HomeMy WebLinkAbout026-1116-60-000
oao 0 W3,
ti d
cz ao
o a
c y
c ? I
_c
o - I
V5
~ r
A 'o > I
V1 L
tY m
h N C U
N ?i t
Z U
C t~ ~
LL 0 -
_ C
3 N
Q c tp
~ I I
3 ~
d
Z
i
O Z ~ C I
z
cn ~ ! a m
o I
O Z
c
~ r ~ N
a0i Z ° o
In 1- E z
v 2 cn
N
c m 4)
a
r _ c0
O
O 3 z ao z
N o Z
N y N
wQ c co E 2 1
E
~~1 U y M V c
v o O O IL
~ " .
n a o
z
•N r-aaa y
CL
7 C~ L cM M y
U) J V O O }
r
(D r
0 0 Y E
N .
m N 0 N
C y Q } to t0
o > 7 '.4
O p c C_ H C
Cd O 30 0 c E O O
O o I- v d op m
o
H r rp~' L O N Y N FL- y fo (o
p_ _U - O r E •R U
Uj Y 'a a
~ CL
tt~~ 0
~1 A c~ a 2 ai ci
STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNERJU&Z 0
ADDRESS -50 W-U S / "T "C lU r~ ~Q 4-h
SUBDIVISION / CSM# LOT # pZ~r
SECTION-/ T_3 0 N-R_Zi!r W, Town of RICA an d
i
ST. CROIX COUN SIN
I
VIEW
SHO THING 0 FEET OF SY4& z
C-1
l a`~ 55 ~
~ zoo- a ~
INDICATE NORTH ARROW
Provide setbac and elevation information on reverse of this form.
Provide 2 dimensions to center of septic tank manhole cover.
1
s ,
BENCHMARK: VIA) COt/hs~. ~ E1~~')'~C~h~; l ar rn~ h
ALTERNATE BM•
SEPTIC TANK / /
Manufacturer: Liquid Capacity: fo?Jr~
Setback from: Well House Other a9 ,44' lftle N'
Pump: Manufacturer Model# Size
Float seperation Gallons/cycle:
Alarm Location -
i
.SOIL ABSORPTION SYSTEM
Width: 1.'2, Length 7;2 Number of trenches
Distance & Direction to nearest prop. line: N17-"t 3
i
Setback from: well: 1'0 House SS Other
ELEVATIONS
Building Sewer ST Inlet; AGA,, ST outlet. /D/, R7
PC inlet PC bottom Pump Off
Header/Manifold Bottom of system
Existing Grade 103- Final grade 7~3. 5
DATE OF INSTALLATION: 4~
PLUMBER ON JOB: P,~
LICENSE NUMBER: 1.5~r-3
INSPECTOR:
3/93:jt
01.30.18 P&N7-7A ~~J~T 2~r
L6?(cc 'i ertra f1S*AL8 SWrMHWY 66 Q~ County:
Labor and Numan Relations INSPECTION REPORT
SafetfVnd Buildings Division ST. CROIX
(ATTACH TO PERMIT) Sanitary Permit No.:
GENERAL INFORMATION 193423
Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.:
44 ~ APR: RICHMOND
ev.: Insp. BM Elev.: BM Description Parcel Tax No.: \ c 60
C~ . C1 /Ov- 6_0 ~ ~1'r a 026-1116-60-000 3 '
TANK INFORMATION ELEVATION DATA A9300083
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic j I y__ f~ r,~ zG~ Benchmark
Dosin
Aeration Bldg. Sewer
Holding St /FX Inlet D~-
TANK SETBACK INFORMATION St/ 14 Outlet
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet
rl
Septic y Q~ ~c NA Dt Bottom -
Dosi NA Header4L 1.
Aeration NA Dist. Pipe / 77
Holding Bot. System 7 2? 77~
PUMP/ SIPHON INFORMATION Final Grade
Manuf Demand Model Number GPM
TDH Lift Friction System Ft
Head
Forcemain Length Dia. Dist. To Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length , No. Of Tr nches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSION DIMENSI
SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING =rer: INFORMATION Type O CHAMBER ~a v Model Num
System: OR UNIT
DISTRIBUTION SYSTEM
Header - Distribution Pipe(s) i x Hole Size x Hole Spacing Vent To Air Intake
Length -6--, Dia Length _71~1 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 / *eh-Center ~ 3) Bed/ T &o4h Edges- - . Topsoil ❑ Yes E] No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.)
LOCATION: RICHMOND 01.30.18.677,SE,NW,LOT #25, HWY 66
Plan revision required? ❑ Yes Lrdq10
Use other side for additional information. F6 /
SBD-6710 (R 05/91) Date 4,00,Inspector's Signat re Cert. No
ADDITIONAL COMMENTS AND SKETCH
f
SANITARY PERMIT NUMBER: 4 '
HR 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 re~ion 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
(Z b W 1 l)2r ~ r SF t!a ft) S T30, N, R Ig- or) W
PROPERTY OOWSNER'S MAILING ADDRESS LOT # Q-5 BLOCK #
1,50- I
CITY, ST TE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR M NUMBER
D! /S - <1 0e i -
II. TYPE OF BUILDING: Check one CI ` ^ NEAREST ROAD
~ Vf ( ) ❑ State Owned VILLAGE fGM~I G G
❑ Public LpJ 1 or 2 Fam. Dwelling-# of bedrooms/ PARCEL NUMBER(S) 47
III. BUILDING USE: (If building type is public, check all that apply) as /V -/04 - 60
1 ❑ Apt/Condo
2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/School 80 Mobile Home Park 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A) 1. ~ New 2. ❑ Replacement 3. El Replacement of 4. El 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 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ 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.) (Gals/day/sq. ft.) (Min./inch) Q ELEVATION
to Q6 959-11 86 t 7 Al / 995 Feet Jd:K Lk- Feet
CAPACITY
VII. TANK Site
in alions Total # of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper.
INFORMATION New istin Gallons Tanks Concrete structed glass App.
Septic Tank or Holdin Tank Tanks Tanks
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 ma, Print): Plumber's Signat • (No Stamps) NW/MPRSW No.: Business Phone Number:
Cu1~ t.1r S 1 s~3 7)5 -5435
Plumber's Address (Street, City, State, Zip Code):
c W d spa/
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved Saary Permit Fee (Includes Groundwater Date ss Issuing Agent Signatur (No Stamps)
XApproved ❑ Owner Given Initial 67) Surcharge Fee) -7
Adverse Determination 0 v /
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s Buildings Division, Owner, Plumber
INSTRUCTIONS
1. A ganitary-permit is valid for two (2) years.
2. Your snnitarypermit 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 San tary Ter ?;!t Transfer/Renewal Form (SBD 6390 to be -
subm,itted.tQ the ourlty prior to installation. ;
5. OnSftP sew,a e systei6gmust be property 'maintained. The y . £ c tank( `rMJ,t be pumped by licensed
pumper, whenever necessary, usually ever! 2 to 3 years.
6. If you have questions concerning your onsite sewage system, contact your local code admtr islrato? or the
State of Wisconsin, Safety & Buildings Division, 608-?6Q-381,5
r
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.
It. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
Ill. Building use. If building type is Public, check all appropriate boxes that apply.
IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or
repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested in ##1-7.
Vii. Tank ;rforrnation. Fill in the capacity of every new and/or existing tank, iis? the total gallons, nurnt:•er of
tanks and iarojfacturer's name. Indicate prefab or :site consb,,,clad and tank material. Gomrlete+ for all
septic, pu!ripf's"phon and holding tanks for this system. Check experime:, ai opproval only if tanks received
experirn-rJal product approval from Dli_t-I t.
VIII. Responsibility statement. Installing plumber is to fill in name, 'icense n srnbe, 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.
Ccmplete> flans and specifications not smaller than 8'% r.: 11 inches mu-at be submitted to tnf) county. The
plans include lc,, `oilowing: A) plot plan, drawn to scale >r with corn,?iete dime, sio s. location of
holding <:ry- <(s± sr rt ; tank(s) or other treatf,wnt tanks; buiidir s3- ewers w lis; water rna.ins hater service;
streams and lakes; pump or siphon tanks; distribution boxes o:i systems; ri pb, `errent system
areas andd' 1-ic !ovation of the building served, B) horizont. 'o;," t~ertica` alevstion referem3c, pc,int:>;
C) complete specifications for pumps and controls; lose v6urr- , elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if,
_`tbA,60unt E) W1 data on a 115.f(um; and F) all 4izin information..;'
.required b
Y Y; ) SQ 9
- - - - - - - - - - - - - - - - - - - - - - - - - - -
GROUNIlW*TtR 9tlRCHARGE T.
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of
regulated practices which can effect g oundwater
The nwnies collected through thO~e surcharges are used for }ion qro in,dv Ater, grourd-
water t%)ntamafion investigations and establishment o stanc rcis.
SBD-6398 (R.11/88)
I I +
i J - -
I_ j~ I l j ~ j i I 4
' i
IY%
I ~I
i
l~ 6S I ~ ,
r
i
~ I_ l t- t
I i I I I ,
if 71' 0
a _ S / !Gay.
,
:
i i
ILI
coi.
III ~C~ ' ! til 1 +
:
I
i -i I I I
i _ 1 i : , I f f ~ I
I
~ t~ j t I i I I I I I ~ I I- 11 _
' I 1 ~ i ~ I ~ I
I ~ I t I - ~ } I I t i a I
I I I {
I I I I I I I I , ~ -1
I
J ~ ~ I I I I I I I ~
- i { { -
I
j
~ I i
I I
I i - I I
7 -
I '
I
' I
f
I I ~ I I t I 1 , I I 1- j j_ I I 1 r I _ 1-- a-
i
i
i
I i f ~ I I i ,
i
1-. T
I
I i I
I t
i
i
I I ~ i ~ I I I I ~ I ~ I 1
I i
I I I i
{
? r
I i
!
A I
. I ~ I I
~ I I ~ I I
i
I
I i
I I ,
I ,
I I
I
- I II
I
I
I I
I ,
I
, i I
(~~5 bSol S PAGE OF
5f
~rrJSS ee~iun p r /1 ~et~ SyJew .
sc /vw 9---J T36 ~
Fresh Air Iniets And Observation Pipe
~-Approved Vent Cap
Minimum 12" Above
Final Grade
20- 42' Above Pipe _ 4v Cast Iron
To Final Grade Vent Pipe
- Marsh Hoy Or Synthetic Covering - - -
Min 2" Aggregate -
Distribution Over Pipe
Pipe ion -
Pipe - 0 0000 Tee
B` Aggregate o
Be., pipe Perforated Pipe Below
o -Coupling Terminating At
Bottom Of System
0 3 . gs
Pr~Pvse~ Final. qre% l<
.SOIL FILL
DISTRIBUT10143 PIPE
APPROVED WVETIC COVER
cam, ° ° MATER1A1- OR 9° OF STRAW
r OF AGGREGATE OR (AARSN NAy
°
C,~BS ° (e~OF12-21/2 AGGREGATE
ELEV. OF / FEET-►
DI•STR151,TIOU PIPE TO BE AT LEAST IIJCHES BELOW ORIGIMAL GRADE
AQU AT LEAST?-0 IIJCHES BUT 1.10 MORE THAI) 42 FICHES BELOW FINAL GRADE
MMIMUM DEPTH OF EXCAUATtmij FRoM f1R &wa 6KAoE WILL BEa ` IMC14ES
MIF41MUM gff "M of EACAVATIoM FROM 00Ki411bAL (3R49E WILL BE INCHES
SIGUED:
LICEUSE DUMBER: `
DATE: -S~ ~7~
STEEL'S SOIL SERVICE
Gary L. Steel
C.S.T. 2298 Derrick Construction Co, Inc.
MPRSW-3254 New Richmond, WI 54017
i`IF4-SIJ;, Sl-T30N-Rl8W (715) 246-6200
town of Richmond
lot #25, Willow River Meadows
v
\31efi o l '
1<
Jam- ~ 0 ~ Flo
dUY~
~•YLr+s~~ rn ~ ~ a tj~ ~ ~
3
v .
c,
STEEL'S SOIL SERVICE 1554 200-thh. Ave.
Gary L. Steel
C.S.T. 2298 Derrick Construction Co, Inc. New Richmond, WI 54017
MPRSW-3254 M,,S A, S1-T30N-R18W (715) 246-6200
town of Richmond
lot #25, Willow River Meadows
1b 01 ~i
Q
flo
LNVI r,
E%LL l~ rY~u~rl~ ~y~'
~v
0
77
Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page 1 of 3
Labor and Human Relations
0iv_++sionof 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 I.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 ICE 114S,q 1/4,S 1 T 30 N,R18 icEx(or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
1505 Hy. #65 25 n/a Willow River Meadows
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE EJOWN NEAREST ROAD
New Richmond WI. 54017 (175)246-2320 Richmond Co. #GG
New Construction Usepx] Residential / Number of bedrooms 4 [ ] Addition to existing building
j ] Replacement [ ] Public or commercial describe
Code derived daily flow 600 gpd Recommended design loading rate . 7 bed, gpd/ft2 •8 trench, gpd/ft2
Absorption area required 858 bed, ft2 750 trench, ft2 Maximum design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2
Recommended infiltration surface elevation(s) 99.85 ft (as referred to site plan benchmark)
Additional design / site considerations niA
Parent material outwash 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 9R S ❑ U 1-21 S ❑ U [SS ❑ U ES ❑ U ❑ S xg ❑ S iaU
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
n 1 0-9 1 3/3 none L. 2/m/sbk mfr c/s 2/f .5 .6
1
2 9-21 10yr4/4 none sil. 2/m/sbk mfr g/w 1/f .5
Ground 3 1-32 7.5yr4/6 none 1s. 0/sg ml g/w 1/f .7 .8
elev.
103.45. 4 32-89 10yr5/4 none co.s. 0/sg ml n/a n/a .7 .8
Depth to
limiting
factor
>89
Remarks:
Boring #
1 0-9 10yr3/3 none L. 2/m/sbk mfr c/s 2/f .5 .6
g/w 1/f .5 .6
2 9-22 10yr4/4 none sil. 2/m/sbk mfr
Ground 3 22-30 7.5 r4/6 none Is. 0/s ml g/w 1/f .7 .8
elev. 4 30-92 10yr5/4 none co.s. 0/sg XICEO /a .7 .8
103.45 ft.
J,
13 >o'
Depth to
.
limiting l;~,,~r
factor '
~9
Remarks:
CST Name-Please Print Pho 49
Address: 1554, 2 0th. Ave New-Richmond, WI. 54017
Signature: Date: CST Number:
5-8-93 2298
PROPERTYOWNER Derrick Construction 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 0-10 10yr3/3 none L. 2/f/pl mfr c 7s n p n p
: 2 10-21 10yr4/4 none sil. 1/f/sbk mfr g/w 1/f .2 .3
Ground 3 21-29 7.5yr4/6 none Is. 0. /sg ml. g/w 1/f .7 .8.
elev.
102 R5ft. 4 29-84 10yr5/4 none co.s. 0./sg ml n/a n/a .7 .8
Depth to
limiting
factor
>84
Remarks:
Boring #
1 0-11 10yr3/3 none L. 2/m/sbk mfr c/s 2/f .5 .6
2 1-19 10yr4/4 none sil 1/f/sbk mfr g/w 1/f .2 .3
3 9-29 7.5yr4/6 none Is. 0./sg ml g/w n/a .7 .8
Ground
elev. 4 9-80 10yr5/4 none co.s. 0/sg ml n/a /a .7 .8
101.65ft.
Depth to
limiting
factor
>80
Remarks:
Boring # 1 0-15 10yr3/2 none L. 2/m/sbk mfr g/w 2/f 5
~OF
5
2 5-31 10yr4/4 none sil. 1/f/sbk mfr g/w 1/f .2 .3
3 1-37 7.5yr4/6 none Is. 0./sg ml g/w 1/f .7 .8
Ground
elev. 4 37-82 10yr5/4 none co.s. 0./sg ml n/a /a .7 '.8
101.45 ft.
Depth to
limiting
factor
Remarks:
Boring #
ay
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
STEEL'S SOIL SERVICE 1554 200th. AVe.
Gary L. Steel
C.S.T. 2298 Derrick Construction Co, Inc. New Richmond, WI 54017
MPRSW-3254 NE%SW%+ S1-T30N-R18W (715) 246-6200
town of Richmond
lot 425, Willow River Meadows
USV
T
4YL,4s2~ in e--t2-
~7r
60xs' 80 "5'tOOutfat 1
17 .07 AGM W 1O w
2A1 AGM h~. ►J~ o
18
16 N.w River
201 AGM 2,,. 19 ?a
20 a Meadows
~aD ~ 20SAO..
15
215 AaM 14 ?'9 ss .,s•
N
us 202 AaM
e
206 13 21
216 AaM ft 201 ACM w
a? sJ YI
? F at
131.13 361.13
m 200 283.18
9 10
2.01 AaM h 2.00 AaM e e
11 v e
200AaM 12 22
201 AGM 200 n
206 214 135.29
Public
2" 466.74
23
N N
N AGM N x.22 AaM T 2.00 ACM 16
in
° a
Zee M.30 24
504.00 09 200 AaM
28
s 6 237
425.25 ~ d~►
.
N o 316
am 5 e 25 -
zal ACM o I, # 2M Ae
N m N e
440.49 41 N 27
to 9 2.33 A.
i
4 V-~ a „ 77.M
wow
20 AGM a 46 RWw
4».13 2S9A7 I& ~ei•ss 77.60 Cry at New aifee0m
4b
26 =
e e 3 w w it ~
e
2.10 3 u a 4:O 211 Aa.. a NS07.06 N 30 42°
206
211.01 s Zoe AaM a
Comet ft m
125.20
• 32 33
.Te 2 N d e « w am AGM N 1,4 ACM e
N 31 N~ ~
1.81. AG.6 « 10 *4m N • _
•
200.50 329.17 226
Highway GG
RRICK (715) 246-2320
Route 1
New Richmond
CONSTRUCTION---=~ Wisconsin
SL°'_'.C "~1:2K '".AL:2T1i:2A~CZ ~L(:ZL~:!E:IT
5r.. Cro i» CJunc•r
Wi~~ow ~,v~R- ,o►NT' ~~►-~In-E
OWNeni 3U't=It G/v VNAyc+ NeE%_ gl r1/EN S
ICUTT-130M IUMBF_I: ISaS ~}wy ~oS Fire "lumber
CLT~~! STt•1 ~~+/R c44 AA Q $41:$
t 7~' Z+Tir~ ~"F~~l~
~
P^f)PS:tT,r L=L=N: SE it. Rw e„ Sac_ion I Z 30 Y, Et $ q
'"own ae ~c.VM0"D St. Croix CaunC7,
' nevi ~w ver ~V~.v~r,
Subdivision WkeNoovvs Lac number 2S
Improver use Xnd maintenance of your septic syseam could result in
its pramac-zre failure cc handle qascas. Proper maintenance eon-
siscs of pumping out the yaotic tank aver? three years or sooner,
i! needed, by a Lic=nsed se_o_c tank ou_mver. %hac you puc izco
the syscam :an arcac: Cho Cuncc:un Of Cho septic tank as a c=eac-
enene stage La the zasca cIi.saosal svseam.
St. Croix Csunc'P residence may be al:gibla Co receive a grant !or
a aaxn_m uz 60Z ad the cost if realacamenc of a failing syscam,
which was is ooeraclon prior to lull L. L978. St. Croix Cuunc•r
aecapead this program in August of L980, vies chee requiramene chat
owners 0! all seta svss agree to keep chair syscams proper! 7
~aaiacalaed.
T:te prooer=;r Owner agrees co submit co Sc. C.oi: C,3unc7 Zoning a
card!ication form, stgned by the owner and by a =as-car plumber,
journeyman plumber, rescrfcead pLumber or a Licensed pumver ver_-
Fv:ag Chat (L) the on-sica wascawacar disposal system is: in procei
operaciag condition and (Z) ad':ar inspection and pumoiag.• (i! aec-
assar7) , chw septic tank is Lass chap L!3 fisl'_ of sludge and scum
Cartl=:cation fora will be sane aporo%I_=acal7 30 days prior co
three year aspiration.
Z;!IZ. Cho undersigned. have read the above revuiramenes and agrae
co Maintain Cho or=vaca savage disposal systam in accordance with
cite standards sac forth; herein. as sac by Cho '.Jiseonsin Depart-
Mane uc lacsral lasources. Cartt!ication forts =use be comoLacad
and recur-red co the St. Croix CaunC7 Zoning Ofaice within TO, day
of the three Fear a:t?i=sclon data.
S:~ ~cD
0AT~
Sc. C=:'= Caunc'r
(y.U. 30
?ammo-a . : Z 31 41 0?
ti i.:^t • :net ~r-~ ;i
ihq,v"- ludcay~ .
APPLICATION FOR SANITARY PERMIT
STC - 100 '
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies will only result in delays of the permit
issuance. Should this development be intended for resale by owner/contractor,("spec
house"), then a second form should be retained and completed when the property is
sold and submitted to this office with the appropriate deed recording.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property V"4W jziyz-~- ~4(.IV
Location of Property 5e ~4 NW I't, Section , T 5,0 N - R 1 g W
Township <1 L44 A4Q -
Mailing Address 1 ~ja S
Subdivision Name 40L/ O w Ao-l ve-rz'
Lot Number 2 S
Previous Owner of Property 5C*tA & L)Total Size of Parcel c
Date Parcel was Created id ~4 - R v
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house) ? Y / \ Yes No
Volume g (a/ and Page Number g.~p as recorded with the Register of Deeds
INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING:
1. Warrant
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. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
PROPERTy OWNER CERTIFICATION
I (We) ce4ti f y that al Statements on this ~oAm ane t.ue to the best o4 my (owe )
hnowtedge; that I (we) am (Nee) the owneh (,s) o(j the ptopenty d"cAibed in this
.infonmati.on 4on.m, by vii tue o{ a wNVean.ty deed uco)Lded in the 066iee oA the
County Regidtoh ( PeerI6 aA Pocumont No. 455 - Zo(a . ; and that I (wo.)
p,mse.ntfy own .the phoposed .bite 6oA. the sewage poe AyAtem (on 1 (we) have
obtained an eaAe.me.nt, to nun with the above desc i.be.d phopeAty, Aoh the
con/sthuction o{ said Aybte.m, and the same, has been duty ucotded in the 066ice
oA the. County Regi,6ten oA Deeds, a6 Document No. Alrs -20 f0 ) .
SIGNATURE, OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE.)
DATE SIGNED DATE SIGNED
455206 FAGt4i 6
REGISIEWS OFFICE
Ue>r>V ick, , • +1 St. CROIX CO.r WI
Michael. R.. Stevens r .William 11 Recd for Record
lliam.M.. rickkas. tenants-ineaommonana..
Ronald JAM 1110)
Ronald L.. Derr 8.30 M
rt►R„•~:< aml ,,:,tlnn~r: to Willow. River.. Joint .1
:....Venture. .
RephletotDeed~
. "thin" to
.:...................................1....... I
I.h!! rollmviltlc desrrihtd ten) ertnte ill St. Xr.uix ..................County,
St to of t{ iaconain: Tout rarcel Not ..............................I
~I .
Southeast Quarter of NortltwestQ~ar~oWnsand hipN30tNorth,QRanger
of Southwest Quarter of Section r
18 West.
a
a
II ~ ~aA s
r
iI
II
'I'hla ...~~..hb~....r hlahth~ltslaal pralial•lr, . , ,1 lli+ir~~,;,1~~I,:L.:,
i (is~ GIs noEl
liNve1lUon tr trittrontleM Municipal and zoning ordinances t easements and
reetrictivns~ of redvrd,,
I
! or J.anur , y............
111011 ..9
it (ltie . . ~ . lln
21 . . .
(SEAL)
Michael R. Stev, ns William M. err ...,r
1 1
L j,.eeefl, (KMA 1.) 7. lift
~i ..William. am:. H. Der.rick.........
AUT1111INITionxtoN
il i " STATF: OF WISCUMBIN
.Michael R: Sievpns
W,I"iin6;iclj a..
a , r ~~,am M.
N, be-r... k ,
. Thoma ~k.-. Ver>: ck.. and County.
nRpulht< ~ d L- De ~7J r .,tl>~ of January-;
nnn Ienled tlds 111..80 __I'ersontilly cM1ne_belora-tne title
.
J 19. the above nnnlcrl
*..Judith A. Rem ng ton .
.y r
....V.......
TITLE- M -15forlt STA•t•a: nAlt or WISCONSIN
(II not............ ....-e It
huthorized by 4 700.0., {fits. Stnl4.) to n ki tnlell to be the person who executed the
foregoing Inatrunlent had acknowledge the same.
M14 11191nuMF_Nt vlA9 bnArttt) nV
J10MtRPT9......................
M NGT N I,llW OFFICES m.. ton
1~~ 5 4 017 .
..~t~c~iilv......► ciotnr~~ rltl,ltc
te esrirntion
(SIrrintutes cony be nulhratlented m nritnrr,~Icd',rd. 1tnl.h M!' ('ttn,misalon is Ilermanent.(Ir not, sta..Counts, Ws.
are not neccaznrr.) dnieI . . 19........•1
•'.nt~t nI prtnons OP111ne In rlnr rnt•nrny nh.nlld hr lltr •1 I,r 1•1I11h4 hrlnty throe f-IL110ot .
ctA7R I+41t pf tVIPGQNa1N a'lrcnnsln I,~~tel 111nrrh 1•.,. Ir.r
IVARIIANtt nrrn