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Home My WebLink About040-1186-95-000 8 STC - 104 AS BUILT SANITARY SYST (0 P EVE6 OWNER ~'Fv NOV 1 1 1997 S CROIX ADDRESS A NTY 1 3 :ZMINGOFFlCE ill ~ ,l S W1 S ~~f✓~ ~ f SUBDIVISION / CSM# ~)C LOT # SECTION T d S N-R_ 1 c W,v Town of ZcS ST. CROIX COUNTY, WISCONSIN / 6 ` o 06U '?(a_ZS.l~. PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~lCIS~~b'dt" 1 ~ct~~~c~ a ~I C~ ~ y P ~lC. i )~S `x~ INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. r ~ BENCHMARK: Top Lt'-)ell d o, ' ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: L~ Setback from: Well c~ House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location I SOIL ABSORPTION SYSTEM Width: Length Number of trenches r Distance & Direction to nearest prop, line: i p Setback from: well: House 0 G~ Other LEVATIONS J v Building Sewer cwt: / ST outlet: S PC inlet PC bottom Pump Off o ~ Header/Manifold v~ Bottom of system /j. Existing Grade Final grade / DATE OF INSTALLATION: PLUMBER ON JOB: r LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of 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 299150 Permit Holder's Name: ❑ City ❑ Village FNI Town of: State Plan ID No.: GORE, LANCE TROY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax 0- J~, 040-1187-10-000 TANK INFORMATION ELEVATION DATA A9700 66 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Iwo Benchmark 40 /00-4 /d0 Dosing Aeration Bldg. Sewer Holding. St /44t- Inlet TANK SETBACK INFORMATION St/yht outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air intake eptic NA Dt Bottom Dosing NA Header/Man. S ZS•O~ Aeration NA Dist. Pipe 59i Sys ~/:8~ { s. 93 Holding Bot. System -7.( 6l5.7 PUMP/ SIPHON INFORMATION Final Grade 34 9'7 - ManufactuPer Demand Model Number GPM JTDH Lift Friction tem TDH Ft Forcemain Length Dia. Dist. To Well ;IMENSIONS ABSORPTION SYSTEM / TRENCH Width Length ~r No. Of Trenches PDIt I N No. Of Pits Inside Dia. Liquid Depth Man fa urer: SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING SETBACK CHAMBER Mo el N er: INFORMATION Type e C10' -70 ° OR UNIT System m DISTRIBUTION SYSTEM M '7Z Header / Manifold Distribution Pipe(s), x Hple Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only fxx x Mound Or t-Grade Systems Only Depth Over Depth Over I Dep th Of xx Seeded / Sodded xx Mulched Bed / Trench Center Bed / Trench Edges psoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: TROY 36.28.19.794,SW,NW 70W WOODRIDGE DRIVE LOT 40 0 -75' nevi/ 3tr o h`La-av~k D --o he'-tt c✓, 2) ~x Os tia,, S~S+e wt was a 6 0ge,11 (1 ,R~ Plan revisVio'regred. C-] Yes ❑ No ~S 7 Use other side for additional ipformation. ~i( 9E~ ____j SBD-6710 (R 05/91) Date Inspector's Signature Cert. Np. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: PERMIT APPLICATION 201eE.Wand ahnllgtonAve sion Visconsin SANITARY Department of Commerce 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 8112 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 ❑ Chec it revision previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property~wner Name Property Location T d?- ' O ~v4 v4 S N R E (or)/ Property Ovl{ne~ Mailing Ad re~o ~ ~ Lot Number Block Number 77 VVtt~~ a r CitJy~t~e U ( Zip Cgd D~ n ( h e u {ar~ Subdivision N m or CS Nu r 4)1 Cot r S Avk I II. TYPE BUILDING: (check one) ❑ State Owned o lt~ f Nearest Road VII age t Public 1 or 2 Family Dwelling - No. of bedrooms own of V" G(.t70Q wr• 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Nummber(s ~y 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. P 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 Pg Seepage Bed ?g- tk5'0 t 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 5Perc. Rate 6. System Elev. 7. Final Grade Req * ed (sq_ft.) PropQsedd sq. ft.) (Gals/d~y/sq. ft.) (Min./inch) El vation , 0 A , -2f ~ Feet , U Feet L (.