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HomeMy WebLinkAbout040-1263-40-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Saiety and Buildings Division Coun INSPECTION REPORTt. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanit1yMtNo.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)1. Permit Holder's Name: El City [] Village own of: State Plan ID No.: iller, Sam Troy "Township CST BM Elev. Insp. BM Elev.: BM Description: Parcel Tax No.: 100. 1 UO -6 1 C CS;T - 60A. *- ( 040 - 1263 -40 -000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 2-S 1 Benchmark rz, Dosing Alt. BM C4 Aeration Bldg. Sewer Ca Holding St/ Ht Inlet �m �, I 7-4 S TANK SETBACK INFORMATION St/ Ht Outlet( 3 3� IZ6,o8 r TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet Air I Septic >Sa > r'p t t NA Dt Bottom !--- Dosing NA Header /Man. Aeration NA Dist. Pipe Cz :� Holding Bot. System C , „ S , 9•� z_ 95.6 PUMP / SIPHON INFORMATION Final Grade 3s Manu er Demand St cover L �. �S (Z . 73 Model Number GPM TDH Lift L Iction I Syste H Ft Fi Forcese am I Length Dia. Dist. To Well SOIL AB TION SYSTEM 36 `6LQ *m / RENO Width f Length No. Of Trenches No. Of Pits Inside Dia. Liquid Depth DIME 3 DIMEN I N SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Mann ac rer: � CHAMBER' —Sa INFORMATION TypeO f t Mode Number: System: I�V , 5 / 00 7 15D OR UNIT (t - 4. u DISTRIBUTION SYSTEM Header / M Mold (� � � � Pipes) x Hole Siz x Hole Spacin Vent To Air Intake Length':PfP - Dia- t h Dia. Spa cing 7 Z60 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 ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: off% /A/ OP Inspection #2: � — Location: 429 New Century Drive, Hudso�jj WI 54016 (NE 1/4 SW 1/4 5 T29N R19W) - 05.28 19.1422 ontmer -1,ot 14 1.) Alt BM Description � 2.) Bldg sewer length = '� �� « ( � 1 l - amount of cover = ""�`^"� &A— ({ . 5) -�► C). 10 - rveQ e s 4, nA =N• Q, Plan revision required? ❑ Yes No Use other side for additional information. 191 0� AX 4111' H_+++1 SBD -6710 (R.3/97) Date Inspector's Signature Cert. No L ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: } t z. E a e a F I 1 } f E e E e 2 t i .. �.. ., e.P.... ,.�. ..cnm .. ... ._. ;,.,„.. m.. w. ..... _ a we t P } t a i F 3 . eee.. ,e a .._ ........ ...... n .,.. `... .. ....., ., e,. ge »P m E t P { t 3 P } F E , F t }� messed -# .a».d z s e t } 5 = 3 3 r } d } . i 3 i i } t � F a.. : 3 i r a F P P _W F }.. ..mom a 7 z t 'a amm..;m :...... _�. _. .»ate m .......�.. _ ...�`.. a _. i —,... a _ g _a..,-.a_. ... ___.. ... :..... -_ ._ .._ .. ... — A...a.�. i 3 C C e'LT(� Safety and Buildings Division Vi sconsin SANITARY PERMIT APPLICATION 201 W. Washington Avenue P O Box 7162 Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707 -7162 • Attach complete plans (to the county copy only) for the system, on paper not less County L /� than 8 1/2 x 11 inches in size. ST . C d I X • See reverse side for instructions for completing this application State Sanitary Permit Number Personal information you provide may be used for secondary purposes heck it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. Stale Plan Review Transaction Number L APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Pro