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HomeMy WebLinkAbout040-1226-00-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Ca NCO u a . ' o ADDRESS v o s~~ SUBDIVISION / CSM#_ Z~,L * V av LOT l:~' SECTION -_T r. N-R_Zf _W, Town of %vo ST. CROIX COUNTY,, WISCONSIN PLAN. VIEA,. SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM UQ 4,h ~e mod' / INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. t 'BENCHMARK: Ssa~.i G Q 5' /,5- .ALTERNATE BM: : :SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ,'~[~,e 7`' v✓~ Liquid Capacity: la2D-e Setback from: Well D -IA House y3 ` Other Pump: Manufacturer ;Model# Size Float seperation` Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: -!C Length 7S Number of trenches 2 Distance & Direction to nearest prop. line: 7 Setback from: well: House 4d 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: PLUMBER ON JOB: LICENSE NUMBER: oil INSPECTOR: /017 3/93:jt \lVisconsin bepartmentof Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 289302 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: P.C. COLLOVA BUILDERS, INC. TROY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /dv, d 040-1226-00-000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark IDD, oo, ttl') 4±t Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inlet Septic -50 i ~ NA Dt Bottom Dosing NA Header / Man. qs yy X52 • r Aeration NA Dist. Pipe a? Holding Bot. System Sgt g~`3 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Fric System TDH Ft Head i ngth Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width , I Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS L~ DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION Type O CHAMBER Model Number: System: EJ gC1 / 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 off:' Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY.9.28.19,NE,SW 541 BRIANA LANE LOT 10 5141 Plan revision required? ❑ Yes eo Use other side for additional information. S r c. SBD-6710 (R 05/91) Date I `spector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division e.~■~r■r~ SANITARY PERMIT APPLICATION Bureau of Building water systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. St. Croix • See reverse side for instructions for completing this application State Sanitary Permit Permit Number The information you provide may be used by other government agency programs ❑ Check i( revisiontprevious application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Name Property Location P. C. Collova BUilders, Inc. g SW 1/4, S 9 T 2 8 , N, R 19XJZRK) W Property Owner's Mailing Address Lot Number Block Number 12575 Kellpr Avenue North 10 - City, State Zip Code Phone Number Subdivision Name or CSM Number Hugo, MN 55038 1612) 439-954 Glover Hillq II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ City Nearest Road E] Public 1 or 2 Family Dwelling - No. of bedrooms 4 Iolwan OF Troy Briana Lane III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 2G - e d 1 E] Apartment/ Condo 6k d-1.2 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 Single f am i ly 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 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) c?Y"s-V Elevation 4a 75-61 1 IF Feet ~g• Feet VII. TANK Ca in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank ~C (off o64 1!;~,,w4jeu J tau ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VI11. 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 Stamps) MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): 2 t d G IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sa itary Permit Fee ( ndudesGroundwater ate Issue Issuing Agent Signature (No Stamps) Approved ❑ Owner Given initial ( Surcharge lee) Adverse Determination /ff/9 Z - =~w X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: 10/ SRD-6398 (R. 05/94) DISTRIBUTION: original to county, one copy To: Safety & Buildings Divi ion, Owner, Plumber INSTRUCTIONS t T 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- 11. 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 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- L' 5 i✓ % .2 l ! G 1 7-1 ~a~co c'Y .`/lam" Y 1 l 'y e rp a ' A ~J 1 - Cti,cr/ A Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Human Relatrons • Division of Safety & BuikGngs in accord with ILHR 83.05, Wis. Adm. Code COUNTY S'r'. C~ l JC Attach complete site plan on paper not less than 8 e. Plan must include, but not limited to ve rtical and horizontal reference pope, scale or PARCEL I.D. # dimensioned, north-arrow, and location and distaAPPLICANT INFORMATION-PLEASE PRI ON REVIEWED BY DATE PROPERTY OWNER: $pcQ,B p~ R , S ir ; JLT LOCATION X3Z 1/4 SW 1/4,S 9 T Z8 N,R `j E( W PROPERTY OWNER':S MAILING ADDRESS ~PNJ LOCK # SUBD. NAME OR CSM # LA S D t~ 3, G t_o vCR c, - 6 l-0 V 1'x`1 u- S CITY, STATE ZIP CODE O NUMBER ILLAGE DOWN NEAREST ROAD `cups tJN, IV 1 S tj (st lL 1 4- t R o S(r_tpojpt l._fk 1 90 Dd New Construction Use [JQ Residential / Number o r in vwrv [ ]Addition to existing building I ] Replacement [ ] Public or commercial desc nl Code derived daily flow V310 gpd/8 EDRUO" Recommended design loading rate bed, gpd/9 0• $ trench, gpd/ft2 Absorption area required - bed, 112 - trench, ft2 Maximum design loading rate 0 , 7 bed, gpd/ft2 • 8 trench, gpolft2 Recommended infiltration surface elevation(s) 5F_S~ ►-joTkZ oQ Pyr6e- 3 , ft (as referred to site plan benchmark) Additional design / site considerations c-Wtn Parent material s t o v~, ~,ptg N Flood plain elevation, if applicable N- A ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for system 14S ❑ U 5 S D U INS ❑ U ®S ❑ U S U O S U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Bounday Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rench itz L Zwn 3b t~.s o, 6 LI o _tit Ll~`1,1t Z ~1-?6 bey 2 Sty - L IMS)bk rv►'~►- cS 1v~ o.s 0.6 Ground bb K R- V 6 - S V a~ wt I - 0. g ~elev. tt Depth to limiting factor u Remarks: Boring # L Z lL-3[, 10`12 3!2 Si' Z'~S~~rt tM `Fy. e S 1vA o,S o" 6 Io'l IZ yl~ Ground elev. 98.0 ft Depth to limiting factor ? 9 0l FI Remarks: CST Name:-Please Print Phone: Arthur L. We erer 715-425-0165 ress: . egerer Soil _T_estin_g,_&De.sign Service-P.O. `Box 74 River Fa11s,WI 54022 q~ Date- lid li , PROPERTYOWNER G~1S9)1yG~2 - CORD SOIL DESCRIPTION REPORT page ?of , PARCEL I.D. ff Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft a';. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. jBed Tni". 3 o_!O SOH R zCZ L Zwi s~ hn~fr CS Zug Z lb-Z,~{ 1~`t 12. 31y - L 2vn sbk 1M `Ft~ cS 1~ R Ground 3 Z4 $ ` 10 `Z tZ t,1/(, S O 0. elev e g8.8 ft. Depth to ' limiting factor LEI I I Remarks: Boring # 1 ZL Zw, Yr► t^ v i ,b' 1 0-9 Z L s C'S hlrc s `I a-Zs 1 O Y2 31 - z.vhs~k v+~~tr ~s 1 ~P In. W 3 zS 9Z IOYh YlG S c3 S9 v+11 Ground elev. 98.8 ft. Depth to limiting factor ~a Remarks: ri, u.. Boring # o_lD ~p`'LQ ~1Z ~ ~ L Zwt 8b ~'+'t `~4• ~S 2,v`~ o.S?o_t~~i~ S Z )0 Z9 I~He fly - L Ztinsbh Y,.,, CS ~ui 3 Z4-9S l u 7e y/6 - S O sg 1 _ b.'1 Ground elev. °14.6 ft. s. Depth to ;D limiting factor X954 r~i Remarks: ; Boring # I 6, i"!d I :2 Ground elev. ft. i l Depth to limiting factor Remarks: i . 1 PLOT PLAN Page 3 of 3 SCALE 1"= SO ' J V L r ~ lrt, al'8~ SuiNCB LN PfRt."R R o a Z v l_,, V'R v l G o D L k N71 1 C3v I ' a ~l A tfL 9 v 8.4 ~fCTL98$ &L 99 C uvgFT 8~ 'h'i' C,RkST ZS'FRoM S` ls'r r Al ~ M d M f IIJST{C~-l. BCC OR, TSL~.=hlCl~-~`$ S2`~ ~l~P 1`}"'f `f~'~ uP'_~Lt)TSE ~G~'. ` b8`~"L~1"11wE S`iS ~-~J ~LL~ 7o"~ /~~Pr7~dvS prT `T17~1 ~F ctriS'fIWC`nON• L e~ L~ is4.o6' q S_i S- 10 - - _ - 7a 5 )=425-nlA-5 -Ij00-5.7.6 CST:S_ignafure _ Date Signed Te(ephonO=No. CST # ` Wiscbnsin Department of Industry, SOIL AND SITE EVALUATION REPORT page l of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY I VC-0 l X Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but PARCEL I.D. # not limited to vertical and horizontal reference point (BR, direction and % of slope, scale or - dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: ~f~Q $ lZ f G jE7jS S 6 t~ PROPERTY LOCATION N~: 1/4 SW 114,S 9 T Z8 N,R 1 E ( W PROPERTY OWNER':S MAILING ADDRESS LOT BLOCK # SUBD. NAME OR GSM # y S D N, G Lro vEV- 2Af D I r _ 6 t_O V 1-~1 L- S CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ®fOWN NEAREST ROAD f ps ON1 IAV ) S Y o L ( 0I S) 38 6- 13 1'1 T2.o' { g~ twtlvq LPtfJ~ Dd New Construction Use M Residential/ Number of bedrooms Ugh Nvwry AdditiT to existing building I J Replacement [ ] Public or commercial describe Code derived daily flow vSo gpd/81Eblzoow► Recommended design loading rate o. bed, gpd/ft2 a trench, gpd1ft2 Absorption area required - bed, ft2 - trench, ft2 Maximum design loading rate bed, gpd/ft2 O b trench, gpdift2 Recommended infiltration surface elevation(s) 5E~ r-oT, OQ P"`-6E- It (as referred to site plan benchmark) Additional design/ site considerations ~zoMh~ Parent material s 111-'%-l o ~T-vk5 N Flood plain elevation, if applicable N- A ft "T- S =Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable for stem [~S ❑U ES ❑U CC'S ❑U ©S ❑U [Rs ❑U EIS ®U 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 ranch Zwr SU "'l~'1- CS Zv'f d.S o,6 ~ o -L~ bu`L1t 'awy' Z t1-fib boy 2 ~[y L ZMS ►+►'~'1- 0- Ground 1~ o.s o. 6 bb `i R.. S!!6 - S V s~ W1 0-7 0.8 elev. fig, b ft Depth to limiting fac>g ~,r - Remarks: Boring# a_1Z to~R zcz - L zMSbk cs 2ui o.S u.6 s a~ Y Z~ sbk m`~. eS l~~ as u.6 3 6-O1o 10`12 `/!(i S ~S°j 0.1 U.$ Ground elev. 98-0 IL Depth to limiting factor T-F ? 9 0~ Remarks: CST Name:-Please Print Phone: 715-425-0165, Arthur L. We erer Address: Reper.er Soil_Testing_ & Design Service-P.O. Box 74 River Falls,WI 54022 _T. irate-~ r . PROPERTYOWNER 6~1SS)1yG ~ORp SOIL DESCRIPTION REPORT Z ' Page - of • PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft a''1 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trendi°. 3 o_ 1v Lo~-L R- z C Z L Zen S~ l+x S 2 u o. S n. 6 i! 1 , 2 ~b-Z~{ 10-~ 31y - L 2vn sb~ ►M `F4- CS 1uR c~•s o 6 Ground 3 24 g ` LO `L tZ ~l~G 5 O S S ~'1 - v • 7 v- :,'I elev. 98.8 Depth to 'I limiting factor 17 9 6" Remarks; 1 Boring # P 0-9 10 z_ZLZ, - L 'n 3'b\, Y+1cS Zv`~ y Z q-ZS Lo 1-1IZ 31 L Z Vb~t I • 3 zS_9Z lv~t~ - ~ Ground ; elev. 98.`d ft. Depth to s limiting factor i ? 9 Z.'~ i I ~ , L Remarks: Boring # s, o_l0 1p`1 Z1Z L Zwt 3) mo-S Zv 0.5 0~ ~1 S Z 1 D Z9 1 e 31 y - Z m s Ult v~, C S v i v• 5 a i Z4-9s 1 u Y y O Sg 1 _ b -1 Ground elev ~ ~ °IQ- L ft. Depth to limiting factor r Remarks: Boring # ; a<<`. bl" a~n Ground elev. ft. Depth to limiting factor I'. { Remarks: j PLOT PLAN Page 3 of 3 SCALE, 1 'l J j LO y r ~ I el. °18 ~ o z tU~Rr~L P o 5 01 1 J3.3 I i ~ ` p rA ~P " Ci -qa Y~~a~ B h'I LAST ZS'FlWM S'Is1'cM. SO'1~T M r M flo 'Z- 0-" S, sZ'` Yi'f `Rt'e ° sLon~ ~ • 1 Nsrn~~ B~~DD 05L 'TZ b~~'~~1~ E S`tS l~r'1 ~L~h'370"-' /~~s1.~1~~pn.,S 7~rT `C1~1~ - 6F Co►~ s'f'1wC`T~01.~. ►s4.o6' q s_~s- ►o 14005-76--.., -70169 CSTStgnature Dafe Signed Telephone r1o CST # - - - - -754. 42 -4 - - W BOUNDARY OF I 66.00',-- POND ING EASEMENT rM BONDING EASEMENT ELEVATION 897.3 tO 1"4 S~, 8 ~e. py' S2" 6S. UU' 3 10._07 ACRES f 3. 52L ss o00o e 90, i 9 1. S O, F Ina I 2u. w \ \ d5 04 I. ...BOUNDARY OF y /N L` 01~~. 2. Go ~ PoNDiNG Easfk6NT ()5 87,.E o o ' /PONDING \ r O ss ° ~J 4e EASEMENT 2.00 ACRE SsC~ h / •ELEVATION / 41 \ D ° 8T, 230 SO. FT. f MN 897.3 w ° 313 Qp~`~ ~0 14° 52' 08' E \ ,p• 22.50' VL 60 Apo 3 00 ACRES Is~ z c h 87, 128 SO. FT. _ 5 C 11 o I 942- 00kt 1339' I>Z FENCE 0 Q f i 1 , , 90 SO ( < to, r / 130, : I ()4 3' A- H I GI I~ 000 D LINT 00. I 2~ 2.07 ACRES 66 WIDE COMMON o 1 I so, rei so. Fr. DRIVEWAY EASEMENT OVER LOT $ { ' a I D She ° I T\~ ti S 88° 50' 51" ~p 66. 00' \ t 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 P. C. Collova Builders, Inc. Location of property NE 1/4 Sw 1/4, Section 9 ,T 28 N-R 19 W Township Troy Mailing address 12575 Keller Ave. N., Hugo, MN 55038 Address of site xxx Br i ana Lane f-e Subdivision name Glover Hills Lot no. 10 Other homes on property? Yes X No Previous owner of property Barbara A. Geissinger Total size of property 2.0 AC Total size of parcel 2. 0 AC Date parcel was created Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? X Yes No Volume 1235 and Page Number 319 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. 558534 , 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. 558534 S' ature Applicant Co-Applicant (7 . 4- aq.-g7 Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWN,,"UYER P. C. Collova Builders, Inc. MAILING ADDRESS 12575 Keller Avenue North, Hugo, MN 55038 PROPERTY ADDRESS B r i a n a Lane (location of septic system) Please obtain from the Planning Dept. CITY/STATE Hudson, WI PROPERTY LOCATION NE 1/4, SW 1/4, Section 9 T 28 N-R 19 W TOWN OF Troy ST. CROIX COUNTY, WI SUBDIVISION Glover Hills LOT NUMBER 10 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 ration date. Cc5 C! ACA ~ ~ S)~~ SIGNED: DATE: d Q'9 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 kiv%Ek -,'HLLL Ht > k.Hl_ I , HI-It _a 1L lei F. ii 1 ' 'r I o0CUMENT NO. I WARRANTY DEED ` TATL BAIL OF WISCONSIN FORM 2-1002 558534 VOL 123 PACM19 FIRIEEGGISTERS OFF1^ F CROIXCTY. v BARBARA 11. GEISSINGER . an ..unrna.rr.i.e0._v.oma.n .............-...........Y.....:... 2 8 199 D i'117tOr, 11:30 A. M conveys find warrants to -4 wskM a. - co zP Qx.d t.i on flspiatrr of L7ee~ta ..Gran.te.eu...I...I.... peTUMN TO in con..sideration.. of 1,QO and othez._.gaad-..and RVA . the following described real estate in .5,t. C.>tiS7.~.X ...........County, StAte of Wisconsin: Tax Parcel No: Y Lot 10 of the Plat of Glover Hills, a rural subdivision located in Section 9, T28N, R19W, Town of Troy, St. Croix County, Wisconsin, according to the plat thereof filed September 1, 1995, in Vol. 6 of Plats, Page 35, as Doc. No. 533327, in the office of the St. Croix County Register of Deeds. Together with and subject to the rights and obligations set forth in the Declaration of Protective Covenants and Easements dated September 12, 1995, recorded September 13, 1995, in vol. 1140, Pages 39-46, as Doc. No. 533786, in the office of the St. Croix County Register of Deeds. Also subject to a ponding easement in the northeasterly corner of said Lot 10, as shown on the Plat, which may not be filled or altered without the consent of the Town of Troy and County of St. Croix. Also together with and subject to utility easements along lot lines as shown on said Plat, and subject to telephone right-of=way recorded in vol. 410, page 567, in the office of the St. Croix County Register of Deeds. This k&..nQt......... homestead property. O~ n (is) (is not) Exception to warranties: Dated this 25th y A ril . 10.97.. - r ~ -(SEAL) ..............(SEAL) .Barbara A.....Gei.ss.i.nq... er (SEAL) (SEAL) AUTHRNTICATION ACKNOWLEDGMENT Signature(a) STATE Or WISCONSIN as. .ST.... a- .County, authenticated this ........day of 14...... Peraonai)y came before me this ...Z.5.th.... day of