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HomeMy WebLinkAbout008-1069-90-000 ti ~ I N Ci a ~ O O ti ~ I ~ I O ~ N j I O ~ t I co `O v c c a~ I N y Ci I O N > O O i', ~ Z = C I li c f0 V1 o O> Q) a o0 0 CD E E Q ° M _ v v Q) E O Z o v L Z L 'a v CO > d m N H U) I' o ozZti' U Z c p N F- N zz hh~~ I M I i Y ~ I `r+J ~ N ~ M1 ~ C ~ • MV 07 O Q O O = Z Z N z C N f0 L m d y N a C r i we c c Lo N O W N L O Q O L) -0 = 11 1 w Lo D O d 0 U) U) m F- F- !N O O O z •ti a a a a ° o i o LO LO ~ o N m I V1 ~ U m rn rn } M CO O N N coo C:) LO (D O C) z3 _ 3 O a c 'o m aNi 4s> ~ a~ o m a Q > / m O N N O C N N C O O O O c b N O O 6) O L" LO H W N C O. 0 C \ M Y a) N 0') E CO 'T v O m N O) L ~ N ❑ W ~ d. In "71 oO N N M n W E U • y' O N W J N O N g -7 Cn O ik E y ik d L d rr~~1 i R 3 +1 A 0 a~ Ornv 7 8. c~ STC - 104 AS BUILT SANITARY SYSTEM REP`, Ga o OWNER ADDRESS -7 / CT7a SUBDIVISION / CSMJ LOT #-At- SECTION ~T N-R 14, W, Town of Fa-u ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Cf~ . I I I S~J l }p~~ INDICATE NORTH ARROW`' Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. t - BENCHMARK o`!pc ~~~ehte ALTERNATE -BM: SEPTIC TANK / PUMP CHAMBER HOLDING TANK INFORMATION Manufacturer: cc~ Liquid Capacity: 3Ooa C> Setback from: Well House E, 3 n 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.7,'),? ST outlet PC inlet k PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: - J~ PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR:-... vv~ 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: ` Labot and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryPermitNo.: Permit Holder's Name: ❑ City ❑ Village p Town of: State PI . LEE, TENG ENG X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septi Benchmark Dosing tion Bldg. Sewer 5 Holding C~ 3 '5*4,;It Inlet TANK SETBACK INFORMATION -4kHt Outlet TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet rl Septic A Dt Bottom Dosing NA Header/ Aeral[on- NA Dis. Ipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer e nd :7~l Model Number GPM fiction System A ' TDH Lift Loss Head TDH Ft Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED / THE H Width Length No- Of Trench-es IT No. Of Pits Inside Dia. Liquid Depth DIMEN I N DIMENSIONS TEMTO P/ BLDG WELL LAKE/STREAM LEACHING Manuacturer: SETBACK INFORMATION Type O CHAMBER Moe Number: System: OR UNIT DISTRIBUTION SY M - Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length ia. Length Dia. Spacing SOIL-C1 VER 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: EAU GALLE.24.28.16W, SW, NW,r COUNTY HWY. t-. ^ C~l F, Plan revision required? ❑ Yes U-1410, Use other side for additional information. CO SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION t~•~L■'■~7 In accord with ILHR 83.05, Wis. Adm. Code COUNTY ST CROIX STATE SANITARY ~ PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 3314 1 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. S95-40381 PROPERTY OWNER PROPERTY LOCATION TENG ENG LEE SW '/4 NW S 24 T 2$ N, R 16 t/O, W PROPERTY OWNER'S MAILING ADDRESS LOT # N/A BLOCK # N/A 271 COUNTY ROAD ,B CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER WOODVILLE WI 54028 N/A II. TYPE OF BUILDING: (Check one) El State Owned VILLAGE NEAREST ROAD EAU GALLE COUNTY HWY B TOWN OF: ❑ Public linn l 1 or 2 Fam. Dwelling- # of bedrooms __4__ PARCEL EL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) 008-1069-90 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 40 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. El New 2. ~ Replacement 3. ❑ Replacement of 4.0 Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ® Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 420 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 600 Feet Feet VII. TANK CAPACITY in allons Total # of Prefab. Site Fiber- Exper. Manufacturer's Name Con- Steel Plastic INFORMATION New xistin Gallons Tanks oncrete glass App. Tanks Tanks strutted Septic Tank or Holdin Tank 260 2600 1 HUFFCUT 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): lumbers Signature: (No S ps MP/MPRSW No.: Business Phone Number: BENNIE HELGESON 1;~ p NIPRS 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 Rary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stam s) n _ Approved ❑ Owner Given Initial urcharge Fee) ? Adverse Determination /d X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: vu/ SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber f INSTRUCTIONS ` 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 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. Il. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. Ill. 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 information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) S 95 -403 8 1 F,c~ W~11 `E` 5~ t~cri. AB~tivc+w • a ~r~,r Ex~~nNE> ss~rlc. !~'4Silm AS VX-R 1Lt1R f'3.C'3fi2 s r<~ Receivep - - NO, 8 R95 ^U c Pr O f ~Of":O I-bIAI' ~a~~ 1 F f=e r c e 8 HOLDING TANK CROSS-SECTION AND SPECIFICATIONS 95-40381 Approved Approved Locking Vent Cap Weather Proof Manhole Cover Junction Box with Warning Label 4" C.I. 1211 Min Vent Pipe 4" Min L Final Grade Approved Joint 18" Min Water Tight Seal Approved h - l ~ Joint w/ _ .110 R C.I. Pipe Extending ®DD 8 ND~. ~"~1D~ 3' Ontoa ©uS~DI. AHD Solid Soil DES SPECIFICATIONS TANK Manufacturer: Tank Size:,Q (2LO Gallons ALARM Manufacturer: (e L~~ Model Number: Switch Type: NUMBER OF BEDROOMS: OWNER'S NAME: Q ADDRESS: a d LEGAL DESCRIPTION: -SU-)4, Sec. T=2_~Y, R L_W TOWNSHIP/MUNICIPALITY: GcA COUNTY: SIGNED: LICENSE NUMB : S DATE : i SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations May 16, 1995 2226 Rose Street La Crosse WI 54603 HELGESON EXCAVATING W1229 770 AVE SPRING VALLEY WI 54767 i RE: PLAN S95-40381 FEE RECEIVED: 60.00 LEE, TENG ENG SW,NW,24,28,16W TOWN OF EAU GALLE COUNTY OF ST CROIX HOLDING TANK The Department has reviewed the above-referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be made. All permits required by the city, village, township or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Sincerel , ra d Plan Reviewer Section of Private Sewage (608) 785-9348 8068R/ 1 SSDA-7887(8. 10/84) Wisconsin Department of industry, SOIL AND SITE EVALUATION REPORT Page I of 3 Labor art; Hbman Relations Divis~ t of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but ST_ Ck(o t x. not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 00 /06. 1? -gd APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION M&r 4v%4erSC>k'1_ GOVT. LOT 5U) 1/4 A) U)1/4,SD T _-)8 N,R ((o E (oro PROPERTY OWNER':S MAILINIG ADDRESS LOT # BLOCK # SUBD.'NAME OR CSM # I r! w n CITY, ST TE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST ROAD [ ] New Construction Use [ Residential / Number of bedrooms [ ] Addition to existing building P-Fleplacement [ ] Public or commercial describe Code derived daily flow 6eOD gpd Recommended design loading rate NA bed, gpd/ft2 trench, gpd/ft2 Absorption area required A)k bed, ft2 Aj ~ trench, ft2 Maximum design loading rate -4-k_bed, gpd/ft2-trench, gpd/ft2 Recommended infiltration surface elevation(s) A] It (as referred to site plan benchmark) Additional design / site considerations Parent material -s; 'IE noe(C `r, Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONS ~ S D / IN-GROUND UPRESSURE ~GS DE SYSTEM El IN Fjkj HOLS G❑T UK U=Unsuitable for system 1:1 S Q U 0'[1 SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence B irlary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. B Trent U Ground 57 IM P