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HomeMy WebLinkAbout030-1035-30-000 z ° o O e» 44 h C ~ N N N O 'p co °O ~ N Y ~ O ~ U M a1 -(D ° N C O ° C C ~V 000 O 30 E . p $ ° C > N V U O N f0 O 7 S > CL j N O O L y o E > U CS _ D (p "Ci O O 11 C p7 X N Q N C o E T ° m (i O` C N U O ~U'rd y ,6 O C M -O •UO O C Z •X L (6 N .5 O N C> C (O (D Q i O I a LL C O C O_ N O - 0) Y C OL UO C LS 7 C (6 O "6 C ~ 7 N N N U ~ M V O. N r N ui Z O v £ O` Z y y o a) z a co o I c z o m o Z Q: r 7 N z 't O c o (n I- r ~ N Z c E a -0 m v M N Q ~ N O N ~ N N C d U ~ O c c O ~ Z F- Z o d ~ a N w z N N E c C E N m C) N -0 LO O LO ` G M i N C (O od 2A -4) 0 0 o a N ~w E -00 3 a-I m o 0 *i 7 0 0 0 Z • rri Q a a a a ~ O N 0 O ~ (n -j U rn rn w } U o o E l ICI 7 Co d O) •6 N O V.. ` N Q Q t"r O y N 3 m y c `o E c c N I~ O M ON F- a 0 O C) N N LO CL V 0 M O 0 C C O o -(D O 7 _ 0 E C:' (D C14 00 M p co N E E U eO ~ V d L a Sat a aw • c m a `Iv E c c A V a 2 0 in v STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 1' `1~e d C-Y2NA 11ArimON IV ADDRESS- Cb SUBDIVISION / CSM# LOT SECTION 10 T -c) 5 N-R__Lj_W, Town of S 1 165C ST. CROIX COUNTY, WISCONSIN PLAN VIEW s~ .5HOW EVERYTHING WITHIN 100 FEET OF SYST M Note : PuN1,0`1 Q oV R Cy*11 Qa~~le (a ~ TRe+~ c~eS ~x SO' L ISM ~oKCQ MA~~! ; ~ l 2 a - 3 BPdR~a~, 37' c + No►hs 5C 3?nL P. a 51 low 4) S Sot, 4D INDIC TE NORTH ARROW r. Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. V 4 BENCHMARK: Ioe J W e ) - Iey. /00, 0 ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION W1. 100094) Manufacturer. ''II~'' WCQ ~S Liqujo Capacity: ~K►+~A e00 9p ` Sc c. y Setback from: Well 00Z 5; House Pu~o 3'1" Other r - i Pump: Manufacturer Zbt ( It it Model# 53 Size Float seperation Gallons/cycle: Alarm Location Ir P & ':SOIL ABSORPTION SYSTEM Width: 5 Length Number of trenches Cp Distance & Direction to nearest prop. line: I Setback from: well :0 Vfg y House-0~bther ELEVATIONS Building Sewer ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: IV \ PLUMBER ON JOB: C~.c n LICENSE NUMBER: 310V INSPECTOR: 3/93:jt • Wiscbnsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROTX 'Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 268506 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: HARTMONr MTKE & GENA ST. JOSEPH CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: /Gtr, /W~ Ga / TANK INFORMATION ELEVATION DATA 71'1 SAC TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic S hid Benchmark S,~s /~jL,(1✓ Dosing Aerati Bldg. Sewer #//o Holding St/ Inlet 93,c6' TANK SETBACK INFORMATION StOutlet R,91 9,2- , TANK TO P/ L WELL BLDG. Vent to ROAD Dt Inlet o; Air Intake I3. - /S Septic > So ~ ~ ~ p l ~9 NA Dt Bottom 17,07 / X 5- 5 g7, 09 Dosing ~at-, ms s/ 37~ >37~ NA Header/Man. 9 Aeration NA Dist. Pipe y Wyss ~SS~ %pq' A~ Holding Bot. System 3 PUMP / Sjj"i INFORMATION Final Grade I~ [Manufacturer~,~QQe Demand 7 -'ib ' Model Number GPM TDH Lift Friction System TDH Ft oss Head Forcemain Length 3 $ Dia. a Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width , LengthSO, No. Of Trenches PIT , - No. Of Pits Insi ia. Liquid Depth DIMENSIONS S ~o DIMEN I N SYSTEM TO P/L BLDG WELL LAKE/STREAM LEAC SETBACK INFORMATION Type O r,wFye CHAMBER Model Number: System: . ^ (U~, t1 e CrC~ > OR UNIT DISTRIBUTION SYSTEM Header/Manifold 7r Distribution Pipe(s) x ole Size x Hole Spacing Vent To Air Intake Length3 t2-Zi Dia. Length 1L Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Gra ystems 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.) `e LOCATTON: ST JOSEPH.10.29.19Wr NW; NEr CTY RD A Plan revision required? ❑ Yes Vo Use other side for additional information. 1/:d - el 1_~] SBD-6710 (R 05191) Date Inspector's Signature Cert- No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: (E! Safety and Buildings Division nr■ SANITARY PERMIT APPLICATION Bureau of Building Water System: 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number c;2<vt 5i~* 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 W y Owner Name Property Location &eNa. 1 /4 -1 /4, S T a , N, R E (or)~ Property Owner's Ma ing Addre s Lot Number IVry Block N}uP her Cit , ate Zip Cod Phone Number Subdivision Name or CS N ber III. TYPE F BUILDING: (check one) ❑ State Owned ❑ It~ Near t Road ❑ VII age Public 10 1 or 2 Family Dwelling - No. of bedrooms Town OF 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 on line B, if applicable) A) 1. ❑ New 2. X 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 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: L-144K oN L. (pal 1. Gallons Per Day 2. Absorp: Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. FiiyGrade Q Req ~~(sq. ft.) Propgs`q. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation .3 .3 Feet Feet VII. TANK Ca in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber gQo ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plu er's Name: (Pri Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: Plumber s Address reet, ; ity, Sta e, Zip Code): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sa itary Permit Fee (Includes Groundwater ate Issued Issuing A ent Sig ture (No Sta Approved ❑ surcharge Fee) Owner Given Initial /~j~//oI Adverse Determination (CJJ 10 1 XTI NS ,F~APPR Al. /REASONS F S PROVAL: c", /04-W7 66 8:;Im SOD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS t 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any 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. Tie septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 4 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and BuildingsDivision, 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- V11. 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 81/2 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. B-, L C 7 _ _ PLOTA 1-11) I'M S S ( !..~.y _ R LUI N A M E a- G~~ 4461/~h•arJ N~l~ N1 E f3ou ~K- AT 10 NJ -1C ENS E-A-'.. IL OC j 0-1 1) A" T E PL -1, M 1-3 c ga~) xrA" C u~ll 6i. FxIf ,W9 ;C s ' Ap b.# F, 11fT / D 'OK 'Of e S1av 11'p t S ' V O~ /1 Q/ p ,S e ~ Kr too, 0 Rar, Siff c ~y.li ¢w. P-4) Lj d ' ~a . PR6 ~N CIMSS SECTION 1 Approved Vent Cap Q Minimum 12" Above I = g17.31 Final 4 D X8.59 E 'F, g~•~9, ~'1pX 4" Cast Iron Above Pipe ~v Vend Pipe To Final Gradr- 82 PRIVATE SEWAGE SYSTEMS - II PAGE OF PUMP CHAMBER CROSS SECTIOKJ AUD SPECIFICATIOAIS VENT CAP 4"C.I. VE'~JT PIPE WEATHER PROOF APPROVED LOCKING JUNCTIOIJ 80X MANHOLE COVER LS' FROM DOOR, I2'MIU. '.Ii~Jccw OR FRESH AIR ::TAKE I Ap" GRADE I y" MIAI. I IC'hlU. COAJDUIT-- . PROVIDE I INLET ~ AIRTIGHT SEAL I III ~ I I I v APPROVED JOINT A I III APPROVED .;01NTS k'; C.I. PIPE I III WIC.I. PIPE EXTENDING 3' I II ALARM EXTENDING 3' ONTO SOLID SOIL QIJTO SOLID SCIL B I I I ON C I ELEV. FT. PUMP-~ OFF D CONCRETE BLOCK RISER EXIT PLRMITfED GNLJ IF TANK MANUFACTURI`R HAS SUCH APPROVAL 5EPTIC E SPE IFICATIOUS 1 DOSE 1 TANKS MANUFACTURER: W~ i Rtf DUMBER OF DOSES: PER DA.4 TAAJK _IZE: OU GALLONS DOSE VOLUME INCLUDIMC, BACKFLOW: (YOGALLONS ALARM_ MANUFACTURER: • w MODEL NUMBER: H,w pp i ~ CAPACITIES: A=INCNES OR Qr• C.ALLCNS SWITCH TYPE: _ rt U l f B= J INCHES OR ~ GALLONS PUMP MANUFACTURER: Zo C= 17 INCHES OR ,A_LO>JS r MODEL NUMBER. hs D= O a INCHES :R aV~'s GALLONS SWITCH TYPE: tVVXC.1 K MOTE: PUMP AND ALARM ARE TO 6E MINIMUM DISCHARGE RATE a) ~-GPM IN/STALLED OM SEPARATE CIRCUITS VERTICAL DIFFERENCE OETWEEU PUMP OFF AND DISTRIBUTION PIPE.. FEET + MINIMUM NETWORK SUPPLY P~KIES0SL;RE . . . . . . . . . Z 5 FEET + -Ly FEET OF FORCE MAIN X •L _F OOF>'.FRICTION FACTOR.. '3~3~ FEET 8 FEET TOTAL O'JIJAMIL MEAD = -8- IUTERNA'- DIMENSIONS OF TANK: LENGTH I ;WIDTH ;LIQUID DEPTH I v 11 SIG~,;EC: j ~ LICENSE NUMB=R: ^MY DATE: ~ Wi.sconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page of 3 Division of Safety and Buildings in accorda wi 1 09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inch Iri`slfe.n(st ✓ County include, but not limited to: vertical and horizontal reference poi t (B direr 'fsl sT percent slope, scale or dimensions, north arrow, and location d distance.6;Heargst` 1. P cel I.D. # ~f 36 - 103,- 3 00 00 APPLICANT INFORMATION - Please print all in tmatio 7 viewed by Date Personal information you provide may be used for secondary purposes (P Cyr Law, s. 15.04 (1 !r` Property Owner Pro e ti /11// k, 6EN,4' II-00 MQ4) G®v~. t 1/4~E1/4,S /0 T 2 y N,R P? E (or0 Property Owner's Mailing Address ~f~rl7 LZTT- Block# Subd. Name or CSM# cry. + city State Zip Code Phone Number Nearest Road H u pSo ,J 4v/ . 54101(0 ( 71-f- )3?6-8~2z ❑ city [__1 Village tTown hf wY- ST• To$E ft- ❑ New Construction Use: esidential / Number of bedrooms Z -3 Addition to existing building [replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate N,e bed, gpd/ft2 3 trench, gpd1ft2 Absorption area required N~ie bed, n2 /yd trench, ft2 Maximum design loading rate!V~ bed, gpd/ft2 • 3 trench, gpd/ft2 Recommended infiltration surface elevation(s) 5-zc P j ' 3 ft (as referred to site plan benchmark). p Additional design/site considerations /~1✓~~ S`f~4//d~J LO.c~ t'r /vo&~J T'E~U~!! S - SSE 41074-37 Parent material _45ifS 7 O 190,Ve1jiY_'D T Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In Groun Pressure AT Grade System in Fill Holding Tank U = Unsuitable for system as, ❑ U Ers El U as S El U 2__S ❑ U ❑ S h U ❑ S 0-6 SOIL DESCRIPTION REPORT -A N/p - NOT ?SWAfME,vP&C:) - Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench vie 3 z /a~,y Z s 6.C vile C S . S /oa 313 lmw 1ris, shf .tit70~,r c'S /zf . s Ground 3 /01 3~ /d C-5 / (Jf y .S ~7. evn. Depth to 16 Y16 057 S 0 C.r X- Q s 7 , limiting E- factor A~77 In. 40 * Remarks: .2.7 $ D ~ l Boring # Z io 'e 3 / z 10, / , . 1 1f Sk tw of2 c S Z 2 p /0 3/ /oh 2 s!~ 1k.,-fk 3 - 1/0 i 3/ - s 17_^s`✓e tw 1~e 'fs , s Ground - /Wi f/p Q $ J ; elev. rj'7.n. S - O 1 S G / ~S,dr~ GP 2 S l . Z 3 2. zo VA -7:, Depth to limiting factor 4P.0-in. Remarks: CST Name (Please Print) Signature Telephone No. 7i5 - 3 P6- 8l8 S Address Date CST Number Ulbricht & Associates , PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z of• '3 PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench s k U{iE> S fL S .Co 2 S ,P 3/3 S/ S4& /f2 S /f Ground 3 l© 3 -441 A& C5 . _5 e ~o elev. y~ fi n. ~'3f Ja Vii y s/ if5k fn cuv , y 5 L 4 -7 C u ) Depth to / / S ~'Mcc11'/ limiting / y o f X Q s 7 factor in. 7 713 af} 'C6*0 C9 UA 'N 13 ' ~Remarks: 614151-s_-I coleyypeto f y ~~,15 LA P Boring # Ground elev. n. ; Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. ft. Depth to limiting factor 'n' Remarks: Boring # Ground elev. ft. Dep~t 0't , i ! € Iim7i ng factor in. Remarks: SBDW-8330 (R. 08/95) IMPORTANT N(1TR Tr) r)T.TATT: Dc c TTTC~MX7 r _ . U-i ~ rn a c L c o ~ m W 1 k-b I al , ' I 1 0 I I I Ih ~ Ivl - 1 I I ~n i I p I I I I° I 1- - I 1 I ~ 1 , I I 1 ' ~ I In I I~ I Imo! t l i I I~ 1 , I 1 I I I I I I I I 1 ~ 1 1 I I I o I _ I I.