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HomeMy WebLinkAbout040-1225-70-000 O 4 0. 0 N ~ C r., o i c N h q y O U O O X Ln y t I U Y ~ c I N ~ Y I o C Z co U. U. co O m Zj °O 3 M z " rn w E cn = o I ~ ~ I E o I z ~ a m rn H Z o 0 O v O 2 aUi Z d' ~ c z N F- ~ N c E 'o O M N N 0 3 CD O C U O •N CL c ca CO U w z z F- z o w N E W N "Its (n U) I; C O _ _ N CL n Cp N d w p 0 o G a O > 04 O 7 fA fn fn E F= o n F- U _ r` _ d O 0 0 0 z O • wul a a M is c a O I W a in J U 3 rn 2 rn ~V Coo~ ~o (6 cn 0 N U" Q IV cn y 4 Y co oO LO O O vJ N C O N O CC O MO ~O E a U O r ai 0 Lr O 0 C m a) C Q ` O) O Tr N_ N pj 0 ~ C EO (O Q r.r O N (yam, N 00 £ia L 06 w F- N E o° N N E N • rr'VV O O F- LL N O N Cn O I r V ~ E d I 5 'k a L CL •O. d U d `1V E 7 A 0 IT m 0 w 0 . R~CEIVEV STC 104 + ST C/x, AS BUILT SANITARY SYSTEM REPORT ZpryN OWNER _~AMES ADDRESS jgRj,4 f',q. GIV,- LIGc7senr SUBDIVISION / CSM# GS LOT # SECTION T X e N-R__JLW, Town of f ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM I r J, e /YOclS~ iooo FL 1'"Ac"ES INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK : /2 TIC X4~< ALTERNATE BM- SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: /04ip Setback from: Well House Other NO w6Fc c Ar 7#1S T~r/E Pni nufacturer Model# Size Float seperation c Alfa-~a~ion SOIL ABSORPTION SYSTEM Width:_ < Length 5 7 Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House_ 7 Other /Yo Cvel-c ,4 f Tff/s Tire ELEVATIONS Building Sewer ST Inlet:_a ST outlet: PC inlet /YA PC bottom Pump Off Header/Manifold Bottom of system Existing Grade 96 96.5 9 C'5= Final grade. DATE OF INSTALLATIO PLUMBER ON JOB: LICENSE NUMBER: _ 32/1 INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary 68685 . GENERAL INFORMATION Z Permit Holder's Name: ❑ CCiity ❑ Village Town of: State Plan ID No.: FORSBERG, JAMES 'j' UUY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9600388 1611611z TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Gc~. s n Q, Benchmark 7777 /o r Dosing ` Aeration Bldg. Sewer z o laf -:V Holding St/ Inlet TAN ETBACK INFORMATION St / Outlet , ~j /oS $a TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic ,q NA Dt Bottom Y 0? 0 )q Dosin NA Header/ Man. /o s loo. Aeration NA Dist. Pipe 'Fill po, 9 iao.a9, Holding Bot. System y ~r PU P /SIPHON INFORMATION Final Grade Manufacturer Demand OVI .der sy' /pL a7 ` Model Nu GPM TDH Li Lrictl S stem TD Ft oss F cemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS s DI N acturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION TypeO CHA Moe System: tren ~S -600). 0 3 )44 O "NIT DISTRIBUTION SYSTEM Header 4AW"W*- / Distribution Pipe(s~)/ x e Size x Hole Spacing Vent To Air Intake Length ILL Dia- Length / Dia. ~ Spacing L SOIL COVER x Pressure Systems Only xx Mound Or At-Gra ys 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: TROY-9.28.19W, NE, SE, LOT 7, BRIA A LANE 16 G(~Z Plan revision required? ❑ Yes No p Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signa ure Cert. No. ADDITIONAL COMMENTS AND SKETCH • i SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION ` 7DILHR In accord with ILHR 83.05, Wis. Adm. Code cour ` ~0 ;Wj STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 40g lid K, 8% X 11 inches in size. Check revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION MAM,AFS '/a