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HomeMy WebLinkAbout036-1078-50-000 Wiscorwin Department of Commerce Count PRIVATE SEWAGE SYSTEM St. Croix Safety and Building Division I A . INSPECTION REPORT Sanitary Permit No: 453096 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: Brock ahler, Henry Stanton Township 036- 1078 -50 -000 CST BM Elev: Insp. BM Elev: BM Desc Section/Town /Range /Map No: Pvc, 31.31.17.487A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic C , h Benchmark 4S9 0 /64 J Dosing F,� Al ToM G r i r` .� �• z6 16 Aeration Bldg. ewer , 18 Holding St/Ht Inlet 4 ,44 j , 4 . `t( pct TANK SETBACK INFORMATION St/Ht Outlet Lo 1 0 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic / I � Dt Bottom \ Dosing Header /Man. 11 q7. Z Aeration Dist. Pipe 1 .( T 9 (y ZZ Holding Bot. System %,15 V k Final Grade � A6 PUMP /SIPHON INFO Manufacturer Demand St Cogrp �d Z_ X13 /0Z S Mod umber S TDH Lf m Head T Ft 10 Forcemain Length Dia. Dist. to Well 1 6�— SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT D MENSIONS No. Of Pits Inside Dia. Liq %D_epth DI MENSIONS - 5 CA 9 � i"� SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturel;/ INFORMATION Type Of System: CHAMBER OR ` Q ;v 0 Z ` UNIT Model Number. J` DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent s ir Int e 1_ Pipe(s) \ ` \ Length Dia �' Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over N7D ver xx Dep xx eeded /Sodded xx M Iched No Bed /Trench Center r Over Edge Topsoil of Yes No Yes COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ^7 / 1 IS Inspection #2: Location: 1429 181st Avenue Star Prairie, WI 54026 (SE 1/4 SW 1/4 31 T31N R17W) NA Lot 2 Parcel No: 31.31.17.487A 1.) Alt BM Description= 1O a `5e.�e eJ �••- ` °✓� ! � 7 j 2.) Bldg sewer length - amount of cover Plan revision Required? Yes I o Use other side for additional information. Date Inse ton's Si ature Cert. No. SBD -6710 (R.3/97) J � . / � / \ (� \ � � J T :i \ Ff \ $ J\ E C& CD cn w S E E § m ) R\ E& f _ E# «g $ \R ° , o w i ; § i § o - n ■ E E \ k $ - , ' > > E R # \ 3 E §\ § 0 ; � 2 o r f � �_ �- @; � § 000 Oro - / g \ CA / ~ § / \ ( \ 1 OD k � n th & i ` a) y .. . \ / \ { \ § \ 0 J a . . CD I 2 Cl) n & to \ \ n 3 k k 0 ` ƒ k / § E \ R R 0 § T i g 2 a . a A M o e --4 � ƒ j 2 ! -�e> @E'< CL _ < U) CL a « 9ay. ® /k \} % . � ?�® � , j9\� =r $ °o, \ (D§ 0i § k �\CO \ G ( _ = n . g/ƒ Q 0 3 % CD ! to { 0 \ $ G § kli ii �§ , 8 : � , Safety and Buildings Division County t 201 W. Washington Ave., P.O. Box 7162 ' N virsconsin Madison, WI 53701 -2 - Sanitary Permit Number (to be filled in by Co.) (' (608) 266 -31 >61 7 Department of Commerce State Plan I.D. Number Sanitary Permit Application In accord with Comm 83.2 1, Wis. Adm. Code, person I information you provi&_g0 ZA may be used for secondary purposes Privacy' aw, s15.04(1)(m) Project Address (if differe than mailing address) 1. Application Information - Please Print All Information / ` � Z j Property. Owner's Name /, / P arcel # of # Block # (I � 0 — LO - 7 — Property Owner's M / ig Address Property Loca�tio�i� / QU1� ( �� r �' /+, , Section 17 City, State t Zip Code Phone Number n �t.1/ T I r 6� _31N; R c'" one) �c. �Eo or r W II. Type of Bui ding (check all that apply) �ST /C[OU� ubdivis C 1 or 2 Family on Name S umber ily Dwelling - Number of Bedrooms - � 0 ❑Public /Commercial - Describe Use 6— El State Owned - Describe Use f S T, ❑City_ ❑Villa Township of \ 111. Type of Permit: (Check only one box online A. Complete line B if applicable) r V A. kNew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System List Previous Permit Number and Date Issued B. ❑ Permit Renewal El Permit Revision ❑ Change of ❑ Permit Transfer to New Before Expiration Plumber Owner IV. Type of POWTS System: Check all that apply) b P Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter XLeaching Chamber ❑ Drip Line ❑ Gravel -less ipe ❑ explain) V. Dispersal/Treatment Area Information: 17 O Design Flow (gpd) Design Soil Application Rate(gpdsf) , Dispersal Area Required (st) Dispersa� o osed s m Elevation 1 � _ VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel b e Plastic Gallons Gallons of Units I ,` _ A „ Q /f �ncrete Constructed Glass New Existing ", W CGC• - Tanks Tanks Septic or Holding Tank 7 �j� .� 7J' © ,� Aerobic Treaunent Unit / VV Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility for i stallation of the POWTS shown on the attached plans. Plu ber's Name (Print) Plum Si at MP MPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Cod _ o bo VIII. .ounh' /De artment Use Onl Approved El Disapproved Sanitary Permit Fee (includes Ground ater D�re sued ssuing Agent ignat a (N t ps) Surcharge Fee) �! D El Owner Given Reason for Denial 1X. Conditions of Approval /Reasons for Disapproval 1 S Y STE M O t ank, effluent filter and J 3 �U 2 dispersal cell must all be serviced / maintain as per management plan provided by plumber. ,�/ / �� as � r7 /��" 2 setback requirements must be maintained p --7'v b� �.�,-.� V 1� 0 .SAIL "� as per applicable codelordinance�t0�—. 0 . q 3 —( Attach complete plans (to the County only) for the system on paper not less tha $112 ;11 iruruhey m s' SBD -6398 (R. 01/03) i � a l r,f o l 3/� - lam cam' 0 -� ool � bj �a a - i J - -1 za, tl ro-( of 3 1y ItIc-, - mo - 7 4-�� - 1 q x +� / ) 9 1406 Wisconsin Department o Commer $OIL EVALUATION REPORT P age 1 of 4 Division of Safety and But grdancE with Comm 85, Wis. Adm. Code Steel's Soil Service Inc. County Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must St. Croix 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 m 70 � �J"�_ ,`J � ad. Parcel I.D. � Please print all information. R ed D Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). G� �p Property Owner Property Location Brockpahler, Henry Govt. Lot na SE 1/4 SW 1/4 S 31 T 31 N R 17 W Property Owners Mailing Address Lot # Block # Subd. Name or CSM# 1672 170th St. 2 na CSM Vol. 8 City State Zip Code Phone Number J City _j Village 01 Town Nearest Road New Richmond WI 1 54017 1 715 - 246 -5598 Stanton Rustic Lane Dr V1 New Construction Use: 16 Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD I Replacement J Public or commercial - Describe: Parent material Outwash Plain and Stream Terraces Flood plain elevation, if applicable na General comments and recommendations: Conventioal system, system elevation 99.70ft. Trenches spaced and depth to code 3.00ft below grade. Boring # _j Boring &I Pit Ground Surface elev. 102.70 ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftl in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -9 10yr3/2 none I 2msbk mfr gw 2f .6 .8 2 9 -15 10yr4/4 none scl 2msbk mfr gw 1f .4 .6 3 15 -22 10yr4/4 none sl 2msbk mfr gw na .6 1.0 4 22 -36 5yr3/4 none Is osg mvfr gw na .7 1.6 5 36 -100 7.5yr4/4 none cos osg ml na na .7 1.6 1 f diameter 10yr5/6 silt (ens at 36" with c2d 7.5yr5/6 redox features end at 48" through the boring Boring # I Boring 0 Pit Ground Surface elev. 101.70 ft. Depth to limiting factor 100 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 -6 10yr3/1 none I 2msbk mfr cs 1f .6 .8 2 6 -16 10yr4/4 none sicl 2msbk mfr cs 1vf .4 .6 3 16 -26 7.5yr4/4 none Is osg mvfr gw na 7 1.6 4 26 -100 7.5yr4/6 none cos osg ml na na .7 1.6 * Effluent #1 = BOD? 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS <30 mg /L CST Name (Please Print) ignature: - CST Number David J. Steel 248956 Address Steel's Soil Service Inc. Date Evaluation Conducted Telephone Number 1564 CR GG, New Richmond, WI 54017 4/6/2004 715 - 246 -5085 Property Owner Brockpahler, Henry Parcel ID # Page 2 of 4 3] Boring # I Boring Y' Pit Ground Surface elev. 100.20 ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -8 10yr3/1 none I 2msbk mfr gw 1f .6 .8 2 8 -30 10yr4/4 none sicl 2msbk mfr gw na .4 .6 30 -100 7.5yr4/6 none cos osg ml na na .7 1.6 61(0. Zlf F-1 Boring # J 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 GP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ❑ Boring # I Boring I Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PD 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. ' STEEL' SOIL SERVICE INC. Page 3 of 3 David I Steel 1564 Cty Rd GG CST - POWTS "enery Brockpahler New Richmond,WI 54017 Lic. #248956 SE /4,SW1 /4,S31,T31N,R17W Bus.(715) 246 -6200 To of Stanton, St. Croix Co. Fax (715) 246 -9372 Lot, 2 Legend 1" = 40' ♦ = Benchmark Ele. 100.00ft Top of 3/4" PVC Pipe • = Alt Benchmark Ele. 99.70ft Top of 3/4" PVC Pipe 7, Z7, ❑ = Borings Boring Elevations B 1 = 102.70ft B2 = 101.70ft B3 = 100.20ft B4 = 00.00ft lag` 3 4 .L I' f �0, z� ,Ce r - , I t c � L O '3nh11Z5o69N 4eaq o4 pallnsse ..�C .• s i C r 'i.?I •r� { �"f O . t£ u0143as jo iNS a44 jo auTT 4 }nos r.•. �,t� ::;;e" v v, a4} 04 paauaaa3 1 aye s6ut_.►saq SPUeI Pa3Teldun 199 -+-� o = 1 of Y i to - 1 •1 S I 3AISO 3NVl 9I1S08 " ► 10 (31£IpEON 'aai) °D IZ6'88E 3116515I ►E6 I �(►68"h9£ •aaJ) 198'SS£ W a 190'E£ I Lj en �o 199 � O c I a .•1 1/1 •O ~ u O (.l '••� 1 .N m C" m 01 16 r to l7 X .0 —� r, N of l+7 to .•r n N •ti Q x j NO r.1 N w {� \ c ° 16Z'99E NuS[ITOoTON o 7 � - -, w �G I I J L 1 si `mi a N I ? 1 .,•.. r. .•....ti. / f� G1 O M _` In Y7 t •L co r O 1 tO J • b r 1 Clq O I I'I '" a O t L M► L I' I '- J I W u u U M r . W an 10 1n a n, ... N O cn m M N ~ d O �I CO 1O p O _ n M h wl , ( � ► m � 1 9a•at£ ' w ' M115T ITOOION C k4 1 � 1 N t9 of- Nn t1T0oI0N t o _ N _ m - '3S a41 �a QU TNS 8 44 j T ° 100' 99 — _ — o Oc H N C C3 N ALL NuSilTOoTON d ca 1 - ' w m ° r- n a o _ 4 s i -, tOS 10S .i. W co W ro t - m i1 L ° u C; m N 0 L On v O O u W L L 4- Q -la c7b L u w w U.J co W •1, cli 166'01£ 311511I0 tOS o z m r*' Aq Pauno�spue[ pallel un y uj s•. . }_ . .i .+ : m _ Q ti .' . i •, •j .Ll In O 1n o LEI U v J.✓t w C Q i. 1 f.^ . + '•. j 3•i H N O m H C } w •n C/1 cn .$ •'a m O '� �i `F' W v 'O m YJ c •v a ?. y ..3 .J A y • ~• (V `, G • • L ul F Of C 0> C N -C c i. M I • .0 w'•'. ♦ m 111 V..:�y" m F. 7 E N a c c C ����ww tdl�'' }. .N m •.� Qf ..•1 �.eY .rl U U W `yy � � u J.• E i� ' � W. 3 h to ry 1 i.•i:k.. c o s 0 x . o 7 .0 . ry "�' '' -�.� .' f� . m 0 m .cool o o m o w m 1 POWTS OW ER'S MANUAL & MANAUt:MtN I ruAuv Page , of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity .S® gal ❑ NA Permit # �' Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms a 13 NA Effluent Filter Model Q Q ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity a l ❑ NA Estimated flow (average) gal/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) 3 0 © g al/day Pump Manufacturer ❑ NA Soil Application Rate / al /da /ft2 Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit A Fats, Oil & Grease (FOG) 530 g/L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 g/L ❑ NA Cl Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 g/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Montt ly average Disp al Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 /L n- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 ff /L �NA 1i At -Grade ❑ Mound Fecal Coliform (geometric mean) 510` fu /100m ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in d a. ❑ NA Other. ❑ NA Other: ❑ NA Other: ❑ NA `Values typical for domestic wastewater and septic to k effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) t O months) (Maximum 3 year:) ❑ NA least once every: ear(s) Pump out contents of tank(s) W hen 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: ayear(s) Clean effluent filter t least once every: 13 month (s �year(sl ) ❑ NA 13 month(s) every: 13 year(s) 13 NA Inspect pump, pump controls &alarm A t least once ev ❑ month(s) ❑ NA Rush laterals and pressure test At least once every: ❑ yearls) ❑ month(s) E3 NA Other: t least once every: ❑ year(s) Other. (3 NA MAINTENANCE INSTRUCTIONS f Inspections of tanks and dispersal cells shall b made by an individual carrying one o the following licenses or certifications: Master Plumber, Master Plumber Restricted Se er; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of a tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and m and to check for any back up or ponding of effluent on the ground surface. The dispersal call(s) shall be visually inspected t check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding f effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory a ority. 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 Selptage Servicing Operator and disported of in accordance with chapter NR 113, Wisconsin Administrative Code. AN other services, including but not 1'imited to th i servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 moat is, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local rei ulatory authority within 10 days of Completion of any service event. I i Page 21 of Z 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. 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. I " • 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. T alua ' a go rng tank � e ai 8 77� 1 01- A16'A1 CONS 10N b Rv�-! ❑ 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 POWT S MAINTAINER Name Name Phone I w _ & e ^ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name G kb ( 20d I Phone Phone This document was drafted in compliance wkh chapter Comm 83.22(2)(b)0)Id) &I0 and 83.541), (21 & (3). Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC 'DANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Mailing Address & Property Address / K (Verification required from Planning De artment for new construction) City/State LIPAA) +� i CGS L Parcel Identification Number 40 /D - 7 LEGAL DESCRIPTION Property Location '/4, ' /,, S 31 . TN -RLW, Town of Subdivision luli4 Lot # 2- Certified Survey Map # _ L �� S Volume Page # Warranty Deed # 7-5 � j 13 Volume j Page # Spec house ❑yes Q'no Lot lines identifiable CJ'yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your s tic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every thr e 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_ The propertyowner agrees to submit to St. Croix 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 wastewaterdisposal 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. Uwe, 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 maintaine4must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiratiomdate. SIGN . OF APPL CANT DATE OWNER CERTIFICATION I (we) certify that all statements on this f rm are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of th perty described above, by virtue of a warranty deed recorded in Register of Deeds Office. e . SIGNATURE 017 APPLICANT DATE « * * * ** 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 from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed I - 7554 3 U. 2 5'1 8 P 4 11 _ STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH WAR"NTY DEED REGISTER OF DEEDS Document Number ST. CROIX CO., WI This Deed, made between Nancy A Hansen RECEIVED FOR RECORD Grantor, 03/01/2004 10 : 30AN and Henry A. Brockpahler and Carolyn . Brockpahler, husband and WARRANTY DEED wife Grantee. EXEMPT # Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Cro x County, State of Wisconsin REC FEE: 11.00 TRANS FEE: 60.00 (if more space is needed, please attach adden (um): COPY FEE: That part of SW 1 /4 SW '/4 and the SE I SWIA, Sec. 31- T31N -R17W CC FEE: described as follows: Lot 2 of Certified Sur v y Map recorded in Vol. 8 of PAGES: 1 Certified Survey Maps, page 2206 as Doc. o. 458575. Recording Area Name and Return Address KH1 )rll 1OGI_AND ATTOi iNEY AT LAW P.O. SOX 359 HUDSON, WI 54016 036 -1078 -50-00 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 UO day of February 1 2004 � . * * Nancy A. Hansen * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) Nance A. Hansen STATE OF ) ss. 4/1.► __ —_ County ) authenticated this day of February 2004 Personally came before me this — day of the above named * Kristina O land -- - -- --- _ -- TITLE: MEMBER STATE BAR OF WISCONSI (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 Attorney Kristina Ogland * _ Hudson, WI 5 4016 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 r printed below their signature. information Professionals Co., Fond do Lac, W1 STATE BAR OF WISCONSIN 800 - 655 -2021 WARRANTY DEED FORM No. 2 - 1999 I i 1 S o t� I I i r : r l GI-- - : - -- l O ; Q fl I q e. L okp 3 ' , , : Q , F-I i co I i j c , �. CO 9 FILED MAY 151990► 11 5 JAMES O'CONNELL J2 458575 Re of . � St Croix Co., V1I<I v r (7 z�0�c zxn az-� zm z 0 n M NO m 00 m 0? m O W C/1 Cn L CJ1 Cr L C �•-+ E c 0 Y C 7 �.� ....,Mj — m :c CD rtr rt� It n ., r �`'Q , m O • 0 x a - 3 a m CD an d m m m C ^' `F - O o _ m a s s m q /� - N.. to r• m O ` G O L O O = -� /Y _ _` �,NP� r —i m -3 w = a m = CD = is = <n Z g x d _r- l r .. a< s a = a m M m m ^$- m N > > 1011 H m o -- r�� ► r N r: -.. i r w "! a l C r O rt r r r cY - CD - Z Ln cn o cn o cn rr ) o rt rn O_ O O C .... r • c c ray ,..,,_,...,: � �" � 3 = N unplatted lands owned by --- - - O - =� -� • D r O D = T �N SO1 ° 01' 15 340.99' x = m ►� rr = ID z L" r" I r r • m C) 00 IO m m N w m S rt 3 x o0 M rn . m +0 X s of m = of C" <-r r• M r 0 O a _ -7 N Cn O v o o rr • •- o O m 4.1 N Ct O 0 C— to m r• C, O T 0 = O CT N . 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NO30131E) cmn rn RUSTIC LANE DRIVE C7 o I• rn to d i � w N I 1 ;K CO N 1 = O o — m � N 661 unplatted - - ands — --- - - - - -- . ti E bearings are referenced to the a'4' south line of the SW} of section 31 o assumed to bear N89 °52'14 "E. Z = CD -5 lAy Ln �+ ':�0t4u'�i"�'1�'•lR1AG ; %;RF:3 i•'f.A!dV�1.;; VoUjt E 8 PAGE 2206