Loading...
HomeMy WebLinkAbout004-1051-20-100Parcel #: 004-1051-20-050 06/13/2006 02:51 PM PAGE 1 OF 1 Alt. Parcel #: 22.28.15.340A 004 -TOWN OF CADY Current LX~, ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 12/27/2005 00 0 Tax Address: Owner(s): O =Current Owner, C =Current Co-Owner O - ROMO, GABRIEL & THERESA M GABRIEL & THERESA M ROMO 273 HWY 128 WILSON WI 54027 Districts: SC =School SP =Special Property Address(es): ' =Primary Type Dist # Description SC 5586 SPRING VALLEY SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE SEC 22 T28N R15W NW NE EXC CSM 20-5135 Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601!4) 22-28N-15W Notes: Parcel History: Date Doc # Vol/Page Type 12/27/2005 815124 20/5135 CSM 12/02/2003 748029 2466/226 WD 10/17/2003 743973 2438/054 TI 07/23/1997 1034/212 WD more... 2006 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 04/18/2006 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 21.000 3,100 0 3,100 NO UNDEVELOPED G5 1.000 100 0 100 NO AGRICULTURAL FOREST G5M 15.000 22,500 0 22,500 NO Totals for 2006: General Property 37.000 25,700 0 Woodland 0.000 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: 25,700 0 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel #: 004-1051-20-000 06/13/2006 02:51 PM PAGE 1 OF 1 __ Alt. Parcel #: 22.28.15.340 004 -TOWN OF CADY Current I X I ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 12/27/2005 00 5 Tax Address: Owner(s): O =Current Owner, C =Current Co-Owner O - ROMO, RETIRED NUMBER RETIRED NUMBER ROMO Districts: SC =School SP =Special Property Address(es): ' =Primary Type Dist # Description SC 5586 SPRING VALLEY SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE SEC 22 T28N R15W NW NE Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601/4) 22-28N-15W NW NE Notes: Parcel History: Date Doc # Vol/Page Type 12/27/2005 815124 20/5135 CSM 12/02/2003 748029 2466/226 WD 10/17/2003 743973 2438/054 TI 07/23/1997 1034/212 W D more... ~nn~ c~ innnn a av Bill #: Fair Market Value: Assessed with: 0 Valuations: Description Class Acres Land Totals for 2006: General Property 0.000 0 Woodland 0.000 0 Last Changed: 04/18/2006 Improve Totai State Reason 0 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 St. Croix County Planning and Zoning Tuesday, June 13, 2006 at 2:37:24 PM Detail Sanitary Information Page 1 of l Computer #: 004-1051-20-100 .Sub/Plat: NA Section: 22 Parcel #: 22.28.15.340A10 Lot: 1 TN/RNG: T28N R15W Municipality: Cady, Town of CSM: Vol. 20 Pg. 5135 1/4 1/4: NW 1/4 NE 114 Owner: Romp, Gabriel 273 Hwy 128 Wilson, WI 54027 State Permit: 453488 Issued: 08/27/2004 POWTS Dispersal: Mound 24" or more suitable soi Permit: New County Permit: 0 Installed: 09/21/2004 POWTS Detail: Bed -Seepage Bedrooms: 4 WI Fund: POWTS Pretreatment: NA Notes Issuer/Inspector As Built Plumber Other Reouirements Additional Notes Monev Owed Not determined NA Helgeson, Bennie house is off Hwy 128; original permit entered as $0.00 Mark Iverson (contr Signed Off: Yes address 3073 30th Ave., but RPL has no such listing for owner Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 9/21 /2007 S`t. Croix County Planning and Zoning Tuesday, June 13, 2006 at 2:35:15 PM Detail Sanitary Information Page 1 oft Computer #: 004-1051-20-100 Sub/Plat: NA Section: 22 Parcel #: 22.28.15.340A10 Lot: 1 TN/RNG: T28N R15W Municipality: Cady, Town of CSM: Vol. 20 Pg. 5135 1/41/4: NW 1/4 NE 1/4 __- _ - Owner: Romo, Gabriel 3073 30th Ave Wilson, WI 54027 State Permit: 453488 Issued: 08/27/2004 POWTS Dispersal: Mound 24" or more suitable soi Permit: New County Permit: 0 Installed: 09/21/2004 POWTS Detail: Bed -Seepage Bedrooms: 4 WI Fund: POWTS Pretreatment: NA Notes Issuer/Inspector As Built Plumber Other Requirements Additional Notes Monev Owed Not determined NA Helgeson, Bennie $0.00 Mark Iverson (contr Signed Off: Yes Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 9/21 /2007 Wisconsin Department of Commerc_s PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL iNFO~AATION (ATTACH TO PERMIT) Personal information you ~~ovide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: _ City Village X Township Romo, Gabriel Cad Townshi CST BM Elev: Insp. BM Elev: BM Description: ~ ~ ~ ~ ~ rov- UU ~. M ~ ss I csT -------- TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ' /~ ~ v v i ,~G,~LY.