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HomeMy WebLinkAbout026-1165-28-000 Wisconsir, Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and quAing Division ` INSPECTION REPORT Sanitary Permit No: 463334 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Dalstock LLC 1 1 Richmond, Tovyn of l Z (a- / �j 2$ OC6 CST BM Elev: Ins BM Elev: BM Descry tion S Section/Town /Range /Map No: (06 .20 C�ZJ� -� (.�J C6'}�.� c�c�� V� f� 22.30.18. 12-1 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 2 Le 0 Benchmark C �� ( 2 a,� SOU- C) Dosing !� Alt. BM ^ 1• f 0 73 Aeration B ldg. Sew er Q.7 f l v` *73 00 - 0 Jr Y Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION b Y 7 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet / l D Septic / J - r 25 Dt Bottom [� Dosing Header /Man. (' / Gj7.03 Aeration Dist. Pipe '1 /0. �j /0.3 9 �. Holding Bot. System 93 9 • Final Grade • PUMP /SIPHON INFORMATION --�� 2 / 0 / , Manufacturer Demand St Cover / 41 GPM 2 r'. (r T • T. /0 Z. ? Model Number TDH Lift Friction Loss ystem He TDH Ft P� (j r> Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width / Length r No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/LQ JBLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Ty e Of System: 0 3 / r 1 t UNIT Model Number: G� r DISTRIBUTION SYSTEM Header /Manifold Distribution �" x Hole Size / x Hole Spacing �V�entto Air I ntake !1 / 1_�Pipes) ! H a Lengt T Dia Length Dia Spac ng -- SOIL COVER x Pressure Systems Only xx Mound t - Grade Systems Only Depth Over Depth Over xx Depth of 7��ded xx Mulched Bed /Trench Center Bed/Trench Edges Topsoil Yes i _I No )Yes L No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ' �5 / 0 ! Inspection #2: Location: 1453 129th Street New Richmond, WI 54017 (N 1/2 SE 1/4 22 T30N R18W) Lundy Meadows Lo 28' / L Parcel No: 22.30.18. 1.) Alt BM Description dP �7 t �N�'� f /bb sl�f Q - / o !�° 2.) Bldg sewer length = 3 0' lI S-Y,f w -1-D rte/ - amount of cover = / c ! L v 1 W_ l ikv- E W Plan revision Required? Yes V No �I Use other side for additional information. nse ctor's si nature G� Date p g . No. SBD -6710 (R.3/97) ii PLOT PLAN PROJECT Dalstock ADDRESS 1748 112th st NewRichmond Wi. 54017 N1/2 1/4 SE 1/4S 22 /T 30 N/R 18 W TOWN Richmond COUNTY ST. CROIX MPRS Byron Bird Jr. 220527 DATE 3 - - 05 BEDROOM 4 CONVENTIONAL XXX -Grade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1260 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE 0 LOAD RATE .5 ABSORPTION AREA 1200 # of chambers 39 BENCHMARK V.R.P. top of Survey Iron ASSUME ELEVATION 100' ❑ BOREHOLE O WELL - H.R.P Same as BM A Vent SYSTEM ELEVATION T -1 =96.5 T -2 =96.3 T -3 =96.1 Bio Diffuser with 31.1 ft ^2 per yt 6„ chamber�y �1 ��;, a'���f Long 3,V Elevation B 06d e 4 358' PL 1 0 = 45' B3 Town d 15 B2 st 4 bed 15 house �- Garage Driveway 19� 383' PL BM L S IN r Safety and Buildings Division County C / r 201 W. Washingt ve., P.O. Box 7162 isconsin Madison, 7 162 Sanitary Permit Numbs (to be f in by Co.) (608 3. 3 I artment of Commerce state plan I.D. Num Sanitary Permit Apph r / q- In accord with Comm 83.21, Wis. Adm. Code, personal inC project Address (i different than mailing address) may be used for secondary purposes Privacy Law, 15.040 Xm) 1. Application Information - P case tint All In rmatio /7 5 �� sT L �(L jParcel g B X Property Owner's Name , property tion property Owner's Mailing Address / /? X V,,-_2�EA Section City, State Zip Code Phone Number , ,le�opne) r/r we �N/ 1 T N: R AC , IL Type of Building (check all that apply) Subdivision N CSM umber or 2 Family Dwelling - Number of Bedrooms rT y� C f �o ❑ PublicACommer vial - Describe Use ❑state owned - Describe use 3 rte! ❑Ym geio hip of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. p New System _ ❑ Replacement System ❑ Trcatrnent/Holding Tank Replacement Only ❑Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T of POWTS System: Check all that appl �, Non - Pressu rotted -. ❑ Mound >_ 24 in. of suitable soil 11 Mound < 24 in of sukabte soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized hi ground ❑ Holding Tank ❑ Peat Filter ❑Aerobic Treatment unit ❑Recirculating Sand Filter 11 Recirculating Synthetic Media Filter VL=chig Chamber [I Drip Line 11 Gravel -less Pipe CO] ( Imo) V. Dis rsal/rreatment Area Inf rmation: ( system Elevalon Design Flow (gpd) Design Soil Application Rate(gpdsf) p Dispersal Area Required (sf) Disperse /213 © ✓ .Z& AO P antic YI. Tank Into Capacity in Total Number Manufacturer Prefab Site Steel Fiber Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks I Tanks Septic or Holding Tank Q t' ' Aerobic Treatment Unit Dosiag Chamber VII. Responsibility Statement - I, the undersigned, assume responsibility for installation shower on the attached plans. Plum ignature Nu Plumber's Name (Print) Business Phone Number / t bus � rl Ism s Address (Street, City. State, Zip Cod VIII. ount L Department Use Onl Sanitary Permit Fee ( cludes Groundwater Date Ins d suin Ag t Sig to Stamps Approved ❑Disapproved Surcharge Fee) 7 ❑ Owner Given Reason for Denial I 3efe' ,- IX. Conditions of Approval/Reasons orDisappro al If A S U T OWNER. 1 Septic tank, effluent filter and dispersal cell must all be serviced I maintained 'der management plan provided b lu 2. All setback requirements must be maintained e pram (to the County **) for the system en pager dot kss than 81/2 a it inches in sin SBD -6398 (R. 01/03) PLOT PLAN ADDRESS PROJECT Dalstock 1748 112th st NewRichmond Wi. 54017 N1/2 1/4 SE 1 /4S 22 /T 30 N/R 18 W TOWN Richmond COUNTY ST. CROIX MPRS Byron Bird Jr. 220527 DATE 3 -1 -05 BEDROOM 4 CONVENTIONAL XXX At rade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1260 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE 13 LOAD RATE .5 ABSORPTION AREA 1200 # of chambers 39 BENCHMARK V.R.P. top of Survey Iron ASSUME ELEVATION 100' ❑ BOREHOLE (DWELL *H.R.P. Same as BM Vent SYSTEM ELEVATION T -1 =96.5 T-2 =96.3 T -3 =96.1 >12" Of Bio Diffuser with Cove 31.1 ft ^2 per chamber 6 " Long 34" Elevation 50' 30' B 30' 358' PL 80' 45' B3 Town d 90 15 B2 st 4 bed 15 house 192' PL Garage Driveway 383' PL BM 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 8 112 x 11 inches in size. Plan must " 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. Please print all information R ewed Dat Persona{ information you provide may be used for secondary purposes (Privacy taw, s. 15.04 (1) (m)l. �,vtrv►•= 3 d� Property Owner Property Location Govt. Lot 1 / 1/4 S 2 T N R IS E( W Property ( Own / er's Mai' Address Lqt, # Block # Subd. Name or M# a 4- City §tate Zip Code Phone Number ❑ City ❑Village �TQO Nearest Road / C s _.., _. New Construction Us ' Residential I Number of bedroom Code derived design flow rate _ GPD ❑ Replacement Public or p5R -Describe: Parent material , 2i J Flood Plain elevatio if applicable ,Pt_�� ft• General comments / and recommendations: Boring E D `� # �D/. U Pi Ground surface elev. ft. Depth to limiting factor �l in. :Wil 4APP1icMzaate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 "Eff#2 X0 =3 ®Boring # Boring / Pit Ground surface eley! ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I •Eff#1 'Eff#2 �- 1 r S �� CS of FY • Effluent #1 = BOD > 30 5 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Sig CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 54017 — f� _ v 715 - 246 -4516 Property Owner _ Parcel ID # Page of ❑ 3 Boring # ❑ Boring 1 2 pit Ground surface elev. ,��ft• Depth to limiting factor i ^• Soil Application Rate Horizon Depth inant C Redox Description Texture Structure Consistence Boundary Roots GPD/ff' Eff#1 'Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ' Uy 2- 17-YPIQL F — I Boring C3 Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor i^• Soil ligtion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft` in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. •Eff#1 'Etf#2 ❑ Boring in. F—I ""g # ft. Depth to limiting factor ❑ Pit Ground surface elev. Soil Application Rate GPDM Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots 'Eff#1 'Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ' Effluent #1 = BO0. > 3o 220 mg1L and TSS >30 _< 150 mgA- ' Effluent #2 = BOD 130 mglL and TSS 30 mglL 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. seo-e330 (RWOD) Soil Test Plot Plan Project Name William Stock/Steve Dalton Shaun Br` Address 1748 112th St. New Richmond Wi 54017 CST , #226900 Lot 2 8 Subdivision Lundy Meadows Date 8/11/03 N 1/2 SE 1/4S 22 T 30 N/1318 W Township Richmond Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of Survey Iron s System Elevation 96.5/96.3 *HRpSame as Benchmark Alt. BM Top of 2" Pipe @ 100.2' 50' Pro Town Road 358' Property Line Please note: Installer must 30' verify all lot lines and setbacks before installation. B -1 30' 1% Slope 5' Not enough slope o 90' -3 Pe establish contours Please Note: Tested area may not be suitable for desired building area. Check system location B before excavating. Scale is 1" = 40' unless otherwise noted 192' Property Line 383' Property Line * Alt. B.M. ST CROIX COUNTY � %� SEPTIC TANK MAINTENANCE AGREEMENT iP JJ� t AND A I J� OWNERSHIP CERTIFICATION FORM u OwnerAB y er 1 Mailing Address 11.2 Property Address 44 I 1 D O' `k 54 (Verification required from Planning Department for new construction) City /State N Parcel Identification Number � f LEGAL DESCRIPTION , ,�- Properly Location ., . �E /s, Sec. T 4 N -W--It�W, Town of Subdivision /1 c vz Lot # , -3 Certified Survey Map # , Volume . . Page # Warranty Deed # 2 41 �o� , Volume Page # Spec house yes ❑ no Lot lines identifiable)R yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mastorplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal syst em 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. Uwe, the undersigned have read the above requirements and agree to rttaij-&e-piivate sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural R , State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. ix County Zoning Office within 30 days of the threeayear expiration date. . �u ILL 'i/ C St�'yv SIGMA TURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of the ro rty descn d above, by virtu of a warranty deed recorded in Register of Deeds Office. oe - GK 1? Pc SI GK ATURE OF APPLICANT ATE « « « « «« Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department.""" ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page / of 1 FILE INFORMATION SYSTEM SPECIFICATIONS Owner ; / V cl c ! Septic -Tank Capacity a l ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units O NA Pump Tank Capacity a l ❑ NA Estimated flow (average) gal/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer ❑ NA Soil Application Rate ✓ al /da /W Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L O NA O Mechanical Aeration O Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection O Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L 19 In- Ground (gravity) O In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) _ 100ml ❑ Drip -Line O Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other: O NA Other: ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: O NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 2, O month(s) (Maximum 3 years) ❑ NA ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume O NA Inspect dispersal call(s) At least once every: ❑month(s) (Maximum 3 years) 13 NA years) Clean effluent filter At least once every: O month(s) ❑ NA 151 year(s) ❑ month(s) Cl NA Inspect pump, pump controls & alarm At least once every: O years) O month(s) ❑ NA Flush laterals and pressure test At least once every: ❑ year(s) Oa O month(s) ❑ NA At least once every: ❑ year(s) Other: O NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in. the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any, service event. GMW (4/01) Page of START UP AND OPERATION —" For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may 6e installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC. PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name hti' r Name / R byi c C Phone Phone SEPTAGE SERVICING OPERATOR (PUMP R) LOCAL REGULATORY AUTHORITY Name It sZ Q `, Name C rvi� r �O Zch n Phone Phone 10 . This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.64(1), (2) & (3). Wisconsin Administrative Code. I U 2`I39P 6 3 y 7443[ZiZ STATE BAR OF WISCONSIN FORM 1 - 2000 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS Document Number ST. CROIX CO., W I This Deed, made between L. Lawrence Williams and Vir ina R. RECEIVED FOR RECORD Williams, husband and wife and each in their own right Grantor, and 10/21/2003 09:45AM