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022-1035-90-000
•o 0 O v3 O ots o rn �o owC-M C m o U•- O tp•O N G N N d Cc y N Cm U E E N N O y o N= (D U vai Cc y y is C co vi 0 f0 N CO a, a L N O) �oL € _ 3 c a ° E�- � m I E_ € CD et acv 3 �° o o y C c w t aa� rn �o mo o c r o @�'�cg T a?oo y .€00 L'� m m N cr w _ yNC ni >'94? °�° � O a—y y o Q a j C Z y y 9 Z L y V a N L y U C {L C w N aZS N LL C N C O f0 0 LO 0 o rno 3 0 o m ayin 3,n 3 T� v, y o c 3 v m �M x p N p 0: C N N y N O Q 0 r— o Q O cFOma�o M o z y y a�o E E z •• o = o z � � •`a I � v I coN am I am I 0 0 o z c v r o o o rn z z E v E M Cl) N N O O p^/d1 m N N v=i O Q' • a m = oC t co O O Q z m z z z z N Z I z I •yp .. d N .. GC1 N N is E N io E �o o .. c L• .. E CL d N d N O- O _ N 41 N ~ 0 0 U) G C d n G G a m N ! a� , jr)a 5 Z� LL a a a a a•N a � Z � a °' °' co c fq J U d rn rn z d m rn z U cCl) Cl) N N y N O� Cj v O O = O E v O E Cj j T m y C a 0 0 m C d 0 U) y y O o 00 4) Q fn o GO 0 ?� Q Z fn o I b C li, O 7 aU O O A C f� : f�yA C � °o rn 1 o 0- -2 o E N v I `o v E g o I Q o °' c vd0I m vdmol (D cv � € c or' c°N v �o c`on aT Y CO c m m c 5 N a� c 3 _rn �n N N C E a) S j O` O` C L O N .yo. j C C •�'V N �rj C ', N N O y (0 (0 R U O O O y O O U ^^VOi o Y LL O z _ _ VJ o Z Z Z cn V a_ d M dam � a I :� # •� cam eat rte• ad a m , d c d d c r A ciao ! 0U) ovU) t Parcel #: 022-1035-90-000 01/12/2006 03:57 PM PAGE 1 OF 1 Alt. Parcel M 13.28.18.P199A 022-TOWN OF KINNICKINNIC 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 HAROLD D MORROW O-MORROW, HAROLD D 314 HWY 35 RIVER FALLS WI 54022 Districts: SC=School SP=Special Property Address(es): *=Primary Type Dist# Description -OW -OW SC 4893 SCH D OF RIVER FALLS O SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 33.000 Plat: N/A-NOT AVAILABLE SEC 13 T28N R1 8W SW NW EXC HWY&EXC CSM Block/Condo Bldg: 3/884&EXC CSM 6/1610 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 13-28N-18W Notes: Parcel History: Date Doc# Vol/Page Type 12/17/1998 593935 1387/507 TI 07/23/1997 959/363 07/23/1997 805/149 07/23/1997 766/218 2005 SUMMARY Bill#: Fair Market Value: Assessed with: 143327 Use Value Assessment Valuations: Last Changed: 08/10/2005 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 27.000 1,700 0 1,700 NO AGRICULTURAL FOREST G5M 3.000 7,800 0 7,800 NO OTHER G7 3.000 24,000 108,500 132,500 NO Totals for 2005: General Property 33.000 33,500 108,500 142,000 Woodland 0.000 0 0 Totals for 2004: General Property 33.000 25,700 99,100 124,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 SANITARY SYSTEM REPORT ,TF CSC y� T, ZI�, Ri CR0 -COUNTY W'ISCUNSIR': LOT LOT SIZE PLAN'. J*-- � uw y "U 'yemviM ,ot H6I) e WITHIN. 200 FEET.00,SYSTEM YSTEM T\a�a� tv a4 `f b �r •'�'� ° r� � �''� i € �q�a� (�°'�'. y`��x� .fit �� .�.4�'f'� ' yy#t,� r�cF" (C� �� � yet`�� 4 Ciu � s � >r �rF lv��ll�p '��C 1.� J Sr �,a f r a e r t4 - R# r, zr sal .. .�n p , RCRET& v y PRY WE_� area ares A AS BU%LT. - � et rY it. Croix County does not imply complete T � . 8tl�f��� atz ive +Go ooe: Theme are _other areas that it is not possible 0, con+srtuctipn.`St. Croix County assumes no. liability for f &I iite is .noted the County will make every effort to S as TIIa"Os$?� THROUGH THIS SYSTEM. i t ti �• � w d r � i� .. rs "INSPECTOR r L ER ON JO ,k Y Lx C9N SE NUMBER 1St d��ti 3 � , ,��k�nr+• 4 r, - z ' • REPORT OF INSPECTION INDIVIDUAL SEWAGE SYSTEM • San.izany Penm.i.t � F State Sep.t.ic 2 7ZI NAME Township z u�xc.. S.C. Cno.ix County Loca#.iox �6,) .� Section SEPTIC TANK °�' Size ga.t.tona . Number os Compan.tmentz I Vi4tanee Fnom: We.t.t #. 12% on gnea.tea e.tope 6# Bu•i..td.ing 6t. W e.t.tands 6t. Highwaten - ix. s DISPOSAL SYSTEM D.iatanee Fnom: We.t.t 12% on gnea.teA a.tope 6#. Bu.i.td.ing it. W et.tand.a Ft. • H.ighwatea it. FIELD DIMENSIONS: W.idxh o6 trench it. Depth o6 rock be.tow t.i.te .in. Length of each tine it. Depth o6 rock oven Z.i.te .in. NumbeA o6 .t.ineb Depth o6 t.i.te be.tow grade .in. To#a.t .teng.th o6 .t.ined 6t. S.tope o6 tAeneh in pen 100 it. Distance between .t.inez_ t. Depth to bedrock it. Tota.t ab.s onbt.ion area 6t2 Depth to gnoundwaten it. Requ.iAed area it Type o6 Coven: Papers on StAaw PIT DIMENSIONS: NumbeA o6 p.itz Gnave.t around p.it.6 ye.s no Outd.ide d.iame.ten St. Depth be.tow .in.tet it. 2 Tota.t abzoAbt.ion area it z A Area %equed it i n m INSPECTED BY TITLE APPROVED ,DATE 197 REJECTED ,DATE 1970 EM115 Rev.9/78 REPORT ON SOIL BORINGS AND PERCOLATION TESTS ' a WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES - P.O. BOX 309,MADISON,WISCONSIN 53701 LOCATION:5W'/e,AIL 1/<,Section 13 ,T.! N,R_#(or)W,Township or Municipality ��h /�l�n J C'' Lot No. , Block No. Subdivision