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HomeMy WebLinkAbout020-1267-90-000 Q o j Q-0 0 J o o ~ 11 p I ? a a ~ ~ I p a O O - N > N M O 'w N N x 3 a N ! ~ O N Lo Y > J O L ~ J N C I x d c N N U N I C M ~ L co O ~ T O ~O Y co L ° E z a O ~ 0 N 0 3 0) O. N U. C Q .N r _ O CD > N V ~ f0 B O O N a c ~ c co Z £ Z :7 O E :~t O z - y a) 0) N a m N F- c O O z :!t c p' e- I O N O fA F- r cD `O) ~ Z O E '2 N LO v M a) M N a 7 N N N O N (U c L L O c C O U Q a~zf-z o E N Z y N - N \i S N m L 1 C ~I N O p, Y C Lo ~ j ~ d ~ O O O 00 li ' S G D a M ~ H N N O L N i W J o c F- F- 1- CO O O O Z • "Nil 4i 5 a a a ~y a o ►i s _ 7 p fn ~n ~n CF) 0) U) m J U Ln O N N O O 0 to oS o C. E N S m o- c a N a) v CL ol O 3 o > w c O 0) c Q 2 c 00 00 N N 00 O o -o Q c c A rn o rvl N Q 01 ~ O C c c M n w C 3 M O N c N N Li a1 O N 00 et; -0 cD 4 1 N 1 a ~ (n ~ CO 0 (n CO 0 04 O ~ 1 EL L: IL rr`1~•r~ ~ E ~ .'c c ~ _1 a 0CL2 Oinv STC - 104 AS BUILT SANITARY SYSTEM REPORT ,~~c OWNER ADDRESS SUBDIVISION ~M# LOT # Z SECTION,. T 9 N-R l l W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOOEVERYTHING WITHIN 100 FEET OF SYSTEM 0 r 0 h 3_ 3 xg,d Tv.eae~~s INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. t Y BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: 091r`oIu~4r7`eY',,/ Liquid Capacity: l 020 Setback from: Well -SHouse a Other Pump: Manufacturer Model#Size Float seperation Gallons/cycle: Alarm Location -:SOIL ABSORPTION SYSTEM Width: Length ____,?-D Number of trenches Distance & Direction to nearest prop. line: Setback from: well: 3_ Go ± House ,3_ O d ~ Other ELEVATIONS Building Sewer ST Inlet: ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: io/3/ F 3- PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Depar 4jtof(ndustry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety-and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: P r i 1e0MU ,bMLOPNMT ❑ City ❑ Village R Town of: State Plan o.: Hild-mon CST BMEEllev.: Insp. BM Elev.: BM Description: 7C Parcel Tax No.: D a Y A95001 72 TANK INFORMATION EL VATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ~o Benchmark Dosing Aeration Bldg. Sewer 3. i ! 1, 2. 7 - ' Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet l08,(7 Verit TANK TO P/ L WELL BLDG. AirIto ntake ROAD Dt Inlet Septic >aS~ ay ras, NA Dt Bottom 8. 8! Dosing NA Header / Man. -7.,94, 6, o9,oN CJio3' /oG-89 Aeration NA Dist. Pipe 8.C, u Holding Bot. System g; qi, /v . ~g PUMP/ SIPHON INFORMATION Final Grade x.91 ,il, Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 5 80' 3 DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Typeo CHAMBER Model Number: System: pii >~O yU }~D u' ~U OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/ Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOC 111161 son. 24 . 