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HomeMy WebLinkAbout020-1407-03-000Wisconsin Department ofGommerce PRIVATE SEWAGE SYSTEM Safety and Building Division r INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. ermit Holder's Name: City Village X Township Bast, Kernon Hudson, Town of ST BM Elev: Insp. BM Elev: BM D cription: SANK INFORMATION TYPE MANUFACTURER CAPACITY Septic I n~ lV' ~7 ~ L. CS ?~ Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Ve ntake ROAD Septic ~ ~ t (O ~ ~ 1 ~ , 2 ~ ~ Dosing ~/ ('~ (~ Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand PM Mod ber TDH Lift Friction Los ead TDH Ft Forcemain Dia. Dist. to Well i County: St. Croix Sanitary Permit No: 463346 0 State Plan ID No: Parcel Tax No: 020-1407-03-000 Section/Town/Range/Map No: 10.29.19.2550 ELEVATION DATA STATION BS Hl FS ELEV. Benchm k ~ `~ X 0 2 l b~ ~~ Alt. BM SUHt Inlet _.--~ , ~~ SUHt Outlet ~_ [y %,~ Dt Inlet ~ ~- Dt Bottom / _, Header an. ~ ~~ /' q , f. l L !J. 1 7 7 Dist. I Q ~ ~ /- ~T _ '~. ~ ~ q (/ ° 1 Z .~ Bot_ S+ y~ m ~W" ~G~c1 ~1TStt ~ 2.. (~ Final Grade D 5 ~' ~ 9 p - 0 St Cover ~ ~ ~rn /. Z . r / 0/ ~~s's sys > 1z~ S~~ ~- ' , ~ d N't-0 SOIL ABSORPTION SYSTEM ~ ~'t" Z. 3 - s aba t~ t h-t~.t%}a~~ ~ a.~~~ BED/TRENCH Width ~) Len to ~ No. Of Trenche~ PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~/ ~~ SETBACK SYSTEM TO P/L BLD WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION ,~~~:~~ y'~ /` CHAMBER Ty a Of S~,~~ ~ / V ' 7 ~ ~ r ~ I V V / Model Number: rpJ~~~ IBUTION SYSTEM 3 ~ ,~ Header anifold r, Distribution a ~ ~r ~ ~ x Hole Si~ x Hote Spacing Vent to Air I/Jnta~ke ,, ~ Length Dia Length ~ Dia d Spacing C(111 ('_f1VFR ., ore~~...e c..~•e..,~ n.,i.. ,... Mn~~nrl rlr Af_(~rarla SvstPms Ctnly D"V1 ~i„ ~ .i. A iLJO~~ Depth Over I Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center + _ r~ Bed/Trench Edges Topsoil Yes ! No ~ I Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: (~/~_~/ (~~ Inspection #2: / / Location: 699 Zephyr LanerH'ud~son, WI 54016 (SE 1/4 NE 1/4 10 T29N R19W Shepard Park Lot 3 Parcecl~No: 10.29.19.2550 (~ 1.) Alt BM Description • ~P/1' ~ ~(~ ~ ~ (,~ ~ '~(!~~"~ "' • S'` ~ /~~ .5~~ ~" ' 2.) Bldg sewer length = Z ~ ~h ~' ~~`r~S' /r ~I Q~y ~'w~~ ~ ~~ -amount of cover = ~ ~ ~ ~" ~~ ,S ,Lt ~ _~__'",'iCUls\/,S~fiyy~ J ~ I s - D ~C. -- , Plan revision Re uired? ~ 'QJ Yes ~ No I /~ ~ I I~ Use other side for additional information. tY- lS. ~-' J ~s~ - -Gt.~YV~- ~ [06 Date ` Insepctor'zSignatj~r ~y 2 Cert. No. SBD-6710 (R.3/97) ~`~~-yL ,~[~pl, Q ~ ~~~~/7 ,1 ~~jL . ~ 201 W. Washington Ave., P.O. Box 7162 ~- C x Sanitary Permit ~ (w be fiTted in by Co.) `~seons~n Min' ~ 53707 - ?162 ____ (608 -®----~ N -~- 3 Department of Commerce ~ ~, , ~. „~,, i „' ~; ~, ~~ I.D. Number Sanitary Permit tion ~ f In accord with Comm 83.21, Wis. Adm. Code, o Probe 1 ) ~ ! ' Project E dress (if different than mailing address) inay be used for seco~ary purposes Privacy f I. Application Inforllualion -Please Prini All Formation d ; ` ~ ~ , G Parcel N t N Block N propertyOwner's Na me 03-#~ -3 o - .e ms ~fYl14~/ / Property Locarion Property Owner's M ailing Address ~~ Ciry, rate Zip Code Phone Number T ~ N; R E Q,~1',,,, II. Type of Bttil ' g (check all that apply) oe $ ~-~M~ -~`~`"~ Su~v~- ame CSM Number ~1 or 2 Famiiy Dwelling -Number of Bedrooms S • ~~ ^ Public/Commercial -Describe Use -" -- -~ ^City ^Village ~owrrship of ypso~ ^ State Owned -Describe Use - e of Permit: (Check only one box on line A. Complete line B if applicable) III. Ty p ,~ ,/ A' l~ New System ^ Replacement System ^ Treatment/Holding Tank Replacement OnIY ^ Other Modification to E~tisting System List Previous Permit Nttmber atd Date Issued B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New _ Before Expiration Plumber Owner ]V. Type of POWTS System: (Check all that a 1 Sand r P l ^ ass og e L~7 Non -Pressurized In-Ground ^ Mound > 24 in. of itable soil Mound < 24 in. of sortable soil ^ At-Grade In-Ground ^ Bolding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Constnrcted Wetland ^ Pressurized ~ ^ Recirculating Synthetic Media Filter [SLLeaching Chamber ^ Drip Line ravel-tens Prpe Q O (explain) V. Dis ersallTreatment Area Information: ~ ~- Design Flow (gpd) Design Soil Appiitation Rate(gpdsf) Dispersal Area Required (sf) D' Area Proposed (sf) System Elevation , ~ fiber Plastic Ca ci• in Total Number Manufacturer l~fab Site Steel VI. Tani: Info Pa ty t;oncrae Constructed Glass Gallons Gallons of Units INew Existing - S . Tanks Tanks Septic or•ifelAiag-1'~ ~ • l~ Aerobic Trratmetn Unit posing Chamber VII. Responsibility Statement- I, the"undersigned, assume ~ ility for' installation of the POW1S shown on the attached plans. Business Phone Number -hff4MPRS Number Plum¢er's Na me (Print) um i Fogerty Plumbing .~/! ~~ ~ 7j~- .3s- 9`0 S = S ~2 ~'~ f~X 7/S-~o3 . plumbe~~LStselt~ ~it~~tate. Zip Code) SpOOiier, WI 54801 dri- o.~- a6 c'- . VIII. C se Onl - S/70 - 7 e6lL Sanitary Permit FeeEudes Groundwater Date Issued Issuing Agent Signam o Stamps) Approved ^ Dis v Sturharge Fee) ^ Ow ~ en Reaso IX. Conditions o pprov _ SYSTEM OWNER: 7 Septic tank, effluent filter and dispersal cell must all be serviced /maintained . as per management plan provided by plumber. 2. All setback requirements must be maintained _ _ as per applicable code/ordinances. Attach complete plans (to the County only) for We system on paper not less tban 81/Z x 11 inches in size /~ ~ i1~ . ~ ~ ,~ it ~ ~, ~~ 4 ~ ~ ° ~~ • `N 1~1 O ~ ~ ~' ~n ^V4 C~ n ` ~ o~~~~o .~ ~A ~ ~ y `y t~ 3 ~ 1' ~ ~+ ~ 1n ~ ~ `~ d' ~~ ~.~~ ~~~ ~~ y~V" ~ ~~ _~ ~~ Z ~~i~ ~ ~ ~ ~ o .. o 4_ b I F , i .\ ~ \ N a 'n ~~z ;, ° V ~: •'~ Jq ~ \ ~ ~ ~• ~v ~ \ ~ ~' 1O o ~ 0 ~, CnN 3 ~ o ~ ~ o. ~~ u d ~ ~ 1p N v p ,~ ~ ' ~ a,~~ ~ ~~ ~ ~5~~%vl~l.~ (' ~ `~~`1617~ p 1 ~ w '' ~~ \ ~ ~, ~(~~ ~~ Y\ S .,L LN T_ _ ~~ • '~* ~ I ~ ~~ ~~ ~ ~ I~ ~ ~~ ~ 4 ~ o ~~ '' ~ ~ O n .~ ~ ~~~y 3 ~ 1~ ~ ~ ,~ `, d, ~ ~ 1~ ~~ r v ~ ~ 1 b ~ ~ o o .. I , o, I b 1 u ~. r 4~ .\ . N ~(~ ` \ " v „ iV O ~ ~ y ~ ~ J „ ~' _ (r`~- ~. W ( ~ ` '`` ~j ` ~,D ~~ j~ w~~~~ O ~ ~ ~ ~"~~'-'G ~~N J 03 ~ ~ ~ a 1 `'~-~ r~ ti ~ ~~ ~ a ~a r ~ ~. ~~ ~` ~ ~ Gl "' I~ I' ~' c 1 ~ ~ • Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT - Page ~ of -~ nl ovwluanw mul VVllwl. ~ , .w. rwnr. wua-. ~~ ~ . ~ 1 ~ r~ 1 x Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must direction and tal ref ren i t (BM) ri it d to ti l d h cl b t t ti , zon e ce po n e : ver ca an in no m o ude, u p, l.p. \ r percent slope, sale or dimensions, north arrow, and location and distance to nearest road. O2,o _ 1 SC p ~. - f 3 - ~ ~ • ZS Please print all information. Re 'wed by Date Personal information you provide may be used for