~~ i~ ~ ~~ U Dosing ~ :]-tom 5 Aeration Holding - ~~ TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ f t)cy' "~ ~C ' ..- ~ ` 3 ~' .~. ...r Dosing ~/~ ~ ~~~i ... ~ S ~ -~_„ -'-- Aeration Holding PUMP/SIPHON INFORMATION Manufacturer /• Demand .t^ GPM Model Number I J r~ ~'7 V y# •8 TDH Lift io. i3 Friction Loss ~?.o~ System Head ~ .s- TDH Ft a$.~o9 Forcemain Leng t35 Dia.~`~ Dist. to well ~~, ~ ~'t~ SOIL ABSORPTION SYSTEM County: St. CrOIX Sanitary Permit No: 453488 0 State Plan ID No: Parcel Tax No: 004-1051-20-000 Section/Town/Range/Map No: 22.28.15.340 ELEVATION DATA `Z'uU STATION BS HI FS ELEV. Benchmark Alt. BM o~d ~'d ~• o Bldg. Sewer /O~ cJ 5~~~ SUHt Inlet /O. ~iS ~~ ~~ SUHt Outlet ` ~, Dt Inlet Dt Bottom J5 ~ p ~ ~ l Heade Man. ~. ~~ ; 5 •.Z} am` Di~ Pipe C~ n~- an/ ~~ ; ~ ~U- ~~ Bot. System ~, IG 3,qo 'J~q~~ l Final Grade ' ~ -, St Cover ~ ~ /Q / ' / J ~i7~~GwY ~ ~ • ~•f ~fQ I 5.Z-J.3 3.~ PIT DIMENSIONS No. Of Pits Inside Dia. DIMENSIONS Ct `'1 ( SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHIN anufacturer. INFORMATION Type Of System: CHAMB R A~OU~'~~ w3(~~ ~3,~5 ~3 ~ r /~ Model Number: DISTRIBUTION+_S,YSTEM ~-i Header/Manifold M Distribution Pipe(s) ~y' , `~ .~ ~r I x Hole Size 1~8 ~ x Hole Spacing ^ 2 3 `I Vent to Air Intake ~---' Length ~ Dia ~ ;. 3` Length Spacing y Dia , L SOIL COVER _~-- x Pressure Systems Only xx Mound Or At-Grade Systems Onlv Dep ver ~ Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes j] No ~~~ Yes ~-l No ~S~ COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 4 /~/~ Inspection #2: 9 /~/ O`iI ~lW ~ ~ ° 2i - Cam{ rt w l ~-i+~( Location: 3073 30th Ave Unknown (NW 1/4 NE 1/4 22 T28N R15W) NA Lot Parcel No: 22.28.15.340 Qlowl~ 1.) AIt BM Description = ~t `~ wGOC~ 5 t ~• Ql o w ~ r..~ '. ~ i 2.) Bldg sewer length = a,~ 1k f ~~ ~{~ -amount of cover = ~ .} ~ ~j . ~ : ~,~~ ,~ ~ J W,~ ~ ~~ ~,~~^ 3.) Contour = Gg ~ r 11 - Plan revision Re uired? Yes No ~ ~/ ,/ /~ Use other side for additional informati ~ ~A ~~J, I ~ _ 'f -~ SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. Safety and Buildings Division County 201 W. Washington Ave., P.O. Boz 7162 ~ (;;~OTX ~ ~S~ O Madison, WI 53707 - 7162 Sanitary Permit Number (to be fWed b by Co.) t t t/ S~ (~8) 266-3151 ~ O De artment of Commerce Sanitary Permit Application start P`at` 1.D. Ntunber TRANS . Ill# 1U53774 personal information you provide Wis Adm Code 21 d with Comm 83 ! . . , . , n accor may be used for secondary purposes Privacy Law, s15.04(1)4tn) ,• , _ _ : Project Address (if diffuent than mailLtg addrt~t) :.~ - I. Application Infortnatlon -Please Print All Information ~ O ?~ ~0 ~-/ ~-~l Propcrry Owner's Na me z '1 ~ ~'~ i .`~ 'J '.J', i Block r Parcel M C 31l of GABRIEL ROIv10 ~~ ~"~~ --~-- `~_/o~j ~ -Goo y - Proptrry Owrttr's M ailing Address ton -- - 273 HWY 128 NW 'k. NE 'ti.Seccion 22 Ciry, State Zip CcxJc Phony Number WILSON, WI 54027 715/772-4556 (circle ne) I -- '{' 28 N: R 15 E ol~ l ) ll h k h y 5~~~~ at app a t ec II. Type of BuildinE (c Subdivision Name CSM Number \ 1 or 2 Family Dwelling -Number of Bedrooms 4 N/A - l D ib U i ^ se - escr e a Public/Commerc ^ Sutc Owned -Describe Use t ~ ^Ciry_^Village!~'I'ownship of CADY III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' ®New System ~ ^ Replacement System ^ Trcatment/Holding Talilc Keplrcemtnt Olily ^ Othtr Modification to Existing System ~ B. ^ Permit Renewal ^ Permit Revision ^ Changt ui ^ Permit Transfer to New Lut Previous Permit Number tttd Date Issued Before Expiration Plumbtr Owner i IV. T vce of POWTS System: (Check all that apply) ____ -' ^ Non -Prusurizeri !n-Ground ~ Mound > 24 in. of suitablt soil ^ Mowu1 < 24 in. of suitable soil ^' At-Grade D Single Pass Sand FDter ^ Conswcttd Wetland ^ Prtssuriztd ln-Ground ^ Holding Talilc ^ Peut Filttr ^ Aerobic Treauntnt Unit ^ Recirculating Sand Filter i ~ ^ Recirculating Synthetic Media Filttr ^ Ltaching Charnbtr Uripl!Linc ^ GraVCI-ICSY ipc ^ Ot11er (ex lain) V Tlt~ al/Tronrmanr Aran Tnfnrmntinn~ ~ x~D b •.~ WILv~/~•y Design Flow (gpd) ~~ 60U Design Soil Applicaliun Ralt(gpdst) 1 Dispcrs:,l Arcs RcyuircJ (sp 600 Uispcrsal Arc:, Pru{wscr) (st) System Eltvatiwt ~ 600 _ 99.3 VI. Tank Info - Capacity in GaIl01u Toul Galloru Number of Unll1 Ivtanufactu}re I+r'~a~nQ. ~- IUD ~%~C~~ ~ Prefab CUnCfCIC Site COf14tNC[Cd Sttcl Fiber GIaSS Plastic New Tald:s Existing Tar>ks Stplic ur Holding Tank 1250 1250 1 WIESER CONCRETE X i Aerobic Treatment Unit posing t:narneer 750 75U 1 WIESER CONCRETE X i VII. Responsibility Statement- I, the wtderslgtted, assuuse responsibility for irlstallatlon of the POWTS shown ou the attached lens. Plumbtr's Na the (Print) Plutr)lxy's Si gnaare„ ~ MP/MPRS Number Business Phone Number ' BEN. HELGESON 2202 2 - Plumbcr's Addre ss (Strut. City, State, Zip Codc) 6J122y 77OT~i AVENliE, SPi-:ING VALLEY, W 54767 VIII. Count /De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee Includts Groundwater Date issued u' Agent Signature (No Stamps) Surcharge Fte) !, ^ Owner Gtvcn Bryson for Dtnial ~ 350 2'1 i IX. Conditions of ApprovaUReasons for Disapproval '3) ~~ = ?~~ SYSTEM OWNER: ' 7 Septic tank, effluent filter and dispersal cell must all be serviced /maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances. AttaeG complete plalss (tu tLe County only) for Ule system ou paper not less th:ut 81/2 x 11 inches In cDTI ~iQOfi' /D n~ /n~~ ;~'r. rye ~~ 1 vin 1~)~C U 1• ~~ h h~ r ~i o+ ~ I a~. ~~a F 8 b~D el~esoG`~'~oa~~ .e ~ pro~os~ ~r~~~ ~, r /~~ ~„! ~~ a ~ .~, ~1~ V (~~ ~~~ ~^ .~--- CSIrOt~~ o~ - F_I-eu, q9~/ .~/ ~,~ , ~ yo .~•~ iZ: sc~ %9. os ~- b©..2 ~ c 3.~- ~ ~ q~,g_ o~ a l~" ~ L !~Je~r ~ -E-o ~..a-~ ~ ~, yyt., ,~ P~~ ~ I aso~ 7sa Gam. ~. Se p.l-~~/ jJo ~ Ta.~~ '~~ of a" Ford ,. Ma~:• sss' .M ~ ~ 1 ,oo ~ /veK t -~ a ~a'~~ w a,-~ , R~ bbo~ ~ ya sioQ _ i R3 c~ our P O commerce.wi.gov ^ ^ iscons~n Department of Commerce Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601-1831 TDD #: (608) 264-8777 www.commerce.state.wi. us/sb www.wisconsin.gov Jim Doyle, Governor Cory L. Nettles, Secretary August 20, 2004 CUST ID No.220292 BENNIE W HELGESON HELGESON EXCAVATING W1229 770TH AVE SPRING VALLEY WI 54767 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 08/20/2006 SITE: Gabriel Romo 30TH Avenue Town of Cady St Croix County NW1/4, NE1/4, S22, T28N, RISW ATTN: POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 Identification Numbers Transaction ID No. 1053774 Site ID No. 688368 Please refer to both identification numbers,. above, in all corres ondence with the a enc . FOR: Description: Four Bedroom Mound System Object Type: POWTS Component Manual Regulated Object ID No.: 976320 Maintenance required; 600 GPD Flow rate; 32 in Soil minimum depth to limiting factor from original grade; System: Mound Component Manual, SBD-10572-P (R.6/99), Pressure Distribution Component Manual, SBD-10573-P (R.6/99); Biofilter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. COrrdii± No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, ~, slats. DcFARTMENT t The following conditions shall be met during construction or installation and prior to occupancy or use: ~~~~ o~~ General Approval Requirements: ~ ~ SEE CORRE~ • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Septic Tank Effluent for Private Onsite Wastewater Systems" SBD-10572-P (R.6/99) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems" SBD-10573-P (R.6/99). • Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area. Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal are prohibited. • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption area. chs. NR 811 & 812c • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Slats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Slat BENNIE W HELGESON Page 2 8/20/2004 • Comm 83.22(7) A cony of the approved nlans specifications and this letter shall be on site during construction and oven to msnect-on by authorized representatives of the Department which may include local ins ectors Owner Responsibilities: • Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. • Comm 83.55 The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number Listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, ~~G~~ r"" ~~~~~~ Charles L Bratz POWTS Reviewer II ,Integrated Services (608)789-7893 , 7:45 am - 4:30 pm Monday -Friday cbratz @ c ommerce, state. wi . us Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 WiSMART-code: 7633 cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 . , PROPERTY OWNER: PROJECT NAME: INDEX SHEET GABRIEL ROMO 273 HWY 128 WILSON, WI 54027 GABRIEL ROMO '~Fc s q~ F~~ q~ ~j 8 _ ~0 Fjy ~o~~ ~~~0 ~so~ PROJECT LOCATION: NW 1/4, NE 1/4 , S 22, T 28 N, R 15 W MUNICIPALITY: TOWN OF CADY COUNTY: ST CROIX DESIGN: PRESSURE DISTRIBUTION MANUAL SBD-10573-P(R/99) MOUND COMPONENT MANUAL SBD-10572-P (R 6/99) CONTENTS: Page 1: Plot Plan Page 2: Cross Section and Plan View of Mound Page 3: Distribution Pipe Layout Page 4: Pump Chamber Cross Section & Specifications Page 5: W1250/750-MR Tank Specifications ~~,,,~~' Page 6: Pump Specifications ~ p k ~' ""'~ ~, ~' ~~ Page 7: POWTS Owner's Manual & Management Plan - Pg. 1 va G~''bfER NG Page 8: POWTS Owner's Manual & Management Plan - Pg. 2 S p OND ENCF Name: Bennie Helgeson Address: W 1229 770th Avenue Spring Valley, WI 54767 Credential Number: 220292 Signed __ Date: August 16, 2004 ~I ©~l 1 (CXv~ .~ ~ Ul ~e t- ~ ~~~ r i e ~ ~a y~ v -- -- ~~-~. ~ ~~ ~ h „~ NeI ~ PSO ~-~oay~.~ ~G taF8 ~` ~- ~~~ ~~ pro~os-~ ~~~~~ :~ C ~~~~ C c~~ fi ~s ~Sho~~-~ ~~ o~ e ~~ ~G ~~'8. ~'/~~, R,bb~~. ~,~rp.~OOSc~cJ~ ~ i aso 7 r~ Gw ~. ,Sept,/JJos-~ Ta,..k L ~~/ oT a~~ ~orc.~ Mai:. ,U~u t -~ b ~a~~ ~ 50 siop _ ~ Qr! F~~~ Rte, ~~ ~~~~ ~~~ 1~0~-11 Gi~o~~p~ El,eu. q9.~ v ~P~c, sss' 9~~ Con ~ou~- Synthetic Covering Medium Sand Topsoil 3 E Page ~ Of 8 Distribution Pipe E7~ ~, i o~, 0 8 IO < _ ~ b C Tr leu / % Slope 9g•S Ce.(I Of i - 2 %2 Force Main Aggregate From Pump Cross Section Of A Mound System Using A Bed For The Absorption Area A ~ Ft. Signed: g (,7 Ft. License Number: K _~ Ft. Date: - L ~_ Ft. ~ ~, a Ft . T ~o Ft . Force Main ~ W O,~ Ft. L T G Plowed Layer D , S Ft. E , ~'9 Ft. F , -7~ Ft. G ,~ Ft. H ~_ Ft. ~ ~ Observation Pipe ~_ g K -. Ir---o _------- ---------- -- ~ i Lr~-yh A I----- ---------------- ----------------------+I o~ Cell w ~ - --T------------------- ~I Distribution ~~II Of ia- 2'2~ Pipe Aggregate I Observation Pipe , ~~/ear a~s~'s . ~~i-5~., ~ ~rt~~ ((~S ~ w,i~l~ ~cc esS BoY- Plan View Of Mound Using A ~e l- For The Absorption Area C )~o.~.o~ t` ~G~~sC .Th r`'`"`~ `~~~ C. ~ E'[lv~ Cx-~~ / _: Ry~ /13y. ~ r, PVC Ford •1.1ain From Pump ~ ~J Jf G~ ~ C+c~~ ~ --a Signed: License Number: Date: Porforolnd Plp• peloll pi~lrtbuflon .• Plp~ Distribution Pipe Layout J / ~ End Vl~w P~rloroleC PVC Pipt ~P ~ dF S C leap ou.~5 Holes Located on Bottom are Equally Spaced x'11 ~l,r rr R ~ c? 3 ~'' s a3a x ~3~ Y 1. Hole Diameter ~ Inch Lateral ~ Incn (es) Manifold ~ Inches force Main " ~ Inches ~.,~~v~~-r ~I~e~. 99 ~ Ho~Qs }~cr ~a.T rro-~ ~~~bet- of ~,a~'era~SX ~ ~~rd~t-~1 ~ww.b~r ~~~ Nome s /tea ~t.J~l~r ~ ~a-~r~~~ ~,t~mc~ Page ~ Of 8 SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4 " ~U~ V ENT PIPE 12" MIN . ABOVE GRADE E NEATHERPROOF 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER -p ~ c~ ~e~l 99• v ~. w / PADLOCK E ~ WARNING LABEL -}-_._._._ 4 " MIN . ~ tY" 18" IN . s.d. u J , ~~ 18 MIM• . INLET ~ 1' WATER TIGHT SEALS GAS- ; '~ TIGHT ~ ~ vPPROVED FIL7ER --~- A SEAL ~ JOINTS KITH ~A$E~ -1-- ~ ALM APPROVED PIPE APPROVED io0 A~ PIPE 3' (a"x/~~' -~- ~ ON 3' ONTO ONTO SOLID ~ ~ SOLID SOIL SOIL PUMP OFF ELEV . g ,lJFT . --~- ~ OFF D 3" APPROVED BEDDING- UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE TANK MANUFACTURER : - (~ /~ ~~ r- ~` ~~y x S" ~' ~~ ~,~ G~1' ~_ ~ =L 1 TANK SIZES: SEPTIC SU GAL. DOSE VOLUME INCLUDING DOSE ~~• GAL. ~5.a (7~.f_ FLOWBAGK: - O`E~___=9~ GAL. ALARM MANUFACTURER: S. ~Ie~~I-v-o S~•~r,,tCAPACITIES: A = a~ INCHES = ~Q~ GAL. MODEL NUMBER: / /. '~ 2 GAL I S SWITCH TYPE: ~- 8 = . NCHE = ~?~r, ~_L PUMP MANUFACTURER: / ~~-~/]er C = ~ INCHES = /GAL. MODEL NUMBER : SWITCH TYPE: /4/l~ ~r~•~i.~.v-•~ /o~"~ D = /~_ • INCHES = ~SGAL. REQUIRED DISCHARGE RATE y(~ ~~ GPM PUMP E ALARM WIRING AS PER I LHR 16.23 WAC VERTICA L DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE ~~~ S FEET + MINIMUM NETWORK SUPPLY PRESSURE ~ FEET ~ ~ ~ FEET FORCEMAIN X 3:(p FT/100 FT. FRICTION FACTOR /U' ~/ FEET TOTAL DYNAMIC HEAD = ~~FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH DIAMETER LIQUID 6Eg'I`FI-' .$ c~ `` C~c•l ~ G~~. ~~ ~~~ P~Fuse S4~ ~a~~k 5~~~, s ~`e~ SIGNED: LICENSE NUMBER: DATE: 1/88 ~u Y~V'l~ ( Rc;w~v 155" ~q J ~ ~ a W1250/750- M R TANK SPECIFICATIONS F TOP VIEW SCALE: 1 /4" = 1' SIDE VIEW SCALE: 1 /4" = 1' DIMENSIONS: WALL: 2-1 /2" BOTTOM: 3" COVER: 6" MANHOLE: 24" I.D. HEIGHT 66' O.D. LENGTH: 155" O.D. WIDTH: 86" O.D. BELOW INLET: 53" O.D. LIQUID LEVEL: 47" WEIGHT: 14,795 LBS INLET AND OUTLET: 4" BORE WITH STOP FOR QUIK-TITE, FERNCO GASKET, CAST-A-SEAL B00T OR EQUAL INLET AND OUTLET BAFFLES: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 25.96 GAL/IN (SEPTIC) 16.12 GAL/IN (PUMP) LOADING DESIGN: 7' 0" UNSATURATED SOIL ~~~~~Q C~~~C~~C~~~ W3716 US HWY 10, MAIDEN ROCK, WI 54750 800-325-8456 MODEL W1250/750-MR SEPTIC/SEPTIC, SEPTIC/PUMP OR SEPTIC/SIPHON JANUARY, 20DD FlLE: W1250 750-MR A" \TAITC 14 12 ~fp 1C ~10.~0 P Q~ W = 6 U Q Z 0 J 4 Q f f 0 U.S. 1 LITER`. N ~• 4 HEAD CAPACITY CURVE MODELS "140/4140" TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE EFFLUENT AND DEWATERING Ft. Meters Gal. Ltrs. 5 1.52 91 344 45 10 3.05 84 318 15 4.57 76 288 40 140 4140 20 6.10 68 257 , 25 7.62 59 223 35 30 1a 9 49 185 . 35 10 67 38 144 30 . a / 40 12.19 21 79 25 45 13.72 5 19 20 Lock V°I Ve: 4 6' 15 10 5 'GALLONS 10 20 30 40 50 60 70 80 90 100 110 I o~ i°~ c4v acv ~~.. 0 FLOW PER MINUTE 010904 CONSULT FACTORY FOR SPECIAL APPLICATIONS • Electrical alternators, for duplex systems, are available and supplied with an alarm. • Mechanical altemators, for duplex systems, are available with or without alarms. • Control alarm systems are available for 1 phase pumps used in simplex system. See FM0732. • Variable level control switches are available for controlling single phase systems. • Double piggyback variable level float switches are available for variable level long cycle controls. • Sealed Qwik-Box available for outdoor installations. See FM1420. • Over 130°F. (54°C.) special quotation required. • Refer to FM0806 for 200° F. applications. 140 Series - 53 lbs. 4140 Series - 73 lbs. 14014140"' MODELS Control Selection Model Model Volts•Ph Mode Amps Simplex Duplex N140 N4140 115 1 Non 15.0 1 or 1 & 5 2 or 3 & 4 E140 E4140 230 1 Non 7.5 1 or 18 5 2 or 3 & 4 BN140 BN4140 115 1 Non 15.5 1 or 1& 5 2 or 3 8 4 BE140 BE4140 230 1 Non 7.5 1 or 1& 5 2 or 3 8 4 16 SELECTION GUIDE ~G ~0~8 1/2 NPr SK1524A 1/2 NPT SK1524B 1. Single piggyback variable level float switch or double piggyback variable level float switch. Refer to FM0477. 2. Mechanical alternator M-Pak 10-0072 or 10-0075. 3. See FM0712 for correct model of Electrical Alternator E-Pak. 4. Variable level control switch 10-0225 used as a control activator, specify duplex (3) or (4) float system. A CAUTION All installation of controls, protection devices and wiring should be done by a qualNied licensed electrician. All electrical and safety codes should be followed including the most recent National Electric Code (NEC) and the Occupational Safety and Heahh Act (OSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL T0: P.O. BOX 16347 ~,L, ro Louisville, KY 40256.0347 Manufaclurersof.. ~J SHIP T0: 3649 Cane Run Road ® ® Louisville, KY 40211-1961 Q!!~d[lTY~UMP9 SNCE ~,9~`,9~ http://www.zoeller.com ~ ~~/Y/P ~0 (~2) 7 FAX (502)1362 ~UMP © Copyright 2001 Zoeller Co. All rights reserved. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 7 of B FILE INFORMATION Owner' GABRIEL ROi`10 Permit # nFSIP,N POROMETERS Number of Bedrooms 4 ^ NA Number of Pubtic Facility Units ~ NA Estimated flow (average) 400 al/day Design flow (peak), (Estimated x 1.5) 600 gal/day Soil Application Rate 0 , 5 al/day/ft2 Standard Influent/Effluent Quality Monthly ave rage" Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODS) <_220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand IBOD51 530 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) _<10° cfu/100m1 Maximum Effluent Particle Size YB in dia. ^ NA Other: ^ NA "Values typical for domestic wastewater and septic tank effluent. cvcrFM ~PFCIFICL1TInNS Septic Tank Capacity 1250 al ^ NA Septic Tank Manufacturer WIESER CONCRETE ^ NA Effluent Filter Manufacturer ZABEL ^ NA Effluent Fitter Model A-100 12" x 20" ^ NA Pump Tank Capacity 750 al ^ NA Pump Tank Manufacturer I~IIESER CONCRETE ^ NA Pump Manufacturer Zoeller Pump Go ^ NA Pump Model 140 ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: ~ NA Dispersal Cellls) ^ NA ^ In-Ground (gravity) ^ In-Ground (pressurized) ^ At-Grade ~MOUnd C' drip-Line ^ Other: O. ,er: ^ NA Oi.~~er: ^ NA Other: ^ NA rv~r~u~ ~ u~r+~w~..av....vv~.. Service Event Service Frequency Inspect condition of tank(s) At least once every: 2 ^ month(s) !Maximum 3 years) ® ear(s) ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ^ NA Inspect dispersal cell(s) At least once ever Y~ 2 ^monthls) (Maximum 3 years) ®year(s) ^ NA ®monthls) ^ NA Clean effluent filter At least once ever y~ 13 ^ yearls) tnspeet pump, pump controls & alarm Ai least once every: 13 ® month(s) ^yearlsl ^ NA ^ month(s) ^ NA Flush laterals and pressure test At least once every: 3 ®year(s) Other: At least once every: ^ month(s) ^yearlsl ^ NA Other: ^ 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 (Y3) 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. 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 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. GMW (4/01) ' OWNER : GABRIEL ROMO Pa>ae,~_ ot,$_... ., . . STARTUP AND OPERATION. ' For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may Impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power Is restored the excess wastewater will be discharged to the dispersal cell(s) in one.large dose, overloading the cefl(s) ~ removed b a e backup or surface discharge of effluent To avoid this situation have the contents of the pump Y Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS llAalrttalner to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or othetwlse disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or eliminat(on of the following from the wastewater stream may improve the performance and prolong the of the POWTS: antibiotics; baby w(pes; cigarette butts; condoms; cotton swabs; degreasers', dental AosB; diapers; disinfectants; fat; foundation drain (sump pump) water, fruit and vegetable peelings; gasogne; grease; herblddes; meat scraps; medications; oil; painting products;' pe$ticides; sanitary napkins; tampons; and water softener brine. ABANDONMNIENT When the POWTS fails and/or 1s 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, Wisconstn'AdminlstratJve Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings seated: • The contents of all tanks and pits shalt be removed and properly disposed of by a Septage Servicing Operattx • • 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 lithe 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 so11 absorption system. The replacement area should be protected from disturbance and compactlon,and should not be infringed upon by required setbacks from existing ar)d proposed structure, lot IUes and wells. Failure to protect the replacement area will result In the need for a new soil and site evaluation to establish S 'suitable replacement area. Replacement systems must comply with the rules In effect St that Ume. ^ A suitable replacement area Is not available due to setback and/or soil Umitations. Barring advanc~ss In POWTS technology a holding tank maybe installed as a last resort to replace the felled POWTS. O The site has not been evaluated to Identify a suitable replacement area Upon failure of the POtM'S a soA 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. CX Mound and at-grade soil absorption systems may be reconstructed In place foAowlrtg removal of the bkunat at the infiltrative surface. Reconstructions of such systems must comply with the toles (n effect at that time. <WARNING» SEPTIC, PUMP AND OTHER TREATMENt TANKS MAY CONTAIN LETHAL GASSES ANDlOR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRC,UMS?ANCES. DEATH INAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICUt.7 OR IMP03S113LE ADDITIONAL COMMENTS POWTS JNSTALLER Name HELGESON EXCAVATION INC. Phone 715/772-3278 POWTS MAINTAINER Name J •Phone 715 - SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULA70RYAIJTtHORI'I'Y Name JOHNSON SANITATION ~ Agency Phone 715/273-5811 Phone 715/386-4680 This document was draRed by the staffs of the Green lake, Marquette and Waushara County Zoning and Sattttatbn ayendga. Thla doCUmattrtteett one minimum requirements of dt. Comm 83.22(2)(b)(1)(d)3(f) and 83.54(1), (2) & (3), Wisconsin Adminlstrativo Coda Use Of title doclrtNOpt rises ItOt guarantee the peAormsnce of the POWTS. GA1V11t?J01) Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT Page j of 3 In accordance wan ~.omm oa, VVIS. HUfII. \.WC County ~ C~~/~ i 11 i h i s st Pl nc es n s ze. Attach complete sit plan on paper not less than 8 1/2 x an mu inGude, 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 near road. Please print all information. ~ i° r~i~ a awed by Date Personal information you provide may be used for secondary purposes (Privacy [:aw, .15.04 ( (m)). , ~.. Property Owner Property Location ~~ 6 ~.. l e. ~ R o trv~ ~ Govt. Lot ~ ~^1 1 /4 ~ ~ 1 /4 S apc T -~ g N R I ~ E (or Property Owner's Mailing Address ~~ H Lot # Block # Subd. Name CSM# , ~f~- ~ ~ i X73 en City State Zip Code hone Number ^ Ciry ^ Village own Nearest Road ~l~Sun I I,UI_tS'yoa~7 (7~s)77.2-ySS~ ~AIJ o `t-l~. ~uc, ~ew Construction Use: esidential / Number of bedrooms Code derived design flow rate _X ~ b~ GPD ^ Replacement ^ Public or commercial -Describe: Parent material ~ neS (9Ueir r'~~-~ CA'at,S k ~G.~~ Flood Plain elevation if applipble TO ec.~C t~a,K $. ft. General comments // Q .~ ~,~ ~, ~( and recommendations: ~ S E •. (o ~~ s~ n ~ C.t h C `e rr W~~ p ~ ~ ~ -~ ~ n b r1 C O ~t '~O t,f v- g~ ~ au~t~ S~, s frh,. E~e~. ~ y9. 3 Cr~`~`~~"~ ' L] Boring Boring # ~g. $Sy ft. De th to limitin factor .3 y in Pit Ground surface elev. P g -T~ Soil A lication Rate l i C tion Descri R d Texture Structure Consistence Boundary Roots GP D/fl= Horizon Depth in. nant or Dom o Munsell p ox e Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 6- ~ d ~. -- ~ ~v- c. w ~ ,~ ~ G .~ -y o ~ 3 ~ ~ fly Boring #~1~Boring I~ Pit Ground surface elev. 9~• ~S ft. Depth to limiting factor in. Soil A lication Rate D th l r i t C D tion Redox Descri Texture Structure Consistence Boundary Roots GPD/fg Horizon ep in. nan o o om Munsell p Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 2 - _~ o R~ a ~ -- rl .~ k v>`s bk tl c L~ a ~ F ~ ~ .~ ~ g ~ g .~ .. ~.~ - 5 L ~. r i , G, / . o - .z / s -~ ~5 ,. . s /. o Effluent #1 = l3UU > :~U <LZU mg/L and I JJ ~JU ~ ~ av my/L ~-~~~~~~ ~~ ~*~ - ~+~+~ . "" • • •a' - "• •_ . -- - -- ...~ - i nature CST Number CST Na (Please Print) 9 ` -2 ~ eso _ ~ ~ o a 9 ~ Address D e Evaluation Conducted Telephone Number ~,a ~ a ~ 7 7a f~ ,4 tom. s r,~ ~ CIQI I Q ~r ~ - ~~- a y 77~ -- .~~ ~ ~ . ~~,~~. ~"y 7~ Property Owner ~ J~U ~ 1 '(' ~ ~ ~ Vrib Parcel ID # Page ~ of _^~ 3 Boring # ~ Boring ^~it Ground surface elev. ~ ft. Depth to limiting factor Soil A lication 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 'Eff#2 j o ~ -- s a l ~ s b k v-~~'t- w ~ ~~ .~ ~ -1~ i i7 3 ~-- ,~ ~ ,,,,` ~ 1, ~ 3 _~ a ._ ~~ vri b ' f 1 ~ ~ g ~ -`f7 ~ ~ ~-F'3 iP r S .~ - I . ^ Boring `~-~ =~--0 Boring # ^ pit Ground surface elev. ft. Depth to limiting factor in. Soil A lication 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 ^ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ^ Pit Soil A lication Rate Horizon th De Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fP p in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 'Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L `Effluent #2 = BODS < 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. S 13 D-8330 (R.07/00) ~Ial ~lcRv~ ~r •, c c ,~- R//~ ~' s 1r- s V ~~ ~ ~x«w~ Ns Show~t ~~ arc P,p~ Jl.1e~ ~' f~ ha`~'~ B~ b c,J/ory. ~4~bbo•~ 1 '_~..++_... L OK I Ukr _- S c.~. i ~a 6 fc 1 ~~,- ~r~ ~ i ~~~ ~, a of (v. ~/ / ~ a-- ~ .. ran c Elev. 9S. ;L [~re Qah~` Of CG.dr Crc~k T3.