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HomeMy WebLinkAbout020-1321-70-000 n: 0 Q) ~ I a I N ' c N C II 0 I c~ O N ti O i 0+ O ti C r I ~ I a z ' C 7 lV ~ LL C O B Q M N z E z ° o v E o z y y t0 N a m z 0 o z ° v O Z U d' r v o p m Z c o E m `•+.J N o N c •1V v Q)_ g O C C O U N i Q t= O Z H Z p Z N ~ I N t0 E Y N _ - N C L L d CL m a) N m o ~ o o c G o a o c~ ° t/~ tq N ~ o w o I C7 ~ ri ~ Lo 0 0 0 Z o •w$;~ _CL IL CL a fn 0 U o N N N ~V = v } v o E I 0 =3 :3 w m a~ N N i> o o a a Q c ca ~1 H H Q Ai O c-, N C O r-- c O O C C E O O O O E p O. O_ Q. O O L' ~ m C E E 4J pp I c co - 3 M y - W tra N F- 'N :3 N E E L) O = (.4 t 0 ~ I ~ E N dt a EL y o CL r~ 'L t y i E o c got A V a 2 0 N 0 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER-=A°r31 7l L 2 ADDRESS -9p x Z V Z- 14 a J s© n► ti j 1 -T- yO r SUBDIVISION / CSM# ~f+ N ~E' ~//l L LE y LOT # SECTION 1,:r T 2-9' N-RTown of H~a Ds e N ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM W E [ t Xdt /NSrpLG~A Al). f'' N A-r NL I CO&Ajce F- (=/oo,ao' 4oL)se ~ACA6£ S cf4 c i/y"_ io' 38 A-M 7S a :''s0 z ~`-al v 3 0 0 y v h 1'u O 30 + I _V- - - - - - - - - s 6 t~ / - DEPT L T C4 AIArF N INDICATE NORTH ARROW Provide setback and elevation informati n on reverse of this form. --Prov-ide-- 2 -dimensions- to -center o-f- septic tank --manhole cover: BENCHMARK: XT e'OeaEe S 9y= ALTERNATE BM: -Fe)? of Blocs t-*v*,-0a71vN E/= .~.8s=1p 2,9 SEPTIC T / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: lomo Setback from: Well ~S House 3 S Other //3" rb ~,<3T ceT <i~YE Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: j Length vo ' Number of trenches z- Distance & Direction to nearest prop. line: S/ rc ERt ST GeT L/,y4E Setback from: well: House o Other 7 Tb 57' /~jAAf 80 LL g. 2 ELEVATIONS Building Sewer - ST Inlet: /0.so = g5.yy ST outlet: o.gs_ 9s,o9 / PC inlet PC bottom Pump Off Ff ~I~n_ 9ygy Header/Manifolde-4/1,yz 9'1,52- Bottom of system / Z Existing Grade ~y S Final grade J9, c~c~ DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/43 :.j.t . _ 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 268688 Permit Holder's Name: ❑ City ❑ Village 51 Town o : State Plan ID No.: MILLER, SAM E. HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA 1//,/ 6 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark S, (Z /dZi- 3, Dosi g Aeration Bldg. Sewer Holding Stle Inlet TANICSETBACK INFORMATION St/J0t Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic > 5-0 7-7/7s 7 4A NA Dt Bottom Dosi NA Headed. /.,),o /O• Y6, Aeration NA Dist. Pipe 7' Holdin Bot. System /g 3. S3 / PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand t°/' s,T' Ojagi,4 97. Model Number GPM TDH Lift Lriction TD Ft ead FoXk%--main Length Dia. Dist.Towell SOIL ABSORPTION SYSTEM f Pits Inside Dia. Liquid Depth ;iA BED/TRENCH Width / Length No. Of Trenches PIT 5HAMBER DIMENSIONS S DIMEN anu acturer SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM e Num er: INFORMATION Typeo r/~., v NIT Mo System: OR UNIT DISTRIBUTION SYSTEM Header /A4aP4eld- Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake Length -f1- Dia- Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grad" s Only ed Depth Over Depth Over xx Depth Of xx Seeded/ Sodded Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUD/SON.15.29.19W, NW, NW, LOT 7, GRANGE ROAD /~,P~tirn~7~r~L &all 9lLf l,4 j Qlto'- cJl 'b-. PPOt c S. E• t. zr,r~d . ~ PeLC(~ E Plan revision required? ❑ Yes [lo / pc Use other side for additional information. 