HomeMy WebLinkAbout034-1067-70-000
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER
ADDRESS `7 )
I
cs
a
S BDIVISION / CSMJ LOT
S CTION:3e) T,;~_q_N-R_L W, Town of IL
~i
ST. CROIX COUNTY, WISCONSIN
i
PLAN VIEW
I
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
y
j
f
! r
s
i
CV C"
! /r'1
23 00
4a)Zc z ?e, L r
3
\yl
INDICATE NORTH ARROW
Provide setback and levation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
-A : C O E
:HOI33dSNI
r - y :HagwnN 3SN33ill
f L :90r NO 2MgWnld
+
: NOI,LVrlgVJ.SNI 3O 3140
apeaB IeuT3 9pe.z0 buTgsTXa
ma-4s'. s 3o ul ggog pIo3TUeW/japeaH
I30 dmnd• oggoq od galuT 0d
a,
gaTgno!yS 3670 u,LS p zaMaS bui
, AV
l SMOIIVA 'I3 j
Ili
t
.za !stnio aM : utoa3 xoeqga
q0 H 'IT S
Lt
..at Tl doldl aleau og uoT~goa.ITQ aouegsTQ
Sa oua.zg 306aqucnN ( tpbua3 : ygpTM
1
walLsxs ',NOILLMO S* ZIOS
1 r
Jp1w llOTgeoO'I uLleTV
:aj3Ao/suotjlq0 uoTge.zadas geoT3
aztS #Iapow .za.zngoejnueW :duind
p vo . f au-40 97noH ~IjaM :moz3 xoeggaS
Z-':A-4T ede0 pTnbT ' n~ sa G~J:~azngoe3nueW
l
NOISKYmoaH ~ ?IN?ds JNIagoig aaHvHO dw/ xrvs oISd3s
O z~_ 7/ ` f ' a as~rrsasz~r
ZL~/ta~9 t J :?i~I`dWHON3S
t
t
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labrtrand Human Relations
INSPECTION REPORT ST. CROIX
Safety and Buildings ngs Division
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION
Perini yVfts fJ; m&ARY ❑ City ❑ Village ❑ Town of: State PI
CST~ICCBl{{MElev..: Insp. BM Elev.: BM Description: Parcel Tax No.:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark /00"
Dosing
Aeration Bld9.-S wer u, 91.7 Holding 0.~ St H Inlet L5
TANK SETBACK FORMATION St/Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header/ Man.
Aeration NA Dist. Pipe
olding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Mead
Dist. To Well
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
INFORMATION Type Of CHAMBER Mode 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.)
LOCATIOP: Springfield.,30,.2{9.15W,j/SE, SW, )Highway 12
/~~i'`t' i G',,C/ a"3 G-`~2'. ~V l? i'. _i 'du~') b!' 42..~l
r Plan revision required? ❑ Yes ❑ No 'aj~6
Use other side for additional information.
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
HR SANITARY PERMIT APPLICATION I
In accord with ILHR 83.05, Wis. Adm. Code DD Nb~-
95_
STATE SAN51A4R P~RWT
-Attach complete plans (to the county copy only) for the system, on paper not less than o~
8% x 11 inches in size. 1:1 Check if revision to pre ous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPER OWNER PROPERTY L~~TION
%U-)%,S50 T~ 2- c(,N,R l E(0
PROPERTY OW R'S MAILING ADDRESS LOT # BLOCK #
tJ 7Z -
CITY ,ST~ITE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
rw' f i I(So fS Ol
LAGE NEA SST ROAD Z
II. TYPE OF BUILDING: (Check one) L1 State Owned O
VILLL
4w w: aj 4.:,l
W1 N
❑ Public ;Z 1 or 2 Fam. Dwelling- # of bedrooms PARCEL TAX UMB G
111. BUILDING USE: (If building type is public, check all that apply) Q 3 /
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash
50 Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) I. E] New 2. D4 Replacement 3. ❑ Replacement of 4. ❑ 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 OrHolding Tank
120 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy
13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy
140 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
VII. TANK CAPACITY 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 e'n dNc D 31"t~
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.
