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HomeMy WebLinkAbout020-1407-01-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (A«'-fACI-PTO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)J. Permit Holder's Name: City Village X Township Bast, Kernon Hudson Townshi CST BM Elev: Insp. BM Elev: B ~ scription: ~a~~~ I I lu TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ Y '/ u.w1~`~ Do ' g I Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~ t~ ~ ~ ~ ~ ~ ~ Dosing Aeration Holding PUMP/SIPHON. INFORMATION Manufacturer ~t Demand GP M Number Q~' 7 "e- TDH Lift Friction Loss System Head TDH Fo main Len Dia. ist. to well SOIL RESORPTION SYSTEM ~EL`~EVATION DATA County: St. CroiX Sanitary Permit No: 453165 0 State Plan ID No: Parcel Tax No: 020-1407-01-000 Section/Town/Range/Map No: 10.29.19.2548 STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer St/Ht Inlet SUHt Outlet ~,y loa . 6 Dt Inlet ----~ Dt Bottom --- _, Header/Man. ~• S ~ ~~, ' Dist Pipe ~b hnr -(-c, R ~ I ~ Bot.Sysem nay I~ 5~~ /0.33 3. Final Grade 6•S6 4?~~" St Cover /' ( ~ •l0 ~b2• BED/TRENCH Width Length ~ No. Of Trenches ~ PIT DIM IONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ! ~(7 S tvJ 1! ~ ,! ~~Q -1 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM EACHING Manufacturer J INFORMATION CHAMBER OR S~C~ - Ty ep_ Of Syst~ I ~ C ~ / y E ~ ~ ST d Ili UNIT - Model Number -7-~~i I , DISTRIBUTION SYSTEM y"`T`'` ~' ~'~t~^- Header/Manifold ~ z , I/ Distribution Pipe(s) x Hole Size x Hole Spacing Vent to Air Intake ~ Length_L Dia_ Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Onlv Depth Over Bed/Trench Center ~ ~ Depth Over ~ ~ Bed/Trench Edges 3 xx Depth of Tops xx Seeded/Sodded xx Mulched ' ~ ~ ~J Yes , ~ o I No "1 Yes i j b~ COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/~/-~~/" I s #2• / / Location: 1047 Scott Rd Unknown (SE 1/4 SE 1/4 10 T28N R19W) Shepard Park Lot 01 Parcel No: 10.29.19.2548 1.) Alt BM Description = ~'°e L ~~L '~ `~ ~ ~~v` '~-rc..>^,~ ~ '~Q,yv.~`~ 2.) Bldg sewer length 1f„~ I/1--- - amount of cover = ?,,~ ~~^'~~ -- ~- '~ _ Plan revision Required? Yes No ~ I I Use other side for additional informatio"n.- ~ ~ ~ G _ib~ ~ _ !!12 - --- _ -_ ~ ~ __ SBD-6710 (R.3/97) Date I sepctor's Signature Cert. No. Safety and Buildings Division County ~ ~ 201 W. Washington Ave., P.O. Box 7162 .. ~S~Qn~I ~ Madison, WI 53707 - 7162 Sanitary Permit Number (m be filled in by Co.) Department of Commerce (~) 266-3151 ,s.3 ~~OS- Sanitary Permit Application S~ ~° i D Number - ( ~ N io accord with Comm s3st, Wis. Adm_ Code, persoml information y«r provide may be used for searKedary purposes Privacy Lae' w. s15.04(1~,~... ,...~ Project Address (if different malting address) I. Application Information -Please Ptult All Inf ,,:,. '~ Property Owner's Na the / O ~ i. APR 2 1 ~ Parcel ~ Block a9 Zo-/yo~~- ~ v - ~ , S _ ~ -- Property Owner's M aili~ Address ~~. EAR ~. ~. ~ "' ~ property Location _ u ~= lf s ti r~ - City. State lap Cade Plane Nnmber ,. , nn ec •~ ©N ~ y0 ~ (circle __ ~ ' - T _~ N; R~ E o> II Type of Boil (check all that apply) ,/ !~1 1 or 2 Family Dwellia~g -Number of Bedrooms ~ Sl~bdivision Name CSM Number ^ Public/Commercial -Describe Use ~- ^ State Owned -Describe Use ~ ,DJ.$~T C~Z(.S / _ ^City ^Village ownship f III. Type of Permit: (C heck only one box on line A. Complete line B if applicable) A. ~'~lew System ^ Replaeemeffi System ^ Treamtettt/Hokling Tank Replacemem Only ^ Other Modification to Existing System B. ^ Permit Recewal ^ Permit Revision ^ Change of ^ Permit Transfer m New List Previous Permit Number and Date Issued Before Expiration Phlmber Owner ~ ~ IV. of POWTS System: (Check all that a ly) Q~~lon -Pressurized la-Gralod ^ MouM ~ ?A ia. of suitable soil ^ Moues < 24 in_ of suitable soil ^ At~irade ^ Single Pass Sand Filter ^ Cor~tructed Wetland ^ Pressurized LtGround ^ Hohting Tank ^ Peat Fiher ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthet~ Media Filter ~'I(.escbing ~ 1--~ ^ Drip Line ^ Gravel-less Pipe ^ (explain ' V. Di P.IIt Area Information: L! _~_ ~ 7u~' - - )y Design Flow (gpd) ign Soil Application Rate(gndsf) Dispersal Area Required (sf) ispersal Area Proposed (sf) System Elevation ' VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel F'dter plastic Gallons Gallons of Units Concrete Constructed Glass blew Tanks TaWa ~. ~~/ _- asd . ~- VII. Responsibility statement- I, the undersigned, assume for imfallation of the PowTS shown on the attached pleat. Plumb er ' s Na me (Print) Plum 's S t MP/MPRS Number Brtsi~ Phon Number e ` , (~ p I! V~ • r ~1~' 1 / / ~ ! ~~~ ~ r ~ ~ ~~i ~~~ ~~ e1 Plumber's Addre ss (Street, City. S .Zip Code) . ~ G'~~ Gf (- j O2 " =/B Fogerty Plumbing & Perk T lti ett ~ s - - 37 vIIi. App~,~ ~ Sanitary Permit Fce (includes Groondwaoer Date Issued ~ Ages - o ) ~ ^ Owner Given Reason fot Denial Sti,reharge ~) ~ ~ ~ .~ ~~~ D 1X. Conditions of ApprovaUReasons jot Disapprov YSTEM OVl~NER ~ ~ ~~ ~ LyA~' y UU 1 eptic an , e luent filter and ~„~I ` ,~., r~~, ~~. O -3~-~~ dispersal cell must all be serviced /maintained i+r~l ` Q~~ 000 /~'1(~~ ~ as per management plan provided b lumber y p .. 2. All setback requirements must be maintained v - sys J/, as per applicable code/ordinances / . ~ C~3. ~~ I ~ ~ ~/ ~ Z C. -' wmpeu plm5 tro tM l:0®1J oru~J roe roe SySI~ OO paper u0[ NSS tnaD allL x 11 U7CLlS IO SQ! °0 ~ o o~ ~,~o N ~ 01 ~ C _ d'-+Y~M N v _u ~' # ~ `p N (n v \ N 0 ~. h ~ _ -~ ~ ~ ~ i 8 `" ~ ~ ~ ~ ~ ~~' ~ b ~ h ~ ~ ~ ~ t ~ ~ ~ ~ * V ~ !~ a ~ ~ 3 ~ ~ ~ a ~ s ~ - `~ ~ 0 ° ~ ~ ho v ~ ~~ ; N ~ ~ {~ OC ~ s ~ vN ~ -+ 3 ` " ~' ~ p t~ n u ~, ~. ~ ~ ~ ~~ d ~ ~ 1 1 I H `N i~ JIc/ - `I v ? ~+^RyV /1, . ~~~ ~ ~~fi ~ ~~ ~ N /: N 0 ~~ ~~ ~ ~ ti ~~ n d n ~~ is b ,~ _~ ~~~ ~ ~ ~ N~ ~ ~ ~ y 0 ~ ~ ~ ~ M x ~ ~ ti ~ ~ ~ ~ ^ ~~ o ~ ~ ~ 1~ ~ ti g ~ o b it y i a F ~~ m Vv~~ o ~rn ~~A N ~~~ ~e oo~o~D ~1D' ~ ~p--a oa O `~' O ~~ ~ ('~ ~ - 1 1 1 j ~1 `~ _ ~ ~ d !