Loading...
HomeMy WebLinkAbout040-1316-09-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 552386 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: Strouth & Peters, Ran &A n ela Troy, Town of 040-1316-09-000 CST BM Elev: Insp. BM Elev: BM Description: rr Section/Town/Range/Map No: 97- 1 To a G ~a4 05.28.19.2065 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark _ z.s' /Zso -r; oG /3.75 llD•~ 57. f- 5A DD"g 1 ' Po l a k SGT Alt.--t-8M / . 77 Aeration Bldg. Sewer c~0 Holding St/Ht Inlet 15.71 St/Ht Outlet TANK SETBACK INFORMATION b l 3 • /J. 2q /D $ 7,4- TANK TO + 'P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet \ Li e'5t _ S 5f-e.,_ Septic i / Dt Bottom 4/6 2-14 > j /66 Dosing Header/Man. -17,1 /,3.75 Aeration Dist. Pipe f /d• 97. 1 13.75 9'5.35 15 Holding Bot. System 9 / PUMP/SIPHON INFORMATION Final Grade es `~9• Manufacturer GP Rand St Cove f ell- 60011- gI g~ 3 Model N er TDH LI Friction Loss System He Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BEDENSIONS Width / Length No. Of Trenches I ' PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS' z re n SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR ~ Z Type Of System: / UNIT Model Number: DISTRIBUTION SYSTEM Ab Header/Manifold Distribution Ix Hole Size Ix Hole Sp 'ng Vent to Air Intake Pipe(s) Length ~Z Dia Length \ Dia Spacing \ ] ado SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only 4a C 5 Depth Over Depth Over ` xx Depth of xx Seeded/ odded xx Mu ed Bed/Trench Center Bed/Trench Edges Topsoil` Yes 0 No es f No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection Inspection #2: Location: 529 Autumn Blaze Trail Hudson, WI 54016 (SE 1/4 SW 1/4 5 T28N R1 9W) Cedar Woods Lot 1(9) Parcel No: 05.28.19.2065 1. Alt BM Description 16 ~ 2.) Bldg sewer length = 3T - amount of cover = -00 -76 6A• yz d Plan revision Required? Yes No q Z 2, Use other side for additional information. l ✓ SBD-6710 (R.3/97) Date Insep or's Sign re Cert. No. U -1 a _ NG~Lr ` ~ • I I ~1 i ~ ~S Zo t I Z11, 5~•O r, ,a.: Ob N THESE DESIC \ v' CONCEPTS Al SERVICE AND n PROPERTY Of AND ARE NOT PUBLICIZED. [ t.v) FOR ANY PRO y' THE WRITTEN 3 V 3 HOMES. LLC 4- : 1505 HWY. lro o IZ~.~`,-~\ NEW RICHI (715) .x DRAWN BY CHECKED B .v SCALE SHEET NUMI 0 c~ o"ar County Safety and Buildings Division ~r D S R 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) rP Madison, WI 53707-7162 JUN ` 6 2p12 J~Z 3 A2 PIA 41i CQ ermit Application StateT`ansactr`°f°N°mbe` In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental 0hit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Addres (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. 1. Application Information - Please Print All Information 11 lp~l V10 V-11' A~31_11f Property Owner's Name Parcel # ProperYy Owner's Mailing Address Property Location 5S ~ (20lps~ G l ' d f, Govt. Lot City, State Zip Code Phone Number S y,, SV1) '/4, Section G~ (circle one 1V T_ N; RI J Eor If. Type of Building (chec ll that apply) Lot # L~ 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name / lock # l~ ~Q r V "v~ ❑ Public/Commercial - Describe Use k 11 City of rs ❑ State Owned - Describe Use CSM Number 1~ r) t7 c l ❑ Village of i / ~7 (J Ja Town of III. Type f Permit: (Check only one box on line A. Co plete line YB if app icable) A. New System ❑ Replacement System t~~ lding Tank Replacement Only Other Modification to Existing System (explain) hexJ l _e da o-n W S'f- e4,d List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New t~ Before Expiration Owner /15Z0I ZO(~ SAzaIpd IV. /Type of POWTS System/Component/Device: Check all that apply) Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ t- de ❑ Mo^und. 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (ex lain)~~ ' SI .lam ❑ Pretreatment Device (explain) V. Dispersal/Treat ent Area Information: 1 !Z~ ►3) Dew Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevati n V~7 gSt f q?- '?&,o qS-/ VI. Tank Info Capacity in Total # of Manufacturer _ Gallons Gallons Units o New Tanks Existing Tanks o 2 Y °JO^ a. U in y s. C7 A. Septic or Holding Tank /,el 1 ~G z s E Dosing Chamber Pp [ t) Z s VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) > LN l 3 s!ti!' J G 6~ sj n ~ri U e !'~~t~ ~C , ' 4 l'~a e~tl, '-/7 S n- 12 VII oun!y/Department Use Only Permit Fee Date sued Iwing Agent ign re Approved El Disapproved El Owner Given Reason for Denial $ ~ t ~ IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained U~ as per management plan provided by plumber. 4~l _ 41'ti 5, `J II setback requirements must be maintained PA 5& AZA, SPS 3 ANNAtA.~ as per applicable)8♦QX -s for the system and su i~o hJoun only o per not less t Pan 8 1 x 11 inghes igtsize SBD-6398 (R. 11/11) Wisconsin r)epartment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Satety, nd Building Division Sanitary Permit No: INSPECTION REPORT 515201 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: / A Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. N Permit Holder's Name: City Village X Township Parcel Tax No:G Z Ross, Eric Troy, Town of 040-1 16-10-000 CST BM Elev: . BM Elev: BM Description: Section/Town/Range/Map No: Insp I P3 G5 1 c~2( loq 05.28.19.2066 TANK INFORMATION 12. ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. i Septic Benchmark Alt. BM y - 3 • Z /Z2 ~v5 Bldg. Sewer Aeration ,k o < <P Holding St/Ht Inlet J+ 165 TANK SETBACK INFORMATION SUHt Outlet gS f ~j, o /v5 . TANK TO P/L WELL ^ B G. Vent to Air Intake ROAD Dt Inlet f J 5 tow% Septic -7 25 / /68' 7p i -7 75 Dt Bottom - Dosing Header/Man. Q r~ y7r / ;Aeration Dist. Pipe C17 ' / Z Holding Bot. System 9~ 9 Io. 5" I Final Grad aV 2t( Sy S TC~ PUMP/SIPHON INFORMATION Manufacturer DeP and St Cover Model Numb rl `E' TDH Lift Friction Loss S ead TDH Ft TPA ^N - Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTE T S SY!'1 ~SSGZ~ B ength / No. Of Trees- - . - IT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 $g ~~S Z J ' SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM CLWT Manufacturer: % INFORMATION Type Of System: ` - Model Number: Gar.Jex, c~~ 7Z5 7 5a 7 /66 /J Ar k-- DISTRIBUTION SYSTEM ZZ +-ZZ c 544 444 ~ x Hole Size x Hole Spacing Vent to A' Intake Header/Manifo~ TP" ution peo Length~Dia a Dia Spacing 1 \ cy SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over /Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center r Bed/Trench Edges ` Topsoil ` es No Yes No b ' COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 525 Autumn Blaze Trail udson, WI 54016 (SE 114 SW 1/4 5 T28N R1 9W) Cedar Woods Lotf 10 Parcel No: 05.28.19.2066 1.) Alt BM Description = e°'~ ~ -A-,, 2.) Bldg sewer length = /06 / S -amount of cover = Plan revision Required? ❑ Yes No Use other side for additional information. Date / L;4:: Insepctor's rgnatur Cert. No. SBD-6710 (R.3/97) PLOT PLAN PROJECT Eric Ross ADDRESS 544 Briana Lane Hudson Wi 54016 SE 1/4 SW 1/4S 5 /T N/R 19 W TOWN Troy COUNTY ST. CROIX MPRS Shaun Bird 226900 11/21/09 4 DATE BEDROOM CONVENTIONAL XXX IN-GRO P SSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK IZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE A RATE .7 ABSORPTION AREA 872 # of chambers 44 ,BENCHMARK .R.P. Top of 1/2" pipe ASSUME ELEVATION 100' Filter BEST Filter ❑ BOREHOLE WELL *H .P. Same as Benchmark Well is to meet all setbacks required by SYSTEM ELEVATION 95.5/94.8' WDNR New town Road Scale is 1" = 40' Vent unless otherwise >6" Quick4 S ndard-W noted of Cover Leaching hamber witW20.0 t2 of Area 12" 5.8ft^2/p r of end caps 4' Long Plans Designed Using 34" 10 Grade System Elevation Conventional Powts Manual Version 2.0 Pro 4 Bedroom House A L Ur ~ ST 250' -3 45' 6'/~ 2-3' X 88' Cells with > V 30' M. B- 90, B-1 10% Slope sys 461' Property Lin L CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: g 1~ Pbu)71S Owner's Name: PSVA-~ -ST20UTH Y.1 AAJC7-~ A POTE_i2`r Owner's Address: 5 ! Ab D lZ_GYS 2 A- i Vlb?I &AZE 'TeAl~, t/pS 0 ~J Vl/ ~&o Lt, Legal Description: "7- C Sm V Z 5-, 194'V- S~O 7 Qq 7 Township: ~~/1 , County: 5 r ~ ~-ei) x C~ ~1 Subdivision Name: CS ✓n Vol. 21 110 Sz 5 b ~ S° Lot Number. / - q Parcel ID Number:() - Z 31 V - Page 1 Index and title Page 2 Plot Plan 'r S 4~ 51S2o System Sizing & Cross-Section IV A - Page 4 Filter Specs I✓ Page 5 Maintenance Information V;" Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form ✓ Page 8 W nt Deed V.- Page 9 CSM r RIe~- Attach/ments: Sol est & House Plans t/~V('~ Desig er/Plumber. 'PAUL. R _ K O0kL(~- _ License Number. Date: 2(v Z o Z Phone Number v~, sale P) k bt Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 U W a r r ~ s q THESE DESIGI CONCEPTS AR NS SERVICE AND F PROPERTY OF AND ARE NOT t- PUBLICIZED. D FOR ANY PROJ ~ THE WRITTEN l 1~ HOMES. LLC y 30" 1505 HWY. ~,,1 ' p d NEW RICHr (715) s a- DRAWN BY X \ CHECKED B' 41_~ .a SCALE,. a„ t SHEET NUMI J ~ ~ - , cc ~ c.. , . fir r. D Z A N 72j" 86" D X m r. 53" D Z z r c m m ~ 0 m v o rTU75 2 m 4" CAS / ° m \ a 0 0 0 / N I ;a rri m 3" 47" 4" -o 0 0 m I m D ° m = v m I N UP 49" m r / L~ 4" CAS n I E I N N J m p(/10 C o ~D~ p ;o 50" v D z IT! rn ° r D > m mDr (n w 0 m r- 0 > I N mD ~~0 D X YM* I r n ;o x D Z C) m n r x r p m o '~A~ A --1 0 v A m m m D om xX m Z Zr-~ C) 0CC) n O~Z D'Z r ~jr-Om IDO ODQ co rpp 0r-(f) p ~FD ~ ~np ~np =per ~mC)z m OrN Oy *t inm o m `5 D (n r-Iz n ~ZC rnNC 'ir- ~r0r.. ~N V ~z Z~ \ C r A Z A=.. NN 4 0) %J.T.1~ N 1. \ z = N DO zm _Dm N I1* m =oN =mJ DN Or p M -0 r- <D<Z OD ym N DNS N I pr~0r-~N O z 018 Z D mm O (?m rn NmD I m r~~~Q s- Zn ?1 v v °D A 0 A m v n V (/I Z G7 _ C N TI D r _ W p v G7W < o o c 0 580 \ Z C O m(°.~~ i 0 ° Ln _ D my m z o W °z cm v ° -a z 'm D mom m0 v vA ' D ~J v m D m 0r C 0 D ?p - OFD r0 m '1, m 03 m m I--I n -0 Z ° z>%o ~ O 0 D 0 O 9 ;o ~ r 0 N_ D D . ;o j ° -n °0 .Z7 - vI I p z O N W N Z C O O ° A 0 0 A m Om N N ~D n° 3 o A -4 0 m r ;o r- > o Z X r- c ao N H X r O m Z m ;o z ~i \ (n W1250-MR I? DRAWN BY: SME SCALE: 1 4"=1'-0" PRE-POUR: m SEPTIC MANUAL DURCAETE REV. ° \ z W3716 US HWY 10 MAIDEN ROCK, N 54750 DATE: JANUARY 2010 DATE:. POST POUR: ° REVISED JAN. 2010 800-325-8456 FILE: W1250-MR W Y U O a U) J W _ z Y N o 0 L U) 3::.~ a C'4 ° U = ~o rg f 3 N~ L U m= Mo M 13 g U-i 25 z1 z ~ z c 0 Q 0 Q U O -n ~a O T7t~7 U O U co r O W M O ] u. M .rte.. co u O U co U J E U C- IQ N M C6 Lq 06 N Lri C'i G7 cfl u u J ~ N LO O ~ i ~ Cfl N u O V l!) r O N N H O z W U) U O oW ¢N U) X Z CO F' ~o 1- M v W U W U U Q O j z z m a > U') O a L J LU L? CL 0 ® ~ ~ ¢ IW- } z LU z 0 J o= d Z w LL ch d CQ Fa- w 0 M Lo I N L J L W- a~ z Z W Q N W Cn J m ~~'Hz:) F-= J < 0 =D Lo 0- a_ a: 0 C.6 II o 0 0 0 0 0 II I 0000 U r 1~ CV O E u N E N ~ 00 U U CD O ~ O ~ CO N N N N u O M a7 U pj N a0 r co O ~ u tc~ .1 O N O WAVJWA , LC E (D IOP6AIVAWI 1~ U V d. j to '0 L (O U C> ~ N W Cl u U = Q U> ~ CL Y J O W m C U Q N LO ~ el N c p r i~ ~ I 1~1 1 ( ,1 S ip O 1v- z ~ vii ~ v O ~ N ~z o Cl = v ~ m ~w ~u>o a U3 ° Oi~ LLJ F- z J O L) - = CO UO w CDWLL. Y p ~Fw-CJ U) F- F- w O 1Q 00 O J LM-rn w ~w w a J / ~I U-) U 04 Of LL N J O U) In o O w q~ J C7 a LL [L ! J F- F- m O O Q J J Z LL LL ~F-w0¢ Q 0 Q Q 0 0 0 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of FILE INFORMA71ON SYSTEM SPECIFICATIONS Owner Al 4 AA 1 ~f' /77v P Septic Tank Capacity -gal ❑ NA 4~~ Permit # V _41 552 3 0 I~l~ Septic Tank Manufacturer r Sir l7 N A DESIGN PARAMETERS Effluent Filter Manufacturer d Lo ❑ NA Number of Bedrooms 3 13 NA Effluent Filter Model ❑ N A Number of Public Facility Units 49 NA Pump Tank Capacity gal ❑ N% Estimated flow (average) gal/day Pump Tank Manufacturer ZNA Design flow (peak), (Estimated x 1.5) gel/day Pump Manufacturer NA Soil Application Rate 0,7 al/day/ft2 Pump Model NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit I N,a Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter / Biochemical Oxygen Demand (BOD51 s220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection 0 Other. Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ N,4 Biochemical Oxygen Demand (BOD5) S30 mg/L T In-Ground Igravityl ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 510^ fu/100mi Q Drip-Line O Other: Maximum Effluent Particle Size Y. in dia. ❑ JNA Other: 0 NA Other: ❑ Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent, Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency inspect condition of tank(s) At least once every: ❑ month(s) ~ ❑ year(s) (Maximum 3 years) ❑ Nit Pump out contents of tank(s) When combined sludge and cum equals one-third (Y3) of tank volume ❑ N/~ Inspect dispersal cell (s) At least once every: ❑ month(s) ❑ year(s) (Maximum 3 years) ❑ Nit Clean effluent filter ~ ~~b eFb At least once every: ❑ month(s) la Nit Al ear(s) Inspect pump, pump controls & alarm At least once every: ID month(s) Akwl ❑ ear(s) Flush laterals and pressure test At least once every: '0 month(s) W. ❑ year(s) Other: At least once every: ❑ month(s) 13 NA, ❑ year(s) 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 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION Page Z of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other ohemic 31s that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(sl 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; fait; foundation drain (sump pump) water, fruit, and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; coil; 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 POWT fails and cannot be repaired the following measures have been, or, must be taken, to provide a code compliant replacem system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorptkn 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. Fa-:lure to protect the replacement area % ill 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. slue ' ' T ) o rng aftk b e a' a Di-ld8 TTLa:I~ O A/ CaN57Rc1 n ❑ 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 NC T 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 INSTALLER POWTS MAINTAINER Name v ~~Cs Name Phone 2 1Ce6"- 2'1Ce Phone -1 F SEPTAGE SERVICING OPERATOR? (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ~-r CRo ( 20til1~u ' Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.6401. (21 & (3), Wisconsin Administrative Code. ST, CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM z ^ ~ Owner/Buyer 0'4..1 P~- Mailing Address M'j ;5s) Property Address ' >-2-9 Ay" M w eA-AZ.