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HomeMy WebLinkAbout018-1038-00-100 o i 0 m I ° I M a O I I O N C N co O O ti C o CL r- ° O C p a ry O O E N o rn I c '5 o ° o c c Z rn E Z s ca LL O U? LL o o - - O lC 3 :3 a o m a a I v 3 ~ I 3 ~ Z r+ 0 a+ 0 z r € p ~ ~ N a m a m r F- to i o I - C Z c c w v o c ° a°i Z 2 c Z E r E a> M _ v rn a m 5 o co ° m N CL Q 4) • Al d L r p r,, o m Q o a O N zF- z zF- z o I Z d N E io N " N „ l0 t0 N N i CL ~ ~ v (0 p,~ 'Ip ~ O C Lo LO 0 N d 2 N N d N o Q e a t o c o a E Y co Q to m to ~ •E I m Hr fn ° E I iI cn 3 CL cn z • ~aac. ~aaa N a o 0 a::2 Eco Ernrn aNi } ~a v~ V Ern o 0) CD O z = 'O O M '`l = O C M O N O r- 0 C2 C-4 y = Q r r 7 O m C r ml N C a r L 'd co a O) L 'O N N O) N r r cO0 a Z Cn d Q} fn Q d ~i C O r N N O N N 1V O O N C a. O O to tm 0) H o C C_ 0 O C Y C JE N 25 o C C r IA tL') o y ai E N v v = v c ° N O z Z N O Z Z r O r: r'L 0 E E V d a d a m c ~1 A vat ',ocnc~ Ornv Parcel 018-1038-00-100 01i06i2006 02:51 PM PAGE 10F1 Alt. Parcel 17.29.17.267C 018 - TOWN OF HAMMOND Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-owner O - MYER, GREGORY E GREGORY E MYER 901 160TH ST HAMMOND WI 54015 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 901 160TH ST SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 3.760 Plat: N/A-NOT AVAILABLE SEC 17 T29N R17W SW SW LOT 1 OF C.S.M. Block/Condo Bldg: 6/1506 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 17-29N-17W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 WD 07/23/1997 WD 07/23/1997 4WRg"njy J 6 k t-,. 2005 SUMMARY Bill Fair Market Value: Assessed with: 90360 318,500 Valuations: Last Changed: 08/24/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.760 31,300 232,000 263,300 NO Totals for 2005: General Property 3.760 31,300 232,000 263,300 Woodland 0.000 0 0 Totals for 2004: General Property 3.760 31,300 239,500 270,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 116 Specials: User Special Code Category Amount 010-GARBAGE SPECIAL ASSESSMENT 60.00 Special Assessments Special Charges Delinquent Charges Total 60.00 0.00 0.00 PLAN APPROVAL Safety and Buildings Division Bureau of Plumbing DILHR P.O Box 7%9 a • • ❑ General Plumbing Plans Madison, WI 53707 ❑ Private Sewage Plans Telephone: (608)266-3815 „7 OFFICE USE ONLY I 6A , L- Plan lden0facation No. Gallons Per Day rW' ~-A 4 PRIORITY PLAN REVIEW ONLY . _m Plan Review h Petition For Modification Project Name i Project Location - Street No. or Legal Description l 1 _ 'v ❑ City ❑ Village Town of: + - ` r., y; •E The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped "conditionally approved". This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. ❑ FOR GENERAL PLUMBING PLANS: This approval will expire two years from the date approved below. If construction has not commenced before the expiration date, new plan approval must be obtained. 13, . FOR PRIVATE SEWAGE PLANS: This approval will expire two years from the date approved below or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. Comments: By: James Sargent Bureau Director If Questions Plans Approved By: Date Approved: Contact ♦ ; 'dr_ f cc: "•.11 OWS ❑ DIPS ❑ H&R & Rec. San. Section 7- County ❑ Local PI ❑ Facilities Need Analysis Section ❑ UW-SSWMP ❑ Plumber ❑ Department of Agriculture DILHR-SBD-6099 (R. 01/84) ❑ Owner ❑ Other ST. CROI X COUNTY K , Tt`~ O' WI S C 0 N S I N ZONING OFFICE xx _ 796-2239 (HAMMOND) 425-8363 (RIVER FALLS) HAMMOND, WI 54015 November 5, 1984 Division of Safety and Building Bureau of Plumbing P. 0. Box 7969 Madison, WI 53707 Dear Sir: An on-site investigation for the Randy John property located at the SW14 of the SW14 of Section 17, T29N-R17W, Town of Hammond, St. Croix County, revealed suitable soils at a depth of 3.16 feet, below which seasonable high