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HomeMy WebLinkAbout042-1079-50-200 ' X ST. CROIX COUNTY ZONING DEPARTMENT ,Y`~~" l ^ AS BUILT SANITARY REPORT Owner / R R t l d a S ,r w ;,r9 • Address 76 7 t' jAa S City/State S y Q Z7 s"r C,9,- ,Qg9 9r i , hQ O F C Legal Description: - Lot _ Block Subdivision/CSM # Sec. TILI~N-RjJW, Town of lg)A 1?,e PIN # SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION: 30 .29 Tank manufacturer Size ST/PC/ i4OSetback from: Housed*yl~ Well P/L ~O4 Pump manufacturer ~o LC.-g Model 3 Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: W©0std Width :2'9Length y Number of Trenches Setback from: House .!'Z Well P/L _ Vent to fresh air intake t, ELEVATIONS: Description of benchmark l /C'YI ,ems L e Elevation 1D®, o0 Description of alternate benchmark Elevation Building Sewer 6 ST/HT Inlet (4 2, ST Outlet PC Inlet PC Bottom 4, 2~- Header/Manifold Top of ST/PC Manhole Cover Distribution Lines ( ) .~C G~ ( ) l ) ) ( ) ( ) Bottom of System( Final Grade ( ) ( ) ( ) Date of installation /,O/Permit number 9 State plan number 7~ dr Plumber's signature /Z-.,-,-*,icense number Date Zf /&Q Inspector Complete plot plan t t NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. We AN VIEW ice--- Sap' kJOT' ~o sC-T , To 1 ~kvZ i !n O Q ® r 13 Bbd I Hov~E MAN 'tz` cuV . I ? ~ f i ~ n ~ sap. INDICATE NORTH ARROW Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor andJ-iuman Relations ST. CROIX ` Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary 9Permit No-: 9139 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: LINDUS, LARRY WARREN CST BM Elev.: Insp. BM Elev,: BM Description: Parcel Tax No.: /l/l~ Gtr /Gf),G `.<<z.,-~PC,S f.2r 042-1079-50-000 TANK INFORMATION ELEVATION DATA A9700455 2.3197 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic w ~wser nC/GCP r Benchmark eV Dosing l~t.,rrr. r'~l. Iu'1.I 3. /0-,f Aerati Bldg. Sewer jCrl.l S, Uo;), J E l St/ of inlet ((77,1 q -2 S` TANK SETBACK INFORMATION St/ Ht Outlet P Vent TANK TO P/ L WELL BLDG. A ir Ito ntake ROAD Dt Inlet Septic lj,4 NA Dt Bottom ( 07-11' 1,2.PD Dosing 11 NA Header / Man. !4~ •~1G~ 3 CP S-7 Aeration NA Dist. Pipe icy,r~ ,Cow Holding Bot. System PU16 NFORMATION Final Grade Manufacturer Demand o 1 &I rn Model Number 1 vM~ ~6 TDH Lift Friction Q b System TDH ) J,!; (F,4 [Forcemain Length IC?' I Dia. Z' Dist. To Well SOIL ABSORPTION SYSTEM ~rly~ BED/TRENCH Width / Length No. Of Trenches P No. Of Pits iquid Depth L DIMENSIONS DIMEN I SYSTEM TO P / L BLDG WELL LAKE/STREAM LE IN nu aaurer: SETBACK INFORMATION Type O HAMBER Model Number: System: V Gf OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole SSP,acing Vent To Air Intake H I I/ _ f h Length = Dia.2 Length ZL Dia. j Spacing - 5 / SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over , r 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: WARREN 29.29.18.452,SE,NW 767 103RD STREET LOT 2 77- 1A1, 7~ 7~ f / 02~ ~~~.*f?a~1~ °7>/C!Y3>P >;C ~to ~ F,rf f`Wtt~s+P`' i Plan revision required? ❑ Yes §0 No U ~tUse other side for additional information. 5 Q~j fr p SBD-6710 (R 05/91) Date Inspe is Signature rt. No. I ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: k&,Adol v "t Safety and Buildings Division Misconsin SANITARY PERMIT APPLICATION 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. 0+-- See • See reverse side for instructions for completing this application State Sanitary Permit Number Z-9 I Z-vq The information you provide may be used by other government agency programs E] Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N 720 (03.6- Property Owner Name t erty¢ c tion /4 1/4, S 2 T,? , N, R Q?E (orL\0 Property Ow er's Mailing Address Lot Number Block Number 7- 7' 2- 0T--Z City, State Zip Code Phone Number Subdivision Name or CSM Number 40 o ( yea j Qao G II. TYPE F B I DING: (check one) ❑ State Owned ❑ ltia Nearest Road. Public 1 or 2 Family Dwelling - No. of bedrooms own of Ga~o--2-~- Ao 3 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo - 145 51 - L~ 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. g