HomeMy WebLinkAbout010-1068-20-000
STC - 10 Q
AS BUILT SANITARY SYSTEM REPORT
OWNER ADDRES u~-
SUBDIVISION / CSMI e7 X0 /4 t~ - C' LOT $ SECTION. T SO N-R /Z W, Town of
ST. CROIX COUNTY, WISCONSIN
PLAN VIER
SHOW EVERYTHING WIT91N 100 FEET OF SYSTEM
lee
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TANK
9,99 M M v6 i~~ NcM
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INDICATE NORTH ARROW
Provide setback and elevation information on reverse of this form.
Provide dimensio,~s to center 01 soptic tan,-: manfiole cpVe1
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LgQAWJAN~ u4MMPtry28. 30.16. %1%:Alff SJW~dVWS% County:
.Lahorand Human Relations INSPECTION REPORT
Safety and Buildings Division ST_ CROTX
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 1 C)()959
Permit Holder's Name: ❑ City ❑ Village [ Town of: State Plan ID No.: I EMERALD
S M Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
/Do. a17 010-1068-20-000 __J
TANK INFORMATION ELEVATION DATA A9300362
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark q7 ' A)61
Dosing
Aeration Bldg. Sewer ft"
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Airi to ntake ROAD Dt Inlet
rl
Septic "/Q NA Dt Bottom
Dosing , J + NA Header/Man. `off 9?
Aeration NA `Dist. Pipe y~ c/ S
Holding Bot. System 98 9a
PUMP/ SIPHON INFORMATION Final Grade, 9 Y: S
Manufacturer Demand
2~ (L U' /a .9 8~f
Model Number 5`3 -3,0 GPM
TDH Lift t Friction, i System TDHIO,i 1 Ft
i 1 Loss Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED / TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMEN I NSd Z DIMENSIONS
SETBACK Manufacturer:
SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING
INFORMATION Type Of CHAMBER Model Number:
System: 51 /DO 7 175 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 11 Depth Over 1 xx Depth Of xx Seeded/ Sodded xx Mulched
Bed/ Trench Center Bed /Trench Edges 10 Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: EMERALD 28.30.16.414 NW NE 140Th AVE.":,
Plap reN4ision required? ❑ Yes No FT
e other side for additional information. ~i'~t -t' IU
Us
1 SBD-6710 (R 05/91) Date nspector's Signature Cert. No.
i
• { SANITARY PERMIT APPLICATION
1 7 ILHR 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 1:1 j L
8% X 11 inches in size. Check a pplication
-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
Se, e/ o'/a z_:%,S.2S' T20 N,R I6 Aft)
PROPERTY OWNER'S MAILING ADDRESS 3 LOT # 7L0 CK #
CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
w of ,fi o/3 1(:2 d.;Z
. TYPE OF BUILDING: Check one CITY NEAREST ROAD
II ( ) ❑ State Owned 0 VILLAGE A-CNIeR.4LoI
❑ Public ®1 or 2 Fam. Dwelling- # of bedrooms a? PAR EL TAX NUMBER ) n
III. BUILDING USE: (If building type is public, check all that apply) ov /D (c! - d
1 ❑ Apt/Condo
2 ❑ Assembly Hall 60 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 ❑ Off ice/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A.t Check line B if applicable)
A) 1. ® 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 ® Seepage Trench 22 ❑ In-Ground 420 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
Zee I Z > S ~ Feet Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holding Tank X i-ov > G-' .~P
Lift Pump Tank/Si hon Chamber ~f7 S
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 Signature: (No Stamps) 1111 SW No.: Business Phone Number:
eft x e, ~/y / * r;; .v 715 5 = ~,3
Plumber's Address (Street, City, State, Zip Code):
a 4, o/
IX. C!p TY/DEPA MENT USE ONLY
❑ Disapproved Sa ry Permit 59e (includes Groundwater Date Issued Issuing A? pt Sign a No S ps) _ff / U j~urcharge Fee) 01 . roved El Owner Given Initial
/ fJY G
a
Adverse Determination
X. CONDITI S OF APPROVAL/REASONSROVACLZ~ `
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'h 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 (R.11/88)
l
MIESER 111INETE
RT. 2 (Hwy. 10) MAIDEN ROCK, WI 54750 • 715-647-2311 • FAX 715-647-5181
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10-29-1993 01:45PH FROM TO 265`7255 P.01
INDUSTRY, 1116.1 VOI N yi l %OWIL- Itrva•arf ~~i.ev . •..s,. DIVISION
LABOR AND P.O. BOX 7969
ILIMAN RELATIONS PERCOLATION TESTS (115) MADISON, WI 53707
(ILHR 83.09(1) & Chapter 145)
LOCATION: SECTI N: OWNSHIP UNIC PALITV: LOT N ,ELK. NO,: SUB I 1 ION NAME:
/T,3oN/R /b E (a W Graf ~
COUNTY: OWNERS 94Ly_e1Mt___ 4#E. MAIt_ ESS:
O, EA 4 u)all-zll
lenc.ucoad Ci ! Z5 416
USE DATES OBSERVATIONS MADE
N. 0 1COMMERCIAL DESLR P I N N TESTS:
evidence ~ j J Q"------- UNaw-_DReplace 1-7 //C/ AvzqaJ
-1-96 z
RATING: S= Site suitable for systern U= Site unsuita for system J Goo 1G' r ? r-+p~
~GOn1Vd~ff : MOUN tN_ -GROUN URE: F OLbING TANK: COMMENDED S STEM:( ptional) `n,,,e ,tom ~S
~V ~~U ~U ❑ S ❑ s ~O a y
If Percatation Tests ate NOT rectuired DESIGN RATE: ~ If any portion of the tested area is in th ~ ] ,j
under s. ILHR 83.09i5)(b), indicate: Floodplain, indicate Floodolain elevation. Nl/zy
PROFILE DESCRIPTIONS
SQr~INu• TOTAL i'TH T R UNDWATeR-INCHE$ CHARACTER OF SOIL WITH THICKNESS, COLOR. TEXTURE, AND DEPTH-
NUh48ER DEPTH IN, ELEVATION OBSERVED S T TO 8EQA0',K IF OBSERVED (SEE A88RV. ON BACK.)
7`
T5 --s
B. o
90 1,2,1 (~o a
V
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVM~-IMLIHES RATE MINUT
NUMBER INCHES AFTERSWELLING INTERVAL-MIN. P PEFiI R PER INCH
P. 0 12 i~jll
P-
P. (y~ t r -c
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hot
zontal and vertical elevation reference oiure sad s A. rh lot a how the urf levation at all borings and the direction and perce:
of land slope, t'.sf 'eP1W't,wtC-9 .D'd
SYSTEM ELEVATION 71. Sb
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r 141s t_f. Cl e c ,
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p 14~ ` I 4
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17.
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I, the undersigned, hereby certify th5t the s , tests reported on this form were made by me in accord with the procedures and methods specified in the Wiscorsi
Administrative Code, and that the data recorded and the IoCatian of the tests are correct to the best of my knowledge and belief.
NAME (pri TESTS WERE COMPLETE0 ON:
ADDRESS;
_ CERT FICATi NUMBER; PHONE NUMBER(Optionul'
CST SIGN RE.
31BUTION, Original and one copy to Local Auihorlty, Propertv Owner and $oil TESter,
,-S6bk;395 {r;, t0lA3? _ _
PAGE OF
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS '
i
VENT CAP.
4"C.I. VENT PIPE
WEATHER RROOF APPROVED LOCKING
JUUCTIOtJ BOX MANHOLE COVER
2S' FROM DOOR,
WINDOW OR FRESH leMill.
AIR IAITAKE
GRADE
w -MIN.
B" MIU
I
I
CQ+JDUIT - -
18"MIN. ,
u. \
b'IE ' I -
INLET PI2OVI
AIRTIGHT SEAL I i i I
APPROVED JOIAIT A I III APPROVED 101"J'
W/C.T. PIPE I (I I W/C.2. PIPE
EXTENDIIJG 3' I II ALARM EXTEAIOItJG 3'
ONTO SOLID SOt
ONTO SOLID SOIL B ( I )
I
ON
C
ELEV. F T.
PUMP
OFF
D
COMCKETt BLOCK
RISER EXIT PERMITTED GNL4 IF TANK MAIJUFAGTURER HAS SUCH APPROVAL.
