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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS X33 /07
SUBDIVISION / CSM# LOT #
SECTION 22 P T --?q N-R i,P W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYS EM
Zje 7-
/o
d~ 2
1
v
w
r
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION'Mol
Manufacturer: ~r~lo✓t Liquid Capacity:3 /iooo
Setback from: Well y ? House .'z 7 Other
Pump: Manufacturer ?o,,caa Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of tre
Distance & Direction to neare line:
Setback e 1: House Other
ELEVATIONS
Building Sewer IIA9, P- Inlet, 98• -&T outlet d
-Pe inlet f.611 -PE bottom Pump Offer 9s-,W W
2 inlr~ 0?.6 A" /f
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB: ~LICENSE NUMBER: ~S off
INSPECTOR:
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor antPuman Relations
Safety and Buildings Division INSPECTION REPORT ST. CROIX
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Permit Holder's Name: ❑ City ❑ Village ❑ Town o : State PI
SEWELL, STEPHEN X
CST BM Elev.: Insp. BM Elev.: BM Description: Warren Parcel Tax No.:
1 a /~r / y i
/00,
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 4?) 6 a~
Dosing 7S0
Aeration Bldg. Sewer
Holding /fa is r, ~1, .Q St / Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
Vent
TANK TO P/ L WELL BLDG. A
irito ntake ROAD Dt Inlet /p, 3 1' q
Ar 3 ~
Septic NA Dt Bottom 7
/y, 96 93, i 3
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand 6 'J" 4&e,,4. ~U 7,/ '77.'75
'
Model Number ` GPM 9 '
✓ 3 y i°5_oz'
riction ~ystem TDH Ft
TDH Lift F
Loss Head
Forcemain Length Did. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS DIMENSIONS
SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
SETBACK
INFORMATION Type Of CHAMBER Moe Number:
System: 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.)
LOCATION: Warren.29.29.18W Part of Gowlt Lot 2 107th ^c F- ^
1 CfJ~/c'
Plan revision required? ❑ Yes ❑ No 1//
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
r
ADDITIONAL COMMENTS AND SKETCH
4
SANITARY PERMIT NUMBER:
I
Safety and Buildings Division
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 Cou
than 8 112 x 11 inches in size.'.
• See reverse side for instructions for completing this application State Sanitary Permit N4-umber
The information you provide may be used by other government agency programs E] Check it revisiiooonn-tQtooj previous application
(Privacy Law, s. 15.04 (1) (m)]. State PI I D. Numb
1. APPLICATION INFORMATION -PLEASE PRINT A MATION
Property Owner Name \ Pro rt !NO&S e e- t/ _ TEA T 29 , N, R IrE (or)(0
Property Owner's Mailing Address Lot Num er Block Number
O
City, State Zip Code P ne Number Subdivision Name or CSM Number
II. TYPE OF BUILDING: (check one) ❑ State Owned ❑ C t Nearest Road
❑ Village ~xrtrr:..J
❑ Public 1 or 2 Family Dwelling - No. of bedrooms Town OF 10-77,11
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment / Condo 0 /a Fcy -
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel / Motel 9 ❑ Office / Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. ❑ New 2. Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
System System Tank OnlyExisting 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 I)o Holding Tank
12 ❑ Seepage Trench 22 ❑ In-Ground Pressure 42E] 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 S. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation
*A- - .tea- Ale-- Feet ,1/2• Feet
VII. TANK Capacity
INFORMATION in gallons Total # of 's Name Prefab. Site Fiber- Exper.
Gallons Tanks Manufacturer Concrete Con- Steel plastic
lass A
New Existin strutted g PP
Tanks Tanks
Septic Tank or Holding Tank 12000 h'i ( t l ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ~ s"U p,! tx7~Y.✓ ® ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signature: No Stamps) P1 PRSW NO.: Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sani ry Permit Fee (includes Groundwater ate Issued Issu g Agent Signature (No Stamps)
Approved ❑Owner G Surcharge fee) w~
iv en Initial
Adverse Determination 3X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
SBD-6398 (R. 015/94) DISTRIBUTION: Original to eounly, one copy To: Safety & Buildings Divwon, Owner, Plumber
INSTRUCTIONS
1. A sanitary permit is valid for two (2) years.
2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the
Wisconsin Administrative Code will be applicable.