New 2. E] Replacemenfr 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 OMound 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 (s ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./' ch) Elevation ( l 102 O Feet /0 q,aFeet VII. TANK Capaaty INFORMATION in gallons Total # of 's Name Prefab. Site Fiber- Plastic Exper. Gallons Tanks Manufacturer Concrete Con- Steel glass App. New Existin structed Tanks Tanks Septic Tank or Holding Tank & ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Prin~ Plu tier's ignature (No Sta s) MP/MPRSW No.: Business Phone Number: Plumber's dress (Street City, State, Zip Code IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved itary Permit Fee (Includes Groundwater ate Issued IssuingAgent Signature (No Stamps) Approved ❑ Owner Given initial mrr n ~ urchargeFee) 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 3 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, num oer 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 narne, 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. SAFETY AND BUILDINGS DIVISION 2226 Rose Street LaCrosse, WI 54603 Department of Commerce d Y ~ ~ • Tommy G. Thompson, Governor 17-Oct-97 William J. McCoshen, Secretary T 2 Wegerer Soil T esting & Desig 19p 97 LAkR LINDUS k-flZONTINGOFFICE 421 N Main St sT cRax UNTY PO Box 74 River Falls WI 54022 LARRY LINDUS Plan ID 9720635 SE,NW,29,29,18W Municipality of WARREN Inspector: Leroy G. Jansky County of St Croix (715) 726-2544 Private Sewage plans including the following element(s): MOUND 450 GPD The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(2)(e), Wisconsin Statutes, is responsible for compliance with all code requirements. This plan action is subject to the conditions listed on the following page(s). A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department. All permits required by the state or local municipality shall be obtained prior to commencement of construction/installation/operation. This project is under the supervision of a state inspector. As inspection concerns arise feel free to contact the state inspector at the number listed. The inspector for this project is listed above. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Please refer to Plan ID number listed at the top of this page when making an inquiry or submitting additional information. Sincerely, Denn Sorenson Wastewater Specialist (608) 785-9336 SAFETY AND BUILDINGS DIVISION 2226 Rose Street ' ~ LaCrosse, Wisconsin 54603 ~~c®ns®n Department of Commerce Tommy G. Thompson, Governor William J. McCoshen, Secretary Page 2 ^LL"a ' r t a - A Sanitary Permit must be obtained from the County where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats, prior to installation. - Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(d), Ws. Slats. SBD-5524-^c (R.07/96) File Ref: r -97 c Page of 6 r PFCEIVED MOUND SYSTEM 1997 FOR A BEDROOM RESIDENCE S t r ULOGS. DN LOCATED IN THE S~ 1/4 OF THE Mw 1/4 OF SECTION Z9 TZ? N, RIFE W, TOWN OF w P~~~Z~1rJ , ST• C-RU UC COUNTY, WISCONSIN. INDEX PAGE 1'of 6 TITLE SHEET PAGE 2 of 6 PLOT PLAN PAGE 3 of 6 PLAN VIEW-CROSS SECTION PAGE 4 of 6 DISTRIBUTION PIPE LAYOUT .PAGE 5 of 6 PUMPING CHAMBER PAGE 6 of 6 PUMP PERFORMANCE CURVE PREPARED FOR -)6'7 10 sT1Z ~Z r RtJ~~2TS►~vi S~o~3 PP.EPAPED BY WECEl:REfZ SCI I L TEST I NC AtO . DES I GN ~lER~1 = CE ~tcicoft F.O. BOX 74 421 K. KAIK ST_ RIVE? FALLS. KI 54022 Aan«AL 715,4,2,--010 "Is p~ KLSWORTH, Wis. ~SIG13~ c cr_ JOB NO. ~l7-3~S PLOT PLAN- Page -?-of (o Scale 1"= 4' 1 d a o L4 tv ) t7) D C> To s~~ I J. y(o 0 o Ca L, ~o o p0 3 7~;b" f 1~oV 3E soot ~t~ PVC S~ ~ j \ o\Z ~\S`1'~J\Zp N i~ ZSMlN . ~IZ° Covmt C*LWI~ n oL 0 t~7 901 -0 \ cow~~pv~z . \ o 340' 10?--0' e 3 A, MIS 'Rr L\ftsT SD' FIW" N7pVNp S WT 1. V Z. S ' F116-1 lVV k s SIP pNUENG NOTES: •1. Elevations shown are existing ground elevations unless otherwise noted. 2. Install permanent markers at end of each lateral. ( Z required) 3. Install 4" observation pipes with approved caps. ( Z required) 4. Septic tank to be ~ ode 1 dto gallon capacity manufactured by VV ~Q5~2. ~ C.