rt Own r N me operty Lo tion E � joh a /a 1 /a, S '! T 7, N, R E (o r rty Owner's Mailing Address Lot Number Block Number AV a t4 � � 1 I Zi Code P ;umber Subdivi ion ameorCSMNumber ./ T YPE F B I DING: (check one) E] State Owned ° Ity Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ° To of 1 111. BUILDIN SE: (If building type is public, check all that apply) Parcel Tax Number(s) Zr 3 P ee- � o 1 Apartment/ CQndo n 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1, New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System ________ System_____________ Tank Only______________ Existing System _________Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 3 Specify Type 41 ❑ Holding Tank 12 M Seepage Trench + 22 ❑ In- Ground Pressure �� 443' �Se 5 42 El Pit Privy 13 Seepage Pit ��� f���f� / 1^,Ix' X 43 [] Vault Privy 14 ❑System -In -Fill ti— �'���r11► "1"',,', VI. ABSORPTION SYSTEM INFORMATION: 3 Z 75 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) tt Elevation, a ob O . 7•11r Feet / , 0 Feet Ca a aclt VII. TANK in llons Total # of Prefab. Site Fiber- Exper. INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete st acted Steel glass Plastic App Tanks Tanks eptic Tank r Holding Tank Y I 4 A T & O 1 . 5 0 ft El El ❑ ❑ "nV u — m — p Tank /Siphon Chamber I 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature (No St m ) MP /MPRSW No.: Business Phone Number: M Al 1 -- & x S -.,, lumber's Address (Street, OR ate, Zip Code): IX. COUNT / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater 1 te Issued Issuing Agent Signature (No Stamps) DApproved ❑ Owner Given Initial Surcharge Fee) d Adverse Determination X. ONDITIONS OF APPROVAL/ REASONS FOR DIS , APPROVAL: / // ® t✓� L o�.. 'f(9 Gc Aar6, / Olt Or�iei•,�vo�tc nee" {v i1 S ><al� 3 ✓c r+G��'s, N6f 2•, 4V e e \ e) f. f ( 4Ja SBD -6398 (R.12/99) DISTRIBUTION: Original to County, One copy To: Safety & Buildin s Division, Owner, Plumber INSTRUCTIONS ` 1 _ A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative.Code will be applicable. 3. All revisions to this permit m.ust be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years_ 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608- 266 -3151. To be complete and'accuratethis sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII:" Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ----------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations`' and establishment of standards. Safety and Buildings Division Visconsin S ANITARY PERMIT A -1 N 201 W. Washington Avenue P O Box 7162 Department of Commerce In accord with Comm 83. Madison, WI 53707 -7162 • Attach complete plans (to the county copy only) for the , of less ' unty than 81/2 x 11 inches in size. • See reverse side for instructions for completing this ap lime io r, Sta a Sanitary Permit Number 3 6 3 3 Personal information you provide may be used secondary purposes � � ST GROIX / r heck it revision to previous application [Privacy Law, s. 15.04 (1) (m)J. GMNT`/ to Plan Review Transaction Number Qt`j�� 0� / � I. APPLICATION INFORMATION -PLEASE PRINT AL ' �MA Property Owner Name n LL 1aa /4, S S T 2 , N, R/9 E (oto Property Owner's