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HomeMy WebLinkAbout040-1196-80-000 A STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER //GU.4 G~'~f~" ~G L~~i(J 3d~(p f!'O!C) Ara ADDRESS 57~ L /N~~/ ~ ~j l~D '/J~,s ' ~D • dDd SUBDIVISION - ~r e%Q6E_ Coux7- LOT 2 d SECTION___~N-R 7 W, Town of T~DY ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM rai~ ,/3e r s a~ lv syS 7-2~ 6,y5T. ztms BNV -kp 76 100 4 ,~j 9 10 l A ~ 11 s 4c ^ ~ECC~d D ~DI G` It S'00 StA t~ S INDICATE NIIOR~H ' A VA' N 1 { Si Provide setback and elevation information on reverse of t is form. .L Provide 2 dimensions to center of septic tank manhole cove W ~ra f BENCHMARK: ete o' - /0 0 ' ALTERNATE BM: SEPTIC-T% ANK/ P C~/ HOLDING TANK INFORMATI~N~ EX fSrl A 146S /r G- Manufacturer: wEEsrS' 4ervuAX-4!~p Liquid Capacity: V Setback from: Well House 200 ' Other Pump: Manufacturer i Model# Size Float seperation.-I Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM 3 Width: -S Length JC~ Number of trenches Distance & Direction to nearest prop. line: 3.-;L' -fO Le. ST L-07'-' L Setback from: well: S7 House Other o c/, SiEP77'C T. 44/4.v 1.-.C ELEVATIONS Building Sewer ST Inlet: ST outlet: N I .40 inlet ~7• ~ 5 9 ~ 6 / Pump Off ti o~}(,er 2 ~G~ ~V,Piv Header/Manifold Bottom of system a VIA-- Existing Grade Final grade 30- DATE OF INSTALLATION: 3~ I - Iq l / -ro/ OF PLUMBER ON JOB: `"oQERT- W, L- (3 I`'/,30// 11"f6U-e LICENSE NUMBER: MPI S 330"7 90f Le INSPECTOR: ~l• /~'l ` so /j 3/93:jt e &tit ,,,_ 4,1 ,1, :i a 7.- . 't ,.__ _ ': -I gs i >ol. 1'\ ort• `t) � N apt t ;. -,,, ,t,, m \ '`6 c(-- T w rk cA -I / " 1 N v w N U I. \)..-3---...(mi l'O'‘,... III (',, "&\ --° o \--,, �- �I tt, •) 4. ,,,, \) :1) 1 - - - ' i ioi \ 1 � I .....„ 1 Ts 0 N i i I �I i mac, xl I ' ----t- '1 1 � l 1 I I ),, w _- ; I Li •I • I I t \ I I I � � I I 1 i 1 �� o 1 ' 1 I 1 1 11 _ 1 r o I I I 11I ,`� � 1di � I I i I I I d ti ,,,Ir: I , �o L \\ y r‘ Z e . 1 i vi `X IT 1- o w o ?� Q ' / 1\ o w w b ' r \-- ,\ ....., , Lf, ' , ______ \\ ,...__....- G ° OR/G/NAL Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division Count§T . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanita WE~o Vi//p.: Personal information you provice may be used for secondary purposes [Privacy S.15.04 (1)(m)). L 2i y Permit Holder's Name: ❑s i ❑ Village Town o : State Plan ID No.: CLUEN, MICHAEL & LIGIA TK~'Y CS BM Elev.: Insp. BM Elev.: BM Description: Parcel o. ~`d-:1196-80-000 TANK INFORMATION ELEVATION DATA A9700212 7/ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Aerati n Bldg. Sewer Holldingr St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet r - TANKTO P/L WELL BLDG. ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom 2 Dosing NA Header / Man. ! c Aeration NA Dist. Pipe Holding Bot. System PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand Model Num PM TDH Lift Lriction. stem TDH Ft Forcemai Length Did. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH width, Length No.0f3renches No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S S~ J D I M E N I Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION Type O ^ .r/c C BE T um er. System:yo R UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) ,x a Size x Hole Spacin nt To Air Intake Length0lt"'' Dia_ ~Z Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Gr5xx Systems n Depth Over Depth Over xx Depth Of Sodded xx Mulched Bed/ Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) k rl .r 4 ) LOCATION: TROY 4.28.19.892,SW,NW 5/71 LUND~ LANE LOT 20 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH t SANITARY PERMIT NUMBER: J h t 2jr o , 5,Z? 73 6;71 v.~ w 517. 3 Y3 n tl 7.53 7,73 U-u1 u o ,13, tb T 3 • Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. `Viseonsin 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 !~T Cleo 1•y_1 than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number 1~9g9all 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 PropertOvj n~er Name • Property Location Gt4•6r<' /4G G(JFit-.-' SW 1/4 &1411/4, S / T 2f , N, R [ E (otD Property Owner's Mailing Address G~ Lot Number Block Number 57/ Gvvp Y 2-6 Cit nps `~1' ZYCode . y (715) um S ~vis~~n NamI~CSM Number IS-7 ,9A1'r. 11. TYPE B ILDING: (check one) ❑ State Owned !t (TU+ R Nearest Road ❑ VII a e 4A) Public or 2 Family Dwellin - No. of bedrooms J_/ own OF Lvvt~ 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 ❑ New 2. replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an _____System System Tank Only______________ Existing System Exl--- -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 1 01. ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 EWepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill 777 a rt N S S X S d P-et~-~- Ida 10 0S VI. ABSORPTION SYSTEM INFORMATION:' 1 Z ~G. S'D ystem Elev. 7. Final Grade 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6._S DO Required (sq. ft.) Proposed (sq. ft.) (Gal day/sq, ft_) Min./inch) l/. 2 S 2~ EWtion -7 S' 5'O•0 Feet • zs Feet in gaTotal # of Manufacturer s Name Prefab. Con- Steel Fiber- plastic Exper. VII. TANK CapHExistin site INFORMATION Gallons Tanks Concrete glass App- New' strutted Tanks Septic Tank or Holding Tank ?00 1 pail O~ ❑ ❑ ❑ ❑ s ❑ ❑ E ❑ ❑ Lift Pump Tank /Siphon Chamber I VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stam s) 'bFP/MPRSW No.: Business Phone Number: JZb g V_W T- 'ULQ lZ tGtnT 3,307 174f-' Owl QOO Plumber's Ac dress (S5 e`City,S~e,ZipCod.~ n • ~~0~ c+s ~(~6` IX. COUNTYW/ DEPARTMENT USE ONLY ~jJ ~-CJ J / Y ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) [Approved ❑ Owner Given initial Surcharge Fee) r g a~ Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: - SBD-6398 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety 8 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. 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/DepartmentU$e-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 cure; pump model and pump manufacturer; D) cross section of the soil absorption system if required bythe.county; E) soil test data on a 115 form; and F) all sizing information. - GROUNDWATER SURCHARGE - v 1983 Wisconsin Act 410 included the creation of surcharges (fees) fora 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. 1 IN . 's;J w N \I m NA \ o y IN l,,, V 0 R� Ivo o Z ' li I � � N C N AN I/I .:'`\ �, , Q w N c o Zri �1 c b N i° to I 101 Ipi - - - - 1 1 I ' 1 i c,� i i I �,\ I o � � t I I�1 11 * b I �I Ili mi I ' I 0 I - -I 1 —1 w � � t 1 I � I �_ I � N , � m Q , I I 1 1 1 1 (r‘ 1 1 I t - - I �� -�-�. 0 - -- - vl � • I 1�1 I I O vo ' N vl y f\t . , \ (h) f\rii- \‘‘: \----- TX, yob) c'l / \I\f-'. ttt\1 %Ct \ � I i O t.,) , k , _ _ Associates I Ulbricht& e Consultants Private �� 665 O'Neil Hudson,Wis. 54016 11AP) � 0 ti 1\,,,,,,, NI 'Wisconsin Department of Industry, SOIL AND SITE EVALUATION / 3 Labor and Human 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 County -5-7: ounty include,but not limited to: vertical and horizontal reference point(BM),direction and `s� C���•/\ percent slope,scale or dimensions,north arrow,and location and distance to nearest road. Parcel I.D.# oyo . //yf . ia • oda APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). Property Owner / / �j� / l Property Location ,/� 7 Ri //f,9�G f 4/&,9•- /'z c- G 2zE ( Govt.Lot 54) 1/4/VK/1/4,S /f T2, ,N,R /9 E(or( J Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# �- 57/ Goxipy GA, • 2 0 ,y;fA, 4v r— /sr "Ap.p•T: City State Zip Code/ Phone Number ,�, Nearest Road Opstvil/ I to/. I S7 9" 1 ( 7/5 ),3F 'five? ❑ City ? age I� own I L -(40 v L.r' . ❑ New Construction Use: Residential/Number of bedrooms / Addition to existing building Replacement ❑Public or commercial-Describe:Code derived daily flow Goon gpd Recommended design loading rate /--- bed,gpd/ft2 • % trench,gpd/ft2 Absorption area required bed,ft2 / trench,ft2 Maximum design loading rate — bed,gpd/ft2 •v trench,gpd/ft2 Recommended infiltration surface elevation(s) Ste- I •3 ft(as referred to site plan benchmark) Additional design/site considerations 6'(/ST/b 6"' SV,SIE"y /5 / j7 Ce,--y9�.1 '7 5 ''4 "C ' /5'4-- '& •2/,ji Parent material s4Uor d197-42-f ..� _ Flood plain elevation,if applicable N/ ft S = Suitable for system Conventional Mound In-Ground Pressure AT -GGr�de System in Fill Holding Tank U = Unsuitable for system I S ❑ U LJ S ❑ U L<5 ❑ U ❑ U L❑ U ❑ SL^-f'o/ _ SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed , Trench 7 o-,c /oyie 2/3 4 /s%e driie .Zs 3 ,f .9 ' . 5 2 •/2. /o y/e Sly S 7L � d,' s - . d% S — . ? .. •S Ground 3 'a�- 0(//� `SL // cS � 444 i>• "L 5 -(.' : .S ill,: ft. y ;9.r6 7syRes/a -- ' - 1�, fe a's — • 1 •S _ Depth to limiting , factor f• in. ' Remarks: Bonn"# / O'7 /D we 3/1/ L /fs#6,- 414 {/P of S ?G f • ef . 5 2- 2 7-4 /o y/e //V •S L /f 5,.e )e,' CY /f . Y ; •S 3 /.Z? /oy nS/i' SiL 2/fsht' /psi7:e Qs — . s G.. Ground 9 23'M 7 SY' Y/f ZS I,LN f/e G[ c es- . -2 , •V¢ . elev. 9'3•S ft. S 31212 /oW S/Cn tii/x fu-r y 5- 0,fq de 4 -e• — • -) '. •g 4 2, SYte ylca LS /�, �,e " — • 1 . •8 Depth to , limiting factor �J in. Remarks: CST Name (Please Print) 120 go?r a Signature I��j l ephon 1C (mot QRiu,T 7is•3Tel�'G •cs"e No.d c Address Date CST Number � Ulbricht&Associates ?Yu-L. 27- qi CS7 2 T/<p 2._-. Private Sewage Consultants 655 O'Neil Rd. Nrrdson,Wis. 54016 ORIGINAL PROPERTY OWNER �G Gv ex)5 SOIL DESCRIPTION REPORT REPORT Page 2-of 3 PARCEL I.D.# °Y� - //!G� • O d • d .4)0 I2.C7CT-- Boring # Horizon Depth Dominant Color Mottles Structure G D/ft2 in. Munsell Qu.Sz.Cont.Color Texture Gr.Sz.Sh. Consistence Boundary Roots P Bed Trench 3 1 o-8 ,'c e 3/t( - L /fs4e /'.e qs 3 f . S 2 iq7'S 'l2 y/g- S d� f G� 2 � s — . � H 37 Ground 3 // /cm> y/ -- /f s ,e 444 f2 . s 3.eig£Yft. -f_--31* L5 1444 fie d,Q . 7 : g Depthto limiting factor - fy in. Remarks: Boring # _ Ground ft. Depth to — — — limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed Trench Boring # Ground elev. ft. Depth to - — limiting factor in. Remarks: Boring # - Ground _ elev. — ft. Depth to limiting factor in. Remarks: SBDW-8330(R.08/95) h4 I N p o 1 cfi' t y- 1 N PI ..,_____I, r----o ry N o � - N L b N 1 I I I i i - - - - - i I 1 I I 1 (I IDi 3 ° ) m i i 10 1 W c I 1 1 oc 1 t N m IH1 Nk\ 1 1 1 1 'Is I I 1 1 11 I I � VI � 1 O • ti I j � 1 - - II ' y c (1\ ; ‘N .,C)) 7-1 /° o� ( d � � o s ;, ( .1 - 4 1 . \l, , , -, kr% N'—. -p`b ` ' o` �, v. 1 w k .„ ,,,, I ______ / kJ., 1 1\ ) ) 1 '), - - �,1 ST. CROIX`COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the 1fj~C/4'tE"z 1"If G Gy'r--A."o residence located at: .51t) 1/4, N41 1/4, Sec. T 29 N, R L7 W, Town of Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. _ Last time serviced ~I~aX ' if%3 Did flow back occur from absorption system? Yes No (if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: 1060 S*-~`S ' Construction: Prefab Concrete Steel Other Manufacurer (if known) : Cl~/€'-S4=;e CD'V ae- 7Q 4:29 - Age of Tank (if known) : I (F a l~ ~7 YaA-R-S 01k) T 0 3 EP T- 24LB P- i &T- (Signature) (Name) Please Print a~ IM P,5 3 30 (Title) (License Number) t&P►g$C onsuttso Ptj'V5h ade C pcWst® $etwRd• S0Ne (Date) ~udson. V~IIs 5m0~6 Form to be completed by licensed plumber (x.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-83, Wis. Adm. Code (except for inspection opening over outlet baffle~~ ~~(~T Zf1Al~1/ 3307 Name Signature +4P-/MPRS 5/88 1GtNA O? . Fresh Air Inlets And Observation Pipe • . r- Approved Vent Cop . —� W.I�( . ^1/t/ VI minimum 12"Above Final Grads i( • __ _—__. 1/i1Jl5/7/ED 9/e41)6 (((JJJ i T/PCti C ,So / 4° Cast Iron 36P ' Above Pipe VMI eip9' -to Final Grade tynIMtic Cover Mg Min. 2" Aggregate ' Over Pipe 1-1 0 Dislributlon .I a —Tee I ' Pipe 0 0 0 0 o L..C i„ Aggregate "V 60 e o Pwferoled Pipe Below J Beneath Pipe -- —Clouping Terminellna Al �""' Bottom 01 System 3 s y s r -Ai — ----1''.- 92 , 5'0 ka :•► W Fresh Air Inlets And Observation Pipe k r Approved Vent Cap J Minimum 12"Above -moo /►'I%PP 11 final Grade // —e_ Fi kJ S HED 6-RAP E- ►' ilj T R r= ►J c H— `j 5; Z S J _ " //-- _4" Cost Iron 3 tP ' Above Pipe Vent Qipti � 'to Final Grade , Synthetic Covering W Mtn. 2" Aggregate l v Over PipeORIGINI• 0istribution _ Tee Pipe o 0 0 0 0 e Aggregate o Pertbrated Pipe Below Beneath Pipe to — Coupling Tecminoling AI S/S TC -1 /�U._ Bottom 01 System Fresh Air Inlets And Observation Pipe r. Approved Vent Cop ...i, , Minimum 12" Abov! -tee vk k, GO&E57`� 1// Final Grade �/ /,v/S //Eft f4ii' TRENCH- gyD r Owt _4" Cost Iron 36, a Above Pipe Vent Pipe' ,o Final Grade N ht&Psso .,„A o,nsotet`lb Synthetic Covering u V1bticte Sewa9 Min. 2" Aggregate pessv" tW`5•-,, • j Over Pipe Hodson• �! Distribullon —Tee C Pipe 0 0 0 0 0 " Aggregate o Perforated PIP. Below pp, '/� Beneath Pipe 0 —Coupling Terminating Al / Bottom Of System y 5 ySTEE-1 6/6 . '-_7—�' . *o, o . y --I •• .. I NO°23'E 0 rn oo . b I60.001 °°offN2 ee CO- 0 � a 6 6' °ao 1BSI 0 • W:p 1 fps s° iSs o 0) — %9 U, °v0, W 0 * Uti CO�k 30 n z N 0°04'E i 4,'°' \ 0' rn co 257.56' `) \ \ 0� umi -o co o p -nmv �5�, G' ni �� ,� '�0' m D W \ F pw, ui m i — w Arsr O � e0 w .p 'p 41 °W) co- 0 / m �`�.61 8 �- o O 0- N CO 0 O Z ��4 et. °° e ��01° W iv - - _ - -r0- �° �0 c)�900 ion 46 24.5 DN m \ z va 0 a0 .,, 10 Ln N 0 p xi oi, �o N. n (n �C)--1 -I O _ C 1 \ • \ o rv'4 D O m `Dto W 0c` 00 ° m-103M p 1a' ° \ \ 0 , C 4 0 m m tD_ is) W O ,_-Cm- �, 120.00 �-N ,1 051'0��p ` rn=c m --Go. 6 61 e��' O 68.43 - m 0 U'_ 0G' j \ O °/0 450. -- Z D n t�° �' Z _ 76%' N -►- 0w� N O 04'\% v1 m °°Doo 1 o c5' b �� 0 v' — zor m c, o-- wrW - O D r •P_ N r N W �- cmi� Do D 1; �° W m xi N D O c0-_<�_ O- 60 I 3,, W- m g7°46 41 E 429. 21 r S� o a 512.98� - W N p .J in W Co -p N •�6� N"N D N W CID-W gcv ID, . W c) O _ N . CP O- ) a) W (I) a) �- - • O - a'.. - - 0 470.85' -m <S7°3015411 E405. 17 .� — Q (71 — N CD p O'0 N IA m rn _ p _ C p- o — 203° G w' �'I. r) D CO I.5' 1 ) p O Oe •• a '56o N 'O N rn IS, c0 O, \ \ 0 - n ( S,60 A 6 3A'E \ m \ \ 3\.5\ co 4 \ O A \ 0 W cp O a Cn 0 O cD 4, /S6°g `N Apr + , NJ'�0 S v) o� w c'0 SO 300�,n 57,9, . CD 9 N c' ;- co rn 0 0p cP W Cl) 0 w �� W'W ti c .0 s ,� -O '' N 1.1 .(9g 3'>0 �O 53>'0 ` v'.7.� N90 5 5,2� W 219.69 • ` ` �6+- p 4 cr m 333Q Gib" N S°22 38 W 178. a 1810,,,, �-� lQ I i - -_� cn STC-105 SEPTIC TANK MAINTENANCE AGREEMENT GAG' A M St. Croix County ale 3~'~ OWNER/ R Ik~~L LVEAl MAILING ADDRESS _571 L UNP y L yf- , fVPI'~Ov 60-1 r . Y~10 /6 PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE ' q PROPERTY LOCATION -64U 1/4, NW 1/4, Section ~ T Z ~ N-R W TOWN OF "d ST. CROIX COUNTY, WI SUBDIVISION Hf' ft _ V,,r7-, , LOT NUMBER 2- 0 CERTIFIED SURVEY MAP 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: V'~2 1;lTu 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. Owner of property Location of property ,61 1/4 /VA)1/4, Section ,T2,00 N-RW Township Ift Mailing address 5-71 Z'4U1'A9'V Address of site subdivision name Lot no. Other homes on property? Yes No Previous owner of property ' /A4 Vi5 rl- Total size of property 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 L---No Volume &0 3 and Page Number 11fQp 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 th Q~ ce of the County Register of Deeds as Document No. © 1 J , and that I (we) presently own the proposed site for the s wage 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 dul recorded in the office, of the County Registe of Deeds as Document No. 2~ a ure o Applicant ;a~t o-ApPo 'ca t IqZ f Signature Date f Sig ature e QOCUU M No. STATa BAR OF WISCONSIN-FORK 2 WAM"I M. ~...foE P01r MCOMN(i DATA GM PacE498 Ty1s VACt MOVED , 360855 ► REGISTERS Office, M/is JAMBS J. WILLIQUETT and JACQUELINE R. WILLIQUETT ST, cam, C0 usband and wife a ' ~ . 4 I~c`d to► Rioo~+tf Rtla 31 day of ~I~Ot t~ . MICHAEL R. MCLUEN and LIGIA M. ` conveys and warrants to DlcLUEN`husband and wife, as Joint tenantstii. L . 14 a[Tum TO pT CrUIX, Coup the following described real estate in tY• State of Wisconsin: Tam Key Ito; r~``a { # N . .v r A psr, o Lot 20, High Ridge Court First Addition to the Town `E, } of Troy. * t e tee` ~ ; ~T t ~ vq 4~ n a TOGETHER WITH and SUBJECT TO easementsr covenartcar, reservations art y restrictions of record, if any. Y a i fi z v ` t" y 1 r'L 3 Ado~ - - - ~ _ ^ i ~ 9ty tx 9 ,w µ * b 7,1 This is 6osiestead property. b ar^a , (is) (is not) a r r r ' c: ~'f Exception to warranties: 10 • ~T '4 33st October Dated this day of C rp ~',+~f, s a.;t ii3 Nt` 5 •f~:~ M i e - (SEAtf r t rt AUTHEk:iCATIOi! ItCKMOWLEDGMEMT'~-" Signatures authen0rated this._ffLh__-T of STATE Oil Vflj:"NSBd N/A is sar.~ - St CrotX N/A ~',E1etoDr~~ibovai eO'. Y TITLE: MEMBER STATE BAR OF WISCONSIN ~ WiI li'ttuett' and` "*Cgu~ ~ ~ ~ R a I (if not, N/A ~ authorized b y § 706.06. Nis. State.) This instrument was drafted by d 'i William J. Gilbert to me " to be pe "l:~i> Gwin, Ga. r - n `Mudge ' Hudson, Wisconsin 54016 p..