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HomeMy WebLinkAbout018-1094-10-000I ~ a3i n~i a, o N 7 7Z' N ~ C ~ N O N N fl. ~ I oo~~ ~ v I 3 0 7 I ~ cnzD m ~ D ~' ~ a W 3 O ~~ ~- O I I ° O -o I =' n ~Q ~ ~ N ~. a Z O O 7 y d O y fD N C V1 W ~ O N Q ~ ~ ~ I ~ ~ -~ ~ ~ O y ~ ~ I ~ y Qo I o ~ > > o m .o ~ ~ I o .. I ~ CDa obi I I Q < a _. o ~ m ~ - ~ Z ~ o a a m 0 m 0 i m n m N I N I O N ~ f O ~ c ~ ~ ~ ~ ~ ~7 ~ ~. 3 3 o ~ ~ O ~~~pp O M m a 7 fll y C ~ - A o a a 0 0 ~ cn c°O N N O O = A A d 3 3 ~ 'o ~ ~ O O O a ~~~~ ~ o v ~ ~ ;~ w o ~'• ~ ~ Cf y 3 °-' ~ .. 3 7 ~ O 7C' - 7 O N ~ O ~p N ~ ~ C C (7 N ~ d N Q. O ~ c in a W ~ a 3 °o ^' N CZ G ~.I.~ T C 3 a 3 d o ~ ~ 3 ~ ~ o~i = s o y V -+ N ~ tD j O -' ~ V ,A a ~ 0 c 0 o y ~ S v' N :'.' 6 3 o~ -• -1 N ~ Z ~ `A 2 O .. O ~ < ~ V ~ Z a ~ z -' m ~ ~I J d C m O A~ 0 O ~• O 0 ~~yy,~,~ • vV 0 x A ``~ N a O 4 0'Q V ~ O ti Wisconsin Department o1'Commer~ e Safety and Building 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)]. Permit Holder's Name: City Village X Township Midwest E uities Hammond Townshi CST BM Elev: Insp. BM Elev: r ()O BM Description: , p~ ~pG~ TANK INFORMATION TYPE MANUFACTURER ~ ~^. o I CAPACITY Septic Z .: ~-,~ ~~ ~ w~-k-5 IoUU GQ Dosing Aeration Holding t.t. b - r c TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~a -~-~p' ~- Z ! ____ Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Nu e TDH ift Fri Loss System Head TDH Ft F cemain Length Dia. ELEVATION DATA county: St. Croix Sanitary Permit No: 430640 0 State Plan ID No: Parcel Tax No: 018-1094-10-000 Section/Town/Range/Map No: 17.29.17.750 STATION BS HI FS ELEV. Benchmark. f 9 ' ` Alt. BM Bldg. Sewer ` y Z ~ ~- 3b~ SUHt Inlet 7.tt ~ (o SUHt Outlet 7 ~~ ~ ~~I L Dt Inlet ~ Dt Bottom f Header/Man. $.2 ~ LJ~rt~ Dist. Pipe Bot. System `~`~' ~ s 4 • av ~ Final Grade ~ I (..9 ~~ St Cover oe r S i ~.~. C.' N ~~ e~ cw~.r 3.8 ~ OD . v SOIL ABSORPTION SYSTEM ~ BED/TRENCH Width Length No. Of Trenc PIT DIMENSIONS No. Of Pits Inside Dia. Liquid De th DIMENSIONS 3~ '70 Z SETBACK INFORMATION SYSTEM TO P/L BLDG WELL g} LAKE/STREAM LEACHING CHAMBER OR Manufacturer. S+~t: l'E ra{'o'/ Type~OfSystem: (f ~ ~ i d ~.x 3~ r` r ZS ~ 9~ , f.J~~ UNIT ' Model Number: ~ .~,.> ..,.y fj Ctti 1- (~~: clC DISTRIBUTION SYSTEM ~O Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake 8 "~ Pipe(s) _ J, g~ Length Dia Length Dia ~ SOIL COVER ~ x Pressure Systems Onlv xx Mound Or At-Grade Svstems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Cent ~- 2, . Z Bed/Trench Edges Topsoil f -, - ~_I Yes L_i No ;Yes No i COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: "Z / rT /~ Inspection #2: / / Location: 990 167th Street Hammond, WI 54015 (NW 1/4 NE 1/4 17 T29N R17W) Prairie Run Lot 10 w t Parcel No: 17.29.17.750 1.) Alt BM Description = 3~ ~~ ~• "'o "" ' ~ ~ P 1 `' ` ¢ `S ~ ~ ; K S ~.-~ ~-'~ ` t' -- ~~ ~G.''t ~ 2.) Bldg sewer length = 3'j f~ - amount of cover = 0~'7 ~~ o.