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HomeMy WebLinkAbout034-1026-30-020 t r rC O N O ° ~ I 0 N U pp .O O O E O II O X Y" O Y C N 0 I' c Z ~j LL c L O 3 a) a ~ I N E U.) Zw = o Z 3 I N N a co F- U) to C ~ O O Z d w u 9 w ) Z y c 0 v 0 O c o .c7 Q V V N N w N Z Z a o Z Z o 0 ' c E I~ w y _ (D O CL ~ n y d ~ N h~ LO ~rooa n n U.) H IN- H E Rr 3 a<n o o o W*A R c IL IL 0. It O U) I O t0 C0 N J U li rn rn D I'; v rn ~ 00 M O N - 0 O O O O C) O N N L Z l0 co O O 251 tU O c '0 m y c co a) cli 7 d O o f6 C U c Q (n 0 N O _0 3 \1 ►`l N L a' Q O O O c E N N c0 r- U y; M O C C O O O O W N w F- CC E c N 4 N lry ON\p O OI - - N O FBI O C N n N e- N ' 5 pro r0.+ j Z` ~ C N o C-4 (a (D 0 • O O r Cn 06 d' N o Z y Cq L 0. `hl E ` 'c c SD ° A 0 a o y U A/q STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER- ADDRESS _~j SUBDIVISION / CSMJ LOT SECTION - N-RW, Town of ST. CROIX COUNTY, WISCONSIN SHOW EVERYTHING WIITHINVEW VEW I100 FEET OF SYSTEM pRjre IV ~neAJc EveLL 3 ~o- y SRM yo N,rG 0 1~ v 4tj 1 i INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank, m nhnlr, cna- BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ~y / e .e, '2. Liquid Capacity: r Setback from: Well jpd House-, V/~ Other Pump: Manufacturer Model# d! / Size _44p__Illv Float seperation Gallons/cycle: -.4- Alarm Location :SOIL ABSORPTION SYSTEM Width: Length Numbe` of trenches Distance & Direction to nearest prop. line: Setback from: well: l~ House lo Other ELEVATIONS Building Sewer Q, e ST Inlet. B. (9 6 ST outlet PC inlet PC bottom_&E, 3 Pump Of f Header/Manifold Bottom of system i g Existing Grade J6 , 3 Final grade DATE OF INSTALLATION: PLUMBER ON JOB: ~l~--- LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations Safety INSPECTION REPORT ST. CROIX ' Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 268574 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: RATHAI, TROY SPRINGFIELD CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: C,~J' /G,~- Ud .rte ,-rv '"2 ~ ' i~~ TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark J-19, , 19 , O, C7 Dosing" 1f`a~ 7 Aeratieff- Bldg. Sewer (TJ /~JJ - ' 1 V l t F Holding St/ Inlet (~_J TANK SETBACK INFORMATION St/ IfOutlet Vent irIto ntake ROAD Dt Inlet TANK TO P/ L WELL BLDG. A Septic 166, A NA Dt Bottom Dosing ' S3 y NA Man. Aeratio NA Dist. Pipe o 3. s J Holding Bot. System 77 36 6 P . PALINFORMATION Final Grade Manufacturer J Demand„r - . F va Model Number P mead TDH Lift w (~4' Lriction1 Z? Sy stems TDH/c/,, oss Forcemai n Length / Dia. ; " Dist. To Well > /(~D~ SOIL ABSORPTION SYSTEM 4BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth %I DIMENSIONS 5 /Gv DIMEN I SYSTEM TO P / L BLDG WELL LAKE/ST EAm LEA nufacturer: SETBACK INFORMATION Type O r C B R Moe Number: System: ry(~d/lyd /OS ~~p OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake f 4- 1 1` ~ p i LengthC~ ~ Dia. V ' Length Dia. o Spacing _7 3y' SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ,34 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: Springfield.12.29.15W, SW, N , County Road W r , ~t? ( C~C2:64~1 { c...F,g .°~'f= 5.35l~ 73f-itsr c r /c k2 o d~'.~r Plan revision required? ❑ Yes Q'40 Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signatu a Cert . No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: Illl~~iiil~ 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 Permit Number The information you provide may be used by other government agency programs [Privacy Law, s. 15.04 (1) (m)]. E] Check if revision o pr vtous applicat on State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION -s"/" Prop rtOwner Name Property Location I-Ne 54v1/4 1/4,S /a TA ,N,R 4& AM W Property Ow er's Mailing Address Lot Number Block Number 6 Ci , State Zip Code Phone Number Subdivision Name or CSM Number 0. 