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020-1306-40-000
N v C) O N O p .^y v~ oU), a o 4 C p o v y 6 ~320 a d C Q C y . C Z N O y" NxL N.C ECOO mN OCO Co c1t, e•u~N 2cco a3 a p O wo _O 10 oO ~U N ~ ~•°~7 ~ I N N> N C U f0 0 y C« N ,o € N y C v ! y 1 O CO L _ N Q f0 "0 m .,E 0)) c~ E g QE~ma ! 4r) 3cL_ilC!g_ N = C C U- O N O.p N L ~,-0 7Oo (D ~.0 O c 0 •Q)? I O - C Z 'C j y z N V Z C L C O N 7 N H V.0 C 7 t0 co fOOt N LL CO fa Cp E N y LL " C d d y N 3 3 - m 0w>, CD yooc~ Q ova o c0 Z to z o c a N v 0) N H U) d co i d m LLJ o z v p - N N N H o r ° c E c CD E E N 9 N N U) L) C N m y C ~ I Y C a C L C U Y O C •p Y AD z x D Z m I I ! c d I m I R > m PO CL d L N - 1) d 2 co NF N V) E 0) a F co v1 U) fn o "N 4i V 0 0 a LL 0 o 0 a LL m IL IL (L IL a d to J U o Z U)) C) o I " j z C o o _ o CU r :3 CD '0 -1 co a) CD p 9 QI Z p CA ! O m a U ! •c y - 'o Q~ Z cn O a I o H H o 7 C co U) c 04 Cj 1- 3FF N U v o p C C O) ~ p 4) CY) 1~ d NVl d '-0 N Y US 4 N :3 CO - 2 m c m co O N N 0 Z Z 0 Z C Z O 4i Y E a E 4) y a m d a L: 0. od CL 2 41 CL 4) rr.~ y c c M C o A c°~a~ oU- 3w o 0 v)C~ , r 1/ r STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER /t";~fX z-P T - Cc ~ ~ t'I~d / -R/~1~ C.~ ADDRESS 70~ Z AyST SUBDIVISION / CSM# t, ~LLr LOT ti SECTION 2z T 2 ' _N-R~f W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM f'~/9C~ 3a / ,13 L s` sr 9 ` 7D 3 ~Lr 7 75- 42k' k' 7-2 INDICATE NORTH ARRO ,E . 16T r"C- ---7 Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: o Q~ % tC 41/ 4D, a / a ALTERNATE BM',Vj SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: [fiarc /Cs . / o0 Liquid Capacity: ~..5'. ZOO Setback from: Well > So House Other Pump: Manufacturer lac-[[tom Model# -S 3 Size ' ~-,p Float seperation_ Gallons/cycle:- .2--Alarm Location #,&F SOIL ABSORPTION SYSTEM Width: Length __2 2_ Number of trenches Distance & Direction to nearest prop, line:- 117 Setback from: well: > Sa" House Other ELEVATIONS Building Sewer_y'j rG ST Inlet. ST outlet PC inlet?,p; 2,z PC bottom_". %Z Pump Off Header/Manifold ?/..z 9 Bottom of system 91,3 Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: r LICENSE NUMBER: 3 2~ INSPECTOR: 3/93:jt WisLofati'n Department of Industry, PRIVATE SEWAGE SYSTEM [Sanitary ounty: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) Permit No.: GENERAL INFORMATION der's Name: E] City Village Town o tate Plan ID No.: Parcel Tax No.: CST B/ Elev.: Insp. BM EleVI A,a ~QA _/:3~ Yb TANK INFORMATION LEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark Septic p/o iD~ eo o Dosing Bldg. Sewer Aeration Holding St/Ht inlet 9 ag 1-7-2-i TANK SETBACK INFORMATION St/ Ht Outlet q, 5a' _q Air Intaktoe ROAD Dt Inlet TANK TO P/L WELL BLDG. vent Septic y/,~r q > 1S NA Dt Bottom / 73 C 6 9 Dosing 115 NA Header / Man. -7,3 r 4 1./) s NA Dist. Pipe 7. /Y 04 Cf 3 Aeration Holding Bot. System ~1. 93- PUMP / SIPHON INFORMATION Final Grade , y Demand ~O GPM Sstem TDH ' Ft ia. i Dist. To Well 09i SOIL ABSORPTION SYSTEM BED /TRENCH No. Of Pits Inside Dia. Liquid Depth No Trenches PIT Width Length . Of DIMEN 1 N l,~ ( 7a ` 1 DI EN I N Manu acturer. SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING SETBACK CHAMBER Mo el Num er: INFORMATION Typeo ~D, ep) '50" OR UNIT System:c Q DISTRIBUTION SYSTEM x Header / Manifold Distribution Pipe(s) Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. Sp acing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only De th Over xx Depth Of xx Seeded/' xx Mulched rDept:h Ove r Yes ❑ No ed rench Center Bed !Trench Edges Topsoil ❑ El COMMENTS: (Include code discrepancies, persons present, etc.) Plan revision required? ❑ Yes ONO RH~d i L ~j ~ Use other side for additional information. Cert. No- Date~ I s gnature SBD-6710 (R 05/91) ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:. Labor and Human Relations INSPECTION REPORT ST . CROIX Safety and Buildings Division Sanitary Permit No.: (ATTACH TO PERMIT) 268601 GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: HUDSON BAST, KERNON (HUMBIRD LLBMDescniption: CST BM Elev.: Insp. BM Elev.: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9600323 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet ventto TANK TO P/L WELL BLDG. Airlntake ROAD Dt Inlet 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. Fi Dist.Towell SOIL ABSORPTION SYSTEM BED /TRENCH =Width Length TGW PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I N DIMEN I N Manufacturer: SYSTEM TO P / L LAKE/STREAM LEACHING SETBACK CHAMBER Model Number: INFORMATION Type O O : I UNIT 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 =rvncrh xx Depth Of xx seeded /Sodded xx Mulched Bed /Trench Center s Topsoil E] Yes ❑ No ❑ Ye s ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.27.29.19W, SE, SE, ORIELE LANE Plan revision required? ❑ Yes ❑ No Use other side for additional information. cert. No. SBD-6710 (R 05/91) Date Inspector's Signature ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: _ Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau Building Water Systems V~~■~■7A 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. State Sanitary Permit Number • See reverse side for instructions for completing this application n r O' 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 f Property Location N, R E (Of~ N SST V y~ ]Yd r--~Wo CQ 1 /4 1/4,S -4,,? 