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HomeMy WebLinkAbout020-1314-90-000 STC - 104 RfC~ AS BUILT SANITARY SYSTEM REPORT EIVEO JU OWNER e sr 199? ~CROrx ADDRESS ~.~p~6'•S~C;>G z0"RJ SCE SUBDIVISION / CSM# LOT # SECTION,,,2,f_Tc2q~_N-R W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I s;z y' 4A y INDICATE NORTH A ROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. n / BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ,(Liquid Capacity: Setback from: Well House _3Q Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Z,2 Length 7~ / Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House Other ELEVATIONS Building Sewer __1-- ST Inlet: 9~',.?5= ST outlet: PC inlet PC bottom Pump Off Header/Manifold ; Bottom of system Existing Grade a; Final grade DATE OF INSTALLATION: PLUMBER ON JOB: /r, LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Ruman Relations INSPECTION REPORT ST. CROIX Safety and Buildings ngs Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284263 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: PERILLO TOM HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 020-1314-90-000 TANK INFORMATION ELEVATION DATA AQ7nnnio 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. Vent to ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. I --A Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction Syestem TDH Ft Loss Forcemain Length Dia. FFii Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth DIMENSION DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM INFORMATION Type Of CHAMBER Mode Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size 7-x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing _ I j 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.28.29.19, SW, NW 517 JOSEPH CIRCLE 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 via~riR SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size-- a~* / • See reverse side for instructions for completing this application State Sanitary Permit Number (/10 4,g 3 The information you provide may be used by other government agency programs ❑ Check if revision to previous application lPrivacy Law, s. 15.04 (1) (m)1. C' r l State Plan I.D. Number . at_ 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property O ner Na Property Lo ation AZ Vi /4 j 1/4, S 1;22 0/ , N, R F,/(or6 Property Owne s Mailin Address I Lot Num er Block Num er City, t to Zip Cod Phone Number Subdivision,Na or CSM Num er ( ) 7/, ) II. TYPE OF BUILDING: (check one) ❑ State Owned City Nearest oad ❑ Public 1 or 2 Family Dwelling - No. of bedrooms Town OF S " E ,4ZLI~,y III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) © /s1~-- aS.a9.19.~s9 1 E] Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. [ANew 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 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. ate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed sq. ft.) (Gals/day/sq. ft.) (Min./i ch) Elevation ZW 1 t S'e L 7 Feet Feet VII. TANK Ca in alloacits Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete con- Steel glass Plastic App New Exis tin strutted Tanks Tanks Septic Tank or Holding Tank E, ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the ndersign~d, assume responsibility for inst la gon of nsite sewage system shown on the attached plans. Plum s Name rP Plumb 's S atur mps MP/MPRSW No.: Business one Number: Plu ber's Ad ress greet City, State, . Code): IX. COUNTY / 15EPARTMENT USE ONLY ❑ Disapproved Sani ary Permit Fee (includes Groundwater Date Issue Issuing A nt :igna ure (No St ps) Approved ❑ Owner Given Initial ~a Surcharge Fee) 7 Adverse Determination Q X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SHD-6398 (R. 05/94) DISTRIBUTION: Original to Counly, One copy To: Safety & Buildings Dim.ion, 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, 608-266-3815- 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 10 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 (--ees) 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 Y ~ 7 S~ : r.l,enlsmIj /Vl) -S cc c~ -Toil X /Ql it f , i ~f.l2S9~ I i t j i i t i j 1 y ' R E~ V f D MAP 0 5 ;1997 I ~ ~ ~ , ~ I I I ~ I i I f f i i II I ; I 1 i i. I 7 r i 1_ _ ~ ! 1 I ' _ i ~ f ~ i i ~ ~ ~ I I I i t I ' i t ~ i ; , , , i I I i ~ I I j ~ , i ' I y , _ ~ - i ~ ~ ~ _ ' f i ~ I I I I I I ~ i -t_-f I 1 1 I} 1 l i i~; 1 ~ ~ I i , ! ! t ~ t + r i_ ~ I I I j # ! ~ i j j i i j ; i ' j I i } ~ I ! i } I i 1 I f I i I i i I I I t + I i ~ ~ ~ I 1 I~ t I ~ I t ~ ~ ~ , ~ j j i I i ~ ~ J- ~ ~ t ~ j ~ ! ~ i I i i I f i , ~ ~ ~ i , ~ ~ I, i ~ ' i I t ~ ~ I + i t_ ~ I j + ~ ~ t _ i 1~ ~ i~ I t i ~ ~ i ~ i ! i I 1 ~ ~ ~ ~ I ~ j 1 1 I i f ~ t + ~ ~ f- } j i i j I i i I I I i ~ i I I I ~ ' ` I ' ~ I ! I t t ?i i I _ . ~ ~ ~ ; ~ i' , ~ j ~ ! I ` ~ - - i ~ i i ~ I i 1_ i I t t I{ d t I i j; I i j{ i i i i ' ~ ~ ~ t t } I ; IL ~ i J } ~ I { ~ i ~ ~ ~ ~ Ili , ~ ! ~ ~ i ~ ~ t ~ j } ~ ~ ~ i ~ C f~ I I 1 ~ t f I ~ ~ t `r ! r ~ i ~ j I ~ { y ~ ~ ~ ; ~ ~ ~ ff I I ~ I } 1 ~ ~ 4 i } I t t t t r t I- ~ ' I I 1 ~ ~ ~ i ~ ~ i s"✓os _1 k1ill®' t x`07 ~ + j MI RIECrIYEP M,AR 0 IW. f}+ I}} i j j t J ! ; i i ' ! I ' I j~ f f t ! ; I I , i i ~ fI i ~ , ~ t 1 } II . ; } ; i I I i i I ~ } . I } i~ f f ~ - ? f!~ I i i 1} I I ~ 1 i~~jj ~ ~'~~I ~;i i{j ►1j~-i f! i c ~ I~ 1 1~ f J ! i i i • i ~ 4 I ~ i j a { { I j- ~ ~ I i j_~---- } ; FROM :ED:NA REF*-TY HUDSON 1997,03-01 13:51 #967 P.01/02 17•`-~J:'!11Gf~ il'I ,7:•~• JJY. ~J1_I!'1..~•1 f I ~ ~t~l'1~ / I I I ` r 1 !'u• _~li: "'>~r,~ijl~' §ati'ctA~VT fFk at_~~~ 1_•L~ ili• 'rx. •IC~I!. 5•~!J ® I . i 1310.32' IN 09'2b' 26"C •e ~ Mo117+1 lIR[ 01 hl[ 6wV4 Of TII( NWW, f(CT. T[ fil 040,61• r i sel•I.' - _ i=6.i/' ^~.lJi.~r'• J iA7.7i• l M K.(N.%so? I loon nmf r. u"o N' b una !a Tii F r=l4,Ae' •g ei.IeT p, I f. / - K : roof.. w .."c y- ~ ~i ~ / 2 F f.M wcni3 cn ~ .Nr 8,43 AOIC/ ~ ; 6t.f61 6J./T. r 3 'h le.eii as. /T. r r r w~ l,e6 ACRES leo.o{= 6a rt. Fib I n 0e. Foe. Ism, tl~ v Rc.nu• so, FT .l OF N rte''/ i, • f AC 11I (y,Ir ' 'i- ►1T'N ISI'ma 8%Ff. 1 / o to jil. 10 3.16 MASS" .c.IT 4 O ACRES 2.411 IfLbe F-. j R- AC. ESG faM=; a.IT. r II so. 68.391 r OGj r ! . 1 ~ • I / ~ J J V 13 I J ACRif i Q I O °a z 4ee.~=• l ~ tu.feQ eQ.tT. t r! ~o' 1` m N w 1.44 ACRES I 1 NTH l•rd° r. , N 101.416 6o. FT. 1 1e r 1 ~ ~ I { ~I 1 1 10- v U Y O w a w .4$.41, A 1144-40 *16' , il~ i ' L li 4, SW 10. FT. m ~ w. 1 T.i[ At. [LC, ieMTl. 94. F7. CAP 6,Fe ACn[a t 1 \ ,1 •1.100 10.11 \`C 7,Oe win[i FL • is S 1 e1.11F / . c Lo I S n , I.r• I .q j IF =,!I lcn[i 0 1~ Y U) } t ''6 DTI . 1; ~rI Ipl.{ae',s~o1.rt W i/ t Z.n Aellc= 8 4~ I:1.t[e io.•r. ^ 1.11, K. [AC CaAlf I `CV _ r ee.T/e fo,/T. , y J RTfn ._Lii;; OSEI'' rae AC. ac. c:wr a / fI.Tr T .1 }~k~ sq. FT. w e0 CV-11A-1 r~? 1 i+y I _'i ~ ~r+ yA•N A:Ris nei I 'V~ 1 I V ~y7 \ 1 rI 61,114 Mel, ~ y UII I+ ZIP 441 F T. .7 01, 06 Sq. i3MT~i I I ~1 ~r I aL [5.103 aQ FT. I I ~7 ' I (,p 1 1 p• ' il*l T I • [a luv"o IN1C o1l~n SwV4 01 114 nM1/t I,. ; {i = - w lez.7l' 114 . 114 - r..- - 044 I ► Ass 00' --t-~ . \t• INw '57.7.49'" ~ sS9"47'16"w 710.67' Se 50'02"w •wv4 COOMER ~•p (j a(CTw#1 of W r J 1^t i. r1 17• ~I^.