ground water was noted. This site should be suitable for a mound system. Should you have any questions, please feel free to contact this office. Sincerely, Thomas C. Nelson Assistant Zoning Administrator TCN:mj WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING P.O. BOX 7969, MADISON, WISCONSIN 53707 Verification of Exception Stratus for an Alternative Private Sewage System In the Country of St. Croix Location SW 1/4, SW 1/4, Sec. 17 T 29 N R 17 X&XW) W Town tC~Xit:Kfx Hammond Street Address Lot No. Block Subdivision Landowner's Name: Randv John The application for this site is for: 11-inew construction use. ❑ replacement system use. If this is NEW CONSTRUCTION USE, the alternative private sewage system is: 11to have one of the first five approvals guaranteed for this year. This is number - - of those applications. (Use one of the first five quota numbers 'issue -d you.) W one of the applications needing a quota number. The quota number assigned to this application is 59 10 - 5 D for one additional homesite on a farm to be occupied by a parent, child, grandchild, sibling, niece., nephew, or first cousin. FIfor an individual lot for which a sanitary permit was issued but was later ruled unsuitable due to new or changed soil criteria established by the department. [__.]for an application on file prior to February 1, 1980. (_.1for a lot that meets the criteria for a conventional private sewage system. If this is a REPLACEMENT SYSTEM USE, the alternative private sewage system is replacing: ❑ a failing conventional soil absorption system. ❑ a holding tank that was installed and in use prior to February 1, 1980. ❑ a privy that was installed and in use prior to February 1, 1980. If this is a REPLACEMENT SYSTEM USE and the lot meets the criteria for a conventional private sewage system, check here. ❑ I certify that the above information is true and accurate to the best of m knowledge. ~ Name Thomas C. Nelson Signature County Official Title Assistant Zoning Administrator Date November 5, 1984 DILHR-SBO-6158 (R 12182) STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS DIVISION OF SAFETY & BUILDINGS- BUREAU OF PLUMBING P.O. BOX 7969 - MADISON, WI, 53707 APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM Location: Township /AH}B 0TMW- SW % SW 141S 17 T 29 N/R 17 00M W Hammond St. Croix Street Address: Subdivision: County: Landowners Name: Mailing Address: ,Randy John R. R. 1, Hammond, WI 54015 I (We), the undersigned, hereby make application for an alternative system on the above-described premises. I recognize that the above premises are not suited for a conventional private sewage system. If approval is granted, I agree to have the system installed in conformance with the Bureau's approval of plans and specifications. I further understand that an alternative system is more complex in nature than a conventional private sewage system and as such will require detailed inspection during construction and monitoring after the system is put into use. I agree to permit both county officials charged with administering county sanitary ordinances and Bureau employes or other authorized persons to have access to the above described premises at any reasonable time for the purpose of inspection the construction of or monitoring of the system. I further agree to either personally or by my agent contact the proper county official to arrange the time and date to begin construction of the system. I understand that this application does not permit me•(the applicant) or my agent (the contractor) to begin installation. If the system is approved, the Bureau will send the applicant a letter of approval which authorizes construction of the alternative system after all necessary permits have been obtained. I agree to give notice to any subsequent buyer that an application for an alternative system has been made and if installed, that the premises are served by an alternative system and further agree to give the buyer a copy of this application. The Bureau accepts this application subject to this understanding and subject to all the conditions and obligations set out in this application. Signature of Applicant Date STATE OF WISCONSIN Subscribed and sworn to before me SS. COUNTY OF This day of 19 Notary Public, State of Wisconsin DILHR-SBD-6413 (N. 05/81) My Commission Expires: DEPARTMENT OF REPORT ON S~ A GS AND SAFETY & BUILDINGS INDUEi'4, , DIVISION LABOR AND PERCO!! 5) P.O. BOX 7969 HUMAN RELATIONS WI 53707 IH63.09 Chap ®G /~E Sr,/3GYV/OE1>- MADISON, 0 v7t of LOCATION: TSECO~j4 NSHIP 14 LQT NO.:BLK.NOON NAME: 50 1/ 1/ l7 N/RE(o W LfAti/~ m~ FAR ,~,a~ ~ /;vim visr 1Y7 fie COUNTY: O ER'S BUYER'S NAME: ING ES SY• e e01X /Njup U-0 tF /Al I t-f ~41~M Lo i S USE _ - ' DATES OBSERVATIONS MADE NO. BEDRMS : COMMER IAL DES RIPTION: w PROFILE DESCRIPTIONS: ER OLATION TESTS: Residence 3 N rV New eplace DC ZO l L! !J(~ 0,C Z~ RATING: S= Site suitable for system U= Site unsuitable for system Sc S / S/o0a's S f/IPGr1 UD /Sd~/J~ G T CONVENTIONAL: MOUND: iN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: REC MMENDED SYSTEM: (optional) 0S©U ©S❑U ❑SEE DSZU osou [under lation Tests are NOT required DESIGN RATE: [Floodplain, any portion of the tested area is in the .H63.09(5)(b), indicate: indicate Floodplain elevation: PROFILE DESCRIPTIONS iN J7,eG%MaQ Ff. BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-IN CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH OBSERVED EST. I HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) i B_ 2 0 97 , _3..20, -67_13W-1) ;73j' ~~~gy t fo/a f',,.,.P 410AIoC-10 _5f._1o w f. /1 Agwk o - N iS f4 r 3. : ' -1o B-3 6.5~ 10.4y f- 3 P0_ .0 ,Q,v. / /zs' cau-k s , .75 ' f• -01A Sh4.2D a j/ f. OAO-84. 1404.f AT' 3.15 ' B_ ~.t - 1Q,4r C/A y w~ 44RS~k ~IPoM . o e-Gy ~o>< - s'S 9a • yo )4,r- 3. yo -7 A. 2 S 7117 B • J10.111/0 w~ e Sif'dD w f F. f• o p-,C3 J• Ho 5 p 7' 3. , B-S 3.5' ~4.5~~ .67' 13N .9313a. 5' , S s M0 f f ow-e4. ,o -S 50'e6 p- '--1_AAfT/O.VS PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLIN INTERVAL-MIN. PERIOD t PERIOD2 PER PER INCH P- 3 P- P- 2 y a. O Z Z/ Z/ ,3 P-_ P y 2.o p Z P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope, SYSTEM ELEVATION SEE ~/iEw /~E~°w is s~ site"NOT AP T-1-1 f6r See'expla af!". IN, f - . I T E I E i i. s F 3 INSTRUCTIONS FOR COMPLETING FORD 115 - SBD - 6335 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section roust clearly indicate whether this is a residence or commercial project; 3- MAXIMUM number- of bedrooms or commercial use planned; 4. Is this a new or dt system; 5. Complete the s,- -'Ing boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS t E RULED OUT BASED ON SOIL CONDITIONS; b. PLEASE use the abbreviations shown here for vviting profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE " a~jram accurately locating your test locations. Drawing to scaly. Is preferred, A separate sheet ma 1' I r desired; S', Make sure your h, nd vertical elevation referer point are clearly shown, an ' . e permanent; 0. Complete all al ; =,.e boxes as to dates, names, adds flood plain data, percol< ` ~st exernp- tic , if approl - . 10 r.-)r rcb as floo,` Oevation) does rw- -)Ply, place N.A. in the app relate box; 11 your ~c.r address and your z number; 12 a,A distrib as rec aired, ALL ~ .-)IL. TESTS MUST BE FILED WITH THE L( 'P TY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - c" r 10") BR Bedrock col:) 1011) SS Sandstone gr - Gr, I ~r 3") LS - Lirnestor°' "I - Sand HG~ - High Gr. cs _ C, i. c a -)Ir rned s - ilr.. l fs - Fir_;. S, rd 'hlinsl Is - Loarny Sand > - Greater Than s _ 'dy Loarn ( Ltuss Than i - Luny Bn- Brown sit - t Loam BI - Black Si Silt Gy Gray cl Clay Loam Y Yellow sf I ( Cla d L R - Red sicl Clay Lc, mot - Mottles SC _ ndy Clay: ith sic ty Clay v x y . d di p pro ` H' - Hic€ _ soil textures -ste disposal ! _ ve Pol'it (REPORT ON SOIL BORINGS PERCOLATION TESTS IIS PLo r p t, AN PROT Eci r. O. ?A'voy --ro)W - S~fevs pArE o~~ 9-~y sw iy sw y s~~, r~yy, 1-7 9v HOME6ITE TESTING CO. 4t~ RT. 3, O'NEIL ROAD BOB ULI,h'd (,..r 1 UDSO V, WIS. 54016 CST SS- aZ y,eZ ScA/E , /"=yo PROPOSED MOUSE MOST LIE 2~'FT. 64 NOME "a-Af ALA TEfT otme,45. PROPOSED W L LL MUST LIE ,SQ FT de ItiO~PF F,QO.ti ALL TEST ,q,PE~9S, . = QA~yoEP%TS Q = EXisr~.~ ~ tvE~~ X PEG /DCg1/o~t/f = y~,~~ f (19e' W o,Q 54a0JEL /j4w5 ll,*riz . 13M ~sa~r-e (l£RTic~~ ,PEFERt:vcE' POi)r" 5 U r• Pf J POs r SEr /3y C s r. LEGEND /EV~~ov o~ y r,PEAPr /0o-0 fr. FAsT LOT T his te;i Site NOT APPROVE for a C.,;yvention an septic System. See expi N 7o' x h X x ~1~ ---------'1 o Pi PL P3 b f3M J 54 0R^ S o V,~ \ '7o A' P f /3y /Sy poi' a M _ 9 l0 STC - 104 R AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS `f/ SUBDIVISION / CSM# LOT # SECTION / rJ T.-,) % N-R / rf W, Town of 1/4'1,f /"-I N ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM J'M lc~ F r r i i 1 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. ' Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK : k'I r ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well House Other Pump: Manufacturer Model# Size Float seperation Gallo c -e:-- Alarm Location SOIL ABSORPTION SYSTEM Width: J Length Number of trenches 01'- Distance & Direction to nearest prop. line: i Setback from: well: House- Other ELEVATIONS wilding Sewer. ST Inlet: Ff- X.5-- ST outlet: PC inlet PC bottom Pump Off Header/Manifold D~ Bottom of system ?f,'eo S' Existing Grade Final grade DATE OF INSTALLATION: o i PLUMBER ON JOB: LICENSE NUMBER: ~Y/ hJr C' ~C% INSPECTOR: 1~~v4 3/93:jt vVis~consin Dcfpartment of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and BIj'i,ldings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284185 Permit Holder's Name: ❑ City ❑ Village Town of. State Plan ID No.. MEYER, GREGORY HAMMOND CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /,00_` I X_-11 &0 -1 1, 1 - J TANK INFORMATION EVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 95. /00. Dosing r Aeration Bldg. Sewer Holding St/ Ht Inlet 71' d X, (0 TANK SETBACK INFORMATION St/ Ht Outlet ~,05~ 8go39 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic Y~ NA Dt Bottom Dosing NA Header/Man. 131 g$oos' ? Aeration NA Dist. Pipe 7,70 ?,9,-7 Holding Bot. System 81dt 8c •8a PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand D.o3~ Model Number GPM TDH Lift Friction System TDH Ft oss Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS .71 DIMENSIONS LEACHING SETBACK Manufacturer: SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION Type 0 CHAMBER Model Num er: System: / OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HAMMOND.17.29.17W, SW, SW, HWY 12 /.IJF~Z~4Y^rs eyj Plan revision required? ❑ Yes [No Use other side for additional information. SBD-6710 (R 05/91) Date pe or's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: s i Safety and Buildin&D ivision 'vti~rfr,t SANITARY PERMIT APPLICATION Bureau of Building ater Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. _5'104 6 G j • See reverse side for instructions for completing this application State Sanitary Permit Number aFC/ /?-5,- The information you provide may be used by other government agency programs ❑ Check if revision to previous application lPrivacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location e ljv4 Lt) 1/4, S TBlock N, R /7~r) W Property wner's Mailing Address Lot Number Number G' City, State Zip Code Phone Number Subdivision Name or CSM Number s -(,2 r) 6^.Z3/d 11. TYPE F BUILDING: (check one) ❑ State Owned City Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms To wan of 11AM 6 d yw~ l2 III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1❑ Apartment/ Condo 0 I lO 3 g- o O 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. 9 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank OnlyExisting System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Do Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5; Perc- Rate 6. System Elev. 7. Final Grade Required (sq_ ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) > Elevation /B P /0-27V Feet p., / Feet Capacity VII. NFORMATION in gallonTotal # of Manufacturer's Name Prefab. Cloth Steel Fiber- Plastic Exper. Gallons Tanks concrete glass App. New Existin strutted Tanks Tanks Septic Tank or Holding Tank / G cl, I ~ -ie e A- 12 E 1:1 ❑ ❑ El L.Ift Pump Tank /Siphon Chamber VIII. RESPONSIBILITY STATEMENT pp ❑ Owner Given Initial Su I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) MP/PAM1111111111111111111"No.: Business Phone Number: L 5-M I t h lv , I.s Z 90 off. zle-- P,? Plumber's Address (Street, City, State, Zip Code): 2 w 7 CrL ,e Nk~ G o~ D IX. C UNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Age t Signat roved Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SHO-6398 (B. 05/94) DISTRIBUTION: Original to County, One copy To: Safety 8 Buildings Divi ion, Owner, Plumber INSTRUCTIONS f 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe 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. Onsifersewage 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 nurnber(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if.1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7- VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc,), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County / Department Use Only. Complete plans and specifications not smaller than 8 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. +»N~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. "Pe X,~o e a s - - Ji~ -t R ---I Z"t - ~ ~ I t i I y' 1- V e 10 _ - _ - - - - - 1 1-7- el R J-i a - - 51 r- r I I I - - ~ ~i - - -I--- --I--- - I- r : I • i I ~ I ` I i I I I , I i I ( I I i II I I I I I I j i I , r I ~ I r }J _J i I i r - - f I j I I I I I I ~ ~ 1 i 1 r } t ' ' I i ' I-A Wi9censin Department of Industry, SOIL AND SITE EVALUATION Labor and Hur+.?an Relations Page L of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and 5S - e p ` percent slope, scale or dimensions, north arrow, and location and distance to nearest road. ~ ~ Parcel I. D. # APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location 40 Govt. Lot 5-4/ 1/4 Sj,/1/4,S / TT7 N,R 8W W Property O rs Mai i Address Lot # Block# Subd. Name or CSM# P City State Zip Code Phone Number El City ❑ Village [ Town Nearest Road v e 4 A/cy' /,,X New Construction Use: [Z Residential / Number of bedrooms Addition to existing building ❑ Replacement ! ❑ Public or commercial - Describe: t- / Code derived daily flow O 0 ® gpd Recommended design loading rate Zbed, gpd/ft2 - 4 trench, gpd/ft2 Absorption area required 1240,0 bed, ft2/0'" trench, ft2 Maximum design loading rate _.Lt+ bed, gpd/ft2_g ~trench, gpd/ft2 f Recommended infiltration surface elevation(s)fZr _ ft (as referred to site plan benchmark) Additional design/site considerations j, Parent material c L A el A rl 4 Flood plain elevation, if applicable /v A ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system X S ❑ U IX S ❑ U [X S0 U [MS OU ❑ S [O U ❑ S RU 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 Yfi _j// 5C 2/14/4'M I'l FX Ground D Jr S F //YoIY f / 't elev. MAI. , Depth to limiting factor in. Remarks: Boring # :I_ ,.5- !3 S G ate' 3 5 F//Ye S, r Ground ellee, Depth to limiting factor lain. Remarks: CST Name (Please Print) Signature Telephone No. S' tee- b' Address Date CST Number 4-4 PROPERTY OWNER i- L SOIL DESCRIPTION REPORT Page of _ PARCEL LD.