Loading...
HomeMy WebLinkAbout018-1083-12-000 o~~ 3 d o C I ~ W ~~~ ~ ~ r' I ~ ~ ~ ~ ~ n ~ `~ ~ C7 '~ r ~ 0 O ~ fD y O O ~ ~ _ d ~ ~ ~ ~ p j a > >. y ~ ~ 3 0 4° ~..' ~ ~~~ ~ ~° ~a ~ Vw ° ° ' a in ~ R `1 0 I n c A 3 c a O ~ ~ o I m " ~ ~ o R I ~ I (nZD ~ d ~ as .o f~ N t0 D y d N C C ~ W 0,.~1 I 3 ~ ~ o ~~ N ~o< p c °o°o~ c~rrn N N y 3 .,~+ Q ~• ~ ~ l`\!ll ~, 3 °1 ' 0003 ° ' o ~_ 0 a J i ~ ~ ~ tnmtn N? ~ c ~ cQp p ~ ~ ~6 ~ i o y N 3 - y I °- K I Z ~ ~ o Ali » O' n N N ? p^'" j 7 O 7 a G O O l I °' ~ ... y ~ N ~ I W m~ ~' ~ ~i o n + v ~ '~' a .+ p? I ~~y ~ ;~~ ~ ~$ o. ~~~ I ~ y m a .. I 3 n ~ ~ rn I ~? a~ m ~ Z . `~, 7 ~ ~ G : ? ~ c ! y I ~ Z ~ I Qo ~ W ~ I ~ ~ n 01 7 ~ ~- cc $ tD c I 7 ~' d C ~~ Z a y~ O ~' 01 N 7 N ~ Gy 07 y to A ~ m ~ ~,e I b I ~ A ~ I ~ o~ a i I ~ ~ ~ I o I .0 0 ~"' I o ~ i o :`~ I cb" ~ a ° ~ ~' i o . qP Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division - INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Preferred Builders Hammond Townshi CST BM Elev: Insp. BM Elev: BM Description: h4a ~ " K ~~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ t".~.t~r J //~ t' Dosing /~ ~ `„~.yN~ / Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ / ( 2 5 + ~ Z~ .-._._.. Dosing ' ~ t ~ + 2s t' ~30 Aeration i Holding PUMP/SIPHON INFORMATION Manufacturer '~„ Demand GPM Model Number # 3~ TDH Lift Friction Loss System Head TDH Ft Forcemain Len thD ~ DiaZtr Dist. to well SOIL ABSORPTION SYSTEM ELEVATION DATA (Pc: 5~~~ County: $t. Cf OIX Sanitary Permit No: 408257 0 State Plan ID No: Parcel Tax No: 018-1083-12-000 t 4 ~ z Q, 17. 581 STATION BS HI FS ELEV. Benchmark Z • 'O2- ~C10.~ ~ Alt. BM Bldg. Sewer ~ SUHt Inlet !S- ~ ~~--tea SUHt Outlet Dt Inlet Dt Bottom 19•so S'3,oo~ Header/Man. 8•~a0 ~ ~ •o Dist. Pipe Q - '3 - ~3 ~ ~-~ 43• c s' Bot. System lo•3a 4220 ~ Final Grade ~ p 9`I-sv 9`f - oo ~ St Cover ~-~ 43. ~ f RENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ 3 ~ a3.~s .~, SETBACK SYSTEM TO P DG V~lELL LAKE/STREAM LEACHING Manufacture INFORMATION CHAMBER OR ~ ~ '° Type Of System: ~~ ~ ~ ~ y' ~ ~ t --- UNIT Model Number: ~~ ~ DISTRIBUTION SYSTEM (IS) [~A~.~S l~7'1~rt~.~t Header/Manifold tt Distribution x Hole Size x Hole Spacing Vent to Air Intake Length ~' Dia Leng is Spacing toy f SOIL COVER x Pressure Systems Only zx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed%Trench Edges • Topsoil ~ Yes ~~ No [~ Yes ] No C~~O''--MMENTS: pnclude code ~scr encies, a ons resen etc.) t(~~o~I-nspecti n #1: / V /~-- Ins ection #2: Locatio~'n':"'11'742 6tH Avenue Hammond 3515 (SE 1~ 16 T29N R17~h~~ ills Lot 12 - Parcel No: 16.29.17.584 t+v1G~w-~ S) E,~.~r«- s e ~ 1 c.oti,ai ~. ~ t~l ~ 1.) Alt BM Description S ~ (.,ct.2. , ~~~ ~„ ~t[SS ,~ ,~n„~s~ 2.) Bldg sewer length = '1,l~ a I ~ ~.1 ~ - amount of cove ~~ E~~'~',~' (~r j2 + s~ °"" ~~~~ °' P revision equired? Y s ~ No j I i Use other side for additional mformation. ~~ _~ ~ L_- ___, ~~ Date ~ Ins: p~ ignatu{p /~ h Cert. No. SBD-6710 (R.3/97) I~,y~~J . ~ .. ®t,,/~C. /~. ~o r '1,i~D l s i #~ ,•~ 02 02 04:22p ,Honte Excavating f/; ~ PAGE ~ QF ,~_, iti'~ME o ~ ~--e. i.OT# ,. ~ z LF,C'rAL T)FSC'~?~,L TQjy_C ~ gJ4J ~ „~ / ri T 2q N,$ f -~ •l~~r•~ ., _ i ~ ~ BM I H,.[.EVATIOI~ /QCa . o ~ BM 1 DESCRIPTION /~Fa ~' I ~~ /0 " Do„b (a t lvn -#~rc r -- ~` --+ 19M ~ EI.EVATIOAT -- ~ ' BM 2 ll1~t.~ItIPTION ~ _ .. f ~ S °__ '_.. ~ 6 . SYSTEM ELI;VATION~ 9 L, ~ o Gam c ~ ~Z'. ~ _ n -. ~~ F~ SYSTEM TYPE__~'on u t r~ ,s o ~,.,., t C'c~NTUTTR EI.EVATION_4Z •Sa , 93 • ~', ?Y-.S'd ~ I__ ~ ~~• ~~. ~~ 1 ~ J ~ ~ ~ ~ ~~ J ~ o bo ~ ~~ ~o ~C ~ ~.,~~ ~ k ~ti ~~ ~`~~ ~'~ ~ ~~ b~ ~~ y SICrNt1'I'UK1; [7151 ?96-2519 p. 3 .~ B-3 ~,~ ~~ .~ ~, ~ ~~~ :.- r /~ ~~ `~~~~ J _~ >\ Or~t 02 02 04:22p Bonte Excavating (715) 796-2519 p. 1 Wisconsin Department of Commerce S~1 ~ EVALUATE QN REPORT Wage ~ of 3 Division of Safety and Buildings , rn accordance with Comm 85, ws. Adm. Code County ~^ Attach cornpiete site plan on paper not less than 8 1 i2 x 1 i inches in size. Plan must .J ` inriudg, but not limited tD: vertical and horizontal reference paint {F,7M), drrcction and Parcel I,D. percent slope, state or dimensions, north arrow, and location and distance to nearest road. Pleasrlnt a!! irtforntation. Reviewed by Date Personal informa~ion you Funvide mPy be used fw secondaiv aurooses FPrivacv Law_ s t5 Da J1) r~.,s) Property Owner - PSOPertY l.n~tion f`4 n v Govt. Lot ~ t'/4 ,(ft„ ~ t'(~f S ~ T ~ ' N " R t ~- E (or) ~i Property Owners MaiUng Addrr:ss ~ ~ ty, # Ktaclt # S+,Lbd. tVasr2 oror CSt~;: ' ~ ~fJ ~~ ,s f . Z City State zip Code Phone Number F~City i~ Village [ Town Neasest~oad m nti.rs rt W j /..~ (7/ ) t> - //2 (o m cs ( 9 ~ ® New Construction Use: ® Resldentiall Number of bedrooms 3_ y Code derived design itow rate ~~ GPD Replacement ^ PubiiC or commerdai -Describe: Parent material ~. ~ ~ ~ Flood Plain elevation if applicable _ _ !t/ /~ ft. General corruner,ls S ~,5~~ yt a /t v, ~+~ `/z . 7~'fl ~ee1 e r qZ. L d and recommendaticns: 1 I Boring # ~ BDdn9 t l O:1 r~rrw inri ei~rfa rn~ atov 9~ . ~~ H rla..~ti e.. ~:...:~:.,.. E..~~... .