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HomeMy WebLinkAbout020-1316-80-000 z w o O oo h ~ ti C C 0 C -O N O ' O N ~ O c O ~ X N 'C U ~ I o E M _O N U 0 CL Z N C N L M LL C f0 O m O a w I 3 ~ I z pj zv £ o 0 z y N a co N H w U) 0 c a -a m o z d c u M 'o - w o 0) (D z E '2 m aa) co N_ CL C c O 0 z° E z z N a ~ I - E N N N d - N E L ~g O c v `l co d a m ° o v o CO °v tN- IN- IN- O co cn ~ - O O O z ° •N ; a a a Q g N m 0 U) 0) 0) (n 3 L) ~C >oo - ~o o o E M m CL C m N N ~ N y a r m co d Q C U-) N N O O W N c ° a 3 w w o o 0 0010 0 g T c c o 0 ] N N (~6 ~ C C N A co N N r N 04 C? oto co U cu cc • O N 2 2 04 0 N Cn ~ E d m IL 7 C i (L CL u 4) rw C C `~1 A C) a 10 2 0 N V PIERCE COUNTY ZONING OFFICE As-built Plan For An On-site Sewage System Date of installation l ' Permit number State plan number Owner Address 11.S 'AfE: Sec.~~TO N-R / W, Town of Soyt Parcel Tax Numberd')p t,~) Lot Block Subdivision/CSM # Description of benchmark J Elevation G) Alternate benchmark Elevation **NOTE: Use filed readings and include benchmark reading for each group of readings. F. PUMP TANK HOLDING TANK INFORMATION: Manufacturer A r a k-' 1 ) xc iz l Setbacks: House ~ -3Well ~S P/L S~ 4i\,PC z~~ Pump manufacturer Model * Holding tanks only Setbacks: Service Road/Road Vent to fresh air inlet Water Supply Meter location Alarm location SOIL ABSORPTION SYST Type of system Yv2 S Width Length Number of trenches Setbacks: Housed L) Well 9/5`x ' P/L 36 ` Vent to fresh air intake .71A) ELEVATIONS: Building Sewer ST Inlet ST Outlet PC Inlet PC Bottom PC Pump off Header/Manifold Bottom System Final Grade Top of Manhole ST/PC Top of Distribution Box Distribution Lines NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system ON THE REVERSE OF THIS FORM. • Two horizontal ref rence points to center of septic tank manhole cover. Plumber signature License numbers Date PIERCE COUNTY As Built Sanitary System Report PLAN VIEW Show everything within 100 feet of system. 91 f f a I tavu q~ ~ a I i o I I I INDICATE NORTH ARROW Wi9consw Department of Industry, PRIVATE SEWAGE SYSTEM County: `Labor and Human Relations Safety and Buildings Division INSPECTION REPORT ST. CROIX (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 284221 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: HOLM, DAVE HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 00 ' IIJ-942le- 1,0 ;4A&!1_ 4VA=22 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic A;wo Benchmark o 06. Dosing o $v' Aeration Bldg. Sewer G,15' 98.35' Holding St/Ht Inlet lo•5v~ 9e.0 TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic s/00 3 NA Dt Bottom Dosing NA Header / Man. s; 30 0$ $ 1? 3 ' Aeration NA Dist. Pipe Y- C. Q$: o6 q.~ 1 s.s'. Holding Bot. System n PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand gg_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 1`20 3 DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type CHAMBER 3 , 0 14 OR UNIT Model Number: System: : 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: HUDSON.24.29.19W.SE.NE.BENOY DRIVE p Lo D (C~(~lc.C ,c.G~ra ~ Plan revision required? ❑ Yes [ErNo / Use other side for additional information. 