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HomeMy WebLinkAbout020-1018-00-100 n CO) O 3 'v n d o f c d o it > > n 3 r* m M w~ O Oi D) O:g W C W N 0 O 0 O ~ RD, CD (a -4 A L N ` O O r-j Cn ~ ~Cy- ~ ~ fD ~ O n ~ (O O lA\ N N N d 7C N 01 pp "7 C3 C, •O n 7 N f0 O O ' hO Cn Oo A 3 N N O- o' D O g N r o p 0 m N W 0 N U1 7 W V C 3 d 0 CD N 0 0 m ~r 00 Ln CL <O tO N O C w (O f0 -0 y N O O O c l ~ ~ e d ~i N ! -n 0 fC C CO) fn to fD - ~f I~ a a y 0 CD A ! Q l~1 N O O W ! C lD O- N N A p o Z W Z 0 N D a o O M N • O M N CD D) N MA N' d ~ N N A Z 0 A CL W T II W a z 0 A .Z) O cn to to z m A W o D ~ d C I 7 y; c CD p d C N z a N p I m ~ N I a ,y I ~ J y N Q y fD ~ A `n N W h 0 N ' O (D D°o v I m 2 o O o O CL I Wiscansin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT St. Croix Safe*y and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION SE4,SW4,Sec. 13,T29-R19,Lot 4 149070 Permit Holder's Name: ❑ City ❑ Village [jkTown of: State Plan ID No.: Craig & Linda Bichrt Hudson CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: fot Z~ d?u 7' f6' It, TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ~4 --likI21 C-) j, Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet ,3 TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet Air I Septic j NA Dt Bottom Dosing NA Header / Man. wry Aeration NA Dist. Pipe - Holding Bot. System (Si ~O PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft oss mead Forcemain Length Dia. Dist.Towell SOIL ABSORPTION SYSTEM BED/TRENCH width Length I No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS -I d % DIMENSIONS SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Model Number: System: 7/60 OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed/Tr nchCenter ~-Z, Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Plan revision required? ❑ Yes No ko I Use other side for additional information. q a SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ' - FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER, TOWNSHIP SEC'T'ION /J T1_N-R~W ADDRESS d,7 ST. CROIX COUNTY, WISCONSIN ter! . . ~y SUBDIVISION LOT ves" LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM S - ~ l T Awe . sc S7: Jvo tt b,~ n~ 7-2 r INDICATE NORTH ARROW BENCHMARK:Elevation and description: DO, Al Alternate benchmark SEPTIC TANK:Manufacturer: Gt/l~S Liquid Cap. Z, j2yZ Rings used: aManhole cover elev:/f>D.9,Final grade elev: Tank inlet elev.: fg. VC Tank outlet elev.: c? plr No. of feet from nearest road:Front , Side L/ Rear Ft.*.;, 1,,P,# From nearest prop. line:Front Side , Rear y Ft. 7 No. of feet from: Well Building: !P (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE DAVE FOGERTY PLiuNtBIN: Ucensed Perk Tester & Plumber #3233 #3289 eights Road Fogerty H ;SCONN ROBE T Ph;ne S 3656 54023 l PUMP CHAMBER Ma acturer: Liquid Capacity: Pump Mode Pump/Siphon Manufact.: Pump Size Elevation of inlet,: Bottom of tank elevati Pump on elev.: Pump off v.: lons/cycle: Alarm: Man.: itch Typ Location Distan~ffo est prop. line: Front, Si Rear Ft. Di ell Bui lding SOIL ABSORPTION SYSTEM 1 Bed: Trench: Seepage Pit: Width: 12- Length X-e Number of Lines: 2 Area Built Exist. Grade Elev. y'pO,'p / Proposed Final Grade Elev. d Fill depth to top of pipe: No. feet from nearest prop. 1 ine : Front , Side , Rear r/ Ft. 7 Imo No. feet from well: e_No. feet from building Sere HOLDING TANK Manufacturer: Capacity:_ No. of r used: Elevation of bottom tanl• Elevation of inlet: No. feet from nearest pro ine:Fr , Side , Rear Ft. No. feet from: building , nea road Alar nufacturer: INSPECTOR: DATE: PLUMBER ON JOB:-.2. est LICENSE NUMBER : 6/90:cj SANITARY PERMIT APPLICATION 70ILHR In accord with ILHR 83.05, Wis. Adm. Code COUNT/ b STATE S7737RMIT -Attach comp lete plans (to the county copy only) for the system, on paper not less than 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 Craig & Linda Bichrt SE Y4 SW tea, S 1 T 2 , N, R 19 E (or PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # 7000 Magda Dr. # 113 4 CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Maple Groove, 53369 429 0694 NONE - 20 acres. CITY NEAREST ROAD 11. TYPE OF BUILDING: (Check one) ❑ State Owned ❑ VILLAGE Fa wiN OF: HITI)SON HY 12 ❑ Public FX1 1 or 2 Fam. Dwelling-# of bedrooms PARCEL TAX NUMB R() ~y 111. BUILDING USE: (If building type is public, check all that apply) ^ O - DO ©O 1 ❑ Apt/Condo 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 120 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. x❑ New 2.E] Replacement 3. ❑ Replacement of 4.0 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.) (Min./inch) ELEVATION 615 636 .73 .5 95.6 Feet 99.0 Feet VII. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank 10001xxxx 000 1 Weeks Concrete 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): PIu s Si nature: 73289 PRSW No.: Business Phone Number: David B. Fogerty 749 3656 Plumber's Address (Street, City, State, Zip Code): Fogerty Hgts. Rd., Roberts, WI 54023 IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ra Issued Issuin gent Signat re ( Stamps) Surcharge Feel ` w C6r *,to 1 Approved ❑ Owner Given Initial ,/Z!7, Adverse Determinationi 5 X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-87) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber i " 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/contractQ'K,("spec house"), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Owner of Property ~ Location of Property Scion I3 N - R L W Township N4 Mailing Address ti Subdivision Name 1 Lot Number Previous Owner of Property Y~tt tom-/( Total Size of Parcel( Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes / No Volume and Page Number as recorded with the Register of Deeds DE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3.. Other recordings filed with the Register of Deeds Office 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 the Certified Survey Map shall also be required. PROPERTV OWNER CERTIFICATION I (We) ceAti6y that a t statements on this 6onm ahe txue to the best o6 my (ouA) knowledge; that I (we) am ( are ) the owner l s ) o6 the pnopen ty deb ch i.bed in this in6onma ion Jonm, by vixtue of a wav.a.nty deed neconded in the Oj6ice o6 the County Register o6 Deeds as Document No. Y-? ; and that I (we) pneaentZy own the proposed site joh the sewage d~zjoozaZ system (on I (we) have obtained an easement, to nun with the above desch,%bed pnopehty, bon the constxucti.on o6 said system, and the same has been duty neconded in the 066dce 06 the County Reg.i.s-teA o6 Deeds, as Document No. 5'7vOn3 SIGNATURE QF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) DATE SIGNED DATE SIGNED ~l ~1' ~1~~ ~S cggrA DOCUMENT NO. I STATE BAR OF WISCONSIN FORM 1-1982 Ii THIS SPACE RESERVED FOR R~N~~ f„ WARRANTY DEED REGISTER S ` ST ° CROIX MINI _AG4 - for Record This Deed, made between .-CriarleS T.__ Berres and U 33 199P. M > Cit 1 • san.-.....wi f e, Dgra_•-Mae-.Berres,_:-•h......................................................... i.ndz_vidual y--and _e, ; urvivo sh1P ma>; 3.1ra1..---•.. Grantor, I~ Register of Deeds r.oRe.rt_y. 4wne p.... and--.Cr_a3_ E,___Hichr. __.and..Linda M. Hallbakken Bichrt-__._ $."W husband-and wife- as survivorship marital.-property........... II - i~ Grantee, j! it Wit,nes.' th, That the said Grantor, for a valuable consideration. y St . CrOl X F RETURN TO iveys to Grantee the following described real estate in ......_-------J_-------------_ County, State of Wisconsin: Tax Parcel No: ii A parcel of land located in th:/P of the SWl/4, the NEl/4 of the 5191/4, the St91/4 of the SW1/4, and th1/4 of the SWl 4 of Section 13, T29N, li R19W, Town of Hudson, St. Croix ounty, Wisconsin, described as follows: Commencing at the SW corner of said Section 13; thence N1°11'56'"E (Assumed bearing referenced to the West line of said SW1/4 of Section 13 which bears N1°11'56"E) 359.49' along the West line of said SW1/4 of Section 131 thence N74°05'42"E 1120.18' thence S15°54'18"E 45.00" to the point of beginning; thence N74°05'42"E 1245.00'; thence N27'42'32"W 296.35'= thence Westerly 1628.19' along a 2739.79' radius curve concave Southerly whose chord bears N80°31'10"W 1604.33' along the Southerly right-of-way line of the Chicago and Northwestern Railroad; thence S15°54'18"E 902.35' to the point of beginning. This parcel contains.21.04_0Acres, more or less, . being 916,494 Square Feet, more or less. Also, a roadway easement located in the SW1/4 of the SW1/4 of Section 13, ? .13P the N411/4 of the NW1/4 of Section 24, and the NE1/4 of the NW114 of it Section 24, all in T29N, R19W, Town of Iiudson, St. Croix County, Wisconsin and further described as follows: Commencing at the SW corner of said Section 13; thence N1°11'56"E 359.49' along the West line of said SW1/4 of Section 131 thence N74°05'42"E 1054.18', to the point of beginning; thence S]5°54'18"E 1457.23'; thence S27°59'51"E 147.02'1 thence N62°00'09"E 66.00' along the Northwesterly right-of-way line of Yellowstone Trails thence Nz7°59'51"W,14D.03'; thence N15°54'18"W 1450.2411 thence S74°05'42"W 66.00' to the point of beginning. This easement -contains !2,420\Acres, more ii or less, being 105,419 Square Feet, more or less. This deed is given in fulfillment of a land contract between the parties hereto, dated April 30, 1990 and recorded on May 7, 1990 in Vol. 870 at page 97 ss document no. 458332 extended on April 4, 1991 by agreement recorded on April 10, 1991, in Vol. 898, at page 65 as doc. no. 468102, all recorded in the office of the Register of Deeds for St. Croix County. VOL 934 F* 351 (is) is not) I Together with all and singular the hereditaments and appurtenances thereunto belonging; i! And..---Charl------------------------------ . Berres and Dora Mae Berres _ warrants that the title is good, indefeasile in fee simple and free and clear of encumbrances except any I lens or Incumbrances created or suffered to be created by the acts or defaults of grantee. and will warrant and defend the same. ~ Pr June Dated this - day of 19, aY~2".tea (SEAL) (SEAL) * Charles T. Berres 7 °QF~1~!li ae Berres (SEAL) (SEAL) Dora AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN St. Croix ss. j .-County. authenticated this day of.......................... . 19 Personally came before me this day of June 1991___ the above named n Char-1e%9 ...T. ~erxas...an~..AQx-a--MR....... -Ber_re..,---- hx_s-_v~.-f-e.... TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) s..•••-.••_ who executed the to me known to be the person foregoing i ument and acknowledge the same. j; THIS INSTRUMENT WAS DRAFTED BY Alex S. Kosa, Attorney HL1-ds-on,r--.W.1---540-1 Not -y Public _._..___5 O~.x county, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) 19-•_-_---.) date: -Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FORM No. 1 - 198.2 Milwaukee, Wis. H 9 S T C 105 r SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County z a 9 H OWNER/BUYER ROUTE/BOX NUMBER Fire Number ;CITY/STATE .-er ZIP~1'a C7 c PROPERTY LOCATION: .:,S 'k, e Section 1_, T Zy N, R W, Town of , St. Croix County, Subdivision Lot number. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed septic tank pumper. What you pdt into the system can affect the function of the septic tank as a treat- ment stage in the waste disposal system. St. Croix.County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), 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. H 0 z I/WE, the undersigned, have read the above requirements and agree W to maintain the private sewage disposal system in accordance with M the standards set forth, herein, as set by the Wisconsin Depart- 'b ment of Natural Resources. Certification form must be completed and returned to the St. Croix County Zoni g Office within 30 days of the three year expiration date. SIGNED DATE St. Croix County Zoning Office P.O.' Box 98, Hammond, WI 54015 DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY,, DIVISION LABOR AND PERCOLATION TESTS (115) P.O. BOX 7969 HUMAN RELATIONS MADISON, WI 53707 (H63.090) & Chapter 145.045) LOCATION: SECTION: TOWNSHIP LOT NO.:BLK. NO.: SUBDIVISION NAME: /T N/R E (o / COUNTY: OWNER'S BUYER'S A E: MAILING ADDRESS:n t FZ/ Y CIv°~~ USE s DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PROFILE DES R PTIONS: PERCOLATION TESTS: Residence aNew ❑ Replace 3 17 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: 't IN-GRnOUN~D-PRESSURE: SYS~T]EEM-IN-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) S 