HomeMy WebLinkAbout030-1051-80-000
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STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS
SUBDIVISION / CSM# LOT
SECTION-_j _T . ~N-RW, Town of
ST. CROIX COUNTY, WISCONSIN
LAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
musE
b,
-sc z
INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form-
Provide 2 dimensions to center of septic tank manhole cover.
BENCHMARK:
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Lv4t_-~ Liquid Capacity -
Setback from: Well_ ~ ` House s Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
.J / SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: House Other
ELEVATIONS
) sr
Building Sewer ST Inlet; ST outlet PC inlet PC bottom 9G,~ Pump Off
Header/Manifold Bottom of system
Existing Grade Final grade
DATE OF INSTALLATION: - -
PLUMBER ON JOB:
LICENSE NUMBER: yJ,
INSPECTOR:
3/93:jt
Wisconsin v, PRIVATE SEWAGE SYSTEM County:ST. CROIX
department of Industry,
Labor and Human Relations INSPECTION REPORT
Safety and Buildings Division Sanitary Permit No.:
(ATTACH TO PERMIT)
GENERAL INFORMATION ] 5~
g~ ❑ City ❑ village Town of: State Plan 0
G Permit HQ s~'1'4 , I&RALD M. R
AKtCI X Parcel Tax No.:
CST BM Elev.: Insp. BM Elev.: BM Description:
0136
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Benchmark
Septic
Dosing
Bldg. Sewer
Aeration
St/ Ht Inlet
Holding
TANK SETBACK INFORMATION St/ Ht outlet
vent to AD Dt Inlet
FTANK TO P / L WELL BLDG- Air Intake RO
NA Dt Bottom
Septic
NA Header/Man.
Dosing
Aeration
M11 T1 NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
L Fie
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM No. Of Pits Inside Dia. Liquid Depth
BED /TRENCH Width Length No. Of Trenches PIT
DIMEN I N DIMEN I NS Manufacturer:
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING
SETBACK CHAMBER Model Number:
INFORMATION TypeO OR UNIT
System:
DISTRIBUTION SYSTEM x Hole Size x Hole Spacing vent To Air Intake
Header /Manifold Distribution Pipe(s)
Length Dia- Length Dia. Sparing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
xx Depth Of xx Seeded/ Sodded xx Mulched
Depth Over Depth Over ❑ Yes ❑ No ❑ Yes ❑ No
Bed /Trench Edges Topsoil
Bed /Trench Center
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: St. Joseph-23.30.19W, SW, SE, 140th Avenue
Plan revision required? ❑ Yes ❑ No
Use other side for additional information. Inspector's Signature cart No
SBD-6710 (R 05/91) Date
SANITARY PERMIT APPLICATION COON
~LHR In accord with ILHR 83.05, Wis. Adm. Code
STATE SANIT RaPERMIT #
only) for the system, on paper not less than ~1 005 0,
-Attach complete plans (to the county copy y) ❑ Check if revision to previous application
81h x 11 inches in size. application. STATE PLAN I.D. NUMBER
-See reverse side for instructions for completing this '
I, APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
DRTY LOCATION
PROPERTY OWNER R - tT , N, R (or
LOT # BLOCK #
PROPERTY OWNER'S MAI NG RESS
ZIP CODE PHONENUMBE SUBDIVISION NAME OR CSM NUMBER
R
CI , STAT
NEAREST ROAD,/ -
CITY AGE
VI LL
11. TYPE OF BUILDING: (Check one ❑ State Owned NUMBER(b)
❑ Public ~ 1 or 2 Fam. Dwelling-# of bedrooms
III. BUILDING USE: (If building type is public, check all that apply)
1 ❑ Apt/Condo 10 ❑ Outdoor Recreational Facility
2 El Assembly Hall 6 11 Medical Facility/Nursing Home 11 El Restaurant/Bar/Dining
3 El Campground 7 El Merchandise: Sales/Repairs 12 ❑ Service Station/Car Wash
4 ❑ Church/School 8 El Mobile Home Park 13 ❑ Other: Specify
5 ❑ Hotel/Motel 9 ❑ Office/Factory
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
2. iny Replacement 3. 11 Replacement of 4. ❑ Reconnection of 5. El Repair of an
rN7
A) 1 ❑ New Existing System Existing System
System System Tank Only
Date Issued
B) ❑ A Sanitary Permit was previously issued. Permit #
V. TYPE OF SYSTEM: (Check only one) Other
Non-Pressurized Distribution Pressurized Distribution Experimental
21 ❑ Mound 30 ❑ Specify Type 41 42 LA Pit Holding Tank
12 ❑Seepage Trench Privy
13 11 ❑ El Seepage seepage Bed 22 ❑ in-Ground 43 ❑ Vault Privy
Pit Pressure
14 ❑ System-In-Fill
ELEVATION GRADE
VI. ABSORPTION SYSTEM INFORMATION: PERC. RATE
1. GALLONS PER DAY 6. SYSTEM ELEV. 7. FINAL
2. ABSORP. AREA 3. ABSORP. AREA 4. ADIN ft 5' (Min./inch)
REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. Feet Feet
Site Fiber- Exper.
VII. TANK in allons CAPACITY Total # of Prefab. Con- Steel glass Plastic App-
New INFORMATION ans Tanks Gallons Tanks Manufacturer's Name oncret structed
Se tic Tank or Holdin Tank
Lift Pum Tank/Si hon Chamber
Vlll. RESPONSIBILITY STATEMENT attached plans.
Plum er' Name ersigned, rin Plumber's g ur assume responsibility for installation f the onsite se 9 system show the e No.: Business Phone Number:
t • ( ) MP n on on th ~
I, the u
t
r.~
Plumber's dress treat, City, Stat ,Zip Code): ~
~ J I g Agent Signatu (No S ps
IX. COUNTY DEPARTMENT U ONLY urge Fee)
❑ Disapproved Sa Permit Fee (Includes Groundwater a e s~
Approved F1 Owner Given Initial W ~-6t) r
Adverse De ermin lion .
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. Ybu'r sanitary permit may be renewed before the expiration date, and at the time c' rer,ew.:l
criteria in the Wisconsin Administrative Cade will be applicable_ any new
3. All rev;siol's to this pear;' must be approved by the permit i,,;vi authority.
4. Changes i,i ownership or plumber require=s a Sanitary Perri ' ~ Insfer/Reilt' . ,
submitted to he county prior to installation. ` ~ r v r r ~ , f,~=-ct to be
5. Onsite se} v"=.terns must be prope►'
rfaintain<id. The
tankt0 ,
pumper vv re,;ever neces~ ,ry, usually every 2 to 3 years.
6. If you havN questions co c^erning your onsite sewage system., cc,,tact our
State of Wisconsin, Safety & Buildings Division, 608-266-3815, y ca( oce j"'"i 4i, afar or the
To be complete and accurate this sanitary permit application must include:
1. Property owner's nao-le and mailing address. Provide the legal description an(; parcel t6 .x r (s) the sy_,ierri is to be installed, e (s) of
II. Type of build ;q t,eing served. Check only one and complete # of bedrooms i . or 2 Fanr i~ i, , ~z
IEing.
III. Building use It building type is Public, check all appropriate boxes that apply
IV. Type ,
of per"rr+r .Check only one in line A. Complete line B if permit is for tank replacement, c:,;nnection, 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 twik., list the total aI{o-~s~
tanks and manufacturer's name. Indicate prefab or site constructed and 9 r :?.bar` of
septic, purnp/siphon and holding tanks for this system. Check experime tall a prov al. ly'ifatar for all
experimental product approval from DILHR. Proval or,l;v f tdr Fs receei
ved
VIII. Responsibility statement. Installing plumber is to fill in name, license number with a
MP, etc.), address and phone number. Plumber must sign application form. pprupri<te prefix (e.g.
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; replani=rnf nt system
areas; and the location of the building served; 3) horizontal and vertical elevation, refere.ice pr_J11f;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction less; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption ystem 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 monles collected througr, 'hese s 3rcharge.s . a ed t r ~ ~:r;
e ;g or . ~c .r;,
water contarnInation lnve s;i9at f v1 yro andWatQr; C3r~Lln{'-
~r~s arrtf-establishrr~~_~,t of parr,;ar►'.~;
SBD-6398 (R.11/88)
SAFETY & BUILDINGS DIVISION
State of Wisconsin
Department of Industry, Labor and Human Relations
2226 Rose Street
May 18, 1994 La Crosse WI 54603
KO CONSTRUCTION
RR 1 BOX 105
STAR PRAIRIE WI 54026
FEE RECEIVED: 60.00
RE: PLAN 594-40332
GARRITY, GERALD
SW,SE,23,30,19W COUNTY OF ST CROIX
TOWN OF ST JOSEPH
HOLDING TANK
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 rapproRal of the system isinased 83 and 84, Wisc
on chapter 145, Wisconsin Statutes, and Administrative Code, and is lhasnnotpbeenoIDeviewed forhtheycodepulations
shown on the plans. This system
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,
l~ •
card Swim
Plan Reviewer
Section of Private Sewage
(608) 785-9348
3834R/ 1
SBD-6423 (R. 01/81)
E SYSTEM Safety and Buildings Division Wisconsin Department of Industry, PRIVATE SEWAGE Bureau of Building Water Systems
APPLICATION Labor and Human Relations REVIEW Waukesha Office
Madison office 1053A EShawano Office Hayward office La Crosse Office Wauke ~Bit
2226 Rose Street 201 E. Washington Ave. E. Green Bay Street 401 Pilot court, suite 209 W 1 st Street P.O. Box 7969 P.O. Box 434 94 Pho4#4 - !0
Rt 8, Box 8072 La Crosse, WI 54603 Madison, WI 53707 Shawano, WI 5616J grax 4 614 Hayward, WI 54843 Phone (608) 785-9334 phone (608) 267-5119 Phone (715) 52
6
Fax (608) 785 9330 08) 267-0592 Fax (7 t 5) 524 33 715) 634-4804 Fax (6 Phone (
Fax (715) 634-5150 licable data and submit this
schedule rior to the appointment at the office INSTRUCTIONS: To save time lans/ nforymation review Your submittal must fbereceived at above leasr one working day p II
in a app the where your review was scheduled. Please call any of the listed
for m together with fees and p you nee hel on therevepselsidefor youroeferencevequestions onwhat information to
submit. PLEASE PRINT VERY CLEARLY. A sample of a completed time: save
umber 1. APPOINTMENT INFORMATION -if ouRehave vie scheduled er Name an a pointment, fill in the information Planrequested below toIdentification Number
Apptimtment Date
2. PROJECT INFORMATION plan this review is a revision or extension to your identification number, provide that number here: ME
❑ City ❑ Village. rM Town Of: County
Project Name
Project Location '
GOVT. LOT 1/4_~ J 114 S T N .R C or
3. APPLICATION FOR 4. FEE COMPUTATIONS FEE SUBMITTED
System Type (check one): System Type I (include new and existing tanks) Up To 1,500 gallon septic tank . • • • • • • • • , , . . . . . $110.00 . $120.00 -
A ❑ At-Grade 1,501 - 2,500 gallon septic tank • • . • • • • $160.00
H ® Holding Tank 2,501 - 5,000 gallon septic tank • . • • • . • • $ 200.00 -
5,001 - 9,000 gallon septic tank $300.00 M Mound 9,001 •15,000 gallon septic tank
$500.00 • , • • • N El Non Pressurized In-Ground (conventional) Over 15,000 gallon septic tank .
p ❑ Pressurized in-Ground S 70.00 . • • • • • -
Up To 1,000 gallon dose chamber $ 80.00 O ❑ Other: 1,001- 2,000 gallon dose chamber • . • • • • • ' ' ' • • •
2,001- 4,000 gallon dose chamber $100.00 •
Building Type (check one): 4,001 - 8,000 gallon dose chamber • • . • • . . . . . . . . . . S120.00 . 40.00 . . . . . . . . ~t,s $ 160.00 • • • • •
D ® Dwelling, 1 or 2 Family 8,001 -12,000 gallon dose ch $1 Over 12,000 gallon dose cha Y ..00
P ❑ Public Building S 60.00 •
Up To 5,000 gallon holcliNA~k 1_6 * • S ❑ State-Owned Building • • • • , 100.00 $ 5.001 -10,000 gallon holding tank / / 94
tank $150.00
Code Derived Daily Flow gpd Over 10,000 gallon rGSe fqy . Experimental System (additional 08 $300.00 ; :
Check If Replacing Existing System Revisions To Approved Plan • • • • • • • • • • • • • • $ 60.
$100.00
Petition For Variance: Setback v Site Evaluation $225.00
Plumbing $225.00 Petition For Variance ❑
Revision . • . , • $ 75.00 . . . . . . . .
$ 60.00 Groundwater Monitoring - Per Site • • • • • • ,
❑ Groundwater monitoring (other than a proposed subdivision)
Site Evaluation in Lieu of Groundwater Monitoring $ 60.0 • • • • • Site Evaluation in Lieu of Groundwater Monitoring
Subtotal:
Priority Review: Enter same amount as Subtotal:
Total Fee:
MAKE ALL CHECKS PAYABLE TO: SAFETY AND BUILDINGS DIVISION
Co to Pers ~
5. SUBMITTING PARTY INFORMATION 1: 1 _11117 Telephone No. (include area code & extension) Comppny Na e
( ) - 7 ~ /S
No. Street Address Or P.O. Box City, Town or Vi lage, State, Zip e
approvic t nks and dose chambers. existing size 1 Aerobic or prepackaged treatment system fees are calculated as extened equivalen
J Revision fees are not applicable to temporary holding tanks or
NOTE: Fees are pursuant to Wis. Adm. Code, Chapter ILHR 2, and are subject to change annually. OVER ~ SBD-6748 (R. 03/93)
15
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nvLUINU i ANK AGREEMENT
,gre•mant to This agreement Is made between the. ;aunty or Local Governmental Unit - - - - - - - S94-40332,
lding Tank(s) Owner(s)
I
Called Munlcl a1J below
No acknowledge that application Is being made for the Installation of (a) hold) g
.ank(s) on the following property, (Provide legal land description:)
/ Return To
sny othert type operty for t se purpose of pr aser contain under or that continued use of the existing premises requires that t municipal holdl e tank be Installed
sewage. Also, the property cannot now be served by pa
Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Slats.
As an Inducement to the County of to Issue a sanitary permit for the above described property,
we agree to the following:
1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner falls to have the
holding tank properly serviced In response to orders Issued by the municipality to prevent or abate a nuisance as described In ss. 146.13 and
148.14. Slats, the municipality may enter upon the properly and service the lank or cause to have the lank serviced and charge the owner by placing the charges on the tax bill as
a special assessment for current services rendered. The charges will be assessed as prescribed by
s. 66.60. Slats.
2. Owner agrees to pay all charges and costs Incurred by the municipality for Inspection, pumping, hauling or otherwise servicing and maintaining the holding tank in such a manner
as to prevent or abate any nuisance or health hazard caused by the holding lank. The municipality shall polity
the owner of any costs which shall be paid by the owner within thirty (30) days from the dale of notice. In the event the owner does not pay the
costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the lax roll as a special assess- ment for the abatement of a nuisance,
and the tax shall be collected as provided by law.
3. The owner, excet as provied by s. 14.20 ,
have he hold nglank serviced and to file a(30)copy(d)of htelcontract orl he owners registration with the, municipality and with lthe county. The owner have further agrees to file
a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within
ten (10) business days from the dale of change to the service contract.
4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a
report In accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under
s. 146.20 (3) (d), Slats., the owner shall submit the report to the municipality and the county. on of 5. This agreement lby erither effect a municipalllseweroo as soil
absorption system that complies wl huCh. (ILHR 83, at Adm. Code. In addition, this
the property Is served
agreement may be cancelled by executing and recording said certification with reference to this agreement In such manner which will permit
the existence of the certification to be determined by reference to the property. the helrs of the owner all gre 8 the This
owner.
register gnof deada lanbe binding upon the d the agreement shall beyrecorded by the register of deeds In a manner which will permit the existenclelof the agreement to be determined
by reference to the property where the holding tank Is Installed.
Ownsr(s) Name(s) (Print) IOwner(*) Signature(s)
Subscribed and ]sworn to belore me on this date:
ary Public
Municipal Official Name (Print) I M Official Signature
My commission expires-.
Municipal Official Title (Print)
SBD-6123 (R. 10165) This 1 lrumenl was drafted b Slate of Wisconsln Department 1 Industry, Labor and Human Relations, Bureau of Plumbing.
HOLDING TANK SERVICING CONTRACT
Co ract Date S 9 4 o `fit03'
r
- - - This contract is made between the- _ - - r - -
riolding Tank Owner(s) Name(s) and i Pumper's Name/ 1QS /n M m-i
l~ G p r r I IUPt~ RICA ►'►'tio (jJ- sw l
We acknowledge the Installation of (a) holding tank(s) on the following property: (Provide legal description:)
Sc vY 5 Ey e . 03 % P 0, Goi ~ CL
y
1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which has
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
with the County of
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to
enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access
road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay
the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner ar)4pumper.
3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis.
Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees
to Include the following In the semiannual 'report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding lank;
c. The location of the property on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volumes In gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract,
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality
and the County named above within ten (10) business days from the date of change to this service contract.
Owner(s) Name(s) (Print) i Owner's Signature(s)
I
ff ~r L y)~ Subscribed and sworn to before me on this date:
~C~.~~.tl r'trC1.0.e Grr1~l I ~l e/
v
i d / _
I "?ovary ublic
Pumpers Name (Print I Pumper's Signature
Powers 4iQ(4 i (jaS* I rn-tr4e I My commission expires:
Pumper's Registration Number
;itf-/0
SBD-7574 IN. 11/85) This Instrument was drafted by the State of Wisconsin Department
of Industry, Labor and Human Relations, Bureau of Plumbing.
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Yo! 1U f 9PAGE 294
This space res+fved for recording data
umentNo. HOLDING TANK AGREEMENT
CL: k 4 i ~.J.~ ~l : / 1
greement to This agreement is made between the : {1 r £ t
07 _ _ _
j Hoiding Tank(sj 0wner((s) M AY 2 3 1994 ,
Governmental Unlt 1 -
unty or Local
JIG
Ca Ned Municl all below
application Is being made for the Installation ot.(a) hotel g
e acknowledge that _
ank(s) on the following property, (Provide legal land description:)
03 30 1(:,P
"Lo ke
Return To
of proper containment of
Ices requires that a holding, tank be installed on the property for the purpose sewage system as permitted under
or that continued use of the existing pram
sewage. Also, the property cannot now be served by, a municipal sewer, or any other type of private
Ch. tLHR 83, Wis. Adm. Code, or Ch. 145, Stab ^
to Issue a sanitary permit for the above described property.
As an Inducement to the County of
and
l oti abtate a niu g tanks. 1 the o nerlf ails to have
we agree to the following: o hold 1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code rela
holding tank properly serviced In response orders issued by the municipality to p and
or cause
rescribed by
ervice the tank
to h 146.14. Slats. the municipality may enter upon the ses event torscurrent services rendered The charges will be assessed septhe owner by
placing the the charges o on the tax bill as a special as
hauling or otherwise servicing and maintaining
a. 66.60. Slats.
2. Owner agrees to pay all charges and costs incurred by the municipality for Inspection, pumping,
holding tank in such a manner as to prevent or abate any nuisane or (30) days health from hazard the caused sed of by the notice. In holding the eto Tk. The o a spemunicipalitycal
shall assess-
the ent the roll owner
ment does not pay the
and rty
the owner of any costs which shall be pale by the owner within thi
the
ees that all
specif
owner
, the
ays
within thirty m3endol a nuisance and the1taxlshallrbe collected as pro ~ded by lawarges may be placed on
for the abate
ation who with Is the municilicensed he emuality r Ch.pNR 113, and Withe county s. Adm. Code o
r's with a registrperson
3. The o municipality and with t county. The owner
or to the ownecontract
caner, except as provided by s. 146.20 (30) (d), Slats.,nagrees
contract or a copy of a new service contract wit
cserviced opy oof and to
nges to the of se the contract
have the holding tank
chafile
further agrees to file a copy any
ten (10) business days from the date of change to the service contract.
4. The owner egress to contract with a person licensed under Ch. NR 113, WIS. Adm. Code who shall submit to the municipality and to the county a
semiannual basis. In the case of registration under
report in accord with s. ILHR 83.18 (4) (n) 2., o. Adm. Code for the servicing on a se
s. 146.20 (3) (d), Slats., the owner shall submit the report to the municipality and the county.
manner certifies the
5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage
the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, WIS. Adm. Code. whtch will permt
agreement may be cancelled by be determined by reference to the p8operry with reference to this agreement in
the existence of the certification to agreement to
6. This agreement shall be binding upon the ownee, the recorded heirs by of the the owner register of and deeds In a assignees of the manner owner. which will The permit r the shall
existesubmitnce t of the the agreement
be
the register of deeds and the agreement shall
to be determined by reference to the property where the holding tank Is Installed.
Owner(s) Signature(s)
Owner(s) Name(s) (Print) Subscribed and sworn to before me on this de e:
ary Public
M Otllclal signature
Munlcipal Official Name (Print) My commission expires'.
a5 I 3--_ I c _ _ 7
Munlcipal Official Title (Print)
SBO Human Relations, Bureau of Plumbing.
55 4 rrL I yt
bt29 (R. 10185) This 1 lrumenl was dratted b Slate of Wisconsin Department 1 Industry, Labor and
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 /y~
Location of property 1/4 x_1/4, Section"-' ~ N-RW
Township ailin address
Address of site
Lot no.
Subdivision name -
Yes No
Other homes on property?
Previous owner of property
i
Total size of property
Total size of parcel
Date parcel was created
_Yes No
Are all corners and lot lines identifiable?
Is this property being developed for (spec house)? Yes No
Volume ZZS_ and'Page Number_ as recorded with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGEE
NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition,
certified survey, if available, would be helpful so as to avoid
If the deed description
delays of the reviewing process.
references to a Certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION the I (we) certify that all statements on this form are true of the
best of my (our) knowledge that I (we) am (are) the owner( s)
property described in this information form, by virtue of a
warranty deed recorded in the office o the that County Register of
presently , and Deeds as Document No. ~ ~.Ze
own the proposed site for the sewage disposal system or for(th)
obtained an easement, to run the above described property,
construction of said system, and the a of has Deeds as been dulyocu odedNin
the office of the County Register o
Co-Applicant
Signa ure f Applicant
Date -of Signature Date of Signature
STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE .RESERVED FOR RECORDING DATA
-DOCUMENT NO.
WARRANTY DEED
V~OL 668 FAOE Liz) REG!cV'T_Fn,S OFFICE
dT tween...... Martin T. Garrity S3. r?•,
anl~d ? d'Garaaeri by, usaind ancT wife, as"_.•........ Rec'd . 5th
3o1nt ---enants,
• day c;__ July -A. D. 1983
' Grantor,
and. --•--Gerald-- M.._.Garrity......-•----••----._...--••- at 8:30 A M.
RegIs1w of beds
I Grantee,
Witnesseth, That the said Grantor, for a valuable consideration......
RETURN TO
conveys to Grantee the following described real estate in .."St".--.CrOix
County, State of Wisconsin:
A parcel of land located in the Southwest
quarter of the Southeast quarter (SW4 of SE4) Tax Parcel No-
of Section Twenty-three (23), Township Thirty
(30) North, Range Nineteen (19) West, and the FEF1
Northwest quarter of the Northeast quarter (NW4 of
NE4) of Section Twenty-six (26), Township Thirty (30)
North, Range Nineteen (19) West, described as follows: EXL14 1PT
Commencing at the Northeast corner of the Northwest quarter of
the Northeast quarter (NW4 of NE4) of Section Twenty-six (26),
Township Thirty (30) North, Range Nineteen (19) West; thence
West 1024 feet and North 10 feet to the point of beginning; thence
North 68004' West a distance of 226.2 feet to a stake on the shore
of Bass Lake which is 95 feet directly North of an iron stake
showing high water mark located on the North line of said Northwest
quarter of Northeast quarter (NW4 of NE4); thence South a distance of
71 feet to a stake on the shore of Bass Lake; thence South 68004'East
a distance of 181.2 feet to an iron pipe stake; thence North 43020'
East a distance of 60.7 feet to an iron pipe stake; thence North 10
feet to the place of beginning, together with an easement for an access
road from the above parcel to the town road as now opened and travelled.
This is a gift from parent to child for no consideration.
This i8..n-Qt........... homestead property.
(is) (is not)
Together with all and singular the hereditaments and appurtenances thereunto belonging;
And warrants that the title is good, indefeasible in fee simple and free and cle: r of encumbrances except
and will warrant and defend the same.
Dated this 3~_th.._.•-•----•--------"--r'- day of :T_LIriC..-- 19_.8.3
r
G~ (SEAL)
(SEAL)
Mary T. Garrity
Martin F. Garrity
(SEAL)
...............•(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature (s) of Martin F. Garri..... STATE OF WISCONSIN
ss.
and__ Mary.. T-=--.Garr] ty. 30th county.
authenticated this _.__....day of.__.__.__._JU1Z 19__x3 Personally came before me this
of
----•---•-----------------•-----••-•------119 the above named
G. E. Norman
* G - N
TITLE: MEMBER STATE BAR OF WISCONSIN
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
AQA,R-1...D ILL..&.SX0.W,---S..._.C....---"-"
New Richmond, WI 54017
- - Notary Public County, Wis.
My
(Signatures may be authenticated or acknowledged. Both 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.
STATE LIAR or wISCONSIN Wisconsin Legal Blank Co. Inc.
WARRANTY DEED -
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