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HomeMy WebLinkAbout020-1369-09-000. /~ Wisconsin Department of Commerce pR1VATE 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.15.04 (1)(m)1. ~~ ~~ ~1 ~~~~ -~ ~ ~ County St. Croix SanitarxP~~AtJVO.: State PL^n ID No.: Parcel Tax No.: 020-1369-09-000 Permit Holder's Name: ^ City ^ Village ^ T wn of: Hudson '~'ownship Bast, Kernon CST BM Elev.; ' Insp. BM Elev.: ~~ BM Description: s " VC '~ ~ •~ 1 ~ . ~ c ( P T~wt TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic l 2 rnD Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/ L WELL BLDG. vent to Air Intake ROAD Septic y~~ N ~t (~ r ---~ NA i D NA ng os Aeration NA Holdin PUMP /SIPHON INFORMATION Manu Demand Model TDH L~rt~t , _ ction I System ~ TDr~/ Ft ~Forcemain ~ Length ~ Dia. ~ Dist. To well ~ Iv,~.q. ~, ~.i~°1 STATION BS HI FS ELEV. Benchmark •LS~ 0(0.25 (41D . o Alt. BM Z 88 o'S•3fi f BIdg.Sewer ~•6~ $•(00 St/ Ht Inlet o°• 38 ,~ r St/ Ht Outlet g. ~ • Dt Inlet Dt Bottom Header /Man. ~~' ~6 9 ~(. ~9~ Dist. Pipe ~ S 1 •94 ~ i 9 •3/ ~ Bot. System r s f ,/ (~ .o 93 3 ~ Final Grade • St cover . ~ ~ ~ SOIL ABSORPTION SYSTEM~I n ~ r- ~ n,,,.. ~OrG OA n~ ~~ RENCH Width i Length r No. f enches PIT No. Of Pits Inside Dia. Liquid Depth DI EN 3 ~a2 •S`a ~~` DIMEN I N SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Man a ture : ~ ~ ~ _ S~~ SETBACK INFORMATION TypeO ~ r ~r ~ " CHAMBER OR UNIT Mo a Number: ` System: ~ 'O -- DISTRIBUTION SYSTEM Header / M nifold t~. k h ~ i l Distribution Pipe(s) S x Hole Size x Hole Spacing Vent To Air Intake ''' D Lengt a. ength p SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over L ( rr Depth Over xx Depth Of xx Seeded /Sodded xx Mulched , Bed /Trench Center 1 ~ "r Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: oS! I~'/ d1 Inspection #2: `T~~ Location: 682 Old Hopkins Place, Hudson, WI 54016 (NE 1/4 SE 1/4 10 T29N RMW) - 102992199 Hopkin's Prairie -Lot 9 ~ "l 1.) Alt BM Description = ~ ~ S'~q ~ ~~~ 2.) Bldg sewer length = 23. c r U ZO°1 -amount of cover = 3G "+` ~%~ cam: ~ u Plahrevlsion re uir~d~?,,~-~+ Yes No Use other side for additional Infor atlon. ~ T~ SBD-6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ~~..~~-- I ~ ~ ~, ~. __ ~ _ i 3 .~ r Z o1..~ 5 Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. PO Box 7302 ~~ ~ See reverse side for instructions for completing this application Madison, W[ 53707-7302 .~~r~~.~ri / Department of Commerce Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(l)(m)] (Submit completed form to county if not state owned. Attach tom .late tans (to the coun co onl )for the s stem, on a er not less than 8- l/2 x -1 inches in size. aunty State Sanitary Permit Number ''~ k ~1}ry Jrs o previous application State Plan L D. Number I. A lication Information -Please Print all Inform• ~ Location: Property Owner Name Property Location i ~ ~ f t •- . L ^ wner's Mailing Address Lot Number Block umber Property - ~~ ~ tuber ~- _ , Subdivision Name orE9t~~Ienrbe~- State Zip Codc City , J .-- ',%`~ ~G~C ~ ~.-7775 l~ TiVS ~ G c II. T e of Bui din (check one `~ •.~ / ~ rty .`" ^ Village YP g~ ) , -:`( ~ ~ ~ . 