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HomeMy WebLinkAbout020-1022-70-000 C ~ m ° I °g ow, c 0 ~ I r~ I v °o I ~ I N y o I 'a c I c "C3 N I, O I C c O 17L c NO O 7 ~ ~ x I d w I 3 r) v ~ I z y rn w E cn w o I 0 ~C14w am o I O z d c v U z` g ° o to I- r m Q) z c ~ ~ a I r7 I N a N N ~ C a~ c O 0 ) c Q z° z _ z° N N C I C d O l6 E N ~N D y - N f0 o6 CL m CL (,0 C N N O N N !n ~ ' ~ O i, E o0 O E1.. (n O v U') a a 0a z p a ~ I 3 0 N 1 c0 Obi Obi D I ~ :3 C~ Co Zi= a) c o o ~ ~ ~ I mI y ? c M N s) O ) d d m :2 (D w O O O O O O x N E O LL c (,M 00 O) , p 0 +-N c c LL a) O V O n _0 ;C L N p~ ~ c c m e0 C~ N C (n M O Q) 3 N W N a0 z z r` N N F.1 p' N "a O N = _ y O • y> p x LL N O z N H (n O ~ C E a ° L: a CL c, E 4) rr~~ 0 V1 U U (L ~L ~1 t R STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER SG L,4+ l-A1Q ~ Fief EIK- ADDRESS 41- /,2 `I Lv Y so&j SUBDIVISION / CSMJ- LOT SECTIONT ZPf N-R~W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SH EVERYTHING WITHIN 100 FEET OF SYSTEM P , r Npv hC ~ ~ 1 51 S ADO ~r LAW INDICATI; tdoRTH ARRO"~ Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic Lark manhole cove" BENCHMARK: ALTERNATE BM: SEPTIC T / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: G.r LF-l 515-p Liquid Capacity: /UCj© NO Setback from: Well Wd House 16 / Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: 5 Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House 3,V / Other ELEVATIONS Building Sewer ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade -7 b, DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93: )t 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) Sanitary Permit No.: Pe,~itkl, 'r's hMTT & CANDACE ❑ City ❑ Village Town of: State Plan Po- CST 1BIVI EEllevv.: Insp. BM Elev.: BM Description: Parcel Tax No.: s 16 ~D j . u~ TANK INFORMATION LEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic /~l9lll Benchmark o /00, Dosing Aeration Bldg. Sewer Holding St/Ht Inlet ~q 91,41(r TANK SETBACK INFORMATION St/ Ht Outlet j, .$.0 Vent TANKTO P/L WELL BLDG. Air Ito ntake ROAD Dt Inlet Air Septic j ( Jp { D ' NA Dt Bottom Dosing NA Header/Man. /7` 0 45; y Aeration NA Dist. Pipe -7 3 S`g, Holding Bot. System g; qy'S PUMP/ SIPHON INFORMATION Final Grade 50/ Manufacturer Demand 3 -1 i ~ 1, Model Number GPM TDH Lift Friction Sysatee TDH Ft Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Tien hes PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O %u__) r q CHAMBER Model Number: System:~fl" /~D 3`/ OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. I Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over U 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.14.29.19W, NE, SE, HOLDEN LAND Plan revision required? ❑ Yes [~/No Use other side for additional information. "Y I;',I~ (~ilX1,1 k a SBD-6710 (R 05/91) Date Inspe is Signature Cert. No SANITARY PERMIT APPLICATION ~•~Li7■~t In accord with ILHR 83.05, Wis. Adm. Code COUNTY St. Croix STATE SANIT Y PERMIT -Attach complete plans (to the county copy only) for the system, on paper not less than a LQ 7Q 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION eer Scott and Candace NE '/4 SE S 14 T29 , N, R 19 E (or) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 612 H 12 East Hudson, WI 54016 8 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Hudson, WI 54016 Hudson Hills I1. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) ❑ State Owned ❑ VILLAGE Hudson &J TOWN OF: _1AC, yeh, 44p, Lo ❑ Public LNfSj 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) C),Z 0 - ! 70 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 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: El Replacement of 4. El Reconnection of 5. El Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 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.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 91f. 0 ELEVATION 41 3'o- 1 750 6 b Feet /8.0 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or 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): Plumbe ' ign lure: N S mps) MR4MPR8WNo.: Business Phone Number: 10)z 6 h7at S Slelder 7~~ 7/6- d r f?-qel Plumber's Address (Street, City, State, Zip Code): 8z 3 o *-r I i-e ra /6 101 IX. COUNTY/DEPARTMENT USE ONLY (Includes Groundwater Date Issued Issuing Agent Signature o Stamps) ❑ Disapproved Sanita P Irmit ~Fee`Surcharge Fee) Approved El Owner Given Initial 9-f- Adverse Determinationi 9D X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber Y 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. SBD-6398 (R.11/88) ~ Sc4~~ ~".30, Sco Ca~.~Py eer loo. 6, 7 ,ha Q ~°~y o ll 4y ~-a ' ~ 78v 7 ~.3 9~ Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 labor a2d Human Relatwns Diviywn of Safety 8 Buildings 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 %'T - not limited to vertical and horizontal reference point (BM R a ! slope, scale or PARCEL I.D. # ZO Z. arrow, and location and distance dimensioned, north O _ APPLICANT INFORMATION-PLEASE PRI NFO TI REVIEWED BY DATE PROPERTY OWNER: PR LOCATION 4 ~ 1/4,S T Z W SC©'- A C.%Yh . N,R L °l E (or~ PROPERTY OWNER':S MAILING ADDRESS LOT LOCK # SUED. NAME OR CSM CITY, STATE ZIP CODE 0 NU ILLAGE ®rOWN NEAREST ROAD 1`~~Sor~, /,c) S ~L o ! b ( ~ 8171 s s ps ~tv `.p lr ~ [,>g, New Construction Use [XI Residential / Number o ~ ~ [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow qS0 gpd Recommended design loading rate - bed, gpd/ft2 • trench, gpd/ft2 Absorption area required °t Du bed, ft2 -ISO trench, ft2 Maximum design loading rate S bed, gpd/ft2 , b trench, gpd/ft2 Recommended infiltration surface elevation(s) SEFe'- t'" tr -:I ft (as referred to site plan benchmark) Additional design/ site considerations Z T M-►dAte'S - QM M S ' x -1 S ' L-6-1 Q - Parent material SFp I wtDNL'-- Uy 92 S ei G►. Flood plain elevation, if applicable N f\, ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN RLL HOLDING TANK U U = Unsuitable fors stem IRS ❑ U 0V ❑ U RS ❑ U [as ❑ U ❑ S [3U ❑ S 1, 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 Tter>ch V"_ R_ at Z - S Z~Sbk ~S - a. S v_ 6 >vt :v >z z~ 1~~-tR 316 s 1 ZW, 3bk m ui - C_ o_ S o. 6 Ground x}-33 113 11 [Z VA - S 0 g9 m ~ - 0.7 0.8 elev. g8.1DfL- Depth to limiting fact $ 3y Remarks: Boring # o _ 9 ) e ! Z - 1 `Z F sdk ~'F►- c - 0- S S 6 ;t~ h o. S _ C~~sl ?