HomeMy WebLinkAbout020-1147-10-000
00 I
Q
h ~ I c
00 0
~ I
o I
0
N I
O
m I
I
~ I
~ I
I
I
a I
o Z I
C
LL C
o
3
I
I
Cl)
N
z "
w
Z 4.; 0
z ; a 0
rn
N F- fn
C
o z g c
a~i z o I
N F- Z
C
E '2
v ~ M I
S
c (D
M I
n (D y c
•t~w d ~ L ~
O Z co z
N z I
~l N
3 R
V
c `D m I
ac ) o a u, c co
(D 0
rn N N N m N I
r w
O O 0 Z O
co CD 0)
o
N O
c O
d I
O m y C
.~1• d d}in m I
~ C
O w 5
° o
O o o m I
O °O ; Z
CL Cl)
0 CO 0 m N w v a -
c c E E c
O N= N O Z N=3 A- a can I
O 4 = I
r at E I
a
~dt a `ate I
• CL d .V 0 p
rr`Iwv E c c
FORM - STC - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER _ I~R CONS TOWNSHIP NUA D.Soh)
SECTION a to TQ9- N-RW
ADDRESS ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT-ff-LOT SIZE
PLAN VIEW
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
IaXsa y7,
/7'
o SO' z
d ~
a9. / 3a'
as
3 1BeDK-) r~ 3
Home.
N
INDICATE NORTH ARROW
BENCHMARK:Elevation and description: -5ff-c
Alternate benchmark BACa, o4 lY~rk3t ~L) COKN2rl-
SEPTIC TANK:Manufacturer: Wet k S Liquid Cap. loon L
Rings used: - Manhole cover elev: /Oa,3(p] inal grade elev:_1 -
Tank inlet elev.: 100.5 -Tank outlet elev.: 100.E
No. of feet from nearest road:Front3`, Side , Rear Ft. 170
From nearest prop. line:Front , Side, Rear Ft.
No. of feet from: Well -go , Building: Da
(Include this information in the above plot plan)
(2 reference dimensions to septic tank)
SEE REVERSE SIDE
• + f
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
Si.-T 5.86 HcpQeR 98.c.6 - W(110
o 0 0 0
SOIL ABSORPTION SYSTEM
/ V1-, .50
a ENS 9$.4y 98.94
Bed: Trench: Seepage Pit:
Width: is Length ~~a -Number of Lines: Area Built (0~v
Exist. Grade Elev. 101. Id Proposed Final Grade Elev.
Fill depth to top of pipe:
No. feet from nearest prop. line:Front , Side , Rear Ft. II
No. feet from well: 13 No. feet from building FjQ
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:
i
INSPECTOR:
DATE: I a 5 O PLUMBER ON JOB:-0-4;1
LICENSE NUMBER:
y~y
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:
SW 4, SE 4, Sec . 26 , T29-R19 >511C ONVENTIONAL ❑ ALTERATIVE (If assigned)
Town of Hudson LotE.5 '4p-,q cic)w Dr - Holding Tank ❑ In-Ground Pressure ❑ Mound
NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE:
0o /e2 - S-9v
,T4i1d,qc)n WT 54016 T)P1 tn. Cc)n,-,f--rurt-ic)n ~206 2nd
BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST RE''Fnn.,,PT. EL
vV ~
Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number:
I Jim '11niimppst-pr '1404 2,9791
SEPTIC TANK/F16h1N8 **N $ o FV~r Ce D2 " s `
MANUFACTURER: LIQUID CAPACITY: TANK INLET ELE ANK OU -T WARNING LABEL LOCKING COgR
n PROVIDED: PROVIDED: ~S~G ,
160, 7(, /G0 • c 1 -Z YES NO ❑ YES NO
BEDDING: itrNT DIA.: VE#T MATL.: HIGH WATE19 NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH
C-.0. L .~U, ALARM: FEET FROM LINE: ! AIR INLET:
4-
❑ YES NO CG>LSt ❑ YES NO NEAREST
DOSING HAMBER:
MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP/SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED:
❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO
GALLONS PER CYCLE: PUMP AND CONTROLS OPER MBER OF PROPERTY WELL: BUILDING: VENT TO FRESH
(DIFFERENCE BETWEEN FE M LINE: AIR INLET:
PUMP ON AND OFF ❑ YES ❑ NO NEAREST -I►
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 continu
CONVENTIONAL SYSTE ` Ok v. m S Y5 • ee_ = S .17 BED/TRENCH WIDTH: LENG NO. OF DISTR. PIPE ACING: COVER INSIDE DIA.: # PITS: LIQUID
TRENCHES: i MAT IAL: PIT DEPTH:
DIMENSIONS (T ~ ,
GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. IPE DISTR. PIPE MATERIAL: NO. STR. NUMBER OF PROPERTY WEL . t BUILDING: VENT TO FRESH
BELOW PIPES: ABOV COV R: ELE . INLET: ELEV. END: a _40 PIPES: LINE: j~! AIR INLET:
FEET FRM ~ t.La'h.Ls t~C/' vZ NEAREST r- ^ 1~ ~lJ !
60 heZ
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:
ELEV.: ELEV.: DIA.: ELEV.: PIPES: DA.:
ELEVATION AND
i DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO
INFORMATION APPROVED PLANS
❑ YES ❑ NO ❑ YES ❑ NO
PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING:
COMMENTS: FEET FROM LINE:
❑ YES ❑ NO ❑ YES ❑ NO NEAREST
O cJ ee
~
Sketch System on tain in county file for audit.
Reverse Side. SIGN URE: TITLE:
c
SBD-6710 (R. 06/88)
~ILI.HR SANITARY PERMIT APPLICATION
cOUNTY~ ,
In accord with ILHR 83.05, Wis. Adm. Code
STATE SANITARY PERMIT #
-Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 8% x 11 inches in size. 4c~?d1s`lo7t0re,4s sapplication
-See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PR ERTY O NER PROPERTY LOCATION
' S lJ:~'Y a s'/a, S a T , N, R 9 E (or) W
PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK #
CITY ST TE ZIP CODE PHONE NUMBER SUBDIVISION N rE OR ISM NUMBER
I e.
V
NA W
_0 j II. TYPE OF BUILDING: (Check one CITY NEST ROAD
) State Owned ❑ V
JOWNOF: UUQSOA)l ILLAGE : 1
❑ Public ®1 or 2 Fam. Dwelling- # of bedrooms 3 PAR L TAX NUMBER
111. BUILDING USE: (If building type is public, check all that apply)
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 120 Service Station/Car Wash
5 ❑ Hotel/Motel 9 ❑ Office/Factory 130 Other: Specify
IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)
A 1.1K New 2. ❑ Replacement 3. El Replacement of 4. El 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 420 Pit Privy
13 ❑ Seepage Pit Pressure 430 Vault Privy
14 ❑ System-In-Fill
VI. ABSORPTION SYSTEM INFORMATION:
1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE
O REQUIREsq. ft.) PRO O~ D q. ft.) (Gal /day/sq. ft.) (M ih) ` Q Feet ~LEVATIO et
VII. TANK CAPACITY 0( J O v
in allons Total # of Prefab. Site Fiber- Exper.
INFORMATION New istin Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App
Tanks Tanks strutted
Septic Tank or Holdin Tank Qd Q
Lift Pump Tank/Si hon Chamber 1 F1 I El
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 Signature: (No Stamps) MP/MPRSW No.: Business Phone Number:
- i M 0L(M R ® 1S 0 $ - 2000
Plumber's O ddresso
~ (Stteet, CitS tate, zip C D 0 N W o /w„
IX. C UNTY/ 1DEPARTMENT USE ONLY J[
❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued issuing A em Signature (No St pa)
Surcharge Fee)
Approved ❑ Owner Given Initial / Adverse ~C^
D termination / v
X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL:
SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber
r r
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 settNage systems musf 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 rapacity 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. Ins'alling 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 :.fphon 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 fo - 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)
l
Q.I_. 67 PLOTAH1 c..'ROSS 5 E CIi~~I~I_
N A M 4a ki --4 r c~....__ N-A M E~?~fm ee '72
~y L 0 C AT 10 N1.... L I ..C E N S -E 3.-1 .
A. E
r-- P L ,0 T (f
m
StU I Ron i 9ap ex fo (boob goo ot►
33 west I"p 1►~e ~L'= ~ao,p
= Row Pen ~ t- 16, Y113
0- B01zkhv1e S~~es
X~ PeQz hole Si~"eS .
