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STC - 104
AS BUILT SANITARY SYSTEM REPORT
ct ,
ST
OWNER E'tnu~iS ~~L c',ptlNTY
i OIVfNG OFFfCE-
ADDRESS_2 S
SUBDIVISION / CSM# / LOT # /V4
SECTION T5,?d_N-R_W, Town of-
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
T6
rLi
r,
Sep q'~ yt
0
A ,
7-e
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
S a~ '
BENCHMARK:
4 S
S ~1 OC c)/1 p,~i,
ALTERNATE BM:
i~pO 75'v Q
SEPTIC TAN / (UMP CHAM / HOLDING TANK INFORMATION
Manufacturer: Liquid Capacity:
H9 °G S _
Setback from: Well House 133f A-o0Qther
Pump: Manufacturer C V ~7~ Mode•l## -L ~
87/ Size ~
Float seperation
~ Gallons/eycle:_
Alarm Location
-:SOIL ABSORPTION SYSTEM
Width:
Length 4~~.
Distance & Direction to ne rest prop. line:
Setback from: well:- House
_13,IiL Other
ELEVATIONS
Building Sewer_Q_(4K_ ST Inlet. ()3.1 ST outlet )7
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
'
Existing Grade (Qe Final grade /o/'d
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER:
INSPECTOR: tf
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations INSPECTION REPORT ST. R
Safety and Buildings Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 262483
Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.:
TYPN
CS E e, Insp: BM Elev.: BM Description: Parcel Tax No.:
Er
/O UD r I Z hLr tj~e
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Benchmark
Septic
Dosing
'
Aeration Bldg. Sewer 141
Holding St/Ht Inlet 163, /a "
TANK SETBACK INFORMATION St/Ht outlet L,09 41
TANK TO P/ L WELL BLDG. ventto ROAD Dt Inlet
- -77 Air Intake
NA Dt Bottom /5. ZI d
Septic T/0 3q.G ~5
Dosing y S NA Header if Man. /64 3'
Aeration NA Dist. Pipe 2 /0/.
Holding Bot. System ~,(0 00.7
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand 57
Model Number GPM
TDH Lift Lriction Headis S TDH Ft oss Forcemain Length2F Dia," Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Len th No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
LEACHING
SETBACK Manufacturer:
SYSTEM TO P / L BLDG WELL LAKE/STREAM
INFORMATION TypeO , CHAMBER Model Number.
System: ; OR UNIT
DISTRIBUTION SYSTEM
++ea~er /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length Dia oZ- Length Dia. ~ Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded / Sid xx Mulched
Bed /Trench Center Bed / Trench Edges Topsoil w f Yes C] No Yes E] No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: EAU GALLE.25.28.16W, NE, SE, 12TH AVE
Plan revision required? ❑ Yes No 6
Use other side for additional information. aL ' " Cl"
SBD-6710 (R 05/91) Date Inspector's Siqnature Cert No
a
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
_ f
Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau 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 FCCheck than 8 112 x 11 inches in size. CROIX
nitary Permit Number
• See reverse side for instructions for completing this application
4~The information you provide may be used by other government agency programs if revision to previous application
(Privacy Law, s. 15.04 (1) (m)I. State Plan I.D. Number
596-40410
1. APPLICATION INFORMATION - PLEASE PRINT ALL INFOR TION
roperty Location
Pro ertyOwner Name 114 D 1/4, S 25 T 28 , N, R 16 100 W
~~,ti~;IS ~.i~c~>E Lot Number Block Number
PropertYYOwner's Mailing Address N/A NSA
iZt 1 • 1•.+"" 665 M Number
i
Zl Roe, ( Subdi Name or CS M
r
Citae,r$ gL ~ or>e umbe IV/
YY~~~ Y ~lf~ //11
❑ Caty NearestfRoad
11. TYPE OF BUILDING: (check one) ❑ State Owned 4 E] wllage~lU' GA),LE. 12T,i AVF;NUE
❑ Public ] 1 or 2 Famil Dwellin - No. of bedrooms own of
Parcel Tax Number(s)
III. BUILDING USE: (If building type is public, check all that apply)
UU~~~:~~1/ yl1
1 ❑ Apartment/ Condo
❑
2 1-1 Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 Outdoor Recreational Facility
3 E] Campground 7 ❑ Merchandise: Sales/ Repairs 11 El Restaurant/ Bar/ Dining
4 E] Church /School 8 F1 Mobile Home Park 12 E] 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) of an
New 2. E] Replacement 3, ❑ Replacement of 4_ E] Reconnection of 5. ❑ Repair S_stem
A) 1 System System Tank Onl Y _ ExfstfngSystem -----g-y-___
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Other
Non-Pressurized Distribution Pressurized Distribution Experimental
11 ❑ Seepage Bed 21 E1 M8und 30 E] Specify Type 41 El Holding Tank
42 E] Pit Privy
12 E] Seepage Trench 22 E] In-Ground Pressure 43 Vault Privy
13 E] Seepage Pit
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. . Fin it Grade
Re uired (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevaton
600 l'00 121)0 .5 VA 100.35 Feet 1` "..t.-' Feet
Capacity Total # of Site Fiber- Exper.
