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Home My WebLink About006-1023-90-000 Wisconsin Department of Commerce Safety and Buit~ding Divi~ on PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Williams, Tim C Ion Townshi CST BM Elev: Insp. BM Elev: BM Description: ~ ~/J~,[~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic /OG ,l v Dosing , S~ rt Aeration Holding TANK SETBACK INFORMATION TANK TO PiL WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. CfDIX Sanitary Permit No: 70 State Plan ID No: Parcel Tax No: 006-1023-90-000 Section/Town/Range/Map No: 11.31.16.157 STATION BS HI FS ELEV. Benchmark r, q /o/ , ~ /O6.CiG Alt. BM ~ Bldg. Sewer 3 i 3 ~ D ~~ O SUHt Inlet ~ ^ J3 S_, I St/Ht Outlet Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover Y~ - ---- ~' d it ~ i rI S ~i BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) 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 i Yes ~, J No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: rZ ' / ~ / ~ ~ Inspection #2: ! / - Location: 2444 County Road H Deer Park, WI 54007 (SE 1/4 NW 1/4 11 T31 N R16W) NA Lot Parcel No: 11.31.16.157 t , 1.) Alt BM Description = r 2.) Bldg sewer length = ~.`1r -amount of cover = IIJr ~ Q"I' la<.• , r~~ 36" c~.{ -Fn.. l~ ' n ~sc.-(` .~-E~ / -lo ~'`-~ ta..~- !L Plan revision Required? Yes (~No /~ ~ ~~ ~~~ ~~ Use other side for additional information. _i_ ,_ Date - Insepctor's Signature Cert. No. SBD-6710 (R.3/97) County Sanitary Permit Application sT. cROlx couNTY wlscoNSIN In accord with 15.04 St. Croix County Sanitary Ordinance ZONING OFFICE Personal information you provide may r Sly ~flppses ~t VV LVJ ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Law. S. 1504(1)( 1101 Carmichael Road ~~ Hudson, WI 5401&7710 (715)386-4680 Fax (715)386-4686 Attach c~mpiete plans for the syste on t ' -1/2 x 1 inches in size. County Sanitary Permit # ^ Ch if revision to re ' ~cati ~°~r~'~~ ~ • p0 ~-O rx _ ~~,~ ,~ 00 6 - ~ 02.3 - qo - rnro(. I S~` I. potation Irformation -Please Print all Informatior location: Property Owner Na e 1/4 1/4, Sec ~ ~ ~ ~ ~ T N, ~' R E (or) W Property Owners Mailing Address Lot Number Block Nu r Ci ,State Zip Code Phone Numer Subdivision N me or C M Number II T~~ of Bui d1ng: (check one) t,,,o ~ ~ ,M,~ , amity ^Villa a own of ~ 1 or 2 Family Dwelling - No. of Bedrooms: ^ Public/Commercial (describe use): 1 ^ State-owned / Nearest ~t d 11.7ype of Permit: (Check only one box on line A. Check box on line B if applicable) Parcel ax u her(s) ~ 1.^ Repair ~ Reconnection .^Non-plumbing . ^Re' ' Sanitation J 6) Permit Number Z ~ Date Issued `~' ~ U ^ State Sanitary Permit was previously issued q p ~ l - N. Type of POWT System: (Check all that apply) ,, (.Non-pressurized In-ground ^ Mound -fl--Sand-Fi er ^ Constructed Wetland ^ Pressurized In-ground ^ Holding Tank ^ Single Pass ^ Drip Line ^ At~rade ^ Aerobic Treatment Unit ^ Recirculating ^ Other . Oispersal/Treatment Area Information: 1. Design Fknv (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min.finch) Elevation i I. ank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete strutted glass Tanks Tanks ^ ^ ^ ^ ^ ^ ^ ^ ^ It. Resporslbility Statement 1, the undersigned, assume responsibility for repair/reconnenctioN uvenationfinstallaUon of non-plumbing for the POWTS shown on the attached plans. A icense is wired for erralift repair or the installati of -p tubing anitaUon system. Na a Plumbers S' e ( ): MP/MPRS No. Business Phone Number L ~ _ f umber's Address (Stre~t~ ity, ,te, Zip 11. County Use Only Disapproved Sanitary Permit Fee Date Issued Issuin gent Signatur No stamps) [~ Approved Owner Given Initial Adverse D i I ~ -._ ~ r l eterm nation iX. Condi t io ns o ppro ~ / ` ~~''~- ~ S t'~'~ ~ ti°_ C_.6,n- ~ ~t 5 ~ 1'~Q.v.>~.~`-O'""`~- -~ 1 "`~S ~~1 S ~+~n. ~ ( .. ~ '~- S S-k~ ~uc~J ~~ ~y 1.~~ ; ~ ~~`c ~'-,°'"` DMA J r -~ ~x.~` '"C" -" s ~ y~e~. ~s nst- ~.~ ~ c~ ~e~. ~~o-~.k.- ~ ced~.Q ce~i~C.~~a~ --- c~ P-~' (~ t, ~n 0 t~~ ~ p.~a,vk~e.- ~ rte. opt /~ S~ v~~ -~-ca.~~„ , -~ ~ ~~-!1,~.~s ~~y ~~ ~~~ ,, ~~ ~- i =~ /oov~,~/~~~ J~~ ~~~ ~ ~/ ~~~io ~.~/,~ r ~ L~~~~6E ~ / is/~~~ ~e~ ,CSR', NF,~ I ~/E ~~t~~~ s<,J,r"<,~1 ~ ~t'~ ~~ - ~3~ -~ b".G- ~~,SQ.~;ee' 1- - - - // ~- ~s.-.} ~~ ~~ , /~ ~~. GS ~ ~ i , v'h'"" ,-~cr- ,~~ 1~, ~~,-~,d~ 1 ~~ ~VV /•S~6 ~~~ ~m f~.J,~ ~r~' 'y ~, ~~~ ~~ ~~~ ~if~ ~~~ 6v'z s~/c~ s ~- i =~ ~~/,,~ ~_, ,/~~~ ~i ~1 u,sr ' ~ i iE I ali-1EtFi - 3.9~ f Nit-cl- b `_ o f ~a/~ ~~7.