~~ PR.uO~cTS 5. Bench Mark 1L-T-2 kz-U. ldO.o'dy 1" ~~ON ~1PE LpT CoS 6. Divert surface water around system to. prevent-:ponding at the uphill side. Page --I--Of (o Approved Synthetic Covering ~1sTN► C?s3 Distribution Pipe Medium Sand Topsoil - H G F Elev-. 3 E ' D b y % Slope Force Main Plowed Trench of k"-212" From Pump Layer Aggregate Undisturbed D \.o Ft. Soil E Z Ft. Cross Section Of A Mound System Using F o- 8 Ft. I Trench For The Absorption Area G 1•,o, Ft. A S Ft. H I- S Ft. 6 7 S Ft. I \S Ft. Linear Loading Rate= b.c GPD/LN FT 8 Ft. Design Loading Rate= 0.3 GPD/SQ FT K to Ft. L °15 Ft. W Z $ Ft. L Force K Main W w Distribution Trench Of 2 - 2 2 Pipe Aggregate I Observation Permanent 1 Pi es Markers r. ` (Anchor securely)~P Co wC> IWO pN0 Eft Mound Using I Trench For Absorption Area SIN ESP~N Page - Df Perforated Pipe Detail ^t r End View a+' _ ..a End Cop. )Perforated l die PVC Pipe Jo-a aocc Install permanent-marker at end of each lateral Holes Located On Bottom. Are EpuoGy Spaced Q / \ End Cap S (Sit . / G~ ally 01016 * S PVC Force main colt * ~ID ANO Distribution Pipe Lost Hole Should Be Next To End Gap S Distribution Pipe Layout P 3S•y Ft. X 5 Inches Y So Inches Hole Diameter J/Y Inch Lateral 1!`y Inch(es) Manifold Inches Force Main Z Inches # of holes/pipe 9 Invert Elevation of Laterals )b7z S Ft. qx 1•ll . !oS'3~ z- Z-~.~b Place lst holes from tee with succeeding holes at 5p* intervals. Last hole to be next to the end cap. Combination Sept .4c; Tank and - PLIMP CHAMBER CROSS SECTICIM AMD SPECIFICATIOUS PAGE j OF -VEIJT CAP WEATHER PROOF JuucTIOU BOX -(c.I. VEMT PIPC ° APPROVED LOCKIAJG ~:.10' FROM DOOR. MANHOLE COVER k1-11V •.JIIJDOW OR FRESH wARNf►J6 L P.6EL. ALR INTAKE r 6 mpry- I O1S 18' MI 11. y"IIJS?L'~~1o1.1 PIPE 11~ - - - PROVIDE I !!J LE T AIRTIGHT SEAL I I I f APPROVED JOINT A I I APPROVED JOINT! PfPE pu VVE0 ,;R W/C.T. PIPEaR Tank construction I III X i tv shall comply with ALAR I II E E ct ILHIR 8)3.15 and 33.20 ° I I ~,~t 0 C I i I ~ S °1Sl-oo NG LLEV. FT. PUMP D CONCRETE fit. °13.00' BLOCK ti DES 3" APPRa~ RISER EXIT PERM11fED ONLY IF TAIJK MAIJUFACTURER HAS 5 GH A-PPROVAL -DD IN~ SEPTIC F SPEGIFICATIOAIS ~~LLLL DOSE 3 TAWKt MANUFACTURER: W►FSLNZ Cokjc-tr t3 IJUMHER OF DOSES: PER DAy TAWK SIZE : 1100 /&Do GALLONS DOSE VOLUME z S S, Z~-ZCIT?4 StTSc.R,-~„ 1S IMCLUDING OACKFLOW: 130'l~ GALLOWS ALARM MAIJUFACTURC.R: MODEL .NUMBER: \Ql HW CAPACITIES: A= Z6 INCHES OR 3O1'3GALLON5 SWITCH TYPE: M'ZLRcuyp-Lr B = Z INCHES OR 1 " G( LLOUS PUMP MAIJUFACTUREII: Zd~'- L L-~Z eo C- 11 INCHES OR \1S3-'3 GALLOUS MODEL NUMBER: S3 D= t2 INCHES OR GALLONS SWITCH TYPE: NOTE: PUMP AMD ALARM RC TO 5L~-~ MIAfIMUM DlSCHAR6E RATE GPM IN5TALLED OIJ 5EPARATE CIRCUITS VERTICAL DIFFEKFMCE 15ETWELII PUMP OFF AIJ0•.D15TRIBUTIOM PIPE.. 8'So FEET + MINIMUM NETWORK SUPPLY PRESSURE . , , , - . , - , - . 2.5U FEET + 6S FEET OF FORCE MAIM X D~S FYoFtFRICTIO►,J FACTOR.. FEET TOTAL OyWAMIC HEAD FEET Pump chamber DIAMETER _ S 1q ILITERIJAL. DIMEIJSIOW~ OF TALA: L.EKI&TH ;WIDTH - ;LIQUID DEPTH BOTTOM AREA - 231= - GAL/INCH AS.PER MANUFACTURER GAL/INCH er. W tv 3 15/16+-6 5/32 PpP Iv~ b 01= O W HEAD CAPACITY CURVE 4 5/8 "53 - 57" "55 - 59" SERIES 1 112 -11 1/2 NPT 25 TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE EFFLUENT AND DEWATERING 3 15/15 6_ 70- 50 SERIES 0 Ft. Meters Gal. Ltrs. 4 1/16 U 1 S ` 5 1.52 43 163 4 129 t`. 6Z - 15 1.57 9 72 I I J F 1U look Valve: 19.25' 1- 2 zl-b 6 v 5 10 1/16 I 0 11 U.S. GALLONS 10 20 30 40 50 1 3 3/32 LITERS 0 80 160 FLOW PER MINUTE shoe slime CONSULT FACTORY FOR SPECIAL APPLICATIONS • Variable level Float Switches available. • Available with special cord lengths of • Variable level long cycle systems available. 15', 25', 35' and 50'. - Alarm systems available. • Duplex systems available. SELECTION GUIDE Standard cord length - automatic 9 ft. 1. Integral float operated mechanical switch, no extemal control required. Standard cord letAth - non-automatic 15 ft. 2. Single piggyback variable level float switch or double piggyback variable level float M055 and 57159 Series Control Selection swtch. Refer to FM0447. 3. Mechanical altemator'M-Pak' 10-0072 or 10-0075. Model Volts Ph Mode Am Simple. Du lex 4. See FM0712 for coned model of Electrical Alternator, E-Pak. M53/55 & M5759 115 1 Auto 6.0 1 or l & 7 - 5. variable level control switch 10-0225 used as a control activator, with E-Pak (3) or N53155 & N 7 115 1 Non _ 6.0 6 3 r 4 t4) float system- D53155 & 7 9 1 40 1 1&7 E53155 & E5759 230 1 Nan 4.0 2 or 2 & 6 3 or 4 & 5 6. Four (4) tale J-Pak, junction box, for watertight connection or wired4n simplex or 2 pump operation, PM 10-0002. 53 Series - WL 22 lbs. 57 Series - WL 27lbs. 7. Two (2) hale J-Pak, junction box for watertight connection or splice, 55 Series - WL 24 lbs. 59 Series - WL 30 lbs. PIN 10.0003 CAUTION For Infomlation on additional Zoeller products refer lo catalog on Combination starter, FM0514; All installation of controls, protection devices and wiring should be done by a qualified Piggyback Variable Level Float Switches, FM0477; F_lechical Aftemator, FM0486; Mechanical licensed electrician. All electrical and safety codes should be followed including the most AiternatofFM0495;SumpJSewageBasins, FMO487;andSinglePhaseSimplexPlxnpControtAlarm recent NabonalElectric Code and the Occu Systems, FM0732 (NEC) paternal Safety and Health Ad (OSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safelytfactor is engineered into the design of every Zoeller pump. MAIL TO. P.O. BOX 16347 Zo Louisv*. KY 347 SNP TO. 3649 9 Ca ti/arlufadulrers of. . anm e Run Road Loressft KY 40211-1961 %j RaW$W Shv'LF R..W 02) 778 -2731 1Iaon) 9X -PUMP ® PUMP L-O. (5 FAX (502)774 W4 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 81/2 x 11 Inches in size. Plan must County -- Include,but not limited to: vertical and horizontal reference point(BM),direction and ( / ego/ percent slope,scale or dimensions,north arrow,and location and distance to nearest road. Parcel I.D.# 4.1.5-7-1.v G— 5Zdf3I 4.41.€0 av/2 - /o7fi'-5o d-' APPLICANT INFORMATION- Please print all information. Reviewed byt Date Personal Information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). A•�a J I l4 . I /0(3I/qi Property Owner Property Location ll�\ ...���vvnttvt G r �ON4 L� �D/. ,tN2EA9s04-1 Govt.Lot $ , 1/4 /UC(J1/4,S 2/ T 21 ,N,R /8 E(orfWD Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# 7Sf /63 ,ems sr. Z. eSM f'e-uoi%) 6- City State Zip Code Phone Number Nearest Road &Bee75 14)/ I SY 'f D z31 (7/5 )7 . 3352- CICity LI Village Er-Town �/Town /d 3 , a 577 [ New Construction Use: EB eesidential/Number of bedrooms 3 • L Addition to existing building 0 Replacement ['Public or commercial-Describe: Code derived daily flow gpd Recommended design loading rate • 5/ bed,gpd/ft? • trench,gpd/ft2 5 Absorption area required OV ./ ' trench,ft2 ./ trench,ft2 Maximum design loading rate ' / bed,gpd/ft2 • ,C trench,gpd/ft2 Recommended Infiltration surface elevation(s) S € pl.. • 3 ( �/�02,) ft(as referred to site plan benchmark) Additional design/site consid ons $' TE SU/T,f-Q/E d vc-y ,C:).e A"OVA0 42 S yS7-&iti 5 Parent material ✓GS I Ei ON —lib' o f/!/✓/ • Flood plain elevation,if applicable ft S = Suitable for system Conventional �Mouunnd In-Ground Pressure AT-Grade System inin Fill Holding TankU = Unsuitable for system ❑S [ LJ S CD E]S [ uss ❑ S ❑S (1'U ElTa S 1 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed ,Trench si / 0-8 /0 y/ 3/3 �oAN1 heck Av v,P CS /-f- . y ; . S 2- s-2Z /o ye 3/ _______. -/L ?,'sSe All-F9 CAI /f- , S; • C. Ground 3 2,2.3f /o 1,e r4 SL. /f Sh4- ,w,-f C'cc — •(..I ;.,S - elev. q.lft. / 39 60 �yy yr( iti 1' o f is 0 s Any. — . S /o 0 6/2_ s vie �/U CL /f 54,E ,1. 7i• z ,• ' 2- ; ' Depth to �/ limiting , factor 31 in. SSS Remarks: Boring# / O_9 /o Yi 3/2 - Zo q y /I'ilk- ,>,v+f/e c$ /f , 1/ ; . 