VII. TANK in gallons Manufacturer's Name Concrebe Con Steel glass Plastic App
INFORMATION New Existin Gallons Tanks strutted
❑ ❑ ❑ ❑
Tanks Tanks El
Septic Tank or Holding T 1200 1 i 11 Alli- )1bM1 ! nt .t.:AS'
1200
ank ty Y. lv Lj
J
Lift Pump Tank /Siphon Chamber ❑ ❑ Li Li Li
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
MP7MPRSW No.: Business Phone Number:
Plumber'sName: (Print) Plumber's Signature: (No Stamps)
lZ1N 11E 11ELGESOPI Iil'kS 3215 715/772-3`L7i3
Plumber's Address (Street, City, State, Zip Code):
W1229 770TH AVENUE, SPRING VALLEY W1 54767
IX. COUNTY / DEPARTMENT USE ONLY
mit Fe=(,ndudesG'Oundwale, te Issue ! Issuing Age erg (1~ O Sta m ps)
❑ Disapproved sanita~.ryPer 1~/,• ~Approved ❑ Owner Given Initial 0 Adverse Determination
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
%HD-6398 (R. OS194) DISTRIBUTION: Original to County. One copy "fo: Safety & Ruildiru3s Division, Owner, Pluml:~r -
INSTRUCTIONS
A sans tary permit is valid fo, tw,, (2) years.
2 Your sanitary permit may L -.ref ewcd before the expiration date, and w. a time of renewal any new criteria in the
%MS - ~-.sin Administrative CAe viii be applicable.
I Ali revisions to this permit ; lust oe r_ oproved by the permit issuing authority.
=owners+fip cr pl,,mt .~r rc Iuires i Sanitary Permit Transfer/ Renewal Forrn (SBD-63)9j to be submitted to the
county prierLo ins>-)Ilatior:
5 C!isil ,evvage sysf rms :nu` be !)1,0:, er y maintained" The septic tank(s) crust be pumped by a ;iccrised pumper vrhe-iev?r
n-~ces---,ry, usually ever,,,2 t. 3 years
6. If you nave questions c• ncr -ning your onsite sewage system, contact your local code administrato~ or the State of
Wisconsin, Safety and Build ngs Division, 608-266-3815.
T - be complete and accurate this s3nitary permit application must include:
1. Property owner's name rnd r sailing address. Provide the legal description and parcel tax number(s) of where the
system is to he installed.
Ii. Type of building being s< rve . Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
1'!- Building use. If building typ( is public, check all appropriate boxes that apply.
!V. Type of permit. Check only c ie on line A. Complete line B if permit is for tank replacement re :r)nnection, or repair.
