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HomeMy WebLinkAbout038-1122-50-000 § K 0 2 � G a I ~ I a � $ � ) � k � kk � . . [k (D }¢J U. 5 2/ 222 \ 0 / � k a 2 \ � z` 0 � ; = n } e § I ( z :!t 2 \ u m 7 % L E k c m E 2 I � I � $f � � �o k k 0 \ z / � .. k � { ® a ` 6 0 a m to @ k ■ ■ U) t \ _ k § § \ ) I - E a a a 7 7 ;E C IL .j N N 8 8 / CD 7 / 2 �k\ 2 E §�� J \f ) 0 7 CD ' ` § }� E _ § G 8 S § / / c 2 § § § C-4 00 k 2! A$ . k k k /// , - b E G a§ \ E E i] S§ e �] g o )$ I CL m is .. CL » a § k J £ 2 & 0 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Cr oix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 405154 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Lotnnes, Tom I Star Prairie Township 038 - 1122 - 50-000 CST BM Elev: Insp. lW BM Elev: Description: S . (Y I BM TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic gj_e� /� Q Benchmark I I Dosing _ ! o 1 Alt. BM 100y /1 Aeration Bldg. Sewer a t Holding St/Ht Inlet � 0 h f p TANK SETS St/Ht Outlet K INFORMATION to . TANK TO P/L WELL BLDG. Vent Air Intake ROAD Dt Inlet J -- Septic 0 ' 1 I ► t Dt Bottom Dosing h+ Hea /Man. I q 6.3 2 C'JY -5 Aeration Di t. Pipe (� , I t , Z • ,L Holding i Bot. System �j 3 s Final Grade PUMP /SIPHON INFORMATION Iq 3.7f j 7,! 7 Manufacturer DerFR n St Cover GPM Z 1 06, 1 7 Model NUIRer TDH Lift ion Loss System Head TDH Ft Forcema' Length Dia. SOIL ABSORPTION SYSTEM BEDITRENCH Width i Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Z 1 ► SETBACK SYSTEM TO / P/L BLDG IWELL L /ST AM LEACHING an urer. INFORMATION CHAMBER OR I"Iti Ll Type Of System: -Cr� ' I J { t UNIT Model Number: DISTRIBUTION SYSTEM 2 YSTEM 2 �j" t " d C4 a71 AWAI Header /Manifold Distribution I x Hole Size x Hole Spacing V it Intake 9 PIps)/ r� r Len th ,� Dia Len 9 th 7 Dia LI �0cl' aan g •� d 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 (1 Bed/Trench Edges Topsoil 1 Yes 1 No [ Yes ' No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: 7 / t 510 Z Inspection #2: Location: 1935 80th Street New Richmond, WI 54017 (NW 1/4 SW 114 30 T31N R18W) NA Lot Parcel No: 30.31. 18.508 1.) Alt BM Description = 5T. C41K12AJ 2.) Bldg sewer length - amount of cover = 5 / ,- a( Plan revision Required? Yes ' No —7 Use other side for additional information. r Date Insepctor's Signature Cert. No. SBD -6710 (R.3/97) _ � � SL �8 �1 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 lViscon.4in 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.) Attac complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size. County �( `-� State Sanitary Permit umber ❑ ec C EI ]ication State Plan I. D. Number 1 /.� 5"` A I. Application Information - Please Print all Information Location: y Property Owner Name / J u N z0�2 Property Loca io 1© 0 4 to Property Owner's Mailing Address . CROIX CO(.i) fy Lot Number Block Number ONING OFFICE 5 City, State Zip Code Phone Number bdivision Name or CSM Number boat II. Type of Building: (check one) „/ City I or 2 Family Dwelling - No. of Bedrooms :_ �lcGyw�i�G ❑ Village Public /Commercial (describe use):_ *Town of ❑ State -Owned °� 4vvl ati 3 W6j-�' u' r !/ or—'e< j- <-- Gc.6 JL�� Nearest Road C" l Parcel Tax Number(s) III. Type of Permit: (Check only one b e A. Che box on line B if applicable) A) I. ew 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only Existing System $) Permit Number Date Issued ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) �i0 Q r j EJj $Pion- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: t;47 V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3, Dispersal Are 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Require ULO Propose (e �a­ Rate (Gals. /day /sq. ft.) (Mir Anch) �/ 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 ❑ ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the undersign assu responsibility for installation of the POWTS shown on the attached plans. Plumb is Name (print) urn ' Signature (no stamps): MP/MPRS No. Business Phone Number A �d r' Plu er's Address (Street, City, / tate, Zip Code IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing gent Signabare (No stamps) Approved ❑ Owner Given Initial Adverse Surcharge Fee) Determination A'� �- — L 3 Q -�-- X. Conditions of Ap proval /Reasons for Disapproval: !� jmo�- �' '' cy+ nK,a'1.�t cisr. ,iidlla.ctc.a.- Ag fa" -�,r<t�" � �� � � 9'✓�20hJ aZ���cO�- ¢4�n. S.A-. S � �ar..w<- arhh2 ��`�'� -d - rn,cet ljr,•t..,. � 3. y3 -/ SBD -6398 (R. 07/00) PLOT PLAN PROJECT Tim Lomnes ADDRESS 671 McCutcheon Rd. Hudson Wi. 54016 NW 1/4 SW 1 /4S 30 /T 31 N/R 18 W TOWN Star Prairie COUNTY ST. CROIX 6 -4 -02 BEDROOM 3 MPRS Byron Bird Jr. 2205 DATE CONVENTIONAL XXX A CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1 000 gal LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE 0 LOAD RATE •7 ABSORPTION AREA 642 # of chambers 22 IL BENCHMARK V.R.P top of white stake base of cedar ASSUME ELEVATIO 1D0' ❑ BOREHOLE O WELL 1H.R.P. Driveway 80th st A VATION ent SYSTEM ELE T -1 =93.4 T -2 =92 Sidewinder High Capacity Leaching Chamber with 17.2 t ^2 per chamber Long Elevation 80th st. drii eway pond 300' \ 20% slope 80 150 3 bed hous �5 100' B4 , BS st 40' P 300' L 70' B 300' B 1 80' B2 � 132 ' ob pipe q o cw� ��1%t�IG��P�✓� C�o vs� - �ia�•• Wisconsin Department of Commerce SOIL AND SITE Division of Safety and Buildings �, Page of Bureau of Integrated Services in accordance with gi1n% ALUATION 6 ;V)�is ';Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in si a Phan mus s County include, but not limited to: vertical and horizontal reference point (BM direlction and percent slope, scale or dimensions, north arrow, and location and dist ce to ro,," road. Parce�t1:Dt # ( _ _Z APPLICANT INFORMATION - Please print all information. Revi e by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).. I - 31- 20wa Property Owners / t Property Location _ y ✓d< c.�l rr' �/ Mt. / �1 /4,S 3� T3 N,R /� E (oN Property Owne s Mailing Address Lot # Block# Subd. Name or CSM# City State Zip Code Phone Number ❑ City ❑ Vil age .Town Nearest Road 9;� Construction Use: residential / Number of bedrooms Addition to existing building LJ Replacement LJ Public or commercial - Describe: Code derived daily flow pd _ Recommended design loading rate bed, gpdfft - trench, gpd /fie Absorption area required bed, ft trench, ft`2� Maximum design loading rate e 2bed, gpd /fi gpd/ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) / Additional design /site consider V s tionns - ��. T 5 T ✓- o� Q Parent material 7a C _ tc/ C. S Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = unsuitable for system I 3 ❑ u 2 S ❑ U ,5Zs ❑ U I AS ❑ U ❑ S E�rU I ❑ S 'f ; 'rU SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /fie 9 Texture Consistence Boundary Roots - in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench r Ground t G g � elev✓ �5 ft• '� Depth to ? 3 Y limiting 39. 2 factor Remarks: Boring # Ground Z - A ft . 4" 144q nee�L ceve/— <� Depth to limiting factor �in. Remarks: CST N (Please Print) / Signature Telephone No. Addrepe Date CST Number SOIL DESCRIPTION REPORT a of PROPERTY OWNER �' P PARCEL I.D.# Borin # Horizon Depth Dominant Color Mottles Structure 2 g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground elev. q �o , Depth to limiting 2q (,p k fact Remarks: Boring # Ground �} el / e � v,- 7f ="eft' Depth to limiting 2 V factor in. Remarks: u�- Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. ; ft. SO Depth to 3 Z limiting fact r in. Remarks: Boring # [3 Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R.9/98) a ,� Soil Test Plot Plan Project Name ,,�� By r Bird Jr, Address 7 Lot Subdivision Date _ A /4 jVl /4 S pT / N/R -,_ .� W Township I3oring O Well PL' Property Line County 1 13NI or VRP Assume Elevation 100 ft-, System Elevation a *HRP o h . D on cl r rte - � Scale 1/4" = 10 Ft. Mien Dimensions aren't stated POWTS OWNER'S MANUAL a MANAGEMENT PLAN Page __L of Z FILE INFORMATION SYSTEM SPECIFICATIONS Septic Tank. Capacity. �— ga l, [I NA Owner J Permit # Septic Tank Manufacturer ee� 11 NA s ss Effluent Filter Manufacturer � ❑ NA DESIGN PARAMETERS - ❑ NA Number of Bedrooms I ❑_,NA. ,Effluent Filter Model /. Pump Tank Capaci Number of Commercial Units ty i gal 13 NA Estimated flow (average) S �, -1 /day Pump Tank Manufacturer <. ❑ NA Design now (peak), (Estimated X 1.5) ral/day Pump Manufacturer C] NA l 13 NA Application Rate gal /day /ft?, Pump Model: _ Soil pp ❑ NA Influent/Effluent Quality Monthly average* Pretreatment Unit <30 mg /L ` ❑Sand /Gravel Filter ea F�Iter. Fats, Oil at Grease (FOG) ❑ Mechanical Aeration ❑ Wetland Biochemical Oxygen Demand (BODs) _ <220 mg /L p Disinfection ❑Other Total Suspended Solids (TSS) 5150 M' Manufacturer Pretreated Effluent Quality ❑ NA Monthly average* * Dispersal Cells) a n= ground (gravity) ❑ In ground (pressurized) Biochemical Oxygen Demand (BODs) 530 m, /L A _a ade ❑ Mound To tal Suspended ended Solids (TSS) _ <30 mg /L ' p _ � . Fecal Coliform (,geometric mean) <_10 cfu /t00ml ❑ Drip -line :.� Other: Maximum Effluent Particle Size I 1i inch diameter e * Values typical for domes`1c (non- commrclai) wastewater and septic tank effluent. * * values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event ! - Service Frequency Inspect condition of tank(s) At least once every ❑ months ea (Maximum 3 yrs. ) Pump out contents of tank(s) When combined sludge and scum equals one third ('h) of tank volume Inspect dispersal cell(s) At least once every ❑months Fears) Maximum 3 yrs. ) ZA Clean effluent filter 4 At least once every,, ❑ months `❑ year(s) Y ( ❑ onths ❑ ear s),._ ❑ NA e ev .. inspect pump, pump controls at:aiarm At le ast once tY m Flush laterals and pressure test At least once every, " ❑ months ` ❑ years) " ❑ N,A Other: At least once every. .❑ months ❑ year(s) ❑ NA Other At least once every ❑ months ❑ year(s) ❑'NA MAINTENANCE INSTRUCTIONS Is shall be made b an individual canying one of the following licenses or certiflcatlons Master and dispersal cells Y tons ons of tanks a p lnsp ecti .. a tor: Tank inspects _ * Plumber; Master Plumber Restricted Sewer; POWTS nspectgr, POWTS Maintainer, Septage Serndng - iieasure'the must include a visual inspection of the tank(s) to Identify anymissing or o d n of effluention en I any the groundasurfac lea Th y...... ersat volume of combined sludge and scum and to check for any back up or p g effluent levels in the observation pipes and to check for anyponding of effluent on cell(s) shall be visually inspected to check the e The ondin of effluent on the ground surface may indicate a failing condition and requires the immediate surface. Th g the ground s P i;r . notification of the local regulatory authority. � When the combined accumulation of sludge and scum in any tank equals one - third (36) or more of tfie'tank °volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with ch..NR 113, Wisconsin j Administrative Code. 0 tand The servicing of effluent filters, mechanical or pressurized POWTS components, pretreat P ,mp ti iner.nY other maintenance or monitoring at intervals of 12 months or less shall be performed by a certified A service report shall be provided to the iocal regulatory authority within 10 days of completion of any service event. START UP AND ` new constructlon,�prlor to use of the POWTS check treatment tank(s) for the'presence of painting procts have the conte S For d et ec ted F . • _ _ _ .L _ 1..._... -.. ��rv�� f f hioh rnn�pntratlORS art I System start up shall not occur when soil conditions are frozen at the infiltrative, surface. p Of During power outages pump tanks . may fill above normal highWater levels.: When power is restored the excess wastewater will be discharged to the dispersal cells) in one large dose, overloading the cell(s)' and may result in the backup or sur discharge. of 1. effluent. To avoid this situation have.the contents of the pump tank removed by a Septage Servicing Operator prior to restorinb power to the effluent pump or contact a Plumber or POWTS Maintainer. to assist in manually operating the pump controls t6 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, t cotton'swabs; degreasers; dental floss, diapers, disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; nedlcatlons; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONEMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with ch. 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 cover removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: - ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be Infringed upon b} required setbacks from existing and proposed structure, tot lines and wells. Failure to protect ttie replacement area will result In the need for a new soil and site evaluation to: establish a rJitable' 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 1n 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 re lacement area.. If no replacement P. p area Is available a holden, 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`CIRCi,IMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE, INTERIOR,.OF..A TA?1K MAY SE;±DIFriCULTR iMPA.C.t(Rt.F.. ADDITIONAL COMMENTS PO WTS INSTALLER R POWTS MAINTAINER Name :7�/.:.� ; •< �� =: Name Phone .��'S';�,���� ' � Phone �j r. o! Zany X a �t6 SEPTAGE SERVICING OP RATOR (PUMPER) LOCAL REGULATORY AUTHORITY" Name I �,/ Qh OA' .