. Together with all and singular the hereditaments and appurtenances thereunto belonging; And Delta Construction Company warrants that the fitle is good, indefeasible in fee simple and free and clear of encumbrances, and will warrant and defend same. Dated this 29th day of December, 1995. DELTA CONSTRUCTION, INC. ,A, i/ _ Virgil Fe or nko, Individually By: Virgil orenko, President STATE OF WISCONSIN ) ) ss. ST. CROIX COUNTY ) Personally came before me this 29th day of December, 1995, the above-named Virgil Fedorenko, to me known to be the person who executed the foregoing instrument and acknowledged the same. Notary Public, State of Wisconsin My Commission Expires: February 4, 1996 TiIiQ TTQTDi T&KV%TT nU A &-M n RV. RF n'RN TO- - .1 - _ _ _ - _ _ - - - - - - - - - - - - - - - D;'!Mr - - - - - - - - - - - rl ally J 11 tr rr ~s£ ~ ~ ~ ~ .III 11! i Ai ~c yp r s4 yy' `I 31 i I~ ~ ~'3X L F.~ .I 3 q, ~ II ! ~ 1 ~~I~IIi ~1 ~~IS ~ ` ! 1 I I ~ I d ` ~ fM 4- f 41 k F r , Y' ~9'' `fi`x { q ~ i! ! 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