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HomeMy WebLinkAbout032-2125-50-000 (3) � �` °� cOfT1 PRIVATE SEWAGE SYSTEM C ounty : oatety and Bui�ings Division INSPECTION REPORT t. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No" Personal iMormation you provice may be used for secondary purposes (Privacy Law, s. 15.04 (1 )( 3 , 95100 Permit Holder's Name: City ❑ Vi Ite Town of: State Plan 10 No.: Din iman. Dale I Somerset Township CST SM Elev.: Insp. BM E ev.: BM Description: Parce Tax No.: OD,i* t�lp.o' aL 'per = C ST - %' I b 32-2125-50-000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark S es,0 tw , p Dosing Al BM 4 o 3 . rl Aeration Bldg. Sewer 5-- {4 02. 63' Holding St /Ht Inlet ' 49.0` Ict TANK SETBACK INFORMATION St/ Ht outlet 9,2,7- 98. TANKTO P/L WELL BLDG. yeatto ROAD Ot inlet Air Intake Septic ? S �' NA Dt Bottom Dosing NA Header/Man. roZ C ts •t(S r Aeration NA Dist. Pipe , 4�` I Holding Bot. System PU P / SIPHON INFORMATION Final Grade Manu urer emand t over Model Nu r M TDH fiction System TDH t Forcemain Length Fi o e 1 SOIL ABSORPTION SYSTEM A.lwrs BED / TRENCH width Length r N f Trenches PIT No. Of Pits inside jDia. umber:- Liquid Deptt IM N 1 N 3 .2 DIMEN 1 LEACHING anu A SETBACK SYSTEM TO PIL BLDG WELL LAKE /STREA ' s ? ReWi � INFORMATION Type r f CHAMBER Mo a System• OR UNIT �k DISTRIBUTION SYSTEM Header/ ni of Oistribultion Pipe(s) x Hole Size x Hole Spacing Vent To Air Intak Length Dia. `'i I Le Dia. Spac ... 2 r •t-- SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of [ x;�xSeeded / Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons presen ln*gaction #1: dq/.If / Inspection #2 : — 4___ Location: 429 172nd Avenue, Somerset, WI 54025 (SE 1/4 SW 1/4 5 T30N R19W) - 0530191123 Chabre - Lot 15 � �- � S ki S t I 6AAr` 1.) Alt BM Description = sill ,� o Ill >> e..Ct 2.) Bldg sewer length = 2 I • , ) 3, 3 -amount covg� -- �') � ) . 6 0 1 q Plan revision required? ❑ Yes No C� Use other side for additional information. kot ggp-6710 (R 3x97) Date Inspector's Signature Cert N< r '08.3 ks d 2I f eoc 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 ��SCOn. in Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce i td f t (Submit completed o county if not [Privacy Law, s. 15.04(1)(m)] state owned.) Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size. County State Sanitary Permit Number ❑ Check if revision to previous application State Pl I. D. N umber 14: Sr. "W yC 39s) m I. Application Information - Please Print all Information 12 Location: Property Owner Name operty Location A /(/ 1/4, S T d,N, R or) ti Property Owner's Mailing A dress t Let'N ber Block umber iVA City, State Zip Code Phone Number Sub&vtion Name or CSM Number II. Type of Building: (check one)oNIraU 1 or 2 Family Dwelling -No. of Bedrooms: Town of Public /Commercial (describe use):_ r. ❑ State -Owned J �� \ I � \� x g� 2$ S : LNe t Road �iy� J � Tax Number(s) III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) 0 3 d — ,2 f 5 _ 5 L —CO O A) I. 09 New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. S 3 � l 7 11 a3 6. ❑ Addition to System Sys tem Tank Only Existing System $) Permit Number Date Issued ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) 1$ Non - pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: `Tt° S� V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. evation 7. Final Grade Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) Sid, J r3 Elevation 66'2 6 �k> 6 /-04' To 9F. ° VII. Tank Capacity in Total # of Manufacturer Prefab Sit Fiber- Plastic 3 Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks R ❑ ❑ ❑ ❑ E T/C EE ❑ ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on t hed plans. Plumber's Name (print) Plu 's Signature (no stamps): S Business Phone Number Q 6A/ Plumber's Address (Street, City, State, Zip o e LC -E r IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Iss ng Agent Si na (No stamps) Approved ❑ Owner Given Initial Adverse Surcharge Fee) 6p Determination Z.Z. X. Conditions of Approval /Reasons for Disap -}o Alt �uU Q -�3 of �ow e - s ' c t�4� S1313-634 ( �O7/ �. III �`�,■. . -- _���� �■■ /��►�Il� ■ ■ ■l�t� ■�I■ !I ■I ■IIII■�Ilr�■■r I■ MEN !.1■ ■ ■■ ■� H ■ ® ■■■■ ■■ 1■ ! t ■ ■■■■■■ ■ ■ ■■■ ■�N� ■ ■■ , r ■■■■■■■■■ ■ ■■■ '� 1 �■� ..■ ■■■�■ ■■■ ■ ■� !is ■� .; ! I.i' 1�■■�14,!�i►� / ■ ■M! ■ilk ■ ■ ■� ■■i I I y n w I I 1 , i , t i 1 r i i y � l 0 I i i 1 1 , - i t 4 pp 1 1 1 • 1 t7- eD - �4 — �7 Jx 7 roll 1 + I 1 • J 41 -1 -1 A 1 A T I � ! i � � i Vij -1. 1 Lill 1056 WlSCOnSIn Department of Commerce _._, SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings /`„(aecordance with Comm 85, Wis. Adm. Code Tom Schmitt Attach complete site plan on paper ot ��sttia�n 8'/: 11 inches in size. Plan must County St. Croix include, but not limited to: vertical,,A�n� izon I ref rice point (BM), direction and percent slope, scale or dimemsiprrls nofth arrof � location and distance to nearest road. Parcel I.D. P /easo _ "` t all information, 1-- t •- � iewed By Da e Personal information you provide m =used f j da& purposes (Privacy law, s. 5.04 (1) (m)). Ib Property Owner lProperty Location Stout, Richard �''� CO�c;, Govt. Lot na SE 1/4 SW 1/4 S 5 T 30 NR 19 W Property Owner's Mailing Address 'f'` . Lot # Block # Subd. Name or CSM# 1353 Awatukee Trail - 15 na Chabre City State zip Co amber City Village id Town Nearest Road Hudson WI 54016 Som erset 172Nd New Construction Use: Residential / Number of bedrooms 4 Code derived design flow rate 00 PD j Replacement Public or commercial - Describe: Parent material Pitted glacial drift Flood plain elevation, if applicable General comments and recommendations: Area suitable for a conventional system with a 0.5gpd /sqft rating. Possible syste"Ii "ste;� trenches for primary area are 97.53', 97.09', & 99.66'. GO BI OF 'tI� 1 Boring # Boring f/ Pit round Surface elev. >114'` -.. J� G 100.03 ft Depth to limiting factor -� : Soi icetion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -7 10yr3/3 none sil 2mgr mfr cs 2m .5 .8 2 7 -21 5yr4/4 none sl 3 msbk mfr gw 1f .5 .9 3 21 -114 5yr4/4 none sl 2msbk mfr - - -- - - - -- .5 .9 -4. s3► 30 6 6 Fil Boring # J Boring Pit Ground Surface elev. 103.52 ft. Depth to limiting factor >116 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/W in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-8 10yr3/3 none sil 2mgr mfr cw 1f .5 .8 2 8 -24 10yr4/6 none sil 2fsbk mfr gw 1f .5 .8 3 24 -49 5yr4/4 none sl 2csbk mfr gw - - - - -- .5 .9 4 49 -116 5yr4/4 none sl 2msbk mfr - - -- - -- .5 .9 g� off- S� * Effluent #1 = BOD? 30 < 220 mg/L and TSS >30 < 150 mg /L * Effluent #2 = BOD 1 mg/L and TSS < 30 mg/L CST Name (Please Print) Signat re: CST Number Thomas J. Schmitt 227429 Address Tom Schmitt Date Evaluation Conducted Telephone Number 586 Valley View Trail, Somerset, WI 54025 5/25/01 715- 549 -6651 Propd Ky Owner Stout, Richard Parcel ID # Page 2 of 3 3� F Boring # Boring 0 Pit Ground