S T , N, R E (o PROPERTY OWNER'S MAILING ADDRESS OT # BLOCK # S CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER t O II. TYPE OF BUILDING: Check one) CITY NEAREST ROAD ( State Owned VILLAGE ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms L TAX . u 111. BUILDING USE: (If building type is public, check all that apply) ® tj ft ' - 7 1 7U 1 ❑ Apt/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 80 Mobile Home Park 12 ❑ Service Station/Car Wash 50 Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~ New 2.E] Replacement 3.E] 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 # - 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 220 In-Ground 42 ❑ Pit Privy 13 Seepage Pit Pressure 43 ❑ Vault Privy 140 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) To r1►tT ELEVATION Q Feet = /O eet _T6 3 -,T.70 0 48 VII. TANK CAPACITY Site INFORMATION in gallons Total # of Manufacturer's Prefab. Fiber- Exper. New istin Gallons Tanks Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank X I moo /C E] Lift Pump Tank/Si hon 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 r' Signature: (No Stamps) /MPRSW No.: Business Phone Number: _ -7-T ~ ( ) IDUCAMIP Plumbers Address &_A6_ezdr?~~_ tr , i , Sta e, ip Code): e IX. COON DEPARTM NT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued 'ng Agent Signatur o Stamps) / Approved ❑ Owner Given initial 07) Surcharge Fee) 4-~q~ Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) 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 pert-nit may be renewed before the expiration date: ~,nd at the time of re . l any new criteria in the Wisccnsir Administrative Cede will be :applicable. 3. All revisions ttt - permit must be appro-4s d by the permit issui:-L a.~Ihority. 4. Changes in .j-tnership or plumber requires a Sanitary Permit Tra sf, /f en:>vrai t -r., `)3~ to be submitte: o the county pronto installation. 5 ensue se --irla Rtost be ,.-opert_ ~r;ainttaikd. The ..,,,t . tank(t_--) tri: pumper wl:i,,never ,ecessary, usually every 2 to 3 years. 6. It you h1_ave ttuestions concerning your onsite sewage system, contact youf !:;cal code, -a ; 'n 9tra.tor or the State of Wisconsin, Safety & Buildings Division, 60E1-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description anil parcel ib;, :,,r her(s) of where the system is to be installed. II. Type of building being served. Check only one and a~mplete of bedrooms if 1 or 2 t=ar•• f; i;rvellnc. ill. Building use. If building type is Public, check all appropriate boxes that apply IV. Type of perrnit. Check only one in line A. Complete line B if permit is for tank replacen,er t c:onrection, or repair. V. Type of .,-stem. Cheek appropriate box depending on system type. V! AbscrDt; system information. Provide a!' information requested in -1,11 i' VII_ raG:...:v File in the apacily of era new ardV6r ,axistim i< t'c;4 c,a~; .rnter of t2P1Ks an :na.nufactiJrer's nar"e. indiG4,8.e tic icy ? or Site construct4~1 i =Ulk !:irtiLial. ><:3r all f~ septic, pi~Wsiphor and holcaing .._riks i 4 systern. Check exp. at ..roval c, ;•e(,eiveca ^xpe ~o ra fxodcc app!,:, al fru it DILIHP VI11. Resporisit)elity statement. rns1ailir,E' , iumber is to fill in name, nr-:mbe, r iln approt o! s ;art it>r (e.g. MP, etc.), address and phony: cumber. Plumber must sign IX. County/ epar'rnent Use Only. X. Cc•unty/C,.-.partrnerit Use Cnly. ( ':?rF and n f'^ ?tIons I sir :vr Man 8Y2 2 x 11 inches mri":t hP ' r.: +!E` .^t r,'k The F r: :-g: ,A.) plo J,-a Vi to scat 4f'aP/it -t-c-% of _ ccr n:{(w) ,)r othpQ ts: r-~. tarik5; >urldir, 'A,ale- ri!c SE:rvice; . _ _ ,,Ste •r, ,r, ,,fi.r t 4 !iea. ' ti -t, ,d l-ik(-S po,to(. phr_,n tank. im-i t-t.ion ho>;es, J!~; ,':irs{;r', ~systent atc:3s ]e lccaf n; of ht' hUi !:rL) St.' CrlZGntal a+ _ C1Y Ie a4 a. ep . complete speci,hcations f6r purr7ps and controis; dose volume; e; t._'rences, fr r ios:3; pump performance curve; pump model and pump manufacturer; D) cross section of wie soil abF +•11on system if required by thQ county; E) soil test data on a 1,15 form; and F) all'suing inforn-lation. s - - - - - - - - - - - - - - GROUNdWATE'R SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a nurn~),--r of rec; '.~'E- x - x,..'.:es which can effect groundwatpr. ff,r monies c,fTe:ted through, v,1,r.,e ircharue :.Jc f ,,r r~ort zc~ ' . grc,-.- ; t -r. -waiter i^orr ,ation investigafit+r>san,y establis'ar>~r~r~ . SBD-6398 (R.11/88) APPRov~r~ caect/Z ?.Y" y'%~UG Siff qo a ~y o t WlxS ® (4` 4 ~ NOTE : el Ell, 4 PONS TO 619F E5; 7.417/S4-&-0 /4 T 0 P~~ pacpaS n ~ o/= corsr/&e r/oar QRoP ~Sv ~,-6~ S,y~ ~~EP ~o a 0 lo~ a %b 4&.J CcagQ Sc,~ct E"=s©1 L o r 7 On, Tcip %y"pv~ /0t, l~2Acv/Nc- FoR: 16-91-,94 ORAW ~6- T.~~.: _ ~A/7~S ~o R Si3riQG . S1'6 ~J/9CLL E y ~/ecv 7/1, 555 13 2/ANA L/V. ®I `t~,Qs'~-T Z)/` yea s- 3.2 0,5- C) o G) rf. 0 3' v < 90 cn ~ o ~ 2 O cn -n O O 7 N v- (D rte' ~ -.g (a e.o Tx ~ J 0 c m 9ee~e~ CO O I fv ~ I (D O CL Z Q m m m r m m 3 Page Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT of Lab*r and Human Relations Division of Safety & Buikings in accord with ILHR 8 m. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 i ze. Pkan must i e t not limited to'vertical and horizontal reference point (B fun, di anct % dfto ~D~t scale PARCEL I.D. # t;? dimensioned, north arrow, and location and distance to ne e ad EEEr4PU - APPLICANT INFORMATION-PLEASE PRINT ALL RM IrY~ N'/( `tJ n REVIEWED BY DATE 1 / j f f f..~ ,R fj PROPERTY OWNER: SA Q,B pr" R . G IZ-1 S S t2 ?,QPFRTY LOCATaO lti~ ~~rv ~ LO Mme . Fo RD ~J /4 SE 1/4,S9 T Z-8 N,R 1 ct E ( W PROPERTY OWNER':S MAILING ADDRESS ' BLb014 SUED. NAME OR GSM # y S O t\3, G t✓p v ~Af~A S'j` . 1 v LO V 1 Ll S CITY, STATE ZIP CODE PHONE NUMBER iv%- LLAGE MOWN NEAREST ROAD IDS ON, W 1 5 O l (~l S} 38 6_ 131'1 'r 2 p g2t P1>uR t_Pcf.►Er Dd New Construction Use N Residential/ Number of bedrooms kj)~JVLrvvw rQ [ ] Addikn to wdsting building j ] Replacement [ I Public or commercial describe Code derived daily flow Aso gpd/en~lioowr Recommended design loading rate bed, gpd/ft2 0.8 trench, gpd/ft2 Absorption area required - bed, f12 trench, ft2 Maximum design loading rate 0,--1 bed, gpd/ft2 O.8 trench, gpd/ft2 Recommended infiltration surface elevation(s) SE'_~►soT>r cQ Prrst= :Z. ft (as referred to site plan benchmark) Additional design / site considerations `'tA►'1M'1~'~~ Parent material s ~o`i o v p vprg N Flood plain elevation, if applicable N- A • It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem WS [1U RIS ❑ U ENS ❑ U ® S ❑ U C3 S❑ U CJ S O U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. Bed Trench ZLZ S z Yb`_ W) 'F tun Zu'F 6.S GA E ~ h ~ o -11 ZO" l,R.- ~ L n h Z ~1-zt 1o~R 3Zy - Sit Z'~sbl~ cs 1~~ '(S•S 0-6 Ground 3 Zl-~ b 10`2 316 S I Z.~SbIQ 1r! ~1- - 0~5 0. 1 elev. 4 ~l~-° lour 2 yLG S O g9 - o.~ o. 3 ft. Depth to limiting factor Remarks: Boring # 6-LO LO`'L~2-zlZ. L Zm3~tr W,-FV- 0-f,) 2-f o.S a 6 Z - Lo -u LoLt2 316 - s) r~sb~C vn uil- ~S )i'k 0-4~ o s 3 22 90 t vet lZ X16 _ S C> Sg Ground elev. - - ~oo •Zft. - Depth to limiting Q factor Remarks: CST Name:-Please Print Phone. 715-425-0165. . Arthur L. We erer ress: egerer.Soil Testing_& Design Service-P.O. Box 74 River Fa11s,WI 54022 _ _ - r f - z S (#05 PROPERTYOWNER G~SSfJUG~2 - RTLt) SOIL DESCRIPTION REPORT Page of PARCEL I.D. Depth Dominant Color Mottles Structure GPD/ft ~;jl;' N! Boring # Horizon In. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed T !'j' i o_~S lp~R 31Z _ 5 ZNS) ►Az Qj- t~ Z\j 0-S o. • z S 3 6 Lo `2 316 _ s 1 Z. a ?~h `~1r S U, S Ground 3 3~-°11 l v `i 2 V/6 elev. N 0~.0 ft. Depth to limiting factor Remarks: Boring # s vw-t V?-- 2s A 0. ~f Z t~ qZ \W-M- W,6 S o sg w►1 - 0.7 :io. 1, Ground elev. Lo~I • Zft. Depth to I+ . limiting I ' factor i Remarks: @ Apt' Boring # o-q 1~`-t2 zLZ L Zvnse~ vh`~I~ cl, Zu o.S o.x I. 5 2- 9 -7_8 JO -j p 3j(, 1 cal o. a. !I; S \M u`~v C_S 3 2$ 90 ~ ~~t R ylb - S p s~ ~ 1 - `o.~ o.~i~~ Ground elev titZ-J- ft. Depth to limiting j factor Remarks: Boring # E , .G I ~4 Ground elev. Depth to limiting i;r•: factor Remarks: f PLOT PLAN Page 3 of 3 SCALE 1"= SO ' X61 3s- ~L. Lb"1 3 Or Qa ✓ ~ B.l N , /r ~ SUtPR'~L~ 1*r R-k~. Fort wITI FrL •4 `ate-Qt_WO.lllOka ws lil6bCTt to'1 °-~13 C nunz 3 t q'` O 1 rl . P~ C P i~ E 6110. s ~LOp 6 L -B•Y- -I tT- Loy z 0 0 1~30TE' llu sT flu ST~^c~ 1. TR- C-tf ~eTS 5 Z ~~l~P qT `jTt6 v ~S LOT LSD G G . ~Q q S_1S-1 S'- W-01-6-5 1400576 CST"Signature Date 5fgried Telephone No. CST # Wi con d Hur ent oooIndustry, SOIL AND SITE EVALUATION REPORT Page of 3 Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY V-0 Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must include, but 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. o i 5 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWS BY DATE PROPERTY OWNER: -SAQ B" 1). G E1 S s w G e-R PROPERTY LOCATION ~tJtir°RL.~ M. 'FORD BOYT-E8T NW 1/4 'SEE 1/4,S 9 T _Z 8 N,R E( W PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK If SUBD. NAME OR CSM # ySp N, C~Lbv~. Rof1'p '1 - vLCoV 1'~1LLs CITY, STATE ZIP CODE PHONE NUMBER []CITY OVILLAGE MOWN NEAREST ROAD 1')DS kj [ 5 y o I. L (-)I S) 38 6_ 13 t'f 'r2,4 gCLI PrYJ/~ LKtiur [k] New Construction Use M Residential/ Number of bedrooms yuhj%Jvwr./ [ j AddibQn to existing building [ ] Replacement [ I Public or commercial describe Code derived daily flow V SID gpd/8 EiDlzwa" Recommended design loading rate bed, gpd/ft2 o • `a trench, gpdt t2 Absorption area required - bed, ft2 , trench, ft2 Maximum design loading rate 0,--l bed, gVW 9.8 trench, gpolft2 Recommended infiltration surface elevation(s) 5E! l-3 oTe oQ Plfr6Es 3 . ft (as referred to site plan benchmark) Additional design / site considerations Tz c *'Q S V-~=_ ~)-t t n F_rb Parent material s ~~py o v-y"i k.3 ~I Flood plain elevation, if applicable N- K ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for s stem 14S O U RIS O U INS O U ®S E 1U U ?S O U EIS MU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed rerldi "MM o_il l0`12 ztZ si z~s~k >~'Fh e-, w zoo o_s 0A Z til-li fit, ~Q 3Ly - s 11 VT 0.5 0A Ground 3 ~l-~ b lost; 3j6 - s 1 Z%~a6v vrt ev. lo- 3 ft 14 1 6-93 to `r IZ YLt S O g 9 ►v~ j - 0.7 0- Depth to fimiting factor Remarks: Boring # ) a-L~ lo`' vZ-I. Z L Zyn3 1) Z„~ o.S a~ 6 Z to a LoLt2 3k s) rC-3 ~v vn viti_ 04:0-S 3 2z 9o w~R.~tr'6 S ASS m ~ - o.7v,a Ground elev. 1oo.Zft Depth to limiting- factor >9p' Remarks: CST Name:-Please Print Phone- Arthur L. We erer 715-425-0165 . ress- egerer_Sol Testing & Design Service-P.O. Box 74 River Fa11s,WI 54022 Page PROPERTY OWNER 'SnSS))~M- RR2D SOIL DESCRIPTION REPORT ?6f 3!; PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boun Roots GPD/ft ' ~i, in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed ITrendi o_~S ~p~tZ 31Z - S ZNSb 1+~v`Fh tcj Zvi 0.5 ~S 3b to~[Z316 S1 Z'Fs~h m'F~ ~s n,s o,Ij Ground 3 3~-°II lv`t2~,/~6 S O S9 0~7 D•1 elev• 5 Z71 S4 ft Depth to limiting factor °l l Remarks: Boring # o_t S 2 Sbk S ' Z t1-°lZ til~`t1Z ~1~6 S D sg ~ - o.-~ ;10.~''~. Ground t elev. Lo~l•Z. ft. Depth to limiting factor Remarks: Boring # o _q \Z Z lz L ZwLS1*t vn C Ix~ Zv`R o.S ! o.l ~ 5 Z 9 -Zt3 L O `1 R 3 2$ `9D ~`-t R Nl b - S D S ern 1 a . --a o.~~ Ground elev ft. ; Depth to i' limiting factor Remarks: ' Boring # kj [L"" 311,11 Ground elev. ft. 1 Depth to limiting factor i; (it<. Remarks: PLOT PLAN Page 3 of 3 ; tLL I"= 3S_ - ~l. tb"l 3 r~ S u t rh'B L~ I R.." i=U R W L-r) ►3\~ •4 ~~-~,Lbo•e o~ 1O t4tG14, S-3 ' 3Iy p1A. Pic Pt at 1 \ w ~ ~ r~"lrl . 1 t I .too 6 - B•`(- I 0 est. ~v ~E fn LsT 2s~ FCtdt~ 1.OT m tt~L ti I i f Tyo~- Z'q 1~ sT1t-t~2..: ~N Sm~ L `TR v clt 57-1 " ~>Ek~3~ PVT- V M vxz~'swP~ LFbGG_ . ~ 1ZY'1 l~ 712 - v Cbl - ~V ~tfil U A-I S ft f- 'T' ~ o CoN S`r1u ~7? u ~v _ q S_LS-~ - 1400576 `~S (]1 4 2 CST Signature Date Signed Telephone No. _ -EST # = 2. 01 ACRES' • ~ \~N, 87,646''§0.. FT. g r P \ rO~ ~ I 6`r?\ \ I O I °s S 14° 52' 08' E 36' rn 22. 50' -3-35. 00 00 0 ~p0 73 / co O N 0 101 c TYP. 0: Z: N \ S ? Q; 14 I2 F-' F \ O 2.08 ACRES 50' • 90, 631 S0. FT. I Z: q I ( I so, I'09 © 00 \ I A--HIGHWAY SETBACK 150 LINE 0• O ~ ~ ~ ~Zo Op 00I O I \QV 1 I I ~ I o y \ I O G F O 2.07 ACRES \ I pp I co / cb I 90, 157 S0. FT. \ • O N•" N 1 \ w 0o \ I 46 ~ S 88° 50' 5 1 " \ \ 66. 00' \ \ 2.41 ACRES I I \ \ 105, 136 S0. FT. 1 I I 1 I ti a~\ 0 I ~ 10 'li NO. \ I ` u JA I \ I v rn i s SPRIG I 3.93 _ CRES r,\ t STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ' v v' S n 1 MAILING ADDRESS' PROPERTY ADDRESS 0 a 17 E? (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION ~1/4,~A Y/4, Section T oZ ?'N-R l~ W TOWN OF ~]]ff ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER / 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 year a piration date. SIGNED: DATE: j' St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - loo 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 i ~o~SCl1 Location of property ~/Wl/4YJ1/4 , Section T d gN-R Iq W Township/ Mailing address ~3g~ A Address of site r /Q 19,q a12 e Subdivision name Lot no. Other homes on property? Yes No Previous owner of property a 1-au~rct~ d- I;PY t' D cL~~ Total size of property Total size of parcel j-Q1 Q Date parcel was created Are all corners and lot lines identifiable? Yes No / Is this property being developed for (spec house)? Yes V No Volume 114(o and Page Number /L(( 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. 