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HomeMy WebLinkAbout020-1304-10-000 o O a a. i o i o ~ ~n 0 0 N C M ti •F Oii G C1 v L u) rn M ~ N Ct Co V y ~ N I c Z a 0 LL c rn O - 3 L> N Q ~ CC I 3 LO v ~ Z rn Z _ O rn r a m o I "D co 0 z 'a d Z d Z U) F- r c E -o N m v 0) N a 7 (U • N 0 N ~ d L t O Q m Z H Z w N Z E Y N CL m a c o c CL a o 0 Z i •N 3aaa 7 G 0) C 0 LO LO U1 J U co rn rn ~ I ~l = co N N Q O ^~I J O O 7 N T h c a 21 (V Q}U o F O 00 C co N c O 9 O C v C 7 co U') 30 y U d pOj r E E 06 -0 c W Cl) r 0 U~ n N U t d N y A? Co ~ c • N N O N tc U O O r 2 N O Z S Cn i E \ '.i M C COL. V ~ # o IL a v c c c r A c°~IL Cac0 Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor a~V Ftuman Relations Jrrswn or 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 -5 ` A) I y 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. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION o -SA lY1 M I LLl.'P- GOVT. LOT SE 1/4 Nt 1/4,S 11 T 2 AR / 1 E (or) W PROPERTY OWNER':S MAILING ADDRESS LO # BLOCK # SUED. NAME OR ~,sM # - ~ '?aN. ~y L~Ot CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OWN NEAREST ROAD f ) No I-, ' "Jcy Lo-je New Construction Use Residential / Number of bedrooms u f4 K. Addition to existing building j J Replacement ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations i yA A ; too tSewe 402 Ar A PPAO V A 1 Parent material Flood plain elevation, if applicable It S = Suitable for System CO VENTIONAL M UND IN•GROUND PRESSURE T•GRADE SY TEM IN FILL HOLDING TANK U= Unsuitable fors stem S❑ U S❑ U 5rS El U S❑ U S❑ U ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourriary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed rerxh o-11 ;ov z - L 1, .SLk fbi~r a Z .4 o.s g, i t-A I Li-2 414 5 !►1 1 to s 0 7 o Ground ~Z -11 v 4 S rh Q .7 4 elev. >o7.pZ ft. Depth to limiting factor Remarks: Boring # 4 1 r2 3 i S C l c r Ai 14 Z 8, 29 0\ Q 2/ L I M b~ m4- S 2 0,416 S B 9- 54 4 - Sit. ► M LK c s I o.~ 0.3 Ground DD elev. D 4.94- 0~/2 414 _ 0 Z' /h J L' s p .7 0 0'A / c9.z t. M/ 0.7 0S Depth to limiting factor >/105o Remarks: CST Name. Please Print [,d' u Phone: 4v %-0 Address: 10, x 7 / !Y u ~1Sda1 s .23 -9 Signature: Date: 194 CST Number: 16- PROPERTY OWNER SdM I fil-IL `k SOIL DESCRIPTION REPORT Page? of PARCEL I.D.# 4 -TwNFY-RrdGc Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench A 0-126-v -e 51. 1 c r M! 5 7 /h .4 O ` ` L ) sbK M C_ 5 Z c~.4 as Ground $ Z$-47 /p'/A 414 ` sit 1 SbK C S / 0.2 b 3 elev. S ~h •7 o 107.,$ ft. V-6 `/e 414 Depth to g 7-ll l0`l~ 4 3 s n II limiting factor ~9 7S Remarks: Boring # A -z /eve 3 Z / sb n~ c s (34' 4 3 s I-ZL5-6 I0\14 4 S O Mr- C s o .7 0 Ground elev. i0AA-A Depth to limiting factor Remarks: Boring # Q Z . o /D l~2 3 1 • S $i 1 -q~ 4y~ 4 3 S~~ 1 n, sbK ~~r C S ~ D.Z ~ 3 -ll 4 4 - S rn p.7 0 Ground elev. 9-/Z~ oy►~ 4 3 5 r►~►1 0 7 0 g /06.~ 7ft Depth to limiting factor ?10,7 Remarks: Boring # 16-17 El ` e z- r' -5't- S S © n-, C 4 3 5 rkh 7 a .g 41-0,1 ~ 4/4' n r- Ground elev. Depth to limiting factor Remarks: A /lagizoc~ JAS Q-0 Se-QAPkkb A(OAY. SBD-8330(R.05/92) t::b, 100 -ZL ~ r G P1 r 6 P ~r v ~ ~jp !V V% 1 ~ I ~ ILV SIN El ~ db 0 o C rte ~ ' O p 0 / N TA iu M E:/ L X .