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HomeMy WebLinkAbout020-1152-70-000 e ~ ~ o ~O I a°i°o I fie ^o a m m 4 0 o ~ ~ I I ~ ch o x N ~O°r Omc m E I y rn E 8 _ I boa _ N a ~ o• ~ y I ~ I 12 [ter 1 •c 4) c „Nm, $ I z aNi E c z° o Irv a) a z _ c co m N LL c= 0 0« U. c O O, - m C O V a)LV c 3 v m j 3 v c Q 'Ua 3a E Q c+) M r z E t E w (n 4i p " p Z m m m m cy, N z a co a to o O z a c ami z 9 2 o c o 91 tin z 1- r E E v $ 2 j Cl) c N ~ y ~ •V m I N N O. E 42 1 C L N V 3 t O CL (L 1 o d c c x O U z o0 7 z 2 D z m I~ m c R E t o E r `li 0 (D CL- a- - c N N« m N d r O > o C [r~ ra a ra r G a o ai= I ~ a~ ° I L°n X 33 =E N33 IL a a a a a o > CL ~ I 'c I to J U ~ co :3 LO LO rn 00 0) ~ rn CY) rn U) o m co v N N N - O O 0 O m °a a - m o v v E A N ON1 prn f0 'd N N m Q } In 'y 'O 41 Q CA m p j ~ 7 « ~ L co f~NIJ C I oi{ N C E IV N p O Q O M C a y cmi a p V ri. N co lo- m y _d c m W O m tm O C p y o N y z Ern y W y c~ ~I Y L O ~ O N 2 "O0 O z I-O N O z C fn ~ I I v~ 4) €a €a at a .2 m = 'I~i a m ` m y m rrww E c ! c c _1 A Ua2 0v«i0 0U)u Form-STC- 104 AS BUILT SANITARY SYSTEM REPORT s OWNER _ /r1E''uyF TOWNSHIP SEC. 3 TN-R W 8 3s JW ST. CROIX COUNTY, WISCONSIN 0 rn t -I SUBDIVISION ✓ OA : 114.4 LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•T,H,R 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM y TAO 1 30 r i 1V / DINE ARROW G4Y Ive P ry con ante-' R1; ATlytTMADV . n___~st _ ~y_ _ _ w. ix-i t PUMP CHAMBER Manufacturer: Liquid Capacity: i Pump Model: Pump/Siphon Manufacturer: ize Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, Q Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed:j Trench: Width: 1~r Length: Y. Number of Lines: 5 Area Built: /l Fill depth to top of pipe: ~g f,O Side 0 Rear,O Pt.,✓/~~ Number of feet from nearest property line: Front, Number of feet from well: Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: ✓ Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop bo 0 or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, 0Ft. Number of feet from well: Number of feet from building: ~ P DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOO 7969 969 MADISON, WI 53707 BUREAU OF PLUMBING XXCONVENTIONAL ❑ALTERNATIVE State Plan l.D. Number: (II assignetll ❑ Holding Tank ❑ In-Ground Pressure D Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER INSPECTION DATE'. Del Wine arten R. R. 1 Hudson WI 54016 - O t.d B ESLV MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN'. FOX Valley REF. IT. ELEV.'. CST REF. PL ELEV.' NE'y of the SEk of Section 23, T29N-R19W, Town of Hudson,Lo #7 Name of Plumber'. JMPIMPRSW Nn.. County. Samtary Permit Number: Roger Timm 3224 St. Croix 69670 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY. TANK INLET ELEV_ TANK OUTLET ELEV WARNING LABEL LOCKING COVER P OVIDED PROVIDED cp•(7~ YES ONO OYES ONO BEDDING: VENT DIA,: VENT MATT IHI(;HWATER NUMBER OF ROAD'. JPROPERT)r WELL: BUILDING: IVENT TO FRESH G ALARM FEET FROM LINE/ AIR INLET' DYES NO OYES ONO NEAREST-_ Q Al DOSING C AMBER: MANUFACTURER BEDDING: LIQUID CAPACITY PUMP MODEL JPUMP;SIPHDN MANUE ACT EH WARNING LABEL LOCKING COVER PROVIDED PROVIDED: OYES ONO OYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL U R OF PHOPEHTV WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEE FROM LINE G AIRINLET PUMP ON AND OFF) OYES DNO _ NE EST-> SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing ,TAME TEH MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN i CONVENTIONAL SYSTEM: BED/TRENCH WIDTH LENGTH INO OF DISTH PIPE SPACING COVER INSIDE DIA -PITS LIQUID TRENCHES A,tAT~iiW1: PIT DEPTH: DIMENSIONS r GRA'a EL DEPTH FILL DE H 11IST It PIPE DES I, PIPE DISTR. PIPE MATERIAL NO D TH NUMBER OF PROPERTY WELL BUILDING: VENTTO FRESH BELOW PIPES ABOVECOVER E) f INL ELEV END PIPES LINE AIR INLET: FEET FROM NEAREST //10 9S G& MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- OYES ONO meets the criteria for medium sand. TIONS MEASURED. SOIL COVER TEXTURE III RMANENT MAHKEHS OBSERVATION WELLS _ OYES ONO _OYES ONO DEPTH OVER TRENCH BED DEPTH OVE H„TH ENCH BED :=OF TOPSOIL JSOODFD SEE UFD MULCHED CENTER EDGES OYES. ONO DYES 1:1 NO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIOTH ENGTH NO OF LATERAL SPACING [HAVE E DEPTH BELOW PIPE FILL DEPTH ABOVE COVER TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE JMANIFOLD MATERIAL NO-TT STH -DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEVATION AND ELEV.'. ELEV. DIA. ELEV. PIPES DIA ~ DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED COHHECT LV COVER MATEHIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS OYES ONO OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LINE: DYES ONO YES ONO NEAREST 7-01 d << / r Sketch System on jin county file for audit. Reverse Side. SI TITLE'. DILHR SBD 6710 (R. 01/82) WISC°neln APPLICATION FOR SANITARY PERMIT COUNTY DILHR °ErxaRTrnEnT ov (PLB 67) UNIFORM SANITARY PERMIT # - InOUSTRV,LRBOR6NUTRn RELRTIOnS l O -Attach complete plans in accord with s. H 63.05, Wis. Adm. Code for the system, on paper not less than 8'hx 11 inches in size. -See reverse side for instructions for completing this application. PLEASE PRINT PROPERTY OWNER MAILING ADDRESS Ly~ f a%z ie ! men Cam` ~s/D/~b PROPERTY LOCATIO C-+;FY: / / 1 1/4 1/4, S , T , N, R (or) Tow /`--~O7i LOT NUMBER IBLOCKNUM-BER SUBDIVX ION N AME NEAR ROAD, LAKE OR LANDMARK STATE PLAN I.D. NUMBER TYPE OF BUILDING OR USE SERVED N 1 or 2 Family Number of Bedrooms: S ❑ Public (Specify: (~ZD-11 Z ' 7 'DUd THIS PERMIT IS FOR A: X New System ❑ Tank Replacement ❑ Repair Replacement Soil Absorption System ❑ Revision ❑ Privy ❑ Alternate System ❑ Reconnection ❑ Petition for Modification IF THIS IS A CONVENTIONAL SYSTEM COMPLETE THIS BLOCK. IN Seepage Bed E:1 Seepage Trench ❑ Seepage Pit ❑ Holding Tank System-In-Fill ❑ In-Ground Pressure ❑ Vault Privy ❑ Pit Privy ❑ Existing, For Which A Previous Permit Is On File, Permit # issued ❑ An Existing System That Has Been Inspected And Is Compliant As Far As Soil Conditions. Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity ~j Lift Pump Tank/Siphon Chamber Holding Tank capacity Manufacturer: . IF THIS IS AN ALTERNATIVE SYSTEM COMPLETE THIS BLOCK: ❑ Mound ❑ In-Ground Pressure Total #of Prefab. Site Steel Fiberglass Plastic Gallons Tanks Concrete Constructed Septic Tank Capacity Lift Pump/Siphon Chamber Manufacturer: PERCOLATION RATE ABSORPTION AREA ABSORPTION AREA WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): PROPOSED (Square Feet): F, r_ 7~ KPrivate ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Nam f Plumber (Print): _ Signature: IMPLUNI'M No.: Phone Number: 3 2 Z (`7/f) to fry f Plumb 's Address: Name of Designer: COUNTY/DEPARTMENT USE ONLY Signatur of Issuing Agent: Fee: Date: ❑ Disapproved '5-00 El Owner Given Initial O~ a Approved Adverse Determination eason for Disapproval: Alternate course(s) of Action Available: DILHR-SBD-6398 (R. 5/82) DISTRIBUTION: Original to County, One Copy To; Bureau of Plumbing, Owner, Plumber INSTRUCTIONS FOR COMPLETING THIS PERMIT APPLICATION, PLB 67 - SBD 6398 ^ . To be complete and accurate the permit application must include: 1. Property owner's name and complete legal description, please circle the appropriate municipal government unit, (whether this is in a city, village or town); 2. Indicate specifically what type of use is served, if public is checked indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.); 3. Complete the block for conventional or alternate system depending on system type, check all appropriate boxes or blanks. 