AP-Q-A oV eR- Q f33 MAJ 6vt 'to be
C4& dowN to • rnk MAX C-0 V(9 Re -
9
NOtc n Add AQpt lots, We l Is Ake
A
3 Se~ ► c; ~ Sy st,~r~
&DRGOn1®-e W ol 'IS
a"he~ ham 7S
Horn
rzoM Se~~ (-4
Sys~'erv,
o U'
0
r 9
(00 ~
js. o. x Lo•
301
- OQD
l I -ri R m A-re A rz,~.A• ej'' N
6~' g o
yo - ~
FRESH All'IItLI,.rS AND OBSERVATION PI-RE
A4CnOSS SECTION
Approved Vent Cap
Minimum 12" Above
Final GraSie__ _
• Ya`' mom.
4" Cast Iron
Above Pipe Vent Pipe
To Final Grade-
Marsh Hay Or Synthetic Cove). i.ng
Min. 2" Agga-cg',.iI _
Over Pipe
Distributio_ ll F- Tee
Pipe l _1
Aggregate 1>er-fora t-ed Pipe Below
9? Dencath Pipe Coupling Terminating T
Bo1• L-om of System
DEPAIRTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
INDUSTKY, DIVISION
•LABOR AND P.O. BOX 7969
HUMAN RELATIONS PERCOLATION TESTS (115) MADISON, WI 53707
(ILHR 83.0911) & Chapter 145)
LOCATION: SECTION: TOWN HIP LOT NO.: BLK. N SUBD ISION NA
'1 y /T N/ (o~ s ~,o~s
COUNTY: OWNI- BUYE S NAME: MAILING ADDRESS:
USE DATES C)BSERVATRONS MADE
ATI TESTS:
NO.BEDRMS.: rMM;R IA SCRIPTION: RO DES IPTIONS: ER CO
Residencelew ❑Replace ~Q gQ
RATING: S= Site suitable for system U= Site unsuitable for system
r O0ENTIO~NAL: MOS. EJU ING0S P❑A RE: SYS El TEM-IN-FILLHO S TRU : REC 1, kn,~ Au_-
If (optional)
'0S 0UU SS ,,((I?f(JJ UU El SS 6 N BATE:
If Percolation Tests are NOT required DESIG\/ If any portion of the tested area is in the
under s. ILHR 83.09(5)(b), indicate: Floodplain, indicate Floodplain elevation:
PROFILE DESCRIPTIONS
BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH
NUMBER DEPTH ELEVATION OBSERVED EST, IGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.)
♦~v7`/'j/S~!/ 3~NA4 S,/y'/1.rG3fGI~
B-~ ,S° 03.08 > i'd
S
B- v S~3 >70
B-J ~S ab r onS `L3~oGS /.67 .1p`
~ y~. ° ,Bj,cs 9 r _ I
B-
PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMB R I+WA4 $ AFTER WELLING INTERVAL-MIN. PER OD 1 PERIOD 2 P PER INCH
3 z
P
P- Z s'~ 3 b 6 <l
,6 6 4
P-
P-
P-
P-
PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori-
zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent
of land slope. 0 i
SYSTEM ELEVATION 0
E
I
W C-
&Av
oc A4"
E
3.
E
M
m
F
I
d~
Ai 5-j 4~r,
r
1~~ w>~~..~~,sE _a -STN
E
w
I 3 ! k
LGI
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 (pr' tl: TESTS WERE MPL TED ON:
~d 9d
ADDRESS: CERTIFICATION/NUMBER: PHONE NUMBER (optional):
CST SIGNAT E:
ZAL
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
DILHR-SBD-6395 (R, 10/83) - OVER -
I 3
INSTRUCTIONS FOR COMPLETING FIRM 115 - SBI - _a
To be a complete arid accurate soil test, your report must include:
1. Complete legal descrila-don;
2. The use section must clearly indicate whether this is a i= . or commercial project;
3, MAXIMUM number of bedroorns or comme€-cial 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 LEGIBL'_ -a:-gram accurately Ioc:atirlg your test locations. Drawing to scale is preferred. A
separate sheet may 1-- ?sed if desired;
8, 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 exernp-
tion, if appropriate;
103 If the information (such as flood plain, elevation) does riot apply, place N.A. in the appropriate box;
11. Sign the form arid place your current adr:ii ess and your certification number;
12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE
LOCAL AUTHORITY WITHIN 30 GAYS OF COMPLETION.
ABBREVIATIONS FOR CERTIFIED SOIL TESTERS
Soil Separates and Textures Other Symbols
st - Stone (over 10") BR Bedrock
` cob - Cobble (3 - 10") SS _ Sandstone
gr Gravel (under 3") LS - Lirraestone
s - Sari=_ VIGW High Groundwater
cs Co<: and Perc Percolation Rate
reed s Mel, r a Sand W Well
fs - F'n i Bidg - Building
Is Loamy and > Gre itei T'han
Asl - Sar ; L < f Thin
" I - Loain Bn n
ksil - Silt Loam BI Black
sr - Silt: Gy gray
*cl - Clay Loam Y - Yellow
sci Sandy Clay Loarn R Red
sicl Silty Clay Loam mot - Mottles
sc - sandy Clay w - with
sic - Silty Clay fff few, fine, faint
kc slay cc common, coarse _
pt Peat rnm Many, medium
rn - Muck d distinct.
p - prominent
HAUL High water level,
Six genera' sil textures surface water
-for 1iqui ` disposal BM - Bench Mark
V RP - 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.
II
l
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/
ROUTE/BOX NUMBER 70 FIRE NO.
CITY/STATE,( her ZIP IU
PROPERTY LOCATION:aL--) 1/4 - 1/4, Section 2- G , TAN, R /9 W,
Town of , St. Croix County,
Subdivision Lot No.~
Improper use and maintenance of your septic system could result in its premature
failure to handle wastes. Proper maintenance consists 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
treatment stage in the waste disposal system.
St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of
$3000 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 verifying that (1) the on-site
wastewater disposal system is in proper operating condition and (2) after
inspection and pumping (if necessary), 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.
i
I/WE, the undersigned, have read the above requirements and agree to maintain
the private sewage disposal system in accordance with the standards set forth,
herein, as set by the Wisconsin Department 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.
t ~
SIGNED L~
DATE
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016
(715) 386-4680
Sign, Date, and Return to above address
APPLICATION FOR SANITARY PERMIT
STC-x100.
This application form is to be completed in full and signed by the owner(s) of the
property being developed. Any inadequacies wilt 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'Yappropriate deed recording
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Owner of Property (F.-LT~,d _0A1S7' x-, C_ T 1. bbl
Location of Property Section N-RW
Township Ya b S G
Hailing Address
Address of Site w l - b L✓ , b' fLi V t
Subdivision Name tit.. G t4 17 cti°G~;.S
Lot Number
Previous Owner of Property o
Total Size of Parcel ~Z A + vt
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.
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 Map, the Certified Survey Map shall also be required.
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
PROPERTY OWNER` CERTIFICATION
I (We) centi.6Y that a t btate.mentd on thin onm ate tAue to the beat o6 my (out)
knowledge; that 1 (we) am (cute) the owneh(a f o6 the pnopercty d"cAi.bed in thiA
in o~cmatc •on
on.m b v.chtue o6 a w
h aAuc
6 by 6 only deed neconded in the 066ice o6 the
County Reg•c.aten o6 Veed~s a.4 Document Na. and that I at (We) p4e6 entey . I
own the pkopob ed z to on the .6 ewa a di,6 oz dyb
6 9 p em (on I (we) have obtained an
easement, to nun with the above , e e de,6 ch,%b d
e no eht on the cons
p p y, 6 tnuctcon o6 a acd
.aydtem, and the same hoe been duty neconded in the 066.tce o6 the County Regizten 06
Veeds, as Document No.
fc-~tw
SIGNATURE 0 OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
DATE SIGNED DATE SIGNED
YT y ~ " 01 7Lar'fpati
C4 WUMMM
ter.
r~ iL r+...
aletnn:.loin.-atlk/.a.•t~~1.
.A.. =•W ,~und•-~ ~ ~ ~
M, .wax=,Arfk.~a..]f}Gael~.a i~18i4~i•.a1h~l ..1i
S» ..W$XQRs...huabAn4.And,.wUaL .8i jLiiUt..
and Delta Con"ru"Icv Co. r.. r~
. ` - \~•afr•a~+ 03,
Witnoweth• net aw sad Grantor, far a wonabie •
Gltann • YIF 3fi.W a
come~a to GreawtlM,> ing fir" MI setate is .•$t. •evoix -
i "Ituity, State Of Wiqspaie;
Lot 1:5, High ftadowa in the Town of Hudill6n ' Uf i w,.»
St. Croix County, Wisconsin.
k. .
.
ti
,
Tnis.. is not
homestead property.
i
(is) (is not)
Toge with all lar to h editaments and 'appurtenances tbarnunto baloa~: r
And Tenn annI `If ucel~a Saxon
.
a: rranti that ttb* title is go*4 indefeasible in foe simple and free and dear Of *aatupbrwK4* except
easements, restrictions and rights-of-way of record, if any.
i,t,d will warrant anal defend the eatsa.
Laud. this day of April , LY...9.0..
(SEAL) ~ZA u ".,..(SEAL)
w
Glenn Waxon a,k
~ato'l ~enn A. V ce~la Wax on a/k/a, Y Cella M.
Waxari Waxon a/k/a Vyce!.'la S. Waxon
(SEAL) 4SMAL)
t
419TOXNTICATION I►CiSiA1(,1WL J~GKiNS ~
~OiY~i1~I i.
3iXaattua(e~ STATE OF W1
St.. CroixGoaaty.
authenticated t4* ........day af. erwnally'camr before .day of
p l lt'v..... the :bciw named s
. • al em .-Waxou•-a./k1a-41 sun _k.- . Waxon;
Vycella:•:Wsxox~f . H.,,. f
TITLE: UEM4XR STATE BAR OF WISCONSIN
Waxon, -a/
(it Mots H t
an4wis4 bj 1 9A 4K, Wis. $tats.) to me known to Le the
ft ro~n;~+, instrt~e {fit
THIS INSTRUMENT P.Aa~CRAEiED 6Y
Kristine 0gl4nd Llundeen
At torney at 1;iw • Alice Joy.
r,ar,n~ , St, .aunty, Wis
Mgnatiirex ma, be antilenticatetl ur a<knoalc1l Id L',tit %I <,-wrilAsiwt itt perm steno " tratil"
.ire imt twee=sary'•) July 12 I 3 l
-Nam.-f prr•asi .dea,ax th a,:b. Fat vity •ho:¢i ba slt*~i nnt.q I,; -h-
WARRAthiY P"D ♦TATe HAU UY N; ~rt!Aiclh NfLa„W Lr,aal ataa~ Ga 3a~. 4"
~.N07
N~l~~rcq (:l~ tci~•
11"s, '0
-If1 :r'•.'~K01' •`.;~.1 ,1100" :i .i: I1
t ~~,II , ~I•' V ~ Iy (~t .11vr10 1I,11nLS 1111AInt[O IO InL €aNl L•l ~l•~
~i h 1 ; YGl.vrl Nllo 1.3f Glnl 01 1110 1( 1/1, Ofw lt9
10
W 1 , „
A~ i .I~ " I • iA't~r
iliuo' to Sl= m x Q S
{1.4 ° O 0 r' x 0
S 0. N 00 `C H
i38 raiior/.,fy-+i~r.~ •i• ~ Yfi :.o Q .7. o ~
F 4 c °0.• a. o f Ic
Iviv"I IID•D
1 :'•="N O.11'I)'v.. s0)OO../ YQ In O S'U C µ 7
X o- 1 I' I J ID m a x ID o
Q• .m 7 2 7
4. 0 go tO
~ ~i D ~Iy ° N m 3 O N
I `l r0 µ t,
Q
111 ID an Q
O, O II n Y p.,,'1)•'r 111 71' ' NO'll'11•r 111 G1N 3
8 sos op ~ i>ow f ~ N'' o m d
y*` 1~,0 j `lY 1 p.•~1 I`nI. 0 Q' Q Q
rr' 1 F j 2; a N O
•s , O 1 . . ~ ~ ~ 1, 3 0 ~
o ro 3
Ile
PO
' f ' • V
11111' Irooo' r ~w ~ ~ ~ 10~,
.r S. ~ •G ' 1 .o r
I• 11110' j I./Y('.i. :Z 11' ~ 14 ~L 1'n/,j0 )p ' In
S 1 t x
I ,J • 1
1 .
• r i
01' w
i$ "
10
y Y s
'
n ~ ° I r .161
y i ~ 1 ~ , `•~1 g' 1,1 C1~~
Y I S iN 8 •l '•r-
p
rl'
I ..li x
~ M.Y•w11••.wrMr
n1. t