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020-1267-60-000
r STC - 10 4 AS BUILT SANITARY SYSTEM REPORT OWNER CJ, j/, u k .~©v e p ADDRESS SUBDIVISION / CSM# LOT j c SECTION2N-RAW , Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1'!r C-4 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. x BENCH24ARK: Sa 4-,e ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING..TANK INFORMATION Manufacturer: Liquid Capacity: Z Setback from: Well i/c,7- qCfse aO ` Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location ;SOIL ABSORPTION SYSTEM Width: S` Length Number of trenches Distance & Direction to nearest prop. line: l✓~~f ~S Setback from: well: House /0d-~-- 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: //Zg_z~~ PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: f 3/93:jt LQQA%T, ,tWP§QRst y# - 29.19.1 ATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety'and Buildings Division • "'GENERAL INFORMATION (ATTACH TO PERMIT) sariitar r it Permit Holder's Name: ❑ City ❑ Village R Town of: State Plan o.. ST B Elev.: s Insp. BM Elev.: BM Description: Parcel Tax No.: , e TANK INFORMATION ELEVATION DATA A9300290 1(103A3 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark rr / O5. 21ZJL C~v Dosing. 3h 3~~r d Aeration Bldg. Sewer Holding St/ ~f Inlet ~r 61d. 9a2 TANK SETBACK INFORMATION St/ Ht` Outlet Vent TANKTO P/L WELL BLDG. AirIto ntake ROAD Dt Inlet Air Septic NA Dt Bottom S Dosing r- --NA Header / Man. Aeration A Dist. Pipe ~j Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manu rer Demand ° S T, Model Number GPM TDH Lift Lrict' m TDH Ft Forcemain L th Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED / TRENCH Width , Length / No. Of Tr riches PIT "'°w f its inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING adurer: SETBACK CHAMBE INFORMATION Type0 i,,1 OR U R Number: -ulem System: yrz'_; a DISTRIBUTION SYSTEM Header / / Distribution Pipe(s) /j x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length $7 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION JiUD ON 2 4.29.19.13 6 `p/ 1 ~I ✓✓✓JII ~ ~ , ~,!N zl ;"3 C-:~ f tl ~ 'V.ih t'~C.i'<:~r / W~ Y. j~~,e,.~ ~ r ~ ~4-'. i.; ~ - ~r7" ~ / 5' Z'7 A/ r l /z3r'L /9, 3 73 / Plan revisi6n required? Yes C611 Use other side for additional information. SBD-6710 (R 05191) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: r =Z91L, R SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY , mmmmms 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. ❑ Chi if r Is'ionYo 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 GiJ, /:fir rn 13v ~ &j s.w/ S 0 T N, R I E (Or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # ~~'d S ,peLrv cs✓ CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) F] State owned VILLAGE NEAREST ROAD !'emu s rt/'!/ ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMBER(S) L Ill. BUILDING USE: (If building type is public, check Z11 that apply) God ~~~',C d 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 1130 Other: Specify IV. TY PEI OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. U9 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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) Q1.740 LE1VA1~14 b 0 o V° N~ 93. ° d 'lee 9 oA et VII. TANK CAPACITY Site in alIons Total #of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system show on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) I$OMPRSW No.: Business Phone Number: Sc~ , T~ G° la Plumber's Address (Street, City, State, Zip Code): e 457 c, - 777,01y s c e IX. COUNTY/DEPARTMENT USE ONLY di I )g issuing en ' ure ( o Stamps ❑ Disapproved Sani Permit Fgiq (includes Groundwater Date Issue Approved ❑ Owner Given Initial M 'Surcharge Fee) I 41A1 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 th;s permit must be approved by the permit issuing authority. 