HomeMy WebLinkAbout020-1479-09-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
569586 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
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 Parcel Tax No:
Swanber , Scott& Lois I Hudson, Town of 020-1479-09-000
q'7
CST BM Elev: Insp.BM Elev: 7,57 Description: Section/Town/Range/Map No:
CJ Lp`T/O 36.29.19.3030
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS FS ELEV.
t'fD•3
is 4 ,n� Benchmark ��
�(l/vS� Alt. BM ����1'1G�Gl l� Q` 6 " � •
Aeration Bldg.Sewer
V v
F,Wm t I et
St/Ht Outlet-
TANK 4� �'
SETBACK INFORMATION AT U
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic - - .- Dt Bottom
Dosing Header/Man. vy"
95 S
Aeration JV Dist. Pipe
Holding _ U7'l Bot.System
-- — - 'C'
PUMP/SIPHON INFORMATION A Y/' AI Final Grade
/
Manufacturer Demand St Cover ��
GPM �- D3 r 0
Model Number "14�
TDH Lift Friction Loss Syste Head TDH Ft /a
�� 5S
Forcemain Length Dia. Dist.to well
/ OIL ABSORPTION SYSTEM ?,�Z t'ii� �,clZ[ Jo?, 7-
DITRENCH Width Length No.Of Trench Tenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth
DI NSIONS (ISI/�//rte/��•�Jf
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM L CHI Manufacturer:
INFORMATION CHA OR
Ty Of System: V 1 N
Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
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 0 No E] Yes
COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1:�/ /�� Inspection#2:
Location: 857 Yost Drive Hudson,WI 54016(SE 1/4 SE 1/4 36 T29N R19W) Cottonwood South'07 Lot 9' Parcel No: 36.29.19.3030
1.)Alt BM Description=
.U"
eA'C!'//rk.K- (6Q/A't A VaA )
2.)Bldg sewer length
-amount of cover
Plan revision Required? ❑ Yes [ No
Use other side for additional information.
SBD-6710(R,3/97) Date Insepctor's Signat re Cert.No.
PLOT PLAN
PROJECT Scott Swanbera ADDRESS 2901 W. Armour Terrace St. Anthonv Villaae Mn 55418
SW 1/4 SE 1/4S 36 /T 29 N/R 19 W TOWN Hudson COUNTY ST.CROIX
SYSTEM ELEVATION none BEDROOM 3/4
CONVENTIONAL AT-GRADE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE
4001715 Hoot System DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE ABSORPTION AREA # of chambers
IL BENCHMARK V.R.P. To be determined ASSUME ELEVATION 100'
❑ BOREHOLE O WELL *H.R.P. SW corner of property.
YostDrive
I
Pro 3/4
Bedroom
House
-09
H-600 Hoot pretreatment syste
300'
Only 30'
Sam semen
531' Property Line
County
�+ r 11114 Safety and Buildings Division
201 W.Washington Ave.,P.O.Box 7162 sanita<y Permit Number(to be filled in by Co.)
w 7-7162
N 052�1� � 3 �(o 43 S��o
J� NN State Transaction Number
CIN.�GN� ermit App ice ion )�
A38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit
I �ired'aor to obtamutg a sanitary permit Note:Application forms for state.owned POWTS are submitted to Project Address(if differeat than marling address)
the Department of Safety and Professional Smvies. Personal information you provide may be used for secondary
sos in ace with tho Law s.15. 1 m Stets.
L Hcation Information-Please Print All Inform tion parcel#
Property owner s Nam O 1
Jc - �+ 9 Property Location �.3 a 30
property OwoerIs Mailing Address
f Zo Govt.Lot
C� rate ZAP Code Phone Number l S� �/. w �'/a 5e..