�t/6 ,Sl 4/�O' . ,: Agency I Page -2- ,Of ,SUP AND OPERATION new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals .at may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents .)f the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • 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 POWT fails and cannot be repaired the following measures have been, or: must be taken, to provide a code compliant replaceme system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ 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 INSTALLER POWTS MAINTAINER Name 21,(_6 -77e-- - Name Phone JS - L f - - 76 / Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name S 7 ; C,QO 1 Cp ?_1JPj 1 17, Phone Phone �� This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer �/ '4ehn - 5 Mailing Address . L� � �'� — Property Address 123S a (Verification required from Planning Department for new construction r3 City /State Parcel Identification Number LE GAL DESCRIPTION Property Location ' /4, � '/4, Sec. © , T,&�N -R W, Town of ,�f y ® r !7,1 C Subdivision Lot # Certified Survey Map # / , Volume , Page # Warranty Deed # d ��� (� , Volume Page # Spec house R yes ❑ no Lot lines identifiable 9 yes ❑ 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 the 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 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. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. ki z / / X0 SIGNATURE OF AP ICANT DATE OWNER CERTIFICATION 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. . _0 SIGNATURE OF AMPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.***,*** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed �l U 1902P 022 68el nIr=' STATE BAR OF WISCONSIN FORM 3 -1998 KATHLEEN H. NALSH REGISTER OF DEEDS ocument Number QUIT CLAIM DEED ST. CROIX CO.. VI RECEIVED FOR RECORD Francis D. Mondor and Joyce G. Mondor, husband and wife, quit -claim to 05 -31 -2002 9:45 AN Timothy E. Lomnes and Michelle D. Lomnes, husband and wife, as survivorship marital property, the following described real estate in St. Croix QUIT CLAIM DEED County, State of Wisconsin: EXEMPT t 8 REC FEE: 11.00 Northwest Quarter of the Southwest Quarter (NW 1/4 of SW 1/4) of Section 30, TRANS FEE: Township 31 North of Range 18 West, Town of Star Prairie, St. Croix County, COPY FEE: CERT COPY FEE: Wisconsin, EXCEPT part for Road on west side of property. PAGES: 1 q o V.IM IOA44.9( Recording Area e and Return Address / /hl Ot'Ity / 5- c st o'C u .7'�A'00 j7L��J D tt t z 3 1122 -50 -000 P entifi tuber (PIN) This is not homestead property. Dated this _5_ day of May, 2002. f 'F ncl D. Mondor �+C * oy a G. Mondor AUTHENTICATION ACKNOWLEDGMENT Signatures) FfarC1 Q. nlo>ldor CZ-'A Joy STATE OF WISCONSIN ) )ss. G lKor�o� County ) authenticated this 3o day of May, 2002. Personally came before me this day of May, 2002 the above named Francis D. Mondor and Joyce G. Mondor to me known to be the G lq �d L S� �� person(s) who executed the foregoing instrument and acknowledge the same. TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Slats.) THIS INSTRUMENT WAS DRAFTED BY Notary Public , State of Wisconsin Ronald L. Siler My Commission is permanent. (If not, state expiration date: VAN DYK, O'BOYLE 81 SILER, S.C. 1 20— . ) P.O. Box 118 New Richmond, WI 54017 (Signatures may be authenticated or acknowledge. Both are not necessary.) *Names of persons signing in any capacity should be typed or printed below their signatures QUIT CLAIM DEED STATE BAR OF WISCONSIN FORM No. 3 -1998 INFORMATION PROFESSIONALS COMPANY FOND DU LAC. WI 800 -655 -2021 i t ar rairie ; ; POLK COUNTY v Pioneer a • • i RtrN i �..r Dairy • Mallard I Ir 8 Vernon D j Fam In, 6 a s 5 y $ I c nnie Lehrman Randall Run 3 p' PC 9 J 50 _ & Ruby 80 Demulb & Judith & Mar Douglas D I T Glenn s� Q o M7 Arkn & !; l7 $nw racrs Ph Ils 1 m STA j & Gwin Teske carLson .l ca Y Lna Dreher • 82.3 Demulling Rivard 261 ts� - Menke 79 J. 59 PR A I R .3 65.4 W5 H Gregory 201 Joan 4 1 I Allen Wri ght _ , • cnanrana Russell Allen & 8 &Linda 126.6 124 Lavaun Sandbar r; �F • 2s Small Taacts zz 28 Nelso StrOhbeen Rodney CYnthia relstad 6 y o • Dennis Ds csr& eta! 4 Bradle c �. snerr , m R1Vard C ampeau y Robert Y Raddatz• e.s JNIZ �� Kevin , • • &s«et • &Mary 40 156.6 • 80 • 64.1 b Annette Peterson Thomas*. 33 9 Vincent • .74 m d o N Becker 128 80 Noak neabwn u �' �,- o &Doreen 80 ' i H - 39 • • sanaiti 62 70.5 my .r o Wilson N • lwm& R&5 Dougbs� • • G&V ` 5& & T &E oM & Ga'1 52lSatl 5 99 Cedar Steven & D 20 H u n t i n t O rl ' w 236.6 Gene &Alva He +i m`n 39.6 EL RC ^•« N 60 Abraham- MeedS Rachel Radda z Y Nelson 39.a �_ J Rfvard w iz eO n„ 43 Robert• 5peeaway Constant Bruce Alfred x 375 H Richard 239.2 4a Z • a - 3 smTrs John &Gary Lsc • 61.4 &Mary &Alice ne n r Eaa & P6. o Norman 80 cook Y s nwan •s:' ic Sey ' Nelson 49.9 88.9 Be Ca� Larson cF ca r j x �•� n • s e o y 14 4.9 D&L•20 Tr '[: 2 94 o M 5 K M &BS 59.9 eW5 hSfRer trDia« (J y Norman Fem •1 &R • • R^ � K Vivage yy R&C P&C • 20 GA r 4r Measner Munwn m Daniel Kevin st & Lawie -(Star Clifford k Pattie E i •Medchi0 Li<ht•]5 Charland S. wait`s 15.1 °41 Estate Ga • • Jeffrey Bever! 1. Daniel • 36 rj &Joyce TY Ahlness J & . D Neumarm eY Pnme Sias Tt,�, p T &1 • m Keith • SmPrs 1&C L Jessen ammi1m Earn & !.eon 39.4 eta! Baillargeon 3z Kreto a Vo Manta I eau 40 ` Bettendorf 14.8 'a Duane & Alfred Orr r DP 46.2 u m 39.3 117 73.9 Zo Bruce Melvin • O 80 2.3 1.) C &A K Rchard 160 K 6 i athryn &Alice %.5 Cky Lowell N Nancv Merlon 36.5 •& 1a«, • Measner 7&D • m 3 Larson • Edin Emerson �I N James Jr n N • "y a Halverwe, Chu,e 40 L&B Om 19 - IS 4()�� Vo1kM Carol A ry Keith 55.2 W &w 1&w f Bell < V 1 BrAt E13 Richard . rY anki. 3.8 W'a^en Wdliam Name 44 5 a1 ~ 7 6e di 1&A >§ 8 ` - S c1OAmu=t is m • Sandor & Janet soro,n Rm, 7 Hansen s e ` eu 7s Anderson etal 5 C1 isdllome r 29.7 C10A s Norman • . .� 40 CC -• 0 4 so,,,, Nemeth 76.99 47.4 1 ` ° ' A • e � 9.6 ,$ a o- zs w 77.4 115.9 Virgini Ed< ! a6 & Joyce � Farm T&M 5 9.6 • 90 Wolf °� . e ` Hwld a • Scott $0 Richard • Harlan Earnest & 78 e & Mari • lama Keith &D C a maw " "'•6 Inc ; Bell l " V get • 40 108 Counter e m > un Stout Vehrs one 2 Birkholz Ma k• D& •zo D&R 13.4 6 n 3s r 12.s 1 Dosedel • 155.9 I Bell zo.7 140.5 Brian & N i t Small 0.9/ 3 ohm W&c Bernard 53.6 MDnica Tracts 9. Lu rTr M10 &S- RObert 1.oL, Wallrich C Keith 5 lr3 m Satterlwm Apple, James Greenwood Ga le & D12gg.r ' • R&D W Patric, Joseph ok n Mark Larson 90 Ri • Ent Thovus 139.9 Y -Doris Clarence & Pnce r&R m a4 aemearoa 75.4 Mal 40 •Callal'an 5mau 133 • m� Sudan &Leona 100 Rivard ca�nmo J Aronson i 2 David wx� Rs es Berra 100.2 79s 1 ' 4 i Alin C+ G n W kl 41.7 Y.