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HomeMy WebLinkAbout040-1261-70-000 Wiscon��' Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety aid Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 463181 0 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: Dougherty, Gregory Troy Town9hi 040 - 1261 -70 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: i� G ty\ I C 18.28.19.1406 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 7. 3 rep. 3 Des3t J Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet 7 • Z� �oU , r .'a St/Ht Outlet TANK SETBACK INFORMATION "7 , to-Z ' , 7`) TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 1 7 2_5 1 Z Z j Dt Bottom Dosing Header /Man. `9, 4$ t 1 9 % `7 Aeration Dist. Pipe I - 7,48 ct , x� Holding Bot. System /a � 4 A7- 9 0 • `Ito `� '� ! Cl 1� Final Grade PUMP /SIPHON INFORMATION 7 U1 _1 w Manufacturer Demand St Cover Model Num t- TDH Lift Friction Loss System He TDH Ft Forcemain Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length / No. Of Trenches IT DIMENSIONS No. Of Pits Inside Dia. Liquid Dept DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer. �� �� INFORMATION CHAMBER OR Type Of System: , i / UNIT Model Number. - 36 7 A114- DISTRIBUTION SYSTEM C1 c}-� Header /Manifold / / Distribution I x Hole Size x Hole pacing Vent o Ai Intakfj A ' � Pipe(s) \ e Lengt Dia Length Dia \ Spacing 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 Q Bed/Trench Edges Topsoil Z ' 05 Yes [] No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 352 Deer Valley Drive Hudson, WI 4016 (SE 1/4 NE 114 18 T28N R1 9W) Deer Valley Lot 27 Parcel No: 18.28.19.1406 1.) Alt BM Description =rte 151c,G V`, 2.) Bldg sewer length = Z6/ - amount of cover = �.0 Plan revision Required? I Yes X No ___ 7 "r Use other side for additional information. � � f SBD -6710 (R.3/97) Date Insepctor s gnature Cert. No. PIOT 44a - r ,;I N kli Uf P! 0140 ` P t 43 to i Q 7 I i 4ta. �_ '"MY and lht8dittgs Div1 r/ 201 W. S� �� Do art * of Commerce (608 266-3131 r, Pram Number (to be filled in by Co. ) Sfditry P i e�r'mh APPIka M AC__ - �_ tan t.. N umber !n aaorMd with Caatm 83.21, Wb. Adm. Cade, petaot>al U' X V i�U� 1j i m.y be used for s000ndsry purposes pl Srou y LAW. 115.04( m) SZ • ' ON1NG OFFIC Address (if difiereat than tttailitta address) I• APp oo IaoFotn - Please PON AN �toreaaeioo _ _.. Z hap" •s N Party! r t 7 Block / f qty U — I u �- - -_- - TO `C'o t 3 PrCPgrty faraday, o t city, State Zip C dee Ph�e Number -A. Sa;MM I Ii ( b �A — circle 7�rpe �" cLat k (sN OW applYj T N, R�E or 2 Family Dweilift - Number of 8edro0rus _ Subdivision Name CSM Num i icJCtxnmereia! - Delcribr Use � , L7 Su- Owned - Describe Use - - - - ! -__ L_)City_ f f7 m- ('Camlik 406 ate box m A, � A Ir e a appiiealik) New System ❑ (rlepiaamens Sysertrr L7 Treaane WHaid Tardt - - � r ,/ RRspiaattsemestt Only [._) Other Modification to Existing System il• n Permit Retaewai op Plana Revaion c hew Previous Permit Number tend to issttcd Berme Eapdruioat < e of Ll Permit 7rartsfer a� New - - - -- Plumber Owner 11 tV• Tape 4t POVttT'3 $Yslns: (t7taeit alb Wet apply) - -- - --I—�� - - -- I flJon "` tn`Gtanad L1 tttamd 24 im of auiosble sod l_1 l+tasnd < 24 m. of tunable Ma L) At -Grady I .J Single Pass Satd Filter U "'� ln"G nd U fioidi"1111 rank I I Peat Fuser O Aerobic Treatment Umt L1 R,,u,,.latirtg Sand Fitter V B 5 Media Filter ❑ Lmchias mber Cha [} i Pipe O ocer h (expiam) � now (IPO t]al�t Sail Appt mdm �t�0 � Area Required (sf) Area Pruiposed (sf) System Elevation • ` g s 0� toy 9 _ VI. Tanit Info m Gailotn of Units in Toad Number Martufacatrrr ptefjb Site Steel Pla ff Fiber — sti c _ New E1ia Concrete Constructed Glau Tanks Tatdcs Howirg Tack �t - -- _ — -- A Tmunww unit ��� - Cattret 's Na tut: ( ) r J for 11110 YO�VIS tdwwa aQ QM attadt pilrns. ; Phurtber'I Si rt MP1tS �uinesl Pltame l�lumtter a \v; � �+t 53 `r 'Mmtber's Adihe ss (Street, City. State. Zip Code) — m. l use �. v 4L __ A�M Selo 17 Approved D DWWPII -vad St miary Prorndt Foe (meiudes Gra ubvaper � Date t�rkd t A Si re (No Stamps) ❑ Owner Given Reason far Demai Surcharge ) L IL- C..aeott of Aop ear Dlopprovm d wt m , �- Aftoch coup p „.,w P t T -Ra I-- Co'^ drk i Aso "V -vf �,�; ; ,�,,� �' � , A nn 4 AT 9 c be Q A X7 1 3 ,73 �Y ngs Division C - - - -- De artment of Commerce ( 9 1 Perr Number be R+ in by Co.) I . . . . . . . . . . . i atxor d with Sani tary permit A PP • n Nov t I.D. Number COMM 83.21. Wis. Adm. Cade, pelippV provide tray be tried for purposes xy purposes Privacy I. A ZONING OFFI �i rtxs (if different than mailing ad drem) DO° - p'kese Phut Ali btfoemrttiop - - �/ Owtttr's Parcel f 1.0t / Block a~ rrPe*tY Own � br Address e _ i _ - no a Prt�ert t adation CKY state zip Code Phone Number _ ' A. 1v 1: ;.Sec11ion 0 (circl ) U. of $I 'Wilet (Mack aU that ply) ,u T I ar 2 Y Dwelling - Number of Satmo11ns _ Subdi Name CSM Number ❑ Ptibiic /Commercial - Describe Use — f S - ate � El S C3� or o-r. t -- -1 owned - Desrnbe�s l 5.e�.�9e�uS 16 K , - - --- b ,._ICi village W. nshipof IQ. Type of (Check ady are box on A. Complete floe a if atpp) New System ❑ Rolplaaemett System ❑ Toe 1116/Hnld' Tank rrrK Replacement Only i -� Other Modificatit)n to Existing System B. �) Permit Renewal ❑ Perm, Revision — 1 l -� Change of n Permit Transfer to New list Previous Permit Number and Date Issued j Hefru a Expiration Plumber Owner IV, of 1rOW f S tC7teclt a� that ) -_ Ntn - Pressurized 1st- crouad ❑ Id ound > 20 in. of suitable soil �] Mound < 24 in. of suitable soil IJ At -Grade ❑ Single Pass Said Filter ❑ Constructed WedaW 1j Pressurv�ed In LJ tlet img Tank 11 p., Filter Ll Aerobic Treatment Unit C.1 Recirculating sand Filter V SY> Moths Filter ❑ ❑ Low Gra -least Pipe ❑ rater (explain) Design Flow (gpd) Design Sold ApPlkkatidm Ratc(� Dispersal Aria Requirrd (sf) Area Proposed Z _ 1 (sf) System E / atio Vi_ Trunk Info C - ap�ty in Tsai Number Manufacturer Prefab Site Steel fiber Gallons Gallons of Uniu Plastic New Existing p Concrete Constructed j �rbv p IO TU6(� Glass w Holding Tads 1 Sepric Tacks Tasks �.� Aeiobic Treadrnettt Unit Ckasitrg <'hamtser _ -- YII. Res�tonlsibl ty fit- t, the , ` — - —J 's Na me ( 1 s Si Aw of Ule PO WTS sown on the attad ied plans, �° fMPRS Hater l Business Phone Number Phtrnbe's Addre ss (Street, City, State. Zip Code (¢9 Ta Lkw a Approved ❑Disapproved Sartirary Permit Fee esdes Groundwater Date Issued I Surcharge Fee) Signature No Stamps) ❑ Owner Given Reason for Derud IX. Coeditiona of Approt ad/R far WBapproral ---- - - - - -- Ll � ` �FJD _ SYSTEM OWNER: 3)Aj 1 1 Septic tank, effluent filter and dispersal cell must all be serviced /maintained as per management plan provided by plumber. /`1 . = 2. All setback requirements must be maintained as per applicable code/ordinances. i - - _ . _ _ pars (b tin wary alY1 tar d. s.. M pier .a i.as 1111.. 