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HomeMy WebLinkAbout030-2124-50-000 O 60 c m a c ° g I c y d I N E ° N (D L O 7 m I `a 000 r 2 n d n c o z o 0.- � U U ,y o O 4) •� N C C 0 L m N O Z m I N 3 c c V1 Y. c f0 C N O 3 o E � c�y v I w E ° co C:l .d. o ° N H Z ! a m C I o z ! c ° m o (D N U 7 O { •� O = O o a O L { O Z c Z 0 N ° z N N I E E { .. 4) Y O = d O. � I co .• � N C w d o N d ,. m e o z o 0 o a a o c E m m m � U Lo a O o *Ana �aaa �o y zt CL Z ° ° o U-) } N J U N N �V O N O O a N 00 9 d Q Z CA O w N e M - N N a) E O ° " U O ° d t € c -0 N N N N CL > O C N N C = N a da .O Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 479228 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: O'Sullivan, Mike I St. Joseph, Town of 030 - 2124 -50 -000 CST BM Elev: Insp. BM Elev: BM Description: _ Section/Town /Range /Map No: /00 ►� C�5 F 25.30.20.1009 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / �, e `�- �� / z ` b Benchmark �, t ' /� DO" O� a �, 52 .7 l0 A lt. BM Aeration Bldg. Sewer Holding St/Ht Inlet z 5 TANK SETBACK INFORMATION St/Ht outlet 13 / ` l 2 - - 1 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet \ ` Septic -7 25 ' 7517 ­T ' $ Dt Bottom Dosing Header /Man. ►3.2Z 92.'�S Aeration Dist. Pipe 2. Holding Bot. System l� -1/r cj v PUMP /SIPHON INFORMATION Final Grade 7 Z 71' cl Manufacturer Demand St Cover Z_-7 Model Number TDH Lift Friction Loss Syste ad H Ft Forcemain Length ia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length r No. Of T PIT DIMENSIONS No. Of P its Inside Dia. Liquid Depth DIMENSIONS 3 I eAd­N_, %.-- --- SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACHING Manufacturer: — INFORMATION Type Of System: ^ CHAMBER OR J-K C b ^jJ� �� 1 -775 1 f Y l— DISTRIBUTION SYSTEM Model Number. /v ��� Header /Manifold r! Distnbut' n \ i x Hole x Hole Spacing Vent to Air ake/� J! c f. Pipe(s) Zvi t,�d -4 Length 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 Mulched Bed/Trench Center Bed/Trench Edges \ Topsoil es [? No Yes [J No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / inspection #2: ! / Location: 1328 27th Street Houlton, WI 54082 (NW 1/4 SE 1/4 25 T30N R20W)) Birch Park Lot 5 Parcel No: 25.30.20.1009 1.) Alt BM Description = ToJ e. _ C 60'1� L=- Z C_ 2.) Bldg sewer length = ' - amount of cover = r Plan revision Required? j Yes 0 q �( Use other side for additional informs o� n' 4� se Date Inpct s Sign ure Cart. No. SBD -6710 (R.3/97) Safety and Buildings Division County ` MY 201 W. Washington Ave., P.O. Box 7162 1SC0nsn Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of C (608) 266 -3151 Co mmerce 9 ZZ.g Sanitary Permit Appl' ian State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal nform u WED maybe used for secondary purposes 'vacy , sl5..f � Project Address if different than mailing address ( g ) I. Application Information - Please Print All 1&6hwon JUN 0 u 2 13 f t / -4 Property Owner's Name P # B}oek AF- ST. CROIX COUNTY Parcel # Lot ZONING OFFICE Property Owner's Mat ing Address Property Location t — %a, .�,�L Section City, State Zip Code Phone Number i �s (circle I . ype of Bui ng (check all that apply) T�� N; R:; E ozo v 4�r� S .0 . 1 or 2 Family Dwelling - Number of Bedrooms ( Subdivision Name C um r ❑ Public/Commercial -Describe Use ❑ State Owned - Describe Use ❑City ❑Villag Township of III. Type of Permit: (Check only one box online A. 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 POWTS 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 Leaching Chamber ❑ prig kine ❑ Gravel -less Pie ❑ Other (explain) V. Dis ersaVIrreatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) I dis_pers ea Required (so Dispersal Area Proposed (sf) I System Elevation VI. Tank Info Capacity in Total Number Manufacturer rreiau Site Steel Fiber Plastic Gallons Gallons ofunits �a A - /Op �� Concrete Constructed Glass New Existing j / Tanks Tanks �� �' Septic or Holding Tank r Aerobic Treatment Unit Dosing Chamber VII. Respo sibility Statement- I, the undersigned, ass ;We responsibility for installation of the POWTS shown on the attached plans. Plum r' ame Print) Plumber'- Si MP/MPRS Number Business Phone Number Pl ber's Address (S eet, City, Staie, Zip Code) VIII. Coun /De artment Use Onl pproved ❑ Di ved Sanitary Permit Fee (in udes Groundwater Date Issued Iss ing nt Signature o Stamps) Surcharge Fee) ❑ n eason or � t7 tp �, IX. ConditionsApprova Rg - ° ^U e . n: -a., _ I SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all pQ 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 x 11 inches in size SBD -6398 (R. 01/03) 14.)��,� Vii✓ �� rr a a tr,O �6 c ,? 7' I� ,,Bra ' 33 e - lees Deb �i .33 ` � �c J Wisconsin artment of Commerce SOIL E T age of -g Division of Safety and Buildings in accordance with Comm 85, Code County Attach complete site plan on paper not less than 81/2 x 11 inches in size. PI ' include, but not limiter) to: vertical and horizo n Parcel I.D. percent slope, scale or dimensions, north a an i L ton a . Please print at information. Re ' by Date Personal informatlon you provide may be used for econdar os& (&ivmq�v, s. 16 04 (1) (m)). 0 S Property Own r Pro arty Location } ST. CROIX COUNTY Go .Lot 114 1/4 T N �(or -!L Pro rty Owners Add ss lodW # Subd. Name or G r City t Zip Code Phone Number ❑ City Village . Town Nearest Ro ( ) � c New Construction Usef Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material _ i ` " kg& Flood Plain elevation if applicable ft. General comments and recommendations: S�.s/��• Boring # E] Boring Pit Ground surface elev. 14,196 ft. Depth to limiting factor S` in. Soil Awlicallion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. rAont. Color Gr. Sz. Sh. *Eff#1 *EfF#2 Zr 4 4 " Q I i Boring # Boring ® pit Ground surface elev. Z ,�Z-5"5 - ft. Depth to limiting factor y /�S in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. nt. Color Gr. Sz. Sh. *Eff#1 *Eff#2 4 ¢ ej • 4 4 Lp SS v • E #1 = BOD > 30 220 mg/L and TSS >30 150 mg/L ' Effluent #2 = BOD a 30 mg/L and TSS 5 30 mg/L CST Na Signature CST Number Address Date valuation Conducted Telephone Number _1 Property Owner Parcel ID # Page r of Boring Boring # ❑ ® pit Ground surface elev. i /.'i ft. Depth to limiting factor - Z in. Soil A pplication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 s 9 9 ❑ Boring # ❑ Boring Soil F lication Rate Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 i ❑ 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/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30:S 150 mgA- * Effluent #2 = BOD < 30 mg/L 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. M4330(6.07/00) r 10'14 -11 2 I i 1� 3 ; 30 �� Wisconsin Department of Commerce SOIL EVALUATION REPORT Page I of 3 Division of Safety and Buildings in,accordahce with Comm 85, Wis. Adm. Code County St. Croix 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 Paroel I.D. 03 O ZQ 7C/ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. J O Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Quest Development, Inc. Govt. Lot E 1 / 2 1/4 SW 1/4 S 25 T 30 N R 20 E Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# Suite 150 10700 Old County Road 15 5 i Birch Park City State Zip Code Phone Number aity Flvllage ■ Town Nearest Road Plymouth MN 1 55441 ( 7¢3 -595 -9512 County Road E a New Construction L1seE] Residential / Number of bedrooms 1 to 3 Code derived design flow rate 150 to450 GPD El Replacement F1 Public or commercial - Describe: Parent material T .oess over out wash sands Flood Plain elevation if applicable ft. General comments This site is suitable as a below grade conventional r recommendations: �ivEO , F] Boring # 11 Boring � ST CRC;LX t a pit Ground surface elev. 99.70 ft. Depth to limiting factor 98 NTY 'QfW ate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boun alts in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#2 1 0 -24 10yr4 /4 Is Ifgr mvfr cs 2f 7 1.2 2 24 -96 10 r3/2 is Ifgr mvfr - - .7 1 . 2 2 Boring # Boring 91.60 96 Q 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/fP in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -13 10yr2/2 sl 2msbk mfr cs - .5 .9 2 13 -19 10 r4/4 sl lmsbk mfi cs - .4 .6 3 19 -26 10yr4 /4 s Osg ml cs - .7 1.2 4 26 -30 10yr2 /2 is Ifgr mvfr cs - .7 1.2 5 30 -41 10yr3/4 is lfgr mvfr cs - .7 1.2 6 41 -96 10yr3 /4 S Osg ml - - .7 1.2 * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg /L * Effluent #2 = < 30 mg /L and TSS < 30 mg /L CST Name (Please Print) Signature CST Number Thomas C Nelson 227387 Address Date Evaluation Conducted Telephone Number 1432 120th Street, New Richmond, WI 10/22/01 715 -246 -2454 'Sty_. 1 L Property Owner Quest Development.Inc Parcel ID # Page 2 of 3 a Borin g # Boring >96 . Pit Ground surface elev. 85'80 ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Ef1#1 *Eff#2 1 0 -14 1Oyr3 /3 - is 1fgr mvfr cs - .7 1.2 2 14 -21 10 r4/6 - is if r mvfr cs - .7 1.2 3 21 -51 10yr2 /1 - is Ifgr mvfr cs - •7 1.2 4 51 -96 10yr4 /4 - s Osg ml - - .7 1.2 F-1 Boring # C-1 Boring M pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring ❑ Boring # Ground surface elev. ft. Depth to limiting factor in. pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD, > 30 < 220 mg /L and TSS >30 < 150 mg/L * Effluent #2 = BOD, < 30 mg/L 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. S1113- 8330Test (R.07 /00) 1�A Of s 3ef 3 �r ISO t �► _ L10 d�► m 1 lop 0rWg1U % 100 b .�5•go Od ag, l� h e r &L �� I S V .� �Z-7 7 i PeAi o/ N ( I - o T -- To B E ft -x� F 4- N EE u> 1A.1 40 / Ur'D vfi L P /1V roe iSsv -" ce ©F 67 Xi 57 - 1;06- AIWS -) 4-11 PERtl f' T - 5 0 30 • 2,03 l • Zo . 0z7v CdN Ti=e T lvIS 30 Z U 3,10 , Ulbricht 8 Associates Private Sewage Consultants 3 0 .2— � Hu on, is. �/ o Hudson, Wis. 54018 _715, 3 SG • ?/8 S- 7i 5 - 77;�- • 3 Vf1-2- f POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page / of FILE INFORMATION SYSTEM SPECIFICATIONS }} Owner Septic Tank Capacity - al O Ni, Permit # I 1 22 Septic Tank Manufacturer - O N 4 � i DESIGN PARAMETERS Effluent Filter Manufacturer `` O Nf Number of Bedrooms ❑ NA Effluent Filter Model O NA Number of Public Facility Units XNA Pump Tank Capacity gal NA Estimated flow (average) al /da Pump Tank Manufacturer ifl NA Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer NA P ump Model � Nf" n Rate z u P Soil AppGcatw a , al /da /ft Standard Influent /Effluent Quality Monthly average* Pretreatment Unit NI- Fats, Oil & Grease (FOG) 530 mg /L ❑Sand /Gravel Filter O Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration O Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection 0 Other: Pretreated Effluent Quality Monthly average Dispersal Cell(sl ❑ N< t Biochemical Oxygen Demand (BOD 530 mg /L ftl In- Ground (gravity) O In- Ground (pressurized) Total Suspended Solids (TSS) S30 mg /L �fNA ❑ At -Grade O Mound Fecal Coliform (geometric mean) 510 cfu /1001111 O Drip -Lieu Q Other: ~ Maximum Effluent Particle Size Y in dia. ❑ NA Other; D Ni Other O NA Other: ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: O month(s) (Maximum 3 years) O NA ❑ ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume 13 NA O month(s) (Maximum 3 years) Inspect dispersal cell(s) At least once every: O year(s) O month(s) . O Ni�, Clean effluent filter At least once every: ❑ year(s) O month(s)F. Inspect pump, pump controls & alarm At least once every: ❑ year(s) Flush laterals and pressure test At least once every: O ear(s) Or. O months) O NA Other: least once every: Cl ear(s) Other: C1 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 of n missing or broken hardware, identify any cracks or leaks, inspections must include a visual inspection of the tank(s) to identify any 9 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 g round 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, vic including but not limited to the servicing of effluent filters, mechanical All other ser vices, g g or pressurized components, pretreatment , b a certified POWTS Maintainer. ' i at intervals of 512 months, shall be performed Y units, and any servicing P A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (ai0 t Paye� of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) In one large dose, overloading the call(*) and may result ln backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator pdor.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 ; 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 systern 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 rnust comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be Installed as a last resort to replace the failed POWTS. - - -­° ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area.. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. El 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, so < < 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 INSTALLP POWTS M AINTAINER Name' Name Phone _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ► ,: ,�, . ; , Phone Phone — ..,- his cocument was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.5411), (2) & (3), Wisconsin Administrative Code ST. CROOK COUNTY SEPTIC TANK MA>ENTAIIWANCE AGREEMENT AND OWNERSH>EP CERTIFICATE FORM Owner/Buyer X k/ G / S�f,{i(/f►ra,n Marlin Address 6qf o% / N Br<< t / ^� • Ss�CZ (V as far new m) City/State 7 /4 Parcel Identification Number 0 0 �> LEGAL DESCRIPTION Property Location' /a, '/a Se�LT�N -I� 2W, Town of CZ ,, ' Subdivision ' 7 ,,e Lot# Certified Survey Map# — — Volume �— Page Warranty Deed# ,:- Volume � Page Spec house yes _X_no Lot lines identifiable d es no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result 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 masterplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on- site wastewater disposal system is in proper operating condition andfor (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 th Department of Commerce and use 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 10 days of the three year expiration date. S- ..7 - 0s' SIGNATURE OF APPL1CAYr DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge l (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. �� ✓ S- .Z3 O S — SIGNATURE OF APPLICANT DATE ****" Any mfarwatim d%A is miarepraeotad may molt as the sanitary permit burg rwokedby the Zamma DRarmazat' Include with this appticMm a dmMed warranty deed from the Rep w of Deeds affix a copy of the cwufud arvey map B rd4mcr istmds in the warranty load VO- 2383 Pr-E5G2 736768 if STATE BAR OF WISCONSIN FORM I - 1998 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS Doa+neln Number ST. CROIX CO., WI RECEIVED FOR RECORD This Deed made between Birch Park, L.L.C. , 08/21/2003 09:30AN a limited liability company under the laws 'of WARRANTY DEED state of Minnesota EXEIP7 t Grantor, REC FEE: 11.00 and Michael W. O.'.Sulliyan and Cathe R. O Sullivan, us and_ an_ w e TRANS FEE: 419.70 COPY FEE: CC FEE: Grantee. PAGES: 1 Grantor, for a valuable consideration, conveys to Grantee the following described real estate In St. Croix County. State of Wisconsin ' (the 'Property): Racordkp Ares Nartta and Relun Address Premier Title ( � I.ot 5)Birch Park 7300 Metro Blvd., #300 Edina, MN 55439 L . �3o_a.laY -So- o00 Parch Idendacavan Nurbr WIN) This is not homestead property. (is) Gs not) Together with all appurtenant rights, title and Interests. Grantor warrants that the title to the Property Is good, indefeasible in fee simple and free and clear of encumbrances except all easements, reservations and restrictions of record, if any. Dated this g day of August 2003 , (SEAL) BIRCH PARK, ..L. C. (SEAL) : s By: J M. Waters, Its Chief Manager (SEAT.) (SEAJ-) w e AUTHENTICATION ACKNOWLEDGMENT Signatures) State of .Minnesota ss. HonneRln Countyy, authenticated this day of Personally came before me this day of Auguat, 2003 , the above named James M. Waters, the Chief Manager of Birch Park. L.L.C.. a minnesota limited • liability company. on behalf of the LLC TrME: MEMBER STATE BAR OF WISCONSIN to (If not, me known to be the person who executed the foregoing authorized by 5706.06, Wis. Stars.) instru nt and ac THIS INSTRUMENT WAS DRAFTED BY Wilkerson b Hegna, PLLP IL N JOAN N. YOUNG Metro Blvd., 0 Notary to of ubfic Edina. MN 55439 MY Y ° a��(A, to expiration date: (Signatures may be authenticated or acknowledged. Both are not J necessary.) • N."W of parson slanlna In arty eapacaY must be typed or prb"d below their signature WARRANTY DEED STATE BAR OF WISCONSIN Wltaarmh Iayel eser* Co.. Ure. FORM No. I - 1996 Mlweetee. win. l t£ Y s w +�+r 2 � J r �'� ," >A }u " ' e, r �I/ � �'t v'ai �,��'�,��+r�y �wb «� � � � , �. i h ` ^w 1 .f ,� � � p ' 1 My •- f I` fi w o� w 2 Q v Q \ \ .-1 N" � N to \ cr S6 99 , U N S16" 88 14' d 1 1 S7 • W cu o cn o �a .-� o, / Co . =816.8 ? m n 0 X !a � CD , ti O � o, o o N co c r+ 1 y C n M C �• � CZ n Z O Q V 00 � . rr Fr CD • r at w rrf rm o S Ri ------- 1 H 3..ZZ A JNPI A TTP / A $R