HomeMy WebLinkAbout020-1177-60-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER J Cons 7 r t,cc~l nti
ADDRESS L'O &X 57K 1163A 7 S y
$ c s MN, ~ L1)
SUBDIVISION / CSM# ~2c~ar M& _ - 5fa&S LOT #
SECTION a g T7N-R~W, Town of it s na
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
-9 k C 100.00' oK Tod Al, k Green
/ref ar feue Yost
'2 of
~I
,ZSb Ie.( Sq4 C. TaN
8 Tait k) e6;or
o °
a x ~Vl, ,d^
Prop -5-d
lvcll
INDICITE ORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK: ,E I U I DQ~ ooak9'., v 1 ~~e . Gr .11t 1-`/ iPn 1T
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: W P s fe Liquid. Capacity: 1.2=ro
Setback from: Well>7AD --House /,J'~ Other
Pump: Manufacturer /\I A Model# Size
Float seperation Gallons/cycle:'
Alarm Location
SOIL ABSORPTION SYSTEM
Length 7 t Number of trenches
Width:
Distance & Direction to nearest prop. line: W" Tp Wo to.
Setback from: well House 9_ Other
ELEVATIONS
Building Sewer ST Inlet ST outlet 9 _
PC inlet-_ NIA PC bottom Pump Off
Header/Manifold y Bottom of system /
Existing Grade Final grade
DATE OF INSTALLATION:
PLUMBER ON JOB:
LICENSE NUMBER: LD 7 O
INSPECTOR:
~i 3/93 : jt
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
""""d ST. CROIX COUNTY GOVERNMENT CENTER
a.~. , 1101 Carmichael Road
Hudson, WI 54016-7710
(715) 386-4680
May 20, 1994
TO WHOM IT MAY CONCERN:
RE: septic Inspection for JHL Construction, Inc. Property
Dear Sirs:
An inspection of the septic system for JHL Construction, Inc.'s
property was conducted on May 4, 1994. This property is located in
the NE; of the NE; of Section 28, T29N-R19W, Lot 16, Cedar Hills
Estates, Town of Hudson, St. Croix County, Wisconsin. At the time
of the inspection, this septic system was found to be code
compliant for a four bedroom home. If you have any questions with
regard to the above, please do not hesitate in contacting our
office.
Serely,
Mary J. Jenkins
Assistant Zoning Administrator
mz
r •
L9,gA WtTp; t §Q&,,;8 29.19 ~11I` XXVA &Ostwo CIRCLE County:
Labor an8ii`yumanRelations
INSPECTION REPORT
Safety and Buildings Division
(ATTACH TO PERMIT) sanitary ermit o.:
GENERAL INFORMATION 12
Permit Holder's Name: ❑ City ❑ Village IR Town of: State Plan ID No.:
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
ADO > l0 C if ~1 ~t~ 020-11177-60-1110
TANK INFORMATION ELEVATION DATA A9400033
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic1 Benchmark ~S /00
Dosing
Aeration Bldg. Sewer
9y~
Holding St/ Ht Inlet 12,7
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic 70, 1,5-" NA Dt Bottom
Dosing NA Header/ Man. Aeration NA Dist. Pipe
R
Holding Bot. System 0, ~Z / 3
PUMP/ SIPHON INFORMATION Final Grade 6.hS- (p~
Manufacturer Demand S (oi/ ! `17
Model Number GPM
TDH Lift Friction Syestem TDH Ft
Forcemain Length Dia. FFii Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 5 ~ 7 $ ~ ;2- DIMENSIONS
LEACHING Manufacturer:
SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM
CHAMBER Model Number:
INFORMATION Type O 7 r T
System: ~/1{ly G'~ (9r;_ 7
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.) + 3,1
LOCATION: HUDSON 28.29.19.1116,NE,NE,LOT 16,ALDRO CIRCLE
r
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. 5 114 p
t -If I i
SBD-6710 (R 05/91) Date Inspector's Signature Cert No.
SANITARY PERMIT APPLICATION
COUNTY
v~~nn In accord with ILHR 83.05, Wis. Adm. Code
. S
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ~6 /
8'/z 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.
PROPE TY OWNER PROPERTY LOCATION
j Cog, n Znc %a,VC'1a,SA N,R w
P ERTY OWN S MAILING ADDRESS LOT # / BLOCK #
CITY, STATE ZIP CODE PHONE NkJMBER SUBDIVISION NAME OR CSM NUMBER
II. TYPE O BUILDING: (Check one) ❑ State Owned NEAREST ROAD Cz;-cle
~QWN OF: J# Adec ❑ Public al or 2 Fam. Dwelling-# of bedrooms ~ PA CELTAX NUMBER(S)
111. BUILDING USE: (If building type is public, check all that apply) 0-703-// 77-CP/ lo
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. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] 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
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 2 ELEVATION
(.R 00 7~0 a y
7j b • 0 3Jf Feet ! 7 Feet
VII. TANK CAPACITY Site
in allons Total of Prefab. Fiber- Exper.
INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks structed
Septic Tank nk Weise,
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plu ,knber's Name (Print): P r' Sign tur ( Stamps) MP/1otPRSW No.: Business Phone Number:
~y 4. 7 u C r_ D 7<~r O
Plu ber's Address (Street, City, State, Zip Code):
8` d IV vier Ail, ku ,Yo z
IX. C LINTY/DEPARTMENT USE ONLY
❑ Disapproved Sa ary Permit Fee (Includes Groundwater ate ssue Issuing A ent Sign o mps)
rcharge Fee)
Approved El Owner Given Initial ~ti a
Adverse Determination C/ /111;~D
►
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(8.08/93) DISTR,BUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
r
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, 608-266-3815.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of
where the system is to be installed.
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
VII. Tank information. Fill in the capacity of every new arid/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 systern. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
-
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (R.11/88)
n,
Owner's name San. Permit No.
H63.05 PLOT PLAN
Show:
Location of building served N A Dosing chamber
It j
Q Septic tank Vertical/horizontal reference point
Building sewer System elevation is °i3•~
Effluent system Q✓ Well
Replacement system area Q Property lines w/in 50' of system
M-7 Distribution boxes t - i Scale = SO , or dimensioned
N•i~ Pump and controls:
Mfr. & Model No. Vertical Lift Size Force Main
Friction Loss T. D. H. Vol. Dist. Pipe Gal..per Min. Gal. per Cycle
Place check mark in appropriate box, indicating item is shown on plot plan below:
Br} - Ls1 , lOp.p' oN -Mp Ov' 2b "tj 1 Gh1 se-t--&j
C''L~RS s ~ w'1L~'Si~l. 1-h'~ cl POST.
B.y : 13.5 ~ 9'7 ~
S' S
~L b O`
t Ir
r P►~2►~n~TF T1Z _ o
_
MW-;11 ~
6-` 35~oF "PVC
I '
8' Th+-t- ~ ~Oo ~ 2.506 c~ I~RcDU cn
e OM2 - r in
c y~~ kt-. SLsP17C rPM►k
V,
1 I ~4
1 aSIO~
~ qS- 6 CTL.R61o P~PUS~
By the granting or approving of the above plan, or upon the event of a subsequent
permit being issued, St.CroixCounty and theSt.CroixCounty Zoning Administrator, does
not assume or hold itself liable for any defects in plans or specifications, plan
omission, examination oversight, construction, or any damage that may result in or
aft Install t'on.
0U a
I 1-' P umber Signa ure icense o. a E(E
~4 L cyly S~Z.u cl~u )1v e. RN V Z L
p,..~ ~ em's Iv +~ne
y''cs v Z PtaeS y'' pv c ~~ttFcRNTz~ PIK
6 w/ t~t~Pa-ov~o eR-ps
C,Z.~ S S S ~C`T10 ~1
~"c2' v>r~v-r \~\PC w/ 1~PP~v~ BHP
\lT L~'hST \ZYReov~ 1=i~lS!{LD GR-~'r~AE
~`~1 1\t ~y PrPPR[1U ~ S~[lU~?}-rat C
a a o D rsUkr2UV G,
~ a
O G ~ ca0
q3`o~
Cl , (j d d
3o
C," eF IIZ "1b Z IIZ4 R65RLlS"
aL\~w 'O\9TQ.t 8~1~70YJ 1~1 Pe?
\~1~5] Z~ of HGGR>L 6h'T~
I~-BOV ~ p1 PE
DISTRIBUTIOU PIPE TO BE AT LEAST Z~ INCHES BELOW ORIG UAL GRADE
AUD AT LEAST ZO IIJCHES - BUT 1.10 MORE THAM 42 IUCHES 5ELOW FIAlAL GRADE
MAXIMUM DEPTH DF 1=XCAVATIOU FROM ORIGIIJAL GRADE WILL BE GS INCHES
MINIMUM DEPT OF EXCAVATIOU FROM ORIGIUAL GRAO;= WILL BE -3 INCHES
SIGOED _
LIGEUSE DUMBER: 2
LATE:
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page \ of 3
"'tabor and Human Relations
Diyision of Safety & Buildings in accord with ILHR 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.
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE
PROPERTY OWNER: PROPERTY LOCATION
Sb~L COhJ S C'`Z~j T?Of~ l/V C°,. GQV ' N 1~ 1/4 N 13Z 1/4,S ZaT Zq N,R 1 q E (or
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
P-o ~px S7 °v 110 5~~~~-r ST. ! 6 - cebfv~L l}i~lS »fs
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MOWN NEAREST ROAD
H-'P" S''nf'36S,Y-1N S5033 (CIZ)y3-) --7 SZS 1 S~11V 1PUWZ_0 CktLCLti'
New Construction Use [pQ Residential 1 Number of bedrooms U [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 6c O gpd Recommended design loading rate a 7 bed, gpd/ft2 0• trench, gpd/ft2
Absorption area required 6 5 S bed, ft2 1 S O trench, ft2 Maximum design loading rate 0--l bed, gpd/ft2 0• $ trench, gpd/ft2
Recommended infiltration surface elevation(s) 93. C) ft (as referred to site plan benchmark)
Additional design / site considerations Z T JL Kj a*Q s Z Cco col wt ENJIl SR*:~ - S • K Z S' LU J G .
Parent material Sit hla.JT ovtTR SRa~~ C G "UE_~L Flood plain elevation, if applicable N .f\ ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable for s stem ®S ❑ U ®S ❑ U EfS ❑ U R, ❑ U ®S ❑ U ❑ S [SU
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 feridl
<)-9 1O `-t~Z 3~3 - L L`F SV ~t~ S - 0.5 0,b
fit.... . At?•. 2 a(- Z'1 l O `1 LZ ~ S 1 2 S ~ lZ W, i - C S - u 5 a • 6
uGround 3 Ll. q to K CZ 3/ 6 - S 6r- O s g ta~~ o u•$
elev.
C1 s •-I ft.
Depth to
limiting
factor ~f
of 4
Remarks:
Boring #
0-l1 lp Z`E 3u1r VVI FL C S - O-S CA,
3 ZZ-39 1O`1tZ 3l6 S I ~S~44t ~U f1- C-1 'S Ground
el4 ev.` c f 39- ti l0 If) Li R 3/6 - S ~l Gh O S g 1n-t ' _ o °-g
SDe.pt!h to
limiting
factor
> l lo"
Remafics:
TName:-Please Print Arthur L. We erer Phone. 715-425-0165
ergerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022
Signature: ~ ~ y - z) Date: Z _ ~ 3 - 9 y CST Number:
PROPERTYOWNER L C.-b JSMU C`i')LW SOIL DESCRIPTION REPORT Page? of'.
O Zp - X117- l~0
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
Z`F s tit w,.41- CS
m v'Fh e'-v 0• V U. 5
Ground 3 3D-qb 104f2 YA. St 0 85 Y0 o•, o•43
elev.
Depth to
limiting
factor 6"
Remarks:
Boring #
0.
0-Q3 W'TR 3/.3 W, c S - u' s
t? 3/L - s) l~, sbk W)U`Ft- Qs - o•y us
Zy-go 1t~`-tIt y/6 _ StIGt~ ~ 59 5 - 0.1 0-8
Ground
elev.
qS.S ft.
Depth to
limiting
factor
? O'
[--T
Remarks:
Boring #
1o-t\- 313 L 7- ~bk YYY a-S - o,S 0.6
C: 1: y
0 _ t 6 ~ u ~ 1Z 316 - s ~ ~ w► S bk 1KI v `E-1r cS ~ o . y 0-S
-3 l6 - `l 6 ) p't V- U /6
- S G~ p Sg wt ` - o. n, 8
Ground
elev.
q7.1 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
Sci~.LL 1~~ = Sp _
n -1 w
z o Z 177
$'~l - 100.0 olLl '[-pF 2~ t GH G2r2~1
114
°ts s w'l`~'Ci~l 1- r1~1 cl PoST.
e's
S'
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J3U
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4
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CEDAR HILLS ESTATES cL,...~,- -
CEDAR
COUNTY 1RUNK HIGHWAY UU N
BILLS
- E03 TATES
3_D 29 So ' PAIJlanr-b 20 ]9 Ststion
~!5 I 1
2143 j SLID 4--To Hudson` To Eau Claire-9
28 SCU) 21
lab 1 /
343 j S 29'1
0 ~
N 47 N G 22 1 / 55 56 j 1 lb 15 j
364 -79 54 57 17
26 StiD ~ y11
g11) Sa 1,4 1 60 14
SID
24 ( t66 y 1°~ 58 18 CA D
.3 U
451 13 i^
15 oN6 SCI D %O j~ M 00
3i7 59 472
=J P 1
URU DRIVE ~ 1 52 cl,
143 90ID P 1 2
15 48 , 51 CP r 11 w StiD rv
.'S of SID z 472
O :1 _ i' 11 SLID
60 3
0031 50 ,SO~~ 11 ,°9 ~ 472 ^ a
y t ~r1d Silb a 472 .4
49`! 61 < 4 to
472
SM) etc ' r 472
10 55
473
33 a `t 62 m / 5 X
73
/ 9111 35 46 Q~ a `Cy `16 rJ
UlD xi
i 1 1 63 9 r. 14
`1? / S !d i9 7
5t1D )oLQ SJLLU
38 31 36 45 33) `.]J t7
(11 %U) 91.1D 44 c,
1 ,.xa
43
39 40 41 42 SOLD
SID C D SID 91D la;'llAR 1111.1,.1 14:1 1.1.1/1'.111"'AT, INC.
W11. 1. IAt., ,Af4WEL1
171 bi 879-!>201, 1311
R
. SEPTIC TANK MAINTENANCE AGREEMENT ~
St. Croix County
fl'L C ~'"►/S `l%S c 11 o
OWNER/BUYER
f 7 t
ROUTE/BOX NUMBER ' '7'~'7 •A 1d t~~ C'r~ ~ Fire dumber tv
CITY/STATE ZIP 5 'el Cl ! rt
PROPERTY LOCATION:'.'ISection, TqN, R_W,
Town of 06-Ascr) St. Croix County,
SubdivisionCe,)6. Lot number .
Improper use and maintenance of your septic system could result in
its premature failure to handle wastes.- Proper maintenance con-
sists of pumping out the septic tank every three years or sooner,
if needed,
treat-
o.tmeesepticttank astainto
m can aalicensed e3eunct ontank
the system in the waste disposal system.
St. Croix County residents M Z be eligible to recieve a grant for
a maximum of 60% of the cost.of replacement of a failing system,
whi.c 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 s sy t'ems agree to keep their system properly
maintained.
a
Zoning
The property owner agrees to. submit to St. Croix County plumber,
certification form, signed by the owner and by a mater journeyman plumber, restricted plumber or.a licensed pumper veri-
fying that (1) the on-site. wastewater disposal system is in proper
nec-
operating condition and •(2).after inspection and pumping
essary), the septic-.tank is less than 1/3 full of dsludpriondtscum.
Certification form will be sent approximately 30 three year expiration. y
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 Depart- W
ment of Natural Resources. Certification form must be completed b
and returned to the St. Croix County Zoningfic within 30 days
of the three year expiration date.
SI ED
DA 2-
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
. APPLICATIONFOR SANITARY PERMIT
STC-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 tot teselt by
owner/contractor,(spee 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 11-114 L' C%Vt/ f T//57 6,, 7-,r "ItJ _,--,41
~Lq'
Location of property -ILL-1/4 Mr Section
Township al
Maliing address
lc4l
Address of site
s ~ F S •
subdlvlslon name C ec/Q1- 115
Lot number
Previous owner of property , [ C`d'uw
Total size of parcel
Date parcel vas created
~Jlo
Ace all cornets and lot lines ldentltlable? on
to this property being developed tot resale (spec house)? K as e
Yoleme ,wand Page Number _ as recorded with the Register of Deeds.
• - - - r - - - • - • r - - - - - - - - - - - - - - - - • - - - r r - • rr - - - rr
INCLUDE •
WITH THIS APPLICATION THE FOLLOWINCs
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLVMZ AND PAGE NUMBER, and
the SIAL OF THE REGISTIR OF DEED9. In addition, a cartifled survey, It
avallable, would be helpful so as to avoid delays of the reviewing process. it
the deed description references to a CeitIlled Survey Map, the Cettltled server
Map shall also be required.
T
PROPIRTY OWNER CERTIFICATION
I(we) certify that all statements on this form are true to the best of my (oucl
knowledge; that f (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. ; and that I (we)
Presently own the proposed site for the sewage disposal system tot I (wet have
obtained an easement, to run with the above described property, tot the
conettuctlon of said system, and the same has been duly recorded in the office
Of the Coun y eter of De s. umant No.
S atute ot-ownec signature of Co-owner III Applicable)
7- C/
as to of Signature - Data of Signature
I
• ' DOCUMENT NO. I THIS SPACE RESERVED FOR RECORDING DATA
WARRANTY DEED
j STATE BAR OF WISCONSIN . FORM 2 -198211
Aftl^
513396 GNP- PAGE 1~ ,
_ - 3 REGiSTEM : OFFICE
r ST. CAOIX CO. WI
Cedar Hills Development, Inc., a Wisconsin Corporation, ►
Ps-ld for Rc"o~
E
j conveys and warrants to Construction Inc. II 8:30 _j!
x
Zwr of
- - - . .
I
j
RETURN TO
I Construction
jJHL
P. 0: Box 578
-
the following described real estate in ,S.t.._.CXA12C County, IL gs-_-II=
State of Wisconsin:
Tax Parcel No:
Lot 16, Cedar Hills Estates in the Town of Hudson.
I ! I'
it
I
0
I~
~I
Ij
j
j
This is n (snot) homestead property.
Exception to warranties: Easements, restrictions, and rights-of-way of record,
if any.
Dated this Z~ G February, 94
19.-----...
- day of -y'
Ce~ar Hills Delo nt, Inc.
- (SEAL) BY-:.?`--!v` - (SEAL)
Dean R. Larson, P sident
. -----(SEAL) By:--' -(SEAL)
* William- C.-. Harwell,_..$ecretary-Treasurer
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) ....Dean R. Larson, STATE OF WISCONSIN ss
William C. Harwell
yQ,~ County.
authenticated this ..day of_...- February , 19--- 94 Personally came before me this ________________day of
I 19-------- the above named
~k~------------------------
Kr; i'911ula O.glaild-----------•.-----•---•------------•---------
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stats.) to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY
Kristina 0 land
*
Attorney a--t------------------------------------------------- Notary Public
.__County, Wis.
(Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration
are not necessary.) date- 19__.......)
'Names of persons signing in any capacity should be typed or printed below their signatures.
WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc.
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