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HomeMy WebLinkAbout018-1038-50-000 4 o N Oo w O vy N M bQ v c a 0. V I n~ > te l ti V K f9 0 i C ~ I a z c ° -Fo w LL o a c a _ E Q I' O I U N M CL i, c > ui E U) O £ a z a d w a co 04 z c 0 c C7 m O z c :p L= r ° 41 (n IZ- r 0) m o z c ° E ~o rn m N 00 N N "ftib c c O ~ O Z f` z z N ° I O E C N - N ~0 > L I d N d . N Lo d ate.. .L.. U C O O U W d N i O O O (6 O C a N A N N LO LO Cl) L) A F- N N IL O O O s z O O • m c a a a E g'I c N E 0) CO N fA J V co rn rn } 01) co ~V 00 N O O If1~ _ N 00 00 E Lo L O O O a O N O O p N (D q) a p O C O N C O 3: -0 E C y = 0 0) CN CD 0 0 paj ~ O O O C O C O O O to N L E Y 'D \ N N 0 (n O M CO C N N 0) L w 3 O N N E I,. -E O N 'O ;5 O CD CD N E m Lo 'o' > CO u> O (6 U • y' O Z N O N Z tfJ O y w w N C/] y M a ° i d w • ~ a E L c c ° w r A 0 a II', O N 0 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER y. a ADDRESS 73 b d SUBDIVISION / CSM$ LOT ~ JtJ SECTION TQN-R /;7 W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYST ~a S i►' 3 ~ INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to r r nt-pr r r r BENCHMARK: 1 v~ Co - BENCHMARK: r me r ; r ALTERNATE BM: SEPTIC TANK / '-CHANIIER / FORMATION Manufacturer: (,J AAA Liquid Capacity: /Q'Lt~ gj~ Setback from: Well_ J V,9 House Other Pump: Manuf,acturer_ Model# Size J Float seperation Gallons/cycle: Alarm Location ":SOIL ABSORPTION SYSTEM Width: .5 Length Number of trenches Distance & Direction to nearest prop. line: _ f gs 3d , Setback from: well- ! r -__/,*:5' House/?D Other ELEVATIONS Building Sewer ST Inlet. °Y,9 ST outlet /9•.ras PC inlet /V PC bottom Pump Off Header/Manifold Bottom of system ge is Existing Grade ~y .Z.. Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt 7 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM • County: Labor and Human Relations Safety and Buildings Division INSPECTION REPORT f r o GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: a ~ ~J! 9 / Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: /l' J] Q m rh U h 1/0 Z__dl CS BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: D 160- 0 s /D f ~cc hw 6/y- 3-50 TANK INFORMATION E EVATION DATA ~9~P06 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark a8 / Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet 17, 99.58' TANK TO P / L WELL BLDG. Airs to ntake ROAD Dt Inlet Air I Septic O " _ NA Dt Bottom Dosing NA Header/Man. O, 3 9 9" Aeration NA Dist. Pipe /0.38 -2,1 ~ Holding Bot. System $s 9 0. ~a j1_21 - f/ PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand f4.r / Model Number GPM TDH Lift Lrict' System TDH Ft Head Forcemain ngth Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS _ 1 ?10 SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Typeo CHAMBER Mode Number: System: 7 ' 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 C] Yes ❑ No ❑ Yes No COMMENTS: (Include code discrepancies, persons present, etc.) 10 C,4 D AJ; a h-, /m} o n al . 7, Q 9 / 7, A/, 7 0 _'S z[ atl -t C l 4.f_F.J f ~ ~ Plan revision required? ❑ Yes 2(No Use other side for additional information. SBD-6710 (R 05/91) Date 015ttor's Signature Cert No COMMENTS AND SKETCH SANITAflTIONAL ERMIT NUMBER: . r ♦ s . . f Iti t Safety and Buildings Division SANITARY PERMIT APPLICATA Bureau of Building Water Systems l.~LnR 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 CIIN "*t- ` than 8 1/2 x 11 inches in size. © • See reverse side for instructions for completing this application state sanitary Peermi`tNu ber O ✓ W The information you provide may be used by other government agency programs ❑ Check it revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property w er Nam Property Location 3y Y-A % V CL r- ~ NLU4 _S1/4, S C T .7 r N, R/ 2 Uor) W Prop Owner's Mailing Address Lot Number Block Number 3q , 11 0V" ST NA_ I )o r+ City, State Z' Code Phone ;umber Subdivision Name or CSM Number IL r~ r O LS II TYPE F BUILDING: (check one) ❑ State Owned ❑ Vi l I Irage Nearest Road ❑ / 70 ~1 Public 1 or 2 Family Dwelling No. of bedrooms -3 Town of Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2. )<Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System ________System______ Tank Only______________ Existing System _________ExlstingSystem B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 %Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation 45(~ t;r 900&f .1:5, 4?6,9 Feet Feet VII. TANK Capacity site in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New Existin Gallons Tanks Concrete strutted glass App. Tanks Tanks Septic Tank or Holding Tank rte1:1 El El E1:1 11 l 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 Nam int) Plumber's Sign tur (No Stamps) /MPRSW No.: Business Phone Number: Plumber's Address (Street, Cit, tate, ip Code IX. COUNTY / DEPARTMENT I1JSE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate issued Issuing A nt Sig ature (NO amps) pproved ❑ Owner Given initial 04- Surcharge fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05M) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings Division, Owner, Plumber INSTRUC=TIONS t 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 ne rv 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 de submitted to the county prior to installation 5. Onsite sduwage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. il. 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 a/! 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. 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. i _ O 1 l - 1 I ,t t I -1 I I I A i I 1 r I I - -~;~i- - I - - ilk r I I i I I ~ ~ I I t li- ' - i I + I j_ I ~ 1 i ~ ' I I 1 i r I i 1 - i I T it C - I ; r ~ L • I ICS' t I o~~~ _ { F t 7 I I J I- I _ I i i I_ t I I I I f , I , I I ~ j ' I t ' I ' i , I ~ -I- J- i I_ 1 I I' i i I ' i I I ~ I I ~ I r I I I a I r ; ' I ~ I I ~ t , ~ i I ' I I f I I - t ~ 1 I I _-I I - ~ ~ I ! ~ j j , I + I , I ~ I I I I i ~ t I { ! I I 1 I r I f I ~ I ! t I ; I I I I t _ 1 ! r I I f i I I j . f ~ I i_ I I I _ I i I- E---1 I- I I. - 1 _ r I I I I ~I I ! 1 I ~ _ 1 ~ ~ L ~ I - i - ~ - _ I - r ~ ~ ~ ~ ~ ~ ~ 1_- ~ - - } E -{I-- r- 1~_ _ I I 7 i I - - i ~ - ~ i -r --j-- ~ ~ i - ~ + , E ~ ~ 1 i - ~ ~ i i ~ i ~ ~ ~ - ~ - ~ - --fi-- - - 1 ~ ~ i i ~ li I 1 , _ - _ . - - + _ _ I I i + ~ r r _ _ _ r - } - ~ - -I - _ _ _ _ - - ~ I _ _ ~ _ i r _ i I - --i i ~ - - F _ 1. ~ L j - ~ I i _ t r i _ i_ ~ _ ~ i i ~ i j ~ i ~ ~ ~ i --Y ~ ~ ~ ~ i i . - -j' ' ~ ~ - - i ~ t ~ i ~ - ~ t. ~ . i i ' ~ i i ' - - - ~ ~ ~ I ~ ~i i l ~ i I - ~ ~ - - - ~ j I I i ~ i t ` - i I I ~ I i i ~ ~ ~ - ~ ~ I i ~ ~ ~ 1 - i ~ ~ I i _ f ~ - ~ + - Y rt--- i i i - - - - - i ~ ~ ~ ~ i i - _ , _ ! i 1-- ~ - - f 1 - - _ - ~ ~ ~ i I i ~ i i - j ~ ~ i ~ I 1 f -__.i , i-- ~ ~ ~ _--i ~ ~ ~ i ~ i ~ I I ~ I ' _i ~ I I - - ~ ~ ~ ~ - t - - ~ I ~ i. i - - i I _ ~ ~ I _ ~ ~ ~ r - ~ ' i i ~ ~ i 1 - j- ~ _ ~ ' I I , ~ ~ ~ - i 1 ~ j i ~ r i i I t ~ a- - - , _ 1 ~ i ~ ~ ~ ~ ~ ~ - 1 i I, I i _ _ - - F ; I ~ ~ - I ~ -i ~ ~ j r- i ~ i ~ ~ ~ ~ _ ' I ; ~ ~ ~ r ~ ~ i ~ ~ ~ I ~ ~ - --t--~- t T ~ _ ~ - 1 _ i I i I i . . ~ I ~ ~ _.__7 ' ~ ~ ' _f I I i { i ~ I I 7 ~ ~ ~ ~ I , ~ - - ~ - i i - ~ _ ~ _ _ ~ t - - ~ - i_. - y~_ ! ~ ~ _ i ~ i ~ i I - I a ~ i - ~ - _ ~ _ ~ - ~ - ~ - - ~ - ~ ----1 i ~ ~ - ! a- _ { I ~ j I I I ~ ~ i 1_ Y ~ ~ _I ~ ~ -i I i ! ~ f ~ 1- I _1 - - i I I ~ ~ ~ - ~ ' li i i j r II 1 1 { t f f G -1- - t t-- ~ ~ ~ - - ~ I ~ - _ _ - i I- _ - ~ - i - ~ - - ~ ~ . _ T- ~i _ ~ ~ i ~ ~ ~ t ~ F- - F - ~--i ~ - - t ~ r - t - I ~ ~ ~ I I 1 , + - r- ~ - - { ~ ~ ~ i ~ ~ t i ~ - r-- - i r I I~ f i + ._--r - 1 I i i-. i ! ~ - a J I I i 1 ~ ~ i - - i ~ - i _l - 1 1 I ~ ~ ~ ~ i. ~ ~ - I _ i I i. ~ 1.. - 1 _ r - - } ' I II i _ _ i ~ ~ ~ - ~ - i I - ~ - _ _ _ _ I I i t.. 1 ~ ---I - i i i ~ ~ ~ I t - - i i i _ I - r ! { ~i T , - - ~ a i T ~ - ~ - ~ ~ I _ ' _ ~ _ i - _ . r ~ ~ i I - ~ ; i i i ~ I I ~ i - - _ _ 1- ~ . . - - i- ~ - a _ 1 - - r * ~ - ~ ~ i ~ I ~ i i I - ~ _ - i ~ L. _ L ~ I i i r ~ - ~ ~ ~ -r-- - PAGE OF CrU55 Sec~ton Ot r't SysTe~1 to Fresh Alr Inlala And Obcarvallon Pipe J Approved Vent Cap Y ^ Minimum 12" Above I t Final Grade Ct3y 1?U'-'k W+ 20- 42" Above Pipe _4" Cod Iron G m rn O ^ To Finoi Grade Vent Pipe 1 A { it S c /j i S t 1~ sh May Or Synthetic Covering ~ V `I Min. 2' Aggregate Over Pipe ~T act N 17 to 01itrlbutlon -Tee Pipe - 0 0 0 0 j 6" Aggregate Beneath Pipe irl Puleralad Pipe Bdor -Coupling Terminating At Bottam Of System SOIL. FILL DISTRI51-IT101.1 PIPE APPROVED SIWj>•IETIC COVER • •`'-MATr RIAI- OR 9" OF STRAW of AGGREGATE OR (1ARSN NA`J ~,qlpj (o OF 1z -Z/z AGGREGATE ELEV. OF FEET--..- b - DISTRIB'JTIOM PIPE TO BE AT LEAST so# INCHES BELOW ORIGIMAL GRADE AMU AT LEASTP-0 INCHES BUT 1,10 MORE THAI) 42 IMCNES BELOW FINAL GRADE MIMUM DEPTH OF CXCAVAT100 FKoM OKI&W AL 65KADR WILL BE IIJCNES JwUNIMWM 9F-p" OF FACAVATION f.RolM. 01 14I AL ()RAPE WILL. BE INCHES SIGUED: - LIC EI.I SE UWABE R: (0 a DATE: mr, Wisconsin Department of Industry, IL AND SITE EVALUATION Rr-nO R T Page of .3 Labor and Human.Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. e COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. O /9 - /D APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION rtf GOVT. LOT f 1/4 ~ 1/4,S PT 0-7? N,R / 7 r) W PROPS TY OWNER':S MAILING ADDFSF S LOT # BLOCK # SUBD. NAME OR CSM # / U ~ N t} iU J~ CITY, STATE ZIP CODE PHONE NUMBER ❑CI ❑VILLAGE OWN NEAREST ROAD [ ] New Construction Use [ ] Residential / Number of bedrooms [ ] Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow 4,56 gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required //.e; bed, ft2 9670trench, ft2d ,Maximum design loading rate •_31 bed, gpd/ft2 ;S trench, gpd/ft2 Recommended infiltration surface elevation(s) q D ® ft (as referred to site plan benchmark) Additional design / site considerations Parent material U t u ~cam`- Flood plain elevation, if applicable ft S = Suitable for system PQNVENTIONAL MOUND IN-GROUND PRESSURE AT-GRAD SYSTEM N FILL HOLDIN TANK U=Unsuitable fors stem S❑ U MS ❑ U Us ❑ U El S 7- El S ❑ S U SOIL DESCRIPTION REPORT ~c~,zlof 5/yc Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench M UPC Ground n\ rn l ew , 5 • Depth to M limiting Remarks: Boring # 34 e4 ::15 Ground::.:: .,y S C Lj f elev e__ - Depth to limiting Remarks: CST Name:-Please Print Phone: kh pwers Address: / 6 J S , _ LUG $'YO/ Signature: Date: p - - t?(o i CST Number: p 8 ~ PROPERTY OWNER v R1'0QL OIL DESCRIPTION REPORT • Pagea PARCEL I.D. SC /d ~8`"~S'G1 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ::vti` / 5 SJ, muf C 4 Ground 3 /9.75 16 k- (o° s'/ C n? 5;44, o G : j , S to ele t 5-35 s G w Depth to S S -y 7-~f, /S 1 m ►~1 G S limiting facto 6- S AD 6-4 5 m I . 7. Remarks: Boring # p>:.:rfi::f:.z px& Ground elev. ft. Depth to limiting factor Remarks: Boring # t,.u Ground elev. ft. Depth to limiting factor Remarks: Boring # J:'f Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) 1 r I ~ ~ I y i , f ~ I IPA- 1 T I + I I I 1 r i ~ I , j I I ~ I I I i , I i , i I I I I 1 41 , I I I 1 t I , ~ j I I ' _ I I I I I I I I I I 1 - - 1- i I I I I i I 1 a- I I I r i t a ~ I -r i I I ' ~ I I r I ! I ! ~ 1 I r I I I I I I ! ~ • I ~ 1 ~ ' j I. ~ I , i , I i I I I ' I r ~ I I I I I I I ~ I I I ! _ I I I I i I I I I , I I - I I I , ! 1 , I ' 1 I I ~Y _ , I I 1 - - - 1- -r - I ~ I C j i I { I I ~ ~ i I ' I p'r 1 txv~ ts~ , t- I. I 1 I i I I i I T fi I i ' I I I I ' i j I , I f I l r I . , • = t ~ I I ~ I I I I I I i i I I I i 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 - I - I I I I STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ~ ~ l~ r~► MAILING ADDRESS ~v PROPERTY ADD R]f~;a ~~j ~17 ion of septic system) P1 ase obtain from the Planning Dept. CITY/STATE q, PROPERTY LOCATION AfF 1/4, 5.L 1/4, Section I? T ( N-R/ 7 W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER 94G'"' CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER i 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, 9s set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expi;,Oon 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 `1c~ h NA Location of property__ 4,rl/4_ 114, Section /Z,T~N-R~_W Township- Mailing address Address of site Subdivision name Lo wo. Other homes on property? Yes_,K No Previous owner of property - Total size of property Total size of parcel Date parcel was created _ Are all corners and lot lines identifiable? /"(Yes No Is this property being developed for ('spec house)?. Yes _No Volume and Page Number 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. t Signature of Applicant / Co-Applicant Date of Signature Date of Signature 4'7 7841 • • - SPR7NGFIELD PLAN N J J Jia Michigan Form 3000-(1958) J Fr M* to Wisconsin 270464 THIS MORTGAGE, Made this 12th day of _ October ;n the year of our Lord one thousand nine hundred and sixty-two between John H. Rivard and Marcella Rivard, as his wife and in her own right, of the County of St. Croix State of Wisconsin hereinafter called "mortgagor" (and said term "mortgagor" and the pronouns, "he", "his" and "him" used in reference thereto, shall be considered as applying to both sexes and to all parties, whether one or more, embraced in said term, and to the heirs, executors, admin- istrators and assigns of each mortgagor), and The Federal Land Bank of Saint Paul, a body corporate, 346 Jackson Street, of the City of St. Paul, County of Ramsey, State of Minnesota, its successors and assigns, hereinafter called "mortgagee". WITNESSETH: That said mortgagor, for and in consideration of the sum of Seventy-three Hundred and No/100 DOLLARS, to him in hand paid by said mortgagee, the receipt whereof is hereby acknowledged, does by these presents, grant, bar- gain, sell, convey and mortgage to said mortgagee, its successors and assigns, forever, all that certain real estate lying and being in the County of St. Croix and State of Wisconsin described as follows, to-wit: The North Half of the Southeast Quarter, also the South Half of the South Half of the Northeast quarter, all in Section Seventeen (17), Township Twenty-nine (29) North, Range Seventeen (17) West. The above described premises contain one Hundred Twenty (120) acres, more or less. TO HAVE AND TO HOLD THE SAME, Together with all the tenements, hereditaments and appurtenances thereunto belonging, or in anywise appertaining, unto the said mortgagee, its successors and assigns, forever. And the said mortgagor does covenant with the said mortgagee, its successors and assigns, as follows: First, that he is lawfully seized of said premises; Second, that he has good right to convey the same; Third, that the same are free from all encumbrances; Fourth, that the mortgagee, its successors and assigns, shall quietly enjoy and possess the same; and that the said mortgagor will WARRANT and DEFEND the title to the same against all lawful claims. 389 PA I,,[3?? t VOL MORTGAGOR HEREBY COVENANTS AND AGREES WITH MORTGAGEE AS FOLLOWS: To pay said principal sum and interest in the manner and form hereinbefore set forth, and to pay when` due all taxes, liens, judgments, or assessments which may be lawfully assessed or levied against the property herein mortgaged. To insure and keep insured buildings and other improvements now on, or which may hereafter be placed on, said premises, against loss or damage by fire and/or tornado, in companies and amounts satisfactory to mortgagee, any policy evidencing such insurance to be deposited with, and