V. Type of system. Check aj..prc )rime box depending on system type.
VI. Absorption system infor iati m. Provide all information requested for nnurribers 1 through ;
ank `ornn;itlc , I it i 'he apcC'-iy of every !new/or existing tanb li~,t the total oallons, nu n of tanks an,!
raru{ turF,=`s name, ir.7ica e p efab orsite constructed and tank mater!; Co • oiele t(;r p_im;n/siphon and
"ioldunc ' i_ani:_s fc- th,,,-sy-`errs Check experimental approval only If tar,-,s r,-(elves exr-erir,ef -a; produf_t approva: fro n
DILNF;
Vill Responsibility st,temen-~ In, `ailing plumber is to fill in name, license, ;wrnber ,.v!' ; app ;.,ri F~refix 'e.c. Nil etc.).
address and phone rum" c-~r. 'lur°,,be, must sign application form
IX. Cou= t,! Department Us On y.
Y,. County )epar',rt en: ;t, Jr. -
Comp ve plans ,I JE TICS _IC f-ot s'71a!IE r 1haP'I 69 '2 x 1 1 inter s fe C, c u "le f )h p, !r r _ ~'I I f pr . ,S US'
.r! (Gi ,'Tr L) ijir t; ,t<S. 70 cLVVa..t. see iIC
,f wa . 71r or pf~ fn 1! -1 S
?xe. 5C) aC U' :+f rI ys r rs, rt- ~c'r) `>r r
eJ
n i.
~ r r ~ l
_ ~ ~ Iz n v: L,n
L
Al,
o~ se !a
,Cc Ve. r D) rrt 1 .)v th. C
vuE fns ri rr 3U ;n.
19Y-'4 ,
Tr';e ,n
and r
j SAFETY & BUILDINGS DIVISION
State of Wisconsin
Department of Industry, Labor and Human Relations
May 29, 1996 2226 Rose Street
La Crosse WI 54603
HELGESON EXCAVATING
W1229 770 AVE
SPRING VALLEY WI 54767
RE: PLAN S96-40410 FEE RECEIVED: 180.00
ROCHE, DENNIS
SW,SE,25,28,16W
TOWN OF EAU GALLE COUNTY OF ST CROIX
MOUND SYSTEM
The Department has reviewed the above-referenced submittal.
Conditional approval is hereby granted for the system plan submittal. All
noted items must be corrected. The review and approval of the system is based
on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin
Administrative Code, and is contingent upon compliance with any stipulations
shown on the plans. This system has not, been reviewed for the code
requirements set forth in chapter ILHR. 82 or in chapters ILHR 50-64, Wisconsin
Administrative Code.
This plan submittal approval will expire two years from the approval date, or
if a sanitary permit is obtained, plan approval will expire on the day the
initial sanitary permit, expires. The licensed plumber responsible for this
installation shall keep one set of plans with the Department's stamp of
approval at the construction site. The installer shall notify the appropriate
inspector when inspections can be made.
All permits required by the city, village, township or county shall be
obtained prior to installation.
Inquiries should be directed to me at the number listed below. Please refer
to the plan number shown above.
Sincerely,
G and M. Sw
Ian Reviewer
Section of Private Sewage
(608) 785-9348
SUDA-7997 (K. 10/84)
1
CJc ~ C•
-4
i r h
o) r
PRIVATE SEWAGE SYSTEM
/ ry Jr
Conditionally
P-9
DL7r. OF INDUSTRY, LABOR & HUMAN RELATIONS
DIVISION OF SAFEf AND BUILDINGS
I
SEE C' SPINIJENC G
N Y
{ - r
C% 4
r ~ ~ 5 jet
a
a
J O 2
T- m
dj- C5' ~
N
C, o
Page - Of _
Straw, Marsh Hay, Or
Synthetic Covering
473 Distribution Pipe
Medium Sand 5
Top
Topsoil oG1<.J, cam. /W
r-~
D
3
G 1
.1
b
% Slope
Bed Of 2M- 2 2 Force Main Plowed
Aggregate From Pump Layer
D / Ft.
Cross Section Of A Mound System Using E Ft.
A Bed For The Absorption Area F 9C; Ft.
G Ft.
A Ft. H I. S Ft.
Signed: B L ' Ft.
License Number: IWZ~ K/fL Ft.
Date: 5-mac; ~iG L 7 Ft.
j - as Ft.
T D Ft.
Force Main W Q7 Ft.
