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HomeMy WebLinkAbout020-1262-80-000 -0 C) a v Mai c 0 ~ I M O N Vj O tl i I I d I ayi I Z LL o ~ I Q I I o Z W rn w 0 O Q O N H (n a m I o z c V p y fA FP C f0 N m 7 y w a C CO y O O O L w O Q II a wV ° o O C O - N N N Z m z O Z o V1 y Z t m 2 m d o O 4 C) U) U) 2 C', " O a a a O O O • w R o o. a. a a y v N J U rn rn } O N O O N N co -0 E y U) N O 00 0 ! ~ I O O lff C 3: 43) V CO d L, N LO W ~ W N C y V a 0 O O I'I y € a N O N N N C~ (NO C ~ N C N EO C 7° N O C,4 0) F • N O 7 1 O y O E U O N= O Z y Z 2 fn 0) M L IL a V C C a0+ C t A tia~l',ovic°~ - SANITARY PERMIT APPLICATION • 1ZYD1LF4R In accord with ILHR 83.05, Wis. Adm. Code COUNTY /Aop - ro~,wK .~nwva.nv~ STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than / i 8% x 11 inches in size. ❑ Ch~Ck if revision to vprevious 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 Saiyt Y4 Itle Y4,S7.O TZ7,N,R 19 E(or 0f PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Ov P* .2 y z .3a CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER f1 a.~/ . r. w Z relo /a (3n ) Z 14.9 R, "7 C, ao c_ c 47` J II. TYPE OF BUILDING: (Check one) ❑ State Owned o VILLLLAGE y NEARBY ROAD a ❑ Public ®1 or 2 Fam. Dwelling- # of bedrooms, PARCEL TA UMB ( ) III. BUILDING USE: (If building type is public, check all that apply) Z 7 S 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ 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. IX New 2. ❑ 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 El In-Ground 42 El 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 ySb &/S- GYB . 00 .3 '72 "TO Feet 74.1-0 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New F-xisting Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank /.060 l 14,-, &;,s c ye Lift Pump Tank/Si hon Chamber El [I I [1 0 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: 5 7 313 3 Plumbers Address (Street, City, State, Zip Cod/e): I- 0 /1 f G 4 IX. COUNTY/DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Sign a o Stamps) Approved ❑ Owner Given initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: 611 SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber J FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER -Sny-, TOWNSHIP SECTION Z CJ TAN-R_Zj~ j ADDRESS j~©X Z 8 Z ST. CROIX COUNTY, WISCONSIN i I s of 4 0 l ~ `f So SUBDIVISION-~;Kt LOT © LOT SIZE 3,00 PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM boRkq-T-tV 1-10A D 5k/stan~ EI• 90' - -p- - Sao- s~l~'14"= la" R 4 B.M. 0 lot P;J "t 15' V K W Iat Lor Kv-r F E1. =100,0" ~3~ W A 0 o ~ sI!L 9{1 NoaS~. I' 2 ~1X 3 i zle ~xsDl ~ Wm11 INDICATE NORTH ARROW BENCHMARK: Elevation and description: lot p-- ~t N w 1,4 cor.ta✓ F 1 • =((b ~ Alternate benchmark q-. r) 1, SEPTIC TANK: Manufacturer: Wes; s-t-c Liquid cap. ioo0 5a- • Rings used:_~__Manhole cover elev: (-0 Final grade elev:`;'(3 Tank inlet elev.: q,Fj Tank outlet elev.: ?a,4f No. of feet from nearest road:Front , Side , Rear X Ft. 107/ From nearest prop. line:Front , Side , RearX_Ft. ("7' No. of feet from: Well Building: 3~r (Include tftis information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE y 1 ~I PUMP 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 :Co,g y"j;en -Trench: -------Seepage Pit: Width:L - Length Number of Lines: Area Built 6 -7T Exist. Grade Elev. 7,~ J Proposed Final Grade Elev. Fill depth to top of pipe: yD No. feet from nearest prop. line:Front , Side, Rear Ft.7S"" No. feet from well: 9/ No. feet from building S S 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 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 BUREAU OF PLUMBING ~1III .20,T29-R19 CONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number: Town of Hudson, Lot 30 Ilf ass gned) ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound Pine Grove Heights IT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE: Sam Miller Box 292, Hudson, WI 7 / BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. IT. EL S REF. PT. EL ar n r s, w . C w F = 01~ ')0 OD. p oZ l Name-of Plumber: IMP/MPRSW Nn.. Cnunry. Sanitary Permit Number: Douglas Strohbee - 5432 St. Cro' 149052 SEPTIC TANK/HOLDING TANK. ( 5, ,"_tecolitrz O MANUFACTURER. LIQUID CAPACITY. TANK INLET ELE ANK OUTL V.. WARNING LABEL LOCKING COVER //ll f PROVIDED PROVIDED ES ❑NO ❑YES BEDDING: V.GfWF DIA.: VEDA MATI HIGH WATER NUMBER ROAD: PROPERTY WELL/ BUILDINGVENTTOFRESH _ M LINE F / AIRI ET- ..O• ALARM FEEFIR0OF ❑YES O Ca-,S-t' ❑YES p& NEAREST Lo v DOSING CHAMBER: MANUFACTURER BEDU PUMP M()UEL PUMP: SIPHON MANU1 A(;TIIHEH WARNING LABEL LOCKING COVER PROVIDED. PROVIDED: ❑YES ❑NO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL PROPERTY WELL BUILDING VENT FRESH : MW4 AIR INLET (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) ❑YES ❑NO NEAREST -0► SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing - JOIAMF TF H MATERIAL AND MA -wG or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to contin i o'-b , o - - MAIN CONVENTIONAL SYSTEM: D' S = Z ^0. n a-Cr l• _ WIDTH NG H NO OF UISTH PIPE SPA(:IN COVER INSIDE UTA SPITS LIQUID BED/TRENCH i TRENCHES Mnr PIT DEPTH. DIMENSIONS 3l G, GRAVEL DEPTH FILL DEPTH UISTVH PIPE UISTH PIPE DISTR. PIPE MATERIAL NU D -T 1 NUMBER OF ` PROPERTY WELL BUILDING. VENT TO FRESH BELOW PI ES ABOVE COVER EI E. INLF f ELEV. END //P,, / PIPES FEET FROM LINE T It AIR INLET:) / -Y/ .3/ 31 ~A ~2 3 NEAREST--i. ' -75 7 (yJ MOUND SYSTEM: D•3 10•~ Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE ADIAGRAMOFSYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. ❑YES ❑NO SOIL C 111111,1111 NT MAHKI RS o1tsE11VATTON wE ILLS _ ❑YES ❑NO _DYES ❑NO DEPTH OVER TRENCH BED DEPTH OVFRTHENCH 1.1111 DEPTH OF TOPSOIL 1111111111111111 1111 5E1 DFU MULCHED CENTER EDGES ❑YES. ❑NO ❑YES ❑NO ❑YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH NO. OF LATERAL SPACING HAVE DEPT ELUW PIPE- FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL IN" UIST DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV.. ELEV. CIA. ELEV. PIPES DIA: ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECT L Y COVER MATERIAL P RTICALLIFT CORRESPONDS TO APPROVED ❑YES ❑NO YE3 - ❑NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING. FEET FROM LINE: ❑YES ❑NO ❑Y/nEtS ❑NO NEAREST O t~ 1 C e a tI6' ('t 2 r C~ ~V.P Sketch System on Retain in county file for audit. Reverse Side. SIGNAT E. TITLE. DILHR SBD 6710 (R. 01/82) on? t • APPLICATION FOR BANITART P LIMIT • 9TC-100 This application form le to be eonplnted In full and signed by the owner(s) of the property being developed. Any Inadequacies will only result In delays of the pzinIt issuance. -Should this development be Intended for resale by owner/contractot,(spec houos)t than a second form should be retained and completed vhon the property Is sold and submitted to this office with the appropriate deed recordlnq. Ovntr of property -CmA" &l%//Q-r Location of property 114 &/1, Section -ZCO TX'7 -R/9 g: Tovnshlp -471 do ~ Malllnl address X-a x -v' Z rz • Address of site _&gr w i K ~ag- lubdlvlston name Cz)y,=- -5 Lot number _3o Previous owner of property Total rile of parcel _ 3.©o ACC.' Data parcel was created _ 8-31-go Are all cornets and lot lines Identifiable? k to No is this property being developed lot resale (spec house)?_ _Tan - 0 Volume _ UD end Pale Number _23 as recorded with the Register err Deeds. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - INCLUDE WITH THIS APPLICATIOH THE FOLLOWINCI A WAARANTT DRID which Includes a DOCUMINT NUMBRR, VOLUM I A?ID PAOR RLFKBIR, and the BYA.L OT THE R9018TBR OF DRKDB. In addition, a certified survey, it available, would be helpful so as to avoid delays of the reviewing process. it the deed deectiption teterenees to a Cettltlld lurvey Map, the Cettllled survey Map shall also be tequlred. PROPSRTx OWNER CERTIFICATION I(ve) eettlty that all statements on this totm are true to the best of my (out) knovledgel that I tve) am (are) the owner(s) of the property described In I. h I a intntmatlon form, by virtue of a warranty dead recorded In the office of the County Regletet of Deeds as Document No. _401rL/4 /8'• and that I (we) Pteeently own the proposed site for tha sewage disposal system (at I Iwo) have obtained an easement, to run with the above described property, tot the cnneltvcllnn of said nyatem, and the same has been duly recorded In the oltlee of t coynty ilegl et of Deeds, as Document No. ~~_/919 signature of owner elgnatuts at co-owner 119 Applicable) 5- --j 5- J9r Date of signature Date of Signature • +DiOCUMRNT NO. STAT>a BA>;f OF SIB 101v[ 11 lME Two so&" e. i B CM rns FOR ALL 'RAM" wired ere ne [a %ANCED AND UI ACT raANSACTIONSI Ciontract, by am beWeeo"..gf ARF:U..... .Qp><lS2N... ("Vendor", d A wbobw one.ot •more) ~r'!!• ("Purchases", whether one or more)- r IjMdis > Vendor Malls and egress to convey to Purchaser, open the prompt and foil per. + fonaarce of this contract b; Purchaser, the following property, togetba with the I rents and other appurtenant interests (all called the "Property"), ' !I iR..S Croix...,., County, State of wiscondnt squaw To ti:` 'mac s gy Lots 28, 29, 30, 1, 32, 33, 35, 36 Pine ova Hei8hts a ft Second Addit to the Torn of Hudson. Tax Pared No. ; yes"' r 1 t~ to r ♦ 91111 This J.. C homestc.,d property. (I$ not) x' agras to purchase the Property and to pay to Vendor at tbatgnrPK ~...a Tr~gam.-QQ in the followia manners (a) i Q~.Q - ..ter at the eelsMUm of this Contract; and (b) the balance of = 113a .OQ a l 111iSrssf: bwoof an the balance outstanding from time to time at the rate of !.1 '~!RN a m a follows: 1 "ymeat of $18,000.00 befot+e Deose~se 31, 19 f; r r, t •4.. , ~ pdd,bi ia11. 1991 , b { k % 3 payments of $18,000.00 each dtttiag , 3 payments of $18,000.00 each 4 naia8 1994; all of eedt F&AW s to bee" applied ass p dodpal. 1 pqmmt of $_.I*t*.00 &WiM 1992.. : • ]h Sddltitao to the foc+s8odtlg psdsients an Principal ttls Pta+chssar will snide emCh* an tsipdd be7sooes at lOR per erase. The First payment to be mdse on die`, 1st deD► of Octobpe, . be in do mv*t 02.70013,12A X 109'# 12). 9ubsecNalt interest pWWy shall J calarl~d aR nauRoe pdedpel wtstsladin for die Preceding WD*, inaladirlg edjusftsllt for p >trdtl bewwer, the antile outstanding balance shall be paid in full on or Were floe. .~dt . dq e! t.; ~ N 19214.... the maturity date). ,•!'ollowiug qtly default in payment, interest shall accrue at the rate of ,,.tiQ..... % par annu* on the eaLir~ a i' bs,¢sfsulit. (v*kk shall include, without limitation, delinquent interest and, upon sasleratbin ote~mnatetsity, tie o P64"', ankes excused by Vendor, agrees to pay monthly to Vendor amounts sufficient to pay reasonsbh angel- psted aaws:el tame, special assessments, fire and required insurance premiums when due. To the extent received by Vendor, Vendote"a61 to ayply' payments to thew obligations when due. Such amounts received by the Vendor for Daywo~ Q= tans, asimaents bud insurance will be deposited into an escrow fund or trustee account, but shall not bear inttrMt, ualas o*wwW required by law. _lr Any , A a's0arlt"mq,be prepaid without premium or fee upon principal at any time-04W . pd WiNssuo-Mmissio . i a%~ b`>ibe eAeat e~ say prepayment, this ooatract Mbau not be treated as in default with respect to paymeat se long •M. ti sapid 6alarnsB of ptrinelpal sod interest (and in such caw accruing interest from month to month shall be treated ~ y °»py Drlosipal) ' Is less, than the amount that said indebtedness would have been had the monthly payments beers , M seei>yed above; provided that monthly payments shall be continued in the event of credit of any pnwoseds rsaft w7Lef eemdsmnation. the condensed promises being thereafter excluded herefrom. ->lwpe"L 96464 that Purchaser is sstisded with the tide as shown by the title evidence submitted to Purchaser ill fee Tram atlsm none ilf i4 Madderation of ft &a pay■eat apecifiad above, roe of the above Into - dll bs not i¢ to do p is l p~ of this Oontraca. They further agree that li Lot`tr111 be =ISO" WM receipt of each of the $18,000.00 psyment on principal specified above a, ~tod It die last Lot vill be MWSY d an reosipt ca the final poymmt of • the $ 5, 124.00. II Parelow agrees to pay the cost of future title evidence. If title evidence is in the form of an abstract, it shall Ii be retained by Vendor until the full purchase price is paid. Poreba w shall be entitled to take possession of the Property on..the• date, hereof 19......... face. axe ores ' I) . 1AM fsMMeaal sae /TM BAR OF WISCONSIN . 7ri;u "k4s.nsin Bifah Co. Ise. (l ~ : 0010 FORM COMMON. *U ,f rl. - w eadgrra ant + - - " eat. levied on the Property Or apw V Pnrebaaar pesslsea.te la,T v/ban dw all tassa sad 011118111416111111 is it sad to delis W Yen WAs demand receipts showing such Payment. -u at d vendor u.7- 2 1pes doom PDrchaaa to not to commit waste nor allow waste to be committed on the Property, to ~ea!'~' to keep the property free from liens superior to the lien of this Contract, and ~k. to comply with all laws, ordinances aa~ regulations affecting the Property. Vendor egrew that in ease the purchase price with interest and other moneys shall be fully paid aced all conditions " shall be filly performed at the times and in the manner above specified, VeL )or will on demand, execute and ddlliAw to h all a Warranty Deed. in fee simple, of the Property, free and clear of all lieu and encumbrances, except ~ &the an liens or encumbr-oss errand by the act or dde~sfault of Purchaser, and except : •L~xistinit recorded easements for public utilities.; ' f Purebmw agrees that time is of the essence and (a) in the event of a default in the payment of any principal or interest wbkb oootbum for a period of 0... days following the specified due date or (b) in the event of a default in dace of other obligation of Purchaser which continues foi a period of ..9Q..•• days following written notice = by Vendor (delivered personally or mailed by certified mail), then the entire outstanding balance under this contract &hall become immediately due and payable in full, at Vendor's option and without notice (which Purchaser hereby wanes), and Vendor shall also have the following rights and remedies (subject to any limitations provided by law) in addition to those provided by law or in equity: (i) Vendor may, at his option, terminate this Contract and Purchaser's rights. title and {ntereat in the Property and recover the Property back through strict foreclosure with any equity of rreeddemption to be conditioned upon Purchaser's full payment of the entire outstanding balance, with interest thereon from the date of default at the rate in effect on such date and other amounts due hereunder (in which event all amounts previously paid by Purchaser shall be forefeited as liquidated damages for failure to fulfill this Contract and as rental for the Property if purch"er fails to redeem). or (ii) Vendor may sue for specific performance of this Contract to compel immediate and IOU payment of the entire outstanding balance, with interest thereon at the rate in effect on the date of default and other amounts due hereunder, in which event the Property shall be auctioned at judicial sale and Purchaser shall be liable for any deficiency' or (iii) Vendor may sue at law for the entire unpaid purchase price or any portion thereof; or (iv) Vendor may deaVur this Contract at an end and remove this Contract as a cloud on title in a quiet-title action if the equitable interest of Purchaser Is insignificant; and (v) Vendor may have Purchaser ejected from possession of the Property and have a receiver appointed to collect any rents, issues or profits during the pendency of any action under (1). 01) or (iv) aiwve.Notwithstanding any oral or written statements or actions of Vendor, an election of any of the foregoing remediies shall only be binding upon Vendor if and when pursued in litigation and all costa and expenses including reasonable attorneys fees of Vendor incurred to enforce.any remedy hereunder (whether abated or not) to the extent not prohibited by law and expenses of title evidence shall be added to principal and paid by Purchaser, as in. curred, and shall be included in any judgment" Upon the commencement or during the pendency of any action of foreclosure of this Contract, Purchaser consents to the appointment of a receiver of the Property, ineludin homestead interest, to collect the rents, issues, and profits of the Property during the pendency of stub action. and such rents. issues, and profits when so collected shall be held and applied as the court shall direct. s Purchow shall not transfer, sell or convey any legal or equitable interest in the Property (by assignment of any of purchaser's ritbts under this Contract or by option, long-term lease or in any other way) without the prior written consent of Vendor unless either the outstanding balance payable under this Contract is rst paid in full or the interest conveyed is a pledge or assignment of Purchaser's interest under this Contract solely •.a security for an indebtedness of y Purchaser. In the event of any such transfer, sale or conveyance without Vendor's w. • ^n consent, the entire outstanding balance payable under this Contract shall become immediately due and payable in full, Vendor's option without notice. t Vendor shall make all payments when due under any mortgage outstanding against the Property on the date of this Contract (except for any mortgage granted by Purchaser) or under any note secured thereby, provided Purchaser makes timely payment of the amounts then due under this Contract. Purchaser may make any such payments directly to a the Mortgagee if Vendor fails to do so and all payments so made by Purchaser shall be considered payments made on this Contract. Vendor may waive any default without waiving any other subsequent or prior default of Purchaser. All terms of this Contract shall be binding upon and inure to the benefits of the heirs, legal rep,wentativee, sucesseors and anigns of Vendor and Purchaser. (If n owner of the Property the spouse of Vendor for a valux-M& consideration J herein to rel"n homestead rights in subject and agrees to join in the execution of the deed to be made in fW llmwt her"M day of 19...V... Dated this yd II Stouby ..i~ .L4i.~~A.~et~,.. C ..............(SEAL) tou~;'bet Actor y..inFBtt ....(SEAL) ..................(SEAL) (SEAL) . ~ . Janet P...Stout • ...Sam. £...Miller. AUTHENTICATION ACKNOWLEDGMENT Signature (s) Cl TtATE (OF.~, WISCONSIN ~l .....1.1. .........County. (~N M ..1... t~ this authenticated this day of 19...... Personal came before ins day of 19....... the above ed TITLE: MEMBER STATE BAR OF WISCONSIA' . ` ^ If not. d:~i lt q.-, :J authorized by 4 706.0A, Wis. pmts.) to me known to be the person...... who executed the f oiug inst nt and. Be n ledge the same. l THIS INSTRUMENT WAS DRAFTED BY , ....l(......... ' .)leyyl .W.S. y .Johc!. D. fty~?od............... P,.Oa.AX.1.29,..t1 i ...54016 Notary P,iblic . .....................County, W~'. (Signatures may be nuthei,tieated or acknowledged. Both My Commission is permanent. (If not, state expiratit are not necessary.) date: 19......... •Namee of p,•r.a.ns sirninK nny capacity should be typed or printed b0cw their r:e~+:,• irt- 14%n COVTRA(T-,Individual end CorSerab-State Dar of wb,raaala. runs Na. !i - 19!] i, fr SEPTIC TANK MAINTENANCE AGREEIIENT CD St. Croix County d 014NER/ BUYER o ROUTE/BOX NUMBE Fire Number r y~ G n CITY/ STATE ZIP r'Yt oit Gy.t - o Ta N, Rff PROPERTY LOCATION: Section zc,.)_•,• Town of St. Croix County, Subdivisionf?,r,s. 4ri, Lot number_30 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 ur sooner, if needed, by a licensed' 's'e t'ic tank um per. What you p into the system can a ect the .unct on o. t e•septic tank as a treat- ment-stage in the waste disposal system. systemor St. Croix County residentsgmaLfbreplacement egtofracfailinggrant a maximum of 60% of the co 1978. St, Croix County whic was in operation prior to-July 1, accepted this program in August of 1980, with the requirement that owners of all new E t'ems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a mater plumber, veri- journeyman plumber, restricted plumber or..a licensed pump fying that (1) the on-site wastewater disposal system is in proper nec- operating condition and •(2)•after inspection and pumping essary) the septic-•tanksless than full 30fdayssludge priordtoc~. Certification form will be sent approximately three year-expiration. y 0 I/WE, the undersigned have read the above requirements and agree 0 to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- •:r ment of Natural Resources. Certification form must be completed and returned to the St. Croix datenty Zoning Office within 30 days of the three year expiration SIGN DATE " St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386-4680 Sign, date and return to the above address. DEPARTMENT OF REPORT ON SOIL BORINGS AND. SAFETY & BUILDINGS ',INDUSTRY, DIVISION LABOR AND P.O. BOX 7969 HUMAN RELATIONS PERCOLATION TESTS (115) MADISON, WI 53707 (ILHR 83.090) & Chapter 145) LOCATION: SECTION: TOWNSHIP LOT NO.:BLK. NO.: S BDIVISION NAM 611E '/a ►~~'/a zo /T29 N/Rig E (o /-lc,,&SaN 3e NElu Pd VC ~lF1GNTs COUNTY: OWNER'Sas4ME: MAILINGADD SS: C )A SaM /n,«Ez i r~ovr .eaok Z,41, 140&S6J`l . USE DATES OBSERVATIONS MADE Np.BEDRMS.: COMMERCIAL DESCRIPTION: k New DE RIP IONS: A I NTS~T~: Residence ~NK IC11New ❑Replace 4r*)` Z9/91/ )L '50ILs K 4 r~4 p ,`ur RATING: S= Site suitable for system U= Site unsuitable for system f gVR JCMONS. 11Y IN- NS UND-Pou RESSURE: SYII J INa-FILLHO~LDING TANK: RECQ~6A4VEW161 4Lp nal~ are N A`A If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the ' V under s. ILHR 83.09(5)-(b), indicate: Ok46S Floodplain, indicate Floodplain elevation: bac tnr PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH AA ELEVATION OBSERVED EST. HI HES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- I 9.7'S 6Z IV ar46 } 9--7 ~3'&crs L 9o"$+PU MS Gr2 B- z 10.00 97.9-7 NaNE: > /D•60 8_941_=rs 2-3-08#.L 6" MS~iGIlk z3°dQ~osfZ0, B-3 9.6t 94,97- NdnJ E > 9.08 ib~ c~7's "8 z 'Q M MS i '6 & 6"$914 MS ~'e, 12 B- A, 1.67 JI.57 NON LE Y @.67 /I"St L-rs -7,&O - 3'k>D$e1) /hs _9 M5~4,t B- S 8.00 91.14 dm(IE > 8.00 Z "g<c s 7'8' WL 7-1 Va&e r) S 6 / I&MA 5 ~ B PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER .6 01111K6 AFTERSWELLING INTERVAL-MIN. -PERIOD PERIOD 2 P R D PER INCH p_ 1 .7a nlorq 7.60 > 2 2 2 < P- 's,►0 rjbjE 9S•00 3 >Z >z >Z <3 P- 3 .-70 jQlLf a C0 >2 >2 <3 P- P_ d 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 slopeCEL T ~)~r r SYSTE N 7 &PLA Kill, IPk7 V ' com L-1 Ili, LLaJ =100,0(0 Lost" b 9 ) Q3 ~ 3 I d I I~' ~~a' I AWL- r~ El _ <<, a $-s I, the undersigned, hereby certify that the soil tests reported on this form were made by r e 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): I TESTS WERE COMPLETE)O ON /J~,ev~Y Joy Sam JaN> N ~2vtV IM(, Aj C_ 30 41 ADD SS: n ' l CERTIFICATIOP NUM ER: PHON MBER(optional): p • &x `I M I'~So ) S~ 0) 3 -1 3T 0~6 CST SIG URE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. 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