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Home My WebLink About030-2007-20-000 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER 'DoygAIA WP' Vefz sew ADDRESS ~o y C 1 AtADS-Otj SUBDIVISION / CSM# LOT # SECTION-3 q T3CN-R__Q Town of S-t ~UStP k ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 3 &vK0Ukn Nv~ ~t 3~ ATN -9TSy .3yb4To f a - 17 sa 80, 7o, Ne W ~ 01 a 3 - TR r r~ c.1u s ~3F . N INDICATE NOR H ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. I t f r BENCHMARK: -rOP OTC fiz, {~L~ lob, a ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION USeo 01 Manufacturer: Liquid Capacity: )000 qq Setback from: Well House Other Pump: Manufactu Float s Ga 11 o n s cyc e. Alarm Location ....SOIL ABSORPTION SYSTEM I r ~ Width: 5 Length IS Number of trenches Jr "XI's Distance & Direction to nearest prop. line: 34' Setback from: well: House Other ELEVATIONS Building Sewer ST Inlet; 97.9 ST outlet 9 7 ~VC n7.e*f Header/Manifold Bottom of `system-'.,._t Existing Grade Final grade W4 TRewck S s ty, I~cr~oe~ q.4~ f3v~ori, DATE OF INSTALLATION: 9 `i o AND In•1~ ~i%v PLUMBER ON JOB: Ccirr• LICENSE NUMBER: ~yo ! INSPECTOR: 3/93:Jt 1y ~U Lc~w e~ l 3 . to N I J-Tq7 Human rterttOfln n PH 34.30•911WTE S'EWA&'FSYE4 I County: L'abc~rand H Huuman Relations Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: 193425 Permit Holder's Name: ❑ City ❑ Village ❑XTown of: State Plan ID No.: ST. JOSEPH M E ev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 106,0 160, U 1 SCcfiy 4=. a_; W , r., 030-2007-20-000 TANK INFORMATION ` ELEVATION DATA A9300084 51,20143 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ° y Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet .Sl. (9 7e 9 TANK SETBACK INFORMATION St/ Ht Outlet ,OS~ 97• TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet rl Septic r l a (a F G, f NA Dt Bottom Dosing NA Header/ Man. 9~ v 9o.07 S6 4i v 4 Aeration NA Dist. Pipe Holding Bot. System %a 17, PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM I Loss Friction System TDH Ft TDH Lift Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED / TRENCH Width , Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS J r .~s DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Model Number: System: ?o) OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- ( Length 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.) S 7 e u ,I' ~~PCATION: ST. JOSEPH 34.30.19.374B,SW,NE,CTY. RD. I 5 .05 Plan revision required? Yes ~1N Use other side for additional informatio .-d o?O 9 FZI02,W SBD-6710 (R 05191) Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH ~ SANITARY PERMIT NUMBER: r ~ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY aaaaaas• aawwm~ns ~ I a~ •aaunwu/.as.aw,wus.w,as. STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than / 934/8% x 11 inches in size. check if revision to prey ous 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 r)n IA 0, A.IVarSU U)% E Y.,S.3~ T30,N,R E(o W PROPERTY OWNER'S MAILING DRESS LOT # et,/ A CITY STATE BLOCK # ,S T ZIP CODE / PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER L:I Ill. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ V LLAGE ~ NEB ROAD^ ❑ Public! or 2 Fam. Dwelling-#~ of bedrooms PARCEL TAX NUMBER(S) ` I Ill. BUILDING USE: (If building type is public, check all that apply) %-CJ 7 o !1 /~1 Oy(J 0,30 1 ❑ Apt/Condo v ~C 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 80 Mobile Home Park 120 Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1.E1 New 2. ~ieplacement 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 420 Pit Privy 13 ❑ Seepage Pit Pressure 430 Vault Privy 14 ❑ System-ln-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 RE UI D ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min i ch) Q9 Q ELEC,V~ATION V / •56 Feet 7~• ' Nest VII. TANK CAPACITY Site in allons Total of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New lExisting Gallons Tanks Concrete structed glass App' Tanks Tanks Septic Tank or Holding Tank 00 U QQ 77 Lift Pum Tank/Si hon Chamber L] El El 1:1 Vlll. 