HomeMy WebLinkAbout030-2131-24-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Buildit.g Division.
INSPECTION REPORT Sanitary Permit No:
453048 0
GENERAL INFORMA ION (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:
Glen Johnson Construction I St. Joseph Township 030 - 2131 -24 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
U 0, U V S 4 23.30.20.1078
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
.01/
Dosing Alt. BM
Aeration Bldg. Sewer
Holding
St/Ht Inlet
TANK SETBACK INFORMATION � � A / C' Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
U Z lez tfMIL4 .4 1L_ � � �0• �
i
Dosing Header /Man.
Aeration Dist. Pipe
Ru.3
Holding Bot. System
Final Grade
PUMP /SIPHON INFORMATION OI G I .3
Manufacturer D mand St Cover
PM i V/ ✓
Model Number
TDH Li Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to Well
S0 a.Y C) - I i
SOIL ABSORPTION SYSTEM
BED /TRENCH Width Length No. Of Trenches C y DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 / S� 3 �c�o
SETBACK SYSTE TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION HAMBER OR oOC
Type Of System: s �P�� � / UNIT Model Number:
DISTRIBUTION SYSTEM V
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
/� // Pipe(s) '
l l_engthL4_� Dia — I 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 Mulched
Bed/Trench Center t V Bed/Trench Edges O Top Yes ' ' No Yes 1 No
V Y
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:ob / 17 /cilL
Location: 1423 Settlers Way Hudson, WI 54016 (NE 1/4 SW 1/4 23 T30N R20W) Settler's Glen Lot 24 Parcel No: 23.30.20.1078
1.) Alt BM Description = (AV4A
2.) Bldg sewer length
- amount of cover =
(n� 3� -d� �,e 4 � & � s - N
- - - --
Plan revision Required? Yes No o
�i, _
Use other side for additional informati _!L j o_
SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No.
Safety and Buildings Division County
I vi— VICObsin ar 201 W. Washington Ave., P.O. Box 7162
Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce ( -3i51 D
Sanitary Permit App ' _ --- State Plan 1.0. Number
In accord with Comm 83.21, Wis. Adm. Code,
perso 1 infor MV �
may be used for secondary purposes Privacy w, s15.04(1)(m)
Project Address (if differ t than mailing address)
t
1. Application Information - Please Print All Information M p `� 1' 123 (,zJ'
Property Owner's Na me _ 2/ S l - a
C Parcel # Lot # Block #
(�7Z - D1 `//x.56 ,�Qll•�.S (/CZ�fCv OF y
Property Owner's M ing Address 2
P e/
ro petty Location v /
I City, State Zip Code Phone Number ry e' 'ti k,Section z 3
G S6 If -5
II. - (circle
T e}
1,t�1. Type of uilding (check all that apply) `Ph — T ,30 N; R E or�
is I or 2 Family Dwelling - Number of Bedrooms r yy[ � _ Subdivision Name CSM Number
❑Public /Commercial - Describe Use lG 0 / X e Y-5
� State Owned - Describe Use
❑City_ ❑Village; Iownshipof d - e
III, (�
I Type of Permit: Check only one bo�oniine a pplicable
I A. (. Syst ❑ Replacement System u Treattuent/Holdin
g Tank Replacement Ottly ❑ Other Modification to Existing System
I B ❑ Permit Renewal ❑ Permit Revision T O Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
I Before Expiration Plumber Owner
IV. Type of POWTS System: (Check all that a I) f sTItE
I N n - P ressurized 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 L! Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter
❑ Recirculating S ynthetic Media Filter Leaching Chamber ip Line ❑ Gravel -less Pipe ❑ Other (explain)
VV Disper sal/Treatment Area Information: ST _
j Design Flow (gpd) Desi n Soil A lieation Rate
T � -� 31 6?�✓
g PP (gpdst) Dt a Area Required (st) Dispersal Area Proposed (sf) System Elevation
- ado 120a 3 9 1.wd 3
VI. Tank Info Capacity in Total Number
mu • cturer Prefab Site Steel Fiber Plastic
1 Gallons Gallons of Units j,{// _ �D Concrete Constructed Glass
New Existing j
anks Tanks 1 / I
Septic or Holding Tank
Aerobic Treatment Unit
f Dosing Charnber
i_
VII. Responsibility Statement- I, the undersigned, asstt;ne responsibility for ins all ation of the POWTS sh own on the attached plans.
Plumber's Na me (Print) Plumber's Si gnature fP FRS Number
Business Phone Number
Plumber's Add re s� de)
Street, City, State, Zip Co �� 7
VII . Connt /De artment Ust Onl
Approved ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued ing A nt Signature tamps)
Surcharge Fee) �� I / O
❑ O wner Given Reason for Denia -- _.L_ �
i IX. Conditions of A proval / Reaso For �i proval" 2/
SYSTEM OWNER: eG tyGt(,4r l y�� �WT�
Septic tank, effluent filter and 0
l / dispersal cell must all be serviced / maintained
V - 7 2'fQ;YIGr/Zc eA—
as per management pla provided by plumber.
2. All setback requirements must be malntaaln
per applicable code /ordinances. SyS�
I 93, q3- r
Attach complete plans (to the County only) 4for the system on per not less 12 x 11 inches in siae t
SBD -6398 (R. 01/03) � �
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•- rw... -r. "� ' " .. .. �.�lr 1 1 C 1 , k ' ' J C 1 " :CA T t 0 w
u" CX VENT PIPE 12" MIN, ABOVE GRADE E
25' FROM DOOR WINDOW ()R 4EATHERPR00F
FRESH AIR INTAKE JUNCTION BOX APPROVED
WITH CONDUIT `iA.XHOLE COVER
FIN7SHE GRADE W/ PADLOCK 8
411 CI RISER ---•� i -- WARNING LABEL
i I t '
K X. ? `
RLET or
I an
WA:ER TIGHT SEALS
GAS-
1
TIGHT PPROVED
�y
^1� }}�'� l A SEAL ' ' ' JOINTS WITH
, PPRO ED 1
)1 S' � R ;. ?ALM a APPROVED PIPE
Wo Slit ID � - ' i ON f � 3' :ONTO
SOL I O, SO I L
PO MP OT ELEV. T ,
-•-- -- ►' RISER EXIT
D ! PERMITTED ONLY
IF TANK
MANUFACTURER
3" APPROVED BEDDING UNDER TANN'K HAS APPROVAL
CONCRETE PAD
SPECIF?CATICNS
SW °TIC DOSE
TANK MAYJFACT'JRER: , �aeY NUMBER DOSES PER DAY:
I: IVY, 5s'2ES: SEP `IC ;Wd GAL. DOS?" VOLUME: INCLUDING
DOSE ov �` GA L. FLOWBACK: 11 ..... 5? ......- GAL.
kL_ MANtJFACTtlR£R: _� crr..� CAPACi;IES: A� -
D� V -- •2 INCHES
MODEL NUMBER: . GAL.
SWITCH TYPE: 2
9 = � INCHES a
GAL -
' MANUFAC :'URER : ._. ,ll�.r'
MODEL NUMBER- ,�- C - ,, INCHES r /'...�e.......... "AL
SWITCH TYPE: D a — j� Zrxc)iES : G GAL.
EQu i RED DI SCHARGE RA Q r•
„� PM PUMP 9 A:..ARM WIRING AS PER ILHR 16.23' k'AC
ERTTCAL DIFFERENCE SE. oF 1 AND D I S TP , IB Li - TON plpE .
MINIMUM NETWORK SUPPLY PRESSURE 1.2 rEE'T
-�. FEET f ORCE;MAIN k �'�d FT /la0 tl F. , ,. T FEET o
,✓� --- F'R.CT.ON FACTOR FEET
6 J T0tAL DYNAMIC MEAD t gM'or t 3�
41TERNAL DIMENSIONS OF FUMF EtiGiH
WID JZ 3rTER
N,- !ma £R : 2ZY :A^'�
WEGERER $CIL T E$Tll G* rural: M
G ou lds POISE -7 o R
Submersible
�-` Effiuertt Pump
3871 EPO4
EP05
LIGAMU • Fiftorr: 300 slrfes • o'u�y �tbmerped in fallraw w h
u desKme ►ear vw sleet. g rade � tw ■ mow Howl* ow iron
1e: ' 4peble at rtm(n9 ubda dw udd1cwt f O( Mvt
systems d! wM1at demepe to hs1t wd dumb 4l
b
connow - a !Meier ftw. Thernpips,
Molar AeliteM@ bf wteaW k end Vc =w a�ndle
'Y sump • t:PO4 �M p a Muni aRuatleo, NO Ilolt>MIlclt atfethmint
der lraftarter 116 or23� V, SO tX, Sb0 ` nsodets tp point.
G RPM, bolt In owrtm with Ftod SWIM Ind • hover come: Sewn dto
Hp,
EP011 Si r 0"; - — PRO d 1h1 rebd of and WK Aelefarft,
N�Dl�AT • EPOi Bi- ny11 0 a n11eAep; per ind lower �fti: D'94 11l3 V, pG HL IRO RPM, t'lkngw vy diAyr brN l rfnq
bul6lrt ctirarload with
1 • " 1Arttadt reset t f 190111r. TNrmo- consb
. a �' ' Pwer Ord: 10 foal 13� Soil -"M *w
ahlle: up to U GPM, p
sw*m rerptt,,18r3 SJTp wrlh pop at � for LACY untN$
- toW heads: up to 2f
.1 twt, Mdg1 mne p amundin macfaW 81101 p
•
=AM l /�' NPT 014 D*naf 20 loot 4 ■ EPH t 11a: Thermo- %W �' a"a°w' »1�Y,�eAt,oarrar
Mhwamb Ci4ot1 �nOth,16�3 &ft whh AMC a m naJ"d"01 fvr (CSA mode! numbers
BUM -N ettisia (ateedttd oAMun ing P "uO 1 MpM d pMlor�reex:a, end En'r:' pr `AC
• 04 ( ro. camas ) Rug
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sous vroviael
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tip in 40 GPM. . r •
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'33/05/2004 14:39 7153862979 GLEN JOHNSON _ PAGE 08
PAGE
NAME - �. u �, c a ,.. LOT/E t " LEGAL DESCRIPTI 1/4 1 /4,S__ - _T
1 / 4, S — F4cw)W
SCALE: i"= �/G' �
ELEVATION: /rc� - c�
BM I DESCRIPTION:
13M 2 ELEVATION:
BM Z DESCRIPTi ; , • ' .-� � � �« c ;
SYSTEM ELEVATION; , ,�✓ V "
1) I wCV
SYSTEM TYPE: (4.- „�, *; ,,� ; ,,., , t • Y V
rtc� I
6
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SIGNATURE: �`
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Wisconsin Department of Corn roe 1 3 Zp,�OIL VALUATION REPORT Page , o f
Division of Safety and Building �;;,.
��fWcor+�e with Com 85, Wis. Adm, Code
"b / � County �
Attach complete site plan on paper not less than 11 in s in size. Plan must L
Include, but not limited to vertical and horizontal refere (BM), direction and Parcel I.D. 0 3U , (/
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 3 /
Please print all Information. evie Date
Personal information you provide may be used for seeondery purposes (Privacy Low, s. 1 5.04 (1) (m))• 2 Q
Propertyowner /f t K // PropertyLocati
�y� (� Govt. Lot &E 114,SG(J 114 S & T - �C) N R ZQ E (or*
Property Owmer's Malling Address L Bloa # Subd. Name or CSM#
o-o � �� �Gcr� r l�l �f Z T 7 e
C / State zip code Number ❑ Village ® Town Nearest Road
® New Construction Use: Residential / Number of bedrooms , Code derived design flow rate �, [ � C) GPD
❑ Replacement ❑ Pubic or commercial - Describe:
Parent material L1 Flood Plait elevation if applicable R
General oormlients /
and recommendations: Sloe w\- eA
' Borhg # D Boling
❑ Pit Ground surface elev. ` �� it.
