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Parcel #: 020-1187-30-000 11/28/2005 05:07 PM
PAGE 1 OF 1
Alt. Parcel M 28.29.19.1175 020-TOWN OF HUDSON
Current ,X] ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type
00 0
Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner
O-EAGLE STORAGE LLC
EAGLE STORAGE LLC
589 LENERTZ ST
HUDSON WI 54016
Districts: SC=School SP=Special Property Address(es): `=Primary
Type Dist# Description *589 LENERTZ ST
SC 2611 SCH D OF HUDSON
SP 1700 WITC
Legal Description: Acres: 3.297 Plat: 2159-LENERTZ ADDITION
SEC 28 T29N R19W NE SE LOT 3 LENERTZ Block/Condo Bldg: LOT 3
ADDITION 3.297ACRES
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
28-29N-19W
Notes: Parcel History:
Date Doc# Vol/Page Type
09/19/2003 740608 2414/424 WD
11/16/2000 633876 1560/233 WD
07/23/1997 998/97 WD
07/23/1997 935/541
more...
2005 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/25/2005
Description Class Acres Land Improve Total State Reason
COMMERCIAL G2 3.297 126,300 578,500 704,800 NO 05
Totals for 2005:
General Property 3.297 126,300 578,500 704,800
Woodland 0.000 0 0
Totals for 2004:
General Property 3.297 123,000 435,900 558,900
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch#:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
DEPARJrMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS
ON
I
LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS BUREAU OF PLUMB DIVISING
P.O.BOX 7969
MADISON,WI 53707
NE%,SE%,S28,T29N-R19W XXCONVENTIONAL ❑ALTERNATIVE (If assigned)DNumber
Town db Hud6Gn ❑Holding Tank ❑In-Ground Pressure ❑Mound S88-03345
Lot 3 Lenettz Addition
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER: INSPECTION DATE:
Bob Lenetc tz Route 1 Hud6on, W1 54016 R_4�0 -EJ1
BENCH MARK(Permanent reference point)DESCRIBE IF DIFFERENT FROM PLAN. REF.PT.ELEV.: JU51 REF.PT.ELEV.
Name of Plumber: MP/MPRSW No.: County'. Sanitary Permit Number:
GIiUiam Schumahen 6382 St. Ctoix 112745
SEPTIC TANK/HOLDING TANK:
MANUFACTURER. LIQUID CAPACITY TANK INLET ELEV.'. TANK OUTLET ELEV_ WARNING LABEL LOCKING COVER
PROVIDED: PROVIDED.
DYES ❑NO OYES FIND
BEDDING'. VENT DIA.. VENT MATE.: HIGH WATER NUMBER OF RDAD'. PROPERTY WELL. BUILDING.IVE NT TO FRESH
ALARM FEET FROM LINE: AIR INLET
DYES ONO
OYES ❑NO NEAREST
DOSING CHAMBER:
MANUFACTURER JBIDDING LIQUID CAPACITY PUMP MODE L. PUMP/SIPHON MANUFACTURER WARNING LABEL IL OCKING COVER
PROVIDED: PROVIDED:
DYES ONO ❑YES ❑NO DYES ONO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL'. NUMBER OF PROPERTY WELL BUILDING V
(DIFFERENCE BETWEEN FEET FROM LINE AIR INLET
PUMP ON AND OFF) DYES 0 N NEAREST
SOIL ABSORPTION SYSTEM.Check the soil moisture at the depth of plowing LENGTH DIAMETER 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:
BED/TRENCH WIDTH LENGTH TRENCHES DISTR PIPE SPACING COVER PIT INSIDE D -PITS JLICIUI�D
I
DIMENSIONS
GRAVEL DEPTH FILL DEPTH JDIITR PIPF DISTR.PIPE DISTR.PIPE MATERIAL. NO.DISTR NUMBER OF PROPERTY WELL BUILDING VENT TOf HESE/
BELOW PIPES ABOVE COVER. ELEV INLET ELEV.END. PIPES FEET FROM LINE AIR INLET
NEAREST go
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.
❑YES ❑NO
SOIL COVER TEXTURE PERMANENT MARKERS IOIISIHVATIIIN WE 11
I
DYES El NO DYES NO
DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED
CENTER EDGES
❑YES El DYES ONO OYES 1:1 NO
PRESSURIZED DISTRIBUTION SYSTEM:
WIDTH. LENGTH. NO.OF LATERAL SPACING. GRAVEL DEPTH BELOW PIPE. FILL DEPTH ABOVE COVE
BED/TRENCH TRENCHES.
DIMENSIONS
MANIFOLD PUMP MANIFOLD DISTR.PIPE MANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATERIAL&MARKING
ELEV.' ELEV.. DIA.'. ELEV.' PIPES DIA.:
' ELEVATION AND 11
DISTRIBUTION
INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED
DYES ONO El YES ONO
COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL: BUILDING'
FEET FROM LINE
DYES ONO DYES ONO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE. TITLE.
DILHR SBD 6710(R.01/82) Zoning Adminizttatotc i
DIL R SANITARY PERMIT APPLICATION COU
In accord with ILHR 83.05,Wis.Adm.Code
�. ....�..o. STATE SANITARY PERMIT#
la '*-745
-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.
-See reverse side for instructions for completing this application. PETITION
1. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑YES 59 NO
PROPERTY OWNER PROPERTY LOCATION
dl 12 A 59 111117-1 '/aSG%'/4, S T , N, R E (Or)
&
PROPERTY OWNER'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
C 1Y/,STATE ZIP CODE PHONE NUMBER CITY NEAREST ROAD,LAKE OR LANDMARK
i�b 45o,l .� Glc6 VILLAGE: // S TOWN OR
II. TYPE OF BUILDING OR USE SERVED: l�S
Number of Bedrooms if 1 or 2 Family OR ❑ Public(Specify): sr ru .g � a
III. PURPOSE OF APPLICATION: (Check only one in#1. Check##2,3 or 4,if applicable)
1. a.;K[New b. ❑ 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.
i�
IV. TYPE OF SYSTEM: (Check only one in##1 and only one in##2)
1. a. KConventional b. ❑Alternative C. ❑ Experimental
2. a. ❑System- b. ❑ 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. ❑
-Seep a e Pit
2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY:
(Minutes per inch): REQUIRED(Square Feet): PROPOSED(Square Feet):
el 9 j l'l s �� t< Feet &Private ❑Joint ❑ Public
VI. TANK CAPACITY Site
in qallons 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 ❑ ❑ ❑ El ❑ ❑
Lift Pump Tank/Siphon Chamber
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) &OMPRSW No.: Business Phone Number:
SGti w C lc� — 51 l l
Plumber's Address(Street,City,State,Zip Code): Name of Designer:
5, s �4afG
Vlll. SOIL TEST INFORMATION
Certified Soil Tester(CST)Name CST#
e v
CST's-ADDRESS(Street,City,State,Zi ode) Phone Number:
IX. COUNTY/DEPARTMENT USE ONLY
❑ Disapproved nitary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps)
'ER Approved ❑ Owner Given Initial j^�� C�� rcharge Fee
Adverse Determination ` pj�h/) •
X. COMMENTS/REASONS FOR DISAPPROVAL:
SBD-6398(formerly Plb-67)(R.03/86) DISTRIBUTION: Original to County,One Copy To:Bureau of Plumbing,Owner,Plumber
INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY PERMIT '
APPLICATION r. . ._
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 property 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:
I. Property owner's name and mailing address. Provide the legal description where the system is to be
installed;
II. 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;
III. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or
repair;
IV. 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'% 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.
_ s
GROUNDWATER SURCHARGE
T_
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 Groundtt_`=
included the creation of surcharges (fees) for a number of regulated practices which Wisco in!
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried recESut
is used in your building is returned to the groundwater through your soil absorption u
system or the disposal site used by your holding tank pumper.
a
The monies collected through these surcharges are credited to the groundwater fund adminis-
tered by the Department of Natural Resources. These funds are used for monitoring ground- t
water, groundwater contamination investigations and establishment of standards. Groundwater,
it's worth protecting.
SBD-6398(R.03/86)
T--)flvGS 0 F
S88 "* 03345
,,-ESE J/ C.F SE--t -C%T,-! --"jz
rT, r (Z op )IT7, r"
Ty, VISCONSIN.
rC
PAGE I OF 4 TITLE S=ET
PA GE 2 OF L PROJECT DATA
PAGE.. 3 OF 4 PLCT PLAN
rAG- PLAN V CROSIEW- S SECT-0-
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PTIPAFID FOP: AUG 15 1988
i to OF F 1,C,E 0,F D,1 V,Sil 0 N
CODES A1,40 APPUGA'11-110','l
ISO
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Not
Nsc 0
ARTHUR L
wEGERER
1).915 P
MLSWORTH,
W wrs.
,GE,RER, WEBER AFT ASSOCIATES
STRUT BOX 74 421 N. MjJF STR�-- %
FIVEH FALLS, WISSCOESHf 54 022 %. ........
3
S88 - 0334
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otJ � �hPW�E�s C��vD Z �LLIOCZ �C�.A/1US•
S EPT? C 'TR1.1 tc
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PLOT PLAN
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888 - 03345
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N OTES
• 'ZY8,1p
1. Elevations shown are existing ground elevations un ss otherwise noted.
2 . Install cast iron pipe 3t onto undisturbed soil both sides of empla tank.
3 , - -
4. Install 4" T' -' pipe with approved cap. ( 1 required)
5 . Septic tank to be v000 gallon capacity as manufactured by
F6. -ench Nark- Elevation w��+I- �7. tuo.0' au Tefl aF v! ?��RGi�u�,�,b." L7E_Mts— :L
888 -, 03345
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GGREGA
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_ �. °> 0N
DEPARTMENT O,F REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INpUSTRY, DIVISION
LABOR AND PERCOLATION TESTS (115) MADISON WI 3707
HUMAN RELATIONS
(H63.09I1)&Chapter 145.0451
LOCATION::�� N OT NO.•BLK.NO.]sTalloorz
DIVISION NAM
NI- / �T� N/V E(or N -- a
COUNTY W E 'S AM •
L,-f C+ROIx t:NCp
USE DATES OBSERVATIONS MADE
B CO M ON: ISRO ESCRIPTIONS:p Ogg
b — STbRdf,G K kr New [:]Replace AUNC 1 l�� uL� '
RATING:S-Site suitable for system Us Site unsuitable for system
rZS O Q . MQ Q� IN � �� . S � 1❑�L Q�G TANK:RECOMMENDED SYSTEMaoptiOnal)
[rte, If(7QS7Jf1Vi ION V E4,4T ION A L 1Ll
if Percolation
its ere NOT required DESIGN RATE: If any portion of the tested area is in the •
under s.HB3.09151(b),indicate: C LAS A
S Fioodplain,indicate Floodplain elevation:
.L PROFILE DESCRIPTIONS
BORING AL P T R D ATER-INCHES CHARACTER OF SOIL WITH HI KN SS,COLOR,TEXTURE,AND DEPTH
NUMBER 0, ELEVATION OB ERV D ST.HIG TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
B- I o,91 5a >�0 9� "�c st;s ''ge.,,S-t4R U "-Ir f S
B- 11b,12 90,71, >/0- 17 Z4„gLs�TS >t+ �te,, 1hS t4`8k (_S f4*
B- '>/0-0 i6„ as 16'1 9k,4'5L W ke v MS*4w, W'&Q
6N� /�.SIS
B- S x,00 I ,b a fqwqk 11.66 ,g��T�. l4"gQN MS,: GR 7e Ms
B-
�� PERCOLATION TESTS
TEST DEPTH WATER IN HOLE TEST TIME S FIXTE MINUTES
NUMBER
lNeOSS aAFTER IN INTERVA L-MIN. PER INCH
P- 5, ry `�O Z �P. Z •zo ab P- =7A 7
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 SO 6� N p,fzr, WNa
PE4�srl4L- 6 .iry lob-DO
•�•3 � 53 5z:
� L
A g PEEEIVEP
1,the undersigned,hereby certify that the soil tests reported on this form were made me in accord with the procedures.and meth6s spa c�fi�i�`fft!'`Wisconsi n
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^^J- —� _—! ��— _~TESTS WERE C 77
YEY Jo>aryS tv �y, ��u?✓ 'C�N�t Iry Luc Y 1 r9�S�
ADDRESS: I WCERTIFICATION NUMBER: PHONE NUMB E R(opt ional):
X38,23 A CST S NATURE;
DISTRIBUTION:01iliinal and mw copy to I.ocal Authoiuy,Prop«rtY Owner mul Soil Tester.
