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HomeMy WebLinkAbout022-2000-20-000 Q ° o ~o p ss Sq O o y o rV m o O N co n~ N ~ I (n N cu O)3t O N U O 0- CO U .5- 02 O 0 U Q C O r O 0 r O y N O E O C Z O ~ N ~ LL C ] X Q a) L) N bo a -a) B O C N O Q U N O Cl) V ' N z E U) o ° z r `y w 00 N a m H V1 co .O N C C7 ~ O Z O aUi Z v (n c (n CL) o E N ~ m ° o • N 'O -C itl N 0 Q Q - O O z z zI C N C) N c ~ m 7 n1 0 N - E }Iti O 05 CL m n 0 0 d O) 1 ~R/ O C E F- F- FL •*Ali Li a a a S; a O O N N N N J U rn ~ ~ a rn rn } ~l r o0 co N ~ E N O V = d N "Mo C o 3 H c R ~..i O C? OU C O O O O O o mj y Q rn o jv\ N C d 7 O 00 C C N O N - L2 L" ON 00 U N) '06 1- O t N C N V C .Pr-- f' O E J • y' O co Y = O (n! Z V~1 xt a ` a a . a w u u o m 3 o A U a o N v iCoTlgepart KlfolluryNNIC 34.2 PRIVATE SELVAGE SYSTEMLE CLUB IZOAD County: Labor anaNuman Relations INSPECTION REPORT Safety and Buildings Division ST. C IX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 171457 Permit Holder's Name: ❑ City ❑ Village [Town of: State Plan ID No.: HANSON PAUL T & LE ANN M KINNICKINNIC CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 022-2000-20-000 TANK INFORMATION -7 ELEVATION DATA A9200222 2 n• TYPE MANUFACTURER LH~ACITY STATION BS HI FS ELEV. Septic Benchmark Aerat' Bldg. Sewer Holding St/ Inlet vz Q8, Z/ ' TANK SETBACK INFORMATION St/ ICE Outlet 9 /Z Q, 6/ Ventto TANK TO P/ L WELL BLDG. Air Intake ROAD Inlet cf a v, Septic 10l NA /Z8,79 ~ ng > IcD NA +leader/ Man. eration NA Dist. Pipe 2S- Holding Bot. System 3.9Zl -ANAIII&IL4 SIPHON INFORMATION Final Grade Manufacturer De d _ i s,S /Z3• ! ; 07 Model Number ~n PM TDH Lift Friction System TDH Ft Head oss Forcemain Length Dia. Dist.Towell SOIL ABSORPTION SYSTEM BED/TRENCH width Length / No. Of Trenches PIT, . No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS LEACAING, Manu adurer: SETBACK SYSTEM TO P/ L BLDG WELL LAKE / STREAM INFORMATION Type O CHAMBER T Moe er: System: DISTRIBUTION SYSTEM Bender / Mangold Distribution Pipe(s)/ x Hole Sze x Hole S ,ig ing Vent To Air Intake Length --~L Dia. Length 2-:~L Dia. Spacing ~ / TU > SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over it xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Ue ad}Center ~U Bed /Trench Edges Z. ° ~O Topsoil ~p al,.*~❑ No W.Ker-`❑ No ' .r 103 0~ COMMENTS: (Include code discrepancies, persons present, etc.) 6 7- F to r /7 20 Plan revision required? ❑ Yes [jr No / Use other side for additional information. SBD-6710 (R 05/91) Date oor Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION T_ILHR In accord with ILHR 83.05, Wis. Adm. Code COUNTY -a STATE SANM RMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than / 8'/z X 11 inches in size. ❑ c / it re3ision to prevl us application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. 4,0 1-4/7 PROPER OWNE PROPERTY LOCATION ) 7 Y. S TO 2, N, R l E (o PROP OWNER'S MAILING ADDRESS LOT # BLOCK # iaW HONE NUMBER SUBDIVISION NAME OR CSM rUjP9jER T PTY, STAT ZIP COD ) P O fl(; 0 : - II. TYPE OF BUILDING: (Check one) VITM : NEAREST ROAD ❑ State Owned VILLAGE ` J j TAX NUMBER(b) ❑ Public El 1 or 2 Fam. Dwellings of bedrooms PARCEL a MN OF: 111. BUILDING USE: (If building type is public, check all that apply) DO` C~ ~,1D/S~' aV 1 ❑ Apt/Condo t/ v 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 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. 