~ 7 / : Soil Appliption Rale i Horizon Depth Dominant Color Redox l)escripiion Texture Structure onsistence Boundary Roots GPDifi= in. Murtseft Qu. Sz. Cont. Color Gr. SZ. Sh. •t?ff#1 'Eff#2 1 o-r1 ~ ~ - S,' j r- G S ~ •S fl Z 11-~ (o f f - s r~ a 'YY'l r' C S ~" ~r ~z~s l6 .s ,y 6 ~ }MS r - ~ t.~ Boring # ^ 8~rng w\ _ / /~~ 1 - .~ ~ y~ rn -.__..___....__ -._.. ~.~ - ... ..,,r... ... ... ~..... ~~ ~.... ... .... Soil Rpptication Rate Horizon Devlh Dominant Color Redox Descriplion Texture Structure C sistence aundary Ront_s C~POttt2 in. Mansell Qu. Sz. Cortt. Color Gr. Sz. Sh. •Eff>Y1 'Elf#2 ~ ~ -tl/ sa r 31Z S~'f -~r' Cry 1 , S , Z r - to r / `- S ~ '~ v-~-~r ~ ,S - ~ S 3 Sa ~ ro ~ 6 -- S L >~ ~i i~~~ C~ _ S 9 trnusnr A~ = tsvus > ~u < 1;tli mgrL ann i 5s >3U ~ ~ 5U mglL ' EHivent #2 = BODS ~ 30 mg,2 and tSS _< 3o rrnyL CST tJame (Please Printt signature l CS-C ntu«zt>Q.~ ~~ir35 ~Q~ s~• sar,~,r~--~~c~~,syc~s ~l.,i .~ ate`Evaluation Conducted Telephone ivumber jg~ 02 02 O4:22p Borate Excavating [7151796-2519 p.2 Properly Chvner Goo ri ~ ~ Patcpl ID # f3orlnr~#^a Doring >.N Pit Ground surface elev. ti. Depth la Jimtting door ~ Z , Pane ~~ Gf I taizal Depth pcminaM Color fiedox S)esaipl5wi Texture Structure C ~ oundary Roots awi ~+pptlcalir. GPQ11t' 1n. MunseJJ t?u. 3z Coral Coror ~• Gr. Sc Sh. .. . •Elfni (it ~i U~tZ 3/ '" ,S•`~•~ in v-n r G S • ~ fI t3orinp q ^ Eiorin,~ ' ^ Pit Ground surface elev. fl. depth talimliin~ factor in. Bail Applir~ticr lioiizon fatrptli' Domfnanl Cu9or Redoot Uesaiprion.,, ,.Texture _5tructure Curlsislence Boundary Roots GPD/itt Jn. Mansell t?u. Sz. Govt. Co1ar Gr, St. Sh. •Elrat •1~ ~' ,~ I .. ~ --- .... ~ --- -L__.1( [S Qtt• Ground surface etov, ft Depth to lirniung (aclo[,,,~ in, r-.---- Norizon Depth Dominant Color Redox Description Texture . SlruUure Collsisience Boundary ...,,1,..,.a ~~,., Roots GPp,ft' 'in. bAunseri Qu. Sr. Coot t:o5or Gr. 5z. 5h. 'Etfgt 'F ~~ ~- ~- . . ~ - ~ ____ j- f ' Ef0uenl #7 = BODt ~ 30 < 220 rrx~/L and T5S >30 < i50 mc}/!. 'Effluent tt2 = (3D115 < 30 m3h,and TS5 < 30 ti~i~ft. _. , The Dcpartir,ent ofCommerce is an erPtal oppot7ttnityservice provider and employer. ifyou need assistance to access ser~icco ; need material in an altcmate format, please contact the departmcrl[ at 608-26E-3 f 5 [ nr TTY 6o8-26q-8777. SDRi110 (1L07/p0) Wisconsin Department of Commerce Division of ~'ety and Buildings SOIL EVALUATION REPORT Page~of 3 to accoraance wrm ~.omm ate, errs. r.un~...uuo County S , Plan must hes in size 8 1/2 x 11 i h . . nc an Attach complete site plan on paper not less t include, but not limited to: vertipl and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 3~D0 ~~ Please print a-i inforrr-ation. /~' 3 - O Z Revi wed by ~ Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). .2~ Property Owner Property Location D ~, Govt. Lot ~ F 1/4 ,(/(,,,) 1/4 S ~(~ T N' R ~ ~- E (or) IU9 o ~ o Property Owners Mailing Address ` Lot # Block # Subd. Name or CS/~# City State Zip Code Phone Number ^ City ^ V illage ®Town Nearest~oad ~ ~unrv~~d I w1 15G/l>/S_1 (?~ ) ~- //Z!o m a 9~ ® New Construction Use: ® Residential I Number of bedrooms 3- y Code derived design flow rate YSO /G ~u GPD ^ Replacement ^ Public or commeraal -Describe: Parent material T • ~ ~ Flood Plain elevation if applipble ft• General comments $ yS~ ~ m e /t v, ~P 9Z • ~ GOctJ e r q~' Z d and recommendations: (-~ ~ 1 0 3 2002 sr. crzo~x couNrY I ~ I Boring # ^ Boring rr.. ~ -~ I t I ~ pit Ground surtace elev. l ~/• J " tt. ueprn [o nmmng racror T ~. ~~r. Soil Application Rate i Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Efi#1 •Eff#2 3 .3(~- L Io ~ 3 b -' L rnbbk t~ r ~ S ~ 5' r1 `~l ~2 ~8 /6 .s . y 6 L 1 wr.s C - r ~ ~ Z 'I2-~/ 42.Zo ~ ~ ~ti Z~`~ 3~~ n 1 Boring # ^ Boring /_ ~i _~,~ [~ pit Ground surtace elev. '73•.~ " tt. vepln to nmrong Tacror v ~> r~r• 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 l o -ly ro r 3/z -- s, "l ~ r c s I v-~ , S . ~ Z I - la r-~/ - S ~ ~~ K v~-~r ~ ~ - ~ S • Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 _< 150 mg/L ' tmuent ~1 = nvus < su mgi~ ana r as ~ ~~ rnyr~ CST Name (Please Print) /Signature /" CST Number Address ~ ~ ,~,~ s / .S ~ -~^t-~~•~.~ W ~..~ y~ S '" Date Evaluation ~~ cted ~~~ p ~y ~ m ~DOd ~-13 1` g -/~- Property Owner ~O n ~~ Parcel ID # Page Z~`ot 3 Boring # ^ Boring . • . ® Pil Ground surface elev. ~~ .,~'d fL Depth to limiting (actor ~ Z In. • ; ~ Soil Appllglion R Horizon Depth Dominant Color Redox Description Texture Structrue Consistence Boundary Roots GPDIII~ In. Munsell (2u. Sz_ Coral Color ~ ~~ -. Gr. Sz Sh. •Effk1 ~ •EffN a Boring # ^ Boring ^ pit Ground surface elev. ft. Depth to limiting factor (n• Soil Application R Horizon Depth Dominant Color Redox Descripdon._ .. .Texture _Strudure Consistence Boundary Roots GPp/ll= In. Munsell Qu. Sz Cont. Color Gr. Sz. Sh. •Eff#1 •Eff# Boring # ^ Boring ^ Plt ' Ground surface elev. ft. Depth to limiting factor in. Soil Application R~ Horizon Depth Dominant Color Redox Description T2xlure . Slrudure Consistence Boundary Roots GPD/ft= in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Ef(N; - • Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent ff2 =GODS < 30 mg/l, and TSS < 30 mg/L ._ , Tile 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. S86t770 (R07I00) .. PAGE ~ OF ,3 ~TAD~ ,F~o n-I-e. LOT# ~ Z. T AL DESCRIPTION S C ~ Nw i4 ,sS ~ G T 24 ,N,R, ~ ~ E(or SCALE:I"= w BM 1 ELEVATION /pC.