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HomeMy WebLinkAbout032-2028-90-250 0 oo, Q c 3 o N C C. ~ N ) ~ I i C O O rn ry p) c6 I C_ O) C) s, ~ O Q 0 v E O O O > E a o L) N C O p N X N ~j >0 M LL 0 O > 6 Z 4) C _ m 60 7 C O c0 C "O LL p w O f9 N 0) U cu )n a io a) Q ~2 N 3 0 v ~ Z N O w O Z IL co m~ c 0 co o z w N z m y z c E v ~ O) p N C- f 5) N y C O U N Z I- Z c N C C N d m m E E N H is Y zn ` a) CL CL ~l N y d L C OI o C a 0 o Z m> LO FN- H H c U a a a +v R c a ° °i N a o ►11hir vJ -j U S rn_ rn e a o 0 } rn (D N O ^ N m d O N 'G m aa) O O O N C N _ co O C N cfl O ® CCS N(o Cr0 O 3 U O O O ~ a p) X 0 0 0 1 L O n E C N 04 `rl O J O 1~ O C O O ~ -p CrD W '~I ~ h O M r Eo > co v 'E o V r .w T ~ ik w N V m a L: CL • CL 4) .V 4) y C rr £ 7 3 p c0a~ o 3 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS S? ,y r G SUBDIVISION / CSM# LOT # SECTION ~7_T,5',,,, N-R 9 W, Town of ST. CROIX COUNTY, WISCONSIN P VIEW SHOW EV RYTHING WITHIN 100 FEET OF SYSTEM ~ -fib Scr ~ ro' ~ INDICATE NORTH ARROW Provide setback and elevation informatbn on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK:a ALTERNATE BM• I SEPTIC TANK /^PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Well House -Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length _ Number of trenches Distance & Direction to nearest prop. line: Setback from: well:- House /,2,,s- Other ELEVATIONS Building Sewer ST Inlet: ST outlet:_ PC inlet PC bottom Pump Off Header/Manifold 9//7 Bottom of system ~,ay Existing Grade Final grade DATE OF INSTALLATION: -c' PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: e,0 3/93:jt ~Wisconiin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT S . Gra; GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. C> 16 -7 Permit Holder's ame: ❑ City ❑ Village M Town of: State Plan ID No.: bwcl i( t CST BM Elev.: ` Insp. BM Elev.: BM Descri tio Parcel Tax No.: I100 loot o p 32 -Zo zS - f!rC7 TANK INFORMATION ELEVATION D A . ie.-oo 20 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Se ti 1000 Benchma Z /qp•9~. / Dosing Aeration Bldg. Sewer Holding Gy C-lnlet q:St 4Z.;~C- TANK SETBACK INFORMATION &W Outlet g. qz d~~ TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Se 0~ ~ppt ~O ij?,pf NA Dt Bottom ~la- Dosing NA Header / Man. Aera NA Dist. Pipe H Iding Bot. System ?0 or PUMP/ SIPHON INFORMATION Final Grade 7?/~ 173.7-1 Manufacturer remand 04, 4 4e r- 641 1(44, Model Number GPM TDH Li Friction a Ft Forcemain Lengt Did. Dist. To Well SOIL ABSORPTION SYSTEM BED N Width Length 5c; No. Of Trenches PIT No. Of Pits Inside Dia. L epth DIM N DIMEN I N LEACHING nufact r: SETBACK SYSTEM P / L BLDG WELL LAKE / STR M INFORMATION Type O CHAMBER del Number. Syste : TO / --70' %6' 10tf' DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x-H a Size x Hole Spacing Vent To Air Intake Length r Dia. Length Dia. Spacing i SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over It Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed/ Trench Center Bed /Trench EzIgFs Topsoil ❑ Yes ❑ No ❑ Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) [f ,1kol 3610 {0( gjc1 l R& 12 Plan revision required.) ❑ Yes R No 1131 7 ( Use other side for additional information. 