:'m_HR•SRD 6395 4R,02/82) OVER
J
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY& BUILDINGS
INDUSTRY, DIVISION
LABOR , PERCOLATION TESTS (115) MADISON WI 53707
HUMAN RELATIONS
(1463,080)&Chapter 146.045)
To
UNICIPALITY: OT NO. LK. : SUBDIVI A
NE t/4S1� IT� N/R19 Etor �SaN -' LfiN3t 2 ihu
COUNTY: (OWNER-518
lr W tE
c
S-s C06
USE DATES OBSERVATIONS MADE
C N New ❑Replace
•
ISMqu.'L Z;;1 .tr Suf�E 30 ��g DESCRIPTIONS: c,4lif 1 41996
Sots totx H4 66 so►4s - Z)08-I�AKO-rA
RATING:S-Site suitable for system U-Site unsuitable for system
V Nom: M UND: 1(V-G -I -F LL OLDI G TA K:RECOMMENDED SYSTEM.(optional)
` s ou s ❑u sou s u OS OU �oNvT►oN A�
H Percolation Tests ere NOT required DESIGN RATE: rFloodplain,any portion of the tested area is in the
under s,H63.09(5)(b),indicate: C Llt1$s indicate Floodplain elevation: 4A
PROFILE DESCRIPTIONS
BORING AL B E V C ER SOIL WITH THICKNESS,COLOR,TEXTURE,AND DEPTH
NUMBER tS, ELEVATION
D TO BEDROCK IF OBSERVED(SEE ABBRV.ON BACK.)
B- p,91 ;6 >/o•9'Z z9"�� s�►-� c)''&ejSt4p R3
B-
lb-1-7 90-71 Now C, >/0. 1'7 ' 4A"tlLSLTS "tej PSIS M„g►e (_s14*
B- �b,i� X7.014 0
B=� p.SO �b.33 oN� /o,St5 3�" (f_i f$E$''g�eriNtS
B- S J,od �? p� 6ry 1106 (3��T� !9"g RN MSS laR 7$'' MS
B-
�� PERCOLATION TESTS
TEST DEPT WATER IN HOLE TEST TIME S T MINUTES
NUMBER 1, S AFTERS ELLING INTERVAL-MIN. PERIOD 1 PFRIOD2 PIERIDD 3 PER INCH
P_ Z 6.2.0 '). I
P. 3 o►JE q:Zp >
P- Y LL A -F 't,T S
a
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 Pi ft�ou14
&N"1V1-AoL- jai" QV' At)NAkilt
tP 4 rib
LOT tN
� 4
4&
�c��
J w
1,the undersigned,hereby certify that the soil tests reported on this form were made 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): V TESTS WERE COMPLETED ON:
�ARYE'f JUL%( /
ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER(optional):
a7 cis h 1, do ) SQor �4 0�0
CST S ATURE:
DISTRIBUTION:0,i1►inal and one covy to Local Authotay,Property Owner;trtd Snil Tesler.
f1Il..HR-SI3D-6395(R.02/82) OVER
1
I
STC - 105
SEPTIC TANK MAINTENANCE AGREEMENT
St. Croix County
OWNER/BUYER (&0 �0 &`°t�
ROUTE/BOX NUMBER� FIRE NO. �y
CITY/STATE i(/,( �D}�'i� ZIP
PROPERTY LOCATION: /L' 1/4 S � 1/4, Section , T v� _'N, R Z9 W,
Town of , St. Croix County,
Subdivision _, Lot No. 2
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.
SIGNED
DATE 71, L?z
St. Croix County Zoning Office
St. Croix County Courthouse
911 4th Street
Hudson, WI 54016 r
(715) 386-4680
Sign, Date, and Return to above address
APPLICATION FOR SANITARY PERMIT
S T C - 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
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ec
owner/contractor, P(s house) then a second form should be retained and
completed w hen the property is sold and submitted to this office with the
appropriate deed recording.
-----------------------��-.�-------/-j-�----------------------------------------------
Owner of property
Location of property N4L 1/4 `T 1/4, Section s , T—a�N-R 1.2
Township j
9
Mailing address �(l
Address of site
Subdivision name
Lot number
Previous owner of property
Total size of parcel
Date parcel was created '7
Are all corners and lot lines identifiable? Yes No
Is this property being developed for resale (spec house)? Yes _ y No
Volume 5 and Page Number 3-3 3 as recorded with the Register of Deeds.
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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.
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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 warrant deed recorded in the Office of
the County Register of Deeds as Document No. r-/ 1 ti,5'S ; 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 duly recorded in the Office
of the Count Regis r of eds, as Document No. ) .
Signature o f wner Signature of Co-Owner (If Applicable)
t7 <
/ '�?Ole.
Date of Signa ure Date of Signature