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HomeMy WebLinkAbout020-1307-50-000 Q c o 3 0 c. Q En c. 5e O 44 0. 0 2 -r et o x a W CL cr-o CY) C' CJ C U i co O a Z N C C O C O O O N f0 Z co N CL) ~ L y ~ Z'c LL C (V N ° E O > to 3 L o U a N N m It E I rn (LL _ C I Z ~ y y a m N H C/) O O Z d c 0 O w N O d Z c z H O N c E -a .0 N M N O) N N C • L (n OC O O c 0) Q w O O U a ~ Z co z p a Z N N N w = d Y ~ o •o o a co co c m L 25 LO G O a aU) . N S(o §m-ff NI 3r. 3: d m Z o c O O O O •rv ~CL CL IL S: a ~ I = I oN o to J U J 0) a) Z *Wftl N O O O cl~ -M E m co .O m a) 0) CD m m m a} v? Q I ~ I O O N C i.a O I` C N O C j 0 1 rOl o 3 a) y d oo N lf) V y ^ ~ N c E r Q) ce) o ua W N a) F- N L 7 L 10 • ~a N I. U Oi O m O E U y O N S Q N O - w E L m a y ~t a L a ~ v C C r 3 cj o O 3 O (or) CL 0 V) 0 Parcel 020-1307-50-000 02i12/2007 11:38 AM PAGE 10F1 Alt. Parcel 27.29.19.1537 020 - TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - PETERSON, NICHOLAS & KAREN NICHOLAS & KAREN PETERSON 692 BLUE JAY LA HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description 692 BLUE JAY LN SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 2.010 Plat: 2122-HUMBIRD HILLS 3RD ADDITION SEC 27 T29N R19W PT NE SE & PT SE SE LOT Block/Condo Bldg: LOT 60 60 HUMBIRD HILLS 3RD ADDITION Tract(s): (Sec-Twn-Rng 401/4 1601/4) 27-29N-19W Notes: Parcel History: Date Doc # Vol/Page Type 07/17/2001 651381 1682/89 WD 03/26/1999 600149 1413/610 QC 10/24/1997 567359 1272/166 WD 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.010 69,000 225,800 294,800 NO Totals for 2007: General Property 2.010 69,000 225,800 294,8000 Woodland 0.000 0 Totals for 2006: General Property 2.010 69,000 225,800 294,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS ,o', SUBDIV / CSM# LOT D SECTI NT~N-R~///'l W, Town of A/'(,,L/ -S J Gte i ST. C,OIX UNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM V ~ o~ I \ v --C S/ I w I U~ INDIC E N RTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: ALTERNATE BM: SEPTIC T / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well//4 u-e~Aouse o"'- Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width- / -/,""'S Length / Number of trenches Distance & Direction to nearst prop. line: / d ~?0e / Setback from: well: House 6 a Other ELEVATIONS ~tss. c Building Sewer' ST Inlet: ST outlet: r / PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing GradeC~;~ j J Final gradey~~. 0 ~r G DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt n Department of Industry, PRIVATE SEWAGE SYSTEM County: La id Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 299157 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: RICHMAR INDUSTRIES HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.. 020-1307-50-000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. /-CC> Septic5 ~d Benchmark 1141 C .rat 9i ' Dosi Aeration Bldg. Sewer Holding St / Ff Inlet 71 1 TANK SETBACK INFORMATION St/oroutlet Sot' TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet ~1 Air Intake Septic / NA Dt Bottom ! Dosing NA Header - Aeration, NA Dist. Pipe p S Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade (l Manufacturer Demand Model Number GPM TDH Lift Lriction TDH t I Head Forcema Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM i BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits ia. Liquid Depth DIMENSIONS DI N f'u Manu acturer.' SYSTEM TO P / L BLDG WELL LAKE / STREAM I SETBACK CHA INFORMATION Type Of Num er: System: ` >4 OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Vent To Air Intake Length Dia- Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound 0 t-Grade s Only [Bed Over Depth Over xx Dep f xx Seeded / Sodde Trench Center Bed /Trench Edges Topsoil ❑ Yes E] No El Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 17. 