~:7 1 (Verification required from Planning & Zoning Department for new construction.) City/State 05C>,-& f \f-J , Parcel Identification Number LEGAL DESCRIPTION '/a Property Location 1/a , Sec. , T 2*0 N R lo! W, Town of ~'Z-Maw ~y Subdivision Lot # Certified Survey Map # LAO'f' Volume s ,Page # Warranty Deed # C1 T~ S , Volume , Pagc # Spec house yes no Lot lines identifiable 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 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. Number of drooms 0NAt`LJAFJP APPLICANT(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) n 8060740 State Bar of Wisconsin Form 1-2003 Tx:4044303 WARRANTY DEED 958380 BETH PABST Document Number Document Name REGISTER OF DEEDS ST. CROIX CO., WI 06/18/2012 10:38 AM THIS DEED, made between G & L Land Development, Inc., a Wisconsin EXEMPT#• NA corporation REC FEE: 30.00 ("Grantor," whether one or more), TRANS FEE: 231.60 and Ryan J. Strouth and Angela E. Peters, as joint tenants PAGES: 1 ("Grantee," whether one or more). Grantor, for a valuable consideration, conveys to Grantee the following described real Recording Area estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is Name and Return Address needed, please attach addendum): FSA "title Services, LLC Lot 1, Certified Survey Map tiled in the office of the St. Croix County 5645 Memorial Avenue Register of Deeds on May 25, 2012 in Volume 25, Page 5856 as Document No. Stillwater, MN 55082 957097, St. Croix County, Wisconsin. 040-1316-09-000 Parcel Identilication 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: This property is subject to Covenants and Homeowners Association By-Laws. Dated June 8, 2012 G & L Land Development, Inc. Q JJE~TT SEAL / ) ~l/i-~ (SEAL) * * Glen M. Wiese, President (SEAL) a; 2 24fz(SEAL) * * Lola M. Wiese, Secretary AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF MINNESOTA ) ss. authenticated on ! WASHINGTON COUNTY ) * { Personally came before me on March 16, 2012 TITLE: MEMBI✓R STATE BAR OF WISCONSIN the above-named Glen M. Wiese as President and Lola M. Wiese as Secretary of G & L Land Development, Inc. ([f not, to sown to be the pegs s w cured the forgoing . authorized''by Wis. Stat. § 706.06) in tram nt ac ed the ~K KRISTIN:? T. DUER THIS INSTRUMENT DRAFTED BY: w; Notary Public * yy ,a i ommission Expires January 31.2014 Baiers C. eeren FSA Title Services LLC ~ 5645 Memorial venue, Stillwater, MN 55082 Notary Public, State of Minnesota ` I My Commission (is permanent) (expires. ~'1 ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOf E: THIS IS A STANDARD FORM. ANY A' IODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. JY'T~ yA~RIRANTY DEEq © 2003 STATE BAR OF WISCONSIN FORM NO. 1-2003 pe name below s gnatures. I ~ I{{Illllllillllll4IIII~IIIIIIIII 8 0 5 8 2 5 3 Tx:4043040 957097 BETH PABST CERTIFIED SURVEY MAP ST.ICROI OF DX CO., EWX LOTS 9 & 10 OF THE COUNTY PLAT OF CEDAR WOODS. RECEIVED FOR RECORD LOC TED IN THE SE QUARTER OF THE SW QUARTER, OF 05/25/2012 11:41 AM EXEMPT S CTION S, TOWNSHIP 28 NORTH. RANGE 19 WEST, REC FEE: 30.00 OWN OF TROY, ST. CROIX COUNTY,WISCONSIN. PAGES: 2 j West 1/4 Corner O_UTL_OT_1 Section 5-28-19 County Plot Steel RR Spike c,f Cedor Woods ~IN 14791916 E\ ~p N88'43'21"E 231.38' I o 341.07 z 816•• ~t - - - - 1488.79' N791 3 2 26.07 F ~ - 1 c t 88.35.18E w IO of I`" oI C4 's\ LOT 1 LOT 2 ~9 LOT 11 o,l ~s. IN ml 93,809 sf. ~N County Plot °O N \ \ 103,801 sf. 0 2.15 acres 2S of Cedar Woods o 2.38 acres I ° NMe r I I z \ ao ~S I ~ o I p 3I W Corner \ `L °o to I ~o 11 ection 5-28-19 \ \ o h J^ Aluminum Cap o 0 o 0 \ s s,1a°- well ~ ~ LOT_ 8 om`sp m s?