Loading...
HomeMy WebLinkAbout018-2005-12-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division • 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: Insp. BM Eiev: BM Description: ~e~.~ ~[vl I I'' PSG TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic I /t / 1~' V ~ Z5 U Dosing Aeration Holding TANK SETBACK INFORMATION ~~ ~~- t`I~U TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~~ \ ~~~ j ~~/ i'7~/ OOCC Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number `~~ { TDH Lift Friction Loss Syste ad TDH Ft Forcemain Length Dist. to Wetl SOIL A6SORPTION SYSTEM _ ~ ,-, > a County: St. CrOiX Sanitary Permit No: 430660 0 State Plan ID No: Parcel Tax No: 0/8 ~ ?-r'~' S t 2 -oav Section/Town/Range/Map No: 31.29.17.GI'3 STATION BS HI FS ELEV. Benchmark j 2 ,2~ I z 2u U~. (.~ Alt. BM I'' -vr + ~ o C~ rnr~1 13,3 3 // ~'. A_`i Bldg. Sewer ~ b, SUHt Inlet 5~6• 6• St/Ht Outlet sy Dt Inlet _ Dt Bottom _~ Header/Man. Dist. Pipe"(p~ t "u,lYSt ~ a C ..~~ cis t i5.2 .oiD Bot. System t,~~t 1~ • Z~ ~ lr •t Final Grade // II•L` ~Ci.L St Cover i BEDITRENCH DIMENSIONS Width ~ Length ~ c ~ No. Of Trenches ~ ,- , PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth ~ ~ ~ ~~~ C~ SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer: ;~ r~l t ~ (' S ~ Type Of System: }~~ ,,;. , , / ' ~~~ 7~~~ i UNIT ~ Model Number: J DISTRIBUTION SYSTEM t'C,SI'" r~ a"• Header/Manifold / Distribution e x Hole Spacing Vent to Air Intake ~ / 1 Length Dia_ Pipe Length Dia Spacing SOIL COVER x PrPSSnrP_ Svstams Only xx Mound Or At-Grade Systems Onlv Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench enter To soil es ~1 - - - o COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: s / ~ /~ Ins Location: 1511 66th Avenue Hammond, WI 54015 (SW 1/4 NW 1/4 31 T29N R17W) Highland Ranch Lot 12 Parcel No: 31.29.17. 1.) Alt BM Description = ~f ~Z ~ ~m ~ I ~~ ~ ~`~ - ~J y ~ ~i '~ ~ ~M~~~ 2.) Bldg sewer length =as ~ ~ rt vi ~'~ S{? ~ (t'Z VU ~~~ -amount of cover = by ~ ~1~ ~ ~(K., ~ D~5 t~® ~ 2~ ~4 ~~~iWyh, ~~e,Q/L .Pm_p~ Use otherlside for add tional in Yes ~] No ~ ~~ I formation. I GS ~b7 v~~ _ ~ - ---- _ i ~~ S~ ;~ ___ , Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) - _ I~ ~ ~ ety an Btuldings Division 201 W. Wash' gton Ave., P.O. Box 7162 County _ - ~j~(. C P~ ~x _ c ,v CO~~ ~ JAN Y 4 Madiso , W1 53707 - 7162 266 3151 8 2004 Sanitary P 't Number (to be filled ili by Co.l ~ / / De artment of Comm rce - ) ( 30 O SilIIlt 1"y ~ ~C IUII i State Plan LD. Number ~ !n accord with Comm ~~F info lion you provide maybe used for secondary purpous Privacy Law, s .04(I xm) oject Address (if di9'erent than mailing add: asj i ~~'// ~~~-h ~V~ 1 li i . App cat on lnformadon - Please Prlnt All lntormatlon l Property Owner's N a e m P q ~J Lot Sla'> ; ' y / , ~ ~ J /T ~ Y / / ~ L 4 ~.~' ~ Z 1' j Pro p erty Owner's Mailing Address tio n j Property Lo ca , / ~ i " - ~ ~ ~ v~ ~ / ' / / ~ ~ w % ' ` `^'h Section Ciry, Srat e Zip Code ne Number Pho ., , ~n ft /~vd%.SO n ~ ~ S~D/~ / tl Q 3~G- Z 7 t°/ ~+ T~ / N~ R l ~cE or V~ 11. Type of Building (check all that apply) ^ 1 or 2 Family Dwelling -Number of Bedrooms Subdivision Nam, CSM Numb.; ~ ~ !) ^ ; / + ~ /~t ~ ~ ~ ^ PubtidCommetnial -DescribedJu ~ ' l ^ State Owned -Describe Uu ~3 % ~ am ors T ~4- ^Village Township of /tea-ss+ .~ee~'I ^Ciry _ l 1. ype of Permit: (Check only one boi on line A. Complete line B If appllcab e) j A' ~ ew Systeut ^ Replacement System ^ TreatmmUHolding Tank Replacement Only ^ Other Modification ro Existing System B ^ Permit Renewal ^ Permit Revision ^ Change of ^ Perniit Transfer to New list Previous Permit Number and Date lssutd i Betore Expiration Plumber Owner l V. T e of POWI'S S stem: Check all that a t Z ~ ~} - /oo Fr / r Non -Pressurized ln-Ground ^ Mound ? 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand F iha i.l Constructed Wetland ^ Pressurized In-Ground ^ lioltiiag Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculatin d Filter ^ i j Recirculating Synthetic Media Filter ^ Leac}tin Chamber ^ Dri line ^ Gravel-less Pi ^ Other (ex lain) ~ V. Dis ersal/I'rcatmt:nt Area lnformatlon: tv\ Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Req ed (sf) Dispersal Area Proposed (sQ y r Elevauou i ~ ', Il ADO d - `7 '~S'1 `~ 33 ~ 96 • sb q6 . a j V1. Tank info Capacity in Total Number Manufacturer Prefab Site Steel Fiber ?last.,; i Gallons Gallons ofUtrits Concrett Constnrcted Glass I Ncw $xi+ain8 Tanb Tanks _,_~ S.~ptic or Holding Tank ~ L~0 / / ~ ~Q~ s ~./ W y ./`. Acrobw Tsatmcnt Unit ~ Daing Chamber , ~ V11. Responslbtllty Statement- 1, the underalgned, assturu reaponslbWty for Installation of the PON'TS shown oo the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business }'hone Number -k~- ~ ohQ.ll < Zz Sa 3 G/Z-S~+! - /9L i r Plumber's Address (Street, Ciry, State, Zip Code) _- ~ ~~~o ~~~f~ ~~~,o~~.. ~~D, ~a~ch w~ s 5~a~.6 ~ `'11L Coun /Dc artment Use Onl ,__ ~ Approved ^ Disapproved ~~' Permit Fee includes Groundwater Date lssue~ !s g A t Signature (N '.ampsi Surcharge Fee) L-JV ~ / ^ Owner Givm Reason for Denial lX- Conditlons of ApprovaUlteasons [or Disapproval ~\ ~ ~ 1 ~~ SYSTEM OWNER: / ~j2. 1 Septic tank, effluent filter and C~Q1ln dispersal cell must all be serviced !maintained f1- as per management plan provided by plumber. Sl~.t? ^ "~ ~-~ , 2. All setback requirements must be maintained ~„$- / as per applicable code/ordinances. (K~"" Attrch eompktc plane (W the County only) for the iyakm oa paper not ksa than 81/2 x 11 luche~ in tlLc SBD-6398 (R. 01/03) ~~ (~~~ ~'~ 1, ~~ ~ Q ~ Q H o ~ ~ M .~ ~ ~ ~ • ~ ~ ,° nl ~ _ ~ N V ~ ~ V S ~ Q Q `~ ..1 ~ p ~~ r• ~I 3 W , ~ ~ + ,Q ~ ~/ ~ a- ~- ~° ~ 'K J i J ,~ ~-~ a ~- .4 i ~SS f_ l , AA M^ ~N .