~1G-~ ` l~J~'4SJ/ ~ ,~,&,o Ja*1~ ~, ,~~~ ~ ~ ~~~~io i rt- -r ~---- - I`, --S --~~ /g ~Q, ~r~/ '~ ~, /~ ~, t 7o:d.~ /e%E ~~ ~o ~/® f~~ is6~ o~~?-~~~ ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to ~e ify that I have inspected the septic tank presently serving the ,L~~ ~L,,, „fih~ residence located at : ~~%, ~~1/,, Sec . ~~, T~N, R_~W, Town of ,a ~„/' St . Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced ~~-~- r-~~y1~ Did flow back occur from absorption system? Yes No~ (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: ~ Construction~Prefab Concrete teel _ Manufactu r (if known) Age o f T k( i f known) ~ ~ ( ign re (Name P eases Print ~~~5 ~~~ ~ (Ti le) (L ce se Number) ate) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements. f ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baff ) , Na ~ ~~ ~ Signature ,' MP/MPRS Other f S'I' C'1ZU1;~C CUUN'hY 51:1''1 l~;' ';'.INK Iv1AlN'I~1~:'~ANC1; AURI:;1~MIANT A ^; ~) (_~~~': .:I~~til~lll' C'l.l~~I~,f~IC.'A'I'ION 1~UJ~Zlv1 0~~, tleril~u}'trr I ~ ~ w t / I!, c. yw ~ M:.iling Address ~ ~ ~ ~ .___ 1'r,~p~rt~ Address S ~~~_ ~. (Vc,iiicauun reyu,rcel born I'lannin6 I~cpartmc:nt for new construction) l' ~~ c.:ily/5tulc ~~~"' G-i'-~ W~Ircc1 l~icntil'ICtttion Nuli~bor I~ 1,,.1~ C_~~[_. FSCRiPT1ON 1 op~rty Location ~ '/~, , ',~.,, Scc. ~, "1'N-R,.,,~.W, Town of ~~. ~~ b c1 i v i s i u n y//' /~~°.E S _______ ___ ,Lot # ~..,._,,,,,,,_. (:~rtifiet! Survey Mah fl ~~lun~e ~' ,Page # `~~'arraaty Deed ~ 12. 5~"2 Yulume zlb~ ,page # ~31 Spec house O yes no Lot lines identifiable D yes O no S_` ~TI;11~1 MAINTENANCI; Inipropcr use and maintenance of your sr~~lir sysicnt could result in its prentalurc failure to handle wastes. Proper maintcr•.u,~c c. zists 01 t,umping out the septic t;uik evrry U,rec yrars ur sooner, if Herded by a licansed pumpor, What you Nut uito the s~~t~u, ca,. alToct li,e t'unclion of the S~(Sllc lank as a treaUUCnt stagC In the waste disposal system, The property owner agrees to submit to St, Croix LOnlll~? I~CparhilCnt a CCRIf1Cat10n POrTn, signad by the owner and by master plumber, journeyman plumber, restricted plumber or a iicense~l pumper verifying that (1) tha on•site Wastewaterdisposai syitcu, is in proper uper;ltin~; candiUOn and/or (2) after inspection and pun~pinb (if necessary), the septic tank is less than 1/3 full of sluuee. l%wc, the undcrsibned have read the above requirements and agree to maintain the private sawage disposal system with the standards set torch, herein, as set by the Dcparnnent of Cummrrcc aad the Department ul' Natural ltcsources, State of Wisconsia• Certificauoa stating that your septic system has been maintained must be completed and returned to the St. Croix COUnry Zoning OfFwe within 30 days of the three year expiration date. SIGNATUfZL OF APPLICANT DATE 9WNER CERTIFICATION I (wc) certify that all statements on t1US fornl are IrUC to t}lc best of my (our) knowled$G•. 1 (we) am (are) tha owner(s) of the property described above, by virtue of a warranty decd rccordr,.~ ~n Register of Deeds Ofr'ico. SIQN~~'1'URJ.~: JF APPLICAN"J~ DATE *•'••" Any int'orination that is mis•rcpresentcd may result in the sanitary permit being revoked by tba Zoning Dapasrtment. •••••• •• Include with this application: a stamped warranty decd from the Rcbistcr of Deeds office u copy oi• the ernified sur•vcy nlup il'reference is made in tha wairranly deed .. . , ~1 2 1 6 ~ ~' tl 3 1 ~ ~ ~s7~ ~,l I STATE BAR OF WISCONSIN FORM 2 - 1999 Dscument Number WARRANTY DEED This Deed, made between Jeffrey R. Frisle, a single person, Grantor, and Timothy S. Williams Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Southeast 1/4 of Northwest 1/4 of Section 1 1, Township 31 North, Range 16 West, St. Croix County, Wisconsin. Recording Area KATHLEEN H. MALSH REGISTER OF DEEDS ST. CROIX CO. , WI RECEIVED FOR RECORD 03!10/2003 09:30A1S EREMRT ik REC FEE: 11.00 TRANS FEE: 345.00 COPY FEE: CERT COPY FEE: PAGES: 1 Name a~~~~ d csOGLAND ATTC ^'~! EY AT LAW P.C3- i~~JX 359 HUE3,~iCiJ, VVI 54016 006-1023-90-000 Parcel Identification Number (PIN) This is homestead property. Us) 1,5(1Qi~Q Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. Dated this ~ day of February 2003 AUTHENTICATION Signature(s) Jeffrey