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Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No'
463369 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
Dalzell, Ryan I Somerset, Town of 032 - 1095 -10 -125
CST BM Elev: Insp. � Elegy BM Description: Section /Town /Range /Map No
1 �/CJ 6 (r\ CS 34.31.19.440A15
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic u 4— ( , Benchmark
sing � Jb� 3 ✓�
Do Alt. BM
Apralmon 5••Z 99 Z9 (` �^1 Bldg. Sewer ¢, 1, &-7 C • 3Z—
Holding St/Ht Inlet I 17Z • ��
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/l WELL BLDG. Vent to Air Intake ROAD Dt Inlet
gar.
Septic Q 7 7 At To / Dt Bottom / ` r Q Z
Dosing S-7 / ` � Header /Man. 7• bZ (o O
Aeration l Dist. Pipe $ • 4 1 b G
Holding Bot. System
PUMP /SIPHON INFORMATION Final Grade 5 D ��•
Manufacturer Demand St Cover cn
r 1 a
GPM Jai f� S• 2� /!• d 1
Model Number t4— (00 - n / • 2 175 6
TDH Lift Friction Lo System ead TDH
. J
Forcemain Length t Dia. �, Dist. to Well
36 z 7 /t2)
SOIL ABSORPTION SYSTEM
BED/TRENCH Width If Lengtj No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 1 J 3 a,r` c, p ` r ° '\,
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: ---
INFORMATION CHAMBER OR
Type Of System: (( r rw 7 Ab 166 A /\. UNIT Model Number:
Con IIvT"• `� }� r
DISTRIBUTION SYSTEM Z q + `f }
HeaderlMonifold Distribution I x Hole Size I x Hole Spacing VeflI to Air Intake
1 Pipe(s) \ v
Length Dia Length e Dia \ Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only G
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center L [. Bed/Trench Edges Topsoil es No es No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 1861 County R oad I Somerset, WI 54025 (NE 1/4 NE 1 /4 34 T31 N R1 9W) NA Lot 5 Parcel No: 34.31.19.440A15
1.) Alt BM Description
2.) Bldg sewer length = p A J I - d' •, ✓�
- amount of cover = 7 `iZ �� �� �` r••• R, 0 ��
Plan revision Required? Yes No
Use other side for additional information. __
Date Insepct s Sign re ' , C ee rt. , No.
SBD -6710 (R.3/97) O � •� ek�r� SA¢S[x -� °'�
Jo� Pet L. G ",.7VI
( Safety and Building DivWw Q=y c
201 W. Wahinow Aw., P.O. Box 7162 O � o i ,/
Madison, Wl 53707 - 7162 tszy Paimit Ni «(to e a In co.)
N VIsconsin (608) 266 -3151
tie artment of Commerce 3 3
Sanitary Permit Application a fla N umber
Soft
m accord whp Comm 83.21, Wit. Ada code, personal iallbansien
may be wed br te000daty purposes Privacy Lew, 615.01(lxm) D ect Address (If diffiaew the mailing address)
L Appiieastion Information - Plan Print All Information
Property Name Pared N Lot N Block P
,�✓ �
-7, MAR MAR 3 0 2005 D32— �v9S -1D— (ZS
ftWerty Ow nes
'710 � / (v � S T.
ZONING OFFICE C Pr�pat Le>cwem
city, stets Z i p C ode Phone Number
f J y� �� se�i�_
er z t.J� 5 462 - 71r-5v3 - i'M T N, �� E )
IL Typo of Building (cbeck W that apply)
poi 2 Family Dwelling - Number of Bedrooms .3 , N
" l 23 741 9s9
❑ PublirJGomooereiat— DescrilteUse
❑ sate Owmd — Describe Use Ocity_O'alav °"ship of S
111. Type of Permit: ( Cbeck only one box o n line A. Compl O ne Bit applicable)
JXNew System ❑ Raplacemmrt System ❑ TroatmmVHolding Tank Replaoemo* Only ❑ OdW MOM NAM to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Chap of ❑ Famit Trani« to New
LAW Pmvlous Pamit Number end Date Issued
Bd= Exphaticn Plumb« Owner
1V. Type of POWTS ftstem Check all that a
X Nan - ftmuriwd b4muod ❑ Mound >_ 24 in. of witablo wH ❑ Mated < 24 is of %, i bb wil ❑ Atria b Single Ps" Sand Flits o
C=ftwwd Weds d ❑ Prasu dzed h sound ❑ Holding Tack ❑ Peat Fitter ❑ Amebic nutmW Unit ❑ Wwula ing Sad Filter ❑
- R*cbwktWg 8ywhadcM4&Fi1ter LachinsChageber ❑ ❑ v&less ❑
V. M! tment Area Idermadon: l
Design Flow (ppd) Design Soil Dispersal Ara Re4 ( Area (d)
VL Tank Into CWwlty in Construcod � of Unfit o 1 la � Plastic
New Ittiaeutfoott�/
w f3
Coocro
nee. Taint,
s�tio ariiot Tatir oov o / 7 JL°
Aerobic Tw m ew Unit
Doa4M cbr
VU. Rnponsibillity Statement- 16 the w=w for WWII* don of Uw POWrS Awn on the attaebod om
Plumber's Name (Pt1nt) Pkambar' MP/MPRS Number Business Phone Number
Plumber's Address (Street, Chy, State, Zip
VILL Cons t use Onl
P( A"roved 13 Pamdt Fee include aliundwalor Aare Issued 4w Sigoa w swaps)
❑ owner vin Re ft Denial V �) � — 31
Ix. Conditions '
SYSTEM OWNER:
1 Septic tank, effluent filter and
dispersal cell must all be serviced / maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable code /ordinances.
Atbdt sampba pbat (M tM Coo* easy) for rig qWn ea papa sett ha flues stn s 11 In" Is she
SBD -6398 (R. 01/03)
Li
T.L. Sinz Plumbing Inc. �� `�� N �' /`� 3� T3 ��
E5609 708th Ave. Phone: (715) 235 -2644
Menomonie, WI 54751 Fax: (715) 235 -2592
1 � www.tlsinzplumbing.com
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T.L. S,inz Plumbing Inc. � �� N E IN s Ts i
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E5609 708th Ave. Phone: (715) 235 -2644
Menomonie, WI 54751 Fax: (715) 235 -2592
www.tlslnzplumbing.com
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• Wisconsin Depar(ment of Commerce SOIL EVALUATION REPORT Page _ - 1 - of - 3 -
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations
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.
....._ .._ _ 03z- �o9 . � - c 40
Please print all rrr�a$ei, i 1 ev ec�By Date
Personal information you provide may be used fsecondary Purl" (Privacy Law, s. 15 04 i) (m))
Property Owner Property Location
Bill La wson °�'�' � �. Govt. (ot !411 NE 1/4 S 34 T 31 N R 19 W
Property Owners Mailing Address Lot # Block # Subd. Name or CSM#
1917 Co. Hwy I pen i I Prop osed CSM
City State Zip C6de one NGM'"5e - rr - -- City Village &I Town Nearest Road
Somerset WI 54025 715- 247 -3242 (H) Somerset Co. Hwy I
New Construction Use: 1 Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
Replacement Public or commercial - Describe:
Parent material Glacial Till - - -_ _ Flood plain elevation, if applicable na
General comments
and recommendations: Install three trenches at elev. 95.00' using 48 leaching chambers. Dosing may be required to reach system
area.
F69 . Zw 2-
Boring # _..� Boring �
16 Pit Ground Surface elev. 9 i
ft. Depth to limiting factor __ >955 ___n. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture , Structure 1 Consistence Boundary Roots GP D /ftz
in. r Munsell Qu. Sz. Cont. Color Gr. Sz, Sh. 1 *Eff#1 *Eff#2
1 0 -7 10yr4/3 none - sil 1 2fcr ds as ! 2f,1m 0.5 0.8 (
2 7 -18 10 r6/4 � none stl 2fsbk — ds cs ( 1f 0.5 0.8 , y
3 �' 18 -26 7.5yr4/6 none 1 gr s I 2fsbk dsh gw - 0.5 0.9
4 26 -95 ' 7.5yr4/4 none gr sl 1 msbk mfi - - 0.4 0.6
F2 Boring # Boring - _-
Pit Ground Surface elev. _98.90 _ ft. Depth to limiting factor - X 9 3 in• Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. 1 Munsell Qu Sz. Cont. Color Gr Sz. Sh I *Eff#1 'Eff#2
1 ' 0 -10 1 10yr4/3 none fsl 2fcr ds as 2f,1m 0,§., 0.9
2 10 -18 10yr3 /3 none fsl 2fsbk ds cs 1fm 0.5 0.9
3 I 18 -44 ! 7.5yr5/4 none 2msbk dsh f gw ` IAfm 0.5 0.9
4 44-69 } 7.5yr4/6 none Ii�F �,sl Xrn s bk mfi gw lvf,f 0.5 I 0.9
_ -' -_ 4 - - —
5 69-93 7 5yr4/4 none gr sl 1 csbk mfi - 0.4 0.6
I
Z.� uw4xfl 4
* Effluent #1 = BOD s > 30 220 mg /L and TSS 30 <150 mg /L 1 d ` - e - s < 30 and TSS <30 m con V
CST Name (Please Print) Sign ure: CST Number r
James K. Thompson 5--- 3602
Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson Lake Lane, Osceola, WI 20 8f7/2003 715- 248 -7767
• Property Owner Bill Lawson Parcel ID # Page 2 of - 3
F3]Boring # Boring
Pit Ground Surface elev. --10.1.03- ft. Depth to limiting factor > 102" - in. Soil Application Rate
Horizon I Depth Dominant Color 1 Redox Description Texture Structure Consistence Boundary Roots �QPDff
in Munsell Qu. Sz. Cont. Color Gr Sz. Sh. *Eff#1 *Eff#2
1 0-7 1 Oyr4/3 none tfs 2fcr ds as 2f,1M 0.5 0.9
2 I 7-27 1 0yr514 none fsl 2fsbk ds cs 1f - 0-ra- 0.9
--- - - ---- - - ------- --
4
--
3 27-50 7.5yr4/4 none gr sl I 2msbk i dsh gw 0.5 0.9
4 4 50- 0 7.5yr4/4 none gr sl 1 rnsbk Mfl 04 0.6
U
4 Boring #
F gol Boring
Pit Ground Surface elev. 104. ft. Depth to limiting factor > 118" in. --- 5 c - niApplication Rate
Horizon Depth Dominant Color Redox Description Texture i Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color I Gr. Sz. Sh. I I *Eff#1 *Eff#2
1 0-9 1 Oyr413 none ftl 2fcr dsh as 2f,1M 0.9
2 9-23 7.5yi-416 none gr sl 2fsbk dsh Cs I ifM 0.5 0.9
3 23-44 7.5yr414
none gr sl 2msbk mfr gw lvf,f 0.5 0.9
4 44-1181 7.5yr414 none gr sl I csbk mfil 1vf 0.4 0.6
- -------- --
- --- -----------
I
5� Boring # Boring
Pit Ground Surface elev. 96.43 ft. Depth to limiting factor 54' in. Soil Application Rate
Horizon Depth Dominant Color Redox Description I Texture Structure Consistence Boundary Roots
in. I Munsell I Qu. Sz. Cont. Color Gr, Sz. Sh. I *Eff#1 *Eff#2
1 0-10 1 Oyt none fsl 2fcr ds as 2frn 0.5 0.9
2 10-23 1 Oyr3/2 none sil 2fsbk ds Cs 2f 1m 0.5 0.8
3 23-36 1 Oyr4/6 none sil 2fsbk mfr I gw 2f 0.5 0.8
4 36-54 7.5yr5/4 none siel 1 1 msbk mfr gw 1f 1 0.2 0.3
54-84 1 Oyt f2d 7.5yr5/8 sil 1 csbk mfr 1vf 02 03
5 i,,f n
Effluent #1 = BOD ? 30 < 220 mg/L and TSS >30 < 150 mg/L Effluent #2 = BOD -S mg/L and TSS < 30 mg1L
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.
.z 91� 77"
.Soil a Pt /,44 on 4, /o E j
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FROM : CERTIFIED SOIL TESTING FAX NO. 715 233 0398 Jun. 14 2002 05:52AM P3
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9fH-GM 509330 UUCSA 4147 115 3'4 130 1000 71 Be 60 49 32 13.8 20' 27 q. 1 x 11.64 x 8.94
4EH•CIM 509340 ULMA 4110 230 314 6.5 1000 71 fib 60 49 32 116 20' 27 911 x 11.64 x 8.94
9EH•CIA-RFS 509350 UUGSA 4,10 115 31 13.0 1000 71 68 60 40 32 1318 211' 27 911 x 11,64 x 6.94
9 H•CIA•RF5 509360 UL DSA 4,110 230 3x4 6.5 1000 71 68 00 a 32 13. 20' 27 9.11 x11. . 4
FLOW- LITERS /k-IULIK Construction.,
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PUMP PFR CURVE Little ittl /"r V is t PUMP CO
115V 60HZ Or lAil
2 * PO Box 12010 Phone: 405.947.2511
Qh1R. City, 0K 73147 Fax: 405.951.5674
www.Litt G�iantFump.com
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/ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner(, Septic Tank Capacity POD a l ❑ NA
Permit # IF / 3 _26 Septic Tank Manufacturer "rr ❑ NA
r0
DESIGN PARAMETERS Effluent Filter Manufacturer & nog: ewmA
Number of Bedrooms ❑ NA Effluent Filter Model )C.',rD fa � � /� ❑ NA
Number of Public Facility Units V NA Pump Tank Capacity 00 a l ❑ NA
Estimated flow (average) .bpd al /day Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) allda ump P Manufacturer .� R?N� ❑ NA
T
Soil Application Rate al /da /ft2 Pump Model ❑ NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit KNA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (600 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 04A- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) :530 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) :510' cfu /100ml ❑ 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
❑ month(s) (Maximum 3 years) ❑ NA
Inspect condition of At least once every: to 3 ear(s)
Pump out contents of tankls) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
❑ month(s) (Maximum 3 years) ❑ NA
Inspect dispersal cell(s) At least once every: 01 � 3 Pyear(s)
❑ month(s) O W /e ❑ NA
Clean effluent filter At least once every: i ffyear(s)
/�, ❑'Fnonth(s) ❑ NA
Inspect pump, pump controls & alarm At least once every: OL r) yearls)
❑ month(s) ❑ NA
Flush laterals and pressure test At least once every: ❑ year(s)
Other: ❑ month(s) ❑ NA
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.
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tankls) 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 tankls) 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:
• 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 � D /4 n Name
Phone 74r 7113r- Z�6 Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone (r.- 3810
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.
FROM HARTFORD LIFE MUTUAL FUND ACCOUNTING (FRI) 3. 25' 05 10:48 %ST. 10:4T`NO. 4864655247 P 2
ST CRO COUN - ry
SEPTIC TANK MAINTENANCE "' G " F- MgMT
OW►dERSK[P CERTIFICATION FORM
pavne;rBuyer �. ale
L Av �_ ?
b� 20 + e-. c.7VYti'�k
Mailing Address -
Pr opo rty Address + S r c
Rd .� �se� v i a. - .s ots
(wriGcation required from Plaaniag Deparn cat for new c astxuction)
City /State �-L Parcel Identification Number _
LF-g TION
property Location Ac c . Y,,
14 E y4. Sec. T ` N -R—D—W. Town of tYyefi��
Lot # S
Subdivision
certified Survey Map # /9 Volume Page 3
W &rrnnty
Deed Volume �i Page #
I
Spec house D Yes)( no .Lot lines identifiable ycs C.J no
S'SC S TENl< M�-NCE
lmptoper use and =int==W -Of your septic syttam could result in its pi
a li cen.� pump tti faiituo to t y. lhut y ou niato the
consists of pumping out the septic tank every dltsec years or sooner, if needed by a li Y F't
can affect the fuection of the septic tank as a treatment singe in the "stc dis "
The property owucr agree to submit to St. Croix 2 d!Ag DePiltmen a ecrtiieation form, signed by the owner and by a
s less i tswatadi cystcm
master plumber, jou= Ymanplumber, tesmicttdplambccor a"c=sedpumpervcgssx ,tss than 1/3 full Ooff sludge.
L, in proper operating coaditioq and/or (Z) ancr insper -dou and pumping (it deecauy) tIh � 6tptic ualc rhoo¢as
Vwc, the w hate rtad the above mQuirements and agree to psa>°t t o Chit pdvatv tural R towage ate of Wisconsla. m Castiticatioa
cot fottb, herein, as xct by the Dapat� of Comma:ce and the Depastmcut of Natural Resotuces, Ofice within �0
stadng tb t your septic system has berg truint"3%ed must be completed and rctumcd to t1�e St- Croix County 7�niag
d ear exptstition date.
3 2z, 200-5
' DATE
fkE O� CANT
QMJaR CFLRURCAPON_ o imowlcd c 1 we am (arc) tilt owacr(s) of
I (We) certify that AU statements on this form arc eruc to the best of my ( our) 6 ( )
4p,0 Try des 'bod above, by virtue of a warmnry dccd recorded in Registtr of Deeds Ofrtce-
33 /Z/�' DATE
(JRE OF
��
0.6.00 ?�Zy information thal is nips- rcprtscnted tday result is th e sanitary permit being revoked by the Zoning Dcp3jt - WccL
•' Include with this applICAUoo; a at&mpod vnrranty dccd from the Regiater of Deeds office deed
a copy of tbt certified survey =P if referoace Is made is the .vsMMY
F�OY HA- R-FOrU LIE MUTUAL F NID ACCO'- TIN (FJI) ;', 2 ' 0 _ ;' `.T, 6A' 52L
U 2668 409
7 7609p�
STATE BAR OF WISCONSIN FORM 2.2000 KATHLEEN N. W&LSH OF DEED
Docunsnl Nurnbcr
WARRANTY DEED S . CROIX Co., wf I
This Deed, made between William E. Lawson RECEIVED FOR RECORD
10/64/2004 t1:55AM
— - — WARRAKT DEED
Grantor, and Ryan C. Dalzefl EIEWT t
REC FEE: tI.88
TRAX5 FEE: 163-
COPY FEE:
CC F":
Grantee. PAGES, I
Grantor, for a valuable consideration, conveys and warrants to
Grantee the following described real estate in St. Croix
County, State of Wisconsin (if more space is needed, picam attach addendum:)
Part of the NE 1/4 of NE 114 of Section 34, Township 31 North, Range Recording Area
19 West, St. Croix County, Wisconsin described as follows: Lot 5 of
Certified Survey Map rdedOCtuber 1, 2003 in Volume 17 page 4623 Name and Return Address
Doc, No. 741959 First Federal Capital Bank
201 Seeoad Street
Hudson, W1 54016
032- 1095- 10-12S
Parcel identification Number (Parr)
This is 00 1 homestead praperty.
dal (is not)
Exceptions to warranties:
e2sements covenants and restrictions of record, if any.
Dated this 630 da of Septertabcr 1 2004
• am E. Lawson
y
i
AIII IfENTICATION ACKNOWLEDGMENT
Signaturc(s) W(uiam E. Lawson STATE OF WISCONSIN }
} ss.
ST. CROIX County )
authenticated this day of September , 2004 �
` Personally came before me this day of
!!!ptewber . 2004 the above narncd
William E. Lawson
-' S A
TITLE; MEMBER STATE BAR OF W��S1}ti...
(If not, = _ �' to me be the person(s) w xecuted the foregoing
r.
authorized by § 706.06, Wis. Sta 1 r'r, ,; i v ins ee)mowl e
V
THIS INSTRUMENT WAS GRAFT D Hi' /'
H wood, Cari & Anderson, S e- , aI6 U * ST
lfa Drive
P.O_ Box 125, Hudson, W1 St016 'ri�7 - " .ti y�� NOS �blic, State of ONSIN
My COT= ' IS permanent. (If not, state expiration daw
(Signatures tray be aulhentieated or acknowledged. So t ywti.q
wry i
Names of pesos,$ signing m any Capacity must be typed or Printed below their signature.
WARRANTY DEED STATE MR OF WISCONSIN
FORM Ne. 2 - TQ00 INFO.PaO (eoo)6s6 -202r v *w+ jfoprvtatrtt5.mm
74 1 9S9 l3
KATHLEEN H. WALSH
REGISTER OF DEEDS
' ST. CROIX CO.. WI
RECEIVED FOR RECORD
10/01/2003 09:00AK
CERTIFIED SURVEY NAP
CERTIFIED SURVEY MAP EXE
Located in part of the Northeast Quarter of the Northeast Quarter of Section 34. REC FEE: 13.00
Township 31 North. Range 19 West. Town of Somerset, St. Croix County, Wisconsin. TRANS FEE:
COPY FEE: 3.00
CC FEE:
Prepared for and at the request of 100 a 100 PAGES: 2
B01 Lawson
1917 C.T.H. '1' GRAPHIC SCALE
Somerset, WI 54025 SCALE IN FEET: 1 inch — 100 feet
Drafted by: Howard H. Hwrgd III BEARINGS ARE REFERENCED TO THE EAST LINE OF THE
APPE NE 1/4 OF SECTION 34. TOWNSHIP 31 N., RANGE 19 W.
I ���� WHICH IS ASSUMED TO BEAR S0113'57'E.
m
§T, pttX COUNT
PIaefiirie gea w "re P. 1&k: The parcel shown on this map is subject to State. County and
Township laws, rules and regulations (i.e. wetlands. minimum lot size, access
k „ OCT 0 12003 to parcel, eta). Before purchasing or developing any parcel, contact the St. N TH
Croix County Zoning Office and the appropriate Town Board for advice.
within 30 daAoipecial exception use permit is required for the disturbance of slopes
� v 4KIOval K sb212 or greater not identified on the approved plat or CSM. This permit
"A* tlw"nd is applied for through the zoning office and is n gh a public
hearing process by the St. Croix County B djustm t.
N 64
UNPLA TIED LANDS OF OWNER '��
S 89 °28'40" E 294.77'
ENTIRE LOT iS C.
PER TOWN OF SOT ' t✓Ei NIA
__ Cn
o
z w
NOR
L07�5 .��
�` nlEAST COR/V
-t o TOTAL AREA: M <57ECn
N
aV
R � f9 y, pl
A 56 00
3.78 A S S g N�t
N awiairaur
J f� tD g O
AREA EXC. R —O —W: CONSj�
131.695 SO. FT. * , TV R * w
3.02 ACRES _ _ _ - - _ - - - - •• DODGE�.I I
w O o 5-2484 `
si ® O ` CLEAR lAlCB..: rr 1 N
— `'-' ygNG S Rd o
O •�. — a o N89'18'25'W ry/h .+�
G �� . I\ a rornnnmtna��� tA k+±
N w- NOO 43'17 -� ~ '
0-- 10.51' 10.51' v LfiW Gr 71st£ I� m
VAR ABLE= o ALF 1/4 a- n eE' AAF 1/4
WIDTH R.O. W.— _NOTE• A b
N89-28'40"W— 354.7 N 89'28'40" W 1000.09'4 N
1 f" V o .�
NOTE: "A "— RIGHT —OF —WAY LOT 3 C I w
CORNER IS OCCUPIED BY A CERTIFIED SURVEY MAP t'= \01 CA
POWER POLE VOLUME 10 PAGE 2903
m
J.�tIJZ EAST 114 CORNER
JOB / WA057SUS 5LC770N 34 -31 -19 w
Prepared by. Section Comer Monument (FIJUJNO ALllA/JN[AII
of Record 1g COVNIY AIONUAIE7VT)
Grow k= • Set 1' x 18' Iron linear woof weighing
Phone No. (715) 246 -4319 O Found 1.25' Iron Pipe
Fax No. (715) 248 -3830 - Building Setback Line 100' from Right of Wo
P.O. Box 325 - 9 ( 9 Y)
New Richmond. WA 54017
Sheet 1 of 2
VOL 17 Page 4623