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002-1068-95-000
STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER_10%^,~ za~- ADDRESS_.2 _ w y SUBDIVISION / CSMJ LOT SECTION _T ~y N_R W, Town o-IJ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM f INDICATE NORTH Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic Lank manhole rovei_ c BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: d so do Setback from: Well House r Other Pump: Manufacturer E9A,ra Model 4(F~5 P3-3 Size ? mP Float seperation y Gallons/cycle: /E6 • 7j Alarm Location < SOIL ABSORPTION SYSTEM Width: Length 7 S Number of trenches Distance & Direction to nearest prop. line: Wcs Setback from: well:- /`•~2 House ~-2C:>-5 / 2C:> 5/ Other ELEVATIONS Building Sewer 9 4•$a ST Inlet. Ob ST outlet PC inlet PC bottom 3 Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: - lj PLUMBER ON JOB: r~ tp L LICENSE NUMBER: 1~..~SS I NSPECTOR: ~ i~o ry ts~ a:1 ~p~ V 7 3/93: )t f n,--~)1/ 1 'e L \ V Vy", t' C~CI 1.L F-~ `.S__..------- h.. 9 I ayr ~~l s^.~ ,a. ~ C C? S E? ~ 9 t~ ~D L, ~ 3 s k i I RECEIVED i JUN - 61995 Nlk ~ Pow Tea tt$4 d~ S~ P. 'voo& a Otto 0 Nouc e 5 ~ S ~{o~~c v C Q ~ v ~f 0 v s hcck i Cou tOLII lei. y BS ~ 97..5 c p3b Moue ~ 5 o m- 5[0 - nru ~ C? 1 i WiscoinsiA De~artmintof Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX ► Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION P Ider' e- ❑ City ❑ village CJ Town of: State PI anID o.: '1~~' & JOAN RaIrlwin CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: y. '~73 TANK INFORMATION ELEVATION DATA r F 1 d TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic d/ Benchmark io , Dosing l j (o SCE 'jf Aeration Bldg. Sewer Holding St / Ht Inlet g, q5 TANK SETBACK INFORMATION St/ Ht Outlet of-; dj nt to TANK TO P/ L WELL BLDG. Ae Intake ROAD Dt Inlet Septic >as ~5 S / ('6 NA Dt Bottom Dosing ~'4 >y<~' NA ddgaer/Man. Aeration NA Dist. Pipe Holding Bot. System " Q~ dCJ~ PUMP / INFORMATION Final Grade Manufacturer ~✓c~/Y Demand Model Number,, ? GPM ~I ~t5°74n k.,,P =-3/ y3•(°S~ TDH Lift Friction ~j Hetem ~ TDH IFt I bA Loss -v ad Forcemain Length Dia. / Dist. To well r SOIL ABSORPTION SYSTEM BED/TRENCH Width Length I No. Of Trenches PIT No. Of Pits Inside Dia. Liqui DIMENSION +r DIME LEA Manufactu . SETBACK SYSTEM TO P / L BLDG' I WELL LAKE / STREAM INFORMATION Type O ~S' rse; CHAMBER del Number: 26 +Na`/J OR UNIT System: ck f0 *DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake 1114 Length Dia_ Length`s Dia. Spacing t``~~ 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 El Yes 11 No Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) I LOCATION: Baldwin.33.29. 16, NE, NE, Highway 12 13 41,) 5 4q9 7 ~e Plan revision required? ❑ Yes No 'I I-S/ Use other side for additional information. g of, vS -l) U~-- i' SBD-6710 (R 05/91) Date I 'sp 'ctor's Signature Cert. No. SANITARY PERMIT APPLICATION Bureasafetyu o oand ff Building S ng Water y • • stems 201 E. Washington Ave. • In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. ST CROIX • See reverse side for instructions for completing this application State Sanitary Permtiitt Number The information you provide may be used b other government agency a Y Y Y programs Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION S95-40568 Property Owner Name Property Location TOM r t JOAN LUND NE 1 /4 NE 1/4, S 33 T29 - N, R 16 V W W Property Owner's Mailing Address Lot Number Block Number P 0 BOX 217 N/A N A City, State WOODVILLE WI Zip lode Phone Number Subdivision Name or CSM Number 54028 (715)684-4057 N/A II. TYPE F BUILDING: (check one) ❑ State Owned ❑ qtr Nearest Road E] Public 1 or 2 Family Dwelling - No. of bedrooms Ea Townn of BALDWIN HWY 12 III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) c / 1F1 Apartment/ Condo Q v a 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/ Mote[ 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 ❑ New 2. ®'Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System SystemTank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ® Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade 450 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation 900 900 .5 N/A 99.8 Feet 102.07 Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic AppNew Existin strutted Tanks Tanks Septic Tank or Holding Tank 1000 1000 1 MIDWESTERN PRECA T ❑X ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber A ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumb 's Signature: (No amps) MP/MPRSW No.. Business Phone Number: BENNIE HELGESON MPRS 3215 715/772-3278 Plumber's Address (Street, City, State, Zip Code): W1229 770TH AVENUE, SPRING VALLEY, WI 54767 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved S4nitari, Permit Fee (Includes Groundwater Date Issue Issuing Agent Signature (No Stamps) LO/, Surcharge Fee) • Approved ❑ Owner Given initial 010 ~j Adverse Determination CK,(j V ~"~7~9✓ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SHE)-€398 (H. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS t ~ r 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Co-nplete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks receives experimental prodact approval from DILHR VIII. Responsibility statement. Installing plumber is to fill in name, license number wit ti approp-late prefi;c (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County / Department Use Only. X. County r Department Use Only. zl~e and ,pe i{ications not smaller than 8 1/2 x 11 inches mc. t kr s.. it,ed 1c: `,e ,nty The plans must c o W,.' 42,) pot F% an, l+.n i_o scale cr with coinp!eie ~~lnt:: Se(Jt~C ~i i~ b'. fil` ~,er5, well. w<:'.;,. u!ll p c) r p 1) on ,or .OnjJsL`;-ns r2j=~tc_r E.I SVS_.. -~u .E lrnlatlo!- ' - - GROUNDWATER SURCHARGE 198 W sconsl . V jr), iuded the Creal.on, of surchargE'S (fees) for a nur,,A)el <Ji at~d f C > Wrtl::f can effect ground'~vaier ilE' rCif?ri-c- c -(--t.'_ d r,*)':hC'SL' "~.<<rchafgeS ar ° Used for mC`i,'.tt0!"~ c;1--,;n,!,/-,1!P1 . ;O`1' !tT"`~ inVP_rtlCJations tandjrds and establishr ent 0', r 4-Inc, Q/ /-2 t i i i ~ vl RECEIVED I i JUN - 6 IM nom.k s~ , 5~; , i SLOGS. r~ C~rtiloo Sep( Pu ~PTahk~ s i. 5c~se Sew 1 5 Tam IP. r Novse 5~.~ .3 v c q ~ -r 0 y Q a. 5 ' 4r ry j J i I C©v~fo«r E Ie~. g5 97.9 p A13b n 5 0 5(o a- > 1 1 ~ ~ p !y ~ 1 i 11A T_C-~kCj G1 1-12inak S 95 - 405 6 Page Of Cross Section Of A Mound Using A Trench For The Absorption Area • ~'l~v, /D~ . 07 H -Hed4tw Sand Fill 3 E ' D Trench Of )j" - 2~" Aggregate, E Ito. 1 7- K P1 owed Layer 6" Below Pipe. Covered.With D e)Ft. Straw, Marsh. Hay Or Synthetic Fabric E / 'Ft. r, h Ft. 1 F . 7 Ft. H Ft. R µt; 0f Mgppd Jsing A Trench For The Absorption Area Force Main Distribution Pipe Permanentv'Markers Observation Pipe W ' o - A B - K \Trench Of -11" - 2 Aggregate I . L r A S -t. Ft. K Ft. W Ft. B 75 Ft. J Io, Ft. L U),qa Ft. License Signed: - lumber: Date: _ - -~5 ~w her' T©a,~ s-cY~c„_t-V~e~, = - . r P~ ~oRA'Tt'b Pt P~ Z. r o.~ ~ F'EZt:PSr,Lh7 S i ~ ~^~G~S~ ~ - ~ ~JSTA L L P~ H H 1J E)..1- M; P~~',1-,~'~ AT CUD OF ~,l1 CH LhT~'RAI. Q 14OLES LOC-A~) OQ ~J ~H ~ + _.PLPE P4ub Ajftt tMo iU,'j SPAC:,~Z . t •v ~ pVC / -~~oRCE A ~ 1.1 FOOT Tau h P "PV C- ' LAT'Rl~ LS V?LACE LNST ltOt~ 1JEXT ~b EuJ CJ~P ~J\S'SRl$UT70U: P1AE LN+`.-r~UT_-_. J P FT. . YT 11J . Op 1iULES/j~l PE }1JV, EI-V. pF LATGl1~_S 'FT. pLt~CE ! sT IfU FRokl TEE w17}) Sv c~E'`"'D11v G tt~1~ES ~T: ,>,6 l JJT~U+~t~ . 1._AcST Hb LE ZO R E 1UEX 1' To Tl-1 E 6~J D C1i- P- _ . SEPTIC TANK 6 PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 95-4 4" CI VENT PIPE 12" MIN. ABOVE GRADE 6 WEATHERPROOF 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE COVE W/ PADLOCK G FINISHED GRADE 4 CI RISER rWARNING LASE -4" MIN. 18" IN. 6" MAX. INLET 10AX WATER TIGHT SEALS GAS- 64 TIGHT PPROVED JOINTS APPROVED .a.;;~ SEAL i i APPROVEDIPIPE PIPE'' r B ' O' ONTO ONTO SOLID ( F• ' OLID SOIL SOIL PUMP OFF ELF-V . . FT. ORISER EX: fF r RMI TTED ON TANK ANUFACTURER HAS APPROVAL E A,BEDDING UNDER TANK ,.n lJ "CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE r TANK MANUFACTURER: tdcL.icy*tct, e(as"1 NUMBER DOSES PER DAY: y TANK SIZES: SEPTIC /OOD GAL. DOSE VOLUME INCLUDING 1 (0 7-1 DOSE GAL. *4,f.qj,---FLOWBACK: GAL. ALARM MANUFACTURER: CAPACITIES: A = S"yINCHES = Sao GAT MODEL NUMBER: ~ L HLj SWITCH TYPE: Mew B = 2 INCHES = GA' la PUMP MANUFACTURER : C = 9 NCNE _ MODEL NUMBER : OS 3 SWITCH TYPE: 1*4tuu D INCHES REQUIRED DISCHARGE RATE GPM PUMP & ALARM WIRING AS PER ILHR 16.23 W14 VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE 10.,9 FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . . . . . 2.5 FEET +FEET FORCEMAIN X FT/100 FT. FRICTION FACTOR FEET T.OTAL DYNAMIC HEAD = • FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTHS ; WIDTH 7qDIAMETER ?,I LIQUID U~T=3, SIGNED: ►,y..w _ ~-,'-'LICENSE NUMBER: &Z r-DATE: w-rj`r5 1/88 . '"YDR-O-MRTIC ' err' ~a ~a v, SECTION 100 PUMPS ENSIONAL DRAWINGS A r - & PERFORMANCE DATA MODEL: OSP33 SUBMERSIBLE SUMP PUMP -MAX. SOLIDS SPHERE -1750 RPM TOTAL 141111111- Lit. No. 113.5 348 HEAD 3/,o HP MOTOR IN FT. 24 22 y 20 C,9A 18 1s 14 12 10 8 6 FULL LOAD 4 AMPS AT 115 V. 6.5 2 0 10 20 30 40 50 60 U.S. GALLONS PER MINUTE S95-40568 MODEL: OSP33 319 4 7 4% 0 0 -7 Q 5'/a 9 4 V=i 11 J7 11/4 STD. 25/16 PIPE THD. F+--- 43/a NOTE: CASTING DIM. MAY VARY t 1/a L ' G OOUN~ E~ A Adm• v D gIIE s. g~~~ AN Ord with -VAR 8 ' D!' aut ARCE1.~ a - f g DAZE us' in acc pl or' gV 'toil EVIEWED ~tt~selagons i e, sea eri & guddin9s ass than 8112)(A td reCeo t, Of on P apex na ofi s R W not 1 ~1ot st to N O C2\ T N, lan reierence to nave ' late gate P ontal d%stan M GA~I .I 114S Attach comp vedlcal and h a d lOCat►on agE p~1. tNF R OPE 1 I N ME OR cSM f arrow, tN SUBD.NA N~E'ARESIROA~~ notlJmktedto NO w d%menswneNv INFORMATION_Pla. Appt.1CA Oc1Ty wl~lAa `L OWNER: eX~stin9 burldrn9 Tv DDRE A ASS pNONE NUMBER 05-7 ` Addr~~on ° dlft 2 PROPER G~~`"` R S to TY OWNE 7-\? CODE l'? ISl trench, 9PER 3 drooms to bed, 9Pdif~ft trench, 9Pdlf<2 PRO? r of be c1T`I, TAT` u9 se es►denba~m~ rd~~ describe m design loading ra to m kl . ~~~R Public or ReCOm ended i ^ 1oad\ g to s%te P r ft oonstrucbOn 2X~mum des g l~ referred L 1 N eplacementgPd 2 trench, o elevatwn ifaPPlrcable STEM H0IDINGIJ s~ W F S filoW bed, v _ Flood 06M Code derived da~1y etea required ~elevatwnlsl F. AT.Gm O S surface suRE S G? C Recommended inf►ltratwn 1N GR°UN~ P design ~ site considerations Q S Roots gad v e REp~RT Additional Mou DU S aterial vENT~oN DESCRtpT10N re Cons►stence to Parentm c4 S Structu e e < le for systeS em so t~ t eXture Gr S% = ~u~ table fors gotdes s C010r gz•Cont Go1or a, . Depth o°mM~ sell Qu ~ a w. S ~ v Horizon in 9 BOOg f- Ground elegy ft DeP~h 10 fitri~trng ~ ~ ~ , . factor , ~ 5 l ~ 1 Remarks • O 3 t 9 Q~ ~ t ~ 5 5 goring # Ground elev • ft. Phone: ~ / s Depth to s 1 Gni IN t„r < v\ Remarks: e.~Please Print CST Narn ~ ddtess. _ , 1 y ~ S,9nature•. ~ gorin9# DESCRIPTI Horizon Depth Dominant SOIL. ON R EPp in, Col RT Munsell or Mottles 3 Qu. Sz. Page `/3 ant Color Texture Str Ground d ucturh r of elev. 3- S Gr. Sz• S Consn~ ft Roots GP p/ft- Depth to ged Trees limiting c v facto - Kc I X61 ~I. lr 6 Boring # Remarks. 'round ev. _ tl ,3j ~ 7, s~~ ~ ht ~F th to s a ~s a w 1 u P ng cs~ # Remarks: X- 3 S V t larks: s f~ 9 X07 v ~k yR Y 4Lo/ S,bl~ ~►v _ -G SOIL DESCRIPTION REPORT Boring # Norizo Depth Dominant Color Mottles Structure in. Munsell Texture Consistence Bouxty Roots GF Uili Du. Sz. Cont. Color Gr. Sz. Sh• E3ed III, , FY" 5. a;>h•,x;rr _ 17 0 K e, l u S-_ Ground 3 S f 3 A L elev. 7 / O y „S s- 5 c l ia`t r t o _ .473e 2 sc bk r .3 Depth to limiting factor sf f~ G, U) Remarks: Boring # Ground elev. h. Depth to limiting factor Remarks: Boring # Ground elev. fl. Depth to limiting factor' Remarks: Boring # t:;%~.xxrw:3 Ground elev. g. Depth to limiting - factor t Remarks: • i D OL V\. Y o ~ i ~a~1,\ i, r f I I U~0.~~ ~~~~~1 4 ay by 93 OIR J) /on ~VL,lr9ir5 Seu~t~r ~~ev", i i oI i da ------i l1 Shy )LLsN~o Qi S a _ S~++Abit r~6 9~.~ Mouvct J 7 9u ` - - a I si , Slp~ S~.~P y ~ ~ i 11, z qo 1, - - - - • Q1 - _ - ~kc~ pf ~s Shower STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER TOM & JOAN LUND M[AII.ING ADDRESS 2365 HWY 12, BALDWIN WI 54002 PROPERTY ADDRESS 2365 HWY 12, (location of septic system) Please obtain from the Planning Dept. CITY/STATE BALDWIN WI 54002 PROPERTY LOCATION NW 1/4, NE 1/4, Section 33 T 29 N-R 16 W TOWN OF BALDWIN ST. CROIX COUNTY, WI SUBDIVISION N/A LOT NUMBER N/A CERTIFIED SURVEY MAP N/A , 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 expiration dater SIGNED:C DATE: 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 TOM & JOAN LUND Location of property NW 1/4 NE 1/4, Section 33 , T 29 N-R 16 W Township BALDWIN Mailing address 2365 HWY 12 BALDWIN, WI 54002 Address of site SAME Subdivision name N/A Lot no. N/A Other homes on property? Yes -""No Previous owner of property ~n ~I 4' 0 P~ a~ Total size of property 2) (~~l p Total size of parcel P-0 C 2~ Date parcel was created ( M.3 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No Volume IM 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. _ SD-00 14 , 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. 521X~r ~l .M 1A, Signature of Applicant Co Applicant 2,r-9'.r' 6-25--85 Date of Signature Date of Sianat ura DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2 -1982 ,520014 von 1090Pa X30 REGISTERS OFFICE Phillip Bauer and Eileen L. Bauer, husband and ST.CROIXCO.,W1 ~ wife - RBC'dfnrRecOrd - l - - - - - --------------I—— - - AUG 9 1994 Thomas--Lund - RL 8:30 ? _ - nAn M conveys and warrants to - - I . I - ReglStBrOfDeeds I - - ~...n.~,..,+...~.... w~.~t 1! - - - RETURN TO I l . the following described real estate in t.....CrO1X County, - - state of Wisconsin: II Tax Parcel No: III i I I The East One-Half (E2) of the Northwest Quarter (NW4) of the .Northeast Quarter (NE4), Section Thirty-Three (1,33), Township Twenty North (T29N), Range Sixteen West (R16W). II This deed is given in fulfillment of that certain Land Contract between the above parties dated May 3, 1985, and recorded in the Office of the Register of Deeds for St. Croix County, Wisconsin, on May 7, 1985, in Volume 711 of Records, at Page 536, as Document No. 401797. fZ II 1-- not homestead I Phis - - property. I )(M) (is not) I I Exception to warranties: Easements and restrictions of record, and except Many; liens or encumbrances created or suffered to be created by the acts,jand default of the grantee, his heirs, successors, or assigns - day of 19._. Dated this ------.~5~" 94 ------------•---------(SEAL) - ..---.(SEAL) Phil ip Bauer - - .-_(SEAL) -----(SEAL) Eileen L. Bauer AUTHENTICATION ACKNOWLEDGMENT Signature (s) STATE OF WISCONSIN ss. -------St.•---Croix---------County. _ Perso a y came b fore me this day of authenticated this .-day of___________________________ 19..... 19.94._ the above named .....h i.l l-i . B.. r anal P• - - - Eileen L. Bauer I TITLE: MEMBER STATE BAR OF WISCONSIN - (If not- authorized by § 706.06, Wis. Stats.) to me k own to be the p who .ei'.O a1~d the forme ' g instrument a1u1 ack dg Vels&ne. % CCII r THIS INSTRUMENT WAS DRAFTED BY Thomas A. McCormack j` - - Baldwin, WI 54002 .1. 1 - - Notary Public St----- - ro x.>~ `•-.~;rCott tk,`~is. (Signatures may be authenticated or acknowledged. Both My Commission ~•ss permanent. (tf., rlot,•_s5ta e-VV i tion are not necessary.) 19 date I ~j ,Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. FORM No. 2- 1982 Milwaukee, Wisconsin L "{`~y-~ - SANITARY PERMIT APPLICATION COUNTY DIL~A In accord with ILHR 83.05, Wis. Adm. Code St- C r STATE SANITARY PERMIT # 2 -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. 86=044-374/-5 -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE RYES ❑ NO PROPERTY OWNER PROPERTY LOCATION I 4 c) E%615 %,S Z- TZ.?,N,R /Co ffp~Dr)W PR PERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME t 4- 1 - /VA ,vA A CITY, STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMARK ILLAGE : 5A L ~ Lt11Al t/ W Z W l i e 7~S ~09 V TOWN OF: II. TYPE OF BUILDING OR USE SERVED: - ®01 - !~(p CI Number of Bedrooms if 1 or 2 Family OR Public (Specify): r 0.C III. PURPOSE OF APPLICATION: (Check only one in ##1. Check 2,3 or 4, if applicable) 1. a. ❑ New b.:4 Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in ##1 and only one in ##2) 1. a. ❑ Conventional b. C9 Alternative C. ❑ Experimental 2. a. ❑ System- b. ❑ Holding C. ❑ Pit Privy d. ❑ Vault Privy e. ® Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. 