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HomeMy WebLinkAbout002-1053-50-000 o ~ I o N d a O C c I' r ~ cc E a ~ .0. C U f6 N O N N O Of E L O ~ W C = p U ~U'3pW I ° f0 NZ Vim' O E C! O O v~ N m T'- N c E h `.C J O N N F" C C w cn m co C N N O In z Q 7 O (n Y O O ca E LL CO O H N z O)'pI. a N o c ~ N 'O p y N N 0 =O E Q Z 7.L-. = U O M N E ! O is = O Q v I! Z d m N 04 z a co c 75 O z v 0 Z c as w (n F- a) z E -a ~~ww 2 Cl) Y N J ca Q~ - •►v m o r- o S'. Q z z z ~l •o Z c a~ c I. O C N c E c 0 CIO) ) .L. c c co N d i O N O O N I~i N O C (L L a) N _ N Z ° E O O O o C> CL IL IL J V N O O N z r d m } O co C) N N N ~ O O c) c) ~ ~ N O O N ~ O Q ~ f0 ~ Fi1~ _ 7 M N H Co 0 rn Q O Q C C O OC) 13 C C u n- W O N 30 N d N M M to 2 a 70 O N Lo r_ O C Q° C gCj 7 N CV -0 C O 3 m~ Z C N CO O fK ~ N N C co R8 'C L`e y co co Q ~ E m _ L: a a m CL • d m £ L 'E c S r A U a O m 00 STC - 104 AS BUILT SANITARY SYSTEM REPORT G CFj() OWNER fE ADDRESS ~3 3 7rT~ SUBDIVISION / CSMf LOT SECTION __a, _T-~Y_N-R W, Town of- ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM tCp•co ~f G d ~ 1F\O~ ~lK~ VCQ h..~ ~r INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: /t~a o6 ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: l~-kIli°G iquid Capacity: QOC ~ r Setback from: Well 2 House 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 i PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Sd Final grade i DATE OF INSTALLATION: CSO J PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: (Q~ 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit H lder's NNaa DEAN ❑ City [_1 Village ❑ Town of: State MOW BALDWIN X 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 /0L fvo. Dosi ng Aeration Bldg. Sewer [Holding 5-;11} St/Ht Inlet 0 9q, TANK SETBACK INFORMATION St/ Ht Outlet Vent irito ntake ROAD Dt Inlet TANKTO P/L WELL BLDG. A Ar Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding >/O' 7 >a 5-' Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand 9 q, D ' Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Model Number: System: 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: BALDWIN'.22.29.16W, NW, SW, 240TH STREET a a 7~ ✓ . 0 317 -7e g n Plan revision required? ❑ Yes [Ef/No Use other side for additional information. ~p QIgs av; ~ SBD-6710 (R 05/91) Date Ins ecto s Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: E u SANITARY PERMIT APPLICATION . =17EQII~nHR d with ILHR 83.05, Wis. Adm. Code COUNTY In accor ST CROIX mmmmme STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than a 3 3 q c ,0 8% x 11 inches in size. ❑ Check if 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. S95-40318 PROPERTY OWNER PROPERTY LOCATION ARDEAN LANGE NW t/4 SW t/4, S 22 T 29 , N, R 16 d ~d W PROPERTY OWNER'S MAILING ADDRESS LOT # J BLOCK # 833 240TH STREET N/A N/A CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER BALDWIN WI 54002 1(715 684-3680 N/A 0 CITY VILLAGE : NEAREST ROAD 11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ Public ❑ 1 or 2 Fam. Dwelling of bedrooms 3 E =N OF: BALDWI 240TH STREET PARCEL TAX N ( ) 111. BUILDING USE: (If building type is public, check all that apply) 002-1053-50 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) 1.0 New 2. © Replacement 3.0 Replacement of 4. ❑ Reconnection of 5.0 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 0 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 REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 450 N/A N/A N//A N/A Feet Feet VII. TANK CAPACITY Site INFORMATION in allons Total of Manufacturer's Prefab. Fiber- Exper. New istin Gallons