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018-1083-22-000
V`+sconsin Department of Commerce S1Nfety arid ~Suilding Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 'ermit Holder's Name: City Village X Township Steinmetz, Gre Hammond, Town of SST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TANK TO P/L WELL BLDG. Vent to Air nta Septic Dosing Aeration Holding ELEVATION DATA County: St. Croix Sanitary Permit No: 499262 0 State Plan 10 No: Parcel Tax No: 018-1083-22-000 Section/Town/Range/Map No: 16.29.17.594 STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer UHt let S t le t Inlet m Header/Man. Dist. Pipe Bot. System \ ~/ Final Grade Ct St Cover 1 C PUMP/SIPHON INFORMI~`lmN ~ nI`-- /_ . D J Manufacturer J~J Flln~and Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to well SAII A[3S(]RPTI~N SYSTEM BED/TRENCH DIMENSIONS Width Length No. Of Trenches Z ; ~~ H.G~ PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: ~ UNIT Model Number: f11CTRIR11T1(1N SYCTFM 1 i1, L' HeaderJManifold Distribution x Hole Size x Hole Spacing ent to it Intak Pipe(s) f Length Dia Length Dia Spacing 7 Cnll f_f1VFR ., n.,.~~.,.~ c.,~se..,~ n.,i.. .... Mnnnrl nr D}-Grade Systems Oil ~ V n I I _ rl ~~. 1/1 ~~ Depth Over Depth Over xx Depth of xx Seeded/Sodd d Bed/Trench Center Bed/Trench Edges Topsoil Y s N Yes No COMMENTS: (Include code discrepencies, persons pre nt, etc.) Inspection #1: ~ ~~ `-iPi pection #2: / / t Location: 1734 97th Avenue Hammond, W 154015 (NE. /4 16 T29N R17 Phea s t 22 Parcel ,N[o:~16~.29~.1-7.59Q4' 1.) Alt BM Description = - ~~~ ~1 ~ ~S T • "~"~ -` V ~Z' 2.) Bldg sewer length = (}-~ ` ~ ~ ~ t - amount of cover = ~ 0~~ ~~ ~ ~~. ~~ (~, ~ ~ -___ _ __. _~ __ ? Plan revision Required? 'Yes ~o ~ 3 i d ~, ~ ~/~~ Use other side for additional information. ~ --- ' Date Inse tor's Si ure Cert. No. SBD-6710 (R.3/97) TANK SETBACK INFORMATION ,~(~,G~` Safety and Buildings Division County ~ ~ 201 W . Washington Ave. , P.O. Box 7162 5 ( C ~) X ~seons~n Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (~8) 3151 9 / 2~pL- Sanitary Permit Applies ion State Plan I.D. Number _._--. In accord with Comm 83.21, Wis. Adm. Code, personal informan u provi may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Address (if different than mailing address) I. Application Information -Please Print All Informatio RECEIVED Sa,~ie- PropertyOwner's Na me ~ DEC 0 4 2006 ~sel !{ Lot k Block ;Y t~ ~ a a. Property Owner's ailing Address ST. CROIX COUNTY Property Location n 3 R C ~ /-t ~tr~ , I(/~ ~k A!! •) ~ 4 S d / ~ City, State Zip Code Phone Number . , , , ec on O t't ~+.~ i ~'~/O ! ~ (p(a2 - ??o - ~ (v'~ $ (circle o e) T ~ "i N / 7 E ~ II. Type of Building (check all that apply) ; R or 1 or 2 Family Dwelling -Number of Bedrooms ,~ CSM Number Su ivisio~ n Na m e~„ ~-0-~-° ,'° ^ Public/Commercial -Describe Use n , r ' C4 .c~'~- ^ State Owned -Describe Use ^City ^Village Township of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) O -. O~ .• ZZ - D~-D ..S A' ^ New System Replacement S stem ^ Treatment/Holding Tank Replacement Only R~Other Modification to Existing System B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New Lis Previous Permit tuber and Date Issued Before Expiration Plumber Owner J ~-1~/ 7 r,/21/0(p. TT 9a` IV. Ty a of POWTS System: (Check all that a ply) F/ _ / o S ` U~'o ~^ 3 ~NOn -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis rsal/Treatment Area Information: ' ~,e Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Req fired (sf) ispersa`Ajea Pr~~ s sf) (~ 7 Syste F,]~va~oy~ b 'T( s ~:ql $.~x. 1J + J VI. Tank Info Capacity in Total Number Manufacture refab to ee Fi er Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank f /oaa ° ~~ Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. ~ Plumber's Na me (Print) Plumber's Si gnature MP/MPRS Number Business Phone Number w Ott ~. ~. ~1e~c. ~` !I ~~ ~ a ~~ -z L a 7~s- ~Y 4 - 3 3 ~~. Plumber's Addre ss (Street, City, State, Zip Code) 4 ~ ~ l-~ ~ s ,Q ~~ ~ .` s ~r o ~ 3 VIII. Count /De artment Use Onl Approved ^ Disap ved Sanitary Permit F (includes Groundwater Date Issued Surcharge Fee) ~ ~ ~A7 Issuin Age Signature ( o ps) ^ Ow Re Denial ' ~. ~~'o~ easons for Disapproval 3~ t'~e,.;r .M. tJ ~+ ~ .~t~lrao t p p 1 Septic tank, effluent Filter and tllZt ~o~ (~ f;.~+~ Saas~t' ~, ~~ ~ • f I / dispersal cell must all be serviced t maintained ~ k~"~`O~ ,' / _,~, ~ ~ ~,~ y tv-~ ~ 'C''^O~ P as per mana lan provided b ement lumber g p y p . ~1 2. All setback requirements must be maintained C:~,~u~~ ~ „~, W~„~ ~~~I~t~.tC-~. (~ '"""`i'"> , as per applicable code(ordinances. Attach wmplete plans (to the County only) for the system on~pt a`per n~l~s~,$1/2 inches ' size /~ / Wt ~~aWI' t.Q_. SBD-6398 (R. 01/03) ~ ~~ ~~~ ~~ tie , ,i ~ ~ ~~~ . ~ , L ~ ~, ~' r ~~ Ai • .-~'`'~p 1~ ~_ w _~ 0 .~ 1~ r i I L E J> ~j • ~ . ;~1'.c~ f~ .~ ~ ~ ~ - W ---~ C J ,e e ~ ~. ,~--- Z,----.< ~~~ POWTS OW E~R'S MANUA Z-- L & MANAGEMENT PLAN Page ~ of FILE INFORMATION Owner ~ Permit # ~~ DESIGN PARAMETERS Number of Bedrooms ~ ^ NA Number of Public Facility Units ~NA Estimated flow (average) o c~ al/day Design flow (peakl, (Estimated x 1.5) SD al/day Soil Application Rate c3~'2 S~ ~ al/day/ft2 Standard Influent/Effluent Quali y Monthly average* Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (GODS) _<220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOD5) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean- <_10° cfu/100m1 Maximum Effluent Particle Size Y8 in dia. ^ NA Other: }~ NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity ` d o © gal ^ Nq Septic Tank Manufacturer ~• ^ NA Effluent Filter Manufacturer ~~~ ^ NA Effluent Filter Model ~. _ ~ 0 0 ^ NA Pump Tank Capacity al t~NA Pump Tank Manufacturer ~NA Pump Manufacturer NA Pump Model ~Nq Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ~NA Dispersal Cellls) ~' In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ~ NA Other: L~NA Other: fi~NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ~ ^ month(s) (Maximum 3 years) earls) ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y31 of tank volume ^ NA Inspect dispersal ceflls) At least once eve ry' ^ month(s) ~ yearls) (Maximum 3 years) ^ NA Clean effluent filter At least once every: ~j ^ year(s)Is) ^ NA Ins ect um p p p, pump controls & alarm At least once every: ^ monthlsl ^ year(s) ~" NA Flush laterals and pressure test At least once every: ^ yearl '(s) ~1VA Other: At least once every: ^ month(s) ^ year(s) ~'NA Other: ~' NA MAINTENANCE {NSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cellls) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of <_12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event GMW (4/01) Page 2 of 2 START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ~, A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ^ A suitable replacement area is not available 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 available 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 removal 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 AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name ~_f'\ „ 6@,'")'1. „_Q.._ .~ Phone ~ ~ ! S~ ^ '1 `Q r{ ~- ~ 3 ~~' POWTS MAINTAINER Name Phone ~l ~- ~'{ Q-- ~~J.Z Z SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name S ~ ~~ Phone ?