Loading...
HomeMy WebLinkAbout020-1084-10-200 STC - 104 AS BUILT SANITARY SYSTEM REPORT , OWNER r ADDRESS 'J 17 e r q `IQ v~ ~r, u cdn s SUBDIVISION / CSM# LOT # SECTION- Q2 _T ~N-R W, Town of _ )A u clsri h c~ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~V ' SV~ I of NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. ' f v P r BENCHMARK: Alp ikc t.•.. 1 sQI~.~A~s. f 1 Oa ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: (~S "o , Liquid Capacity: 1 00o a Setback from: Well AAA House Other Pump: Manufacturer_ h) Model# Size Float seperation Gallons/cycle: Alarm Location All -..SOIL ABSORPTION SYSTEM Width: Length_ ,S Number of trenches Distance & Direction to nearest prop. line: o~ ! Setback from: well: House- a Other ELEVATIONS Building Sewer ST Inlet : i `t ST outlet q S PC inlet PC bQt-tom Pump Off Header/Manifold. 3, (,o Bottom of system 9a .S Existing Grade Final grade 9 DATE OF INSTALLATION: - - 9 PLUMBER ON JOB: LICENSE NUMBER: IT C_ INSPECTOR: 3/93:jt M Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. C ROIX 'Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: _ _ _ _ Permit Holder's Name: ❑ City ❑ Village ❑_Town of: State PIA DOMMEYBR. BRIAN K X HUDSON CST BM Elev.: Insp. BM Elev.: Bscription: Parcel Tax No_: v ! 11 TANK INFORMATION ELEVATION DATA 176/ 9; TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Bench>mark Dosing ( X13, .g Gd, 7~ Aeration Bldg. Sewer Holdin St/ Ht Inlet W 27 1,119 TANK SETBACK INFORMATION St/ Ht Outlet S / Vent TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing NA Header/ Man. Aeration A Dist. Pipe Holding Bot. System 7 951691 PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand° 0/ 9F, S'7 I odel Num M TDH Lift Ion read t oss Forcemaip•' Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length ✓ No. Of renches PIT No. Of Pits inside uid Depth DIMENSIONS DIMEN anu acturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM rtll , CRAM R INFORMATION Typeo /IQr t y r (~O Z Moe Number: System: n OR UNIT DISTRIBUTION SYSTEM q~g , Header cl. Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length _62~_ Dia. Y Length ~ Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grad 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. 29.29.19W , NW. SW. DEER HAVE DRIVE v , >7 rz` Plan revision required? ❑ Yes M-K-0 Use other side for additional information. 106/ BD-6710 (R 05/91) Date Inspector's Si nat r ert. Noy ~ O1.JGJ /v Cy 7Q C C C ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Safety and Buildings Division SANITARY PERMIT APPLICATION BureauofBuildingWater System! 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less Count than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State sanity eer um eerr D The information you provide may be used by other government agency programs ❑ Check if revision to p-reJious application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Prop yOyvnerName Propertykocation 4 1~ Do yn m2 e.r AW 1145~t,! 1/4,5,27 T a , N, R r) W PropertyOwner's Mailing Address Lot Number Block Number Pi /A City, S ate Zip Code Phone Number Subdivision Name or CSM Number II. TYPE BUILDING: (check one) ❑ State Owned Nearest Road ~ O.sar~~`- Public 1 or 2 Family Dwelling - No. of bedrooms LIOF UILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) III. B 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. K New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ----System ___System_____________TankOnly- 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 JKSeepage 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 Y.5 C) Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) -(Min./inch) qp Elevation G/S 6 7 9.3 Feet Feet VII. TANK Ca in gallons Total # of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ? ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT f I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Nam (Print) Plumber's Sign to : (No Stamps) MPR$W No.: Business Phone Number: Ull. T6 ca1e.W X56 7r.~ -al 6 i Plumber's Address (Stre ty, State, Zip Code): 6/ IX. COUNTY / DEPARTMENT USE ONLY Q Disapproved Sa itary Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps)` Approved Surcharge Fee) ❑ Owner Given Initial / OT Adverse Determination O U X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD-6398(R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 9 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 cr 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 online A. Complete line B if permit is for tank replacement, recorinection, 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. A 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. F 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. v , , a~1 Ato A 16.4t t t is _n .,_,---r.,.. _.A. _ p...-__ -W,. __2.__,. _ r - , i ' , ~ 3 1 i , i , j ,j . , u V j , I i 3 Q 1 i a - , i j j ` i s 4 i ~ I 6 QrVV% j yr ~ r PAGE OF ae Ilk, Cry 5 S Sec tun o SYS teen Fresh Air Inlels And Observation Pipe C:- Approved Vent Cap Minimum 12" Above Final Grade 20- 42" Above Pipe _ 4" Cast Iron To Final Grade Vent Pipe Mash Hay Or Synthetic Covering min. 2" Aggregate Over pipe Olurlbullo^ -Tee pipe 0 0 0 0 0 6" Aggregote o Perforated Plpe Below BeneatA Pipe o -Coupling Terminating At Bottom Of System Prp~oSei~ T'Ir,kl: gre.eic - / • ~~cJ.•_~ tom . SOIL. FILL D1STRIBUTIOU PIPE APPROVED ~JWPETIC COVER ° 'e`MATERIKt- OR 9" OF STRAW Z" OF g6GREGA1E OR Mims" HAy e a'. 0 F 12 -at/Z AGGREGATE 'CLEV.OF9FEET DI•S-1"1115'UTIOM PIPE TO BE AT LEAST IKICHE5 BELOW ORIGIUAL GRADE AQU AT LEAST20 INCHES BUT.IJO MORE THAfJ 42 ItJCNES BELOW FMAL GRADE MAXIMUM OWN OF F-XCAVATIOP FROM OBI WAL r5KAVR WILL BE Of INCHES MINIMUM Mrd OF EACAVATIOM f.POM 01~1611WA1L. 6944E WILL. BE ~ INCHES SIGHED: Rsc~ 0--~13 LIGEIJSE IJUMBER: 5' DATE:" ~6 I)FPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS a1vlsloN 1`iztm-~Ty- P.O. BOX 7969 I ?1BOR AND - PERCOLATION TESTS {115) MADISON, WI 53707 HUMAN RELATIONS 1) & Chapter 145.045) LOCA J SECTION: T NO.. LK NO.: SUBDIVISION NAME: %451 /T R 1 q ► v .x+ ► ~ COUNTY: A t ~ (Z 1. C.F~ ~ ®140 1 USE DATES O ERVA'TIOMS DE Residence New ❑Replace FIN h A l x~t.