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HomeMy WebLinkAbout038-1013-95-000 Wisconsin Department ofCgmmerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Buildir,7.Division INSPECTION REPORT M nitary Permit N (ATTACH TO PERMIT) !Z 52 GENERAL INFORMATION /f- o,l?4Z3 3s tatePl I G • 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: Klescewski, Karen Star Prairie Townshi 038- 1013 -95 -000 CST BM Elev: Insp. BM Elev: BM Description: / �^ � ` 166. a O?} , d (j a¢ / rO TANK INFORMATION ELE TIO DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic t / � � � Benchmark Dosing Alt. BM Aeration Bldg. Sewer 7.8g X 17 -�( Holding St/Ht Inlet " � 1 7. J TANK SETBACK INFORMATION St/Ht Outlet /�/ --- TANK TO �P /_ L fA WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ' r Z / 4— Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORM Manufacturer Dem d St Cover GPM I Model er esv�e IC J DH Friction Loss System Head TDH Ft Forcemain Le Dia. Dist. to wen SOIL ABSORPTION SYSTEM A)/,4- BED/TRENCH Width LengthZ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer. INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM JIl Header /Manifold Distribu • n x Hole Size x Hole Spacing Vent to Air Intake Pipe( Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil I L9 Yes 0 No ff] Yes R No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / /D Inspection #2: 4 .1 Location: 2365 W. Cedar Ln. New Richmond, WI 54017 (Government 3 T31 RI 8W) NA Lot 1 Parcel No: 03.31.18.36C 1.) Alt BM Description = J Qf `s 5�•� �2 0 ��`� "�-�` /h 2.) Bldg sewer length = Z r ytt(•i,,;,gG+�r�(� —� GuGP -Q� Imo- amount of cover = Plan revision Required ? Yes "_ No T Use other side for additional information. SBD -6710 (R.3/97) Date Insepctorure Cert. No. Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 iscons�n Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned.) Attach complet plans (to the cou nty copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size. County State Sanitary Permit Number ❑ Check if revi on to previous application P an I. D,�Number yz, S � d� 3 I. Application Information - Please Print all Information Lo tion: S(�yh2 WaJ Property Owner Name r ;/Ji7/4�/ ation ri7 r G7 f�G '► I i 1)4, K ,N, *Q (o ja Property Owner's Mining Address a Lot umber Block Number City, State / Zip Code Phone Number Subdivision Name or CSM Number AZ II. Type of Building: (check one) ❑ City 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Village Public /Commercial (describe use):_ 7 5 -� Down of f � ❑ State-Owned �E�/Y�rr/ < Nearest Road / 4� .� '/ r Parcel Tax Number(s) . III. Type of Perm (Che only one box on line A. Check box on line B if applicable) 3. 3 . ( 36 L A) 1. ❑ New 2. A 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only Existing System B) Permit Numb Date Issued 60 A Sanitary Permit was previously issued 1 0 QS r � IV. Type of POWT System: (Check all that apply) ❑ Non - pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ,JNdiolding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade / / C Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) Elevation VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks ❑ ❑ ❑ ❑ r ❑ ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Pi s Name (print) ( Plu r s gnature (nos ps): MP/MPRS No. Business Phone Number u is Address (Street, City, SM6, Zip Cod IX. Cou ty epartment Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuin Agent Signature (No stamps) J Approved ❑ Owner Given Initial Adverse Surcharge Fee) Determination -A �j p S L w� X. Conditions of Approval /Reasons for Disapproval: 1. The existing system was required to be abandoned per code requirements (Comm 83.33).�J 2. The $125 fee required for St. Croix County permit #0052 was applied to this application to fulfill the $300 Holding tank fee. SBD -6398 (R. 07/00) Safety and Buildings 10541 N RANCH ROAD HAYWARD WI 54843 TDD #: (608) 264 -8777 cons in www.commerce.s i www.wiscon isconsin.gov n.gov Department of Commerce Scott McCallum, Governor Philip Edw. Albert, Secretary November 15, 2002 CUST ID No.220527 ATTN.