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HomeMy WebLinkAbout020-1304-50-000 Q c ~ o I O c M ~ ~I c q y O r. 0 i C a I C~j O O a x 'Itt _O O p i Y cn C _N (6 6 O r C N 7 C N 4 I I 3 ~ O Z y o Z ~ m d ' N w a m c 0 o zv' c o ° c z ~ a .p v m N c 7 N N N N ~ • ~ N ~ C O .m ►~1 ~ 4. u) ,c _ Q O O o Q w CO z m z Q N Z Q CM Q1 ~ O U') LO N " d i N C 0 00 00 C CD o a a a 0 N Nw C to m to E O Z O O •ti m 3aaa N a Lo n w N C) (0 o N N p c) N O I O E O ~z cn m d r O C m N co O N Q Q O r+ E 00 CC) CC m C O0 C C 7 0 O n o aUi a s CL T N N V (n E E O0) C M O o C,4 12 - CO O O a rn b.r N ti N m ~ ~ "O N O N 7 = N E E U r w Cr ~ w ~ ~ E m ✓)y m y a it a a • ~ II. v V N a~+ C C C 7 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 54114 M I CLLR ADDRESS 80k *2,?z- SUBDIVISION / CSM# T/-NNY R/g6,r- A-/AE ~0 4~ LOT # SECTION 17- T Z'? N-R W, Town of HL10.5oiV ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM L6T*'' 12,03 AC, SeAt- E '(4r _ )o' r'7 41 v ~ WELL -~7 9z' !4 n Q4 }(JtI;E e z6 ---yt~-- 3 I - - a -7 (6A2µ6E - auxz_y I DIVE \h'A y t/; t AL7C i2 AIAT - INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: Top o~ IeON ?IPE. A-r S.F. Lo7~o~N~R F-/: 6,43 - iDV, Ov -1 71 ALTERNATE BM: Top o ~ B I DC k f©vi(DAT 10 A) E/, . 3, $ S = l D 2 , (o ff SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: VVE/SE,e. Liquid Capacity: /ZSO6,4L Setback from: Well House ZG Other 4V rep Nf LoR*,e eF,%w5E Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: /51Length SO ~ Number of trenches - Distance & Direction to nearest prop. line: Z.7"T"oFEAST LoT"L/NE Setback from: well: 9Z House 3YI Other 5~2/ TO 50078 L071-1NE ELEVATIONS Building Sewer ST Inlet Z=9753 ST outlet 71' 70 PC inlet PC bottom-- Pump Off Header/Manifold 9-yy = 9G.SS Bottom of system 0 = S, S 3 Existing Grade Final grade /oo, rya " DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: A4,R A 5 - 0,9620 INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: I ibor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: PeMILLERS Name:: ❑ City [I Village (Town o : State Plan No.: , AM - - CST BM Elev.: Insp. BM Elev.: Description: Parcel Tax No. d0 c w. 6,d 7,sa"~e as TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic PoSCT yf ~ ~ ~Sd Benchmark - S!5 /a eO Dosin 3.97 16o, 5e, Aeration Bldg. Sewer Holding St/}K Inlet 9,jp~ 97' TANK SETBACK INFORMATION St/)K Outlet 279 6,76 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet 4- d Air Intake Septic © NA Dt Bottom Dosing NA Heade G S3~ io. z✓' Aeration NA Dist. Pipe /2 17 H 0K ng Bot. System //00' ' Jr c17 i PUMP/ SIPHON INFORMATION Final Grade 7a' spa Many Demand ln,a-4 /(!e Model Number PM E TDH Lift Fri TDH Ft Forc_ Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width , Lengthy r No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS N C SYSTEM TO P/L BLDG WELL LAKE/STREA _M -1EA_ SETBACK HING nufadurer: INFORMATION Type Of htj rn o CHA Z System:H r9- OR-UNIT DISTRIBUTION SYSTEM Header/Manifold „ Distribution Pipe(s) „ / ole Size x Hole Spacing Ve Air Intake Length ~ Dia. Length ~ Dia. Spacing to SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Syst my Depth Over Depth Over xx Depth Of x seeded/ /Sodded xx Mulched Bed / enter Bed / es a - Topsoil ❑ Yes E] No E] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.11,29.19W,SE,NE,LOT 8, MOUNDS DRIVE„ 17 Plan revision required? ❑ Yes Use other side for additional information. J~-- SBD-6710 (R 05/91) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: L I _1q SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code L<~, n „D STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than Z Z 8 3 / 8 8% x 11 inches in size. CK 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 s LC.F42- S JE '/4 S T ZIP, N, R E (or )o PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # ,8oxZ"'Z _ S/ CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER o u 55/0/4 3 Z-747 T/IXN / De. r- S z- S7 sG II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned ~f O VILLAGE ~vSON v N 40 S D~ V+~ ❑ Public X1 or 2 Fam. Dwelling-## of bedrooms ! PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) D L _~3C7- S O 1 ❑ Apt/Condo 2 ❑ Assembly Hall 60 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 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~ New 2. ❑ Replacement 3. ❑ Replacement of 4.E] 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 300 Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 430 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 Loco $ Sc~ . 1j 00 .7 173-1 r Feet 9 If S Feet CAPACITY VII. TANK Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks sfructed Septic Tank or Holdin Tank X / ( S E F7 n I F-1 Lift Pump Tank/Si hon Chamber F] El I F1 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 mps) RSW No.: Business Phone Number: M144 M ` IYE 41- MP/MP s -035bO 3rd S6s~ Plumber's Address (Street, City, State, Zip Code): `10 / 0 k4r u_. 1 QI~ N~vso~ W / Sao/~ IX. UNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e slue Issuing A ent Sig No S ps) Approved E-1 Owner Given Initial Surcharge Fee) / Adverse Determination ! 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 i 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. ll. Type of building being served. Check only one and complete. # of bedrooms if 1 or 2 Family Dwelling. 111. 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 I 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) ~/ES7 !oTliNC 2 O1,' 7~ D c ~ p r- c k-A Z .70 ~ b z _ r n U C o ~ G y oc1 o~ h ~ l11 ~ ~ r Pu d O ---job In v O Z o w rn d-v 0 nl w fn -t, O m ~.T rn ca h' Q Pool 41, a F~ ,t?4 a r ` r , . k 41. z I I I I ~ I ~ z I I = I ~ ~ I C7 m I I I m I I O h O I I I ~ I 0'~ CA 0) (A y. I L o J . ~ ~ I I I m I I -u C) t4h z I i v ! I -v o I w m 3 v I I I CA I 'd I I ~ ~ ,P I Q I I 1tr m ~ aI z W : tI cc, o Z LA V -u s~ C b r m .1 to VZ Az~` M X V O e v r. m O o ~=O -u o tA z m r1 -P C rri ~ o Z O \ g Safety and Buildings Division ~~i~'■•i~ 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 8 112 x 11 inches in size. S~ • ~t''O • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency Y Y Y programs ❑ Check if revision to previous application IPrivacy Law, s. 15.04 (1) (m)]. State Plan LD. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location S EI 5E11441E 1/4,S TLS' ,N, R/ E(O W Property Owner's Mailing Address Lot Number Block Number O # Z-b -.-19 1 City, State Zip Code Phone Number Subdivision Name or CSM Number UDSON S O (46) Z (6 'r4N V 41D6E- II. TYPE F BUILDING: (check one) ❑ State Owned ❑ citly Nearest Road ❑ Public 1 or 2 Family Dwelling - No. of bedrooms 3 rowan OF ICI U 5 I AA DUB( 0 S DR/ VE III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 6 ;?o _ /30 q- 050 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 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 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 [X Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq_ ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation (p 1/ Z d U~ 7 /-Si S Feet 4X, 0 Feet VII. TANK Ca in gal Ions Total # Of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank ~D ~~SL~~ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume respo si ility for installation of the onsite s wage system shown on the attached plans. Plumber's Name: (Print) P ber's Signature: (No mps) /MPRSW No.: Business Phone Number: 3,?i - Plumber's Address (Street, City, State, Zip Code): G/ / CIZE,E Al M I LL LAHZ J AS01~1 W y0 /(o IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved sS itary Permit Fee (IndudesGroundwater Date Issued Issuing Age Sign ure (No amps Surcharge Fee) Approved ❑ Owner Given Initial p/1 Adverse Determination 4C/ - X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County. One copy To: Safety s Buildings Division, 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 'I or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank; list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks receives 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. Comr;iete plans and specifications not smaller than 8 1/: x 11 inches must hA SUbmit?ed to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holdincl tank(s), septic ank(sl or other treatment tanks; building sewers; wells; water mains/water sevi(e; strearis an lake-,: pump or siphon t ar,k; ; Ji-,., i ;ution boxes; soil absorption systems; replacement system area;, a,.,i 0e loc,,tior-I 0 the building served,- ')orix ":sal and vertical elev<iJon reference points; C) complete specsficatio- for pumps anc -ont-ols; dose volume; elevat,on di fferences friction lass; pump performance curve; pump model anc:: t; _:mp manufa:_ urer, D) cross section of the soil -absorption system if required by the county, soil test data on a 1 1 for-n; an:? F) )l ,izinq 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. 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N•p[ 1 ° MOI1Jlt ~Mi114 /O MM Ml !0 1Y11 ~M a3IEd-sd►in ° } 3 3 ~ e " S 3 A oil t Z •.i• •i m"•m v mwg •°0.0ciu . _ $ s e w 3:9: Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Human Relations (Division 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 ize. Plan must include, but cpzo of not limited to vertical and horizontal reference point ti of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and dicta &J rest roa . APPLICANT INFORMATION-PLEASE P j *ALL It ItATIO/J REVIEWED BY DATE PROPERTY OWNER: J, , ERTY LOCATION o /LL Q I v 0 LOTS E 1/4 J& 1/4,S / T 2q N,R 7 E (or) W M M' Ft WR PROPERTY OWNER':S MAILING ADDRESS - C' 1- 1, BLOCK # SUED. NAME OR C~yI # CITY, STATE ZIP CODE ;,"E B ;yy ITY ❑VII LAGE OWN NEAREST ROAD - O >64w TANU A►Ci J!-New Construction Use [T(] Residential / Number of Dedt U to K [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 0 b 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 E V A. L UA ;1O N ho,.) t: T~OP zAr 40P IRo VAL Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL OUND IN-GROUND PRESSURE T RADE SYSTEM IN FILL HOLDING K U= Unsuitable fors stem ~I S0 U S❑ U S❑ U WS F-1 U S❑ U ❑ S L U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bwxiary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmrch A p 2 L I ri c, n r C rh 0A a. SQL n, shy ri,~ G~ z .3 Ground ,1k 4 S 0 Yt+ I .8 .7 Cg lev. 9~, 4'/ ft. Depth to ~o,JS z Lby~ limiting fact~or~ 61-121 p , 3 'f' ri~ C S Remarks: Boring # A Q -n JQ~/r2 3 J L M C r r►, r C ZM Q 4 '•.C~ •S /6x/R 4/* s , ! sb cS 1 F O z o .3 8z 21/7 16VA s Al a g Ground elev. 100 :S4ft. J~jC L oN ~Z LA v~ 1e Depth to , limiting 16YR4 3 S 7 /yt GS 0A Remarks: CST Name: Please Print Phone: Address: Signature: Date: 1 f ✓1 4~ CST Number:S4qR- PROPEMOWNER-SAfh M/LLOA SOIL DESCRIPTION REPORT Page? of 3 PARCEL I.D. # LOT O % ANA WY i &CG Depth Dominant Color Mottles Structure Bed TM Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bourxlary Roots Bed Tn 3*%~M" r L r" r r C S r~ 0 A b A 0-z a 1 b~ 3 ~-42 / o~P 4. 3 M ,b ~ 0- Ground 2- IZ lD'/ 4 4 S /1 i 7 0 elev. i0b,20 ft. Depth to limiting factor > 1a4Z Remarks: Boring # l r~ r r c s Zrh 0.4 p S < > A /~~i~e3 L 4 $ iby~4 ~ 03 Ground elev. rob, - ft. Depth to limiting factor > JO k~ Remarks: Boring # _ r 3 1M Cr 92n, 6.4 1224 /d`/ - S 1 m sip n~~ 5 0 Z `O ; ~ ~ i4-3-7 Jav~_ 414 Ground D elev. Ig3 7-1Z IDy S n, 6, t 0.~ 00, I I ft. Depth to limiting factor 7 /a.Jl Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) M 84 1 I G j_ yt j~ O ¢ ue / e-yi L I 1 \ gs J t Vr r ~ l~\ 4 M ~p~ 39p~r} ~ VV ~ V' 77 STC- 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County O WNER/BUYER Si4 M 141 /L L ,E e- MAILING ADDRESS Qox -W Z$ Z- µv jy5©0 w SYo16 PROPERTY ADDRESS 10 ~ ~ 1\4000p 5 D2.IVE (location of septic system) Please obtain from the Planning Dept. CITY/STATE t~U Lb *LON W I C-Vol 6 PROPERTY LOCATION S L- 1/4, N-F- 1/4, Section / "I- Z' N-R TOWN OF H- L,) D 504 ST. CROIX COUNTY, WI SUBDIVISION T!