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HomeMy WebLinkAbout020-1185-10-000 0 o C) c 0 I e I c o I N rry N I U 0 ~ N ~ I h i x 0 N NO ~ Z N - c LL 0 (0 O O) 00 Q ~ I M ~ I N z rn U) w O Z a m I c C7 0 z d c u W o' c ~ N N 7 O L' 0 K n p O N N 0 O O N 0 Q ~p N Z CO Z Z O N Q I o I N _ C 0 ~ m ~ y~ 0 I 0 0 in (L L o N N fA 0 2 a ~ 0 0 0 •wa m a a a a 3 0 (n (n (n VJ U m C2 rn (D z 0 c 4 N M J O C ~ d N n -6 u) CD .O N Q Y (0 D ~ O O 00 C C In r- E O T O a a 0 p l ~ S E E N M M %2 C co - O O 5 r W L L O C) roil O N N f H N V V ~..r oN ' 7 N E E U • LW O N 2 co O uJ 0 r.r EL a w E y c c D 0 n. n 0 co 0 00'0 00'0 00'0 lelol soBjeyO;uenbullaa soBae40 lelaadS s;uewssessy lelaadS ;unowy AjoBojeO epoO lelaadS -jasn :slepads 431e8 mea uol;eounjeo 0 :;unoO w1elO :IIpa.lo Aigno-1 0 0 000'0 PUelpooM 0 0 0 000'0 A:padoJd le-Iaua0 :BOOZ ao; SIMI 0 0 000'0 puelpooM 0 0 0 000'0 A:padad IWOUGE) :9002 ao; sie;ol ON 0 0 0 OZO'9 bX 2131-I10 uoseeu a;e;S le;ol anojdwl pue3 saaay sselO uol;dposaa 9661/£Z/90 :paBueyO;sea :suoljenleA 0 :411M passassy :enlen;a)IJeW ne3 1118 Auvwwns 9002 1St,/099 L661/£Z/LO edA1 aBed/Ion # aoa wa :tio;slH IaaJed :sa;oN ONlallfl8 M61-N6Z-OZ Ho~inHO 80d Ol 13 Z/1 £9 3 13 L'09Z S '13 1 1 ~1-unn L'LOZ 3 '13 9'LZ£ N-1 M JTd S '13 9'LZS M (b/1 09 b/ Ob 6u 1-asS) :(s);aej1 Hl '13 OOb N 13 £0£ „Z 1„ AMH 9180 Nl N30 0-1V 3 030M '8Od Ol 13 9'6101 M Hl '2100 :131318 013u0Op13018 b4 S W00 b/1MS-b43S M6121 N6Z1 OZ 03S 3-l8`d-11` AV lON-`d/N ILId OZO'9 :sway :uol;dliasea Owl 011M OOL 1 dS NOSanH 6192 OS uol;dljosea #;sla edA1 tiewud = x :(so)ssaippy A:podoad lelaadS = dS IooLloS = OS mouisla 9101,5 IM NOSanH „J„ N 1S H18 ZOL . 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O o o!aa I Rings used:_L> Manhole cover elev:9(,P•&S- Final grade elev: ,~C< q3 / Tank inlet elev.: j•-r-~4'ws Tank outlet elev.: 10.05.= 9&1 (O No. of feet from nearest road:Front~_, Side , Rear Ft. -100" From nearest prop. line:Front , Side X , Rear Ft. G 3~ No. of feet from: Well _(:Z'O~ , Building: (~~.23Fom NFLo~.~.iat/` (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE f ~ i PUMP CHAMBER b i Manufacturer: _Liquid Capacity: Pump Model: Pump/Siphon Manufact.: Pump Size Elevation of inlet: Bottom"of tank elevation Pump on elev.: Pump off elev.:Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front_,, Side,_,, Rear_Ft._ Distance from: Well Building ? ff ; ►►.1zs. SOIL ABSORPTION SYSTEM 4 41 : l i • 30 = 9 3 , ~S ~ Bofen, 1'2.2s= 92.90 Bed: I Trench: Seepage Pit: 01 Width: J9Length_ 2 Number of Lines: Area Built Zex t Exist. Grade Elev.LY 3 Proposed Final Grade Elev._ . l/_ Fill depth to top of pipe: 1-16 No. feet from nearest prop. line:Front Side!, Rear X Ft. I'S" No. feet from well: s3 No. feet from building HOLDING TANK Manufacturer:/q/ ~l C apacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop, line:Front Side,, Rear Ft. No. feet from: Well-., building_., nearest road Alarm Manufacturer: INSPECTOR: DATE : PLUMBER ON JOB : LICENSE NUMBER: S 3 6/90:cj Ppplp)~CATION: HUDSON 21.29.19.1163,SW,SE,21, LARSEN LANE Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and-Buil4ings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 149288 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: BENOY, VERLYN E & CATHERINE HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 020118510000 TANK INFORMATION ELEVATION DATA A9200134 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic C,06 Benchmark -T. o7 ol 16d, GO Do ' I /05 a 3 0~/ S Aeration Bldg. Sewer Holding St/ Inlet 10 TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 16 114 NA Dt Bottom p NA Header/ 93,91 Aeration NA Dist. Pipe 7 Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade 3~ (D, Manufa Demand vl /yl~~, < r 7, 57- 1-,51 Model Number GPM TDH Lift I Friction stem TDH Ft Loss d Forcemain Length Dia. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width i Length No. Of Trenches PITS Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N LEACHING-- Manu acturer: SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM INFORMATION Type O CVy, LI`__ CHAMBER Moe er System: 2 g, d 37 163 OR UNIT DISTRIBUTION SYSTEM Header MaefaesidcL Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length I Z Dia. Length _2 Dia. Spacing __~L SOIL COVER x Pressure Systems Only xx Mound Or At-Grade ystems Only Depth Over Depth Over xx Depth Of xx Se ed /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes No ❑ Yes COMMENTS: (Include code discrepancies, persons present, etc.) v' Plan revision required? ❑ Yes Use other side for additional information. SBD-6710(R 05/91)-' Date Inspector's Signat a Cert No. ADDITIONAL COMMENTS AND SKETCH r SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code 4~ MIL R CO! STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1 yqa 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. PROPERTY OWNER PROPERTY LOCATION CLr $a W % ,S' F_ S Z/ T I-Y , N, R /7 E (or PROPERTYNER's MAILI G ADDRESS LOT # BLOCK # 19 OK CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER WI: 2 G ♦ ; r; P; j t-* II. TYPE OF BUILDING: (Check one) ❑ State Owned 0 VILLLLAGE NEAREST ROAD 101 Y~J~ AR NUMB La~S ~-N .Lt/► ❑ Public ®1 or 2 Fam. Dwell ing#of bedrooms P 1111. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo 2 El Assembly Hall 6 El Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ RestauranUBar/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. VV New 2. ❑ Replacement 3. ❑ Replacement of 4.0 Reconnection of 511 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) ELEVATION 720 72-o . ZS L 3 9Z-00 Feet S~Z Feet VII. TANK CAPACITY Site in allons Total #of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks Concrete glass App. Tanks Tanks structed Septic Tank or Holdin Tank x DD GtJti Sdr Lift Pump Tank/Si hon Chamber 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 damps) MP/MPRSW No.: Business Phone Number: D 5f.-o! ~r 31 ZY 3Z 3 Plumb rW Address (Street, ity, State, Zip Code): IX. C NTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing A nt Sig lure (No ) Surcharge Feel ..QApprOved ❑ Owner Given Initial TT Advers 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 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 (SBO 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 tl-e 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, purnp/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 manufa.-,turer; 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) . ,.''"-.'...._...~"T..'...,'_"'."'"' ,...s."•^-'T9 ~,'•y 7-;.'.a^."."...".^-S!4" 17"►.?--T, --*-IIY^'~'+4.*~-^*-_ - DOCUMENT NO. STATE BAR OF WISCONSIN FORM 6-190 TMIa SPACE Ria[RVLD /OR R[COROIMe DATA PERSONAL REPRESENTATIVE'S DEED 410421 ' -_.ir3rp 1 Harry J. Stewart _ I N,)" Co., WIS. . R:: fsnx)ii $!113 311;t . as Personal Representative of the estate of March 86 a~~S~a. Adzo..LaXS.ei} e 9:45 A G~>r ("Decedent"), Verl n E Beno for a valuable consideration convoys, without warranty, to ._........Y.....--r-.-• y _ and. Cather,tne A.__Benox._.as..husband..ard- wife.-as--marl-tal.. Pat~"wler D"ds Pr4PertY wt[h-•righ->i-•of--surviyorship Grantee, RETU To the following described real estate in St..__ Croix County, State of Wisconsin (hereinafter called the "Property") West Half of the South East Quarter of Section 21, Ta=Parcel No: Township 29, Range 19. .N I ,u Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which the Decedent had immediately prior to Decedent's death, and all of the estate and interest in the Property which the Personal Representative has since acquired. Dated this . ..28. . day of . ~41rdi - 19_.d6- C,h - . . . . . _ . . . --4 ~r.~.~: ..........(SEAL) (SEAL) . Harry..:?.....S.GtWa.TC.----- •-------------`------~.b.R • P' r.onsl ro-prmentative ~L~~J ~ Personal Representative V Q J AUTHENTICATION ACKNOWLEDGKr?,LT~,~, C7' :o• J Signature(s) STATE OF WISCONSIN ` 7 ;Z Q l 1 _..CL..-CLQIY...._.......... County. authenticated this ........day of.......... _ 19.. Personally came before me this .....h.-.day of 19.SG... the above named ry.-,1.. titewart, as_l'ersgl)a~..Kepreentative _ liar fOr Ole .QSL4.U4-.Qf- luhn.Aldro•M~fxen-.La•> sea, TITLE: ME:<IBER STATE BAR OF WISCONSIN a/k/a. john Aldro 1,arsen.,."a/kh4.-4l4r9_ (If not, Larsen _ authorized by § Ioa.oG, Wig. Sung.) to me k own to he the person who executed the forty g instrumeut and a w/ledge the same. THIS rRUMFNT WAS 011AF11"D nv .`•1"'~ i l..-~t l Lois A. `hurray of 11L`114001), CAKI P.O. .Box 7229, liudsuu, .l 5401.6 Nota-p l'nhlir tit. Croix I✓ (c County, Wis. (Signaturf- may he authenticated c,r arkm,wOcd,:•,-d. B,,Ih MY Commis=ion is permanent. (if not, state expiration are not n- ~~:•arc.l dale: kn •Nam..+ e.nnn: HiSnm¢ in s s .r rt: h.. J Si I-I. BAR (IF WI$I o.\111.' W'1ye.,n.in 1.~,[al nlsnk Cn. Lu'. PERSONAL REPRESENTATIVE'S DEED IOR)t N.. s-17"2 _ _-Stilwsukrc, Wis. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS .IN.DUSTRY, - , DIVISION L=ABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 539069 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.:BLK. NO.: DIVISION AME: 4 . ] /4Sr 1 z! /T29 N/0 E (or) W cs sew S )eh~ (STA C UNTY: OWNER'S /BUYER'S NAME: MAILING ADDRESS: C0_6xx S4)q USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: E ATI N TESTS: Residence t4 N~ IxNew ❑Replace 13 9Z 3 Z:N 9- 5oIc.S 4 S~ _ ,A ,czar ' RATING: S= Site suitable for system U= Site unsuitabT9 for system g CONVENTIONAL: NAL: MOUJVD: - IN-GROU P RE: S®EM-FILL H ~ ING TANK: RECOMMENDED SYSTEM: (optional) {~L~1(JIJ SS ~UU ® S ("'S aU S U S U T ~Q 1. f 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: LAS_ / Floodplain, indicate Floodplain elevation: bU_1;1 PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH oral ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1 .So Q6.d~ I460L >9.s6 /4"'$z~~ 3~ Ba.~~s~cG,e ~'BC$e..,S~tCre 6o'SQ~,~S Z~ 9b•~~ zS 63"Sew MS46t 46 "Qao CSr62 B- IJoWLC > B- 3 ~.4Z ~q~ n(o > ~•4Z SL46r~cObl~"90,,A! W2 6 JZbvM:5 B- 4 9.1- 9s 91 0 ~.l i~'' csc.~e'~Bw~Sc.~G~ i~'Ba~MSdG;3o eQ►r►~ 4g~ eN st4e B- S ~S 9~.~~ nloN > 9.~5 ss"Ba~►n~s~~e S6"'8RN fhS B- L PERCOLATION TESTS TEST DEPTk},WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER iR}G1t AFTER SWELLING INTERVAL-MIN. PERT 1 P RI D PERIOD PER INCH P. S O e .OS a. 'Z > 2 > 4 P_ p t404'- 96 3 > 2 >'Z >Z .4 3 P- o > >z > P- P- ELF-4A-00 AT -A,(- P_ I 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 Z.Oo t 71 I , -at -4' i I I i ~ I -r. i I 1~ 2 I ~ I A ~,-3 ! ~o~~KaSS d 62 4- 7 4- i t"v 10~ . OCS .L g_S I, the undersigned, hereby certify that the sdl tests reported on this form were made by rpeq accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the locNorLpf tht&ts ar correct To the best of my knowledge and belief. NAME print : \ TESTS WERE COMPLETED ON: [1 ~1 Jo u NScs~ Jp)4A Saw v' /tiJ4 A~>~ Z E4~Z ADDR SS: CERTIFICATION NUMBER: P ONE N MBER(optional): u ~ I S~O1 Arc-4 66 CST S ATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) -OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6335 To be a complete and accurate soil test, your report nu,rst include. 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedroorns or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 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 to scale is preferred. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation) does riot apply, place N.A. III the appropriate box; 11. Sign the Morn and place your current address and your 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 rob - Cobble (3 - 10") S5 - Sandstone gr Gravel (under- 3") LS - Limestone s - Sand HGW High Groundwater Cs Coarse Sand. Perc - Percolation Rate reed s - Medium Sand W Well fs - Fine Sand Bldg - Building Is Loamy Sand > Greater -i-han ~s€ Sandy Loam < Less Than Loarn Bn Brawn ~si€ - Silt Loam BI Black si - Silt Gy - Gray *c - Clay Loam Y - Yellow scl - Sandy Clay Loarn 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 III - Muck d - distinct p - prorninent. HWL - High water level, Six general soil textures surface water for liquid waste disposaj BM - Bench Mark VRP Vertical Reference Point 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. 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 C h d ; Location of property,.<,j(d?l/4 1/4, Section T- N-RA Township Mailing address ZGG aj Pr I.2-ft. k 5a:-_~ (~1~ ~y 1~~ Address of site,,- subdivision name ~DrL;ria-,. 1/1`S - Lot no. Other homes on property? yes-A _No Previous owner of property ,A)ck„o s~ Total size of parcel _ z.0tt A C~ Date parcel was created I Are all corners and lot lines identifiable? -A-Yes No Is this property being developed for (spec house)?)Yes No Volume - 1.5and Page Number less-- 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. 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. > , and that I we ) r own the proposed site for -t the sewage' disposal system or I e(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. Signature of applicant Co-applicant Date of Signature Date of signature SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ADDRESS : 7(~06 /JJ aai ,Dcv~ FIRE NO: LOCATION:_S W _1/4, S 1/4, SEC. T Z7 N-R, W TOWN OF : Lsa rl ST. • CROIX COUNTY SUBDIVISION: c i d yi_. ' LOT NO. S- 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 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 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: DATE:__ St. Croix County Zoning Office 911 4th St. - Hudson, WI 54016 B s. w_ ` ~o!~Cr.rr E ~ - IUD-O Q J7OItS C/~4ck too) qs~ pri -s ue, 14 tit BOO °o - w J J c 6S- -3 61 4~ E Sle acVO A5 a1, t4 P µS ~s S How s (pec ra f ~u XIb ww 11 D R Z ~ ~-M'T fi 5 w CvtNm✓' w E~, s ~po.o A Y ' SAN E BARS E N m sI C I fzzT7 , c~ I;I ' ~ . ~ z ~ Y I! ! 1, ,I u I u• ~it . P4 O c i7 !II i ~i ~ ~ crr ` ao ~ r I~~ I o v p o ca CIO FTi x x < r v o S TJ Chi P 0O © `C C ITl P i I tA _ P A ..w N `o 0 ut