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HomeMy WebLinkAbout018-1094-13-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION ~ATTAC~-1 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: 7~ Insp. BM Elev: BM Description: ~ ~ - ~. ~., t, TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic WL ~ ~~ .~~, ~i ~~~ Ds>si17g ~~ j Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~~~ ~ ~ T~ ~ ~ f Dosing . Aeration Holding PUMP/SIPHON INFORMATION ~. ELEVATION DATA county: St. Croix Sanitary Permit No: 453203 0 State Plan ID No: Parcel Tax No: 018-1094-13-000 Section/Town/Range/Map No: 17.29.17.753 STATION BS HI FS ELEV. Benchmark J ~ /0 tJ ,~, -7 , 7 _] ^ ~j Alt. BM l~lor,1*i- ~~ t3a ~a ~ ~ G ~ ~l : Z , ~6 /d 3 . ~ ~ Bldg. Sewer I ( Q$ 9~' ~ ~ SUHt Inlet SUHt Outlet ~ I, 7~ G~~ I~ D 3 Dt Inlet Dt Bottom ~ ~ Header/Man. ~ ~~ ~ 9 3 . Dist. Pipe , I q~ G / ~(~•~ Bot. System 1L.`~ Z.~( Final Grade f3 3 ~ 9 8'. ( ~ ~ ~ ¢ o St Cover . f ~ A/ Manufacturer Demand G Model tuber TDH ift Friction Loss System Head TDH Ft Forcemain th Dia. Dist. to well SOIL ABSORPTION SYSTEM /~J / (p~{i BED/TRENCH DIMENSIONS Width ~ ~ Length ~ j ~ 1i2 No. Of Trenches Z ~~~G~ t 1t PIT DIMENSIONS ~ No. Of Pits ` Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufactu~ J '~ fi ~ (~~ -•~ , . Type Of System: C W.,,~~.~-~~a ~.. i 3~ y Zy -~~~ ~- UNIT Model Number: ~,~, ~ DISTRIBUTION SYSTEM Header/Manifold ~~ ~ L th ~ Di Distributi Pipe(s) ~ \ ~ x Hole Size ~ x Hole Spacing ~ Vent to Air Intake Z~ eng _ a_ Length Dia Spacing SOIL COVER z Pressure Systems Onlv xx Mound Or At-Grade Svstems Onlv GIB.-a ...L~..~ Depth Over Bedlrrench Center ~ I Depth Over Bed/Trench Edges \ xx Depth of Topsoil \ xx Seeded/S dded ri Yes i~ No xx Mulched ^ +I Yes ~_~ No COMMENT ude code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / /. Location: 972 167th St U(n~known (NW 1/4 NWl1/4 7 T29N R17W) Prairie Run Lot 13 Parcel~N/oO:~1,~7,.,2,9.1~7.7~53p~ 1.) Alt BM Description = t~J>z ~a ^" ~~ `~ i ~ ~ !~ S `J~ ~ ~' " " ""~^"' 2.) Bldg sewer length = Zb ~ ', ~ ~ 'Z . ~ Q" / r~ 0 -amount of cover = ~ , Z -~hS~,~,dti~ 6v~ (~ ~~ 5~.~1~J~. •~u ~;iY~Ow -~~ ~o Plan revision Required? Yes No \ ~~ ~ ~, i ', I I iU~Z Use other side for additi nal in orm on. ! ~ ~, _ ___-___ _______ __ SBD-6710 (R.3/97) Date Insep is Sig ature Cert. No. Safety and Buildings Division 201 W. Washin ton Ave., P.O. Box 7162 Counry ~ y ` ,S~D~Sj~ Madison~Wl ~37U7 - 7162 Sanitary rmeP it Number (to be filled in by Co.) (608)266-3151 ~5~2~3 Department of Commerce Sanitary Permit .Application p~~ State Plan LD. Number ----. personal inl'onnution you prove 21 Wis Adm. Code In accord with Comm 83 , . , . may be used t'or secondary purposes Privacy l.aw, s I S.U4(I)(m) #, Pro'ect Address (if different than mailing addraas) 1. Application Information -Please Print All Information ,; -' --- ~ - g~~. ~G~~ Property Owner's Name ~ i ~ { < { r~ { ~ ~ ~~ ~ 4 Parcel p Lot # ~-3 ~ deck-~-• ;n ~ ,, O t ~'- 0 ~ !3 -~ C. 53 Pr perry Owner's Ma'ling ress i CRV!X COUiVi 'r' Properly Location ~ - I_OtiiNG OFFICE "'"~"" Section ~ ~%, ~'h City, State Zip Code Phone Number _ , , , r (circle one) 1 • ~E