R. Frisle, a single person, 4M authenticated4this ay of February 20(13 l ~~. *Kristina Ogland ~/ • _ s Je ey risle * ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. County ) Personally came before me this day of _ , _ _ _ the above named TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing (If not, instrument and acknowledged the same. authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Ogland Notary Public, State of Wisconsin Hudson, WI 54016 My Commission is permanent. (If not, state expiration date: (Si natures ma be authenticated or acknowled ed $oth are not a essa ) •) g Y g n c ry. , * Names of persons signing in any capacity must be typed or printed below their signature. ~~rormeGOn a~orasswne~: canpany. Fa,d au ~~, tM WARRANTY DEED STATE BAR OF WISCONSIN 8oo~s55-202 FORM No. 2 - 1999 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~ -~J`- l6!' ~~ ~ _ P1_ C ~ G 1 ~- ADDRESS -~~~~j ~ ~(~~-~~ ~~{ ,l~es~ ~~ ~ ~ ~~ , 5 y~0~ SUBDIVISION / CSM# _ ~ / LOT # r SECTION- f~ T~_N-R / ~ W, Town of~~~,~-~ ST. CROIX COUNTY, WISCONSIN PLAN VIER ~°6. s~~ l ,~9 r ~„ i,~ I• ~ 1 ~ ~ ~ ~~ ~~ III ~3',~e<,Q~~u.i'~P~ f ,~~ rl INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARR• ~C(~_SL ~7 '~ ~O W ~,(- '1 ~,`~. ALTERNATE BM: -~-pm (~ `]' m (~ /~ ~ D ,~-.~ SEPTIC T / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ~~k.F Liquid Capacity: Odd Q~ ~ Setback from: Well G 3 House ~ 3 Other Pump: Manufacturer Float seperation Alarm Location Model# _ Size y Gallons/cycle: '- ~ SOIL ABSORPTION SYSTEM i Width: ~ Length ~C~ Number of trenches ~ ,~P~/( Distance & Direction to nearest prop. ~ine;~pu~~ /~Q / i Setback from: well : ~Q House--~~ Other y ELEVATIONS Building Sewer `~r/~ ~ ST Inlet : ~~ E~ ST outlet ~ PC inlet ~- PC bottom Pump Off Header/Manifold ~ ~ Bottom of system '~L Existing Grade ~ ~~ Final grade ~ ~ DATE OF INSTALLATION: ~/~~/~~ PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: ~~ F ~% 3/93:jt ' Wisconsin Department of Industry, Labor and Human Relations Safety and Buildings Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) --- ~°~ST. CROIX Sanitary Permit No.: State Plan ID No.: Parcel Tax No.: Pe~i#1-fQldex~Nam~HARLES (OwC fB3 C : : ^ City ^ Village [~ Town of: CST BM E I : e Insp. BM Elev.: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ,~~ S f~ _ , a4_~'!' f Dosi Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Air Intake ROAD Septic y~~' ~~ ~ ~ NA Dosi NA Aeration H of d i nt}---- PUMP/SIPHON INFORMATION Man Demand Model Number M TDH Lift Lriction Syste Fie Ft Forcemai n Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED /TRENCH Width p~~ Length ~ No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I N 0 DIMEN I L Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM INFORMATION TypeO a ~ CHAMBER Mo e System: v-,(~, ~ /~ $ OR UNIT DISTRIBUTION SYSTEM Hea9 er 1~+4e~d-• . ,~ I ~ Distribut9 n Pik ~,~ I x Hole Size x Hole Spacing I Vent To Air Intake Len th Dia. p g Len th Dia. S acin ~ ~_ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems On Depth Over ~j ,, ~ Depth Over „ ,~ ~ xx Depth Of xx See odded xx Mulched Bed /Trench Center - _ ~ Bed /Trench Edges~ Topsoil Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Cylon.ll.,/31.16W, SE, NW, 250th Street ~ ~ ~; n,,~~~~~~. ~` ..~ ~~~ !'~ ~~ ~"'~ ~! f/~~2.-`~ ~ C~ ~ ~!/~ ~C_ /'' Cam' c>L]~-'l -P ~~~"rte ,-~~~ ~ ~"-~° `~P~ /-~~~~~ `~'r-~ , Plan revision required? ^ Yes ~No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signat re Cert. No. ELEVATION DATA ~/~ 7~~ STATION BS HI FS ELEV. Benchmark ~ ' ~~~ ' ~ C~.., a, f'-t , to ~ f d~ d 3 Bldg. Sewer ' 99 3~ r St/ Inlet ~dZ ~ 8,1,7 ~ St/ Outlet g8,~/ ~ Dt Inlet Dt Bottom ~/~ Header- d, /a' $ ' Dist. Pipe d i s,~,fs Bot. System ~, D ~ 9~(,(~' Final Grade S, ~ D~, 03 CAp11TARV D~RMIT ADDI 1['_OTIAN ^~r ,-~ ~~ t-'~IiL.lllr~let In accord with ILHR 83.05, Wis. Adm. Code COUNTY ~/~ / ~E STATE SANITAR P RMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than i h i 11 i 8t/ a ^ ze. n s z x . nc es cneck i# re~i ion to previous application -See reverse Slde for IflStrUCt10r1S for Completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. PROPERTY OWNER ~~GG /~- G'O PROPERTY LOCATION t/a ~/lt)'/a, S ~~ T.