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HomeMy WebLinkAbout026-1116-10-000 AS BUILT SANITARY SYSTEM REPORT OWNER l (f~60J t P I~ . SECTION _-_T-3d N-R I g W l 1&6 1 Li . 2, ADDRESS 15 D $ ~5 ST. CROIX COUNTY, WISCONSIN SUBDIVISION lt~~~(9~.✓!►~- LOT_,~b LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM eW.~11 „M s y~ INDICATE NORTH ARROW BENCHMARK: Elevation and description: Alternate benchmark SEPTIC TANK:Manufacturer: ~.c~ILcon Liquid cap. /02p-o Rings used. 0)3 A `f y ''Manhole cover elev: ~ inal grade elev: Tank inlet elev.: ~ Tank outlet elev.: 9D, &S No. of feet from nearest road:Front-z-1 Side , Rear Ft. From nearest prop. line:Front Side,, Rear Ft. ! as No. of feet from: Well~~ , Building: ~V (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE F PUMP CHAMBER Manufacturer: Liquid Capacity: Pump Model: Pump/Siphon Manufact.: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front_, Side_, Rear_Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: y~ Width : 1 ;L- Length-zE y Number of Lines:__,--' Area Built Exist. Grade Elev. 7-5,3-5 Proposed Final Grade Elev. Fill depth to top of pipe: 'Del No. feet from nearest prop. line:Front , Side jC , Rear Ft.-A~ No. feet from well: No. feet from building HOLDING TANK Manufacturer: Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front , Side , Rear Ft. No. feet from: Well , building , nearest road Alarm Manufacturer: INSPECTOR: DATE : S 9 PLUMBER ON JOB : 6 LICENSE NUMBER: 6/90:cj ~~l(A 1 '~T arcr> t rq 01.30.18phiw&w%,[~, Bever Meadows coonY: l~7tt Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ST. (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 193363 Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.: ~FMI Insp. BM Elev.: FBM Description: Parcel Tax No.: /UC?.© /ate D IL=._u 4 026-1116-10-000 TANK INFORMATION ELEVATION DATA A9300023 S ~q~Q3 : /p°a,Y. TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ie,uc Benchmark ~J4!c ou. Dosi n 1 Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe a C/ Holding Bot. System PUMP/ SIPHON INFORMAT N Final Grade g qS Manufacturer Demand Model Number GPM TDH Lift Lrictitin Syestem TDH Ft C6 Forcemain Length Dia. FFii Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O tkA , CHAMBER Model Number: System: c{1 /0 ° ~lFj ' OR UNIT DISTRIBUTION SYSTEM Header/Manifold Il Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length U Dia. I Length 3 Dia. LA U 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 )-I• Bed /Trench Edges c Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: RICHMOND 01.30.18.672,SE,NW,Wi11d River Meado/w~s,Lot 20_-, an revision required? ❑ Yes eNo Use other side for additional information. taf 01 fog SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. f ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: j =ZM M SANITARY P ERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code ouNT~' S'C STATE SANITARY PERMIT # Attach complete plans (to the county copy only) for the system, on paper not less than l 3 6? x 11 inches in size. ❑ Check if reviil to pous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OW ER PROPERTY LOCATION D dke be t "mklike S a '/a %a, S T , N, R for) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # /505 hew S D CITY, ST E ZIP CODE PHONE NUMBER SUBDIVI ION N WE OR CSM NUMBER pas LJ S}o/ 7 1(7j-5 ~ Wl d II. TYPE OF BUILDING: (Check one) State Owned 0 VITM NEARESTROAD VILLAGE ~ OF: ❑ Public 9 1 or 2 Fam. Dwelling-# of bedrooms PARCEL AX NUMBER(S) III. BUILDING USE: (If building type is public, check all that apply) //f to 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 Outdoor Recreational Facility 3 ❑ Campground 70 Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 120 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) 1.0 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 0 Seepage Bed 21 ❑ Mound 300 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 !J0 REQUIR sq. ft.) PROPOSED (sq. ft.) (Gals/d /sq. ft.) (Min./inch) G.