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HomeMy WebLinkAbout040-1282-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 429963 0 GENERAL INFORMATION (ATTACH TO PERMIT) State P lan 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: Derrick Construction Inc. I Troy Township Q — o� 0 CST BM Elev: I Insp. BM Elev BM Description: Section/Town /Range /Map No: 00. 00 .a C VAA* 19.28.19. 5 TANK INFORMATION . '#-LEVATOR DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic w� S>L Benchmark Q l ` 9 / e0 . o Dosing Alt. BM Aeration Bldg. Sewer 1 . J eo. 0 ( Holding St/Ht Inlet 73 l•(o� NK SETBACK INFORMATION St/Ht Outlet �D•-} .ZS TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic P ► Dt Bottom 2� ----_ Dosing Header /Man. �• 38 �� � / Aeration J , Dist. Pipe �� ?d �,-Z,Q • Holding Bot. System Final Grade PUMP /SIPHON INFORMATION 4 ftz Manufacturer Demand St Cover GPM 7 Model Numb r TDH Lift Friction Loss System Head H Ft Force Length LDia. I Dist. to We SOI ORPTION SYSTEM ( t,,,,.!�S joq!RENC idth Length No. f Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth 3 , 1 DIM S / 2 �. SETBACK SYSTEM TO v � P/L BLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION � D r CHAMBER OR Type f System: UNIT Z / � } � Modetrn gr: p � DISTRIBUTION SYSTEM l-*3)ia% L Header /Manifold 1 Distribution x Hole Size x Hole Spacing Vent to Air Intake P' e t Length '� Dia� Length Dia Spacing > Sb SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes ❑ No j', Yes JI No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 0 Q��nspection #2: Location: 222 Muirfield Trail Hudson, WI 54016 (SW 1 4 SW 1/4 19 T28N R19W) Troy Village 4th Lot 129 Parcel No: 19.28.19.�f ?� 1.) Alt BM Descriptior( S• ( WNw� ���'� 2.) Bldg sewer length - amount of cover Plan Use other de for additional Yes No a rnformation. � � � SBD -6710 (R.3/97) D t Insepctor's Signature Cert. No. S I I Safety and Buildings Division Courtly 201 W. . Washington Ave., P.O. Box 7082 ST b I Nv isconsin Madison, WI 53707 — 7082 Sanitary Permit Number (to be fi ed in by Co.) Department of Commerce (608) 261 -6546 Z ,6 • Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you rovide maybe used for secondary purposes Privacy Law, s 15.04(1)(tn Project Address (if different than mailing address) I. Application Information - Please Print All Information V I - Pr overt v Owner's Name MAY O 6 U Parcel # Lot # `aq Block # �� 00 -emu 1 Prop Owner's Mailing Address X COQ AaagAo ZONING OFFIC IS City, State Zip Code Phone Number �' w �' Section kA ( C I J irc II. Type of Building (check all that apply) � � S � � T _�N; R�E o� b ItAAgfL t� •ts. ( X 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name CSM Number ( ❑ /Commercial - Describe Use c l \ ❑ State Owned= cribe se ❑City ❑Village ownship of Pli S III. Type of Permit: Check only one bo n line A. plete line B if applicable A. XNew System y 11 Replacement System ❑ TreatmendHolding Tank Replacement Only 11 Other Modification to Existing System B List Previous Permit Number and Date Issued ❑ Permit Renewal 11 Permit Revision ❑Change of 11 Permit Transfer to New (� Before Expiration Plumber Owner J IV. Type of POWTS System: Check all that appl �l on - Pressurized In -Ground El Mound > 24 in. of suitable soil 11 Mound < 24 in. of suitable soil ❑ At -Grade El Single Pass Sand Filter El C Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ d Recirculating Synthetic Media Filter ❑ 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 (so System Elevation qpo 0 o ge VI. T ank Info Capacity in Total Number Manufacturer P Site Steel Fiber _Plastic Gallons Gallons of Units Concrete Constructed Glass New I Existing Tanks Tanks Septic Iding Tank s.Fy c aC� W 'Q Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for instpUst6V of the POWTS shown on the attached plans. Plu beer's Name (P 'nt) P umber's Si a /MPRS umber Business Phone Number .�Q OS3 !S S< Plum er's Address (Street, City, Stat Zi Cod v /� J� O VIII. Court /De artment Use Onl Approved El Disapproved Sanitary Permit Fee (includes Groundwater Date Issued I Agent Signatur Stamps) Surcharge Fee) ❑ Owner Giv Reason fo r Denial IX. Conditions of Approval/Reasons for Disapproval 36 ►�a -� r v - 11A &Z V � ua Attach c Piet ((o the County only) for the / ystem on paper of less than 41 ' " 'nches size 1 � � I Vi U yt- SBD -6398 (R. 08/02) -- I �vil 1 I I I I - rcad� oI �! - -; �- � -� _ •q,.�:�Ct��_21_Qc?I ( ' A. '- '� -,�, — - -�- - -- � -- l� d j ' I - I i ✓ *1 I I 1 I I i 1 I ' 1 1 1 I 1 1 1 I A, : I '; I —1_ - : I a I : ' I I � 1 i ; ; : I , T l� Pa L lla A4, . A 4 04 S ca 1�e. t - y 7 I � 9'a ` �, __ � __. __ ___ _ ___. n _, ;, ., � __ { -_ _ �. '.. s _. ', ,� p Wlscops h Department of Commerce SOIL EVALUATION REPORT Page of 3 Divf*an of Safety and Buildings f County Z -r V/ G/ e in accordance with Comrp N '/is , Adm. ode S Attach complete site plan on paper not less than 8 1/2 x 11 inch st ilze. Plan Cm 1 x include, but not limited to: vertical and horizontal reference poira.(BM), direction and parse I D P �} N 6 / ZY• ( ) percent slope, scale or dimensions, north arrow, and location aid distangg�tq�nees( ro& _ a - 10 - 000 Please print all information ` 1i CROix ed b Date Personal information you provide may be used for. secondary purposes (P,rivacy, Law Property Owner Fr rN C �t�LeS S , L°U01 -z Property Loca o G /4 S W 1/4 S T Zg N R ) q E (or nW Property Owner's Mailing Address L ck # Subd. Name or CSM# 11.8 aQ DEIEQ ti to 1Z9 - FAZ-oy \J L _ ,G C City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road �L~I tiE MN I S3q qg 063 )'157 - X56& _T_\_U)L' New Construction Use: Residential / Number of bedrooms _�_ Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: Atg� d / .) OD pF Sr�r�Piyr, Q Parent material L,b EMS o U�.Z FrL 0UTwP, N Flood Plain elevation if applicable Iy A ft. General comments and recommendations: Y ' CEL S OF WIG[+ C-Pr9fl 'ILl. I h.l S T -tL� Ors) PA-G(�- l L y Boring # ❑ Boring S � - • y © pit Ground surface elev. Depth to limiting factor 7 1 Z 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 I 'Eff#2 0 -}0 } o -t rz -- sit Z-Fsbk ,-a Z )o _zq I 10-tk _1A I si f Z�sblz \ V1 $ 3 2? - 1b 10 VA - `F5 O S m l - • S • 9 1Z ❑ 9 Boring # Boring pit Ground surface elev. q 0 • b R Depth to limiting factor Z 3 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. 'Efr#1 'Eff#2 o -g 1,z {Z 3 L Z s t. l Z'Q�bl2 n�`� -- CS Z. $ -Z3 io `tl 3Lb - S i 1 Z`�Sbk `tR 5 `� -' - . p . 0 t cal U M w/ ,I,/ t y Z`' Slb S 11 G M 't ' 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) _ Si g ature CST Number Arthur L. Wegere 00 -31 -129 220254 Address W e g e r e r Soil Testing & Design Service Date Evaluation Conducted Telephone Number 421 N. Fiain St. River Falls, WI 54022 Ica - Z3 - 715 -425 -0165 's Property Owner NCR. 1� R P . Parcel ID # N Page 2 of 3 T Boring # ❑ Boring ® Pit Ground surface elev. a U Z ft. Depth to IlmiUng factod 1 u In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPO /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 o -1z 102 rz Z C z - sit z�F sbl� >n`Fb- c I.J l t, -F • s • $ tiz �oti� 3t6 — si Zs�k �n�Ft- c.s •s - 3 �8 -vz)i loyR W L S O sg Yrj 1 .