29 , NW, Lot 22, Hutton Hill Circle 11: 1 fU Plan revision required? ❑ Yes ❑ No Use other side for additional information. q a~ 4S,,~ a 6 SBD-6710 (R 05/91) Date Inspector's Signature Cert . No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: - 77 - (21 Safety and Buildings Division I~~i~.Itnltt►i SANITARY PERMIT APPLICATION Bureau of Building Water Systems 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 Count, than 8112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check it revision to previous application (Privacy Law, s. 15:04 (1) (m)]. State Plan I.D. Number 1. APPLICATION IN - PLEASE PRINT ALL INFORMATION Property Owner Name c: op Property Location 114.,g),,J 114, S Al T Q , N, R /q E (or V SA) Property Owner's Mailing Address 5030 V7, -kA:, -e- Lot Number Block Number L G 1. 2 City, State Zip Cod6,S'/2 Phone Number Subdivision Name or CSM Number I. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road ❑ Village ❑ Public 1 or 2 Family Dwelling - No. of bedrooms 2-- Town OF <5, GZ .4 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment / 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 box on line A. Check box on line B, if applicable) A) 1. fly 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 ❑ 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 Gt~~ Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) jo F' c Ie t1i~a O CI QQ d t t7 ? U Feet iif Feet VII.. TANK Capacity in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel lass Plastic ANew Existing strutted g pp Tanks Tanks Septic Tank or Holding Tank 9 El 1:1 El ❑ El Lift Pump Tank /Siphon Chamber ❑ ~ El ❑ 1:1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (N Stamps) /MPRSW No.: Business Phone Number: Af kip"L _T el A & e Plumber's Address (Street, City, State, Zip Code): zo o 5 G c/ , , l IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved san)Jary Permit Fee (Includes Groundwater 16 ate Issued Is g Agent Signa (No Stamps) + #Approved ❑ Owner Given Initial Surcharge Fee) ^~(/1 Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Divi ion, Owner, Plumber INSTRUCTIONS _ 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. 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 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, num!)cr 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 orefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the ,-o,inty. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, locatio,i of u:ldinc; tank(s), septic tank(s) or other- treatment tanks, building sewers, wells; water mains/waterser,~ice, strc<.,s nl lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and t'-re to ._tios c:sthe building served; horizontal and verP cal elevation reference points; CI complete specifications for pur a c c ont,ols; dose volume; elevation differences; friction loss; pump performance urve; pump mode.; and pump manuf, _;re; D) cross section of the soil absorption system if required by the county, soil test data on a 11 j form, acid F) al 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 