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HomeMy WebLinkAbout026-1114-40-000 o O °e o a) a o ~ I ° m a E 1 y a a o con CU N n o as x a h ~'Y I o Z c `a) (a N 7 C6 -0 N LL O Q C N z co _ o 0 z d (D F-- z n co 0 75 O z :!t c .U Qa ~ O N - d 2 O H z .s E '2 o ch N N U a Q) N Q) Q) c N Cl) N N O O co O o o c z m z N z a c ° 10 E N N > j ~ d y f6 w G a CD N Lo O F- H H O ~w E 333 an. z~ O O O ° •N a a a a 3 N 2 0) 0) 0) N q! J U i ~ 0) ~ v m Q N a) ~j N N ►~l o0 3 co N C o E o l O R ° U N N am 0 °v ~ - a) c c m a a) o l N (O Y Y 'L3 N C C aJ r r o 00 'r..i N a> O E N It -U N (O I- (D tp _ m ~ N (0 (D ~ U • 7a O O R N O N Cn w °i dt a m a • a m '2 ~1 A U d O N U 1 'Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT 'rte of 3 Labor and Human Relations Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code COON A ,Croi r.a Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but Y not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PAR L+{9. # dimensioned, north arrow, and location and distance to nearest road. 2 111`4-'40 V BY APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVI 00E PROPERTY OWNER: PROPERTY LOCATION Derrick Construction, Inc. GOVT.LOT SE 1/4SW 1/4,S1 Z <yrN,A 1 PROPERTY OWNERS MA!I.ING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM 1505 Hy. #65 5 na Willow River Mead6*9 CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE)OOWN NEAREST ROAD New Richmond, WI. 54017 (715)246-2320 Richmond 144th. St. [ New Construction Use [x] Residential / Number of bedrooms 3 ( J Addition to existing building J Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 -8 trench, gpd/ft2 Absorption area required 643 - bed, ft2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 - 8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 99.13 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND T71NIGS ROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for system I® S ❑ U E S ❑ U ❑ U 91S ❑ U I ❑ S Q U ❑ S -t7 U SOIL DESCRIPTION REPORT Borin Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ITter& VIN NET 1 0-11 10yr3/3 none 1 2msbk mfr gw 2f .5 .6 lei 2 11-29 10yr4/4 none sil 2msbk mfr gw if .5 .6 Ground 3 29-90 7.5ry4/6 none Co. s Osg ml na na .7 .8 Depth to limiting factor +90" Remarks: Boring # 1 0-10 10yr3/3 none 1 2msbk mfr 9w 2f .5 .6 2 10-27 10yr4/4 none sil 2msbk mfr if .5 .6 2' gw 3 27-80 7.5yr4/6 none co s Osg ml na na .7 .8 Ground 101'38 ft Depth to limiting factor +80" Remarks: CST Name:-Please Print Gary L. Steel Phone' 715-246-6200 Address: 1554 200th. Ave. New Richmond, 10-5-95 cstm 02298 Signature: Date: CST Number: f PROPERTYOWNER Derrick Const., Inc. SOIL DESCRIPTION REPORT Page _of PARCEL I.D. # 026-1114-40 Boring # Horizon Depth Dominant Color I Mottles Texture Structure Consistence I Y i Roots GPD/ft in. Munsell Gu. Sz. Cont.Color Gr. Sz. Sh. Bed iTmnch 1 0-14 10yr3/3 none 1 2msbk mfr gw f 3 : ;2 14-30 10yr4/4 none sil 2msbk mfr gw if .5 .6 3 30-90 7.5 r4/6 none co s Osg ml na na .7 .8 Ground Y 103 35t, Depth to limiting facto +60" Remarks: Boring # 1 0-11 10yr3/3 none 1 2msbk mfr gw 2f .5 .6 4 ` 2 11-3 10yr4/4 none sil 2msbk mfr gw if .5 .6 3 30-9 7.5yr4/6 none co s Osg ml na na .7 .8 Ground ev. 10 3.8ft. epth to limiting factor +90" Remarks: Boring # 1 0-11 10yr3/3 none 1 2msbk mfr gw 2f .5 '.6 5 2 11-2 10yr4/4 none sil 2msbk mfr gw if .5 .6 3 25-80 7.5yr4/6 none co s Osg ml na na .7 .8 Ground l85'. 5§. Depth to lii iiiti^g Remarks: Boring # I Ground elev. 1 ft. f Depth to limiting factor Remarks: SBD-8330(R.05/92) a STEEL'S SOIL SERVICE Gary L. Steel Derrick Construction, Inc. 1554 200th Ave. CSTM2298 SE4SW4 S1-T30N-R18w New Richmond, WI 54017 MPRSW 3254 town of Richmond (715) 246-6200 lot #5-Willow River MEadows N 1"=40' BM.= top of SW lot stake C el. 100' 'V 251a , p~ tict Re, T (7 )0 Gary L. Steel 10-5-95 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER__L~,, ADDRESS Q SUBDIVISION / CSM#_ ktQA t~)Q~ j ni&~ LOT SECTIONT 30 N-R W, Town of_je, ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTH NG WITHIN 100 FEET OF SYSTEM i ~.l I i la ° dra INDICATE NORTH ARROW 17g a7 3 g Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. t . BENCHMARK: S Ca WYl e V` ALTERNATE BM: SEPTIC TANK / HOL ORMATION Manufacturer: Liquid Capacity: Jo?Sd 6 Setback from: Well N~cJc,1 House Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location 4L, SOIL ABSORPTION SYSTEM 4Z-//7,e5 Width: /oZ Length 7a Number of a Distance & Direction to nearest prop. line: So, i Setback from: well: House lp3 Other ELEVATIONS Building Sewer ST Inlet. JD/, ST outlet PC inlet PC bottom Pump Off Header/Manifold J00, Z Bottom of system Existing Grade /OJ / Final grade 6 Z, DATE OF INSTALLATION: 107 ~ PLUMBER ON JOB: aL~~ LICENSE NUMBER: 156-3 INSPECTOR: 3/93:jt 'gretfW e7 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION l,, ,.r 48 P 's City El Village 9. Town of: State Plan o.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic) 5'0 Benchmark Q Id af_t r Dosing QQ,L ~c d~9a Aeration Bldg. Sewer Holding St/ Ht Inlet ~.3s ~el.83 TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet Ar I Septic yd S *10 a ' ya 5 ' NA Dt Bottom Dosing NA Header / Man. O Aeration NA Dist. Pipe ' orJ• Holding Bot. System b 1-7- ' PUMP/ SIPHON INFORMATION Final Grade y,qg /03.1 Manufacturer Demand Model Number GPM TDH Lift I Lrictio Syeatem TDH Ft Forcemain Len Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS a 2' / DIMENSIONS SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O CHAMBER Model Number: System: LA" °1 3 N 1 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 F, Depth Over i' 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: Richmond.1.30.18W, NE, SW, Lot 5, 144th Street Q) cut - 1.(.J Plan revision required? ❑ Yes Q(No y~ Use other side for additional information. jot of SBD-6710 (R 05/91) Date i'nspector's Signature Cert No. S SANITARY PERMIT APPLICATION In accord`with ILHR 83.05, Wis. Adm. Code COUNTY r STATE SANIT Y PE MIT # -Attach complete plans (to the county copy only) for the system, on paper not less than p~ l 7 Ug 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 nn PROPERTY LOCATION T 30, N, R {or) W PROPERTY OWNER'S MAILING A DRESS LOT # BLOCK # S C) * -51 1 Nct, CITY, STATES ZIP CODE PHONE NUMBER SUBDIVISION NA OR CSM NUMBER N w IK: Vn. A S o l /S 1-1, 1 t, - a kp : M ea A o ws II. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE : 11 ` 1 NEARES `RO qyh SVT 5j TOWN OF P,,,r4yy\ AA- ARCEL AX NUMBER(S) ❑ Public r 1 or 2 Fam. Dwelling-# of bedrooms P III. BUILDING USE: (If building type is public, check all that apply) 1C 1 ❑ Apt/Condo r 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. V New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 A Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 El Seepage Trench 22 El In-Ground 42 ❑Pi t Privy 13 El 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) 1, 13 ELEVATION Odr 1 a~ I ~j g6 I, Feet Feet Vll. TANK CAPACITY Site in alIons Total of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete structed Con- Steel glass Plastic App Tanks Tanks Septic Tank or Holding Tank s~~d dS Lift Pump Tank/Si hon Chamber 0 El El Eli nn =4= LJ El Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): D Plumber's Sign No Stamp) MP/MPRSW No.: Business Phone Number: \o .A ~ p o'-0 e [,j S L3 1( -7 js S~ l0 S~ Plumbe 's Address (Street, City, State, Zip Co M ~Q gu)e lie C11PA0 (,vim fyY 017 OA VZ IX. COUNTY/DEPARTMENT USE ONLY Groundwater Date Issued Issuing Agent Signature (No Stamps) ❑ Disapproved X nitary Permit Fee (includes Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination ZL - X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber t 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 Ibe 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.11188) i a D~ --t__4--_,4_ i 1 f ! ; 1 F x 1 ' 3 i i t a-.. po ~11'1 i i t 1 I 1 i G ( i t i I ! l a f { I ~ ~ I _ ~ I r ! 3 1 ( w , j i , E , E f ..-y...__._-f- r.,._.. i.. j... _ {...,__...y I.. .1 _ , _ E-._i.F i j 1 1 i ~ ( 1 ~ - A L- s E ~ ~ J I ~ 1 4 f~~ ' i _ 1 I cry ~ ~.u~ v r-gs . W ( 1 PAGE OF 1 ~~htta ~1 e-mss Crv5S Secflun p~ SyS~en-1 Fresh Air Inlets And Observation Pipe Q Approved Vent Cap Minimum 12" Above Final Grade 20-4 Z' Above Plps -41" Coel Iron To Final Grad• Vent Pipe Marsh Hoy Or Synthetic Covering min. 2" Aggregate over Plpe Olurlbullon -T , as pipe - 0 0 0 0 i 6" Aggregate LO Perforated Pipe Below Beneath Pip a -Coupling Terminating At Bottom of System Prp~oSeD ~inal: 9rc%c1< SOIL. FILL DiSTIZIBUTIOIJ PIPE APPROVED S'~MPAETIC COVER . ° "-~-NIATr ROR q" OF STRAW 2" of M R EGAT~ OP, MAt~sN HAS le_OF%p_ P_'/t AGGREGATE v\~ //ice ELEV. of FEET. - OIST1115UTIOU PIPE TO BE AT LEAST INCHES BELOW ORIGINAL GRADE AUU AT LEASTLO INCHES BUT.JJO MORE THAN 42 Mr-RES BELOW FINAL GRADE MMuMUM WN OF FXCAVAT100 FROM OKI&INAt 6KAVF-.WILL BE tNCHES MIr41MUM 9SF" of EXCAVATION f.RoM. 01~I411JqL GROE WILL 6E INCHES SIGIJEO: LICEMSE DUMBER: J-7L3 - DATE: _ WiisodrIsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page -Of L%jor and Human Relations DwWon of Sat" a euadings 'in accord with 11-HR 83.05. Wig. Adm. Coda - - OUNTY St. Croix Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but PARCEL I.D.+ not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or dimensioned, north arrow, and location and distance to nearest road. 026-1114-40 APPLICANT INFORMATI0 N-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Derrick Construction, Inc. GOVT. LOT S•E ~Am SW 1/4,S1 T 30 N.R 18 xiK(or) w PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM e 1505 Hy. #65 Zip q 5 na Willow River Meadows CITY, Richmond, WI. 54017 CODE X115 j 2468320 C Riichmond OWN NEAREST 4thA St. I j ( New Construction Use (xl Residential / Number of bedrooms 3 Addition to eiosting building I 1 Replacement ( ) Public or commercial describe Code derived day flow 450 gpd . Recommended design loading rate • 7 bed, gpol • 8 trench, gpdfft2 Absorption area required 643 = bed, ft 2 563 trench, ft2 Maximum design loading rate • 7 bed, gpd/tt2 •8 trench, gpdtft2 Recommended infiltration surface elevation(s) 99.13 It (as referred to site plan benchmark) Additional design / site considerations na Parent material outwash Flood plain elevation, if applicable na ft S - Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK u= unsuitable for system i ®S ❑ U ® S 13u ® S ❑U ®S ❑ U 0S L] u C) S u U SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Texture Structure ConsistencelBmsxliry Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trerxr ' 1 -11 10yr3/3 none 1 2msbk mfr gw 2f .5 .6 1 ; 2 11-29 10yr4/4 none sil 2msbk mfr gw if .5 .6 Ground 3 29-90 7.5ry4/6 none Co. S Osg ml na na .7 .8 103 .'3~ Depth to limiting factor +90 i 77 I Remarks: Boring # 1 -10 10yr3/3 none 1 2msbk mfr gw 2f .5 .6 21 2 10-27 10yr4/4 none sil 2msbk mfr gw if .5 .6 3 27-80 7.5yr4/6 none co s Osg ml na na .7 .8 Ground 102.38 , Depth to limiting +Boll Remarks: 121 CST Nunes-Pleases Print w10Ae' Gary L- Steel 715-246-6200 C.~~ JU344 W-/1 pond. WT. 4017_ Address' 1554 200th. Ave. New Ric 10-5-95 cstm 02298 F . STEEL'S SOIL SERVICE Gary L. Steel Derrick Construction, Inc. 1554 200th Ave. CSTM2298 SE4SWh S1-T30N-R18W New Richmond, WI 54017 MPRSW 3254 town of Ricbmond (715) 246-6200 lot #5-Willow River MEadows N 1"=40' EM.= top of SW lot stake @ el. 100, ~ .2a7a ~ Rm 178 " -9.#7 30 Gary L. Steel 10-5-95 '~J I ~ . 1 , a •.i . It. 1,' viii: ii; ;::r ti; , T • ' ,r. 00.111+ ' , 1' r • Outtott . 1.7 IMAM 2.00 Aare 1. f am AOhs , is ' ' , ve 16 w f:' Lai Aa" -Me' LISA" zo. 13 2.,. Aaw t AaM 1 M.13 9 1 283.14 2M Acne ~ 2.00 Aaw • zo $ ' 12 22 >z ! 241 Aovv ~ M AG M • ~ i 'am 21t ,36.2s W. :1 ' Public 206 4U.76 f 23 :m 20A.30 24 ,'2,00 ACM. a. 6 a 28 p 2A2 AaM. « 227 Aof>ta UL ' 42525 1 ' Oe ; 5 316 ~ 1 25 ; . Z.OS Atns 2.0, A" 4 ' + 27 ° e s4o.4s• N 29 ZMA" 4 A t32 77." wlbw A"- 478M Z,ypV • • 77:t0 C&IctMwRklmw4 , 26. ' 2.30 AaM 3 0 425 ' So7.06 2u no 211.03 0 2.OSAM o Cane Rd GO . 32320 O 32 33 0 : . " .a 2.20 AaM 1." MU ' G. N 3 N O h y 1.61. AaM a 2.03 Aaw r 200.50 320.37 Ms• • Highway GG (715) 246-2320 RRICK Route 1 Q New Richmond CONSTRUCTION--' wisconsin STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County W L LA_ow 17-jv%52- )o ► t4T Vel-t (title OWNER/BUYER 616 ►c+v,&eL- MAILING ADDRESS 'Po Vjox . t CA+ OA O D, \61 i 4 O I ^1 PROPERTY ADDRESS I1 S l0 144 (location of septic system) Please o tain from the Planning Dept. CITY/STATE ]~CA-~Nt a 90 S 4~ 1 -1 PROPERTY LOCATION 1/4, ~ 1/4, Section T N-R W TOWN OF C.41 m o u0 ST. CROIX COUNTY, WI SUBDIVISION V I t.r a w T2-AV Q- Me_bD0W_S + LOT NUMBER S CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER i 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 m be completed and returned to the St. Croix County Zoning Officer within 30 days of the three ye. SIGNED: DATE: lO -icy -13-S 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. a 7 - - - - - - - - W1 wow Owner of property NLC 44e Location of property 5~ 1/4 SQL 1/4, Section T ~ N-R 19 W Township `1C,4f,40"10 Mailingaddress P© L-30 X, -Ar t ~ V c-N- M+a "o., VS(t S40 0 Address of site 1"IStc 44-`►} 0=--v4 (2~c,4rtob.lc>, ( Spa 1 Subdivision name \/41L ow ~ Vo't. NA4E~h-00 W-5 Lot no. S other homes on property? Yes No Previous owner of property (.2aU"7 IAOc SC+ trA10 C Total size of property Total size of parcel ?i Anx4Z5 Date parcel was created J() l 9 - ct'a Are all corners and lot lines identifiable? -)(,.._Yes No Is this property being developed for (spec house) ? Yes No Volume 651 and Page Number 4 91 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. 45-V7(,-1 , 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. 45 i. -1 too -7 Signatur of Appl' ant Co-Applicant /o /o -gS 3J4 PACE 4&) DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-19821 THIS SPACE RESERVED FOR RECORDING DATA ! 452767 • ~ _ GIIARDIAN'S DEED - REGISTER'S OFFICE This Deed, made between ST. CROIX CO., WI ...._Gertrude___E.._.Schmi.t. by Bevermy__Buckner,._Guardi_a Recd for Record Grantor, OV i 2111989 M and___-.Michael.' R_..._Steyens_,__•William H-.--_Derr•ick..____.._- A. .Wi l l i a m M De r r i c k Thoma s E Der r i ck and Ronald.' L.---.Derr_i_ck..as...tenants _in---common------------- I R iaterof~ Reg Grantee, Witnesseth, That the said Grantor, for a valuable consideration...... Gertrude E. Schmit b Beverl Buckner - - - - - conveys to Grantee the following described real estate in St.•...CroiX••••_ Rc,unN to County, State of Wisconsin: Southeast Quarter of Northwest Quarter and - - Northeast Quarter of Southwest Quarter of Tax Parcel No: ic£ion 1, Township or Range 18 West. This deed is given pursuant to the Order to Sell, dated October 16, 1989, and the Confirmation of Agreement and Order, dated October 19, 1989, both duly authorized by Order of the Court and whereas the undersigned, Beverly Buckner, is authorized to sell the same by Letters of Guardianship certified on October 22, 1989. rRANSOM A Ym This _ is not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And..... Gertrude... E..-Schmit---by_.-Bever.ly...Buc_kner.............................................................. warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights-of-way of record, if any. and will warrant and defend the same. el- Dated this ---"--------"Z•-•••--•--•-------••••-••...... day of 1989_... (SEAL) (SEAL) 4 ~E. Schmit by Beverly Gertrude (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT I Signature(s) STATE OF WISCONSIN Beverly Buckner ss. - n County. authentic ted thls~........ day of._OctOber . 19..8...9 Personally came before me this ................day of 'L~ ~V, 4a y1I-K. 19........ the above named Kristina Ogland Lundeen TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. Attoxnay...at.. La-W.•---•••-••-•-•••••...•----••-•••-•.... Notary Public -•-••••••-••---County, Wis. (Signatures may be authenticated or acknowledged. Both All Commission is permanent. (if not, state expiration II are not necessary.) ) date: 19 'Names of persons signing in any capacity should be typed or printed below their signatures. l; L WARRANTY DEED STATE. n 1It OE NVNC )]RIN Wi-- it I: ,-al Blank Co. In,.