Surface elev. 99.66 ft. Depth to limiting factor >118 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 1 mfr cs 1 f .5 .8 0 -10 Oyr3 /3 none I 3fsbk 2 10 -29 5yr4/4 none sl 2csbk mfr gw 1f .5 .9 3 29 -118 5yr4/4 none sl 2msbk mfr - - -- - - - - -- .5 .9 9�.cO 4 ] Boring # Boring id Pit Ground Surface elev. 106.48 ft. Depth to limiting factor > 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDtW in. Munsell Qu. Sz. Cont. Color Gr, Sz. Sh. *Eff#1 *Eff#2 1 0 - 10yr3/3 none I 2fsbk mfr cs 1f .5 .8 2 4 -36 5yr4/4 none sl 2msbk mfr gw - - - - -- .5 .9 3 36 -120 5yr4/4 none sl 2msbk mfr - - -- - - - -- .5 .9 I F -5 1 Boring # 01 Boring 01 Pit Ground Surface elev. 106.21 ft. Depth to limiting factor >115 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -5 10yr3/3 none I 2msbk mfr cs 1f .5 .8 2 5-21 5yr4/6 none sl 2msbk mfr gw - - - -- .5 .9 3 21 -115 5yr4/4 none sl 2msbk mfi - - -- - - - - -- .5 .9 * Effluent #1 _ BOD 5 30 < 220 mg /L and TSS >30 < 150 mg /L Effluent #2 — BOD 5 < 30 mg/L and TSS < 30 mg/L — The Department of Commerce is an equal opportunity service provider and employer. If ou need assistance to access services or P 4 PP tY P Y — ,1 morAr;ol ;,, — oIt�. f, f — f nI—A —t—f 4,A A—r—A„t .r AnR_7fA_Z 1 1;1 — rF fOR ')f A_R777 Propefty Owner Stout, Richard Parcel ID # Page 3 of 3 F6 ] Boring # Boring jo Pit Ground Surface elev. 105.10 ft. Depth to limiting factor >110 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -8 10yr3/3 none I 2fsbk mfr cs 1f .5 .8 2 8 -16 5yr4/6 none sl 3psbk mfr gw - - - - -- .5 .9 3 16 -110 5yr4/4 none sl 2msbk mfr - - -- - - - - -- .5 .9 F-1 Boring # j Boring j Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 j Borin 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 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 L30 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 „ws..1 material ;,, on oIt—tA fnr f -1.— '—f—t the iianorf —t at lr1R_1AA -1I G1 — T rV AI)R_')AA_27'7'7 Q Ao 16 3' 0 i i ` M / / � � j � _ Q / 135`31oCo -A Ao.e e !� es Thy ?a WY A,,a! n- r wz T-yo/ 6 sw z1a l/e l/e o Z-al / 5;) sue, ZUT, S-VW s eir S�1 �4 `WiscSn De artment of Commerce SOIL AND SITE EVALUATION Divisionraf Safety and Buildings Page of Bureau of Integrated Services in accordance with Co Wis. Adm. Code Z,jdk edtion Attach complete site plan on paper not less than 8 1/2 x 11 inches iat must County include, but not limited to: vertical and horizontal reference point ( atAd � percent slope, scale or dimensions, north arrow, and location and neaiest'r640 " 7 parcel I.D. # APPLICANT INFORMATION - Please print all information. Reviewed Date Personal information you provide may be used for secondary purposes (Privaky Law, s. 15.04 (t) Property Owner l 'Pr6ody L9cation , 2 " ��- Govt. Lot �& 1/4� f 1 /4,S S T Z ,N,R I E (or(w Property Owner's Mailing Address Lot # Block #. Subd. Name or CSM# City State Zip Code Phone Number ❑ City ❑ Village a Town Nearest Road New Construction Use: Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow & 6C gpd Recommended design loading rate ' 5' bed, gpd/ft - 6 trench, gpd /ft Absorption area required / 200 bed, ft /Cso CJ t�rrench, ft Maximum design loading rate - bed, gpd /ft • - 6 trench, gpd/ft Recommended infiltration surface elevation(s) C 7 d • Z d ft (as referred to site plan benchmark) Additional design /site considerations eG 646 c,J' - (.e v • 9 7 Z U Parent material 1-0 1 ( Flood plain elevation, if applicable S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ❑ S U S ❑ U El S N? U ❑ S '� U El S [U El S �U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft r,tu/ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench Co _ C) 46 T:® 3 3 Z r o S I f � Z C5 Ground 3 45 l 6 elev. Depth to limiting factor Remarks: Boring # _� CS • � t o, to 3 � �.I�S�, ice. - Z Z 2 5 "c"� MG2 3 3i • z `/ K tM t- L - ��Ground e LO ft. Depth to limiting factor in. Remarks: CST Name (Please Print) �wWre Telephone No. Address Date CST Number 5 J I .mss ♦ .. , SOIL DESCRIPTION REPORT PROPERTY OWNER Page ko PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 MLt in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Af Z ©� w) 5 S ` C Ground 1 7,4-3q CZ 1 4 11 S L ►,rAb f , LS elev. Depth to limiting factor min. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ;: €::,' Ground , elev. ft. Depth to limiting ; factor ' Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) PROPERTY O ev WNER SOIL DESCRIPTION REPORT Page of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Structure 2 y , 4 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed .Trench Co. x. Z 511 S I c S Ground 1 3 / Z `� S Z 1�/`�� �►'� CS ,/ elev. Depth to limiting factor 7-4 Remarks: Boring # [3 Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor ' Remarks: SBD -8330 (R.9/98) s. PAGE_3_OF_ NAME LOT# )J LEGAL DESCRIPTIONSa! 'YIW' / <,S STWN,R / (or)L -) SCALE: 1"= ffe2�) , BM I ELEVATION /y-). BM 1 DESCRIPTION ✓tai (, A 10 14/ �1 BM 2 ELEVATION !OU - O BM 2 DESCRIPTION _nu [ ; ti, b ti t vv1 6 eFl I SYSTEM ELEVATION C O.. 0 j_ ALTERNATE ELEVATION CONTOUR ELEVATION o 303 �0 Z �� � �g� • t3,�,t le,� tent 0 i 3r..2 D3 I SIGNATURE DATE Page of MANAGEMENT PLAN 'Ibis Private Onsite Wastewater Treatment System (POWTS) has been designed and is to be installed and maintained in aocordingto Comm 83, Wis. Admin. Code, the in- Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems (SBD- 10567 -P; June 11, 1999), 1. This PO TS has been designed to accommodate a maximum daily flow of (7D gallons of domestic wastewater -per day. The quality of influent discharged into the POWTS treatment or disposal component shall be equal to or less than all of the following: a monthly average of 30 mg/L fats, oil and grease a monthly average of 220 mg/L BOD 5 a monthly average of 159 mg/L TSS. Wastewater shall not be discharged to the POWTS in quantities or qualities that exceed these limits or that result in exceeding the enforcement standards and preventative action limits specified in ch. NR 140 Tables 1 & 2 at a point of standards application, except as provided in Comm 83.03 (4)m Wis. Admin. Code. 2. The owner of this POWTS is responsible for system operation and maintenance. The following maintenance shall occur within three (3) years of the date of installation and at least once every three years thereafter: 1. The septic tank shall be pumped be a certified septage servicing operator, licensed under s2.81.48, Wis. Slats, unless inspection by a licensed master plumber or other person authorized to make such inspection, finds less than (1/3) of the tank volume occupied be sludge and scum. More frequent pumping may be necessary to prevent solids from exceeding one -third (1/3) if the volume of the tank.. i f accordance with ch. NR 113 Wis. Wastes shall be d disposed o the pumper in by P pe Admin. Code. At each pumping the pumper must visually inspect the condition of the tank, baffles, rizers, and manhole cover and verify that any required locks are present. 2. The soil absorption component(s) shall be visually inspected by a licensed master plumber, certified septage servicing operator or POWTS inspector. Inspection shall check for evidence of discharge of sewage to the ground surface and for ponding of effluent in the distribution cell. 3. The ank fi r s) shall be i nspected and c leaned to remove any accumulated solids ____ according to manufacturer's specifications. The filter cartridge shall not be removed unless provisions are made to retain solids in the tank. Cleaning of the filter at more frequent intervals may be necessary. 4. Any pump, alarm or related electrical connections shall be visually checked for defects and tested to confirm that they are operating properly. 5. Reports for all system maintenance shall be submitted to St. Croix County Zoning in accordance with Comm 83.55, Wis. Admin. Code. 3. Defects or malfunctions identified during maintenance described in item #2 above shall be repaired in conformance with Comm 83, Wis. Admin. Code. 4. Anytime a failure or malfunction occurs, it shall be reported to the owner of this POWTS. Repair or connection of such failure or malfunction shall comply with Comm 83, Wis. Admin. Code. 5. No one should enter a septic or other treatment tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within these tanks may contain lethal gases and rescue of a person from the interior of the tank may be difficult or impossible. 6. No product for chemical or physical restoration or chemical or physical procedures for POWTS may be used unless approved by the Department of Commerce in accordance with Comm 84, Wis. Admin. Code. 7. In the event that this POWTS or a component of this POWTS fails and cannot be repaired, the following contingency plan is proposed: The failing Quipanent shall be m ]p aced. This may require a new soil evaluation to determine where a new soil absorption c component can be. 8. If this POWTS is replaced, or its use is discontinued, it shall be abandoned in accordance with Comm 83.33, Wis. Admin.. Coda 9. Name and number of local health agency St Croix County Zoning - 715- 386 -4680 10. Name of service contractor in case of failure or malfunction Schmitt & Sons Excavating 715 -549 -6651 it /`rte ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 0/fV LYMA( ro-111'7 Mailing Address �� /f s El✓ - M C t- /I�o� rfr � r� l.� c .� 1'/ Property Address 0 J!:F- (Verification required from Planning Department for new construction), City /State :yD/V E? s'F T L$�; f - Parcel Identification Number Q 3-2- t 11 S O -y v0 LEGAL DESCRIPTION Property Location ,:_ i /4, g_ ' /a, Sec. 5 T N -R Ly _W, Town of c / 2s e r . Subdivision C f/dQ L . Lot # Certified Survey Map # , Volume r— . Page # Warranty Deed # Volume . Page # 9 Q , co lb I o Spec house ❑ yes 91 no J@ es ❑ no no Lot lines Y 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mastor 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 Zoning Office within 30 days of the three year expiration date. ( — '/ O j SIGNATURE 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 owners) of the I Tp erty described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF 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 167SPAGE 10 65C> KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI Document Number Document Title RECEIVED FOR RECORD St. Croix County 07 -10 - 1:30 PM AFFIDAVIT Occupancy Affidavit EXEMPT # CERT COPY FEE: / '� COPY FEE: Ll L F TRANSFER FEE: / tr& M A M RECORDING FEE: 10.00 Name — (Owner) Typed or printed PAGES 1 being duly sworn , states, under oath, that: 1. He /she is the owner /part owner of the followin arcel of land located in St. Croix County, Wisconsin, recorded in Volume Page Document Number St. Croix County Register of Deeds Office: Recording rea parcel of land located in the Name and Return Address A P ,E '/< of the �'/< of Section DA' p11VC-1Y.4 Al T .30 N - R / 2 W, Town of �5 , St. Croix County, Wisconsin, being duly described as follows (include lot no. and subdivision/CSM or detailed legal description): C h �/� /yid S J�3 / LcYl 5 T, U /X L ou fi - y GU f rcioxvx r Parcel Identification Number (PIN) As owner of the above described property, I acknowledge that the septic system serving this residence is sized for a Y bedroom home, or a design flow of 600 gpd. The design flow is calculated by assuming 150 gpd for 2 individuals per bedroom. There are currently _ occupants living in this residence; _ occupants are permitted based on the design flow. Therefore the septic system serving this residence is code compliant. However, I understand that if there are intentions to exceed the number of permitted occupants, th@ system will need to be modified to accomodate any increased wastewater flows and /or contaminant loads. I al %d acknowledge that I will make this information available to any future parties interested in purchasing this property. Dated this day of I AUTHENTICATION A Signature(s) STATE OF W+SeeWAN ) m ) /U Ntrso� authenitcated this day of St=Smix County. ) PN U r- - Personally came before me this day of J I I� f DU the above names) — T 62r4 AID * IJ TITLE: MEMBER STATE BAR OF WISCONSIN All (If not, to me kn a pens@ authorized by § 706.06, Wis. Stats.) instrume Wedge cute t foregoing tSAbM THIS INSTRUMENT WAS DRAFTED BY "" ;ion Expires Jan. 3t, 2006 C r Notary Public State of W M) NNE.SaT (Signatures may be authenticated or acknowledged. Both are not My Commission is permanent If not, state expiration date: necessary.) Date: _ "THIS PAGE IS PART OF THIS LEGAL DOCUMENT — DO NOT REMOVI" This information must be completed by submitter.• document title. name & return address, and PIN (if requir @d), Other information such as the granting clauses, leagal description, etc. may be placed on this first page of the document or maybe placed on additional pages of the document. Note: Use of this coverpage adds one page to your document and $2.00 to the recording fee. Wisconsin Statutes, 59.517. F ' VOL 165 1 FAGS 580 STATE BAR OF WISCONSIN FORM 2 - 1998 1647950 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS Document Number ST. CROIX CO., WI I RECEIVED FOR RECORD This Deed, made between 06 -11 -2001 11:00 AM it tTCHARD O S.TS2UT and JANET P STOUT-, h n c ha n d and wife � WARRANTY DEED Grantor, I EXEMPT N j CERT and DINGMAN DN TR 1 _TTON, Is � COPY C OPY FEE: TRANSFER FEE: 168.00 RECORDING FEE: 10.00 Grantee. PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St Crni x County, State of Wisconsin: j R Lot 15, Plat of Chabre, Town of Somerset, a - m e Area andReturn Address St. Croix County, Wisconsin. 1 Nam 'I 032 - 2125 -50 -000 ! Parcel Identification Number (PIN) �I This not homestead property. (is) (is not) ii I I (j II �i j j Exceptions to warranties: easements, restrictions, rights -of -way and covenants of record. i� Dated this day of 2001 (SEAL) (SEAL) . Richard O. Stout Janet P. Stout (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signatures) State of Wisconsin, ss. St. Croix County., authenticated this day of Personally came before me this day of 2 0.0.1, the above named Ri - d O Stnlit and Janet P Stout TITLE: MEMBER STATE BAR OF WISCONSIN to Of not, me known to be the person who executed the foregoing authorized by §706.06, Wis. Stats.) �•�.......,,a <a strument and acknowledge the same. CHERYLJACOBSEN Notary Public THIS INSTRUMENT WAS DRAFTED BY State of Wisconsin Janet P. Stout 1353 Awatukee Tr. Hud son, WI 54016 Notary Public.2 ae of sconsin My commission is permanent. (If ,dot, statg expiration date: j (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. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc. WARRANTY DEED FORM No. 2 - 1998 Milwaukee, Wis. � / v C HAB R E MINW FIST ELEY TICIN ON ��, E SW7 /4 OF THE SW1 /4 AND PA OF THE SE1 /4 OF THE SW1 /4 �2 on RT LOT 9se0 3W, TOWN OF SOMERSET, ST. CRODC COUNTY, WISCONSIN. LOTI 95 IATS es7a ��9� a LOTS 957.0 Lo I Lo19 / LOT i LOT? WA LOT WA GS.Y IN VOL 6. PC 1689 ` /� V \ p r ry � L� a WA ------------ - - - - -- \ WS�_ - - jJ V j% 8.--- 1V._me LOT V's LOT 12 "BA L0T 13 WA LeD111N UN•aFnu BlB Or 7N7 iW,AS \ 4788.si4' LOT 14 9BOD LOT 73 aBA LOT to DAA LOT 17 Ilm I 1e a L 19 WA OT 20 9E = LOTSA 4 y LOTS/ M0 7 . 22 M P A LOT 23 3 Y� L mi ^P'� 6 Lar 9eeA a7sACTle7 SAM ,i0 '«" : f Is = 1770 oo rr ,70701 70 rt 0.000 9� 1709010 rT N w P �r1CSTE z A 7 stTE b $ 0 it A 7 ± 3 711AN1/L� b 3 nrr z [ H.W.L. . 9a3.00 i{ A i z z S •A H.W.L.954.00 i SAM ACNlr7 • lsOA" so R S9• DRAINAGE EASEMENT 1 A / ` WETLAND $ II 9 I A \ �.. w .. �... 4 AY mwN wo N 11'4410` 7 70Yr 7yA 17La0 ,f7A0' 147.N' a0La0 �\ S SrTE JJ A A . 18 H. .9m.00 16 : 14 2,002 ACROSS Isar" 40 v LD"ACfM 100630 60 Ff 120=6 so IFF SEP16SITE i • 0. w s , 17 1 1309" A•� . 1 B SAM AMOCO A 19 •� l7 **Fr � 8 as ALO,111 • tIL sErOGSrtE (� 1777 w rr 99 ` J 969.00 A (,L 1E .._.. .. 9� AY SET - BACK PER TRANS 233 — . . • — • . _ — • • — • • _ • • — • — t4�yj ACCESS 187 8.88 SOM U E OFT1E SMA PJWP0A4JSD 36 & 84 STATZ TJWNJC HIGAWAT ----------------------------- D.O.T. NOTES PER TRANS 233: As ow w I hereby rstrid all Lola and Blocle So met and w owrwr, possessor. SCALE IN FEET V user, loerwee or odwr Person may have wW rpk of dad vat bAw Inpss from or e{,es 90 any hWtwmy Ntw wift me dpM- cf+Aay of State halt Wphway 3S A W, as down An me land division map: a Is eWessly 100 0 100 200 300 ht.rldW and Of nwModon ocnad le a rsslctim far the beneE of lw Public as provided In s238293, Stake. and shop be eNoroeable by the depadmarl a ke asWo. UILITYEASWENCS NO POLE OR TaeRT) GAMES AM TO BE PLACED SUCH THAT TIE INSTALLATION WoLLD The bls of M lerld divWw may experience noise at levels aceedlrp OISTLIwANY SIITEYSTAXF OR OBSTRUCT W1ON ALONOAW LOT LIE OR Smf4T LIE. ft Ovals h e. Tram 405.04. Table 1. 7Ms! suds aw based on Tiff DLSTUR8M E OFASUMEYSrAIE 6YANAOW E AVIOIAnON OF 9ECnON 2ws OF WISCONSIN STAMM UTelrY EASEMENTS AS TEIM SET PCRTNAFE OR F THE USE OF hdoraldvKWrda. Omwre lots deR 9pon91ble for abs" PUBLICBODFBAND PWATEMMMMITESNMING THE Is OHTT0 OEM 1W AREA noise sul cleft 10 protect "Be Iota. EACH PARCEL ON rHw Mw Pula w asecr To STATE couNTx AND rovNiw LAWS, WAZBAD REOLIATDNS Q.E.. WETLANDS. MN04U11 LOTSLrE, ACCESS TO PARCEL, ETC.). BEOIE PUR04ASM OR DEVELOPING ANY PAFMOF LAID CONTACT DIE ST CRW COl1NTY ZONING OFFICE AND APPROPFMTE TORN BOARD FOR ADWCE sHEW 1 OP 2 sXJSM