L
Observation Pipe
d r
6
r r- K
A I E I
-----f---------------
W ° -
Distribution \,-Bed Of z - 2
Pipe Aggregate
I
Observation Pipe Permanent Markers
Plan View Of Mound Using A Bed For The Absorption Area
t ~C Z E r l y1 V), 6C f'l-t
I
Perforated Plpe Detall
0
End Vlew
End Cop y, )Per foro It d
PVC Pipe
Permanent End Markers
s
Holes Located on Bottom
are Equally Spaced
e
x PVC Force Main
i From Pump
~No e PVC
CA Manifold Pipe
I" tovc..
Diclribullon..
Pipe
Lott Hole Should Ole
Next To End Cop
Distribution Pipe Layout
P
R
S Y
X
Y 41
Signed:
~ Hole Diameter Inch
License Number: MSS d/ Lateral /1 Inch (es)
Date: Manifold " Inches
Force Main Inches
Off. 3S
PUI"kP CHAMBER CRuSS SEC IC'.; ojC, `,PECIF IC I IU"!`_
VEIJT CAP
4"C, I. \ EN;T PIPE t
T WEATHERPROOF APPROVED
JUUCTIOU BOX MAIkJHOLE COVEF:
- 25' =ROM GOOK,
WINDOW OR FRESH 12"MIU.
AIR INTAKE
GRADE
411 y„ M11..1.
18'MIIJ.
COIJDUIT--
18"MIN. ~
I
INLET PROVIDE
AIRTIGHT SEAL ( III V
I I
APPROVED JOIIJT A I III APPROVED JOIUTS
W/C.I. PIPE I III W/C.I. PIPE
EXTENDIUG 3' I II ALARM EXTEA]DIIJG 3'
OWTO SOLID SOIL D i I I ` ONTO SOLID SOIL
I
I o m
C
E=LEV. 92Z FT. I J I I
PUMP OFF
0
CO►JCRETE BLOCK
RISER EXIT PERMI?rED OIJLy IF TAUK MAUUFACTURER HAS SUCH APPROVAL
SEPTIC E SPEGIFI'CATIOUS
DOSE
TAUKS MA►JUFACTURER: ~~~CYt Zc?~~i'v~ ~'1' CCcS I CUMBER OF DOSES: / PER DAy
TAAJK SIZE: 7 C'? GALLONS DOSE VOLUME
ALARM MA►JUFACTURER: S•~, I~~ v y INCLUDING BACKFLOW: 7Y GALLONS
~ S`S s. ~v tray ~
MODEL IJUMBEK: fib( lA2 CAPACITIES: A=QUICHES ORy03.1A GALL OAI5
SWITCH TYPE: /I4,%r-CCrrxkz- CL- B=IMCHES OR s CALLOUS
PUMP MAMUFACTURFR: (4:,5 d/ C = Rr INCHES OR /S 7S GALLOWS
MODEL AIUMBEK:j S3 7~ D= INCHES OR GALLONS
5WITCH TYPE: ~1 - I ih9~rCWr~-r ~-IM AJOTE' PUMP AMD ALARM ARE TO BE
MINIMUM DISCHARGE RATE-27TGPM INSTALLED OIJ 5EPARATE CIRCUITS
VERTICAL DIFFERENCE BETWEEU PUMP OFF AND DISTR16UTIOU PIPE.. 6110 FEET C
+ MIIJIMUM NETWORK SUPPLY PRESSURT7E//. , , . . . , . , , . 2.5 FEET
} ~s FEET OF FORCE MAIM X '?.7~F/phFTFRICTIO►J FACTOR.. FEET
TOTAL DYNAMIC. HEAD = 2_ FEET
WTERNAL DIMEIJSIONS OF TANK: yLE `•.,C~TH ;WIDTH j LIQUID DEPTH C-' '
SIGFJEO - ~-t ~ - ~ L.ICE.U F LJUMBER'. UATE'.
`-S~
Submersible MODEL: 3871
SIZE: 3/4 SOLIDS
Effluent Pump RPM:
METERS FEET
8 25 I--
~ i
Q I
6 20
n 5
z 15
0 4
F<- 3- 10
2-
5
0 00 10 20 30 40 50 GPM
0 2 4 6 8 10 12 m'/h
CAPACITY
MGOULDS PUMPS, INC.