5- MIZ 9. iyioyR3/y God, /fs4 - �f-ei ,.s /7c , :, S Ground / If-see/Om t// ,, AW 576. SGL 2,.... ,6,t ,i e7/ — r , z/, .3 elev. /0/•eft. , �,S•Depth to , limiting . factor 21 in. Remarks: CST Name (Please Print) Signature ) • " Telephone No. X)o8�er 7iL8R,c ) /S- 3g6 -e/as Address Date CST Number y20 • �7- esrAioZ ./a' 2-- Ulbricht&Associates Private Sewage Consultants 655 O'Neil Rd. At \121 .I 7 Hudson,Wis. 54016 o/ REct 1997i. 2 OR6\NA zoN010. °,®�_ �` k PROPERTY OWNER Doti /4, ei s& 9 SOIL DESCRIPTION REPORT Page Z of 3 PARCEL I.D.# L D r 2 - &JA I . ii, Boring # Horizon Depth Dominant Color Mottles Structure Texture Consistence Boundary Roots G D/ft2 in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. P Bed ,Trench 7 0-6 /o /R 3/2_ — L /fsAE of S / .s L 6. /3 /o ?/y L. /fr.�)� -e �' s — • `f' . S Ground 3 /3.20 A!, lie /f L/ L. Zf Si7J . i Cs — S. . 6elev. /Of . y Zt7IV Jo yp y i , nSL /� c� _ • q . s �CV Depth to 5 3V-6o x y/6 3-vie� /l �v vL 44., • -1 , • 5- limiting factor 3Y in. 6'35 Remarks: Boring # Ground elev. . ft. 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 # Onet Ground elev. ft. Depth to limiting factor in. Remarks: Boring# Ground elev. ft. ' 4 Depth to limiting factor in. Remarks: SBDW-8330(R.08/95) /6 3 72z 5T 1, a w t " Z --, _ . . ri' ?k. O , , o � O W O o ) $ I o 0 o 3 'I rts " P.1 i -- N �, Z b *.\ ao i N v -‘z, , 0 m Cn b , 4 • CERTIFIED SURVEY MAP DONALD AND EDIE ANDERSON Part of the Southeast 1/4 of the Northwest 1/4 of Section 29, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin. O Indicates 1" x 24" iron pipe weighing 1.13 1130.1 N1/4 COR. SEC. 29, T 29N,R/8W, _�,,_ lin. ft. set. ( COUNTY SURVEYOR'S NON./ Indicates driveway location. °a P7' UNPLA T rED LANDS N L/Nf 5(1/4 NW 1/4 M • t S 89. 3B'S6"W //57.93' f� I .'i c r 1% 390,00'' 734.9/s 423.02 ' f 1 A 32' MIn I 1y'/00'ROA0 SETBACK LINE' ti Lori h �M e / t� o W I. M 0 'l. 2.507 ACRES t j01L t M I ,_ N N /09,208s0.FT. 7�sr t„ 2 h o. O Q 2.3/1ACRES EXC.ROA0 R.O.W. tV •J „I h 2 `C �1 b /00,684 50. FT. 1 0 m I S. y I , ‘► • OM ,°0, ! — — —J OO h oo ( S t1 3 N89'38'36"E 423.02'til 3.02'03 1 390.00' 3 C 2 : O LW Ili _ , Lo'r2 I M � " QI v ti � I � 1 t. � 1� � • O O 2.2/J ACRES c0IL 1 0 C 1 .3 • \ lo Q I I 0 N)1.p" 96, 393 SO. FT. TEST I; " QI " m k 144 Nr 8 2.040 ACRES EXC. ROAD R.O,W. N 0 Q �& 1 n BB,B69 SO,f'T. I ' I I I ( cc 2 S//4 COR. SEC.29, Q I . J`,,I2' I 390 00' �'- -' J W .N T29N, R /AW, Y`�[ m i. IIZV� , , 'cautery SURVEYORS. S B9 JB 56 'W 423,02' JI o e �, LLNPLA rrEO LANDS N • ,NON.! toN.89. 38 56"E 35/.72' z 0 0 —This',instrument drafted by 33.Lj2' I 318. 70' Laurence W. Murphy Lora II 3.403 ACRES SCALE / " 8'150' 148,235 SO.FT. 0 50' /00' 150' 200' 300' 400' I (q b 3.226 ACRES SHED q (Jtril N I N I40,515 SO.FT. ❑ o — I 1 DWELLING In Q I ' 1 o .4 Dated: February 29, 1997 I— — — on tu ,,�1111111111I�y/I VI S BS•JB'S6"W n 0 • i `�� 5 • 33.02' R GARAGE GARAGE Q ��� `Y •�•••, •••'.., _/1/ ,, m LAUR C..... Z • I : � W RP : cc : 1 13 • o t .RIV�VI ALLS,: j/ S89'38'56 "W 3/8.70 ' 4j '0, to LAND 5 �q... UNPLA TIED LANDS ��stisili,li%0`� Owner's Address: 759 103rd St. ° Laurence W. Murphy Roberts. WI 54023 Registered Land Surveyor SHEET 1 OF 2 FILED 9 M4)' 2 8 1997 10- RTM u~ ow/r 10 560006 SL Croix Co; Wj CERTIFIED SURVEY MAP DONALD AND EDIE ANDERSON Part of the Southeast 1/4 of the Northwest 1/4 of Section 29, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin. O Indicates 1" x 24" iron pipe weighing 1.13 lbs./ N114 COR. SEC. 29, r29N,R1ew_ lln. ft. set. (couNrYSURVEYOR'S NON.)' 00-Indicat6s driveway location. w UNPLA r TED LANDS 27' N LINE SE114 NW114 N, SSS*58'S6"W //17.93' I o 390. 00, 423. 01' 52' 734.91' h f 1-100'ROAO SETBACK LINE ti W fo L07' h 2.1 07 ACRES /09,208 SO. Fr. 3// ACRES EXC. ROAD R. O. W, N /00, 684 SO. FT. 3 OI . O a N 89•$8'36"E 423.01' 3 ` Z Z 3-90.00, C 3. W q f ro J W 2 Q I~ M LOr2 M WI h J O p 2.213 ACRES O 'O ~ 1y h b Q 0 N I ph 96, 393 SO. Fr. h Q 'm Z I Q) Lai I ^ N~ O Z. 040 ACRES EXC. ROAD R.O.W. N QI b Q y, 88,06S SO. FT. N Z N ~ m N 1 w S 114 CDR. SEC.29, \ Q 4I 3. I2' f 590.00' W` N T29N,R/aW, m ti S B9 38'16 "W 423. 02' /COUKTY SURVEYOR'S. =I ° I V-&ELA_L_rEQANDS h~ON.J O ~ t b N.89. 