- POWTS Inspector ZONING OFFICE BYRON BIRD JR ST CROIX COUNTY SPIA 896 68TH AVE 1101 CARMICHAEL RD AMERY WI 54001 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 11/15/2004 Identification Numbers Transaction ID No. 809935 SITE: Site ID No. 653538 Karen Klescewski Please refer to both identification numbers, 2365 W Cedar Ln above, in all corres ondence with theagenc Town of Star Prairie, 54017 1 St Croix County NW1 /4, NW1 /4, S3, T31N, R18Wy FOR: Replacement holding tank, 3 bed room residence Object Type: POWT System Regulated Object ID No.: 882221° q i 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. �� The following conditions shall be met during construction or installation and prior to occupancy or use: , cc General Approval Conditions } • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Holding Tank Component Manual, SBD- 10571 -P (R.6/99)" • In the event this holding tank malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must insure that the operation, maintenance and monitoring duties as described the Holding Tank Component Manual are complied with. A copy of this information must be given to the owner upon completion of the project. • A Sanitary Permit must be obtained from the county where this project is located or other appropriate permit issuing agency in accordance with the requirements of Sec. 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. Slats. • The maintenance plan for this system must be given to the owner of the POWTS. • Note: County regulations concerning the prohibition of holding tanks may vary. Check with the local permit issuing agency. • Note: The servicing of POWTS holding and treatment components, including septic tanks and holding tanks, is required to be performed by licensed pumpers under chs. NR 113 and NR 114. Review Notes • Manhole cover or service port to be no more than 25' from service road or drive per Holding Tank Manual, Table 1. BYRON BIRD JR Page 2 11/15/02 Reminders • A meter shall be installed by a properly licensed plumber on the water system that adequately measures the amount of water used by the structure, excluding hose bibs and wall hydrants, which do not discharge into the sanitary system. • Anchor tank as necessary to negate buoyant forces per COMM 83.43(8)(g). • Materials shall conform to the requirements of COMM 84. • Abandon failing system per COMM 83.33. 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. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /instal lation/operation. 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 shal rpvide a copy of this letter to the owner and any others who are responsible for the installation, operation in mtenanc of the POWTS. Sincerel Fee Required $ 120.00 Fee Received $ 120.00 Balance Due $ 0.00 Patricia L Shan o POWTS Plan Reviewer ,Integrated Services WiSMART code: 7,633 (715) 634 -7810, Fax: (715) 634-5150, M -F 7:45 am - 4:30 pm pshandorf@commerce.state.wi.us cc: Leroy G Jansky , Wastewater Specialist, (715) 726 -2544 i PLOT PLAN -PROJECT Karen Klescewski ADDRESS 2365 W. Cedar Ln, NewRichmond Wi. 54017 NW 1/4 NW 1/4s 3 /T 31 N/R 18 W TOWN StarPrairie COUNTY ST. CROIX 11 -11 -02 3 MPRS Byron Bird Jr. 220527 BEDROOM DATE CONVENTIONAL IN -GROUN RESSURE CONVENTIONAL LIFT HOLDING TANK XXX MOUND SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE 3000 gal LOAD RATE ABSORPTION AREA # of chambers BENCHMARK V.R.P top of walk out doorway ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H,R,P Same as Bm SYSTEM ELEVATION to be determined i C0Nj ID�NGS F ON NC PL 10' B 1' 10' well , < � G 6'� 3 75 3 vent CedarLake W. Cedar 3 bed house 18 X54' B3 Ln bed B septic tank colapsed G —0 B2 B2 10' 5' Garage Driveway 10' HOLDING TANK CROSS- SECTION ',proved Vent Cap Weather Proof Junction Box 4., C.I. Approved Locking Manhole Cover Vent Pipe With Warning Label Attached l Minimum 12" r I /Final Grade t /Final Minimum , l � I Approved Joint ' f ' - - -- 18" Minimun• Water Tight --4- Seal High Water ' Alarm Switch SPECIFICATIONS New Existin istin � 9 -_ - - -` - / Approved Manufacturer: �� h/ w/ C.I. Pipe Blind C.I. Tank Size: • 2 d al Gallons Extending 3" Plug r Onto Solid ALARM Manufacturer: � d , Model Number: , Switch Type , NUMBER OF BEDROOMS GALLONS PER DAY ,5 3" of Bedding Under Tank r Owner's Name: Address: Legal Discript10n: T /Municipality: County: � -- - PLUMBER /DESIGNER Signature: License Number: Date / �/ r 4p6 #@ ♦� *�P�!► �� T ®� ®� -V ®�T Pnl®ii.� �-Aii�P 5�- ��T + -0��� Byron Bird Jr. Plumbing Inc. User Manual Owner= Location l4 li'GrJ 1 /4 STN /RW Township fur r+ u ( ,,�Lot -- Subd name or CSM County :57 ' ,A The owner is responsible for operation and maintenance of the system, locking device, alarm, and must maintain an access road. The county is responsible for inspection of the site before, during, and after construction. The holding tank must be serviced by a licensed pumper. An alarm system is installed to activate when the tank is 90% full. At the time of the servicing, the service.provider files a report with the department or designated agent. A remote reading water meter must be installed on the water supply of the facility that discharges into the holding tank. Phone Number Installer Jam. No. Pumper ©r No. ��i.