3. All revisions to this permit must be approved by the permit issuing authority.
4_ Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the
county prior to installation
5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever
necessary, usually every 2 to 3 years-
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildings Division, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the
system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 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.
Vl_ Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank. information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and
holding tanks for this system. Check experimental approval only if tanks 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.
Cornplete plans and specifications not smaller than 8 1/2 x 11 inches must be subr-,iitted to -the cc unty. The plans must
includ the following: A) plot plan, drawn to scale or with complete dimension, locatior of h ding tank(s), septic
t0nk.(s) o> >tl~e, treatment tanks; building sewers; wells; water mains/water sei ce, strearn, r -_l lakes; pump or siphon
tanks; dIstriouti on boxes; soil absorption systems; replacement system areas ar,:i the Io -at, o`the building served;
B) horizontal and vertical eleva ti on reference points; Q complete speci fIca Li ons for purnps anti controls; dose volume;
elevation d;fferences; friction ions; pump performance curve; pump model and i,ump manuf,_('urer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; a ~c. 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 contamination investigations
and establishment of standards.
i
UL.BRICHT & ASSOCIATES 'CO.
655 O'Neil Road ` Hudson, WI 54016 Reg. Designers of Engineering Systems
715-386-8185 Private Sewage Consultants
PROJECT INDEX S93-04290
5 9 3- D y/?. yo Datec ' ~O 4 3
DILHR Plan I.D. #
Owner STFPffEN, S~464tPhone X25"'^ 76 D
Address 1 7010 , 32- ti..X. ST-- M l ,vA.;6A Po ( . - s M )'A..) A-3 , s s yo 0'
Legal Description /,a yy .55 e-, i 9 T Z S Al /P 1,P 40
Town of County ST. CAOO~ X
C.S.T. -p u j.QRj'rk GST 2t~ ~Z Installer
Local Authority/ Supervision
sr. c L x -o v.0 r y 20Aj; G- AE-p -r--
PROJECT DESCRIPTION 6x 7-1.,o 7157
~900,~Es s 73 3 /07 57- R06 6k r5 ~ GviS. 5 "yo z 3 kt.5
,c:,4 i a G- CPA.$vE -vrl a-~ ff c. o,P yw 5 y s ~ .~-r /UO w sv X6.4 ER6~~,p
IN 4/4 ll E 6- S~T~ So~'L /,v v~STi tf ~tTio.v S AP_WEI-L
lS ND `TOM F012 ~ ki,up OF A -reEArMeAj T
S t/ s rem , Aj op- AP r 'i~t Sods So i'TA-61E a llEAJ FOie- ~ YO&A-949
sy s T -,e M ; 74/ ova y e -coves- ~ 1:5 To 07~s6-
~fOGl~/•l,(~- T~N~ si'TED DST 0~ 2 /OOQ ~ko?
Pg.I PLOT PLAN VIEWS
Pg.2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEWS
G~/'~IS/►
CROSS
FO~~BpMp~I W~
F 1 UUN
5 ~'0 S G 5 U r. f
D1160
NUDWK
ly_ Wis.
%
SAFETY & BUILDINGS DIVISION
State of Wisconsin
Department of Industry, Labor and Human Relations
December 6, 1993 201 East Washington Avenue
P. 0. Box 1969
s `9 $ a Madison Wl 53701
ULBR I CHT & ASSOC I A
R08FRT ULLiRICHT r-
655 0' NE I L. L ROAD 1 '
HUDSON Wi 54016
`i
r C7
Rk . PLAN S93-04290 ~ FEE RF`ElVE0: 60.00
SEWEL.1., STEVE 9 9
NE,SF.,29,29,18W
TOWN OF WARREN COUNTY ()17 ST CROIX
HOLDING TANK
The Department has reviewed the above--referenc..ed submittal.
Conditional approval is hereby grantees for I'tie system plan submittal. All
rented items must be correctkd. The review and approval of the system is based
on chapter, 145, Wisconsin `statutes, and rhaptPrs Ii HR 83 and 84, Wisconsin
Administrative Code., and i contingent upon rcmpl iaor.r- with any stipulations
shown on the plans. this system has not been reviewed for the rode
requirements set forth in chapter IL.HR Hi or, in chapter> ILHR 50-64, Wisconsin
Administrative Code.
This plan submittal approval will expire two years from the approval date, or
if a sanitary permit is obtained, plan approval will expire on the day the
initial sanitary permit expires- The licensed plumber responsible for this
installation shall keep one set: of plans with the Depart.rrrenf's stamp of
approval at the construction site, The installer ..hall notify the appropriate
inspector when inspPctiorv, ccan be made.
All permits required by the city, village, township of county shall be
obtained prior' to installation.
Inquiries should be di re f-Jed to me at the number listed below. Please refer
to the plan number shown above. ,
Sincerely..
A
nth Stiemke
`elan Reviewer Section of Private Sewage ORIGINAL
(608) 266-8230 7;00 to 3:45 Mon. thu Fri
SBD•6423 (R. 01191)
-
93~o4290
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PUMP CHAMBER CROSS SECTION ARJO SPECIFICATIONS psfyE- OF 5
~l~lJfiTion) J
VENT CAP /04`0 F/~~~tTia cev{.P - /6 y!p
4"C.Z. VENT PIPE WEATHER PROOF APPROVED LOCKING
JUNCTION BOX MAWHOLE COVER
25' FROM DOOR, Af-Wl
WINDOW OR FRESH I Q
AIR INTAKE I ~•D ~P/ St`~'S
GRADE 1
z IB"MIIJ.
M/1.4' CONDUIT
~
PROVIDE I
INLET AIRTIGHT SEAL I III
99.o' I III
APPROVED JOINT A INSI~~K I I i ( WPC =VEED PEOIWTS
W/C I. PIPE ~A"fOM I III EXTENDIWG 3'
6XTENDINC. 3' 'D0 ALARM OUTO SOLID SOIL
ONTO SOLID SOIL ( I .
3 i I ON
9 x.2.5 c ~ I
ELEV. FT. PUMP-~
OFF
D I.5
K UPPIA) I
BLOCK
~~rEmf/DAl
D, - RISER EXIT PERMITTED OIJLS IF TANK MAMUFACTURE:R HAS SUCH APPROVAL
SEPTIC E 5PECIFI'CATl0kJS
DOSE Z
4(J i 71ER'
TANKS MAWUFACTURER: IJUMBER OF DOSES: PER DA-4
TAAIK SIZE: -75-0 GALLONS DOSE VOLUME y
ALARM MAWUFACTURER: Lt~&/ G- - INCLUDINC, SACKFLOW: I S GALLONS
MODEL IJUMBER: 3)' V. L CAPACITIES: A= IAIC14E5 OR 2'00 GALLOWS
SWITCH TYPE: H£eC(J RY FLOhT- Bc Z IWCHES OR 3? GALLOWS
PUMP MANUFACTURER: -'Al YF~S' '~d' , r- = 9 IWCHES OR 15 3/ GALLOWS ~
MODEL NUMBER: 1-p I-/!~;- ` 2' RP D= I9%C° INCHES OR 35 GALLONS
SWITCH TYPE: IMERCUEY (-10A T- MOTE: PUMP AMD ALARM ARE TO BE
MINIMUM DISCHARGE RATE 30 GPM C INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE DETWEEW PUMP OFF AND DISTRIBUTION PIPE.. 5" 5 FEET -rAok SP1FG S •
+ MINIMUM NETWORK SUPPLY PRESSURE . . . . . FEET EAG(A, k P -
+ Zd FEET OF FQRCE MAIN X 'I"s F/ooFZFRICTIOU FACTOR.. " 3y FEET t-40,A IIA
TOTAL DYNAMIC. HEAD = FEET
I?DUN>) 00q /I
INTERNAL DIMENSIONS Of TANK: LENGTH ;WIDTH ;LIQUID DEPTH
PUMP CtfAM(3EYA S HA 11 aF IUA' f-Pp1200f= D AT- ff*C7-o1Q/ -
looriA. 131'fuMAStrc EPOXY C0hTiN6r- .
TAulc SH-All (~c ANctbPE70 c~I'jl,-
sUTfrC teAJT- C3hCr FI'1( Off Ex-rPA- 3 of
,S rEc '+AD,pess : 7.3 1o') T1% ST-. RoaepT-S cjt'S . SyoL3
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page / of 2-
Labor and Human Relations
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but 5r C~~'tx
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.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
5 rj 0/f~X; 54E GOVT. LOT &Z' 1/4 SE 1/4,S 2- 4 T 21 N,R /I? E ( W t
PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
1700 w . 3Z .,A !5T-- tifi
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE OWN NEAREST ROAD
/it I RVEA P6keS ` AJ . 5500 W-14 ?15 _7&0u/A ALII /e 7 fft, 5T' .
( ( New Construction Use [ Residential / Number of bedrooms 2- Addition to existing building
jy-,Replacement [ ] Public or commercial describe
Code derived daily flow Soo gpd Recommended design loading rate ~~bed, gpd/ft2~ trench, gpd/ft2
Absorption area required A1+ bed, ft2 N"' trench, ft2 Maximum design loading rate bed, gpd/ft2 trench, gpd/ft2
Recommended infiltration surface elevation(s) It (as referred to site plan benchmark)
Additional design / site considerations 5717E S0,f'r4 3/F o I! L /try i'2 ft 4Di;VG- 74 AK
Parent material . SGS G7 H V- N ff-01313heD 5 Flood plain elevation, if applicable 10 I. ft
S = Suitable for system CONVENT~IO,N~yA MOUND IN-GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK
U
U = Unsuitable fors stem ❑ S I!d'CJ ❑ S E11 ❑ S ape~ ❑ S [!tr ❑ S ~ 2-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 mnch
,r o•I)-. lovR 3/2 5 0, qR e5 3- 71 :00
r
15 0, CS Aj N
`k t3 I~t- 15 /o yt 313
Ground 'C , d5 -3 /O V R `l 3 572' s` g S f9,f 5,e •k, 1,4 f' e S - IA-)p Al P
elev.
Sa 5,C-l -F N N
103 • ft. Ct - 3.
y p,
Depth to
limiting k
factor 5 e T 'Z*e- PO A.) a T_ / f ,e v/
IZ .r
Remarks: IfoRr'zo&j 13 I'S AlSO by+f~G~'U As titscoet'a-fbR_ CI
Boring #
t
k£. }}i}ray.\Y.•
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
CST Name.-Please Print IRO BG.P_T '44 L Q P_ f`G GL T- Phone: 15- 3 g& _,9jg S
Address: .p s S 0o ,4j e z ;tD • H_017Sa,.) Gv I. S',yo/ 11-1-13 C67-Al 2-11,p:)-
Signature: Date: CST Number:
ORIGINAL
PROPERTY OWNER SOIL DESCRIPTION' REPORT Page , of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourday Roots GPD/ft
in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. Bed Trench
,•;5~3
P
~ is\>vFvtiiGround
elev.
ft.
Depth to ,
limiting
factor
Remarks:
Boring #
M
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft
Depth to
limiting
factor
Remarks:
Boring #
f
Ground
elev.