contarninati c:n investigations and establishment of standards. r 7- ;2 AJ jr- ~,p/9% 2 G,l ow^ ~ ~C (/Gloms gin SGe~-~ flb, 8 f aZ ti o fN F i i i C R b 1~~ woks{ )o s r ~t 6a _ r nlFi~}Rsf.r,`b! ~ w:. tn^kYrawRma.ra+3aar.w-.tk`XY +7bir-:.' :rn. ...de .z ~,m,?MI" v -5 7 wUwohsin Department of nsindustry. SOIL AND SITE EVALUATION REPORT Page of 3 labor and Human Rel a tio Division of Safety a Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTYST, C~Po~'X Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must kwWe, but not limited to vertical and horizontal reference point (Blot), direction and % of slope, scale or PARCEL I.D. # dmensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCAnON J0 L) Cr R a r r y GOVT. LOT VW 1/4 N4"'114,S 2YT 19 N,R If E ( W PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUBO. NAME OR CSM # L33 0 1 /0 Ilk- AVE- , 2- 5uN R OGE CI1y STATE ZIP CODE PHONE NUMBER QGTY [YLLAGE OWN NEAREST ROAD (~>4L~w/~✓ ~01S, 5,y00Z (715) 3053 HvD.Scv NtiTTo" CIRCI&C- jqfew Construction use [ <Residential / Number of bedrooms y Addition to existing building 11 ( ) Public or commercial describe Code derived daily flow C06 0 gpd Recommended design loading rate bed, gpolft2 trench, gpolR2 Absorption area required .00 bed. {t2 ..5- 00 trench. ft2 Maximum design loading rate bed, gpd/ft2 trench, gpolft2 Recommended infiltration surface elevation(s) R (as "fired b site plan bastdartark) Additionaldesign/site r .tu~T'~trB/~" way ^ve Af&444 &V SySTE.y Parent material SCS S9 Wh /E•r/ j Sf rTiPE _Rood plain elevation, d applicable IV f¢ ft IN GROl1ND PRESSURE ATGRADE SYSTEM N FILL HOLDING TANK r.u Suitable for system CONVIE21NTIONAL MOUND urtsl~table for system OS C C o u 0S of f a s Bia o s oi' o s Epr- SOIL DESCRIPTION REPORT Boring lti Horizon Depth Dominant Color Mottles Texture S> re Consistenoe Boundary Roots GPD in. Munsell Gu. Sz. ConL Color Gr. Sz. Sh. Bed lariat A2 0( j7h 7/7 Ground , l(- yy /O y1f y 7 s, 3, 40, Ak ~ elev. Depth s/ f 9i~ f / a limiting f 2- his G SI 612 PM: t (313 e laxP naU0 . t"j Remarks: !/~~li Gt1~T -/f/.~lO s T spTvri'~ry - r' .SCE " Boring r4 Yf y/.x Si'/ 2,f, Sbk ~,-f2 CS ;r- /0 . S 2 2,~j 2f K'P A3P , S - , /(-3v /0 yle 3/ s/ 2, be ~vnf/' C s /f Ground elev. C -7~- 'I s YR y G .9 ~DFO fS f Q~Q .n, ~fe a -C / : s - ~o gi9- fo ft. Depth to Z. 5 y .61 limiting So utk r o F eA0 faCtOr fiP~4C r a L~ M ~S ,c> 1-r' 3,6 /01 Remarks: U 2~-~1ET .BIOS 1` -sif7-04tTE-,~:) /}T 3~~ _ Aso 7-7- 4,67 L::) l Name:-i.i®asa ~~rint ~p ~~ipT Z1L~12 / Li 7- Phone: 713~ 3 S06 r'' /8 <P/ ress: l9 f~ © ~ / Q l`L PT 0 ! S S 0/ 67 SS Signadxe: i D 9--/? 3 Date' CST Number Q~'•~~Z~~ l~ csry z y~z ORIGINAL S/ 13If'vDS IN )%,e .7 . / 'S fl s r 0 E4,& Z C ~M ti r v , see ti 10, z J More loco zoning] ptlt m" can be granted - i THIS PROJECT WILL REQUIRE STATE LEVEL t`,~,`~ PLAN APPROVAL. Plans k sc~ ttrNl need to bs submitted by a qugM%d designcr per I.L.H.R. 83.08 ON Tr , y- ~~v~ ~~~~oTry Z PFAW- YOWNER SOIL DESCRIPTION REPORT Paged -3 PARCI3I.D. # 60 22 S v ,A-~ (I Depth Dominant Color Movies Texture Structure Canoe gourdary Roots GPD/ftz goring # Horizon In. Munsell c" Sz. Cont. Color Or. Sz. Sh. Bed Tiench 7- 747 7 677- ra1f2 s 3 O-~ d ,Ve ~2- 57 . c s = G i~. /o!~ y S~/ f,5 6,it- ~f,e ~s 3f-- .s ~ L Ground B , is -33 7,5 y/z 7 V f/f e-5 ,5' . - S y y 3~ V 31 51 ,4CT,~,p D L ~1E57r~ > , 9d r• m iMng 5 Y belor ~I JN T 7~e 3 v6/ 'PoyiD.vS 176A i ?o.J "(f ~40,6eE- U6,~R/K WE 7 Remarks: Boring # G /o YA y S.l 2, f, ,rk n~►fi2 s 3 f , 571 -6 l3 /5-33 S Ground 7 S YA 316 y4 n~ Ufa a~ NP elev. C 3 -LO 9 y,~S ft ` Depth to kMng Remarks: s! /fob ~o,✓ t t C Boring Ground elev. It. Dop1h to Factor Remarks: 'Boring # 131 Ground elev. it Depth to knAng factor Remarks: OWN 01"^10 ^e/nn% Cry iti o r ~ ~i'T~ ,oe0/3 LEA S ~ ~~i'! vsE «l GEs D/ FFNT" rz X rv~ s (Gt'yf ~'~e s / Q So./s ~p.;it~t~3A /ti/S so;~s Gvov~v X07- • O o ELCUhT'iOA.3 S 'BI 9y~~ ~Z 99, 90 X33 f3 y 9 h' 9~ - Mav.vO s/ STEM v Q q5 p q7'~D o R. ~ B ioo ' Gy 1. 3Z 53 AUc NEXT TiPEES ~o Sv,Pve yoR' S 5^~~EL '~~cE POST - oN west tor- ~,PoPo6e0 Tor of PIA4 ~lEU~r~oa = iod• 0 /107 Z Z Scq~~ • /'I- y0 /3Ac~l o~ PiTs 0 a - ~'x.'ST~,v Cr ~ipADE E/E!/~!-7'io~t/ 5 -5 Ac -nE~s T- ~ , - _ w and Huxrarnan Department Relations Industry, Labor and SOIL AND SITE EVALUATION REPORT Page of 2- Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY 77 Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but S . ~~POi. not limited to vertical and horizontal reference point (B", 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 SOU G- P CD2o7TY GOVT. LOT 5w 1/4 Nw 1/4,S iy T Z-7 N.R 1'7 E (011(i) PROPERTY OWNER':S MAI ING ADDRESS LOT i BLOCK # SUED. NAME OR CSM S 23,30 00 f{UE zz suNQ106- CITY, STATE ZIP CODE PHONE NUMBER OCITY OVILLAGE N NEAREST ROAD 13h1-D6J1.J &J/,S S'yZ Z (715)643K-3053 upset J H0TT6"-, crt?cIE [ gNew Construdion Use [ y-'_ResidenIW / Number of bedrooms [ J Addition to ehostirg btildng [ J Replacement I J Pudic or commercial describe Code derived dally flow &00 gpd Recommended design badng rate I/P bed, gpd/tt2 tench, gpd/R2 Absorption area required NP bed, 42 tench, g2 Maximum design loading rate A/' bed, gpdM2 • 5 tench, WW Recommended infiltration surface elevation(s) .Sct F; • 3 tt (as referred to SOB plan benchrmaN Add'itiond design / site considerations AV-"c"7 _7re -t"i-5 aw d-Y /wl 04913OX Z f5'r r'8v T/o A_) Parent material SCS - _5~fT77',~5_ Flood pUn elevation, d applicable It S - Su le for system CCc0Nv 'S D U LA'S O U a °0 u Ae o u 0 " FILL7 0 IrtG Tu~lc U = Un Unst~table for system I SOIL DESCRIPTION REPORT Boring * Horizon Depth Dominant Color Mol les Texture Structure corisistence, Bou rcby Roots GPD in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed 5 a-5 16yX y 2-- S ! T, 67h& 1b4 I/ f~ cs zf , y . 5 Z s -/ff 75 yR y/Ce s1 i f R 6", fie 6-.s ~ f . Y s Ground g~CP r3,~F uDEO /S . F elev. It. p /0 I/H '51 O, f q,P S a S - - . S Depth to C S' 9O /O y/~ Ce fs 4J "?k bMng favor for a cone tional septic sst m. Remarks: Boring # 6--7 56,e lwvfR e5 Zf . y s 4, 7- Zo f s y2 y~(v - S y,p .w►f/p C S l>c y . S Ground elev. fL o'~R L/ y /st", Depth to lo y~e imtiting nn n.] k. ftlor Remarks: T Name:-Please Print :f)o 13elP T Z1L13,' c /f T Phone. -711_ 3 JO (o A&Iress: GSS 01,V&/ Z_ ;eo • lyooSso&,.~ 4o1S. syoe(o 9- iQ- 43 csr.,/ zgyZ Sisnatrxe: T , _ h ~ _ c I Date: CST Number / GWQ i A-) C&OT, ,4 5 T _/0 #t /~?/f"Dz o soy/s /a TES 7 /hPZ~~,t o~ 7''5 1-07-- 'Ands 7%LeR 3 111 /5 4x- Zwr 40..11 P"i-0i6p av,~A W,C)eF for- 40&7T -;r-~ DitF~ie~~T -r&.y 7v eEZ) 44t} _5 Gvt7?~ S7-E,oct . n/I-rP - 1507- 116Ay 100T16 /:3 s0f7- /,C! 40A)s1 S f / L O~ L cAJGe erS S A ov ez) 4-f- bN V /t//ETA /I'>>tI(l.~t i z€" SiO~ GcJfi!/ /J>E•P~ i fii3 i' /i'~~ ~ w -Dpv pep o y PROPEMYOWNB TT SOIL DESCRIPTION REPORT Pape? 3 PANCS. 1Q4 Lo7-0 -2- -2- svAl ~Pi~(rte # l DeW Dominant color Mollies Structure GPI Boring Horizon In. Munsell CAL SL Oont. Color Texture Qr. Sz. Sh. ~ Roots tied 57 ~0 yl z S1 2, nM, f a s Zf N w Ground T3tG l`l- 9p io yR y - s/ o, f, yes ti S • y S elev. ~i,e y 1,4~~~P 9,e tt limiting Remarks: - - - Boring #t SwIlING Ground elev. It Depth to Ntniting factor Remarks: Boring # Ground elev. It Depth b furWin9 tailor Remarks: -Boring #f h ~ R. AIT- Ground elev. Depth to limiting factor Rem con 004f1/O #%CKIN ^ V s~ N CP coU f\r V O C TES r z Z o 0 4-r- 4014/ LCT eodr,Jtl2 . %-v hT~o•J = io D • d ~ ~/2 .135-f3G-T3.,~ • 0 0 SCALE • / r= y0 sa a ' pV I01.0 • _ .~A~~hfoE Pi'T5 (f,tA ftA y~ D 10 '°'su55tsrEo 10 i~ / Sy /ZG I o 131 . { m Fob TES T AeC4 ~Ep/,~E,,, r s~pri~ /►,pE.f 40111 /j.C-lovvv C LE VATt o,v,5 3s ///,oy, r3-7 i~z"o " - by/~?EAo ~SE .3 ~~f'EuCES t i9 Gf1 !J" x Q O lfi ~G~ T/'E~ s y5' 7',M /ae" p Su ggEST~~ M/p T/~c~oti Z , A, /0 7, p S s rc h LEV~tf~ov5 y5 TE ocv s y S 7- o ' 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 _ b0 a{jL C2~ .L r1G Location of property_ 1/4 AJ )1/4 , Section , TN-R_J_9 __a Township- 0Yl SVo Mailing address y-. Address of site Subdivision name Lot no. Z Other homes on property? Yes 4No Previous owner of property LU Total size of property o7, Total size of parcel .2, 1 &"e A Date parcel was created S - g Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes `v/No Volume and Page Number_ 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. ,j 3 Q'Z 0Z , 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. ~Iv MAPLEWOOD DEVELOPMENT " & CONSTRUCTION, INC. S ignatu o Applicant 303(EG A Oakdale, MN 55128 '~Pj License #0001011 Date of Signature Date of Siqnature STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County t OWNER/BUYER 9nf~dl J.Pj, Pmt t i MAILING ADDRESS 3 C-✓` . s+ Ili ' p 6 , 67 /1 PROPERTY ADDRESS Z H I z'p n i4j). V (location of septic system) Please obtain from the Planning Dept. CITY/STATE l(A V, r . sL~ PROPERTY LOCATION i 1/4, ~JUJI/4, Section T? N-R_ TOWN OF Ct ST. CROIX COUNTY, WI G i-1 SUBDMSION S+ LOT NUMI3ER 2 Z_ CERTIFIED SURVEY MAP , VOLUME S, PAGE LOT NUM13ER- 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 I/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 u t be completed a td returned to the St. Cron County Zoning Officer within 30 days of the three ye tion dat . SIGNED: DATE -Oa-UEVELOPMENT- St. Croix County Zoning Office & CONSTRUCTION, INC. Government Center 3030 Granada Ave N. Suite A 1 101 Carniicliacl Road Oakdale, MN 55128 Hudson, Wl S4016 License #0001011 Y,`!R OF SECTION 24 26 MATCH LINE - SEE SHEET 2 S 89'03'50"W 636.00' .pp• 266.00' 220.00' ~ Z O O N W O = C z O r W • T "fi:~~ LA t71 .4N O D 1 40 w 01 O COON 01 O i -1 A a 10 6+ p y D N p D N O im fiYr.r .N o :~n I,0 Lo ON r; 3c i r ca ! N O C ' d p 10 = • N V z 0 ca I0 1 ~ ~ Irn im 10 r O 4i v V • . . S . ~4 v .00. N t , . A S s~ 1~• 4 X00, 00 7~ .3 its F i R O • C ~ O cD -I 1 c~o N N N m I w m 0 4S 0° m z ~ow ~ - - N cn D -I rn tlf l ~ i Z 0~ O w~ vaAli m~ 66' 0031140W 318.19' S 8803'14"W 287.00' N HUTTON S 88'03' 14"W 672.35' HILL ROAD N - - - 222.35'- - - - - - - 225.00 - - - O- _ 73 .009-- ca yyW Y cn CD co - OA 01y - pO O ~N OA w 0 0 Op N D -4 .V 5b OD 0 ~ N CD P n NN O ~ ~ ~p p ?D m m ~ m • DOCUMENT No. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 5 - 0208 6ooKIINPAU 369 ST. Cimm Co., Douglas G_ Pedrotty and Judith C. Pedrotty, t~sic'clir,rR. :.rtl1 husband and wife, survivorship marital t J U N 16 1995 ......Pro . .....P-e• ..ry at 1:00 P. ~ conveys and warrants to - M3pleWOOd D@velOpment .and , Q Construction Inc.:`: - L - - - - R RN T - 9o Sf i. y ? A4?_&fSOr1. CcJI Syo~ the following described real estate in S.t_...Cr.Qix County, State of Wisconsin: I Tax Parcel No II i Lot Twenty-two (22), Plat of SunRidge in the Town of Hudson. I i j~ II ,fEG This is. nOt....... homestead property. :KDOX(is not) Exception to warranties: Easements arid restrictions of record. ~mv 95 Dated th is day of 19......... (SEAL) 267...~J• ---,6t (SEAL) Douglas G. Pedrot - (SEAL) C.. 111~ (SEAL) J~h C~ . ' Pedrotty " ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN St. Croix ss. County. authenticated this day of 19...... PersonallY came before me th~ day of r .!_S~ri . 19........ the above named Doug.. las G Pedrotty- and--Judith... * C Pedrotty.......................... TITLE: MEMBER STATE BAR OF WISCONSIN f......'........... (If not, . P authorized b y § 706.06, WIS. Stats.) to me known to be the per S. . he who ex! a 16 1 forego'ng instrument and. c+k~i6 ~ }hl QIM. • ~ _ THIS INSTRUMENT WAS DRAFTED BY .i. Thomas A. McCormack w e " 10 N BaldWlri, WI 54002 Notary Public t~! (Signatures may be authenticated or acknowledged. Both My Commi on is pe Ianent. (If" not, stati~(~~~~ Ffration are not necessary.) date: ..=c~~J~°-Ll$.-11 oo ) 19.f- •Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc.