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HomeMy WebLinkAbout020-1265-70-000 ~L o I a°i CD 3 0~ Ql O h 0 o i N 00 'I j C z c LL O 3 a a 3 cn Z fl! W E O Z a m N I- (n ~ O O Z aUi Z a O C 'O N CD C O N y N of "O N ~N a O O ~ a L O f° O L o a~i aw z m z o w N z _ z 7 <O N O R U 12 R m a? _ CL ~g w ~v ` m aa) N 3 O ° IL - °o N :3 m L) co N d ~5 5 Zo a o M n N C O - .0 O m y c CL U C y y rn CD 7 a } O 00 p ui N C 0 o^ 3 c d a o rn o ` o rn o r ~ N O co D_ C V ~ -p N N W N O O y 0 N OO L n "=0 i O C O N O H C N N O> > O co O C E U cO O N S O Z_ l4 .~i a 0 a • C. d V d d `Iv E c C a> Form- STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~Rety~ d Sam ~ JA S~NSoFx TOWNSHIP HU d S ()13 SEC. ~L T o< g N-RjLW ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION KUSS J N G COtAK)J 1c ',A LOT 430 LOT SIZE VieW Ad~ PLAN VIEW Distances and dimensions to meet requirements of I•T.HR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM - C~~,~, View KOKO 1 8x 3 Bey 0 5G' y5' ° /►91 S9' IS' YOM Z - INDICATE NORTH ARROW I~ BENCHMARK: Describe the vertical reference point used 71De Elevation of vertical reference point: COQ, U Proposed slope at site: ~IX /O SEPTIC TANK: Manufacturer: U, yz t~ S Liquid Capacity: 1 000 ~A Number of rings used: I a, Tank manhole cover elevation: 11~.~9 Tank.Inlet Elevation: Tank Outlet Elevation: 10(.7 Number of feet from nearest Road: Front,O Side,O Rear, O fet ..From nearest property line 'Front 10Side ,ORear, 0 p9 f Number of feet from: well building: (Include this information of the above plot plan)( 2 reference dimensions to sept' SEE. REVERSE SIDE i PUMP CHAMBER Manufacturer: y Liquid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, © Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). 5k,, f ,zrANp, 101.86 AND .3u 1 SOIL ABSORPTION SYSTEM I & ) 1 o ('q. $0 10y t~ 8 3s o , Bed: IJ Trench: Width: Len$ih: Number of Lines:_ Area Built: la lU Fill depth to top of pipe: Number of feet from nearest property line: Front,' O Side, Rear,O Pt. Number of feed from well: eta Number of feet from building: 7 S~ (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector: Dated: Plumber on job: License Number: 34oV 3/84:mj A ri,00/6 • DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LIASOR & HUMAN RELATIONS DIVISION P.O. BOX 79M ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: SW4,NE4,Sec.29,T29-H19 X I CONVENTIONAL ❑ ALTERATIVE (ltassigned) Town of Hudson Lot ❑ Holding Tank ❑ In-Ground Pressure Mound A E MIT HOL ADDRESS OF PERMIT HOLDER: INSPECTION DATE: 1~17~4~ REF. PT. ELEV.: CST REF. PT. ELEV.: B AF(Permanent re • ence point) D R 8 IF DIF E ENT FROM PLA 45,14ammand., WT .54 Name of Plumber: MP/MPRSW No.: County: Sanitary Permit Number: SEPTIC TANK /H * : 3.3I! / s 1/0.29` MANUFACTURER: LIQUID CAPACITY: TANK INLET EL K OUTL LEV.: WARNING LABEL LOCKING COVER P O IDED: PROVIDED: YES ❑ NO ❑ YES NO BEDDING: VE#7 DI A.: .HIGH WA ER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT T F ESH 4ALARM: FEET FROM LINES~AIR I T:❑ YES NO El YES NO NEAREST---► ' CD /J DMANUFACTURER: B--- QUID GAPALA I Y: EL: PUMP/SIPHON MANUFACTURER: PROVIDEDLABEL pROVIDED:OVER ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH GALLONS PER CYCLE: uNE: AIR INLET: (DIFFERENCE BETWEEN FROM PUMP ON AND OFF) I ❑ YES ❑ NO NEAR SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: METER: MATERIAL AND MARKING: or excavation. (If soil can be rolled in wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: rrm o~ trn = /O .73 WIDTH: LE H: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH ' TRENCHES: MATERIAL: F DEPTH: DIMENSIONS 7G GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPS: ABOVE COVER ELEV. INLET: ELEV. END: ~~OYr f ,~P PIPES: FEET FROM LIB' t ~S r AIR `NW e 1:;EeL~W_ ~ - NEAREST MOUND SYSTE 4.x'v' 3 Mound site plowed perpen icular 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 SOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH: LENGTH: TRNO.OF ENCHES: LATERAL SPACING: GRA EPTH BELOW PIPE: FILL DEPTH ABOVE COVER: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANI MATERIAL: NO. DIST . ISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO FOLD ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST in in county file for audit. Sketch System on Reverse Side. SIGNAT E: TITLE: f SBD-6710 (R. 06/88) UYf SANITARY PERMIT APPLICATION 41405171 too 100 COUNTY In 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. c r i n to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. i PROPERTY LOCATION PROPERT:TER r Q 4- S O Sq 7y 5(.0 X. Sa T ,N,R 19 E(or)W PROPERTY OWNER'S MAILING ADDREtS LOT # BLOCK o. s o CI, STATE ' , JZNUMBER S DIVISION NAME OR CSM JNMBER Ail l, I'S r X.. 'Pos ok \111W ~ii oN tSC s° N I ~/3 11. TYPE OF BUILDING: Check one) CITY NEAREST ROAD ( ❑ State Owned VILLAGE : Has 0 jcwAKmr.N ❑ Publ ic [A 1 or 2 Fam. Dwelling-# of bedroom PAR EL AX NU BER() 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 8 ❑ Mobile Home Park 120 Service Station/Car Wash 50 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. New 2. ❑ Replacement 3.E1 Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an bystem 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 N, Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION O 61-S (Q ;t , < f 03• 0 Feet / ! 48 C)Feet CAPACITY VII. TANK Site ~in gallons Total # of Prefab. Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank 010 C r] H Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): ~ 1 Plumber's Signature: (No Stamps) MP/MPRSW No.: MVS7 ness Phone Number: ~m LII~ 3 86-96N Plumber's Addres (Street, City, State, Zip Code) 1861 162-111. 5t, guip's(w IX. OUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued issuing ent Signature (No Sta s) 4A I Surcharge Fee) Approved ❑ owner Given Initial _ ~ Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-8398 (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 system. Check experimental approval only if tanks received experimental product approval from DILHR. Vlll. 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- watercontamination investigations and establishment of standards..- SBD-6398 (R.11/88) P F% 0 J EC M E dik)-su►~._ _NAM E Tim -BAkmee l= k L 0C AT 1 0 Nro,~. O C E N S 3.Y u Y 3 &prCyom 39' ys ~ I ~ ~ ~ N~fie ~ Aa~aceN~ leis, (fie I I V Ofn No We~~ 44,v Soft fxur,, SC FRESH Ail. iP.LI,rS AND OI3 E Ct;nSS/ SECTION _ I Approved Vent Cap Minimum 12" Above NA) GIZhax Final ,rasle~__i _ W.ab M RN A" Cast Iron Above Pip Vent Pipe To Final Grade! r Marsh Clay Or Synthetic Covering Min. 2" Aggroyl. _ Over Pipe Distributi.~~ Tee Pipe I 11 ~ 43,70 Aggregate Perforated Pipe `130-:'low T Dencath Pipe t CouplAng Terminating ~Qi~_-~~ Bottom of System DEPARTMENT RY, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS ,INDUSTRY, DIVISION LABOR, AND PERCOLATION. TESTS (115) MADISON W 7969 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SE I N: TOWNSHIP/AAW=C1RAd.I4W LOT NO.:BLK. NO.: SUBDIVISION NAME: sw N~ Z9 /T-Z9 N/Rid E or 1,/ d 30 Ross/.445 co" A, I EV COUNTY: OWNER'S ESWERLS-AFPeiotE: MAILING ADDRESS: STCP_o,I),_ 5,arvl AVER n USE DATES OBSERVATIONS MADE NO. BED MS.: COMM R AL DESCRIPTION: G~ Q O Residence /N New ❑Replace I -S/?