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HomeMy WebLinkAbout020-1022-40-000 Q o ° p c 0 c 9 C~ ' U C (n 2) o = o a~ o ~ S n a> c I N cn 0 Y N O CL C C rn N E(D x cL 'C -a%2 Oyi O n 1 m a7 a) m c Ui y c c c - N h t ~-o 7 N O - U J a) - X N O O O co E M, O O O z N N O WE C LL C N - (q 3 f6X o .O o co. c =0 3 ~ vi ~c v E I E Q w Naoo:° as au U I Co N a I " rn W E U) = O O ~ E Z N w a co ~i-ZI, c o I o Z : o u - N F- m acs Z c o E ' M O CL O m N w C • 'I.. a L O C C U O O2? Q Z F- Z o N Z N C "O cli, O " lC L Z ~ `°"„d 8~ L o Q) o G C a U E co E rn `O H H H a 0 0 0 a= Z 0 a a a y N a n *i o = rn rn !A J U o a~ rn } C o o 'O W o Cl) o A~ O J N M O O O O C a.- E N N uJ O O>~ O V co t0 OO 04 n O 'p 0 N N _ 'C d N Q I a) " " O O O) N C O E © O V c U o o W 7 CO N O O_ O 3 a) w to U c O o O y;i H C O- a C -O N N N N w o of a c o o ° o v m co 0 LO G 7 w E o F- F- m N N ~ O' N ? v L N a E E cLi y 0 2 F- o ? U1 O v ~ L E m a a a • E d d y c r~ y U C C L r A u a o N V ~ ~/ftc~--,cr~vT S Tim sy s r~~ ~,v s704 SEP~` , Z-3 - Iff 3 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER (//~(T/~/ ✓ ✓~~~1/ c~ ~C~ ^ /7 ~7 2 ~D ~ilJ GiIJ ADDRESS ~~p Sd •u S S yGv ~ SUBDIVISION / CSM# LOT SECTION./7 T 'f N-R W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 77 E 7 1Nq CATR )HA RROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 'fDp 1"01`7?,jWS _f0kM E~p Sft L. ~ p aC BENCHMARK: ALTERNATE BM: /2t SEPTIC TANK ON Manufacturer: W 5 Co-y t ~J, Liquid Capacity: 161VV Setback from: Well /3o House lad Other Pump: Manufacturer Model# /!/,f Size Float seperation Gallons/cycle: y~ Alarm Location i ':SOIL ABSORPTION SYSTEM Width: Length l00 Number of trenches Distance & Direction to nearest prop. line: Setback from: well: 200 House IO 5 Other ELEVATIONS Building Sewer z ST Inlet: Z ST outlet PC inlet PC bottom Pump Off - 10, s-~ 7: O Header/Manifold tL.~ Bottom of system 97, Existing Grade la 2' O Final grade ADO. ~10 ' N DATE OF INSTALLATION: stp r, 23 3 L ~ T ~G / PLUMBER ON JOB: LICENSE NUMBER: 1 '33 INSPECTOR: T~~ 7/td,/00, SD.✓ 3/93:jt 45- /3 v ~ ~~7-" /OGO / 2 1XVA N ~ I Sc.~lt - / = 3 O I, i~St.9!/ED - Sc4. ¢o W fiPos 7- ~~cnF c/O HOMESITE SEPTIC PLUMBING CO. /00 155 O'NEIL RD., HUDSON, WIS. 54016 ROBERT ULBRIGHT WIS. ASTtR PLUMBER LIC. NO. 3307 M.P.R.S. MIN N. INSTALLER & DESIGNER LIC. NO. 00663 X O 4V'r-4k'5- ca s~,o rr c /v rf 70~ of 3 - 1 (~GD D~/H•cJF/'tL0 r4 7- 2, ~O,t' ,FVTV,P ES~ . ~S 01.4 13 r/o.%/ 13OX G,lp~~~ , 5 •~f Lo T~t° ~4 1V4t r TO G/p SySr 1'5 /NGET To I ~'0,---,---- Oip'v ~c k S vGo vI 7/0 ev e- k r/t'E,ur.L,. ,mot tos r3 ~Sr ELE (/~fT/D~u S - TR£voGc Gi,v f / Tap PipE ToP • ~i joE SyS?F.y ~vvE.e HEs/~,e vE~r n 14 N /oo 9O 9~• D 2 • S7, ,?Z 9G. y~ J " l3. /o o yo" ~'Z ey • f70 „ o f w~► S h`>~ U z w R o O~ Zr~vpp? DI'S rAP/;?v ,oipEs . • Ss~e rE ,ono T~ c r~ v ~v~'s~- 7'yAoot4- L is part a us r • 29.19.10P_%MWAbW%TEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) sanitary rmit Permit Holder's Name: ❑ City ❑ Village X Town of: State Plan I 15 o.: lev.: nsp. B Elev.: BIVI Description: ^ Parcel Tax No.: /40 ~ 020-1012-40-000 TANK INFORMATION' ELEVATION DATA A93002513 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ,Benchmark 9Z Dosing Aeration t Bldg. Sewer Holding _ St/A Inlet TANK SETBAC INFORMATION St/ ICY- E Outlet ZLA0. &3 TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic It NA Dt Bottom Dosing NA Header.a Aeration NA Dist. Pipe 97.72 Holding Bot. System PUMP/ SIPHON INFORMATION = e~~ > Manufacturer Demand ° 03 . ~Sr a. Model umber GPM TDH Lift Friction S DH Ft oss Forcemain Lengt Dia. Dist. TO e SOIL ABSORPTION SYSTEM BED /TRENCH Width > Length / No. Of Trenches PIT No. Of Pits Inside Liquid Depth DIMENSIONS 1 b MEN I N SYSTEM TO P/ L BLDG WELL LAKE / STREAM -LtAC_H I N G Manufacturer: SETBACK CHAM INFORMATION Typeo OR UNIT ° m be r: System. DISTRIBUTION SYSTEM Headers Distribution Pipe(s) r x Hole Size x Hole Spacing Vent To Air Intake Length J 1L Dia. Length 57 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Sys ly Depth Over Depth Over 0 xx Depth Of Seeded/ Sodded Yes ❑ No El Yes E] No ,(-/Trench Center 03CLLTrench Edges Topsoil E3 COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 14.29.19.103C (HOLDEN LANE) x,71' two ~-Q =7,,93 7. S~ , try Plan revision required? ❑ Yes Ly'~o q Use other side for additional information. / SBD-6710 (R 05/91) Date nspector's Signature Cert. No. -4 ~ ( -30, 3 ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: t w it 4 DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code Coue c~Gr, STATEYk I ARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ ~j,~ 8% x 11 inches in size. cn 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. /V101- PROPERTY OWNER r PROPERTY LOCATION ~ l& ~~tO.tit Sd~✓ Ale_%s;e7 S /Y T 29 , N, R / E (o W PROPERTY OWNEFY~ MAILING ADDRESS LOT # BLOCK # 7f2- AV CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD 11 State Owned LAGS Ho Are ~ l,v Gw ❑ Public ❑ 1 or 2 Fam. Dwelling-# of bedrooms 2 PARCEL TAX NUMBER(S) 111. BUILDING USE: (if building type is public, check all that apply) 02' O /0 2 7 000 0 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 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) Z000, A) 1.0 New 2. IJJ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair ofan 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 [1 Vault Privy 14 El System-In-Fill 'reeAje ff ES L` ACLi fS VI. ABSORPTION SYSTEM INFORMATION: 9 7 Q 1. GALLONS PER DAY 12.ABSORP.AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE +y~® REQUIREDD((sq. ft.) PROPOSED (sq. ft.) (Ga~ljs/day/sq. ft.) (Min./inch) ELEVATION l Q d Feet ~O~r S Feet VII. TANK CAPACITY Site in allons Total of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank /1700 eA11E5& Lift Pump Tank/Si hon Chamber CQ ~~Q f ,Q, 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) NlrYMPRSW No.: Business Phone Number: Rd/T- Zl/,~ifl GLUT, 330 7 015 Plumber's Address (Street, City, State, Zip Code): &5S O'AvI-tL R q f vs~,~ s S c~! 