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Home My WebLink About030-2087-10-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER Q i3 J= % &~,VO A/ ADDRESS 67'? Af RAE/ IS'OA n SUBDIVISION / CSM# 13ASY /Ct:F NDgTly LOT # SECTION T D N-R~W, Town of S ! I C;0 I ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM N0, 6,4y RVAO GvRNe2 A) 7 ~c ~'o C 5-4 L)j Nvu s - - L e-21 10"& u . 3X57 rREHCN~~ i INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: 74P OF ST~~L ~~PF ALTERNATE BM• SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: IvIlp;KS Liquid Capacity: 1006 Setback from: Well House Other Pump: Manufacturer AA Model# &A Size AA Float seperation IYA Gallons/cycle: i4 Alarm Location A SOIL ABSORPTION SYSTEM Width: S Length -5- Number of trenches Distance & Direction to nearest prop. line: igA- 5% Setback from: well: 50-f House 30' Other ELEVATIONS Building Sewer 7 5 ST Inlet, 9e, y~ ST outlet PC inlet PC bottom Y_A Pump Off NA- Header/Manifold q?,6 Bottom of system Existing Grade Final grade Z,4 tl DATE OF INSTALLATION: J 3 PLUMBER ON JOB: LICENSE NUMBER: 3,ZD INSPECTOR: 3/93:jt L9QAW'siTi4')*portA5en,e ofv1,9 H 22. 30 • AIVATHEV1 R E ~VSYEMBAY RD. County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division qROTX i (ATTACH TO PERMIT) Sanitary ermit o.: `GENERAL INFORMATION- Permit Holder's Name: ❑ City ❑ Village 1~ Town of: State Plan ID No.: ev.. Insp. BM Elev.: BM Description: Parcel Tax No.: /04 1 /6)0.0 TANK INFORMATION LEVATION DATA A9300022 a TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ei5 j OQQ Benchmark S,p / IUS,vi oo, D Dosing Aeration Bldg. Sewer 5, ~;L 9 Holding St/ Ht Inlet 6.0 TANK SETBACK INFORMATION St/ Ht Outlet 6, S g, 1/ TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic >,S6 /Q 71p NA Dt Bottom Dosing NA Header / Man. 7,q Aeration NA Dist. Pipe 7.56 9 7, V Holding Bot. System yy PUMP/ SIPHON INFORMATION Final Grade 5'! /00, Manufacturer Demand Model Number GPM TDH Lift Friction Syestem TDH Ft Forcemain Length Dia. FFii Dist.Towell SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 1-5- 2_1DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION Type O _ CHAMBER Model Number: System: s lj&tt, ~ a y O > O V OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) t' x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length ! l 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 r Bed /Trench Center Bed /Trench Edges Topsoil E] Yes E] No E] Yes [I No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION',.(ST. JOSEPH 22.30.19,NE,NE, LOT 1, N. BAY RD. _ M)"- 7-,l f 4 Plan revision required? ❑ Yes PNo fo Use other side for additional information. 5 a ;t,,ti< SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: m SANITARY PERMIT APPLICATION DILHR In accord with ILHR 83.05, Wis. Adm. Code couNTY t STATE SANITARY PERMIL# -attach complete plans (to the county copy only) for the system, on paper not less than 1 ~~//i V, 8% x 11 inches in size. ❑ Check if vision 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 Ra t_1 I& Af CAA NA:-. % E Y4, S 21 T30 , N, R E (or) PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 4 22 N, 9AX OA /3 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER L E 02 /f II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD El state owned VILLAGE 0 A ROAD ❑ Public X1 or 2 Fam. Dwelling- # of bedrooms 3 PAR T . UM R( ) III. BUILDING USE: (If building type is public, check all that apply) 030,20A 7/io 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. 11",1N 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 ~~V q. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION REQUIRED (sq. ft.) PROPOSED (s 3 S 7/5 g Feet f0 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New lExisting Gallons Tanks Manufacturer's Name oncret Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank QD Lift Pump Tank/Si hon Chamber F1 I [I F1 F1 I Ej El VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plu s Signature. (No Stamps) MP/ PRSW No • Business Phone Number: S~ / -6 CS D6AtA1zW Se,~V.