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HomeMy WebLinkAbout038-1209-70-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 430114 0 GENERAL INFQRMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 4so& Permit Holder's Name: City Village X Township Parcel Tax No: LeQue Builders LLC I Star Prairie Township 038 - 1209 -70 -000 CST BM Elev: Insp. BM Elev: BM Descri tion: Section /town /Range /Map No: /( Z) /l�a-a �� � / v � 13.31.18.1135 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic \ Benchmark M kt � /05, D �` Dosing (/v (� Alt. BM L* 3.3 lozl Aeration Bldg. Sewer JGJ S Holding SVHt Inlet 7o TANK SETBACK INFORMATION SVHt Outlet G / t 3 0 - 3 -4 TANK TO P/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic n I ) r f,4 Dt Bottom v Dosing - -- -- Hea r /Man. " 'r 3 Aeration Dist. Pip 7- 3 X17. 3 I Holding Bot. Syste t q v (, . f " PUMP /SIPHON INFORMATION Final Grade S�3 Ob' Manufacturer Demand St Cover 2 GPM 3 ottf� y /60'•73 Model Number /� r --, TD H Lift Frictiop L System Head TDH Ft Forcemain [ Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM 7 S Ck_ BEDITRENCH Width �� r Length t No. Of Tr ches PIT DIMENSIONS No. Of Pits Inside Dia. liquid Depth D ENSIONS IM ' 1 b � SETBACK SYSTEM TO / P/L BLDG WEL LAKE /STREAM LEACHING Man to er: INFORMATION C Ty Of System: / t ) ' UNIT del Number: Z 91MIBUTION SYSTEM j H:e;dter/ an i old Distribution h f THole Size j xH ole Spacin Ve to r Intake Pipe(s) 17 h Dia Len th Di a Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only s f Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center .� Bed/Trench Edges Topsoil t1 � _� Yes [! No COMMENTS: (Include code discrepencies, persons present, etc.) Inspec' #1: d- / 0 Inspection #2: Location: 1334 212th Ave Star Prairie, WI 54026 (N1/2 SW1 /4 13 T31N R18W) Northgat L 4� �) Parcel No: 13.31.18.1135 1.) Alt BM Description = 10 i 2.) Bldg sewer length =7- � s - amount of cover = (g ( 2.09 " ' - v f 4 4 �i Vtllt�lJ QhP l_ °'t 4 �� �� (ob Plan revision R Yes o f __ —_ - - \ -- - Use other side for additional information. t SBD -6710 (R.3/97) Date Insepctor's ignature Cert. No. Safety and Buildings Division County 1*2 an 201 W. Washington Ave., P.O. Box 7082 sconsin Madison, WI 53707 - 7082 Sanitary Permit Nu her (to be fi lled in by Co.) Department of Commerce (608) 261 -6546 3 D ' I � Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.2 1, Wis. Adm. Code, personal information you provid maybe used for secondary purposes Privacy Law, sl5.04(1 xm) Project Address (if different than mailing address) I. Application Information - Please Print All Information f ? ° , >^ /� 7 ai a� AU s Pro perty Owner's Name Parcel # Lot # Lr Block # ¢� ^; N t6 `" 0 T - 1ZO9 - ie - C i135� Property er's Mailing Address Pro , rty Location V 10 '/., '/4, Section City, State Zip Code i -V 5 o I s a 7 3 curt II. Type of Building (check all that apply) T � N; RE o w QA $ r ,6 ` Subdivision Name CSM Number K1 or 2 Family Dwelling - Number of Bedrooms ❑ Public/Commercial - Describe Use t ❑State Owned - Describe Use � ❑City OvIgmrownship of r Q, III. Type of Permit: (Check only one box on line A. Complete line B if applicable) i A. � Iew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System 13 ❑ Permit Renewal ❑Permit Revision 11 Change of 11 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all th apply) 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 ❑ Leaching Chamber ❑ Drip Line vet -less Pipe ❑ Other (explai