4. Indicate the design percolation rate listed on the 115 soil test report, the number of square feet required by code and the number of square feet to be installed; 5. Complete the section on water supply; 6. PRINT the name of the master plumber or master plumber restricted who will install the system, circle the appropriate license classi- fication, place your license number in the space provided and sign the permit in the signature block; 7. Please place the plumbers business phone number in the blank provided, if there is a problem or question this will speed review of the permit; 8. Change of ownership or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to installation. Failure to comply will void the sanitary permit. 9. This permit may be renewed, and at the time of renewal any new criteria in the Wis. Adm. Code will be applicable. 10. A new permit will be needed if there is a change in, estimated wastewater flow, (number of bedrooms, etc.), location of the system, depth of the system, type of system. 11. All revisions to this permit must be approved by the permit issuing authority. 12. A complete plan including a plot plan, drawn to scale or with complete dimensions. 13. Horizontal and vertical elevation reference points that are permanent and clearly shown. 14. Piping detail including pipe size, separating distances, distances between beds if appropriate, tank locations, effluent line from tank(s) to system, building sewer and vent observation pipe(s). 15. The permit issuing agent may require a cross section drawing of the effluent disposal system. TO THE OWNER: This is valid for two years. Changes in your building plans or locations may require you to obtain a new permit. Private sewage systems must be properly maintained. Have a licensed pumper clean your septic tank whenever necessary usually every 2 to 3 years. If you have questions concerning your system, contact your local code administrator or the Bureau of Plumbing, DILHR, State of Wisconsin. APPLICATION FOR SANITARY PERMIT 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. - - - - - - - - - - - - - i--,- - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property ~~n2G0~r Location of Property S1G 14, Section X23 , T o7- 9 N Township Aa~"SO}C1 Mailing Address X!!! Subdivision Name ~X !64l T Lot Number ' Previous Owner of Property AeftlibE Kp2Mftti Mft(, >.'i &my- L±611 rr_e Total Size of Parcel 3,d ael-n Date Parcel was Created J44066d V Are all corners and lot lines identifiable? 4Yes No Is this property being developed for resale (spec house) ? Yes No Volume and Page Number X280 _ as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3.• Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (We) ee4ti6y that aU e.tatemen-ta on Chia 6on.m are t.u.e to the best o6 my (our) h.nowtedge; that I (we) am (are) the owner(s) o6 the property descAibed in xhiA in6o4mati.on 6onm, by viAtue o6 a waA&a.nty deed neeonded in the 066ice o6 the County Reg.iAten o6 Deeds as Document No. p 6, ; and that I (we) nhOAOntfu MAIN J%0 nhnnnAOd Alto Lnh tho AMAYMP rAnnA AuAtPm (OA I (we) haV2 Orr, *Man C. NNW ad Milk I It Nis a, 2.7 3 ....._a.s'..N1 ...-a.. and, wormob _ . ......r.. ~l ~ ~ty1 { Q.00 J ib t v 1..G70t~. iii 307 two following AswAw road a"" is M..C' Cwvo Shit of Wiswasia: • 'Pas latwi 31191-- T= of 9udao>t, U* 7, plat aE Poo Vallay, a rural auhdiviaiaa in the ' at, Croix Qomty, Wisoonsin, aooording to tba PLt ehs~eof Mad jamuzy 14, 1981, in WI. 4 of the Plat, ymP 87, Doc. 368671, in tit CM!B s Of the APgiabw of DOOM far Bt. Croix OotsYty, itLm ain. , T*V&ear vdth and &*rlo t to assess, Covenants, nsNCVati+ar and ? rmitrictiav Of record, if any - i i Tbis is..rA* bomestsad propertt. y . (is) (is not) deeption to warranties: t v ~ + 1 dal of .-.._.r ?I!I.._........_. Dated this ......................s• .....i (SLAL) N~• ........................................................(SEAL) FraNc R. lank era P' W*'IAP2Mrft ATTUNUTTCATION ACKNOWL10dINH of N0I=m C. liars and STATS OF WISOONSIN a, W +(a) Pz nnk R. LoPlanft ' h'a manic LP ` .l , • _ , _ 19... Penoaallq casts befe as a ' it . lliae ilbsrt TITLZ: NZ BZR STATZ BAN OF WISCONSIN . (If aak .rtberW by ; Taw. Wi.. Stats.) to no known to be the r.on . foragaw instrument and aek INAN 774 State of Wisconsin. County of St. Croix 1 hereby certify the this I*rumwd is a fuh, true and correct copy of the docu no►t on fife and of record in my office and has been con+pared by me. Attest September 18 19 85 James O'Connell James O' Connell ReO*w of Deeds Deputy z CA ~ H a STC - 105 r `r a H 's SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z a a OWNER/BUYER IM2C1Hi2TE/~ H j ROUTE/BOX NUMBER Fire Number CITY /STATE y f t d o s D n j Z I P s PROPERTY LOCATION: ASC k, 6C k, Section, T,2~N, R i' Town of /7`L~psdly St. Croix County, Subdivision Ax Valley Lot number. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. t. St. Croix.County residents may be eligible to receive a grant for f 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 systems properly maintained. The property owner agrees to submit to St." Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic 'tank.is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. -3 0 E I/WE, the undersigned, have read the above requirements and agree z to maintain the private sewage disposal system in accordance with x ri the standards set forth, herein, as set by the Wisconsin Depart- ro ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. 1 SIGNED GIJ , DATE St. Croix County Zoning Office P.O. Box 98• Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. c y = n m Y ~ c ~ N w~~ w ~ ro3 p V (D CD X O A A cD 0 N a o m a3 sew 3 to C w2 O Cc C N W N 7C ' < =r 3 (a A (D 0 0 CD cl 0.000 1 w O wID N 0 D cD N a N _A ElF C=D' Er 0 3 -0mg r O CD a C w O 000 (!R N W > > ~ ~ O CC Aa a ~ > > C c 1 3: w a co Poc L C g'a N 3o0 w o -•o am N - 30 00 D < N Q A~ Q ~ ID y O D C m G tD (O -Ct W 0 I'D O 0) 0 N C m oN(D cD~Q►a~ CO) (D -D ' Z a awA 3`-DOO?a n N N Coo j!, "4 M QN (D > > - w y cD N =r CL 0 d 3 c ? v c.w et S. CL cr w CA. C A_ Q1 G) wOw cNDC o ~c:*= m awo a G) ~c ~<'00 ~w, : pn F A C tp O O N • O C Q O 0 O a d C C N i= a O a ' .O. 7• w A amc 3 0 ~D o 0 0 aCD ~o3 3 ' < CL Q _ INDUS T OF REPORT ON SOIL BORINGS AND SAFETY 4- BUILDINGS iNDUSTA Y, DIVISION LABOR AND PERCOLATION TESTS P.O. BOX 1969 WUMAN.RELA'f'IONS (115) MADISON, WI 53707 (H63.0911) & Chapter 145.045) I.Or; : 11 W---__ TOWNSHIP MORIL'R1XttTY: OT NO.: BLK. NO•: SUBDIVISION NAME: TWIN: N IE _ 4<(/, Z3 ~1'Z91rJR E ( 1 I-~ A &-.0M 7 - Fox 1I~tLE` COUNTY: W AM Cgox--- f~4 N t EUV O,PMEN-r . P 3 6 --S-T. Cto I Sr, NckTu 14t46so N W. S O1 6 USE (DATES OBSERVATIONS MADE i1C.iResidence COMMERCIAL A JvNew ❑Replace I ~cJE~f 1A / SS SEf~T. /Ei lqj~ j SOIL OeIZ AbL~ 58 -!561LS _ SaC'r - SANTrAC~Q RATING: S- site suit". for system U- Site unsuitable for system _S 1 g - S A-r &t ICONVENTTONAL: M N : 1. -GROUN V FILL OLLDIING "TANK: RECOMMENDED SYSTEM:(opti al) S CCU 10 S 15T, ~S C1U ❑S J&U 1 0S ou r LONVEN 1 10AIAL E p If Percolation Tests are NOT required DESIGN RATE: - If any portion of the tested area is in the under s.1-163.09(511b), indicate; I Floodplain, indicate Floodplain elevation: 7-1 ~-f PILE DESCRIPTIONS I PR BBRIERN~~ ELEVATION N DW -11W T CHARACTER O SOIL WITH Tti KNESS, COLOR, NUMBTEXTURE, AND DEPTH V T BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B' 9-ZO t-5"zS' IJo&l } °J.Z d-LS $ittiL w/4'6R /.S-3.4 $LStL 3.1-4.7 $eN 5.1 61L 4.7-5A Meal Sf6t S.4-'S•a CS16aW CA S.aA.Z ewdSY0i B- 2 ~j •ot~~ y9 -Al" No1vE 9 .p' 0-/-Z 6fw SL -66~ /-2-3.A RL SL 3.R- S•4 QeN,S, L 5.4 8.9 ^-*cI'Sf6t A.s,-l3Eesw~.U .4Gk Ca H B- 7.70 99 ~3~' a-O-s e„ SL-tf-R 0.8-2.7 $t. L'6R 2.7.4-Z- 0t4 S, L n1QwC 7.7 4.2-7.7 mocl S f&e 7.7 ,r$t,LntaCSY6e CrIA. B. 8.00' 98 NONE $.d 0-1.2 $L SL" t rz-ZA $QN R'LS, L G e T-4-'Y-0 CS*6t Ccoh 7.p-Q o h,S } Git 6' $ _ X9 .'40 oNt y 8.0' 0-3-o MS 46ee&A' MS I C,e ~*CO(D D PERCOLATION TESTS TEST RATE MINUTES NUMBER DE #Q"" 1002 PTH AFTER K. IN IN RVAL•MIN. _ PER INCH P. .7 7 0 2 5 P- Z 4 p,ZC 10 L..Q. P- P- - ` P- 31LOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what ate the hurt wntal and vertical sWation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent )f land slope. SYSTEM ELEVATION 5S,00' v(C i T"- . i "o 104 SAV -6*, } • , Z' L PIT a iN , A 6 1 i - wiry1 L: Is t I • I ` i ,,1 i ~ ~ ~ t I Jn y J WM . Z o 5 4 ~ • m At a Z AAA . O ~ ~p r (h Ar o h D"' z ,1 - O~ t a. 7v k N - In I~ ~ ' P. %I p -w *6 } s:N p f, q, ' ze f~ IV b m / f j ' 19- JOB . 1,14ne ROHL & TIMM EXCAVATING SHEET NO. OF Z 310 Arch Street HUDSON, WIS. 54016 CALCULATED BY--- 11 Z"f* DATE T /p l +r_ . (715) 386-8664 P S 3 z -z.5/ CHECKED BY DATE V SCALE ICJ ~ llz~Q - zr- PRODUCT 2011 E'a Inc., Groton, Mass 01471. PAGE OF 2 CroSS Seejlun O~ A Ze0 System r Fresh Air mists And Observation Pipe 1) - Approvdd Vent Cap Minimum 12" Above Final Grade 20- 42" Above Pipe _ 4" Cost Iron To Final Grade Vent Pips Morsh Hay or synthetic covering Min. 2" Aggregate Over pipe Distribution - Tee Pips -L- 0 0 0 0 i Aa Be nsoth Pips Plpe a Perforated Pips Below o -Coupling Terminating At Bottom Of System P/tu o5en ~ina) Cjrac~C 1~ 3lP P 1 ~ I i ~LIcJP.T ton / SOIL FILL DISTKIBUTI01.1 PIPE APPROVED SiIJU PETIC COVER ° ~`MATERII~t- OR 9" OF STRAW Z"OFAGGREGATF . . ORMARSM V4Ay 4o' 0F%2-Zt/2 AGGREGATE e8 ELEV. OF-L-FE6T 3 ~ ~ J a DISTRIF3+JT101) PIPE TO BE AT LEAST ICHES BELOW ORIGIIJAL GRADE A►JU AT LEASTE0 ICHES BUT 1.10 MORE THAM 4Z INCHES BELOW FINAL GRADE MAXIMUM ®EQtH OF EXCAVATIOP FX014 bRI&wu 6RADF. WILL BE FICHES PUNIMUM AEPr" of EXCAVATION FROM 04ltGIbAL CaRAVE WILL BE 77 INCHES I SIGNED: i LICEMSE DUMBER: i DATE: READIED STC - 104 ry AS BUILT SANITARY SYSTEM REPOR DEC p2 1997 r OWNER ~O~N.'~ IN OFFICE s~ ADDRESS_ y ~~flDLr Plc. SUBDIVISION LOT # 7 SECTION. 7-3 T2 N-R W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW y~ SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Ave-'- <<S' T- a,_7 7 4 -7 ~ /3/~ • ~ti~ ' ivy /~i~s ~ o .vim Y ~ ORIGINAL INDICATE NORTH ARROW. Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: k)~Ie_ 4S ~zyv ~jU!/ • ALTERNATE BM: 19077D-L ~S!`C SEPTIC TANK / R / Manufacturer: Liquid Capacity: Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: / Alarm Location a r -:SOIL ABSORPTION SYSTEM 2 ~ 2 Width: `3 Length Number of trenches Distance & Direction to nearest prop. line: 74 &VS 7- Setback from: well:? House 55 Other ELEVATIONS Building Sewer ST Inlet; ST outlet 76 PC inlet ti PC bottom Pump Off Header/Manifold Bottom of sy t 472. g-S m 491 PMA) Existing Grade Final grade 9/./O 4ov~ DATE OF INSTALLATION'- PLUMBER ON JOB: LICENSE NUMBER: 33 o ~7 INSPECTOR: Poo 3/93:jt a Nl- o LAI as vp N N r J W65 T Lo r O cw Z oo ~ Z ~ °C 11~ ~n lo/ 10 L I I p z ~o ;,j T tj/ j I 41 - 0 /,cot O 1 v /,119 ~y Puy ~ y s 00 Fry z o r Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT S`, Ctro't 7. GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Personal information you provice may be used for secondary purposes [Privacy Law,.15.04 (1)(m)]. Z9919~ Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: C--79A 1A,ZqL/A , ~c~t-- a Shia "So"j CST BM Elev.: Insp. BM Elev.: BM Description:, ~~t12 Cg'f zs Parcel Tax No.: C4 J i.l BYIIJ ~Zd°l/S2.'7D~6UC~ O TANK INFORMATION ELEVATION DATA ,¢970o so$' TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing 5 j3 lD w 5:/( Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Vent to ROAD Dt Inlet Air Intake Septic 00 NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe /0•7f fZ 3S 98-77 0 Holding Bot. System 12--59 13.3V V-17 2~r 7 PUMP/ SIPHON INFORMATION Final Grade g.Z~, I o •7S 3.32 90 Manufacturer Demand yJIc4ih4ee- /c v, 3 9~/• AS- Model Number GPM 1301/ Va~u~ -7 0- 9Y .3 -1 TDH Lift L Iction System TDH Ft ~w /a Zp Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED E Width Lengt No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIM I N ' o 7- ,~J DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEA NG actu SETBACK C AM Model Number: INFORMATION TypeO ~ ~ NIT System ..Val DISTRIBUTION SYSTEM Header / Manifold p gox Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length,~16 Dia. Spacing de- wi SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over f xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discre ancies, persons present, etc.) / ~rD l f va C e. C&q G~ - ~C,~~~o r~ak - -Ile 41- 3 o CUiv~~tlt g3 s~ b ~2s r'~ l r~ls K)/ Qx1s¢-1w~ i~ Y) IZ i i•i3 PI ~ revlslon requl e ? ❑ Yes ~ No .7 Use other side for additional information. (Z , ( % Lv go r, SBD-6710 (R.3/97) Date Inspector's Si ature ert o ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: 'Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: -SaVc-ty and Buildings Division ST. CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary2P~rgmiit Personal information you provice maybe used for secondary purposes [Privacy La s.15.04 (1)(m)). 9 Permit Holder's Name: nn Cit nn village Town of: State Plan ID No.: GRAMAGLIA, PAT & SHEILA ~IiU~SON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Ta2ciNQ_1152-70-000 ULl1 TANK INFORMATION ELEVATION DATA A9700508 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic W r G~ 000 Benchmark ' t3.h . Dosing -Y ,2 Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. ventto ROAD Dt Inlet Air Intake Septic .0 NA Dt Bottom Dosing NA Header / Man. Aeration ry NA Dist. Pipe /0.1 3S 010.77 ~q- Holding Bot. System /2.319r7 PUMP/ SIPHON INFORMATION Final Grade 93,,,Z fa.- Manufacturer Demand Sr~lrae (o. 3 R8', I j Model Number GPM ~i• { o 725 'N,3 TDH Lift Friction System TDH Ft Loss ead Forcemain Len Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED kTIENCLW Width Length i No. Of Trenches PIT No. Of Pits---- Inside Dia. Liquid Depth DIMENSIONS -3/ DIMENSIONS 1 N SYSTEM TO P/ L BLDG WELL LAKE/STREAM LE NG ct er: SETBACK INFORMATION Type O I q t CF(AMBER Ma del Number: System: vCvrl~j I SS 1S ORUNTT' DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) ~ f y x Hole Size x Hole Spacing Vent SIntake Length Dia Length Dia. Spacing g SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over Of xx Seeded / Sodded xx Mulched Bed /Trench Center Bed /Trench Edges of ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 23.29.19,NW,{SE 834 BRADLEY DRIVE i y~ ~ f f 1 one, Qc'.r s 1~ Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH Y T SANITARY PERMIT NUMBER: Safety and Buildings Division lfiiconsin SANITARY PERMIT APPLICATION 201 E. Washington Ave. 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 , ~ /t than 81/2 x 11 inches in size. t • See reverse side for instructions for completing this application State SaninittaaryyPPermitit Number The information you provide may be used by other government agency programs ❑ Check if revisio nto prdvious application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION /V Propej1v Owner Name r / Q Property Location q- SAt/ 14 U'/1/'f lr /J10 /4 1,&- 1/4, S 13 T -I/ , N, R ,rte / ! E (or W Propert Owne "s Mai ing ddress /C Lot Number Block Number .City, ate Zip od r Phone Nu a Subdivision Nam r C umber , o~J Gtl l - S~ D~CP (1 s )~'~07 t i4 - 11. TYPE F B IL G: (check one) ❑ State Owned o !tN crest R ad u 1 or 2 Family Dwelling -No . of bedrooms own of I11. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 Apartment/ Condo 0),0 + 115-1 76 , 400 $ S 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 on one box on line A. Check box online B, if applicable) A) 1. ❑ New 2. placement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ......System ______System_____________Tank Only Existing System _________Existinci 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 [Wepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit C-2,) ir,GMc ~p 571 LU/•y~ .43E] Vault Privy 14E] System-In-Fill ! J AX-f,6 ,,r 3 A .F VI. ABSORPTION SYSTEM INFORMATION:/ 07, SO %,I. Cp 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.) Pro osed sq. ft. (Gal ay/sq. ft_) (Min./inch) $7 U Elevation, Gr 5 Feet O, s Feet VII TANK Capa ity INFORMATION in gallons Total # of 's Name Prefab. Site Fiber- Plastic Exper. New Existin Gallons Tanks Manufacturer concrete stucted o Steel glass App. Tanks Tanks Septic Tank or Holding Tank ! /Cvz'j / ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ 0 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) SW No.: JB7usiness Phone Number: h i Zl`~/~~C7rrT 3 31~ ~~l~S Plumber's Address Street, City, State, Zip Code): 0I/ /tl - asdti t ~ S'ya~ IX. COUNTY / DEPARTMENT USE ONLY ❑Disapproved Sanitar Permit Fee (Includes Groundwater ate Issued Issuin gentSignature(NoStamps) + """~A roved E] v~ Surcharge Fee) pp Owner Given initial Qv f `1.8- T7 Adverse Determination 00 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPR VAL: S8D4 a (H.11M) 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 ispto 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 13 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 1/2x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with cot plete 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 vv %vsp E~ Ti~~ NIA1. 2 iff L - P4Vii!7 1) 7'?r&to K .-r~ ~ S S TAM y OR()a SS SEC Tio v TI CIU64 s /I ZI.Si~v G- IN i Z- 7,C4 7-0t 5 IVIAI Iff _ AZ_ F~iv/SEED tN N c w p A'i W,65 T Lo 7- w x ti vi b J Jo/ • 'Y ! / C OO\ N 4 n Wisconsin Department of Industry, SOIL AND SITE EVALUATION / 3 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 County include, but not limited to: vertical and horizontal reference point (BM), direction and 57- Cjt°D/~ X percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. If d 20 - SZ - -7 O. 000 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)). 9 ~Z • 97 Property Owner Property Location p P94 Govt. Lot /Pj4) 1/4 S~1/4,S y3 T 2-!,' N,R E (or) W Property Owner' Mailing Address Lot # Block# Subd. Name or CSM# 9W 131?14oge oK • ? Fox l/~~r~ City State Zip Code Phone Number y~ Nearest Road S'fo/Co (7/s )300(~ ' 5F07 ❑ City VSa Town f3 (c ApLE ❑ New Construction use: Residential / Number of bedrooms ✓ Addition to existing building replacement ❑ Public or commercial - Describe: Q1 Al Code derived daily flow gpd Recommended design loading rate bed, gpdfft2 • trench, gpd/142 Absorption area required bed, ftl 3 trench, ft 2 Maximum design loading rate bed, gpd/ft2~trench, gpd/ft2 Recommended infiltration surface elevation(s) sit 3 ft (as referred to site plan benchmark) Additional design/site considerations *,%:5 7i eloazf .5 do'K PI-Y7'. Parent material /HESS &&S- OP7IV14,?4- -s/9N~S Flood plain elevation, if applicable Lfl~ It S = Suitable for system Conventional Mound In-Grrou/nd Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system El's ❑ U ❑ S B-u- [E S E] U ❑ S ❑-s~ U ❑ S 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 yL 14_Yj1<-" /h4 7r- .5 Ground 3 Z /(9 }%f AeI9 .s • D, (;2q 17 7 ' elev. eft. /D S S D. S c~~ . 