HomeMy WebLinkAbout018-1048-50-100. ~/* r
Wisconsin DepartmentotCommerce PRIVATE SEWAGE SYSTEM
Safety and Buildings Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provice may be used for secondary purposes [Privacy Law, s~5.04 (1)(m)].
Permit Holder's Name:
Kooiman, Roger ^ City ^ Vil}agte,1,t~OT~4Vr~o~~Ship
nnaa Cl
CST BM E-ev.: Insp. BM Elev.: BM Description:
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic IM ~ c~, 12g'D Qe'D
Dosing ~2 G~vti;
Aeration
Holding
TANK SETBACK INFORM N
TANK TO P/L WELL BLDG. Vent to
Air Intake ROAD
Septic o2 S 9-- ~~ -L ' ._ NA
Dosing ~` (~~ ~ .,,, 2Z~ NA
Aeration A
Holding
~~
PUMP /SIPHON INFORMATION ~
Croix
'Plan ID No.:
r.
-°1048-50-100
ELEVA~'ION DATA
STATION BS HI FS ELEV.
Benchmark -Z.o pp•ZD ~OZ• Zo
1.aoi
+ gc$,cf.Dt
Bldg. Sewer (2 , p ~ ~$. Zfl r
St/ Ht Inlet (z. z5 ~~•95r
St/ Ht Outlet =~
Dt Inlet -~
Dt Bottom (S~~s z r
Header/Man. ~°~ 9z-~ r
Dist. Pipe • ro
qZ .~-p
Bot. System ~
G p ~ (, ~ Ias
Final Grade ~~ ~,; --~ -~ 96.0 r
cover ~ , ~ ~
3•
~ ~ Z ®~
B$D RENCH Width Lengt ~ }
, ~ No. f T enches PIT No. Of Pits Insi a Dia. Liquid Depth
DIME I 3 s
4 DIMEN I N
SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING turr: ,-
Manu a(
c~
~
~
~
~
SETBACK ,
,
"`
"-"
"
INFORMATION Type O ~ ~
__~ CHAMBER Mo a Number:_
System: J, ^' Q (~ __ OR UNIT ~ _ ~
DISTRIBUTION SYSTEM v ~ ~ v
Header / nifold ~~
th `~ Di
L
~ Distribution Pipe(s) _~--.___
acin
tF~-6i~ S
L
~ x Hole Size x Hole Spacing Vent To Air Intake
~- Q ~
eng
a. g
p
en
j
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched ~ -
Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No'
COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1• (T-/~8/~ Inspection #2• / /
Location: (SE 1/4 NEB 22 T29N ~~}}7W)~ -Lot 2 $S2 l°l0~- • ~~
1.) Alt BM Description = ~ °~°~ ~r~^~v~ ~ "~""t ~ ~~ a~ S~G~ - -- ~
2.) Bldg sewer length = l 3.0'
-amount of cover = > `F Z ~~~a-i ~ G~~ `
`F ~ «l~i~ fit- -t tip,
Pla~revision required. ^ Yes ~ No
Use other side or addit-ional i formatio - ~ t ~ ati C
SBD=67T0 (R.3/5 ~' `~ ~~ Date
Inspector's Signature
1 ~~
(_ '. ~ ~
Le) '~ ~ ~ l~ ~~s~
I Z~
Cert. No.
SOIL ABSORPTION SYSTEM 5
52- t ~o ~ Sanitary Permit Application Safety & Buildings Divisio
`~ In accord with Comm 83.21. 4~'is. Adm. Code
See reverse side for instructions for cornpieting this application 201 W. Washington Ave
PO Box 730
sconsin f
d Madison. WI 537117-730
Department of Commerce ary purposes
or secon
Personal information you provide may be used
[Privacy Law. s. 15.04(I)(m)} (Submit completed form to county if r
state owner
Attach com fete laps (to the count ~ co onl~~) for the system. on a er not less than 8-1/2 ~ 1 ! inches in size,
County
5 ~ Cad .' -c State Sanit Pemtit Number CI Check if fpvi~ion to pCevaou~apprl\teation
-{i~ ,.. State Plan i. D. Number
I. A lication Information -Please Print ail Information ~ • ~ '' i Location:
Property Owner Name ,~ ~ .: ~ ; ; , l ( : • ` Property Location
/ ~"
'
' N
R E or
~~1/4 ~i/4
S~~T
~ O
mot/
6 ! ,
,
,
-^~ i. - ~ ~ l~t~~
Property wner's Mailing Address --
. Lot Number Block Number
.
/~
Iv0 pS 3~~ 1~:~~ ST Cc;G1y _~
Ctty, State Zip Code / , ` `
Pbene Ntt~b Subdivision Name or CSb4 Number
ah~nro~0~ W' ~
~1~L~15 ~
~%~~ INGtaFFICE (,
~~,A:,,\. )
~ SH'! G:Z?B12 o//y 9
II Type of Building: (check one) j C j`~ ~ ,~'~ ~
` ~- ^ City
^ village
---~_-
D t or 2 Family Dwelling - No. of 13edrooms;~_ ~TOwn of
O Public/Commerciai {describe use): v °~
y" o
a
D State-owned ,
.~,
III Type of Permit: {Check only one box on line A. Check box on line B if applicable) Nearest Road ~ 4071
A) I. .`'New System 2. ^ Replacement 3. ^ Replacement of 4. ^ Addition to Parcel Tax Number(s)
S stem Tank Onl £xistin S stem D/ 8' - ~i'~ ~ 5 D -'
g~ Permit Number -9Me'Issaed"'
^ A'Sani Permit was reviousl issued ~~- 33 9
IV. Type of POW'I' System: (Check a}[ that apply) - / ~
don-pressurized in-ground ^ Mound ^ Sand Fitter ^ Constructed Wetland
^ Pressttrized In-ground / ^ Holding Tank ^ Single Pass ^ Drip Line
h
^
Ot
er:
O At- ade / ^ Aerobic Treatment Unit ^ Recirculating
~'S -~--~`
°~`°° 30
9 3
l
C~ ~ ~
~
~
~
L
?
`
~
.
-
.
~ ~
..
5,
~ W .
.•U
s a ti,. e s
x
/ G
~ 7
V Dis ersallTreatmentAraa Information:
I. Design Flow (gpd) 2. DispersalArea 3. Disprrsai Area 4, Soil Application S. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed Rate (Gals./day/sq. ft.) (Min.Jinch} Elevation
VI Tank Capacity in Total ~ of Manufacturer Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con• Con- glass
New Existing Crete structed
Tanks Tanks
~ ^ ^ ^ ^
se~t° ~ vC 1 d4 . ~ wQ t ~-,~
C~ K- ~t~O ~/ QJG9~~Y,~/
VII Responsibility Statement
I the undersi ed assumt res onsibilit far installation of the POWTS shown the attached lens.
Pltmber's Name (print} Plumber's Signature (no stamps): PRS No. Business Phone Number
' ll, ~~ ~ ,~ t, ~ ~~..~~ a~7PQO 7~ - s - 3ia
lttmber's Address (Street, City, Stau, Zip Code)
VIII County/Department Use Oniy
^ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Siprtature (No stamps)
