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HomeMy WebLinkAbout020-1290-10-000 SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY S4. C<-o STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El /1 4 revision 97 8% x 11 inches in size. chec 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 PROPERTY LOCATION S 1 L L,F~ (L)'✓a ✓K '✓a, S z T 4', N, R/ E (or) PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # OTC r CITY, STATE ZIP CODE OK ONE NUMBER SUBDIVISION NAME OR CSM NUMBER u~So K wL SYc~/~ Z7~9 /!2 ILL S ~9 ~7'J o~ [T -ClTY ROAD 11. TYPE OF BUILDING: (Check one) F] State Owned VILLAGE: JrI TOWN OF: gubSo 1)7111REST ` em eat v ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMB R(S) III. BUILDING USE: (If building type is public, check all that apply) ZV - / O /o 1 ❑ Apt/Condo / 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel - 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. W New 2.E] Replacement 3.E1 Replacement of 41:1 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 ❑ 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 !O REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION Y J 72 0 0• S 1? 0 Feet ~ J. Ov Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App. Tanks Tanks structed Septic Tank or Holding Tank t S Lift Pump Tank/Si hon Chamber Vlll. 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: ( mps) MP/MPRSW No.: Business Phone Number: S PO t~,B'Er z 3L 3 Plumber's Address (Street, City, State, Zip Code): 60 -"P' / ZZ ~k,) C D U S 7 IX. COUNTY/DEPARTMENT USE ONLY j I ate ssue Issuing A e tamps) ❑ Disapproved Sanitary Permit F~e (Includes Groundwater ,tj Surcharge Fee) A~ ~ Approved ❑ OwnerGivenlnitial / 1'~j t/V r✓- XT - Adverse Determination e X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety & 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 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 Sanhary 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, 603-266-3815. 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 muss: 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. - I 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.11/88) CL _ jr o w a 0 o W = ^ F- F-; ~ Y l X `Z j . 41 0 Z) 4 O w I PO z I U ~ I w ► ► vi io z w I ri { (L o I I v I Pr) (L I WEL I I z 0- Eno- CL , I I I I a LL I L~J I I I O0 I 1 I I a ~ J I LLI I I I ~ I `a I I I ~ I ~ ~ M <p cp t7 I W I I I w d °4" U9 3 I ~ j I I W m o I UO, o ``'U I CL I I a j ~ ► R`r I I Z j I 10 ~ I I j 1 v~ I I I ~ 1 Z I I I tt I' w to to 982 GO" . Drainage an•i ponding easements to elevation shown SUR - Section corner monument - Aluminum cap found HU (356.67')Previou3ly recorded information I Y V f CURVE DATA TAB LOCATION SKETCH w Curve Lot Central Radius Arc Number No. Angle Leng NE CORNER I Bndry 46.00'00" 167.00' 134. SECTION 27 T29M. R19w j 2 - 46•00'00" 233.00' 187. \ 2 6 20.31102" 233.00' 83. 2 Road 16'17'08" 233.001 66. GNPLATTED~ LANDS 2 7 . 9 11150" 233.00' 37.. t r wl OUTLOT 2 ZI 6.300 S0. FT.' QI 14.14' 0.144 AC. S 00'00'14"W 898.38' 217.38' 217.88• 217.56' 217.56' JI' n~ 14-00' 884.24' 933 Fr1I~ 1:~• I 21 1 jERS aEF~~~' I qt 12 I E/ c 2's0. 10 o ~ I a . ~4} 97, SFT. 0D n 97, 5833'''50. -F7. 975 50. 'r 7. 97.580 SR F7. -q W 2.240 AC. W 2.240-AC.. W 2.240 AC. --thp m o 2.240 AC. • I WI ~,AC c 69 r m Y ^ Oi ~ _ ,1 1 ' Z 01' 01 0 V . , V m 0 m 1 p 1 , _ r Z Z CD I i i Z o I N I O a _ ~I BENCHMARKS TOP OF C NCRETE L 1 o .o, v 1 Oi SOUTM POST OF H MBIRO HILLS"IGN. ELEV.+ 3.02' 14 216.13' 216 13 216.18' .00 14-W 302 .88 CI} O 1 7201 37 2a57• io LL = Arr2i-N ROAD 3 00 00 t4'M 1202.27' II 1 205.31' 200.00' I I 200.00 200.00' 200.00' , 360.45' m { m - 14"GJ~ - I - 1183.7 . - i 938 Gv' m 1 I i _ I. 1O• 1 I 40' X 40' JOIN r T i .--9RAINAGE EASEMENT DRIVEWAY EASEMEN I RUNNING 40'ALONG- ` i - -1d - r COMMON LOT LINE I I V-BUILOINb AND 20' ON EACH • _ \ SETBACK I I 'LOT.' 50-w LINE w m I "a - - o w 3 CI v 1 v 88.39 5 20. FT. . 1- q Cg~6O I o o ly m I Be;39 0. FT. 88.3 50.. FT. '(11 88.345 SO. r"T. 118•;03 SO. FT. t ~I o o. - 8'12791 S0. FT. 2.029 AC. » I 2.029 AC .2.029 AC A 2-.029 AC. 2.711 AC: -2.061 AC. mot I m I uI Is y a 1;I 1 II 1 F o NO.. `J I z7.ez~ I I 1281 .34':.- I Y 200.06' 200.00' I I 200.00' 200.00• - 200.00' 267.94' 6 I. 14.00' N 00'00' 14-E 1309.16' .ty„ I /I I CUT L07 1 r1 UNPLATTE LANDS_ - _ n I 6.188 SO. FT. AC. NI/4 CORNER - - - - SECTION - 27 - I, Harvey U. Johnson, registered •wisconsin Land -5urveyor. nereby certtty to-the- - best of my professional knowledge, understanding and belief: That I have surveyed, EYING' & MAPPING divided and mapped HUMBIRD HI LS, Phase 1, located in the SOUTHWEST quarter of the Northeast quarter and the Northwest quarter of the Northeast quarter of - SON. WISCONSIN Section 27, T29N, R19W, Town of Hudson, described as follows: Commencing at the North quarter corner of Section 27; thence S89 44'13"E 363.00' to the Point of Beginning; thence S$9 44113"E 957.991; thence S00 00'14" W 898.331; thence N89 49'46"W 450.001; thence S00 00'14"W 30Z.86'; thence Southeasterly 134.08' along the arc of a 167.00' rauius curve concave to the Northeast whose " chord bears S22 5946"E 130.501; thence S45 59146"E 334.38; thence S44 00'14"W 66.00'; thence S69 45101"W 308.00'; thence S16 41'55"E 675.49'; thence - - - S16 39'ZZ"W 271.451; thence S89 57'17"W 293.00'; thence N00 00'10"W 1308.391; thence N89 53128"W 287.901; thence N00 00'14"E 1309. 16' to the Point of Beginning, - containing 1,486,047 square feet (314.115 acres) more or less, and being subject to all easements, restrictions and •-ovenants of record, Chord Chord Tangents That such plat is a correct representation of all the exterior boundaries of the land h Length surveyed and. the subdivision thereof made; 8' S2Z'59146"E 130.50' S00'00'14" W Thatsuch plat was made by direction of the Humbird Land Corporation, owner - S45*59'46"E of said land ; S22'59'46"E 182.08' S00'00'14"W That I have fullcomplied with the provisions of Chapter 236 of the State of 54559'46"E y 4' 51015'17")i 82.99' Wisconsin Statutes and the subdivision regulations of the Town of Hudson and St. -Croix County in surveying, dividing and mapping the same. 3' 528'39'22"E 66.00' DAted th is 16t ay of September, 1990. 00 0 S ~ 0' S41'23'51"E 37.36' r Harvey G. oh son 5-1899 _ HARVEY O. Johnson Surveying, Inc. S-1899 H s s 407 Second Street = HUDSON - REV SED THIS L Dar - Hudson, Wi. 54016 fy W13 OF 1990- t~< N {p ssUUS~ ;l > /^g• N h959 / 4 tDA 3 1 g•3 9a0 O UN PI----LANDS - / •oooi • 9,?1~1t' ` A9. 929.00/, tasraa °rn • aS' 5gr 919.00' m S ~6 u o, 7 0 i 890 30. FT. F ; 6 2.064 AC: ~ n _ . 288. 696 50. FT- A- w) e' 8.628 At- iR It, 100 0 - tS 07 Z Sosnsa aASaraar - IA o Z v . D11311 93TOd UJ ~I ••••1242.39 e 88.00' 330.01' 91?.34' 11 N 00'00110'M 1308.39' w ;.a - - - m p UN_PS AT7 EQ_LANOS .3 to N - -----1 t_ 3 - 10, 10' N m DRAINAGE AND UTILITY EASEMENTS u7 BEARINGS REFERENCED TO THE EAST LINE Drainage and utility easements are shown thus: being 10'- 01 OF THE NE I/4 OF SECTION 27. ASSUMED in width and adjoining street lines and being 51 in width 5 OO° 01' 22"E. and adjoining lot-lines.. unless otherwise shown on the Z plat. • 10080 60 40 20 0 loc. 200 300 - SCALE IN FE47 - I" • 100' SHEET ; OF 2 - DRAFTED By JSI 490- 1495 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Ai" ADDRESS 13 0 X f Z l L. SUBDIVISION / CSM# l~ IM Q 1 D 14 1 LL, 5 LOT SECTION Z -7 T 2-7 N-R `J Town of HO < a vN ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 4 s~u(a.`~~ -/o INA 4 42 OR G lr<C A6E, -De fu 1A) A ,o- Slo~f 3 v- ~ t3.[O, TOP oar E . 50UTN lDZ LIVE INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 1 BENCHMARK: Ta © -?(Pjc,+T S t loiy~~ ~ ' /coo eo . 3 . ALTERNATE BM: l v~ S/ (l ° n [34 S c s~,tQ. Oo r I - 7 -6 Z- SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer:_(jQ u s c-r Liquid Capacity: /.no o~•~ Setback from: Well y House qD Other_.T.,,dF (07- //.rte Pump: Manufacturer Model# Size--~-_. Float seperation - Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: / I Length 41 Number of trenches Distance & Direction to nearest prop. line: ~/o~ t° So~'fiC (ot CL_ Setback from: well House 79 Other ELEVATIONS Building Sewer ST Inlet. f ST outlet /40, 3 PC inlet - PC bottom - Pump Off - Header/Manifold 3 , 8 Bottom of system Existing Grade `1JO Final grade 9. 5O DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor'and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ' Permit Holder's Name: ❑ City ❑ Village Cl Town of: State Plan o.: MILLER, SAM R CST BM Elev.: Insp. BM Elev.; BM Description: Parcel Tax o. /60 16i) A9400196 TANK INFORMATION ELEVATION DATA //3 9 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark/(o /dv p~ Septic zzx Dosi wi .1- ,/Y~, X2'331 ~D4 i Aeration Bldg. Sewer Ho St/W Inlet Id. 64 TANK SETBACK INFORMATION St/t4 Outlet p7' 09' TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic -rcls~, ~51~ NA Dt Bottom Dos' NA Header- /510 s~~ Aeration Dist. Pipe H g Bot. System PUMP/ SIPHON INFORMATION Final Grade M ufacturer Demand/" Ina, A _K i Model Num GPM TDH Lift Friction Ft F -of Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width i Length NO. Clf T enches PIT No. Of Pits Inside Di Liqu Depth DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEA anufacturer: SETBACK CRAM INFORMATION Type O A~o r , Model Number. System: OR 7 OR IT DISTRIBUTION SYSTEM Header / Manifold „ Distribution Pipe(s) i „ x Hole Size x Hole Spacing Ven Intake Length Dia. Length 3 7 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Depth Over y Depth Over f/ xx Depth Of xx Se /Sodded xx Mu c e Bed/ TCenter 3~1- V42 „ Bed /TtifiEFFidges Topsoil Yes C] No ❑ Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON.27.29.19WJNW,NE,LOT 1, HILL FARM ROAD -1 PT I Plan revision required? ❑ Yes D-fTo Use other side for additional information. v v SBD-6710 (R 05/91) Date Inspector's Signat a Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: sAM M/tLE 2 HUMPIA? D HILL s Lor # / 7-'8 44ILL F.44M e-OAD S.ySTE/VI F_lV c Nv.crH: S8,ce' S®aTi`{ 8$,sa Sc,4/.~ /ate •~s~ ~~3~ ~ _ HI~I FAZ AA iZoAD / Vhs7'coritNE zo6,31' / NEXT To rEl. j PC D. El;: Ioo,ov' e ! '\,vELL l4<>us L-~_ XJ ~AQAbf , 7s /rs j ~ 1~Xul JJ i fff tiI y ~s a 1 2 S PLT F ~Nli7E - - - e 0 4 AZ fA 13-3 J Ak6,Q ~1pE~) °j~ 404 0' i2(o V ~ o AI I i I i i I I Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page I of labor srxlj,Human Relations Division otSafety,& 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 J Cf~ X 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 Q SA Ah Mt LC GOVT. LOT NW 1/4 /4 LK- 1/4,0-7 T Z9 N,R E (or) W PROPERTY 0 ER':S MAIZCA ADDRESS LOT # BLOCK # S B . NAME OR CSM 1 u R& ~I/L s I ROAD C STATE ZI CODE PHONE NUMBER []CITY ❑ ILLAGE OWN IN EST 14UL150N 1 S~I~ ( ) LSD 14d s New Construction Use [Dy'j Residential / Number of bedrooms [ J Addition to existing building j J Replacement Public or commercial describe Code derived daily flow S~ gpd Recommended design loading rate O bed, gpd/ft2 7 trench, gpd/ft2 Absorption area required 750 bed, ft2 6 4!~ nch, ft2 Maximum design loading rate C~.7 bed, gpd/ft2a -g trench, gpolft2 Recommended infiltration surface elevation(s) arJ Z' (C S m- ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable It S =Suitable for system XVENTIONAL ~guND tr ROUND PRESSURE GRADE SYSTEM IN FILL HOLDING T K U= Unsuitable fors stem s❑ U f~ S❑ U Ifs S❑ U 1 S ❑ U S❑ U C] S U 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 rertcfl 3 A - /dY 2 Cr Ar CS Z 50 -zo IoY 4 4 bk rm~r C S .3 Ground ~j o 3b I.SW 4 r M S 7 elev CK;9 ft. $ z l S M 0,7 10% Depth to limiting factor '7If?~~ Remarks: Boring # -1Z 2 AiC r ~r C S Z S 0.6 El m/1' A 4 5,[ 1 sbK m sir C S I OZ 0.3 $ 6-29 7 S 3^, r/M C S (S.? ~J$ Ground elev. /OY 4 15 © 0, r >rt - CX q/,zg ft. Depth to limiting Remarks: CST Name: P sePrinntt \~N I ' Phone: 3 56 4 r~ Address: , ~ c., 4L)&-so N I ~2~- Signatu Date: L CST Number: A RROPEUYOWNER JS4A1 ~t SOIL DESCRIPTION REPORT Page? of PAkEL I.D. # LcoT ► wl i 1 ~1 lg } R~ Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 3 0-/l b,Y V 'Z L Z r r CS 2 b,S O.G 'rh g; l-~$ iby 3 3 ~J L S 6K no r G S S Ground - Z /by 4 S n m 1 p.7 q~te~~ft. Depth to limiting factor >~©U Remarks: Boring # $ 4.33 Jo % g th r. C 0,Z 6.3 d.7 10,% B-Z g-?-i 16 YA 414- 9V A7 Ground lev. C) 73 ft. Depth to limiting grZ fact > Remarks: Boring # 4 -2 3 16YK 43 - S,l 1 S / i 63 02 -'S 13 Ground elev. ft. Depth to limiting ctor~ 7 Remarks: Boring # Ground elev. ft Depth to limiting factor Remarks: SBD-8330(R.05/92) t N W G ~ O b o o -fb ~ t t ~ W 1~►' Ale, v r 3 w rj- All G` a w 0 t m p~ a o 1 r 16 G I STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER SA M M I L LC d'?__ MAILING ADDRESS .&o, ( z C'2----- PROPERTY ADDRESS ~ ct 8 N f L F ,4 Q M 2 o I40 (location of septic system) Please obtain from the Planning Dept. CITY/STATE V Lb -SO A( W -7 PROPERTY LOCATION A/ k) 1/4, /V F-- 1/4, Section Z 7 , T L~_N-R / W TOWN OF t}C>1~ SD iV ST. CROIX COUNTY, WI SUBDIVISION lW y g/e:D f j/LG S LOT NUMBER CERTIFIED SURVEY MAP y~ VOLUME s, PAGE^I 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 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. f SIGNED: DATE: Z cr r 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. Owner of property Sq M M I L I f rL Location of property A uW 1/4 AIF_ _1/4, Section 0,T 2-11 N-R / 1c- W Township Y-cJyrz> y Mailing address &.DZ Z ~z- Hvb so K IN / 5-5b /'6 Address of site -7 HI LL FARM R040 Subdivision name R/2q &/L` S Lot no. Other homes on property? Yes__No Previous owner of property c?/9,0 I-A f,0 lo. Total size of property L-U G/ /¢L Total size of parcel z y(, i A-L Date parcel was created -7 -1 Z- - 9 3 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)?-,k' Yes No volume 10?-) and Page Number Z Z 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. :So 7_-2- o9 , 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. ,SOzz0~ Signature of Applicant Co-Applicant Date of Signature Date of Signature ' DOCUMENT NO. .?ATE BAR OF WISCONSIN FORM 1-1982 THIS s►AU Reseav¢D FOR rccoROiNO DATA _ WARRANTY DEED 502209 _ VOLREGISTER'S OFFICE This Deed, made between .....Humbird..Land•-.-orporation' ST. CRO7X CO., ctrl ................C-.-- Rae'd for i:2cord A Minnesota Corporation authorized to do business in--wisconsin-------------------•-------..••--••••-•••--••--•-----•-••...--- JUL 12 1993 • Grantor. 4:20 P. at snd..... .X.M ..}ller.••••-•-•-••-•---•• ~~Wste of Deeds Grantee Witnesseth, That the said Grantor, for a valuable consideration...... cone to Grantee the following described real estate in ._-Ott....roix RcTURH TO t1 c. County, State of Wiacon:in: Lots 1, 2, 3, 4, 5, 6, 7. 0, 9, 10, 11 and 12 in the Plat of Humbird Hills, Town of Hudson as filed Talc Parcel No: and recorded in the office of the Register of Deeds for St. Croix County on April 7, 1993 in Vol. 5 of Plats, Page 99, Document No. 497107. Lots 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24 and 25 in the Plat of Humbird Hills 1st Addition as filed and recorded in the Office of the register of Deeds for St. Croix County on April 7, 1993,`ia Vol. 5, Page 100, Document No. 497,108. VIA- This ilt_.nQt--------- homestead property. cw (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And-.-Rumbi,rd.14kn_.d_ C4rp_9;ay_ion_..---- warrants ttat the title is • - - - - good. indefeasible is fee simple and free ee and clear r of encumbrances except easements shown on the above mentioned plats. and will warrant and defend the same. Dated this •..12th------------------••••-•---•••-- day of ...July----------------------------- 19.93-.. Humbird Land Corporation, a Minnesota Corporation authorized to do business in Wisconsin ' -------(SEAL) By -......(SEAL) + Austin J. Baillon President (SEAL) --•---•----------•----------------(SEAL) ' ' AUTHBNTICATION ACSNO WLBDGMBNT Signature(s) STATE OF WISCONSIN • ss .County. authenticated this --------day of 19------ Personally came before me this __..__~!tday of July 19.-9 the aM e-.~led • = ---Au9tip_ J.__Baillon,__ Presideltt._.ol** C TITLE: MEMBER STATE BAR OF WISCONSIN " ' • ---Humbrd_.la;-Corporatiog_• s (II not, > P~ authorized by § 706.06, Wis. Stats.) to me known to be the person '%V4 ecuted tbi foregAing ' trum ent and acknowledgA4 a. Q THIS INSTR1.e:ZNT WAS DRAFTED BY d .f IT tL al h I C -'y V' AQ~I, _ Zueppersr--Hackel__&--Kuepp.era-----•--- l1// I_/ V r ►N R= O v [ = ! • •1350--Capital..Centre,-St._pau1,--MR- 55102. Notary lie ._._S.T...... e -6.l.J----------- County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (if not, state expiration are not necessary.) date: - +Names of persons sirnins in any capacity should be typed or printed below their signatures WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Leral Blank Co. Ina j FORM Ns. 1-1982 Milwaukee, Wis. A c ~ 3d ~0 C ~1 o m eo ~1. ~ w 3 " '7 C/) z C3 N c, 0 07. 3 3 to O N~ C V O ~ }~0~1 • S c g A a N ~••y ` 1 A v t0 CL :3- =r tN to p N `A\ N W Z-1 O O O V t0 t0 O O W O tD N 3 3 N N Q Q oo °o tOp m N N fD m N O O N V -4 C tD 7 7 7 A p 3 O O 7 N C O O 0 (D u> < D o e~ a , m d C A D co co \ N W c n ca co ° ~ O 3 O N to 2 N N _ C, 0 co v lot f00 A OOO Q" CD A A N r u) O 3 D M 0. 000 ~ ltVil W 3 3 vi vi vi o_ Oro m Im to S' a tA~ _ Z p O O y (D 0) Q z O Z co z O O o D (D O o. N n NO N N N l~1 • c) 7 O CD to l~Vl O O N C N N Oro fD Q N tp N ~ p 2 tD n P Q F! I N v C A A co C. 3 z O X z y m z ( A W C a a ~ I ° o m 'm c a o a m N CL d m o ~ I ° a am A A O N I ti I Gro b o m ot"o m ~ C9 O o g o b C) CD CL ti