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HomeMy WebLinkAbout032-1072-10-000 / o 2 $ ~ � 7 0 8 & , \ 2 E 2 0§ \ 0 M § a2 § _ i § k� § \ �/ $ \ cc § EE 7 \ 97 \ z �k; \ L ki- mod/ . � m z � � § w ( E § � o R E ° ■ 64 w z ( B z ¥ ( 2 $ - 5 § » i A { � � a % ) . \ K ƒ 2 2 S § + k Q \ / / \ z \ z / z \ " z U) \ k { k . co a 7 & � m 9 o o a % E < 0\ 0 m m 0 , - I \ ( U) 0 CL k k k -� m \ S a g a 2 \ o B\ o cr ƒ � w \ B k/ z 6 2@ \ § k \ \ / E / i \ Q ` _ G \ _ J 7 a / . \ 0. G \ <\ § §§ G \§ a k k§ 8 3 c ( 7 \ r ° ® 2 @ $ / / \ § k \ \ / \ \ \ k - g m / §/% o 2$ 2 2 2\ J % \ ) ) k / \ /\k \ J 3 a 2\ 3� c /* , Wisoo"n Department of commerce PRIVATE SEWAGE SYSTEM County- Safety and Buildings Division St. Croix INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Urm it No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 370365 Permit Holder's Name: ❑Ci ty Village .Q TjQwrLO State Plan ID No.: Moe, Bill Somerset Townshi CST BM Elev.r Insp. BM Elev.: BM Description: Parcel Tax Nn ,9 I I to ,�/ = cc; 032-107 TANK INFORMATION ELEVATION DATA a( TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic I Benchmark Dosing Alt. BM S Z r 03, 25 ` Aeration Bldg. Sewer ?j .(o Holdi St/Ht Inlet -9 `8 I CE). 5Z- TANK SETBACK INFORMATION St/ Ht Outlet S' 2( Iw • 2 - 9 I TANKTO P/L WELL BLDG. Ae lntake ROAD Dt Inlet Septic -� Q 1 / 8 NA Dt Bottom — Dosing NA Header /Man. 8•�3 qR -�� I Aeration A Dist. Pipe Holdin Bot. System lo. $ PUMP/ SIPHON INFORMATION Final Grade Manufacturer De nd St cover Model Nu er M TDH Lift riction System TDH Ft Force airs Length Fi Towers SOIL ABSORPTION SYSTEM 15C� , k 'F3. C TRENCH Width I Length No Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth D IME 3 alAOe 1 1 DIMENSION Man ur r: SETBACK SYSTEM TO P 1 L BLDG WELL LAKE /STREAM LEACHING INFORMATION Type Of CHAMBER Moe um er: System: 1122 OR UNIT — DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hoe Spacing Vent To Air Intake Length Dia. L engt ia. Spacing 2D 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 I Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1:195/ Fh/ 01 Inspection #2: -- Location: 697 200th Avenue Somerset, WI 4025 (NE 1/4 NE 1/4 26 T3 IN R19W) - 263119351A - Lot 1 1.) Alt BM Description= 6 - I,5 � 2.) Bldg sewer length= L( - amount c cover t8. o' Plan revision required? ❑ Yes No Use other side for additional infor aUon. SBD -6710 (R.3l97) Date Inspector's Signature Cert. No. I 09/22,/00 FRI 07:52 FAX 715 386 4686 ST CRX CO ZONING U002 Sanitary Permit Application Safety & Buildings Division 201 W. Washin on Ave, In accord with Comm 83,21. Wis. Adm. Code See reverse side For instructions for completing this application P ox 2 Madison, W53 730 N Personal information you provide may be used for secondary purposes Departmenr or commerce (Submit completed form to county if r [Privacy Lam. s. 15.04(I)(m)J state o Attach complete plans (to the county co only) for the system. on a er not less than 8 - 1/2 x I I inches to size. County State Sanitary Pemiil Number ❑ Check if revision to previous application State Plan 1. D_ Number - SrC_ r *; fO (n I. Application Information - Please Print all Information Location: Property Owner Name Properly Location & • L ` W E1/4 G 1/4, S-26 T -JI N. R 11 or Property Owner's Mailing Address Lot Number Block Number (3 '12 S'' City, State Zip Code Phone Number Subdivis on Name or CSM Number ST CC w N-t S`s 4'Z t ) $ 2 6 II Type of Building: (check one) �✓ as Sw O City �` I or 2 Family Dwelling - No. of Bedrooms a Vi vi a n or O Public/Commercial (describe use): ] � O State -owned -� —, III Type of Perinit: (Check only one box on line A. Check box on line B if applicable) Nearest Road volt A) 1, JiLNew System 2, ❑ Replacement 1 3, ❑ Replacement of 1 d, 13 Addition to Parcel Tax Number(s) system Tank On Existing System V 2 - — —od B) Permit Number 13AW7tsstzad ❑ A Sanitary Permit was reviousl issued - 3S IV. Type of POWT System: (Check all that apply) . ;@Lblon- pressurized In-ground ❑ Mound ❑ Sand Filter C3 Constructed Wetland 13 Pressurize IQ- roun �0 3 x`k3•�� 1I ing Tank ❑ Single Pass ❑ Drip Line �crr 13 At- grade2 1 ``C! , > �' Ae obit Treatment Unit ❑ Recirculating D Other: '�6 CA V Dispersal/Treatment Area Information: I. Design Flow (gpd) Z. DispersalArea 3. Dispersal Area 4, Soil Application 5. Percolation Rate Required Proposed Rate (Gals. /day /sq. ft. (Min. /inch) VI Tank Capacity in Total of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con - glass New Existing crete strutted Tanks Tanks ❑ ❑ D VII Responsibility Statement �-= /w 1, tltz undersig assume res ensibilit for installation of the P6w shown on the attached Plans. Plumber's Name (print) Plumber's Signature (no stamps): PRS No, Business Phone Number yyi 4 L Plumber's Addross (Street, City, State, Zip Code) av s Q� YG �k.1 w t' VIII County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued i \\ ,.thing Agent Signal (No stamps) I QLApprovcd I2 Owner Given Initial Adverse Sur arge FCC) /: :� Determination LP ' - Jas - . db - IX. Conditions of Approval /Reasons for is pproval: SBD4398 (R. 07/00) &dp LWA i 1 , s/ : t I I , . I , t i , , , t , , I -- i - - -- -- - - - - -! D O , i C , 1 1 -_L L 4 i , , I t -- -- -- - I E - I i c ,Q c) lap i me- , r I i I E f i , - T;T, e i I I t i , I I , ! I E a. , , , Wisconsin Department of Commerce SOIL EVALUATION REPORT Page -/ Division of Sa fety 5a a and Buildings s 9 in accordance with Comm 85, Wis. Adm. Code , Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County 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 Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Govt. Lot 1/4 1/4 S T N Ra E (orr Property Owners Mailing Address Lot # Block # Subd. Name or C SM# Z. City State Zip Code Phone Number City Village [Z Town Nearest Road V New Construction Use:Z Use: [ Residential !Number of bedrooms Code derived design flow rate GPD [] Replacement Public or commercial - Describe: Parent material !f Flood Plain elevation if applicable 4 ft. General comments and re — � �`n fL q U6 — 121 Boring # ❑ Boring ® pit Ground surface etev. ft. Depth to limiting factor 9 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 _ J7C S • ® Boring # ❑ Boring ❑ pit Ground surface elev. /fJJ , S` ft. Depth to limiting factor 9 e 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 `3 s s - �� � y * Efflu nt #1 = BOD > 30 < 220 mg/L and TSS >30 _< 150 m9X * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name I se P. ) CST Number Address ate Evaluation Conducted Telephone Number t t Property Owner Parcel ID # Page �� of Boring # ❑ Boring 0 pit Ground surface elev. 11-:91 � — ft. Depth to limiting factor 9 61 1 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Pont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 C k 3 s - 2 SS- L ❑ 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 GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 I I I I I � 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 GPD /ftz 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 < 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.6I00) I I� i Z1 ay Alle I � j 3 407 i Private Onsite Wastewater Treatment System Management Plan Y 9 Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private O nsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground i Soil Absorption Component Manual for Private Ons to Wastewater Treatment Systems SBD- S y 10567 -P (R.6/99). Table 1: System Design Specifications Sanitary Permit Number 3G Number of Bedrooms Design Flow - Peak (gpd) cry Estimated Flow - Average (gpd) Septic Tank Capacity (gal) Soil Absorption Co mponent Size ( ft 2 ) SO z 4 Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Opera Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) aS-9- z Maximum Influent Particle Size (in) U 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained b an individual certified to service septic tanks p Y I under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the sep ' and outlet filter shall be assessed at least once every 3 years by inspection. roper outlet fil shall be cleaned as necessary to ensure proper operati The filter cartridge shou not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. ins Manhole risers, access risers and covers sh ould be inspected for water tightness and and assessment shall be sealed watertight on ht u soundness. Access openings used for service n g P the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for an reason without being in full compliance with OSHA standards for Y 9 P entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. P Y Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 Management Plan for a Septic Tank and Soil Absorption Component Plantings of deep- rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. 3 imiNimmiii ■wifiifOa ■iii / ■flNONiR ■fl11 r _, 7/'! w ■mmmmm / f■■f■ffafONffifff►�■a■NU nomflNOi!■ ■ ■! !1111■ 1111 I./■ ��������!! ! ■ /! / ■ /liaO! /mOI �►II�Iif' /! ■! /f f /! / /! ■�- i.... ����!!►7 ■!!ff / / ■ ■f / ■ ■/ ff //f !■!/ mmam � rr ... ..■■.■ ■■■ ■NN ■■ �■■ ■!f ■Ial'!!" lama/ N■■■■■ Nlf�� ! ■!mf ■ / / ■ ■!!! ■!! ■ /! ■ ■NEi Oia/■ afaif■ ►7ilf ■///f���/f//�������f//!r�■ wit!!■■!! f!!! ■!! ■!!!f!/lflf�Nlf■!//f!!/f ////ff/f/f ffff / /!! ■r.....r5ii...- �- -�-.._rr-r rrr r r���t ����...■■■■■■■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ / ■ ■. /....�� \ ■ ■iN ■1NEO ■ ■l imam �ilO■ O■/!/ ■ ■ll���� ■! ■ ■ii \ ■tf� ■��! ■!! ■ /�!� ■!fff ■ ■ ■! ■ ■ ■! ■ ■ff ■ ■! / ■��Y ■ ■�! ■/ \■!!■ Nmmm!!!m ■f11l mammal mail m■ mm■ m■■ mmmmmmmmam iN !!■!liiii■!!!■!!■■ /! ■fi ■ /! / ■ ■// ■BOGiAm.7 /fm mmmm mmENRitifmmm■ mamma!! mmm■ ml mmm!!■ m/!! mm■■! mmmmmmmmmmmmfi/ / ■! ■ / ■! ■ / / / / / / / / ■ ■aIl / /ffm /■ ■!/!!//!/■ Ilmm/ OiifmmamlROifam E■ mmmmmmlmmm!!! !lmmmmmmm ■ ■ ■ ■ ■! ■ ■Nm ■ ■ /! ■! /!!! /■ /111/ /aim //!/!liOfn ■O■ iii■■■/ fEf■ OENiiifiii■ i!■■ ifN■!/!/■■■// ■ ■ /! ■ /!! ■! ■ ■mmmm ■ /! ■fONNin ■ ■! /■ i/ ffffiff■ �BiiiiifEfmOEf�AiiNi■ fOfffmimiiiiii ■iiiii ■iifiifii ■ ■! /! ■foil■ ■iii ■ ■ / / mlamma /� ■!!■■ ■!!!■// Of■ ImNiififfii�It Om�m■ m�m�■! i■ ■■■■ ii■■ �!■//■/!■■!!!■ ■ ■ ■ ■Nmmmli ■! /! ■!!l111f / / /� /!!im f / mmm ■ /illlifOfi ■ / ■ /!!� � ■�:'�i.■ ■■.fi.■■! ■ii ■ONNN■.r !� / /! ■! ■!! ■ ■!l mmmmmmm ■l ■ ■ ■ all ■ ■ //� ■ii■■ ■ /! ■ ■ /fmm / ■a!m ■RNEmfL11 ■�l / ■// /! imam ■NE■■ /mm / /!� /mf■���aff ■ / / ■ / / /mmmmim /!lmll ■ ■!!� ■!! ■■ ffffiilio■ O■ ii■ iflRli \IffiN ■filiNififNff ■ ■ONi■ iii■ iiaOOi■: �■ � !!! ■!! ■ ■ ■looNN ■nlioli! ■oimoff ■■ ■ ■l ffff ■oififi ■ifl ffff \ ■ ■N ■OiNifiME ■f ■Oi ■iOmiifiiii iiii iOi\\■ / / /!■ ■fff ■!!! ■ ■ ■ ■O!i ■ofNm oNN■■ it iii■ ffm!■ mlOii/ mmmmOr// mmmmRNENROfimfmio iORNmORNERO!■■ NEm► \lRmEimmmmilm ■]fmm / /B ■ /! /■ NNE ■O ■fROiiliiiif ■fRiifRNi miff iifim■mm ilO RO /fimm ■amn Oaf■ ■ ■ / ■ ■ \f ■tifm /nf ■ / ■llliOifB / ■! ■! ■ ■■■■ ■■ mail! mmm mm m■ Nimf!■■ iiNifffaiifii■■■ Emiiiim mammallmammlmmmmiiimmmmmlliamfllmfmmm ffiooil Non ffff■■ faiiiiiiii/ fmmmfaifii /iiflfoNlioNiifNfoNlfoNt mo /NOni ■onn ■ /n ■ ■al i■Onnrl■!!■■ ' mmmmi ■ifii ■ffii■ NON■ wiiiffffoi Om limmRN■ O■ Nmmmmmmmmifiif .�!!!■!!loni ■oNloill ■onnllfniai ' !!■■!■■■// ilmmmmlMEmwl7B ' +Nr %NENRlEmam//!!! ■/!!■■/■■ lffOEmiE ■ ■mmm11lmmlmm ■mmmmammfi 11 ffff! 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Boni ■soiif!■ it ifiaim Omiamim■ /mmmimmm!■■!!■mlmmf mammlliinoi NiSEE■ Immn' liNEmmm!!! Ef mammfa!■ NEfmm/ m ROEmiimNiiliiamRNEORNE /mmmmmmmmlmmm ■ ■!!I!RIB!!/ iOno['\I \ran Nii NEl ilflfffOERmlI■ iffmi■ NRf/■ amfmimmOiiimEOmmimmmmma ■ /m /mi�� ■mfiimNf mmfmf (1 %Nn ff■■' t7/ NOiifm■ mmNNO►. iimlmiiNOmfma!/ mm!/ e\/ fmamfmmmmmmimlrlORNEON IERNEmRmf.,tm \��'%afmi mNMEB7fJRine■ Nilllmm��r�o_ ii�fr�����11/ �����������i���r1���m����A����im l .._.. � ...r......rr ■......rrr..�.ililNiI mRNiimmAMoi■ Om■ Blamummmm iiiiii iiiiAfNJiiiiiiii iii \ iiQiiiiii iiiii�i� ���\ iiiiiiiiii�Rtiiiiitiiiif /i�fiiiiiiispun I � � �� -' �. %.. . � �� • '� �� 'Wiscons epartment of Commerce SOIL AND SITE EVALUATION Division 6f Safety and Buildings Page —/— of Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel # APPLICANT INFORMATION - Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Prope w Property Location Govt. Lot 114 1l4,S T . N,R E (or)p Property Owner's Mailing Address Lot # ck Subd. Name or C City State Zip Code Phone Number ❑ City ❑ Village f Town Nearest Road ( a ear 55a ( _ 5q)9 I ,3 New Construction Use: Residential / Number of bedrooms 3 Addition to existing building ❑ Replacement El El Public or commercial - Describe: Code derived daily flow __ " 9Pd Recommended design loading rate C�_bed, gpd /ft �. , trench, 9PdJ11 Absorption area required _?7S bed, ft -- trench, It 2 Maximum design loading rate _� 2 bed, gpd /ft _ trench, gpd /ft Recommended infiltration surface elevation(s) �_� It (as referred to site plan benchmark) Additional design /site considerations t r Parent material "f, // Flood plain elevation, if applicable It S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system ❑ S _X U � S ❑ U ❑ S Va U I ❑ S ®U I ❑ S 1Z U ❑ S IN U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Co . Color Gr. Sz. Sh. Bed Trench Ground elev. 9Z7-ft. 6 �� Depth to limiting factor in. Remarks: Boring # ,r _ y Ground �elev. /�tt• , Depth to limiting factor _S;�._in. R marks: CST Na f easePrintL Signature / Telephone No. Address Da CST Numbe SOIL DESCRIPTION REPORT 7 ; PROPERTY OWNER Pag of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. llSh. Bed , Trench 6� S GZGJ Ground a elev. J Xn. s Depth to limiting factor Remarks: Boring # Ground zv - h elev. Depth to limiting factor Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # .......................... ......................... ........................... .......................... .......................... Ground elev. ft. Depth to limiting factor ' Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) 7 off�✓Ce /l�siJ�,�nc'►fE.! ^��� ©le, S s' 9a �, 1 f CROIX COUNTY • SEPTIC T, ;'.NK MAINTENAI'vCE AGREEMENT 01 AND OWNERSHIP CERTIFICATION FORM . 21JBuyer Mailing Address �p� b. Doe L '721" .STe'Z (c,,,r? -� .� -t Property Address 1 S'? 2vo' (Verification required from Planning Department for new construction) City /State _SQA,,4, x.Pyl w= Parcel Identiftc:+;)c)n Nutnbcr LEGAL DESCRIPTION Property Location )Ve r /4, )Vg� r /4, Sec. .26 , T -1 N- R_/ /,W, Town of ScA e_ -s 4- Subdivision _ , Lot # T Certified Survey Map # 1 -/669"Ll _, Volume Page # 22Jr`r' _ Warranty Deed # 6/ 006r , Volume �ys'"r , Page # Spec house ❑ yes R-.no Lot lines identifiable k yes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceol'your septic system could result in its premature fat Iure to handle wastes. Prope; maintenance consists of pumping out the septic tank every three years or sooner, it' needed by a licensed purnper. What you put rnlo 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 t tier and by a master plumber, journeyman plumber, restricted plunther or a licensed pumper verifying that (1) the on -site wastewaterdi:.posal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commejcc and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) tue owner(s) of the property described above, by virtue of a wan deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DA "I u "'•'* 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 Goon the Register of Deeds off a copy of the certified survey map it reference is made in the warranty deed .14b5PAGE ?7j G� STATE BAR OF WISCONSIN FORM S — 1982 61 OO16S D =VRXXnNURl MXr1 DEED KATHLEEN H. WALSH REGISTER OF DEEDS DOCUMENT NO. SPECIAL ADMINISTRATOR'S ST. CROIX CO., WI RECEIVED FOR RECORD Paula Grace Chirhart, Special Administrator, 09 -09 -1999 9:30 AM DEED of the estate of EXEMPT N Br»rQ �� an CERT COPY FEE: COPY FEE: TRANSFER FEE: 186.00 ( "Decedent"), RECORDING FEE: 10.00 for a valuable consideration conveys, without warranty, to PAGES: I Wi 131ram n. Mr)-- an Pu r•a A. Fazendir husband anti ua a�,a wi ft?, Grantee, the following described real estate in St r't'C11X County, THIS SPACE RESERVED FOR RECORDING DATA State of Wisconsin (hereinafter called the "Property "): NAME AND RETURN ADDRESS KRI,;T'INA OGLAND Zilz, Estreen & Ogland P.O, Box 359 Hudson W1 54016 032 - 1072 -10 -000 PARCEL IDENTIFICATION NUMBER That part of NE1 /4 NE1 /4 Sec. 26- T31N -R19W described as follows: I lfl Certified Survey Map recorded in Vo 1. 8 of Certified Survey Maps, page 2250, as Doc. No. 460843. �I 1` 4 i Ij �I u Sedal Administrator x{p(gg by this deed does convey to Grantee all of the estate and interest in the Prp ert which the Decedent had immediately prior to Decedent's death, and all of the estate and interest in the Property which nas since acquired. 2� d Dated this day of August 19 99 I I (SEAL) I' i, * Paula ace Chirhart Personal Representative Personal Representative i� AUTHENTICATION ACKNOWLEDGMENT �) l Paula Grace Chirhar , Speelal State of Wisconsin, r, A dministrator of the Estate of Bruce Z ss. j � County. authenticated this day of _ Ar _ lg __qg Personally came before me this day of j 19 , the above named * Kristina land ii TITLE: MEMBER STATE BAR OF WISCONSIN (If not, `1 authorized by §706.06, Wis. Stats.) to me known to be the person who executed the foregoing instrument and acknowledge the same. i THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Ogland * Hudson, Wi 54016 Notary Public, County, Wis. (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date: necessary,) Names of persons signing in any capacity should be typed or printed below their signatures. PERSONAL REPRESENTATIVE'S DEEP STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. ii Form No. 5 — 1982 Milwaukee, Wis. I 1 ` QSZZ � l� 1 j o 1 sPus7 PO4i Un a N C C V N C C _ L) 41 9t uot438S 40 �3N a4� jo Prue 1- o i 3SE3 c i 4 A1 ► IF a M ..01 ate 00 got wmiwm i W 'e I •,� . —Z u 1 N C �+ I W p, N1 O 2:1 I,n I W, O yO. O W .� 4'• �Cp N 0 . �1 N G I H_ Z y :: 1 4J ,..1 0 of 14 1 -- ,10'OZO— ,to esa 3 „09 ,lbo ON .w 1 Y ff 3 ..Of,ZO,LON ) N' O 1s JI £ £ 4. ..Cil ~ O J y y ) O. I N i 4. 10 1 ` C Z I h l ^ W W. Z > I YI r..... 'rl 0 7 4 C Q YI NI m m Z N t0 to , •u 1 7 1 } O V I 0 1 rl W ,Zf • as£ �, 0) O 3 .,Oslllp000m 6 to U4 `..N :92:uotl�PS 30 ?3N 2 44 4 13N 8 44 40 Pull ;SON W o �- W '� spuel P•11e15un o.o a vs I' n v }� W A ► - 't �, � V •1.1 V . 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