1~2 Property Owner's Mailing Address Lot Number Block Number MV City, State Zip Code Phone Number Subdivision Name orE9 -NVM ber A/. Lc~ "-Yo ( 3 0 72 /~ui cK /ftLLS W. TYPE F BUILDING: (check one) ❑ State Owned LJ itj~tearestftoadd ❑ village Public 1 or 2 Family Dwelling - No. of bedrooms Town OF U o L Parcel Tax Number(s) 111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apartment/ Condo 030 o yo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 El Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ MobileHomePark 12 E] Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. C] Repalnof A) 1 Tank Only Existing -System g_yst - System System em Q(o.Zif168 S'J,ZV~b B) A Sanitary Permit was previously issued. Permit Number Date Issuedp /5-/ 9A7 V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 110 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank ❑ 12 ❑ Seepage Trench 22 F1 In-Ground Pressure 42 Pit Privy 43 E] Vault Privy 13 E] Seepage Pit 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. E. Fin evati l Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 6 ©O doI 3 Feet 'Feet VII. TANK Capacity Site Fiber- Exper. in gallons Total # of Mapufacturer's Name CoPrefab ncrete Con- Steel glass Plastic App INFORMATION 7Ne w Ex istin Gallons Tanks L strutted ks Tanks ❑ ❑ ❑ ❑ ❑ Septic Tank or Holding Tank /Z ~4 d O a~ c __A77 : ❑ ❑ El ❑ 11 Lift Pump Tank /Siphon Chamber - 0 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Si9nat r1N0 St , ps) hRP{MPRSW No.: Business Phone Number: v - Plu er's Address (Street, City, State, Zip de): e (--.,-F~ IX. COUNTY / DEPARTMENT USE ONLY ❑ mps> Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agen surcharge Fee) Approved ❑ Owner Given Initial 8 l4 ! Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: -TT%10 Cn. 105q5 p AA t ,J' A.Q 10-•!) PAA SBD-6398 (R. 05194) 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. 111. 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. Vlll_ Responsibility statement. Installing plumber is to fill in name, license number with appropriate pre,-!x (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. 4. DAVE FOC&W Pwrr~er Ucensld PKk 03233 fie fty f <otis'T C &rST ©fi LiH- ~ s' G-At= s ~ s-o 4 1 LvT y 9 F 5'~C La 7- ~r k =/3orccrv~ L/ O /~2S/7Sr/ 6/4G to~sriT- n 7WN4 O = u,~~c I , oc x,6 3 37 #y #6 X K /2 ~r 2 r +St 3 x ~l 6016 #Cnopaojr!!~v ~P/? ORr~GF z0 I ~ '.i J? ~ h a ~ w a~ V WA: t1 I Na I~ ~ A A a N _ ~ ~ ,i ! CdZ'u~i W ~ N { to C c j i ^ ~ 11 w I ~ ~N r C. F ~ PUt-^\P CHAMBER CROSS SEC T IOIJ AMC) SPECIFICAT10kiS PAG F / VEMT CAP ``C.I. VENT PIPE WEATHERPROOF APPROVED LOCKIAIG JIJUCTIOIJ BOX MANHOLE COVEF, ~ 25' FROM DOOR. ~s WINDOW OR FRESH 12"MIU. AIR IAITAKE I GRADE I Y" MIIJ. 18" xi W. COIJDUIT-- X11 PROVIDE I INLET AIRTIGHT SEAL f A I ICI ~ III I I I ALARM B i I AI/ y *APPROVED I ON , / YS JOINTS WITH I 123 7~ ELEV. FT. APPROVED PIPE I 3' ONTO PUMP OFF D SOLID SOIL COUCRETE DIOCK RISER EXIT PERMITTED OQLy IF TAUK MAIJUFACTURER HAS SUCH APPROVAL SEPTIC E SPECIFItATIOUS DOSE TANKS MAUUFACTURER: u~~r~EJZ (JUMBER OF DOSES: PER DAB Zia TAWK SIZE: 7-5-0 GALLONS DOSE VOLUME GALLOWS ALARM MAUUFACTURE.R: D`L ✓ IkICLUD)NG 6ACKFLOW: GALL MODEL IJUMBER: CAPACITIES: A= 33 UICHES OR q42- GALLOWS SWITCH TYPE: /0;1 c k1p N g . z INCHES OR 2k GALLOIJS PUMP MANUFACTURER: 957dk425- C= 14 IWCHES OR 22y GALLOWS MODEL NUMBER: wr -xL D- L INCHES OR Z- GALLOMS SWITCH TYPE: AlTkl Iy~.r~ C NOTE: PUMP AMD ALARM ARE TO BE MINIMUM DISCHARGE RATE -3D GPM INSTALLED ON 5EPARATE CIRCUITS VERTICAL DIFFERENCE BET WELD PUMP OFF AUD DISTRIBUTIOU PIPE.. JP FEET Y rrrx7rlc,(, + MINIMUM NETWORK SUPPLY PRESSUR~T,E~/. . . . . . . . . . "Z'~ FEET + " FEET OF FORCE MAIN X FY loo FtFRICTIOU FACTOR..' FEET - TOTAL DS JAMIC HEAD = /oD FEET IUTERAIAL DIMEMSIOMfo OF TAIJK: LEAIGTH ;WIDTH -;LIQUID DEPTH 57 SIGUED: LICEOSE HUMBER: j~~ g DATE: Performance Submersible Effluent Curves Pumps METERS FEET 100 30. - SERIES: 3885 ' p SIZE: 3/4' SOLIDS 1 RPM: VARIES I ~ i %5GPM 80 i sy........._ . - - - i I = 20 lip U O'L t ' . ` . I , z I 40 W O ~ 10 : ! 20E 3 : i i f 0 00 20 40 60 80 100 120 140 160U.S. GPM 0 10 20 30 m3/h FLOW RATE ~GOULDS PUMPS. INC. WATER TECHNOLOGIES GROUP SENECA FALLS. NEW `1VW 13148 METERS FEET I ! SERIES: 3885 120 35 SIZE: 3/4 SOLIDS 110 I RPM: 3450 k 5 GPM 30 100 i 5 90 I I ; W 25 80 i_- . - _ i l I U 70---+- 20- z : 60- o W 50 y 15 r O 40 10 30 I . I I 20 f 10 I . 0 00 10 20 30 40 50 60 70 80 90 100110 120 U.S. GPM 0 10 20 30 m'/h CAPACITY Fl1edive July, 1993 4'~ 1993 Goulds Pumps. Inc. SPECIFICATIONS ARE SUBJECT TO CHANGE WITHOUT NOTICE. PRINIED IN U S.A. 038853450 W, S, ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: tttt~~~"~"in Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave. 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. . CRe27X • See reverse side for instructions for completing this application State SAT eer,,i fiber The information you provide may be used by other government agency programs (Privacy Law, 5. 15.04 (1) (m)]. ❑ Check if revision to previous application State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name _ Property Location . > , 7 ? . N, R E (O Property Owner's Moiling Address Lot Number - Block Number ly 9_ Ci State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ icy Tel rest Road L~ Village Public 1 or 2 Famil Dwelling - No. of bedrooms j Town OF ZEL III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment / Condo / -3 ? _ Vd 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. El New 2. ❑ Replacement 3. Replacement of 4. ❑ Reconnection of 5 E] Repair of an - ----System System Tank Onl y _ Existing System Existing System B) F1 A Sanitary Permit was previously issued. Permit Number t ,ti ' , r 3Y Date Issued ,~"f r°,JF V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 IJ 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 13. 