- ca~K_.- to rL•5 a a><C~ ¢ ~~~.~I~ra'or RATING: S4 Site suitable for system U- Site unsuitable for system s h4AA1W-7'_ N A M U - - LL OLDING TANK: RECOMMENDED SYSTEM: (optional) S CU S t,..J~ S ou S U ❑S CotitV, . , -SIZtf To Btt ICTaitt If Percolation Tests are NOT required DESIGN RATE: If any portion of the:tested area is in the , I 1 under s.H63.09(5)(b), indicate: /Itsej y >`3 M f1J Floodplain, indicate Floodplain elevation: I PROFILE DESCRIPTIONS pec- R ISAIr BORING L A N H ACTER OF SOIL WITH THICKNESS COLOR, TEXTURE, AND DEPTH NUMBER DEPTHW* ELEVATION V TO BEDROCK IF OBSERVED EE ABBRV. ON BACK.) 1.00• Bt- 5. 2 . s ' + ds R.~ Z•5D' FsN f~ B-0 /0,0o CX .s5 14 04a >io' 1,5a sMc,s• Z,5'0' L34 Mav /.Z-S' 131- 1 0,75•' 9.1 FF 5L w 11<~ 0.75 RD g_ Z 7. -7 °Jr.ZZ. l~IohiE >"7,7s aw.9 p', .50L . 3;J SZ-Q`C 0.63' Ls.1.rs,Z•sw&jC w R; G,oo'LT. A B- 3 ','•33 74- lgot4a 7 , 33 cc S 0.75' 6L S; L j L.So' 8A 15 e~i 6, S01 ~-T. B-4- 11.75 96,3Z- NO Al 9- 5 ~,l' o , Sn' B c. ,'c. T5. 1. So' B "1 Tr - B- 5' 7,•Q- . C~ili ON it > 7, 45 ey11~ ' a I .oU' N 3 B- ~1xTAL PERCOLATION TESTS Fri-L TEST DEPTH WATER IN HOLE TEST TIME NUMBER AFTER SWELLIN INTERVAL-MIN. LEVEL-INCHES PER INCH ES P. 1 4-gl NOME 91,.S71 7-27--s 014 TU9. < 13 P c . L •c 3 P- P- p- P:LA.VAT% ON PLOT PLAN: Show locations of percolation tests, soil borings an '"ImensWs-,*4t~kuitable it areas. Indicate scale or distances. Describe what are the hori- ILT R surface elevation at all borings and the direction and percent zontal and vertical elevation reference points and show their to ibn/on the pla. Shdw-t a of land slope. r'" l I"I tto'j Pipe t- L_ I Al IL SYSTEM ELEVATION 9 5-0 ` Q~4'o G I t T! 1 j 1~C N M. K; t S /t± ; a1 1 "(-151 0HWIlkG74E 00T TO ArCD r fbf~kR_ , 00~ 00 i , P i i a. plz•INire'. I RLA#bf~ t N!,ar tD 0 , tr r' sir rt~ a~ { . .....T~ T 1 C] 1 + "F.. I PARIMENT'UF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS J ^TrS?7tY DIVISION •,BO,l AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707 IUMAN 1,,ry_ATION5 1) & Chapter 145.0451 T NO.:BLK. NO.: SUBDIVISION NAME: W TI J wm~ ~_~_4 ~Lv ~4 = plj~ UNTY. A~ ;-r- .1 0 I -:it R i C.+4,4 s o14-0 • I 40-9-0/ G DAT S O SERVATIOMS AIDE NO vF~: S ,Residence 1e At PZNew ❑Replace 2, P, COI `1 c~ /L S : 3~ccz ¢ 8~~(kArRDT vC~ TING: S- Site suitable for system U- Sits unsuitable for system s 71 )N ENTIONA . MOU : r`► I G` 11 ('Y~STE ILL OLDII TANK: RECOMMENDED SYSTEM: (optional) S ❑U WS [IU ~S ❑U t„C~J S C7U ❑ S COnll/, -S/ZS 70 t TEPt M. Percolation Tests are NOT required DESI N RATE: ( If any portion of the tatted area is in the der s.H63.09(5) (b), indicate: A ASS = >3 M 1J L Floodplain, indicate Floodplsin elevation: MA A"~ PROFILE DESCRIPTIONS PS& M RING AL EPTH AT •IN H CHARACTER THICKNESS, COLOR, TEXTURE, AND DEPTH BER DEPTHv* ELEVATION 085 EST. HIGHEST V TO BEDROCK IF OBSERVED SEE ABBRV. ON BACK.) l-Do' &L- S• ; Z - S w79 R; F575 e...j i-z 1/0,00 9G.s5' 140ma >io' 1-5ae0`4 4,S; Z•5'o'r3,IMeo 5 _r /•ZS' (3L S : L S 0.75 AJ V >L w R-; Z Sv c.5 Z 7.7.._ ~r.Z? NOfIE >~.7'S 3-1~' w ia~- ?.SO, LT. &J so - - n. i23' L s ; C rs z. 5'o' e,.! C w Q.