Sa ECA FAILS NEW `rCW 0148
De-V\ nt~ t~oC~
P(LiLYyk~eA7'. 'Z(0
5-ZC,
Effective October, 1988
e1988 Goulds Pumps, Inc. SPECIFICATIONS ARE SUBJECT TO CHANGE WITHOUT NOTICE PRINTED IN U.S.A
o ~
Q ~ ti
~ ~
D'' `H R in accord with ILHR 83.05. Wis. Adm. Code couMY .
~r'o X
St.
Attach,complate site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL I 0
not United to vertical and horizontal reference point (8M), direction and y. of slope, scale or
dimensioned, north arrow, and location and distance to nearest road.
I % GATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
PROPERTYWYNEFt Senn %s- $ PROPERTYLOCATI,t~ s-
GNT. LOTS u 7 y 1~ ice: it T ~(a~
c r.e-S Ct f paGXe,
PROPERTY HEWS MNU R~ESS LOT BLOCK .9tio0. CSM ca
NA NA
CITY, STATE ~ ZIP CODE PWE NULMER OCITY OVILLAG OWN EAREST
P'n e G. f /11,1. s5 d1.3 (,,~3Zo-6Zq-61 ST c4 ; f
w •
New Construction Use M Residential / Number of bedrooms u.. r o w K
[ J Replacement (j Public or commerdal describe
Rem mended design loading rate ° Z bed, gpd/ft2 ' 3 tench, gpd/ft2
Code derived daily tknv gpd
Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed. gpd4t2 trench. gpd/ft2
Recommended Infiltration surface elevation(s) It (as referred to site plan benchmark)
Additional design / site considerations
Parent material S 1 , Sc `ten e Flood plain elevation, it applicable Alit
S - Suitable for system OONVENT NAL ricW"PRESSURE AT-GMDE SYSIat IN FIL 1-UDING TANK
U= Unsuitable fa ten O S A U S O U O S IRU [Is A U [Is 2•U cis 1'U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Roots GPD/ft
Boring # Horizo In. Munseli 0U. SZ.Core Color , Gr. Sz. Sh. Bed Ttt
7 r,~5" r Ge.J •5
/ Q'$ /oYR 3 A//on r-
Ground -3 20-49 7, y: Al, n C, S~ m r9V . /-r~ • ~ ~o
elev. • 2
n 29-3y ~ ':5',VK 6 C d .5 5-c- l s: A) f y - F-3
)epth to t
limiting
,
factor
Remat i I
Boring # 3
6 ? /oyR ~3 Nor e- Z ms h7 7cv LA3 -M
Ale Z „ = 2 Z /D Y>e 3 ,-t s,' 2/r1 s D 7~ /y,4--r E.r~ b
3 Zc-Z _7,5"Yk"1 an!✓ S~ 2~ri~ /y111 W 05
Ground
• Z I - 3
elev. y 2?-3 7,!5%/k 44 ~r e. SC- l /Y2
/00.53 ll
S 30- ?,SY ~b C Z ,5'` 5C, s~7~ M4 - '21 . 3
Depth to
tuniting
factor
Remad,S:
r'Signattirs: Name:-PlsttsePrint' Phone 3 3 79
ress: Dale: CST Number:
Boling # fiorizo Depth Dominant Color Mottles
in. Munsefl Texture Structure =GF'Diti2
Qu. Sz. Cont. Cow Gr. Sz. Sh. Roots
/OYEZ 3 Bed rc
o n Ci s." Zr~ S~ r ~ • 5 ~ ~
Z 9-~/ lD YR L-Y.3 doh e, s,'~
Ground .3 Z/ Z8 `7,5 ~ J .~s'~ ~r w • ,6
elev. Y,~ /Jo n G s/ m 5 ,r LJ • 5
Depth to
6rniting
factor
Remarks:
Boring #
-9 Hoye / 0ri
z -Z4
li7
!i, 2, sk r
3 219-37 7'5 YR y~ Alon e,
S/ 2mSGround
elev. 37- • 5' ' ,
953 7 C z o '7,5Y~ sc
Depth to
limiting
!aclof
Remarks:
Boring #
- -
L4
Ground r
elev.
Depth to - -
limiting
factor
ET
Remarks:
Boring #
4:.. vivVlW
elev.
Depth to
limiting
factor
Remarks:
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER I.b,L~S 1404445
MAILING ADDRESS X (O C7
it 1, S 5 b ~0 3
PROPERTY ADDRESS a~Ps~ I~~-'~1►4 + :~V~ I~-LL-s
/(location of septic system) Please obtain from the Planning Dept.
CITY/STATE 41?P L W yl *l ,L ~ \Aj 4 yJ 4'4 b ~
PROPERTY LOCATION V4W 1/4, ~7E 1/4, Section 2 S T N-R b W
TOWN OF ET&AA CIO- "Ai5 ST. CROIX COUNTY, WI
_ SUBDIVISION X.x.x LOT NUMBER XKX
CERTIFIED SURVEY MAP XKV , VOLUME% PAGE y-X , LOT NUMBER AX
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.jCroix 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 mu ht be completed and returned to the St. Croix
County Zoning Officer within 30 days of the three year a ration date.
SIGNED:
DATE:
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
S T C - 100
This application form is to be completed in full and signed by the
owner(s) of the property being developed. Any inadequacies will
only result in delays of the permit issuance. Should this
development be intended for resale by owner/ contractor, (spec
house), then a second form should be retained and completed when
the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property UEV-LV1VS ~Gl c
Location of property gW 1/4 (7E 1/4, Section ZS T `L90 N-R L, v W
Township F.Am U NL' Mailing address ~dK
(DtoC7 4-1 Mtt►~~J 550
Address of site t24- E , 5 l~ll~t t~U
Subdivision name Lot no.
Other homes on property? Yes No
Previous owner of property J~C%-' V":A 1
Total size of property ~S+ 4Cw-a'
Total size of parcel
Date parcel was created 11- 1- CM
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for (spec house)? Yes No
Volume lot and Page Number as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available, would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the
best of my (our) knowledge that I (we) am (are) the owner(s) of the
property described in this information form, by virtue of a
warranty deed recorded in the OQffice of the County Register of
Deeds as Document No. ~2'~710`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 No.
~23 ~a9
Signature of Applicant Co-Applicant
S -q-''Co
Date of Signature n~~^ ^F ~~,4--
UL 1101PaSE-34
THIS SPACE RG SERV ED FOR RECORDING DATA
DOCUMENT NO. STATE BAR OAF WNDISCONSIN CONTRACT FORM 11-
Individual and CorpurIONaraS WHERE OVER
CT . .
r 1yJ~ li
523109 I•ro 13E USED FOR AI.L TRANSA R
('2%000 is FINANCED AND IN OTHER NON-CONSU%IE l; V~~~S
ACr TRANSACTIONS) V
r.3clZ faf Raoord
James L. Kar and. Carole A:
NOV 3 1994
Kar d between
Conti ~tt b an
yk/ Carole A. Renner, husband and wife:....••....
s it 8.30 r, A
("Vendor",
Whether one or more) and...... Dennis_•C..•Rnche and. Shirley_~.._._....
I
.
it .._....Racne,..husband and w~. e,
("Purchaser", whether one or more).
ii
Vendor sells and agrees to convey to Purchaser, upon the prompt and full per- I -
'I formance of this contract by Purchaser, the following property, together with the
_
rents, profits fixtures and other appurtenant interests (all called the "Property"),
Sit CrQix County, State of Wisconsin: 1 RETURN To
~ I
it
II
Tax Parcel No l
W 1/2 of SE 1/4; W 1/2 of SE 1/4 of SE 1/4; W 1/2 of W 1/2 of NE 1/4 of
SE 1/4; and W 1/2 of E 1/2 of W 1/2 of NE 1/4 of SE 1/4; all in Section 25-28-16.
d
f )
1I
it
This 1S nOt...... homestead property.
,i ~C (is
s not)
'ace Vendor directs
Purchase: agrees to purchase the Property and to pay to Vendor at
the sum of 1 .69.,~Q~.QO In the following manner: (a) $.,201%
( I' st the execution of this Contract; and (b) the balance of S.•48,37QA-QQ................... together with interest from date
• per cent per annum
hereof on the balance outstanding from time to time at the rate of p
II until paid in full, as follows: Commencing on December 1, 1994, and on the 1st day of each
i it and every month thereafter, equal monthly installments of principal and interest
in the amount of $505.00.