-i S, STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER SsF/Y) ~~~LE ADDRESS $OAC~` Z L frvp 5o IY W / s Yo SUBDIVISION / CSM9 TA AIN ~l LOT SECTION P T Z 9 N-R / I W, Town of / /~JC) SO A/ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM N 2~TM GOT ~ ~ NE 'IS AA or of 1 "Pif E ALT,r uATE 48~ Imo---- b S ~ ~I ~ I/ i AR6 GI _ _ c l I i s' ° l3 Nv~ s T ) s' INNID w is I ~--WELLORTH hRRO~~' Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank m<-Inhole coved. BENCHMARK: 7-0/7 ALTERNATE BM: P TIC TANK / PUMP CHAMBER HOLDING TANK INFORMATION C Manufacturer: 4CK- Liquid Capacity: / 5'G s ~sfL Setback from: Well 13-s- House Other Pump: Manufacturer Model# - Size Float seperation Gallons/cycle: Alarm Location I SOIL ABSORPTION SYSTEM Width: S Length 6S Number of trenches 3 Distance & Direction to nearest prop. line: 36 Setback from: well: i Is ' House ~S Other ZS , 7a Z,95r 1eT1,1yE ELEVATIONS Building Sewer - ST Inlet. --7 /S ST outlet PC inlet- PC bottom Pump Off Header/Manifold Za Bottom of system I Existing Grade Final grade DATE OF INSTALLATION: ✓J ~ PLUMBER ON JOB: LICENSE NUMBER: S O-3S DO INSPECTOR: 3/93:)t I WisconsinOepartmentof 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 MILLER, SAM X CST BM EI~ r Insp. BM Elev.: BM Description: ricittamw Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Ing St/,If Inlet TANK SETBACK INFORMATION St/ Outlet /07, 3~ TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet rl Septic NA Dt Bottom Dosing____ NA Headed Aeration NA Dist. Pipe K ~S p ~sl D H. Bot. System 9 PUMP/ SIPHON INFORMATION Final Grade Man facturer Demand f° P 3,yl'7 Model Number TDH Lift Fri System TDH Ft Forcem Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width ,!S- Length No. Of Trenches PIT No. Of Pits Inside D id Depth DIMENSIONS S (rr5 ~ D N SYSTEM TO P / L BLDG WELL LAKE /STREAM Manufacturer: BER INFORMATION Type O C T Moe Number: SETBACK System: a` Cow R UNIT DISTRIBUTION SYSTEM Header/ Manifol .r Distribution Pipe(s) r x Hole Size x Hole Spacing Vent To Air Intake Length"~,5 Dia. Length ~PC3 Dia. ~ Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Gr stem 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: Hudson.11,29.19W, SE, , Lot 4, Tanney Lane U I lo Ian revision required? ❑ Yes Q-N'o / Use other side for additional information. y- SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. - ADDITIONAL COMMENTS AND SKETCH a ;~TARY PERMIT NUMBER: a I J 0 In _ m ' c 30~ SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code C TY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than a 933 7 -1 8'/z 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. PROPERTY OWNER PROPERTY LOCATION SAS LL 2 SiF- '/alVe-'/a,S TZ'r,N,R l E(o ifVo PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # ex -1`1 z s'Z-- CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER uD.S O N w Syv 3 A. 27 (o 9 Y D NEAREST 11. TYPE OF BUILDING: (Check one) State Owned CITY ROAD 1Y Ali" ij ❑ ❑ VILLAGE : / w / C PARCEL TAX NUMBER(S) L / V G ❑ Public 1 or 2 Fam. Dwelling-#~ of bedrooms '57 J;L III. BUILDING USE: (If building type is public, check all that apply) d Zd _ 3 0 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor. Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~ New 2.E] Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ SpecifyType 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED1sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 7 s o 3 7.!s7- 9 75 IF /0 2, 7 Feet /O 6. S-Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank o0 S Lift Pump Tank/Si hon Chamber 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/MPRSW No.: Business Phone Number: / E M X00 eLL- 7L1 PRS-03Sb0 z Plumber's Address (Street, City, State, Zip Code): / (~,,MXNAWZ, L E J sort) IX. COUNTY/DEPARTMENT USE ONLY a Issued issuing Agent Signatur (No Stamps)' p Disapproved Sanitafy Permit Fee (Includes Groundwater 14 Surcharge Fee) ~Approved ❑ Owner Given Initial ~Q/1 a~~G) Adverse Determination pV X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy 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 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. 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 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.' Y SBD-6398 (R.11/88) L 00'O$~' 9.Vj7 Lo7 1S~/L! W h 7 w o 60 'n J O ~ v ~ °r r M ~ ho . T m e+l ~ 1 1 r N ~ ~o I Vl z w Z c( (,L• ? rh ~ V Q ~ q 9 ac A ,o ~ a M rnw ~p,~l1 ca ~pS ra =-~I a~ z o O. r I <D s dog ~ R q- - a 4 a ~ W I M \ I t 1 ~ 11 I! 40 N I 'I i .p 4 i f I ~ ~ I J cf- W~ + ~ v i j o 2 I t ~ e ~ fi 1 VI M h v ( ,I a H e ~ J s to \ V N N Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page I of 3 •Labo7 and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY C k Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but PARCEL I.D. # not limited to vertical and horizontal reference point (BM), direction and /o of slope, scale or dimensioned, north arrow, and location and dista r d. APPLICANT INFORMATION-PLEASE N REVIEWED BY DATE PROPERTY OWNER: ° PROPERTY LOCATION p M e,-4' OVT. LOT SE 114 A1r 1/4,S I T 19 N,R E (or) W PROPERTY OWNER':S MAILING ADDRESS 0 # BLOCK# SUBD. NAME ORM # CITY, STATE ZIP C ;AH ` iddt>}t1EER CITY ❑VILLAGE OWN NEAREST ROAD N K [ ] Addition to existing building Q~ New Construction Use (7j] Resident ~ j ] Replacement [ ] Public or c Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/ site considerations L yAt_ t) A-, i d tj tso*L go-e, <A r A f Y AO'V A L Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MQUND IN-GROUND PRESSURE AT-GRADE SY TIM IN FILL HOLDING TANK U = Unsuitable fors stem S ❑ U ® S ❑ U EX S ❑ U t(S ❑ U ?S ❑ U ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends a ► 16 3 - L 1 S6k iib r o 7S z 0.4 Q.s s n~ 1 a s O•~ o~ 4 14 Ground $-z 49-1/5' y S ,7 0 elev. Io7.oZ ft. Depth to limiting factor 9Z Remarks: Boring # °J4po,~ 3/ S~ I « n,I CsZmd4o.s 29 0v le / L rh bC ,i~~c C 5 2 O p. g 9- 54 / 5; J ,fix art ; C Ground IV elev. t. g 4.94 ave 414 rh 1 G 5 0.7 19 4-J Y-e 4j3 O;A 0.7 6S Depth to limiting factor Remarks: CST Name:-Please Print ikay6y IJ Phone: 4o %-o Address: P, -66 x 9 / lAl0 fls6-, W Signature: Date: 11194. CST Number: PROPERTY OWNER 7SdM A111-4LE'R- SOIL DESCRIPTION REPORT Page? of 3 PARCELI.D.