04 SBD-6710 (R.3/97) Date Inspector's Signature ert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ' • Safety and Buildings Division 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 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Perm yu~nh;er 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)1. State Plan I.D Number 1. APPLICATION IN ORMATION - PLEASE PRINT ALL INFORMATION S - Propert owner N me Property Location S T , N, R ~(or n~ Property Own is Mailing Addr ss Lot Number Block Numb r Al d= r114 tate Zip Code Phone Number Subdivision Name or CSM Number itr Neares Road TYPE F BUILDING: (check one) E] State Owned VII ❑ age Public 1 or 2 Family Dwellin - No. of bedrooms Town OF S III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 0~` ~el~ -000 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 a ash 5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 12 Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. p 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 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 /t* Elevation Feet Feet VII. TANK Capacity site in gallons Total # of Prefab. Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. New Existin structed Tanks Tanks r~ Septic Tank or Holding Tank - 0 IOC El ❑ Lift Pump Tank /Siphon Chamber I' I I-E] 1 ❑ VIII. RESPONSIBILITY STATEMENT I, th undersigned, assume responsibility for i tallation of the onsite sewage system shown on the attached plans. Plu be s Nam : (Pr Plum is nat e~ 5 s) MP/MPRSW No.: Business Phone Number: 1 - - 9/ P umber's Address et ity, Stat P Code): IX. COUNTY! DEPARTMENT USE ONLY ❑ Disapproved San ary Permit Fee (Includes Groundwater ate ssue Issuing Age t Sig ture (No am A roved Surcharge Fee) pp ❑ Owner Given Initial / / ~i~ 0 v S/~~~ Adverse Determination ` X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One ropy To: Safety & 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 Dwel!ing. 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- The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. f SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations January 10, 1995 2226 Rose Street La Crosse WI 54603 K 0 CONSTRUCTION 308 MIDPINE CT STAR PRAIRIE WI 54026 RE: PLAN S94-41529 FEE RECEIVED: 110.00 RIVARD, MIKE SW,SW,7,30,19W TOWN OF SOMERSET COUNTY OF ST CROIX NON-PRESSURIZED IN-GROUND SYSTEM The Department has reviewed the above-referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin Administrative Code. - The plumbing for this project discharges to a private sewage system. The approval covers only domestic/sanitary wastes directed into this system. The Department of Natural Resources must be contacted regarding the treatment and disposal of all industrial wastes, including those combined with domestic/sanitary wastes. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be made. All permits required by the city, village, township or county shall be obtained prior to installation. SHOA-7997 (R. 10/94) SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations K 0 CONSTRUCTION Page 2 January 10, 1995 PLAN S94-41529 Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Sincere , rard M. wim Plan Reviewer Section of Private Sewage (608) 785-9348 7342RJ 2 I i I SRUA-7997(R. 10/84) • Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM Safety and Buildings Division Labor and Human Relations REVIEW APPLICATION Bureau of Building Water Systems Hayward Office La Crosse Office Madison Office Shawano Office Waukesha Office 209 W 1 st Street 2226 Rose Street 201 E. Washington Ave. 1053A E. Green Bay Street 401 Pilot Court, Suite C Rt 8, Box 8072 LaCrosse, WI 54603 P.O. Box 7969 P.O. Box 434 Waukesha, WI 53188 Hayward, WI 54843 Phone (608) 785-9334 Madison, WI 53707 Shawano, WI 54166 Phone (414) 548-8606 Phone (715) 634-4804 Fax (608) 785-9330 Phone (608) 267-5119 Phone (715) 524-3626 Fax (414) 548-8614 Fax (715) 634-5150 Fax (608) 267-0592 Fax (715) 524-3633 INSTRUCTIONS: To save time, schedule your review with one of the offices listed above prior to submittal. Fill in all applicable data and submit this form together with fees and plans/information. Your submittal must be received at least one working day prior to the appointment at the office where your review was scheduled. Please call any of the listed offices if you need help filling out the form or have que~u2~on n®h4rilmationto ftsubmit. PLEASE PRINT VERY CLEARLY. A sample of a completed form is on the reverse side for your reference. CC)) 1. APPOINTMENT INFORMATION -if you have scheduled an appointment, fill in the information requested below to save time: Appointment Date p Reviewer Name Plan Identification Numbe-r 2. PROJECT INFORMATION If this review is a revision or extension to your existing plan identification number, provide that number here: Project Nam ❑ City ❑ Village ® Town Of: County Pr7ec1 Location GOVT. LOT, 1/4 1/4,S T N ,R or ' J 3. APPLICATION FOR 4. FEE COMPUTATIONS FEE SUBMITTED System Type (check one): System Type t (include new and existing tanks) Up To 1,500 gallon septic tank $110.00 A ❑ At-Grade 1,501-2,500 gallon septic tank $120.00 H ❑ Holding Tank 2,501 - 5,000 gallon septic tank $160.00 M ❑ Mound 5,001 - 9,000 gallon septic tank $200.00 N ® Non-Pressurized In-Ground(conventional) 9,001 -15,000gallon septic tank $300.00 Over 15,000 gallon septic tank $500.00 P ❑ Pressurized In-Ground O ❑ Other: Up To 1,000 gallon dose chamber $ 70.00 1,001 - 2,000 gallon dose chamber $ 80.00 Building Type (check one): 2,001- 4,000gallon dose chamber $100.00 4,001 - 8,000 gallon dose chamber $120.00 D ❑ Dwelling, 1 or 2 Family 8,001 -12,000 gallon dose chamber $140.00 . P Public Building Over 12,000 gallon dose chamber $160.00 S ❑ State-Owned Building Up To 5,000 gallon holding tank $ 60.00 5,001 -10,000 gallon holding tank $100.00 Code Derived Daily Flow Zyl:!~_ gpd Over 10,000 gallon holding tank $150.00 ❑ Check If Replacing Existing System Experimental System (additional one time fee) $ 300.00 Revisions To Approved Plan Z $ 60.00 MEWED— Petition For Variance: Setback $100.00 r Site Evaluation $225.OOfAN.- ❑ Petition For Variance Plumbing $225.00 Revision $ 7WE.Ty.&-6L Groundwater Monitoring - Per Site $ 60.00 ❑ Groundwater Monitoring (other than a proposed subdivision) ❑ Site Evaluation in Lieu of Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring $ 60.00 Subtotal: //(2 - Priority Review: Enter same amount as Subtotal: /4~1_ MAKE ALL CHECKS PAYABLE TO: SAFETY AND BUILDINGS DIVISION Total Fee: 5. SUBMITTING PARTY INFORMATION Telephone No. (include area code & extension) Coma Name Cont Pe on i 91 No. & Street Address Or .0. Box City, To n or Vi ge, State, Zip Code Aerobic or prepackaged treatment system fees are calculated based on equivalent size septic tanks and dose chambers. 2 Revision fees are not applicable to temporary holding tanks or extensions to existing approvals. NOTE: Fees are pursuant to Wis. Adm. Code, Chapter ILHR 2, and are subject to change annually. 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C 0010 1 O 0 N. -h r+ O W N -f IA -S a c m m O .0 1 n 1 1 0 c a m- 1< .0 O K 1 O r+ 0 1 9 O m 0 M C "O m x o m a N v 1 m m o• to r+ E o 8.,+5. 