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HomeMy WebLinkAbout030-2093-40-000 T" • STC - 10 4 AS BUILT SANITARY SYSTEM REPORT OWNER ; pz 'Q19 Q ADDRESS C? ~ i SUBDIVISION / CSM# r LOT # SECTION TN-RW, Town of r ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM l~ w INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. r BENCHMARK: 5ttd '544 3,,5-0 ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: /000Q - ~n~( } I Setback from: Well House Other Pump: Manufacturer Model#_ Size Float seperation' Gallons/cycle: Alarm Location.? SOIL ABSORPTION SYSTEM l Width: Length-/00 t Number of trenches Distance & Direction to nearest prop. line: S"~ • Setback from: well: House Other ELEVATIONS r Building Sewer 14 ST Inlet: f~ ST outlet: PC inlet PC bottom ♦ G Pump Offs Header/Manifold 7 ' Bottom of system ♦ ~ ~ Existing Grade Final grade DATE OF INSTALLATION: Q~ PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: • 3/93: jt .Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitarn"89vft: Personal information you provice may be used for secondary purposes [Privacy LaAV, s.15.04 (1)(m)]. ~old~rAs~IfCE [}~F~ity [~1f~ Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel TO'3V--:2093-40-000 TANK INFORMATION LEVATION DATA A9700291 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet ventto TANKTO P/L WELL BLDG. A iirlntake ROAD Dt Inlet Septic 0 (D p, - NA Dt Bottom /57. 82 6 ~J Dosing NA Header / Man. 17' 9~• 3? Aeration NA Dist. Pipe 7 ~6 a3' Holding Bot. System o s` 9 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Jam, Model Number y ) GPM TDH Lift ~ll Friction System -q TDH q,Ft / Loss H Forcemain Length J DiDist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth DIMENSION 5' ~ DIMENSIONS SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Of 14u,,,) CHAMBER Mode Number: System /5 OR UNIT 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 xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil E] Yes E] No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH 29.30.19,NE,SW 427 HIGHLAND VIEW LOT 4 / uu 1 ' Plan revision required? ❑ Yes 0~ No Use other side for additional information. 167 SBD-6710 (R.3/97) Date I spector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division 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 8112 x 11 inches in size. . • See reverse side for instructions for completing this application State San ita ermi lufnber The information you provide maybe used by other government agent ProJrams Checkitit reisiio'n tto prreevviious application [Privacy Law, s. 15.04 (1) (m)]. Qa f 9'9)76! !d V / fed - State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location tjE1/4.5a) 194, S 2 T , N, R ICI A.(or) ID Property Owner's Mailing Address Lot Number Block Number City, State Z Zip Code Phone Number Subdivision Name or CSM Numb r ( City Nearest Road r IL TYPE F BUILDING: (check one) ❑ State Owned E] Vi e ❑ Public 1 or 2 Family Dwelling - No. of bedrooms t Town OF 'j r III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 E] Apartment/ Condo RQ- li J O. P? - 7r7 p - 2- 092 - 40 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. VNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System ________System Tank Only______________ Existing-----y--- _________Exi----yytem 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 1 P 21 ❑ Mound 30 ❑ Specify Type 410 Holding Tank 12 V Seepage Trench2- E.5000 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 l_15~) 160D MIA jC3L3v o 5o Q Feet 9 Feet VII. TANK Caacit ns Total # of Prefab. Site Fiber- Exper. INFORMATION in gallo Tanks Manufacturer's Name Concrete can- steel glass Plastic App New Existing Gallons strutted Tanks