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HomeMy WebLinkAbout002-1012-80-000 Parcel 002-1012-80-000 01/30/2013 03:17 PM PAGE 1 OF 1 Alt. Parcel M 06.29.16.85B.86A 002 - TOWN OF BALDWIN Current ❑ ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner 0 - GELDERLOOS, HAROLD J JR TR HAROLD J JR TR GELDERLOOS 16548 VILLA PKY SPRINGLAKE MI 49456 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 1190 HWY 63 SC 0231 SCH D BALDWIN-WDVILLE SP 1700 WITC Legal Description: Acres: 56.000 Plat: N/A-NOT AVAILABLE SEC 6 T29N R16W LOT 1 & 2 ALSO 2 1/2 A Block/Condo Bldg: IN NW FR. TOWN BALDWIN Tract(s): (Sec-Twn-Rng 401/4 1601/4) 06-29N-16W Notes: Parcel History: Date Doc # Vol/Page Type 05/07/2004 761890 2566/599 QC 10/14/2002 694064 2010/581 AD 05/03/2002 678017 1884/108 QC 12/21/2001 666041 1797/341 TI more... 2012 SUMMARY Bill M Fair Market Value: Assessed with: 173665 236,200 Valuations: Last Changed: 10/26/2006 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.000 71,600 174,100 245,700 NO UNDEVELOPED G5 21.000 12,300 0 12,300 NO PRODUCTIVE FORST LANDS G6 30.000 51,000 0 51,000 NO Totals for 2012: General Property 56.000 134,900 174,100 309,000 Woodland 0.000 0 0 Totals for 2011: General Property 56.000 134,900 174,100 309,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: 04/17/2001 Batch M PRGRM Specials: User Special Code Category Amount 010-GARBAGE SPECIAL CHARGE 60.00 Special Assessments Special Charges Delinquent Charges Total 0.00 60.00 0.00 a 04 q1 Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM Co nty: Labor and Human Relations INSPECTION REPORT St. Croix Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION NW4 , NE4 , Sec. 6, T29-R1 6, Hwy. 63 1 491 90 ermit Holder's Name: ❑ City ❑ Village (H Town of: State Plan ID No.: S91-40717 CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: & 002-101-280-086 85B TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Benchmark Dosing Aeration Bldg. Sewer i Holding IV/ Ht Inlet TANK SETBA INFORMATION Seca Ht Outlet 0 TANKTO P/L WELL BLDG. Aiirlntake ROAD "Inlet 20. Qr S / NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding 6_ Bot. System PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand 9/. Model Number GPM TDH Lift Friction System TDH Ft I Loss mead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM -,:57 a, 52 BED/TRENCH Width Length No. Of Trench PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS es DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type CHAMBER O ~ Model Number: System: OR UNIT DISTRIBUTION SYSTEM 1y Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. Spacing ~'~j 1 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only %iy Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) 7 Plan revision required? ❑ Yes [~NO Use other side for additional information. ~C7 P 2 - SBD-6710 (R 05191) Date Inspector's Signature Cert. No. EalL HR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COU TY Ceoftx S AT SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 / 6 previous 11 inches in size. check. re i ion previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. 