~I b I I I 1 El In Z~ ~ I I I I I 1. O ~ p 1 I 1 I ti C~ ll~ N I (a I I~ 1 1~1 1 ~ ~ I I t~ I kA I I I I ~ ~'I I I I I I I mV1 ~ I I I Z ~ 1 W ~ ~ I ~ L ~ O N L w W ~ - _ r STC - W5 Sl,"PTIC "TANK NIAINTENANCI,. AGREY'NIENT St. Croix County. OV1'NER ]MYEIZ i Ldla k n~ Genet ya •r>o.v MAILING; ADDRESS PROPERTY ADDRESS /U 9/- C vur~j` / ~~k~ ~y~so ✓ ~s Syo~~ (location of septic system) Please obtain f rom the I'Ia11111ng Dept. CI'I'1'/S"['A"TTY, udSa~ GCJ ~ S`~°~~ PROPERTY LOCATION N W 1/4, N E_ 1/4, Section I 1' a~J-N-ll I ~ti' TONNIN OF ST. CROIX COUN'T'Y, \VI 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 properly 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 (il necessary), the septic tank is less than 1/3 full of sludge and scum I/We, the undersigned have read the above requircmcnls and agree to maintain the private sewage disposal s),stem in accordance with the standards set forth, herein, as set by the Wisconsin DNR Certification staling that your septic has been maintained must he completed and rettlnu•d to the Si. Croix Count\, %oning Officer within 30 days of the three year expiration date un St (;l,nx ('„unty loninl; ()It WC (low-111111C11t (,Clltel 1101 Callnichael lZoad 1111dNon. \":I V1010 I ^ 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. of property /'l'J ~ L/ia e ~ n d Ce "-J Owner Local ion of property N wl 1/4 F- 1/4, Section N-R /7 W Township 5k Jose.4217 Mailingaddress /01/- CGLtn)/y eOAd ~dsoN w~ ~Ll 6 i(10 Syo/~, Address of site /U 9/- CvKn ~ 00ed f-/u'15dA . 60-Z Subdivision name Lot no. Other homes on property? Yes No Previous owner of property :Tj, cC-yre nc say-, Total size of property YP aC y--P Total size of parcel ~a a(C-RE- Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes )C No Volume and Page Number -5-199 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 shat 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. 3 657-7Y , and-that I (we) presently own the proposed site for the sewage disposal system or tI, (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 o.£. Deeds as Document No. 1-72, ignatur of Applicant Co-Applicant I t cat i(inature [)atc of Signature l Of ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the l'e,~~^ f yam/,/ residence located at: N' Sec. T_,g N, R__Z_!~?W, Town of St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and , and it appears to be functioning properly. baffles to be in good cond'ti77(4 Last time serviced a Did flow back occur from absorption system? Yes No (if no, skip next line. Approximate volume or length of time: gallons minutes ~v Capacity: Construction: Prefab Concrete Steel Other Manufacturer (if known): Age of Tank (if known): (Signa re) (Name) Please Print NA S~e~ V\' RQ1t( J'e ~yoj (Title) (License Number) 1b e) ~ I Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name JA/1')P Signature MP/MPRS ~35~~ WARRANTY DEED .t, DOCUMENT NO. 615 ~//~R STATE OF WISCONSIN-FORM t y VOL C7" V THIS SPACE RESERVED FOR RECORDOW DATA 365778 REGISTERS OFFICE THIS INDENTURE, Made this . ...day of ST. CROiX EO., wa . A. D.. 19............, between....... darome...Andersan,... D.avid.._A.._. Ander.sorl, Recd. for Record 6* 15th .and. -Rober.t...A.....Antlers.an............ - day of A A. D. 1980 at ---11: A ,9 . _ ....................part.ies...of the first part and Michael_..H--.Ear.tenon--.an.d...... Gje-na-..M_....Har--t-mon r/ 691s1w of D• r t part iesof the second part, TURN TO W I It n e s s •t h. That the said partAes..of the first part, for and in consideration of the sum of_.One.