HomeMy WebLinkAbout002-1076-90-000
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER- z ac TOWNSHIP_ J .4,M")
SECTION 3,) T 02 N-R ; W 2 74 ~ v
52-_
ADDRESS' /4, /,>C- . k/7- r ST. CROIX COUNTY, WISCONSIN
SUBDIVISION C f4t 6~e~
LOT LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
fi 7lJ ~ ~ ~ ~ fJ Gr ~ AC L) ~N~
U
t ~
t de - ~GZ
kl- 4/j,
INDICATE NORTH ARROW
13ENCILMARK: Elevation and description:
Alternate benchmark
SEPTIC TANK:Hanufacture Liquid Cap..,
Rings used: Manhol cover elev: Final grade elev:
Tank inlet elev.: Tank outlet elev.:
No. of feet fr nearest road:Front , Side , Rear Ft.
from nearest rop. line:Front , Side , Rear Ft.
No. of fee from: Well , Building:
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
PUMP CHAMBER
Manufacturer: -Liquid Capacity:
Pump Model: Pump/Siphon Manufact. : Pump Size
Elevation f inlet: Bottom of tank elevation
Pump 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 AB ION SYSTEM
Be Trench: Seepage Pit:
idth: Length Number of Lines: Area Built
Exist. Grade Elev. Proposed Final Grade Elev.
Fill depth to top of pipe:
No. feet from nearest prop. 1ine:Front , Side , Rear Ft.
No. feet from well: No. feet from building
HOLDING TANK
Manufacturer: / C11-4 T''" -Capacity: c2eor-V)
No. of rings used: Elevation of bottom tank:-
Elevation of inlet: Z-
No. feet from nearest prop. line:Front , Side,,, Rear Ft 30
No. feet from: Well , building, nearest road
Alarm Manufacturer:
J
INSPECTOR:
~ PLUMBER ON JOB: /C~ - 1 5
DATE:
LICENSE NUMBER:
6/90:cj
DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING
LABOR & HUMAN RELATIONS DIVISION
P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION
MADISON, WI 53707 State Plan I.D. Number:
NE 4j SE 4i Sec . 30 , T29-R16 ❑ CONVENTIONAL ❑ ALTERATIVE (Ifassigned)
Town of Baldwin
4WXT 19 Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME F PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Natrogas Inc. Hwy. 12 E, Baldwin. WI 70e_g0
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.:
"0 i~
Name of lumber: MP/MPRSW No.: County: Sanitary Permit Number:
Lyle Myers 6219 St. Croix 128841
SEPTIC TANK/HOLDING TANK:
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER
PROVIDED: PROVDED:
,r4?_j 2YES ❑NO YES ❑NO
BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
ALARM: FEET FROM LINE: AIR INLET:
❑ YES EaN ❑ YES ❑ NO NEAREST . r <
DOSING CHAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES [__1 NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FEET FROM LINE. AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST 10-
SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING:
or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN
the soil is dry enough to continue.)
CONVENTIONAL SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID
TRENCHES: MATERIAL: PIT DEPTH:
DIMENSIONS
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET:
NEAREST
MOUND SYSTEM:
Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM
slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW
❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED.
SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS;
❑ YES ❑ NO ❑ YES ❑ NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED:
CENTER: EDGES:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
PRESSURIZED DISTRIBUTION SYSTEM:
BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER:
TRENCHES:
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING:
ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.:
DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
i'.
I
i
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Retain in county file for audit.
Sketch System on
Reverse Side. SIC ATWE: TITL
SBD-6710 (R. 06/88) ~ f) /I 'j./
,
i,
=~DILHR SANITARY PERMIT APPLICATION
In accord with ILHR 83.05, Wis. Adm. Code CouNTY I 0~9
STATE SANITARY PERMIT
-Attach complete plans (to the county copy only) for the system, on paper not less than 1:1 G~
8%x 11 inches in size. C visont6p viousapplication
-See reverse side for instructions for completing this application. STA FERLAN I.D. NUMBER ~O
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. Yv
PROPERTY NER PROPERTY LOCATION
~iC ='aC '/a, S T27 , N, R / E (or
-
-
71(1 PE ~ Z WNER'S MAILING DRESS LOT # BLOCK #
CL
CITI~ STATE / ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER
rte ~(J (S - Z
II. TYPE OF BUILDING: (Check one) CITY J / NEAR ST ROAD
❑ State Owned VILLAGE
N OF: 12
AX NUMBER(S) I
N Public El 1 or 2 Fam. Dwelling-# of bedrooms - PAR EL T
III. BUILDING USE: (if building type is public, check all that apply)
1 ❑ 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 12 ❑ Service Station/Car Wash
5 ❑ Hotel/Motel 90 Office/Factory 13 ❑ 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 El Seepage Trench 22 11 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
7~ REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION
Feet Feet
VII. TANK CAPACITY Site
in allons Total #of Prefab. Fiber- Exper.
INFORMATION New xistin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holdin Tank 50o @ l% CZ07- Dig n _F 1-1 1 11 Li
Lift Pump Tank/Si hon Chamber
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name (Print): Plumber's Signat re: (No Stamps) P PRSW No.: Business Phone Number:
-2 -3 2
Plumber's Address (S eet, City, State, Zip Co
L:
IX. COUNTY/DEPARTMENT USE ONLY
X ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuin Agent Signature (No Stamps)
Surcharge Fee)
Approved ❑ Owner Given Initial
` << VV
Adverse Determination
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
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.
II. Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling.
Ill. 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 systE:m. Check experimental approval only if tanks received
experimental product approval from DILHR.
VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g.
MP, etc.), address and phone number. Plumber must sign application form.
IX. County/Department Use Only.
X. County/Department Use Only.
Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The
plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of
holding tank(s), septic tank(s) or other treatment tacks; building sewers; wells; water mains/water service;
streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system
areas; and the location of the building served; B) horizontal and vertical elevation reference points;
C) complete specifications for pumps and controls; (Jose volume; elevation differences; friction loss; pump
performance curve; pump model and pump manufacturer; D) cross section of the soil absorption 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)
DEMRTMENT`OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTRY, CC DIVISION LA60R AN
P.O. BOX HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON WI 53707
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION, TOWNS IP/MUNICIPALITY: OT NO.:BLK NO.: SUBDIVISION NAME:
c'/~ / N11 VJ E (o 1D,W_i `N,
COUNTY: MAILING DRESS:
ST00
USE DATES OBSERVATIONS MADE
NO.BEDRMS.: COIIJ,~R ALAS V~ PROFILE DESCRIPTIONS: EFICOLATION ❑Residence rFP aG 'l 1~New QReplace r TESTS:
Jay ("}P1
RATING: S= Site suitable for system U= Site unsuitable for system
ONaVENTIONAL: MO~UND:~ IN-GROUND-PR E: SYSQTEM-IN-FILL ~INGaNK: RECOMMENDED SYSTEM: (optional) S S A is u
If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: I` Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH IN, ELEVATION OBSERVED EST. HEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
B-
B-
7MAlt l
B-
B -
B-
B-
PERCOLATION TESTS
TEST- f DEPTH. WATER IN HOLE TEST TIME DR I WATER LEVEL-INCHES RATE MINUTES
t NUMBER INCHES AFTER SWELLI INTERVAL-MIN. PERIOD 1 PERIOD 2 PE R I OD 3. %,r% PER INCH -IMS
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.
SY
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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 i TESTS WERE COMPLETED ON:
ADDRES CERTIFICATION NUMB ONE UMBER(optional):
zIg
Y'q pip tAj T- '51/rin
CST NATURE:
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHRSBD-6395 (R. 10/83) - OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - SOD - 6395
To be a complete and accurate soil test, your report must include:
1. Complete legal description;
2. The use section must clearly indicate whether this is a residence or commercial project;
3. MAXIMUM number of bedrooms or commercial use planned;
4. Is this a new or replacement system;
5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER
SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS;
6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan;
7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet
may be used if desired;
8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent;
9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if
appropriate;
10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box;
11. Sign the form and place your current address and yur certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL
AUTHORITY WITHIN 30 DAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st - Stone (over 10") BR - Bedrock
cob - Cobble (3 - 10") SS - Standstone
gr - Gravel (under 3") LS - Limestone
's - Sand HGW - High Groundwater
cs - Coarse Sand Perc - Precolation Rate
med s - Medium Sand W - Well
fs - Fine Sand Bldg - Building
Is- Loamy Sand > - Greater Than
's1 - Loamy Sand < - Less Than
'I - Loam Bn - Brown
'sil - Silt Loam BI - Black
si - Slit Gy - Gray
cl - Clay Loam Y - Yellow
scl - Sandy Clay Loam R - Red
sicl - Silty Clay Loam mot - Mottles
sc - Sandy Clay w/ - with
sic - Silty Clay fff - few, fine, faint
'c - Clay cc - common, coarse
pt - Peat mm - Many, Medium
m - Muck d - distinct
p - prominent
HWL - High water level,
surface water
Six general soil textures BM - Bench Mark
for liquid waste disposal VRP - Vertical Reference 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 permit. The sanitary
permit must be obtained and posted prior to the start of any construction.
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raEi~al and -rA4,4j,1_ STO2AZ15
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9 0,,. 40
HOLDING TANK CROSS-SECTION
Approved Weather Proof
Vent Cap Junction Box „
4" C.I, /Approved Locking Manhole Cover
Vent Pipe With Warning Label Attached
Minimum 12" And Padlock 1
Final Grade 4" Minimum
►
Approved Joint '
18" Minimum
►
Dater Tight' i
Deal High Water '
SPECIFICATIONS Alarm 'wit-h '
t
TANK New ~ Existing
ManuTa cturer: m Approved Joint
--L T sc' Pipe
Blind C.I. Tank Size: W/ C.I. P , Gallons Extending' 3'
Plug ALARM Manufacturer: zy- a ~jQnto Solid Soil
Model Number: 1P5~ ~c14 61`16.
Switch Type
NUMBER OF BEDROOMS:
,F,.
GALLONS PER DAY: . 5✓ - 10NS
3" of Bedding Under lank
Owner's Name: jcf,4-~~
s
1 -7
Address: / - 2 .
Legal Disc T,1 Of Township/h Pei) ee-~
County:_S'r'
PLUMBER/DESIGNER
Signature: 3 r
License N er
Date: /yli o
7, s
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d /0 f 5 SS /~<c1,~rdJ~njG G~4L. /mot ,2 D,41
cis cz7Z 6 S aJ cl
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State of Wisconsin \ Department of Industry, Labor and Human Relations
SAFETY & BUILDINGS DIVISION
PRIVATE SEWAGE PLAN APPROVAL Western Regional Office
2226 Rose Street
LaCrosse, Wisconsin 54603
LYLE'S PLUMBING & REPAIR Owner: NATRO GAS
ROUTE 2 BOX 47A HIGHWAY 12
BOYCEVILLE, WI 54725 BALDWIN, WI 54002
RE: Plan Number: S90-40650 Date Approved: October 31, 1990
Gallons Per Day: 68 Date Received: October 30, 1990
Project Name: NATRO GAS Location: NE,SE,30,29,16W
Town of BALDWIN County: ST CROIX
The plumbing plans and specifications for this project have been reviewed for
compliance with applicable code requirements. This approval is based on Chapter
145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are
stamped 'conditionally approved'. This approval is contingent upon compliance with
any stipulations shown on the plans. All items that are noted must be corrected.
All permits required by the city, village, township or county shall be obtained
prior to construction. The licensed plumber responsible for this installation
shall keep one set of plans with the department's approval stamp at the
construction site. The installer shall notify the appropriate inspector when
inspections can be made.
This approval will expire two years from the date approved or if a sanitary
permit is obtained, it will expire the day the initial sanitary permit expires.
The Section of Private Sewage has reviewed these plans for private sewage system code
requirements only. These plans have not been reviewed for the code requirements
set forth in Section ILHR 82 for general plumbing or in Chapters 50-64 of the
Wisconsin Administrative code.
This approval is for the following components only:
- NEW HOLDING TANK
Inquiries concerning this approval may be made by calling (608) 785-9348.
Sincerely,
aaokloua~
GERARD M. SWIM
Section of Private Sewage
Division of Safety and Buildings
4PP039/0009n/34
cc: NATRO GAS X Private Sewage Consultant
SBD-6423 (R. 08/88)
1
r +rr 207
Document No. This space reserved for recording data
461.256 HOLDING TANK AGREEMENT
Agreement Date
_ 9a This agreement is made between the - - REGISTERS OFFICE
County or Local Governmental Unit Holding Tank(s) Owner(s)
CROIX CO.,
WI
7-vwv o-~ /3a d w, w /I✓~mss;.1~c; ST.
Recd d for for Rec Record
(Called Municipality below) A U G 0 91990
We acknowledge that application is being made for the installation of (a) holding at 3' 15 P M
tank(s) on the following property, (Provide legal land description:)
Register of Deeds
N ri/ ? T tea G~ S'1~ 3 ! T 1v / 7 x f 1--r Return To
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
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.
9
As an inducement to the County of r~ 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 ss. 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 contract 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.
Owns) Name(s) (Print) Owner(s) Si ure(s)
L 1 d I /~-C%~ Subscribed and sworn to beforQ m9 onthi§ date:"
ya,es'' 04/' oil`
j/ I tip' uZI 7 t~
X4
Municipal Official Nam (Print) , Q Municipal Official Signature Not- Public
k ""~'~"r /a My' ommission expires:
ZY ~_2 I _1)P7_ s144-yri Notary Public-State of W=Wsin
Municipal Official Title ( rint) I My conuntssion Expires Nov 3, 1991
SBD-6123 (R. 10/85) This i trument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing.
i
ST. CROI X COUNTY
WI S C O N S IN
ZONING OFFICE (715)386-4680
911 Fourth Street
Hudson., WI 54016
0 W N E' R
P U M P E R
A G R E E M E N T
PLEASE BE ADVISED, That until you ate again noti4ied, I wilt
contract with 1 I m 1'~l17"TJ-4SQ9,o7T 04 68(-v ~1 gje
Wi,6 eon,6in, (Pumper) , 4ot the putpo.3 e o4 removing att wa.ate 4tom the
.6an.itaty 6y.6tem to be toeated on the ptopetty and 4utute home Aite
.located in St. Croix County, Wi.b con.6in, Township of
being in the 4 o6 the 4 of Sec. T. N.-R. W.
(0t mate butty de.ac,%ibed a6 jottow.e: )
Dated thin day o j -106 Is us 7-
O 19 .
(OWNER)
'IV 11115 -
State o6 Wizcon.6in)
bd
County o6 St. Croix)
PetaannattyappeaA d b Jote me h " da o1 199 .
the above named to me % n to -Fe-the
petaan who execute the o ego.cng -6 Au en and a knowtedged the came.
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ota y u .cc, t. toix aunty,
My Comm. (iz petmant) (Expi,%ea) -9
I, heteinbebate tebetted to as Pumper,
1 akn in the a ave agreement to e extent at have e a conttact with
Owner a.6 above btated.
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SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
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OWNER/BUYER'
ROUTE/BOX NUMBER Z40, Z2 4f Be ( Fire Number
,CITY/STATE & ZIP
PROPERTY LOCATION: , SG 14, Section, T N, R ~W,
Town of ~jGls2 , 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 put 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
I/WE, the undersigned, have read the above requirements and agree
to maintain the private sewage disposal system in accordance with x
H
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 Zoning Office within 30 days
of the three year expiration date.
SIGNE >l-ci
DATE
St. Croix County Zoning Office
P.O. Box 98
Hammond, WI 54015
715-796-2239 or 715-425-8363
Sign, date and return to above address.
APPLICATION FOR SANITARY PERMIT
STC - 100
This application form is to be completed in full and signed by the owner(s) of
the property being developed. Any inadequacies will only result in delays of
the permit issuance. Should this development be intended for resale by
owner/contractor,(spec house), then a second form should be retained and
completed when the property is sold and submitted to this office with the
appropriate deed recording.
Owner of property
Location of property 1/4 S<, 1/4, Section < , T,, N-R jeg W
Township eJ
Mailing address 42 t 1c i f
Address of site = - S
Subdivision name
Lot number
Previous owner of property V>0
Total size of parcel
Date parcel was created 310 19012
Are all corners and lot lines identifiable? X Yes No
Is this property being developed for resale (spec house)? Yes ~No
Volume 322 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, and
the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if
available, would be helpful so as to avoid delays of the reviewing process. If
the deed description references to a Certified Survey Map, the Certified Survey
Map shall also be required.
PROPERTY OWNER CERTIFICATION
I(We) certify that all statements on this form are true to the best of my (our)
knowledge; that I (we) am (are) the owner(s) of the property described in
this information form, by virtue of a warranty deed recorded in the Office of
the County Register of Deeds as Document No. ; and that I (We)
presently own the proposed site for the sewage disposal system (or I (we) have
obtained an easement, to run with the above described property, for the
construction of said system, and the same has been durecorded in the Office
of the County Register of Deeds, as Document No. `7 /I/S-
S ignature Owner ,j,, Signature of Co-Owner (If Applicable)
Z/-
Date of Signature Date of Signature
So. S-4. Wnrrnnty Deed--Common Form I STATV OF WINGON41N) Publl,hed by Eau Claire Book 6 Stationery Co.
-To Corporation. (See. 235.16. Wis. Statutes) Form No.4
2'7 161 5 t ,
VOL t Fr. 'f w _ - t
Tbi!~ InUntUre, Made this 31st day of December A. D., 19 62,
between Oscar Berkseth and Celia Berkseth, his wife,
parties of the first part, and Natrogas, Incorporated,
Minnesot9
a Corporation duly organized and existing under and by virtue of the laws of the State of x§tMSist,
located at Minneapolis, Minnesota , 1*UxD =iwWarty of the second part.
Ckiitnroortb, That the said parties of the first part, for and in consideration of the sum of
Three Thousand Dollars ($3,000.00)
to them in hand paid by the said party of the second part, the receipt whereof is hereby confessed 1
and acknowledged, ha ve given, granted, bargained, sold, remised, released, aliened, conveyed and
confirmed, abd by these presents do give, grant, bargain, sell, remise, release, alien, convey and confirm
unto the said party of the second part, its successors and assigns forever, the following described real
estate, situated in the County of St. Croix and State'of Wisconsin, to-wit:
,A parcel of land located in the Northeast Quarter of Southeast Quarter (NElu of SI
of Section Thirty (30), Township Twenty-nine (29) North, of Range Sixteen (16)West
Town, of Baldwin, St, Croix County, Wisconsin, more fully described as follows:
Commencing. at a point on the center line of Highway 12 as 'presently laid and trav-
elled, which point is North 770 03' West 9116.70 feet from the intersection of the A
East line of said Section Thirty (30) and the said center line of Highway 12 as
the point of beginning; thence continuing North 770 03' West along the center line I~
of said,Highway 12 a distance of 251.30 feet; thence North a distance of 177.59
feet; thence East a distance of 21-111•.91 feet; thence South adistance of 233.91
Feet to the point of beg:.nning. Said parcel containing'1.16 acres, including
Highway 12 right of way. Above bearings based on East line of said Section Thirty
(30) being due North and South.
r
C.,ogetber with all and singular the hereditaments and appurtenances thereunto belonging or in anywise
- appertaining,-and all- t-he estate; -right title; interest, claim or demand-whatsoever,'-of- the said "part ic!s" of`
the-first part, either in law or equity, either in possession or expectancy of, in and to the above bargained
premises, and their hereditaments and appurtenances.
LI tiabr allb to L, olb the said premises as above described with the hereditaments and appurtenances,
unto the said party of the second part, and to its successors and assigns FOREVER.
klttb Or ~§adb Oscar Berkseth and Celia Berkseth, his wife,
for themselves, their heirs, executors and administrators, do covenant, grant, bargain
a)td agree to and with the said party of the second part, its successors and assigns, that at the time of the ,
cnsenling and delivery of these presents they are well seized of the premises above described,
as of a road, sure, perfect, absolute and indefeasible estate of inheritance in the law, in fee simple, and
that the same are free and clear from all incumbranccs whatever,
and that the above' bargained premises in the quiet and peaceable possession of the said party of the
second part, its successors and assigns, against all and every, person or persons lawfully claiming the
whole or any part thereof, they will forever WARRANT and DEFEND.
31il Wituriio Ujorreof, the said part ies of the first part ha ve hereunto set their hand s and
seaR this 31st day of December A. D., 19 62.
Signed and Sealed in Presence of
...(S al)
Oscar Berkseth e
{ t u..:' ~:G:' ..J, d .........(Seal)
Harold D. Olson ; Celia Berkseth
..,...:.-.............,..........(Seal)
I . S . Berkseth z wT .......................(Seal)
Drafted by Harol.d..:Il...... Q san Attarney....at._JLaw
t N1.11-ch. no Will. stnte, prnvldes that all instrnmentle to be reeotrlyd ohall have Plainly Ilrlnted or typewritten thereon the
~.uune, r,f the yrontore, ltrnnteetl, witneanee and notnry.l
%tate of altoconotn,
ss.
St. Croix County. '
Personally came before me, this 31st day of December A. D., 19 62 ,
~i the above named Oscar Berkseth and Celia Berkseth, his wife,
to me known to be the person s who executed the foregoing instrument and acknowledged the same.
~
Harold D. Olson
Notary Public, ....._.St....... .Cxoj............. County, Wis.
,
My commissionexpues......as....perl&
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