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HomeMy WebLinkAbout042-1020-70-000 STC - 104 6' AS BUILT SANITARY SYSTEM REPORT fI' r~Q !c ' 6 6998 OWNER ST'CaO1X COUNTY ADDRESS zONINGOFFICE l /,0 7-Ai -A-,I) -e_ c.. , "o ob TS e SUBDIVISION / CSM# !f',~ G~GvtS LOT # SECTION- T_,f,?_N-RAW, Town of ~~CrYC-y ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM All .r-1x~yBe ,mod I3 RG Gov 4 ~~BM INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. j 1 , BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop, line: Setback from: well: House 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: INSPECTOR: 3/93:jt .f BENCHMARK: fu yn t eL S' j / ALTERNATE BM- ,~s~5'a Jm ~,tJ r S',(~ ~j SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Jh,iGJ es~~f"~ Liquid Capacity: Setback from: Well yp House 2G Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: /.2 Length -I- f Number of trenches l Distance & Direction to nearest prop. line: Setback from: well: House FD Other ELEVATIONS Co RCl°Ov-7 Building Sewer ,q ST Inlet:- ~•5-7 ST outlet: g~j•1 PC inlet PC bottom Pump Off Header/Manifold ~I( Bottom of system- ~p 1 Existing Grade Final grade ~ 6-7 DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: C 3 / 9 3 : j t WiscoUsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety snd Buildings Division CountT . CROI3C INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar2m,"-: Personal information you provice may be used for secondary purposes [Privacy , s.15.04 (1)(m)). Permit Holder's Na(,~ illage Town of: State Plan ID No.: GLASSING, 51VE & PATRICIA CST BM Elev.: Insp. BM Elev.: BM Description: Parcel N 20-:1020-70-000 /00 ! op' Yla r (i 'owe PO/C - Cs-r 5 TANK INFORMATION ELEVATION DATA A9700266 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic /0 VIP D00 Benchm P4.11-7 S~ vG•SS Dosing Alf_ P-4 .OD /o0-:5~ Aeration Bldg. Sewer/2 quo ~3 Holding T ~>MIN Inlet (p q8~ TANK SETBACK INFORMATION (940 Outlet (o, Ventto TANKTO P/L WELL BLDG. Airintake ROAD Dt Inlet Septic +100 NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe Ns a9 91 •1 ' go96 Holding Bot. System q o - 1 PUMP/ SIPHON INFORMATION Final Grade L/ -q 8' q5.5 7 Manufacturer Demand ~ah~ l o✓~, /fir 5/. (0 Number GPM TDH Lift Friction System TDH Ft oss H Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM ED TRENCH Width 12- r Length No. Of Trenches PIT No. Of Pits Inside ia. Liquid Depth EN I N DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Man facturer: SETBACK INFORMATION Type O CHAMBER ( M e Number. System ".j;") +1-75 qd OR UNIT DISTRIBUTION SYSTEM S7M 2~z~I Header /Manifold r Distribution Pipe(s) x Hole Size x Hole Spacing Vent To A i ir Intake Length Dia. Length Dia. Spacing r0 SOIL COVER x Pressure Systems Only xx Mou Or At-Grade Systems Only Depth Over Depth Over xx Dept Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topso ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, a c.) LOCATION: WARREN 08.29.18.117A,E,NW 1041 110TH AVENUE second ~'eSie~6vlrk. U)cts ND'!t' c(rSw~zr.w'~`~CC~ ~f ../y,~ ;rr•r~ .1.~ ?~s,l„~Cc.~~J /nS~a'It~eeC Witt i1aVe 4f e eXtSfi►~-4tv/( abovdooeel (a~reede 9V) rivnq Il-to -01- Plan revision required? ❑ Yes NoQ I Use other side for additional infor atlon. ( (9 7 w(, SBD-6710 (R.3/97) Date Inspector's Sig ture 41- No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division v~;n 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 8 112 x 11 inches in size. 15r~ % Ctro X • See reverse side for instructions for completing this application State Sanitary Permit Number A9a45-d 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)J. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location ct U .e, 7lt~z U rv . ` : C. ;J*W rJG 1/4, S T 2 . N, R If E (or)60 Property Owner's Mailing Address Lot Number Block Number ,/G? ZV / Z/62 71 S & City, State Zip Code Phone Number Subdivision Name or CSM Number R O N II. TYPE OF BUILDING: (check one) ❑ State Owned El it~a Nearest Road L' Public 1 or 2 Family Dwelling - No. of bedrooms C] VIITow9e oFIJ,-~ C', I,- c,cJZ 1Z 7'1 14 III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) e412- 1, 4go ` 70 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. 8 Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an -----System --------System Tank Only______________ Existing System _________ExlstingSystem 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 jJ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 1 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 ~S 4113 Feet qj*, C-' 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 X l w o /Gy Z,) c'- ~P v,J ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se "e system shown on the attached plans. Plumber's Name: (Pant) Plumber's Signature: ( `Stamps) P PRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): n IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing gent i nature ( mps) A roved Surcharge Fee) pp Owner Given Initial S Adverse Determination l4 X. CONDITIONS Oy.p PPROVAL/ ASONS FOR DISAPPROVAL: /ret,~-e ey,~,YCsal ,ayo-mac' 4/ aa0 Lmt-'~ . SB 398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety s Buildings Divi ion, Owner, Plumber INSTRUCTIONS L` 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. 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 into 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; Q 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; Q soil test data on a 115 form; and ) 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. t-~r~ t Or c- r/I A" ~ it~rG,- ~ jrr ~ v t , 1~ J.1 A S y ,r,,'e~t r,3 ON, ~ a o° ~G l~DtvSL L) 'T 2Y ~ N DOI~~ o co ✓ ldO dr~ ifs Se e S r c u ~y'o:rz ~"e v r ~s r~ .T a / Te Wisconsin,Gepartment of Industry, SITE EVALUATION Labor and Human Relations Page 1_ of 3 Division of Safety and Buildings in c &d' a'nc R 83.09, Wis. Adm. Code A, County Attach complete site plan on paper not less than 11 i Plan include, but not limited to: vertical and horizont i~ rence point direction nd St . Croix percent slope, scale or dimensions, north arrow locatjq~r4fttar>~,g gnea ad. Parcel I.D. # U NJ CROIX Ll Y,2- /10 APPLICANT INFORMATION - Please all in n. Reviewed by Date Personal information you provide may be used for second p saq%WS~1 . m)). Property Owner L operty Location Dave Glassing Govt. Lot E 1 /2 1/4 NW 1/4,S 8 T 29 N,R 18 E (or)XV Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 1041 110th ave 80 acres city State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road Roberts Wi 54023 (715)548-3327 Warren 110th ❑ New Construction Use: [Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow 4 5 0 gpd Recommended design loading rate _.7 bed, gpd/ft2_ _8-trench, gpd/ft2 Absorption area required 6 4 3 bed, ft2 563 trench, ft 2 Maximum design loading rate _ - 7 bed, gpd/ft2 - 8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 9 0 . 1 0 ft (as referred to site plan benchmark) Additional design/site considerations Parent material Flood plain elevation, if applicable ft Glacial De_jjUZ:)_Lt S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system ] S ❑ U R7 S ❑ U ® s ❑ u ®s ❑ u ❑ s ® U ❑ S U U 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 1 1 -24 10yr3/2 none L 1mabk mfr gs if .5 .6 2 4-4 10yr3/4 none is lmabk mvfr gs .7 .8 Ground 3 8-1 0 10yr4/6 none ms os ml .7 .8 elev. 9 5-6-Oft. Depth to limiting factor 110 in. Remarks: Boring # 1 -24 10 r3/2 none L 2 2 4-4 10yr3/4 none is 1mabk mvfr s .7 .8 3 2-9 10yr4/6 none ms os ml .7 .8 Ground elev. 9 3 -6-aft. Depth to limiting factor 9 6 in. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number PRQPERTYOWNERDave Glassing SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Structure 2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench - L lmabk mfr gs if -5 -6 2 124-42 10 r3 4 none lS 1m b imvfr gs .7 .8 Ground 3 42-115 10yr4/6 none ms osg ml .7 .8 elev. 9 4 _ZJD-ft. Depth to limiting ; factor 1 1 5_-in. Remarks: Boring # Ground elev. tt. , Depth to limiting factor in. 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 # Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) A5`! oecl ► N ll DN j - f~°o ws e a,oos t~ .,O,e 0 rYo t...e /!fd v • a Tipp ~ sx~ 6 ~ ~ 9~ ,3 - _ ZAP lrj/ej-r2 ;A'ev-tom J. 5e5 Te --l I Vsconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page / of 3 i Labor'nd Human Relations Division of Safety&Buildings in accord with ILHR 83.05,Wis.Adm. Code COUNTY _ 5 f C45'7)e Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include,but not limited to vertical and horizontal reference point(BM),direction and%of slope,scale or PARCEL I.D.# dimensioned, north arrow,and location and distance to nearest road. D As APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION � � Of/1E �14 SS/.06— PROPERTY OWNER':S MAILING ADDRESS GOVT.LOT ,4/f 1/4 ,4jfe)1/4,S T 2-9N,R /� E(ohl'J LOT# BLOCK# SUBD.NAME OR CSM# /o'// //D ' ,9 u f S'D �4atz. �>f-/DM CITY STATE ZIP CODE PHONE NUMBER ['CITY ['VILLAGE [�]fOWN ROAD fro 63E 1��5 W/ S Y0 L3 (7/S) 7y 9-33 17 CcI74/'IP .A' 1NEAREST //o f A iT .. [,'] New Construction Use [,r] Residential/Number of bedrooms 3 0,e ¢' ( ] Addition to existing building ---- ----- [ ] Replacement yso_ [ ] Public or commercial describe Code derived daily flow coon gpd Recommended design loading rate '7 bed,gpd/ft2 , ' trench,gpd/ft2 Absorption area required bed,ft2 trench,ft2 Maximum design loading rate , 7 bed,gpd/ft2 ' i_trench,gpd/ft2 Recommended infiltration surface elevation(s) SEt fI . ft (as referred to site plan benchmark) Additional design/site Asiderations — 