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HomeMy WebLinkAbout026-1175-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 479359 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 Homes of Hudson, LLC I Richmond, Town of 026 - 1175 -10 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No: 6 rA % 30.30.18.1410 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ZS 4 /� Alt. BM oli S 4Z Aeration Bldg. Sewer /C5 9 ► -7 Holding SVHt Inlet �.' 3 TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ! ( Dt Bottom Dosing^ w w Header /Man. ,bG CID Aeration Dist. Pipe Holding Bot. System , . PUMP /SIPHON INFORMATION Final Grade 7,S T 6 Manufacturer - _w _. Demand St Cover PM Model NurYa er TDH ift Friction Loss System H,gaQ TDH Ft -� Forcemaima., Length Dia,,... -- Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length f No. Of Trenches PIT DIMENSION No. Of Pits Inside Dia, Liquid Depth DIMENSIONS / SETBACK SYSTEM TO P/L BLDG IWELL LAKE/STREAM LEACHING Manufacturer. INFORMATION CHAMBER OR Type Of � �� UNIT Model Number: ti rr 11UQi 1 18 z C. DISTRIBUTION SYSTEM _r�L Z3+az.3 =`loo Header /Manifold DistributiQn x Hole Size x Hole Spacing Vent fir Intake ' r , Pipe(s) \ Length Dia ` �' Length \ Di Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grad a Systems Only Depth Over Depth Over xx Depth of xx Seeded /S dded xx Mulched Bed/Trench Center y Bed/Trench Edges ` Topsoil ` Yes I %I, No Yes Fr] No i COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 915 131st Avenue New Richmond, WI 54017 (SW 1/4 SW 1/4 30 T30N R1 8W) Willow River East Lot 10 Parcel No: 30.30.18.1410 1.) Alt BM Description = 1 � �. � � 2.) Bldg sewer length = - amount of cover = l Plan revision Required ?] Yes No Use other side for additional information. i_ —� - -J — -- Date A �Insepcto s Sigma re Cert. No. SBD -6710 (R.3197) Safety an ui ings t ounty _ � Ma 201 W. Washingto ve., P.O. Box 7162 1 *i s c O��, dison, WI 3707 -�3 62 Sanita Permit Number (to be filled in by Co.) (608)2 '= 31y�U� 2, 8 ZOO 93S Department of Commerce State Ian I.D. Number Sanitary Permit Applicatio I CROIX COON Y In accord with Comm 83.21, Wis. Adm. Code, personal informatio o ING OFFIC may be used for secondary purposes Privacy Law, s15.04(l X - , Address (if different than mailing address) 1. Application Information - Please Print All Informatio o z(. - IRS` orb Property Owner's Name KIO Parcel # Lot # Block # I fla F/1 -- WD MFS / Property �Owner's Mailing Address Property Locatio 0.' /I /4 d l7 5 'h, Section 3 '0,) City, State Zip Code Ph 3 716 5 �p g( circleAeJ T N, R E o II. Type of Building (check all that apply) Subdivision Name CSM Number ❑ 1 or 2 Family Dwelling - Number of Bedrooms W !tom w 111 - Er4r�s? ❑ Public/Commercial - Describe se ❑ State Owned - Describe Use �� -ENS ❑City_ ❑Village (township of QIGN'ult.� z- 3' K4 Z' TIELSMe. III. Type of Permit: (Check only one box on line A. Complete line B if applicable) IF) A, )Z New System ❑ Replacement System [3 Treatment/Holding Tank Replacement Only El Other Modification to Existing System C 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 3 6 Non - Pressurized „In -Ground ❑ Mound > 24 in. of suitable soil C1 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 Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dis rsal/I'reatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Pr posed (sf) I System Elevation o � C� ''__ - ,� 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 ' Z,{b U3 . 1 5 4F7rt— FILTZ Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number 7 es Number MIk.F- tM= d�Kc�� tM;�.. K �2� -z�3� iz- V4s -/sz7 Plumber's Address (Street, City, State, Zip Code) VIII. Count ' /De artment Use Onl Sanitary Permit Fee includes Groundwater Date Issued suing nt Signature (No Stamps) Approved ❑ Di oved Surcharge Fce) ❑ Owner tven Reaso r Denial I7(. Conditions o prov 1 l '� SYSTEM OWNER: / 11 1 Septic tank, effluent Filter and dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances. Attach complete plans (to the County only) for the system on paper not less than 81/2 111 inches in size SBD -6398 (R. 01/03) •c �0 s 0 s d rr Uj ID n O �\ L� v •v �1 1 c o p*4 $� is r m N 1► LV rA 1 � f \ q -Z 16 - Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings In accordance with Comm 85, Ws. Adm. Code Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must � include, nottxut 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 MW346�! � [) R 'owed by Data Personal information You provide may be for secondary purpc (Prr -CY t.aw. . 