~S' ~g(o_ y~ $O This document was drafted in compliance with chapter Comm 83.221211b111)Id1&(f) and 83.54(1), (2) & 13), Wisconsin Administrative Code. r Yl?, 1572Pa~~34~ ' STATE BAR OF WISCONSIN FORM 2 - 1999 Document Num6cr WARRANTY DEED. This Deed, made between Chad Bleeker, -. d a ~~al;tg B,ilt Hom Grantor, and Gr ory M. Steinmetz and Cindi M. Steinmetz, husband and wife Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): / _-__ % ~~~~~~ l:ATHL.EEN H. WALSH j kEGISTEPi OF DEEDS ST. CkOIX CO., WI \ kECEIItED FOR RECORD 01-04-2001 11:00 AM WARRANTY DEED EXEMPT ! CEkT COPY FEE: COPY FEE: TRANSFER FEE: 757.20 RECORDING FEE: 10.00 PAGES: 1 Recording Area Neme and Retum Address LoI 22, Plat of Pheasant Hills in the Town of Hammond, St. Croix County, Wisconsin. F N ~ - N~~y~~~ 018-1034-60 Parcel Identification Number (PIN) This is not `homestead property. 0?t) (is not) Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. Dated this ~~~~~ ~/ day of December 2000 r AUTHENTICATION Signature(s) authenticated [his day of * TITLE: MEMBER STATE BAR Ol (If not, _ authorized by Z? 706.06, Wis. Si THIS INSTRUMENT WAS Attorney Krishna Oland (Signatures may be authenticated or acknowlei * Names of persons signing in any capacity must WARRANTY DEED * ACKNOWLEDGMENT STATE OF WISCONSIN ) ) SS. County ) ~~ Personally came before me this Z9 day of December 2000 the above named Chad Bleeker, ~~ tomek~to * Pubiie, State of W emission is oermg trgt~teetattatssety.) or printed below their si lure. STATE BAR OF W ISCONSiN FORM No. 2 - 1999 ;s) who executed the forego the same. ;nt. (If not, state expir~j~to~n~date: ,.4~t«' ) Information Prorauionalf Cdnpany, Fa,d du Lac, WI 800.655-2021 ./ 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 Steinmetz, Gre Hammond, Town of CST BM Elev: Insp. BM Elev: BM Description: TANK IN FORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: 109 State Plan ID No: Parcel Tax No: 018-1083-22-000 Section/Town/Range/Map No: 16.29.17.594 STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer SUHt Inlet SUHt Outlet Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Onlv 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 0 No Q Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / /_ Location: 1734 97th Avenue Hammond, WI 54015 (NE 1/4 NW 1/4 16 T29N R17W) Pheasant Hills Lot 22 1.) Alt BM Description = 2.) Bldg sewer length = -amount of cover = Inspection #2: / / Parcel No: 16.29.17.594 Plan revision Required? Q Yes ~ No Use other side for additional information. - SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. v~,1i.`1 County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN G O ~~11 to accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT I , G~p~f~Y $ Personal information you provide may be used for secondary purposes [Privacy Law. S. 15.04(1)(m)j ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715)386-4680 Fax (715)386-4686 Attach complete tans for the system on pa er not less than 8-1/2 x 11 inches in size. County Sanitary Permit # ^ Check if revision to previous application O /d plication Information -Please Print all Information Location: Property Owner Name N < ~ > 1 /4 /t145 1 /4, Sec N0~ ~ ~ 206 N, R I7 E(o W Property caner' Mailing Address ST. CROiX COUNTY ~, tot Number Block Number 4~ A~ ~ ity, State Zip Code Phone Numer Subdivision Name or CSM Number II Type of Building: (check one) / !~ 1 or 2 Family Dwelling - No. of Bedrooms: ~ J amity ^ Village BCfown of ^ Public/Commercial (describe use): ^ ~ ~~ State-owned Nearest Road II Type of Permit: (Check onl on b li A k ~ ~ Z '~"~ S . y e ox on ne . Chec box on line B if applicable) o Parcel Tax Number(s) A 1.'Q( Repair 2. ^ Reconnection .^Non-plumbing 4. ^ Rejuvenation ~ r$ -- Lo$~ _ ~..,it - o ° d Sanitation / t'Q , ,24 , / ? , ~' 4 Y g) Permit Number Date Issued State Sanitary Permit was previously issued ~] 9 ~? ~ - o2y ~ p G7 IV. Type of POWT System: (Check ail that apply) I,S Non-pressurized In-ground ^ Mound ? 24 in. suitable soil ^ Mounds 24 in. suitable soil ^ Mound A+0 ^ Sand Filter ^ Constructed Wetland ^ Peat Filter ^ Drip Line ^ Pressurized In-ground ^ Holding Tank ^ Single Pass ^ Other ^ At-grade ^ Aerobic Treatment Unit ^ Recirculating . Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade d / ~~ / Required / oo Proposed , < (Gals./day/sq.ft.) / / (Min./inch) T / , q~ Z 3 Elevation Q jcb S l~A. T~ g Q.Sa lo,7.S8 1. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks ^ ^ ^ ^ ^ II. Responsibility Statement 1, the undersigned, assume responsibility for repair/reconnenction/rejuvenation/installation of non-plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non-plumbing sanitation system. Plumber's Name (print) w Ne h ,,il~ ~ t f Plumber's Signature (no sta ps): ~ MP/MPRS No. Business Phone Number ' ~, , ~ . e ~~ta -Zi,~ -7514- 33~~ Plumber's Address (S reet, City, State, Zip Code) 4 4.? t~ ~ 5 R~ ~ J ~ ~3 -~- c~ . ~ ~~ Vllt. County Use Only ap d Sanitary Permit Fee Da Iss ed Issuin gent Si nat (Nos s p) Approved Owner en 'til Adverse ti ~ ~(Z D~ . ~ W ~I ~~ ~~ na on IX. Conditions of Approval/Reasons for Disapproval: SYSTEM OWNER: 3~ Y l ~vw~s.~ ~--b fp1~,~ (~ ~; ~ Go+w: J~.-5 1. Septic tank, effluent filter and -IYI I J dis ersal cell must all b serv / i t i d ~ ~ - ~ p e es ma n a ne b ~- p jPp~ ; L -G n.~. ~.p he~,~.~2~, " as per management plan provided by plumber. ~ 2. All setback requirements must be maintained G~ ~ ,ne ~ .~ ~p,fL ~l 5 , ~ , _ O as per applicable code J ordinattCes. r ~.~ v~~ .1572PAGE 341. STATE BAR OF WISCONSIN FORM 2 - 1999 Document Number WARRANTY DEED This Deed, made between Chad Bleeker, -. _ dba Onali y $,ilr unmo Grantor, and Gregory M. Steinmetz and Cindi M. Steinmetz, husband and wife Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): / - / 636•~~3 I:ATHLEEN H. WALSH j FiEGISTE'R OF DEEDS ST. CROIX CO., WI \ kfCEll?ED FOR RECORD Ot-04-2001 11:00 AM WARRANTY DEED EXEMPT M CERT CORY FEE: COPY FfE: TRANSFER FEE: 757.20 RECORDING FEE: 10.00 PRGES: I Recording Area I Name and Return Address Lot 22, Plat of Pheasant Hills in the Town of Hammond, St. Croix County, Wisconsin. .g - N~~sc.~~ 018-1034-60 Parcel Identification Number (PIN} This is not `homestead property. Q~) (is not) Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. Dated this _~~!~~%%/ day of December 2000 r Signatures} AUTHENTICATION authenticated this day of « -~" _ _ TITLE: MEMBER STATE BAR OF IS ONSIN (If not, ~ ~(~ ~. ~ authorized by § 706.06, Wis. S .) THIS INSTRUMENT WAS D tj~ Attorney Kristine Ogland 0~ G~ Hudson, W 54016 + Chad Sleeker ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. County ) 1w---- Personally came before me this Z9' day of December 2000 the above named Chad Bleeker. to me kn to be th rson(s) who executed the foregoing insiru n edged the same. '" ~ .~~ Notary Public, State of Wisconsin M C mission is per ent (If not state ex it i d t ...% p on a e. (Signatures may be authenticated or acknowled~~t11[~9sety.) ~ .) Names of persons signing m any capacity must he typed or printed below their si ture. Information Qroro„wnal. company, Foxe au Lac, va STATE BAR OF WISCONSIN eoo~ssso~t WARRANTY DEED FORM No.2- 1999 r~ ~ * r TYPE MANUFACTURER CAPACITY Septic ~~~(,~,~,,~ 6U osing Aeration Holding Wlsconsm Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: ^ City ^ Village ^ T n of: Bonte, Ron Hammond Township CST BM Elev.: Insp. BM Elev.: BM e c ti n: p ~r ~ -~~ s TANK INFORMATION TANK SETBACK INFORMATION c w, `~ 'I ~LEVATION DATA Count St. Croix Sanitary Permit No.: 374927 State Plan ID No.: Parcel Tax No.: 018-1083-22-000 STATION BS HI FS ELEV. Benchmark ~~ !~S ~~ Alt. BM ~Tt.L j„t ..~~p-ie, C,v/E ID(o.03 .Bldg. Sewer c~. / 5 ~p/, ~. ~/ b~l'~Inlet .3 /b /•S3 ~~ Outlet gyp/ ,~. Dt Inlet Dt Bottom Header /Man. S. 0(J h FS~ Dist. Pipe '~ i° !o - Bot. System 1~- 3p q Final Grade ~.3~ p cover,}-I+, ~ -.1 ~ / Df . 03 PUMP /SIPHON INFORMATION t,~ Manufacturer Model Number GPM TDH Lift Lriction stem TDH Ft Forcemain Le th Dia. Dist. To Well TANK TO P/L WELL BLDG. vent to Air Intake ROAD Se ~~ /`~~., ~ (t ~a ~ NA osi ng NA Aeration NA Holding SOIL ABSORPTION SYSTEM ~~ r/~. ~'' I?- ~ ~(~j ~Slti~ IBS - Q `S' BED / T Width ~ Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I N 3 9•?~ d- DIMEN I N SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manufacturer: ~ ~ " ~~ I SETBACK r ~ INFORMATION TypeO _ ~ ~ ~ CHAMBER Mo a Number: Syste ~ 0 7 S ~ OR UNIT ~ ,~ ~.~,, DISTRIBUTION SYSTEM Header /Manifold , , _ Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air In ~ ke r , Dia. cam! Length _$~$ ~ / Length a~? ~ Dia. ~ `~ r Sparing ~ -~ 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 Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: !~ /3 /~ Inspection #2: / Location: 1734 97th Avenue, Hammond, WI 54015 (NE 1/4 NW 1/4 16 T29N R17W) - 162917594 Pheasant Hills -Lot 22 1.) Alt BM Description = - °~ ~ w~ u w ~-~C-e c°v'r-c. ~r p~~ , .,.D ~ ~'1 t~ t f ~t~' ll~f co n •`f ~~ .b cc~_ `rF y~~, S 2.) Bldg sewer length = ~ I ..t-GC~ ^o~' ~1~-~'~~'~-O" Qn''P -amount of cover = f a '` ~ ~- ~~ ~'^ ~ ~ --~ Lw ~d `~'^l.'~~ ~dGl.~^^-IKN- Tr-ws. a ~. c.~ ems. <I Plan revision required? ^ Yes ~ No Use other side for additional information. l~ ~P ~ a SBD-6710 (R.3/97) Date Inspector's Signature rt. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ~ ~ ., ~ t .__ ~_ ~.. __ m. ~ ~ ~ ~w~. ._ ~ a ~~~ , ,, ti ~. ..._ -- ,a a a a ~~ ~._ .MM ®~ ®m ~~ t ~ y i ~- 3.,€ .. t V . ~ __ ~~ - - S fd i ~S ,~ ~ m ~ ~~. ~~ ~ ~. ~ t ~m e _ _ ~~~. ~~ ~~. ,. w~~b~ ~ ~,1a~ ~ 3 - '~''~ ~.~.. a ~ ~'~d`-' .~~~_ rt ~ ,~ ,, .~ _ _.. ~a: ~,.. ~ ~ ~----! ~ . ~ _ ~ ~ ~._ ~. ~ 1~ ~f :. . ~.. ®a l ~_ ~~ p~-1 ~a~ ~-~ ~ a~~ ~~ ~~ ~ ~~ E ~~~, E f ii d .< $a®® i s 1 ~ ~ e ~~ ~. ,. ~e ~ E.. ..~ ...... .__...W...mw_W_ ..e..v.e .................,...... .,,. ...m...e.s ,...e.. m....a....a........ ...W ~ ~~ ~ ~~t Sanitary Permit Application Safety & Buildings Division S' ]n accord with Comm 83.2 t. Wis. Adm. Code I 201 W. Washington Ave. PO Box 7302 j' ` SC~~sI~ I See reverse side for instructions for completing this application oses d ~ f Madison. Wl 537Q7-730^ + Department of Commerce purp an or secon Personal information you provide may be used [Privacy LaH'. S. 15.04(1)(m)] (Submit completed form to county if r state owner Attach com l ets fans to the county co • only} fort a er not less than 8 -I/2 x 1 t inches in size, County State Sanitary Permit Number ~ ~ 'f o t pFe ' us application State Plan 1. D. Number S 3 Z c I. A Iication Information -Please Print all Informatio '` Location: property Owner Name - ~ " ~ ~' ~ Property Location w ^ ~ y I/4 ,(J 1/4, S T N, R/ or ~ ~ _._} Property Owner s Mail ing Address , Lot Number Block Number , _, t ~„~, S7 CR(JIX D rC o >' F~ ~, coutvrv ~ City, State Zip Code ~ Pli!dddd I ~ A vision Name ar CSft4 Number Subdi J ' uti. f v p Ca[ ~ r~ CS II Type of Building: (check one) ~- ,~ar. s ~bm i'~cd( QS ~ ~'ty O village ~~ ~ O I or 2 Family Dwelling -Na of Bedroom )~7'own of O Public/Commercia! (describe use): O State-owned Ill Type of Permit: {Check only one box an line A. Check box on line B if applicable) Neazest Road / 7~ 7~ s A) 1. p3..New System 2. D Replacetent 3. O Replacement of 4. O Addition to Parcel Tax Number(s) S stem Tank Onl Existin S stem B) Permit Number 6/~- l0 3, 2 Z - ood Date Issued D A Sanit Permit was reviousl issued /G . z ~. !~: S~ iV. Type of POWT System: (Check all that apply} Its-Non-pressurized in-ground ^ Mound O Sand Filter ^ Constructed Wetland ^ Pressurized In-ground D Holding'Fank ^ Single Pass ^ Drip Line ^ At-grade ^ Aerobic Treatment Unit O Recirculating l3 Other: V Dis ersaUTreatme nt Area Information: ' I. lksigrt Flow tgpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application S. Percolation Rate 6. System Elevation 7. Fine! Grade tion El Required Proposed Rate {Gals./daylsq. R.) (Min./inch) 7-/ /~Q, ~ / s eva /0.~. ~,S'd ,/ ~' / Oct ~ - ~ ./ oL ?2 ~9• d i. S VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plast'sc Information Gallons Gallans Tanks Con- Con- glass New Existing Crete structed Tanks Tanks fit.. O ^ ^ O ~G T. C ~Q / ( . G~G~'S v ^ O D O VII Responsibility Statement the tutdersi ed assume res onsibilit fer installation of the POWTS sho the attached !arts. plumber's Name (prin!) Plumber's Signatur tno stamps): PRS No. Business phone Number .~/~e'GIHy SG L7k-7rea ~`.h o2v~~ l~ ~J~~'l. ~.~ ~j Plumba's Addross (Street, City, State, Zip Code} ~" s~ ~Zt ~' ~ C VIII. County/Department Use Only ^ Disapproved Sanitauy Permit Fee (Incli:des Groundwater Date Issued Issuing Agent Signature: (No stamps) Approved O Owner Given initial Adverse Surchazge Fee} .~ Z' 2 s G lJ aC Z Determination IX. C/!oa//ditio/ns o//f Approval /!Reasons for Disappro/val: ~/ / ~ l-) ~~llr >r7 b~ :nS~4~~G~ ~~r hlQrccc. ~ael`Lc/'Pr-,^S /P~O~Wor/~.er"tlrs`M S -/ /l Z.,~,'~l Lll~~~ dt Y@Qk6/Pd o~~r "t. W~~,~of<~y ©T ~P ~iVSTrI~+'~ 74j IYI~reKT4~~. /2" Ot CUU~v-. 3~SsrS>`ew~ Cr'rva ~"~ skel/ ~p'f' HOC ,r~eef~r Y-rnsrr.. Z4/~~ b~/dam e•i9~'r.e/ grade SBD-6398 (R. 07!00) ~o.~ ~0 .r/ f~ H a ~,2~ ~/~(e a Sa y ~ l-~, ~lS ~ ~//~ 0 f ~a ~ m 6,v ~ _~Ga~.~ f =~Q .,~h9 1 zoo ~ ; .~ .-¢.- %d6 0 ~in ~ f. of ~,;d e ~Z D ._~ ~~ ~~ ' s Wisconsin Department of Commerce . Division of Safety and Buildings SOIL AND SITE EVALUATION l ~~~~Sj~cl 1 with Comm 83.05, Wis. Adm. Code Page 1 of 3 Certified Soil Testing Attach complete site plan on paper not less tfiaffBY~~TT1'1FChe size. Plan must ' County include, but not limited to: vertical and horizoAtal reference point (B M~, direction and St. CroiX r lo e l r di ti rest road t i rth r d l d di ta t p , sca . pe cen s e o mems ons, no row, an oca on an nce o nea s ~ l LD P # ~ ~,~ ~ arce . APPLICANT INFORMATION - lease p~in~alU~lfi~ormatio~ . Personal information ou provide ma be us,d for'seconda ses riva Law, s: `95.04 1 m Y Y ~Y'P~ ' cY ~) ~ )) ed B Date Z U Property Owner rn 1 s rx+~"a~ ~ ~ ~~`troperty Location Bonte Ron - ;;~C.aX NE 1/4 NW 1/4 16 29 17 W ovt. Lot S T N,R Property Owner's Mailing Address ~%t''•~!_ ., _ ~ "" ~ of # Block # Subd. Name or CSM# 1011 170th St. ~r.~,tint+tGC)~""~~ ;, ' 22 Pheasant Hills City State Zi o~ 'Phonel~um~ d ` ' ~ City [ ]Village ®Town Nearest Road 170Th S Hammon WI 5 '7~5~~:916 52 t. I-~aammond ®Residential ! Number 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 •3 bed, gpd/ft2 •4 trench, gpolftz Absorption area required 1500 bed, ftz 1125 trench, ftZ Maximum design loading rate •S bed, gpolft2 •6 trench, gpd/ftZ 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 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 ~7VIL IJC~7\+Rlr I IVIr RGrVR 1 Boring# 34 Ground elev 103.0 ft Depth to limiting factor > 82" . ~`..a• Ground elev 102.9 ft Depth to limiting factor > 60" - Horizon Depth Dominant Color Mottles Te r t Structure Consistenc Bounda Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color x u e Gr. Sz. Sh. ry ~ r 1 0-4 - 7.SYR 2.5/1 - sl 2 m gr ds cs if .5 ~ 2 4-16 • 7.SYR 2.5/1 - sl 2 m sbk dsh cs if .5 Y~ 3 16-34 l OYR 4/4 - sl 2 m sbk mfr cs 1 f .5 4 34-56 ~ lOYR 4/4 - sl 1 m sbk mvfr cs lm .4 5 56-82 - I OYR 6/4 - s 0 sg dl - - .7 ~ Remarks: 1 0-4 . 7.SYR 3/2 - sl 2 m gr mvfr cs 2flm .5 2 4-10 • 7.SYR 3/2 - sl 2 f sbk mvfr cs if .5 `~ 3 10-26 7.SYR 4/4 - sl 2 m sbk mfr cs if .5 ~ 4 26-40- 7.SYR4/4 - sl 0 m mvfr cs - .3 5 40-52 • 7.SYR 5/4 - ]s 0 sg ml cw - .7 52-60 l OYR 4/4 - s/mcos 0 sg ml - - .7 ~ ~ Remarks: noncon o nas cons-aeraoie gncooisi SST Name (Please Print) Signature: Telephone No. Henry F. Grote ~ 715-665-2681 4ddress ertt to of estmg D t CST Number Ref # P.O Box 57, Knapp, WI 54749 4~1~/2000 222774 1043 PROPERTY OWNER: Bonte, Ron SOIL DESCRIPTION REPORT PARCEL I.D.# ~ Page 2 ~f 3` . CertifieA Snil r'T chno ` Horizon Depth Dominant Color Mottles Texture Structure onsistence Boundary ~ Roots GPDIft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Tre r~ 1 0-3 ~ 7.SYR 3/2 - sl 2 m gr mvfr cs 2flm .5• 2 3-11 • 7.SYR 3/2 - sl 2 f sbk mvfr cs if .5 Ground elev 3 11-26 - 7.SYR 4/4 - sl 2 m sbk mfr cs 1 f .5 100.5 ft 4 26-41 - 7.SYR 4/4 - Is 0 sg ml cs if 7 . Depth to limiting 5 41-68 ' 7.SYR 5/4 - sl 1 m sbk mfr - lm .4 / factor >ss~• ~. 9y.~ I~r. RGI I IQI ICJ. ~~/ Ground elev 101.5 ft Depth to limiting factor > 75. , ~~ R,q `° /~,I •~ - 1 Ground elev 102.1 ft Depth to limiting factor > 70~ . 1 0-3 7.SYR 3/2 - sl 2 m gr mvfr cs if .5 2 3-8 7.SYR 3/2 - sl 2 f sbk mvfr cs 1 f .5 / ~6 \ 3 8-30 • 7.SYR 4/4 - sl 2 m sbk mvfr gs if .5 / \ _ .8 4 30-44 7.SYR 4/4 - sl 0 m mfr cs - .3 / 5 44-50 ' SYR 4/4 - sl 0 m mfi cs - .3 / ~4 \ 6 50-65 • I OYR 4/4 - s 0 sg dl cs - .7 / ~ 7 65-69 • l OYR 4/4 - lfs 0 sg ml cs - , ~ ~ ~ RCIIIQI ICJ. -- - - - _. - ~~~-' -O:-.y -F S (l S 9 Q l . `/ 1 0-4 - 7.SYR 3/2 - sl 2 m gr mvfr cs 1 f/m .5 ,~ 2 4-10 ~ 7.SYR 3/2 - sl 2 f sbk mvfr cs if .5 `(~ 3 10-33 • 7.SYR 4/4 - sl 2 m sbk mfr cs If .5 ,/ 33-50 - 7.SYR 4/4 - sl 0 m mvfr cs - .3 5 50-59 • SYR 4/4 - sl 3 f sbk mfr cs - .5 6 59-70 . l OYR 4/4 - fs 0 sg dl - - . ~{ ,.r,~.,,, ,~ ~,,..,A ,.,,. „~.,, ~~ loo . ~ aN .,~ „ 0 ~~ Ground elev Depth to limiting factor ~, rv N~ -Nw-fib- 2a-1~ W ~ ,,..~ , ~wwwo~.~ ~ 3 a (.,o /~-J 318 20'4-. 32~ ~l o'S.o~ r~.3 ~~• << ~.~ ~ az ~` ~2A.~ C5 ~sx' t~ q C~ ~z•-~ o ~~ ~•-3 4 1 e3.a) j~ .,~ M~ LJ C~'V S C Y O N 1 (,l uo.o ~ ~9. z.o ~ 'k r ~ ~ e.~ts * ~ A-v •~io b A~, r~x 443.8 4 ~,~5 . ,, ST CROIX COUNTY '~" SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSIiIP CERTIFICATION FORM OwnerBuyer 1~ 6 ,y ,~a ~ ~~- Mailing Address ,1 ~ %/ 17 ~ 7-h S ~ ~~. rn ~~ ~,~ ~ G~1 • ~ uT ~/a'/S Property Address ~ ~ ~ `~ ~ ~ ~ ~`~- (Verification required from tlanning Deparimeat for new c~astuction) City/State LEGAL DESCRIPTION Parcel Identification Number property Location ~~ -%<, ,r/~ `/., Sec. J6 . T~_N-R_[~_W, Town of ~ R~ =ova Subdivision `i a- a„~ ~ f /S Lot #~2 ,_. Certified Survey Map # ,Volume .Page # 'Warranty Deed # r~~ 0 Gj~ ~ , Volume ,Page # Spec house ^ yes (1~-- no Lot lines identifiable ^ 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 masterplumber, journeymanplumber, restrictedplumber or a licensedpumperverifyingthat (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 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 Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and retu-~ed to the St. Croix Comrty Zoning Office within 30 days of the three year expiration te. ~, ~1~~~ SIGNATURE 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 e property d ribed abov by virtue of a warranty deed recorded in Register of Deeds Office. ~~7j SIGNATURE OF APPLICANT DATE ****** ****** Any information that is mis-represented may result in the sanitary pemut 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 ~~.1.15~1PAGE 372 6209Cs3 KATHLEEN H. tdALSH REGISTEk OF DEEDS 5T. CkOIX CO., WI RECEIVED FOR RECBRD Dine M. Bonte, as Trustee and Ronald C. Bonte, first alternative 04-10-2000 10:30 IN1 Trustee of the Karl M. Ulferts and Katharina G. Ulferts Family Trust, for a valuable consideration conveys without warranty to TRUSTEES DEED E%EMPi D Ronald C. Bonte and Dine M. Bonte, husband and wife, Grantee, CERT COPY FEE: the following described real estate in St. Croix County, State of i~R FEE: 240.00 Wlsconsirl: RECpRDI11S fEE: 10.00 PtAGE5: 1 ReCOrdin Area Name and Relum Address Thomas A. McCormack 1020 10"' Ave. Baldwin, WI 54002 018-1034-60, -70 (Parcel Identification Number) The North Half of the Northwest Quarter (N %: of NW %,) of Section Sixteen (16), Township Twenty-nine (29) North, Range Seventeen (17) West. Dated this 24t1-iday of ~'ch AUThIENTICATION Signature(s) authenticated this _ day of , signature type or print name TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.08, Wis. Stets.) _ ~~~~~~ ~ J ..~ THIS INSTRUMENT WAS DR~E~,~ Thomas A. McCo a ! '' ~''~ ~ F ~ Baldwin, WI 540d~.' O ~ ~ ,!`•: ~. Q .r ~•. ~ .S~ ..M ' ~,...r......w. 2000. Dlne M. Bonte Trustee 'Ronald C. Bonte Trustee ACKNOWLEDGMENT STATE OF WISCONSIN ST. CROIX COUNTY Personally came before me this 24thday of ~~ 2000 the above named Dine M. Bonte, Trustee and Ronald C. Bonte, as first alternative Trustee of Karl M. Ulferts and Katharina G. Uiferts Family Trust, to me known to be the person(s) who executed the foregoing instrument end acknowl~ge thpr same. signature type or print name Dale I~ Jensen Notary Public St. Croix County, Wisconsin. MyOcpm~is~Qn is permanent. (If not, state expiration date 'Names of persons signing in any capaGry should be typed or printed below their signatures. Mnormaaan 7rdauionala CamOarry FoM du lac. WlaCanan 80(1~655- ' --- ~ _ t )S p(/aRffH CORNER (TO SE COR. PLAT) NORTH-SWTH WARTER UNE _ __. . _ ~FfrS SHEET) ` - __ ~- -- -- . I --~ - - -- 3? 7. S1' ' ~ ~, , , ! ~ , ~ , ~ / ~ w: n , , ~ ~~ -- ~~ _ ~ r ~ ~ ~ , ~ W r ~ ~ ~ ^ o ~ ~ ~ ."' o I I , ~ ,.~ ~-- , '., a 1 ' I , I y~. I ~ l~ ~ i \ ~^~ ~ 7 ' ~ ~ / I I '' , , ys~ ., `f~ ~ ~ ~ ~, %. , °mrti ~ ~ cv ti U ,i;, ~ , \ ~ I Q N r .., ~ r , Qm ~, ,n k~.~ I _..1 ~. ~ n ~ J (V CV 'z ~ ., I ~ 1-- ~ ~ , >. r rr R; 4Q i I ~ r :+ , r Q ~ C) I ~, ~ V l11 l \ il ' --.-- ----- - r ; , ~ ~pb~ /~ n \ ~,~ 'ten ~ ~- 4. % 8 yp r ~ ~~~ ~ 9, o ~ ~ ~',~ 2dy i ~ y N w ci te r p ~.. ,' (nom ' \ ~ ~ y? «)'; ~,~.\ e" N c , Mw N v ~ ,,m 1 ~ ~ ,, ~ . o ~ b ~ ~ ~ ~~ n ~ m ~ ,~ 4-. Q _ ~6 r I ~ 0 ~ ~ ~ ,:, J N ~. p1 n p N 0 J ~ , 62 `~ 0~ ~ ` z _ ,y N e°j ~ 2 \~ I Og ~ ~„ ~ • 04. 3?' 2 79. 76' -,-- 7E 1 74 \ -` ~ / ~I 23A.32' I . ?j2.50' • . ~ \ \ i \ ~ ' ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM wne Buyer Mailing Address Property Address City/State !73 ~' 47~ ~-~-~ (Verification required from Planning & Zoning Department for new construction.) ~~ ~ , LEGAL DESCRIPTION Parcel Identification Number o ~ ~ - ~`' s3 -~~ - ° ° ° Property Location /U E y, , /tl w 1/ ,Sec. / ~ , T a q N R ~ ~ W, Town of 1-( a„,5~-. Subdivision I_~~-ao.~" ~~ ~~ ,Lot # r2-~- . Certified Survey Map # ,Volume ,Page # Warranty Deed # ,Volume ,Page # Spec house ^ yes ^ no Lot lines identifiable ^ 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 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 113 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 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 knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 5 NATURE F APPLICA ( ) 1 a>~ / ~/ d 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)