SEPTIC E SPEC.IFICATIOW,
DOSE 1✓ / eseg
TAIJKS MAAIUFACT URER: It1UMBER OF DOSES: PER DA-4
TANK SIZE: /000 Q~( .CdD GALLONS 06SE VOLUME
ALARM MANUFACTURER: 1W.LUDIMG BACKFLOW: GAL ONS
0 /
MODEL UUMBER:
CAl'AC171E8: A=,3--5' CHES OR ~GABLLOm 3
SWITCH TYPE elg C L1 R g= 2- INCHES OR 1`GK-10U5
PUMP MANUFACTURER: =G L° LL F~ C =_L_-IMCHE$ OR ,LY:5 /L_/LONS
MODEL NUMBER: ~3 D=._ IUCHES OR,-/`GA LOKIS
SWITCH TYPE: Sf L R~ 4:5- 10 13C)I E: PUMP AND ALARM ARE TO BE
MINIMUM DISCHARCaE RATE GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFEKEMCE BETWEEM PUMP OFF ARID DISTRIBUTION rPE.. FEET
+ MINIMUM NETWORK SUPPLY PKESSURTT,E~. . . ~F.LET
+ _L1 j" FEET OF FORCE MAIN X F I."FtFRICfIQU FACYOA.._.L~.L.-1 FEET
= TOTAL 09UAMIC HEAD 1D 77 FEET
IAJTERNAL. DIMEWSIOMS OF TALIK: LEU&TH -,WIDTH r.~.~;LIQUID DEPTH
SIGNED: ~ _ LICENSE IJUMBER:. DATE: ~ 3
w iu t'itr-AW ~,Ae Al.f 1 y %.,Uh''V E 4ve-
"53-55" SERIES 45/6
25
TOTAL DYNAMIC HEAD/ I 41/8
FLOW PER MINUTE
EFFLUENT AND DEWATERING m -
CAPACITY
Q 6 20 HEAD UNITS/MIN -11/2 -
W FEET METERS GAL LTRS6 112 NPT
= 5 1.52 43 163 m
10 3.05 34 129
15 4.57 19 72
Q 15 19.25 5.87 0 0
z 4
D
Q 10
I-
O
~ 2
5
915/16
0
I
US 10 20 30 40 50 33/32
GALLONS
LITERS 0 80 160
FLOW PER MINUTE
CONSULT FACTORY FOR SPECIAL APPLICATIONS
• Piggyback Mercury Float Switches • Available with special cord lengths of 15',
available. 25', 35' and 50'.
• Variable level long cycle systems • Alarm systems available.
available. • Duplex systems available.
Standard cord length - automatic 9 ft.
Standard cord length - non-automatic 15 ft.
SELECTION GUIDE
M53/55 SERIES Control Selection 1. Integral float operated mechanical switch, no external control required.
Model Volts-Ph Mode Amps Slmplex Duplex 2. Single piggyback wide angle mercury float switch or double piggyback mercury float
M53/55 115 1 Auto 8.0 1 Or 1 & 7 - switch. Refer to FM0477.
N53/55 115 1 Non 8.0 2 or 2 & 6 3 or 4 & 5 3. Mechanical alternator 10-0072 or 10-0075.
D53/55 230 1 Auto 4.0 1 or 1 & 7 - 4. See FM-712 for correct model of Electrical Alternator, "E-Pak".
E53/55 230 1 Non 4.0 2 or 2 & 6 3 or 4 & 5 5. Sensor mercury float switch 100225 used as acontrol activator, with E-Pak (3) or (4)
float system.
53 Series - Wt. 23 lbs. -.3 H.P. 55 Series - Wt. 25 lbs. -.3 H.P. 6. Four (4) hole "J-Pak", junction box, for watertight connection or wired-in simplex or
duplex operation. P/N 100002.
7. Two (2) hole "J-Pak", junction box, for watertight connection orsplice, P/N 100003.
For information on additional Zoeller rodu t ref CAUTION
p csertocatalogonCombinatlonStarterFM0514•
Piggyback Mercury Float Switches, FM0477; Electrical Alternator, FM0486; Mechanical Alterna- All Installation of controls, protection devices and wiring should be done by a qualified
nator, FM0495; Alarm Package, FM0513; Sump/Sewage Basins, FM0487; and Simplex Control licensed electrician. All electrical and safety codes should be followed in addition to the
Box, FM0732. most recent National Electric Code (NEC) and the Occupational Safety and Health Act
(OSHA).
RESERVE POWERED DESIGN
For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump.
MAIL T0: P.O. BOX 16347
Louisville, KY40256-0347 Manufacturers of .
OYZZ11j-ff OI SHIP T0: 3280 Old 216 Lane
Louisville, KY40216
o (502) 778-2731 .02J 1 774-(800)3624 928 PUMP QUAL/TY PUMP9 SNCE ly3Y
FAX (5
QU PUMPS 3NCE Supersedes
Product uct information presented d here re
reflects conditions at time of 0292
publication. Consult factory regarding MAIL TO: P.0. BOX 16347• Louisville, KY 40256-0347
discrepancies or inconsistencies. SHIP TO: 3280 Old Millers Lane • Louisville, KY 40216
(502) 778-2731 • 1 (800) 928-PUMP • FAX (502) 774-3624
COMPARE THESE FEATURES
• Non-clogging vortex impeller. "53" Cast Iron Series
• Float operated, submersible (NEMA 6) "55»
2 pole mechanical switch. Bronze Series
• UL-listed 3-wire cord and plug.