~1/ ?C ELEVATION 6' (e A) /,0 Feet 95 ,3.6 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 structed I 7- M -7 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 shown on the attached plans. Plumber's Name (Print): Plumber's Sign r (No S mps) fW/MPRSW No.: 71 Business Phone Number: C U/h P wars 24f y6 -s cis Plumber's Address (Street, Ci State, Zip Code): ~9b~ /1Y~5 iJtt. d ~JZ" a IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date l9suep Issuing Agent Signature (No Stamps), Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination I A16 X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-8398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety A 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. orm (SBD 6399) to be 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal F subruMeo,tg the county- prior to installatio. 5. Onsife sews e systems must be ro erly maintained. fhe se fid`tank s must be pumped by a licensed _ s purnper,ywhenever necessary, usually every-2 to 3 years. 6. If you have questions concerning your onsi a sewage system, contact your local code administrator or the State of Wisconsin Safety Buildings pivisiop;Fi.08-266,815. v. ti. U To be complete and accurate tFtry.prgrmit 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 instalre'd.,'~', 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. Vlll. 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 curie; pump model and pump manufacturer; D) cross section of the bsorption system' rmatio . Oquired by"the county; E) s%ilaest data on a't1~6 form; and F) alt'sxtirig info GROUNDWATER SURCHARdE i 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. T ;T{1e rrl~es c"' cted through these surcharges are used for fponito_r'ngigroutidNrater, ground- , n. water contamination investigations and establishment of standards SBD-6398 (R.11/88) STEEL'S SOIL SERVICE Ga►y L. Steel 988 N. Shore Drive Ferric}: Const. Inc. New Richmond, WI 54017 C.S.T. 2298 SEVJP'-S1-T30N-R]_ 8Vj MPRSW-3254 Richmond, twonship (715) 246-6200 I J G i ~ I I b r ~ _ I I I ~ ~ i ~ I I I I T r , 1 i I i I ~ - - - 6Y41k, I - - - - - j - - -1-- 1 - I iX 441, I , I I I 1 ~~b A- 1tr1 a~ - 1 cts i fr.~c G+ c Be~c -1 el --r AL, 415 3 I- - I - --a ! } 15 fi rt -21 - 1- - i r - I 1 F~ _ I I I /L I. ~ I , I I i I I i I ~ T- r ---I - i I f { I 1 I I ' i I i ~ ~ r ~ i 1 1 t I I ' i r 1 I ~ , I I I I I ~i I ' I I I I I I I I ~ I I I l- I I r I I ~ f I I l I ~ I I ~ I I j I i I I t- I_ I I I r I~ I t~ i I I I I I a- I I ' I t T I-_ I 1 i - i I I I I T I 1 a + I I , I i I I I I I I I I I I ~ ~ I I I I I I I I, I I I I i I r I ' I I I I - - I I I I I 'I I_ I ? I I I I t I ~ I I I , , - t I I 1 I I i - - ! - - - - - - - 'r I ~ i I i_ I I I III I~ I I I I ~ fi i F I I i- i r I I I l I I I i I ~I , ~ I, ~ i I I i I I I I I ' . I. i I I I I I I I _ { I • Cro 10 o f fl Ur17 S k!r%-) l~ I ~~w ~t der ~'a, ~ V•~,~Iy~aL/~ i S-~a,~,,~,s J-0 t 0e) froth Air In181► And OD►orvailon Pips S~ ZYW S ~Q 1 1 3d R l~(f~ v- Appre.i. Vint Cap ..v III ►rlnlmwn 12" Men final Gedd. iy~ 20- 42' Above P1pp _ 4' Coil Iron T• final Orode Vint Pipe Reran Hof Or Srnlnetk Co.irlnY~ lrtn 2- Apprepoi• Over P106 Olilrlhrllon tip, of e e Te• + 6' AOaraO.1• Beneath PIto a PulerUeo Pipe 6ilw o -'CG,01Aj Torminelinll At • Bolcom 01 Sr►lem i i 9S . 