Depth to limiting factor
f lion Rate
Horizon Depth Dominant Color Redox Description Texture Structure Cons �V -w
Gr
In. Munseli Qu. Sz. Cont. Color . Sz. Sh. (/ `Eff#2
o C S
3 32 - 71 r — L AS Z Ax C 5 1 c 119
❑ Boring
L= ! � e ® Pit Ground surface e(ev..� ; � n. Depth to iimi ng %cW in.
Soli &VIcaft Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPOM
In. Munsell Qu. Sz, Cont. Color Gr. Sz. Sh. "EMl "EM
I
6 r3 ft — S L ZmS6 Ln r Z C-
Zrn SL /'
D
" Ettltent #1 BOD > 30 1220 mg/L and TSS >30 c 150 mg& ' Effluent #2 s BUD 1 30 frtgll. and TSS 130 ffq&
CST Name (Please Print) lure CST Number
d
Address Date Evaluation Telephone Number
�/-� S a s- - a
Property Owner � Cv Vl ki Paroel ID #
��� ❑ Boring Page w � or
Pit G roun d su rface elev. � R Depth to lirniting factor _ L5 o i
Solt Rate
Horizon Depth Dominant color Redox Description Texture Stru tore Co wWen a Boundary Roots GPDNf
In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •EfF#1 •EfF#2
G 1° 3
�/3 - S` Zm�S CS I , s-
2 SiGI Znl�sJo / CS 2
(�o U L
y �s t - -
. i/o -(/ a
BorkV a# ° Borft
❑ Pit Ground surface elev. ft. Depth to limiting factor In. Sop Rate
Horizon Depth Dominant color Redox Description Texture StWuure Consistence Boundary Roots GPD"
in. Munsel Ou. Sz. Core. Color Gr. Sz. Sh. - Efi#1 'En#2
❑ °
❑ p Ground aurtaoe eiay. R. Depth to Nrrtitirig factor in
Sati APD11cation Rate
Hortam Depth Dominant Color Redox Description. Texture Structure CorWsteno Boundary Roots I QP
in. Munsel Qu. Sz. Cont. color Gr. Sz. Sh. •M1 •Eff#2
Effluent #1 = SM > 30 _< 220 aVL and TSS >30 _< ISO nV& • Effluent #2 s BOD, 130 mglL and TSS 130 mg1L
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 408- 266.3151 or TTY 608 - 264.8777.
sso.taso taeoo�
PAGE_OF
NAME: !�S k n LOT# Zz-I LEGAL DESCRIPTION: 1/4 Tjd _ E(Or)f
SCALE: I' fir
(�yv� ELEVATION: l a
BM I DESCRIPTION: Vl 1 ' � 1 r� ' ` c
BM 2 ELEVATION:
BM 2 DESCRIPTION: ' �' n j Z o a I C
q _
SYSTEM ELEVATION: [ fi
SYSTEM TYPE: 06 n r�� J�✓t� I
�°-
S
�lv \ J(
u
i 1 .
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 81/2 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 I rest road. Z�
Please print all torm Reviewed by Date
Personal information you provide may be used for ary purposes (Privacy Law. S. 15. (1) (m)).
Property Owner; T rty Location
Lot NE 1/4 5 �� 1/4 S 23 T �j N R 2U E (or W Property Owners Mailing Ad s Subd. Name or CSM# City State zip Code Phone Number
ity Vila a I1 Town Nearest Road
hN 55o 2- vp5i )y ?9 -2 11 14 , 14 3s
[� New Construction Use: [p Residential / Number of bedrooms Code derived design flow rate 1 1' 5 -0 /6 0 0 GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material C� y +L Q S � Flood Plain elevation if applicable ✓�� - n•
General comments 5 y,54 - elm e k V , 6 /( 0
and recommendations: � r e l e tf /� Sv
Boring # ❑ Boring
® Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2
0- 1p lCs 3 z SI 2
2 -30 1(4 — SL 2ms r c
3 30- q0 10 1 C
7Z # ❑ Boring n
® Pit Ground surface elev. t' -66 ft. Depth to limiting factor 12 � in. Soil Application 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 'Eff#2
tDlir 31 2- S i I 2i� (v
Z 10 - 24 v 413 S t- 2
(-0s I
Effluent #1 = BOD > 30 < 220 mg1L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
Adam 253309
Address Date Evaluation Conducted Telephone Number
tit3 �d�� 5� . Sorr,2r Sep UJ ! 5�kv25 $ - / fj O Z C 1 5� Z4 I - 4ad$
` .- .
Property Owner Gxrj Parcel ID 11 Page Z o
F
Boring # ❑ Boring
f ...:
❑ Pit Ground surface _g° IL Depth to limiting factor 120 In.
Horizon Soil Application Ra
Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDtIt
In. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. 'Eff #1 •Efff12
- 10 10 3 S ( Zrti ,alJk
m�- c5 lv�
3
30 -60 cep . 5 ;- l6 - s
F] Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rai
Horizon Depth . Dominant Color Redox Descriplion.._ .. Texture - Structure Consistence Boundary Roots GP D /fl:
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 'Eff#2
Boring # ❑ Boring
❑ Pit ' Ground surface elev. fL Depth to limiting factor in.
Soil Applicalion Ralt
Horizon Depth Dominant Color Redox Description Texture . Structure Consistence Boundary Roots GPD /ft=
In. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. 'E(t #1 'Eft #2
• Effluent #1 = BODs > 30 < 220 mg/L and TSS >30 < ISO mg/L • Effluent #2 = BOD < 30 mg/l, and TSS < 30 mg /I.
The Department of Commerce is an ecptal 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.
SBM1330 M07/00)
i
Property Owner
Parcel ID # Page Z of
3 Boring #. ❑nn Boring
•: : [jI Pit Ground surface_elev.% - n ft. Depth to limiting factor in.
Soil Application 1
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/1l'
In. Munsell Qu. Sz. ConL'Color '.' " Ge. Sz. Sh. •Eff#1 •Effh
- l0 10 4r NZ 5 i J Z� r,�.bk mfr c 5 v 5
, Gl
IO r 4kp CZ - 1"Syr 9 ko .5c-L Zry 5 mvr' - (�
F Boring# ❑ Boring
❑ pit Ground surface elev. ft. Depth to fimiting factor in.
Soil Application R
Horizon Depth Dominant Color Redox DescxipUon..- .. Texture _Structure Consistence Boundary Roots GPp /fl=
In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 'Effie
a Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting /actor in.
Soil Application R
Horizon [ fin. th Dominant Color Redox Description Texture . Structure Consistence Boundary Roots GPD /ft'
Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eft #1 •Elf#
Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mA • Effluent #2 = BOD < 30 mgN and TSS < 30 mg/l.
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608- 264 -8777.
Sea13"M07 /00
I
f
v
PAGE - OF 3
N A ME LOT #Zy LEGAL DESCRIPTION /yF Y510 X ,S Z 3 T 30 N R Zo 1~(orl�
--------- - SCALE: I"= �Q
BM 1 ELEVATION 16::�)- y
BM 1 DESCRIPTION
BM 2 ELEVATION
BM 2 DESCRIPTIO cc L
SYSTEM ELEVATION
SYSTEM TYPE f)) ou V'A _ �-
CONTOUR ELEVATION
I
0
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-s
d� _yea
s
� D � 1
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0
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SIGNATURE DATE L3 a
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer GLej �Dj4 (mob _ m UC7? olJ . �lV C
Mailing Address ov
Property Address
(Verification required from Planning D artment for new construction.) S-
Gn���
City /State Parcel Identification Number - 2 / 3 / — Z `� — W
LEGAL DESCRIPTION
l
Property Location S6 '/4 , S '/4 , Sec. , T N R 2 6 W, Town of J�
Subdivision cirt C a uAi ,Lot # .
Certified Survey Map # , Volume , Page #
Warranty Deed # - 7S& S S , Volume Page # 06))
Spec house yes no 114 ('C 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. 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.
I/we, 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 tstati your sep tic system has been maintained must be completed and returned to the St. Croix County Zoning
Departm ays o the three year expiration date.
u
SIGNA OF APPLICANT DATE
OWNER CERTMQATION
we a 'fy that I statements on this form are true to the best of my /our knowledge. I/we am/are the owner(s) of the
pro escr abov by virtue of a warranty deed recorded in Register of Deeds Office
S ATURE 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.
S T CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FOR-M
Owner /Buyer h �ei sem C,
Q
d.0fX
\Zailirg Address h Street No La e mo
Property Address
(Verification required from Planning Departm t for new constntetion)
City /State Town nf qt- _ .7'-% nh WI Parcel Identification Number Gan Afta rhed 11ocC3 4�Mr
LEGAL DESt`RI TON A30 — y� 6::z
Property Location Y�, Sec 23 , T 3n N -R 26 W, Tow o f ._S.t _ aIn h
Subdivision Sattler' s Glen
Lot
Certified Survey Map #
—, Volume __, Page #
Deed # - 7 �O SO S
'arran —
h' _700569 &e �C4_ SA P, Volume .2 52:0 Pa,e # C /
Spec house 9yes D no Lot lines identifiable, yes D no
SYST N ,
Impreper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper in intenan�t
consists of pump� out the septic tank every three years or sooner, if needed by a licensed pi=pe What you p;,t into the system
cam 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,
master plu signed by ti,4 ;,�.�,.r
mber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site ed by r titer disn al d t` m
is in proper operating condition and/or (2) after inspection and pumping (if necessary), t11c septic tank is less than 1':r full of ;( �'; z.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system, v;itl. Gu
set forth, herein, as set by the Department of Commerce and the Department of Nariaal Resources, State of '�:'iscrnsin
Your septic syste . Ce t fic2:ic,c
stating t;at m has been maintained must be completed and returned to the St. Croix County Zontrts ufficc witi,�,
gays of the three yetr expiration date.
APPLICANT Z d
�TT<r h rOt l U.• F
OWNER R'1f 1r AT N
I (we) certify t t all statements on this four, are tru best of my (our) hr ouitd�., 1 3111
t e r ;cper c
y derib ove by virtue of a wa e w t11c rranty deed recorded in 1?eGister of Deeds Q ;c,
4 14A �':PIE OF APPLICANT Lf
Any information that is ,- r.i3- representedmay result in the sanitary permit being revoked b% ,h. 7- n.. , .....,_.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page _L of Z
FINE INFORMATION SYSTEM SPECIFICATiONS
Owner
rmit # �OM/JS Ai cIG�O / Septic Tank Capacity ,,Z rJ al D NA
Pe
Q Septic Tank Manufacturer O NA
DESIGN PARAMETERg Effluent Filter Manufacturer O NA
Number of Bedrooms 0 NA Effluent Filter Model �`� 0 NA
Number of Public Facility Units ❑ NA Pump Tank Capacity al 0 NA
Estimated flow leverage) oVda Pump Tank Manufacturer l ie s to 0 NA
Design flow (peak), (Estimated x 1.5) �ry g al/day Pump Manufacturer ,,, / ❑ NA
Soil Application Rate S al /da /ftz Pump Model 0 NA
Standard lnffu&WEffkjent Quality Monthly av erage' Pretreatment Unit NA
Fate, Oil & Grease (FOG) S30 mg /L (3 Sand /Gravel Filter ❑ Peat Filter
Siochamfcal Oxygen Demand (800 9220 mg /L O NA 0 Mechanical Aeration O Wetland
Total Suspended Solids ITSS) 515 mg /L O Disinfection C3 Other:
Pretrested Effluent Quality Monthly average Dispersal Collis) O NA
Biochemical Oxygen Demand (800 930 mg /L O In- Ground (gravity) 0 In- Ground (pressurized)
Total Suspended Solids (TSS) 530 Mg /L NA 0 At -Grade 0 Mound
Fecal Coliform (geometric mean) 510` cfu /10 p Drip -Line ❑Other;
Maximum Effluent Particle Size Ya in dia. p NA Other, O NA
Other: Otrar-
❑ NA (] NA
*Values types for domestic wastewater and septic tank effluent. O tt : ❑ NA
MAINTENANCE SCHEDULE
service Event Service Frequency
Inspect'conditicn of tank(s) At least once every: a a tliilardnmm 3 years) O NA
Pump out contents of tanks) When combined sludge and scum equals one -third 14) of tank volume O NA
inspect dispersal cells) At least once every: 3 earths) (Modinum 3 years) 0 NA
Clean effluent fiker At least once every: months) p NA
Inspect Ptmtp, Rump controls & alarm At least once every: ---- O eartalIs) O NA
Flush laterak and pressure test At least once every: . month(s) O NA
Other:
O earls) At least ante every: --.- months)
p ar(s) ❑ NA
Qther.
E3 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 tankis) 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 around surface.
The dispersal cellis) 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 912 months, shall be performed by a certified POWTS Maintalner.
A service report shall be provided to the local regulatory authority within 10 days of comp"n of any service event.
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KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO., WI
STATE BAR OF WISCONSIN FORM 1 - 2000
RECEIVED FOR RECORD
Document Number WARRANTY DEED
03/12/2004 10:00AlI
THIS DEED, made between St. Joseph Development Corporation a WARRANTY DEED
Minnesota Corporation Grantor, and Glen Johnson C onstruction, I nc., a EXW #
Wisconsin Corporation Grantee. REC FEE: 13.00
cantor, for a valuable consideration, conveys to Grantee the following TRANS FEE: 257.70
described real estate in St. Croix County, State of Wisconsin (the COPY FEE:
"Property "): CC FEE:
PAGES: 2
SEE ATTACHED EXHIBIT A
Recording Area
Name and Return Address:
Land Title Inc.
1900 Silver Lake Road Suite 200
New Brighton Mn 55112
U o 7 3
Together with all appurtenant rights, title and interests. 030 - 2043 -10 -000 030 - 2032 -10 -000 030 -2032-
70 -000 030 - 203 - 340 -0000 30- 2033 -20 -000 030 -
2032 -50 -000
Parcel Identification Number (PIN)
This is not homestead property.
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except
Dated this 1 Ith day of March 2004.
St. Jose Development Corpor tion
�•
* Kellei St. Martin, Vice President
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF Minnesota )
WASHINGTON COUNTY. ) ss.
authenticated this I Ith day of March, 2004 Personally came before me this 11th day of March, 2004
the above named Kellei St. Martin, Vice President of St. Joseph
* Development Corporation, a Minnesota Corporation to me
TITLE: MEMBER STATE BAR OF WISCONSIN known to be the person(s) who executed the foregoing
(If not, instrument and aclanowledged the same.
authorized by § 706.06, Wis. Stats.) IV, K, C
THIS INSTRUMENT WAS DRAFTED BY
Notary Public, Atate f Minnes to
My commission is permanent. (If not, state expiration date:
Greg Booth A ttorney 1900 S ilver L ake R oad S uite 2 00
New Brighton MN 55112
(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 NANCY J. LENTZ
NOTARY PUBLIC - MINNESOTA
WARRANTY DEED STATE BAR OF WISCONSIN My Comm. Expi FORM No. 1-20
r '
Il; 2526P 002
EXHIBIT A
Lot 24, Settlers Glen located in the Town of St. Joseph, St. Croix County, Wisconsin.
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