HomeMy WebLinkAbout032-2100-50-000
STC - 10 4 A ~r
AS BUILT SANITARY SYSTEM REPORT
• ri
OWNER ,
1 l ~lri FF.
ADDRESS CC)!jIN'•Y
195 ZOJINGOFFIC,E
SUBDIVISION / CSM# , LOT
SECTION
-,--,2~_ T. s / N-R_22_W, own of ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTH G WITHIN 100 FEET OF SYSTEM
3
w
40 sco-~
A
f
7 r h'Q u sit
7o J~a" ~rreck
AI&X
INDICATE NO TH ARROW
Provide setback and elevation information on reverse of his form.
Provide 2 dimensions to center of septic tank manhole cover.
R 7
BENCHMARK'
ALTERNATE BM:'_s,d:nv C' ? -
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
Setback from: Well 9,:~-_ House Other
Pump: Manufacturer „ Model#jL Size /
Float seperation. Gallons/cycle: L~
Alarm Location //01 w
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop, line:
~S r
Setback from: well:lZo /I House___~v2 Other
ELEVATIONS
Building Sewer ST Inlet: 2--2 ST outlet:
PC inlet 7 PC bottom !2s-1/9 Pump Off
Header/Manifold Bottom of system 9,? 7e-
Existing Grade Final grade_,~Z20 2
DATE OF INSTALLATION: ~J
PLUMBER ON JOB: n,
LICENSE NUMBER: INSPECTOR:
r
3/93: it
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
ar~d Human Relations INSPECTION REPORT ST. CROIX
Safety and nd Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No-:
GENERAL INFORMATION 299137
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
PETERSON, DAVE SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
032-2100-50-000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
/000 Benchmark
ep i
Wee, , K
Dosin Lt (3U >k14 A PA
Aeration _ Bldg. Sewer 13, IC7 90.9 C
Holding (9/ Ht inlet `1~ QO,~OUF
TANK SETBACK INFORMATION OS) Ht Outlet t~.60 90-S, Veritto TANK TO P/ L WELL BLDG. Ai Intake ROAD Dt Inlet ? 75 g o• 351
SeptI rao+ ~pt 0 ' NA Dt Bottom A0.0% cd ~ U
osing 3L' 33r NA Header/ Man.
3~~ (00 y5
Aeration NA Dist. Pipe 8, to 0i q,?-
Holding Bot. System t~ 3b ' q°I y °
PUMP/ SIPHON INFORMATION Final Grade a, 01' 10; .0
Manufacturer } Demand Q7,
Model Number /Lr t g," GPM
TDH Lift,3?4 Friction i I System TDHjI,V1 Ft
Forcemain Length 0 r Dia. a Dist. To Well 'SC)
SOIL ABSORPTION SYSTEM
BED/TRENCH Width , Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS y ~y ! DIMENSIONS
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type O /h,,, 0 CHAMBER Mode Number:
System: rr 6X.a<: , ' 0 OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) / r x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length ~y Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over o xx Depth Of xx S eded / xx Mulched
Bed /Trench Center Bed /Trench Edges /oZ-p Topsoil ~p [Yes No t{?res E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
Z ~ F-F ~rr1'; f d i ~
LOCATION: SOMERSET 26.3 19,NW,~~W 1950 62ND ST - PINECLIFF LOT 1A i
U } - VuU ' Jkr
(j/kct( BM Co- Icl wotlAe l6ca,-fer ( .
(ockf~ R, nn , & t qrr;A, ~ (V-w VJ01S ~ wl cm'j kAftl,) of P10101 W.
/
a✓G r/c t,, r6/ ",cc' s' K tt.cC ~ 14o se oe5 Ou /0L LkgGy-,e n4our d
Plan revision required.) ~Pks ff No
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER: '
hb~~
C -I
d C76,
ashington Ave sion
w SANITARY PERMIT APPLICATION 201eE. Wand ldings
`fscons-n In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969
Department of Commerce Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County j
than 8 1/2 x 11 inches in size. ✓
• See reverse side for instructions for completing this application State Sanitary Permit Number
X013
The information you provide may be used by other government agency programs ❑ Check if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION
Properly Owner N Property Location
X va 1/4, S T , N, R (or~V
Property Owner's Mailing Addres Lot Number Block Number
St.
O a n
City to Zip Code Phone Number Subdivisio ame or Csll~lumber
II. TYPE BUILDING: (check one) ❑ State Owned ity Nearest Road
I b
Public 1 or 2 Family Dwelling - No_ of bedrooms s ❑ Town OF
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground, 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. 0 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 ❑ Seepage Bed 21 M 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:
7. 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
Feet 3 Feet
VII. TANK Caallo
inacltns Site
Total # of r Prefab. Fiber- Exper_
INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- steel glass Plastic App
New Existing strutted
Tanks Tanks
Septic Tank or Holding Tank d S ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for in ,~~atiqon gkpe onsite sewage system shown on the attached plans.
Plum (P Plumb 's N t s MP/MPRSW No.: Business Phone Number:
Plumber's Ac dress (Stle t, ty, State Code)
S~ L
J;~Ap7p COU TY / DEPARTMENT USE ONLY
❑ Disapproved Sa Itary Permit Fee (Includes Groundwater ate Issued Issuing Ag nt S' nature to
roved surcharge Fee)
E] Owner Given Initial X81 1~6~
Adverse Determination C/
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6396 (R.11/96) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner, Plumber
' t
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.
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.
SAFETY AND BUILDINGS DIVISION
15837 USH 63
NVisconsin Hayward, WI 54843
Department, of Commerce Tommy G. Thompson, Governor
16-Oct-97 William J. McCoshen, Secretary
K O Construction
Kim A O'Connell
504 Third Ave
Osceola WI 54020
Dave Peterson Plan ID 9710604
NW,SW,26,31,19W
Municipality of Somerset Inspector: Leroy G. Jansky
County of St Croix (715) 726-2544
Private Sewage plans including the following element(s):
MOUND 450 gpd
The submittal described above has been reviewed for conformance with applicable Wisconsin
Administrative Codes and Wisconsin Statutes. The submittal has-been CONDITIONALLY
APPROVED. The owner, as defined in chapter 101.01(2)(e), Wisconsin Statutes, is responsible for
compliance with all code requirements.
A copy of the approved plans, specifications and this letter shall be on-site during construction and open
to inspection by authorized representatives of the Department. All permits required-by the state or local
municipality shall be obtained prior to commencement of construction/installation/operation.
This project is under the supervision of a state inspector. As inspection concerns arise feel free to
contact the state inspector at the number listed. The inspector for this project is listed above.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or
at the address on this letterhead. Please refer to Plan ID number listed at the top of this page when
making an inquiry or submitting additional information.
Sincerely,
Carl LiPP~p
Wastewater Specialist
(715) 634-3484
Private Sewage System Plan Index/Checklist
All plan sets should be legible and permanent copies, organized into sets, bound with staples and covered
by an index sheet such as this sample. No other pages need be signed as long as the index sheet for each
set is signed. Your cooperation expedites your plan review and shortens plan entry time.
Play s aa»
Le Descriptwn Ad&= ~d
ltyn+ul.rowp )
Contests Comments/SpecW Instructions
Pap / included 71wo copies Now for au
tans
1 Plot Plan Prn 2 Plan View/, ? Ratum by Mail
3
4 Tank A Pump/ 0 Fax Letter to (County) (Submitter)
Siphon Infonnation Circle One and Provide Fax ( )
6 62" F 0 CW1 for Pick-Up: ( )
7"
Other
I, the undersigned, hereby certify that tba Seat (it applicable)
plans and spec eadoes subnittetl
bomwitb wrm pnipand ender my
direction and eantrot,
i
SWAN*
" For office Use P Only W.T.S.
Att ORWO:
ApoladuW.a..ao. Conditionally
PIP
APPROVED
Y J
Needed for HAidiag Teak S bafth DEPARTMENT OF COMMERCE
one off ofsawlaad WWI" tank D1V ON of SAFE Y AND BUILDING
evelatiaL (Ar1 aM w fib)
Needed for At-Grads Suba lfth RESPONDENCE
Orwaal aipied~ao
of a AS- tarixad SEE~~
arada a~ ~
Como aa-aiN
sdn-102u (N.011%) ow add&8W M Or
ono
yC..i,.~i4' -AaS~ ,~a ~ S~~f/ - s.~ - ~.~I/✓- ~/~'o~/ .¢G•~,r/o ~ lam;
yo
oir
y
X47
low
~~r~ p.0.~'11.T•S
Conditionally
DEPARTMENT OF COMMERCE
ON OF SAFE AND BU4LDINGS
D1V
SEE G RESPONDENCE
t ~
0 33S
30N3CINOciS3
51 Wy~tld3a
SON1011in8 GO
3'y Non-Woven Filter Fabric
Awn Cpl v ion Pipe
/Distribution Pipe
dIII)uorill p OA'I T M - G 33 Sand /
-S-I'M'Q'd H o Alter, Poe. of
Topsoll r Force Main
__J t E e ' p: ;
i
% Slope
Bed Of %PM- 2 = Force Mo in Plowe d
Droin Rock From Pump Layer
. a
Cross Section Of A Mound System Using F
A Bed For The Absorption Areo F --,gy
G
AH~
B.2?, Ft.
I Ft.
J Ft.
K i Ft.
Alternate Position L j4QXFt.
of
Force Main Ft.
L
14"Observotion Pipe
-13 K
r 1
F., J-
O
Force Main
C From Pump
W
3
e7 Distribution Bed Of i2- 2 %Z
Pipe Drain RocK
I
4 Observation Pipe Permonenl Morker
Pipe or Rods,
Plan View Of Mound UsInq A Bed For The Absorption Area
PAGEa OF,
r
PERFORATED PIPE DETAIL
and
DISTRIBUTION PIPE LAYOUT
Perforated Schedule 40
PVC Pipe
End
Cap
,*V 4
Holes Located On
a Bottom Are Equally
Spaced
End
Cap * 4
Last Hole
Should as / ~"I L'~y y~~w
Next, To ~'~y ►v
End Cap
Of
Owner's Name s" ~m~ l1 G~ f
p eat
Plurber/designer's Signatures x inches
Y . inches
Dates License No.: Hole Diameter inch/
Lateral Diameter inch(es)
Force Main Diameter inches
Holes per Lateral
feet. Ir~vu W.T•$.
co ""knWir
AP
RTMENT DF COMMERCE
DE
D iON OF SAF TY AND BUILDINGS
Pag
SEE C E PONDENCE
' 1 b
a
r En
W W
~ IP s
o a 0
M
--Tll
1,® N
A
FF
A
N
~ W
A r
' A
rt
w
0
i o
O
hA
M
< Ip
fp N
~ N
W
R
N ~
0
O• 1 _Z17
A
fIN
M
r
►pin ~
' O
x
0
rt
conditionally
A?PR OVE:D'
M D pWMENT OF COMMERCE
OAF Y A ND BUILDINGS
*IVF-
SPONDENCE
a
a
PAGE or
PUMP CH^MBER CAOSS SECT10►) AND SPECIFICATIONS
VIE NT CAP
VE14T PIPE WEATHERPROOF _APPROVED LOCKING
JUWCTIOIJ DOA MANHOLE COVER W ITM
2S' FROM DOOR,Tj MtU WAM1tNG LABEL
WINDOW! OA FRESH
AIR INTAKE I
GRADE I
T I N" MI►J.
