HomeMy WebLinkAbout032-2150-00-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
453152 0
GENERAL INFORMATION (ATTACH 'in PERMIT) State Plan ID No:
Personal information ou p rovide may be used for seconds
y p y secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Ellingson, Brett I Som erset Townsh 032- 2150 -00 -000
CST BM Elev: Insp. BM Elev: / BM Description: Section/Town /Range /Map No:
tso .o o a 02.31.19.1306
TANK INFORMATION ftEVA1 ION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic , ^ `�s Benchmark , t ere -D If
Dosing %.62 /�• / / kZ0• Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet 0
Septic , �► }S ' 9 I Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe lo. ONO
b _
Holding Bot. System : 1 G� I
7
PUMP /SIPHON INFORMATION Final Grade 7" 40
Manufact rer Demand St Cover
2.0
Model Numb
TDH Lift n ' Loss System Head T Ft
Force Length Dia. Dist. to Well
SOIL RPTION SYSTEM
se /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DI / �\ i
1 ( 25
SETBACK SYSTEM TO P /L JBLDG IWELL LAKE /STREAM LEACHING /�71 p
INFORMATION CHAMBER OR
Type Of System: UNIT
— �� Model berg c.
y
DISTRIBUTION SYSTEM
Header /Manifold (l Distribution x Hole Size x Hole Spacing Vent to Air Intake
�/ 4 Pip (s) _ Lengt Dia 1 Leng 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
' Yes l -;', No Yes No
CO� (I ude co s, discreperci per ons present, gtc.) Inspection #1: ..2� Inspection
Locati / / 233 5 1 61st St Unknov�(NW 4 SW 1/4 2 T31N R19W) Grandview Estates Lot 10 Parcel No: 02.31.19.1306
1.) Alt BM Description = '1 ,>�'�`
2.) Bldg sewer length = :Zb
- amount of cover = i s
Plan revision Required? Yes XNo 3D & �1
Use other side for additional information.
SBD - 6710 (R.3/97) Date Insepctors Signature Cert. No.
f
Count
Safety tutd Building Division Y
Y 8 �-
1 *is
2 01 W. Washington Ave., P.O. Box 7162
eonsin Madison, V49 53 v T - 7162 Sanitary Permit Number (to be filled in by Co.)
(608) 266 -3151 �- Z
Department of Commerce
Sanitary Permit Application State Plan I.D. Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide
may be used for secondary purposes Privacy Law, sI5.04(1)(m) Project Address (if different than mailing address)
I. Ap Information — Ple se Print All Information
pp S
3
Property Owner's Name R Parcel # Lot /6 Blecle 9
P -
Property Owner's Mailing Addres APR 23 2004 1 Property Location
AW L /+, _f7�' /., Section
ip k n mber
City, fate e�NING FFICM circle e)
ew L N; R10
11. Type of Building (check all that apply) S
i S bdivision Name Camber
2 Family Dwelli — Number of Bedrooms
1 or y g
❑ Public/Commercial —Describe Use
❑ State Owned — Describe Use 2 )c $ ?j ❑City_ ❑Village .STownship of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. JgNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
❑ Chan List Previous Permit Number and Date Issued
B. ❑Permit Renewal 11 Permit Revision Change of El Transfer to New
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 eaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dis ersaVTreatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdso Dispersal Area Required (st) Dispersal Area Proposed (st) yttem Elevation
4 -Aa n 4 Ti aci m TotaT 'Minber Manutheturer _...._ _.C�fa a `Constructed Plastic
- -Steel Fiber Info P i5'
Gallons Gallons of Units Glass
New Existing
Tanks Tanks
Septic or Holding Tank _
Aerobic Treatment Unit
Dosing Chamber w
VII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POW FS sh on t he attached plans.
Plumber' ame (Print) a Plumbe 's ' ure MP/MPRS Number Business Phone Number
A ,
Plu s Address (Street, City, State, Zip Code)
S -
VIII. County/Department Use Onl
Approved El Disapproved Sanitary Permit Fee (includes Groundwater Date sued Is uin Agent Signatur (No Stamps)
Surcharge Fee) Oy
El O ven Reason for Denial
IX. Conditions f Approve
SYSTE
1 Septic tank, effluent filter and = -'
dispersal cell must all be serviced / main 1 Z
twined ,Q�QM.I- 2t�01•tl�A90 �-C
as per management plan provided by plumber.
2. All setback requirements must be maintained 'y,
as per applicable -code /ordinances.
Attach complete plans (to the County only) for the system on paper not less than 81/2 x I I inches in size
SBD -6398 (R. 01/03)- -
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page Z of 2—
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all Information Reviewed by t5 ate
Personal infomiation you provide may be used for secondary purposes (Privacy law, s. 15.04 (1) (m)).
P Owner + F I ! / Property Location
Govt. Lot UK 1/4 S , :; ? , T N R / d(or&
Property owner's palling Addres4 Lot # 91k # Subd. or CSM#
1 0114 h i
State Zip Cod_ e Phone Number City [I Village fffown Nearest Road
44V-1T '1 :7019 NI 1 C ,
New Construction Use1O Residential / Number of bedrooms —j _ Code derived design flow rate GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material _ CC�, f/ Flood Plain elevation if applicable ft.
General oorrirrlents / L 3
and recommendations:
Boring # E] Boring
t�l Pit Ground surface elev. 9 -9 3 ft. Depth to limiting factor 7 1119 in.
Soli 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
4 4
A
FI-:?] 0 Boring # ❑ Boring
Pit Ground surface elev. 3 ft. Depth to limiting factor in. Appl ication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Color Gr. Sz. Sh. •Efl#1 •Eff#2
a �
9 9
4 9
• E t #1 = BOD > 30 220 mg/L and TSS >30 150 mg& ' Effl #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Sig na ` CST Number
Address nag Evaluation Conducxed Telephone Number
Property Owner �� Parcel ID # Page
# [] Boring � JS Pit Ground surface elev. � ft. Depth to linng fa
utictor in.
F7
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlf?
In. Munsell Qu. Sz. Pont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
Boring u
Y
❑ # ❑ Borin
❑ 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
Boring # Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
F-1 " Soil Application Rate
Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPDHf°
in. Munsel Qu. Sz. Cont Color Gr. Sz. Sh. •Eff#1 'Eff#2
•
Effluent #1 = BOD > 30 < 220 ffV& and TSS >30 < 150 nV& ' Effluent #2 = BOD, < 30 mg1L and TSS < 30 mWL
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.
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• 1044
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Tom Schmitt
Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County St. Croix
include, but not limited to: vertical and horizontal reference point (BM), direction and
percent slope, scale or dimensions, north arrow, aggjoc$ion distance to nearest road. Parcel I.D.
Please print al \formation. ewed B _� Date
Personal information y ou p rovide may b ,*onda , y
y p y e .� purposes (Privasy`lpw, 15.04 (t) (m)). Q r�
Property Owner p � operty Location o
M & G Inc c�� \��-�' Lot na NW 1/4 SW 111 S 2 T 31 NR 19 W
Property Owner's Mailing Address 2 to�# Block # Subd. Name or CSM#
1359 Awatukee Trail X r. , 10 NA Grandview Estates
City Stat Cgtp ode Pho _p�y11 f _j City `J Village tf Town Nearest Road
Hudson WI N 597* Somerset Cty.Rd.I
New Construction Use: tej Resia ti I / =r�clra6oms 3 Code derived design flow rate 450 GPD
`J Replacement _j Public or cocribe:
Parent material Outwash Flood plain elevation, if applicable na
General comments
and recommendations: Suitable for a conventional system with a 0.7gpd /sqft rating. Possible system elevation for Area I, (high
trench) 96.20 (low trench) 95.70. Based on a 7% slope.
Boring # _j Boring
V1 Pit Ground Surface elev. 99.78 ft. Depth to limiting factor >99 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ttz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -7 10yr3/2 none sl 2mgr mfr cs 1f .5 .9
I
2 7 -22 10yr3/4 none scl 2msbk mfr gw 1f .4 .6
3 22 -35 10yr4/4 none Is 1 msbk mvfr cs - - - -- .7 1.2
4 35 -99 10yr5/4 none ms Osg ml - - -- - - - - -- .7 1.2
i
� •20
Boring # _j Boring
Id Pit Ground Surface elev. 99.67 ft. Depth to limiting factor >98 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft=
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2
1 0 -7 1 Oyr3 /3 none si 1 m mfr cs if .4 .6
2 7 -22 10yr4/4 none sicl 2msbk mfr cs 1f .4 .6
3 22 -98 10yr5/4 none ms Osg ml - -- - - - -- .7 1.2
W 20�
* Effluent #1 = BOD 30 < 220 mg /L and TSS 30 < 150 mg/L
* Effluent #2 = BOD S30 mg/L and TSS < 30 mg /L
CST Name (Please Print) Signature: CST Number
Thomas J. Schmitt 227429
Address Tom Schmitt Date Evaluation Conducted Telephone Number
586 Valley View Trail, Somerset, WI 54025 5/18/01 715- 549 -6651
Property Owner M & G Inc Parcel ID # Page 2 of 3
3] Boring # � Boring iel Pit Ground Surface elev. 97.62 ft. Depth to limiting factor >98 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 - 10yr3/2 none sl 2mgr mfr cs 1f .5 .9
2 7 -21 10yr3/4 none sicl 2msbk mfr gw 1 f .4 .6
3 21 -40 10yr4/4 none sl 2msbk mfr gw - - -- .5 .9
4 40 -48 10yr4/6 none Is 1 msbk mvfr cs - - - - -- .7 1.2
5 48 -98 10yr5/4 none ms Osg ml .7 1.2
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 Stricture Consistence Boundary Roots GE D 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
F-1 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 GP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD 5 > 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
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner _ Septic Tank Capacity a l Cl NA
Permit #
t 5 2 Septic Tank Manufacturer ; t C NA
5
DESIGN PARAMETERS ' '' Effluent Filter Manufacturer Ci NA
Number of Bedrooms ❑ NA Effluent Filter Model 1 ❑ NA
Number of Public Facility, Units 25 NA Pump Tank Capacity a l 12�-NA
Estimated flow (average) g al/day Pump Tank Manufacturer ZNA
Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer ZNA
Soil Application Rate A al /da /ft� Pump Model _dNA
Stands, I Influent /Effluent Quality Monthly average` Pretreatment Unit A
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L O NA ❑ Mechanical Aeration O Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) O NA
Biochemical Oxy Deman& (SOD) S30 m /L
yg s g 04n-Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L 0 NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510 Cfu /100m1 O Drip -Line O Other:
Maximum Effluent Particle Size Y in dia. O NA Other: ❑ NA
j Other, NA Other: O NA
"Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: 13 months) (Maximum 3 years) O NA
� 0 ear a .
Pump out contents of tank(s) az . , ,.r When combined sludge and scum equals one-third (Ys) of tank volume O NA
Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) O NA
y ear(s)
Clean effluent filter At least once every: O month(s) ❑ NA
J5 - ear(s)
Inspect pump, pump controls & alarm At least once every: O month ❑ eaarrls) (s) l ANA
Flush laterals and pressure test At least once every: 13 month(s) 13 -Z NA
ear(s)
Other; At least once every: ❑ month(s) Z NA
❑ year(s)
Other:
O NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual Inspection of the tank(s) to Identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the 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 ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires tho
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 entiro
contents of the tank shall be removed by Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized .components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
GMW 14/011
Page C-2 of
STARTUP 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 oell(s) and may result In backup or'surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior 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 irea
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;, meat 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 lie taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
e All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
e 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
roquirod 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 must
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 POW
technology a holding tankmay 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.
❑ 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. .,
<<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 IN TALLEW POWTS MAINTAINER
7,14amelL, 7.7777 Name
Phone / — Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
G
Name
Phone Phone
"his document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(t) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT,
.
0WN[ _`h�SHlP CEJ"T!FICATION FORM
OwncriButi'er ��� �L(�(. 6'L ' ��� •
Mailing dt'u ess � A SSe�F 5 '���6lLr✓�4��' �� ��U��Z
g
tVriilicauun rr�lt:ie�i (run; Planning Dc;paruncnt for new �unstruction)
Parcel ldetitification Nunibor
LEG DESCRIPTION c
operry Location _ ' �- S,,:. '1'rN��N R W, Town of
Subdivision , Lot # •
Certified Survey Map # , Volume , Page #
Var•rauty Deed # l�� I 13 _ \'JIUme V `� , Page #
`spec house ICI yes C3 no Lot lines identifiable ,gyes 0 no
ST EM MAINTENANCE
Improper use and maintenanccof your septic system could result in its premature failure to handle wastes. Proper mainter,an;c
into the s •�tCui
.un•isls o nun yin � out the • � t; �� • � u � • • �, nor it n�edcd h a licensed p umper. What you pu }
s I I F 6 u Sepi utk � � • t) tl << �
}pats r sou � ) P P
:an affc�t 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
1 t on -site wastewaterdi osal system
lumber, 'ournc an 1 ervenf in that a sP
p , � yin plumber, restricted plumber or a licensed pump verifyin ( )
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•
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
d y of the three year expiration date.
` al o
; IGNA URh OF APPLIC T 6ATE
WN ER CERTIFICATION
1 (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owncr(s) of
t,lypoperty described above, by virtue of a warranty decd recorded in Register of Deeds Office;
c) `f
SIGNATURE OF APPLICA 1' DATE
Any information that is mts•rcpresented 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 ma if reference is made in the warranty deed
P
i
J l II 9 5 f' Z 4 1 6703593
STATE BAR OF WISCONSIN FORM 2 - 1999
KATHLEEN H. ItIALSH
Document Number I WARRANTY IDEEDw REGISTER OF DEEDS
ST. CROIX CO.. NI
This Deed, made between G rand Pr operties, LP, RECEIVED FOR RECORD
.. 05 -21 -2002 9:45 AN
WARRANTY DEED
Grantor, and Brett C. Ellingson EXEMPT #
REC FEE: 1i. 00
- -. TRANS FEE: 161.70
_ - COPY FEE:
- — -- CENT COPY FEE:
Grantee. PAGES: 1
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
LPl o f Granview Estates in the Town of Somerset, St. Croix County, Name and �geiu d e Ktil! { OGLAND
ATTO F — : NJ E Y AT LAW
P.O. BOX 359
HUDSON. WI 54016
032 - 1005 -20 -000
Parcel ldentirication Number (PIN)
This is not homestead property.
QC) (is not) -
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this �? _ day of May 2002
Grand roperties, LP,
11 i A . Germain —
- — -- -- -- - Mic G erma i n - -- -- -
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) G rand P LP, by Michael J. Germ STATE OF WISCONSIN )
) ss.
County )
authenticated thi a of May _ 2002
Personally came before me this day of
the above named
+ Kris Og land
TITLE: MEMBER STATE BAR OF WISCONSIN
(Ifnot, to me known to be the person(s) who executed the foregoing
authorized by § 706.06, Wis. Stats.) instrument and acknowledged the same.
THIS INSTRUMENT WAS DRAFTED BY a
ttorne Kristin Ogland Notary Public, State of Wisconsin
Hu dson, S 1'1 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
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