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HomeMy WebLinkAbout030-1056-90-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ADDRESS ~p 7~ S T SUBDIVISION / CSM LOT # .3 SECTION_g2 -3 N-RW, flown of ST. CROIX COUNTY, WISCONSIN PLAN VIEW L A ~c-°O' EVERYTHING WITHIN 100 FEET OF SYST M 1 4XI4 r 0 E ~ 5 I ' ~ kl d E 0141 M~ +'4~Vs INDICATE N RTH ARROW 100, ,36F 7 1-7- Provide setback and elevation information on reverse of this form. Provide 2. dimensions to center of septic tangy: manhole cover. a BENCHMARK: elZ CY-~f~SrAa4- ICJ G~ ALTERNATE BM: ~Q 9 Z SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer:MQWI~ST~it~►,1/ F~i4sr/~~ Liquiq Capacity: /.200 Setback from: Well House !Other Pump: Manufacturer I=- Model# Size Float seperation Gallons/cycle: Alarm Location 1 SOIL ABSORPTION SY TEM Width: Length ` Number of drenches i Distance & Direction to !neres prop: line: Setback from: well :3rHouse J/,) ijOther nf I i ELEVATIONS Building Sewer j l~, 410c ST Inlet!. ' ST outlet PC inlet PC k otiom Pump Off Header/Manifold Bottom of system y~. Existing Grade /Q Final grade DATE OF INSTALLATION: Z2 - -7- `y t PLUMBER ON JOB: LICENSE NUMBER: 1271, INSPECTOR:_ Al 3/93:jt - - - Vyisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor-and HymanRelations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State Plan WO DOVE, TIMOTHY & JUDITH x r" Q2 ZQRRPH 1101,56-90-000 CST BM Elev.: Insp. BM Elev.: Description: Parcel Tax o.: BM TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic r % /a 6 a Benchmark Dosing Aeration Bldg. Sewer 7 a~ I? q, (b [Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet g 3 f Vent TANK TO P / L WELL BLDG. Air Ito ntake ROAD Dt Inlet Air Septic >C ~ m° c a q, NA Dt Bottom Dosing NA Header / Man. q 7 a- Aeration NA Dist. Pipe 6t.36 9706 Holding Bot. System C/.~y (o PUMP/ SIPHON INFORMATION Final Grade y 3 (0~ , ~g Manufacturer Demand Lt ^q< t j p )L- qq. c/ all'i Lt, Model Number GPM TDH Lift Friction System TDH Ft Loss H Forcemain Length Did. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length Q No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ` DIMENSIONS ~ SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O "0 CHAMBER Model Number: II' System: 415 OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pip x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length 71 Dia. q Spacing (o I SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over + rr xx Depth Of xx Seeded/ Sodded xx Mulched No Bed / Trench Center Bed /Trench Edgesv Topsoil E] Yes ❑ No E] Yes E] COMMENTS: (Include code discrepancies, persons present, etc.) q S~ L ~ LOCATION: ST. JOSEPH 23. Q. 19.200D,NE,NE,LOT 3,78TH, STREET / I'P F , ~y:f{ - ilk cot_,_ Plan revision required? Yes ❑ No 07 Use other side for additional information. Id (p a SBD-6710(R 05/91) ate 1 p Cto sSignature Cert No. J i ADDITIONAL COMMENTS AND SKETCH , SANITARY PERMIT NUMBER: I'I, SANITARY PERMIT APPLICATION coU In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than El 1 Xrevi 8% x 11 inches in size. c eck if Fion(;t~o3previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP RTY OWNER PROPERTY OCATION 9j ~ ~ovc G'/14 "S23 T3 ,N,R 117 E(or W PROPERTY OW ER'S MAIL ~IJ`G ADDRESS LOT # ~ BLOCK # ZM -17 - arm S CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 7 ~ D 7 1 -0 II. TYPE OF BUILDING: Check one) CITY NEAREST ROAD ( State Owned 0 VILLAGE : -11 C, .ty s^ TOWN OF: _3 ❑ Public 5J 1 or 2 Fam. Dwelling-# of bedrooms ~ ARCEL TAX NUMBER(S) Ill. BUILDING USE: (If building type is public, check all that apply) 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. El Replacement 3. ❑Replacement of 4. El Reconnection of 5. ❑ 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) ELEVATION Feet Feet Sef' d . CAPACITY VII. TANK Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank ,ZOcJ 2c9c~ F] F-1 F1 1 EL F1 Lift Pump Tank/Si hon Chamber li VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumbe ' Sign re: (No Stamps P PRSW No.: Business Phone Number: Z3 240 Plu er's Address (Street, CIV, State, Zip C de . 2 s IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue ssuing Agent Signatu (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: Of v SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety 8 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 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 and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and Specifications not smaller than 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 gilding 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) IZVD Tt )z NJ N O O 03 a G y 44 - V ,o I ZOT d i rk, A L" 7R 14 ty , BEING LOT 3 OF ST. CROIX COUNTY CERTIFIED SURVEY MAP VOL. 1. PAGE 45. LOCATED IN A PART OF GOVT. LOT 4. SECTION 23 T.30N.sR.1DESCRIBED IN VOLUME 46Z ON PAGE PREVIOUSLY ' 699 PREPARED FOR MIL r *aAs mm LEGEND 3104 HARVEST L.A. ALBANY. oEOMA 31707 ~ GOVERNMENT CORNER (AS NOTED) PREPARED BY cmm covomnaN O FOUND IRON PIPE (AS NOTED) 604 SM MENOMOM4 MS 34751 0 SET, 3/4"X24' REBAR WEIGHING 1.502 L.B& PER LINEAL. FOOT. VZV PREVIOUSLY RECORDED AS • : WAAK • d-1a,p SCALE 1 " 100' KNOMONIE •••Q° 7 12'? 4?4- ~2. Wia. ~ O• foo v e f Sr~ 0' SO 100 X00 NdK on 43-•,*.1g 5271.40' Nair41'mrw N.E t7C11. FD. Q%fm YON. 1214.s 16 ~3b-13 LOT Z - CDM VOL 1, POL 45 ! 43.31' 19' ` SaeR7'ts'E wow AS I% r fat. M°' ra 4 LOT 3 28,750 SO. FT. - I 0.66 ACRE,.S QQI 44.32' i 1am l = i 727.x7' N89'27'18'W / o) LOT 4 - CBE! )LX. 1. P0. 48 I NOM M 1EiUM*; p Tp Im NORTH Ln OF 11E NONDFAR 1/4 OF !lCM 43 311 WOO is AMUM W iErMt NM 41'4WW PAZ 1w1 EAST PARTST. JOSEPH T 29-30N-R.19W. ai 15o rH SEE PAGE S HDU/e- bL~1'S N ~ ~ y~ rr~,~ /20 A ✓ .Pufh v,.n ya 5`~ l7 tS T0/! Tors G tl ~jY • d'i e/ 4 • /oa. y 90 • He/ene f7 - p'~ Ho. ~dc. cron - au r/s. (3a.s ' • Nav/e 4 tl r plva Inc. 4'. A -ZJcr~a i~ ri a 1. red- ~n 9R/GH If ✓ud ^11 T r, s rr- a,.v r,aR eo.~.~e lyL bhne Schm.tt°~' Strom S e. cTohn q /f~afh/een LS'choff/e/' 4° y d7 ./~10 ttke cSc oft/e/' M ry //B +v a .sB w eve.ae h 22825 3/6..8 6. z9 °h%:: os. i u s E$$d va/d .a _ S R ? o (U/2 van Dyk °j v R4 //a AS /ao ~ml~ z '57. 2 q 1 o Ciis~ 34/ b 0n y e w i7 74.9 190 N M egos E/;c(csmrf/; b~ K15 T / Dav d q W 2 LK ay y 4° /J 2ND .7 L 5 Jf///a. PE H L. = oo Q h Y rank n.. p ' • R caGack Y SAD. 243 ENCX P S RaE rv~f/f uF i}7d' 2B 1 (>O•d3 a 0 K r *e M K lE. \y_R 41 v M x /.r-.~ sM-1 ; Rr ,\p • c e 9 41 h "t. 'r2S.9G :y~: wf w T(fPC aienhf V' y^~ v /7)nleff'' '.SaEs9 Q nan c c.a. `e h/arq oi'ef r /X5.49 rexe 0~0o LaXynes•s A d aNo~ a !'h b e!y son, elu w /5503 //J w4f ~t~y John 9 FU ene g E/earrore ~ ur- g~ Gear /x . I ~ h /iss ~ Ray ~ p y E o Sc/ro/er c 0041 xr~•rcc~ Via) SKz 6'r .~iE/2/.C //S/o • ~N p N 40 39 nn • maid aSS I .QfMfi ~4~. ~iAr s ta% o sm:.: .,y FhY 0 e ;a E o 1 N Kenneth amen ,,,s - l P"Wwm jBa/'bara. t Naricy Dumin 'Yw . Mi/eS3 45 70/4 ttcw-'E 7 29285 c T W . i s va e-ie rT P t RY 20 y rneo- RoberrJ ~ir~ (t7 L,•••a ' AM L• 2 6M aE°x E Shir/e3r I { 1 .PiCJ/0/d s ~ q' TRn @ Ym ~.b eo • ,io OrF a0 W , Phi7iPp/ne • o r~. N • ' Beer • ~ J W.sLc»S~in,~ d".1 /99y c7me V L~o%/✓ah/~a/kL`sav /L PON ~r,/.:nrYad e Qi ~ t/unf/n9 C/ub. ~ WILLOW RIVER yp 3se 79 L,G. ames o TTATE PARo a, 9 d aaoa3 f/a/ o h ~ URK ° carsrvirw 7.9 RC o F~I LLS L. ce ua. _ of K• 2 f ~ 9i~/Q /60 Z~ft ~ e7a/ i ~ ©/99/ Roc o/d MoP Pub/s,I c. SEE PAGE 27 cSt C/o x Co s stir <✓/6. 500 600 700 800 900 b NEW RICHMOND PREPARE FOR THE Reinstra, Van Dyk GRANITE WORKS FUvRE & Needham, S.C. le~l MONUMENTS - MARKERS IN X GENERAL PRACTICE OF LAW BRONZE PLAQUES Y L. R. Reinstra - Hendrik W. Van Dyk 246-20 1 1 - I Scott R. Needham ® NORTH JUNCTION OF 201 SOUTH KNOWLES HIGHWAYS 64 & 65 NEW RICHMOND 246-6806 ® NEW RICHMOND, WISCONSIN Wisronsi- Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3 L.-A a44 r*jman Relations Division of Safety ri Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1i ize. Plan must include, but St. Croix not limited to vertical and horizontal reference of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and a to nearest roa 030-1056-90 APPLICANT INFORMATION-PLEAS NT RMA REVIEWED BY DATE PROPERTY OWNER: 4 OPERTY LOCATION M; 5 n 1 VT. LOT NE 1/4 NE 1/4,S 23 T 30 N,R 19 ) W Timothy & judif.1i Dove PROPERTY OWNERS MAKING ADDRESS ra ` OT # BLOCK # SUBD. NAME OR CSM # I-A 223 Crest Dr. 3 na csm a e 45 CITY, STATE ZIP CODE w, ER []CITY []VILLAGE MOWN NEAREST ROAD Houlton, WI. 540821-:'9=f6(' St. 150th. Av New Construction Use Residential / Number of bedrooms 4 [ ] Addition to existing building ] Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2 Absorption area required 858 bed, ft2 750 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2.8 trench, gpd/ft2 Recommended infiltration surface elevation(s) orig=96.52 alt=94.97 ft (as referred to site plan benchmark) Additional design /site considerations orig area 13x48 bed alt. 12x63 bed Parent material stream terrace Flood plain elevation, if applicable na It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem 56 13 U ❑ S 12 U 5S El U ®cS 13 U ❑ S 5 El S M SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Ou. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench l 1 0-8 7.5 r4/4 none scl 2fp1 mfr 2f np .2 2 8-22 7.5yr4/6 none is Osg mvfr gw na .7 .8 Ground 3 22-84 10 r4/4 none s Os mvfr na na .7 .8 elev. 9gqri It. Depth to limiting factor + Remarks: Boring # s~; { 1 0-11 10 r4 4 none 1 fill na crw 1f in Inp 2 11-17 10yr3/3 none sl 2msbk mfr gw if .5 .6 3 17-33 10yr5/4 none sil lfgr mfr gw na .2 .3 Ground elev. 4 33-84 7.5yr4/6 none co s Osg ml na na .7 .8 1OQ - it. Depth to limiting factor +8411 Remarks: CST Name:-Please Print Gary L. Steel Phone: 715-246-6200 Address: 1554 200t b. Ave., New f' chmond, WI. 54017 Signature: Date: CST Number: ref 5-5-94 cstm 2298 PROPERTY OWNER T. & J. Dove SOIL DESCRIPTION REPORT Pam c$ 3 PARCEL I.D. # 030-1056-90 Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed iTw&! 1 0-9 10yr4/4 none 1 2msbk mfr 2m .5 ..6 3 2 9-17 10yr4/4 none sicl lfsbk mfr gw if .2 .3 Ground 3 17-33 7.5yr4/4 none is Osg mvfr 9w na .7 .8 elev. i 109:$2ft. 33-94 7.5 r 4/6 none s Os ml na na .7 .8 Depth to limiting factor +9 " Remarks: Boring # 1 0-12 10yr3/3 none 1 fill material gw if np p 4 2 12-21 10yr3/3 none 1 2fpl mfr 9w if np .2 3 21-32 7.5yr4/4 none sil lfsbk mfr gw na .2 .3 Ground elev. 4 32-84 7.5yr4/6 none s Osg mvfr na na .7 .8 99.97 ft. Depth to limiting for Remarks: Boring # 1 0-6 10yr3/3 none 1 2msbk mfr gw if .5 .6 k> 5 2 6-17 10yr4/4 none sil lfsbk mfr gw if .2 .3 .5 .6 3 17-33 7.5yr4/4 none s1 2msbk mfr 9w na Ground elev. 4 33-84 7.5yr4/6 none S Osg ml na na .7 .8 99 , 02 ft. Depth to limiting factor - +84 " Remarks: Boring # i Ground elev. ft. f I Depth to limiting factor I Remarks: SBD-8330(R.05/92) STEEL'S SOIL SERVICE Gary L. Steel Timothy & Judith Dove 1554 200th Ave. CSTM2298 NE4NE4 S23-T30N-R19W New Richmond, WI 54017 MPRSW 3254 town of St. Joseph (715) 246-6200 N u0 E 1"=40' 7 BM.=top of neighbors well at el. 97.62 lPJt}'I q l02 alt. bm=tel.ped at el. 100' top + w 33 f j 67 I ~ 25r lb,! g8' 1 26- 1' $1-3 y-.t I~t v~ Gary L. Steel 5/5/94 STEEL'S SOIL SERVICE Gary L. Steel Timothy & Judith Dove 1554 200th Ave. CSTM2298 NEaNE4 S23-T30N-R19w New Richmond, Wl 54017 MPRSW 3254 town of St. Joseph (715) 246-6200 N 1)E, 1"=40' BM.=top of neighbors well at el. 97.62 ~m U 7~(oz alt. bm=tel.ped at el. 100' top I, ~I d ►v~ r2 16 T I~ 33- + 107 p % 2~r P-4 let f I 100 Gary L. Steel 5/5/94 STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER / ' MOny A-40 Jt4O i -A D V'c MAILING ADDRESS Nc?0 78 S7TLE'557-', Alfz J 4 t c H M o N O, Ct/Z' Sao , PROPERTY ADDRESS 9 ~g SST - (location of septic system) Please obtain from the Planning Dept. CITY/STATE egj el " Nil co6o 0 , kj-Z v5-(/O l 7 PROPERTY LOCATION A16 1/4 N6 1/4 Section Z-71 T ~J N-R 9 W TOWN OF 3 5iE7Q ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIEDSURVEY MAP , VOLUME , PAGE LOT NUMBER ~J 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. SIGNED:--7~_Zr~ DATE: l0 - -94 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11193 STC-100 This application form is to be completed in full and signed b 'the owner(s) of the property being. developed. .Any inad quacies will only result An delays of the pdrmit issuance. ,Should this development be intended for resale by owner/cohtractor,(spec house), thensa 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 /Mc7 /4qp Ju0J} ,4_ QoVG Location of property A16-114 Alc 1/4, Section 'T 30 N-R /9 W Township Mailing address q90 -78•T" S-p~7T N:-::z j A w n4c "0 A_a' 5 440 1 ~ Address of site SAA4 Subdivision name 9,541 Lot no. Other homes on property? yes X No Previous owner of property _ NIQ4 r) LA--S /PC- ~ Total size of parcel GG 14C%~ Date parcel .was created 9T ~f 'Are all corners and lot lines identifiable? ;__Yes No is this property being developed for (spec house)? Yes X No volume- /098 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 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 1(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 ' I .nformation norm, by virtue of a warranty deed recorded i the office of the County Register'* 'of Deeds as Document No.ZZ 2(9y , and that I (we own the ) presently 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 county Register of deeds as Document si nature applicant Co-applicant (D - k Date of Signature Date of Signature. J i • r DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1-1982 THIS SPACE RESERVED FOR RECORDING DATA f WARRANTY DEED • ~Fi~Fi~`t VOL. 10J P r This Deed, made between .--NiCholas__....___Retza, Jr. + Z T. CTIOI C C-~,, I. and.-Marilyn-Retza, husband. and wife._____________________ R-ed~rh~~~•~ Grantor, OCT 7 1994 and....... Timothy...Dove.._and Judith A.____Dove_,_,.husband ,y 11-15 ~ nA~. ...and..wi.fe.,._as..suryivorship marital property, a ~-arn;yl•~-Ci• t rc~PL^rs~",3 Grantee, Witnesseth, That the said Grantor for a valuable consideration...... - of one dollar and other valuable consideration conveys to Grantee the following described real estate in ....S...-y Croix RETURN TO County, State of Wisconsin: Tax Parcel No: Part of Government Lot "4" of Section 23, Township 30 North, Range 19 West, St. Croix County, Wisconsin, described as follows: Lot 3 of Certified Survey Map filed April 13, 1970 in Vol. "l", Page 45, Doc. No. 300122. TOGETHER WITH an easement for ingress and egress over a road 12 feet in width to the above described property on the Easterly side of the above described property, which the parties will have the privilege of using with other parties who own property. ..1.y This .....13 h~ homestead property. (is) (is not)' Together with all and singular the hereditaments and appurtenances thereunto belonging; And...Nicholas J. Retza, Jr. and Marilyn Retza warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, covenants, and restrictions of record, if any, and will warrant and defend the same. c Dated this fe...~ day of e.rh.b~c-...... 191. . (SEAL) (SEAL) „ ? Nichol J. etza, Jr. .....................................................................(SEAL) ! ....................(SEAL) tza * Marilyn AUTHENTICATION ACKNOWLEDGMENT Signature(s) _ STATE OF WISCONSIN ST. CROIX County.. authenticated this ........day of ..........................119 ersonal y came before me • _191 .4 'nL:,( t Nichol s J. Retza,.,a _yiro r Z~ --•---Mail. . . TITLE: MEMBER STATE BAR OF WISCONSIN V „_,•,n trt (If not, authorized by § 706.06, Wis. Stats.) k.O to me known to be the person S.......... w a executed the foregoing ' WQ,,led_ge he sa e. THIS INSTRUMENT WAS DRAFTED BY Robert F. Wall • -WALL--&•--MI-LLER,...S...G - 522 Second Street a -Huds-on-i...W1-------- 40-3:6•-----•--••-----------------•-••••-- Notary Public St.. Croix 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. , PORNT No. I -I 9RZ ~t'I„, ~~I wic I' ST. CROIX COUNTY WISCONSIN 1 - ZONING OFFICE M r Pine ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road - Hudson, WI 54016-7710 (715) 386-4680 March 27, 1995 Derrick Construction P.O. Box A New Richmond, Wisconsin 54017 ATTN: Mike RE: Septic Inspection for Timothy Dove Address: 1490 78th Street, New Richmond, Wisconsin Dear Mike: An inspection of the septic system for the above address was conducted on December 7, 1994. This property is located in the NE1/ of the NE4 of Section 23, T30N-R19W, Lot 3, Town of St. Joseph, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a four (4) bedroom home. Should you have any questions, please feel free to contact this office. Sincerely, t Mary J. Jenkins Assistant Zoning Administrator mz