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HomeMy WebLinkAbout006-1091-80-000 -0 0 -0 0 Q c 3 Oo I 3 0 'I N O ~o cq a~ I m 0. N 0 c F - x r. °o CL w N Y O Q ~ aL... . C m O. CL E r y w v 3 m rn ar N O +C+ N p Q J s .0 N C C III i• U '00 C 01 m L C O) O f0 w C Z y O O 7 Q1 LO m N 0 O U O O C Z N .0. C Z O COO C~ 3 m a v, m m r m ~ LL C U. C _ 7~ T7 C d N 'a 7 N N -a '600 01 0 E Q o.Q. E Q Jr(V m.S U U m M m M (D aai 4i w E E U) 0 0 0 d m M a m C M H Cl) 0 C C7 U O 2 ~ w tli Z c c o I v Z N H r EN ~ ~ v M Y N N C L C L O j O '5 0 m O Z Z 2 Z Z N E Z LO c m -o N m LO .y. W U O d_ it, _ d_ Ll N p C a m b m O. M w Y C (O (D C) 0 01 O Lo - d 4) W i N O O O O co Y L C O a n o G(L co 2 m O F• F H U E N N E333 0 (n Zav O O L) 0 0 0 O O I a a a i ~ a a a y i e 0 y 0) 0) Z u1 N J U rn co Z rn rn } f (o rn I 4 N N CA O N y ib co t rn rn _ E W O O E N O O 3 r I~ ~ a fir, fn Oi r N m O 0 N a a co d c~ U) cl 0 m p E O '0 C E co N ~V O 0 N O N C © i 0 0 C O U C N N E rn a W O o a 00 L p~ O w N E <4 _N N r- Lo r- En W W m H C n . O C C .0. 0 0 0 N r C, C'4 3 Z m > ao a H c t rn (o M o > (o co co N 0 0 O 0 Q) y O~ O N O E U • ~a O M T O co U J O - H Z J O Z Z (!1 O ~ it I I I y a v w m y CL 3 t o a L: CL w CL 4) 4) "~1 C 0 a 2 0 in V 0 v) v STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Y~rti e ~Ca de~-9 ADDRESS SUBDIVISION / CSM# .N~ LOT # SECTION T N-R W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM N INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. Y BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: /1i~6~GJQS~ccros-/-Liquid Capacity: -Dam Setback from: Well So' House Other Pump: Manufacturer Model Size Float seperation Gallons] Alarm Location -SOIL ABSORPTION SYSTEM Width: Lengt Num~Q renches Distance & Direction a est prop. line: Setback fro • ell: Hous Other ELEVATIONS Building Sewer ST Inlet ST outlet. PC inlet PC b ttom Pump Off Header/Manifold Bottom of system Existing Grade Fi 1 grade i I DATE OF INSTALLATION: Q PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: - 3/93:jt LgarxT parimYhWdl:i , 31.16 60 Layorahd Human Relations y sPRIVATE SEWAGE SYSTEM County: 5pfety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar rtni Permit Holder's Name: ❑ City ❑ Village X Town of: State P Elev.: , BM D caption: Parcel Tax No.: e [TRp.%M_ M) ~J 0 006 !091 se e TANK INFORMATION ELEVATION DATA A9300232 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septi Benchmark Dosing / Aeration Bldg. Sewer Id 3 121 WHt Inlet Holding TANK SETBACK INFORMATION / / Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration Dist. Pipe Holding > > } Bot. System PUMP/ SIPHON INFORMATION Final Grade % Man Demand 2- Model Number GPM TDH Lift Friction m TDH Ft 11/(a Loss ead Forcemain Length Dia. Dist. To SOIL ABSORPTION SYSTEM BED/TRENCH width Length No. Of Tr w Lb- es PIT No. Of Pits Inside Dia. Liquid Depth DIME-ustm I EN I N a!!i / L BLDG WELL E / STREAM LEACH IN Manufact SETBACK CHAMBER INFORMATION Typeo o umber: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x H ize x Hole Spa Vent To Air Intake Length Length Dia. Spacing SOIL COVER x _Pr Systems Only x ound Or At-Grade Systems Only Depth Over Depth Over xx Seeded/ xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil E] Yes [3 No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: C/Y~LON 33.3 .16.549~a / -7"'" ~„~-c~/Gc- tee' ~ ~ ~ I'`:"/ ~ r✓.. ~ ~ ~ G . , Z2 Plan revision required? ❑ Yes 0 n g ' Use other side for additional information. 