1 II. TYPE UILDING: (check one) ❑ State Owned ❑ 'ty Nearest Road ❑ Village ❑ Public 1 or 2 Family Dwelling - No. of bedrooms Town OF S' % /C Gp v 141 III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo r l0.2 X- 30 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. q Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ----System System Tank Only Existig n 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 gJ 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 6 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min /inch) Elevation OO D© X, 2 S """'Feet 6?o," Feet VII. TANK Capacity INFORMATION In gallons Total # of r Prefab. Site Fiber- Ex er. Gallons Tanks Manufacturer s Name Con- Steel Plastic p New Existing Concrete strutted glass App. Tanks Tanks Septic Tank or Holding Tank x /.2D er / i &Se t 0 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber X ❑ ❑ ❑ ❑ 1-1 VIII. RESPONSIBILITY STATEMENT l J I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: ( Stamps) MP/PMMNWNo.: Business Phone Number: H C Gv SM/~~`"~Lv.d ~9G 7/.5-'-2 Plumber's Address (Street, City, State, Zip Code): :Z r A/ AL-1 Y 1241 C111-14 e /V IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sa Itary Permit Fee (Includes Groundwater Date Issue Iss ing Agent Signature (No Stamps) XApproved E] Owner Given initial '"'7 Surcharge fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: original to County, 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. Onsite3sewage 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: r.connection, 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, nurr -er of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete f)r all ;.?ptic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experi rem 3' product approval from DILHR. VIII. Responsibility statement. Installing plumber isto fill it name, license number w1th appropria' c 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 thF (ounty. The plans must include the following: A) plot plan, drawn to scale or with complete dimensior,s, locati _,n of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water ser lice; stre:;mis 3:id lakes,- pump or siphon tanks, distribution boxes; soil absorption systems; replacement system areas,- a, id the to-Aic. i of the building served,- B) horizor,4 and vertical elevation reference points; C) complete specifications for purips -d controls; dose volume; elevation differences; friction loss; pump performance curve; purrp model and pump rr 3n,3' 3 _turer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 1 1 `orm, a rd F) Al sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated !~rac1 (es which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contaminat on investigations and establishment of standards. L 7T - - t1' ~y - - _ -t- - - - --1 f i - - , ~ - - - - - - - - r, F is 10 Rd , k/ I .-1- - - ~ i _ r - - i N - I .o / - - ,EX~'Sf./ N' Sys I - b • y 1 joc 1 40, 2-.f `[rLccAt~t~~ i I1~la•t~ Yin , is Me,* Ex ~Sl i~rGy , 'e cv ®,q -itli~l G i_ r~ Ne rv ,6L dp Se- we R SA Me e e vii oN LI' N;L- e. S'S Nc f'~ d I ~ ~ I • VA, _ A pi i I - - - - - - neT.' e~ 11" 0 t MUM 11 .f f I lol a3VORqqA a, Ift. of Page Straw, Marsh Noy, Or • Synthetic Covering 11 Distribution Pipe Medium Sand G Topsoil F I E D b % Slope Bed Of -12* - 2 %Z Force Moin 111u..ed Aggregate From Purnp I ayc. r F- Cross Secti:,n Of A Mound Systern Usirig ~ A Bed for f he Absorption Arc c C ~ Signed: , tg ,Sri It License iiun,ber : /~'l~~_ ~l>_ _ _ l f0.•~/ 1 t . - - L - Ur ~otiun ('it ® - - K - - A OrGe Main W From Pump Distribution Bed Of 2«- 2 %2« Pipe Aggregate Observation Pipe Permanent Morkers Pion View Of Mound Using A Bed For The Absorption loco ~g6 Page- of.L Perforated Pipe Detail End View FORA & PeR a pVJ, plN~ +t~Rs i A~~ Q15 -Force i•:ain PVC f+ Holes located on botto°, of force main are equally spaced cap Last hole snoald be next to end cap Distributatior, pipe-layout P!b Ft Q -Invert Elevation of Laterals R Inches %~1~J5 Ft S Inches X--,~LInches S igned s L Y Inches Liaense t ~ Hole Diameter Inches Dates 'T-- Lateral ~L Inches Manifold - Inches Force Hain " -2--Inches # of holesAipe S96-20716 • PAGE ~ OF PUMP CHAMBER CROSS SECTIOW AMD SPECIFICATIOfyS ' VENT CAP 4"C.2. VENT PIPE WEATHER PROOF APPROVED LOCKING 25' FROM DOOR, JUAJCTIOU BOX MANHOLE COVER WINDOW OR FRESH i2"MIU. AIP, INTAKE GRADE I I 4" MIN. IB" MIIJ. COUDUIT 18"MIN. ~ 11~ IAILET PROVIDE AIRTIGHT SEAL' III APPROVED JOINT A I I I APPROVED J' C.Z. FIFE EXTENDIAIG 3' '+✓/C I FfFc L`T SOLID 3SOIL ' I II ALARM EXTENDIIJ'. B i I OI•JTO SOLID 5 A I Oti I CIEV. y2~T.--" PUMP OFF D BETE BLOCK mould tM1r dark In RISER EXI IF TA►JK MANUFACTURER HAS SUCH APPROVAL SEPTIC E /0 10 SPECIFICATIONS C 0 5 E r,# N ff T ~iJ / X 5,+1 AIJKS MANUFACTURER IJUMBER OF DOSES: _ PER DA-4 TANK SIZE: 1204,-:0- -tZJy GALLOMS DOSE VOLUME ALARM_ MANUFACTURER: _ S./ G~ ERG INCLUDING BACKFLOW: -Z&- GALLO1 S MODEL WtAbCR: CAPACITIES: A= INCHES OR ~49 GALLOK; i SWITCH TYPE: ed ' N 8= 12 INCHES OR `Z2 GALLOI`.'S PUMP MANUFACTURER: C>O t'/la, C=INCHES OR _1-9.3GALLOX.'S MODEL NUMBER: ED D=- INCHES OR ~ GALLOrIS SWITCH TYPE: ELG'Ljf/k'0 FL/ NOTE: PUMP AND ALARM ARE TO BE MINIMUM DISCHARGE RATE ' -2%-f GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFEKEUCE BETWEEAI PUMP OFF ARID DISTRIBUTIONpIPE.. FEET + 141MIIMUM NETWORK SUPPL I PRESSURE FEET + -1-0 FEET OF FORCE MAIM X "-~F/ppFEFRICTIOW F4T ft.._L,2- FEET TOTAL Dy1JAMIC HEAD = L97 FEET IMTERNAL DIMENSIONI; OF TANK: LENCsTH WI DTH ;LIQUID OEPT F-1 SIGNED: A LICEMSE NUMBS : /~~.5~ 0 • "96 R - 9 DATE. ! VIiESTBU N SUPPLY INC. pVe. 12 dDUSTRIAL RD. Goulds Oi Jj W1 54016 Submersible Effluent Pump _ 3871 EP04 EP05 APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. • Effluent systems dry without damage to heat transfer. ■ Motor Cover: Thermoplas- • Homes components. Available for automatic and tic cover with integral handle • Farms Motor: and float switch attachment • Heavy duty sump • EP04 Single phase: 0.4 HP, manual operation. Automatic points. • Water transfer 115 or 230 V, 60 Hz, 1550 models include Mechanical • Water ring RPM, built in overload with Float Switch assembled and ■ Power Cable: Severe duty automatic reset. preset at the factory. rated oil and water resistant. SPECIFICATIONS • EP05 Single phase: 0.5 HP, ■ Bearings: Upper and lower 115 V, 60 llz, 1550 RPM, FEATURES heavy duty ball bearing Pump: EP04 built in overload with construction. • Solids handling capability: automatic reset. ■ EP04 Impeller: Thermo- 1/4" maximum. • Power cord: 10 foot plastic Semi open design AGENCY LISTING • Capacities: up to 55 GPM. standard length, 16/3 SJTO with pump out vanes for • Total heads: up to 24 feet. with three prong grounding mechanical seal protection. SP Canadian Standards Association • Discharge size: 1112"NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo- for Mechanical seal: carbon- length, 1 6/3 SJTW l 20 f with plastic enclosed design (CSA listed model numbers rotary/ceramic-stationary, three prong grounding plug improved performance. end in "F" or "AC".) BUNA-N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: thermoplastic design provides 10411F (40"C) continuous superior strength and 1401(60°C) intermittent. corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. ---10 • Capable of runnin g o d without damage to ' dry I 30 f j GPM I comp neWs. ILL~~~Jjj Pump: EP05 ! 2.5 FT • Solids handling capability: 0 251 I 3/4" maximum. W % • Capacities: up to 60 GPM. X • Total heads: up to 31 feet. s 20 • Discharge size: NPT. i 5 • Mechanical seal: : carbon- > ~ rotary/ceramic-stationary, ° 15 BUNA-N elastomers. iQ 4 ! EPos • Temperature: F- s 10 104111' 4001Ccontinuous I I 140"F 600C intermittent. 2 ; T ePOa ~ I 1 I I ~ 0 00 - 10 20 30 40 50 GPM 0 2 4 6 8 _L L 10 12 ml/h rn) CAPACITY . O Mt995 1995 Goulds Pumps, Inc. B3871 Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and G! percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # ECEI APPLICANT INFORMATION - Please print all information. 3 l0 Reviewed by . •aaz 7Date ; Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner ' r R0 Property Location NTY Govt. Lot Sit/ 1/4 /4,S Tt~F Property O er's Mailing Address Lot # ]_6_1o_c_k#FSubd. Name or CSM# ¢ i L v City State Zip Code Phone Number ❑ [RI Town Nearest Road p wN/~V 11-11 ' S' 73 /3 )a63 = City 3 la a /P. d Ar l ❑ New Construction Use: Residential / Number of bedrooms !4~- Addition to existing building Q4 Replacement ❑ Public or commercial - Describe: Code derived daily flow 010 gpd / Recommended design loading rate bed, gpd/ft2_N,~ trench, gpd/ft2 Absorption area required ___[~~bed, ft2 b O o trench, ft2 Maximum design loading rate bedgpd/ft2_ ffh trenchgp , , d/ft2 Recommended infiltration surface elevation(s) 9'X,.2,3-- ft (as referred to site plan benchmark) Additional design/site considerations /y .sM01 AOi11dCR rV Sf~M Parent material A 0 / A L r/ 4 L Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system ❑ S ® U WS ❑ U ❑ S ®U ❑ S Co U ❑ S ®U ❑ S RU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots / Bed Trench v- 1- a.S l= 2 :.5~ c5 I- G AW / F r Ground lev AMA Depth to limiting factor -Lin. Remarks: Boring # - 4E a A 14,64-M A r G-w . : 5 SG a 54 M Fz /Y /YA Ground lev 4-ft. to limiting factor !-_in. Remarks: CST Name (Please Print) Signature Telephone No. A Address ~VAG"_ Date CST Number 2 2 ~ o' 6~1 eNS,J po do o%7 z-26 PROPERTY OWNER tR~ SOIL DESCRIPTION REPORT Page of , ` , PARCEL I.D.# l-qd 6 -v Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots Gep/ft Boring # 2 , in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench S6 /►1,•r - N,1 Ground , qv• Depth to limiting factor if-in. Remarks: Boring # Ground elev. ft. ' 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 in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) 41 r~ j--z : - i r i 1 i o i i - 1- f ( I _ L_J I T I I I I ~ I-- I I i ' a I I I l i t ( I ~ I - I- I r I ~ I I I I ~ ~ I _ I --I I r- - I I- I I I I I L. , I I 1 l I ~ i I ~ I I ~ r ~ I I i I- I - - I -4 j I - j _ i_ - - - - I I I I I- I l I ~ I I I I I _ I I I ~ ~ I I- G - L i C I t_j I_ -4 I STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERMANAR 7'"Ro l°,9 f'h sl I MAILING ADDRESS ~d O 00 Ad W PROPERTY ADDRESS J"A m e (location of septic