~ J M 0 ,os~~Iz Vim' r~ :~ `~ f v J ~~ ~~ ~ ~ J ~ ~ ~ ~ ~~ M~ ~- o a ,~ ~ r m ~ h ~.n ~~ CRY ~..q1 h~ N 3 ~ ~~ ~F~~~ ~ 9tyLfi'j F. ~ .~ OS'L /2° ~~P~ M ~I ~` ~I ~L~ / - ~~/ i ~~\ I ~~ ' ~ ~~ ' ~O J t"~ `~ o ~.~ (. W' v2 ~ N ,, Q 6M ~'~ ~,~`~ M ,O.s.~: Bz- ~ Qlro _r J ~ ~ v ~ ~ uu"' R ~ 0 J J ~\ f`~ lir ~ W a. a a N .. N ,~ ~ o "~ M ~ `` 4 ~' ~~' ~- ,~ ~~ ~ ~ ~ v ~,_ ~ .~ v~ ~ ~ ~ ~ ~' O 9 ~ Q O r J ~ v '!~ ~ ~ J n . ~ Q ~ !n ~ f J' ~ tY 111 4- "~ J ~ ~~ ~ i ~ ~~ ~ ~ @~ NN .©s-~,~Z v3- C / L- r ra J L 7 0 N M i~ ~--' ~~ De~rtment ~ ~ SOIL EVALUATION REPORT D'rvisfon of Safety and buildings in aa~rdanoe with Comm 85, yVis. Adm. Code Attach complete si6e plan on paper not leas than 8 9/2 x 11 iodise size. ,,...r.__~~_,..,_,~.~~; e- indude, but not Ihnited to: vertlcat and horiaorttal reference ~ ( ). d~'~a~id"` Paroel percent sbpe, scale or dimensions, north anow, and tocetion and d nce to nearest road. Please print ap inibrmadon. . ~;' ~ ~ % 0 C 3R Persoae! infom~atfon You D may bs used for stacondary purposes IP ' Larr. a 15.Q4 (1) (m)?• Property Owner proppetryl.0~sd1~: "C6T~`7~ ~"fl4'~i C O Property D ~ rs Mailing ~d~ l.ot ~ bbcl` # Suttd; C;ty State zip Code `Phone Number ^ Cfly ^ ~~ge I-4~ m YM O yl c~i. I.tll I tVi 2~ (7 (~ ~J~' ~~/ Page ~ ~ _ 3 ID. ~ Date .. ~~ n S 3 ~ T Z9 N R I ~- E (or~ or CSMff Nearest Road i G7~ (~ New consbuction Use: [`~ Residential I Number of bedrooms _ ~ _ y Code derived design Aow rate y ~U ~~~ ~O GPI ^ Replacement ^ Pubflc or canmercfaf - Describe: F-bod Plain elevatlon rT applicable /U / ~- ft. Parent material .~ ~ ~ h~ Gera:rai oaranerris s` / ~ ~ rr~ e ~ e v , ~P ~ e nc ~l ~~p . 5~ Low P i- ~Cp , Q~ and recommendations: 7` ©boring # ~ ~g ~U' ft ~ m' th to Limiting tactor D l ~, . Ground surface elev. t ~ Pit - ep Sol tiorr Rate Horizon Depth . Domiruurt Colar Rsdox Descriptiar Texture Structure Consistence Boundary Roots GPD1f~ 'Eff#1 'Elf#2 in. Munsdl Qu. Sz Cont. Color Gr. Sz. Sh. S ~ i r ~~ ~-~ r -- fri Z _ - S' 'G r (' W s 7 ,.i itn ._ ~ /f// ....r ~ /1~~ ~ I ~ _~ a fi Z q6.a Boring # ~ Boring ',~ ^ ~' Pit Ground surface elev. LZeOCU ft. Depth to flnnBmg factor ~~__._ in. .Horizon Depth in. Dominant Color Munsefl a - ~ ~z I~-~Z y2 - (p / ~ ~0 Redox Description Texture Strucdtrre Consistence Boundary Roots Qu, ~_ ~~ Cp(pr Gr. SZ. Sh. Sig b -^ ~ ,11~ S 6~ ~~ .. • Effluent aM'I ~ 80Ds > 30 < 22p CST Name (Please ) m ~c~wm0.~- t'`_ Address ~-~' l0 2- d Thy __C r. ~~ •Eifl~1 'Efitif2 r~ ~~ !Z < 15D aryl. ' Effluent fC1.= BOD < 30 mglL.ard TSS <_ 30 mgk. CST Nun~er ~'amre -~~ ~. ~`~ 3G ~i S~ (n - /~j -03 7~5- 7la v -az ~~ r__ ~QT ~ Z Page ~ of~ yy~ ~~ Parcel ID # ProPertYOwner _.J1-f . (] Boring ,r t3orarg # / a~' ~~ ft. e elev f ~~ Depth m 6'MBng factor -~--~-- in. Soi Rate Grors Pit . ac rd sur Texlrue Shucture Consistence Boundary Roots GPDIff Horizon Depth Own&rant Cobr MunseN Redox Qu. Sz Coat Cobr Gr. Sz. Sh. 