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HomeMy WebLinkAbout018-2005-02-000,nsin Department of Commerce PRIVATE SEWAGE SYSTEM Katy and e~uilding Gtvision • 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 Miller, Sam Hammond Townshi CST BM Elev: b Insp. BM Elev; U BM De tion: ~- ~V~ __ ~~ /D ~ ~ /OD' TANK INFORMATION ~ ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic / ~ Dosing ~~/~ ~/ Aeration ~~ Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ i ~ ~ / - Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number _~..----- TDH Lift ,/ cti Loss System Head TDH Ft Forcemain Length Dia. is . o ell SOIL ABSORPTION SYSTEM /~`~~ ~~_. county: St. Croix Sanitary Permit No: 430466 0 State Plan ID No: Parcel Tax N Se ion/Town/Range/Map No: 31.29.17. STATION BS HI FS ELEV. Benchmark ~ Q ~ I ~ /~~,~ lam. a Alt. BM ~~ ~ ~ /D~• ~ Bidg. Sewer ~~c-~1--~ ~~/ ~ a 5--,~ 0 ~D 3. ~ S t Inlet l~~~5~ 2, SUHtOutlet ,Z 10~, Dt Inlet ter. /' Dt Bottom s ~-/ Header/Msnn. ~~ ~ Gj J!'. Dist. ~e ~ f ~ , Bot. Sys m I ~ ~ Final Grade /rr2v GI~C..- ' .3 b St Cover / r'r~ /.~ 5 p ,d BED/TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ / OJ II ~ / d"' SETBACK SYSTEM TO P/L BLDG K / LEACHING Manu s~ INFORMATION CHAMBER O Ty Of System: ~~ ~ ~ / D 1 / U Model Number: I DISTRIBUTION SYSTEM Header/Manifold Length Y O Dia b Distribution Length ( ` Dia ~ Spacing ~ x Hole ~/ ~ ~C/v SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only nd -~~ Depth Over ! Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center ~, Bed/Trench Edges Topsoil Yes No ~'~ Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/ Inspection #2: / / Location: 1510 66th Avenue Hammond, WI 54015 (SW 1/4 NW 1/4 31 T29N R17W) Highland Ranches Lpot~2 ~ ,,PQanrcel No: 31.29.17. 1.) Alt BM Description = 5 ( (,p17~, le, SySTQ/y~ f^•~, S'TC,.~~° ~ ~-~'+'~~ ~ v~~ 2,) Bldg sewer le th = ~-~ i /~~ ~~~~~/~~~~ _! _ / uu~ ~~ - amount of cover =' .~ / ~~~ a I /Q''u-" ` tZvh.~ l~v~( Plan revision Required? [_j Yes [ o ~ ~~~~ ~ ~~5~~ -L~ t/~-~"'~ Size x Hole Spacing Vent to Air Intake Use other side for additional information. ~ ~ ~ ,; ,_. __ ___ _ ___ `~ _. __~ ~- - ___ ,. __J ~ -- SBD-6710 (R.3/97) Date Insepctor's Si a Cert, No. 51-R rK I~t ~ (E c r I-( -5 k ! c -. ~~ ~.ar.c.~ LdT 'a' Z / S/o G ~7 ~ H dt.__-- s ~ .5~ ~ ,M, C- ! , ~ r°~~ qN,;a' Le ~~~ `I yoa' S Gd ~~ ~/y ~:: /o " iY~ !'Lt ~`'° O ~ Z ~' sa 3 ~ d v ti V I' _ -- Z. c. 0 5.,1 S'r ~+~I~~-.1 rt~loo C'; i fem. / /'~ ~ ~-? ~~c/ New: ~ -~-~__ . .2 f` ~ ! yQr,.. ~~ s ~rv~~,~ ~ { ~~~~ ~ f~' ~ " ~ ~~-,~ ~,,,~ e.~-,~° ~ ~^~~ ` ~,.~. Q `~ 4~ ~ ~r3 k'~t3,75Trr„~~ 1S- 8~o~:~~s`.s Fq.~~ ~ G ~ "(' bTs, l ~ `~*~/r.~s.h ~s"xrc' ~ ~'~«~k G ~tosa a-y ;~r3~' 3 a Z 2, 23' 1 J N- Z ' -roP m4 ~ "P~ L _„~ ~t i ~a ~~~ ~" PVC T•~'°~ £t~InO,oo' N y C ~p~ Safety and Buildings Division : County ~ - ` _ - . ~ 201 W. Washington Ave., P.O. Box 7162. ~ ( • C. ~ /x l SCOI1 Sll~ Madison, Wl 53707 - 7162 Sanitary Permit Number (to be filled in by Co. ) De artment of Commerce (608} 266-3151 30 Sanitary Permit Application scams Plan 1.D. Number !n accord with Comm 83.21, Wis. Adtn. COdc,•pers u.~Cevtda-.....-,. .,._ maybe used for secondary Purposes Privac l,aw, .~ ~ r~ ~ : ~ ~ i Project Address (if di$'erent than mailing address) 1. Application information -Please Print All Informati n i /~~ O ~~~ ~~L` Property Owner's Name Parcel t q Block a 00 - o0 Property Owner's Mailing Address t Property loca . Section ~ '/ ~'/~ City, Stat e Zip ode C Phone Number _ , ti D b ~ / 7fJ~~s ,~~~ ~ '7 y T ~~ (cirri N; R~E 11. Type of Building (check all that apply) ~ CSM Numb~:r me Subdivision N 1 or 2 Family Dwelling -Number of Bedrooms / a Q ~ ^ PublidConunercial - Describellse ~ ~ ~ 1~ K G ~ ~•~. ^ to Owned-Describe Use ~ j~ ,, Village~I'ownshipof ~~~Q ^City - _ 1 pe of Permit: (Check only one boi on line A. Complete line B if a 1 cable) T .~~rw; ~t,t qr A" New System ^ Replacement System ^ TreatmmdHolding Tank Replacement Only ^ Other Modification to Existing System B • ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit'Ilansfes to New list Previous Permit Number and Date issued Before Expiration Plumber Owner IV. T e of POl~'I'S S stem: Check all that a 1 a I -~fFd Non -Pressurized !n-Ground ^ Mound ? 24 ia. of suitable soil ^ Mound < 24 is of suitable soil At-Grade ^ Single Pass Sand Filter G Constnrcted Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatmeat Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ~.eachin t]tambtr ^ Dti line ^ Oravel-less Pi ^ Other (ex lain) V. Dls rsal/1'reatmentAre~ Information: s. .~l~ "r ~ ~ s... a /•/ I3~ ~:ign Flow (gpd) Area Requirod (s Dispersal Area P it Application te(gpds ~ 93 ~ 8~• '~' S st~ E13eva~tion~~~ ~ m o 3 7 3 3 ~~ <ow.. Vi. Tank Info Capacity in Total umber Manufacture Site Steel Fiber ?lactic Gallons Gallons of Units Concrete Constructed Glass ~ New Bzi~sing Tanks Terries S<:ptic or Holding Tank K I ~~ Aerobic Tn:a[mcne Unie Dosing Chamber Vli. Responslblllty Statement- 1, the under red, assume respons(bill for Installation of the POWTS shown on the attached plans. Plumber's Namt (Print) Plumber's Signature MP/MPRS Number Business Yhone Number i k Yl~t ~ p 1 ZZSo 3~ ~ 1 a -~~ s= ~Z ~ . . m, . Plumber's Address (Street, City, State, Zip Code] ~ old vw~`~ W..~, S u l Vlll. Coon /De artment Use Onl proved ^ Disapproved Sanitary Permit Fee includes Groundwater Date lssue,¢, issuing gent Signature ( S~.antps) Stuchar a Fee g ) 2~ -- / y/~"f /O ^ Owner Given Reason for Denial 3 1X. Conditions of ApprovaUReasons for Disapproval ~ •t 3~~ ~C ~ SYSTEM OWNER: ~ n / ~ 1 Septic tank, effluent filter and RQ ,~.-, B'`'~ t D•t~~ dispersal cell must all be serviced / maintained ~ t ~ ~ as per management plan provided by plumber. ~ I 2. All setback requirements must be maintained ~ . as per applicable code/ordinances. Attach compktc plans (!o We County only) for the sptcm on paper not kas taaa M1rZ z t l mcbcs to stzc SBD-6398 (R. 01/03) Kevin Grabau Subject: Start: End: Recurrence: hammond--hidden ranch--soils at #--lot #2(#430466) & 11(#430467)--onsite with Mike McD Tue 11/11/2003 3:00 PM Tue 11/11/2003 4:30 PM (none) ~~ ~~~~~ ~~~~~~~ ~~Sb ~~ / ~~~ ~ w ~~~ ~O~ e_ 1, OJR~. n~~ I~.t~ 5 ~ .s`lr ~ w• C ~,, ~ ~'~ er ~ y, s a' Le ~u.r ~/ you ~ 5' Ga ~~ i/y ': /o " /9a-~'y~ ~-~ ~ W . L ti L1 ~Z~°5~.) ST' w/tdb.l ~ • ~ ~fl r; ~ ~'~ ^ ~ ~~ ,w~,/~JC y!ii ~~, ~ r © wQ~ ~~ ~VA~ ~~ Q~ ,'~`Y~ .~~s_.-~~te' O ~-3~ 5 \ 3o-T6T4 ~ `~s~~'QrM'1 ~y'XJO' ~4MC~l G moo, frt'r 3 N- . ~ ~ -~ ~~~ / P ~ ~~`'. ~~~ 2 Top o~ / rv ~. -~ . ~f 1 • ~l ~~ to •~ _- s~\~ -,,1 ~ "rrP~ ~,~:ln0,o0~ 1 y SOIL EVALUATtON REPORT wrsoonsm Deparbnent of Commerce D'rvisiorr of safely and Buildings ~ accordance wAit Comm 85, wre. Adm. Code coumy Attach complete si6e plan on paper not less than 8112 x 11 indres in sae. Plan must include. but not prrri6~ to: vertical and horizontal reference port (BM), dknction and Pare !D. percent slope, scale or tftmensions, north arrow. and Iocatton and distance to nearest road. Please pr(nt all lnihrmadon. Reviewed by Parsoaar inlomlatbn you provide mey ee utsd rw y..____.. tl~J' ~-"'~ st 15.04 ~t) {m)). property Owner Propertytocation 1.~ ~ 1 ~ # Subd Name ar Page ~, ~ -~ ./'rac'e _- Date T Z qN R / ~- E (arm Property Owners MaiNng Address ` ` loot Block .. ,~ ( a ~~ ~'`~- ` Nearest Road cry state code Nu~er~ ; ~ ^,c~ ^~u~gg ~ ~- ~jy~t SO , ~~ ~ .__ ,1 r ..~ ~ C4w.1 C 1 f 7/~1 7~r(n J'71 a:, [~ New Construction t)Se: ~ Residential / Number of bedrooms ~._,..yL. Code denved design flow ram ~ ~ ~~ ~ ~ GPD ^ Replacement ^ Public or commercial - i)escn'be: y / ~ ft. Parent material ~~~t ~'V ~- S ~ -- Flood Phain elevation fi applicable General oorrnrtents ~ S~P~1 -2 ~~' U ~ ~ f r~ nc h ~y, ~ G G-uW Prq ~/,Qa and recommendations: ~--~ ~-9 ~j~ ~~ ~ Bonng # ~ Pit Ground surface elev. _! _!J_.-? ~! ft- Depth to IimNing factor ~~ in. Soi tiorr Rate Horaon Depifr Dominant Color Redox Description Texture Structure Consistence 6ouncfary Roots GPDitg in. MunseU t1u. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'EB#2 ~ -i I ( S,~( m 1'Y~~~ C~ ~ ~~ ~ Sr Z ~~-Zy w ~ - ,`~ I k vn ~~ C ~ ' ~ Boring ~ Boring # ~ pg Grou Horizon Deptlt Dominant Color in. MunseA J o-Zg v 3 3 Z Zg 3 ~ I ~/ in. nd surface elev. ~ ~~ ~ _ ft. Deptlt in limiting tailor _ ~ Redox Descriptbn Texture Strut3ure Consistence Boundary Qu. Sz. Cont Cobr Gr. Sz. Sh. ~ Si~ ~ ~~ S~ c~ 11~ r ~ Roots ~' -- c~ tron Rate GPDlfl2 'Eff#1 'Eff#2 , s- , on .....n e...i TCC c afl mnk. • F_ffluerlt iM'1 ~ BOt) > 3t) <_ 2Zp mg/f_ one r ~ ~sv : jai rsw,ya. -- _ __- _ -- --- - _ - ST Marne ( Print} ~Sjgrrature CST Number -~,~a r-L~~w-2a~ oe^ ~~~~ .~ S 3309,' ~~ Date Evaluation Conducted Telephone Number /.3 `~3 ~/S- ~l o -dZ ~ s Property t~wner Boring # ^ Boring ~~[.~~ ft. Depth to faclor..~d in. ® Pit 6rorxrd surface elev. -- - --~ s_.~. Page ~ of-~ 0 Boring # ^ Bormg Grormti suttace elev. ft. Depth 10 limiting factor in • Sod lion Rate ^ Pit Dominant Cobr Redox Desrxipdon Texhre Strutiure Consistence Boundary Roots ~ti#GPD~Efr#2 HO~on ~~ Gr. Sz Sh. ~. Mceseif Qu. Sz Carl Color Boring a ~~ # Ground surface elev. ft. Depth to timit~rg factor in. ^ Pit Soi ~ ticn Rate Flor¢on Depth DamirtaTrt Color Redox Description Texture Struchrre Consistence Boundary Roots GPDIfI= in. Mansell flu. Sz Copt Color Gr. Sz Sh. 'Eff#t 'Eft#2 • Eftluerrt #t = BODS > 30 <_ 220 mg1L and TSS >30 <_ 150 mgll • Etllrrent #2 =GODS < 30 mglL and TSS <_ 30 mglL The Department of Commerce is an equal opportunity servcce Provider and employer. If you need assistance to access services or need material in an altermtte format, Please contact the department at b08-266-3151 or TTY 608-264-8777. sao-a~soia.arronr • PAGE 3 OF~ ~TA1~~E h'~-~ ,, LOT# ~- T E AL DFSCRTPTIO S ~'' ~ ~~ `a ,S 3 ( T Z- ~ ,N.R. I ~- Elor)~ ~ _ SCALE:I"= yC> i 1 ~ i BM 1 ELEVATION (~Cd • U ! + I, I BM 1 DESCRIPTION ~v~ c5-.~ 1 "Q~ c P~,D~ C~ ~ BM 2 ELEVATION °I ~, (U ! ~~ I ' ' BM 2 DESCRIPTION ~ U c c • ~ ~ C ~ 3 ~ ~~~~ P PP i SYSTEM ELEVATION -~ p 9 ~~ ~ ~•ow e ~ q~~ vU I ~ SYSTEM TYPE ('~ n., ~ r~ ~-~ `v ~^ 0. ~ CONTOUR ELEVATION ~' i ~_r_ ~-- - ~ _ _, ~W ~\ 6,~ ~6 ~ q~~ -~ s S{.~~ ~ 1 v r~q ~° ~ Z .~ ,~fi ~ (~- ~ -~ 6~` SIGNATURE -/SYi- ~ ~ -~u tN ~ r S ~m ~ ~ S ' ser S if ication~ ~~oD~f f u p-ec ~.. J 76' - ~ ao c~ c~ c-,~ 4' Knockout ~, Cnan+ber Universal End Cap fr •,- POWTS OWNER S MANUAL & MANAGEMENT PLAN FILE INFORMATION owner 5~l/N uG Permit f/ ~~ DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ^ NA Estimated flow (average) ~ al/da Design flow (peak), (Estimated x 1.5) m ~ al/da Soil Application Rate al/da /ft2 Standard Influent/Effluent Quality onthly 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) S30 mg/l. Total Suspended Solids (TSS) 530 mg/L ^ 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 effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Page ' of Z Septic Tank Capacity ~~(dp al O NA Septic Tank Manufacturer ~(S ^ NA Effluent Filter Manufacturer ,,,L- ^ NA Effluent Filter Model ~ CS~O ^ NA Pump Tank Capacity al Pump Tank Manufacturer A Pump Manufacturer A Pump Model ~ A Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: L~bNA Dispersal Cell(s) ~In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other. ^ NA Service Event Service Frequency Inspect condition of tank(s) At least once eve rY~ / ^ month(s) (Maximum 3 years) f' ~ ~' ear(sl ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y,) of tank volume ^ NA Inspect dispersal celt(sl At least once every: ^ month(s) (Maximum 3 years) ~ (» earls) ^ NA Clean effluent filter At least once every: ^ month(s) (~ ~ year(s) ^ NA Inspect pump, pump controls & alarm At least once every: ^ month(s) ^ ear(s- NA Flush laterals and pressure test Ai least once every: ' O month(s) ^ yearfs) A Other: At least once every: 0 yea~l ~(s) ~6VA Other: A 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 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 IY31 or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and dispo$ed 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 512 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. '~ ' Page 2 of 2 START U'P AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemical that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the content of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will 6 discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge c effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restorin power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls t 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 are 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 th POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fa foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; of painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system i properly and safety abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled wit 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 complier replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soi! absorptio system. The replacement area should be protected from disturbance and compaction and should not be infringed upon b required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area wi result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems mu: comply with the rules in effect at that time. ^ A suitable replacement area is not available due to setback and/or soil limitations. technology a holding tank may be installed as a last resort to replace the failed POWTS. /~ T -arart~tr='--1-i/ alua ' b e ai ~~~~d18 ~ g=C~- Barring advances in POWT rasraitaUt€aTiolding an CpNS7RU~. DN ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at th 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 NO' ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF ~ PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS fNSTALLER Name ~ ~-LL Phone ~ ~ Z ~,~ ~ 9Z~ POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name S ~', ( 20~l~~ Phone Phone '715- 3g(o_ (`j ('~ This document was drafted in compliance with chapter Comm 83.221211b)I1)(dl&(f) and 83.54(11, (2) & (31, Wisconsin Administrative Code. ST CROIX COUNTY c ~~ SEPTIC TANK MAINTENANCE AGREEMENT I ~ AND . ` OWNERSHIP CERTIFICATION FORM ' OwnerBuyer Sf~ ~'1 ~'l /~ L ~R-- Mailing Address ~D ~ ~ ~ r s ~ /emu ~-S o vi (.(, / .S~O~~, Property Address /S/~ ~~°~ ~ J ~~- (Verification required from Planning Department for aew construction) City/State ,~0.1nn 1ti1. o KtY Parcel Identification Number ~1 ~'~~~ 9 " °b " ~~ LEGAL DESCRIPTION property Location S Gt./ r/4,~ `/4, Sec. ~ T~N-R / W Town of J~.Nt Subdivision ~ ~' c ~ ~h ~ ~-K ~~ ~ Cer~tif`ied Survey Map # 73?0 7-3 , Volume ~ .Page # ~~ Warranty Deed # 7 3 ~ ~ ~ Z-- , Volume oZ y~ ~ .Page # ~-~~ .Spec house ~, yes ^ -no Lot Isles identifiable., yes O no S~S',~M M,A,INTENANCE ..Improper use and mainteaanceof your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank Query three years or sooner, if needed by a licensed pumper. What you put into the system caa affect the function of the septic tank as s treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a 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 full of sludge. Uwe, 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. Certificatioc stating that your acetic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 f the three year a piration date. _ ~ d /OZ/ O O APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form arc true to the best of my (our) knowledge.. I (we) am (are) the owner(s) of th roperty descri above, by virtue of a warranty deed recorded in Register of Deeds Office. '` - lD /et/o OF APPLICANT DATE •trrt* ••••«• Any information that is mis-represented may result in the sanitary pemut being revoked by the Zoning Department. •• Include with this appllcatloa: a atamped warranty deed from the Register of Deeds office ' a copy of the certified survey map if reference is made in the warranty deed U 2`i08P 256 I STATE BAR OF WISCONSM FORM 2 - 2000 Document Number WARRANTY DEED This Deed, made between Bruce J. Moll and Thomas S. Aaby Grantor, and Sam E. Miller, a single~erson Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum:) Lots 1, 2, 3, 11, 12 nd 13, Plat of Highland Ranch in the Town of Hammond, St. Croix County, Wisconsin. '73g84~ KATHLEEN H. 1tALSH REGISTER OF DEEDS ST. CROIX CO. ~ liI RECEIVED FOR RECORD 09/12/2003 10:30A?1 MARRAHTY DEED EJlEMIpT i REC FEE: 1 i. 00 'fRAltS FEE: 792.0@ COPY FEE: CC FEE: PAGESs 1 Area Name and Return A""ddres~~ 1=t.t.~t F~~e~,~tY 4~j~ /~ J ~ 6 £~ Ol&1069-00-400 Parcel Identification Number (PIN) This is not homestead property. 6isJ (is not) Exceptions to warranties: Easements and restrictions of record. Dated this ~ ~~ day of ~ , 2003 AUTHENTICATION Signature(s) X ~J....- '~ Bruce J. Mol~ 'E ! i * Thomas S. Aaby ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. St. Croix County ) authenticated this day of , ~~''~ RY p V.A~ttt. Personally came before me this ~ ~ day of ~~- 2003 the above named Bruce J. M Il and Thomas S. Aaby TITLE: MEMBER STATE BAR OF ONSIN ~`ti c: ~~~, (If not, s' TAMARA K. tom o be the person(s) w xecuted the foregoing authorized by § 706:06, Wis. St'yS+~ HER$ST Z ~ ins m d acknowIed e 3 THIS MSTRUMENT WAS $D BY ,.• ..•• ••. ~`'_ O r * w~A a Thomas A. McCormack tttr .... Oie ~~cLG ~~ ~ ~ Notary Public, State Of ONSIN Baldwin, WI 54002 '~~~~~~~~"``~ My Commission is penman t. ( not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ~ , ~_ •) f Names ofpersons signing in any capacity must be typed or printed below their signature. WARRANTY DEED STATE BAR OF WISCONSIN INFO-PRO (800)855-2021 www.infoprofom~s.com FORM No. 2 - 2000 0 M (~ O 0 ~_ 1.17 J r/° ~V ~ 11. 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