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HomeMy WebLinkAbout004-1013-20-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS/ 9 S~~~h e~ i v.~ SUBDIVISION / CSM# LOT # SECTIONT N-R W, Town of oci ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. I BENCHMARK: ()C~, e~) p~ U x 4 ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: S U c~~2st~?y-t,~~,.&jLiquid Capacity: Setback from: Well House (other Pump: Manufacturer Model# W no Size ^7P Float seperation k Gallons/cycle: Alarm Locations ;SOIL ABSORPTION SYSTEM Width: Length_C73~_ Number of trenches Distance & Direction to neare prop. line: Setback from: well:- _ House Other ELEVATIONS Building Sewer ST Inlet, ST outlet PC inlet 9 k -S- PC bottom 97- a.? Pump Off Header/Manifold 9 Bottom of system Existing Grade_ aj7, S Final grade /Q'0 ao DATE OF INSTALLATION: g "J PLUMBER ON JOB: ~Q 0 LICENSE NUMBER: INSPECTOR: 3/93:jt le- -C ~t ~4 , t.Lw.. l~ a t- ]r_ _ k ~ ` ~i~' ~I S Ca.l,e ~ ~ ~ y o ~ct~~s ` 1Jo UHF ~l-y ZA 100.Coc L l p~J p F ~ ~ 1(~ bl' J 1 aK ~ ~C7 h~bls~r Li v~ •C Alxoc- gr5r4e I~~. 41.5 ga 9° O o A. r c_ 1 i I 07)0 ( i ~N ~rt.~Maln~ rcleos a O- ~ • ~Ol~/G SO 1 ~0tp06 ~ sep y `Jr we.. 5 l7o5t fahK ~rorfos Propose'- Gc~r. Wiscwn in Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT f ST. CROIX Safety and Buildings Division I GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI WALKER, JEFF X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: QD~ /DO, r~e~ btv TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark i "0 CAb 64, f! "vo; Dosingi (p,5v %vyo' loo 'jtee Aeration Bldg. Sewer Holding St/ Ht Inlet 3.~7' 90. 95 TANK SETBACK INFORMATION St/ Ht Outlet q, 7' TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake / y 6 F?' y_5- Septic Ya7S 2 rte, NA Dt Bottom 1~2 ,a S-' NA Header / Man. ~q f q Dosing S-~ 0 Aeration NA Dist. Pipe Holding Bot-System 9 8.5- PUMP/ SIPHON INFORMATION Final Grade 3.3 Manufacturer rDemand Mod el Number Ow i~•o~ ' g~, i/ TDH Lift/,l,o9' Lrictioi Systema s, TDH/(,,`g'Ft oss Forcemain Length//z, Dia.a-, Dist.ToWell SOIL ABSORPTION SYSTEM BED/TRENCH, Width Length No. Of Tr nches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION & 3 DIMEN I N SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of 7y_5_.ZZ) CHAMBER OR UNIT Model Number: System: /"j7/_~ 435 3'1 DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia o~ a Length ~ Did. / w r Spacing A/ " _11'e " ' )S- M SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of! xx Seeded/ See1d'~ xx~M/ulched Bed /Trench Center Bed / Trench Edges Topsoil 4 2. M/yes No L7 Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.),y,'; ~a 30-95 LOCATION: CADY.6.28.15W, NE, SW, 270TH AVENUE 0 12/7 t l1?.C.~4 7,0 S- -7 . e 6 Plan revision required? ❑ Yes ET"No Use other side for additional information. SBD-6710 (R 05/91) Date ns a or's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i 171 iii°r w~rrs Safety and Buildings Division ~~■~=-.rs SANITARY PERMIT APPLICATION Bureau of Building Water system: 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 81/2 x 11 inches in size. ST CROIX • See reverse side for instructions for completing this application State Sanitary Permit Number ...216 708' The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION S95-40659 