orb N; R (check all that apply) (~ ~^^ II T e of Buildin , . yp g - ~ Su ivisioa Name C-~M-i~amtrer 1 or 2 Family Dwelling -Number of Bedrootr~s 11 rr a ^ Public/Commercial -Describe Use vt C - . ^ State Owned -Describe Use ~- Z~ 3 t IC b~ t ~.Q t~ ^City-^V' ageTownship of ` III. Type of Permit: (Check only one box on line A. Complete lice B if applicable) _ A' New System ^ Replacement System ^ TreatmenVHolding Tank Replacement Only ^ Other Modification to Exis[ing System e. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Proviow Permit Number and Ante Issued Before Expiration Plumber Owner IV. T e of POWTS S stem: Check all that a I Non -Pressurized [n-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 ^ Dri Line ^ Gravel-less Pipe ^ Other (ex .lain) K. V. Dis ersaLTreatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (st) S E atio - ~~ ~s~l S ~ he 4xt ~ VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units W ~ziola~ ~ ~~~ L~~.Q,,~„t' Concrete Constructed Glass New Existing ~ ~~ /'v Tanks Tanks Soptic or Holding Tank - Aerobia Troatnteat Unit Dosing Chamber VII. Resp sibility Statement- I, the undersigned, ssume responsibility for installation or the POWTS shown on the attached plans. Plumb r' ame (Printl Plurnb is Si ore ~ ,, MP/MFRS Number Business Phone Number Plumber's Add ss (Street, City, State, Lip Code) VIII. Coon /De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee (includos Groundwater Date Issued ss ' g Agent Sigtiattl (No Stamps) ^ 0 er Given Reason for Denial Surcharge Fee) ~ i ~~ IX. Conditions o Approval Y ~ ~ ~ ~ Se t c tank, effluent filter and Q 1 dispersal cell must all be serviced /maintained. p ~~J1.4- 0.S _d~/~+~ l b er. um as per management plan provided. by p 2. All setback requirements must be maintained n .~ '~''~~ ~~ ~~ ~~^fD~- ~~ as per applicable code/ordinances. ~X9~ Attach complete plans (to the County only) ror the system on paper not Ies9 than 81lI x 11 inches in si2a- `~ ~~ ~) h SBD-639$ (R. 01/03) , ~~.,~- C --..~, y~ ~~~~sf ,E~u,~~ zee ~g, N~~y ,{/taJ~ see /7- >~79X ,(i yal ~~./o ~ ~~~ '~ a~~ ti / 9~ Y 0 ~ ,, /~ • lR~asen ~/ousE ~~,~ . ,~,~ boo' A •Sm: ~ ~ar;.v~s \ /'= ~ s~~ ~ S~'~,~ >,f~,W- ~o~~,~/ cJ~,c-~s~ ~.~1/S . ~.3~r~~' L ~~,~s v1.~~G3 l ~i3 __ \ r' o' -y~ _, ~ P ~.3a ~ ,, ~~ h So' C~pY ormr.~~ ~~ ~ es ~;~y+?Fsf~~ru,~~ ~~e 9q~//~,~,~s~S~ s'u,~.~ //c ~~i~~~~ ti~/y ,~~~~ s~~ i~- ~a9~ ~'~r~ ~/~.~,~n / 30 .r' ~~A / a~ ~/ 9 ~, ~\ // ~ - ~Pw ~ /G~ ~ ` L-rse,ICk ~ .~3.~~f~.~r~",ley ~{%~~~r~~ - \ ~~,~ ~ ,t,~' ~ooo' ~ \ ~~~m//: ~ ~ar,.v~s ~~ '7"C? SC/t/l= ~~=fir e. ~,f,~,Vf'- /Dp~~.t / Gt~.~,et~S' ,(~~~-~" . (/ , ~ ~ ~ , , ~ ~/ ~~~ ~~\~y / ~~% ` lR~as.So f/ouSe. D~iJ~w~ ~. ~/3 so' 4 1 .~ Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT ~ Q ~~o Page ~ of County 51 ~' ' Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must , T Oi K f include, but not limited to: vertical and horizontal reference poi irection and Parcel I.D. percent slope, scale or dimensions, north arrow, and location p~ ry~~ to nearest road. Please print all information. rA Re iewed by Date Personal information you provide may be used for secondary purposes ( L aw, s. 15.04 (1) (m)). ~ ~ 3 Property Owner Property Location I ~' ~ ~ ~~ Govt. Lot till 1/4 ,f/w 1/4 S / ~ T Z4 N R /~-- E (or~3 Property Owner's Mailing Address ~' ' Lot # Block # Subd. Name or CSM# q ~ ~ I G > ~• 13 ~ci~n-e, ~ n City State Zip Code Phone Number ^ City ^ Village [Town Nearest Road l~rvtrY-artr~ S~iars (7is) 7~` Z ~f 3 uvn mond JGU'vr' [~ New Construction Use: [~] Residential /Number of bedrooms 3 _ ~ Code derived design flow rate ~/rG ~ G ~ d GPD ^ Replacement ^ Public or commercial -Describe: Parent material J ~ ~ Flood Plain elevation if applicable /f// ~- ft. General comments s' Y J~`~ ~ ~(t U . ]"U j~ r1 G • G v ~' ~"'' ~ ~ Q S • So and recommendations: /~Gf ~ ~e ~ ~GP gs.Go LGw-Pr~ 9~~~ ~ nP~ Boring R r,~"'- ,~ po"~" Boring # ~r •vwt(~vFrp~ ~ ~ LEI Pit Ground surface elev. ~!f• ~U ft. Depth to limiting factor O[~ in. ` ,, i11P ation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bound Rb~t PD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `*Eff#1 *Eff#2 I d - 10 z / -- 5il Zm C.S • 5 . ~ z l -~!o t~ ~f s a l Zm I ~ ~ 5 •$ ~ y~- t `~~ -- mS -" - 1.2 - 39•x/ .cP -- -- Boring # ^ Boring ~~ ®Pit Ground surface elev. 99. ~ ~ 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 a-~5 Ia r 2/Z -- 5.1 cs 1 v-~ ~ 5 .8 z l 5-3~ 1~ - 5 ~ I -fir- cS - ~ 3 -9b l~ 4 c~ mS i - - . ~ /- 2 ~ - 9 s: }' -- " ~ -~ ~ ~ 7• ~ ~', Z * Effluent #1 = BODS > 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) Signatur CST Number }-~tm ~chumcLk.er zy~~-- /~ l/ -------____ L~.~3r~9 Address Date Evaluation Conducted Telephone Number 2-~3 $o'}' JI . ~orr,erse-~, w 1 S~IbZ S 1/-2~-ai r"~i _~ )z~ 7-y~sv 8 2a^ ~i ~- .~ . r .~ .~ SBD-8330 (R07/0( ~. f. Property Owner ~~.cJlGns Parcel ID # Page ~ of 3 Boring # ^ Boring ~ Pit Ground surface elev. S. ~~ 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 v-- l~ r2 Z c5 ~ .5 $ z _, 9 ~a y -~ -- ~ I ~s - 5 ~ L9-$~ ID ____ I - . ~ 1.2 ^ 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. 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 * Effuent #1 = BODS > 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) ,' • ~ A PAGE 3 OF ~ NAME '-~-~ ~-• ~'''L 5 LOT# 13 LEGAL DESCRIPTION N W ~ dl w i4 ,S I ~• T 2 `~ N R i ~' E(orY~ SCALE: 1"= ~D BM 1 ELEVATION / U a • v BM i DESCRIPTION {o p cs ~ ~ y ~~ QUL ~ .' p e BM 2 ELEVATION ~pU • G BM 2 DESCRIPTION~o p o ~. (~ ~ ~ ~~ Q ~ ~ e SYSTEM ELEVATION ~P Q , . 6 v J,~,~ qs'. ~-o ALTERNATE ELEVATION ~vo 4'So o Gaow-~r9`l•~ ~ CONTOUR ELEVATIONS , o o~ q ~ . Sd, ~Q. vv 3`14. s° N I Cam' 1. $ec. I ~. t tb G/fib ~~ •/ ~j 1.' N'~ ~~,,~-t /, // ~, ~R-~'~ SIGNATURE DATi~ / / ~ z -/ ~-- Q, POWTS OWNER'S MANUAL & MANAGEMENT PLAN =ILE INFORMATION "~'~~ `'' '' Owner ~i d.~COu,Tt - ANC Permit A' 1_l-~1 ~fS3 20 3 OFSiQN PARAMETERS Number of 9edrooms ~. ~j O NA Number of Public Fsdlity Units ," A Estimated flow (average) 60 al/da design flow Ipeakl, (Estimated x 1,b) al/da Soil Application Rate ~.~' al/da /ft= Standard Influent/Effluent Quality" Monthly average' Fats, Oil & Grease )FOG) 530 mg/L Biochemical Oxygen Demand (BODa) 5220. mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent duality Monthly average Biochemical Oxygen Demand (BODE) 530 mg/L Total Suspended Solids ITSSI 530 mg/L O NA Fecal Coliform (geometric mean) .510' cfu/100m1 Maximum Effluent Particle Size Ya in dia. ^ NA Other: ^ NA "Values typical for domestic wastewater and septic tank affluent. MAINTENANCE SCHEbUt.~ ~ ~` `SYSTEM SPECIFICATIONS Page f~ of Z Septic Tank Capacity l~ al O NA Septic Tank Manufaoturer t`,>t-E~s ^ NA Effluent Filter Manufacturer O NA Effluent Filter Model f{- - (tTD ^ NA Pump Tank Capacity al A Pump Tank Manufacturer A Pump Manufacturer I~jNA Pump Model ~ ~YDNA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ~ O Peat Filter ^ Wetland ^ Other: ~7NA Dispersal Cell(s) ~n-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA O In-Ground (pressurized) O Mound ^ Other, Other: A Other. A Other: A Service Event Service Frequency Inspect condition of tank(s) At least once every: month(s) (Maximum 3 years) ears . ^ NA Pump out contents of tanklsl When combined sludge and scum equals one-third (Y,1 of tank volume ^ NA Inspect dispersal cell(s). At least once every; ^monthls) " (Maximum 3 years) ear(s) O NA Clean effluent filter ~ ~ - At least ones every: / _Z O .month(s) ( ear(s) ^ NA inspect pump, pump controls & alarm At least once every: ^monthls) ^ ear(s) 561,,A (`r'~ Flush laterals and pressure test At least once every; ^monthls) .. ^ ear(s) ~A Other: At least once every:. O month(s) O earls) A Other: i~1NA 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 tankls) to identify any missing or broken hardware, identify any oraoks or teaks, measure the volume of oombined sludge and soum grid to check for any bank up or ponding of effluent on the ground surface. The dispersal cell(s) shall by visually inapeoted to ohsok the effluent levels in the obaervstion pipes and to oheok for any pondln{i of nffluant can the ground surface:"' Ths ponding of effluent on the ground surface may indicate a falling oondition and requires thu Immediate notificatlora of the looal 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 entir© contents of the tank shall be removod by a Septage Servicing Operator and disposed of in accordance with chapter NR 1 t 3, Wisconsin Administrative Code. '~~ .. All other services, (nciuding 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`provkled"t~"fhb'locbl"ragtalatory authority within 10 days of completion of any service event. OMW (4/011 Page ~ of 2 START UP AND OPERATION For new construction, prior to use of the POWTS check treatment rankle) for the preaenoe of painting produots or other ohemicals that may impede the treatment process and/or damage the dispersal celNsl, If high concentrations are detected have the contents of the tankls) 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 oellls) and may result In the baokup or surface disoherge of effluent. To avoid this situation have the oontenta of the pump tank removed by a Septage Servioing 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; diafnfectants; fat; foundation drain laump 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 grid/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abartidoned 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 Serviaing 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 r lacement area should be r clad from disturbance and compaction and should not be infringed upon by required setbacks from ex sting and proposed structure, of I nes an we s. allure 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 ANDIOR 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 ~ t.,n (' ~ CoNn)EL 1. • Phone ~~~ ~"5~.. / ,~., POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPERI Name rJ C-'2 ~S ~ l L ~. Phone `` ' LOCAL REQULATORY AUTHORITY Name ST, Ce®/~C ~ f`r9t.t ;t ~N/N Phone ~~. 3S'~o. `7(pbv . This document wee drafted in compliance wkh chapter Comm 83.2212)Ib)11)(d1&(f) and 83.64(1-, l21 & (31, Wiscoruin Administrative Code. S7[' CIS®TX CtDIJNl'Y SEPTIC TANK MAINTENANCE AGREL~MLNT .AND OWNrRSI-IIP CERTIFICATION FORM ~wxter/Buyer Mailing Addn Prop©riy Address % / ~ / ~ ~ ~~"" `'~`" - (Verification required from Planning Depar(ntcttl for new 2~- City/State ~~'n.~~>~ „/~ Parcel Idetxiihcation Number O l8- I o9`~ ^l 3 t~ ~ • ~-S3) I.,TG,~A.L DrSCRIP'I'TOIV Property Location .'/., '/~, Sec. ,.,,/ ~ . TN-R~~N, Town of ~~-=Z~ -~~-' Subdivision ~' °'-~~~ ,Lot ## .~ ~ Certified survey 11~~ap #f ,Volume .Page # Warranty Deed # ~-~~ ~S"l , ~Iolttme ,--~~5'~ ,Page ## _ Spec house ^ yes no I.ot lines idetifiiiable~yes ^ no SYS'TI;IVf MA><NTFNANCIC Improper use and tnaintcnatace of your septic system could resul t iu its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tattle every three years or sooner, if Headed by a licensed pumper. What you put into the system can afTect tha function. of the septic tank as u treattt~ent stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoui~tg Deparimettt a certil<icatiou f'vrni, signed by the owner and by a nna,~rplumber, journeyman plumber, restrictcdpktmbcr or a Iicettsed putuperverifying that (1) the on-site wastewaterdispQSal system is in proper operating condition and/or (2) aljer inspection and pumping (if necessary), itte septic tank is less than I/3 full of sludge. Uwe, the undersigned have read fire above requirccnettts and agree to ntaittlain the private sewage disposal system with the standards set forth, Ixercin, as set by the Dc~tartntent of t;onttucrcc and iltc Dcparlweat of'Naturat Resources, State of'Wisconsin_ Certifcadon stating that your septic systetu ttas beta maintaiucd must be contplcted and rctuined to itie St. Croix County Zoning Office within 30 days o tltc three year expiration date. /~Z/ 0 3 NA I3 OIL APl'I.IC.AN-~ DAT>; tpWNI~R CT+;RTII?ICATION I (we) certify that all statccncttts on this form arc taste to the ltcst of ttty (our) I:nowlcdge. I (we) ant (arc) tltc owner(s) of the pro rty described above, by virtue of a warranty deed recorded in Register of Deeds Office. ~ ~ ~Z2/© 3 1 S NATU OI: ,APPLICANT ~~ DA'i'E Any information that is cztis-represented tuay result in the sanitary pcrn~it being revoked by the Zoning Departrucnt. ****** .*.*.+ ~s Include vrilh tl-is appticalton: a stamped wan-anty decd fiotn ttie R.cgisicr of Deeds office a copy of the certified survey ntap if refcrctice is made is the warranty deed ,r r ,... , z p, C m 2 C v rn Cr m m v D Z v N y ~N ~0 O O ~~ N ~Q V 3 a N a srrs v s c -~ N a------.