1,_e IWI co d SBD-6710 (R 05191) Date I pe o ignature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: • ttttr~iiEii~ Safety o and Bu ilding Water Division Systems v~`■~n SANITARY PERMIT APPLICATION Bureau 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 /1 than 8 112 x 11 inches in size. 5 - Crui_ • See reverse side for instructions for completing this application State Sa~nitarryy Permit Number The information you provide may be used by other government agency programs ❑ Che~fc t revisi n to prev~fr application (Privacy Law, s. 15-04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner N^ ropert LgLation IIIALL) t MA ~ -1 /4 1/4,S T E (or Property Owner's Ming Address Lot Number Block Number Cit tat ~ ZMCd Phone Number Subdivision Nam' or CS umber t dQe 2r 11. TYPE OF BUILDING: (check one). ❑ State Owned ❑ ot~ N rest Road ❑ VII age ~n Ptfblic ' 1 or 2 Family Dwelling - No. of bedrooms Town of Ill. BUILDIN USE: (If building type is public, check all that apply) arcel 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. r%aNew 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( t t Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 25eepage 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./ c ) /de'•J Elevajign ~tt) D ~C3~ 144~Yln i 'yFeet /1 _ q Feet VII TANK Capacity 17 in gallons Total #of Prefab. t Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank p7l~ ` m El El 1:1 El 11 Lift Pump Tank /Siphon Chamber ❑ 11 ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sew ys shown on the attached plans. Plumber's Name: (Print) P b "s Signature: (N St ps) MP Business Phone N er. Plum er's Address (Street, ity, Stat gi off): 05,.- ejr j t ey&z~IY IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sa Itary Permit Fee (includes Groundwater Date Issue Is Agent Signature (No Stamps) Surcharge Fee) A /T^ pproved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: S9D-6398{R. 05/94) DISTRIBUTION: original to County, One copy To: Safety & Buildings Divi ion, Owner, Plumber INSTRUCTIONS 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. 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 administrato- 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- 11. 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 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. ♦ ♦ J ~ T I ~ C~ ~L Il ti~j ~ site. 3c? 36` tl M. 0,1 i.P iabo ~C 9rr~o3`d D° t tlo ~ t ~z i LWisconsin of abor and Labor and HumanRelations SOIL AND SITE EVALUATION REPORT Page of ~ 3 L and Division of Safety a Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY ST c,poi'X 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 nearestfoad. APPLICANT INFORMATION-PLEASE PRINT ALL IftF(~ 1 ~R~NrA.`~fQN REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION c?/ 14 3 /0,,f/P Y lPUSo OVT. LOT SF 114.VE 114,S29 T 29 N,R E (o Wi~ PROPERTY OWNER':S MAILING ADDRESS OT # BLOCK A SUED. N V E (2 06-E /Yl 3RD S T-. CITY, STATE ZIP CODE MBEd1 `t, CITY []VILLAGE [BrOWN NEAREST ROAD tfUPj.0 GJI, 510 fop vDSo.v /Y A/0y f>R . ['New Construction Use [kj-'R-- - enbafi/ 1Vprnber ofb6droom"s Addition to existing building [ j Replacement [ j Public or con mefdial a crib'P yS6 - Code derived daily flow &o O gpd Recommended design loading rate !!ff bed, gpdfit ~ trench, gpolft2 Absorption area required N )k bed, ft2 6'0 trench, ft2 Maximum design loading rate All?- bed, gpd/ft2 G trench, gpd/ft2 Recommended infiltration surface elevation(s) PC4 73 ft (as referred to site plan benchmark) Additional design/ site considerations &S46- i-k N C4-0 S - cvev&p D.~ e*o-qj T a U lt- Parent material 5o S .Sr> 13 uje&A 0Py7- /S47-7 *°E- Flood plain elevation, if applicable H A- ft S = Suitable for system CCONV~xrIONAL MOUND INN--G UND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for y stern LAYS ❑ U O S [ 1 01 ❑ U ❑ S 17 S ❑ S 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 iendi 10y'e 342- S// / 77,07 n~fit° $ Z T'C 'T 1-2 -1~ ~o y,2 ~//4y S// ~~wtS~,t iw►iFJQ cs l , S .G Ground 3 12-5^G 7, s Yie y/ Is cif a~S cS '5- elev. yy ft. 7,S R Y s ~,2 - - - Depth to j limiting factor _7V_ Remarks: Boring # / - 7 100f 3/a- -Fs .1 ,,-r,C S l of y . 