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HomeMy WebLinkAbout002-1083-30-000 ry o (D °o o ti p v3 o W ^� a � � I H � I N _ it C 0 cc I L Ma 111 y i N N C � V N U C a z c m °. o c �+ E CD o O E a z U ^ m M I \ 'a 1 c3o Z w c CD w C.,, w a m M H Z z o z t ... 0 m r E 1 NN� LL O 2 Z Z O E d �i a �a O C,4 y m o Q z a = •N aaa �1 a v co CD 3 0 N f0 rn rn Z lA U m o v n ro O C) ° M V z cn Z j t O H C rO O 'o 3 c C_ ` l M O v O aMD fr C N O N N N '30 m N - v f0 L N O •O oo M O w a • o d .� dam c °' DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O.BOX 7969 BUREAU OF PLUMBING MADISON,WI 53707 NF4-jNW4-,S33,T29N-R16W El CONVENTIONAL ;ALTERNATIVE IS,,,,f ass Plan 1, D Number. Town o6 Batdwin [ }-Holding Tank ❑In-Ground Pressure ❑Mound S88-01815 HWV 12 NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: RobW ChambeAti.n I Route 1, Batdwin, W1 54002 BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber: JMPIMPRSW No.: Co—V: San.wv Permit Number: Date B. Hudson 6629 St. Cxoix 112707 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY. TANK INLET ELEV.: TANK OUTLET ELEV.. WARNING LABEL [DYES OCKING COVER PROVIDED. ROVIDED. DYES ONO ONO BEDDING: VENT DIA.: VENT MATL. HIGH WATER NUMBER OF ROAD' PROPERTY WELL. BU IL DING. JVENTTOFRESH ALARM. FEET FROM LINE. AIR INLET DYES ONO DYES ONO NEAREST DOSING CHAMBER: MANUFACTURER JBIDDING LIQUID CAPACITY JPUMI MODEL. PUMP/SIPHON MANUFACTURER WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. DYES ❑NO ❑YES ONO DYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF IPROPERTY WELL BUILDING JVENTT3FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) DYES ONO NEAREST SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH IDIAMITEH MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire,construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH. LENGTH NO OF DISTR.PIPE SPACING COVER =NSID1 DIA tPIiS LIOUIU BED/TRENCH TRENCHES MATERIAL DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH IDISTR PIPF DISTR.PIPE DISTR.PIPE MATERIAL. NO.DISTR. NUMBER OF PROPERTY WELL BUILDING VENT TO FHES/1 8E LOW PIPES ABOVE COVER. ELEV.INLET ELEV.END'. PIPES FEET FROM LI NE AIR INLET NEAREST-i MOUND SYSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE.SHOW ELEVA- meets the criteria for medium sand. TIONS MEASURED. DYES ❑NO SOIL COVER TEXTURE PERMANENT MARKERS JOBSIRVATION WELLS 1:1 YES ONO DYES ONO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES. DYES ❑NO DYES ONO ❑YES ONO PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH WIDTH LENGTH NO.OF LATERAL SPACING GRAVEL DEPTH BELOW PIT PF FILL DEPTH ABOVE COVER TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR.PIPE MNO DISTR DISTR.PIPE DISTHIBO T ION PIPE MATERIAL&MARKINi ELEV.. ELEV.. DIA.. ELEV.. PIPES DI AELEVATION ANO DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY ERIAL VERTICAL LIFT CORRESPONDS TO APPROVED PLANS ❑YES ONO 1:1 YES NO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OM PROP M PROPERTY WELL: BUILDING. FEET FR ❑YES ❑NO ❑YES ❑NO NEAREST Sketch System on Retain in county file for audit. Reverse Side. 777R E. TITLE. DILHR SBD 6710(R.01/82) Zoning A&nin ztAatox r — SANITARY PERMIT APPLICATION COUNTY ,D1LHRR In accord with ILHR 83.05,Wis.Adm. Code -� L'�o�.1' '�'°^'" '°" STATE SANITARY PERMIT# —Attach complete plans(to the county copy only)for the system,on paper not less than STATE PLAN I.D.NUMBER 8'/x 11 inches in size. sk?_01TIS —See reverse side for instructions for completing this application. PETITION I. APPLICANT INFORMATION—PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES ® NO PROPERTY OWNE PROPERTY LOCATION /1?0 r' �/�Q/�?/���''!s ,--%. /4, s33 T2g, N, R / I[ (or W PROPERTY OWNER'S MAILING ADDRESS LOT NU ER BLOCK NUMBER SUBDIVISION NAME AIX CITY,STATE ZIP CODE PHONE NUMBER 0 CITY .301 NEAREST ROAD,LAKE OR LANDMARK Cl w/'/I L(Ji♦ Q 7/S' 681� �i9 VILLAGE: Z01/ 7 /, Wa �Z II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family —3 OR ❑ Public(Specify): bV III. PURPOSE OF APPLICATION: (Check only one in##1. Check¢#2,3 or 4,if applicable) 1. a. ❑ New b.4'J Replacement c. ❑ Replacement of d.❑ Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit¢# Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in##1 and only one in##2) 1. a. ❑Conventional b.Z Alternative C. ❑ Experimental 2. a. ❑System- b.JX Holding c.❑ Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) 1. a. ❑ seepage Bed b. ❑Seepage Trench c.IC SepAge Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ORPT AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes per inch): REQUIRED(Square Feet): OSE are Feet): Feet Private ❑Joint ❑ Public VI. TANK CAPACITY Site in gallons Total ##of Manufacturer's Name Prefab. Con- Steel Fiber- Plastic Exper. INFORMATION New xisting Gallons Tanks Concrete structed glass App. Tanks Tanks Septic Tank or Holding Tank 2000 ,Z000 ' j Lift Pump Tank/Siphon Chamber 1 ❑ 1 ❑ I ❑ ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. Plumber's Name(Print): Plumber's Signature:(No Stamps) MP/MPRSW No.: Business Phone Number: Plumber's Address(Street,City,State,Zip Code): Name of Designer: F20 144a/l) S7` VIII. SOIL TEST INFORMATION Certified Soil Tester(CST)Name CST# �Qr>✓ � S'O!7 CST's ADDRESS(Street,City,State,Zip Code) Phone Number: Rx" / Box / /- Z. ol IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Iss'King Agent Signature(No Stamps) E�Approved ❑ Owner Given Initial S ar a Fee Adverse Determination X. C MMENTS/REASONS FOR DISAPPROVAL: fay 6Aonvid SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber 3 INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT APPLICATION TO THE APPLICANT: 1. This 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 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 where the system is to be installed: I:. Type of building or use served: if public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; 111. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; 1V. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: Certified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. Complete plans and specifications not smaller than 8'/2 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; dosing or pumping chambers; 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. -------------------------------------------------------------------------------------------------------------------`----------------------------------------- GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Groundviater included the creation of surcharges (tees) for a number of regulated practices which WisCO [C3'a can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried r6.' ute is used in your building is returned tc the g undwate.- through your soil absorption o system or the disposal site used by your holding tank pumper. 0 The monies coilectec through these s-ircharges are credited to the groundwater fund adminis- rc:red by the Department of Natural R:^sources. These funds are used for monitoring ground- t grourldwmer contaminatio,i irr,astigations and establishment o standards. GroUndwat=r; r s b:�rtl� protecting. :' ,03;8B) INDLrSRTME OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS INDUSTRY,- DIVISION LABOR AND PERCOLATION TESTS ( P.O. BOX 7969 ;HUMAN RELATIONS \ MADISON,WI 53707 pp (H63.09(1) & Chapter 145.045) LOCATION: SECTION:/1/E t��� 33 /T2gN/11�lj�(or TO��HIP �/�ALITY: LOT NO.:BLK.NO.: SUBDIVISION NAME: COUNTY: OWNER'S BUYER'S NAME: MAILING ADDRESS: A S • Cf'n ' e r� Z? USE ATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: P—R-0_FI Ele D E S C RIP I NS: A I ESTS: [Residence ^ ❑New Replace / _ f �_ �7 RATING:S=Site suitable for system U=Site unsuitable for system Co 4, / CONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-IN-FILLHOLDING TANK:RECOMMENDED YSTEM:(optional) ❑S ©U ❑S ®U ❑S ®U ❑S MU I ®S ❑U I 6 . i If Percolation Tests are NOT required DESIGN RATE: 4 If any portion of the tested area is in the under s.H63.09(5)(b),indicate: I Floodplain,indicate Floodplain elevation: AIX PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST.HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV.ON BACK.) /Y In P /770 lo B-2 ' 10 . o46 of �d 9''3151" ., If "ZZ„�s o B-3 y D / , ryl/� P mo S' ' 27'7f5,c� B- '6/7 �y'z� /I��r e of P'� ' ` /3'' , >� Z3ns�I 37 Z5 c B- 5 3'92 3 Mon e, B- / Y-09 924e Alon e mn -:F- -5.. IS/1- 8hs,l 30"ecSC PERCOLATION TEST TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD 2 PERIOD 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- 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 _ I N I I 1 1 I 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(print): TESTS WERE COMPLETED ON: -Da/e . ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional): CST SI NATURE: 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 incluiie: . 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence'or commercial project; 1 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 o/riting 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; 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 exemp- tion,if appropriate; 10. If the information (such as flood plain,elevation)does riot apply, place N.A.in the appropriate box; 11. 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") BR — Bedrock cob Cobble (3- 10") SS — Sandstone gr — Gravel (under 3") LS — Limestone *s — Sand HGW — High Groundwater cs - Coarse Sand Perc - Percolation Rate med s — Medium Sand W — Well fs Fine Sand Bldg — Building Is — Loamy Sand > --- Greater Than *sl -- Sandy Loam < - Less Than *1 — Loam Bn - Brown *sil — Silt Loam BI - Black si — Silt Gy — Gray *cl — Clay Loam Y Yellow scl -- Sandy Clay Loarn R -- Red sicl -- Silty Clay Loam mot - Mottles sc Sandy Clay w1 - with sic — Silty Clay fff few, fine,faint *c Clay cc - common, coarse pi Peat snni - Many, medium rn — Muck d — distinct p _ prominent. HWL - High water level, Six general soil textures surface water for liquid waste disposal BM — Bench Mark :r VRP - Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary perinit. The county or the Department may request verification of this soil test in the field orior to permit i:!;suancre. A complete set of plans for the private sewage system and a permit application must be suhmitted to the appropriate local authority.in order to obtain a permit. The sanitary permit musi- be �mtaow l ,nd posted prior to the start of any construction. Sea, 33 - �wnCr; 0 • 3ald`v��, GJ,'r .5'y�oo2 N°' NEy NWT Tz9N CJe I� Carole 73arn n' E---57 -� ' H BZ pd rllo i �.M• -/p0.0� 3l0 l3/.- 97,E arM. 1-lou se '� 83 4 7�, By_ 9#7 0 2- 000 G'ol. A1,4M 25-m:n.Prom �tJ 92.98 4d,'iA i n /® �ee�- w.no%&J or- o%or� o-F -?,a-17 Ks. 83 a 3' 5y b of f'om of s�'D��'»q ail; a3' � 3 A10. pNSiTE SEWAGE S S M `f 7' 09 APPROVED DEPARTMENT OF INDUSTRY. LAQOR AWD iUMAM RELATIONS No i.Q A _ IYISiO �QF SAFETY AND� ING5 By SEE CORRESF'O _ CE Qc.�. f✓uc�ae-,•- I OsT 3411.3 /�iivay /Z ST. CROIX COUNTY �rj WISCONSIN ; ZONING OFFICE 796-2239 (HAMMOND) { 425-8363 (RIVER FALLS) HAMMOND, WI 54015 June 30, 1987 State of Wisconsin, DILHR Bureau of Plumbing p.0. Box 7969 Madison, WI 53707 Dear Sir: An onsite investigation of the soils was conducted on the Robert Chamberlin property located in the NE 1/4 of the NW 1/4 of Section 33, T29N-R16W, Town of Baldwin, St. Croix County. The inspection verified that the soils were suitable to a depth of five inches. This site should be suitable for a holding tank. Should you have any questions, please feel free to contact this office. Sincerely, Thomas C. Nelson Zoning Administrator TCN:rmc Sec. 33 ' m4. s; goberf Chom,b lI'� A0. 3Q0 • NEy NWT Lj Tz9N R a,-age Barn 57 .---� 761 36 If B2 -/ohp.-Ir 1pst• 83 � 7(v' Douse 1 B-q 9y;ZS' o z-i000 a /�lo/d,r,C! Tan s J 9. .79 1 45 _ —T Sar Ge RoaOr _ 25'n;n.Prom Fe i f A in /O -red�' 0-p Ks. Big h Mae s �3 0 z� y, sLl b o-ft-om of s/Gj�i»q a 23' /CIO. ONSITE SEWAGE S S M 7 4 �� °yam uAl 0 { AP P RQVD V DEPARTMENT OF INDUSTRY. L UMAN RELATIONS IVISIO ,OF SAFETY AND A�NIDINNGS , BY SEE CORRESPO CE �. �u �e-r•- �,o��Z9 Cs7'34t/3 ,cvay 12- PAGE OF 'Z u� }' t° �\ `� WxawJ OW C) �l K 0 W p a V 7�► yG,, C It � . � &L W a itr � � J W L1.! FX W J F La 0 �? v - � 2 v t' of a W n �. < (� Q 0 W C Li on y. o _ Q ° no v k u � z £ w " r 2 ° Q W.o � o ¢ oA oa °` o yr > o w5 o W � H a x y� �` ah O% H oc oac w o i� o 0 O 2 O �- d K o i- F- �. 1 � Q J• w o � Qi- � . M — t2 ww O 1— O > pG W" p w.� .n of d O .. > Q � .Wt � V •r : rn J a Z h t� • 2,D Et1' cc cc be tj t W O Q C 00 Cf o. ° W LN ¢ �" f C'� x, V p r W Q ,t•' I h TI 7 ' Q .06 A J U £ to 6e t �_ 1 Q v J M u '` cn a A W • It 0Q tOF W �( > 4 o O J 0 :2 0 cC a a W4 Zwa W N ? w T v Y F H oC Lo F' ,� 0 Cl a C) 'D f- d W J < W 7 W = = Q Q N > W p O J , a. a ce O � W > W � x -2 a a'LL N d :2 vV > a pW:LA. ce Li d v,. id 0 CC cc nC F- o Ld p '" _3 h > I �I W o. W rO -d � J T U N _ ix � x y a o c.1 0 W � cc H v W I — .J µ1 0 ' C za W s T _s 0 c \ Cj � R Q J q1 a -� Lj a a X QW H z H ST C - 105 r a ' H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z d OWNER/BUYER C�12azWZe �11 ROUTE/BOX NUMBERf. Fire Number CITY/STATE ZIP PROPERTY LOCATION : NZ— 1 14, Section 33 T N , R /4� W, Town of 3a 1,91,,,4.,'82 , St . Croix County , Subdivision Lot number_,&A-. I 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 after inspection and pumping if nec- essary) , condition and 2 a p p g ( operating ( ) P 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 . Ho E I/WE, the undersigned , have read the above requirements and agree to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- ►d ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning Office w ' thin 30 days of the three year expiration date . SIGNED X 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 . i t 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 inadequaoies 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 2e_d.3.�L Lklf✓'/i ' Location of Property Section _33_, T 9 N - R W Township 30Ut ,��i7 Mailing Address , Subdivision Name N� Lot Number Previous Owner of Property _ - i 1�,�� �1�.��; r,;, �ja !;d"}4� Total Size of Parcel __ _ _fj xc11 e5 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 f and Page Number as recorded with the Register of Deeds INCLUDE WITH THIS APPLICATION ONE OF THE FOLLOWING: 1. Warranty Deed 2. Land Contract 3. • Other recordings filed with the Register of Deeds Office In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing .procese. If the deed description references to a Certified Survey Map, the the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) ee ti.6y that att 6tatement6 on thin 60AIn ane true to the but o6 my (oun) knowledge; that I (we) am (cute) the owneh(a) 06 the pnopeh ty de.6cA bed in thia .tn6onmati,on 6oAm, by vchtue o6 a wahhanty deed neeonded in the 066ice 06 the ..County Re is teA o 6 Deeds as Document No. 0 and that I (we) pneaentty^own the phopoaed a.cte�6on the sewage poa sya.tem (on I (we) have o r.,. a w .. .... r the pN, 6 ..ta-En... = e�,rcr�w���, A0 J-azn WZth .vie above deze/L beQ O o1(. .rhe con,6tAuctfon o6 aai,d 6yatem, and the same has been duty Aeconded in the 066ice 06 the County Reg.i.a.ten. o6 Deeda, as Document No. � 7'"_ ) , x . n SIGNATURE OF OWNER w. SIGNATURE OF CO-OWNER (IF APPLICABLE) f DATE SIGNED DATE SIGNED f y t . { n I TY, i y fi Parcel #: 002-1083-30-000 05/25/2005 03:00 PM PAGE IOF1 Alt. Parcel#: 33.29.16.485A 002-TOWN OF BALDWIN Current X' ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type 00 0 Tax Address: Owner(s): *=Current Owner *CHAMBERLIN, ROBERT A&CONNIE M ROBERT A&CONNIE M CHAMBERLIN 2339 HWY 12 BALDWIN WI 54002 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description *2339 HWY 12 SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 15.000 Plat: N/A-NOT AVAILABLE SEC 33 T29N R1 6W E 1/2 NW N OF OLD RR Block/Condo Bldg: R/W EXC W 215 FT Tract(s): (Sec-Twn-Rng 401/4 1601/4) 33-29N-16W Notes: Parcel History: Date Doc# Vol/Page Type 07/23/1997 886/193 07/23/1997 789/471 07/23/1997 747/386 2004 SUMMARY Bill M Fair Market Value: Assessed with: 42661 Use Value Assessment Valuations: Last Changed: 06/28/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 9,000 47,100 56,100 NO AGRICULTURAL G4 8.600 1,100 0 1,100 NO UNDEVELOPED G5 3.400 1,100 0 1,100 NO PRODUCTIVE FORST LAND G6 1.000 700 0 700 NO Totals for 2004: General Property 15.000 11,900 47,100 59,000 Woodland 0.000 0 0 Totals for 2003: General Property 15.000 13,100 47,100 60,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch#: 510 Specials: User Special Code Category Amount 010-GARBAGE SPECIAL ASSESSMENT 45.00 Special Assessments Special Charges Delinquent Charges Total 45.00 0.00 0.00