HomeMy WebLinkAbout036-1055-20-000
, n Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
,ety and Building Division
INSPECTION REPORT Sanitary Permit No:
567244 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
O'Shea, William & Lori Stanton, Town of 036-1055-20-000
CST BM Elev: Insp. BM Elev: BM Des ion: Section/Town/Range/Map No:
~t~ 1 (11 /66 ~ -rrd ti lj/.D.,,, -,j_' 23.31.17.351
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark t
.Q c~' D
5
Dosing Alt. BM -
!ifJ~, Lt Z- r ~'7 G' U 1-l( Aei~nhelt_
Aeration Bldg. Sewgr-
" 157711+~T" rites / • 2 .
Holding St/Ht Inlet t /
St/Ht Outlet -~7 ~
TANK SETBACK INFORMATION C~5
TANK TO P/L WELL,. BLDG. Vent Air Intake ROAD Dt Inlet
Septic Dt Botto
Dosing r.r Header/ a L 3 5
Aeration Dist. Pipe ~y ~63~ C ( ✓ I 'L
Holding Bot. System 1-
5%144(. i
r
PUMP/SIPHON INFORMATION Final Grade
Manufacturer Demand x/Cover
GPM
Model Number
TDH Lift Friction Loss tem Head TDH Ft
Forcemain Length Dia. Dist. to II
SOIL ABSORPTION SYSTEM 3 7,, r `j '
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 3
SETBACK SYSTEM TO Y✓ P/L BLDG WELL LAKE/ EAM LEACHIN Man r,~"
V
INFORMATION Typ fOfSystem: r 11 CHAMBER R t ;P"+7
>Model Number:
PWR,IBUTION SYSTEM !LX 4 I,✓ YZGL 6
Head n if Id Distribution X15 f Ix Hole Size Ix Hole Spacing cNew-tQXir Intake
( ~ ~ 1 f Pipe(s) ! ;,ry f / rrjt,2.L_
Length is Length Dia Spacing
SOIL COVER 9 x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center ( Bed/Trench Edges Topsoil
Yes D No Y Yes ~ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 10/ 1/1 a 17QInspection #2:
Location: 1824 200th Ave New Richmond, WI 54017 (SW 1/4 SW 1/4 23 T31N R1 7W) 40 acres Lot Parcel No: 23.31.17.351
1.) Alt BM Description =
2.) Bldg sewer length =i( ?G~f
- amount of cover = 1
Plan revision Required? 0 Yes No
Use other side for additional information. CAD Z~ Ct~-~
SBD-6710 (R.3/97) Date Insepctoes Signa ure Cert. No.
b:i~t%V~ } cu TAY
. J T
Industry Services Division -
xv.
f) '1400 E Washington Ave Sanitary Permit e eb~lflled it by Co.)
F'.O. Box 7162
S qtr
-7162
Madison, WI 53707
r,
k
2
- Sanitary Permit Application stateT'rnnsactionNEdf~,,
In accordance with SPS 383.21(2), Wis. Adm. Code, submission ofthis form to the appropriate irne lA unit
an maili tg address -
is required prior to obtaining a sanitary permit. Note: Application fonns fur state-own( ~OWTS a )Initted to PrpjecI Address nl th
the Department of Safety and Professional Servies. Personal information you provide IY4it~ used fbttl d'
Purposes in accordance with the privacy Law, s. 15,04(I)(rn), Stabs. n
1. Application Information - Please Print All Infoi-ination
Property Owner's Name - Parcel #
Property Owtter's Maiti❑ Address Property Location
Govi. Lot
City, ,tale Lip Code - Plione Number - / L~ A, Section 27 Z
ZU)
IL Type of Building (cheelc all that apply I Lot 8 _ _
E or2 Family Dwelling-Nurr,ber6f ^dros Subdivision Name
y Block 4
❑Public/Commercial-Desch I
CSM Number IJ t`illage of'
State Owned --Describe Use
- -
Town of
11I. Type of Permit: (Checl .ortfyon--e Ciox on linti Complete line B it'applicabie)
A,
❑ New System placement System ❑ 'freatrnent/Holding, "funk Replacement Only Other (Modification to Existing Systt n (explain)
B. ❑ Permit Renewal ❑ Permit Revision i Change of Plumber ❑ Pcrnut I i taster to New List Previous Pennn Number and Date ssued
Before Expiration Owner J-c--CT z,5f
IV. Type of P WTS System/Component/Device: (Check all that ae1rl
Non-Pressurized In-Ground 11 Pressurized In-Ground U At-Grade LI Mound _ 24 in. of suitable soil ❑ Mound e'214 in. of suitable soil
