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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
• s INSPECTION REPORT Sanitary Permit No:
430315 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No
Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)J.
Permit Holders Name: City Village X Township Parcel Tax No:
Ellingson, Brett I Somerset Township 032 - 2147 -20 -000
CST BM Elev: Insp. BM Elev: IBM Description: Section/Town /Range /Map No:
15.31.19.1283
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark C - ioz 7
Dosing Alt. BM
Aeration Bldg. Sewer J
Holding — __ St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic �� y j Dt Bottom
Dosing Header /Man.
Aeration 9ist. Pipe
Holding Bot. System
PUMP/SIPHON INFORMATION Final Grade
Manufacturer Demand St Cover
GPM
Model umber
��cu✓�
TDH Lift ction Loss J System Head TDH Ft
Forcemain r ngth ia. Dist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS �'� 7y�
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR �J 2� c1
Type Of System: UNIT
Ce -lVe- t �c>i, '7Ge-f NC' Model Number:
DISTRIBUTION SYSTEM �_y 7 ;"1 p'• ,� u
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
a Iv Pipe(s) -7' — 2 c 0 t
Length 1 Dia `� Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center to Bed /Trench Edges Topsoil —
Yes [ No '7 Yes �� No
COMME I o iscrepencies, persons present, etc.) Inspection #1: / 3 / 3 Inspection #2: i !
Location: 44 214th e omerset, WI 54025 (NE 1/4 SW 1/4 15 T31 RI 9W) Oak Haven Lot 12 Parcel No: 15.31.19.1283
1.) Alt BM Descrip ion = _TZ C
2.) Bldg sewer length
- amount of cover = �1... �� w o�-� lJNr a r C�e Z✓o i. j1 -� fj,x >�rr
Plan revision Required? Yes No
Use other side for additional information.
SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No.
i
Ilr
Sanitary Permit Application ) afety &Buildings Division
• In accord with Comm 83.21, Wis. Adm. Code 5 z I LI - A . W Washington Ave.
` See reverse side for instructions for completing this apply PO Box 7302
iscons>,n Personal information you provide may be used for secondary purposes adison, WI 53707 -7302
Department of Commerce [Privacy Law, s. 15.04(l)(m)] (Submit completed form to county if not
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 Stateanitary Permit Number ❑ Check if revision to previous application State Plan I. D. Number
ST OEc At 30
I. Application Information - Please Print all Informati n Location:
rN
Property Owner Name t Property Location
- Rizea CLLIMLSOIJ 9C /
Property Owneess Mailing Address ��- -- Lot Number Block Number
VA )Ti `���J� P
City, State Zip Code L_ o Number- Subdivision Name or CSM Number
4WEW
II. Type of Building: (check one) y� S , V" ❑ City
W 1 or 2 Family Dwelling - No. of Bedrooms : ❑Village
❑ Public /Commercial (describe use):_ S�' ' ,Town of �b►S1 S�`T
❑ State -Owned
[ r E Nearest Road , T H Av
t C
,..._ 2 3 r >< U�- � Parcel Tax Number(
III. Type of Permit: (Check only one box on line A. Check box on line B if applicable)
A) 1. EZNew 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)
IgNon- 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: 22 STAtJ Al2n E IQ Q1 FUSE
1, Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area . Soil Application 5. Percolation Rate . System Elevation 7. Final Grade
Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) Elevation
qso �y3 ��y �7 93.E 4�6 A .
VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks I Tanks
S E_ PT 10 l bw 10DO WCE KS ❑ ❑ ❑ ❑
❑ ❑ ❑ ❑ ❑
VIII. Responsibility Statement
1, the undersigne assume responsibility for installation of the PO TS shown on the attached plans.
Plumber's Name (print) iZ a (nos M RS o. Business Phone Number
O F F � Z232y2- Is -ZT-1- :314 1
Plumber's Address (Street, City, State, Zip Code)
Pe. i3ak ns bites G - W( 5qc-
IX. County/Department Use Only
❑ Disapproved Sanitary Permit Fee (Includes Groundwater L -ol Issued Issuin Agent Signature o stamps)
Approved ❑ Owner Given Initial Adverse Surcharge Fee) `
Determination 25b W3
X. Conditions of Approval /Reasons for Disapproval:
SYSTEM OWNER.
1 Septic tank, effluent filter and
dispersal cell must all bg serviced / maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable code /ordinances.
SBD -6398 (R. 07/00)
Pr,ETt ELL) OLDS b Q Ate// 5vtl y S 1 S T 3 l�), R f a v✓
22Ga� VAWTASSE L tD wl� o� So r2SET
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B�rJCt{NIfltZIC = 7n o 1 ~ WO- PI PF:5 EL = t_
A AL 13A. - rbP OP i PYC PIP& Ct - 95.75
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page __ of 3
Dividbn of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County St. Croix
Attach complete site plan on paper not less than 8 112 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, p endi n g
Please print all information, sewed . Date
Personal information you provide maybe used for secondary purposes (Privacy Law, s. 15.04(1) (m)). .
