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HomeMy WebLinkAbout020-1016-00-001 CD I N. ° O Fn a N o C a~ o w N --2 o R E i' ccEc c(D5 I N O. U N a w c N is O C U) O U~J ~ON ai O .0 E N N :3 E O 0 m co z Y~7 c 2 O I U. c Y 3 [0 N O a E LN a I O O N y a a vi (0 Cl) N z y W 0 X O Z d d CV !N- a m I c I c C7 c O z c co i r 0 N m Z ° o U) I- rn Q> z E '2 M ] N .C N O N f0 CC) s c C O c O Z m D U Z w E N O C W m o O M C: D (L O y y y E p I ~ Z N > - LL LL y O O O z 7aaa N CL •N ~ aLO LO Q 0 rn 0 U) x 0) a' -cc N a O m E a co N O N c 0 04 O C c U c d O O O I >>>f'r O O N n C u 0 co CC) to l \ y,,, n H N v C O O H p o c a ~2 2 CD Q~ ~ O N = O) N ) C-4 N a) O y V v~ d m € d a w CL c rrww• m m _1 A vat 0 0)0 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS SUBDIVISION / CSM# LOT # .Z SECTION 12 T-.11_N-RJW, Town of ST. CROIX COUNTY, WISCONSIN ' v PLAN VIEW SHOW EVERYTjiING WITHIN 10.0 FEET OF S STEM 30' X73 loo B / I ~ c~rnr DuT 39 / # l = S'1. ~LLB 9v~ L = 7So ~R s~ A ` INDICATE NORTH ARROW Provide setback and elev ~tion information on reverse of this form. Provide 2 dimensions Jo center of septic tank manhole cover. t BENCHMARK: /y ,1/ !'fir c /a~ p ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING.TANK INFORMATION Manufacturer: Liquid Capacity:l.S, Irv S. % ;-AP Setback from: Well T/5ZZ Housee15Other Pump: Manufacturer Model# Size ll r Float seperation ~ Gallons/cycle: Alarm Location .SOIL ABSORPTION SYSTEM / Width: Length S7) Number of trenches- Distance & Direction to nearest prop. line: Setback from: well: ? Do House Other ELEVATIONS Building Sewer ST Inlet,_ _ f,X6 ST outlet PC inlet 7f j- PC bottom_ L- 7 Pump Off ~ Header/Manifold Bottom of system i Existing Grade ~lflD.Z Final grade j; DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: y 9 INSPECTOR: 3/93:jt vyncw sin Department of Industry, PRIVATE SEWAGE SYSTEM County: .1_aboran Iuman Relations INSPECTION REPORT ST. CROIX S?{?tv ar Buildings Division _ (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION Permit Holder's Name: ❑ City ❑ Village Town o : State PIA o.: HEIMSTEAD, SCOTT & MARY CST BM Elev.: BM Elev.: BM Description: Parcel Tax No.: . ;7nsp- n /lJ , C~ Samar, 0,5 TANK INFORMATION ELEVATION DATA /Z/// p TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic LQrs ~n~ Gds Benchmark ll),Gli' Dosi ng << 1- 3 Aeration- Bldg. Sewer Holding-, St/,* inlet TANK SETBACK INFORMATION St/,N¢ Outlet TANK TO P/ L WELL BLDG. Air I to ROAD Dt Inlet irlntake Septic NA Dt Bottom 9,P.72 .166 tl 7 # Dosing +r ~,/M/ NA Headers Aeration NA Dist. Pipe f!5 ' rtlt~ r - Holding Bot. System Sr u' PUMP / &MMOWINFORMATION Final Grade 3D 9,S(o Manufacturer Demand t°t' ° c ~ / >f( / Model Number I >6-' j~ GPM -I-P c ' g ~`9~ ga,rj 1i ¢ V' 'sQ-~ 9r i c , v TDH Lift U" Friction System TDH Ft oss Forcemain Length F a. mead " Dist. To Well F \V SOIL ABSORPTION SYSTEM W flDIMEN BEtTRENCH Width i Length i No. Of Trenches PIT No. Of Pits Insi a. Liqui pth SQ DIMEN I N SESYSTEM TO P / L BLDG