Dalstock, LLC, a Wisconsin limited liability company Grantee. WARRANTY DEED Grantor, for a valuable consideration, conveys to Grantee the following EXEMPT # described real estate in St. Croix County, State of Wisconsin (the "Property") REC FEE • 11.00 (if more space is needed, please attach addendum): TRANS FEE: 3015.00 The South One -half of the Northwest Quarter (S '/2 of NW '/ of Section COPY FEE: Twenty -three (23), Township Thirty (30) North, Range Eighteen (18) West, CC FEE: EXCEPT Lot One (1) of Certified Survey Map recorded in Vol. 8 of PAGES: 1 Certified Survey Maps, Page 2305 as document number 465057; AND The North One -half of the Southeast Quarter (N %Z of SE ' / 4) of Section Twenty -two (22), Township Thirty (30) North, Range Eighteen (18) West. Virginia R. Williams joins in this deed for the sole purpose of conveying any Recording Area interest she may have in the subject property under the Marital Property Laws Namc and Rcturn Address of the State of Wisconsin. Robert J. Richardson Parcel Id numbers: Bakke Norman, SC 026- 1068 -80 -000: 026- 1068 -90 -000. 026- 1066 -80 -000. 026- 1066 -90 -000 S233 McKay Ave., P.O. Box 399 Spring Valley, WI 54767 Together with all appurtenant rights, title and interests. See above Parcel Identification 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: easements, restrictions and rights of way of record Dated this 15th day of October 2003 I * L. Lawrence Williams * Vir is R. Williams AUTHENTICATION ACKNOWLEDGMENT Siznature(s) L. Lawrence Williams and STATE OF WISCONSIN ) Virgina R. Williams ) ss. County 1 authenticated this 15th da f October 2003 Personally came before me this day of 2003 the above named * ob rt J. Richardson TI LE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the Derson(s) who executed the foresoina authorized by X706.06, Wis. Stats.) instrument and acknowledeed the same. THIS INSTRUMENT WAS DRAFTED BY ROBERT J. RICHARDSON, Bakke Norman, SC SPRING VALLEY, WI 54767 Notary Public, State of My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ) ` Names of persons signing in any capacity must be typed or printed below their signature. INFO -PRO (800)655 -2021 www.infoprofonns.comSTATE BAR OF WISCO WARRANTY' DEED FORM No. 1 - 2000 l ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT • AND OWNERSHIP CERTIFICATION FORM Owner/Buyer /f�c �� Zf Mailing Address / ? f / / l-t 3Y / t c Property Address `f 53 (Verification required from Planning Department for new construction.) ,I r City /State N,�t� � Parcel Identificat; -)n Number LEGAL DESCRIPTION Property Location / W, Town of _ Xf C r Subdivision �-, L� t , Lot # Certified Survey Map # �,, _, Volume , Page # Warranty Deed # 7 y 3 C - , Volume Page # Spec house yes no Lot lines identifiable ( (ye! ,,/ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in § Comm 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County 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 wastewater disposal 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. I1we, the undersigned have read the above requirements and agree to maintain the p rivate sewage disposal system v th u e standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Departnjent within 30 dais of the three year expiration date, . _ „ ! lose � fly y,; SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION Uwe certify that all statements on this form are true to the best of my /our knowledge. I/we am/are the owner(s) of the property described bove, tfy a of a warn d re ded in Register of Deeds O Ice o -- SIGNATURE OF APPLICANT DATE * * * * ** Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** Include with this application a stamped warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. 0 o ca ? a 0 ° 2 Ln J % k (k 0 0 % 'A ® 2 / ƒ ° § 2 0 U 2 CD n- k \ X : 0 r� /�f ] § \ ( \ @) / Q 2 � 9 v / k c: E 3 R Z) 0 \ 7 f 8 S )I C # 0 / § }� / m \ § % 0 r co 2 « « m & & CL \ 0 0 0 0 �- 2 � � � � � . OD CL } 4 \ $ o { f / § 3 m \ �` �� 0 \ m c \ / 000 § 7 /# §� C ( C § § \ o* k\ 2 z m ; - ® c & 0 ] I G 9 CD m ■ \ 2 E CD / 2 / ; E CIO § CD OD j / % � � k n 0 j C)(D /2«\f CL @ #fi/ §3g2 }§$£ 5 §fw age, 2 �2 \} @�[E � k CL yamƒ « \). o g em . 2 2 ` \ CD ._0 A \CL � 4