-2 t_ Z 1 4t V'n lire � l o I . 17- Boring # ❑ Boring ® Pit Ground surface elev. q.0 S • Y ft. Depth to limiting factor ? LO O 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 -9 fZ /2 — Sil z S61t yvt e-w wit . g ,8 Z I -Z3 1,04 23A. — S11 Z►nsbk mf'H cS s .g 3 23 - VL Lost P - S16 — ) A A, 0 10`11L y/ s O s I - •S -q 31 3 2 `� O - L'' fra a , t 1Z.-q Boring # ❑ Boring pit ' Ground surface elev ao 4 3 ft. Depth to limiting factor ? Lt) 3 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD 1ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 Z q�S R- 3A) — sll Zmsbk m'Fi- Zoe 0 `12 ✓6 — s O �9 r� Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L • 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. SBO.9330 (R6100) ` PLOT PLAIT Page 3 of 3 `� Lcsl \z 6_ Scale 1' = SO ' 3•t2RA 901 S'rgll�i . N � ZI � — 1zgE. PtL�T��f'R -E w Y� a- zq 8 1�DTD Cod Jr�� 6�l / � SMI►J, Zl � 'N I 10 Q. D 9'o I .lZ 2J' I l�jL ON 4 LOT l Zq I I �L COTE -M AN, sTt'Sl,uz =1►� S'CY'�L�.. _CAS �C'� `' - D ��'Q o � >°�" Ls�T �Z`' t IvYO TTY S►�'�.1� �'OYZ I.Zt1N 1P=TA S Lg 1E�6, eouh. Am' A S " U- Uwere- D p i - �liv� S�L3 j �Z.N`U lUhrs I"rT 11ttz T2 w1< of Ikv STA2LA uxi . 715- 425 -0165 220254 pU -3l$_ lZ CST Signature Date Telephone Ito. CST No. Job NO. y _ _ LOT 4 o / I C.S.M. ' � - _ � VOL. 4 '� Z h . I �' PAGE 9S / o B -406 8-408 i / /� / ! / 0 I r / / / , I e� I B -405 t 1` 1 .' , - - - - - - - - - - - - - - - - - - - - • •, / I L �i / I r r / I / / PT 1 1 68 +d 04J I / • / / 9 Zc(, 1 � � I I � I 1 894.6 / ' • / , 1 `gR �g� LOT 3 / ►� I C.S.M. VOL. 4 B -349 �- , \.�' r ,'.. \ �,,,_,�,% % ` IiAGE 99.3 VCS sll.l �T/ 25.89 \ + , L 15.0 LL- 1 , j 6' --4A4 11 B-348 a cs' �, ,/ ► \ .. i / P 63 .09 I X� 9.3 400 ` / / 3 +0�.5 o •�� ..�� nn LOT 1 /y .r i �-4G�1 ?' _ C.S.M. V 6 1 1 0 PAGE 1627 81347 ! \ \ Olt \ C'� 91 .3 40 1 90.9 C, 891.4 `1203. � jZn 4.62 *•► j Ct► T.T • -s T.T •T. •.♦ TT ~ • • 112 Circ. •T T �t 3 Void p ort; ~ 1Rn to 57.4'X,. of4 °Pq* 4.623 1sit� r Vo+d vol,rre per linor S's)i (,► Side�y�� Jsl. 1>2 Ei Q. D_ of q� G fit CY#Mdr 12 5 encAq $ 1�2gt - ° 3.13 Vaud va1� i. °�CSatr of f --.... ' ;YOnder N . e.:Sm ' Tout S° Isterbca Are. 2.00 0.0. of outwc cybrid . 12 w k I2 f - 574. 422 1p &14 S . 1 I J V�1, 'F'o�tdeeYdmtkrs. -�a!_1 •.szi.. Pro e 112�rft� 90 )f. T ' 90) �Wd voles u bwrom Sidewwail Hight � e 1� in. •2 1 [R [,hQdM ° 2.00 Sq.Ft. 61" , Bottom s ti'orrl vot es at outer t2a r fi t 2 rot 2 fl � t i is " 0,215 1T" P 70+31 v 36 in, z 3.pp Srj Ft. l 1� rQleeted Trench A . � � Korn ro+raers l dd2 of woluRk bee S.op SWldrt. urge ` 0.117 + 0.422 + e1'A*+dcrs? 0 21S lob 1}, Per R . 1 .753 X 7,43 Ceallan� ' 0 40i + 0 213 + 0. to8 - < 1 -761 a� R t t CPS Aggregate Trench SYS t ern EZ12 ©3H 6S Rin g ' t Industrial Group � w Oakland pork Rd. TN' -18060 SC F.E ' E2t�tgr3.,bt t 1 If "_a7_ot r POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pa l of FILE INFORMATION SYSTEM SPECIFICATIONS E '� Tank Manufacturer W 4 QS -� vS 0 NA # `� q(, XSeptic 0 Dose 0 Holding vol. ( Oo c7 gal DESIGN PARAMETERS Tank Manufacturer 0 NA Number of Bedrooms 0 NA 0 Septic ❑ Dose 0 Holding vol. 9 al Number of Public Facility Units ❑ NA Effluent Filter Manufacturer E7 NA Estimated (average) flow OZ_�') gal/day Effluent Filter Model A [pc Design (peak) flow = (Estimated x 1.5) � g al/daV Pump Manufacturer 0 NA Soil Application Rate r gal/day/ft' Pump Model Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg/L 0 Sand /Gravel Filter 0 Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA 0 Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L 0 Disinfection 0 Other: Pretreated Effluent Quality Monthly average Manufacturer Biochemical Oxygen Demand (SOD.) 530 mg/L Dispersal Cell(s) 0 NA Total Suspended Solids (TSS) 530 mg /L 0 NA kn- Ground (gravity) 0 In- Ground (pressurized) Fecal Coliform (geometric mean) 510` cfu/10Um1 0 At -Grade ❑ Mound Maximum Effluent Particle Size Y in dia. 0 NA 0 Drip -Line 0 Other: Other: 0 NA her: 0 NA 'Values typical for domestic wastewater and septic tank effluent. Other: 0 NA MAINTENANCE SCHEDULE Service Event Service Frequency 0 months) Inspect condition of tanks) At least once every: 3 ar {s) {Mum 3 years) ❑ NA Pump out contents of tank(s) � When combined sludge and scum equals one -third (Y3) of tank volume 13 NA 0 When the Pugh water alarm Is activated .Inspect dispersal cell 0 months) s} At least once every: � ar(s) (Maximum 3 years) O NA Chan effluent fitter At feast once every: ❑ month(s) arts) ❑ NA Inspect u 0 month(s) ❑ NA p pum pump controls & alarm At least once every: ❑ Y ear (s) R 13 month(s) laterals and pressure test At least once every: ❑ ear(s) 11 NA At least once every: 0 month(s) 0 NA ❑ ear(s) Other. 0 NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator (pumper). Tank inspections must include a. visual inspection of the tank(s) to identify any missing or broken hardware, Identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one -third (Y or more of the tank volume, the entire contents of the tank shalt be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, i 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. GMW (2/02) Page �of START AND OPERATION use of the POWTS check treatment tank r the presence of painting Products. solvents or other For new w s) for construction, Prior to and/Or damage the soil dispersal cell(s) if high concentrations are detected chemicals that may impede the treatment Process service operator prior to use. have the contents of the tanks) removed by a s on a re frozen at the i e surface. System start up shale not occur when soil cont alghw wer in the backup restored the excess tanks mate fill above normal h ighwater levels. when Po or surface During extended power outages pump call m one I.M. dose and may overload them resulting O erator prior wastewater will be discharged ed to the dispersal�� of the pump tank removed by a Septage SerriciServicingP discharge of effluent. To avoid this situation have t S Maintainer to assist in manually o perating the pump to restoring Po wer to the effluent pump or contact a Plumber or pOWT act, the area controls to restore normal levels within the pump tank cabs. not drive or park over, or otherwise disturb or comp Do not drive or park vehicles over tanks and dispers sorption area. within 15 feet down slope of any mound or at-grade rnance and prolong the life of the improve the Perf or Reduction or elimination of the followirotte butts; c ondo a stream may tides: meat scre is; medications, oil; • baby wipes; condoms; cotton swabs: degreasers; dental floss; diapers: disinfectants; fat; POWTS: antibiotics, by es; discharge: fruit and vegetable Peelings; gasoline; grew% foundation drain (sump Pte ��� tampons; and water softener brine* painting products; p�icldes; sanitary nap ABANDONMENT amend taken out of service the following steps shalt be taken to insure that the system is When the POWTS fails and /or is Penn i(ance with chapter Comm 83.33. Wisconsin Administrative Code: properly and safely abandoned in comp ' • All piping to tanks and Pits shall be disconnected and the abarndoried pipe openings sealed. its shah be rerrnoved and properly disposed of by a Septage Servicing Operator. The contents of a • il tanks and p filled with • After mping, all tanks and Pits shag be excavated and removed or their covers removed and the void space pu soil, gravel or anther inert solid material. provide a code compliant CONTINGENCY PLAN measures have been, or must be taken, to If the pOWTS fails and cannot be repaired the following the location of a replacement soil absorption replacement system: by A suitable replacement should d structur replacement area. Replacemen area has been evaluated and m be u uce and compaction and should not be infringed upon will p from to disturba and wens. Failure to Protect the replacement area system. The replacement area required setbacks from existing and prop t sy stems must result in the need for a new soil and site evaluation to establish a suitable comp with the rules in effect at that time' and/or soil limitations. Barring advances in POWTS [� A suitable replacement area is not available due to setback as a last resort to replace the failed POWTS• technology awing tank "my be installed nt are ment area is available evaluation m a. Upon failure of the POWTS a soil and site The site has not been evaluated to identify a suitable repla last be performed to locate a suitable replacement area. If no replace a holding tan • may be installed as a last resort to replace the failed POWTS- place following removal of the biomat at the Q Mound and et -grad. soil absorption systems May must comp with the rules in effect at that time. infiltrative surface. Reconstructions of such system < <WARNING> > TANKS MAY CONTAIN LETHAL GASES ANDiOR INSUFFICIENT OXYGEN. DO NOT SEPTIC, PUMP AND OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A ENTER A SEPTIC, PUMP OR OTHER TREATMENT PERSON FROM THE INTERIOR OF A TANK MAY SE DIFFICULT OR gii�OSSIBLE. AOOITIONAL COMMENTS ' POWT$ MAtNTAIA�R pOWTS INVALLER Name Noma ` phone Phone � f� LOCAL REGULATORY AUTHORITY SEPTAGE SERVICING OPERATOR (PUMPER) Name Name Phone 7 js Phone M and Waushers County Zoning m and Sanitation agencies in co rr,pliance with This document was drafted by the staffs of the Green Lakesco�n Adrninisufft'we Code. chapter Comm 83.22(2)(b)l1l(dl &tf) and 83.54111, ( ) & 131, ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer _ �1Z� lLk. �� S Cr p r.1 60, / C1 Mailing Address PU 60 S ( 5 h" A u-+-It a sxA Property Address Z 72'-2" /''� �� 1 E1_4 L (Verification required from Planning Department for new construction) City /State u4 -id *J i Parcel Identification Number © O /O --p 4 LEGAL DESCRIPTION Property Location PW y,, 5 W y,, Sec. / , '1 g W, Town of Subdivision 1 ���/ � ���� Lot # Z / Certified Survey Map # . Volume , Page # Warranty Deed # GWZ O . Volume 1 I Z . Page # G S Spec house yes ❑ no Lot lines identifiable Ryes ❑ 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 plumber, journeymanpl*nber, 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 your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of l- thr a are . do o SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the pro de d a ve, a of a wa �tydeed recorded in Register of Deeds Office. SIGNATURE OF APPLIC 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 i 1\1 v"IN vnLLL I nLV 11 \nk. I 1 QA • 1 1J .JVV 1 VV-4 - Jai I .!V LVVJ 1L • VJ r. VV z J 18) 815 MA SS N. WALSH STATE 1AR OF WISCONSIN FORM 2 - 3tiW W 0 �S WARRANTY DEED ST. E CO. , V1 ooataee % m eow RECIxI VED VO RECM ti16- 19''+200 This Deed, m ade between 9130 All le ' ruieasota Corporatt nn EXW ► snd rr c on , Grantor, TRANS nMt 8 90 PERT COY FIE f; AGES/ 1 . Grantee. Grantor, for a vidw bit consideatlon, conveys and warrants to Gronwe the following described real estate in St - Croix County, State of Wisconsin: Zot120� Of the Plat o! Troy Viliatge 4th ! Rgcona UAM ....._ _ Addition in the ..... Town of 'Troy. 9t. Croix County, N+. &W Mtrn, Addnes Wis in. Derrick Construction:COmpany, In Subject to Declarations of Covenants, Cozlditiona and P.O. Box 445 Restrictions for Troy vil�,age, recorded nd vain 1 241 , and New Richmond, WI 64017 li Page 286, air; Doe. No. 539964, and the Declaration of ii recorded Course Vol. nt 1 ClmWltiani< and Saaiments, , if • 1241, Page 301, as Doc. No. 559969, "X 80-000 ( X81•+90 -QtI ^ ,, 'i all ael appeatrilag in the office of the Register of Deeds 040-'1282'00-000 040 - 1282 - Q�I for St. Croix Count , WiwOngin, and such other Pivcai W"ifte1 t Nunbw F" t� �' Gas I te, restrictions and reaemtiotx of record, Thu not hmmstead propertyt or in twee, and the Anyer obligations contained in (,$) ( p is ia ) the Purchase Agreemnt for this lot. 'i . I I it r • .I • I i Exceptions to warranties: {; �f Dated this 3M da of My (SFiAL) i� Charles s. Cook Prealde3nt ve 'i'roy Delopment Corporation + (SEAL) !i (SEA i► AUTHENTICATION ACKNOWLEDGMENT i t si8n.ture(s) Hinnsoota State of 4V•FaooxrsMr 1 . ii Anoka �, authenticated this day of PersonatiY cams before me this day of Cook Preside ibt7Ye t,am.el Qri=es S i � it Tro�r p�veiomte:it Corporation i • . r �i TITLE* MEMBER STATE BAR OF WISCONSIN ornot, me known to bb the Person who executed the foregoing authorfzad by $706.06, Wis. StatL) instrument and acknowledge the same. :s 71116 iNsTfttlwtgr WAs DRAFTED BY TROY DrV3= i PM$'N'P CORPORATION • s ick A. Johnson �. Chad ea S. Cook, grSit #deaf; Notary Public. g+►ss Ww ollisioAnoka County, Minn. My commis16A is permanent. (If not. state expiration date: (Signatures may be authenticated or acknowledged. Both arc not _ I-amue a 31,,, V. I� ' Piweq of pawn a411ft M "c+prreky mum be wpm at prime wow #qjr pen.wre t WARRANTY 089D STATE BAR Op wtsGONStN ta, FOAM Nn 2 - iego I 1k � NDlatMi'IftaN•1C +#NA9QL1 CW JAiri.6R W 31, 2= Jessie Nye i Subject: #429963 Powers/ Derrick Constr. Location: Troy, Lot 129, Troy Village 4th Start: Wed 10/20/2004 3:30 PM End: Wed 10/20/2004 5:00 PM Recurrence: (none) 1 I �� \ "1 t N Y o N d904 33 40�„ W - U, o J! J N v, Z J o 0 O —�__ _I _ 1 , � i z N N I I — — — — — — — — — — — — 1.027 ACRES N I 44,743 S.F. U I Q I ° N 89 °40' 20" W o w i l U' 334.37' I C*" In I � ?� 127 � I mil cD I cn I 1.022 ACRES I , O 1 T L O T 13 44,532 S.F. U I i I I 0.550 ACRES _ 23,974 S.F. Ilw - - - - - - N 89 °28' 54" W 3 3 ►� �- - - � � N 20 Lo. 128 � O r od u� to (N : `\ 1.037 ACRES , Z N/ L 0 T 1 � \ It N 45,173 S.F. / 1 ' � 3 C. s�., Mo VOL. 6 o S ff) , 'd N 1 12 9 I `� \ / ' �/ //� , M _PAGE 1627 1.036 \ V o ACRES / K) w 45,130 S.F. / -E - L_ _ �I, O S 89 0 28' 14" E 6 (�I Z 57.89' �' t,'v' / X11 w OZ POINT OF ;h ��`IWI KIWI I o ° _ O'� �0i BEGINNING "� N IZI I ?I �— �IUI C16 A J� ` 7 .62' o 0 89 W 57.89' 4 01 P S. • \ I 1 ' � � N — — 322.55' 0'I X50 \ 66.00' Z SC 1 210.3 3' N 89 0 28' 14" W 395.17' — -' — — — _ N I 89 40' 23" W 2506.91' 1412 9 LOT 1 0°' I ` — — — — I— — I _ — = DRI VE — 4 O T � 0 T CENTERLINE OF PLAINVIEW ORl S M. VOL. _L ._ 12, PAGE 3264,_DOC_ ,560007 I UNPL A T TED LAND