1 or 2 Family Dwelling - No. of Bedrooms : ~- ~ ^ ~ (Town of /i ^ Public/Commercial (describe use):_ L ce ^ State-Owned / G IH ~ S R Nearest Road d ~ ~~ ~ / • ' b ~ • ~ C ]~) T-3 = s T-~ ~ ~ ` Parcel Tax N rmber(s) I o - Z . S ( l . v. ~ -- III. T e of Permit: Check onl one box on line A. Check box on line B if a licable ~~ 6 ^ Additio~nlto . A) 1. New 2. ^ Replacement 3. ^ Replacement of 4. S• Existin S stem S stem S stem Tank Onl Date Issued B) Permit Number ^ A Sanita Permit was reviousl issued IV. Type of POWT System: (Check all that apply) D Sand Filter D Constructed Wetland Non-pressurized In-ground ^ Mound Pressurized In-ground ^ Holding Tank D Single Pass D Drip Lirte • ^ At- de ^ Aerobic Treatment Clnit ^ Recirculatin ^ Other: V. Dis ersal/Treatm 1. Design Flow (gpd) ent Area Information: Ares2 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 2. Dispers ~~ 7. Final Grade Elevation ~ Required ~~JJ Proposed Rate (GalsJday/sq. ft.) (Min./inch) T /r ~ ~ 3 I (DD .~ 33 .b' 9.s Tank VII Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic . Information Gallons Gallons Tanks Con- Con. brass Crete strutted New Existing Tanks Tanks ^ ^ ^ ^ VIII. Responsibility Statement I, the undersi ed, assume res onsibili for installation of the POW o non the attached Ions. Business Phone Number Plumber's Signature (no stamps): PRS No. umber's Name (print) ~, lumber's Address (Street, City, State, Zip Code) / ~O C,E' O IX. County/Department Use Only d I Issuing Agent Signature (No stamps) ^ Disapproved Sanitary Permit Fee (Includes Groundwater ssue Date Approved ^ Owner Given [nitial Adverse S charge Fee) ~ ~S ~ ~ l"IIv- Determination . o ,,,,~ L ~~ ~ ~ a~~~ ~ f,e.tvt Conditppr~a~ Reaso~ isa a, l: , ~ ~ ~~__. T= 3 _ , f6 . ~,~" N4u`K loT LavE Fogerty Plumbing #221180 28288 McKenzie Rd. Spooner, WI 54801 (715) 635-9609 ~~ ~i~c Cm's 3r ~ - ~iG6 ~>i S r-a~ r-~ r-~~ .. s~~~ G ~'~ R ~ ~I __-- 3~~ LI R ~-~. ~_ ~ X 3~ ~X f3-y_ DoT ~ f ~Cm~(-,r,~/s ~i+cZfF /~JSE IJA~/ QW1 ~ r,-,~ of i''~v~ Pt~E ~i~ ~po.0 ~ .. - ©/ \ / ,Q #2 = AST /.3~ jbp of / ~ Svc I I K = /3o~tt.A/6 ; /-iJU/~/D LoT ~O.Cg1~R ry I /~ = kvcLG~ ~ .S~f ' Tito w~ 1 ,¢,~ ,user of sy~,.~ I 1 -= vE~'ZcA~tJ 6CYYlrrJ~ '~°` I I `~ 1„J = 3. TflicEr. 7~~ ~ 9 0 ~ .mac. I /~aG6E ~/6T~ = T-~ rs 6j.i . T 1 ~ lo,2S l / I T 3 tr sG.zs~ l - ~b F~E~yr,~,v~ Tv S~c~-, s~G ~r.~u~s,N•H jET dam/<t' ~c~ou~vr~v r~ ' wisc~n,~sin De'f±~rtment of Industry, $ O I L AND SITE EVALUATION R E P O R T Labb?r aid HuI}~n Relations hivisia.~'of safety 8 Buildings __,., ...:,~. ~~ ~ in ~., .,~ ~.~:., n..i.., n,.,~,. Page 1 of 3 ~~ ~ u.,....,....,.,, ~" „ , ~.,..,.....,~. , ..,.....,.,..., COUNTY St. Croix but Plan must include er not less than 8 1/2 x 11 inches in size Attach com lan on a lete it , p p p . s e p not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 020-1010-70-000 APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION R VIEWEDBY DATE l l -I s -Zl>ap PROPERTY OWNER: PROPERTY LOCATION Kernon Bast GOVT. LOT ~ 1/4 SE 1r4,S 10 T 2g ,N,R lg ~ (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # 9 BLOCK # na SUBD. NAME OR CSM # kins Pra~~~ Ho 848 LaBArge Rd. p CITY, STATE ZIP CODE PHONE NUMBER ^CITY ~V~LLAGE [MOWN NEAREST ROAD Hudson, WI. 54016 (715)386-7775 u son Olk Ho kins Pl. [x] New Construction Use [ x] Residential / Number of bedrooms 4 [ ]Addition to existing building ]Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate • 7 bed, gpd/ft2 •8 trench, gpd/ft2 Absorption area required 858 bed, ft2 750 trench, ft2 Maximum design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2 Recommended infiltration surface elevation(s) A=94.8/B=9~ .00 ft (as referred to site plan benchmark) Additional design /site considerations na Parent material outwash Flood plain elevation, if applicable na ft S =Suitable for system U =Unsuitable for s stem CONVENTIONAL LAS ^ U MOUND ~7 S ^ U IN-GROUND PRESSURE ~J S ^ U AT-GRADE ~7 S ^ U SYSTEM IN FILL CAS ^ U HOLDING TANK ^ S ® U SOIL DESCRIPTION REPORT Boring # :::::i....... Ground elev. 99.8 ft. Depth to limiting f+96 Boring # 2 Ground elev. 100.8 ft. Depth to limiting tactor +110:" r~ Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/ft Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed Trerrtt 1 0-20 10yr2 2 none 1 msbk mfr gw f ~ . 