~ (P. o o ' 1--r. 'j °J•33 '•`7,47 IVO/1J E, > 33 eb S 0.75' B1_ S. 'L Zsa' 6.~ 5 -,e,~ B. So' I_-~. 1-4- /1.75' L)6,3z NOA/1= ~.7.5' s 5 7, 4-> ")3-2-7, ON 45 7. 4 5 • r. o v' N AGIMAL PERCOLATION TESTS Ft'sET EST DEPTH WATER IN HOLE TEST TIME LEVEL-INCHES RA E INUTES ER AFTER SWELLING INTERVAL-MIN. PER INCH G 3 I~4-o No e G,SI Z. o ~ 9 7G < 3 0 0 z < 3 T PLAN: Show locations of percolation tests, soil borings a(~,' hs dirnonsLts jOuitable,Eoil areas. Indicate scale or distances. Describe what are the hors tal and vertical elevation reference points and show their loc on the ploj p%j , Show the surface elevation at ell borings and the direction and percent and slope. r r1 z , r. STEM ELEVATION Ply I t I i J -1 0 o 'r3AcK-F1d ! D1JrTE "re; S I j 'I°S~lN G N M~#~ I S A O ItLC~L_R I c. I , l 40 µd~c+ aiak«n~T Tv ;SQ SPy I In! k i ; I lbf~ kR- TLt~E 4 61 E 1 i L: tsi V. 0'0 o o CD SCE S L- it rl~ vh' w 3 1TH; I j ©IzF~Nfirc ' N o' 1 O l ~ ; FrL Atb Ea t NU ~0 . ~ ~ I I ' 'V • I 1 ~ I I I I , I ' ~ 1 1 - 33 L a` i WEST...~UDSON T29N-R.20-19W Zs PART oLO .rs Hw SEE PA~ 9coco eaUCwoc r AA'{ZT. En nun Z~ev.= E:STHfFS L L Ec.~ert [.„r.f - so a _ c3'fafc e 2 ~T/ so -s.QR ptlWmp'. r'WlL ~K 'Qe/1Sin SOLD ✓oc,in Ro MALL aACr W/LLOWB ~Q G een b _ .11 1 t roan Kec-d s s.r ,r ii txACrSy LA. •R/V e ~ B46B RS .a "1 r~l n Q y1 C DC/o f~of• FOR SALE ~ Hannah ~AEGE.. ; Nofura/ .Pas• IF West ~r• Q41GE 460 Hart t . ^ sus pO K L Y NUtYs ^ ✓rW TRAITS 7%~~ • • r....`_~~ 35 REALTY WCIRLDu Rd€eK r~ar,< E. °zyyr cAa Ems" St. Croix /°o s n K'B E'h ' J ~acoEs G t r /G<5... TR3 R Realty 1 13 ff~~rs°r, 4d 3 386-9855 N O k U D S O N ':r/C/u6 R K UT~ ~l~y yl THE RESOL FS PEOPLE• W f a~oW L r K mere eosr /&D. 7v p• o cE PK"c. : _ . 0 W L. A l;AL/ Nn gpo°F 1 S ° i~ A 509 Second Street - Hudson CALL TODAY, TOLL FREE: / a^~ 4 F• sM b vs. P' ea'i = .~:.e N 9no/d U`,eS 800 657-4553 Ir W ~g ju~~ ; e~Ee ` 20 NO OBLIGATION MARKET ANALYSIS a k 6s /70.v a o V• W m O N unvimrKanv is 3 c d , .ems N 0 .E. T- MLS • L/f✓ Z 0-4 OPPORTUNITY m ~ \ h'o~skad 'a ad to N -and Co. = 40 ed, o L'1 O `'O Phoebe v y ~ ~ ~ ~ Gu9,ron ~ (1 rn.ae~e. ~ a y~ ..rvd . . < ILA ' HUDSON, WISCONSIN 0' 0.5 2$ `/P• ffc nson ° rO sear'A us .Pa eh WiSCC s/n sa HUDSON A/ 67 If. Ca•5T e313:CO/P. •f hr " C70ff4' /2 35 /2 94 O A ~ ~ra Borer ~J N eT 295 ¢,~TS FA4~ o~Q "►o GMC TRUCKS 9 sCh /o#~ ior, 6eor e PONTIAC D" D` z7 Lau~/in". OLDSMOBILE G, H F/ eta, re-emctn ! 9s1a E° /s Gs u 224./ O SALES 9.7, oc,T "o e %aPA-z' SEE PAGE /3 S~Gorr u~fy,w.9 SERVICE 200 R. 20 W. 3JO R19 w 400 500 BODY SHOP Phone: 386-5155 Metro: 436-5764 1-94 & 17th STREET HUDSON, WISCONSIN ILL gasoline / convenience foods HUDSON DOWNTOWN HUDSON HILL HUDSON SOUTHSIDE CENTER RIVER FALLS NEW RICHMOND 100 SECOND STREET 1207 COULEE ROAD 1920 CRESTVIEW DRIVE HIGHWAY 35 NORTH HIGHWAYS 63, 64, 46 386-9491 386-7401 386-7799 425-6371 246-5188 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 a~ ~M MCp'- Location of property NW 1/4 5V41/4, Section 29 , T 1,01 N-R al W Township LA 050 1.l Mailing address 14 1 4 '17 l~lp~4L c24-r1+ KAN 5 S O lb L Address of site j~LQsa ti, subdivision name C-5 M Lot no. 1 Other homes on property? Yes A. No Previous owner of property `JG~IL P~R~ 1DOM M!~ E CJL Total size of property 2, 4 ~►c,~2G'S Total size of parcel 2. 41 Date parcel was created O - '1 - tic Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? Yes X No Volume tb1L and Page Number 170'Z7 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 n the office of the County Register of Deeds as Document No. 'T 'LO IS S , 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. 42,E ~'S S ' ~ c Signature of Applicant Co-App- lida~nt el Date of S ianature n~+- 6 , ' '4- STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER OVA A•W Dn0A M~ MAILING ADDRESS 14 4 ~i LAL-)a4ti 5-4114 STIww art ~ MW PROPERTY ADDRESS 4 i D a,L P,0q.:::yA bel, (location of septic` system) Please obtain from the Planning Dept. CITY/STATE ~l0 Sa 14 W 1 S 4c i b PROPERTY LOCATION VAW 1/4, 'W 1/4, Section 29 , T IP( N-R 1 W TOWN OF lz-~AjP '50 W ST. CROIX COUNTY, WI SUBDIVISION , LOT NUMBER CERTIFIED SURVEY MAP'*% 1$3"~VOLUME I 'PAGE 1%, LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: ~'9 ~ 2 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 ~f~ iUdb 0 CO Ejowv N)4.11 101 4 404 t C~. CERTIFIED SURVEY MAP Located in the NW 1/4 of the SW 1/4 of Section 29, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin, being part of the Certified Survey Map recorded in Volume 1, Page 258. Surveyed For: Ben Dommeyer EI/4 CORNER Rt. 1, Carmichael Rd. SECTION 29 Hudson, WI 54016 T29N, R19W UNPLATTED LANDS EAST LINE OF THE NW I/4 OF THE SW I/4 S O°08'41"E 2.63 33.0 290.31' 4.3 9 I S0009'37"W 323.31' 1-6-69' 6.72' - I_ (R- SO'25'02"W) THIS MAP IS BEING APPROVED M BY THE TOWN BOARD WITH THE In 0 O UNDERSTANDING THAT THE OWNER OF Ui LOT I WILL NOT OBJECT TO CN CY DEDICATING UP TO 5000 SO. FT. If) 7 { I\~ y/~~ z I FOR ROADWAY IN ADDITION TO THE A C W W W LOT I C33 ORNER EOF NLOT TI THE NORTHEAST ~2IM 105354 SOFT (2.419 ACRES) u) M ON 01 19136 aUj~It INCLUDING RIGHT-OF-WAY N 0 Q ' 94628 SO FT (2.172 ACRES) M CC INI 0) W I co EXCLUDING RIGHT-OF-WAY :J".rSF. f 1',IVF F'A!(!! : N1, ."t'rr. I Z ii1J ZJ:Tt:I: r'-" Z1 I (01 JI 0 ° o <1 O O 1 O -JI Fzc,u,r In I0 W i' W I ID I j m' O 3 wl Z N _ I SO°09'37"W 324.97' '-1 1 1 O 0 F- of E-I J 33.00 i 2 91.9 7' i ~l c7 N W F- I O 00 CY) al z 0 a d s 0 3 1 Z D• O Z I C1 C 1 a l x ,.T 1 0I U 0.I N w w I LOT 2 11 ~I w 3 M ~ W IOM 105895 SO FT (2.431 ACRES) M?-IN INCLUDING RIGHT-OF-WAY Z Z V) T w W 95169 SO FT (2.185 ACRES) Z O I- 3 - ~IrrW EXCLUDING RIGHT-OF-WAY w o 1_r U- O In ~n W ~ ° 0 z 1 F O . o z - N1 a v N 16 O a o~ 0) a) N M W Z a ir In °o I W J o _ m _ co- OD I '0 _ z _ -j Z~ Z N = O N OD Izl I I L) 0 X l0 Iii V) W °O_ I a~ M w M 3 iii 33.00' 293.64' .36' • o DOCUMENT No. WARRANTY DEED - - - TII~IT TNI• e1Arg Rtt[RV[D /OR R[ ORDINO DATA STATE BA)t OF WISCONSIN FORA( 2 - 19Ai - REGIS MRS OFFICE Be.Caa.I.~...~l.. Dommpygr and Lena M, Domme_ yens his ST. CROIX CO., WISo wife and in her ow.n..ri het Rid. for lew.rd this 9th 86 y of Dec A.D. 19 conveys and warrants to ....;.3 a.R..K....QORl4l@ n 1 3 45 P ♦ bl Iwo, wllt Brmele Rt. 1 R......................................................... Hudson, WI 54...................... of lollowins Wiso~nsin: described real estate in - - State the St~.. - 41.01 X County. Tat Parcel No: ....................Part of NWISW} Section 29-T29N-R19W described as follows: I,ot 1 Of Certified Survey yap filed October 7, 1986 in Vol. "6r", page 1720. Subject to and together with private roadway easement as shown on said Certified Survey Map. Together with an easement for roadway purposes across the Nly 33 feet of the Wly 661.09 feet of said NW SW;, I This J.S..RQL....... homestead property. QW (in ne0 Exception to warranties: Existing highways, easements, rights of way and restrictions of record. Dated this day of ~Q ..................December........................ 18.86.... D (SEAL) . ......(SEAL) • Bernard J D (SEAL) /J (SEAL) I ' Lena . M r. Domm I AQTHSNTICATION ACHNOWLBDt3li8NT ~1[aatnre(a) STATE OF WISCONSIN 815. authenticated this ••-•••D ~ FS?,~X ..............Couaey. ...."..day of 19 Personally came before me this day of .._.....4'4gJn.I?.Jr 19.66... the above named Beyn~r.~. Ao~!~~Y..>•..and......na........AQmro..... TITLE: MEMB"•""""_"ER S""" husband and wife TATE BAR OF WISCONSIN (If sot . authorized --Y I 706.08. Wfa. Stata.) he to me known to be the pe n s......... Tu - .who executed the ST. CROIX COUNTY WISCONSIN ZONING OFFICE A N N N N g N N■ KNOW" ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 .ry (715) 386-4680 September 18, 1996 Mike Stephens Derrick Construction Co. 1505 Hwy 65 New Richmond, Wisconsin 54017 Re: Septic Inspection for Property Located at 417 Deer Haven Drive, Hudson, Wisconsin Dear Mr. Stephens: An inspection of the septic system installed to serve the above described residence was conducted on August 1, 1996. This property is located in the NW, of the SW, of Section 29, T29N-R19W, Lot 1, Town of Hudson, St. Croix County, Wisconsin. At the time of the installation, this septic system was found to be code compliant for a three (3) bedroom home. If you have any questions with regard to the above, please do not hesitate in contacting our office. Sincerely, ames K. Thompson Assistant Zoning Administrator pe