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 Sig ure: (No Stam s) MP/MPRSW No.: Business Phone Number: rv\ &u Mk>R Q 6 7/S 3S 1 a~ PI ber' Address Stre City, fate, Zip Code): , ~~0 M) C.~M 6 S N ulDs pN 1 I~ IX. CO TY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date -sue Issuing A nt Signature Approved El Owner Given Initial ~~pf ppp/QQQ/// Surcharge Fee) . C 7 Adverse Determination X. CONDITIONS OF APPROVALIREASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber 7 INSTRUCTIONS v 1. ~ A sanitary-permit is velid for two (2) years. 2. 'Your sanitary pernfit 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. To be complete and accurate tf`iii 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% 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). S- r. A, NAME C N - _ _ , L C T :M ~A_P a 7' r r~1~(` `ate t c Va Je : - w { C~~ t trs e'.1 k r7 / s f . \IJ t FRHII A''I'; [fJLrI:'iS3 11tJD O13SSPtVJ17?C}t7 PUB C FOSS SECTION Approved Vent C.. Minimum 12" Above / F1 a►ki' GITa Final G je 4" Cast Iron Above Pipe` -'Vent Pipe, To Final G r a d r W------ ti.:.r. Or...SyPnthetic Covering Min. 2'° 11gC)1 CrJ+` ~ 1 t1" •erW Over Pipe Tec- Aggregate Wisconsin Department of Industry, S OIL AND SITE EVALUATION REPORT P Page !`abet anc] Human Relations 7/ division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code ' COU Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but fl'~ 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 PROPERTY 0 NER':S~AIILING ADDRESS GOT # LO BLOCK # 1/4 I SUBD NAME OR CSM O N,R S(or~N to Cr ~ n~ Z CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE GOWN NEA ST R MD N ~ -5 ('71 ya - 1/ f _ S~ Toss, Z, ic /Z [ ] New Construction Use 1>61 Residential / Number of bedrooms [ ] Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow ~O gpd Recommended design loading rate bed, gpd/ft2 trench, gpd1ft2 Absorption area required bed, ft2 25 trench, ft2 Maximum design loading rate:, bed, gpd/ft2, trench, gpd1ft2 Recommended infiltration surface elevation(s) ~QS ft (as referred to site plan benchmark) Additional design site consZcfm rations ma- ~e Parent material Sf" ,e 'SW ^e o_Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE T-GRADE SYSTEM IN FILL HOLDING TANK U- Unsuitable fors stem S❑ U S ❑ U S❑ U S ❑ U T ❑ S U ❑ S 1 SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon Munsell Qu. Sz. nt. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Tmnch 0-.91' d YR 3 Ne o~ -n / rn r s 211 2- 91~ 5 ly-1 Ground ~ 91-~p 1 Y S6~ W► a~ 5 `73v$~ ft. Depth to limiting factor Remarks: Boring # y 7,7 V z sr~ y~ loG, I Sd~ fyl ~r S a, -s Ground elev. S, Z.~ ft. Depth to limiting factor 1 Remarks: CST Name: se Pyiht Phone: 3 ` 3 Address: v ,~S N Ss I/Lj .S y0l6 Signature: Date: CST Number: `-J 03 PROPERTY OWNER SOIL DESCRIPTION REPORT Page of PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD/ft i,f Munsell • , Roots Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence Bed Tren y1f s 3 / r 14 S 2v( Ground VZV. 3,; i Depth to limiting factor >q, 33 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: .Boring # x>r<+YV s:;~:s Ll Ground elev. ft. Depth to limiting factor Remarks: cQ dam, v~ ~ r S I O \ V _ tic)~ ? 1 yo ~~ror r~~tv ewe- ",o s r~` s f o~ t1,~uSGI ~9 ST. CROIX COUNTY ~.k WISCONSIN r{hr,v~~~~ ZONING OFFICE ST. CROIX COUNTY COURTHOUSE a 911 FOURTH STREET • HUDSON, WI 54016 - (715) 386-4680 March 23, 1993 Donald Halverson 1264 Co. Hwy. I Hudson, WI 54016 RE: Soil Report, Glenn Johnson, lot CSM Vol. PG. Location: SW1/4 NE1/4, S.34, T.30N., R.19W., Tn. of St. Joseph, St. Croix Co., WI Certified Soil Tester: Mike VanWey, CST# 3447 Date of evaluation: Not Given Dear Mr. Halverson: After reviewing the above described soil report, it has been determined that an onsite soil verification must be conducted in conjunction with this office as allowed by s. ILHR 83.06(4)(a) WI Adm. Code. The purpose of an onsite soil verification is to verify soil suitability for onsite sewage disposal. The verification may result in a different size or type of septic system than that shown on the soil report. As a result, neither sanitary nor building permits can be issued for this property until the soil verification is completed. ely, mes K. Khopson Assistant Zoning Administrator cc: Property owner CST file Vftcon.4rn Department of Industry, SOIL AND SITE EVALUATION REPORT Pap of Labdi and Human Relations t?ivi§ion of safety & euiidngs in accord with ILHR 83.05, Wis. Adm. Code COU Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but V not limited to vertical and horizontal reference point (EIM), 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 'Z'61Q IGL Q I L/ or- GOVT. LOT 1/4 1/4,S T 3 0 N,R PROPERTY OWNER':S AILING ADDRESS LOT # BLOCK # rBD. NAME OR CSM # /a (o C:0 ti CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE OWN N ST R D [ J New Construction Use ~oJ Residential / Number of bedrooms [ ] Addition to wdsting building Replacement Public or commercial describe Code derived daily flow .SAO gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area requiredbed, ft2 trench, ft2 Mabmum design loading rate ' bed, gpd/ft2 . trer>ch, Recommended infiltration surface elevations $ Q S gP ft (as referred to site plan benchmark) Additional design site consi rations Parent material a f 4a, , ` ve a Flood plain elevation, if applicable It SYSTEM HOLDING S - Suitable for system CONVENTIONAL ~ S D U IN- S UND U ESSURE &T-GRADE U ❑ ,$J U ❑ $ TAW FILL I U - Unsuitable fors stem S ❑ U SOIL DESCRIPTION REPORT Boring # Horizon De AnFl, pth Dominant Color Mottles Texture Structure Consistence Boundl3y Roots GPD/ftMunsell Qu. Sz. ~ont Color Gr. Sz. Sh. B Wrtch 0-.92' OYR 31-13 Ile 011-^ / -ET;T /n ~l s 2v 13 Z fz~- 92 .f• y~ ~owM^ S yYl T, tz S ~ VT Ground 3 9t =~0 ` Y ` t S. /cNr- to ~i a -S -4 ' 13 5r fL Depth to limiting Ctor d I Remarks: Boring # 0-/'9' It) YR s3- vF•- Sb lvt -rr S 2 v - 131Ground 56~ o, s plev. 72SfL Depth to limiting factor 7 6.zs Remarks: CST Name: 0 Pyih R t Phone: 3 ~C l ~f 3 l- .1, Address: ,,7.7 3 s S LtJ ' S YO /6 Signature: Date: CST Number: 03%x'7 rnvrcni i vnncn OVIL Lic"WunIF' I IVIV HtF uhI Page jof~L PARCEL I.D. t Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence eour>dary Roots GPD/ft in.A Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed T ndi -77 3 d z~ /o YIP >-/-3 / W 5 2v( Ground 3 5~~, ~/0 R s 3 ,~s bk S sik ~O , 45 Depth to limiting factor W, D Remarks: j Boring # I 13 j Ground elev. tt Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: .Boring # Ground elev. ft. Depth to limiting factor Remarks: j 1V . l.a+ L; F N ~ O `Z o ~ I M Df°-' .aa ~ s.s J ~ t O ® yl k 1 k a~ a). 1,0 s f,k s pp ~J V C Or ~kSe-) Wisconsin Dum nReltofIn ustry, SOIL AND SITE EVALUATION REPORT Page of ' ision ohSafety & 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 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 - DAT PRO ERTY OWNER: PROPERTY LOCATION GOVT. LOT U_)1/4 e1/4,S3 T Q N,R W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VIILLAGE N NEAR ST ROAD ` p. sr' ] New Construction Use [ esidential / Number of bedrooms [ ] Addition to existing building jLpRvpfacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate bed, gpd/ft2 trench, gpd/ft2 Absorption area required bed, ft2 trench, 1112 Maximum design loading rate bed, gpd$ trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U ❑S ❑U 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 i rGt' v m 77 i 6r~ h'vy zmSbK aq elev. , , r 2 m S b - w/ tJ~ a 2 -A ft.y~ p 16 m O. O.S ' c1 ~l ~Zd l~ Depth to limiting factor Remarks: .-y /e0 wE { ± air f. Cd . Boring # Ground elev. ft. Depth to limiting factor Remarks. ~1 CST Name: Please Print i / Phone: Goo~ Address: U Signature: Date: CST Number: - { f 'r. x ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT A FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify thatI have inspected the septic tank presently serving the 10VV 4P'1V 2S61 residence located at: J (A) 1/4, ~ 1/4, Sec. .3T , T30 N, R W, Town of St J O ~►1 Upon Inspection, I certify that I have found the tank and baff'les"''to be in good condition, and it appears to be functioning properly. Last time serviced U 11 Did flow back occur from absorption system? Yes No-~< (if no, skip next line) Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacurer (if known): Age of Tank (if known): I h1 U)~ -RAJ' ~ (Sig ture) (Name) Please Print Cn"4~fi-e.L 1u~ 3 VOY (Title) v (License Number) (Date) Form to be completed by licensed plumber (x.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will conform to the requirements of ILHR-83, Wis. Adm. Code (except for inspection opening over outlet baffl Name 3)h'~ Signatur MP/MPRS 3voy 5/88 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER 1141 d % 74'Lko/ -.S04/ ADDRESS: C-6 FIRE NO: C,~ LOCATION: SLR 1/4, ~L 1/4, SEC. 3T,30 N-R TOWN OF: S7 5~.~~ ST. CROIX COUNTY SUBDIVISION: LOT N0. "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 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 to help with the cost of the replacement of a failing system, which was in operation prior to July 1, 1978. St Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to the St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification from will be sent approximately 36 days prior to three year expiration. 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 form must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: ~G DATE: St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), 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.Scv 1/4 IV, 1/4, Section 3'1 , T -,9o N-R-29 W Township J ~T3 Mailing address Z2.0 rT lko& Gri J y~ ' Address of site Subdivision name_ Lot no. Other homes on property? yes__Z_No Previous owner of property e e h701 sry,y Total size of parcel of Jy Ze _r Date parcel was created j j/ Are all corners and lot lines identifiable? Yes No is this property being developed for (spec house)? Yes No Volume and Page Number 53o as recorded. with the Register of Deeds . INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. certified survey, if available, ;would be helpful so asdto 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 warranty deed recorded in the office of the County Register of Deeds as Document No. , and own the proposed site for the sewage disposal t system) orr I e(we) obtained an easement, to run the above described the construction of said system, and the same haso been duly recorded n the office of County Register No. ,~Y gister of deeds as Document Signature of applicant Co-applicant Ddte,~,,or S nature Date of Signature DOCUMENT NO. I STATE BAR OF WISCONSIN-FORM 2 WARRANTY DEED 323844 Boo 515 ra~E530 THIS SPACE RESERVED FOR RECORDING DATA BY THIS DEED, Lawrence M. Halvorson and REGISTERS OFFICE Barbara A. Halvorson, husband and wife ST. CROIX CO., WIS. Reed for Record this_JAh_ Grantor conveys and warrants to Donald G. Halvorson and day 191.4 Patricia J. Halvorson, husband and wife as ' 0----P' joint tenants Register of Deeds Grantee $ for a valuable consideration One dollar and other valuable RETURN TO consideration the following described real estate in St. Croix County, State of Wisconsin: Gwin, Gilbert & Gwin Tax Key a 8 This is not homestead property. The East 475 feet of the North 250 feet of the Southwest Quarter of the Northeast Quarter of Section 34, Township 30 North, Range 19 West, containing 2 3/4 acres more or less. FE13 EXEMPT Exception to warranties: Executed at Hudson, Wisconsin this 7th day of Se tember 74,. _ SIGNED AND SEALED IN PRESENCE OF /-)Lawrence M. Halvorson a• AL) Barbara A. Halvorson (SEAL) (SEAL) Signatures of Lawrence M. Halvorson and Barbara A. Halvorson authenticated this 7th day of September 'fl I 7 a Title: Member State Bar of Wisconsin Yh Authorized under Sec. 706.06 ~>/zl STATE OF WISCONSIN I ss. Personally came before me, this day of 19_, the above named to me known to be the person who executed the foregoing instrument and acknowledged the same. This instrument was drafted by Hugh H. Gwin, Attorney at Law Notary Public County, Wis. The use of witnesses is optional. My Commission (Expires) (Is) Nemea of persons signing in any capacity should be typed or printed below their signatures. M.GMiwl~rcanpanr® WARRANTY DEED-STATE BAR OF WISCONSIN, FORM NO. 2 - 1971