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HomeMy WebLinkAbout040-1224-20-000 • FOGERiY PLUMBING 1 DATE: JOB PT:. Lodz STC - 104 JOB SP: _ y, AS BUILT SANITARY SYSTEM REPORT OWNER L y< r ~f L,q~i : ADDRESS SUBDIVISION / CSM# LOT L SECTION. 7 T Z ' N-R_f _W, Town of_ 22Q0% ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM _ $y'I jd a F SU /t v~~ori /Z acl • J~Irl~~70y S /~iod J~ ~07~ lmrh~r O wr// O - >ew l cs~ S / a-_ jZ. G~ Ys /7j < SS oF--- INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: _y,CI.~~~-s.✓..~.~t.F ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: _~,.z ~d Setback from: Well House l` Other Pump: Manufacturer Model# Size Float seperation Gallons/e Alarm Location :SOIL ABSORPTION SYSTEM Width: Length 7 ~ Number of trenches 2 Distance & Direction to nearest prop. line:- A-,/ > ~D i Setback from: well: 76 House Other /JI•t`f ~O ELEVATIONS Building Sewer Q7 P ( ST Inlet. . F`, « ST outlet ~6.y2 PC inlet PC bottom Pump Off Header/Manifold. QZ3- Bottom of system_ Existing Grade_ j9" Final grade_o ' DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: or 3- p9 INSPECTOR: ~~`3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and HSman1304tions INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 284294 Permit Holder's Name: ❑ City ❑ Village CE1 Town of: State Plan ID No.: LANDERS, EVERTT TROY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: x,/ 040-1224-20-000 /JJ/ OD TANK INFORMATION ELEVATION DATA A9700063 -7 197 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. ~ Benchmark Septic (I . 0<7 Dosing I?.Nl, Aeration Bldg. Sewer ( . a 9? Holding' St/,}off Inlet (29~ TANK SETBACK INFORMATION St/,Wf Outlet L' TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic a~ y Si ' yj,¢ NA Dt Bottom Dosing - - NA Headers, ;2' y15, G Aeration A Dist. Pipe, S`f. > 3.~ Bot. System 9 3S 9 '30 S8 Holding PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand !~,7 r' Model Number M TDH Lift L6Ss Ion S' em TDH F Forcemairi Length Dia. Dist. To We SOIL ABSORPTION SYSTEM BED/TRENCH Width _ Length = No. Of Trenches PIS----_. No. Of Pits Inside Dia. Liquid Depth -7 DIMENSION DIMENSIONS LEACHI anufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LE BER INFORMATION TypeO Mo e Num System:,11, , l,''~rF',' R UNIT DISTRIBUTION SYSTEM Header- r/,/ Distribution Pipe(s) x Hole Size x Hol ing Ven Air Intake Length Dia- Length 1-1,2 Dia. Spacing X11 SOIL COVER x Pressure Systems Only xx Mound Or At-G a Sy Only Depth Over [Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed / Trench Centered / Trench Edges 3(j c1c~ Topsoil E] Yes ❑ No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY.7.28.19,SW,SF CEDAR VIEW RD --,,LOT 2 J1 Plan revision required? ❑ Yes Ca"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: Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. 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 than 81/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ 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 Property Owner Name Property Location V&X 7T 4,f 'D SW 1/4 /c 1/4, S 7 T ZS1 , N, R q E (ora Property Owner's MaiIo~nggAddress Lot Number Block Number Cit , State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE BUILDING: (check one) ❑ State Owned o ItrNearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 6 own of 2D E ul III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo o 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. 8 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only DExisting System Existing System B) A Sanitary Permit was previously issued. Permit Number 2 t7 5/,)-fy Date Issued p V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11E] Seepage Bed 21E] Mound 30E] Specify Type 41 ❑ Holding Tank 12, 0Seepage Trench 22 ❑ In-Ground Pressure 42E] Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14E] 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) Elevation fy. S Feet 3 Feet pp a VII. TANK Capacity gallonTotal # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank p ,ZpV f fne ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of he onsite sewage system shown on the attached plans. PI tier's Name: (Print) Plumber's Si nature: No St ps) MP/MPRSW No.: Business Phone Number: r ;LJ1 g - J24 u is Ac dress (Street, Cif, State, ode): It 12e F COUNTY/ DE ARTME USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps), ~Approvecl Fee) I ❑ Owner Given Initial Adverse Determination c~7 kaa~2~ X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: I/ V SBD-6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 11- 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. Cam, ~ Oo b o Tch b 1~ y C Vj o e H ~ ~ y o y w N CA C\ o X00 ' T-,, \b X 51 W ~ ~ ~ a v ~ ~ h 14 G Safety and Buildings Division vii..'r■'~ SANITARY PERMIT APPLICATION Bureau of Building Water System! 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 SanitarPermit Number The information you provide may be used by other government agency programs E] Check if `rre~evviision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location iF N 114.$;5 1/4, S T Z y, N, R E (ortv Property Owner's Mai ing Address Lot Number Block Number Z ICi , State Zip Code Phone Number Subdivision Name or CSM Number Ill. TYPE F BUILDING: (check one) ❑ State Owned ❑ !t~ Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms / ❑ ToVil wn OF p III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo D 02- /,2,Z y 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 ❑ 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) _ Elevation APO SD P . ~ Feet ,2 Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex per. INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App structed Tanks Tanks Septic Tank or Holding Tank 4 2w E] E] ❑ 1:1 El Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of th nsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stam PRSW No.: Business Phone Number: vIr 3i09 7 - ~sI Plumber's Address (Street, City, State, i ode): d ".4&- A IX. COUNTY/ D PARTME USE ONLY ❑ Disapproved San it ry Permit Fee (Includes Groundwater =Issued Issuing Agent Signature (No Stamps) g Approved E] Owner Given Initial Surcharge Fee) 7'"C Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-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. OnsiCe sewage systems must be properly maintained:- The septic tank(s) must be pumped bya licensedpumper Wheriever 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. Tobe.comolete 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 1/2 x 11 inches must be submitted to the county. The plans must includ'ethe 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 perf rmance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by thtfcounty; 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. ♦ ~ L 1 00 N 0 C 3g © fQ, -A c i I h v ~ \c c) _ - s'X7Jr - s ' h ul t TM y %a A s N c w n ~ ; 4 r i + _.1 f i - V . ~ ~ M~ f~ ~T '$i.9a .w.. ~ • y J' . ? ~ _ - ~y_ +Rl ,+#k A' r 4 y-. ~ ~ A~ ~ i_ n,.,, ~ v \ ~ ~ _ ~ ~ ~ ~ ~ ~ a~~, ~ ~ ~ ti~ ~ ~ ~ ti ~ ~ ~ ~ U~ I N 1 y c 10 K ° \ b Ol a Z u n - ~ I ~jj °o • 0 w Its W y o 0 ram` Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT . ' Page J of 3 Labor and Human Relations Division of Safety&Buildings in accord with ILHR 83.05,Wis. Adm. Code �,•� COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size,-.Ptatrmt st VCIttlik,but not limited to vertical and horizontal reference point(BM),direcJt'on.and%of slope,so`'ate-or \ PARCEL I.D.# dimensioned, north arrow, and location and distance to nears t4 rd. 1,:.,.. ` APPLICANT INFORMATION-PLEASE PRINT ALL INFA MATION "- ;� i REVIEWED BY DATE m. PROPERTY OWNER: % - '' PROPERfY[OC P zr4Pte s ? G-/0RIA WAHPiN L3 k Gcx1.OTS •-. /4 fE- 1/4,S 7 T 2P ,N,R lei E(or0 PROPERTY OWNER':S MAILING ADDRESS BL SUBD.NAME OR CSM# //oI 50. FORK c ( RcLE- / cE'DAR RiDGt= . CITY,STATE ZIP CODE PHONE NUMBER V GE E (OWN NEAREST ROAD f{L)L S c z 01. 5 4 0 t(, (1/5) .3.1, ' I P _ o y c><aAre we et) PV. [vew Construction Use (-1--Residential/Number of bedrooms f/ [ J Addition to existing building [ ] Replacement [ I Public or commercial describe Code derived daily flow boa gpd Recommended design loading rate •7 bed,gpd/ft2 - r trench,gpd/ft2 Absorption area required /--lied,ft2 15-.° trench,ft2 Maximum design loading rate - I bed,gpd/ft2 • P trench,gpd/ft2 Recommended infiltration surface elevation(s) $:12-k- 1 d • .3 ft (as referred to site plan benchmark) Additional design/site considerations ZC T.�E.AsGGL.t$ • Parentmaterial 5-05 13 i•I I oT S i". 5 i I. I o F SS Flood plain elevation,if applicable N/ft!-- ft 4P buE R s NDY G-/hci�1 L DR i F • S=Suitable for system C_O,NyENTZONAL MOU IN-G;OUND PRESSURE AT_ DE SYST I❑N ULL a s NG TAN�- U=Unsuitable for system I�5 ❑U ISO U Bls ❑U {�S ❑u Lrl O SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence ecunday Roots GPD/ft2 Boring # Horizon in. Munsell Qu.Sz.Cont.Color Gr. Sz. Sh. Bed Trent «<.>,.>,; .4_v ( Q-// 1 o YR -2-It S f 1 . 2-F S b k f i IS ( f . S :«:>: Z //- 4 /o YR 3/1— ________ SW. /f She frm fje 7S — • Y •5 Ground 3 ly-.30 /© yg 3/3 5/ 2 f s bK 44 fi ' `t S -- • 5 . CP elev. ft. q 30-f2_. 7.5 yte wy ---_ . S . D Si ,,,,Q • 1 I .s Depth to limiting factor " Remarks: Boring # 1 0- IZ 10kIR 2/I 5iI. 2_+ sbk -Fie ; S 1-F- . S .G ei Z h 1 . 11-1-6 /0 I/13/2- _ S It• 1 f 5 b1� ,r►„f R 7S -- •`( •5 3 26-3/ /o use 3/3 SI zf sbk fe 1.5 . S .CD Ground elev. tj 3/- V 7.5‘IQ //c/ C S 0 S1 4,Q. Cs — . Z ' • 8 5 eii-y /o V,e %"4 -• 4 ,s. o s 1 d-e Depth to limiting factor a 9 Remarks: CST Name:—Please Print R o t3 E Q T LI L(3 12 1 c k T- Phone: 1 15_ 3 g . c( e5 Address: Co5.5 0' ,, e'i L. D. R00.5 op-3 601 . 5 y O t(, 3-7.1/5=y5-- c S rm a•y('Z-- Signature: -4)6c/4 „zez ( Date: CST Number: • ORIGINAL PROPERTY OWNER whtHREN3 BRock SOIL DESCRIPTION REPORT Page 2 of PARCELI.D.I 101- 2- G East e Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bour�aty Roots GPDfft2 in. Munsell Qu.Sz.Cont.Color Gr. Sz. Sh. Bed Trench tr,Mqn o-/V /o w eft 50.• z-E 56i Au.fR j s L-f- . 5 . c, :::.... z iy_)-3 ioYe 3 /2- Si I. 2.-Fsbe ,► -Fe 7s (f . s .G Ground 3 23-3? /o ye 3/3 _ --- s/ 2-F She ,�.�F,e 4 s . 5 • elev. ev. It. 1/ 31-fr /oyle iv( ---- O S J2 -- Depth to limiting factor .� Remarks: Boring # :..::.:::.::::.: ( o-13 1 o Ye /It S j I . 2-F s bk- ,4%4-F`e g s i f . 5 .c 13 io 3 Si I. Z b th..-F e s .G 3 W-37 /6 be 3/3 S 2-F sbk nn-Fg et .5 . Ground TQ•l v. ft. `f 37-50 /0 Vie y1 . 1( --� C $ 0 5 . cn c s -- - 7 •� Depth to S ,5^� 13 /o l S/� M4-47 s• 0 ,s lJ�� — limiting factor r Remarks: Boring # 0-13 /o Ye 211 S'i I. 2-F she /44-rie g 5 f f •S . siI. 2f ..........:...:... ................. 3 -3 7 /o'ie 3/3 - Si 1. l - S be A.cFie a S — .47 •3— Ground 7?.qs. 4/ 3?-9Z /o Or/4/ a _ 41 , . S. o Scse. _ . 1 • 2 ft. Depth to limiting factor I Remarks: Boring # .................. Ground elev. ft. -- — Depth to limiting factor Remarks: con eoanio nc mf� .. . r • J Q _ / J 11 O z) Q N --; (N .1% _ b )' (Ric Z ?p UP RI I .1 4 (1)R �` o . c ki op 0 P O 1 o y b w w r N In R 1 n l____\_ _ W 1t 0 -h oC l� y o I 0 , L d 09? 3„ 6 S , 00 • I 1 LT : . • (•.\\ 1 I \.' o *._____ ...\ i al NI '33h 'I O > 1- No J J O\ No Q J 7 I Q O W 11 I •\ 3 N o n C..) L, LO\ **-(C' ...r. '..,-. v N...h 1 r 0 0 _ , - O V:1 e p Crco N 1 ii 1' Jam. 2 -------3\• CO .... _ - 1 cif! Q1 CD\ .... _.... ... Q. i kJ v7 �\ 00 r^ 0 J i 1- q I N h .• co O J e} 4 I— ►` • f • Q I a a 0 h �, i �- W `` 1 \ 1J / O �JI o N 0 0 v h o f •^ o o s t- b N rn 0 N l• ^h ") p 4� W m O • ~ - Y1 c 4 o O N • N o) p h a ^n �\ Ni _ N 0 h ` .. . N O) 01 CA N i \ ,""\ CO I / �� I ,g8 SZf ZZ . l ' 00 09/ '7,. 9b 9e•go • �I ,. 0 0 01 9• ' 8, � I NV > Q3 `_,cn kl Q N.CO s 4 o p 3 0 o 0 to \ '* J 0 1. 3 N 3.1). 0 /' p 2 • ` -i 3 0 0 , f0 ' b6F 2 , b ; 9 ?6 ♦ • `\ M „ Ob , b0 . /ON 092 39 Vd ' c • 70 /I ` •W 'S ..7 ` l 1 07 % V {p ` ti .r r W ON r._ b ~i tend` M a i 0.41 \ v ` ~ 4 1 0 g - 2 o h 1 b ~ O QI m ~ O 0 r ,Z ~ ID V h ! h ~ J~ i Wo Q a1 M N O ~ ~4/ V h ~ W~ 0 N 0► i n V ~ h Q \ ~ h w h t~ V✓ r Q W b $ • r a ` d • to . " W H h h w • 4. - a 1 h 00 *oe/ W v O V h O 2 0 O O ~ v h v ~t Q N r b r a ti % to 3 0 74 ,ro'r6r AI op, . 10 is IO N 091 39 Vd `f '70A 107 far: < . -r`• _ . , , . . . 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,Scy 1/4 SC 1/4, Section 7 TZk N-R /f _W Township 7;& V Mailing address ~p6 yS7` r/ Address of site yt1, L /ls?~,~/s~J;, ~u~Sd Grll~/,G Subdivision name (!::,4,e- Lot no. Other homes on property? Yes_~~No Previous owner of property Total size of property Total size of parcel Z Z Date parcel was created _JT'f:s Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes r/ No Volume %23 *;t- and Page Number /22 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. S,77 7 s.3 , 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. Si ur of Applicant Co-Applicant Date of Signature Date of Signature f . A n • w ST C-10.5 SEPTIC TANK N[AINTI?NANCI? AGREEMh:NT St. Croix County OWNEIZIBUYI,,1Z j (J56 Z,*it/V,`7 s 7077 MAII,ING ADDRI!:SS 14~ ST► ~ Syo/~ PROPERTY ADDRESS -2.Z GE~~.~ f/.ZEtc~ AD (location of septic system) Please obtain from the Planning Dept. CITY/STATE) pg~ ~'NOIG PROPERTY LOCATION 1/4,_ 1/4, Section "I'.zY N-R-~~ TOWN OF 59e I/ ST. CROIX COUNTY, WI SUBDIVISION CL2s?1t r~u~ LOT NUMBER .2- CERTIFIED SURVEY MAP , VOI,UNIE -,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. Tile 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. IA~Ie, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forih, 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 expir a SIGNED--- St. Croix County Zoning Office Government Center 1101 Carmichael road Hudson, WI 54016 103 DOCUMENT NO. WARRANTY DEED 557 753 W 12,32 PACE 177 James B. Wahrenbrock and Gloria M. Wahrenbrock, husband and wife, c ~rr~ M OE conveys and warrants to Everett J. Landers and Cynthia L. REGIMR$ MOM Landers, husband and wife as survivorship marital property, Grantee, CROIX n~ the following described real estate in St. Croix Count State of •r Wisconsin: redbrfftw r APR 9. 19911 Lot 2, Cedar Ridge in the Town of Troy. 11:55 A. -K IG~.ck Register Ot DeOft NAME AND RETURN ADDRESS TRANSFE=R ,CVO 5 so P-7- '01 FEE Parcel Identification Number (PIN) This is not homestead property. Exception to warranties: easements, restrictions and rights of way of record, if any. Dated this / day of Mareh / 1997. (SEAL) (SEAL) JTr e ck d (SEAL) 4ZM-5/ A k /1) 'OS Ems) i r ro k AUTHENTICATION ACKNOWLEDGb1ENT Signature(s) STATE OF WISCONSIN ) ) ss. 6!C e. E- COUNTY ) authenticated this day of 19 Persona" ame before me this day of y 0A R 19 the above named James B. Wahrenbrock and Gloria M. Wahrenbrock to me known to be the person(s) who executed the foregoing instrument and acknowledge the same. * TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stats.) * li f~ E THIS INSTRUMENT WAS DRAFTED BY: Notary Public ~iteGFQ County, Wis., My commission is pe nent. (If not;+•expiration daf-e:-;R Joseph D. Boles Rodli, Beskar, Boles & Krueger, S.C. P.O. Box 138 L " River Falls, WI 54022 c9, Qr. --Alt