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HomeMy WebLinkAbout026-1175-21-000 Wisconsin Department of Commerce Count PRIVATE SEWAGE SYSTEM St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 479394 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal)nformation 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 Richm d, Town of 026- 1175 -21 -000 CST BM Elev: Insp. BM Eley BM Description: tJJ Section/Town /Range/Map No: /(� Iv 13 tm l 30.30.18.1421 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. �8 `►b - I.3. Septic S a- Benchmark R�' � / z�a 5• � �d5.2o 1 uo B c �- Alt. BM q " 2 � JZ �r l , o a� �oc,�Z Aeration Bldg. 8ewer $ .a 1 q4. Z Holding St/Ht Inlet I. V5 95.35 TANK SETBACK INFORMATION St/Ht Outlet 16. 15 T 01 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 54 /�/ , / 4 , Z7 1 27 i _ Dt Bottom Dosing Header /Man. /6-3 Aeration Dist. Pipe 97. 5 I Holding Bot. System C136 Final Grade 6'.® 1 ! , L- O� PUMP /SIPHON INFORMATION Manufacturer Demand St Cover r ` 4. Z0 16 GPM , LA Model Num r 11, Z I Z7. TDH Lift Friction Loss System d J TDH Ft ci.5 95.7 Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width t 7ength No. Of Trenc PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 1 ' Z ✓, SETBACK SYSTEM TO I P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR c Type Of System 12 ` /]__ /V - UNIT Model Number: `VI, eve" , a 1 z Zc� t � DISTRIBUTION SYSTEM 2 3 f"�-- Header /Manifold / / Distribution x Hole Size x Hole Spacing VentAiy/IntalSg r Pipe(s) (/ Length P Dia Length \ Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulch d Bed/Trench Center Bed/Trench Edges \ Topsoil \\ Yes No Yes [ No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 1312 92nd Street New Richmond, WI 54 17 (SW 1/4 SW 1/4 30 T30N R18W) Willow River East Lot 21 Parcel No: 30.30.18.1421 1.) Alt BM Description = °�- i 2.) Bldg sewer length = `I 7 AkLj - amount of cover = 1 Plan revision Required? 'J Yes No Use other side for additional information. IZ' I 65 L Date Insep or's Sig t re Cart. No. SBD -6710 (R.3/97) I , Safety and Buildings Division County J T - f p � 201 W ` . Washington ox 7162 l` f��O��I� Madison, WI 707 -{' ermit Number (to be filled in by Co.) �7 608) 26 -3151 - -"Etv / ?9�9� Department of Commerce State P I.D. Number Sanitary Permit App JUL 2 8 20 - -- - In accord with Comm 93.2 1, Wis. Adm. Code, personal i provide may be used for secondary purposes Privacy Law, s15.040 Project ddress (if different than mailing address) �T• CROIX COUN 3 1 4 Z., AAA S T 1. Application Information -Please Print All Information j !I /eqM vp Parcel Property Owner's Name # Lot # Block # LL�� -- o�I�S 5 '� � °t� z' / Location Property Owner's Mailing Address n a Property 'h O tP a�� „ 5 . s � ' /., Section O City, State Zip Code Phone Number (, circle P t D a , x t�) 5 � � � s T 3 tO N; R / E O II. Type of Building (check all that apply) Subdivision Name CSM Number ❑ 1 or 2 Family Dwelling - Number of Bedrooms , b I %e e� -S7_ WIL� Gyt_ �rI ❑ Public/Commercial - Describe Use a ❑City_ ❑Villageownshipof �d ❑state owned - Describe Use - Qv 1 e.k s /9 dt rAc:4 c.0 a- - L 111. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑other Modification to Existing System ❑ Permit Transfer to New List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Before Expiration Plumber Owner IV. Type of POWTS System: Check all that ap l eNon - Pressudzed_In- C,round ❑ 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 W.L.eaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑Other (explain) V.DistvermsaVlTreat ment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Pro (s System Elevation �mm q5 23 89o.Z 90.70 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 X I Ls I u t Pot to 1c Dosing Chamber 0 - SZS VII. Responsibility Statement - I, the andetsigned, assume responsibility for installation of the POWTS shown on the attached platys Plum bees Name (Print) Plumber's Signature ^ - MPlM� �m� 3 � Business Phone Numb N(l� E- NI - oN L L VALA_ Plumber's Address (Street, City, State, Zip Code) VIII. Count y /De artment Use Onl Approved = Sanitary Permit Fee -.-.udes Groundwater 1 suin Agent Signature o Stamps) Surcharge Fee) yt rven R or Denial ��(JJJ IX. Conditions pprtiva Reasons farBisapproval 3\ S� SYSTEM OWNER: J ` 1 Septic tank, effluent filter and p� ��Q o.A 4c lw_v� 0_1 dispersal cell must all be serviced / maintained P r1 as per management plan provided by plumber. V S u tiM 2. All setback requirements must be maintained c�� as per applicable code /ordinances. Attach complete plans (to the county only) for the system on I paper not test than 81/2 x It inches in size t SBD -6398 (R. 01/03) wt s C) /j'! r'LL� ►2 /-/o tit E S w/ C G ocv P1UEQ -. r'W 37 z / s y 0' ,P El� = 9 a, s 1 3iz 9Z 57A o�� : Tip/ i s / 5 f1 ►? �0/l S� a �l MFR � N �:.. �a o IM , Top ¢.+1, sr r M4 ' Z Zoe / 3' f} �TEly-NA o - 0 �',�e�MNT Wboonsin oepartrnent 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 8112 x 11 inches in size. Plan must JC include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions. north f)oaaod disddo crest road. ,.._ R by Date D Please print !! lrfln� * f= I Personal information you Provide may be used secondary Purposes (Privacy Law. s. 5.04 (1) (m)). J y Owner LoVon - 5? O Lot N 1/4 1!4 S� T d N R '0 E( W pl w Property Owners Mailing q t Biodc # Subd. Name or L ` JIiVCi UFI =ICE /' Oily Tip Code Number City ❑ U T Road y �J ( ) i New Construction Use: C4 Residential I Number of bedrooms 3 Code derhod design flow GPD ❑ Replacement ❑ Public or commercial - Describe: -- Parent material Flood Plain elevation if cable N) ft. General comments and rxxxrsrlendetiorw: Sy -cWe "~, e- D Boring # a Pit Ground surface ekw. R Depth to trrlifhg factor f-- In. Sot AplAcation Rate Horizon Depth Datrlirlt d Color Redox Description Texture Structure Consistence Bou ndwy Roots G PDff In. Munset (2u. SL Cont. Color Gr. SL Sh. •EB#1 *EiF#2 ,- 312 -- — ' co .� i Z 7- Boring # /A ® R Pit Ground surface eiev. ft �' . Depth to limiting factor —,.= in. Sot beplication Rate Horizon Depth Dominantcolor Redox Description Texture Structure Consistence Boundary Roots GPDf! In. Munset ChL Sz. Cont. Color Gr. Sz. Sh 'Efl#1 'Etf#2 & r 3 ,� L 2 r F" r S Zr `l CP e w • Effluent #1 = WD 5 :o 30 2M mg& and TSS >30 :*AIL ' Effluent #2 = BOD _< 30 mg& and TSS <_ 30 mg& CST Number r Address Date Evaluation Candu cted Telephone Nt mkw /ov;� .s` o> i A �d` �/� Property Owner Parcel ID # Page of Soft# ❑ o Pit Ground surface elev. —! % Depth to kni ft factor in. - Soll Application Rate Horizon Depth Dominant Color Redox Description Texture Sbu gure Consistence Boundary Roots GPD/ff In. Munsel Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 2 L� s zn l Z 3 . 3 o Y s os - Z F # ❑ Boring [] Pit Ground surface elev. ft Depth to fnTOV factor in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPI &r. Muni Qu. Sz Cont. Color Gr. Sz. Sh. 'Eff#1 'Etf#2 Boft# ❑ Bong ❑ Pit Ground surface elev. ft Depth >p lmiting factor in. Sol Rafe Horizon Depth DominentColor Redox Description_ Texture Stnxxtre Consistence Boundary Roots GPD/Ff In. Munsel Qu. Sz. Coat Color Gr. Sz. Sh. 'Etf#1 'Eff#2 Effluent #1 = BOD > 30 < 220 mglt and TSS >M : E 150 mglt ' Effluent #2 = BOD 1 30 mWL 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. sso•aswtaA" Soil Test Plot Plan Project Name David Railsback Sha r Address 845 133rd Ave New Richmond Wi 54017 #226900 Lot 21 Subdivision Dat 10/12/05 SW /NW 1 /4 /N W1 /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 System Elevation 92.7/90.7' *HRPSameasBenchmark Alt. BM Top of Steel Fence Post CC 104.0' Please Note: Tested area may not be suitable for desired building area. 300' Check system location before Property excavating. Soil test was done to satisfy Line Zoning Requirement. 427' Property Line 97' 2% B -2 Slope 96' 3 -- 95' 10 80' - 7 , 5 6 B -3 B -1 0 ' * Alt. B. M. B. M. 192' Property Line c SAFETY AND BUILDINGS DIVISION Plumbing Product Review P.O. Box 7162 ` isconsin Madison, Wisconsin 53707 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 c2ps = 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 150 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 th6 drainpipe that discharges into the chambers. SBD- 10564 -E (N 10/97) File Ref: 04003003 Quick4 rM STANDARD CHAMBER — 52 Quick4 Standard Chamber - -- - -- ------ - - - - -- 48°----- - - - - - - i (EFFECTIVE LENGTH) IM ­ EN 34" SIDE VIEW SECTION VIEW i Multil End Cap i - _ 34° - _._ ____ _ _ -_ SIDE VIEW TOP VIEW FRONT VIEW y "� t Quick4 Standard Chamber Nommal;Specifications MultiPort End Cap Nominal Specifications Size (WxLxH) 34 x52 "x12: Size(WxLxH) 34 "x16 "x12" Effective Length - " k Invert Height 8" or 1.25" Invert Height 1 d- g' g �{ ,,.. NFILTRATOR__SYSTEMS,.,INC, ST ANDAR D LIMITE WA RRANTY .... •.•._ �.,..., - n �, n3 nn se�rnerm,s.sund lo•��r e.lc :v: rr�laa :n�� �. -w,ln: )if S'N: S JBP.4RA(;F7AFF aI ARE 1=J(CLU$NE II11 f71- AI1E rJn 7ll WAr7f.�ul I� wllll IMF Spf_(r SYSTE - P t T U:.r ySle 'I't IflG1 e Y 1 y I I I III IO I V I �-: Environmental Onsite Wastewater Solutions' p.ls. o� otl ores or r pe .r,. r�l 1 , Irn Inlp th1.r, �, nv .nIP cl a Iv 1 1 1 o rc .n t h,ch ,re ,o1 >ecnnn1 b _.,I 1 1 .. r,., 6 Business Park Road " P.O Boy I .. v I n� I d P,Ic , ., mss, Old Saybrook, CT 06LI 75 Inhli: al< ^ -t \N be V id if ,ho Inch. li 1; 860- 577- 7000•FAX 860 - 577 -700' „a11 .le,hn 1pine„01, , 800- 221 -4436 i Fnr lhis Lrl,lfft Wec anly ;,nnn. ml... hn it n , - ,r _o n - ' - .,q ret!by'.SIA - ,.,. (, al. ] r,tf >I,bCablP. law And tifil1r:ic I;tllt :n,cl r ,QF 3(... a0f 11F ,0 ,- - r •('.} c F' _,.�., 9tr.. .... ­ It �Ir�gq atr)c 5 v Ir r r-) , Inhltntnr Svsloms In r n:n; 1 n ! i SA - ., ` <<o� Rr�ER �,�sT Polylok PL -525 Support Stand 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 112" SS screws. i 1 i 1 Anchor 1 -2 Stainless steel screws through housing and into pipe. Use #10 X112' 6" Schedule 40 Pipe Pipe rests on bottom of tank Al i POWT OWNER'S MANUAL & MANAGEMENT PLAN Page or 2 FILE INFORMATION SYSTEM SPECIFICATIONS Owner /�/LL Ax_ p Septic Tank Capacity aS al ❑ NA Permit A' 79 354 Septic Tank Manufacturer Lo 16S6R ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer POLY_OK ❑ NA Number of Bedrooms fL ❑ NA Effluent Filter Model Pf S2S ❑ NA Number of Public Facility Units NA Pump Tank Capacity al XNA Estimated flow (average) yGQ g al/day Pump Tank Manufacturer S �_- NA Design flow (peak), (Estimated x 1.5) 00 gal/day Pump Manufacturer qNA Soil Application Rate d, 7 gal/day/ft' Pump Model [�CNA Standard Influent /Effluent Quality Monthly average' Pretreatment Unit XNA 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) ❑ fvA Biochemical Oxygen Demand (BOD 530 mg /L XIn- 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 ec Ins p y t condition of tank(s) At least once eve ❑ month(s) (Maximum 3 ears) [I NA earls) Pump 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 ❑ E] y month(s) (Maximum 3 ears) NA 3 � year(s) Clean effluent filter At least once every: f -L ❑ month(s) 7— NA liryear(s) Inspect um ❑ month(s) ❑ NA p pump, pump controls &alarm At least once every: ❑ year(s) 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: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certificat cns Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer, Septage Servicing Operator. Tar , inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or IeaKSr 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 dispo$ed of in accordance with chapter NR I I 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. , ., TAP'UP AN OPERATION Page of 7i � 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: J� 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. 11111 til fill it T alua b e ai a �ROI -II'B TT�� �Ote•- AID✓ CaNS7K(1�7L n�ank ❑ 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 mt �Lku t_ PA (L rr l-L Name � 6-S Phone 12 . CJ�j ,57 2 00 to Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ( (h 20ti11 �J Phone Phone _771:3'_ (O D 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 M OWNERSHIP CERTIFICATION FORM Owner/Buyer / /L 1 1� S Mailing Address ��t � 0 Q /4 s� ^t S `l ° Property Address 13� q ZN 5T2Y (Verification required from Planning Department for new construction) W� eat (. -fore8' f5'-o aF Ciry fi� /State /� Parcel Identification Number ozr. - 1 6 9/- 7n - eoa o P`rT LEGAL DESCRIPTION Property Location !w ' /4, `) ' /,, Sec. 3° , T 3CD N -R W, Town of 2164 -uo t4 Subdivision W 1 L L-cD w 2 vim— C/-`5 T Lot # z - Certified Survey Map # 7 g 3 7 7 Volume a ' , Page # Warrauty Deed # 7 2 y Z s Z Volume Z - 7 2 - 06 , Page # ZSy Spec house X yes ❑ no Lot lines identifiable Y1 yes ❑ no SYSTEM MAINI`ENANCE Improper use and maintenance of your septic &tem could result in its premature failure to handle wastes, Proper_ma ate �::: e consists of pumping out the septic tank every throe. years or sooner, if needed by a licensed pumper. What you put into the s ;rs.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 b. a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal systcc: is in proper operating condition and/or (2) ,$fter 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 s un d':d sct forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Ccrtiflc: ^e:: stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office N „- I _" : 3 days of the three year expiration date. -tit_ NA 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 the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. �ZS OS - 0- � __ SIGNAIUU, 0 APPLICANT DATE 4 " 04 * Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Deparment. .... ” Include with this application, a stamped warranty decd from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed U, 2726P 2 54 ?84;E-- tfi2 State Bar of Wisconsin Form 2 -2003 KATHLEEN H. WALSH REGISTER OF DEEDS WARRANTY DEED ST. CROIX GO., WI Document Number Document Name REGEI YED 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 ll 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). COPFEEEE: 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 addend Lots 2, 3, 4, 6, 8, 10, 12, 19 21 nd 22, Plat of Willow River East in the Town of Richmond, St. Croix County, Wisconsin. r -51�6 026- 1088 -95- 000:026- 1091 - -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) �� , � , W 4 V (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. COUNTY ) * Kri. , is O Lyland 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.infoprolorms corn - r--4 - - r- . �.04' i C .04i \ rn N r co cc F- `_ � -� N Q �� �� �j �N� r�� « d -7cy t D NI oNO d X V80 .8Z ME �1�� ��iS3M 100009 n\mCZ, ooOON bc c, 7 ?S3�S� OWNERS COUNTY PLAT DAVDA ARIA RAILSBACK 845133RD AVENUE 111 CORNER WILLOW RIVER EAST NEW RICHMOND, W154017 SECTION 3o LOCATED IN PART OF THE SW1 /4 OF THE SWl /4 OF SECTION 30 AND IN PART OF THE NW1 /4 OF THI SECTION 31, ALL IN T30N, RI 8W, TOWN OF RICHMOND, ST. CROIX COUNTY, WISCONSIr\ SURVEYOR aa EDWIN C. FLANUM b NORTHLAND SURVEYING, INC. 856 A HWY'65' 1 P.O. BOX 14 ROBERTS, N 54023 NI CO/V LANN EDWIN RADIUS TEMPORARY ? FLANUM CUL.OE.SAC EASEMENT TO S -2487 /, BE EXfINGUISNEO UPON ' AMERY Y ROgp EMEN51pN N89 "E 1442.08' SOUTH UNE OF THE NORM 185.09 ETOFTHESWI /4 -S '�9yO... pr p It 132.29 524.' DRAINAG_E EAS_EMENI ___ 2�ae.TS xos.4s rrrrr n `\`t pc+ "\ _ . _ __ - \ _ _ _ _ NW4055E ` ++ 10 �1� '� '� `.` <__ N8B ° AO'55 /E 19105 ". - 49 9 t l E 105,W W40551 132.87 \ NT9°0 e, ef,`, y, `\` LOT 5 2.60 ACRES 113.235 sq. e n. �m \ I5 \ \ LOT 1 �'- I \ \ 1.88 ACRES �6,b\ LOT 6 81,887 sq. n., 2.10 ACRES 89V�pI WTI D Lmns I........... 1 91,345 sq. n - - ---------- i + I BENCHMARK 914.96 AT ` BENCHMARK ` SBg583T}W LOT 22 SEEDTLUNAGE `� ` ELEV.. 912.31 DING ++ ` x2.99 2.04 ACRES I I CASEMENT DETAE. ` .`� PON 66,e63 sq n. LOT 2 "ARE A v \ E nv. 1 ° se 6 2.42 ACRES r 2i LLEEV�Ai� _ _ _ �- Q $ 105,473 sg. n ,k 9,,. +` <� EASEME loc 148 100.00 ., TOSETE S8 wmw .300.49 LOT 4 " {W�1 1 , i 1 ` r!•�' 1.82 ACRES + + 4 70435 sq. ft. LBO -913.8 $ 2 I \ d 7 34 _ q� 88282 . n' `\ 10 r 1 \ \gs 1 FO NDIN LOT 3 ,s„ - --- 7 `. .�, \ '' I / `T2• I e 1NA•9kV'� 81,771 sq.h ` -- --- \ 1.88 ACRES LOT �' � /�v / Q '�,\ 2.04 AO / LOT 20 l e v. I \ \ ¢ 'Tb eo s, LOT ® 1.81 ACRES USO�93D.o S7 I BENCHMARK 5S \ ' �' I EIEV..9295t 5T0� \ \ ��• 1 / ' . �'i i`` ✓, t944 ACRES s \ N \', ; '/, ,: `• ELEV. .p33.,! 84,295 sq. fl•'' 2 , LOT 10 2.53 ACRES 110,395 sq. n. SEE AE LOT 16 1 1.88 ACRES , \ Yx �\ •zL `� LOT 11 'Zi I Y SEE ACCESS RESITBCTION 55YV NOTE \ 1.88 ACRES O SW CORNER r i I N85°30 3D423- '' NIP \ s 81,753 sq. n' SE ULU ION 31 LOT 17 ® / LOT 13 1.57 ACRES / 2.14 ACRES 68,226 sq. n / \ ` / 93,081 sq. n 1 LBO -931,0 ..' LOT 12 LOT 16 �� of 34 ACRES �j - = ACCESS RESTRICTION NOTE 5 ♦P _ N - °-°_' ns.a• 1.79 ACRES 844 s 101,q. n �` sr Nes'75T»'w 76,143 sq. n L30 931. U3o.922V �9• V / PONDING 1 ELEV. "MA 72 AREA j _ LOT 14 HW ) SEE ACCESS RESTl*CTION NOTE 928.59 1 2.10ACRES BENCHMARK 91 8q. n. 2400 ELEV..937d5 SO LOT 11 b ��