7 ~ •B Depth to limiting factor 7 Gamin. ' 7 Remarks: Boring # o•L io 1f 2-15 `DH &7_,F12 1Q0 ~ S/•L l~ ~Y+ • N ; v Z 1•3 -8 /Oy/e S' d S 7 d Ground elev. •--ft. Depth to limiting factor 7 In. Remarks: CST Name (Please Print) RDA y/h '~T Signature Telephone No. l nS Address Date CST Number ~r~fJ/~IA ff SOIL DESCRIPTION REPORT j PROPERTY OWNER Page Z of PARCEL LDI 020 000 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G~pjft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3 r 0•/g /oy,e 41,4,1 z 3 10 3 SiL hey _ Ground 3 2 - S~ © GC~ - , ' S elev. q3. l.2-, ft. Depth to limiting factor -in. Remarks: Boring # Ground elev. n. ; Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots PD/fe 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: W N c a CIQ c~ N - N i 4065 T Go T N I! r rr 11 ~ ~r 1 H 0 r l~l . ryr ~ ~ o~ ~ PS y V- N ~ rt ~ o ~ 'I 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 IA/g residence locat.;d at: 1/4,__1/9, Sec. 23 , T21 N. R /f W DSD~ . Town o f 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 7 3 Did flow back occur from absorption system? Yes XNo (if no, skip Approximate volume or length of time: •Sb b next line) gallons minutes Capacity: /00"0 6i-es Construction: Prefab Concrete steel Other Manufacurer (if known) : ' Age of Tank (if known) : 0 Tap,* P1613&WT WSR C-ti/ (Signature) (Name) Please Print (Title) ~19 330 (License Number) Q~C ' S` - Cart (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 baffl Name_?O~aT I,6117"Signaturee). 0 L.,PRS 5/88 " I r4A STC-105 SEPTIC TANK MAINTENANCE AGREEMENT 3 g~p .S 6 0 7 St. Croix County 5~•T~- MAILING ADDRESS 9-3 7 13 6fPG y Ze • h1&,PrV L) 4~i SyO~~ PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION 1/4, SE 1/4, Section 2 T Z ? N-R j OW TOWN OF ~f visa , ST. CROIX COUNTY, WI SUBDIVISION y` 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 canaffect 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: l d / /I DATE: 12:: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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 -S{18711,, " P r,?,, ~f- Ldcation of propertyNtt) 1/4 SE 1/4, Section 23 T N-R ~y W Township ff& Pj4 N Mailing address ~~SyGI~ Address of site 83 1,3^91, PIP, 17'~je'f6 -1-J Subdivision name Lot no. Other homes on property? Yes No Previous owner of property L lrjE%y511'/e Total size of property 14 en-es* Total size of parcel Date parcel was created 4-001 Are all corners and lot lines identifiable? Yes No / Is this property being developed for (spec house) ? Yes ✓No Volume 92& and Page Number 2-73 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. Y1/2-'73 , and that I (we) presently own the proposed site for the ewage 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. Signature of App cant Co-Applic n Date of Signature Date f Signa ure DOCUMENT NO. e WAMAKY THIS Shea atesavea roe eA7A STATZ BAR OF WISCONSIN FOR[ I -1Nil REG ISTER'S MICE ST- am co., va Dell R. Weingartgn and Judith A. Rata for Record We n arten husband and vile ~oin t..........-...... NOY 01198$ . n e as a . 10:35 Mil conveys and warrants is .A G.~4.. fir.:.. CrR A44i 91 a ~;ramaslia,...hueslBand..and..Ir~.tie.........araroe.~ Cital..pCApecty....................................... .............4 On following described real estate In St..- nau ..................County, State of Wiseonsin: Tax Fared No: Lot 7 Plat of Fox Valley, NW% of SE% of Section 23, Hudson Tovnship, St. Croix County, Wisconsin. liooormm to the plat theseof filed Jolmmy 14, 1981, in Volum 1'4" of Flats, Page 87, Dxuwrit 368871, in the Office of the Aegister of Deeds far St. cmix amty, Kwomdn. "Fil This 1:Q........ homestead property. (b) (is not) E:eeption to warranties: Subject to easements, reservations and restrictions of record. Dated this day of CT. ee.<. . 19.88... I ~ 1 (SEAL) ...........................(SEAL) f • D LL R. INGA N (SEAL) ' • • DITH._A._ WEINGART.EN/...I...._...-- AUTHENTICATION ACKNOWLEDGMENT ' 8i~~°re(s) STATE OF WISCONSIN ~ i~ St. Croix aa. ..............County. 1 authenticated this day of 19...... i Personal; came before me this .of i' • Iit_8_ t be Doll ..ti.....Keingarten --arid......... ; ' -1udt.th..A.....19.e1ngact-en............. ` TITLE: MEMBER STATE BAR OF WISCONSIN (If not . authorized by S 70A.OA, WL. StaGJ - - . to me known to be the person 8......... Who e=ecated .the foregoing instrument and aw go the II THIS INSTR1IMENT WAS DRAFTED BY l ' 1 _ .•~'C