2 20-29 10yr3/3 none 1 2msbk mfr gw if .5 .6 3 29-53 10yr4/3 none sil 2msbk mfr gw if .5 .6 4 53-9~ 7.5yr4/4 none cos Osg ml na na .7 .8 Remarks: 1 0-11 10yr3/3 none 1 2msbk mfr gw 2f .5 .6 2 11-26 10yr4/4 none sil 2msbk mfr yw if .5 .6 3 26-11 7.5yr4/6 none cos Osg ml na na .7 .8 i Remarks: CST Name:--Please Print Gary L. Steel Phone: 715-246-6200 Address: 1554 200th. Av ew Richmo WI 54017 Signature: Date: 11-17-99 CST Number: m02298 PROPERTY OWNER Kernon BAst SOIL DESCRIPTION REPORT PARCEL. I.D. ~ 020-1010-70-000 Boring # ...:: ~:> Ground elev. 99.0 ft. Depth to limiting factor ioFn Boring # 4 `. ................. Ground elev. 98.0 ft. Depth to limiting factor +96" Boring # 5 Ground elev. 98.5 ft. Depth to limiting factor +~00„ Boring # .................. ................. .................. ................. .................. ................. .................. Ground elev. ft. Depth to limiting factor Pages q` ~, Horizon Depth Dominant Color Mottles Texture Structure Consistence Bax>dary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0 19 10yr2/2 none 1 2msbk mfr gw 2f .5 .6 2 9-46 10yr4/4 none sil 2msbk mfr gw if .5 .6 3 6-96 5yr4/6 none cos sg ml na na .7 .8 / f 930 tE' ~ - V Remarks: 1 -13 10yr3/3 none 1 2msbk mfr yw 2f .5 .6 2 13-32 10yr5/4 none sil 2msbk mfr gw if .5 .6 3 2-96 5yr4/6 none cos Osg ml na na .7 .8 Remarks: 1 0-12 10yr3/3 none 1 2msbk mfr yw 2f .5 .6 2 12-29 10yr4/4 none sil 2msbk mfr gw if .5 .6 3 29-10 7.5yr4/6 none c s Osg ml na na .7 .8 ~~ i Remarks: Remarks: SBD-8330(8.05/92) ~° ~"~ w STEEL'S SOIL SERVICE Gary L. Steel Kernon Bast 1554 200th Ave. CSTM2298 NE4sE4 sl0-t29N-xi9w New Richmond, WI 54017 MPRSW-3254 town of Hudson (715) 246-6200 lot #9-Hopkins PrARIE This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of the test may or may not be as shown as permanent Iot lines were not established at the time the test was conducted. /1"=40' = p of 1" pvcpipe 2 e1.100.00' ~~~ Alt. nM. top of 1" pvc pipe C~ el. 9x.40' D _ ~' Wisconsin Department of Commerce SOIL EVALUATION REPORT Page ~ of 2- Division of Safety and Buildings m accordance wnm Comm oa, vns. Ham. t,ooe Plan must lan on er not less than 8 1/2 x 11 inches in size Attach com lete site a County ~+ 7~` ~, p . p p p inGude, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. Bl. ~ --~ /3 - , Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy l.aw, s. 15.04 (1) (m)). ~ ~l-ib- ProperlyOwner Property Location s"~ Govt. Lot ~~' 1/4 1/4 S./~ T~9 N R ~ E Property Owner's Mailing Address Lot # Block # Subd. Name or E9MIi - State Zip Code Phone Number City ^ City ^ Vllage Town Nearest Road , / New Construction Use: ~ Residential / Number of bedrooms ~ Code derived design flow rate ~r} GPD ^ Replacement ~,[ Public or commercial -Describe: _~ __-__-_____~__. ~_ Parent material ~w/ W~ Flood Plain elevation if applicable '~~- ft. General comments ~ ~•,~-~//y1,7.~,~ /l~I- 9~• 01 ~' /1~t ~ .t/Oj` ~L G~.