^ N E&M RM Raboin § Annp COO: r rs Sub D&c r.,.,. Emerson 155 Neumann & SOS c�v • rxss Dupre 20 9.9 • RW B 3 &L 14 z y b 5 3 M& O G&P <narn.m • • 4 • E&E 37.7 m5 z �Zm Cue*. Pk=P 4 Marcel Patrick • Joseph s. T 6 Everett & P 3 q George & c ;`+; &S v sin T. C & Denise Rivard Dc s ry n k m 9 - 38.7 Alice r Kdtly &Joyce Adeline 1 Mrm ° s o7P a &P,ua yvonne t r'� Takna a • 391 • Bruce $ w co Plourde 40 1&7 va F a l0 1 I.non Brolzler h • • g ry 80 •Y•e Belisle 3er s Cloutier Tr 13 ^ �' s4 9 37 7 �: ,• • a n n Q u r g 3y g Jones HHe�nmway 3BJ CC Emerson .9 1 In C v - RV Darrell & T& etal s 3 K 16 q Pahicia .V I n10°'a' 04 90 71.4 Rivard v J R H ht Ruth 127.1 p Tai M"R" m 9 59 4 O 4.5 90 a'i lo. • Cynthia FoEe Germain S. &Nzncy 4 +d 78.6 Henx^w Steven 3 4 • 78 78.5 3 m.r Trs Olson '. Ic 5 • Asplund 6 fi 34.9 Gwer Roger & • & Cristy z s cau�& ames,Joyce .w& 3o.s 1 • K&L20 a Stan Laurie WickenhatL9er @ Ir;vard &Mark • Gerald 73.7 mac.. em Bonestroo, J Lev & Ralph & 77. lendem • Phillip Lake 101.7 Neumann 142.5 M.Myki 42.9 63 6 g 4o Klemestud gp Cloutier .z , s Rosene & • M sh.wan• Ma Mondor D srenen & Anna David 92 s � 31 101.2 4o z.4 ry ua.a Railsback ll Joseph & M,ary Lamoyne & s r oA s Anderlik • Curtin s"`B 14 M - are • Rivard D 6 114 Robert, Fritz • s V Eva Halvorson • 2Q5 a & a n &Assoc 157 im. .a Ronald 50 .5 S V 0 85 Fam Tr go Marl« M« DW 6 \¢ a '15.1 5r1 & Violet Asplund so n Wohlen °0 2 e&r v W&159 wD6 QsQ� 5.2 T + 80 • GJ 5 T. ¢t. bob Tr• N LangrLre S.7 5e t Gerald &Marcella ' d Tracks Steven Genevieve 97.2 G I & Bonnie n n R&DH Ulrl ry 5-11 g 6. C 1 90 0.m1 DkL54 Uving T_ Backes Tr "P 33.5 D&N d f EII K 9 Cr1.9ty Francois 185.5 • ,` \0 63.3 • w Pine Estates • A^"w^r Dougla6 Wickenhauser 100 omr •&Ag &lanet M Daniel • VrID Star OF c &K B '" 221.8 ram9abaj Gaon 160 212.9 • an .s& Prairie Is a.l g 10.5 r w 39.1 �1 Casey Ltd �; ,-/J► JoYCe E "'k H:r ry P a m o r K B a ill a eon 40 PrIn 8 car'ld f B ui a a 19.6 • Vrie z City of Dankl & Iuletrdat sin i" 34 • a g = y sin & ze 78.4 wi one 40 40 case Jars« iYaijteld g.4 u u • Cary KM9 et BM 2 $m M 5 rs • T. • X1 16 • Canton &1 T. Victor 103.4 PY.S Re • $t CT Helene Marc • c 2.5.7 Myers III • 40 COUIIty Houle 71.5 St ^ � ` M.W. Cecil Robert lamest ` Sron Plourde McE;ver &Cleo G r • tarai Coon kr St Croix e,ra t • 39.2 C s au • sn�ron 40 271.3 Ralph S& Jeart as 36.8 & ceaa 4o Newby County 120 eb • 19.4 & Ma Coun CC Catherine o 99 xx D°'ry Russell Mondor Boucher rm GI NE W Rivard DL 6 1 F be Flandrick 120 • 156.9 C AS N -b 90 R I C H M 0 D 1 1 A 2 5&l Co NR 136.2 Lindalou st u • ur•'cz Nardj mKa n DkL010 at X 10.9 2 New Rids K • • • Jensen 74.7 as • 'g a 1&M 245 Michael Mary 3).611.3 Friday •GolfcTub 39.6 LTD 64 o • �;e Alice 5.9 ° 1 Robert & wa x.� r ' a 92.4 & Kathleen K Rc Iz: C GE �. co 9 Y ^ Carol Duffs S € Mark & Cody T ° m 153 1 InC 1R & "' a r m Trs 49 • = 3 Kathie Cellotti t 116.2 • S D° W A\ 212.6 K 111 '00 SEEPAGE 60 900)r + sa 1000 1100 SEE P AQE 46 K 1200 1300 140( d t otue offi, more "information contac hone: (745) 294 -3186 or 755 - 3186:• Fax ,(715) 755 2998 • ` ¢ OR CALL YOUR DIRECTOR$ 1 John Heintz Edward Sontag Richard or Sharon McCurdy David Neldemire Henry Heintz 248 - 3833 549 - 6579 646 - 9303 294-WW 357 Phyllis Clark George Setter Stack Insurance Agency Paul Hedlund A g en 265 -7079 269-5481 265 - 4614 643 -3311 �" Tom Heintz 265 -7394