V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Requ red (sf) rspersal Area Pro ed if) rem Blevation� c7 (P a o r VI. Ta k Info Capacity in Total Number Nfanufacturer Pref Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New I Existing r Tanta Tanks -6 ptic Holding Tank ®O c r Aerobic Treatment Una Dosing Chamber VII. Responsibility Statement- I, the undersigned, ssume respo sibility for inst of the POWTS shown on the attached plans. Plumber's N Z t) P s cure M PRS tuber Business Phone Number `t Is S 1 PT umber's Address (Street, City, State, Zip i VIII. County /De artment Use Onl Approved ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued I urn gent Signature Stamps) Surcharge Fee) ❑ Owner Given Reason for Denial 22 S r Z 3 IX. Conditions of Approval/Reasons for Disapproval a,,,,Q Attach complete plans (to the County only) for the system oa paper not ins than 81/2 x 11 Inches In size SBD -6398 (R. 08/02) I a`r Q v1. I � • i I I I , � ff oo._ •� ST; Coo IX i I I y I cam, I I - I : : �I I •�. `9Of_ � I I , i I ; : I I I , : I - I I I � i r _ LA 4(o X�.. 1-17 ILI �. a lr b I I ! I I ; � I : _ i I j 1 r I _ I I i : -- I i I I I ' : i I i a� IL 4 '14 Aw•2. 1 �Or 101 sc�M•0✓`S zt lIlt S Stir )W o38 -lam ©OD �, 5 .4:c/a P(OO �.as�•s STCro �,►C 5� sa�� a 1- p 3 T �`r' r 7 l� 63 Oj 16 33, o DO �r _. nr►r&5w►w►► v�,�ua►nw►c w u►►x►ar►►r, S t j I L AMU *11 C G V A L U A I .I U IV M t r V M 1 rap - I of I ` Labor and = Relations Weim 6 166" i 6uildr►96 in accord with ILHR 83.05, Wis. Adm. Code Attach complete site plan an paper not lose than 8112 x 11 inches in size. Plan nwst include, but FPARCG;E . Cra not limited to vertical and horizontal reference point (BM), direction and % of slope, scale -or dimensioned, north arrow, and ration and distance to nearest road. 5 APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION GOVT. LOT NE 114 SW V0 13T 31 AR 18 fides) W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 1416 Third ST. CITY, STATE ZIP CODE PHONE NUMBER 45 TY ILLAGE TOWN TNEARESTAW HudeM, WI. 54016 (715)386 - 3674 StU a3 i f i NOW Construction use f . Residential f Number of bedrooms 4 ( Addtion to ewis" buil ft t l f) Public or oomoordal dewri Code derived dail9► ftw _. Wd Rwwff ended design► loading rate _ bed, Abso p*m area required '858 bed, f1 750 -- trench, 82 kb*ntsn design WIM rate -- a — bed, bed, DpdW.__.A_ renM, 9pdW Reoontrrlended VOW" WINN 010ft"O 96.65 a (as referred to site plan benchmaN Additional design / she aoWderatiorts na Parent material Flood plain eletrgm, N apocable _ na R I s : W4R"Q PRESSURE ar GAaoE SVSTGN W i s L Ha otrlG TAPNC u�ia GdS ❑u [as 0 WS ❑ u a s C}Ll as Ou 0S au SOIL DESCRIPTION REPORT Boring Horiz Depth Dominant Color �1� Texture structure ture Go vWenoe Borrdwy Roots GPI in. Munson Qu. Sz. Cont Color Gr. Sz. Sh., Bed 1>tlndl l 1 2 12 -26 10 r Y4 rJOW si mfr uw Uf .4 1.5 Ground .7 .8 elev. 99. *l. �C aa- DOW U i, ' IBM Remarks: Boring # i • C .3 . Ground rev. none _ 10 it. j / j S i br 84 ►► Remarks: CST Name: -- Please Print Gary L. Steel phew: 715 - 246 -6200 Aridness: 1554 2W&L Ave. Rkbmo 17 Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of _'3— Laoor arid.HUman Relations Division 61 Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Croix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 038- 1055 -10 APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION R IEW BY DATE PROPERTY OWNER: PROPERTY LOCATION Greenwood Enterprises, Inc. GOVT. LOT NE 1/4 SW 1/4,S 13T 31 N,R 18 kor) W PROPERTY OWNER':S MAILING ADDRESS LOT # I BLOCK # I SUBD. NAME OR CSM # 1416 Third ST. 45 na NorthGate CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE KrOWN NEAREST ROAD Hudson, WI. 54016 h15)386 -3674 Star Prairie 214th Ave. ] New Construction Use [ Residential / Number of bedrooms 4 [ ] Addition to existing building ] Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate _ .7 ed, gpd /ft gpd /ft Absorption area required 858 bed, ft2 750 trench, ft Maximum design loading rate .7 gpd /ft a_ trench, gpd /ft Recommended infiltration surface elevation(s) 96.65 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable for stem ®S ❑ U ®S ❑ U ® S ❑ U I& S ❑ U [2 S ❑ U ❑ S �U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft Boring # Horizon in. Munsell C lu. Sz. Cont. Color Gr. Sz. Sh. Be6 0 10yr 313 none I 2msbk mfr QW if .5 .6 2 12 -26 10 r 4/ none sici msbk mfr QW 11f .4 .5 Ground 3 26 -84 7.5 r 4/4 none cos 0sa ml na na .7 .8 elev. 99.7 Depth to limiting factor +84 Remarks: Boring # 1 0 - 10 r 3/3 none 1 2msbk mfr CrW if .5 .6 2 2 9- 10,yr 4 / 4 none mfr QW if .4 `:.5 Ground 3 .21-29 •3 elev. . 4 29 -84 7.5 m .8 10 ft. r Depth to limiting _ YEL factor +84 .. ST CROIX Remarks: l' CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 j ZONING OFFICE Address: 1554 200th. Ave. w Richmo d I 54017- ` ti Signature: Date: 11 - - CST Nu1Y4be'& rA0 298 PROPERTY OWNER Greenwood Enterprses SOIL DESCRIPTION REPORT Page -2-,,of _ PARCEL I.D. # 038 - 1055 -10 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITirench ..3...> 1 0 - 12 10 r 3/3 none 1 2msbk mfr gw if .5 .6 2 12 - 10 r 4 4 none sici 2msbk mfr gw if .4 .5 Ground 3 22 -30 10 r 5/4 c2d 7.5 r 5/6 sil lcsbk mfr gw na .2 .3 elev. 1 4 130-84 7.5 r 4/6 none cos OSQ ml na na .7 .8 Depth to limiting factor +84 y � Remarks: Boring # 1 0 -12 10 r 2/2 none 1 2msbk mfr gw if .5 .6 2 12 -28 10 r 4/4 none sici 2msbk mfr 9w if .4 .5 Ground 3 28 -84 7.5 r 4/6 none ms os ml na na .7 .8 elev. 100.2. — Depth to limiting factor +84 1 , Remarks: Boring # 1 0 -12 10 r 2/2 none 1 2msbk mfr g if .5 .6 5 2 12 -28 10 r 4/4 none sici 2msbk mfr gw if .4 .5 Ground 3 28-84 7.5 r 4/6 none ms osg ml na na .7 .8 elev. 1 Depth to limiting factor +84" Remarks: Boring # Ground elev. j ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel Greenwood Enterprises, Inc: 1554 200th Ave. CSTM2298 NE SWj' S13- T31N -x18W New Richmond, WI 54017 MPRSW -3254 town of Star Prarie (715) 246 -6200 lot #45- NorthGate This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of the test may or may not be as shown as permanent lot lines were not established at the time the test was conducted. N 1 " =40' BM.= top of 1 pvc p ipe C el. 100 Alt. BM.= top of 1" pvc p ipe C el. 100.10' ` N Y r 0 Gary L. Steel 11 -5 -98 EZ • ►*. iRw ►� '. J * i► ► T *. t 2, �.f�L5 w`* .� tia. Ri 1 v* * ** • r• V wi ' R i►* =! 1 1! '" j i!2 Circ. vv *. *s ►i 1`w'liie 7i` wRrgt * ♦ R *iRi iiiii ** ♦lR1t�:R f 36tt 'Void ems„- I)tA. (typ,.) 010, of 4_ pq. - 1523 h.l 4 Im IQ EL � 4W ft ° 3.F1•(.�Su�� � �t�tn Q,A. ttf centar Bottom iR �dsca '''Oid wium in ag orcrnacr (( Total Sail fat 2.00 ?.00 1 1.I •3.ii . ( 6 farC Art1 + ^ � M! " 5,14SQ. U.U. oraytsii{ 1i t QmIt1 j , 4z2 ft Void I+tim 12 411111 t 1 11_ " ^� 04 "i* t0intim 3. � 3, taf — ' � P rojected Tr (12att8j `.57a> 901 W eaN Area Ol� aiYR1C Sidewall "right - 12 ;n. ti 1t t bosom � � 2 � 2.00 }'oai vqj t2is�ri F2 R ) - 3,rp ` � - 6 = 3 € l 1 1 za t3 " 0 : s ft' Sq. Ft. Total v at 1461 bottom corm { to of voce volume �tweeo 11 Projected Treac6 Area $� pf Ga ore wti 0.117 + 0, 42z s 0.901 108 C) " -dam) 0.2 1 d pp� 26 x to v EPS Aggregate Trench SYstem EzI 203H r� R ' ndustrial Group � Ojv 65 Industrial park Rd { 0akl0nd. TN .18060 1 • POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pa of tiI-E INFORMATION SYSTEM SPECIFICATIONS Owner S� n`a Tank Manufacturer W " ❑ NA Permit # ? j l7 / Septic ❑ Dose ❑ Holding Vol. iJ gal DESIGN PARAMETERS Tank Manufacturer ❑ NA Number of Bedrooms 3 ❑ NA ❑ Septic ❑ Dose ❑ Hold Vol. gal Number of Public Facility Units ❑ NA Effluent Filter Manufacturer ❑ NA Estimated (average) flow O gal/day Effluent Filter Model 100 Design (peak) flow = (Estimated x 1.5) s - 0 ga l/d ay Pump Manufacturer NA Soil Application Rate aifda /ft= Pump Model Standard Influent /Effluent Quality Monthly average* Pretreatment Unit!A Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel (liter ❑ Peat Filter Biochemical Oxygen Demand (SOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS► 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Manufacturer Biochemical Oxygen Demand (800 530 mg /L Dispersal Cell(s) 0 NA Total Suspended Solids (TSS) 530 mg/L E3 NA Al In- Ground (gravity) ❑ In- Ground (pressurized) Fecal Coliform (geometric mean) 510` cfu /100ml ❑ At -Grade ❑ Mound Maximum Effluent Particle Size Y in dia. ❑ NA ❑ Drip -Lipe ❑ Other: Other: O NA her. ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other. ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency 0 month(s) Inspect condition of tank(s) At least once every: 3 ar(s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one - third (Y) of tank volume E3 NA ❑ When the high water alarm Is activated Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA earls) Clean effluent fitter At least once every: months) ❑ NA year(s) )aspect pump, pump controls &alarm At least once every: ❑ month(s) ❑ NA ❑ earls} Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA a eer(s) Other: ❑ month(s) At least once every: ❑ Yeer(s) 13 NA 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 (pumper). 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 a 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 treatment tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (21021 I Page - �L — of ce of painting products, solvents or other START Up AND OPERATION of the POWTS check treatment tank(s) for the presen a the soil dispersal rretl (s). if c h e micals that may impede high concentrations are detected For new construction, prior to use and /or damag the treatment process avail b a septage Servicing operator Prior to use. have the contents of the tankls) rem soil conditions are fro2en at the k►fittrative surface. System start up shat riot occur when ma y fill above hi hwater leve. When Power is restored the excess norrnai ls g in the backup or surface extended power outages Pump t real catt s() in one large dose arid may overload them a Sep ag $ervicing Operator prig to the d'►spe tank removed Y the pump wastewater will be discharged to have the coMer► to of the PUMP discharge of e ffluent. To avoid this or contact a Plumber or POWTS Maintainer to assist in manually open to restoring power to t e ffluent ► Pump tar►k. ver, or otherwise act, the area the cowztrots to restore I mss, Do not drive of park o disturb or come Do not drive or Park vahtcles over tanks and disperse absorption area. the life of the within 15 feet down slope of �y �� or at-grade soil may improve the Performance and prolong from the wastewater strewn degreasers: dental floss: diapers; disinfectants: fat; Reduction or elimination of the following curette butts; condorr►s; cotton swabs: � herbicides; meat scraps% medications', oil; pOW'TS: antibiotics; baby wipes: peelings; gasoline; WOO"; foundation drain (sump pump) discharge: fruit and vegetable water softener brine- products; pesticides; sanitary napkins; tampons; painting p ABANDONMENT anently taken out of service the follow slaps shall be taken to insure that the sys tem is When the POWTS fails and/or is perm Wisconsin Administrative Code' property and safely abandoned in compliance with chap ed and the 8 bandoned pipe openings sealed. p shall be disconnect disposed of by a Septage Servicing Operator. • The contents of all tanks and pits shall be removed • AN piping to tanks and p and property its shall be excavated covers removed and the void space filled with and removed or their • After Ping t and p p` pun si! tart mart solid material. soil, gravel or another ' compliant CONTINGENCY PLAN aired the following measures have been, or must be taken, to provide a code comp if the pOWTS fails and cannot be repaired a bsor p tion replacement system: be utilized for the location of a replacement soil n by replacement area has been evaluated from distance and compaction and should not be infringe will fd A suitable wells. Failure to lea protect the replacement area system. The replacement area should be structure, lot lines and required setbacks from existing and Prof ble replacement . Replacement systems must result In the read for a new soil and site aluation to estabGst► °elate advances in POWTS comply with the rules in effect at that time. and /or soil limitations• Barring E3 suitable be ins replacement area is not available due is ort to replace the failed POWTS setback technology a holding tank may Installed as a last res nti a suitable replacement area. Upon failure area t is availab e a holding tank ❑ The site has not been evaluate to te a e a s uitable replacement area. If no replacement evaluation must be performed ace {ailed POWTS• may installed as a last resort to rep) reconstructed in place following removal of the biomat et the 13 Mound an d at -grade soil absorption systems may with the rules in effect at that tune. in surface. Reconstro�O� of such systems inrush comph < <WARNING> > grT TANKS MAY CONTAIN LETHAL. GA ANDIOR INSUFFICIENT OXYGEN. DO NOT C PUMP AND OTHER TREATMENT TANK UNDER ANY C �UMSTANCES. DEATH MAY RESULT. RESCUE OF A SEPTI ENTER A SEPTIC, PUMP OR OTHER TREA PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMppSSIBLE• ADDITIONAL COMMENTS POWTS �NTAINER POWYS INSTALLER Name Name r' phone Phone S f LOCAL REGULATORY AUTHORITY SEpTAGE SERVICING OPERATOR (PUMPER) Name c Name phone � 5 Phone efts and Wewshara County Zoning and Sanitation agencies in compnance with This document was drafted by the staffs the Green Lake, i n Administrative Code. chapter Comm 83.22(2)(bl(1)(d)a►(f) and 83.3. 5411). (2) l3). ST CROIX COUNTY • SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM (( 1 Owner/Buyer R fNpa ��e L��rS mot- Mailing Address Ll ( ! - 7 a r�.rS ea Wr b S Property Address /S3:9 (Verification required from Planning Department for new constriction) City /State Up Lx .,) R ; r lnvvv� A b.S � Parcel Identification Number LEGAL DESCRIPTION Property Location W V., SW V., Sec. 1_2 T N -R W, Town of � r 3 Subdivision --N , Lot #_. Certified Survey Map # Volume , Page # Warranty Deed # 7 ,U S 7(o Volume 'aa„t,s4 Page # Spec house P yes O no Lot lines identifiable Q§ yes O no SYSTEM MAINTENANCE 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 thug system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner 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 wastewater&Rmsal system is in proper operating condition andlor (2) after inspection and pumping (if necessary) the septic tank is less than 113 full of shtdge. Vwc, the undeiaigaed have read the above requirements and agree to maintain the private sewage dispowd system with the standards set forth, berein, as set by the Depatmew of Commerce and the Department of Natural Resources, State of Wisconsin. CertafKatibn stating that your c system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 da f the tier date. GNA PP 1 D TE 7 OWNER CERTIFICATION I (we) cphfy that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the perty Ar ve, by virtue of a warranty deed recorded in Register of Deeds Office. A P I NT D TE "• •"" Any infiinmation 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 L - J 2 2 6 4 P 4 11 - 7 a4 15 - 7 CE, 1 21 STATE BAR OF WISCONSIN FORM I - 1998 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS Document Number ST. CROIX Co., vi II 4 RECEIVED FOR RECORD This Deed, matle. between GrfhenWood_EnterPriseS,. -Inc. 06/05/2003 10 Wi ,Consj M-Cox*porZLt- WARRANTY DEED EXEMPT # Grantor, --- -- -- -- - and ___Brian_TieQ1,-j.TeQ1t- REC FEE: 11 ii . TRANS FEE: 69.90 COPY FEE: 2.00 CC FEE: Grantee. j: PAGES: i Grantor. for a valuable consideration, conveys to Grantee the following described real estate in County, State of Wisconsin (the 'Property Name and Return Address of the Tot 45 Plat of NorthGate II, recorded in the -n*c, C, Croix ce of the Register of Deeds for St. County, Wisconsin on June 20, 2001, in Volume 8 of Plats, at SDfkftl PIN Sf 4 Page 55, as Document Number 648882. k&ovi u)I 54011, r-P- :3 ji Parcel Identification Number (PIN) ji This ___kS not— homestead property (is) (is not) I j Together with all appurtenant rights, title and interests. Grantor warrants that the till- to the Property is good. indefeasible In fee simple and free and clear of encumbrances except easements, restrictions, and reservations, if any, of record. Dated this.— IW� day of 9003 INC l t� (SEAL) —_ (SEAL) James E. Rusch, Presiden (SEAL) (SEAL) Mar _y R. 84,sgh. Sec/Treaa AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, St. Croix _ Cou nt authenticated this day of Personally came before me t; ) day of !I 2063 the above named James and Mary R. Rii-strh TITLE: MEMBER STATE BAR OF WISCONSIN Af to (if not. me known to be the person s. who e. authorized by §706.06. Wis. Slats.) Instrunie and acknowledge 4; THIS INSTRUMENT WAS DRAFTED BY ' j Mary R. Rusch __5andra 11irke Notary Public. State of Wisconsin New Richmlbnd, My commission is permanent. (If not, state e P (Signatures may be authenticated or acknowledged. Both are not --gepterilber.-14, 2004 necessary) �j 'Names or persons signing in any capacity must L .. tylWd or printed below their signawre. STATE BAR OF WISCONSIN WiSCd13,n Legal Biank Co.. Inc. 1 WARRANTY DEED FORM N.. I - 1998 Mfl­.kee. Wi, I - WrL 0. ALL a:tluxY.uutnuriJS NORTHCATE H xI wY, ask Nw, «.M,:R.w+v ,m: 4 -. 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