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Al L'- 6 Ground /'4 6-: C' e'lev~.~ Depth to limiting factor 94-in. Remarks: Boring # 7 C' ;2 o - `%H 19 17 Ground e~le~v. j Depth to limiting factor 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 -5 l 'M /q 1'/4 C 5 j Al Z Ground elev. Depth to limiting factor Bin. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) PROPERry01 AER_ R ege f k &&,q SOIL DESCRIPTION REPORT p p( PARGELLD.# Boring# Horizon Depth Dominant Color Mottles Texture Structure Consl Bourd3y Roots GPD/ft In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed vxh o z C z 6 2- i 3 d.4 sik EX- to 1 VF Ground elev. 9~. -2fc Depth to limiting >c i Remarks: Boring # d l Ao R 3 AL S ,I M i 2 -l a s S, G 4/. VF .r d K3 hr / leg X Ground -8 O 1r iN d elev 9a it. Depth to limiting i factor , i ? 88 Remarks: Boring # ; l v-/o /0 3 L s6 M S 2 /v- Iv e k I (Ai F S v 14,4 Ground elev. Depth to limiting facto Remarks: Boring # 4 i Ground - r elev. It. Depth to limiting factor Remarks: lvv s ~ tt i 1 Q - -j i - - I - - - - i Ik i i ~ 1 t ~ Alba r i i ; I ! ro .5L4 esi Me tccl .234 i -?•_76 Rj E. f ! i Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 268644 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: MYER, GREGORY HAMMOND CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9600339 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet verit irIto ntake ROAD Dt Inlet TANKTO P/L WELL BLDG. A Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. I f Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HAMMOND.17.29.17W, SW, SW, HWY 12 Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH 4 SANITARY PERMIT NUMBER: ` e_ _ z SANITARY PERMIT APPLICATION BureaSafetyu o oand ff BuiluildiinWater S ngWater Division stems 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. sf a/°1 61 /-X • See reverse side for instructions for completing this application State Sanitary Permit Number J(od'~ `rr The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location G t° O S~2) 1/45 1/4,S /17 T-29 rN,R /1/7 "W) W Property O ner's M iling Add ess Lot Number Block Number .573 c v d 'T I / Cit State lip lode Phone Number Subdivision Name or CSM Number _z ;Z nit . v • G , r S 6 s .s o 3 ( II. TYPE F BUILDING: (check one) ❑ State Owned ❑ city Nearest Road ❑ Public 1 or 2 Family Dwelling - No. of bedrooms Village Town OF /4~'I/N 0 /V0/ III. BUILDING USE: (If building type is public, check all thatapply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo O le 10_Z? 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 online B, if applicable) A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System _________Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 M Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14E] 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) 8 9,38 Elevation 6 d D /a O O /D D Q 9/~O~ Feet 9, ,O-? Feet VII. TANK Capacity in allons Total # Of r Prefab. Site Fiber- Exper INFORMATION g Gallons Tanks Manufacturers Name concrete strutted Con- Steel glass Plastic New Existing App Tanks Tanks Septic Tank or Holding Tank OO 4,-e e ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: ( Stamps) MP/1V No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): /~w 70 G-,Cetiwoo ci7` ~c~~~ .S o/3 IX. CO NTY / DEPARTMENT USE ONLY ❑ Disapproved sagitary Per t Fee (Includes Groundwater ate Issue Issuing Ag t Sig Approved ❑ Owner Given Initial SurchargeFee) Adverse Determination o / zlo X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBO-6398 (R. 05/94) DISTRIBUTION: Original to Counly, One copy To:. Safety & Buildings Divr_ion, Owner, Plumber 4 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 e)) 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 applicMior must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or vvith 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. ^',,rG.