534iU4?7 , 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. 53 S L17-7 S*nature of Applicant Co Applicant e 13 ` Date of Signature Date of Signature WARRANTY DEED llOc;UMCN7 NU I I 'TA7'E BA K t F 5354 sCo,%;St:r FORM 'l -ir3R' i I 1 ~ ~ : r f 141 I ~ T '7'7 1146 it REGiSitWS CriWE ST, MIX CO., W1 ~ r Ra6'd BARBARA A. GEISSI.NGF.R anc' DONALD M. .FORD,... as orReccrd tenants in common and each in their--o~.n ri3ht, ~ r - - a9 OCT 2 ? 9^ anto_rs....... _ 9.1 t" jl cuuvcys rind warrants to JAMES C. FORSBERG , and LOIS M. ;I C . FORSB.ER~,r -hus2~a17d. dfld xife I. I~ Re&tarof s'?Ws GraatPe,.. i - - .1 . 11N - . - in consideration. of.__ 1. and other_ coed and , I valuable. consid-era.tJ_Qr1 r y -..yrQl.x . ..Cou n t - y. i { the following descrdicd real estate in St, State of Wisconsin: ~ Tax Parcel No: 040-1.22-5-30_.. I I' . f I Lot 7 of the Plat of Clover Fills, a rural subdivision located in I s Section 9, T28N, R19w, Town of Troy, St. Croix County, Wisconsin, according t:, the plat thereof filed September 1, 1995, in Vol. 6 of Plats, Page 35, as Doc. No. 533327, in the office of the St. Croix County Register cf Deeds. Together with and subject to the rights and obligations set fort,, in the Declaration of Protective Covenants and Easements dater'. September 12, Y, 1995, recorded September 13, 1995, in Vol. 1140, Pages 39-46, as Doc. No. 533786, in the office of the St. Croix County Register of Deeds. Together with a non-exclusive 66-foot wide coon driveway easement over the northerly ! i part of toot 8 as shown on said Plat of Glover Hills, for the purpose of providing I 4 vehicle and pedestrian access, utilities and similar services to both Lots 7 and 8. ii The cost of installing, maintaining and repairing utilities or similar services to each lot, and of repairing resulting damage to any driveway ar-A vegetation, shall be b the responsibility of the utility or service provider and the owners of the lot receiving such utilities or services, The cost of installing, maintaining and improving any driveway within said easement shall be share owners of both fain s to the extent they agree thereon, but the owners of either lot tawY install, or improve any driveway therein at their own expense; provided, however, that no lot owner or other person shall cause or allow, by act or omission, anything to diminish li I I This _ _ it3.IIQt prorwr~ 'y or interfere with the rights of the other - homestead ~ (;s) (is not) -cklot owners and their use of said easement. ! Ex option to warranties: Dated this _ 19th day of - _QCOrr , 19.9 . y I ~ EA t. i~ ...----(SEAL.) ~ (ti ' ) II B tiara A. Geissinger F - - (SEi (SEAL) " i x Donald M. Ford i .I yti S + i AUTHENTICATION ACKNOWLEDGMENT II °a)gn:aturC(s) WISCONSIN ,~,iigy* STATE OF . . . SS- Y ST.............................................. . CROIX County. N Ir ..da I authenticated this day of 14 Personally cams bc!ure nic this 1...- -9th Y of - QC.ES?~t r 19.95.. the above namai " Barbara A. Geissinger and j TITLE: MEMBER STATE BAR OF WISCONSIN Donald M. Ford - I If not . . . who executed the to we k nwri he the person. _ n authorized by § 706,.06", Wis. Stats.) $ - - for mi i „i•n , nd ci! • +sr 1 e Ile.