1< 0 c 3 1 w r+O 3 m O m O z dV1 m m m 1 w 7 ~•n m r+ O a w 0 m r+ N tq 1 0 H N 1 j E d w -h IA I (A m r+ o 911.4 0 CL B a to rt - a 0 a r+ m m E V ID C tT m j d O -tom l1 m 1 0 m r+ a mmm CL " 1 WsoonsinDepartmentof Industry, SOIL AND SITEEVALUATION REPORT Page -,L- Of Labor and Human Relations Division of Safety & Buildings in accord * h§H 83.05, Wis. Adm. Code 41,5 ~ COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include; but not limited to vertical and horizontal reference point (SM), 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 PROPERTY ~WNER: PROPERTY LOCATION GOVT. LOT 1/4 1/4,S T N.R /(o& PROP RTY OWNE ':S MAI G ADDRESS LOT # BLOC # SUBD. NA E OR CSM # CITY STATE `ZIP CODE PHONE NUMBER []CITY VILLAGE &TOWN NEARE ROAD ~(J New Construction Use [ J Residential / Number of bedrooms [ J Addition to existing building Replacement p(J Public or commercial describe Code derived daily flow /?,S- gpd Recommended design loading rate__ -T- bed, gpd/ft2_,,2,trench, gpd/ft2 Absorption area required.27,:j_ bed, ft2,-Z;~j- trench, ft2 Maximum design loading rate -,-gybed, gpd/ft21L/, _trench, gpd/ft2 Recommended infiltration surface elevation(s) ,mil ft (as referred to site plan benchmark) Additional design / site considerations Parent material 4-25- W"2 Flood plain elevation, if applicable ft = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK F S U=Unsuitableforsystem toS ❑U ®S ❑U OS ❑U 0 7 ❑U ❑S ML ❑S OU SOIL' DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouxlary Roots GPD/ft in. Munsell Qu. Sz. Co t Color Gr. Sz. Sh. Bed Trertdi :.:.v. SS i 55 Ground elev. ft. Depth to _ l9in --7 1, g imiting factor - 96 Remarks: Boring # -ZL Ground elev. ft. 91 '7 A> Depth to limiting factor1j Remarks: CST Name: Please Print Phone: Address: L Signature: Date: CST Number: PROPERTY OWNER ,U ✓1 SOIL DESCRIPTION REPORT Pag@ctf PARCEL I.D. # Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouncl3y Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench _'.,?a :l Ground elev. Depth to limiting factor 91 Remarks: Boring # - v? Y<,Z64 41Z ""t Ground - elev. _ 8 23~ ft. 7- 4~ez Depth to limiting factor `1 Remarks: Boring # a Z!2 5L E/.~2 lea Ground elev. AS //1 .a Depth to limiting factor > Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) i _ r_. i .I y I , Cs r,~o: any i 4 ~ i 7 Z , X lgl- ~~✓J~ksav ..S~;a,1' _WJr'1'O ~W - -t- ' 1 _ _ L , V. ~ _ _ T- - i i I I ; s l , I , i r- ' 219 OA i i I J, I ~ 3o i i 4 lccc, CAL- McrA#4 v, - : 1 - -r- 4-1 • - , r ~ ~~'r~C-fit- _ - f - ----~-rt--;----• i i 7~1 s I ' I j 2 1 --1__ ! 17 } -rt-~- - V2 i -T-'- cn - 42a _ I p lQ~s RY' pF A I i j I ! i i 894 -4-1 529 PAGE OF CroSS fl.ill AI( 111101• And Obis(vallon pipe ice- Approved V lrQB I+~~ Mlnlmuw 12• ALar. ' f_ /~~~y final Gtad. l1ena itl I F. A ID rt ~p~s 20- 42• Above PIPP _ c 1 1V'e* to final 014d. Vent P!P. lAB~R & H M+~.~~ i~~s Ltay.n )toy 01 Synthetic Cor.llny "In 2• AUVooyol. a~ Or.t PIP. D V"N1;l ola,iPrllon s.~GE Plp. 0 0 0' T.. Adpl.pal. o Pot ii.ilfv~ s` B. n.ap Pipe 0 o++plIng a+lnalinp At log lam OI Sy.l.m Pau o)eD ~I~t-~ cl~~.c~t 9`~7 SOIL- FILL OISTRIBUTIOM PIPE APPROVED Sy)JJ-HETIC COVC0. ` -/'~11TEF~1/~t Olt 9" OF STRnW 20OFhGGREGAIE OR MARS" HA-J I.~OF1z-zl/z AGGItCC-AT E ELEV.0F,22-L FEEr MSTnIry~JTIOW PIPE To BE AT LEA.VT(5; IUCHES BELOW ORIGIIJAL GRADE AQU AT LCA.S'T ZO IIJCHES BUT KIO MORC THA)J tit IKICHCS BELOW FINAL GRADE tWIMUM DI:Pr11 OF EXCAVATI00 FXOM ORIGINAL 6K11D~ WILL BE IUCHES n,qI LIM pq rH of ExcAVATIOW, r-KOP\ 0164JAL GRAVE- WILL BC IIJcHcs slruEO: Q LIGEUSE ►JUMBEIt: DATE: _,C 2-2~ :Y + 1 1 ~ 1 V u r ~a vre , ~~c ~r~poSeoPufur~ O.ySri e: fit, ouI~f b ~ q rv ~S ~y ~Y.; office osJf~ce' r ,a P ~ Y K: V` O S~1at~ f~ooN1 19r~~ 5#. .L ` t x Fr e~ En A`~ r "All a1 E• STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MAILING ADDRESS 3 Ir y 3 5- Sao-or ,r~7`', ,rya as- PROPERTY ADDRESS Scr ore (location of septic system) Please obtain from