Loading...
HomeMy WebLinkAbout026-1175-02-000 Wisconsin Department of C�mfherce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division a INSPECTION REPORT Sanitary Permit No: 463312- 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: Miller, Sam Richmond, Town of o"- i 1 75'o Z +D CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 60 is m 1 GS 3 .30.18. 1410 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark W i Q; 1250 5.43 /6543 / 00 Bcsiuy. ( j ( Alt. BM (� N to �• �� I'e S rj,.Dj --14 ZZ /a/ Aeration Bldg. Sewer .9 1 q(G - 4 Holding St/Ht Inlet D $ /0. 95 TANK SE St/Ht Outlet p TBACK INFORMATION J6 , fo I 1 � 7Ap TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet \ \ Septic 1$ S • I ^ _ Zs / 7- 5 > Dt Bottom Dosing 'V I � Header /Man. 1 z -35 Aeration Dist. Pipe c� 3 r,Z• Holding Bot. System 13 � Gy J • y /� PUMP /SIPHON INFORMATION Final Grade 7.57 1 9 7 • Manufacturer Demand St Cover -77 GPM �� t0 • IG�Q Model N ber TDH Friction Loss ystem Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia Liquid Depth DIMENSIONS 3 1 9 I L 2. , f� SETBACK SYSTEM TO 1 `� /L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System ��to - 36 5 9 N /r— � /� UNIT Model Number: 1� F7 f a DISTRIBUTION SYSTEM 3o Header/Manifold i/ Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) \ \ _ ✓e n11 Length kJ Dia —#— Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over j Depth Over xx Depth of Seeded /So ed xx Mulched Bed/Trench Center 5 1✓ Bed/Trench Edges Topsoil \ 1 Xes No Yes „ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 1315 92nd Street New Richmond, WI 54017 (SW 1/4 SW 1/4 30 T30N R18W) Willow River East Lot 2 Parcel No: 30.30.18. _ � f 1.) Alt BM Description = ° P ° �o�r` a '^ G�,a o �- 2.) Bldg sewer length = ` - amount of cover = /� L l Z Plan revision Required? Yes? No Use other side for additional information. Date Insepctor's S ature Cert. No. SBD -6710 (R.3/97) f - Safety and Build' _ - - my I F V " i sc 201 W. Washin n A Y 5 �. �✓ p t x r'Mf o nsin Madison, I 53 J3 - S itary Permit Number (to be filled in by Co.) Department of Commerce (60 266 -3151 q09312- Sanitary Permit Stale Plan I.D. Number i �4 ro ( v i — In accord with Comm 83.21, Wis. Adm. Cod in orm , be used for second u e - Y secondary rpos s vac w, ma s15. (1)(m) �'GNiNGC>FFI(%IE o t Address (if different than mailing address) I. Application Information - Please Print All Information 10 1 F - Property Owner's Name Parcel # Lot # Block # M /L1, 451C_ � 2_ Property Owner's Mailing Address Property cati City, State .5 t o �, 'Y4, Section 3 Q Zip Code Phone Number S �Q D circle Cv J Ty30 N, R�E orlw/ 1Z 41� R. Type of Building (check all t at apply) V I or 2 Family Dwelling - Number of Bedrooms Subdivision Name CSM Number ❑ Public /Commercial - Describe Use r t L t2 &) killf RF,45T e ❑ S e Owned - Describe U Z - 3)f '?I - _ 7 f ' TRFN a ❑City ❑vinag of }� N m - G III. Type of Permit: (Check only one box on line Complete line B if applicable) A. `New System ❑ Replacement System ❑ Treatment/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. Type of POWYS System: Check all that appl /Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ALeaching Chamber ' -El Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dig ersal/I'reatment Area Information: Design Fiow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Requi