law, s 15.04 (1) (m)). ~ ~ I ~ 2ofl3 Property Owner rty Location p ~/~,~~ nQh T Lot S L 1/4 S~ 1/4 S j O T Z~ N R(-1 E (~) V Property Owners Mailing Address 2 2002 ~ ~ ~ L t # Block # Subd. Name or CSM# 1y$ (_a ~ r City State Zlp Phony UNTY City ^ village ~ own Nearest Road ~h i I ( I) ~ ~ o co~" New Construction Use: ~ Residential I Number of bedrooms ~' Code derived design flow rate ~Sd ~ ~ GPD ^ Replacement L ^ / Public or oommerclal -Describe: Parent materia{ C9UT I~G.S Vl Flood Plain elevation ff applicable N /~ ft. General comments ~YS~P~ ,~~cvl ~y, ~-p and recommendations: Boring # ~ Boring _ _ 4~,~ r1 _. _ ... .. ... ._ I I /~ _J ~ Pit vlvuuu suna~c alcv. ~ ~ ~ u. ucNul w luluwly la.avl ~ 1 v ol. Soil Appliption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I 0-i 2 i6 ~ 2 ~ ~- ~ Z.mcal~ (~, ~r C S ~ ~ - ~' Z IZ-<(0 ~ ~ ~ v rv~~~ c 5 - . 5 - c~' 3 y~} -~~~ ~ = `-Ifs - t ~ s ~. I - - ~ 1. Z ~- 9'~! SUS ~/~y Boring # -~ Bonng O n r~~ 1 1 ~~ ~ Prt 1.7f {JU(W SWIGVG cIGV. / /1 • J - 14 vcNUl lV Iu 1NUliy IGHIVI 1 1 V 111• Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ~ ~-~ ~ 10 2 5; I 2t r~n~ c S lv ~. . 5 .8' 40-11 0 III - m d ~ -- - . -1 f . z ~r $ FY 'Effluent #1 = BOD3 > 30 < 220 mgJL and TSS >30 < 150 mg/L • Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number A,,,d.r...v, Cc ~ , ~,,,,-~ I~~ r' /~~__~~ I ~ ©Z ZS' 3 3 O 9 Ztl3 ~o ri' S~: Sowte~SL" f w1 ~{O2~ ~1~"' Zy? 4008' ~ ~ ti G ~ "~ ~ Parcel ID # Page ~ of Property Owner Boring # ^ Boring ; j p fl Ground surface elev. Q~~ ~d ff. DeP~ ~ flmitin9 ~~ I `-- in. Soil Application Rate tion x Descri R d Texture Structure Consistence Boundary Roots GPD/ftz Horizon Depth Dominant Color p o e ' ' in. Munsefl Qu. Sz. Copt Color Gr. Sz. Sh. Eff#1 Eff#2 I -~ (O 1 -- s l ZrY~rab~ ~S I v 5 , g '~ -110 ( -~ ~ m I - . -1 / . Z l~ ~~ s . ~- I .- I b~c ~ ,~', o . 2 sus 2 .d ~ , ~B' ~~ ~ ~ ~ it ~~ ~ 3, p Boring # ^ Boring ^ pit Ground surface elev. ff. Depth to I'imiting factor in. moil Applicetion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsetl Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ^ Borin # ^ Boring g Ground surface elev. ft Depth to limiting factor in. ^ Pit Soil Appligtion Rate dox Description R Texture Structure Consistence Boundary Roots GPD/ffz Horizon Depth in. Dominant Color Munsetl e Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 'Effluent #1. =GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Deparhnent 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. SBD-8330 (807/00) I + ~ .~, PAGE 3 OF 3 TAM 3 cs ~ T OT# 3 LEGAL DESCRIPTION SL- ~ ~ ~ ,S ICs T Z R ,N,$, / `~ E(or~ ~ SCALE: 1"= W ~ BM 1 ELEVATION fCsC~ • U BM 1 DESCRIPTION ~j ~ c--.~ %, S ~--e c.° ( ~ ~ ~ BM 2 ELEVATION Q % Ll ~= °~ i ` BM 2 DESCRIPTION -EvP a -~ /N S'FQ~- ~~ SYSTEM ELEVATION ~y ~ C3 ALTERNATE ELEVATION 9~/. S ~ CONTOUR ELEVATION h U S l o b ~N S~C.~a i l ~~~ K e~ ~~ DATE ~`~ ~l - G ~ c ~~C1 ~~O E ~ a~i ~ ~ ~ II ~~ ~ a Yam (~ N V -~ ~ 1 A N ~ L "CS y#c0 c~ ~ c N av ~ ~~ II II •~ ~ C7 ~ ~ o w !; ~ U ~ r..- ~. ~ d0 O II by .; ~ , ~. U ~__-- _-. ---- ~ x- ~ ~ + ~ • ==-- •. .. ~,, ~ ;} 111 -~ a~ •• _ ... -~ .. ~. ~ t ~~~ V - 1 '-~ • ' ~ ` j,,~ • ~ ~ II II II e V] ? end j ~ ~ ~( ~. ~ ~ w ~` i c~ ~~ ~ _~ O ~ O o H ~^ ai U .~ Cd .~ it _~ b 0 3 N U a~ ~.., U 0 U N o W .~ a~i 0 s .* FILE INFORMATION Owner Pemit # ~,.~.~ 3 3 ~o 1)C,Ii7N1 riynrunc ~ c~.v ^ NA Number of Bedrooms Number of Public Facility Units -. ~~ Estimated fbw (average) al/d Design flow (peak), (Estimated x 7.5i day Soil ApPr~ti~ Rate -- , aUday/ft2 Standard Influent/Effluent ~aGty Monthly ~~~` Fats. Od & Grease (FOG) <30 mg/L Biochemical Oxygen Demand tBODSi ~1.2U m9d- ^ NA Total Suspended Solids tTSS) <_150 mg/t_ treated Effk~ent QuaCRy Pre Monthly average _ Biochemical Oxygen Demand tBODsi ~U ~ Total Suspended Solids (TSSi G30 m9~ ^ NA '-Fecal CoGfomn (geometric meant 514'` dull OOmI Maximum Effluent Particle Size ya ~ nm- ^ NA Other: ^ NA 'Values typical for donies6c wastewater and tank effhrert. SYSTiflYi 'ti+°r~Nn.~ Septic Tank Capacity ~ ~ ^ NA Septic Tank Marlufacurrer -~j~ ^ NA C-fflue<It Fttiter Marwfactu~ --G ^ NA Effklent Flter Model ma ^ NA i l tY putrlp Tank C~ac a Pump Tank Manufactluer NA pump Manufacdrtx -NA Pump Model - ~NA PYetrezdrrlent Unit ~~ ^ Sid/Gravel Filter ^ Peat Filter - ^ Mechanical Aeratwn ^ Wetland ^ D'~anfection ^ Other: pispexsal Cegts) ^ NA tn-Ground (g~.y) ^ In-Grolmd (Pressurized) ^ At-Grade ^ Mound ^ ~~; ^ Other: Other: ^ NA 4~; ^ NA Other: ^ NA MAINTENANr:t ~ncwa.c Seniice Evert Inspect condition of tank(s) At least once eves Pump out contents of tank(s) When cambaied skldgE Inspect dispersal celllsi At least once every: Clean effluent filter At least once every: Inspect Pump. PAP ccetrols & alarrr- At least once event= Flush laterals and pressure test At least once every: other.- At {east Once every: other. Service Fl~equencll ^ monthtsi ~year(si tMaxurxen 3 years) d NA aix! scum equals orm-thrd IY,! of tank vokune ^ NA > ~ ts) ^ 3 ~ 3 yean:) ^ NA ~ y ^ montittsl ^ NA ^ monihlsl - ~7.NA ^ yearlsl ^ mwiti~(s1 (~ NA ^ year(s) ~ tsi ^ _ ~, NA ^ a!~ MAIN'T~IANCE INSTRUCTIONS one of the fo0owing licenses or certifications: Inspections of tanks and d-rspersal cis si-aQ be-made by an ~d~u~ cog Operator. Tank Master Plumber; Moister Plumber Restricted Sewer, POWTS hispector; POWTS Maintainer ~a9e Servr~n9 cracks or leaks, s must wickide a visual inspection of the tanktsi to ide~ntifY anll g or woken ~w~' ~~~ round surface. inspection of Effluent on the g measure the vokune of combined skldge and scum and to t~ieck for any back up or P~n9 and to check for any Ponding The dispersal cegisl stlali be visually inspected to check the effluent levels pr the observatuon fig ~~ and requires the of effluent on the ground surface. The pond-ng Of effkrent on the ground sixface may - immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (~Y3lofrmmorace~of ~Ce ~ o~ pi ~~ 3e contents of the tank shall be removed by a Septage Servicing Operator and dispo Wisconsin Administrative Code. All other services, including but not limited to the serv~mg of effluent filters, mech~l~ or~S ~~~COmponents, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified A service report shall be provided to the local regulatory authority within~l0 days of completion of any service event. ', . iaHT UP AND OPERATION oducts or other chemicals For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting pr that may impede the treatment process and/or damage the dispersal cell(s). ff high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior iQ use. System start up shall not occur when soa conditions are' frozen at the infiltrative surface. Durip~ power outages pump tanks may fN above nomnal highwater levels. When power is restored the excess wastewater wiU 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 conterns of the pump tank removed by a Septage Sery~9 Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist -in rr~uaNy operating the Pump c~trols to restore normal levels within the pump tank. Do not drn+e or park vehicles over tanks and d'sspers~l cell. Do not drove or park over. or otherwise disturb or compact, the azea within 15 feet down slope of any mound or at-grade soil ~sorptwn area. Reduction or elimination of the following from the wastewater stream may mnprove the performance and Prolong the Gfe of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; d'rap~s; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medicatwns; 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 replacemern system: A suitable replacement area has been evakiated and may be utr'hzed for the location of a replacement sotl absorption system. The replacerrrent area should be protected from d"rsturbance ~d ~ and should not be infringed upon by required setbacks from existing arx! proposed structure, lot fines and wells. Fagure to protect the replacement area will s must result in the need for a new sod and srte evaluation to estabish a witable replacerr>ent ~' ~t system 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. ~], The site has not been evaluated to identrfy 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 may be 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 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/t~~~l ~UL~ RESCUE OF A =~ A SEPTIC, PUMP OR OTHER TREATM811T TANK UNDER ANY ~ P~SON FROM THE INTEWOR Of A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ' - e.~. ...__~~:_~ #221180 . c enzle Spooner Wr ~a~~ - (715) 635-9609 ~ POWTS INSTALLER POWTS MAINTAMIIER - Name I ~~i ~ -Name - - Phone Oq Phone ~- ~ ,~ SEPTAGE SERVICWG OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Nye x'71 ~.~C X C~U~~ ~ / phone Phone ~s . ~ ' ~ _ This document was drafted in compliance with chapter Comm 83.22t211b1t111dllktfl and ~-541t), l2! & l3), 1lY dative ~' _~ r ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Ownerl~yer- ,~~/Did ,~i¢sT Mailing Address ~i ~1F `~''~.~~._/~upfox/ rv-f= 3-c/~i6 Property Address (Verification required from -~ v~ Department for new construction) i~j'r/tCl~,a City/State LEGAL DESCRIPTION Parcel Identification Number .zo -~ya~ - ~3 ~~_ Property Location S~ ~/,, ,~~ y,~ Ste. !6 , TAN-R~~~i~, Town of ~f.~ Subdivision S•<l~Ai~[Rr) ~~J . - - ,Lot # ~ Certified Survey Map # Volume ,Page # ~~ Warranty Deed # ~_~(, /Q/ Volume _~S' Z3 ,Page # h'_3 Spec house yes ltd no Lot lines identifiable ~es D 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, restrictedplumber or a licensedpumperverifying that (1) the on-site wastewaterdisposal 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 of the three year expiration data S ATURE O APPLICANT / / 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 the prpperty described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF 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 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT _ AND OWNERSHIP CERTIFICATION FORM Ownerl~Bttyer ,t~~,c~/B,i/ ,~~/~ -- Mailing Address Property Address (Verification required from Planning Department for new City/State LEGAL DESCRIPTION Parcel Identification Number Property Locations y,, ~_ '/., Sec, f4 , TAN-R,~_V~~, Town of ~6i,P1,~rrJ u division ,~CQ_; - Lot # `3 _.