HomeMy WebLinkAbout032-2106-30-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y:
Safety and Buildings Division Count
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)]. 374938
Permit Holder's Name: ❑ City ❑ Village ❑ Tyawn of: State Plan ID No.:
Dr eyer, Da vi d Somerset Township —
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
c o , fl r (vo . � Qd L 032- 2106 -30 -000
TANK INFORMATION ELEVATION DATA 42 3 ° ` ` X' 497
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Z Benchmark (0.(9 0 10.(00 &0 .c7
Dosing Alt. BM
Aeration Bldg. Sewer k _`
Holding St /Ht Inlet `a - `�� - 110 2 - .13'
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. AirI to ntake ROAD Dt Inlet ---
Air I
Septic } abf & ?j NA Dt Bottom ----
Dosing NA Header/ Man. 4S I�•bS�
Aeration NA Dist. Pipe ° •�3 I ,
E ldi Bot. System S C� fs f
PUMP / SIPHON INFORMATION Final Grad 9.o Iol•SI
Manufacturer Demand St cover 2,
Model Nu er GPM
TDH Friction System H Ft
H ead
Forcemain Length . Dist.Towell
SOIL ABSORPTION SYSTEM (�
BED/TRENCH Width r Length r he PIT No. Of Pits Inside Dia. Liquid Depth
D IMENSION S ° 13.� °"� N O Trenc 1 EN I
ure
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING an
SETBACK I _ INFORMATION Type O f CHAMBER Model N ber:
System: �Sn (b ( OR UNIT (i -
DISTRIBUTION SYSTEM
Header / anifold Distribution Pipe(s) x Hole Size I x Hole Spacin Vent To Air Intake
Length Dia. Dia. Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over FBed h Over xx Depth Of xx Seeded/ Sodded xx Mulched
Bed /Trench Center Trench Edges Topsoil C] Yes ❑ No E] Yes [] No
COMMENTS: (Include code discrepancies, persons present, etc.)
Inspection #1: oa' /off /0 Inspection #2: �—f
Location: 820 165th Avenue, Somerset, W1 54025 (SE 1/4 NW 1/4 12 T30N R1 19 9 W A ) - 123019997 North Bass Lake Estates -
Lot 3
1.) Alt BM Description €5• '"�"" C
2.) Bldg sewer length = alt? . o
- amount of cover = > 6 5 , CAAr, ,
j e� ob 6Z - -� l•4er-
PI n revision required? ❑ Yes ,� No
Use other side for additional information. 04 - 1 03 0 ( —.
52� I CV,
SBD -6710 (R.3/97) Date Inspector's Signature Cert No
t
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Sanitary Permit Application Safety & Buildings Division
In accord with Comm 83.2 1, Wis. Adm. Code 201 W Washington PO Box 73
Ave.
��SC ®�Sln See reverse side for instructions for completing this application
Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302
Department of Commerce rivacy Law, s. 15.04(1)(m)] (Submit completed form to county if not
P
state owned.
Attach complete plaq &%kkaUk14oiYo6Iy1 for the system, on paper not less than 8 -1/2 x 11 inches in size.
County Sta PRW , u Q �heck if revision to previous application State Plan 1, D. Number
". '� �
I. Application Information - PI s rint tion Location:
Property Owner Name :� Property Location
? �� 2 V t5lz 7 SE 114 /4, S t T3jo ,N, R `% ( or
Property Owner's Mailing Address ST - Lot Number Block Number
� t �� ..• }` COUN z
City, State Zip o a,. -, Phone Number Subdivision Name or CSM Number
U ( ) 2 2a =t3"
II Type of Building: (check one) ❑ City
A 1 or 2 Family Dwelling — No. of Bedrooms:_ �� ❑ village
❑ Public /Commercial (describe use): NA
q Town of
❑ State -owned AFA J oJ`;rC .4SC7
III Type of Permit: (Check only one box on line A. Check box on line B if applicable) Nearest Road (o S'
A) 1. C9 New System 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Addition to Parcel Tax Number(s) 03Z- (, - 3 0 - 0
S stem Tank Only Existing System C7
B) Permit Number i z . 3 U. / 9. 4 �� Date Issued
❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply)
allon- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other:
V Dispersal/Treatment Area Information: r v o f
1. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. S tem Elevation 7. Final Grade
Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) Elevation
5,00 V/ VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
12 �3 (2-,- lK ❑ ❑ ❑ ❑
42 /� / i �✓��/� 5
❑ ❑ ❑ ❑ ❑
VII Responsibility Statement
I, the undersigned, assume res on ibility for installation of the POWTS shown on the attached plans.
Plumber's Name (print) Plu is Signature (no stamps): L PRS No. j 711usin Phone Number
f T i - ,, .-tom" .�l 7
Plumber's Address (Street, City, State, Zip Code)
VIII County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issu' Agent Signature (No stam )
Approved ❑ Owner Given Initial Adverse Surcharge Fee)
Determination Z Z S O U 3 Ad
IX. Conditions of Approval /Reasons for Disapproval:
L•� �o Qr r.grc, 4 21} arAat 5lIQ�( d[ ouf OT �YA ra't P[LS�vrPnl.
SBD -6398 (R. 07/00)
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• Wisconsin Department of Industry, SOIL / L U AT I O N R E P O Fi T Page 1 of 3
Labor and Human Relations
1pivision of Safety & Buildings .� cor*With 83,�§, Wis. Adm. Code
COUNTY
R E��1�
Lach complete site plan on paper not lesp, n 8 1 /2tt . 1 inch n. ' ize. Plspe, must include, but St. Croix
not limited to vertical and horizontal refers oe -point (BM , rf ti wt''3�i�d % of, scale or PARCEL I.D. #
dimensioned, north arrow, and location and di tanc�i'(t� e reg 5gad. Z �Z 0 s 2-0 0
S� G
V2WED BY DATE
APPLICANT INFORMATION —PLEAS t ALL @a10
z q 0
PROPERTY OWNER: ` PROPERTY LOCATION N
Gerald J. Smith / GOVT. LOT SE 1/4 Ig 1/4,S 12 T 30 :R(or) 19 �(or) W
PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM #
11160 190th. Ave. N.W na N. Bass Lake Estates
CITY, STATE ZIP CODE PHONE NUMBER []CITY ❑VILLAGE ]DOWN NEAREST ROAD
Elk River, MN. 55330 (61� 441 -88
[xJ New Construction Use k ] Residential I Number of bedrooms 3 [ ] Addition to existing building
(] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate ___Z bed, gpd /ft gpd /ft
Absorption area required 643 bed, ft 563 trench, ft Maximum design loading rate .7 bed, gpd /ft gpd /ft
Recommended infiltration surface elevation(s) 99.20 ft (as referred to site plan benchmark)
Additional design/ site considerations alt. system el.= 98.7' & 96.9' trenches
Parent material outwash Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ® S El FK] S El U �cS El ® S E] U ® S ❑ U 1:1 S ® U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD /ft
Boring # Horizon Texture Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. B
1 0 -9 10 r3 2 none s icl lcsbk mfr Cs
2 9 -20 ' 10 r4 4 none
Ground 3 20 -84 7.5 r4 6 none cos osa M na na
elev.
103 ft.
Depth to
limiting
factor a
+8 4" ro
Remarks:
Boring #
1 0-8- 10 r3 3 n
2 2 8 -22 • 10 r4 4 n f
Ground
3 22 -28 7.5 r4
elev. 4 28 -84 7.5 r4 6 none cos os
1 02.2 ft.
Depth to
limiting 3 ,
factor
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200 e. New Richmond, WI 54017
Signature: Date: 4 -15 -97 CST Number: m02298
PROPERTY OWNER J. Smith SOIL DESCRIPTION REPORT PageZof
PARCEL I.D. # 3 2- " 2-O'6- 20^ / Od
Depth Dominant Color Mottles Texture Structure Consistence GPD /ft
Boring # Horizon �ry Roots
..................
