HomeMy WebLinkAbout040-1258-50-000 I'
4 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Buildings Division
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 363939
Permit Holder's Name: ❑ City ❑ Village ❑ TiSwn of: State Plan ID No.:
Tangwall, Gary Troy Township
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
�b ; , ems 040 - 1258 -50 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic 5�� Z Benchmark j2 '
DQiOc
Alt. BM b
3 2
Aeration Bldg. Sewer 111 (P 3 ff
Holding ( / Ht Inlet 2.SC7 ( /S`, Q�?
TANK SETBACK INFORMATION S)/ Ht Outlet 4e 3.
TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt I
Air
Septic / Z_// - Z NA
- Dosing NA Header/ van. #i.
Aeration A nst. 4 4 • /q ( 9 1 , 9 9lo • I
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer and 7 St cover At
"
vrs��s
Model Number GP
TDH Lift -- Friction tem TDH Ft
Loss ea
Forcemain Length Dia. Dist. eu g>Mr% Z - 5r [ (� [uS, f(o �• o r
SOIL ABSORPTION SYSTEM (�D r
BED / REN H Width Len h r No O Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3 to , SD 3 DIMENSION
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LE any d rer:
INFORMATION Ty Of HAMBER o e Number:
System: L
INFO ON YP r
' 1S 62 7C _ �-
DISTRIBUTION SYSTEM
Header if Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length S Dia. � u 0
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over t[ Depth Over xx Depth Of xx Seeded / Sodded xx Mulched
Bed/ Trench Center , P l - �� Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No
COMMENTS: (Include code discrepancies, persons present, etc.) 4 S F,.tk — 0
Inspection #1: je lZ SI nv Inspection #2: p / 01
Location: 337 Lindsay Road, Hudson, W1 54016 (NW 1/4 SE 1/4 2 28N - 7 Trnv 7-)
1.) Alt BM Description =top - Cau 4111,1 li J 2.) Bldg sewer length =qO l� I• �O • g `' - amount of cover t• 2 a
Plan revision required? ❑ Y e s N o OZ ZZ o 1 l
Use other side for additional infor ation. o
SBD -6710 (R.3/97) Date Inspe r' ignature Cert No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
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Sanitary Permit Application Safety & Buildings Division
201 W. Washington Ave.
In accord with Comm 83.21, Wis. Adm. Code PO Box 7302
see reverse side for instructions for completing this application Madison, WI 53707 -7302
*js Personal information you provide may be used for secondary purposes (Submit completed form to county if not,
t]epartment:of Commerce (Privacy Law, s. 15.04(1)(m)) state owned.
Attach complete fans to the county co onl for the s stem, on than 8 -1/2 x 1 I inches in size.
State San+��� Number Check if revisi ko vi State Plan 1. D. Number
CourLUL I. A lication Information - Please Print all Information cation:
.Pro rty Location
Pro y Owncr Namc 7 tel/W j � i /45F 1/4, T r W
(� �C;t f C.o mbcr Block Number
Prope, Ownc MailingAddr fit N n
'3r C c M, f t '7 Tt
r Nor
y j >1, `6u :vision Nam
City, State e or C �� Number
p Code / n�
F�C� / (`O
r- _ -.. '. City
II. Type of Building: (check one) _ •�s S " ❑ Village
a = '
�Q 1 or 2 Family Dwelling - No. of Bedrooms :� ( � � Town of
O Public/Commercial (describe use):_ f r p
❑ State -Owned NearcIttoad
r v\ O O�
Parcel Tax um
D
III. T e of Permit: Check only one box on line A. Check box on line if app licable) 5 6, ❑ Addition to
A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. Existing S stem
stem System Tank Onl D tc Iss d
B) Permit u ber _� 11 —
A Sanitary Permit was previously issued
IV T pe of POWT System: (Check all that apply) ❑ Sand Filt ❑ Constructed Wetl nd
XN on- pressurized In- ground ❑ Mound
❑
❑ Iioldin Tank Single Pass ❑Drip Line
❑ Pressurized In- o nd r Treat Unit ❑ Recirculatin ❑ Other:
01 At-grade K 2 ❑ Aerobic
V. Dis crsal/Trcatment Area Inform
1, Dc ign Flow (Bpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6.Aystem _ a " Elevation rode
Required Proposed Rate (Ga y /sq. ft.) (MinJinch) C 9�
E>o cso
VII; Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic
Gallons Gallons Tanks Con - Con- glass
Information Crete strutted
New Existing
Tanks Tanks K 13 ❑ ❑ ❑
` ❑. ❑ ❑ ❑ ❑
VIII. Responsibility Statement
I, the undersi ed, assume res onsibili for i tion of the POWTS shown on the attached tans. Business Phone Number
PI bets Name (p ' umber's gnat o stamps): off/MPRS No.
