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HomeMy WebLinkAbout020-1367-03-000Wisconsir`l Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)1. Permit Holder's Name: []City ❑ Village ❑ T6wn of: Corcoran, Joe Hudson Township CST BM Elev.:- Insp. BM Elev.: BM Description: q T. (,O Ct -+ - Ga C t3 A, —2 TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic LL /Llz�v ACE Dosing Sol Liquid Depth Aeration — NA Holding � 4v_ TANK SETBACK INFORMATION TANKTO P/L WELL BLDG. Air to Air i ntake ROAD Septic Sol Liquid Depth 11 — NA Dosing � 4v_ �' -x-15 ' NA Aeration p6.3; r St /Ht Inlet �� BLDG WELL NA Holding St/ Ht Outlet SETBACK INFORMATION CHAMBER Type Of r PUMP / SIP-HON INFORMATION Manu cturer Demand Model Number, GPM Liftkrj.OS Friction Svst TDH (�I .O t 0 , r m Forcemain Length „( Dia. 2 " Dist. To Well ELEVATION DATA County: St. Croix Sanitary Permit No.: 363974 State Plan ID No.: Parcel Tax No.: 020 - 1367 -03 -000 3a - a ?, /T - STATION BS HI FS ELEV. Benchmark �•�� Inside Dia. Liquid Depth W -Go Alt. BM DIMENSIONS Bldg. Sewer + 6 Ct p6.3; r St /Ht Inlet �� BLDG WELL /�.�� "•31 f St/ Ht Outlet SETBACK INFORMATION CHAMBER Type Of r r Dt Inlet System: S 2/ O �9 Dt Bottom A OR UNIT t4'-j 8'Z • 2 r Header / Man. ' • -� (� 3 - 3 r Dist. Pipe b' W,67 r Bot. System qfo • 3 3 r Final Grade St cover - I 3' SOIL A SYSTEM 3 -? x 6 -; k , - - 2,c , ' ( rA r 1 __ G „, 4_vQ -J- 8CED RENC Width ( 3 Len th \\ ��a) No. enches 1 PIT No. Of Pits Inside Dia. Liquid Depth DIM N DIMENSIONS + SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufa tur r: '�• i�c4a�t SETBACK INFORMATION CHAMBER Type Of r r Moe Number: System: S 2/ O �9 OR UNIT DISTRIBUTION SYSTEM h Jitll.. 4 &•10) {_ ( Q] el l ) = V.(a Header/Manifold tl Distribution Pipe(s) x HoleS42e x Hole Spacing' vent To Air Intake Length s Dia. 1 + Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) � y3 Inspection #1: 06)OS / Inspection #2: Location: 680 Cottage Lane, j1udjsQMW1 54016 (NE 1/4 1/4 2 T29 R19W) - 3229192187 S lage ^ °-” -Q 1.) Alt BM Description = `� Cnl 6 &"""'J (Z ' 2.) Bldg sewer length = 13.Dp °P '" to 11.6 (,5 d� - amount of cover = l 8 z to a Z Plan revision required? ❑ Yes (3 No 0g o$ Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ... .a.m.. i a { € �m [ f � ® »_ »m ....5_....,„ + 3... �,.,,. �. �.... �...».,®. y.,. �...«» �.., �... �j.»».: ....m. ®.m.,�„e. . t t � ��. SSSS ¢ .m..�s....... .....m,.. I E }j l a L .�...«.d ..»,..,.�.�...».... ; .�...� z ..m.. ..�.« .�.... �- «.....:(.o..,a. y j ( 1 �- a�......- ,�.«..�.e e...« "»..,..,..,.. p ... 3 ..,.ow. §�..�..,.II[ ..«. a... ; f f 3 3 7 17 a q g gg a � erg.. _ .,. ...,..iq. ..b �..._. �..«...«..�...,._.K.... .,..�.,.,,� �.„.„„,.. a 4 € ILI s I � t ii f ]Etj 7 :e �... .....g m . .�...,», .,..p ..,.....g �....p._ i t 2 [ ... ...,.. -....w n..�... -. ...w...m...�,.,.,., ..S,w.»... ,_.....e. � � m- ...,.a.. ,m .m 3 .... �m.., «.,...,,�...,�»,®..,L........_P ....� .®m..�.am..- n._.._.....�.�.m ._3._. ...,1.�,_...........�... �. Sanitary Permit Pp1lCatlOri Safety & Buildings Division 201 W. Washington Ave. In accord with Comm 83.21, Wis. Adm. Code PO Box 7302 See reverse side for instructions for completing this application Madison, W[ 53707 -7302 Mi Personal information you provide may be used for secondary purposes Ca »S Per Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned. Attach complete plans to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size. County State Sani r - Z, Check if revision to previous application State Plan I. D. Number 7 1ft . , Pr I. Application Information - Please P ' Info mation Location: Pro Owner N / j [ �� � Property Location 47\E��N Q or ALL 14, S3ZT.2 i \ 1/4 1-,N,1 P er s Mai ' g Address } _ _ ' Lot Number Block Number City, S e Zip 5 NSA P,h@gg umber Subdivision Name or CSM Number II. Type of Building: (check one) (`t.' /` 0 city ❑ Village A` i or 2 Family Dwelling - No. of Bedrooms :' �' A&Tow • Public /Commercial (describe use):_ • State -Owned Nearest good / Parcel Tax Number(s)QZ , 3& 7 - &013- III. T ype of Permit: Check only one box on line A. Check box on line B if applicable) 3 2 . Z q. 0?. z /P A) I. ew 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to Existing System System System Tank Only Permit Number Date Issued B) ❑ A Sanitary Permit was p reviously issued IV. Type of POWT System: (Check all that apply) Non - pressurized In- ground ❑ Mound ❑Sand Filter ❑Constructed Wetland • Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line • At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment 1. Design Flow (gpd) Area Information: 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Ra 6. System F,}gvation \ 7. Final Grade V.I Elevation / 41 ✓ Required Pro al 3 .� cf alsJday (Mi ^�ch) i y `yZ.9 h 4 �1�G — 'row �� Z VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Con- Information Gallons Gallons Tanks Con- glass crete strutted New Existing Tanks Tanks lk:ff .a ❑ ❑ ❑ ❑ s /ODo /�m'� i 1 N . I — - 6od o 0 o e VIII. Responsibility Statement I, the undersi ed, assume res onsibili for installation of the POWTS shown on the attached plans. Business Phone Number Plumber's Name (print) P r s Signature (n ps): MP/t"" No. III r` S (1 -m y v7 / 7�� �.26 9'� CC 7 Plumber's Address (Street, City, State, Zip Code) �7Z / 6 V i IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issu' Agen Signature (No stamps) Approved ❑ Owner Given Initial Adverse Surcharge Fee) Determination X. Conditions of Approval /Reasons for Disapproval: 6. Ia;n I < h K, a �cL k ( n ' . / / ��., P i ¢- 1e &6644M&, `IUU�[ �`✓te 6 r5��r+� B��J2f:0+� �e S� trOr�- D' nom/ vcc�e. Nntrtr¢ r Cw7ir� (O(�u�✓ ,� �' poi f;a,.�s a�' �Q ,� {�, r /e ✓a1;� ex {� clQ� �-.- s�a� �� " � r ` P �° (111"s e� r V pr 7 Se,44 -4 fi&t (t/k S /eff /,� 7/Z 7/b J) I - CON 1MTI0N SEPTIC T_f W/pu�� ` (No scat*) Approved Loc ang Manhole; Cover With, Warning Label Attacled warning Label we+eti erproof Junci; ion Box Final 'Grade- 1 6" Mir fmum 6" Maximum � 18" Minimum 4 " C. 1. Insp. F' Ipe - ,,..✓Baffles i APPR{YED JOINTS WITH APPROVED PIPE 3' OFTO SOLI:: "SOIL Pag _.....,Of..._._ 4 Ci vent Pipe with Approved Cap. +251 From Buildings Approved Vent Cap - --_.__ ic " Mi�mum 4" Minimum 1 Quick Di sCa nnect iI ! A arm B )n 0 f C )ff --�." 3" of BEcdinq nder Tank 1/4" Weep Role C'lnc. Block fibte: Pump and Alarm Are On Separate Circuit: Number o ` Doses: Per Davy Gallons 'er Day /doses: /SO Gallons Tank Manufacturer: 4 Volume o' Backfiow :....... tlon$ Total Da. Tank Size -Septi c/Pump 6 o a Volume: ........ = Gallons �a o s Alarm Manufacturer: Nodel Number: Switch Type: a'�,3y _ Capaciti: s :„inches or �ailons Pump Manufac urer: - B inches or Gallons iodel Number: 0 inches + et, or Gallons Hnimum Discharge a e: o + nches i Total......0 _:y_Z incfies or g allons or` oa Gallons tertical Difference Between Pump Off iinimum Required Supply Pressur: and Distrit-stion Pi pe 42- feet 1 Feer of Force Main x Friction Factor/1 )0 Feet: + ® � _,�In0 Diameter Force Main . eat Total Dynamt , Head: ... qS 73 Feet nternal Tank Dimensions: Length Width _. ,; Liquid DES )Lh � � ( S' ;'natur:e 1 cense Numbe 7-Z/ 7 Date ?-.2 a 0 CONSULT FACTORY :'OR :S PEC IAL APPLICATION`: ElectrklMalter►�Mrs, for cuplex s +ntems, &re. availabt-� and supMaed with an alerrn. Mechanical sitetnators, for duplex systems, dre aveftble with or without alarms. • Cor&d alert ayslsrns are Ietrai for 1 phase purnps used In SIMPiex syalem. See FM0732. Variable laud mdrol swWws are available for controlling single phase - Double pippyback verieble level float swilig"s are avallaW for variable level long cycle controls. Sealed llvlrNa k% avalltrrbte for outdoor installations. See FM1420, Over IWF. (54 special quoletion requited. Refer to FM ON for 200 F. applications, 140 Series . 53 Ins. 4140 Series • 73 Ibs. _ 14 140"' MODELS Cal" Selection MeiN Mdtl VAPOR Oak N140 Nltt40 115 1 Nan 15.0 _: y 1 or 1 I S 2 or 3 8 4 140 1 64140 30 1 Nrin 1 ar 1 aY is 2 or 3 4 4 20i3AQ 2or364 •« r+m,Nj4 MOWS "a adilowe 4" Onalm4NlantanlwSW PSI r4cator Opt &sftWnNEMAInrNEMA4x RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered Into the design of every Zoeller pump. NAIL TOt P.O. 80X 16347 ioWs". KY 47256.0347 Manldectarertol r I101 70: 3 K r Can* Alin 61 1 Loi A A6/ l AN W S� A 0 lnwNr, K 410271-111 P1IA�lP 4f0 (502) 77&273 f • T (900) 928 -PUMP FAX {E02) 711 .3624 rOr4I. bvNAA4tr I /EAD/ APAI�Vty Ofr7 71 WI% CFFLL:F,NS AMC) UWATt:HING Ft. 1 Melero Go IIr4 .__. . _.. - _ a.ce e. �r• 15 457 16 )RM ?0 6A0 �15 767 5y 111 ' _...1D } 9 t4 _ 19 ... ' M. _ X41 35 '067 45 S L'X% VOWe 46 �;.rf� •N ti +/) ki9 t 4 1/% _ i t , SELECTION GUME 1 Single ptggybeck variable level 00 Switch or daft plgpybeekVIrla le levw float swltch Refer to FM0477. 2. Mechanical aSernator M•Pak 104072 w 10.0076. 3 See FM0712 for owfeci model of Elec*sl Ah m Wr E 4. Variable level Control Swllch 10.0225 used asa control scr*IW, spe* duplex (3) or (4) toot system 5 Four (4) hole J• Pak ; .amnion box, for walOAiptlt mm*CW awirod -in shvw or 2 pump operat�en I0-0002 �.i All installation of cony ots, protection devices artdVA" stwW bedoneby a qualified licensed electrician. All ekwilical old teddy Codes ehoW be followed including the most recent Nelin Eletdrle Cale "M) and she Occupt 0013at SaMtY -mvl ►ieaNh Act tOS". 11 1-c nsin Department nl Industry SOIL AND SITE EVALUATION ! ibor and Human Relations DIA!,san of Safety and Buildings in accordance with \ ' Wis. Attach complete site plan on paper not less than 8 112 x 11 Inches in sii: Coun �Plarr mus c Include, but not limited to: vertical and horizontal reference point (SM), ertlon an percent slope, scale or dimensions, north arrow, and location and dist0rtce to nearest road: APPLICANT INFORMATION - Please print all In/ormitfon. Personal Informntion you provide may be used for secondary purposes (Privacy I tiw s 1 04 ! 1 RN I Property Owner `ti Pfoperty i_ocation Property Owner's Mailing Address Lot yzq STAC 3 City State Zip Code Phone Number tj V p„S'CAD . I I (715 )3r6 --Z(V o5 El aty " fr o Page j of .:3 57. CR O/' X, If o(�T Of- L/ 9 - /090 - 30 ,i14 NAA4,S 3) T 2 1 ,N,R P E Subd. Name or CSMI1 Nearest Road ^ , Town 1 O in New Construction - Use: [EPResidential / Number of bedrooms 3 - 'Y Addition to existing building [] Replacement U Public or commercial - Describe' /V f jQ = V O T AF4Q yAjr E, C© yso - & Code derived daily flow gpd Recommended design loading rate A l m bed, gpd/it S trench, gpd/tt Absorption area required " — - __bed. ft -- trench, It 2 Maximum design loading rate IV / / f bed, gpd /ftz trench, gpd/11 Recommended Infiltration surf ace elevation(s) -e 4 • It (as referred to site plan benchmark) Additional design /site considerations Q G ,O 6- - 4 u/ P 1 3O X 'PI Parent material �B�SS �1�� T/ V - __ Flood plain elevation, if applicable N It S - Suitable for system uv vo u� m � rv _ rvi / ntU m vrounu rressure HI lira aysrem m nn of in i U = Un f system [ } U 1�!f S ❑ U [❑ U S ❑ U 11 S Boring # Ground elev. - e' Depth to limiting factor — In .� Boring # IN 00 2 Ground 2 , lev ft. . Depth to limiting factor O g _in. SOIL DESCRIPTION REPORT Horizon Depth In. Dominant Color Munsell Mottles Ou. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GP f1 8ed , Tre h o f IV /aYr 313 Y/6 51 1- �- �, h �� w y ' s • y ! 10 X Wee- 174S,d 04_ 4 S Remarks: Remarks: CST Name (Please Print) Signature Telephone No. I PoG F - ?T 7403RtC O ?t 5.38(D• 0 185 Address Date CST Number Vltirioht & Associates Q 1 6 f Y �•ZCe 31 5 Private Sewage Con: 055 O'Nell Rd. Hudson, Wis. 54016 i s test site APPR VED for 4 '"nventional septic system. 4 b 7 /o Y� 3/3 _ L 2, , hle dl. w 1 • s 2 - /0 YA 3 51 1- / fsd w . z _ • y ! 10 X Wee- 174S,d 04_ 4 S 3' • Remarks: CST Name (Please Print) Signature Telephone No. I PoG F - ?T 7403RtC O ?t 5.38(D• 0 185 Address Date CST Number Vltirioht & Associates Q 1 6 f Y �•ZCe 31 5 Private Sewage Con: 055 O'Nell Rd. Hudson, Wis. 54016 i s test site APPR VED for 4 '"nventional septic system. 4 PROPERTY OWNER G o T- 3 PARCEL I.D.N Boring k Gmund Plev. 19.0 tt DPpih to Iimlling factor ?I * 101V E S _ SOIL DESCRIPTION REPORT Page 01 ; Horizon Depth In. Dominant Color Munsell Mottles Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consi kBoundat y I nc a Boundary Roots Alt Bed . Trench Roots 2 Bed . Tr ch -It /o Ve 3 /3 — 4; Z,�I sh w / 2 •�oY)e 3 SQL 7si � � d 4" Z Y N S / - 2_ �I r r Remarks: Boring N y Ground PIr!V. DPpih to limiling factor . Boring 9 S ?3 Remarks: I loriznn Depth In. Dominant Color Munsrrll MoltIPs Ow Sz. Cont. Color Texture Structure Gi. Sz. Sh. Consistence Boundary Roots Alt Bed . Trench v l wt, j 4; w L . .sL / f d 4" Y N S / - 2_ �I r r Remarks: I loriznn Depth In. Dominant Color Munsrrll MoltIPs Ow Sz. Cont. Color Texture Structure Gi. Sz. Sh. Consistence Boundary Roots Alt Bed . Trench L l wt, j 4; w Ground q8 ev. o___tt. DPpih to lirnffing factor In. Remarks: Boring t;* Ground etPv. fl Depth 10 l 1_ Iimlling factor in. -- - Remarks: SBDW -8330 (R. 08195) i IMPORTANT NOTE TO OWNERS & INSTALLER: All the finer textured soils (loams,silts, etc.) can & will be easily smeared Or compacted even by a backhoe bucket during trench construction. When this occurs premature failure will result. As per ILHR 83.13 (t, the installer MUST be very careful to properly hand rake t e sidewalls & bottoms to re- expose all of the soils natural structure. Minn. even recommends that scarifying devices be mounted on the sides of the bucket. Only in this way can treatment & absorption be most enhanced for normal longer system life. �Sr 1� 3� Asp k consullsnl� Ulbdchl gews9 P,W�1•NelI Rd' 54016 H ud on. V419. N. 3of3 PI G 5-A z-5 /„ _ -O _ 134rk-4oe No Go 3 ?R 3 -(ov"O = SviP of �/OR S O 6,4 A, GN Got' Li%ct�C l b0�0 S� 0 9 3 ^ Ry as i Top of ff -f , �' P� /3.Y4z. G b� % 000c w o, Go r A 131 d7. l 85' I ar— sa 136 sT GDi11-le- U i ;`(b 67 ' - l b0�0 S� 0 9 3 ^ Ry as i Top of ff -f , �' P� /3.Y4z. G b� % 000c w o, Go r A 131 d7. l 85' I ar— sa 136 sT GDi11-le- U i Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code _ County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must S ` include, but not limited to: vertical and horizontal reference point (BM), direction and parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road, C� Z d 13 C? - O - Om c Please print all information. 7 Re by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Z Property Owner Property Location Govt. Lot N r—F- 1/4 1/4 S32 T ,2) N R / q E (orG Pro Owners M i ' g Addre� svt Lot # Block # S Nam or CS U Lj/ 3 City f State Zip Code Phone Number ❑ City Town rest G✓.F S�YoiG ( ) �/ IS New Construction Use: ❑ Residential /Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: _— Parent material Flood,plain elevation if applicable ft. General comme and recommendations: M Boring # Boring ❑ Pit Ground surface elev. oZ. ft. Depth to limiting factor 7 1�J in. Snil Anolicatien Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/fg 'Eff#1 'Eff#2 r / ©' 2- -/ 3 L FY-1 Boring # ❑ Boring p ❑ pit Ground surface elev. / - ft. Depth to limiting factor. �Z in. Soil Aoolication Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDM 'Eff#1 •Eff#2 I - 0- � 2- -/ 3 q? Effluent #1 = bou > :1U < zzu mg/L ana I S5 >3u < IOU mg1L tmuent JM _ CST Name (Please Prin Signature �l7i9 S ri r '- Date Evaluation Cc J 3 7 Z l �a T� S A� -e <(, (�i�`� 7 z7 oO a ou mgiu ana 1 00 � Ju myrL CST Nu Z2 /'�/71 id Telephone Number 21r 2 Gr-("a 1 i Property Owner _ Parcel ID # isi Boring # ❑ Boring [] o pit Ground surface elev. / rI P-0 ft. Depth to limiting factor / S in. Page of Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/fF 'Eff#1 'Eff#1 'Eff#2 0_r ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/fF 'Eff#1 'Eff#2 Boring # ❑ Boring Ground surface elev. ft. Depth to limiting factor in. E] Pit Snil A Ratc Effluent #1 = BOD, > 30 1220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. SBD4330 (8.6/00) 07/2012000 15:28 N Owner/Buyer Mailing Address — 715- 268 -6637 GILLE TRK & EXCAVAT PAGE 02 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM rizic"Y1 a P� Property Address 6 b (Verification required from Plaidiing Department for new construction)__._ City /State � . - Parcel Identification Nurnber — /o SO Z a IJEO&L DESCRIPTION Property Location � %,, '/4, Sec.3 , T (9 I N -R "W, Town of k Subdivision Lot #. Certited Survey Map 61? 2301 W Volume 3 . Page # ��� Warranty Deed # 6 / -� � — '7 F Volume / � . Page # ,3 1 "S � Spec house 0 yes XBO Lot lines identifiable )(yes 0 no SYSTEM M- AINTENANU Improper uae and maiutenanco of your septic system could result in its prsma0m failure to batrdle wastes, r Msintenamce consists of pumping out the septic: tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the wpste disposal system. The property owner agrees to submit to St. Croix Zoning Department 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 wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/wc, the utxdersigued have read the above requirements and agree to maintain the private sewage disposal system with the shards set forth, berein, ass th De nnment of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating drat yo 'system bas been maintained must be completed and returned to the St. Croix County Zoning Office widbin 30 da of the ee ar tlatc. SIGNATURE OF APP IC T Tai 1 e CO f � DATE ONVPWR CERTEF1 N I (we) c it all statements on this form a t of my (our) kmowledge. I (we) am (are) the owner($) of th o rty c ri d above, by virtue of a deed rc otded in Registe eeds Office. VD SIGNATURE I+ APPLT NX DATE � / ,t � � * ** "• Any information that is axis- represented may result in the sanitary permit being revoked by the Zoning Department. ***640 Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified aurvcy map if reference is made in the warranty deed STATE BAR OF WISCONSIN FORM I - 1998 WARRANTY DEED Document Number woi_ 1495 This Deed, made between EINAR D. HORNE and RITA M. HORNE GRANDCHILDREN'S TRUST AGREEMENT DATED 0 TOBFR 14, 1991 Grantor, and JOSEPH J. CORCORA and KATHLEEN F OR 0 Ate, husband and wife as survivorship marital prop Grantee. Grantor. for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (the 'Property ): Recording Area Name and Return Address Barry C. Lundeen MUDGE, PORTER, LUNDEEN & SEGUIN Post Office Box 469 Hudson, Wisconsin 54016 Lot 3, Plat of Stageline Ridge, Town of Hudson, St. Croix County, Wisconsin. Together with all appurtenant rights, title and interests. 619595 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 03- 13-2000 9:15 AN WARRAMfY DEED EXERT I CERT COPY FEE: COPY FEE: TRANSFER FEE: IA7.50 RECORDING FEE: 10.00 PAGES: 1 0 20 - 1090 -30 Parcel kfentification Number (PIN) This is not homestead property. (Is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Dated this 10th day of March 2000 (SEAL) wTr� EINAR D. HORNE, Trustee of the E inar D. Horne and Rita M. Horne Grandchildren!s (SEAL) Trust Agreement (SEAL) AUTHENTICATION Signature(s) authenticated this day of , 111LC: MCMtlCK JIAlh BAR UH WISCONSIN (if not. authorized by §706.06. Wis. Stats.) THIS INSTRUMENT WAS DRAFTED SY ACKNOWLEDGMENT State of Wisconsin, ss. St. Croix County. Personally came before me this 10th day of March 2000 , th above named Einar D. Horne wFi.j t ' to me known to be the person �` h0 ei e6uted a)iAmgoing instrument and acknowledge the same. 7 Attorney Barry C Lundeen �! MUDGE, PORTER, LUNDEEN & SEGUIN, S.C. Notary Public, Stue of Wisconsin 110 Second Street, Hudson, Wisconsin 540 16 My commission is permanent. Si:vtKxXW gc$ (Signatures may be authenticated or acknowledged. Both are not ) necessary) • Names of penotn signing in any capacity must 1. typed or printed below their signature. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal elank Co.. Inc. FORM No. 1 - 1998 Mdwaukae. 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