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HomeMy WebLinkAbout030-2035-50-120 ST. CROIX COUNTY ZONING DEPARTMENT„ AS BUILT SANITARY REPORT LA 2 ' i 9g Owner L` E Ck S S' cRGIX Address /`/~S a2Y 7A' zavAGQF a;E City/State A0u L,i d y ' a i ` L,agKl UoNUrlplluus Lot Blook &A Subdivision/CSM # l ,gaA, rQ v s to = ESi~T~S %a'/a " Sec., T,Lo N-R;W, Town of S% ~ os ,o/1 PIN # 03o 1D3S-SU-)a2o SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION: Tank manufacturer _ 11)€EA'5 Size ST/PC/ADD/ Setback from: House Well PAL YO' _ZL Pump manufacturer A/A Model _ NX , Alarm l location N~ KS ONLY) Setbacks: Service ro sh air intake Water Line Meter location Alarm►location SOIL ABSORPTION SYSTEM: Type of system: 7-RC-1Vcl-I Width i Length 49, 7S Number of Trenches 3 Setback from: House 130 Well PAL 6- Vent to fresh air intake /DO' ELEVATIONS: Description of benchmark 4446= Elevation &V0 Description of alternate benchmark 7,w g ~ PL/C Al og Elevation 4d3_3.~ Building Sewer ST/HT Inlet 9,-3.1 ST Outlet PC Inlet 1Y14 PC Bottom /VA Header/Manifold 7 Top of ST/PC Manhole Cover /03, 03 Distribution Lines (i) 94 7-5 (.Z) f 9, 7 (3) Zf,, 25 Bottom of System (1) 9~. (2) ~Yf, (3) ,Z Z57 Final Grade (l) /D/- f (z) ~D X (3) .420, C/ Date of installation 7L2S/?A Permit number 1- 2 State plan number ~(/fl - Plumber's si ature Luka.- License number Z;Zl7y/ Date'2i/&2,6 Inspector Complete plot plan • NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two hodwiltal 1,13115101100 pointo to unutor of aahtiu talk nintiholo uovnr. • Show alternate benchmark, if applicable. PLAN VIEW 11A 07W L. I 3X czs i T/l~itrc~f~S /D - /NF/c. T.P<}TOi?S ' /X /-'jL TQi RTO,(r GARgG~ i4/IC.4 /0/7- G sq Fr, 1200 GC- SP i J o W y SCAtt INDICATE NORTH ARROW } w Wiscon.inDepartment of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) sanitaN9122 GENERAL INFORMATION Permit Holder's Name: ity ~OViSa eP Town o : State Plan ID No.: MEYERS, FRED I -ST. CST BM Elev.: Insp. BM Elev.: BM cripN ion: Parcel Talc No.:VG I ?k -1 30-2035-50-120 TANK INFORMATION ELEVATION DATA A9700440 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark J Dosing f, ij rA 7j• /O ~7. Z Aeration Bldg. Sewer Holding //N Inlet TANK SETBACK INFORMATION © t/ Outlet JOd KTO P/L WELL BLDG. Arintake ROAD Dt Inlet J y !O NA Dt Bottom epti Dosing A Header/ Man. -2 • Z A 2- Aeratl NA Dist. Pipe $ • S7 51 Ice-?4 ' Holding Bot. System .~3& qX71 `t f• 411 PUMP/ SIPHON INFORMATION Final Grade SL i -rz 7y ManA De nd 5- 76) 103 -oli Mod r ~ J--/ G TDH ft Friction System TDH Ft Forcemain Le H Dist. To Well SOIL ABSORPTION SYSTEM BED Width Length / No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth IMP DIMENSIONS 7 DIMENSIONS L CHING Ma urer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION Syp to OR C UNIT ER a Num er: Y DISTRIBUTION SYSTEM Header/Manifold M Distribution Pipe(s) e r L.H~l Sizee x Hole Spacing Vent To Air Intake Length Dia Length ~ s ' Spacing _6 lip 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.) QCATION: OT. JOSEPH 24.30.20,SE,NW 1475 24TH STI3MT LOT 2 Plan revision required? ❑ Yes 9 Use other side for additional information. - I - K~ SBD-6710(R 05/91) Date Inspector's Si nature e ADDITIONAL