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HomeMy WebLinkAbout034-1087-20-075 a a 0 w n o I N O ~ h U) U O i Cl. Cl) C O C f0 ~ 01 L Qp 41 C id Y O f0 m Y N I N O 0 LO~ T N C_ O Z W Y 46- C C LL CO C co O N ~ C d 3 'a o o C) U I E a~ CL o ~ I 01 D Z co 04 a F- fn O O Z fn IZ- r N Z E 'p Cl) H •N rn t o f0 O = Z Z O N _ z N d N 4) (~Il A N = a y m J c v N O o 'c . o a m p ! r- N N N >I T w N > Z I7,ooo ° ~ •N IL IL IL N a ~ 3 O tl~ N fA J U _ rn rn N Cl) Q O O O C m N C d d N N N 04 'Q 41 QI fn f0 A Q N U) O C O N C ..r cy N o Q o o c j o O C~ ~ C C N UCMD CD In co C. d V € d O a) c y p c c) C O o) 00 0) 4) FL- ° a ~ d C N M F_I N « 'C M, m O a rn • O N fn I C O U) CI m O Z Z:9 .rG uuU V~ w a € a U - ` ~ I - ` a • a m 2 d m ~ Ift; y o 'C c R ~r ww o : cQ -1 A Ua~ :.omv , ~I 'ILI STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER, 67-1 s e t' ADDRESS 142Zi V1 o4-'- S+.' ~ Y1i6v~Q SUBDIVISION / CSM# LOT SECTION rZ V T ot2 N-R W, Town of 5)4'/2>/J9 ~7L~ i7 ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM op", P( s~v e d~ 211) %e) 4. 04,40,,0 G Z" 0, on~~y 69 ' 3D!' d i l 7~xlvsu s' ,Bax INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. R t BENCHMARK: a TL" /®l»t?It//`~,r ~dJ~ ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: c1y Setback from: Well House 40 " Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: Setback from: well: House Other ELEVATIONS Building Sewer .ST Inlet. ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade. DATE OF INSTALLATION: PLUMBER ON JOB: "°t .,z S LICENSE NUMBER: INSPECTOR: %~~i~SeN 3/93:jt LQQA 1Q1, lpe,,$j,,F;1 gK,;,ELD 28.29 r~ VA f t jtWAgGg '(STEM 4 AND 5 Coun y: ,Labor and Human Relations INSPECTION REPORT Safety and Buildings Division CRQTX (ATTACH TO PERMIT) Sanitary Perm itNo.: GENERAL INFORMATION 1913 9 7 ❑ City ❑ Village a Town of: State Plan ID No.: Permit Holder's Name: I SPRINGFIELD e Ti sp. BM Elev.: BM Description: Parcel Tax No.: _ -nnn TANK INFORMATION ELEVATION DATA A9300045 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 7//0 0 Benchmark ~U' FJ Dosi ng Aeration Bldg. Sewer Holding ~01-lt Inlet 6.Q 97101 TANK SETBACK INFORMATION $t/ Ht ° 7 Verit TANK TO P/ L WELL BLDG. Airito ntake ROAD Dt Inlet Ar Septic Dt Bottom Dosing NA Header / Man. Aerat' NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufac Demand Model Number GPM TDH Lift Friction Sys TDH Ft Head Forcemain Length Dia. Dist.Towell SOIL ABSORPTION SYSTEM BED / TREN Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIME SYSTEM TO P / DG WELL LAKE / STREAM ING Manufacturer: SETBACK CHAMBE INFORMATION Type O Num er: System: 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.) LOCATION: SPRINGFIELD 28.29.15.566B1,SW,SW, LOT 4 AND 5, 42ND AVE. VA d G Plan revision required? ❑ Yes a-w- q Use other side for additional information. xlz SBD-6710 (R 05/91) Date Inspector's Signatu Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ~ SANITARY PERMIT APPLICATION 1_Y.T 0ILHR In accord with ILHR 83.05, Wis. Adm. Code C J STATE SANITARY P MIT # -Attach complete plans (to the county copy only) for the system, on paper not less than R3 3 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this-application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. S 513 " O O Q PROPEfTY OWNER PRO ERTY L°~`TION ~'/<s(,tJ'/a, S T~ E (or) W PROPERTY OWNER' MAILING ADDRESS LOT # n BLOCK # CITY, ST TE IP CODE PHONE NUMBER SUBDIVISION NA OR CSM NUMBER .9 -0 I 11. TYPE OF BUILDING: Check one CITY NEAREST ROAD ( ) State Owned W 1= OF: VILLAGE ~ ~ ad C/.7- ((j, 1~jgf ❑ Public ❑ l or 2 Fam. Dwelling-# of bedrooms - PARCEL TAX NU ( ) ©3 y -/D 15'1" _ dc~rJ 111. BUILDING USE: (If building type is public, check all that apply) g - 02 S~^ S , 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 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 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ❑ New 2. g Replacement 3. ❑ Replacement of 4.0 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 130 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) ELEVATION Ile 6 Y47- .5, 1 Feet Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed FP-- Ej :1 Septic Tank or Holdin Tank 00 d 0 G G Lift Pump Tank/Si hon Chamber I El El 1:1 El Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. PI mbar' Name (Print): Plumber's 5 ignature: (No S amps) MPRSW No.: Business Phone Number: !2Y&P2,,S /Z'Z~yg, Plumber's Address (Street, Ci State, Zip Cod : 7? 