~`l,Approved ^ Owner Given Initial Adverse charge Feel <
Detettttination ~~5. ~ - $'Z~
IX. Conditions of Approval/Reasons for Di^na,~,~pr val: ' ' n .
'1~' E~a~ ~ ~ „~.~- ~s~. tiy~~~ t5~~o,,,n t3w%C"l~ ~~ `r-~ ~ C.(e~,~.~,~.- • ~l~-~}.t.c~t.t.or,
.~ ~ nr,.ua~ N~IIJnJt-4.1.~t d>~"l~:A~n~t d~ ~ Cts /~^~aG ~Qt,l`Ft~Ca~p~s• U
SBD-6398 (R. 07/Op}
)CC3~ ~ ~ r r~ y~ ~
~a~
ti ~ ~v, H.ov/
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Q~~ckr`a
VYI}pL35aylii U1~FJYtlpltlflj L'C ~ommorce
Aivlaion of Safety anC Buildings
- Bureau of integrated Services '~
Attach oomplate s(te plan on paps not less than 8 1l2
inoiude,-but not limited to: vertical and horizontal refer
percent elope, seals or dimerulone, north arrow, and 4t
SOIL AND SITE EVALUATION
orda -l.tHR 83,09, Wis. Adm. Code
~_ ~ ,~ ~,'_._.> _..~~ i, ,,~ ounty
.~ s rn s .Plan r'ncisu;
alnf an~~.~ ~
n and~j nearest l~pad. parcel I.D. M
~r
of
Rage l of __~
APPI~iCANT INfORMATION - Please pr! t~! lnfbkrillirtlo,;~ 1 _ >3e swan ay ~aa
'~ s Privacy 't!bYb4 } {rr~V' ~ /g'"2lXJD
Personal information you provide maybe used far secandarY { 19
.''
Property Owner ~, '" Pr y atfon
y ~, ~~,,. :--~"o~- S~ 114 1/b.8 ~ T~ ,N,R ~7 E{o Y~i
~~ C !J ~ r ~ ~ sR/ ,~ ~ ~....
Property ar's M ing Addnse ~~ -' _ ., I_.. ft Block# i 8ubd. Name or C3M#
P~ ~ ~~ 3~l 1 ~~ slrl
Ctty State Zip Code phone Number ^ City ^ ViVage ~ Town Nearest Road
New Construction use; Q,ResidentEal / Number of bedrooms -3 Additlon to existing building
^ ReplecemeM ^ Public or commercial • Describe:
Code derived daily flow LSD Opd Recommended deaiDn badinq rate ~ 7 bed, gpd/itzl~Vench, gpdRt2
Absorption area squired 5G 3 _,bed, ft2 ~~_tre-xh, ft 2 Maximum design loading rate ,.~_bed, gpd/fl~ ~ f~ .trench, gpd/ftx
Recommended tntUtratlon surface elevaUan{si ~ ~'' ~ ~ Q Y ~ 9~ *°2 ,~,t 1' ~X. 2 tt (as retsrr«l to site plan benchmark)
Additional desigNsits coneiderafiona
Parent material ~~ ~ ~ ~ u- / ~1 cf~'~lr~~ s ~ Flood plain elevation, if applicable h
8 Suitable for system nventlonal and n• roan eseure - e System n r W ng ask
u unsuitable for system ®-s ^ u ~ s ^ ~ ~} s ^ u ~?I-s ^ u ^ s Q i1 ^ 8 ~ U
BoGring #
ii~. n.~S: J!! ~N
f
Around
.~. ~
Umkl
in.
Boring #
.,.
e ^ ~
around
el
~ft.
Depth to
limidng
factor
q2,l,~-.In.
C8T Name
t
SOIL DESCRI PTION RE RORT
H
l th
D l
r
i
t C
D Mottles Structure d t
R
or
xon ep
in. nan
o
om
o
Mansell
Qu. Sx. Cont. Color Texture
Gr. Sz. 8h, Conaletence ary
Boun oo
s
Seri Trench
1 0_~ ~~ r ~ -- ~l a ~~K Y ~ s ~ ~,~
~ ~ 7 ~ rQ
~• oS'•6 ~ °°~
`~
Remarks:
~y- r~ i~ s - ,' a ~-,~~ r Y c ~ - ~ ;~
Remarks;
eleaae Print) $ignatun Telept+ons No.
<<a S'~6-i. n~ G h'e~ d ~ ~ 7~S"3~G'-3I2 ~
p~ CST Number
(t
PROPERTY owNEp _ SOIL DESCRipYION REPORT ?age . ,. of
PARCEL I.D.Ii
Baring #
~y~~:.
{ 3
~.~:~v
Ground
ae~.
y.~ft.
Depth to
limiting
actor
,~,_,in.
Baring #
~" Li'a:"~''9tLy~y,
Sr ~
y*y. f:
at= .
Ground
elev.
9s. Gn.
oeptn to
limiting
factor
~in.
Horizon Qepth Cominant Color Mottles ~ Structure d
~ R
t 2
In. Munsail Qu. Sz. Cont. Color Texture
~ Or, Sz. Sh. Consistence Boun
ary oo
a Bed :Trench
z - - s~
c s
-
.~~ ~ ~
3 ~//~~ s - -- - 7 ~ ~
Remarks;
:,~
Remarks:
Horizon Depth Dominant Color Motttes Structuro l
t
C d
b Ro
ts
in. Munesll Qu. 5z. Cant. Color Texture Gr. Sz. Sh. ence
Ona
s oun
ary o tied ~ Trench
/ a -~Y ~ ~ ~ ~ r- .' ~ ~ z F ~ S .
3 S ~~ s ~ -
(~ (• 2 9~-Z
Boring #
~s, , ~,;,~ ~,
~' ~
Ground
y~'~oft.
Depth to
Umklnp
faotor
~,in.
f3oring #
"~i~a, -
~.y~~~
a4~ ~
'n8~i
t
4a~F ` ..
Ground
elev.
ft.
Oapth to
limiting
factor
in.
Remarks:
Remarks:
SBD-8330 (R. 07!08)
,~
'~~ T~ o ~ fe.~~ ~pos~ 1D.2 ad
Sc~~ ~ I < <ya ,
OC
~~ T
~ ~~
of 3
.81
~/17~
~Od, c
~' o F
~~acKj-d jC
4"t.I. VElsT PIPC
~ 2S' FROM DOOR.
WINDOW OR FRESH
AiR 11JTAKE
PL;N'~P CHAMBER CR0~5 ~EC ~ 101,1 At~G ~PECIf1Ca•ri0~~5
IAILE:T
* A
e
ELEV. F'f.
C
0
r--- V E 1J T C A P
WI"ATNERPROOF
.ILIAICTIOIJ BOX
IZ"MtU. (
I
GRADE I
CO-JDUIT ~"
V `'
PROUIoE
AIR'i'IGH7 SEAL
*APPROYEO
JOINTS WITH
APPROVED PIPE
3' ONTO
SOLID SOIL
PUMP ~
CQAICRETE 6LOCK
f'Al.; 4 G F
APPROVED LOGS,(1AIG
MANHOLE COVER
I ~. ~ 18" 1"(I ~1.
I
I ~ `i
~ l ~
I
I
I
I I ~ ALARM
~ f.
I I
t oN
1 I
i
--~
,~ OFF
~/
R15ER 1`XIT PERMI~I'ED Qi~iLy IF TAAJK MAUUFACTURtx.R HAS SUGIi APPROVAL
SEPTIC E SPECIFIGATIOIJS
OOSf< del ~`a~cJe 9 t'~ ~ ~/
TANKS MAIJUFACTURER: IJUM$ER OF LOSES: PER OAy
TAAJK SIZE: ~6~ GALI,.OtUS aosti< UatuME ~;
~$
~
ALARM ~'AAIJUFACTUR.CR: ~. a Ue./Q„r t.,•~
` (,AttbN
~-
INCLUptNG 6ACKFLOW- •
~ ~ ~ GALLON
{AICH[S {}R
~
IESf A
MOD>El. I.Il1Mba<R: .
_
=
CAPACST
SWITCH T~PC' ~ ~ ~' C
I ~/~
B = ~ IIJCNES OR _L_ 6ALLOfs
~v
ldPS ~ GALLOfJ
~IULHES OR ~
Ca
~,
PUMP MAASUFACTURCR: .
~
G ~~ ll p
INCHES OR L~~ GALLOA!
D ~
0
~
MOp£L UUMDEiC: r.
.-.
5W1'TCH T?lPE: ~ ~ ~ ~ iJOTE: PUMP A>wID ALARM ARE TO bE
MiGI1MU1"1 QISCHARC+E RATE~GPM INSTALLED 81J SEPhRATE CIRCUITS
yERTIGAL D'PFEREAICE 6ETWCCA! PUMP OFF ANO OISTRI6UTIOAI PIPE.. L-.._ FEET
.. .. .. `~' FEET
E
MUh't NETWORK SUPP4.y PRESSUR
~- MI
AI
i
TT
/~
~
i
S
+ ~'! .FEET OF FORCE !''fAlAl X '-~ 7 F/pp ~LFKIC'CIOiJ FACTOR. _ /°G 7' FEET
._... TOTAL C~IJAMIC HEAP -= l` ~ FEET
~~-~1p1
I~.ITER0.1At.. b1ME1J510Ais; Of TA1JK: LEIJGTH ;WIDTH J;LIQUID OEPTH
/ ~ _ ~'. ~ LICENSE IJUMBER: ,~~-2 7 ~p~ _- DATE:~~~~~~
SlGIJE D:ld~
~- .
..f-
4
3871 EP05
APPLICATIONS
Specifically designed for the
fallowing uses:
• Effluent systems
• Homes
• Farms
• Heavy duty sump
• Water transfer
• Dewatering
SPECIFICATIONS
Pump: EP04
• Solids handling capability:
3/4 maximum. •
,---M • Capacities: up to 55 GPM.
}`'f~- Total heads: up to 24 feet.
` ~ • Discharge size: l'/i NPT.
• Mechanical seal: carbon-
rotary/ceramic-stationary,
BUNA-N elastomers.
• Temperature:
104°F (40°C) continuous
140°F (60°C) intermittent.
Fasteners: 300 series
stainless steel.
Capable of running
dry without d~i~i~age tii
components.
Rotor:
EP04 Single phase: 0.4 HP,
115 or 230 V, 60 Hz, 1550
RPM, built in overload with
automatic reset
EP05 Single phase: 0.5 HP,
115 V, 60 Hz, 1550 RPM,
built in overload with
automatic reset.
Power cord: l0 foot
standard length,16/3 SJTO
with three prong grounding
plug. Optional 20 foot
length,16/3 SJTW with
three prong grounding plug
(standard on EP05).
• Fully submerged in high
grade turbine oil for
lubrication and efficient
heat transfer.
Available for automatic and
manual operation. Automatic
models include Mechanical
Float Switch assembled and
preset at the factory.
FEATURES
^ EP04 Impeller: Thermo-
plastic Semi-open design
with pump out vanes for
mechanical seal protection.
^EP05 Impeller: Thermo-
plastic enclosed design for
improved performance.
^ Casing and Base: Rugged
thermoplastic design provides
superior strength and
corrosion resistance.
,~
LJ
^ Motor Housing: Cast iron
for efficient heat transfer,
strength, and durability.
^ 1Wotor Gover: 7hermoplas-
ticcover with integral handle
and float switch attachment
points.
^ Power Cable: Severe duty
rated oil and water resistant.
^ Bearings: Upper and lower
heavy duty ball bearing
construction.
AGENCY LISTING
SP• Canadian StandardsAuociation
(CSR listed model numbers
end in "F' or "AC".)
• Fasteners: 300 senes METERS i=eEr
stainless steel.
~ • Capable of running
dry without damage to
components.
Pump: EP05
• Solids handling capability: c
3/a' maximum. a
Capacities: up to 60 GPM.
• Total heads: up to 31 feet. g
• Discharge size:l'/x"NPT. z
• Mechanical seal: carbon- c
rotary/ceramic-stationary, a
BUNA-N elastomers. ~
• Temperature: ~ °
104°F (40°C) continuous l~
140°F (60°C) intermitten 1 °i~
T'O ~'
e~k"~~ f
i ~ ~
--
._~
i
10 20 30 40 50 GPM ..
0 2 4 6 8 10 12 m~/h
10 I _
9
1 ~ ,~
30 ! ~ ~~".~
_
e
~
I ~:
I ,-. , ~~ ~
2s
~ ' t ~ ~
s 20 ~
i
5
15
! !
~
~
a ~ ~
' ~ I
~ ' I EP04
2 5 ~ f I - i
1
~ - I ! I -~.
.,
~~~~r~
~~~~~r~i~le
~f~jue~# ~~~~
CAPACrrY
Private Onsite Wastewater Treatment System Management Plan
Septic Tank And Gravity In-Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWYS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or governmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In-Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
Table 1: System Design Specifications
Sanitary Permit Number 3~`f4b
Number of Bedrooms
Design Flow- Peak (gpd) f~mb
Estimated Flow -Average (gpd)
Septic Tank Capacity (gal) 2$0
Soil Absorption Component Size (ft2) 0 2 ~- S~d~.~bie, use
Type of Wastewater Domestic
Table 2: Soil Absorption Component -Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow -Peak (gpd) z.$ti 'S~
Maximum Influent Particle Size (in) 1/8
Maximum BODS (mg/L) 220
Maximum TSS (mg/L) 150
a)
Tab le 3: Maintenance 5cneduie
Septic Tank Inspect and/or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure
proper operation. The filter cartridge should not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
. ~ .,
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the inferior of the tank maybe difficult or impossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
ST cRax covtvTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATIQN FORM
4wnerBuyer .,~
1Wttiling Addt+esa ,
Property Address
~. (~
z, l ~0 r~l .S~' ~/~~/~!~,a.,~`~ ~~, , _ ~~ ~/sue
(veri5catioa 6om Piaaeioj Dapatenan for oew coomactiorr) - ~ -
City~ata / ~ -~ ~ Ptutxl Itieotificatiat Nuntbetr ~~„fZ .. /~ ~ ' ~Q
Property Location S ~ ~/., ~ Y.. Sec. •~ .~ . T~,~.N-R~W. Town of 1~~2~•
Sttbdfvitaon . Lot N ~ „_;
Ce~daea Satrvtey Msp tv ~ ~ 7 ~Z ~ . Votumo ~~ Page ~ ~;'~~,_+.
bad 3qS X53/ aS
Warrul~- Deed N ~,_,~,,, Voles t . Page tY
Spec house O yer~ no
Lot tines ideatifubte,~ ya O z~o
Tmpst~ar arc and maioaemmoeoty~aa septic system aoald tantt ire its premaaaee 4iite+e to handle rvasks. Proper~si:aeamce
oeesists of pwaptrtg vve the septic Lot every ttnee years a wooer, if arxdad by s lioeaisod pamper. What yat pat ittro are ayalem
can a~sct are lbection of tha aepo9e Uant as a staamreoet ~ b tha w~asb dispoaat aparsm.
'tom Pr'oPe~ ~~ ~ b atdt~sdt 1o St. tSois Zaabtg Depatame>,t a ctxtidcattoe ~ dpod hY the parser and by a
~'P'. jouereytaasplambar. nshicladphm+bet a a lit~pnmpex vailyiag drat (i) the as-site arattow~ataQiopoaai ayalem
t in proper opeta'tiaR cosditioa atWar (2) altar iarpectios tad pampipt (if eeoesptp), the septic tsnic is laa than 1/3 >bll of ahdge.
thw, the aodpaidned how sad the shore eegait+taoeaL and ~ to oraiaesin the priwte seanige dispoaai system wroth tha standards
~ f10~ ~ ~ ~ ~ ~ ~' Comouetce std the Deparo~oent of Natural Raaouras. SWe of Wisc~sio. Ce:>rlieation
ayatrm hq boon maisariaed most be campleoed sad eeturned to the St. Qroix Cottaty Zotriag Qiyttx Mrithia 30
y~ . th~a.
TVRE t~ APlLiCANf DAT$
OWNER +CKR1'iFdc~~rtnta
I (*"e) certify that a!1 statatiotasts ere this form are user oo the best of ray tour) ivrorvledge. i (wre) am (.re) the owneKs) of
~ described, a ve, by rirtue of a «~tranty deed t+ecarded in Register of Deeds OlSce.
/~
8 Ti1R>t OF APPLCANT A~
~~~~~~ Any isdoraaatioa that is miarepreseos~ tory rewlt is are sanitary permit beius revoked br the Zoaiag Department. ••••••
•• ludude w~ttb et'rb apptleatien: a ataetpod wyntaaty deed Liom toe 1~ of Deeds office
a copy of are eattilied sarvey map iE retereaee v made i$ the •ramaty deed
voi.1531PAGf 25
Document Number WARRANTY DEED 627395
KR'rHLEEN N. wALSH
kI=GISTEk OF DEEDS
5T. CRDIx CD. , WT
RECEI~D FOk RECORD
Wahlquist Bros., a partnership, consisting of Jeffrey oe-o]-2000 9:~o an
Wahlquist, Charles Wahlquist, and Robert Wahlquist, IIRRkRIiTY DEED
conveys and warrants to Roger G. Kooiman and Lori M. EXEMDT N
Kooiman, husband and wife, holding as survivorship marital LOPY FEEY FEE:
the following described real estate in St. Croix
property TR~
FF
ia:oo
,
County, State of Wisconsin: RDIkG
EE:
k,CO
PAGES: ]
Thomas A. McCormack
t 02010'" Ave.
PO Box 2120
Baldwin, WI 50002
018-1048-50
(Parcel Identification Number)
Part of the Southeast Quarter of the Northeast Quarter (SE '/4 of NE '/.) of Section Twenty-two
(22), Township Twenty-nine {29) North, Range Seventeen (17) West, Town of Hammond, St.
Croix County, Wisconsin, more particularly described as Lot Two (2) of Certified Survey Map
filed July 25, 2000, in Volume 14 of Certified Survey Maps, at Page 3904, as Document No.
627022, office of the Register of Desds for St. Croix County, Wisconsin.
Exception to warranties: all easements and restrictions of record.
This is not homestead property. Dated this ~_ day of J~ L -r , 2000.
' n. •
Robert waNquist - ~ , ,I t
/,, ~r ~.:
.;
~,
Charles Wahlquist
AUTHENTICATION / ACKNOWLEDGMENT
Signature(s)~~~c' ~i~/`~ ,,,,~ / STATE OF WISCONSIN
~~G~~~ ! ~` /~M~~~2 00, athe abovee namadthJe(Frey Wahlquist, Charles
authenticated this.a day of ~'?~ Wahlquist, and Robert Wahlquist to me known to be the
persons} who executed the foregoing instrument and
~~~ --~ acknowledge the game.
type or print name signature
type or print name
ro
TITLE: MEMBER STATE BAR OF WISCONSIN Notary Public SL Crooc County, Wisconsin.
(If not,
authorized by §706.06, Wis. Stets.) My commission is permanent. (H not, state expiration date:
THIS INSTRUMENT WAS DRAFTED BY
Thomas A. McCormack 'Names or persons signing kr any capecNy should be typed or
Baldwin, WI 54002 printed below their spneturea.
InbmuGm ProfKSgnMc Company Fond du Lac, W;scatpn 6W-055-1021
62'7022
_ THIS INSTRUMENT DRAFTED BY: WILLIAM KANE J08 N0. 00-76 DATE: 6/16/2000
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ASSUMED TO BEAR S89'36'S7"W
Vol. 14 Page 3904