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. j i , 14 I , y _ j~A i ,v' 1 / c J-,i i aj~l i ra - _ _ _ j- - -E' A-4 - ~7`wo 5 I 11V v 4-G, Slam, N ~L , rl) I , I I i , i ° I I I i I ~L - - - - n- - - I i I i i ' I C r I I I i I ~ I I I I ~ I I I - I i I- ~ L I C I I I I I I j I I L i -L-- - -I-- - -I--J- 77 - - - _ - _ L_ - 1----I-I-- ~ j ~ ~ I r r 1 1 ` l I I I -i I I I l i i I ~ I I ~ I I I I- i I I ~ i , I I 4- _ ICI Wiscpnsin Dedartment of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page of Division of Sal}ety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and S~ e percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law. s. 15.04 (1) (m)). Property Owner Property Location f~ c I v? Govt. Lot Sc~ 1/45_4, 1/4,S f Tu2 / N,R OW W Property O is Maili g Address Lot # Block# Subd. Name or CSM# City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road CIE' S k' e; Y (.Ji h )"w" , N,-J A/ /ot. New Construction Use: td1 Residential / Number of bedrooms- Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate `gibed, gpd/ft2 1 trench, gpd/flz Absorption area required t: L' bed, ft2 trench, n2 Maximum design loading rate bed, gpd/ftz trench, gpd/ft2 Recommended infiltration surface elevation(s) '4' . , of S,' 3'Y n (as referred to site plan benchmark) Additional design/site considerations d Parent material L Al el o41- Flood plain elevation, if applicable IV A n S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system Xs ❑ U 2s ❑ U [5 S0 U ® S ❑ U ❑ S ® U ❑ S 4 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench /C I - S c L .2 / ZA /Vt F'.I & 5 l ✓ F Ground 3 elev. Depth to limiting factor F`in. Remarks: Boring # . 1 1, /►7 MFR d c 3 e 01y e IS' Ground ele Depth to limiting factor 7F&- in. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number PROPERTY OWNER SOIL DESCRIPTION REPORT F Page of 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 r t i. Ground Ier/N ~4 elev. y C' qn. Depth to limiting factor Remarks: Boring # ll. 0 /C M Cr A1-- 4'F Ground pele-v /K. l Oft- Depth h to limiting factor 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 ;L j 4,rA /%I /r,s C Ground zelev. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) I L ! 61 lk ::T- - - - - - - - 1 I _I f t - -rA - t -a -t - - - -C 7p 1. "w ! S t I i j t r i 1 L - ~ - - _ . - , , _ - , - Imo- ; - - - - - _ - i - - - - - _ _ - - - - f ~ I I; ~ I I__ i l I I ~I i ~ I I I ~ I I I I ' I I I I ~ i I I I I l ; I r I i ~ I I I I I f - I l j r- I I ~ i ~ I I I- - - -1 - -I-- - -I i f I ~ I I I I FILED FES 191985 >N~ aisD JAIU3 Of coiit4a, w' ' am* ~ W ~ tiYlwr CERTIFIED SURVEY MAP Located in the SW 1/4 of the SW 1/4 of Section 17, T29N, NW CORNER R17W, Town of Hammond, St. Croix County, Wisconsin SECTION 17 Surveyed for: Randy John, Hammond, WI. T29N,R 17W I"IRON PIPE FOUND UNPLATTED LANDS LEGEND S8902430"E 420.00' 6161 m9° 387.00' o BERNTSEN MONUMENT 33' 33' 24, I SET OR FOUND 'C O I°X 24" ROUND IRON j~ PIPE WEIGHING 1.68 LBS/ FT SET Z LOT 1 O I-1 G) rri o 1 163792 S"Q FT/3,76 ACRES 1r z o INCLUDING RIGHT-OF-WAY ( /132,452 SO FT/3.04 ACRESI 0 i w o `EXCLUDING RIGHT-WAY/ M 110Up~,~i W io o ' `N~p6eG ON, 0 CL O Z t0 °o JAMES E. RUSCH owl { S-1316 \6 Z Hudson, 'r Q' \\T°02 i9 CIS ~f O e 620 RIGHT-OF-WAY LINE mss, 4g, 2 53033,N 8902430" W 93°" SI/4 CORNER- °35~ SECTION 17 U.S. HIGHWAY "12" W i MONUMENTww /1'IpRPROVED N.89 ° 2 4 30" W 4_20.00' w rn w POINT OF BEGINNING- NAIL