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HomeMy WebLinkAbout018-1083-19-000~f00neinO°~CO11f1efOe PRIVATE SEWAGE SYSTEM 8efefy and fjtrlldirlps 0lvisbn INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Psnoonel NMortna8on you pr+ovlce maybe used for secondary prxposes [Privacy I.sw. s.15.04 (lxm)j. ~o'~ ~0. mrt H r s Name: Crty Vi age Town o itz erald John Hammond Township M E .; Insp. 8M E v.: 8M Description: b0 ~ / CrsC ow~~`' L TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic 1000 ~6~ Oosing ut. ~~~~ t r Aeration . Holding TANK SETBACK INFORMATION TANK TO P/L WELL BjAG. vent to Airlntake ROAD Septic ~ $D 1 1 I~ D I --~ NA Aeration NA Holding r PUMig! SIPHON INFORMATION 4,~ Manufacturer ~ k•~`~ ma Model Number S tt~ F '~~ ,~, 32 g TOH lift ~a•ZO Fraction 1-~ S em ~., ~Ft Forcemain Length-`' fl Dia. Z II Dist. To Well SOIL ABSORPTION SYSTEM ~a\ _ 0 I_ f_ -1-„~.. ounty: St. Croix Sanitary Permit No.: 384194 State n 10 No.: Parce Tax No.: 018-1083-19-000 8E0 /TRENCH Width , length '~~ N . Trenches ,PIT No.Of Pits Inside Dia. liquid Depth 3 t •~ ~ I SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREA LEACHIN CHA adurer INFORMATION ype ~' f ~.r ~' 2+ ' c 1 ~~ t ~ 130 -~ NIT Num er: System: pwt r ,> DISTRIBUTION SYSTEM / He er/Mani Distribution Pipes ~ x Hole Size x Hole Spacing Vent To Air Intake length `~ ~r`S Dia. engt~''~--66a. Spaang T - i ~ r' ~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched I Bed /Trench Center ~ Bed /Trench Edges Topsoil ^ Yes Q No Q Yes Q No COMMENTS: (Include code discrepancies, persons present. etc.) Inspection #1: ~/ IS/a I Inspection #2: Location: 1739 97th Avenue, Hammond, WI 54015 (NE 1/4 NW 1/416 T29N R17W) -162917591 Pheasant~Hills -Lot 19 „n S~ { .,,Q~ 1.) Alt BM Description = `t'~~s -~ - ~' CS.S. 2.) Bldg sewer length = q 0 ~, -amount of cover = ~Z ~ - Plan revision required? ^ Yes '~[ No I Use other side for additional information. ~ ° ° l ~ SBO.6710 (R.3Ig7) Date Inspector's Signature ert. No. . ELEVATION DATA ~' ~ -t'3~ ~- Sanftsxy Permit A; Yn a°eord with Comm 83.21, ' See r aide for intttruetions for tx Dapunno~nt at'~Corriaiareu Peraonril inlormetion You provide may be • (Privacy Lew, s. 15.0 ~~ Code -t_° ~Typc of Bnildingt (t:Leck onto) ~ errs 1 or a PamiTy Awellirs8 - No, of Bedrooms ; ~aag ~ I'abliclCotnmeraiai (ds8eribevae)` O Stato-Owned l ~~ ~~ x 9~' ~~~.~ ~ TTY. '1' o of ermit; Chock oxxl ono box on line A. Check box ~ A,) 1. New 2. Rt:plsaernglt Replactment o S stern 3 ttem Tank O»1 B) i P 'twea issued ~ Type oI 1'OWT System: (Cluck ell that apply) ~ Non-presaurit:Zd In-ground D Mound O Pressurized In-ground ~ Holding Tank Q At-~rede ^ Aerobic Trent / RsqulrW Prppesed Rate ~ S ~' / g VII. 'Y'ank Capaciry in 'T'otal * pf Infnrmatiori Cra llana Gallons Tanks New Existing T a n ks Tanks ,vv ~~ ~ j 1 ~'I.AA I~ `soil i'~ B n zip /// ~~~ IX. County/Depitrtment Use Qnly ^ Disapproved Sanitary Permit Fee (Isfcludei Groundwater Dax Tasacd 'ag gent S' flue {NIo camps) pprovod D Owner C3ivon Initial Adverse s Fae) ~ ~ c Dea~trnj on X, C~a~nditiotts of A~ roust rlR~cn~so~ _fq~,plyapp~r_oya~ ~ 12 u i j~ s ~-.