18' 56"E 31/,72 I ThisIzristrument drafted by 33.L~2' i s /B. 7o' Laurence W. Murphy 66' I LOr 3 I 3.403 ACRES SCALE I 150' b I b 148.2J5 SO. Fr, O 10' /00' 150' 200' 300' 400' % I J. 22 6 ACRES SHED O I M N N 140, 315 SO.Fr. O^ I 1 DWELLING h Q I (]rJ JI Dated:'. February '29, 1997 _ r m "Revised this 21st day of May, 1997." tttlir~~ n W NO~~ttt SB9•J8'56"'W p `CJCjONS~''~I~i► 33.02 N GARAGE GARAGE 'Y / tQ C OR/VFWAY O QI 1.1 41 m ► ' LAUR C.. M i JI • W Rp c 0 3 • .,RiV VALLS,_. CERTIFIED SURVEY MAP D.ONAfb AND EDIE ANDERSON Part of the Southeast 1/4 of the Northwest 1/4 of Section 29, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin. Description: That certain parcel of land located in the Southeast 1/4 of the Northwest 1/4 of Section 29, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin, more fully described as follows; Commencing at the North 1/4 corner of said Section 29, thence S 00°13'58"W (assumed bearing on the North/South 1/4 line of said Section 29), a distance of 1320.90'; thence S 89°38'56"W 734.91' on the North line of said Southeast 1 /4 of the Northwest 1/4, to the POINT OF BEGINNING, of the parcel to be herein described; thence S 01°34'58"W 486.31'; thence S 8938'56"W 423.02, thence N 01°34'58"E 486.31'; thence N 89*38'56"E 423.02' to the POINT OF BEGINNING. ALSO, Commencing at the North 1/4 corner of said Section 29320 90e than e S 89°38(56°W 1d57bea&g on North on the North/South 1/4 line of said Section 29) a distance of W 552.3 35to the line of the Southeast 1/4 of the Northwest 1/4 of said Section 29;the3n$ S 01'34' 59"' hence S 101 °34 j POINT 89'38'56"E OF BEGINNING, of the parcel to be herein described; thence N 507.19'; thence S 89°38'56"W 318.70'; thence N 01°34'58"E 207.19'; thence S 89x38'56"W 33.02'; thence N 0 1°34'58"E 233.96' to the POINT OF BEGINNING. The above described parcels containing 8.123 acres or 353,836 sq. ft. being subject to easements of record. Note: Each parcel shown on this map is subject to State, County and Township laws, 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: State of Wisconsin) County of Pierce) I, Laurence W. Murphy, Registered Land Surveyor, do hereby certify that by direction of the Owners, Donald and Edie Anderson, I have surveyed and divided the lands shown hereon in accordance with official records, Chapter 236.34 of the Wisconsin Statutes and the Ordinances of St. Croix County and that this map and description are a true and correct representation thereof. n \\\,1~ItttitttkJJ Dated: February 29, 1997 "Revis%4,:i s 21st day of May, 1997``\~ ~~de This instrument drafted by Laurence W. Murphy LAUREL E ,APPROVED W MU HY o 13 MAY ? 8 'c~7I7 . Riv ALLS,; . Wisc. .Q CERTIFIED SURVEY MAP D.ONA6 AND EDIE ANDERSON Part of the Southeast 1/4 of the Northwest 1/4 of Section 29, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin. Description: That certain parcel of land located in the Southeast 1/4 of the Northwest 1/4 of Section 29, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin, more fully described as follows; Commencing at the North 1/4 corner of said Section 29, thence S 00°13'5$"W (assumed bearing on the North/South 1/4 line of said Section 29), a distance of 1320.90'; thence S 89°38'56"W 734.91' on the North line of said Southeast 1/4 of the Northwest 1/4, to the POINT OF BEGINNING, of the parcel to be herein described; thence S 01034158"W 486.31'; thence S 89°38'56"W 423.02'; thence N 01°34'58"E 486.31'; thence N 89'38'56"E 423.02' to the POINT OF BEGINNING. ALSO, Commencing at the North 1/4 corner of said Section 29, thence S 00°1358"W (assumed bearing on the North North/South 1/4 line of said Section 29) a distance of 1320.90'; thence S 89°38'56"W 1155293' on tthe he POINT line of the Southeast 1/4 of the Northwest 1/4 of said Section 29; thence S 01 *34 58 OF BEGINNING, of the parcel to be herein described thence N 89'3t8 S 1.72' then 33.02% 1the c'e N 507.19'; thence S 89638'56"W 318.70'; thence N 01 34 58 E 207.19'; hence 01°34'5.8"E 233.96' to the POINT OF BEGINNING. The above described parcels containing 8.123: acres or 353,836 sq. ft. being subject to easements of record. Note: Each parcel shown on this map is subject to State, County and Township laws, 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. State of Wisconsin) County of Pierce) I, Laurence W. Murphy, Registered Land Surveyor, do hereby certify that by direction of the Owners, Donald and Edie Anderson, l have surveyed and divided the lands shown hereon in accordance with official records, Chapter 236.34 of the Wisconsin Statutes and the Ordinances of St. Croix County, and that this map and description area true and correct representation thereof. 