Plumber's Address (Street, City, State, Zip Codc) 1 r
1 _ �k 1 2.. /"�QA.ai t Cep!_ J E
IX. County /Department Use Only
❑ Disapproved F ry Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps)
lg[ Approved ❑ Owner Given Initial Adverse Ige Fee)
Determination P 5�' n-7-3 X. Conditions of Ap roval /R aeons for D p roval:
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County t, C r O t x
Attach complete site plan on paper not less than 81/2 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.
Please print all information. Reviewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). •� 10 `Z3-
Property Owner Property Location
.r- ` Govt. Lot ffik) 1/4 St= 1/4 S d y T A ,�r N R c9 U $(or) W
Property Owner's ailing Addr s Lot # Block # Sub Name or CSM#
40Oq Z S r e�� Co o. 117 ro
city _ State Zip Code Phone Number ❑ City ❑ Village Q Town Nearest Road n
W �ll 2 42�uv— C`R 55 // n �
New Construction Use: ❑ Residential / Number of bedrooms Code derived design flow rate _ GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material .r! e eSS _ �H.� kxIySA Flood Plain elevation if applicable _ ft.
General comments
and recommendations:
171 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 GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
O ° ! • ? 5/ a m5�k, h) J C.a 5 ► 9
M rn t u>
34 r,
3.0
b
a Boring # a Boring
I�t Pit Ground surface elev. ft. Depth to limiting factor �� in. Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Eftujnda Roots GPD /fP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 'Eff#2
6 /b ,• a s/ d m 5*x. tnu Mfr 5
3 a S rNI I L
36
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 5 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Plea "n) Signatur CST Number
>5
Address Date Evaluato Telephone Number
l s dow loo: �� 7iS" ollG 5/35
r
roperty Owner � gv`�1�4 net V1cz�� Parcel ID # - f 5 t / y Page - of -
F Boring #� p �} o /� in.
Pit Ground surface elev. A (� ft. Depth to limiti factor Soi Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fg
in. Munsell Qu, Sz. Cont. Color Gr. Sz. Sh. "Eff#1 'Eff#2
I nll % r / 3 /o s 5, c
�. /, 2
- 1 6 Y 6
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Boring
❑ Boring # Ground surface elev. ft. Depth to limiting factor in Soil A lication Rate
El Pit
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots .EGPD/ft Eff#2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
Boring in.
Boring # Ground surface elev. ft. Depth to limiting factor Soil lication Rate
F
❑ Pit
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Eff #GPDIfFEff#2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
Effluent #1 = 60D, > 3o:5 220 mglL and TSS >30 < 150 mgll- ' Effluent #2 = BOD < 30 mg/L and TSS _< 30 mglL
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777.
SBD•8330 (R.6/00)
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' Safety and Buildings Division
Vi sconsin SANITARY PERMIT APPLICATION 201 W. Washington Avenue
P O Box 7302
Department of Commerce In accord with Comm 83.05, W. f e ' Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) forth sy pap no C ounty
than 81/2 x 11 inches in size. Rico (� a Sanitary Permit Num er `
1 ' `o
• See reverse side for instructions for completing this app c on
ju N o z000 eck �3 R39.
