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HomeMy WebLinkAbout002-1048-30-000 AS BUILT SANITARY SYSTEM REPORT OWNER efe~ ~~C ~Cr , TOWNSHIP 9a /0 w# n SEC.2O T21N, R~W P.O. ADDRESS am r».o„alT ty,IS. , ST. CROIX COUNTY; WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM M me it tG &0' a a o SEPTIC TANK (S) O00 MFGR. h je CONCZE1 STEEL NO. of rings on cover Depth DRY WELL TRENCHES NO. of ,Z width 3 length /G U . area UU BED no. of lines width length area -depth to top of pipe AGGREGATE ),),,X PERK RATE AREA REQUIRED b 00 AREA AS BUILT ZOO Disclaimer: The inspection of this system by St. Croix County does not imply complete compliance with State Administrative Codes. There are other areas that it is not possible to inspect at this point of construction. St. Croix County assumes no liability for system operation. However, if failure is noted the County will make every effort to determine cause of failure. GREASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM. INS TOR' DATED S- 2. - 7 Q PLUMBER ON JOB o,t LICENSE NUMBER V RRPORT Or ITISPECTIO11--INDIVIDUAL SEWAGE DISPOSAL SYSTEM ~j Sanitary Permit r S to Septic .'A:IE T61,111SHIP • t. Croix County SEPTIC TA'?T: Size ;ZQ = gallons. `umber of Compartments Distance From: Well _ft. 12% or greater slope Buildin 0_ gft. Wetlands /y7f f: I1ighwater ft. 2 DISPOSAL•SYSTF1 Tile Field rr Seepage Pit(s ) Distance From: well ft. 12% or greater slope ft Building ft. Wetlands FIELD Highwater CIA- ft, Total length of lines ft. Number of lines Length of each line 1---ft. Distance between lines ft. Width of the trench Z4~ ft. Total absorption area ~o 41V sq. ft. Depth of rock below the Dp-pth of rock over the ~ in. Cover ....over.rock, Depth of tile below grade in. Slope of trench in per 100 ft. Depth to Bedrock /(//-.-ft. Depth to ground water A14 £t. PITS "lumber of pits 0 s'' meter ft. Depth below inlet ft. Gravel aroun ' t __,yes no, . Total absorption area sq. ft. Square feet of seepage trench bottom area required `%quare feet of see ; '-t required Inspected Title*:.'-. Approved Date 197. Rejected Date 197. r PLB67 State and County State Permit # Permit Application County Permi for Private Domestic Sewage Systems County *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: Peter K492W gannoad. W"ooinin B. LOCATION: SW '/4 3B '/4, Section 20 , T 29 N, R 1 W Lot# City _ Subdivision Name, nearest road, lake or landmark Blk# Village Township PaldMis C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family Z Duplex No. of Bedrooms 2 No. of Persons 2 ' D. TYPE OF APPLIANCES: Dishwasher YES x NO Food Waste Grinder YESS_NO # of Bathrooms_- Automatic Washer YES I NO Other (specify) E. SEPTIC TANK CAPACITY 1000 Total gallons No. of tanks 1 *Holding tank capacity Total gallons No. of tanks New Installation Z -Addition- Replacement _ Prefab Concrete Y *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1) 3~ 2) 30 3) _3~L_Total Absorb Area sq. ft. 60 New Y Addition Replacement *Fill System Seepage Trench: No. Lin . Feet Width 30 Depth 48 0 Tile Depth 36'1 No. of Trenches 2 Seepage Bed: Length Width Depth Tile Depth No. of Lines Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land Distance from critical slope I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared -.by the Certified Soil Tester, NAME Leith 8. A-ltei&taoa C.S.T. # 55 W1 and other information obtained from r ter l (ownerAbUd 4t. Plumber's Signature MP/MPRSW# 5184 Phone #715 - 698 2407 Plumber's Address 1111140" PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well. k , A_j oor y LD y'~J`Jfa. to o& d 'd Haas Pik q6 4 V op ° VVII , e i l JIM 1"4940 C 'VENT , Do Not Write in Space Below - FOR DEPARTMENT U,SE/ONLY L2 Date of Application Fees Pa' : State -A0 0 C aa',',9,4 Date <r~ Permit Issued/BajigIfid (date) -Issuing Agent Name' I/ I Inspection Yes No Valid# Date Recd 1. county (whi copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 ~2. state (pink copy) 4. plumber (canary copy) Revised Dat66/1/76 t f,4spart~etrQ • 29.16.30~22C ggW, SE LOT 1 225TH STREETount Labor and Human Relations PRIV~ITE SEVI~AGE S1f~STEM y: Safety and Buildings Division INSPECTION REPORT ST. C:ROIX (ATTACH TO PERMIT) Sanitary Permit No.. GENERAL INFORMATION 199182 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: E1 & RUTH 1BALDWIN XfFWffi3v.: 71 ,P nsp. BM Elev.: BM Description: Parcel Tax No.: 002-1048-30-000 TANK INFORMATION ELEVATION DATA A92M453 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss Forcemain Length Dia. If 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 CHAMBER INFORMATION Type O Model Number: System: OR UNIT DISTRIBUTION SYSTEM 11 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: BALDWIN 20.29.16.302C,SW,SE,LOT 1, 225TH STREET Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710(R 05/91) Date Inspector's Signature Cert No. EIE:9 ILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code ~t,ommommums STATE SANIT~~/ -Attach complete plans (to the county copy only) for the system, on paper not less than 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. N MBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. 1 /1(1 PRO TY OWNER PROPERTY LOCATION c~ -t l~ '/a '/a, S 2 T , N, R / E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # S 7"h `V7' CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one) CITY T EAREST DAD El State Owned VILLAGE ~ s T ~j S~ ❑ Public 211 or 2 Fam. Dwelling-# of bedrooms 2=. AR L M III. BUILDING USE: (If building type is public, check all that apply) d ©2 ®y~- 3~i 1 ❑ Apt/Condo 20 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. El Replacement 3. El 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 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 93.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) ELEVATION a d o 4-d 0 0-; O e 9 r ~F Feet Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamp) MP/MPRSW No.: Business Phone Number: /7 /Y L f/~ S' 9~3 6 3 > 3a Plumber's Address (Street, City, State, Zip Code): 17 - 3m`Th 5 IX. LINTY/DEPARTMENT USE ONLY Groundwater Date Issued Issuing Age Sig N tamps ❑ Disapproved Sani ary Permee (includes Surcharge Fee) XApproved E-1 Owner Given Initial Adverse Determination (P X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at they 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 authoray. 4. Changes in owre:rship or plumber requires a. Sanitary Permit Transfe~!Re.- wal Form 6399) to be submitted to the county prior to installation. 5. Ons to sewage _systems rnust be properly-maintained. The t;ept;c tank(s) m:: Jt be P.urnped i;y 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 adrr!'nistrator 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 ni;mber(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. Ill. 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. V1 Absorption system information. Provide all information requestnd in ##1-7. V;;. Tank rito!-idtion. Fill in the rapacity of ever-y new and/or ex,_rin.;; ':yak, ist tl.e total g El!, _ number of tanks and manufacturer's name. Indicate; prefab or site corns ru•-.r3 f and tank material. Complete for a// Septic, pug ip/siphon and holding tanks for this system. Check Experimental approval cn y it tanks received experimental product approval from DII-HR. Vlll Responsibility statement ir,etailing plumber is to fill in name, 1werise nwiihe> with appropri,ete prefix (e.g. MP, etc.), address and ph:..nc r;umber. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Oi;iy. Comp~r. s ; ' rs and spe , no` smaller than 8% x 11 inches rr,k, be ~ ubn'ifll?r1 to ttl :nor nty. The pians mu-,t C:I;,1e1 fO11 Ls:ir'g: A) Pic," (Ian, draw'. to Scene or `.vitE dime isi,::l ; %,tion of hc'sding vials) seo ir, tank(s) or other tr _tr, '^i tacks: bi.tilding sow-.-F : <<e! wate+, eater service; streams ~iod lak.193; t?ump Of siphon tank-,; dist0oUtion box,~s; Soil ti_~ :"=i~•~I', ~ystein2-3 i~t,;11"~ riert System areas, and the location of ",i building servecSi 9) horizont"a arid ve,P: _tion p ir?f-s; C) complete specifications for pumps and controls; dose v(.j!ume; eleva €or, d;`terences; triction 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 41 inciude:d the creation of surcharges (fees) for a number c, reg_flate d practices w!,och car effect groundwater. Thy; n-,or, ut)i,ieected through these surcharges are used f;,r t`l0 Ifi ! fir; . S, !Q' ; water contamination inves69aw--)ns and establishniriE; 0 standards. i SBD-6398 (R.11/88) r PLOT PLAN Page 3 of 3 SCALE 1"= 6~z.K6E b U r~wV~M '~I \31•'1 - IAII -t~ tU'~ GF~Z f~G~ Fwwk- 1 k {i fkk P X WrL.L 1 5 N y ~ k { f~ hJ [ o ~ a I 'J 1 ~ 't a' 2fizvCt~ E' S ~ - i O O 1 83_313 (715 ) 425-0169 M00576 CST Signature Date Signed Telephone No. CST # .Wisconsin Department of Industry, SOIL AND SITE rA PORT Page of 3 Labor and Human Relations Division of Safety & Buildings in accord with IAt7t1i,COUNTY h complete site plan on paper not less than 8 1/2 x 11 inc n must include, bt Attac not limited to vertical and horizontal reference point (BM), dire gpe, scale dr PARCEL I.D. # dimensioned, north arrow, and location and distance to neare Lgad. APPLICANT INFORMATION-PLEASE PRINT ALL INF RUATIOfJ t--~ REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATI SE Z O T z , N,R E 1 . (orAI/ PE'TL``~ ~0b W-Q-M ~c LQ~ GOVT. LOT 5 1/4,S PROPERTY OWNER'S MAILING ADDRESS LOT # BL9 SUBD. NAME OR CSM # Z 3 ZZ S 1-1k ST voL L, 9 CITY, STATE ZIP CODE PHONE NUMBER [)CITY [)VILLAGE RrOWN NEAREST ROAD ~Ft~.'ibi,-') f•V[ St-Loot Pl'& y-3032 \3PcLDw1N ZZS Iii 5i. [ j New Construction Use [Xl Residential / Number of bedrooms z- Addikn to existing building [ j Replacement [ ] Public or commercial describe Code derived daily flow 3Q~ O gpd Recommended design loading rate - bed, gpd/ft2 - trench, gpolft2 k!'7- sl-tw Abso!Ption area rr - bed, ft2 6 01D trench, ft2 Maximum design loading rate o • y bed, gpd/ft2 0- S trench, gpd/ft2 infiltration surface elevation(s) °l 3. o ft (as referred to site plan benchmark) Additional design / site considerations s cFE-_ ►vo'T~ glow Parent material s \ Flood plain elevation, if applicable N It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for s stem IRS ❑ U as ❑ U QI S❑ LI WS ❑ U ❑ S O U ❑ S is U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Corts6vfm Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench O -9 \13 t-AvX13 - sit Z sdl~ r~'Fh a-s o,S o• l x:k[oY,: Z 1 S [ l~ J S I 2, rY, 5 b1~ 1ry1 v '~1- c S O . S o. Ground 3 43_ St, -).SyR.~/y - 3( ~e.SU1z wl~'~ CS b•`l o•S elev. - SI Owe >►I - o. n, q).O ft. -'IS S ti e Y/L Depth to tS tU UT.J 1.S >n 1'O L7 (xd L C r'Y LI Pv v : w/ limiting factor Sv S lv S . _ Q- ~S~1kJ Z. N3 fl You 1 L- 'S 'tu g Z Q Z P Q 1Z wl -u w L LLt_ Remarks: Boring # Z3E Yz ~S ~vC sL1 o Lv1 ct t3 I>LI Po ~s~w r, 10 C iJl T' 11 Ground S T1 e 1''t~ w s C S Ul L S elev. ►~-}U Q E 1GF L s 7' S ft. Depth to 3 X UCH (.-cam c, e cob ti 6 limiting 0 F- o, S G is S 4 factor _ S `t [Z U1 l Er Eil- 6 0 S Q FF 01= T~ vcN w C-11 t -M / SD /v P~m Remarks: OU L`lZ 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 Signature: Date: CST Number: ' :22 `1 3- 31 3 \-I-Cf M00576 PROPERTY OWNER ~L- SOIL DESCRIPTION REPORT Page of PARCEL I.D. # Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft c Boring # Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench v.,.,........... - S L 1 S 1~'I w Ground ep1U ~V1YU fi=t ~'zi B~ 1~vS ~"1'~ 1tv IU elev. ft. Y"1 - -C O L W f~J U V C Depth to S S `7 "1 A t tv 6 S V L ~!v ~1 limiting factor F S S Remarks: Boring # C43 tal'2 O U E'R 1 S y+✓ G ~'t v 1 S S S U V) Ground G s elev. t3C t2 1W UL~ 5 v1 ZZ fit )NJ poce- ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) PLOT PLAN Page 3 of 3 SCALE 1"= 6ft~t~6E ~3r'1 - tTL • WO . p 6~ G1~iZR~E ~(.uU12. ~ E i a ell ~o u o GflcL S~'P'I7 c- 'tR~1lrt 1 .O nu I t a I~ i III o j Zit2y LS'Oyuc- 0 - i 01 / 0 vt~t-s i i (715 ~tt-e s 1 ~ q3 _ 313 ) 425-0165 1400576 CST Signature Date Signed Telephone No. CST # CERTIFIED SURVEY NO. 449 Part of the SW,, of the SE-1, of Section 20, T29N, R16W, Town of Baldwin, County of St. Croix, State of Wisconsin, described in Volume 2 of CertMA#r- Page as Certified Survey_hLq . D ..s 1. 10 s o, ~0197T 'O I I ~ sr• G S 870 32' 18" E 657.17 Vol SCALE I F O` ° ati p 1200' M I T I o x LEGEND I rn I N D 3/4"x30" ROUND IRON ROD LOT ' m p y WEIGHING 1.502 LBS./L.F. r 9.68 ACRES r 0 S -0 r o 0 m o RAILROAD SPIKE 0 I i Aze ti 0 y o o\~ a ` rn ~SGONS~ eo 0 0 ~ ~ ~ ~I O w. 256.13' 6~ ,r N 870 35' 32" W . . i ~ MEM I M N 000 07'46" E = ~y g ~y rn 143. 41' OA. S-1345 1 A A2 p9. I Now"* VA fi. 0`6 • gION" 4 0 5 T f' r N 87°35'32" W IrnlyyiSUR►` 10 ~#Ntts• I-4 1X I, Thomas G. Kuester, Registered Land Surveyor, hereby certify: Iy rn I' That I have surveyed, divided, and mapped a part of the SW-14 of the SE4 of Section 20, T29N, R16W, Town of Baldwin, County of St. Croix, State of Wisconsin more particularly described as follows: APPROVED SOUTH 1/4 COR_ TOWN SEC. 20,T29N, R16W -----------_____~9AQ_-- AUG 17 1977 Commencing at the South 4 corner of said Section 20; ST. CROIX COUNTY COMP:-EHENSIVE PARKS PLANNING Thence NO0° 07' 46" E 744.39 feet to the poi nt of begi nni n" ZONING COMMITTEE Thence continuing N 00° 07' 46" E 567.57 feet; Thence S 87° 32' 18" E 657.17 feet; APPROVAL Or fHIS MiN! R SU L);V;s,cN Thence S 00° 14' 07" W 710.30 feet; DOES NOT M6AN APPROVAL FOR Thence N 87° 35' 32" W 405.71 feet; BUILDJNG SITE OR SEPTIC SY;ITEM. Thence N 00° 07' 46" E 143.41 feet REFER TO H62.20. Thence N 87° 35' 32" W 250.13 feet to the point of beginning. Said parcel contains 9.88 acres more or less. That I have made such survey, land division, and plat by the direction of James and Bonnie Niemann. That such plat is a correct representation of all exterior boundaries of the land surveyed and the subdivision thereof made. That I have fully complied with the provisions of Chapter 236 of the Wisconsin Statutes and the subdivision regulations of the Town of Baldwin and the County of St. Croix in surveying, dividing, and mapping the same. Dated this ~ day of 1977. Volume 2 Page 449 10'-812"' _ 4'-1~' Y-Ir o ~ I I I I J ~ c,,~ l • I I a I `q I b I I I ^t I rm- rl - - - - - - i ~ I l I 1 i L DRYER °f e TIMOR u L-.~.--J e~ ^t I a M ~ J-Lq a ~ ~ c / ~ I G II - D 10 II I f 4 ,OTC I 4 6'-7 11,C 6'-7 11,C 13'-tl' 13'-0' 26'-0' C ~ ' S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ADDRESS 2 7_4 ~S,7-/ EzRE NUMBER` CITY/STATE wiA zip- PROP ERTY LOCATION: , 1/4 ,_L~1/4 , SECTION, r TOWN of ~^-St. Crol X County, - _ - SUBDIVISION CSM LOT NUMSER_J Improper use and maintenance of your septic systen 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 60t of the cost of replacement of a failing system, which was in operation prior to duly 1, 197s. 5t. 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, j journeyman plumber, restricted plumber or a licensed pumper verifying that (I). 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,/Iae, the undersigned have read the above requirements and aciree 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 Sr. Croix Co. Zoning officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix co. Zoning Office 911. 4th St. Hudson, 141 54016 a STC-100 '1'llis application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property Location of property S w 1/4 S;=1/4, Section' -2,::n-, T21; N-RAW .Township Hailing address Address of site S',~/rl Subdivision name- o-sm ✓ 1),Q Lot no. . Other homes on property? yes--->C- No Previous owner of property _ Total size of parcel Zz Date parcel was created Rtd ii' Are all corners and lot lines identifiable? Yes No Is thin property being develope. or (spec house)? Yea No Volume; 5 and page Itumber as recorded, with the Register of Deed;. I14CLUDE WITH THIS APPLICATION THE FOLLOWING: A WARIUUI 'Y DEED which includes a DOCUMENT NUItDER, VO,LUHE AND PAGP. NUMBER & `rill: SEAL of THE REGISTLR of DEEDS. In addition, a certified survey, if available*, ;would be helpful so as to avoid 4 delays of the reviewing process. If the deed description references to a cortified survey Hap, the certified Survey Hap shall also be required. PROPERTY OWNER CERTIFICATION I(wc) 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. ,3 L~ 2 p , and that I (we) presently own the proposed site for tie sewage disposal system or I (we) obtained an easement,. to run the above described property, foe the construction of said system, and the same hpp been duly recox d'in the office of County Register of deeds as Document No. '7.25 Pd s gnature o ap~l cant Co-applicant _12._ Date of s gnature Date of 9 gnature STATE BAR OF WISCONSIN-FORM 1 DOCvMENT f10. WARRMTV DEED `V ~OL 559 PA%,E484 THIS SPACE RESERVED FOR RECORDING DATA 342580 REGISTERS OFFICE f - _ made between James G Niemann and Bonny a ST. CROW' CO., WIS. T1D3 DEED, Rec'd. for Record tws 24th -Granter day of August A.D. 19Y7 M and ~ ooY T EeC Grantee, - Anl 1 ar Rspbw of adr Witneeseth, That Ike said Grantor for a valuable consideration (S1 0nd VaCt ('Y0i County, conveys to Grantee the following described real estate in orley tville State of Wisconsin: A part of the SW 1/4 of the SE 1/4 of Section 20r T.xICeTownship 29 North, Range 16 West, more particularly Tax is homestead property. described as follows: Commencing at the South one r 46" o quarter corner of Sthence continuing N 00° 071 46" E.7567.57ffeet; the of hence1St870 inning; 321 18" E 657.17 feet; Thence S 00° 141 07" W 710.30 feet; t thence N 870 359 32" W 405.71 feet; thence N 00° 071 46" E 143.41 feet; thence N 87° 359 32" W 250.13 feet to point of beginning. TBAN R -0 FEE Together with all and singular the hereditaments and appurtenances thereunto belonging or is any wise appertaining; And . warrants that the title is goad, indefeasible in fee simple and free and class of encumbrances except and will warrant and defend the same. Wl3^nnci n this day of A g1MSt _ 14 7• Executed at • ~ ~ O (SEAL) SIGNED AND SEALED IN PRESENCE OF James G. Niemann (SEAL) Bonnie A. Niemann (SEAL) 1 ~(SEAL) w Signatures of 19_• If day of authenticated this Title: Member State Bar of Wisconsin or Other Party Authorized under Sec. 706.06 vix. STATE OF WISCONSIN 19.7 St. Croix ss. County. } day of August._--- r r personally came before me, this the above named to me known to be the person- who executed the foregoing instrument and acknowledged This instrument was drafted by O Notary Public St. C .(~Iunty,AW t- .•..••r ~r II R BFRT 4JAT mcy My Commission (Expires) (Is) The use of witnesses is optional. typed or printed below their signatures. Rcwewoswr+® Names of persons signing in any capacity should be wARRANrY DEED-STATE BAR OF WISCONSIN. FORM NO. 1 - 1971