system) Please obtain from the Planning Dept. CITY/STATE DO w gi/ / N4. A,., PROPERTY LOCATION Sw 1/4, Alt=_ 1/4, Section, T R q N-R W TOWN OF 5-,OR /'A/ 11,P:/e° ~ pl ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP ---7VOLUME 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 must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three ye expiration dat SIGNED: DATE: l 76 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- 4D RA"`j A % Location of property-rA/ 1/4j/e1/4, Section ,T_2M-R- Z' W Township .SPR/w o ie4 Mailing address Address of site s;¢ M.e Subdivision name Lot no. Other homes on property? Yes No Previous owner of property ~e/-, y o Rde L Total size of property /a eq A &.0 ,e Total size of parcel /A d A G R le- Date parcel was created Are all corners and lot lines identifiable? Yes ~i No Is this property being developed for (spec house) ? Yes __,k'_No Volume A// and Page Number 114? 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.'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 offic of the County Register of Deeds as Document No. f . Si nat e of Applicant Co-Applicant 'C)- -3 r floo Date of Signature Date of Signature r h A f oocuMeNT No. WARRANTY DEED THIS SPACE RESERVED FOR RECO4:x 544996 STATE BAR OF WISCONSIN F RM 2-1982 - 183PAGE 211 Vol - REGISTER'S OFFICE Be.t.ty...L...N.orde.l.l.,..an..undi.vid.ed one-h.a.lf.. int.eras ST. CROIX CTY, WI .t.,..an.d...... FWd for Reead Elaine. L.o.e-,_.an...undi.vi.ded...one-ha.lf...in-t..er.e.s.t............................ JUN T 1996 - 1:40 P. conveys and warrants to _Troy. J._Rathai_an..Magaret_-Z. -Rathat M husband -and_-wi.fe.,..as..survivo.rs- mat r-ita-x pxoper.ty. - a of JAI, Register of Deeds . RETURN lieyw d & Cari, S.G. 204 Loc St, P.O. Box 229 - lluds WI 54016 / the following described real estate in .St ....Croix............ .County, State of Wisconsin: Tax Parcel No: Q34-1-Q96-1.Q........ 034-1026-30 Southwest Quarter of the Northeast Quarter; Southeast Quarter 034-1026-40 of the Northeast Quarter; and Northeast Quarter of the Northeast Quarter, all in Section Twelve (12), Township Twenty-nine (29) North, Range Fifteen (15) West, Springfield Township. $ TRA NSER This - - not homestead property. em (is not) Exception to warranties: Easements and restrictions, if any, of record, and reservation of mineral rights by the State of Wisconsin. Dated this 31St---------------- day of . MBy. 19.96.... (/~J ,11.. - o= -T - (SEAL) E -cc[!f?.._.... - . ......-----(SEAL) Betty I. Nordell Elaine Lo. _ _ ------.(SEAL) _ (SEAL) ` . - _ AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St. Croix County. authenticated this day of---------- 19...... Personally came before me this ..-31St- day of 106_.. the above named Betty I Nordell and Elaine Loe a LE: MEMBER STATE BAR OF WISCONSIN If not............................................................. authorized b y § 706.06, Wis. State.) to me known to be the person who executed the foreg ' to trument and ackno ledge e s e. THIS INSTRUMENT WAS DRAFTED BY He wood & Cari S.C. Samuel_.R.__Carl y - - Jan Terkelsen a - - - 20,-_-Locust--Streets--Hudson--IlI.---54016------ S ro - N tnrY P lie t C ~ . ix _ ...........County, Wis. (Signatures may be authenticated or acknowledged. Both M} Co ission is permanent. (If not, state expiration are not necessary.) date: 118Y_ 9 1999----•) 'Names of persons airning in any capacity should be typed or printed below they aignatu .a, JANE TERKELSEN Notary Public .Sl~ln ..f Wi- .ntaif~..-h ../1RI ..d r Inr