HomeMy WebLinkAbout032-1054-10-050 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Cr oix
Safety and Building Division
INSPVCTION"REPORT Sanitary Permit No:
453258 0
GENERAL INFORMATION (ATTACH TO P�k'tMIT� State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Fuller, David I Somerset Township 032 - 1054 -10 -050
CST BM Elev: Insp. BM Elev: Description: Section/Town /Range /Map No:
/00 7 8111 r C, 's \ 21.31.19.269A20
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt.
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
Septic i a tg " r g > Dt Bottom 1155
Dosing i /g 1 �� ! _ Header /Man. J
7
Aeration Dist. Pipe
Holding Bot. System % 7 , . ,/ a�
PUMP /SIPHON INFORMATION Final Grade U ` ` 9 1 *
5. de .
Manufacturer
962� / Demand St Cove ( i p./
GPM gL
Model Number 0 d . . ....................
TDH Lift 1 Friction I o System Hem TDH/ . r Ft
5 r (a \ (p
Forcemain Length,, Dia, 2 j/ Dist. to Well /�
SOIL ABSORPTION SYSTEM �-
BED/TRENCH Width 3 1 Length ! INo.OfTrenches PIT DIMENSIONS No. Of Pits Inside Dia. DIMENSIONS 1 3 "°� 7 ! A _ \ �\
SETBACK SYSTEM TO P/L BLDG WELL � LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR b�
Type Oj, 4; WA � 'k 4 UNIT Model Number:^ i
DISTRIBUTION SYSTEM ��- 4,C.l1— 1 2— 1*4 (� J Z_ 5 a
Header /Manifold l' Distribution x Hole Size x Hole acing Ri to Air Intake
L Dia Length Dia � Sr
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
D Bedfrrench Center epth Over / Depth Over \ xx Depth of xx Seeded /Sodded I xx ched
Bed /Trench Edges Topsoil Nk
Yes No es [] No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / 1 Inspection #2: i /
Location: 477 210th Ave Unknown (NE 1/4 N 1/4 21 T31 N R1 9W) NA Lot 2 /r 4 S Parcel No: 21.31.19.269A20
1.) Alt BM Description = <_ �w` ��'� �`� e (��+
2.) Bldg sewer length = 3(
- amount of cover =
Plan revision Required? Cj Yes No 1
Use other side for additional information. I �a�� � `�
SBD -6710 (R.3/97) Date Insepctor Signatu Cert. No.
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GENERAL ST. CROIX COUNTY, WISCONSIN OLD TXSCR01
REAL ESTATE TOWN OF SOMERSET
COMPUTER NUMBER 032 - 1054 -10 -050 Parcel Number 21.31.19.269A -20
Claimed Date Re- certified / / Relate Number:
OWNER NAME: First DAVID W & KATHRYN L Last FULLER
CO -OWNER
Mailing Address 1736 174TH ST
City NEW RICHMOND State WI Zip 54017 -
Type Vol Page Doc # Rec.Date Type Vol Page Doc # Rec.Date
HISTORY WD 2454/ 470 746387 11/12/2003 AFF 24411 64 744426 10/21 /2003
PROPERTY ADDRESS:
Hse # 1/2 PD -- Street Name- Type SD Apartment Post Office
477 210TH AVE
School District: 5432 - SCH D OF SOMERSET
Special District: (1) 1700 - (2) - (3) -
W ITC
Plat Code: Last Changed on: 05/12/2004 Book Number: 1
SECTION 21 TOWN 31N RANGE 19W 1 /4160 NE 1 /440 NE Map Number: 00 - Sales Area:
Parcel Control 0 TAXABLE
Number of Units:
ZONING: Permit Number: Type:
Bank Numbers:
F4 -Prev, F5 -Next, F6- Legal, F7- Value, F8- History, F10 -Exit, F12 -More
SaK4y ai County
Mr W 201 W. Was Madishington Wve.j 1 Box 7162 ST C /2-01 Y
on, W1 53707 - 7162 Sanitary Permit Number (to he filled In by Co.)
sconsin
'Department of Commerce (608) 266 -315
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, s15.04(1)(111)
ect Address (if different than mailing address)
I. Application ion - Please Print All hiformat I)[]
REGEIVEr
Property Owner's Na me Farrel N Lot # Illock #
JDAO) tO Fal-C t-111Z 1=2
n in MAY '�, i )(i
'If
Property Owner's M�jgjress Property ocal on
Sj CRUIA--Uui ,
ZONING OFFICE AJE 'A, _A2
City, statr Zip Code ltone Number 1 A • Section
k4
(circl "
tj i �-* 77 - 31 N; Lr 0
__7 R-L ,
11. Type of Building (check all thuFfi ..........
04
N; I
IKI or 2 1 Imnily Dwelling - Number of Bedrooms
❑ Public /('o
minercial - Describe Use 7P 38`7
❑ State Owned - Describe UseS313) I Icily I/ lvin aj-,v )Township or &7
- N 4 4 I —
Type or Permit: (Check only one box on Him A. Complele ]lite u If uppoicnwe)
0 32-1.11.
A, 0(her Modification to lNisling System
.w SyNteln Itcphicemmit System Itcplitccinco( Only •
11crinit Renewal I 1 1 Revision I I Change of I l Permit Traiisfi-i- to New I isl Previous Permit Number and Date Isstiol
flefore Expiration Pl Owner
IV. Type of 1 System: (Check - all that
PJYT
❑ Non -pressurized In-Ground [J Mound > 24 in. of suitable soil i..l Mound < 24 in. Of Sklilillk soil I I At-Grade Single Pass Sand Filter
El Constructed Wetland � Pressurized In-Ground I Holding Tank Peat Filter Aer,)NcTreannenl Unit 1. I Recirculating Sand Filter
❑ Recirculating Synthetic Media Filter i eaching Chamber Drip Line 17 Gravel less Ilip I I Other (explain)
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil Application Rale(glxl.qt) Dispersal Area Required (sf) Dispcisal Arcs Proposed (%I) System 11
(74
/ - -- - - -- — _ _ �- ��?_ Lin -2 5 .
-J--
0, 7
V1. Tank Info — Tallacity In Total Number Manufacturer Ili efith Sit Fiber Plastic
Gallons Gallons of I Jilits GF;icrefc Constructed Glass
New I'MINIIII),
.Septic or ii(wi(iiiii; 00
AcrolftTrviouieut l7o"i
. .... .. . . . M-Jje� (Z-5 4� e-1 o 'MY7 . ......
r _rt
I)oSIns Cllloof;�
5 J _5 160
VII: Responsibility Staten►cia- 1, the undersigned, usskinie responsibility for Insfallathoi of the I'MVI'S shown mi lite attached plans.
Plumber's Na me (Print) Plumber's Si gnature Nil"MIRS Numhet I)lisiliess Phone Number
Ity 0 0 -
A fr , 0. 6)4 7/s cs S 33
Plumber's Addre ss (Street, City, State.'Zili Code) L/
- 7 f
C; 10 ILC,� IT W1. s Lldd
V111. County/) epartment Use Only
ICY Approved, ❑ Disapproved
❑ Owner Given Reason for Denial
Surcharge Fee) $2S-0—
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IX. Conditions oQ�Pprlov
A�a tl
SYSTEM OWNER:
I Septic tank, effluent filter and
dispersal cell must all be serviced I maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable code/ordinances.
Allach co;n`pl� — Pl- , -s (to the County only) for (lie system on paper not ler:4 than 81/2 x I I inches fit size
SBD-6398 (R. 01/03)
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1146
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Tan 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 dimemsions, north arrow, and location and distance to nearest road. Parcel I.D.
Please print all information. Fe wed By a e
Personal information you provide may be us ec �iK)W s. 15 (1) (m)). / Qtr
Property Owner P perty Location
Goodman, David .Lot NE 1/4 NE 1/4 S 21 T 31 NR 19 W
Property Owner's Mailing Address Lo # Block # Subd. Name or CSM#
485 210th Ave. 2 Proposed CSM
City State Zip ode y "FICE City Village r/ Town Nearest Road
Somerset WI 54 - 47 - 4250 Somerset 1 210Th Ave.
Use: Code derived d flow rate 450 GPD
✓ New Construction ✓ Residentia Number of bedrooms 3 9
Replacement Public or commercial - Describe:
Parent material Outwash Plain Flood plain elevation, if applicable na
General comments
and recommendations: Area is suitable for a conventional system with a 0.7 gpd /sgft rating. Possible system elevation for Area I
is 94.40'. Slope is 4 %.
❑ Boring # Boring
✓ Pit Ground Surface elev. 97.93 ft. Depth to limiting factor >111 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft'
in. Munselt Qu. Sz. Co nt. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -12 10yr313 none Is 1 msbk mvfr gw 2m,2f .7 1.2
2 12 -28 10yr3/4 none Is 1 csbk mvfr gw 2m,2f .7 1.2
3 28 -39 7.5yr4/4 none s Osg ml cw if .7 1.2
4 39 -111 10yr514 none s Osg ml - - -- - - - - -- .7 1.2
`f 2.3b t'o
Boring # ,Boring
✓ Pit Ground Surface elev. 97.93 ft. Depth to limiting factor >113 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
1 0 -11 10yr313 none Is 1msbk mvfr gw 2m,2f .7 1.2
2 11 -20 10yr314 none Is 1msbk mvfr gw 2m,2f .7 1.2
3 20-31 10yr413 none sl 2csbk mfr gw 2f .5 .9
4 31 -40 7.5yr414 none s Osg ml ca - - - - -- .7 1.2
5 40 -113 10yr5 /6 none s Osg ml - - -- - - - - -- .7 1.2
36
* Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg /L * Effluent #2 = BOD 130 mg /L and TSS < 30 mg /L
CST Name (Please Print) Signature: CST Number
Thomas J. Schmitt ` -tea/ 227429
Address Tom Schmitt Date Evaluation Conducted Telephone Number
1595 72nd St., New Richmond, WI 54017 12/9/02 715 - 247 -2941
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COMBINATION SEPTIC TANK /PUMP CHAMBER
(No Scale) P� - 'sr:�
,Approved Locking Manhole Cover pl, P
With Warning Label Attached � w.;,d.� P
Weatherproof Approved _ CTr'R7jlve
Warning Label Junction Box Vent Cap -�
7.0 12" Minimum
Final Grade 6" Minimum ` 4 Minimum
7 __ i #
6" Maximum
4" C.I. Quick
18" Minimum Insp. Pipe Disconnect
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1/4 Veep
Baffles
Hole
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d Alarm
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*APPROVED ��� 6 Off Q"
JOINTS WITH
APPROVED PIPE D ptppr0 o
3' ONTO Conc. Block
SOLID SOIL
3" of Beddinq Under Tank- .. "
Noce: Pump and Alarm Are On Separate Circuits Number of Doses: Day
Gallons Per Day / o - Doses: e5-AaI ons
Volume of Backfl ow:!O. °� Gal Ions
Tank Manufacturer: �JcsP �'�«�'� Total Dose Volume ......... _ /v;�_ GalIons
Tank Size-Septic/Pump: /000 e Gal Ions
Al arm Manufacturer: Leyeldla��r.
Model Number: Pike Capacities: A .)-/ inches or 3 -5 - 7 Gallon
Switch Type: Shoe/ a -i // + B ;�_ inches or
Pump Manufacturer: / + C 6 inches or to . Gallons
Model Number: /'/,F b + inches or )5 3 Gal 1 ons
Minimum Discharge ate: a D Total F inches or 6'4,6 Gallons
F, o -s _r
r'er Difference Between Pump Off and Distribution Pipe: 6 Feet
,Minimum Required Supply Pressure: ............... ........+ 0 Feet
/00 Feet of Force Main x - Friction Factor /100 Feet: +� eet
Inch Diameter Force Main /
Total Dynamic head:... /�7 OFeet
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Internal Tank Dimensions: Length ¢ ;; Width 6 + Liquid Depth 3 6
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ME40 P RFORMANCE
CAPACITY LITERS PER MINUTE
0 50 100 150 200 250 300 350 _
40 12
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CAPACITY GALLONS PER MINUTE
23833A275 O
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Early Plumbing & Heating Inc.
221 Broad Street
)`-7 Prescott, WI W1
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Early Plumbing & Heating iii
221 Broad Street
PmQmft W1 21
STANDAR0 CHAM8F1Y
�- _. -- - -- - 52 "-
Quick4 Standard Chamber - - - - 48
(EFFECTIVE LENGTH)
IMP
112" OR
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SECTION VIEW
MultiPort End Cap
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Quick4 Standard Chamber Nominal Specifications MultiPM End Cap Nominal Specifications
Size (W x L x H) — 52"x 12" Size (W x L x H) 34"x 16" x 12"
Effective Length 48" Invert Height 8" or 1.25"
Invert Height 8"
INFILT SYSTEMS. INC. STANDARD LIMITED WA RRANTY
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POWTS OWNER'S MAItL14L & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner C o r /3 e y e- ¢� Septic Tank Capacity /Ov b al ❑ NA
Permit # 75 3 2 5 Septic Tank Manufacturer 661 � .,. ��, � ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer S;�f�� ❑ NA
Number of Bedrooms 3 ❑ NA Effluent Filter Model J 7 - Jr 10 a ❑ NA
Number of Commercial Units - ffl NA Pump Tank Capacity 6.S`0 g al ❑ NA
Estimated flow, (average) ,�JO g al/day Pump Tank Manufacturer 6VIc e- G ❑ NA
Design flow (peak), (Estimated x 1.5) + - a g avday Pump M9pufacturer ❑ NA
Soil Application Rate C? - 7 aVda /ft = Pamp)1✓ii�del 4.0 ❑ NA
Influent/Effluent Quality Monthly average' Pretreatment Unit . ,z 'AN
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand/Qravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 420 mg /L ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 m /L ❑ Disinfection ❑ Other
Manufacturer
Pretreated Effluent Quality . 9 NA Monthly average" Dispersal Cell(s) 9 1 � y awn y�Yc�a
Biochemical Oxygen Demand (BO D 530 mg /L ;K in- ground (gravity uAn- ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ At -grade ❑ Mound
Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip ❑ Other
Maximum Effluent Particle Size Y inch diameter Values typical for domestic (non - commercial) wastewater and
septic tank effluent.
�• Values typical for pretreated wastewater.
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every ❑ months % year(s) (Maximum 3 yrs.)
Pump out contents of tank(s) When combined sludge and scum equals one -third (�) of tank volume
Inspect dispersal cell(s) At least once every ❑ months Xyear(s) (Maximum 3 yrs.)
Clean effluent filter At least once ever ! -
Inspect pump, pump controls & alarm At least once every ❑ months )Kyear(s)' ❑ NA
Flush laterals and pressure test At least once every ❑ months R year(s) ANA
Other At least once every ❑ months ❑ year(s) S$ NA
Other At least once every O' months ❑ year(s) Id 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 %) 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 ch. NR
113, Wisconsin Administrative Code.
The servicing of effluent filters, mechanical or pressurized POWTS components, pretreattment components; and any
other maintenance or monitoring at intervals of 12 months or less 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.
START UP 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.
w Page of
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,"csotton swabs; degreasers; dental floss; diapers;
disinfectants; fat; foundation drain (sump pump) water, fruit and vegetable s gasoline; 9 p�ttng , ga of e, grease; herbicides; meat
scraps; medications; oil; painting products; pesticides; sanitary napless; tampons; and water softener brine.
ABANDONMMENT
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 ch. Comm 83:33, WisconsWAdministrative 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.
O 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.
0 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.
O 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 111 col '%R Name ,T'o 4 -r'�4-Ad
Phone -Phone 7.e S`
SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY
Name ,�d�.s., Sds: �.�>`�'�� Agency Sd,; f - Cam' Ca,.,, z
Phone 7!S — Z 7 — ,� �' Phone 1 7 I —
This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies. This document meets
the minimum requirements of ch. Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not
guarantee the performance of the POWTS.
GMW (2/01)
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMEN 'I'
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buycr oA di U fit) !' q&l,C— 1?_ f ieATH _tz>,/j ___ - e-,-
Mailing Address 1
Property Address '4 - 7 - 7 A ve , -, - - -- — —
(Verification required from Planning Department for new construction)__________
City /State Parcel Identification Number
L EGAL DESCRIPTJQN
E/tST ' .
Property Location N ' /.. ' /., Sec. a > T_ �IZ_1 Town
Subdivision _ _ Lot 9 0
Certified Survey Map # - 7 P 0 35�- ' _ _ Volume Z_ __, Page #
Warranty Deed # -- z jtg'� Volume 2_ ^ , Page # I 1
Spec house O yes no Lot lines identifiable A yes L7 no
SYS TEM MAINTE
Improper use and maintenanceof your septic system could result in its premature failure to handle �,, Prvprr rnainteuance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper What you put unto 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
master plumber, journeymanplumbtr, restricttdplumber or a lictmedpumper verifying that (1) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and purttping (if necessary), the septic tank is less than 113 full of sludge
l/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standaid�
set forth, herein, asset by the Department of Commerce and the Deparhncnt of Natural Resources, State of Wisconsin Certification
ststing that your septic system has been mamtainted mast be completed and returned to the St. Croix County Zoning Office within W
days of the three year expiration date.
SIGNA77JRE OF APPLICANT DAZ-E �-
OWNER CERTIFICATION
e certify that all statements on this form are true to the best of my (our) knowledge I (we) an, (are) the owner(s) of
the pr tty sc ab VC, by virtue of a warTanty deed recorded in Register of Dccds Office
SIGNA OF APPLICANT DA7 E
" "" An information ......
Any that is mis- ropresented may result in the sanitary permit being revoked by the lonm� C>cpartrncnt
Include with this appllcation: 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
U. 2454P 97
' ; M
� 746387
STATE BAR OF WISCONSIN FO 2 - 2000 KATHLEEN H. 1WALSH
Document Number WARRANTY DEED REGISTER OF DEEDS
ST. CROIX CO., MI
This Deed, made between David A. Goodman and Rita B. Goodman. RECEIVED FOR RECORD
formerly Rita B. Bailey, husband and wife Grantor, 11/12/2003 10:00AN
and David W. Fuller and Kathryn L. Fuller, husband and wife 'WARRANTY DEED
Grantee. EXEMPT #
Grantor, for a valuable consideration, conveys and warrants to Grantee
the following described real estate in St. Croix County, State of Wisconsin REC FEE: 11.00
(if more space is needed, please attach addendum): TRANS FEE: 187.50
COPY FEE:
CC FEE:
Part of the E'' /: of NE 1/4 of Section 21, Township 31 North, Range 19 PAGES: 1
West, To f Somerset, St. Croix County, Wisconsin described as
follows Lot 2 f Certified Survey Map filed May 21, 2003 in Vol. 17,
Page 4522, Doc. No. 722387.
Recording Area
Name and Return Address
`� I -
&L-c"ta ` w-T '4 - yo. 1 a
032 - 1054 -10
Parcel Identification Number (PIN)
This is not homestead property
(is) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this Y 7� day of November , 2003
* * — avid A. Goodman
J00 o
+ * Rita B. Goodman
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) David A. Goodman and Rita B. Good STATE OF
formerly Rita B. Ba iley, h usband and w ife ) ss.
County )
authenticated day of November _ , 2003
Personally came before me this day of
the above named
*K ristina Oglsnd _
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, _ _ 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
Kr Ogland, Attorney at Law
304 Locust Street, Hudson, W1540 Notary Public, State of
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. INFO -PRO (800 )655 - 2021 www.infoproforms.com
STATE BAR OF WISCONSIN
WARRANTY DEED FORM No. 2 - 2000
VOL 17 PAGE 4522
KATITEM H. WXUM
REGISTER OF DEEDS
ST. CROIK Co. t MI
RECEIVED FOR R ECORD
CERTIFIED SURVEY MAP 05/ 02:50PK
LOCATED IN PART OF THE NEIA OF THE NE1/4 AND IN PART OF CERTIFIED SURVEY MAP
REC FEE: 13.00
THE SE 1/4 OF THE NE 1/4 OF SECTION 21, T3 1N, R19W, TOWN OF COPY FEE: 3.00
SOMERSET, ST. CROIX COUNTY, WISCONSIN. PAGES: 2
!
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Lo4_�_c� °�ou�e_nm
�� 27 OTH A� �rsl�I�
NORTH UNEE OF HE T HE N 1/4 0
LL
1302 .29 IVa T � 7
9°3aa 'W 65 . 8
N. 114 COR TMI
SEC. 21 2 O 66 NE COR.
r 66.f)2� ;r 6.'234 b—
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411.25'
S89 °3758' E c� C h� 651.22' $ o
w q �I Isla ELI
i 5I
.... ............... i
� d N
1
W SURVEYOR:
Lu 175,132 SO. FT. INC. N SHED WELL �° DOUGLAS J. ZAHLER
RIGHT OF WAY r 0 ° S & N LAND SURVEYING, INC.
w i - r O I HOU5E o 2920 ENLOE STREET
ch N 3.839 ACRES` r r` I O I HUDSON, WI 54016
r CQ 167.229 SO. FT. EX ^ I �
z O RIGHT .OF WAY m 0'� L6 O '
{
W CO *- i
Lo w uj ;,,I n SEPTIC ^ I` PREPARED FOR:
co
LOT 7 DAVID GOODMAN
485 210TH AVE.
O 6.494 ACRES i
CONTIGUOUS : I US 282,874 SO. FT. INC. ° I SOMERSET. WI.
i
BUILDABLE AREA
66- RIGHT OF WAY AND
_ 3.32. ACRES INC. EASEMENT p
I
° i O 5.167 ACRES
' 225,076 SO. FT. EX.
Q) RIGHT OF WAY AND N O
d
EX. EASEMENT I� �
co `�
I
°; r S8921'21 *E q q 652.06' `
w I w
�-
s
z
A �I 3 2.0 Q
� i W 3 26.00 '
o 260.04' w L1 r �- - - - � L � u-
O ' rs�.4y f 133.43 • razsz' >
cm 3. 1 ' 29 5' �I IG 359.0 eo x o
L7 LS 9 �
r I
i g I O CONTIGUOUS' 9
° ; O BUILDABLE AR _ CONTIGUOUS
Z 0.9t ACRES O BUILDABLE AREA ` (n ? Cn w Z
ctpp 2.7t ACRES O
Q � Q
cam, APPROVED p �
( � r
I � CONTAINS I+ ACRES � ST. CROlX COUNTY °' Z z ¢ 23 �
Lr ' I
ca W
I �
Qp I NET BUILDABLE � Piatuttny Zoi)inq and Petits CoR+r<+ � � � �„ $ � � 1 g
MAY 2 1 2m w
LO
S LO • O
^ cD If n recorded within 30 do �1
�p .i W app al date approval shat o�
cD 1z Zo nutLond void 9
LOT 3
5.001 ACRES 4
217,833 SO. FT. O LOT 4 °
U)
4.950 ACRES 5.000 ACRES i NOTE: ALL LOTS HAVE ACCESS
215,640 SO. FT. EX. 217,815 SO. FT. � i AVAILABLE WITH OUT
EASEMENT ray DISTURBING 20% SLOPES.
4.950 ACRES
215,652 50. FT. EX. i
EASEMENT '
SOUTH LINE OF THE NE 1/4 `�► i
OF THE NE 1/4 ° p d
- - 4,54' - -
NORTH LINE N8W21 X 27' 652.89
OF THE SE I/4 �O4
OF THE NE I/4 � 05
°°mo O ___ ( SCALE IN FEET I"= 150'
________________
b0L 913 p®o_Osw@ 150 O MbiiiiiiiiFmw
150
THIS INSTRUMENT DRAFTED BY: WES ANDERSON
JOB NO, 6221 -01 DATE: 11/20/2002 REVISED: 1/27/03 SHEET 1 OF 2 SHEETS
Vol. 17 Page 4522