-Sb "t U Cg Z-23 l0 `iR j )G, 3 Z3 - 85 ) o -lR 114 S S9 - ° ~ $ Ground elev. Depth to limiting factor 7 1551 i Remarks: CST Name:-Please Print Arthur L. We erer Phone: 715-425-0165 egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 of Signature: yf1 Date_ CST Number: oLS-lSZM-l 7.619` 'I~657`b PROPERTY OWNER TER SOIL DESCRIPTION REPORT Page? of PARCEL I.D. # -3 2.0 OZ2 O Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Tram .6 (31S 0_X V-3-11k -2-Z Z s i Z S b e s - o IM Z ~o`C2 3l6 St, Z'+~►Sbk~r C-S o,S Ground 3 2$-36 l~~i 2 3/6 - S °LS bk ~n v~h CS - o~ o. S elev. 1o ft. 36-8S S Ll 31 - S o s ~ m.`1 ! o• $ Depth to limiting factor - Remarks: Boring # zf V ilz s l` ~~s~k wt'FH c5 o.S o.~ k' hy~~ Z 1Z-30 1o~lR 3/6 - s ZmS~~U`~y. cg O•So-~ $Yka~~iti•'4`titi~'.i'~i~ 3 3o-bo 1o`2tZ ~~6 `~S D s c.S 6.3 'o-L Ground elev. y 6v_8Z LOYR Y/ - S O S9 Wi - oZ 0.8 °[~l•~ ft. Depth to limiting fa~Or82Remarks- Boring # S Z lu 428 lo~-t 4.- 3/6 S ~-~n s~k w~ o~ s' 0-6 3/6 s o_~bk v~1, e Ground elev. D `12 Ti--] ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: PLOT PLAN Page 3 of 3 SCALE 1"= 3 ' ~t p ~1 OZA. I~ZZ 0 v ,pj 0 0~ ~v Ac ~ • 1'v C. ~ll~~ w~wUUQ l.~} 9,g ~t9.8a Z ~ chg. ~ C\ F~ p L w tr,p~ tt-~S \ g\ `nZ~ c C \ F s ~''S L-t 6 Y ,S\ \ 5 EL too Y \s eL 9-1 Vail' \ C►'3uT s ~t LIk, '0 'o I', Z vuS 'To a~ ►rT L-EVT ZS' FIvJM S431&I `A W ~-L TCZZI, C 1b 3~i_ 4 z K D ~ prT lltll~ bowr-i5 LO Ps l"DGE. ~y bz 1~ 2~ c 7-15 _495-GI-65 M00576 CST Signature Date Signed Telephone No. CST # Wisconsin Departrnent 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 81/2 x 11 inches in size. Plan must include, but ST - 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. OZO - 1,0 ZZ. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION SCA-tr > GOv"AT_ fJi~- 1/4 SL 1/4,SlgT Z°t N,R Lct E(or W) PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK If SUBD. NAME OR CSM i_. b~Z `Z ~r - CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILI AGE KrOWN NEAREST ROAD 1aN~Sf,~ w Sq u16 ()I S) 381-\1S 5 soSbly "t -b e.1 [A New Construction Use [XI Residential / Number of bedrooms 3 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived dally flow qSO gpd Recommended design loading rate - bed, gpdIf2 ' trench, gPcW Absorption area required bed, ft2 -ISO trench, ft2 WWmum design loading rate S bed, 9pd/ft2 - 6 trench, gpd/ft2 Recommended infiltration surface elevation(s) S V-" rr 3 ft (as referred to site plan benchmark) Additional design/ site considerations Z TR-E4jd-tWS - IMM S ' _1S ' l_VQ C Parent material SAD 1 wif Z Uy d2 S tf (Si. Flood plain elevation, if applicable N • f\ , It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN RLL HOLDING TANK U = Unsuitable for stem [$S ❑ U RS ❑ U (&S ❑ U (as ❑ U ❑ S 19U ❑ S I NU 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 Tmnch 1 d -1 Z Lb ~i IL z L Z - S ~-`FS b k w~ 1. c S - o' s o_ 6 Z t2 z~ loL-tR 316 - s 1 Z+VL 3bk rn u`QI- cS a- S o. 6 Ground lo`1 R. ill6 _ S O 19 M, - 0.7 0-B elev. Ct D ft Depth to limiting f8 V Remarks: Boring # 0-9 )~~e z!z - ~i 1 2~-WL V-ITV C- S - o-S o.6 r U'~rcg i 3 Z3 -135 ) o y R V /6 S O S9 - Z $ Ground elev. OU4 ft Depth to limiting factor i 7 t~ 5 u Remarks: CST Name:-Please Print Arthur L. We erer Phone_ 715-425-0165 egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 S~natuts _ Date: CST Number, a(~S`78 r ' 3 PROPERTY OWNER SOIL DESCRIPTION REPORT Page Z of PARCEL I.D. # - OZZ 'I O Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Fiz in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. .<it S ~1-2g 1,o~ttZ 3l6 ~ S t.~ ZwtS~h ~ o, S Ground 3 Z$-3b ~O`•t2 3/6 - S 1 es ~k vnv~>" CS - O•~( O' S elev. m 1 p, $ oo ft. 36-85 S 4p-- 3J - S o s ,►•t Depth to limiting Si factor Remarks: Boring # , ~oti.R. zlz s t` ~.~sbk m'F►~ cS o.s ~ o,~ •S o-~ Z 1Z-30 to`1R 3/6 - S ZmS~~ mu`~y. c$ ca 3 30-60 1o`2tz ~16 - `FS s S - Ground a 8 elev. y 60-8Z LCoyR- v/ - S O S9 Wi °Fl•1 ft. Depth to limiting factor r Z` Remarks: Boring # S x. Z 112$ 1o`-tQ- ~/6 S11-~s~k~~ c o. Ss o.6 ~tiiti•12•'ii Ground elev. 3$-$3 l~`lR7~G `~S CJ 5rj yvt l o,S d 6 ft. Depth to limiting factor r Remarks: Boring # ti,'.V ~Jw Ground elev. ft. Depth to limiting factor Remarks: PLOT PLAN Page 3 of 3 SCALE 1"= 3p ' SQL 0 "P x Ac~3~'"l-~`L.10U,QON • i~v e \-"t O)E W / 1"Ouz L-M-I} g`1 a•► trk_ q5 C \g s ~Z "-*S F :P\ \ 6'j , L--L -1(. rL Lou X L. 9-1 .a 1'` tuSt -To aE PrT t.LTksT Zs' s'-tS1L t t `C~L(D-j CWQ3 lb. I 42 1"rr -Rt(i bA)w►JS Lo PS L--DGE . ~S ~SZ %s-7 MG,05-76 CSTSignature Date Signed Telephone No. CST # STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ~ } ➢'1C CCUX-&n MAILING ADDRESS l(~ o~ 1T W y o~ EC t f-Y (Tr% VA I 9L/I d ~0 PROPERTY ADDRESS 28D P.YI ~t .YLf (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION M-1/4, 2)E 1/4, Section T_2=9___N-R ' W TOWN OF AIA ~S-CM ST. CROIX COUNTY, WI SUBDIVISION 'l~oa SCm :l ~S LOT NUMBER - CERTIFIED SURVEY MAP , VOLU AGE 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 date. SIGNS e:__1 DA 1 I~ ' St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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 &,4~t, o-n and cwt-, r-cfsr Location of property_E 1/4 EE _1/4, Section 1,4_,T_2aN-R_LCL_W Township 4~ud,a n n Mailing address iol Q 4AAA~11 6E :Vs+ Address of site Subdivision name 1AVIds -n IS Lot no. Other homes on property? Yes__~__No Previous owner of property TP~ 3. O-rj f-tn in MC) LP4 Total size of property 5. D5 W r(f S Total size of parcel 5, a'9 0-0,1 fn Date parcel was created _ pri n-r Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes __X_No Volume 11 as and Page Number '1 5 0 as recorded with the Register of Deedsp 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. -S29 i pu , 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. 