0 New 2.E] 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 R Mound 30 El Specify Type 41 El Holding Tank 12 El Seepage Trench 22 in-Ground 420 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 I d-0 '3 7 7 C 5 Feet Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufac)urer's Name Concrete Con- Steel glass Plastic App Tanks Tanks t FS r'n k CA5 i strutted Septic Tank or Holdin Tank K i' V U El Pump Tank/Si hon Chamber, so VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumbe 's Name (Print): Plu r s Signature: (No Stamps) MP/M S We- Business Phone Number: ' 3a3( ~s S~' Plumber's Address (Street, City, State, I Code • /~j IV A 10~ I b ~ 7~ U 't IX. COUNTY/DEPARTMENT USE ONLY ❑ ODisapproved Sanitary Permit Fee (Includes Groundwater Date Issued I ng Agent Sign a (No Stamps) Surcharge Fee) Approved ❑ wner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11188) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1.7 4 ,A sanitary. permit is valid for two (2) years. 2. i 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. -Akk* ev_isions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. , 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be -pumped by a Iicensed " pumper whenever necessary, usually every 2 io 3 years. 6. If you have questions conperning 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. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross,section of the soil absorption system if Jequired by. the county; E) sojl test data on a 115 form; and F) al•I,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) SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations PRIVATE SEWAGE PLAN APPROVAL Western Regional Office 2226 Rose Street LaCrosse, Wisconsin 54603 ~2a aooo-, as WANG EXCAVATING Owner: PAUL HANSON W9672 770TH AVE HWY 29 RIVER FALLS WI 54022 RIVER FALLS WI 54022 RE: Plan Number: S92-40367 Date Approved: May 29, 1992 Gallons Per Day: 450 Date Received: May 28, 1992 Project Name: HANSON, PAUL - RESIDENCE Location: SE,SW,34,28,18W Town of KINNICKINNIC County: ST Ci~'MX The plumbing plans and specifications for this project have been reviewed for compliance with applicable code requirements. This approval is based on Chapter 145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are stamped 'conditionally approved'. This approval is contingent upon compliance with any stipulations shown on the plans. All items that are noted must be corrected. All permits required by the city, village, township or county shall be obtained prior to construction. The licensed plumber responsible for this installation shall keep one set of plans with the department's approval stamp at the construction site. The installer shall notify the appropriate inspector when inspections can be made. This approval will expire two years from the date approved or if a sanitary permit is obtained, it will expire the day the initial sanitary permit expires. The Section of Private Sewage has reviewed these plans for private sewage system code requirements only. These plans have not been reviewed for the code requirements set forth in Section ILHR 82 for general plumbing or in Chapters 50-64 of the Wisconsin Administrative code. This approval is for the following components only: - NEW MOUND Inquiries concerning this approval may be made by calling (608) 785-9348. Sincerely, GERARD M. SWIM Section of Private Sewage Division of Safety and Buildings PPP039/0009n/27 cc: PAUL HANSON X Private Sewage Consultant SBD 6129 A. OI/BU i H ` •r 1 S KInn ~c~''( nn~ C, 0(3 rr5 ONSiTE SEWAGE SYST C rv IQ ConditionalIV mftPR(Jvhu Aly 1) 403 v RELATIONS , Q c b~9 `N "G~ rbc ©EPARTMENT 0 SlON U fTRY,~ LABOR O BBU N IN ~_\-3 e e~o^ s r i v c- $EE CORRES N ~o ,moo y w\ s 31D 'oSi sI zlvx, (ALL b kO S ~75r ) Tha aroe ?5 ft. (o Q ~p a 6 d Absorption -ow thO do oil System m. wemr►Fe odge ~ 3~ the lpp,oo N in undlsturlaad n 3031 5/9s ~a f Page - Of - t Straw, Marsh Hay, Or `:Synthetic Covering Distribution Pipe Medium Sand ' H G 6" Topsoil F _J D 3 E ONSIT (fo lope . w Bed Of 12,.