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HomeMy WebLinkAbout040-1291-20-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safefj and Building Division INSPECTION REPORT Sanitary Permit No: 515028 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Klewicki, Joseph & Tanae I Troy, Town of 040 - 1291 -20 -000 CST BM Ele : Insp. BM Elev: Description: Section/Town /Range /Map No: go • 20 . 2a BM 2U e Bova WO-0 -- 24.28.20.1659 TANK INFORMATION ELtWiON DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ! U Benchm rk D to Alt. B Aer cion ins /� ` Bld wer 3o 3 M — f a 7 Holding SUHt Inlet / C 3 3 TANK SETBACK INFORMATION St/Ht Outlet p �f /° 7.5 t�D, l S TANK TO P WE BLDG. Vent to Air Intake ROAD tic S f �L 2 l ' � H �.�Q� Otto�� •"`(��j�' �l r�� 0 6 Zj � n Jtr'f ` : i Header an.�Q •f �.�[ 0, b Aeration Dist. Pipe p T - S - �.d $ R %61, 14 Holding B ot. Syste /0./ S F Grad PUMP /SIPHON INFORMATION 1 Final ;V Manufacturer Demand Sher GPM 11 r• ��/Zr Model Number V TDH Lift Friction Loss Head T DH Ft Forcemain Le Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width , Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 'I 1 SETBACK SYSTEM TO � P/L BL WELL LAKE /STREAM EACHI Ga Manuf Type INFORMATION CHAMBER R _ /l f System: IYO s j ! It ,y UN Model Number. ,s DISTRIBUTION SYSTEM wt A - / ` eade Manifold,. Distribution x Hole Size x Hole Spacing renit Air Intake N 5 L Pipe(s) +/ Length / Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over j Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed /Trench Center 15` 5 + Bed/Trench Edges Topsoil El Yes D No E] Yes E] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / Inspection #2: / / Location: 329 Lindsay RoRoja�d{�Hyudso , WI 54016 (SW 1/4 SE 1/4 24 T28N R20W) Troy �Village 5th Addition Lo 11 � Parcel No: 24.28.20.1659 1.) Alt BM Description 2. Bldg sewer length= yt / amount of cover (r c Plan revision Required? ❑ Yes VNo q Use other side for additional information., _ SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. , commerce.wi.gov Safety and Buildings Division County 201 W. Washington Ave.. P.O. Box 7162 t (IDs' cons n Madison. WI 53707 -716 p Sanitary P rmit Number (to e tilled in by Co.) epartment of Commerce D Z 8 Sanitary Permit Applieat State Transaction N umb er appro In accordance with s. Comm. 83.21(2)_ Wis. Adm. Code, submission of this form to the priate governmental 7 J unit is required prior to obtaining a sanitary permit. Note: Application f Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you pr vide rr�3��dary p urposes in accordance with the Privacv Law. s. 15.04(1 )(m). Stats. I. Application Information - Please Print All Informatio Property Owner's Name NOV 2 0 2008 Parcel # �-W 11 y C Property Owner's Mailing Address ST. CROIX COUNTY Property Location Govt. Lot L ZONING OFFICE City. State y Zip Code Phone Number y - �� y,, Section (circle one TN: R L Eo N H. Type of Buil mg (check all that apply) Lot # 1 W 1 or 2 Family Dwelling -Number of Bedrooms Subdivision Name ck # J j El Public /Commercial -Describe Use 0 \ 0-A4 `21.AOJK ❑ City of &f,<A a�L- ❑State Owned - Describe Use CSM Number El Village of Zr �/ 19 Town of III. Type of Permit: (Check only one ox online A. Complete line B if applicable) A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B' Permit Renewal ❑Permit Revision Chance of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued ❑ ❑ Before Expiration - IV_ Type ofPOWTS S stem /Corn onent/Device: Check all that apply Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Treat ent Area Information: Design Flow (gpd) Design Soil Application Rate(gp tDispersal Required (sI) Dispersal Area Proposed f) System Elevation - ` V1. Tank Info Capacity in # of Manufacturer Gallons Units New Tanks Existing Tan ` = y y F o A. U � y vt ri C7 a Septic or Holding Tank / Dosing Chamber VI Respo sibility Statement- I, the undersigned, assume respo ibility for installation of the POWTS shown on the attached plans. P'.c-n r � . ' ame ( rint r J Plumber's ign re ( MP/MPRS Number Business Phone Number c:r'; . ddress treet_ City, sate. 2- Code) X I1 L CountvlDepartment Use Onl \n ^rot ed tsa Permit Fee Date I ed Issuing nt Signature ppro � iven Reason ial t � • � l / � o I\. Con tiAw weasons for Disapproval t. Septic tank, effluent finer and dispersal cell must all be services be services / mainta� as per management plan provided by plumber. 