HomeMy WebLinkAbout038-1008-95-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH 'rd) PERMIT) 453391 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:
Anderson, Roger I Star Prairie Township 038 - 1008 -95 -000
CST BM Elev: Insp. BM Elev: BM Description: I Section/Town /Range /Map No:
16�) 1 8JLz "^_ 8� j ; 02.31.18.24G
TANK INFORMATION ELEVATI N DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic -3 wC, B mb+o m rk s Z J6s Zit I&S
Dosing Alt. BM
Aeration Bldg. Sewer L +
�•�S
Holding St/Ht inlet c,
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic / I Z /2 I Dt Bottom
Dosing Header /Man.
I
Aeratio Dist. Pipe
Holding Bot. System
Final Grade
PUMP /SIPHON INFORMATION 5 ' & fee) Z
Manuf urer G P m m�and St Cover 3
tT !:
Model umber
TDH Lift System Head Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENC No. Of Trenche PIT DIMENSIONS No. Of Pits Inside Dia. z Depth
DIME NS
SETB SYSTEM TO BLDG ELL LA /STREAM LEACHING r:
INFORMATION CHAMBE
Type Of Sys em: NIT Model Number:
7f� /
DISTRIBUTION SYSTEM
Header /Manifold IDistributio g� x Hole Size x Hole S Vent to Air Intake
Pipe(s)
Length Dia [Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over 0 epth Over xx De th of xx Seeded /Sodded xx Mulched
Z.
Bed/Trench Center Bed/Trench Edges Topsoil No No
� �l- .
COMMENTS (include code discrepencies,; persons present, etc.) Inspection #1: 7 / J9 / Inspection #2:
Location: 1210 Cty. Rd.((��H New Richmond, WI 54R17 (Government Lot 3 2 T31N R18W) metes & bounds Lot Parcel No: 02.31.18.24G
1.) Alt BM Description= &Azi'_ O+ / \\ /� ``
2.) Bldg sewer length = A7 ��� �S C �^` �� b�o.�✓� (�c : �
J�
�
- amount of cover = q � �,��� .•/� Z
1Q
Plan revision Required? Yes No [�J_6j g [Use other side for additional information. (J - - 1 L
Date Insepctors Si nature Cert. No.
SBD -6710 (R.3/97)
Safety and Buildings Division County 1 V
201 W. Washington Ave., P.O. Box 7162
N V Il i s c onsin Madison, WI 5370'1 - 7162 Sanitary Permit Number (to be filled in by Co.)
ment of Commerce (608) 266 -3151 5- 3 -3
De art
Sanitary Permit Application S tate Plan I.D. Number
In accord with Comm 83.21, Wu. Aden Code, PpCc�'s nal information you prove PMD D ��
may be used for secondary purposes Prtv*cy Law, s15.04(lxm) Project Address (f different than mailing address)
L Ap p l ication Information — Please Print All Information
PP� g �l 2
Owner's Name arcel # # Block #
2
Pro Owner's Mailing Addrds tapperty Location I la - l A / 54, 54. Section
City Zip Cod�e / Phone Number / Z
T of ; M�E or W ,
7 II. T e of Building (check all that apply) r--,
Subdivision Name CSM Number
or 2 Family Dwelling - Number of Bedrooms
PublidCommeidal - Describe Use
State Owned - Describe Use F citY7
III. Type of Permit: (Check only one box on line A. mplete line B if applicable)
A. New System t system TFeatz=VHoldrng Tank Replacement Only Other Modification to Existing System
List Previous Permit Number and Date Issued
B. Permit Renewal Permit Revision Change of Permit Transfer to New
Before Expiration Plumber Owner
IV. Type of POWTS S stem: (Check all that a 1 )
Non Pressurized in- Ground Mound >_ 24 in. of suitable soil Mound < 24 in. of suitable soil At -Grade Single Pass Sand Filter
Constructed Wedand Pressurized in- Ground ad, Tank Peat Filter Aerobic Treatment Unit Recirculating Sand Filter
Recirculating Synthetic Media Filter g Ihi p line Gravel -less Pipe Otber (explain)
V. Di tment Area Information:
Design Plow (Wd) Design Soil Application Ratc(gpdsf) Dispersal Area Roga uKd (d) Dispersal Art Propo (sf) System Hevation
VL Tank Info Capacity in Total N Manufacturer Prefab site Steel Fiber Plastic
Gallons Gallons of Units concrete Constructed Glass
New Existing
Tanks Tanks
Sepdcor Holding Tank
Aerobic Treatment Unit
Dosing Chamber 1 r
VII. Resp onsibility Statement- I, the undersign asibility for Installation of the POW15 shown on the attached plans
Plu Name (Print) Plurmber' MPJMPRS Number Business Pbone Number j
Plumbers Address (Street, City. State. ) l �
Vill G
Coun rtment Use Onl
Appro s urd, Per Fez ('includes Groundwater Date Issued Signature
Disapproved (N tamps)
8z � 2 s • �—° � l s/ 6 L / f
Owner Given Reason for Denial
A
Ix. Conditions of val/Resce Cf/YtGr� �Lt7Yts b S�G� G!/�GC — pL� �(jwvCCt/yt f
��ti
G n than SDl1 1 Inches in ^/
� a my only) for the /O / /'l �j JW ans (to the
J R/ti e3-` S-4 r —� /mil
Safety and Buildings
commerce.wi. OV 4003 N KINNEY COULEE RD
g LA CROSSE WI 54601 -1831
TDD #: (608) 264 -8777
isconsin www.commerce.state.wi.us /sb
Department of Commerce www.wisconsin.gov
Jim Doyle, Governor
Cory L. Nettles, Secretary
July 08, 2004
CUST ID No.226900 ATTN. POWTS Inspector
SHAUN R BIRD ZONING OFFICE
BIRD PLUMBING, INC ST CROIX COUNTY SPIA
1008 192 ND AVE 1101 CARMICHAEL RD
NEW RICHMOND WI 54017 HUDSON WI 54016
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 07/08/2006 Identification Numbers
Transaction ID No. 1016702
SITE: Site ID No. 685976
Roger Anderson Please refer to both identification numbers,
1210 Cty Rd H above, in all correspondence with the agency.
Town of Star Prairie
St Croix County
Government Lot(s) 3, S2, T3 IN, RI 8W
FOR:
Description: Three Bedroom Replacement Holding Tank
Object Type: POWTS Component Manual Regulated Object ID No.: 967161
Maintenance required; Replacement system; 450 GPD Flow rate; System: Holding Tank Component Manual,
SBD- 10571 -P (R.6/99)
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements.
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06,
stats.
The following conditions shall be met during construction or installation and prior to occupancy or use:
• This system is to be constructed and located in accordance with the enclosed approved plans and with the
"Holding Tank Component Manual for Private Onsite Wastewater Systems" SBD- 10571 -P (R.6/99).
• A Sanitary Permit must be obtained from the county where this project is located in accordance with the
requirements of Seca 145.135 and 145.19, Wis. Stats.
Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with
the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats.
• Comm 83.52(3) The activities relating to evaluation and monitoring mechanical POWTS components after the
initial installation of the POWTS in accordance with an approved management plan shall be conducted by a
person who holds a registration issued by the department as a registered POWTS maintainer.
• Comm 83.22(7) - A copy of the approved plans specifications and this letter shall be on -site during
construction and open to inspection by authorized representatives of the Department which may include local
inspectors,
Owner Responsibilities:
• The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating
to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and
maintenance manual and/or owner's manual for the POWTS described in this appro al.
90.WiI.T.S.
Conditionally
APPRUO"VED
SHAUN R BIRD Page 2 7/8/04
• Comm 83.52(1)(a) - The owner of a POWTS shall be responsible for ensuring that the operation and
maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s.
Comm 83.54(1).
• Comm 83.52(2) - A POWTS that is not maintained in accordance with the approved management plan or as
required under s. Comm 83.54(4) shall be considered a human health hazard. In the event this holding tank or
any of its component parts malfunctions so as to create a health hazard, the property owner must follow the
contingency plan as described in the approved plans.
• The owner is responsible for submitting a maintenance verification report acceptable to the county for
maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized
in the POWTS.
In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should
conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review
shall relieve the designer of the responsibility for designing a safe building, structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the
installation, operation or maintenance of the POWTS.
Sincerely,
Fee Required $ 60.00
Fee Received $ 60.00
Gerard M. Swim Balance Due $ 0.00
POWTS Plan Reviewer - Integrated Services
(608)- 789 -7892, Mon. - Fri. 7:30 am to 4:15 pm
jswim @commerce.state.wi.us WiSMART code: 7633
cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544
s N �
Cover Pag �'Y °
� ®1
Shaun Bird
Bird Plumbing Inc.
1008 192nd Ave
New Richmond Wi 54017
715- 246 -4516
Date: 6/26/04
Owner: Roger Anderson
Location: Govt lot 3 S2 T31 N,R18W 1210 Cty Rd H Star Prairie
System type: Holding Tank
Manuals Used: Holding Tank Component Manual
Page#
1. Cover Page
2. Holding Tank Plot Plan
3. Holding Tank Cross ion
4. Maintance and Con ' ency Plan
Signature
License nu r 2269
DEPARTMENT OE COMMERCE
A ISIOA10f ET Y AND BUILDIVS
SEE GORRES NDENCE
PLOT PLAN
PROJECT Roaer Anderson ADDRESS 1210 Ctv Rd H New Richmond Wi 54017
Govt lot 3 S 2 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 6/27/04 BEDROOM 3
CONVENTIONAL AT -GRADE CONVENTIONAL LIFT HOLDING TANK XXX
MOUND SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE 3000 gallon LOAD RATE n/a ABSORPTION AREA none # of chambers none
Ilk BENCHMARK V.R.P. TO be determined ASSUME ELEVATION 100' Filter Zabel A -100
❑ BOREHOLE WELL *H. R. P. SW corner of ro er
P P tY
SYSTEM ELEVATION none
Tank is to be properly
bedded and provided
with lockdown cover
with approved warning
label
Ceder Lake
Property
Line
Property
Line
Area of seasonal flooding due to depression The grade where the
tank is be installed is
6' above current lake
10% elevation and the tank
slope will not need to be
anchored
HT Id tanks are to be �. 3. 33
Existing 3 pumped and buried Please note: a maintance path is
Bedroom to be built to access HT, also the
U� House manhole cover is to be put over
We the inlet of the holding tank
D WST
Scale = 1/4" =10'
Driveway
Area of filled driveway
P.
Cty Rd H
BOLDING TANK CROSS - SECTION
Approved Weather Proof
Yent Cap Junction Box
Approved Locking Manhole Cover
4" C •I• With Warning Label Attached
Vent Pipe
Minimum 12"
Final Grade
4" Minimum
f Approved Joint
18" Minimum
J A
Water Tight —°`
Seal Higha
Al a Ssi i.t;``tr" i
:: E_
S PECIFICATIONS New ICATIONS _- - _ _ _ _ i
TANK Exis 'n
Approved Join
Manu acturer• w/ C.I. Pipe
Blind-C.I. Tank Size: Ga lons Extending 3"
Plug Onto Solid So
ALARM Manufacturer:
Model Number: I/
Switch Type : s
NUMBER OF BEDROOMS
GALLONS PER DAY
3" of Bedding Under Tank
Owner's Name:�q
Address ;/ Z �� c
Legal Discripti d 3 f �
Township /Mu icipal,ity: --
County: .5�',�� x
PLUMBER /DESIGNER
Signature:
License Number:
Date:
HOLDING TANK MANAGEMENT PLAN
This Private Onsite Wastewater Treatment System ( POWTS) has been designed, and is to be installed and
maintained according to Co m 83,YVis. Admin. Code, the Holding Tank Component Manual (SBD- 10571 -P
611111999), and the /v I _ County Sanitary Ordinance.
1. This POWTS is designed to accommodate an estimated domestic wastewater flow of gpd.
2. The owner of this POWTS is responsible for system operation and maintenance, including all provisions in
the attached Holding Tank Servicing Contract and Maintenance Agreements.
3. Each time the wastewater in the second tank reaches a level of 12" below the inlet invert (at which time the
alarm will activate), the pumper listed in the current Servicing Contract must be called to empty the tank's
contents and dispose of them in accordance with NR 113, Wis. Adm. Code.
4. At each service event, the service provider should visually inspect the condition of the tank, risers and
manhole cover(s) and verify that the alarm system functions and manhole locking devices are present.
Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions
shall comply 1 with the county sanitary ordinance a nd C omm 83 and 84 Wis. Adm. Code.
coun 5. All service events or inspections of this POWTS shall be repo rted to the within 10 business da ys.
6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be
removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes
from this holding tank to the ground surface, including intentional discharges and discharges caused by
neglect, constitutes a failing POWTS and may result in issuance of correction orders or a citation by the
county or state.
7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue of a
person from the interior of the tank may be difficult or impossible.
8. In the event that this POWTS fails and cannot be repaired, a code compliant replacement holding tank may
be installed in the same location (a new sanitary permit is required for such a replacement). Connection to
municipal services would also be considered at this time if they are deemed available to the property.
9. If this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in
accordance with Comm 83.33 Wis. Adm. Code. .
10. If there is a problem with, or question about this installation, the following persons should be contacted: yJ `
a. Installer .... ....................... L"I
Phone:
b. Service Provider ................ e�— Phone:
c. County Zoning or Health Dept Phone:
11.
Project:
Transaction Number.
I
HOLDING TANK SERVICING CONTRACT
Contract Date
9 — — nd This contract is made between the
H %ding Tank Owner(s) Name(s) a 1 Pumper's Name —
A(16L 'b. A,4c-A e.- 1 .�
t IMP- 6
t
We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal descriptions:)
i 31 A) lFe,1J
,QT L 3 sec Si.v /� L 3 7# N U If o 'I'1 `J Qfi lis N LN G /l to �0l3
1. The owner agrees to file a copy of this contract with the local governmental unit that has signed the pumping agreement
required in Ch. ILHR 83.18(4) (b), Wis. Adm. Code and with the County of C/�►1
2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and
to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the access road or
drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the
pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper.
3. The pumper agrees to submit to the local governmental unit which has signed the pumping agreement required by s. ILHR
83.18 (4) (b), Wls
. Adm. Code and to the County, a report for the servicing of the holding tank(s) on a semiannual basis. The
pumper further agrees to include the folowing in the semiannual report:
a. The name and address of the person responsible for servicing the holding tank;
b. The name of the owner of the holding tank;
C. The location of the property on wtdch the holding tank is installed;
d. The sanitary permit number issued for the holding tank;
e. The dates on which the holding tank was serviced;
f. The volumes in gallons of the contents pumped from the holding tank for each servicing;
g. The disposal sites to which the contents from the holding tank were delivered.
4. This agreement will remain in effect unto the owner or pumper terminates this contract. In the event of a change in this contract,
the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the local
governmental unit and the County named above within ten (10) business days from the date of change to this service contract.
Owner(s) Name(s) (Print) 1 c's Signature(s) Subscribed and swom to me on this date:
/) 1
�
` 1 Todays Date
1
1 �
1
Pumper's Name (Print) 1 Pumperis Signature tary Public Signature
CA
A �' x
!�. Commission Expiration Pumper's Registration Number y / C6��
..�
Drafted by —'2 ��
LEGAL ST. CROIX COUNTY, WISCONSIN OLD TXSCR02
REAL ESTATE TOWN OF STAR PRAIRIE
COMPUTER NUMBER 038 - 1008 -95 -000 Parcel Number 2.31.18.24G
OWNER NAME: First ROGER D Last ANDERSON
PROPERTY ADDRESS: Hse # 1/2 PD -- Street Name -- Type SD Apartment
1210 CTY RD H
SECTION 2 TOWN 31 N RANGE 18W '/4160 1 /440
Line Description Line Description
TOTAL ACREAGE 0.000 PLAT LOT BILK
01 SEC 2 T31 N R18W PT GL 3 15 03 DEG W 33'; TH N 19 DEG W
02 (PARCEL D) COM SW COR GL3, 16 173.87'; TH S 75 DEG W
03 TH N 724.77', E 675.08' TO N 17 50.17'; TH S 19 DEG E 163.37
04 LN HWY H TO POB: TH N 16 DEG 18 FT; TH S 03 DEG E 33'; TH N
05 W 164.3' TO LK, S 78 DEG 19 86 DEG E 52.22'M/O/L TO POB
06 W 70 1/4 FT TH S 16 DEG 20
07 E 149.5 FT TO HWY R/W TH S 21
08 89 DEG E ALG HWY 72.99' TO 22
09 POB CONT .26A 23
10 ALSO COM SW COR SEC 2; TH N 24
11 01 DEG W 1320.'; TH N 89 DEG 25
12 E 1353.12'; TH N 0 DEG E 26
13 696.99';TH WILY 151.68'; TH S 27
14 86 DEG W 489.99' POB; TH N 28
F1- General, F4 -Prev. Parcel, F5 -Next Parcel, F7- Valuations, F8- History, F10 -Exit
i;
s,. DOCUMENT NO. WARRA^, ` DEED THIS [PACK R[,[RV[D FOR R[CORDINO DATA
STATE BAR OF WISCONSIN FORM 2— an
REGISTER S OFFICE
S J)0&
_ I I Redd for Record
Micha�l� C, -• Anderson and Connie - - R. - Mdereon h)csband and
li
>riit ... MAR 91995 t
I ............... .................... ........... 12:30 A.
I M
conveys and warrants to ... RQgk t.. D..A ndereQna .- d..R i- \_, -
ingiA- .F!}xAQA..... .I1� a f
............................... ............................... ................................ ............... Regl3terofDeseg a
....................................................................... ............................... I
the foliowin demribed real estate in S.t.... aiR . .....................Count
¢ Cz
State of Wisconsin:
I
Tax Pared No:
A arcel of land located in
P prt of Government Lot Three (3) of Section Two (2), Township
Thirty -one (31) North, Range Eighteen (18) West, Town of Star Praitie, further described
as follows: Commencing at the Southwest corner of said Section 2; thence North 01
West, 1320.00 feet along the West line of the Southwest Quarter (SW}) of said Section 2 to;
the Southwest corner of said Government Lot 3; thence North 89 ° 22 1 10" East, 1353.12 feet
along the South line of said Government Lot 3' thence North 00 ° 04'59" East, 696.99 feet
along the East line of said Government Lot 3 to the centerline of C.T.H. "H ", said center -'
line being a 1637.16 foot radius curve concave Southerly whose central angle measures 5 it
18'30" and whose chord bears South 89 ° 22'14" West and measures 151.63 feet; thence Westerly!
151.68 feet along the arc of said curve to the point of tangency; thence South 86 °42'59'• �I
West, 489.99 feet along said centerline, and the point of begianing :,f the parcel to be 1
described; thence North 03 °17 West, 33.00 feet to the right -of -way of said C.T.H. "H";;!
+thence North 19 West, 173.87 feet to a point 16 feet, more or less, from the water'E
edge of Cedar Lake, being the beginning of a meander line along said lake; thence South
75 West, 50.17 feet along said meander line to a point 16 feet, more or less, from
said water's edge, being the end on the meander line along said lake; thence South 19 ° 47'
22" East, 163.37 feet to said right of way of C.T.H. "H "; thence South 03 ° 17 1 01" East, ;�
+33.00 feet to said centerline of C.T.H. "H "; thence North 86 ° 42 1 59" East, 52.22, more or it
less, to the point of beginning. Including all lands lying between the meander line I�
described above and the water's edge of Cedar Lake lying between true extensions of the �tt
, easterly (N19 "W) and westerly (S19 0 47'22 "E) boundaries.
The above described parcel is a part of Lot I
This ....... U.Aot-........ homestead property. of Certified Survey Map -
(is) (is not) recorded August 18,. 1989 in Volume " 8 '• of"
Exception to warranties: S Certified Survey Maps, Yage2141, as Doc. No.
450697. Said parcel is being conveyed to sn f
adAoini g owner, and cannot e sold or
y co veye as a aeparate parcel
Dated this .......... ......1 ............... day of 6s.Y,r. .. .............. 18..95..
7. 1
}
t ................
(SEAL)
_(SEAL) ...... ..- I
1 ................................................ • ...
.......(SEAL) ... r...
................. • ... Connie ._R...Anderson ................
r
AOTBHNTICATION ACSNOWLRDOMBNT
Signature (a) ............................. ............................... STATE OF WISCONSIN
ss.
.............................................. ...............................
........ 81- .-i"XVU ............
County.
authenticated this ........day of ........................... 19...... Personally came before me this .... 14 ....... day of
......... ... .rr_4! ....................... 19.95... the above named
............................................................................
... _ Mt, aha,, a3.. .CA... AudaxsQA ..aad._OQnaist._Rx..._._.._...
• ._._..... _&"z6.9A ....................... .......................................
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not . ............................................................ ................._.._........................_._........._........_........__..-
authorized by J 706.06, Wis. StatL) to me known to be the person ............ who executed the i
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Document:+lumher/Plan I.D. No. HOLDING
�AA� AGREMAT 7' 6 8 5 4 :3
q This agreement is made between the government KATHLEEN H. WALSH
unit and holding tank owners . ' REGISTER OF DEEDS
ST. CROIX CO.. WI
Name d Return Address
�,,� A wtv--� RECEIVED FOR RECORD
/Val 07/12/2004 12:15PH
/JC--J 4 (Axi..-P, W/ S* /7
H OLDING T# NK AGREEMENT
Parcel identifier number (PIN Agreement Date REC FEE 13.00
_� 6tc TRANS FEE:
ZHolding Tank Owner's) COPY FEE
Govemme tal Unit r �,, y�,- CC FEE:
f � _ r eo PAGES: 2
We acknowledge that applicati is being made fons llation of (a) holding tank(s) on the
following property: (Provide legal land description. Use reverse side if additional space is needed)
it�o C"t i Il ¢ a l SL o2 -3��'� �' c`c Z . %3/�/ ,QfB n on4h�eprop�erty
A
�� rw�' @� t �a t, 7 L
E��fe ` T - Av W il� H _ — ,QL 4. !v: 7 Z 79` or that continued use of the existing remises requires that a holding tank be installe fort purpose of proper containment
W sewage.
Alto, the property carnet now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR S3, Wis. Adm.
Code, or Ch. 145, St the ats. -� �,
�7' C �� B �` to issue a sanitary permit for the above described property, we agree to do the following:
As e, inducement
1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the
holding tank properly serviced in response to orders issued by the governmental unit to prevent or abate a human health hazard as described in s.
owner by placing governmen
cing the charges o the tax bill as ent pet al assessment forcurrent servi es rendered. The charges will be assessed as prescribed by s.
66.60, Stats.
2. The owner agrees, pursuant to s. ILHR 83.18 (10), Wis. Adm. Code, to have a water meter installed in a new building or new structure. The water
meter shall be installed by a plumber authorized by the State to conduct such installations, with said installation complying with State regulations
and manufacturers specifications. The owner agrees to be finally responsible for the purchase, installation, maintenance, and repair of the water
meter, and agrees to allow the governmental unit to enter the above described property on a regular basis to read and/or inspect the water meter. or o
3. Owner agrees to pay all charges and cost r as to re prevent a ent or abate any human health hazard caused by the holding t The governmental unit
d
manner as es of
such a ma P owner do n
holding tank in notice. In the event the
shll notify the g to of notic
maintaining
r of an costs which shall be paid by the owner within thirty (30) days from the date tax roll as a special assessment
e owner n the P
shall not' th Y be laced o
�Y charges may p
caner specifically agrees that all the costs and g Y
' t 30 days, the o P
pay the costs within thirty ( ) Y provided b Y law. for the abatement of a humsln health hazard, and the tax shall be collected as P
provided b s. 146.20 (3) (d), Stats., agrees to contract with a person who is licensed under Ch. NR l wner , furt furthe a grees to file a
4. The owner, except s as p Y the g overnmental unit. Theo to
is re g i stration with g •
the holding tank serviced and to file a copy of the contract or the owne gi
copy of any changes to the service contract, or a copy of a new service contract, with the governmental unit within ten (10) business da from the
date of change to the service contract.
submit to the govern mental unit and the county
5. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who for the s to t of the holding tank. In the case of
ce with s. ILHR 83.18 (4) (a) 2., Wis. Am
re i semiannual basis a report ( accordan d governm unit and the county. The governmental unit
hall submit the report to the governor
registration under s. n the d (3) rt S or
tats. the owners P 'cafe that the
county may,enter upon the property to investigate the condition of the holding tank when pumping reports and meter readings may indi
holding tank is not being properly maintained.
6. This agreement will remain in effect only until the governmental unit responsible for the regulation of private sewage systems certifies that the
property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this
agreement may be canceled by executing and recording said certification with reference to this agreement in such manner which will permit the
existence of the certification to be determined by reference to the property.
7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit the agreement to the
register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be
determined by reference to the property where the holding tank is installed.
0 ner(s) Name's) - Please Print
Governm Unit Official Name - P ease Print Subscri and swom to before me on this date: �:
- �t ti e4se. /` 6 // tic
Not 'zed Owner's) Signature's) Governmental nit Oftici I Title - Please Print
Govern ntal Unit ial Signature My commission e 9
��1-- Personal information you provide may be used for sewn (Pnw, m)
Drafted by �SCONS�1l�
1�) 2614 P 473
I
♦ ;' _ + DOCUMENT NO. (� WARRANTY DEED TNM SPAC2 0999aV90 ,OR RtCO DATA I
STATE BAR OF. WISCONSIN FORM 2 -198111 . i
526 630 _
AEGISTER'SOFFICE
-- Sr. Mono.. WI
I� Reo'dforRecord
Micha!), C,, .... .. . ... .. .. . ... .. n onnie Andersop� „husband„ and i
wif # ........... .. .. ............: �) LIAR 91995
.:...:........ ..:....:. . ...................::•- :..:
convoys and warrants to I at 12:30 A.
... AttdAXaQna ..a..11lAB�s..FAXRQR..... �
Re94ter of De^rs t
............................... ............................... ........ ............................... .... i
.................................................................................. ............................... I ,
........................... ................................................ ............................... aaTunN TO
................................................................................. ............................... I
...................................................................... ...............................
the following desnribod real estate in .......9.t.... CAr:0.ix . ......................County, --
State of Wisconsin: '
Tex: Parcel No: ........................... �I
A parcel of land located in prt of Government Lot Three (3) of Section Two (2), Township
Thirty -one (31) North, Range Eighteen (18) West, Town of Star Prairie, further described
as follows: Commencing at the Southwest corner of said Section 2; thence Korth 01
I West, 1320.00 feet along the West line of the Southwest Quarter (SW}) of said Section 2 toil
the Southwest corner of said Government Lot 3; thence North 89 °22 East, 1353.12 feet
I along the South line of said Government Lot 3' thence North 00 °04 East, 696.99 feet !I
slong the East line of said Government Lot 3 to the centerline of C.T.H. "H ", said center
line being a 1637.16 foot radius curve concave Southerly whose central angle measures 5 11
18 and whose chord bears South 89 °22'14" West and measures 151.63 feet; thence Westerly
151.68 feet along the arc of said curve to the point of tangency; thence South 86 °42'59
West, 489.99 feet along said centerline, and the point of begianing of the parcel to be �\
described; thence North 03 ° 17 1 01" West, 33.00 feet to the right -of -way of said C.T.H. "H ";�
thence North 19'48'58" West, 173.87 feet to a point 16 feet, more or less, from the water'q
edge of Cedar Lake, being the beginning of a meander line along said lake; thence South
75 West, 50.17 feet along said meander line to a point 16 feet, more or less, from
said water's edge, being the end on the meander line along said lake; thence South 19 47
22" East, 163.37 feet to said right of way of C.T.H. "H"; thence South 03 °17 East,
33.00 feet to said centerline of C.T.H. "Il "; thence North 86 East, 52.22, more or
less, to the point of beginning. Including all lands lying between the meander line
described above and the water's edge of Cedar Lake lying between true extensions of the
easterly (N19 ° 48 1 58 "W) and westerly (S19 ° 47'22 "E) boundaries. I�
The above described parcel is a part of Lot I
This ....... 1.A.319t......... homestead property of Certified Survey Map
(is) (is not) recorded August 18, 1989 in Volumes " S.." of!
Exception to warranties: W Certified Survey Maps, Page2141, as Doc. No. !l
450697. Said parcel is being conveyed to an !
adAoiniAg owner, and cannot pe sold or i
r co veyed as a separate parcel.
D ated this ............ .... �......................... day of ........................ !?W9W!� .. ....... 19..95..
. .........................(SEAL) .. ..(SEAL)
• ................ l................. ............................... • ..klichaal..CA. Aada att.
.. ........... ............................... .........................(SEAL) :.l.r... ' 44AL) `
............ ............................... • ... CRAAie.. Ra.. AAdarIIAA ...........................
i
r
AUTB'NTICATION ACSNOW LRDOMBUT '
Signatore(s) .. ........................ ............................... STATE OF WISCONSIN
.............. ............................... ............................... ........ x...Jujaim ............ County.
authenticated this ........day of..... ...................1 ..... Person came before me this ....+fdr.......day of
........... .TYr ... .................. 19.95... the above named
..........................................•---... ..............................- i
. . Mi. tb,+ �, l9, h. �... �uotdaxt£ an ..and..�annla..R,�............ ,
• .. .. ....... . . ....... . AA4AZA. QA ................................ ..............................
TITLE: MEMBER STATE BAR OF WISCONSIN
(Ifnot�
................ ......................... .................. ........ ................................ ...............................
ssthosi2ad by ; 706.06, Wis. Stab.) to me known to be the person ............ who executed the
forego!fe instrument and adrnowled the same.
p_ ♦�TII INS DR BY
I» .. ...... .. .. .��.....�. ........
•.....�i'i,r, .A...SA,7. r. .. .......................
201 South Knowles Ave, P.O. Box 127 �
RR N�'g� C dBe; ... 4II t' 1 ................... _........... Notary Pdblie ..... It.,...0 s..................County, Wis.
(8�gnatnTell may 6e or acknowledged. Both My Commission Is permanent If not, state expiration
are not necessary.) dabs ..... � :�..� .......................... e�..) i
........... ,
•Naar d 0009010 ,Ipalof In any 0apadty sbould be typtd or priat,d bdew tb r mlMturoo.
WAXMAN" D=iD eT Ain SAM OF MWO Wisconsin L"al Blank Co.. Inc. � yy
FORM Na 2 —. 1952 Milwaukee. W=onsin i