0 Seepage Bed b. ❑ seepage Trench c. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION'AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square quare Feet): PROPOSED (Sure Feet): / CIJ d Feet ❑ Private JEJoint ❑ Public VI. TANK CAPACITY Site in gallons Total of Prefab. Fiber- Exper. INFORMATION Manufacturer's Name Con- Steel Plastic New xistin Gallons Tanks p y~IsQ~ Concrete structed glass App. Tanks Tanks Septic Tank or Holding Tank t7 ( a Lift Pump Tank/Si hon Chamber ❑ , =1 1 01 / -,7 1 Rr H;ETT VII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamp MP/MPRSW No.: Business Phone Number: by le. Hel e.5oN ~ 3,Q 1 L 7/5 778--j71zrLa5 Plumber's Address (Street 2y, State, Zip Code): Name of Designer: 1~- b + r, a 1 'le, VIII. SOIL TEST INFORMATION Certified So' Tester (CST) Name CST CST's DRES (Stre t, city, State, Code) Phone Number: Al C /J,~7 7 IX. COUNTY/DEPARTMENT SE ONL ❑ Disapproved Sanitary Permit Fee Groundwater Date Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee Adverse Determination v 19-11- 94~ X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber orm-STC-104 AS BUILT SANITARY SYSTEM E~P RT d OWNER fl TOWNSHIP SE TN-R _W 16 ADDRASS p~ ST. CROIX COUNTY, WISCONSIN to ~ CQ L2 i) ) -e- SUBDIVISION LOT /V14 LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I1HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM j E5C3 C (i-e,.~ i ~ ldSc Synf-it Sys ~u 03 73 w~^s~ G, . /41 31 a~1V C-~ 4 S INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used (DV ~~G~c14 zoo, C Elevation of vertical reference point: -_/00. C Proposed slope at site: SEPTIC TANK: Manufacturer: r5 Liquid Capacity: Za LC, Number of rings used: Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: Number of feet from nearest Road: Front Side ORear, ,O O feet .From nearest property line Front,OSide, DRear,0 feet Number of feet from: well, building: S- ` (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE r PUMP CHAMBER Manufacturer: f--e s e&-S Liquid Capacity: /1'000 Pump Model: Pump/ nu r Pump Size .33 Elevation of inlet: 20. a 9 Bottom of tank elevation: e?Z_ QA Pump off switch elevation: p ( Gallons per cycle: Alarm Manufacturer: S.T Alarm Switch Type: _ r Number of feet from nearest property line: Front, O Side, Rear, Q Ft. Number of feet from well: ''7-5'- Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM / ►v~ Bed: ✓ Trench: Width:' Length: C) Number of Lines:Area Built: Fill depth to top of pipe: 1/9' Number of feet from nearest property line: Front, O Side, (aRear, 0 Vt.~ y~ Number of feet from well:U Number of feet from building: (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: _,Ltl SO Dated: Plumber on job: C~C~.r r-t/t c s a~. License Number : 3/84:mj oco) O' c ~ r C -0 0 d ~1 0 CO) m e o 3 C~D ~ 7 !D ~ ~ ~ ~ A7 • V *k d CD CD r I ~ 0 9_31 y o y o ° w c o m w o w w 00 c Co °o• w :3 00 :3 n Z m w° CL K) m o D M m C` En oo co CD CD 0) Co- C- D CD :3 CD M :3 g (A C) CD IMO .M 0,. c ID CD 0 a o O o n~ O w ai 11 ai u~i rn ! ° °o O w C v to < D ~o Qr rn l (n Z D ~D cc m cn' cn a cn N O W a W cm 0 C c C1 CD C o 3 rn s 1 O O cD i F W v CD C U) OON w 0000000 r- ca to cco (D n (n Cn O CA S 3 O "0 V M "a 'a 'a 000$ 1 000: Y• O Z A E 0) ca Ch ' C 0 in co (1) * I (a No - co v C O yCD T @ p 0 N CD 0 coil > > V in N =A c9 co co CD I CD N d CD 7 • • CD 7 •4 w Z N c D D o D D o ~i O O o a a h• :3 CD CD X I CD c c w 'm m a 3 I Z CD CD -4 N 2 <D O A w T ao 'o ` m CL o z 3 3 I $ °;o o » m N N ;u A 00 w N 0 O-1 D 3 :3 O'D =r CL CD O CL 55 3 O 0)G n N y O a> N T N C CD C 0 (n CD 7 CD N \ O< 9 S O CS N S - - CD CD N CD I I m a N ~ O CD O CD CD { .S 'fl CD O (D m fi Q: I m (Waal y f_. A N 00fa N OS S 15 ~X Pr cDD U) cr j, Q) $ .C. O CD I ~ I 3 v y. °l ~ i a gg v I 3 I c~~a?1~ ti o1nP olv m a m a:3o~ 0 CD lv o OOqb to A o o °p b CD (D °ro °p O O 00 C, C) C a ° ti Parcel 002-1068-95-000 01/26/2006 07:59 AM PAGE 1 OF 1 Alt. Parcel 27.29.16.415 002 - TOWN OF BALDWIN Current X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner 0 - LUND, THOMAS R THOMAS R LUND 2365 HWY 12 WOODVILLE WI 54028 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 2365 HWY 12 SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE SEC 27 T29N R16W SE SE EXC.12A TO STATE Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601/4) 27-29N-16W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 992/194 WD 07/23/1997 975/300 07/23/1997 433/516 2005 SUMMARY Bill Fair Market Value: Assessed with: 87179 Use Value Assessment Valuations: Last Changed: 05/19/2005 Description Class Acres Land Improve Total State Reason COMMERCIAL G2 2.000 14,000 107,500 121,500 NO AGRICULTURAL G4 15.000 1,700 0 1,700 NO UNDEVELOPED G5 2.000 200 0 200 NO AGRICULTURAL FOREST G5M 21.000 8,400 0 8,400 NO Totals for 2005: General Property 40.000 24,300 107,500 131,800 Woodland 0.000 0 0 Totals for 2004: General Property 40.000 32,700 107,500 140,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: 04/17/2001 Batch PRGRM Specials: User Special Code Category Amount 010-GARBAGE SPECIAL ASSESSMENT 45.00 Special Assessments Special Charges Delinquent Charges Total 45.00 0.00 0.00 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 - Q/. QD~ OF PLUMBING MADISON, WI 63707 0 ❑CONVENTIONAL KRALTERNATIVE StataPlanl.D.Number 11f affipneel O Holding Tank O In-Ground Pressure Mound 86-04374-S C014 ERCIAL 0- a _ - 0A NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Russell Lund Woodville, WI 54028 BEN MA X TPeFinanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CST