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HomeMy WebLinkAbout030-2037-50-000 o a~ p a ~ 0 I c o ~ I o I O CL w ~ I 3 Q4 ~ I N N w C O 0 a z c U. c N o V t! a 3 ' Q) E a w ~ I v y I w o z o N Cl) Z d m o o z q c a 'z 2 o U) F r z c E m N CL ~i : IDI c • C C 0 t 0 z H z z '0 d C W m (V O t6 O CL D y ~ y d ~ (-D 3:F cQ 0 E N rG rc CL 0 U) U) U) 'o T 3 3 3 aU0 E z IL IL IL a ~1 O co M N J U o rn rn O M In ~~l N M O 0) N N a, y rn rn w O E M rn u7 I~ li y O O C a N N N L ,O y tT N 00 co O N 'd d Q } (n f6 ~l p 02 CO O J M y C o y c O N p co °o co o v o w o co H d Q> - v d °p °p °p °p r N N N N V M p C C 0 O) M O Co w O N N C p 7 N N N N 0 -0 ~ .ry<V. j f' C L co 00 co co 00 a M O (n O E O m Lo --j U • O N Cn m O z z ~i Cn V v, d ~v € a I dt a L a a d c o 'o 4 STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER~RL ADDRESS_ l`3 8_3 ZY Tf/ S , FTou c i gQM a),,. 6-`/06 SUBDIVISION / CSM# -A(A LOT # SECTION. T N-R W, Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM at L~ N /10uSC- ~L roa 0 jZbo s: r F G1 4 CEEpn our ~ ~9dPfG'C' _ INDICATE NORTH ARROW Provide setback and elevation information on reverse of this -form. Provide 2 dimensions to center of septic tank manhole cover. r r BENCHMARK: Z d P ALA17- Do a Sf L ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING.TANK INFORMATION Manufacturer: E,U~~1C S Liquid Capacity: /.zD© v,-,900 ~ C. Setback from: Well House Other urer Model# Float 7seperation s A ion .SOIL ABSORPTION SYSTEM Width: Length 70-,r'p- 3D Number of trenches 3 Distance & Direction to nearest prop. line: ,SQ" I-DE Si C7-R Setback from: well House Other ELEVATIQN6,g / Building Sewer 22,,0-2 ST Inlet; ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system? Existing Grade 27,5-1 Final grade r DATE OF INSTALLATIO T_3Q F3 PLUMBER ON JOB: - LICENSE NUMBER: INSPECTOR: 3/93:jt L4r`~iparttritntoTirlUCStt}1 H 25.30.2%oi SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (ATTACH TO PERMIT) sanitary ermit GENERAL INFORMATION Permit Holder's Name: 11 City El Village A Town of: State Plan I o.: "ROME v.: Insp. BM Elev.: BM Description: Parcel Tax No.: led 030-2037-50-00n TANK INFORMATION ELEVATION DATA A9300255, TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic oo Cl,,, Benchmark 3 51 410, @ ' Dosing Aeration Bldg. Sewer S Holding St/* Inlet 3 ~ ~ ~ . .5 q4 - TANK SETBACK INFORMATION St/ Ht Outlet 3,~6'g~, 97 TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet Air I Septic >~Q A- NA Dt Bottom Dosi NA Headern. S , 8a Aeration NA Dist. Pipe Holding Bot. System PUMP / %WeN INFORMATION Final Grade cdt ' Manufac Demand P~ ZfL 99,~✓ y Model Number GPM TDH Lift Friction S m TDH Ft Forcemain gth Did. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length r No. Of Trenches PIT o. Inside Dia. Liquid Depth DIMENSIONS .3 DIMENSIONS ctur a LEACHING SYSTEM TO P/ L BLDG WELL LAKE/STREAM CHAMBER Ma SETBACK rf INFORMATION Type O System: o7J!` CO~ ~ f~ ~ OR UNIT. a Num er . _ DISTRIBUTION SYSTEM Header /idtartifatd - „ Distribution Pipe(s) H le Size x Hole Spacing Vent To Air Intake r Length _2527 Dia. LengthZ 44ia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Onl Depth Over Depth Over xx Depth Of ed /Sodded xx '/Trench Center 4~Id%Trench Edges "COa Topsoil E] Yes No C] Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH 25.30.20.478B U 77-~,n ~ ~ ~GCGC1 c-r , ? C E.- eov c J/ , c r 'fo_v 3 Yes No f Use other side for additional information. G C / SBD-6710 (R 05/91) Date Inspector s Signature( Cert. No. ~I ADDITIONAL COMMENTS AND SKETCH t. SANITARY PERMIT NUMBER: -77~,,, d.Cac~, cal~i~Fc7a~/~ w y ; e i i SANITARY PERMIT APPLICATION T 1LHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY STATE ITRY PER # -Attach complete plans (to the county copy only) for the system, on paper not less than El 8% x 11 inches in size. h . 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 3,012 0 C W% C- X, S S T, Z , N, R 4 E (orffl PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # S i - /VA A 1383 a.,5 T CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER D _0 CITY II. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE I^ NEAREST ROAD ❑ Public VN 1 or 2 Fam. Dwelling-#of bedrooms PARCEL X NUMBER(b) 111. BUILDING USE: (If building type is public, check all that apply) a 30 _ L,t3 7 . D 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. X Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Vol 751 ELEVATION 6 ® v , ga Feet 93 Feet VII. TANK CAPACITY Site in ailons Total of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber El I L1 1:1 0 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 is Signature: (No Stamps) /MPRSW N Business Phone Number: Plumber's Address (Street, City, State, Zip Code): IX. C LINTY/DEPA TMENT USE ONLY ❑ Disapproved San' Permi Fee (Includes Groundwater a e s ue Issuing ent Sign ary Surcharge Fee) Approved ❑ Owner Given Initial Adverse D terminati n X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS ` 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will' be applicable. 3. All revisions to this permit must be approved by ?he permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed- pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. 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'/z x 11 inches must be submitted to the county. The plans must include the following: A) plot elan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or ether 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) hcrizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model end pump manufacturer; 0) cross section of the soil absorption system if required by the county; E) soil tes" 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 cFflle _l(;d tt t.t :fit th~3e surcharges are used ror monitoring grOLWdw,iter, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) CI% I i ~ r I . o cn N Ali Q - 0 o CA o Z C Q G i ~b3 ~R 14 S ~ c R~ I w . o Z Fri a n u 0 W W W v~ Q ~ ~ u o p W G cl L'L7'~, w r , e u ' 'kw e L, 90, 7 g of + y b ~ e . M ~ l~ V`y9 X ~ • 1 \i Vim, ~~~'....r///~ ` ` ~p~o~ \ ~ ' may,, q K ~ ~ ~ 'y~►S,. ~ `1 10 s 5 ~ rte. (4 VN v . i cSG~?G~ 30 / o^- ]i 9 F ` 1383 ,Z,5- ? ~ c~~~~~ y v« ~ ifOcrc~c»v w ` . S ~aS2 =Se'fY~ .S'~=T cGd s yam, 71 Cr Wisconsin Department Industry, Labor and Human Relations SOIL AND SITE EVALUATION REPORT Page L Of 3 Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY s,T, Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION S,q t>f~j~ $ (y/~~~ ~OiP~E~r/ GOVT. LOT *6; 1 /4 kE 114,S as T20 N,R 10 E (or) T: PROPERTY NE~~ ILA ADDRESS LOT # BLOCK # SUED. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE ®I'OWN NEAREST ROAD lvLTO^J k? t S 5V0,?2. (-713) sy9 6o/ sr: JoSCO h-- 2- 5* d>~ ._J [ ] New Construction Use [Xj Residential/ Number of bedrooms [ ] Addition to existing building V4 Replacement [ ] Public or commercial describe Code derived daily flow (00(0 gpd Recommended design loading rate • 7 bed, gpd/ft2 ± 8 trench, gpd/(I? Absorption area required c57 bed, ft2 75-0 trench, ft2 Maximum design loading rate f bed, gpd/ft2 ~ trench, 9pdfit2 Recommended infiltration surface elevation(s) S~ ?