ed (sf) Dispersal Area Proposed (so System Elevation ®0 (moo T 70 1 T 3 3 0 1 9Z.oa VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank I ' a �✓ Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) �ua� Signature MP/MPRS Number vac n Business Phone Number Plumber's Address (Street, City, State, Zip Code) I O 1 D �m ✓ � d 4%_ VIII. Coun /De artment Use Onl Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuin gent Signatu (No Stamps) Surcharge Fee) ❑ Owner Given Reason for Denial I 36 M D .10 IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER. 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. All setback requirements q s must be maintained as per applicable code /ordinances Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) G 0 o - p � OD P' 0 -� �a Oq Ld op v ( � a � o N d cJ r /yc S ~I Do O_ o J ti U � o LSD cC f / l o z N D S?'� cl o � d r r Wisoinsin Deparbrnent of Cornrnarce SOIL T1O REPORT pop of Division of Safety and Brings c oun t y Attach rxxr�lete site Plan on paper not less than e x „ In size. must C &rclude, brR not tirrrited to: vertical and hordiaontat re e / -7 Percent slope. scale or dmrensions, north arrow, and lion ton Parcel I.D. 0 L IO —) 02 _b Please print ell informs n. rzON?�� F � Reviewed by Date PenwW hdamation you provide may be used for seoondaq Bs ( 5.04 (t) (m)). Propertylocepon �td ao �j ys Govt. Lot �N 114 ,/4 3 T b N R U E yy CRY Code ❑City ❑ Village WT No Roar ja j New Construction user Residential / Nurnber of bedroorns 3 Code derived design flow rate �p ❑ R� nx ❑ Public or ccnentai - Describe: Parent materia) � �� Flood P1j elevation if applicable NI General ootmrerws I / R ' MWM=mwWatkww 5� y,k. a 1��� q0' 0 Borkv# Boring Pit Ground surface elev. R Depthloliffiftfactor r Fbtiton l Depth Dorninanicalm Recbx Description Texture Shuchme Consistence a in. Munsd CkL Sz. Coot Color Gr. Sr_ Sh. Jr 7 7 — e✓1� - "7 I ao" B oring ® pit. Gmund surface efev. Depth to knifing factor Sol bmimm Rate MoFbW Depth DwdnWCokx RedwDescriplion Texture Structure Consistence Boundary Roots GPDW In. MMunsel CAL Sz Court Color Gr. Sz. Sh. •dm !o r 3Z l a� MA r M l C 5 Z Z -lid /U , s/ (Z , • Elfuant #, _ l30D > ao < ZW mgll. and US >W < ,6r' CU NWIS Address T Number , al;�L PropedyOwner Parcel ID # Page of rM Boring # Bo Pit Ground surface elev'-a,-�— D epth pth to IkWft factor h Rate Horimn Depth Dominant Redox Description Te*" Structure Consistence Boundary Roots GPDAE �. Muned Ou. Sz. Cont. Color Gr. Sz Sh. 'Eft# 1 'Ef!#2 C L 3� 0 v `� — S d t a n o, • 7 1..2 F Boft # ❑ Eloring ❑ Pit Ground surface elev. ft. Depth to Il MM factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary (toots GPM In. Munsell 4u. Sz. Cori. color Gr. Sz. Sh. �� Z F # a ❑ Pit Ground surface el�r. ft Depth to favor h 1 Sall Rake Hoemn Deptu Dominant cow Red= Description. Texdme Structure Code Boundary Roofs GPGIfE' In. Murrell Qu. Sz. Cont. Color Gr. Sz. Sh. 1 2 •.I ftx t #1= SOD, > 30:S 220 mglt. and TSS >30 1150 mg& ' Effluent #2 = BOD _< 30 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 ) sac- nrotR.aoo> �-3 Soil Test Plot Plan Project Name David Railsback Sha ird Address 845 133rd Ave New Richmond Wi 54017 M #226900 Lot 2 Subdivision Date 12/12/02 SW/NW 1 /4S W/N W 1/4S 30/31 T 30 N/R 18 W Townshi Richmond P Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of Survey Iron System Elevation 95.1/90.0 *HRpSame as Benchmark Alt. BM Top of Steel Fence Post @ 104.0' 179' Property Line ote: Tested area may not suitable for desired building area. Check system location before -� excavating. Soil test was done to satis Zoning Requirement. 207 V B -1 Alt. 12% B. Slope 45 60' -3 3 o . 394' Property Line 423' Property Line 45' B -2 95' 97' 99' i ' r weou�inpapartrnerrtofComineroe SOIL EVALUATION REPORT P age of Division or Safety and Buildings in aooadanoe with Comm 85, IAAs. Adm. Code Attach mete site plan on paper not less than 81/2 x I I inches in size. Plan must County ' � inckide, but not knited to: vertical and horiaoMal 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. Re w by Date Personal irdammoon you provide may be used for secondary purposes !privacy law. s. 15.04 (1) (m)). cc p o Property Owner Property 3µ/n uJ 30 Govt Lot N tj 1/4 tjj 19 S a I T ) N R '% E( W Property Owner's Mailing Address # Block # Subd Now o CSM# Y Zp Code Phone O qt ❑ VAIa T 7 le- j New Construction Use: Resided / NmAw of bedrooms Code derived design flow rate `y lrC3 GPD 0 Replaoerrrefnt ❑ Pub6c or commercial - Describe. Parent material General corrernerds Flood Plaiq elevation if applicable ft .. and recorlarlerrdaUons: s y S�e r� G �'�SJr.(J�.t�y� � 5� q0, d Boring I 1 # Boring Pit Gr+oiM surface elev. LS. y ft Depth to tadw m. Sol Application Rate Horizon Depth Dominant Coloi Red= Description Texture Struck" Cmdstence Bmldmy Roots G POW In. Munsel Qu. Sz. Cort. Color Gr. Sz. Sh. `W1 *Eii#2 Iz rji S f',r A1- z ______.. 1'nsi k 007 ot- 2 ---- -- S ©.s t77 44 0 - "7 a4- 92 - 3in / El' ® Baring # Borin �J�} R Pit. Ground surface elev. 2 NL ft Deplh to factor n. Horizon Depth Ootriln" Sol GPD� Rabe Description Texture S61x�ure f:ansistence Bal�ary Roots In, Munsell Qu Sz. Cart. Color Gr. Sz. Sh. + 2 S/ R r l C S Zrn r Z a4 -- qz. 0 �-1•Z 1q E mmm t #1 =1300 > M < =0 M& and M >W < 1W' • Eftiuent #2 = BOD _< 30 m4/1. and TSS < 30"A. Address C5T Number >✓ Date Evaluation conducted Tw 0 w 0 Number C;�L 1 Property0wrier Parcel ID # Page ol � Boring 0 a e ��* � ✓✓ O Pit C,rourrd surface elevl - i -3--1— ft Depth to limiting factor SOU Rat Horiaon Depth Dominant Color Redox Description Texture sbucb re Consistence Boumfary Roots GPON In. Munsel Qu. Si. Cont. Odor Gr. Sz Sh. •Eff#'1 •Eff#2 D 12 (01/r 3 1 7 - $ L 2 m r M'� L 2 n-► Z 5- / 1 4 LL w QSC4 M F e � # ❑ ere ❑ Pit &wnd surface elev. ft. Depth to WMV factor in. Sot Application Rate" Hortwn Depth Don*wdColor Redox Descdpfion Textire S6uchre Consistence Boundary Roots GPM In. Munsel Qu. Sz. Cont. Color Gr. Sz Sh. 'Eff#i 'Eft#2 i F-1# ❑ ❑ P Ground srrfacoe elev, ft Depth to Csniting factor In. Sot Application Rate }orb Depth Dorru(nant Color Redox Description. Textwe Structure Co wstence Bmwwy Roots GPDI(>t hi. Munsel Qu. Sz Cont. color Gr. Sz. Sh *EW • • E%m t #1 = SM > 3o <_ 220 mgit. and TW >30 150 nv& • Eftkcent #2 = BOD <_ 30 mg& and TW < 30 mglt. The Department of Commerce, is an equal opportunity service provider and employer. If you need assistance to access services or . tined material in an altarnate format, please ooatact the department at 608- 266 -3151 or TTY 608- 2648777. I i I� S a al-3 * Soil Test Plot Plan Project Name David Railsback Sha ird Address 845 133rd Ave New Richmond Wi 54017 M #226900 r Lot 2 Subdivision Date 12/12/02 SW/NW 1 /4SW /N W 1 /4S 30/31 T 30 N/R 18 W Township Richmond M Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of Survey Iron System Elevation 95.1/90.0 *HRpSame as Benchmark Alt. BM Top of Steel Fence Post @ 104.0' 179' Property Line ote: Tested area may not suitable for desired building area. Check system location before excavating. Soil test was done to satis Zoning Requirement. 207' B -1 Alt. 12% B.M. Slope 45' 60' - - 3' 394' Property Line 423' Property Line 45' B -2 95' 97' 99' i J Bi o Diff user S Heir fit•. � � it• f�...�. Jf• � fly a• Jt• r•� .. �� ��s �� r,r, �■� ter, �� �� .. ter, �� �� �� ter, �■� �� �� � � OJT ..�� � � .�■ ■�. � � ...� .�..�. Kn Univmal End 1 Chamber 11" Stan• 14 "High 16 "High •� • • Dimensions dard Capacity Capacity ���i�I /6 IQI' `q'�• d�• ,�. yr �, ,.....: :,'..:. � s.r •O.• • •C i�.n.Si•: lr.� t .. v• .1 vilJlJiP�JH!•9:1�'!.•.• •s• ��•. '. 5:.. «f ii. ..� ur. rSf . w +. !di ��...•. tV1rSG.�~r ,A 1� i.l.. ..: •[.• •�•• f. � •tI .• t,.�:�.il �`., • r .. y'� J ,�• �� 16 Y � ; ' . �1 �j�i: t v�t;�•f� .4 •� ti:•l•J ' ,�• r L`�IFi�.".i y Jt�ah ' L s`3. �!'�•.`'I.41Gr�:'� �R•3....;a..:v • i �tiiA 1�� ••t r••'t• .e1�����iL•it qJ• 11• ��: �! �i � . . • I r �k•i• I•�'t' ���•��iWi �A} 1 A` ��! y h,'.q.`I��� • ��i�!yjj��` } d.':�� `�Stir,(�RYi►°I'j:�- // POWTS OWNER'S MANUAL& MANAGEMENT PLAN Pa I o! Z cE INFORMATION W! / -/ -46 LO , �a''eEA ff `. SYSTE SPECIFICATIONS Owner — , A-*N � IZ L� Septic Tank Capacity / ZSO al C' Nr Permit a 4 /4 , 33/2- El Septic Tank Manufacturer N� DESIGN PARAMETERS Effluent Filter Manufacturer 2� 13 E ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model A-1 ❑ NA Number of Public Facility Units NA Pump Tank Capacity al Z NA Estimated flow (average) L4 SD g al/day Pump Tank Manufacturer NA Design flow (peak), (Estimated x 1.5) ( g al/day Pump Manufacturer ZNA Soil Application Rate 0.7 gal/day/ft' Pump Model X NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit (rNA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: j Pretreated Effluent Quality Monthly average Dispersal Cell(s) C N Biochemical Oxygen Demand (BOD 530 mg /L In- Ground (gravity) ❑ In- Ground (pressurized; Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound I Fecal Coliform (geometric mean) s10' cfu /100ml ❑ Drip -Line ❑ Other: 1 Maximum Effluent Particle Size Y in dia, ❑ NA Other: C, NA II Other. Other: 0 N CNA 'values typical for domestic wastewater and septic tank effluent. Other ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s)0-Year( (Maximum 3 years) N.� Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume C NA inspect dispersal cell(s) At least once every: 3 ❑ month(s) (Maximum 3 years) NA ❑ year(s1 Clean effluent filter At least once every: / - Z [I month(s) ❑ NA JS ear(s) Inspect pump, pump controls & alarm At least once every: ❑ m ❑ ye r(s) a ) r(sl Flush laterals and pressure test At least once every: C] month(s) C NA ❑ year(s) Ocher At least once every: ❑ month(s) C N �, ❑ year(s) Other ❑ N:: 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. Tan inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or ieaks. 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 visual) inspected t e observation pipes and to check for any pond ng P Y p o check the effluent levels m the p p of effluent on the ground surface, The ponding of effluent on the ground surface may indicate a failing condition and requires the mme notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y3) 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 11 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. r 1 UP AND OPERATION Page T of 7 / 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. T alua b e of e . FR Dg1$1TE�. rO 2. A/�✓ Ca cI� rNSTR c )tQ ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat a 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 ML0O+j �L L Name Phone 1Z 8�� q Z Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ( ZD� /� Phone Phone — 7 /S_ 3e ,_ +'O This document was drafted in compliance with Chapter Comm 83 . 2 2(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrptive Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer _ l (( lz� Mailing A ddres s 3 v I S S Y g x 1 � �.�� (.� / (o Property Address l 3 l 5 ° C Z-r A St t E i m a< P rty 7 (Verification required from Planning Department for new construction) / 1t ' 4 Identification Number City/State V� �. e �,�C W / Parcel Iden ti LEGAL DESCRIPTION 2 Property Location ' /,,S W ' /,, Sec. , 'F N- R/�own of �'t� "r+ o L Subdivision UJ I LL D LO 2 ( V E/L. *s7 . Lot # z-- Certified Survey Map # .77 : 1 7 Volume �/ , Page # 3 "'�b - 1 Warranty Deed # / 'Z—S Z-- , Volume 7 Z- � , Page # Z— . Spec house ❑ yes ❑ no Lot lines identifiable ❑ 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 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. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the 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 Office within 30 Z A f e yea" e`p' tion date. O Z OF PLICANT 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 owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. � L /0 ©� .5rmo kvfk .0 NA PL IC DATE as « «s. Any information that is mis- represented 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 R copy of the certified survey map if reference is made in the warranty deed U. 2 7 2 6 P 2 5 4 -7 8 -+2tfi2 t� State Barbf Wisconsin Form 2 -2003 KATHLEEN O DEEDS REGISTER OF DEEDS WARRANTY DEED - ST. CROIX CO., WI Document Number Document Name RECEIVED FOR RECORD 01/05/2005 01:00PT1 WARRANTY DEED THIS DEED, made between David H. Railsback a /k/a David H. Railsback 1I and EXEMPT # Aria J Railsback, husband and wife ( "Grantor," whether one or more), REC FEE: 11.00 and Miller Homes of Hudson LLC a Wisconsin Limited Liability Company TRANS FEE: 2115.00 Grantee, whether one or more COPY FEE: Grantee, more) FEE: PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant Recording Area interests, in St. Croix County, State of Wisconsin ( "Property ") (if more space is needA please attach addendum): Name and Return Address Los 2 3, 4, 6, 8, 10, 12, 19, 21 and 22, Plat of Willow River East in the Town of Richmond, St. Croix County, Wisconsin. 026 - 1088 -95- 000:026- 1091 -70 -000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated December 30, 2004 (SEAL) (SEAL) * * David H. Railsback (SEAL) (SEAL) * *Arla J. Railsb k AUTHENTICATION ACKNOWLEDGMENT Signature(s) David H. Railsback and Aria J. Railsback husband and wife STATE OF ) authenticated o ember 30 2004 — ) ss. , t � COUNTY ) * Kristina Op-land Personally came before me on TITLE: MEMBER STATE BAR OF WISCONSIN the above -named (If not, to me known to be the person(s) who executed the foregoing authorized by Wis. Stat. § 706.06) instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: * Attorney Kristina Ogland Notary Public, State of Hudson WI 54016 My Commission (is permanent) (expires: ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED © 2003 STATE BAR OF WISCONSIN FORM NO. 2 -2003 * Type name below signatures. INFO -PRO Legal Forms 800- 655 -2021 www.infoproforms.com 77 Pal _ .._ WILLOW RIYER EAST 14 Aa i% LOT 2 tt•>•CNES ....... L r \ . -swn.r ��,,pp 7 L. , `fi r 1 • 7 `\ i ' - .. s, . r. V DSi xGASS c r,1as LOT Rs I a a,.ixr.1, t SU�f7 Yq, il. ( • LOY 9 d I IRM:,IJR•M, 7q a 7 2 .42ACFIt`.., wl�� nn. Kq :t; '-- % 1 ICOAJ:tq.� .�; II ` �_ �'�i� raet�/,lerrwr4 ` ., +iS'A �� ' -`� , j am . .7� +. k,s! _'•tfar L 4 >IY N:M4 .K4• ,,� / ' \ L _l 2.• '1 R:Ib1fIt11d _� t X.45 =t ..14fix po .s .; p; - IrJ'1 sf1 ._',. ' i +\ �•.. - 4 t ` �` ��- x \ a ,1, rte• •� I c ,yf• NS' ._.t.' +`•,. �A.,Y SLOT 5 An • f�'" ,/ �' _ - - :•....... ..............- t .., Laro f � ItY -r .. ,• � �\ 1 � s�t,Z• J �i$• e.a�aa z �C '•b �' ,+:. - aet 7 l a„ I 1 L ) , ` LUZ , V „p L4T 0 I j � D ...'' ,,,,q� ,.. `,•,., q, q... :xwefr:NSTa 5 I t.xw w^wra ♦ r „ ,r •,,.. t „ �, Y � .� M� I. ):YryY. +.f,f \. hi � �� �\ .^t�� f.aa hcl'iRn' l�3 -r% /., t07 17 ` Ea f F9 LOT 93 �` r ✓ C i aq G n. r+ AEB •. ' lids I f , LOT :y d M...:ay . r,f;,v ne y . � +� • �'4 �• �n�. � 1.11 hC�� is �4 ✓ I • -' • ~ -�, ,at.aK rlu h F, ;'�` - •e •M,aiw !L ./yl'•G P',� 1 `;�,,;�`�', -•' PP4"3SVC'. ur -ran'. a r Ott!: rgy✓ r'v�%`• O nnl 4tiv. x I I -0Y q F�11;. .i / \+�. •�• f o ' lZ1.St � .►A - C`14H 1Y.sf.:f+C�. .,: ' t�,J' r' .`\ f r ' ✓' 4 W,uss.: 1iAP / �g°ANir ` " t, i a i !IU+r.ae•m q � J r ,�",'r , : � + �G r l ` � �.\ ..r • "` � .✓ � _• + 7`''; f r YEA �'' G " ' V . �.�g�� � A a c r B 6 � � � - �� \�ti� •r "I ^/' a � ' "�„'' rr i�V tF.'ar ^vti%�4Ut1?r.' z •- rf f � LET ty r / � ✓✓ .= nx fcw:t•ar.s +•+c' er r m .,''' 'f. ,.� @, r i 3.11 n =S � ✓ �'" l r 1 . ,.......... LOCATION SKETCH 1 ° 30 will - �� ,� / ✓ ✓ r \ FLAT Ya: = wnru xlncnf:,cra+ LCT7 - 1. 2•. ' wrlc MILLER Call )im Henry & Associates for more details. H OMES (800)221 -$OLD [*/JM w Information deemed reliable but not guaranteed. Jim H & Associates . , UbPWU T Ell LAM 80 RADIUS TEMPORARY JL•DE•SAC EASEMENT TO 3E EXTINGUISHED UPON ROAD EXTENSION N89 0 40'55 "E 1 442.08 ' SOUTH LINE -f32.29 4 � 24.70 DRAlNAGE EASEMENT 2 1 1 30 09 9.79' - -- -- - -`� - --------------- N89 - - 1 N - g.95 � \ ' \ Pt8'9°4055'E 194.05' •. 4 .T•57 a 105.00 �5,. , \ I,- �' B9 °40'S5'E 132.63• . \ N7 2 8`0 e �d ��� .60 A _. -- —�- I` •�� \ �• -- SS�i° .� '`�? .60 N 14 \ '�` �°; 113,235 Sq. ft. °� 15 \ LOT 1 LBO =913.8 �>p' 1.88 ACRES ` 2 • 81,887 sq. ft.� N�5 i ' v "x BENCHMARK Q-58376 LOT 22 + SEE DRAINAGE \s ELEV. =912.31 1NG 22.00 2.04 ACRES I I EASEMENT DETAIL p QND A 88,963 sq. ft. I m ( LOT 2 °'�� „ARE V. I r 2.42 ACRES ', `* r K _ _ . 6 <o >> • BENCHMA cs 9 1 S 4 ft. ELEV. = 933. �+ 7 � 105, 73 sq. i I \. I ::� + 200.48 100.00' ti a S89'%28 W . 300.48' I Q LOT 4 + 1 W 1 � w +w � t � �• 1.62 ACRES R I - .d� � �1 i R 1 , \ � 70,435 s ft � J I Q i �` \ �� LBO-913.6 16\ 13 1y �+ LOT 21. 2z � ms's- — 8 ,2 28 A 2 sg •.. LBO =930.0 I � � k LOT 3 ' � Et � \ \ `�'o c o- 1 W i 13 / n2T•nr'. 81,771 Sq. ft. �. 1.88 ACRES / N16ar 17 LOT 20 18 ~ / ,' 1.81 ACRES ^ (� c o `''J j 78,649 sq. ft. ]c 3'S 'v�J4 p LBO =930.0 I •s BENCHMARK 1 —