'EJf#1 'EtNf2 in. s ° cs ~1,~ rs- ~ -zs ~~, rz , - m - Sri I ~~ ZS v ~ r_ ._~ ice. _/~`~ ~ ~ _ ~ ~ ~~ bZ ^ Boring # ^ Boring ^ P8 Ground,surface elev. ft. Depth ip 1'mi~g factor in• ~~ Lion Ra Horizon Depth Dominant Cobr Redox Description Texture Sbudure Consistence Boundary Roots GPDIft? Gr. Sz Sh. 'Eti#1 ~ff#Z in. Mrarseil Qu. Sz. Cont Cobr Boring Borng # Ground surface elev. R Depth to laniting factor in. ^ Pit Soa ioalion Rate Horizon Depth Domir~rt Color Redox Description Texture StrucWre Consistence Boundary ;Roots GPDIfEr ~. Hansel{ Du. Sz. Cont Cobr Gr_ Sz. Sh. 'Etf#t 'Etf#2 ' Eft #~ = BODS> 30 < 220 mglL and TSS >30 <_ 150 nrglL ' Effluent #2 = GODS < 30 mg1L and TSS <_ 30 mgll_ The Department of Comumerce is an equal oppottwrity service provider and employee If you need assistance to access services or need ~~~ ~ an ~~~ format, Phase comact the department at 608-266-3151 or TTY 608-264-877?. SBD-K7301R.0'NOIq PAGE 3 OF ATA I~:E ~a ~ ~ T OT# ~ Z LEGAL DESCRIpj'IONTSGJ ~Nw~ S 31 T Z °'C N R. ~ ~ E(orDW ) SYSTEM TYPE (~~ n u t ,~~- c `y .~ ~ CONTOUR ELEVATION "' QN. ~ 8~^ 1~~.6v g,1 e2 ~~ ~ ~. G ~ ~ ~° ~ c ~ l b~Z ~~ ~ x ' - ~~3 r ~~ SIGNATURE .-~ ~~---- DATE G ~~~~ 5,~--,~- Iii l ~~- ~,~. ti ~ ~ w ; ~, ~. ~ J.. ~~~'" ~ , l z-- BioDif fuser Spec~f ~cat~ons 76' _-_-.l ~o ~o 00 00 ~o 00 00 00 00 00 00 00 00 00 00 0 ~o o 00 ~~ 00 o0 00 00 00 00 00 0~ 0 00 o0 0 ~ 0 00 ~o 00 00 0 ~o ~~ oo 00 4' Knockout ~ Universal End Cap ~- ~' POWTS OWNER'S MANUAL & MANAGEMENT PLAN FILE tNFOR11~1ATION Owner ~ ~ ~ ~ ~ 1 ` ml, Permit t! 1/~~~~0 DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units NA Estimated flow (average) ~{ SO al/da Design flow (peak-, (Estimated x 1.5) Qp p b al/da Soil Application Rate D_ ~ 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 (BODb) 530 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 I_ of Z Septic Tank Capacity ~ 2- f'O al ^ NA Septic Tank Manufacturer ~G~ s ~- ^ NA Effluent Filter Manufacturer ,2,41$ E ^ NA Effluent Filter Model L~ - J DO ^ NA Pump Tank Capacity al ,Ia NA Pump Tank Manufacturer ~ NA Pump Manufacturer (T~'NA Pump Model ~ }~ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: UYNA Dispersal Cellls) 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 every: ^ month(s- (Maximum 3 years) ear(s) ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y31 of tank volume ^ NA Ins ect dis ersal cellls) P P At least once eve ry~ ^ month(s) (Maximum 3 ears) ~ ^ year(51 y ^ NA Clean effluent fitter At least once every: O month(s) / - Z fSyear(s) ^ NA Inspect pump, pump controls & alarm At least once every: ^ month(s) ^ year(s) ^ NA Flush laterals and pressure test At least once every: ~ ^ month(s- ^ year(s) ^ NA Other; At least once every: ^ month(s) ^ year(s) ^ NA Other: ^ 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 cellls) 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 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 