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HomeMy WebLinkAbout040-1278-70-000 � o m 3 S tv. 3 C (p O CD CL fD 0 so N O p fD c W 'I, O CO O O 0 OD CD � d n m (D V D O ' (D cSj A N CL N W _ c g ° p n O O .« C" p C ! �,. z p po O O O O. ', o r' U1 N N NO M Q Z CD O 7 3 U O O O l t \ i l l N 0 o N m MA CD O C7' v N N N v �/ y o m CD CD O 0 m O _ co n7 0 Q Q N Z a .. z�z c D m O O o' ? @ I N • C m CD io S. v m w a o n Q 3 5 Z O A Z cn I 0 w C � - O A Z w a .. o, M < _ W M < W G z A 0 ° z _ CD �N Q c o a N a ti 0 0 a 0 A � aro a CD rs� O F ° b � o I °o CD V .cons in Department of Commerce County: =.ty any Building Division - PRIVATE SEWAGE SYSTEM St. Croix t INSPECTION REPORT Sanitary Permit No: 399516 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: Cook, Charles Troy Township 040 - 1278 -70 -000 CST BM Elev: ` > "It`yY, Insp. BM Elev: IBM Descnvtion 7, J- r l � ✓ 'V,::��, �,,�n x �/r /.gin, ?k.'� l �� 7- ,�., ' ;� y A TANK INFORMATION ELEVATION DATA rL, x'rv.'/vC; /1i/�7� 3 H•1�. TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing _ _ - Alt. BM : „ 1- , Aeration \ / Bldg. Sewer 8t,/Ht Inlet SVHt Outlet TANK SETBACK INFORMATION r /3 -e i T ANK T O PIL WELL BLDG. Vent to Air Intake ROAD Dt ialet' Septic �, / Dt,Be#t6 - m Dosing -.,,_ Header /Man. Aeration Dist. Pipe Holding 65, System r i_ ! Final Grade PUMP /SIPHON INFORMATION �/ -Z 10, f Manufacturer Demand St,Cover ti GPM ' 3t .t) ki fl"I, Cd V L Model Numbe TDH Lift Fri Loss System Head TDH Ft Forcemaig- Length Dia. Dist. to Well �. SOIL ABSORPTION SYSTEM BE ENC Width ; J f:. ength No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DI wx fit' SETBACK SYSTEM TO P/L LDG WELL LAKE/STREAM,­ LEACHIWG Manufa rer: INFORMATION CHAMBER OR Type Of System:�� � i / Model Number: / j 1•�� / `7 d � ? UNI - j : I DISTRIBUTION SYSTEM Header /Manifold Distribution j I x Hole Spacing lVent to Air Intake L Dia Length t' Dia � �I, / �i � ( >;[S��ing ' / `--�� 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 �:t ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: i i CZ- Inspection #2: ! / Location: 385 Cedar Court Hudson, WI 54016 (NW 1/4 NW 1/4 16 T28N R19W) EAGLE BLUFF Lot 27 Parcel No: 16.28.19.1559 1.) Alt BM Description =❑ 2.) Bldg sewer length =� i - amount of cover = a r Plan revision Required? ❑ Yes Lk No / _ f Use other side for additional information. ' - -.� y z� :�. 1 SBO -6710 (R.3/97) Date Insepctor's Sign ure Cert. No. r i 1 4' \fir i �4 n r r- a r t 'fi 4 t - 7 IY 7& ZVI' ,ff /�/ /� / '_v��_-��°~-'_�_.~~��_� 6�� ���� _____� ST . C 3z- �/� / u7 '���/^ ||- -' �Y�,� '--~- ''' - �-_'______-/u - ------ --�- --- C�0 A2 CT. 6 ✓tc Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. 14sephs See reverse side for instructions for completing this application Madison, WI 1 5 Box 7302 Personal information you provide may be used for secondary purposes 53707 -7302 Department of Commerce (Submit Completed form to county if not [Privacy Law, s. 15.04(l)(m)] state owned.) Attach complete plans (to the county copy only) for the system, on paper sr 11 inches in size. County State Sanitary Permit Number ❑ Check if revision to s,,gpplidatiori Sta an I. D. Number �rrn` 3 I. Application Information - Please Print all Information f Locatio Property ' Owner Name f ` - ' - Property, Lo Aat ion ,r T I Wl /4, 9'k T� I, RAE ( 91 Property Owner's Mailing Address ST (:4�Oi TbkN er Block Number l rio S v� 1 . City, State Zip Code Phone Number , -., v Name or CSM Number II. Type of uilding: (check one) w� W ❑ 1 or 2 Family Dwelling - No. of Bedrooms: t' ❑ Village ❑Public /Commercial (describe use):_ Town of ❑ State- Owned �� Neagest Road t Parcel Taxax Number(s� '� �2 3 ' X 95• s otf —11 7 — Z - III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) & 2 A) 1. ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only Existing System $) Permit Number Date Issued ❑ A S anitary Permit was previously issued IV. Type of POWT System: (Check all that apply) Onion- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculati� ❑ Other: «04 l L L ' T lo'� V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) 5 - Elevation 4 'Oa SOU 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 c X -- r L, e C�S,(/' JR" ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (print) Plumber's Signature (no stamps): MP/MPRS No. Business Phone Number Plumber's Address (Street, City, State, Zip Code) 30�� �c� -cam- IX. County/Department Use Only 11 Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued ssui g Agent Sign lure (No stamps) Approved ❑ Owner Given Initial Adverse Surc arge Fee) er0 / e Determination X. Conditions of Approval /Reasons for Disapproval: ( / '3D -6398 (R. 07/00) r iT w In u Q 1 a `1� fi o_ W Q u� u v n , AA g als i I I i 1 1 . I I I 5 1 i I 1 I -_ - - -- - 1 � f i 1 I + I j I f Wisconsin Department of Commerce SOIL EVALUATION REPORT Page I of Division of Safety.and Buildings in accordance with Comm 85, Wis. Adm. Code County ST Cr y Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must Include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. I Date Please print all information. a iewed y 0 Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ' Property Owner Property Location Ck ARIES 5. .COOK Gavt -L A)W 1/4A11� 1/4 S ((P T Z$ N R Iq W 1( Owner's Maili Address Lot # =#b1 or CSM# Props y 9 5100 aDe N S E u%TE 00 81-UFF- City State Zip Code Phone Number ❑ City ❑ Village X Town Nearest Road Lek �M1 SS�I`t9 ( 3 )757 -75fo� -f T(AxIA)3VAtl>rV 1 . -`` „ �] New Construction Use: ® Residential / Number of bedrooms 9 Code derived design flow rate � �._�.1 ) i �" PD ❑ Replacement ❑ Public or commercial - Describe: i Parent material 5{tNDSTO►.1� Flood Plain elevation if applicable ? A& General comments 2 T(L>:,IJCt L and recommendations: 5 i Pd V 0 7 � I i L�t�O 5 T C V : r Boring ZONING QFFICc- Boring # pit. Ground surface elev. 1 ?-?-' 7 T - ft. Depth to limiting factor )90 in.' % i ti Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary k61 I `*, f In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Eff#1 - Eff#2 1 0 -7 Oy 4z I -y>1 mV ab 3vf-c� Z)6 0.8 qk v) 0S _ 6, , x 7- -13 0 3 1 I I bl rn 3 _ 3 51 I m s b► o,_5 L4 o `t g}.36 Z \-4D ,5 `1 14 IS lm -t- 5 k1 Z4- 0, I,Z 7.5`124 S Q -m 0, I, Z. �5 -qD ►6 , 11z 3 1, — 5 0 1 1 m 0,-7 1 L so M l; 5 ON t✓ Boring # Boring ® Pit Ground surface elev. qZ0,77 ft. Depth to limiting factor — 2q () q() In• Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots -E GPD/ Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 1 0 -l0 to tZ 15 ml 0. 3 0,1 1,2 1s m1 aL_b 3f -CA 7 1,2 at� 3 1 2jo 7, 5\wLi1 1 d1 s 2� -ca C),-7 i, a y y .. s m l 2�- 55-cto 6 yl im b2t, So vEt l ODRIUA) 2 Olt I I n Effluent 1 BOD ` 30 < 220 mg /L and TSS >30 < 150 mg/L - Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L 1T ,, CST Name (Please Print, ature i,[ CST Number "g,j 30 +ia�usTER cJ0 2z 832 Address Date Evaluation Conducted Telephone Number \�J9��s e9o�''`fl RIV,�AUS ws ��UZZ 10 - 30 -0o C ?1s)4� -nos r• LDT Z y Property Owner COp . , 4 C14 t11ZLE — �5 Parcel ID # _— Page .7 of FE] Boring # ❑ Boring pit Ground surface elev. °I 19 3 ft. Depth to limiting factor >� in. Soil ADDlication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I D 5 loyrZ24f 5{ 3 f mJ�r 0,6 34(- 0S 019 Z , 12 3 I7- 10 N 01 I 1 msb K ab z-f - 0,y 0.6 y z -31 0 \4 1S ?�- b d s CS Lf-Yn 0. 1'2 5 31 -L18 — Lb \4 m-L sb d - G W I FPM 0.5 O,q (o y &80 �Yh — s Q5 ❑ 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/ff In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 a Boring # ❑ Boring Cl Pit Ground surface elev. ft. Depth to limiting factor in' Soil A lication 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 E F - Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 a 150 mg/L ' Effluent 92 = 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 -9330 (ROOD) i- PROVVRTY OVUR: COOK CHAJZL. -rs LWL K5C , 1-M2 61.E +6LUr-F A- a ne 5F M I 4 E•A LOC ATED WT W 0 C- /Uv) y Glzbukb 5 # -TU OF SEC, Ib T2 W W OFTKUX el-- PVC PIPE "Ae)ove &ozotmz E C"Ix COUNIN 1 o ►J 51 F-1-5011, [30t;ING W/ PACKNM NO COMM 65 5WACK ROMM5 Lo T2-c l� EL g Z VI T/A L 827 Q EL QZO.72 , a J � r✓t�19.Rs' �o r r LO 2- Cp r7 c �L 9 ,q3' E �2l.Ib' Q k� LET S x � P� 51GNW Cyr Z2 I7At�: (7 -30 -00 �I` Aa6e y of y COWTULk K to )J) 5 FoK t nT D ElC-t-E ISI — St St) A ll 4 z' -- V r` B 26B 7� B -276 B— 45 i B -27C T Private Onsite Wastewater Treatment System Management Plan .Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567 -P (R.6/99). Table 1: System Des i n Specifications Sanity Permit Number 3 Number of Bedrooms Design Flow - Peak ( pd) Pfi Estimated Flow - Average pd) G Septic Tank Capacity (gal) Soil. Abso tion Component Size ( ) a - Bt-- C6 CS Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable O ration Septic Tank Component Soil Abso on ComF2nerit Design Flow - Peak ' t-O 31 Maximum Influent Particle Size (in 1/8 Maximum BOD ( / L) 220 Maximum TSS (mg/L 150 Table 3: Maintenance Schedule Septic Tank Inspect and/or service once eve 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic T$nk The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Slats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of'the se and outlet filter shall be assessed at least once every 3 years by inspection. Th outlet fil a s hall cleaned as necessary to ensu p r e =a tion. The filter cartridge s be remoovv urn ess provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the Management Plan for a Septic Tank and Soil Absorption Component filter Is equipped with an alarm, the filter shall be serviced If the alarm Is activated continuously. Intermittent filter alarms may Indicate surge flows or an impending continuous alarm. The septic tank shall have Its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. if the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers. access risers and covers should be Inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8-4nches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason without being In full compliance with OSHA standards fbr entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be dHfflcult or Impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual Inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 Managomant Plan for a Septic Tank and soil Absorption component within ten feet of the Plantings of deep - rooted trees and shrubs directly over or may obstruct wastewater component should be avoided since root intrusion into the component flow. 3 CONTINGENCY PLAN If the POWTS falls and cannot be repaired the loliowlne measures have been, or must be taken, tv proVlde a code compliant replacement system: A sultabk replacemwnt area has been evaluated and may be utilized for the location of a repimment sou absorption system. The replacement area should be protected from disturbance and compaction and sb&M notbe injrtrpd upon by required setbacks from exlstint; and proposed structum, 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 sultabie replacement ana. Replacement sys.erns must comply with the rules In effect at that time. * A suitable replacement area is not available due to setback and/or soil dmlgtlons. 6arrin9 advances in POWTS techno10P a holding tank may be Installed as a test resort to replace the called POWTS. 0 The site has not been evaluated to Identify a sultabie replacw4it am. Upon (allure of the POWTS a soil and site evaluation must be performed to locate a sultablo replacement area. If no replacement area Is available a holdng tank may be lnstalled as a last resort to replace the failed POWTS. O Mound and it-grade soil absorption systems may be mcotcmtscted In place following removal of the Nomat at the Inflivaclve surface. Reconstrualons of such systems must.complay with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYCEN. DO NOT ENTER A SEPTIC, PUMP OR OTHm TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT RESCUE OF A PERSON FROM TiR INT9R10R OF A TANK MAY EE DIFFICULT OR nes►neerser r. . ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name o F IN ame Phone -_ /- y hone SFPTAGE SERVICING OPERATOR (PUMPER ) LOCAL REGULATORY AUTHORITY Name Agency 4- Cro' 4 6616 o ftone �s- - 10 /10 /O1 WED 13:38 FAX 651 439 3417 AMERICAN CLASSIC HOMES 9 002 OCT -10 -2001 13:20 COHT I �ZNTAL VA-P CORP 763 767 2532 P.02/06 ST CROIX COUNTY SEPTIC TANK MAWMAN(M AGVX� AND OWNEUMP CERTIFICATION FORM Ownear/Buyor ✓ SS Y y q Muffing Mdrew p Address (Vcrifiaatioa !soma Planning Depattmeot for atw C�y/Steate r 1- L�JCSC' Parent IdeaMfic adm Namber - �? 78 ` - 70 - <Z 0 ��?rAr DESCRTPTTON 5( Sac. T -7"f N R, = W, Taws of - ..� • Lot # ��: Subdividm Cet d Survey Vohme Page # WatralLty Deed # ��` _. Vobmw l . Page # Z L� Z Spec bouse tV y es 0 nb Lot lines idotdflable a yes 0 80 � aa�d ma�ao fyea: sywem.caald t�lt � pcamasano ih0ose m haodlewa�- o adM ofp=Wiog oa the MW UA evet7► tmoe yem ac mmm", if needed bye hamod pumper. What 3mm put facto tie system can affeat tare unction of &C optic teak as a 1 aes1 - a - et>rgei In the waste 4isposal sT a ems &M td�ed by *c owner and by a The property owner agteee to wb�t to St C7aoix, Zoe D that (I) � oa- slov�s�aatioraiapoawl syst'M vIm*er.�d7=m a edpdaopberorslleaaweedpumpm J, m VMm opew ft condition wWor (2) ages iaapec ion and pampin8 (d' nooeaa'Y), do optic ft* is lane than 1/3 Sun of adadgc. vve, to ndwalpaadhM vad the ab m x*qdw=mmu and agree to the 1mva* � wide tlra sw�dae net foa<� heroin, as aret by the Depatimrracof Coo and �e Depatttmnt of Natural Rno�s. �e of Wisoansao. t�tituatten svd ft that ya w optic trysoem line been mainrdaed toast be oomapleted end a um"d 60 the St CwftcoumW7j=ft0MCGw des of the *m !pear eTbadon date. DATE WA'IVU OF APPLICANT S � I w�a am ( nee ) owoet(g) o[ ilia ( ) I (we) oatlify tbt►t all awAtesnearrs 4M tius form. are" tore to *c boa of � Deeds O�toe- dw pmpedy desadbed abovo, by wir of a wananty deed aecoed in e - - � , - 4 -.- 10 ,14,x! DATE SIMATURR CIF APPLICANT •.+.•• A is t� is mis- mep:asamood msy:malt is drs saaim7y Pegmit bOims cavaok*4 by &a 7.onhrE 1 " `*_• � we Ada wi& WS apps e SaWW" w2may deed fiam the p of Doe affix* d a copy of the cwt€tted mvey map ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer / ✓ �/�, 11��f ,O �� Mailing Address l/ 8 U C��L P�Lt�O��[ 5 WE , d L!� L 01 -IV Property Address S �C (Verification required from Planning Department for new construction) City /State 7 - 4)' , LOW , Parcel Identification Number � �� ` `"�0 b LEGAL DESCRIPTION Property Location %., %., Sec. . T N -R W, Town 4f Subdivision r Certified Survey ap # Volume . Page #.. h Warranty Deed # Volume . Page # Spec house I yes ❑ no Lot lines identifiable [ yes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof 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 masrplumber, journeyman plumber, restricted plumber or a licensed pumper vmfyM 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. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best ofomy (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. SIGNATURE OF APPLICANT DATE * * * * ** ' An information that is mis- resented may result in the sari permit being revoked by the Zoning Department Y nP Y �' *• 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 OCT -10 -2001 13:18 CONTINENTAL DVLP CORP 763 757 2532 P.01i02 CONTINENTAL DEVELOPMENT CORPORATION 11800 Aberdeen Street NE -Suite 100 - Brine, MN 55449 Phone (763) 757 -7568 T Fax (763) 75 Total Number of Pages (including this sheet): © t FAX COVER SHEET • I0/ TO: i X COMPANY NAME: FAX NUMBER: _ 25 13 ft FROM: RE SO Ho do COPY TO FOLLOW 6 U.S. MAIL: YES NO COMMENTS: OC1z -10 -2001 13:19 CONTINENTAL DVLP CORP 763 757 2532 P.02i02 ST CROIX COUP17.`Y SEPTIC TANK WMNTEMANCB AGRRSM13NP AND OWNERSHIP CERTIFICATION FORM Owacr/Euyea` Mailing Address w 8 a U ..czlz, � 5 / VE r 1,6 0, Property Address (Verification required fmm Planning Department for now 6=*uoti0n) Cit3atate 7-!'C WIS6 - Parcel Identification Number � ' - Ye) - C� d LIQAL DESCItIPTrON Proputy Location - y4, i /., Sec. . T N -R-W, Town of Subdivision Lot # .. . Certified Survey Lp # . Volume _, .Page # Warranty Deed # G S Volume �° Page # yam, S pec house yes O no Lot lines identifiable yes ❑ no SjEU .M MARDZNANCE Impmopor use and waintonancoof your acptic system could result in its premature fadum to hr<ndle . �t 0M of pumping out the septic tank every three years of scone . if nwdW by a licensed pumpm What ' w tan aftj die tunGpon of the septic tank as a urataioat stage: in the waste disposal syatam The prvperty ownet agnm to submit to St. C.toix Zoning D%wanow a =rdr"don S signed by the owner and by a masterplQmber, Son mymaaplumbet, rracri udplumbcr or a lkm mdpumper vwifyittg that (I) the on-sito wautowaterdispoul system is is ptopet oparatiog condition and/or (2) after inspection and pumping (if necessary). the septic tank is less than 113 M of sludge. I/rae, Se umdem4pod Haire read dye above tegaizz wvb and agree to mudsin die paivata sewage disposal :ysu m with 6e atswdar+ds sat fook basin, a sot by the Dcpattmeat of Commerce and the Depattmo t of Nabmal Raouwas, State of Wisconsin. Certification stating that your septic system has been maintained mast b aomplefed and tcu=ed to Oc SL tgoix County Zoning Ofaw vridiin 30 days of the three year expitation date. SIGNATURE OF ,APPLICANT � DATE OWNER CERTCATION I (we) certify that all sutana s on this fom am true to the beat oftimy (our) k wlodge. I (we) am (are) dye owner(s) of the p wcrty desaabed above, by vittrte of a waaanty deed rvcotded in Register of Deeds Ofliee. slomTURE OF APPUCANI' DATE 000 *06 Any infotmadan that i5 mis-tepresented may result of die sanitary pet=t being mvoked by the Toning MpartmeaL sf "sr s• bda4e with tbu application: a aaumpW wan=iy deed fiom the Register of Deeds 0 a copy of tbo certified survey map if tetetcOcc is tw& in the vALURUty decd TOTAL P.02 x:11. 16 ! 4PArIE 402 650252 KATHLEEN H. WALSH REGISTER OF DEEDS Daum: umber Document ride ST. CROIX CO., WI AMENDMENT ill TO DECLARATION OF COVENAN S RECEIVED FOR RECORD CONDITIONS AND RESTRICTIONS FOR 07- 05-2001 3:30 PM EAGLE BLUFF COVENANTS EXEMPT I CERT COPY FEE: COPY FEE: TRANSFER FEE: RECORDING FEE: 14.00 PAGES: 3 Recotding Aran Noma and Return Address Dy0 -137 set Parcel Idead&sdoc Number (PIN) TV* iotam dm count be eoaplalnd by eub"aee 4oeoenenr rtde. Aare A rclum address. and PIL N regw& d . od"r.bormadan each - she 1—dRS dorm, 19r1 &—W —, M. Ala) be placed on dds JLee page of dre docwmm er bf grey p(aco/ an addidornal pages of Ac daerwoenr. &-W Use of AU caw pets ddds one page so yd docmnens and 1:2.017 ro d w recot fine fee. Wltc mrk Snorer. 59.517. WRDA 2M �4PAra 403 Date Revised. 312911001 AMENDMENT #1 TO DECLARATION OF COVENANTS, CONDITIONS AND RESTRICTIONS FOIL: EAGLE BLUFF The D elarant herein makes the following amendments to the Declarat' o f Cove ants Conditions and Restrictions for Eagle Bluff, for the purpose of adding Lots I, 2, and 3 and Outlot I of C.S.M. Volume Page�� —�`—' Document Numbe This Amendment shall effect those lots of the Plat of Eagle Bluff described on Exhibit "A" attached hereto. Section 3) 11sc is herein amended to read: Ilse of Residential Lots - Added Text: Residential lots specifically excludes Outlots. Section 4) Common Area O I]= is herein amended to include Outlot t of C.S.M., Volume , Page Document Number — -Added Text.• The common area outlots shall be owned and managed by the Eagle Bluff Homeowner's Association of Troy, Inc., as provided in the Bylaws for the Association. Section B.A.4) [. (ldc ane Plane is herein amended to require a minimum landscape budget of $10,000 for Lots I, 2, and 3 of C.S.M. Volume , Page_ , Document Number Section 25) Tree Trimm nQ on Common Area Outlets is herein amended to include Outlot I of C.S.M. Volume Page Document Section 27) Homeowner's Association is herein amended to include Lots 1, 2, and 3 of C.S.M. Volume , Page_ ,Document Number Exhibit "A") Lc9al ny,rintiort is herein amended to include Lots I, 2, and 3 and Outlot l of C.S.M. Volume Page Document Number In witness hereof, Troy Development Corpor Lion bas caused this Amendmeut to the Covenants, Conditions and Restrictions to be executed on thi _ day of _ 20 Q oy Development Corporati a r C, _ Charles S. Cook, President Ills Documeat waa 1rafted Bv Troy Development Corporation I 1800 Aberdeen Street NE, Suite 100 Blaine, MN 55449 STATE OF COUNTY OF r BEFORE ME Z eA"l on this day personally known to me to be the person whose name is subscribed to the foreg0bg instrument and acknowledged to me that they executed the same. GWEN MY HAND AND SEAL OF OFFICE this the Z day of a 2tY� Notary Public, State of_��L�%F My Commission Exp'y ' VOC 1674 404 Date Revised. 312917001 EXHIBIT "A The lots of F4QLe Bluff, as referenced in the Declaration of Covenants, Conditions and Restrictions for Eagle Bluff, shall include: Lots 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 2F 2 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 4142, and 43 and Outlots 1, 2, 3, 4, 5 and 6 of the Plat of Eagle Bluff, and Lots 1, 2 and 3 and Outlot l of C.S.M. Volume Z Page ��Document flumbc located in the Town of Troy, St. Croix County, Wisconsin_ E 1/4 OORNIR SiWi Kc. i s LOCATION MAP f I ON 8, THE 0 1/4, OF c�rla Il " n w iia a 01 CM °+i CIE THE NE 1/4 OF SECTION �a� IN Tsar. RIM. Teal aF TROT. ST. amlx aalrtY. w1kaal". AIDING ALL OF LOT 1 30 8 9 1 3. D= MW #498385. I NF-EE KBE N.-w K- 1W y � y AV TTDIPOR ,lap'. I 7F T'O111aV K SW64M 39-11101 s stet II I E r AA OF TIC TO BE 11I14PaNT W SCALE IN FEET ExeallaN M K-11w ON" ROAD p J ' $w-Nw SE-Iw 10 DAD 140Aass I / 1x151. I 0 150 300 600 1 16 109,99E 1u. — (7oaw I LEGEND 00' sr. SCALE: 1" - 20 {q� I / \t o+" '" 4,3• 1 ) /+' d COUNT =104� MU11Ral , x woul m 9W IMIL -. W. YI F BUILDIN0 Et1MaL LINK (OR HIM 03)• IROI PIPE. FV ND (OIAMr= NOTED)• 10' Wla UTILITY 01110M. � 1 ,1 1.000 ` 0 SF. r: 300* 11110 PIPE NCIOIINO 3.�y/�NE/R �O NO oftimm EAR (o�l01E{ 1911). f00T. SfT. 1- x 24- IRON PIPE tAElON SUILDINi WT &W uK W11N 10x1 OF ?W e4sA Sr. \ ° i. ee//L INCAR FOOT SET AT ALL OTTER LOT VMIANOE AFPFMW 11FTIE1� 11. 2000. AND cOu2i I ON PIP 114IONING NrVlaiY Ritoaium Iwim"Tla1. 1 -81101LIMAR I=. SET. I COMM 10 O \ UNPLATTED LAW N v 1,16 .� 2a ACKS OF BEGNNNG TM R Nw N WW DO- E 2614 -W NORM LK OF THE NN 1/4 MAW COMM 57L17• 1]0619 \ SOCI 17 13OLi9 D): "Im TO M e T22( R1E01 KI11R 17.411 sF. ' \ 1 54160 &F. Z5" A Aa1p (]I OUTLOT 4 10°° IF ' I / 3a ' $� _ -� 9 t " L�tv 01a . 6 i 21 20 ' 1 Q I 1 L 2 Sf, I 133DA I F. 1 \ _ '�� I asAaO Sf. see" MAM 7 M R 7 \ / �I IOIOINW Ss. IA77 5 g 1 SF, 17 e4Ore 1A70 ALsFTSII 4seaT sF 2" AaW3 . 1 977 ' d € 22 i�•' auaa g 10 _ J 2000 ACIE4 ENIGENf \ I \ \ 31 1=1 1 AaES A ID 14.1 1.2" � Lleoe sF. � 4 � m 1 32 ,am AL1es / 1 ea Aces f , 52A" sF. as= SF. R 1 1 F 34 �� ' 1 �� 1 1 29 . 1 t 1 1 1 �6 G V 4 m7 9 &F. 28 r f — T 1 46,721 sF 1 fg � �`� 1.104 AOM I J 5.701 SF. / _12 OUTLOT 5 3MI A0110 0. 28 1 / 8 27 154AM SF. 1 - 1200200 Mae! sF. — �• " / 104 � �� 1141 � 1y1 61,1x9 13 11• SOUM LIE OF M WE 1/4 OF M - K 1/4 UNPLA TIED LAND TOPORARY at SDUM LIE of M NW 1 OF TIE Nw 1/ EASEMMM io Tli°TVANO ALL M M — — — — — — ) N ��� UARATTED LAND a PIP M V RITES AND — — — — — — — — E EO'd� PIR OMSINO OR M APPROPRIATE TOW BOARD JAMES D. FLKM s -2246 I d REGISTERED LAW SURVEYOR r M ROAD RIONT - army OWEN ENGNEERNO COMPANY I 113 WEST WALNUT STREET A 9A D.gININ R EDUCE D O LOT I TO 1 S (210 RIVER FALLS. WISCONSIN 54022 14_ (TAKE SLRUCnIp AS DATED THIS 7TH DAY OF NOVEMBER. 2000. _ W,Tm UPON $Taw E>11TMION. SHEET 1 OF 2