Loading...
HomeMy WebLinkAbout032-1084-80-120 cz °o• N p ry ~ o ' n C x C N f•- C O ~ N y ~ O U O ~ O O Q N ~ •E j CL L N = N D N U Nn c z 3 3 m o LL O c -0 N a O O Q Uco U~ ~ M d' N z N O i O z ~ E a a m N I- O z d c U r O m Z 2 N N ~ C ~ N }I+ w N O r- c (o N O O O y U CD N CL o a) m Z Z CD O Z N N . U') d E E O _ N d N C. .Y r N `l O N N L LZ a C c o o za>° ~0 ° 0 M U C N N N N to -j U co rn rn "-1 -0 0 o N 0 O ~ O co ~ O 6 n Q) L 2 Q Q L •6 7 w O O O O 06 N C 3 LO 'O C E Ln aw a _ E G O N C O. a- 0) N a O 00 O C O 00 fr" N O O N '00 I- O N M E N v o E v • y'in' O N (A z ; 0 N z U) O ~ 4i E 0) r a ° a L: (L • 0. N U N i C L C A 0 a 2 o m 0 J c AS BUILT SANITARY SYSTEM REPORT OWNER , A1,V--itA) TOWNSHIP 24Z.J 1 SECTION N-R--Zj-W ADDRESS _ST. CROIX COUNTY, WISCONSIN 4/ SUBDIVISION LOT LOT SIZE PLAN V~1 S 3 ' SHOW EVERYTHING WIT IN 10 FEE OF SYSTEMleM ~~,ll~,~ /louse ®l 41 /s 3~L G 67 ~ /W INDICATE NORTH AFROW BENCHMARK: Elevation and description: Alternate benchmark SEPTIC TANK:Manufacturer: Liquid Cap. Rings used: Manhole cover elev: Final grade elev: Tank inlet elev.: Tank outlet elev.: No. of feet from nearest road:Front , Side, Rear Ft.(= From nearest prop. line:Front Side, Rear Ft. ie No. of feet from: Well Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE fPUMP CHAMBER 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 SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: Width:--,4' ) Length -4 Number of Lines:-,-.2 Area Built-;42? Exist. Grade Elev. Proposed Final Grade Elev.--22-s-/ Fill depth to top of pipe: F~SI~ No. feet from nearest prop. line:Front Side , Rear,>(_Ft.,~L" No. feet from well: o. feet from building HOLDING TANK Manufacturer: Capacity: 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:- 6/90:cj `Wish'con~inISepartme~nf-o n3SAT ry, 29.31 • 19PRIVATE'Jrd%i ? SjgM311 County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division (;T- r-ROTX (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 171494 Permit Holder's Name: ❑ City ❑ Village EiTown of: State Plan ID No.: NELSON, GARY D & JILLIENNE J SOMERSET CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: i 032-1084-80-100 TANK INFORMATION ELEVATION DATA A9200265 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic, Benchmark j/yy~ od 12 Dos t /1!~ 35 ~Z 7-6 Aeration Bldg. Sewer $ 9~~v 99,12 Holding St/1,K Inlet A9? , S I TANK SETBACK INFORMATION St/ I;W Outlet &';7 310 ' TANKTO P/L WELL BLDG_ Ventto ROAD Dt Inlet Air Intake j el, h C, NA Dt Bottom Septic Do i NA Header-fem. Y.;_" 96,77' Aeration NA Dist. Pipe .6,/, Holding Bot. System 92" 96,97 PUMP/ SIPHON INFORMATION Final Grade 9,9 ?6' Manufacturer Demand 'S'T odel Number GPM I b-m r TDH Lift Friction m TDH Ft 0 Forcemain Length Did. Dist. To Well 247 D7,c / SOIL ABSORPTION SYSTEM BED/TRENCH Width i Length/ /l i No. Of Trenches PIT is inside Dia. Liquid Depth DIMENSIONS V / DIMENSIONS LEACHING nu acturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION Type Of -V_ CHAMBER Mode N er: System: 3 I 1 OR UNIT DISTRIBUTION SYSTEM Header/ Ar a"if&d- Distribution Pipe(s) I x Hole Size x Hole Spacing Vent To Air Intake i Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over 11 ?p „ Depth Over i~ xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center 3~ ~o~/ Bed /Trench Edges 36 1 3~ Topsoil E] Yes E] No El Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) r 'J Plan revision required? ❑ Yes B-1 of~_ Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: SANITARY PERMIT APPLICATION couN ILHR In accord with ILHR 83.05, Wis. Adm. Code Ems ZQ__ STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than E] 1-71(,19 ~ 8% X 11 inches in size. Check if revision to pr sous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICAN'~ 1WORMATION - PLEASE PRINT ALL INFORMATION. PROP TY OWNER PROPERTY LOCATION 5b , '/a_~>ti' '4, S T , N, R PROPERTY NER'S MAILING DDRESS LOT # BLOCK # CITY, STATE ZIP C DE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one) CITY A NEAREST RO ❑ State Owned VILLAGE ❑ Public 91 or 2 Fam. Dwelling-#of bedrooms - PARCEL TAX NUMB ( ) Ill. BUILDING USE: (If building type is public, check all that apply) C Y~Gy/ s3c jeC; /11 j 1 El Apt/Condo 2 ❑ Assembly Hall 60 Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 80 Mobile Home Park 120 Service Station/Car Wash 5 ❑ Hotel/Motel 9 ❑ Office/Factory 1130 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 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ® Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) ( in./inch) ELEVATION CI '~s ( 7S Feet / Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank " Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT [,the undersigned, assume responsibility for instal lati of the onsite sewage system shown on the attached plans. Plumbs 's Name (Print: Plumber's i ature: No Stain MP/MPRSW No.: Business Phone Number: Plumbe 's Address (Street, Ci~ tide, Zip Cole): v ~r IX. COUNTY/D -P RTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater a e ssue Is Agent Signature o stamps) Surcharge Fee) 3 Approved ❑ Owner Given Initial - Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by 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 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. 11. 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. Vill. 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 dimensiois, ocation of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water riains/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 absorptior: 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) cfl ti S AILED b o z ~ssz~ J►,MES 01 Dees Ae9 485438 SL CXA, Co.,w► CERTIFIED SURVEY MAP Located in part of the SW4 of the SW4 of Section 28 and in part of the SE-4L of the SE144 of Section 29, all in T31N, R19W, Town of Somerset, St. Croix County, Wisconsin; being Lot 3 of Certified Survey Map recorded in Volume 8, Page 2193 at the St. Croix County Register of Deeds office. o n... v. - E} Corner of Section 29 Wi Corner of Section 28 :r d zl OWNER N " f s $ --11 Gary Nelson d 1919 137th Street j : Somerset, WI 54025 WI O N C ~ 1 r u ao L1=1 0~ an N N .p O ti L C G V O Lc11 C m Mal 1 Tr~acr NP- AT-rr7- ANDS N M 1 - QI 0•._.. 111 ~ L - , - - s o EE'T m x N890431 3011W SHED ~0 2 0 HE, 6OS s ^ V~ V S •~s- Off, 1 i 1 /h/ goo' `.rIr-o"'6 ,133.017 Sq. Ft. a, a, ~ ~ /11 O) ✓vt_.8 PG. G1 93 o j/ ' /s6,fld/ 3.05 Acres N "'VN f J 388.671 S890581.1311E I /~Q J~/ a 33-33- - SVI 149,509 Sq. Ft. i 3.43 Acres ® S89oS811311E 828.751 - ~1 Y d , I N P I` , A T r a ti c PPR'~?VED V I , ~1.~ sp[ 0 2 `92 h LEGEND : = o m n 3 S-r CROIX COUNT/ - Cast Iron Section Monument Found m • - J6lt, Iron Pipe Found c N s %rrylrx Zoning n g and Lning aril m o - le x 2411 Iron Pipe Set, weighing 1.68 lbs. P•arkSCcArn!_•.e0 per linear foot o K i - Existing Fenceline nefroCblded Roadway Setback Line vOtunn' all daYy!' bf N Y y .L V ar.43rCval date 1.00 ioVal sh)iWiio SCALE IN FEET SE Corner of Section 29 SW Corner of Section Aso 9' V61d 0 100 20D 400 VOLUME 9 PAGE 2507 I I T I I I _f I i Y - I ~f_~~! h Gam" _ _ I - - - - ' t YYY -t ~ I - 41c - - t - , r I i I ~ i I I , I I i I' r I I i : ' _ I I ~ : f I II~ X27 ~ _ 1 y , I I I , 1 - - I , ' ~ I I I ~ 1 I I _ r I I I I I I i , I ` I I I I - I ~ I _I ; I I ~ I l l l i l l i! ~ ' . I i i , I f I I ~ I I , I i J I I ~ ' I I I I I I I I - II ; , j I 1 i ~ I I I - I- I I I I i ~ I ~ ! I f , t I I i I ; _ I I l i I I i I I ~ ~ ~ I I ~ ' j i I I I , I I I, I I I I I 1 i ~ I I I I j : I I : I -Y I I J I I I ~ I i I I ~ I , I I --r-- i I I I I _ I 1 1 1 1 1 1 I 4! 1! 1 1 1 I i ' j ~ ~ I I i I I I r i ~ 1 I I I I i ~ I ' ' i i I ~ I ~ I I I I ! 1 ~ ~-I i - I I I I I~ I I I : I ~ I I I I I ti 1 PAGE: OF . ~ Ct`vSS• S~cc~lon p~ A Vltl7 y ffa►h All Well Amid 01116olvallon pipe 1~ A 1•vi1 • rv vIII Cop MwlnrA 12' A.•►• to• A►•r• Plrr 4' C••1 h•s To ft.•1 06•60 Veal No _U4r•~ Ibr 0. StnlMlk C•rr~lna Is 2' AVae•0N• Ora Pipe 01.111►r1g11 . ' ft1• 0 0 T•• J. AIC~•2.1• 0 _ ••0••t► Itr• r6fl•r•1•. P1r• N•1•Ir "'01e1 1011"14.1142 Al /•11.41 01 Z/•1•I4 SOIL FILL OISTRIBUT101.1 PIPE • APPR011E6 S•19T11ETIC COVC 2"OF AGGRCGATE . . ""''-MATERij% OR V OF STPtK%. OR JAARa1+ NAy ELEV. OF ~/L FELT '•'eYr 1:0Is Z1/: AGGRCGATE. 4, ' / ,95 t OISTRI15UTiou PIPE TO bE AT LEAST INCHES BELOW ORiGIWAI, •..~ADE AU[I AT LCAST,LO INCHES BUT 1.10 MORE THAW `I2 IMC14ES BELOW FINAL. GIIAOE mx1mur► DEPTH OF EXCAVATIOP FKoM 0KI6 JAL 6KAK WILL. BE _ _ I►JCHES PVHIIIVM OErni OF EXCAVATION r'&OM 1,14IWAL GRAPE WILL. 5C INCHES SIGNEO: • 1• LIGCAISC WUMBEIZ: - O AT C : t ► o REPT131 . SOMERSET ST. CROIX COUNTY ZONING PAGE 1 09/8/92 11:12 REQUESTS FOR INSPECTION WORK SHEETS FOR: 9/18/92 AREA: JT 1'------I------------------------------------------------------------------------ Activity: A9200265 9/18/92 Type: CONVSEPT Status: PENDING Constr: Address: SOMERSET 29.31.19.411A1,SW,SW,LOT 4, 37TH ..Parcel: 032-1084-80-100 Occ: Use: Description: 171494 Applicant: NELSON, GARY D & JILLIENNE J Phone: Owner: NELSON, GARY D & JILLIENNE J Phone: Contractor: O'CONNELL, KIM A. Phone: Inspection Request Information..... Requestor: O'CONNELL, KIM Phone: Req Time: 15:09 Comments: Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION Inspection History..... Item: 00012 FINAL INSPECTION DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, : DIVISION .LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 7969 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: I OT NO.: BLK. NO.: SUBDIVISION NAME: SE 1~f,E 1/4 29 /T31 N/1t9xE(or)W n Somerset, t?i. n/a n/a n/a COUNTY: OWNER'S 'S NAME: MAILING ADDRESS: St. Croix Gary D. Nelson 1919 37th. St., Somerset, Wi. 54025 USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DESCRIPTIONS: PERCOLATION TESTS: Ix~aesidence 3 n/z flew ❑Replace I 5-2-92 n/a RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) ❑V ®S ❑U ~S ❑U S [ S ®U conventional 1QS If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s.H63.09(5)(b), indicate: Class 1 Floodplain, indicate Floodplain elevation: n/a PROFILE DESCRIPTIONS page 17 AoB 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 7.17 99.40 none >7.17 .92,10yr3/2,1., 1.50, 10yr4/4,sil., 4.74,10yr4/4, 0. B_ 2 7.41 99.40 none >7.41 1.00, 10yr3/2,1., 1.58,10yr4/4,sil. 4.83, 10yr4/4 co.S. 100.00 .75,10yr3/3, 1., 1.50, 10yr4/4, sil.- B- 3 7.25 none >7.25 4.83 1 4/4 co. S. 4 8.08 101.40 none >8,08 .58, 10yr3/3, 1., 1.50, 10yr4/4, sil. - B- 6.00 1 4 4 co. S. Bs 5 8.25 101.15 none >8,25 •75, 10yr3/3, 1., 1.67, 10yr4/4, sil. 4 Co S. B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES UTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. -PERIOD 1 PERIOD 2 P (OP- rn P_ L7 1-r 1 P__ se design rate P- n p_ 1S PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scal w are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at al gs a e i ion and percent of land slope. SYSTEM ELEVATION 95.75 3 : I 3 Nk~ i 1 G._._ N r 3 3 E I e..s- I A..,.. ..