19 ~7 E6 2 - SBD-6710 (R 05191) Date Inspector's Signat a Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: t DSANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. Chkr 1 o o evlous 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 r 0 m G A S W %a,$ '/a, S 3,? T , N, R E (or) PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # ga r I 2G Tx -7 .doh' CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER r~ R►`o~i Koval : 5YD17 II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLLLAGE ' NEAREST ROAD rj2. C ❑ Public 1 or 2 Fam. Dwellin of bedrooms3- PARCEL AX NUMB Ill. BUILDING USE: (If building type is public, check all that apply) O O G _ ~d 9 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 80 Mobile Home Park 12 ❑ Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. El New 2. ~ Replacement 3. ❑ Replacement of 4.E] 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 Al SZ /If-110- .~(/a-- Feet - Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel lass Plastic A New istin 9 PP Tanks Tanks structed Septic Tank or Holdin Tank - 4~0 .Z. i~cJg Lift Pump Tank/Si hon Chamber 101 Vlll. 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 Signature: (No Stamps) P PRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): Id-2d SGT /X2-1so IX. COUNTY/DEPARTMENT USE ONLY I L] Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuin gent Signature (No Stamps) ❑ Approved ❑ Owner Given Initial Surcharge Fee) Q-143 Adverse Determination o .00 X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner. Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. 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 Saritary Permit Transfer/Renewal Form (SB0 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, 638-266-3815. t 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. Ill. 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%2 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), see r, tank(s) or other treatment tanks; building sewers; wells-, water rnains./water service; streams and iakes; 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 `1~is~.:anK>ir= Act 410 included the creation of surcharges (fees) for a numb-, r of regulated practices which can effect groundwater. The ironies f-ollected throu~jh lh(:s56 surcharges are use.1 for monitoring groundwater, ground- water contamination investigations and establishment of ;standards. SBD-6398 (R.11/88) Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 'i of 3 Labor and Human Relations - Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY . Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but ST. C~1X 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. 00 6 - 1 O °I ] - $ l7 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION 4 Lep, (01313 Gov r. LOT S W 1/4 S L 1/4,S 33 T 3) N,R ) b E (orU PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # l S Z 1 zz 6 lit ST• -1 S or CyWN CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ®FOWN NEAREST ROAD Me-3 R)C-ljm(1 Ajbp)I Skjp n (71S) Z.yt- Sk5Z G`-1 LON zZ6 T* 3T. [ ] New Construction Use [,XJ Residential / Number of bedrooms 3 [ ] Addition to eiasting building K Replacement [ j Public or commercial describe Code derived daily flow 4 SO gpd Recommended design loading rate bed, gpolft2 - trench, gpdfft2 Absorption area required - bed, ft2 - trench, 112 Mabmum design loading rate bed, gpd/ft2 - trench, gpolft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations % -t upj G `1 Pct k R erZ U 1 RL D Parent material s L t_T4 5 k--M I~t E-hlj r Flood plain elevation, if applicable FN , ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for stem ❑ S ®U ❑ S ®U ❑ S ®U ❑ % f~ U ❑ S ®U I$ S ❑ U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boaxiary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Tmnch [ 1 o-t tio~-12 z-t Z 1 s'D m v~v o• y o: S eY Z l~j-33 Lb`LR3/6 1S CSbk Vn Uif ' es v•1 a.~ Ground 3 33-3. 1 d`2 2 -3 GS Q VA. S 1 eS \b hi Olt V, C S - elev. tiou -2 ft. 36-S3 to `2 V-- 3A, tj C'b w\ ►-t-t - Depth to limiting factor Remarks: Boring # q _ 0' / 1b~12 31Z S `FSbk YtlU~h c-S o.~(p,S 2 Z 9-Z7 31Z - s I cg~k ~v'F►- dlS o Y o S 3 z-)-q) L-I.Q316 ~5 y y/6 St ~~sbk ~`~I~ - Ground elev. 41. 613 -)-S LIP- 3) S t 1 s bk ~n t^ - - Ois-e ft. Depth to 3 l G S ~vD Ohl Q limiting 9g factor 9 Remarks: OF T Name: Please Print Phone: / Arthur L. We erer 715-425 Z ; egerer Soil Testing & Design Service-P.O. Box 74 River Falls,WI 5 +2 Signature: °13 - 13 3 Date: ~`Y LL, ) 773 CST Number: M00576 PROPERTY OWNER L Vt)y S SOIL DESCRIPTION REPORT Page?-.of- 3 PARCEL I.D.# 006- 1~sqL- tO • ed Tre Depth Dominant Color Mottles Structure Boring # Horizon in. Munsell Texture Consistence Boundary Roots Bed Treridi Qu. Sz. Cont. Color Gr. Sz. Sh. 0_ t( Zo `-t v- 3 l Z - s Z ~h S o. S o- 3 Z t1-3S ~oK2 3!2 - s I 1 ~sbk \"Av cS "Y o.S Ground 3 3 S-S~ L0 `L Q 31 ` S 2 3~ S i 1 S bk Yn C-S elev. OL-1. 0 ft. (4 Depth to limiting factor 3S ' Remarks: Boring# \ b_~d Lb`~123~2 s Z`F:5 bt~ `~1L1'Fh CS - S 0.6 I ~t iZ 31 y - s I 1 c~bn ~n ~H c g o• Y o s Z6_S8 ~O`12 3/L SCR 31$~ 1 o.h Vrt`F~ Ground elev. 3 w S L o k Sn v~ vDs 101 0 ft. Depth to limiting fact Remarks: Boring # - SOILS PIr t F'ML SuL - 1-k I >w<«: Kw Ground F U ! L -t UI IZC Ut)Z elev. ft S ~~1f'1 WELL ~U v L I U 1. fN S . IAJ - 'M Ti-St Depth to SUl L U - `jL Q - L L limiting t VC 113 factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations August 12, 1993 2226 Rose Street La Crosse WI 54603 ART WEGERER PO BOX 74 RIVER FALLS WI 54022 RE: PLAN S93-40770 FEE RECEIVED: 60.00 LEAVENS, JEROME SW,SE,33,31,16W TOWN OF CYLON COUNTY OF ST CROIX HOLDING TANK The Department has reviewed the above-referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be made. All permits required by the city, village, township or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Sincerely, Gerard Swim Plan Reviewer Section of Private Sewage (608) 785-9348 1401R/ 1 SHDd423 IR. 01/91) HOLDING TANK Pa ge of 3 For A 3 Bedroom residence oT 7 13A-.&-W6 LOCATED IN THE S~J 4 OF THE SE OF SECTION T 31 N, R 16 W, TOWN OF Cat Lo N ST-• c~>-zLK COUNTY, WISCONSIN. i I INDEX i PAGE 1 of 3 TITLE SHEET PAGE 2 of 3 PLOT PLAN PAGE 3 of 3 HOLDING TANK SECTION I PREPARED FOR 18 Z z ,-z- 6 TTf S T . New 2tcN~luw~,wr s4o1'1 IPREPARED BY i WE=-:C-3EfZEFt S3 C3 I. L TESTS p4 (3 AND N4eoee® IDES I CCtV SEI:;tV I CE `§C® Iya'sy P.O. HOT 74 421 N. MAIN ST. ~~~"~.•••»•«••./~i RIVER FALLS. NI 54022 • i ,s 715-425-0165 : WEGERER L S asur fiILSWORTH, • = i WIS ? 1 ~ I G Nh~aN~ JOB NO. ~l 3 - 133 ~L~T ~l.f~tJ ~ ~E Z OF 3 SALE 1 Zo ' ~v R c~~ S ~ i ~G t iy 41 Ry, EPY. 5 SIGN aF o / 010 ~g V- 9 / L-t. 101= I o~V I I I ~ n► uaPuQ VM4 C.W Scam, UW3 ° f Bo. ~`Srv R '`-fie ~ q3 p 3 Q12r 1 g3,: 99 ~ x vx Q~S1p~►VeT of SIb)tiG C S%F AjoTfr wW4 o IkVrL Ili S o c>PcCt-k 6le ~oc~c_~i o N 7 !*L L O 1~ So x tTt, lO1 = I a~z..w L3wrM 66- 1 ~ C~ Ste. t`L loo,, _ vt rt~~ Z z b vlw ST. D NOTE: 1. Install a 3" PVC service suction line from each tank to separate service ports attached to the garage or to 4"X 4" treated posts. 2. Each service port to have a quick disconnect fitting with a removable plug terminating at least 2 feet above final grade. 3. Install a sign at the service port location reading "SEWAGE SUCTION LINES" with letters at least h" in height. 4. The existing septic tank is to be abandoned as per code. cn ~ M a m U' y = tea +riw a c m f7 c+ s m ;ri a a O -s ~Z S 00 X O G7 Z A --i N ~n C N E ~ f or D c r a ° p~ P c r- a m C) m ;'L7 co 3 fl rr..'' V) o N 3 3 no w (ZD n ;a co C+ R. m 0 ~fi ►-a Na C) Cl u O a ..11x z S- o --I z r m c N I- - - - - - _ o • 3 v Cr c -1 fD 'J r (n m m m -s m: s U) m -0 t• i~ _ =-o w n U c C+ 71 0 7Z am (7 w W ~ Cl O t3 C •f b d o W n) - .d a s o z N a Z C n :j a o m p, w m V> p •s n :3 =3 N r- y y c )L G C+ :3 0 L40 W U X [ m a -J3 7r S a j ct =r n m 060 f ~ y c) r \v (I 3 (tl c+ e+ v O m C7 -7 _ I :3 0 O • m c NO :2c t1 L C Q W-0 O 9 i O D 7 r C+ J HOLDING TANK SERVICING CONTRACT Contract Date 3 This contract is made between the Holding Tank Owner(s) Name(s) and I Pumper's Name I Jerome G. Leavens I I O \ ~Y(J'~'v' We acknowledge.the installation of (a) holding tank(s) on the following property: (Provide legal description:) L-ot_ 7,B-lock- 5__i47,-.-the_-Yi-11-a-ge- -Of--Cyion, -being in _t-he--Towrr--o-f--Cp1-0n----- - - according to the plat thereof on file in t_he_ Office--o-f- .~~t~r or -D eeds, St;.Croix County, ~disconsin. Mcorded -i-n-No-l-ume--574- on-Page--514.-,_-document 1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which has signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and with the County of S t. C r o i x 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pum r further agrees to include the following in the semiannual report: t11 ; a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; O) c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; AU e. The dates on which the holding tank was serviced; (p ; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. e. ZONING JFMI++ 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a c is contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) I Own Signature(s I Jerome G. Leavens ( Subscribed and sworn to before me on this date: Pumper's Name (Print) Pumper's Signature Notary Public I rrFSlFi~ePr lufycofnmZp explEes e r / u a Pumper's Registration Number r SBD-7574 (R. 09/88) This instrument was drafted by thatate .of Wisconsin Department of Industry, Labor and Human Relations. VOL 1023PAGE 317 Document No. This space reserved for recording data 502746 HOLDING TANK AGREEMENT Agreement Date This agreement is made between the _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ k,:_t..: County or Local Governmental Unit I Holding Tank(s) Owner(s) ST, C ROA CO_, W) Recd for Record Town of Cylon I ,~erorle G. Leavens (Called Municipality below) I J U L 2 2 1993 We acknowledge that application is being made for the installation of (a) holding at 3.30 P M tank(s) on the following property, (Provide legal land description:) p' Lot 7,Block 5 in the Village of Cylon, being in Reelsterofoeeds t-h-e- Yawn of C y l o n a-c e-o r d i-n g to- the plat --t-here-of on file in the Office of the Register of Deeds, St.Croix County,Wisconsin. Recorded in Volume Return To -574-on--page 514, doc-ument no..; 3-48874._ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containinpni of sewage. Also, the propert)p 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, Stats. As an inducement to the County of S t .Croix 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 charges 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 contract or the owner's registration with the municipality and with the county. The owner further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within ten (10) business days from the 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. ILHR 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) I Owner(s) Signature(s) - --Je.r ome -.G . L e-aviens I - - Subscrib and sworn to before me on this date: I _ I Municipal Official Name (Print) I Municipal Official Signature Notary Public -'I- My commission expires:  I i -tr hh I/ / h o Municipal Official Title (Print) I 1~ SBD-6123 (R. 10/88) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations. t,.  