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Parcel 034-1046-90-000 09i22/2006 11:44 AM
PAGE 1 OF 1
Alt. Parcel 20.29.15.320 034 - TOWN OF SPRINGFIELD
Current [A1,, ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner
0 - LARSON, VICTOR L & BONITA R
VICTOR L & BONITA R LARSON
2894 80TH AVE
WOODVILLE WI 54028
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 2894 80TH AVE
SC 0231 BALDWIN-WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE
SEC 20 T29N R15W 40A SE SE Block/Condo Bldg:
(EZ-U-1108/378)
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
20-29N-15W
Notes: Parcel History:
Date Doc # Voi/Page Type
07/10/2003 729583 2308/547 EZ-U
12/10/1998 593482 1385/527 WD
1096/474 QC
689/543
2006 SUMMARY Bill M Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 04/14/2006
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 37.000 4,300 0 4,300 NO
UNDEVELOPED G5 1.000 50 0 50 NO
OTHER G7 2.000 9,550 68,500 78,050 NO
Totals for 2006:
General Property 40.000 13,900 68,500 82,400
Woodland 0.000 0 0
Totals for 2005:
General Property 40.000 14,500 68,500 83,000
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 121
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
-_..SPRINGFIELD R.29N--R.15W 37
w DD SEE PAGE 49 1&G
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O/9B5 R ¢✓cfo~d roa sib/sir c. SEE /PAGE 23 StC o/x County,w.s.
STEINER SALES & SERVICE, INC.
We can
Management Computers make your
t ^COWS worth Feeding Computers
Dairy Equipment 1~ - more. Water Softeners
Dairy Sanitation SURGE Bulk Tanks
~ Phone: 684.3261
Baldwin, Wisconsin
4
t
Form - ST C - 104
AS BUILT SANITARY SYSTEM REPORT
OWNER TOWNSHIP SPiFII/V~'~i~Ld SEC. ~a T ?~,N-R 1,41W
ADDRESS , ST. CROIX COUNTY, WISCONSIN
SUBDIVISION LOT LOT SIZE
PLAN VIEW
Distances and dimensions to meet requirements of IIHR 83
I
I
SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM
K
fa ei., /oa'
13r r/wM oA~ Sr~f•v~•
A e
yy/
1~,~~ ~N 8~~~ weR Ad
INDICATE NORTH ARROW
BENCHMARK: Describe the vertical reference point used
Elevat n of vertical reference point: Proposed s at site:
SEPTIC TANK: Manufacturer: Liquid pacity:
Number of rin used: Tank ma a cover elevation:
Tank Inlet Elevation: ank Outlet Elevation:
Number of feet from near t d: Front,O Side,o Rear, O feet
From neap property line : Fron , Side,O Rear, O feet
Number of feet from: well , building:
(Include this information of the above plot plan)( 2 reference dimensions to septic tank)
SEE REVERSE SIDE
z
PUMP CHAMBER
nufacturer: Liquid Capacity:
Pump Mo Pump/Siphon Manufacturer: Pump Size
Elevation of inl Bottom of t elevation:
Pump off switch elevation: allons per cycle:
Alarm Manufacturer: Alarm Switch Type:
Number of feet from ne est property line: Front, O Side, O Rear Ft.
umber of feet from well
Number of feet from building:
(Include distances on plot plan).
SOIL ABSORPTION SYSTEM
Be Trench:
Width: Length: Number of Lines: Area ilt:
Fill depth to of pipe:
Number of feet from ne st property line: Front, )OOSide, O Rear,0 Pt.
Number of et from well:
Number of feet from lding:
(Include distances on plot plan).
SEEPAGE PIT
Size: Numb of pits: Diam er:
Liquid depth: Bottom of seepage pit elevatio
Area Built:
Has eit a drop box O or distribution box 0 been used on any of th above soil
ab rbtion sytems? (Check one).
HOLDING TANK
Manufacturer: Capacity: _7000
Number of rings used:- Elevation of bottom of tank: 9Ov~
Elevation of inlet: 47-4 r, 7 6
Number of feet from nearest property line: Front, 0 Side, O Rear, 0Ft.#~
e
Number of feet from well:
Number of feet from building: -70/
Number of.feet from nearest road:
Alarm Manufacturer:
Inspector:
Dated: Plumber on Job:
/
License Number : /V( ~'~'6 90
3/84:mj
PARTMErNT OF INDUSTRY, INSPECTION REPORT FOR ' SAFETY & BUILDINGS
tLBOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION
BUREAU OF PLUMBING
.O. BOX 7969
AOISON, WI 53707
❑CONVENTIONAL LYALTERNATIVE s1.u Phn l.O. Numt el
EXHolding Tank O In-Ground Pressure O Mound 11$~n~15816-5
NAME OF PERMIT HOLDER: JADDRESS OF PERMIT HOLDER INSPECTION DATE
John Davis Rt. 1, Woodville, WI 54028 /4
REF.
MARK (Permanent relnence Iwmfl DESCRIBE If DIFFERENT FROM PLAN PT. ELEV.: CST HE I P1 ELE V
SE SE, Section 20, T29N-R15W, Town of Springfield
F- nl Plmnbr(. MP/MPR5W No.. Coumv Samlary Pr1 mn Numbs
Gale Smith 5690 St. Croix 88387
EPTIC TANK/HOLDING TANK:
MANUFACTURER LIQUID CAPACITY TANK INLET ELEV. TANK OUTLET ELE V WARNINll LABEL LOCKIN(; COVER
PROVIDED PROVIDED
uS Soo o q 5.7( Gv,9 E~YES ONO OYES MNO
BEDDING VENT DIA. VENT MATL HlliH WA H NUMBER OF ROAD: FOPERTY WELL BUILDING VENT i(lTMESH
JALAHAI FEET FROM ~ I NE AIR INLE
❑YES NO YES ONO NEAREST 7 3~0
LABEL TPROV CK I NGCOVEH
OSING CHAMBER: WARNIN 1111ANUIACTUREH BFUUING ILIQUIDCAPAC IV PUMP MI IUEL I'UMPSIPHONM NUIACTtMEH 1PROVIDEG
D ID ED
❑YES ❑NO ❑YES UNO ❑YES CINO
GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL NUMBER OF PIi(IPIH1y 11111 LI HIII1 DIN(. VENT TI)I11f 511
FEET FROM LINE AIR INL F T
(DIFFERENCE BETWEEN
PUMP ON AND OFF) ❑YES ONO NEAREST 0.
%lAlf
OIL ABSORPTION SYSTEM. Check the soil moisture at the depth o'lOwin IENOTt1 JOIAIII111+ T 141AIANDMAIIKINI.
r excavation. (If soil can be rolled into a wire, construction shall cease until FORCE
MAIN
IthONVENTIONAL e soil is dry enough to continue.)
SYSTEM:
WIDTH LENGTH INO Of UISIR PIPE SPACING COV H INS101 D1A -vils
PIT 1O.1F0P1.
11f
BED/TRENCH TRENCHES MATEHIAL'
DIMENSIONS
I,HAVFL UFPTH FILL UEPTII UIS1.4 PIP! U15TH PIPF. DISTR. PIPE MATERIAL NO DISIH NUMBER OF OHOPEit IV WELL HUILUING VENT IO 11+1::.4
HE LF)W PIPES AH(IVE COVE N 1IlV INIII ELEV ENU PIPES FEET FROM UNF AIII INLET
NEAREST-~~
OUND SYSTEM:
Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM
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 TFXIUIIF PF HAI A N I N1 MAHK111S Ulttil llVAl11-N WI 11 ti
_ ❑YES LINO OYES _ LINO
OF P 104 OVF H THE N(:14 Elf IT jDfPIIfOVIH 11-41-NCH BEO 11111`11101 ITIPSOIL IS' 'IIIH I) REF 1111) _11101111)
CFNIEfi EDGES
❑YES ONO OYES ONO ❑YES LINO
PRESSURIZED DISTRIBUTION SYSTEM:
W IDIN ILtN(ITII NO. OF LA/EHAL SPACING T HAVEL UEPTII Hl LOW PIPI F It L DEPTH AtiOV( COVI It
BED/TRENCH TRENCHES
DIMENSIONS
19Pf 11S11+IH1111nN PIf•I NO.II THAI KAIAHKINI,
MANIFUIU PUMP MANIF 01.1) UISIH PIPE JMANIIOLD MATEHIAL I_N"111',111 I:ISIP71137-
ELEV ELEV DIA ELEV. PIPES U1A
ELEVATION AND
,DISTRIBUTION
INFORMATION HOLE SIIF ffOLE SPACING 0I411-t LO 1:011111 C11 V C )VFH MATERIAL VL11411CA1 111 1 C014HESPIINUS 111 APPHOV11)
❑YES ONO [YES [1NO
COMMENTS: i'ERMANENT MARKERS: OBSERVATION WELLS. NUMBER OF PROPERTY WELL BUILUING
FEET FROM LINE
OYES ❑NO ❑YES ONO NEAREST
Sketch System on Retain in county file for audit.