3-S / SOIL FILL OISTRIBUTIOM PIPE :f a APPROVED S4)JPACTIc COV[R .r ~_-tj KT ~I Ifil- OR 9•r OF 5TI1AV1 2" OF hGGREGA1F- OR MARSM ~J q L E V. O ~Y L~• O F lZ - 2Z AGGREGATE I 3. DIS'rRID'JTI0Q PIPE TO 0E AT LEAST a~ IUCHES BELOW ORIGIIJAL GRADE AIJU AT LCASTLO IMCHES BUT EIO MORC THAI) 42 IAICHES 13ELOW FIMAL GRADE MAXMUM DEPrH OF FXCAVAT100 FKOM OKIGWAL 6RAoF- WILL BE S'3S IIJCHES ruKJMVM OEPrN OF EACAVAT10" r-P011\ CAkl6 NAL RAP F- WILL BE. IQ45' INCa1C5 SIGIJCO: LICCUSC 1JUMBEI2: DATE: 3~dr~9 60151 60 s2s.10OutIOt 1 o~e9 x.o3 AGM ry``S 9'S~ J'1.07AGM o 17 WiIIow 16 2.02 AaM ; 0 18 River 2.01 AaM 19 z q ~y 20 Meadows LOA== 15 w 21s AaM 14 s, 305 202 A&= ryy. 13 • 21 206 ~Jl ~S ?)0 2.8 AGM 2.03 AaM n CD !a 4j v iw 301.13 N 161.13 200 » 203.78 9 N 10 2.01 Aaa 2-00 Arms ~ ~ 11 vq s ZOO AGM 'Ory 12 « 22 O 201 AGM ~b 200 AOfM o 206 214 135.29 Public IN 4M.74 to X 23 8 a 7 zoo AGM N 7-00 AGM N 2.22 ACM T 6 s N 209 206.30 24 504.30 cv 2.00 ACJM 6 o _?8 s' ACM h 425.25 0' m/ 1 N 5 e 316 25 N 7-01 AGM o 7-a AGM 440.49 y a 27 r 29 213 AaM 232 AGM a 4 77.60 a Wmw 2.0 AaM a e Aiwr 478.33 260,57 1 77.60 City of New Richman N a 3 26 Z.30 AGM o a s@ 211 Aa o Highway 84 507.06 30 42° 229 xoo = 211.03 S tos ACM County Rd. GG 323.20 32 33 A a « « w 220 ACM 19a Aa e G Mo ° w ; N 31 181. AGM « 201 AGM _ 200.50 326.37 226 Highway GG (715) 246-2320 RRICK Rowe 1 W New Richmond CONSTRUCTION Wisconsin .F La bdHu a Industry, • Lab6orr and Human Relations SOIL AND SITE EVALUATION REPORT Page 1 of 3 Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St . Croix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL 1. D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Derrick Construction, INc • GOVT. LOT SE 114jq-j 1/4,S1 T30 N,R 18 )5Qor) W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUED. NAME OR CSM # 1505 11y. #65 20 n/a Willow River I`teadows CITY, STATE P CODE PHONE NUMBER E]CITY ❑VILLAGE OkOWN NEAREST ROAD 1`1ew Richmond., tdi. 54011' 1715) 246-2320 Co. Rd. #GG "New Construction Use [ ] Residential / Number of bedrooms 3 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2 Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate . 7 bed, gpd/ft2.8 trench, gpd/ft2 Recommended infiltration surface elevation(s) Al _35 ft (as referred to site plan benchmark) Additional design / site considerations entire area to be cut to el. 95.35 Parent material o twash Flood plain elevation, if applicable n/a ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem Z ❑ U ❑ S U :as 1:1 U aS ❑ U 0S ®d1 ❑ S k 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 Trench 1 0-16 10yr4/3 none L. 2/m/sbk mfr c/s 2/f ,5 .6 - 2. 16-43 10yr4/4 none sil.-s1. 1/f/sbk mfr g/w 1/f .2 .3 Ground 3 43-82 10yr4/4 none co.s. 0/sg ml n/a n/a .7 .8 elev. 93.60 ft. Depth to limiting factor >$2_- Remarks: Boring # 1 0-15 10yr4/3 none L. 2/m/sbk mfr c/s 2/f .5 6 2 2 15-27 10yr4/4 none Is. 0.1sg ml g/w 1/f- .7 .8 3 27-48 10yr4/4 none co.s. 0/sg ml c/.s n/a .7 .8 Ground elev. 4 48-12 10yr5/4 none co.s. 0/.s ml n/a n/a .7 .8 96.70 ft. g Depth to limiting factor >120" Remarks: CST Name:-Please Print Gary L. Steel_ 715Pft-6200 _ Address: 1554 20001. Ave., New Richmond, WI. 54017 Signature: - 3-5-93 Data; 2 )r)f; CST Number: .PROPERTYOWNER Derrick Const. / SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0-13 10yr4/3 none L. 2./m/shk mfr c/s 2./f .5 .6 3 2 13-33 10 r4/4 none ls. 0/sg ml g/w 1/f. .7 Ground 3 33-92 1.0 r4/4 none co.s. O/s ml. n/a /a .7 .8 elev. 95.15ft. Depth to limiting factor Remarks: Boring # 1 0-13 10yr4/3 none L. 2/m/sbk mfr c/s 2/f .5 6 4 2 13-27 10yr4/4 none sl . 1/f/shk mfr € /w 1/f .4 .5 3 27-53 10yr4/4 none Is. 0/sa ml g/w n/a .7 Ground elev. 4 53-11) 10yr4/4 none co.s. 0/s¢ m1 n/a n/a .7 .8 ()5.70 ft. Depth to limiting factor >J 12 Remarks: Boring # 1 0-10 10 r4/3 none L. 2/msbk mfr c/s ?./f_ .5 •'.E 5 2. 10-24 10 r5/4 none sil. 1/f/sbk mfr g/w 1/f .2 .3 3 24-36 10yr4/4 none Is. 0/s,, ml g/w n/a .7 .8 Ground elev. 4 36-80 10yr5/4 none co.s. 0/sg DJ. n/a n/a .7 .8 04-3 ft. Depth to limiting factor >80 Remarks: Boring # 13 Ground elev. ft. Depth to limiting factor Remarks SP?D 81IO(R05/92) i • SL.'":'rC "~~:lK SAL:1TT:tA~C_ ~~CZL:!E:1T 5 r.. C ro L : Ca tLL ~,{JJLLOCt-' Rl vt5a JCS/ NT I/e-N ru2c OWNL•:t!lu7ma !,/o A464AEL- R. 571CVEJS Et0(ITcl~30°_ 'ITImBE:t /SOS PwY (o Fire 4umber /Sos CITY! S".lT~ Ak-W )eIC.F-I A40AJO, V!I ZIP P^IIPS:t' 7 LOC.ITION: S~ NW Section 3c) i, .'own of kcINA40AJO SC. Cro i» CaunC7, All-A0occtS Lac number a~ Subdivision Zmaroper use Xad maincanance of your septic syscam could, result is its premacura failure cc [candle wastes. Proper maintenance can- siscs at pumptag out Cho septic tank ever,7 three years or sooner, i= needed. 'oy a Licensed sea c tc Cank oumve r . tihac you puc Laco the syscam can at-'ac: the cuncc:un oc the septic tank as a c_eac- menc stage La che3 wa3ca disoosal syscam. St. Croix Caunc-r restdencs may 5e aligibla cc receive a grant cor a maximum it 60z ut the cost it replacement of a tailing syscam, whtLch was is oaeraci.on prior to July L. L978. St. Croix CounC7 accepcad this program La Ammusc or L980, with the requiramenc that' owners or all Mari svsnts agree to kaeo Chat-= syscams properly maiacaiaed. ,%a Pprover:7 owner aq_ees to submit Cc Sc. CraL: Cuunc7 Zaniag a cart :_cac:.on loom, signed by the owner and by a =as-car plumber. lourneyetan plumber, rescriccad pLumber or a Licensed pumper ver:- Ey.ag Chat (L) the on-sica wascawatar disposal syscam is.La prooe;~ operac_ag condition and (I) at'_ar LasaecCion- and pump Lag. (i! nec- essary) , Cher seocic Cank is Less than L13 tall of sludge and scum; Car_i:_cation fora will be sane aporosintaealy 30 days prior cc three year axpiracion. L!'.:E. the undersigned. have read the above reauirsmencs and agree to mac :coin the prtvacm savage disposal syscam Ln accordanca 'Jith the standards sec forth; herein, as sec by Cate '•iLsconsin Depar:- menc uc Vacural lasources. CarCi:=cation fora must be comoLaced and racer-.zed co Cate Sc. Crot= CounCl Zoning OE_ice within To* days of the three year ex?ir:scion data. S .C:: cII 7A3-8 -93 Sc. Cro - Count? :Jni:t4 UE__cs 7.U. 3on uCmmorvQ. '.:7 34.3 L 3 ti i.:1 2'.. ;nit ~r-r ;i thuv•~ lt{d:ra. . APPLICATION FOR SANITARY PERMIT S T C - 100 f- 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 (/ILL-OW )&Z m J/~ " t16" Ae:G7 IMIC4446:L- /00• S~EV'C"S 5e / .4 fit, Section , T 30 N - R l W Location of Property Township k CRI(4 a /1I D _ Mailing Address OS Subdivision Name !mot//t 1w e, v~Z ~ ADG~S Lot Number o20 Previous Owner of Property SC.4+iW i A Total Size of Parcel -2•d 3 2 Date Parcel was Created Are all corners and lot lines identifiable? It Yes No Is this property being developed for resale (spec house) ? X Yes No Volume 8Co and Page Number 49(a as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE. OF THE FOLLOWING: 1. Warrant D 2. Land Contract 3. Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. Tf the deed description references to a Certified Survey Map, the the Certified. Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER. CERTIFICATION I (We) e.e,hti{,y that aXt statements oh this Koh.m axe tA-ue to the best oK my (oux) hnowtedge; that I (we) am ( cute) the ownex (,5) o(j the. pnopent y de s cA i.bed in .tdws i.nAo4mat i.on 4oh.m, by v-vr.tue o(j a wa)oan.ty deed Aeeonded in the 066ice oA the ('runty RegiAteh 04 Deo? ldA 0,1 Pnot)meyr.t No. 4/S5--WG : and that 1 (we.) p.v,sentXy own .th.e phopose.d Aite. 6oh. the. sewage disp~.a. -,sys,te.m (on 1 (we) have ob.ta,i,nc.d an easement, to hu.rr. with the above deSc ibe.d pnopexty, Am the covr,sfi~tuction o6 na,id AyAte.m, and the bcune haA be.e.n day ,Leconded .in. the 044i-ee oA .the. County Re.gistvi oA Viced~s, aA Document No. SIGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED L _ 5•f ATU ItAlt f1r WISWVIJJIN FORM 2-19A2 ~jG~pAGE4Jl1 45,5206 REGISTER'S OFFICE St. CROIX CO., wi - Michael. R.. Stevens, William lI._ Derrick, , i. . William..M.. Derrickr Thomas.. E..b Derrick. a.nd........ ReC'd for Record Ronald L.. Derrick as. tenants-in-common ,1/kN Iq lJ90 of 8:30 M roncr}s :Ihtl t,:nrmtt tit Willow. River. I.uint i ...Venture. . Repl~let of deeds . _ . ` f1lrUhN t0 II ............................1....... till folimvitle desctil•rtl re") e:+tnte hl St. ..Croix ..................County, State or tVirconsin: II Tax Parcel No: Southeast Quarter of Northwest Quarter and Northeast Quarter of Southwest Quarter of Section 1, Township 30 North, Range 18 West. .i Rik s I~ t. j rim .I li 'I'hh! , ..~.R.,hbti. Ilnhtt!3(~lII( ptnpchly, • • ' , ,1 I (!s) (is not) 1 ,;reel+Uml to wnrrnntiem municipal and toning ordinances, easements And rd9trictiond of record, ~I Itdthd lhis tiny of Jan U rjf (SEAL) William M. Derrick Michael R. Stey n....... * . .g... r. lot,. j'.eee .1 ,A1•) A +1'~I /iill ' ~flf/../. (SrA1 e tq~ R► d ek / . q ..William.. N..ber,r.ick Thomas Y A UT E17!IrVT1oATitoN ~ R1 o rt MHNT K hq'.gA-.-a:-,.StevPna; - sTATF OF WISCI)NSIN Wi.l ain H. Derrick, Wiliam M. e~• Der-1kThoma ••R. Derrick- and Ro County. Def&k a au Pntlented this dy Ilf..•---ITalltua>•y.,.; 1li..g0 --l, cMlne-betord-me title -.:.,...,...r,,.:tiny of L~11....,.. . 19........the above named Judith A. Rem ngton TITLE: hIL"AI lEtt 9TATn PAR ar wisCON's1N Wis. (it not. iluthorired by 4 700.0A, Wle Stnfa.) to me known to be the person who executed the foregoing Instrument tend acknowledge the some. TF1111 IfFSrnUMM'r VlAS bnAPM) nV . RFM NGTQN...LI......O..SIC cAi~mi~ton54017 R xi11v.....►._.. Nota.- i+lll,lic ............County, Wk. ISIMmtures may lm mtlhrut.icnted or arkntrt+•lcll•;cd. Ilot.h M?' ~'ommisslon Is permnnent.(If not, elate expiration nro not neceminry,) dates , 19.........) 1 "'+nt~t of pernon~ virnln~ In nap r•nt•nrllp nHnuLl I.r :)n ••1 r.C 1•rbtl,•d W-11M Ih.•Ir rhn111IM-1.4• %VAnnANtT tnrrn FTATR Pill OT IVI9C0N31N ~1'1•,tmt.-.In /eytel hlnrd: 1'•.. ir,. REPT131 RICHMOND ST. CROIX COUNTY ZONING PAGE 1 0,5/1+8193'16:46 REQUESTS FOR INSPECTION WORK SHEETS FOR: 5/19/93 AREA: MJ Activity: A9300023 5/19/93 Type: CONV93 Status: PENDING Constr: Address: RICHMOND 01.30.18.672,SE,NW,Willow River Meadows,Lot 20 a Parcel: 026-1116-10-000 Occ: Use: Description: 193363 Applicant: WILLOW RIVER JOINT VENT Phone: Owner: WILLOW RIVER JOINT VENT Phone: Contractor: POWERS, CALVIN Phone: Inspection Request Information..... Requestor: CALVIN POWERS Phone: Req Time: 10* 5=Qe is : la" Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION