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038-1080-20-000
o 4) N~ p ~ o°° °o I p I m C C bq lzz 4 0 Y c ~rn 0(D N a o E~ N N N O m L N co a rn ~ 'f6 O m I I O V1 M ui Z C 0 CU ~O C U E yv y8, € = o 3 N C1 W n N in z °o 0) r O Z Tx 7 We ` 7 f6 N O - U. c La aL LL OC CD d0 cn E 'D (D '0 0 Q a.aL ¢ vii o, I 4) 0 z a! z fn CO E E CO Z z Y o = o IL m a m °.'~Z I I I o 0 z :!t c c v Q5 o o 4 0 :!t ` ` d Z c c fA r z O N c E c E -o Cl) 4) (D ' N 4) =3 N m n CD c a z 0 y c a~ D aU) L g 01 c v c v Q w z z - Q ° m z z o m Z N c = c ~o E S is E E N U'j a a~ V to a o r ` c m ID C14 ° G C a a o G G a m e 0 C, ~ N oNfnfn 3rmrmrm =~j O 3 a a 3 3 3 a 0 Z 't :4 1 o • m a a a N a a a v, FL 4) E N N y E r- r y (A J V ! ) co 0 (D fn OOi OOi 4) O O cM 0 0 0 0 O O N L O O 'O L O a ~ E a ° m N C o m CD c a LM V rn a~ v d Q in Lo~ d ¢ i~ m o `•4 0 `+4 00 N few/! C N 0 C O N O d O E 2 U C N O O O O M O N C C', CD N U a 0 0 ( L. o CO c m y c€ c 2 N N v co M a :3 N Z E° w CD w c ? co cb ^ o o E 5 • O- in a N- z 2 H d co O z z U) 0 ~ I I p E U d j € € CL • ad ! dad` da S c c 3 2 A oIL2 i0 v o 0 U)u Parcel 038-1080-20-000 11/22/2006 10:42 AM PAGE 1 OF 1 Alt. Parcel 19.31.18.330 038 - TOWN OF STAR PRAIRIE Current I X'i, ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - PLOURDE, MARCEL D & DENISE MARCEL D & DENISE PLOURDE 2095 80TH ST SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 45.000 Plat: N/A-NOT AVAILABLE SEC 19 T31 N RI 8W NW NW FRL Block/Condo Bldg: EZ-UT-1295/560 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 19-31 N-1 8W Notes: Parcel History: Date Doc # Vol/Page Type 03/12/1998 574889 1305/17 WD 07/23/1997 707/498 2006 SUMMARY Bill M Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 10/05/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.000 25,000 289,100 314,100 NO AGRICULTURAL G4 16.000 1,800 0 1,800 NO UNDEVELOPED G5 28.000 70,000 0 70,000 NO Totals for 2006: General Property 45.000 96,800 289,100 385,900 Woodland 0.000 0 0 Totals for 2005: General Property 45.000 96,800 289,100 385,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 141 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel 038-1080-30-100 11/22/2006 10:42 AM PAGE 1 OF 1 Alt. Parcel 19.31.18.331A 038 - TOWN OF STAR PRAIRIE Current XI ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - PLOURDE, MARCEL D & DENISE MARCEL D & DENISE PLOURDE 2095 80TH ST SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 5432 SOMERSET SP 1700 WITC Legal Description: Acres: 39.755 Plat: N/A-NOT AVAILABLE SEC 19 T31N R1 8W SW NW FRL Block/Condo Bldg: EZ-UT-1295/560 EXC PT TO CSM 15/4187 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 19-31N-18W SW NW Notes: Parcel History: Date Doc # Vol/Page Type 03/12/1998 574889 1305/17 WD 07/23/1997 707/498 2006 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 10/05/2005 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 19.755 2,300 0 2,300 NO UNDEVELOPED G5 20.000 50,000 0 50,000 NO Totals for 2006: General Property 39.755 52,300 0 52,300 Woodland 0.000 0 0 Totals for 2005: General Property 39.755 52,300 0 52,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 WNSHIP,(V ;K W ~t----SEC/?'14 OtNr It TO AUllF~tESS ST. CROIX COUNTY, WISCONSIN. Sk% " 49 t SUIillIVISION LOT LOT SIZE PLAN VIEW Distanced and dimensions to meet requirements ut H63 EYI':MTHING WITHIN 100 FEET OF SYSTEM i ~ i n y r I di a e o th Arrow SC L BENCHMARK: (Permanent reference Point) Descr.Lbe Elevation of vertical reference point.- _Slupe at site. SEPTIC TANK: Manufacturer: ..Liquid Capacity: Number of rings on cover TaWmanhule cover elevatiunk- r. , 19 Tank Inlet Elevation: Tank Outlet Elevatiun. PUMP CHAMBER Manufacturer; _ Number of gallons _ Number of gal. pump set for a c yc 1- gallons; total apac ► i y o dibtribution lines --galluil: size a pump-_ hluJ, gallon per minute , horscpuwer_ brand name ut pump and model number Type of warning devi+e HOLDING TANK: Ma" acrurer Number of gallunb Elevation at manhu_ie cover Ty Pe of warning device AEPAG PIT SUP Numbc:Y ul P1 feet diatucl "I feat. liquid dbpC~► s<- paRe pt kolu1 Pipe-Clevdt 1011 bot tuui of deepay YP tievat I." r1 ) I e, I ' /11 W PAGE PAGE hED JLZE; CaIL[LIbei ut Wco W 1 rt .t ll~:,( ~A/~ 1 1 i t Il 4 f. li 1•.' VA6E "HENCH W r3 Vi l,f 1 ` i AT A•`~ M UAW ~ :AREA kl 1kF.i5 k tip. l,11I1 "1' 7<A'C DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR _ SAFETY & BUILDINGS LABOR & HUMAN R'E'LATIONS PRIVATE SEWAGE SYSTEMS q' DIVISION P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 LiCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number: Ilf assigned) El Holding Tank El In-Ground Pressure El Mound NAME OF PERM,yT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE. --V ,0 f 1 `drnmer' e- f BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV. n w Lv Svc,19 T31 n W S}o r P f i t Na,,,- of Plumber MP/MPRSW No.. County: Sanitary Permit Number: I Ro P I)563 <R I -I - - I L! d SEPTIC TANK/HOLDING TANK: -7.7 1 • 6 Z MANUFACTURER. LIQUID CAPACITY TANK INLET ELEV.. TANK OUTLET ELEV.: WARNING LABEL LOCKING COV - PR V ED: PROVIDED ' YES ❑NO ❑ NO BEDDING: VENT IA VENT MATL HIGH WATER NUMBER OF ROAD: JPROPERTYO WEL BUI I C J VENT TO FRESH P n ' ALARM FEET FROM ^ , 1 y LINE AIR I YES ❑NO ❑YES ❑NO NEAREST L V / DOSING CHAMBER: MANUFACTURER BEDDING. LIQUID CAPACITV PUMP MODEL JPUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF EROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM AIR INLET PUMP ON AND OFF) ❑YES ❑NO NEAREST _7 SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing T11 AMETEK MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue. LMAIN CONVENTIONAL SYSTEM: _ WIDTH JLENGTH NO. OF DR PIPE SPACING COVER -r INSIDE D~~--IA =PITS LIQUID BED/TRENCH TRENCHES MATTEE7RIIAL: PIT DEPTH: DIMENSIONS CO3-~ I- - - C FILL DEPTH I ID STH. PIPF DISTR PIPE DISTR. PIPE MATERIAL: NO. DI R NUMBER OF PROPERTY WELL. B~UrI/LDING. VENT TO FRESH ~ AIR INLET'. BELOW PIP S A ECOVEH E E V INLET ELE V. END PIPES FEET FROM LINE d~ 61L G ! r NEAREST -~Iv2t/0 /r MOUND SYSTEM: '(Q ipvi Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO SOIL COVER TEY,TURE PERMANENT MARKERS OBSERVATION WELLS ❑YES ❑NO ❑YES ❑NO DEPTH OVER TRENCH BED IDEPTH OVER TRENCH BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: NIDTH LE NG TH NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL. NO DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL $ MARKING ELEV.. ELEV. DIA. ELEV.' PIPES DIA.: ELEVATION AND DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED [~~MATION "POLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS ❑YES ❑NO - - ❑YES ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: IBUILDING. FEET FROM LINE: 0.70 ❑YES ❑NO ❑YES ❑NO NEAREST 3 C9. 8T ~0,0 Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE - TITLE - f^ a y DILHR SBD 6710 (R. 01/82) f J DEPARTMENT OF APPLICATION SAFETY & BUILDINGS INDUSTRY, FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: Mailing Address: Property Location: Ci4y-,-VRtge or Townlship: County: A< Y4S J N/ R (or) W / - 1 Lot mber: Blk N Subdivision N m a: Nearest Road, Lake or Landmark: State Plan I.D. Number: (If assigned) WOE OF BUILDI G Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: 5d 1 or 2 Family *State Approval Required. TOTAL NUMBER PREFAB POURED-IN STEEL FIBERGLASS NEW RE CE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION I 4T (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): 50 New ❑ Replacement ❑ Experimental 0 Seepage Bed ❑ Seepage Pit ❑ Alternative (specify) ❑ Seepage Trench Water Supply: Owner's ame as Listed on Soil Test Report (If other than present owner): ❑ Private 0 Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plumber: SignaZQe: MP/MPRSW No.: Phone Number: J V /S_ Plumb 's Address: )C,, Nam f Designer: )JZ COUNTY/DEPARTMENT USE ONLY Signature of Issuing Agent: F e: O 0 Date: F-1 APPROVED Sanitary Permit Number: S 3 rya ❑ DISAPPROVED Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White-County, Canary-Bureau of Plumbing, Pink-Owner, Goldenrod-Plumber D I LH R-SB D-6398 (8.07/81) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, ' DIVISION LABOR HUMAN RELATIONS PERCOLATION TESTS (115) MADISON WI 53707 LOCATION: SECTIO /N:T3 N/R (or) TOWNSHIP/I1TY: LOT O.:BLK. O.: SUBDI ISION NAME: WI , ~ v UNTY: OWNER'S/BUYER'S NAME: M AI LING ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMER IAL DESCRIPTION: NS: PER A ON TESTS: F Residence [4New ❑Replace I ~a RATING: S= Site suitable for system U= Site unsuitable for system CONVENTION'A'fL: MOUND: IN-GROUND-PRESSURE: SYSTEM-I -FILLHOLDI G A NDED SYSTEM: (optional) S ~V ®S ou S F-lU OS ZU EIS NK: REC M r. If Percolation Tests are NOT required DESIGN RATE- is STEM If any portion of the lot is in the under s.H63.09(5)(b), indicate: I Floodplain, indicate Floodplain elevation: ROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHffS-T- TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B_ 9,3 u s B- .3 ? C PERCOLATION TESTS G TEST DEPTH WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD t PERIOD 2 P R D PER INCH P- P- 7 > P_ r7 P- P - P- % - ~1 r ~ 'z~ Tusr 7 PL N VIE 4Show locations of p a r c o at ion tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slop. SYSTEM ELEVATION J r r 7 lip F Ey ~ AN s , _ ~yf r G~ b , f Y i t /(PA STC - 104 AS BUILT SANITARY SYSTEM REPORTr , / A/ OWNER ADDRESS SUBDIVISION / CSMf SECTIONTN_R_Zff W, Town of ST. CROIX COUNTY, WISCONSIN . PLAN.VIEW SHOW EVERYTHING WI N 100 FEET F SYSTEM ~FBn Qy`' f i yD SG1l S r INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 'BENCHMARK: ALTERNATE BM:, , 1, 98 7/ .SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer 1ie5 Liquid Capacity: Setback from: Well 6~ , House "1 Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length 75-~ Number of trenches Distance & Direction to nearest prop. line: f i Setback from: well:T House .so Other ELEVATIONS Building Sewer ST Inlet: 9S-j,? - ST outlet: PC inlet PC bottom Pump Off Header/Manifold 2 Z2 Bottom of system Existing Grade Final grade DATE OF INSTALLATION: i" PLUMBER ON JOB: r / LICENSE NUMBER: _ ,2 " INSPECTOR: 3/93:jt vuisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count Safety and Buildings Division INSPECTION REPORT yS'~. ~RCjIh~ GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary29yt1V.: Personal information you provice may be used for secondary purposes [Privacy L% w, s.15.04 (1)(m)). is" ~tCEL DjW e L@wn o : State Plan ID No.: CST BM Elev.: r Insp. BM Elev.: t BM Description: t GCS S ' S Parcel T(yS%0-;10f 04-20-000 ( ao 40 V? 9' TANK INFORMATION ' ELEVATION DATA ~97~~221 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic obv Benchmj!t.t. .05- 102,0,; (aD Dosing Aeration Bldg. Sewer 9-7 D Holding (5PJ6 Inlet TANK SETBACK INFORMATION &PO Outlet 5~ S TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic /00t 70-r 1-7' 25t NA Dt Bottom Dosing NA Header/Man. 7 Aeration NA Dist. Pipe , F.36 C/ 3 .(0 8• Holding Bot. System P.t{S '12 (P PUMP/ SIPHON INFORMATION Final Grade -f G . GI Manufacturer Demand ofdaorS%l~a V ei. 3 -71 Model Number GPM /a 97.) TDH Lift Friction S stem TDH Ft Forcemain Length Dia. Dist. To Well SO BSORPTION SYSTEM EDE RENO H width 11L( Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE / STRE¢ ` LEA Manuf urer: SETBACK INFORMATION Type O _1P_ i CHAMBER System nvcnora 7 ,,//6 SO 13`~ R t11~TT DISTRIBUTION SYSTEM , S 2 Header/Manifold Distribution Pipe(s), x Hole ize x Hole pacing Vent To Air Intake Length Dia. Length -73 Dia. Spacing (5 7 Z 5" SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx h Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges", Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE.19.31.18.330,NW,NW, 2095 80TH STREE'T' I'IV1'T/~ Plan revision required ❑ Yes Xati NoUse other side for addi tional inforon. ` I ~i✓ SBD-6710 (R.3/97) Date Inspector's Sig ture Ce ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 9 ^:p;^ Safety and Buildings Division ~.■~r■r. SANITARY PERMIT APPLICATION Bureau of Building water systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State sanitary ermit Number A' 9 4116 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 FORMATION -PLEASE PRINT ALL INFORMATION Prop y Owner Nam P operty L cation 1 /4 1/4, S T , N, R (or P operty Owner's Mailing~ress Lot Number Block Nu ber I at Zip Cod Phone Number Subdivision Name or CSM Number II. TYPE OF B 1LDING: (check one) ❑ State Owned ❑ tit Nearest Road E] Public 1 or 2 Family Dwelling - No. of bedrooms Towan 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 online B, if applicable) A) 1. Z New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5_ ❑ Repair of an _____System System Tank Only-- Existing System _________E 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 L Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12E] Seepage Trench 22E] In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43E] 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 h ch) Elevation C' r Feet Feet VII. TANK Capacit in gallons Total # of r Prefab. Site Fiber- Exper INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank or Holding Tank 'SC 4~J ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the )undersigned, assume responsibility for installation of onsite sewage system shown on the attached plans. Plu s Na It) Plumber' ign ur . No am ) MP/MPRSW No.: Business one um r: J J Plumber's Ad ss ($eet, ty, Stat p Code) IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing Agent Signatu (No Stamps) Surcharge fee) pproved ❑ Owner Given Initial ln ` Adverse Determination l~ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) 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, 608-266-3815- To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. Ili. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. lee, e, tY'OD r~o oZ/4'N.r1~~'~ Po5 Sao ~ ~ d• t~ j r' I Wisconsiri Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services in with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less 8 x 11 i es ins 70n must County include, but not limited to: vertical and horiz ntal refers di and ' percent slope, scale or dimensions, north ow," and I tance pae rest road. Parcel I.D. # 11 Uraon. Reviewed by Date APPLICANT INFORMATION - pt a $ Print Personal information you provide may be used fo itdary purp~iy Law, s.`i(1) (m)). Props Owner 20NINGUMLor /property Location x> Govt. Lot 1/4 1/4,S T ,N,R (or) P operty Owner's Mailing Address Lot # Block# Su . Name o CSM# ~7. d. City Statp Zip Code Phone Number Ci ❑ illage Town Nearest Road D4 New Construction use: R Residential / Number of bedrooms Addition to existing building ❑ Replacement Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate gibed, gpd/ft2__z_4/e_trench, gpd/ft2 Absorption area required ~eQ bed, ft2 trench, ft2 Maximum design loading rate . 5 bed, gpd/ft2__,j~_trench, gpd/ft2 Recommended infiltration surface elevation(s) 7 ft (as referred to site plan benchmark) Additional design/site considerations Parent material ~/~",-7 k d lzL <4s Flood plain elevation, if applicable Nll_ It S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank u = unsuitable for system ©S ❑ u EIS ❑ u ® s ❑ U IDS ❑ U ❑ S Q u ❑ S 011 SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 / in. Munsell Qu. Sz. C nt. Color Gr. Sz. Sh. Bed ,Trench I / Ground _7? ze elev. X-2_ft. w'c Depth to limiting factor Remarks: Boring # , 70 -7 3 Z 3 3S Ground elev. ~n-~ r • Depth to limiting factor %2~_in. Remarks: CST Name Pie a Pri t) Signa re Telephone No. ' ;z / - Address 4~7)" z2__'9' Date CST Number , ~~Oel 'JS ~ ~/-7 SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots Gep/ft2 13 & in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench -7 i '12" /1y - 5-Ground 3 elev. Depth to - - limiting fa r Remarks: Boring # L a---Z4 'Z,4)eSZ41 is JZ Ground t~ s- elev. Depth to limiting factor Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/1`12 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Bo ring # l 13 /1,111 110~ 17 #,1 .v / d Ground S _ elev. W -L' ft. Depth to limiting ; factor Z266n. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD-8330 (R. 07/96) / Se~,s s s--~ 97 H '/oQ ~ ~O~ aih 1 Y I S S S T C loo 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 &-CO/ lezl'r Location of proper ty_1/4( 1/4, Section -T_ -~LN-R W Township_ Mailing address Address of site Ci°'~`~~_ Subdivision name Lot no. Other homes on property? Yes ~;,4- No Previous owner of property Total size of property S Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes _ No Is this property being developed for (spec house) ? Yes )e 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 ttie office of the County Register of Deeds as Document No. S- ~41 ture of Applicant Co-Applicant DatC of Si_gnati Date of Signatu STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County oWNE UYER m a re~~ Q\d ca,e MAILING ADDRESS y05 ~"c•S S~ So c.,eos2~ z synz5 PROPERTY ADDRESS (location of septic system) Please robtain from the Planning Dept. CITY/STATE /])I- PROPERTY LOCATION 4Za-1/4, _ 1/4, Section T-2 / _N-R W TOWN OF ~r R~r per ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP 9 VOLUME , 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 expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 AGE - IM V"\ A{afaYC no a<Oa9 I i oocu sr► r No STATE RMk Ol* WISCONSIN CT RK 11- LAW C*#CM i WM7 lTO'E USED yeEa ALLL'"RANSACl7R N0 118 ;I i , C q{q tteaeo IS ANCXD ' Iia,ACTIONa1 - - (ijw( - ~'Rii Of~iCE li Cj'V.x oo., wIL I Contract, by a~ between ----11ll~tti__~e uxMdi for Recall ok 160 11 dy f_. !!are:h A.D. t*ss s~ i arcel•'p . ourde and-jNA. -e.... +i 8x30 A W old- .11AAIX u~ os on). rd~s. Sb Mpuxb*Me wbebW IE } to _-Pnrd►aseR, UPee~ !haprapsDt and loll Dee' _ VesuB~or was arras to convey together the ' : the follcwins P"Peirty+ - i! feRmanca of this sontraet by Purchaser t Interests (4111 celled the rants, D=olkts► °ProDetb►")• I - - - f( Si:ara and ether DD a Ultenan County. State at WI- "TV*" To ha_----------- -:...G~..... - l ti The Northwest Quarter of Southwest Quarter t (NW, of SW%) s the southwest Quarter of Northwest Quarter (SWh of NWU : and the Tax Parcel Na j rtes of Northwest Quarter ( of ~ t Worthwest Q Townh P all in Section Nineteen elEighteen (18) --thirty-one (31) North, of Rang West. I; it i This s homestead property' (is) (is not) such_.P.lag...t!$..Sers93?$ to pay to Vendor at oQ (a) ~1.Q•eDQOa- YUreha to urchese the Property and manner: of tn i the following with interest together '`o boo.q the son of from date annum east par a + st the pcecUtion of this Contract; and (b) the balance nine 19s)--- at . ilielnCi g m at the rte of- - - rital~fnents"of S4bd•db, co hereof on the balance II o,tstandin n month~Y ns antu paid in fall, as follows: of each month thereafter, March 15, 1985, and on the 15th day until paid in full; bQ}9*Cr'sEla'i~bt'P~"" "'~~~la ~e'r'+~r.~twASr+~w+.wiww~ provided.'~weve~r. the-en!'tre-aalsla+~+~ -tg- _.M'rm=n~t9 per annum on the entire amount ---_-_7- Following any default in payment, interest shall accrue at the rate of upon acceleration or maturity, the entire in default (which shall include, without limitation, delinquent interest and, principal balance). tici- to pay monthly to Vendor amounts sufficient to pay reasoned! Vendor, ~trhr, ardess excused by Vendor, agrees payment of special assessments, fire and required ►ms u monthly premiums when due. To the extent received by pated annual taxes, to these obligations when due. Such amounts received by the Vendor for psym Vendor agrees to apply payments into an escrow fund or trustee account, but shall not bear interest taxes, assessments and insurance will be deposited rinciPal- Any Unless otherwise regal by law. specified and then to p first to interest on the unpaid balance at the rate spec ill XXX payments shall be aPPlied time after.-----~los--...~ -9. X without premium or fee upon principal at any amount may b• prepaid }betr t shaof be '2 ~ to payment so long LtlEre"rtUC7'i~e ~ ~°PaYt"e In the event of any prepayment, this contract shall not be treated as in default with rasp ants been as the unpaid balance of principal, and interest (and in such case accruing interest from month to month shall be tree any proceeds as unpaid principals is less than the amount that said indebtedness would have been had the monthly made as first specified above; provided that monthly payments shall be continued in the event of credit of xcluded from. of insurance or condemnation, haser is satisfied ewithsthlt tlehas shoewneby t e t tleeevidence submitted to Purchaser Purchaser states that P Puc None for examination except: s. ~7/w 499 the Property or upon Vendor's isteeeat assessments ied py wbea due all ta>:si "d such payment occa by lire. 4w lose or d=W net p~e &W w to V des Te receipts is it ~ to ~ deUver to Vendor insured nsitbeut eo-i.. thro,& insure:. °ppTO~ ments on tba Property PWCWWW shall b° as Venda may require, mT}~ie hazards store anwast pails uIinsurable y14at v~~> „m;~, w ~ Waded co"rass .1 * =V endor. in the anon etc sc . t. purebaw shall Pay in of Was to his waij Vendor otherwise agree the the loaa d-11U= I se in.fsver elt Vendor's WW44 "Vendor Purchaser shall promptly ame Iris .hall mat" the aad Vendor Wwrwisa down tthegie~toratio or rol, air to be be &POsited Witt 411 ann policies Go" ~ ' the V of of the party, to the PIQP*rty and icstl7 fessibl&n waste nos .lbw waste to be committed the PrOl Ian of this Contract, sovenanta net b aoatnttt the Propsrty free from Was for to t1N to good ~ o6oditim sand repsa= tO_ k!!~~„~ igoidas the Property shill be fdi~' p~ sad ail amdlt'Om to deliver to eoZ4 with au is s. in eass the yu j`rehase•e price With iaweet sad 00" Vendor will de>~• szeente sad . above apaciA4 Vender agrees tb@ thaw and in the asannsr tree sad clear of all liens and eeymbrsuces. e~ shall be Billy peri°rAed at is fee stmplq the Prow:rY► eatept:.._Irll1 ?i~-'1 51..+CNl3.ll$•-••-and e' a Warranty r scrested by the act or default of Purchaser. lira. o: nd restons__ of•_ rgcgd tbe Pur easements... a ricti ordinances a...................... - ent of any Intact or is and la) in the event of a default in the p'1 eat of s des that time is of the essetttx specified due date or (b) in the - purchaser agree 60 days following the follow* wri tten notice of period of ..-6Q- daYs~anee mLr this contract t,terat which continua fora period Purchaser which continues for a tmance of any other oblige tied mail), then the curve outstanding(which ided by law) in Vendor (daivered personally °T matted by eerti without notice Purchaser he fp ome immediately due able in lull. att,V~nRd°reri'es (8 bject to any limitations rov P shalt > glue following rigb terminate this Contract and Porches of Vendor shall also hs it y. Vendor may. at his oyptil with waives), atnd Property s2 through strict foreclosuwith re interes tt~he~nfrom addition to those provided by law or in and recovsr the It ats pnviousiy title and Interest Jim the ekeser's full Payment of the entire hereunder (in balance, rental for the =pt+on to be conditioned ~p such dateaadotheramoun due hreunderwhichevet and as to or the perfo manoce fthisaContraet Compel tpe data of default at the sate 1t, liquidated damages for sue for specific p for ap rchaser by Purchaser shall N .t; ladee3 os (11) vendor if purchaser lath to oetstanding imisnee, with interest thereon at the rate in effect on the data ion and ~y tef the vent the Property shall be auctioned urchas price or any portion and full pay die harauttder, in which sue at law for the entire unpaid p quiet-title ion default and other f s yu~. 4W (Si) Vendor end and remove this Co have Purchaser ejected from Pion .pelf be liable (his ♦ Vendor may ndeno of any .1cent; and thereofif ° the i Vendoi slay ~intRs to lgn, any t,• usuea or profits during the Pe an election action equitable interest ~it~p statements or actions t of aVendor nd all costa and expenses f any and have a ~~Wnding any oral or e! the Property or (iv) above.A Vendor of and when Pursh aderg(whether abated or not) to ti;e snider 631431 ~r be binding Upon enforce any remedy and aid by Purchaser, as m" remedies of the foregoin Mor"ye fee of Vetsdo incurred.I shall be added to principal paid not prohibited by law sand ea *title ev►de vded in ant judgment. action of foreclosure of this theorems, i~ es, and Profits a' end eft Burred, and shall be inel of any UP" p nI homestead ' and interest, profits when so rnllectsd shall be held the cowaosucmw" or dariae the P:" wty. of tba trope n, and ene rents, t""°a i ment of any ment of s reede of sveh actio to the appoint out ignment the propert;r during the pande~tcy or uitable interest in the property (by ass shall direct, " ya or in any other way) with. the prior written court applied as for sell or convey . Y legal long-term for indebtedness of Purchaser sbt, [I not u~t this Coet tract or by balance Payable under this Contract fastsecu ity in sn full or indebtbtsnding punhaser's nigh Landing t under this Contract soleY 010 consent of Vendor unless either nthe t of Purchaser's interes ante without Vendor's written consent, the entire ou due and payable in full, at BtetherPropertY without notice- conveyed is a pledge or assignor such transfer, sale or convey on the date of Purchaser. In the event of any mortgage outstanding age thereby, provided Purchaser balance payable under this Contract shall become immedis Y made on payments wher due undnh r) or under any note secured v such payments directly to Vendor shall make s11 Pam granted by make an, this Contract (ez,ept for any mortgage made by Purchaser shall be considered payments makes timely payment of the amounts a het, a1l uPaemen~ts Cro retract. Purchaser may pr~gtiva, the Mortgagee if Vendor fails to do other subsequent or prior default of Purchaser this Contract. aive any default without waiving an and inure to the benefits tl athe 'heirs. f Vendo nor a valuable vendor may w ntract shall be binding up= s owner of the Property to jo,rn in the execution of the All terms of this of Vendor a" d Purcbaser: (if not and agrees successors and assigns i n to Vendor homes teed right, in the subject Property r-Wasi consideration joins hen 19 85. deed t. be made in inltlilment hereat• February.... 12th day of Dated this ~~~~V'• A n (SEAL) ~ _ „mac-lac-~ (SEAL) ~GKG Marcel D.. plourde (SEAL) (SEAL) . Denise Plourde ACHNOWLSD0 ig . ION STATE OF WISCONSIN ADTgSNT - IC . AT - as. store(s) - Sign St.! ..-_Croix_...... ----.Conn y• l.2tZt.... asy of Personally came before me this - - • - - - 19.E .r?... the abcce named day of - 19...... February $lOtlXde.-.. authenticated this Ruth..Plourde.,-..Mar-~~.~._ and.-Den se...Ploul•. lct'O^ISiN - the MEMBER STATE B d f not AR OF „ TITLE: 's..,- the me known known to be ~Yar $y, r t e O, -d by 4 706.06, Wis. Stara.) inatrum!,n „rhorize ;