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HomeMy WebLinkAbout040-1306-07-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 488278 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: w/ Personal informati y ou p rovide may be used for seconds p urposes [ Privacy Law, s.15.04 1 m %_ / Y P Y second P P I Y O( )1 Permit Hower',# Name: City Village X Township Parcel Tax No: Y ork, Adam Troy, Town of 040 - 1306 -07 -000 CST BM Elev: Insp. BM Elev: IBM Description: Section/Town /Range /Map No: 91 40 1 CST AC I _ 08.28.19.1834 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV t 9.1 Septic w 1 Benchmark-W2— b Z� r Dosing Alt. BM 5.o I n •z Aeration Bldg. Sewer Ho Ing St1Ht Inlet j St/Ht O utlet TANKS TBACK INFORMATION ti7 • q�• 3l' TANKTO PIL WELL BLDG. V ent o Air Intake ROAD Dt Inle S ept ic > 51 75 30" B ott om osing Header/Man. 1� •,� / 3• o l era lon is . 1pe � o mg o. ysem� ! 2. 3 �'� , I Z, 2.� Ina ra e PUMP/ PHON INFORMATION 5 `I'`i• 1 m anufacturer D e mancl StC over (p•D q• 2 m odel um er I UN IL ITt FricrN oss I system ME e 1 c J . (p dL ri I DIMENS101 S 1 Of PITS lliblue Uld. [qulu EMptil NS 3 ea. INFORMATION CHAMBER OR S / UNIT rc UM apdully Pipe(s) Lengt Dia L th Di Spacing '} x Pressure Systems Only xx Mound Or At -Grade Systems Only Y Y Bed/Trench Center Bed/Trench Edges Topsoil Yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:� . D Inspection #2: Location: 465 Dylan Court Hudson, WWII 54016 (SW 1/4 NE 1/4 8 T28N R19W) Sunset View Lot 7 Parcel No: 08.28.19.1834 1.) Alt BM Description = t X A WVA 2.) Bldg sewer length = 30 1 1 amount of cover = 36' {- Plan revision Re( uired. ] Yes XjNo 0 - rt. No Use other side for additional informal F r �� —_ Date nse or' Wtur- Ce SBD - 671Q ( 3/97� l it ` S iD 120 r` — 44a Safety and Buildings Division County 201 W. Washington Ave., P.O x 5 O C Wisconsin Madison, 537 - 7 Sanitary Pe Numbero a filled in by Co.) Qepartment of Commerce ) Sanitary Permit Applicati State Plan I.D. Number - In accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privacy Law, sl5.04 1 Project Address (if different than mailing address) I. Application Information -Please Print All Informa D�,6 on y6 ' 41V Cou r- Property Owner's Name U L 1 Parcel # of 4 Vock# d - /075.10 SAM V iD eK 27 �- - Property Owner's Mailing Address ST. CR X Property City, State Zip Code Phone Number �"" E %, Section �� circle o e) 15A wo 12 27.46 II. T pe of uilding (check all that apply) T a a N; R�E v �� ��,j Subdivision Name CSM Number 1 or 2 Family Dwelling - Number of Bedrooms r .t _ ❑ Public /Commercial - Describe Use S U �'S eT V i e w 1)r V ❑ State Owned - Describe Use ❑City_ ❑Village BTownship of TRO III. Type of Permit: (Check only one box on line A. Complete line B if applicable) t4 * A. X New System y ❑Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System B • ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that appl 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 b, Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) Elevation yso - 7 6 /-13 �o System F /V, VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units WIZ .46 e e - Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank / ©© G !' /000 t - �S - A Aerobic Treatment Unit / vV Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plu r' Signatur MP/MPRS Number Business Phone Number J aMN Scmoyl11T .2._3 715 Plumber's Address (Street, City, State, ' ode) o e 5.rl eAa- � %> VIII. County/ De artment Use Onl Sanitary Permit Fee (*ludes Groundwater Date Issued i Issuing Agent Signature (No Stamps) Approved ❑ Disapproved Surcharge Fee) , ❑ cane Q r Given Reason for Denial � , / t. � +" t ,y l A ", e.. -- t^.1- )• j �`;; _. IX. Conditions of'Approva epson for Disapproval " SYSTEM O 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances. Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) 1 5 js�, J L w ZZ'T T g � V F h1 rr r. 75.3 qq i � SLoP, r QAL T. ciie4,ce 3 6",6w - crcl w:Tlr - /CU ff rl.