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008-1068-20-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 563839 0 GENERAL INFORMATION 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: Rominski, Richard & Ellen Eau Galle, Town of 008-1068-20-000 CST BM Elev: 1 17 C.0 Insp. BM Elev: BM Descri tion: Section/Town/Range/Map No: VV*\ re ,n ct- Po b 23.28.16.3528 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER S CAPACITY STATION BS HI FS ELEV. Septic Benchmark 17 CP Dosing (od $ / / Alt. M 97. 8 Aeration Bldg. Se r F/ I I~ S 5 5~ 'A, . Holding St/Ht Inlet g 45 92 • 8 St/Ht Outlet TANK SETBACK INFORMATION TANK TO G P/4 WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic / Dt Bottom Dosing 72- ;;1166 qd I 3 7L 7166 / 'F6 i _ Header/Man. Aeration Dist. Pipe 3 y~ Holding Bot. System :5.75 57. 5 PUMP/SIPHON INFORMATION Final Grade 13 ~ Manufacturer 1 Demand St Co^r QJ 1 S GPM ICJ v Model Number f6 i5- d TDH Lift- f Friction Loss System Head G 7DI)II6. pO Forcemain Len~S Dia. Dist. to Well 7 /66 1 77 SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No. rench PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS I Z c Se SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type Qt~,ystem: ~Jlz CHAMBER OR fl $ 7 /46 UNIT Model Number: O V DISTRIBUTION SYSTEM 1nal Header/Manifo~ /I Distribution /3 i/ .01 x Hole Sizg x Hole Spacing V t o Air In ke Pipe(s) ( ` Length Dia Length ~T Dia /PZ`5 Spacing 3L Z-7 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seed /Sddded 6W&Ad-- xx M !;~.Yes Bed/TrencCenter / '7 Bed/Trench Edges Topsoil Yes M No 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 7 17-31 ~3n Inspection #2: Location: 208 CTY RD Woodville, WI 54028 (SE 1/4 SE 1/123 T28N R1 6W) metes & bounds of P rcel No: 23.28.16.3526 1.) Alt BM Description = ~J•t~ ~slr~ d 2.) Bldg sewer length -amount of cover I S5 36 g >I-E. 7 '7'2- a 11664-- In o l~~o Plan revision Required? Yes No -7 ZZ / C~ Use other side for additional informati n. J J SBD-6710 (R.3/97) Date Insepctor's ignature Cert. No. 105-A~U_ 4,4 J ~a R ~d County Industry Services Division ' `:F• 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.) :x v 5 P.O. Box 7162 Madison, WI 53707-7162 5'6o, 3 33 7 W M__ Application State Transaction Number In accordance with SPS 3 1(27 Wis. Adm. Code, submission of this form to the appropriate %nt.1 unit ZZ(OO is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTd to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may- 4used for se n 'IF purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. vLJ~_~`/ (`mss 1. Application Information - Please Print All Info a ' n Property Owner's Name J T CR C ~f Parcel # Property Owner's Mailing Address Nj~ Property Location C, s b Ct vt Govt. Lot l J\ City, State Zip Code Phone Number S 1= 1/4, ''/a, Section ;W O V l (LE µe-1 (circle one,,,. IL Type of Building (check all that apply) Lot # T ?3 N; R / E oltvi X 1 or 2 Family Dwelling -Number of Bedrooms N Subdivision Name A ~riCE.V~AC Block # /i I+-a /Q ❑ Public/Commercial -Describe Use AJ / N ❑ City of ❑ State Owned - DescribeTse CSM Number ❑ Village of O✓ AJ/A Town of GC, E IIL Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System 19 Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) List Previous Permit Number and Date Issued / B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New Before Expiration Owner IV. Type of POWTS System/Component/Device: Check all that a I ❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ff Mound > 24 in. of suitable soil TI-Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Treatment Area Informaflon: Q Design Flow (gpd) Design Soil Application Rate( f) Dispersal Area Requi Dispersal Area Propose f) System Elevation 14 icy 61 /11' 6 4-6b ]d(s `f SL) p -1 cy / ,G7 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units p o New Tanks Existing Tanks a a, a W o f7 ~ LC U V] V] fW C7 A.. '0 U2 Septic or Holding Tank 00 ® Dosing Chamber 4,00 Ci ~ t e_ Ce Y X VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's nature MP/MPRS Number Business Phone Number _~5eyin e_ Plumber's Address (Street, City, State, Zip Code) ~J -76, ~ q 14-w 1 ;;(FS 1~, ~a l l C,c.# t q-74-7 VIII. County/Departinent Use Only Approved El D Permit Fee Date Issued Issuing t Signature ❑ $(025 7 tll3 to rven Reas for Denial IX. Conditi'i s axons for Disapproval "'tank. eitlt6nt filter and e- dispersal cell must all be services / maintained ~~Q n ~ as per management plan provided by plumber. ' . AW t et1;1abk regw6rhants.must . be maintained fI1~~ n as pet apppcatie c6de / ord'marices. rrs nn ~ ~ 0 !~a~4Do,Vl e 4: O•d O' , Attach to complete plans for the system and submit to the County only o paper not less than 812 x 11 inches in size SBD-6398 (R0313) o a.xTMF~T DIVISION OF INDUSTRY SERVICES 051? °1P 3824 N CREEKSIDE LA D ' HOLMEN WI 54636 3 S Contact Through Relay P S www.dsps.wi.gov/sb/ www.wisconsin.gov SIONAL'~ GScott Walker, Governor Dave Ross, Secretary 03 July 09, 2013 CUST ID No. 220292 ATTN. POWTS Inspector BENNIE W HELGESON ZONING OFFICE HELGESON ENTERPRISES ST CROIX COUNTY SPIA N7649 STATE ROAD 128 1101 CARMICHAEL RD SPRING VALLEY WI 54767 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 07/09/2015 SITE: Identification Numbers Richard Rominski Transaction ID No. 2260663 208 County Rd B Site ID No. 792092 Town of Eau Galle, 54028 Please refer to both identification numbers, St Croix County above, in all correspondence. with the agency. SETA, SETA, S23, T28N, R16W FOR: Description: Three Bedroom Mound System / 5% slope Object Type: POWTS Component Manual Regulated Object ID No.: 1434333 Maintenance required; Replacement system; 450 GPD Flow rate; 24 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01101, R. 10/12), Pressure Distribution Component Manual Ver. 2.0, SBD-10706-P (N.01101, R. 10/12); Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. NDITIONAL The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code APPROVED requirements. DEPT OF SAFETY No person may engage in or work at plumbing in the state unless licensed to do so by the Department erPs-RORSSIONAL SE stats. DIVISION OF INDUSTRY The following conditions shall be met during construction or installation and prior to occupancy or use: Reminders • A sanitary permit must be obtained from the county where this project is located in accordance with th S requirements of Sec. 145.135 and 145.19, Wis. Stats. ORRESPO • 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. Stats. • A state approved effluent filter is required. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided per SPS 384 product approval conditions. • All POWTS component piping material shall be SPS 384, Wis. Adm. Code compliant. • The area within. 15' downslope of the dispersal cell shall remain undisturbed. Vehicular traffic, excavation or soil compaction is prohibited in this area. • A cony of the approved plans, specifications and this letter shall be on site during construction and open to inspection by authorized representatives of the Department which may include local inspectors BENNM W HELGESON Page 2 7/9/2013 Owner Responsibilities °N • The current owner, and each subsequent owner, shall receive a copy of this fetter uiilttk1ing instructions relating to proper use and maintenance of the system. Owners shall receive a copy-of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval • 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. SPS 383.54(1). • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • 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. In granting this approval the Division of Industry Services 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 and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 Fee Received $ 250.00 52 x~~;n Balance Due $ 0.00 rard M Swim POWTS Plan Reviewer, Integrated Services (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm WSMART code: 7633 jeny.swirn@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm "s Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly R Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with C "SPS to recognize the relocation of the Division of Industry Services from the former Department of Commerce to ' the, Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. BENNM W HELGESON Page 2 7/9/2013 Owner