Tanks Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank 2000 2000 1 MIDWESTERN PRECAS El R 1:1 Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumbs ' Signature: (No Stamps) MP/MPR$,11x11Nt: Business Phone Number: BENNIE HELGESON MPRS 3irG~L / 715/772-3278 Plumber's Address (Street, City, State, Zip Code): W1229 770TH AVENUE SPRING VALLEY WI 54767 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater a e slue Is uing Agent Signature (No Stamps) Approved ❑ Owner Given Initial n Surcharge Fee) 7 g Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: UVV SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 4 1. A-sanitary;.permit is valid for two (2) years. 2. Four sanitary permit may be renewed before the expiration date, and at thta 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 San'tary ''ermit Transfer/Penn lwa Fc 7,?, (c,R,-J 6K-9', to be submitted to the k.ounty prior to installation. 5. Or,site sewage sy itwris must be properly maintained. -"he i ; tank(s) rn >s ..s~ f ~i L y e ic: snL-ed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning-your onsite sewage system, contact your local code, adii!inistiator or the State of Wisconsin, Safety & 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 towelling. III. Building use. If building type is Public, check all 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 rnf{ rmation. Fill in the capacity of every new and/or ew_,i . K.. '=„t t e total ~ a•= r'umber of tanks and manufacturer's name- Indicate prefab or rite construl-t,~;C yank rnalorial. ,o:rr~ ?°e or all septic,:, pump/siphon and hoiding tanks for this system. Check c.,X"r str--" <~I:orovai c, i%l received experi r zv ;tat product approval from DILHR Vlll. Responsibility statement. Installing plumber is to fill in narne l r_.<>rlse -rribt r with a :rp•op,wtre prefix (e.g. lvi', etc address and phone number. Plumber must sign appii(;a"ir<)n jkurm. IX. County; a partment Use Only. X. C;ountv"DePartmen:t Use Only. Cornpiete plans ano specifications riot smaller than 8'/2 k 111 Ir=+:b ,t h ,ubrrritt ,I 1 t"• co,,-nty. The pl )ns !r tj,;! iocklde't;td following: A) plot pian, drawl to scolF? 11 F' i:: jl''r18 a o C-1 of holding tanK(81, cep tir tank's) or tither treatment tanks- hull i f?! water "T_te' service; streams and lakes, }rump or siphon tank-, ;_iistribution boxes; soo ~:~rr syRt'i71 _ i, ~:r(+Ie!_r system areas, and the Ioca,: cjn of the building ser --"t "or ozortal and o ; 'F ,.:±tion rc'4 nisi C) cornpiete specifications fo. pumps and contiV;3. dose volume, cl,flerence:: t:ra Eo>s; pump performance curve; pump model and pump man,ufar,turer; D) cross secti ,Nn 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 surchariles (fees) for a rrurr,,-,<~r c'> regulated practices which can 01fect g, oundwator TF e monies collected through 11h9s(- F... cha gt ;,I. v iTJ ,,t > ftPs ?r U water contamination i e 9.ig,ri<, ,s and estabhs'ri^ ~r SBD-6398 (R.11/88) r r- S95_40 T e . 1.0 I wQQ Xg~A~OwpLy~ cJ OLIO s c° ~ X61 v i S ~p F~ c `t"u„ ~ t Yro oScc~. `r~ CA ~ a.rr,< v.IZ.P . r ono. oo T~ i ~ r nD{';NDCIL: '~tL ~7CiST~tul' S~,P i lC. S~ Sid: Nl As F'-f,, lLi}iL •f p s~ ~ht. I i qq.0 y ` Al, Q I r f . "a -AIO -SWO 11 J1MN SM 1 Z ddV 03A1303W ' HOLDING TANK CROSS-SECTION AND SPECIFIC§TPk 4 0 3 Approved Approved Locking Vent Cap Weather Proof Manhole Cover T Junction Box with Warning Label 4" C.I. 12" Min Vent Pipe Min Final Grade f 18" Min Approved Joint Water Tight N Seal Hi~h~-W6d t-er - - - - - - ' Switch Approved I Joint w/ C.I. Pipe , Extending 3 Onto 1AUMP1,11 V. 110014S Solid Soil per, OF INDUS ~ u p g~y4i °ut ,~!s 0 E C SI'0h1U: i•tvf~ SPECIFICATIONS TANK Manufacturer: c sTPv PPf CalsS Tank Size:- _r~ 00 o Gallons ALARM Manufacturer: S .v -F- f e,f, S c4 s Model Number: t Switch Type: M+7 ,-C a- NUMBER OF BEDROOMS: _3 OWNER'S NAME : 14 r d e o L A p ADDRESS: S ti r W LEG DESCRIPTION : ~4 S 4 , Sec. L, T21 N, R f6W TOWNSHI /MUNICIPALITY : 13a (j •0 , CO Y: St. APO I SIGNED : ~y~~------- LICENSE NUMBER: .S DATE : - 7 S 5 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of LFMr and Human Relations Divion of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY S "r CRO irk Attach complete site plan on paper not less than 8 1/ 1 ~ ~i a must include, but not limited to vertical and horizontal reference point ection and coo ' I scale or PARCEL I.D. # dimensioned, north arrow, and location and dista earest r Ocw Z -le S - G REVIEWED BY DATE APPLICANT INFORMATION-PLEASE PR LL pR Nr PROPERTY OWNER: :5I ry PR PE; LOCATION dE'a Q vt G~ tr y GO`~T. L T )j W 1/4 S,t)1/4,S?Q T 'Dq N,R t(6 E ( W PROPERTY WNER':S MAILING ADDRESS ® BLOCK# SUBD. NAME~OR CSM # rk A') NEAREST ROAD CITY, TATE e ZIP CODE PHO QCITY VILLAGE 00WN 1A Ljo, , .0 Q 7K S' a 17/S~ a New Construction Use [ 4-11-esidential / Number of bedrooms [ ] Addition to existing building [1pKe'placement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate X)k bed, gpd/0_NeLtrench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate /,)A ed, gpd/ft2_&4 _trench, gpd/ft2 Recommended infiltration surface elevation(s) All ft (as referred to site plan benchmark) Additional design / site considerations n V Parent material S; 0 ver I Flood plain elev tion, if applicable f~ ft S = Suitable for system CONVENTIO_N_Aj.- MOUND IN ❑ -GS UND P URE A ❑ T- S DE SYSTEM ❑ IN CD.FIy HOL ❑T UK U = Unsuitable for s stem ❑ S 211 ❑ t 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 Tmrich eat. - Lo Iv Ground c l 5 L 14141 elev. ft. Depth to limiting factor D" Remarks: Boring # 4- t t _ 6 -4 fo -7 x- ~sb t Ld L) Ground elev. ' ft. Depth to limiting factor,, t Remarks: CST Name:-Please Print Phone: v~ 2 e Address: A/ C' SO S-(Y 76 Signature: Date: CST Number: 0 3i Yy 3aq PROPERTY OWNER ~~CY La us SOIL DESCRIPTION REPORT Page 3 of-/ , PARCEL I.D. # Z90-A Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 'CDA U a - O\, 1 3 ? .5 (l 5 i n1 5 Y1l r l.+J ( - v) 10 .~y ` t t 5 b k u - Ground q- YK elev., ft. Depth to limiting factor O Remarks: Boring # s' Lk M .vo.~CA - 4-L3iP y f 5 u a3 - O Ilk- Ground elev. ft. Depth to limiting factor Remarks: Boring # 3 ` t E i*K ,,►1 1~►1 to Ground elev. ft. Depth to limiting fact, ~.6.tP Remarks: Boring # C I CA i 0~ co <s 2~ SJ 5~k as - ti~':_<'ti1 2 - ~ ~p -F ~ d. ~ ~ lr►~.~ v- C uJ ~ ~ - Ground elev. - ft. Depth to limiting factor,, Remarks: SBD-8330(8.05/92) 44 L~.Z /0~3 -SU SOIL DESCRIPTION REPORT pa5c Qfy Boring # Horizo Depth Dominant Color; Mottles Structure G F' l)llt in. Munsell Texture Consistence Bour-d-fy Roots ;n Chu. Sz. Cont. Color Gr. Sz. Sh. Bed Tn, C~ o s k v►~ S a~ F- o b V l~ Ground elev. Depth to limiting tact,, E51r jk6.~1 Remark's: Boring # c I u IZ -37.3 19-~a L'-14 ry ~ a w. a cl O \4P 14 1, -7. q F<: < 3 S s: sc 1 c s - - Ground L6--3& elev. - h. Depth to limiting factor ~c l s~ K•Citc' Remarks: Boring # r. Ground elev. ft. Depth to limiting factor' Remarks: Boring # Ground elev. ft. Depth to _ limiting 1 factor Remarks: , Qo~ a fy rl"ce .r Q ~'oe t L r e I , -73 4 4 G I' F -IJ L+° 1 i I y ~OIcL S~~ 0 EKlst~~4 I lr' Sep{<< `ra"y: t ti far. a,Y1,t Ll_~.P. c~o.oa a T~ ~I I 4T' ci t h 4 ~ \ 1~o~10w~ Ob ~tlC1uLe `~t1,~ I Qrc« ~ 'I r OIL I i 11 ~r T 44L" 1 _ ~xce~ As y 1 c'N