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HomeMy WebLinkAbout032-2124-60-000 vV�COnsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT 5 - 4 . Cr'o GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)). 3 10 q Permit Holder's Name: ❑ City ❑ Village ®.Town of: State Plan ID No.: K" Z L CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: lex> 100 CST's R. TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. w IZ Benchmark , 2 lU tag Aeration Bldg. Sewer ?j, �Y 9 7 Holding St/ Iff Inlet 7 LS ` 7 9 TANK SETBACK INFORMATION St/ outlet 7 Q'2 • TANKTO P/L WELL BLDG. Air I ntake ROAD Dt Inlet Air pt, f . T.(7 (Ob 6 3!7- NA Dt Bottom Zo• NA Header / Man. `l r • J Aeration NA Dist. Pipe fU r Holding / Bot. System 9"r7, 6 PUMP/ SIPHON INFORMATION Grade .Lj 43.g Manufacturer � G l l-e r Srr 7c . — M-, Cavtil_ Model Number �� { O� qS GPM -C �• ZZ L Lift12, Friction ystem TDH(Ic, t emain Length 1ZSr Dia. If- L'" Dist.ToWell SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Insid Di a. Liqu ^d Depth DI MENSIONS 1 3 N I Manu urer. SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM CHAMBER LEACHING INFORMATION Type Of 1L1 ORUNIT Mo a N er: _ Syste r� �Zcb Zob S'irG DISTRIBUTION SYSTEM Header / Manifold � DistributionPipe(s) x Hole Size x Hole Spacing Vent TO Air Int h ake Lengt Dia. Length q3 Dia. F Spacing � )_ SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded / xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil C1 Yes ❑Yes (3 No COMMENTS: (Include code discrepancies, persons present, etc.) �S3Q19 / //Y �iZ I ?L Z' � . S+%f' , WS SLfo2. -S �Sw /� SW �i' C/ �o'fia (- AtO& ((ter Plan revision required? ❑ Yes -o Use other side for additional information. `f °f E: g ` I � SBD -6710 (R.3/97) Date Inspector's Signature ert No. i o$Ao� ►-r' Nib - .0 tiz x, �;- t�Vj� ✓Jw�lulr� X1,1 Nnus Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)). 384104 Permit Holder's Name: ❑ City ❑ Village ❑ 1own of: State Plan ID No.: W & G, Somerset Township CST BM Elev.: Insp. BM Elev_: BM Description: Parcel Tax No.: JC> ? 9 _*- - C 1 032- 2124 -60 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Z S Benchmark , 2- /0- /p Dosing Alt. BM Z. l Q,rd Y./ Aeration Bldg. Sewer 3. 4(v :7 Holding St /Ht Inlet ZS �L qS TANK SETBACK INFORMATION St / Ht Outlet Ve TANK TO P / L WELL BLDG. Air I to ntake ROAD Dt Inlet Air I Septic 3 (, NA Dt Bottom LD. 7g• 3 Dosing NA Header / Man. /. Aeration NA Dist. Pipe Holding Bot. System (d•S 3 (� PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand St cover Model Number _7S _ GPM TDH Li �23 Lrictio 12 Syste TDH1Io�4�,bt - Head Forcemain Length 12 S I Dia. Z Dist. To Wel SOIL ABSORPTION SYSTEM BED /TRENCH Width 4, length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENS 3 ?3.7 75 DIMENSION Manufacturer SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING SETBACK CHAMBER m ode l model Nu m er: INFORMATION Type O , " Syste Ho i5b -1LoL 2c�0 —� OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) / x Hole Size x Hole Spacing I Vent To Air Intake Length -2 V Dia. `>t Length 13 _ Dia. �i y Spacing fi 2 ?U 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 I Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: to / i /01 Inspection #2: / J Location: 432 172nd Avenue, Somerset, WI 54025 (SW 1/4 SW 1/4 5 T30N R19W) - 0530191114 Chabre -Lot 6 1.) Alt BM Description = �O.F 4M d� : M hov 5-t 2.) Bldg sewer length = 3 4 �4_ 4 � 4 1.0 - amount of cover = ( Z - 3 , ( 0 6 trANt -_trl1 Pi�f.S C,-rL in *,P 414,rG( C(1Ua.{itr4 y) bc A- -it Plan revision require ❑ No Use other side for additional information. ' SBO -6710 (R.3/97) Date Inspector's Signature Cert. No. 1 �, . - -- o �s� �o �� ��� �o�E� �L� / I � � � ,� ��� �o 1" 3Z 117- C Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 lVisconsin Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only) for the a er of less than 8 -1/2 x 11 inches in size. County State Sanitary P rmit Number ❑ C ck v' 'en td previous application State Plan I. D. Number I. Application Information - Please Print all Information Location: Property Owner Name Property Location h _ i f� '.;, v`. l,U 1/4 1/4, S cy T Q,N, (or Property Owner's Mailing Address „_.; Lot Number Block Number City, State Zip Code epe ber Subdivision Name or CSM Number .[ Ph SoAll II. Type of Building: (check one) us �x.r 5 - ❑ City ❑ 1 or 2 Family Dwelling -No. of Bedrooms : InauiaQ_ tr+tiS� —)'! ❑Village 9 Town of ❑Public /Commercial (describe use):_ ❑ State -Owned I-1 — Nearest Road D Av Parcel Tax Number( 7 ,G10 III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) o A) 1. Cd New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only Existing System $) Permit Number Date Issued ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) 56 Non - pressurized In- ground Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground S de � 5 ; Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade Aerobic ent Unit ❑ Recircu ting ❑ Other: V. Dispersal/Treatment Area In orma ion: 7 riw C 1. Design Flow (gpd) 2. Dispersal Pea 3. Dispersal Area 4. Soil, .. 6. System Elevation 7. Final Grade Required k Proposed Rate (jls./ .) (Min. /inch) Elevation VII. Tank Capacity in Total # of Mm6facturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks /c 6 / S3 �� , ❑ ❑ ❑ ❑ Pump ®® 1 ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the under signed, assu responsibility for installation of the POWTS shown o ed plans. Plumber's Name (print) Pl is Signature (no stamps): /MPRS No. Business Phone Number - z 1s -- - y9- Plumber's Address TStreet, City, State, Zip Code) IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued ature (No,stamps) RApproved ❑ Owner Given Initial Adverse Surch ge Fee) Determination s, 09 1(, t X. Conditions of Approval /Reasons for Disapproval: _ 14.11 Sl.ru.c�� .��,eys .oak- w.� reana.tn... oa'S L, ob ' Srt� e,:. � ""'`51 . - t't 1, 1�C� e t 5 . 4 r S. SBD -6398 (R 07/00) T l- /ILIF N --- 1 F A T 4--- ry AA LT ir LE I to -j-3AI Ak� - — - ---------------- R ip tlj 6j : rffe 4S pflopo p4 --l-4-4 --T o i DM flAi I -7� i , = f } , I ' + rt- t • , 1 ° ' t t , r i i 1 , � r ' , 1 Y r t , , i - - f I I f ' f ° � y , i t t i < , , + ; , 1 • 1 � f 1 } I E 4 t , , i s r I ; • t i 7 i + II .W isconsin Department of Commerce SOIL AND SITE EVALUATION pivision of Safety and Buildings I Page of Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/215 xl nd(1gsiin'size; Plammust County include, but not limited to: vertical and horizontal ref l f1 b dai'nt (BM , direction and C ('Zp ,' Y, percent slope, scale or dimensions, north arrow, ai lobation a dunce to nearest road. Parcel I. D. # APPLICANT INFORMATION - Please rMt allair;fOrmation. Re ' ed Date Personal information you provide may be used for secontiary { urposes'(Priva� Law, 's.14 D4 (1) (m)). Z 00 Property Owner Property Location i L� - -��±`n aU Govt. Lot 1 /4�G�f 1/4,S S T a,N,R �� E (orV Property Owner's Mailing Address Lot # I Block# I Subd. Name or CSM# t3s3 V4 b2E� City State Zip Code Phone Number ❑ City ❑ Village ! Z Town Nearest Road �L )D t> of,� 54016 (715 ) Sc�w.e�s t- e cP.•✓� in New Construction Use: R!�iesidential / Number of bedrooms '> - y Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: 1 Code derived daily flow 6pff o gpd Recommended design loading rate bed, gpd/ft r o trench, gpd/ft Absorption area required / ZUO bed, ft 10nCD trench, ft Maximum design loading rate ed, gpd /fl trench, gpd/ft Recommended infiltration surface elevation(s) %Q • ! O ft (as referred t e plan bench Additional design /site considerations a 9 C) Parent material Flood plain elevation, if applicable 'I- ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system S ❑ U 5's ❑ U ®S ❑ U I Ei� S ❑ U ❑ S 5� U ❑ S [4 U SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots :: in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. Tr g tAr2 Ground elev. y -o ft. Depth to limiting factor Ilc� in. Remarks: Boring # 1 _ b. 3 Z 1 rib v cs ` J �- ` Z o -yo- t o Ya, rk� -6u lis �crL 3 6 3� 1 r�s' t — Ground y M­q 5 w 314t c s elev. X1.3 4o ft. . f 0 . r Depth to limiting o rO factory '�► sw li✓ t, . �°`�. Remarks: CST Name (Please Print) Z 7 , _ ture Telephone No. ADA(A h� Address Date CST Number 4 ���p f5 5 Cc, Jw 1 PROPERTY OWNER c`k3rl— SOIL DESCRIPTION REPORT ' Page ��--- of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Structure 2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. h Le Nk 'FID •Z W3 L to 2 y � S +1 ✓►�Ab w\ �S 5 Ground 73, lt� ,� C� elev. LS 0 Depth to limiting 90 • o factor in. 'FS• 4 �.ln Remarks: Boring # kb it yq, Ground elev. 9 So ft. ' Depth to 3• Zo . t limiting factor /b in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ch Boring # S J 1 1 4 --6u •1Q - 11 2 L S F c Ground o -11\ . 3 j L FS eiev. Depth to limiting ; factor Lit in. Remarks: Boring # Groipd elev Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) PAGE_OF 3 NAME f OCk LOT# (o LEGAL DESCRIPTIONSO 1 16(cY4,S S T 30,N,R ( (or)k SCALE: I"= // BM 1 ELEVATION (O ' B�ESCRIPTION (,,, BM 2 ELEVATION IW BM 2 DESCRIPTION .(J h i , A (Q ` � oa wi SYSTEM ELEVATION qU • �( C) + ALTERNATE ELEVATION CONTOUR ELEVATION ____ v �v � • aS q� SIGNATURE DATE r . i • PA&E OF ' PUMP CHAMBER CROSS SECTION AMD SPECIFICATIONS VENT CAP `i "C.I. VENT PIPC WEATHER PROOF APPROVED LOCKING ,IuAICTIOM BOX MANHOLE COVER • 0 +1' ► 0►11'4 lillop , Il "MU1. 1 41NDUW UK t14Lbll I AIR INTAKE GRADE i N'MIN. ow I � le•MIN. COWDUIT �-"- - - -- - - PROVIDE INLET AIRTIGHT SEAL. I I v APPROVED JOINT A I III APPROVED JOINTS I I W /ca. PIPE W /C,T.. PIPE 1 11 1 I ALARM LXTLUDIN6 3 EXTENDILI(o 3' 1 I ONTO SOLID W16 ONTO SOL.10 *O1 L O ( 1 ON C LLEV. FT. PUMP --� ^' OFF � I 0 I CONCRETE 5LOLK �3" APPRovIED RISER EXIT PERMITTED ONLY IF TANK MAN C UFACTURR HAS SUCH APPROVAL "00ING SPECIFICATIOUS SEPTIC E , � 00 CL 4e - &pAY. 005E LL - � NUMBER OF DOSES: PER DAU TA K MAIJUFACTURG.R: �Ll� TANK 51ZE Roo GALLONS DOSE VOLUME / fD 7S ALARM MANUFACTURER: c�lt°7 �L.d2/ti IIJCLUDING OACKP40W: , 6A��ONS MODEL NUMBER: �L L/ CAPACITIES: A= _INCHES OR GALLOWS SWITCH TSPC: 2�ti[a'1 �� B =- - INCHES OR 4917 GfLLOAIS PUMP MANUFACTURER: zOELLC _ Ca 9 A ULHES OR • CALLOUS MODEL NUMBER: �y0 D - -INCHES OR "GALLONC SWITCH TYPE: MOTE: PUMP AND ALARM ARE TO DL ; �� INSTALLED ON SEPARATE CIRCUITS MINIMUM DISCIARGE RATE Y GPM VERTICAL DIFFERENCE CETWEEN PUMP OFF AIJO.,DISTRIbUTION PIPE.. AQ FEET p"ps 6L41 /I e9/L 1 N• t MINIMUM NETWORK SUPPLY PRESSURE . . -e-5- FEET T ♦ r 0 FEET OF FORCE MAIN X 3.91 FYoTT.FKICTIOU FACTOR.. °ZS FEET „- TOTAL ojWAMIC. HEAD = 3o °7g FEET rr INTERNAL. DIMLWSIOIJt OF TANK: LENGTH ;WIDTH __..;LIQUID DEPTH ov 510WED: LICENSE NUMBER 2��7y� DATE: Zy —3 2 —0 0 'Single Seal w w HEAD CAPACITY CURVE IOIAI DYNAMIC FIFAD /CAPnC v I'C - R MINUII: '� 'I Weight •' I MODELS "140 /4140" EFFLUENT AND DEWATERING Ft. Meters Gal. Ltrs. 1 14 45 5 1.52 91 34a 10 3.05 84 318 40 — 15 457 76 288 1 d 12 — — 1 40,41 40 20 6.10 68 257 35 25 7.62 59 223 I I i I 411 8 12.19 21 79 ii II I 25 45 13.72 5 19 Lock Volve: 46' I X 6 U j li li, ,1 n 15 6K1624A 0 J 4 Q ' 0 10 2 D oub l e D _ 5 Weight 73 Ibs. 1 U,S. GALLONS I IU 20 30 4U �U 6U /U HO 9U .0 IIU i 1 LITERS 80 160 240 320 400 0 FLOW PER MINUTE 010940 1 CONSULT FACTORY FOR SPECIAL APPLICATIONS • Electrical alternators, for duplex systems, are available and supplied with an alarm. • Mechanical alternators, for duplex systems, are available with or without 1 alarms. • Control alarm systems are available for 1 phase pumps used in simplex 1 1 SK1524B system. See FM0732. • Variable level control switches are available for controlling single phase systems. • Double piggyback variable level float switches are available for variable SELECTION GUIDE level long cycle controls. 1. Single piggyback variable level float switch or double piggyback variable level • Sealed Qwik - Box available for outdoor installations. See FM1420. float switch. Refer to FM0477. • Over 130 °F. (54 °C.) special quotation required. 2. Mechanical alternator M -Pak 10 -0072 or 10 -0075. • Refer to FM0806 for 200 F. applications. 3. See FM0712 for correct model of Electrical Alternator E -Pak. 4. Variable level control switch 10 -0225 used as a control activator, specify duplex (3) or (4) float system. 5. Four (4) hole J -Pak, junction box, for watertight connection or wired -in simplex 140 Series - 53 lbs. 4140 Series - 73 lbs. or 2 pump operation, 10 -0002. 14014140*** MODELS Control Selection Model Mo Volts -Ph Mode Amps simplex Dup N140 N4140 115 1 Non 15.0 1 or 1 & 5 2 or 3 & 4 CAUTION E 140 E4140 230 1 Non 7.5 1 or 1 & 5 2 or 3 & 4 All installation of controls, protection devices and wiring should be done by 1 or 1_& 5 - . 2 or 3 & 4 a qualified licensed electrician. All electrical and safety codes should be BE140 BE4140 230 t Non 7.5 1 or 1 & 5 2 or 3 & 4 followed including the most recent National Electric Code (NEC) and the Double seal pumps are available with optional moisture sensors. Seal Fail indicator light available in NEMA 1 or NEMA 4x Occupational Safety and Health Act (OSHA). control panels. RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL TO: P.O. BOX 16347 Z Louisville, KY 40256 -0347 Manufacturers of. O SHIP TO: 3649 Cane Run Road i' KY 40211 -1961 Louisville, p / p O QU,4L /TY PUM S SNCE �9�� PUMP !O. (502) 778 - 2731.1(800) 928 -PUMP FAX (502) 774 -3624 Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567-P (R.6/99). Table 1: System Design Specifications Sanitary Permit Number $ /0 Number of Bedrooms Design Flow - Peak (gpd) Inot Estimated Flow - Average (gpd) Septic Tank Capacity (gal) y Soil Absorption Component Size (ft $ 5 Z — Type of Wastewater Dom tic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) 2S3 e Z s Maximum Influent Particle Size (in) 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic-Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the :e ti t nd outlet filter shall be assessed at least once every 3 years by inspection. The utlet filter hall be cleaned as necessary to ensure pr` per o n. The filter cartridge shou not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage he system is from t t m prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 r Management Plan for a Septic Tank and Soil Absorption Component Plantings of deep- rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. 3 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Y S t ' OwnerBu er Mailing Address Property Address (Verification required from Planning Department for new construction) City /State Parcel Identification Number C)::�Q LEGAL DESCR Propert} Location L�'` W Town of '.!�, _( l /�, Sec. _, Tad R CjQ�(`(��Y S-�\ ?_ Certified Survey Map # , Volume , Page # Warranty Leed # (Q33 1 , nr Volume Page # /5�_._ Spec houseXyes ❑ no Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank cvec i, ;Iii cc years or sooner, if needed by a licensed pumper. What you put into the syster can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 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 stating that your septic system has been maintained must be completed and returned to the St, Croix County Zotei_ng Office within 30 days of th, year expiration date. i kxlsfv_�' I/ / /v / SIGNATURE 6F APPLICANT DATI OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) ant (are) the owner(s) of the property descri be above, by virtue of a warranty deed recorded in Register of Deeds Office. 1,1� K�A // /N/ SIGNATURE OIN APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. •` Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed . VOL io STATE BAR OF WISCONSIN FORM 2 - 1998 633355 WARRANTY DEED KATHLEEN H. WALSH i REGISTER OF DEEDS Document Number ST. CROIX CO., WI ii RECEIVED FOR RECORD This Deed, made between 11 -09 -2000 3:15 PM STOUT WARRANTY DEED and WIFE, Grantor, CERT FEE: and M &G. r ev COPY FEE: 2.00 TRANSFER FEE: 171.00 RECORDING FEE: 10.00 PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in _ Croix County, State of Wisconsin: Recording Area Lot 6, Plat of Chabre, Town of Somerset, St. Croix County, Wisconsin Name a nd Return Address ( I � NN4$ON W 5­1 *1 Ij I' i i 032- 2124 -h0 -000 Parcel Identification Number (PIN) 1� !I This i g not homestead property. (is) (is not) �t !i 1 ' j! Exceptions to warranties: easements. restrictions, rights -of -way and covenants of record. �i Dated this g day of Ne '- eFik� er 2000 (SEAL) � (SEAL) is * — Richard O. Stout Janet P. Stout (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature (s) State of Wisconsin, ss. St. Croix County. authenticated this day of Personally came before me this S day of N-vemhp- 0 0.0— the above named it R s;i -el- tni t and a ;nei; R. 2t013t TITLE: MEMBER STATE BAR OF WISCONSIN to (If not, me known to be the person Q who executed the foregoing authorized by §706.06, Wis. Stats.) nstrument and acknowledge the same. CHERYLJACOBSEN THIS INSTRUMENT WAS DRAFTED BY Notary Public I Janet P. Stout State of Wisconsin 1 Awatlikee Tr Hudson, WI 54016 Notary Public, 9 te of Wisconsin My commission is permanent. (If no� state expiration date: (Signatures may be authenticated or acknowledged. Both are not 723 .) necessary.) " Names of persons signing In any capacity must be typed or printed below their signature. i STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. WARRANTY DEED FORM No. 2 - 1998 Milwaukee, Wis. ;,e„ • •....•..,...e...ta..e. sr at«acwa�.00n k a I s Is n �. l A�► A 1 �� � m •j� lzV � p // rte. _ � 3 t 1• Fi 1 if � . \ • � I A� lei ; 7 Vi arows �,. � ,, � A. � .. .•I � I <.I I o t i I � �, y �1 6 ItMH1I' w. N mid � 0 w ' xl O' ! . �NM /r I I INI r O.;C r p y i �` 1 < t �/ ./ / � + fib `�. *t / . r � �I � 11[. 7 .•tY1. M.•W N / ' � . � +f � / \J• �1 � \�� �\ I �I R, Q c / „ • I d, • < y , / ,� D I Y$ ex r © t N w 0 LL a DWVJ: t � f „_1._..— •. —.,_ W.7Y113S4Y=N71N.00 J rx yy`R■ -- '1 n.�a.l•.mT T rl w.ra ,� ii'ti� /IIVK1r.OW •.w sw a Stagy aSSn 4t S2332V M