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HomeMy WebLinkAbout016-1030-60-100 ti '0 0 cam. ~ ' O I ~v y 0 0. o I c o N O E ti O y X J G ~ Y q I c o 0 1 h D o 00 .O c o 0 LL o U .J N '0 N Q v 3 Cl) z E ~n z o ~ v o I z £ a d v ~ Z a m .N o c o z v N Z d' 7 ~ .p I Z N fn F- r N 0 0 ~ I N C 0 7 O O z z Z Z o N z N A M N O y d N CL c0 O m o o y o oo 25 G G d a N N Z > N F- H d E w N O O V V 0 0 3 a Z O O • o a a pr d 3 c Lo U) 0 0) 11 Q) 0) 0) fA J U rn rn ~l j N co M CO tm 0 0 C A N ~ N N I > C) 0 _ > N O O a N O N 3 w O I' O) y N _O 3 M_ U) C O C E 1©V Q 00 O) Oc N f0- N N C N 0, 0) 0 0 N _ 0 Y C N N 1) C E ~ N C'7 N ~ O In o 0- O O N -0i t O ~ En 'o _ O C O N F- N O 04 M N 0 0 N d m E 0 C • L O~ C~ Y N O N~~ Cn C~ w V1 a ip ► a SL N d w •V • G r A v a 0 y v i STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER r ADDRESS SUBDIVISION / CSM# /~O 0,30 - O O LOT # SECTION T1'0 N-R_ W, Town of ~,L e/V mid a !l ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Z' G'aRNeA Pa s1` I PRopased ~ ~,qn~t fto t~S~ 9' b h et L si7`~ ( /~®o-boo INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. Y BENCHMARK: &M/00 OA- LyOOcl eaR"ye"? ALTERNATE BM: 7Q"yz"° /7,-0/0 O , 3~1` yS,0eGr7`/01V SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Z&/eSe/Q Liquid capacity: /0-ey --moo Setback from: Well House Other Pump: Manufacturer (7;aa46 -Model #d&ea3/C Zsize 0 4P Float seperation i~ Gallons/cycle: Alarm Location 6,4.s-e, Ni °/Y/-,- D ---XP kxe~ !l Y .SeRY%G e lg ~Iy l_ SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House J'E1 i Other ELEVATIONS Building Sewer ST Inlet. ST outlet PC inlet PC bottom Pump Off yo, UQ Header/Manifold Bottom of system Existing Grade it Final grade 77. d l DATE OF INSTALLATION: PLUMBER ON JOB: ..4e,5:9~ 441a~,17 LICENSE NUMBER: /S'I/o,s69D INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sa n ita ry Perm it No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State Pla KNOPS, PETER X CST BM Elev.: Insp. BM Elev.: BM Description: , y Parcel Tax No.: TANK INFORMATION ELEVATION DATA y~ TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV- Septic e~SE.✓ C'►C - D Benchmark / ,77 Dosing Co, 611-7a,4;c GCS Lt ,d~~ Aeration Bldg. Sewer , 3 SJ Holding St/ Inlet q ' TANK SETBACK INFORMATION St/IROutlet Vent TANK TO P / L WELL BLDG, A ir Ito ntake ROAD Dt Inlet Septic NA Dt Bottom 3 33~ ,2~ Dosing NA P/ Man. / Aeration NA Dist. Pipe 9 Holding Bot. System `0/ 97 - PUMP /'INFORMATION Pn1 Final Grade Manufacturer Demand 4'f , W Model Number (.t~ L, 75t rdMi ~ ~ o 'C C%~J TDH Lift0 Loss ~(p Sysead tems I TDH jj Ft Forcemain Length Dia. H9 n Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width , Length No. Of Trenches PIT No. Of Pits Insid ia. Liquid Dep 1\10 DIMENSIONS DI I N SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING cturer: SETBACK INFORMATION Type O h -J CHAMB Moe Number: Q~ System: n^c d OR U T I'll DISTRIBUTION SYSTEM Header/Manifold A,zd Distribution Pipe(s) r x Hole /Size x Hole Spacing t To Air Intake Length Dia. Length Dia. 02 Spacing h~ 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 /_Ir k enter Bed / Ecles Topsoil Yes g C] [I No ❑ Yes ❑ No q COMMENTS: (Include code discrepancies, persons present, etc.) 'LOCATION: Glenwood.14.30.1 w, NWf 160th AVe e f / Q 0/ 1 I l Gc" pl I`~revtsion required? [E3] Yes Use other side for additional information. 