-2 12 Force Main Plowed RP-RO"DAggregate Layer AN r'~1,T+~~row Pipe) III DEPARTIMEN" OF INDUSTRY, LASOR AND 0 VISION OF F AND. I lD GS D Ft. s Sec n Of A Mound System Using E Ft .E=~•~{' SEE CORRE E F Ft. A Bed For The Absorption Area • ~ Q G 1.0 Ft. A V Ft. H 5 Ft. Signed: B y7 Ft. License Number: ~c~ 5 C K _1 Ft. Date: L Ft. d Ft. Alternate Position I L!o Ft. Of ~ Force Main W ~'Ft. = 3Z :L. J Observation Pipe 8 K U-77 ----------------------•I Force Main w o - eDistributian Bed Of '2"- 2 2" Pipe Aggregate . I Observation Pipe Permanent Markers Plan View Of Mound Using A Bed For The Absorption Area Page Of Distribution Pipe Detail For A Four Lateral Network End Cap / Alternate Position Of Force Main \ P % PVC Force Main PVC Distribution Pipe P Holes Equally Spaced PVC Manifold Pipe On Bottom I S X ONSITE SEWA S x L lOna fly x 2 . AMR_ * a S uld Be Next To End Cap I ' 0' INDUSTRY, LABOR AND iiELr'1;±ONS I Y I i ION 0 D LAIN _ P 1.. Ft. SEE CORRE S 41 On Ft. 112, X--~ =I nches Y _Inches Signed: 1 Hole Diameter I Inch License Number: 3 Date: j Lateral Diameter I Inch(es) Manifold Diameter Inches Force Main Diameter 3 Inches N Holes Per Pipe ' Invert Elevation Of Laterals Ju S Ft. Page Of SIPHON CHAMBER CROSS SECTION AND SPECIFICATIONS APPROVED LOCKING COVER 4" C.I. VENT, PIPE MANHOLE - WITH-APPROVED CAP 12" MIN. 25'. MIN. FROM DOOR, -f-~ WINDOW OR FRESH AIR 4" MIN. INTAKE 18"-MIN. ~ E SYSTEM- ; NOD ,,r S APP ROVED JOINTS " N , LAi3p~9 $ ptN~ • ~ tP~DtI • ? pEPAF~~"~L 1V~J~p~ 00 125 , d 0OAPPROVED INVERT ELEVATION JOINTS WITH APPROVED PIPE 3' ONTO SOLID SOIL SPECIFICATIONS TANK MANUFACTURER: ~Q o- &4~5f TANK SIZE.(GALLONS): 1 S SIPHON SIZE (DISCHARGE DIA.): DOSE VOLUME (GALLONS): ows pus FORCE MAIN DIAMETER (INCHES): :)Us FORCE MAIN LENGTH (FEET): ~u5 ELEVATION DIFFERENCE FROM SIPHON INVERT TO DISTRIBUTION PIPES (FEET) : 2(~ ous FRICTION.LOSS IN FORCE MAIN (FEET): , 53 SIGNED: w LICENSE NUMBER: DATE: Q~ THE MILLIER • 3", 4", 5", 6", 8" Standard Design Single Sewage Siphons I 1, I v C I ~ n i - B_ a •o: _ low YkTee foie - • p' Y .ti, 1 ONS .6Y tT JPq0 to t iv AOL APPRU V &M ^ I'- ►r_ Reducer, discharge pv;e• end t AHIEtb' ° v back vent and overt r• w are DEPART Iti{IE OF INDUSTRY, LABOR Atot S not /urnished or sold by r:ew 11/IJ1UiU OF AFETY AN PFT Division. Vitrified the pipe and /ittinys are generally used for this purpose. Sri: CORr~£S EP Approximate Dimensions in Inches and Average Weights in Pounds 3 4 - 5 - 6. & Diameter of Siphon , , , , , , A Drawing Depth . D 13 17 23 30 35 Diameter of Discharge Head C 4 4 6 8 8 Diameter of Bell B 10 12 15 19 21 InvtatBelow Floor E 4'/. 6'A 7'h 10 9 Depth of Trap F' 13 14Y. 23 3010: 40 Width of Trap G 8•~4~ 11 14 16 25.5/8 Height Above Floor H 7'/, 113/4 9% 11 . 16 Invert to Discharge-D+E+K , , , 3 25% 33% 44 47 Bottom of Bell to Floor 3 4 3 Center of Trap to End of Discharge Ell L 12%: 14'% 17 19 25 Diameter of Carrier . . S 4 4-6 6-8 8-10 8-12 Average Discharge RateG•P.M , , , , , , , , , , , 72 165 328 474 950 Maximum Discharge Rate G.P.M......... 96 227 422 604 1400 Minimum Discharge Rate G•P.M, , , , , , , , , , , , 48 102 234 340 500 Shipping Weight in Pounds . , . 60 150 210 300 800 Detail Drawing 1F , , , , , , , , , , , , , , , , , , , 373 374.2 375 376 378,2A Note:-Two single Siphons of this type set side by side in the same tank will alternate. Sel• page 4 for discription of operation. The draft "D" will be 1" to 2" less in this case. Siphons listed here are carried in stock and can be shipped promptly on receipt of order anct payment. The drawing depth "D" may be reduced in certain cases by special air piping. Contact the manufacturer for these special applications, IL 1 i DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS IN,DUSTFiY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N, WI 7969 HUMAN RELATIONS (H63.090) & Chapter 145.045) LOCATION: SECTION- dff=UN I I PALITY: OT NO.: BLK. NO.: SUBDIVISION NAME: 1~~ Dell (o ~ J 1 L464 it C NTY OWN ER'S N MAILLl G ADD -ESpS~: / 9) t 'K RL E~SMA !t f v c~ ! r c~ r ! J W ' 5`'7`d r~ USE DATES OBSERVATIONS MADE NO. BEDRMS : COMMERCIAL DESCRIPTION: ~7 PR F D RIPTIONS: R T N TESTS: DO New ❑Replace Residence 1 31 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: TIS TEM-IN-FILLHOLDING TANK: RECOMMENQED SYSTEM:(optional) ❑ S El U ® S S ©U ©U ❑ S ©U a d If Percolation Tests are NOT required DESIGN RATE: ^ If any portion of the tested area is in the under s.H63.09(5)(b), indicate: .J I Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- 1"k e .3 A B- B- ra,c. ,10te5hole PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERT D P R PER INCH P- E , P-_ P- P- 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 E , i le It ~I i j _ E ( t 1 _ Q ~ - N - f Lx r _ - - 4 I, the undersigned, hereby certify that the soil tests rep rted on t orm were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the ca " of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLE ED ON. ADDRE p~ ) 1~ f (uil r R / ~ 60t _ JVo~ CERTIFICP~TION N BE PHON~BE (optional): I S CSTSI~O(yURE: ISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. R-SBD-6395 (R. 02/82) - OVER - 1 4 IN TRUCTION FOR COMPLETING FORM 115 - SBD - 6395 To be -a corm accurate soil test, your report must include: 1. Complete ' ption; Z. The use sz! r'early indicate whether this is a residence or commercial project; 1 MAXIMUM of bedrooms or commercial use planned; 4. Is this a new rent system; 5. Complete y rating boxes. A SITE IS SUITABLE FOR A HOLDING TALK ONLY IF ALL OTHER w RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use vi sttons shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIE dig gram accurately locating your test locations. Drawing to scale is preferred. A separate shoe i, ed if desired; 8. Make sure your rk and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all an boxes as to dates, names, addresses, flood plain data, percolation test: exemp- tion, if approl: i,4" ; 10. If the inform titi>r s flood plain, elevation) does not apply, pl-, I ;n the appropriate box; 11. Sign the form and ur current address and your certification n 12- Make legible copies d disti-ibute as required, ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30. DAYS OF COMPLETION. .DEVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st - Stone' (over 10") BR - Bedrock cob - Cobble (3 - 10") SS - Sandstone gr - Gravel (under 3") LS - Ling tie s - Sand HGW - Hi,,'- Undwater cs - Coarse Sand Perc - F to.. Rate coed s - Medium Sand W - IVA fs Fine Sand Bldg - I. Is - Loamy Sand ) ( Tl.,n 'sl - Sandy Loam < I an 1 Loam Bn *sii - Silt Loam BI - I~ si Silt Gy G cl - Clay Loam Y - Y _ scl - Sarzdy CIS ;am R - RE sicl - Silty Clay mot - Mo - Sandy Clay w/ - with Silty Clay fff - ft-, int Clay cc C, Peat rnrn - Ct I in - Muck d - dit+:. ID pro. HWL Hig' 1, eral soil lµ,` rr rid waste BM - y VRP - Vet Point a TO THE,- ,il report is th- o in sec sanitary ~,rmit. T I, the Department may request ,n Of this sc ( Id rr rm r is inn A crel ref N., -,r the private ;term rim! rt or "le+r to oerrr~i y 17r i .s r O r STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT . St. Croix County OWNER/BUYER/ ROUTE/BOX NUMBER IL't4 9 FIRE NO. CITY/STATE FAA 2' ZIP PROPERTY LOCATION: 43L1/4 43 IA_ /4, Section TNN, R-011-W, Town of St. Croix County, Lot No. Subdivision 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 $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 St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED DATE zg 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 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. ---------------------------------r--------------------------------------------- C Owner of property let Location of artY 1/4 1/4, Section T_~SLNR,~Y s.~ ZTownship 77, ° L Mailing address I1 r~ 4 1 j ~ ~ Ts~-/Vo- Address of site, Subdivision name Lot number Previous owner of property tC r~(° t` Total size of parcel Date parcel was created Are all corners and lot lines identifiable? as o Is this property being developed for resale (spec house)? as o l J Volume 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 PACE 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 eedrac rded in the Office of the County Register of Deeds as Document No. . ; and that I (We) presently own the proposed site for the sewage d sposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been du y r o ded in the Office of the County Register of Deeds, as Document No. Signature of Owner Signature of Co-Owner (If Applicable) A Z-- 4 - Date of Signature Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 1 - 1982 TMS SPACE RESERVED FOR RECORDING DATA . WARRANTY DEED '473485 VO 915 PAGE 45 s REGISTER'S OFFICE This Deed, made between _...Richard F. Pommer and ST. CROIX CO., WI .-...P-Qmca x,_..huaband..and..w~.f- Recd for Record S c P 131991 Grantor, at 830 A M and.._..Paul___T.__Hans_gn___ai d__Le__AMR__ M,___Hanson_}________________ husband__ and__wife.. lrvivorahipmar_ tal__-_____••___ pxopexty - lftle*o i ste►ofDeeds Grantee, Witnesseth, That the said Grantor, for a valuable consideration-- - - Twenty_-_aeve11 __Thousand___.027-pQ9_ - -.t Agencyj-irr~=-- conveys to Grantee the following described real l estate in 5.L,..._CX.Oix .,-U W County, State of Wisconsin: 129 S. Maid River Falls, WI 54(1') All that land lying North of the public Tax Parcel No: town road located in the Southeast Quarter of the Southwest Quarter (SE1/4 of SW1/4) of Section Thirty-four (34), Township Twenty-eight (28) North, Range Eighteen (18) West. Consisting of 17.1 acres, more or less. • d~ r.=~ Q This Is...no-t....... homestead property. XXMftR*XX Together with all and singular the hereditaments and appurtenances thereunto belonging; And Richard..F_._..Pommer..and- Jane- N-.---Pommer -_husband_--and_,wife,________________ warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, reservations, restrictions and rights-of-way of record; and will warrant and defend the same. Dated this - - - day of September-------------------------------••.., 19.91--. .....-----•-•----------------•------------------------•--•-•-•-•--_..(SEAL) (SEAL) • ..Richard F. Pommer n.. •-------------------------------•-•------------•-----------------•.--(SEAL) (SEAL) ' • _-Jane N• Pommer AUTHENTICATION ACKNOWLEDGMENT SignpAure(s) STATE OF WISCONSIN Pierce se. ' County. authenticated this day of 19 Personally came before me this _ 5th _day of 19-91 the above named ----lZ_el~a?~_d..F - - - - - - - - Qe, husband.__aS_.Wfe-1---------------- TITLE: MEMBER STATE BAR OF WISCONSIN (If not- - authorized by § ?06.06. Wis. Stats.) - !II!-E:•Cfa11Et8R to the persons who executed the and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Charles E. White1 Attorne................. at aw " L= 1 River Falls,--_WI-__•-54022 -t;E~ Li~lwvi~~ Notary Public (Signatures may be authenticated or acknowledged. Both My Commission is - -County, Wis. are not necessary.) permanent. (If not, state expiration date - 9 ;Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED 8TATE LIAR OF WISCONSIN - FORM Ns...l-188Y., tiVisconsin Legal Blank Co. Inc ' -'LS_!''!~~I~"-t'!11_i .....~nr,~wmeww~•~r~xr..we..»...,,,~...w,•:Milwank~p~W1s.«.M.,w ST. CROIX COUNTY ti y t ~,~xa WISCONSIN t~;''c` ~sri•,~y ZONING OFFICE ~Yri zaA ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 Mar. 25, 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 Paul Hanson property, located in the SE 1/4 of the SW 1/4 of Sec. 34, T28N-R18W, Town of Kinnickinnic, St. Croix County. This onsite revealed suitable soils at a depth of 40". Should you have any questions, please feel free to contact this office. Si erely, James K. Thompson Assistant Zoning Administrator cj