HomeMy WebLinkAbout032-1081-95-000 _ 1
Wisconsin- Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
'Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
515196 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)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Bradshaw, Jason I Somerset, Town of 032 - 1081 -95 -000
CST BM Elev: Insp. BM Elev: I BM Description: Section/Town /Range /Map No:
/ ao �J 1 GS ( 28.31.19.393C
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER ti5 5 CAPACITY STATION BS HI FS ELEV.
Septic / M00 Benchmark ,�j4 „7 /6Z 5
Dosing W S / g If 16 O Al >i� I
#. 7 917• G!
Aeraflo Bldg. Sewer
r �b Cl .416 4% q 2. 47
Holding St/Ht Inlet 4,P
1a1 9Z . Z
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septi 7166 AA— /b 7 7` D ,� —OUP /6 .SS) 7/ jd
Dosin -7 �� 1 - Header /Man. iI 3Z l h o 2
Aeration Dist. Pipe 1 / 3Z 71,o3
Holding Bot. System
L
PUMP /SIPHON INFORMATION Final Grade 1 4 . 7 - 5 c 7 7 •
Manufacturer GP nand St Cpv r a 4 74 9 7 G/
Mod I Number #F OJ{- 1e,�r- '14-- 7
TDH Lift Friction Loss System Hea DH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Pit` Inside Dia. Liquid Depth
DIMENSIONS 2 l �— ____
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: �
INFORMATION CHAMBER OR '77, C I
Type Of ' O 7 /�' 21 r J �1 l� _ 1)1+_ UNIT Model Number:
C
DISTRIBUTION SYSTEM ?Z 27— A-Z Z = e�od -•�
I L ength eader / Manifo� I Distribution x Hole Size x Hole Spacing Vent to r Iryt�ke
Pipe(s) � _ Dia T Length \ Dia \ Spacing .—
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only IF Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center - �/ _ Bed/Trench Edges Topsoil
0
t � Yes No es � No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 1945 Apple River La a Somerset, WI 54025 (NW 1/4 SW 1/4 28 T31 N R1 9W) NA Lott /_ Parcel No: 28.31.19.3930
1.) Alt BM Description = ` D > �A GOVT— G WI+ICI�6 (q/ - 6ac is
,l
2.) Bldg sewer length = 3d k ct A04- }^ �, ,�I� a� / � ^! N Q�
- amount of cover = / •'�”
Us other l s de for Required?
dditional i No _._ — _ .- - -- . - - -- —� -- -
Date Insepc s Sign re Cert. No.
SBD -6710 (R.3/97)
l _
A !!4 r 1
Aga elk m
commercemi.gov Safety and Buildings Divis' ounty
201 W. Washington Ave., P.O. Box 7162
t leparUnerrt sco n n Madison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.)
of Commerce 6 15
Sanitary Permit Application State Transaction Number
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental 1
unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if dif ie than mailing address)
submitted to the Department of Commerce. Personal information you provide may be used for secondary ���
p urposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. ��•
I. Application Information - 'Please Print A forrnatio
Property wner's Name Parcel #
Property Owner's Mailing Address Property Location 393 G UUON 'Y Govt. Lot r
City, State Zip Code pLAN one Number G � y, <�1dL y. Section
T 3J N; R � l E o
11. Type of Building (check all that apply) Lot #
I or 2 Family Dwelling - Number of Bedrooms —� Subdivision Name
Z lboA, 4r1.,J Block #
❑ Public /Commercial - Describe Use 11 4 /� . /I ❑ City of
t
State Owned - Describe Use CSM Number Cl Village of
❑ / ti• ✓ � �,. 1
r 4486 ( I 0 Town of -
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. VNew System y El Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System (explain)
-------------�
B. ❑ Permit Renewal ❑ Permit Revision ❑ change of Plumber List Previous Permit Number and Date Issued
g ❑Permit Transfer to New
Before Expiration Owner r
IV. Type of POWTS S stem/Com onent/Device: Check all that appl
Non - Pressurized In- Groun ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersaUTreatment Area Information:
Design Flow (gpp Design Soil Application Rate( dsf)
J Dispersal Area Required (sf) Dispersal Area Proposed (s System Elevation
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units U o
New Tanks Existing Tanks e
rsil U yr y rn w C7 a
Septic or Holding Tank J1
Dosing Chamber
VII. Respop§ibility Statement- I, the undersigned, assume respopsi6jifty for installation f the POWTS shown on the attached plans.
Plumb ame Vnt�,Plumber's i e - ,_ MPIMPRS Number I Business Phone Number
Plum er's ddress (Street City, S Zip Code
O
� I
VIII. ounty /De artment Use Onl
Approved lsap rven Reason for Den 1 Permit Fee )D�ate ssued Issuing A t Signature $ / X' �� / IX. Conditoeasons for Disapproval S� K1tM�dr►1.�
1. Septic tank, effluent filter and -:07 6,VA 1
dispersal cell must all be services / maintained
as per management plan provided by plumber. 1111 1 a �� .� w � /D� qC� �-
2. RU setback requirements must be maintained I f- a e I 19 • % a
ac to comp e e p e system and submit to the County only on paper not less than 8 1/2 x 11 inched in size
a DQ;a�,tLa�cA a Sl ZO +Cb
5� A- �•. c,onaui,Set� -:one w'Ja�,py� os.. �1 ��/�9 A je r" Irk /r'.11 Ale.
SBD -6398 (R. 02%09) Valid ffim 02/11 � � � pi e�` �✓ e2� /x. sr t
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Wisconsin Department of Commerce EVALUATION REPORT Page—/— of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County
Attach complete site plan an 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 Pal I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. Revi by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). I 0 d
Prope Owner RECEIVED Property Location
Govt. Lot 1/4� 1/4 S T N R f E (or
Property Owner's Mailing Address NOV 1 0 Zg09 Lot # lodc # Subd. Name o CSM#
NOV
City a Zip Code PhoBe Number--" OFFIC City ❑ Village A Town Nearest Road
PLANNING & ZO NING _
l 1 \ J
❑ New Construction Use: 14 Residential /Number of bedrooms Code derived design flow rate GPD
❑ Replacement Public or commercial - Describe: :
Parent material �` fl��7>2/_ Flood Plain elevation if applicable ft.
General comments
and recommendations: �� FO �c �� , 88, "e' Fes'
�Q.tCi lvry 1�- GDOeA , o 0 eA - "e. $
Boring # El Boring
® Pit Ground surface elev. ft. Depth to limiting factor _ 41'Z in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 I " Eff#2
i zo
7� a
y
Boring # El Boring
pit Ground surface elev. 9/,9 ft. Depth to limiting factor /, C) in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fi?
in. Munsell Qu. Sz. C nt. Color Gr. Sz. Sh. *Eff#1 *011#2
R Q'
s
cy 9
�.b
* Effluent # BqD ?2qoo2and TSS >30 150 mg/- ent #2 = BO D < mg/L and TSS < 30 mg/L
CST Name (P � Signature CST Number
/ _
Address Date Evaluation Cond Telephone Number
�� 1 - /
Property Owner � _.n Parcel lD# Page of
0 ring # Bori
Ground surface elev. &6,h --2 ft. Depth to limiting factor D in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP
in. Munseii Qu. Sz. Cont. Color Gr. Sz. Sh. *Effffi1 *Eff#2
4 'u
17 Boring # ❑ Boring
11 Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *0102
F-1 Boring # ❑ Boring
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/fl=
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& * Effluent #2 = BOD < 30 mg& 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.
SB - 8330 OL07/00)
Property Owner Parcel ID # Page �--2 of
F Boring # t �lf Boring
lc�r Pit Ground surface elev. , ab, l ,- ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f?
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
4
4 «
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 GPDffff
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 GPD/tt;
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 (8.07/00) -
ys �
I
� J
Soil Absorption System Cross Section
— ''E
�- -- — ft x`34
%"g--? ft
4° Schedule 40 Final Grade
PVC Vent Pipe
With Vent Cap �8 7� ft
Leaching
Chamber �— ft
System Elevation
ft ft
Soil Absorption System Plan View
ft
ft {
ft Leaching Trench 1
Chambers
4" Dia.
Trench 2 Header
Vent Or Observation Pipe
Trench 3
Leaching Chamber Specifications
Manufacturer And Model
EISA Ratin sq ft per chamber Soil Application Rate , '7 gpd /sq ft
�DD gpd Design Flow , �7 Soil Application Rate a z 2� EISA = Chambers
3 rows of _fi chambers each.
I
Page of
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page rte_ of o<
FILE iNFORMAT ON SYSTEM SPECIFICATIONS
Owner
t Septic Tank Capacity ga l ❑ NA
i Pe' mrt r Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model _ ❑ NA
Number of Public Facility Units d Pump Tank Capacity ga l Ll!� NA
Estimated flow (average) gal /day Pump Tank Manufacturer AA- NA
Design flow (peak), (Estimated x 1.5) al /day Pump Manufacturer 6-NA
Soil Application Rate gal/day/ft' Pump Model '0 NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit NA
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 Pi In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L 9 NA ❑ At- Grade ❑ Mound
Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in die. p NA Other: ❑ NA
Other: Other:
❑ NA ❑ NA
{
* Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAiNTENANCE SCHEDULE
Service Event Service Frequency
!7 condition of tank(s) At least once every: ❑ month(s) (Maximum 3 ears) ❑ NA
n'' -0 ears) y
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y,) of tank volume ❑ NA
aspect dispersal ceti(s) At feast once every: E3 month(s) (Maximum 3 years) ❑ NA
year(s)
Clean effluent filter At least once every: ❑ month(s) ❑ NA
year(s)
p, pump controls & alarm At least once every: ❑ month(s) � NA
ncDec` ` ump t
❑ year(s)
Fivsh I.a -e-ais and pressure test ( At least once every: CI month(s) -�El NA
❑ year(s)
Gu ❑ month(s) At Least once every: ❑ year(s) X7 NA
athi r`
❑ NA
VIAINTENANCE 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.
AV 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.
START UP AND OPERATION Page '�;2_ or
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 cel((s). If high concentrations 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 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.
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:
0 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.
0 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:
JRf
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.
!kDDiTIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name Name
Phone C Phone
;EPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone
- his document was dra` eY '- :::-:; ance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
START UP AND OPERATION Page 142 or
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 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:
• Alt 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, ail 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:
,R 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 j
;EPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone
'his document was dra ,_t ::=- :;"ance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Q � '� �Y��G 11ra'AAW't
Mailing Address ,�j�i �aS�.�/!��� � 2 S -
Property Address q L f J5 l e r �4 k
(Verification required 6o4i Pfarming & Zoning Department for new construction.)
City /State o,&66r� , Parcel Identification Number 2 -9. 31. l • 3ci�
LEGAL DESCRIPTION
Property Location 1 /4 ,, '/4 ,Sec. . , T jjkN RLq W, Town of
S'abdIV2sAo11 __ .. I
Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # , Volume , Page #
Spec house yes - no Lot lines identifiable - yes ' no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site
wastewater disposal 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.
Lwe, 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 Planning &
Zoning De-jai within 30 days of the three year expiration date.
I/v�-e certify that all statements on this form are true to the best of my /our knowledge. Uwe amlare the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms
/D 9 1 ,0 9
SIGNATURE OF APPLICANT(S) DATE
* information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department'
_-;lade with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
-ence is made in the warranty deed.
t'R'051
i
8398£34
KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO., WI
STATE BAR OF WISCONSIN FORM 1 - 2000
RECEIVED FOR RECORD
Document Number WARRAINTY DEED
12101/2006 03:30Plf
THIS DEED, made between Michael G. Sager and Linda J. Sager, as WARRANTY DEED
survivorship marital property, an undivided 2/3 interest and Jeffrey M. EXEMPT M
Sager, an undivided 1/3 interest Grantor, Brea A. Belisle and Jason J. REC FEE-. 11.@0
Bradshaw, `110 J n t k l' l nt,-,a Grantee. TRANS FEE: 465.00
Grantor, for a valuable consideration, conveys to Grantee the following COPY FEE:
described real estate in St. Croix County, State of Wisconsin (the PAGES I
"Property"):
The NW' /< of the SW% of Section 28, Township 31 North, Range 19 West,
Town of Somerset, St. Croix County, Wisconsin, EXCEPT that part of the
South 700 feet lying Easterly of the Town Road AND EXCEPT Certified
Survey Map recorded in Vol. 9 of C.S.M., pg. 2468. Recording Area
Name and Return Address:
St. Croix County Abstract and Title Co., Inc.
252 S. Knowles Ave.
New Richmond, WI 54017
Together with all appurtenant rights, title and interests.
Parcel Identification Number (PIN) 032 - 1081 - 95
This is not homestead property.
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except
easements, covenants, and conditions of record.
393
Dated this day of November, 2006
Michael G. Sager' * Linda . Sager
*
Jeffrey M. Sager
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
COUNTY St. Croix ) ss.
authenticated this Personally came before me this day of November,
2006 the above named Michael G. Sager and Linda J. Sager
and Jeffrey M. Sager to me known to be the
* Y person(s) who P
TITLE: MEMBER STATE BAR OF WISCONSIN e e ut foregoing instrument and acknowledged the same.
(If not,
authorized by § 706.06, Wis. Stats.) i a M. Green , • .......
THIS INSTRUMENT WAS DRAFTED BY Notary Public, State of Wisconsin r < '.,t •'� ';
My commission is permanent. (If not, stag t
G
Robert L. Lober 2 -I5-2009 — )
Lober Law O ffi c e 3 = l
L Offc SSU60 9 — ..,
...•1 -
(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 • ••. 0 ,.••'�
• S7' / Q
WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1-20W
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