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HomeMy WebLinkAbout040-1237-30-000 c 3 o O N ~ O aC c rv, ~ O N ~ O O N O v W p X O L c O N i O Y c (6 N U N O 9 Z w c LL O m LL C. Co O "6 O Q ~ co Z N 3 w E O Z = OO Z y d N d m Cl) F- Z p 76 E C) z .4 C O N O ~ O N F- m N Z c y E ih m N O_ O _ N d I 3 ) (Y N y N O N t •ova d V O U O Q O Z ~ Z O Q Z N N V- N O O O A 0 c O O ~ O IA y N O O O O c ,t LL U fD LO N N 3~ N N h w V (0 F- F- F- ~'°~J z o 0 0 0 0 0 0 (L CL CL N i IL l~ 7 O (1) 2 1 :1 'o = 0)i OOi N N J V U rn (7) ty rn N 0 (j N O O N N T N j L p p N N to 00 d Q 1" O d ~ 3 N O > N C p E to O) O O N C C A:3" N N N N 9 - Oi O N M 3 C C C C N 75 CO 0) 0 E d, N N N •tq U H O N U7 N F- U • L' O O O ~ I ~ ~ = E d V ~ T ~ E ID ~O d #t a L a .r .2 4) O 61 C w C p c°> a 0 in c°v Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Duman Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code Z Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, t)ut a ro ix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or [REVIEWED RCEL I.dimensioned, north arrow, and location and distance to nearest road. en APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION BY J DATE PROPERTY OWNER: PROPERT` LOCATION Richard Stout GOVT. LOT` 1/4 SW tT4;S 3 T/ ~-2y (N,R 19 f(or) PROPERTY OWNER':S MAILING ADDRESS LOT # BL%11;k_ SU8D: IVA btj 1353 Awatukee Tr 62 na . CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAG NEAREST ROAD Hudson, WI. 54016 (715) 549-6731 Troy Tower Rd. [x] New Construction Use [ x] Residential / Number of bedrooms 3 [ ] Addition to existing building ( ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate • 5 bed, gpd/ft2 •6 trench, gpd/ft2 Absorption area required 900 bed, ft2 750 trench, ft2 Maximum design loading rate • 5 bed, gpd/ft2 •6 trench, p 2 Recommended infiltration surface elevation(s) 100.81 ft (as referred to site plan benchmark) Additional design /site considerations alt. system el.=98,741 Parent material pitted outwash plain Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem lI S ❑ U El S ❑ U l] S ❑ U EIS ❑ U ❑ S ®U El S O u SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boiunday Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 -10 1 none if .5 .6 1 2 0-14 10 r4 4 none Ground 3 4-29 10 r4 6 non s elev. 104.16 ft. 4 9-84 7. 5 r4 6 none na . 5 • C Depth to limiting factor +84" Remarks: Boring # 1 -15 10 r 2 2 1 2 m s bk m f r Cs if 2 5-25 10 r4 4 n lfsbk mfr . 3 5-36 10 r4 w na .4 .5 Ground elev. 4 36-84 7.5 r4/6 none Ifs 1 104.88 ft. Depth to limiting factor +84" Remarks: CST Name. Please Print Phone: Gar L. Steel 715-246-6200 Address: 1554 200th. ,Ave. New Richmond, WI. 54017 m02298 Signature: Date: CST Number: 11 4-22-96 PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D.# pending Lot #62 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 w 1 b-10 10 r 2 2 none 1 2 *~..4...h. 2 10 -18 10 r w If. .2 Ground 3 18-33 10 r4 4 none elev. 103.81ft. 4 33-84 7.5 r4 6 na .5 1.6 Depth to limiting factor +84.. Remarks: Boring # 1 -15 10 r2 2 none w 1 2 5-37 10 r4 4 n Ground 3 137-47 10 r4 6 none w elev. 4 7-84 7.5 r4 6 none I f s, lcsbk mfr na na 102.74 ft. Depth to limiting factor +84" Remarks: Boring # 1 0-11 10 r 2 2 none 1 2 cs if .5 i.6 5 2 11-17 10 r4/4 none s' If .5 .6 Ground 3 17-32 10 r4 4 none m elev. 102.49t. 4 32-88 7.5 r4 mvfr , Depth to limiting factor +88 Remarks: Boring # 't Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel Richard Stout 1554 200th Ave. MPRSW 3254 NW4SW4 S3-T28N-R19W New Richmond, WI 54017 town of Troy (715) 246-6200 lot #62-Country Wood N 1"=40' BM. = top of 1" steel.pipe C el. 100' marker stake =103.3' G1 JI-o ~Aj 'S 41 ~Y Gary L. Steel 4-22-96 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS SUBDIVISION / CSM# LOT # 6/ 2_ SECTION 3 T 2-f N-R If W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 5w sel~ q l~ ORIGINAL 9 Z~ytt ;GCS r W INDICAT Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. s BENCHMARK: 7 O/ S(/,eUEyD~'S I Z"~ fI % SE /07 4pZ4 . ALTERNATE BM: T4~ of ~i}SE~~iy% !~'uNJ7i4T~ 6,c~ r¢ j SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION o Manufacturer: ~C/E~ if~S ~N `y• Liquid Capacity. Setback from: Well House ~yZ Other GrT L . C~ _ ? s , Pump: Manufacturer //l Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM 2 Width: S Length Number of trenches Distance & Direction to nearest prop. line: 5 s~ do Setback from: well: N~/¢ House y~ Other AAA-4p mil/-l.L S 2 oOo ELEVATIONS CD Building Sewer ST Inlet: ST outlet: ~F/• 30 PC inlet 1--' PC bottom Pump Off Header/Manifold Bottom of system s~~ Q Existing Grade Final grade /dL,-) 7- DATE OF INSTALLATION 13 ~f y4e PLUMBER ON JOB: LICENSE NUMBER: /~P/~✓ / INSPECTOR: ~A 3/93:jt cq ~pm~ po .C b m m oe ^ N d Y y 0m 1 \ i o y \ ~ w 1 1 I I I ~ I w W ; I I I C p ~ 1 I ' I ~ I 1 I I 1 I I ~ I ~ I I ~ 1 I _ I I cn N ~ 71 ~ I x I p O, o I I o i I ~ I I I ~ ~ I I ~ I I I I I i I 1~ I I I I ~ I ~ I I ~ I °WO Q ~ ~ i - I I 1 I 1 I o` o ~ II Wisconsin Dpoartmentof Industry, PRIVATE SEWAGE SYSTEM County: Labor and Hu Relations INSPECTION REPORT ST. CROI Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284216 Name: DVE E] City [I Village Town of: State Plan ID No.: ~~I.;~~~S TROY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV- Septic Benchmark b6"?? Dosing q (orb Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P / L WELL BLDG. Ai,ito ntake ROAD Dt Inlet ir Septic ' NA Dt Bottom Dosing NA Header / Man. gb, 3 ~ ' coo. 5/'I Aeration NA Dist. Pipe q, 4e, ZI Holding Bot. System q a S```a/' PUMP/ SIPHON INFORMATION Final Grade ~y (ro7,/9 Manufacturer Demand , A441 )19 Model Number GPM TDH Lift Friction System TDH Ft oss ead Force main F ength Dia. Fi Dist. To Well 'Z I SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S 8d a- DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM INFORMATION Type O CHAMBER Model Number: System: ,U f} OR 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~ ,~Y~ TROY.3.28.19W, NW, SW, LOT 62,, TOWER/ 4. nrr... /'/,T f- ~ :OV Plan revision required? ❑ Yes akNo / Use other side for additional information. / y+o , (o SBD-6710 (R 05/91) Date 1 o Signature Cert No. ADDITIONAL COMMENTS AND SKETCH c s, SANITARY PERMIT NUMBER: a S1-Tt Apj)jee~55 - 6/0 O-AKcy cc iceilt Safety and Buildings Division v~LH: SANITARY PERMIT APPLICATION Bureau Building 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 59/ ceol X than 8 112 x 11 inches in size- • See reverse side for instructions for completing this application State SA anitary Permit Number The information you provide may be used by other government agency programs ❑ Check it revissiiio/n to pprryevvious application (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Prop grty Owner Name Property Location AVF GLE10~~S AIW' 6AI 1/4, S 3 T 2 , N, R P? E (or W Propert xxOwner's Mailing Address rte{. z_ Lot Number Z Block Number St Y t~~T_,1;1Q- 6TT 41 y, State Z Code Phone Num er Subdivision Name or CSM Number S t v jJso.J Gc~ I-S' • 9V O t 41 c7j5 23 J/- S% Ca v~ rR 4,-? o o r7 I II. TYPE F BUILDING: (check one) ❑ State Owned o City Nearest Road Public or 2 Family Dwelling - No. of bedrooms ❑ own Village OF 'r QY Tote III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment /Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office / Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. 2-frew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ------System _-______System Tank Only- ____Existing -System _____Exl-----ystem 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 ❑ S page Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 [veepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit , r 43 ❑ Vault Privy 14 E] System-In-Fill ZEN s S x "1(s VI. ABSORPTION SYSTEM INFORMATION: Sq 7. 