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HomeMy WebLinkAbout020-1108-90-000 r STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 44AI ADDRESS /x~S- e,~.>row/ A~Q/Gs SUBDIVISION / CSM# b51~';/~ks LOT # SECTION _3S- T~N-R_Zq_W, Town of , ,4L2ta1 ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW E ERYTHING WITHIN 100 FEET OF TEM 3 ,aP' r ,L INDICATE NORTH ARROW Provide setback ~nd elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 1 i BENCHMARK: ~ ZI L', d, T1-s,-,&41,012 h T f/7i i-17 ALTERNATE BM: _a=Z, SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity ~S 7d ~st/G' Setback from: Well, X478 House , S' Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSQRPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House Other ELEVATIONS i3- /0,/-~17 7 Building Sewer _ ST Inlet: / 7 ST outlet~b q/ PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: G _ 7 PLUMBER ON JOB: LICENSE NUMBER: 1.2 INSPECTOR: 3 / 9 3 : j t Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarg9492. Personal information you provice may be used for secondary purposes [Privacy L S.15.04 (1)(m)]. ftjqfqto,1de('s*lM: [ CP Rage Town of: State Plan ID No.: CST B%El Insp. BM Elev.: BM Description: Parcel T~~r -4106-60-000 -J7 , D TANK INFORMATION ELEVATION DATA A970 307 q s TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ~JU Benchmark //0' Dosing e2 % w0 / D0O ~~S ~./71 !o / Aerations Bldg. Sewer 8~9~ 0 6 Holding St/k* Inlet 10q. V7ova TANK SETBACK INFORMATION St/kK Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet , Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holdin Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction H Ft / , ~3 O, ~/O /~7 35 ForceTriain Length Dia. Dist. To Well SOIL ABSORPTION SYSTE / BED/TRENCH Width Len No: Of Trenches PIT No. Of Pits inside Dia. Liquid Depth DIMENSIONS DI N SYSTEM TO P / L BLDG WELL LAKE / STREAM L urer: SETBACK INFORMATION Type Of CHA ER model Numer: System: O NIT 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 7xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes E] No ❑ Yes E3 No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 35.29.19.421B,NE,NE 675 KI N Y ROAD L r~ e r~CL . v~ •<c~/ic~ d'~~ 2~ mi=l tr c~ / Tom' + n~ C c~JP 6, 7 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 SANITARY PERMIT NUMBER: Safety and Buildings Division e-.■la_r■r■ 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 J than 81/2 x 11 inches in size. J • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Prope Owner Name Property Location 114 - 1/4, S T , N, R )Aor) W Property Owner's ailing Ad S Lot Number Block Numb i City ate Zip Coe Phone Number Subdivision Name or CSM Number II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cityyage Nearest R d Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Vill Town OF 2~LS711A) III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo C, 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.VYNew 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 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. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./i 'ch) Elevation ,Z Feet Feet VII. TANK Ca in gallons Total # of Prefab. Site Fiber- Ex per. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the ndersigned, assume responsibility for ins I atio of the onsite sewage system shown on the attached plans. Plum er' ame (Pri Plumb 's S m s) MP/MPRSW NO.: Business Phone Number: Plumber's Address greet, ity, State, Zi Code): 3 ° ' e IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issue Issuing Agent Signature (No Stamps) Approved F1 Owner Given Initial Surcharge Fee) !LILO $ ~a/~ Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: safety & Buildings Divr ion, 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: I_ Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s); septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for rrionitoring groundwater contamination investigations and establishment of standards. ~c~ GUS s~©/o ls' op~ OCS,//p/U S~SUC m S~itO ~[Jleis/ j WI Ste' , uiE</ 3 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER - ADDRESS SUBDIVISION / CSM#_ 'G~ a're LOT SECTION ZjC T ?Q N-RW, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM tl ' r r<e • ~V Se~7 , t I / i 11 ~oY (µtNY /?r .1i -T 0 ( \ S7 Gi4 aX v y COCKY ZCNPNGOPR E ti 14~ . INDICATE NOR Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and kuman Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: PerKANmit r 's GREG [I City [I Village C1 Town of: State Plan o.: X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic .C,/~~ ~2 CAS Benchmark 7,75- V Dosing I O.-V Aeration Bldg. Sewer H ng St/ K 2/ Inlet /dy S' TANK SETBACK INFORMATION St/, KOutlet Verit TANK TO P/ L WELL BLDG. AirIto ntake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing N HeadertMan- Aeration NA Dist. Pipe /off y7 Holding Bot. System 42,24 PUMP/ SIPHON INFORMATION Final Grade Manu curer and Model Number GP TDH Lift Friction System TDH Ft Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Insid Li Depth DIMENSION S / 3 DIMEN I N SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACH Manufacturer: SETBACK INFORMATION Type Cin,t.r ckr,S CH,, BER Moe Number: System: >/<~Z OR UNIT DISTRIBUTION SYSTEM Header/Manifold / Distribution Pipe(s x Hole Size X Hole Spa Vent To Air take Length Dia. Length 2 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grad stem [D~ep~th Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched /r 71 Trench Center , Bed./Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Hudson.36.29.19W, NW, NW, Kinney toad 2D D Plan revision required? ❑ Yes 0-1410 Use other side for additional information. Q SBD-6710 (R 0"I) Date Inspector's SicInatur Cert No. Safety and Buildings Division l~•■Lnttn 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 Count than 8 112 x 11 inches in size. S~ . • See reverse side for instructions for completing this application State Sanit ry ermit Number The information you provide may be used by other government agency programs ❑ Check it revision to prevt us application lPrivacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINTAL INFORMATION Prop Owner Name Property Location X1/4 1/4, S T,2 , N, R l 4VE (or) Property O er's Mailing Address Lot Number Block Number ,,i O ac.t-~ s City, State ) Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road ❑ Village ❑ Public 1 or 2 Family Dwelling - No. of bedrooms 2ot- pipiown OF Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1❑ Apartment/ Condo 4 2 G- 6 Q 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 _ rpT 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 11 X1 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 RSeepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation ~e-d lit /3a ot C<- Feet SOS, 2 Feet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank c ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ EL I ❑ 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) P/ PRSW No.: Business Phone Number: 1110 a, .Z f S ^ 3P'6 -_5Pi.7 e Go 'Ili u s.-c .3c k a m a, Y lJ Plumber's Address (Street, City, State, Zip Code):-- 16 ? d s o ?-,e- l'2 1V. IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (IndudesGroundwater ate Issued sluing A nt Signature (N Stam ) ❑ Owner ply/W Surcharge fee) A roved pp Given Initial Adverse Determination X. CON ITIONS OF APPROVAL / REASONS FOR DI APPRnOV Ired~G.¢6! K .~..ee.1~ .sYcX~° -u-n ' pR.~ Y E 9 ~a.rJ.d e {//.J~ ~ s s c T d2 Y R Z !J ~4 Qa~~e s T~u/efh/~. ~sd c/ U 4i .Q s U v1 J ~a 4 _ aL a 4-1, o~ 3 p Q ~n n Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Ls~por and Human Relations Division of Safety 8 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 St. Croix 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 t 020-1106-60 APPLICANT INFORMATION-PLEASE PR REVIEWED BY DATE PROPERTY OWNER: OPERTY LOCATION Greg Kanne R~ , O VT. LOT NW 1/4 NA-14,S 35 T 29 N,R 19 ta(agr) W PROPERTY OWNERS MAKING ADDRESS T If BLOCK # SUED. NAME OR CSM # 2204 Hanle Rd. na na 80 acres CITY, STATE ZIP COD PHONE NI~MB qq CITY QVILLAGE QCOWN NEAREST ROAD Hudson, WI. 54016 X75 )386:~~r74 ,F Hudson Kinney Rd. :jai New Construction Use (x ] Residential /•NJmber of Odrooms 7 Addition to existing building j ] Replacement Public or commeerriCae' Code derived daily flow 1050 god Recommended design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2 Awvrption area required 1500 bed, ft2 1313 trench. fc2 Maximum design loading rate • 7 bed, gpd/ft2 •8 trench, gpd1ft2 Recommended infiltration surface elevation(s) 101.70 It (as referred to site plan benchmark) Additional design / site considerations na Parent material outwash Flood plain elevation, if applicable n/a ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for svstem US ❑ U ®S C ]U EIS O U ®S ❑ U OS ®U ❑ S :E] U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure consistencelBotndary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed tt3hd ,{~Y.x~.t{3,xvCIX 1 -8 10yr3/3 none 1 2msbk mfr gw f 2 -11 10yr4/6 none sil 2msbk mfr gW if .5 .6 Ground 3 11-22 7.5yr4/6 none is Osg mvfr gW na .7 .8 106.3n 4 22-96 7.5yr4/6 none co s Osg ml na na .7 .8 Depth to limiting AM Remarks: Boring # 1 0-12 10yr3/3 none 1 2msbk mfr 9W 2f .5 .6 2 ? 2 12-20 10yr4/4 none sil 2msbk mfr gW if .5 .6 ~4x~ 3 20-28 7.5yr4/6 none sl 2m sbk mvfr gw na .5 .6 Ground elev. 4 28-84 7.5yr4/6 none co s Osg ml na na .7 .8 104.7ft, Depth to limiting factor +84" Remarks: CST Name =Please Print Gary L. Steel Phone: 715-246-6200 Address: 1554 jq2th. Ave., Ne Richmond, WI. 54017 Signature: - / - - - Date: CST Number. PROPERTY OWNER Greg Kanne SOIL DESCRIPTION REPORT Page 2,, of 3 . PARCEL I.D. x 020-1106-60 Depth Dominant Color Modles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Roots Bed ITren ch z 1 0-14 10 r3/3 none sl 2mgr mvfr cs if .5 i .6 2 4-84 7.5yr4/6 none co s Osg ml na na .7 .8 i Ground MT. 8ft. 1 Depth to limiting factor +84" Remarks: Boring # 1 0-17 10yr2/2 none 1 2msbk mfr gw 2f .5 .6 4 2 7-29 10yr4/4 none sl 2msbk mvfr gw if .5 .6 mid 3 9-78 7.5yr4/6 none cos Osg ml na na .7 Ground elev. 99.2 ft. Depth to limiting factor +78" Remarks: Boring # 1 -10 10yr3/3 none 1 2msbk mfr 9w 2c .5 .6 5 2 0-24 10yr4/4 none is Osg mvfr gw lm .7 .8 <v 3 4-80 7.5yr4/6 none co s Osg ml na na .7 .8 Ground elev. 100.2 ft. Depth to limiting factor +80" Remarks: Boring # Ground elev. ft. Depth to limiting factor i i Remarks: SBD-e330(R.05/92) STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 Greg Kanne New Richmond, WI 54017 MPRSW 3254 NE4NE4 S35-T29N-R19w (715) 246-6200 1 town of Hudson IN 1"=40' BM.= top of 1" steel pipe C el. 100' Alt. Bm.= nail in tree C el. 105.00 00 for ~.2 ' I O 0~ ~m ~ S; k t AIN - 1b K, 3G' 1001+ o ~o t-b. ~ ~.In t= C) Gary L. Steel 7-26-95 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER (p 12 C-_6 0 2 MAILING ADDRESS D~' /fIi'!{C.~Y T/itOsox~ meu&y A PROPERTY ADDRESS 675 e (location' o--f septic system) Please obtain from the Planning Dept. CITY/STATE itI~Sc .5- JO ~gT;90#& w~P.Aafi'y D~FD PROPERTY LOCATION /4, 1/4, Section , T N-R W TOWN OF kjLt0SOAJ ST. CROIX COUNTY, WI SUBDIVISION AJCAJE_ LOT NUMBER L. CE -MAP g3 63 /,VOLUME M, PAGE 7 , LOT NUMBER ,yo .~C DocuM~~•r ~ 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 expi on date. SIGNED:- DATE: 7 .~3 St. Croix County Zoning Office Government Center 1101 Carmichael Road Eludson, WI 54016 11/93 8 T C - 100 e 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 o f property c coe U • K<N f1 Ap- F -9 - Irr7n(V 1Z 7Y Location of property 1/4 S 1/4, Sec ion , T N-R--W Township_ S'T, CQ6jk Mailing address 220 H RoO LE e KQ V 7 u. O is c, q 0110 Address of site Lr S Kttom&'( P.p p$o~ SAOl Subdivision name IJ64E Lot no. /)0.06- Other homes on property? N LE x No Previous owner of property NLE U AFFod.Tr2 A-fj10 OTHE25 SEE /t~~CNE~ Total size of property -1 to ACP-e-S ~ Total size of parcel -1(0 Rc o L-5 Date parcel was created TP03 . 4. 19 9 3 Are all corners and lot lines identifiable? Yes _2~,._No Is this property being developed for (spec house) ? Yes .mac No Volume 30 8 and Page Number 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 iq tY~e office of the County Register of Deeds as Document No. _!3 (030 , 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. 2193 63 / . A%,A 0,CWPAA Signatu Applicant Co-Applicant rl /93 /76- DatE( of ignature Date of Signature = DOCUMENT NO. WARRANTY DEED Tins srACF. nr.scnvco FOR RECORDING DATA ii ' i STATE I3,jjR OF WISCONSIN FORM 2 - 1982 - - 433631- - - VOL 988PAGE 414 REUISILR'S 61111(1 Dale W. Affolter, Debra M. Affolter, Jerry L. Carr, Judy ST. CROIX CO., WI L 0"1• v. Carr, Daniel G. Affol ter, Cindy L. Affolter, and. ;I Recd for Record Je-ann.ie..A...Affolt-er._,.-.aLk/. JAN 5 1993 Jean n.ie..T.alb-er-.t..V.an..B.eek_, .;is..tenants...in..commQn 10:00 A conveys and warrants to _Gregory..W....Kanne...... 8t f ~ M ovax RETURN TO the following described real estate in .........County, - State of Wisconsin: Tax Parcel No: All that part of NEI of NWk lying South of Interstate "94" in Section 36, Township 29 North, Range 19 West. All that part of NWI of NWI lying South of Interstate 1194" in Section 36, Township 29 North, Range 19 West. North 350 feet of SEA of NWI of Section 36, Township 29 North, Range 19 West. North 66 feet of SEI of NEI of Section 35, Township 29 North, Range 19 West. Subject to easements of record. Beginning at a point on the North line of the SWI of the NWI of Section 36, Township 29 North, Range 19 West, 132 feet east of the Northwest corner, thereof, thence West 132 feet, thence South 66 feet, thence Northeasterly to the Point of Beginning. MANSFEK $1 M-0 FEB This i.s-.not......... homestead property. QOX (is not) Exception to warranties: Dated this . day of . . . rnrn .!C..~ --...-(SEAL) ..ll.~.... _ (SEAL) A l a W. f of ter De ra M. ffo ?w.~ (SEAL) * - -..........(SEAL) Je L. tar y:L~~1~Carr • (SEAL) I.11W.Lo (SEAL) Daniel G. A o ter dy L. A f It t, ~ vv *._.......Ql......(SEAL) Jeannie Talbert Van Beek ~7C AUTHENTICATION ACKNOWLEDGMENT Signature (s) STATE OF WISCONSIN ss. ~ . ...County. P t FAX ST. CROIX COUNTY ZONING OFFICE 1101 Carmichael Road Hudson, WI 54016 (715) 3864680 DATE: TO: Fax Number. 7 0 7 8 Name: (/C FROM: Fax Number. 386-4686 Name: jLda4 Number of Pages Including Cover Sheep. IF COMPLETE- AND LEGIBLE INFORMATION IS NOT RECEIVED, PLEASE CONTACT: NAME: ~a TELEPHONE NUMBER: 3~Ip - gd