im
„7S/1 C� TG 1--N; R'/711!'' -1E W
II Type of Building all that pply) 9
/ Subdivision Name
1 or 2 Family Dwelling-Number of Bedrooms /� /
Block t-OT
❑Public/Commercial-Describe Use ❑City of
CSM Number ❑Village of
❑State Owned-Descnbe Use wn of
s A+0
gI, o P it: (Check only one box on line A. Complete IinL..if applicable)
A. System ❑Replacement System )KTtratment/Holding Tank Replacement Only ❑Other Modification to Etstmg System(explain)
�^
B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber hermit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration
IV.T of POWTS S stem/Com nent/Device: Cheek all that a 1
❑Non-Pressurized ln-Ground ❑Pressurized ln-Ground ❑At Grade ❑Mound-24 in o it ❑Mound< sut0 a so
❑Holding Tank ❑Other Dispersal C-Vomit(explain) ent Device( lam) '
V.Dis rsal/Treatment Area Information: R aired s Dispersal Ar ea Proposed(so System Elevation
Design FIo Desi Area gn Soil Application R/ate(grdsf) Dispersal e4 (f1
Total #of anufictnrer c
DO A
VL Ta Gallons Units tg
New Tanks Existing T a a, C7 a
septic or Holding Tack
Dosmg Chamber
VII Responsibility Statement-i,the naderslgaed, a responsibility for installation of the POWTS shown OR the attached plans.
Plum gnatrve MP/MPRS Number Business Phone Numbcr�
Plumber's Name(Print) t VVV /7�-- /(J
.�
Plumber's Address(Street City,State,Zip Code
VIII.Conn /De artment Use Only Signature
permit Fee Date sued lssuing � ae
X. !n<-1br Dente
S �ldv & 9 /�
IX.Condit► ns for Disapproval �(�'; 3 r JG5 ,.ti
1 - 5eptia tank,effluent muall b see U h, I�OJ��'�- r✓�
tiispersa'f cell must all be services!maintaintx! / PA_
as per management plan provided by plumber. d IN L
c I t pGk reg Uwe merta mint Qe'maintaitied
st per tipplicaWe
Attach to eompk empi ordinances. ,l
be plans for tlm system and sabmit to the County 0*of PAP&W has g trl z I l inches in site
SBD-6398(R.11/11)
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 6/5/14
Owner: Scott Swanberg
Location: SW 1/4 SE 1/4 S36 T29 N,R19W Lot 9 Cottonwood South Hudson
System type: Hoot Pretreatment unit H-600
Manuals Used: none
Page#
1. Cover Page
2. Plot Plan
3. Hoot Cross Section
4-6. Maintanance and Contingency Plan
/t.
Signature
License nu er#226900
PLOT PLAN
PROJECT Scott Swanbera ADDRESS 2901 W Armour Terrace St. An
Villaae Mn 55418
SW 1/4 SE 1/4S 36 /T 29 N/R 19 W TOWN Hudson COUNTY ST.CROIX
SYSTEM ELEVATION none BEDROOM 3/4
CONVENTIONAL AT-GRADE CONVENTIONAL LIFT HOLDING TANK
Hoot S
MOUND SEPTIC TANK SIZE 400015 stem DOSE TANK SIZE
15 y
HOLDING TANK SIZE LOAD RATE ABSORPTION AREA # of chambers
BENCHMARK V.R.P. To be determined ASSUME ELEVATION 100'
❑ BOREHOLE O WELL *H.R.P. SW corner of property.
YostDrive
Pro 3/4
Bedroom
House
30'
H-600 Hoot pretreatment system
300'
100'
30' Sanitary Easement
531' Property Line
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page Of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Is � Tank Manufacturer. CcJ ❑ NA
Permit# ❑selpyfic'P6 Dose ❑Holding Volume:YGV 7i f (gel)
DESIGN PAwETER9 Tank Manufacturer: JZCNA
Number of Bedrooms: ❑NA ❑Septic ❑Dose ❑Holding Volume: (gal)
Number of Public Facility Units: 0,NA Vertical Distance Tank Bottom(s)to Service Pad: (tt)
Estimated(average)Flow: t/ (g�day) Horizontal Distance Tank(s)to Service Pad: (ft)
rZD 7 Spect9c servicing mechanics must be provided if vertical Is>15 feet or
Design(peak)Flow-(estimated x 1.5): (gamey) if horizontal is>150 test Spedflc Instructions to be provided on back.
In Situ Soil Application Rate: — (gaudayR) Effluent Filter Manufacturer: x ❑ NA
Standard(Domestic)Influent/Effluent Monthly average.. Effluent Filter Model:
Fats,Oil&Grease (FOG) s30•mglL Pump Manufacturer:
Biochemical Oxygen Demand (BODs) 540 mglL ANA • NA
Total Suspended Solids SS 's150 mgfL Pump Model: .
High Strength Influent/Effluent Monthly average Pretreatment Unit/5"
(FOG) 2�/- >4—NA Manufacturer 1160/- ❑ NA
(SODS) ;ZM achanical Aeration ❑Peat Filter
SS >150 mgA 0-Disinfection ❑Wetland
Pretreated Effluent Monthly average ❑sa WGraval Filter ❑Other:
(BODs) s30 mglL Soil Absorption System
(TSS) s304mgIL ❑ NA ❑In-Ground(gravity) ❑In (pressure) �:Nq
Fecal Coliform(geometric mean) s10 "
Maximum Effluent Particle Size Ifs in dia. �A ❑Drip-Una ❑Mound
❑prip-Line ❑Other.
Other: NA Other:
MAINTENANCE SCHEDULE
Service Event Service Frequency
Pump out contents of tank(s)
[I When combined sludge and scum equals one-third I[%)of tank volume
❑When the high water alarm is activated
Inspect condition of tank(s) •At least once every: U s)s) (Maximum 3 years) [3 NA
91 yaw
Inspect dispersal ceN(s) At least once every: month(*) (MaximLwn 3 years) ❑NA
❑yews)
Clean effluent filter At least once every: month(s) ❑ NA
❑ s)
Inspect pump,pump controls&alarm At least onceovery: �j moMh(s) NA
•
Flush laterals and pressure test At least once every:. month(s) NA
� ❑year(s)
Other: At least once every: ❑month(s) NA
❑YoWs)
Other: NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and soil absorption systems shad be made by an individual carrying one of the following licenses or certifications:
Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper).
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 a check for any back up or ponding of effluent on the ground surface. The soil
absorption system 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 treatment tank equals one-third(%)or more of the tank volume,the entire
contents of the tank shad be removed by a Septage Servicing Operator(pumper)and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services,including but not limited to the servicing of effluent filters,mechanical or pressurized components, pretreatment units,
and any servicing at intervals of S12 months,shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 30 days of completion of any service event.
GMW4M(02105)
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents.or other
chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. if high concentrations are
detected have the contents of the tank(s)removed by a Septage Servicing Operator(pumper)prior to use
Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these
conditions is not recommended,as the excess wastewater will be-discharged to the soil absorption system in one large dose causing an
overload that may result in the backup or surface discharge of effluent.and damage to the system. To avoid this situation have the
contents of the pump tank removed by a Septage Servicing Operator(pumper)prior to restoring power to the pump or contact a Plumber
or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
Do not drive or park vehicles over tanks or the soil absorption system. Do not.ddve or park over, or otherwise disturb or compact,the
area within 15 feet down slope of any mound or at-grade soil absorption
the ance and the life of the treatment
f fire following from the wastewater stream may improve perforn prolong
Reduction or elimination o ng Y.
tanks and soil absorption system: adds, antibiotics, baby wipes,-cigar'ett0butts, condoms, cotton swabs, degreasers, dental floss,
diapers, disinfectants, fats, foundation drain(sump pump)discharge,fruit qwd vegetable peelings, gasoline, greases, herbicides, meat
scraps,medications,oils,painting products,pesticides,sani�y, napkins,solvents,tampons,'and water softener brine discharge.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the foioWng steps shall be taken to insure that the system is property
and safely abandoned in compliance with s.Comm 83.33,Wisconsin AiMiihistrstiva Lode:
• All piping to tanks,pits and other sal absorption systems shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and property disposed of by a Septage Servicing Operator(pumper). y
• 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 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 the time of their permit issuance.
❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be
rehabilitated and barring advances in POWTS technology,a holding tank may be installed as a last resat
❑ 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 maybe 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.btomat at the infiltrative
surface. Reconstructions of such systems must comply with the rules in effect at that time.
WARNING TREATMENT TANKS, .PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK
SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY
RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE.
ADDITIONAL INSTRUCTIONS:
i
�-d
POWTS INSTALLER POWTS MAINTAINER.
Name j�2 / < /
Name
Phone - Phone„ — ✓ 1.
SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY
Name Name S7l i
Phone -'J L_ Phone �/J--- —���
v
This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections
Comm 83.22(2)(b)(1xd)&(f)and 83.54(1),(2)8(3),Wisconsin Administrative Code.
PREPARED FOR: COUNTY PLAT
COTTONWOOD SOUTH
w awie xpo LOCATED IN PART OF THE OF SWIX OF THE SE1/4.IN PART OF THE SEI/4 OF THE SWIX AND PART OF
THE NE,/4 OF THE SWIM OF SECTION 36,TEEN.RISK TOWN OF HUDSON,ST.CROD(COUNTY,
SURVEYOR WISCONSIN;INCLUDING LOT,OF CERTIFIED SURVEY MAP RECORDED IN VOLUME S.PAGE 1642.
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TREATMENT SYSTEM INITIAL SERVICE POLICY
C3ur Comp y, ,k cl/ et4 t+ —,will operate and maintain the Boot Aerobic System
located at is (legal description only)
_. _.
Permit## _ _ , for the period of 2 years beginning..... wand ending lsmc�+
This contract will provide for all required inspections,testing and service of your HOOT Aerobic Treatment System. The policy will
include the following:
I. inspections a year/service calls(at least one every _months),for a total of over the two-year period
including inspection,adjustment and servicing of the mechanical,electrical and other applicable component parts to ensure proper
function. This includes inspecting the control panel,air pumps,air filters,diffuser operation,and replacing or repairing any
component not found to be functioning correctly.
2. An effluent quality inspection consisting of a visual check for color,turbidity,scum overflow and examination for odors.A test for
chlorine residual and pH will be taken and reported as necessary.
3. If any improper operation is observed,which cannot be corrected at the time orthe service visit,you will be notified immediately in
writing of the conditions and estimated date of correction.
4. The Homeowner is responsible for maintaining a chlorine residual of at least 0.s mgtL in the treatment system. This can be
accomplished by using chlorine tablets designed for wastewater use, NOT SWIMMING POOL TAB LETS. E:pon visit,if the
system needs chlorine tablets the service provider will add them and charge the customer. If the customer fails in their responsibility
to add the chlorine to they are in violation of law and appro t to action will be taken.
Initials of Installer Initials of Homeowner •—"
S. Any additional visits,inspections or sample collections required by specific Municipalities,Water/R ivcr Authorities,County regencies
the TCEQ or any other regulatory agency in your jurisdiction will be covered by this policy.
At the conclusion of the initial service policy,the Service Provider will make available,for purchase on an annual basis,a continuing
service policy to cover labor for normal inspection,maintenance and repair. According to state law,all owners of aerobic systems must
maintain a factory authorized service provider for the lifetime of the system.
With 48 hours of a request for service (weekends and holidays excluded), your system will be visited by the service provider listed
below or their authorized agent. If there are any items which need correction and can not be immediately remedied,the service provider
will inform the home owner,in writing,of the conditions and the estimated repair date.
The'HOOT homeowners Manual trust be strictly followed or warranties are subject to invalidation. Pumping;of sludge build-up,for
reasons other than due to warrantied mechanical failure,are not covered by this policy and will result in additional charges. By signing
this form,both Installer and Homeowner agree to the terms of this policy.By signing this form,both the Installer and the Homeowner
agree that the Homeowner has received a copy of the Homeowners Manual and the Installer has made a reasonable effort to explain all
pertinent information to the Homeowner,
HOOT is not responsible for service,it is the SERVICE PROVIDER indicated below.
HOME OWNER SERVICE PROVIDER
t �
2,ar Name of Service Company R p�r�sen 3t vv
Address Address °
City 'r� city
t. }
P Phone
Signature of Horne O e. — Si ice Provider and License
-6-
8 2 3 4 8 8 4
Tx:4192160
Document Number Document Title
996868
St. Croix County BETH PABST
REGISTER OF DEEDS
AEROBIC TREATMENT UNIT (ATU) ST. CROIX CO., WI
SERVICING AGREEMENT RECEIVED FOR RECORD
06/06/2014 0$:54 AM
EXEMPT #:
State Plan Transaction Number- REC FEE: 30.00
PAGES: 1
_Scott Louis & Lois Marie Swanberg
Name—(Owner) Typed or printed
Being duly sworn, states,under oath,that:
1. He/she is the owner/part owner of the following parcel of land
located in St. Croix C isconsin, recorded in Volume, Page,
Document Number dated /-`!-dZ o/D, St. Croix County
Register of Deeds Office: Recording area
A parcel of land located in the SW 1/4 of the SE 1/4 of Section 36, T 29 NAME AND RETURN ADDRESS
L
N—R 29 W, Town of_Hudson , St. Croix County, :F0 /'L/11
Wisconsin, being duly described as follows (include lot no. and
subdivision/CSM or detailed legal description):Aa4-
Agreement Date: 6-5��J r,,�y ///// Parcel Identification Number(PIN)
As an inducement to the county to issue a sanitary permit for a POWTS equipped with an Aerobic Treatment Unit on the above-described property,
we agree to do the following:
1. Owner agrees to conform to all applicable requirements of SPS 383, Wis. Adm. Code relating to Aerobic Treatment Units (ATU) and the
maintenance requirements for the proposed POWTS (Private Onsite Wastewater Treatment System)technology. If the owner fails to have
the POINTS and ATU properly serviced in response to orders issued by the governmental unit or the Department of Commerce to prevent or
abate a human health hazard as described in s. 254.59, Stats., the governmental unit(Town) may enter upon the property and service the
tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current
services rendered. The charges will be assessed as prescribed by s.66.0703,Stats.
2. The owner agrees to maintain a contract Oth a licensed POINTS maintainer for the life of the system.The POWTS maintainer will perform
periodic inspections and maintenance as required by the manufacturer and the Department, including, but not limited to:the blower,electrical
controls, and treatment unit operation and sludge depth. These inspections are to be scheduled every 6 months for the first two years of
operation and yearly thereafter.
3. The owner agrees to contact the POINTS maintainer immediately upon any malfunction of the treatment unit and to maintain the unit so as to
not create a human health hazard as described in s.254.59,Stats.
4. The owner recognizes that the county, Department of Commerce, or POWTS maintainer may make periodic inspections of the components
to complete performance monitoring of the unit.
5. The owner or the owner's agent agrees to report to the department or designated agent at the completion of each inspection,maintenance or
servicing event in a manner specified by the department or designated agent within 10 business days from the date of inspection,
maintenance or servicing.
6. This agreement will remain in effect only until the county office responsible for the regulation of POINTS certifies that the aerobic treatment
unit no longer serves the property. In addition,this agreement may be cancelled by executing and recording said certification with reference
to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property.
7. This agreement shall be binding upon the owner,the heirs of the owner,and assignees of the owner. The owner shall submit this agreement
to the Register of Deeds, and the agreement shall be recorded in a manner that will permit the existence of the agreement to be determined
by reference to the property where the Aerobic Treatment Unit is installed.
Owner(s)Name(s)-Please Print Subscribed and sworn to before me on this date:
Scott Louis Swanberg
Lois Marie Swanberg Mail 3a oZ D!q
Not ed Owna� nature Notary Public nQ/'�
d W Q&44.4
Governmental Unit Official Name,Title-Plea Print My Commission Expires
.1.�J 01`
Governme Unit Official Sig ture Drafted by:
Perso al info tion you provide may be used for secondary purposes[Privacy Law s. 15.04(1)(m)]19 HMI►
KIM M.CAVALLARO
Notary Publia-Mlnnesota
My Comniiiielon 6cp m Jan 31,2018
��.u.n..
"THIS PAGE IS PART OF THIS LEGAL DOCUMENT—DO NOT REMOVE"
This information must be completed by submitter.• document title.name&return address,and PIN(if required). Other information such as the
granting clauses,legal description,etc.may be placed on this first page of the document or maybe placed on additional pages of the
document.Note: Use of this cover page adds one page to your document and$2.00 to the recording fee. Wisconsin Statutes, 59.43.
ST. CROIX COUNT"e
SEPTIC TANK MAINTENANCE.,kGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer
Mailing Address z;�f
SS
m
Property Address
(Verification re q uired from Planning&Zoning D eP artInent new construction.)
City/State Parcel Identification Number
LEGAL DESCRIPTION
Property Location V4 ,5J� 1/4 , Sec. 3 , T ??_N R-O W, Town of
Subdivision ��-( _ SCP-{ __ , Lot# 7
Certified Survey Map # �\ — , Volume ,Page#
Warranty Deed# / / U , Volume '�� ,Page#r—
Spec house yes no Lot line;: identifiab yes o
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of 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 wasl:e disposal system. Owner maintenance
responsibilities are specified in§Commn. 83.52(1)and in Chapter 12-St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St.Croix County Planning&Zon:Lug 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.
I/we,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 Planning&
Zoning Department within 30 days of the three year expiration date.
I/we certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s)of the
property described above,by virtue of a warranty deed recorded in Register of Demis Office.
Number of bedrooms /
SIGNATURE O APPLICANTS) DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning&Zoning Department. ***
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV.08/05)
111111 I IIII IIIII II III Ifill IIIII Illl 111111 IIII till
910287
STATE BAR OF WISCONSIN FORM 2-2000 BETH PABST
WARRANTY DEED REGISTER OF DEEDS
Document Number I ST. CROIX CO., WI
THIS DEED,made between Kernon J.Bast and Donalda J.Speer-Bast, RECEIVED FOR RECORD
Husband and Wife,Grantor,and Scott L.Swanberg,and Lois M. 01/15/2010 11:OOAM
Swanberg,Husband and Wife,As Survivorship Marital Property, Grantee. WARRANTY DEED
EXEMPT t
REC FEE: 13.00
Grantor,for a valuable consideration,conveys and warrants to Grantee the TRANS FEE: 291.00
following described real estate in St.Croix County,State of Wisconsin: PAGES. 2
Recording Area i 3.-
Name and Return Address:
Edina Realty Title,Inc.
400 South 2nd Street,Suite 115
Exceptions to warranties: Hudson,WI 54016
Easements,restrictions and rights-of-way of record,if any. 893740
020-1479-09-000
Parcel Identification Number(PIN)
This is not homestead property.
Dated this 4`l'day of January 2010
7mo'n4J�. t Donalda J.Spo r- ast
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
St.Croix COUNTY. )ss.
authenticated this 4t'day of January,2010
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not, Personally came before me this 4`s day of January,2010 the
above(Kernon J.Bast and Donalda J.Speer-Bastl,
Husband and Wife
authorized by§706.06,Wis_Stats.) to me known to be the person(s)who executed the foregoing
instru n nd acknowledged the same
THIS INSTRUMENT WAS DRAFTED BY
Martin D.Henschel Notary Public,State of Wisconsin
50 East Fifth Street,St.Paul,MN 55101 My corrtn fission is permanent. (If not,state expiration date:
(Signatures may be authenticated or acknowledged. Both are not necessary.)
'Names of persons signing in any capacity must be typed or printed below their signature
A. Wiiman
NOiatY Public
State of Wisconsin
WARRANTY DEED STATE BAR OF WISCONSIN FORM No.2-2000
1 of 2
Parcel t:
Lot 9, Cottonwood South, St. Croix County, Wisconsin.
AND
Parcel 2:
Together with an undivided 1/61h interest it Outlot 2,C .onwood South,St. Croix County, Wisconsin. (�
yC C " +� f o f'L0.
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