~ • ~ BM 1 DESCRIPTION /~ ~' ~ ~ n !0 " Dom b (a ~ I w- -Fr e C BM 2 ELEVATION _ BM 2 DESCRIPTION SYSTEM ELEVATION ~j Z• ~ o Guw e r Iz• Zy SYSTEM TYPE o ut .d CONTOUR ELEVATION 9Z •Sa , 93• ~'~ 9y S`d ~ Sec. ~6 -fl °l "': a,.- ~ L^I 'G B-3 ~~~ ..~'~ ~~ ~- I ./ SIGNATURE ,r °'`,/f ~ -- Cr `_' D TE ~ -~ - C1 ~ ~~ ~~~t~~ ~ ~~ i~~ ~N,~~o G'so~s - Sid N Ti9iU~~ ~ooc~ -rv~ /a~~r~m SJ e, l ~. ~~ ~ocfG~ ~Q~ /~L.~ ~~~ ~y`~~~~~~, .~~~~~ ~y~ i~,~-,~ i .-r-,o,v ~, 3 ~~~ ~0~2 cJv1~m C ~~~~s~`~ /~o.g /~ -= ~~ r` nn/~ _ Z = C..~ ,~ = G 3~3~~~ v~~° ~ c' 84 - ~ ~,~ ~`~ ~ `-~ ,g. I Pump runs but delivers only small amount of water. 1. Pump may be air locked. Start and stop several times by plugging and unplugging cord. Check vent hole in pump case for plugging. 2. Pump head may be too high. Pump cannot deliver water over 24' vertical lift. Horizontal distance does not affect pumping, except loss due to friction through discharge pipe. 3. Inlet in pump base may be clogged. Remove pump and clean out openings. 4. Impeller or volute openings may be plugged or partially plugged. Remove pump and clean out. 5. Pump impeller may be partially clogged causing motor to run slow, resulting in motor overload. Clear impeller. Fuse blows or circuit breaker trips when pump starts. 1. Inlet in pump base may be clogged. Remove pump and clean out openings. 2. Impeller or volute openings may be plugged or partially plugged. Remove pump and clean out. 3. Pump impeller may be partially clogged causing motor to run slow, resulting in motor overload. Clear impeller. 4. Fuse size or circuit breaker is too small. 5. Defective motor stator: return to Authorized HYDROMATIC Service Center for verification. Motor runs for short time then stops. Then after short period starts again. Indicates tripping overload caused by symptom shown. 1. Inlet in pump base may be clogged. Remove pump and clean out openings. 2. Impeller or volute openings may be plugged or partially plugged. Remove pump and clean out. 12' 3. Pump impeller may be partially clogged causing motor to run slow, resulting in motor overload. Clear impeller. 4. Defective motor stator: return to Authorized HYDROMATIC Service Center. 9 30 6 zo = a 0 3 10 0 0 Capatity-U.S. G.P.M. 0 10 20 30 40 50 liters/Second 0 1 2 3 4 SHEF30 Performance Curve 12. Use pump submerged for pumping waterlike liquids (temperature to 120° F). CAUTION: Do not pump flammable liquids, strong chemicals or salt water. 13.In applications where the pump may sit idle for months at a time, it is recommended that the pump(s) be cycled every few months to insure the pumping system is working properly when needed. 14. An audible alarm, such as the Hydromatic Q-Alert for high water conditions, should be installed for additional protection against high water conditions. NOTE: The Q Alert alarm panel is for indoor use only. For applications and product information, contact your HYDROMATIC Distributor. Your pump warranty is void... If... power cord has been cut. If... pump has been used to pump mud, cement, tar, abrasives or chemicals. If... pump has been used for pumping of hot water (above 120° F). If... pump has been dismantled by other than authorized HYDROMATIC Service Center or Distributor. Servicing should be performed only by an authorized HYDROMATIC Service Center. WARNING: Always disconnect the pump from power source before handling or making any adjustments. Always wear rubber boots when there is water on the floor and you must unplug the pump or make any adjustments. NOTE: Automatic thermal overload protects the sealed-in- oil motor. Running dry may overheat the motor and activate the overload protector until the unit cools. Pump does not run or just hums. 1. Line circuit breaker may be off, or fuse may be blown or loose. 2. Water level in sump may be too low to activate automatic switch. See installation for proper on/off levels. 3. Pump and/or switch cord plug may not be making contact in receptacle. 4. If pump is using the series (piggyback) cord plug, the two plugs may not be plugged together tightly. 5. Float may be stuck. Be sure float operates freely in basin. 6. If the unit is being operated by the optional float control switch, unplug the pump from the "piggyback" receptacle and plug the pump directly into the power source. If the pump starts each time it is plugged directly into the receptacle and does not start each time when plugged into the piggyback switch with the float raised up to a start position, replace the complete piggyback switch assembly and retest with new assembly. 7. If all symptoms check OK, motor winding may be open; take to Authorized Service Center for check. Pump runs but does not deliver water. 1. Check valve may be installed backwards. Arrow on valve points in direction of flow. 2. Discharge shutoff valve, if used, may be closed. 3. Pump may be air locked. Start and stop several times by plugging and unplugging cord. Check vent hole in pump case for plugging. 4. Pump head may be too high. Pump cannot deliver water over 24' vertical lift. Horizontal distance does not affect pumping, except for friction loss through the pipe. 5. Inlet in pump base may be clogged. Remove pump and clean out openings. 6. Impeller or volute openings may be plugged or partially plugged. Remove pump and clean out. Pump runs and pumps out sump but does not stop. 1. Float is stuck in up position. Be sure float is not hung up and operates freely in basin. 2. Switch contacts may be stuck, replace switch. 3 Sanitary Permit Application - Safety & Buildings Division `~ In accord with Cotnm 83.21, Wis. Adm. Code See reverse side for instructions for completing this application 201 W. Washington Ave. PO Box 7302 ~COiI1Sin personal information you provide may be used for secondary pu oses ~ Madison, WI 53707-7302 • DepartmenN.of Commerce [Privacy Law, s. 15.04(1)(m)J (Submit completed form to county if not state owned.) ' Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size. County ~ ~~" State Sanitary P rmit Number ^ Check if revision to previous application State Plan I. D Number ~ r S q. I. Application Information -Please Print al Information Locatio ~, Property Owner Name - Prope cation /~ ~~''{ ~~ l/.C oC ~ I L ~ !~/~~ ~~-. ~ /4 ~~1/4, S ~~v ~' E (or) Property Owner's Mailing Address t Number ck ber City, State 5~ ~t ~ Zip Code Pho , ,E}~I);.=r-;~;~_ ~~ ~~ Subdivision Name SM umbe~ !~ P ~ ~ , Aso ~ ~ s- o ( r ~ ~s l IL Type of Building: (chec e) ~ t~ `f3 1 or 2 Family Dwelling - No. edrooms : ^ City ^ Village ~~ Public/Commercial (describe use): $ee, A,rG t~ l1 i~a Ui ~. Town o ' ' ^ State-Owned fQ rfg,.La~ ~ = ~~ ~y PfoPo 'T stRoad bI~- o t~ ~X to~~ - Z , 2. l~ I O (o Z ~ Parcel Tax Nu r(s) III. Type of Permit: (Check only one box on 1 A. Check box o e B if applicabl • A) 1. New 2. ^ Replacement 3. Replacement o 4. ddition to System System T Only xisting System $) ermit ber D ^ A Sanitary Permit was previously issued Type of POWT System: (Check all that apply) ~ N d I i d ^ M ^ C l d ' W on-pressur ze n-groun o F er et an o ^ Pressurized In-ground ^ H ing T ing e s ^ At-grade ^ obit Treat t Unit ^ c' ating ~ • S- V. Dispersal/Treatment Area Information: , 1. Design Flow (gpd) 2. Dispersal Area Required 3. Dispers ea Proposed i~ 4. Soil Applicatio Rate (Gals./day/sq. 5. Pe ion R 6. Elevati n 7. Final Grade g Elevation (Min./i h) ~~ l,j7i7- , VII. Tank Capacity in otal # of - anufacturer Pr b S Steel Fiber- Plastic Information Gallons allons Tanks o Con- glass New Existing ~' ~ ~~~' I ' " c strutted Tanks Tanks C ~ ~~7" f!L /000 /ODO / ~C~11~ ^ ^ f1d~~ 1600 O ~ ~ ^ ^ VIII. Responsibility Statement I, the undersigned, assume resp ibility f installati o e POWTS shown on the attached plans. Plum 's Name (print) Plu is Signa a (n tamps): MP/MPRS No. B ess Phone Number a ~ S ~~ ~~/3 ~6z 2l 3s= z.~~sa Plumber's Address (Street, City, Z' d IX. County/Departme se Only A ro ed ^ Disapproved ^ O Gi iti l Ad I Sanitary Permit Fee (Includes Groundwater Surcharge Fee) Date Issued Issuing Agent Signature (No stamps) pp v wner ven a verse n e s ~~ S 7~~0 ~ ~Z ~`~ '' Determination //o~, - X. Cond``it~~ions of Approval /nR^eapsons for Disapproval: ~ . F(,etx{p~~in =~ q ~tNS Nwf.,: ~u~ N~A~'~-{~TG~u~~I~ °W(~.~ J'~(,L6LG~.~~B"t .'I~e o~1.ca~ ~D jdP,u~ ~~ ~i -f`IO-~ ~ tl/51 ~~ Vl~ ~,~.e.'~Yk,u.r (~1 -wk,~,_ ~,,{., ~..t, ct ((s~cr~ ~ r:eaz~{.e. et~{``~l~:is I~~, u ~ ~~ ~ `U`~ ~~ ~ rr~i C ~~ ~ ~e-f~i=~~e-e ~~u~l~ ~ I K--~~`t ~ q~Z~ ga w i c a-~ z o ~a h~it'LG~ ~ $D1I GO-IL -~ Il`.~(~,ttil/L~o~ !l1"t°it `+~ ~Dp (~`}~/I,~lQyw~,~-,Su SB -63 8 (R. 07/0) ~J T.L. Sinz Plumbing Inc. ' E5605''108th Ave. Phone: (715) 235-2644 Ivlenomonie, WI 54751 Fax: ('715) 235-2592 www.tlsinzplumbing.com P~~ ~-e~.ecp ~~~~D~S 'Nc., ~u)/1 Dr ~~w(V''~D 1 l l s ~v b ~- ~,s ~~ P1-~E,ts~- f~-~ ,1 sT c~o~~ C'o~~r~ ~ ~'~ . (moo' i p g>r~ ~u.,~/, n~ ~ ro -~ e 5~ C~rn~'~- (Ino,r,~ (~ B ~ Z ~ t_i~/ D ~ ~ Lo v- S.oJ ~orr~ ~°~. X93, ~~ ~9~ by ~q i ~~ s T.NL( Z- ,2.-7 ~ I vv I - ~.~ u iDb~L~ S r><-rt O rtrt,~ L.1 ~i t Ft •S•3 SKST{~ ~~~, = 4 . ~~a V~ ~`'I as% QvSY ~- a ~,~, ~ S ° r ,Yt"` ~d~,, ~~,w`'w~ ~•2 '.1 ~ U W O ~ ~• 8 211 / ~~~ N ~~GeJLf loo%OD l9~""V t~OiK~o Z-tB~E ll--loo Gr cf-r/~ gwl #L ~' ~~rorcN-F~c ~sl~L so ~3,~ t W`"P ~~ Q4 •~ ~ ~V~S~ ~ 3.~t - ~ ~~~~ ~ ~ DD T.L. Sinz Plumbing Inc. E5609 708th Ave. Phone: (715) 235-2644 R~Ienomonie, WI 54751 Fax: (715) 235-2592 www.tlsinzplumbing.com ~u)/~ or t~W+ ~ v K D 1~ l~~ f i S~ ~~~~~~ Cloo.o~ Z ED g wl ~ ~~/ a .~ S.r,J ~o rh ~ X93, ~) ~ ~ q~ •~ ~Lo~ B~ ~L ~' 3.7 9~ by ~q 44~~ ~vss~ ~ ~~-~ ~~~I ~ IOD T.L. Si Plumbing Inc. E5609 708th .venue Menomonie, 54751 Date: _ l = ~Zy~o2 Phone: (716) 23S-2644 Fax: (? 15) 239-2592 No. of Pages: Z (including cover) To: ?S/ L~Dr ~ ~ ~~~•~-r Attn: /~J +~ Fm~ l ®d{J~ X37 ~I L n Subject: PI(1 ~'(-e~ 1~U + ~ l~ ~'~. 1 ~ ~ ~ 7- ~ ~ ,,,) Message: ~~ ~ ~ / ~~ C,?/~ ~ Signature: Nll1J~/ 11 ~o ~ o fjtt~ L.y ti ~ ~ To ~ ~HIS3If1'IdZHI5'IZ Z85Z5£ZSTLT %v3 00 ~ ~o ZooZ/8Z/Lo .7r~. 38~- ~~~~ T.Z. ~Sina Pl Tnbing Inc. F5609 708c1i A~ Menotnottie, Wl 4751 (" ~ ~oD ~ ~.. , Phone: (71~) 235-2644 Fix: (715) 235-2592 ~~~ti~~•.rlslnr.~lumhin~.c~ im 1 Q 8~ ~t,c,/, r'Y t f ~ ~ Q B~ Z ELEJ n I~CoYt ~ ~~ r O I - _ ••~ •~ ~ 1~ z~ ~~~ ~~~~~r--~..~ 41_4. /~o.d lL~ ~n~,~,-- ~h~c -~e ~~ _ --~ r~ [' ~ ~, WFiI- ~ ~Jlp Fv'd~" r O Zoe ~ ~ZIISAIf1'IdZlsI5'I,L ZBSZSCZ9TLT %E'3 00~vo ZooZ/BZ/Lo wl~onsin Department of Commerce ~ SOIL AND SITE EVALUATION .k Division of Safety and Buildings ~R~~~~h Comm 83.05, Wis. Adm. Code Page 1 of 3 Certified Soil Testing Attach complete site plan on paper not less than 8'/: x 11 inches in size. Plan must COUnt y include, but not limited to: vertical and horizontal reference point (BM), direction and percent slo e scale or dimemsions north arrow and loc arest road ti n n n d di t t St. Croix p , , , . a o an s a ce o e Parcel I, D.# APPLICANT INFORMATION - P ptinf~ti~iformation ,: , . Personal information you provide may be us f s~cQadary purybses (Privacy Law, s. 15.04 (1) (m)). R2VIe B Date T-~a-OL Property Owner .~ ~ , il~. Property Location Bonte, Ron ~ Govt. Lot SE 1/4 NW 1/4 S 16 T 29 N,R 17 W Property Owner's Mailing Addres ~~ ~ Lot # Block # Subd. Name or CSM# 1011 170th St. 12 Pheasant Hills City t State Zi Code..RhiarteNumber ' ' ~ ~ b•' ^ City nVillage ®Town Nearest Road Hammond ., WI. 5 01~ . _?1~-796-524 I~ammond 170Th St. ~,^, New Construction Residential / Nur>'tti®r` bedrooms 3 ^Addition to existing building Use, ~'~ Replacement ` -Public Ar rxirrlrrt3~describe Code Derived daily flow 450 gpd ~ ~ ~ Recommended design loading rate •3 bed, gpd/ftz •4 trench, gpolftZ Absorption area required 1500 bed, ftz 1125 trench, ft= Maximum design loading rate •5 bed, gpolftZ •6 trench, gpolftZ Recommended infiltration surface elevation(s) 24" below contours ft (as referred to site plan benchmar Additional design I site considerations `nstall 2 - 5' x 112.5' shallow trenches along contours for 3 br Parent material till Flood lain elevation, if a licable NA ft S=Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U=Unsuitable for system ® ^ U ®S ^ U ®S ^ U ®S ^ U ^ S ®U ^ S ® U a~~~ uca~.r~ir i can r~cr~R i Boring# K Ground elev 97.9 ft Depth to limiting factor > 90" '~ Ground elev 97.9 ft Depth to limiting factor > 60" Horizon Depth Dominant Color Mottles Texture Structure Consistenc Boundary Roots *l GPDIftz ~ in. Munsell Qu. Sz. Cont. olor Gr. Sz. Sh. ed I , 1 0-12 7.SYR 3/2 tt-~^~h ~~ sl 2 f-m sbk dsh cs if .5 2 12-29 l OYR 4/4 - sl 2 m sbk mfr cs 1 f .5 3 29-32 7.SYR 4/4 ~,V ~ sl 2 m sbk mfr gs if .5 6 4 - 32-54 7.SYR 4/4 0l ~ ~ a` ~ is 1 m sbk mvfr cw 1 f .7 .8 5 54-74 l OYR 4/4 - s 0 sg dl cs - .7 8 6 74-80 SYR 4/4 - sl 2 m sbk mfr gs - .5 .6 7 80-90 SYR 4/4 - sl 0 m mfr - - .3 .4 Remarks: ~`'~'`~'~iiai gi, wu, ~~ uciuw cy, wns~ucraoic gr m noncan ~ 1 0-4 7.SYR 3/1 - sl 2 m gr mvfr cs lm .5 6 2 4-12 7.SYR 3/1 sl 2 f-m sbk mvfr cs if .5 6 3 12-24 7.SYR 4/4 ~ ~ ~q ` sl 2 m sbk mfr gs 1 f .5 6 4 24-33 7.SYR 4/4 - A'° ~~1 sl 2 m sbk dvh cs - .5 6 5 33-60 7.SYR 4/6 - is 0 m dh - - .7 Remarks: ""` """ ~ uas suuic gr, wo, lulu s~ ,- uccasronai ~ r x 4iw si mciusrons CST Name (Please Print) Signature: Telephone No. Henry F. Grote ,~- 715-665-2681 Address ert- ~e o~ estmg D to CST Number Ref # P.O Box 57, Knapp, WI 54749 328/2000 222774 1024 PROPERTY OWNER: Borate, Ron SOIL DESCRIPTION REPORT ~ Page 2 of 3 PARCEL LD.# Certified Sail e'I~sh~ 3 Ground elev 99.6 ft Depth to limiting factor > 60" 4 Ground elev AO ~ G Depth to limiting factor > 60" 5 Ground elev 99.5 ft Depth to limiting factor > 64" Ground elev H i Depth Dominant Color Mottles Texture Structure ~ onsistence Boundary Roots ,+f GPDIftZ eaL or zon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh, Tfe+~h 1 0-3 7.SYR 3/1 - sl 2 m gr mvfr cs lm .5 .6 2 3-9 7.SYR 3/1 - sl 2 f-m sbk mvfr cs lm .5 .6 3 9-24 SYR 4/4 - sl 2 m sbk mfr cw lm .5 .6 4 24-38 SYR 4/4 - is 0 sg ml cs - .7 .8 5 38-60 7.SYR 4/6 - is/s 0 sg dl - - ,7 .8 K@fT18rKS: 1 0-4 7.SYR 3/1 - sl 2 m gr mvfr cs lm .5 .6 2 4-8 7.SYR 3/1 - sl 2 f-m sbk mvfr cs lm .5 .6 3 8-30 7.SYR 4/4 (yam - sl 2 m sbk mfr cw lm .5 .6 4 30-42 7.SYR 4/6 - is 0 sg ml cs - .7 .8 5 4 6 SYR 4/4 - sl 0 m mfr - - .3 .4 ,t KeR1arKS: ..,..~.,.. T .....~ .,,,.,.u..,..~1, ...,...~..,..~ ., ... ~, T ~., ...,..~.,..., ..~ b. ~.,..,.,,, ~.,...., .~ "...,,u~,.,..~ 1 0-3 7.SYR 3/1 - sl 2 m gr mvfr cs lm .5 .6 2 3-8 7.SYR 3/1 - sl 2 f-m sbk mvfr cw lm .5 .6 3 8-24 7.SYR 4/4 - sl 2 m sbk mfr cw lm .5 .6 4 24-50 7.SYR 4/4 - sl 1 m sbk dh cs - .4 .5 5 50-64 7.SYR 5/4 - s 0 sg dl - - .7 .8 KemarKS:...,..~.,.. ~ ..~ ....,.,..,..,..~ ,...... ~,~ .~ ~.,, mob, ...~ Depth to limiting factor w • • 0. ~~OT ~Z~ + ~~4.S4yT ~~~`tS S ~ - 1y w _ t l`o`- Z9 - l'~- w o So bo ~~ ~T't~ z.z.z ~~ S t3K Q,1.~ o h :ror. ~J Sw w.wati, (q3.~) ca ~~~~o~ : ~( lY L'40~ 3W.. t3 . t3.3 O (94.6) 3$3.03 3.L'? b / 13 -~ 1'3 (~t9.r Lq~a.s` '~ t3-4 ~F ~•t 4 Q`,$ Z~'' (~ K ~ q ~.~5 252 (~ n s ,~ 3 U ~ rl' / LD fJLS !~- ~ES1GN PARAMETERS Number of Bedrooms ~ ?j ^ NA, Number of Commerdal Units ^ NA Estimated flow (average) ~p ~NgtS ~~ gal/day Design flow (peak), (Estimated X 1. ) ~~ gal/day Soil Application Rate ` 3 gal/day/ftZ Influent/Effluent Quality Monthly average* Fats, Oil ~ Grease (FOG) s30 mg/L Biochemical Oxygen Demand (BODs) <_220 mg/L Towl Suspended Solids (TSS) s 150 mg/L Pretreated Effluent Quality ' ^ NA Monthly average* * Biochemical Oxygen Demand (BODs) <_30 mg/L Total Suspended Solids (TSS) s30 mg/L Fecal Coliform (geometric mean) <_10' cfu/100m1 Maximum Effluent Particle Size ~ inch diameter MAINTENANCE SCHEDULE S.ervlce Event Inspect condition of tank(s) Pump out contents of tank(s) Inspect dispersal cell(s) Clean effluent filter Inspect pump, pump controls az.alarm Flush laterals and pressure test Other: At least once every SYSTEM SPECIFICATIONS Septic Tank Capacity Db0 al ^ N, Septic Tank Manufacturer ~j~rY? ^ N, Effluent Filter Manufacturer ^ N, Effluent Filter Model J¢- /DD ^ N' Pump Tank Capacity (~.D gal ^ N, Pump Tank Manufacturer ~wjj' ^ N, Pump Manufacturer D/DN~if~L ^ N. Pump Model !~E¢' +Sp ^ N. Pretreatment Unit ^ N. ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: Manufacturer Dispersal Cell(s) ~In-ground (gravity) ^ In-ground (pressurized) ^ At-grade ^ Mound ^ Drip-line ^ Other: * Values ryplcal for domestJc (non-commercial) wastewater and sep tank effluent. * * Values typical (or pretreated wastewater. Service Frequency ^ months 1~"year(s) (Maximum 3 yrs. ) When combined sludge and scum equals one-third (Ys) of tank volume At least once every 3 ^ months J~year(s) (Maximum 3 yrs. ) At least once every At least once every At least once every ~At least once every At least once every ^ months ~year(s} ^ months ,year(s) ^ NA ^ months ^ year(s) ~'NA ^ months ^ year(s) ~''NA ^ months ^ year(s) ,~I' NA MAINTENANCE INSTRIICTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Ma: Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspecti< must include a visual irupection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure 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 or 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 (ys) or more of the tank volume, the entire contenu of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with ch. NR 1 13, Wiscor Adminisvative Code. The servicing of effluent filters, ervals of 12rmonths ordlessOsh I beoperformed by a certified POWTS Main~tainerany other maintenance or monitoring at int A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START V P AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or ocher chemi chat may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the come nr ~ha ranlr(s'E ramovPd ~,y z ~ent~ue ServidnR operator prior to use. Pa~c _of.,i System start up shall not occur when loll condltJons are (roan ac the Inflltratlve surface. During•powcr outages pump tanks may fll1 above nomul hlghwata~ levels. When power is restored the excess wascewater will be discharged co the dispersal cell(s) In one large dose, overloadlrtg the cell(s) and may result Ire the backup or wrfaee discharge of •effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servking Operator prior to restoring power co the effluent pump or contact a Plumber or POWTS Maintainer to ass4st In manually operatlr~ the pump controls cu restore ncrmal levels w•Ithln the pump tank. • Do not drive or park vehicles over unks and dispersal cells, Do not drive or park over, or otherwise dlsWlb or compact, the area within 1 S feet down slope of any mound or at•gl'ade soil absolpckn Brea. Reduction or ellminaclon of the followings from the wastewitor stream may Improve the performance and prolong the life of the POWTS: antlblocla; baby wipes; cigarette butts; condoms; cottocs swabs; degreasers; dental Aoss; diapers; dlslnfectanu; fat; foundation drain tsump pump) water; fnllt and vegetable peelingLs; gasoline; greaser herbiddes; rncat straps; medications; oil; wlntlnR t:roducts: oeslicldes; sanitary napkins: tampons; and water sofuner brine. ABANDONEMENT shall be taken to Insure that the system is When the POWTS I•ails xnd/or Is pem~anently taken out of service the followingz sups proprrly and safely abandoned In compliance with ch. Comm 83.33, Wisconsin Administradve Coda • All piping to unks and plu shat! ba disconnected and the abandoned pipe openingzs sealed. • The contents of cell tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. AhPr pumping, cell csnks and pits shall be cxcavaced and removed or their covers removed an4 the void space filled with soil, gravel or another Inert solid material. CONTINGENCY PLAN If the POWTS falls anti cannot be repaired the following measures have been, or must be uken, W provide a code compliant replacement system: O A salable replacement area has been evaluated and may be utl(ixed !of the location of a replaeemertt soil 3bsorpdon system. The replacement area should be protected from dlswrbance and compaction and should real be Infrinlted upon Dy required setbacks from exl:dregs and proposed swcw+'e, lot fines and wells. Failure to protect the replacenxnt area will result In the need (or a new Boll and site evaluation to esubllsh ~ suitable replacement area. Replacement systems rnusc comply with the rules In efTect at that time. O A saleable r.eplacemcnt area is not avaUable due W setback andlor soil IimlatlOris. 6arringt advances In POWTS technology a holding tank may be lnstaAed u a last resort to replay the failed POWTS. D The sltr lus not bccn evaluaced to Identify a suttabk rep(xemait area. Upon failure of the POWTS a loll and site evaluation must be performed w locate a suitable rcplacel~ent area. if no replacement xea Is available a holding tank may be Instilled as a Ixsc resort to replace the failed POWTS. O Mound and at•9Tade soil absorption systems may be reconswctedwgth Ithc rukso Inl effe tit athat ttmeebiomat at the Inflluative surface. Reconswalons o(such ryscems rtwsi.eomply < <WARNING> > SEPTIC, PUMP AND OTKER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT DEATH MAY RESOUIl'~NRESCUE OF A~P6RSON (FROM TKE INTER OR OFAA 7 NK MA 6E DIFFICULT OR E5. IMpntClRl i. Al)D1710NAL COMMENTS cntarrs INSTALLER v Name J G. S~.JZ P~~a~,~. ~~~ Phone ~[S 2~S- 21•'f SEPTAGE SERVICING OPERATOR (PUMPER Name Phnn~ POWTS MAINTAINER Name !•[,. ~iNZ ~Lvwt ~i~" INt- Phone ?~ f 23.f- 2.~ ~ tACAI RlrGULATORY AUTHORITY l~ncy ~T• ~r~ .~ vw Z.ryti h n - 3 t -' ~ 1930 Document St. Croix County Occupancy Aiffrdavif Preferred Builders Inc. Name ~- {Owner} Typed or printed being duly swum ,states,. under oath, that: I. He/she is the owner/part owztez of the following parcel of land located in St. Croix Co~mty, Wisconsint, recorded in Voltuiue ~_ page ~^ Document Number(a~~st Czoix County )1`egister of Deeds Office: 684662 REGISTER OF DEEDS ST. CROIX CO. ~ yI RECEIVED FOR RECORD 07-22-2002 10:35 AM ZONING AFFIDAVIT EXE1~T # REC FEE: 11.00 TRANS FEE: COPY FEE: 2.00 CERT COPY FEE: PAGES: 1 A parcel of land located in thes~'/, of ~~'/. of S lion j ip Npame and Roturn Adcke9s T_~ N - It ~_ W, Town of St Czoix T I~~a~4 ~ rdlE;S TN~- County, Wiscaosiim, being duly descrt'bed as follows (include lot no. and t 33S ~ RD P. subdivision/CSM oz detailed legal description): ~~ ~ S ~ P,l-KG N 5~ o Y ~~`~. ~ ~ ~T ~~~01~SA~n"~ i"#'E I! cJ,r-.jcx.ppr~ V ~SiOri ~ ~g '~~~ .- ~ ~ ~,~~j Parcel IdenWication Number (PIN} As owner of the above described props , I acknowledge that the septic system serving this residence is sized far a ,~ bedroom home, or a design flow of gpd. The design flow is calculated by assuming 150 gpd for 2 individuals per bedroom. There are currently ~, occupants living in this residence; ~ occupants are pemtitted based on the design Bow. Therefore the septic system serving this residence is code compliant. However, understand that if there are intentions to exceed the number of permitted occupants, the system will need to be modified to accomodate any increased wastewater flows and/or contaminant loads. I also acknowledge that I will make this information available to any futurTe parties interested in purchasing this property. Dated this ~ 7~>, day of ~ . -~ J ~ y , O`"v~ . * ~~ v ~~~ _LT~ w AUTWENTICATION ACKNOWLEDGMENT Signature(9} STATE OF 1aH8BANStl1 } /)jam , Q0!~7~~~,o_~~'. )ss. authpnitcsted this day of $l~~Couniy. ) Personally came before me this ~ day of ~~~, the above named # ~ _ ~ TITLE: MEMBER STATE BAR OF WISCONSIN ' (If not, to me _ (s) eCfon~g authorized by § 706.08, Wls. Slats.) Instrument a a the ~~tnne5ota THIS INSTRUMENT WAS f)RAFTE~ BY h1y Commission Expires pan. 31, 2005 Preferred Builders Inc. ~' 1325 County Rd D St.Paul, Mn 55109 T~~ ~ w Notary Public, State tMlaoowsht (Signatures may t~ authenticated ar acknowledged. Both an: not My Commission !s rmanent. If not, state axe on date: necessary.) Date: ~ 3/, ADO 6 "THIS PAGE IS PART OF THIS t_EGAL DbCUt~IENT - DO NOT REMOVE" ~i30 Thts infarmatlan must ba completed by aubmitter. doggmmenf,~dle. name d, retum_~ddn:ss. and P!N (tf requ/nt+d)_ ether intbrmation such as the grentlng deusas, !saga/ description, etc. maybe pieced on this firs! page of the document or may ba placed on additional pages of the document. ~; Use of this cover Page adds one page to your document and S2 00 to the n:cadina fee Wisconsin Statutes, 69 617. OwnerBuyer Mailing Address P~ ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT . AND OWNERSHII' CERTIFICATION FORM i 3 a S C-t y Qo ~~ C~i^~ Property Address ~ .1 (Verification required from Planning Department for new ~ N S'~Jo~ ~~ S~~ 1S City/State ~c~Mrr`c~ s~Z~, ~~ Pazcel Identification Number ©` (~ ~" ~~~3 ~ ~ ©~ -~°' LEGAL DESCRIPTION ~/ Property Location ~ '/., / ' ~ '/., Sec. ~ T ~ N-~ ~ W, Subdivision ~- ~~t Town of ~YY~i^~ Lot # 1 ~ Certified Survey Map # (~ ~ a ~~ ~ ,Volume .Page # Warranty Deed # ~ ~ ~ ~ ~ ~ ,Volume _~ .Page # Spec house ^ yes ~ no Lot lines identifiable 1~ yes ^ no SYSTEM MAINTENANCE Improper use and maintenanceof 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mastCrplumber, journeymanplumber, restrictedplumber or a licensedpumperverifying that (1) the on-site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than I/3 full of sludge. Uwe, 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 Zoning Office within 30 da of the a expiratio date. GNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form arc true to the best of my (our) hiowledge. I (we) am (are) the owner(s) of the ropcrty desc 'be above, b virtue of a warranty deed recorded in Register of Deeds Office. ~~~ ,~ / I O IGNA OF APPLIC DATE *****s ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. *« Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed 06/21/02 FRI 07:57 FA% 715 386 4687 , Dpcument Number STATE BAR OF WISCONSIN FARM 2 - 1999 WA~t]Et..4.NTY DEED 'T'his Deed, made between William C. Jahner and Jennifer A. Jahner; husband and wife, Grantor, and Preferred Builders, Inc. Grantee~ Grantor, for a valuable consideration, conveys to Grantee the following described real estate ~in St. Croix County, Stare of Wisconsin (ifmore space is needed, please attach addendum): Lot )2, tat of Pheasant I-sills in the Town of Hammond, St. Croix ~`ounry, Wilco in_ Recording Arcs 0002 s~i2131 R~~zs ~ of a~ros ST. CROIR CO. , YI RfiC$IVED FUR RECORD 86-19-2002 12:35 P~} REC FEE: 11.80 TRAH$ FfiE: 96.00 COPY FEE: CERT COPX FEE: . PAGES: 1 Name and Retunr~d~ T~~. ~~G_ SUlTi; ~0 Eller 1VC?; ~~ r -.. ~. oil-los3-lz-ooo _ Parcel fdentificaiionNumMcr "':~ ~ ~ " " This is not ~._-__ _.__ - hr~,.•.-,~;, _ ..]pc., w Oft (is notj I lrxceptioac to warranties: Easements, restrict+ons ~~:a riph~~ _,:F,N~,v ~frecord, ifany_ 4 y ~ r1JTHENTICATION f pn:..:~r,°`s) __Wxlxam C. Jahner r '. ;,"firZt~lc,P ~Y'~h1S .+-•-.. ~p~' Wye i r :.'dal y' s, • .,~a#~ri1' ~ _ _ er ~u.'i3t~ -- -.~w. _ _ _. .. __ ._ ,...`._- hTi_l 1. "~ ,A Jahner . ...,. ~~ _ _ _ -- ---- -R- ; ACICNt`f',~.E ~~MEI'a7 ST~+ ;'lu tJF~i'~'1N3~ ~ ) 1 -.. ~_ _ ~,~. ~17~N~ raN County-) ~ -`"- - - Pcrs.onally carne i~c~foi'': me this f ~ _ d:,y of _ _-___ .Ia~ne _ _ Z00: the abo.•,. _ amt.d Jes.~ifer A. Jahii?r, , (If not;'" •12/2fi/p4 to me known to be the person(s) who executed the foregoing ~` ~ --- instr eat and now cd the amc. authorized by § 706.Q6, Wis_ Stats.) THIS INSTRUMENT WAS DRAFTED BY Attorney t;Cristinu Ogland N ary Pubt , gludson, WI 54Q16 ___ y Comtni i ariYllA~1F t'Lt,RE)fiBAO~ ion date: (5ignatun:s may be authenticated or acknowledged-Both arc not accessary.) a -)r ` Names of persons signing in any capacity must be typed or printed below their signature. ~ _ Fondsa Lee wl STATtr SAIi t7F WISCONSIN ~~`~~ WARRANTY DEED FORM No.2-1999 REGISTER OF DEEDS 1913P 169 ~ OCA TED i N THE 'NE I i4 OF THE NW i ~4, THE ~E i i4 OF THE NW I i4 AND PART OF 7HE . ~. rSW 1•~4 OF THE NW I i4, AND PART OF THE ~ o NU'~ ! i4 OF THE NW 1 i4. ALL l N SE ND Oi'J , T. 29N. , R. ! 7W. , TOWN OF HAMN'0 , 5 T. CRO 1 X COUNTY, W 1 SCONS IN J E +oorr. AVENUE - - -- j j _~ ~ TNtS w-.c i ~•. I -------..L.._.._.. __ ( I j ~ -c A T s.-.- ~ it •+r i ~ LOT 2 3 0 ---_.._.. ~ .__._.. ( x : ~ (' ~ ' 3 "~ ti ~ ~a/~ ~.. '~' . ( ( ( ~'"- ~ LOT 1 7 --~ ~_'-. _.~ , +r, • ~,~ m+ ~aAr+ow tKE rc.+ N J ~t C T ~ LYI 1 ~. I. IM.. R. ~ >r.. Tpv Q iMe.~.~ N, _. _,_ _ UTII f TY EASEMENTS w HO POLE ~'R euR~fo cAetES ARE to 8E P.l.CED suc+. rr+Ar *•~F AiONGt~Y~ OT~NE ~SSiREETNLIM£RVEr srAxE. Cy1 a9sta.~Cr v+slGr e tnE ptSfURBANCF OF A SURVEr SrAxE tfr ANr.:~vE t3 A vt(kar~~ ~' SFCI tCN lJ6. JF Qi w+5C~131N S1ATt'TES. UT's t TY £oaf~~F`Jr~l~~f5' Y .~ sET fORTH ARE I'OR r,rE USE of oU9CrC BOOZES AhD HAVING THE R t GM r i0 SERVE i0 ARf A. ~~ LOT 1 5 v SHEET ~ "-- ~ ` _ ~ --~ Q _' ~ ~,. SEE b 2 `-` - tt ti v ^s LEG£kD f F0~'ND t• IRON PIPE O SFr 2•xJ0• tRCN PrPC wE+G~irG J. 6y LAS. PER IINE.IR FJOT NOr E: SEf +•X24' IRON PIPE rf+~+~+ !. +! 195. °ER C (NEAR Poor AT Al: ~ OTnER LOT CpRNFRS t rrP 1 -- --- . urrt. +rr EASEMErrT 1 • SE TgACKS ,p ~a~vcwAr ~ocAr+cws QC ~~gc ~~ ~~~.~ x~srs tit ,~°' ~ ..,? c ,~~ ~.a..5`~`~ ~st~s ot~^''cr:~/ +V~ C.~rwW 7~'~ ~~~~ Y~p,~.Q~ n t r ~~ .is ~a.~ ~' ~• . 4.S'' .- .. .. 28 t : 00 ...., .. .. •~ ~ • _. jJO. W~ • ' . 1 ,;:~~.-.' '''~ ~ f .d ~ N 1 !~ ~ t" •i c~,, i -• ` \ • ~ ` •c ti t \' N / ~ r 1` -+ a 'OC fi ~L~' ~ . ~ 1-~! o. ,y Ott ~= ;• W tt~ V : • F" 01 ~ . '~i~' • yl, ~A . 1 of \ ~ , ~ • Z 1~ ~ .. M• yj W ~ i , ~ t `; .~ •,...+:` r ~ ,t ^~• •'~jti .fit ~. O Of~..~ .Sy.. ~,.r,' • ~ ~ • i ..1` ...~ ~. 't t ',y,~.;; ,.. ~ - :y. `lb.•' o: t _ ~ O ={ • .i: '~ :;tea'. ~~ r ~ `,,,,~~..~ ~ 36. ~/ ~ ~`!R0 ~ 4~1- {~ 1 Q~ a l7 C1 ~ ~ ~ 33•f. 3S. ~'-. ` : ;'ter'-•„~~,= , • /:, ~,, ~ •~co ~ , . •a+z. ~ es J N W p ~ _ •l... r1 O a ~ . • © ~. ~ .~ a t ~L .. ~~ ))) ~ ~o .::~t•:.. _ ~, _ ~ 33 • \ Q ~•~. :~~ = ~ ~ ~- H~ ~~ W a Q H Z Q N W H a 0 0 W a J W Z W a W Z ~ o ~~ ~ a o ~~ 0 a ~ w a ~ ~ A ~m `o E c t ~ m Q N ;mo ~ o~~ C ~ o~ ~ yyg . € o w ~ ~ > q = ~ ,~ h Z $~a ~ a m av $ ~ ~ ci c~ ~ O ~ x c~iz ~a v € v ~ ~.r o E ~ ~ ~ ~ m ~ c N ~ ~ _ c '> Z + m Z ~ r L° p w q ~ .r z o N q ~ pp q ~~ g g C T C ~ ~ C 01 ~ A ~ ~Cf ~3 • Nf h M W G ~ ~~rnq/Oa C i r ~ w ~m~~ ~ a~ . $~ ~ ~ m .~ ~ L~,~w°€ w a o a ~ c -° w~~€ ~ ~ m w ~ ~° ~ ~ a s ~ ~ ~ Q$~ ~€ o~ ~~ ~ ~ p w ~ ~maoa ~~~~~ a ~ ~ ~ v ~ .~+ N S O 2 W Z O ~' 0 N V O Z _~ O N a Q 0 W W Z w J w a w W a W z Q J Z H to 0 Z _~ U ~~~ I.JLL_ 1~ V J Z O U c~ Z 0 J W z Z O Q O W 2 H O J m ~_ 0 a ~, 0 a