Propert Owner Name Property Location JEFF WALKER NE 1/4 SW 1/4, S 6 T 28 , N, R 15 E (or) W Property Owner's Mailing Address Lot Numb ~Ar Block Nt{tnfiAer 4MI 419 SKYLINE DRIVE 11VV// City, State Zip Code Phone Number, Subdivision Name or CSM Number EAU CLAIRE WI 54703 (715)834-4738 N/A II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road ❑ Public 1 or 2 Family Dwelling - No. of bedrooms 3 El Town OF CADY 270TH AVENUE 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo WU/ 34-004-1013-20 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 13E] 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 System Tank 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 30E] Specify Type 41 ❑ Holding Tank 12E] Seepage Trench 22 ❑ In-Ground Pressure 42E] Pit Privy 13E] Seepage Pit 43E] Vault Privy 14E] 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 98.5 Feet 100.8 Feet VII. TANK Ca in gallons Total # of Prefab. Site Fiber- Exper INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank 1000 000 1 MIDWESTERN PRECAS [29 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber 650 650 1 MIDWESTERN PRECAST ® ❑ ❑ ❑ F] ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Sta s) M.P/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 Sa tary Permit Fee (Includes Groundwater Date Issue Issuing Ag nt Signa Approved ❑ Owner Given Initial 1#1.1 +6 */~o Surcharge Fee) f~ Adverse Determination f X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: B (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Divr ion, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe 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 informatior 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 t.: nks and manufacturer's name, indicate prefab or site constructeJ and tank material. Complete fo. a!I septic, Dump/siphon and holding tanks for this system. Check experimental approval only if tanks received experilrient:3! aroduct approval from DILHR. VIII- Responsibility statement Installing plumber is to fill in name, license number with appropriate ;)-efi> (e.g. MP, etc.), address and phone number. Piumber must sign application form. IX. County / Department Use Only X- County/ Department Use Only. 5pzf 3 S u f. iIt X 'Gi'4 US_ t) F' tc t? . l.y_ 1e pans must i J+Nf' a1 i,_ c;:-_ 1- r: septi< t r=_ - . ~ t.unip or_iphon se, eu A 0 GROUNDWAT!=R SURCHARGE 1983' i,ccnsin A.c~_ r.' 0 imp ,jdeci the creation of surcharges (tees; for i:, number of re(-Ji,fated p,::( aces which can effect groundvvater. I fie monies collected through these surcharges are used for monitoring gro_,nd,.t.fate.: ontamint !.;on rives igations and establi=.hment of standards-` 5 V~GLVK RECEIVED r~ 4 0 6.5 9 JUN 2 g 1995 SAFETY 8 BLDGS. Dl FQnGe of /Ve~[p~ST Y'l^o ~~,r \ ~r~ eta z'.,, cam" Dtc. S,,AsVAGE- SYSTEM (g C6 ? u Tti+ Ave . _cl P ern`f` C. R4~ e eoa r~R4~3iaas OF !~{€1USTRY, yv kcp-Es S Ca e _ C) DEPTAZT ~Jo 3.M~ JR,w,to©.c~o ((ff ,T6P pF 1' -C I" Cr SfiaVC ~ ~bh'Cbl~v ~rv. e C)o IJv+- ~ ~o r Cowes ^ \ A-cc- i a7ort ~--fig I tSt ~ \I ~ ~w For c~ OCJ% s0 SeP bJ r tv.e I ~ro,~se~P 3aec~ Propos Car. \ VIP" n'eFa Q \A)0j K-e ✓ 8 7 5 m `t 0 6 5 9 Page Of T Straw, Marsh Hay, Or Synthetic Covering ASCN1 L_23 Distribution Pipe Medium Sand ' _ H = G Topsoil F -J E D 3 ov A,! aVu % Slope i Bed Of 2M- 2 Force Main Plowed UV" Aggregate From Pump Layer :d ~ i~~i.~~►a~as D Ft. e~is►m/ . 3 l~ ss Section Of A Mound System Using E Ft. A Bed For The Absorption Area F_ Ft. 0;1 G V O 0 Ft. 'A /o Ft. H /S Ft. Signed: B 3 Ft. License Number: 14 ~ e K Ft. Date: -a 7-SS L S 3. SPFt. J - rd Ft. T IFt. Force Main W ~y Ft. L Observation Pipe A Distribution Bed Of 2 - 2 Pipe Aggregate Observation Pipe Permanent Markers Plan View Of Mound Using A Bed For The Absorption Area Le 895m40659 Perforated Pipe Detoll / 0 End View End Cop )Perforated PVC Pipe (j <~ab"'c• Permanent End Markers G Jo ,oo d~• s Holes Located on Bottom are Equally Spaced e 51 PVC Force Main OkPP~ $ From Pump, X10 ENb PVC CA / Monitold Pipe 1~` Pvc. ~ h N~ ~,,u 4 gOR ov, Distribution... tA Plpe Lost Hols Should Do Next To End Cop 5 Distribution Pipe Layou P ~O R S ~i X Y Signed: t Hole Diameter Inch License Number: Lateral " Inch (es) Date: Manifold " _ Inches Force Main " Inches AAoI _.S Pen- p-e- ti eo 9 9. o r c~-LT 5 4 0 U gage Of COMBINATION SEPTIC TANK/PUMP CHAMBER 4" CI Vent Pipe with (No Scale) Approved Cap, +25' ,Approved Locking Manhole Cover From Buildings With Warning Label Attached Weatherproof Approved _ Warning Label Junction Box Vent Cap 12 Minimum Final Grade 6" Minimum 4" Minimum s 6" Maximum 4" C.I. Quick 18" Minimum Insp. Pipe Disconnect 1/4" Weep - Hole Baffles , Appro ed JoJin i A w/C. I. PR j " I \ Ili Extendi nib' Alarm 64 B Approved Joint Onto S id" On 6; w/C.I. Pipe gQA I C Extending 3' ~~F t~o~s p~ --y•".~'` ~/fv86S Off ' Onto Solid Soi RAE Conc. Block S~ 3" of Bedding Under Tank-/ Note: Pump and Alarm Are On Separate Circuits Number of Doses: Per Day Gallons Per Day/ o Doses: I~ a,s Gallons Volume of Backflow:.......+1 © y Gallons Tank Manufacturer: Total Dose Volume:........_ Lao, s Gallons Tank Si ze-Septi c/Pump : ~or~n,/L o a 1 ons i7 Alarm Manufacturer: Fla 4L, s.~s -mss Model Number • Capacities: A/7>~Jnches or o :2 al1ons Switch Type: o(,f M rc~~ u4Idf l~ + B inches or 3 y.~ Gallons Pump Manufacturer: Gpt~-!. D _ + C 3 inches or 3.2. s,sGal l ons Model Number: Q + ~ftjnches s orJ g3.&L~sGal l ons F- I L- it) Minimum Discharge Rate: Q U U Total _ inches or Sy o7sGa11ons Vertical Difference Between Pump Off and Distribution Pipe: la.s"Feet Minimum Required Supply Pressure: Q.5 Feet Feet of Force Main x 2.g)- Friction Factor/100Feet: +eet :_Inch Diameter Force Main Total Dynamic Head:... Feet Internal Tank Dimensions: Length Width 11~75; Liquid Depth 3 9 y Signature License NumberL y7PS.-/S"Uate 1-Q7415 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page L of Labor and Human Relations Division of Safety & Buildings in accord with ILHR Is A ode . , COUNTY ST Attach complete site plan on paper not less than 8 1/2 x 11 inch th.re Plan mu,,inclu ` C a` ~ I x not limited to vertical and horizontal reference point (BM), direct d % of'SJope 6or a PARCEL I.D. # dimensioned, north arrow, and location and distance to neares Eqa 5N --60 q -10 t -3 -24) ! REVIEWED BY DATE APPLICANT INFORMATION-PLEASE PRINT ALL INF ANllp IiL _A_ -.h E OCAT PROPERTY OWNER: _ c (JIJa 1 OVT. LO ~ ~ij (J 1/4,S 6 T $ N,R fS E (o W PROPERTY OWNER':S MAILING ADDRESS T# SUBD'. /NAME OR CSM # CjrC 1-c- y A)A 5 L,cc s CITY, STATE ZIP CODE PHONE NUMBER ILLAGE WN r REST ROAD ( 3s~- ~ C4,DY a7o Tk AL e [ New Construction Use [ Residential / Number of bedrooms [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow ~(L50? gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required to ° 11 bed, ft2 7,:5:Q trench, ft2 Maximum design loading rate S bed, gpd/ft2y_4._trench, gpd/ft2 Recommended infiltration surface elevation(s) yS,s 'L: ~b oS (as referred to site plan benchmark) Additional design / site considerations S c,W C ,.'e,- BUJ to - 6~?.s 3cZ = 37S 4 Parent material; Flood plain elevation, if applicable 1y,4 ft S = Suitable for system CONVENTIONAL M~OUt~ IN-GROUND P SSURE AT- S DE SYSTEM IN_ FILy HOLDING TAMS U = Unsuitable fors stem ❑ S O'll C9'S ❑ U El S ❑ LKt1 ❑ BIC HT11 SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench U 4-- to .-I 17-tV ioy& .7 6k Ground 3 SIZE. (c r „v 4 ' S 6 elev. + G 5 %Z 0 ft. T.5 'M- .Y F U £ 'Fr w~ cr drdf~ - 7 Depth to limiting factor N$„ , Remarks: Boring # a 10 yr- 0A V_ Q 1-0 s ~N. e rK V e. t,✓ S71, Ground elev. ft. Depth to limiting factog„ 5,;.T. Remarks: CST Name: Please Print Phone: Z S) ' J~-7 W K 14 e so 7 70 1 1 Address, W ] r t n Ual 12 W_ y 7 Signature: Date: CST Number: /-/0- S PROPERTYOWNER T- C-9 )-1J k4L,- SOIL DESCRIPTION REPORT Page of PARCELI.D4 314 -004 - /01-3 -,;~G Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxby Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmr& 0-& 5 3 Ground - 7 - .24-, p Y n) Y~ car r~ ( ? , 8 elev. y °So -Y s . s' Y/2 -7. 5- Y Z i s~ .z c 56k- M .S , S Depth to limiting factor C4 0,6. LL) Remarks: Boring # .3 --3t> 7 k r 1 S c, 5 r aA) I U Ground J elev. < . ft. .30_3V Q Sr-1 561 vvrr, Depth to limiting factor Remarks: f Boring # 3- AS w -S1 Ground , dL I elev. ft. Depth to limiting factor 18" Remarks: Boring # 4 a.S S , vY 2 a VC Lk ?it I JA (P4- Sf rC r1 ~S 3 Ground elev. Depth to limiting factor ) Remarks: SBD-8330(8.05/92) L , CJ ~ 9 Fit-so ij OR 27, 1995 ~ KATHLEEN H. WALSy ReQistor of qg SL Croix Ca, Wl CERT IF I ED SURVEY MAP LOCATED IN THE NW 114 OF THE SW 114 OF SECTION 6, T28N, R 15W, TOWN OF CADY, ST. CRO I X COUNTY, WISCONSIN. PREPARED FOR: HANLEY TERKELSEN NOTE: BEARINGS ARE REFERENCED TO THE WEST LINE OF THE SW 1/4 (ASSUMED). UNKATTED. LANQS.• W 114 CORNER OF SEC. 6. ( 1- IRON E-W QUARTER SECTION LINE I I - - PIPE FOUND). S 00000138'W i i-- 66.00' I N 89° 04' 530 E 852. 85 3.00' 819.84' ~ I I ~ I I - 7 ey; - N• 133 33,1...,.NfO _ I I co p,ur. a 11. ~.I I N I 1 `]e.:p F'ILI~S IRn.~.~.;rt.:; 1~.1 I w 10 SAO-t- a+ I N i (A . I a 1 C, Z' PLC J: IOD i °0 J $B+ti Q j IN I Z Q lil.~ 1~ I 1 S 89659'22"E ' LOT I 0 ~Q L 33. 00' Z: M 18.99 ACRES 3 a ~ ~`j,y' 8Z7,035 SO. FT. M 18.66 AC. EXC. R.O. W. R 812,894 SO. FT. 6 a g o (.t _ $ to 9 r? R.O.W LINE N 850164 14-W 854.74' - w co M _ WIDTH VARIES 8 ~ ~~~evsoev~~ IV's SW COR. SEC. 6. - JAMES M. (COUNTY MONUMENT FOUND). - ----WSMR 3-1804 SPRING VALLEY WIS. Q 0 ~41 SET I' X 24" IRON PIPE WEIGHING 1.13 L BS PER LINEAR FOOT. edo,~0 0S vk 200 0 200 400 600 GRAPHIC SCALE - FEET JAMES M. WEBER S-1804 SHEET 2 NELSEN-WEBER ~TAND SURVEYING I OF DATED THIS-3 DAY OF 1995 L 95-38 THIS INSTRUMENT DRAFTED BY JIM WEBER VOL. 10 PAGE 2913 1 ' STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER JEFF WALKER MAILING ADDRESS 419 SKYLINE DRIVE, EAU' CLAIRE WI 5470 PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE tI VLF PROPERTY LOCATION NE 1/4, SW 1/4, Section 6 , T 28 N-R 15 W TOWN OF CADY ST. CROIX COUNTY, WI SUBDIVISION N/A LOT NUMBER CERTIFIED SURVEY MAP , VOLUME s , 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 date. 1 SIGNED: i DATE: i St. Croix County Zoning Office Government Center i 1101 Carmichael Road I Hudson, WI 54016 11193 I I S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/ contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property JEFF WALKER Location of property NE 1/4 SW 1/4 , Section 6 , T 28 N-R 15 W Township CADY Mailing address 419 SKYLINE DRIVE EAU CLAIRE WI 54703 Address of site 5L4 ~ Subdivision name N/A Lot no. N/A Other homes on property? Yes No Previous owner of property Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? l Yes No Is this property being developed for (spec house) ? Yes k_No Volume jj~-< and Page Number ~~-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. S:a'~q!!S29 to , 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. -14 Sig of Applicant Co-Applicant Date Sictnature Date of Sianatiira ~~,7~0~~ State Bar of Wisconsin Form 2 - 1982 WARRANTY DEED DOCUMENT NO. Hanley Terkelsen, a married man, JUN 7 1995 E ~5 12:15 P.:i I uy conveys and warrants to Jeffrey K. Walker, a single 1~e person, THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS 4cLa I eq Te,r k.o-Iseh r I~ the following described real estate in St Croix County, State of Wisconsin: to"Isun w 'UOa 1 (Parcel Identification Number) N1/2 of the SW1/4 of Section 6-28-15 EXCEPT Lot 1 of Certified Survey Map filed April 27, 1995, in Volume 10 of Certified Survey Maps, page 2913, as Doc. No. 528248; also EXCEPT parcels taken for highway in Volume 339, page 495 and Volume 340, page 440. This is not homestead property. XKK (is not) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this day of May 19 95. (SEAL) (SEAL) Hanley erkelsen (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) Hanley Terkelsen STATE OF WISCONSIN ss. County. authenticated this day of May '19 95 Personally came before me this day of 19 the above named Kristina 0 land _ TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Kristina Ogland Attorney at Law * County, Wis. _ Notary Public Y, (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration (late: necessary.) 19-_-.) "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 ST. CROIX COUNTY WISCONSIN ZONING OFFICE 1 r r If NNE Noun ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson WI 54016-7710 (715) 386-4680 October 31, 1995 First Federal 201 South Second Street Hudson, Wisconsin 54016 ATTN: John Sias RE: Septic Inspection for Jeff Walker Address: 549 270th Street, Woodville, Wisconsin Dear John Sias: An inspection of the septic system serving the Jeff Walker residence located at 549 270th Street, Woodville, Wisconsin, was conducted on June 15, 1995. This property is located in the NEh of the SW; of Section 6, T28N-R15W, Town of Cady, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. I If you have any questions with regard to the above, please do not hesitate in contacting our office. Sincerely, _ Mar J Assistant Zoning Administrator St. Croix County, Wisconsin mz C;( U LJ