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HomeMy WebLinkAbout036-1084-80-000 �'V partment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix uXWY.nd il ding Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 515204 0 GENERAL INFORMATION 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: Ulrich, Joseph A. Stanton, Town of 036- 1084 -80 -000 CST BM Elev: Insp. BM Elev: BM Description: Sectionfrown /Range /Map No: / 6U 6W 1 GS 32.31.17.511 B TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic JI Benchmark oao �!• S Ali 5 An D Alt. B�, 2 -IT /a Aeration Bldg. Sewer Holding St/Ht Inlet 9 Z5 / 1 7' D� ��5 • �S St/Ht Outlet TANK SETBACK INFORMATION �' ��j • `7 TANK TO P L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic � � Dt Bottom � C Dosing Header /Man. !�i7 Z 7 Aeration Dist. Pipe 77 97- z5 Holding Bot. System / � Z 7S . "7 Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover f GPM f1 {+wLp Z Model Nu TDH Li Friction Loss System Head TDH Ft Forcemairi Length i Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width / Length o. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 13 W (��� r _ SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAM OR Type Of System: ~ 3d UNIT Model Number: C aA.Lje� r T l3 D /0/ DISTRIBUTION SYSTEM al� $/-/�= 3` A o vL Header /Manifold I Distribution Hole x Size x Hole Spacing Vent to Ai Int Dia Pipe(s) \ \ Z Length �� Length Dia \ Spacing \ I �\ SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only t .. Re_ _ Depth Over Depth Over xx Depth o xx Seeded /S dded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ,Yes ® No s Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 1628 Cty Rd K Richmond, WI 54017 (SE 1/4 SE 1/4 T31N R17W) NA of 2 11 ` Parcel No: 32.31.17.511B 1.) Alt BM Description = ` ' CoOV,.p_� &V � T'(��� air Ln p d So#16 2.) Bldg sewer length = 3 / GM a P . �— - amount of cover = J ' 7 -5a a5 Plan revision Re No -�- - - - Use other side for additional information. 1 SBD -6710 (R.3/97) Date Insepct i r e Signat Cert. No. I r - R.e m e commercemi.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 S'� d / k t i s c o n s i n Madison, WI 53707 -7162 Sanitary Permit Number (to a filled in by Co.) Department of Commerce ;! 2 Sanitary Permit Application ► Sta Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental AM — unit unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you rovid nd /4,7-8 purp oses in accordance with the Privacy Law, s. 15.04 1 m Stats. I. Application Informa ' n - Please Print All Infor r Property Owner's Name Parcel # Y o C (y� 0 3 � - / 0 o ®dv Property Owner's Mailing Address Property Location / `3 ©? L 70 ' .Sf ST. Q( & NINA OFFICE Govt. Lot L 7 City, State ^ Zip Code c y, tS� %, Section J 'z " v.Y l' 1/0 (1 - t`u c� (circle one T � l N; R _, E orW H. Type of Building (check all that apply) Lot # V or 2 Family Dwelling - Number of Bedroo Subdivision Name l d.�+[. Block ❑ Public /Commercial - Describe Use - ❑ City of ❑ State Owned - Describe Use CSM Number :{ T 4,31 ❑Village of 2 �. b 174-17 C��G1 V6 1 v M 3 Town of III. Type of Permit: (Check only Jae box on line A. Complete line B if applicable) A. ❑ New System placement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS System/Component/Device: Check all that appl W on-Pressurized In- Ground ❑ 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. Dispersal/Treat ent Area Information: Design Flow (gpd) Design Soil Application R (gpdsf) Dispersal Area Re uired (s Dispersal Ar opo� (,Sfj Syste Elevatio;r VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units 2 o New Tanks Existing Tanks c Y e d a 0 I f-A. Holding Tank j �Gt K� V. Dosing Chamber - 71 3 - `9 • ZZ.77 VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the P OWTS sho he attached plans. ber's Name (Pri ) Plumber's Signature MP RS tuber Business Phone Number a e wt H A_ r_ S 2_7 L87 Z_ Plumber's Address (Street, City, State, Zip Code) VIII. oun )De artment Use Onl Approved Disapprove Permit Fee Date Is ed Issuing A Signature ❑ Owner iven Reason o f enial $ / 7 ' IX. Conditions of p roval/Reasons fpr Drs oval i r Ae-. '* 0 1/4�1) Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SYSTEM OWNER: 1. Septic tank, effluent lifter and disper . j , ell m ..st all be services/ maintained as per management plan provided by plumber. SBD -6398 (R. 02/09) Valid thru 02/11 2. All setback requirements must be maintained a per applicable code / OrdUtandes. a Q I ' 5 - � �+ a 0 la \ of vj � k$ 4 6C PY 1-70 d c a /rs O ` u, C) I d J� '/k A t 41 0. a o L,v 0 �6 A' L 4 0 Q 0� to �ks N o h o /mss g 0Z ��� mot. -)7y we) / t —� a j d _ 6 ,44 / / jr r P A V') Wisconsin Department of Commerce SOIL EVALUATION REPORT a Page of .3 Division of Safety and Buildings 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. O �(� 16&g � D 000 O Please print all information. Revie d by Date Personal information you provide may be used fors onda © a. 15. (1) (m)). /� 3 16 ? Property Owner II �• Prop rty Location QEQ Govt. of a ef 1/4 3 tr 1/4 S ZT 3/ N R 1'7E (or) W Property Owner's Mailing Address Lot # I Block # I Subd. Name or CSM# V 7 ^ D 9T, CROIX COUN Ci State . Zip Code 1 1 hRANNffilQAZQNINQQ1FIVq - ty ❑ Town Nearest Road cl ❑ New Construction Use: &Residential / Number of bedrooms 3 Code derived design flow rate J� GPD 50eplacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft. General comments and recommendations: q `1 C [] 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/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 k a s' / , Z .3 o s , - l c w- i r '7 Y8 yl d yip ---/ S Q�� — • - 7 /. Z o f v ® Boring # E] Boring 9 [g 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 'Eff#2 � � n = BOD > 30 < 0 m /L and SS >30 < 150 m /L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L Effluent #1 mg /L — CST Na tase Print) ;gnature CST Number 2- 2, -'7 Z Address Date Evaluation Conducted Telephone Number j 3 /z Property Owner Parcel ID # Q Page L of 5 -1 Boring # ❑ Boring 9 q. to 7GU ® 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/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ❑ 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/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring 17 El # Ground surface elev. ft. Depth to limiting factor in. El Pit - So ­ iiAppiication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff 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.07 /00) Q .� e h L ,oL .0 9Iw �o �s� N 7d Q~ 9D2 i70 6JA -C ti�iEs G �� zz 4 p7 I K rt U u 3 l �`� . LU r` K .. 4 dlli i LOCK I" olf, 1&111 �1--- qa 4t i 'BLOCK 1 o-. Lei r Y'1 t � co [J de 06 Q W Z` ' Z Li m 'J lY l - r 3 CL w � 1 cn 53 , t o �,w � 9 3199 ► t0 53'7431 v CERTIFIED SURVEY MAP LOCATED IN THE SE 1/4 OF THE SE 1/4 OF SECTION 32, T31N, RIM TOWN OF STANTON, ST. CRO I X CO. WI. PREPARED FOR JOE ULRICH NOT BEARINGS ARE REFERENCED TO THE SOUTH LINE OF THE SE 114. s (RECORD BEARING) • r z UNPLATTED LANDS WEST LINE OF THE SE -NE N 90 00' 00" E 609.26' 364.26' 245. 00' LOT 2_ N LOT 3 5.78 ACRES ( 251, 809 $0. FT.) h ( 195, 856 A SO. FT.) N: 2 5.47 AC. EXC. R.O.W. 4.23 AC. EXC. R.O.W. a O: Q: O (238, 252 S0. FT.) M 184,343 SO. FT.) O Q; rn a; cp � m a p; p: ro O N N W a: a Cb .J; W BARN r J; 1 N 90 22.00' SHED GARAGE R w ~ MOBILE HONE HWY. FETBACK M NM LINE DRIVE HOUSE _• TO BE' REMOVED) " o I '� ° N 00 OO' 00" E 0 N90 00' 00 W 5. 00' 339_55' �_ ` 129. 39' N 90 ° 00' 00" a 140, f 9' a 131 7_.94' q 40.0!' 338.33' 40.00' 270.93' 45.01' U 70 8.68' won ° ' E d N 90 609.26' " �� N 90 00' 00' W _ • • • S 1/4 CORNER OF SOUTH LINE OF THE SE 1/4 SE CORNER OF SECTION 32. (1" IRON SECTION PIPE FOUND). IRON PIPE FOUND). .U�JP�.A��;�Q y'� . ,.::• ;.. ' +`"ICJ " r1 �� O - SET I' X 24' IRON PIPE WEIGHING 1. 13 LBS. PER L INEAR FOOT. ++ ft x7 JAMES M. ;1 x • - f " IRON PIPE FOUND. b1E:+�i,.R n Is S i:iAa SPRJ,vG VaLiFY W is. { a 150 0 150 300 450 �*O;'40 �i� � �1 R� �s• GRAPHIC SCALE —FEET JAMES M. WEBER S -1804 NELSEN -WEBER AND SURVEYING SHEET I OF 2 DATED TH I S L4 DAY OF _=__7_S_ ; 1995. Qom, • � � -`3 -� t 95 -139 THIS INSTRUMENT DRAFTED BY JIM WEBER E:)ESCF;tI 1= ION A parcel of land located in the SE 1/4 of the SE 1/4 of Section 32, T31N, R17W, Town of Stanton, St. Croix County, Wisconsin, being Lot 1 of the Certified Survey Map recorded in Volume 4 of Certified Survey Maps, Page 909, more fully described as follows: Commencing at the SE corner of said Section 32: Thence N90 "W along the south line of the SE 1/4 a distance of 708.68' to the point of beginning: Thence continuing N90 "W along said line 609.26'; Thence N01 "W 735.00'; Thence N90 "E 609.26'; Thence S01 "E 735.00' to the point of beginning. Contains 10.28 acres subject to C.T.H. "K" right -of -way over the southerly portion as shown. Also subject to any and all easements, right -of -ways or conveyances of record. SLJRVBYOR ' S CFS2T I F I c I, James M. Weber, registered land surveyor, hereby certify: That in full compliance with the provisions of Chapter 236.34 of the Wisconsin Statutes and the provisions of the St.Croix County Subdivision Ordinance and under the direction of Joe Ulrich, I have surveyed, divided and mapped the above described parcel of land and that this map is a correct representation of the boundary thereof. Dated this k : S ' day of ycr o3<'si ,1995. James M. Weber S- 1804 NELSEN -WEBER LAND SURVEYING n -`i -C% NOTICE: THE PARCELS SHOWN ON THIS MAP ARE SUBJECT STATE, COUNTY AND LOCAL LAWS, RULFS AND REGULATIONS ( I .E. WETLANDS, MINIMIA4 LOT SIZE, ACCESS TO PARCEL, ETC.). BEFORE PURCHASING OR DEVELOPING ANY PARCEL, CONTACT THE ST.CROIX COUNTY ZONING OFFICE AND THE APPROPRIATE TOWN BOARD FOR ADVICE. SHEET 2 OF 2 95 -139 THIS INSTRLMENT DRAFTED BY JIM WEBER r �l n v 1 � V ID b I �b �b sy a / a a� J Uvvlvth'b MANUAL & MANAGEMENT PLAN Page of FILE INFORMATI Owner SYSTEM SPECIFICATIONS c Z Septic Tank Capacity Permit �� p U /1-- --+► -- al ❑ NA Septic Tank Manufacturer S/5 ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer 616,45, ❑ NA Number of Bedrooms j ❑ NA Effluent Filter Model 616,45, f f1I`'/� 1:1 NA Number of Public Facility Units -ErNA Pump Tank Capacity "OVA Estimated flow (average) al —p �� gal /day Pump Tank Manufacturer _Q-NA Design flow (peak), (Estimated x 1.5) 3 7 -2 al /day Pump Manufacturer .E3-NA Soil Application Rate al /da /ftZ Pump Model ,fl-NA Standard Influent /Effluent Quality Monthly average' Pretreatment Unit p-W Fats, Oil & Grease (FOG) :_30 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD :5220 mg /L -21"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 n- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L EMA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510" cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. NA Other: ❑ NA Other: 93-NA " „NA Other: ❑ NA 'Values typical for domestic wastewater and septic tank effluent, Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 ears) 11 NA —) year(s) y Pump out contents of tank(s) When combined sludge and scum equals one -third IY of tank volume ❑ NA Inspect dispersal cell(s) At least once ever ❑ month(s) y' - B-year(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every : l b — ��onth(s) ❑ NA ❑ year(s) Inspect pump, pump controls & alarm At least once every: A "month(s) ❑ NA ❑ year(s) Flush laterals and pressure test At least once every: ! ❑ month(s) ❑ NA -B Other: At least once every: ❑ month(s) ❑ NA ❑ 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 cal regulatory authority within 10 days of completion of any service event. GMW (4/01) Z2- Z872- of the tanKis) removeo D a S y eptage 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 tie 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: O 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 INS7ALLER POWTS MAINTAIN 9R Name e - Q W , r„s Name a Phone t I y 1) L — 2 yZ/ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name �]R , � X 4 Phone Phone ��(, - e'o U This document was drafted in compliance with chapter Co 3.22(2)(b)(1)(d) &(f) as 8�(2) & (3), Wisconsin Administrative Code. Zzz157Z ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer d e' r ti _ Q Mailing Address 9 o 2 7 0 _)h r tir ` 1n� ; '� o u q G Property Address � � L e� - �S �t /� Ar w / , " ;, P, J (Verification requir from Planning & Zoning Department for new construction.) City /Stat9% C _ /_ (_+'C4 r-_' , r 11J L- ! Parcel Identification Number LEGAL DESCRIPTION Property Location �I '1 4 � ' /4 , Sec. 3 Z T 5 f N R J / W, Town of Subdivision Plat: , Lot # Certified Survey Map # , Volume 1 , Page # Warranty Deed # (before 2007)Volume , Page # Spec house i yes ;$60 Lot lines identifiable )k-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 ( I ) 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. 1 /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 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 Department within 30 days of the three year expiration date. I /we certify that all statements on this form are true to the best of my /our knowledge. I /we am /are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 3 + � 2 / L / —/rq SIGNATURE OF APPLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) 1 U. 2 5 6 9 P 0 19 KATHLEEN H. WALSH REGISTER Of DEEDS I ST. CROIX CO., MI STATE BAR OF WISCONSIN FORM 3 — 2000 QUIT CLAIM DEED RECEIVED FOR RECORD Document Number 05/11 /2004 09:30Aff This Deed made between ELIZABETH M. ULRICH, a single person OuIT CLAIN DEED Grantor, and JOSEPH A. ULRICH, a single person Grantee. EXEMPT t 8M Grantor quit claims to Grantee the following described real estate in ST. CROIX County, State of Wisconsin (if more space is needed, please attach REC FEE: 11.00 TRANS FEE: addendum): COPY FEE: j CC FEE: Lot 2 of Certified Survey Map recorded in Vol. 11, page 3024, in PAGES: i j the Office of the Register of Deeds for St. Croix County, i Wisconsin. THIS DEED GIVEN PURSUANT TO THE TERMS OF A ! JUDGMENT OF DIVORCE GRANTED BETWEEN THE j ABOVE P IN THE CIRCUIT COURT FOR ST. CROIX Recording Area ! COUNTY, WISCONSIN ON APRIL 1 , 2004. Name and Return Address t i Attorney Barry C. Lundeen Together with all appurtenant rights, title and interests. 110 second Street i Hudson WI 54016 i 0 36- 1084 -80 -000 Parcel Identification Number (PIN) This is not homestead property. Dated this day of A il , 200 i i i 1 *Elizaga M. Ulrich t i j AUTHENTICATION ACKNOWLEDGMENT t STATE OF WISCONSIN ) Signature(s) authenticated this ZS day ofa , ) ss. St. Croix County ) / ✓ �/l�( �• / (� Personally came before me this day of A ril, 2004 the rbu rrn i ti above named Elizabeth M. Ulrich to me known to be the person TITLE: MEMBER STATE BAR OF WISCONSIN who executed the foregoing instrument and acknowledged the (If not, authorized by § 706.06, Wis. Slats.) same. THIS INSTRUMENT WAS DRAFTED BY Attorney Barry C. Lundeen Hudson WI 54016 Notary Public, State of Wisconsin (Signatures may be authenticated or acknowledged. Both are not necessary.) My Commission is permanent. (If not state expiration date: j •) 'Names of persons signing in any capacity must be typed or printed below their signature. QUIT CLAIM DEED STATE BAR OF WISCONSIN FORM No. 3 — 2000