Personal information you provide may be used for secondary purposes o� if revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. ST CROIA Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT AL
Pro Own Name rope y c n
� Q.v� /4 a Tag , N, R Q 5W
Propert Owner's M fling Ad ess ,4 Q t Block
y, S i de j Phone Number Subdivisi Name or C i umber
( )
I1. T P F B ILDIN (check one) ❑ State Owned ./ o v ia e — Nea t st ad
Public 1 or 2 Family Dwelling - No. of bedrooms own OF
111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
0q0_
1 ❑ Apartment/ Condo aq.�e `
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. y New 2_ ❑ Replacement 3. ❑ Replacement of 4 E] Reconnection of 5. E] Repair of an
'_(( ........ System _______ ^ _____Tank Only______________ Existing System ________ Existln9 System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 Seepage Trench 22 E] In-Ground Pressure �\ 3 x 4y *N '�S�' a `Qd _ 11 42 ❑ Pit Privy
13 Seepage Pit %, ) 43 ❑ Vault Privy
14 ❑ System -In -Fill a. 1 4 r,�
VI. ABSORPTION SY M NFORMATION: I p , 5D
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 1 6. System Elev. 7. Final Grade
a Re uied(sq. ft.) Proposed (sq. ft.) (Gals/dasq. ft.) (Min. /inch) Elevation
Feet Feet
VII. TANK in Ca a clt llo Total # of r Prefab. Site Fiber- Exper.
INFORMATION g Gallons Tanks Manufacturers Name Concrete con steel glass Plastic App
New Existing structed
Tanks Tanks
Septic Tank rlk- V Q El ❑ 1:1 1:1 1:1
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ I ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for instajlakLon of the onsite sewage system shown on the attached plans.
PI mber's Name:( t) Plumber's Signa re: (No mps) MP /MPRSW No.: Business Phone Number:
s v 7 % 7ts QUO /
Plumber's Address (Stre Cjty, Stale, Zip Code): \ C
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sa itary Permit Fee (1ncludesGroundwater ate I ssue d Issuing Agent Signature (No Stamps)
Surcharge Fee) t
Approved E] Owner Given Initial
Adverse Determination o`Z�S (lb 3�1-
X. CON S PPROV RE SONS OR DISAPPROVAL:
� (�
AA- �- 110. 5'0 �ro�.Q� n �
SBD -6398 (R. 4/99) DISTRIBUTION: briginal to County. One cup To: Safety & Buildings Division, Owner, plumber
INSTRUCTIONS
1. A sanitary permit is valid for two
2. Your sanitary permit may be renewed befaeN }iblexpiratic'gkl e, and at a time of renewal any new criteria in the
Wisconsin Administrative Code vvillbe applicable.
3. All revisions to this permit must J ed ty thp- permit, i g authority.
4. Changes in ownership or plumbei,requAres ?W 1' errtxt -Transfer/ Renewal Form (SBD -6399) to be submitted to the
county prior to installation :.{
5. Onsite sewage systems'must be properly r,ha r�4 -- e'septic tank(s) must be pumped by alicen ;ed purnlJer whenever'
necessary, usually every 2 to 3 years. - -�
6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of
Wisconsin, Safety and Buildic►gs•Divisien, 608 -266- 3151. -
A
To be complete a.ncl accurate this sanitary permit application must include:
I. 'Pi`operty fl d.�Ma �ress. Provide the legal description and parcel tax number(s) of where the
system is ffin s ta e
II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
III. Building use. If building type is public, check all appropriate boxes that apply.
IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair.
V. Type of system. Check appropriate box depending on system type.
VI. Absorption system information. Provide all information requested for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and
manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and
holding tanks for this system. Check experimental approval only if tanks received experimental product approval from
DILHR.
Vill. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc,),
address and phone. - number., Plur ber must sign application form.
IX. County/ Department Use Only.
X_ County/ Department Use Only.
Complete plans and_ specifications not smaller than 8 1/2 x 11 inches must be submitted to ilie county. The plans must
include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic
tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon
tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served;
B) horizontal and vertical elevation reference points; C:) complete specifications for pumps and controls; dose volume;
elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section
of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information.
----------------------------------------------------------------------------------------------------
GROUNDWATER SURCHARGE
f
1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can
effect groundwater. J
The monies collected through these surcharges are used for monitoring groundwater contamination investigations
and establishment of standards.
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j Wisconsin Department of Commeroe SOIL AND SITE EVALUATION Page 1 of 3
Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code
Environmental BY Design
Attach complete site plan on paper not less than 8'h x 11 inches in size. Plan must
include, but not limited to: vertical and horizontal reference point (BM), direction and - County
percent slope, scale or dimensions, north arrow, and location and distance to nearest road: St. Croix
Parcel I.D.
al in #
APPLICANT INFORMATION - Please print all information.;
Personformation you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)� R D
Property Owner Proper�y t L`b °' LQ :ir it:
Continental Develop Gov 1W 1/4 SE 1/4 S 24 T 28 N,R 20 W
Property Owners Mailing Address Lot # BW #. J Subl. Name or CSM#
12301 Central Avenue NE, Suite 230 I 17 Troy Burne Village
City State Zip Code PhoneNumber ❑ City ❑ Village ®Town Nearest Road
I Minneapolis MN 55434 612- 757 -7568 Troy Lindsay Road
® New Construction Use: ❑ Residential / Number of bedrooms 4 ❑Addition to existing building
Replacement ❑ Public or commercial describe
Code Derived daily flaw 600 gpd Recommended design loading rate 7 bed, gpti/fF 8" trench, 9p�
Absorption area required 857 bed, ft 750 trench, fls Maximum design loading rate .7 bed, gpd/fF -8 nch, 9p�
Recommended infiltration surface elevation(s) -94-W 1 k ! 2S ft (as refs ed to site t at�.%�
Additional design / site considerations S s • "'^ � S
t Parent material LOES S OVER OUTWASH SAND Flood lain elevation, ff licable a ft ble for system Conventional Mound In - Ground Pressure AT - Grade
System in Fill Holding Tank
itable for system NS ❑ U ® S❑ U ® S❑ U ® S❑ U EIS ®U ❑ S® U
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure Consistence Bound Roots GPD/fF
Bodng#
Horizon in Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh. Bed Trench
1 1 0 -10 10yr3 /2 - sl 2msbk mvfr cw 2f .5 .6
2 10 -27 1Oyr4/6 - sil 2msbk mfr cw if .5 .6
Ground 3 27 - 90 7.5yr4/6 - s Osg ml - - 7 8
elev
113.10 ft
Depth to
limiting
factor
>90
Remarks:
2 1 0 -19 10yr3 /2 - sil 2msbk mfr cW 2f .5 .6
2 19 -53 l 0yr4 /6 - sil 2msbk mfr cw 1 f
.5 i .6
Ground 3 53 -90 7.5yr4/6 - s Osg ml - - .7 .8
elev
115.8 ft
Depth to
limiting
factor
>90
Remarks:
CST Name (Please Print) Signature: Telephone No.
_Thomas C. Nelson 715- 246 -2454
Address Environmental By Design Date CST Number Ref #
1432 120th Street, New Ricbmond, Wl 54017 2/17/99 227387 99
PROPI_R1Y OWNER: Continental Development SOIL DESCRIPTION REPORT ® P age 2 of 3
PARCEL LDS Enviromnental By Desi
Horizon Depth Dominant Color Mottles Texture Structure onsistence Boundary Roots GPD/fts
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench
3 1 0 -16 10yr3/2 - sil 2msbk mfr cw 2f .5 .6
2 16 -39 10yr4/6 - sil 2msbk mfr cw if .5 .6
Ground
elev 3 39 -90 7.5yr4/6 - s Osg ml - - 7 8
114.73 ft
Depth to
limiting >< / /o• 5�
factor
>90
Remarks:
4 1 0 -24 1 Oyr3 /2 - sil 2msbk mfr cw 2f 5 6
- 2 2448 10yr4 /6 - sil 2msbk mfr Cw if .5 .6
Ground
elev 3 48 -92 7.5yr4/6 - s Osg ml - - .7 .8
115.72 ft
Depth to
limiting
factor
Remarks:
5 1 0 -19 10yr3/2 - sil 2msbk mfr cw 2f .5 .6
2 19 -38 1Oyr4/6 - sil 2msbk mfr cw if .5 .6
Ground
elev 3 38 -88 7.5yr4/6 - s Osg ml - - .7 .8
114.42 ft
Depth to
limiting JJ
factor
Remarks:
Ground
elev
Depth to
limiting
factor
Remarks:
w
[KV f * P0KA[KTA L 1
1432110 STREET, NEW RI MOND, WiROOK
051 MvU R7VO M5 HQ501v
M- 146-1954
TROY BURNE VILLAGE -- Lot
NW' /4 SE 1/4, SECTION 24 T 28 N, R 20 W
Troy Township, St. Croix County, Wisconsin
Page 3
g�2
rc.� Aced
I �
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glot�c
a�
3
acre
I�
SC 1" =40 Tom Nelson
BM 1. NE LOT CORNER TOP OF IRON PIPE ELEV. 100' 227387
BM 2. NW LOT CORNER TOP OF IRON PIPE ELEV. 11 S.98
ENVi i 6K
1132120 STREET, NEW PUMP, WK(ON51N
WN SAvU 6r TNOn 5 NELSON
715-296-2959
TOM NELSON
Oil TOM 227387 -- -REGIS QU SANiiAN614 5RM713
Troy Village — Lot
NWY SE /4, SECTION 24 T 28 N, R 20 W
Troy Township, St. Croix County, Wisconsin
Page 3
4M S I b' lrl
(�1ferna�'Q C-les
Sys��►� �
W x.11 s e
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SCALE 1" =40 Tom N n
BM 1. NE lot corner top of iron pipe ELEV 100' �—
BM 2. NW lot corner top of iron pipe ELEV 11 S.98'
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer.
Mailing Address 1y6}a2 sa.hgcnf Four -/- /Lord D
Property Address J 5 C, +
(Ve required from Plannin epartment for new construction)
City /State 4-F(.0 — G �� f Parcel Identification Number
LEGAL DESCRIPTION
Property Location V� ' /., G E %,, Sec. �, T_,IN -R,2aW, Town of re) 6A
Subdivision I e Lot # 1
Certified Survey Map # , Volume . Page # _
Kwarranty Deed # (0 0 q 1 4 ] 5 , Volume IL13 Page # - q
Spec house ❑ yes no Lot lines identifiable P 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, journeymanpltimber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
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 been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
m lvd
SIGNATURE OF APPL CANT 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. ))
§IGNAfURE OF AlfOLICANT 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
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
dy l6s
Mailing Address r .23n i 02h - o I � Zl ' 4 (7 3 yI e
3 �.....
Property Address r/� �
(Verification required from P Department for new construction)
City /State 4dL 11 , L2' I Parcel Identification Number
LEGAL DESCRIPTION
r Property Location AI V4 %., sC '/4, Sec. T�N -R Town of
Subdivision ` �O V V1
Lot # /I .
Certified Survey Map # . Volume . Page # _
Warranty Deed # , \) C'(� , Volume 4- Page # 2 ,' .
Spec house 0 yes 0 no Lot lines identifiable X yes 0 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, journeymanpllunber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the SL 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 of my (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.
"/L� <� te / V1
SIGNATURE OF 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
�1432�«a 34
StAIE BAil nr wisr- otimis rO"FA 2 — 19" 6C»k41 S
DOCUMENT No. WAnnANTY DEED KATHLEEN H. WALSH
---- - -
REGISTER OF DEEDS
ST. CROIX CO. WI
Tro u gveiopmoiit_Corporatlo il pECEIYED FOR REM
Corporation. Grantor - - - -
_ -- — 06-07 -1999 9:00 411
corweys And wmraMs to -- _ YARRMTY
e
EXEMPT r
Gary Tangwall and Deanna Tangwall, CERT COP y FEE:
husband and wife COPY FEES
TRAfISFER FEES 719.70
- ---------- - - - - -- RECORDING FEES 10.00
PAGES% 1
1110 0 0 1 10w hip rfr- SCrRwad real estate In $ t •— C C O X — Ca rly.
Sir" of Wisconsin: —
ttFTUF*1 TO
Lot 117 of the Plat of Troy Vi 1l age in the Town of Cary and Deanna Tangwall
Troy, St. Croix County, Wisconsin. 6042 Sargent Court North
White Bear Lake, MN 55110
Subject to declarations of Covenants, Conditions
1 and Restrictions for Troy Village, recorded in
Vol. 1241, Page 256, as Doc. No. 559964, and 040 ,fast — �O
the Declaration of Golf Course Covenants, PmcelidsrONMOMNurnber0"
Conditions and Easements, recorded in Vol. 1241,
Page 301, as Doc. No. 559969, all a3 appearing in the
office of the Register of ilePds for St. Croix
County, Wisconsin, and such other easements,
reservations, restrictions and reservations of
record, or in use, and obligations contained
in the Purchase Agreement for this lot.
I'
' is not
lids _ -- ianw!slearlp�olxnly.
4 �► (is not)
Exerpllon to Warranties:
f
' -
oared nda 28th _ rlry of - -- May 99
(SEAL) MAL)
• Kathy M. _Coo_, Vice President _
Troy Development _Corporatio_ n
(SEAL) (SEAL)
AUTI IEN 1ICAIION ACKNOWLEDGMENT
Slprmk�els) — MINNESOTA
s TAT E or44W -AX 1&M
_ An ok a }
_ Cnr
mulherrllcated MAS lkry d _ 19 Pers"Ry came before me IMs 28th day of
May ,18 99 "abode as 0
'Ratty M. Cook Vic Pregi
�Trov 129y l__ooment Cnrpnrartipn
TiTiF: MEMDEn SIAIE oAn or. WISCONSIN
-- -- -_.– _ — - . - -- - -- _ - -• -- M rnr kixmm In brr the person,_— who exedAed on
w1vorhe d M 4 70n.(6. Wia. S1,11n.) IOrrgok krshunirnl And •knowler ge tltt'sams.
11*9 IN9Tt1 Ih1F,Nt WAR rPnArtro ny A r
TROY DEV CORPORATION
------ - - - - -- •— Nancy L _ lift
rintary roaAc Anoka Count.UIWINN
(Skyarkees m,v Ixs At111mnllCnil!d q ACkIpYylr±rlprrd, HUIII ate n01 My Commission is permanent. (1t not. •Isle ex iralloe
necrss.•ay,)
dalo: _ January 31 , )
rrr�.. , r,. , .. «o,► b w., enr�rA1 .nma r M tyrrA pidM M11w eKw •w..•n.. Sii NTF mt1A
WAnnANTr Deto nAn nr VVKrnnsw Here rarmc r.o. "a* 1071M, Green ft Wt S43a7 -om
Y L. CLIFT m "M 2
�Public - Mi COUMy Cs Jan. 31, 20Q0