loss thereunder to be payable to, mortgagee as its interest may appear. At the option of mortgagor, and subject to general regulations of the Farm Credit Administration, sums so received by mortgagee may be used to pay for reconstruction of the destroyed improvement(s); or, if not so applied may, at the option of mortgagee, be applied in payment of any indebtedness, matured or unmatured, secured by this mortgage. In the event mortgagor fails to pay when due any taxes, liens. judgments or assessments, lawfully assessed against property herein mortgaged, or fails to maintain insurance as hereinbefore provided, mortgagee may make such payment or provide such insurance, and the amount(s) paid therefor shall become a part of the indebtedness secured hereby and bear interest from the date of payment at the rate of six per cent per annum. To use the proceeds of the loan secured hereby solely for the purpose set forth in mortgagor's application for said loan. This mortgage is subject to the Federal Farm Loan Act and all acts amendatory thereof or supplementary thereto. If the premises herein described be acquired in whole or in part, by one who does not assume and agree to pay this mortgage, the whole of said mortgage indebtedness shall become due at the option of the mortgagee. That should the premises herein described be not worked in a good and husbandlike manner or be abandoned of cease to be used for farm purposes, or should the buildings on said premises become vacant or unoccupied or be not maintained in reasonably good repair, or in the event of the actual or threatened demolition or removal of any of said buildings, or upon the cutting or removal of wood or timber from said premises except for domestic use, or in the event of such acts which would amount to equitable waste being committed thereon or substantial injury being suffered or permitted to said premises, the principal shall become due and payable at the option of the mortgagee. The mortgagee may at any time, without notice, release all or a part of said mortgaged premises from the lien of this mortgage, grant extension and/or deferment of the time of payment of any indebtedness secured hereby, or release from liability any one or more parties who are or have become liable for the payment of the indebtedness secured hereby without affecting the personal liability of the mortgagor or any other party liable for the payment of any of the indebtedness secured by this mortgage. If, there be any security other than this mortgage for the indebtedness secured hereby, then upon default the mortgagee may proceed upon this and other security, either concurrently or separately, in any order it elects. In the event of entry or assertion of right of entry on said premises for the purpose of oil, gas, coal or other mineral exploration `or development by a lawful claimant to such right, under reservation or conveyance paramount to this 'morfgage,'to the exclusion of and without compensation to the mortgagor, then or thereafter, at the option of the mortgagee, the whole of the mortgage debt shall become due and payable. The mortgagee shall at once receive all sums which'may accrue to the mortgagor or which may be realized by him for any purpose out of the leasing and/or develop. menr of oil, gas, coal or other minerals in or under the land herein described, or which may so accrue or be realized : !from eminent domain proceedings affecting such lands, or any portion thereof. The mortgagor hereby assigns to the --mortgagee as additional security all such sums and agrees to immediately account for and pay the same to the mortgagee. All such sums so received by the mortgagee shall be applied on the mortgage debt in such manner as it may elect. _ Nothing herein contained shall obligate the mortgagee to accept sums accruing to the mortgagor by