Tanks Septic Tank or Holding Tank 1004 ❑ 11 El 1:1 ❑ Lift Pump Tank /Siphon Chamber 1.0 EJ ❑ El ❑ 1 1:1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plum er's Signat (No Sta "'ft5-W NO- Business Phone Number: -1 15- 2-tog- q C6 Plumber's A ress (Stre , City, State, Zip Code): P.6. e)w 222-1 LQrrj.,0_rW IX. COUNTY / DEPARTMENT S ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing A ent Sig ature (N tam ) Surcharge fee) XApproved ❑ Owner Given initial /,f6~/Q7 Adverse Determination ~0 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SHD-6398 (R. 05194) DISTRIBUTION: original to Caurdy. 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 administrat r or tine "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) o 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, purnp/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 monitoring groundwater contamination investigations and establishment of standards. J cs~ CA PQ op b V'\ k;j coU IZI. ~o o ~ Q G~ `Q = SEPTIC TANK 8 PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4" CI VENT PIPE 12" MTN. ABOVE GRADE WEATHER PROOF 2:25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE C FINISHED GRADE 4" CI RISER W/ PADLOC 6" MIN. WARNING i ABOVE GRADE 4" MIt 1811 IN. 6" MAX. INLET WATER TIGHT SEALS L GAS- f ~ TIGHT i v A SEAL 1 ~ Ott BAFFLE APPROVED Cl PIPE 3' ONTO B t ALA JOINTS W1 SOLID --F- ON PIPE 3' 0. ;OIL C t SOLID SOI PUMP OFF ELEV. FT. t OFF RISER D PERMITTED IF TANK MA NU FAC TU! 3" APPROVED BEDDING UNDER TANK HAS APPRO'. SPECIFICATIONS CONCRETE PAD SEPTIC / DOSE 'T'ANK MANUFACTURER : .,c NUMBER DOSES PER DAY: TANK SIZES: SEPTIC GAL. DOSE VOLUME INCLUDING DOSE 4roD© GAL. FLOWBACK: GAL. /ALARM MANUFACTURER: CAPACITIES: A MODEL NUMBER: =INCHES C SWITCH TYPE: B = INCHES = G PUMP MANUFACTURER: 2 MODEL NUMBER: C LIZINCHES = D ,LG SWITCH TYPE: ~ppqq = INCHES = 1udac REOUIRED DISCHARGE RATE GPM PUMP 6 ALARM WIRING AS PER ILHR 16.23 VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE l~ + MINIMUM NETWORK SUPPLY PRESSURE FEET + 100 FEET FORCEMAIN X ♦ 7 FT/ 100 FT. FRICTION FACTOR . , 5 FEET TOTAL DYNAMIC HEAD c S/FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH FEET WIDTH s; DIAMETER _ LIQUID DEPTH , ZGNED - LICENSE NUMBER: ~~~Cf/sj nATf+_ e W w 3 15/16 6 5/32 HEAD CAPACITY CURVE 665315791- 6155159" SERIES 4 5/8 25 1 112 -11 112 NPT TDTAL DYNAMIC HEAD/CAPACITY PER MINUTE EFFLUENT AND DEWATERING 3 15/15 e 50 SERIES - Ft. Canters Gvi. Ltrs. 4 1/15 V 1 S 5 r,>Z 41 t 63 + ZQ 4 10 3.05 .N 129 1{I Y O 15 4-57 19 72 0 I ~ LocM Y•M1m: 19.25' 2 S t0 7/t6 0 U.S. GALLONS 10 20 30 0-0 SD I 3 3132 LITERS 80 160 O FLOW PER R MfNUiE SILM Volta CONSULT FACTORY FOR SPECIAL APPLICATIONS - Variable level Float Switches available. • Available with special cord lengths of 15', 25', 35' and 50'- Variable level long cycle systems available. • Alarm systems available. • Duplex systems available. SELECTION GUIDE Standard card length - automatic 9 ft 1- Integral float operated mechanical switch, no external control required. Standard cord lerKM - non-automatic 15 ft. 2. Single piggyback variable level }bat switch or double piggyback variable level float X28' switch. Refer to FM0447. am e A g4S 3. Mechanical aRemator "M-Pak' 10-0072 or 10-0075. 11.0 4• See FMO712 for correct model of Electrical Alternator, 'E-Pak". 5. Variable level control switch f 0-0225 used as a Control activator, wAh E Pak (3) a 4 (4) float System- n 4.0 or 5 6. Four (4) hole'J•Pak", junction box, for watertight connection or wired-in simplex or 53 Series - Wt- ?2 tbs. 57 Series - Wt. 27 tbs- 2 pump operation, PM 10-0002. 