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 . 7 7 ~3. Feet e-' Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Plastic Exper. New Existing Gallons Tanks Concrete Con- Steel glass App. Tanks Tanks strutted Septic Tank or Holding Tank S ❑ ❑ ❑ ❑ ❑ 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. Plufber's Name: (Print) Plumber's Signatt re jNo Stamps) fCRP/MPRSW No.: Business Phone Number. f 1i`~ i f T ' F%f s7 t_ . "/;r - 5-4, PI ber's Address (Street, City. State, ZipaCode) ' IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved SAnital Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (N9.Sta,}xrps} ••1 Surcharge fee) e a . Approved ❑ Owner Given Initial 11 Adverse Determination / 'J - - - X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety 8 Ruildings Division, 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 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'3 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 K 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 ontrolsl- dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manu facturer; D) cross section of the soil absorption system i f 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. AS The monies collected through these surcharges ar d for monitoring groundwater contamination nvestigafiions and establishment of stand14sNumba Name pate tt~tri""iill~ Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building water systems In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave. 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- • See reverse side for instructions for completing this application State Sanitary Permit Nurser 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 Owner Name Property Location 7-. F 1/4 c 1/4, S T y^ , N, R E (or( Property Owner's Meiling Address Lot Number _ Block Number Ciiys State Zip Code Phone Number Subdivision Name or CSM Number - 7j2 II. TYPE W BUILDING: (check one) ❑ State Owned ❑ clt~ Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms Town OF l'a> Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1❑ Apartment / Condo f- s a_ y 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. E] New 2. [j Replacement 3 Re lacement of ` S E] p 4.0 Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) d A Sanitary Permit was previously issued. Permit Number Date Issued TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 E J 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 G J 11 `t ' ? Feet` . Feet VII. TANK can City INFORMATION in gallons Total # of Manufacturer's Name Prefab. site Fiber- Ex per- New Existing Gallons Tanks Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank f"s; t,.. ,c-r ❑ ❑ ❑ ❑ ❑ 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'sName: (Print) Plumber's Signature:_(UoStamps) Pfl- RSWNo.: Business Phone Number: PM_P . 47A TY] Plumber's Address (Street, Ci , State, Ziprode) a~ IX. COUNTY / DEPARTMENT USE ONLY j ❑ Disapproved Sanitary Permit Fee (IncludesGroundwater ate Issued IsSuing;Agent Signature (Nq.Sta ps) Approved ❑ Owner Given Initial/ SurcbargeFee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety 6 Buildings Division, 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 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 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. AS BUILT The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of std NWAber Name Date Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water System! In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave. 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. - cxarr • See reverse side for instructions for completing this application State Sanitary Perml Number The information you provide may be used by other government agency programs (Privacy Law, s. 15.04 (1) (m)]. ❑ Check if revision to previous application State Plan I.D_ Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location C 1/4 v4, S ~7 T.,._ , N, R E (or Property Owner's M fling Address Lot Number Block Number mo .2 a0V City, State Zip Code Phone Number Subdivision Name or CSM Number W) DZ xr1 Ill. TYPE F BUILDING: (check one) ❑ State Owned o Ity Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Village Town OF I&P5 ZX II. 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 0 SyNew stem 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ______________System Tank Only Existing System Existing System --------------------------n------------- B) A Sanitary Permit was previously issued. Permit Number ~S ~a C~Cpg Date Issued g' .y V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 pf Seepage Bed 21 ❑ Mound ` 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure ~D VJ e- V d 42 ❑ Pit Privy 13 ❑ Seepage Pit ~J 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 13. Absorp. Area 4. Loa reVQACe. stem Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/, P Elevation 10a Ifs- Ir ' / YA 3. Feet . 6 Feet VII. TANK Capacity INFORMATION In gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex per- New Existin Gallons Tanks Concrete Con- Steel glass Plastic App Tanks Tanks trusted Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of th onsite sewage system shown on the attached plans. PI tuber's Name: (Print) Plumber's Signature: N Sta 11aWMPRSW No.: Business Phone Number: T ~Z d 9 7 umber's Address (Street, tit , State, Zip de): r r f 6 s~r IX. COUNT if DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No S) Approved ❑ Owner Given Initial f ' Surcharge Fee) Adverse Determination pO X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-6398 (R. 05/94) DISTRIBUTION: Original to Counly, One copy To: Safety tt Buildings Division, Owner, Plumber INSTRUCTIONS =r', 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. Onsit'e 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 rame, 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. Safety and Buildings Division ~~■~r■r. SANITARY PERMIT APPLICATION Bureau of Building water systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. j. ~..T, • See reverse side for instructions for completing this application State Sanitary Permit Number C*a q 4 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 LD. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name •_S Property Location 1/4 T /4,5 N, R`° E (O' t 7 Property Qyyner s Mailing Address Lot Number` Block Number Ci~Y/State ZI Code P er,I Subdivision Name or CSM Number 164 4j- X1:0 i!~1_CS II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ city Nearest Road Public 0 1 or 2 Family Dwelling - No. of bedrooms E] Town OF !`'-fir: L/1%. III. 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 online B, if applicable) A) 1. E] New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank OnlyExisting System Existing System 8) ❑ 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 E] Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 n Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43E] 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) v. Elevation / i > C? Feet Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Plastic Exper. INFORMATION Tanks Manufacturers Name Concrete Con- Steel glass App. New Existin Gallons strutted Tanks Tanks Septic Tank or Holding Tank ?f! f`~" ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation ofrthe onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's SignatyLe:-4O Stamps) r.PRSW No.: Business Phone Number. I 171, Plumber's Address (Street, City, State, Zip Code): 17 IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issue Issuing Aggnt Sig naturgANo5Cjmps) Approved ❑ Owner Given Initial SurcnargeFee) , j Adverse Determination - X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety a Buildings Divmion, 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. 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 all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. Vlll. 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 cf 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 1 15 form; and F) all sizing information. r 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 m ,A"Woundwater contamination investigations and establishment of standards. Job Number Name Date rI DAVE ~eT y9 Rood RWIN 5023 749-3656 /00.v "r /z OD X = p0/Zt'N ~ = sNR Fov ~llE p w6GG > 0 EL6r/ . 93.'~ ~ Ll i 8• Q=-F i X 9o ti N 42 6, I 2 f ~ n acs X YaT rsr ~r/ r .vc Kr ro T~ ~R d W/ cloy i =fit' !v t ~ , i i i - - _ . _ t ~ - : _ i - i _ ! 11 ; } ~ _ _ _ i_ i ~ I r - - _ ~ ~ - _ ~ i , t i i i i ~ _ ~ t I a a ' j DAVE FOWTY PLUMBING 1-OT V? ~#3~ Pkmftr 23 sci4 « / 2O ROYEWM11 Road = ~ OD• 0 ` jo/~ of / " rti.~ vs~ ~ phone 749.3656 4 +*l x = f/O/Z rN ~ ~ = sy~~~y Fov ~rE i, Zoe S • ~ • I O _ ~ ~ wF LL > ~v F,~ON~ s ID s. t_ j i ~ i - ! I l Ll !b z , g, P2.~ f i I / i I r l ~ i I I t i 90, K L K m J -7 C I x ,___J !I X LUT 17 I I A w of Z p b CAM j ~a ~w II ~ W Labor bor and d n Human Relations Industry, SOIL AND SITE E V A W' 11 9"P P O R T Page ~ of 3 Division of Safety & Buildings in accord with ILHW K / Pa COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inch si~size. kab,0lude, S! C not limited to vertical and horizontal reference point (BM), directotnd % of slope, scale o PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest 't j?t _ D V-0 APPLICANT INFORMATION-PLEASE PRINT ALL INF TION ST CRCXX REVIEWED BY DATE t_01 +fly PROPERTY OWNER: i~A,r/ 3 7- 5 VT. /4 rE 1/4,S-7 T ,N,R E (or~ PROPERTY OWNERS MAILING ADDRESS ~ L _ # SUED. NAME OR CSM # i /SrTGGS CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST ROAD 9 (42"22-a 6- WX p 6 ( ) - 7071 C 4~r~GE New Construction Use [~J Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 6D0 gpd Recommended design loading rate __._7 bed, gpd/ft2 . S trench, gpd/ft2 Absorption area required off-8 bed, ft2 7-5-0trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) ' ft (as referred to site plan benchmark) Additional design / site considerations .76 " car ofz- *3 Parent material Flood plain elevation, if applicable It w7 S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem [a S❑ U El S 0 U 0S ❑ U ❑ S m U ❑ S O U ❑ S VU SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Boring # Horizon Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench y": I s~ Sd F!z S "3 - SsL L FT S elev. nd _ 2 2 7 5_ - 6 o SG L ,9s F8.6 ft Z - 9~ - 5' 6 I o L _ Depth to limiting i factor Remarks: z w co~3 Boring # :r:<.<r.