reason of any leasing, development or extraction of oil, gas, coal or other minerals of or from the lands herein described; or constitute a consent by the. mortgagee to any such transaction; or obligate the mortgagee to receive any partial payment on said debt during the pendency of any foreclosure of this mortgage or the running of the period of redemption in connection therewith. dum shall bear simple interest at the rate of 6 per centum per annum, to be secured by this mortgage. Either (1) the whole ' of said principal sum, when so deemed due, together with all other sums due hereunder, all with interest thereon as povided in this mortgage, or (2) any sums which may be past due hereunder without accelerating the maturity of the whole debt hereby secured, with interest on such past due sums as provided herein, shall be collectible in a suit at law, or by foreclosure of this mortgage. Whenever the said principal indebtedness has become due, by acceleration or otherwise, or whenever any sum secured hereby has become past due, it shall be lawful for said mortgagee, its successors or assigns, and the mortgagor hereby empowers the mortgagee, its successors or assigns, to grant, sell and convey the said real estate, with the appurtenances there- unto belonging, at public auction or vendue as provided by the statutes; and on such sale, to make and execute to the purchaser or purchasers, its, his, her or their assigns, forever, good and sufficient deeds of conveyance pursuant to the statute in such case made and provided. Out of the moneys arising from such sale, or sale under decree of court, the mortgagee shall retain (a) the principal and interest which shall then be due on the said promissory note, (b) any sums advanced by the mortgagee, its successors or assigns, and secured by this mortgage, with interest thereon at the rate provided herein, and (c) all costs and charges, together with an attorney's fee in such amount as shall be allowed by law or the practice of the court, or in a reasonable amount; and the surplus money, if any, shall be paid to the said mortgagor or successors. And the mortgagor, for himself and all successors in interest, expressly agrees that at any sale held pursuant to the power of sale herein, or pur- suant to decree of court, all of the said described premises, or all of the same not theretofore released, may, at the option of the mortgagee, be offered and sold in bulk as one parcel; and that all provisions of statute and rules of law to the contrary are hereby waived by mortgagor. IN WITNESS WHEREOF, the mortgagor has hereunto set his hand and seal the day and year first above written. Signed, Sealed and Delivered in the Presence of: `3 - cw. Se exa er (SEAL.) C~~~~ Jo H. Rivard (SEAL) Michael a onne -Owl arcella~~~ (SEAL) Marcella ELDERAL UND DAK Olt: Si. PAUL (SEAL) (SEAL) (SEAL) Li STATE OF WISCONSIN County of St. Croix On, his 16th day of October , A. D. 19~ before me personally appeared John H. Rivard and Marcella Rivard, as his wife and in her own right, w Y to meykn'ov~c(to•.be the person-k- described in and who executed the foregoing instrument,* AXXVXXXXX 7'tt7t and acknowledged the same. , S ' - :J ' .ry qNotary Public of County My commission expires 19 MICHAEL W. O'CONITELL i\iot+ary PuLlic Sauk Co., Wis. Co,mission E:pires Aug. 1G, 1964 STATE OF 53. County of On this day of , A. D. 19. before me personally appeared to me known to be the person- described in and who executed the foregoing instrument,* and acknowledged that o I"h o b b~ m z ;m m o 0 0 • 1 e :1.• I 1 30 ~ NUMBER ,This Indenture, Made this iEth.................... day of............. P-ril................. , in the year of our Lord, one thousand nine hundred and... Fifty... one................... between. tlizabeth.. l?cEahe..... 