4z IX. UN DEPARTMENT USE ONLY ❑ Disapproved San' ary Permit Fee (Includes Groundwater Eessued Issuing A nt ure (No jinamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination 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 ruing authority. 4. Changes in ownership or plumber requires a Sanitary Pe rrvr ' ansfer/Renewal Form (SRI) 6399) to be submitted to the c,: my prior to installaliorr. 4 . 5. On rte se aje must be properly maintaiied Tih tar?-,'s) must bepi:rrt)8d fly a,!icense,d pumper whenever necessary, usually every 2 to 3 years. Y 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-38)5. To be complete and accurate this sanitary permit application must include: 1. Property owner2s na¢ie_and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be instarled. IL Type of building being served. Check only onE and complete of bedrooms if 1 or 21 i=amily 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 pe(rnit is for tank replacement, reconnection, or repair. V. Type of systern. Check appropriate box depending on system type. - VI. Absorp*art system information. Provide a`:I information request-' in #1-7. VII. Tank °t.:. ration. Fill in the capatcay at -very new and/or exit r'• 'sist the total gallons, number of tanks and manufacturer's name. indicate, prefab or site eonst ano tank materiai. Oornr:'ete for all septic, I-Iurnp/siphon and holding tanks V this system. ChecR f, ,,rimentai approval only i` tanks received experirr+.,-191 product approval from DILhR- VIII Rt sror,,?t ;il ty statement. Instariin q t,iurrher iF, to fill in name, s r,se number with appropriate prefix (e.g. tv'n et es~> and phone number. Plumber must sic r; -)r.r- Ic. :on fc', rn. IX. G gun yiD) paf!--lent Use Only. X. Gou ity 'e-.artment Use Only. Complete plans and specifications not sn°,aller than 8% t must be submitted to the county. The ;nclude ft-le following ;t ,.flan, drawn to ff. complete i.morsion~; Iccation of eater noa~: , .Aiatei service; hoi d no ~a ,k( s) set>cic trek(s) or rt4. '4ea{tetr;nt tank; st,eanls ar-d lak-s. S---lump or giphf o ink, flis'tlbutlon `yster'ls, rer,,14r-'ment system ar'ttas, aw the location of the 1,wi!.-ng; s -rveu `Z) hot tr t f eo en"e r,QVI's, C) complete specifications for Fu„'+ps and controls; dos( 'Merences; ft ictron loss; pump performance curve; pump model and pump manufacturer; D) cross sect err :,f the soil absorption system if. required by the county; E) soilrtest data on a 115 form; and F) all sizing information. GROUNDWATER SUhCHARGE 1983'N sconsir, Act 4' t included the creation of surcharges (fees) for of reg.: ?4 wl,iucan effect groundwater The, monies c-oilected throt.y ',hose s`"cha,g," water contamination investigations and establisho t SBO-6398 (R.11/88) Vllisconsin Departrne of Industry, SOIL AND SITE EVALUATION REPORT Page of 3 4 Labor and Human R'I, tions 1 Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Cnde COUNTY ST C/P~X Attach complete site plan on parser not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEI.D. D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFO RMATIPN-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION /W/3 TLiQ~y~ SO.tJ GOVT. LOT A/9- 1 /4 SE t/01/ T 1 y AR If E ( W PROPERTY OWNE ':S MAILING ADDRESS LOT i BLOCK # SUED. NAME OR CSM ff ~y ~L / LQE',cJ G.c/ CITY, STATE ZIP CODE PHONE NUMBER [)CITY ILLAGE QfOWN NEAREST ROAD SON f/10 [ ) New Construction Use [,Residential / Number of bedrooms Addition to existing building Wkeplacement [ j Public or commercial describe Code derived daily flow oo gpd Recommended design loading rate • 7 bed, gpdm2 trench, gpoll(t22 Absorption area required y1 bed, ft2 37~ trench, ft2 Maximum design loading rate -,7 bed, gpd/ft2 : ,F trench, gpd* Recommended infiltration surface elevation(s) s~ I~ ._ft (as referred to site plan benchmark) Additional design / site considerations S1'26 v~ Parent material SCS 3-P BuR~'ti~iPT- ovT~ti. fs//L Flood plain elevation, if ao.i„able Nom-- It S = Suitable for system coN~tyD IN GgOUND PRESSURE ATGRdDE SYSTEM IN FILL. HOLDING TANK U =Unsuitable for stem O's ❑ U US ❑ U Ers ❑ U R! ❑ U ( ❑ U ❑ S Btt' SOIL DESCRIPTION REPORT Boring # Horizon De1h Dominant Color Mottles Texture Structur c ComMnce Irxxx* Roots GPD/ft in. Munsell Gu. Sz. Cont Color Gr. Sz. SO. Bed Trench 0-2 /DYE z t S/ L,f, sh,< eS 3f , S %K 3/141. s/ z. M4-fk eS z of , I'lJ2 i /oy/f 31C S/ /,-F, s~,C 'M Ground 3 •F,2- i / S elev. I ioo,ft~ /0"Y . o yt-- s/ 4f sic fie 5 , y i• 5 . Depth to 93 X130 /0 y40, 'y/~ s G p - y /O y/e S/ - S ~91 M., .5 ,w►SZ . 7 i Remarks: _ Boring # -,f 122' 7-11 S~ Z,-f ,sy.~ y,~ CS 2f - S /a y s/ 2, Am '5 ~ /W FR es Vf s le 1 Z 2 f` 13, oy~ 3/le s/ ~2,~,, 1'k,k'5't"e es of - s •6 Ground is fi, 1~,C ~l '2- s -2 f 7 elev. A- kil-1G 0 Y- p Depth to limiting i factor ,r RG~^arks: ! _ s CST Name:-Flsaso. Print 120 SEP 7- ~ L-G R CC GlT Phone: 1 I s - 3 ' 5 Address: (e S S 0' A-) t i L N u flso -J 10, .57101 j' 3- p 3 CST~y ~y~ Sgnature: 1FC~UiQ/l~ ~ ~n Date: CST Number: ORIGINAL. 2 0 TE 130,P C # S r4 ez`ti 15 C67" T 7-6 ~~,~o sy sr.y , +s o~,E re:~L",e 11;1~ti7- so,is 0 ~q w 00 cn ~Q S Sc Ole 1-11.5 7 '0"' ~'/~t> l.o v ~O S( 9 PROPERTY OWNER ScAll SOIL DESCRIPTION REPORT page 2- 0, PARCEL LD.# Boring # Horizon Depth Dominant Color Motues Texture Structure Consistence BMIIVY Roots GPD/ft in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed oxh 3 A 0-13 io l 2 i 5/ 57t Tv, c 5 3 f 7s 7 f4 Z 1.3-/P D f/le 31S/ f s b,~ 4m-FR S z of Ground l0 Pie y ~5l 5A& 40 fR eley. .4-F-7 10fie Depth to ' /b y~J/ ^ , /ht Q ? _ , Q limiting --F-_ face i i 3 Remarks: Boring # r . 13-- A Ground elev. ft. Depth to limiting 1 factor Remarks: Boring # 1 i 13 Ground elev. , ft. Depth to limiting factor ' Remarks: Boring # Ground elev. It. 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Ism ueid 'ez!s ul se you! l l x Z/l a ueyl ssel iou jeded uo ueld el!s eleldwoo yoegy AWnOO OPOO 'wPV 'S!M 'SO'E8 HHII Qm WOODB uI seuiplne g Pelee;o uq"o JOMn to-eBed l~COd3a NOI1Vf1lV~A3 311S dN~/ 110S 'Ansnpul oilU w UPLM!SUOMA w Z ff~•I~' s°~ wt ~ ~ iS ~it'L~~s} s l" 56~dric T~t~K f' ZfvKvow.t~ S~'Z~ 9 ' P~EscwFD 10I&M771, ,i L.Z. vfuT I p v V ~ y oN ovFiow~~f ? 4: i ?~IPM;v F~'~GD I ~ ~ y STEM I ❑ 1 2v * - ~o - . /3 l ' M MP ?off o~ E/ec7VC p -rAf,vf fdeMCt /3090 ~ 3~sy • f /bv frV A,; I 3 /0010 J - L VkT iO~J S - /oo, 4z I l !0 SCALP- 30 i CA. . Z g tvR~ #oAfe 101 well I o ' ZISE ~X /s J'/~u G- ,o.PFl~5 T NCO o A(sE p C E7~t/ Fi Eo AS P.E'EC~}sr n~sre~Qvre,~. '966, TD "f'EE~ OGD ~E/N~r co!'E' Sys TEM ce v vEc r~ p e VAy 0 /i /!.v T (C+/p-off OLD SySrfM> 3 FoR yenRs / I y „ v~uT S CIO PA) ovERF 1 4: ?1IP"t~;u FI'eG0 ~ e ~ ~ i ~ ~ s y s7-EH o p i Z. ❑ i2o' 13 ' • - • 5"x58 ----~1 SYSTEM 1770 /3M z' -fop °F 1------- ?,!'~},vSf42Mfk' SYSTEH /3o~C 910, SO " 375y • /evfrVA,' 0 3 /00,0 F:;;. L vkt►oAJ S 131 /oo, ~ z I 13z ~vl,G6 53 ~Ff fo SCALE 30 7~PEti ~ ~ E /E v~ rrav s ffa~Deti ~c. cv/ 1/~ rIG.711 n , ~fi'Gf~ TiC'E•c~ c f ~ . Approved Vent Cap Minimum 12".Above ' Final Grade 4" Cast Iron 3!0 " Above Pipe Vent 91pe' 1o Final Grade Synthetic Covering min. 2" Aggregate Over Pipe Distribution . 2--72-f Tee Pipe co 0 0 0 0 . e Aggregate o Pertbraled Pipe Below Beneath Pipe 00 -Coupling Terminating At bottom Of S.ystem Go w T~Eti~ Fresh Air Inlets And Observation Pipe C~••--- Approved Vent Cap Minimum 12" Above Final Grade 4. NNW 4" Cast Iron X00, 36 "Above Pipe Vent Pipe 'To Final Grade • Synthetic Covering Min. 2" Aggregate Over Pipe Distribution Tee Pipe 0 0 0 0 0 , i Co " Aggregate o' Perforated Pipe Below s VsrBeneath Pipe 0 Coupling Terminating At Bottom Of System • ' Co Zip . ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT n FOR UTILIZATION OF AN EXISTING SEPTIC TANK 7,V2- This 1~~.v L,~,v~> is to certify that I have inspected the septic tank presently serving theStVB Adqgs,0",-/ residence located at: A114,56 1/4, Sec. , T 2-f N, R_/~7 W, Town of JIM i2fe,✓ 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 3 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): Age of Tank (if known): !n G _ e CGS rn '(A( m r) r n G n) (Signa'ture) (Name) Please Print ~~n/s~(tr f r (~~Len~f`/ ~ctn/~1~GTiGn( C~ (Title) (License Number) q /Z-0 4 (Date) Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Coda) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 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 for inspection yopening ,,over /outlet baffle). Name &GOe2E)? ) y l bR ( Cam! T signature /4j3e-~Z /MPRS 33c, 5/88 S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ADDRESS -7 FIRE NUMBER CITY/STATE~-~ D'✓ - ZIP 5`y0/ ~p PROPERTY LOCATION: tiF- 1/4, 5~ 1/4 , SECTION L , T -~-f-N-R J! ,.W TOWN OF i-' ` R-f St. Croix County, SUBDIVISION' , 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 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 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 Co. Zoning officer within 30 days of the three year expiration date. SIGNED: DATE : - g St. Croix co. Zoning Office{ 911 4th St. Hudson, WI 54016 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), thenla 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 Location of property NE 1/4 1/4, Section T N-R 1 f W so-~ Township Mailing address Address of site Subdivision name A lf - Lot no. Other homes on property? yes-No ? Previous owner of property J 2 Total size of parcel Date parcel-was created Are all corners and lot lines identifiable? X Is this property being developed for (spec house)? Yes X No Volume56 / and Page Number S 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) th a owner(s) of I the property described iz this information form, by virtue of a warranty deed recorded I~' n the office of the County Register of Deeds as Document No. 5 y?4/1/' Ci , and that I (we) presentl own the y 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. v . Sig ture of pp cant C plicant ~~~_1 .3 Date of Signature D e of Signat ' DOCUMENT NO. A STATE BAR OF WISCONSIN- FORM 2 VAI 561 °r , 465 WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA 343446 REGISTERS OFHCE BY THIS DEED, Lyle A. Baer and Crystal A. Baer, ST. CROIX CO., WIS. s wi e, Rac'd. for Racord INS 27 day of Sept A.D. 197 Grantor conveys and wawa is to Virgil Thompson an t 101 M. Barbara A. Thompson, husband an wife as Joint tenants, h fir sods ii Grantees for a valuable consideration sETusN TO i! ! the following described real estate in St. Croix County, State o( Wisconsin: A parcel of land known as Parcel #9 located in TaxKey0 the Northeast Quarter of the Southeast Quarter of This lsnOt homestead property. Section 14, Township 29 North, Range 19 West, Town of Hudson, described as follows:. Beginning at the East quarter corner of i said Section 14; thence South 88031145" West (true bearing) 589.38 feet; thence South 4044120" East 575.60 feet; thence Easterly 59.25 feet along the Northerly right of way line of a proposed town road on an 85.00 foot Ij radius curve concave Southerly whose chord bears North 88022130" East 58.06 feet; thence North 18020140" East 100.00 feet; thence North 54°39' 10" East 556.96 feet; thence North 0044' West 170.00 feet along the East line of said Southeast Quarter to the POINT OF BEGINNING. I~ 'I i ii TRANSFER FEE !i Exception to warranties: j Hudson, Wisconsin 26th day Sentembe?- ,I97 j Executed at thin . i~ i~ !I SIGNED AND SEALED IN PRESENCE OF (SEAL) ) !i yle A. Baer ! L422~iL a, it (SEAL) j C stal A. Paer I (SEAL) j~ (SEAL) Signatures of Lyle A. Baer and Crystal A. Baer, his wife authenticated this 26th day of September 19 l'77 Z' hn D. Heywood j, Title: Member State Bar of WisconsinXe Z Authorised under Sec. 706.06 viz. STATE OF WISCONSIN a s. County. JJJ ! Personally came before me, this day of . 19, the above named ~j to me known to be the person- who executed the foregoing instrument and acknowledged the same. I (j This instrument was drafted by HEYWOOD AND CARI y.,A nn GTi cnnnci r Notary Pyblic__ County, Wis. I~ I' The use of witnesses is optional. My Commission (aspires) (Is) i~ j) Names of persons signing in any capacity should be typed or printed below their signatures. Kcwr.ce.v.a® (~WARRANTY DEED-STA' BAR OF WISCONSIN, FORM NO. 2 - 1971