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HomeMy WebLinkAbout022-1076-70-100 STC - 104 AS BUILT SANITARY SYSTEM REPORT.. OWNER ou `UN~ rY ADDRESS wty Fw~~! bJ 1 S4oZL SUBDIVISION / CSM# V 1(i p, age 6 LOT # SECTION 34 T' R N-R 8 W, Town of k,etc- ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 9 011 i-~u n P r- Q L 9l- c 0 I e a1~1 to0.p1 / 00 + G 1-2 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: Top T4 ~GGC F2. 100, 0 ALTERNATE BM: Goy. c v t`~r_ s /e L cif J'L, 162)? SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Wkeh, Co~-~ Liquid Capacity: IQSa Setback from: Well wa-r i'N House 5 ' Other N T P ! 7, I'D, Pump: Manufacturer Model# Size - Float seperation Gallons/cycle.- Alarm Location - SOIL ABSORPTION SYSTEM Width: Length / o o Number of trenches i Distance & Direction to nearest prop. line: 450 Setback from: well: w.nrtr House Other ~ ELEVATIONS Building Sewer ~06,)7 ST Inlet: 105,20 ST outlet: PC inlet - PC bottom Pump Off Header/Manifold 4S-S1o Bottom of system 9,SS Existing Grade 97.5 Final grade f?, .1 DATE OF INSTALLATION: f 9 PLUMBER ON JOB: C w,+ L,41 <<, LICENSE NUMBER: 17 ?0 INSPECTOR: 4hv "~6K 3/93:jt Vyisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Bpildings Division (ATTACH TO PERMIT) sanitary Permit No.: GENERAL INFORMATION 284339 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: PESKAR, RONALD & ROBIN KINNICKINNIC CST BM Elev.: , Insp. BM Elev.: BM Description: Parcel Tax No.: / -U . GU /OD Ga, zZ 6-S C._G )L 1 022-1076-70-100 TANK INFORMATION ELEVATION DATA s , v TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic PS.n_:,r' !!:,rt Benchmark 66, cd / Dosi ng- /-0 7 7" Aeration Bldg. Sewer 11/34 p(, 17" Holdi-Pe St/ F Inlet 5- '34 S,a p' ANK SETBACK INFORMATION St/I f Outlet oV 27i TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake NA Dt Bottom Septic Dosing NA Header. 6 5/' S SG' Aeration NA Dist. Pipe --;Zp Hal#drng Bot. System 9• SS PUMP/ SIPHON INFORMATION Final Grade M a n u u r e r Demand 77 /67 Model Number GPM 7 TDH Lift Friction System TDH Ft Forcemain I I Length Dia. Fi Dist.Towell SOIL ABSORPTION SYSTEM I PIT Of Pits Insi Liqui pth BED/TRENCH width/~ Length, No. Of Trenches DIMENSIONS t J DIME N SYSTEM TO P/L BLDG WELL LAKE/STREAM LE NG acturer: SETBACK AMBER INFORMATION Type O ,7~,. 0 , Moe Number: MB System: 7~ OR UNIT DISTRIBUTION SYSTEM Header / Distribution Pipe(s) / x Hole Size x Hole Spacing Vent To Air Intake / ~L- / i Length 7 Dia. S< Length Dia. y Spacing C~ SOIL COVER x Pressure Systems Only xx Mound Or AtTjxx a Syste I e Depth Over Depth Over xx Depth Of Seeded/ Sodded xx Mu c Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: KINNICKINNIC.34.28.18,NW,NW 1206 RIFLE RANGE RD LOT 1 ,..<.x'~.,L4 i x?'f 'i 1" a - -16- ;'r (nom-.--,t 7 CSC. ~~r 1. A.L (nf"y[~. GYr... 4"~ Plan revision required? ❑ Yes ❑ No Use other side for additional information. FT1 IJ SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division ~.■I`r■rt 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 1/2 x 11 inches in size. Oral 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 Pro erty Own r Name Property Location o A a~y Q r 5 Wbtl 1/4 i4l 1/4,S 34 T a8 , N, RIB x(or) W Property Owner's Mailin Address Lot Number Block Number 254 t d na A Cit State Zip Code Phone Number Subdivision Name c CSM Number 01 I .9 a 9 /L ktote 1=~ jl W ` .540 Z-- 1(7)5-) I 11.0- 554 II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Clty Nearest Road n Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Town OF ~t wrulc ktnn t L~ R.1 III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 0 O OZZ- V0747 -70 1 ❑ Apartment/ Condo 2 ❑ Assembly Hal[ 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 120 Service Station / Car Wash 5 ❑ Hotel / Mote[ 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. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System SystemTank 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. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation Q Q ' © 00 1111 4 , S Feet q 7.6 Feet 1/II. TANK Caacit in gallons Total # of Prefab. Site Fiber- Exper INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank or Holding Tank 1200 1 zoo YVtij W tS~ i2i,ea• N ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumb r'sSignature: Po Stamps) MP SW O.: Business Phone Number: C, 6L I I r H Cc 'e f,3) l S 42S X17 Plumber's Address (Street, City, State, Zip C de): /04Z S_jog, s k er tT ~l a' 5 v' Z IX. COUNTY/ DEPARTMENT USE ONLY V Approved Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) 17p Approved F1 Owner Given Initial *01 Surcharge Fee) T' Adverse Determination /Ifo X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Divi.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: 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 8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Fresh Air Inlets And Observation Pipe P. • L "AN ap o r Approved Vent C 10 ulrjmum 12" Above Final Grade SIZ11-Z vf• ~A)iS...~.1:.54922::...`: 20- 42" Above Pipe. _ 4" Cost Iron caw P ;41i, Vent Pipe _lp!'~f✓W-- To Final Grade Synthetlo Coverlnp• win. 2" AggregoII Over Pipe Oletrlbutlo. Pips 0 0 0 0 0 -Tee 6" Aggregate Beneath Plpe i 1 Nor*~ OW15LL e Scc~~c ga 4 9ue- ` ove t1p ►f,;~ ~,c+ o- j~ (3m 100.0, 5" r 00 75 1z f3 S o r A 1 Tt,,.F~r~ ~ f3 Z-• -ISO! Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page \ of 3 Labor and Human Relations DiviLion of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8112,;K"~,1 i si must include, but not limited to vertical and horizontal reference point ABM), direction a f , scale or PARCEL I.D. # dimensioned, north arrow, and location and distarfce to neare5,road. APPLICANT INFORMATION-PLEASE P I'T ALLITNFORMA- N REVIEWED BY DATE PROPERTY OWNER: RbE~-1 ~E PR LOCATION ©uKL2 ; l~ptil 1 ~ k 14 frt. oo . S W 1/4 I SW 1/4,S 2.1 T Z Z N,R IS E (or)( PROPERTY OWNER':S MAILING ADDRESS' ®s e-Ow L BLOCK # SUBD. NAME OR CSM # ~z.sy 1~L1=Ltv RfRw6~ ~.cy°t - 4Rupo5~ esM CITY, STATE ZIP CODE P ~B.ER ❑VILLAGE ®fOWN NEAREST ROAD Z~~~ ~L.L.s WI syozZ ~-~'g~3 tf~i~Clk..tN>u~c RIFLk~RhwGF 2D. A New Construction Use [~Q Residential / Number of bedrooms L{ [ ] Additkn W existing building [ I Replacement [ ] Public or commercial describe Code derived daily flow 60o gpd Recommended design loading rate 0- S bed, gpolft2 0. 6 trench, gp~ 'Absorption area required \ZO O bed, ft2 1000 trench, ft2 Ma)dmum design loading rate 0 . S bed, gpd/ft2 0 • b trench, gVW Recommended infiltration surface elevation(s) C t 4.5 ft (as referred to site plan benchmark) Additional design / site considerations Parent material S IN IQ\"-y 0 y T whkStl Flood plain elevation, 9 applicable ft S = Suitable for system CONVENTIONAL MOUND "ROUND PRESSURE 7AT-`RADjE GSYSTEM IN FILL HOLDING TANK U Unsuitable for system ® S ❑ U ®S ❑ U ®S ❑ U S U ® S ❑ U ❑ S L$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 rer>Ch S 11 9 0.6 Aar Z ~ -31~ "I• S Y Y!6 - `rFS o s w► ~ ~i - o. S Ground 3 36-91 L o ti R VA - 't S s g _ a. S o. L elev. ft Depth to limiting factor C19 11 Remarks: Boring # o_S __)•S7R 31Z 1S Z. 'F 41, vn\) i1- ok-S Z Z S -~l 6 7. S Y R X16 `~4 s9 rv► r9-tti o. S a 6 3 y 6.$0 10 `t h.. SE /6 - '~S ©S g ~ 1 - o, s o, b Ground elev. q6- It Depth to limiting fac RD" Remarks: CST Name:-Please Print Arthur L. We erer Phone: 715-425-0165 egerer Soil Testing & Design Service-P.O. Box 74 River FaI1s,WI 54022 Signature: Date: CST Number: M00576 PROPERTY OWNER ;F> es%M-P R- SOIL DESCRIPTION REPORT Page' 'of ~ s PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench o- S '11Z - \S Z ►y Uitr CL4 - C3 0• a Z S-uo 7•S `f2 u!b T3 u S3 cSl.w s n• 6 Ground 3 yo ?S ~Ir.) `1R V/ C> S~ n~ _ o »S o.6 elev. qS•o ft. Depth to limiting factor 7ZS`' Remarks: Boring # Z S-3o 7.3'-iR u16 O S9 Y►1 1. ~►v - o S `0.6 3 3b~y tll yR ~l(, - `~S S9 1M) - o,S 4.6 Ground i elev. ft. Depth to limiting factor i > 8%4 1 Remarks: Boring # \ 1S tiwtG S - 0-7 `•u•~ S Z S-3S-S `1R Y4 O Sg vhf a~w 1 o-S in. 3 3S-88 1U `t.2 ~!6 - ~S O S w, ~ - o.S o_ ~ Ground elev. °l7.O ft. Depth to limiting factor > Remarks: Boring # E3 Ground elev. ft. ! Depth to limiting factor Remarks: Cgf1 RQ'7l1/R ~1S!!1?1 PLOT PLAN Page 3 of 3 SCALE 1"= 30 t-__@~TDS. ~-TL lei t, r4, 01,j S x vi :31,4 0 w/LHTH S `~o g-4 I^► ~d LSL°lal ~t~G~ @\?'p y'L1RX\V'lUM'1 L4z4Ogv? N>r `CSI S RL~~ ~t~-La-) ° \.)v WVO 0> GE . U F3.3 ~ ~ ~i3 Z. ttgS"-' L--v.? 3g~ ly N M &0 M s TI ~~C p~1p~J 51~ 1 ~ t1 ~•7S~f R F4/V GF RD °•SS wt Tp e'T ~ ST" q S- (-7 C/~~ l °l5 (715 425-~1 ~5 _ 100576 CST Signature Date Signed Telephone No. CST # Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Human Relations Division of Safety & Buiktngs in accord with ILHR 83.05, Wis. Adm. Code COUNTY 5'r'_ C12..c1~X Attach complete site plan on paper not.less than 81/2 x 11 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- Pfb ~ UUE P 1t1~R PROPERTY LOCATION. ear.-tm . VZON.) V-*-S~r-h R GOVT. tOT S W 1/4 1& W 1/4,S L')T ZS,N,R 1% E (or)( PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK #t SUBD. NAME OR CSM # 1Z-sy 12l R~fu 6E $or'tA ~ QRopoS~i CS M CITY, STATE ZIP CODE PHONE NUMBER [)CITY []VILLAGE RrOWN NEAREST ROAD 1Rwlu t RILLS W1 syozZ (-)IS)yZ$_ 963 t~tr~.~~Ck-ll~Ntc Rl Rhw6F RD. New Constnrdion Use bd Residential / Number of bedrooms 4 [ ] AdMQ,n to e*1ing building [ ] Replacement [ ] Public or commercial describe Code derived daily flow boo gpd Recommended design Wig rate o • S bed, 9pol(t2 ° b trertch, gpolR2 %Wxpfion area required \ZO O bed, ft2 l DOo trench, ft2 Matamum design loafing rate o - S bed, gpolfl2 0.6 trench, ! Recommended infiltration safte deta6on(s) °l 14. S It (as referred to slte plan b _ Additional design / site considerations Parent material S N li'j0`f O U T W M4 1A Flood plain elevation, I applicable N • - ft { S = Suitable for system COMfWWNAL MOUND Pl-ROtArD PRESSURE AT-GRADE SYSTEM W FlLL 7HOLDING TANK U=Unsuitable fof system ®S ❑U ®S ❑U ®S 11U ®S ❑U ®S ❑U ❑S L2fU SOIL DESCRIPTION REPORT Depth Dominant Color (Mottles Texture Structure Cor>sistlmce Bottldary Roots GPD/ftBoring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tench [ o-y -)-s'-tR 3! Z - ~S 51- y,.v'FV- 0.. S - 0.7 0- Z 4-3~ ~•S Y~ ~l6 - `FS o sy wr I o.S 0.6 Ground 3 - oi9 L o `I R ~l !6 - S S 9 - v- S o_ L elev. Q~ ft. Depth to limiting factor R.9 a Remarks: Boring # e.~ a.~ Z Z - S-u 7- S 9tz c~16 - ' c~ sq m rS, - o. S a 6 _ 3 y6.8o ZO `tR SEl6 - ~S o sg . wf I = o s 0.1~ Ground elev. °!6- Z ft Depth to limiting oy re Remarks: T Name:-Please Print Phone. 715-425-0165 Arthur L. We erer gerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 e M Signature: S_6, Dater ~S CST Number 900576 PROPERTY OWNER ~~S~r~-PctZ SOIL. DESCRIPTION REPORT Page Zof ~ PARCEL I.D. # Boring# Horizon Depth Dominant Color Mottles Texture Structure' Consistence BoUXWY Roots GPD/ft In. Munsell . Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench o- S 7.S `t P- 11Z - `S Z wt U'FV- C-S - a.-) o- a Z S-~co 7•S Y2 vlt, ~3 u S9 w► cSl,w s n: 6 Ground 3 4015 it Vl ` 't C> Sbj o » S o . 6 elev. °LS•o ft. 1 Depth to limiting factor Remarks: Boring # El Z S-3O ~ S H lL u 16 O S9 yv1 ~-1N - o • S ~ o. 6 Ground T elev. 0.•S ft. Depth to limiting I factor ' > 8%4 Remarks: Boring # S Z S-9S 7•3 `tR Y!6 O s9 v~ o~w o-S io. 3 ~ S-8 fi 1 D ~L (Z 4rl6 _ ~ g O g wry - o . S o , ~ Ground elev. 017.0 ft. Depth to limiting factor > 8$' Remarks: Boring # .13 Ground ` elev. ' ft. Depth to limiting factor Remarks: gan.aa~nin nsro?~ . PLOT PLAN Page 3 of 3 SCALE 1"= 3p ' ~o`CLr -'~o~~~_ --97- . @eD.s, - - K tt 4 K S Q' ~t t tt am -mil .100 O O►~1 S "~}~GH 31y~ Q I1A. tLal`LS \~vC \~lV-E w/LrwV4, • i 1 l^► ~St, °l9 B- i `l ct Y ~ 8CT0 1V11'1X\WIU1"I \ B. S S 807 y?"O' Pt'r ~C \t~L an g-~ oa l \ ~ ~Y3 Z OL s! EL 212 a~ i r y N M M S L~ ~b C~~~ S 1 Zl ~ R~wsE R-b ° ss r•►' To ~•Ttt•ST" v qS_(-7 '47- l °l5 715 425-01 n5 M00576 CST Signature Date Signed Telephone No. CST # STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER /l Dhd Id J and ~a bin L ~eS ~a r MAILING ADDRESS /Z /e ~i an 9e Ad /7, Wr / //S S5'022 PROPERTY ADDRESS /fz 0 C i'%P Ad.,?r;e 061 (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION IV 1/4, _ NW 1/4, Section 3'1 T a $ N-R /P W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP VOLUME /D , PAGE Z94 , 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 complet d returned to the St. Croix County Zoning Officer within 30 days of the three year it i dat SIGNED: 14.e~ DATE: 7 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. Rpt7 a& J, Ind, Rodlh Z. deSA-ar Location of property_~/~/ 1/4 IV X1/4, Section 3 1/ ,T RR N-R /X W Township 1<1,74,( /'C' Mailingaddress lz541 /~j ever r-~ X15 , d✓ _510 z z Address of site- /a.06 ,f;l(/e lea„ A011/1, ~?yP, its 'h/, subdivision name CS17b /G Lot no. / Other homes on property? Yes j No Previous owner of property .4deh'", P K~ r Total size of property 9 CCcre.s«o~ Total size of parcel 9,91 aLlre S u~~ea 00j3/9s Date parcel was created nIQrC~i / / 99,5 ~urvt y~~ , ~/tca~ rtcvr~~/-3 9~ Are all corners and lot lines identifiable? X_Yes No Is this property being developed for (spec house) ? Yes X No Volume //5'S and Page Number 55,1 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. -,5'3 DcoO , 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 Co ty Register of Deeds as Document No. 53'0 ~ Signatu e App icant Co-Applicant Z/a/- 5 ) y~- -97 Date of Signature Date of Signature U01 Cc~ FILED a MQY 0 3 1995 I► Z KATHLEEN H. WALSH Register of beeds 9 SL Croix Co., WI 528471 CERTIFIED SURVEY MAP LOCATED IN THE SW 1/4 OF THE SW I/4 OF SECTION 27 AND IN THE NWI/4 OFTHE NW I/4.OFSEC- T ION 34, ALL IN T28N,R18W, TOWN OF KINNICKINNIC, ST. CROIX CO., W1. WI/4 CORNER OF SEC. 27. (COUNTY MONUMENT PREPARED FOR: ADELINE PESKAR FOUND). S I- fin O i O ~ y~ S,2 a .llNPC S41 T 10„ • FD F NOTE' BEARINGS ARE REF- 9, .`.ANDS 3 ERENCED TO THE WEST LINE OF THE SW 1/4.( RECORDED BEARING). 6 170 / 2' S 3 T ~F C• - a: U) L0 N. OD• OD LI• CU, a 00 a LOT I Co E CL• H M 9.91 ACRES y' w ro ( 4,31, 729 SO. FT.1 N ~S Cn. s 9. 56 AC. EXCLUDING ROAD R.O.W. C Z' Co• U. _ ( 416.557 SO.FT.1 m Q• _ U. -J: 0: cc APPROVED uj. _ Q• z z ~ 3 L > J to MAY 3151 (r. w M W w' 3 O 1• J. DRAINAGE WAY o ST. CI~OIX r0i}IdY-Y ,-~Omprehensive Plan nit Zoning and Parkscom"wtee HIGHWAY SETBACK' LINE \ If not recorded /A% 4 within 30 dayrdf approval dtft o approval ShAtl'bs \ • ° nug~r void NORTH ON8='J0„w hi 76.27 0 ~?I3.49• ` N80 I3 . 5p, SIN CORNER OF SEC. 27; i. 30 l4/ ( COUNTY MONUMENT SOUTH FOUND) LINE OF THE SW t/4 . UNPLATTED LANDS ~eko400~0~@Bi._ . o ~ r- GL~RVE DATA TASLi~ NO. CENT. ANGLE RADIUS ARC CHORD CH. BEARING s 1-2 14032'50" 958.00' 243.23' 242.58' N73039'05"W 3-4 15026'38" 925.00' 249.33' 248.58' N73012'11"W TANGENT BEARINGS AT 1 AND 3= N80055'30"W AT 2= N66022'40"W AT 4=N65028'52"W DESC•R I PT I (D" A parcel of land located in the SW 1/4 of the SW 1/4 of Section 27 and in the NW 1/4 of the NW 1/4 of Section 34, all in T28N, R18W, Town of Kinnickinnic, St.Croix County, Wisconsin, more fully described as follows: Commencing at the SW corner of Section 27, T28N, R18W: Thence NORTH along the West line of the SW 1/4 a distance of 76.27' to the SE corner of the Certified Survey Map recorded in Volume 8 of Certified Survey Maps, Page 2282, said point also being the POINT OF BEGINNING: Thence continuing NORTH along the East line of said Certified Survey Map a distance of 868.55'; Thence 572054'10"E 391.14'; Thence S64014'37"E 212.51'; Thence S9003'26"W 772.80' to the centerline of Rifle Range Road; Thence N80055'30"W along said centerline a distance of 213.50'; Thence westerly 243.23' along said centerline also being the arc of a 958.00' radius curve concave northerly whose long chord bears N73039'05"W 242.58' to the point of beginning. Contains 9.91 acres subject to Rifle Range Road right-of-way over the southerly 33' as shown. Also subject to any and all additional easements, right-of-ways or conveyances of record. SLJF2.V EYOR ' S CERT I iF I C'A-r I, James M. Weber, registered land surveyor, hereby certify: That in full compliance with the provisions of Chapter 236.34 of the Wisconsin Statutes and the provisions of the St.Croix County Subdivision Ordinance and under the direction of Adeline Peskar, I have surveyed and mapped the above described parcel of land and that this map is#"se&Ww t representation of the boundary thereof. Dated this•~_day of ~AQ~N '1995. - - 41 JAMES K James M. Weber S-1804 WEBER NELSEN-WEBER LAND SURVEYING SPRING VALLEY W 13. 9~ , Jas ~ aufi > , Uba s~'irl ~ ; Ys'v~;}tab ~i 0~;r ~o l• ~,~rj 8%h °o ~lr la 9'~ ~71r, Q?rq Sg~t/ as Ja!+~a~raA~saj std ds~ ` 00 STATE BAR OF WISCONSIN FO t Qtt . a t °j1° 95380c-10 WARRANTY DEED ,~MP dAa. aadw In`' ; , M °~rga!Gg ill . S; VOL 11'5PAGi 554 DOCUMENT NO. h I, ''^~On~!a~U 'h~•. 'yL M - K 'or Rccord This Deed, made between -Ada1inP J Peskar, a JAN 3 1996 -single-person ~a 9:30 A. M ~yy Grantor, and Ronald J. Peskar and Robin L. Peskar, h1iqhand tor 6f Dwas and wife, arvivor np marital pnTerty Grantee 1D Witnesseth, That the said Grantor, for a valuable consideration II Jo THIS SPACE RESERVED FOR RECORDING DATA- One dollar and other good & valuable consideration ~I NAME AND RETURN ADDRESS conveys to Grantee the following described real estate in St . Croix -ourty, Stab of ~'✓isconsin: T14~TrM &I,]) 200 Fast Elm Street River Falls, VLs=E n 54022 Part of the SW 1/4 of the SW 1/4 of Sectiort 27, Tzu~ p 28N) Range 18W aryl also part of the Del l/4 of the IOW 1/4 of Section 34, Twid-dp 28N,Pmge 18W,St. Croix Canty, Township of KiTrdddniie, (Parcel Identification Number) 1 described as follows: Lot 1 of certified stxvey crap recorded. in the office of the St. Croix Canty Register of Deeds, on YW 3rd, 1995, in Volura 10, at Page 2916 as Iloaltmt ember 528471. i. 1 FEE # i This i s not homestead property. it I Together with all and singular the hereditamcnts acd appurtenances thereunto belonging; And grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions, reservations and covenants, if any of record, and highway rights of way. i and will warrant and defend thevsame.Q , Dated this - day of 111$t oe~ 19-9-5 (SEAL) (SEAL) Adeline ,L.-Peskar (SEAL) (SEAL) j AUTHENTICATION ACKNOWLEDGMENT OWISCONSIN Signature( T, Ari e 1 i ne T Ppska-r STATE OF WISCONSIN )1 ss. 0 -4 o .0 0 C: o (c o 0w n ' m m )C ❑C)C)~c]❑ o ; 0 0 x1 V 0 Ln p W N O o D c d z Q cn ❑ ❑ o V~ o C> ° ~ 3 ra o ~7 < in rk) z C7 (2) m (D M Z3 = -AC m.Aa vi 0o a u cn fa] m v (C) D°= _0 c c ac -n m a 0_ a .n ti c' r- r rmr~ p" o n o+" c~ 1 cD G> -C f,~ fU A O = Oj - m 33 c Q a r (~D r m I m m CC) j X q :x m r ~ N Q 'a a a m x O Q m -I 3 ~ O 4 vi m° _ -i co O O CD c m _ c a 7 7p 3 O < w 0 4r M m L d ul~Id ~Q1M VIZI'9 w~ o~ 0% ;o mz~am 0 f ZZo Z N m _ OItz- ~~w ~ N o ~ w m o IZIm N a'Z a ooaoaZ Vitro!r- lO0D m m °D z 1 3V n? m ro L.J 01 .60 ro Z fA ro ro ~ d I o a C] _ p