Depth to
limiting
factor
Remarks:
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VOL 1O5 I PAGE 466
Dor,.ument No. This space reserved for recording data
511135 HOLDING TANK AGREEMENT
Agreement Date
U-9-15 This agreement is made between the 1 EGISTER S OFFICE
County or Local Governmental Unit I Holding Tank(s) Owner(s) ST. CROIX CO., WI
lvA'/Q/Qfti T Gt/,,~/ SGT%p S e k;II L_ L Reed for Record
S~ S`- E DEC 2 9 1993
(Called Municipality below) I 10 DO A.
We acknowledge that application is being made for the installation of (a) holding at M
tank(s) on the following property, (Provide legal land description:) *A:4
f Ii hterOf Deeds
N~ ly C Yil SECT. if T 2-f M, /00 40
Return To
or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of
sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under
Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Stats.
As an inducement to the County of to issue a sanitary permit for the above described property,
we agree to the following:
1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the
holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and
146.14, Stats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by
placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by
s. 66.60, Stats.
2. Owner agrees to pay all charges and costs incurred by the municipality for -imnina. hauling or otherwise servicing and maintaining
the holding tank in such a manner as to prevent or abate any nuisance or, he. shall notify
the owner of any costs which shall be paid by the owner within thirty (30) di / s not pay the
costs within thirty (30) days, the owner specifically agrees that all of the cc d C t w14 Ls 3cial assess-
ment for the abatement of a nuisance, and the tax shall be collected as provi
3. The owner, except as provided by s. 146.20 (30) (d), Stats., agrees to contra(Adm. Code to
have the holding tank serviced and to file a copy of the contract or the own( ry. The owner
further agrees to file a copy of any changes to the service contract or a cop) county within
ten (10) business days from the date of change to the service contract.
4. The owner agrees to contract with a person licensed under Ch. NR 113, Wi U ~y ~Y o the county a
report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the s Wation under
s. i45.201(3) :.:ata., iiid Jv~i i7er sl:a!! ii ii di ci vrt tv u 8 r.iii ~IClpalii; , ,
5. This agreement will remain in effect only until the local governmental unit is certifies that
the property is served by either a municipal sewer or a soil absorption sy! n addition, this
agreement may be cancelled by executing and recording said certificatic ich will permit
the existence of the certification to be determined by reference to the prop
6. This agreement shall be binding upon the owner, the heirs of the owner, a agreement to
the register of deeds and the agreement shall be recorded by the register the agreement
to be determined by reference to the property where the holding tank is it
Owner(s) Name(s) (Print) I Owner(s) Signature(s)
Subscribed and sworn to before me on this date:
Municipal Official Name (Print) I Municipal Official Signature Iv ii'~ I/ o( tary Public
I "
M issiODMO ;BEY
NOTARY PUBLI"INNM:A
Municipal Official Title (Print) I HENNEPIN COUNTY
y ommission plres .
SBD-6123 (R. 10/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor an =man elations, Bureau of Plumbing.
L
HOLDING TANK _SERVICING + CONTRACT
Contract Date 105 1 PAGE 467
t I - g -4 3 This contract is made between the
.
Holding Tank Owner(s) Name(s) and I Pumper's Name
2b v S~w~ sT Ay~~ SEw~/ i PA-0 L 64L
I
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:)
724,V, IrIJV40
"t_b LJ M o F f~ ice e e,.j
L The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which ha
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
with the County of s' a G/?0/X
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and tc
enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access
road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pad
the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis.
Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agree:
to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the pruperty on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered. x "
DAVID I D&AND
NOTARY PUBUC-MINNE80TA
4. This agreement will remain in effect until the owner or pumper terminates this contra evpapNEW08tlNNn this ntract,
the owner agrees to file a copy of any changes to this service contract or a copy of a eje
lQfimgtb6aft"W11114 ipality
and the County named above within ten (10) business days from the date of change to th
Owner(s) Name(s) (Print) I Owner's Signature(s)
Sty Q/J /I-
Subscribed and sworn to before me on this date:
Sew CZ~ I S
Pumper's Name (Print) I Pumper's Signature Notary Public
My commission expires:
Paul R. Cudd
Pumper's Registration Number
MPRSW2739
SBD-7574 (N. 11/85) This instrument w;.., F the State of Wisconsin Department
of Industry, Labo 'ions, Bureau of Plumbing.