the Planning Dept. CITY/STATE Sn " &PAe 1 , PROPERTY LOCATION S 4L/ 1/4, ~Sw 1/4, Section T_ o _N-R__Z,_W TOWN OF Jm~Prf'e7~ , ST. CROIX COUNTY, WI SUBDIVISION _ AI A 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 ( I ) 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: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/ contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. owner of property /-',&.n,P_# ~n Location of property 5&,, 1/4 S4~,, 1/4, Section T_3.0N-R16_W Township, ~xp sp Mailing address 36- V- 6 Address of site ~t•yt Subdivision name lV A _ Lot no. other homes on property? Yes No Previous owner of property ~vel( tea.-~ Total size of property Total size of parcel Aritec Date parcel was created t rc`i f 3 /9f-y Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes )_No Volume &,3& and Page Number _ as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBLIJ, 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. 4 Z9 &1& and that I (we) presently own the proposed site or 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. Signature of Applicant Co-Applicant mite of Signature - Date of Signature 39" Fv~F?l ).AND CU N'1'IG1("t'-)unur.~nci• l'Ln:ni•. STATE OV %%'111 ONSIN -FORM No. 33 nsc~e se lion 3,,.1( \1'm~ onein FL:tut[.a 1\'lade and concluded this _ _lst. day of • April 63, 1 by and between..... EVELYN G. MICHAUD, formerly EVELYN G. RIVARD, part y of the first Kurt, ' and.... LOWELL RIVARD and VIRGINIA RIVARD, his wife, - - - - of the second par-I. Witnesseth, First, That the said parties.. _ _ of the second part herchy agree and' bindthems elves and j I their legal representatives, to pay, or cause to be paid, to the said party of the first port, her hrirs or assigns, the sum of Thirteen Thousand Five Hundred ($13,500.00) - - in r,il:rr the manner following Party of the first part acknowledges receipt of the sum of $3,375.81 paid on the principal herein previous to the date of this contract: RT012ppal balance owing at this time in the am f~~'6X~ XXjX Yxex- ' 0,12~+.19 shall be paid for in the manner fol owing• , on or e- fore the 31st day of December, 1963, and $1,000.00 on or before the 31st da of each succeeding December until the principal sum; together with interest on-the unpaid amount, shall be paid in full. Interest to be at the rate of! r Three Percent (3%) per annum on the un aid balance. Out of each payment shall be first deducted interest and the balance applied on principal. If the parties of the second part sell or assign this contract, interest on the unpaid balance shall be 6/o per annum. I The said ay cuts to he made to the party of' the first part, at Rout e , Chippewa Farts,. Wisconsin and the same being intended to apply, when fullyy' cornplctCd as the purchase money for the following tract, piece or panel ,r of land, situated in the C ounty of . St. Croix and State of Wisconsin, to -wit: West Half (Wk) of the Southwest Quarter (SWk) and the Southwest Quarter (SW'k) of the Northwest Quarter (NWk), Section Seven (7)--Thirty (30)-- 1 Nineteen (19); and The Southeast Quarter (SEk) of the Northeast Quarter (NEk), Section Twelve (12)--Thirty (30)--Twenty (20),; and The East Half (E~) of the Southeast Quarter (SE) in Section Twelve (12)-- Thirty (30)-=Twenty (20); r i II The.said parties. of the second part further agree. that.... -they will pay, when due and payable, all taxes and assessments which have been assessed or levied on the above described premises since the 1st day of January, A. D., 19... 