230816' 4 partp:r..:....of the first part, and...._.JQhn_!L...RiY3rd...al1d...Alarcella._Rivlra.,. h s._W~ fe Of _....Hammond husband and wife, and the survivor of them in his or her own right, parties of the second part. WITNESSETH, That the said part..y of the first part, for and inconsideration of the;sum of ................eyen_.Thous..nc.._and-.no~lOg...(.............................................................................................................................................. ........................Dollars, to.......... M?.......................... in hand paid by the said parties of the second part, the receipt whereof is hereby confessed and acknowledged, he given, granted, bargained, sold, remised, released, allened, conveyed and confirmed, and by these' presents doe.S......give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said parties of the second part, a life estate. ae Joint tenants during'their joint lives and.an absolutb fee forever in the remainder to ,R. the survivor of them, his-or her heirs and assigns, in affil to the.following+described real estate, situated in the 0ounty of St..;-.Cr.Qix k ~ l and State of Wisconsin, to-wit: South Half (Sj) of the South Half (Sz) of i`lortheast quarter (NEI), all in Section Seventeen (17), Township Twenty-Nine (29) North, Range Seventeen (17) West; North Half (N-1) of the Southeast Quarter (SEq), all in Section Seventeen (17) j Township Twenty Nine (29) North, Range Seventeen (17)'west, (°$72.10) ( R.S. ) ( Can. ) .-J TOGETHER with all and singular the.hereditaments and appurtenances thereunto.belonging or in-anywise appertaining; and all the estate, right, title, interest, claim or demand whatsoever, of the said part..:....._..of'the first part, either in law.or equity, either in possession or expectancy of, in and to the above bargained premises, and their hereditaments and appurtenances. - TO HAVE AND TO HOLD the said premises as above described, with the hereditaments and appurtenances, itnto the said parties of the second part, as follows, to-wit: -a life estate as joint tenants during their Joint•lives-and an absolute fee forever in the remainder to the survivor of them and to his or her heirs and assigns. AND THE SAID ,F.,U70.1?.Pt.b..XcCabe_............................. -•Dart„.y..~..ot the first part, for lqr,Seafi..hgr...:..._........ heirs, executors and administrators, do:..eS covenant, grant, bargain, i and agree to and with the said parties of the. second part and to and with the survivor of them, his or her heirs and assigns, that at the time of the she is ensealing and delivery of these presents _..well seized of the premises above described, as of a good, sure, perfect; absolute and inde- feasible estate of inheritance in-the law, in fee simple, and that the same ara free•and olear•frbni all inoumbranoes whatever................................................... and that the above bargained premises in the quiet and peaceable possession of the said parties of-the second part, as joint tenants of the life estate therein during. their joint lives and an absolute fee In the remainder to the survivor of them, his or her heirs and assigns, against all and every person or persons lawfully claiming the whole or any part thereof A!!? .......................will forever-WARRANT- AND DEFEND. IN WITNESS WHEREOF, the said part.Y.-.::....of the first part ha: 5........hereunto set....her .--.............;.....hand.-::.and seal. .....this ~ 7th day of.».......................... April..........................................., A. D., 19..5.x...... 11izabe.th 1.kcCabe. ........................................(SEAL) Signed, Sealed and Delivered in Presence of Elizabeth McCabe, ..................._(SEAL) S elmex:...J......Qraat..------..............--------------...------------------...---°°- 0-1--- r fl-+ • ................................-----..........(SEAL)