~~ r 1 County_ Plot of__Cedor Woods \ ti`s / o,~a c~, CD DANIEL c FODDER C E . Q' b q~'L\\2 jam/ p CURVE DATA CURVE RADIUS CENTRAL ARC CHORD CHORD ANGLE LENGTH LENGTH BEARING PRE A RED BY: C-, 283' 37'08.11 " 183.43' 1 180.23' 1 S66'32 27.5"W Daniel' J. Fedderly P.E.; RLS DJ Fe derly Management Consultant LLC Note: Each parcel on this map is subject to State and County laws, rules and regulations (i.e. wetlands, minimum lot size, access to parcel, etc.). Before purchasing or developing any pa cel, contact the St. Croix County Zoning Office and Town Board for advice. PREPARED FOR: SCALE. 1" = 150 G&L Land Development, 1`,- W 12491 890th Ave River Falls, Wi 54022 0' 15 G' 300' LEGEND DRAFTED BY: Joel A. Brandt ..Found Government Corner JB SURVEYING LLC North is re erenced to the o.... _ _.Set 3/4"x18 Iron Rebar West line of the Southwest weighing 1 52 lbs per lineal foot. Quarter of Section 5-28-19 Found 1.25" Iron Rebar which bear N01°24'42'"E Found 1" Iron Pipe (St. Croix C unty Grid System) Sheet 1 of 2 1 oft Vol 25 Page 5856 pt-o (I IlI~ ~IIIIIIIIII~IIIIII 111111 State Bar of Wisconsin Form 7-2003 6 x64044303 9 TRUSTEE'S DEED 958379 Document Number Document Name BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI THI DEED, made between Glen M. Wiese and Lola M. Wiese 06/18/2012 10:38 AM as T ustee of Glen M. Wiese and Lola M. Wiese Marital Property Trust dated Se t mber 2, 993 EXEMPT#: 17 ("Grantor;' whether one or more), REC FEE: 30.00 and G & L Land Development, Inc., a Wisconsin corporation PAGES: 1 ("Grantee," whether one or more), Grantor conveys to Grantee, without warranty, the following described real-estate, toge her with the rents, profits, fixtures and other appurtenant interests, in Recording Area St. Croix County, State of Wisconsin ("Property") (if more space is need , please attach addendum): Name and Return Address Lot 1, Certified Survey Map filed in the office of the St. Croix County FSA Title Services, I.I.C Regi ter of Deeds on May 25, 2012 in Volume 25, Page 5856 as Document No. 5645 Memorial Avenue 9570)7, St. Croix County, Wisconsin.. Stillwater, MN'55082 040-1316-09.000 Parcel Identification Number (P(N) Date June 8, 2012 Glen M. Wiese and Lola M. Wiese Marital Property Trust _;2,2- Dated Se t mber 1 93 frl (SEAL~~ (SEAL) ` Glen M. Wiese, Trustee Lola M. Wiese, Trustee (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Sign ture(s) STATE OF MINNESOTA ) auth micated on ) ss. WASII(NGTON COUNTY ) • Personally came before Inc on June 9, 2012 TT E: MEMBER STATE BAR OF WISCONSIN the above-named Glen M. Wiese and Lola M. Wiese, as {If not, Trustees authorized by Wis. Stet. § 706.06) to me known to be the person(s) who executed the foregoing i u Went and acknowl dgg-3 tl a same. T'HI INSTRUMENT DRAFTED BY: • y SS T Baiers C. Heeren FSA Title Services LLC WsLlcr Notary Public, State of Minnesota 5645 Memorial Avenue, Stillwater, MN 55082 woM 0lDtiF155J3j1•( t nent) (expires: \ ) (Signatures may b ~terolAtyrjpgpg~~Iv~-e e~ MBre t necessary.) NOTE: T141S IS A STANDARD FORM (FICA t3,~Eyt lbli3S FORM MOULD BE CLEARLY IDENTIFIED. TRW "E'S DEED il8 1 zFires nua ONSI }q FORM NO. 1-2003 O, p m une below signatures. SSW I