REF. PT. ELEV SE SE, Section 27, T29N-R16W, Town of Baldwin Name of Plumber MPIMPRSW No. Cnunry. Sanitary Permit Number Bennie Hel eson 3215 St. Croix 83863 J SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY TANK INLET ELEV. TANK OUTLET ELEV WARNING LABEL LOCKING COVER D n' PROVIDED PROVIDED ~z1t is ~ --17,01 YES ONO OYES KNO BEDDING: VENT DIA.. VENT MATT HIGH WATER IN UMBER OF ROAD: PR OPERTV WELL PNG7ENT TO FRESH ALARM ~~p LIN AIR INLET. ❑YES NO ❑YES ❑NO FEET FRO DOSING CHAMBER: MANUFACTURER BEDDING JLIOUID CAPACI IY P1IMP MODE I. 111,110,11PI101 MANIII ACIIIHEH WARNING LABEL LOCKING COVER PROVIDED PROVIDED ❑YES F-INO YES ONO ES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PHOPE RTy WELL BUILDING VENTTOFRESH (DIFFERENCE BETWEEN FEET FROM LINE r AIR INLET PUMP ON AND OFF) Ise YES ❑NO NEAREST 01 Arc_/ la-0 f SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing I f Neill IIIIAMI TE H 1AND MARKING or excavation. III soil can be rolled into a wire, construction shall cease until FORCE 7 e /_Q the soil is dry enough to continue.) MAIN / CONVENTIONAL SYSTEM: WIDTH LENGTH JNOOF11`1 SPACINt, COVFH INSIUL DIA aPli$ LIQUID BED/TRENCH THE MATERIAL' PIT DEPTH. DIMENSIONS IIA11L EPTH FILL DEPTH [)ISE'v" PIPE UISTH PIPE ERIAL NO OISIH NUMBER OF PROPERTY WELING v NTTOFRESH BELOW PIPES ABOVE COVER INL1 I EL[ V END E S FEET FROM LINE AIR INLET. NEAR EST--► MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. YES ❑NO SOIL COVER TEXTURE P1HAIANFNIMAHKIHS OHSFHVAIIONWELLS YES ONO YES -]NO DEPTH OVER TRENCH BE D D EPTH OVI R TRENCH HED OI VTI/ )I TOPSOIL StIUI)FO JEf OFO MULCHED CENTER EDGES / 15 OYES. RNO YES ❑NO C~PYES ONO A S ( e PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH© LENGTH TRENCHES LATERAL SPACING GRAVEL UEPTit HF/L'UW PIPE FILL DEPTH ABOVE COVER DIMENSIONS 0 a 0 ~ tP 1 FO PUMP MANIFOLD DISTR. PIPE MANIF OL.O MAif.l(IAL Nf) DISTH DISTH PIPE. ELEVATION DISTHIBUI ION PIPE MATERIAL & MARKING AND ELEx Dln ~y E rS DIn / rA DISTRIBUTION - L~ oC (C/ 7 HH PACING DRILLEDCOHRFCTtY ICOV,R MATERIAL VERTICAL LIFT CORRESPONDS TO APPRO'JED INFORMATION PLANS YES ONO NO J\ L L YES ❑NO COMMENTS: PERMANENT MARKERS OBSERVATION WELLS. NUMBER OF - PROPERTY WELL. BUILDING. FEET FROM LINE YES ❑ NO YES ❑ NO NEAREST 'ketch System on Retain in county file for audit. 'verse Side. SIGNATURE. TITLE IR SBD 6710 IR. 01 /82) r SANITARY PERMIT APPLICATION COUNTY C T DILHR In accord with ILHR 83.05, Wis. Adm. Code S • r STATE SANITARY PERMIT 239-63 -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. a -014 S -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE RYES ❑ NO PROPERTY OWNER ) PROPERTY LOCATION R LA ~S5 'P- 11U17CI 5EF%6 155 ,S Z- TZ.1,N,R /40 Wr) W PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME R+- 1 AI A k )A A CI`T'Y,, STATE-1 ZIP CODE PHONE NUMBER CITY NEAREST ROAD, LAKE OR LANDMARK ~►v ooCJ l , w S ?A VILLAGE : _6A L b U_hA/ t /C.[~ /Z II. TYPE OF BUILDING OR USE SERVED: ` ^ ©,;Z Number of Bedrooms if 1 or 2 Family OR jnj Public (Specify): ra c 111. PURPOSE OF APPLICATION: (Check only one in ¢#1. Check 2,3 or 4, if applicable) 1. a. ❑ New b. X Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in ##1 and only one in ##2) 1. a. ❑ Conventional b. Alternative c. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c. ❑ Pit Privy d. ❑ Vault Privy e. ® Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. X Seepage Bed b. ❑ seepage Trench C. ❑ See a e Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION'AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED (Square Feet): - PROPOSED (Square Feet): Feet ❑ Private 19 Joint ❑ Public VI. TANK CAPACITY Site in allons Total of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New xisting Gallons Tanks Concrete glass App. Tanks Tanks 1wel$Q~s structed Septic Tank or Holding Tank D l a ❑ ❑ Lift Pump Tank/Si hon Chamber ICMI 1/420 Q / ❑ ❑ 1 4 1' F911 VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamp MP/MPRSW No.: Business Phone Number: hri~e. I~>✓I e.so N ~ e 3a ) 7/5 778- 5~~5 Plumber's Address (Street ity, State, Zip Code: Name of Designer: VIII. SOIL TEST INFORMATION Certified So' Tester (CST) Name CST / f 77G C S d9- CST's DRES (Stre t, City, State, ' Code) Phone Number: IX. COUNTY/DEPARTMENT SE ONL ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee Q Adverse Determination M 41` X. COMMENTS/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber I r INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) 1'o be submitted to the county prior to installation; 5. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2to ~ years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 608-266-3815. To be complete and accurate this sanitary permit application must include: n, 1. Property owner's name and mailing address. Provide the legal description where the sy"stern is to be installed; 11. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; Ill. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; dosing or pumping chambers; 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. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is rrrore commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bi".l Groundv4ater included the creation of surcharges (fees) for a number cf regulated practices which VViscortsin's a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried reasare is useu in your building is returned to the groundwater through your soil absorpti;t-r system or the disposal 'site used by your holding tank pumper. \ 1o1 ) The monies collected through these surcharges are credited to the groundwater t._nd admin... terecl by the Department of Natural Resources. These funds are used for morMorii g ground- ~t vvatw, groundwater contamination.irn estigations and est~ibiishspent of standards. s worth protecting. SBD-6396 ;8.03!86) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION P.O. BOX 76 LABOV AND PERCOLATION TESTS (115) MADISO N WI 53707 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNS IP/ LOT NO.:BLK. NO.: SUBDIVISI NAME: S 1/ 4 N/R J(L) W a- c,J i'v\ COUNTY: OW ER'S MAILI GADp RESS: nn II II e G. u h I®u~"e ~p o dC cJ i t l USE DATES OBSERVATIONS MADE ❑ NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFIL DESCRIPTIONS: 'PERCOLATION TESTS: Residence [ ~QL ❑New ~eplace I J~ ~S-/1} L w4E► ~ ~P~r~~' O RATING: S= Site suitable for system U= Site unsuitable for system /a -71 r ONVE~+NTIONAL: MOUND: IN-GROUND-PRESSURE:SYSTEM-IN-FILLHOLDINGTANK:RECOMMENDEDSYSTEM: (optional) ❑ S ®U 15as ❑U ❑ S ®U ❑ S ®U NS ❑U A1,0aAd" / If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the '4 under s.H63.09(5)(b), indicate: ✓ VN Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) B- a s:d' t10h .3f &S',l s;/ •y% / Hof Si ~cI,Gy~10~4 m9' ~ '~1' e 5;l r5 l, S'~ i ~-t AO A- 00 V-1 s.0 8~~1I /.J eX*6-y ,5; •V ~r .7j~ F Q > tea''/ B- .0" 01-33 6 PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PI1__K1UU PER INCH P- / ~O /2406-e O P- ;2 hole :5 0 P- P__ Pi o PLOT PL AN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. EM ELEVATION ~3. r •71J`h`'F„` c4 f- ~~~U CCC!!L// r'^5 76-~C~(~ 6,44-7- w , , •4 s f ~ E _ i t N s, S< Tsi /_/4 f (514 -e- L E - 417 1 , E , , _ I_-.... I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME ( rint): TESTS WERE C MPLETED ON: c r e e soli 3 A DRES : CERTIFICA ION MBER: PHONE NUMBER (optional): 9 4 -e 4 Of - S-" CS SIGN URE: e copy to Local Authority, Property Owner and Soil Tester. - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a cornpietr: ; :I accurate soil test, your report must include: 1. Complete ion; 2. The ur a 'I clearly indicate whether this is a residence or commercial project; 3. IVIAXIMU J r ber of bedrooms or commercial use planned; 4. Is this a new :ement system; a, Complete the suit. l_:l''y rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 0. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred, A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevaticn reference point are clearly shown, and are permanent; 0. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation) does riot apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and your certification number; 12. Make legible copies and distribute as re(juired. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil s and Textures Other Symbols St ___ne (over 10") BR - Bedrock col) - Cobble (3 - 10") SS -Sandstone gr - Gravel )under 3") LS - Limestone ~s - Find HGW - High Gron r cs - ( Sand Perc - Percolation coed s rn Sand W - W e I I is - it e Sand Bldg BUildifIg Is - Lc arny Sand j - Greater Tharr sl - !v;y Loam Less Than I _ L Bn Brown Loarn BI Black si - Silt Gy - Gray "cl - Clay Loan, Y Yellow scl - Sandy Clay Loam R - Red sicl Silty Clay Loam mot: - Mottles sc Sandy Clay w/ - voth sic - Silty Clay fff few, fine, faint r c Clay cc - common, coarse pt: Peat mm - Many, Medium rn -truck d - distinct p - prominent HWL - High wat,=revel, Si- general soil textures st,rfac~ t r lic aid vvaste disposal BM - Bench M< VRP - Vertical F ~.rr TO THE OWNER: r. is fast stela rn secnrrng a s nt y , rr The ,.a., D-p:, ';Iaer : r J~st n the fir,ld pfior to,, I ~e. A Ipplicat must be sul °,ii 'r ob'ained ar: osted prior 6~9 ~gS ygt0 'alto 'Plof- Play" .5 610 C'57. / ~sa~ 3oQy ~8' i f ~o ,8! A5 K- I f 29L, aCCI ~$asz I~.in t ti05' ~ I alo X32 , Pz_~_ t ? Sy a a SloI e. ' I I S;~;rt~61~ M~hcQ ~ ~ I aP3 ~r1i.+U.~\. /OVe~~ 0 i _ ra G ra d e_ J PO-V- ko T 370'o rHwY /~'r Cam/ DS BPS / -P/napCI- V ~w1'vl~ QoctSQ.- ^E'kottS~ ~f Ivy f I ~ i w2lt J10t -P~Ckh- Phe Hd, `QRS RE grJ N ~~L S 14--:7 1. 67fs~ + gtt~~(; . ~c T lo a 1-}a. FI c 1 ENS U~ 86, y,2 i~ s~o G4 ! I J U, R. P. 100.6 t ro ~psec f s Mom 0~ A l 11~ f 10.1 r 27 7tjop rlr\ E~SS SCC ~xls~,n5 fac kag inS s I , Par~I^°5 ExcPpf 4S ShaV,. ~c Q G - i Gc:)~-c)l(1\ 370' 0 4 Y ( 131~i). , ~ alatl: i^~ 1r 1•gr:eta) plumsia~; ;yste ~jr sewtk ,iplnN to the eptwitaidin~ tank that is required for this project. Those plans must be submitted and approved before construction on this project is started. Page - Of Straw, Marsh Hay, Or Synthetic Covering Distribution Pipe Medium Sand Topsoil G F 1 3 E D e a~-V fp Slope. Bed 0f i»- 21. Force Main Plowed legate From Pump Layer LPg©R Y; NQ D ~ Ft. ME%D~~ ` SAF E .3I Ft DEp ~s Section Of A Mound System Using . A~j ~S A Bed For The Absorption Area F .7_5- Ft. c G Ft. A Ft. H Ft. Signed: B r~o Ft. License Number: K 13_;IFt. Date: L Ft. J lo. Y3 Ft. Alternate Position T /3,i5'Ft. of Force Main W Ft. L J Observation Pipe 6 K A Iii d1 cU-' trS w 0 T - - Distribution Bed Of %M- 2 2 2 t P604 04 ipe Aggregate f, I Observation Pipe Permanent Markers y.,i Plan View Of Mound Using A Bed For The Absorption Area PAGE OF PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VELIT CAP `I"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING JUNCTION BOX MANHOLE COVER 25' FRCM DOOR. WINDOW OR FRESH 12"MID. AIR INTAKE I I GRADE I 4" MIM. IB"MIIJ. CONDUIT 18"MIN. 11~ INLET PROVIDE P`uwi6,tAGAIRTIGHT SEAL i I i I R APPROVED JOINT A APPROVED JOIIJT. W/C.I. PIPE C~ I III W/C.I. PIPE EXTENDING 3' I II ALARM EXTENDING 3' ONTO SOLID SOIL B ~PT1pN~ I II ONTO SOLID SOIL PhA I C C~ ~ - A A p1N ( I TM~N~OF oN (>F i I pE~AR v ~ Oft S PUMP--- OFF, D S~ CONCRETE BLOCK RISER EXIT PERMITTED GIJLy IF TAUK MANUFACTURER HAS SUCH APPROVAL SPECIFICATIOUS SEPTIC AND DOSE TANKS MANUFACTURER: I.CS,e I'C WMBER OF DOSES:. PER DA-9 TAMK ::IZE : J--0 GALLOLIS DOSE VOLUME: L•S0 ~G-~ALLLOKAS ALARM MANUFACTURER: _S ~.L F, L~r s~~ryls CAPACITIES: A= 7 INCHES OR - GALLOUS MODEL NUMBER: 8=-,INCHES OR 6-0 GALLONS SWITCH TYPE: ~Ler G« y~ I C= INCHES OR /Sd GALLONS PL1MP MALILIFAC_TLIRE R: 7F Irt1 y1n D=_1-2 IAICHES OR -160 GALLONS MODEL NUMBER: c°lS 1? 23 NOTE. PUMP AND ALARM ARE TO BE SWITCH TJPE: _ act- cl.F INSTALLED ON SEPARATE CIRCUITS PUMP DISCHARGE RATE _ GPM 4 VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. FEET + MINIMUM NETWORK SUPPLY PRESSURE . . , . . " . 2.5 FEET + ~r-: FEET OF FORCE MAIN X +4F3,/ooFT.FRICTION FACTOR--79 FEET t TOTAL DJNAMIC. HEAD = L0 - A FEET OUP ( INTERNAL. DIMENSIONS OF TANK: LENGTH 0 ;WIDTH ;LIQUID DEPTH SIGUED LICENSE DUMBER: ~ ~•rr '-2._ DATE: , L l 10 Perforated pip* Detoll n VI N )POfforoled Eno Cap PVC Pipe e L d~ MOM Localsid On Bottom. 4~ Are tQuoey Spaced Q O Hole's Pet_ kCXfiro, PVC Foree Mo. From pump , PLUMBING--r, ~k1 J a _ /P PVC COJUOJ~ E~Vq ego ff ~ titadfola Piq MOM MRk Distribution AOF AN AN PiP* DEPARTMENT I U Y; LAS R SAF N7 it ING Lost Hole Should Be D1V1 Next To End Cap Distribution tpe Layout fir P j S 5 X t/ Y 3- Signed: Hole Diameter Inch License Number: Lateral Inch(es) Manifold Inches Date: Force Main Inches 6 8 Y Va~y Ala }>kr # ~X",. % ell H z H • a STC - 105 r r a H SEPTIC TANK MAINTENANCE AGREEMENT Ho St. Croix County z t7 a l -I H OWN ER /-$4E-RLC~ P Lt ~t ~l ROUTE/BOX NUMBER Fire Number CITY/STATE ZIP PROPERTY LOCATION: SK 14, SL 14, Section o1 `7 T_,)f_N, RZ_W, Town of J30LI~ u>>A St. Croix County, Subdivision Lot number ItIA Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treat- ment 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), the septic'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 0 I/WE, the undersigned, have read the above requirements and agree En to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- w ment of Natural Resources. CertificatiQ-u- for must be comple and returned to the St. Croix County Zoning ffi e within 3 day of the three year expiration date. SIGNED DATE zz"z St. Croix County Zoning Office P. 0. Box 98; Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. 1- APPLICATION FOR SANITARY PERMIT STC - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, ("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property RaS4,e f L Location of Property SE SE 3%, Section -r\ -7 , T_2~ N-RW Township Sc, (A? h Mailing Address Wo01y t, `(Z° Address of Site 011_kyt Subdivision Name .AZA Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created Are all corners and lot lines identifiable? X Yes No Is this property being developed for resale (spec house) ? Yes X No Volume And Page Number as recorded with the Register of Deeds. _it23 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I (We) ce ti6y that att ~6tatement6 on thus Sonm ate tAue to the best o6 my (out) knowledge; that I (we) am (ate) the owneh (d) o6 the pnopetty dens cn i.bed in this .in6oAmation 6onm, by vi tue o6 a waAAanty deed tecotded in the 044ice o6 the County Reg.ustet o6 Deeds a3 Document No. e) ; and that I (We) pnesentt y own the pnopobed .6 to Got the -sewage duspos syzs em (on I (we) have obtained an easement, to nun with the above de6n bed pnopenty, bon the cowstAucti,on ob said ,sybtem, and the .same hays been duty neconded in the 046ice o6 the County Reg"ten ob De Document No. S NATURE OF OWN SIGNATURE OF CO-OWNER (IF APPLICABLE) (p DATES ~dNED/ DATE SIGNED 7 7 41, L S r " QjF"rfSM "l 4 ~ ~~'y 11.. aEa~ 208710 WARRANTY DEED THIS INDENTURE, Made by Gina Johnson; Hilda Nelson; Allie Peterson; Lillian Skelton; Oscar Haugeland, a single man; Leonard Haugeland and Myrtle Haugeland, his wife; Leland Randall and Gladys Randall, his wife; Wesley Randall and Joan Randall, his wife; Vincent Randall and Arlene Randall, his wife; Ila Sittlow; and Arlis Butler, grantors,'hereby con- veys and warrants to Russell Lund and Lucille Lund, husband and wife, as joint tenants, grantees of St. Croix County, Wisconsin, for the sum of Nine Thousand Dollars ($9,000.00) the following tract of land in St. Croix County, State of Wisconsin: Southeast Quarter of Southeast Quarter (SE k of SE and South Half of Northeast Quarter of Southeast Quarter (S-2 of NE k of SE-4) of Section Twenty-seven (27), Township Twenty-nine (29) North, of Range Sixteen (16) West, St. Croix County, Wisconsin. The above described real estate is subject to alleasements of record and highways. Possession to be given to the parties of the second part on June 26, 1967. r r IN WITNESS WHEREOF, the said grantors have hereunto set their hands and seals this 7th day of June 1967. SIGNED AND SEALED IN PRESENCE OF e (SEAL) Harold D. Olson. Gina Johnson / 1 - L L L t t-eParl' 'ro en uis Hilda Nelso.~ (SEAL) (SEAL) Allie.Peterson . fir. (SEAL) Lillian Skelton (SEAL Oscar Haugeland (SEAL Leonard Haugela d . (SEAL Myr e,Hauge1 d (SEAL Leland Randall (SEAL ladys ands 1 'AL Wesley Ra a- (SEAL an Ran ail (SEAL Vincent Randall (SEAL Arlene Randall 1-W?2: _ ~~c rJ . (SEAL Ila Sittlow /rk~~ C/✓r.OJ,GG~I/~ (SEAL Eugene Volstad Arlis Butler Harold D. Olson STATE OF WISCONSIN ) : ss St. Croix County ) Personally came before me, this 7th day of June , 1967, the above named Gina Johnson; Hilda Nelson; Allie Peterson; Lillia Skelton; Oscar Haugeland, a single mar.; Leonard Haugeland and Myrtle Haugeland, his wife; Leland Randall and Gladys Randall, his wife; Wesley Randall and Joan Randall, hlsd w :ps V~ W Randall and Arlene Randall, his wife; and Ila Sittlow,/ To me Known to e the persons who executed th foregoing instrument and acknowledged the same. Harold D. Olson 511.4`.1 Notary Public, St. Croix Co., Wis -CASTERS OFFICE My commission is permanent ST. CROIX CO., WIS. f~ec'd for Record this,.-?! 5,-L day ot_-.Dune.----_A.O. ~9 L7 at1: 00 11 a M. R sie~ o~~~k i 1 J k. ST. CROIX COUNTY WISCONSIN 40, ~a ZONING OFFICE 796-2239 (HAMMOND) 425-8363 (RIVER FALLS) - HAMMOND, WI 54015 July 10, 1986 Division of Safety and Building Bureau of Plumbing P. 0. Box 7969 Madison, WI 53707 Dear Sir: An on site investigation for the Russell Lund property, located at the SE14 of the SE14 of Section 27, T29N-R16W, Town of Baldwin, St. Croix County, revealed suitable soils at a depth of 1.0 feet, below which seasonable high ground water was noted. This site should be suitable for a mound system. Should you have any questions, please feel free to contact this office. Sincerely, 'Zi Thomas C. Nelson Assistant Zoning Administrator TCN/mj i . WISCONSIN DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS DIVISION OF SAFETY & BUILDINGS, BUREAU OF PLUMBING P.O. BOX 7969, MADISON, WISCONSIN 53707 Verification of Exception Status for an Alternative Private Sewage System In the County of St. Croix Location SE 1/4, SE 1/4, Sec. 27 T 29 N, R 16 U4 W Town x tC30W Baldwin Street Address Lot No. Block Subdivision Landowner's Name: Russell Lund The application for this site is for: ❑ new construction use. ]replacement system use. If this is NEW CONSTRUCTION USE, the alternative private sewage system is: to have one of the first five approvals guaranteed for this year. This is number - - of those applications. (Use one of the first five quota num rsissue-d to you.) [ ]one of the applications needing a quota number. The quota number assigned to this application is - - for one additional homesite on a farm to be occupied by a parent, child, grandchild, sibling, niece, nephew, or first cousin. D for an individual lot for which a sanitary permit was issued but was later ruled unsuitable due to new or changed soil criteria established by the department. [J for an application on file prior to February 1, 1980. [_]for a lot that meets the criteria for a conventional private sewage system. If this is a REPLACEMENT SYSTEM USE, the alternative private sewage system is replacing: Ega failing conventional soil absorption system. 0 a holding tank that was installed and in use prior to February 1, 1980. ❑ a privy that was installed and in use prior to February 1, 1980. If this is a REPLACEMENT SYSTEM USE and the Jot meets the criteria for a conventional private sewage system, check here I certify that the above information is true and accurate to the best of my knowledge. _ Name Thomas C. Nelson Si ure County Official Title Assistant Zoning Administrator Date July 10, 1986 DILHR-SBD-6158 (R 12/82) STATE OF WISCONSIN-DEPARTMENT OF INDUSTRY, LABOR & HUMAN RELATIONS DIVISION OF SAFETY & BUILDINGS - BUREAU OF PLUMBING y P.O. BOX 7969 - MADISON, WI, 53707 APPLICATION FOR THE USE OF AN ALTERNATIVE SYSTEM Location: Township SE 14 SE S 27 T 29 N/R 16 M W Baldwin St. Croix Street Address: Subdivision: County: Landowners Name: Mailing Address: ,Russell Lund Rt. 1, Woodville, WI 54028 I (We), the undersigned, hereby make application for an alternative system on the above-described premises. I recognize that the above premises are not suited for a conventional private sewage system. If approval is granted, I agree to have the system installed in conformance with the Bureau's approval of plans and specifications. I further understand that an alternative system is more complex in nature than a conventional private sewage system and as such will require detailed inspection during construction and monitoring after the system is put into use. I agree to permit both county officials charged with administering county sanitary ordinances and Bureau employes or other authorized persons to have access to the above described premises at any reasonable time for the purpose of inspection the construction of or monitoring of the system. I further agree to either personally or by my agent contact the proper county official to arrange the time and date to begin construction of the system. I understand that this application does not permit me (the applicant) or my agent (the contractor) to begin installation. If the system is approved, the Bureau will send the applicant a letter of approval which authorizes construction of the alternative system after all necessary permits have been obtained. I agree to give notice to any subsequent buyer that an application for an alternative system has been made and if installed, that the premises are served by an alternative system and further agree to give the buyer a copy of this application. The Bureau accepts this application subject to this understanding and subject to all the conditions and obligations set out in this application. Signature of Applicant Date STATE OF WISCONSIN Subscribed and sworn to before me SS. COUNTY OF This day of 19 Notary Public, State of Wisconsin My Commission Expires: DILHR-SBD-6413 (N. 05/81)