9 ft. standard for automatic. ' MIGHTY=MATE "
15 ft. standard for non-automatic.
• Cast iron or bronze motor and
pump housing. No sheet metal parts to
rust or corrode. DEWATERING M*~'
• Cast iron or bronze switch case
• Glass filled polypropylene base and OR
strainer plate. EFFLUENT PUMP
• Engineered, glass-filled impeller ~
with metal insert.
• Stainless steel screws and switch arm. SUBMERSIBLE
• Model "55" stainless steel guard and PASSES '/2" SOLIDS
handle.
• No screens to clog. 11/2" NPT DISCHARGE
P1Y1A
Water tight neoprene "F-I" ring between
MEMfER
motor and pump housing. ~
• Automatic reset thermal overload suwP
protection. AND SEWAGE
• Oil filled motor
-hermetically sealed. Sump & Sewage Pump Mfg. Assoc.
SSPMA Specification
• Entire unit pressure tested after assembly. Numbers
• Carbon and ceramic shaft seal - 53 Series #SC 4425
55 Series aS8 4415
• Maximum temperature for effluent or
dewatering-130°F. - 540C.
• Passes 112" solids (sphere).
• 11/2" NPT discharge.
• RPM 1550, 60 cycles.
• On point-71/2".
• Off point-3".
• Major width -101/4".
• Height-93/4".
COMPLETELY SUBMERSIBLE
HERMETICALLY SEALED
Water tight - dust tight. Permanently
oiled bearings.
VARIABLE LEVEL CONTROL
SYSTEMS AVAILABLE
7EZZLff O~ MODELS AVAILABLE
• Automatic or Non-Automatic
• "53" - .3 HP, 115V or 230V
• "55" - .3 HP, 115V only
MAIL TO: P.O. BOX 16347• Louisville, KY 40256-0347 • N53 available packaged with
SHIP TO., 3280 Old Millers Lane • Louisville, KY 40216 Piggyback Mercury Float Switch. LISTED
(502) 778-27319 1(800) 928-PUMP • FAX (502) 774-3624
Manufacturers of
a ® QL/AL/TY PUMPS swrz- J~3~
N
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County ~
w
OWNER// o
a Fire Number
ROUTE/ BOX NUMBER ~_e~ GS~ ~ ~
ZIP la
CITY/ STATE PN e0ood
PROPERTY LOCATION:'.&~~k, -_k, Section T ?e N, R IX W,
Town of St. Croix County,
Subdivision - Lot number
Improper use and maintenance of your septic system could result in
con-
its needed, failure to handle wastes. Prover maintenance or s
you years
sists of pumping out the septic tank every thWeehat ye put into
sists
cens'ed 's'e t'ic tank pumper. P
theeded by a li
the system can affect t e' .unct on o, the-septic tank as a treat-
went-stage in the waste disposal system.
St. Croix County residents-may be eligible to recieve a grant for
a,maximum of 60% of the cost-of replacement of a failing system,
which was in operation prior to Jul 10, 1978. St. Croix County
to requirement that
accepted this program in August
owners of all new systems agree P their system properly
maintained.
The property owner agrees to submit to St. Croix County Zoning a
certification form, signed by the owner and by a mater plumber,
journeyman plumber, restricted plumber or..a licensed pumper veri-
fying that (1) the on-site wastewater disposal system is in proper
operating condition and •(2).after inspection and pumping (if nec-
30fdayssludge
essary), the septic.tak be is less Sapproximately than full
priordtoc~.
Certification form will
three year-expiration. y
I/WE, the undersigned have read the above requirements and agree
0
to maintain the private sewage disposal system in accordance with
the standards set forth, herein, as.set by the Wisconsin Depart-
ment of Natural
and
StCe Croix Certification
to the Resources.
County a Zoning Office t within completed
30 days
and returned rned
of the three year expiration.date.
SIGNED s~
DATE __.1 L
St. Croix County Zoning Office
911 4th St.
Hudson, WI 54016
386-4680
Sign, date and return to the above address.
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.
Owner of property -j;R,L t ?A/0/
Location of property&~L_1/4 ~1/4, Section ,?if , Tao N-R A~ W
Township l~
Mailing address 14 Ve
y y
6Y 6?,y w o v G i7`v lv .3'!0/3
Address of site S t~f
Subdivision name Lot no.
Other homes on property? es No
Previous owner of property fc✓4"A gd IU Z Ls~
Total size of parcel
Date parcel was created
Are all corners and lot lines identifiable?
Yes --,t-No
Is this property being developed for (spec house)? Yes X No
Volume/ and Page Number -2ff as recorded. with the Register
of Deeds.
INCLUDE WITH THIS APPLICATION THE FOLLOWING:
A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE
NUMBER & THE SEAL OF THE REGISTER OF DEEDS. In addition, a
certified survey, if available', would be helpful so as to avoid
delays of the reviewing process. If the deed description
references to a certified Survey Map, the Certified Survey Map
shall also be required.
PROPERTY OWNER CERTIFICATION
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()
the property described in this information form, by virtue sof oa
warranty deed recorded in the
office of the County Register of
Deeds as Document No. ~p3:2- -5- y'
own the proposed site for the sewage , and disposal t system ) orr I e(we)
obtained an easement, to run the above described
property
the construction of said system, and the same has been,duly
recorded in the office of County Register of deeds as Document
No.~d 3a
Signature of ap licant
~ Co-applicant
l z. 2.• CU
Date of Signature
Date of Signature
i
10-29-19971 01:47FH FF•I:H TO ~6572Sc F'.01
lr
~f OOCUMEN'- 'No ~i i'
•
WARRANTY DEEP j! TIDE ZDACE 0nrr, EU nnR ALf.nwn,hG OA Iw
i'STATE BAR OF wlSCON_SIV-FORM 2
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50, i
2917 P{t'Al {ER
S OFFICE
EDW&RD..M`A~~VH AND zIZEN xT _ w`►~. CRt~D~(CO►.,yyj it
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1993
AU0 2 +i
I conve•vs and warrant, to EAFL M. T~r7Iv'SEitrU T..+ atj~, TOWP~,S E\~ 1 . - AJ-_ V.~ CSI..
eIlC3..ai1d. WI.fe.
.
~L$?329r Of Doff
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the icli ;v.,Ino descI bed c:r i ta:a'w _ t_. r_
• StdtB of 'A' 4 SS:0 1737C;. _ II
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Tax Parcel Flo: -
ii
Ine East. One•-nal f (6,1/2) CIf t
he Northwest Quarter (NT,71/4),
The S,:)ui, nwe 3t : ua.rter {Sxnr? ~ ,
) o the , c+r j1,a^~st guar. ter 4NiJ i /4) ,
;i
The West One-haif 'WI/2)) a_ the Northeast Quarter (NE1/4),
The Northeast Quarter
OL the NL`lrtheeiSt Quarter (NF'1/4) II
I~
ii
ALL in Secti T'4entY--ei 'ht (I. g~ ZS), Township Thirty (30) North, Range
Sixteen (16)
~i
i Southeast Quarter (SEE /4) o ' the Southwest Quarter (qWi/4) of
Section Lwenty (20), Township Thirty (30) Nclr".h, Range Si teen (16)
lgest.
,i
is
i niS »r eYt•.
T e:,tcud
Exception tf ,.^.:CLr:.ti? '>%~Semez , rest-r 1 5 i:-:t•iQns arl:.i 1"7yhtS-•rJf-t~,3y
of record, if any.
i~ 93
Dawd this ~,f t Jul,
day
f ~ ' ~~•~~i~4-~ (.SEAL) Al,
' Edward M rn'a1sh ~ I>rene I,. i'alsh
(SEA 1.1
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it
iI ALTTH1;PaTI rA'T'IflN ACKNOWLEDGMENT
Stgiixtur0(s} STATE OF 1XV4 kl1NSIN
County so o", ii
authenticated this _..day of._........ 19.•• St Croix
If Jui crsanall came before 19..$3 the llrov d'me~
_ c h a i
f
c~~
i E a Irene't Walsfi.. .
.
'T'ITLE: MEMBER STATE EAR OF WISCONSIN ~
-
' (If not, .
II authorized by 706.06, Wis. Stats.) to me kninstru be the, d person nS-.... •e,the who executed the
S lil
ii TL05 INSTRUMENT WAS DRAFTED BY
Kristina Ogzand _.i?n
Atorriey at ~ari_.... Alice Joy o
i Not ary Public St + ..C.r0.1 .......C unt Wis I,
1 (Signatures may be authenticated or acknuwledked• Both My Commission is prI ~Innent. (I rof, stntaoc~i~'ratinn
are not necessary.)
dote: 19
►Na" of persons slicrtinr in any cane,-lly chOUI4 b., iaPC:' p,.ntnd belne- signxlurc>.
it
it WARRANTY DEED STATE IInR nF rovrrrnnicrw• nre~ tee; v..
TOTAL P-01