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HomeMy WebLinkAbout040-1077-95-000 ~C o °O N ~ 0 o ao ° a o d ~ c °o I N I a i y I f0 a h N ~ U ° 1° o C z M U- 0 N C -0 °f CQ o I O Z ~H r w U) U) 8 Z O FN O- ~ d m O 0 z v c in c z R' aD c E o N M N C1 7 C co N • d OC CO ° Q Z m z o N w d E N A a - d it, 0 CL U C, ~Iw~ N ^V Z M > f/1 fA fn a It= o a~ 16 •N 4.; ~aaa y N a c ~i y N a o N co m A J V = OOi OOi ° Z - 0 O 94~ -0 O O -0 E N j N 3 ,t c a p m ¢ L an d a z U o O O° N a C 0 LL U) N O L6 W° m C CL- V ) O C 0 C -p N N OH n O F- O O N wC O H U N 'O n a co N t ~I 6 N C) Q H j fA O z c z PL n t \ ~k w - C v v~ m m € a 5 a L a • CO C. d V m E ` c c m r*xi r A 0IL I~mv STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER o~✓/~S ' jai LS ADDRESS ~clG ~r1os✓/n/~/7 L.i SUBDIVISION / CSM# 3l~ 6 (e 3 c,/ LOT SECTION. /g T _N-RAW, Town of -~'eo y ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Al.w..(or~'bPNE77 E(E V /00. 00, p,r v~ T e IgQ~~K N~I~f+PE T~oO~~ QP~V~w AT ,41e,,4 P~,NT OF ~'Pc'~ -04/A) G8lv~ T a~~~H, yo Ave Q/l~L~ EFFuc.c.v r 4 i.,j ' (M~,v y~•of ,~eP7M) ~5, 1~~R7St0 i Lu~tt /.'{'.SO 6AI SgOTiC 4.J/7N S/*ScNS/0 '54f,"'ef , , uF /R^/O c'FFuG.ivT 4/NE' jiVSOxeT/o v v/T~`✓ A//fr~vEO 4P11-GI/7 A"A INDICATE NORTH ARROW &J/7W 5'c d y~ I~C.v f S'c ~r u7 lt~tl E Y iN€ Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK: s}T A/ G.J. 1 ,jlAil f- 4-o?.VE,P = /c, (3,oo, ALTERNATE BM: /oO ofivc,C /~/iSE~/~ uNDrfTinnJ 91~. SEPTIC TANK PUMP CHAMBER HOLDING..TANK INFORMATION Manufacturer: b✓,Liquid Capacity: '7S0~ Setback from: Well House Other Pump: Manufacturer ~LTf Model#, h- nu Size Float seperation -19S " Gallons/.cycle: ~cS 0. GS Alarm Location L~~,t~ 1t,~~L SOIL ABSORPTION SYSTEM Width C~D Length ~ Number of trenches Distance & Direction to nearest prop. line: Alverq '7 Setback from: well: 34/9" House 30/" Other rJES-r t0Po1.W-,G,u,,C- g" ELEVATIONS Building Sewer fO. 88 ST Inlet; ~o• S/ " ST outlet I9_ PC inlet X9,21 PC bottom Pump Off Header/Manifold Bottom of system 9e•ia' Existing Grade Final grade 1,do. PO DATE OF INSTALLATION: PLUMBER ON JOB:, LICENSE NUMBER: 9S INSPECTOR: 3/93:jt LQgT;V l ertWyf IA,%ny28.19. 299FPRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division ST- (--R0IX .GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Permit Holder's Name: ❑ City ❑ Village X Town of: State Plan ID No.: TROY 5F v.: Insp. BM Elev.: BM Description: / Parcel Tax No.: lti 14ZIz- 040-1077-99-000 TANK INFORMATION ELEVATION DATA A9300295 as fn TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ^eSe/ C, ZS~ Benchmark 7CCJS~~, Dosing 1.3 Aeration Bldg. Sewer ~a, 3s gS,~ Holding-__----- St/ 10 Inlet ' TANK SETBACK INFORMATION St/Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet a' 85(0 Air Intake p i Septic l NA Dt Bottom 66 Dosing NA Header-/dn. y(C Aeration Dist. Pipe Holding Bot. System 5 cg. 1.;2 PUMP / St NFORMATION Final Grade Manufacturer Demand``' Model Number GPM A-v G). O , s, ' S 6 / TDH Lift i7,t~ Friction System TDH Ft &,a 0,r S. Loss mead t es s 1-i-65 Forcemain Length d-,55-' Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH width r 1 Length 7 No. Of Trenches p1fi - No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS 'Zo SYSTEM TO P / L BLDG WELL LAKE/STREAM LEAC Manuf r: SETBACK INFORMATION Type O E?k. , c5! 5 Model Num er: System: CtnV, OR UNIT DISTRIBUTION SYSTEM Header H*mi futd- Distribution Pipe(s) „ x Hole Size x Hole Spacing Vent To Air Intake Length 2 Dia Length Cd Dia. Spacing , SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over ( Depth Over (~i,; xx Depth Of xx Seeded/ Sodded x Mu Bed /Trench Center Bed /Trench Edges - 3~Z Topsoil o ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc. r q --7 LOCATION: TROY 19.28.19.299F l t r f~ C~Ud G"t1.~ Plan revision required? ❑ Yes 2-9-0 Use other side for additional ' oron. SBD-6710 (R 05/91) :!c~10 ~1~ ~A~ Date Inspector's Signature Cert- No. ~ 4( 7 DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY -Attach complete plans (to the county copy only) for the system, on paper not less than TAT UX QS( STATE Yf YPrevious # 8i4 x 11 inches in size. c eck if r vis ❑ ion t 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 ,S',- Y4 rk/ t/4, S /,9 T N, R 19 E (or W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one) ❑ State Owned 0 VILLLLAGE : NEAREST ROAD ;~~L24 11 B R() ~y Tip F ❑ Public ®1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX =W RF: NUM 111. BUILDING USE: (If building type is public, check all that apply) 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. ❑ 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 M Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 430 Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) q ELEVATION U 6 6 U • y- / ./O Feet /04 /D Feet VII. TANK CAPACITY Site INFORMATION in gallons Total # of Manufacturer's Prefab. Fiber- Exper. New xistin Gallons Tanks Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank O - Lift Pump Tank/Si hon Chamber s VIII. 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 Signature: (No Stamps) W/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): -r 91 r7 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent ur mpg) ❑ Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination 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 reneir,al 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 (SI3D 6.:951) 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 ad ninistrator 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 totail gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. C:ompletE! for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIIL 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 dirrensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mainsiwat3r service; strea.,ns and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areal; and the location of the building served, 8) horizontal and vertina! elevation refere,ice points; C) complete specifications for pumps and controls; dose volume; elevation differences; `ric:ion 1003; 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 moni(!s collected through These surcharges are used for nr--~nitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) /gE,uc/l/t1.9?K- „*reo v 47- Al. w. ORoPE~°ry e'U'plxq 4 n7- 7- ' ~,L ~ ~l . / cJtJ. owW 8 . /UnRrN Q/poDE~~~,~v6 40T x~ 3 PLB 67 ~Evr PLOT & CROSS SECTION PLANS ZAPPA BROS. EXCAVAfi1NG INC PLUMBING UNIT 7iG i 6,i3 Y j0, PROJECT AfoOo5, 2 0 bw~l1/f s 8?A e8 ~QEaK Qo/Nr , 6t?AV ITY 62 ~ • ~~a • ~oM ►-}EPE To f~8,c,,~Orio,U ~ ~ AP.1 c -7 U /X d Oil/ ®✓C s pR 35 I k«{~E,vr,(.vt ~ ~~oo,fa ~ I"~n004EA CM/v. O! ~/~"QEOTfI) /~"1 aol ~S.prut<= GJE~L //~r, 36 /So' /~aoE?TY /C7UN SITE /AJC /~Sa 6a ~ S"E~r/C T.