#.L6T 4 -r4NNEY-R+&(,F- Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trend A p Z D~~ 31 5 L 1 c r n, l S Z n, 4 D c S Z ©,4 ©,s /z-z~s p~ Z I 1 sbiC m Ground 8-47 /O`l4 4 _ SiL SbK `r,' C S J O.Z b,3 elev. IO -A ft. 7-67 '/e 414 S !h /I S Q Depth to $ limiting ctor 47? I Remarks: Boring # V-5-6 4 r~>s Ground elev. Depth to limiting factor > 10>~~ Remarks: Boring # 4 C :5> 'Z 16 S $i / -~S' av 4 3 S / ,z, sla1C ,fi r C 5 : 0,2 0:3 Ground 4 S lh~ p; elev. ' 9-/Z I &Y r2 4 3 S 19't 0.7 0 g 106.E 7ft. Depth to limiting factor Remarks: Boring # yy\ r i Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) a ~ r n . V W ~ p w d? 10 f" ~ \ I y VD 00 ON V i d O ~ - _ - O R, ~ - N ` N --rAIVNr\/ _Ld &J S, Yp°nr PO HIY <Yprpn■ • ri ~nvi W i V w r • / ^ r i°w°' $rweow n°N ~ . ~°ppnM~es~a~sa IF G r -on go ~ BEARINGS W REFERENCED TO THE EW- WES a E ^ w u•• r N O BBBl2o'F6o~wKCTIOM 11. ASSUMED TO BAN nr° V•''r- rp ppa f$ r ° r p P R°• IF ~i. SN irrwi lMr rnY n•- a iwir~ro•Gi ena nlBi $ r 000;4 • no'ii 9 _g • 6 • n°Y all o pS f UNPLATTED LANDS T 'rt WEST LINE OF THE SEW OF THE NEW. SECTION 11 ~2. • • SOB.M • _ Itl d LIL1\ 20?TE•~ x pa ie0 I8 \ O a tJ II~U m O x ox k px r3t 'If ~,_r z p f 6 txR xs O : r o r .p 9 o a E° s 0 ' c 3 a 0 0) I'V 8 ~yFr 032D 179.17 of O • EDICATEW ~0 4I5r PUBLIC \ aon~MOUND - T-HEROAR-SOUTH --8 p u 0\ \ / = i D j E IN.T9 E IG ! ~ i „r x / ' oo > r 2: ' m ~O 8 n a LAO 8 i° //NV/ i, B »='V Y8 O w N ~f -1 f 0 y -l I!/T I~ O U la R .A 8~ p 7 1N ir- O F/ O e N N Tl 10 i1 -t IA R N 11jT Rv ~ / N 422.N ' q R /11 0 O W 1 W O = N 182..2' 504 4408E 240.24 u i I~ w u: o R CID lot ° i~ I / r ]27.3• 0104.73' J N SOW 03 20'W 481.72 . 119.00 I~ IN R _ A ~-A H2e•~ / i-4~ iO lts Ir 0,pa~ c I<,+ o r g a W N Q 9 / O A Tom. Xt If I ;v L y \ n 0 a A\ 502. E -M g N w \ • 1 I ~o / ax a= o O I y' m a o % / • e r Sr w 0 'p # r~ w m ti 1 . t c Lk Ij X90• r' / 0 1 ~ 1 J ~ b" R ~ ~ Cp s3• la c' u a - / ' 3s R r ~I W - - ~ - \Gyo i / ~ 445 `~?qOO \ m qtq I 8 g ss,• T.NNET F LYRE J r s m e "bob r% 10 LANDS I ~1 I o • 0j z°8eF r J STC- 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County O WNER/BUYER S IVt M MAILING ADDRESS JE~D J( S Z'" V D S~ W Sy f( , PROPERTY ADDRESS 10'T<3 -TAN u r t A K F- 4450N L 'or Zyc) f(. (location of septic system) Please obtain from the Planning Dept. CITY/STATE -t~ D 50 ll~ PROPERTY LOCATION S 1/4, 1Sl w 1/4, Section t ( 1 2!7N-R / 9 QN' TOWN OF 011) S d ST. CROLX COUNTY, WI SUBDIVISION ~k I D E LOT NUMBER CERTIFIED SURVEY MAP' -7;11 s(, VOLUME, PAGE 2-S , LOT NUMBER ~T 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 Count)' 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 SIGNED: St. Croix County Zoning Office Government Center 1 101 Carmichael Road Hudson, AV'I 54016 11/<)3 f 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 S A, M /l/M I LL-K-- Location of property ~1/4 NE- 1/4, Section T Z-1 N-R / W Township j UD.S0 N Mailing address Rom ZBZ--- 400 SDA/ wa S yo l6 Address of site /O S r6 TA Al N y Li4/Y11r- Subdivision name T,4KN K 21 pe, F- Lot no. Y II' Other homes on property? YesY No Previous owner of property kAUDEE«- 5YNA Total size of property z . o 1 Ac- Total size of parcel 2, o A e Date parcel was created 9- i -'F-3 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? A