21st day of May, Dated: FgN,4ry 1997 29, 1997 "Revis ti``°~~SC 0 NS/+~'•. This instrument drafted by Laurence W. Murphy ' ,APPROVED ' LAURE E': - W MU HY c • t 13 44, . RIV ALLS,•.' y MAY 2 8 '97 v wisc. Q • STC-105 SEPTIC TANK MAINTENANCE AGREEMENT l St. Croix County OM ERMUYER Z 14 0"~ s MAMING ADDRESS PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE vim] Zcl r.5 PROPERTY LOCATION , ~1/4, 1/4, Section , T N-R ~W TOWN OF U-J. go'A ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER 62; 65 CERTIFIED SURVEY MAP no VOLUME I 4PAGE3 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 expiration date.. SIGNED: J DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 8 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 n Location of property .s'~1/4 h~ 1/4, Section ,T~N-R_ W Township_ fz a ~ Mailing address Address of site d 3 " Subdivision name Lot no. 2 Other homes on property? Yes___X_No Previous owner of propertyo-&/I iA->l~/ti Total size of property` Total size of parcel Date parcel was created AA- r Are all corners and lot lines identifiable? _'5-~Yes No Is this property being developed for (spec house)? Yes ,C No Volume and Page Number 066 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 n the office of the County Register of Deeds as Document No. 5 6 x,32 , 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. 9 (.vii-, S1gnat~ e of Applicant Co-Applicant /-4,? Dat o S ature Date of Signature 00f V • :3EiE).3~iAr State Bar of Wisconsin Form 2 - Igi2 WARRANTY DEED DOCUMENT NO UL INS pp.rc Of ; IJ l,l)V F35 ISTER'$ QFFIGE yoW %n wl Donald D. Anderson and Edie R. Anderson, husharl ._and .rtif~_-__--- OCT 03 199 9:45 A M conveys and warrants to Larry R i incites and Cat•harina T TAn.iug- ht-hn .d Ra 1K of 0"da and wife as survivorship marital Rroperty THIS SPACE •ESERVEO FOR RECORDING DATA NAME AND RETURN ADDRESS t` First National Bank of Hudson the following described real estate in St Croix 915 Davis St. County. State of Wisconsin: Hammond, W1. 54015 Part of the SE} of NW} of Section 29, Township 29 North, Range 18 West, St. Croix County, Wisconsin desr:ribed as follows: Lot 2 of Certified Survey 042-1079-50 Map filed May 28, 1997 in Vol. "12", page 3203, (Parcel Identification Number) Doc; No. 560006 y a AIV% ER F This _ is homestead property. (is) (is not) Exception to warranties: Dated this - - - ---)-a~ 4.y of C 19-g~ (SEAL) iI ~ --1SEAL) • Donald D Anderson - (SEAL) J~ ~ C2¢Yl - (SEAL) • Edie R. Anderson AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN Signature(s) sS County. authenticated this day of '19- Personally came before the this day of 19_ the above named TITLE: MEMBER STATE BAR OF WISCONSIN (if not. w authorized by §706.06. Wis. Stats.) to me known to who executed the n nde me. "ng instr, Wisconsin Department of Industry, HOLDING TANK AGREEMENT Safety and Buildings Division Labor and Human Relations Bureau of Buildings and Water Systems Document No. / Plan Identification No. This agreement is made between the This space reserved for recording data governmental unit and holding tank Agreement Da owner(s) I-q 2, 2 County or Local Governmental Unit Holding Tank Owner(s) called Municipality below We acknowledge that application is being made for the installation of (a) holding tank(s) on the following property: (Provide legal land description) 16`3 114 -5 Mc, - F .2 /v d/90 Return To or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Stats. r As an inducement to the County of ©f A- to issue a sanitary permit for the above described property, we agree to do the following: 1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the municipality to prevent or abate a human health hazard as described in s. 254.59, Stats., the municipality may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Stats. 