Reverse Side.
SIGNATURE
DILHR SBD 6710 (R. 01/82) ,
SANITARY PERMIT APPLICATION COUNT
DILHR In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT #
Jc'PJ
-Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I_DD.NUMBER
8% x 11 inches in size. ~p to
-See reverse side for instructions for completing this application. PETITION
FOR VARIANCE ❑ YES ❑ NO
1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION.
PROPERTY OWNER PROPERTY LOCATION
Al A V 1^S, ~C '/a 4 S ~D T2f, N, R 1,5- 1W) W
jj~ III
CITY, LOT NUMBER BLOCK NUMBER SUBDIVISION NAME
PROPERTY OWNER'S MAILING ADDRESS
NEAREST ROAD, LAKE OR LANDMARK CITY STATE ZIP CODE PHONE NUMBER 0 171 VILLAGE : IN Fie L
2
11. TYPE OF BUILDING OR USE SERVED:
Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify):
111. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable)
❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an
1. a. ❑ New b. Replacement c.
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.X Alternative c. ❑ Experimental
2. a. ❑ System- b. X 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. ❑ See a e Trench c. ❑ Seepage 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): Q Private ❑ Joint ❑ Public
Feet
CAPACITY Prefab. Site Fiber- Exper.
VI. TANK in allons Total # of Manufacturer's Name Concrete Con- Steel glass Plastic App
INFORMATION New xisting Gallons Tanks structed
Tanks Tanks El
e D D Cr/ / f° 4° +t ❑ ❑
Se tic Tank or Holdin Tank
Lift Pum Tank/Si hon Chamber El El ❑ [Ell ❑
VII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans.
PRSW No.: Business Phone Number:
Plumber's Name (Print): Plumber's Signature: (No Stamps)
L IV ~"hF o ,ids"
Name of Designer:
Plumber's Address (Street, City, State, Zip Code): ~ O~ • - j~~
A o4/ ~ v
VIII. SOIL TEST INFORMATION
# 9 f i
Certified Soil Tester (CST) Name CST #
T l e bl~ S'M l f~ Phone Number:
CST's ADDRESS (Street, City, State, Zip Code) _ ~
R It J_ ~L eN Gvo® W C 1 4 I o ~
IX. COUNTY/DEPARTMENT USE ONLY Issuing Agent Signature (No Stamps)
[Q] Disapproved Sanitary Permit Fee Groundwater ate
Approved ❑ Owner Given Initial T S charge Fee
CJ
` Adverse Determination 1,0
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
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;
Il. 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'Y2 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 Groundwater
included the creation of surcharges (fees) for a number of regulated practices which
can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that Wiscorfsin's t
is used in your building is returned to the groundwater through your soil absorption buried treasure J
system or the disposal site used by your holding tank pumper.
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-
water, groundwater contamination investigations and establishment of standards. Groundwater,►
it's worth protecting.
SBD-6398 (R.03/86)
DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS
' INDUSTRYTRY, , C DIVISION
LABOR
BOX HUMAN NDATIONS PERCOLATION TESTS (115) MADISON WI 7969
.
REL (H63.090) & Chapter 145.045)
LOCATION: SECTION: TOWNSHIP LOTNO.:BLK.NO.:SUBDIVISION NAME:
S' - '/4 W/4 v /T;_f N/R/3&r) W R I,-,- '
4-~Z,4 it COUNTY: OWNER'S/BUYER'S NAME: AILING ADDRESS:
e o Lvi,~ ~t~e s a t
-57 USE DATES OBSERVATIONS MADE
NO. BEDRMS.: 1COMMERCIAL DESCRIPTION: ~r F ROFILE DESCRIPTIONS: PERCOLATION TESTS:
Residence El New I Replace Ff /0,
RATING: S= Site suitable for system U= Site unsuitable for system
CONVENTIONAL: MOUND: IN-GROUND PRESSURE: SYSTEM-IN-Fl LLHOLDING TANK: RECOMMENDED SYSTEM: (optional)
If Percolation Tests are NOT required DESIGN RATE: LFloodplain, any portion of the tested area is in the
under s.H63.09(5)(b), indicateindicate Floodplain elevation:
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.)
B- r Ty, / //,,,2 7 ! /T 0t
13- /j, 4e /,01 &0 dr
B r a L FJ Al /
B-
B-
PERCOLATION TESTS
TEST DEPTH, WATER IN HOLE TESTTIME DROP IN WATER LEVEL-INCHES RATE MINUTES
NUMLF-Q INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PER1002 PERIOD 3- 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 ELEV ION ~ Bo ~Nr OF S1d/Nog
M• N_ F _ • 4s
E y~ a f T o
I ~
1
f
IN
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$ i € 1-
. _ r W_.. _ _ .t.._ ---.m..._.. s.
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:
H -
ADDRESS: CERTIFICATIO NUMBER: PHONE NUMBER (optional):
-Z 4 C o o !o t' o 1.3 / ';7,j(8"
CST SIGNA RE-
DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester.
ILHR-SBD-6395 (R. 02/82) -OVER -
INSTRUCTIONS FOR COMPLETING FORM 115 - SBD - 6395
-mete and - urate sail test, y„11, report must irw1wie:-
rly indicate commercial project;'
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Smith Plumbing & Heating PHONE (715) 265-4838
GLENWOOD CITY WISCONSIN 54013
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State of Wisconsin ` Department of Industry, Labor and Human Relations
PRIVATE SEWAGE PLAN APPROVAL SAFETY & BUILDINGS DIVISION
Bureau of Plumbing
201 East Washington Avenue
P.O. Box 7969
Madison, Wisconsin 53707
SMITH PLUMBING & HEATING RE: Plan Number: 86-05816-S
Gallons Per Day: 450
ROUTE 2 Date Approved: September 23, 1986
GLENWOOD CITY WI 54013
Date Received: 9/23/86
Project Name: DAVIS, JOHN & KATHLEEN - RES. Location: SE,SE,20,29,15W
Town of WOODVILL.E County: ST CROIX
The plumbing plans and specifications for this project have been reviewed for
compliance with applicable code requirements. This approval is based on Chapter
145, Wisconsin Statutes and the Wisconsin Administrative Code. The plans are
stamped 'conditionally approved'. This approval is contingent upon compliance with
any stipulations shown on the plans. All items that are noted must be corrected.
All permits required by the city, village, township or county shall be obtained
prior to construction. The licensed plumber responsible for this installation
shall keep one set of plans with the department's approval stamp at the
construction site. The installer shall notify the appropriate inspector when
inspections can be made.
This approval will expire two years from the date approved or if a sanitary
permit is obtained, it will expire the day the initial sanitary permit expires.
The Bureau of Plumbing has reviewed these plans for private sewage system code
requirements only. These plans have not been reviewed for the code requirements
set forth in Section ILHR 82 for general plumbing or in Chapters 50-64 of the
Wisconsin Administrative code.
This approval is for the following components only:
REPL HOLDING TANK
Inquiries concerning this approval may be made by calling (608) 266-6952.
Sinc ely,
~/►yl Q~
ROMAN A. KAMINISKI
Bureau of Plumbing
Safety and Buildings Division
PPP026/0009w/15
cc: Private Sewage Consultant v-.-County _.__UW-SSWMP Plumbing Consultant
Owner Plumber ____Environmental Health
01 LHR-SBO-6423 (N. 04/81)
State of Wisconsin ` Department of Industry, Labor and Human Relations
SAFETY & BUILDINGS DIVISION
0
o °y ~ G
1
DILHR-SBD-6423 (N. 04/81)
HOLDING TANK SERVICING CONTRACT
Contract Date
This contract is made between the
Holding Tank Owners Names
and Pumper's Name
I-Ille--e v.,I - Gc
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide le I description:)
82
1. The owner agrees to file a copy of this contract with the local governmental unit hereinafter called the "municipality", which has
signed the pumping agreement required in Ch. ILHR 83.18 (4) (b), Wis. Adm. Code and
with the County of
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to
enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the all-weather access
road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay
the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (4) (b), Wis.
Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees
to include the following in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
c. The location of the property on which the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract,
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipality
and the County named above within ten (10) business days from the date of change to this service contract.
Owner(s) Name(s) (Print) I Owner's Signature(s)
'a
N 'U v ` S I - - Q Subscribed and, o before me on this date:
4ecf 1v DA 11.1.r
Pumper's Name (Print) XPn er's signature Notary Public
y commission, expires:
~7
Pumper's Registration Number
SBD-757!4 (N. 11/85) J This instrument was drafted by the State of Wisconsin Department
of Industry, Labor and Human Relations, Bureau of Plumbing.
Boor; 51 PACE 43T ,cam
Docum-.nt No. This space reserved for recording data
&9&ff7 V O ! S3 HOLDING TANK AGREEMENT
Agreement Date
X9,6 This agreement is made between the
7 - - - - - - - - n - - - - - - - -
County or Local Governmental Unit I Holding Tank(s) Owner(s)
SOH w RESTERS OFFICE
0 tS~iliN~F•~4' . ST, CROIX LO., WISI
(Called Municipality below) I 1)4)'h11'_ e, t- j D v /S Reed. for Record Ntis 25th
We acknowledge that application is being made for the installation of (a) holding day of Aug - A.D. 19 16
tank(s) on the following property, (Provide legal land description:) 8:30A Return To
- - - - - - - - - - - - - - - - - - - - - - - - - - - -
or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of
sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under
Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Slats.
As an inducement to the County of S 7" 6,2 a X to issue a sanitary permit for the above described property,
we agree to the following:
1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the
holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and
146.14, Slats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by
placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by
s. 66.60, Slats.
2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining
the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify
the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the
costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed on the tax roll as a special assess-
ment for the abatement of a nuisance, and the tax shall be collected as provided by law.
3. The owner, except as provided by s. 146.20 (30) (d),.Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to
have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner
further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within
ten (10) business days from the date of change to the service contract.
4. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code who shall submit to the municipality and to the county a
report in accord with s. ILHR 83.18 (4) (a) 2., Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under
s. 146.20 (3) (d), Slats., the owner shall submit the report to the municipality and the county.
5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that
the property is served by either a municipal sewer or a soil absorption system that complies with'Ch. ILHR 83, Wis. Adm. Code. In addition, this
agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit
the existence of the certification to be determined by reference to the property.
6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to
the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement
to be determined by reference to the property where the holding tank is installed.
Owner(s) Name(s) (Print) 10 r(s) Si nature(s)
.To fH N - Y IT Subscribed and sworn to before me on this date:
/f, 7`%i A -e4 N A4 v %S"
I ~1 ~
Municipal Official Name (Print) I Municipa Official Signature / Notary Public
I . My commission expires:
Municipal Official Title (Print)
SBD-6123 (R, 101851 This instrument was drafted by the State of Wisconsin evartment of Industrv. tabor and Human Relations FitirAa11 of Pit-hinn
H
• z
W
H
a
STC - 105 r
a
H
SEPTIC TANK MAINTENANCE AGREEMENT o
St. Croix County z
d
a
OWNER/ j?11N Pi4 p'
ROUTE/ Fire Number
.CITY/STATES p o~ L~ ZIP
PROPERTY LOCATION:.,r,,oc~''~, , Section_~2,0, T _N, R ,f'W,
Town of St. Croix County,
Subdivision , Lot number`-
.
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. y
0
E
I/WE, the undersigned, have read the above requirements and agree N
to maintain the private sewage disposal system in accordance with x
the standards set forth, herein, as set by the Wisconsin Depart- v
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
DATE , - 27
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.
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 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
Location of Property T-r _'4 ~4, Section ?n , T N - R W
Township c>l
47
Mailing Address 12t
Subdivision Name
Lot Number
Previous Owner of Property
Total Size of Parcel aV
Date Parcel was Created Alh
Are all corners and lot lines identifiable? Yes X_ No
Is this property being developed for resale (spec house) ? Yes No
Volume and Page Number -4as 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 process. If the deed description references to a Certified Survey
Map, the the Certified Survey Map shall also be required.
PROPERTy OWNER CERTIFICATION
I (We) celcti6y that aU statements on thi,a ~onm aAe tAue to the best o~ my (oun)
knowledge; that I (we) am (ahe) the ownen_(b ) o6 the pttopWy de~scAibed in this
in~onmation 6otm, by viqtue ob a wai arty deed teconded in the 066ice o6 the
County Register oA Deeds as Document No. 1 ; and that I (we)
pnaenzl' y awn the pnapos ed site Marc the .6ewage dizpoutt system (m I (we) have
obtained an easement, to nun with the above dew cAibed pnopeh ty, 4ot the
constt.uct on o6 said system, and the same hays been duty recorded in the 066ice
of the County Register o6 Deedb, as Document No.
r
iGNATURE OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE)
-7
DATE SIGNED DATE SIGNED