~k ~. o vs-fL ~ ~ -POL.U ~ 1 ~z-y~ ? Plan revision Required? Yes [] No ~ ~ Use other side for additional information. ~_~ ~ ~ _~ Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) ' Safety and Buildings Division County i ~ ~ 201 W. Washington A ~ ~seonsin Madison, wI s ~o~ -~~EIVE ~ 't Number (to be final in by Co.) De artment of Commerce (~$) 26 3151 ~jD(o O Sanitary Permit Application JAN 0 7 20 ~`At0 laaLD. Number In accord with Comm 83.21, Wis. Adm. Code, personal information u provido may be used for secondary purposes Privacy Luw, s13.(Yt(I)( ) ST. CROIX COU roJect s (If different than rtwling address} ZONING OFFIC 1. Application Information -Please Print Ail Lil'ormution Property Owner's Na me Parcel q Lot M ' - s ' - 1 c4' - to - avo - '~ $U Property Owner's M ai ' Address _1 Property Location 1 Ci St ty, ate Zip CuJr Phone Number ~ , ~- ~ _ (circlryAe) ~ ' II ' ' T N; R~_$ or(yf . t ype of Building (check all that apply) S 1 or 2 Family Dwelling -Number of Bedrooms ~ Subdivision Name GSM-Alnmbvr ^ Public/Commercial -Describe Use ~ ^ State Owned -Describe Use Cct~ sty ^Villa owttship of It III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' New S stun ~- y ~ U Replucvmertt System U 'freaunvnUHulding'I'artk Kvplacemem Ortly ^ Other Modification to L7xuting 5ysteot B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New' L-st Previous Perttut Numbvr aad Date Issued Before Expiration Plumber Owner IV. T e of POWTS S stem: Check all that a I) Non -Pressurized 1rrGround U Mound > 24 in, of suitable soil ^ Mound < 24 in. of swtable soil ^ At-Grade ^ Single Pass Sand Filter ~] Constructed Wetland ^ Pressurized Ih-Ground ~...) Molding 'l'ank ~.,~ Yeut Filter ^ AeroblC Troatment Unit ^ Recircultting Sand Filter ~ ^ Rccirculatin Synthetic Media Filter Leachin Cha r ^ Dri Line Gr vel•less Pi ^ Other (ex lain) V. Dis ersal/Treatment Area Infor ation: ~ Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Requir (sf) Dispersal Area Proposed (sf) System Elevation ~~ L ~ n~ V1. '['ank Info Capacity in 'total Numlxr ~ ~ Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units I Concrete Constructal Glass New Existing Tanks Tanks Septic or Holding Tank _ S., ` / 7~ Aerobic Treatment Unit Dosing Chamber L ___ _ _ __ V11. Responsibility Statement- I, the uudvrsigned, • ~umc responsibility fur ittstullaUou of the PUWTS shown ou the atwched plans. Plumber's a me (Print) Plumber's Si tar • ~ MP/MPRS Number Business Phone Number ~/ ~ - _ _ z s Plumber's Ad re ss (Street, Cuy, State, Zip Code) J~~ t E ~ ~ - ~~ Vlll, Cowtt /De artment Use Onl nppravvd ^ Disupprovud Sanitary Pvnnit Pvv (includes Grourtdwutcr Date Issued I sal Ag`nt Signatu (No Stamps) ^ Owner Givvn Reason for Denial ~llfChal'bl' I'CI') ~y~ 2 Jv ~--- ,d4 iX. Conditions of Approval/Reasons for Disapproval 3` Il1o rr ~' / ~ f ~ ~ i SYSTEM OWNER: J -t`l, q~p~1Mq 1 Septic tank, effluent filter ,]rite I ` ~ a ..~.K " 0. ~0. w t dispersal cell must ali be se~;~re~d ~ rr,aintained ~ ~ / ~ as per management plan provideG ny plumber. ~t. ~, ~ i~ C~„ ,~,, 2. All setback requirements Irtus: ut =,~;Irttai d ""a" ne ~ as per applicable code/ordinarll:;: ;~, _~ . - VV i V V ..