55 Series - WL 24 tbs- 59 Series- Wt 30lbs. 7_ Two (0 hole °J-Pak', junction box for wateAigM connection or splice, Pihl 10-0003- CAUTION For nlonna{ion addiioffal 2oeer Y Wwids ralq to caeft an Cootanebon atarter, FWS14; p"ybadf variable All ins Lannon of controls. flfotectidn devices and awing should be none by a cl,.ed ieensed electncian. Level Foot S.dte el FAM477., Elemi®I Aeef Tatar, Fph1)"S' bAsdynjcal Al6rnxer Illil , Alarrn p th 0c,-Pat- nd sSahry afety and Health Act tOSHedtncluding[hemosl recent Naf~onal Eieclnc COdeINE:,land Fi405f3; Ind SfaroGe talSnow, FA104e7, and Ssnpbt ConburB=. FM0732. the onat and Health a~ lOSNAj RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. - - - MAN. T0.• P O. 80X 76347 Leo Lm w*, KY 40256-M7 aw To 3281 n!d Mifeas Lade 402 - - PUMP !D. (502)778-2277331- ~tB 92&PtrMP s /9.9.9 - FAXMJ774,W4 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of L.Wfand Hdman Relations Divsion of Safety & Buildings accord with ILHR 83.05, Wis. Adm. Code revised 2/25/94 (Sub, T & R) ~ 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 to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION part NW-SW-29 plus JoAnn Persico GOVT. LOT NE 1/4 SW 1/4,S 29 T 30 N,R 19 W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # Highland Hills 7nO Second St. 4 CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MOWN T EAREST ROAD Hudson, WI 54016 (715) 386-8236 r.THW "F" [X] New Construction Use rx] Residential / Number of bedrooms 3 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow. 450 gpd Recommended design loading rate NA bed, gpd/ft2 •45 trench, gpd/ft2 Absorption area required NA bed, ft2 looo trench, ft2 Maximum design loading rate NA bed, gpd/ft2 -8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 95.4 ft (as referred to site plan benchmark) Additional design/ site considerations bed not recommended: install 2 - 5' x 100' trenches Parent material fluvial outwash over glacial drift Flood plain elevation, if applicable NA ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem EIS ❑U EIS ❑U ❑S ®U ®S ❑U ❑S OU ❑S OU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence B yclary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0-7 7.5YR 3/3 - is 2 f sbk mvfr cs 2f/m .7 .8 2 7-12 7.5YR 3/3 - is 1 m sbk mvfr as if .7 .8 Ground 3 12-27 7.5YR 4/4 - is 1 c abk mvfr gs if .7 .8 elev. 4 27-49 7.5YR 4/4 - is 0 sg ml gs - .7 .8 98.8 ft. 5 49-75 7.5YR 4/4 - s 0 sg ml cs - .7 .8 Depth to w/ some mfs & w/ 7. YR 3/4 sl (0 m) ba ds: 1/4" @ 49, 1" @ 1/2-1/4" @ 63, 70, 72 limiting & w/ some as ociated sl inclusions factor 7511 6 75-78 7.5YR 3/4 fad 10YR 613 sl 0 m 3 .4 Remarks: texture changes @ depth indicate trenches oversized Boring # 1 0-7 7.5YR 3/3 - is 2 f sbk mvfr cs 2f/m .7 .8 2..? 2 7-10 7.5YR 3/3 - is 1 m sbk mvfr as if .7 .8 3 10-15 7.5YR 4/4 - is 1 c abk mvfr gs if .7 .8 Ground elev. 4 15-43 7.5YR 4/4 - mfs 0 sg ml as .7 .8 97.1 ft. 5 43-57 7.5YR 4/4 mfs 0 s4 m as - .7 .8 Depth to „ - - . t limiting 6 57-72 7.5YR 4/6 f2d 10YR'6/3 s1', 3 4 factor Q->' . 75 " / inclusions 7 5YR 4/4 mfs Remarks: CST Name:-Please Print Henry F. Grote ne. 5-655r 81 Address: PO Box 57, Knapp, WI 54749-0057- Signature: CST Number: 3 3065 PROPERTY OWNER JOAnn Persico SOIL DESCRIPTION REPORT Page PARCEL I.D. # + Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounday Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends k 3 1 0-8 7.5YR 3/3 - is 2 If sbk mvfr as 2f/m .7 .8 "<z< 2 8-15 7.5YR 313 - is 1 m sbk mvfr cs if .7 .8 Ground 3 15-26 7.5YR 4/4 - is 0 sg ml cs if .7 .8 elev. 9B_1 ft 4 26-84 7.5YR 4/4 - mfs 0 sg ml - if .7 .8 w/ 1/811 irregular 7.5 R 4/6 is & s band @ 46, 56, 61, 64, 66 & w/ s grading to s belo about 68 Depth to limiting - factor 8411 Remarks: Boring # 1 0-7 7.5YR 3/2 - is 2 f sbk mvfr cs 2f/m .7 .8 2 7-14 7.5YR 4/3 - is 1 m sbk mvfr cs if .7 .8 4 3 14-22 7.5YR 4/4 - is 1 c sbk mvfr gs if .7 ::.8 Ground elev. 4 22-58 7.5YR 4/4 - is 0 sg ml cs if .7 .8 1 nn A ft. w/ very occasional .5YR 4/6 sl inclusions Depth to 10YR 613 limiting 5 58-78 7.5YR 4/4 f1d is 0 sg ml - - .7 '.8 7,5YR 4/8 factor 58" w/ 1-211 irregular 7.5 R 4/6 sl (0 m) ban 58-60 f1d R-Gy m ts; horizo generally tight Remarks: Boring # 1 1 0-12 7.5YR 3/2 - is 2 f sbk mvfr as 2f/m .7 .8 5 2 12-22 7.5YR 4/3 - is 1 m sbk mvfr gs if .7 .8 3 22-40 7.5YR 4/4 - mfs 0 sg ml gs if .7 .8 Ground elev. 4 40-68 7.5YR 4/4 - mfs/fs 0 sg ml as if .7 .8 101.3 ft. W/ 7. YR 3/4 sl (0 m) bands & associated inclusio s: 1/2" @ 5 & 1-2" @ 6-58 Depth to limiting 5 68-74 7.5YR 3/4 f2d 7.5YR 4/8 sl 0 m factor w/ some inclu ions 7.5YR 4/4 mfs 68" Remarks: Boring # Ground elev. ft. Depth to limiting factor -17 Remarks: SBD-8330(8.05/92) a rl l r4 b X 3 r< °S bd o S bo J .I I! V I) I 1`n j ' 0 -9 f d' r 4 r r d ~P ,I 0 2 ` J Ci 1. JJ J v J~ Af W W I- Q S Q LL" O ► •oz .0 6 W 3,. 9p. ~Z o LON o z Q J W `1rw U- rZt LO W d' O M u V) O c W z 3 0 to ..I ~a = O W_ N- l0 N M M U) J W c O O W f~ O N 2 CID (A W V Z I- _ U W O co q w J O O Zg9 W z N 7 C~`'~\~ OR pR rn O O U O c0 / ~ w nn2 L0~ 2 W / O m ~p~C 3 c • 4 7 , P PGE MAP 8 T C - 100 r ` 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 recprding. Owner of property Aa&Ax,,x ,ep Location of property 1- 1/4.5_ Lk4 1/4, section T C, N-R~W Township: Mailing address Address of site LoT eSubdivision name Lot no. Other homes on property? Yes No Previous owner of property Total size of property 3 , CQ,,t~,il,~- QSou~'~.~ - Total size of parcel 3 a- Date parcel was created Are all corners and lot lines identifiable? ->-<-/-Yes No Is this property being developed for (spec house) ? Yes A No Volume 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 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. 4igare of Applicant Co-Applicant e 7 v r Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County 0WNER/BUYER MAILING ADDRESS 7 { P1OPERTY ADDRESS Lo (location of septic system) Please obtain from the Planning Dept. CITY/STATE , W 2 S ° b PROPERTY LOCATION N J!5 1/4, ! 1/4, Section N-R_14_W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION UA6t- , LOT NUMBER CERTIFIEDSURVEY MAP , VOLUME PAGE 1-0$~LOT NUMBER - D 3D z~q 3 - 11D 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 jo 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 tion date. SIGNED: `'t 4~:~ DATE: -2 77 `I L57 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 ' - ' STATE BAR OF WISCONSIN FORK 2 - 1162 1,17184 WARRANTY DEED DOCUMENT NO. YIl MR PAU26T Rmion.mo r l_ Gina C. Osowski, a single person, $T,~c~p(CiY.,W! } r JUL`2.3 1996 conve)s and warrants to _ Laurence A• Bert and Vicki L_.Berg, ~ husband and wife. at 10:45 A. - THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St - - ni X State of Wisconsin: 030-2093-40 PARCEL IDENTIFICATION NUMBER Lot 4, Plat of Highland Hills in Town of St. Joseph, St. Croix County, Wisconsin. This is nOt homestead property. (is tat) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. r r July A, D., 19 96 Dated this day o ((rr' (SEAL) (SEAL) ll~~`it1~:. Gina C Osowski (SEAL) (SEAL) h i! ii AUTHENTICATION ACKNOWLEDGMENT Saatc of Wisconsin, Signature(s) ss. St_ Croix County ~I authenticated this day o[ 19_ ?It-siu:h came before me this day of July 19 96 ,the above named Gina C nG_a_.single_p rso y t, TI"FLE: MEMBER STATE BAR OF WISCONSIN (If not, - authorized by 9706.06, Wis. Stats.) i~• _ to be the x n who r. cutedtthe foregoing i! . ~ c ow ge the same. THIS INSTRUMENT WAS DRAFTED BY Attorney Ogland 11 Q _ z A ~ = A K 1 Ne k-