0 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau Building Water System 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 '(240011 than 8 1/2 x 11 inches in size. i • See reverse side for instructions for completing this application State Sanitary Permit Number c previous application The information you provide may be used by other government agency programs E] Check it revision o 6 ►Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location -_54 ty( M ILLIE/~ NOA kJ 1/4,8 ~ T 7- rN,RE(0(1~ Property Owner's Mailing Address Lot Number Block Number Z O IP Z _:F City, State Zip Code Phone Number Subdivision Name or CSM Number V 5c)N Lo ► s- 0/ 13,gw Z"1c4C, 4A N<2~ RLL15 II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ ity Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms 3 C] Village Town OF>1 L)L) 5 N c..eIaKGF ZOA 1) III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) pzc~-1321-70 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2. ❑ 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 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 Ll SD 543 00 - '7G' Feet 00.9 Feet VII. TANK Capacity site in gallons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper INFORMATION Gallons Tanks Concrete glass App. New Existin structed Tanks Tanks Septic Tank or Holding Tank oco/S~~ ® 01 ❑ E31 ❑ El Lift Pump Tank /Siphon Chamber ❑ 0 E VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. ss Phone Number: Plumber's Name: (Print) Plumber's Signature: o Stamps) MP/MPRSW No.: Bu;~, ~~9 z._ I S h 61 a ~L` i _ ~~es-o 3 Soc~ ~40- Plumber's Address (Street, City, State, Zip Code): /070 h`1-1N7fR_ <D~E h~vO6oAl Lu IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issue Issuing Ag t Sign ure (No M Su rcharge Fee) Approved ❑ Owner Given Initial It 08' Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to Counly. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3_ All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. ChecK experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber 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 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 aQd 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. S fl /r'1 M 11, Lf 2 (:;Z1ZA NEE Y f & Lf y 4e®7- 0#7 Fr ~z ~©9 p j /15 LD 2 q - DoT 5 ~ E /4 C tv a TAx~ ~zo-/3z~- 7o hV a ~ ,gc.TE ~ ~ kT ~ ~ S 1 o --per Ci-3 - s3 a4~ So v ~ f~ DoT t /.YE ,~o 3 y-, - m r\-t~ I 11 ~ o arn -u I -41 I ~ ~ x s ' i n -Ic -o I I I I z n 4' v r I I I Z ~ I -u 11~ z, -0 1 90 0 ° t± . z •V,. O 0 ~ O O o 0 in LA Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Human Relations Division of,Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but i 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. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPS PTY OWNER: PROPERTY LOCATION &h / a{'! LLIL-9 GOVT. LOT aW 1/4 AjL0 1/4,SIS T Z~ N,R 9 E (or) W PROPERTY OWNER':S MAILING ADDRESS L # BLOCK # SUBD. N E OR CSM # IeA& tC,ZC 04tiZ-t CITY, STATE ZIP CODE PHONE NUMBER []CITY []VWGE OWN NEA~S R AD f.( r [ New Construction Use [)Q Residential / Number of bedrooms t4j'e- [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate 6,6N bed, gpd/ft2 6.7 trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate __CL2_bed, gpd/ft20.g trench, gpd/ft2 Recommended infiltration surface elevation(s) (as referred to site plan benchmark) Additional design/ site considerations a~~L LV4-(j4Tl0, L6,!` -,ck H-A r k PP 4,6ydL Parent material Flood plain elevation, if applicable ft S = Suitable for system 0 VENTIONAL tv0 JND INS- 'ROUND PRESSURE T AT-GRADE 7 SYSTEM IN FILL HOLDING T K U = Unsuitable fors stem {!PJ S ❑ U ® S ❑ U ®S ❑ U ~Y] S El U t3 S ❑ U El S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Twich 90 ti a•::2 -Il y3/ C r fM sm CS 4 4 c'1 Ground 3N 643 y ~,r ter, o P, 4 14 iele ft. Depth to limiting factor > /R.~ S, Remarks: Boring # Z.~I -33 i0Yk4 S,L. si~ MCS .z A- kw~ . /14 r nrs - /AYe 414 Ground elev. iGYt3 ft. Depth to limiting factor /bbs l Remarks: CST Name:-Please Print 4INLY Nj5kl ~j Phone: Address: Signature: Date: Z l 9 1; CST Number: / PROPERTYOWNER'~~4' 111 "L"' SOIL DESCRIPTION REPORT Page 0t3 # PARCEL IA Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft rends Bed in. Munsell Qu. Sz. Conti Color Gr. Sz. Sh. l ~~l 1~ 3F5 1 6tilPk_4 Z S , L ] sk, r r s 1 ~ 0.-, 6.-3 Ground -Q 7 /Q'y P,6 h S i ] n, S b v T•) S C~ .2 (S.3 lev, S rn j CS 02 ~C3 0,3 17,5 Depth to 9-1Z~ JQyK4 L~ / limiting factor ? &A Remarks: Boring # Q - j 16,q 1-- ] A,,gU vTr W 0.4 `Q.< m.3- -rvl 6A :0,~ Ground ~ ~ !h ~ - .7 elev. pg3 S 12 l y 4 4 9rY7 ft. Depth to limiting factor 7 Remarks: Boring # In-to 16ve_,?j1 A Sb 1`- GW ]AF 0,416.,> lb-Z% / . S , C m S (A~ r,7 r US -1: $ IF,, g-3B J Ground ' ev. 'g3 6-f 16 kA 4 S ~7 r O. O ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: 8330(8.05/92) i la~Au(6 AT LsrC-60~jvk ~m . g ~ 2 ~ 1 ry vim' ~ ~ IVo~'T►-1 ~ \ J SU4LC ~ Ati 13 i ~;J C LOCATED IN FART OF THE N`V I/4 OF TiC NVV 1/4,OF SEC=TION 15 LEGEN - --1-- T 29N, R 191 , TOWN OF' FM)SON, S [CROiX COUNTY, W15COINISIN. 9 ALU.1 Mal 11 l`.l:i, 0 2'. X 30 LINEAR NOTE' sus vaxs.x . cl;ar2 ercAra. 12' wror I, Allen C. Nyhagen, rcjir:tered Wisconsin I,~r.' S:urvey,r, hereby certify that in full coei,liance with the provisions of M*pter 236 of the Wisconsin So' RO. Statutes, and un:l<.r the direction of Saes Biller, owner of the land RON01K dercribe'. on this plat, I ha.a surveyed, diviG. 1 aFKI rtWpp•d G: V1 X rP*.L7iY; that such plat correctly represents the exterior boundaries and the RROROS' 8uv<11v5e1c•n of the land su:vcyed; and that this plat is located in part of SHALL the N41/4 of the NW'_/4, in Section 15, T299i, R1901, Town of Nuds.,n, St. Croix County, Wisconsin; v¢1ON @£3.1011.4 at the NW cor==er of said Section 15; thence N810 11'15, along the north line of the NW1/4 of said section, 1320.96 feet to the cat line 1 J RREVIOU' of the NW1/4 of the WWI/4; thence S00002'10-9, along said east line, 183.42 feet to the southeasterly line of tLc ahonden•-d Chicago 4 North ern Railru4d; thence S42o151181N, alma] said southeasterly line, 1539.01 feet to th.> south line of the JWI /4 of the NW:/4; thence S89054'44'W, alonq said south line, 281.27 feet to the west line of the NW1/4; thence N09 1.2'49'W, along said west line, 1320.74 feet, to the pQlat D-f b,- *,ii;ej. Atwe described parcel contains 26.47 Acres (1,1.53,064 Sq. 4S I AS W'LLOSa RIVER ~i,NTE- PARK MM COPIER OF 1 SECTON 15 NORTH LINE OF T.E 4W N OEOIC aTFO TO N89'54' 9'E 1320 96 THE RVBr K 16u 41 92'-- ~cx>' YsJ toe R6' ~.sc~oo' ~ ?t - a 10' 00' Y ~1~ NwL •919.8 ! Ilr ~ N`'. ®I IL 9047 [K) 12798226'- 0 Z©~ l J z t5 I~ C Sff E r 2 4J 7it7"1 JZ ~-W r IB/~/" moo, I~ ) LOT 2 LOT 1 ® _ 2.11 ACRES 219 AC kES 92,085 0 FT 219 A'C O FT R BLIC Q OC// / q0 Jul ) O 201 ACREi EXC ESMT - 1,71ACAES EXC. ESMT W -77 67,633 50 F7 71,488 SG. Y " 2,cQ Ap / / 2/O0 30 1~[tjN / - t r Yom- \ Gs1 G 5 ~ E " LOT `0 3 LOT 4 2.47 AC RE5 .0 2 SR 4CF!ES / Q I EGG OS SO i W.640 S,') FT 2J 112,496 50 F[ 2 37 AC EXC. ESM- 2 225 ACRES E< ESMT a Ar•CP LOT 9 / 103, 324 50 FT. 91,997 S0. FT. .fib/ 2.73 ACRES IIAr79 50 FT \ 8300' `S 4 ..24 _._.•--y T ~~'C1jCCi i •i CIO " ----GRANGE 0900 20700' 15 7, 89'47'11 w 138 74'-~ r/" LOT 8 v 2-)- - - - _ - I 70 2242 ? .1 Q 2 ~ I 1242?r22 -A ' T j / / 0 O Z O ' ~Z I - 50 ~ LOT 7 329 ACRES 143,347 SO FT 00111 {AT UD10S CKMAL 01017 c10tD 3 LOT S e S IL IL UFM 77x12.7 lll]IN UNTI 2.73 ACRES 3.21 Ar Ex_ E;MT ? 1 119,002 S, FT 139,949 50 FT 1-2 4 117.09' 27147'10• 17515110 10.21' ° W,/ 1-1 7 ]11.19' 21°03'22' 174002'51.5'1 97.21' N •N , o° S-f 2 217,10' 76021'17' 171121'19'1 99.11' 2.68 AC EXC E-1 Z.S 116,703 SO. FT. R ~JJ q ,,p 7.1 1 211.11' 10021'00' 1711{2'22'1 121.11' 2 ~O I i .t" ti 1-10 f 111.90' 10011'00' 57409:'52.1 16 91' 0 ^ l(/ //C~ / 11-I1 1 211.00' 26021'14' S7205i'39'1 129.61' D 'q 11-14 7 167,01' 2100S35, S74102'51.5'1 69 72' I^ / / 15-11 6 111.00' 21042'10' 275121'111 121. 17-11 6 251.00' 79061'41• 125011'11.1 I21.7; t: ,kola 0 2 ]17.00' 1071'41• 162029'16'1 20.11' STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER _54/71 MAILING ADDRESS 34>K z 8 Z PROPERTY ADDRESS 2- A IV k_0 AD (location of septic system) Please obtain from the Planning Dept. CITY/STATE 14 y Q S o N W io t 6 PROPERTY LOCATION N LL) 1/4, A( k/ 1/4, Section ~s T N-R ! `l cii) TOWN OF P U DS ® W ST. CROIX COUNTY, WI SUBDIVISION &R A N VA L ~-E y1 LOT NUMBER -7 CERTIFIED SURVEY MAP 55o2y. , VOLUME (P 'PAGE , LOTNUMBER 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. o SIGNED: Q DATE: (O 7 - (o 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 .5,4 M M i L. L. Or- Q'L,_, Location of property /~~cJ 1/4 / !U 1/4, Section ! S TAN-R Township N U Duo (~l Mailing address Bo)( ~*a8Z ~E y0Sas W ( SYo/G Address of site Go'@ Subdivision name A N,Gt 1/~L~,E y Lot no. 7 Other homes on property? Yes A/ No Previous owner of property Do y ra L*S AINE Total size of property 3, Z 1 A L, Total size of parcel - 3, 2 / 14 L Date parcel was created '(P'- z 9 - l Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? X Yes No Volume /W2_ and Page Number /6? A 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. 5 cV yp a A , 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. S 3 q 4/ op Si ature of Applicant Co-Applicant i<zt ofig~~atur Date of Signature • / /~ICr Stale Bar of Wiua nyin 1 a t 2 1992 T/ DOCUMENT NO VII/ A R ~i v t~`( • pry Sf. , C~7., r! % Douglas C. Katner, BertkarJ J. N ut~an' SEf, 2 9 I9,,b ---rand Chris -P. -Neuman 12: 30 P Sam E. Miller conveys and warrants - Dri)F 'ik 0A A - o SPA~'C rESE1+VL nh.i NAVE AND RE TURN ADORES, I ~ the following described rea! estate in St . Cr0 i x County, State of Wucoasin: f! II ~+u (Pa t.0 Identification Numhcr) Z; NW1/4NIKI/4, Sec. 15-T29N-R19W, except Certified Survey Map recorded in Vol. 5, P-ge 1418 as Doc. No. 393288, and except Certified Survey Map recorded in Vol. 6, Page 1761 as Doc. No. 420627. i ( 1 i~ II II I' This is nothomestead property. (is) (is not) i I 'I Exception towarrantic.s: easements, restrictions and rights-of-way of record, if any. iI September 95 it Dated this -------~QI day or 19 _ ± 1 - (SEAL.) '1X1UltYle*o- (SEAL) Douglas C. Katner Bernard J. Neuman ? ~i - - (SEAL) - (SEAL) Chris P. Neuman AUTHENTICATION ACKNOIN'LEDG&fE.NT Qa-ere--~-c Signature(s) B~r)lard J_. NE'umanSTATE OF %Vkw~,W ! Chris P. Neuman Yt - County. i authenticated this day of _Sg.etDb-__ , 19_9.__ vu. n me this day of ISO amed t f as C. tfiet' Ra a , ZQ Krist-itna gland - TITLE: MEMBER STATE BAR OF WISCONSIN _ _ •,wM~~~~~~ • (If not. - - - - - - a of authorized by §7()6.06, Wis. Stets.) to mt known to be the perwn _ 4}yL'.( W,:, exanuLtfb foregoing inArurkwnt and acknowled tffe ~.1 y 7 '•?Z; j THIS INS rRUMENT WAS DRAFTED BY Kristina Ogland s -