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HomeMy WebLinkAbout022-1026-30-000 STC 10 4AS BUILT SANITARY SYSTEM REPORT OWNER 71C ADDRESS ~T7) 1 ~5 SUBDIVISION / CSM# LOT # SECTION___~_T o N-R / W, Town of. ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 3e, gal C~ar+ ~4r S M 3l fie R INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. ti BENCHMARK: loo.6 ©p a I ~~C ALTERNATE BM: HOLDING TANK INFORMATION ~j . Manufacturer: < ~1/`1/11~~'• Liquid Capacity: QDU ~~D6 Setback from: Well ? ~U House Other Pump: Manufacturer it 14 Mode14AF6V1/I Size AT_ Float seperation Gallons/cycle: C; W Alarm Location ~r /Q~UDU~ SOIL ABSORPTION SYSTEM Width: Length / Number of trenches Distance & Direction to nearest prop. line: Setback from: well: ~0~40 f House Other ELEVATIONS Building Sewer ST Inlet: ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATIO 9y ` PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt n Department of Industry, PRIVATE SEWAGE SYSTEM County: rat r,d1-luman Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TOIPERMIT) Sanitary Permit No-: GENERAL INFORMATION _ 20901017 Permit FW61s gum e~,~HY ❑ City ❑ Village I Town of: State Plan ID No.: Kinnickinnic CST BM Elev.: n~ Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO 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 Syesttem TDH Ft Forcemain Length Dia. If Dist.Towell 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 TypeO Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Kinnickinnic.9.28.18W, SE, SW, Coulee Trail Plan revision required? ❑ Yes ❑ No _T] Use other side for additional information. SBD-6710(R 05/91) Date Inspector's Signature Cert. No. SANITARY PERMIT APPLICATION q ( !,Z4, ord with ILHR 83.05, Wis. Adm. Code CO ZZ In acc all!HO STATE SAT~4RPER0T # -Attach complete plans (to the county copy only) for the system, on paper not less than ~ V 'i// 8% X 11 inches in size. Check if revision to prey ous application -See reverse side for instructions for completing this application. s[TST$- I. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. OWN 5R PROPERTY LOCATION PROPERTY N 16~_n -Y.S"h;%.,S TN,R E(or W LOT # BLOCK # PROPS TY WNER' AILING AD RESS 0(? T PODE`/~~ PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER C t STATE r Ii 1( 13 TY II. TYPE OF BUILDING: (Check one) El State Owned ❑ VILLAGE NEAREST ROAD ❑ Public ®1 or 2 Fam. Dwelling- # of bedrooms to =12 W: A PARCEL I AX NU Ill. BUILDING USE: (If building type is public, check all that apply) Jc Ob- 3 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. ® New 2.E] Replacement 3. ❑ 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) x Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 S 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 A Feet a~ Feet 11170 1 :?74 VII. TANK CAPACITY Site in alIons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank K 1 -7 r R-1 Lift Pump Tank/Si hon Chamber / t ' VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. 7lun)ber's Name (Print): Pluy~ Signature: (No S mps) MP Business Phone Number: Plumbers Address (Street,ji, State, Zip ode): 4/'~t 7(T t r o 1 rAS 4_/)" Q F IX. C NTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Issuing Age Signa Sta s harge Fee) Approved ❑ Owner Given Initial Adverse Determination ledl'~50 Surc X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) 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. ~ re ie- (r I any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions Xo ii_, permit must be approved by the permit sc.,:;g asthorily. 4. Changes in owc ship or plumber requires a Sanitary Perm. t. ?'rnsfer/F er _wal F~)rt:r 6399) to be submitte i to the county prior to installation. 5. Onsite se w s,7u rnust be prcape y rnairtained. The s`. tank (S) E,,~at he ~Li _ a i°censed pumper when-', r l ;ecessary, usually every 2 to ci years. 6. If you have questions concerning your onsite sewage system, cvntact 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 n imber(s) of where they •:.ystem is to be installed. II. Type of building being served. Check only one and complete: # of bedPC ours if 1 or 2 Farnily 7)welling. 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. Hype ct system. Check appropriate box depending on system type. V!. P.bsc system informs`ion. Provide a?l information r?q,aesf7? V ,.i!`k . :r,. ation. Fill in the capr ;'v of ,ry new and/or e0I i ,f.:!„: ::c+ tt'te total i ; 1"_ T1I`cr Ot t; -ks jn1,1 nufac,turer's name. IrtCtii c s; Jrefab Or Site consa.., a;,K -nate,ii;i;. " rl for all sef rz pL.r, ~`sif.hc and holding tank this system. Check received exp _ P approval froir Vill Fe~,.~ n~ tr ity stat-rent. instaili--i airs , i~ r 's to fill in nar! , c e r!,,,nt)e~ with sat -,ri t!x te,g, 1'0;1', etc 9,'::i;, and phone pumbr r °IL`riber must sign aGr , fc:r^~. IX. CourstyilJ: a°trrie fse Only. X C !'U ~ ile 'r ,,:c'r,t "ISe Drily. v4mp',(f'!an8 and specif.:atior!S not sn-aller tt7an 81/ ?1 `;ubr!!tled it' _:r- r-ty. The plans r`iJ l itic it `lie 4r)I1otuvir?g: plot plan, draw : to sr c Cyr 'en . .4ttorl of hci ling :ar (s` sept:._ tpr k s) or other treatmr .t tanks. , .;ildir: i1f:' SerViC e, stie.ams any l4k", pUnlp ne siphon tanks, distribution boxes 4Gs nip Ai0f, -ystp-,T. "r(t'i't syst(-.r! are2S, r'i;ld `he ;oc,,a~,-, of `,e building served, 3) horizontal ;Irc: rtC : .ie "?I : -f' _ 'i1,3; G) cornpiete spec !satins for pumps and controls; dose volume, ~~Ieva!:Uti 6,;ferP less; pump performance curve, purnp model and pump manufacturer; D) cross section o+ the so i at>.>,or;.rtiar, system if required by the county; E) soil test data on a 115 form, and F) all sizing information. - - - - - - - - - - - - - - - - - - - - - - - - - - GROUNDWATER SURCHARGE 1,83 'A'isconsin Act 410 includc".`d file creation of surcharges (fees) for P%t-' )f re pr ?cf ces t-ch ca :=ffect g,oundwater. .pit 4 )r Monitorlr ,:r,. ,G j 'to° :iitjaii-ns anfi e sfa-. '!~?li rr' 4 ri;i arelS SBD-6398 (R.11/88) SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations May 6, 1994 2226 Rose Street La Crosse WI 54603 WANG EXCAVATING THOMAS WANG W9672 770 AVE RIVER FALLS WI 54022 RE: PLAN S94-40283 FEE RECEIVED: 180.00 LA MOTHE, CATHY SE,SW,9,28,18W TOWN OF KINNICKINNIC COUNTY OF ST CROIX MOUND SYSTEM The Department has reviewed the above-referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be made. All permits required by the city, village, township or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Sincerely, e erard Swim Plan Reviewer Section of Private Sewage (608) 785-9348 3686R/ 1 $HD-6483 M. 01/91) 1I ~ , . z 3 ~ 31 ''I as 504-40283 F - Lin.1oa.u T6p la ~U.~. l f e _ _ l= ql.D Grd kel Eleo 4jiJ ?2.5 Rem A014 aFt D ~ ~ ~ ~lDD ra CDR ~°~~~-~;::a►~i ,f DtVt ON DF SAF g3 O e E N , ,,1ti N {i R 1 ~ n as ~ -4 m ootSmat-i CA: ~2ECgs t' a Propas~-a ~ eea tZes~ , { vn 1 b o RECEIVED I L~eoae~ logo ~.I Se f~ 6- n, V.=. Wy MAY - 4 1994 .c tyt~csc P"EcAAs-C SAFETY i SLOGS. DIV.' t i page - Slrow, Marsh Nay, 0r S9 4-40283 Synthetic Covering Distribution pipe Mfidlum S4rid Topsoil - --J i F D ~l Slope Bed Of 2 ? Force Main Plowed Aggregate Frorn Pump Loyer D 1.0 - Cross Section Of A Mound' System Using E 1/ i•Z~f I A Bed For The Absorption Area F -_,'7 S G D Signed: • A ---g Ft. H --~r - - B y -7 Ft. License NuulDer: Ft. 1594 Date : d Ft. K 0 Ft. /rtc~ ~~::t`e Position L Ft. Force Main W Ft.32~ - L - - ~y Observation Pipe--,,,,, III A I, _ o I FDAce i tin Prom ~uMP Dis;ribulion " . Dad of 'z - 2 2 Pipe . SYSTEM Aggregate Observation Pipe M, II Permanent Markers e Y JIF ~ Plan ViewP~f T~' .~8 U`~AN . PEs.a3tON8 V $The Absorplion Area 6L4 SEE CC S N ENCE i Of Page . 894 0 4028 3 Perforated Pipe Detall I n End View Perforated End Cop PVC Pipe -11 duo Motes Located On Bottom. s. Are Equally Spored A PVC Force Main Q Distribution Pipe ' Lost Mote Should Be Nest To End Cop Distribution Pipe Layout P Ft. R_0 S _3 X Re Inches Y 3_ Inches )c , Hole Diameter Inch At, 4 Signed: Lateral ~YL Inch(es) License Nwllber: Manifold " 7L Inches JIF ;Plot Date: r Y. Force Main " 2. Inches # of holes/pipe A.~ _ Invert Elevation of Laterals ~.75 Ft. Y Of INDUSTRY. LABOR HLIl qi q`°-°A3i0NS DEPT. OF S FETY BUI4•'' DIVI ON PC7i`i~S~a i~:' S E PAGE OF ' PUMP CHAMBER CROSS SECTION ARID SPECIFICATIONS S94-40283 VC WT CAP C.I. VENT PIPE WEATHER PROOF APPROVED LOCKIW lr1ANHOLE COVER W JUIJCTIOW OOX Ltlorrl~It+~ ;,clbrl 25' FROM DOOR, It•MIIJ. INDOW OR FRESH Ift INTAKE I GRADE G i M" MIN. was= IB'MIU. COWDUIT-- 18"MIIJ. \ ~ INLET r gN!5e AIRTIGHT srAL p~~' JOINT A 5; ( III APPROVED JOIIJTS 1PPROVED ~,ond~ ~ ~w ~ ( I I ~ w/C.t. PIPE :XTEWXTENOIN G ►IPE 3' I I I ALARM EXTEU01NG 3' I I ( ONTO SOLID SOIL NJTO SOLID SOIL'' r ."s1(1IS I I ~y cl`u , I I oN C 0¢ 1ti ;SAO spF ;xv :LEV. FT. UMP1 Off D SEE , CONCRETE BLOCK 49 a i 3" APPROV Zub" "p KISfR EXIT PERMITfEO Ly IF TANK MANUFACTURE-It HAS SUCH APPROVAL. $6DpINf~ SPEGIFICATIOWS SEPTIC E AV DOSE Ii ~S HUMBER OF DOSES: PER OAy TANKS MANUFACTURER: TANK 51ZE; 2,50 GALLOWS DOSE VOLUME 74 A INCLUDING OACKfLOW: - GALLONS AL_ AtIM MAIJUFACTUiICR: MODEL WUMBE10 CAPACITIES: A=14- IUCHE5 OR 3` N GALLONS L 6 = d INCHES OR ~ 3_+L_ GALLONS SWITCH TYPE: J 1a"i C s__-INCHES OR GALLONS PUMP MANUFACTURER: -7 p~ D =1~ INCHES OR ' GALLONS MODEL NUMBER: SWITCH TYPE: e1 ePr MOTE: PUMP AND ALARM ARE TO BE INSTALLED ON SEPARATE CIRCUITS MIIJIMUM DISCHARGE RATE 6PM d, -0 FEET VERTICAL DIFFEREUCE BETWEEN PUMP OFF ANO DISTRIBUTION PIPE.. ♦ MINIMUM WETWORK SUPPI.`! PPKEESSURE✓.. . . . 2 5 FCET + 2'FEET OF FORCE MAIN X &LFYOrtFRICTIOAI FACTOR. .~•vJ-- FEET TOTAL DyWAMIC HEAD = FEET INTERWAL DI STOWS OF TANK: LEWCaTH :WIDTH ;LIQUID DEPTH DATE: SIGAIED: LICENSE NUh DER: f DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS r115 P.O. BOX 7969 HUMAN RELATIONS MADISON WI 53707 (ILHR 83.0911) & Chapter 1451 S-g</- yoaP3 LOCATION: SE TION: TOWNS UNI IPALITY; LOT NO.: BLK. NO.: SUBDIVISION NAME: ~ 1/4 3bJ~ Xt N/R E (or ~~M ` MAILING ADDRESS: C NTY• , Cacti 114 ~ e, USE 115ATES OBSERVATIONS MADE I~rs~ NO. BEDR :COMMERCIAL DESCRIPTION: PR IPERCOLATION TESTS: ~esidence New ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECO ENDED STEM:(optional) OS ®U ®S OU OS ®U losou Os 2t oat? If Percolation Tests are NOT required DESIJGN RATE: ` TT I If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevatio PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) r B 60 `r 3, d Ale b 4`lr" /3 6 l3~lk S" l J 36- SYe~IS'it s 6✓ B-~ fin ~ ~'G~1G?,~?~t'f~~° S• B- b d I I / t/ V J b r I - o? / Ls,; 10-36 B- B-3 . S o p w~'~e S f7 V (I 3 d r r e K 1 s z IF -yd S-; -~/f B- 11 o "IJA "Te S PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUM ER INCHES AFTER WELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 R PER INCH P- -3D 1/9- -ft P_ P- 30 ? P 3 3 "G ' G P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 9d, U Wild a It 7 Al le _ ._1 =cam F-1 J I i 1 i ..+1_ 3 0- 6, ' bet- 3 E `OC. a 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME rin TESTS WEE OMP TED ON: ~ Z 9~r ADDRESS: CERTIFI ION UMBER: PHONE NUMBER (optional): Q ~I vPr u &X. 5cln,0 6 99 CST SI URE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SOD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use suction must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS: 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soll Separates and Textures Other Symbols M - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Standstone gr - Gravel (under 3") LS - Limestone 's - Sand HGW - High Groundwater cs - Coarse Sand Perc - Precolation Rate med s - Medium Sand W - Well Is - Fine Sand Bldg - Building Is- Loamy Sand > - Greater Than 'sl - Loamy Sand 'c - Less Than '1 - Loam Bn - Brown 'sit - Silt Loam BI - Black si - Slit Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silty Clay fff - few, fine, faint 'c - Clay cc - common, coarse pt - Peat mm - Many, Medium m - Muck d - distinct p - prominent HWL - High water level, surface water Six general soil textures BM - Bench Mark for liquid waste disposal VAP - Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. STC-105 SEPTIC TANK MAINTENANCE AGREEMENT Sett. Croix County OWNERBUYER Al L mo fge_ MAILING ADDRESS i 90e? ~l n c l~,'~In Trva ~ e PROPERTY ADDRESS 9 ~o c>~_G /✓a i (location of septic system) Please obtain from the Planning Dept. CITY/STATE /Z ] V Y' /Ct 115 &)i 5 Y6,,2a C PROPERTY LOCATION Jr 1/4 5 U/ 1/4 Section T N-R W TOWN OF lh/inn,&znn,*L ST. CROIX COUNTY, WI Sb1M77V791QN L CERTIFIED SURVEY MAP , VOLUME , PAGE , 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. l~ SIGNED: lrz." I - A DATE: ZZ St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 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 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 _A4/~ /'a &It- Location of propert l/4 14V1/4i Section , T, N-R W Township k ~ t Mailing address Address of site 14 1&I 15 4/r Subdivision name Lot no.- other homes on property? k yes `No Previous owner of property 6ce h 5e c Total size of parcel -O C1~ k' S Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No Volume and Page Number k<1 as recorded. with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. 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.'~ , 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 recor~ed i the office of County Register of deeds as Document No. _ A. Sig ture of ap¢licant Co-applicant r Date of signature Date of Signature DOCUMENT NO. I STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA 516789 I WARRANTY DEED VOL 1078PAGE604 # _F This Deed, made between Gregory A . Bisel and Roxanne D. Bisel, husband and wife Cec`s~rr>rF:~v;rf7 MAY 19 1994 Grantor, and. -_ICa-t-hr_yn_-A-,_- LamQ-the.,_ a single person xt ' 8:45 A ~'°I srol~zn3 Grantee, Witnesseth That the said Grantor, for a valuable considerationQne do-ilar...and.-o_t~er___good_•and valuable consi r der oix atio conveys to Grantee the following described real estate >n St C . RETURN TO County, State of Wisconsin: Tax Parcel No : Southeast Quarter of the Southwest Quarter (SE4 of SW4), Section Nine (9), Township Twenty-Eight (28), Range Eighteen (18) West. j I I j This 1-s.- no thomestead property. 34Q,-4 (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And..gr3ntOrS warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions, reservations and covenants, if any, of record, and highway rights of way and will warrant and defend the sAme. Dated this / da of MaY 94 19......... 7 -(SEAL) ................................••--.••--•...(SEAL) G.e r A. : sel w . EA (SEAL) * Roxanne D. Bisel ACKNOWLEDGMENT A Bisel and STATE OF WISCONSIN Signature,.(s) __Gregor.......................................... Roxaxine D. Bisel ss. [17 C ~ ~ County. authentic ted s 1. f. 19.9 4 Personally came before me this .day of MaY , 19........ the above named w Edward F. Vlack Gregnry._A....his_el...and..8nxznne.-_D....... Bis .l 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 Edward F. Vlack DAVISON & VLACK w 200 East Eln Street fiver---Fa11.s,...WI..... 5.4C.22............................ 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. F ~ 3•~Z FL 0 X50 0 I 9.g 1 7_ as , 7~ rn c~ S~4C,c Z9 0 3p J. V J-f y 38 7 J Gru ,N ~