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HomeMy WebLinkAbout040-1237-20-000 V STC - 104 • AS BUILT SANITARY SYSTEM REPORT OWNER ADbRESS 4), SUBDIVISION LOT- > SECTION T N-R W, Town of ST. CROIX COUNTY, WISCONSIN 6116 1a3~- 2l-v0013. a8. M. flif PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM r E tii- INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 'BENCHMARK: ,105; j~ ALTERNATE BM: t►r SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer:. 4.; cis 7`ay,,~ Liquid Capacity: Setback from: Well u sel~ ~ Other Pump: Manufacturer c~ _Model Size 2 f~ Float seperation Gallons/cycle: Alarm Location ~o w -:!5 SOIL ABSORPTION SYSTEM Width: Length G Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House %Dh .4 Other ELEVATIONS Building Sewer ST Inlet: ST outlet: PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: 71 fj~ PLUMBER ON JOB: LICENSE NUMBER- F-2 INSPECTOR: J71 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Lappranc Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit 1 GENERAL INFORMATION 284301 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: P.C. COLLOVA BUILDERS, INC, TROY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 040-1237-20-000 /DO lDU 6~:v TANK INFORMATION C/ V ELEVATION DATA A9700071 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic - Benchmark .0 o7, p 7 i O Dosing Aeration Bldg. Sewer 10d, &d' Holding St/ Ht Inlet ( , 160"91" TANK SETBACK INFORMATION St/ Ht Outlet z,7 71 TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet ~7 Air Intake 7777 _5 4 4. _ 2-1 Septic JaS S! , NA Rt Bottom c..oS~ to/mod-' Dosing NA Header / Man. g~ 44's r , ~s 8 s l~,JS~ roo,8'3 ~ Aeration NA Dist. Pipe g. 9 F_9: Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer r Demand Model Number -l o 9,15 GPM TDH Lift Friction 3 Syste TDFjn~,4,3 Ft oss mead Forcemain Lengthy Dia. a u Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width , Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS & 7 3 DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION TypeO CHAMBER model Number: System: f✓ rl~ S -/00 a 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 c/ a Bed /Trench Edges ~Z2-Zv Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY.3.28.19,NW,SW OAKLEY CIRCLE LOT Fit Z-P /66 u Plan revision required? ❑ Yes I~No Use other side for additional information. 97 C-~~Jt o~ G SBD-6710 (R 05/91) Date I spe s Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 517. Safety and Buildings Division v~G~~■'~i 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 811 x 11 inches in size. e • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)J. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location ,P C: C-01- .0 11 Q dia a 'f 4 Al G q) 1/4 .54V 1/4, S 3 T eq f, N, R E (or)~ Property Owner's Mailing Address Lot Number Block Number / 7 s- -r t- & Th t City, State Zip Code Phone Number Subdivision Name or CSM Number 41 S (iz ) X/S q-re v? a c.Jer, d II. TYPE F BUILDING: (check one) ❑ State Owned City Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Village of `~oW~r Ip~2 111, BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 61 'VQ 8 7 _ 2 e?l 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. [„New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ------System System Tank OnlyExisting System --Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 [ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ("Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft-) (Min./inch) /040 Elevation ~4ee 4-11~ 0,10 t doh f G ifJ~~ S Feet ,"^0.,A/, o`-Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site - Fiber- Plastic Exper. Gallons Tanks Concrete Con Steel glass App. New Existing strutted Tanks Tanks Septic Tank or Holding Tank id zj e- 702❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) P/ PRSW NO.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) [A roved Surcharge Fee) - pp E] Owner Given Initial 46 -q7 Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05194) 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: 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 forma 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. o ~~•°L ~.elr~s uJ S'G~ s° fQ~J Z`~/ ~ c, ~1av d ~ ll Ale Saal-e- ,~j !r a I ,A"'jP'd po S C et. Alm ,Gff 3 y Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code QU NTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must inpfudt9 Ibut ` Croix not limited to vertical and horizontal reference point (BM), direction and % of slopes °le or PA L P.. dimensioned, north arrow, and location and distance to nearest road. r erld APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION VIEWE Y DATE PROPERTY OWNER: PROP RV LOCATION Richard Stout GOVT.'S NW 114 SDy''"1/4,S 3 ' l N,R 19 k(or) W PROPERTY OWNER':S MAILING ADDRESS LOT # 13lOCK# - ;$U80,,'f 0 1353 Awatukee Trl. 61 f"fi~.'+. Co Wood CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑ l~ipE 'q NEAREST ROAD Hudson, WI. 54016 (71$ 549-6731 Tro r``,ae Tower Rd. [x] New Construction Use [ 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 na bed, ft2 750 trench, ft2 Maximum design loading rate • 5 bed, gpd/ft2 .6 trench, gpd/ft2 Recommended infiltration surface elevation(s) upper trench=101.04' ft (as referred to site plan benchmark) Additional design/ site considerations trenches 3' below surface and spaced to code Parent material pitted outwash plain 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 91 S El U ❑ S O u 91S❑ U El S [3U ® S ❑ U ❑ S 13U 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 Trench 1 0-9 10 r3 3 none 1 2msbk mfr CS 1f .5 .6 1 2 9-16 10 r4/4 none sit 2msbk mfr w if .5 .6 Ground 3 16-34 10 r4 4 none lfs os mvfr na na .5 .6 elev. 101.14. 4 34-84 7.5 r4 6 none is os mfr na na .7 .8 Depth to limiting factor +84" Remarks: Boring # <•»._<:;_;::: 1 -10 10 r3 3 none 1 2msbk mfr cs if .5 .6 2 4 2 10-32 10 r4/4 none sicl lfsbk mfr w if .2 .3 Ground 3 2-80 7.5 r4/6 none s os ml na na .7 .8 elev. 102.37 ft. Depth to limiting factor +80" Remarks: CST Name:-Please Print Phone: Gar L. Steel 715-246-6200 54 200th. 49ve., New Richmond, WI. 54017 M02298 Signature: A11119 Date: CST Number: 4-19-96 PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D.# pending Lot #61 Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0-9 10 r3/3 none 1 2msbk mfr cs if .5 .6 x?<C4;,>s.:••:;; 2 19-23 10yr3/4 none sil 2msbk mfr gw if .5 .6 Ground 3 123-36 10 r4/4 none sicl lfsbk mfr gw na.2 .3 elev. 104.21 ft. 4 36-8 7.5yr4/6 none s osg mvfr na na .7 .8 Depth to limiting factor +8411 Remarks: Boring # 1 0-9 10 r3/3 none 1 2msbk mfr cs 2f .5 .6 4 2 9-28 10 r4/4 none sl 2msbk mfr gw if .5 .6 Ground 3 28-7 7.5 r4/6 none s osg mfr na na.7 .8 elev. 97.43 ft. Depth to limiting +/8,1 Remarks: Boring # 1 0-17 10yr3/3 none sl 2mgr mfr cs 2f .5 .6 5 2 17-7 10 r4/4 none lfs osg mfr na if .5 .6 Ground elev. 92.57 ft. Depth to limiting factor +741t Remarks: Boring # 1 0-24 10 r3 3 none sl 2m r mfr cs if .5 .6 6 2 24-7 7.5yr4/6 none lfs lfsbk mfr na if .5 .6 Vii:: •M14 i:i: Ground elev. 88.98 ft. Depth to limiting factor +7411 Remarks: SBD-8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 Richard stout New Richmond, WI 54017 MPRSW 3254 NWgSW4 S3-T28N-R19W (715) 246-6200 town of Troy lot #61-Country Wood N 1"=40' BM. = top of 1" steel pipe @ woods line C el. 100' r \'7 d~ 0 i E 171 ` ~ v" X32 1'~ ~ ,p~ -41 Gary L. Steel 4-19-96 PAGt (;F PUMP CHAMBER CROS5 SEC TIOIJ AIJG SPECIFICATIOUS VEUT