2. All se%ack requirements must be maintained PK :lttach to complete p a6s or the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size �_ �.g R. 01 0-) Valid thru 01/09 " f ` { f� t ' . 111 I r lz P _ i 3 p f E copy t �` �(�� � 1, •' a �l r ! " P I �. Ct 11 t fj _ -6 171Y - G�.�/ �-� Wisconsin Department Industry labor,and Human Relations SOIL AND SITE EVALUATION RU, O R T Page I of 3 .-- W t)iv;,F�ion of Safety 8 Buildings in accord with ILHR 83.05 " Aim,' 0Dde'. COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. flan must include, but!' S - GZO �k �t , ot limited to verti.,�l and horizontal reference point (BM), direction and °/q of slope, scale or PARCE I.D. # rensionek north arrow, and location and distance to nearest road. APPLICANT INFORMATION PLEASE PRINT ALL INFORMATI ©N REV RWED BY DATE PROPERTY OWNER: PROP ERTY,(D4 tON eb>J -nN _Z ti�M r er;rLp S�Q 1/4 SE 1/4, Z4 6 ;, W �. . PROPERTY OWNER':S MAILING ADDRESS • LOT #_ BLOCK # SUBQ.AIAME OR # \Z - TTt.o CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE [MOWN ' NEAREST ROAD 1 7 s >_tr.fU e , wi N s S 4 ,1y ( ) Ttx opt t_tir�st�t c [XI New Construction Use [aQ Residential / Number of bedrooms y (J Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 6bo gpd Recommended design loading rate bed, gpd/ft • a trench, gpd/ft Absorption area required $S8 bed, ft2 '1 So trench, ft Ma:dmum design loading rate -1 bed, gpd /ft • _ trench, gpd/ft Recommended infiltration surface elevation(s) 8S b 9 86Ri 'TtZTKJe�es ft (as referred to site plan benchmark) Additional design / site considerations Std f0 `M 1k%n71KkM oN ?f�G F 3 Parent material _1� S oy et� 6uvt - L o tt Slj Flood plain elevation, if applicable I-JA ft S = Suitable for system cONVENTIONAL MOUND 7 N- GROUND PRESSURE AT -GRADE SYSTEM IN R HOLDING TANK U= Unsuitable fors stem ® S El U ®S ❑ U ❑ U I RI S El ®S El U ❑ S IRI I SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft 9 Texture Consistence Bounc�ry Roots Bed ter>Git \_L0 in. Munsell Qu. Sz. Cont Color I Gr. Sz. Sh. '.i:�.K•ia:L3niyv xs CD-VI ws'l vz_ 3 f z sit Zi sblz WA, .s Z 11 -1Z3 Z.S `.t►Z jl _ S e* 6>• Sg M Ground elev. 86 ft. �A Depth to limiting factor Z Remarks: Boring # 1 o_1n tLt�tz 3Lz S11 z.`Fsbk. Y✓L�h Cw - .s . S Z 10 �o� t� 3l6 _ 3 a 48 - I'S ytZ 3!Y - S � 6�. o Sg >M 1 - •� .rd Ground elev. � 6z.8 It Depth to limiting factor a ?9B Remarks: CST Name:— Please Print Phone: Arthur L. We erer 715 - 425 -0165 e�gerer Soi Testing & Design Service -P.O. Box 74 River.Falls,WI. 54022 Signature °Y 13 - 2.9 7 - 1Z-13 Date: CST Number:. 220254 PROPERTY OWNER C•U►J�II tbAlct 'Z ZQ, SOIL DESCRIPTION REPORT Page? of 3� PARCEL LD. _ �� Jup) !v C. d t Bores # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourdary Roots GPD t in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITren Z to 3� 1041 3A. s i I Z►n sblz �'�'1- es — . s b Ground 3 36 - 1p7 1.S Y R 31 y - S d G► p S g y►� -- - 7 _8 elev. $ 63.1 ft. t Depth to limiting q factor 7 l C) Remarks: B �rg4# 0 -19 v6`1R 3 1Z. 2 la 49 IQ4V- 37 l — S Z�nSbk wt'f'H � ;...:.. =.:z S Ground yg�6 �.S`� yl6 1eSbt� wlv'� e le ;l ft. y 66 -L32 -).S ya icy S et6h 0S9 Depth to limiting f factor ! ? 1.3 Z '' / Remarks: Bori�nq # ` :::.....:.:.: ► 0_�3 )�`'l�z- � 1Z- - s i 1 z`('sblz �`�` cw ,: .5 i _� >'r;. »;:.. >:.;€ Z 13 �8 ! 13 `'1 R 3I6 ., s t 1 Z. w► S bk wt`� 1- CS - - S � . �' Ground 3 tq-CZ2 -7•SyP_ 3! _ S g-G 0 S9 m � _ . .$ elev. $6V -Z it. r Depth to limiting factor L -Z. -77 Remarks: 3oring # around 3lev. it. )epth to imiling actor Remarks: _ , • 4 PROPERTY OWNER C1>`f QkiDiu3•tct_ 'Z)Sy . SOIL DESCRIPTION REPORT page of 3 PARCEL I.D. I !v C- r � Boren # Horizon Depth Dominant Color Mottles Structure , �' in. _ Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots GPD1�Ft y�'ti<: }ri v�4 Bed Trendi >:;::<:;:::::: >::<: Z ►a 3� l�`-li 3/ b S l J Zvn S b1z elev. Grou 3 36 -1p') 1.S Y R 3 l Y - S G p S g e 63.1 tt. Depth to ' limiting factor Remarks: # zro 1a -\IS to V- 37 S l 1 Z,t►t Sbk vn '�- cs — S Ground 4 �•S�lR V /(, , • lesb►z wtv ef;Y J ft. y 66 -t32 �•S `/R 31y S d6H �S9 Depth to limiting factor Remarks: 3oring # Z 138 IDHR 3l6 S t J ZwiSbk r around 3 tq'122 �Sy� 3 !y _ S C&- 0 1 9 m � •7 .8 lev. i4_Z ft. lepth to$ S niUng �( rctor Remarks: I )ring # 'ound ;v. rt. !pth to Ring :tor Remarks: _ L_ PLOT PLAN Page 3 of 3 SCALE 1 "= 50 ' �i tPrl1J PT 6 E_ I..u�' V20 �i C� 3 _g_. --wy —R � gbh— ,\y �' v g B•` - ` ° � / -O ��"�' -L'1 . $65.88' au lupnL ON t`� � - �� :�T LN"iiST :z5' �M - �� • / � � F to ` pup �� 99 _z.q 7 -1'Zo 11- 24 -Q zzols`f 1 ( 715 ) 425 -01 65 e CST Signature Date Signed Telephone No. CST # ! �1. li N 88 Q O , O U cr- vi LL- ti� J\ 1 O w v) o \ 1 ww 13 / N O '�j �-� z � _ O O °! 0 / N O w LLI LL: �dlp� 0 11 A • 0 / U v) , 9 %K i Q 9 \ _ + 0 4 �3 ! O s' � N 1 p O 00 00 i C7 I d'b y b7 0 v N o N `t � 12 o 0 > ! 5 °0 65� � � 3 ~ Q N � ,I J� 16 M O NM M �n J _ J O� M I w 60 It 00 00 W In Of V) zo P O 00 OI o U U') 00 O o/ � o �. o z LO 0 N 00 ° 00 00 -- -- -- �/ l 3S 3H1 30 �/ L MS 3H1 �0 3N1� 1Sd3 0 ,00' l ZZ 0 00 \ \ ! 0 3 A Z ,ZOo LO N �k W / t' LO 00) 10 \ Z N O Q N (0 U / 1 z w . woo... / 6 ' �'� 6 r- 41 , 0/ o � O o� / / a �� y o 1 0 � M ° 9 / / S� cO O` h r (O N 0 � / N � o / R to O / ti ti � _ _ ` C27 / M ..£5 l l 0£0 N w 9,� ON � \ � I W C10 - - co � (D �, _ / �I �� \\ D o / U) ���) I U 0 c� I ole) Q) POWTS OWNER ' S MANUAL & MANAGEMENT PLAN Page / Lof FILE INFORMATION SYSTEM SPECIFICATION Owner , Septic Tank Capacity al ❑ NA Permit # Septic Tank Manufacturer ) S ❑ NA Effluent Filter Manufacturer; ❑ NA DESIGN PARAMETERS Effluent Filter Model (- ❑ NA Number of bedrooms ❑ NA Pump Tank Capacity alIs1A Number of Com mercial Unit NA Pump Tank Manufacturer p Estimated flow (average) gal/day Pump Manufacturer 7-NA Design flow (eak), (Estimated x 1.5) gal/day Pump Model I� Soil Application Rate 'y _ _ gal/day/ft gal/day/ft Pretreated Unit Influent /Effluent Quality Monthly Average* ❑ Sand /Gravel Filter ❑ Peat Filter Fats, Oils &Grease (FOG) <30 mg/L n Mechanical Aeration ❑ Wetland Biochemical Oxygen Demand (BODs) <220 mg/L o Disinfection ❑ Other: Total Suspended Solids (TSS) < 150 m Manufacturer Pretreated Effluent Quality NA Monthly Average ** Dispersal Cell(s) ( In- ground (gravity) ❑ In- ground (pressurized) Biochemical Oxygen Demand (BODs) <30 mg/L ❑ At - grade ❑ Mound Total Suspended Solids (TSS) <30 mg/L ❑ Drip-line ❑ Other: Fecal Coliform (geometric mean) <10 cfu /100mL Maximum Effluent Particle Size '/8 inch diameter Values typical for domestic (non - commercial) wastewater and septic tank effluent. ** Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequenc Inspect condition of tank(s) At least once every ❑ months ear (s) (Maximum 3 rs) Pump out contents of tank(s) When combined sludge and scum equals one third '/3) of tank volume Inspect dispersal cell (s) At least once every ❑ months 3 t ear(s) (Maximum 3 rs) Clean effluent filter At least once every ❑ months earls Insp ect purrip, purnp controls & alarm At least once every ❑ months ❑ ear(s ) NA Flush laterals and pressure test At least once every ❑ months ❑ ear(s) pNA Other: At least once every ❑ months ❑ ear(s) a NA Other: At least once every ❑ months ❑ year(s) a 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. 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 to 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 tank equals one -third ('/3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatment components, and any other maintenance or monitoring at intervals of 12 months or less 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. START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that my impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tanks(s) removed by a septage servicing operator prior to use. Owner: Page---,?of-, , System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal high water levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the 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 cells. Do not drive or park over, or otherwise disturb or compact. The area within 15 feet down slope of any mound or at -grade soft absorption are. 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 pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONEMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with ch. 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 lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been 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. Reconstructions of such systems must comply with the rules in effect at the time. <<WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASES 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 BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLEi POWTS MAINTAINER Name I Name Phone _ — one SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY � Name . Name �- Phone � Phone ,• •-- �; -� Owner: �d� i = ✓/ ��¢3�ir��Ge� �l Page�of Y System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal high water levels. When power is restored the excess wastewater will 1 be discharged to the dispersal cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the 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 cells. Do not drive or park over, or otherwise disturb or compact. The area within 15 feet down slope of any mound or at -grade soft absorption are. 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 pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONEMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with ch. 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 lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation'to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. • The site has not been 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. Reconstructions of such systems must comply with the rules in effect at the time. <<WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASES 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 BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLFi POWTS MAINTAINER Name <- Name Phone — Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name r Phone _; ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer r 4 Q Sew Mailing Address �5 ✓Uyf" LPL Property Address 3 ;z 1 (Verification required rrom Planning & Zoning Department for new �� construction.) City /State _671J All Parcel Identification Number LEGAL DESCRIPTION Property Location t/a ,Sec., To N R :20 W, Town of !moo Subdivision �^-� r �1 , , Lot # �-3 Certified Survey Map # , Volume , Page # Warranty Deed # , Volume , Page # Spec house yes no Lot lines identifiablG no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, 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. 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 Planning & Zoning Department within 30 days of the three year expiration date. 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. Num ours —s 02 J IGNA LICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) ! !111111111! lllli Il11111111 IIIlI lIN 1f Ili! 11111111 State Bar of Wisconsin Form 2 -2003 zls 1 UL2 � 1 WARRANTY DEED KATHLEEN W ALSH Document Number Document Name REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 10/01 /2008 02:30PM THIS DEED, made between A & D Investments of St. Croix County, LLC WARRANTY DEED EXEMPT r ( "Grantor," whether one or more), REC FEE: 11.00 and Joseph A. Klewicki and Tanae G. Klewicki, husband and wife TRANS FEE: 705 .00 PAGES: 1 ( "Grantee," whether one or more). Recording Area Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant Name and Retu s interests, in St. Croix County, State of Wisconsin ( "Property") (if more space is J� Est�n needed, please attach addendum): 304 Locust Shot ��q CA Lot 131, Troy Village 5 "' Addition, St. Croix County, Wisconsin. Hudson fit/ 540 6 040 - 1291 -20 -000 Parcel identification Number (PIN) This is not homestead property. (is) (is not) Exceptions to warrantie s: Easements, restrictions and rights -of -way of record, if any. / Dated f o A& D Inves ents o St. Cr C nty, LLC (SEAL) (SEAL) * *Steve rrick, Member (SEAL) (SEAL) * s AUTHENTICATION ACKNOWLEDGMENT Signature(s) A & D Investments of St. Croix County, LLC by Steve Derrick Member STATE OF ) authenticated on q 'Zli 1 O ', ) ss. COUNTY ) * Kristina O land Personally came before me on TITLE: MEMBER STATE BAR OF WISCONSIN the above -named (If not, to me known to be the person(s) who executed the foregoing authorized by Wis. Stat. § 706.06) instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: * Attorney Kristina Oeland Notary Public, State o f Hudson, WI 54016 My Commission (is permanent) (expires: 1 (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003 * Type name below signatures. INFO -PROTM Legal Forms 600 - 655 -2021 www.infoproforms.com 1 of 1