•.•..,. ww+p~a~a paws tw wo ~Owtq unryl wr taf gstga 0a paptr a0t riU ttIAA atR X li WC4U t# ttW SBD-6398 (R. 01/03) ~ ` a L` -' ~II~ w f~~a ~~ i .--' ' ~ U~ © ~ ~\` ~~ nl ~~ ~ ~ ~' ~ ~ ~~ ~ ~ ~~ ~~ ~~ W t _ ___ ~ _ _. _ __--~~ 1, ~~ I r~ I J ~~ ' ~. J 1 ~ -_ M q W ~~`' • " ~ ~ ~ ~-- \ b ~i ~ . a ~\ ~` n ~ ~ ~ ~~ ~ ~1 ~ \ \X ~~~ ~~ \ ~ ~,~o ,~ s-p' t3/off s,eY~B/k',~ --~--- _. _ _ _ - - - - -- -- -t,-~-,-,-~ (Q(~ .l ~, 09 1gd~ ~~ ~ ~ ~ y ~' ~^ ~ ~ ~~ ~~~~~ ~~ ~ ~ ~~ ~~ ~ ~~ ~~, .- --_--- ~W _ _ _. .~? / I ~J~=fi6rC.Cri.~;.~~ u~' v -+"-r-----~ t~ ~~ 1 _T _-____ ~. ~. ~; ~~ ~,z. ~~ ~t ~l ~~' l ~ __ ~'~ c' ~~ "~ .~ ~ , ~~ ~ ~1 ~~ °~ ~, R1l~ ~ ~.a~, ~ ~~~ - 8,., h~ ~. ~-, ~-~ ~ E3ia! sKrB,tc,~ ~~ ~~ a~'~° ..~ . ,~ . Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT Page ~ of 3 ... ,..,.,.,...~.,.,., ..,.,, ..,,,,,,,, .,.., ..~~. r,..~~,. .,.,,.~ County C ~ Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must fCDIX • 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. ev' wed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ ~ ~ 9 Property Owner Property Location ~j t~ t Govt. Lot ~~ 1 /4 if//~' 1 /4 S f~ T z q N R!~ E (or)1dD Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# ~~~ ~~ ~ s~• 10 Iai 1J City State Zip Code Phone Number ^ City ^ Village ~ Town Nearest Road ,~/~ 17~ t4't v-'t o rtG( i S` ai S (7~/S) 79G - z ~Y o /~ " . G~J` i~ ~ - New Construction Use: [~ Residential / Number of bedrooms 3 `~ Code derived design flow r8te~1! .„~R'~ G .a ~ GPD ^ Replacement ^ Public or commercial -Describe: ~ ° `~ ' Parent material ~ ,• ~ ~ Flood Plain elevation if applicable ~/!~- i ` ft. General comments 5~ s .f~~ ~~~ 0 , ~,~ y y. ~d Gou..~r q'~' ° v ~""~ and recommendations: Q t ;r' ~~ `.L,. I l ~ Boring ~"~~•~ Boring # a ® Pit Ground surface elev. 7 ~ ~G 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 f d -I(~ 2 ~i ~ 2m r~r ~-5 l v~ - 5 8 Z 1 - )p y 13 ~'c.i ZrruabK m r c - • ~! 3 -~! ~ U I ~- S m m r c s - .~ /. 2 `~ y -goo In mS S 1 - - - ~ ~. Z q .~~ ^ Z Boring # ^ Boring ~ Pit Ground surface elev. `~~~ 3 ~ ft. Depth to limiting factor ~ ~ in. Soit Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ~ -IZ I~ ~l s,l 2 ~ I~-~ .5 . ~ 2 _ 2~ t- I t_ S 1 l~s r c - 2 3 ~-~~ i ID I ~-- ~-, s rr, - - . ~ I • Z * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 =GODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number 1~dgm ~~_ maker ~ ~ 25~ 3~ 9 Address Date Evaluation Con u Telephone Number ~I/3 gU'}' S~. ~omer5e-~, tl ~f ~5Z1y2~ l/-28'-d/ ~~~5)Zy7_ ~lUaB 'r Stall-8330 (KU7/OU) w!. _~ • / Property Owner t lult~lU -'~S Parcel ID # Page ~ of ^ Boring Boring # fSl Pit Ground surface elev. 97 • ~O ft. Depth to limiting factor ~~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 I p-~ Z 5i 1 2 r C.S f v . 5 $ 2 ~- I - L5 rns -~ c.5 ~-- - 2 °~. cs.2 - .~ - _ ~ s ^ Boring ~''~''r ~ '~ "~ ` * ^ 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/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ^ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ^ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L 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 deparhnent at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) . ~ • .. -, r "PAGE 3 OF 3 NAME ~ ~ ~ ~ ~ ~` ~ S LOT# JD LEGAL DESCRIPTION ~tIW ~ NCB ,S t ~' T 29 N R. t ~ E(or~ SYSTEM ELEVATION ~s p qW. $ d Gow c r 4 W O v ALTERNATE ELEVATION ~oQ~l5.4S0 ~owcr9S0o CONTOUR ELEVATIONS g, G ~i t I oy•o v 3~ - ~^ ~ grn ~ .o ~~. 8.3 I si~P~ Y, 3 ~1 5 Pte. ~- ~" y.a d g-Z J• e-- ~~ ~,o°~ SIGNATURE ~~ ~- 4~----~~~ DATE / Z - /-~ _ ~ ~ ._~~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of FILE INFORMATION Owner Permit M D / O DESIGN PARAMETERS Number of Bedrooms ,~ ^ NA Number of Public Facility Units f2FNA Estimated flow (average) al/da Design flow (peak(, (Estimated x 1.51 al/da So!~ Application Rate al/da /ft~ Standard Influent/Effluent Quality Monthly average' Fats, Oil & Grease (FOG- 530 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODE) 530 mg/L Total Suspended Solids (TS51 530 mg/L ^ NA Fecal Coliform (geometric mean) 510' cfu/100m1 ~,~a,:imum Effluent Particle Size Ye In dia. ^ NA Other. O NA '"Values typical for domestic wastewater and septic tank effluent, MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity al O NA Septic Tank Manufacturer _ O NA Effluent Filter Manufacturer ., O NA Effluent Filter Model _ -'] O NA Pump Tank Capacity al ANA Pump Tank Manufacturer ANA Pump Manufacturer ANA Pump Model O NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration O Disinfection ^ Peat Filter ^ Wetland ^ Other: ~. NA Dispersal Cell(s) ,~ In-Ground (gravity( ^ At-Grade ^ Drip-Line O NA O In-Ground Ipressurizedl ^ Mound ^ Other; Other: O NA Other: O NA Othor; ^ NA Service Event ~ Service Frequency Inspect condition of tank(s) At least once every: ? ^ month(s) (Maximum 3 years) ~ ear(s) ^ NA P~~mp out contents of tank(s) When combined sludge and scum equals one-third lY,l of tank volume ^ NA `.Y __ Inspect dispersal cell(s) At feast once every: ~ O month(s) ~ ~. ear(s) (Maximum 3 years) O NA Clean effluent filter At least once every: O monthlsl ~- earls( O NA Inspect pump, pump controls & alarm _ At least once every: O month(s) ^ ear(s) .® NA Flush laterals and pressure test At least once every: ^monthlsl ^ yearlsl ,~ NA ~;tnor. At (oast once every: O monthlsl p ear(s) O NA Gihor O NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any 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 cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to cheok 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 IY,1 or more of the tank volume, the entiro 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 S12 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. BMW i4/011 . Page ~ of _~ START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tanklsl for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cellls-. If high concentrations are detected have the contents of the tenklsl 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 putegss pump tanks may fhl above normal hlghwater levels, Whon power Is rsstarad the exoess wsstewetar will bo discharged to the dispersal cell(s) In one large dose, overloading the oelllel and msy result Jn the baokup or surface dlsoharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servloing 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 tie 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 disposod 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 repla,.clement system: ,eSl 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. D 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 aroa. 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. O 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. 1DDITIONAL COMMENTS ,: 'OW ~ S INSTAL E ~ POWTS MAINTAINER Name -. ~ Name Phone -_ - _ ~ Phone ~EPTAGE SERVICIN(? OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone _ ~~.s document wee drehsd In oompllsnce wkh chapter Comm 83:22(211b111-Id1&lf) and 83,6411), 121 6 (31, Wisconsin Admtnlstretlve Code. ST Ci:~~DTX CtD~(JN'l'Y SEPTIC TANK MA1N"1,L~NANCE AGREE'MEN'T' AND OWNER5IIIP CL~RTII~ICATION FORM owner/Buyer Mailing Address '1~ ~~ sib d a- Proporiy Address 7 ~ ~ ~ ~-~-~~ (Verification required from Planning Departzncnt for new construction) ~ / ,_._ tc Z1/y1'Ze~1/LCQ~ l I'areel Identification Number O Ig ' ~D9`l -1 ~ ' ~ L' ~~~ City/St,a ~rGAZ, DrscR~P~zON Property Location ~._.'/,, ~'/~, Sec. ~ 7 . T~_N'R-~-~-W, Town of ~~ ,(..rtz, .Lot #~ ~. Subdivision Certified Survey Asap # ~- .Volume ____ .Page ## ~;'- ,Volume r~~1~~~._.-._.., Page ## <~ Warranty Deed ## 70?~ ~ Spec house ^ yes no I,ot lines idetififiable~j yes ^ no SXS'I'EM MAZNTFNANCE Improper use and maintenanccof your septic systcnz could result in its premature failure to handle wastes. Propermaintenaacc consists of pumping out ilzc septic tatzk every tltzee years or sooner, if Aiecded 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 systczzz. The property owner agrees to subznit to St. Croix Zovi++g DcparhTient a ccrtifiz;ation form, signed by the owner and by a aza$tFrplumber, jourtreyrnauplumber, restricted plumber or a lieeziscd putr~perverifyiug tItat (1) the on-site wastewaterdisposal system is in proper operating condition and/or (2) a filer inspection and pumping (if necessary), tfze septic tank is less than l/3 fvl.I of sludge. Uwc, the undersigned ]rave read itze above rcquirctnc+zls and agree to nzaizzlaizz the private sewage disposal system with the standards set forth, Iiercin, as set by the Department of Conzzucrcc and the Drparluzent of'Natural Resources, State of Wisconsvn. Certification stating that your septic systezu Uas been maintained must be conzplcted and returned to the St. Croix County Zoning Once antWn 30 days zc tbz•ce year expiration date. . ~ ~~-~ b~ NA : OP APPLICANT DATE ®WNrR