~ , N, R ~~ E (o W PROPERTY~J MA R SS~- LOT # ~,,, BLOCK # CITY, STATE ~ ZIP CODE PHONE NUMBER ~ SUBDIVISION NAME OR CSM NUMBER «r ~ (.c> ~ ~ Od 7 ~~'S ~ S ,--- NjfREST RO/~ 11. TYPE OF BUILDING: (Check one) ^ State Owned ^ vILTMLAGE ~ /b ~/ ~J ~ ~ / ~ .Public ^ 1 or 2 Fam. Dwelling-#~ of bedrooms PAR ELTAX N BE () ~ 111. BUILDING USE: (If building type is public, check all that apply) O O ~ -^ `O ~~ ,..._ /Q 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 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 in line A. Check line B if applicable) A) 1. ^ New 2. ~ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5. ^ Repair of an System System Tank Only Existing System Existing System B) ^ A Sanitary Permit was previously issued. Permit # Date Issued V. TYPE OF SYSTEM: (Check oily one) Non-Pressurized Distribution Pressurised Distribution Experimental Other 11 Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 12 ^ Seepage Trench 22 ^ In-Ground 42 ^ Pit Privy 13 ^ Seepage Pit Pressure 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 REQUI ED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVA~STION ~~~ ~ ~~ s ~~~Feet ~ d Feet VII. TANK CAPACITY in allons Total # of M f ' N Prefab. Site Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks ame anu acturer s Concrete glass App Tanks Tanks structed Se tic Tank or Holdin Tank d~ ~~° ~ uF Lift Pum 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): Plumber' nature: (No Stam s) \ MP/MPRSW No.: ~ / ~ Business Phone Number: 3 fan ,~,~~~ ~ s ~-~~r Plumber Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ^ Disapproved Sa itary Permit Fee (Includes Groundwater surcharge Fee) a e ssue Issuing Agent Si nature (No Stamps) ~ Approved ^ Owner Given Initial ~ ~~ "' ~ ~~ /` Adverse Determination ((( X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398{R.08/93) 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 the 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 & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. 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 ali appropriate boxes that apply. IV. Type of permit. Check only one in 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 in #1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for a// 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'fz x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) PLOT PLAN PROJECT Charles Babcock ADDRESS 2253 250th St Deer Park Wi 54007 SE 1 / 4 ~ 1 /4 S 11 /T 31 N/R 16 W TOWN Cylon COUNTY ST. CROIX MFRS BYRON BIItD JR. 3318 ~ ~ 5/21 /94 BEDROOM 3 DATE CONVENTIONAL XXXX IN-GRO D PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 Gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE •5 ABSORPTION AREA 900ft"2 BED SIZE 18' X 50' BENCHMARK V.R.P. Base of Power Pole ASSUME ELEVATION 100' ^ BOREHOLE O WELL *g,R,p, Same as Benchmark ~V~' SYSTEM ELEVATION 94.6 TYPAR COVERING 12;' 3' 6' ® 3' 3' Q 3' b SEWERR CK 18, 12' ~ nn a., T i Soil Test Plot Plan Project Nar~e~C~h~rles Babc ~ k Byron Bird Jr. Address ~~,a S • Deer Park Wi 54007 ST 3479 Lot Subdivision Date 7/13/94 SE 1 /4 NW 1 /4S11 T 31 N/R 16 W TownshipCylon Boring O Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Base of Power Pole System Elevation 94.6 * H R p Same as Benchmark ~nnn+„ni STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER C//[ 2/' ~°~-3' ,~.7Gc, ~ C?~ C~~ MAILING ADDRESS ~ ~ ~~ ~~/- SZ~ • J/~~r ~tc ~' K 1~~, ~ S~a (~ PROPERTY ADDRESS ''" O~ ~ ~ (- _ ~ ~-F \`~ / / ~ r ~Q h (location of septic system) Please obtain from the Planning Dept. CITY/STATE ~~ r ~~. /` ~ L(~ ~ PROPERTY LOCATION .f ~ 1/4, ~L~ 1/4, Section / ~ , T~_N-R~W TOWN OF Lf'~dn ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP ,VOLUME ,PAGE ,LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying, that (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 expir ion SIGNED: DATE: Q 7 ' I ~ ~' 9~ St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 WiscdnsinDepartmentoflndustry, SOIL AND SITE EVALUATION REPORT Labor and Human Relations ' Divisiorl Of Safety & BUIIdIngS ,,.a ...:a~. ~i uo en nc per.., n.~... n..,a,. Page _ of ... ,..,...,.,........~.....,.,..,,,, ..,........,...,.,..., COUNTY ~, J c ( ~ Attach complete site plan on paper not less than 8 1/2 x 11 inches in size Plan must include but / ~,",~ rV / , . 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. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION ~ ~ mac.. ~,~ GOVT. LOT ~ 1/4 /4,S T ~~' ,N,R E (or) W PROPERTYf~ ~ AILI~I S ~~ ~,J ¢_. LOT # ,-- BLOCK # SUBD. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER ^CI ~ ^VILLAGE MOWN NF~AREST ROAD [ ]New Construction Use ~ Residential / Number of bedrooms [ ]Addition to existing building Replacement [ J Public or commercial describe Code derived daily flow ~~~ gpd Recommended design loading rate ~ S bed, gpd/ft2: trench, gpd/ft2 Absorption area required ~c~ v bed, ft2 ~.~ trench, ft2 ximum design loading rate ~ bed, gpd/ft2 ~ 6 trench, gpd/ft2 Recommended infiltration surface elevation(s) __ ~ l ft (as referred to site plan benchmark) Additional design /site considerations Parent material 0 , ,~~,?~ Flood plain elevation, if applicable ft S =Suitable for system U=Unsuitable for s stem CONVENTIONAL L3rl S^ U MOUND ~ S ^ U IN-GROUND PRESSURE ~ S O U AT-GRADE JAI S^ U SYSTEM IN FILL ^ S [~U HOLDING NK ^ S U SOIL DESCRIPTION REPORT Boring # :..:::1~::: Ground lev. ~~ ft. Depth to limiting fac~ y~ Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ~~ ~z s ~~ CS ,S .c 3 ~'y.~ yb' ~ r ~Jlt~ ~s ~i~ ~ ~ s~- y s ti,~ ,a . ~ , ,, ,, ~~ Remarks: ~ - r S j~~," - ,~ s --~ 7 ~ s/ Y .. c s . -~ 8'S ~ l r ~ r~~.-~ ~. ..S~ ~ ~ _ -~' 01 Remarks: CST Name:-Please Print ~U / '/Tb ~'/ !/ ~~ - ~ SY~oi Phone:~~s ~~~ j~~ l Signature: ill ~~ c-~j , _ Date: N PROPERTY OWNER SOIL DESCRIPTION REPORT Page_of PARCELLD.~ ~ ' Boring # ' ktiti . ti t44\ vi ~.ii'C': Ground ~ev. ft. Depth to limiting fac ~' ~ i H Depth Dominant Color Mottles Texture Structure Consistence Botx~dary Roots GPD/ft zon or in. Muns ell Qu. Sz. Coat Color Gr. Sz. Sh. Bed Trerxh // P~ Z ~ ~..~/ [^ S 3 ~2-3a o y ~ cs ti~ , s .~ o- ~d ,- y ~s _ ~n ~ ~ h,x~ ,a ~ ~ -~ Boring # .................. Ground elev. ft. Depth to limiting factor Boring # ................. ................. ................. Ground elev. ft. Depth to limiting factor Remarks: Boring # €w Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) Remarks: [li( DQCUMENT NO. ~ , :1 '~~ ~ pp ~rMUi~ .V J ~ STATE BAR. OF ViIISCONSII3 FORJI 11 - 19$$ LAi•I3J GC~r"1CT yAd1Y1dYA1 [n$ Cor}orsl• ITO 21E U$FD FOP. AI.L TRANSACTIONS R'HERE O'r EN X53.000 IS FINAYCED AA'D IN OTHER NO:'-CONSU:M F.R =-~y_~ACT TRAN$ACTiONR) _'~` TM~4 •-AC[ RLSL.PY[C spR R6iORD~it4 DATA ~~+1 t . ,' Red for ~•~ ~ ~,, ~! JUG. 0 31990 M., 804 A. UAA d elf ` l:olltract, by :.nd bat~ee~ ..EYer.~ra.pct.-Sh~1.t~r.~d-.Earm~._Ltt~• ..a._I~islrAns_in_.soxps~xs.L.i o~ ................................................................ :.... :.........................•--..... _ ... .... ..._.. .--• ----. (°V don", ~vhather one or more) and__..~.~.h~rYeS , W:_: ~abcocTc_: and': Joanne !~`: .. .:Bab~s~~.k,_.husb~a.od. ans. ~;_fa,.__ds ._surxivarshi.R_ ma~ri.ii~~..-.-__--•- --{1CQ~2£1"i;~t..__._._,.--.-- ......................... ("Pnrchaser^, whether one or more). Yendol• sells and agrees to convey Lo Purchaser, upon the prompt and full per- tormance o1 this contract by Purchaser, the fohowing property, together with the rents, pro9ts, lUctures and other appurtenant interests (all ealIed tk) "Property"), I ~--------- - --------•-- Styr- Craix.........._...... _... County, State of Wisconsin: ~ , l E ~ PARCEL 1 SE~/q of KWI/q of Section I1-31-16. • PARCEL 2 KE1/4 of KE1/4 of Section 11-31-16. - PARCEL 3 • Sit of N4J114 of Section 12-31-I6. 1~ ~z Tbis _...._i :................. homesteaa property. vendor's residence or such other ("~ ~~~ place as the vendors designate Puncha~e g~~e t~,,purchase the Property and to pay to Yendor at in. Wr~tlli9_________________________________________ the sum of ~ l~~=UU,~.UU----------------•------------------ is Lhe :ollowin manner: (s) #_35.sQ~~.QO.-_.-_.-°--• --- -.-.---•.- sY the execution of this Contract; and {b) the balance of $..__~~Qe_.~QtQ~_______________ together with interest from date hereof on the balance outstanding from Lime to time at the rate oi____. $~5~____________________________ per cent per annum until paid in fnll, es follows: Bi-monthly payments of X433.92 each, including principal and interest, the first of said bi-monthly payments to be due July 21, 1990 an~i August 6, 1990 and subsequent bi-monthly payments to be due on the same days of each month thereafter sub3ect however to the balloon payment provision set forth below. On this date a Chattel Security Agreement and UCC-3 Financing Statement are also being executed. Any default on said documents will also constitute a default on this' land contract. Provided, however, the entire outstanding balance shall be paid in fall on or before the..__..___ 6th.......:._ day of -+Iul:y-------------------------------- XeC2000 (the maturity date). Following any default in payment, interest shall accrue at the rate of _~_..rJ_._.% per annum on the entire amount in default (which shall include, without Ii:nitation, delinquent interest and, upon acceleration or maturity, the entire principal balance). ~~ p1Ll1e~RXd4?f~ PS~r~~~s~XdS~~~X~~c~X~X~ l4•X~?41(rY+3i)4d~eXDfc~~4~1(,~ ~~~~, I~ vltlente>h(~t~+~(x*x~ixxl~-xneic~t>~~t~a~e>~ISxu~,iaxdct~axatx~;lcaaltxx~x•.~lcrdt~.rtac~cx~cxtwcxxra~>~a~c>~x~acatxa~ t~6~slc;r~4~tltl[~ttr-xawex~,l[i~t6xdcl~cx~ax~xx~1e6x3HCx>iF;~~~4~43ialr>~~crx~X~d6a~(rXX,a4~~XIA~~ii~~f~4~ - ~ nXi~~16X~E~ib~¢x>? ' ~ Payments shall be applied Srst to interest on the unpaid balance at the rate specified and then to principal. Any amount map be prepaid withart premium or fee upon principal at any time after.__._ JUIy 6 __ ____ __~ ig 90 ~~~ tl>Btt(~f~§fl{xi()~6X~JQlP~YdhINdfX~4'Ydf•Y~}t16~16X~341(~'t~lf?ILXiXXRe~E'J4gdCX I Ia the event of any prepayment, this contract shall not be treated as in default with respect to payment so long as the unpaid balance of principal, and interest (and in such case accr::ing interest from month to month shall be treated J+ sa unpaid principal) is less than the amount that said indebtedness would have been had the monthly payments been (i made as Rrst specified above; provided that monthly pa}Znents shall be continued in the event of credit of any proceeds 1{ of insurance or condemnation, the condemned premisPa being thereafter excluded herefrom. ~tj Purchaser states that Purchaser is satisfied with the title as shown by the title evidence submitted to Purchaser S for examination ezcept: I~ No exceptions. ~` '~ Interest is to accrue on this land contract from and inc uding July 6, 1990. i` ~~ ~ i t; Purchaser agrees Lo pay the cost of future title evidence. If title evidence is in the form o.` an abstract, it shall }~ be retained by Vendor until the full purchase price is paid. i' Purchaser shall beentitle.tto take possession of the Property on .............._ ~U~y..3_.._.._._.__...__.._. _., 19...90.,, !; ;. •ct~ outotf- except the house. Purchasers shall have possession of the house beginning ~ e~ ,._ _ ;._ July 15, 1990... - {f 0 ~' LAND CONTRACT-Individual and 9TATF. B\R OF R'I5~~0X31.~ w~.e•n<'n Lrcal Riwnk Co. Inc. j COtpotate FOR)1 ,. 1I - 1382 Sliiwa.; ,er, W.;. Purchaser pmmis~( to pay phcn due all t, sled assewsluNnLs ~evisd on the Property oz ppoi4 Pend s in~a~, ''~ in, it and t4 deliver to Ve:Idor on denaa»d zeceigts showing spills pa/ymea:t.• :.,:: - = ~ ` , _ "`+ -~ # tended~cov ~r perUa an psa~eh ompa~r 6 ~ as Vend r m Y rN~uire,, p~ pt ~ grauC~toned 7 ~i _- • d tti q ~ Y oq w!{ho - h insat~ce A I-ra~P~d ~ b Vendor, in the sum oi ;1_`tl~~..tn~~i!"_s~kx~..~f~~ld~..:., but Vendo;• ahesil not ~overa~l Ca sn aDioapt a+ore ,~,. ~,,,ro , than the balance owed and®r this Contract, Py r~ shalt yar the inauzaaa@ap~f~ whe» doer The pofieiert rsAdl w contain the standard clause in favor of the,. Yeadiu~llsn~~ l~ t~d. naleat Vendor W agrees t~ i~ri4n ,the pr~ipti ~'' ~, - ef all policies covering the Progsrtyy ahal# be deport ` with Vendor. 'Purchaser shall promptly give of loss to insurance companIea and Vendor. Unleea Purchaser pnQ Vendor otherwSas agree fin writing, insurance roceeds shall - '~ ~ be applied to reatoraNon or repatz of the Property.. dsa-aged, provWed the VandoR deems !h@ restoratio4 or TapaiT to be :.rte- .~,t economically feasible. , ._ ~ ,:- ~' •~ Purchaser covenants not Zo commit pasta pot allow waste to be committed~op the Property, to keep the Proysrt-• ~~ fn good tenantable condition and repair t9~p the tq free from liens supezior to the flan Of this Coatzact, aa~ :~ to comply with all laws, ordia>inces an~ regulaKo>ss a~g the Property., - ," . s e Purehaasrp a W arranat the ti ~ fw~itl i~ pminawr above sp three soil taut off all lies-s snd~e ^um~br ae, ssoe'Pt~ i •~~~ tt. ty e~ s plc, .the Property. p. . any Hens or encumbrances crested by the acct or daifai of Purchaser, and except En5.2111!'li~.,..1~secYflti_nns " .. .- f r rd and exc a ticable munici al and zonin ordinances ..and._r_~~tr_~~tiQnf--Q------~~4_.._. ..............~P.....PP.....-----.._..........---..P----._._... ------.._~...._.._. ....._,..._ f Pnrchaaer agrees that time is of the essence., and (s) in the event of a default in the payment of any prindpd or' ' '' ,. interest which continues for a period of :,~~-days following the specified due date or (b) in the even: of s default ~ ppeerformance of any other obligation of Pnrcliaser which continues for a ~e~{ad ot. ~.... days following written aoties • r.~ thezeot bq Vendor (delivered personalty or t+isiteibg certified mail), then the entire outstanding balance under this contract _ E ~ shall become immediately'due and payable"In`fnil at Vendor's option and without notice (which Purchaser hereby .waives), and Vendor shalt afro have the following ratgbts and remedies (subject to any limitations provided by lawj ib addition to tho4e Provided by law or itI equity: (i} Vendor may, at his opLion, terminate this Contract and Purchaser's - `~ ` ;' rights, title and (merest in the Pro and recovez the Property basic through strict foreclosure with. any egaity of - _ j redemgtion to be conditioned upon ~~ser`s fall_;payment of the entire outstanding balance, with interest thereon from - the date of 3efault at the rate to effect on aucl`t'dattandotheramoantsdueherenader(inwhicheventall amounts previouatp ri. paid by Purchaser shall be forefeited as Iignidated, damages for failure to fnlfiH this Contract and as rental for the x - Property ii purchaser fails to redeem}), or (ii) Vendor maq sue for specific performance of this Contract to compel x immediate and full payment of the entire outstanding balance. with interest thereon at the rate in effect on the date of '" default and other amounts due hereunder, in which event the Property shall be auctioned at judicial sale and Purchaser ,,.. ~~ shall be liable for any ueficiencq• or {iiij Vendor may sue at law for the entire unpaid purchase price or any portion thereof; or (iv) Vendor may declare this Contract at an end and remove this Contractasacloud on tide in a qu(eLtitle action ii the equitable interest of Purchaser is insignificant; and (v) Vendor rosy have Purchaser ejected lrom possession a _ of the Property and have a receiver appointed to collect anq rents. issues or profits during the pendency of soy action ~~ under ~i), (ii) or (iv) above. Notwithstanding any oral or written statements or actions of Vendor an election of any of the oregoing remedies shall only he binding upon Vendor ii and when pursued in litigation and sly costs and ezpenaes including reasonable attornegs fees of Vendor Incurred to enforce:any remedy hereunder .(whether abated oz not) to the extent not prohibited by law and expenses of title evidence shall be added to pru-cipat and paid by Purchaser, as in- , c(Irred, and shall be included in any judgment. Upon the commencement or daring the pendencyy of anq action of fot~eclosnre of this Contracts Purchaser consents ` to the appointment of a receiver of the Property. including homestead interest, to collect the rents, Issues, and zoftta of Lhe Property daring the pendency of such action, and each rents, issues, and profits when so collected shall be~eld and A'I applied as the court shall direct. _ Purchaser shall not transfer, sell or convey any legal or equitable interest in the Property (by assignment of any o! Purchaser's rights under this Contract oz by option, long-term lease or in any other way) without the prior written consent of Vendor anlesa either the outstanding balance payable ender t1-is,Contract is first paid in InU or'the interest conveyed is a pledge or assignment of Purchaser's interest under this Contract solely as security for an indebtedness of Purchaser. In the event of any such transfer, sale or c~Invey ance without Vendor's written consent, the entire outstanding balance payable under this Contract shall become immediately due and payable in full, at Vendor's option without notice. Vendor shall make all payments when due ender an^ mortgage outstanding against the Property on the date of this Contract (except for any mortgage granted by Purchaser) or under any note secured thereby, provided Purchaser makes timely payment of the ameunta then due under this Contract. Purchaser may make any