15.04 (1) (m)) C 0" Pmpeqoww 5 2003 f ot�} 1143 Li 114 S� T () N R $ E( W PropeRy s Malting Address S . C1 : U ! X C 0 U N l k" t Block # Sttxf Name or CSNdN J •-/ -- / � fJ OFFICE M Cry pate Zlp Code Phone Number ❑ CRY ❑ T Nearest Road �% SY& A ) i Pf Now Construction User Residential 1 Number of bed ooms Code derived design flow rate `7�.rD GPD ❑ Replacement ❑ Pubic or commercial - Describe: -- Parent material oa C.� Flood Plain vation If applicable N) it. General comments and recorrrrrendatione: Sy 5W-e,k. e, 9y a Boring # � Pit Ground surface elev Depths to limiting factor � in. r"s R ate Fhorixon Depth Dominant Redox Descrip4on Texture Structure Consistence Boundary Roots G In. Mtmsel CXL Sz. Cont. color Gr. Sz. Sh. ff#1 •Eff#2 3 i -/ o CIO 151 Pit Ground surface elev. ft Depth loo limiting factor lo ' Sol Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDff It. Munsel Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 rn > cs Z r m ^ r -Z -L w r ID r /'Z. 3� 42 • 1= SOD > 30 < 2 =11W . S Etf�t #2 = BOD <_ 30 mg& and TSS <_ 30 moo. E11ueM # CST Number s e Evaluation Conducted Telephone Number 400 o Property Owner Parcel ID # Page of BOFh9 # ❑Boring a 0-Pit Ground surface elev.� # Depth to limiting factor SoN Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIf'l' In. Munseti Qu. Sz. Cont. Color Gr. SL Sh. 'Eff#1 'Eff#2 �U 3 SL o� rTi ►' C 2m Z �G' s 4 w f 6's t n a Z 3, ti Bodng # ❑ e ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soff Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW IM Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'ES#1 'Efr#2 Boring F-1 # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to Cxniting factor in. Sol ' Rate Horizon Depth Dominant Color Redox Description. Twd ure Structure Consistence Boundary Roots GPDW In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD > 30 _< 220 rng& and TSS >30 1150 mgA- ' Effluent #2 = BOD < 30 mg& 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. Soil Test Plot Plan Project Name David Railsback S u d Address 845 133rd Ave New Richmond Wi 54017 C M #226900 Lot 10 Subdivision Date 12/12/02 SW/NW 1 /4SW /N W 1 /4S 30/31 T 30 N/R 18 W Township Richmond ❑ Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. =Top of Survey Iron = _g A System Elevation 94.5/91.9 *HRpSame as Benchmark ItDBM -T op of Steel Fence Post @ 104.0' Alt t� B.M. B.M. 50' 303' Property Line 40' B -1 •, 40' Please Note: Tested area may not be B- 170' suitable for desired building area. Check system location before 80' excavating. Soil test was done to satisfy Zoning Requirement. 9% Slope 97' 363 95' Property 96' Line I F - G11la4-d etaj — i64',57 4T' ` SAFETY AND BUILDINGS DIVISION Plumbing Product Review ' / P.O. Box 7162 I ����— a/V��S Madison, Wisconsin 53707 N visconsin Department of Commerce Jim Doyle, Governor Cory L. Nettles, Secretary February 18, 2004 INFILTRATOR SYSTEMS,INC CARL W. THOMPSON 6 BUSINESS PARK RD. PO BOX 768 OLD SAYBROOK CT 06475 Re: Description: LEACHING CHAMBER Manufacturer: INFILTRATOR SYSTEMS, INC Product Name: INFILTRATOR QUICK 4 STANDARD Model Number(s): INFILTRATOR QUICK 4 STANDARD (EISA for chambers = 19.1 sq. ft. /chamber, EISA for end caps = 5.8 sq. ft. /pair of end caps, Laying length of chamber = 4.0 ft., Laying length of end caps = 1.0 ft., Width = 34 inches, Height = 12 inches, Max. depth of bury = 8 ft., Open Bottom area = 9.1 sq.ft. /chamber, 1.96 sq.ft. /inlet end cap, 1.51 sq.ft. /outlet end cap) Product File No: 20040030 The specifications and /or plans for this plumbing product have been reviewed and determined to be in compliance with chapters Comm 82 through 84, Wisconsin Administrative Code, and Chapters 145 and 160, Wisconsin Statutes. The Department hereby issues an alternate approval to s. Comm 83.44 (4)(a) 1.a. based on the Wisconsin Statutes and the Wisconsin Administrative Code. This approval is -valid until the end of February 2009. This approval supercedes the approval issued on February 2, 2004, under product file number 20040030. This alternate approval is contingent upon compliance with the following stipulation(s): • This product must be installed in accordance with the manufacturer's printed instructions, product approval, and plan approval. If there is a conflict between the manufacturer's instructions and the product approval and /or plan approval, the product approval and /or plan approval will take precedence. • When this product is installed in a dispersal cell that is sized based on the EISA rating stated in the regarding block of the product approval letter, this product must receive wastewater having a BOD5 value between 30 and 220 mg /L and a TSS value between 30 and 1.50 mg /L. • When this product is installed in a distribution cell that is sized based on the EISA rating stated in the regarding block of the product approval letter, this product must be installed in individual excavations that create a row of chambers that are horizontally separated from other rows in other excavations by at least 3 feet. The 3 -foot measurement is measured between the closest out side edges of the leaching chambers. • When this product is installed in a distribution cell that is sized based on the EISA rating stated in the regarding block of the product approval letter, the distribution cell design must allow at least six inches of ponding in the chambers without backflow of wastewater into the drainpipe that discharges into the chambers. SBD- 10564 -E (N.10/97) File Ref: 04003003 Q Iick4rM STANDARD CHAMBER _._ - - -- 52 - - -- - - - -- Duick4 Standard Chamber -- - - - - -... -- 48'' - - .. - - - -- -- - - _ (EFFECTIVE LENGTH) a I to i -- - - 34" --- - - - - -- - -- -i SIDE VIEW SECTION VIEW MultiPort End Cap 16" 3� -- - SIDE VIEW TOP VIEW I FRONT VIEW Ilk Quick4 Standard Chamber Nominal, pnciftcations ;; MUItiPM End Cap Nominal Specifications Size tarUR�. ( ) 34"x52 x12 Size 34 "x16 "x 12" W xLxH Effective Lengthk:t�. 48',� Invert Height 8" or 1.25" Invert Height r 8' ; i i i NFILTRATOR SY STEMS, _INC. STANDARD LIMITE WARRANTY e , ,I I pe o 1 will be, l q t 1 r pate HP. 1 (1 M rt,SAl I O R F11 I, II r I A, r ,,! 1, ,l ,, WTI ' N t : 14 , N r 5 SYSTEMS INC 3� Or rarPrt aN Af311 Iry R FI - N - ,^ r rir n , .�' I I v ?U R{ ) t I V l S , Iao eo I I J 1 to v In ,v e , „ t r 111 ll el n Environmental Onsite Wastewater Solutions oll 10. -, . 1 .> c t ch of I 1 • r -'. 6 BUSIfIeSS Park Road ' - 0 . Box Mh' e .nt of p p 1 li I' r - -e , e z Old Saybrook, CT 06- 75 . by hfllral, "IP Wx 'rr be void it theH 860 - 577- 7000•FAX 86C -5 r r:C'' j _ o cbal be I V ­s > ,l : 10 be >ln l F , 11,111, v , 800- 221 -4436 r�du_t 1,at t.v c1v r l - -1, For this b"1110.0, Warr;, 1v , aupl�. rr n t, , sl br; , , ,,, ,. , t, cc — by sl., , c 1 r5. i1 )Ibrr .,1,1, -able. I —, „7l, n 19?r IbS L' „e( Wftr V , ,.I . oll — , 'y e,ll ., n lm lea n 1,ry �1.. , �� _ e „1 Old Sevb nol.. f n, , ,. -. , a ' v IW a., ,.,. wa •anlV n or n L P o ,rG a,r. r r Jnd�;. RF L.C;I 5 10 1 '. '.0 10 ', 1111 1.1111 ,.. ,. C E "C(. O 1 F1 ,1 ., SN , '� Conecr,l,on. M,t�.rnl � , 1nq. � •.1, 1 „ �.,.. (.), (huc al'I;te 'E S:t i) Inc '( .- Inhllrnlnr c )valems In ap;,, 1 ,' U :, A Z ' IIEX /�Fa wt,Es w luEA E — Polylok PL -525 Support Stand o Should you feel it necessary to add additional support to the PL -525 filter, use a six -inch Schedule 40 or SDR 35 pipe to extend from the base of the filter to the bottom of the tank. The extension pipe needs to be anchored to the filter housing with one or two #10.X 1 /2" SS screws. Anchor 1 -2 Stainless steel screws j through housing and into pipe. Use #10 X 1 /2" a -- 6" Schedule 40 Pipe Pipe rests on bottom of tank - -- - F 7 - An � - z POWTS OWNERS MANUAL & MANAGEMENT PLAN Page of _ i ILE NFORMATION SYSTEM SPECIFICATIONS Owner / / �/ �� Capacity 25V al [, /`f p Septic Tank Ca acit ❑ NA Permit A Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer oL _YL,ok ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model �C.SZS' ❑ NA Number of Public Facility Units XNA Pump Tank Capacity al ❑ NA Estimated flow (average) yo gal/day Pump Tank Manufacturer ❑ N A Design flow (peak), (Estimated x 1.5) 6pa g al/day Pump Manufacturer ❑ NA Soil Application Rate 0.7 gal/day/ft' 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 ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L ](In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510' cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other, ❑, NA Other: ❑ NA Other: ❑ NA '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 eve ❑ month(s) (Maximum 3 ears) Cl N A ears) 3 y ears) out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once eve ❑ month(s) (Maximum 3 ears) ❑ NA n years) Clean effluent fitter At least once every: 1- Z ❑ month(s) ❑ NA ,JZ year(s) _ Inspect pump, pump controls &alarm At least once every: ❑ month(s) ❑ year(s) El N~ Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ N A 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. Tarr, 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 pone ing 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. I ,_TART UP AND OPERATION Page o f 7i or n,ev� 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: X 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 e..V alua ' a bu Mule re b e ai e FfZO",,5 nsz, AD � N N C0S l 0 tan C3 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 POTS MAINTAINER Name W Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name S Name Phone b 20, Phone '7 1s— (O o This document was drafted in compliance with Chapter Comm 83 .22(2)(b)(1)(d) &(f) and 83,54(1), (2) & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 1111 LLEt 1 Mailing Address W 4v lfs , a 1.1 / Property Address `� ( 3 I ' �rJ� v (Verification required from Planning Department for new construction) City /State MiU 2re* w/ Parcel Identification Number 4= z /09 LEGAL DESCRIPTION Property Location S� 1 /4, -3 ' /,, Sec. Town of to 1+ me) N .) Subdivision Lot # Certified Survey Map # 7 7 `'� Volume ° Page # 5Z6 Warranty Deed # '7-?5' z--SZ Volume Page # Z ' 5 Spec house yes ❑' no Lot lines identifiable/] yes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof your sep6c could result in its premature failure to handle wastes. Proper ma irate : _ e consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the s; s:e�: 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 'c;• a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposa l syst is in proper operating condition and/or (2) 4fter inspection and pumping (if necessary), the septic tank is less than 1/3 full of sl dgc. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the sued : set forth, herein, as set by the Department of Commerce mee and the Department of Natural Resources, State of Wisconsin. Certif c o stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office «der 3G days of the three year expiration date. �_ SIGNATURE F 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 the properTy described above, by virtue of a warranty deed recorded in Register of Deeds Office, < �7� hf ( 21-0-1 — 7 IZrG! o S� ' ­ � ' IGNATUP± OAkPPLlCkNT DATE .o**** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Depamnent • • Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is trade in the warranty deed i L� U, 27 26P 254 -7 8 -4 x152 State Bar of Wisconsin Form 2 -2003 KATHLEEN H. REGISTER OF DEEDS LEEDS WARRANTY DEED - ST. CROIX CO., WI Document Number Document Name RECEIVED FOR RECORD 01/05/2005 01:00PH WARRANTY DEED THIS DEED, made between David H. Railsback a /k/a David H. Railsback II 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: CC 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 Name and Return Address needed, please attach addendum): Lots 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. r�A6 026 - 1088 -95- 000 026- 1091 -70 -000 Parcel Identification Number (PIN) This is not homestead propert). (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. ) 1 � COUNTY � * Kristina Ozland I 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 -PROT' Legal Forms 800- 655 -2021 www.infoproforms.com J �O EAS �/o W ILLOW %�� .... i�ssr�ta ,.; �, -_ -� - Kt'lijt[2' '-- ;on: -- '93%rK1". -- ' `'. L.OT5 k G ( LOT 1 '\ u4.w:, 2 L.0 7 `mi 5 •�^ ci•..r +z 7;'9 aCf1,s ' '•� I' I �' �� ``� qA Ed, 1q 1. L �: / 3 ! 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' l r' f ., Ll I -v '� / 1 F.�tf ^rslvcut -0E'�4C aL '— T L..'T lr - / L OCATION SKETCH •� / - � FO •S-I �, i'' {\�. „• ,� 3I 'i ,.�,�yr,�T 1 nry ,6r v . 0 i ,' �4n1 uv..,.; r . _, P I .4, r WIF! i � /� a 1 • i � FLAT ,.a-: ��+.ru v{V,.,ymq d,ly f_cL Jn'1'_ft 0 flf:'MJil. f. ,T MILLER Call )im Henry & Associates for more details. �ef H OMES (800)221 -SOLD R��J Kv Information deemed reliable but not guaranteed. Jim Henry & As sociates �l . \ m .. m `✓ \ Zn I G►� TD mj' n u ' CO •O m co n F tv r � C P n n i v) \ _ m