Mailing Address Lot Num be r Block Number c i1 City, State li Phone Number Su division Name or CSM Number (3*) zn f Fieo FR Nearest Road T YPE F B L IN : (check one) E] State Owned ❑ C it y E] Vil Public 1 or 2 Family Dwelling No. of bedrooms Town OF 20/-1 R III BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) o 4 . I,3 ' *o --p11n) 1 ❑ Apartment / Condo fin/ S- Z 19 14 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Hom 10 Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an __System ________System _____________Tank Only______________ Existing System _________Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 Q Holding Tank 12 Vseepage Trench L okp 22 ❑ In- Ground Pressure t 42 ❑ Pit Privy 13U Seepage a e Pit A A/ Fi'- 1 - 44102 -Q-!Ii --Q-!Ii X rivy 14 t C 5 stem -In Fill 3(� SQ� �Fi4`LI ❑ v 8F4 s 6 l4jmzh� pad" VI. ABSORPTION SYSTEM INFORMATION: T. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 0 000 , (� 4 S i � Feet /00,00 Feet Capacity VII. TANK in Ca allo Total # of Prefab. Site Fiber- Exper INFORMATION g Gallons Tanks Manufacturers Name Concrete con- Steel glass Plastic App New Existin structed Tanksl Tanks _ Septic Tank r Holding Tank 1 Z60 W 5 1 S ❑ ❑ ❑ ❑ ❑ _)6_+_ Li ump Tank /Siphon Chamber ❑ IT ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) O z z ' Sign ure: o Stamps) MP /MPRSW No.: Business Phone Number: r ap ' Z D �6 -3 V( Plu ber's Address Stre c it y , State, Zip Code): 1 6 - )6 cll�l l i d (oE olf 0 14 D SoF4 W1 n LOO IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved IL ry Permit Fee (Includes Groundwater D ate I ssued Issuing Agent Sign ture (No Stamps) Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination c-S. � /� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R.12/99) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS ` 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be� instal led. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County /'Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smallerthan 81/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form;. and F) all sizing information. ------------------------------------------------------------------------------------------------ - - - - -- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Iv I A wt tv I L � AIE W e'"CN k I L 4 4v7� L Aop 4 1 4f AN "�'"�,, �! S 1 '1.1 ��7�D U � l , _ � 3 , b 'S 7/7/00 2r .� �. ru jvw IT s Y t re Aii LaT I L 4 LMT 2, 64 Vu ti C,4r WW= in Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 Division of Safety and Buildings in accord with Comm 83.05, W is. Adm. Code . A.C.E. Soil &Site Evaluations Attach complete site plan on paper not less than 8'/: x 11 inches in size. Plan must County include, but not limited to vertical and horizontal reference M (BM), direction and St. Croix percent slope, scale or dimernsiors, north arrow to nearest road. parcel I.D.# Prt of 040-1021-90 & 040 - 1022 -10 APPLICANT INFORMATION - P/ gprint all iriformat�ie n. R g Date Personal information you provide maybe used sbCOndary pugelses vary Law, s. 15.04 (1) (m)). Property Owner . ` ' ' Property Location Miller, Sam t . Gbvt. Lot NE 1/4 SW 1/4 S 5 T 28 N,R 19 W Property Owner's Mailing Address -1 Lbt # Block # Subd. Name or CSM# P.O. Box 151 sr `��' 14 Plat Of Frontier City State lip Code P it : ' � City [j Village ®Town Nearest Road Hudson WI L4040. 386 -27� Troy Tower Road ®New Construction Use: Res - 911 Nur�b rooms 4 ❑Addition to existing building ❑ Replacement ❑ Public or commercial describe Code Derived daily flow 600 gpd Recommended design loading rate .5 bed, gpolft' .6 trend), gpd/ft Abso tion area required 1200 bed, fl 1000 trench, ft Maximum design loading rate .5 bed, gpdr .6 trench, gpd/ t Recommended infiltration surface elevation(s) 95.50 ft (as referred to site plan benchmark) Additional design / site considerations Install 3 trenches using high capacity infiltrators. Parent material Glacial outwash Flood plai n elevation, if applicable NA ft S= Suitable for system Conventional Mound In - Ground Pressure AT - Grade System in Fill Holding Tank U= Unsuitable for system ® S❑ LI I ®S ❑ U N S❑ LI 7 E S❑ U EIS M U ❑ S® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD� Boring# Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ;Trench 1 1 0 -27 10yr3 /2 None sl 2fsbk mvfr cs 2%m. 0.5 i 0.6 2 27 -43 10yr3 /3 None sl 2msbk mfr gs 2f,lm 0.5 0.6 Ground 3 43 -68 10yr4/4 None sil 2msbk mfr cw if 0.5 0.6 elev 101.83 ft 4 68 -128 10yr5/4 None s Osg dl - - 0.7 0.8 Depth to limiting factor t` I1.9b >128" Remarks: 2 1 0 -8 10yr3/2 None sl 2msbk mvfr as 2f,lmc 0.5 0.6 2 8 -20 10yr4/4 None gr.ls Osg ml aw 2f,lm 0.5 0.6 Ground 3 20 -24 10yr5/4 None ifs Om mfr gs - 0.4 0.5 elev 100.76 ft 4 24 -116 10yr6/4 None s Osg ml - - 0.7 0.8 Depth to limiting factor >116' Remarks: CST Name (Please Print) Signature: Telephone No. James K. Thompson 715- 248 -7767 Address A.C.E. Soil & Site Evaluations Date CST Number Ref # 340 Paulson Lake Lane, Osceola, alt+I 54020 12/31/1999 3602 1163 PROPERT$OYYMER. Miller, Sam SOIL DESCRIPTION REPORT 183 Page 2 of 3 PARCEL LDS Prt of 040- 1021 -90 & 040- 1022 -10 A.C.E. Soil & Site Evaluations Depth Dominant Color Mottles structure sistence Boundary Roots GPDW Hor zon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz Sh. Bed Trench 3 1 0 -14 10yr3 /2 None A 2fsbk mvfr cs 2f &m 0.5 0.6 2 14 -28 10yr3 /3 None A 2msbk mfr gs 2f,1m 0.5 0.6 Ground elev 3 28 -47 10yr4 /4 None sil 2msbk mfr cw if 0.5 0.6 99.54' ft 4 47 -59 10yr5/4 None s Osg dl gs - 0.7 0.8 Depth to 5 59-109 1 Oyr6 /4 None S Osg dl - - 0.7 0.8 limiting factor >109' Remarks: 4 1 0 -25 1Oyr3/2 None fsl 2fsbk mvfr cs 2f &m 0.5 0.6 2 25 -36 10yr4/2 None IS lmsbk mvfr cw 2Qrn 0.5 0.6 Ground elev 3 36 -52 10yr4 /3 None gr.ls Osg ml cw if 0.7 0.8 94.57 ft 4 52 -75 10yr5 /6 None s &gr Osg dl gs - 0.7 0.8 Dmi9 5 75 -124 10yr5 /4 None S Osg dl - - 0.7 0.8 factor >124' Remarks: 5 1 0 -12 10yr2/1 None A 2msbk mvfr as 2f,lmc 0.5 0.6 2 12 -19 1Oyr4/2 None gr.ls Osg ml aw 2Qrn 0.7 0.8 Ground elev 3 19 -39 1Oyr4/3 None ifs Om mfr gs if 0.4 0.5 90.86' ft 4 39 -51 7.5yr4/6 None s Osg dl cs - 0.7 0.8 Depth to 5 51 -116 10yr5 /6 None s Osg dl - - 0.7 0.8 limiting factor >116 Remarks: 6 F3 2 0 -27 10yr2 /1 None sl 2fsbk mvfr as 2f &m 0. 5 0.6 27 -39 10yr4/2 None si lmsbk mfr gw 2flm 0.4 0.5 Ground elev 39 -55 10yr5 /4 None ifs lmsbk dsh gw if &m 0.5 0.6 91.15' ft 4 55 -118 10yr5 /4 None IS & s Om & Osg dl - - 0.4 0.5 Depth to limiting factor >118' Remarks: H#4 consists ot a mixture ot UM US & US9 S. Horizon g rate aaJUkC&to re most reslncttve SOD con n. Owner: P. N ��Yy�Sw�'� d r/w��rswyy Sec. 5 T, 284,, �l rc6r: el ev-= Boa. g¢ er ■ ■ 'tea.. � ^��4 ■ .¢ ^ �Q S 4 �'' ■ S/ooP, g8 ■ ,� ■ B3 fi e To P off' u�axf �, �Gn ce Aosf . Lof jit p /✓� • s CV) (D E Z m a X . N .. N r � X cN M O N ca CL - �0 ld N N N co N — yy r RS 01 N O g ID l e Q O N X cri m� ��� N V -0 � r �� � a � N> O d J WU. E O = U N U cn5053 a • • • • kL ox 33 m � a f .•,ti! . • ° �. 0 v w t� O 9.+ p, n 0.11 g 3 © E • E 5� a Zj N s o o � 1 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer` —' M L Mailing Address ' / Properly Address q Z y E � ell c /V T L) A- V D(I I Vj " ✓ (Verification required from Planning Department for new construction) City /State R O 0�O 4 V.) Parcel Identification Number LEGAL DESCRIPTION Property Location / ' /s, 5 '/•, Sec. . T !8 N -R I g , Town of O Subdivision r '� � �"-- Lot # .L�. Certified Survey Map # 4 " '? S So Volume - . Page # I gLl Pag OY Z Warranty Deed # �' 4�55`� � , Volume g - Spec house 0 yes ❑ no Lot lines identifiable yes ❑ no SYSTEM MARMNANCE � 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. 1/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the year expire ' n date. / /3 / Oo I F P ANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (ate) the owner(s) of the ropetty described above, by virtue of a warranty deed recorded in Register of Deeds Office. ATURB F fAPPLICANT 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 Vill.1442PACE 42 STATE BAR OF WISCONSIN FORM I. 1998 606841 KATHLEEN H. WALSH REGISTER OF DEEDS This Deed, made between Kathryn B. Tularen, and Ferris — ST. CROIX CO., WI R- T111 gran , wi f npA h­ FOR RECORD Grantor, conveys and warrants to 07- 14-1999 11:00 AM Sam E. Miller, a single person. WHANTY DEED EXEIFT 1 Grantee. CERT COPY FEE: Grantor, for a valuable consideration, conveys and warrants to Grantee Corr FEE: the following described real estate iit St. Croix ` County, State of TRANSFER FEE: 2221.10 RECORDING FEES 12.00 Wisconsin (The "Property "): PAGES: 2 I Rgoordi4a Am Name and Return Address 001(02-10 010- IMI -90: 040.1024.20: 010.1021 -70 Parcel Idetaitiation Number (PIN) This is not homestead property. (See Attached Exhibit "A ") i Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any Dated this 13th day of July, 1999. • ' adwyn B. ulgrcn 17 «n ­9� ,? ' Ferris R. Tulgren AUTHENTICATION ACKNOWLEDGMENT Signarurc(s) STATE OF WISCONSIN ) ) ss. authenticated this _ day or St. Croix County ) Personally tune before me this ] 3 dsy • of July, 1999, the above named Ka(hryn B. TuIrren. , TITLE: MEMBER STATE BAR OF WISCONSIN and Ferris R. to (If rot. me row. t the per (s) who executed the foregoing authorized by 1706.06. Wis. Stan.) ins( ru and aclno ge ttx sa THIS INSTRUMENT WAS DRAFTED BY Gli , Attorney Kristin Ogland Hudson, Wl 54016 N blic, Sute of Wisconsin (Sisnawres maybe authenticated or acknowledged. Both arc nor My Com mi i0 s.,pe d �ni. (if not, state expiration date: ACe Bread& Poulin T CA Notary Public State of Wisconsin "Names of persons signing in any capacity should be typed or printed below their silrratures W AtaANrY Dana arATZ a" or w5com" YOM N.: -1906 .F0AWT10N Mt09E0a10NK1 C0WAHY FOND W UC, 0 900499.2021 1442 43 EXHIBIT "A" That certain parcel of land located in the NE'/+ of SE ' /• of Section a and in�tan a 9 1/+ W 1/4 and the NE 'A of SW 4/' of Secti isconsin i ore fully described as follows' of S St. Croix County, W , West Town of Troy, Beginning t the West quarter comer tine said Section 5) distance of to a g on the East -West quarter er l (recorded bearing 854.00 feet; thence N87 °51'0 E, 288.00 feet 2342.24 feet; thence S00 °13'24 'E. i • thence along said East line, point on the East line of said NE ' /+ of SW o of said W'' /+ of SW al .E' 08 feet to the SE corner of said NE '/• of SW ' / +; thence along the S00 °13'24 66 4 41 feet; thence N00 °30'28'E, 170.48 feel; thence the a lo n g said S8 South line of said of SW ' /+ and the South �n 4 of SW' / +; thence along of said NWIA 7 °54'64 23 941.26 feet, thence 273.91 feet to the monume�rded as N01 32'36 "E), North line of said NE' /� West line, N00 30 r E ( ° ,, 458.40 feet to the N64 °57'47 "W (recorded as N63 54 50 W). N88 °20'13 "E (recorded as said North line, to the Point of of SE '/, of Section 6, thenc* a g 69 feet (recorded as 26'A rods) S88 °40'19 "E and N89 24 42 E), Beginning. / Ya !l Y � I s ' N I P' �� mb� St � F' • 3H1O A8 Q3NMt0 SON - Ail Sa IAI vi Y )XVit Nr •— .YI'U191 LYt.1l �U S - - -- { 3 q Q AT M ].ILCI.)5 III �rYU .-I 1 l' .90 lyd I yy boo — d` , �t ui y ml Tt C r -.. •Y� Q t`. -' °'� /'cr ,rf I)Ri© 8 cc ZI J rYOlr �N�/ 1 lL•9C.S S �! r dP Aj �NSl c •�. e i �21 �• , • _7 � .�' �`y(� I • , s�lvs IIL51!w'wY'y� . _te _ s' I �S �'Ju5 �I11SY /III .97 &.40. 5'. - - -- - --- \ m 1 Z No. xx I ! .• jiflO I 3.I f•(N W i I ! !s i bl I', ' • 'I F w j V V9 F \p ! AA sr "• _i .�ui.or.o N V M y 'K .WN/ r "i16 I.9G.%o N 4T Y' II I ' / ° Is .9C.u.1o w tll E >I 1 ?� �f�b�C�ad S1HJI3H �Ia�ON � .. I i �� -- a �: l '.�. � / r,a; �.. ``''1r �`'�Ii i � -. li 1 J � I I i I J r 1101 Carmichael Road Hudson, WI 54016 Phone: (715) 386-4680 St. Croix Fax: (715) 386-4686 Zoning Department Fm To: Jae Olson or Tammi From: Shaw Moe Fax: 386 -9281 Date: July 25, 2000 Phone: 381 -5000 Pages: 2 Re: Septic Report — Fro ntier Lot 14 CC: ❑ Urgent x For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle -Comments: ST. CROIX COUNTY WISCONSIN ZONING OFFICE AN "Ali r n �,,, ST. CROIX COUNTY GOVERNMENT CENTER \. 1101 Carmichael Road Hudson, WI 54016 -7710 (715) 386 -4680 Fax (715) 386 -4686 July 25, 2000 First Federal Attn: Jae Olson 201S.2 n, Street Hudson, WI 54016 RE: Septic Inspection for Sam Miller located at 429 New Century Drive, Frontier (Lot 14), Town of Troy, St. Croix County, Wisconsin Dear Ms. Olson: A septic inspection of the above referenced property was conducted on July 18, 2000. This property is located in the NE 1 /4 of the SW'/ of Section 5, T28N -R19W, Frontier (Lot 14), Town of Troy, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a four (4) bedroom home. If you have any questions regarding this, please contact our office at (715) 386 -4680. Sincerely, 1� �V� &Axt, Kevin Grabau Zoning Specialist �s m cc: file