~__ ~i veprr u w ~ 1 OPi DBLE tAY ao m~ ~ ~ ~ ~ WWm1 ; mo O~ E ~ ~ ~ "8 ~ a aF +$~ $r~'' i ~; ~ a ` B~ ~~ ~~ ____3~c~~_ ___ I ~ ~ r 1 ~~ S F E A = ^' ~ z e Ar -- D 0 m wP W g~ ---r g RQQ i~ 0 XJ C r _ O ~ 3 C ~ .n ~ ~_ _ c D - ~ ~ k D ~ ~ , Z ~ ~~2 ~ ~ C 'V ~ y -~ p tD ' "s ~ ~ ~ CC o ~ C ~ N (?1 ~ C - x Qp ~ G7 N ~ N r.. ._ N C y ~ A N ~ m ° ~ j ~ ~ v -~ °. r _ o ~ ~ O m w ~. Riverview Homes Inc. List of Included Features in: House # 10 68 x 32 Skyline Lexington Limited Double Set Dormer OSB Wood Sheathing Tyvek House Wrap 200 AMP Service 24x24 Skylight -Master bath & Hall bath 48x48 Skylight -Kitchen Exterior Frost Free Faucet Exterior Electric Receptacle Finished Drywall Sidewall Heating Wire/switch for Living Room Ceiling Fan 2 Phone Jacks & Bridge 3 TV Jacks Wired for AC Oak Cabinet Doors Throughout Ceramic Back Splash & Counter Trim Appliance Package -Deluxe -White Side-by-Side Refrigerator w/ lcemaker in Door Dishwasher Garbage Disposal Gas Range -Self Clean Water Filtration System Spacesaver Microwave -White Single Lever Faucet -Kitchen Washer & Dryer -Electric SteeUStorm Door with Sunburst Vinyl Patio Door w/Vertical Blinds & Valance Double French Doors Upgrade Wood Trim/Ceiling Cove Computer Center in Den 'J 2252P 340 DOCUMENT NUMBER wAx~ANTY azsD William E. Hawkins, Grantoz, conveys and warrants t idwest E u' s, LLC, Grantee, the following described real estate in St. r , State of Wisconsin: Lots 1, 3," 6, 10, 11, 12, 13, 17, 18, 19, 22, 27, 30, 35, lA and 3A, Prairie Run, Town of Hammond. __------ NAME ND RET RN ADDRESS fjj~~S~ i-~'+CS L. 9~Dfd~/l~r~sf S~ ~/c~ ~,~i h ~,~' S ~v 7-- 18-1037-10-000; 16-1036-90-000 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. ~~2~s1 KATHLEEN H. YALSH REGISTER OF DEEDS ST. CROIX CO. , liI RECEIVED FOR RECORD @5/23/2@@3 @2:20PM itARRANTY DEED EXE~IPt # REC FEE : 11. @0 TRANS FEE: 594.8@ COPY FEE: CC FEE: PAGES: 1 Dated this S 3 day of May, 2003. ~,~~ C. ~~~ (SEAL) William E. Hawkins (SEAL) (SEAL) AUTFiENTICATIOAT Signature(s) authenticated this day of 2003 (Sianaturel (Name Printed or Twedl TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by 5706.06, Wis. Stats.) THZS ZNSTRL7I~NT TiPA3 DRAFTED BY: Leo A. Beskar Rodli, Beskar, Boles & Krueger, S.C. P.O. Box 138 River Falls, WI 59022 ACIQIOWLED(~lBNT (SEAL) STATE OF WISCONSIN ) ss. COUNTY ) `~ ~ ~ • .,~ J ^^~~22 V Personally came before me this~.J ~ ; 8ay~1i~"Ifidg, 2,903 the above named William E. Hawkins`' :'' o to me known to be the persons (s) whd"ex~~u~the r foreq in instrum t and acknowledge ,•t ~c„s~me.p~ v'. 1 '1 Si nature M ~n )• * ~' • 1 v ~'. Name (('',,r' ~d or T ed Notary Public '~N..~o~n~ty, •Wis. My commission is permanent. (If not, exo.iratiori date:) ~1 ~~ a~a~ ~ ~~'~ i .. ti~ ~ h~ _,,.. ~ N y ,-.. I ~ ,~~ ~~ e I O ~ _ tiry ,~. o I ~" et ~ a Z __1_ __~_ - ._ r- N \~Ob, I / \~d/ ~ ~ ~ ~ '~ /- \, \, ~~ ~ i / .~ ~. \ ~ ~ o• ~~° b~99 ' \' ~ ~1 ,Fe ~r X99 ~, ~ . , _ Ste. `. J ~ ~ 4 w / / ~. O ~N .._,) / ~, / `~ / `` / / ~ "' ~ ~ 0 ~ ~~ / J ~ °r~ ~ I / z \ \ \ ~ ' ~ v ~~~ ~ r /. 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