~/~ and recommendations: a Boring # ^ Boring pit Ground surface elev. ~ y ft. Depth to limiting factor i Soil ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 L -Y~ ~o - rt . 6 3 ~ - cs' S~ txG -- - / 6 ~ ~ ~© a Boring # ~ Boring • ^ pit Ground surtace elev. ft. Depth to limiting factor in. Soil licetion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 `Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mglL ' Efflue - BOD < 30 mg/L and T55 < 30 mglL csT ~`~~tu~i "+~ing & Perk Testing si naa, .-- csT N"r-,ber 2.z ~~d~ address C 8nZ18 ate Eval lion Conducted Telephone Number Spooner, WI 54801 // - /© -Oct 7/S =~~.1--909 _ ~~ . ~- - ~- "~ -~ Property Owner Parcel ID # Page of ^ Boring # ^ Boring. ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 a Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fF in. Munsell Qu. Sz. Cont. Cdor Gr. Sz. Sh. •Etf#1 •Eff#2 Boring Bonng # Ground surface elev. ft. Depth to limiting factor in. ^ Pit - Soil liption Rate Horizon Depth Dominant Color Redox Description. Texture Stnxxure Consistence Boundary Roots GP D/ff in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Etf#2 'Effluent #1 =GODS > 30 < 220 mglL and TSS >30 < 150 mglL • Effluent #2 = BODS < 30 mglL and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-7~6-3151 or TTY 608-?~1=8777. sao-ssw tR~) Fogerty Plumbing #221180 28288 McKenzie Rd. Spooner, WI 54801 (715) 635-9609 ~~ ~~ ~~ 1 ~ ~y $,r _~ ~f~ Cor#f ~~~ ~7^~~ ~~o ' -~ #i p ,4~r ~ ~ rop o~ r ^~v~ ~~~~- qBY ~.- 2. X K E ~ i Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In-Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWYS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In-Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- Table 1: System Design Specifications Sanitary Permit Number 3~ 39S Number of Bedrooms Design Flow -Peak (gpd) ~~ Estimated Flow -Average (gpd) Septic Tank Capacity (gal) Z,c7o Soil Absorption Component Size (ft2) 3 ~' ~ ``$~ ur Type of Wastewater Domestic Table 2: Soil Absorption Component -Limits of Reliable Operation ~-e~ Septic Tank Component Soil Absorption Component Design Flow -Peak (gpd) ~ Ztr0 t ~' Maximum Influent Particle Size (in) 1/8 Maximum BODS (mg/L) 220 Maximum TSS (mg/L) 150 Tab le 3: Maintenance Schedule 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 se tic t nk and outlet filter shall be assessed at least once every 3 years by inspection. Th outlet filte shall be cleaned as necessary tom proper operation. The filter cartridge shou 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 interior 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 CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/l~er ~C' ,~. ~rlD ~ ~~-ST Mailing Address 8 `1~'L~ &~9~.C' /~!~ • l~Gfl~ldA/, W-~' ~ ~O /~ Property Address (Verification required from Planning Department for new City/State ~u11 S~it~ ~ S ~,6 Parcel Identification Number ,~ 20 ~' ~3( 9-~9 LEGAL DESCRIPTION Property Location ~!/~ %4, ~ '/., Sec. /0 , TAN-R~W, Town of /~~~f8 ~~ Subdivision , ~" r' '~ ~ t ~ S P I~Q ~ (Z ~- ,Lot # Certified Survey Map # ,Volume '~-..Page # --- Warranty Deed # ~B~ S'6~ ,Volume 1Y?G_ ,Page # _~/~o Spec house ^ yes (~ no Lot lines identifiable ~I yes ^ no SYSTEM MAINTENANCE 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 waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeymanplumber, restrictedplumber or a licensed pumper verifying that (1) the on site wastewaterdisposalsystcm is is proper operating condition and/or (2) a8er 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 standazds 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 wither 30 days f the three yeaz expiration date. SIGNATURE OF APP ICANT 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 thq p perry described tiove,~by virtue of a warranty deed recorded in Register of Deeds Office. SIGN TUBE OF AP LICANT DATE *«**** ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed /~ 'v!~!. 1~cJl1rX;~ 516 Documant Number ~ WARRANTY DEED 'hia Deed, made between, Jean M Hendrickson and,Kernon J Bast and Donalda J Speer-Bast Grantor, hushand and wife, as survivorship marital property Grantee. Witnesseth, That the said Grantor, far a valuable consideration of one dollar and other valuable consideration conveys to Grantee the below described real estate in St. Croix County, State of Wisconsin. This is not homestead property. Together with all and singul?r hereditaments and appurtenances thereunto belonging; And Grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, covenants, and restrictions of record, and will warrant and defend the same. (Parcel Identification Number) 020-1010-70 605568 KATHLEEN H, WALSH REGISTEk OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 06-2M-1999 8:30 pM YARRANIY DEED EXEID'T 1 CERT COPS FEE: COPY FEE: TRANSFEN FEE: 450.00 RECORDING FEE: 10.00 PAGES: i Name and Retum Address FIRST FEDERAL SAVINGS 201 SOUTH SECOND HUDSON, WZ 54016 Part of the NE'/. of SE'/. of Section 10-29-19 described as follows: Beginning in the center of Scott Road at the NW corner of Lot 1 of Certified Survey Map, filed in the office of the Register of Deeds for St. Croix County, in Vo[. " 3", Page 6S 1; thence N89°48' 13"E 561.0 feet along the N line of said Lot 1 to an iron pipe mo^ument; thence Sly along the E line of said Certified Survey Map to the SE corner thereof; thence N89°48'13"E 759 feet to an iron pipe stake; thence Nly parallel to the E line of said Section 10 a distance of 924 feet to an iron pipe monument; thence W 1320 feet to the center of Scott Road; thence Sly along the centerline to the point of beginning. ~ted this day of~/ 199[9/ n M Hendrickson AUTHENTICATION Signature(s) authenticated this i day of cL si r SC.~I type or print name TITLE: MEMBER STATE BAR OF WISCONSI C, (If not, authorized by5706.Ot3, Wis. Stats.) W ~ > O THIS INSTRUMENT WAS DRAFT Robert F. Wall ~' (Signatures may be authenticated or acknowiedg ~B ~re not necessary.) ~"""'~t~ ACKNOWLEDGMENT STATE OF WISCONSIN COUNTY ST. CROIX Personally came before me this f Sday of ~~-~^ v- ,~ 9 the above named Jean M Hendrickson to me known to be the person(s) who executed the foregoing instrument and acknowledge the s • ~ ~ j ~ ~-- type or print name ~ y ~~' IP_-Y~ ~. --~G~'~ 1"~~ ie~~' Notary Public County, . S t: • C !X My commission is permanent. (If not, state expiration date. ~ /~ v~ U O `2- .l of persons signing in any capacity should be typed or below their signatures. " ~~ N M N d N f~ N d .- ~ ~ q~ ^ I ~ MOMMM dMN~A~~AM~A Q~I dao m oDtu'~do0dndoDn I N Z N N N N Z Z Z N Z Z Z Z N I ~1 Z~Z I WWW'WWW33333333W wl ~ pppp ~ I MM~!'~fO~~NOi1~NMM ~1 ~.-dti7Nddl~cV t t.a0•-~ NI M~ANU'IOMMMdMNN~ANiA I CNOdO~DG~Ot~O.~FO~OC~D~~~ONO~dd ~.I i N N Z Z N N Z Z Z Z N N Z Z N ~•~ ~N._._ N N~ n~~ d O of O vzrigrn~`tO..r~~~`airo~viad~ri N lsa Ol N ~ Ol ^ OD iA M OI ~ iA M ~A •- ~ .f.-~d~~.- N ~/ i ~ ~• o i ~ •/ cV M • ~ y'~ /~ ®/ / ry°• / /® ,~y .~ • ~ ~ `~ / . .• ~ / ~ • OS'SS M iQ L AOS . ' ~ / • ~~ ~1~<O. ONCO. CfO. 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