1111111 1:11 11 ttl.1. dze - - - - -- T lob a Go o !rn er� SE Y N� S 18' 7 oZ8'N letg W 13 2:.3 Wo�d C' L L Y U-x � � q �n l C S (o t (0 3 5� C),, , to t � s •ec�; o.ti.s E z��n w 1 c (oo *+ loos' 7' Nar 8n, - - rte ���p►� @E.� low f z PT4601 -rop �vc, .5 I ham' of ` S. N d c O v * y�a .�3 r - 13 3-J U�ac�c��gnd C� • ` �a�.���.� Lo�'� �7 ►* 040 —L kD asp v � 5.���; �..�w � •eS�e��,� l�, l0 Co o V� f r oc cc ` P P—SL©Ec g� � I g o f ;4 Si N c •4(3 .•7 - 3 Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of Safety & 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 point (BM), direction and /o of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distan 4earbst road. 040- 1072 -10 R t,. DATE APPLICANT INFORMATION— PLEASE INFORMATION -15- 26op PROPERTY OWNER: y �v. , , PROPERTY LOCATION Derrick Construction, GOVT. LOT SE 114 NE 1/4,S 18 T 28 N,R lg ;(or) W PROPERTY OWNER':S MAILING ADDRESS _ 7 u �a {` 4 LOT # BLOCK # SUBD. NAME OR CSM # 1505 Hwy #65 t cs > ' �qP 27 na Deer Valley CITY, STATE ZIP C PHO R ❑CITY [ KFOWN IN EAREST ROAD New Richmond, WI. 5401 2303,;° Troy E. Cove Rd. [ :4 New Construction Use [x] Residents "tbt F of Addition to existing building j ] Replacement [ ] Public or co mm8fsialideslr[ib Code derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd /ft •8 trench, gpd/ft Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate .7 bed, gpd /ft .8 trench, gpd /ft Recommended infiltration surface elevation(s) 96.90 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 62 ❑ U ® S ❑ U ®S ❑ U CR S ❑ U � S ❑ U El S CCU 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 Trtct 1 1 0 -14 10 r 2/2 none 1 lmsbk mfr cs 2f .4I .5 2 14-20 1 Ground 3 20 -28 7.5 r 4/4 none sl (!1 r mfr QW if .5 .6 elev. 1 4 28 -84 7.5 r 4/6 none cos 0SQ ml na na .7 .8 Depth to limiting factor y. Y +84 Remarks: Boring # none lmsbk mfr cs 2f .4 .5 2 <> 2 10 -25 10yr 3/3 none sil lmsbk mfr 9W if .2 .3 Ground 3 i elev. 1 00.9 ft. Depth to limiting factor +84 Remarks: CST Name: -- Please Print Clary L. Steel Phone: 715- 246 -6200 Address: 1554 200th. A w Richmond 4017 Signature: Date: 5 -27 -99 CST Number: m02298 k-1- 2 2�_ i PROPERTYOWNER Derrick Construction SOIL DESCRIPTION REPORT Page 2 of 3' PARCEL I.D. # 040 - 1072 -10 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 0 -12 1 mfr cs .4 .5 2 12 -28 i mfr if .2 .3 Ground 3 28 -88 cos 0sa m1 na na .7 .8 elev. 1 Depth to limiting facto 3. z Remarks: Boring # 1 0 -14 10 r 2/2 none 1 lmsbk mfr cs 2f .4 .5 2 14 -22 10 r 3/3 none sicl lcsbk mfr 9w if .2 .3 Ground 3 2- none cos I osa m1 na . na .7 .8 elev. 99.5 ft. — Depth to — limiting factor +90 11 Remarks: Boring # 1 0 -19 10 r 2/2 none 1 lmsbk mfr cs 2f .4 . 5 2 19 -30 10 r 3/3 none sicl lcsbk mfr gy if .2 .3 Ground 3 30 -88 7.5 r 4/6 none cos 0SCf m1 na na .7 .8 elev. 10 ft. Depth to limiting factor +88 Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) r STEEL'S SOIL SERVICE Gary L. Steel Derrick Construction, Inc. 1554 200th Ave. CSTM2298 SE4NE4 S18- T28N -R19w New Richmond, WI 54017 MPRSW -3254 town of Troy (715) 246 -6200 lot #27 - 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. t " =40' 1 BM.= top of 1" pvc pipe C el. 100.00 --� Alt. BM.= top of 1" pvc pipe C el. 99.80' o > 3 gb �A/(/� "7 Gary L. Steel 5 -27 -99 I EZ?203H I � PPi rPP 1,' Pf ♦ir a T!il PT. •T!!!P 4 .fi��" f.. 7! If 7. IF ♦ ► i tf 7 w! T ... 1 1/2 Cuc. = 18.8 " T P! T!• !!! •7TlTT! • iPl77 . f ►1.7rTf •T.s7. •ff.Rr• 7.il ►i PPTrT rTTr :tri�� !rT! srsrrr• --- -24 -- / 36" DIA. (typ.) Void Co frtaiern m wl 8►aen u �a.4ec. 1tl 12 EL 59 F. Q.D. of4" pyte ° 4,625 12 Sidewall (2 Sidewsgs) IS E4in Vold = is d Yolwttc Per linear ft 3 2.JlISw i 12a ■rR ,� g ift 0") of l2_5 i,,,ba Total Sail (aterlsre Are Void wl etc 4 9wellaft of teeter i a •; ° f s. s s - t g ' , S. I i S( . � - 1. --! 723w 1 FFt# {i7aiR 1, 32wrR � �� 37e- 473 fY orout we Cylinders t2 >h I i Vim voltmw to p agttde cYillfdGtt = a • 6 0 MC1ti fir!? Pro ected Tr j tlZiprA� 'spa 401 ft, Sidewall fief ght II 12 in '3 = 2.00!i Y uiU vnlwm at botwm bevwere+ ea• tiwficty - i ?4 "' „ jj Battaan = 36 in a 33 00 Sq�Ft. y ! f3Ssrfi f2ia+R " l 1 �t:is;01 O.aS R' f P retKted Trtaci Area = ( VOW Yoluttte ax outsede 5.09 Sq Pt. j bO {.- toretts (l/? of ro =Lt tofucne Totel void valemee =° I5 .` ? - G f 48 ft' t 4.117 . 0,422 + 0.901 . 763 ciebic ft r ft 1 Ga9iote per fl a 1 .763 X 7.49 - ! - �Lt4ss ter --, f ` ! i 1 a I f (( n /C> S V EP A 1 99�'egclie Trench System EZ12Q3N RKtg - lrtdustriQl Group. 65 Industrial Park _ R d �' -" Dakfand, T" fj � r� ♦.,,�' f jj ME MAMt- £Zt20Jri -tisl SHRFf; 1 of 1 17..27 -i31 R'S MANUAL &MANAGEMENT PLAN page -- �- °t POWTS OWNER'S s � 0 NA E , RNIATUM Tank W " t -ES '4L� vow o cE 1j;(S 0 pose 0 HddM9 0 Na errnit # I I Tents Mentitsch MAWN PARAl�tiETERS 0 NA O Septic 0 pose 0 Holdinil vat.. gal lumber of Bedrooms NA Effluent t M. Mxrfts p revt Cc7 ❑ NA public Facjwy Units Model 't _ OAS � 1 "Tiber of 00 Effluent. €V Estimated (average) flow Pump Manufactu Design (peak) flow = (Este x 1.51 Mode :Son Application Rate ' , Pretres"ne"t unit S"ridard InfluentlEffluent OualitY Fllorrttrhl avam9e 0 SandlGrevel Ffter D Pest Ffter R etland Fats. oil & Grease (FOG) 530 0 Meal Aeration 0 W Demand t !220 mg/L. 0 NA Dial 0 Other. 'actrernic� O Dernan Totes Suspended sotids (1'ssl Mon" average Manufacturer ❑ NA pretreated Effluent Quality Diapered Call(s) 0 NA Biochemical o xygen Dernand {bop 53n mgii- 0 NA %rn.Ground (t � Ct In-Ground ip $ Total Suspended Solids (TSSI 530 en9/l 0 At - Grade man) Mound mean) 51 W c4ul1 OOm1 0 NA D Drip t i(re 0 Other: Feral Conform {geaurtietric ys in die. Maximum Effluent Particle Size 0 NA 0 NA other: afar and asPbc tardc �°�. +V'alues ty pical for domastic vvactew MAtNTEN NA SCHEDULE trtor� ❑ NA Servim � 3 ) At lest once every= 3 of tank volume Inspect condition Of tank(sl combined sludge and ter' a °f � (Ki CI Wl, Purr dents of tank(s) C7 When � '�°� °� Is activated �'sl �rn'J yesrsl 0 NA Inspect dispersal couls) At least orsce every: monk sl 0 NA At least once every morfthtst 0 NA Clean eff fi� o t once every: con t r ols & alarm at lass ❑ morrtN(s) O NA Inspect pump, pub At b 0 y w(s) least once every' ❑ NA push laterals and pressure test 0 (s) Qihers At least once every: a Cl NA the observation lit:er>geS or e� cations: NS carrying one of the following fte s Operator (pumparl. ANTEtions of and dsPer 'I c�1ts shalt 6e made by u pO �tairar, septa fe y any cracks or I rcted sewer, POW f m fg oc broken h ardware , t the ground Tank s s) to identify any Master ember; Mtn � a tad $ludge and s� ( a for any bade up or Po � �Ic far any inspec of the ton in m ns of corm inspected to check the efflu may Olt levels in the pipes leeks, me cells) be visually an the Wound oWound a indicate a falling condition and surface. surface. The ponding of effluent Wound on the 1 r P� ndi ek�nt ration of the local regulatory qty or more of the tank volume. ttw tha «re -third ty,) t �k equals chapter NR 113 i any When the combined accu mulation of by as Septage n9 o and disposes of in accord entire contents of the tank urized components- Pretreetme or press Wisc onsin A d m i n i s t r ative Code• effluent wise of Maintainer* the servicing pOWTS An other services- includi but not limited to i 2 shall be pa by a certified at interva of 512 months. of com pletion of any service event. units, and any servicing y Whin 10 days GMW 12102 A service report shall be provided to the local regulatory 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, solvents or other chemicals that may impede the treatment process and /or damage the sod dispel cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when sod conditions are frozen at the infiltrative surface. During extended pourer outages pump tanks may fill abmre normal highwateer levels. Where power Is restored the excess wastewater will be discharged to the dispersal c+aMs) in one large dose and may overload them resulting in the backup or surface discharge of effluent. To avoid this situatiron have the contents of ttne 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 ceps. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade sod 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 pumpl discharge; feet and vegetable peelings; gasoline, grease; herbicides; most scraps: medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS falls and/or is permanently taken out of service the following steps shad be taken to insure that the system is property 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. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • 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 Dues and weft. Failure to profit the replacement area will result in the need for a new set and site evaluation to establish a suitable replacement area. Replacement systems must comply with the ales in effect at that time. ❑ A suitable replacement area Is not available due to setback and /tK soil limitations. earring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not bosom 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. Reed 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 13E DIFFICULT OR IMPOSSIiILE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER N ` ors Name c!L Phone i s Phw►e . SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name 1 1 7 _ L' Name St , G(`p i ZfJvl e h Phone Ptxxne 6.3 This document was drafted by the staffs of the Green Lake. Marquette and Waustwa Canty Zoning and Sanitation agencies in con dance 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 ► I "1 jJ� '�l r b{� Mailing Address /a'6'.50 t, 1l / vfo C b Property Address S Z 6c�''L- VA C-LC - -t &24 ki< (Verification required from Planning Department for new construction) City/State Parcel Identification Number 9 Z� 74 — O O o LEGAL DESCRIPTION Property Location ' /,, 1 /4, Sec. l � , T - N -R `41 W. Town of Subdivision V4L- Lot # - . Certified Survey Map # , Volume . Page # Warranty Deed # 7 7 5 '?" Volume Z '�d , Page # —7 7- . Spec house ❑ yes 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and' by a masterplumber, journeyman plumber, restrictedplumber 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. 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 b en maintained must be completed and returned to the St. Croix County Zoning Office within 30 da a three year iration e. SIGN OF A*LICANT DATE O R CERTIFICATION I (we) certify that all state T qs on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the rty described abo e y v' of warranty deed recorded in Register of Deeds Office. SMNATJ OF APPLI 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 10/25/04 MON 13:18 FAX 715 386 4687 REGISTER OF DEEDS 0002 775E399 U Z 6 7 ` P 3 3 9 K H. MALSH REGISTER OF DEEM ST. CROIX CO.. Yx s ("Grantor') RscuVED FOR RECORD a Gregory M. D he and Kristine P. Doughy usband and 10/01/2004 12: wi , vors maritai prope , WITNESSETH, that the said Grantor, for valuable =1sideration YARRA D EED Conveys to Grantee the fallowing described real estate in St Crobc County, State of Wisconsin: REC M -- 11.00 TRANS FEE t 283.50 of 27 ( ntyseven), Fiat of Deer vailoy in the town of Troy, Area COPY FEE County, lMscon n Name and w. ' 1 040426170.000 (Pared IdwWftW- NUMb0 Tbis in not 1wm dod WOMV. Grantor, Doer Valley partners, a Wisconsin Limited ).iabDity Partnership, is an affiliate of Derrick Homes, LLC, a Wisconsin Limited l.isNkyy Corporation. Grantor develops land and Derea Homes, LLC Is a home construdlon cantra=. Grantor agrees to sell this tot to Grantee on the condition that Derrick Monies, LLC will be the bulder of the home for Grantee. If Grantee does not commence wnstrix bn with Derrick Homes. LLC as the contracw1builder within two (2) years of ftte date of sate of this Wt to Grantee, Grantee gales Graramr the Irrevocable right to re�puxhase the lot for the same price as Grantee paid Grantor for It when Grantee bought It from Grantor, if Grantee desires to sell the lot to another purchaser before constudfng a home upon this bt, Grantee gives Grantor the right of first refusal to re- purchase the lot for the same price as Grantee paid Grantor for it when Grantee nought It from Gra,►tor. 0 ."' . AUTHFwnCATION ENT Slgnature(s STATE OF WISCONSIN ST. CROIX COUNTY Pemo+aiy came before me this 201h day of ;>UJImtiM 204. duthenticatw!this day of 1t! . the above flamed Michael R. Stevens and Ronald t.. ss parbiers of Dear valtCy Partners to me known tc rgons who the foregoing it owent and efgnapac C7=: 1110 " orp intnroe RuTLt bdLC TITLE MEMBER STATE BAR OF' WISCONSIN rtamo Plane (if not.N �f1l�ensln a,imo62ed by 7ati.aS. W' is SbttB) Mob" Pubic SL Orvbr (',aunty. Wisconsin. My Commisamn Expirw awlembcr 27, = 1W5 INSTRUMENT WAS DRAT" TES BY Nmw at pawom danwo in ow cwa* shaiM be typao or Deer' valley Partners paned babw Moir q% PO Box 445 Nm Richmond. WI 54017 . � O Z C) !n N O O X of M Q Cl) fn CO W N oti D O o `t N U) fn Cl) CO CO O 1 o O O O CO) U) co J r- J O O CD N O O O r 0 tV r � CO CO) � CO) C M J N U 0 E fn CO •O Q Q. M M c4 � rn N �U) o � co J Cf) J t CC `mil d o J O CO LL N t 0 M o 0 o w ° O a a a O 00 0o Q) � U ¢ 0 > o a < w O U) y J ; w o LU LL LL w 4� � A o ti W a r := 26 S. P587 ACR S ate' Lij St e � E � b i i N89'47'154" 41 8,53' ,27 w AC RES .. A�,` ............................... ................. ol wt - DCWAIM TO THE NY S8"13'41 "E 856. . EA ST COVE ROAD r - : DEER VALLEY F NE 1/4 OF THE .NE 114 PART OF THE 5E 114 OF THE NE 1/4, PART OF THE S'WI14 AND PART OF THE NW1 14 OF THE NE 114, OF SECTION 18, T28N, R19W, TOWN OF TROY ry, lrt'ISCONSIN: ............_.. ro �r l..i i 22 fib, bE , � 13 / i'4 ? . 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