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Home My WebLink About010-1022-70-050Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)l. Permit Holder's Name: City Village X Township Warren, John & Pe Emerald Townshi CST BM Elev: - Insp. BM Elev: t BM Description: TANK INFORMATION u TYPE MANUFACTURER CAPACITY Septic ., ",~ }. , {. ~~ Dosing Aeration Holding ' ' TANK SETBACK INFORMATION. TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~'~ t / , ( ~ - ~ Dosing Aeration Holding PUMP/SIPHON INFORMATION GPM SOIL A OPTION SYSTEM ~ ENCH Width Length DIM S r 3.,} t SETBACK SYSTEM TO INFORMATION Type Of System: Ce>'- DISTRIBUTION SYSTEM Head No. ELEVATION DATA STATION BS HI FS ELEV. Benchm ~~~~ . 2 ~„~ ~S ~ 9~ ~G~ ( Alt. B 5•~ ~ ~ ~.~ Bldg. Sewer ~ •'SD • yt~ 7 SUHt Inlet g• ~ A}'~~ ( St/Ht Outlet Q ~,~ ~ b. ~? - Dt Inlet Dt Bottom Header/Man. "Dist. Pipe / . ~ ~,,• ~ ~~ Bot. System ~ Ib".3 o• Sa ~ •S Final Grade bur. ~ St Cover Pits CHAMBER OR UNIT Liquid Depth r~ ~ S~ 'r. -~~~ v Header/Man'fold Distribution x Hole Size x Hole Spacing Vent to Air Intake Gt ~ ~ Pipe(s) ~ lab- Length Dia Length Dia Spacing SOIL COVER Y Prpssura Svefamc nniv YY Meund Or At-Grade SvStems OnIV Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ^ Yes [] No ^ Yes ^ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~1 1-- /~Z' Inspection #2: 'T-'fi Location: 170th Avenue Unknown (E1/2[~NW1/410 T30N R16W) NA Lot l Parcel No: 10.30.16.140 1.) Alt BM Description =~ ~ ~`~ ~1..~'~~'~~'?"`~~J 2.) Bldg sewer length = c~ u - amount of cover = ~ •{ 5~~. n re siJi on Required? ^ Yes No ~ j I ~ ` n ~ ~~ Use other side for additional information. ~ 0 Date Insepdor's Signature Cert. No. SBD-6710 (R.3/97) • ' ' Sanitary Permit Application ~ safety & Buildings Division ~ In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. ~ ~ ~ `~ See reverse side for instructions for completing this application PO Box 7302 SC®hs~n Personal information you provide may be used for secondary u oses p ~ Madison, WI 53707-7302 Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size. County u ti State Sani Pen~ it3 er ^ Check if revision to previous application State Plan I. D. Number 9 I. Application Information -Please Print all Information Location: Prope Owner Name Property Location ~ ~` ~ ~14, S Q T3QN, R~oE (or}~ Prop Owner's Mailing ss Lot Number Block Number ~/~ ~ ~ ~_ City, State r Zip Code Phone Number Subdivision Name or CSM Number II. Type of Building: (check one) ,,t (~.c~ ~ .,; -~`"~ "" ~~= ~ ;` __.ti , ~ ~,,, ' ~ ''t "^'~ ^ city ^ Villa e y ~ / .~ ,- , 1 or 2 Family Dwelling - No. of Bedrooms : " ' ~ g ^ Public/Commercial (describe use): y Rfi!'[~'tl ~%~ ~ ~ ~ Town of _ ~ ~? r~rvCTF i ~~ ^ State-Owned - d } „ r . _ ~$ \ ~ ' " "• ~ ^ -- Nearest Road :~ ~,t 1' 1 V ST (:AOIX .nn [.~S !bt1~tT1' azcel Tax Ni ber(~ , k (I ~ C 2- . _ D III. Type of ermit: (Check only one box on line A. Check boz;on line B i apphca le) ~ ~ /o. go . 16. 1~a 1 A) 1. ew 2. ^ Replacement 3. ^ Replacement of~ 4. 6~' S. 6. ^ Addition to System System Tank Only ~" ~ rL Existing System $) Permit Number Date Issued ^ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) ~ l4-loo ' Non-pressurized In-ground ^ Mound ^ Sand Filter ^ Constructed Wetland ^ Pressurized In-ground ^ Holding Tank ^ Single Pass ^ Drip Line ^ At-grade ^ Aerobic Treatment Unit ^ Recirculating ^ Other: V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (Gals./d y/sq. (Min./inch) Elevation VII. Tank Capacity in Total # of ufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing Crete structed Tanks Tanks Oort -~ /Ova ..z. ^ ^ ^ ^ ^ ^ ^ ^ ^ VIII. Responsibility Statement I,.the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plum be r's Name (print) P er Signa stamps): o. ber Business Pho ne N um / ~ ~J~ 1 S r I~Q. / / p+ ~J ~ 0 ' to (4 3 Plumber's Address (Street, City, State, Zip e) 3 z ~o ~ s?~ ~ ~~ ~~ ~S"Yoo 1 IX. County/Department Use Only ^ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issu' g Agent Signature (No stamps) Approved ^ Owner Given Initial Adverse Surchazge Fee) ~ ~ ~ ~ / ~ Determination ~5 , ~ ~ ~ O X. Conditions of,,Approval~tgasons for D'saRpro~al: '+E {k-tl s¢:~n-clis .~u.uo.-l'- "~ w~.u.~~.dl ~.e ~ c~ ~i ce-Q~~_ Cm~° ~o~taQ,ttita~..~tGeS. ~-+~,- C~oK-l t~a.cl~a.~.,,. ~re,~'~G ~~ -~` ~~r a, F°^ ~" /w ~_ ,~ff ,~ ~ r -~ I SBD-6398 (R. 07/00) ~~i Y S Io73a/Vi~/6ui _ 22 i ~7/ ~ _ ~ .3 ~' ~ .~~ ~ ~~ b'.~ ~ s $ ~~~,~, ice' ~a) `-~s~,Q.~, 1,'; `~ , ~ ~ ~R~ Q.~ ~~~~°~ ` ® ..r f 7~ L t ~~ i l ~`" ~, ~.4 +j ~/ ~ ~ S / t ~ ~ %S4.k~e ~, • ~ r i~ G ~ ~ ~' l ~ , `' ~ fa Jam' r enr ~4, _ b" ~, .J.. ~ ~ i ~ ~. ~ ~"'` f ~ ~ ~ ~~~ ~~ L y S io ~7~ /Vita/~ ui ~' h'~ ~ ~ ~ $ ~~c~ak~w 1~ ~ CQ~ ~ 7' ~~ 9G, 6 7 ,~ ~ °~.~` ~ ~ ~~p ~~~ ~~~ ~~ ` ~ R. ~ 1~ i lt,,.,,r 1~ _-- ~70 *~ ~ . q~~ l C /~ t3 ~~ M v '~ `, ~~ l ~~ . 22 i Sr7/ X38' ~ f2 ~ 14 ~~ /s~ 1„; ~~ w~,"~ i gy,S ~Y,t ~ ~ v f ~ ~;, e / 4 i 1 ~ r Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings Page ~ of ,.....,...,.,.u,.......,.,, .,.,,,,,,, .,.,, ..,~. ,,,.,,,. .,,,..~ Attach complete site plan on paper not less than 8 1/2 x 11 inch !an must County ~ include, but not limited to: vertical and horizontal reference in (~ ), d' srDt'~cin d percent slope, scale or dimensions, north arrow, and to o~ istance e . road. Parcel I.D. ~`' ®--~~~ /~ _ %O ~ O ®~ Please print all infor ~i. '~"' ~ Reviewed by Date Personal information you provide may be used for second ~ poses aw, s. 15.04 ( - IZ oS /O Properly Owner ~Ir~ ~~ ~~/ ~/ -"I ~ ~, ,~ 1 ~~ t ~ rty ca on ovt. Lot 1/4 ~f1/4 S~Q T~Q N R ~d ~ W Property Owner's Mailing Address ~ I k # Subd. Name or CSM# '~ G1+gl~ ~ ~ ~ , ity tate Zip Code one N _ it '~ ^ Village ~ Town Nearest Road f New Construction Use: ~ Residential /Number of bedrooms ~~ Code derived design flow rate ~®_,}O GPD ^ Replacement ^ Public or commercial -Describe: s Parent material ~s, ~ ~ /~ ~ ~/ ~L Flood Plain elevation if applicable _~~/~{ ft. General comments j ~~ ~ ~~ O ~ A 1 ~ ~ j'~s, ~~-- d~ ~ Z / ~ N~ and recommendations: j7r /O C~ O u L G ~~O S ~'~`~~ ~,~e yr `~/.. ~"' Boring # ^n Boring ~~ ~l Pit Ground surface elev. ~ ^ ft. Depth to limiting factor ~ ~~ in. Soil Application 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 ~ o - .~ ~ ---- s , 8 ~~. ~- <} 6 ~ c~ __---- ~ „ _ z . i. ~r 2 - 4,..U, ~-I ~ c,~. Boring # ^ Boring p /-7 Pit Ground surface elev. /~s -/ ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 vw %a L ,~ F /~ , d~ 2- - -- S e s M ,' ~- ~' 9/. so ~ * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signatur ~ CST Number ~ ~~~~ Address Date Evaluation Conducted Telephone umber ~~~~ t1~Y /7a' G~L<° NGVC'dc~ Gii7"Y ~ /-S!/a/. 3 ro °~2 - ~'/ ~1/.S 2~S-°~!~'.~~ SBD-8330 (R07/0( ~ ~ Property Owner ~~ ~ M /4 S / ~ ~ ~/~~ Parcel ID # Page .L of _~ Boring # ^ Boring q Q ®Pit Ground surface elev. / ' ~ ~ ft. Depth to limiting factor (J in. Soil Application 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 - 0 0 ~ SiC 1 ~ C < < 3 ~• `ftf 3 - ~ ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz 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. SBD-8330 (R.07/00) « i . v° ~ ~ _ _ _ ~ ~ __ ~ _ ~ ~ _ -- -- _ - - - ~ ~ . - ~ ~ ~ ~ /~ ~ I l / ° ~ ~ --- --- - I -- -- - - - --- _ - _ - _ ~_ . - --- - -- - ~ -- , __ / o - -- - - v ~ --- - -- _ - - --- - -- -~ -- -- -- - -- _-_-I ~ - - - -- ~ - -= - - - -- - - -1 ~_ - - - - - -- __' _-~ __~ _ _~ -_ - -- - ----' --I r- - - - - _- -- -- ~ I t .. i 1 - - - - ~- - -- --- - -- --11 _ f -- ~ --i __-I ~ --', ll _-_4 -! _ ~, _ -- -- ~ i _~ -- - -~ -- - I -- -~ - -- ---- -- i I - - - -- --- - ~ - -- - -- - , ~ , ~l ' ~ ' ~ - - _ -- - _ i _, ~ J i -- -- - ~--- - ~' 1 ~` ~ _ - h ~ -- _~ , --- -- .- -- - j ! ` i - - -- -- - - -- - - - . --- __ ~ ~ ~ --' ~~~ _ - ~ - ; i ' -- -- ~ -__ ~ t-- ~ -- ~ - _ __- - ~ ~ --- -- - - --- --- ~ - 1 - - _ _ - -- - ' - ~~ - I - - ~ - ~ __ _ _ ~ ~ ~_ ~ --- --- - -- -- r - - -- - _ -- ~ -- - - ~-- - _- I -- __ _ _ I - ~ - -- --- ;-- - - - - -- __ ---- - ; - -- ~ - -- -- - - - - _ _ _ - q - _ _ - - a -- _ - I__ , i e s ' _ e _ ~ __ --- - _ _ _ -- ---. _ . _ _ -- - ' -- _ e ~ - - ~ i ~ --- _ _ I _ ~ - --- ~ W" - ~ _ _ - - _- - ._ _ LJL __ _. _ i.. -J~-~ __..._ __. __ _~_ L ~ ___ ._- .-__. __._ ___ ._-. __-. l .. .. I._ __ __ _._ . _ _. __..__ _.._ __- .____ _~_-. ~ __.. __. -- . _ . .~. .~_ .- ~ -~. _ ,_ _ __ _ _ v~ 'NFL Owner Permit # POWTS OVYNER'S MAN(L1AL ~ t"1Hnt+uc~ ~c~f o I~,,,,1 ~ t~-~ 399 ~v3 `~ cvC'TFM SPECIFICATIONS Septic Tank Capacity (~ al ^ ~ Septic Tank Manufacwrer ^ NA Effluent Filter Manufacwrer ~L ^ NA Effluent Filter Model /~---Ic1'9 ^ N'°` Pump Tank Capacity gal ~~ DESIGN PARAMCtti~ 3 ^ ~ Number of Bedrooms • Number of Commercial Llnits » NA Estimated flow (average) ~ gal/day Design flow (peak), (Estimated x 1.5) ~~-~ gal/day Soil Application Rate s p c~•~-~ a y/ft Influent/Effluent Quality Monthly average* Fats, Oil 8t Grease (FOG) <_30 mg/L Biochemical Oxygen Demand (BODs) <_220 mg/L Towl Suspended Solids (TSS) <_ 150 mg/L Pretreated Effluent Quality ' ^ NA Monthly average* * Biochemical Oxygen Demand (BODs) <_30 mg/L Total Suspended Solids (TSS) 530 mg/L Fecal Coliform (geometric mean) <_ ] 0' cfu/ 100m[ Maximum Effluent Particle Size ~ inch diameter MAINTENANCE SCHEDULE Service Event Inspect condition of tank(s) Pump out contents of tank(s) inspect dispersal cell(s) Clean effluent fllter tnsped pump, pump controls 8t:alarm Flush laterals and pressure test Pump Tank Manufacturer ~~~~ Pump Manufacturer ANA Pump Model ~NA Pretreatment Unit LS>\NA ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Ocher: Manufacturer Dispersal Ceii(s) '~In-ground (gravity) ^ ln-ground (pressurized) ^ At-grade ^ Mound ^ Drip-line ^ Other: * Values typical for domestic (non-commercial) wastewater and septic tank effluent. * * Values typical for preveated wastewater. Service Frequency At least once every 3 ^ months 1i~year(s) (Maximum 3 yrs.) When combined sludge and scum equals one-third (Ys) of tank volume At least once every ~j ^ months ~8(year(s) (Maximum 3 yrs.) At least once every I - Z ^ months ~ year(s) At least once every ^ months ^ year(s) At least once every ^ months ^ year(s) At least once every ^ months ^ year(s) Lg,NA At least once every ^ months ^ year(s) 1Q NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shalr• POWTS Insaector; POaWTS Miaintaine~f Septage ServicingnOperator. iTank inspectio Plumber; Master Plumber Restricted Sewe , P must include a visual inspection of the tank(s) to i kefor an nba k tp o~ ponding of effluention the ground surfacee The dispersal volume of combined sludge and scum and to chec Y cel(ls) shall be visually inspected to check the effluent lound surface msay indi atei a fa lingt~onditionoand requires the immediaten the ground surface. The ponding of effluent on the gr notification of the local regulatory authority. the entire When the combined accumulation edsb da Septage Servicing Operator land di posed o)f in ac~ordanceewith ch.INR 1 13, Wiscon contents of the tank shall be remo Y Administrative Code. The servicing of effluent fliters, mechanical or pr ~ o`de O~ be perfot•med by a certified POWTS Ma n~tainer.ny °cher maintenance or monitoring at Intervals of l 2 mo A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION For new conswt:tion, prior to use of the POWTS check treatment tank(s) fo i htgh oncentrations are decected have~the once' that may impede the treatment process and/or damage the dispersal cell(s). nr rl,o ran4(s'R romovPC? by ~ tent~We tervic3nR operator prior to use. J System start up shall not occur when toll condltloru are frown at the tnfiltratlve surface. t)uring power outaEes pump monks may fill above nomul hl~hwater levels. When power fs restored the excess wutewater will be discharged a the dispersal cell(s) In one IarYe dose, overloadlt>S the cell(s) and maY result Ire the backup or surface dlschar8e of eftiuent. To avoid this situation have the contents of the pump tank ttilnovtd by a Septaee Servkln~ Operator.prior to restorlnti power to the effluent pump or contact a Plumber or POWTS Malatalner to arrest In manually operatln~ the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over unks and dispersal cells. Ao not drive or park ever, or otherwise dlswrb or compact, ehe area within 15 feet down slope of any mound or at-grade roll abso~ptlon area. Reduction or ellminatlon of the following from the wastewater Jtrearn tray lrnprove the performance and prolorsa the lik of the POWTS: antlblotles; baoy wipes; cigarette butts; condoms; cottotl swabs; de¢reasers; dental Ross; diapers; dlslnfectanu; tat; foundation dram trump pump) water; frvlt and vegetable petilt>es; EuoNne; Crease; herbiddas; meat scraps; medications; oil; palntinr{ croducts: aesticldes: sanitary napkins: tampons; and wacer softener bHne. ABANDONEMENT When the POWTS fails and/or Is permanently taken out of service the followinS steps shall be taken to Insure that the system is properly and safely abandoned In compliance with ch. Comm 83.33, Wlscons(n AdminIstradve Codet • All plpln¢ to tanks and p1u shall be disconnected and the abandoned pipe opentn8s sealed. • The contenu of at( monks and piu shall bo removed and prc+perly disposed of by a SeptaEe SetvkinS Operator. Aher pumpi~Y, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, Eravel or another inert solid material. CONTINGENCY PLAN it the POWTS fails an<i cannot be repaired the toitowln~ measures have been, or must be liken, to provide a code compliant replacement system: d A suitable replacement area has been evaluated and may be utilized for the loatlon of a replacement roll absorption system. The replacement area should be protkc"ted (turn dlswrbance and compaction and should not be Intrin>~ed upon by required setbacks from ext:tiny and proposed struCWrt, lot tines and welk. Failure tv protect the replacement area will result In the need for a new soli and site evaluation to est;abllsh a suitable replacement area. Replacement systems enure comply with the rules In effect at that time. D A suitable replacement area is not available due to setback an4lor soli Umltations. Barrtn>j advances in POWTS technoloiD a holding rank may be InstaAed u a last resort to reptatx the-fatted POWT'S. D The site has not been evaluated to identity a suitable replacement area. Upon failure of the P01MTS a soli and site evaluation must be performed to locate a suitable replacement area. If no roplacement xea b available a holding tank may be instilled as a Oast resort to replace the failed POWTS. O Mound and at•grade soil absorption sysums may be retonstructed In place following removal of the biomat ac the Infiltrative surface. Recoruwatons of such rystems rrwst.comply with the rules In effect at that time. < <WARNING> > SEPTCt;, PUMP ANd OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFIGIEN7 OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHEiR TRJEATMENT TANK UNDER ANY CIRCCIMSTaNCES. DEATH MAY RESULT RESCUE OF A PERSON FROM TKE INTERIOR OF A TANK MAY 6E DIFFICULT OR IMpnCtlRl i. ADDITIONAL COMMENTS POWTS INSTALLER Narne e~n,~.~ S ~t~ Phone S- ~,S - (06 3~ SEPTAGE SERVICING OPERATOR (PUMPER Name Phnn• POWTS MAINTAINER Narne Phone LUCAL R>EGLILATORY AUTHORITY minty ST" cep i >< wiz`( ~-i~ hon - ~ - S'I' t~1~UI~ COUNTY SF.1'TIC '.'ANK M~NT'r?NANCE AGR.EEME?NT' ANI) OWP~ ERSHIP CEkt'I'I1~ICATIC?N 1?C)It.~rt Owner/Buyer ___,~ ~-' ~r__ _...~.---._._.__ - .r.._..__ ._. Mailing Address ~_.,/^/^~r/ //~~__,__ G~~.~__~ ,.T ~~-4. ~~ Frope3~ty Address _ Z _-- - -----------. (Varif Gattoa rcgttired frea~ i Planning DepaY•di~ncnt for new constructiar~)~___~_~..,,__..,~,,......_ _. City/State Farce( Identification Number LEGAL,, bESCI~IPTIgI~f Locatzan ~ ltJ_ '/,, Si ~c. ~~ T.-~ ~-~.~.W Town of _~~ ~'cc,~fl ~ropexty ..-~-- ~ ~- • Subdivision --- -~~.._.~__~,.... _ -- . ~ ,.~,_.._ ~ .___ ,);~t #~ _ ...._ i ~ ~~--,~ Gert~ed Survey Map #` -, 'Volume^~~ ~., P~ge~~_~----• ~Varraniy Aeed # ~ ~ 2_6 39 .',~ Volume ~~ ~ Page ~ _ ,L~v -__... ~..- ~~,~ k~ouse ~ yep {-,~ nq ~ Lot lines identifiable IK~ yes ~ no SYS~IVL~I~IANCE itnpfroper ~+e and tnaintestanveof your se; pc system could result in its premature failure to bandte wastes. Prapermatiz~tenancn consists of puuaping ont the selatic tank every tht'~ a years ar saoaer, iEatedodby a liconsed pumper. W~;rat you put into the systeuor- can affect tlae function of the septic tank as a tre,~ pmeAt stage in the waste disposal system. The property awner a#lre~es to su6zruit to ~5*n ~rt?ia zoning L-epartmeut a cnrtiftcatzun form. signed by fhc cxrmcr and by a masterpfuxnbar, j~eymatiplttmber, restrictedp]' ~ ber or a lioc~e~dpumperecess ryg ~ tee )tic@ta»lc is 1 as than 113~fult a£ slaAge. is itt proper opexatiu~g canditi~m and/or (2 after in: e~tion a:pd paxnpluS ( 1~ Ilwe, tho undersigned have read the above rcquirr~ ttatats and agree tea maintain the private sewage disposal system with tht standards set forth. herein:, as set by the I"lepartmettt of Cat'~• a axtd tkze Ltiepnrtment vt`Natural FCesatu'eea, Statr of Wisaansln. CE:~titeAtioss st~tittg that your &ols~e system tree been maintainel I tmuat !~ cotnpleted sad ratarn~ed to the St. turaix Ceunty zoning Of~'tez t+u'itlxuz 3t) days of the three fax expiration date. SIGi~1AT OF APFI,IGA~I7' _ / ~ -- DA'~'E o'~!NER c:j~~ T~ ION I (we) catti~~y that all statomants on this ;tern aze true try ttrn boat of my (our) )r~owledga. I (we) am (are) tl~e awncr(s) of the ptvperty de5eribed above, by Virtue of a waml 1ty deed reGdrd4:~ i~ Rtgirtrr of needs bi~ice. SYGNA L' 0~' APpLICAl'Q'I' .~, I]A'I`p ~,~4r«..'-. spy information that is this-reprG5CiltCd 1X ay result in the sanitary pCrmit being revoked by the Zomiz~q Department. "''t*'~` *s Include with ttKis Applicati~~n: a stamped warrl'aty doed from tEie Register of .Deeds nffTre a copy of the a rtif"ied Survey rn~p it' r4fezoace is tt~ade ~o the ~varrwty deed Document Number This Deed, made between Heintz, husband and wife, ~~~. ~ 767 PA,E 226 STATE BAR OF WISCONSIN FOItIv12 - 1999 WARRANTY DEED Thomas M. Heintz and Annette F. Grantor, and John Warren and November Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): The East Half of the Northwest Quarter (E1/2 ofNWl/4), EXCEPT Lot 1 of Certified Survey Map recorded in Volume 14 on page 3981 as Document No. 632477, Section 10, Township 30 North, Range 16 West, Town of Emerald, St. Croix County, Wisconsin u e ~~w y~.~-• ro ~ Exceptions to warranties: Easements, Dated this _~_ day of hnchanrl and wifa ~~ fro. ~ ~ ~~~ EsEa2639 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FDR RECORD 1i-21-2401 9:15 AM IdARRANTY DEED EXEMPT # CERT COPY FEE: CDDY FEE: • TRANSFER FEE: 454.40 RECORDING FEE: 11.04 PAGE5: 1 Recording Area Name and Return Address ~~~~~~,~ t c~ ~o 010-1022-70-00 , 10-1023-10-000 ~ ' - - - - - ~ ~o-+ :~ j..:.J .S ,1_ This is homestead . ~ •Ib .Ic{o (is) 1~XOQ nd rights-of--way of record, if any. J 2001 * AUTHENTICATION Signature(s) authenticated this day of TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Sta[s.) THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Ogland Hudson, WI 54016 0. 3o.1~•I~`3)~ SE~Nw \ Se~# • ro . ~~Z~~-s~•-•~v 'o~ "1 e * T mas M. Heintz " * Annette F. Heintz ACKNOWLEBGMENT STATE OF WISCONSIN ) ss. St. Croix County ) Personally came before me this ~p ~v d~y'~pf ~ ": November 2001 the ov '~tame:d '~ " Thomas M. Heintz and Annette F. Heintz, husba~Id: ~w' V ,:, • 4 U .. ~ ''rte-- ~~y =: _ to me known to be the person(s) who executed the$or,4~in®~ , . instrum/e+nt and acknowledged the same. ....., / / n i ~- * ~/1 L FL-~/ i i Notary Public, State of Wisconsin M ommiss' n is permanent. (If not, state ex iration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) L _~~~~~') • Names of persons signing in any capacity must be typed or printed below their signature. ~MOm,alion Frorasslo~a~s company, Fond du Lac, Vw STATE BAR OF ~VISCONSIN aoo~ss-2oz~ WARRANTY DEED FORM No. 2- 1999