I S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ADDRESS~~ ;2--7L t~ S FIRE NUMBER ~ CITY/STATE APIA 7 R I , , Lc.JI 1 Z I P_~ x,17 PROPERTY LOCATION .5k 114,S e'-_'1/4, SECTION_ T_/N-RW TOWN OF0_;4 , St. Croix County, SUBDIVISION LOT NUMBER_2. 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 a 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 600 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 certifi;catiion 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),1 the septic tank is less than 1/3 full of sludge and scum. I/We,,the undersigned have read the above requirements and 'agree tp maintain the private' sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. 'Certifi~cation stating that your septic has been maintained must be ;completed and returned to the St. C x Co. Zoni Officer within 130 days of'the three year expirati n ate. SIGNED: DATE - 93 St. Croix go. Zoning Office .911 4th 'St Hudson, WI54016 ~jl i 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. - - - - - - - - - - -e - - - - - - - - - - - - - - - - - - - - - - - - - Owner of property j' Location of property25;~tJl/4 Section 53 , T 31 N-RW Township G /0-n Mailing address Z Z~ S .W.~ szt®v~cj ) b) 7 Address of site Subdivision' name__ a_/9Lot no. 7 Other homes, on property? yes.. No Previous owner of property Total size of parcel .111A- Date parcel was created 7F Are all corners and lot lines identifiable? --Zk-Yes No Is this property being developed for (spec house)? Yes 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 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 ito 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. 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 County Register of deeds as Document No. ~7 gnature,of,applicant Co-applicant Date of Signature Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN-FORM 3 • 7 VOL 574 ; d•, 514 QUIT CLAIM DEED 3488 THIS SPACE RESERVED FOR RECORDING DATA „ Gloria J RECASTE~OFFiCE BY THIS DEED, J. Leavens - ST. CROIX CO., WRS. Recd., for Record Oda._ I - Grantor i quit-claims to Jerome G. Leavens day o'IFMa~ IC i"p. 19 78;I - pf-- 8:3.0 A . AA, h II Grantee-, v luable consideration ° One an N6/100 h I$oalfars I Rashter of s if the following described real estate in St. Croix County, State of Wisconsi r RETURN TO i! ;xP'E REINSTRA & VAN DYK, S.C. li Tax Key r - ~I This is-=Lt-homestead property. II Lot 7, Block, 115" in the Village of Cylon, being in the Town of Cylon, according to the plat thereof on file in the Office of the Register of Deeds, St. :;roix County, Wisconsin. i; gFER This deed is given pursuant to a judgment of divorce $ rendered on April 13, 1978, St. Croix County Court. FEE if I I i Executed at New Richmond, Wisconsin this 25th day of May .1929 iI l~ SIGNED AND SEALED IN PRESENCE OF (SEAL) / Gloria y LJeavens ~I (SEAL) ii If I I (SEAL) (SEAL) If r ! signatures of Gloria J. Leavens i II II authenticated lets t day of May 1978 ripa JEAN RICKASD an Rickard Notaay Public - Stata a Iviscoatid My 120mn2ssion Exp l MiXWXX0iIK7Xl{I07iW[~IdNotXlE Parr Authorised under Sec. 706.06 via. Notary y PLIb11C My commission expires: 2/8/8'1' STATE OF WISCONSIN County. ss. 1 Personally came before me, this day of 19~, the above named I - I~1 to me known to be the person-- who executed the foregoing instrument and acknowledged the same. I li ~I This instrument was drafted by REINSTRA & VAN DYK, S.C. Notary Public County, Wis. New Richmond, WI 54017 The use of witnesses Is optional. My Commission (Expires) (Is) ,III j Names of persons signing in any capacity should be typed or printed below their signatures. KOra.«Oa.w~r