~~ ~~. -~ SET?-6398 R L ~at~ ~ t,~ra.~~~-a~wet~ an ~ w~ t 00 [~j ZHI5 QQO.L a.-~. .LNIdAIdO'Id~Q ~I.L11f10~ NlldIIQ 6601 ZSZ SiL T XV3 SS ~ i'i S[1L OOOZ/l~T/ii ,-~:~. ~`~~ ,cater" f a ` Adm. Colo ~tingF,tiiis app ~br attcon~i ~1~. _ . L OA p~Ot 7A aa! tc pt~eVjOUr *: ~ fl ~, f ~nq s r,6,~~c~.~ ~~ 201 W. weahirtg[on Ave. PO Box 9302 Madison, WI 53707-7302 compdeccd form to couary if »oc UIi t/4~ l/d, S tl ~ TO' / ,N. Ii B (a) Y..ot um ~ I~ ~bdiviaion Name or CSM a cr . ~~ i ~s o ry ~-- owq of Ncereat Road / ~© 5 T arc o ~/ ~ .~- _ p~ ---i.~g ' 7 ~ ... 6. ddition to Ci ~'Cuusr~r'lT '6' "~' ' O Sand Filter ^ Consanctcd Wetland , O Sittple Pena O Drip Litu O ReeiroulaliA, O Other. . ercot on to stem evano>1 to a ~.) (Min./i»ait) I'levadoa ~ Prefab Sitc Steel Ftber- Ylasdc Con- Con- glass crcte strutted ~~ O V \ i ~, N o z e v ~' 0 ~` ~o s ~~ ~~ ~ ~ ~ ~ c ~~ G n ,~. S Q/1 s ~~ c 0 N~ ~~~ 1 ~'O Z R\ 4' ~ ~ ~ ~_ X -~ s ,~~ N ~ a g~ ~~ ~ ~ ~~ ~~ r~ G ~ ~ ~~ ~~ ~ ~ ~~ ~ ~ ~~ ~ ~~ ~c, -~ V ~~ 1 v o ~ ~1 G 1 A O V \ ~'; O r~ v ) 1^ V` ~ ^ `f./ ~ 1~ \ (~ V ~ Z ~., ~ NC ~ s ~ -a _ ~ } ~ ~ n ~ ~ Z\ °~ ~ ~ ~,\ ~ 8 ~ o u ~ A. x , L, ~~ ~ ~~ W a r~ ° ~ r G -b ~ n ~ ~ ~ ~ ~ ~ ~ ~ O ~ O ~ O ~! yy `^\` v t l` `~ ` ~/ ~ `\{ V t ~ ~ ~, ~~_~~ o`~ a ~~ yl ~ ~ ~ ~ ~ ~ ~ ~ G Q~' `~ ~_ _ ~. ~_ ~ ~ ~. 3~ ~ ~• . ~~ ~ ~~ ~ ~ ~ ~~ ~~ ~~ ~ ~ wiaronsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 ,~ ' Division of Safety and Buildings ¢0rd with Comm 83.05, Wis. Adm. Code `~ ,ORIGIN'QI.. Certified Soil Testing Attach complete site plan on paper not less than 8'/: x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal refs"ranee po`?rt{$M), direction and St. CrO1X percent slope, scale or dimemsions, north arroCv,`arld location end dunce to nearest road. Parcel LD.# APPLICANT INFORMATION - P/ease pant alh•informatio~. Personal information you provide may be used for secondary purposes (P~r vacy Lavv §. X5.04 (1) (m)). Reviewed By Date Property Owner ,. operty Location Bonte, Ron ~ E ~~ ~E.i G vt. Lot SE 1/4 NW 1/4 S 16 T 29 N R t7 W ~~ ~' Property Owner's Mailing Address - - ` .l~t # Block # Subd. Name or CSM# 1011 170th St. " "''` ' ~ 19 Pheasant Hills City State Zi Code PhoneNumber ` r' 15 W 50 5 7 5 40 `` ~ City fT- Village ®Town Nearest Road d 170TH ST Hammond I - 2 ; 1 7 96- . ammon ~ Residential % Nu`mtier of bedrooms 3 ^Addition to existing building New Construction Use: Replacement ~ Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate •4 bed, gpd/ft2 •5 trench, gpolft2 Absorption area required 1125 bed, ft2 900 trench, ft2 Maximum design loading rate •5 bed, gpolft2 •6 trench, gpd/ftZ Recommended infiltration surface elevation(s) 24" below contours ft (as referred to site plan benchmar install 2 - 5' x 90' shallow trenches on contours for 3 br Additional design /site considerations Parent material tits 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 Boring# 2~ ~:; Ground