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HomeMy WebLinkAbout040-1259-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division , INSPECTION REPORT Sanitary Permit No: 453428 0 (ATTACH TO PERMIT) GENERAL INFORMATION 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: Haney, Jeffrey S. Troy Township 040 - 1259 -90 -000 CST BM Elev: Insp. BM Elev: BM Description: Sectionrrown /Range /Map No: o >, c}G, e 5 T 5,-L - JA— f 18.28.19.1388 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing ,..._ -.. _..._- Alt. BM Aeration , Bldg. Sewer _. nn Holding St/Ht Inlet "7 1 3 TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet -` Septic '� Dt Bottom Dosing Header /Man c�o.S Aeration FYI.,- Dist. Pipe Holding ° Bot. System w I r-1. 9 1 - 7 d ter.+ - 1 Sf Final Grade PUMP/SrI INFORMATION Manufacturer Demand St Cover GPM CJ- 30 c). f 1 1.7T Model Number. TDH Friction Loss System Head TDH ft Force ain Length Dia. ist. to W ell J SOIL ABSORPTION SYSTEM BED/TRENCH Width j Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 ✓1 SETBACK SYSTEM TO P/L BLDG — WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake rt Pipe(s) Length Length � Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over r - G Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Byd/Trench Edges Topsoil IJ 0 Yes No ;71 Yes No COMMENTS:- (Include code discrepencies, persons present, etc.) Inspection #1: /0 / Ki / 4 E Inspection #2: / / hw r Location: 389 Deer Valley Drive Hudson, WI 54016 (NE 1/4 NE 1/4 18 T28N R1 9W) Deer Valley Lot 9 Parcel No: 18.28.19.1388 1.) Alt BM Description = S' 1� �uz �/ w 3 �r 64 Y + r �S E \T' eJ . r �! 2.) Bldg sewer length = y Ej - amount of cover = ` Plan revision Required? i JI Yes ! No Use other side for additional informati n. SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 Madison, W1 53707 - 7162 Sanitary Permit Number ((to be led in by Co.) I3 /*►� (608) 266 -3151 Department of Commerce Sanitary Permit Application 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(l)(m) roject Address (if different than ding address) V . 1. Ap&cattton Information - Please Print All Inton nation Property O 's Na me Farrel N Lot j 3 gg Blo , a Property Owner's M ailing Property Location JV_ —! C 56,A'- (fSection Cit7 g Zip Code Phone Number 11 � (circt ) i �� S�� 3S T � N; R E W . Type of Building (check all that apply) f9 � Subdivision Name @SM- IFntnber i or 2 Family Dwelling - Number of Bedrooms ❑ Public/Commercial - Describe Use ❑ State Owned cribe Use ❑City_ ❑Village Now hip of f 8 t III. Type of c: (Check only one b�,,m omplete line B if applicable) A. New ��R�wvI- m ❑ Treat mendHoldio�Tannk pl acement Only ❑ Other Modification to Existing System List Previous Permit Number and Date Issued B. ❑ permit Renewal ❑ Permit Revision 11 Change of ❑ Permit Transfer to New Before Expiration Plumber Owner IV. Type of POWTS S e in: (Check all that apply) Non -Pressurized In-Ground El Mound > 24 in, of suitable soil El < 24 in. of suitable soil El At Grade ❑Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized in- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit El Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ravel- less Pipe ❑ Other (explain) V. Dis etment Area Information: Dispersal Area Required (sf) Dispersal Area Proposed (sf) System �Elevation Deli Soil A lication Rate:(gpds0 pe e q w Desi Flow (gpd} gnu pp J 7 7i 0 57 �� VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber plastic Gallons Gallons of Units tt (t-l' 4 ' ortcrete Constructed Glass New Existing Tanks Tanks Septic o Holding Tank e „ Aerobic Treatment Unit Dating Chamber VII. Respondbility'State went- 1 , the undersigned, bility for inst of the POW17S shown on the attached plans. Na ( ' t) Pl cure PRS N r Business Phone Number 7's r (11V\,ALL)A> OCR Plumber's Addre ss (Stmt, City, State, Z' Code) 01 VIII. ty t i ature i Approved ❑Disapproved Sanitary Permit (dudes Groundwater Date Issued ing en t S gn ( N Stamps) Surcharge Fee) ru ❑ Owner Given Reason for Denial 2,v 3D IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced I maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances. AUach —plot p1m (to the Coady only) for the system eu POW Rot less than $'a x 11 Woes In size �i pjOT -qa Ain NE �y ti Y s 8 Taa ,u R I g w LO t-0-t-4 Ck-0— � . s 357g — r r p A IU4- 04 1 S9 - qo - 00 `� v` Tie ne_��s 0 @ (S( N 8 e Q:Y s E �� -T-1 c.E©�.� a22,Ds a, Qum -top o� `` ��c,�; �C �� f00 t v \ K1 IS a L!V t� . ------ I ------- I --------- 0.0 p 40-0- act n �e N���y N E �/q s,� �a� u R 19 w Ar k Pf- ci� r � �. �� S�e. S 35 - 79 — rro l s r Cr�o ")C asp. S 1 <<, -4A;- --e 7 a2.oS 3'7 J) 6 rv Top vc P a. E � t oo' � ® �� 8th rtv� D � `` P �Cp Pa, @�� 100 Qv g� .\s a F i T V � Eli m �� • MMM • % U • '' Rarrsgr OaarR F�uastlLt i ly1 El ❑ M GMMdOAoosatm. t Oaphlawrdy�dor h AroMrw bosdoo"t coo Aurlr ONGIWA , 7iowoM. Smo irrt ` ! wsola IWL loured Qs. $s. COL Color Q: 8:_ Soh. E �# ❑ eo�g pit Qouid aadroaalar. IL Qgo 10 aeawg b dw OL !!nine D"M !moor! lirrct nootm 1wafta swig" AooR k iieeol qr. at OWL Elea Q. Ss. SA 'fit El 0 s ❑ ve aeea/a.rowelow. R oswaa.MMwsMr rti t +D Oas# rwit Cft Nr 000alMlnR. Two >�o wsosa ira Y�roi Ot,Sc. Qai1. Qr. So. �. '� Ell wa i" qw, > US= WQ& and TW 3to :E Nang& 02. 9OQ,: S W ag& and IW :E aQ at* Uw Dapenwoot of'OrMUSac m is sa apl apporaopfty anvioa lwi&vM randsagleya if'ym good asolassw * now lil VION seed milsaw a so ohm"" fnwo. phase awo,tt ft depict at 606,W -31St ar TIY +5116- 3644M?. ..au�.«.a W tL{ f al � r�s�v , QLo �n , � , .Q�, ��� LoT 1 P � e.`, h`.•e, fl S�C, ls�s'�- 53s7$' � r© s ro A 6 rrA - T y i p6 j 4w orr� �r a �s �o n M �g 5 3 75� Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of Safety 8 Buildings in accord with ILHR 83.05, Wis. Adm. Code • COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size' Plan must include, but St. Croix not limited to vertical and horizontal reference int i tion " 0 9 of slo e, scale or PARCEL I.D. # Po ( ,6 P dimensioned, north arrow, and location and distan �® �st`road. 040 -107 — APPLICANT INFORMATION - PLEASE P Nl LL I 0{ MATION Y \ R VIEWED BY DATE PROPERTY OWNER: '/ PROPERTY LOCATION Derrick Construction, Inc. - Aij GOVt. LOT NE 1/4 NE1/4,S 18 T 2 N,R 19 R(or) W PROPERTY OWNER':S MAILING ADDRESS Criok., � } LOTJt BLOCK # SUBD. NAME OR CSM # 1 Deer Valle CITY, STATE ZIP CODE H AI F ITY ❑VILLAGE MOWN NEAREST ROAD New Richmond, WI. 54017'x.246 -23.= Trov E. Cove Rd. (x] New Construction Use [x] Residential/ Number of-b� 4 [ j Addition to existing building [ ] Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate _ .7 bed, gpd /ft gpd /ft Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate .7 bed, gpd /ft -- trench, gpd /ft Recommended infiltration surface elevation(s) area A= 99.7 —B= 98.20 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem Cx) S ❑ U 0 S ❑ U W S ❑ U U ❑ U WS ❑ U ❑ S LR SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft .................. in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ................. .................. ................. .................. 1 >; 1 - sl 2msbk 2 7 -41 7.5 r 4/6 none cos Ground 3 41 -84 7.5 r 4/6 none ms osa mvfr na na .7 .8 elev. 1 03 . 5t. Depth to limiting factor qR, +84 14s. Remarks: Boring # 1 0 -13 10 r 4/3 none sl 2csbk mfr QW 2f .5 1.6 .... 2.` 2 13 -84 7.5yr 4/4 none cos oSg ml na na .7 1.8 Ground elev. i 10 ft. Depth to limiting factor +84" Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 200th New Rictmond, WI 54017 Signature: Date: 6 -3 -99 CST Number: m02298 4� PROPERTYOWNER Derrick Constructio SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL I.D. # 040 - 1070 -10 Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Ba�rxlary Roots Bed Trench 3 <' 1 0 -8 10 r 4/3 none 1 2msbk mfr cs 2f .5 .6 2 8 -18 10 r 4 4 none sl lcsbk mfr Ground 3 18 -84 7.5 r 4/6 none cos oscf ml na na .7 .8 elev. 1 Depth to �#- 98. z o limiting �- r--- factor Remarks: Boring # 1 0 -9 10 r 3/3 none 1 2msbk mfr cs 2f .5 .6 4 ` ? 2 9 -19 10 r 4/4 none sl lcsbk mfr qw if .4 .5 Ground 3 19 -84 7.5 r 4/6 none ms osg ml na na .7 .8 elev. 100. 7t. — Depth to - limiting 30 ? factor +84 Remarks: Boring # 1 0 -10 10 r 3/3 none 1 2msbk mfr cs 2f .5 .6 10-91 10yr 414 none 1 2msbk mfr if .5 i .6 Ground 3 21 -84 7.5 r 4 n - e ms oscr ml na na 1 .7 .8 elev. 10 ft. Depth to limiting factor �' ` ' ` +84 Remarks: Boring # 13 Ground elev. i ft. Depth to limiting factor Remarks: S13D- 8330(8.05/92) f r STEEL'S SOIL SERVICE Gary L. Steel Derrick Construction, Inc. 1554 200th Ave. CSTM2298 NE %NE% S18- T28N -R19w New Richmond, WI 54017 4 4 MPRSW -3254 town of Troy (715) 246 -6200 lot #9 -Deer Valley This soil evaluation was conducted to satisfy.a zoning requirement, it may or may not be suitable for your use. The location of the test may or may not be as shown as permanent lot lines were not established at the time the test was conducted. - = top of i pvc pipe @ el. 100.00 M t. BM= top of 1 pvc pipe C el. 100.30' X or 5' 6 t F Pr f� .5 jet �' Gary L. Steel 6 -3 -99 1 I i �I EZ vvv T � ++ 333 M i wow ' *' f i ' 4.625" ... ww wv f •" ww .` 1/2 Ciro. vv w ww..... .... wr..rs. tiaa d 1 Valid Cali>acm m at ,n V"m u 57.4%, itlafM A y r es O.D. ©f4 Mqc 625 bx*4cs S +H t2 Sidew ? IS."n -4 D I Voed " PM t+a>tia► ft. - J.la - tt � 2.,If25ir 12itf 3.J1 s2 n '� ' ift Dotticxta of a:ma6rr CCY14 der - r2.3 i,, Seii luttlIf", Area • 4 aMd vu tuRU , a ltc8aae caner 3.10 •� 6"''� }j - 3 , a • i ___-t,__Z �1i Mmlft �€ • ilaarn T 1 cadets - t ? "wkAm � � V °'d "olum& m aautsfde eyl ,� , • j, t� aNe '_ P*'o)a^eta:a! TraateiM Area tl2ip10� -.5�0° 402 Ft Sidewalt Heir � 12 in •2 = 2.00 Sq.Ft- 4 Did �ni f aaa+ee as Eauecsa ber+-crsa "Il laitm 244, x But 36 an Iberia s 2a�i }) s 3 -00 Sq. R. l 12®+ R J !'e acted Tra urr8 Area j at votyvy sa uaaaSade bon JJJ 5.66 S�,Ft. ? j fP of void vwuvw betwmo �Ytftwm) 0.21 S ? - !3 f 08 ft l t j Toasm! void valet 0 + 0.40! . 0-215 - p. 108 • 1 7ti 3 cuka.c ft , n j � Gailasau per Bt • 1. 761 X 7.48 - ►]. rails � i f _ 34, X !a �� 3 EPS Aggregote Trench S ystem EZ1203H � � 1 Ring Industrial Gra fl I 65 lnd"' fa! P P Olakland. 7N ark Rd. �8QS0 SCALE 1 FILE >wL €arm -" Pow`cs OWNER'S MA NUAL &MANAGEMENT PLAN Page --,�- o r . SYSTW SpECIRCA 0 NA 3E N Tank Marsala �S �''� gel Owner S. q( 0 Dose E3 Sapft Holding vol I � (� �� Z DNA Tw* Mare ai PARA#IIt Vol. 8 © NA t3 Septic C] Done C) Holdirsa DNA Nun*w of Sedmo ms Effluefft Fftw NuAnber of public FewcOM t Lhr}ts Effluent FVW Model _ o� �NA Esfmted (average) flow rump M a D Design tpeaW flow = tEstirrratad x 1.51 © �P Model A Soil AppficWw Rata Monthly ava rase, Retreatmant unit Standar Irdkord ► Effluent ouaTity 0 swxv ravel filter 13 post t Fats. Oil A Grease (FOG) 530 mgli. ❑ NA ❑ Mechanical Aeration ❑ Wetland g cal Oxygen pemand tB�sy 6220 mgA © Flisinfeciwn q Other: Total Suspended Sow iISS) St 60 mgn- Manufacturer Monthly average L7 NA pretreated Effluent t'rtY pal Cells) Biochemical oxygen Demard (SOD 53O mg1L , « igravityl G7 in-Ground (pressurized) Total S Solids (TSS) 530 mgll CI NA D A ❑ Mound �3 t)'` •cftu(100m1 CI t -Grade Fecal Cofr#rxrt tgeanetrZc ) ❑ NA Q Drip 1->� ❑ Othw-. Particle Size Y in dis. ❑ NA Maximum Effluent ❑ NA Other: Ot her. NA Other *Valdes tyQical for vv wwvmtw and septic tank gam• MAMITIMANGE £ELF swvk* tlerp►emv Service Event I I I is) Inwdmm 3 YOM) ❑ NA At least once every: s) k condition of tank(a) 'When combined sludge and scum equals one -third (%) of tank volume ❑ NA Pump out cont+n of tank(s) ICI _ When the high water alarm is activated U ( C3 NA rrronrtlr � 3 yearn) At West once every: ) tNf Inspect dispersal CONS) CI nrrorrtls(s) ❑ NA At least once every: as) Clean effluent filter C3 nnoreth(a) A At least once every: 0 ) 1 pump, pump con trols & alarm �# Wig} A Inspect p At least once every: ❑ a ts) Rush lateral and test D morrthis) Fl A (east onrS every: d ) A or certifications. MANITENANC.E cells shalt be made by an kK iwdusl ca m ° of the frdio operator (pumper }. mom of tanks and dispersal ct Sewer; WOWTS . pOWTs Maintainer: SaPtall r cracks or an y Master Plumber, Masba include ReW i of the tanks) to iders�Y anY miss U broken hardwaf on the 9rounc Tank Icons must inckda a visas; reap n sludge scum and a Check of P to check for ant leaks, me Of nmrr►birred udge for enY b� Up r and measure the volume and t levels in o art WhV an, surface. The � cell(s) shall be vtsW to check tfre on the indicate wd m poncTrng of effluent an the sue' The pord'� of effluent requires the immediate n0tifWvd n of the local regulatory wthodW' re of the tank volume, th When the combined � labors of sludge and st:�un in any fitment tank equals of in accordance with chapter NR 11 entire contents of tha tank shall be removed by a stage Servicing Operator disposed Mee Wisconsin Adrninfstrative Code- l or pressurized components, pretreatmer Al! oZ> services but not limited to the servicing of effluent filters, by a certified pOWTS Maintainer- units, and any servicing at intervals of 512 months, shall be performed by of any service event. A service report shall be provided to the local regulatory au torltly Within 10 days of GMyy {2102 START UP AND OPERATIO Pageor For new construction, prior to use of the POWTS dad* treatment tAnkls) for the presence of painting products, solvents or other char"IcalS that may impede the try process and/or damage the sod disperse( can(s!. If high concentrations are detected have the Contents of th tanks) removed by a septage qwVjCkV open Prior to use. System start up sh not occur when sac/ conditions are frozen at the infiltrative surface. During extendad wastewater will be dscharVW Po wer o utages Pump tanks may fill above normal highwater levels. When pore is restored the excess to the dlWersai ceft) in one large does end discharge of effluent. To avoid this situation have the contents the pump may overload them tank moved by u e or surface chorrtraa to restore normal levels within�the pump tankank� Pluunber or POWTS Mainiafr to assist i� pump r to restonng POw`Qr to the off luent ©o not drive or park vehicles over tanks and dispersal ceps. Do not drive or park over. or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grada =a absorption arse. Reduction or elimination of the following from the wastewater stream may improYe the Performance and prolong the rife of the POWTS: antibiotics; baby wipes; cigarette butts; c ondonW cotton swabs; degreasers; dental floss; diapers; disinfectants; fah; painting per :) discharge. fruit and vegetable peelings: game; grease; herbicides; meet scat medications, oil; napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shed be taken to insure that the system is Properly and safety abandoned in compliance with chapter Comm 83.33, Wisconsin Administn b" Code: • All pining to tanks and pits shall be disconnected and the abandoned pipe openings sealed. ' The contents of an tanks and pits 3h8V be removed and properly disposed of by a Septege Servicing Operator. • After Pumping, aff tanks and pits shall be excavated and removed or their cogs removed and the void space filled with sail, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS falls and cannot be repaired the following mammas have been, o must be taken. to provide a code compliant "Placement system: A suitable replacement area has been evaluated and may be utilized for the location of a rva system. The replacement area should be Plaot soli absorption protected from � and cvrrgesction anc�! shored not. be infringed upon by require setbacks from fixisting and Pro structure, lot lin and wept. Faihse to protect the replacement area will result in the need for a new soil and site evaluation to establish a imitable replacement area. compl with the rides in effect at that time. Replscrient avatars mus ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring technology a holding tank may be Installed as a last resort to replace the tailed POWTS. advances in POWTS ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a sal and site evaluation must be performed to locate a suitable relhlaCariwd. area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and atVade soli absorption systems may be reconstructed in place folio infiltrative surface. Reconsbtuctions of such systems must following o of the biomat < C WARNWG> > at the avrriply with the rules in effect at that tine. SEPTIC PUMP AND OTHER TREATMENT TANKS MAY COiI t Eh1At B/ iCENT OXYGEN. 00 NOT PB=N ENTER A SEIrM. PUMP OR OTHER TREATMENT TANK UND@t NTAA AN T t A R L O G A STASSES ANCES AND/OR INS DEATH MAY RESULT. RESCUE OF A FROM THE INTERIOR OF A TANK MAY E DFFICULT OR [MPOSSIW.E. ADOiTIONAL COMMENTS POWTS INSTALLER POYYTS MAINTAINER Nave ` Name Phone �S Phone . SEPTAGE SERViCWG OPERATOR (PUMPER) LOCAL REGULATORY AUTHOAiTIf Name Name Phora S . This docutaint was drafted by the staffs of the tueen take. Marquette and Waudmwg County Zor*v and Sanitation CI nin Comm 83 . 2 2t21ib1i1)tdl&ff) and 83. 54(1 ). 121 a (3i. Wisconsin Adr[sirative Code. in compliance with ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer S. "A-" Mailing Address \N 1 `}- I Z I Ca W Pa p.trwE (�A Ste M'-700 Property Address (Verification required from Planning Department for new constriction) City /State D id "A \ Parcel Identification Number 0 4 (3 — ZS q - -9 <3 - 0Q - 0 LEGAL DESCRIPTION Property Location M i/4, Tr i /4, Sec. , T 2 T -R W, Town of Subdivision be VA. Lot # Certified Survey Map # _ , Volume Page # Warranty Deed # - I b - 11 Volume 24oa 1 . Page # ti Spec house ❑ yesA0 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master phimber, journeymanplgmber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the abot;e 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 be n maintained must be completed and returned to the St. Croix County Zoning .Office within 30 s f the three ye iration ro l7, -'/ J `� IGN F APPLICANT DATE OWNER CERTIFICATION (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the pro described ov , by v' a of a warranty deed recorded in Register of Deeds Office. GN 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 RIVER VALLEY ABSTRACT Fax:715- 386 -7664 Jun 28 2004 16:59 P.02 U. 2604P 5 - 7 6 s2 STATE BAR OF WISCONSIN FOR'Ni 2. 1999 RATHLEEII H. WALSH WARRAN DEED REG ISTER OF DEERS S7': CROIX Co., NI Document Number RECEIVED FOR REMO This Deed, made between Rom D vis d Ines. Davis. 06/28/2084 11:00A1f 'e Grantor, J 1t are hrrsban d wife WARRANTY DEED Grantee. Grantor. for avaluable consideration, conveys and warrants to Grantee REC PEE: 11.00 the following described real estate in ' . Croix COriaty, State Of Wisconsin TRANS FEE-. 265.58 fif re space is needed, please attach addendum): C F FEE: CC FEE: Lot Plat of Deer Valley iva the Towm of Troy, St. Croix County, PAG£5: 1 onsin- Recording Area Name aAd Retmn Address 9- p=Cd Men5cadon Numb" (M) This is n homestad propftY Gs) (is not) Exceptions to warratlties: Easements, restl ietious and t'ights-of -way of record, N any. Dated this __n day of J e , 2004 s Robert A. Davis - 0 : e L. Davis A,UTf WMCATI ON ACKNOWLEDGMENT SignaRUe(s) STATE OF ) county ) authenticated this day of \r Personally came before me day of \SGO , 200 the above na�ooed S�a�Pr Robert A. Davis and gxistine L. Davis, husband an8 wife s • MEMBER STATE BAR OF WISCONSIN tp ICr1 to be the perso who WGectrted the foregoitng (R sue, and a 1 ed a same. sutbarized by $ 706.06, Wis_ Seats.) �� . THIS INSTRUMF3Nr WAS DRAkTED BY I / ' tX ! , Attorney Srisdua Ogtand No Publi , to of Hudson, WI 54016 no matron date: My Cammissi is pecmaneut- (If C, state �Q (Sipjwms may be autbenticated or ndmowledged. Both are not necessary.) ) must or printed below thou signad�re. womidon Professionals Co., Pond du Lac. Wt s Names of persons signing in any Wa ' tYP� 800.655 2021 STATE BAR OF WLSCONSIH W ARRANTY DEED aR VALLEY Located in the NE1 /4 of the NE1 /4, Part of the SE1 /4 of the NE1 /4,.Part of the SWIM of the NE1 and art of the NW1 /4 0 14, p f the NE1 /4, of Section 18, T28N, R19W TOWN OF TROY, ST. CROIX COUNTY WISCONSIN i LOT 12 2.3 Acres LOT 11 LOT 13 2.7 Acres � G 4.8 Acres 2 G LOT 10 W 2.7 Acres LOT 14 3.2 Acres a LOT 9 N 3.3 Acres Q Z LOT 15 UNPLATTEO LANDS LOT 16 2-3 D 2 - 3 Acres LOT a F Acres 3.4 Acres J a Ml LOT Acres ' 24 Apes LOT is LOr 23 LOT 7 LOT 20 2.5 Apes 2.6 4.7 Acres 2.9 Acres LOT 22 Acres LOT 29 2.7 rl 6 8 Acres Acres LOT a LOT 19 2.4 2.7ACres a 2.3 Apes Acres LOT 20 C 3.4 Acres 0 LOT 5 2.7 Apes LOT 4 LOT 2s 4.a Acres 2.3 Acres LOT 2 LOT 3 2.8 Acres 3 T Acres LOT 26 3.3 Acres LOT 27 2.7 Acres LOT 1 2.3 Acres Existing "Ouse East Cove Road Jessie Nye 14t Subject: Powers, Deer Valley Lot 9, 453428 Location: Troy Start: Tue 10/19/2004 3:00 PM End: Tue 10119/2004 4:00 PM Recurrence: (none) 040 - 1259 -90 -000 18.28.19.1388 389 Deer Valley Drive