Yes No Volume O 3 and Page Number S~ 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 i?3 the office of the County Register of Deeds as Document No. So 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. SD y ~ SS" S' ature of Applicant Co-Applicant 1 5 1- q Date of Signature Date of sianat,,,-P THIS SPACE RESERVED FOR RECORDING DATA i i DOCUMENT NO. STATE BA F WISCONSI ORM 1-1982 ARRANTY D D - iPAGE456 504855 VOL - r 4 41 r made between R 0., This Deed Randall W, . Synan and Patricia_E. Sxnan, Ord is husband and -wife - ` S oP45 1' 1993 Grantor, ~ i A and Sam E' M3laer' a sngle person 7 R-rts`er a1 Oee® Grantee, Witigesseth, That the said Grantor, f r a valuable consideration Randall W. S.................................................... nan and Patr~cia E. Synan .roix RETURN TO - St . C conveys to Grantee the following described real estate in County, State of Wisconsin: Ii Tax Parcel No: r The SE1/4 of NE1/4 of Section 11; the SW1/4 of NW1/4, the N1/2 of SW1/4, and the South 53 rods (874.5 feet) of the SE1/4 of NW1/4 except the East 74 feet thereof, all in Section 12; all in Township 29 North, Range 19 West, Town of Hudson, St. Croix FF~1 County, Wisconsin. AND - , A parcel of land located in part of the NE1/4 of SE1/4 of Section 'I 11, Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin further described as follows: Commencing at the E1/4 corner of said Section 11; thence S89 3010011W, along the North line of the SE1/4 of said Section, 1212.32 feet to the point of -',ginning; thence continuing S89 3010011W, along said North line, 66.00 feet; thence S00 28103"E, 500.00 feet; thence N89 30100"E, along the North line of Certified Survey Map filed in Vol. 113", Page 722, 38.08 feet; thence N00 1113311W, 150.00 feet; thence N03 58134"E, 351.07 feet to the point of beginning. This i.,R-Agir,_... homestead property. (is) (is not) Together with all and singular the hereditamenta and appurtenances thereunto belonging; nan and Patricia E Synan . And-----A 114A1.1 W-°--•--Y warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights-of-way of record, if any. and will warrant and defend the same. 19..9.1. Dated this day of AAQLiSt ~ 11 - ~L--- (SEAL) RGI/Yt~C' -14 -C/, (SEAL) ~Orsf~u-cam! Randall W. Synan a Patricia . Synan ' y ----(SEAL) ........................(SEAL) l ACKNOWLEDGMENT j 10 AUTHENTICATION STATE OF WISCONSIN II St. Croix county. sa. 19 Pe sonally came before me ..../-1........ day of !,I authenticated this day of August 119 the above named S nan, Patric Randall W. ia E. 1 ..-•----------•--•--•----•---Y--------•----••--•-••-•• TITLE: MEMBER STATE BAR OF WISCONSIN Synan I ~ . (If not, 'I II authorized by $ 706.06. Wis. Stats.) S. NxIE't he to me known to be the person ~ ~ 5(a0 _ qgoininstrruu g nt and a n wle THIS INSTRUMENT WAS DRAFTED BY Kristina Ogland . o ors At corrtep..at..l;aW Alice Joy o Notary Public Of X .County Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. f not, state exp atlon are not necessary.) date 1Q7) *Names of Persons signing in any capacity should his typed or printed below their signatures. • WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FORM No. I-1982 :Milwaukee. Wis. i