CrRTIJC+'ICt~.'T'ION I (wc) certify il+at all statements on tl+is forrrz arc tnzc to the Ucst of nzy (our) kzzowlcdge. I (we) am (arc) llic owner(s) of the pro criy described above, by virtue of a warranty deed recorded in Register of Deeds Office. IGNA' ~ OIL ,APPLICANT DATE Any inforzzzation that is mis-represented may restzlt in tire sanitary permit being revoked by the Zoning Depa:imcnt. ****«* •~R~Y ~F• •• Include with Qzts application; a staznpcd wananty decd from tlzc Itcgisicr of Deeds office zz copy of tire certified szzrvcy mal+ if refcroncc is made in the warranty deed 'J 2252P 340 DOCUMENT NUMBER pARRANTY DBSD William E. Hawkins, Grantor, conveys and warrants to Midwest Equities, LLC, Grantee, the following described real estate in St. Croix County, State of Wisconsin: Lots 1, 3,' 6 10, 11, 12, I3, 17, 18, 19, 22, 27, 30, 35, lA and 3A, Prairie Run, To n Hammond. NAME ND RET RN ADDRESS ~- S vi~~CS 9~ofd~/~~~ fsf.5~iib 18-1037-10-000; 18-1036-90-000 18-1036-80-000; 18-1036-70-050 Parcel Identification Number This is not homestead property. Exception to warranties: All easements, restrictions and rights-of-way of record, if any. Dated this S 3 day of May, 2003. (SEAL) William E. Hawkins AUTHENTICATION Signature(s) (SEAL) authenticated this day of 2003 (Signature) (Noma Printed or Twedl TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stats.) THIS INSTRUMENT WA3 DRAFTED BY: Leo A. Beskar Rodli, Beskar, Boles 6 Krueger, S.C. P.O. Box 138 River Falis, WI 54022 ~~~~~i KATHLEEN H. YALSH REGISTER OF DEEDS ST. CROIX CO., MI RECEIVED FOR RECORD 05/23/2003 02:20PM 1tARRANTY DEED EXEMPI ~ REC FEE : 11. @0 TRANS FEE: 594.00 COPY FEE: CC FEE: PAGES: 1 ACIQ70WLED(~II+NT (SEAL) (SEAL) STATE OF WISCONSIN ) ss. COUNTY ) `)~J''~1 J` Personally came before me thispfJ ~ •:~ayt3~'~M`dp, $p03 the above named William E. Hawkins' :' `' to me known to be the persons(s) whO•ex~~u~the ~ foreg in instrum t and acknowledcSe;~La.,satne.p~ v', ~~ ttll ~. Si na CUte M vn ' * ~' ` 7 ~ ~'. Name ~r ~d or T ed Notary Public ~k •~o~n-ty, •Wis. My commission is permanent. {If not, exoir_atiori date:) ~tl ~G a~6~ v ~ O ~ I ~I J I „J I I .I I IVI I __ ___ --_ _ _ _ - I - _ - _ _ _ _ _ ._____.~ J' r I ---~ m ~ I I I~ ~ - I I a.l N I , ~' I I ____-I_ _ ____ - I ---t--- ~- -" ~ I ~ _ 1_-- _ - .--. - - - I ,~ ------- I o 1 6 6' I E T I SHE _ , I I ~_-_-___._.--~---- - _ ` I _ _ _ - _ `_ -- -- - ----~ --- - M PUBLIC-_..__ - _ --- R oA D o -___-- ~, N00°39' 03"W 91 I. 86' .~ ' ~------ 200.32'-------•---- M 116.35 _--~,~~ III '~"~ - 'r " 76'---------- ____-- 227.89 ----- o - 227.89 s~,,, W.r~ ® .............I.................~....................... o ~ co ~- ~ ~. ~~ ~ N M ~ (~ N ~ W N L ~ ~ W L Q f _ M ~ O ~ tt ~ r ~. aC 1~ N sr N M .J . cp ." J . ~ ~, O0 N i. ~ 80 5j3• Q33. a 83' - 55 ~~ S00° 39' 03" E . 2 .89' ~°R '~ 255. T6 a`°` ~: -,.` . T O~W' ~ DRA 1 NAGS ~ 1 N1..3,'g1' 3 ...-- 3 i . 5T. 88 ~- ,.., , sr 57• ge' . 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