~R/r Certified Survey Map # Volume Page # Warranty Deed # 736 /e/ Volume ,L.S'.2.3 ,Page # ~ 3 Spec house ^ yes C~no Lot lines identifiable dyes O 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 awaer and by a masterplumber, journeyman plumber, restricted plumber or a licensedpumperverifying that (I) the on-site wastewaterdisposal 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,of the three year expiration date. / / SIGNA OF APPLICANT 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 the Icroperty descri~byrd above, by vi/rtue of a warranty deed recorded in Register of Deeds Offce. SIGNA OF APPLICANT DATE- ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** i- ** 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 ...®- U 2 3 P 0 4~ - A STATE BAR OF WISCONSIN FORM 1 - 1998 A WARRANTY DEED Grantor, and Grantor, for a valuable consideration conveys to Grantee the following described real estate in St. Croix County State of Wisconsin (the "Property"): Name ~ s ~ 1 ~ i KATHLEEN H. MALSH REGISTER OF DEEDS ST. CROIX CO.. MI RECEIVED FOR RECORD 03/08/2004 12:30P1f MARRAHTY DEED EXEMPI i1 REC FEE: 13.09 TRANS FEE: 2175.00 COPY FI.E: CC FEE: PAGES: 2 RETURN I ~ Burnet Title 7550 France A~= First Floor Edina. MN ; ~+-~ \T 1 ~: Post ' _ C'entr~l 020 1009 20 000/ 020 1010 80 000 Parcel Identification Number (PIN) This is homestead property. (is) (Is not) See Exhibit A attached hereto Together with all appurtenant rights, title and interests. Grantor warran,)s that the title to the Properties good, indefeasible in simple fee and free and clear of encumbrances except 1 Dated this day of ` ~Q,~ C,\ ~ , 2004. (SEAL) (SEAL) Rodney G. Nelson Ma et !Nelson AUTHENTICATION Signature(s) authenticated this day of (SEAL) TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stats) THIS INSTRUMENT WAS DRAFTED BY Coldwel! Banker Burnet 1301 Coulee Road Hudson, WI 54016 4-22808 (Signatures may be authenticated or acknowledged. Both are not necessary.) Names of or ACKNOWLEDGMENT State of Wisconsin, (SEAL) ~ } ss. St. Croix County 5 rs~~l came before me this ~_ day of 2004 the above named Rodney G. Nelson and_Mar~B_eth R. Nelson. husband and wife to me known to be the person who executed the foregoing instrument and acknowledge the same. Notary Publi fate of Wisco sin My commissio is ~AR~!'eJ~Ets ff~t, s ate expiration date: NOTARY PUBLIC ) COAI.~I PAM A. SPF_NCER NOTARY PUBLIC 117 STATE BAR OF WISCONSIN Wisconsin Legal Blank Co, Inc. WARRANTY DEED FORM No. 1 - 1998 Milwaukee, Wis. 4 r ~~ ~ ~I w o '75 ~ucl ~,Lt;,L~o00S W o w~ ~ NL3N 3H1 ~0 3NIl 1Sb9 `i U Z ~ U ~ ° ~Lti'6EE L 3. LZ~8Zo00N ~ o w o W atro- .EL' L 44 ~LO'948 / U ~i ~ i 9-'LZ4 ~_: iv p tr rn~ I \ I m ' J:ZW 2 ~ ' L1E'Z4B 3.1Z,8Z,00N ~ ~ _ ~.~ ~ r~ 0 ~ j w O ~ pLL~ r V ~ oo W U ~ OO ~ wiu~ ~. i Q~^ N. rn O~ ~ ~ Q p w \ W ~- I ~ .I r u ~• (A O w Z ~ ~ I . Jam ~ ui f.~ ~m0 Z~ ~ I~ ul LL ~ O p ~ U ~ ~~; N p o ~ O W N ~ Z w a¢ ~ I Z I W NN aq~~ a~ ~g?~ ~ I ~ NCO 2 r a~ ¢¢ ~121°Z ~ i j1 i i ~. V (A w ug ° 04 ~ I~ ~ O ~ ~ F ,o.~" i i i ~~ JN^ :°j 2 1'' ~ ~ i N N ~~ ~: ~ ~ / ` ~j~, i. 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