si ^h ayments directly to the Mortgagee if Vendor Pails to do so an3 all payments so made by Purchaser shall be :onsidered pagmentc made on this Contract. ~ endor may waive anq default without waiving any other subsequent or prior default of Purchase:. All terms of this Contract shall be binding upon and inure. to the benefits of the heirs, legal representatives, snecessors and asstgas of Vendor and Fnrchaser. (If not an owner of the Property the spouse of Vendor for a valuable consideration joins herein t~ release homestead rights fn the subject Property and agrees to join in the execution of the deed to be made in fnlfttiment hereoLl Dated this ..-----•-Zild---------------------- -••_--._ day of _-.._...._ .. _.:Ju~tY---- --.:-.....------•--- ------°--_.:, 18_~---• ~EIVERGREEN SHE TERED FARM, IN ~/~/r~ !'~ ----~Y:_---?~ _ ------ ---- -----~!.- • ----• ----•---••----.(SEAL) •---~ :~~_.--`''.`-:.- -•-•-•-• ..... ..............(SEAL) . Herbert H. Fouks, President , Charles'W Babcock BY: .~-rC~•~T~L~Z~~C./~ L~I-~~l---(SEAL) -•- •-~-~J-.-... --•--•----•--(SEAL) canoe M. Babcock •Sharon--C.-_Fouks,_-Yice._President •-__ ~~ ACKNOWLEDGMENT '~ STATE OF WISCONSIN) AcglvowLSna~$xT ` ss. COUNTY OF POLK STATE OF WISCONSIN Personally came before me this ~rv~ ~- day of July, 1990 the above named Herbert POLK--°-'~-°--°-'----°~-°-°COIInts'' H. Fouks and Sharon C. Fouks, the President pe~snnany came before me this __O~n!~.___daq of and `(ice President of Evergreen Sheltered -duly--°----------'-----'----""---" la.~__ the above named ~ Farm, Inc., respectively, to me known to Charles•W,__Babcock and_Joanne M.-Babcock, be the persons who executed tale foregoing husband and wife, as survivorship __, in~t umen~ nil a nowle a the same. marital, property __________ __ _ _„ _,•___.__._, ---- --- '` 1 to me I.nown to be the person 5 --._.. who eaecvted the NOtdry PUb11C foregein~ instrument and acknowledge the same. .. THIS INSTRUMENT W45 DR iFTED BV •• ~ •'~~'~••.'-•._^• -'- --- -- Rasmussen & Krupa, Robert H. Rasmussen -"------ " -_ ~ ~ ~ `•~ ~--~ _ ----------------- -----•----------a P.O. Bax 168, Amer ,Wisconsin 54001 -" - -~~ • _... ....- ---y - --. --.. ...- ---- ---•- ^+otarv 'Plblicr;--- - /---•_POl k -.. - .. - Coun , Wis. (Si,~tiatiire.~ may be att`.~enticated or ackn~~uled~~d. Both }t} Crflr;mi=sion is permanent. (lf not, state exp ration arc not necesssn-.) ` ~' • date: -'~~~3- •---------- ------- -----•----•------~ ls9a_-..) '? ~ ~~ •Ss^:c; cC p r -. ..c b.•~,ink ,n any ~sre;~i•c should be b.+rd o7 i`rinted helm.- their signa'.'rccs. L.\\:) Chi QTR+.fT - (nd(•-idua' ~nd 'brDnrnte -Slate R~r of Wi+~ onsln, From Vo. I l - 198: STC-100 •This application form is to be comp],eted in full and si ned ~he owner(s) oP the pxopertY being: developed. .An lnadeg by will only rESUl~ ~n delays o£ the p~rm~.t lgsuance Y, quac~,es development be intended for resale by owner/contr chtoold this house), then~a second form shottld•be retained and completedCwhen the property' is sb]:d and submitted to this office with the appzopriate deed recording. -------- Owner of property Location of property~~,F 1/4 ~/.~j•/4~ Section ~~, ~T 3/ N_R /1 ~ ~W Township (~ Mailing address ~~ •~ o~j~~~ ~~,~~• - , ~ •~~p~~ Address of site a y ~' ~ ,~„~'"~/ ~ u ~/ i\ i~ r subdivision name -- Lot no. other homes on property? _ yes ~ No Previous owner of property • Total size of parcel • Date pax•cel •was created 'Are all corners and lot lines identifiable? -_._•Yes No Is this property being developed for (spec house)?__„.,yeS No ~~5~ volume__and pageumber ~ 0 6 as recorded with the Register of Deeds. INCLUDE WITI{ THIS APPLICATION THE FOLLOWING: - `-- A WARRJ~NTY DEAD which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMF3ER & TIIE SEAL OF THE REGISTER OF DEEDS. certified serve ,Tn addition, a ' y, 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 tha property described in this information form tbhe owner(s) of warranty deed recorded in the office of the County Register~~of Deeds as Document No. own the proposed site for the sewage disposalt system, rr I e(wej obtained an easement, to run the above described the construction of said system, and the~same halo been duly recorded, in the office of County Register of deeds as Document No. Signature of applicant ' • Co-applicant Date of Signature ~ Date of Signature•