� k 81 7 pk e �_ t,,; r� Y� � 1_` Aw j 4 k'GF'G.5 c 0 rl-. W'rLL N tf 4 Ao4 tit V o a r. Y N `� U 'o lr 7 _14 3- ' cLt � ►� , �fo'! � ® Qty Te6ucµ4-: S 99 _ � L - PRoPus�p_ jVoo 6AL I N ©use DRIv_ LA; A1� WE" 1 COT�aea e �!r 8m ! E1. - X00,00 P� I` ,► a am a . = 99. / FlP4a ter ccjeuc-R .5 Y!>75 . 6L. y- 7 / 2 -Ott 6 `' ° j)kAW,N � roQ o ,537 C,�;VrRA L A045 RA r /Y.. 55003 Sow �,esF r 11J s� /o a t-f A) t-' y 5 i a? P R I 1 �1 Ae s as 3 76 fl __ - -- - .. _- - _ _ -- _ __ i -- i - -_ -_ - -, - _ - _ _ � _ __ -- f c Wisconsin Departure t of C C"VED SOIL EVALUATION REPORT Division of Safety an Buildings Page of O 2 �fl94�corda ce with Comm 85, Wis. Adm. Code County S 1 C h complete sit plan on p not less than 8 1 2 x 11 inches in size. Plan must l e, but not limi d to: — ant slope, scale or dim���� �nYtal ref rence point (BM), direction and Parcel I.D. JIQ�T6Cn� location and distance to nearest road. G Please print all information. R iewed by "Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner �"`wlvv` ZZ Property Location 3 $ `- ��v �C17 d�!� ^N•J�- SW 1/_4. 1/4'S � T Z 8 N R �� E ( ) W 1 Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# P o. Sox 33 `7 City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road t3f�LSR•M �R1•c„� Lv a 5 cl 8'IO (1 I S) �!$S _33 S 1 TR -O`1' ' New Construction Use: IS Residential /Number of bedrooms Z - Code derived design flow rate � S C) - t UO_ ❑ GPD Replacement ❑ Public or commercial - Describe: Parent material el 1 Flood Plain elevation if applicable rQ 1l General comments ft and recommendations: J �V17 3 � � W tiv Fl L - P( 1 -tL3 s2S �(..S `ry sE M Yv, I Boring # ❑ Boring ® Pit Ground surface elev. to ft• Depth to limiting factor in. 2op� f Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 I •Eff #2 Z O-I0 l0`l\231Z ct, Z,`F •S $ j �kD P 3 l 6 — S r I Z Yl S (, 3 i ❑ Boring a Boring # --, ® Pit Ground surface elev. �1 n ft. Depth to limiting factor �a in. Soil Application Rate � Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 0 -1.Z cz3c - S; l Z Mme- Cam, Z`� •S .g Z �1 3y 10 kIz 3!6 - s i ! Z m Sb� � 3 .� � l si I USg Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg& ' Effluent #2 = BOD < 30 mg/L and TSS _< 30 mg/L , CST Name (Please Print) Signa re CST Number - Arthur L: ^ Wegerer 03Z1S —7 - 220254 Address W e g e r e r Soil Testing & Design Service Date Evaluation Conducted Telephone Number 421 N. Bain St. River Falls, UI 54022 1 Z - V3 1 715 - 425 - 0165 1 Property Owner `���(� 1��1�/`1 Parcel ID # �`/l�1 jlJ G Page Z ' 0 41.1 a Boring # ❑ Boring ® pit Ground surface elev. C l l - ft. Depth to limiting factor q17 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft= In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 p_� tio�1{z 3 I Z I <I 3 b 1o`t2 3l6 — s i I Z wt s b vt y,) 3 - 36.0,7 i(3-jYZ a Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft' In. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg1L ' Effluent #2 = BOD < 30 mg /L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 - 264 - 8777. SBD -8330 (R.6/00) _ I PLOT PLA_T Paae 3 of . l Scale 1' =�0` t S.l r�*�1 J h c _ — C) I ss ss` L C; 1 v - 1 w O LvT � LoT � - - -- - -- - C � LZ - -03 715 - 425 -0165 22254 03 _ CST Signature Date Telephone Ito. CST No. Job NO. Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings Page of in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference paint (BSA), direction and peecent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. Please print all information Reviewed by "Date Personal information you provide may be used for secondary purposes (Frvacy Law, s. 15.04 (1) (m)). Property Owner I Property Location 1/.4. 