2. The owner agrees, pursuant to s. ILHR 83.18 (10), Wis. Adm. Code, to have installed in a new building or new structure a water meter approved by the County and State. The water meter shall be installed by a plumber authorized by the State to conduct such installations, with said installation complying with State regulations and manufacturers specifications. The owner agrees to be financially responsible for the purchase, installation, maintenance, and repair of the water meter, and agrees to allow the municipality to enter the above described property on a regular basis to read and/or inspect the water meter. 3. owner agrees to pay all charges and cost incurred by the municipality for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. 4. The owner, except as provided by s. 146.20 (3) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis.. Adm. Code, to have the holding tank serviced and to file a copy of the contractor the owner's registration with the municipality. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service contract, with the municipality within ten (10) business days from the date of change to the service contract. 5. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit to the municipality on a semiannual basis a report in accordance with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code, for the servicing of the holding tank. In the case of registration under s. 146.20 (3) (d), Stats., the owner shall submit the report to the municipality. The municipality may enter upon the property to investigate the condition of the holding tank when pumping reports and meter readings may indicate that the holding tank is not being properly maintained. 6. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit the agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. DF Owner(s) Name(s) - Print Notriz 'Owner(s) Si we( S d 1w 7wum)v tS~fgrgme on this date: fn Not ry Pub► MuniciPal Official Name - Print Municipal Off ical Si ature zl~~~ ~L 7 My commission expires: Municipal Official Title - Print 40-ILI-t WAA--V- The information you provide may be used by other government agency programs [Privacy Law, s. 15.04 (1)(m)) SBD-6123 (R. 04/94) q HOLDING TANK SERVICING CONTRACT Contract Date This contract is made between the Holding Tank Owner(s) Name(s) and I Pumper's Name I I S ~euicr•e~ We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal descriptions:) 1. The owner agrees to file a copy of this contract with the local governmental unit that has signed the pumping agreement required in Ch. II-HR 83.18(4) (b), Wis. Adm. Code and with the County of S Z'6~ ^Q /^Y- 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the local governmental unit which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code, and to the County, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; a~ ~►0 `L1e-) b. The name of the owner of the holding tank; C. The location of the property on which the holding tank is installed; %XOTAR N d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; :'z f. The volumes in gallons of the contents pumped from the holding tank for each servicing; y , PUBLIG c~ r g. The disposal sites to which the contents from the holding tank were delivered., "Z' \c0 0F SGO 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a Bch jq,N,WJ ' ontract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the local governmental unit and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) I Owner's Signature(s) Subscribed and sworn to me on this date: I I I ♦ o~~ Today's Date I' I ieyiL L~~1 US Pumper's Name (Print) I Pumper's Signature Notary Public Signature LC R /S s C f `C SS I t Pump/e~r'ss Registration Number Commission Expiration V 2 Drafted by