--dollar--.. and.... other ....go-ad ...and.. ualuabl-e--•.--------- . -cons iteration _ to,-them.......... in hand paid by the said parties-of the second part, the receipt hereof stheents confessed and acknowledged, haVeI..... given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by these P .hei do give, grant, bargain, sell, remise, release, alien, convey and confirm unto the said part-i.e .of tate he e n ponsirtjj&taW t rs and assign forever, the following described real estate situated in the County of..-St...... -Gro3 x--.•--••°--•° Part of NW 1/4 of NE 1/4 of Section 10-29-19 described as follows: Commencing at the corner of the stone wall on the Southwest Corner on the Post Office building in the Village of Burkhardt; thence Southerly thence South line with the West side of said building 70 and 3/4 feet; 1873 feet 24 degrees and 50 minutes West 45 feet to a point directly West from the Northeast corner of Section 10-29-19; thence tthenc Southerly along the East line of the highway on same angle, feet to a stake; beginning South 24 degrees, 50 minutes West, 233 at said stake and running thence South 24 degrees, 150 minutes West along the Easterly side of said highway 132 feet; thence Easterly at right thence angles 165 feet; thence Northerly at right angles 132 feet; Westerly at right angles 165 feet to said stake, containing one-half acres of ground. In NW 1/4 or NE 1/4 of Section 10-29-19. This is Homestead Property. (IF NECESSARY. CONTINUE DESCRIPTION ON REVERSE SIDE) Totether with all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and ail the estate right, title, interest, claim or demand whatsoever, of the said partiea.of the first part, either in law or equity, either in possession or expectancy of, in and to the above bargained premises, and their hereditaments and appurtenances. To Have and To Hold the said premises as above described with the hereditaments and appurtenances. unto the said part.1e-of the second part, and totheir._.-heirs and assigns FOREVER. And the said.--.derame...Andersnn,..._Ilaaid__A-..... Ander-so-n-,•••-and---- Rohe-r--t----A..--Andersan-s--------• r.............. for.......... __----•-••--••...their----......._heirs, executors and administrators, do...... .__-------covenant, grant, bargain, and agree to and with the said partieS.of the second part their.-......... heirs and assigns, that at the time of the ensealing and delivery of these presents • they wer.e....:_...well seized of the premises above described, as of a good, sure, perfect, absolute and indefeasible estate of inheritance • in the law, in fee simple, and that the same are free and clear from all incumbrances whatever - ie--of the second part heirs and assigns, and that the above bargained premises in the quiet and peaceable possession of the sat Lrh against all and every person or persons lawfully claiming the whole or any part thereof,. f ~y......wi will forever WntRRA~NT AND DEFF. D: IWitness Whereof, the said part..i.e~f the first part ha~1e._-.her~euun-t-o- set.... fie-I•r .S.-- !J day of - tl k, -,kf A. D., 19... 0... \ (SEAL) SIG)ED AND SEALED IN PRESENCE OF 1 ome Aiade_r5.4--t~_.._--..----•- - r (SEAL) . David A I ereon- - (SEAL) Robert A".- ricIerso (SEAL) STATE OF WISCONSIN, ss County nlrl A. D., 19.50- August. Personal) came before me, this ................day ot............ •,rs . ..a ..Ro.bert._.A.._..Anders~an---•--------------_... the 14th above named---der.Ome ...AnS3.erS.QTl.i_._.:----.....__... to me known to be the person-3---.who executed the foreejoitj in rrent and acknowl Red the same. i i t. i I LD