elev. ft. Depth to limiting facto" Remarks: Boring # C i ION O " c~ 2 3 . S .'C' a.w Ground S7- V elev. ft. Depth to limiting 1:r factor r) Remarks: 191, 17 CST Name:-Please Print Phone: e Address: 6/~ r ► L l7~ Signature: Date- CST Number: PROPERTYOWNER Qrj 2~50~ SOIL DESCRIPTION REPORT Page 2C of 2) PARCEL I.D. # OD8 l e6 9 -5;'0 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench Yk S- C'.3- s b s c N~ Ground elev. ft. Depth to limiting factor~ Remarks: Boring # I-A J114 14, j Ground elev. - ft. Depth to limiting fact Remarks: Boring # s U~5S k ~s /U4- i1V4 Ground... 3 Y(3 10 Y S 5 2 8 S S wig ~v 11 - elev. ft. Depth to limiting facil r, Remarks: Boring # T 1) e- 4 cec-Rer, ej LA Ground elev. 6 ` Ls kc ( o w '1-0~ Sa ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) 3 of 3 r h,< _ .~?In ~ h ; 1 " 1 fir.. 1t t,r~r~ ~lr s o Fvncc a-K.J pr~,'pej- r1-%C 3GW'V%- YO-V- (0- 1 gy ~11 ~ 11 VV yr C~1n ~ 51 i 0 •taj ~ I L J t ~rtoc%-OCL7 Sht~ i 5(op u~l I ii zek a, CA. 0, loo.co rr ovv~ ot' Rouse.OLLsC- Q ~~q 150' 4 X Slop S j Dr-~ ~ ~ c.xa ~ C7Jer~(o~.il jj j ! j _ Excep+ As Showt- 6~~ " Q3 g~,5 Acres 51~~ HOLDING TANK cERVICING CONTRACT 4/22/95 This contract is made between tho - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Holding Tank Owner(s) Name(s) and ( Pumper's Name 7-E-N67 C-4,Q6, r!-C e 2-fE M~ 1IA" --44~FF i HELGESON EXCAVATION INC Tu I We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:) SW-41, NWa, SECTION 24, T 28 N-R 16 W 271 COUNTY ROAD B, WOODVILLE, WISCONSIN 54028 = 1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and . with tho 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 I the pumper for all charges incurred in servicing the 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 Aram. (ado, and to th@ Fnonty, a raport for th@ §Prvicing of Ilia holding tank(§) on a mmiannual bmi§, The pumper further agn to Inuluda Ilia fulluwlilu III ilia fact ltlatl11tinI topurl: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank: c. The location of the property on which the holding tank is Installed; d. Th® witary permit number i§§ued for the holding tank; o. Tho datos on which tho holding tank was sorvicod; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agroomont will romain In olloct until the owner or pwnpor torminates 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 municip C1Itil Ilia Cruelly namad ahnvo within tan (10) biihinaa§ rlay4 from Ilia dale of ohanpe to thi§ gorvico contraot, Owner(s) Name(s) (Print) I Owner's Signature(s) Subscribed and sworn to before me on this date: Lei i~ - - Y (/-66r-51 i Z 2J-15 re Name (Print) I Pumper's Signature HELGESON EXCAVATION INC I My commission expires: l _ 9 y Pumper's Registration Number 1282 5I3a-7574 (N. 11/85) This instrument was drafted by tho State of Wisconsin Department of Industry, Labor and I luman nolations, Bureau of Plumbing. GIF-,INIENT Safety and Buildings Division Wisconsin Department of Industry, HOLDING TANVA u of Buildings and Water Systems Labor and Human Relations Vet j Burea rc+J Document No. /Plan Identification No. This agreement is made between the This space reserved for recording data T Jr governmental unit and holding tank ,greement Date owner(s) REGISTER'S OFFICE. 4-22-95 ST, CROIX Co", kil County or Local Governmental Unit Holding Tank Owner(s) Rcc'd for TOWNSHIP OF EAU GALLE TENG ENG LEE APR 2 6 1996 called Municipality below We acknowledge that application is being made for the installation of (a) holding at 9:30 A. Fyn tank(s) on the following property: (Provide legal land description)„. ^nir+"rof Dory; ~L SW- 41, NW- 4L, SECTION 24, T 28 N-R 16 W, TOWNSHIP OF EAU GALLE /c. 271 COUNTY ROAD B, WOODVILLE WI 54028 Return To T1,9 fn 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 clothe 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 agreement to be determined by reference to the property where the holding tank is installed. Own Name(s) -Print Notri Her(s) atu s) ;.:ge" Subscribed and', atAQ betitore me on this date: f y~ ~r) 8 tary Public loy De Official ajm~e -Print n i Of ca ature Delp `c/ / ~ r /~d j~e My commisiibin,~if s Municipal Official Title Print -'4•• The information you provide may be used by other government agency programs (Privacy Law, s. 15.04 (1)(m)I SBD-6123 (R. 04/94) State of Wisconsin County of SL CMk I hereby cwtify than thb brat ment b a full; true and ra sct copy of the document on file and of rewd in my oNkg and halls been comparod by ma Attest Apr i 1 26 .1925 Kathleen H+ Walsh [Cathl H, Walsh later of ,7 , i~ - ,7 i I ':~,1 ~ si h~~ms.~nt r:t~ tart, :,=,r~a , fe+wtt.~:x~h !cif b (qo~ !:»'x» hr~a s: Ali 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 Lee. 1, A N Location of property SW 1/4 NW 1/4, Section 24 , T 28 N-R 16 W Township EAU GALLE Mailing address 271 COUNTY ROAD B WOODVILLE WI 54028 Address of site SAME Subdivision name NSA Lot no. N/A Other homes on property? Yes X No Previous owner of property MARY ANDERSON Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? LIZ Yes No Is this property being developed for (spec house)? Yes No Volume 1101 and Page Number 11-7 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. ,2 q`9f , 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. Signa re of Applicant Co-Applicant Dat of SianaturP_ natP ref girrnatiirP i DOCUMENT NO. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 t REGISTER'S OFFICE Donald-R.-Mary_C._-.Anderson.-- ixdxatd ST. CROIX CO., WI -_Div~rced _and-_unremdrried_ as tenants in common Redd for Record - - JAN 9 1995 conyeys and warrants to Teng_Eng Lee__and__j4__My._Van =Lee,-______ --husband..and..w3.fe,---as..survivorship..marital._propertX,--a._ 9:00 AM one-half _ nterest,__and --Tou..hee.,..a_oDe-ha.1-f._iatereat...... &U6w*A. (,Ja94. ~ as---.poi.nt._tenanta, ME ReabterofDeeds - _ RETURN TO 8aAtk_E- C9v - QS,c2~i Sri a v the following described real estate in St...CrO1X........ County, c2,Di o, State of Wisconsin: The South 1/2 of Northwest 1/4 of Section 24-28-16,& Part of NE-1/4 of SW 1/4 of Section 24-28-16 described as follows: Commencing at the NE corner of said SW 1/4; thence West along North line of said SW 1/4 until it intersects the former highway running East and West; thence South and East along said highway to the East line of said 1/4 section; thence North along East line of said 1/4 section to Point of Beginning, St. Croix County, Wisconsin. I 1'RANS~'v FEE This is homestead property. (is) (w Exception to warranties: Easements, restrictions and rights-of-way of record, if any. 10 Dated this day of ------December 19 - (SEAL) * Donald R. Anderson ------------------••----(SEAL) 1? R------- - SEAL) * Mar y . Anderson AKA Mary C. Ben ey AUTHENTICATION ACKNOWLEDGMENT Signature (s) STATE OF WISCONSIN St. Croix ss. County. authenticated this day of___________________________ 19 Personally came before me this J__........ day of December _ 19-9.4.. the above named Donald R._ Anderson and_-Mary--C,__Anderson, * husbanci __and_ wife,............................. - - TITLE: MEMBER STATE BAR OF WISCONSIN (If not- authorized by § 706.06, Wis. Stats.) to me known to be the person S_.......... who executed the eand c owledge the Connors THIS INSTRUMENT WAS DRAFTED BY =W~ oConnors C -----Krlstina_ Ogland----------------------------------- * Sjate.oj.Wisconsin l~tt0 rT1ey__ at_ Za----------- County, Wis. Notary Public (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: 67 T *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 - 1882 Milwaukee, Wisconsin