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Home My WebLink About040-1161-50-100 w STC - 104. AS BUILT SANITARY SYSTEM REPORT 'spy OWNER ) e rai d Do.ookoff j. ADDRESS o23 a Gl en Rd Rl u t,r teal/s U2 't Tay bGf~ - IIGI -.a SUBDIVISION / CSM# LOT # SECTION o;Z 7'0* T A? N-R o -OW, Town of Leta z ST. CROIX COUNTY, WISCONSIN Pj PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SY M ~G Iddck ~ ~ prop Bey \ \ scale l~f= 3t~r INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: lD l a D/ a GPL pi 10 .640 ALTERNATE BM• ~ SEPTIC TANK PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Wei t ell Liquid Capacity: Setback from: Well House Other P Manufacturer Model# Size Float peration GAlarm Locat n -,SOIL ABSORPTION SYSTEM Width: Length 7~ Number of trenches 0 Distance & Direction to nearest prop. line: ~lrQ 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: PLUMBER ON JOB: J LICENSE NUMBER: INSPECTOR: 3/93:jt Wisconswt Department Of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations ST. CROIX Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village ❑ Town of: State Pla DOETKOTT, GERALD X CST BM Elev.: Insp. BM Elev.: BM.r~Description: y Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 7 Benchmark GU. Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent TANKTO P/L WELL BLDG. A irIto ntake ROAD Dt Inlet Air Septic (p ~a~/ / ~a0 NA Dt Bottom Dosing NA Header/ Man. -S Aeration NA Dist. Pipe 9 7 - -30 Holding Bot. System l S°. PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain LengI Loss th Dia. Fi Dist. To w SOIL ABSORPTION SYSTEM BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION 5 ~ .11, DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER , INFORMATION Type O Model Number: System: r So SS Sv / nJ /.4 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 } f; Depth Over . A . e xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center i Bed /Trench Edges Jf+ Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: Troy.25.2 .20W, NW, SW, Glenmont Road Plan revision required ❑ Yes ❑ IV6o~' / Use other side for additional information. ( 6 SBD-6710 (R 05/91) Date sp is Signature Cert. No. l f ADDITIONAL COMMENTS AND SKETCH A _ i SANITARY PERMIT NUMBER: ' SANITARY PERMIT APPLICATION ■ COUNTY In accord with ILHR 83.05, Wis. Adm. Code St Croix STATE SAN TAW RMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ( q-1- 8% x 11 inches in size. 1:1 Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION NW %SW %,S 25 T 28,N,R 20 W BLOCK # PROPERTY OWNER'S MAILING ADDRESS LOT # 232 Glemont Road CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER River Falls WI 154022 1(715 425-7812 11. TYPE OF BUILDING: (Check one) El State Owned NEAREST ROAD MOWNOF: Glenmont Road ❑ Public nJ 1 or 2 Fam. Dwelling-# of bedrooms 3 PARCEL TAX NUMBER S) III. BUILDING USE: (If building type is public, check all that apply) 040-1 161-50 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.E1 New 2. ® Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.E] 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 U 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. RA 6. SYSTEI)A ELE 7. FINAL GR REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inc ' qJ, 3 ELEVATI N , 450 1563 563 .7 7 f Feet 0l•D~- ~e~ VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks siructed Septic Tank wqiyJdkybTxp1x 1000 1 _Tx Lift Pump Tank/Si hon Chamber El El El El El 1-1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. tAR 1(11 No.: usiness Phone Number: Plumber's Name (Print): 7al(A' at ur : (N Stamps) MP/ Paul C.J. Steiner 6780 715 ) 425-5544 Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DEPARTMENT USE ONLY g Agent Signature (No Stamps) ❑ Disapproved. r anita Permit Fee (Includes Surcharge Fee) Groundwater r e Issue Issu' b Approved El Owner Given Initial % n Adverse Determination o X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: ~1 6141 &:6 SBD-6398(R.08/93) 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 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. i 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) lq~- PLOT Pk o' -yyD%~ Ovc Oyu wlloojd A.4k 5 eff l c'. Tan k 3809A Q W Y1 Na fk xo Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Hurt Relations DiviNon of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY ' s't-, c,zo t x Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but PARCEL I.D. # not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or p ` 116 j _ SD dimensioned, north arrow, and location and distance to nearest road. AOPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION 6~RR~_b 1~ -T-V-,-oTT- 6AW. L9T ~W 1/4 SW 1/4,S 2-S T Z-8 N,R 7k) E(or)Nl PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE DOWN NEAREST ROAD R2 UifL F-rrLLS, w1 SL10zz DISNZS'- -1$lz Z o 1GLAaM)j0k)T- R-b [ I New Construction Use [)Q Residential / Number of bedrooms 3 [ j Addition to existing building Dq Replacement [ j Public or commercial describe Code derived daily flow `1 S0 gpd Recommended design loading rate bed, gp&II2 0.6 trench, gpd/ft2 Absorption area required 643 bed,ft2 S61 trench, ft2 Ma)amum design loading rate o - "1 bed, gpd/ft2 0 • $ trench, gpd/ft2 Recommended infiltration surface elevation(s) GE 3 ft (as referred to site plan benchmark) Additional design / site considerations s e-L- Nc'I-L- oxi X-" e- Z . Parentmaterial sep~ ovZz srvvj,;:~ d CM-*rQe1_ Rood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDNG TANK U= Unsuitable for s t e m IZIS ❑ U OS ❑ U I N S ❑ U 12 S❑ U W S ❑ U ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Coisistence Bouxla<y Roots GPD/ft in. Munsell Qu. Sz. Corti Color Gr. Sz. Sh. Bed rttd~ Ib1-I,R_3 11 Z'Fsbk `n'.,U a-s - O.5 0.b Z 6-18 `w-[ R- 3/6 - S z,sbh W _ cS - o• S o. Ground 3 1$-39 -)•S `III V/y - stl Z Fsb`z `~1- e S elev. qq•3 ft. 39-9 S `IR V/6 - S ~Gh o g S vn o.~ 0, b Depth to limiting factor 7 Remarks: Boring # Z.. Z-3i ►u`-ttZ 3/6 - S11 Z`Fsbk m~~ cS o.S 0.1, 3 31_61_ 7.$ Lip VIV S11 `7 SbIZ w. `f~- c S n~,6 Ground elev. y 66-ab ~.S ~2 y/b S ~G►~ 0 s 9 J` 0.7 rs',ti` X06.5 ft ti Depth to limiting facto ?96" Remarks: TName:-Please Print Phone Arthur L. We erer 715-425-01 Address Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Signature: y Zl 6 Date: 9-16-q CST Number: M00576 SCALE 1"= 30 ' 31Y`' ~ tt1 Pvc PIPE w/ wooU ~'A`ri1 ~-lnu = $•3 e~ 5 _ 5 v -14 t=L. 96 ~ -ZP r~ ~ p sL~Ttc s TR> S X ~S Z s S• L ~ ~L. ~ o b s ~l- 9. q 3 1 3 app t i~w ty O qCk 0 ~ 2.3 Z x ~N STPc LL_ `n'L,~~ CHETS `1Z" b~tP R't' `'R~~ ~~wt.~SLO~ ~'OvE. ~.F-'C1tE St1ti0 G ~ !'~i~21Z1~►J \ s ~Ufvl~ ~'1T 'A 14 1 G t} LR t~L~ ft`17tY•~ , `R1 E ' TR- CL} S Wl" ~IL 8!; 1r..,STP~LI.~D 1'rl' `C^64•PST ~-~IJ~1`ROu. ,o ~ ~ Y~11(~Ih1~11J Wt~K1P'IUM'I ~-t2,`, c0U~12 ov~Z ~m ~~sT~zti3UT~D>J ~1at:s. 0 ki C? d- F cj_ lG- (715 ) 42A-n169 1400576 CST Signature Date Signed Telephone No. CST # PROPERTYOWNER ~~~~-lzU~l'T SOIL DESCRIPTION REPORT Page ` of k 3 PARCEL I.D.# Wu O- S Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 3 0-9 Zu~-tR Z - L Z -a Yr U,- ~,S - (3-S 0,6 Z 9-ZZ ~k-)`1\Z') Iv S I ~(!-Sbk )mUf- CS 0,y v.5 Ground 3 120-1 i3 1~~liZ 3/c~ _ si I L~-sbk 1v)`FI~ CS O S n elev. \1% ft. L/ 3$-9Z -).siZ vl6 - S8G►~ 0 90) Depth to limiting factor 7 of Z " Remarks: Boring # 1 0- B ~~Z Z! I L S b1Z >Av~1- Z a. S o. S o. 6 EL 3 Z g-z,y \u`t t~ 3ey - s 1 c sb12v `F~- c s y s 3 zw-93 7• S yR S/A S 0 G~- o 15 . M 1 - (3. O. a Ground elev. Depth to limiting factor > 3" Remarks: Boring # ti~ >v1t1V1 f+~U - Z C S X S fir[ 6. "*e S km C L S )C- -I S Lava Z `CSZ- Ground elev. 1V Lo Z h/G S ft Depth to S limiting factor Remarks: Boring # { 01 Ground elev, ft Depth to limiting factor Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 Labor and Human Relations t Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY s'r-, c,\-Z.o x Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but 4 iwt limited io 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. ~y - 6 I - SO APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION N; 6~RALb ~O ET~oTT GGVF-.E NW 1/4 SW 1/4,S ZS T "Z-B N,R Z.O E(orc PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # ' Z 3Z G LeIJ l~OrvT . - - CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE DOWN NEAREST ROAD CZMu!Z 4- rLus' bill St1U 2.z (pis) Los, '1$tZ z~ 6t-L~►~o~uT RD. .5 New Construction Use pq Residential / Number of bedrooms 3 [ ] Addition to existing building Dd Replacement Public or commercial describe Code derived dally flow SO gpd Recommended design loading rate _ bed, gpd/It2 0.6 trench, gpd/82 Absorption area required 614 3 bed, 112 S 6 3 trench, ft2 Maximum design loading rate o - '1 bed, gpd/ft2 0 - $ trench, gpdHt2 Recommended Ifiltration surface elevation(s) s P~ F 3 ft (as referred to site plan benchmark) Additional design / site considerations is L "L- ox) V, Z Parent material SLII~A,,> Z*J'- ov)z Sri 4 G lt. u eL Flood plain elevation, N applicable t'-1 It S = Suitable for System CONVENTIONAL MOUND IN4GROUND PRESSURE AT-GRADE • SYSTEM IN FILL. HOLDM TANK U =Unsuitable for stem R S O U R(S O U IM S O U ®S O U Ems O U [Is U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Wisistence Bouxfary Roots GPD/ft in. Munsell QU. Sz. Cont. Color Gr. Sz. Sh. Bed IBn~ - lb'-t(Z 3li - si Z~-Sbk w, UJ{ _ a-S - 0A o.6 Z b-l8 `z'-1 R- 3l6 - S > 1 z F 3bk o. S o- b Ground 3 1$-39 -)•S`iLZ y/V - 31J Z ~'sbk ~t- c S - o.S o.b elev. S `1R Y /6 - S ~Gv S3 m 0.1 ; D. 8 q~1-3 It. Depth to limiting factor 7 9y Remarks: Boring # o-~ 10`12 3lZ s, 1 sb~ m F'~ aS o S o o. S o- ` Z Z ~-3z 316 - Sal Z~sbk mph cS 3 31_6~_ 7.S Lip u/y S ( `1 Shcz rn S - o-S o- b Ground elev. 4 66-9 6. S I R V/;, S G►~ 0 S g 1'+1 J - 0 7 \106- S It Depth to limiting factor 64 Remarks: CST lress: --Please Print Arthur L. We erer Pine' 715-425-0165 egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Signature: y Z/ 6 Date: 9-1 6 _4 CST NurnMM 00576 PROPERTYOWNER SOIL DESCRIPTION REPORT Page? of 3. PARCELI.D. 0L.O- k151- bO Depth Dominant Color Mottles Texture Structure Consistence Bwd3y Roots GPD/ft Boring # Horizon in Munsell Qu. Sz. ConL Color Gr. Sz. Sh. TBed,ch 3 Nz) -m L A Y.n u iCam. S Z 9-w ~wi\L ~/y Ground 3/y elev. V) ft y 3$-CJ-Z- -).S,-fm V/~ SgGt- C7 S~ yvt 1 - o,~lo,$ Depth to limiting factor i Remarks: Boring # Ell Z g_z vw-m- 3/y _ s I 1 C sb4t hiv s y s 3 7,V-93 n, S VP VA - Sig Gl- O S9 r+, 1 - o• 7 ~ o, a Ground elev. a 6 ft. Depth to limiting = factor 3" Remarks: Boring # , l Z `V SZ.. S c6 S'Y- -I S LOVG O ;-t 13- Ground elev. 1 UVLD _ Ir '2 ~G ft Depth to S limiting factor i Remarks: Boring # 13 i Ground elev. ft Depth to limiting factor Remarks: SBD-8330(8.05/92) ° PLOT PLAN Page 3 of 3 • SCALE 1"= 30 ' ~3w'I-tTl-.ll)0.0 ON 1D ~lG1i~ . 3Jt(Gp1~ PvcP1PE W~ wooer L'R'1'!t t3.3 c~ 5 5 8.4 LO 96 Flo r~y~Q,, st2IPTLc S s1 5-7- ~.~ob s a•1 S I eo~tL, 2.3 Z LA-)t-LL CHI qz b t `M NF `«tE sr1k,% 1 R 1217~t►J 13 F-OUKb >~T 11) HlGt}LR , v L~L~1 Pr~IY~J i `T?~ F `TTZ C"hl Ct}-~._S 1"11( ~~'A dN 1tiS1'PcLL~TQ Prl' `C'aN~'~ ~t-~'tJ~l`17Diu. Y~tP )PJ~`Pr11J WtRX11 1U1"1 142-" coVtR o~~z TTi~ Z 3 i12113UInk) 1~t1~t=S. F q- l6- 2~ (715 ) 425-0169 M00576 CST# N CST Signature Date Signed Telephone o. STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER Col, Q19Z 6 L ; , / d % / MAILING ADDRESS '42 PROPERTY ADDRESS S1i►~7~~ A~/~ (location of septic system) Please obtain from the Planning Dept. CITY/STATEtl{'~ PROPERTY LOCATION A)jQ _ 1/4, _ 1/4, Section , T_ag- N-R ~W TOWN OF MC2V ST._CROIX COUNTY, WI SUBDIVISION I1~1 LOT NUMBER CERTIFIED SURVEY MAP , VOLUME 051), PAGE 5 , LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the t. Croix County Zoning Officer within 30 days of the three year ex i ti SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 4 ` 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 6 Location of property 1/4 1/4, Section ,T N-R W ls~ L/~nD~j Township Q Mailing address 2 6 ~ C~r~ i~1a c - ,622/ 6YZ2 ~L,21 Address of site / Subdivision name Lot no. Other homes on property? Yes No Previous owner of property e1R&9 r!> Total size of property Total size of parcel Date parcel was created IC Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes _k_No Volume 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 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 n the of ice of the County Register of Deeds as Document No. and that I (we} presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the J construction of said system, and the 'same has"been duly recorded in the office of the County Register of Deeds as Document No. ignature o Applicant Co p icant -3 -ice Date of Signature Date of Signature W ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the pra/d )-)n tk6tt residence located at: uJ 1/9, -5 tU _1/4, Sec. , T g N, R_ 6 W, Town of /~"('U Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced /C /QI Did flow back occur from absorption system? Yes No (if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete-Steel Other Manufacurer (if known) : We15Cr /060.rt Age Tank (if known) : I T 7~ o (Signature) (Name) Please Print AA P 6790 (Title) (License Number) / (Date) Ile) /Q'~( Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-83, Wis. Adm. Code (except fog inspection opening over outlet baffle) Name Signat ur D MP/MPRS 5/88