HomeMy WebLinkAbout040-1218-60-000
9 10
STC - 104
AS BUILT SANITARY SYSTEM REPORT
9 1994
k.'
OWNER John & Susan Alger
hiTY}'
ADDRESS Post Office Box 851
Hudson, WI 54016
SUBDIVISION / CSM# Clearview Addition LOT # 8
I
SECTION , &.q T2jj_nr-R_ 19 W, Town of Troy
ST. CROIX COUNTY, WISCONSIN
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
lu ~
A
y
B
3
r
/ INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
I
BENCHMARK: Elevation 100.0' on 3/4" dia. PVC Pine
ALTERNATE BM:
SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION
Manufacturer: Weeks Liquid Capacity:
Setback from: Well House Other
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location
SOIL ABSORPTION SYSTEM
Width: Length Number of trenches
Distance & Direction to nearest prop. line:
Setback from: well: 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 INSTALLATION: November 3, 1994
PLUMBER ON JOB: Paul C.J. Steiner
LICENSE NUMBER: 6780
INSPECTOR: Q~~U
3/93:jt
Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County:
Labor and Human Relations 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 PI
ALGER,JOHN & SUSAN X
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
W.00 /61.0
TANK INFORMATION ELEVATION DATA /0-3 19
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 6(~_5 c"r+? . 41 L22 Benchmark
r
Dosin 3a'
Aeration ~~Fdg. Sewer 9 psl' 3
Holding St/~ t Inlet 99 L
TANK. ACK INFORMATION St/ art Outlet
TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet
Ar I
Septic 4 NA Dt Bottom
Dosing NA HeaderY~Pd9aa. S 97 r
Aeration NA Dist. Pipe 7.3-3 97
Holding Bot. System
PU IPHON INFORMATION Final Grade 5,3~ 99 sa
Manufacturer Dem nd
?
-7 0
Model Number GPM
TDH Lift Fri n System TDH Ft
Forcemain ength Dia. Dist. To Well
Head
SOIL ABSORPTION SYSTEM
BED / TRENCH Width Length i No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
S I S DIMENSIONS
DIMENSION
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING
INFORMATION Type O k1_1_- , CHAMBER Model Number:
j
System: ecn4,t -77'
DISTRIBUTION SYSTEM
Header Distribution Pipe(s) „ i x Hole Size x Hole Spacing Vent To Air Intake
Length Dia. Length Z/ Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade System
Depth Over F~r/ / Depth Over / xx Depth Of xx S d /Sodded xx Mulched
.@~GTrench Center c~D 'av 8g$1Trench Edges .0b aq Topsoil ❑ Yes No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) -fps (3
LOCATION: Troy. 5~ & 8.28.19W, SW, SWJ NW, NW, Lots 7 & 8, Rd. FF
~ l j ~ ~ `~r~ y~G' lC.~ ~ a~ fpJ~ ✓J~~oy. , ^1 . ~rr_ l.~ , ~ . .~,(t'! ~*Q.~ ~ 1 L ~ / ~
q
Ile-
~R i~
Q) 0-741 C
Plan revision required? ❑ Yes : ryo
Use other side for additional information. /Z I a 5p~ 1 41191
SBD-6710 (R 05/91) Date Inspector's Signature Cert. No.
~L
r
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
Fµ° SANITARY PERMIT APPLICATION
COUNTY
r~~IILIIIr■IlR In accord with ILHR 83.05, Wis. Adm. Code
sc
STATE SANITARY PE/ yMULi #
-Attach complete plans (to the county copy only) for the system, on paper not less than OO~~~~11--
8% x 11 inches in size. ❑ Check if revisioln to previous application
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROP TY OWNER PROPERTY LOCATIO
V Su SW
a fr$T ,N,R /47 W
W IN %a Ste
PROP OWNER'S MAILING ADDRESS LOT # BLOCK # WX Z wi
CI STATE ZIP CODE PHONE NUMBER SUBDIVISION NA CSM NUMBER
II. TYPE OF BUILDING: Check one NEAREST ROAD
( ) ❑ State Owned 1~ e-~attt~t
❑ Public N for 2 Fam. Dwelling-# of bedrooms L PA
III. BUILDING USE: (If building type is public, check all that ap ly) DLf~ g (Q dtj(L*) - 70
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
40 Church/School 8 ❑ Mobile Home Park 120 Service Station/Car Wash
5E] 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. W New 2. ❑ Replacement 3. ❑ Replacement of 4.0 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 M 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) l G 1;L ELEVATION
7510 Zrn 9 1-1 -r Feet Feet
CAPACITY
VII. TANK Site
in allons Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New lExisting Gallons Tanks Concrete glass App.
Tanks Tanks structed
Septic Tan I ,uq 0 t .t 1 F] F] Q F-1 F]
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plum Signature: (No Stamps) MP/MpRew-I+Fo.: Business Phone Number:
CJ e►K-eiv- ZeQ 7~ ya if y
umber's Address (Street, City, State, Zip CodeT.
2 7A/r t ,C <
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Sanita Permit Fee (Includes Groundwater Date Issued Issuing Agent Signatur
rcharge Fee)
e<,Approved ❑ Owner Given Initial 06 - Q
Adverse Determination
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398(R.08/93) DISTRIBUTION: Original to County, One Copy To: Safety a 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 t? installaYron.
5. Onsite sewage systems-must be ptoperly 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, 608-266-3$15.
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.
11. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
111. 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 building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if
required by the county; E) soil test data on a 115 form; and F) all sizing information.
GROUNDWATER SURCHARGE
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect groundwater.
The monies collected through these surcharges are used for monitoring groundwater, ground-
water contamination investigations and establishment of standards.
SBD-6398 (8.11/88)
_ ) Dlb I P/@ G2
Plot 7-o -o 8 C lairv/e.il •
CCQ
cP
3 ~
a
Q pl ~
Y ~ ~ J
v
93~j'
Pa us e
Wed
x /a2 oc~v 1 Wee ks SP94« Taw k
~1- B/K Cle v. 100. 3/~ . ~a~~~
PLOT PLAN ['age of
03~
operty owner John ~ Stkz qn A19cr
Legend:
Legal Description L.o+%, Glcarvicv-)Addn. BM = ~L. Ioo.O' on 3/y" pn. pVC P~~
SW'ly 0-f }ht SW /y-0 Sec, oro-r~je, 4 l -Cc
S ~ l r\ par+ o-~
lJ1J`~`f J~ t1•t nlt~l112-1 Xe, o, I I TZ%AJ, i?-)9 ~~r~per }rep
IIU, . roman of- T-,(D ❑ = soil boring w/backhoe
C.T,H Fr aPPm)(, 50' Slze a~prax. 2-3
e
I -F
o
71K \9
Q ~ I
E E3
E4..95-0'
r~
/ r
k
/ Sq 1,
~o gb PC-
~g-3 5
T / I ICI
t) e
C1 s (o~C~ Egg e rh ins a F/eU, I` U
J 'T ~ I
r To ke tt~~ bleu.. fi ~~.7 fi,1~~' ~~~►a~
- -9c~.-1 - - - - _ _8- I~~O✓1
i I
I ~
x
ApfT°'L. 1 Ou--" ara ux\l to ~
L/~ovv^
Signed CST
Date, I~+ IR9y
Wisconsin Department of Industry,
Labor a rx! Human Relations SOIL AND SITE EVALUATION REPORT Page of
Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY I
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but 5*' ~0
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
PROPERTY EWNECi' (iY1rIZ5 PROPERTY LOCAjION
Sohn 50.n 5-4 '
! eew-tm s L,) 1/4 NLk) 1/4,S g T 2q' N,R 1q . r W
PR PERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
P0, 60K 951 - cl-earv eel;Wn.
CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN NEAREST ROAD
4 Uason Wl 54011 01s) 384-D99S e:TH, FP
[)Q New Construction Use ( I Residential / Number of bedrooms `4 [ ] Addition to existing building
j J Replacement [ J Public or commercial describe
Code derived daily flow & 00 gpd , Recommended design loading rate e 7 bed, gpd/ft2 6 trench, gpd/ft2
Absorption area required N 4- bed, ft2 ZVO trench, ft2 Maximum design loading rate gibed, gpd/ft2t)j trench, gpd/ft2
Recommended infiltration- surface elevation(s) Sff !><o re / ft (as referred to site plan benchmark)
Additional design / site considerations e1jr' es
Parent material %n a 47-6 rzro a Flood plain elevation, if applicable tiA ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U= Unsuitable fors stem OS ❑ U I% S❑ U WS ❑ U OS ❑ U ❑ S NU ❑ S O U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
-Fr 0.6
v..:::=. r:>< < y 920 7,S YR 3)2- - 5i J Z sb K m~i~ s - O.S O.~'
Ground A-Zq 7,t5- y1c 3 S 0 s m l S - 0.7 6.9
elev. _
?9gft. 2q-W 10 Yn `-I/ 5 0 5 rr\ ~ - 0:7 0-F
Depth to
limiting
factor6 „
Z-
Remarks: )-log 1 a0►a 4f' 3 I Borne ra U~l rYt+X n .
Boring #
2 FsbK r~~r S - p,S O.f~
1 043 10 YR AJI - s k i
2 o-22_ `?,5YK5Jz s I Z-~sbl< ~r S-
3 2Z_-7Q )O I2 LIy
Ground S 0 0.
elev. 6'
Depth to
L%% 7 V4.0
limiting d -v
factor
,
70
Remarks: ortZOr'L hcs ,Same Irat/el rriircedln, acs
C me:-Ple Pit lIt 1 Phone: ~i
rp (7 f5~~s
Ad res u-kh X 2. I q W I 54020
J
Sign tur : .4 -&(&3 Date: CST Number:
1 ~V v
buyyeK5
PROPERTY (~WNfft_ Igf-r, IohN Sysap, SOIL DESCRIPTION REPORT Page?, of 3
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends
o- )0 YK 2-11 z-F5b rn-Fr - a................ Z S-Zy ?sYrl3/z s11 Z- 5bk rrl-Fr
Ground °j ~4-lam 10 Y►2 ` jq S Sol m I 0,-7 01
elev.
gg0ft.
Depth to
limiting
factor
21,14
Remarks:
Boring #
1 0-110 )b R zl ► sl I Z~sbK m~~ - O.SO.b
Z )1,-3{ 10 YI`3 - I 24-sb S U.SO.b
~L4 y - 5 ml 7 s0.~
10 Ground
elev.
Q ft.
Depth to
limiting
factor Remarks:
Boring #
I 0-14 royr 2-1I 5~ 1 Z-FsbK n-r~r - s o,b
2 Z-5by 5 S
3 "9 to yj~ y/ s 0 0.- 0
Ground
elev.
R5.0 ft.
Depth to
limiting
factor
Remarks: FLo6 zom-- 03: -mra< ~jray~~ YYl' x ed `tr1 .
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(R.05/92)
i,
Page_ of
PLOT PLAN
Preperv owner Jphr., ~ Sksan A13c-r
Legend:
Legal Description Lo+%, clca Viet) Addn- BM -
W~ oro.y,5e. 4C I ac)
sW'ly o-F +he SW Y'4 Sec.S In parl- o~ +he-
Ai W the NW'/z, Sec, o.1 ~ I Ir% TZW, X219 =,~~-~'`aPer free
Scllcr e mown of-1, C] = soil boring w/backhoe-
Lowry Real EX-6-4e Li 0 I
CT.,I. FF approx, SU' Lof 5~ze expPrO. Z-3
~Cr t S
i
d Lod- (0)
Q ~ a
6e.. 9°I.05
8 5
EC. 91-0
ru.. 97.1.
b P~
~p s
D~-3 5
/ sc.gq.o' 0 6-4
MAX-30 be-fle
Prom, ~t p s ore -5;-- -
t,fte
_ _s_ Ioca44on
i
X
APprox. I ~ou~e ar d X11 I cab
Signed CST 11
/410 3-70
e. jqqq
CLEARVIEW ADDITION
~~•te r1 LOCATED IN PART OF THE SWV4 OF THE SWIM OF SECTION S AND !
I IN PART OF THE NWV4 OF THE NWV4 OF SECTION 84 ALL IN 1
T28N, R19W, TOWN OF TROY, ST. CROIX COUNTY, WISCONSIN. iS
»I.• YKL r S I ISI N CATION l~ T1
T*
T
\ ' ; I to
j* \ \ I ernt s (
N[ IN !it[. r ~I
I MYM .ffC.f
~..z`
SCALE IN FEET
12 i
W N. w. \
j I. •I ««I w tcccNo
7: ~ • ~ • v~f~ \ O IMI• MI•y aw•«•• . N• t• NN
~ 11 •M/• M. w«• .•1 prl•1 .r•M•rlr ,
' M. •IN•rI .11 •11 •1• .,•1 •r• • •o.
•N.rN N. to.
I.N NtN ~ ~ InN•N 11«I••r
j ~ • IT VV I- D \ 11•r•r.. .••1 r M• M•I t•»•1••
[ 10 \
[ •Jr 4 ` 9
13
g1.rN
kervi
. NM. •~a »..rN N. ,I.
••.fT ll••Ie r T 9a a Nl\
Sol.
•y, N. NI ll.
1.11 .I60
t
\
ui 1 K lusxxt Ifrrl: Mt or aI•N I. ml ur
aa,yoo,
:f.06
y • •O. • M t• •Ir ff' • f
f: -OL
it ~ • ~ i i
G 1 u~. 3 4 y
1i i Su L D 114Y•I«NI 1 N••« N. It, N.NI N. .I. N,IIN N; w
yy ■ 1..• NNI 1.4 »NI 11 ~i
~ I A •
1 S 2
60~, p Sorb Sv~.D 1
;I 11 7
\ ro tIt[ ~ IVnI[ I
$"-Is 43 to
nntsl[ frtn \
CURVE DATA ! \
7
's
y T evw wla1 a•wN t11N1 0011 Ntl INram I» w
Il'ym am mm SAM Ilmla
1 / Iwp.bw •N.N• IwNY1• rw•1'ILIw IILN' IIbN• •NN19/•• IMIf•N••
1 • • twpellw u•.N• INr•M rI•N••r,W IN.N• Nr.N• NMM•N•• tlMln ll••
1 / /N1rbr NLN• Iwll'IY •11•N9Id•11 IIAM I1, 11• •II•p•11.1 •Iw11'1/••
• • 4r,1Mw1 IN, N' IMN•II• NMI••N.1`I IN. N• III. w• IMII•N1 IMII•IM • w r »I N 1 . • •1 » r • 1
• I I.r1.•I..N IN.M' IMM•»• INI~ i11, 11. 7N. N, IN.N •r I11.i1 111•tw1 Itl,
N•N••N•• III.M' 111.11• N••11.11•• NI•II ••1•• •11. IIN1., eN IW 1/ •1 W YII, twi•, tew
I • W 11 1«.N• IMI/•1/' r1••1•M.W N.N• N.Ir• 1•wIM N 1«. 711.U 111, 11,, It•N.
NMII•t1•• «MII•NY
• 11 Nt \ •M. M' INN•M JIrN/'11.I•• MM- I».r• •Ir•N•M•• I•NI/'•IY ~1' - . o
IJ 11 Y. 1 •I.N• IIM•I•• r/eN'•r.1•• /l1. N' 1••.11• IMI1'N4 •Ir11.1.1 iH1111« YI• .~...,Nr .•V,WiM,,, ,ll~
A's tt,,.-
SCALE
0
LEGEND
COUNTY SECTION MONUMENT -
0 1" IRON PIPE FOUND
0 2" X 30" IRON PIPE SET, WE
NOTES ALL OTHER LOT CORN
PIPE , WEIGHING 1.68
---it- EXISTING FENCELINE
BOUNDARY LINE OF JOINT DRI
SMALL TRACT BOUNDARY LINE OF RIGHT-OF-
TELEPHONE COMPANY
10 FOOT. WIDE UTILITY EASEA
\
q
103,750 SO. FT. ?0.2 spp
2.38 ACRES O• \
3
UNPLATTED
o~^ O~
8
2s
103, 750 SO. FT. 0'00•
2.38 ACRES
01~
y P
g
QO/v
2 • /e , 2S0 112, 375 SO. FT. Q~a4~a N ac
2.58 ACRES M
N z
N 0
H
v
w
N 15°29`19"E w oil
45.06'
417.96 N 89 ° 31' 30" E 464.10' 01 3 o
227.96' 227.96' 236.14' Q z a I
t0 _
w
1 IL
0 0
3 3 ,
o ti 5 ti Q°
0 92.303 SO. FT. '96.228 51:,
3, 146 SO. FT. z 2.21
14 ACRES z 2.12 ACRES
L S Z
Wo
STC-105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER J O I'L S
MAILING ADDRESS (1" C~ 23OY e?5) . ' 11Gc el s n h GAT y0/4
PROPERTY ADDRESS `7I i?- -FP
/(location of septic s stem) Please obtain from the Planning Dept.
CITY/STATE Ad S Dui ~iC~
' sw scv ;33
PROPERTY LOCATION i U) 1/4, N(J 1/4, Section fl T c2-9 N-R__Z?W
TOWN OF T✓'D V ST. CROIX COUNTY, WI
SUBDIVISION leatrf!!-e Pe LOT NUMBER 7♦
CERTIFIEDSURVEY MAP , VOLUME, PAGE 1.3 LOT NUMBER 7+-F
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 y expimt n date.
SIGNED:
DATE: Z o /3 -9e/
St. Croix County Zoning Office
Government Center
1101 Carmichael Road
Hudson, WI 54016 11/93
• 8 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 ddn n I S u< A l age
on 3 0 , T_C2LN-R_Lf_W
Location of property ~~i/4 Ai Jw 1/4, SectiV *o
Township Zkov Mailing address (PO R&y ss-l
19 wspoq Lk)' 3'6tn / L
Address of site 1/7 Cfv FT /g l~d'tOK ~.t
Subdivision name .Jeor- U J;~'Uj A ~cl a Lot no.
Other homes on property? Yes__,,K_No
Previous owner of property
Total size of property
Total size of parcel SDOl x q /5
Date parcel was created J
Are all corners and lot lines identifiable? Yes No
Is this property being developed for (spec house)? --X-Yes No
Volume 1699 and Page Number /33 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 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
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. _1 1 1.1S , 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 recorded in
the office of the County Register of Deeds as Document No.
S' nature o ppl ant Co-Applicant
zo -/.3-9y
Date of Signature Date of Signature
,N;" : t
DOCUMENT NO. -WARRANTY DEED neS SPACE FKSVWEO PON WCOPONG DATA
, l •
STATE BAR OF WISCONSIN FORM 2 -1982
522155 VOL ~O9gPASE-
David R. Knighton
S.T. CF101X CO., Wll
Read fbr Raw.
OCT 5 1994
t conveys and warrants to' Jo P. Alger an Susan M. Alger, 11: 30 A
joint tenants, Survivorship Marital roper y at4 & e M
Y Re~sowd~Qeade~i J~
"E"ro John P. Alger
PO Box 851
Hudson, WI 54016
the following described real estate in St. Croix County.
State of Wisconsin:
Tax Parcel No:
Lot No. 7 and Lot No. 8, Clearview Addition
Subject to Declaration Establishing Protective Covenants and other easements
of record.
x_11,-2a
r
Of This is not homestead property,
(W (is not)
Exception to warranties:
Dated this day of-filer
(SEAL) (SEAL)
s (SEAL) (SEAL)
•p
AUTHENTICATION ACKNOWLEDGEMENT
Signature(s) STATE OFJ MINNESSO
as.
Hennepin ~,rqy
Personally came before me this day of
authenticated this day of • 19 October 1994 the above named
David R. Knighton
TITLE: MEMBER STATE BAR OF WISCONSIN
(if not to me known to the aerson who executed the
auttonzed by S 708.08, Wis. Stets.) foregoing t and ac same.
= THIS INSTRUMENT WAS DRAFTED BY •
David J. Butler, Attorney at Law
6625 Lyndale Ave So, Suite 526 • David J. Butler
Richfield, MN 55423
(612) 869-7123 Notary Public Hennepin County, Wis.
(Signatures may be authenticated or acknowledged. Both My Comm nt (ti not state expiration
are not necessary.) date: )
• Names of persona sib in any eaW-Jty W- M be types or prYMW Dhow Cwk sipnaaxsa IIME?Mi cu
w anams~o oars 430
WARRANTY DEEP) STATE BAR OF WISCONSIN • e ASSOCIATION
FORM No. 2 -1992 4801 Mayes v wAmin 53704