410717 P PERTY O E PROPERTY LOCATION r 1 r NW%a#FIY4,S T21, N, R (or; ` PROPERTY OWNER'S I&AILING ADD ESS LOT # BLOCK # tq3L4 pe f4 ) I ITY, TATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER #A I 4 1:1 II. TYPE OF BUIL N Check one) CITY s NEAREST ROAD ( ❑ State Owned VILLAGE Ld 1 3 ❑ Public or 2 Fam. Dwelling-# of bedrooms - A EL TAX N -7 ER Ill. BUILDING USE: (If building type is public, check all that apply) /Q / 7 - Life- i~g 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 1o ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 11 ❑ Restaurant/Bar/Dining 40 Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/Car Wash 50 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)4Replacement 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 F1 Seepage Bed 21 ❑ Mound 30 El Specify Type 41 ~KHolding Tank 120 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) ELEVATION Feet Feet VII. TANK CAPACITY Site in gallons Total # of Prefab. Fiber- Exper. INFORMATION N w istin Gallons Tanks Manufacturer's Name Concrete structed Con- Steel glass Plastic App e an Tanks Septic Tank or Holdin Tank 3000 Lift Pump Tank/Si hon Chambe El El El n VIII. RESPONSIBILITY STATEMEN AW 1, the undersigned, assume responsibility for installation olthe onsite sewage system show rf on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip Code): t J / IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) M IApproved Owner Given initial q_ z Adverse Det rmination ~ Surcharge Fee) C~V ' / 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 - U D t = O O r M b G 3 ? Q r O^ fir. 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BOX N WI 539069 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSH P/ LOT NO.:BLK. NO.: SUBDIVISION NAME: IV W '/a 6 /T2 N/R It ,(.f~jJ A/ N 14 1014 COUNTY: OWNER'S BUYER'S NAM : MAILING ADDRESS: USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFIL DESCRIPTIONS: EFIOLATION TESTS: esidence ❑ New 1zSLReplace U Yl _q 05 f L / S RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIO L: IMOUND: IN_ -GROUNcD-PRREES`~S~URE: SYSTEM-IN-FILLHOLDING TANK: REC+OM ENDED SYSTEM: (optio/nal) EI S %U DKS El , U 14ST441~ - MC4V C Sf.,AjUe A-" i n'u CPO, If Percolation Tests are NOT required DESIG VA: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation: k02 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- B- B- B- B- B- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. -PERIOD 1 PERIOD2 PERIOD 3 PER INCH P- P- P 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 3 i 3 3 3 ,EE I, 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: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - ST. CROIX COUNTY x WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE „ 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 Aug. 16, 1991 Division of Safety and Building Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 To whom it may concern: An on site investigation of the Harold Gelderloos property, located in the SE 1/4 of the SE 1/4 of Sec. 36, T30N-R17W, Town of Baldwin, St. Croix County, revealed 13" of suitable soil making the site suitable for a holding tank or a mound with state approval for a variance. Should you have any questions, please feel free to contact this office. Sincere y, lames K. Thompson, Assistant Zoning Admini ~11s~►-~ ~ ~ ors s~a~/ / ' 1~ v~.vNJ PIf r 93 ~u n5 ~aS C-> P`~e D d -AeAtmcO 'C~e tSTI n •ce SC.PT C, s I(STEM Ac. C-9 t l ~o° ►D er''' tL~N R S2 ~z l e,, ie~A O-0Y,.Y~~~ r.,s om ~ ~ro 11 TW sPrr<<t ~u3 o~`;~,Q~J ~s ! ro be ,~~G ~~~~~d ~ ~9,•~+~,~a,Md is oles oh !4 ~ oil r"4 ks 0 00 b, 7' 5 o 1 P66 ~~,E SYSTEM y"n4 S' _ r~ = f I qL Jay r ~y"{~~~ U ,rcQ ! p~Op•+io~±ti~ a 14 - ~S t✓r,llr~w 7 R~TIOh law vf, ` ~,,,~96 9 per f-,,.i ,~►k~;~,,•~ ~ . ~ e Q rtdC~ el? wt1\~ c~ COQ to f (p la n {nor H o v- o) d Ce I de v-l oos caged t h ~.1 J w h To s 4;p S Cro ; x Ca U hTY o o sec. Al . 0 + L h0 .G M QJ v Q E O- Cfrr~ 4-1 C L V N O •rl b 06 4-) 4J 0 0 3 U L 0 N 06 ~ O T! " sr ~ C" S 410-4 Q 0 S OWN ~ r " ~ c ~ ~ '~G~1~F err C O m Z _ C J IWO C Q! rF~;t v~ yea t GN ~p C O G d S~ = V- S s j ~ W b L ti~ ° m v+ I-. ~r • CL v 4- CL." 0 4J C> d E 1 ; W L. ci 4) 40 Ln > .OE C36 0 N s ~Mp N 40-) N V ~ a Y O to C/1 O W 4 m OC LJLJ ~N V N b b f E N L~i Z F- OC Z CC co t • W Z f O N f- ( Q Z C9 l ~t L. U d► 41 0 39 3 ~m ~N 4 o. r s. c c •w' ~e v 4J 0 d 1-M w 06 3 "s d dl S. V C L • _ d ) a O .V. W 41 1 L 4) 14 ~o -r- Is m Cs. C`ft Z N Z 0: GA=:Itt 'C7 d +J ` N N A r W 4J N > v d/ L fd CA .E C N N pp •r C "o M O1 U yJ -1 M J V m t/1 J 0 . CL Go L. O Q a > ,d,' 3 N pj" ti,rn~n~ e CEO DFRLOOS 10COrd It, t4e VYx o~ P01 of sc-c C -t,20' l~ 16 bs r 13rv( C8,3 M P c - p log- 0 ~o+l eVQIaot"$ ~ ) 4e,5 hove d° t. 4V soil evolail off, a e G. ) etier ' rvm Tames Aofilsop) 20)-&Il 4) ni ~ h / S 't l St- CV o)x sSfs ►rt ~ Cow h f), q page 7 on site scwVe sY itam fla11 of fVOve,~ l ~~PI rcatlv►'~ lqh W 1,01j;h -~qnkS Page plot P ~ pie 9 Wj')~)d *h4 c ress. SCOW) hk reem~~i-- . e 1 / 51- Gar Can /00 Pv~'Ilr ~vret'hPh~ e- 19.- St-CYO)y COVOY dwntvl Plot of- S o) l e,vOO C&JD h ©c) Cc. parciel ®f- l avid oulw ed b y pWu 64evloo& located 'h t~►e ~W~~'~ o ff F of secfifoh Towhs~iP a:9 Uov~~ Ruv~ye ~ip D ~q~c ✓ h~ '=ire ' ©F ResidC~cp is 1190 Ul~st" Towns Soil 1 fi~ ~~v~'T~ verlFl'ca1'1ov~ r eva Wog wcL5 POoc ~t~a-Y v fi' i9dw,jv►is1~~" b Tj Thowpsan St C fOjX_ CoOL`11Y ~s srnsfiuvrt y~nv~l~►fl- Y CS-T- S so 0v ~e 3' j" Gr~'JN eft w 8 i 4 ~DI Or~~e z5 vv ~r~rtlJ~ R galls V~Mc'~ h Oh Figr mF midmu- Gt~~Q~'t vh P~gnnv~ 96 ? l l off. o - s a i l eva I0a Jo h ©h Parcel O f= I d~J owweJ by _N 6e%Je►-lca5 .P locafie) n fide NIT A o~ ffB Y4 D F $eCtIOh 6 Ta 1194ip " 00VIk R~tv►ge i we5t~ ownsL)p o~ octic,vJh, rivc e~ Residence is "go r I vwv% was johc Momday #lt)W J L Lduh?r verl Flcatroh soil eva ~ dvhjv,fs~~" ~'Iw, Tho'"san - 5r C roiX Gv"7Y l}s st tram ~~~1►~~- /9 by S91 4071 7 g rte- 916 We k ler C. S'-' 5'5'0 19 0 ~L 15 1 Gro,,N~ ~ o~rc ~ „~Je~ l 1 70 51oP 6~ e~v~ ~ct~lbrlthp, - eNC~ Or10c tI~ d,``t i eon, HOtmot dabs 1O ~e5 WI eq, UdrNel~ sl~~"~ Oh RQ r New t~ m4iitc N ~ ST. CROIX COUNTY =Y WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 S.9 ~ 40 I Aug. 16, 1991 Division of Safety and Building Bureau of Plumbing P.O. Box 7969 Madison, WI 53707 To whom it may concern: An on site investigation of the Harold Gelderloos property, located in the SE 1/4 of the SE 1/4 of Sec. 36, T30N-R17W, Town of Baldwin, St. Croix County, revealed 13" of suitable soil making the site suitable for a holding tank or a mound with state approval for a variance. Should you have any questions, please feel free to contact this office. Sincere y, ames K. Thompson, Assistant Zoning Administrator c7 I i I WisconsinDepartment ofIndustry, ONSITE SEWAGE SYSTEMS Office of Division Codes and Application Labor and Human Relations Onsite Sewage Section Safety and Buildings Division 201 E. Washington Ave., Rm. 141 PLAN APPROVAL APPLICATION P.O. Box 7969, Madison, WI 53707 (608)266.3815 INSTRUCTIONS: Please fill in all applicable data and submit this form with plans. Plans will not be reviewed until all fees are received. The reverse side of this form describes most of the required plan information. Further requirements maybe contained in the Wisconsin Plumbing Code, which can be purchased from the Department of Administration, Document Sales and Distribution, 202 South Thornton Ave., P.O. Box 7840, Madison, WI S3707, Telephone (608) 266-3358. 1. PROJECT INFOItIWAT10N (type or print clearly) Plan Number Previously Assigned Na e o u mitt q arty (p a s eturne to same) Project Nam h V,**,* I- G,~IdP~ logs St eet Address, P.O.8 x 1i or Rural Route Project Address or Leg Description 11- 9" wt `/4v sic6 T-n N2 `W City or Village State Zip Code City ❑ County ±L"91I& Q/ Village ❑ of q I I hone No. (include area code) town S& P Designer MP ? /-7 Name tr Owner t fir' t ',_J - / GP p c'v-S Telephone No. (include area gre) Telephone No. (include area code) Stree Address, P.O. Box # or Rural Route Street Address, P.O. Box or R ral Ropto FIB( 3 V Y Lvlc~ Ocu"J City or Village State Zip Code City or Village St to Zip Code u4 r, dl r aV 9yy z 2. APPLICATION FOR: ❑ Experimental ❑ Mound System Holding Tank d Now c6hitructlon Q Large System ❑ Conventional Gravity System ❑ Groundwater Monitoring XReplacement ❑ At-Grade ❑ System In Pill ❑ Petition For Variance I1 Revision ❑ Pressurized System ❑ System in Flood Plain (attach SOD-6698) ❑ Other Alternatives 3, FEE COMPUTATIONS (include existing tanks) FEE SUBMITTED FOR OFFICE USE MARE ALL CHECKS PAYABLE TO SAFETY ll, BUILDINGS DIVISION. a.- 'DSO- i,S00 gallon septic tank S 50.00 b. 1,501- 2.S00 gallon septic tank $ 60.00 C. 23611 - 5,000 gallon septic tank S 80.00 d. S,0011. 9,000 gallon septic tank $100.00 e. 9,001- 15,000 gallon septic tank S 150.00 I. Over 15,000 gallon septic tank $250.00 g. SOO- 1,000 gallon dose chamber $ 30.00 h. 1,001- 2,000 gallon dose chamber $ $0.00 1. 2,001- 4,000 gallon dose chamber 3 70.00 j. 4,001- 8,000 gallon dose chamber S 90.00 k. 6,001. 12,000 gallon dose chamber S 110.00 f, Over 12,000 gallon dose chamber $150.00 m. SOO - 5,000 gallon holding tank 30.00 d n. S,00i - 10,000 gallon holding tank _ o. Over 10,000 gallon holding tank S100.00 p. Revisions S 20.00 q. Groundwater Monitoring - Per Site S 32.00 (other than a proposed subdivision) r. Petition For Variance: Setback S 25.00 Site Evaluation $ 50.00 Subtotal: y r s. Priority Plan Review: Enter same amount as Subtotal Total Fee: Il ~-wrYr~rwrirr ■ SOD-6748 (R. 04188) NOTE:Fees are pursuant to Wis. Adm, Code, Chapter Ind. 69, and OVER are subject to change annually. 1 :T ~ Xltv ST. CROIX COUNTY WI S C O N S I N 9ryVJ~~k n:. r Z O N I N G O F F I C E (715) 386-4680 911 Fourth Street nrq: Hudson, WI 54016 891-40717. 0 W N E'R P U M P E R A G R E E M E N T PLEASE BE ADVISED, chat unt.it you ate again not.ij ied, I Witt contract w.itGi 06~~• Wi.6 eon.6in, ( umpet), {oh the putpoa e o6 temov.ing att waste 6tom the Aan.itary ay.dtem to be toeated on the property and 6uture home 6 ite .located in St. Croix County, CCWi4 conz in, Town,6hip o6 GO ~v5 being in the SF % of thec~f~ 4 ob Sec. 1L., T. b N.-R.P7 W. (On mate Gutty de.6c&ibed ass jottow.s: ) Dated this ~G day of 19 (OWNER) i State o6 vIcklGA)r ) bd County o6 MUMEGON Petbonnatt yappeared be6ote me this 26th day a~ August 19 91 . the above named Harold J. Gelderloos to me known to Fee .the person who execute the oxego.ing .instrument and acknowledged the .came. MICHAEL J. DORNBOS Notary Public, Muskegon County, Michigan 0 at y u ,1 c , _ ftugust 11, 1993 My Comm. (.id permant) (Expi,%eA) I, heteinbebote xejenred to ad Pumper, Jo7n in th a ave agreement tot the extent that I have a contract with Owners as aveztated. ~~-('~UMPER ) P14 . VOL... 91JPAGE 599 w 47376 ry S91 40 GoctnentNo.l This space reserved for ram Ing dab HOLDING TANK AGREEMENT Agreement Date This agreement Is made between the County or Local Governmental Unit i Holding Tank(s)Owner(s) REGISTER'S OFFICE,. ~T G-0; X OW0. 1d Qlderloos Recd for CO. W1 Record Called Mm►1c1 li below ( We acknowledge that application is being made for the installation of (a) holding S t P 2 J 1991 tank(s) on the following property, (Provide legal land description:) f~f 4:15 P.M s~ `ly S~ of sec 36 T30 917w G y Register of 0efids Return To - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 1 or that continued use of the existing premises requires that a holding-tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Slats. As an Inducement to the County of 9t. C nQ '14 to issue a sanitary permit for the above described property, we agree to the following: 1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in as. 146.13 and 146.14. Slats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Slats. 2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner. does not pay the costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess- ment for the abatement of a nuisance, and the tax shall be collected as provided by law. 3. The owner, except as provided by s. 146.20 (30) (d), Slats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within ten (10) business days from the date of change to the service contract. 4. The owner agrees to cortract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under s. 146.20 (3) (d), Slats., the owner shall submit the report to the municipality and the county. 5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the Agreement to be determined by reference to the property where the holding tank is installed. a) a) ) IOWO Signet ( = wa. '''tz,m~ !'r'4©-5 Subscribed and sworn to a d{e: I _ b-for t~ On tCt, --------C~--- -h--~~' _ _ 1 . - bus: /99! s• ~ _ - K,4~t 50 V) Municipal Official Name (Print) I Municipal Official Signature Public I My commission expires: ( MICHAEL DORNBOS Municipal Official Title (Print) I Notary Public, Muskegon County, Michigan SBD-6123 (R. 10185) This instrument was drafted by the State of Wisconsin Department of Industry. Labor and Human Relations, Bureau of Plumbing. S T C- 10 0 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 lie vlooS Location of propert , Section , T62 N-R W L hd ?tic rvrs sd ~e. US /Yo G d e s~/~ Township W 1 t Mailing address N cye rh W ►C h pog b U to o is ~ iq q, Address of site subdivision name Lot no. Other homes on property? -eyes No r Previous owner of property Ro ~eyt L Sh/ Total size of parcel ' Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes ZNo Volume 1 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 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 . ~ 716 qd , 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. X7~, Signatu a of applicant Co-applicant -C7 Date of Signature Date of Signature ~L o Ell ly, . !n.,0 77 ~ pia: rc=n - - - , laic P a il, forty-A Alvo*k. a'' Jim l . t ,A ieg 1, ' ` e#r #t~ oP 4iAt~ ~~c ` ,Ole -Al " ; 5 f { tooix aspaty~ W A R. ` H t **W .f T b,~ tr -KEN y k ft F tai aw *no%* to s ±d t the. O "at and iC r' CIF,R4ft~ by: 441 _ Lam.,'' C ; ~A~'` afar 5- :fir n '!4 f r wt1ye jot, Z 'l'ax Parma No. k_ t artxr (SC t~ 4 ; , Seat ~rri~t ti v~` " rty-Six 1i Yft . 0 M: Sevewte Thirty 00) worth, Rang Lots alii {t; Wd,, Tito (9) • section six (6? . '1'w~ttY+~Mi~M l~ north, Range Sixteen ~ t i6 f ' of ~lp of land being asp th• p* t bet ' N , p!! fro the ; •i. i k: Nest 1;t' ss" ~ Irk r i"w' F-ULM' '64 Nor u x PAIL-As -ft. ft*I c .*~tY• Miscewsinr stt lacat t tns . es". A :ot Job a . . -tssorded at i ibis ► . stirs o#t#le r ih is, swrtre deY; r~ * ~CNNON~~ ` ' i of Robert L. snippe 8TAT9 OF 1~lCN~ f 44ated this daY KENT Per 11y bsoaw.. tow. to . i' to t . ` exult 04 went and mewl t y* A t was drafted by ;eis;. ilO°s # i[ a f^gavn._ 40441 irstior % 0., be ioth~t 6 tux'eb usy icated Or kl:: ~q t # to h~.