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HomeMy WebLinkAbout020-1017-20-100 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS Z C-- -5F 0z SUBDIVISION / CSM# LOT - SECTION _T_ f N-R fW, Tn of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING W© IN 100 FEET OF SYSTEM ! 77 33 ' X i i =IiNI ! 47fHMc /OV j Z [GtT o/~ sT paw/,.v 3 4 ~4 O = s I tP S . T. 4 Co Nt ~§'PC~ ~ S ~tt/. IAN Gam/ ~ INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. a v f~ lGS•d r BENCHMARK: ALTERNATE BM' SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: ~.cC, Liquid Capacity: / mvc) Setback from: Well > ?m~9 ~ House > /,,rD Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: _ Alarm Location SOIL ABSORPTION SYSTEM Width: /L Length !op Number of trenches 2 Distance & Direction to nearest prop. line: ?mp Setback from: well: >.~p House>.ZOD / Other ELEVATIONS Building Sewer ST Inlet. J9, 4J' ST outlet PC inlet PC bottom Pump Off Header/Manifold f7071 Bottom of system i~~ Existing Grade 97Final grade 10-p DATE OF INSTALLATION: PLUMBER ON JOB: r1s LICENSE NUMBER: INSPECTOR:- 3 / 9 3 j t :I~ JOHNSON'S SANITATION, Inc. FHA and GI Certifications - sewer and Water Septic Tank & Dry Well Pumping I Unclog sewers from sink to main sewer lines with electric rooter Licensed & bonded - Wisconsin & Minnesota Duane Johnson Call anytime - 7 days a week Office: 273-5811 or 425-5043 3 Trucks: 2300 Gallon Tank 200 ft. Hose Truck: 792-2737 FAX: 715-273-5877 & 3300 Gallon Tank - 200 ft. Hose W5990 570th Ave. Ell 5rth, WI 54011 Portable Toilets for Bent ~nloadin Driv r *t ruck Time Loading_ ~ 9 Time Dump Site DATE MEMO CHARGES CREDITS BALANCE Septic Tank gals. Pumping Chamber gals. Dry Well gals. Holding Tank gals. ,f L~ 1'/2% Monthly Finance Charge - 18% Annual Percentage C-- Rate if not paid within 30 days. 50¢ Minimum Charge. fr1+ ase In Thy mn ■ PLEASE RETURN DUPLICATE COPY WITH YOUR REMITTANCE. Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and quman Relations INSPECTION REPORT ST. CROIX Safety and Buildings ngs Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State PI RAYMOND, RONALD X CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 7 4 /00 ,0 100 U L41 J/ r TANK INFORMATION U (1, E EVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / Qo c-Benchmark lo(, 7 Dosing ,a) Aeration Bldg. Sewer Holding St/Ht Inlet q9 ~g TANK SETBACK INFORMATION St/ Ht Outlet ; Vent TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing NA Header/ Man. f Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer mand Model Number GPM TDH Lift Friction System TDH Ft oss Forcemain Length Dia. H Dist. To Well SOIL AB ORPTION SYSTEM BED/TRENCH Width Length No. Of Tr hes PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / _ - d DIMENSIONS Manufacturer: SETBACK SYSTEM.TO P / L BLDG WELL LAKE/STREAM LEACHING INFORMATION Type O CHAMBER Model Number: System: a 2 c~0 2 00 ' Zv o 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: Hudson.13.29.19W, NW, NW, McCutcheon Road Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. J ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: _r w r r 1 I I 1 ' I II i SANITARY PERMIT APPLICATION arses ■ ■rs C TY ~■l~nn In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than a 2`N9 O b , 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. PRO RTY OWN PROPERTY LOCATION '/4 GM,S T ,N,R E(o PROPER OW E 'S AILING DD ESS LOT # BLOCK # CI STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned VILLAGE ZQWN OF: CEL TAX NU ❑ Public ❑ 1 or 2 Fam. Dwelling-#of bedrooms PAR III. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo J 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 100 Outdoor Recreational Facility 30 Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (C eck ly one in line A. Check line B if applicable) A) 1. Q New 2. Replacement 3. ❑ Replacement of 4.E] Reconnection of 5.E1 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 Z Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Lt ^0 7 Feet 907. OF Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank VAI-A 77- F1 F1 [71 0 Lift Pump Tank/Si hon Chamber Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsi sewage system shown on the attached plans. Plu s Name (Print):~~. Plumber's Signat o S mps) WMPRSW No.: Business Phone Number: r' / 7 36.SG J. 1Z / - 14C to- s ddress (Street, ,City, State, lp Cod o t,rJ.ai= O IX. CO TY/DEPA TM NT USE ONLY ❑ Disapproved Sanit Permit Fee (Includes Groundwater a e Issued Issuing A nt S ture (No mps) Approved F-1 Owner Given Initial urcharge Fee) t` Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber Will INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be-properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 6013-266=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. ll. 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 8iz 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 SLIkCHARGE 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 IRA 1/88) 1-7 $cQ /.p ~ _ 6 o r nq i i !e ~r / QY/I1 ; ✓t Why GPPrD ~ i"~r~tCe by 1•nS~R /)'l.. /9/~ J~~~~eL~ r ~ G/~ Pr ls~G.^ veil{~ l~iN' i S cl I ! 'mop V [/1= ~ i at 1 ;I. 1 w Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Did~s9on of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code . COUNTY Ste. C~IZUI >C 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. O Z-O- Z43 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION. 13 to g gT. NW 1/4 NK11/4,S 113 T z-9 .,N,R lc] E PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # _ 43 ~Z w'L C. CvTC~-t=0ty Rv~ - CITY, TATE ZIP CODE PHONE NUMBER []CITY []VILLAGE ®fOWN NEAREST ROAD t ►vU3o)" W1 Sv0I.6 (-)is) 386 6102 \AuDSOtV f~LCCuTC~t~oN Re. New Construction Use [>Q Residential / Number of bedrooms 3 [ ]Add in etass6ng building P4 Replacement [ ] Public or commercial describe Code Ide I rived dally flow 4 SO gpd Recommended design loading rate o bed, gpoltt2 trench, gPd1ft2 Absorption area required bq `4 bed, 1111? S 163 trench, f12 r Matti num design loading rate o• 1 bed, glxW 0- IS trench, gpd!1112 Recommended infiltration surface elevation(s) 016. O it (as referred to site plan benchmark) Additional design /site considerations 19-K -0nM a yb lt,'K b S' coin) Le1'jnwy_ SiM Parent material S ft1-_1z1 - aC <Z tzar U Et.. Flood plain elevation, if applicable N A - ft S = Suitable for Systam CONVENTIONAL. MOUND MIROUND PRESSURE AT-GRADE SYSTEM IN FU HOLDM TANK U =Unsuitable for stem 5aS ❑ U 13 S ❑ U ®'S ❑ U W S ❑ U IN S ❑ U ❑ S gTU SOIL DESCRIPTION REPORT Depth Dominant Color Motiles Texture Structure Consistence Botlrtdary Roots GPD/ft Boring # Horiion in. Munsell Qu. Sz. Cunt Cola Gr. Sz. Sh. Bed 111ench 0-S 1ll`1RZ12. - S~ ZMS~k r+1 Cw - p.S o-b Z 8-29 to`2 R 31y - st I tin sbk >~~'L. c,~, - 0- z v.3 Ground 3 Z4-VS 1•S'-12 3j y - S l c3bk u'fh CS d-`t o.S, elev. g9-1 it )4S.-89 _~-SK2 V/1 S 61. o s9 _ Vn 1 - o-~ i 0.8 ~f Depth to i ~ w . ~ - limiting- factor Remarks: ' Boring # o -1 t o`t R ,L ? 0 S l~ ZwtS 1~k t~ lti 1 0; S o. 6 Z 2 Z-3o ZZ) 12- 31 r sl l \ rn sbh ~w o z. o. 3 11. 3o_SS -7 .S`1R 31Yn 1 0-S O.1 .0.% Ground elev. SS_9o S tZ ~!!6 S 6~. o s wl - a.-f 0. 99 it Depth to limiting factor > CIO" Remarks: CST Name:-Please Print Arthur L. We erer Phone' 715-425-0165. eg rer Soil Testing & Design. Service-P...0. Box 74 River Falls,WI 54022` Signature: Date: . __7 ` .7 Z- C) CST Number: M00576 - PROPERTY OWNER "M0hJb SOIL DESCRIPTION REPORT Page? of 3 PARCEL I.D. # O ZO - l 0 1`1- Z 0 ; ` Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 0-8 tio~t~ zcZ s• Z s~k rn~t^ Gw - o•s v-6 z 8 2>~ tioti.~z 3!y - si 1 ~~s~~ ~S ~ o•s o- 6 Ground 3 Z8_tZ2 7.S'm yA - S eL Gi. t,~s S - 0 7 a•$ elev. bO Z.. -L ft. Depth to limiting factor Remarks: Boring. l Ground elev. ft. i Depth to ! limiting ! factor Remarks: Boring # i Ground ' elev. ft. Depth to limiting factor Remarks: -:Boring Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(R.05/92) 3 Page of 3 PLOT P LM nl o . ez~ - t o - zo SCALE 1"= ZQ' R-ft~l►`7U~VL~ ti c~+~`Nv~Z Er L011.0 LL`i°i 4 a-7 ~G 69 010 0/ WL M 7- Q' e.1 t!t 4a1 o gJw - et. ~ou.o ow tt"4mm' : \ '31y~'pll~PVC - S"~~t~. wooD PosT: au:Fvt' IM►j -M4fi : 8l D yn NI I : W~ 11 1 S1~FrLLg1S P,T ~ lZs'L8U"tau. N~ c, ham' . V'1`HcX.1M-►l~.!"'1 Z w C. U U ~Z _01J X12 _ :'T?F.6 _ !'cvv 5~, i~n~ LJ ~1.~ ~u C.tL~~ Z, S 0~ -_ISI@li~dhJ ~LP~S- Sw ot= st1. 'X tS T1rub ~R~iP~R-lY Uw~s - - m t~tz boo' Fv4m sc-Te, v`CVt U'r Uwe s 10 8 E 'yP~'1- LL`RRS`~- S' F~01y S\-t STEM. _ o. ~S wt~ To - 'TpclutJ~ L-f~1~ET (715-) 4 -5-01 h5 M00576 ~CST Signature Date Signed Telephone No. CST # Vl bi :r sinDepartrnentoflndusby, SOIL AND SITE EVALUATION REPORT Relations Page 1 of 3 Labor and}Iuman Dion ofsafety> 6utl~ngs in accord with IL.HR 83.05, Wis. Adm. Code COUNTY Attach complete site -plan on paper not less than 81/2 x 11 inches in size. Plan must include, but 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. O Z.p- Ip t`7 - zo APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION. t~l~ 1~ A~ k'I O IU D 861fTL8T; N W 1/4 N W 1/4,S t 3 T .,N,R lg E( PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # - S ~Z Wt Z C.~T'CL}~Orv ~v~ - - _ CITY, VATE ZIP CODE PHONE NUMBER OCITY []VILLAGE MOWN NEAREST ROAD `t vUS01J 1~ l S~f b L (CIS) 38 6 610 Z 1c~CUD S ON McCu-M*enJj RD: [ j New Consin dion Use [~Q Residential / Number of bedrooms 3 [ ] Mffkn to existing building N Replacement [ ] Public or commercial describe Code derived daffy flow LI S O gpd Recommended design W q rate IN-1 -bed . 9P tr enCh, gpd/ft2 Absap6ort area required 6q bed, ft2 5 6 3 trench, ft2 , HNa>a nn design baring r& m •'1 bed, MW a,15 trends, gpd/tt22 Recommended kgfttion since elevation(s) 01 6 , O ft (as referred to site plan benchmark) Additional design I sib oasiderdons T-tLO M eN& its Y -b G` ~~u'no t. ii~D Parent material S i ~p k y Ht. Rood plain elevation, I applicable N - R - It S =Suitalble for system CONVENTIONN MOUND N1aYi0 M PRESSURE AT-GRADE SYSTEM IN F LL. HOLDW TAM( U =UrstMable for tem ~1 S ❑ U INS ❑ U - Us ❑ U [as ❑ u ®S ❑ U ❑'s RFD ` SOIL DESCRIPTION REPORT r Boring Horizon Depth Dominant Color Mottles Texture Structure Consistence Bou>dary Roots GP D/ft . in. Munsell Qu. Sz. Cart. Color Gr. Sz. Sh. Bed rertCh 0-8 tv`1R z l2 S L ZM 5bk m Cw o. S a- some lo Z $-Z9 Loll R Sly S1 I ~n sbk ~n~t- c,~, - o- i u.3 Ground 3 zq:.VS -].S 1t 3j y s 1 t caUh 0.s- elev. 99- -7 ft uS:_g9 -~.S-f2 q1t, Sa`61- o s9 _ 1 - o-~ ; 0.8 Depfltb limiting har ~rq ;r Remarks:: _ :Boring # to't2 ZCz Z wxIlt)k W)-F Lk, rs o. b 2 Z-3o Zo`ttZ 3l 'T \rn 3bk ►v,~'t~ 0-w o•Z 0-3 3 3o_S s ~.s ~r R 3! Ground 1 S o s w, cg - p.~ o. elev. S . S'_go 45 • S ~ 2 Y!6 S > tit. o s wi - a.7 u,>° 9 It _ _ DepUt b _ limiting fador > 90" Remarks: CST Name: Please Print Phone: Arthur L. We erer 715-425-0165. .egg rer Soil Testing & Design Service T. Box 74 River Fa11s,WI 54022 Signature: ) Date: - ` Z 2 y- Z'] 9~ CST Numbet M00576- PROPERTY OWNER tUfj SOIL DESCRIPTION REPORT •Page?•ot-3- PARCEL I.D. # O ZO l 0 1`I - 2A Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Du. Sz. Coat. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trerxh wv• _ 3 0_8 1.0-M ZCt s*bk r"`Ft~ Gc,v o-S 0- 6 Z a -a's 1Z Ground 3 78_fZZ ~.S y2 Y/6 S CL G~. O s rn - elev. Depth to limiting factor Remarks: Boring Ground elev: ft. i Depth to limiting !factor Remarks: Boring i [:3 Ground elev. ft. Depth to I limiting factor Remarks: ,:Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD•8330(R.05/92) PLOT PLAN Page 3 of 3 ~t p -U)- tOl1- ZO SCALE 1"= ti - ~~.o►v R.tty r~ u~vt~ coti`MV'k EL, [00.0 X1..'39 4 - • 5•Z _ Fe" ce by o~ k7,i,lo2,? .Q - Q" a.l tt 9a~ . - 4~ -31yaQli~PVC P~P~• ' Q,~ - L't, toV.l' av ~''oP of _TAI~ ~ -Z-L~_•_ S``oiq. wooD Posr. IU7L , _'st 8~ wt tom.-BE I~ulcc~s V-~y~kl~"~tU~!'1 ~1.L4 WIl: Z`._Dy_ .-AFB !'riv5t An~n~ Wcu- Sw ov:- s I.M. `r j ~'X.t,S Riu6 1 ;;tLUpHv-lY UPS Piit~ 3 b0' Fao,K s -re . Lc"- Uwe s 'm 0~'p~3J wt T o - _ _ X14-~Z1 (715 ) 425-0169 M00576 CST.Signature_ Date Signed - Telephone No. CST # STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERBUYER G . F a 7f ~o~ m o-n c~ MAILING ADDRESS PIZ 6- e c~ c h e cm ?Z~ . - w _ c s urc 0 PROPERTY ADDRESS a e c~ s cab o Cj e_-. ~pefo P (wF) CITY/STATE cp w '1_ s? 6(/ as e crn s/ n PROPERTY LOCATION 1/49 AJ &J 1/4, Section 3 , T d- al N-R /9 W TOWN OF D d cryl , ST. CROIX COUNTY, WI SUBDIVISION , LOT NUMBER CERTIFIED SURVEY MAP , VOLUME106PAGELOT 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. I SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 8 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 Fo-r, aL c1 /L Q m un c1 Location of property &LJ 1/4 Al &J 1/4, Section / 3 ,T J-q N-R W Township ~4 Lcj S o-ri Mailing address 81 .7- Address of site $ 1, Mc C u+C-A can 12d - j4u-J g cryr,- bJ 5-40/L Subdivision name Lot no. Other homes on property? Yes v✓ No Previous owner of property L.Ja L E Fes- e F-- Total size of property Total size of parcel _ Date parcel was created ~q S~ Are all corners and lot lines identifiable?' dentifiable? ✓ Yes No Is this property being developed for (spec house) ? Yes _ylNo Volume 2 D and Page Number Zfj~ 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. ~6 7 3 4A , 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 of the County Register of Deeds as Document No. CX 2~ ~cc r, , v» U Signatu of AA15 plicant Co-Applicant 4 38o 0107 z y 9 Da e o 'gnature Date of Signature F DOGUMEAIY VO- 11 I STATE BAR Or WISCONSIN-FORM t i I W"~"I DEd i THIS IoACC RESCPYCO FOR RECO GOROINO DATA i 62U 136 4t~1 > DB made between Wdyne _A, Feder s>zd•. byra REGISTERS Off1CE `,tieder,usband• and wife, and. ...i11 _.h.i s_. or;St. CROIX Co., W► I her own separate right, . ftx Record this 30th f . •.--•-.Granto- t O j RC~l~ of Oct. KO.1 nai4~._G,_..)tit ymfrnd...A»,d_-baretid_-.B*.__Ra Qnd,.-- doY li k ;nr husband.. arkd__~di ~ as...3s~i>~t__tez~ants, at :2 P r .........Grantee ii - s ~ ttnesseth That the said Grantor, for a valuable consideration...... Y I' ~ twnveya to Grantee the following described real estate in ....fit r.._rrYDi.X....__.._ 'i RETURN To i i y Co"ty, State of Wisconsin: 3et~arthwest Quarter of the Northwest Quarter of i' Bectivn 13, and the East 2 rods of the Tax Key No. i~ 1%0rth &st Quarter of the Northeast Quarter of ~eaion 14, all in Township 29 North, Range 19 West. ~i SUBJECT To a mortgage from the above named grantors to the Federal Land Bank of St. Paul, dated December 2, 1977, and recorded on December 14, 1977, in Vol. 566, Page 152, as Document 345379, which mortgage the grantees assume and agree to pay. ro . 1 I1111`1 SFM sAL.0 FEE This __.1&--------------- homestead property. (is) 0. not) a Together with all and singular the hereditaments and appurtenances thereunto belonging; And------- the...said __-grantors warranb that the title is good, indefeasible in fee simple and free and clear of encumbrances except the above mentioned mortgage, and utility easements of record. and will warrant and defend the same. Dated this ------------------3Dth-------------------- day of ---------------October----------------------- 19--$0.. ,x . (SEAL) ------(SEAL) • . WAYNE A. FEDER (SEAL) -!r'°` (SEAL) } LYNDA I. FEDER ~i AUTHENTICATION ACKNOWLEDGMENT r Signstures but ca•„ed this 30th__ day of STATE OF WISCONSIN -------October - 19 _80- as. / a county. - - --.1 --S - Personally came before me, this day of • S L R . GARI the above named TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY to. me known to be the person who executed the foregoing instrument and acknowledge the same. HEYWOOD,. _CARI---&-_MURRA_Y,...SAMUBL---R..._.CARI Hutlson~ Wis.cunszn . 5-40.16 (Signatures may be authenticated or acknowledged. Both Notary Public County, Wis. are not necessary.) My Commission is permanent. (If not, state expiration date: 19 ) oxames of persons signing do any capacity c!+,u!d be typed or printed below Qxir signatures. - - - - i WARF_4Ih STATE NAM OF WISCONSIN Wisconeln ! gib! Biank Co- Inc. T0VLV No.1 - 1977 Milwaukee, Wis. (Job 34 yg; )