I 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. ,M,------------------ Owner of property ARDEAN LANGE Location of property NW 1/4 SW 1/4, Section 22_ •;T 29 N-R 16 W Township -BALDWIN - Mailing address 833 240TH STREET BALDWIN, WI 54002 Address of site SAME Subdivision name Nin Lot no. N/A Other homes on property? Yes No Previous owner of property L ,c d R,4 /SS Total size of property c2 Q A CR Total size of parcel *V / Date parcel was created / 7 7 Are all corners and lot lines identifiable? XYes, No Is this property being developed for (spec house)? Yes No Volume, a Page Number;p 36 as recorded with the Register of Deeds. and Sao 613 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, tae Certified Survey map shall -..1so be requir_ed. 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 off~ice f the County Register of Deeds as Document No. 3 02 1~ J0 0 Cie).o 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. Si nature o vic Co-Applicant Date of Siqnature Date of Ri"nat„rsn HOLDING TANK SERVICING CONTRACT MAY 3, 1995 1 1114 Itillill tent 14 ntiulu bulwuwn Iltu I folding Tank Owner(a) Name(s) and I Pumper's Name I ARDEAN LANGE I HELGESON EXCAVATION INC We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:) 833 240TH STREET, BALDWIN WI NW4i SW4f S 22, T 29 N, R 16 W TOWNSHIP OF BALDWIN, ST CROIX COUNTY _ 1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "munlclpaality", which I signed the pumping agreement required in Ch. ILHn 63.18 (4) (b), Wis. Adm. Code and with the County of ST CROIX 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access an. enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather acc road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to tho pumper for all chargos Incurred In servicing tho 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), V Adm Gndp, and in the rminty, n report for Iho sarviliing of Me holding tank(§) on n seminnniml basis. Tho p impor further Aon 141 Ituilrnla flits IUll11wittu III III" boll ►Inloll loll tnlrurL a. The name and address of the person responsible for servicing the holding tank; b. The name of tho owner of the holding tank; c. The location of the property on which the holding lank Is Installed; d. Tho sanitary pormit number isguod for the holding tank; o. Tho datos 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 altos to which tho contents from the holding tank were dolivorod. I 4. This agroomont will remain In oflocl until tho owner or pumper terminates this contract. In the event of a change in this contr. the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipa atril III" ('(turlty namail ahnvo within tan (10) husinass day4 from Iho dal@ of ohango to thin oorvioo contract, owner(s) Name(s) (print) Owner's 8Wr Olra)s) a on This date: - - _ Subscribe n swref I I _ •gR Y ( y. .tie's Pumper's Name (Print) I Pumper's Signature Notary Pt ,1►~ i fie 1 e Sv a, . My commission exp' es: ) r flr✓) ~`itrn c~ a •-r~c_> 4?.9 r umrror'a neggiir,lrollon Numbor SIln.7!04 (N, 11/05) This kwirumont was drnflod by lho Stale of Wisconsin Department of lodimlry, I,nhur nail I lummn nulnllona, ntironu of I"Itimbinp. Wisconsirti Department~of Industry, HOLDING TANK AGREEMENT Safety and Buildings Division Labor and Human Relations Q Bureau of Buildings and Water Systems Document No./ Plan Identification No. VOL III 9PAS 20 This space reserved for recording data This agreement is made between the 117- governmental unit and holding tank S owner(s) OFF-ICE i ..greement Datel 1 j / 6' Sl: CROIX C3.4 W1 Rac'd fix R~nr~i County or Local Governmental Unit Holding Tank Owner(s) MAY 11995 BALDWIN' TOWNSHIP ARDEAN LANGE (called Municipality below 10'30 A. We acknowledge that application is being made for the installation of (a) holding H~• tank(s) on the following property: (Provide legal land description) 833 240TH STREET, BALDWIN, WI Register of Deeds NWZ1, > S- 22, T 99, N-R 16 W Township of Baldwin St. Croix Count R tyrq To b40~ f:.ctIlAh 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. As an inducement to the County of ST CROIX 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 have 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 placing 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 installation complying with State regulations and manufacturers specifications. The owner agrees to be financially responsible for the purchase, installation, r 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. 3. 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. 146.20 (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 the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreeiiment to be determined by reference to the property where the holding tank is installed. Owner(s) Name(s) -Print Notrized ner( ignature(s) " ,49DZ,2,,v(1 11P. / Subscribed and sworn:to b~!~~,~~( rSlate3,' f O tar ublic ,rnicipal Official Name - Print Muni ipal Off cal igna .u ' ,~1 H'/ a N e y~'f my commission expires: Municipal Officia Title - Print I~ !lW'ry The information you provide may be used by other government agency programs (Privacy Law, s. 15.04 (1)(m)1 SBD-6123 (R. 04/94) State of Wisconsin County of St. Croix I hereby cerd* that this hNOW. nt b a full; true and corl4d CW of the dOculnent on file and of record in Wq afliae and has been compared by me, ~ AttestMayl 1995 Kathleen H. Walsh Kathleen Walsh register of Deeds CLAIM DEED . THIS !PACK RgBgMV[O FOR RLGORDINO DATA 11 ~ uocuMervT No. STATE BAR O OF F WISCONSIN FORM 3 -ilea D 11 !I VOL 6fi~ rA~E bJ~ NEGIWERS OFFICE t Sandx__.Scott,_.f/:./`a Sandy Lange, wife cif........ ST. CR01X CO., WoS. i At•de_an R ....Lange Roc'd. f•.)r Record this 2nd 1 day of Aug. A. D. 198_3 gait claims to Ardean .R..... Lane . . at 8: 30 - _ 1 . lg4lgg of Dead I~ the following described real estate in ...St.r_..C.fQ.ix County State of ':.cunsin: RaTURr TO Tax Parcel No: West Half of Northwest Quarter of Southwest Quarter (WI NW4 SW4) of Section Twenty-two (22), Township Twenty-nine North (T29N), Range Sixteen West (R16W). I iI I This deed is given to replace a previous deed given pursuant to Judgment of Divorce. FEE This is..n.ot------- homestead property. NA)K (is not) Dated this day of Ju ly 19 83 (SEAL) - (SEAL) • .-.Sandy ' Scot , f %k/a Sandy Lange .(SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St . C ro i x ` --------County. 29th authenticated this -..----.day of 19...-.. Personally came before me this day of U 1 y 19. 3. the above named ..Sandy--S.....?...r•.:...E, k/.a.-S_andy...L TITLE: MEMBER STATE BAR OF WISCONSIN (If not....... - R eok t known to be the person who executed the authorized by § 706.06, Wis. Stats.) r Thily INSTRUMENT WAS DRAFTED BY - va NOrq r Thomas A. McCormaclc f~)- _4 Attorney at, Law-- y.t pv 1.inda L. K a n i 990 Hi llcrest Street SLIC r tare Public . ~k. C1,oI K County, Wis. E3aldw11ir W1, S 00 2 etc Con;mi<sion is erman~nt.t if not. Mate expiration (Si nature, may be ~ut;,enticatec( or acknubJeQ~at1'•flntfl p are not necessary.) 1y 1 t' 1 ' date: \111 U~t .1 106- •NAmeR or persons signing in ■ny capacity should h, typed : r 1~r!nUd htduw their +:Rrnt.rv w. IlGMdlryr Con+parrym sr rt: n vt of w 1:rt1N;1. Stock No. 13003 t~ PUNK Vo. t I'e.+: