HomeMy WebLinkAbout040-1035-90-200 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
453298 0
GENERAL INFORMATION (ATTACH TO P,,EIW,AIT� State Plan ID No:
Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)j.
Permit Holder's Name: City Village X Township Parcel Tax No:
Seaok, An _Wo Troy Township 040 - 1035 -90 -200
CST BM Elev: Ins !A BM Description: -7 �v Section/Town /Range /Map No:
<• -K� -15 08.28.19.115D20
TANK INFORMATION EL ATI N DATA 0 •,
TYPE MANUFACTURER CAPACITY STATION BS HI I F Q � V�
Septic Bench ark
C. C
Dosing Alt. BM
Aeration Bldg. Sewer
`17•z � ��� �; .z -f
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet _
Septic r Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe L cr
fr �i - ;
Holding Bot. System s� �L 4 r 3 l 1 S
5 '1
PUMP /SIPHON INFORMATION Final Gradenw r 9X 1 2.1
Manufacturer Demand St Cover
[- t4A C� u� GPM
Model Number
1- 1 X7.
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM m Z -&'L-
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L JBLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number:
C:..� .1 V a...y�'� c..� r-- �`. - rr' `1' r"•+ i`i, Tr.ti,._r .S�C� � �-�
DISTRIBUTION SYSTEM
HeaderNanj .:10 Distribution x Hole Size x Hole Spacing Vent to Air Intake
1 Pipe(s) - -._
`` -- / f" <
Length �"'� pia -� Length in
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 i Yes it No Yes No
COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / 'Z .Z I nspection #2:
Location: 430 Red Brick Rd Unknown (NE 1/4 NW 1/4 8 T28N R1 9W) NA Lot 7 Parcel No: 08.28.19.115D20
1.) Alt BM Description = _ S _ <_� z '� c r a f'
2.) Bldg sewer length = 2' �" ' S ` j •�
- amount of cover= "! 1 t<_..IL 7 a �.4 hc. szi_ �_ " tl i, ir,_c.- l..a,c. i� c✓� t �
Plan revision Required? Yes No L.,11r� L1 -
Use other side for additional informatio
Date Insepctots Signature Cert. N
SBD -6710 (R.3/97) ( `� t :4 G r " U t% t -t_ 6 Z, R
� � w
N
N ���.r� Count
Safety and Buildings Division y
201 W. Washington Ave., P.O. Box 7162 _ C ro l
= Madison, WI 537 — 71 Sanitary Permit Number (to be filled in by Co.)
sconSI (608) 266 -3 PAID
De artment of Commerce Slate P lan I.D. Number
Sanitary Permit Application A
In accord with Comm 83.2 1, Wis. Adm. Code, personal information you provide Project Address (if (Ccrenl than mailing address)
may be used for secondary purposes 1'rivac ) (s1>}-------- ,--
1. Application Information — Please Print All Informatio 1 13 0 1L
Property Owner's Namc V l'arccl ll � Lot Block
# 11
BONING OFFICE
Property IACaII°n
Property Owner's Mailing Address _
4 \j c>rl1 �OaA aaa - O A
City, State Lip Code Phone Number
U(,o (cir Ic
T S.ixv_ N: K °
bl
II. Type of Buil(iing (check all that apply) ✓ /I„ M Number
1 or 2 Family Dwelling - Number of Bedrooms ✓• 17 . `t` 73 T /
❑ Public/Conuncrcial - Describe Use
3 ❑City_❑villagc XToNmship of 1 r - _ �_
❑ State Owned - Describe Use
III. Type of Permit: (Check only one box on line A. Complete line B iC ppl cable)
A. )(New System t ,Replacement System ❑ Trcauucnl/Holding'fank Replacement Only ❑ Other Modification to Existing System
B. ❑ Pcmiit Renewal ❑Permit Revision El change of El 1'crmit'frans(cr to New
List p permit Number and Date Issued
Before Expiration Plumber Owner
IV. T e of POWTS S stem: Check all that appl
i(Non - Pressurized In- Ground ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand
❑ Aerobic Treatment Unit ❑ Rccirc aging Sand Filler ❑
Gonslrocicd Welland ❑ Pressurized In- Ground ❑ llolding'1'ank El 1'cat Niter � 1
Recirculating Synthetic Media Filter 11 Leaching Chamber ❑ Drip Line El Gravcl -less Pipe El other (explain) /
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil Application RLatc(gpdsQ Dispersal Area KcquircJ (sQ Dispersal Area Propose (s System Elevation .6t
C�
VI. Tan m Info Capacity Total Numbcr Manufacturer Prefab Site Steel ibex Plastic
Gallons Gallons of Units Concrete Constructed Glass
I � G tsa �}. --(t7D
1 f_
Ncw Existing
Tanks Tanks
Septic or Holding Tank
Aerobic Trcatmcnt Unit C
Dosing Clamber 1 w >
VII. Responsibility Statement I, the undersigned, assume respo sibility for installation of the I shown on the attached plans.
Plumber's Name (Print) Plumb S' ature MI'/MI'RS Number Business Phone Number
1 �z� le- C
t �
Plumber's Address (Street, City, State, Zip Code)
1 Coun /Dc ;'artment Vic onl
Sanitary Permit Fee (includes Groundwater Date Issued suin Agent Signalu a (No Stamps)
� pproved ❑Disapproved
Surcharge Ircc) `
❑ Owner Given Reason for Denial ✓ v
IX. Conditions Appro al
3 >
SYSTEM OWNER: Lk "3
1 Septic tank, effluent filter and Z � �
dispersal cell must all be serviced / maintaingd �Sa 2_ SM-� as per per management plan provided by plumber.
2. All setback requirements must be maintained lS r^sQo t�• �j—
as per applicable code /ordinances.
Attach complete plans (to the Counly only) for the system on paper not Icss than 8I/2 11 inches In size
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' Private On -Site Wastewater Treatment System (POWTS)
Index and Title Sheet
Owner: - Ai"
Project Name and System Type: `V h� e Qe d'oo
Location: X41 � Q�
e� �� Z cso ► �O llo
Street Address
Legal Description
Township/County
Contents: Page l:
Page 2:
Page 3: 1�� �Qioc.. CVEE A :ep �u Pp Cs�vv�
Page 4: 7 40b" N \OO
Page 5: V00
Page 6: Vym Ot 1 n2Y'S
Page 7: y es wnac e.A - �bm���iu� c�.n
Page 8: O�J`CS
Page 9:
Attachments: i es �e r
Plumber/Designer: e, Signed:
Credcatial Number: tR a to Date: Lo -a-O__V ,
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SEPTIC TPNK b'PUMP CHAMBER CROSS SLCTION AND SPECIFICATIONS
WEATHERPROOF
JUNCTION BOX APPROVED
'lank vent shall terminate in accordance WITH CONDUIT M OLE C
with s. Comm. 82.31( WARNING LABEL
FINISHED GRADE �qn MIN.
18" IN • •���
INLET
GAS-
WATER TIGHT SEALS TIGHT i pPROVED
_ A SLAL JOINTS -WITH
ea��le Fill 7 -�' i ALM
PROVED PIPE
APPROVED Pfo.t4:+ • -4/1 — ON SOLID SOIL
PIPE 3' tYlodel � /.�'icd � �
ONTO SOLID C OFF A* RISER EXIT
SOIL PUMP OFF ELEV . ° IT. PERMITTED ONL
D I F TANK
MANUFACTURER
HAS APPROVAL
Bedded in accordance wit , product approval unde COComm 84PAD
SPECIFICATIONS
SEPTIC / DOSE u NUMBER DOSES PER DAY
TANK MANUFACTURER: F - DOSE VOWME INCLUDING .�'� Z '�
SEPTIC /� G' GAL. FLOWBACK: GAL.
7`ANK SIZES: DOSE GAL.
Lz.� -v
CAPACITIES: A
�, z«�C,�,'c:
z� INCHES = 3%3. �y GAL•
MANUFACTURER: v �— r G -
M GA
ALAR _ r.
R • wi _ 2 INCHES
MODEL NUMBS y 4Z B
SWITCH TYPE: ����`' j /34r�2
SW I "-�� -- _
C INCHES _ GAL.