►•~K w / ri/ S/" 5~.1 s~v 6n <7f4lZlf 4>AIE ~c9in ~Gti<,0/NG X Vn /mil / Lags IV(- L/l r g~Q e'l- .c<ciFNour _T~SO-e-cr/o, L✓rTAl VF✓) Ai z GG / 11 9so ~~L, ~ /fr C~~/.4 M/S~ L✓ /r/! ~ T i/E.v T GJE57 NOrC ' - VERr ~iF~ /,J~TL✓CE^I l~tq/~-I~ .1./17 ~G~/•f(~/T4'~ /J~E/t1( ~/PoOr/jry dd /NL ~U/nO/5 A&1 , SCS/y - SW M b u tires ON ~o v C ~6rt ~L O C NO 5014 19,e- tir- ~v SCALE FRESH AIR INLET AND OBSERVATION PIPE APPROVED VENT CAP MAXIMUM 12' ABOVE FINAL GRADE 771 I • w 4' CAST IRON VENT PIPE MAXIMUM OF 42' ABOVE PIPE TO FINAL GRADE r i SIGNED: MARSH HAY OR SYNTHETIC COVERING I LICENSE: ~,PS 33 5S MINIMUM 2' AGGREGATE I - - --"~7 I DATE: OVER PIPE 1 DISTRIBUTIOP! PIPE TEE SOIL TESTING BY: V'ia~v ~/t T5' 417 33 ELEVATION BED 6' AGGREGATE • BOTTOM PER SOIL,",,, PIPE PERFORATED PIPE BELOW TEST IS • I COUPLING TERMINATING /o FT. AT BOTTOM OF SYSTEM R i ~ s Ix I N % V ~i Iq s ti w w _ al n ~o M ~ Q .31 0 n i~J i 1 V i ~~4 ~ DEPARTMENT OF INDUSTRY, REPORT ON SOIL BORINGS )w HUM N RELATIONS PERCOLATION TESTS 115 (H63.090) & Chapter 145.045) LOA I N: E ION: Sf . 4~ TOWNSHIP/MtiNtCtPAtyTY: I ITAf N/R E (o OT NO.: B COUNTY- . OWNER'S r` S' ~ MA LIN ADDR SS: USE c, NO. BEDRMS : COMM R A OES RIPTION: DATES G ©Residence ? 7e. RATING: S- Site suitable for system U- Site unsuitable for system ONiVENTI NAL MOUND: IN-GROUNDPRESSURE: S STE S M-IN-FILL OLDING TANK: RECOMMENE c ❑u as au as au cas ❑u Jas au If Percolation Tests are NOT required DESIGN RATE: under s.H63,09(5)Ib1, indicate: If any portion of the tested aret r'! Floodplain, indicate Floodplain PROFILE DESCRIPTIONS N ~ NUMBER DEPTH IN, ELEVATION BORING TOTAL PTH TO GR UNDWATER-INCHES CHARACTER OF SOIL ~WITH 'THIC OBSERVED I HE TO BEDROCK IF OBSERVED (SEE A B- B- .3 dy B. C. B- s 3 S / s?} Lv r!l i I/lPl~ f B- F ~ y3 ,fY i . S 3 PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST NUM INCHES AFTERSWELLING INTERVAL-MIN. DROP IN WATER LEVEL-INCHES P D P- / y P- P- 2 .1P P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate sca zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation a ' of land slope. SYSTEM ELEVATION I i j 71 . I I I r ~ I , ~ i f ~ I, the undersigned, hereby certify that the soil tests reported on this funn were made by me in accord with the 1 procedures , Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and bel N rinl -i. TESTS WERE COMPL ADDRESS: CERTIFICATION NUh T SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) OVER - FORM NO. 985•A K~ wu.ta...b® F I L ED SEP 261980 JAMES O' CONNED 3loglilor of Deeds -r A sA Crola Cornly' CERTIFIED SURVEY MAP gl wnpIatted lands - - - - 356 298.00' o 71. o rr1 M N O 1 3 - o o . co N ^ u'f N 3 «IVVV M _ 4 . S Q, 4.19 ACRES pl N 00 Z r N W C4 co APR ° 00 . 90- co co LST. ROIX COMPREH NSIVd P.. 11=80' AND' ONINO • C M.a. 1 N °42' 38".W v) ,~I1 96.-961,, 6r r 11 t. - 57"- t+ 2 POINT OF 2 '•o 0 BEGINNING F~-I O o M 1o0ti , 900 Q 08~ 6 -J I o m. 6 g30y 330.00' 70a (L I SO°13'50"W DI ch Zr SOO w 2 Q 'n 0& = Q1 2.09 ACRES O I in 1 ! UNPLATTED LANDS I-- cn to p~ H 0% M N LL M I rv O M zo V) w M ~I Z Q ° w ZI J o o N M JI ~ 0 rn _ ' 00 ~7R S0°55'52"E 0 1 TRUE BEARING z 257.18 00 n► o in r. 01 N SCALE IN FEET c ao 0 DI o 6 l6' 112 0' 0' 120' 0000 1 I z w Q 01 2.01 ACRES,'. o.. 01 ~ M D I uii M W^rn ow WESTERLY F~ o ac M O (o RIGHT-OF-WAY a . 001 U 0~ LINE CLI a1 ^?.~I N ROADWAY EASEMENT Z V) F' _ 256:79' 66.02' 0 322.81' c ~ COUNTY"E TRUNK HIGHWAY "Ell N 900 1 65.42"3965.42' 1305. 30' _ NO°13'50"~E E_AST_ LINE OF S_W_ 1/4 / ,,M1, DD Q C~ < -11►1 r11 ATTr"'n - I n- VfJ''~- . DESCRIPTION A parcel of land located in the SE1/4 of the SW1/4 of Section 19, T28N, R19W, Town of Troy described as follows: Commencing at the S1/4 corner of said Section 19; thence NU°13150"Ii (true bearing) 1305.30' along the East line of said SIV114; thence N89°38'W 660.00' along the North line of said SE1/4 of the SIV114 to the point of beginning; thence SO°13'50"W 330.00'; thence S89°38'E 581.93'; thence SO°55'52"E 322.81' along the Westerly right-of-way line of present County Trunk Highway "F"; thence N89°42'W 1221.10' along the South line'of the N1/2 of said SE1/4 of the SW1/4; thence NO°10'30"W 654.17';'thence S89°38'E 637.26' along said North line of the SE1/4 of the SW1/4 to the point of beginning. Contains 13.87 acres, more or less. I certify that the above description and map are correct and that I have fully complied with the provisions of Sec. 236.34 of the Wisconsin Statutes and Section 5.4.2 of the St. Croix Coun Zoning Ordinance. Date: October 19, 1979. Revised Date: February 27, 1980. Francis '11. Ogden S-882 Job No. 1196 Ogden Engineering Co. 40i, 123 E. Elm Street O IV yJ~••'"" ~iL'~i~~, River Falls, Wisconsin 54022 FRANCIS H. OGDEN I Hereby certify that this map has been approved S-882 by the Town Board. RIVER FALLS, Wis. t Date LEGEND SECTION CURNER MONUMENT FOUND,•BERNTSEN CAP • 1" IRON PIPE WEIGHING 1.68#/LINEAL F001', FOUND) O 1" x 24" IRON PIPE WEIGHING 1.68#/LINEAL FOOT, SET -k--- EXISTING FENCE LINE • CURVE DATA TABLE CURVE NO. LOT NO. RADIUS CHORD BEARING CHORD LENGTH CENTRAL ANGLE 1-2 80.00' N23°19'41"E 147.32' 225°55'22" r 3 80.00' N38°07'39"W 125.23' 103°00'42" 4 80.00' N74°50'U2"E 140.55' 122°S4'40" SURVEYED FOR OWNERS RICK CHERRY AND STEVE PETERSON Steven L. Peterson 2727 Mc KNIGHT ROAD Richard A. Cherry NORTH ST. PAUL, MINNESOTA•55109 Gregor}, K. fled 2727-Mc-Knight Road NOTE: THIS CERTIFIED SURVEY MAP REPLACE''•S N. St. Paul, Minn. 55109 THE CERTIFIED SURVEY MAP RECORDED Mr, & Mrs. Richard Jackson 1 VOLUME r PAGE DOCUMENT 1424 Hallam 3 6822' Mahtomedi, Minnesota 55115 POLICY OF THE- ST. CROIX COUNTY COMPRE II NSIV_ E PARKS PLANNING AND ZONING CO til'ITEE The roadway s ot, oti tjl s map is a j': vate roa wc~ y • ny iikrinteirance costs of the private road- way, after its approval by the Zoni,nl; Administrator as a standard road, shall be shared pro-rat This instrument drafted by Robert K. Krisak. by the adjoining; property owners. ShoLIYd the roadway be taken over by a municipality as a public road, maintenance costs thereafter would be a public expense. Volume It Page 993 S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER. 'y ADDRESS.. 8 /0 FIRE NUMBER.. 21 CITY/STATE.fty/~<S~JJ GJi zip_ _s PROPERTY LOCATION :-5-F 1/4,,-)w 1/4, SECTION, T 0 Y N-R-L2_W TOWN OF i , St. Croix'County, n `1~3- LOT NUMBER -3 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 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 system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater 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. I/Ile, 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 stating that your septic has been maintained must be completed and returned to the St. Croix Co. Zoning officer within 30 days of the three year expiration da e. SIGNED• W 4LL DATE•_ St. Croix co. 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 ~n 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 SS 1/4 S 1/4, Section, T~ N-R,L_W Township Mailing address C1 . ~r Address of site _ ~'S'r✓1 V Lot no. - 3 Other homes on property? yes No Previous owner of property Total size of parcel Date parcel -was created 1 'Are all corners and lot lines identifiable? ___✓_Yes No Is this property being developed for (spec house)? Yes No volume and. Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEhD which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & 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 Registerof Deeds as Document No. , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of County Register of deeds as Document No. signs ure of a licant Co-applic t i6 r z -13 1 3 Date of Signature Date of Signature J N #I.LYF` YL i ae: Y•..~fS -s'l y"e;..f . , rt',M .w. a. ~,v :.,r L •II` TN19 SPACC RESERV[D POR R[COROINO DATA DOCUMENT No. WARRAlITY DEED I) STATE BAROF WISCONSIN FORM 2-1988 49742() 1002PAGE .101 K17IJ1 B S OMVE ; ' STeco -o"; Steven M. Stepaniak and Wendy K. Stepaniak, RscdfaRacotd. ..hiistiarid--and..wife APR 1 41993 • 11:30 A= M, conveys and warrants to lOIi1aS -W' ..S~ile.. and'-Lor Y ~ i -Stiless..husband and wife. RETURN TO . ` the folio wing described real estate in St. Croix County, of Wisconsin: Tax Parcel No:.............................. Part of the SE% of SWk of Section 19, Township 28 North, Range 19 West, St. Croix County, Wisconsin described as follows: Lot 3 of Certified Survey Map filed September 26, 1980 in Vol. 11411, Page 993, Doc. No. 366634• SUBJECT TO AND TOOTHER WITH private. road for ingress and egress as shown on said Certified Survey. 1 MANSEEa .O ;i i is not homestead This property. (is) (is not) Exception to warranties: easements, restrictions and rights-of-way of record, if any. Dated this ~3. day of Aprl1........... 19 93" ~Q (SEAL) (SEAL) par ak a Wendy X1 Stepani Steven M. Ste ......(SEAL) ---•-•-----•--•-------------(SEAL) s AUTHENTICATION ACKNOWLEDGMENT Signature (a) STATE OF WISCONSIN I, St. Croix County. authenticated this day of 19 Personally came before me this .3--_-.day of April________________________ 19.93._. the above named _ _ Steven M. Stepaniak- Wendy K. eP TITLE: MEMBER STATE BAR OF WISCONSIN (If not- . authorized by 1 706.06, Wis. State.) to me known to be the person S--___•_ who executed the re ing ins ent and a owledge the same. THIS INSTRUMENT WAS DRAFTED BY - Kristine 0gland Alice Joy rs Attorney at Law - - joy. £~n Notary Public --------3t,._. ty, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. s~Ree iration are not necessary.) July 11 $tQt~ p Wis date: COI ►93 ) *Names of persona signing in any opacity should be typed or printed below their signatures. s WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. FORM No. 2 - 1982 Milwaukee, Wisconsin