~1. ~-f I~c~~ bo 7"0 ~ o i'' Puc P,~ P ~~ -~ ~ Lath cyif~r~. R+bbort 9a s~o~ ~ -~-'_ M p w~. r!Z v -~- c~ Q u Q. ~ $~~ ~ v Y I' l ~ ~~ ~' ,, ~_ ,~ ^i. -~-,. ~, j /, ._ L , ,,, -~'~ i , ~~ -- ---r-- T ~1 /~ r .S ~/ ~:~" .L ,, , , _ _... !"C` .~.. -~. -r- ~~... "', ~~ ~~ ,,^~~ ~ ' !. '" G ~a'~f --- ----- ay ~ <~ ,. j ~~ ~~~ W 7 ~ ~ ^/{ ~~ A '~ f ~~ N ~ c.-~ ~ R ~ r~ ~,., t ~ ~ ~ / i~ S ~.. \j /, ~~ ~yA `\ \ \ R, ~_ --- -_ r- n I' /,y. ~ . ~~ f _ (/ ~ J '' i 4, J f, i/ l ~~ -~ W ~. w ~, . IA y\~ ~l r`\ ..L ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Mailing Address ~ ~ ~ / ~ , Ls~J Gc~~ r' `/~~-7 / 30 3 3 0 ~' ~ v~e , `~ Property Address , _ (Verification required from Planning Department for new construction) City/State Parcel Identification Number ~ - /6 `-~/ -aa -066~~ -~v ~/`.~a " C? 66/ ~ -/05v~ ~0~0 -DDo LEGAL DESCRIPTION /~ ' Pro e Location Nu-} `/., N E '/s, Sec. ~, TAN-RAW, Town of ~_,~,_____ P ~' l Subdivision N/~ ,Lot # _______. 1 Certified Survey Map # /~l ~ ,Volume ,Page # Warranty Deed # '~7 ~l ~ oa ~ ,Volume a ~~ ~ ,Page # ¢3a__~._-. Spec house O yes D no Lot lines identifiable '~ yes O 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 tha 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 aad by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (I) the on-site wastewaterdisposal rystCm is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less thaa 1/3 full of z;ludge. 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. CettifiCStiOA stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Ot~ice within 30 days of the three year expu~ation date. ~ ~ SICi~NATURE 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 erty described above, by virtue of a warranty deed recorded in Register of Deeds Office. ~ •f rC~C/~'/1/ ~ l l ~~~~" DATE S NA F APP ~ICANT . ****'* 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 U 2y66P 226 - ~ STATE BAR OF WISCONSIN FORM 2 - 2000 Document Number WARRANTY DEED This Deed, made between R Kent Miller, a/k/a Kent Miller, and _ Margie M. Miller, husband and wife Grantor, and Gabriel Romo and Theresa M. Romo, husband and wife as survivorship marital property Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix _ County, State of Wisconsin (if more space is needed, please attach addendum:) The West Half of the Northeast Quarter (Wl/2 of NEl/4), and the North Half of the Northeast Quarter of the Southwest Quarter (NIl2 of NEl/4 of SW 1!4), Section 22, Township 28 North, Range IS West, Town of Cady. Exceptions to warranties: Restrictions and Rights-of--Way of record, if any. Dated this ~ fo-rr~ day of ` y ~~~~`~^ , 2003 * * AUTHENTICATION Signature(s)R Kent Miller, alk/a Kent Miller and Margie M. Miller authenticated this day of , 2003 * Jorv R. Gavic - TITLE: MEMBER STATE BAR OF WISCONSIN (If not, _ __ authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Jorv R Gavic _ ~48ta~~ KATHLEEN H. MALSH REGISTER OP DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 12/02/20031 03: iSPtl IiARRAIiTY DEED EXERT lk REC FEE : 11.00 TRAttS FEE: 660.00 COPY FEE: CC FEE: PAGES: 1 Area 1' Name and Re Address n ~~Y C~ Gab 'el a Theresa Romo 273 way l28 ~ P,t~lC ~~U Wil n, WI 54027 (~jp,l,~,t/~/ G~ l~~ p O ~°`S `~ 4L7a- 4-10~-~2 4-1054[- 4-1052-20-000 1 Parcel Identil5h~tion Numbs (PIN) This is not homestead p (six) (is not} ` ~ 1~ / , * R nt Miller, a/ ,~G ~ * M r¢ie M. Miller oe~- r~rz ~ -a+~ (3~~ '''1 ACKNQWLEDGMENT STATE OF W ~SCt~Y1S'Lh ) ~j~' Cl'~D! k Coun ) ss. n' ) Personally came before me this ~v`l~ day of (~py{,n.,j1_,p~ 2003 the above named R. Kent Milter, a/k/a Kent Miller and Margie_ M,11~hgr to me Lrnown to bathe ~p~~Fvhtf~the instrument and ac v3ttlsorgytrtl~r~`~`^^^'' Notary Public, State of ~~)1 S C,tTl1S U'~ Spring Valley, WI 54767 My Commission is permanent. (If not, state ex iration date: (Signatures may be authenticated or acknowledged. Botb are not necessary) _ ~ ~ 1 ~~$ ~') * Names of persons signing in any capacity must be typed or printed below their signature. WARRANTY DEED STATE BAR OF WISCONSIN iNFO•Pft0 (800)655-2021 www.inFOproforms.com FARM No. 2 - 2000