~ AII(R 00mumerr, ra1RS ^J fAl1llY,b.1M'Cn 41'-714t -e 7 l~ l~ Z 4,1 z Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page of 2- 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 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Govt. Lot 1/4 114,S T N,R E (647 Propert y Owner's Mailing Addres Lot # Block Subd. Na a or CS # City State Zip Code Phone Number Near st Road ( ❑ City Villa e ® Town New Construction Use: Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate 7 bed, gpd/ft2 d_ trench, gpd/ft2 Absorption area required, _8s'8 bed, ft21reench, ft2 Maximum design loading rate __7 bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site con iderations Parent materialf Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system [Z S❑ U S ❑ U ~&S ❑ U S ❑ U ❑ S 2 U ❑ S 03 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. C t. Color Gr. Sz. Sh. Bed , Trench ' a 0 )A) 6 3 Ground - Depth to limiting factor Remarks: Boring # AIIA - 3 G a2 S .5 /s y 7 8 S e Ground 7-3- 110 Cap ev. Depth to 5 limiting fa for ,>in. Remarks: CST Nam ease Pri ) Signature / ~ZZKT Telephone No. L~ Address Date CST Number SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Co t. Color Gr. Sz. Sh. Bed Trench 1 157 1 4, Ground Alkk 9-.Z!!k Al 1A Depth to limiting factor Min. Remarks: Boring # -7 jo Ste' v Al S ~j Ground elev.. X Depth to limiting factor Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. ont. Color Gr. Sz. Sh. Bed Trench Boring # v 42 V-) w S Ground elev Depth to limiting factor ?`min. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) W:+s m intiepartmentofIndustry, SOIL AND SITE EVALUATION REPORT of 3 Labor and N;iman Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code CO ~ n r z ' Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but 5t. x not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or JARqL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION WED BY DAT PROPERTY OWNER: PROPERTY LOCATION John Rauchnot GOVT. LOT SW 1/4 NW 1/4,S28 T 29 N,R 1(or) W PROPERTY OWNERS MA!i.ING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 527 Co. Rd. #W 9 na St. Croix Es e CITY, STATE ZIP CODE PHONE NUMBER CITY E]VILLAGE MOWN NEAREST ROAD Hudson, WI. 54016 715)386-3052 Hudson Crosby Dr. New Construction Use k j Residential / Number of bedrooms [ j Addition to existing building (j Replacement [ j Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate . 7 bed, gpd/ft2 .8 trench, gpd/ft2 Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate . 7 bed, gpd/ft2_,a__trench, gpd/ft2 Recommended infiltration surface elevation(s) 96.13 ft (as referred to site plan benchmark) Additional design / site considerations alt. site = 94.98' Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE I AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for svstem ( gJ S El U 91S clU ®S ❑ U S O U ❑ S 12U ❑ S 97 U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed WT_ 1 0-6 10yr3/3 none 1. 2msbk mfr CTW if .5 .6 1 2 6-18 10yr4/4 none sicl lfsbk mfr tna w if .2 .3 Ground 3 18-24 7.5yr4/4 none is Osg mvfr w na .7 .8 elev. 4 24-84 7.5yr4/6 none co s Osg ml na .7 .8 99.33 ft. Depth to limiting factor +84" Remarks: Boring # 1 0-8 10yr3/3 none 1 2msbk mfr gw if .5 .6 24 2 8-18 10yr4/4 none sicl lfsbk mfr gw if .2 .3 3 18-25 7.5yr4/4 none is Osg mvfr 9W na .7 .8 Ground elev. 4 125-88 7.5yr4/6 none co s Osg ml na na .7 .8 100.0:~- Depth to limiting factor +88" Remarks: CST Name _Please Print Gary L. Steel Phone- 715-246-6200 Address: 1554 200th. e. New Richmond WI. 54017 Signature: Date: CST Number: ~1 11-4-95 cstm 02298 PROPERTY OWNER John Rauchnot SOIL DESCRIPTION REPORT Page 2 of.t3 PARCEL I.D. # pendinct Boring # Horizon Depth Dominant Color Mottles Structure I lBourrivy I GPD/ft in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Bed iTmnch 3 1 -8 10yr3/3 none 1 2msbk mfr if .5 .6 2 -30 7.5yr4/4 none is Osg mvfr gw if .7 ;.8 Ground 3 0-84 7.5yr4/6 none co s Osg ml na na .7 .8 Depth to limiting factor +84 Remarks: Boring # 1 -7 10yr3/3 none 1 2msbk mfr gw if .5 .6 4 2 -14 10yr4/4 none sicl lfsbk mfr gw if .2 .3 3 4-24 7.5yr4/4 none is Osg mvfr gw na .7 .8 Ground elev. 4 4-80 7.5yr4/6 none co s Osg ml na na .7 .8 97.981t. Depth to limiting factor +80" Remarks: Boring # 1 -13 10yr2/2 none 1 2msbk mfr gw if .5 ' .6 5 2 13-28 10yr4/4 none sicl lfsbk mfr 9w if .2 .3 3 8-36 7.5yr4/4 none is Osg mvfr gw na .7 i.8 Ground elev. 4 6-80 7.5yr4/6 none co s Osg m1 na na .7 .8 98.33 ft. Depth to limiting factor +80" Remarks: Boring # Ground elev. ft. Depth to limiting factor i Remarks: SBD-8330(R.05/92) x STEEL'S SOIL SERVICE Gary L. Steel John Rauchnot` 1554 200th Ave. CSTM2298 WIWI S28-T29N-R19W New Richmond, WI 54017 MPRSW 3254 town of Hudson (715) 246-6200 lot #9-St. Croix Estates N 1"=40' BM.= top of steel pipe C el. 100' Alt. BM.= top of 1" steel pipe C e1.102.30' A1~ _dD 1 ~ -7, z~ 21z' AGa L. Steel 11-4-95 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 _zo>. Location of property Sc</ 1/4 M-1.) 1/4, Section Ze<, TAN-R_Zf_W Township Mailing address 45-7 Ttv E -5~61'1s , 1/ 4ul NO Address of site Subdivision name ~e 1 5 /q' Lot no. 9 Other homes on property? Yes )e No ` Previous owner of property ~A0 lCAc~ Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? ~C Yes No Is this property being developed for (spec house)? Yes K No Volume .42Z-L and Page Number S7~z 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. 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. ignature of pp is nt Co-Applicant -21- Date of Signature Date of Signature - o STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 10-.-1 MAILING ADDRESS 7 T PROPERTY ADDRESS (location o septic system) Please obtain from the Planning Dept. CITY/STATE C45 !n~ / PROPERTY LOCATION _ 1/4, N-J 1/4, Section $ T _L-7 N-R~W TOWN OF JS ~^f ST. CROI K COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year ex iration date. SIGNE . DATE: 24- rJ7 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 5g412G VOL 121.6PAcE5,96 DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 WARRANTY DEED Roc' J got Record Bridgeland Development Company. a Minnesota corporation I JAN 6 1997 11:35 A. conveys and warrants to Thomas L. Perillo and DianL _]?eriilo husband and wife of UnU4,, the followin„ described real estate in St ;Croix C omily, State of Wisconsin i mi; "Nfiill 11loii111Cir to fNii f 104 . _hontcstead propcrty, (is) (is net) Excehtiorls 10 Warranties: P l:) tied this 171h -_clay of __Dcc;entUcr, 19------26 ~j Po/~ " Ncal KrryLaatimsij ct AVFHENTiCCATI ON A0-"KN0!YT; XQJ",'i' Signatures authenticated this _,__.---____-__-----_~___cpay of STATE O MINNESOTA Dakota County F;:rs n aiiy c;anic befb c cuc, this ?7 --_ur.y vi` mace; TITLE: MEMBER STATE BAR OF WISCONSIN _ Neal K z~zas~ik_-._ (If not.-_ authorized by 706.06, Wis. Slats.) 'I'bis instrument was drafted by ~ ~ _ to me known to be the person who cxc: u cc: tit; I3ridgcland PjnLelovmen Co any foregoing instrument and acknowledged Lh.- sxnai . 2t)1 ti_ Eccnic Tr. Suite BL,& iite NN 55044 (Signatures may be authenticated or acknowledged. (loth are not necessary.) ,4,. °A °i.. # mi-ITArty Put"10.._ _ Notarv Public nt!n:v i3 S J~A ` r ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 I ~s (715) 386-4680 June 25, 1997 Hartmann Homes Inc. 103 Main Somerset, WI 54025 RE: Septic Inspection for Tom Perillo To Whom It May Concern: An inspection of the septic system for Tom Perillo's property was conducted on May 30, 1997. This property is located in the SW1/, of the NW1/ of Section 28, T29N-R19W, Lot 9 of St. Croix Estates, Town of Hudson, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a four (4) bedroom home. If you have any questions regarding this, please contact our office at (715) 386-4680. Sincerely, homas C. Nelson Zoning and Environmental Health Specialist sm