Name County Owner's/Buyers Name: pe r nz p(! Fla M e 4 Mailing Address: TYPE OF OCCUPANCY: .Resid�ce'� r No.of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW _REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS O PERCOLATION TESTS SOIL MAP SHEET NAME OF SOIL MAP UNIT A PERCOLATION TESTS TEST HOURS WATER IN TEST TIME DROP IN WATER LEVEL,INCHES RATE NUM- DEPTH CHARACTER OF SOIL SINCE HOLE HOLE AFTE INTERVAL NU INCHES THICKNESS IN INCHES 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/IN P- ) �y ' 's'A ' �'►e a No � ? P— a 1.9 gip" P- P- P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE,MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- 2 ? a 'Jk TS � Sl'Y Cr B- „ 5 ' et B- y " s " G B— 5 e/ " S 7" 6� B— , <� PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the locati n and quare feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy .Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. e f 5 _ P m E E _ r At A►�i� w'a.y _ or_ r� ' d ' 7 g` } a E y f e s 3 E t S E u ; ; 3 JN g p I,the undersigend,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 location of test holes are correct to the best of my knowledge and belief. Name (print) yy�� „ Certification No. 5e� b 0 Address KWIC Name of installer if known 1 Copy A—Local Authority CST Signature J S �:.�' �, �, h i i( - , .,. C f ... .. . ,, 1, `. :: � a. � � 7 � � ....,.. ..H,....+.... _.�. rawer ,. . _ _ i V � _..dc .. � . i x 1 :' w t rr� � �`� ~ �'� . ~�' �� �. r j •�', :. C: ;y �;. h PLB State and County State Permit #7 Permit Application County Per # for Private Domestic Sewage Systems County,,, - *DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: Ae f-A -e41 B. LOCATION: 6v 1/,, Section T N, I E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village Township ' L� C. TYPE OF OCCUPANCY. Commercial *Industrial *Other (specify) Variance Single family Duplex No. of Bedrooms No. of Persons_ D. SEPTIC TANK CAPACITY lee C Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete 4- Poured-in-Place Steel Fiberglass Other (specify) New Installation _ 4/ Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other (Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq.ft. New V— Replacement Alternate (Specify) Seepage Trench: No.of Lineal�t. Width Depth Tile depth (top)�_No.of Trenches Seepage Bed:�Length�Width Z _Depth � Tile depth (top) � f No.of Lines Seepage Pit: Inside iameter Liquid Depth No.of Seepage Pits Percent slope of land— Distance from critical slope WATER SUPPLY: Private Joint ❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: 1, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certifie it Tester, NAME , �c t ✓✓ C.S.T. # .,`7_�7 �� _end other information obtained from 12 (owner/builder). r' Plumber's Signature ! VP/MPRSW# -577---5L2 Phone - e Plumber's Addressc 01 PLAN VIEW: Provide sket below of system (include direction of slope and all distances in accord with H62.20.Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. F , s 3 t 3 G 4 E r E � r .. m ..m...— ._........__. .._ ....,,, ,�..n,.. .._..tee .e. .: .. ......�� .... d e � 9 i .. .....,� mm..R ..— r ` t 3 3 3 e i s E I i E E .m i 3 i f € E I a € S t � S z Do Not Write in Space elow FOR COUNTY AND STATE DERARTMENT l) 0 LY Date of Application / Fees Paid: State Count ©© Date Permit Issued/ (date) � Issuing Agent Name Inspection Yes _X No State Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 7/1/78 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY&BUILDINGS LABOR&HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION BUREAU OF PLUMBING P.O.BOX 7969 MADISON,WI 53707 CONVENTIONAL ❑ALTERNATIVE Slate PlanLD.Number. SW 4j NW%,S 13,T28N—R18W "'a"igoed1 El Town of KinnicKinnic J Holding Tank El in-Ground Pressure 1:1 Mound CTY INSPECTION DATE: AME OF PERMIT HOLDER: ADDR ute 5, River Falls, WI 54022 DRESS OF PERMIT MOLDER: Harold Morrow Ro N BENCH MARK(Permanent reference Pomt)DESCRIBE IF DIFFERENT FROM PLAN: REF.PT.ELEV.: CST REF.PT.ELEV.. Name of Plumber MP/MPRSW No.: County Sanit ary Permit Nu m ber: Thomas A. Wang 3231 St. Croix 102855 SEPTIC TANK/HOLDING TANK: MANUFACTURER. LIQUID CAPACITY: TANK INLET ELEV.. TANK OUTLET ELEV.. PROVIDEDLAB L PR,' IDED..OV ER DYES FIND YES ❑NO BEDDING. VENT DIA.. VENT MATL. HIGH WATER NUMBER OF ROAD: PROPERTY WELL. BUILG. VENT TO FRESH JALARM LINE. AIR INLET FEET FROM DYES ❑NO ❑YES ❑NO NEAREST DOSING CHAMBER: II MANUFACTUREH BEDDING: LIQUID CAPACITY PUMP MODE L. PUMP/SIPHON MANUFACTURER WARMING LABEL PROVIDED OVER ❑YES ONO ❑YES ❑NO ❑YES ❑NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL BUILDING VENT TO FRESH LINE AIR INLET (DIFFERENCE BETWEEN FEET FROM PUMP ON AND OFF) DYES NO 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 MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH'. LENGTH. NO.OF DISTR.PIPE SPACING COVER INSIDE DIA -PITS LIOUIU BED/TRENCH TRENCHES MATERIAL! PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR.PIPE DISTR.PIPE DISTR.PIPE MATER IAL. NO.DISTR. NUMBER OF PROPERTY WELL BUILDING VENT TO fHE S/I BELOW PIPES ABOVE COVER ELEV INLET ELEV.END: PIPES FEET FROM LINE AIR INLF7 NEAREST 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. SOIL COVER TEXTURE ❑YES El NO ]PERMANENT MARKERS OBSERVATION WELLS DYES ❑NO ❑YES NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTH OF TOPSOIL SODDED SEEDED MULCHED CENTER EDGES DYES El NO DYES El NO El YES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO.OF LATEERAL'ESPA NG GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISMANIFOLD MATERIAL NO DISTR DISTR.PIPE DISTRIBUTION PIPE MATE HIAL&MAHKIN(i ELEV.' ELEV.. DIA. ELE PIPES DIA ELEVATION AND DISTRIBUTION VERTICAL LIFT CORRESPONDS TO APPROVED INFORMATION HOLE SIZE HOLE SPACING DRILLED CORRECTLY COVER MATERIAL PLANS I _ P YES ❑NO YES ❑NO COMMENTS: PERMANENT MARKERS OBSERVATION WELLS-. NUMBEROF LRIOE ERTV WELL: BUILDING. FEE DYES ENO DYES ENO NEAREST I Sketch System on Retain in county file for audit. Reverse Side. SI GNATURE. TITLE I Zoning Administrator DI LHR SBD 6710(R.01/82) I DILHR SANITARY PERMIT APPLICATION COUNTY 6 Rai In accord with ILHR 83.05,Wis.Adm.Code �.�.���.....,,.�...� STATE SANITARY PERMIT# iD ss -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 L No PRO TY 0 R PROPERTY LO/CA'TIO, N 41 ' 1 E(or S �/a v PRO E TY WN R'S MAILING ADDRESS LOT NUMBER BLOCK NUMBER SUBDIVISION N l� TY,STATE ZIP CO DE PHONE NUMBER CITY NEAREST OQQ LAKE OR LANDMARK IJ6P Q <W,00 ❑ VILLAGE : eh 1f II. TYPE OF BUILDING OR USE SERVED: Number of Bedrooms if 1 or 2 Family -3 OR ❑ Public(Specify): III. PURPOSE OF APPLICATION: (Check only one in#1. Check#2,3 or 4,if applicable) 1. a. ❑ New b.❑ Replacement c. ❑ Replacement of d.0 Reconnection of e.❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. O•A Sanitary Permit was previously issued. Permit# 1,J 7y Date Issued /4 -23-7 q 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. ❑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. ❑seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 14. ABSORPTION AREA 5.SYSTEM ELEVATION 6. WATER SUPPLY: (Minute per inch): REQUIRED(Square Feet): PROPO LD/(Square Feet): / 10 Feet C Private ❑Joint ❑ Public VI. TANK CAPACITY Site in allons Total #of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holding Tank 00 400o S e ❑ ❑ Lift Pump Tank/Siphon Chamber I ❑ VII. RESPONSIBILITY STATEMENT I,the undersigned,assume responsibility for installation of the private sewage system shown on the attached plans. 3 Plu .ber's Name(Print): Plu Signature:(No tamps) MP/MPRSW No.: Business Phone Number: U� 3�3 Plumber's ress(Str et,City, t te,Zi Code): Name of Designer: 6 per s l VIII. SOIL TEST 114FORKIATION Germ oil Tester(CST)Na CST# 1A n l Q v a , U (� CST's RESStreet,City, ateipC i ) � Phone Number:k3l 9 �oT IX. COUNTY/DEPARTMENT USE ONLY ❑ Disapproved S itary Permit Fee Groundwater ate Issuing Agent Signature(No Stamps) Lp Approved ❑ Owner Given Initial S charge Fee Adverse Determination X. COMMENTS/REASONS FOR DISAPPROVAL: 'Piah oproj-04 0 , h P 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 s 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 sewacle 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 owners name and mailing address. Provide the legal description where the system is to be installed; 11. 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; 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. ------------------------------------------------------------------------------------------------------------------------------------------------------------ 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 nego,.?ation and public debate. The groundwater ball Ground aatet included the creation of surcharges (fees) for a number of regulated practices which Wiscor n'S can effect groundwater. The surcharge took effect on July 1, 1984. All of the water tha':. buried i° St2ff.' is used in. your building is returned tc; the groundwater though your soil absorption o system or the disposal site used by your holding tank pumper. a The monies collected through these :,urcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for rnonitoring ground- t vlater, groundwater contamination in.estigations and establishment of standards. GroundwatEi-, i''s worth protecting. SBD-6398(8.031'36) i APPLICATION FOR SANITARY PERMIT STC - 100 his application form is to be completed in full and signed by the owner(s) of the roperty being developed. Any inadequacies will only result in delays of the permit ssuance. Should this development be intended for resale by owner/contractor, ("spec ouse"), then a second form should be retained and completed when the property is old and submitted to this office with the appropriate deed recording. er of Property Location of Property _k . k• Section 3 , T gH-R W Township X�iyw_ e4u?ye7ix_� Mailing Address Address of Site Subdivision Name S Lot Number Previous Owner of Property Total Size of Parcel Date Parcel was Created 1,0 - -79 Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume 7and Page Numbs tk� as recorded with the Register of Deeds. INCLUDE WIT}1 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 (tool CCAXi.6y that aCt btatements oil ti Ls ortm ahe tltue to the best o6 my (ouA) hncwtedge; that 1 (we) am (ahe) the owneAk 1 06 the phopeAty deAcAi.bed in thia •i"401mdti.on 6o4m, by viAtue 06 a waAAanty d ed n cohded in the 066ice o6 the Coi,n.ty RegiAten o6 Deedi ais Ooeument No. / ; and that I (We) pneeentty nun �1�e pnopoded a i,te bon the 3elvac�e di�spo�5 d ye em and I (we) have obtained an easement, to Aun with the above deAchibed pnopehty, 6oh the eonetnuctLion o6 chid a ya.tem, and the game has been duty Aecohded to the 066.iee o6 the County Reg•eateh o6 Deede, ab Voement No. ) . or SIG URE OF CO-OWNER (IF APPLICABLE) /d — I�Afg SICKED DATE SIGNED DOCUMENT NO. STATE BAR OF WISCONSIN FORM 11-1982 ' 1NIS SPM.G RESERVED FOR RECORDING DATA aI I ! LAND CONTRACT'1 2 Individual and Corporate Q n �� (TO BE USED FOR ALi, TRANSACTIONS WHERE OVER; �V ' $25.000 IS FINANCED AND IN OTHER NON-CONSUMER] U L 1; ACT TRANSACTIONS) b_] 12o oh 1- 1,�- 39 ii Contraet, b and between ...._Robert L. Phillipps and........ 11 [� ..............Dorothy.E._.�'liil�l ipps-------------------------------•-------------------------------------- i • --•--•-----•--•------------•-•-------•---------------•-----------•-•--------•--•--•----------•-. ("Vendor", W ieth.r of a or norc) and__...Harold D. Morrow and Joanne M. Morrow, 1lusDania and wife,- as marital survivorship__pro ierty ________ .......................................................... ("Purchaser", whether one or more). I.I Vendor sells and agrees to convey to Purchaser, upon the prompt and full per- formance of this contract by Purchaser, the following property, together with the rents,profits fixtures and other appurtenant interests (all called the"Property"), � Croix County, State of Wisconsin: ! In .............................................. RETURN TO West Half of the Northeast Quarter (WiNEI) , except ". that part described as follows: Commencing at the j center of the highway 1478.2 feet S 89007' W of the East quarter corner of said Section; thence N 0046' E 298.8 feet; thence S 89°14' E 96 feet; thence S 0 046' Tax Parcel No. .................................. W 34.5 feet; thence S 89 014' E 289.5 feet; thence S OG 46' W 253.4 feet to the center of the road; thence S 89°07' W 385.5 feet on the center of the road to the place of beginning. All in Section 14, Township 28 North, Range 18 West. AND, West Quarter of the Northwest Quarter of the Northeast Quarter (WINWINEI) , Section 27, Township 28 North, Range 17 West. Vendors agree that if they default on their mortgage to The Federal Land Bank of St. Paul, Purchasers may cure the default by direct payment to The Federal Land Bank of St. Paul. Any amounts so paid shall be credited against the balance owed on this contract or upon amounts owed under a land contract recorded in Volume 516, p. 593, as Document No. 324318, and amendments thereto. This .... - iS_ not homestead property. (is not) Purchaser agrees to purchase the Property and to pay to Vendor at ._...their residence------------------------- the sum of $....35s000.UU in the following manner: (a) $ -0-..._.....-.. . -it the execution of this Contract; and (b) the balance or $_..._ ________________ together with interest from date hereof on the balance outstanding from time to time at the rate ol........... _.5.......................... per cent per annum until paid in full, as follows: in monthly installments of $641.42 commencing 02/15/87 and continuing on the 15th day of each month thereafter Provided, however, the entire outsta aiding balance shall be paid in full on or before th.........15th day of January_____________________ 195M--- ( the maturity date). Following any default in payment, interest shall accrue at the rate of---L 5..% per annum on the entire amount in default (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire Principal balance). Purchaser, unless eycused by Vendor, ngrees to pay monthly to Vendor lunounu; sufficient to pay reasonably antici- pat.ed annual taxes, special assessments, fire quid required insurance premiums when due.To the extent received by Vendor, Vendor agrees to apply payments to these obligations when due. Such amounts received by the Vendor for payment of taxes, assessments and insurance will be deposited into an escrow fund or trustee account, but shall not bear interest unless otherwise required by law. �(! 1Pa-y/mLe[nts shhall-l/be /applie/d�first to interest`o]np the p unpaid balance 1at the J rate specified and then to principal. /Any t!'Yr��II�Y NF���PIgF'>��41rI �OU P>�premium nZ'P /7vJ�P�i1�/I�Vi7' vofi/�l��Ftl�fne Af�A-. i/1�... /(,YlYs In the event of any prepayment, this contract shall not be treated as in default with respect to payment so long as the unpaid balance of Principal, and interest (and in such case accruing interest from month to month shall be treated as unpaid principal) is less than the amount that said indebtedness would have been had the monthly payments been made as first specified above; provided that monthly payments shall be continued in the event of credit of any proceeds of insurance or cotidenin ation, the condemned premises being thereafter excluded herefrom. Purchaser states that Purchaser is satisfied with the title is shown by the title evidence submitted to Purchaser for examination except: a mortgage to •Ille I'CCleral I,alld Bank or St. Paul jj Purchaser agrees to pay the cost of future title evidence. If title evidence is in the form of an abstract, it shall �! be retained by Vendor until the full purchase price is paid. J I Purchaser shall be entitle to take possession of the Property on.......................J3i1t1aTy 15 . 19 87 *Crow Out One, "I _ ri N.C.Mill*carvgmm� STATE TIAR OF WISCONSIN "°°•" FORM No. 11—1982 Stock No. 13011 Purchaser promises to pay when due all taxes and assessments levied on the Property or upon Vendor's interest in it -tnd to deliver to Vendor on demand receipts showing such payment. Purchaser shall keep the improvements on the Property insured against loss or damage occasioned by fire, ex- tended coverage perils and such other hazards as Vendor may require, without co-insurance, through insurers approved by Vendor, in the sum of none......................., but Vendor shall not require coverage in an amount more than the balance owed under this Contract. Purchaser shall pay the insurance premiums when due. The policies shall contain the standard clause in favor of the Vendor's interest and, unless Vendor otherwise agrees in writing, the original of all policies covering the Property shall be deposited with Vendor. Purchaser shall promptly give notice of loss to insurance companies and Vendor. Unless Purchaser and Vendor otherwise agree in writing, insurance proceeds shall be applied to restoration or repair of the Property damaged, provided the Vendor deems the restoration or repair to be economically feasible. Purchaser covenants not to commit waste nor allow waste to be committed on the Property, to keep the Property in good tenantable condition and repair, to keep the Property free from liens superior to the lien of this Contract, and to comply with all laws, ordinances and regulations affecting the Property. Vendor agrees that in case the purchase price with interest find other moneys shall be fully paid and all conditions shall be fully performed at the times and in the manner above specified, Vendor will on demand, execute and deliver to the Purchaser, a Warranty Deed, in fee simple, of the Property, free and clear of all liens and encumbrances, except any liens or encumbrances created by the act or default of Purchaser, and except: ................................................ ...-------•--•---------••-------•-•••--------------•-••--------------------•---------....... ............ •--------•----•------.........._._._......-----...._...._....... -------------------------------•--------•-----------....--•-••-----.....-------------••--.........------------•-••-------._....._--•------•-°-_...-----•--- ••--••........•--------••-------•------•------••-------------•--•-------........._.......... ---•-._......_....--------....._.....------------•---------------------..... - -------•---•---------------------------•---•--------•......--•-•----•--------......-•-••••--•--•---•....---•-------------......_.._-- Purchaser agrees that time is of the essence and (a) in the event of a default in the payment of any principal or interest which continues for a period of ...R...days following the specified due date or (b) in the event of a default in performance of any other obligation of Purchaser which continues for a period of..3Q... days following written notice thereof by Vendor (delivered personally or mailed by certified mail), then the entire outstanding balance under this contract shall become immediately due and payable in full, at Vendor's option and without notice (which Purchaser hereby waives), and Vendor shall also have the following rights and remedies (subject to any limitations provided by law) in addition to those provided by law or in equity: (i) Vendor may, at his option, terminate this Contract and Purchaser's rights, title and interest in the Property and recover the Property back through strict foreclosure with any equity of redemption to be conditioned upon Purchaser's hill payment of the entire outstanding balance, with i nte rest thereon from the date of default at. the rate in effect on such date and other amounts due hereunder(in which eventall amounts previously C + aid b Purchaser er shall be forfeited as liquidated damages for failure to fulfill this Contract and as rental for the P Y q 1. Property if purchaser fails to redeem); or (ii) Vendor may sue for specific performance of this Contract to compel immediate and full payment of the entire outstanding balance, with interest thereon at the rate in effect on the date of default and other amounts due hereunder, in which event the Property shall be auctioned at judicial sale and Purchaser shall be liable for any deficiency; or (iii) Vendor may sue at law for the entire unpaid purchase price or any portion thereof; or (iv) Vendor may declare this Contract at an end and remove this Contract as a cloud on title in a quiet-title action if the equitable interest of Purchaser is insignificant.; and (v) Vendor may have Purchaser ejected from possession of the Property and have a receiver appointed to collect any rents, issues or profits during the pendency of any action under (i), (ii) or (iv) above.Notwithstanding any oral or written statements or actions of Vendor, an election of any of the foregoing remedies shall only be binding upon Vendor if and when pursued in litigation and all costs and expenses including reasonable attorneys fees of Vendor incurred to enforce any remedy hereunder (whether abated or not) to Vie extent not prohibited by law and expenses of title evidence shall be added to principal and paid by Purchaser, as in- curred, and shall be included in any judfnnent. Upon the commencement or during the pendency of any action of foreclosure of this Contract, Purchaser consents to the appointment of a receiver of the Property, including homestead interest, to collect the rents, issues, and profits of the Property during the pendency of such action, and such rents, issues, and profits when so collected shall be held and applied as the ccntrt shall direct. Purchaser shall not transfer, sell or convey any legal or equitable interest in the Property (by assignment of any of Purchaser's rights under this Contract or by option, long-term lease or in tiny other way) without the prior written consent of Vendor unless either the outstanding balance payable tinder this Contract is first paid in full or the interest conveyed is it pledge or assignment of Purchaser's interest under this Contract soley as security for an indebtedness of Purchaser. in the event of any such transfer, sale or conveyance without Vendor's written consent,the entire outstanding balance payable under this Contract shall become inintediatelydue and payable in full, at Vendor's option without notice. Vendor shall make all payments when clue under any mortgage outstanding against the Property on the date of this Contract (except for any mortgage granted by Purchaser) or under any note secured thereby, provided Purchaser makes timely payment of the amounts then due under this Contract. Purchaser may make any such payments directly to the Mortgagee if Vendor fails to do so and all payments so made by Purchaser shall be considered payments made on this Contract. Vendor may waive any default without waiving any other subsequent or prior default of Purchaser. All terms of this Contract shall be binding upon and inure to the benefits of the heirs, legal representatives, successors and assigns of Vendor and Purchaser. (If not an owner of the Property the spouse of Vendor for a valuable consideration Joins herein to release homestead rights in the subject Property and agrees to join in the execution of the deed to be made in fulfillment hereof.) Dated this . . ........ . .. . . - day of JaIlUS?Y............................. 19.87.... ....... .......(SEAL) .. --- •-----•- ........... ........----•-------.................(SEAL) Harold D. Morrow Robert L . . ...... ....................... ... .... ..P}iil.... . ...................... ------------------------------------------------------------(SEAL) -----.......-•-•....................................................(SEAL) Joanne M. Morrow Dorothy E. Phillipps ..-•---------------------------------------------------• AUTHENTICATION ACKNOWLEDGMENT Signature(s) ............................................................ STATE OF WISCONSIN ss. ................. ....................County. authenticated this ........(lay of........................... 19...... Personally came before me this ................day of ..........................................1 19........ the above named •-•-•--•.......................•------.._....._............•-•-..--•--- ...............................•--..........---..._.........-----......_---••--- •............................•-------•-•-----.._...__..........----------•--•-• ---•---------•------------------•----•---...--•••----••------....._............. TITLE: MEMBER STATE BAR OF WISCONSIN ---•-•---•.............................................•---..................... (If not- ................................... authorized by § 706.06, Wis. Stats.) to me known to be the person ............ who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY ....................................•-----•---•--•............._...........- Stuart J. Krueger_x.Attorney 710 North Main Street, Box 167 '---•••----------•...........................•--•--•--....................----• River-Tal-1-s;-Visconsin.......54022•-••---••---•-- -•• Notary Public ........................... . ..County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary.) •Names of persons signing in any capacity should be typed or printed date: ......................................................... 19.........) below their signatures. 1 H ' L N H 9 STC - 105 r' 9 H SEPTIC TANK MAINTENANCE AGREEMENT o St . Croix County z v a OWNER/BUYER M ROUTE/BOX NUMBER `" Fire Number CITY/STATE"'R �� ZIP PROPERTY LOCATION : SQ ;L, }L, Section T c b N , R I� � W, Town of �j11 St . Croix County , Subdivision Lot number 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 operating condition and (2) after inspection and pumping ( if nec- essary) , the septic 'tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration . H 0 I/WE, the undersigned , have read the above requirements and agree N to maintain the private sewage disposal system in accordance with H the standards set forth , herein , as set by the Wisconsin Depart- o ment of Natural Resources . Certification form must be completed and returned to the St . Croix County Zoning Office within 30 days of the three year expiration date . SIGNED Grp' DATE /7 Af UCJ 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 . BUILT SANITARY SYSTEM REPORT r';I SEC � T,gf1Q. Rit ., ST CROP OUNTY, WYSC NSIN.. L 1 rJ c 'L Ava iJ Jim LOT LOT SIZE ha •!k�:�tY b !1x '�' ' "� 3 - �i. PUtSt 1 Ar EV �Ir i t iono . 4 seedt agt�irements o H62.20 V L yam..: „�tA ' JJ ttl'; ✓ "y" end J � J ,,it i�"� ';< 4 iwt:; ,d;, t ;• WW AVU YTHI W ITHIN, 0:YOO FEET YSTEM t qv ,v"�,tRk b-�•'FS •u1 � 9��+ f + �� ," �r r �.1 ��,� �y' -�ti �+t dr: '4, ��.,t`�SI t J y4 �f I t a ,�� - • rr ✓ nk d"r J "rF�'rt' yn§'•Jt 7�J. 1 � ���a r '.p� c dy{,fu - �, z }•1 f't.'' 1 1 1.4 1 '� t. M1.11x� d,4�'•14t µ J 31 1 t s �� Iu, J�.xe',;:-a t ��'.iMVJ� 7 ,l�d f t� 4 vI/` .I//�•�Q/� *.. 4'd�;��Y.Fl nit :�/'�ti��#t■. ('i srAJ +q ntR 7yr( � •'� °�'� � � / � I �j yd� i Y4� d ��p�•x t'�JJd� ���r , ' I •��'!/ `����i���'C./ iYJt}'1'X11 Yt �''��..'t�rd„r 7n n�. ' J'�Sk1,��5• Y �lTy J�%ty ,+ 1 / L N���/" ., J1 "M v •�l ,b * J4s�1? J ' �, V,1 r ' �� kT�t r J t ry�l Jh 5 r 1}I`rltl y1 f `1, c� �4 �atT! `v f�L' • •A J �f,ri: J ��+i � ++ �v,.. �r,i J;+^' d .* r J {''' ► : 3 NCRETE /A .STEEL .Doot.�, ... DRY WE "! t{ `'� th .2e, tEs� area L I it AREA A8 BUILT d r r '" sr�; nspetou' of tfi3a ;$patens bq`St Croix County does not imply complete !Mate;Adailoist 4tive Codes,. There 'are other areas that it is not possible 4t ct 4 this pAistt of construction. St. Croix County assumes no liability for "�bp+e, A4o How if failure is noted the County will make every effort to to "'rrlyq��e� f f'anst4: SHOt Jwr SE DISPOSED .THROUGH THIS SYSTEM ` ` 7 ``%- NSFBC'TOR 'M "0 k > AA l cam' /C70LIMER ON JO laCRNSE',NUM$ER �. �r.. 7 REPORT OF INSPECTION_INDIVIDUAL SEWAGE SYSTEM San.itany Pehm.it � State Septic / 9 -1 NAME ti�ti-t .�� u�z � rownbh.ip�C�C -J.L- y t,�� ACC =�s�t "l/ S Cho.ix County Locat.i.ox ,5&) .A)o Section /3- _ SEPTIC TANK - Size gattona . Number of Compantmentb I ViAtance Fnom: Wett 12$ on greaten atope 6t Bu.itd.ing 6t. Wettanda � • H.ighwaten DISPOSAL SYSTEM D.iatance Fnom: Wett 12$ on greaten. Atope 6t. Saitd.ing 6t. Wettandd Ft. H.ighwaten it. FIELD DIMENSIONS: Width o6 trench it. Depth oS nock below t.ite .in. Length of each tine it. Depth o6 %ock oven .t.ite .in. Humbeh o6 tines Depth of tite below grade .in. Totat .length o6 tined 6t. Slope o6 trench .in pen 100 it. Distance between tines_It. Depth to bedrock it. Totat absonbt.ion area 6t2 'Depth to gnoundwaten. it. 2 Type o Pa en on Straw •� Requ.ined area �t yp � Coven: p PIT DIMENSIONS: 1 Numbex o6 pits Gkavet around p.itb yea no Outside d.iameten St. Depth below inlet St. 2 Totat abaon.bt.ion area it A Area n.equk';xed it2 "' INSPECTED BY TITLE APPROVED ,DATE 197 . REJECTED ,DATE 197_. EH, 115 Rev.9/76 REPORT ON SOIL BORINGS AND PERCOLATION TESTS q WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES ' - 9 P.O. BOX 309,MADISON,WISCONSIN 53701 r LOCATION:5 W'/a,tvsv K,Section 13 Tj N,R-&*(or)W,Township or Municipality ��h b"ani"IC Lot No. , Block No. County p �+ Subdivision Name Owner's%Buyers Name: �J& I, IP d C i d m d Mailing Address: TYPE OF OCCUPANCY: ResidTce 1 r No.of Bedrooms COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW —REPLACEMENT ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS— Tul'q TU PERCOLATION TESTS — SOIL SOIL MAP SHEET NAME OF SOIL MAP UNIT r PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS Ri TEST TIME DROP IN WATER LEVEL,INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE INTERVAL BER 1ST WETTED IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 MIN/1N P- l Y V A ' te e IP P- a zo" G JG� P_ " A ' a,, P- P- P- SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER,INCHES CHARACTER OF SOIL WITH THICKNESS,COLOR, TEXTURE,MOTTLING AND DEPTH TO BEDROCK NUMBER INCHES OBSERVED ESTIMATED HIGHEST IF OBSERVED IN INCHES B- 2 ;P Aa '31- T5 p .5s,"" Gr B- d t0 �� 0 "" G IL B- �. .5 � � B- y 1 s AO G B- 10 SLT S 15 "' PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the locati n and quare feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy .Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope, g[1/� ., , Ear m kse N gore )40le re5T Steel Pe fc Tesi A ref. Ele v shed scale- -1 Ref. 6a5e of Preszti* Came 1% �PC3'f AG way ♦ A loo 1'� X X A X � 7< �1�►s 11> s f i i • � s __ E 4 1 7 e n L I,the undersigend,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 location of test holes are correct to the best of my knowledge and belief. C Name (print) M Certification No. 5�i v Address �_ y 1 9 M 9-P I.+¢_ .Name of installer if known Rnlu Copy A—Local Authority CST Signature r # PLB 6 7 State and County State Pe it m Permit Application County Per # for Private Domestic Sewage Systems County 'DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: ! ri OLLLr / g B. LOCATION: S"lt-`14A' L,,"/ Section TJZIN, R E (or) W Lot# City Subdivision Name, nearest road, lake or landmark Blk# Village tnzl�— yt"� Township ,rcit�ss: cr!?ii•.� C. TYPE OF OCCUPANCY: Commercial `Industrial "Other (specify) Variance Single family t--- Duplex No. of Bedrooms No. of Persons D. SEPTIC TANK CAPACITY /e� t l' Total gallons No. of tanks HOLDING TANK CAPACITY Total gallons No. of tanks Prefab concrete ` Poured-in-Place Steel Fiberglass Other (specify) New Installation Replacement Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured-in-Place Other(Specify) E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area E2S5 sq.ft. New J Replacement Alternate (Specify) Seepage Trench: No.of Lineal ft. Width Depth Tile depth (topl No.of Trenches Seepage Bed:4::� Length idth Depth . ''Tile depth (top). No.of Lines 5 Seepage Pit: Insidesliameter Liquid Depth No.of Seepage Pits Percent slope of land—Y Distance from critical slope WATER SUPPLY: Private Joint❑ Community ❑ Municipal ❑ Owners name as listed on EH 115 if other than present owner: I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH-115 prepared by the Certifie oil Tester, / -11 NAME � ,- C �l'c L C.S.T. # .- � �?� � 'and other information obtained from (owner/builder). Plumber's Signature /MPRSW# Phone r_ �V r' Plumber's Addres PLAN VIEW: Provide sket below of system (include direction of slope and all distances in accord with H62.20.Well loca- tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors property. If well has not been drilled please indicate. z Do Not Write in Space elow - FOR COUNTY AND STATE DE RTMENT U O JNL Y Date of Application / Fees Paid: State .' �� Count Z/Z7 Date /0 Q—S Permit Issued/Reiund (date) �0 Issuing Agent Name Inspection Yes X No State Valid# Date Recd 1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) , „r=__ 71. — -