>.::>.:: S2L TRH L 0 , O _M Fr Ground 3 -~S - S c L L t/.? X &I F/Z eS elev. a, ft ~ co b S ~ /Sll L r - ~ Depth to S ~O6 5 a G /Yt L limiting factor Remarks: #y - F -r,5-* H7- CST Name:-Please Print Phone: v1 13. Fo X E T -36 5_6 Address: Apr i3o o 19c -rr w1 S Yoe 3 , 3133 Signature: ,1 ~~2! Date: 7/-4 f IC CST Number: PROPERTYeOWNER :t'Ftiy rli~ST SOIL DESCRIPTION REPORT Page z of PARCELI.D.# ~~o- i~od-YD Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bouncf~y Roots Bed Trencfi - / r L ZZY S XA~ / s::< 3 93, y /a - 1 z~ 3 N F GS O o Ground _ z /o ^ sZ L /V) L 17 s . o • o elev. /DD,/ ft. 9A-17 - f ©SG All 1- 7 "V Depth to s 42-,rd s- _ s co sG Al L /9'S ~AXA limiting factor 6 0 /of 5- - 6 s o s~ Z - - Remarks: aAi s- frFe-z) *5&vE rv®T retL- etlt= Boring # x• SIk Ground -3 4- - MsL~ L 17 I~ 3 elev. y6_3 9 0 /u r- /W L 9G.6 ft. Depth to limiting factor Remarks: Boring # j~ Z- 3M -5,6x /H Fr RY 2, 3X M Fr es \S:•.iitiiii:iii Ground elev. y8 -3y 92.3 ft. Depth to limiting factor Remarks: 43 70 Boring # f t :r » I o-~J i o- 3 i - Sr L A//f S ~ v 2 lo-37 SG L -.114 34?1< I C I F s Ground 3 0,/S-6 ) L - 7 elev. - 71/ 7.5- - 4 - ©SS L s ft. to s~ 7 - • s - M v L Depth - - . limiting factor Remarks: SBD-8330 R.05/92 - ~Lc jd S'<,gGF, 1f/Q /pB, a~ Taf B~^ tip Lv7 CORNER / ~t/~~ Tedw #3n3 #3289 F R !f2 t1 = y~ ~i, ToP os.eiv~E ors R~$,-M A$ Mmm 749.3854 X = doAtdG 93. y ' SST /~sF i G~+~rtCG Q ~ 2 fi~A , ~~C~dGf X I t /Ax-l"Ay ~y 90 , I ~z i r I a~ yv' f X I / CiYLT F/eR~ATE) x ZD #3 J x s t 3~D ,2t" cuT , y8' l~ 2> p oaZ i I : R~JCf.'11'tt'~ t •;;~4~ ~R~'~ ~i317'lt~ia_: ' _ , - I I 2 f-O _ I I j I I i { 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 P lfiol. errs N D CORP (BASF KERN ~)City E] Village Town of: State Plan ID No.: , ~ Hrips'n CST BM Elev.: Insp. BM Elev.: M Description: Parcel Tax No.: B TANK INFORMATION ELEVATION DATA 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 ir Ito ntake ROAD Dt Inlet TANK TO P/ L WELL BLDG. A 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 I Loss Friction System Head TDH Ft TDH Lift Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of 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: HUDSON-27.29.19W, SE, SE, ORIELE LANE Plan revision required? ❑ Yes . ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. SANITARY PERMIT APPLICATION Bufereaauu oand f of B uildildiinnggWaterlSystems Bu In accord with ILHR 83.05, Wis. Adm. Code 201 E. Washington Ave. 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 8112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check if rev ion to revidus application (Privacy Law, s. 15.04(1) (m)]: State Plan I.D. Number 1. APPLICATION INFORMATION --PLEASE PRINT ALL INFORMATION Property Owner Name t .,,ti f r (y„~ Property Location A- r eY K Car orb 114 1/4, S,Z7 T ,,Z9 , N, R E (ool ? Property O ner's Maili Address ,J Lot Number Block Number t3r-7 city/state Zi Coe P Subdivision Name or CSM Number Ill. TYPE BUILDING-: (check one) ❑ State Owned ❑ City r earest Road Public 21 1 or 2 Family Dwelling - No. of bedrooms Toan of Grp p Fz L III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment / Condo Z d 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 Q 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. rpj 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 410 Holding Tank 12 01 Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fi I I VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate L6. System Elev. 7. Final Grade Required (sq_ ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ! Qya Elevation 7 D r0 . $72.91 rFeet pT.s' Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Site Fiber- Ex per. New Existin Gallons Tanks Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank Q 0 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ El El El El ❑ I I VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation o e onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signatur mps) r PRSW No.: Business Phone Number: 7Yf -A" um er's Address (Street, City, State, Zi Code): IX. C UNTY7DEPARTME USE ONLY ❑ Disapproved Sary Permit Fee (Includes Groundwater ate Issue Issuing Ag t Sign Approved Surcharge Fee) ❑ Owner Given Initial /Zvl A50 SE 7)< s/a~- Adverse Determination ` X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings Division, Owner, Plumber t • r 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 plan's 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, locationof 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 1 15 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin-Act 410 included the creation of surcharges (fees) fora 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. DAVE FOGEi f PLUMW46- l Tor,' af= PZ j~ f=~'o ~sE Llco~ Park T r Pr alber I zs qS- y _ ~E she TG ROOM", WIMRO*d IN X23 Phone 749-36% i Td T/~~S ~LC~G~RE Gf ~y i. ski 'Al 4 i ~y i ' ~3 ~-'tea • " ~ #3 x r +eas ~ v 1 Ike > moo' s! Z A/ 27` Li T 9 lrclw_ ' / a =30 1j = I. A& I 7v,-,;' Of I" $T NC L e7` c o~e~vs X =ddRrNG e = rok~v 46- ceye.vFjZs ° = cvscc a lSeoJK s-T• s'•7 = - O, zZEv W.2- ti 92.s ' (ECG ~,.rN- SE7'~C~cs /rccvttrv7~~ Mf 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 ST. G~Po~ )C 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 PROPERTYOWNER: f L,q,vD PROPERTY LOCATION vL- 0,4 ,v - GtiAr.P.y y GOVT. LOT SE 1/4 SE 1/4,S 2 7 T ZY N.R If E (or) W PROPERTY OWNEIT:S MAILING ADDRESS LOT BLOCK a SUBO. NAME OR CSM a 3321 )Z.12oB~TS ST V -ViUMRi PD Hills CITY, STATE ZIP CODE PHONE NUMBER (]CITY (]111LLAGE HfOWN NEAREST ROAD T / uL ~1N S5/0/ (G.i) zz2-5555 +1uf)Sot') Vf'New Construction Use ( /.j-iesidential / Number of bedrooms -3 Addition to existing building I ] Replacement ( ] Public or commercial describe ys~ - Code derived daily flow raoa gpd Recommended design loading rate bed, gPd1ft2 trench, gPdjft2 Absorption area required bed, ft2 trench,1112 Maximum design loading rate bed, gpd/ft2 • trench, gpo19 Recommended infiltration surface elevation(s) S C 3 ft as referred to site plan benchmark) Additional design/ site considerations ,f/rt~,t°0 w 7i °'-t~44(-f • Parent material $CS ~/P~h.9 SOT Flood plain elevation, if appli6able &-4- ft S =Suitable for System ATONAL MOUND IN c~oUND PRESSURE AT GRADE SYSTEM NJ FU-i HOLDING TANK UK! O S O S U= Unsuitable fors stem 11_7 5 O U ❑ S 2 Ir S❑ U D S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouxby Roots GPD/fi in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed tericft 0-/g/ /o%e,3/3 S/ if S4X 4,vlre e5 3 . S .G y /y'13 /dl//~ CS Ground 3 23 -5x 7S i/i2 elev. C'-S Q .S .7 00 %/'9;L ft. • o o io s/4 Depth to limiting factor l Remarks: Boring # ca,yP~ { / D-/ 4"' t,54/" 2S Z+ a iti El z -2s /o y,P y/'e /-f y -5 Ground / D e S ~ ~ 7 elev. y~~ /S ~f' G~~C V-5--4 ft. 5 Depth to y limiting factor ~ w PROPERTY OWNER SOIL DESCRIPTION REPORT pap of 3 PARCEL I.D. f y~ ` 1•y~i.P1~ ~filjs Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourd3y Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed tench /o f 23 ~sy 4 4 fill si 2 r era u 4 t' 0-5* N m Ground -3 3G /a iP y 56,e elev. Depth to R r s, D = S , ~,Q _ . 7 limiting factor F-T Remarks: Boring # / 10-// /oYe 3/3 S~ /7rS~✓',~ ~ S z f y - s a //-141 m )1w 17-f 3 zy%3 /o ye y/3 Ground elev. sp 7 yw 0/~ - l5 iP CS - ' 97_5G_ ft. . ? j Depth to € limiting tactor_ „ y Remarks: Boring # 313 - S~ /-(SAe n.+V;e 7S- z f y S /29 es- /of S elev. Ground c 7. 5 A0 S G'.S. D,S 7 Depth to limiting factor N > Remarks: Boring # ' € Ground I j L ol- I N 13Af=ro~afi„ SCSI E • I 30 =P. Ar .v. E a r co~ev by ~y A5 W 0 /r0 $ 90 a, /-,Z 06 z7' c So.wr L. L O it U,4Tioag 13 z yS,Zg " SvG~sa~,~ sysr~,,y ~~TiOVS ~i~,Pz',¢ 's3 -13yS X33 cvpv~ T,c'~-vy~~ /~c ~f'lo~S 1 N °3010 W 664,12' S F9° ~ V S45'50'00°W ti,t 86.82' S44°10'00"E' J..-.I 66.00' 7 S76 463.13' I I V u So S9 I S~8 S89°30'15'W 942.42 Z ~y 0 (.0 QD ~ ti M w w 0: U O cr p °ry 10 a c~ a (A N\ ? J O N M ~ p ° ti N w 0 1 OD R ~ 391-71 to co RIOL E _ / - ~ ~N 0 0 S _ 9 52'4q.. --~~211.75 W -X. 391.75' 6 o~ _150.00 / . 3b.00'- - - - M (D ` M M LO t0 Q qq- O O C U) w N ww c; u U N ~ Q v_ st m n O 1. N O NM_ ~ 0 If) M M ~ N OQ V ~ 10 ~C -cw ^ lq- t0 p N05059'3q"E (n U- N LL 3 ^ u (n Y h Q W U N W 0~ OD Q p _N o Lc; CID .10 J M M o p M 0 ^a. ~ ~ M 3 ~ 2 M cf) OD N Z O O w 9i LO cr M U a Ocy i 200.00' 95.00' 255.43' 230.00' N 00° 19 '40" W 1' If WEST Ll U N PLA I I rE v LA'NDG STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MAILING ADDRESS :zoo - PROPERTY ADDRESS 7 " - (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION -5 1/4, .,S 1/4, Section 27 T~N-R ! 9 W TOWN OF ~-s ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER_ 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 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 b completed and returned to the St. Croix County Zoning Officer within 30 days of the thr ion date. SIGNED: DATE: St. Croix County Zoning Office 400-- C 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 . Location of property .SL 1/4 .Sr- 1/4, Section 2-7 , T~N-R_ !1 W Township MailingaddressZpD - Address of site 7l-L Subdivision name Lot no. Other homes on property? Ye No Previous owner of property ~ 49L;7 /4' 'C - Total size of property_ rA.d-. Total size of parcel '-3, / Date parcel was created /1 c~ T Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes No Volume,?.'5-9 and Page Number 2~J 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. _ ys L Z-(r , 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. Z" S' atu is Co-Applicant Date of Signature Date of Signature - DOCUMENT NO. LSTATE OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED IOR RECORDING DATA WARRANTY DEED 85.9PASE 29 REGISTER'S OFFICE This Deed, made between ._.-David Kelly and Katherine T. St. CROIX%, W1 Y 1Ce11 _ his__vife and on her own behalf Reed for Record • DEC141989 aad___.Humbird--Land•-Cor oration---••- Grantor, : 1?..... ' 12:05 P M ly of ~ Grantee, Witnesseth, That the said Grantor, for a valuable consideration • conveys to Grantee the following described real estate in .St.-Croix_______________ ETU RRN TO County, State of Wisconsin: The following described land all located in Section 27, - - Township 29 North, Range 19 West: Tax Parcel No: The NE} of the NE} EXCEPT Lot 1 of the Certified Survey Map filed December 3, 1979 in the Office of the Register of Deeds for St. Croix County in Vol. "3", Page 894, Document No. 361546 and all land Easterly of the Westerly line of the "Private Easement" as shown on said Certified Survey Nap; The NWJ of the NEk EXCEPT the West 22 rods thereof; The E} of the 3W} of the NE};PlNSF The SE} of the NE}; $ 7 0o The NE} of the SE}; FM All that part of SE} of the SE} which lies North of the right of way of Interstate Highway 94. This S Aot------- homestead property. !os) (is not) Together with all and singular the hereditaments and appurtenances themunto belonging; And..... David• _ Ke 11y . And - Ka the ring. T.,- Kelly • warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except - - - - - - subject to existing highways and easements of record and will warrant and defend the same. Dated this /Y day of December 19... 89. .---•--•......••••------••-••-----....(SEAL) ......tl„✓.4. (SEAL) ' DAVID KELLY • (SEAL) - (SEAL) . KATHERINE T. KELLY AUTHENTICATION ACKNOWLEDGMENT Signature(s) avid- Kelly_ and__Katherine T. STATE OF WISCONSIN ss. aatheatica ed this Zuday o!. December County, 19... 4 Personally came before me this ----------------day of ---:7` 19 the above named • J D. HEYWOOD MEMBER STATE BAR OF WISCONSIN (If not authorized by 706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS ❑RAw- e.. DISTRIBUTED BY WISCONSIN REALTORS ASSOCIATION Approved by Wisconsin Department of Regulation and Licensing 11-7-94 (Optional Usb Date) WISCONSIN REALTORS* ASSOCIATION d-7.95 (Mandatory Use Date) 4801 Forest Run Road Madison, Wisconsin 53704 WB-13 VACANT LAND OFFER TO PURCHASE 1 THE BROKER DRAFTING THIS OFFER ON .~7-(DATE) IS THE AGENT OF EL EE(BUYER) I-SSTRIKE AS APPLICABLE . 2 GENERAL PROVISIONS 3 The Buyer, 77t T !L ! offers to purchase the 4 Property known as W- c 5 In the TOW it) of 90h--> County of ~T Wisconsin. 6 (Additional description, N any:) 7 - 88 111111 PUR yASE PRICE: , - on the following terms: 10 ■ EARNEST MONEY of $ Dollars . S~• In the form of IIA- accompanies this Offer and earnest 11 money of a~ In the form of AY/-' will be paid within A112+ days of acceptance,- 12 ■ THE BALANCE OF PURCHASE PRICE will be paid in cash or equivalent at closing unless otherwise provided below. 13 r ADDITIONAL ITEMS INCLUDED IN PURCHASE PRICE: Seller shall include In the purchase price and transfer, frerti and clear of 14 encumbrances, all fixtures, as defined at lines 214 to 217 nd as may be on the Property on the date of this Offer, unless excluded at lines 15 17 to 18, and the following additional Items: 50t / offs 16 17 ■ ITEMS NOT INCLUDED IN THE PURCHASE PRICE: v U AWILWWAYS. 18!~/Crh1 ^ SJ~QtJ~ tiN - ~M~GrJ~4 L 19 ■ PR ERTY CONDI ION REPRESENTA IONS: Seller represents to Buyer that as of the date of acceptance Seller has no notice or 20 knowledge of conditions affecting the Property or transaction (as defined at lines 178 to 208) other than those identified In Seller's 21 disclosure report dated N/A- which was received by Buyer prior to Buyer signing this Offer 22 COMPLETE DATE OR STRIKE AS APPLICABLE and 23 24 ■ ZONING: Seller represents that the Property Is zoned 45AJ (A-A- 25 r TIME IS OF THE ESSENCE as to: (1) Earnest money payment(s); (2) binding acceptance; (3) occupancy; (4) date of closing 26 STRIKg-AS PPLICABLE and all other dates and deadlines In this Offer except: - 27 26 OPTIONAL PROVISIONS AND ADDENDA See lines 252 to 305 for optional provisions including contingencies. See line 306 to 29 determine if addenda, riders or other doc ants have been made a part of this Offer. 30 ADDITIONAL PROVISIONS A SMAX -Ro S~~AAq-4 5 31 S O1T i.0 ,a fi't' f6iC 32 AJIA- 33 34 ACCEPTANCE, DELIVERY AND RELATED PROVISIONS 35 ■ BINDING ACCEPT CE: Thjis Offer is binding upon both parties only If a copy of the accepted Offer is delivered to Buyer on or before 36 /4Lf4+et /D 7 r iwz . CAUTION: This Oft r may be with kmm prior to deNvwy of the accepted Oft. 37 ■ DELIVERY OF DOCUMENTS AND WRITTEN NOTICES: Unless otherwise stated In this Offer, delivery of documents and written 38 notices to a party shah be effective only when accomplished in any of the following ways: 39 (1) By depositing the document or written notice postage or fees prepaid in the U.S. Mail or a commercial delivery system addressed to the 40 party at: Buyer: 41 Seller: /N~-- S, - t79Gi~r a ~C,D! 42 (2) By giving the document or written notice personally to the party; 43 (3) By electronically transmitting the document or written notice to the following telephone number: 44 Buyer: Seller: 7r c)lo r~oZ 45 OCCUPANCY AND RELATED PROVISIONS 46 ■ OCCUPANCY of 47 shall be given to Buyer at time of closing unless otherwise agreed in writing. CAUTION: Consider an agreement hich addresses 48 responsibility for clearing the Property of personal property and debris, If applicable. 49 ■ LEASED PROPERTY: If Property Is currently leased and leases extend beyond closing, Seller shall assign Seller's rights under said 50 lease(s) and transfer all sac~ritdeposits and prepaid rents thereunder to Buyer at closing. The terms of the (written) (oral) STRIKE ONE 51 lease(s), if any, are 0CJ _ 52 ■ CLOSING: This transaction Is to be closed at the place designated by Buyer's mort a or _ f O 53 no later than lot L t P _ w _ _ _ _ ,19 4 70 , unless another date or place is aarsed to in writing. 249 PROPERTY DESCRIPTION: page 4 of 4 - VACANT LAND 250 OPTIONAL PROVISIONS: THE PROVISIONS ON LINES 252 THROUGH 306 ARE A PART OF THIS OFFER IF MARKED, 251 SUCH AS WITH AN "W'. THEY ARE NOT PART OF THIS OFFER IF MARKED NIA OR ARE LEFT BLANK. 252 FINANCING CONTINGENCY. This Offer is contingent upon Buyer being able to obtain, within days of acceptance of this Offer, 253 a TATE LOAN PROGRAM AND STATE IF CONSTRUCTION LOAN 254 (fixed) (adjustable) STRIKE ONE rate first mortgage loan commitment, In an amount of not less than $ for a term of . 255 not less than years, amortized over not less than years. If the purchase price under this Offer is modified, the loan amount, 256 unless otherwise provided, shall be adjusted to the same percentage of the purchase price as in this contingency and the•monthly 257 payments shaft be adjusted as necessary to maintain the term and amortization stated above. 258 IF FINANCING IS FIXED RATE the annual rate of Interest shall not exceed % and monthly payments of principal and Interest shall 259 notexceed $ 260 IF FINANCING IS ADJUSTABLE RATE the Initial annual Interest rate shall not exceed The initial interest rate shall be fixed 261 for months, at which time the interest rate may be Increased not more than % per year. The maximum Interest rate during 262 the mortgage term shall not exceed Initial monthly payments of principal and interest shaft not exceed $ 263 Monthly payments of principal and Interest may be adjusted to reflect Interest changes. 264 MONTHLY PAYMENTS MAY ALSO INCLUDE 1112th of the estimated net annual real estate taxes, hazard Insurance premiums, and. 265 private mortgage insurance premiums. The mortgage may not include a prepayment premium. Buyer agrees to pay a loan fee In an amount 266 not to exceed % of the loan. (Loan fee refers to discount points and/or loan origination fee, but DOES NOT Include Buyer's other 267 WROPOqgD costs.) SEE LINES 230 TO 248 FOR ADDITIONAL FINANCING PROVISIONS. 268 USE CONTINGENCY: Buyer Is purchasing the property for the purpose of, ' 46,.J?( 41 _ 269 This Offer Is contingent upon Buyer obtaining the following ' CHECK ITEMS THAT APPLY 270 Written evidence at (Buyer's)(Seller's) STRIKE ONE expense iron) a qualified soils expert that the Property Is free of any 271 subsoil condition which would make the proposed development impossible or significantly increase the costs of such development, 272 See line 88. 273 [Written evidence at (Buyer's)(Seller's) STRIKE ONE expense from a certified soils tester or other qualified expert that 274 Indicates that the Property's soils at location sele_ ted by Buyer andga `0er coWitions which must be approved to obtain a permit 275 for a private conventional septic system for. Gw 276 Imsen pmposeo use or Property, e.. ree bedroom sin to family home) meet applicable codes In effect as of the date of this Offer. A 277 conventional system (does)( es o TRIKE ONE Include alternate private systems such as mound systems or in-ground 278 pressure distribution systems or the purposes of this contingency. A conventional system does not Include a holding tank, privy, ?79 comp sting toilet or cheml 280 [ 3 Coples at (Buyer' elle ' STRIKE ONE expense of all public and private easements, covenants and restrictions affecting ?81 the Property and a written determInation by a qualifled independent third party, at Buyer's eVense, that none of these prohibit or a/gnlficantiy delay or )82 I_~n.c,p,s,. a the costs of the proposed use or development Identified at lines 268 to 269. ?83 L3P Permits,. approvals and licenses, as appropriate, or the final discretionary action by the granting authority prior to the Issuance of !84 such permits, approvals and licenses at (Buyer's)(Seller's) STRIKE ONE expense for the following Items related to the proposed !85 development !86 CUA map of the Property at (Buyer's e 1 r' STRIKE ONE expense of the following type: !87 O a boundary map, O mortgage Inspection map; UVIs"urvey map CHECK ONE BOX TO DESIGNATE MAP TYPE . !88 See lines 218 to 226 for definitions of each map type. If this paragraph is checked but more than one type or no type Is selected, a !89 boundary map is deemed selected. CAUTION: Consider cost and the need for the features of the various map types before making 90 a selection. The map of the Property shall show no significant encroachments or any Information materially inconsistent with the 91 prior representations to Buyer or which render the proposed development Impossible or signitbantly Increase Its cost. !92W1 00~ Written evidence at (Buyer's elle . STRIKE ONE expense that the following utility connections are located as follows (e.g. on !93 the Property, at the l/f, e, across the street, etc.): electricity?o AdTA1~ . ;gas 16 to !94 municipal sgyv~ municipal water /7T tele hone 10 e !95 other ~(,I / STRIKE AND COMPLETE AS APPLICABLE 196 This contingency shall be deemed satisfied unless Buyer within days of acceptance delivers written notice to Seller apeclfylng 97 those Items of this contingency which cannot be satisfied and written evidence substantiating why each specific Item Included In Buyer's 98 n cA cannot be satisfied. 99 SPECTION CONTINGENCY. This Offer Is contingent upon a qualified Inspector(s) conducting an Inspection(s), at Buyer's 00 expense, of the Property and which discloses 01 no defects as defined below. This contingency shall be deemed satisfied unless Buyer within days of acceptance delivers ,to Seller a 02 copy of the Inspector's written Inspection report and a written notice listing the defects Identified in the report to which Buyer objects. For 03 the purposes of this contingency a defect is defined as any condition of the Property which constitutes a significant threat to the health or 04 safety of persons who occupy or make use of it or gives evidence of any material use, storage or disposal of hazardous or toxic substances 05 2111 property! D D6 OTHER. The attached 5ML Rff !T~ tu«/~pScJrQt~, Is/are made part of this Offer. 07 IF ACCEPTED, THIS OFFER CAN CREATE A LEGALLY ENFORCEABLE CONTRACT. BOTH PARTIES SHOULD CAREFULLY READ THIS 08 DOCUMENT. BROKERS MAY PROVIDE A GENERAL EXPLANATION OF THE PROVISIONS OF THE OFFER BUT ARE PROHIBITED BY LAW 39 FROM GIVING ADVICE OR OPINIONS CONCERNING YOUR LEGAL RIGHTS UNDER THIS OFFER OR HOW TITLE SHOULD BE TAKEN AT CLOSING. in