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HomeMy WebLinkAbout006-1076-70-000 yDEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HLIVIAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: NW4,SE%, Sec. 33,T31-R16 ❑ CONVENTIONAL ❑ ALTERATIVE (If assigned) Town of Cylon ❑ Mound Holding Tank ❑ In-Ground Pressure O IT RIDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE, Joseph Lombardo 1833 Co. Rd. 0, New Richmond, WI / o& 0 r iSr° BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. . ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: Kim O'Connell 3259 St. Croix 128869 SERT4G-*A*K/HOLDING TANK: wo t cLC e~ n Sa1'/ 26 MANUFACTURER: LIQUI15 CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER PROVIDED: LOCKING S t, GLY • o? ~ YES ❑ NO YES -1 NO BEDDING: VENT DIA.: VENT MATL.:• HIGH WATER NUMBER OF ROAD: PROPERT WELL: BUILDI G: VENT TO FRESH ALARM: FEET FROM LINE: r , AIR INLET: EYES NO Z~ YES ENO NEAREST of 0- D?~ ~ 4 1 E- & DOSIN CHAMBER: MANUFACTURER: BEDDING: QUID CAPACITY: PUMP MODEL: UMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVDED: ES ❑ NO ❑ YES ❑ NO ❑ YES I] NO GALLONS R CYCLE: PUMP AND CONTROLS OPERATIONAL: ER OF PROPERTY WELL: BUILDING: VENT TO FRESH LINE: - AIR INLET: (DIFFERENCE BETWEEN nST PUMP ON AND OFF ❑ YES ❑ NO SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: 7 DIAMETER: MATERIALAND 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: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENC TRENCHES: MATERIAL: PIT DEPTH: DIM S GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PI .PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LIN AIR INLET: MOUND SYSTEM: Mou i Plowed pe icular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM pe and furrows thrown uns 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 DEPTH F TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ O ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: TNO.OF RENCHES: LATERAL SPAC01G~ GRAVEL DEPTH BELOW PIPE: FI DEPTH ABOVE COVER: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATE RTAt: DISTR. DISr~, ELEVATION AND PffiE ` DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV. DIA.: ELEV.: PIPE`Si DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO WELL: BUILDING: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF P COMMENTS: FEET FROM LINE: ❑ YES E] NO ❑ YES ❑ NO NEAREST e,y /y,~-~° ~.c-~ Q.~G~-r ~ cr✓~~, ~ ,Q%~ ..~'l ~l o~t,~.j w~.~i' ' ~ t r ~ i.1.x'~~:r c~f~. _ _ , c/ Cvtlir) e=~..C~ a-~ cc'r?~ ~il ~>~Y7'' ( r, R tain in county file for audit. Sketch System on Reverse Side. SIGNA RE: TITLE: ~SBD-67/10 (R. 06/88) 110o, Noolv^j ✓~t r~ t A~. t.1/-"a' ; /fj JQ~if►~~it./f ~2<~,'l.l L'~~• i~vQ c 4 DILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code 70, .d...,..e,.......~..e~ STATE NITARY~ERMI -Attach complete plans (to the county copy only) for the system, on paper not less than alf ooj~((JJ//~`~Y8% x 11 inches in size. ❑1 C c 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. 4590 - 0 3 1 *7 PROPE OWNER PROPERTY LOCATION /a S T , N, R E (or) W' ' PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # CITY STATE ZIP CO E PHONE NUMBER SUBDIVISION NA OR CSM NUMBER W.nj / - ST RO II. TYPE OF BUILDING: (Check one) El State Owned CITTLYi4GE NT ❑ Public r1 or 2 Fam. Dwelling-#of bedrooms PARCEL TAX NUMB I ' Gdl~ - /U7 (p - 7(}-CUQGIII. BUILDING USE: (If building type is public, check all that apply) 1 ❑ Apt/Condo ~7 J 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. El 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 19 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. SYST M ELEV. 7. FINA GRADE ATION % REQUIR D (sq. ft.) PROPO D (sq. ft.) (Gals/ ay/sq. ft.) (Min./i ch) ELE Feet Feet Al Ar VII. TANK CAPACITY Site in allons Total of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for install tion of the onsite sewage system shown on the attached plans. Plumber s Name Print):1 P7ris ignat e: (No St) rP/MPRSW No.: Business Phone Number: le I Pum is Address (Street, City, State, Zip Code); L 111. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanita~permit Fee (Includes Groundwater Date Issue r uing em: Signature No Stu ) S rcharge Fee) APp ~(C roved F-1 Owner Given Initial c~(~ ~ Y 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. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection,_or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. 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 tanks; 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; dose 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) DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY„ , DIVISION P.O. BO H LA~t)R AN UMAN RELATIONS PERCOLATION TESTS (115) MADISON W 7969 (H63.09(1) & Chapter 145.045) LOCATION: SECTION: ,/t/ TOWNSIj,IP/ ITY: LOT AI~O.: O.: SUBDIV ION NAME: ~4 3 /Ls/ N/R/!D I (or C/=/ C U TT: OW ER'S BUYER'S NAME: MAILING ADDRESS: 141t S`44JZ t e USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMER IAL DESCRIPTION: (PROFILE DESCRIPTIONS: ATIN TESTS: " Residence ❑ New Replace /y2 RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK: RECOMM N SYSTEM: (optional) o s 1Z u Os ©u o s ou o s ®u ZS ou If Percolation Tests are NOT required DESIGN ATE: If any portion of the tested area is in the under s.H63.09(5)(b), indicate. Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL ELEVATION DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- - 3 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 PEMOD2 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- heir location on the plot plan. Show the surface elevation at all borings and the direction and percent zontal and vertical elevation reference points and Zsho t of land slope. SYST M ELEVATION 71 r E -e ('l - _ i 1 ~ I t B !4 , , E I 1, the undersigned, hereby certify that the soil tests reported on this Lm 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 ( ri \ TESTS WERE COMPLETED ON: 1 e~2 4Z ZL AD S : CERTIFICATION NUMBER: PHONE NUMBER (optional): C SIG A E: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 02/82) - OVER - INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use sectic must clearly indicate whether this is a residence or commercial project; 1 MAXIMUM --')er of bedrooms or commercial use planned; 4. Is this a ne., acement system; 5. Complete the titability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 0. 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 to scale is preferred. A separate sheet may be used if desired; B. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all appropriate boxes as to dates, names, addresses, flood plain data, percolation test exemp- tion, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A, in the appropriate box; 1 1 . Sign the form and place your current address and your 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") - Bedrock cob Cobble (3 - 10") - Sandstone gr Gravel (under 3") LS - Limestone *s - Sand HGW - Nigh Groundwater es Coarse Sand Pere Percolation Rate med s - Med' m Sand - Well fs r- nd Building Is - Loa r Sand > Greater Than `sl Sandy Loam < Less Than I - Loam Bn - Brown sil Silt Loarn BI Black si - Silt Gy - Gray el - Clay Loam Y - Yellow scl Sandy Clay Loam R - Red sicl - Silty Clay Loam mot Mottles sc; : ,s dy Clay wl - with ~ sic - / : ay fff few, finc, int c _y cc common, se pt rnm - Many, m, .'.--m rrr :k d - distinct p - prominent HWL High water level, x taxtures surface water i } disposal BM - Bench Mark VRP Vertical Reference Point TO T; i' :R; rPfa 4 :Aa stn +ri*t°* F` :I:'St I -vate at t a or, 3er to wait must: be c pi ?art of any construction. c rn ST. CROIX COUNTY WISCONSIN y^ w sd ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 Dec. 12, 1990 Leroy Jansky 13 E Spruce St. Chippewa Falls, WI 54729 Dear Leroy: Enclosed are copies of all the information we have on the Joseph Lombardo holding tanks. The tanks were installed on Saturday, Dec. 1, 1990. We became aware of the situation Dec. 4 and conducted an inspection Dec. 6. I issued a permit for the system on Dec. 7. Our office has issued a $250.00 citation to the plumber as allowed by our ordinance. We have taken no further action against any of the other parties involved. My inspection revealed that the system has been installed in accordance with the state approved plans. This installation is not complete yet as the old system and second drywell used for gray water disposal have not yet been abandoned. If I can be of any help in this matter give me a call. Sincerely, rye „I°iJ111 f ames K. Thompson Assistant Zoning Administrator cJ y, I 8 Ul; i ~ I ~ 7jII , I 4-.,6~a.S/ ~Jl,~x.- ,C~/•/ _ o. s/p%~~ 9 1990 i. c0f~0 V~ oN 04 . 1 i { ,f r fat ~ T,~l . S . /f A;6A. IS 7 r 114DING TANK CROSS-SECTION AND SPECIFICATIONS , r Approved Approved Locking Vent Cap Weather Proof (Manhole Cover Junction Box 4" C.I. 12" Min , Vent Pipe 4" Min i Final Grade i 777-1 1 ,77'177-7 1. ,Approved Joint I8" Min Water Ti•pht Je - 1 A High Water 1 Alarm Switch J. ! SPECIFICATIONS ' Approdsd Joint/ I. P;1 p r • TAN K M a n u f ac t u r e r:_ S_... _ C oe. -k)42k + Gallons' kktenditnR' Tank Size:,-)- ..3 ' Onto f ALARM Manufacturer Splid Model Number: Switch Type is NUMBER OF BEDROOMS: 7 e s i OWNER'S NAME: T....... ADIAESS A)Z -J y~ L F. C A L D I S C R I P T I O N: k. k• S • N~~kll'~T„ ~ ITY: V VQW ulm TOWNSiIIP/M COUNTY e1 1 r, EID A!Pno . S I G N E D . tA90R AND HUMAN R L T C I: N S E Il 1`I II I R THE VI INDUSTRY, UILO1` I ~ GS DIVSION OF SAFETY DATE: E CORRESPONDENCE Oft rid m tL • LY r < D m m ~ n Im r U) -0 JW 0 (D CL 4 p --4 r- :to CD X to C3. c ~ CD W = IW -1 CD uo a (D • V) C mm vfDi~ •oa M \ -a v rn vi M vm v. z -v o~ e-nt (D C 1 C N C (D to -s z O 'O C ? f . m E. J C) a ~ ~ •a fD = c c=+ n . c~ (<D -o Cr z a • c m v a a Cr m n e+ a O C+ = m I Q, o o -S v -s cn c+ •o B ~ W Z f + X O' c+ m i i ' O ' r ~ v ~ z J. N n _°r z r 3 D I~ m CD m C) ~ z z -*1 O _ a C) N O to 3 3 VU W CD C) G m N -0 -n X o 0) m CL 7r C ;a ca c+ m C -h O O 0 J- Nn CD t~ .41, _ C) M m m V `v~ 3 Z C+ (n -PAO 106 3 C(D m N •Tm Z 'T X J• 0 4ry~ - : 03 CL a m J. ~ d to ~ o a c. r co O Cr In c+ >r ct 0 6 0) J 7r n m N ~ (D C) v~ Q m W J. 0 O+ ..J O /fir •A -h O MX A m O x ~-a OD N c+ c+ T7 = 3 n O (D C) -i a :3 0 N CL < 3 o O J.. m a c+ CL (D J. m ~ C j C N WrDD O 3 0 HOLDING TANK SERVICING CONTRACT Contract Date This contract is made between the Holding Tank Owner(s) Name(s) and Pumper's Name ~osP P L.o rKC r4 r2 e (P- o M 3 RDt, G~-- We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal description:) II 1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which has signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and with the County of St J- go ~ x 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis. Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) i Owner's Sig ture(s /O zoSep'N P-iotABPQ¢-c (l Subscribed and sworn to before me on this date: Pumper's Name (Print) Pumper's Signature Notary Public xpires: Mycomm' sio 91 Pum/per's Registration Number Or f SBD•7574 (N. 11/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations, Bureau of Plumbing. 4G4732 C"8V E1 9 Document No. This space reserved for recording data HOLDING TANK AGREEMENT REGISTER`S OFFICE Agreement Date STY CROIX COY, WI This agreement is made between the _ _ Reed for Record C S ty cal Govern n~ nlal llnil i hold g Tank ) Owq~er(p) Q; Dr 0It 1990 M 86, ay1°.l; Affl," 11 Called Municipality below We acknowledge that application is being made for the installation of (a) holding Regis<terofDeeds tank(s) on the following property, (Provide legal land description:) Commencing at a point 353 feet North of the Southwest corner of the NW!4 of the SGfy of Section 33, Township 31 North, Range 16 West, running thence Gast 93 feet, thence North 100 feet, thence West 93 feet, thence South 100 feet to the p1nr.e of beginning. - - - - - - - - - - - - - - - - - - - - - - - - - - - - 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. r~ As an Inducement to the County of C D( to issue a sanitary permit for the above described property, we agree to the following: t, 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 lank 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 properly 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 lank 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 properly. 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. Owner(s) Name(s) (Print) I Owner ) Signatu e(s) ZOS C P H A, LO MB A R \)0 I ~l Subscribed and.sworn1t%§pjpjp me on this date: ~j~1~~~ LOM13lR12~U ~f ~~~IOC~tic~l~ C/cd Municipal Official Name (Print) I Municipal Official Signature NOTE W Public My com issi n, kr4g1 D'1.0 %1. T Municipal Official Title (Print) SBD-6123 (R. 10/05) This instrument was dralled by the Stale of Wisconsin Department of Industry, Labor and Human Relations. Bureau of Plumbing. H , z cn H ST C- 105 r' H SEPTIC TANK MAINTENANCE AGREEMENT Ho St. Croix County z d t~ OWNER/BUYER ~as~ 1'1 • d-~Re44 (e° \1 , LO m -y,2 Qc) y IIQ? ROUTE/BOX NUMBER !UJ co. Rbr Fire Number CITY/STATE ~l.(J ~ ( C G ~ l ~ { C K ► ~ W1 S, Z I P S Q (`7 PROPERTY LOCATION: V4, S ~4, Section , T31 N, R W, Town of C y Lot 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 H three year expiration. o E z I/WE, the undersigned, have read the above requirements and agree v, to maintain the private sewage disposal system in accordance with 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. / SIGNED DATE St. Croix County Zoning Office P.0 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 his application form is to be completed in full and signed by the owner(s) of the roperty 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 =_-Sse_Q 4 A• A 1 C LDM A 1217 G 3,53 V Location of PropertWCo&eRof'©FfitSE1%, Section , T2_N-R [ W Tovnehip C Nailing Address (837) C o , R a 'O, N CLLR (2 ~C (AND NO - Ap) 7 Address of Site 1 MiO S©U+- x dF 4Wn 64 oN C~y'ro" ~~/ZoN Subdivision Name Lot Number Previous Amer of Property GAL C d- ~2Q,S pe-C-4 AVeR Total Size of Parcel C13 ~ I oa , Z ko P-C fLE Date Parcel vas Created L I~ t 1 f o f Are all corners and lot lines identifiable? >1/ Yes No Is this property being developed for resale (spec house) ? Yes No Volume (90 S and Page Number 5 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 refer- ences to a Certified Survey Hap, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPERTY OWNER CERTIFICATION I ((ee) centi.6y that a.Ct 3tatement~s on th.L6 onm ane true to the best 06 my (ouh) hnowtedge; that I (we) am (aAe) the owneA(,5~ 06 the phopeAty dezchi.bed in this .i.n6aAmation 6oAm, by vi&tue o6 a waAAanty deed neconded in the 066ice o6 the Coiuity Regusten 06 Deedhah Uoeument No. ~}~2 ; and that i (we) pneaenLty own -the pnopoded site bon the Aewage dizpoA 6ya 'em (on I (we) have obtained an eab ement, to nun with the above de d c& bed p)topen ty, bon the eonetnucti.on o6 &aid system, and the dame has been duty neconded in the O66.tce o6 the County Reg.i.ateA o6 Deeds, as Doewnent No. ) . Ol ~.'~C'~ a r~~'1 NA~URE Oh ER SIGNATURE OF CO-OWNER (IF APPLICABLE) r DATE SIGNED DATE SIGNED f :March ie>a Gneatiat t45. A wade and by Vitt" Of the Wwa of dw Stats at VYitooM" M to AM Pa and qty. . ittrsband . afs~l Dat • J . tbitd° Tafftsats pTSM T9 2., iki iwt tee. be Y aesiindeM "aI M and"oaluabla 0o ea a*tyt wbeiMt _ to it b'1 609 MM o~---~--°I dw andow. ps geodasd li `4F wrdpti• br mA bet/eisad. eobi. twetieei. r~es do ~tew~ bf adh h~ti sds@*• Hies. aatrbr and aes8= wC tit ~sd 900 of wbOaai• a ~~~ye~tteeadislbaCaaaeyd S Ct~i7[ K 3S3 feet worth of the Southwest corner of the 3 of tlia 8~1 ttS at a point running thence East 9 93 feet theme M a ==itiietioa 33, Township 31 Borth, the n16 c penge nc West. to'r'ch 100 feet, thence west 93 feats e South 100 feet to the place of bKiss ~ I QII as# 1004 I (r tT. ml'tl' R tbueesaa bdeadW W is asy win aAnMida~i Zy * wifiit eg asd oYpier tM btt s*~ asd sPOstyo Omer is law ar pdb►• ~ Y p ~ ar ~wtMrllt tilinar ~tesr/ wMao• d as rid 1~Y of dts lnt0~• ~~~..Nra rrrMi..+ w~M• ad tbetr ' r N she Md aiP soft - ' aa aid e*MW* A. ~w 6-OW wink d. a~rfta+sM~as~ ~ . rrl Masi dot etiM ! u~ oast, bniieis MA W" d fliM~ ~artafs b fa "'il'g ~etgr d be oft Part. iaslt d ~ Nat does at ootetie ttaaaM% ta d the eneditft dsYVer! abeobite and „ tsteatibleastaM d isbetMsse~ is do Yw, V tee d #eeeisesaba~ dteetM~• M d a . Mo.l L aw ~ aai eittr ben of isewetdssmsa rr . d eM aid peK1A-~d tM eeoest /aet.LlM+ifFlais WARRANT A11n. ~s! boo -A Pp~n is do oai.t and P~bol pes, Y g dwed, it wN fawner s " Porso" lawlay dsiniK tba s~hola or MY Part a ytYet an aVny do „w -..:..firat. ..k it>wantia ..:Savaz►f~i~.. Assiatl Qa 1147 DA &L PMOR or .ids F a~ 1147 lMrsY at ~ . bas cawed these presents to be by west .........aito9lwts°R st-....... L...Jitr$e1L+...~tica..P.Les1d A. D.. WAS-. wed:,by.-~+arT des of......... ftrch , - r MlitcOSeis, and its corporate *W to be herenato affixed this.....l7.th.... Y t CIAL SAX sunup AND S&MAD IN PRZSZNM OF ST F o , XDi _ Ga. Ju..Seil INTATi Of WYOONM• w 3 ......Cwtaty.} A. D.. 19 - e at'tM ~titln~! r TSb _ sae. tbjL LL V d-....eeident ..L.s...Jul&glla,...:Vi..Le..p=...R~• carne bda+ V nta Faues'yr G. ~c-:Ptesi day ~ Ko~4e~ek, .........Sr,iel4. and... ~FY. wbo ted the (moping indroseest. and to me knows to be sttcb -me" as "'h oRoers as the san~ed Cgeporatian. to esa known to be the Wows iast It A said Corporation; ana acknowledged that they executed the foregoing ,CR... t=tf and.... deed of said Corporation. by its authority. ~ • to o S h • ."4w, Notary PabYo_ ports a ieette um dmhod by first Financial Savings Associs 1e` Mycoesteitios0;*0114 }}y'1 . tl; star tree! Tr11IMd a ! _ Ma yp , wtrwaises M M .0164 N -