WELL LAKE STREAM LEAC durer: INType O C R UNIT R Mo a Num er: System: epyrtl_ > DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) ✓ x, a Size x Hole Spacing Vent To Air Intake Length Dia_ Length Dia. Spacing 5j,m SOIL COVER x Pressure Systems Only xx Mound Or At- a Systems Depth Over Depth Over xx Depth O xx Seeded/ Sodded xx Mulched Bed/ Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOC TION: H dson.12.29.1 W, SE, SE, SW, SE, Lot 2, Moonbeam Road Plan revision required? ❑ Yes [&-KKo q Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signatu a Cert No. SANITARY PERMIT COUNTY DILHR TRANSFER/RENEWAL UNIFORM PERMIT # (PLB 67-T) a~ ~1 Jo g PERMIT RENEWAL DATE: PER MI TRANSFER DATE: ORIGINAL PERMIT ISSUANCE DATE: STATE PLAN I.D. NUMBER: I '~d -a o : Q,TION: CITY: 9ERT t L~ C VI .v /4 /4,Sa T 2f N,R /f E (or) Sd~~ LOT NUMBER: BLOCK NUMBER: SUBDI Z~ NEAREST ROAD, LAKE OR LANDMARK: PREVIOUS SANITARY PERMIT HOLDER (IF CHANGED): SANITARY PERMIT TRANSFERRED TO: NAME: SIGNATURE: NAME: PHONE NUMBER: ADDRESS: PHONE NUMBER: ADDRESS: I, the undersigned, hereby assume respons'bility for installation of the private sewage system that has previously been approved for this property. PLUM E 'S SIGNATU E: PREVIOUS LU BER'S NME IF CHANGED): 01 J/ 'apt PL MBER'S ADD ESS: PREVIOUS PLUMBER'S ADDRESS:1 O C/ `'Y' 44 /'q fo % /t r day- ~!J l 2 VP7MPR.I;IAI NUMBER: PHONE UMBER: MP/MPRSW NUMBER: HONE NUMBER: IGNAT RE OF fS$UING T: DATE APPROVED: DISTRIBUTION: Original - County Copy - Bureau of Plumbing ix~ Copy -Owner I LHR-SBD-6399 (R. 5/82) Copy - Plumber ' SANITARY PERMIT APPLICATION ' DIL.HR In accord with ILHR 83.05, Wis. Adm. Code COUN Ci X STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 41 ! .7 4 Q 8% x 11 inches in size. Check if revisiorn to previo/s 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 Scc c, 7',-, St %4, S l~2 T,-8, N, R 74 ,f(or) W PROPERTY OWNE S MAILING ADDRESS LOT # BLOCK # 470a Pal e L, 2- w if- CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER W S 4 fv 3.5-117.;7 -Z, 3 -IQ 5 CITY 11. TYPE OF BUILDING: (Check one) ❑ State Owned O VI LLAGE NEAREST ROAD II~~tt U& ~ art) C'0 s ❑ Public t~11 or 2 Fam. Dwelling-# of bedrooms 3- AR L TA E ) 111. BUILDING USE: (If building type is public, check all that ap 1❑ Apt/Condo ply) 0 1 U/ ~ U p c G 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 in line A. Check line B if applicable) A) 1. D? New 2.0 Replacement 3. ❑ Replacement of 4.0 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 El Mound 30 El Specify Type 41 1:1 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 12. ABSORP. AREA 3. ABSORP. AREA 14. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION .45c) ( I © 0 FOO t Q5..$_ Feet Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank orlOG 14)nG Lift Pum Tan r 7fo SSG i Vlll. 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) M PRS ^o.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sani ry Permit Fee (Includes Groundwater Date Issued I ing Agent Sign re (No tamps) y pproved ❑ Owner Given Initial Surcharge Fee) Adverse Determina i n JJJ~~~ X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) 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 :irm I;SE3D 6399) to be submitted to the county prior to installation. 5. Onsife sewage systems must be properly maintained. The tic tank(s~ mu ;t ue ~ t.1miie by :::?censcd pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code ac'minicstrator 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. If. Type of building being served. Check only one and complete # of bedroon-6-- if 1 or 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 cc apacity of every new and/or existing tank 'ist the o t . , nr, mber of tanks and manufacturer's name. Indicate prefab or site constructed ano lank neat* : ial. C o rplele for all septic. pump/siphon and holding tanks for this system. Check expennl-:r : apprc) ;-iI cn°y tar,ks rece'ved eYpe,rime ltal product approval from DILHR. VM. Resporsibility statement. Installing plumber is to fill in name, license wrn-er with tppYc 1. s late rprefix (e.g. MP, etc_), address and phone number. Plumber must sign application iJr11 IX. County/Department Use Only. X. County/Department Use Only. Coinpiete plans and specifications not smaller than 8'/2 x 11 inches -r1ust he subr,, led t^ 'he county. The pia^E rniiist include the fc riowing: A) plot plan, drawn to scaie or with 1.01 (ate c ~i r r ;oc -tion of hol ding lr~rlk(s). septic t kt } or other treatment tanks, building sew ii . VV >i W< .ter service; streams -„-J lakes; purYip of `i'ph, - Tanks; distribution poxes; soil ab- r, n c iSOf.. ,ic r.r:, 9Ceorent system areas a'Y i t , ij%,aation of the tji`d1;'.1g served: horizontal and V„I M r~2[ - e p.;ints; C) complete specifications for pumps and cont,~ols; dose volume; Giuvat,o, ~itiE ~P sc.e~ 'r ..tion loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil ao,,orption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. - - - - - - - - - GR'OUNDWA,TER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a numh of regulated practices Viich c=an effect groundwater. The ioonlfr#s C.si ei-ted throe these surcharges 01 e Used , rnoi)itol-1 i 7r~. AvW,, t wv,-. .r cr rlt~rmination invest ations and establishn,ell' (it _-;iarii F3;', SBD-6398 (R.11/88) Fresh Air Inlets And Observation Pipe 67, PLAN Approved Vent Cap f0~ Minimum 12" Above G~ Final Grade -Rn 20- 42 Above PIP PIPS 4" cast Iron To Final Grad• Vent Pipe Synthetic Covering u1n. 2" Aggregate Over Pipe Distribution Plp• 0 0 0 0 0 - Too 6" Aggregate t Beneath Plpe o 04 a 1c,. Q5.5 of! 30 r A~Tcr Dz o:. ~f3t t31 tz. SP 9►I C ~oa ~ 6r l X190 PuC 1 0 l boo ~b Nam ' 3191 e WELL d l49 i 7S' ' Z of 3 PAGE PUMP CHAM6E0 CROSS SECTIOIJ AND p p • SPECIFICATIOtvS ' ' VCWT CAP Co I-' VCN7 PIPt . ~ WCAT14CK PR00Jr APPROVED LOCKING .4.. ; -:.5 •FROM DOOR, JUIJCTlO1J BOX • WIIJ00W OR FRCSH It MI U. MAWHOLE COYER AIRI~JTAK6 • fir: I . . t GRADE AIM A >,~IO'MltJ, w COlJDUIY Ie'M1U. . IM LET PROVIDE 11 AIRTIGHT SEAL I III AP.PROYEO JO,IUT II I APPROVED JOINTS CXTCNOlNG 3' ou o.;601.1o toll I III W/c.T. PIPE b • I 1 ALARM EXTEAIDiIJG ONTO a0wo SOIL C I Ii ON FT 12•x- PUMP .._J wr C 0 COOCKCTC BLOCK •3•#r RISr`R-YXIT PCRM11YE0 OIJLy W YANK MAUUrACTURER }{f, `uY } 3" ^PPRoV "As SUCH APPROVAL th ~SCPTIC SEODIN~j . cv:; a SPE'CIl:IGA710 DOSE `4 'j : TA K c . AuUFACYURER: w Mtg. CpaC p,~.~ ¢ 7SD NUMBER OF DOSES: ` sTA1JK: LIxE GALLOWS PER DAy .VOLUME LA , ItANUF DOSE AGTURCR, - ilLv7`or IIJCLU CR •DIIIG 6AGKILOW: M.. 135 x M 6 • t~L t/ < OOCL IJU` GALLONS CAPACITICS: A i xrY,,' #SWI7GH TyPi hlcrca.-..11JC{{CS OR 3G'~ I GALLOJ,IS PUMP ftMUFACTU99ItS z~Gllcr 8 Z IUCHCi OR S a r , . y G(ILL0" ~cM00CL WUAB!`R: 9 7 C'~-- --...I►JGNES OR I•~~ GALLONS SWITCH TyPEi Y✓ ell! # D --11~lCNES OR GALLON6 a"n~kr MriuiMUM OcH~RG.' RATS ~S ` u rE PUHP AND ALARM ARC TO bC ;,INSTALLED ON SEPARATE CIRCUITS "VORTICAL, DIFFEICEWCE bETWEru PUMP OFF AIJD OISTRIESqTIOU PIPC.rr .zip- vo M-'' /M uCTWORK' SURPIy PRESSURE z.5 FEeT sy y° F• / FEET OF FORCE MAIN X • `J F'CE7 Ioofr.FalCYlou FACTOR..- 1•~2 ,FEET ell, TOTAL D~IJA Ji!~Z FEET l 1J 7 E R Al A 1. DIM t: IJ 5 t 0 Al ~i Of TA W K L E LI (Y T H; • LIQUID ~ 1 ~wIDrH 1 ID O~)YN M Iceuse uuMBER rnP/ S 1. cc w LL. F- W W k115- 34 110 32 105 30 ,00 - 95 28 90 26 85 24 SO- 75--MODEL MODEL _ 189 uj 22 165 Z 70 V 20 65' Q } 18 60 55 ..I 16 O 50 MODEL 1- 14 45 163 MODEL 188 12 40- 35 10 - 30 MODEL 137, 139 MODEL 8 25 185 i 6 20- MODEL 4 15 - 161 2 MODEL 5 53, 55, 0 57, 59 GALLONS 10 20 30 40' 50 60 70 80 90 100 110 LITERS 0 80 160 240 320 400 FLOW PER MINUTE as 'Wisconsin Department of-Industry; SOIL AND SITE EVALUATION- . REPORT Pa of 3 Labor and Human Relations 9e- Division of Safety & St ildings- _ in accord with ILHR 83.65, Wis. Adm. Code - - - - COUNTY Attach complete site plan on paper not less than 8 1/2 ST . C-4wtX Plan must include, but PARCEL I.D. # not limited to vertical and horizontal reference point lope, scale or dimensioned, north arrow, and location and dista arest road. APPLICANT INFORMATION-PLEASE P, BALL I RTION REVIEWED BY DATE PROPERTY OWNER: * P TY LOCATION Y-1 J&T- 11/4 S E 1/4,S 1 Z T Z-9 N,R l 9 E (ore PROPERTY OWNER'S MAILING ADDRESSa , L BLOCK # SUED. NAME OR CSM # ~l`1 ~Z P►~~tr►~lZ Lf~~ y,3 _ cs>1 S Ps t x[,1-7 CITY, STATE ZIP CODE . WKE NUMBER ❑VILLAGE MOWN NEAREST ROAD 'L~Pty c,~A~t1 ►N Sy.-) 0Z ( I'W- r AUD S(►" r~00Na~r~ tza (>Q New Construction Use [JCS Residential / Number of be 3 [ ) AdditQn to existing building j) Replacement Public or commercial describe 1ti~ R Code derived daily flow y,SO god Recommended design loading rate n• 5 bed, gpd/ft2 ,S trench gpd/ft2 Absorption area required °to o bed, ft2 °t 60 trench, ft2 Maximum design loading rate o bed, gpd/ft2 b , B trench, gpd1ft2 Recommended infiltration surface elevation(s) S. S 1 ro`Ti'~t ft (as referred to site plan benchmark) Additional design / site considerations SE)~j- 7'.;tS1 otv p}t6E Z - ~ugE Py► ~P \-L' Ql RED Parent material S fl~upy v uT wN-S N Flood plain elevation, if applicable t") ,tom. ft S:= Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem S 11 U C$ S El U IN S ❑ U ®=S ❑ U ®S ❑ U ❑ S ~I U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots ]GPD/ft2 in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. d Trerrtt ><V<: ~_8 1o~t 31z - s ` Z`~'~bk w~ - e-S - 0.S o.U Z S-ZZ log-ttz 31C~ St1 Z~►ts~k to Ground 3 ZZ 7 l~`iR t!