&.5 ft (as referred to site plan benchmark) Additional design /site considerations 2/sE T.P ~G~s w/ /.fox 7)/s'7-. ifr Parent material sc5 Dvr-ter<' o-f~y - Flood plain elevation, if applicable yy1`' h cs w s S - Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE AT GRADE SYSTEM W f~l HOLDING TANK U = Unsuitable fors stem X) S ❑ U ❑ S cau S ❑ U ❑ S U ,t~S ❑ U ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundaly Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed 5-rich '94 /6Y/z ?13 //.y~l •C~~`~s S ~,C, fW 3 440 D144 2- -/oYK s/ GS i MVP A)P 18 Ground /o jVle 7 !2o v o f JA` e 4„-7Ci 73.0 6 fL - 56 16 y/2 y ' f Sd1C 4*1 7C1 C S 7G . Z; j limiting 11-/00 /ayx S/~ S s -4-7 . • 7 / oU„ Remarks: Boring # ,.x D'/O 10 fie 313 Af sit 41, 7< s , •'~v~ 2_~ 2- 0-/G 6 r//e S C, S nom, 9 ~ S i NP N Ground z 3 /O yle ,3 ~oq, y ; S`✓~ //{i GS NP A YX y / , f, 56,E ~►7~i ` ~S Z 3 93. elev. ft. 3 " P /0 Depth to d "/O -2 limiting factor ~~oZ 13 Remarks: /'S ee'4-f CST Name:-Please Print Phone: HOME SITE SEPTIC PLUM81NG GO. Address: 655 O'NEIL RD., HUDSON, WIS. 54016 Signature: ^r{S. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. Date: CST Number: ~j• 7&& ~`C~ ``°dN. INSTALLER & DESIGNER LIC. N0.00663 NO7 5 ORIGINA 12 tECiIWSg _ w v sys ~o4 Ywl~? 7b s ~.'Y°~~~~~ s ~ PROPERTY OWNER SOIL DESCRIPTION REPORT P Z age _of 3 PARCEL LD.# Depth Dominant Color Mottles Structure GPI t2 Boring # Horizon Texture Consistva Boundary Roots in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed mends 3A^ VP k)P 2 y 8 % s/ l~ „ s D. , s n~Q c s ,v o Ground - /d- /0 /P 3/ f 5,6x 1w Ufi e-5- Ai p Ai elev. ~y ft. l3 /oY2 y S~/ /f fi& 4-1 -IC/ ` es 3 Depth to C - /0 Ie S/~ S o, lo, S limiting factor Remarks: Zl ZO•cl S Boring # k i t 13 i Ground @I@v. i ft = Depth to limiting factor i Remarks: Boring # _ Ground elev. it Depth to 6mdir g factor Remarks: Boring # _ i 13- Ground elev. ft s Depth to limiting factor Remarks: con ooonio ncnrn JAWORO A a . i i i ~ r g - n Q • ~ O W oo ~ - u ~ . t. w 0~ Z C IU3 o N-k - O IZI P o (oN N ~ n k UA New CO•u .STip U c Tr o.v . w 3' f/S Tam ..-r 3 ~ ~ B-~' ~ IC ~-I S Ale) 4-Xio w,v CSM °.e G o 7- _ Safety & Buiwangs Division Wisconsin fZ artment of Industry, SOIL DESLKIPTION REPORT P.O.8ox 7969 Labor and Human Relations (Attach Soil Profile Location Map - To Scale - On A Separate, Signed Sheet) Madison, wl 53707 SC $ %o/f0A~-p 1*5 C(j G Z Page / of Z- 3 l a'Ss 3 uttomer Name i va wtwn ate / urrent Lan Utt or Vegetative cover Parent Matena t L(J P~' Tr ~ D G ~ / q s Gt M,9 / ¢ - F,- SA,v D P eA~' RI 7,(-'f tumate a owe,„ rou water P am evatson uttom r _/J v f SIC w f a ~ E' o v CX /TV o ~Uj //0 ~ County ax era ystem l~ ~nq rz~ j ST- C/?O 1C Tavti Ot osf,A~ J 11 ystem eomttry an Dept aa^f0 p - -a - J foR Lot Legal petcnpuon Z o C-0 _r_ee A sw ,vE 572c.2- 5T-3o .v Iz ,vc~r- r Z Structure Remarks: clayskins Loading Horizon Depth Dominant Color Mottles in. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary ores Hand other GPD/ft.2 v ~ „ hb,P~lov I~~S /X 1-1Z S ~~M,S~ M~~ a'S 6E v LUT Off 61 Remarks: clayskins Loading Horizon fDepth Dominant Color Structure Munsell u. S:. Cont. Color xture Gr. Sz. Sh. nsistence Roots Bounda ores Hand other GPD~ft•2 110,e Zo 4-) 13 ~ /6 1/ A'e'-olg D,re S , C oo /o 4 S/ S' ,S - Structure Remarks: clayskins Loading Horizon Depth Dominant Color Mottles In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots 8oundar rest an_other GPD/ i Gc- S sr,PAriF: X17 G' 3 _/o /o es I Fe also D 1V /J!E7 (/y} jio,~ `I' Jam. /ot Horizon M-2, Dominant Color Mottles Structure Remarks: claysk~ns Loading 10 Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundar ores H and other _GPD/ft.2 /d '/k'~'i- /s 5iP~ l f a S A'~'~ , ~~J 11 V r3 Horizon Depth Dominant Color Mottles Structure Remarks: clayskins Loading In. Munsell u. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Roots Boundary ores H and other GPD/ft.2 c ~y /a S. s . 9 Z 2'- 1 v a 01 p z~ -4 ti HOMESITE SEPTIC PLUMBING CO. 8a` 5 O'NEIL RD., HUDSON, WIS. 54016 T z y8Z ROBERT ULBRIGHT 0" t Z JJS. MASTER PLUMBER LIC. NO. 3307 M.P.Ft& t ',NN. INSTALLER 6 DESIGNER LIC. IJO: 000 1 DVC ~ 1 dition I Remarks: CS /S ~iv64/-t/ 0,~ a Ski T 3 / file f.., /•c, S,~ v~ 0 Co v v~ N i ~ o.~ c sfif r ,~-c Other Site Features: Limiting Factors/Depth: CST Signature Date Signed Telephone No. CST i r SOD-B3]0(N 01190) sc~Lc ~ yo ' Gl- -7 t~ 5T, I~ u~-t-i o~S i I 52 z 17 gd' 1~-o7,V r3 3 5'fi' • Sfo PUG • / 133 ~ ~i3Obar /~~P~YDE &p rlivAu 4 I = /00,0 ~ ~ R~yIAr~MrNT Sys rer qo I AAJ # Z S T. frt°eA~ ry y~o YO 0 7- sy BUT ~j -L i HOH~S ~ TE I i , 50 + R 14 T Re Aj 0, M i o -t- ~e Nc.G~ 93 S~ D o T /Oc,J T,~'~,ucti, 93, D ~~X cvEST Fnv~D~ 8 w 000 T. fSLwc.e ~ O 5 ~A a A Pf PA !9y- . S G.> STA7E- y,yti way cuk~~ G07 GdRNEi2 6U/9Pra1'N6- 5571 1, y" NGv Go T L~NoS • S a N LAND SURVEYING • HUDSON , WISCONSIN 54016 (715) 386-2007 Nome St. Croix Co. Abstract Co. Address 212 Walnut St., Hudson, Wis. 54016. Description A parcel of land located in the NW h of the NE k, of Section 25, Township 30 North, Range'20 West, Town of St. Joseph, St Croix County, Wis. A-1237 PLAT DRAWING N This is not a Land Survey W E S 350' - - 7.61' ~ 208.80' I i u V 110' 42' r C House 0 22' x N 208.80 o d i C- 250. 0' N 0 U") ` garage c L 30, C O Y I Y w N w J w a,, o ) N N- CL A O O O ~ v 208.80' 33.56' 350' The location of improvements on this drawing are approximate and-are based on a visual inspection of -the premises. The 1,ot dimensions are taken from recorded plats and deeds of county records. This drawing is for informational purposes only and should NOT be used as a Land Survey. Mop No. 85-04-65 Drown By B.R.B. Aug. 27, 1985 Scale . 1" = 60' v STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County 6WNER~BUYER LQtx. c-e n c & * 34xNc L t-o-- R o v-aen ROUTE/BOX NUMBER M3 2-S T FIRE NO. CITY/STATE k pct-I+O n , W ZIP :5qa g PROPERTY LOCATION: hLL01/4C~1/4, Section , T_ N, R ZO W, Town of St. Croix County, Subdivision , Lot No. 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 NAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to 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 form will be sent approximately 30 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 Department of Natural Resources. Certification form must be completed and returned to the /ED~ roix County ni Office within 30 days of the three year expiration date. SIG Gtr DATE 22,3 St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above address H + 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 L.o~mfnce G. °-r a Bo r-aen Location of property ~W 1/4 E 1/4, Section , T 30 N-RZ_C) W Township- ~dS~p n Mailing address S` Og z Houd+o o W -T rF S C~ 82_ Address of site l ~ g 2 Subdivision name- All A Lot number Previous owner of property I y (G CE t BcLt bat-c- j. ~s a Ocv Total size of parcel Zs~ X 3 SO ' CW 12 r-OX Z 0--i uS Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes _x _No Volume Lo 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 warranty deed recorded in the Office of the County Register of Deeds as Document No. L7and 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 id m, and the same has been duly recorded in the Office ;0f t County R is s Deed as Document No. gnatur Owner Signature of Co-Owner (If Applicable) en Z Date o Sign ure Date of Signature w DOCUMENT NO. T WARRANTY DEED 1} THIS SPACE RESERVED FOR RECORDING DATA a f~#041883 STATE BAR OF WISCONSIN FORM 2-1988 v 4: . ~ RFGISTEi~„ r' Michael G. Jarchow and Barbara A. Jarchow, ST. aor c-r ~ hl$band_-and- wife-------••--------•--...