PUMP MANUFACTURER: c . INCHES Iq 9, GAL
MODEL NUMBER: Gi�ti D s / : _•„__ _.
SWITCH TYPE'
REQUIRED DISCHARGE RATE GPM PUMP E ALARM WIRING AS PER ILHR 16 WA(
o-0 FELT
VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIPUTION PIPE • .�� FEET
� MINIMUM NETWORK SUPPLY PRESSURE .°7' § •x • ' • • '
FEET
+ /'o e FEET FORCEMAIN X FT /100 FTDTALIDYNAMICAHEAD •=
INTERNAL DIMENSIONS OF PUMP TANK: LENGTH ; WIDTH_ ___
LIQUI bLTFr"
d
3
F ilter
d Comore rcial T ank
FF.
an
Lb e l
A100 R
Why do septic ranks need an Al
00 Zabel Filter? and rental properties all have two things in
I
Homes, schools, churches, shopping centers, apartment
common: Exrremcly high wastewater peak rates and no way to predict what the users of those septic
systems are likely to put down their toilets and drains. Every year [housands of drain fields fail and under
1 *0 expensive repairs because they,are clo.oed with Solids than gor out r,f an un filtered tank.
What does an A100 Zabel Filter do?
Tle
X100 filter removes up c� 909(, of the solids and `l5 " of the I3QD" hat l Prn eerTrh n
A100R l
field from clogging with solids.
How often does the A100 Zabcl Filter need Servicing?
- filter is viraially self cleaning. Anaerobic organi.ms on the tilt kr dis tan`iacd residential installation
The
causing them to lose their buoyancy and fall to Lite bottom Of the can I
the filter only needs to be cleaned when the tank is normally sere'iced l) the � asc watcr tallations
servicing will depend on the tlow rate tend solids loading characteristics
What is the difference between a filter and a screen?
The larger filtration area of
screens (usually five to eight
tunes the size cif filters) and the
(1;f3 inch tii•: ;•:.t .,. :•;.,r,.;�,,.:;�.�►�.'t::,rr?'
larger screen openings
for screens versus 1116 inch for kr�X.'i2'.E�
filters) are required because
screens tend to plug easily `and
collapse. Zabel's exclusive pat-
ented disc dam design provides
198 lineal feet of filtration in a
compact packagel6 inches
high and less than 12 inches in
diameter making it the easiest
filter on the market to install
and service without sacrificing
its ability to remove solids from
the waste stream.
Call 1. 800 - 221.5742 or Fax (502) 267 -8801 for further information.
C ommercia l
E$ up - n f e�
SPECIFICATIONS
�-0
APPLICATIONS: The A100 is used in residential and commercial sepcice
i e ffective in multdamilyhousin�, � m t�ol s ids content. : 3
and everywhere wastewater has hlgatsprntled j
FLOW RATE: 3,000 �pdper. er
. Install two or more filten inaMorconcrete
manifold to ac hie v e flows of 6,000 Qpd or more. Check with Zabel
for details.
The 26 Disc D ' ams 0 1!16 inch provide 198 linttii feet of 2
FII,TRA11 filttation.
The filar may be installed inside the. tank or installed in a Zabel
IIJSI'ALLATION: Container Assembly outside the septic tank. k
SSRVICF: ,
Service residential installations whenever you pump the tank.
t • ...... ..�
O
So O.D. 41!2' I.D. I
i @ '
tests'- -`
I
I 1t•13/tE' t
DIA
a•altr
'i
1 lilt
it
11
4n
�`.
•-- 11.3!8'. DIA. —
lnm Dnett ton-
mamrw speci>BCAtiOTU VATVJ& 2 26 Ptla+<
Cases, Lids, Reducers Rigid Vinyl PVC 87371 UST 3 1
Discs High Impact Polystymno 4 3 Rod
Rod, IJuts High Density Polyethylene 5 HIM
U.S. Patent No. 4
Ca111- 800.221 -5742 or F ax - (502) 267 -8801 for further information.
Put 3.20b
File name. = J C 2beYcgra1o0 A 100.w7xs
POWTS OWNER'S MANUAL MANAGEMENT PLAN
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner � Qe,..o v�
Sep tic Tank Capacity hoc 1 ❑ NA
Permit # Septic Tank Manufacturer jv_o, ❑ NA
DESIGNPARXMETERS Effluent Filter Manufacturer ❑ NA
Effluent Filter Model ❑ NA
Number of Bedrooms 100 droom J ❑ NA Pump Tank Capacity 1 ❑ NA
Number of Commercial Units NA Pump Tank Manufacturer ❑ NA
Estimated flow (average)* al /da Pump Manufacturer ❑ NA
Design
* Ida
est imated x 1.5 a / NA
flow k cst ❑
(peak Pump Model
Soil Application Rate al /da ft Pretreatment Unit ❑ NA
Influcnt/Eftluent Quality (NA❑) Monthly Average" ❑ Sand/Gravel Filter ❑ Peat Filter
Fats. Oil & Grease (FOG) < 30 ing/L. ❑ Mechanical Aeration ❑ Wetland
Biochemical Oxygen Demand (BODs) 220 mg/L ❑ Disinfection ❑ Other:
Total Suspended Solids (TSS) Manufacturer: Model:
s 250 m Dispersal Cell(s)
Pretreated Effluent Quality Monthly Average "' In-ground (pressurized)
y �In- ground (gravity) ❑ gr
Biochemical Oxygen Demand (BODs) < 30 mg/L ❑ At- grade ❑ Mound
Total Suspended Solids (TSS) <_ 30 mg/L C3 Drip-line 1] Other:
Fecal Coliform (geometric mean) Leaching Chamber Manufacturer ��.���cc+i�
<10 cfu/100m1
Model C .Aj &A n
_ Approval Stipulatio_
Maximum Effluent Particle Size 1/8 inch diameter Soil Application Rate�_gpd/ft Area Req.
*Wastewater Flow Verification on and calculations:
(Other than bedroom based) Absorption Area Credit per unit kq • 1 W
Minimum Numbcr of Chambers 3
❑ Aggregate Design Flow /Loading %itc =_ ft min
** Values typical for domestic (non - commercial wastewater Materials: all materials must comply with WI Adm. Code
COMM84 and be installed per manufacturers specifications
and septic lank eflluenL
** *Values typical for pretreated wastewater. and approval letters.
DESIGN CRITERIA
❑ "Wisconsin At -grade Soil Absorption System, Siting, Design & Construction Manual" (Converse et.al.1990)
❑ "Wisconsin Mound Soil Absorption System: Siting, Design & Construction Manual" Converse, J.C. and E.J. Tyler.
Publication 15.22
❑ "Design of Pressure Distribution Networks for Septic Tank -Soil Absorption Systems" Publications 9.6
($1 "Design of Conventional Soil Absorption Trenches and Beds ". R.J. Otis – ASAE Publications 5 -77 and "Design Manual –
Onsite Wastewater Treatment and Disposal Systems'. EPA 625/1 -80 -012 October 1980
❑ SBD – 10570 –P (R.6/99) "At -Grade Component Manual Using Pressure Distribution'
'K SBD – 10567 –P (R.6/99) "In Ground Absorption Component Manual"
❑ SBD – 10705 –P (N.01 /01) "In Ground Soil Absorption Component Manual" Version 2.0
❑ SBD – 10628 –P (N.6/99) "Recirculating Sand Filter System Component Manual"
❑ SBD – 10656 – P (N.6/99) "Split Bed Rccirculaling Sand Filter System Component Manual"
❑ SBD - 10572 –P (R.6/99) "Mound Component Manual"
❑ SBD - 10691 –P (N.01 101) "Mound Component Manual" Version 2.0
❑ SBD - 10595 –P (R.6/99) "Single Pass Sand Filter Component Manual'
❑ SBD - 10657 –P (R.6/99) "Drip -line Effluent Disposal Componcnt Manual"
❑ SBD - 10573 –P (R 6/99) "Pressure Distribution Component Manual"
❑ SBD - 10706 –P (N.01 101) "Pressure Distribution Component Manual" Version 2.0
❑ Drip - line Effluent Dispersal Component Manual for Multi - flo Onsitc Wastewater Trcatincnt Units
MAINTENANCE AND MANAGEMENT
MAINTENANCE MONITORING SCHEDULE
Service Freq uenc y
Service Event months year(s) (Maximum 3 rs.)