((;. elev. 4 3 ft. Depth to limiting factor N Remarks: Boring # 13 w Z, Z l0 Zb' 1b`2R316 S1) Zwtsbk Cs o.b Ground ` elev. y . 39 g3 lug-l,tz ~ ~L - 5 6 eS O s9 _ 0.7 0.8 Depth to 3 flS P g3•o9 Ct{ L~sS lZ rr o t_ pv limiting C G~ Zfactor`3 Remarks: CST Name:-Please Print Phone: Arthur L. tdeaerer 715-425-0165 ~egerer Soil Testing & Design Service-P.O. Box 74 River Fa11s,WI 54022 Signature: Date: CST Number: .l. ~S-Z(,}~ Uj ZB~L'M M00576 PROPERTYOWNER `t~t~l'11ST~ SOIL DESCRIPTION REPORT Page of PARCEL I.D. # Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench € ! 0-9 10~Q Z - sit -3 'x r ~-S o.s 3 ~0 Z q-3~ ll~`2R 3!6 S t) Z-w► sbk wt cS ~ o,S o. Ground 3 36-43 lu`tR ~fly elev. zo~2 ct- "31 G _ s o s9 1o ft. Depth to 3 StCw1 !vu ~S $Z limiting factor ,~~S Remarks: Boring # _ S 1 Z~S b"( m~:.: o-l0 1~KR 312 z lo~rP 31r, - s ~1 Z►~sbh cs - o.s~ 6 Zq- 35 VW ~-,.S~tR 31~ s• 1 Z~ sbk m~►~ eS 3 z-7 Ground elev. 1 f 3 S g l l u `i ►z VL _ 1 g 0 S Y4 U gq. Z ft. Z- Depth to 3 s N - limiting Via?, o°! 1 Le Remarks: Boring # 1 O- LO 1 O`rl 3 L2 S L Z `F 3 S m0-20 tb`l.2 316 S l) -Lill, Sb12 l+t`FS~ 3 Zo-aS L O `t tZ.. S ~ ~ S b g ln ~ o, v. `d Ground lev CI .6 ft. Depth to limiting a s~ factor Remarks: Boring # - S 1 2 ~S \DAZ vvy,- -h V-S - Zen ~ sb 6i 31 k 4 t. .I 3 2q 4S 1lz~ `j tin V/6 S S D S M Ground elev. jJp`Tg w6 o v--0 . -s l b 1oo•Zft. Ldp su, Q 13 JUG U A r~o l,u u S -Nei bv~ 5 Depth to i limiting 1 g G Lw L U L Z-` factor `tS` Shy t_` Remarks: - S13D-8330(R.05/92) PLOT PLAN Page 3 of SCALE 1"= 30 J ~ zrl~F \ Lt,loB ~ -v d Vt \ d ~ctr-mss loo z e SZ~ DIs~P LL99 ~.y \ S 1°rr'r 'Tim UP3 tApE \ S 9 o p ~ $.a e~ goo ? S'~ eto a" kJ~ t G!{ , 31yY Dtlj , p 2 puC Pt4F ~vooD l..pr*~ l r.> > ~t PrC. %Cp ~0' v~ ~~xZ- TO Flu Cdr Of ~ stt~ b~ e5a Is"> Lo c.~-tue~ s iz~-C,H qS-z6y a. Pf\-) 5 (715 )---425-0169 M00576 CST Signature Date Signed Telephone No. CST # STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER _ c d f- q- f~ P y ~ I'm 5 ~Y MAILING ADDRESS 1~? p , fib" PROPERTY ADDRESS (location of septic system) Please obtain fro the Planning Dept. CITY/STATE &Ucl s y~ I ~Pa r+ PROPERTY LOCATION5 z1/4,5& Sal 114, Section A,?, r 9 N-R_ / j W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP 3 q, VOLUMES , PAGE I X11 7 , LOT NUMBER A Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration te. SIGNED: DATE: ~ St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 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 Location of property~Es 4 a/ or1/4, Section 1,5q , T~,~ % N-R W Township_ Mailing address a ~Ka~lv w Address of site Subdivision name Lot no. _ Other homes on property? Yes 1--"No Previous owner of property C -S V- C, Total size of property ;7 Total size of parcel Date parcel was created Are all corners and lot lines identifiable? ✓'yeS No Is this property being developed for (spec house)? Yes No volume -5 and Page Number L!_L.L- 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. own the proposed site for te sewage disposal tsystem ) orr Ie(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. IL3__f T, c z A ('lA. Signature' 'Applicant Co-Applicant Date of Signature Date of Signature d z J- /Ui~-Uu-oJf i; State Bar of Wisconsin Form 2 - 1982 533483 WARRANTY DEED I - - ! - 1 1iJ~ REGISTER'S OFFICE DOCUMENT NO. - j-- yQ9PAG' w ST. CROIX CO. WI Recd for Reoord _ Eric D. Blomquist S EP 6 1996 at 10:00 A. M j' j conveys and warrants to Scott G. Heimstead and Mary Registercf Deeds Heimstead, husband and wife, i THIS SPACE RESERVED FOR RECORDING DATA i NAME AND RETURN ADDRESSn~ the following described real estate in St. Croix County, State of Wisconsin: i (Parcel Identification Number) I' II Part of SEk of SFr and part of SA of SFk of Section 12, Township 29 North, Range 19 West, St. Croix County, Wisconsin, described as follows: Lot 2 of Certified Survey Map filed May 8, 1984, in Vol. "5", page 1417, Doc. No. 393111. ;I TOGETHER WITH the right of ingress and egress over the 66 foot roadway easement as shown on said Certified Survey Map. I it This is not homestead property. X¢ (is not) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this day of August 19 95 (SEAL) (SEAL) * * Eric_ _ D. Blom st (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St. Croix County. authenticated this . day of , 19 Personally came before me this day of August 19-9-cL the above named i - - - Eric D. Blomquist - TITLE: MEMBER STATE BAR OF WISCONSIN l (If not, - - authorized by §706.06, Wis. Stars.) to me known to be the person executed the ISCU fo e of in`trument ao a same. THIS INSTRUMENT WAS DRAFTED BY I! _ Kristina Ohland_- * Alice Joy Con rs I! Attorney at Law Notary Public - County, Wis. - - j (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date: necessary.) ( 19 7 7 - - jl '"Names of persons signing to any capacity shoula be typed or printed below their signatures. WARRANT\' DF.F.D STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc. FORNI No 7 I9H2 Milwaukee. Wis- NOV 27 '95 08:03 GEHRKE 715 386 9774 T0: P01 November 27, 1995 Carl Heise 1042 S. Main St. River Falls, WI 54022 Dear Mr. Heise: From October 1st on, Dave Lee and I have tried repeatedly to contact you regarding the installation of the septic system on Moonbeam Road for which you hold a sanitary permit, Number 249709, issued on September 19, 1995. Being unable to get any kind of response from you, the zoning office has suggested that we proceed with the following action. You are hereby informed that you must call the St. Croix County Zoning office by the end of the business day on November 30, 