---•---•---•-------------------------------•-•---•---• Rft d. fo...,. d 11i1i 3rd df Sept. Dr 1so_ conveys and warrants to P. M wBorden--and.-Sandra--R.-._Borden,-_,usband and ife. as .Dint tenants RETURN TO { the following described real estate in S.t.....Cr IXI ........................County, State of Wisconsin: 7 gB A parcel of land located in the Northwest Quarter of the Tax Parcel No- j Northeast Quarter of Section 25, Township 30 North, Range 20 West, Town of St. Joseph, St. Croix County, Wisconsin, described as follows: Commencing at the North quarter corner of said Section 25; thence South 0019150" West (true bearing) 686.43 feet ~j along the West line of Said Northeast Quarter to the POINT OF BEGINNING; thence South 4 ' 0°19'50" West 208.80 feet along said West line; thence North 88°59'30" East 208.80 feet; thence North 0019150" East 208.80 feet; thence South 88°59'30" West 208.80 feet; to the POINT OF BEGINNING, subject to existing roadway easement for Stone Lake j Drive. A parcel of land located in Northwest Quarter of the Northeast Quarter of Section 25, Township 30 North, Range 20 West, Town of St. Joseph, described as follows: Commencing at the North quarter corner of said Section 25; thence South 0019'50" West ~j (true bearing) 678.82 feet along the West line of said Northeast Quarter; thence North j 88°59'30" East 3.8.99 feet to the POINT OF BEGINNING; thence North 88°59'30" East 350.00 feet; thence South 0040127!' West 250.00 feet; thence South 88059'30" West 350.00 feet; thence North 0°40'27" East 33.56 feet along the existing Easterly right of way line it of Stone Lake Drive; thence North 88°59'30" East 171.12 feet;-thence North 0°19'50" East 208.80 feet; thence South 88059130" West 169.87 feet; thence North 0°40'27" East 7.61 feet along said Easterly right of way line to the POINT OF BEGINNING. This _______ls_________________ homestead property. ! 11."uN (is) (is not) G • Exception to warranties : f~ Dated this 3-0-t-h day of August.------------------------------------------------19_85-... ------(SEAL) -(SEAL) e4 16 Jarc Aaiel G. f -------------------------------(SEAL) ! -------------(SEAL) l Bar ara A. Jarcho * II t AUTHENTICATION ACKNOWLEDGMENT Signature (s) STATE OF WISCONSIN ss. -------------Count;,. authenticated this ........day of 19------ Personally came before me this - OUi.._...day of August 19-_$$_.. the above named • i --Michael ._G_.Zax_chow -_.and_B.a.xba,ra_.A.---,zar.r-how, husband_a&ud_wlf-e------------------------------------ - - - TITLE: MEMBER STATE BAR OF WISCONSIN (If not- authorized b y § 706.06, Wis. Stats.) to me known to be the person __s...__._. who executed the ii foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY I REALTX WORLD PauleX . & Johnson, IncC. 221 E. Chestnut, Stillwater, MN 55082 - 1----1-1-`----- Notary Public - - unty W s. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, sta a :xpi n are not necessary.) date: --TERRY G.-McEOAaAI1GNElf. 9--------•) NOTARY N19UC-MINNESOTA { -Names of persons sliming in any capacity should be typed or printed below their signatures. WASHINGTON COUNTY l My Comm. Expires June 17 1991 HGMiIIerConOa1~Y® STATZ BAR OF No. wt 1982 SIN Stock No. 13002