S T C - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER S ~t&N SZ vJ CLL
ADDRESS FIRE NUMBER / 3
CITY /'STATE_
PROPERTY LOCATION: 1/4 ,1/4, SECTION, TN-R~_W
TOWN OF -(Z , St. Croix County,
SUBDIVISION , LOT NUMBER
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 a 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/Ile, 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 Co. Zoning officer within
30 days of the three year expiration date.i_
SIGNED: _ Is 4.01 `
DATE: _ b e C 19, E
St. Croix co. Zoning Office
911 4th St.
Hudson, WI 54016
1M • •
S T C 100
This app. ication form is to be completed in :Full and signed b
fthe owner(s) of the property being developed. Any inadequacies
will onl.y result ~n delays of the issuance. , Ss
development be intended for resalee bytowner/contr ctor,l(shec
house), thenla second form should'be retained and completed when
the proper'ty' is sold and submitted to this office with the
appropriate deed recording.
Owner of property L,
AAacat-ion
, _R
Sec~xon Q2 <:7
__q- T-49N -J(ZW
Township
Mailing address
Address of site
Subdivision name ~
Lot no.
Other homes on property? yes No
Previous owner of property D N L.
Total size of parcel
Date parcel -was created
!'Are all corners and lot lines identifiable?_
Yes No
Is this cproperty being developed for (spec house)?,_Yes _xNo
Volume 'l.~L
and.Page Number 7&-*;' 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 & THE SEAL OF THE REGISTER OF DEEDS.
certified survey, if available, would be helpful so asd ofoavoid
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 , and that I (we) presently
proposed site for the sewage disposal system or I (we)
obtained an easement, to run the above described property, for i
the construction of said system, and the same has been duly
recorded, in the office of County Register of deeds as Document
No
._~~✓.?t2S~o
signature of applicant Co-applicant
16 CA 4
Date of Signature Date of Signature.
'),'94 17:16 %T COUNTY CLERK Z 0021i002
furl i/AC~ rt[iar,VLO colt ribCOI1DtRQ 6►Yp
559,+t"k. 46
342256 vOt
REGISTERS OFFICE
PLY THIS DEED. UP t §0FELL and RUTH F. SEWELL ST. CROIX Co., WIS,
husband and urife a aseirt tonant,, s~ Ree°d. fcxeec~rd skis ~,~Qtl
- dint of Au at D. 1 t
Gromee cunrsyr xw-tants W . EP EN - I'` - 4E-WELL AAA-T-HOMA4--L.- at
SEWELL-._
r.a w .t oar:
- e
a ■~juatiiY CMx~314rrf i~S -
the (016*ing datrcxltwie r**1 ,ta:at# to 'M L& is bomowtw4d WaymM..
Gat J t~
That c. Tot ' n Sec t iou 9-, Town 29, Range 13, described as
fol3.~ 4_. s at a point i. the e -ter of the north aid s,auth
ng oug" said lat 958,9 feet South of North line of said
lot, x _ -t pa.rallel with North line of said Lot 219 feat; thence
sou"', : -t „tag f--?-v or less to the lake shore; theme southerly a1ona
T.ak r, - t . ooth lir of said Lot; thence directly West along T. k
tsout 1. t--4 of Q:A i d Lot, 2411 feet; thence North 15-1/2 feet to ceD
i t line td rr-Ail thenco easterly and northerly along center lit,
to pbint of beginning* Containing 1.26 acre.-r-
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u son, Wisconsin 5-4 6
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