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. g
<..3.... _ ' s 1 lcsbk mfr cs 2f .2
2 9 -18 " 10 r4 4 none scl 2msb'. mfr gw if .4
Ground 3 8 -84' .5 r4 6 none cos 0SQ ml na na .7
elev.
1 02.7 ft.
Depth to
limiting
factor
+84 zP
Remarks:
Boring #
_ 1 0 -8 10 r3 2 none sil 2msbk mfr cs 2f .5- .
2 8 -12 10 r4 4 none sicl 2msbk mfr gw if .4 ✓
3 12 -22 .5yr4/4 none is osg ml gw na
Ground
4 2 -8 7.5 r4 6 none cos os ml na na .7 ✓��
1 9 ft.
Depth to
limiting
factor
+R4
Remarks:
Boring #
1 0 -8 10 r3/3 none 1 2msbk mfr cs 2f .5 ✓ .
2msbk mfr Cfw if .4 ✓•, .
Ground I - ml na na .71.
elev.
9 9.4 ft.
Depth to
limiting
factor
+84 1,
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
it SBD- 8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Gerald Smith 1 1554 200th Ave.
CSTM2298 SE4y S12- T30N -R19W New Richmond, WI 54017
MPRSW 3254 town Somerset (715) 246 -6200
lot #3 -N. Bass Lake Estates
N
1 =40'
-ai- top of .z' pvc pipe C el. 100'
Alt. BM.= top of SW lot stake C el. 94.35'
P 79
5 /
w
r9s
/0
Gary L. Steel
4 -15 -97
I -
7Viscansin Departrneni of Industry, SOIL lid L TI ON U AN . R E PO P age 1 of 3
Labor and Human Relations
Dhision of Safety & Buildings Cor*ithALHR 83*, Wi Cod �.
COUNTY
�,yE St . Cro
Attach complete site plan on paper not lesp, B 1 1 inches ' ize. p ust inoltd9 t ix
not limited to vertical and horizontal refers iM (8 rt tii�n d 1 0 pe, U CEL I.Q. #
dimensioned, north arrow, and location anti dijtand e e 5pad. .'Jt �� ,- 3 2 -Z- p 1- — Z a — / 4
APPLICANT INFORMATION - PLEAS fxfiINT ALL �I i 'o ! L + WED BY DATE
PROPERTY OWNER: �. OPERTY A tG)N
Gerald J. Smith 0 i Lol cysiuof /4 ,S 12 T 30 N,R 19 :k(a)W
PROPERTY OWNERS MAILING ADDRESS TAf� 4LOC K - ME OR CSM #
11169 1 Bass la E sta teg
CITY, STATE ZIP CODE PHONE NUMBER OCITY OWN NEAREST ROAD
Elk River, tv1AT. 55330 ( 61 441=8888 I qsit�h
[)j New Construction Use k I Residential / Number of bedrooms 3 [ j Addition to existing building
[ I Replacement [ I Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate ___,Z - bed, gpd/ft
,_,B— trench, gpd/ft
Absorption area required 643 bed, ft 563_ _ trench, ft Maximum design loading rate -- ,2 -- bed, gpd /ft gpd/ft
Recommended infiltration surface elevation(s) 99.20 ft (as referred to site plan benchmark)
Additional design /site considerations alt. system el.= 98.7 & 96.9' trenches
Parent material outwash Flood plain elevation, if applicable na ft
S - Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U a Unsuitable for sy stem I ®S O U t Rj S ❑ U I I36 ❑ U ®S ❑ U ®S ❑ U [is [R U
SOIL DESCRIPTION REPORT
3oring # Horizon Depth Dominant Coior Mottles Texture Structure Consistence Bourg Roots GPD /f#
in. Munsell Qu. Sz. Cont. Cola Gr. Sz. Sh. Bed TWO
1
1 0 -9 10 r3 2 none sicl
2 9 -20 1 r4 4 mfr rM
Ground 3 20 -84 7.5 r4 6 none Cos
elev.
Depth to
limiting
factor
+8 4"
Remarks:
3oring #
�sg 1 0 -8 _
2 2 8 -22 1 r4 4
a>
if
Ground 3 22 -2
elev. 4 7.5 r4 6 none i
U,Ift.
Depth to /-
limiting
factor
+84
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200 e. New Ric and WI 54017
Signature: r Date: 4 -15 -97 CST Number: m02298
08/30/00 11:49 FAX 2475086 JERI*KOESTER.... Iij01
Standard Erosion Control Plan
for 1 & 2 Family Dwelling Construction Sites
i ��roa.�. •.t.. `a7F U .. 4 ... :. •�, ' .S,:'i.•:f <: :fi•.'" Kv�' }:
# o �-r; Doti �coatml'
76 Oaleg a es� t•Un�QDt7t1.0110 ►G.S s01 'C[03 :rte!,'•:' :;; :..
Past -it"' Fax Note �1 P 9 i •` b' fd n • flits °fo & 2fam.,QYI[Wd it uWt}�••
of I! !" P� .�:, r'. .
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: ;SrY:i - ;:tr:r - a .r� ` Lw:ar:r... ::rr.. .�.�,.,'e';r:... E'v ..zt
Applicant: Daytime telephone number
Name
1p� Sd6 vr�ar f�v.� -5� I� ��.1•l„ SS l0�
Street address, City, zip code
Landowner: z, Daytime cetephone number
- Name
M
Street addrress, city, rip code
Location of tba building site (complete as appropriate):
Al
N uarter of Section _ 1 j Town 2 0 N•, Range Q -
Lot . Bloc k
Street address
Ia5uructions:
1. Complete this plan by tilling in requested information, marking appropriate boxes, and completing the site diagram
2. In Completing the site diagram, give consideration to potential erosion that may occur before, during, and after grading.
Water runoff patterns can change significantly as a site is reshaped.
3. Chapters ILHR 20 & 21 of the Wisconsin Uniform Dwelling Code, the DNR lirsconstn Construcrirn Site Best Management
Handbook, and IJW - publication Erosion Control jot Home Builders can be referred to for assistance in
completing this plan. ;The Wisconsin Uniform Dwelling Code and the Wtsconsin Consrrucrio's Site Best Management
Handbook are available through State of Wisconsin Document Sales- 6=66-335 Erosion Grntrol for Home Builders
(GWQ)Wj) can be ordered through Cooperative Extension Publications, 608/262-3346.
4. Submit this plan at the time of building permit application.
08/30/00 11:49 FAX 2475086 JERI*KOESTER.... X102
Standard Erosion Control Plan
for 1 & 2 Family Dwelling Construction Site;
According to Chapters ILHR 208 21 of the Wisconsin Uniform Dwelling Code, soil erosion control Informa-
Issuance of buildi
lion needs to be Included on the plat plan which is submitted and approved prior to the g
P we
permits for 1 S 2 family dwelling units in those jurisdictions where ilia soil erosion control provisions of the
tin
'1 (
1
Uniform Dwelling Code are enforced. This Standard Erosion Control Plan s pro vided to � ss sl In mee
this requirement. -
Instructions:
1. Complete lids plan by filling In requested information, completing (lie site diagram and marking (J) appropriate boxes
on the Inside of this form.
2. In completing the site diagram, give consideration to potential erosion that may occur before, during. and after grading.
Water runoff patterns can change significantly as a silo Is reshaped.
3. Submit this plan at the time of building permit application.
Site Diagram Scale: 1 Inch = �O 3 �g �teel
EROSION
CONTROL PLAN
LEGEND
PROPERTY
LINE
EXISTING
_ — — DRAINAGE
— _ — •~ T+- To 7EMPORARY
— olvEnstoN
8e -- FINISHED
ri —^ DRAINAGE
LIMITS OF
GRADING
' SILT
FENCE
- — — X — — STRAW
BALES
GRAVEL
O VEGETATION
r SPECIFICATION
— S ® TREE
PRESERVATION
STOCKPILED
SOIL
Please indicate north
�- by completing the
- -- - -- — — – — — — — — — arrow below_
_ _— - -- — -- --- -�— 'lei - - - - -- - -- -N-
PROJECT LOCATION � t� aosc Ln,C'�
0✓.el -Jre.a +I OWNER
BUlL.pEFi -
r. / r GATE 0400 WORKSHEET COMPLETED BY JJn v d � � p ,e r
08/30/00 11:49 FAX 2475086 JERIsKOESTER.... 90 3
lndicsate management strategy by eheclrina (.o the appropriate box:
S , Mariat!emeat Stnted�
E3 Temporary stabilizadon of disturbed areas.
Note: Although not specifically required by Code, it is recommended that disturbed areas and toil piles left
inactive for extended periods of time be stabilised by seeding (between April 1st and September 15(h), or
by other cover, such as tarping or ,mulching.
permanent stabilization of site by r vegetation or other means as soon as possible.
E3 C1 Use of downspout andbr sump pump outlet extensions.
Note: Although not specTcally required by Code, it is recommended that flow from downsuouts and sump
pump outlets be routed to stable areas such as established sod or paventenL
8 'Trapping sedbnent during dewratering operations.
Note: Although not specifically required by Code, it is recommended that sediment - lode -i discharge water from
pumping operations be ponded behind a sediment barrier until most of the sediment settles out
Proper disposal of building material was ao that pollutants and debris are not carried off - s ite.
Maintenance of erosion control practicm
Sediment will be removed from behind sediment fences and barriers before it reaches; a depth
that is equal to half the barrier's helght.
• Breaks and gaps in sediment fences and barriers will be repaired immediately. Decomposing
straw bales will be replaced (typical bale life is three months).
All sediment that moves off -site due to construction activity will be cleaned up before: the end
of the same workday.
a All sediment that moves off site due to storm events will be cleaned up before the end of the
next workday.
Gravel access drives will be maintained throughout construction.
All installed erosion control practices will be maintained until the disturbed arcs they
protect are stabilized.
{eras. .. ...... .. - _
•4
2..
t-
:...
}
"f.hereby= certifq that I understand the`"coristeuctiod site eroslou control provisions l [ ifie : :Wisc+insin`UniCoriri:
n l P ;: ding .C6de, and that l_•accept responsibilit y. far carrying out - the. above crust is approved by..
ott•t�nito •. n
ent authority
.lft a .enfo .. '
n '
. £.. ..p r� : ': ��.. :.'� •' -�_. :' • ,.,fig '.
,Si aLitrG pC -a lltxnt; _ :a:,,:,.,...t'? :_�• :;:
A publication of the University of Wirconsitt- Errenslon, Ron Struss, UWT-X Water Quality Education Specialist (11193).
This publicQlan may be freely duplicated Additional copies are available through the UWE.X Environmental Resources Center,
_ " 216 Ar Hall- 1450 Linden Drive Madison. iVl_ 53706 6081261 -3652
08/30/00 11:49 FAX 2475086 JERIsKOESTER.... [a 04
Check (,e) appropriate boxes below, and complete the site diagram with necessary iaformadon:
I
Site Characteristics
North arrow, sole, and site boundary. Indicate and name adjacent streets or roadways.
ti
i/ D Location of existing drainageways, streams, rivers, takes, wetlands or wells.
❑ t9' Location of storm sewer inlets.
Q The gradient and direction of slopes before grading operations.
The gradient and direction of slopes after final grading operations.
Location of existing and proposed buildings and paved areas.
❑ Overland runoff (sheet flow) coming onto the site from adjacent areas.
Erosion Control Practices
❑ Location of temporary soil storage piles.
*ote: Although not specifically required by Code, it is recommended that soil storage picks be placed
behind a sediment fence or more than 2S feet front any downstape road or drainalreway.
!� Location of gravel access drive(s).
Note: Recommended gravel drive design is 2 to 3 inch aggregate stone laid at least 7 jee. wide and 6
inches thick Drives should extend from the roadway Miter or to the house foundation (which
ever is less).
t ❑ Location of sediment fences (filler fabric fence, straw bale fence) or vegetative strips that. will prevent eroded
/ soil from leaving the site.
C9' ❑ Location of sediment barriers around on -site storm sewer inlets.
❑ W Lo talioa of diversions.
Note: Although not specifically required by Code, it it recommended that concer.•trated flow
(drainageways) be diverted (re- directed) around disturbed areas. Overland runoff (sheet flow)
J from adjacent areas greater than 10,000 sq. fr. should also be diverted around disturbed areas
❑ GV Location of practices that will be applied to control erosion on steep slopes (greater than 12% grade).
Note. Such practices include maintaining erisnng vegetation, placement of additional sediment fences,
/ diversions, and re- vegetation by ,sodding or by seeding avirh use of erosion control n �ats-
D Location of practices that will control erosion in areas of concentrated runoff flow.
Note: Unstabilized drainageways, ditches, diversions, and ialers should be protected front em through
ruse of such practices as in- channel fabric or straw bale barriers, erosion control mats, staked sod,
and rock rip -rap. When used, a given in- channel barrier should not receive drainage front "fore
than two acres of unpaved area, or one acre djpavcd area. !n- channel practices sh ould not be
/ installed in perennial sireants.
E3 W Location of other planned practices not already noted.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer �Tlal) •V ✓rte y'{'�
Mailing Address 1,9
Property Address __ A ve-
(Verification required from Planning Department for new construction) a VLF C 7 FT
City /State IAI? . Parcel Identification Number
0 3 .2 - 2 106-- 30 -0do
LEGAL DESCRIPTION
Property Location 1 /4, _At&L / 4 , Sec. 12 , T _,? j 2 N - R_Zf_W, Town of S24z .Q s =T.
Subdivision ia Es�o4es Lot # 3
Certified Survey Map # , Volume , Page #
Warranty Deed # 6,-2P , Volume / 7 , Page #
Spec house ❑ yes ❑ 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 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 wastewaterdisposal 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.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
N et forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
ting that your sep ' system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
of the ye xpiration date.
9 X / 20 .0 d
Av
SIGNA F APPL IeANT DATE
OWNER CERTIFICATION
I (we) cert ifv that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
I cTuperty scri above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGRATU OF ARPLffANT 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
I
Vol. 153 7 PAGE 110 I�
62500
STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH
Document Number
WARRANTY DEED REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed made tw Forest Oaks Condos Inc. RECEIVED FOR RECORD
be een ,
08 -24 -2000 9:45 AN
WARRANTY DEED
Grantor, and Wide —Area. Inc., a Minnesota CERT N FEE:
Corporation, COPY FEE:
TRANSFER FEE: 89.70
RECORDING FEE: 10.00
PAGES: 1
Grantee.
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in St. Croix County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
Lot 3, North Bass Lake Estates, St. Croix County, Wisconsin. Name and Return Address
0� 190K
032 - 2106 -30 -000
Parcel Identification Number (PM)
This is not homestead property.
0j) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this 23rd day of August 2000
Fore" aks Condos, I
* * Gerald Smith, President
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Forest Oaks Condos, Inc., by Gerald Smith, its STATE OF WISCONSIN )
President, ) ss.
County )
authenticated this 23 rdday of Au 2000
Personally came before me this day of
I e��� y I the above named
* Kristina Ogland
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person(s) who executed the foregoing
instrument and acknowledged the same.
authorized by § 706.06, Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BY
Attorney Kristina Ogland Notary Public, State of Wisconsin
Hudson, WI 54016 My Commission is permanent. (If not, state expiration date:
(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. Information Professionals company, Fond du Lac. wi
800-655 -2021
WARRANTY DEED STATE BAR OF WISCONSIN
FORM No. 2 - 1999
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