Property Owner Property Location
Govt. Lot NE 1/4 SW 1/4 S 15 T 3 1 N R 19 Fjor) W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
11160 190th. Ave. 12 1 na Oak Haven
City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
Elk Riverl MNI 55330 (612) 441-8888 Somert I 210th. Ave.
New Construction Use: II Residential / Number of bedrooms 4 Code derived design flow rate 6 0 0 GPD
.- -'t "�.
❑ Replacement ❑ Public or commercial - Describe:
Parent material Outwa s h Flood Plain elevation if applicable ri
General comments c °
and recommendations: RECEIVER n �?
trenches @ el. 93.25', spaced to code 4.00' below grade JUN
pi ?8ni a
c x
Boring 4 U111'Y
z
1 Boring # Pit Ground surface elev. 9 7.25 ft. Depth to limiting factor +100 i - �,., cXUfry 1
Soil i n to
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary , Oo6t P
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
a" "Eff #2
0 -1 mfr w 2f 5 9
2 1:2. -4 7 5 r4 6 none ms os mvfr w na .7 1.2
4 5 -10 7.5 r4 6 none ms os ml na na .7 1.2
Cry'
Boring # El Boring 96.85 +100
2 Q pit Ground surface eiev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft'
in. Munsel( Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 I "Eff#2
-12 10 4 3 none sl — 2mcrr mvfr CjW 2f .5 .9
1 oscl mvfr w 1f 7 - 1 - 2
3 2 -10 7.5 r4 6 none ms osg m1 na na .7 1.2
F 71
' Effluent #1 = BOD > 30 220 mg/L nd TSS >30 5 150 mg/L ffluent #2 = BOD < 30 mg/L and 7S5 < 30 mg/L
CST Name (Please Print) Signature . CST Number
Gar L. Steel 02298
Address Date E aluation Conducted Telephone Number
1554 200th. Ave., New Richmond, WI. 54017 6 -1 -2001 715 -246 -6200
II I
Property Owner Gerald Smith Parcel ID# .pandirig Page 2 of
F Boring # E] Boring
3 ® pit Ground surface elev. 94.1 5 ft. Depth to limiting factor +100 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 I 'Eff#2
1 0 -16 10 r4 3 none sl 2m r mvfr qw 2f .5 .9
2 16-28 7.5yr4/4 none 1 osg mvfr gw if .7 1.2
3 28-100 7.5 r4 /6none ms osg ml na na .7 1.2
D Boring # E] E] ❑ 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 /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Boring
Boring # Ground surface elev. ft. Depth to limiting factor in.
El Pit Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = BOD > 30 —< 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS 5 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777.
SBD -8330 (R.6/00)
1, r
AV STEEL'S SOIL SERVICE
GadFsteel Gerald J. Smith 1 554 200th Ave.
CSTM2298 NE4Sw4 S15- T31N -R19w New Richmond, WI 54017
MPRSW -3254 town of Somerset, (715) 246 -6200
lot #12 -Oak Haven
This soil evaluation was conducted to satisfy a zoning requirement, it may or may
not be suitable for your use. Ttve location of the test may or may not be as shown
as permanent lot lines were not established at the time the test was conducted.
-
1 " -40'
top of 1" pvc pipe @ el. 100.00'
top of 1 " pvcpipe @ e1- 95.95'
-22-1 i
440
a
Gary L. Steel
6 -1 -2001
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner _9K'9_1r CUJ iUITs Septic Tank Capacity Oct) a l ❑ NA
Permit # -11 3031 Septic lank Manufacturer W,591(S ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer 'z A aLG ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model A )811 ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity a l &NA
Estimated flow (average) g al /day Pump Tank Manufacturer [KNA
Design flow (peak!, (Estimated x 1.5) g al/day Pump Manufacturer ["A
Soil Application Rate .7 gal/day/ft' Pump Model O(NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit gNA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD,) 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD,) 530 mg /L kin- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) :530 mg /L "A ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) _ <10 cfu /100m1 ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ 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: ❑ month(s) (Maximum 3 years) ❑ NA
y ear(s)
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: s ❑ month(s) (Maximum 3 years) ❑ NA Ea- years)
Clean effluent filter At least once every: " month(s) ❑ NA
� years)
Inspect pump, pump controls & alarm At least once every: ❑ mo ❑ yeaarr(s) (s) ) I& NA
Flush laterals and pressure test At least once every: ❑ mo ❑ yeaarr (s) (s) ) NA
Other: ❑ month(s! A
At least once every: ❑ year(s)
Other: ❑ 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 the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
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 (4/01;
i
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tanks) 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 cell(s) and may result in the 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. 1.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, area
within 15 feet down slope of any mound or at -grade soil absorption area. IT
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 be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled`?with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems 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 POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
❑ 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 INSTALLER POWTS MAINTAINER
Name_ Name
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
i
e UP AND OPERATION P� � of
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 entrations. are detected have the contents
of the tanks) 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 cells) in one large .dose, overloading the cell(s) and may result in the 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 area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics;. baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; 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 be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their Covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or. must be taken, to provide a code compliant
replacement system:
hn A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not. be infringed -upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems 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 POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
❑ 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 MAYBE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name Name
Phone 5-^ Z _ �` Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY `/
Name Name S`r C en IX Cn0 K -
Phone Phone -2) 5 _ S8 1� - L' b A Z)
This document was drafted in compliance with chapter Comm 83.2201b)(1)IO &M and 83_54{1). (2) & Wisconsin Administrative Code.
02/26/2003 10 :42 71524 73038 BELISLE Er.CAVATING I PAGE 01
S T C ROIX COU
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Et1" L�'LLI N o N
Mailing Address 221, B 1 AKrrA - , SEL S
LL'WUATc 2. NI N X56 � Z.
Property Address t
(Verification required from Planning Depamnent far new construction)
City/State
Parcel Identification Number -
E AL ESCRTPI'ION -
0 32 - 2�� -
� 2v - am C.12g3
Property Location s y,, s4✓ y S / S , T 3 I N -R ,� W, Town oI sD►�E(LS r "
Subdivision b1E k t A VE O
Certified Survey Map # �—
y Volume Page #
Warranty need # — Sz -7-?1 _
v olwre 1 page # _
Spec house 6k yes Q no Lot lines identifiable ❑ yes 0 no
S TEM MA 'rL- Ar�cR
Improper use and maintenanceof your septic system could resur't in its premature failurc to handle wastes, Proper maintenance
consists of pumping out the Septic tank ever/ three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the SoMic tank as a Treatment stage in the waste disposal system.
The props; owner agrees grees to submit to St. Croix Zoning Department a certification fo m, signed by the owner and by a
ma„ rerplumber, journeyman plumbcr , restricted plumber oralicenscd um
is in proper operating condition and/or (2) after inspection and pumping (if n ce sary the se tank is less than 113 full of sIndge.
Uwe, the undersigned have read the above requirements and agree to
i a artmert f � 6 maintrin the private sewage disposal syste:r, with the standards
ct forth, herein, as set by the De
P a Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stt►ting that your septic system has been maintained inust be completed and returned to the St. Croix C o unty Zoning O
f tbo three year expiration date.. C Office within 30
5IGr 4 ATVRE O
DATE
0 WND T1FICAT'ION
• I (we) certify that all statements on tYus fotnt are rntc to the best of ray (our) kvowledgr_ I (we) un (are) the owner(s) of
th arty described abo e y virtue of a warranty deed recorded in Register of Deeds Office,
IGtYATURE O
F F ApPI�ICA
DATE
Any information that is mis- roprescnied may result in the sanita permit being revoked by the Zoning Depatzrrtent. +�► + +•*
++ Inctud'e with thts application: a stampr_d wa rranty deed from the Registor of Deeds office
a copy of the certiFed survey map if reforcnce is made in the warranty heed
Pp ?19
STATE BAR OF WISCONSIN FORM 2-1999 6. 7 S 1 1
PEED WARRANTY KATHLEEN H. WALSH
Document Number Q REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made between Forest Oaks Condos, Inc., a Minnesota RECEIVED FOR RECORD
Corporation
01 -04 -2002 9:35 AM
WARRANTY DEED
Grantor, and Brett C. Ellingson and Alison E. Ellingson, husband EXEMPT I
and wife, CERT COPY FEE:
COPY FEE:
TRANSFER FEE: 255.00
RECORDING FEE: 11.00
Grantee.
-- PAGES: 1
Grantor, for a valuable consideration, conveys to Gmntee the
following described real estate in St. Croix County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
].A 12 nd 13, Oak Haven, 5t. Croix County, Name and ite" I.71 11�1A OGLAND
wis ESTREEN & OGLAND
304 locust
Hudson, WI 54016
032- 1043 -80- 000;032 -1043- 90-000
Parcel Identification Number (PIN)
This is not homestead property.
0@) (is not)
Exceptions to warranties: Easements, restrictions and rights-of - -way of record if any.
Dated this 13h day of December 2001
Forrost O ks Condos, I
• • Gerald Smith, L zt��—
s ••
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
ss.
S +C racy County) '
pN #
authenticated this day of �.
Personally came before me th day of
December 200 r epove,named
• Forest Oaks Condos, Inc,, a Minneay rp ation, ¢fit Gerald
Smith, its President
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, to me known to be the person(s) wht~r �r tftt'fgregoing
authorized by § 706.06, Wis. Stets.) in tru e t and acknowl ed e s ip, 1
THIS INSTRUMENT WAS DRAFTED BY
Attorney Kristine OgIand Notary Public, State o Wisconsin
Hudson, W 1 My Commission is renriWMffrjjrn state expiration date:
(Signatures may be authenticated or acknowledged. Both arc not necessary.) —aeD )
• Names of persons signing in any capacity must be typed or printed below their signature. s,romwdon vrormalamis Compny, Fond du L•4 0
S TATED" OF WISCONSIN eee4655
WARRANTY DEED FORM No. 2 -1999
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