elev 112.5 ft Depth to limiting factor > 74" "' Ground elev 109.2 ft Depth to limiting factor > 62" Ho i n Depth Dominant Color Mottles T t Structure Consistenc Bounda Roots GPD/ft2 r zo in. Munsell Qu. Sz. Cont. Color ex ure Gr. Sz. Sh. ry Bed ~ Trench 1 0-12 7.SYR 2.5/1 - sl 2 f-m sbk dsh cs If .5 .6 2 12-24 lOYR 4!4 - sl 2 m sbk mfr gs if .5 .6 3 24-28 •--- 7.SYR 4/4 - sl 2 m sbk mfr cw if .5 .6 4 28-53 7.SYR 4/4 - s/mcos 0 sg dl cs - .7 .8 5 53-70 l OYR 4/4 - s 0 sg dl cs - .7 .8 6 70-74 SYR 4/4 ~ -SrJ ~ sl 0 m dh - - .3 .4 zy bo Remarks: 1 0-3 7.SYR 3/1 - sl 2 m gr mvfr cs if .5 .6 2 3-9 7.SYR 3/1 - sl 2 f sbk mvfr cs if .5 .6 3 9-26 7.SYR 4/4 - sl 1 m sbk mfr cw if .4 .5 4 26-46 7.SYR 414 - mcos 0 sg dl cs - .7 .8 5 46-60 l OYR 6/4 - s 0 sg dl as - .7 .8 6 60-62 SYR 4/4 - sl 0 m dh - - .3 .4 Remarks: consraeraore gr at coo m nonzon 4 CST Name (Please Print) Signature: Henry F. Grote P.O Box 57, Knapp, WI 54749 ~~16/2000 "Telephone No. 715-665-2681 CST Number 222774 Ref # 1064 PROPERTY OWNER: Bonte, Ron PARCEL I.D.# SOIL DESCRIPTION REPORT ~ Page 2 of 3 Certified Soil eT Stine Horizon Depth Dominant Color Mottles Texture Structure ' " ' onsistence -' Boundary Roots GPD/ii~~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench ~ 1 0-3 7.SYR 3/1 - sl 2 m gr mvfr cs if .S .6 2 3-8 7.SYR 3/1 - sl 2 f sbk mvfr cs I f .5 .6 Ground elev 3 8-22 7.SYR 4/3 - sl 2 f sbk mvfr gs if .S .6 111.4 ft 4 22-38 7.SYR 4/4 - sl l m sbk mfr cw if .4 .S Depth to S 38-60 7.SYR 4/4 - mco~.. 0 sg dl cs - .7 .8 limiting fac' 72" 6 60-72 l OYR 6/4 0 ; ~ ~ s 0 sg dl - - .7 .8 4 Ground elev ~~ncu Depth to limiting factor > 62' Remarks: ~-~" 1 0-S 7.SYR 3/2 - sl 2 m gr mvfr cs if .S .6 2 5-14 7.SYR 4/3 - sl 2 f sbk mvfr gs 1 f .S .6 3 14-36 r--- 7.SYR4/4 - sl lmsbk mfr cw if .4 .S 4 36-62 7.SYR 4/4 - lmcos 0 sg dl - - .7 .8 2~ Kemancs: 8. w .,.,,, ..~Y...,.u.., ............. 5 Ground elev 109.6 ft Depth to limiting factor > 70" 1 0-4 7.SYR 3/1 - sl 2 m gr mvfr cs if .S .6 2 4-8 7.SYR 3/1 - sl 2 f sbk mvfr cs If .S .6 3 8-15 7,SYR4/3 - sl 2fsbk mvfr cs if .S .6 4 1S-SO 7.SYR4/4 - sl 1 msbk mfr cw if .4 .S 5 50-60 7.SYR 4/4 - mcos 0 sg dl cw - .7 .8 6 60-70 lOYR 4/4 - lfs 0 sg d] - - .S .6 rcemancs:.. ............ ..............~..,..~ .., .._ .,,T .. ~.,, ~b, ..., ~ ., .~ '' 3 ~6 ~, , ~ ~ ~ s ? ~ ~ ~ ~ ~~ 1 .+ 3 , V ~ ~, ,.1- o ~ ~!! ° ~ ~ ~ ~ n h ~i o ~ J ('~, ~ 1 ar ~ ~ o M~~ Y ~ -IF J N, ~Q~I ~, ~ ~I d~ ~ 1 0 ~~ ~ 0 0, ~ ..~ M ~ ~ ~. v ~ ~~_~ ~ O J n f 4 ~ I ~ v~ ~~ °~ ~ ~ ~~ t !~ s ,- 3 3 ~ z N -~ :.~ s ® ,• o ~ a ~~~ a ~~ ~ ~~ ~ (~1 ~ o r---~• _~ ~ ~ :., Z ~-- a J p f.~J a ~I 0 ~~ Page _ of j i 18" MIN Inlet Approved Joint ~ II \~ II G 1. >_ 10' from door, window Approved locking manhole or fresh air irrcake cover w/ warning label ~~ Weather Proof - Vent Cap 1 Junction Box 18" MIN \ ~' MIN t 4" ins eoti< pipe /cap Con uit - Z~bl~ ~i- - lov ~,}(e~- ~ T ~ Ctuick ~ I ~.i:4~~nnect -- ~ I ~ ~ 18" MIN II .I \ ~ ~~ i. II ~; a' W e ~ e p ~ ~ ~'rOvic;e ;.~ Hole ~ '.irLi~~ht ~ 1 ~ `~eai ~ i U ~A I 1 ~ it A:=Droved \ I I ~.larm6' ~B \ ,_)Oint5 \ , ~ ~ ~n p f ~- 1 ~ C II `, ~ ~ it ELEV. ft VA ~ C ~ ~ cnc. ~; I. ~ ~wc'~ ~~ . .~~ .//. ~ i I . q n ~\ ~\ ,. ~\ ~ ~ I ~{ q ~,~-l s I ~ 3" acoroved bedding maTZri~i ~r.c:er tank SPECIFICATION Note: Pump and alarm are on separate I N'~li:,~`..er of Doses: s' 8_ Per Day circuits as per ILHR 16.E VVs. Adm. Code G~!i~n:; r er Day /' or Doses: ~o~•aGallons 2.8 Volume of Bac'~71ow: (9ox,i63) /y.7 Gallons Tank Manufact~ ~rer: ,~z~~t~' ~ Tot..~l Dose Volume: `l ~l ,s Gallons Tank Size: UUO Gallons Alarm Manufacturer: 5JE -~~~ ~~ Model Number: Pump Manufacturer: h~~'~h~/-~f~G Model Number: ~5____~,~.._ Minimum Discharge Ra e: 30 GPM Ca; .:c.es. ,- o~g-8ii-lch~_s :;~: L~~4 Gallons B ___~_ ,Aches or 2~4•g Gallons C _S.a inches :;, -7~•~Gallons D _~__ inches o~ -~'y Gallons Tota; ....,... . _~ inches or(~2a~$ Gallons Vertical Difference Between Pump Off and Distributiol~, Pipe :............ ~? F. Minimum Required Supply Pressure :..........:..................................... + o? Ft. 90 Ft. of Forc ain x ~~ g Friction Factor/10~;~ rt .................. + /~7 Ft. Totai G'~,~n~_~i~~iic Head = /~ Ft. rC ~ De th to inlet In ~:•~; real Pump Tan Dimensi ns: Length ~q ~~ `^.r. ="`' ~_~ F ,_.n O`~ ~ IJ~ I by Signature: PUMP CHAMBER CROSS SECTION Min.2'Ve'~t pipe with cap Warning Label Final Grade \ kJC P7leS ~~I' ~~ License Number Dace '~'~ l~ Pump Characteristics Pum /Motor Unit Submersible Manual Models SW25M1 SW33M1 Automatic Models SW25A1 SW33A1 Horsepower 1 /4 1 /3 Full load Amps 8.0 10.0 Motor Type Shaded Pole (4 pole) R.P.M. 1550 Phase 0 1 Voltage 1 l5 Hertz 60 Operation Intermittent Temperature 120°f Ambient NEMA Design A I~ Insulation Class A Discharge Size 1-1 /2" NPT Solids Handling 1 /2" Unit Weight 30 lbs. Power Cord 18/3, SJTW, 10' std. (20' optional) Materials of Construction Handle Steei lubricating Oil Dielectric Oil Motor Housin Cast Iron Pum Casin Cast Iron Shaft Steel Mechanical Shaft Seal Seal Faces: Carbon/Ceramic Seal Body: Anodized Steel Spring: Stainless Steel Bellows: Buna-N Im eller Thermo lostic U er Beorin Bronze Sleeve Beorin lower Bearing Sin le Row Ball Beorin Strainer/Base Plastic Fasteners Stainless Steel Performance Data 1-1/2 NPT DISCHARGE PUMP 11-1/8 ON 9-t~2 i IARGE GHT 3-1/2 PUMP OFF l . All dimensions in inches 2. Component dimensions may vary ± 1 /8 inch 3. Not for construtlion purpose unless certified 4. Dimensions and weights are approximate 5. On/OH level adjustable 6. We reserve the right to make revisions to our products and (heir specifications without notice AURORA/HYDROMAT,IC Pvmps, Inc. 1840 Baney Road, Ashland, Ohio 44805 (419) 289-3042 Dimensional Data Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In-Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWYS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Ws. Adm. Code, and the In-Ground Soil Absorption Component Manua{ for Private Onsite Wastewater Treatment Systems SBD- Table 1: System Design Specifications Sanitary Permit Number Number of Bedrooms 3 Design Flow -Peak (gpd) Q Estimated Flow -Average (gpd) cr0 Septic Tank Capacity (gal) ® p Soil Absorption Component Size (ft2) /f Type of Wastewater Domestic Table 2: Soil Absorption Component -Limits of Reliable Operation Septic Tank Component Soif Absorption Component Design Flow -Peak (gpd) Maximum Influent Particle Size (in) NA 1/8 Maximum BODS (mg/L) NA 220 Maximum TSS (mg/L) NA 150 Maximum FOG NA 30 Table 3: Maintenance Schedule Septic Tank Inspect and/or service once every 3 years Outlet Filter Should inspect once a year and clean once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the se tic tank and outlet filter shall be assessed at least once every 3 years by inspection. The utlet filte shall be cleaned as necessary to ensure proper o e„p ration. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic Management Plan for a Septic Tank and Soil Absorption Component tank shall have its contents removed when the volume of scum and sludge in the tank exceeds T/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. Fhe afmosphere within the sepfic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank maybe difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Solt Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing. fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. Plantings of deep-rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. 2 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~©~ ~~Zq Mailing Address ~o ~{ ~ p~`-E ~ ` ~ ~~ ('C' ~`~ I ''~Le.} V~ iC~ hip ~ W ~ S ~17 r- Properly Address ~ 7 ~~ ~ ~ ~ ~ ~ ~ lr~ t~ ~ ~ ~CJ~rn h~DlY~-~ (Verification required from Planning Department for new construction) City/State ~~f^n r~ ~ ~ ~ ~ Parcel Identification Number ~ ~ g "~~ ~ 3 -' ~~ -~ LEGAL DESCRIPTION J Properly Location N~ '/., ~ `/., Sec. / ~ . T~ N-R~W, Town of ~~h'~ subdivision ~~~~~ 1~--'~ I I ~ ,Lot # ~ 1 Certified Survey Map # ~ ~ °~ J ~ r Volume ~ .Page # Warranty Deed # ~0 3 D ~ ~ .Volume I S `~ S~ ,Page # 2 ~~ Spec house ^ yes ,~l no Lot lines identifiable ,~I yes ^ no SYSTEM MAINTENANCE 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mastorplumber, journeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on site wastewaterdisposal system is is proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 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 days of the three year expiration dat . ~ ~ / ~~/ ~ ATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property descnbed above, by virtue of a warren ed recorded in Register of Deeds Office. ` 3 ,Ib, o S ATURE OF APPLICANT 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 • STATE BAR OF WISCONSIN FORM 1 - 1998 630501 WARRANTY DEED Y,ATHLEEN H. WALSH v~ 1.545 2~0 kEGISTEk OF DEEDS Document Number pp(c ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between Ronald C. Bonte and Dine M. 09-25-2000 11:45 AM Bonte -- WARRANTY DEED EXEMPT N _ _ _, Grantor, CERT CODY FEE: and John Fitz erald and Rebecca E. ____ COPY FEE: Fitzgerald, hus an and wife as survivior- TRANSFER fEE: 119.70 RECORDING FEE: 10.00 shag mars tai p~pPrty PAGES: 1 Grantee. Grantor, for a v~y~ableCiOldXratlon, conveys to Grantee the following described rea! estate in LL County, State of Wisconsin {the 'Proper[y'~): Rf;ccrdiny Area Name and Return Atltlress Part of the NE ~ of the NW ~ of Section 16, ;T©hp A. Fitzgera Township 29 North, Range 17 West, in the 641 ~ reet Township of Hammond, St. Croix County, N ichmond,`"~i~F~54017 Wisconsin, described as follows: ~>~ of Pheasant ~i 1 1 ~ filed May 5th, ~ V~~t vU~ ~~ b S~ 2000 in Volume 7, Page 86, Document #622544 018-1083-19-000 Parcel Identification Numl>ar (PIN) This 1S nOt homestead property. (is) (is not) Together with all appurtenant rights, title and interests. Grantor warrants that the title to the Property is good, Indefeasible in fee simple and free and clear of encumbrances except Easements, licenses, zoning ordinances, and restrictions of record Dat(e~d)thi~s~(~2`5~th day~of ~~September , YKc%"v_av-t1..7 ~ . ~~Je'~/'t~ (SEAL) 2000 ~0 J/1~D ~ 7"~U7 L.L~/ (SEAL) Ronald C. Bonte (SEAL) AUTHENTICATION Signature(s) authentkaC>kY([hTsia Coates-Knutson otary ~u°~ !c --~++.«-of U1/iSCOnS~n TITLE: MEMBER STATE BAR OF WISCONSIN (!f not, authorized by §706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Ronald C. Bonte 1011 170th St, Hammond, WI 54014 {Signatures may be authenticated or acknowledged. Both are not necessary.) a Dine M Bonte ACKNOWLEDGMENT (SEAL) Slate of Wisconsin, ss. St. Croix County Personally camr, before me this 2 5th day of September 2000 ,the above named Ronald C. Bonte Dine M 8osa,te to me known to be the person c who executed the foregoing instrument and acknowledge the same. ~ / t!C~ ~ No~Public, State of Wisconsin, My commission is p rmanen (If not, state expiration date: ~d" ) Names of perwns signing in any capac ay must he ,yped or pnnred below [heir signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc. WARRANTY DEED FORM No. I - 1998 Mawaukee. Ws. * ,, .. 24 a acaEr ,~ a0. R. WTLOT l r~ae ~aeEs 611.01 as R. T 22 ~ a LOT 21 ~s s a. -r. $ s.» wdeEa ~ LOT 20 ~ rt4.11r t0. fi.~ ~N Ap1Ea ~ ~ laa, 6r6 30. fT. ~ f ~ ~ i 6 ' IC 14 23 wt1 ~ ao LOT t 7 ~'a LOT 18 a er saeES a. es AGEa ras. see so. Fr, ras, us sa n /srres~ ar•E rrr.rr - Q, ~:;, "- i >?0+, yO 2 y `~, =~ PHEASANT H1LLS LOT IS n ~ w r. w ,wrxEa a ma as n ~ LOT 13 b' y s. aa~s a a. r+e as Fr. ~ s. ra aatEt a w, ta- sn n Lx . r ,~, § e~ aoo sa n 8 0. ar Lr' ~ E raq q ~ p!y ~ ~ rQ.10' ~CI' ~ ~ °a aM'ra'rME aaa f1' ~O Sa n' rr~ oa ._,~ _OT 8 a LOT 8 o r.K ~a = LOT 11 er ,wxEa ~ s. K ,IaeEa a rr aae sa fr. ° s. w aaen xt sa F raa o0o ao. rr. E rrs. o0o as rr. LOCATED i N THE NE 1 i4 OF THE NW I i4, ANL THE SE I i4 OF THE NW l i4, AND PART OF THE SW ! i4 OF THE NW 1 i4, AND PART of THE NW 1 i4 OF THE NW 1 i4, ALL 1 N SECT 1 ON 16, T. 29N. , R. 17W. , TOWN OF HAAfNIIlDA ST. CROIX COUNTY, WISCONSIN 8-~~ SFpll~ 1NU,tflr, ~~~ LOCATIpV SKETCH SECT f ON /8, T. PBN. , R. I TM: , TOYk OF MAIM7ND (MOT TD SCKE )