¢IIIIVP ~Ifl6~ LOT NUMBER CERTIFIED SURVEY MAP slS9fG ,VOLUME(o,PAGE a'S,LOTNUMBER 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. UWe, 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 SIGNLD: DATE- _~--Z_ O - - St- Croix County Zoning Office Government Center 1 101 Carm ichaci Road Hudson, \1I X4016 11/93 sTC - 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 :54M M l LL € CL_ Location of property S 1/4 NE- 1/4, Section T 29 N-R Township 4 U D -ZZD N Mailing address any zrrL_ 4- V i-i5 nM W I -5-q0 1G Address of site N\bVRD AQJk1~ 4ut SotkW 1 s-t~ol~ Subdivision name 7 ,40 R (D (oE Lot no. Other homes on property? Yes X No Previous owner of property _ /ZA N O ALL S V iV A N Total size of property 2-,o 3 kc., Total size of parcel , p 3 AC, Date parcel was created 9- / - 43 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? X Yes No Volume D 3 and Page Number VS4 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-0 518.5-S , 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. So Ig CY~4 ^ Signature of Applicant Co-Applicant Z- Z 0 Date of Signature Date nf nr at P 111~~` DOCUMENT NO. STATE BA F WISCONSI ORM 1-1881 THIS [rwc[ e[s[ev[D FOR R[coeoiNa DATA ' ARRANTY 0 0 504855 - - YOL 10 31►IIGE 4% r- ' r._CJSTc~4'S OF-ICF This Deed, made between i X Co.. MA Randall W- Synan_.and Patricia E. Synan, ^ac'd 'br Recard _------husband, and..Yi-fe................ R , Grantor, S EP 1' 1993 and .Sam E ...Miller, a single: person 45 A. M ac t+-, ---------1------ 1 R-~s~er,t0aeds Grantee, Witllesseth That the said Grantor, for a valuable consideration...... L I.. Randall W.' Synan and Patricia E. Synan Si:-.... C o R[TURN TO conveys to Grantee the following described real estate in ...St . County, State of Wisconsin: Tax Parcel No: - x3 The SE1/4 of NE1/4 of Section 11; the SW1/4 of NW1/4, the N1/2 !"r 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 - i Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Wisconsin. F6~# AND A parcel of land located in part of the NE1/4 of SE1/4 of Section 11, Township 29 North, Range 19 West, Town of Hudson, St. Croix Count described as follows: Commencing at the Y~ Wisconsin further E1/4 corner of said Section 11; thence S89 3010011W, along the i~ North line of the SE1/4 of said Section, 1212.32 feet to the point of -.eginning; thence continuing S89 3010011W, along said North line, 66.00 feet; thence SOO 28103"E, 500.00 feet; thence N89 30100"E, along the North line of Certified Survey Map filed in Vol. "3", I Page 722, 38.08 feet; thence N00 11'33"W, 150.00 feet; thence N03 58134"E, 351.07 feet to the point of beginning. This 4_.n42ti.... homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances ti,ereunto belonging; And-----Randy 1-_ W,-_-Synan-- and--Patr-ici-a.--E_..--Synan......................... 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. 3 and will warrant and defend the same. Dated this ,J day of PALl9.115t 19-91.. UfiHdr Li'. (SEAL) ~GldLl6f! - !ll!✓......--• .................(SEAL) Randall W. Synan Patricia Synan • ---•-•-----•--------------------•---•---••----------•--••----------(SEAL) . (SEAL) I E- AUTHENTICATION ACHNOWLBDOMBNT Signature(s) STATE OF WISCONSIN as. . ix County. authenticated this day of_________________________ _ 19 St Per nally came before me day of August 19. `33 } above named Randa l l W' Synan Pat ric ia ETITLE: MEMBER STATE BAR OF WISCONSIN Synan ~I (If not, . r .~OAMrs authorized by j 706.06, Wis. Stata.) to me known to be the person ..4......# A he ~jB li going instru nt and a n wleoe INS THIS INSTRUMENT WAS DRAFTED BY Rristina Ogland At-corney--wt--f;av------------------------------- a Alice Joy 0 ors Notary Public County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (/j_f not, state exp ation are not necessary.) date: 1-1................. 1Q77.) ---'Names of persons signing in any capacity should be hped or printed below their signatures. WARRANTT DEED STATE BAR OF WISCONSIN Wisconsin Kral Blank Co. Inc. FORK Ne. 1 - 1961 Milwaukee. Wis.