5 cl~ o io C S l f, s, G Ground 3 elev. 1 • `f D 5 S//2 /~,t' ~~/ys . a ~Q - 7 ~oi.8o ft. 7, Depth to limiting factor Remarks: CST Name:-Please Print r2 o Q ER T- U 113 R I-C i..T Phone: 71 8 3 • s- Address: CSTti 2- y10 Z Signature: Qnwana consultants Date: CST Number: PROPERTY OWNER J-1 3 M - RU SC"(A- SOIL DESCRIPTION REPORT Page 201 3 PARCEL I.D. t LOT 53 SU.vR /DG Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Wed 1 a- 10 311)-- si I -W& -P pe c s Z 76 S 2-- NG / o YR 3/ S/. f Sl r ^.,-rR c s t -ic- , S • G f~ tiry .5 Ground 3 1~'1 7,5 l /*Vf C S • elev. 11 . a ~g ft. 1 -9 7S 7~w Depth to limiting factor Remarks: Boring # 0/f shJ~ A,. f~ C S f die 3 / . Y i. s /y 3y gay 3/~ si z he ~s ,s- Ground 3y-s' 7 s Vie sl 40 J~e a s y ' 103e1 it. s Y /s / f ,e ell e s s!- G Depth to l limiting factor Remarks: Boring # ; 1- /o 3 3 z -F s b K ~rv~f lz S f , S=• G So / o Vie 3~y S F / ' a, s , S G Ground yam,/~y elev. i i 7 /dC -1 7. (-'ft. Depth to limiting factor i Remarks: Boring # Ground elev. it. Depth to limiting factor t LOT /-or ~U 3 $ 5q J o 07- ,6A4 6G ' 12- Is • z T/ oA3 S Q y%. /(a , &V /moo a uD : Sv pu~yo p'S (3 Z /o 80' 2 " X;P ,117' 6 3 113 0 ' e/EP,trro.v ~y _ro3. f'o' f3s /07,ro 0/ 5G.4~E • ' 30 . O . 6 6 SOLD; . si . N ~ N .,.fir:;, •.i~ s ~ y -i D N s - tJi i1i , nw / 08W..T•~. / N sy - 6 N O of ;~r•:~ CO) OD > o N nco `O nw N r i r" to yos- ~ ~ o ' . s • ~ 1 k - •A Ln s , CY) I, ~ r fir' 1• A• r nri!t 1} 'l, tl~ , -ne 10 t~ ~ trj ,+a n ~~CLIi1~r,^t( l to X~', ul WT,.5 i (j1 It7 ;y TAwr~' C F ~t ~1.~ k~1s t`~ 00 ~In i fx y•,pt,• l , }y,J, . .y.s f .11.1 «.~n ,j~,Fl ~ ,t'. >t~a fit.( ,YZ ,'§~r: ~r :~1 l;'.~.1~~'•t'~'~'~~,}j.:~~.tr~~ ~1~.•t yy,~t ,,,~',!~~[A";.. 7~},., a .t~ 1' 1f~~ C •r X i3' ',ip,~r~jY • . . ~ '`r~4.t'd!''!+` _ ~ . + .{•'.Mp ' • '~.1~`L~. j. T.6e 1 ~ .1! .n ::.;r ~ • 1 i I ' f S k X • FRnM :EDIMG REALTY HUD_ON 1995.09-©4 11:41 #S@S P.0--'1o Wisconsin rrepartmsnt of Industry, SOIL AND SITE EVALUATION REPORT Page of Labor and Human Relations 151vislan of salary A 13Uldings in accord with ILHR 83.05, Wis. Adm. Code COUNTY 5r c,pol'X Attach complete silo plan on parer not lass than 8 1/2 x 11 inches In size. Plan mull Include, but PARCEL I.D.0 not limited to vertical and horizontal relarance point (IBM), direction and % of slope, scale or dimen9loned, north arrow, And locallon and d sianca In nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWN R: PROPERTYLOCATION 71,14 d 1"Iv y eosG A GOVT. LOT SE 114 A--` 110.1 T 19 ,N,R /9 E (oo PaOOEnTY OWNERS MAILING ADDRESS LOT 8 BLOCK 1 SUBO. NAME OR CSM I y%G 3Rv ,5 r. 53 so') R 106-9 CITY, STATE ZIP CODE PHONE NUMBER CiTY L-YILLAGE OWN NEAREST ROAD HUPJ-0-) CJf. 540 i(o 171513re-367 vDSd,v 9'cmo DR [t~Naw Construction Use [A4- Pssldential I Number of bbdrooms 3 I I Addition to existing building I i Replacement f'SC , i I Public or commercial cescribe _ Code defNed dally low e00 0 go Recommelided design loading rate N«' bed, 9Pdlil2! Of VenCk gPdAt2 Absorption area required N _ bed. P.2 trench, 112 Maximum design loading rate /V/4 bed, OW -1 6 bench, 9W2 Roosrtar &xW inllralon stxlace elevatlon(s) 5-44 Adi fl jas referred to Sits plan benchmark) Addltlonai design i sle considerations AI $ E- Tip N Goa i S - "J l t0 O-Ad Co-v 7" 0 V Parent material _ 5C5 5-1 14,veAA.wPr /s*77Zag Flood plain elevation, Itapplobte N ~ R S ■ Suitable Tor system ~ Q AL mol/NO IV-G UND PRESSURE AT-GMpE SYSTEM IN FIL FgLDOVf1 TAW U . Unsuitable for stem CAS I3 U ❑ S l~ t~ S ❑ U ❑ S ❑ $ My- 1 ❑ $ SOIL DESCRIPTION REPORT Boring N Horizon Depth Dominant Color Mottles Texture Structure Consistence GPD/it In. Muncell Qu. Sz. Cont Color Gr. Sz. Sh. Y Roots Bad TMn:h IF" k 0 -a 7 /0 Yk y/Y s/ ~-"s4e s ..rt 1°y2 c s ~ ~ , . ~ r Ground Z S ' 7, so V !s Ow. MIt trrr/ 9 9AL rt. 7, 5 00 4/ l' $ .2 • 7 - Depth to limiting lactof rl Remarks: - Boring N / - 7 /a vF m.e- n 7- Cy 'S '6 Ground ate". - yo p 0 It. Depth to - lmiting factor it - > f t~- Remarks: ST Namo:-Please Prin! Q O (3 E iZ 1_ u t• (3 R I.C L. T^ Phone. 