Cl Holding Tank ❑ Other Dispersal Component (explaLl Prereatment Device (ex I ton) V. Dis tersal/Treattnent Area Information: _ _ -
Design Flow(gpd) Design Soil Application Rate{ sf) Dispersal Atea tecc cd (sf} Dispersal Area I' rposed sf) System Llev reh'
.o _~~.1' 930
Capacity to "total # of Matutact
y
VI. Tank Info
Gallons Gallons Units a, .2
New Tanks Existing Tanks _ - / j~,~n~~ ' ~ v o ,N 2
14e v u.. U n v i C7 0
- -
Septic m Holding Tank
Dosing Chamber
VII. Responsibility Stat_e_n_tent- 1, the undersigned, assurn ronsibility for installation of the POINTS shown on the attached plans. -
Plum r' Name (Print Plumber' above - i- MP/MPRS Number Business Phone N irn r
Plumber's Address (Street, City, State, Zip Code)
IA2
VIII _ount /I)e partment Ilse 0- - _ -
A Date Issued [stung Agent ignat 'e
Approved lJ Disa rued Permit Fee
pp U Owner Given Reason for Denial S [10 /~5~~
IX. L1%Nf 7 t y{I ►val/Rexsons fur Disapproval ,Ff 3 3
1. Septic tank, effluent filter and✓
dispersal cell must be serviced / maintained
as per management plan provided by plumber. l% Q 30e)
2. All setback requirements must be maintained
_ 100 _ - -
A"_ _
- ~s PPpltsable - -
- r not less than ti i z x 1 aches m s~zc
A". a f c ns bur the system and submit to tile County only o pape
SBD-6398 (80313)
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 10/22/13
Owner:William O'shey
Location: SW1/4 SW1/4 S23 T31 N,R17W 1824 200th Ave Stanton
System type: In-ground absorbtion system(conventional)
Manuals Used: In-ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. Chamber Cross Section
4-6. Maintanance and Contingency Plan
7. Filter Specifications S eet
8_ t
Signature
License nu r#226900
PLOT PLAN
PROJECT William O'Shev ADDRESS 1824 200th Ave New Richmond Wi 54017
SW • 1/4 SW 1/4S 23 /T 31 N/R 17 W TOWN Stanton COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE 10/22/13 BEDROOM 4
CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 915 # of chambers 45
BENCHMARK V.R.P. Bottom of siding
ASSUME ELEVATION 1001 Filter BEAR Filter
BOREHOLE WELL
❑ Q H.R.P. Same as Benchmark
SYSTEM ELEVATION 89.9/89.8/89.7 6.5' below qrade
200th Ave
96'
0'
Scale is 1" = 40'
40' B-2 Vents unless otherwise
noted
Slope B-3 3-3' x 62' Scale is 1" = 40'
cells with >3' unless otherwise
spacing noted
0' 35'
Install System 6.5' below grade
B-1 40
20' 30'
Old system is to be B M * All piping shall be SDR 30/34, within 10'
pumped and buried 25 of tank, piping shall be Schedule 40.
' I
D W Existing 4
40' Bedroom House
5'
S cation 100' Well
unknown
Vent
>6" Quick4 Standard
of Cover Leaching Chamber
with 20.0 ft2 of Area
5.6ft^2/pair of end caps
4' Long 12"
3419 Grade at System Elevation
1320' Property Line
Cross Section of Quick 4 Standard Leaching Chamber
Typical cross section for 2 of 3 cells
Quick 4 Standard
Leaching Chamber with
20.0 ft2 of Area per
Chamber 5.8ft^2 pair of end plates To be >1' above grade
- / Finish grade elevation
Typical Installation 96.5'
Vent Grade vent
A A
4' 4" 4'
-~30/34 Septic Tank
4' Long 1 5' 4' Long 1 „
Grade at System Elevation
3491 Grade at System Elevation 34"
Spacing 5'
3-3' X 62' Cells
Observation tubeNent
Same on other end To be located on end of Cells
A '
B
System elevations: C
A__89.9
B89.8 15 chambers per cell
C__89.7
a
Wisconsin Department of Coma SOIL EVALUATION REPORT Page/ of 3
Division of Safety and Build
accordance with Comm 85, Wis. Adm. Code
County J-{• jq V
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must'+c: .