'USE 74 CAJ64 S ( .) L i ill 12, 7/) 4 0 X n/,ST'tai'6 a7 et1 Parent material SCS S) 0(w C - P1't 1 t t) 'Ar o..I Flood plain elevation,if applicable h 4 • ft S=Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable for system ©S El ®S ❑U ®S ❑U ES ElU ES ❑U ❑S EU SOIL DESCRIPTION REPORT G /A.)74-k TES T t0-c9Di TA/-vs ; s�-�tiy, 30 -F., 6," -to le- �it°osr-. Depth Dominant Color Mottles Structure GPD/ft2— Boring# Horizon in. Munsell Qu.Sz.Cont.Color Texture Gr. Sz. Sh. Consistence Bounder)/ Roots Bed Trench :: /<:><:i: �� �, io 1/4P 3/3 4ii: / / .f, sbk- A..f,e es /0c- , y , S M:.; 15 ' iy — / I -F s ,e Cs /uf . y , S Ground 8 /5- 2' 7,5 vie 4// /S O 44, 9/to ,,,e ,s , 7 •cC3 l5erg ft G 2'//e) iS a S/y __----- ,� 67. 40 S Ai- /.e � 7 ,/ j Depth to limiting factor ,' //Q Remarks: //0/02-ati C //S /i'F.A-f/AA",7z0.a izv- ' '�,'`)r^e. , ' . Boring# A p n-7 /0 yie 3/3 / /'7/ /,I? f/c? (1s /Of ,V/" . 3 tvti:: ::;ti 8/ 7-'2 7 c y e 0 S/ I,4, 5 6 ,w► i/e e 5 /u f . �/ . S Si IV 29 7,3- y,r /6, /s 04v,, 74.) ,e g• .S i , 7 , P Ground elev. C 1 y'ld 0 -S kg 5.//y -=' D 4 S4_ .�Q .e i .i , 7 ' , r 6,_SO ft. Depth to - limiting factor "" /00 Remarks: /fDip/Zo Ai „a „ ".s /4Mi.✓/r7 t /OOSE , CST Name:—Please Print Phone: 7/i , 3 26 _84r.c Address: -OMESITE SEPTIC PLUMBING CO. -.Z - f 3 y yP,,�,�„ 655 O'NEn RI) HIID$fN_WIS 5401R Signature: T � ROBERT ULBRIGHT Date: CST Number: ����""' Y :'"IS.MASTER PLUMBER LIC.NO.3307 M.P.R.S. -�_ 2, I 'INN.INSTALLER&DESIGNER LIC.NO.00883 / _,1/,9 is, t: zG x IS) -74 g -P- „ ORIGINAL cds3 e=3 ., This test site APPROVED *410° for a conventional septic system. PROPERTY OWNER /11-3.S7,36— SOIL DESCRIPTION REPORT Page of= PARCEL I.D.# Fo '7 7'4 ii43M Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Bout y Roots i in. Munsell Qu.Sz.Cont.Color Gr. Sz. Sh. Beded T Trenn ch 3 ,4 P p-/D /oye 3/3 — / 2,f .2 „w/'k C5 /01 , 3 .ami /3 /o-/2 75 /,' 4/V - 5/ /,f,sdk es /uf , r , .S Ground 52 if;9 7s Y f/ /s a MI) fk m .� gs ,-- , 7 1 . elegy. .s O,434, d,Q .� , 7 j2 Depth to limiting factor ,, 2//O Remarks:. Boring# p O-e soy 3/3 / 2,f p,Q 4-fi . CS /of ti,' ,3 x: 33 c19"/ zSY, 7/ — 5/ %f s1,t .14174e eS /w , /32, it zy o, , ye �►�, .e s 7 , Ground elev. C z y/0� 151,1 s/y .S ae- .- / . 7 , 8 �y.7yft. Depth to limiting factor( r Remarks: Boring # 4 p p,/o /0 ye 313 - s /C f/'i C S lvf S lit5 l3 , 0o-i7 2 s yR 4/4 — _5/ /,-f, she ,,.,,,f',' es /crf , y , S 6, I -3014VA `F/C lS 0, A44, yta 4.(9 s / • 7 Ground elev, ft. C 30 -/oo S YR Sly s O, ,5j_ a As 7 -F Depth to limiting factor „ Remarks: Boring# .................. Ground • elev. �._._ Depth to limiting factor l I Remarks: con oonnio ACFAO •JAVIrrlIPO • • 20 4 Cr-2 Fn,eM To /3 c e..r,5TiuCr- /?1¢2E7, o/45e ffiiP-ti ///Car E 'OMESITE SEPTIC PLUMBING CO. 005 O'NEIL RD.,HUDSON,WIS.54016 ROBERT ULBRIGHT e S r-i -1492- 'IS.MASTER PLUMBER LIC.NO.3307 M.P.R.S. 'NN. INSTALLER&DESIGNER LIC.NO. i J6 w #044E 1? Z�'Q'` tow APr-4 iiek-- 4/fr /90.44 f 3 3 v - - - ' L. vES,'T& w f . I , 8A1, - ?o7o of p►R°VED c'a , .-k Laoov This test s'Ite •sePti system• 1 Fes-uc� /osr '.or a conveennat te,/dk 'o ieid/3oN e/eu.'17'OA.) _ /00.0 v e&FU.4-rio_, S e/ ; GO - . 3 70 . 131 �1 i I \ 1 1 NI 1 NI l �/ / _ �d � I 1 NI ' I ill `� 1 I( 11 �� I 1 9 .). 2 ; i l y, i s 72 3 9/ B3•1 1 1 1 1 1 9 0 - -- il k 1 C4, , yi , NI I % , I , 1 1 � 1/3S n0 1 I i I N 1 I- - I , i G! • f35 3 % 13Z 5u 6 e 6 Tt p %,ez-A)L ft ,' ORIGINAL I-4yoo7- $404v.✓ Sys?E AA. Lk U TI'DJJ S Scht.e ; / ��= 30 • 3 2 5- ' h/y t T�'ev ' + /.SAG/'//off 1)/7 5 , 9a . yp /ow ree.var, 3 eri S T C - 100 t 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 Q =j r. J Location of property /_G' f4 y!Y(~% 1/4, Section, TAN-R / W Township Mailing address 4,0 ~t l f~v -f-l, Address of site Subdivision name Lot no. other homes on property? k Yes No Previous owner of property A r Total size of property For A- ir 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] and Page Number S- L/C 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. - 3S -72 , 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. ~ l Signature of Applicant Co-Applicant 7-• Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER « s S .',ti' MAILING ADDRESS / 6) G PROPERTY ADDRESS _fi f: r s Lu S G' 3 (location of septic system) Please obtain from the Planning Dept. CITY/STATE +E L) 6 C a- ?s' > ; ~ ~ {/l: 7 3 PROPERTY LOCATION 114, ,z/1O 1/4, Section c TAN-RI L_W TOWN OF Lila Irv e ' ST. CROIX COUNTY, WI SUBDIVISION ~T LOT NUMBER CERTIFIEDSURVEY MAP _1 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 113 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. r ~ SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, Wl 54016 11/93 f~ DOCUMENT N:) sra~r on;e rr:• WARRANTY DEED c , 353572 vc,. 585 ,54b T - This Deed, made between . Donald B. Currell, Allan E. )1EGiSTIRS OFFICE Siekmeier, Lawrence Solarz, Jeanne Lundquist ST. C-ROI~C CO., Wj James R. Burdette Grantor 'd. fCf r?•COfd 6115 2:-+-,, andDavid--L,.-Glassing and. Patricia. J. Glassing,,.doy of ~rO~s q, D. 19.L; husband and wife M. 1 - Grantee, _ Witnesseth, That the said Grantor, for a valuable consideration R•a~tk ~~~d' conveys to Grantee the following described real estate in St.. CrOiX County, St-ite of Wisconsin: The Fast one-half (E,) of Northwest one-quarter (NW74), of Section 8, mi;N, R18W. EXCEPT the Northeast quarter of the Northeast one-quarter of the Northwest Tax sey ~o.. one-quarter (NEjb of NEtw of NW34 of Section 8, T29N, R18W. L SFER State of , MI d I4S9TA County, y er>onaily, cj,nc before tile. this day t,I._.-.-_ October the above named Lawrerce Solarz~ Allan- E- Siekmeier,..Jeanne Lundquist - - to me known to be the pcrs,n uho executed rile forcCoing instrumc;frt and - THIS INSTRUMENT WAS DRAFTED BY - T T- ~y.p1 NOTARY Notary Public, ...10HP1 LCURRELG"N. 11 NOTARY PUBLIC - MINNESOTA s ?•;v c.,m ni, :on ) ..WASHINGTON COUNTY e My Commission Expires Mat. 11, 193: ISectioo 59.31 (1) of the W ix -in Statutes prove- that a n•.em t be l~ ;he Ia.:1.S ~,t the g'. t t, es• e' -d r.•t ry . •V re m ec c .u e.c ' 1 ental ayeny who~h, fattc.l ,urh :a tr•u..~nt, Shall F< • t•.:. r- r n, 't wr tc❑ - - ST1'rR or NISCU\SLY W tICRASTY UF:F7D This is not homestead property. (is) (is not) Together with all and singular the hereditamenta And_ warrants that the title is good, uldefew,'bia in fee simple and will warrant and defend the uune. Dated this Z( day of (SEAL) /Donald B. Currell A C ~a _ G!. yG~~s t c ~1 (SEAL) .585 q5f~7 / Allan E. Si.ekmeier~„J AUTHENTICATION AC KNOW LE DG N1 F r Signatures nuthentiofitrd this day of I'.\ i•E: OF ~(°(1}C~~ c.~ ~ !:1 A - SAN DIEGO t J* 40' i'• n,tii : ann, I,r r, t n I,. 16th September tE.e - TITLE: MEMBER ,TATE: BAR OF WISCONSIN Donald 3. 'U-'eil 4t authorized by § ithLOti, Wis. Stats.) A J - r ff e A = TH.: INSTRUMENT WAS DRAFTED BY t,, ii-,e kii,wn to be 0-X pl`r,(,•1 A :mv, r, 'nstri it t m dce t'rc ..I..'.t _ T__ Att 1~ ' y NO STATE 9AR WISCONSIN—FORM 1 DOCUMENT WARRANTY DEED 4 TWS --E RFSERVLD t'•R It::I:IIRDING DArA 353572 vc!.. 585 :~A E 54 This Deed, made between .-Donald.-B-.. Curreil,._,A11aq.E..- REGISTERS OFFICE Siekmeier,.. Lawrence Solarz, Jeanne :undquist . . . . . - _ $T, CROIX CO.. WIS. - James_R..-Eurdette Rec'd. for Record this__221h Grantor and °-rid--L...Glassing-and-_Patric-za_J,--Glassing,.......... day O j'w. at 1: M. husband and. wife. - - _..-.---.Grantee, _ - _ - . Rspis h of ode Witnesseth, That the said Grantor, for a valuable consideration--..-. - RETURN T conveys to Grantee the following described real estate in .-St.•-.Croix County, St-tte of Wisconsin: The East one-half (E/,) of Northwest one-quarter (NWA), of Section 8, T29N, R18V. EXCEPT the Northeast Tax Key No quarter of the Northeast one-quarter of the Northwest one-quarter (NO/4 of NE7,4 of NW34 of Section 8, T29N, R18W. T'RANSFER State of MINNESPTA October-.. A. D., 19---78-, 1 County. ) ersonally came before me, this day of : _ the above named . Lawrenc•---e Solarz ,_..Allan-.E.--Siekmeier-,...J-eanna..Lund uist---- 1 L to me known to be the person who executed the forgoing in strum a d acknowlsd}, the same. ' r - THIS INSTRUMENT WAS DRAFTED BY - NOTARY Notary Public, .......lomlL~LIRRE1Jirount 1t NOTARY PUBLIC - MINNESOU MY GtmmlSiton ) W*SHINGTON-EOUNTY...... • My Commission Expires Mar. 22. 1981 (Sectioo 19.51 't) of the Wisconsin Statutes pr-dc. !hat a!I :-t nl ment, to be more : d~ the nu::cs t [tie grantors, grantees, -tn.ea1es and -'-,n W.s 11 similuly requires that the name of the person ~Iho, or guvern. !ncnul en vrh-:,h dratted such •nstrument, shall le )Pewntten, stamped or written thereon in a iegVe mxnner.l aT IL T E F: UM WISCONSIN IVI", c-tn Le: ni °r-oz npary WUtItANTY UF: F.U F'UILN New 1 Milwaakee. Wis. ( Job ?13 i7 ) This - is not _ homestead property. tis) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And - - warrant, that the title is good, indefeasible in fee simple and free and clear of encumbrances exrep and will warrant and defend the same. ~ d7 ~1~ day of 19 Dated this .7- - ~4SEAL) James R. Burdette 1 _ (SEAL) (SEAL) Donald B. Curren Lawrence -1• lard. - -(SEAL) ;4L►y1~•L l .!/StQ... ....(SEAL) ' Allan-E.. Siekmei.er . Jeanne Lundquist-- _ AUTHENTICATION Signatures authenticated this - tray of ACKNOWLEDGMENT 19 S-Ci\TE OF )9(MONTAN) is, Cascade Count%. Personally came before me, this 25th. -day of TITLE: MEMBER STATE BAR OF WISCONSIN September-- . the above named - .ames_R..Burdette _ (If not, authorizad by § 706.06, Wis. stats.) - - TH.S INSTRUMENT WA? DRAFTED BY ~ - _ _,_.......a "*I