HomeMy WebLinkAbout040-1043-30-100
Wisconsin Department of Commerce SEWAGE SYSTEM
"Safety and Buildings Division PRIVATE CountBT. CROIX
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanita2r8geliglyo.:
Personal ninformation nyyo~u provice may be used for secondary purposes [Privacy LXw, s.15.04 (1)(m)].
PgLp1, der WAL'1'~R " BUD" @A f ❑ Village ❑ Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel@40e•-„043-30-
TANK INFORMATION ELEVATION DATA A9700296
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Aeration Bldg. Sewer
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
irIto ntake ROAD Dt Inlet
TANK TO P / L WELL BLDG. A
Air
Septic NA Dt Bottom
Dosing NA Header/ Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
I Loss Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth
DIMENSIONS DIMENSIONS
SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION Type O CHAMBER model Number:
System: 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 Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: TROY 09.28.19.142C,SW,SE 405 GLOVER ROAD LOT 2
Plan revision required? ❑ Yes ❑ No
Use other side for additional information.
SBD-6710 (R.3/97) Date Inspector's Signature Cert No.
Visconsin Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 E. Washington Ave.
P.D. Box 7969
Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7969
• Attach complete plans (to the county copy only) for the system, on paper not less County 5 7, C~D< X
than 8 1/2 x 11 inches in size.
• See reverse side for instructions for completing this application State Sanitary Permit Number
0?6 9YA/Claw/
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)1. State Plan I.D. Number
1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION e-l"114
Property Owner Name « Ar Property Location
4V4-L?-C /.3 VP ;&11/4 F- 1/4, S T T18 , N, R P? E (orko
Property Owner's Mailingddress~ - Lot Number Block Number
~p~( Z
City, State Zip Code Phone Number Zo' Subdivision Name or C Number
O.J • ~a 4 (7/S > CSC 54Uo% ~2- • -7317
II. TYPE F B ILDING' (check one) ❑ State Owned It~ Nearest Road
Public 62,11 or 2 Family Dwelling - No. of bedrooms `3 0 gown of ?A'010y GL I~~
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 E] Apartment /Condo ' vb • 1 2,64 a fO ' /O y3' 304ddO
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. E] Replacement 3. ❑ Replacement of 4. t] 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 C Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit 43 ❑ Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION: 97.0
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
u~O Requ i red (sq. ft.) Proposed sq. ft.) (Ga~ ay/sq. ft.) (Min./inch) ~G.?5 Elevation
7 S ! Feet 3,75 Feet
VII. TANK Capacity gallons Total # of r Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App
New Exist in structed
Tanks Tanks
Septic Tank or Holding Tank rjoeof 3 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber, ~!J ❑ ❑ ❑ ❑ ❑ ❑
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 Sta ps) /MPRSW No.: Business Phone Number:
RO ISM T` V 1-13 R tC(4 TA~ z; r 33.-2 7j5: 30; • B18.4
Plumber's Ac dress (Street, City, State, Zip Code):
IX. UNTY / DEPARTMENT USE ONLY
(Includes Groundwater ate Issued Issuing 9 A entSi t N S)
=Owner oved Sanitary Permit Fee
Surcharge Fee)
Approveiven Initial Determination /O (U
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
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• Fresh Air Inlets And Observation Pipe
rTh• Approved Vent Cap
Minimum I2".Above
Of)
Final Grade 7C7,l//.5 ��
6 Above Pipe 4" Cost Iron
Vent Pipe
-To Final Grade
_ Synthetic Covering
Min. 2" Aggregate
Over Pipe
Distribution ( Tee
pipe ---� 0 0 0 0 0 ,
� 11 Aggregate
o Perforated Pipe Below
Beneath Pipe o Coupling Terminating At
Bottom Of System
7S �
1c3,
Goy �'p /U Fresh Air Inlets And Observation Pipe
(Th Approved Vent Cop
Minimum 12" Above
Final Grade fi O PP7fP&
3� Above Pipe _ 4" Cast Iron
-To Final Grade • Vent Pipe
•
Synthetic Covering
Min. 2" Aggregate
Over Pipe
Distribution - Tee
Pipe o o o o o
0 " Aggregate 0 Perforated Pipe Below
9115 Beneath Pipe
lo Coupling Terminating At
Bottom Of System •
• Wisconsin Department of Industry, SOIL AND SITE EVALUATION3
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
include,but not limited to: vertical and horizontal reference point(BM),direction and 55r c")(
percent slope,scale or dimensions,north arrow,and location and distance to nearest road. Parcel I.D.# (f0/ /f t4' /0 444.5
01/0 • /6Y3 - 3oO
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)). I '
•
Property Owner//�� �1 ,/ Property Location
hie i/ A6'C• w�I>7 & 4 U/, /d,9fA 4J ,j Govt.Lot o 1/4.5-0. p 1/4,S / T 1g ,N,R / ' E(or()
Property Owner's Mailing Address Lot# Block# Subd.Name or CSM#
9// /V. ,7 • f e csAt "Eti�/A-)6---
City State Zip Code Phone Number Nearest Road
U Pfo ) lU/. S�(D/<o ( 7�jr)3 v 5 $ ❑ city ❑ Village Town ' /d0&7e R.27 .
Errs-law New Construction Use: Residential/Number of bedrooms 3 Addition to existing building
0 Replacement ❑Public or commercial-Describe:
Code derived daily flow g7/d gpd Recommended design loading rate bed,gpd/ft2 - P trench,gpd/ft2
Absorption area required bed,ft2 C3 trench,ft2 Maximum design loading rate bed,gpd/ft2 trench,gpd/ft2
Recommended infiltration surface elevation(s) - 11 • 3 ft(as referred to site plan benchmark)
Additional design/site considerations NSF Tiet=ocG.<I - ativ'i` OA) S/p`rt Gee/ 94, n 40X'E-.S •
Parent material S'-5 77 — /U,t, 'Artiev 7-- Flood plain elevation,if applicable N/4- ft
S = Suitable for system Conventional Mound In-,Grown ressure AT)ade System' i I Holding Tank--
U = Unsuitable for system 1�5 CD ❑ s u L'-S L7 u airs ❑ U s El ❑ Et-u'
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
ii / o- , /o ye 3/.1_ — L /i54e /frr IX CS Z-f- . Y ; . 5
2 613 iO!/e 3/3 L /f'S/l.e 441-62 CS /f t( ; . S
Ground 3 (3-ZL/o we 3/V — 5L // - rw-7i c S' ,- . q: .S
elev.
fg, 5a_ft. y 2-4 /0Ye Y/9 — -s / 0 d Z e S — . -,. .8
Depth to
limiting -S y/�/� /D VI 5/6 5 D i . d�_ — � , -? ; •8
d
factor
/d D in. ,
Remarks:
Boring# / O-g /OY/Q v, 51- /51/, 411-6:e e5 2,7c . y ; .5
is .
2- e /9 /D/A 3/K - cS/G 77t & 41/i74X ' 15 /74- . y ; .5
3 / Q — km �P ,Z e5 . -2 . •5
Ground 7 ?y/// /t)!' 5/ _ .5 o s, IL - — • 7 , -�
elev. ,u{�
� .f0 ft. - ,
Depth to •
limiting ,
factor
7//4 in. Remarks:
CST Name (Please Print)
Signature Telephone No.
�� . 7/5- 38‘ • f�/�S
Address Ulbricht&Associates Date CST Number
Private Sewage Consultants Y_��_f' L'S'pl. .)-- W•2 .
055 O'Neil fld. /
Hudson,Wis. 54016
•
ORIGINAL
k
PROPERTY OWNERtO /"kei0 y,P SOIL DESCRIPTION REPORT a $
Page of
PARCEL I.D.# 4/-GG() SM
Boring # Horizon Depth Dominant Color Mottles Structure G D/ft2
Texture Consistence Boundary Roots P
in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed ,Trench
3n-� �o re 3/3 �s i y,e �s e s /f . : . 8
z 7-1/ /2y, //v - s D,S /11 cS : 7: •f�Tj
Ground 3 �j/-/� A e $/
elev. S GC/2� — . 4
1..."
j 0 ` ft.
Depth to - '
limiting
factor
/ _in.
Remarks:
Boring #
i,,,,,::
0-60 /60 3/3 — L5 //14'fy/z do CS if • "' : -f
2 -ao /0/eyf — s os di � c — - � .8
3 �o/o6 /00e 5/6 — s .Q IJ — — • -) ' 8
Ground
elev. '
8y.2° ft.
Depth to .
limiting
factor
Tin.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed , Trench
Boring # / p.4/ /O y//2 3/.2_ GS / yj' 1% cs 2. F • -) : -g
V'/9 ,o .3/y sL_ /fi-'k cs wie- - Y ; •s
3 / 3y 7s mei ,7Y sue^ D,S d-Qe cS — • ? ; -g .
Ground N 3 y/) /Q�/,SA. ----- 5 O j 4L ___ — ' 7 : .s
elev.
y.3.FO ft. .
Depth to
limiting
factor
-
/ in. Remarks:
Boring #
Ground
elev.
ft.
Z._T----------------- -- .
Depth to
limiting '
factor
r in.
