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HomeMy WebLinkAbout020-1448-29-000 . Croix Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St Safety and Building Division INSPECTION REPORT Sanitary Permit No: 561060 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 Holders Name: City Village X Township Parcel Tax No: 020-1448-29-000 Husb Homes LLC, do Jeffrey Husby Hudson, Town of CST BM Elev: Insp. BM wev: BM Description- Section/Town/Range/Map No / 0-0 32.29.19.2862 I'V ELEVATION DATA -`yt q TANK INFORMATION TYPE MANUFACTURER CAPACITY STATION B H, FS LEV. Septic Benchmark p 2Sa 3 f 5 I o v ~d Dosing 4>6 Alt. -,4 Z Aeration r 7 Bldg. ewer Holding Sit! Inlet (O t'9 ir a / TANK SETBACK INFORMATION SUHt Outlet TANK TO SP/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 0 / / G~ Dt Bottom / Dosing Header/fvtgf' (n 1`- Dist. Pipe Aeration Holding Bot. S stem 9 Final Grade C~ glL PUMP/SIPHON INFORMATION Manufacturer Demand Covgr 3 2 GPM S'Z Co h uu.6e Model Number ~N f to n Fricti oss stem Head TDH Ft Forcemain Leng Dia. Dist. Well b I (~~i 5 Z SOIL ABSORPTION SYSTEM C- BEDITRENCH Width / 7en~th, No. Of Tre ePIT DIMENSIONS No. Of Pits Inside Dia. quDepth DIMENSIONS 10 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM CHAMB ING R Manuftrez INFORMATION Ty Of System: n / Q) Orf' UNIT Model Number: ehd D T BUTTON SYSTEM x Hole Size x Hole Spacing pVentt Air Intake H eader anifId [PP~se('U-nta I Q„I, ^ ibution 3 Lengtf, Diength 1p;U Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only De Bed/Trench th Over Center Depth Over xx Depth of xx Seeded/Sodded xx Mulched p Bed/Trench Edges Topsoil Yes No H Yes®No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:/ Inspection #2: / / Location: 642 Cobbles" Court Hudson, WI 54016 (NE 1/4 SW 1/4 32 T~2~9N/R19W) Windsor Hlelights 1st Ad Lot 29 Parcel No: 32.29.19.2862 1.) Alt BM Description = t o p 6-K, GGLL1i Ilk 25c 2.) Bldg sewer length = 1 ?4- &f L(U qv'~ z -amount of cover - p, i Plan revision Required? ❑ Yes o sl3 _ _ q Use other side for additional information. Date Insepctor s signa r Cert. No. SBD-6710 (R.3197) / RAY, c M . ) IOU~ N- i L_tLCXi as - - - C' ~bb~a Tor{ c r C ~`gR-►C-- -e A PING r{a lb% / ~f rim o r • - C6uC o4 _c SAP?/c. ~f OW g~ .o Fly k doh raaCa~/ Ct,6 au2- ~ ~ a 3 ~f .z r t PAGE ~OF NAME: be ~l-(u LOT#_~, LEGAL DESCRIPTION: OE 1/4_<,w 1/4,S TZg,NX_TE(lDr)!0 SCALE: 1"= tI(~f g~\ELEVATION: /00,0 BM 1 DESCRIPTION: W n IZ i~ e BM 2 ELEVATION: 1p y ' 0 3 Z- BM 2 DESCRIPTION: l t' n W~ re J&5 SYSTEM ELEVATION:.i,j) g7-,60 ~okef `~l' SYSTEM TYPE: C©h u y ne, - r U~ t,ti ~ f r SIGNATURE: DATE: 3-100`F(s pu f 2~t~4'is`"' kit commerce.W1.90V Safety and il slkilKi Cowry _ 201 W. W in x 7162 ) r C I J( i s c o n s in M n !,ff~y Sanitary Permit Number (to be filled in by Co.) Department of Cottnwme S-& l 6 (Q O Sanitary Permit Application State Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the a hate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for s'WTS are Project Address (if di t than mailing address) submitted to the Department of Commerce. Personal information you provide maybe dary 9 ~OPb47., W purposes in accordance with the Privacy Law, s. 15.04(l m , Slats. d g), P 17rw 9,, I. Application Information - Please Print All Information tyk A J r Ld 1 Property Owner's Name ~ O1~ Parcel # L4f:Ltley Pk4X 1( 15t us L (~ZO-/If Property Owner's Mailing Adds / Property Location 0 4 J v17ce- 2L A / Govt. Lot -7,-T ► Z ~i City, State Zip Code Phone Number Numberv~ ~y IJ ~ a_ y,, Section 3 a 1 i v 1 ~ J 1-502- 1 -5 o2ac `T 2 -3/ (circle on H. Type of Building (check all that apply) Lot # T N; R ~ E or~V 1 or 2 Family Dwelling - Number of Bedrooms ~K Subdivision Name S 1 S' QS Block # 1A.~ 1 , ~S t )k vi 1S I ❑ Public/Commercial - Describe Use rl~ ❑ City of JSQ, C.1 ❑ State Owned - Describe Use CSM Number ❑ Village of _ i~ L~'Town of u Ag A) III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous P it Number and Date Issued Before Expiration Owner IV. T ypof POWTS S stem/Com onenVDevice: Check all that apply) 10 Non-Pressurized In-Ground ❑ Pressurized In-Ground At-G-rade ound 24 . 2o<f s~~ ' ble soil ❑ k4and < 24 in. . of suitable soil ❑ Holding Tank 11 Other Dispersal Component (explain ~ 11 V e ` r `C~f'rZtre/trifent mce-(~lain) - V. Dispersal/Treatment Area Information: r] Design Flow (gpd) Soil Application Rate(gpdsf) Dispersal Area Required (st) Dispersal Area Proposed (,St) System Elevati G~QO ~ C7. I ✓ / ~a~ ✓ )Soo ✓ 4I, 3 Is, 3 VL Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units U 2 y New Tanks Existing Tanks w a c3 $ _x CG 3 ~ ~ m fs. t5 R. Septic or Holding Tank YV SO Y r~ c t•:/ Dosing Chamber 142o O S ZS V VII. Responsibility Statement- L the undersigned, assume responsibility for installs ion of the POWTS shown on the attached plans. Plumber's Name (Print) / Plumb-pr's Signature MP/MPRS Number Business Phone Number &v i2 H erS &ff 7 ~SS &-5 412 $SQ¢ Plumber's Address (Street, City, Sta~Z-ip Cod ) LJ cis c U uc 21 vGV 1 ~l LV 1,S 4 u z Z VIII. oun /De artment Use Only Permit Fee Date ssued ssuing Agent Si pproved ❑ Disapproved L- ❑ Owner Given Reason for Denial $ Ll q/30/13 IX. Conditions of Approval/Reasons for Disapproval W 4) SYSTEM OWNER; 3 ~ An /J / 1. Septic tank, effluent filter and / L,,Q~.C 4 IN 61~ ~1 9 11-0 dispersal cell must be serviced / maintained GLd C~ la~ I as per management plan provided by plumber. 2. All setback re uirements must be maintained rlt~ as per applicable codtal"in plans for the s m and s" to the Courtly oId per sot les~thapn S xa 1;11 Inches in e ^ n ` , / ''J' J 502~ ~d~ci~ m ~G~~t-~(.~-CCLG~C. rtS-FyUytS ~/.~'1 LI.GTWtx- t ('Wt b SBD-6398 (R 02/09) 41 l K Dn • ~~t~'``' CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: o S L1 L '`s~~---- owner's Name: 4 3 ~7eed~ fd / )7r, -V Owner's Address: i Legal Description: n j A) 12 4 13 l ~I 1-11 Township: _ da)5,g o County: 5 0 r o J t f S ~ I Subdivision Name: w i- n e t Lot Number. 2 Parcel ID Number: Page 1 Index and title Pag 2 Plot Plan Pag 3 System Sizing &Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: v I orb J License Number. 220 5-5 Date: c7 °3 Phone Number le,31 4FZ 6~ k Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POVVTS Version 2.0 SBD-10705-P (N.01101). Page 1 PLOT RAN AV Awlez HUSB~ NOMr-S -W&r 40 L o7 Z T W.;N A$BR 4 ~ . i 44)U N if Z L 1OO, Oo -M # 2- NA-11, I N ! p AGM >R~ E t / Aa. 00- c-,r ~bb~e STar~ x I! ose - fillTi7`. CguS ~a ~E- ~~lL ~~a~lE~tT.~_ cvvfR~D ~i A p~4a~ 0 9 Ali Pa au c n L r GAl sFP?~c 4 SDIZ 3 303 MFR Ira '46Z I N' 4Z.a q1.9 3 rLaI,7 kL9l5 9 •3 oco&v4ll AS7"M # o~-, 6~, `/d~lti Wisconsin Department of Commerce SOIL EVALUATION REPORT Page _ L of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County / 1 Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. ri 0 10 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. /27; - Please print all Information. Re ad D to Personal information you provide maybe used br secondsly proposes (Prhraey Lew, s A5.04 0) (m)). ' Property Owner Property Location r~tl~`J>< &t i /~P(?0A Lot ^/E 114 3u) 114 S 3 Z T 29 N R I q E (or~ Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# P. U r _703 z~ ~rr~dSo~ hlC~ -ls /ST clot . D/7 City State Zip Code Phone Number City ❑ Yllage S Town Nearest Road _r . w_.. e.. u o SO rl FDI (D ( ) a""6' New Construction Use: Residential / Number of bedrooms Code derived design flow rate y a GPD ❑ Replacement / ❑ Public or commercial - Describe: - Parent material Flood Plain elev~ applicable ~.`r3- ! a (j Si2(~ / ~ General comments r • F K A' 1 recom endations: SyS~ ety) 4_t ev a/ " l6Y) (OP Q2. do 111 Sol' 1 re - la ~ti~~- ~r ` j7r -wii a Boring # E] Boring ® Pit Ground surface elev. • 700 ft. Depth to limiting factor _ ( in. Sol Application Rate FZ- rizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfF in. Munseii Qu. Sz..Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff##2 O 1 O-~ b r 3(2 Si( 2 vYl e S I -V $-30 IQ STc~ mS1~k CS `f 3 30-~5 i a s c cis k~ . 9 LnS -75 r ,5- to ro N 'P KP 2•o = 2 `r FF1 ❑ Boring / Boring # Pit Ground surface elev. 2vff• Depth to liming tailor -70 in. Soii A ication Rate Horizon Depth. Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlfP in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Etf#2 5I 2irsbK C iv-~ - z g- 3 /v r L(( Sic b S 3 3 (n - - L 3m5~~ i Tt-~v I s/k !Va MP Effluent #1= BOD > 30:n 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L: and TSS < 30 mg/L CST Name (Please Print) Signature - CST Number / d&+-n 5chuw-y5lzcr 25330 Address Date Evaluation Conducted Telephone Number 2() 8073 . erSeF >cl( 5`fU25 "3 ~7(5)76,0, O2-79..._ . f 40 Parcel ID # Page _ of 3 Property Owner _ ~ ~ E] Boring n Q~, IS] El Boring # Ground surface elev. %3 ft. Depth to limiting factor in. Pit Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft?Eff#2 in. Munsed Qu. Sz. Cont Color Gr. Sz. Sh. 6-10 10 3~z 5S ( Zmsbk- c S -C • S 2 16- l ~5 - L4 -~0 3 -m 1 5L 31Y 51- - - 4 6- ( vr-Sho Fra I i -)e5 r VP ❑ Boring # ❑ Boring ❑ Pit : Ground.surface elev. ft. Depth to limiting factor in. Sod A lion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIff In. Munsed Qu. Sz. Cant Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ❑ Boring F-1 Boring # Ground surface elev. it Depth to limiting factor _ in. ❑ Pit Sod icafior» 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 '01#2 I ' Effluent #1 = BODS> 30:S 220 mg/L and TSS >30:S 150 mglL ` 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) rz PAGE ~OF NAME:~~k=--LOT#LEGAL DESCRIPTION:I/4 cJ I/4,STzq.,N,,E(or SCALE: ELEVATION: 100° t BM I DESCRIPTION: flA (i n I Z" ~ BM 2 ELEVATION: -j d y° G Z BM 2 DESCRIPTION: h d ti~ t ~9 P~ IM SYSTEM ELEVATION:-60 4Z ,6© jgu er Ql• o d SYSTEM TYPE: Co U~J~~ H~ ( II Van ~ f5 SIGNATURE: DATE: 7-- -d 00, 30 1 i -i o I / 14 _WINDSOR i -0 / - - N 88°46' A - 0 F7 ;00 c 242.03' LOT 2 C.S.M. O = ~2 - VOL. 3, PC. 883 m 29 a z --j 44631 S. F. 1.02 Ac. CA VE N 83'1886» W i 76, 236' O q~ 30 COBB s I = z , COUR o m o 45801 S. F. (A o O o o 1.05 Ac. I z r Ln / / r\j m o 31 (E _ ~ 45708 S. F. R ~ m o / 1.05 Ac. - ; P z / UT m -F 385.54' -I A UNPL, I ET d c 'HF II oil o 0 0 © o 0 0 II I U O Uf d U r U CN V O C7 u I - lf) 00 U C=; CD LQ r N U CV u N O v v rn N ~ r 00 u E CA ~ m 1 CV CD V wee ti U CO L6 In I lyy 101~A~9/A91 V; J, J m co MN I - W O u 17 E Co U N C6 Cn U Q W ~ CL Y CL O m m ~ I V 6 co I lil,lll ili N ~ In 2 0 O in -j C) O to Cf) zT m w m CN 0 O 2 FL .U- ti J CJ W C~ Ln C'7 LL. m LL.I H r O W H O LLI LLJ 7 co~ ¢ o C W LLI O F- d W 0 CO C/3 Z o U L rn W d U J Lo ' l¢L LL- _ d z d O m I- W 0 z- O ¢ LL LL ~ i- w 0 Q- C 0 O O 9a o o g 0 fi =4 17 =1 N L[7 O _ cn C d' M M N co LCD co Co CD rL- - O ti U7 Z o U IN- d F= Z a- cn V d° X X W Z C.0 w w = W U I- C7 W Z_ N Z = C W - X O co v w Elf LL. w = CD U Z W J N O = m O CD cj:) N m = :D LO Z F- J ® C) C-4 =D9 C:) ZD ~M =Ocfl z L N F- W `1 ~ Q Cl- 0~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page l of 1__ FILE INFORMATION SYSTEM SPECIFICATIONS Owner S 14AeS Septic Tank Capacity al ❑ NA Permit # Septic Tank Manufacturer, ❑ NA S&I V& 0 El DESIGN PARAMETERS Effluent Filter Manufacturer 5,2!O NA Number of Bedrooms 4 ❑ NA Effluent Filter Model s~5 ❑ NA Number of Public Facility Units ITNA Pump Tank Capacity gal At NA Estimated flow (average) 1400 6 gal/day Pump Tank Manufacturer 49 NA Design flow (peak), (Estimated x 1.5) wSQ gal/day Pump Manufacturer ieNA Soil Application Rate gal/day/ftz Pump Model `~tTNA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit A Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD5) <_220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) :5150 mg/L ❑ Disinfection ❑ Other: / Pretreated Effluent Quality Monthly average Dispersal Cell(s) NA Biochemical Oxygen Demand (BODS) :_30 mg/L ,fzTJn-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) :530 mg/L A ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) :51 ° cfu/100m1 ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y8 in ia. 101 NA Other: ❑ NA Other: ❑ NA 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) (Maximum 3 years) ❑ NA 1!5,year(s) 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 every: 3 ❑ yea~(s)(s► (Maximum 3 years) ❑ NA Clean effluent filter At least once every: month(s) ❑ NA 3 ❑ year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) 9`NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s)] NA ❑ year(s) Other: ❑ month(s) At least once every: ❑ 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 <_12 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) Dec, h. 1011 4:11 NM No. 0934 P. 1 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 ch. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN: If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: 0 A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. 0 A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology olding 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 avai a e a o i ay a installed as a a . Mound and at-grade soil absorption systems may be reconstructed In place following removal of the blomat 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/0R 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 INSTALLER POWTS MAINTAINER Name F Name v y C~ Phone S-0 Phone 4 -5 SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name Agency j 2-00)w, n Phone Phone ' - 4 94 D z N 72j" 86„ m r. 53" D Zm z c ~ rn D N ' 0 ni m m v o UP 52" x o ;'pt \ m 4" CAS -pt N 0 D ;a v) m 0 3" 47" I 4" p o 0 S X D ? rn S m I = v I m N UP 49" m / Vo 4" CAS 1. ..L- I - I I t lj N N v m O ,o O ;o D- P m 50" c °Dz m mP D mm z nr~ I p~> D ~~0 D Xm r n~ D Z O m C A ZO D r 2 C Z Z 0 -I rno A v_ 6 A M -mi m D c: co r OR N D D Z Z ° D G)4 D> rrl rnmDO ~DN 0 M XX rn z Zr 9-A O Oco 0 O9Z D Z rvZ N° m° ~ m vrvl m yMD ~n° env 2pgOS=~ prZ 1D (Nm n m `3= (n r~Z n moo mN0 CA 0z ZQ -Z' C D 5 C7=X NSO i C JmrZOD r~lm~ N N Z = In Z Do -4?m nD NAm aONN 0m~ m C)'1 y" a~ O p y 0 ~m D D , r-0 ns z 6 z 00 D NN O O s v~ n O 20 X -TI N z D r~+ rn pc 22 1nm~ D~ Wvwcaw -Di u o n N Z O N m C O mmp I U) O O a m z° can Z ~ 0 Z z -m D mDm m0 vA ' D m o m~ H X1-1 r~ O Z >:t v pp O N ° Z r 0 N D D v 0 ?n Oo m -a O Z -n ;u m rn 20 r~* r r -gym 0 w Cf) 0 U) pp U) C p p M O pC Z O 3 m m 'D n Z . ;o O D C7 O = -1 O (A rn r A 0 Z r C H ; r X 0 m 1n z A z F \V) W1250-MR 10- m MIENER DRAWN BY: SME SCALE: 1/4"=l' -0" PRE-POUR: ConGRETE REV, ~ SEPTIC MANUAL W3716 US HWY 10 MAIDEN ROCK, WI 54750 DATE: JANUARY 2010 DATE:. POST-POUR: \ P REVISED JAN. 2010 800-325-8456 FILE: W1250-MR Oct-i5-2010 01:54 PM 5t Croix County: PlanlZonng 715-386.4686 1st ST. CROIX COUNTY -4E1 1C'TANK MAiNT NANCC A(JXl EMl NT AND OWNERSHIP CERTIFICATION FORM LLC- ~C,b~1c,~Tr~Nri GduC~" PrppcrlyAdclress P+~( (Vey i la'tinn Mg1li:~ed f otil Ptaxaning & Zoning Depart Avow con$111totiorr,) Ci*y/St8te 004 5C>N V 1: Parcel Identification Numt er ~ Z d-~~ ~T- 6aJ P t Ttt I #'ra;ae, ty Location rte . Se . _ , T Q N R 14 W. Town of Subdivision Flat, 'I h e5 n j~ et ~ 1 5 ~ ~ Lot # ~ q Certified Survey Tap # Volume , Page # Warranty Pceti # _ 5~ ~V ~ (bdorc 2007)Volute Page Sgeo l ousa yes na Lot lines idemiffnblo. SYSTEM l) AfNI RANGE AND t.7W NE CERT,IFXCATLQN_ ~ Improper use and nUintciiance of your septic system could result in ina premature failure to htu0e wastes. Proper nisintenanoi consists w1pumping out the septic tank ever three years or 3tooner, if neoded, by a licensed pumper. What you put iwo flit system can aftect the Ibnclioit of the septic tank as a treatment stage in the waste disposal system. (honer maintcrtance respcrilbilides ere spoa;Fed in pComni, $3 2'tt} and in Chapter 12 - St, Croix County Sanitary Ordinance, T 're property Gw leer aigrecs to sobrnit to St. Croix County Planning & Zoning Depormcni a ceriifkntion farm, slgtltsd by the crwvner and 1}v a rrtagtcr plumber. jour t yruan t~it4inber, rcstrkted plnrrtbcr er c iiuxt p~rirtper verflyin that { l t tilts site t€altewater &sPoserl systvrn it, in propci` op.~ratiog condition e nftr (2) nfler inspection and pumping (iffrcrcasury)' ilir reline teak is }ens 1l1a,7 113 brit ofslt:dgc. llwc, the undersigned have read tka above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the 13"rtmont of Co e= and the Departrcent of N4tural Rasouraes, State of Wisconsin, C'ertifiaatiorr stating that your septic system has been maintained trust be completed and raturncd to the St, Croix County Planning & Zoning Department within 30 days of the three year expiration date, liwc certify that afl slattmtslts on this terra are true to the best of mylour krowledv, i/eve Ware the owner(s)of the prapm-;y d ncied abcvc, by virtue of a wfarrawy deed recorded in Register of D ds Office Number of be roomy _ GXAT . flF fi1'f'l ~C#~N l'~ } DATE ***Any 6nforwz*aon that is vnisrepresented tray result in the sanitary permit being revoked by the Pluming & Toning Deparinmt. include with ties spplicavon a recorded warranty deed trrom the Register of Deeda Cfee and a copy of the certified survey nine it rei"erencc is made in the wartaitty deed. (RED' 08/05) Il l l IIIIIIIIIIIIII I II I IIIIIII I State Bar of Wisconsin Form 1-2003 $ 1 4 1 9 9 7 WARRANTY DEED Tx: 4114928 975502 Document Number Document Name BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI THIS DEED, made between Edward M. Hendricks and Lori L. Hendricks, 03/25/2013 11:16 AM husband and wife EXEMPT#: NA REC FEE: 30.00 ("Grantor," whether one or more), and Husby Homes, LLC TRANS FEE: 299.70 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 Name and Return Address St. Croix County, State of Wisconsin ("Property") (if more space is David J. Estreen needed, please attach addendum): 304 Locust St. Hudson, WI 54016 Lot 29, Windsor Heights 1st Addition in the Town of Hudson, St. Croix County, WI-21391R Wisconsin 020-1448-29-000 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: Easements, restrictions and right-of-way of record, if any. Dated March nU , 2013 (SEAL) (SEAL) * *Edward M. Hendricks (SEAL) (SEAL) * *Lori L. Hendricks AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF Wisconsin ) ss. authenticated on;! BRIDGET K. DELO:,]- St. Croix COUNTY) t NOTARY PUBLIC ~~na~ zo13 Personally came before the on March , STATE t the above-named Edward M. Hendricks and Lori L. * TITLE: MEMBER STATE BAR OF WISCONSIN Hendricks, husband and wife (If not, to me k n to be the person(s) who executed the foregoing authorized by Wis. Stat. § 706.06) instrum ft a no I e e same. THIS INSTRUMENT DRAFTED BY: Attorney David J. Estreen Notary Pu tc, State of Wisc nsin 304 Locust St. Hudson, WI 54016 My commission (is permanent) (expires: ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATION TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ©2003 S'rATE BAR OF WISCONSIN FORM NO. 1-2003 *Twfame below signatures. INFO-PROT" Legal Forms • (800)655-2021 • infoproforms.com SaN`dl 0311V1dNf1 ~ I~IN ! I I t/t MN 3NL e0 Im t/t MS 3Nl A t/L t 19 'A 3N 3NL A 3Nn Lca% M 9.00 N MW 13VHDWWVD ,*0.66£ M «Z L,O L LO N - .14 C8 I` Eel C) 00 . \ N CD \ Z A oi / - , zl 'Ss > 00 L L W i~ 00 4 °D in Z I A I° ;u A~~ r r M •6G OD 41 I / w c~ N is kp rMA5 N 1 I NtoWI O ~h lug, N z N a I CD OD OD Co J / 1 n ° g A N 50. 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