CAP 4'*C.I. VEMT PIPE WEATHERPROOF APPROVED LOCKIAIG > 2_5' FROM DOOR JUMCTIOM BOX MAMHOLE COVER - , WIMDOW OR FRESH 12"MIU. AIR IAITAKE GRADE I I I 'i" MIA1. ~ l-- COAJDUIT 18"MIM. 18"MIAs. \ 11l IMLET PROVIDE I = AIRTIGHT SEAL I I I * A I III I III I I I ALARM a I II I I 0 *APPROVED I I om JOINTS WITH I ELEV. FT. APPROVED PIPE 3' ONTO PUMP OFF D SOLID SOIL COAICRETE DLOCK RISER EXIT PERMITTED OULH IF TAIJK MAUUFACTURCK HAS SUCH APPROVAL SEPTIC E SPECIFICATIOUS DOSE TA AI KS MAMUFACTURER: IJUMBER OF DOSES: PER DAU TAIJK SIZE: GALLOKIS DOSE VOLUME ALARM MAMUFACTURER: -e I.-f A ti-- ft-l IMCLUDIMG BACKFLOW: ~G d &ALLOWS MODEL MUMBEK: )9A CAPACITIES: A Y7INcA[s oP, GALLOUS i SWITCH TYPE: )72 t,- e B= -Z_INCHES O;t-V,21%GALLOUS PUMP MAMUFACTURER: va C= ((f_f4WCHES OR GALLOUS I MODEL MUMBER: 24' d D- -R- INCHES OR I S6 GALLONS SWITCH TYPE: _ /~17 °Q^c- MOTE: PUMP AMD ALARM ARE TO BE MIKIIMUM DISCHARGE RATE 3~~ GPM INSTALLED OM SEPARATE CIRCUITS VERTICAL DIFFEKEKICE BETWELU PUMP OFF ARID DISTRIBUTIOM PIPE.. 13 FEET + MIKIIMUM METWORK SUPPLY PRESSURE , . "FEET + ~O6 FEET OF FORCE MAIM X F/poFLFKtCTIO1J FACTOR__ Av7 FEET TOTAL D9MAMIC. HEAD - lY 123 FEET IAITERKIAL DIMEIJSIOKIC OF TAAJK: LEKIGTH f 7s* cwt M ;WIDTH ;LIQUID DEPTH I SIGKIED:-_~.`~ ria 3871 EP04 EP 05 APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. • Effluent systems dry without damage to heat transfer. ■ Motor Cover: Thermoplas- • Homes components. Available for automatic and tic cover with integral handle • Farms Motor: and float switch attachment • Heavy duty sump • EP04 Single phase: 0.4 HP, manual operation. Automatic points. 115 or 230 V, 60 Hz, 1550 models include Mechanical • Water transfer RPM, built in overload with Float Switch assembled and ■ Power Cable: Severe duty • Dewatering automatic reset. preset at the factory. rated oil and water resistant. auto • auto Single phase: 0.5 HP, ■ Bearings: Upper and lower SPECIFICATIONS 115 V, 60 Hz, 1550 RPM, FEATURES heavy duty ball bearing Pump: EP04 built in overload with ■ EP04 Impeller: Thermo- construction. • Solids handling capability: automatic reset. plastic Semi-open design 3/4".maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING •,Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. SP Canadian Standards Association • Total heads: up to 24 feet. with three prong grounding EP05 Impeller: Thermo- - • Discharge size: 11/2" NPT. plug. Optional 20 foot (CSA listed model numbers • Mechanical seal: carbon- length, 16/3 SJTW with plastic enclosed design for end in „F„ or AC'.) rotary/ceramic-stationary, three prong grounding plug improved performance. BUNA-N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 1040F (400C) continuous superior strength and 140°F (600C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. 10 • Capable of running r dry without damage to s 30 sow components. Pump:EP05 - .5 FT • Solids handling capability: °a $ 25 -l - /4' maximum. • Capacities: up to 60 GPM. _ i U 6 20 - _ _ I • Total heads: up to 31 feet. • Discharge size: 11/z' NPT. Z 5 ! j I • Mechanical seal: carbon- } - - rotary/ceramic-stationary, ° 4 151 + BUNA-N elastomers. o EPOS • Temperature: 3 101~ --~--I- 1040F (400C) continuous 140°F (600C) intermittent. 2 ! ePOa 5 - - - ---t - - - 1 ~ 0 0- C - 1 1 - 0 10 20 30 40 50 GPM , , 0 2 4 6 8 10 12 ml/h CAPACITY ©1995 Goulds Pumps, Inc. Effective May, 1995 83871 1 J \ v 1� \\� \\'\ ''t I._, ICJ ,r.•I iry\ ;M ,p ;U Iry "'• 'N 1_, --+ it ;y ,n • f(•-' i L omm `,1J t�0 ,, Im :7 �S -1 � � 1� I ;1" -1 l �1 " 'W 11•1 - - 1 1- 38 i-i I< t•l 1 /lu,.of u/ •vutnw n T 1 NVT.,..(Or S. Ow ale Of M �� tom:Y NO+.•�•(10.•0 {,Utuw[O TO et A• RSV Ili't• '3id3�4 TR.CT MC)T Late or I.( r•v. .t•'wN'{./.1!' QI )tw'A'.('1 ���— -502'0'7•t awo'S.."S•I 896.79' t • - V WW1 (o(.x • a ..1I' `.nt.a..�� ro(.u" If soi t<r.\' m.n• ee • "i E " . t ">i \ I • g r ...1.) s. 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I-, 1-. it\ \ 't; C°ter : r:tF y- _ 1 t. ` -Ft• •} \t F t• R j 8 e f R • II E" Kacnxe!Eer. ts**..Egpxme fo N\ \.R 2 " 1\ l'‘.. -. ....- r \ .._ \ t ? 4. 1;0 t ory i \` L \1µ( �� 6v Cg.as�ss - - �Sc'z __ a_aka \ } \,17 o ` i I i, 1 "• ; t pp; b` K vsc . . . . .4544 . .. . .5a14i \ o , t 1 t}t Y,y. i' .a 8 s L E JCJC�c rr 6��y^� E. � :� cT') l ©P6r�p 2a Im• \ �' 6 bGa�ccrostraanc-4.. $� \�,. K e �• 1 /; 6 Ai \ • !Ifn 0 op H J— • : CQ[ ^ k ga r, ci u�1< =6n6`{" =C °n� '6 6 Ast CC, �`�af C gr A A Sod fY,S ;" z n STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County P.C. COLLOVA BUILDERS, INC. OWNER/BUYER 12575 KPUer Ave WITHROW, MN 55038 MAILING ADDRESS PH. 439-9547 ID. #1073 p~ PROPERTY ADDRESS I1 ~i['o A I l !„1. C L~ (location of septic sys m) Please obtain from the Planning Dept. CITY/STATE ~'-'o n (IJl / PROPERTY LOCATION N ~1/4, S ~ 1/4, Section __3 T a N-R W TOWN OFT -o u ST. CROIX COUNTY, WI SUBDIVISION ~Ot 12y W noI) f Si Ac~~! LOT NUMBER l(P CERTIFIED SURVEY MAP 5gga 6?, VOLUME M, 1 ` , PAGE 3 D , 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. /0 C' 11W'4_1 /.~1,111 SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - 100 This application form is to be completed in full and signed by the ..owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/ contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. -S-~L4YA.BU1LDEBS.LNC-------------------- 12575 Keller Ave. WITHROW, MN 55038 Owner of property PH. 439-9547 ID #107-1 Location of property r 1/4 5V) 1/4, Section 3 ,T~N-R W Township TAOII Mailing address f-1-re l Address of site II ``A v C. - df)o n Subdivision name O 'rr~ C~1~rdJkLot no. Other homes on property? Yes No Previous owner of property ;r GHQ rcr Q 5~6 u Total size of property Total size of parcel I a~ Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No Volume and Page Number 30(~o 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. ignatu e of Appli ant Co-Applicant Date of Signature Date of Signature { STATE BAR OF WISCONSIti F06tM 1 - 1982 5492,67 WARRANTY DEE/D~ ` DOCUMENT NO. VOL . * " E . . REGISTER'S U Cr. ' - This Deed, madebetwetn-Richard O. Stout ST CROIXCo., VJ Re:'a>«~«a I~" x Grantor. SEP 10 1996 r and -__p__C- rol14va Builders,__Inc. r- a aty 11:30 A. M ~t fIi PSQta CorPorationt T• t.la...`~ fz1ijefL Z,► _ Grantee, Registt,r of Deeds Witnesseth, That the said Granim. for a valuable cc"64de"wri- ,r RECORDING TmIS SPACE RESERVED FDA DATA - - - to Grantee the followin4 described real estate in S t_ C ro i x ~ NAME AND RETURN ADDRESS conveys County, State of Wisconsin: p fC~, -~3 Y Lot 61, plat of Country Wood First leAr Addition, Town of Troy, St. Croix County, Wisconsin. ;s PARCEZ,DENTI BER $ T LjFER e This _ not - homestead property. ---i-& - (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging. And RlOh,ird -0 StOut warrants that the title is good, indefeasible in fee simple and free and ck3r & encumbrances except a. easements, restrictions, rights-of-way and covenants of record, t if any.+ and will warrant and defend the same. 19 96 ust k Dated this day of Au 1 (SEAL) (SEAL) 4 • RiCharS~ tOUt (SEAL)y (SEAL) ACKNOWLEDGMENT AUTHENTICATION State of Wisconsin, Signature(s) ss ' St. Croix ~y - Personally came before me this _ day of v' authenticated this day of 19- 19_--, the atxwe named art-- i 11 TITLE: MEMBER STATE BAR OF WISCONSIN ? who executed the foregoing f (If not. n Q{ v.: to be ytg authorized by 4706.06. Wis. Stats.) [and ace the hame. NSTRUMENT WAS DRAFTED BY ~l THIS I Janet P. Stout Brenda Poulin - - ' St. Croix -County.W-