~J I b I Capacity VII. TANK in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallon Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks ?,afkl El I El Septic Tank or Holding Tank X, X U(J(~ C Gu e$ 7' b 3 0 ❑ ❑ Lift Pump Tank /Siphon Chamber El ❑ El ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage s stem shown on the attached plans. Plum er's Name: (Print) Plu r' Signature: (N S m s) M Business Phone umber: 7A bA D d 5 14 Plumber's dress Str et City, Stat , i 70 Code : Iqv U~U IX. COUNTY / DEPARTMENT USE ONLY In Age}t Signature (No Stamps) ❑ Disapproved nitary Permit Fee (Includes Groundwater ate Issued ISSUR Approved- I ❑ Owner Given initial Ra surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R 11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber 5 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 / 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. l&R ce 3 _31- l _3 91 o° ~ , bo', - PLOT PLAN Page 3 of 3. SCALE 1"= 'SO ' Zoo' $•1 ~oR~'C►+u~~o ~$uS~K~S ih 1 P x v t gut ,Puc. A ~hivS E n o h 8.3 Y Sv l~`tcLS~ FWOR. 3 A"R~ °I S 3 Q 4 so• ~ 3 t--a8 t oT y0 Z°O" LOT \(1 S S Fie v. ~93' o Bpi - r-L- llao.1 `MNI FLtc~kw~t'~-lhc~t ~lz" ~ovv~z vv~ -~~~av~u~ Ptp~S. ~t1~"Ct'l@~S uvST~~rcD OF T~GGZ~•M'~. ~ ! SiZiu_G _ _ ~►J '8EU 'T'tiPE S4s1'a-ts '~v vu~l'.g":. 'QtT 3` K- b- 2S" rvc~~:0 3F Q~Q VR~I Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labpr and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY ST CtZtJ Attach complete site plan on paper not less than f 3l cl~e@ t Plan must include, but N not limited to vertical and horizontal reference , i~I- Ior P slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and to nest r ad. Y;? C314 1) _ ~1~1- LO CU R IEWED BY DATE APPLICANT INFORMATION-PLEAS r~ NT A~ Q 9 MATIO 3~q PF114 ION PROPERTY OWNER: ! rs? n s J r PERTY LOS W U4 IJbJ1/4,S 36 T Z% ,N,f3 L E o W PROPERTY OWNERS MAILING ADDRESS # BLOCK # SUBD. NAME OR CSM # 3 W, W 0 0•D 2I 1b G i R NC,O>~FIGE l7 - ►'vv ub \Z.L O G C D t N. CITY, STATE _ ZIP CODE .PI)N, UMBER 4 CITY ❑VILLAGE RrOWN NEAREST ROAD Z,tU~Z. ~-KL-tS,►v! S~tD~..z h ~ `U•wooO~ttD6E OR. [ ] New Construction Use K Residential / Number of bedrooms 3 [ ] Addition to existing building pd Replacement [ ] Public or commercial describe Code derived dairy flow Ll SO gpd Recommended design loading rate • S bed, gpd/ft2 - trench, gpd/tt' Absorption area required 'M'0 bed, ft2 -ISO trench, ft? Maximum design loading rate' S bed, gpd/ft2 -6 trench, gpd/ft2 Recommended infiltration surface elevation(s) °l 3 • B ft (as referred to site plan benchmark) Additional design/ site considerations ~~S o CW %J" Wy1Yl. W&> f\ - ft Parent material s L t. -N SZblh t~4 u-IM S"Y o~ ere H Flood plain elevation, if applicable TQ S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for s stem 93S ❑ U ®S ❑ U ® S ❑ U R I S ❑ U ❑ S ®U ❑ S IOU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence BoLindary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed mach ~ 10`12 Z L Z - s ~1 Z `F s~ m`F~. C.. w l v f • S . b r yv„ Z zY_gI low rZ 3ey S, J Zm sbk r~'~t~ cS -s Ground 3 X16 9 ~ -7_ S `fZ_ VA. - ~ 1 S e S g elev. °I It Depth to limiting factor Remarks: Boring # QQ. 1 030 1e~2 ilz st'► `Z~sbk rn'I^ etv 1~~ ,5 6 x4 Z ~ Z ~ a.so. t oti ~z 311. s L [ 2..wt s bh w, e S ~ , s 3 sb_gy 1.s ~R y/ - S o Sig wt 1 - .1 . Ground elev. °18~ ft Depth to limiting factor 'Remarks: CST Name:-Please Print Phone Arthur L. We erer 715-425-0165 Address: Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Signature: Date: _ CST Number: 1C 31 -97 M00576 .4ti 3 S 2 PROPERTY OWNER GORE. ~ ~ ~ SOIL DESCRIPTION REPORT Page L Of, 3 PARCELI.D.# ~~IO- X181- lv Boring # Horizon Depth Dominant Color Mottles Texture Structure. GPD/ft in. Munsell Qu. Sz. Cont. Color Consistence Boundary Roots Gr. Sz. Sh. Bed Trench lu 1 0 -Z S t is 2 2 t Z s i l Z `Fs 1bk w►, S • 6 S i l Z ri s bk 1'►'l '~I- e s ~ • S• 6 Ground 3 y0-S g y(Z Y~6 S I c elev. S~k tM U S , `l • 5 at3.Yft. sal-9Z S `?RY! - is t ° sg »4 v 'f-r• . S i ~ to Depth to limiting factor i _ i Remarks: Boring # 13 Ground i elev. ft. Depth to EF- limiting factor Remarks: Boring # ~~tivt„ 5 { i Ground elev. ft. Depth to limiting factor F Remarks: Boring # i. f .13 Ground _ elev. ft. Depth to limiting factor Remarks: qpn nacntp nrinn~ PLOT PLAN Page 3 of 3 SCALE 1"= So ' Zoo' 9• I - DRP~►►u l=t LLD ~ k/ bjejr I V l8~~ ,,h s lm" Q a o 9 Y Ey o h g3 F;tkLi. J el 3 8 S v'A'{Z~ l L. ~I a 3 Q 4 So -----.0 3 tae- LoT y0 200- LOT 41 e)"! - ~L. 100. D n N 't-oP of ►~fi~.l ~t'b'`feD . N~~`b _w S1'M-lk~Z pt_ w++~'~-lhu-t ~l z"" e~v~~z nvLCt _ aZS~a.~~~ u~ ~~P~s. ti C►'IQ S ~fvST~~►cp OF ~CsG2 hTi`T. },x~ ~ /U St2.11v_G s EY•~'1ITT titi "lai '7~K S`l%lrv "!31 Vb _ j"Ur- - r 3` X b 2S' ~vcwLp 3F Q~QVLRLU. /1 ~i~-3SZ (715 ) 4 .5-(17 h5 _ 1400576 CST Signature Date Signed Telephone No. CST # Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page ~ of 3 Labbr and Human Relations D~ ision of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code . ST Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but COUNTY CIZO I.X PARCEL I.D. not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or 0 ` _ l0 dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION R IEWEDBY DATE 1 9" 6jyNLfd PROPERTY OWNER: PROPERTY LOCATION - = Lr N J CL, Go VLE GOV"DL- SW 1/4 IJW1/4,S 36 T Z$ N,R Vol E (oeW PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # -l0 W • W0 0'D ~V~GE D2- y~ - w~ub--LOGS N'~b I CITY, STATE _ ZIP CODE PHONE NUMBER []CITY []VILLAGE CQTOWN NEAREST ROAD ZtU~2 RLLS, m S~lbZZ cm)q2S- -)0-)9 "r1Z.f3 It 'v.WW't tVlb6E OR• [ J New Construction Use pq Residential /Number of bedrooms 3 [ J Additi.~n to existing building [4 Replacement [ ] Public or commercial describe Code derived daily flow Ll SO gpd Recommended design loading rate • S bed, gpd/ft2 trench, gpd/ft2 Absorption area required q00 bed, ft2 _AS O trench, ft2 Mabmum design loading rate' S bed, gpolft2 •6 trench, gpd/ft2 Recommended infiltration surface elevation(s) °13-'6 ft (as referred to site plan benchmark) Additional design/ site considerations t0' Y- S o ' CW v tp ouryt 3q Parent material s t %-Tf 51b1y1 taT o+ m ShvOY o~~.er8 H Flood plain elevation, if applicable N A - ft LU = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK ❑ S 10 U =Unsuitable fors stem S U ®S ❑ U [OS ❑ U ®S ❑ U ❑ S ®U SOIL DESCRIPTION REPORT Depth Dominant Color Motbes Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rends = J o-zy ~ o ~t 2 z L Z ~ s h1 Z s~ m`F e., w l v . s , b 31y s/ ZhnSbk 4. Cg Ground 3 alb 9~ ~_SY2 u/6 1' S ° sg w,l v - . S _L elev. 9 fL Depth to limiting factor Remarks: Boring # S oho ~b~ICZ Z lz - st► Z` 3 bT ^ e~., 1v •b rg~ I 0-sr) 1\w-1kL 31L Zmsb M-f~- ,S 3 sb_gy 411?- yl - S o sg wt 1 - . Ground elev. 98~fL Depth to limiting factor flemarks: CST Name:--Please Print Arthur L. Weerer Phone' 715-425-0165 egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Signature: Of Date- CST Number: C~ 11L.' ~`h ~ ~ ~i 7 - 3 S Z I Ib )i _9'7 M0 0 5 7 6 PROPERTY OWNER GOR.L SOIL DESCRIPTION REPORT •Z 3 OHIO-X1$'1- lv Pa9e_of PARCEL I.. # Boring # Horizon Depth Dominant Color Mottles Texture Structure. GPD/ft in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence Boundary Roots Bed Ttend~ 3 o ZS t~~2 z(Z - Sit Z `Fsbk cw 1v~ 5 • 1, Z Zs~uo t~~~ 3l` - s i 1 Z~, sl~k wt ~I- eS ~ • S • 6 Ground 3 yU-S Y S `1 R elev. Y/4 S~ c S~~C Y" U -f- C g y• 5 a8~fft, sV-9Z ~S yRy! - Is ` ~ sg ,u~f-~. S ~ Depth to limiting factor - f Remarks: ` Boring # i f Ground elev. E ft. Depth to limiting Yactor Remarks: Boring # Ln": I E Ground elev. ft. Depth to limiting factor I Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: CRn-aiwniR nr/ooi PLOT PLAN Page 3 of 3. SCALE 1"= 3p ' z.oa' gl..q 8 V 8• I ORKuu t=t~1„~j ~I 3 l8• r V ~'KivS E o v E24~ y o y g•3 ~ Uy Sv ~~`tRl~ ~WO}L J 91 6 wv-eK fit. °I 8 3 so' -moo ~ B.T. ~ntw, L 8' ' t*~-ae - ~.oT 40 LOT 41 ex'1- 100, D C►►v '~P of WALL !}b``~'p . I.iUT = IA w ~M•lk~Z ~ PVh~►")R'~-lhtyt i(Z,~ t-0VL~ UV~T _~C~'~tRlP~1 O~J tom- 1A~S. 'cr- - _Q',2 t tz qo , w sTkA L 7YriE- s vO ML 0 )P jFl ? Lac 1- ~ 'l@~RS L~l~Z'~MD OF mGZ leg. 1~ Doi.n.~ st-LI-i :G _ 15 _ vuLTT-= .FiT 3` X b- 2S" t%vcX~L:p_ ,8F Q~Q V~RN 9 3s~ sm. l0 -3J-~7 (715 ) 475-0165 _ 1400576 CST Signature Date Signed Telephone No. CST # STC-16~ SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER n C ~ ll ' c o r e MAIIING ADDRESS ~V to (,b o d d ar. PROPERTY ADDRESS Al C (location of septic system) Please obtain from the Planning Dept. CITY/STATE Cbtv F4A W)10. ! 1w d PROPERTY LOCATION 1/4, 1/4, Section 3 , T c29 N-R /11 TOWN OF rt6 14 ST. CROIX COUNTY, WI SUBDIVISION (~IJD b LOT NUMBER P6 CERTIFIED SURVEY MAP _9 VOLUME ' , PAGE , LOT NUhOER~ 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 expi ation . SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 8 T C - 100 y. . 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 ~G yl d e 4 Tb l) e Ce if e Location of property,~1/41/4 , Section 36 , T;~-N-R N Township 'rift Mailing address LJ ZU00 d'rid~ S VD Address of site p subdivision name ~~►D j~' i d~ Lot no. 7U_ other homes on property? Yes_2No Previous owner of property Z/j A i)e,6i222 Total size of property Total size of parcel Date parcel was created _ Unp Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes X_No Volume ?13 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 t office of the County Register of Deeds as Document No. I q1-1 , 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 th office of the County Register of Deeds as Document Igo. gnatu e of Applicant Co-Applicant Date of ignature Date of ~lnnatiirn DOCUMENT NO. ± STATE BAR OF WISCONSIN-FORM Y 1 WARRANTY DEED ~I ^ n X139 THIS SPACE RESERVED FOR RECORDING OATO 438.`10 e~ ~,j ; {J o REGISTER'S OFFICE Rolling Hills DeveE ° m n rn~ poratP~, ST. CROix CO., WF a Wisconsin coronrati nn _ Reed for Record .11A 15 :988 conveys and warrants to Lance C Gore and Tul ° Gore , husband and wife, as % rMivsyh.i n marita1 5:00 PM n propArty $%Roqlstar of Dee& Y p RETURN TO the following described real estate in C 't . Croix Ceoars.. State of Wisconsin: Lot Forty One (41), Oak Ridge Acres, to the a Town of Troy Tax Key No. 3 t 1 a i yu.F,r~ Z I I This is not homestead property. (is) (is not) Exception to wanan:ies: easements and rights of way of record, if any. i 1 Dated this ~D day of ~bai~ ✓cc n ! , 14. -`='i (SEAL) Lri') Richard N. Fox President ~ (SEAL) ~ C_1' a - ~ ._V (SEAL) Frances J. Fox, Secretiry AUTHENTICATION ACKNOWLEDGMENT Signatures authe dated thiflay of STATE: OF WISCONSIN t9 88 I'ss- County. Prs crae ly came before me, this day of - L. Gaylord .-------the above named TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by 1 706.06, Wis. Stats.) - - - - This instrument was drafted by C. L. Gaylord, Attor,iey to -ne 4_~. YZ to be the person _ who executed the fore- going .r._ -ument and acknowledged the tame.