include, but not limited to: vertical and horizontal reference point (BM), direction and I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nQgrpst road. Q 3 6j - vv i5 j o -MO
Please print all information. V ly 03 , Re ' ed b Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 1Sjf)41), (m)). ;3 (~f ti{~/. Q
Property Owner Prope C M&
'fit/ !l / Q X,/ r✓ Govt. Lot-. Z4 1/4,5 /4 S 2.3T N R 7 E ( W
Property Owners Mailing Address 671 Lot # Block # Subd. Name or CSM#
City State Zip Code Phone Number ❑ City ❑ Village own Nearest Road
F on Use Residential / Number of bedrooms Code derived design flow rate ~e) GPD
cement ❑ Public or mercial - Describe: ateri Flood Plain elevation if applicable
General comments ~pd-C.e~
and recom mendations:
/ > 7
System Type System Elevation/g2. gq
F-/1 Boring # Boring
pit Ground surface elev. 4,1 L- ft. Depth to limiting factor -6)in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. -Eff#1 •Eff#2
ng C] I E ~
Boring /
Bori# A Pit Ground surface elev./ cy , L-- 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
o 6 s o,,-
V/ 01\
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Nam (Please Print) CST Number
Bird Plumbing, Inc. Shaun Bird S' 226900
Address Date Evaluation Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 ~'Dr/ 715-246-4516
f
Property Owner Parcel ID # Page of
-
n Boring # ❑ Boring
(~_J• pit Ground surface elev. ft. Depth to limiting factor S Z- in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDO
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
'
0-V r2
1
Z s-i~o /0
3 U' k? b7 W
F-T
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil lication 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 # Ground surface elev. ft. Depth to limiting factor in.
❑ Pit Soil lication Rate
Horizon 7epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPDIff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
I
i
Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mgA- ' Effluent #2 = BODS < 30 mg/- and TSS < 30 mg1L
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-6330 (RAW)
r
f Soil Test Plot Pla
Project Name William O'Shey Sh Bird
Address 1824 200th Ave
New Richmond Wi 54017 CM #226900
Lot Subdivision Date 9/30/13
S W 1/4 S W 1/4S 23 T 31 N/R17 W Township Stanton
F-I Boring 0 Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Bottom of siding
System Elevation 89.7/89.8/89.9 *HRpSameasBenchmark
200th Ave
96'
0' 9' Scale is 1" = 40'
40' B-2
unless otherwise
noted
1%
Slope B-3
0' 35'
Install System 6.5' below grade
40'
B-1
301
125g *
D W 40, 4
m House
ST Location 100' Well
unknown Boo
1320' Property Line
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner
Septic Tank Capacity _ _ S gal ❑ NA
Permit # JJ
2 Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms _ ❑ NA Effluent Filter Model NA
Number of Public Facility Units - --NA Pump Tank Capacity - al NA
Estimated flow (average) - ytr7__) gal/day Pump Tank Manufacturer NA
Design flow (peak), (Estimated x 1.5) 6 gaUday Pump Manufacturer NA
Soil Application Ratite ~ aUda /ft2 Pump Model NA
Standard InfluentlEffluent Quality Monthly average* Pretreatment Unit - - ~ NA
Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/G,avel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODs) <220.'mg/L ❑ NA 0 Mecharical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal t;ell(s) - - ❑ NA
Biochemical Oxygen Demand (BODs) 530 mg/L In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L /--f9AA ❑ At-Gracie ❑ Mound
Fecal Coliform (geometric mean) 5104 cliu/100m1 ❑ Drip-Line _ ❑ Other:
Maximum Effluent Particle Size 39 in dia. ❑ NA other - NA
Other: Other: _
❑ NA 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 eve' ❑ onth's)
- ry ear s~ (Maximum 3 years) ❑ NA
Pump out contents of tank(s) When combined sludge and scum equals one-third of tank volume ❑ NA
Inspect dispersal cell(s) - - At least once every: month! s) um (Maximum 3 years) ❑ NA
- - ear(s;Clean effluent filter- At least once every: ,Cymonthi s) - - - ^ ❑ NA
ears;
Inspect pump, pump controls & alarm At least once every: ❑ month(s) NA
- - ❑ years,
Flush laterals and pressure test At least once every: ❑ monthls) - NA
❑ year(s)
Other: At least once every: R ❑ monthl s) NA
EI 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 criAcks or leaks, measure the volume of
combined sludge and scum and to check for any back up or ponding of effluent or the ground wirface. The dispersal cell(s) shall be
visually inspected to check the effluent levels in the observation pipes and to checi: 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 or more of ti ie tank volume, the entire contents of
the tank shall be removed by a Septage Servicing Operator and disposed of in accordanc•'i with chapter NR 113, Wisconsin
Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechar ical or pressurized components, pretreatment units,
and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of cc,mpletion of an!, service event.
Page of
• 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 abave 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 thi-i pump tank removed by a Septage Servicing Ooerator 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 scrap;; medications; oil; painting products;
pesticides; sanitary napkins; tampons; and wate+r softener brine.
ABANDONMENT
When the POWTS fails andlor is permanently taken out of service the following steps shall be taken to insure that the system is properly
and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
e 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 Septagee 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
replace ent system:
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.
❑ A suitable replacement area is not amiitable due to setback and/or soil limitations. Barring advances in POWTS technology a
holding tank may be installed as a last resort to replace the failed POWTS.
❑ 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 avaiiitble a holding tank may be installed as
a last resort to replace the failed POWTS.
❑ Mound and at-grade soil absorption systems may be reconstructed in place following mmoval of the biomat at the infiltrative
surface. Reconstructions of such systems must comply with the rules in effect at that time.
<<WARNING>>
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANDIOR INSUFFICIENT OXYGEN. DO NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DE ATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.
ADDITIONAL COMMENTS
POINTS INSTALLER POWTS MAINTAINER
Name Name
Q. Llrti ) 3f
Phone LEij - a %
SEPTAGE SERVICING OPERATOR PUMPER _ LOCAL REGULATORY AUTHORITY
--Name Name S~
Phone Phone ~Jv .20
This document was drafted in compliance with chapter;3PS 383.22(2)(b)(1)(d)&(f) and 383.54(1), (2) & (3), Wisconsin Administrative Code.
~I
FILTER CARTRIDGE INSTRUCTIO NS
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Lank Nrruuulf It" ausk6t er wifueut "to (Okml addltlurtal piprt tooth, the uuitltri
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werkelt'
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ti4M iutrl Hitrlr ,yrtri '
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tfrr, tilhtrluckc lllt'cr Y'h~r LntivrcrL pf'tlram ~vre. w tt
the t/tdat, kt i►rrf jil'udl►ltlf
itt,+ltriactr tlltd su4llre ittut itC 4ttltti yl r
1+kilffylJ Ylfr 1hU tank. _ ~aa
• VNI :"Vt :1lfyLr f~ v ` .ii' y
, .L ri,' L hwr t.rt:
ST. CROIX COUNI"e
SEPTIC TANK MAINTENANCE iGREEMENT
AND
/ OWNERSHIP CERTIFICATION FORM
Owner/Buyer l A C" C2 S _ (57 -7
Mailing Address oZ[7-
Property Address S«~~
(Verification required from Planning & Zoning Department f for new construction.
)
City/State P
_ arcel Identification Nur,zber 4,3,x _le~2s'5- 02o -MZJ
LEGAL DESCRIPTION
Property Location,_)LO 1/4 , tJ 1/4 , Sec. T 3N R W, Town of
Subdivision yn ~~i1Q~ , Lot #
Certified Survey Map # u , Volume Page #
Warranty Deed # Volume. Page #
~
Spec house 05) Lot linen identifiabl yes no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the wasi-e 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 forth, 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.
Vwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
I/we certify that all statements on this form are true to the best of my/our is.aowledge. I/we arn/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Demis Office.
Number of bed
SIGNA APPLICANT(S) DATE
***Any information that is misrepresented may result in the sanitary permit being v.,voked 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. i PERSONAL REPRESENTATIVE'S DEED I
Genevieve Francois, as Personal Representative of the
Estate of Joseph E. Lumphrey a/k/a Joe Lumphrey a/k/a REG'iS T i" 'S~ r
y
~ • ~ ^ ~ X C0..
i
Joseph Edward Lumphrey ("Decedent"), for a valuable
consideration conveys, without warranty, to William C. i
and Lori A. O'Shea , husband and wife, Grantee, the DEC 1 1997
following desc ibed real estate in St. Croix County, State of 11:45 A
%
Wisconsin (hereinafter called the "Property"):
Ra. 1.2 1 of Heeds
REIAINGTON LAW OFFICES
126 South Knowles Ave.
P.O. Box 177
New Richmond, V%'l 54017
Southwest Quarter of Section Twenty-three (23), Township Thirty-one (31) North, Range Seventeen
(17) West.
This is not homestead property.
Exceptions to warranties: municipal and zoning ordinances, easements and restrictions of record and
any lien created by act or omission of Grantee.
Personal Representative by this deed does convey to Grantee all of the estate and interest in the Property
which the Decedent had immediately prior to Decedent's death, and all of the estate and interest in the
Property which the Personal Representative has since acquired.
This deed is given in full satisfaction of that certain land contract between Joseph E. Lumphrey
("Vendor'') and William C. and Lori A. O'Shea ("Purchaser,), husband and wife, dated September 15,
1994 and recorded in Volume 1095 at page 379 as Document No. 521447. Joseph E. Lumphrey passed
away on March 31, 1997.
Dated this _o ?l 4-"" day of November 1997.
(SEAL)
Genevieve Francois; Personal Representative
ACKNOWLEDGMENT
}
STATE OF WISCONSIN
) ss.
ST. CROIX COUNTY )
Personally came before me this dls~ day of
November, 1997 the above named Genevieve
Francois to me known to be the person who
executed foregoing instrument and acknow,led& ihe•,.
same. Fotdith A. Remington
ry Public St. Croix County, WI
My Commission is permanent.
TI-TTS INSTRUMENT WAS DRAFTED BY:
Judith A. Remington
REMINGTON LAW OFFICES
91016706
126 S. Knowles Ave.
P.O. Box 177
New Richmond. W1 54017
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