57- , and also all such as maybe hereafter assessed or levied thereon or upon the interest of said part Y of the first part in said premises; and also all taxes and assessments now or hereafter assessed or levied against any molt - gage which may exist against said premises or against the note.... . or the indebtedness secured by such mortgage or against the interest in said premises of any party holding a mortgage against said premises during the term of this contrurt, and promise-..- and agree......... that the interest of the party ___.._..of the first part and the interest of the part ies of the second part in said real estate and the interest of any y party ~ ~ holding1 mort6lte a;ainst said real estate during the tcrnr i' " [ of this contract, shall be assessed for taxation and taxed together, without separate valuation as Unincumbered real est:U c and shall he paid by the said parties _..of the second part and the said part ies_- of the second part hereby waive . all rights of offsets or deductions because of the payment of any such taxes and assessments, until the aforesaid purchase money shall he fully paid, in t1iftecr above stated. Second Tt- - V . -r r1- -1-91A .,.,ter G-1- .1- fl,- -;A l es ..F rL. rAx -t ~i-il --1 1-11111 said pai4PS...__of the second part to pay such premiums when due, said part y__ ...of the first part, her heirs, legal representatives or assigns may pay the same and charge the cost thereof with interest thereon at the legal rate, to the said pzrt__......ies . ..o.r the second part, and the same shall be considered and taken to be an additional part of the consideration of this contract. The pa4e=P....... of the second part.further agree.....-to hold the said premises from the (late hereof, as the tenant .S. by sufferance of the said party........... of the first part, subject to-be removed as....:... tenant.s.... holding over, by process under the statute in such case made and provided, whenever default shall he made in the payment t. of any of the installments of purchase money, interest, taxes, assessments or insurance premiums as above specified; and also to keep the buildings.--, fences and improvements on said premises in as good repair and condition as they now are, except ordinary wear and decay, -and not to do any act whatsoever which tends to depreciate the value of said premises. Second, That the said part_.y---- of the first part, hereby at;rce.S and hinds... her. , _ heirs, executors and administrators, that in case the aforesaid sum ofThirteen ThousandFive Hundred. -.-----ars, with the interest and other moneys shall be fully paid and all the conditions herein provided shall be fully performed at the times and in the manner above s, ecificd,_ she on demand, thereafter cause to be executed and delivered to the said part- ie S_.of the second part, or_.__:their - heirs or legal representatives, a good ano sufficient Warranty Deed, in fee simple, of the premises above described, free and clear of all legal liens and incumbrances, except the taxes and assessments herein agreed to be paid by the parties_._ of the secqnd. part, and except any liens or incum- i brances crcate(1 by the act or default of the part ieS of the second part,.--. their... heirs, legal, representatives or ~ assl;;ns - - - - - - It 1s distinctly agreed and understood by and hctwccn the, parties hereto, that if the said parties. __of the second part shall fail to make any of the payments of purchase money and interest above specified, at the times and in the manner alxrve specified, or fail to pay the taxes and assessments, or fail to insure and keep insured the premises herein i, as above stipulated, or fail to pay any or all insurlnce premiums herein specified, or violate any other terms or conditions I~! herein contained, this agreement shall at the option of the said part-y._ of the first part be henceforth utterly void II ' Without any notice whatsoever, and all payments thereon forfeited, subject to be revived and renewed only by the act of the party of the first part, or the mutual agreement of both parties; and whenever such default or violation shall occur, the parties--....of the second part shall have no further right to collect rents from tenants, if any, of the said real estate, or any part thereof, but such rents shall be collected hy, and belong to the part. Y.- - of the first part. The said part-ies----- of the second part further promise - and agree that in case of the commencement of an j~ action to foreclose this contract and also in case of the foreclosure thereof,. . - they. - - - will pav, in addition to the taxable costs and expenses incurred, a reasonablrsum of money as attorney's fees-- _ In Witness Whereof, the said parties have hereunto set their hands and seals this 1St day of Aril. A. D., lo 63. ' SIGNL)AID ' %LED Tu, ~ usta,ct, OF Evelyn G_ _Michaud d ~r'jcz,L• Mar 'lien Marlette Ldwe11- --Rivard ; A • THIS NST RUMENT WAS DRAFTED BY Wi liam D. O'Brien, Attorney - ~ nn State of Wisconsin, __-Virg, nia.._Rivard - ss Chippewa. - - county. Personal) came before me, this 1St day of April - _ , n. D., 1463-- the alovc named . Lowell. Rivard, and Virginia Rivard, his wife, and:Evelyn G_._ jj - Michaud, - to me Known to he the person. 3 who executed the foregoing instrumeru and acknow <11, -the me WC ~ti m._ WilIlam . O'Brien a `;.tt lti_ t - - - - - - - - - a Notary I'ubllc, . - --..Chippewa . N1y commisslunCCQ6 1S perlD$I£,~r} (Section 59. SI (I) of the Wiuonsin titatutes provides that all instruments to tti recorded ahall have plainly prime 1 a tyheutri~~.,t[ •Q~r c n ~A I t1 a names of the grantor grantee: w to sses and notary. Section 59517 similarly reywres than the name of th per,on M o.. r~tp"yy~At 4 ntntal +tpency which, drafted such instrument, shall hie panted, tyreu ritten, stamrxd or written [hereon in a Iegi L.Ie manner}~' l,`! y r ~I i' _ n O N l~ / l Q t~ Scn Opp 5824' FILED ~o JUL C 7 1998 JUL i1 KpTMLEENH.W~~ Re4lster of Deeds 11 0 ° EY MLOCATED IN PA SW114 OF THE SW114, Nwo °z SECTION 7, T30N, R19W, TOWN OF SOMERSET, 1V ,w 0 ST. CROIX COUNTY, WISCONSIN. O L_~ o in z LOTS 2 & 3 SHALL BE ACCESSED o a SCALE IN FEET 1" = 200' 0 FROM 160TH AVE. AT SUCH TIME Z 5;: V) Li ACCESS IS RESTRICTED FROM S.T.H. 510111111111 ~w N a m "35" & "64" DUE TO REALIGNMENT. 100 0 100 200 300 w NOTE QA L =m ~ OUTLOT 11S CREATED 3/4N47'" 05'30"E REBAR , 0.48' FOUND Of 00 < FOR THE PURPOSE OF o INGRESS AND EGRESS FROM COMPUTED POSITION. Q zL w FOR LOT 3 AND IS TO UNPLATTED LANDS J BE RETAINED BY PLATTER z =N F~ NORTH LINE OF THE SW1/4 OF THE SW1/4 Q ~ a Z N 9'07'22"W 756.77' l m°^ iE 233.65 523.12 EXISTING q FENCELINE Wi ~I N OWNER LOT 3 (D L 119 AC. (D 0 LOWELL RIVARD Qi CA 606. 823SQ. FT. BOX 318 I 000 3 HWY 35 & 64 SOMERSET, WI 54025'Ji M _ w 06 L 06 I CV 0 C`+ I b \ Z w O O 1 (n OUT N 1 BUILDINGS Li I I w 1kt 89'46'10"W GARAG 66.00 H SEPTIC F a~; aS89'46'1 ®WEL54OT AC. o ao 0"E ❑ CONC. PAD 34,880 so. FT. q1 264.9' u+ ' 0.743 AC. EXC. pp .43'30'E) 32,354 54 S0. FT. . ~i N (589 ~ N LOT 2 0 00 iv N oO m o / Q 1 N NW o mac} a (_j 4.044 AC. INC RW 0, N p~ 176,154 SO. FT, C~uj ~K a LOT > o~ 4. All W I % °0 cw u, L'_,S'. M -i-4 N 53 AC. 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