Inspect condition of tank(s) At least once eve ❑
Puri out contents of tank(s) When combined sludge and scum equals one -third (1/3) of tank volume
c dispersal cell(s) At least once every ❑ months year(s) (Maximum 3 yrs.
Inspect lter At least once every ❑ inonths years)
Clean t disp cfflucnt r a eas
❑ months ❑ year(s) r NA
Ins cct um , um controls & alarm At Icast once every
Flush laterals and pressure test Al last once every ❑ inonths ❑ ycar(s) ❑ NA
Valves At least once ever} ❑months ❑ ear(s) ❑ NA
At Ieast once every ❑ months ❑ vcar(s) ❑ NA
Other: Page of
V
�J oD�L. lOa
Maintenance
The interval for servicing septic tanks is set by state and local code. Throughout the United States there is a
wide difference of opinion on what this interval should be, but mos; regulatory agencies suggestuo to five years.
The Zabel'" filter, which does not increase the frequency of servicing for the tank, should be cleaned when the
septic tank is normally Inspected and pumped. However, our filter is virtually self - cleaning. The continued action
of the anaerobic organisms on the Zabel filter causes lod particles'to disintegrate and fall to the.bottom of
the tank. If your filter contains a SmadFilter alarm, you wlll be notified by an alarm when the filter needs servicing.
To ser 6e the filter:
'SerWcing any zabel filter should only L9 done by a certified septic tank pumper or installer.
F
Locate::the
outlet of the '
septic'atank.
Flrmly pull the filter handle
5 3
and slide the cartridge out
Remove the tank 8bV0lry of the cASd..'
and pump the tMf111;. 'Note: A tee handle may h
` necessary to to be used if the titter Is foci t11Rz
any Sol below ground level to'
escaping to t C on t act zat»r for info !
when the
re
r
f; f
While holding tf1•� 4 ' + '
the access t�l tkfi elf 111�M,1t Insert the dbet'
cartridge with back In the`
careful to rinse all sure the 0
*Note: It Is not completey
The
bebOon
m r bs PC place
41101 M VM
The product(s) showri an cc by one or more of the following patents:
U.S. 5,762.793.5.6N,453.5,591,331. 5,759,393, 5,583,577,5,5.;_;2,716,5,779,W- 5,583,504,5,795,472, 4,710,2 s,3n,3sT, 5,02,e2A
U.S. Dee. 386,24t, 349067, 4805501,5098568, Da s. 309007, Australta :134440: Canada: 2,135,937; Israel: 111574: Am Zealand: 284824,
C 'tier Patents Pwe no
Cali for a free ZABEL <_ONE An Qnsite Wastewa :` 4agazine 1-x.00 -221 -5741' - Websito httpl/www.zaeei.c'om
AI08M.I.M.614"
❑ Mound, At- Grade, In- Ground Pressure
The inspection shall include recording the levels of ponding, if any in tic observation tubes and a visual inspection for any
evidence of surface seepage or discharge. Any dischargc to die ground surface must be promptly reported to the regulatory
authority. Ponding greater than 75% of die height of the compontnt may indicate overloading or impending hydraulic failure
necessitating more frequent monitoring.
The pressure distribution systcm is provided with an opening at the end of cscli lateral to be used for fluslung. Tlhc laterals
should be flushed at least once every three (3) years. Pressure checks of systems with multiple laterals should be done to
ensure that equal distribution of effluent is occurring to promote the longevity of the systcm.
REPORTS
Reports for maintenance, inspection, and monitoring shall be submitted in accordance with COMM 83.55 Wisconsin Administrative
Code.
ABANDONMENT
Whcn the POWTS fails and/or is pernancntly taken out of service the following steps shall be t aken to ensure that t1C SySIC1h1 1S
properly and safely abandoned in compliance with Ch. COMM 83.33 Wisconsin Adminis s s o d e. .
All piping to tanks and pits shall be disconnected and the abandoned pipe openings
- The contents of all tanks and p its shall be remo s tcd n rot o spos oo b
ers S epoved
gc and die S ervicin g O
filled with
- After pumping, all tanks an p
soil, gravel or other inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, top ovidc a code compliant
replacement system:
d and may be utilized for the location of a replacement soil absorption system.
A suitable rcplaccmcnt area has been evaluate
Tlhe replacement area should be protected from disturbance and co►npaction 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 ill the
rom existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
need for a new soil m r o new soil and site evaluation to establish a suitable rcplacccnt area. Replacement systems must
result in the need l
comply with the rules in effect at that linee.
❑ A suitable rcplaccmcnt area Is not available due to setback and/or Solt hlhUlali011S. Barring advances in POWTS technology a
holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has riot been evaluated to identify a suitable replacement arca. Upon failure of the POWTS a soil and site evaluation
must be performed to loc ate a suitable rcplaccmcnl -area. If no replacement area is available a holding tank may be installed
as a last resort to replace the failed POWTS.
[3 Mound and at -grade soil absorption systems may be reconstn►cted in place following removal of the biomat at the infiltrative
surface. Reconstructions of such systenhs ►nest cou►ply with the nlles in effect at that time.
<<WARNING>>
SEPTIC, PUMP AND 01 TREATMENT TANKS MAY CONTAIN LETHAL GASES AND /OR INSUFFICIENT
OXYGEN. DON
NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMS
DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY DIFFICULT Y BE
IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLE POWTS MAINTAINER
Name �hti V,
t✓
L"
Name e' Phone �� -
, i�
Phonc ( � - LOCAL REGULATORY AUTHORITY
SEPTAGE SERVICING OPERATO (Push her
Name Cw`��- cwS V` A vcncy � CcoCX r`
Phone l �4bS0
Phonc`1k� 3•la-
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wisoonsln Department of Commerce SOIL EVALUAT i PORT Page _ ` of
DhAslon of Safety and Buildings f•�
in accordance with Comm 85, Wis. Mm. ode ty
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Attach complete site plan on paper not less than 8 112 x 11 inches In size. Plan must
Include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. tcN� 1►1G
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Plt3ase p rint r evlew Date
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CST Name (Please Print) Signalur CST Number
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Address Date Evaluation Conducted Telephone Number
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i 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 Try 608- 264 -8777.
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224832
PK: 61- -x4 -o3
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer �� d X-
Mailing Address 1 4 l le �-
Property Address
(Verification required from Planning Department for new construction) 1Q.�
City/State ��d tJ Parcel Identification Number 0 I d3s - 90--20
LEGAL DESCRIPTION // 5 2 0 zo)
Property Location '/4, � %' Sec. T 2 N -R _W, Town of
Subdivision . Lot #
Certified Survey Map # Volume . Page # S
v/Warranty Deed # S S 3 3 Volume - � 51 - 7 - , Page # �5
Spec house ❑ yes no Lot lines identifiable U ❑ 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
mastor 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.
I/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
ds o hree year expiration te.
F APP 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 owaer(s) of
the pro
rty described above, virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE OF APPLICANT 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
ST. CROIX COUNTY
WISCONSIN
ZONING DEPARTMENT
ST. CROIX COUNTY GOVERNMENT CENTER
N ■ ■ ■, — . ■r 1101 Carmichael Road
Hudson, WI 54016 -7710
Phone: (715) 386-4680 Fax (715) 386 -4686
www.co.saint- croix.wi.us
To: m:
P ages:
Phone: Date: !�L
R CC: LL
low- A.,
❑ If this box is checked please submit a check for a $5.00 fax fee made payable to "St. Croix
County Zoning" along with a copy of this fax sheet to St. Croix County Zoning Department, 1101
Carmichael Road, Hudson, WI 54016.
• Comments:
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Glen pelike Plumbing,
Heating and Well Drilling
Inc.
3.;5 ItIVoIA do AYlatle
?iaMdnvi, WI5�755
-13CS-MI"
............ x;:•.
C
Z Faz: To: C, O' ^X
From Glen PelkePlbg, Well Drill Fax 715 92()' -3840 _._.,.•- .— . �– =J•� –._
_ Pages.
Date:
❑ Urgent IX For Renew O Pleeee Cwww t ❑ Plem Reply ❑ Piem Recycle
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WEL S . PRESSURE SYS MAS . SE'P! SYSTEMS . VME PLUMWor- . HEATNG . AtR =MffIpNM
715 ti28Gi816 T4�
08 323-M
... ...............................
...,
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TO 'd bZ: ZZ 170, 17 Unf 6b82- 9Z6 -SZZ: xp3 '91H '8 '9H�d 3)1 N3�9
LEGAL ST. CROIX COUNTY, WISCONSIN OLD TXSCR02
REAL ESTATE TOWN OF TROY
COMPUTER NUMBER 040 - 1035 -90 -200 Parcel Number 8.28.19.115D -20
OWNER NAME: First GARY A Last SACHSE
PROPERTY ADDRESS: Hse # 1/2 PD -- Street Name -- Type SD Apartment
RED BRICK RD
SECTION 8 TOWN 28N RANGE 19W 1 /4160 1 /440
Line Description Line Description
TOTAL ACREAGE 2.739 PLAT CSM 17 -4567 040/03 LOT07 BLK
01 SEC 8 T28N R19W PT NE NW 15
02 LOT I CSM 3/659 (5.805 16
03 NKA CSM 17 -4567 OT 7 17
04 (2.739AC)��--
05 19
06 20
07 21
08 22
09 23
10 24
11 25
12 26
13 27
14 28
F1- General, F4 -Prev. Parcel, F5 -Next Parcel, F7- Valuations, F8- History, F10 -Exit
GLEN PELKE PLBG. & HTG. Fax : 715 -926 -3849 Jun 4 '04 12:27 P.01
to 13 05:09 FAX
NOR Tow NOME
1823 HiphWOY 53 C/�(�c/�-
swt Falls, WI 5 9
472
Ch pp r �
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715) 832 -5003 J7 63 soon �► 61 S �
MARINER
N Towne Rom fea res
d d ' rice of home:
out *Plush Carpet +NO-WAS Vinyl by Coa9
*Drywall Through pastel Cabinet Doors
.r nod
Dry ack -u Raised 'Rardw,
,r tan
with Battery 8 p
tec
Smoke De ountertoPs
aa,rdwood
Stiles x'25'' Wgb- Pressure Lamimte C
$Ceramic Backsplasb ThroughOilt. De l a oll ts O
Sinks
+one -Piece Fib Tub /Sho >
ced T
Service
wSwitched Light in All Wslk'In"Ci �se CA �I,t�Lto 1 Shut- Off
*40 Gallon Electric Water Heater M I
*E * t e ry o r Water Faucet Two GFI- Panel
,Vinyl Front & Rea t D ors w/Dcudbolt
*O,S.B. Sheathing Under Siding 8t ae16
Locks +Vinyl Insulated Windows w/ T,on - Glass +216 EYtkrior Walls "
on 16
ea + x4 for it O tt ' Ca t
*5112 Roaf Plteh *90 Plus Efieient Gas Furnace *Ssud Microwave r L
+ Sid b Side Fridgc wnee is Door Space ma
t. 9
22C`u F Y Dishw asher
iSa ning Range *6 Panel Interior Doors `3 Ceillug Fans w/Ligbts
� her D
lf Clea
*Garbage Disposal *Pat scrub
*R if Clou Can Lights e o
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U 2 5 1 ? P 5 5 8 - 7 ss 335 I �
STATE BAR OF WISCONSIN FORM 5 - 1998 KATHLEEN H. WALSH
PERSONAL REPRESENTATIVE REGISTER OF DEEDS
Document Number
DEED ST. CROIX CO., MI
RECEIVED FOR RECORD
Tamera L. Sachse , as Personal Representative of the Estate
of Gary A. Sachse "Decedent "), for a valuable consideration 02/27/2004 09:4$AM
conveys, without warranty, to Senok An and Hwichul Kim wife and d PERSONAL REPRESENTATIV
husband , Grantee, EXEWT #
the following described real estate in St. Croix County, State of Wisconsin REC FEE: 11:00
(the "Property"): TRANS FEE: 246.00
That part of NE 1 /.NW r/4 Sec. 8- 19W and SE t /.SW 1 /4 r 5' COPY
178N-RI9W described as follo .Lot Certified Survey i1la PAGES: 1
4567 as Doc. No. 731741. St. ounty, Wisconsin.
Recording Area
r
Name and Return Address
David J. Estreen
304 Locust Street
Hudson, WI 54016
040-1035 -90-000
Parcel Identification Number (PIN)
Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property which the Decedent
had immediately prior to Decedent's death, and all of the estate and interest in the Property which the Personal Representative has
since acquired.
Dated this -10 day of February , 2004 e
* * Ta mera L . Sachse
Personal Representative Personal Representative
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF UJ rSC,4A&r�j )
) ss.
tt- FA County )
authenticated this _day of _
Personally came before me this ZO day of
February , 2004 the above named
Tamera L. Sachse, Personal Representative of the Estate of
* Gary A. Sachse
TITLE: MEMBER STATE BAR OF WISCONSIN --
(If not, to in sown to be the person(s) w $d Aje foregoing
authorized by § 706.06, Wis. Stats.) ;, � o '•��
ins nt and acknowledged th 'G5T �"•• � ,:
THIS INSTRUMENT WAS DRAFTED BY
A tto rn ey Kristin Ogland
Huds WI 54016 Notary Public, State of
My Commission is permanent.
(Signatures may be authenticated or acknowledged. Both are not necessary.) `'\„ _3+•' ` )
* Names of persons signing in any capacity must be typed or printed below their signature. Information vc3sionals Co.. Fond du Lac. W
STATE BAR OF WISCONSIN 800 -655 -2021
PERSONAL REPRESENTATIVE'S DEED FORM No. 5 - 1998
7 3 1 7 4 1
VOL 17 PAGE 4567
XATHLEEA H. MALSj
REGISTER OF DEEDS
ST. CROIX CO.. MI
RECEIVED FOR RECORD
07/23/2003 10:O0AM
CERTIFIED SURVEY MAP CERTIFIED SURVEY MAP
DrC FiiB }.b 00
LOCATED IN THE NE 1/4 OF THE NW 1/4 OF SECTION 8 AND COPY FEE: 4.00
THE SE 1/4 OF THE SW 1/4 OF SECTION 5, ALL IN T28N, R19W PAGES: 3
TOWN OF TROY, ST. CROIX COUNTY, WISCONSIN, BEING ALL OF
LOT 1. CERTIFIED SURVEY MAP, VOLUME 3, PAGE 659. N 1/4 CORNER
POINT OF . \ SECTION 8
BEGINNING \ T28N. R 1 9W
1327.66'
.\ \\
ER ,
bmiv Q c
i \ \ 441 RED BRICK ROAD 4o
\ HUDSON, WISCONSIN 54016
NORTH LINE OF ` \
o\
I\ THE NE 1/4 OF
THE NW 1/4
LOT 6 s� *� \ \ IN, 1 S 1/4
{\ .�� �• \ d� SECTION 8
\ T28N. R 19W
' ' C ,
go I ^ Z coo
O I 3 34 v9'.
�I �^
cc
W I� <o , LOT 7
\
� I N Z e ( nI W u; � a nd Ou'v \
° APPROX /ANTE < N C rr.
W I Z EX /ST /Av SEPT /C I rn $ <\ �U 2 2 �' ""
M�C
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NO A CCES' a' s s4• . $ r � c4 6 �c / 3
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SHARED DRIVEWAY \
EASEMENT (SEE
LEGEND NOTE 2 ON PAGE 2)
Lu
ALUMMIN S COR NER MONUMENT,
NUM CAP, FOUND m L 0l
40 1 1/4 1 RON P I PE, FOUND. ZM ZO —lo-
0 1.68# LINEAR FOOT. ICI L�9Cz��Z` -4 SCALE IN FEET
BUILDING SETBACK LINE, 50'
-- UNLESS OTHERWISE NOTED. 0 50 100 200 300
(!t-- ) PREVIOUSLY RECORDED INFORMATION.
THIS INSTRUMENT DRAFTED BY JEROD A. FINK PAGE 1 OF 3
Vol. 17 Page 4567
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