9.,19,SE,SE 692 BLUE JAY LANE Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710(R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division ISConSin 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 than 8 1/2 x 11 inches in size. o See reverse side for instructions for completing this application state sanitary Permit Number ts The information you provide may be used by other government agency programs ❑ Check if revision to previous ap l,cation [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 / ` X1/4 1/4, / T , N, R E (o W Property Owner's Mailing A ss Lot Number Block Number b City, State Zip Code Phone Number Subdivision Nam/~' orrC~M N mber II. TYPE F BUILDING: (check one) Q State Owned ❑ it~ Neares Road ❑ VII age Public 1 or 2 Family Dwelling - No. of bedrooms own OF III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo ~°2 O ^ 7-60 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 ew _2.-❑ Replacement 3. E] Replacement of 4. E] Reconnection of 5. E] Repair of an stem __System_____________TankOnly______..... ____Exlsting System _________ExistingSystem 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?1seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 1Seepage Trench 22 ❑ In-Ground Pressure 42E] Pit Privy 13E] Seepage Pit 43 ❑ Vault Privy 14E] System-In-Fill lee. a 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 Re~uisq. ft.) Propose(sq. ft.) (Gals/day/sq. ft.) (Min./inch) Ele ion 61.1 Feet Feet TANK Capacity VII. FORMATION in gallons Total # of Prefab. Site Fiber- Exper. New Exist Gallons Tanks Manufacturer's Name Concrete strutted Con- steel glass Plastic App- s Tanks Tanks Septic Tank or Holding Tank 1200 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber PE-31 ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumbe ' ignature: (No S ps) IMP/MPRSW No.: Business Phone Number: r~ 5 T3 -1 r- ri, I - 3 -4 ~ ~z - c- --7 Plumber's Ac dress (Street, City, State, Zip Code): o 11 & 6 7-VVL IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent ignature (No Stamps) Surcharge Fee) W Approved ❑ Owner Given Initial ©2Q U - W Gi-7 I I "!v Adverse Determination i ! X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: S SBD-6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years- 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3151. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on 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 ?I 1 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. PLOT PLAN PROJECT ADDRESS d. S 1/45~1/4S N/R W TOWN COUNTY ~'r X ' _Y /97BEDROOM MPRS Shaun Bird 3532 DATE CONVENTIONAL -GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE,5~ LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE ABSORPTION AREA BED SIZE BENCHMARK ~ L~ SSUME ELEVATION 100' ❑ BOREHOLE O WELL *g,R,p, ~~l,~~rnc~~"~/r✓ VENT SYSTEM ELEVATION gC>? 12" GRADE TYPAR COVERING . 2'6, l,G.! vS,~ 12" 3' 3' 3'0 3' i ~ SEWER R K 18' ~~Z N ~ ;g xyg~ I 8a I , {fib ~ \ s allfi consin r)epartment of Commerce SOIL AND SITE EVALUATION Division of tafety and Buildings Page of Bureau of Integrated Services in accordance with s.. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in si .~I must i / include, but not limited to: vertical and horizontal reference point (BM a ion aC?oaf~o percent slope, scale or dimensions, north arrow, and location and dis to near YoE Parcel I.D. # N O~ O APPLICANT INFORMATION - Please print all inform t" ST CRo I)( Re mid by Date Personal information you provide may be used for secondary purposes (Privacy tN 15.04(l) (IiNTY Property Owner l ,Property ocation r' 9 i' ~I WL 4 S V/ N,R E ) W Property Owner's Mailin Address Subd. Name )CSM/////J City State Zip Code Phone Number ❑ City Vill ge Town Nearest Road New Construction Use: residential /Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: -7 Code derived daily flow gpd Recommended design loading rate . / bed, 9P 'U~ trench, gPd* Absorption area required gS~ bed, ft2~trench, ft2 Maximum design loading rate bed, gli ' D trench, gpd* Recommended infiltration surface elevation(s) ft (as referred to site pl benchmark) Additional design/site considerations r "CZ Parent material Flood plain elevation, if applicable S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank u= unsuitable for system ZS El u s❑ u As Ou /Ds El u ❑ s u ❑ s ~u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground 5- Ile S D 2 ; 8~ ft. Depth to limiting fa r Remarks: Boring # l Ground Depth to limiting factor Remarks: CST Name (Please Print) n e Telephone No. Address -Date ~ CST Number PROPERTY OWNER IQESCRIPTION REPORT Page ,Of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground O - yyfJ /L/ e Lev. ft ; Depth to limiting facti Remarks: Boring # r I ' I Ground elev. ft. I Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; I Ground elev. ft. Depth to limiting factor 'n. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD-8330 (R. 07/96) Soil Test Plot Plan Project Name Shaun i Address 01 13 o,< 73 c;? 6:41111t- CSTM #3922 Lot Subdivision D a t e S~ 1 /4z~1 /4r).~ T N/R::~g W Township Boring ()Well PL Property Line County BM or VRP Assume Elevation 100 ft.z System Elevation * H R P N~ d Ai is -3 - U ~ e M Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of _3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY ST. G~oi'x Attach complete site plan on paper not less than 8 1/2 x 1 t inches in size. Plan must include, but PARCEL I.D. / not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: U,y~/,PQ f PROPERTY LOCATION vL ~ / 0 / - G~iAl.P.y y GOVT. LOT sE 1/4 SE 1/4, 2~ 29 N,R /f (or) W PROPERTY OWNERS MAILING ADDRESS 91d LOT # BLOCK # SUBD. NAME M# # (Ptins~ 3 33~ .,t°oB TS ST L/ 0 !~4 }~UMRi PD 1' 0-5 CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE WN NEAREST ROAD T 1q/jUL 1'IN• 55/0/ (Grp-) 222-5SS5 +1UvSOtJ arty L,v New Construction Use [ /.}Residential / Number of bedrooms 3 Addition to existing building I ] Replacement [ ] Public or commercial describe o- Code derived daily flow Goa gpd Recommended design loading rate bed, gpoltt2 trench, gpd/tt2 Absorption area required -o~ bed, 1112 U trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpolft2 Recommended infiltration surface elevation(s) S-~ P !A • 3 ft (as referred to siteebenchmark) S Additional design / site considerations ~fSE 7-° ~ ~•ls' o ti S Al 14 w/ P o X ~ Parent material s s S Q P It' k 120 7- Flood plain elevation, if applibable 414- ft S = Suitable for system,_,~ MOUND / IN-G0-5 K O U PRESSURE A[]T-GS DE SY[T9 11 STEM- U O 3C- U = Unsuitable for system t~5 LTU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bourft Roots GPD/ft Boring # rHorizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed tench p-/Z !D y/ie ~/L S/ ~M r9~T ~I Q S - N tip- Z /~-zs /o UP 31(:~' sI Z shK rw~-ttf2 c5 ~f S Ground 3 1'/D l~,e S /4 0-5 S'q elev. 98L 7L ft. , Depth to s limiting factor~r Remarks: Boring # y ~o r~ 3/L ~s/ z,~, sd~ f~ s Z s 4; /y z r33 )G /o ye y/y .~7~' Of y/ Ground elev. y- /0/, 02- ft. Depth to limiting fact el PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z of 3 PARCEL I.D. # LO'F 0 - ~f u M (31 R D EF i !IS Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bou day Roots GPD/ft in. Munsell Qu. Sz. Conti Color Gr. Sz. Sh. Bed Trench , s. G Ground 3 G- 3 /o e y Sit z-F-S6, a S /of /D2 elev. y -SS ~,S S . 4= S G~~ c S 7 i Depth to S - /O s q. limiting > If/I Remarks: Boring # 3 F)--,y6 7,s ye y , S. O S dPlL , Ground elev. 0 io ye s C S S d - , "7 - ~p it. £ i Depth to limiting factor 7;L i i Remarks: Boring # /0 2/2- Imp 2- /0 yr c 3 -3 7,S0e y!~ - S D,S cS - - 00 Ground elev. l D//,P 5/gyp e'S d S 7 0 lOs ft. Depth to limiting I factor J Remarks: Boring # ! i 13 Ground . • _ _ o~P~tLt-- Lti . rzs cn s W O` O Q O °O Z Z Z ~ to °o 0 ~ a A Oo ~ L 'M Z rn o 0 .N b r CN, r ~ G O .c Cat, li W og W t,b w i N °3010 W 664.12' S S45°50'00°W " r 86.82' S44° 10'00"E 1'. 66.00' 7 / s ;,E3 2l'41 "E 463.13' So S9 S z S~ Sty S(3 ` S y w.. r S89° 30' 15"W 942.42 Y ,i; 1Ok Z tot 76 °2 7.4 m / 463. l ~ z l ~ r /19 2S> ~ 1 1' , 00 33' 33, ' EL =1005 LOT 62. I I I 1 1 2.30 ACRES N 100,072 SO. FT. N 01 O ! - No O - Ul 7 1 N° LOT 61 f o ~ 2.62 ACRES rn ~V rr + 113,914 S0. FT. N s I z -q y 0 OD 4+ w S89°20'47"W 265.16 (D W r ILL U ~ W W 1 .p 616, ' IL 62 LOT 59 W 337.' to I S810p4r 48 w 2.30 ACRES C v 100,069 SO. FT. 118 ' iA -CA cn 4 0 N 1 W i f'i 11 I 111 (0 ~ I ~.7 LOT 60 - W 11 1 2.01 ACRES hl 11 \1 1 87,557 SO. FT. .1 1 r- 11 ~ TEMPORARY 1 - / CUL- DE- SAC I Cl 17 - 23.99 265.16' \ -9 2Po 15 w w JO S89°47"W 289.15' rn m 16 8°' JAY -w --LANE 14 W N89°20'47"E 289.15' ~St, O gy ~2 - - 260.00' 13 9.15; - - \ N LOT 58 9yy O / -A 2.03 ACRES ~ o-TO / N ~yy T r 88,401 SO. FT. O 12 8 mm - LOT 56 w W o z 2.23 ACRES m m O 96.965 SO. FT. STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER CCh~~iIQ ,TD~ST I C-~ MAILING ADDRESS F o 6o x 72.2- /1W!!~5a-%1 w / n"_~ Fv~'~O~ ~6 PROPERTY ADDRESS C~ ~ j (location of septic system)) Please obtai rom the Planning Dept. CITY/STATE 6t " -110 /,z PROPERTY LOCATION J~ 1/4,55 1/4, Section l~ T-,2 LN-R~W TOWN OF 1111D--s 0 /J" ST. CROIX COUNTY, WI SUBDIVISION b~G'~MD 1711LGS LOT NUMBER O 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 expiration date. SIGNED: DATE: 31 ` / St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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 Location of property,SE 114J~A_-- 1/4, Section Township Mailing address ~'c P X 73 z ~ ,S v y~'-P Address of site 2 ,511o16 Subdivision name f~? /3 /LG<S Lot no. C1 Other homes on property? Yes No Previous owner of property ~"-z1-/-C---j ez,-? , Total size of property ~ l Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes X. No Volume and Page Number b 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 inf ~e o ice of the County Register of Deeds as Document No. t~ , and that I (we) presently own the proposed site or 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 o~ e of the County Register of Deeds as Document No. Signa u of Applicant Co-Applicant - 31-9/ Date of Signature Date of Signature VOL "li~ PA . DOCUMENT NO. vi STATE BAR OF WISCONSIN FORM 2-i98aI~ j .I 567359 - - - _ _ - W, REGISTER'S OFFICE Humbird Land... Corporation, a Minnesota Cor oration ST, 0O o. li R Ri ~ Roo ' OCT 2 4 1997 L . . . . I! c. , a tli scoffs i n.....••- 10:00 A 8 i' - In u triers. couw•ys and warrants to . RlchpW' . j~ Partnership laJala~ ; I <It3►wti I of Deeds r go. 13s- . - . - St Croix - - - _ ...County, tho folblwiol; describe.: real estate in ~ 3 07_~ Stale of Wisconsin: Tax Parcel No~~.----•• Lot 60, Humbird.Hills Third Addition, Town of Hudson; St. Croix County, Wisconsin i a F L f S. This is not homestead property. (Yo (is not) I I Exception to warranties: Easements, restrictions and rights-of-way of record, if ary t' October • 19 ..97 Dated this day of - ratio taebi rd Land rpo . ...........(SE:AL) (SEAL) Austin J. Baii on, Its Pres#dent (SEAL) (SEAL) la AUTHENTICATION ACSNOWLEDOMEN STATE OF jMC] IfRtIIIMINNESOTA tt Signature(s) Rase ss. County. Personally came before me this .-?•j-^• day of 7` - auihenticated this day of I 19__.._. 1997.... the above named 0 _UftC Aus~iQ_J.a.~)llonx-President.o I#,rlbird Land Cor -ration Hum P° . TITLE: MEMBER STATE BAR OF WISCONSIN (If not. . who executed the " authorized by § 706.06. Wis. Stats.) to me known to be the erson foregoin-, instrument and } NTY y, THIS INSTRUMENT WAS DRAFTED BY lACrii?ETON COU - .....fmLG4mla.fix8f,es-len.•3e:- r_-----jinn _ 0-11 Raillon