FOUND-MONUMENT TO BE SET FEB 6 1985 a w. CORNER SECTION 17 SCALE IN FEET S7. CkOLX COUNTY O SO 100 (111-1001) 200 300 00AkPX**9N31VF PARK$ ►tM M##40 Am LOWKG COAlMMU DESCRIPTION A parcel of land located in the SW 1/4 of the SW 1/4 of Section 17,. T29N, R17W,. Town of Hammond, St.. Croix County, Wisconsin, described as follows: Beginning at the SW corner of said Section 17; thence NORTH (assumed bearing referenced to the West line of said Section 17.,...bearing assumed NORTH) 390.00' along said West line; thence S89 241-30"E 420..00'; thence SOUTH 390,00' to the South line of said SW 1/4; thence N89 24'30"W along said South line and the centerline of U.S. Highway "12" to the point of beginning; containing 163792 square feet (3.76 acres) including highway right-of-way, and being subject to highway right-of-way across the Southerly and Westerly 33' of the above described parcel, and the vision triangle as shown at the Southwest corner of the above described parcel, and also all other easements, restrictions, covenants and ordinances of record. STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/ t et Re ` /14 MAILING ADDRESS f7,12 0 0 A' cV T PROPERTY ADDRESS / C' / 11'a . >f (location of septic system) Please obtain from the Planning Dept. CITY/STATE &A M /yie'Al '-1 PROPERTY LOCATION 5-4'Ll 1/4, ~ 1/4, Section 1, T ,2 cZ_N-R__L2W TOWN OF H14 Al oiVa ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP P /M2 VOLUME j PAGE /.5-y' ~ , 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 , A P 7-1 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 y r R y Al Location of property ' j l/4__,< 1,/ 1/4, section T2f N-R W Township HA c, A/d Mailing address e z; go/ Address of site 170 / 0 ,_z,L - Subdivision name A% Lot no. Other homes on property? Yes x No Previous owner of property RA A/ c6y ~ / Cy ii .f A'/ Total size of property Z A 17,9 1 Total size of parcel 7 Z 4,2 g Date parcel was created / `r6-~9- Are all corners and lot lines identifiable? A Yes No Is this property being developed for (spec house)? Yes X No Volume //~3- 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 office of the County Register of Deeds as Document No. 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. JS' n e of A licant Co-Applicant Date of Signature Date of Signature 403111 I STATE BAR OF WISCONSIN FORM 2 - 1982 WARRANTY DEED DOCUMENT NO. ) _ . _ REGISTER'S OFFICE ST. CROIX CO., WI Randall R. Guski and Diane K. Guski, ftediaPAcA husband and wife, AUG 16 1996 conveys and warrants to Gregorr Myer, a c' ,--]c- per-mn, at 2:00 P M '~K.1 -R k4k Rpts»r d ONd~ THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in $t Croix County, Equity Title Services State of Wisconsin: 400 S. 2nd St. Hudson, WI 54016 163407 018-1038-00 PARCEL IDENTIFICATION NUMBER Lot 1 of Certified Survey Map filed February 19, 1985, in Vol. 6 of Certified Survey Maps, ?age 1506, Doc. No. 399829, being a part of the S-11/4 of the 911/4 of Section 17, T29N, R17[7, Town of Hamond, St. Croix County, Visconsin. S T oSOFER FEE- This i S not homestead property ft (is not) Exception to warranties: Easements, restrictions and rights-of-lay of record, if any. I• Date his day of 3llgi!st__ 4A.D., X19016 (SEAL) (SEAL) - Randall R. Guski Dane Guski - _ (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT State of Wisconsin, Signature(s) ss. St. Croix CounjY authenticated this day of 19 Personally came before me this day of __-Atlgtis_t, 19-q6-., the above named Randal-L-R Guski and Diana X • jSuski,- _ h sband_ and-wife.- TITLE: TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stats.) r to me fen to be the person who executed he foregoing ti of 0'"u" instrun nt and acknowledge salryp THIS INSTRUMENT WAS DRAFTED BY n~f ~~i. Attorney Kristin )eland ends Poulin ~4. ~ c ~ ~