71'5--- 3 • 8f "p rasa: //`a1 I- f G's'T~ ~-yd Z Sl~naturs; rIllt fkhi ►aaooltitsti n Private Sewage Consultants Date: CST Number: (1(', 885 O'Nsll Rd. Hudson, Wis. $4010 `pa o-/llro S >.~tam 14'~fi nt f' y r FPCM :ED I NIP PEPLTY HUDSON4 .v=._10 • 1995. D9-~:1 1142 lST,~~S P o; PROPEMOWNER_r' 3 RUS"- SOIL DESCRIPTION nEPORT Page Z of 3 PARCEL I.O. I Xa r .53 -570 AIR ID& Boring a Horizon Depth Dominant Color Mottles Texture Structure CoreAlAnce atonally Roots GPD/fl In. Munseil flu. Sz. ConL Color Qr. Sz. Sh. bed Tw& 717 -47 7& Z-- -/G o o J 141 I f s 6,r ^,-FA C Grouse 3 j/y /.y., n,, C s L( S eley. YR set .00 Depth to Orrddng facto f~ G`A Remarks: Boring A r . 1 /y , s , G (bound V--;re 7, s w s/ / An .s et t! 7, S Y~ y~ 1S / f oe Gl s C s 5 r L raj. D~pth to _ ilmlil faccttor Remarks: Boring A I-ayle J/L s iaye,~Z,3 zfsbx f/L s /f , 5 Ground 2 SD / 0 V4 S 3 441 el(eo - 0 ' O 7~S oe. gX E% /a7. 7<. - Depth to Amiling lector Remarks: Goring 0 - Ground elev. Depth to tlmiting factor _ Remarks: i' l..U ► L J T iU 3 8 s~ ~i ~I 3G ' 4M (35 I r i 1 5 E/EUhT~orJS ~ ~ II f3 s9. /(o ' /3N = fo u~,~ : sv,pvFyo,P's ` ,Z " zP -f 7- N~ /oT 1 Z 1o 80 fo~P~1E~P, Q 3 //3. o Ptr~oa ! ioo.o " ~S 0 30. -664 1- 6 $c~~(~ES~© ~Cl°~vC.G EIEV~T~O,uS = Q~K~' P~•TS N r~G~. T1e~~ ~ ioo•o ' Co~PIJ F T,~~-u tests .t s ~'Fo En M~ i J e j cam. 9 775' ' o~ ta.~, 7o v R low TR~~~~Gt 9S,~D 0 ~,.0 P I ! / ~1 ~ n ~ i L~ Mr ! r/ rr ,r ~ OD rt; T:I y ~a1 ~ ~ r ~ N O alb . r / ~ / +L ~ d I ~ ? 00.. 9 rr / ~ N .J v 00' PO? ^ I (~1g r 1 /1 ` bu y Nq~°t ZO 7g90 1 '0 S l' ~ f 1y > I V A, cl Ni VI 4 D N O ~ ~j11 fv w W j 'T~ ,w K - M ` ~ o v. w c :•j ar hP ry in ~ry _ V N g ~ `7Aild':•ei Q ti ~ • W W ON cgs y t i OI Q'. 7~ . \ ~ w s YY vd, (It 12 \ N A 'o t t'~~ S ~ n ~ ~ 60~{i u~ i C• I ~i g ~jp 1• ~y ryn0 js rJ Bill yC lftiS x , S I d ~nr~j C `,Q g~ 4( OY1 r Q \ d a m A OEv R~r~ X414 V¢ \M\, f I~1 Y y a Q \ tA- pg \ c n K t Y a ~~4 1 ;rl 61 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER( ' MAILING ADDRESS PROPERTY ADDRESS rC1 4 15~ Z' (location of septic system) Please ob in from the Planning Dept. CITY/STATE /4, ,9~ PROPERTY LOCATION 114, kt7i Section t o T G N-R,~W TOWN OFG ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER 5.' CERTIFIED SURVEY MAP , VOLUME , PAGE, LO NUMBER Improper use and maintenance of your septic system could result in its pre ature 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 fu ction 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 fo , 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 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 mai twin the private sewage disposal system in accordance with the standards set forth, herein, as set b the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and turned to the St. Croix County Zoning Officer within 30 days of the three year pi ration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 8 T C - 100 s This application form is to be completed in full an signed by the owner(s) bf the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/co tractor, (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 iL-e A~ A-)4 Location of pro erty2_1/4 F- 1/4, Section C""~v, 2q N-R W Township S6 Mailing address lc Address of site 5 Subdivision name of 22 t no. Other homes on property? YesX_ Previous owner of property N /4 X, t rT- /7 Total size of property ~ Total size of parcel r7 4 Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed fo (spec house)? Yes 7 zV No Volume and Page Number as recorded with the Register of Deedg>.~OD I l 9 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 rZyj~) ice of the Cou ty Register of Deeds as Document No. L, and that (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 my recorded in th%~cYi Vgf the County Register of Deeds as Document No. Signature Applicant Co-Appl can Date of Signature nat-P of ~in~at „-A _r t VOL 20f1 PACE15-9 REG R'SOr-r;ic WARRANTY DM) SE M CO., Wl 54974L SEP 2 0 1996 Document Number. st 8:30 A. M 'c Reaun 6 a oaaas legs ~ o r k Parcel I.D. Number. t r THIS DEED. -je between Greenwood Enterprises, Inc, a Wiacaosia corporation. Grantor and David Holm and Jodi K. ys', Holm, husband and wife as sur worship marital property, Gfaree- and valuable consideration conveys WTTNESSEI'H. that the said Grmtor, for a valuable consideration of osue dollar and other good to Grantee the foBawiog described rag estate in St. Croix County. Stsae of Wisconsin: III, filed in the Office of the Register of Deeds for St. Croix County, Wiscow in, on January 2, 1996 Lot 53, of the Piet of 9unRidge in Volume 6 of Ants, at Page 46, as Document Number 538046. <i This is not homestead property. Together with an and aiag aw the hac&umeata and app wwwu cm &mcionto belonging: and Greenwood rises, Inc. warrants { flat the tide is good, indefeasible in tee simple and free and clear of a wambrancea wcept easements, ions and reservations, restrio if my, of record and wig warrant sod defend the same. Dated this 12,'0 day of September, 19%. TRA ER $ D GREENWOOD ENTERPRISES, INC. GREENWOOD ENTERPRISES, INC. By: 110 By: amts B. Rusch, its president 4M* ,its se AVI'HF MCATION ACKNOWLEDGEMENT Y~ Signature James E. Rusch. as president STATE OF WISCONSIN ) this day of , 1996. ) sa. ST. CROIX penowdly came before me this Lois M y , 1996 the ve named Mary R. Rusch, its secretary • MEMBER ATE BAR SCONSIN day of Ifthlic, to be the who executed foregoing instrument ? and / THIS INSTRUMENT WAS DRAFTED BY: l`'~ dLG~~ , • e Las A. Murray Zilx. Edreca 3 O&W State of W 304 Locust Stied lty ooo=saan expires y ~1 P.O. Box 359 Hudson, WI 51016 Brenda Poulin Notary Public t ,tc. of Wisconsin t r # ~ ~ i a ~ s STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER alz ' MAILING ADDRESS no M 6 ~ r PROPERTY ADDRESS &PAn 2. (location of septic system) Please obtain from the Planning Dept. CITY/STATE U' PROPERTY LOCATION 114,A6114, Section T 2 N-R W j TOWN OF S6 ST. CR IX COUNTY, WI 2E LOT ER SUBDIVISION ' CERTIFIED SURVEY MAP , VOLUME PAGE 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 y or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the func on 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 maxim of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 197 1. St. Croix County accepted this program in August of 1980, with the requirement that owners of all ew 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 puff per 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 main in the private sewage disposal system in accordance with the standards set forth, herein, as set by he Wisconsin DNR. Certification stating that your septic has been maintained must be completed and remed to the St. Croix County Zoning Officer within 30 days of the three year piration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93