HomeMy WebLinkAbout018-1094-02-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 538855 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Manske, Evan elene Hammond, Town of 018-1094-02-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
17.29.17.742
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER S CAPACITY STATION BS HI FS ELEV.
/ G
Septic Wt'e1'~j~i c + Benchmark
t Gov
t 1 {~w
Dosing Alt. BM
AepstmeR -160 Bldg. Sewer
i 4 are v~
Holding St/Ht Inlet '7
.L~ 9 f07
TANK SETBACK INFORMATION St/Ht Outlet Cf
TANK TO . I P/L WELL BLDG. V t to Air Intake ROAD Dt Inlet CJ~/, Z( -2/0 7.3 X11 ( V
Septic 75 ZI Dt Bottom
5
Dosing / Header/Man.
N If
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cove
GPM
Model Number
TDH Lift Friction Loss Syste Head TDH Ft
Dist. to Well
Forcemain Length 7`_
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L %D,(;., WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution T~'le Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of odded xr. Mulched
Bed/Trench Center Bed/Trench Edges Topsoil xx Seeded/S 0 Yes Z No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 992 166th Street H mmond, WIC 5 ( W 1/4 NE 4 7 N R17W)( -Prairl un Lot 2 Pa a o: 7.29.17.742
1. Alt BM Description aC~
CpJ fA, L6
2.) Bldg sewer length = ~ d.• ~jG,L,~',
-amount of cover= 6C., 0" 1') Su. 1~ ~ -t ~•t. ~r+
Plan revision Required? Yes No Elb L~] „ Use other side for additional information.
Date Insepct s Sign a Cert. No.
SBD-6710 (R.3/97)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 538855 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Manske, Evan elene Hammond, Town of 018-1094-02-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
I 1- 17.29.17.742
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header/Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP/SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
i
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. T id 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 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 51 Yes H No [0 Yes 0 No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 992 166th Street Hammond, WI 54015 (NW 1/4 NE 1/4 17 T29N R17W) Prairie Run Lot 2 Parcel No: 17.29.17.742
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? 0 Yes No
Use other side for additional information.
Date Insepctor's Signature Cert. No.
SBD-6710 (R.3/97)
commerce Safety and Buildings Division County
Com M 2 1 W. Washington Ave., P.O. Box 7162 5 r ° +
SC Madison, WI 5 3 707-7 1 62 tary Permit Nu>nber (to be fillen by Co.)
DepartmAV 53 SS 5
Stat umber
Nani it plication a
In accordance with s. Comm 83.21(2~~V i~ ~n~i of this form to the appropriate governmental
unit is required prior to ob inin13j ote: Application forms for state-owned POWTS are Project Addr (if different than mailing address)
submitted to the Departmen o Personal information you provide may be used for secondary qG;t Z
purposes in accordance with th nvac Law, s. 15.04 1 m , Slats. c A m / / Ln
1. Application Information - Please Print All Informatio d ~7
Property Owner's Name / Parcel #
15 Vc>-h el ec~e A. Nlc~-s. s !c e. o r8 - Eo4Y- off- ooa
Property Own s Mailing Address Property Location
C) J 2 1 lc ~O ST, Govt. Lot I ~T
City, State Zip Code Phone Number (J yy 14 16 y,, Section 17
GJ i S Lf c 116- q ,circle one
tL'M Tq a 'T d T o2 l N; R 1[ E okW
H. Type of Building (check all that apply) Lot #
Subdivision Name
61 or 2 Family Dwelling - Number of Bedroo
Block# Piad- of t~/La..r rie R~ rti t4 ❑ Public/Commercial -Describe Use nt A ❑ City of
CSM Number ❑d Village of
❑ State Owned -Describe Use LAS Town of N a rn 'M Z.- -n Id
III. TypVoermit: (Check only one boo on line A. Complete line B if applicable)
A. ❑ New System ❑ Replacement System $,T'eatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
List Previous Permit Number and Date Issued
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New !
Before Expiration Owner ~j b
IV. Type of POWTS System/Component/Device: Check all that apply)
❑ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dispersal/Treat ent Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area ProposUSystem nyn 9
(oc,a Qr5 / Zdb /Z/Z • VI. Tank Info Capacity in Total# of Manufacturer Gallons Gallons Units New Tanks
a U rn :t: Cd
~ i+. C7 w
Septic or Holding Tank / '1 0 p 1A50 / G3 t `1 F A,
Dosing Chamber 0~-
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number
/3ta1+ec-Nec,h~~ l!c t~ ;zX-7 -I/ 0 '714 ;Z2_
Plumber's Address (Street, City, State, Zip Code)
4(0 -1 6d L,>7 I. s A e,- , s q Z)
VIII. Coun /De artment Use Only
Permit Fee Date Issued Issuing t Signature
Approved rsapprove $ 256 . oo /Z /
er Given Reason for Denial J
IX. Condit" SVt#F4)VVNWeasons for Disapproval 6~~ ~a P2f , 601 )a
1. Septic tank, effluent finer and 3) t I r
dispersal cell must all be services /be maintainer
as per management plan provided by plumber.
2. All seflAck requirements must be maintained ,
am code / Wd rWWAS. G4 t
Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x 11 inches in size
SBD-6398 (R. 02/09)
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Pl pNNING & ZON►NG OFFICE
ENTIONAL COMPONENT DESI
Residential Application
INDEX AND TITLE PAGE
Project Name: "Y►'~ u-~v~i
Owner's Name: rQ Owner's Address: 9 14 env fi'`'r o 1 S
Legal Description: IJF S_xe l?, T d2 9N R 1 ?
Township: _ a s+ri rY
County: s+D~-
Subdivision Name: 1
Lot Number: o~.
Parcel ID Number: 8 - [off o
Page 1 Index and title
Page 2 Plot Plan
Page 3 System Sizing & Cross-Section Sr f~
Page 4 Filter Specs q 00 za blt
Page 5 Maintenance Information
Page 6 Management Plan
Page 7 St. Croix Cty Septic Tank Maintenance Form
Page 8 Warranty Deed
Page 9 CSM or Plat
Attachments: Soil Test & House Plans 14
Designer/Plumber: L-\ License Number: a2;-7 710
Date: 9-;L7- l Phone dumber
Signature
Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01).
Page 1
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O 2 WLP1250-MR SCALER/4" = 1' REV N0. DATE:
m MIESER CCIICAETE DRAWN BY:SWT
Z SEPTIC MANUAL W3716 US HWYt0. MAIDEN ROCK, N 54750 DATE: JANUARY 2008
V REV. JAN. 2008 800-325-8456 FILE: WLP1 250-MR
MADE IN USA
i
A100TM, A300TM, A600TM 12 Series Filters
TM ut the
wide
there
difference The interval for servicing septic tanks is but mostare regulatory agenc es suggestotwo to f vetyears. The Zabel" filter which does not and local code. opinion
what this interval should be, cleaned
ected
norma
tank
particles toer,
and increase the frequency -c of serving for eanin Thetcontinued act on of the a ae obichorganisms onlthe Zabel filt pr causes pgeump ed.
our filter is virtually self
the bottom of the tank. If your filter contains a SmartFtlter alarm, you will be notified by an alarm when the
disintegrate and fall to thea g
filter needs servicing.
To service the filter:
*Servicing any Zabel filter should only be done by a certified septic tank pumper or installer.
Locate the
STIOR
outlet of the Y
wfi
septic tank.
t Firmly pull the filter handle and
slide the cartridge out of the
Remove the tank cover and case. -
G pump the tank if necessary *Note: A tee handle may have to be -
to prevent any solids from usedif the filteris too farbelow ground
escaping to the field when level to reach. Contact Zabel for info
TIM, 17 hfilter is removed. on tee handles
4k,STC~' " STEP
' ~~''ii fll(I Insert the filter cartridge back
in the case making sure the
While holding the cartridge over the filter cartridge is properly
access opening rinse off the cartridge aligned and completely
with fresh water, being careful to rinse inserted in the case.
all septage material back into the tank.
*Note: It is not necessary to clean the Piker Replace the septic tank cover.
"spotless". The biomass growing on the filter aides
in the pretreatment process and should be left on
the filter. (If necessary, the cartridge may be
disassembled for cleaning.)
Residential
Certiplications
citified to
Notes: A
to
• If you have a Filtered Versa-Case" Model Filter, be sure and spray clean the outlet opening before replacing the Filter. s d46
The product(s) shown are covered by the following patents:
U.S. 4,710,295, 5,593,584 Other Patents Pending
Call for a free ZABEL ZONE® • 1-800-221-5742.Or Order Online: www.zabelzone.com
071102-229
Owner; L ' _ (,L/ .e'c rasa pry
System start up shall not occur when soil conditions are frozen at the; infiltrative surface.
During power outages pump tanks may fill above normal high water levels. When power is restored the excess wastewater
will be discharged to the dispersal 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 soft absorption are.
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.
ABANDONEMENT
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 ch. 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 m"y pe 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.
o 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'gite-figs'-'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.
Q 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 the time.
<<WARNING>>
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASES 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
?OWTS INSTA POWTS MAINTAINER
Name Name
Phone , -
Phone .
>EPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name '
Phone
Phone
Owner:✓/~-NaYcc,?-ot 1
System start up shall not occur when soil conditiuns are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal high water levels. When power is restored the excess wastewater
will be discharged to the dispersal 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 soft absorption are.
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.
ABANDONEMENT
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 ch. 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 Jy Pe 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,
'o 'Thy site ti s'tiof'been evaluated rto id entifywsuitable replacement area. Upon, failure-of the POWTS,a-soil ~ands to
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.
Q 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 the time.
<<WARNING>>
.
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASES AND/QR .
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
WAY BE DIFFICULT OR IMPOSSIBLE.
kDDTTIONAL COMMENTS
?OWTS INSTA y POWTS MAINTAINER
Name
Name
Phone ,
Phone
>EPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone .
Phone
is
P?
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
caner uyer "V~ A3 m o.,~
Mailing Address
Property Address
/ (Verification required from Planning & Zoning Department for new construction.)
City/State 14 Parcel Identification Number d l 8- 16 T'q -00 - 0a
LEGAL DESCRIPTION
Property Location NO '/4 , ^(E /4 , Sec. / 7 , T 0-7 N R / 7 W, Town of )I
Subdivision Plat: 091~ Lot # Z
Certified Survey Map # Volume , Page #
Warranty Deed # (before 2007)Volume , Page #
Spec house yes)<no Lot lines identifiable eyes no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1 /3 frill 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.
Numb of drooms 51
SIGNATURE OF APPLICANT(S) DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08/05)
930521
BETH PABST
REGISTER OF DEEDS
STATE BAR OF WISCONSIN FORM 2- 2000 ST. CROIX CO., WI
WARRANTY DEED RECEIVED FOR RECORD
Document Number 01/13/2011 10:01 AM
THIS DEED, made between Ryan P. Fuglie and Maggie A. Fuglie, EXEMPT # N/A
husband and wife, Grantor, and REC FEE: 30.00
Evangeline B. Manske, A Single Person, Grantee TRANS FEE: 510.00
PAGES: 1
Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee the --The above recording information
following described real estate in St. Croix County, State of Wisconsin: verifies that this document has
been electronically recorded
returned to the submitter
Recording Area
Lot 2, Prairie Run, St. Croix County, Wisconsin.
Name and Return Address:
Edina Realty Title, Inc. O
400 South 2nd Street, Suite 115
Exceptions to warranties: Hudson, WI 54016
Easements, restrictions and rights-of-way of record, if any. 9 - q 7 Z
018-1094-02-000
Parcel Identification Number (PIN)
This is homestead property.
Dated this tl`s day of August, 2010
Fuglie Maggie A. .u 'e
AUTHENTICATION ACKNOWLEDGMENT
)
Signature(s) STATE OF WISCONSIN
St. Croix COUNTY. ) ss.
authenticated this 20 day of August, 2010
TITLE: MEMBER STATE BAR OF WISCONSIN f 1/6%
(Ifnot, Personally came before me this/7`h day of August, 2010 the
above Ryan P Fuglie and Maggie A. Fuelie, husband and
h wife
authorized by § 706.06, Wis. Stats.) to me known to be the person(s) who executed the foregoing
instrument and acknowledged the same
THIS INSTRUMENT WAS DRAFTED BY
*Chen rows
Martin D_ Henschel Notary Public, State of Wisconsin
50 East Fifth Street, St. Paul, MN 55101 My commission is permanent. (If not, state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.) 02/27/2011
)
*Names of persons signing in any capacity must be typed or printed below their signature
WARRANTY DEED STATE BAR OF WISCONSIN FORM No.2-2000
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Parcel 018-1094-02-000 07/07/2005 09:09 AM
PAGE 1 OF 1
Alt. Parcel 17.29.17.742 018 - TOWN OF HAMMOND
Current X', ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): = Current Owner
VASSER, CAMERON L & CLAUDETTE
CAMERON L & CLAUDETTE VASSER
1423 HAZEL ST #3
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description 992 166TH ST
SC 2422 ST CROIX CENTRAL
SP 1700 WITC
Legal Description: Acres: 1.480 Plat: 2349-PRAIRIE RUN LOTS 1/35 018/02
SEC 17 T29N R17W PT NW NE PRAIRIE RUN Block/Condo Bldg: LOT 02
LOT 2 1.480AC
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
17-29N-17W NW NE
Notes: Parcel History:
Date Doc # Vol/Page Type
05/29/2003 723348 2256/118 WD
05/29/2003 723347 2256/117 WD
04/15/2002 676384 9/02 PLAT
2005 SUMMARY Bill Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/14/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 1.480 22,900 98,700 121,600 NO
Totals for 2005:
General Property 1.480 22,900 98,700 121,600
Woodland 0.000 0 0
Totals for 2004:
General Property 1.480 22,900 98,700 121,600
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 430076 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Vasser, Cameron Hammond Township 018-1094-02-000
CST BM Elev- Insp. BM Elev: BM Description-. Section/Town/Range/Map No:
Lii~g 141r"k 461 17.29.17.742 iAll. TANK INF MATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark I
.9
1216 D dit BI 5-05'( 103-95
Dosing Alt. M ! I toG pZ .2-1 t
Aeration Bldg. S / r
4 io !S=1S
Holding St/Ht Inlet / C1 I y-
TANK SETBACK INFORMATION St/Ht O let
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD In-let 2
t~4-0-
Septic l o t ? r'O r 24 t _ Dt Bottom (f 3.3o go. (0s,
Dosing
3 r r Header/Man.
12 ~ (o0 3 L40 Aeration Dist. Pipe ~ S b .~i T r
Holding Bot. System .157
Final Gr d v dic
le L., PUMP/SIPHON INFORMATION e.w:rr tZ ti„ - 4 ',rJ
Manufacturer C GA-1- L e- ~ Demand GPM t Cover \
Model Number (0t
w £-0 3 It t.•- S ~
TDH Lift Friction Loss System Head TDH Ft
t
Length0r Dia. ti Dist. to well
cemain
2
I Cr 40 F
SOIL ABSORPTION SYSTEM 3
(TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
Dl 3' .go 3)
SETBACK SYSTEM TO P/ BLDG WELL LAKE/STREAM LEACHING Mai u act .
INFORMATION CHAMBER OR
' r I UNIT Model Number: Z it
Type c..") am: , 4 ~ I co
v.A~ w Q
DISTRIBUTION SYSTEM Jv t. i-7
Header/Manifold It Diribution x Hole size x Hole Spacing Vent to Air Intake
yy,,,, P EL I
Length A12pS Dia 4 LSpacing > 95
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
Bedrrrench Center Bed/Trench Edges Topsoil
0 Yes 2 No 0 Yes ~ No
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: W•/ Z3 #r?,403 Inspection #2:
Location: 992 166th St Hammond, 54015 (NW 1/4 NE 1/4 17 T29N R17W) Prairie Run Lot 2
1.) Alt BM Description = 8 a (~5 i ~l~ C4 S S
2.) Bldg sewer length= 2 ' • I S = 9~1 V,
es / 4,.1-+ a " 7'V
- amount of cover = I~p-~' VAk ' 9
S - - -t5"
Plan revision Required? Yes No I ~3
Use other side for additional information.
Date Insepctor's Signature Carl. No.
SBD-6710 (R.3/97)
' Safety and Buildings Division Count",
an ME 201 W. Washington Ave., P.O. Box 7082
sconsin Madison, WI 53707 - 7082 Sanitary Permit Number (o be filled in by Co.)
Department of Commerce (608) 261-6546 360
Sanitary Permit Application State Plan I.D. Number
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide
may be used for secondary purposes Privacy Law, s 15.04(1 xm) Project Address (if different than mailing address)
1. Application Information - Please Print All form iI ( 9 Z ~
Property Owner's Name Parcel # Lot # Block #
UI'd it 6 '2003 - o
Property Owner's Mailing A Property Location
-ZOIXCOUNi ,
62 City, S e ^ um r '/4 f--%` Section / 7
(circle )
T Z N; R~~o
II. Type of Building (check all that apply) 5,, ,,mot
Subdivision Name CSIV4Number
1 or 2 Family Dwelling - Number of Bed ms S .
Public/Commercial - Describe Use/
❑ State Owned - Describe Use (3 3 t r- 9 S []City V' age Township of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. flNew system
❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. List Previous Permit Number and Date Issued
❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New
Before Expiration Plumber Owner
IV. Type of POWTS System: Check all that apply) On
jg~Non -Pressurized In-Ground Mound > 24 in. of suitable soil ❑ ound < 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. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (st) Dispersal Area Proposed (sf) System Elevation
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New Existing
Tanks Tanks
septic or Holding Tank
Aerobic Treatment Unit
Dosing Clamber
VII. Respo ibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plum 's me (Print) Plumber's Si MP/MPRS Number Business Phone Number
l
lu ber's Ad treet, i , State, Zip e) '
VI
VIII. Cozen /De artment Use Only l•~
Approved ❑ Disapproved Sanitary Permit Fee includes Groundwater Date Issued Issuing ent Signatur o Stamps)
Surcharge Fee)
❑ Owner Given Reason for Denial
IX. Conditions of Approval/Reasons for Disapproval
~j~ 9~w., ` ✓ i.i.~ C, vw:.tni 0uunn1 12- nt CAriJ-2/ C?vt~ t~'~t-, ~ 0 1 aq
ct- sZ3i s~~ Q c e s
~ L 4~
Attach complete plans (to he County only) for tthee srem on pa tot les than JIM 1 11 Inches in size
B ~ 98 (R. 08/
) \Oe- w\.
I
f~ -
- .
I
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:
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County S4,
~
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. Re ' wed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). fir' 2
Property Owner Property Location
t k t r vs Govt. Lot 1 /4 ~&gr 1 /4 S T Z ~ N R ! E (or)(90-
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
7(~ 176 Run
City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road
vhw`wvLcA wt !i~ yor.s (7/5 ) q--2793 hr",n,, n-d oaf
New Construction Use: Residential / Number of bedrooms 3 _41 Code derived design flow rate Q GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material (I Flood Plain elevation if applicably, .f// A ft.
General comments S S e wl e (e v, 9 ~7. re Lo---I- o
and recommendations: Y r 'F!VEO
~L1 el LV • Q,7, f/v Gowtr 9 7• a a t
aT fsf i.'
Boring !0NifgGCrFF?0E v!
Boring # e~
® Pit Ground surface elev. WQ ft. Depth to limiting factor '1- in. di pplication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary , Rqpts, ` GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
I -I ( 1 isZ rno-bk rY?cr C-
Z I- 10 5' Zrr,ab -'G' C- 5 - 5 8
3 - 1 5 l m5 rn-~( 1 • Z.
I S bra ltmeS6e AJP NP
Iz Yr
Boring # ❑ Boring
Fz--] Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
I b-iq a r3 I S;1 Z k ry~ c (v~ .5
Z I -4Z. \6 I S; -,Y ~r- Ls - •5
Z
3 `I2- 10 LS rn m c5 - .-7
0 sl rtn A) P P
* Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature CST Number
Adoj" .5r-A make 253 3
Address Date Evaluation Conducted Telephone Number
Yoe)
13 02 (745 2q 7-
SBD-8330 (R07/00)
Property Owner -~4hok1 rS Parcel ID # Page Z of
Boring
F~] Boring #
Pit Ground surface elev. 7 Z o ft. Depth to limiting factor Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
5
2 c 34 S/I rr r C-
s S $
3 15L r`I L5 l ~s - .7 1.2
~f s p s/~, ~rq 1` e - - fVP AJ P
❑ Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
❑ Boring # ❑ Boring
Pit Ground surface elev. ft. Depth to limiting factor in.
El Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L
f The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
SBD-8330 (R.07/00)
r ,
- T
PAGE_ OF 3
NAME bk&4/c ' n S LOT# Z LEGAL DESCRIPTION~vw Y ,u►-- Z,S / ~ T Z q ,N,R, E(or)~O
SCALE: 1"= y0
BM 1 ELEVATION
BM 1 DESCRIPTION a pJL p~ -
BM 2 ELEVATION ~9 SU
BM 2 DESCRIPTION -~,e
SYSTEM ELEVATION p 9QU Low c r
`l $
ALTERNATE ELEVATION Q7jfj9 tow c,r T 7. o O
CONTOUR ELEVATION 99.;0, q Y, a o
-l
vmc-
z
d-Z
qq d" q g', c~
$f2
SIGNATURE _ DATE
r C~/!~/lzP6a! 1!/rSS~C° PAEaE of
PUMP COMBER CROSS SCCTIOKJ AhlD SPECIFICATIOKIS
VEWT CAP
4~ VCIJT PIPE WEAT}{ERPR00F APPROVED LOCKING
JUIJCTIOIJ DOX MANHOLE COVER WITH
25' FROM DOOR, W~rWING LnBEI
WI4DOw OA FRCSN 11. MIU. i
AIR INTAKE i
GRADE I
q* MIU.
~ i a' PSI1J.
COQ DUIT-~
IAILET A KTI .HT SEAL I
7
APPROVEp j01UT A I III APPROVED JOf~;`
P pip
i W/ ' PIPE
W/ IPC EXTENDIMC► 3' I III ALARM EXTCWDIUG 3'
O►JTO SOLID SOIL I I I ONTO SOLID Sol
e I I
Ou
c I
I ~U_EV. FT. Put1P- __J
b OFF
v
COWCRCTC CLOCK
RISER EXIT PCRMI-MCD OWLy IF TAUK MAULlFACTURCK HAS SUCH APPROVAL.
3" PtPPROVEh, f~E>I ijNG Uvidcr rtsr.IK
SEPTIC E SPECIFICATIOLIS
D05C l a1
TAUKS MA►IUFACTUR[R: `~d r NUMBER OF DOSES: _ PER DA-4
TAWK 51ZC: AV) GALLOWS DOSE VOLUME
f l f Oe IMCLUDIMG 6ACKFLOW: /-~?ms- z -GALLONS
ALARM MAUUFACTURCR:
MODEL WUM6CK: CAPACITIES: A= _ IUCHCS OR GALLONS
SWITCH TypC: IwtHES OR GALLONS
PUMP MAMUFAC'TURCR: C INCHES OR L''rl_~In CALLOUS
MODEL MUMDCR: D INCHES OR G A L L 0 Q E
SWITCH TyPC: I1111'17' PUMP AUD ALARM ARE TO DC
MIIJIMUM DISCHARGC RATEr~ IN57-ALLCD OW SEPARATC CIRCUITS
VERTICAL DIFFEKE'UCC bETWCCIJ PUMP OFF AUD 0I5TRI2,UTI0U PIPL.. FEET
+ MIIJIMUM NETWORK SUPPLY PRESSUR,E.. . . . . . . . . _ FCCT
+ _ Fir ET OF FORCE MAIM Y,1-2O~ F/~oo►r.FRlCilo►1 ~:ACYOR.. FEET
TOTAL O'iQAMIC. H%Al) FEET
1UTERIJAL. f)IMEUSI C OF TAUK: LE►4GTH _ ,wiurii --LIQUID DEPTH
.01 7
IGQE0I _ LICENSE KJUMBER: Z VQZ- DATE:
PerloftAnce Submersible Effluent,.,,,!:.•r,r
Curves Pumps
METERS FEET
90
MODEL 3885
26 SIZE 3/4" Solids
E15
70
t 20 WE10H }
60
N
HWE(SWEOIH~
so
15
40
H 10 E03
30
E
03
W N,
20
k"t
5
!9 1 OWN=
0 0
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
L 1 i i
0 10 20 30 m'/h
CAPACITY
[ GOULDS PUMPS, INC. f
SEAECA FALLS NEW YOPK 13148
METERS FEET
120 MODEL 3885
35 SIZE 3/4" Solids
110 WE15HH
100
30
90
25 80
70
20
80
0
~
50 WE05HH
15
40
10- 30
20
5
10
0-
0 10 20 30 40 50 60 70 80 90 100 110 120 GPM
1 , i 1
0 10 20 30 W/h
CAPACITY
01985 Goulds Pumps, Inc. Effective July, 1985
C3885
11ONVI'S OWNER'S MANUAL & MANACEMLNT PLAN Fogs L.h_5
FILE 'INFO MATION SYSTEM SPECIFY TI
Owner 4:f _11111 Septic Tank Capacity al o NA
Permit i# o o Septic Tank Manufacturer o NA
Effluent Filter Manufacturer - o NA
DESIGN PARAMETERS Effluent Filter Model 4-11,60 O NA
Number of bedrooms o NA Pump Tank Capacity al o NA
Number of Commercial Unit NA Pum Tank Manufacturer S o NA
Estimated flow averse al/da Pump Manufacturer o NA
Design flow (peak), Estimated x 1,5 gal/day Pump Model o NA
Soil A plication Rate _ gal/da /ft Pretreated Unit
Influe11071,11uont Quality Munthly Ayer{ ngcl' u Smid/Oravul filter to I'cntt Filter
Fats, Oils & Grouse (I.OG) 510 ing/L ri Muc:hanival Aeration U Wetland
Biochumicnl Oxygen Demand (BODs) 5220 mg/L o Disinfection o Other.
Total Suspended Solids (TSS) < 150 m L Manufacturer
Procreated Effluent Quality O NA Monthly Average** Dispersal Cell(s)
!n•ground (gravity) o In-ground (pressurized)
*
Biochc;mic;il Oxygen Demand (I30Ds) <10'ppg/I-' grade o Mound
Total Suspended Solids (TSS) 510~mg/L c o A Att- -line o Other. rip.
Fecal Coliform (geometric mean <10' cfu/I00mL
-Maximum Effluent Particle Size '/A inch diameter Values typical for domestic (non-commercial)
wastewater and septic tank effluent,
Values typical for pmtmilod wastowacor.
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tanks At least once ever o months itf ears Maximum 3 r~
Pump out contents of tanks When combined sludge and scum a uals one third of tank volurl
Inspect dispersal cells At least once eve o months ears Maximum 3 rs
Clean effluent filter At least once ever o months your(s)
Inspect um , nlm colllrols & alarm At loam once. ever u months vur s c NA
Flush laterals ;ind prossure lest At least once ever o months o curs "A
Ocher; At least once ever o months o eur s ANA
Other: At least once ever o months o ears --e:-NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certification
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 tl
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 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 ('/3) or more of the tank volume, the ent
contents of the tank shall be removed by a Seputge Servicing Operator and disposed of in accordance with ch, NR 113,
Wisconsin Administrative Code,
The servicing of effluent filters, mechanical or (pressurized POWTS components, pretreutment components, and any other
maintenance or monitoring at intervals of 12 months or less shall be performed by a certified POWTS Maintainer,
A service report shall bo providod to the locuI r(:guhoory authority within 10 days of completion of any service event.
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 my impede the treatment process and/or damage the dispersal call(s), If high Conoentrawons Am detected ha
the contents of the tanks(s) removed by a septage servicing operator prior to use.
Owner: "4fa1 " nl Pu8a';j'?_o1 112
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal high water levels. When power is restored the excess wastewater
will be discharged to the dispersal 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 soft absorption are.
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.
ABANDONEMENT
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 ch. 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:
_~K-A suitable replacement area has been evaluated and mly Abe 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.
o 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.
'taf'~:'The site'bi i ot'been'evaluated-6 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.
Q 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 the time.
<<WARNING>>
SEPTIC, PUMP AND OTHER TREATMENT N TANKS MAY CONTAIN LETHAL GASES 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.
ADDI'T'IONAL COMMENTS
POWTS INSTA POWTS MAINTAINER
Name Name
Phone ~ - Phone ; .
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name '
Phone Phone
ST CROIX COUNTY
SEFTIC TANK MAINrI E.",''ANCE AGREEMENT
A. L)
0 6 I•I11) r~-:Gl<1'iI,'IC'ATIQN FOJ- vt
Owner/'Buyer auk&,)
Mailing Address
Property Address
(VvriilcaUon rvgkmed f rum 1'I,ioning Dcjnriwcm for new construction)
(y/S(at0 1AJ l )--r l'arcvl Identification Number
LEGAL_ DESCRIPTION
1 rop4rty location ACYl)- ''/a, ~ Svc. -Z7 T N-R LZ_W, Town of n
S,ibdivision A~w 6 r , Lot #
('crtified Survey Map ii _ T V Jume , Page #
Y a r r a n ty D c e d# V U I urn e , Page #
Spec house Q yes fW no Lot lines identifiable- yes 0 no
S`'5TEM MAINTENANCE
Improper use and maintenanecor your srl tic systein coup: Ic;olt in its pruntaturc failure to handle wastes, Proper maintca;.ui~c
c~ ists of polls ping out ihr septic tank every three yours or sounrr, if deeded try a liconsodpumpor, what yvu (gut into the sy~teut
ca.. affect tie function of the suplic tank as a trvatnent stage in the waste disposal system.
The property owner agrees to submit to St, Croix Zoning ')epartment a certification form, signed by the owner and by a
master plumber, journeyman plumber, restricted plumber or a licensee: pumper verifying that (1) the on-isite wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pump rig (if necessary), the septic tank is loss than 1/3 full of sludge,'
Uwe, the undersigned have read the above regwrcmvnts and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and tho Uepartmont o!' Natural Resources, State of Wisconsin. Certwicatioa
stating that your septic system has been maintained must be complctcd and returned to tho St. Croix County Zoning Oftico within 30',,
days of the three year c r • n date.
SIONATURI, OF A PLICANT DATE
W ER CER IFICATION
I (we) certify that all statements on this form are true to ,he best of my (our) knowledge.. ).(w;) ,Am (are) the owner(s) of
the property, described above, by virtue of a warranty decd rocordru in Register of Deeds Office.
-6
StuNATUI J1' 1' APPLICANT DATE
Any information that is mis•rcprescnted may result in the sanitary permit being rovokod by the Zoning Department.
Include with this application: a stamped warranty deed from diQ Rogistor of Deeds office
a copy of the certified survey wup if reference is made in the warranty dood
J 2 2 5 6 P 118
7 2 3 3 4 8
DOCUMENT NUMBER KATHLEEN H. WALSH
REGISTER OF DEEDS
E WARRANTY DEED ST. CROIX CO., MI
RECEIVED FOR RECORD
05/29/2003 08:00AN
Midwest Equities, LLC, Grantor, conveys and warrants to Cameron L -
Vasser and Claudette vasser, husband and wife, holding as survivorship WARRANTY DEED
marital property, Grantees, the following described real estate in St. EXEEl~T
Croix County, State of Wisconsin:
REC FEE: 11.00
Lot Two (2), Prairie Run, Town of Hammond. TRANS FEE: 109.50
COPY FEE:
CC FEE:
PAGES: 1
i
NAME AND RETURN ADDRESS
0,4472 &-72e.v
3 }~A~EL Gt i4E -3
018-1036-80-000 ~d ~7
Parcel Identification Number
This is not homestead property.
Exception to warranties:
All easements, restrictions and rights-of-way of record, if any.
s
Dated t is d 3 day of May, 2003.
(SEAL) (SEAL)
rry J. a dfi s, I-MiTaging Member of
eat Equities, LLC
(SEAL) (SEAL)
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN
s
U'Le COUNTY s.
authenticated this day of 20 Personally came before me this Z34ay of May, 2003
the above named Larry J. Wellens
(Signature) to me known to be the persons(s) who executed the
foregoing strument and cknow dge the same.
(Name Printed or Typed)
TITLE: MEMBER STATE BAR OF WISCONSIN (Signature) li
(If not,
authorized by §706.06, Wis. Stats.) * )Name Printed or Typed)
THIS INSTRUMENT WAS DRAFTED BY: Notary Public County, Wis.
Leo A. Beskar my commission is perman nt. (If not, expiration date:)
Rodli, Beskar, Boles & Krueger, S.C.
P.O. Box 138 Q
River Falls, WI 54022
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