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. }_ START UP AND OPERATION Page ?' of ~/ ---~,q, For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that~may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents 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 be discharged to the dispersal celllsl in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent, To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade 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 be 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 disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or, must be taken, to provide a code compliant replace ent system; ~A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absor lion P system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS ` / technology a holding tank may be installed as a last resort to replace the failed POWTS. Iv molding `ank - - - CafVS'7R11~ DN ^ 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. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name ~ Ync..~NL [_L Phone ~O ~z . 0 ~/ S'. ~ / 2 Name ,' a,.~ 4 Qo .+~ ~~ Phone ~ 2 ,. ~~5, ~ / L SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone This document d Name S C ( d ZD~I~~I Phone '?/~~'- 3~(p- (O (] was rafted ~~ compliance wrth Chapter Comm 83.22(2)(b)(11(d1&(f1 and 83.li4(1-, (2) & (3), wsconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSIiIP CERTIFICATION FORM OwnerB uyer s' /~ ~'rl ~1/l % 1 ~ ~~' Mailing Address p ~ X ~ / s ~ ~ ~ ~3 d vt, ~ ~ s ~ ~ ~ ~' Property Address I S I I `` r -. ,~ ~a (Verification required from Planning Department for new City/State ~~~ rf1 IMe n Q ~~ Parcel Identification Number - o "` EGAL DESCRIPTION p~ V J / L I Property Location 5 ~'/., ~'/,, Sec. ~, T Z 9N-R~own of 1~~~. Subdivision ~'~ ~ S ~- ~ ~-~ ~- ~'0~-~ ~- ~'1 .Lot # ~ Z-- Certified Survey Map # ~ ~ 7o7 3 ,Volume Page # 8 Z Warranty Deed # 7 3 `~ 5' ~/ Z-- ,Volume 2 `~ ~~' ,Page # 2-s~o Spec house( yes ^ no Lot lines identifiable yes ^ no SYSTEM MAINTENANCE Improper use and maintenanceof your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. 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. Uwc, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the year expiration date. m/ llzl e~/ NATURE APP ANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of thc~rty described above by virtue of a warranty deed recorded in Register of Deeds Office. ~.~ a~ /iZ~ ~ y ATURE APPLICANT DATE «««««« Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. "`«" «• Include with this App[icAtion: s stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed ~ 2 `1 0 8 P 2 5 6 '?39842 KATHLEEN H. MALSH STATE BAR OF WISCONSIN FORM 2 - 2000 ~ REGISTER OF DEEDS tbcumcntNumber WARRANTY DEED ST. CROIX CO. , WI RECEIVED FOR RECORD This Deed, made between Bruce J. Moll and Thomas S. Aaby 09/12/2003 10:30AM NARRANTY DEED EXEMIF~i # Grantor, and Sam E. Miller, a single person REC FEE: 11.00 TRANS FEE s 992.00 COPY FEE: CC FEE: PAGES: 1 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 Recording Area Hammond, St. roix County, Wisconsin. a and Return Addres J= F.~~•~ ~.~ ~ ~6 £~ ~~' ~. ~y t?~ v 01&1 9-00-400 Parce! Identi 'on Number (PIN) I ~ P • of homestead property. 6isd (is not) Exceptions to warrattties: Easements and restrictions of record. Dated this ~ ~~ day of ~ , 2003 s AUTHENTICATION Signature(s) authenticated this day of , + Bruce J- Moll ~ ~ ~~ -~- *Thomas S. Aaby ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. St. Croix County ) Personally came before me this lt7 day of Wit- - 2~3 the above named Bruce J. M~II and Thomas S. Aaby TITLE: MEMBER STATE BAR OF3v~~^ONSIN ~`~ n•~~; (If not, $ TAMARA K. tom o be the person(s) w xecuted the foregoing authorized by § 706:06, Wis. St ~S~ HERBST _Z ~ ins m d aclcnowled e 3 THIS INSTRUMENT WAS ~~ ~ F,D 13Y,,,.°O?ys * rn.A a Thomas A. McCormack r4ti, Op ~~cLG ~~~' Notary Public, State of ONSIN t'~~h~~..~"ms`s Baldwin, WI 54002 My Commission is penman ti( not, state expiratioAn4date: (Signatures may be authenticated or acknowledged. Both are not necessary.) J'~ ~~ , ~C?."~,f~+_,~') ~ Names of persons signing in any capacity must be typed or printed below their signature. ~~ WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2 - 1000 INFO•PRO (800)855-2021 www.infoproforms.com ,. ,, ._..,..,.s. us»° 19°39'38" W ~~:3 ~ _ ,~. ~ ;`' N 89"dpM~g• E 434.00 ~ t °. ~Ja~ ~ - ~ 330.01' 3 99'39"d8' W 434.43' _ _ _ -- - - T~ ~. . 13 104.42 __..---' ~~ ~ ... '~ .~ •~• ~~~•'~ . . 363.01' . • ' ` ~ . ~ ` '.oiir~ ~ ~ f sl LOT 11 `~ • .:.:.,,.•;,.... . ~ a M _ 1.T5 ACRES ~ _ _ o ~UU ao l a'0.~. IOL~ ~ ~ ~ ~ < ~ a .78298 S0. F'T. ~ • . , . • . ' • , • .: , . ; ! _ ~ ~~ ° Q ~ ~ ~ ~ ~ MNE =998.00' ' 0.~ ~ - - - - - - - ~ LBO ELEVATION = 99g ~, . ~ • ~' ... ' ~' ~• ..:a~'.'..... • . 3: BENCHMARK ~• •...~ ..... . ~~ ~ : ELEV. = 1012.86 _ , ' ~ . ' •M 80r'S _ m : ~ . ,r.J.....~, °~" __ ____b ~ ~~ S89`48'28'E311.87 .',',','.' ' ' ~`~ _ ~ .~ ..... u~:, i \ S 89'48'25' E BB.Od • , • ~ . .2.80 A L~04 9 ~ ~ 1.55 ACRES ~ • ~w ....121 17a ry~ S ,.~.....,~. ~o~JoQ~a ~a g ~ & 87711 SO. FT. Fib, •' ..f'I~IVE'p~,'1 ~ ~~~ 9 ~p ° Q' 0 0 8 ~ FiWE = 1000.00' ~ , ' . '~, d•EC.EYrA-71( .. - - - - - - - -- ea LBO ELEVATION= 1003 ', ~' '• •. • ••'. •. •.'.'.'. ; .' ~ ...~, 89°39'38" S89'48'25'E311.07 1 ,•,.,...;.:.'.'.'. . _ ~ ~- - -- - - - 106.6' LOT 13 ~ C S"o y ~ • .'.'.'.'. •..:.: ~'.~, i:. 1' ` r ~~. 1..~'. 3 2.92 ACRES `•~•••~•" 128,999 SCE. FT. c ~ .......~ • ~(~L~d ~~ I-IwE= 1001.00' N `~'.'.'•'.'•'...'.'. :. LBO ELEVATION =,1004 ~ • • • .y '~ _ ~ ° ~ ~ ~ CONCRETE ~ ~ ~ • . ' ... '. • -:~ FOUNDATION '~' ~' .. ~'' ~• 483.19' `~' • N89°39'38'£ 258.29 - ~ ~ ~ 148:73' • ~ . SEE DETAIL ~,~ 9 EAST - wEST 1i~ LME N 89°39'38" E 11.,