4 Changes in ownership or plumber requires a Sanitary Per nit fansfer/Renewal Form (SRD 6320 to be submitted to the c.o.jnty prior to installation. 5 Onsite sew3 - _y Iums must be property maintained. Thu, _ tan s) mr.:st be FT ir_'d 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. IN. 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 a.li information requested in #1-7. V11. Tank infor. Non, Fill in the capacity of every new and/or f?x:~ • tank. ist t`ie total gallons, number of tanks an ;manufacturer's name. PraicaW prefab or site co:rstrrac.•:'f3 and tank r7aterial. Complete for all septic, Frump/siphon and holding tanks ic,- this system. Che0 s;; ;erimental :7pprovai only if tanks received experimtr,fal product approval from DII_ H I VIII. Responsibility statement. installing piurnr-,r s to fill in nary e, kir f- !ise number with appropriate prefix (e.g. MP, etc.i, :address and phone number. Plumber must sign ppt;~ ation form. IX. County/Department Use Only. X County/Department Use Only. Complete ,.dins and specifications not snialler than 8% x 11 inct-t~,; rnust be submitted to the county. The plans must rnclFXlp the following: A, ple =aa. Iraw-, to scale s,vith coop plete location of holding 'c'oke's) sfyptlC tankisj r+r i ;cr tre,meat tanks; bull dfr „ Neli~t; 4v i,"f 2, -1ter service; sireams and lakes.. pump nr ro r, anks; distribution boxes; ~ni+ ti+.rn sysierr7s repia,errrer.t system areas; and the location of the.. bui`(,+ing served; B) horizontal an(4 _le-ation refarencE, Points,; G) complete spec tications for pumps and controls; dose volume; e;evatiorl 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 (fe::s) `or a number of regulated pra&res whicf? car= effect gr indwater. The mo.:ies co_ acted hrOUQ t~+s se S. rcharges are used for :,a.ind- water contamination investigations and establishment ct sta ^vr~r~,~: - SBD-6398 (R.11/88) ko7 led ty W",V5e- 5, l Y • Q3 SX D ego . T ~ dSP Lbor aIid Human Relations use' SOIL AND SITE EVALUATION REPORT Page 1 of 3 Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY S,T„. CCU l~C Attach complete site plan on paper 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 PARCEL I.D. # dimensioned north arrow, and location and distance to nearest road. O --O - 1Z b-1 - 6 0 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION ►,uVal~ 1~3pyUD GOVT. LOT Sri 1/4 SW 1/4,S LV T 2 Ivw N,R 19 E (or0 SUED. NAME OR CSM # PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # ZSOS ~ UI~V ti°1 - SQ Rib&J CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE EVOWN NEAREST ROAD Rl~ . P')~fuoM'lt)1UlN ~v 5 1-15) (~lS) Z35~~1Z49 ti~vbSON FAQ Tnn) Hi LL K New Construction Use Residential I Number of bedrooms 3 [ ] Addii Qn to existing building j [ Replacement [ ] Public or commercial describe Code derived daily flow \ASO gpd Recommended design loading rate - bed, gVW °'ys trench, gpdtft2 Absorption area required bed, 112 y Q~ trench, ft2 Maximum design loading rate ~ • y bed, gpdtg 0, S trench, gpd/ft2 Recommended infiltration surface elevation(s) SEIt ObT& 1D J"S1*LLPtt f, 3 ft (as referred to site plan benchmark) Additional design / site considerations Parent material a t%_:r QQ)zxa . S ftlkaU f G 2 -ytrL Flood plain elevation, if applicable WIN- IN- ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem US ❑ U S❑ U OS ❑ U ID'S ❑ U ❑ S ®U ❑ S 1 SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tench [ 0-8' ~oyR 3! - i Z C. -S Zuo S 0,6 Ground 3 ~S-yo lb'1 fZ 3! 6 S$ 6r- o 30J Vv► C S - 0.7 0 elev. CIS. 3 ft. q0 -)8 l0 `I it V/V Gh S-~ N►'I - O`7 0, Depth to limiting factor „ ? ~a Remarks: Boring # 7- 3bk n~-~~. cS zv~ b.s o,6 Z Z ~-t~ ~o~tf~ 3/6 - S j) Z'F sbh e S 1 o~ S v-b n -3L t b 2 31 6 - s Z S l~lz f19 v ti• S o. S o Gro 4 41~ S 3A. SgG\~ bq vn~ aS - n.~ p "5 S Lo `?t2 v - vn v'EH ep mitin factor ' C9 -Pleas rtt Phone: o> rthur L. We erer 715-425-0165 ege oil Testing & Design Service-P.O. Box 74 River Falls,WI 54022 Signature: Date: CST Number: q3-l\49 -Z9-~3 M00576 1 PROPERTY OWNER SOIL DESCRIPTION REPORT Page 'o4 PARCEL I.D. # o ZO - IZ61- bb ` Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BounClary Roots Bed Trench in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trerxh 1~ 31 - 5 1 2 $ bk 'F h cS 2 u'~ • S 0 't 'LO vs 3 ,..r.;><:: Z 8-~6 LOUR 3/6 - S C-SVm U ~s 1~~' o S b Ground 3 1b-y0 1023/6 _ S~61, U gS y„1~ ~S _ 4-~ o,~ elev. ft. y yb ~y Io Y R 11~y 3 0'~ rn V'F Depth to J Xu S P, ~o S OF \ o ~-t y l S limiting factor ~y Remarks: Boring # 1 _ • l~`1 R 31 S 1 S h1z Y~'FI- C S Z~'r' o. S 0.6 42 1l-\tS l 1~y2 3/b S t Z~ 3~1T V►1 U f 0- C 1! `Fl- S Ground ~S-l3 10 R 3~6 Sfs sbk kn u o. S elev. 013.3 ft. Depth to limiting factor ? Remarks: Boring # tiu`vF- 3fy - st I Z`~Sbh rvt`Eh cs o•S 0.6 5 Z 8--LL LbK~ b - s t Z`~sbk w►~'~ s 1v~ o_ s o. hlt~vv•hi:t 3 Z6-~6 LZOLt.~ 3~L - S 1 cSek ~^nV`~4 _ o-~('~.S Ground elev. ~1D.0 ft. Depth to limiting factor Remarks: Boring # So.~ o-~ 1ok~3~y SCI Z~sbk~~. ~s z~~ o. M1tx~4 Z-2 S 1 ~`1- 3/L - St Z'F~bh yn cS of o. u. S 3 25-33 Lu`~tZ31ro - C' S~ 2'nSbk v,.~`Fr. ~S - o.S o•', Ground elev. 33_S2 1o`-Itz 3/6 - S 6L6 ~ 3'~ CS °I I.O ft. S SZ=1S lv`1tL3/4 - al \cg'bk 111U~h o,y o.S Depth to limiting factor Remarks: SBD-8330(8.05/92) `K, ozo-Lib?- bb PLOT PLAN Page 3 of 3 SCALE 1"= aO ' -100 r ~U TZ'O lv ~ l 1. L. RO FAD 'f'1 c ~t'~zr✓r ~n two Zzs~ ►,~o = t~o~st 3E VVT ~-R3T wLT.L 5p Oro -AtsN 3)y„ PvC P 1 A~ w / L A`TN LSL. q'l ~ . B. L s' G• ro 9 o s sa„ 0 4 a a a se~ ~ q,3 ~ 3 1l2 fiZ)v ~.a3? ~feS sa.y \ a.~ a s' ~i 8 38' A irvptcoems ~j C, T2-!NG \ ~A V ~ ~ ~ L o C. R't10 ~ S w r`rr~ ~ ~T~ \ \ \ -•-Z, Ito ~o ~2~c`iv~Z~ B No Roc4t g z~•, o~ ~ ZZS' 1 14TP -M TAJ S-MZ.LLT: -A~STI~- 4 Tiz uC.!{ 3, L1PtCL~1 S' ~c 50' u~n~G b ` "L-r,, 36" 'CNQIO RT vas L b ?c LSD G E. WST~-U~ ITS DLrEIZ~° IAJ t'CN TRJeV t LLv `f~ C hT T)) 1 E o t= cCVv S'~~Z.u c`n D IV °i3- ►49 (715 ) 425-0165 M00576 CST Signature Date Signed Telephone No. CST # +p F CD T- -4 N ~ N J C) C \ -4 O O N W J OD I N N ti C) I to D 4h~ J O O \ m Z p (O Q NON \ - -I- - T N(L 0 N ' Z ~w rW~m o ~c~a1 661 a' - S 88003'14"W 287.00' I S 88'03'14"W 318.19' - m m HUTTON S 88'03' 14"W 672.35' HILL ROAD - - 225. 00- - 222.35'- - ~ ~ - - - 225.00'- - - Z (n D N O (0 (0 O t0 cD N N (n If r*t O CJ1 co N (n Iv O a) O - O m O O A. CD O0 - O A . 1..& , CD - 0 0 OD O (n D i D O (n t0 m (n D a) n ,tn m O p O r; fTl m --i (n - ~M~ Z P O O v i ;o Z 0 i Z Lln (D '0 A cn .N 225.54 ' 225.00' 225.00 N 88'03'14"E 450.54' N 8803'14"E 0 w m N N cn p a► (D N r O U1 / Z N Ln I-r1 i s i m C 0 O i (Tl W A X (D 0 O N 0) ~ .o /p m0 -1 00) O = UI cn m y (D FWD m co W i (n , N m Ln 445 w o o S 81 3 o. N A O r m O OJ c O 1 Q ~ p ~ ~ ,2~ ~ ' 622 ` s ss es s V1 to ` C~,QT N N O n \\/`~~FQ S S W w oa ? . O cn - z m 0 .S S L 9 ~ D Vi • ~'Q n c'oS2 t8 . ~O p F SANITARY PERMIT APPLICATION . 7DILHR 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. ❑ 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 • a tiw 1/4 v 1/a, S T , N, R 137 E (or) PROPERTY OWNERS MAIL 04G ADDRESS A LOT # BLOCK # 02 S'O S pe e-te01cGJ /17 1 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one CITY NEAREST ROAD ❑StateOwned VILLAGE: ❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms R L x Nu B III. BUILDING USE: (If building type is public, check all that apply) Q a 0- aG 7 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. 0 New 2.E] Replacement 3. El Replacement of 4.E1 Reconnection of 5. El 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 0 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) 3-f/ 90 ELEVATION D S ti , ore °t y' 9 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holding Tank GJQ .ST Lift Pump Tank/Si hon Chamber 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) MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/ TMENT USE ONLY Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) ❑ Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. C NDITIONS OF PPROVAL/REAS NS FORJDISAP O : o' SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s 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. 1 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. 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- s water contamination investigations and establishment of standards. SBD-6398 (R.11/88) aDILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code 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. ❑ 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 fti/a, S T_;,, N, R,2 E (or1 PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER t e CITY NEAREST ROAD 11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE : ❑ Public Ell or 2 Fam. Dwelling# of bedrooms-; PL AR C TAX EL MBER( 111. BUILDING USE: (If building type is public, check all that apply) r^/ 1 ❑ Apt/Condo CP 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Reereational 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. ® New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 511 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 91 Seepage Trench 22 ❑ In-Ground 420 Pit Privy 13 ❑ Seepage Pit Pressure 430 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.) (G41s/day/sq. ft.) (Min./inch) / 70 ELEVATIqVo < fey' _ eet FiRet VII. TANK CAPACITY Site in as Ions Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks ranks structed Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber EE Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Paint): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phones Number: 7 Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/ TMENT USE ONLY } Disapproved Sanitary Permit Fee (includes Groundwater Date Issue Issuing Agent Signature (No Stamps) ti Surcharge Fee) ❑ Approved Owner Given Initial Adverse Determination X. CONDITIONS OE'APPROVAL/REASONS FORMISAPPROVAL• .;-f SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS M i ~_p. xis 1. 'A sanitary permit is valid for bNa,(2) years. t 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any now- criteria in,thwWisconsin Administrative Code will be applicable. 3. Alf revisions to this permit must be approved by. thelaermit issuing authority.. . '04 4.- Changes in ownership orplumber requires a San vy 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 yourpnsite sewag*system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division,' 108-266-3815: 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. ll. Type of building being served. Check only one and-complete # of bedrooms if 1 or 2 Family Dwelling. 11L 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,jf 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. ,i •i X. County/Department Use Only. `Complete plans and specifications not,smaller than 8% x 11 inches mu§t 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"pdmps and controls; dose volume elevation differences; fiction 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) mzzl LHR SANITARY PERMIT APPLICATION ccord with ILHR 83.05, Wis. Adm. Code COUNTY In a -EMNEMMN 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. ❑ 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 1 a %a . '/a, S T N, R E (or),W PROPERTY OWNERS MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one) CITY NEAREST ROAD ❑ State Owned ❑ VILLAGE . , ✓ t s ❑ Public El l or 2 Fam. Dwelling-#~ of bedrooms - PARCEL 4OWN TAX. NUMBER(S) III. BUILDING USE: (If building type is public, check Z11 that apply) 77 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 50 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. ~ New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 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 0 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)„~, 3-71,70. ELEVATION an,CFBet F t VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank Lift Pump Tank/Siphon Chamber R F] VIII. RESPONSIBILITY STATEMENT it 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) MP/MPRSW No.: Business Phone Number: S9 .J f(. d ir! r._ P k a Cf(7A' ' =,C _ - , ,v Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/DE TMENT USE ONLY LF9 Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approvl~d 1~ 7 Owner Given Initial Surcharge Fee) ❑ Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-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. ti x 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'fi name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) 7DILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code 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. ❑ 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 PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) El State Owned VILLAGE: NEAREST ROAD / { rf . r ❑ Public ❑ 1 or 2 Fam. Dwelling of bedrooms - PARCEL TAX NUMB ERIII. BUILDING USE: (If building type is public, check all that apply) 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. El 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) I 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 GELEVATION REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 70 L.~ s Pr lLr. meet 4 re VII. TANK CAPACITY Site in alIons Total # of Prefab. Fiber- Exper. INFORMATION New xistin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App Tanks Tanks structed -1 1 F1 F1 Septic Tank or Holdin Tank ' Lift Pump Tank/Si hon Chamber El F1 F1_ L1 I Ll F] VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: [Business Phone Number: x e - - -,;~c e ~ , Plumber's Address (Street, City, State, Zip Code): IX. COUNTY/D TMENT USE ONLY Disapproved Sanitary Permit Fee (includes Groundwater roue water ate Issued Issuing Agent Signature (No Stamps) ❑ Approved Owner Given Initial 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 issuing authority. 4. Changes in ownership or plumber requires; 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: i 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. VI'. 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 rnains/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) i ' i j S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County I" OWNER/BUYER L/ V. (1- ~l p ;i ADDRESS. f/✓TTO^~ ~7I LL A:1- FIRE NUMBER ~ D3 CITY/STATE W00501-1 GcJ -_U . ZIP 5_*01 ro PROPERTY LOCATION: 1/4, 1/4, SECTION 2-' , T Z 9 N-R Ig W OWN OFy St. Croix County, SUBDIVISXON SUw,e /J0 G6 LOT NUMBER 9 i , 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 orIsooner, if needed by a licensed septic tank pumper. What you put.into the system can affect the function of the septic tank a;s a treatment stage in the waste disposal system. St.,C,roix 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 ~equiremen,t 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 master plumber, ~D,ourneyman plumber, restricted plumber or a licensed pumper ,vverifying 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/.jqe,;' 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. LZ/ SIGNED: DATE 101A11 9 St. Croix co. Zoning Office 911 4th St. Hudson, WI'54016 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. Owner of property l~ ILG i 91- 5 (/SX,,,J $4 D Location of property 1/4 1/4, Section 2 ; T N-R 19 W Township I Mailing address ffv a so,✓ w i S~E-o / Jo i Address of site _ ~fU T7?~N ~~LL ~o.4D I Subdivision, name__ 5UN2/D E- Lot no. Other homes on property? yes k' No I Previous owner of property T i m 2 U S C 44 Total size of parcel 2 . 10? 4 G~t2~ S Date parcel, was created T1f~Nll I ) Are all corners and lot lines identifiable? X Yes No Is this property being developed for (spec house)? Yes X No Volume and Page Number 71 of Deeds, as recorded with the Register :INCLUDE WITH THIS APPLICATION THE FOLLOWING: A,I.WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified, survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner() of the property described in this information form, by virtue sofa warranty, deed recorded in the office of the County Register of Deeds as Document No. 45"/7,$"0 , and that I own the proposed site for the sewage disposal system) orr I sntl e(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. Signature o pplicant Co-applicant fig - 47k 93 Date of signature Signature Date of Y • DOCUME!•47' NO. - WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982;" i Greenw.4.4.41..Fn.CP,..a_.Wi;?cQn;5zn..CiZxpQration.,... ii i. - William V. Boyd and Susan K. Boyd, conveys and warrants to - - husban~ anc wife as survivorship marital property. . . . RETURN TO Heywood & Cari, S.C. P.O. Box 229, Hudson, WI the following described real estate in St-.-.Croix County, ;i State of Wisconsin: Tax Parcel No: Lot 19 of the Plat of SunRidge filed in the Office of the Register of Deeds for St. Croix County, Wisconsin, on September 22, 1989 in Volume 5 of Plats, at Page 71, as Document 451750. This is not homestead property. (is) (is not) Exception to warranties: r Dated this ----..Z.LLd_...---_--------------------- day of Augus t - . . . . . . . . . . 19 - - - . 93-- A ---(SEAL) `1~ (SEAL) James E., Rusch, President Mary , Rusch, Sec.re-t-ary/Treasurer (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) . James E. Rusch, President STATE OF WISCONSIN ss. f 511-CRUX County. authentic ated this daY of... August 19 ay of 9-3-- Personally came before me this .3 y- , 19.9-3 the above named * Walter HodynAy'-" --Mar-y--R-.- Ftseh, Set re Lary/Treasurer TITLE: MEMBER STATE BAR OF WISCONSIN I (If not, . - authorized by § 706.06, Wis. Stats. ) to me, kno n to h erso who executed the foregoi instr n nd a owledge the same. THIS INSTRUMENT WAS DRAFTED BY ~L Heywood & Cari•,--5_sCt.,--by-Wa•lter_.Hodyrl-~~Cy Box 229_, _Hudson_,__WI__ 54Q1•(••__________ Notary Pub is ..Bt_...Croix........... County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) date : 19......... ) *Names of persons signing in any capacity should be typed or printed below their signatures. WAAR.AWTV TIPAT WrA•rn oen nv grran~~rar~r m:.. rH.. 9 1p 0 Z., 1J Ow ~ S T C - 105 i SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYERLL/i4m V. 4- 5[>~;A ~l RO y ADDRESS fI✓TT©~ ~1L1- FIRE NUMBER CITY/STATE I //(J DSO/ { GcJ 2:7 ZIP ~5_*01 4. PROPERTY LOCATION : 1/4 , 1/4 , SECTION 2-q- , T 20 N-R_) 9 W OWN OF; 'yDsa~ St. Croix County, SUBDIVISION SuNQ , LOT NUMBER ! 9 . 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 ;aGCepted 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 c,ertification form, signed by the owner and by a master plumber, j,ourneyman 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 complet,ed'and returned to the St. Croix Co. Zoning officer within 30 days; ofithe three year expiration date. SIGNED: DATE. l0 6 9 St. Croix'co. Zoning Office 911 4th St ' Hudson,' WI; 54016 i .j,tA1 Livic1N 1 TRI-COUNTY SANITATION SERVICES Ben Morgan TRINCOUNTYy\ 507 5th Street, Hudson, Wisconsin 54016 Phone: (715) 386-2130 -R a- Statement Date C Previous Balance 0 Pump Drywell Pump Drain Fields Septic Inspection Water Test Clean Sewer Line Pay Last Amount in This Column -ift.