/96 STS: I/L 01 is 1< G ~ 6 - So I C.S AEr E RATING: S- Site suitable for system U= Site unsuitable for system ~Z- RkNdR~T ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SY^SQT~EM-IN-FILL HOLDING TANK: RECOMMENDED SYSTE optional) M rXS ❑U OS ❑U LAS ❑U ~S [:]U ❑S C-oNVEAJT10044t, A If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: ~S5 Floodplain, indicate Floodplain elevation: a t~ PROFILE DESCRIPTIONS BORING TOTAL DEPTH T GR UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTHIS. ELEVATION OBSERVED EST. HIGHEST_ TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- I 33 oS.3~ rJoN~ >9.33 6.,AC.4-r5 71 8,e- CSI LP, B- z C.6 rozts4 40 i >6.67 A'9LI-TS /Z"2e,4M5,E6,19"8RNcs G B..''~. .L7 tdS.69 0 ~.~7 /6"$c5t►s ~Sffi" ,~GS~G~ ~~ob B-4 &Az Ss~ No a.4Z / "Q«TS 63~~a~r~tS~FL.Q Z~}"$QNCS lG~ B- S ~z7~ t~9,s4- > iZ ?S ""$~scn 3g""Q+eN►"~s~G>~ /0l~N~s~ R l B- PERCOLATION TESTS j C_ rT TEST DEPTH WATER IN HOLE TEST TIME DROP N WAT R LEVEL-INCHES RATE MINUTES NUMBER 1 S AFTERSWELLING INTERVAL-MIN. PERIOD t P RI D PERIOD PER INCH P_ ro9so > 2 > > ? < 3 p_ Z 4.rU ~.8~ > > 2 > t3 P- 7 dd N~ IuS•~0 3 > 7. > > <3 P- P_ - r1T ► o>J AT RC- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori. zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION Ibs+ 3~ I i i QpT 30 B e , 3 ( i i t I, the undersigned, hereby certify that a soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data r corded and the location of the tests are correct to the best of my knowledge and belief. NAME print : TESTS WERE COMP ETED ON: Ak'4 JOHN sav .~ON SoN Sub del/NG S 9 d ADDRESS: 11 CERTIFICATION NUMBER: IP ONE NUMBER (optional): 467 SEcoN ~ Flo dso*j VI SgC' 16 3AZ-4 CST SI ATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHA-SBD-6395 (R. 10/83) - OVER - .7 lz-- v u v wv u. vT r A "a i A L GATED IN PART OF THE NWI/4'OF THE NEI/4, PART OF THE SWI/4 OF THE NEI/4 AND PART . THE SEI/4, ALL IN SECTION 29, T29N, R19W, TOWN OF HUDSON, ST. CROIX COUNTY, WISCC -6 'CORN-tq .:T}ON 29 ' )M, R 19 W L-•- COUNTY SURVEYOR CORNER T7cs$ C. T H. s LEI' R r A N89•I5•22•E 393.88• :99.66 66.00' :3o.od -T- B cou f OI I d' 21 N OI I O e7. 122 $o. rT. 22 2.00 ACRES g g o `i f~,RTjF1E0 SURVEY MAP IN V04uME 7, PAGE 1937 nR g !1,993 30. /T. c, • I 2.11 ACRES ♦ Q I ALL i v JI 1• 2 h W I I I Ft" 9 R•1•ra' •W frr 299.32' , 4, i LOT S I LOT 1 y w i w •1' NB9•IS•22*E 611.98' 230.00' 70.00 $66.00• 104.00 271.90• • 20 -466.00'_ -)7l.f6'- r w 2 , 07.120 SO. /T. I 7~ „ g 2.00 ACRES 8 • 2Z8.20 e 23 2T13.:e ere C' •9,137 so. FT. I" Ad"" 0 2.00 ACRE) ' C • Z 389'IV22'W C.e111tl3d 1Dis 296.7 300.00• 166.od 27 ^ Dep6Amenl 192. 710 30. IT. ti N O °,A2 ACRES W tl T N A in R tl . A zl N rw.r 19 8, 24 MOTE, ANY Sulu o• « R WATER 1 67,123 SO. IT. 1 w Hi 07.121 s0. /T. : ' ; 2.00 ACRES 2.00 ACRES O i•~ . 0: O n 6 • N se9•y'2YW w 2!6.21 300.00* 1 x 26 N.9• e•3e ,ni w n _ 16i.H0 $O. /T. p~•=j 01 - zl 3.92 ACRES Q1 ° JI 7 « es.os718so. rr. 1 ® 25 " w 01 2.03 ACRES 100.37! SO. /T. 2.30 ACRES ~CJ32;M. F-1 ~L 8 1 m / co a1 a Nee•xe'oo' ' ® m z1 O- 346.22' / N 1 V _ o Vlr ' '1r;/sJ Y7, 112 Se. .T. • u •\'JC j J. °,E~ Q 2.01 ACRES : .T cr W, J ~•w _ • N N J6 • 17 a7a.so ~ NS9!!• 17~W z • • 6 i~ 29.7 O f 150,699 30. /T. • Q g z 3.66 ACRES 16 112.953 s0. /T. O` 29 39 ACRES • \ w . 0, !el 30. FT rtli 2. 1 ACRES N • \ 7.6.79' 770.93' 399.13'2Yw 617. N' / 241.64, • LO / \ - SECT \ 03:.619 $0. /T. : •...._.__.....J ' 3.11 ACRES « w W r• . • 8 0 $ OUTLOT i ARCA N 1 9 776 $0. • 299.339 $0. ff. 2. S QV 6.07 ACRES OR 04-At AREA 1 • WATER ORAIMACE Lle9.1s 27 2!0.00' f1' EOYN -596.03•-~ { CYNIC 6009 D 0 N • V •W 1C 90~_ 589.13• . 300.09'2 st.al• :y $ . 2 a.o7' . r AREA ' ~ LOT WATER o Im 14 w J?• 120.336 $0. Ft RgaSSING p 2.76 ACRES 31 Irl s ' 6 S. r S o7 . / . 6 117.0ty so Ff. r" Is 2.02 ACRES LOT 13 6'•91 It d J 1RNER STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER _E9E*4-r F SoNJh M J041' l ROUTE/BOX NUMBER -F_oSS! rJ CT's Visa ~ ~n FIRE NO. CITY/STATE,LLJ_::~O/j l1V ZIP J, PROPERTY LOCATION: 1/4 N& 1/4, Section TJ-9 N, R L 9 W, Town of St. Croix County, -Ai Subdivision jV561 lb 0--TO tEW , 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/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. ILL/ (r- S I G N E D DATE 25 9o ~a 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 - 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 '5?-Ei1"T E. t SokUA 0- 30+4N1S0t.4 Location of property W 1/4 WE 1/4, Section ~-9 , T 2 9 N-R 19 W 1 ' Township AN uve~tA Mailing address _Ro. Boy, 445 NA'nANkoKD w% 54015 Address of site M0 4;Zyoee-6 YE.T' Subdivision name ?-DSStk.1V COL_04-MY VIEW MD6t-rior,1. # 30 Lot number Previous owner of property JP`s ~~~-~fZ Total size of parcel 2 0 2 Q~-GEES Date parcel was created 317-189 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? Yes No Volume -71 and Page Number 3(v_7 as recorded with the Register of Deeds. I 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. _45 B e ?1 ; 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 duI recorded in the Office of the County Register of Deeds, as Document No. Signature of Mier Signatur of Co-Owner (I Applicab e) 9 i5/y Wa5/R' 6 Date of Signature Date of Signature I tifr1l I•; PAR UI•' 11•I8U0NSIN FUJUI 1 -1992] 1`r„• erwr-e ne.rnvrn 1`0111 eeeo111onvo DATA • I WARRANTY DEED 458871 S"11 -1`36'7 This Deed, made between ...5 E. Miller a sin .C ers n REGISTER G OFFICE ST. CRoix CO., WI _ Reed for Record Grantor, it MAY 2 410 ana Brent .E.,_.Johnson.,and. Sonja M.. liall,..individuals as. 9 11:00 joint tenants r Grantee, _ liftghl* DNS II Witnesseth, That the raid Grantor, for a valuable consideration j I conveys to Grantee the following described real estate in St.. CTOiX, nclunN ;o County. State of Wisconsin: Lot 30, Rossings Country View First Addition to the Tax Parcel No: ~I Town of Hudson, St. Croix County, Wisconsin. i~ i s app I. FM !I II I I i ' This .J.S.-Mt......... homestead property. fp~t) (is not) Together with all and singular the hereditaments and nppurtemaices theteunto belonging; And........ grantor-,.. yam. E.. Miller warrants that the title is good, indefeasible in fee simple and free will clear of encumhrames except II easements, covenants and restrictions of record, if any, and will warrant and defend the same. Dated this 23rd day of MaV Ifl9O (SEAL) I1 11 I e (SEAL) Sain C. Miller li (SEAT.) I - (SEAL) ~I i AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF Wl-~CONSIN ! ss. St. Croix (minty. ruthenticated this day of. 19 I' r~,nnlly •;on( 'wfor^ me this ?3rd. day of Mil)' Itt9O the above named Sarn E. Mi 1 ler ii TITLE: NIENIBER STATE RA It tte « (If not, . t authorized by ; nr,.or; fy y ' r<nn ut.n executed the insh-un, ul krwtvt1. cntyo. THIS I!J 71.1 V- ':7 T f TEYWOOD and ' CART ii. by Samuel R. Ca r i P.O. BOX 229, • t T~Intnrn K. lhidson, W4 S 1i 1ti I.. Lr St , Croix (Sienntnre, may h,, :rill, tCia. ! nwi;n-11•,1.,,1 1t"11- 't1` oxnn'nti•~, :Ire tint nee,..;,.:1, , int. 12-22 91 . V.nl- -f w r. - • v „ , . . WARRANTY DZED SIAl F. It,%It 01 ee t,, u•, FORM \o. I - y