552SA IBI " R Signature of Applicant - licant D of ignature to o Signature 8 o c 6!r a0' I - • i- Y _ < r \ ~ U 0u A 0 ► O V ^ 11I C. Y Y C III N , " a A ► O i 0 w ♦ O V I O Y r 3 N - 620 46'_ d.~ _ t f l a t' a do 0 7 r 4 O A N ^ A o 1 ~ s AO - O Y O -1 oN * r O o m O A N 1. O6' 20"W Ie 0 I p f 1. 04' 02g I A a U H Y O iO Y L ~ M O y r 7 Y ~ O I 1 N 1•Ot't0"M t ljj 620 L2' .y 416 2,' Z . ♦ a• of toi--"" N I^ \ ~ I L j 1 ~ Y © v fit 6o - - I 4. . IF •0 g8~ 1 pIt' EA \ ~ ,,V,Id ' S L r (li~r ► y 4 • , N r • A J J ► l{2 i 6• A . N O oI • • • O O I at .kw.a? ,'.ti: aessc ~ NkSS • State Bar of Wisconsin Form 2 - 1962 529181. WARRANTY DEED DOCUMENT NO. VOL G. EGIST€R S OFFICE SE CROIX C3, W1 P40d 1w Res:,j.,ti . Ted J. Nolen and Arm M. Nolen, husband and MAY 2 2 1995 -f at xo; 00 a Ed Stan "a' _ Sftntt R FrINPr and rAMIC a it- ODOYeya and warrants a Frearia lambrttd end` wife- _ Re911" of Doedtt THN ar+ACB naaBOYED PM RECORD" DATA - HAM! ANO 09TUM ADOPAU - i, a nit Y~ y IC~'. x aw fooowi%datxibed into" (a St. Croix Ofir /rl cottat2, snort d wises t Pared Identification Number) Part of NEl/4 of SEt/4 of Section 14, Township 29 North, Range 19 West," St. Croix CamtyiL Wisconsin described as: follows: Cotanemcing at the Fast 1/4 corner of said Section 14; thence SO°44'E 170.0 feet along the East line of said SE1/4 to place of be~irnting; thence S0°44"B 752.88 feet alas said East line of SEi/4; thence N63 58'15"W 4%.10 feet; thence Northwesterly 144.92 feet along the Northeasterly right of way line of a proposed Town Road on a 85.W foot radius curve concave Southwesterly, whose chord bears N22'4845!V 127.99 feet; thence NI&°ZO'4(Y1 100.00 feet; thence N54°39'1WE 554.96 feet to the point of be&IrW ing. This deed is givers in fulfillment of that land contract between the parties hereto dated November 11, 1994, recorded November 18, 1994, in Vol. 1103, page 197, Doc. No 5235869 in the office of the Register of Deeds for St. Croix Camty, Wisconsin. TW is not homestead property. 4p" pia not) Exception to warranties- Fast' 1 r ts, restrictions and rights-of-way of record, if any. May • 19 95 Dated this day of (SEAL) I (SEAL) ~f Ted J. Nolen j (SEAL) .-1~ 6=tf~ (SEAL) Arm M. Nolen AUTHENTICATION ACKNOWLEDGMENT s> STATE OF WISCONSIN sa St. Croix county- authenticated this day of , 19 Personally came before me this day of Ma" 19-91 he aboie named re J. Nolen and Ann'M. len, husband and wife. TITLE, MEMBER STATE BAR OF WISCONSIN (if nok authorized by §706.06, Wis. Stata.) WER O me know to be the pe s who executed the 'TT ~y~~Y~a~'atPUBLIC foresoi m a nowledse the same THIS INSTRUMENT WAS DRAFTED BY #1R113i~'+'+rt•M- =NS1M. _ I 1 :tristina Ogland Attorney at Law N Public County, Wis. (Signatures may be authenticated or acknowledged. Both are not M co mission is per tilt. (If not, state expir111160 t necessary.) •Nanees of persons signing is any capacity +hould be typed or printed below their si,;tnttues WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc. FORM No, 2 - 190 Milwaukee, Wis.