~ i ~ d ~ ~ tP t O ,,~ it 11 ~ II =' ~ - o ~- ~. -~ . - f . t o ~+ #. - • :.. .~----__..___ _a.:. n 'mod 3= •r b p ~ N IW- - ~ CD ° +rj 1 ~~i (Q'-4 , (~ ~ ~~ : ` 1 ei• ` --.. ~ p ~ ;~ ~ ~ o ,~ 0 0, ~ ~~ -- -- - - - '1~-r - ~. ~ '`~ d ~.+ a .... :C ~ ~ f ~- •~ a ~ ~' ~ a, , ' ~ 0 ~- ' 11 it : C~ ~ ~ $ ~ ~ ~• j S1D ~ ®, v fop # ~ ~ - ~. ~ w ~ ~ w~ ~~~ ~ ~ a i.' A OQ ~ • wscensin Department of C men~ECEIVED IL EVALUATION REPORT ~ Page I of -~ Division of Safety and Buildin s .. 111 GWVIVOIII.G ri/YI INII VJ~ •~IJ. rW111. waar. A P~ ~ t~~2~A~ lete site plan paper no e x 11 nches in size. Plan must Attach com ' a c`' - ~ - Cr ~ p include, but not Limited to: erti and horizontal reference "nt (BM). direction and percent slope, scale or di nsi~c~. !~~+I~r-~faLJe(yddocati nand distance to nearest road. Parcel l.D. p,Zp - ~ ~O } - O (- ~ C.25 `f ~NING FFI Please n. Re ' by Date • Personal information you Provide may t1e used for secondary Purposes (Privacy Law. s. 15.04 (1) (m)). ~ I '~ properly Owner Property Location ~ ~ Govt. Lot s ~ 1/4 SLR 1/4 S (Q T Zq N R (q E (or) Property Owner's Mailing Add ~ Lot i Block # Subd. ~ me or CSM# .~ City State Zip Phone Number ^ city vil! a own Nea_ rest oad ~ New Construction Use: [~ Residential / Number of bedrooms 3/L~ Code derived design flow rate ^ Replacement L ^ Public or commeraal -Describe: Parent material T General comments S y S f p vc~ ~ (c ~ q'S. G o ,;,., t ,- q ~/ o 0 and re~mmendations• • ~ ~~ , el e V' ~ -gib p q3. S v Lv,:,l~ ~ ~ ~' 3,. a v m if applicable ~ 14 ft. ~YtiA~ Boring # ~ Boring _J ~- Pit vrvuw surrace e~ev.~ ~. ar -- u. vepul au ulluully lauavl t , - 111• Soil Application Rate Horizon Depth Dominant Color Redox Destxiption Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell_ _ Qu. Sz. Conl Color Gr. Sz. Sh. `Eff#1 "Eff#2 r -2~ 1 `_ S ( k,k ran 'r ~- S -- _ S -~ ~-- s ~s - - ~1 I . Z 9y, d' `f3• Z L Boring # ^ Boring =J ~f1 Pit urvunv surrac:e elev. - - la. vepul w luluully laa.avl ~ w N1. Soa Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 *Eff#2 ~ O-y ~0 ~ Si ~ Z. m-~r c S 1 ~ . S ~ ~ 2 -io ~ ~4 `- s ~ I ~ r ~5 = . 5 .8 3 - -goo ~ 1 `- S o~ ~ - , -, 1.2 Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L `Effluent #2 =GODS < 30 mgJL and TSS < 30 rngJL CST Name (P{ease Print) Signature '~ CST Number k r ~ -G 2 2S Address Date Evaluation Conducted Telephone Number 2413 sso ~~ s f sayers e~ wl I~'~r oz~ pis zk~ ~o ag GPD +~.;. ~~? ,".', Property Owner ~~ `'~s , ` Parcel ID # Page ~ of ~.J Boring # ~ Boring pit Ground surface elev. ~~ Yd ft. Depth to Fmiting factor~_ in. Soil Appligtion Rate tion Descri d R Texture Structure Consistence Boundary Roots GPD/ftz Horizon Depth in. Dominant Color Mansell p ox e flu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ~ ~ d_~ Z ,- ~- S,~ S'. CS ~ ~ 1v - _ ~ . . S ~ I ~ ~ ~ - - - ~ ~- 2- ~( = Z S~ 93 -off ~ ~ Boring # ^ Boring ^ pit Ground stuhace elev. ft. Depth to limiting factor in. Soil Application Rate tion Descri d R Texture Stnxture Consistence Boundary Roots GPD/ftz Horizon Depth in. Dominant Color Mansell p ox e Qu. Sz Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring # ^ Boring ^ Pit Ground surface elev. ft Depth to limiting facts in. Soil Appf'~cation Rate dox Description R Texture Structure Consistence Boundary Roots GPD/ft2 Horizon Depth in. Dominant Color Mansell e flu. Sz. Cont. Color Gr. Sz Sh. 'Eff#1 'Eff#2 'Effluent #1 = BODS > 30 < 220 mgJL and TSS >30 < 150 mglL ' Effluent #2 = BOD$ < 30 mg/L and TSS < 30 mgR. 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 608-266-3151 or TTY 608-264-8777. ssn-saw (rt.mroo) PAGE~OF~ rT M c3.S 7" LOT# I T EGAL DESCRIPTION SF ~ S ~_~ ,S ><3 T Z9 .N.R. l~ Elor~ l SCALE: 1"= ~~ BM 1 ELEVATION lG ©- O -----~ BM 1 DESCRIPTION ~ (~ 6~ -~ %1 ~~ BM 2 ELEVATION ~ ~ ~ Z D BM 2 DESCRIPTION ~p ~ -~//-~ /r jC o SYSTEM ELEVATION .an Q R ~~ Uv Z~~-" ~" r_ y~ O 0 ALTERNATE ELEVATION ~ ~ 4 ~. Sy Lot. ~-+" `~ 3, o `~ CONTOUR ELEVATION (~ <<~) ~e.c r 1 Q - --~ - ~ ~ ~ ~ ~3-( 5~~. ~- w~~, ~ ~~~~~~ ~~ ~ -~ W~~ sy~ ~ ~ a„Q.~. ~, s~s~ ~' S~.J~ .~ ~ ~~`,~`1~-~lc~~,s ~~ o ~ _ ~- ~~o ~, o 0 ~ ~ I~ ~~~ ~ s~7 ~ ~. ~ sY sue. ,.a~.o..Ke.~ ~-:we . 3-Z D i \`~~° Sd „d!~' SIGNATURE c~.~._.~---~-~~~---~ DATE ~-~ 2 ~` C'' ~ ~- - _- ' - lYV W 1J V VYIVCf'[ ~ IVIAIVIJHL Ot IYIMIVMVa.~rra~^~ ^ ^ ^-~+^~ rays ~ v~ CII F INFORIIIIATION Owner r- ~ ~ ~ - Permit ~ - S3 l~ Cv_c-rcae ca~P_1FICATIONS Septic Tank Capacity S' al ^ NA Septic Tank Manufacturer . • ~1~ ^ NA Effluent Filter Manufactur~x Z ^ NA Effluent Fher Model d ^ NA Pump Tank Capacity ~ NA Pump Tank Manufacturer NA Pump M~ufacturer ~ Pump Model ~ }'] NA pretreatment Unit ^ Sand/Grave! Filter ^ Mechan"veal Aeration ^ Disinfection ^ Peat Fiber ^ Wetland ^ Other: ~A - Dispersal CeNtsl In-Ground !gravity) ^ A - rade O Drip-Line ^ NA ^ In-Ground (Pressurized) ^ Mound ^ Other. Other: ^ NA Other. ^ NA Other. ^ NA DES16N PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units - ~NA Estimated fbw !average) ga(/day Design flow (peak!, lEstanated x 1.51 aUday Soil Application Rate __ al/day/ftz Standard Influent/Effluent Quality Monthly average` Fats, Oil & Grease {FOG} 530 mg/L Biochemical Oxygen Demand (RODS) 5220 mg/L ^ NA _ Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent O.uality Monthly average Biochemical Oxygen Demand !RODS) 530 mg/L Total Suspended Solids ITSSI 53O mgt NA ~. Fecal Colifomn !geometric mean) <10' 1 OOmI Maximum Effluent Particle Size 'Ya in din• ^ ~' Other: ^ NA 'Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SGFIEDIJI.t Service Evert Serwce ~ Inspect condition of tank(s) At least once every: ^ month(s) tMaxirnum 3 Years) ~ ms(s) t7 NA Pump o_ut contents of tank(s) When combined sludge and scum equals one-third IY31 of tank volume ^ NA Inspect dispersal cell(s) At least once every: ^ month(s) {Maxiimum 3 years) ~j yeartsl ^ NA ^ rrwrrthtsr a NA Clean effluent fiber At least once every: ' yearts- ^ month(s) -~q Inspect pump, pump controls & .alarm At least once every: ^ y~ts) ' ^ monthlsl Q NA Flush- laterals and pressure test At least once every: ^ year(s) Other:- At least once every: ~ yea lhsl s) _ r1. NA tither. Q..1VA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an ind"vvidual carrying one of the folbwing 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 celltsl 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 pond'mg 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 1Y31 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 fibers, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be perfomned by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within~l O days of completion of any service event. Z 3 . saHT UP AND OPERATION For new constructierr, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals that may impede the treatment process and/or damage thb dispersal cellist. If high concentrations are detected have the contents of the tankls) removed by a septage servicing operator prior ta• use. System start up shall not occur when soi( conditions are freizen at the infiltrative surface. During power outages pump tanks may fill above nomnal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) 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 acode-compliant r lacement system: A suitable replacement area has been evaluated and may be utilized for the locatwn of a replacerrlent soil absorption system. The replacement area should be Protected from disturbance and corrlpaction 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 eva~ation to establish a suitable replacem~t area. Replacement sYstmns 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 - f 'I d POWTS ~~; ~ology a holding tank may be installed as a last resort to replace the a~ e . si ha not been a al ted to identi suitable replace nt ar a. Upon fa' a of a POWTS a soil and site tion m st be pe rm to locate suite le replaceme area. If o repl ment area a bte a fi Idin be install as ast reso to re ce the fai d PO ^ Mound and at- de soil absorp ion systems may a 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 INSUFFlCIENT 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 DIFFlCULT OR IMPOSSIBLE. _ , e.. J i _ #22118U c en e Spooner WI~~ - ~ (715) 635-9609 ~ PAVUTC INCTAI 1 FR - -Name - - - -- 1 ~~-v Phone '~/S~ ~3 ~ 09 POWTS MAINTAINER - Narrle Phone ~ J-- SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY ~, l- Name Name X71 G~ (x Co~~~ """ Phone Phone ~(r- ~ ~ °- This document was drafted in compliance with chapter Comm 83.22(21(b11111d1&(f) and 83.5M1i, 121 & (31, Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerlBuyer Mailing Address „~'~%~ G~~2~,~ fD, ~~~~-~ f/ , .,,. y~,,` Property Address /4~, 1e~~r- ,C~ ~.._ ..,,~ _., _ _~ r, (Verification required from Planning Department for City/State Parcel Identification Number ~°.ze - /D~~ -O/-ooD LEGAL DESCRIPTION Property Location ,~' ~/,, ~,E y,, Ste. a T ~ N-R ~ d ~~~~ .1_, -L ~_~~i , Town of /~/~'so./ Subdivision Certified Survey Map # ~- Lot # ~ _ Volume - ,Page # Warranty Deed # G r'7 , t'~ ~ Volume /72Sr ,Page # G/ 9 Spec house ^ yes Ca'no Lot lines identifiable (ages ^ 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 master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (I) 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. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days the three year xpiration date. - - ~ / / SIGNA OF AP LICANT 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 th p operty described above, b/y~irtue of a warranty deed recorded in Register of Deeds Office. ---__- - t` J -- SIGNA OF APPLICANT ~ / 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 STATE BAR OF WISCONSIN FORM I - 1998 WARRANTY D~~iiEED V~!. 172~/AG£ p~~ This Deed, made between Weldon E . Richert and Lee Anne Richert, husband and ~Nife Grantor, and Kernon J. Bast and Donalda J. Sheer-Bast ____ Grautec Grantor, for a vaiuablc consideration, conveys to Grantee the following described real estate in St . Croix County, State of Wiscousir (the "Property"): - I~ (~.~"7:324 +.Ft s HLEc:N H. Wf~LSH ie~i i~ ~c~r_LUE>7 rGR RECGk) oy-26-2001 12:30 ~n idAkiiANTY DEED ~XElfPT N ::Er:T ~~F~Y FEE: CGAY FEE: iR~NSFER =EE: 1224.00 kE~GRDING FEE: 13.00 r•ts~cS: 2 rca ~iumu erod Return Address L)e~a~~a d ~.~e~--Saae- 1.95-i Seet~t-32esP1- l3u~se~, t'i~~~-~ EdlnaRealtyTftle #33~~~0 400 S. 2nd St., #115 Nt trisnn W I .ridfll R See attached Exhibit A Together will aE[ appurtenant rights, title and interests. ~9,3~- ~~- /Q/ (7 -3C7 - s I~:urcl Identification Number (PI\} This ~g Nu t--" homestead property. (is) (is not) Grantor warrants that the title to the Property is good, iudefeasable in simple fee and free and clear of encumbrances except Gif'`-i Dated this ~r~ day of September 2001 ff (SEAL) (SEAL) *s~~irl ~ l-~Alv~ Weldon E. Richert ee Anrie Ri "her (SEAL) (SEAL) AUTHENTICATION Sis;uaulre(s> anthCllttC ated II115 day of TITLE: MEMBER STATE BAR OF W'ISCONSiN (If not, authorized by X706.06, Wis. Slats. ) THIS INSTRUMENT WAS DRAFTED BY Coldwell Banker Burnet 01-2935'7 1301 Coulee Road Hudson. WI 54016 ( Signatures may be authenticated or acknowledged. Both arc not necessary.) :xmes ol'nersons sienine in anv c.nntcity must be twed or urinted fichnv thei .ACKNOWLEDGEMENT St:-te Oi~~lcssawe'rt, ~~ j ss. ~ _ County. Personally came before me this ~Q y~J day of September ,2001 .the above named Weldon E. Richert and Lee Anne Richert, lru~band and wife me known to be the person 5 who executed the foregoing instnuucut and ucknowl gc the same. +~«~, w Nolary Public. State ';'l~si~n~7.~~~~gr ~u5_tC • :naaesor~ My c01171111S510t1 1S pc lt:/~~ ,. (t,{.;tQ~.;s~~~,,exp[r~tl~sd e: w'AItRANTI' DEED l~Oli~•1 No. 1 - 1998 M;lwnukuc, Wis. '~ - .i -- von 1'725.~~f 620 EXHISIT "A" Legal Descriptlon Part of 5E 34 ofNB 34 mnd Pact of NE S4 o€SE'd~ of Settiaa 10.29-19 desatibe+d as follows: Conoaacaeiug at titre NW coaaR of 1~B 5G of SE 34, Sodiaa 10-?9-19, Eb~ace 13Z feet S, twee S L320 feel co st~ekq ttveane N m tbo poas~ of iate~s0ctioa nth C endNW RR>< of'sva~y, tlleaco Sw elcaa~ Bald sight of ~v~y m the ponoot cf sutrasecaos>. with the ca4tdr of Soars Roa4 ~e S W rtes of bcgiania,~ The :tale retals+ud to is aia is'an tripe that is now in pisay ~ be get m ceaa~t There is a1BO a~a iron pipe stafee on the 5 'bosmciatq of tho above 1Aad as>d'. t~ E boundary o! scow Roe~i. T}u+se staYc+s era oongotliug over fixoane satveyr:. ~s~d, Part of the 1~IE 54 af8ie SS 44 of Saxiom 14,29-19, desaabed as follawa: Ca~adIIg at • YtMel ~ stake loc~teQ ere ahe IZE oorsie~e ~ the SE ~i4 of e~od Sentfoa 10, thaaot S 132 feet to a oemaol+ed in itna alske-. ovbtch is tla'e POINT OF 8$C~iq tl>,erpe Why 1287 ~eeE. tltOnB oR' less, to a cwmtepea3 in ^tee3 st~oi~' flieraos o 33 trot W; tbowos 8 298 ie+et, as>Ioaf os lsss; tltiae;oe 833 shot m a Ccmesmted i~ aeet2 stabalbaios coiaai:~iag~y 1287 gees, mote ac less, in a ocmeute~. is steel atalaes th4aee N 298 f.~ ,me.,r o: teas. ao ~a Poi ofBegin~ag_ E THE P ROD( ~FTED BY EDNYIN Fl.ANUM ~ DATE 7-11-02 o, ~' I ~~ ~~ a~ ~' I o; ~~ 00 'I o~ ~~ °' I ~~ ,, ~~ ~~ I ~~ o~ ~~ a' Q°' ~ I ~~ ~1 i ~1 a; a~l o~ a~ 0~ o ; ~~ ~, o~ 2~ ~~ ~ ' ~ "~ / / i i i / ~P~/ // I ~ ~/ / ~ / / I / ~i ~ r~ / / J~o~ / ~~Q~~o~ ' / o ~cQ' ~' 1 S'~' ~ 0 ~~x\ I / ~~~~ O~G~O,~CT; ~~ i ~- ~: g ~: ~1~ fi` `~ ~ '" LOT 2 6.1 a ACRES y 224.487 SQ. FT. ~~ aED LOT 1 2.32 ACRES 100,91 O 8Q. FT. 396.78' 2.46 AC 107 2.09 AC 90, FEN( OF L .00' 35 --. -..~ 360.83 _~ X ~~ O I ~, '~c~~~0a~ I ~\ ~ \ ~~ Parcel #: 020-1407-01-000 11/19/2007 05:19 PM PAGE 1 OF 1 Alt. Parcel #: 10.29.19.2548 020 -TOWN OF HUDSON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O =Current Owner, C =Current Co-Owner O -CHHAY, BUNYI BUNYI CHHAY C -CHHEUM, NHEM NHEM CHHEUM 1047 SCOTT RD HUDSON WI 54016 Districts: SC =School SP =Special Property Address(es): ' =Primary Type Dist # Description ' 1047 SCOTT RD SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 2.320 Plat: 09-025-SHEPHERD PARK 1/11 020-02 SEC 10 T29N R19W PT NE SE SHEPHERD PARK Block/Condo Bldg: LOT 01 LOT 1 2.320AC Tract(s): (Sec-Twn-Rng 401/4 1601/4) 10-29N-19W NE SE Notes: Parcel History: Date Doc # Vol/Page Type 11/19/2004 780447 2699/420 WD 08/02/2002 685871 9/25 PLAT 2007 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/25/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.320 76,300 273,400 349,700 NO Totals for 2007: Gene ral Property 2.320 76,300 273,400 349,700 Woodland 0.000 0 0 Totals for 2006: General Property 2.320 76,300 273,400 349,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSM ENT 27.00 Special Assessments Special Charges Delinquent Charges Total 27.00 0.00 0.00