0 Z ,g - c G IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved ry Permit Fee (Includes Groundwater Date ssue Issuing Agent Signature (No Stamps] Approved ❑ Owner Given initial T Surcharge Fee) 41 J;2 Adverse Determination d (J 7 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 sanitaryipermit is valid for two (2) years. 2. Your sahitary permit may be renewed before the expiration date, and at the time of renowal aiy new criteria in the Wisconsin Administrative Code will be applicab.le. 3. ,t; ,AM revision, to this permit must be approved by the permit issuing authority. 41. Change: ir-i ^wr,ership or plumber requires a Sanitary Permit Transfer/Re-iewal Form (,1,131) 6399) to be submitted to the c:ntjnty prior to installation. 5. Oesite sewage sysrems must be properiy maintained. The septi,f tank(s) must be punahc:d ffy 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 -adminisi:rator 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. IL Type of building being served. Check only one and complete # of bedrooms if 1 or 2 1=amiiy 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 systern. Check appropriate box depending on system tvpe. VI. Absorpti-Dr, sx/:,tnm information. Provide all information rer!!est,_a+ in #1-7. VII. Tank informat can. Fill in the capacity of ever,,yew and;nr f l ;;',,i tank. list the nuriber of tanks and r Arlt `acfurer's name. Indicate pref.'v or site Carr rt :.ted and tank maieriai (rinfJete for all septic, pump/siuhon and holding tanks for tfi, _ r,ystem. Check Fx r,I~,~ ntal approva; --nl, ~f anks received experi!ne-ntal product approval from DILHR VIII Resporsibility statement. Inst.ailirg plumber is to rill in name, licwise number with aoprop,ir?:e prefix (e.g. MP, etc.), add-ess and phony number. Plumbe, :sign application form. IX. CountyiDeparl:ment Use Only. X. County/Derarrment Use Only. C0rr;jtet6: r'ar,s, :and specifications not smaller than 8'h x t1 itwhes m;s-~t hF .>ubmittf-1 t., !hl- co,-Inty. The pif a, ,Yrsrr u e the following: plot plan, ,±rawn to scale or -Jtb r --replete dimen, 4 :)ca.icn of holy#_n,j roar • . „ SC:j~`i:, 'auk(s) m- clher treatment tanks; hu~1di -'i L;, veil-,: ,Nater r a;: 3 k,ater service; Str'earns 'oo i pE it;*Ytp or slph(- -I ianks; distrirw64a)r g c,,7 ~('•~tn~! 5vs'e!TIS, rid. t.. t1-nt system areas, cars(; h 'tocaiion of the bu. served; ;ter v refereri t C) complete; pecifications for pur ,ps and controls; cl ,s . v urn evati ifferences; tri ;tic.n loss; pump performance curve; pump model and pump manufacturer; f1) 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. - - - - - - - - - GROUNDWATEIR SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated pry-ctice- which car effect grpundwater. The rnonieS ~:L7f.E~1f?'i threw-3-;h these surcharges are used !!-w l:'_„t~ 7; sr`S ~'tlwc?tom g,roV inG- water :ontar;,ination investigations and establishment of Ae..-.;ards. SBD-6398 (R.11/88) ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE - 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 II June 18, 1992 Division of Safety and Building Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 To whom it may concern: An onsite investigation of the Walt Briskie property, located in the SE 1/4 of the SE 1/4 of Sec. 20, T30N-R15W, Town of Glenwood, St. Croix County has been conducted. This onsite revealed suitable soils at a depth of 18" making this site suitable for a replacement holding tank. Should you have any questions, please feel free to contact this office. SSin;cely, Thompson Assistant Zoning Administrator cj DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115 P.O. BOX 7969 HUMAN RELATIONS l MADISON, WI 53707 (ILHR 83.0911) & Chapter 145) LOCATION: IU/T0VN/M5E N: TOWNSHIP/NICIPALITY: OT :LK. NO.: SUBDIVISION NAME: .e A!n for COUNTY: MAIL N A ESS: VET -sr USE O TES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DES RIPTION: PROFILE DESCRIPTIONS: P A ST ❑ Residence ❑ New ~ Replace RATING: S= Site suitable for system U= Site unsuitable for system ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: JSYSTEM-I N-F I LL OLDING TANK: RECOMMENDED SYSTEM:Io ti al) a s au ❑ s ou o s ❑u a s au Hs []U I If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH T GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED ES . HET TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- B-DO E B- IL 9 fog B- B-Looll~ B PERCOLATION TESTS TEST DEPTH , WATER IN HOLE TEST TIME DROP I WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVA - P PER INCH RIOD 1 PERIOD 2 P R i v P- P- P- P- P- P-'.0001' ~ .400T, 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 - I ( _ _.._3.,.._.. ' I ` - - 3 ~ i r I T- _ _ ~J 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 pr' t : TESTS WERE COMPLETED ON: ADD ~j~ CERTIFIC TI NUMBER: PHONE NU ER(option I): ATU . DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHRSBD-6395 (R. 10/83) - OVER - r t' INSTRUCTIONS FOR COMPLETING FORM 115- SBD - 6395 To be a complete and accurate soil test, your report must include: Ae`' 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HPLDiNPJAN PNIkY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. 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 scale is prefered. 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 apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; ~ -1 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Standstone gr - Gravel (under 3") LS - Limestone 's - Sand HGW - High Groundwater cs - Coarse Sand Perc - Precolation Rate med s - Medium Sand W - Well is - Fine Sand Bldg - Building Is- Loamy Sand - Greater Than 'sl - Loamy Sand < - Less Than 'I - Loam Bin - Brown 'sit - Silt Loam BI - Black si - Slit Gy - Gray cl - Clay Loam Y - Yellow scl - Sandy Clay Loam R - Red sicl - Silty Clay Loam mot - Mottles sc - Sandy Clay w/ - with sic - Silty Clay fff - few, fine, faint 'c - Clay cc - common, coarse pt - Peat mm - Many, Medium ri'Q - Muck d - distinct p - prominent HWL - High water level, surface water ' Six general soil textures BM - Bench Mark foriliquid waste disposal VRP - Vertical Reference Point t f - t 1.1q s ~ TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. I~ k W A- L 72 -~2.. .8 2 1 s /'f! 2 i _ ~ , ~i S SyD.~ 7 s .zB 2g~~/2 /:5,1,J PLU P Z ac)K 7 00 s 11; Q" 'pISAWN:44 Tt4E ~?cLST(NC~ SfcPi"1G 67 f S`KTc:M At PEa II.Ete 53.03 (2,) 3Yl 99-01«16 77~1J/'C ~ y.. r fvc.~ r ~ y . ~ cJ A-9 ~l s~ r~ IC rj, ~ Q ar i ~ PRIVATE SEWA©E SYSTEM ~.f D AF K DEPT. OF INDUSTRY, LABOR & HUMAN RELATIONS - DIVISION OF SAFETY AND WINGS _ e SEE COR O ENCE t Ai 7T" L72 Sacs M,4otc fuc S mw ~L~CO'`~- ~FSCIZ ~ ATl tl 45 Le '/Y s u1 1 ~ Ii d W ~S -SP2 ~aJG'~tE=t o ~VpJT 1 C 2D t X t42 83.16` G S F~oo2 c7 2,~„~ 5-0 Gds G~~ S C~►L~z-- rz/Yt owe y~ ~-~i~1 c- 1~Arc G~s Lr / l D , caftz. S r /e 7-7- A-I?yeo~s /0 ~a q HOLDING TANK CROSS-SECTION Weather Proof ~ Approved Vent Cap Junction Box /Approved Locking Manhole Cover 4" C.I..--•, With Warning Label Attached Vent Pipe And Padlock Minimum 12" I_ /Final Grade 4" Minimum • Approved Joint - 18" Minimum eater !Tight-" ;eal High Water ' s Alarm Switch I SPECIFICATIONS f- TANK New X Existing Approved Joni` : w/ C.I. Pipe Manufacturer Plug C.I. Tank Size. e, 0,0 a ohs Extending 3 9 Onto Solid Sq ALARM Manufacturer: Model Number: i Switch Type NUMBER OF BEDROOMS: GALLONS PER DAY: rr 3" of'Bedding Under Tank Owner's Name : 4r, 77 /1.1 S /L 465- Address: C / -rt 1 7 I Legal Discr p on: S 1'/ a, U_ IA- _~A E2 i~-4.J Township/Munici al ty: 2 i~cJG County: PLUMBER/DESIGNER 01 JAM A'~ S~AaE signature: ndtionully License Nu er:1,01.704~1 /C Date: CRY, LABOR ~ HH¢AAli RGS TIONS BE%. DIVISION S OF SPIEL" 0 6U w D N NCE SEE COB 6PAGE ' Document No. 490217 HOLDING TANK AGREEMENT This space reserved for recording data Date Agreement Date /A ~R Q _ a~ I- This agreement is made between the REGISTER'S'OFFICE County or Local Governmental Unit Holding Tank(s) Owner(s) - ST CROIX 00.1 isf nnou ?11 V J14-L-'-1_,< T B~ Recd for Rocor ~ra i X (y t f+ ^ (Called Municipality below) OtJ'9 t `J92 I We acknowledge that application is being made for the installation of (a) holding Ct 4: CO iM tank(s) :n the following property, (Provide legal land description:) ~,~l/o/ t 9 R~s~o.a V ood~ - / (I a 9~ O-rl j S Return To or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Stats. if As an inducement to the County of 1S r C it Q to issue a sanitary permit for the above described property, 1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and 146.14, Stats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Slats. 2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess- ment for the abatement of a nuisance, and the tax shall be collected as provided by law. 3. The owner, except as provided by s. 146.20 (3) (d), Slats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within ten (10) business days from the date of change to the service contract. 4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under s. 146.20 (3) (d), Stats., the owner shall submit the report to the municipality and the county. 5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. ~~rO,,w11ner(s) Name(s) (Print) I Owner(s) S~iggnnaturelss)) wQ t~~ r ~Y f `S k) r ( v"40e. 0- /cam Subscribed and sworhjt.4,hipjore me on this date: Municipal Official Name (Print) Municipal Official Signature - jo TW OT Pry i e~ mmisslois expires:' (L f . Municipal Official Title (Print) I ` •2 ~ ~ ~ " ' ~ 3'/ 0.t r Vv\a. aB0.6129 (R. 10!88) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human R4iahons MOLDING TANK SERVICING CONTRACT Co~tract'oate This contract is made between the Holding Tank Owner(s) Name(s) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - and Pumper's Name - - - - n ~ I S /C L✓ I S We acknowledge the installation of (a) holding tank(s) on the followin property: (Provide legal description:) r 's Li Vy "s Li fly 71e) 9 AJ/2 /57 LJ 1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which has signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and with the County of 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all,charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality and the County namRd above within ten (10) business days from the date of change to this service contract. ner(s) Name(s) (Print) i Owner's Signature(s) i i ( Subscribed and sworn to before me on this date: YL a2v 13, t / per's Name (Print is Signal I *~h ~y~- y, commission expires: per's R giktra)tl° r • 7574 (R. 09/88) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations H z H ST C- 105 r 9 H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z d a H OWNER/BUYER lam// t I Sk, ROUTE/BOX NUMBER Fire Number IV9 CITY/STATE ZIP y~y0 ,7- PROPERTY LOCATION: fy' IJ 1, Section, T1 01 N, R /6W, Town of St. Croix County, Subdivision Lot numb er+C!!6t&) &.O-ry 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 septic tank pumper. What you put into the system can affect the function of the septic tank as.a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% 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 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 I/WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with x H the standards set forth, herein, as set by the Wisconsin Depart- b ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNED-v6d4 9 i DATE [ 02 S St. Croix County Zoning Office P.O."Box 98r_ Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. . APPLICATION FOR SANITARY PERMIT 8TC- 100 This application form Is to be completed in full and signed by the OVnettsf of the property being developed. Any Inadequacies Vill only result In delays of the potmit issuance. -Should this development be intended got resale by evnet/conttectoc,(apec house),, then a second Iota should be retained and completed when the ptopetty le sold and submitted to this office with the appropriate deed recording. - " - e r cz cDY i k.) i t o A4 Owner of property -f Location of property ,4V&LJ/4 .'-Stl)1/4, Section T aN-R_j::CY Township 'I Y16 Mall ing address -1 `a a o?4 D4 h I cnS _ t 3 Address of site •ubdivlslon name„ • Lot number Va 6 Ptevlous owner of property 10 sa A 11 % l1, . Total $lse of parcel 412 36' S Q, r7-, . Date parcel was created - - Are all cornets and lot lines ldentiflable? Yes ~~fo Is this property being developed for resale (spec house)? as Volume and Page Number - S= so recorded with the Register of Deeds. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - • INCLUDE WITH THIS APPLICATION THE POLLOWINOt A VARRANTY DZND which includes a DOCUMENT NUMBER* VOLUME AND PAGE MUMaER* and the 8EAL OP THE RE0t8TER OF DEEDS. In addition, a certified survey, If available, would be helpful so as to avoid delays of the reviewing process. It the deed desctlptlon references to a Ceitlfled Survey Map, the Cettlfied Survey Map shall also be required. PROPERTY OWNER CSRTIFICATION 11Ve) cettity that all statements on this form ace true to the best of my jour) Rnoviedgel that I (we) am late) the ownet(s) of the ptopecty described In- this Intotmation totm, by virtue of a warranty dead recorded in the office at the County Register of Deeds as Document No. `17/ / •q 1 and that I IVs) ptesently own the proposed site for the sewage disposal system lot I (we) have obtained an easement, to tun with the above described ptopesty, for the conattuctlon of said system, and the same has beagd Iy~g cosd,d lnVthe. Office of the County Register of Deedst as Document No. 'off G ~ 2LAZL - I I signature of owner 81q tuts of Co-owner lit Applicable) Date of sl atuse Da a of 819natuse i DOCUF'ENT NO. WARRANTY DEED I TNIS SPACE RE SE RYEO F<)R RECOaJ,hG DA?A I I STATE BAR OF WISCONSIN FORM 19ia 49144 980PA . , 2 George Sct . ' l lin er _ a A,/4 Mix ~0,, Wa g la Clarenc -Schillllger a12ci. t2~'~I # card Dorothy A.. Schi.llinger aA, a Dorothy Schillinger............. tI 9 husband and. wife;, 4 J~7L conveys and warrants to WAltur_BrlSkae - - W and `orah.Briskie, 10:05 A. M husbauld. and. wife,- as_ioint_tercL is--..-- . - -------r;f RETURN TO i the following described real estate in St Croix County. State of Wisconsin: West 33 feet of Lot 4 and all of Lot 5, all in Block "19", Tax Parcel No_ Village of Hersey, subject to right of ways, privileges and easements of record. s• The grultees are buying the buildings and the premises on an "as is" basis. I This deed is given by the grantors in satisfactior. of the I~ terms of a contract entered into by and between the same j parties as herein, said contract recorded with Office of Register of Deeds, St. Croix County, Wisconsin, on 12-11-91 in 926-81, #476669. I I~ This is.XlOt-------- homestead property. (is) (is not) Exception to warranties: i, I~ I. Dated this day of I 19.92 - CE~_ - ..-(SEAL) - _ _ . ...........(SEAL) George--Schill-in r--,--------------- i -_4lJ ft J _ -(SEAL) ~ (SEAL) , •-Dorothy A...Schillinger-------- AUTHENTICATION ACKNOWLEDGMENT Signature(s) Qf_-George __Schillin ger._aIld____.___ STATE OF WISCONSIN ---Dorothy- _A.. _ Sch i 1 1 i nger SS / - - . ' I - County. ' .l! y da of__ --~r--__ . 19 92 authenticated this Personally came before me this day of I 19- the above named • John G. Nes TITLE: MEMBER STATE BAR OF WISCONSIN If no - authorized b ~ ' - - , Y § 706.06, Wis. Stats.) - - to me known to be the person . who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Jcbn--G- -1Vestingen,--.Attorney---- II ~I 5tls~ n------54002 Notary Public - - - - (Signatures may be authenticated or acknowledged. Both ..-County, Wis. aldwin, are not necessary.) My Commission is permanent. (If not, s-tate expiration II date- - - . 19.-.-...-.) ~I amen of Demons aiQniny in any capacity should be tppe.i or printed below their s isrlat-, WARRANTY DEED STATE BAR OF W tx~UNSi?i Wisconsin !_egal Blank Co., Inc. FORM No. 2 - lye. Mllw..ukee. Wisconsin ' Y Y . , ~ t.-. .H' ~ , A±. l' `jt n: iJ x,, 1 ~:ir. n:~` T. C a^ y.,; :,r S t ,.4 . _ K .j~ A "Y „X WI t