Plumber's Name (Print): Plumber's %)gnatu (No Stamps) /MPRSW No.: Business Phone Number:
~2/ 15'6 ZSJa
s F 1(
r Plu is Address (Street, State, Zip Code) II _
-t Z ~>C '7 tJl C_L ~ S 7 -2 5
IX. COUNTY/DEPARTMENT USE ONLY
,~j ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e Issued Issuing Agent Signature (No Stamps)
~J Approved ❑ Owner Given Initial surcharge Fee)
I "o
Adverse Determination J10
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
s
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 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 tarks; 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.
a
SBD-6398 (R.11/88)
~ 73 2 ~ /Z
Gt.~, L s o c,~,s
Y
y
i
Rev
An-
~l
At Z. 0
CAS l~
HOLDING TANK CROSS-SECTION
Approved Weather Proof
Vent Cap Junction Box, r
Approved Locking Manhole Cover
4" C,I,- With Warning Label Attached
Vent Pipe And Padlock
Minimum
/Final Grade
4„
Minimum
PProved Joint-
• • - 18" Minimum
4ater Tigh
Teal i, High Water
Alarm Switch
~PIFICA •
S PE TIONS
ANK New Existing
/ Approved Joint
Manu acturer: Wn~,) w/ I
6~_
, Pipe
ind I. Tank Size: in g Gallons Extendng 3'
Onto Solid Soil
Plug ~LARM Manufacturer: Z' ~r7c f
Model I Number:
Swi tcM Type ~-•s
~I !
i UMBER OF BEDROOMS: '
GALLONS PER DAY:
3" of Bedding Under Tank
I
Owner'siName: _
Addre 3 ' ply
S 5 5 GCS
Legal Di1scr ption: C S 30 7-a ' `"kAJ
Township Municipal - - ` a
County:' 2D'/ x t~::.^`
PLUMBER/DESIGNER°
Signature: ~j 'A6•
License er
prW
Date:
a s.,.
0_1-consin Department of Industry, SOIL AND SITE EVALUATION REPORT rage I ui
Ai and Human Relations
Dv ion of Safety 8 Buildings in accord with ILHR 83.05, Wis- Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but 1 YnQX not limited to vertical and horizontal reference point (BM), direction
and % of slope, scale or PARCEL I.D. #
j dimensioned, north arrow, and location and distance to neares at
t" " w REVIEWED BY DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFb- MAT 6N cJ
P,R}OPEFI iY OWNER: PROPERTY LOCATION
F E~-f GOVT. LOT ZE 1/4 1/4,S 30 T aq N,R 15 ~`(orW
PROPER OWNER':S fpi LING ADDRESS 1-017i BLOCK SUBD. NAME OR CSM #
CITY, STATE ZIP CODE PHONE NUMBER OCITY []VILLAGE MOWN NEAREST ROAD
AEI 5 a- ('115) (098- b8 0 ~ Hw Ia
(J New Construction Use Residential I Number of bedrooms )~n o Q [ 'J Addition to existing building N. A .
Replacement [ ) Public or commercial describe a ra
Cerle derived daily flow 45o gpd Recommended design loading rate N • A - bed, gpd/ft2 N. A trench, gpd/ft2
Absorption area required bed, ft2 _ N. A. trench, ft2 Maximum design loading rate nl , Abed, gpd/ft2 N , A- trench, gpd/112
Recommended infiltration surface elevation(s)._ N. tA . ft (as referred to site plan benchmark)
Addiptionnall+deession~if l y~/ site considerations N. a
Par blE r , ED Q . (A- Flood plain elevation, if applicable t'1.11 - ft
, . rf S CONVENTIONAL MOUND IN-GROUND PRESSURE I AT-GnAC." SYSTEM IN FILL HOLDING TANK
YOWT
U= Unsuitable fors stem O S 19 U 0S au O S L-t U EII S- 9 U 0S ®U ®s O U
SAFETY & BLD S. DIV. SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Botxxiary Roots GPD/ft
Boring # Horizon in Munsell Clu. Sz. Cont. Color j ;r. Sz. Sh. Bed Trt d1
. r
~ I r
1 N. P.
0
Ground t Or
alev ( C t FC
it. ~~su= r-IJ
Depth to
factor k a 2 . a
Remarks:
Boring # 1 - f
Y tiLIL
(12 as.AA-4L _,rk r `
r c Jl
Ground
elev.
ft. ~.U !1
Depth to
I . I
limiting Paw
factor - (
I
l
Remarks: r -
CST Name:-Plf,ase Print / Phone:--work
Acc,essi --work
54('7 -5
Date: CST Number-
S~nature: Q n+~i p~
f ~l l CST fi
17~ J
' r. i~ it `_l. s.,. ~ Y•~ l~~
Bowman Plumbing, Inc.
~ Page 2 of 2
Master Plumber No. 5875 n
2819 Knapp Street Menomonie, WI 54751 N
(715) 235-4634
FAX (715) 235-3650
SOIL, AND SITE EVALUATION REPORT
h'1 A r°s vj
PLAT'
Gary Krieger
SE4S 4S30T29N/R15W
spfi gfieid township Cx)
6t;. roix county
r eta rabee CST 3719'
LEG ND
BM: N. A.
Borings dug wi ckhoe
Borings 1,2 & 3 e open
No Scale - si an is in proportion to site area.,
X
f` x
3
~ =a~umc~°n
1 G~ ~4 m~y a_yz~- 3 rm~k_c_a
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page I of
Labor and Human Reiet ons
' Deis on of Safety & Bo;ld7 rGs in arc° ird with iLht", P3,05 Wi-- Adm. Lode
_ COUNiY
Attach complete'site plan on paper not less titan 8 ?/z x 11 inches in size. Plan must include, but r ~
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.
REVIEWED BY DATE
APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION
P OPERTY OWNER: PROPERTY LOCATION
o E~C GOVT. LOT SE 1/4 $W 1/4,S 30T Z-q N,R 15 K(or@
PROPER OWNER':S LING ADDRESS LOT # BLOCK # SUED. NAME OR CSM
o,~ 1 aJ• rv,A N. A-
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE MOWN NEAREST ROAD
I 54oa ('115) ~98- bg d Hw IA-
New Construction Use Residential / Number of bedrooms n o Q, [ 'J Addition to existing building N. A .
Replacement [ J Public or commercial describe a ra
Code derived daily flow 45o gpd Recommended design loading rate nl -A - bed, gpd/ft2 N. A •_trench, gpd/ft2
Absorption area required N bed, f±2 N. A. trench, ft2 Maximum design loading rate 0, A W, gpd/ft2_N , a :_trench, gpd/ft2
Recommended infiltration surface elevation(s) N. A . ft (as referred to site {plan benchmark)
Additional design / site considerations N, a
Parent material tJ - A- Flood plain elevation, if applicable nt .R - ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE 1 AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem ❑ S IN U ❑ S Tau i ❑ S U -ILL. 4 U ❑ S ®U ®S ❑ U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color i ir. Sz. Sh. rr Bed Trench
TY)
70
o
Ground
elev.
ft.
Depth to I h
limiting
factor
Remarks:
Boring #
r cn o Yr~ _ r c~ Yn A~~la
Q V 6
Ground
elev.
Depth to Q 1 "w
limiting S x
factor
~ C+O~N FfiGE
r. ,
Remarks:
CST Name:-Please Print Phone=-Ork
4j :7
Acdress=--Work ~QJ 767"42 _ Zje7211? S/
o mr~ru.~ 5
Signature: Date: CST Number:
CST 7/
PROPERTY OWNER SOIL DESCRIPTION REPORT Pag%, of x;,14•
PARCEL I.D. I
Depth Dominant Color Mottles Textare Structure Consistence Roots GPDlft
Boring # Horizon in. Munsell Du. Sz. Cont Color Gr. Sz. Sh. Bar>dary Bed Trends
Ground
elev.
f t.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
Boring #
.M
Ground
elev.
it.
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD•8330(R.05/92)
•
Inc.
Bowman Plumbing,
Page 2 of 2
Master Plumber No. 5875 A
2819 Knapp Street
Menomonie, WI 54751 N
(715) 235-4634
FAX (715) 235-3650
m Q rs h ---S- 09L. AND _SITE-EVALUATION REPORT
x -
Gary Krieger
SE4 4S30T29N/R15W
Sprf gfield township x
Mt. roi county
x
r tta rabee CST 3719(-
LEGEND
BM: N. A.
Borings dug wit backhoe
Borings 1,2 & 3 left open \
No Scale - site plan is in proportion to site area_ _
1
X ha.~.
x
x
l~11 yam.
ARA
~V rn ~a f~ 3 fi~a A
i
STC-105
i
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER .
MAILING ADDRESS 2 ( S
PROPERTY ADDRESS z ,1,)~ 7
(location of septic sy ) Pledse obtain from the Planning Dept.
1 CITY/STATE z d JI-1
PROPERTY LOCATIN 1/4, 1/4, Section T
TOWN OF ST. CROI k COUNTY, WI
l SUBDIVISION LOS' NUMBER
CERTIFiEDSURVjanmamtenance , VOLUMES.? . PAGE LOTNUMMER
1
Improper usof your septic system could result in its premature failure to handle
j wastes. ~'Q per main onsists 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 fim on of the septic tank
as a tiv.tment 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
j accepted this program m" August of 1980, with the requirement that owners of all new systems agree to
keep their system properly maintained.
Thb 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 anSl (2) after inspection and
pumping (i 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: 6
DATE: - /
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, Wl 54016 11/93
irs
Document No. This space reserved for recording data
QS HOLDING MG FMENT
r
Agreement Date r
This agreement is made between the
County or Local Governmental Unit Holding Tank(s) Owner(s) RE G", : i ~t~I~S TICE
~z
ST. CROIX CO., WI
I Recd for R✓ord
(Called Municipality below) i AUG 3 0 1994
We acknowledge that application is being made for the installation of (a) holding
tank(s) on the following property, (Provide legal land description:) 1: 35 P.M,4
f f`~ icy S ` e~
d ~Z 9 ..fj lZ~~.S~UJ Register of Deeds
Return To
- - - - - - - - - - - - - - - - - - - - - - - - -
or that ccntin_ed use of the existing premises requires thzt a holding tank be installed cr: the property for the purpose of proper containment of
sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under
Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, SStttaats.
As an inducement to the County of T+ 0 f2 D 1 K- _ 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 fails 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
146.14, Stats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by
placing the,.charge.s on the tax bill as a special assessment for current services, rendered. The charges will be assessed as prescribed by
s. 66.60, Stats:
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 tank. The municipality shall notify
the owner of any costs which shall be paid by the owner within thirty (30) days from the date 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 tax 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, except as provided by s. 146.20 (3) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to
have the holding tank serviced and to file a copy of the contractor the owner's registration with the municipality and with the county. The owner
further agrees to file a ropy 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 date 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), Stats;, the owner shall submit the report to the municipality and the county.
5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that
the property is served by either a municipal sewer or a soil absorption system that complies with Ch. 1! HR 83, Wis. Adm. Code. In addition, this
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.
6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to
the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement
to be determined by reference to the property where the holding tank is installed.
Owner(s) Name(s) (Print) Owner s) Signatur s)
(74" Subscribed and sworn to before me on this date:
.
r I
M unt' r al Official int) Municipal Official Signature r tic
1 My commission expires "
C.yLI.t.1~yY1Gi~v c Q ~ ~ . -
/aQ V
'Municipal Offic 1 Title (Print)
r
SBD-6123 (R. 10/88) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations.
.Jt r'
HOLDING TANK SERVICING CONTRACT
Contract Date
r~
This contract is made between the K+ L>. .
Holding -
Tank Owner(s) Name(s) and Pumper's Name S'Laj e_
4,6 C
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:)
f /
i
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which ha
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
<711
with the County of V f
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and t
enter upon the property forithe purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather acce!
road or drive so that theputnper can service the holding tank(s)with the pumping equipment. The owner further agrees to r
the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper ;agrees to submit to the municipal) v`~sAVSDgned the pumping agreement requ y ad by s. I`HR 83.18 (4) (b), Wi
Adm. Code, and to the county, a report for ths yicl of the holding tank(s) on a semiannual basis. The pumper further agre(
to include the following in the semiannual repo 91191%
SAFETY & BLDG&n
a. The name and address of the person responsible for serAYng the holding tank;
b. The name of the owner of the holding tank;
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 gai Ions 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 contra(
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipals
and the County named above within ten (10) business days from the date of change to this service contract.
Owner(s) Name(s) (Print) Owner's Signature(s)
py p I Subscribed and sworn to before me on this date:
Pumper's Name (Print) is Signatu Not a y dub
'1~~~APT My c s^o"/e fires: f
Pumper's Registration Number
~7F
SBD-7574 (R. 09/88) This instrument was drafted by the State of Wisconsin Department
of Industry. Labor and Human Relations
APPLICATION FOR 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 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.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 11
Owner of Property ,
Location of Property ~D Section T~N-R W
Township
Mailing Address ~tjf
,~S`G PS ~TyZ
R
Z Sd rc/
Address of Site 222-
~2
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel / C '4G -
Date Parcel was Created
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Yes No
Volume_ and Page Number Z_ as recorded with the Register of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A Warranty Deed which includes a Document number, volume and pagte_ number, and the
Seal of the Register of Deeds. In addition, a certified survey, if available, would be
helpful so as to avoid delays of the reviewing process. If the deed description refer-
ences to a Certified Survey Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTy OWNER CERTIFICATION
I (We) centi4y that aft ztatements on thiz Sonm ahe true to the best os my (oun)
knowledge; that I (we) am (ane) the ownen(6) os the pnopenty de6Cnibed in thi6
.insonmation Sonm, by viA tue os a wauanty deed neconded in the Oss.ice o6 the
County Regi6ten o6 Deeds ass Document No. .2 , " ; and that I (We) pnesentty
own the p to pob ed site Son the b ewag a dims pod .6 y6 em (on I (we) have obtained an
easement, to nun with the above dedcJtibed pnopenty, Son the con6tnuction o6 .6aid
eyatem, and the .6ame ha6 been dut neconded in the Oss.ice o6 the County Reg.i.6ten o6
Deed6, a6 Document No.
) .
SIGNATURE 0 ER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
1=1UG 30 '94 14;22-- Fps( TPJMUTr-4' P.1
9
DATE:
ATigUION
OWN &
HOUSING
TOTAL OF PAGES ~DIN~
42gg S. Prairie View54R+~~~8617
4285 S Falls. FAX NLIMM. 715-834-7048
P'!w: 715-834-1279
a w'94 14:23 507 637 9167 1994.09-30 10:46 #22:p. 2.02
'r
46 45 14 46
st N 3/4 4 ------ion , f~
____4 tN ~~•2N'
MCI I
;fn
~ , @ b •loN t31' ~ '`Z'
J
6
• i33" Ii ,E;) i 1 ~,xtlF., j
a s
S
•
Ai 49"
i ~
tmm--11! 1/ 1R
e.o
-LJ.J-A-l 3w 7 ~
Fi.
~3w Y1 3 3f ~p
m .
c
x
48.
36 V jj 48 co
. r
RAW
a tra, oil
cu - # .
DOCUMENT NO. STATE BAR OF WISCONSIN-FORM Z
V 5-2) MAMMA DEED II
V^!.5'Q 7
1928984 1} ,Z THIS SPACE RESERVED FOR RECORDING DATA
BY THIS DEED, Thea Soika, a woman, REGISTERS ST. OFFICE
CROIX CO., WIS.
Recd for Record this__~?r _
Grantor conveys and wurrants to Gau_J. Krieger and Caro yn day Of---- 5PA-m-__A.D.193.5
Krieger, husband an-dwwi e~joint tenants, A.
_
1 Regkter of Deeds
Grantee S
for a valuable consideration RETURN TO
the following described real estate in St Croix County, State of Wisconsin:
All that part of Southeast Quarter of Southwest Quarter
(SE- of SW-14) of Section Thirty (30), Township Twenty- Tax I N _
nine (29) North, of Range Fifteen (15) West, St. Croix Ilia is s not homestead property.
County, Wisconsin, lying South of the Chicago, St. Paul,
Minneapolis and Omaha Railroad Right of Way, excepting
therefrom the East 644 feet of said quarter.
TRANSFER
$ a 0
FEE
Exception to warranties:
Executed at Spring Valley, Wisconsin this 25th day of August 1975
r
SIGNED AND SEALED IN PRESENCE OF (SEAL)
Thea Soika
,SEAL)
(SEAL)
\J (SEAL)
Signatures of
euthenticated this day of 19_.
Title: Member State Bar of Wisconsin or Other Party
i Authorized under Sec. 706.06 viz.
STATE OF WISCONSIN
St. Croix gg
County.
Personally came before me, this day of _ August - 19 75
the above named__ Thei -,So ika.WUtilan,
to me known to be the person who executed the foregoing instrument and acknowledged the same.
I
This instrument was drafted by Harold D. Olson
Harold D. Olson, Atty. v V St. Croix
Notary Publ:c___.__ County, Wis.
O N *
The use of witnesses is optional. Di O ^ J My Commission ¢EupQes) (Is)__pe rr__na_n_ent
Names of persons signing in any capacity should be
.ty`p0d or printed below their signatures.
G1111"tiiC FIIiNTNG <O [AU CI~IM[, WI[
WARRANTY DEED-STATE BAR OF WISCONSIN, FORM NO. 2 - 1971