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HomeMy WebLinkAbout034-1037-70-000 c I v o I a p oe~ 1 I kn Op Q. ~ c I °c I N C O Ci y a y w 0> 1 v Z oo 0 C co i 7 N Y. CO C 6 O T 7 E Q S U N O CD N W I' d m F U) o U O Z d U ~ ~ N d Z G O H r ~ Z a O O c Q) C • ~ 01 (D O oil 0 O = z z N z -°c I ~ N U E 00 L N y PV N ,t CL 0 LO N C O O \i d C N O Fir. o F_ F- CO o a LL m I •1V o a a Z a ~ ~ m 7 o L) } to U rn rn O Ir~y > M O 0 r o o = E rn m v, CL d N 7 ~ L:. O C CO N C m 00 In (n 0) 0 L C'4 F-- N C C p M V) N co EC N N rn v rH N ` ~ rOn N c6 N ~a O T U) LL N O N U) C8 .r y ~!I 0a 3 at a' a L CL d a 2 c E o 10 A u m 0 in CO) STC - 104 f"' > AS BUILT SANITARY SYSTEM REPO OWNER r e yJ e r YJ y'~ tit Fe r7 n ADDRESS SUBDIVISION / CSM# LOT # SECTION It- T N-R S W, Town of SIO 12 1'.41 I r.a 12 ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM J G . ~ ,4 t~ i I CAT arti /~U~ Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: a v ~G ~J ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: c~4~actc-n Liquid capacity: ?G 4 v Setback from: Well 3 S House S~CU 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 Other ELEVATIONS Building Sewer ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATIO : PLUMBER ON JOB: LICENSE NUMBER: li L ~l L~ INSPECTOR:- 3/93 : jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: LAor and Ouman Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 268621 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: FERN-KAMM, JEAN SPRINGFIELD CST BM Elev.: Insp. BM Elev.: BM Description: ' Parcel Tax No.: /ODD 00.00/ r L4141 406!2! L__' TANK INFORMATION ELEVATION DATA A9200464 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Di Dosing Aeration Bldg. Sewer Holding 3g~p -Ir/ Ht Inlet TANK SETBA K INFORMATION St/kix Cutlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding >/D 3s ' '5o ' :;.47 Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand 493 161,5 7 Model Number GPM TDH Lift Fri ' n System TDH Ft Head Forcemain L 9th Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length N renches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO BLDG WELL LAKE/STREAM LEAC anufacturer: SETBACK INFORMATION Type O C BER de Number: System R UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: SPRINGFIELD.16.29.15W, SE, SW, 90TH AVE j Plan revision required ❑ Yes [B'/No Use other side for addi tional information. l~ SBD-6710 (R 05/91) Date Inspe is Signature Cert. No ADDITIONAL COMMENTS AND SKETCH L_ t SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION safety and Buildings ter y Bureau of of B uilding Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. 3 Vino( • See reverse side for instructions for completing this application State Sanitary Permit Number 0~ (ogb*01 ( The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan LD. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Prop rty owner Name Property Location 1? Q 2 R Yl t! n? H'1 S,471 /4 S 1/4, S T N, R ) f E (or) W Property Owner's Mailin Address Lot Number Block Number 2 z L, r 4L City, State Zip Code Phone Number Subdivision Name or CSM Number woo ct 1 lti qLY 6-) ? q 21 II. TYPE OF BUILD NG: (check one) ❑ State Owned ❑ cityage Nearest Road E] Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Vill Town OF lc&4 1Tllq Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1❑ Apartment/ Condo 031-1 103? 906 &0 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel / Motel 9 ❑ Office / Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box online B, if applicable) A) 1. ❑ New 2. r4 Replacement 3. E] Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System _ System Tank OnlyExisting 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 W Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation Feet Feet capacity VII. TANK in gallons Total # of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App. New Existing strutted Tanks Tanks Septic Tank or Holding Tank Is_" - C'C~C /'}'1 L d r.