� Health Authoriy — z" N0. P e ;� - -O-W�c Contingency Plan: If the tank were to fail, the owner shall have the tank pumped and properly abandoned by license provider. The tank than must be replaced by a licensed Master Plumber or Restricted Master Plumber: r County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN In accord with 15.04 St. Croix County Sanitary Ordinance ZONING OFFICE Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Law. S. 15.04(1)(m)l Hudson, WI 54016 -7710 D Z. 3 !�a o (715)386 -4680 Fax (715)386 -4686 Attach complete plans for the system on paper not less than 8 -1/2 x 11 inches in size. County Sanita Permit # ❑ Check if revision um to previous application Z 1. Application Information - Please Print all Information Location: Property Owner Name 1/4ek Se� Property Owner's Mailing Address / Lot ber Block Number f J r ! C ity, Zip Code - Phone Number Subdivision Name or CSM Number II Ty of Building: (check one) Mity ❑Village own of 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Public/Commercial (describe use): ❑ State -owned Neare t Ro ` d �r l� il. Type of ermit• (Check only one box on line A. Check box online B if applicable) : �� �l Parcel Tax Number(s) 3 3� 13(D L A) 1�Repair 2.❑ Reconnection 3. ❑Non - plumbing .[]Rejuvenation Sanitation B) Permit Number " 7 Date Issued ❑ State Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) • Non- pressurized In- ground C] / Mound ❑ Sand Filter ❑ Constructed Wetland • Pressurized In- ground u Y Holding Tank [] Single Pass ❑ Drip Line • At -grade - K Aerobic Treatment Unit ❑ Recirculating ❑ Other V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals. /day /sq.ft.) (Min.rinch) Elevation A. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass � Tanks Tanks a ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ II. Responsibility Statement I, the undersigned, assume responsibility for repair/ reconnencbon /rejuvenationrinstallation of non - plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the install n of non- plumbing sa ' ion s m. Plu s Name (pn Plumber i ure (no stamps): MP /MPRS No. Business Phone Number L _0 Plu is Address (Street, City, State, Zip C e ll VIII. County Use Only Disapproved Sanitary Permit Fee Date Issued Issuing A ant Signature (No stamps) Approved Owner Given Initial Adverse /7 Determination / Z ✓ < �v IX. Conditions of Approval /Reasons for Disapproval: 1. The existing system shall be abandoned per code requirements (Comm 83.33). 2. The service road shall be maintained to within 25 feet of the manhole as specified in the state approved plan. 3. This County permit was issued as an emergency. The state approved plans should be received soon and a state application will then be submitted. The fee for this permit will be applied toward the state application fee. PLOT PLAN PROJECT Karen Klescewski ADDRESS 2365 W. Cedar Ln, NewRichmond Wi. 54017 NW 1/4 NW 1 /4s 3 /T 31 N/R 18 W TOWN StarPrairie COUNTY ST. CROIX MPRS Byron Bird Jr. 220527 DATE 11-1 -02 BEDROOM 3 CONVENTIONAL IN- GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK XXX MOUND SEPTIC TANK SIZE LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE 3000 gal LOAD RATE ABSORPTION AREA # of chambers IL BENCHMARK V.R.P. top of walk out doorway A SSUME ELEVATION 100' ❑ BOREHOLE O WELL *H.R.P Same as Bm SYSTEM ELEVATION to be determined PL 10' B1 10' well 75' 3 3' ° vent I I CedarLake 5' W. Cedar 3 bed house 18 X54' B3 Ln bed By septic tank colapsed ) — � nl B2 ' 10 � 5 Garage Driveway 10' nr Wisconsin Dtapa of Commerce SOIL EVALUATION REPORT Page of 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 jrD 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. -- Please print all information. Re , ed y Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location 1 -4—l are n � jG� � Govt. Lot 114 � /4 S T N R l 0 Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# Ict S to Zip Code Phone Number ❑ City ❑ Village ' gTown Nearest Road V1 ( /D hf � - ❑ New Construction Use;,® — Residential / Number of bedrooms Code derived design flow rate GPD We placement T p ❑ Public or commer ial - Describ Parent material _ ��^r� l �i �S Flood Plain elevation if applicable General comments and recommendations: Al ill I 4 /( F-/1 Boring # E] Boring a 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 /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 !( / d 7 Boring # ❑Boring L� Pit Ground surface elev. l a y ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz 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 CST Name (Plea rint) 1 ignature CST Number Address Evaluation Conducted Telephone Number SBD -8330 (R07 /00) Property Owner ., 0 Parcel ID # Page of Boring # E] Boring / [Z Pit Ground surface elev. �9- (r ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I 'Eff#2 F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 F I I I F] Boring Pit Boring # E] Boring Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz 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) ~ Soil Test Plot Plan Project Name Karen Klescewski Byrq�rr-Bird Jr. Address 2365 W. Cedar Ln. NewRichmond Wi. _ 54017 C M #220527 Lot ------ Subdivision -- ---- --- Date 11/11/2002 County CROIX NW 1/4 NW 1/4 S 3 T 31 N /A W Townshi S tarPrairie [] Boring Q Well PL Property Line# Alt. BM ,BM or VRP Assume Elevation 100 ft top of doorstep System Elv. 95.5 H.R.P. same as BM PL 10' B 1' 10' 50' 75 ° vent CedarLake 5 ' W. Cedar 3 bed house 18 X54' B3 Ln bed :B septic tank colapsed st �B2 5' Garage Driveway PL i HOLDING TANK SERVICING CONTRACT Contract Date This contract is made between the Holding Tank Owner(o) Name(of and Pumper's Name e, < e We acknowledge the installation of (a) holding tank(s) on the following property: (Provide legal descriptions:) A arose/ - /an l oaa - f over m li "Sermon (3 h 2& 3/ bA I RaM a r K Ce Act %- L.nke t, h e ire The td, me.' oif �iu f L6* -- -.9 -- — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — 1. The owner agrees to file a copy of this contract with the local governmental unit that has signed the pumping agreement required in Comm 83.52(1)(c)1. Wis. Adm. Code and the approved Holding Tank Component Manual. This agreement will also be filed with the St. Croix County Zoning Department. 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 that has signed the pumping agreement 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 following 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 which 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 volume 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 until the owner or pumper terminates this contract. In the ew nt of r. change in this contract, the owner agrees to file a copy of any changes to this service contract or a ,opy r f a new service contract with local governmental unit and the County named above within ten (10) business days from the date of change to this service contract. OwnerkV Name(s) (Print) Owner' Signature(s) �Ljbscribed and sworn to ine on this date: r ignature o Karen J. Klescewski Kl�sCe``�slC` November 17 , 200 1 -4 _ � Todays Gate • Commission Exp:`1 /2/2003 Pumper's Name (Print) Pumper's Signature Notary Public Signature Pumper's Registration Number Commission Expiration r i �o 0 C O A Z C7Z Z ic t G m a Q O z 0 �'`' om z `� m m Q. 0 f.'0 F'- Q m .m0 C ..m O C C W O Z W a m is b o a a Z IL > c �o '_ o ro ? ._ a c a : o c " s. m U O mom c oarn - of Z` om W c c o 12 o c a Z om v E o S my W ui V co Q2 N ¢ �■ V C a € N E v n N °- N O .0 c c ¢ °c �c(A c mo p >K-0 1 m U �x = � c= z V C U w • ^� �_ •m C O N O _ C y j O y O p. 7 m t N CL !Q O m c3 m mm E 3'.� W C' w -� `o a� m C 3 c o Q c F" Q N O d Q N y m ^ �+ m W m L ro;r t m L w U m m = m 0 = O aci H m ►- m E m m W H z LL W Z tiJ 0 u0 W Z H V} o 0' 00 U) m (1) J Qco • LL ❑ z o z z h1 z cn = Z W en o 0 ' U ¢ o �_ O 4 w ~ x ° ti U w m U ' Q } a� 0 X 01-0 0 w LL o w w O • w 5 z Q U) Slate Bar of Wisconsin Form 3 — 1482 550612 is QUIT CLAIM DEED DOCUMENT NO. VOL 12dZPACE57H 1 1 fi EV, — - — - -- - SL CMCG( CQ., 1 171 It P.ra !:r Escx! ,i John E. Rlescews ACT 9 1996 at 10:00 , AI quit - claims to Karen T- _Kl escew sk; �1;�.•t,. `'; 1�L4:1. i' the followin described real estate in St- Croix County, j! __ .._.� THIS SPACE RESERVED F R DATA State of Wisc0lBin; ii NAME AND RETURN ADDRESS Timothy J. O'Brien P. O. Box 50 New Richmond, WI 54017 a i! 038- 1013 -95 i{ (Parcel Identification Number) A parcel of land located in Government Lot "1', Section Three (3), Township Thirty -one (31) North, Range Eighteen (18) West, described as follows: Commencing at an iron pipe stake located on the high - water mark of Cedar Lake where the same intersects the South line of said Government Lot "1 "; thence North 50 West on meander line of t�4 Cedar Lake for 120 feet; thence North 57 ° 11' West on meander line for 200 feet to the point of beginning of this description; thence South 39 °52' West for 165 feet; thence North 50 West for 100 feet; thence North 39 °52' East for 165 feet; thence South 50 °08' East for 100 feet ` to the point of beginning. TOGETHER WITH all land between meander line and Cedar Lake, and ,.i TOGETHER WITH access road from above parcel to Town Road. � p I : d II �i This is homestead property. i (is) (is not th i - 4 ' II Dated this r i• r U.- 2047P 341 696491 KATHLEEN H. MALSH REGISTER OF DEEDS ST. CROIX Co., MI RECEIVED FOR RECORD Document Number Document Title 11/14/2002 12s10PM St. Croix County EXW : Holding Tank Agreement REC FEE: 11' TRA COPY FEE: 2.00 tate Plan Transaction Number - CERT COPY FEE: PAGES: 1 _a ven J >�(eseecJ� Name - (Owner) Typed or printed being duly sworn, states, under oath, that: 1. He/she is the owner /part owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume IQa a Page Document Number$SQgW St. Croix County Register of Deeds Office: Recordiric Area Name and Return Address A parcel of land located in the '/4 of the _'/4 of Section 3 �Qr :;r, Ae of T N - R W, Town of �S7`a r f a r r r . c_ , St. Croix County, Wisconsin, being duly described as follows (include lot no. and 401S �I eQ r 1-4 r? � subdivision/CSM or detailed legal description): t7 y� 38- ors - 9s =O0d Agreement Date: /� Parcel Identification Number (PIN) We acknowledge that application is being made for the installation of (a) holding tank(s) on the above described property or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private onsite wastewater treatment system as permitted under Ch. Comm 83, Wis. Adm. Code, or Ch. 145, Wis. Slats. As an Inducement to the county to Issue a sanitary permit for the abov:j- described property, we agree to do the following: 1. Owner agrees to conform to all applicable requirements of Ch. Comm 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 or the Department of Commerce to prevent or abate a human health hazard as described in s. 254.59, Slats., the governmental unit (Town) may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.0703, Stats. 2. The owner agrees, pursuant to s. Comm 83.54 (2), and Comm 82.40(3)(e), Wis. Adm. Code, to have a water meter installed in the structure. The water meter shall be installed by a plumber authorized by the Depalment of Commerce to make such installations, with said Installation complying with State regulations and manufacturers specifications. The owner agrees to be financially responsible for the purchase, Installation, maintenance, and repair of the water meter, and agrees to allow the governmental unit or the Department of Commerce to enter the above - described property on a regular basis to read and /or inspect the water meter. 3. Owner agrees to pay all charges and costs incurred by the governmental unit or county for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. The governmental unit shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. 4. The owner, agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have the holding tank serviced and to file a copy of the contract with the governmental unit. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service contract, with the governmental unit within ten (10) business days from the date of change to the service contract. 5. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit to the county on a semiannual basis a report detailing the servicing of the holding tank. The governmental unit or county may enter upon the property to investigate the condition of the holding tank when pumping reports and meter readings may indicate that the holding tank is not being properly maintained. 6. This agreement will remain in effect only until the county office responsible for the regulation of private onsite wastewater treatment systems certifies that the property is served by either a municipal sewer or a private onsite wastewater treatment system that complies with Ch. Comm 83, Wis. Adm. Code. In addition, this agreement may be cancelled 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 sub rljls agae9ment to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit thk eoof the, agreement to be determined by reference to the property where the holding tank is installed. •' C•(/N,.•. p Owner(s) Name(s) - Please Print Subscribed and sworn to before me on this date:{ Signature of: Karen J. Klescrvt5'k>«?''S { �a Y'l° lrl. � K le se a wsl( )V o • ��. ; , November 77; 24?02., alx ' . •' n . Notarized er's Signature Notary ry Public JC �� C C A 5 � Q.v Commission Exp:1/2/2003 Governmental Unit Official Name, Title - Please Print My Commission Expires f o ph , Mo NdOl Su er v 1 0 &: Governmental Unit Official Signature Drafted by: I j V / An 1) f - �f'I�eselecvs� � Perso al information you provide may be used for secondary purposes [Privacy Law s. 15.04(1)(m)) "THIS PAGE IS PART OF THIS LEGAL DOCUMENT— DO NOT REMOVE" This Information must be completed by submitter: document title. name & return address. and PIN (If required). Other information such as the granting clauses, leagal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document. Note: Use of this cover page adds one page to your document and $2.00 to the recording fee. 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