9 p L SBD-6710 (R 05/91) Date Inspector's Signat re Cert. No. r ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION BureaSafetyu o oand ff BuiluildiinWater System! ngWater 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. .Sy` l% w / • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs a 14 cl -70 Z ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan LET. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION S7-6-- , o, -a Propert Owner Name Property Location N Rr) W e A O ~S )V4 j 1 /4 W 1/4, S Tao Property Owner's Mailing Addressd Lot Number Block Number /7 v$ City, State 7 Zip Code Phone Number Subdivision Name or CSM Number ,4 fN zua adG' ^ 6 ( 24r ) 215= II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ itv Nearest Road E] Public 1 or 2 Family Dwelling - No_ of bedrooms E Town of III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 0 /e - /0 _Zo -la 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 System Tank OnlyExisting 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 00 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 Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft_) (Min./inch) Elevation Illro -7 7.S 37 7,e~ l r 9~ ,~',.Z Feet d~Feet VII. TANK Capacity gallonTotal # of Prefab. Site Fiber- Plastic Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App- New Existing strutted Tanks Tanks Septic Tank or Holding Tank X p7~jJ .1j /16 S_e_ 0 El I El El El _E1 Lift Pump Tank iphonChamberl X I I er X00 r/ ® El 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 Stamps) MP/Pd.: Business Phone Number: 17 - 1101/1 1 Plumber's Address (Street, City, State, Zip Code): 1.2- a 00 H Lv ?o lrZ e-& Gv o0 co" C 7" k, _,!Polo / IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved San tary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) AApproved Surcharge Fee) ❑ Owner Given Initial Adverse Determination b T X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SRI)-6398 (R. 05/94) DISTRIBUTION: Original to County, One cupy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at 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. It. 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 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 oroduct 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 1/2 x 11 inches must be submitted to the coL my The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, locatio. of l,, ding tank(s), septic tank(s) or other treatment tanks, building sewers; wells; water mains/waters strel is a,~ I lakes, pump or siphon tanks, d; s r ~)uiton boxes, soil absorption systems, replacement system are,,s,- ar:(. the loco t on c f the building served; `,o,,2orw! and vertical elev<:tion reference points, C.i 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 sot! absorption system if required by the county; E) soil test data on a 1 15 form; any', 9 all sizirg 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 contamination investigations and establishment of standards. lye L -e, i 111!III ~pRoloo$eat 4r_ eL~ k 'Fi om Se,oJlic AN/f Home i j- - i % s,t o p~ "104z; -I UrYd/s~`NRdea/ c 4Re~ _ Z aA4 - _ SCE e - / 3e uN Less ivo and 4 JJ I k r~ I r ~ Y 4F.E i _ _sg1- a52: Page ? Of S Straw, Marsh Nay, Or Synthetic Covering Distribution Pipe Medium Sand G Topsoil F E D 3 b % Slope Bed Of 2M- 2 2 Force Main Plowed Aggregate From Pump Layer D . E . Cross Section Of A Mound System Using F ' 3 A Bed For The Absorption Area , G ,D Ff L-~'' ~p A y Ft. Signed: GaJ .4~ B 9 . Ft. 1~ ,S"~9D I 9 Ft. License Number: Ft. Date: K 1D-17 F`t- L Ft. Ft. Observotion Pij)e-~ A Force Main W ° From Pump Distribution E3ed Of Pipe A9gfeg,ai;e`-" DE's!. Observation Pipe )ent Morkers ti U Plan View Of Mound Using A Bed For Tfie Abso(pk n A(ea 595-20524 , Page Of- Perforated Pipe Detail End View ~PerforoteC Erd Cop) F VC f',pe ~,I~`~~t A.- - Cr 6 Holes Located On Bottorn, Are Equally Spaced / K -FoR G i"vI141N .r `j t'ipr asr t4.-le Srou'.1 Be Next to E^-0 C-cc Ent cr' _[)i5'rih~tipr F'i:e`l Ovr),1~- r 90~ Ft. P J X Inch FS ' Inches hole diameter Inch Lateral oZ Inch Manifold Inches (late: FoY'c ~hlain Inche:. of holes/pi pe-,,2l I I-vert Eleval.ion ov Laterals77,-J?2 Ft. DEPT. OF INDUSTKY. LABOR 8 Nu ~,~i+ DIU ` N OF SAFETY AND BUILDIN" )rjDENCE -11F~- S95-20524 PAGE OF. PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS VCNT CAP 4"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING JUNCTION BOX MANHOLE COVER ? 25, FROM 000 t, j 12"MIU. WINDOW OR FRESH A.IR INTAKE GRADE 1 4° M110. _ ~ IB"MIIJ. COQDUIT `r - 7L PROVIDE I - I~I ET AIRTIGHT SEAL I ~ I APPROVED JOINT A I III APPROVED ~C J" C.T. PIFE I III W/C.I. PIPE EXTENDING 3' I ALARM EXTEfJDIU(. 0)JTO SOLID SOIL., B I I I ONTO SOLID S A I I I Cti c I I ' CLIV. Ull F02FT. - PUMP L OFF D CONCRETE BLOCK ISER EXIT PERMITTED GAJLy IF TAUK MANUFACTURER I-1,11,S SUCH APPROVAL SEPTIC SPEGIFICATIOI`!S TAIJKS MAN FACTURER: ~~~`Se/~ yOM6~/ NUMBER OF POSES: PER DAB TAIQIK ;,IZE : /0~~ 60 0 C~ALLOIJS DOSE vt~~lr~,~ INCLUflfI~FIG BR`s' , W~ ' GAttOr S ALARM_ MANUFACTURER: S,T,,,riedtto MODEL WIJMBER: CAPACITI.E$ ~ CHES OR ,-Zj~'~ GALLOti i SWITCH TYPE: ~RG~~fR Iy?""`►' INCHES OR GALLC0 i PUMP MANUFACTURER: 6:0 w O r.INCHES OR GALL01'.:3 GALLOr!S N MODEL IJUMBER: D= ryr° INCHES OR SWITCH TYPE: _SJ~Le~~`'RO DAD MOT E: PUMP AND ALARM ARE TO BE MINIMUM DISCHARGE RATE GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEE111 PUMP OFF AND DISTRIBUTION °PIPE.. 0, D FEET + MINIMUM NETWORK SUPPLY PRESSURE . 2•,5 FEET + ..L_-FEET OF FORCE MAIN X ~36 F/opFtFR1CT1okIFACTOR. , /'OZ FEET TOTAL DYNAMIC HEAP L.al,6 -A F9b5 -20 5 INTERNAL DIMILUSIONS OF TAIJK: L.EIJGTH y3 ;WIDTH _ -;LIQUID E)EPTH,-Jp/ -e = 8.? awZ, PeR iaCh SIGNED: LICEWSE tJUMBER: INP67;6Ze -Orl Goulds Submersible Effluent Pump C~ 3885 lol j 1 CANADIAN STANDARD ASSOCIATION Sh APPLICATIONS • Three phase:''/2 HP - FEATURES Motor: Fully submerged in Specifically designed for the 1'/2 HP 200/230/460 V, Impeller: Cast iron, semi- high-grade turbine oil for following uses: 60 Hz, 3500 RPM. Class B open, non-clog with pump- lubrication and efficient heat • Homes insulation, overload out vanes for mechanical seal transfer. Farms protection must be protection. Balanced for Designed for Continuous • Trailer courts provided. in starter unit. smooth operation. Silicon Operation: Pump ratings are • • Motels • Shaft: threaded, 400 series bronze impeller available as within the motor manufacturer's • Schools stainless steel. an option. recommended working limits, • Hospitals • Bearings: ball bearings can be operated continuously upper and lower. Casing: Cast iron volute • Industry without damage. • Effluent systems • Power cord: 20 foot type for maximum efficiency. standard length (optional 2" NPT discharge adaptable Bearings: Upper and lengths available). for slide rail systems, lower heavy duty ball bearing SPECIFICATIONS Single phase: 1/3 and'/2 HP Mechanical Seal: Silicon construction. Pump: -16/3 SJTO with three carbide vs. silicon carbide Power Cable: Severe duty • Solids handling capabilities: prong plug. %-1'/2 HP sealing faces. Stainless steel rated, oil and water resistant. W maximum. -14/3 STO with bare leads. metal parts, BUNA-N Epoxy seal on motor end • Discharge size: 2" NPT. Three phase:''/2-1'/2 HP elastomers. provides secondary moisture • Capacities: up to 128 GPM. -14/4 STO with bare Shaft: Corrosion-resistant barrier in case of outer jacket • Total heads: up to 123 feet leads. On CSA listed stainless steel. Threaded damage and to prevent oil TDH. models - 20 foot length design wicking. • SJTW and STW are . t on three O-ring: Assures Mechanical seal: silicon phase models dels t to guard 9~ positive carbide-rotary seat/silicon standard. against component damage sealing against contaminants carbide-stationary seat, 300 on accidental reverse rotation. and oil leakage. series stainless steel metal parts, BUNA-N elastomers. • Temperature: METERS FEET 1040F (40°C) continuous 90 140°F (60°C) intermittent. - - SERIES: 3885 • Fasteners: 300 series 25 80 SIZE: 3/4• SOLIDS RPM: VARIOUS stainless steel. wE1 ~5GPM - i . • Capable of running dry 70 WE1 5FT without damage to 20 - - - - I r___-_ - - components. W 60 Motor: S? • So 15 Single phase:'/3 HP, 115 z - or 230 V 60 Hz, 1750 RPM; J 40 weo R j 1/2HP,115V,60Hz, a - j- 3500 RPM; '/2 HP -1'/z HP, ° 10 30 T 230 V, 60 Hz, 3500 RPM. weo Built-in overload with 20 ! j automatic reset. 5 - Class B insulation. 10 ! 0 - L _J- HIT., 0 0 10 20 30 40 50 60 70 80 90 100 110 120 130GPM L I 0 10 2'0 310 m3/h CAPACITY 595-20524 ©1994 Goulds Pumps, Inc. Effective May, 1994 11 83885 SOIL AND SITE EVALUATION REPORT pap Or,.1- D'LHR in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but 5' C not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. 8 dimensioned, north arrow, and location and distance to nearest road. d /'X- APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATInN GOVT. LOT 1/4 1/4,S T 7 N,R / for) W PROPERTY OWNER'S MAILING ADDRESS LOT N BLOCK 4 SUED. NAME 0 CSM # A02 Figg "r /_7'Q. CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE (,MOWN NEAREST ROAD el I b(j New Construction Use [ j Residential I Number of bedrooms J*7 (J Addition to existing building [ ] Replacement [ j Public or commercial describe Code derived daily flow 4" gpd Recommended design loading rate & bed, gpd/I12125' trench, gpd/ft2 Absorption area required ?7_!5-' bed, ft2 ,?;!5- trench, ft2 Maximum design loading rate bed, gpd$ -'-trench, gpd/112 Recommended infiltration surface elevation(s) 7. ?"Z It (as referred to site plan benchmark) Additional design / site considerations ox' 5i# Nd N N do q S~rs7"cM ~M o l-1N d~ Parent material GAL A d Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ❑ S ® U 0 S ❑ U ❑ S ®U ❑ S O U ❑ S ®U ❑ S O U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 51 ,2m IVA d S 7 S/L~ Ig Lt/ r 0. J r .2 M f,6 ~ ~r _ Ground X elev. gs~ft. Depth to limiting factor T_ I Remarks: 111~4& ~ I Boring )'--R 14S M - ` C 2 Al A I. 13-V 19 Y~& 21_rvv~ 2M A~ Ground elev. 0 2ft. r~ a -I A, Depth to ,,limiting factor,/ 'y~ t~V I>~s Remarks: _ CST Name: Please Print ~A~~ e G~ Phone: 7I L6-- .2 'CAI Address: 1.2,;2,? &4."v 17e 6;~ / Signature: Date: b ^/I; 9~ CST Number: P EWOWNERA,66At Aflek itz SOIL DESCRIPTION REPORT Pap of PARCliI.LD.# 616 - /D3® , Za Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rends o - o s ifs lv3 2 2,4M 'Vla - si )f t C W . 6 Ground S AA /V M F elev. ys~ft. Depth to I limiting factor I i Remarks: e- ✓r Boring # I Ground elev. ft. Depth to ' limiting 1 factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # i Ground elev. ft. Depth to limiting factor Remarks: i r-- Ply" -An I I C/I _ - i i J i ! I r OA4 i - J ~ i F ~ I I I i i L I I i 1--_ I 11 I I F F i ~ f 'I I _ I l - - I I I ~ l I t-J- STC-105 SEPTIC TANK MAINTENANCE AGREEMENT n ~iSt. Croix County O WNER/Z e MAILING ADDRESS X02,5- SyJvl e ,4 le (71 e:-w ado 0" e /;7y 4> PROPERTY ADDRESS ~C 0 (location of septic system) Please obtain from the Planning Dept. CITY/STATE (5-'l e1V Gyd O' d z ~y , /4-,.,/ ~4-"/.3 PROPERTY LOCATION 1/4, 1/4, Section, T _~?a N-R 1S W TOWN OF G1 (°/Y G`/d d ST. CROIX COUNTY, WI SUBDIVISION - LOT NUMBER CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three U9 ion date. SIGNED: C~ DATE: _ /i 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 A.~ / I lya "9,5- Location of property Alk) l/41/4, Section ,T;N-RW Township (Z4 & ct l o a p( Mailing address` S'y , GL env u.0 G ~L`- Address of site a _th 14 ye, Subdivision name Lot no. Other homes on property? Yes No Previous owner of property 101 Z/;, elf 7` Total size of property. L1D f~ Cf~ e Total size of parcel LfD Date parcel was created 9- 7 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes _/No Volume IV f and Page Number Oo2 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. ?3 S-. -7 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. Signatur of Ap icant Co-Applicant 5 Date of Siqnature Da et of Signature DOCUMENT NO. THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED STATE BAR OF WISCONSIN FORM 2-19821! 533539 REGISTER'S OFFICE ST. CROIX CO., WI Recd for Record Robert J. Palewicz, a married man I! - SEP 7 Z9~~ - - - - - - at 1 II ..Peter.-Kim-Kno s and Brenda Kno s 'I 2.15 P. M conveys and warrants to P----- p.e y l II ~ .husbansi__and..wi.f_e_,-.-as.. survivor~ship._marl.t.al.- . pxgr.opert:y. Register of Deed I - - - v ~ - the ? II following described real estate in ......._..St. Cr -olx - - - II of Wisconsin: - County, State Tax Parcel No:.. 016-1030-60 I 'I The Northwest Quarter of the Northwest Quarter (NWJ of NWJ), of Section Number ~I Fourteen (14), in Township Number Thirty (30) North, of Range Number Fifteen ~i (15) West. I I it ~ I ;I i ~I IRAN SF 1:;, FEE' I j i I This - - --not----------------- homestead property. (is) (is not) I I I Exception to warranties: Subject to all easements, restrictions and covenants ii of record. r ii ~j Dated this September - - - day of - - 19.. _5.-. l - - - - L) (SEAL) ~I Robert J. Palewicz ~ I --------(SEAL) ---------------------------------(SEAL) I' I I !I AUTHENTICATION ACKNOWLEDGMENT i! Signature (s) .....Robert-J. Palewicz STATE OF WISCONSIN i ss. 1i/-A, County. li I, authentic ted this LY_-`day of Sep ember 1995-- Personally came before me this ________________day of I l , 19 - the above named' II *_--_Hendrik_-W. Van_Dyk L TITLE: MEMBER STATE BAR OF WISCONSIN (If not- II authorized by § 706.06, Wis. Stats.) i. to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY REINSTRA & VAN DYK, S . C . I 201 S. Knowles A venue s - WisEansin-.54.017--------- Notary Public CountWis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date: - ri'd I II ames .)f persons signing in any capacity should be typed or printed below their signatures. I I I WARRANTY DEED STATE BAR OF WISCONSIN Wisronsin Legal Blank Co., Inc. l FORM No. 2 1982 Milwaukee, Wsconsin