^7 /7' 7- Plumber's Address (Street, City, State, Zip Cod l): o 5064 0ALZ_A;;rX lHely _ 7- IX. COUNTY/DEPARTMENT USE ONLY Disapproved M716~;E e (Includes Groundwater Date Issued Issuing gent Sig ature (No mps) Approved El Owne r Given Initial Surcharge Fee) D~ Advers D rmin i n ' 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 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 administratof 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. 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 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 mauls/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; (lose 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 01 regulated practices which can effect groundwater. Th ; monies coi!ected through these surcharges are used for ► -onitoring groondwatat, ground- water contamination investigations and establishment of Standards. SBD-6398 (R.11/88) i i I I i Q ' ~ f i ~ a- I i I I I ~ I t ' _ PP~~ovro I ~ _ } 1 1 . I i PP L - I c '0 6 I o I I ! I vi 74 , I- 1 10 - - i - l - - i 14c, ~ ~ I ! ~I T. Std t l i , 000 f , -I s s~ , I ; ~ I TAE t~ESI ~ G ! i s T /4th 9 i 611 { I I i t I { , _ I , ter- i j i r , ~ ~ ' I j i i - , I ' j i i I j 1 ~ , i I i i ~ j ~1 ~ ~ i ~ I ~ ~ - : ~ _ i ' j I I i j i i j I j~ j j I i i i I _ ; _ j ~ ~ - y , I i _ _ i j i i i I _ . I ~ ~ i ~ _ _ I ~ - ~ ~ ' i ~ j r i I ( I j ~ ; ! ~ , i i j ~ I i i , i I I ~ I i 1 j i i _ _ i ~ I i ,I I j ~ i 1 i I j I I . , I i i ~ . ' ~ ' ~ - ~ j _ ~ ~ ~ I _ . 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J....q 0 UI Z' Z $ I.tt u g ` ~ JI'18f1d 3N1 01 3,- ° - .£9'099 363ri,£f'.wS - n NO1197f IC 1/t3N 3Nl Af W13N 3N1 AD 3NIl lS3c v g N I N AVMH~JIH NNt12l1 AlNl10~~ s a ffi: ~a DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, c DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX 76 HUMAN RELATIONS N WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: 71N SHIP/ TY: LOT NO.: BLKNO.: SUBDIVISION NAME: NE 1 1/4 22 /T30 H/R19XE (or) W t . Joseph 1 n/a Bass Lake North COUNTY: OWNER'S ME: MAILING ADDRESS: St. Croix Richard Stout 11353 Awautkee Trl., Hudson, Wi. 54016 USE DATES OBSERVATIONS MADE NO, BEDRMS,: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: E OLATION TESTS: Residence 3 n/a )ENew ❑Replace 4-26-92 4-26-92 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑U CAS ❑U ES ❑U ❑ S ~U ❑ S conventional If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: n/a Floodplain, indicate Floodplain elevation: n/a deciaml' PROFILE DESCRIPTIONS page 34 BxB BORING TOTAL ELEVATION D PTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH I OBSERVED EST, IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B-1 7.01 99.85 none >7.01 .83, 10yr3/2, 1., .92, 10yr4/4, sil., 5.33,co.s. B_2 6.51 100.15 none >6.51 .67, 10yr3/2, 1., .67, 10yr4/3, sil. 5.17, 10yr- 4/4 co.s. B-3 6.50 100.10 none >6.50 •75, 10yr3/2, 1., .50, 10yr4/3, sil., .92, 10yr- 4/4, l.s., 4.33, 10yr4/4, co.s . B-4 6.84 99.17 none >6,84 .67, 10yr3/2, 1., .67, 10yr4/3, sil., 5.50, 10yr- B-5 7.00 100.10 none >7.00 1.2 10yr3/2, 1., 1.00, 10yr 3, sil., - 4/4 l.s. 4.25 1 r4/4 co. s. B- decimal' PERCOLATION TESTS TEST DEPTH, WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 PERIOD PER INCH P-1 6 6 <3 P-2 2.57 none 3 6 6 6 <3 P-3 3.50 none 3 6 6 6 &3 P_ PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 96.6C d E E I y ~ r f (1f ~ I F t rr% E :1 t - A 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: Gary L. Steel 4-26-92 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER optional): 1554 200th. Ave, New Richmond, wi. 54017 2298 7U-246-6200 CST SIG RE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SRD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section rnust clearly indicate whether this is a residence or commercial project; 1 MAXIMUM number of bedrooms or cornmereial use planned; 4, Is this a new or replacement system; S. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL. CONDITIONS; 8. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing to scale is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to (fates, names, addresses, flood plain data, percolation test exemp- tion, if appropr:;Ite; 10. If the inform as floc 1 elevation) does not apply, place N.A. in the appropriate box; 11. Sian the f„..., your cu_ address and your certification number; 12. Make legible cot I distril as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY -1THIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Textures Other Symbols st - S"')ne (over 10") BR Bedrock cob Gobble (3 - 10") SS - Sandstone gr Gravel (under 3") L° - Limestone *s - v:3 HC',,.' - High Grou - cs _ r Or"id P- Percolation reed Sand Well fs 1 Bldg Building Is L I.)d > - Greater Than "s' L1, =m < Less Than Bn -Brown sil - Silt L_~arn BI Slack si - Sill Gy - Gray cl - Clay Loam Y Yellow scl - Saw!, Clay Loam R - I sicl - Sil'Clay Loam mot - :ties se - S ' ; Clay w/ n sic - 5~-y Clay fff - fine, faint c f_, cc - men, coarse pt. - - mm y, medium m _ d - distinct r p prominent f HWL - High wa 1I, Six general soil textures surfac Vv for liquid waste disposal BM - Bench Mari VRP Vertical Reference Point TO THE OWNER„ 7 ,1 test report is the first step in securing a sanitary permit. The county or the Department may request 11 -n of this soil test in the field prior to permit. issuance. A complete set of~ plans for the private so system and a permit: application must be submitted to the appropriate local authority in order to o!,,ain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. S DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDIN INDUSTRY, DIVISION N LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 I-{UMAN RELATIONS \ 1 MADISON, WI 53707 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/ TY: LOT NO.:BLK. NO.: SUBDIVISION NAME: NE 101/4 22 /T30 N/Rl9xk (or) W St. Joseph 1 n/a ' Bass Lake North COUNTY: OWNER'S ME: MAILING ADDRESS: St. Croix Richard Stout 11353 Awautkee Trl., Hudson, Wi. 54016 USE DATES OBSERVATIONS MADE F]U NPROF E DE CRIPT ONS: PE TION TESTS: Residence n/a )E New ❑Replace ( 4-26-92 4-26-92 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) ® S ❑ [:~S ❑U E S ❑U ❑ S ®U ❑ S ®U conventional IIf Percolation Tests are NOT required DE IGN RATE: If any portion of the tested area is in the under s.H63,09(5)(b), indicate: 1 n/a I Floodplain, indicate Floodplain elevation: n/a deciaml' PROFILE DESCRIPTIONS page 34 BxB BORING TOTAL DEPTH TOG GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH I ELEVATION OBSERVE EST. GHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B-1 7.01 99.85 none >7.01 .83, 10yr3/2, 1., .92, 10yr4/4, sil., 5.33,co.s. B_2 6.51 100.15 none >6.51 ..67, 10yr3/2, 1., .67, 10yr4/3, sil. 5.17, 10yr- 4/4, co.s. B-3 6.50 100.10 none >6.50 •75, 10yr3/2, 1., .50, 10yr4/3, sil., .92, 10yr- 4/4, l.s., 4.33, 10yr4/4, co.s . B-4 6.84 99.17 none >6,84 •67, 10yr3/2, 1., .67, 10yr4/3, sil., 5.50, 10yr- B-5 7.00 100.10 none >7.00 1.2 , 10yr3/2, 1., 1.00, 10yr 3, sil., - 4 4 l.s. 4.25 1 r4/4 co. s. B- decimal' PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER Riftift AFTERSWELLING INTERVAL-MIN. I PER INCH P-1 6 6 <3 -3.25 none 3 P-2 2.57 none 3 6 6 6 <3 P-3 3.50 e 3 6 6 6 0 P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION q6-6a I i ~ ~ i I! I ~ ( 1~ p rr /y~ Id ~ , I 3 ^V~~ I , 1. , , I I i 1, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: Gary L. Steel 4-26-92 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): 1554 200th. Ave, New Richmond, wi. 54017 2298 7 CST SIG URE: J L. DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. D11.1-IR SPD-6195 (R. 02,182) - OVER - in SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County ~ OWNER/ BUYER ~LiY o ';r14 ~'c Fire Number 0 ROUTE /BOX NUMBER Co 'V/ M E r rt ifc ~~9 v _ M CITY/STAT ZIP L~ PROPERTY LOCATION:~ ' Section s TI') N, R/7 W, s~' n h Town St. Croix County, Subdivision 1.;,s Lot number. Improper use and maintenance of your septic system could result in its premature failure to handle wastes.- Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed 'se tic tank pumper. What you put into the system can al ect the .unct on t e peptic.tank as a treat- ment-stage in the waste disposal system. St. Croix County residents mad be eligible to recieve a grant for a maximum of 607. of the cost.of replacement of a failing system, wh c was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new 'sys't'ems_ agree to keep their system properly maintaiined. Th'e property owner agrees to.submit to St.. Croix County Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or..a licensed pumper veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and .(2)•after inspection and pumping (if nec- essary);, the septic'•tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year-expiration. H WE, C;heundersigned have read the above requirements and agree 0 to'mairta in!the private sewage disposal system in accordance with y the sCandards set forth, herein, as..set by the Wisconsin Depart- µ ment`of Natural Resources. Certification form must be completed •d and'returned to the St. Croix County Zoning Office within 30 days of thej.three year expiration date. SIGNED s DATE St. Croix County Zoning Office 9114th St. Hudson,,WI 54016 3864680 Sign, 'd,ate and return to the above address. 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 Location of property /9A6-' 119 AZC_1/9, Section TON-R/W Township Mailing address ~c~~"~e-s~✓ l~~c Sw ~s Address of site Subdivision name /Se s Lot number Previous owner of property P/I ~c/f a'O~ Total size of parcel b -Xc-rxcY i Date parcel was created' ~d - Are all corners and lot lines identifiable? X Yes No Is this property being developed for resale (spec house)? 2~"/ Yes No Volume _and Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and 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(s) of the property described in this information form, by virtue of a warrant deed recorded in the Office of the County Register of Deeds as Document No.~/S<" ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County egister of Deeds, as Document No. Signature of Owner Signature of Co-Owner (If Applicable) Date of Signature Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2-1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 495596 y 995PAGE I-36 REGISTER S OFFICE ST. CROD(CO., WI Richard O. Stout and Janet P. Stout, husband R cCM for R@COfd i and wife survivorship marital property, MAR 21993 at. , . 11: 00 a . 7 conveys and warrants to Robert W. Swanson 1 V RETURN TO the following described real estate in St. Croix County, I State of Wisconsin: Tax Parcel No: ,Lot 1, Plat of Bass Lake North, Town of St. Joseph. This is not homestead property. (is) (is not) Exception to Warranties: Dated Rthis day of March 19 93 (%AkAJ aQ 4s cc (SEAL) (SEAL) • Richard O. Stout Janet P. Stout (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ss. St . Croix County. authenticated this day of 19 Personally came before me this ,,i,K day of March _19 92 the above named Richard O. Stout and Janet P. Stout TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person s who executed the authorized by § 706.06, Wis. Stats.) foregoing instrument and ack wled the same. THIS INSTRUMENT WAP D~%FTED BY Janet tout ' wa u ee rat fl~ I re y Lai sort Hudson, WI 540.16 Notary Public C r p' x County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) -q GGY~,,_~/ date: / '19 / 7- Names of persons signing in any capacity should be typed or printed below their signatures. SB2 NTF 0021 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms, P.O. Box 10208, Green Bay, WI 54307-0208 Form No 2 - 1982 REPT131 ST. JOSEPH ST. CROIX COUNTY ZONING PAGE 1 05/26/93 08:35 REQUESTS FOR INSPECTION WORK SHEETS FOR: 5/26/93 AREA: MJ Activity: A9300022 5/26/93 Type: CONV93 Status: PENDING Constr: Address: ST. JOSEPH 22.30.19,NE,NE, LOT 1, N. BAY RD. Parcel: 03072087-10-000 Occ: Use: Description: 193362 Applicant: SWANSON, ROBERT Phone: Owner: SWANSON, ROBERT Phone: Contractor: SCHMITT, DONIVAN Phone: 568-4948 Inspection Request Information..... Requestor: SCHMITT, DON Phone: Req Time: 10:05 Comments: to; 06 Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION J