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HomeMy WebLinkAbout042-1084-70-750 b " CP COUN P LANNING &. ZONING June 24, 2010 Oevering Homes LLC 1433 Cernohous Ave., Suite A Code Administrat New Richmond, WI 54017 715- 386 -4680 RE: POWTS Installation Inspection, Sanitary Permit #515231 Land Information Planning Location of Property: St. Croix County, Wisconsin 715 - 386 -4674 Municipality: Warren Township Real Prop Subdivision or Plat: CSM 24/5634 715 -3 677 SE 1/4 of SE % of Section 30, T29N, R18W Lot Number: 7 Re cling Address: 711 99 Street - 386 -4675 Dear Mr. Oevering: An inspection by county staff of the POWTS servicing the above referenced property was conducted on April 9, 2010. At the time of the installation inspection, this Private On -site Wastewater Treatment System ( POWTS) was found to be code compliant for a three (3) bedroom home with a design wastewater flow of 450 gallons /day. Included is a copy of the inspection report. If you have any question regarding this wastewater treatment system, please contact our office at 715.386.4680. Sinc fj_VVV Pam Quinn, POWTS Inspector #665054 ST.CROIX COUNTY GOVERNMENT CENTER 110 1 CARM/CHAEL ROAD, HUDSON, W1 54016 715 - 3864686 FAX PZ@CO.SAINT- CR01X.W1.US WWW.CO.SAINT-CROIX.WI.US Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix ' Safety and Building Division INSPECTION REPORT Sanitary Permit No: 515231 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: Oevering Homes LLC C/o Kenneth J. Oeverin Warren Town of 042 - 1084 -70 -750 CST BM Elev: Ins p. BM Elev: BM Description: Section/Town /Ran a /Map No: P �? P 9 cfry — U- ( Z dZ , y "74- % 30.29.18.475E70 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / D Bench 2rk/ _ 2- 6 1rS 0 I o ` o Dosing �[a �if� Alt. BM� a � rJA^ A6Z4 21 IV3• �b Aeration Bldg. Sewer � - fl g. o , o s Holding &I—It Inlet 17, z S Ht Outlet 7 TANK SETBACK INFORMATION iSu I ys ad 3` TANK TO P/L WELL BLDG. Ve t Air Intake ROAD Dt Inlet Septic f Dt Bottom � J14 Dosing IdPr /Man s D. b 9G. b Aeration — -- Dist. Pipe Holding ot. System PUMP/SIPHON INFORMATION Fln ' e 8 Manufacturer Demand St Cover _ I GPM 3 V13"Oir • O /OI. b Model Number TDH Lift Friction Loss System Head DH—Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM W v -( lCeo BED/TRENCH Width Length / No. Of Trenches PIT DIMEN�SI6NS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS /h `7 SETBACK SYSTEM TO I P/L tJ BLDG L WELL LAKE /STREAM AC NG Ma e . INFORMATION Typ ' f System: Z / CHA UNI Mod Numbe: I S Djq,RIBUTION SYSTEM Q Y5 Header anifold Distribution Qjt S 7 x Hole Size x Hole Spacing 1 7 r n e / � Pi es J PO i Cj p V � � Di in Dv. l Length Dia Length a Spac g fBedp/Tren -CO ER x Pressure Systems Only xx Mound Or At - Grade Systems Only U Over q /--- Depth O Edges xx Dep h of xx Seeded /Sodded xx Mu hed ch Ce e r 0 Yes ❑ No Q Yes g No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:q /J V Inspection #2: / / Location: 711 99th Street 1 D Roberts, WI 54023 (SE 1/4 SE 1/4 30 T29N R1 8W) NA Lot 7 Parcel No: 30.29.18.475E70 1.) Alt BM Description = �7 a R� Taws �� 1 7_ yA&M ..('Jr-WW° w k 2.) Bldg sewer length = 4 - amount of cover Plan revision Required? Yes W q i Use other side for additional information. Date Insepctor's Signature Cert. No. SBD -6710 (R.3/97) r commerceml.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. BU 62 , ��(. O y 't i sco n s i n Madison, WI 7�7�2 Sanitary Permit Number (to be filled in by Co.) Department of Commerce 51 State Transaction Number Sanitary Permit Applica n=,, kA- In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary .7 ( 9 1 +J t :54. purpo in accordance with the Privacy Law, s. 15.04 1 m , Stats. I. Application Information — Please Print All Informa ' Property Owner's Name Parcel # vy - /oP y- 70 --75,O Proper Owner's Mailing Addres / M Property Location l7` C L,f �'1u 11 COUNTY Govt. Lot City, State Zip Code NZ1 1�INING OFF ICE S � Y< j� ` 1 ) t5 /., Section e — A )EvJ i !: Gr>✓�'rr D �—� W: cS�/ T c N; R I circlE or W II. Type of Building (check all that apply) 6k, C4 ,, Lot P 1 or 2 Family Dwelling — Number of Bedmom Subdivision Name PICA Bl ❑ Public /Commercial — Describe Use ❑ City of ❑ State Owned — Describe Use CSM Number $ g 3 2 ❑ Village of ►) `` JNti 1� 7 o � :5 ®Town of ' III. Type of Permit: (Checll only one box on line A. Complete line B if applicab ) A' New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS S stem /Corn onent/Device: Check all that appl 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/I'reatment Area Information: 07 - C 3 'X b ,.k Design Flow (gpd) I Design Soil Application Rate(gpd f) Dispersal Area Required ( ispersal Area Pro ed (sf) System Elevation Co43 (08, 9Z 95 Z/ VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units c d New Tanks Existing Tanks T �� ✓ 0. U in h rn fw C7 P, epti or Holding Tank X_ d UU c J w Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS sh on the attached plans. tier's Name (Print) Plumber's Signature M /MV Number Business Phone Number ZzL97Z Plumber's Address (Street, City, State, Zip Code) 2- C S'o -t-h -� . � � c VIII. Coun /De artment Use Onl A pproved Disapprov Permit Fee Date sued Issuing nt Signature teen Reason for Denial IX. Conditions of Approval/Reasons for Disapproval SyM, M O ER: Septic tgAk, effluent and 1 cog must a ll U be be a±!vkea /maintained S6 per management plan provided by plumber. ��,�� ! _0 ^/ 2. AN tirtlbtck tet#uirements must be maintained as pfr appocable code / ordilWW". Attach to complete plans for the system and submit to the County only on paper not less than s In x 11 inches in size R n A �, _ T r P"MWoe� SBD -6398 (R. 02/09) Valid thru 02/11 I ) No Q o � H Co Ik -116. All m (1 d l' 0 A Al 2 a F N� z ;]C® fir' isamsin Department ofComme IL EVALUATION REPORT Page —Lof-3 Diviskin of Safety and Buildings in accordance with Contionand + C my Attach complete site plan on paper not less than 8 1/ 2 2 x11 nc �i st include, but not limited to: vertical and horizontal reference poin and Pa I.D. 1l) 7 ?7Q — 7D percent slope, scale or dimensions, north arrow, and location a ne�re> roi Please print all information." Re ewed by to you provide ma y be used for seconds ur es 1S� Personal information ry p pos te 'WO z �� Property Owner Pro Govt. Lot 51gs, 1 /451 /4 S N R E ( W Property Owner's Mailing Address Lot # Block # Subd. Name CSM# City State , Zip Code Phone Number ❑ City ❑Village own Nearest Ro d 47 1 S - W) I .-S oa3 ( New Construction Us dential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or mmercial - Describe: __— Parent mated aL�/z-; : �ex - Flood Plain elevation if applicable ^"� '0 ft General comments and recommendations: FT] Boring # F1 gyring pit Ground surface elev. a l ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 - , Boring # Boring ci G 1 'T ❑ Pit Ground surface elev �� ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDAf in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 2 1-Y4 ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mgA- Affluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) — Signature CST Number Bird Plumbing, Inc. Shaun Bird l 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 54017 ---1 `� �� 715- 246 -4516 • M " f Property Owner _ Parcel ID # Page of Ong # ❑ Boring 5 f3•. 6 / a f pit Ground surface elev�L_ ft. Depth o 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 •EfP#2 0 Z_ l a" - /n e r 7_1 .Z rr Boring # _ a BOring ❑ Pit Ground surface elev. Z ft. Depth to limiting factor /2D 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 F-1 Boring # E) Boring Pit Boring Ground surface elev. ft. Depth to limiting factor in. Soil Appl ication 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 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. SBD -8330 (8.6/00) Property Owner _ Parcel ID # Page of © Boring # ❑ Boring l 5 �„ '0 f Pit Ground surface elev. ft. Depth o limiting factor in. Soil icetion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 rZ �r © Boring # _Boring 6 ❑ Pit Ground surface elev. ' Z ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 Z F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 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. SOD -8330 (R.NOO) Soil Test Plot Plan Prnjegt Name John Pearson Shaun Bird Address 992 70th Ave Roberts Wi 54023 CSTM #226900 Lot 7 Subdivision ---- ---- Date 12/17/05 SE 1/4 SE 1/43 30 T 29 N /R W Township Warren Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of 1.5" pipe System Elevation 95.4/94.5 *HRpSame as Benchmark Alternate Benchmark Top of 1/2" Pi @ 100.2' 5" above grade Scale is 1" = 40' unless otherwise noted 457' Property Line All!B. 0 , 10' B.M. B -2 175' 15' B -1 45' 45' Id 45' 25' 4 99.5' 11% Slope B -3 96.5' -4 Future Rd /99th St. CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: 06 U t -lo Owner's Name: OE y n_- , ,�, G l-�d �,,, s Owner's Address: ! Y 3 Legal Description: - 3 SE c . 3 d %� Z 9 •� % .0 l f3 :�..� Township: LAJ k A- ti £ � County: Subdivision Name: — Lot Number: 7 Parcel ID Number: cl'VZ Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross - Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenanc Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer /Plumber: License Number: Z Z-Z 87Z. Date: 3 Z, ! - d Phone Number k 4 7,?-- Z 4'Z Signature Designed pursuant t t e In- Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD- 10705 -P (N.01 /01). Page 1 �N 3 a �• � � 0 Q 4 h h h � s ^ s 1 1 w (� 00 Nk w N o W W I Soil Absorption System:Cross- Section z ft 4' Schedule 40 Final Grade PVC Vent Pipe LIb l 1 9,1 1 With Vent Cap ft Leaching Chamber ft �— System Elevation ft 5 ft Soil Absorotion System Plan View (° ft I 3 ft IIIIIAIIIII S ft Trench 1 f ow Vent Or Observation Pipe Leaching Chambers 4' Dia. Trench 2 Header Lea_ chins Chamber Specifications Manufacturer And Model EISA Rating o. a sq ft per chamber Soil Application Rate gpd /sq ft L / gpd Design Flow + • - 1 Soil Application Rate + Z EISA = Chambers 2 rows of - Z — chambers each. P�S Zzz 8 7Z. Page of -d a� a� Cd an u cz cd N U Ln .0 > O U C: ctj O O MCI c cz cz O C w O r te + bA � F+.I •..i � I.r N 4-+ .O c y O C O U "Co CO y rn G cz > O WO a v, .L �. �s w N 0 cz v M ci M Gj rA >, Z .L Cd a 4.0 C o Cd co o '° LU o c u cn cd E Ep C13 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 or other chemicals that may impede the treatment process and /or damage the dispersal 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 soil conditions are frozen at the infiltrative surface.; During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the 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 soil 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 pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT 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 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 PQ.WTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: &7 7 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 structucd, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluatioFr 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 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 BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTA POWTS MAINTAINER Name 1�TCtw N.S �f t�. Name Phone -7 _ 2_y - Phone 4-72- — Z YZ 1 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name S7 C 2 v �'X �U Phone Phone 3 8 to - yb8 G This document was drafted in compliance with chapter Comm 83.22(2)(b)0)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. POWTS OWNER'S MANUAL & MANAGEMENT PLAN FILE INFORMATION SYSTEM SPECIFICATIONS Owner ELF ^ s Septic Tank Capacity O NA # Permit O D 0 al Septic Tank Manufacturer Z7 a O HA DESIGN PARAMETERS Effluent Filter Manufacturer = S -� O NA Number of Bedrooms 3 O NA Effluent Filter Modal -t — O NA Number of Public Facility units O NA Pump Tank Capacity al &16A - Estimated flow leverage) y U auaa Pump Tank Manufacturer A Design flow (peak), (Estimated x 1.5) Jr al /der Pump Manufacturer A Soil Application Rate - 7 al /der /W Pump Model Standard Influent/Effluent Quality Monthly average* Pretreatment Unit Fats, Oil & Grease (FOG) S30 moll. O Sand /Gravel Filter O Peat Filter Biochemical Oxygen Demand (BOD 5220 mg/L l9'IGA O Mechanical Aeration O Wetland Total Suspended Solids (TSS) :5150 mg/L O Disinfection O Other: Pretrested Effluent Quality Monthly average Dispersal Collis) O NA Biochemical Oxygen Demand (BOO s30 mg/L �3Jn- Ground (gravity) O In -Ground )pressurized} Total Suspended Solids (TSS) S30 mg/L O NA O At -Grade Q Mound Fecal Coliform (geometric mean) 51 W cfu /100ml O Drip -Une O Other: Maximum Effluent Particle Size Y In dia. 044 Other: O NA Other: I va a Other: O NA 'Values typical for domestic wastewater and septic tank effluent. Off: O NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(:) At least once every: 3 M eat s s) (Maximurn 3 years) O NA Pump out contents of tank(s) When combined sludge and scum equals one -third 13 of tank volume O NA Inspect dispersal can(,} At least once every: O month($) (Maximum 3 ws) O NA y oZ earls) Ye Clean effluent filter At least once every: month {s1 O NA ll.e O saris) Inspect pump, pump controls & alarm At least once every: month(s) O NA . >D earls} Flush laterals and pressure test At least once every: nnonth(s) O NA M- err(si Other: At least once every: month(s) O NA O ear{sl Other: O NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an Individual carrying one of the following license$ 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(sl 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 (Y 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 chapter NR 113, Wisconsin Administrative Code. AN other services, Including but not limited to the swvichtg of effluent filters, mechanical or pressurized compononte. pretreatment units, and any servicing at Intervals of S12 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. OMW (4101) ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer L/ tj A /0 i£s Mailing Address / V3 3 V r A,. • �t w /� 1,�, o � Irv; ,T y�o ! 7 Property Address -711 9 q _�h ' 5f , (Verification required from Planning & Zoning Department for new construction.) City /State. Parcel Identification Number . 0 W z ' 76 "70 LEGAL DESCRIPTION Property Location '/4 , '/4 , Sec. 3 0 , T 6" 9 N R l8 W, Town of �N�,�•c -£�✓ Subdivision Plat: , Lot # 7 Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house i yes Xno Lot lines identifiable k.yes 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 prop owner agrees to submit su to St. Croix Count Planni & Zoni D 1 P Y g y g g p t o 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. Number of bedrooms -3 �2� 3 / / SIG ATURE OF APPLICANTS) 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) ' i 111111 IIIII illll liill liill IIIII 1111 111111 Illl lilt State Bar of Wisconsin Form 1 -2003 * 9 1 3 5 88 8 1 WARRANTY DEED 913 588 BETH PABST DocumentNumber Document Name REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD THIS DEED, made between Jon Pearson and Christine M. Pearson 03/23/2010 10:50AM WARRANTY DEED ( "Grantor," whether one or more), E%EKPT # and Oevering Homes, LLC REC FEE 11.00 TRANS FEE: 109.50 ( "Grantee," whether one or more). PAGES 1 Grantor, for a valuable consideration, conveys to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County State of Wisconsin ("Property") if mores ace is Recording Area needed, please attach addendum): Name Return Address Title e � 706 Street South y `� The SE '/4 of the SE '/4 of Section 30, Township 29 North, Range 18 West, EXCEPT H° on, WI 54016 the South 500 feet of the West 200 feet, Town of Warren, St. Croix Count;, Wisconsin described as Lot 7 of Certified Survey Map filed June 17, 20091ts File 14965 Document No. 898321 042- 1084 - 70-750 I n �blu�nnt, a'� O� C•S . IU • �r� 5 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except: Roadways, easements and restrictions of record. Da d March l2, 010 (SEAL) '' (SEAL) * on earson * . Christine M. Pearson (SEAL) (SEAL) * s AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) authenticated on ) ss. ST. CROIX COUNTY ) * Personally came before we on March 12, 2010 , TITLE: MEMBER STATE BAR OF WISCONSIN the above -named Jon Pearson and Christine M. Pearson (If not, authorized by Wis. Stat. § 706.06) me known to be the person(s) who executed the foregoing 1 tru and ac owl ged th same. THIS INSTRUMENT DRAFTED BY: Michael H. Forecki, Attorney V'�� * velyn NC4aeger Notary Public, State of Wisconsin My Commission (is permanent) (expires S? ` (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. 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