COMMENTS AND SKETCH r SANITARY PERMIT NUMBER: i Visconsin SANITARY PERMIT APPLICATION 201 E w shnllgtonAvevision P.O. Box 7969 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code 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. • 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 &Khec if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. Q 1 y ~5 a sf, State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location tia wtia,S T 340 ,N,R0pE(o 'I Al Property Owner's Mailing Ad ess Lot Number Block Number i Cit , State Zip Code Phone Number Subdivision Name or CSM Number /O rY (lo ) 6.. _ a7 11. TYPE BUILDING: (check one) ❑ State Owned ❑ city Nearest Road E] Village Ty Public 1 or 2 Family Dwelling - No. of bedrooms Town OF Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo I2,q• 3,0. a 0.468 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 12E] 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. p`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 11E] Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench ✓ 22E] In-Ground Pressure 42E] Pit Privy 13~ Seepage Pit 0nh Gwc.~ 02 _3 67 43E] Vault Privy 14 ❑ System-In-Fill Sa~l~ct~~ n~i lt,ra.(ors (hla.wtb 78 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) q8,y 9j;9 Elevation D Feet D Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel lass Plastic A New Existing structed g PP' Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sews e s stem shown on the attached plans. Plumber's Name: (Print) Plum r' Signature: (No Sta Business Phone Number: AJA- umber's Ac dress (Street, City, State, Zip Code): et IX. CO TY/ DEPARTMENT USE ONLY eIssuing Age t Signature (N ❑ Disapproved Sary Per F (includes Groundwater ate ssukA Owner Given Initial Surcharge Fee) Approved E] S-- Adver se Determination t X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 IRA 1/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3151. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal.description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use_ If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7- V11. 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 monitoring groundwater contamination investigations and establishment of standards. I Evisco zy-%8 f} ax G2~A- D.~-/ ~Z y2 Ar / I✓ ~ / ~ T/1 /+T0~0 y 98; p A4, Tf4TAA r4Oq 3 7 eL, 9~, 4 AM, qtr OAA ~y7 L AfMe&Zx 8'3 n 6~ ,d 1314 ~ ~ LT T i TI? E)vd#,Os / GARAGE ep / W J /-Zoo 6-4 ~/?opos ~ ~ h ppopos eo BJ9 % " PUC p/~~ EL /cc E eR S ,?Y T S~6 ~/~ccEY v/E~v f,P, 11,0aC7-o,V C11~' s Yo~~. $O/'Y~IIS Ce-V t/`' WUe A P,o ox t1?AOA= /o% / 30 4/¢~P~~o~v 30 4 c vv~/L oa ee C` EL. 9Br ~ EG- Q~J w J 2 'f q - It Gff jf L 17 7,9 --7~,- S - -71 Atr VA /y7' A(AQ, oJf#AeRZX L °la t C ----t p M /-22 ( ~4 LT ` r GARAGE Bp J I,7DO GG Si f'., ~ /~ocrs r h w aSCigGE' ^ y0' ~/Q(~POS~/) Bl7 %~J a? ri PU~ P/~~ EL /off' At7WIV t' Ile te W BL(, / s FRED E e/1 S p~ /YES 2Y sT- 5,86 41,46/-6Y vre4v 7 " f{oucT~,cr s yof2. 501'FeR , Chi -r5eozs • Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division o(Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach-complete site plan on paper not less th i es in size. Plan must include, but St. Croix not limited to vertical and horizontal refer: PARCEL I.D. # IpF. crtotnd % of slope, scale or dimensioned, north arrow, and location d~~tance t e are6t-r,90 030-2035-50-120 W 1, APPLICANT INFORMATION-PL PRI REVIEWED BY DATE IkR 31ORNIAT N PROPERTY OWNER: _ Fredrick Meyers PROPERTY LOCATION ( F GOVT. LOT SE 1/4 NW 1/4,S 24 T 30 N,R 20 .2 (or) W PROPERTY OWNERS MAILING ADDRE " 'A•M ~ LOT # BLOCK # SUBD. NAME OR CSM # 13746N 10th. St. . COUNTY ',V 2 na Countryside Estates .41 CITY, STATE ZIP PHONE NUMBE& ❑CITY ❑VILLAGE [RrOWN NEAREST ROAD Stillwater M. 5508 St. Jose h 24th. St. ] New Construction Use [x ] Residential / Number of bedrooms 3 [ ] Addition to existing building ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate .5 bed, gpd/ft2 .6 trench, gpd/ft2 Absorption area required 900 bed, ft2 750 trench, ft2 Maximum design loading rate .5 bed, gpd/ft2 .6 trench, gpd/ft2 Recommended infiltration surface elevation(s) 98.80 alt. site=99.30 ft (as referred to site plan benchmark) Additional design / site considerations trenches spaced to code 3.5' below surface grade Parent material pitted glacial drift Flood plain elevation, if applicable na ft t:Uunlsuitable able for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK fors stem ®S El U ] S ❑ U KI S ❑ U ® S ❑ U ❑ S MU ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmr& ....1..`__ 1 0-11 10 r 4/3 none 1 2msbk mfr 2f .5 .6 2 11-30 10 r 4 4 none sicl lcsbk Mfr cm 1-f .2 .3 Ground 3 30-80 7.5 r 4/6 none elev. 101.8ft. Depth to limiting factor +80„ Remarks: Boring # 1 0-16 10 r 4/3 none 1 2msbk mfr 2f .5 .6 C1W 2 2 16-37 10 r 4/4 none sicl lcsbk mfr if .2 ~:.3 Ground 3 37-80 7.5 r 4/6 none sl 2csbk mvfr na na ; .6 elev. 102.3 ft. Depth to limiting factor +An,, Remarks: CST Name:--Please Print Gary L. Steel Phone: 715-246-6200 Address: 1554 200th. Ave ew Richmond I 54017 Signature: - Date: 10-2-07 CST Number: m02298 PROPERTY OWNER Fredrick Meyers SOIL DESCRIPTION REPORT Page 9 of, 3 PARCEL I.D. # 030-2035-50-120 Depth Dominant Color Mottles Texture Structure Consistence Bouridary Roots GPD/ft Boring # Horizon in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 1 0-11 10 r 4/3 none 1 2msbk mfr 2f .5 .6 2 11-27 10 r 4/4 none sicl lcsbk mfr C1w if .2 .3 Ground 3 127-43 10 r 4/4 none si 2m r mvfr c1w if .5 .6 elev. 103.3 ft. 4 143-84 7.5yr 4/6 none fs os mvfr na na .5 .6 Depth to limiting factor +84" Remarks: Boring # 1 0-12 10 r 3/3 none 2 12-17 10 r 4/4 c2d7.5 r 5/6 sil lcsbk mfr Crw if .4 .5 3 17-36 10 r 4/4 none sicl m na if n .2 Ground elev. 4 36-82 7.5 r 4/6 none lfs lcsbk mvfr na na .5-..6 102.7 ft. Depth to limiting factor +82" Remarks: Boring # 1 10-12 10 r 3/3 none 1 2msbk mfr 2f .5 .6 2 112-27 10 r 4/4 none sicl lcsbk mvfr if .2 .3 3 127-48 7.5 r 4/4 none sl 2m r mvfr if .5 .6 Ground elev. 4 148-80, 7.5 r 4 6 none fs os mvfr na na .5 .6 101.0 ft. Depth to limiting factor +80" Remarks: Boring # 1 0-12 10 r 4/3 none 1 2msbk mfr 2f .5 .6 .ti« 2 12-26 10 r 4/4 none sici lcsbk mfr if .2 .3 3 26-34 7.5 r 4/4 none sl 2m r mvfr if .5 .6 Ground elev. 4 134-80 7.5yr 4/4 none fs osg mfr na na .5 .6 102.4 ft. Depth to limiting factor +80" Remarks: SBD-8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 Frederick Meyers SE 4NW4 S24-T30N-R20W New Richmond, WI 54017 MPRSW 3254 town of St. Joseph (715) 246-6200 lot #2-Countryside Estates N 1"=40' BM.= top of 2" pvc pipe C el. 100' Alt. BM.= top of 2,, pvc pipe @ el. 103.35' z5 17 MC 13 ..3 Ili ,L)'1?- 8fP 0 N 38~~ 2 N r3'5 . "b'-j r~ Gary L. Steel 10-2-97 { L't4 r~i~f}.~.r 17, 7 IL som ado, 77,77 .OT ' 2 LOT .3 SLOT 65 A 465A-~ 46 -3n G S. - 10 / 2 99 NW l ±A i,i All 8!02 !i 2072,F~ 1 803 n WT, T 8 ' 801 r 40,i 1064 F~' n i. 7 I 468A Lov* ' 468 C -o AT cm 6 C ,,S. M ' $"/23Z twe SE LOT t x x 463 F` i, CERTIFIED SURVEY MAP Located in part of the SE4 of the NW4 of Section 24, T30N, R20W, Town of St. Joseph, St. Croix County, Wisconsin. s s = \ M LEGEND OWNER NL~ CD B Aluminum County Section Monument Found Steve Skoglund y L • 111 Iron Pipe Found 149 High Street o d New Richmond, MI 54017 ` o , 1" x 24" Iron Pipe Set, weighing 1.68 lbs. v ° APPROVED per linear foot ° d ■ Existing Fenceline r ~ H i.1 l d N U A C d L d d N ° J, ST. CROIX COUNTY 41 L ° ' Conrprabanahra PhrMi ro v t- Parks Commit O~..~ U.i.r .ly h' " rn w N not re"n0 d within 30 dos of approvd 4MN 4pprovill o"be M4 3 Vdd N1 Corner of Section 24 1K t D FILED 9 APR 2 6 1994'0- 12 n JAMES O'CONNELL QSL CMIX C06. M I t s M O1 ICA '.d' ~ M O • / \ t pD co CJ I V) 1 O N •O 1 fib' C d a-I N A UNP'LAT"ri~D•• `ANDS t~ v Y U) I Chi " Z I m 2 1 N8903515711E 567.00' ~I b Q 1 1l 520. 59' W 46.41' 2C - I I ti M pp M ~ 0 0 LOT 2 o W o° c] I o VJI SURVEYOR'S CERTIFICATE I, Allen C. Nyhagen, registered Wisconsin Land Surveyor, hereby certify that by the direction of Steve Skoglund, I have surveyed, mapped and described the land parcel which is represented by this Certified Survey Map; that the exterior boundary of the land parcel surveyed and mapped is described as follows: A parcel of land located in part of the SE1/4 of 'the NW1/4 of Section 24, T30N, R20W, Town of St. Joseph, St. Croix County, Wisconsin; further described as follows: Commencing at the N1/4 corner of said Section 24; thence S00016'03"W, along the north-south 1/4 line of said section, 1437.44 feet to the point of beginning; thence S00016'03"W, along said north-south 1/4 line, 250.00 feet; thence'S89035'57"W, along the north line of Lot 1-of Certified Survey Map recorded in Volume 8, Page 2374 at the St. Croix County Register of Deeds office, 567.00 feet; thence N00016'03"E, along the east line of Outlot 1 of said Certified Survey-Map, 250.00 feet; thence N89o35'57"E, 567.00 feet to the point of beginning. Above described parcel contains 3.25 Acres (141,740 Square Feet) and is subject to all easements of record. I, also certify that this Certified Survey Map is a correct representation to scale of the exterior boundary surveyed and described; that I have fully complied with the current'provisions of Chapter 236.34 of the Wisconsin Statutes and the Land Subdivision Ordinance of the County of St. Croix in surveying and mapping same. / fz Allen C. Nyh n Date Spa rr' Approved by the Town of St. Joseph a a Each parcel shown on this map (plat) is subject to state and County laws, rules and regulations (i.e., wetlands, mknimun lot size, access to parcel, etc.) Before purchasing or developing any parcel contact the St. Croix County Zoning Office for advice. VOLUME 10 PAGE 2748 i STC-105 SEPTIC TANK MAINTENANCE AGREEMENT / St. Croix County t ► W N 1!;It/Itl 11' i!;H ..I ~ t.~.__ y~ /l.~ - _ _ MAILING ADDRESS /3746 N, 51 -57_/ 11wATc-0 In PROPERTY ADDRESS ly-15- s 1 S n,yr t/1 s c ii LO :f S yap 5 (location of septic system) Please obtain from the Planning Dept. CITY/STATE S,o," 6A s c w- 5 ~110 mss' PROPERTY LOCATION !5 i 1/4, A/ W 1/4, Section ~2' , T 30 N-R av W TOWN OF 5T. ,j o 6'Ep h ST. CROIX COUNTY, WI SUBDIVISION C0,,i711X 5io6 EsT,F:-)E-S LOT NUMBER /A CERTIFIED SURVEY MAP 51 5Frg5 , VOLUME / v , PAGE -27q ff LOT NUMBER o2 Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: ` 1- DATE: 9-le-91 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 recprding. Ownerofproperty~~eo n~~~rryts atr~s~c, c iz ,,J Location of property / Wv✓ 1/4, Section ~q T 3o N-R o~0 W Township _ .5-F 3o5 e~ ti Mailing address /37 N. /o T-0 sr S(i//wk~F4 m,1) ss'aFsZ Addressof site 147SS _7q i S~^~~~1sET" w Syoas- Subdivision name CouKr?y si JE rkr. Lot no. / A Other homes on property? X Yes No Previous owner of property V r 4,JCtL R 5K0G j A1J01 SFE'phEd G-, 5 KoG(Rr►d Total size of property 7qo s g ; asp' x 56 7 Total size of parcel .3 . s A e rd S Date parcel was created - qpw-y Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? Yes A-' No Volume /o and Page Number a-74K as recorded with the Register of Deeds. INCLUDE WITH THIS AVVDICATION 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. 515-am-S- , 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. Signature of Applicant o-Applicant:, ?-/ff- p7 I I D Date of Signature Date of Signature "ARRANTI DEED DOCUMENT NO REG'S ~ ~ - _ TEr,; r=r! ST. CRI"A CT 'i . Pac d Pea:• J Vernell A_ Skoglund and Step--.e:' Skogluni FL8 2 7 1996 A n _ at 1_1:30 ~ A. K4 conveys and warrants to _ Lucresha R. Chamber-,-'-- _i=', Fredrick Allan Meyers Reglster of Deeds T1..:- '.:ACE ;EP ~D f JA Ac..- t9DiN.i 7ATA NAME AND FE'.. aN A:'CUESS ^ n/~1 J the following described real estate in St • Cro i x Counts. State of Wisconsin: 030-2035-50-120 (Pa•cel Idenuficat,on Number) Part of SE1/4 of NW1/4 of Sectio- 24, Township 30 North, Range 20 West, St. Croix County, Wiscc-sin, described as follows: Lot 2 of Certified Survey Map fi_ed April 26, 1994 in Vol. "10"", Page 2748, Doc. No. 515845. $ TP . a This _ _is not homestead property. list tis note Exception aDwarranties easements, re_t_=`ions and rights-of-way of record, if any. Dated this 1av _Y February .19 96, _ - - _ _ - ~_~-yf3E`ALl - - - (SEAL) Vernell A. Skoglun Stephen L. Skoglund ISEALt (SEAL) AUTHENTICATION ACKNOWLEDGMENT ;V J. t~ctt Signature(s) A STATE OF WISCONSIN - ~ - a - 1-- St. Croix ~ Dusty. authenticated this _ day of Lt . 19~► Personally came before me this day of February_ 19 96 the above named K 4U_(_~ Yernell-A. -Skoglund 'l~'r IJ I r c"~ LrJ t~ Stephen- L. Skoglund_ - - - TITLE: MEMBER STATE BAR OF WISCONSIN - - - - - Ilf not. authorized by §70606 Wis. Stats.) w me known, e,he ibe- person S - - - who executed the im(wegT ng msgiiinent and acknowledge the rmr. c `v THIS NSTRUMENT WAS DRAFTED By jug.! tilt L 1. L x d Kristina Oaland n ;6r~, CGDTVFD