Responsibilities • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy-ofthe appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • 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. SPS 383.54(1). • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • 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. In granting this approval the Division of Industry Services 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 and the PO WTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 Fee Received $ 250.00 Balance Due $ 0.00 rard M Swim POWTS Plan Reviewer, Integrated Services (608)789-7892, Mon - Fri, 7:15 am - 4:00 pm WiSMART code: 7633 jerry.swirn@wisconsin.gov cc: Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with "-SPS° to recognize the relocation of the Division of Industry Services from the former Department of Commerce to T'i `f the, Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered MY and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed TY u . by SPS- Chapters 360-366. t;r`9a- -P) er' 13e~c►~ ~1_e~~ so~ ~ac~? s rock C h~ S a f .S E4 Sep , i Top of 6'! b,Q FeY)c.~ t -Prooci-~ kin e 66rn~er Pc&-f y98, s ~~l~.s Q3 z v Qi p P~-,D lp 06 A ioo% Gam/. .5cpf: L ,poS~ 7'a h ~ Poly /C l -to 6e ey~~i I (.e J on. o a I,, r 9 3 Be A -c-, ~r~ve u~cAy ~ F ' ~~CEIV~® JUN 13 2013 INDEX SHEET ijvj)USrR, PROPERTY OWNER: RICHARD ROMINSKI (SERVICES 208 COUNTY RD B WOODVILLE WI 54028 PROJECT NAME: RICHARD ROMINSKI PROJECT LOCATION: SE 1/4 , SE 1/4 , S 23, T 28 N, R 16W MUNICIPALITY: TOWN OF EAU GALLE COUNTY: ST. CROIX DESIGN: PRESSURE DISTRIBUTION MANUAL VERSION 2.0" SBD-106706-(N. 01 /01) MOUND COMPONENT MANUAL VERSION 2.0" SBD- 10691-P (N.01/01) CONTENTS: Y Page 1: Plot Plan AND Page 2: Cross Section and Plan View of Mound v~c~s VICES 3ERVICES Page 3: Distribution Pipe Layout Page 4: Septic Tank and Pump Chamber Cross Section and Specification Page 5: WLP 1000/600 MR ZABLE Tank Specifications Page 6: Pump Specifications Page 7: POWTS Owner's Manual & Management Plan- Pg 1 Page 8: POWTS Owner's Manual & Management Plan- Pg 2 Page 9: Payment Voucher Name: Bennie Helgeson Signed: Address: N7649 hwy 128 Spring Valley, WI 54767 Credential Number: 220292 Date: 06-11-2013 rd _ ~ Page Synthetic Covering ASTM C33 Distribution Pipe Medium Sand ~~s~ 9 ~ Sy S~r~•, Efev, Topsoii 97, s C oK4our E/e✓, *14 Slope. C iELLOf ? = 2 %2 Force Main Plowed Aggregate From Pump Layer D / Ft. Gross Section Of A Mound E ~y Ft. F , g4 Ft. G Ft. A 9 Ft. M / Ft. Signed: B ~6. asFt . License Number. k Ft. Date: L 71/,) Ft. J b Ft. T_ Ft. W a.3.7 Ft. L Observat-Ion Pipe w T_..-_._. 4 (71 Distribution 7 C LW- Of %2 2 %z" ' Pipe Aggregate i Observation Pipe sa (.rca 990 Plan View Of Mound Perforated Pipe Detail Cleanout Access Threaded End V l l w Cleanout Ptrlorolto PVC Pipt End Manifold Holes Located on Bottom Are Equally Spaced / Force Main From Pump S First Hole Next to Manifold P Cleanouts Distribution Pipe Layout P R S 32 x a 7 Y Hole Diameter Inch Lateral Inch (es) Manifold Inches Signed: License Number: Force Main " 02 Inches Date: Invert Elevation , a Holes Per Lateral 05 S Number of Laterals „3 Total Holes 7~ d(AJvte--r; ktA"j t bvn~n L-' Page Of SEPTIC TANK PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS 4" fikVENT PIPE 12" MIN. ABOVE GRADE E WEATHERPROOF 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER W/ PADLOCK E ~ roLuA _ WARNING LABEL e leo. 9 b. 3 4 MIN. zy" 18" IN. _ ~ 18 MIN• " WATER TIGHT SEALS GAS- TIGHT, , \ APPROVED INL13~ FILTER - A SEAL JOINTS WITH APPR6[ 1 ° -l- ; ALM APPROVED PLPf PIPE S'-5 B ' ON 3' ONTO OIL ONTO T ' SOLID S C SOIL PUMP OFF ELEV . 99.S-FT. OFF D 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS `fates. l r ~.I s r~ i' ~ SEPTIC / DOSE TANK MANUFACTURER: t eSPr /0, 3 X S S/, PS ("al. TANK SIZES: SEPTIC ((DO0 GAL. DOSE VOLUME INCLUDING DOSE p Z> GAL. q. f 67-.(.~ FLOWBACK: • 7S GAL. ALARM MANUFACTURER: SJE-- Rho,,,.~b~s CAPACITIES: A = /S INCHES = 01,49 AL. MODEL NUMBER: , r re-f. J L 2 INCHES = 33. S.~ GAL. SWITCH TYPE: h 1:51 00L B PUMP MANUFACTURER: ~~f C = ~c INCHES = /D GAL- MODEL NUMBER : 3 &'7l 1:P©y L GAL. SWITCH TYPE: yr ,cti~r~ I_ FIOce D = /O INCHES = L61, REQUIRED DISCHARGE RATE .30.7.5-GPM PUMP E ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE g,-~ FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . . _ FEET +Q- FEET FORCEMAIN X c),O-/ FT/100 FT. FRICTION FACTOR 6~ FEET FEET DYNAMIC HEAD TOTAL INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH DIAMETER LIQUID 6iiEI5Tff--[„ . (Plea s e- e- -ra -e -~o c) SLi•ec SIGNED: LICENSE NUMBER: DATE: 1/88 rLrLJI 0 0 O J \ to " U) o p mu wQ - BCD N(L °o U) L~ D J aG LC) Of w Z W Z F-w ° O M ao O 0 U m C; (L N F=l FO dM p ~ o In Oaf Yi-- w~ ¢ N mw I CYO oF- v~ w O~U q _ Q 0m ~a ZZ < r-- -1C0 °~w O LL O J w 2 Q IL~ cV ' O L`W En ¢ U QQ z t-ICJ=CO wQ' CL (f) 1 J W W p I-- 1 j f O nf O V ° ( n 0 s s m o f I.L p !n 00 W CA A WA ~ Q p N co -1 UI Q U- 00 n ¢O 0 e W fW Ii sr°QOq 1-- ~_ir CY) H~V mNH N~ r- O Q `CA Nf~(n¢ w w~U wZ~ LLI F- En oD uj V) (D o~OE-1i- 3p~- OOY OOw ¢ m WW w ° Q Z°JI~->z zC,-J ~ z00Q Z~~ U in a°ocww wow a~rc0 a§.. Q~ '~3mc) M=J~sm53 z L'i w ~ 5 ° o o Z Z J O V) o s J wZ~ Z s M is i i LLI W w5 I d s ~ I I r' 1 I 1 1 W U 1 I Q J a N U In I I I I f I 1 U) C I I ~ 6 •1 1' Z I ~ I 1 r 1 IA i i S I I 1 1 w P QL „~s .s£ y „95 i ~Wr1e~;,rd ~►1,in MODEL 3871 Submersible EP04- EPOS p I~rj "1 t I G O U L - METERS FEET 10 . MODEL: 3871 9 30 - i 25 7 11- } - W 6 20 -._i......_ --+y1 S L-? 5 Y ° EP05 0 3 to z EP04 S / 0 00 10 20 30- 40 60 US GPM - 0 2 4 6 S 10 12 0&. CAPACITY Pump Specifications Features and Benefits /to and 1/2 HP •EP04 impeller- semi-open design Up to 60 GPM with pump out vanes to protect Maximum head to 32' mechanical seal. a Discharge size 11/2° NPT • EP05 impeller - enclosed design Solids: 3/4' maximum for improved performance. Motor • Rugged glass-filled thermoplastic All motors feature ball casing and base design provides bearing construction* superior strength and corrosion Single phase: 115V resistance. Materials of Construction • Cast iron motor housing for Cast iron efficient heat transfer, strength, Thermoplastic and durability. Stainless steel • Corrosion resistant threaded ' stainless steel shaft. •Available for automatic and manual operation. • CSA listed models available. operation and feature stainless steel hardware. • POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 7 of 9 FILE. INFORMATION • Owner S.Y3TEM SPECIFICATIONS . Perrriit# Tank Manufacturer: Wieser Ip NA Septic [I Dose.❑ Holding Volume: 1000 (gal) DESIGN PEA ETER$ Tank Manufacturer. Wieser ❑ NA Number 0 Badrooms: ?a p NA ❑ Septic 13 Dose 0 Holding 600 .(gal) Number of Public Facility Unitss M NA Vertical Distance Tank Bottom(s) to Service Pad: (ft) Estimated (average) Flow : ova (gal/day). Horizontal Distance Tank(s) to Service Pad: (n) Design (peak) Flow = (estimated x 1.5): p (gal/day) Specific servicing mechanics must be provided Ifvertical is >15 feet or If horizontal Is >150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: (galtday/ff) Effluent Filter Manufacturer: Po 1 U C_ Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: VOL L. c - ~ fl NA Fats, Oil &-Grease (FOG) s30•mg/L Biochemical Oxyg en Demand BOD Pump Manufacturer: ~r> ( s) s220 mg/L ❑ NA "(°t S Q 188 $u= • ctarr lids. SS . stsq t f xip Medela _Z>'9 7-1 ❑ NA High Strength Influent/Effluent - • Monthly average Pretreatment:Unit (FOG) >30 mg/L' Manufacturer. (BODs) >220 rng/L ❑ NA 10 NA SS) >150 mgd- ❑ Mechanical Aeration r] Peat•Flltei• . Pretreated Effluent: Monthly average El Sand/Gravel ❑ Disinfection I7 Wetland (gODs) s30 mg/L el Filter [I Other. (TSS) 530 mg/L O NA Soil Absorption System. Fecal Copform (geometric mean) s10' • ❑ In-Ground (gravity) ❑ In-Ground (prassurq). NA Maximum Effluent Particle Size ❑ At-Grade 3si in dia. ❑ NA ® Mound Other ❑ Drip-Une ' Other Other: ❑ NA ❑ NA MAINTENANCE SCHEOULE Service Event Service Frequency Pump out contents of tank(s). When combined sludge and scum equals one-third.(%) of tank volume When the high water alarm is activated Inspect condition of tank(s) • At least once every: ❑ month(s) Z E year(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: month(s) year(s). (Maximum 3.Year) p NA Clean effluent filter At least once every: 1111 month(s) f year(s) ❑ NA Inspect pump, pump controls & alarm At least once,every: month(s) to 25 ❑'year(s) ❑ NA Flush laterals and.pressure test 'At least once every: • ❑ month(s) ❑ NA At least once every: C7 month(s) . Other: DIGS r(s) b NA O NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems-shall be made by:an individual carrying one of. the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS "Maintainer or'Septage Servicing Operator (pumper). 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 a check for any back up or ponding of effluent on the ground surface. The soil absorption system 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 immadiate notification of the local regulatory authority. When the combined accumulation of -sludge and scum in any treatment tank equals one-third or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing, Operator (pumper) and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code: Allother services, including but not: limited.to the servicing of effluent filters, mechanical be',Oressurized components; pretreatment units, and any servicing at intervals of 512 months, shall be performefty a certified POWTS Maintainer. A service report shall be provided'to the local regulatory authority within 30 days of completion of any service event. GMW-005 (02/05) Page a of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process 'and/or damage- the soil absorption system. If high concentrations: are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of,power -under these conditions is not recommended, as the excess wastewater will b&discharged to the soil absorption system in one large dose causing an overload that may result In the backup or surface discharge of effluent.. and damage-to the system.. To avoid ihis'sltWatlon have the contents of the pump tank removed by a Septage Servicing Operator (pumper)-prior to-restoring power to-the .pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil•abso do rp n system. 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 wastewaterstream may Improve the performance and, prolong the life of the treatment tanks and soil absorption system: acids, antibiotics, baby wipes; cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons. 'and water softener brlne.discharge. . :..ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken twin5u`re thatthe system is properly and safely abandoned In compliance with s. Comm 83.33, Wisconsin Admiriistrative.Codei • All piping to tanks, pits and other soil absorption systems 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 (pumper). • 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: ❑ 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 infinged 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's(te evaluation to establish a suitable replacement area. Replacement systems must comply with the rules In effect at the time of their permit issuance. A suitable replacement area is not available due to setback and/or soil- limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. ❑ 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 :•eplacement area is available a holding tank mabe installedas a last resort to replace the failed POWTS. y 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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE, NEVER ENTER ANY TANK. UNDER ANY CIRCUMSTANCE. DEATH MAY MULT. M APE"Oft fi2itSCUE FROM THEIMUOR OF A-TANK MAY NOT BE POSSIBLE: ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWWTS-MAINTAINER. Name °TjQytvi t t?_ Name `~01, h s~ Savi ; -I-1o nr Phone I 'lZ 0 - '3 Phone ` X SEPTAGE SERVICING OPERATOR PUMPER L CAL REGULATORY AUTHORITY Name vh n SL.-., e> a_v, i ;-r~1-t o Name / Phone `115 - -Z-I:!> - `JfSI Phone ~7 1 This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. V I.tJ~~ rLx' ~ l A_r✓' ~ Y ~Ltt4'l t ~1 'S . c STARTUP AND OPERATION Page 9 't i For new construction, prior to use of the. POWTS check treatment tank(s) for the presence of painting products, solvents.or other chemicals or sediment that may impede the treatment process 'and/or damage- the soil absorption system. If high concentrations. are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be-discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system.. To avoid :this `sifuation :have'-the contents of the pump tank removed by a Septage Servicing Operator (pumper) priorto -restoring power to•thepump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the Infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. 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 treatment tanks and soil absorption system: acids, antibiotics; baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drajn (sump pump) .discharge, ;fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons,'and water, softener brine. discharge. . - -ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to'insur ' that-the s stem is and safely abandoned in compliance with s. Comm 83.33, Wisconsin Adniiriistrative.Codd~ y properly • All piping to tanks, pits and other soil absorption systems 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.(pumper). • 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 node compliant replacement system; ❑ 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-#f ifringed 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 the time of their permit issuance, A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may, be installed as a last resort: ❑ The site has not been evaluated to Identify a suitable replacement area. Upon fallure of the POWTS a soil .and,site :evaluation must be performed toloeate a suitable replacement area. If no •eplacement area is available a holding tank maybe installed as a last resort to replace the failed POWTS. Mound and at-grade soil absorption systems may be reconstructed in place following removal of the blomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING TREATMENT TANKS, PUMP TANKS, :AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK.UNDER ANY CIRCUMSTANCE. DEATH MAY FfsSULT ESCAPE-OR ktSCUE FROM THEMTERIOR OF AfTANK MAY NOT BE POSSIBLE: ADDITIONAL INSTRUCTIONS: POWTS.INSTALLER POWWTS MAINTAINER . Name vi t p ENa Phone SEPTAGE SERVICING OPERATOR PUMPER LOCAL. REGULATORY AUTHORITY Name i -I c+ ys[ [Name er- - . i ~C r GPI yt t +'d Phone Phone "7 1 "=4 This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance wHh sections Comm 83.22(2)(b)(1)(d)&(0 and 83.54(1), (2) & (3), Wisconsin Administrative Code. 1 R Wisconsin Department of Commerce SOIL EVALUATION REPORT Page/of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. unty rJ Attach complete site plan o of less than 8 1/2 x 11 inches in size. Pla~nust 67, CA / V include, but not ' d v ci horizontal reference point (BM), directiaWj~1 lZAlf I.D. percent slo s o s, north arrow, and location and distance to neafesdotl /64,~ p ou v e print all information. viewed Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location RI C V O: rA b IM I 'LA Govt. Lot s 1/4 S,51/4 S,> T N R) E (or Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# '~z O 8 e 7 A~04-4 . IE - CRY State Zip Code Phone Number ❑ City ❑ VIlage g Town Nearest R ad n if W0CJ0 t12 Wl 541A9 (I/f)1,M-.246 Gcll~ (.T/~ 9 ❑ New Construction Use: ❑ Residential / Number of bedrooms 3 Code derived design flow rate 4-5-0 GPD mi replacement ❑ Public or commercial - Describe: l Parent material _Z c') e SS n "er %i// Flood Plain elevation if applicable ~i4 ft. General comments „ J and recommendations: U5257.' .st(n o~ ~'1'P`- "`T'~'f'~ e~9~ ° Ce OK C OK 40uir 76.1- Nl4ee 4 s Ei-eJ. 97 S- F y Boring # E] Boring Q7 b pit Ground surface elev. ft. Depth to limiting factor o~ 7 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fly in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 L) L (g ? y :3a ~o aD 7. s c s 6 uk 3 a e vle /1' .21) C - O a F51 Boring # Boring Pit Ground surface elev. fl. 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 ! (j lpy 1-- 3 L') a~ , 4 8 F g -3 0yk D 7s'Y2 s~ C t- Ld Id 31-41 12'2 P y d i e o 6 • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2' = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Prin SignatuCST Number ~h11t Pe~ eS0~ --Gf aaoa/~~ 14 Address 1 Date Evaluation Conducted Telephone Number U I.TT A'11 TI~.f MI~~ Property Owner Parcel ID # r PaAe C of Boring # ❑ Boring F31 Pit Ground surface elev. ft. Depth to limiting factor 4~) in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 -Eff#2 / aS O Yid r f f C I J 57- Y8 /0Y CAD 757 56L F-1 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/fF 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/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Effluent #1 - BODS > 30 < 220 mg/Land 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 (8.07100) 3 ~ I (-~a♦eA Parcel 10 # Page -")of Property owner Boring # 0 Boring In. Soil lication Rate Pit Ground surface elev. ft. Depth to limiting factor. GPD/fP Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots .E 1 'Eff#2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh{. It 'Y 011 t (f Cu,f lop ~ ~ / a?S O Y~ 1 i 1 ~ S-Y8 /0Y CAD -75-Y SCE E 0 Boring O in. ate Boring # Ground surface elev. ft. Depth to limiting factor Soil lcation R Pit i Horizon Depth Dominant Color Redox Description Texture Structure. Consistence Boundary Roots GPD/fP 'Etf#1 'Eff#2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. i n Boring ❑ Boring # Ground surface elev. ft. Depth to limiting factor in. Pit Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *E GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. = • Effluent #1 = BODE > 30 <220 mg/L and TSS >30 < 150 mg/L Effluent #2 BODs < - 30 mg/L and TSS < 30 mall- 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) - Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 81R x 11 inches in size. Plan must County Include, 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 to nearest road. C / p G Ff Z U oG7C7 Please print all information. Aeviewed by Date Personal information you provide may be-used-for secondary purposes (Privacy Law, s.15.04 (1) (m)): Property Owner Property Location T? I C~ arA b MI (A T Govt. Lot SE 1/4 -§45114 S.,~) T N R 1 (o E (or Property Owner's Mailing A dress t # Block # Subd. Name or CSM# acs e' ~f'~. Lo City 4 State Zip Code Phone Number ❑ City ❑ Village Town Nearest R d N It 0eJ0'lt2 VJf 5114Zi (11f)10,ff--2/80 EaLA- 6all-e e.Ti t~ ❑ New Construction Use: ❑ Residential / Number of bedrooms 3 Code derived design flow rate GPD (I'6-piacement ❑ Public or commercial - Describe: Parent material © e SS nc per Flood Plain elevation if applicable N it. Generatcomments / P~ ~r ~GQ G o Ce ~l and recommendations: (,LSLC SQn or ctn~/d 9 ovt C OK ~'Ouv- y6.S' Nlor~ v► o~ sy~>~ ~i-~~. 97 s- Boring Boring # Ft I Pit Ground surface elev. 9?, 0 ft. Depth to limiting factor a in. Soil ApplicationRate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDflF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Efr#2 tic a 3' i 0r a 7 Ss 3 a b vR Ma D -7, C, - o a Boring # . i41 Boring I Pit Ground surfaceelev. 9S, ft. Depth to limiting factor In. Soil 8pplication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP0/1f in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 1 - 0"Y`1 3 b a ~ 8 -3 NYL* 7SW L C) IJ P 7. Vtz, CZ, a o 6 ` Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 150 mg/L ` Effluent #2" = BOD < 30 mg& and TSS < 30 mg/L CST Name (Please Pd t Signature CST Number T~fKpkt-e' Pe Address r r Date Evaluation Conducted Telephone Number 7;0 - ~)7 :~~9rlo 7 "7 II oi 0 1 pal, 3 0 ~ J ~ d w ~1 0.-~-14 ROrn ,vtS ki , wS.T : ev,v~t ~arsor. a~oa9d T, ~ROII~ (-Ock S o dec. 13 Ya~~ - R.II~ W ~.M, 9G.oo -rove Cf 6" Dt O_. COrV1vr T I`chc a 'p"qe Lint qy-,51 a J q~s, i~133 ~ ~ ~ 'c M" An c' r \ i \A e_ U op % 1 u ~ i f Scxl XiS~ ~f` fi los / ~ PPr~tit. 5•t' - v ~4~~g L ~ R.M. 1on.od ~ Ao{~o•n of tX~S~+Nq .3 $ecl 4'ryve F-k 9(v.5- A~ Nous c E ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ~ ILhdtA 0 M , u\ S k .Mailing Address a O g L ~y . ~~~~,(~Q n c~ of 1 ~P (.Q~ D a 8' Property Address S& M-e Ct S a2 6 O L) p (Verification required from Planning & Zoning Department for new construction.) City/State (~VOnd d , I I -e Parcel Identification Number 00'? /04~ D O © 0 LEGAL DESCRIPTION Property Location 5E % , 5 '/a , Sec. T N R W, Town of L5 t u 64 LL 4L _ Subdivision Lot Certified Survey Map # Volume , Page # Warranty Deed # ?5'( ! -d / , Volume 5- (i 3 , Page # Spec house ❑ yes 19/no Lot lines identifiable eyes ❑ 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 teal 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 tFue to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty 7corded in Register of Deeds Office. Numb r of bedrooms ~ ~/✓r,~ 20 i 3 SI ATURE OF 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) DOCUMENT NO. STATE BAR OF WISCONSIN-FORM I ~l y WARRANTY DEED Vol. THIS SPACE RESERVED FOR RECORDING DATA t-4 I REGISTERS OFFICE a Frant•e~ F $T. CRC~IX CO., WIS. THIS DEED, made between Will Powers Powers husband and wife Rec'd. for Record t'his_l t Grantor day of Iiaz~ A. D. 197.(2 and Richard J. R Minsdr-1 at 12: 1 , M. and wife as joint tenants Z Grantee, R~gb of eed+ W i t n e s s e t h, That the said Grantor, for a valuable consideration ood and valuable consideration qET RN TO conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin: I The N 330 feet of the S 660 feet of the SE14 of SE34 of ii Section 23-28-16, Town of Eau Galle. This deed is given in fulfillment of a certain land contract Tax Key No. between William Powers and Francis E. Powers, husband and III wife, and Gregory H. Nelson, dated September 27th and September 30th, 1974, and recorded September 30, 1974 in Book 516, at page 302, and 3039 as Document No 324134, in the Office of the Register of Deeds for St. Croix County, Wisconsin, which land contract was subsequently assigned by Gregory H. Nelson to Richard J. Rominski and Ellen A. Rominski in an Assignment of Land Contract dated October 13, 1978, and recorded November 11 1973 in Volume 5839 at page 457$ as Document No. 352750, in the Office of the Register of Deeds for St. Croix County, Wisconsin. i i TRANSFER • _ FEE This is not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And the grantorq warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except for any actions as to Gregory H. Nelson, Richard J. Rominski and Ellen A. Rominski, and subject to privileges and right of ways and easements of record. I and will warrant and defend the same. ~ Dated this 7 day of 19 I (SEAL) (SEAL) 4 * (SEAL) (SEAL) i i *Frances E. Powers * 1! S AUTHENTICATION .L ACKNOWLEDGMENT } Si natur s uth icated this day of STATE OF WISCONSIN l Her li 19 79 ss. County. ) y t-ire Register of needs ror bt. Croix t.;ountiy, W3.scon5n. TRANSFER .d FEE This 18 not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; And the grantors warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except for any actions as to Gregory H. Nelson, Richard J. Rominski and Ellen A. Rominski, and subject to privileges and right of ways and easements of record. and will warrant and defend the same. I, Dated this 7~ -7day of mcm= , 19 ~ . i ~ (SEAL) CJ~ /(W1 / ~i\a'~ ..-(SEAL) (SEAL) ~--(SEAL) Frances E. Towers I~ * I AUTHENTICATION ACKNOWLEDGMENT Si natur s uth icated this day of STATE OF WISCONSIN I ` SS. } 19 79 County. 1 Personally came before me, this day of * J Nestin en the above named TITL EMBER STATE BAR OF WISCONSIN ji (If not, l~ authorized by § 706.06, Wis. Stats.) { i This instrument was drafted by ai John G. Nestiagen, Attorney to me known to be the personwho executed the fore- 3t going instrument and acknowledged the same. Baldwin, Wisconsin 54002 (Signatures may be authenticated or acknowledged. Both Count Wis. i II are not necessary.) Notary Public County, My Commission is permanent. (If not, state expiration II, , it date: 19 *Names of persons signing in any capacity must be typed or printed below their signatures. I~ WARRANTY DEED-STATE BAR -OF WISCONSIN, FORM NO. 1-1977 I i I lil Q, O ~ O I 0 G9. a 0. 0 ~ I M O N b tl y s ~ I I I m o 'o Z d c m O LL 3 L Q oc I 0 I g a) _ Z y co W E o = o d c z € d N N IN - ~ a m lC M ozv r E"' I 0:_ E w ~ m I m Z d; ~ c w U) c to N h w N O " E • a o m O Z Z Z N N o. d I a d ca CL c N 2 0 CUI 3 C o a a o CD E W W W v H H H .2 c o 0 0 0 a= •N i ~aaa a M 3 i N " o N J OnI OnI Z "0 I a~ o N O O O j ca a cn Q 0 W _ Q Z CA C6 p G N 0 o0 w `o E ~l 3 r I O m o -8 -8 d N o C C V a M o H y N `vl it ~ M N tll ~ ~ IV ~ N N W CO N U) 14 c6 O N E H '0 'O 1 N C N O O OD ad+ 7 t • ►~1 ' O N W Q' O Z y Z Z (n p p I C~ V1 ~ .o, € a I o L a E u 'c c ~t c t A L)a.a I00))u