.I
I
I~ ~7 Provided, however, the entire outstanding balance shall be paid in full on or before the...... lst day of iI
y a .....November 19...96. ( the maturity date).
Following any default in payment, interest shall accrue at the rate of % per annum on the entire amount II
I in default (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire
j principal balance). I
li
Purchaser, unless excused by Vendor, agrees to pay monthly to Vendor amounts sufficient to pay reasonably anticl- I
i
pated annual taxes, special assessments, fire and required insurance premiums when due. To the extent received by Vendor,
II Vendor agrees to apply payments to these obligations when due. Such amounts received by the Vendor for payment of
taxes, assessments and insurance will be deposited into an escrow fund or trustee account, but shall not bear interest i
unless otherwise required by law.
Payments shall be applied first to interest on the unpaid balanco at the rate specified and then to principal. I
! Ij 1i4(~a`SXIJdC~}fd¢l4}@t:1Lr&l1XilQX~4r'I~YdCXdEX}6XX+`~7GIK~~'iiXysKX~
I
~ I Arent, this contract shall nvt be treated as in default with rasped to payment so long II
"
In t event of any prepay
~I as the unpaid balance of principal, and interest (and in such case accruing interest from month to month shll betreated
II
11 as unpaid principal) is less than the amount that said indebtedness would have been had the monthly payments
11 made as first specified above; prr.vided that monthly payments shall be continued in the event of credit of any proceeds
I~ of insurance or condemnation, the condemned premises being thereafter excluded herefrom.
a I Purchaser states that Purchaser is satisfied with the title as shown by the title evidence submitted to Purchaser
for examination except:
t ~
in it ,,Purchaser promises to pay when due a VOL o=;r
deliver to 'Vendor on demand receipts showand jngasuch tents levied on the Property or upon Vendor's interest
Purchaser shall ken Payment.
tended coverage Verils and keep the such imp other rov hazards eazardmentse on the Property insured against loss or damaxce occasioned by fire ex-
contain Vendor, in the sum of s.......NIA Y requi
than the balance o re, without co-insurance, through insurers app
w ,
the standard~nuncen favor out---- Pu as rchaser. Vendor may
~•a",lor shall not require coverage in an amount more
of all policies coverin of the Vendor's inters tll irPay the insurance premiums when u
insurance cot K the Property shall be deposited withVendor~ss Vendor otlierwise agrees nwritin policies snal
in applied to p restoration or repair of the -hall bPurchas;r
economically feasible promptly K, the original
e and Vendor otherP e a
d p` Property damn Kree in writing notice of
loss
be 3 r' ged, Provided the Vendor deems the r estor~a .e proceeds shall
ll
Purchaser coccuants not to commit ` rn or repair to he
n good tenantable condition and re waste nor allow waste to be r ~ to comply with all laws, Pair, to keep the Pro rent • >nrmitted ou the Pro y ordinances and
regulations alreetin S (nee open liens superior to the lien oaf th k the spContr"ctpanJ
Vendor agrees that in case the purehnso K the Property.
s price with interest raid et
hall Ge fully Perftrrrnwl at the titre and in the manner above specified , V
J the !'urchaset, a Warranty Deed, in pre aim le
her ror wily, shall bn full
, conditions
any liens or encumbrances created by P , of the ProPertY, tree and en for clear wil ofl all ll lit'
r'
mands end execute encumbandranceess,
and".right s!-!of-!Way. the act n default of Purchaser, and except
.of..record,.. if. ~asementa expxcept
r any........._... ...res kris lions
.
7:10 Purchaser agrees that time is of th7
urchaser a6'rces that time is of th
interest which continues for essence and (a) in the event of a default in the n ent -o-f--any
a period of . days follow in P Yt principal or
:i performance of any other obligation of Purchaser which continues for a
K the specified due dnt or (h) in the event of a default in written notice
thereof by Vendor (delivered person ally or mailed by certified mail), the I re shall become immediately period of days followin
waives), and Ven#r3r shall also have the following rights and remedies
due and payable in full, at Vendor's optionnanrdewithout notice (whichcPurcha'sesrchereby
r` h
r~ (subject to any limitations provided by law) in
r Bits, title thand os °teridedin by law or in the Proper equity recover the Property
° redemption to be conditioned upon Purchaser's full payment o'( o[
tat his he entire outstnndjrrr.ate this Contract and Purchaser'f
the date of default at the rate in effect on such date andother amounts
P 1, Galante, with interest thereon from
Raid at P deal shall rte in ited tre ou tandi g bale heventell to hunts any equity
due hereunder (if,
roperty if purchaser fails to redeem as liquidated damages for failure to fulfill this Contract !'Fill as rental for the
~ immediate
~mediate and full or (ii) Vendor may previously
r- default and other nmonnts due hereunder, in which event the Property specific Performance of this Contract to compel
Payment of the entire outstanding balance, with interest thereon at the rate in effect on the date of
i
shall be liable for any deficiency; or (iii) Vendor nra shall entire auctioned ed Puatrcjhasudice judicial
price e and Purchaser .4ue at law for the i thereof; or (iv) Vendor may declare this Contract at an end and remove is thContract as a cloud is title
in a any
t5 action if the equitable interest of of Purchaser is insignificant; and v or an
operty and have era may have Purchaser portion
under appointed to collect an rents,) Vendor maay have eject
of the Pr d from possession
e
4 of the foregoing remedies shall only h
i , (r)• (li) or (iv) above. Notwithstanding any oral or written statements or actions of Vendor, an election of any
e binding upon Vendor Y if and when issues puorrsued in profits dur litigatiingon the and pendency dency costs of and any expenses
including reasonable attorneys fees of Vendor incurred to enforcearv rernerly hereunder (whether abated or
G extent not prohibited law and expenses of title evidence shall be added to
extend, oand f shall be included in any judgment.
the
SL principal and paid by Purchase)' to as in-
! Upon the the commencement or during the pendent of any action ton commencement
a receiver of the Property, y
Property the including homestead linteres foreclosure
applied as the court shall direct.
the during pendency of such action, and such rents, issues, and profits when so collected shall
collect rthe rentstisties, and r proofitsof
and
Purchaser shall not transfer, sell or convey any legal or equitable interest in the Property (b
!e of Purchaser's rights under this Contract or by option, long-term lease or in any other wa
y be assignment held of any
r' consent of Vendor unless either th,; outstanding balance payable under this Contract is first
conveyed is a pledge or assignment of Arrchaser's interest ender this y) without the prior written
Purchaser. In the event of any such transfer, sale or conveyance without Vendor's paid in full or the interest
balance payable under this Contract shall become immediately due and without Vendor's written as con. en for an indebtedness of the Vendor shall make all payments when due under
any mortgage payable i fut the 's pertyton Chet notice
this Contract (except for an mort a outstanding against the Property de the date er
makes timely payment of the amount then due under this Contract Pu chaser may make any suchpayments Payments maddirectle on
this Contract.
the Mortgagee if Vendor fails to do so and all pa} tent so made by Purchaser t sh llubedcons:'dered provided Purchaser
to
Vendor may waive any default without waiving any oche: sub.equent or prior default of Purchaser.
All terms of this Contract shall he binding upon and inure to the benefit of the heirs, legal re resentatives,
successors and assigns of Vendor and Purchaser. (If not an owner of the Prc rt P
consideration joins herein to releaee homes+nad right in the subject Property p
deed to be made in fulfillment l e se h and agrees the s O11se of Vendor fora valuable
to join in the execution of the
Dated this day of
(SEAL)
..t. (SEAL)
/V. ames L. Kar
Dennis C. Roche
(SEAL)
~.C?
Carole A. (SEAL)
....-...Kan-g,..._k/a Carole A. Renner Shirley A. Roche
e
AUTHENTICATION
ACKNOWLEDGMENT
Signahrre(s) STATE OF WISCONSIN
St. Croix
authenticated this day Of County, '
19......
Person . came be ore me this R%
day s
r . 19 the above named
James L. Kergz_and_Carole,
TITLE: AMUR— - -T-
James ~61Y-O
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