(.: c 6- ❑ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plum is Signatur Stamps) /MPRSW No.: Business Phone Number: S0 e, St c:vt cam' L'~ ~?1S Grf~ 22~l0 Plumber's Address (Stre,et, Cit tate, Zip Code): e _G" C, (~f /G,.., jDIp 1-"/Uvd v, !lP I-(lI I~ IX. COUNTY/ DEPARTMENT USE ONLY ❑Disapproved Sa taryPermitFee (Includes Groundwater ate sue n gent Sig tur No. Stamps) Surcharge Fee) *Approved ❑ Owner Given Initial Adverse Determination :06 S o 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 fi 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III- Building use. If building type is public, check all appropriate boxes that apply. IV- Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, re,::onnection, or repair- V. Type of system. Check appropriate box depending on system type. Vl. Absorption ~ystern information. Provide all information requested for numbers 1 througl- VII. Tank. =nformation. Fill in the capacity of every hew/or existing tank, list the total gallons, nurot ~ r of tanks and manufacturer's name, indicate prefab or site constructed and tank material- Cornplete fo, 311, ?ptic, pump/siphon and l olding tanks for this system. Check experimental approval only if tanks received experiment., !product approval from DiLHR. Vlli. Responsibility statement Installing plumber is to fill in name, license number will-, approl:;riat prefix (e.g. MP, etc.), address and phone number. Plurnber must sign application form. IX. County / Department Use Only X_ County/ Departrner?t. Use Only not smaller than 8 1l< x. 11 inch- must: be su_ It!ecl to _unty. The plans must plot , flan, drawn to scale or with coinp:e'- c :rnensicr~, locatk ~f i king, `ank(s), septic bu idi,F trv-z? rt, vvr.iIs, w pump or siphon _ ;I„- arri'n~;stc"r~5. ~f.a;ater /s,?rr. f `he ouilding served; (,I dose Vol ume,- -,mp ~n er, 'j) cross section zinginformation- GROUNDWATER SURCHARGE 1983 Wisconsl A-ct 410 includeta the c°eation of surcharges (':-ees) for a number of r-o, lated pr,v. i(: which can e'fe t Orou,r a'dv_l Tide monies collected thror!gh these surcharges are used for monitoring groundwate ontarrili at.ic i investigations and estabiishmenc of stanciards. f SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations August 16, 1996 2226 Rose Street 9 W La Crosse WI 5460 00 WEGERER SOIL TESTING AU 3 X996 421 N MAIN STREET ST CROx PO BOX 74 Co WTY RIVER FALLS WI 54022 f►' SCE ti RE: PLAN S96-40990 FEE RECEIVED: 60.00 FERN-KAMM, JEAN SE,SW,16,29,15W TOWN OF SPRINGFIELD COUNTY OF ST CROIX HOLDING TANK 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. 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. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Sincerely, a erard WM. im Plan Reviewer Section of Private Sewage (608) 785-9348 SBDA-7W7 (R. 19/94) HOLDING TANK Page of RECEIVED Z For 8 9 6 409 90 A Bedroom residence AUG 1 4 1996 SAFETy & BLDGS. DIV. LOCATED-IN THE SE~: 4 OF THE Sw 4 OF SECTION 16 " , T Z.9 N, R \5 W, TOWN OF Sp~il~ G FLT Lp , Sr Q_I Rw4 LX COUNTY, WISCONSIN. INDEX PAGE 1 of 3 TITLE SHEET PAGE 2 of 3 PLOT PLAN PAGE 3 of 3 HOLDING TANK SECTION PREPARED FOR c•q'BT~~ ~y Z °1 Z~ C 1O `r l+ ft-lip, N c 17 PREPARED BY lrJ ECEERER SCSI I TEST I P-4 C9 AND ®ooe~~ F.D. BDI 74 421 N. MAIN ST.} . .ti RIVER FALLS. VI 54022 ~ S ARTHUR L 715-425-0165 Ko g' F i 6LLSWORTK i ' wts. A®° ~IGl; JOB PTO. 6' ~98 _ PLOT PLAN Page Z of ?3 SCALE 1" L11~ ' D- 0 O k 0 ~q W~I,L 4'~ PVC O j E U J $5 ibZ P PiVO a j 1 ~ w {gg `c1 t G tl wP~l ~Z-~3 do NkTG~ MAS .~Q1.iS'~RY, 1►Nd 14 I SSE 0 HOLDING TANK CROSS-SECTION Approved Weather Proof Vent Cap Junction Box /Approved Locking Manhole Cover 4" C.I. With Warning Label Attached Vent Pipe Minimum 12" I Final Grade } 4" Mi ni mum Approved Joint 18" Minimum ~ Water Tight' -~_4__ Seal High Water ' h SPECIFICATIONS Alarm Switc 1 TANK New Existing Approved Joint Manu acturer. r~ t pw~s Z~v , T ~x,e w/ C.I. Pipe Blind C.I. Tank Size: 3ooc, Gallons Extending 3" Plug ALARM Manufacturer 5< Onto Solid Soi S', AC Qt Model Number: l v l CoR P t~ w Switch Type 1~1 t~j-ZCuk, ( NUMBER OF BEDROOMS: Z GALLONS PER DAY: %0Q 3" of Bedding Under Tan tS S V511 oil wrsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of Z ag and Human Relations r ' Division of Safety 8< Buikings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but ST C' X not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 0_3(4- APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: V" - wf}m PROPERTY LOCATION C/13 ~ n GGW. L- S~ 1/4 S w 1/4,S 16 T Z. g N,R l 5 E (or w~ PROPERTY OWNER`-S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # Z- OL -7. 9 O `I'N INfue - - - CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE EFOWN NEAREST ROAD 1~voU~vL~I.~, ~vl S~ll1Z~ (ifs) ~-,Z_ t~~ty s ti~ j_- New Construction Use [>4 Residential / Number of bedrooms Z [ j Additign to existing building J}d Replacement [ j Public or commercial describe Code derived daily flow 3 kWb gpd Recommended design loading rate - bed, gpoltt2 1 trench, gpd/ft2 Absorption area required - bed, ft2 trench, ft2 Maximum design loading rate bed, gpdfi trench, t Recommended infiltration surface elevation(s) _ ft (as referred to site plan benchmark) Additional design / site considerations l~toLp 1 Jy G ~P n.Jlt V-t!'Q ~ Parent material S L QTY- S M%Li rat" oy► t` 2. -n U_ Flood plain elevation, if applicable N- It S = Suitable for system 0MENnONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for system ❑ S R1 U ❑ S RIU ❑ S 9W ❑ S ®U ❑ S 21 U R IS ❑ U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bax>dary Roots GPD/ft in.. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 4~ _ 1 a_a Zo~2. z, It - si5 Z~F-sb ~~P~ cs - • S • 6 ' Z : g - j,fo l~ `'f. ~ 27 C 1 \,~1S.Z fL 3 ! 3 S 1 1 ~ Ivy Wt ~'r - Ground elev. ft Depth to limiting faci~ << Remarks: Boring # 1 g: I+L co l~ ft-~_ Tab i /^.l S/ c L $ W1 U l 6 Z-S ~ 1uv iar 04, b L U~lf'S-t '`.~S S ~U 2` - i Ground elev.. i S _ C3 l U 12 1 S ? R.o Depth to limiting l factor I LLJ Remarks: CST Name:-Please Print PhonB Arthur L. We erer 715-425-0165 g rer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Signature: - - - Date: CST Number 8'- M00576 PLOT PLAN Page Z. of, Z ' SCALE 1"= LAO o $ 3 vE~1 Q4 O K ly w L t3DR.►~t - B, ~Z P o.-1 yn1 (715 42~-01(,r, ) ICI 7 CST Signature Date Signed Telephone No. CSOO ST Labora mF~~Relafarn ustry, SOIL AND SITE EVALUATION REPORT Page of Z of Safety & t3ukirgs in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but S~ = Cpl ~X not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 02q- 103-2--)o APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: _:Y C F~ -'-chr'l M PROPERTY LOCATION -EK2N GBV~. A S41~E 1/4 S W 1/4,S % T 7-1 NR t S E PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # Z CI -L. 9.0 )--H- _ flue- - CITY, STATE ZIP CODE PHONE NUMBER ❑CTfY ❑VILLAGE MrOWN NEAREST ROAD WOIA t•l, , Zvi S4 Z ZS [~fS) n~ Z . 4~ iy S Z1ivG ~-t C.0 fj'ue" [ I New Construction Use N Residential /Number of bedrooms Z [ ] Addikn to e)dsfiq building id Replacement [ ] Public or commercial describe Code derived daily flow Sub gpd Recommended design loading rate bed, gpo11t2 _ trerx h, gpdW Absorption area required bed, ft2 trench, ft2 tut Wmum design loading rate bed, gpd/ft2___trench, gpdAt2 Recommended infiltration surface elevation(s) 1 ft (as referred to site plan benchmark) Additional design / site considerations -O N G '1f'OJ\r, 1Z "is Parent material - S L LTy . S M- i" ewt- oJC rL. Tt u Flood plain elevation. if applicable K3. f~ • ft S = Suitable for system CONVENTIONAL MOUND "ROUND PRESSURE AT-GRADE SYSTEM IN FILL KUM TANK U = Unsuitable for system ❑ S ® U ❑ S ®U ❑ S [WU ❑ S la u ❑ S ®U RfS ❑ U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bot -day Roots GPD/ftin.. Munsell Qu. Sz. Cont Coke Gr. Sz. Sh. Bed mrxh ~ 0-8 102 if - si 1 Z`f-sb r-►.~PI- c.S - • 5 • ~ Z: $=l~ 10 `'t 2.b!'1 C~1~_S`tTz313 S►~ Oh, mr`r - - Ground elev. L {ft Depth to Ilrrilting faC~ Remarks: . Boring # Mdm A`L fl M A-k- j lcNIZJill C~ t S I Al 1 L v,)It~V fl W 6 Z S 130 ftT F_r Oy, D L Urvl~ LAS S TU Ground 1►`.)01Z 1~ t~'cs ~..~~1 ~ . - elev. Nro `t~PCt~~ i. S lz"k3 l U bZ Depth to limiting factor 11C F)t ' i Remarks: CST Name----Please Print Phone: Arthur L. We erer- 715-425-0165 Me'% r e r Soil Testing& Design Service-P.O. Box 74 River Falls,WI 54022_ Sijnatura: date 8 = _ fm Number 0 j~ -F3 ' _M0 576 pC ` PLOT PLAN Page ' Z of, SCALE 1" X117 IL .@ 3 k O Tij WF.'L1. k $~s I , vy\, in _ 3o-n+ Prue. _ 9'b-198 ' 715 425m -ni 65 CST # ;CST Signature Date Signed Telephone No. - ~0~ ,~„1~JYRGtUl) WisconsirrDepartm.entof Industry, HOLDING TANK AGREEMENT Safety and Buildings Division Labor &nd Human Relations Bureau of Buildings and Water Systems Gacument No./ Plan Identification No. This agreement is made between the This space reserved for recording data governmental unit and holding tank owner(s) greement ate REGISTERrS OMCE County or Local Governmental Unit Holding Tank Owner(s) S ROMMM Town of Springfield AWdtrRo=d called Municipality below AUG 13 1996 We acknowledge that application is being ma for the installation of (a) holding tank(s) on thefollowing property: (Provide legal land description) at 9:30 A- M JAk Re&Wr of Deeds The SE4 of the SW4 of Section 16, T29N, R15W, Town of Springfield, St.Croix C un Return To -Z ~a, y_ or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Stats. St.Crolx t As an inducement to the County of to issue a sanitary permit for the above described property, we agree to do the following: 1 Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to ham the holding tank properly serviced in response to orders issued by the municipality to prevent or abate a human health hazard as described in s. 254.59, Stats., the municipality may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by pk.cing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Stats. 2 The owner agrees, pursuant to s- ILHR 83.18 (10), Wis. Adm. Code, to have installed in a new building or new structure a water meter approved by the County and State. The water meter shall be installed by a plumber authorized by the State to conduct such installations, with said installi7tion complying with State regulations and manufacturers specifications. The owner agrees to be financially responsible for the purchase, installation, maintenance, and repair of the water meter, and agrees to allow the municipality to enter the above described property on a regular basis to read and/or inspect the water meter. Owner agrees to pay all charges and cost incurred by the municipality for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice- In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. 4 The owner, except as provided by s. 146.20 (3) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality- The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service contract, with the municipality within ten (10) business days from the date of change to the service contract. 5. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm_ Code, who shall submit to the municipality on a semiannual basis a report in accordance with s. ILHR 83.18 (4) (a) 2., Wis- Adm. Code, for the servicing of the holding tank. In the case of registration under s. 14620 (3) (d), Stats_, the owner shall submit the report to the municipality. The municipality may enter upon the property to investigate the condition of the holding tank when pumping reports and meter readings may indicate that the holding tank is not being properly maintained. 6. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis_ Adm_ Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 7. 'This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit the agreement to thL, register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. Owner(s) Name(s) - Print Notrized Owner(s) Signature(s) Subscribed and sworn to.bef ore me on this date: T\41 /n 61 JT~ JrV V a - AU Notary Public rnicipal Official Name - Print Municipal Offical Signature L C/4 a-n~! 33iop~>1~p3 1 Munici 1 Official Title - Print •~`C7 Oct C 51f The information you provide may be used by other government agency programs (Privacy Law, s. 15.04 (1)(m)IE con ci Yin nAIGA\ HOLDING TANK SERVICING CONTRACT - Contract Date This contract is made between the Holding Tank Owner(s) Name(s) and I Pumper's Name ~1JLYU ~GZ~:~2iY~u I 1 I O SS ce We cknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:) The SE-4 of the SW-4 of Section 16, T29N, R15W, Town of Springfield, ~ ..-C-r_o1_x--Gguu-tyT -TVA-is-c-©nsin - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which has signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and with the County of S t. C r o i x 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) I Owner's Signature(s) J^F)q'V FEKAI I( Subscribed and sworn to befRre me on this date: I I Pumper's Name (Print) I Pumper's Signature Notary Public I My commission expires: I p-G~✓' (O dB C/f5SC_&4(5 Pumper's Registration Number 5, 5- SBD-7574 (R_ 09/88) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations HOLDING TANK SERVICING CONTRACT Contract Date This contract is made between the /07 Holding Tank Owner(s) Name(s) and I Pumper's Name I I o /0 ~f ASS- 4 We cknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:) The SE-4 of the SW4 of Section 16, T29N, R15W, Town of Springfield, S t-..-C-r-o ix-.-C "n-t Wi .c-o n s in- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which has signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and with the County of S t. C r o i x 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) I Owner's Signature(s) J17n./V / EKE/ K AM ^ I Subscribed and sworn to before me on this date: Pumper's Name (Print) I Pumper's Signature Notary Public I My commission expires: d,G C Ss e_ !us I A4j ~ (Q Pumper's Registration Number -5-,5- ? SBD-7574 (R. 09/88) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations 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 le c( vi -"~e r rt - /~u t' is t Location of property S 1/4 S L.-; 1/4, Section l ,T_ILN-R -/5 W Township Id Mailing address 'Z 9 2 l Address of site a-i e- Subdivision name Lot no. Other homes on property? Yes ~No Previous owner of property Total size of property Total size of parcel Date parcel was created 6 - Are all corners and lot lines identifiable? V11 Yes No Is this property being developed for (spec house) ? Yes L,---No Volume Wq and Page Number 2 G ~ 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. 4 6-0(, 3 y , 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. q 4 b & r3 gnature of Applicant Co-Applicant a 9 X99 Date 16f Signature Date of Signature FOR: Fla Wkaftn AppmpdatsFaawtth liagbtw dD*Q s WER 4GM9 V!. WW" OF PROPERTY TO SURVIVING JOINT TENANT, mismirs oma LW TENANT OR REMAINDERMAN (sedon 86'.045, ere. Sbt &sl ST. C" Me V~! Recd for Read GARY CONFIRMAT~''N OF INTERE§T IN PROPSRTY pWjoiniil67.046(4 Wls. 9tahrtee) 4)8 JUL 2 0 so- s: ~ It. OCES THE PROPERTY USTED BELOW CONSTITUTE ALL OF THE PROPERTY L4 I R rVtlif THE DECED NT OWNED ANY INTEREST AT THE GATE OF DEATH? U of Oaf Li, YES Lj NO 8pulrw oanaD.:th sodas •~aM Dec Harold L. Fern 10/3/87 B-20-0964 sm. z4coe. Asar.aa ow 90th Ave. Woodville, WI 54028 2924 1. Sbde, bonds, savkngs and dved*q aooounts. and vendors' Person Receiv Fu1 Valor At Dab dDeatil Interests In land cw&acb (11 more space is needed, attach echedule). Up Prope* for Properly Tmnslemed Under. pearra,uoro Number L867,045 or 6.167 ;y r $ i SE-M of 16-29-15 TOTALVALUES. Transferred Under Person Recewft To Be Completed by R9gkler oI Deeds (deck-) Propertyitawa.sora Assessed Data = E Rod e ,.867:045 Is. 867.046(2) yen, Lh-AftBak valuation 727,900 yaNallon Reoordrp X a i 27,500 $ Vol. 434 Page 368 pEC1 ARATION l (are) dedam that this *Wadon ks. to •fe best al (Our) knowledge andb". true, correct and oorrptets and is in conWrAy wtih Im Wovislons and -bW lentteloos d the Wsooneln Statutes and mss na release any tau la ks. a NameardAddresadPersonReceivlnpProperly tDO°ceder't swab" Date 7/18/90 a Jean E. Fern Wife b. G t 1 osrlly OW I have mimed a delivered copies d tins apptieation as tlwan.b tdja,n JX!XT 1 1990 provided in s. 867.045(3) or s. 867.046(4). Wis. Stays. on Pdator: M O Connell C,a~' f a•► 'Chou July 20, 1990 23, 1993 Dab Thisapplc3flo~ tl ~rlntortypenaroebelow) Jean !►ern Register of Deeds (signature W.110pt5•a0 ORIGINAL v ~ yon.195013 Wilconsin Department of Industry, HOLDING TANK AGREEMENT Safety and Bu-Idings Division Labor and Human Relations _ Bureau of Buildings and Water Systems. Document No. /Plan Identification No This agreement is made between the This space reserved for recording data F; a 81 governmental unit and hcAding tank .greement ate owner(s) County or Local Governmental Unit Holding Tank Owner(s) KMVA Town of Springfield •IAIMr~r1 (called Municipality Below AUG 13 1996 We acknowledge that application is being ma for the installation oil (a) holding _ _ _ tank(s) on the following property: (Provide le al land description) 9:30 A. M The SE4 of the SWk of Section 16, T29N, R151.1, ""I" ""'Deft Town of Springfield, St.Croix Return To or that continued use of the existing premises requires that a holding tank be rnstaAed on the property for the purpose of proper containment of sewage Also, the property cannot now be served by - lunicipal sewer, or any other type of prtwete sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Scats. St.Croix As an inducement to the County of to issue a sanitary perwor for the above described property, we agree to do the following: 1 Owner agrees to conform to all applicable requirements of Ch ILHR 83, Wits Adm Code relating to holding tanks If the owner falls to have the holding tank properly serviced in response to orders issued by the municipalxty to prevent or abate a human health hazard as described in s. 254 59, Stats., the municipality may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered T1xe charges will be assessed as prescribed by s 66.60, Stats 2. The owner agrees, pursuant to s. ILHR 83 18 (10), Wis. Adm Code, to have westalfled in a new building or new structure a water meter approved by the County and State The water meter shall be installed by a plumber authorized by the State to conduct such installations, with said installation complying with State regulations and manufacturers specifications The owner agrees to be fmanciilly responsible for the purchase, installation, maintenance, and repair of the water meter, and agrees to allow the munKVah y to enter the above described property on a regular basis to read andror inspect the water meter Owner agrees to pay all charges and cost incurred by the municipality for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazar fcawed by the holding tank The municipality shall notify the owner of any costs which shall i a paid by the owner within thirty (30) days from the dace of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law 4 The owner, except as provided by s 146 20 (3) (d), Stats, agrees to contract wale apt. son who is licensed under Ch NR 113, Wis. Adm. Code, to have the holding tank serviced and to file a copy of the contractor the owner's regs»raaron with the municipality The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service contract. wrtRi the municipality within ten (10) business days from the date of change to the service contract. 5. The owner agrees to contract with a person licensed under Ch NR 113, Wes Adm Code, who shall submit to the municipality on a semiannual basis a report in accordance with s. ILHR 83.18 (4) (a) 2., Wis Adm Code, for the sera arrig of the holding tank In the case of registration under s. 146.20 (3) (d), Stats , the owner shall submit the report to the municipality The munK4u-*CV may enter upon the property to investigate the condition of the holding tank when pumping reports and meter readings may indicate that the hordlmg tank is not being properly maintained. 6 This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certif ies that the property is served by either a municipal sewer or a sod absorption system than complies with Ch ILHR 83, Wis Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with me4erence to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property 7 'This agreement shall be binding upon the owner, the heirs of the owner, and asu green of the owner The owner shall submit the agreement to the register of deeds, and the agreement shall be recorded by the register of deeds am a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed Owner(s) Name(s) - Print Notrized Owner(s) SignacureW Subscribed and sworn to before me on this date: Notary Public inicipal Official Name - Print Municipal Offical Signature j 0 c J h My ~milSroslp Z es . c Munici l Official Title - Print u / r~ r 0 fn QC1 C 8,41 r? /V arly The information you provide mdy be used by other government agency programs PN a. La-.: s 15 04 (1)(m)I SBD-6123 (R. 04/94)