-a-- -_4 ~A1 t k I J _ [ I t ~I ~ E - s t 1 E , 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 (print : TESTS WERE COMPLETED ON: Gary L. Steel 5-2-92 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): n. 71 246-6200 CST SIGNAT R DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - T1 w . INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a cornpletr I accurate soil test, your report must include: 1. Complete legal ion; 2. The use section rr if trly indicate ~r this is a residence or commercial project; 1 MAXIMUM numk -r bedrooms or con rcial use planned; 4, Is this a new or t- anent system; 5. 0 , 'Ie ?y rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHI `3YSTEr ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEA r ! weviations here for writing profile descriptions and completing the plot plan; 7. M ' 3' diagram -ely locating your test locations. Drawing to scale is preferred. A used if d 3, amark and ti l elevation reference point are clearly shown, and are permanent; 0. C:a r ,,riate boxes as o dates, names, add flood plain data, percolation test exemp- tic -1, 10. if i ich as floc in, elevation) does not apply, place N.A. in the appropriate box; 11. Sign 1 ,...:ace your curr t address and your certification number; 12. M " :e copies and distrik as required. ALL SOIL TESTS MUST BE FILED WITH THE LOC,t ~kUTHORITY WITHIN PAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and T Other Syrnbols st - Stone (over 10 ,j BR Bedrock cob Cobble (3 - 10") SS Sandstone gr ~vel (under 3") LS Limestone s HC a, :,h Ground,,vater cs - ,e Sand p- -ol-;'ion Rate we'd s liu' l send fs e Sand B 'img Is f gamy Sand > - ' -r Than sl ^dy Loam < I Than sil Learn B1 si .t1 Gy ~y cl - C', =y Loam y - ` -ovv Clay Loam R - f- d Clay Loam mot - ~ttles - Clay W'I - sic Clay ffif faint C - cc; - , _ anon, coarse pt: trim I -.y medium in - d - p _ pi -tinent HWL - High water level, Six Glen- rI )it textures surfac# water for liquid . disposal BM - Bench RA-,k VRP - Verb `erence 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 perrnit. The sanitary permit must be obtained and posted prior to the start of aw/ construction. STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER CIIR\z D. Tai S i S fir t OF t/d "S c _T /4 N-. Bu [ / p 1 q ROUTE/BOX 'NUMBER / qi 1 CI 37-7-' ILL FIRE NO. / p / k5_ CITY/STATE 144 Qf 5-eT LAJ -T' ZIP PROPERTY LOCATION: Sw 1/9 L-0 1/9, Section T_3L,o R l~ W, /fin o A/ 14 w .S6 /Y VY a q 31 Town of Saw► elr 5 , St. Croix County, Subdivision Lot No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents 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 - St. Croix County Zoning Office St. Croix County Courthouse 911 9th Street Hudson, WI 59016 (715) 386-9680 Sign, Date, and Return to above address J STC-100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property e 4 -TI I r•i e wI v, e. :Toll( ~ li,.i < A)&7/-S6 L-\ Location of property,SW 1/4 iGu l/4, Section- , T_jl&R_d_W S-t 4"Y Ty 02 9 3 ~ iv (R w .Township S;/2 r- S'Q Hailing address Address of site Subdivision name_ ZoT of 1~, Lot no. O N L. o T t~ other homes on property? _ves O~ _No J• Previous owner of property j&LA I D ~ eAgRc( ,,9 I" A Total size of parcel 3-Y-3 c r t s Date parcel was created JLAI oZ Are all corners and lot lines identifiable? -'y!x-_Yes No Is thins property being developed for NcuSe rS (epee house) ? Yes •-S./_No 5-,)/,o T'a Volume and Page Number cZ570 as recorded, with the Regist r pANgtirer of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARIUUITY DEED which includes a DOCUMENT NU1iBER VOLUME AN ~ D PAGE MURDER & THE SEAL or- THE IZEGISTL I 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 Hap 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. L/7 3a ~ O , and that I own the (we) presently proposed site for the -sewage disposal system or I (we) obtained oil easement, to run the above described property, for the construction of said system, and the same has been duly recorde n the Tice of county Register of deeds as Document No. Si at of 'ap~licant Co-appl t 77111 - Date of Signature Date of Signature • Ile DOCUMENT' NO. WARRANTY` DEED THIS SPACE RESERVED FOR RECORDING DATA ~I STATE BAR OF WISCONSIN FORM 2-1982 473270 VOL 9 .....14PAGE244 REGISTER'S OFFICE Sr. CROIXCO., WI husband .and. wife--- (jgCFd for Record SEP 4 51991 I conveys and warrants to ....car' ry-..I~_,...~I~~.,~QX1..SI1S~_..tT a 9:00 . A. M .....I... Mellonrhusband.-and-xife-as..mar.ital.._......... v► I suruiuor-ship-..prop.erty W of 0" Rep~ - I RETURN TO II I S t roi........................ . the following described real estate in ...............................................County, State of Wisconsin: Tax Parcel No: Part of SA of SA of Section 28 and Part of SEk of SEk of Section 29, all in Township 31 North, Range 19 West, St. Croix County, Wisconsin described as follows: Lot 3 of Certified Survey Map filed March 22, 1990 in Vol. 8, Page 2193, Doc. No. 456847. is not This homestead property. (is) (is not) Exception to warranties: easements, restrictions and rights-of-way of record, if any. August 91... Dated this day of 19 . ~ yA% ! `.......--..(SEAL) .r g4,0'C.~t!... .................(SEAL) I Ronald J. Germain Carol A. Germain (SEAL) (SEAL) * AUTHENTICATION ACKNOWLEDGMENT Signs Ronald J Germain, STATE OF WISCONSIN t;arol A. Germain _ ss. vcj......... f-s authe tic this day of.... AUgust . 19-21 Personally came before me this ................day of 19 the above named ' Kristina Ogland Lundeen • TITLE:.MEMBER..STATE BAR OF WISCONSIN (If not, authorized by $ 706.06, Wis. State.) to me known to be the person who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Kristina 0 land Lundeen Attorney at Law • Notary Public County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration ) are not necessary.) date: 19......... -Names of persons signing in any capacity should be typed or printed below their signatures. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc. i WARRANTY DEED FORM NO"2-1982 Milww''E.+. Wisconsin o3z /D:r~ ie 04 -YI /09,~ /zo 39~~1 zG S 77 j ©';u /0991 80 AM .IUL 0 0"F-LL O . / ~ „ JAIAES O'GONNEII 485438 ~rc,.O,, WI CERTIFIED SURVEY MAP Located in part of the SWi of the SWJ of Section 28 and in part of the SEZ of the SE's of Section 29, all in T31N, R19W, Town of Somerset, St. Croix County, Wisconsin; being Lot 3 of Certified Survey Map recorded in Volume 8, Page 2193 at the St. Croix County Register of Deeds office. t S E ' I.t Rii ~t 1~V , VA E} Corner of Section 29 W} Corner of Section 28 N w v: z ro t I QI OWNER N ~ i9 r s < Gary Nelson .,r.. 1919 137th Street LA = Somerset, WI 54025 O N u w ~I ° Ic C N O d C M L G - O LLIf C ..r I- U O Ol.i•f M - M CD -al 319 N8904313011W 9.111 /O HEO `0T 2 OF 01 L SOS ssi HOUSE M IN o M~ /001 9,133,017 Sq. Ft. O n I 3.05 Acres N°rN O, ✓vL. 8 fG. L I 9~ c N N ' 1 z 1 388.67' S890581.1311E ~ 33' 33' a 1 Sq. Ft. `~o? 3.43 cres ® S89058 11311E 828.75' N 1 d 1 - ^PRA ~ ' uNN`aTTP~c ~atiD., N LL. 1 N d LEGEND 4- - Cast Iron Section Monument Found ST- CROtX COUNT'% 4 . - 111 Iron Pipe Found o °°O, dmrxe`tinsive Planiii;i Zoning and d o - 111 x 2411 Iron Pipe Set, weighing 1.68 lbs. CD RarWt CoiiitiM!F'. ~ per linear foot ° y o - Existing Fenceline d " Z6f rdd&d6d - Roadway Setback Line vdt~e~tri' 3d' ctdy't 6f d a~►irovat d** SCALE IN FEET a ~r SE Corner of Section 29 SW Corner of Section 0 100 20.0 400 ,~r VOLUME 9 PAGE, 2507 ~~k~