1/4 "S � • T Z8 N R Property Owner's Mailing Address E (� W Lot # Block I Subd. Name or CSM# Sl�rvs�- v l City State Zip Code Phone Number City Village Town Nearest Road 3R�r'1 i - New Construction Use: IS Residential / Number of bedrooms Code derived design flow rate I S Q — UCH_ ❑ Replacement GPD p ❑ Public or commercial - Describe: Parent material G L4-1 Q-) 14 Flood Plain elevation if applicable N ) General comments ft and recommendations: ' ° r ` `r aE 1 ry X76 R L�`r er;- P�teQ%)zZ Boring # ❑ Boring ® pit Ground surface elev. 0 ) C � So ft, Depth to limiting factor 6 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture ( Structure I Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 'Eff#2 - 1p� 1 \Z 3 l Z — i I Is b �C I m'rt- c t,� Z • S a Boring # ❑ Boring ® pit Ground surface elev. ':>� "� O ft, Depth to limiting factor �` �� in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Eff#1 Eff#2 vzm 2 3 C Z — S i 1 z `�s }c tivl C I.v Z� • S z - 10 Litz 316 Z 3 3 � X1'3 tom � �f�G — s i ( U Sq ►mil - , 7 � . Z Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L ..- CST Name (Please Print) Signaoire CST Number -Arthur' L �Wegerer — 220254 Address W e g e r e r S O i l T e s t i n o & Design Service Date Evaluation Conducted Telephone Number 421 ii. Bain St. diver rails, K 54022 1Z- ZZ_-o3 715 -425 -0165 1 Property Owner `���(� N)�l�/7 -- Parcel ID # G Page of a Boring # ❑ Boring ® Pit Ground surface elev. Ol - ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft= in. Munsell Qu. Sz. Cont. C olor Gr. Sz. Sh. • Eff#1 •Eff#2 1 �_1 �o-R 3 L — s i Z�s�1� w►�- ew Z l <� 3 b lo`t 3L t, — s i I Zwr Sb�c yn C5 . 5 - 3 F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft= In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg /L • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L T7te Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 -264 -8777. SOD -8330 (R.6/00) PLOT PLA-A Page S of . Scale 1' =S0' x.11 `F3 m l 1 — H I g,ZI O IV 1 - �Oa10 - O}v �- Z.Z-03 715 - 425 -0165 2 _Z 54 03 kS_7 CST Signature Date Telephone ito. CST No. Job NO. i BIODIFFUSER CROSS SECTION 4 11 PVC Inspection + Vent Pipe n Approximate Grade i = E1 .= 12 " I II�; I Il,i rJ El.= 7 n , I _� -- - - -- I- E Arfrogr OpM Arco Widln Ave ^ vne , A WOIn Il f -- POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pa of FILE INFORMATION SYSTEM SPECIFICATIONS F PO, wner ` .0l4 ` O Septic Tank Capacity 10 0 0 ai E3 NA rmit Septic Tank Manufacturer Week ' s C . P . O NA DESIGN PARAMETERS Effluent Filter Manufacturer Zabel 0 NA Number of Bedrooms 3 ❑ NA Effluent Filter Model A -100 ❑ NA Number of Public Facility Units 11 NA Pump Tank Capacity al 0 NA Estimated flow (average) al/day Pump Tank Manufacturer ■ NA Design flow (peak), (Estimated x 1.5) al /da • Pump Manufacturer 0 NA Soil Application Rate al /da /ft= Pump Model 0 NA Standard Influent/Effluent Quality Monthly average • Pretreatment Unit 0 NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen. Demand (SOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 1 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODj 530 mg /L m In- Ground (gravity) '0 In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L 0 NA Cl At -Grade ❑ Mound Fecal Coliform (geometric mean) 510` cfu /100ml ❑ Drip -line ❑ Other: Maximum Effluent Particle Size Y in dia. ` r r ❑ NA Other: 0 NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once eve ❑ month(s) (Maximum 3 ears) ❑ NA n' y 3 0 ear(s) Pump out contents of tanks) When combined sludge and scum equals one - third (Y,) of tank volume 0 NA, .jL Inspect dispersal call(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA 3 ® year(s) Clean effluent filter At least once every: ❑ month(s) ❑:NA 1.. 10 year(s) ❑ month(s) Inspect pump, pump. controls & alarm At least once every: o NA• ❑ year(s) N, A-. ❑ month(s) Rush laterals and pressure test At least once every: O NA; ❑ year(s) Other: least once every: ❑ month(s) 0 NA. ❑ year(s) Other: ❑ NA` MAINTENANCE INSTRUCTIONS � Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or canjIfications: Master Plumber, Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. nk Inspections must include a visual Inspection of the tanks) to Identify any missing or broken hardware, identify any cracks or: leaks; measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surfaoe'. The dispersal calls) shall be visually inspected to check the effluent levels in the observation pipes and to check for any,.,pondin" ,of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requlres' the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third %) or more of the tank volume, tho,entire contents of 'the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter. NR113; 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. Page - of START UP AND OPERATION For new construction. prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may'impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior ;o 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 call(s) In one large dose, overloading the call(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. e The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. e 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 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 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. 17 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' John. Schmfttt Name Owners choice Phone (715) 549-665 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATO AUTHORITY Name o wners choice Name St. Croix Ct . Zonin Phone Phone 715 386 -4680 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 OA1 "le Mailing Address 53 7 C�i► « l� v� �a y �a M N S S - 0 03 Property Address — v1. (Verification required from Planning Department for new construction) �o –/d35 =10 -D00 City/State �44,Q can< IWI Parcel Identification Number ave - fo3s - 02 -06en 6y'o -- / 304 -©7 --000 LEGAL DESCRIPTION - Property Location '/., ' /,, Sec. TAN -R_W, Town of -a' —� Subdivision Sep O f t 14; T 0 1,EtU , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 0136 k e , Volume 93S , Page # 101 Spec house ❑ yes 4 no Lot lines identifiable ® 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. s i 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 wastewaterdisposal 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. 6A, -7 // SfO OF APPLICANT 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 t the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. O• C � 7 // 2 / SIONATUI(B OF APPLICANT UWE c * * * * ** Any information that is mis- represented max result in the sanitary permit being revoked by thdzoning 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 i i i U .. _. 2 9 35P 201 KATHLEEN H. WALSH State Bar of Wisconsin Form 2 -2003 REGISTER OF DEEDS ST. CROIX CO., WI WARRANTY DEED RECEIVED FOR RECORD Document Number Document Name 11/28/200,5 03:00P11 WARRANTY DEED EXDPT # THIS DEED, made between B & L Land Development, Inc., a Wisconsin REC FEE: 11.00 Corporation TRANS FEE: 250.80 ( "Grantor," whether one or more), COPY FEE: EE CC F : and Adam York, PAGES: 1 ( "Grantee," whether one or more). Recording Area Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant Name and Return Address interests, in St. Croix County, State of Wisconsin ( "Property ") (if more space is needed, please attach addendum): Lot 7, Plat of Sunset View Development in the Town of Troy, St. Croix County, Wisconsin. 040 - 1306 -07 400 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptions to arranties: Easements, restrictions and rights -of -way of record, if any. Dated l (SEAL) (SEAL) * *B & L and ve o meat, Inc. (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) authenticated on STATE OF ) ss. CO TY * TITLE: MEMBER STATE BAR OF WISCONSIN Personally came before me o (If not, the above -named B & L Land Development. Inc., a Wisconsin authorized by Wis. Stat. § 706.06) Corporation to known to be the p son(s) who executed the foregoing THIS INSTRUMENT DRAFTED BY: ins q^and ac a dith same. Attorney Kristina Oland Hudson, WI 54016 No Public, State 6f L My Commission (is permanent) (expires: (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003 • Type name below signatures. INFO-P!10" Legal Forms 800 -655 -2021 ~.infoproforms.com Tracy L. 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