1995, giving them permission to transfer the permit to another plumber. You are to talk to either Tom Nelson or Jim Thompson about this situation. On September 18, 1995 the general contractor issued you a check for $395. This covers all of your expenses and services with respect to obtaining the sanitary permit. It is our belief that you are paid in full and there are no monies owed to you. Weather conditions and the frost level are becoming a major concern. In addition, this property was to be ready for occupancy in December. Because of your unwillingness to respond to our requests to have this system installed, there may now be additional expense involved with respect to the depth of the frost and with respect to a delayed closing. For that reason, we have contacted Attorney Matt Biegert regarding recovering any increased costs we may incur due to your refusal to install this system in a timely fashion. We intend to pursue this avenue of recourse if necessary. Again, you must call the above named zoning administrators by November 30 to release the sanitary permit. Sandra Gehrke 2P2 1 FILED MAY 8 1984 w A"" of CERTIFIED SURVEY MAP Located in the SE 1 /4 of the SE 1 /4 and in the SW 1/4 of the SE 1 /4 of Section 12, T29N, R 19W , Town of Hudson, St. Croix County, Wisconsin Surveyed for: B. & H. Excavating ~QPRO v 836 St. Croix St. No. Hudson, Wi. M AY o 81984 N r aoix COUNTY mss, M m n EO+4M ~~HENSIVE PARKS PLANNpiG M a W AND ZONING CO)AA c Sae 20/S z r- C r.., % c • • • . N . 00, 41 o z o UNPLATTED LANDS CIO > orn e O 9300' - - - cc -n % C -1 C x r z ~C v In I m 145,961 SO. FT, z in M D 3.351 ACRES 300 , Ike, m m -11 w .00/ 0~1 0.N; ~m 3 om 10 O 2yti o cn m ~ r D X20 M~ Ory 2 M M o o v N 88° 32' 39" WiO,0~ 4 ti 105,884 SO, FT. o I w 2.431 ACRES o_j Z m p0 ?SC 3 43.30' c 8.80 32140,&.* F o ID y~ y 320.66 \ ` 2 , W 0~ a6 ~ A~ ~ Off` ~ I 1 _ o 159° 1747j' W 9 b m 0 0 .32140 u W o oh y5 0 A N 88 2 , ~ o_ tKq, A0 ~S 367.68' S`9o e~ ID z 116 437 SO . FT . 10 v Fjsg iF 2.673 ACRES y c» 0 Flo a 00 O F R^ Set' v RHO; ~0, 00, 0r1r~' FENCE ° 00, Z1 t roadway easement o 0 . 0 3 89° 57' 16" E 0 66 ti's . h ~s. r9 301.06 ooh bo~~ ~i~ \ (R) EAST S S q- .h C.ertified urvey Maw 156025'53" W0 V01._1, _P_age _17_4 507,028 SO. FT. 11.640 ACRES C _ INCLUDING PRIVATE ROADWAY 00 ° 01 yp~ EASEMENT 6' NORTHERLY RIGHT-OF-WAY LINE 4j~ = c0 ~ 165.001 POINT OF BEGINNING 1071.32' a i S 1/4 CORNER SECTION 12 S 89056'43"E LOCATION FROM TIES-CORNER S.E.C ORN E R SECTION 12 ' FALLS IN LAKE / T29N,R19W. NOTE- THIS MAP IS INTENDED TO REVISE AND REPLACE THAT CERTIFIED SURVEY MAP 1ECORDED IN VOLUME 5, PAGE 1388. SCALE IN FEET 1"=200' 200 100 0 200 400 LEGEND • 1" IRON PIPE FOUND SECTION CORNER MONUMENT,' BERNTSEN CAP NOTE* THIS MONUMENT NOT 0 [".X 24°ROUND IRON PIPE WEIGHING 1.68 L&S. / SET DUE TO ITS,-FALLING LINEAL FOOT SET IN THE ROADWAY (R) SLANT DATA INDICATES PREVIOUSLY RECORDED i 960 INFORMATION 000 110>' 3/4"STEEL BAR FOUND av'• 4672 019 EXISTING BUILDING 8~330 iN81032' 51"E W n