Remarks:
SBDW-8330(R.08/95)
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Fresh Air Inlets And Observation Pipe
- Approved Vent Cap
Minimum 12"Above
Final Grade
_ 4" Cost iron
a(o Above Pipe
'To Final Grade Vent 'Pipe'
Synlhetic Covering
Min. 2" Aggregole
Over Pipe
Distribution Tee
Pipe 0 0 0 0 0 ,
Aggregate
Beneath Pipe v I-Perfbroled Pipe Below
0 Coupling Terminating At
Bottom Of System
qS M/4
Goy
p~iUG%Gv Fresh Air Inlets And Observation Pipe
Approved Vent Cap
Minimum 12" Above
Final Grade
3~'/'' Ahnvo a:.,e 4" Cast Iron
.
Wisconsin Department of Industry, SOIL AND SITE EVALUATION
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 ST CADS
Include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
o 1/o Y3 - 3 0z"-0
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)). '
Properly Owner Property Location o
h,. -41V3. Govt. Lot 5~4
V 1/4 SO 1/4,S / T 18 N,R E (or(D
Property Owners Mailing Address Lot # Block# Subd. Name or CSM#
y// ,4 Ae-v m-)6 -
City State Zip Code Phone Number Nearest Road
K u fIIo.J C(1 Sr ID/ <o E3
City El Village Town G/aaC72 ~1~.
eNew Construction Use: Residential / Number of bedrooms 3 Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow O gpd Recommended design loading rate ~ bed, gpdi* trench, gpd/11:2
Absorption area required bed, ft2 !~O trench, ft2 Maximum design loading rate bed, gpd/ft2 ' trench, gpd/It2
Recommended infiltration surface elevation(s) 5-4f- 3 ft (as referred to site plan benchmark)
Addiflonal design/site coonsideraboons ~sF ~E~GD l f - t O~ S/D Gv ~~E'p /BOXES
Parent material _ se/ 77 ~!1/~°~L1A~lf~~ Flood plain elevation, if applicable ft
S Suitable for system Conve tional Mound In-Grown assure ATykade System I Holding Tank
U= Unsuitable for system C ❑ u p s U Ch's ❑ u Lf s❑ u s❑ u ❑ s
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
100e 342- S
Z •/3 ~D `/Z. 313 L /-lesAe /M77e CS
Ground 3 3 - 2-1 - o - 5L /~Sf✓if' L' s' . t ; •S
elev.
Y/ i~z
S S S Gf~ • C~
Depth to
limiting
factor
Remarks:
Boring # P-11? io
yle Z ,SL /fsh~ ,P e15 Z f y •S
2 Z /D 3
3 LS / /Vitt C-5 • S
Ground S QS r 7 -p
„ft.
elev.
61-
Depth to
limiting
factor
7//,O--In. Remarks: L
CST Name (Please Print) Signature
46 Telephone No.
7/ S- 386 - A/8S
Address Ulbricht & Associates Date CST Number
Private Sewage Consultants Y _ J--/- 7 7
A111_t1 fJ
SOIL DESCRIPTION REPORT Z
PROPERTY OWNER nc Page of
PARCEL 1.131 ti-r~() WTI
Boring # Horizon Depth Dominant Color Mottles Structure 2
g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
f 5/3 14,MIIX Y5
L --1 S D . 2-
Ground /vr S Q 7 - jc~
elev.
Depth to
limiting
factor
Remarks:
Boring #
/6' 3 - GS S C S 17G '
3 -a S - S
Ground
elev.
Depth to
limiting
factor
in.
>1/044- Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # p, ~p /2 3 Gs lit/e C~ 2 f g
z o 3 SL CS 4/11- -S
-3 111-3% ZS
Ground
elev.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
SBDW-8330 (R. 08/95)
I
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W ~ ^
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563ILSIL
CERTIFIED SURVEY MAP"
LOCATED IN THE 1/4 OF THE SE 1/4 OF SECTION 9, T28N, R19W, TOWN
OF TROY, ST. CRO I X COUNTY, WISCONSIN
PREPARED FOR: WALTER LONGEN
I GLOVER HILLS
.
S 88°55'08"E 422.82' NORTH LINE OF THE SW-SE
I REC. AS S89011' 02"W
2 ~
41
z
g
I
m
~ CC O
~ I Tj!
m '
2 HOUSE
~N LOT
•z
285,088 SO. FT. cn
r - NOTE: BEARINGS ARE REFERENCED
y ~ OR 6.54 ACRES ,j I - TO THE SOUTH LINE OF THE
~ I w (278,279 SO. FT.
1D SE 1 i4 (ASSUA4ED BEARING).
:m m rv'v OR 6.39 ACRES EXC. RAW) o?
276,102 SO. FT.
r ru OR 6-34 ACRES EXC.
R/W AND EASEMENT z ( O " SET I" X 24' IRON PIPE
I (0 WE I GH 1 NG 1. 13L 9S PER L I NEAR
;1 v-- EXISTING DRIVE
FOOT.
~ I
•
I a
I N 89016' 05"W 292.57'
SCALE 1" = 150'
03
I g
~r
w ro L OT 2 z 0' 75' 150' 300'
I w 149,666 SO. FT. : N
3~~ v_ . OR 3,44 ACRES '
~ o
` 70. w `O- ( 135,648 SO. FT.
0 p.w 3. 11 ACRES EXC. R/W) cNn .e~
s
FILED
VI NT DRIVE EASEME 8
c+ JUL 3 1 1997 ► _
I?. rv
I °D ' rn Z KATHLEEN H. WALSH
• I 50.17' N kisWofDeeds
Z s cn SL Clok Co. m
`
' I ~ \ 7TH" ~ Awn Fj~• VO p,
0 •y`~ac~. ~5~,• 9C4 . G1
C-) m
OyO ~0cp
cl)
<0 I IM
r
1 r
CURVE RADIUS ARC LENGTH DELTA CHORD CH.BEARING TANGENT BEARINGS
1-2 2392.00' 107. 17' 2°34' 01' 107.16' S430 10' 07. 5' E AT I - S41 ° 53' 07' E
AT 2- S44027' O8' E
DESCRIPTION
A parcel of land located in the SW 1/4 of the SE 1/4 of Section 9, T28N, R19W,
Town of Troy, St. Croix County, Wisconsin, more fully described as follows:
Commencing at the S 1/4 corner of said Section 9;
Thence S88°59'55"E along the South line of the SE 1/4, 19.29';
Thence N02°09'33"E 506.61' to the POINT OF BEGINNING:
Thence N02°09'33"E 799.89';
Thence S88°55'08"E (recorded as S89°11'02"W) 422.821;
Thence S02°00'38"W 1251.05';
Thence N41°42'22"W 614.74' to the point of beginning.
Contains 9.98 acres (434,754 sq. ft.) subject to North Glover Road right-of-way as
shown. Also subject to joint driveway easement as shown and any and all additional
easements, right-of-ways or conveyances of record.
SURVEYOR'S CERTIFICATE
I, James M. Weber, registered land surveyor, hereby certify: that in full compliance
with the provisions of Chapter 236.34 of the Wisconsin Statutes and the provisions
of the Town of Tr roix County Subdivision Ordinances and under the
direction of alter Lon en wner, I have surveyed, divided and mapped the above
described parcel of land and that this map is a correct representation of the
boundary thereof. %o~N~dG O 'r°
wo
Dated this day of 1997.
-~~r o .M~ • 7~I JAMES M.
•
WEBER
James M. Weber S-1804 $ g . 1804
NELSEN-WEBER LAND SURVEYING SPRING VALLEY
Wis.
Pt ~S U R0
NOTE: The parcels shown on this map are subject to State, County and I cap~lavs,
rules and regulations. (i.e. wetlands, minimum lot size, access to parcel, etc.). Before
purchasing or developing any parcel, contact the St. Croix County Zoning Office
and the appropriate Town Board for advice.
N~
.S/'TE' /~/,D~.'~'ss G~D ~ ~~G U~2 • I~1~~o-J <S' c1oL ~
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWN ER/R
ADDRESS__ Cfl~~ FIRE NUMBER
CITY /STATE___
PROPERTY LOCXTIONIJ 1/4,5 01/4, SECTION , T~ N-RBI 9 W
TOWN OF NQ St. Croix County, '
SUBDIVISION__ CPCA ►-z- a/ l 3367 LOT NUMBER
Improper use and maintenance of your septic system could
result in its premature failure to handle wasten. Proper
maintenance consists of pumping out the septic tank every three
years or sooner, if needed by a 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 Co. Zoning officer within
30 days of the three year expiration date.
SfGNEDs
DATE:
St. Croix co. Zoning office
911 4th St.
Hudson, WI 54016
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 4 dl i~~
Location of property,5'0 1/4 -s~ 1/4, Section / T2-91 N-R / W
Township Mailing address
Address of site o5 P- li
Subdivision name OS14 5 631 (fl V01. 12- ~ lLot no.
Other homes on property? Yes No
Previous owner of property -<t-l2
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 No
Volume S 4 `I 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. j 3 4 D Z z , 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.
Signature hfr-p scant Co-Appli t
Date. of Signature ate of Signature