141,
~ le•rclu^
COIJDUIT
lo•nIN. _
WLET PROVIDE I
AIRYIGHT SEAL I i i I V
I I I
APPROVED JOILIT A I (I I APPROVED JOI►JT
II W/ ' PIPE
W/ PIPE EXTCNDIIJG 3' I III ALARM EXTEWDI►JG 3'
OWTO SOLID SOIL 1I OJTO SOLID SOIL
e I 1
Ow
c i f-ELEV. FT. PUMP
b OFF
0
L COUCKETC BLOCK
RISER EXIT PERMUTED OIJL`J IF TAUK MAWUFACTURCK HAS SUCH APPROVAL
3" APPROVED 15E.0biNG undcr TI%►aK
SPECIFICATIOKJS
SEPTIC E
DOSE
TAWA MAIJUFACTURE P.::IJUMBER OF DOSES: PER DAy
TAA1K SIZE' !GA L DOSE VOLUME
' ~ J IIJCLUDIIJG DAGKFLOW• ,r -<--2 GALLONS
E /
ALARM MAUuFACTURCR:
MODEL WUMDCR: CAPACITIES: A= oC IWCHC5 Olt GALLOWS
SWITCH TYPE' ' g - IAJCHES OR GALLOWS
PUMP MAMUFACTURLR: C.-. INCHES OR , GALLOWS
J a MODEL WUMDCK' D - _R_ INCHES OR y25~ GALLOW6
SwITCH TYPE: DOTE'
INSTALLED OW PUMP A MD ALARM ARE TO DE CUITS
MIMIMUM DISCHARGE 'RATE L2
VERTICAL DIFFERCIJCE OETWEEU PUMP OFF AUD DISTR18UTIOIJ PIPC.. 22,0 FEET Conditionally
+ MIULMUM WETWORK SUPPLY PRESSURE. . . . . . . . . . . 2.5 FCC pPR~VEp
1~F/ FKtCTIOtJ FACYOR..~L- FEE
FEET OF FORCE P'Aim y loo rr. DEPARTMENT OF COMMERCE
FE IONOF S ETY AND BUILDINGS
TOTAL D%JWAMIC. HEAD =
. Ate..;.
WTERNAL OIMEWSIOLIt OF TAWK: L.CIJGTN jWIDTN ;LWP ~t*QN
LICENSE NUMBER. GATE:
SIGIJEp:...._ _
.t
_ e ormance V E. t u e n t
Curves Pumps
MET2 t FEET
- go MODEL 3885
25 60 SIZE 3/4" Solids
WE1SH
70
20 WEIOH
60
0 WE07N
tS SO
W EOSN
40
10 30 WE03M
20 EO3L ~
S
10
0 0
0 10 20 30- 40 SO 60 70 60 90 100 t10 120 GPM
0 10 20 30 m+n1
CAPACITY
r~GOULDS PUMPS, INC.
u sctcA "ILS NEW rcra .r+..
METER& FEET
120 MODEL 3885--
35 110 SIZE 3/," Solids
WEISMH
30 100
90
25
70
20
1 60
O
~ WEOSHH
15
- 50 _T1 1-11 1- L I
40
10 30
20.
S
10
0 0
0 10 20 30 40 SO 60 70 60 9o 1G0 110 120 OPM
0 10 20 30 m+/h
CAPACITY
•11116 Gould& PWnPG, In*. E.40,M" July. I Ws
C)II1'
Wisconsi.+t Department of Industry, SOIL AND SITE EVALUATION
LAr ah *uman Relations Page of
Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis.
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must Count'
include, but not limited to: vertical and horizontal reference point (BM), direction and r, ! :a
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
'XI'
APPLICANT INFORMATION - Please print all information. Reviewed by - ' , ate
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ !f`
Props Owner Property Location r- ' -10 a)
Govt. Lot fftil 1 /4SCjr 1 / T ST A~r1R
Property Owner's Mailing Address Lot # Bloc k# Subd. Name or ING OFFICE V
r s J`~'
City state Zip Code Phone Number a >;ti o d
( ) ❑ Ci 'tif4Mape ~ 'Town ~vv
New Construction Use: Residential/ Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow /-'/V/ gpd Recommended design loading rate _,_~bed, gpd/ft2~~trench, gpd/ft2
Absorption area required !5u~00bed, ft 2 (1,- trench, ft2 Maximum design loading rate j~/ bed, gpd/fi2_'~__trench, gpd/ft2
Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark)
Additional design/site consid rations
Parent material I~n 42•1.dpi-) Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system ❑ s EMU [0 S ❑ U ❑ S Z U ❑ S ®U ❑ s ® U ❑ s ® U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
Ground _ 3✓" _ S
elev.
ft. -
9j- A114-
~ 7s k
s
Depth to V" )00
limiting
factor
in.
Remarks:
Boring #
4
s
/,9 je -V/9 Al /11 9:
Ground -c1 m -
elev.
gft. 7S f
- s s
Depth to
limiting
factor
_ in. Remarks:
CST Name (Please Pri ) Signature Telephone No.
~G
Address Date CST Number
_
A'10 Z 1A_ _f c22Y_-1Z
PROPERTY OWNER SOIL DESCRIPTION REPORT Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G~pjft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
16
Ground
i
1gve
lev,
att.
.6 lc!rk- s
Depth to
limiting - ' _
factor AAd VI"
Remarks:
Boring #
Ground
elev.
tt.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Boring # ;
Ground
elev.
--ft.
Depth to
limiting
factor
'n' Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBDW-8330 (R. 08/95)
1. ! ~ ~~~lj°✓,c" y~.c:~ ~
s 7;k, .7.,2.?
yy
STC-105
A.
SEPTIC TANK 11ZAMMANCt AGREEIVIIENT
St Croix County
OWNERWYER 6k v6- Iff 1_t6,eyW Y
MAILING ADDRESS " 9>-0 6_ - ~7 .
PROPERTY ADDRESS .Coi l5 /117e e/_X~1_
(location of septic system) Please obtain from
the Planning Dept,
CITY/STATE SSG L. ,v
PROPERTY LOCATION _ 1/49- ;S:A) 1/4, Section,_, T_Z~_N-R
TOWN OF E,ET C[~ ST. CROIX COUNTY, WI
SUBDIVISION _ 7110ECGlAc~ LOT NUMBER lS_
CERTIFIEDSURVEY MAP VOLUME 140_1 PAGE LOT NUMBER
Improper use and maintenance of your septic system could result in its premature failure to handle
wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed
by licensed septic tank pumper. What you put into the system can affect the function of the septic tank
as a treatment stage in the waste disposal system.
St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost
of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County
accepted this program in August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner
and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that 1
the on-site wastewater disposal system is in proper operating condition and (2) after inspection and
pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum.
I/We, the undersigned have read the above requirements and agree to maintain the private sewage
disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR.
Certification stating that your septic has been maintained must be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year iration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016
11193
f aTC-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.
ownerofproperty I' 'OyeTl/y Y02-~T6%:9r)
Location of propertyl 1/4_S 1/4, SectionT .Z• N-R W
Township GT Mailing address
Address of site
Subdivision name Lot no.
/s
Other homes on property? Yes No
Previous owner of property 4w"E me~ /
Total size of property .115-0 AnM
Total size of parcels
Date parcel was created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house) ? Yes X -No
Volume W- 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 he office of the county Register of
Deeds as Document No. T~7s'o10 , 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 o ice of the County Register of Deeds as Document No.
Signature of Applicant CC o-Appli t
Date o S' nature Date of Signature
%L mall-5
WARRANTY DEED
558'76
AEGISTERSOFFl^,F ,
Document Number BE t C... Nn
NWUrirrr[
MAY 21931
9:30 A. M 1 r
Return Address KRISTINA OGLAND -4 0u..., +t
Zilz, Estreen & Ogland "~''`aOi`'
P.O. Box 359 }
Hudson, WI 54016
fi Parcel I.D. Number:
pinecliff Partnership, consisting of Michael J. Hartman and Weseto V. Viebrock, conveys and warrants
Dorothy M. Peterson, husband and wife, as survivorship marital property,
to David A. Peterson and
the following described real estate in St. Croix County, State of Wisconsin:
Lot 15, pine, Cliff in Town of Somerset, St. Croix County, Wisconsin. ;
This is not homestead property.
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
f Dated this VA* day of April, 1997.
T A IL
O 4
Pinecliff Partnership Y
By (SEAL)
Michael J.
AUTHENTICATION
Signature(s) Michael J. Hartman for Piaecliff
Partnership authenticated this day of April,
1997.
Kristine Oglan
TITLE: MEMBER STATE BAR OF WISCONSIN
THIS INSTRUMENT WAS DRAFTED BY:
Attorney Kristina Ogland
Hudson, WI 54016
~F.
~ ~ ~ i ~ _~,,~Yr- rho Y•,
YA
Ats
• x