0 3F/ o 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 77 29 SU -7 S © • Cv • S Feet 70•0 Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks _ Septic Tank or Holding Tank I OM W E KS ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ~'v L ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) /MPRSW No.: Business Phone Number: J~ogecr u/✓aei44k1 f r330 ?!s- 3~~'~~~5 Plumber's Address (Street,,City, State, Zip Code): S 5 0- N-e % G O.lO,J W J T IX. COUNTY / DEPARTMENT USE ONLY ry Permit Fee (Includes Groundwater ate ssue Issuing Agent Signature (No Stamps) ❑ Disapproved Sava Surcharge fee) Approved ❑ Owner Given Initial /L ~J Advers e Determination ^ X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety a 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. 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. 11. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. 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) "sail test data on a'l 15 form; and F) "all sizing information. ------------------------------------------------------------------------7--------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) fora 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. Fresh Air Inlets And Observation Pipe Approved Vent Cap Minimum 12"Above • Final Grade I q ~ / to 3(P Above Pipe _ 4" Cast Iron 'io Final Grade Vent 'Pipe' Synthetic Covering Min. 2" Aggregate Over Pipe Distribution Tee Pipe 0 0 0 0 0 RI-Coupling Aggregate Perfbroled Pipe Below Beneath Pipe Terminating At SyST, Bottom Of System ~7•Q Fresh Air Inlets And Observation Pipe Approved Vent Cap Minimum 12" Above Final Grade ~45• L 3~ "Above Pine _ 4" Cast Iron w v ~ sysr= sa y~ SP6 133 o ~ ~ 0,2.a7b j i ~ I C4 5/, Q I I I I I ~ ~ j' I ' 115 Sys y I g I I' I I- I I I I ~ ~ i I '5y5; 7- ,4,Pe14- 2 7 S?7o CCxrsr, S so o io --RAO ~F;Z, 50 5~ . I M 05T - our O i 1 i l !v FnvND, rap %r v° 1340V P r 7-75 Wisconsin Department of Industry, SOIL AND SITE EVALUATION / 3 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 57" include, but not limited to: vertical and horizontal reference point (BM), direction and l'/L Oi' X percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. If 10-12-3 7 APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location p p ./,AV G- CLEMAI,6V~ Govt. Lot IP/V 1/4540 1/4,S T 24 ,N,R 1/ E (o& Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# sts tq 0"-rm Z- l~Z C'av.~r~'y WOODS City State Zip Code Phone Number Nearest Road (1P fO.-) W 1. 5YOI& (7/ ,s ' S%?7 El City ❑ Village 1=1 Town ?oGv~~2 . New Construction Use: Residential / Number of bedrooms 3 ` Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: ySo - Code derived daily flow &Q0 gpd c Recommended design loading rate _'5' bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, tt2 ✓ trench, tt 2 Maximum design loading rate .S bed, gpd/ft2 ' ~O trench, gpd/ft2 Recommended infiltration surface elevation(s) s-~ 3 tt (as referred to site plan benchmark) Additional design/site considerations V;t 2- a.5 _ 5"' K -75 Parent material aVrVAYA, l :vS Flood plain elevation, if applicable tt S = Suitable for system Conve ional ,MMou/nd In-Ground Pressure AT-G" e System in Fill Holding Tank U = Unsuitable for system S r ❑ U L~ s El U S ❑ U R U El U B❑ U ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench .s- 2 7- 0 3 51& zf5hk- G S kthX Ground ,SL Z fS,~iL /1•d! G S elev. • cc J.Z. 0 ft. y LS / 1;V f / S : . G Depth to limiting factor in. Remarks: Boring # f 0- 9/ O y'f 311 GOf} 17'5he Am S 3-f-- 5 Z -z a 3 LSiL / SAe /tin f CS Z ' 3 3 -3 k lo Y/e SG a fshe e S ; . Ground L S /O le G S 1lYjI/1G - S - cv elev. 0 /4 Depth to limiting factor I0 2In. Remarks: CST Name (Please Print) Signature Telephone No. ROBERT- 241-13PcC ~ 715-396• Arlrlrecc r._,_ PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Structure 2 In. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench 3 0-'e /Oy/ 3 ~A,y / fs6,~ -~iP s 3 f . 2 P-9-3510M 3 5/L / Sf✓.~ G' Z f Z'. 3 Ground 3 _ 3 elev. /J ~d .eft. -/o O lG Gwt L S /f ~'.Q S ; . l Depth to limiting factor /D-&-in. Remarks: Boring # / 0- 21 ioyi2 3/ Go.ci /~s~✓,~ ~i c S 3 f- , 5 z 29-3 R V Cs o, s 40f -7 ; g Ground w- 10 S elev. Depth to limiting factor -71 in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G D/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 0-13 / O Yk J (t ~>9~l ff5hle 4"{m e5 2 . `f S .6- 2- 3-3 100 3 SQL /fsd.~ /W7 f CS /f 3 3 -4 14#1 Ground elev. /'/0 ft. Depth to limiting , factor fxo} j ' Remarks: Boring # Ground elev. ft. Depth to limiting factor in. /Remarks: SBDW-8330 (R. 08195) E(~u ~Ttoo S - , ~Z.p y6 43 • f3 4 5~, o Ps ' ,ygSys 10 su(~UEs '-cam T1~~,~r-C~, 4-7-iov s Z 7'7' ~o cv TiP.ew;~, / r. o u T' I 7 f/arlE _ 1 33~/ l 5~ r-'r- ` 1 30 f314 = FnvND, T°p 2 F! v ^0/ GII'n lip VVe ~l 1 r% d1b n r*% ter. S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 0 4, v e-, CA "5 ADDRESS5 g Pr 1A+ FIRE NUMBER CITY/STATE MAIStJ-k+, Wl, zip 5510/4, PROPERTY LOCkTION t 1W 1/4 ,1 1/4 , SECTION y , T 2 N-R /9 W TOWN OF St. Croix County, ' SUBDIVISION LOT NUMBER Z . 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 a 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 Co. Zoning Officer within 30 days of the three year expiration d e. SIGNED: DATE: //°~QIv St. Croix co. Zoning office 911 4th St. Hudson, WI 54016 • - 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 C. ~ ens me- A 5 3V 5 iT ` Location of property Nw 1/4 -5W 1/4, Section ,T ~ N-R h W Township ~ D Mailing address 6?lti~ 1'496-- - 2-Address of site 610 L -C'-a l 671(~v Subdivision name COO Al Tle w 00 ,0 S Lot no. < Z Other homes on property? Yes No Previous owner of property 57-f-DU 7_ Total size of property Total size of parcel .33 plc Date parcel was created /9~61 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes __y No Volume 12.0-7 and Page Number 11 7- 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. 5S/-7 1FV_, 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. Signature of Applicant Co-App 'c !l d q D e of Signature to of Signature *)a00 µJ, 5A794 STATE eAAVOi►FARRANTY'DEED 1- 1982 DOCUMENT NO. 120 7 w MW This Deed, made between Richard O. Stout SE Cm~ ~wa*w NOV S 1"6 am David D. C emmens and Jutta B. Cleetaens~ at 1:45 -p~ us an an w fe, `K.Rtt.I.•~1 4~.A~ Viltnesseth, no the said Gomm for a vsiutbie .St. Croix TW SPACE REST FM MWOMM DATA conveys to Grantee the tolloariug described teal estate in - Coungc State of Whcmksim MANE AND RETURM ADDAM s-i t Lot 62, Plat of Country Wood, First Addition, Town of Troy, St. Croix County... Wisconsin. &Of- d T07TA ~(E .rI M IDENTMATIOM MlV6EA i'. jl Ii TRAASM ~ I. rim I~ i. I~ i 4i This is not bmsmd pope W ua w~ ~ Together with all and singuLr the heredframents and VWrtermnm thezeuno b&w9w& AM R " O Stout warrants that the title is good, bWekwg* In fee simple and free and clear of ence-b-m-s apt eaisements, restricitons; rights-of-way aad covenants of record, %j is any. ~I and will warrant and defend the same. 19 !i Dated chit Al _&y of (SEAL) II Richard O. Stout OEAL3 (SEAL) i AUTHENTICATION ACKNOWLEDGMENT Seaee of Tiliscessin, SL St. Croix Coaus~ --Ihm od this any of _ 19 Reath; ease bdao me tds amy d I9. 9 6 at Aom tnmcd 21cm O. Stout TfllE 11EMBER STATE BAR OF WIS(ONSiN mtharized by 0706.06, Wisp Stays.) a ee b wwtQ*be thr pm= afro esoceted the fore THIS assTRUMeNr WAS own BY Ora 0a