2DU E IS ~Y SOU E J DU EA Elu .lr 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: W -3-;- I Floodplain, indicate Floodplain elevation: u1z4 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- s ' S sr h' L/z' B.r Vvs,.. B- r ' & 7, S, l ' ohs- C, 3 0A CS 6- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 P R PER INCH P- S~ P- P- /lte T P-_ z 3 EP-1 OT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- PL 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 yr:6 F 4 - o E ` 3 F 3 S ~~7 E - i ( L wL 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. DAVE FOGERTY PLUMBING NAME (print): Licensed Perk Tester & Plumber TESTS WERE COMPLETED ON: 03233 #3289 z Qd ADDRESS: Kft S, WlS ONSIN 54023 CERTIFICATION UMBER: PHONE NUMBER (optional): Phase 749-3656 CST SI ATU n ~ r DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) -OVER - i ro ~ ~ 2 w' ~ S C~ ~a S In • aN~NO ~~11 lei W G1Z~~ C rn A .~a ~ e a a k+ i C 1 ~ z w 1 O ~ I 0 ♦ 14 v L ` cJ 1 a r, COMMERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 715-962-3121-- 800 - 962 5227 ST. CROIX ZONING REPORT NO.S 14653/01 PAGE 1 ST. CROIX COUNTY REPORT DATES 12/04/91 COURTHOUSE DATE RECEIVED! 12/03/91 HUDSON ,"WI 54016 ATTNS THOMAS C. NELSON OWNERS Craig Bithrt 0~/Q LOCATIONS 935 Chipopewa Path, Hudson COLLECTORS M. Jenkins SOURCE OF SAMPLES Kitchen faucet Repeat COLIFORMS p /100 ml INTERPRETATION'# Bacteriologically SAFE NITRATE-NS 3 ppm Above 10 ppm exceeds the recommended Public Drinking Water Standard. Collform Bacteria/100 ml Nitrate-Nitrogen, mg/L LAB TECHNICIAN. Pam Gane `2F 1a WI Approved Lab No. 19 r~ 1; t Means "LESS THAN" Detectable Level Approved by'* ® PROFESSIONAL LABORATORY SERVICES SINCE 1952 CQ"ERCIAL TESTING LABORATORY, INC. 514 Main Street, P.O. Box 526 Colfax, Wisconsin 54730 k4j Imio 715.962-3121 600 - 962.5227 ST. CROIX ZONING REPORT NO.! 13849/01 PAGE 1 ST. CROIX COUNTY REPORT DATE** 11/18/91 COURTHOUSE DATE RECEIVED* 11/13/91 HUDSON, WI 54016 ATTNI THOMAS C. NELSON OWNERS Craig Bichrt L' LOCATIONS 935-Oh+ppeaa Fath, Hudson I 2 COLLECTORS M. Jerk i SOURCE OF SAMPLE# Kitchen faucet COLIFORMS TNTC /100 ml INTERPRETATION'# Bacteriologically UNSAFE NITRATE-NS 3 ppm Above 10 Fpm exceeds the recommended Public Drinking Water Standard. Coliform Bacteria/100 mi Nitrate-Nitrogen, mg/L LAB TECHNICIANS Pam Gane WI Approved Lab No. 19 ~.uwev~NOaNr < Means "LESS THAN" Detectable Level Approved by! ® PROFESSIONAL LABORATORY SERVICES SINCE 1952 ST. CROIX COUNTY ZONING OFFICE 911 4th Street Hudson, WI 54016 Telephone - (715)386-4680 The St. Croix Co. Zoning Office offers the service of septic and t water inspection to Lending Institution, Realty Firms, and private individuals. COMPLETION OF THIS FORM IS ESSENTIAL SO THAT THE PROPERTY CAN BE LOCATED. Please provide the following information, enclose appropriate fee made payable to ST. CROIX CO. ZONING, and mail, along with form to the above address. Testing will be done as soon as possible after fee and form are received. WATER TESTING FEE:$ 25.00 (For nitrates and coliform bacteria) WATER TESTING FEE:$175.00 (VOC'S) SEPTIC SYSTEM INSPECTION --------y-~~------------FEE:$ 25.00 PROPERTY OWNERS NAME: RIB l C~ rJ l G 1e PROPERTY OWNERS ADDRESS: 3 P~IQP A CITY: S Legal Description_*, 5_ Lo_ 1/4, Sec._) T q N-R, _W, Town of PUpSo,j Lot No. Subdivision FIRE NO. 3rj LOCK BOX NO. Color of house rjzAy Realty sign? Firm: PLEASE INCLUDE, IF AT ALL POSSIBLE, A MAP, i.e., COPY OF PLAT BOOK, WITH LOCATION SHOWN, AND A COPY OF THE LISTING SHEET. Testing of residential water requires a sample that is fresh. If the home is vacant, and has been so for some time, the water line must be purged by running the water for several hours before the test can be conducted. WINTER TESTING: Many times water lines are turned off, or sill cocks are turned off, making access to the home necessary. If this is the case, please make proper arrangements with this office to ensure time when entry may be gained. Firm or individual requesting services: Telephone No. l. ornqc_ -(ril.S) I -12p5o [(atz) ZZ-4 -144 - nrzic REPORT TO BE SENT TO : _ q3'5 CJ l Epwr.,LOA S~arL44 CLOSING DATE' Signature: