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Home My WebLink About020-1407-05-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and. Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACF~ TC: PERMIT) Personal information you provide may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Bast, Kernon Hudson Townshi CST BM Elev: / Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration 1 Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ,~ 5 i '~ f z~ i Dosing _ .___.-._-._..- Aeration Holding r' PUMPISIPHON INFORMATION Manufacturer Demand ly.~ -.._..._-- ------ ~~ GPM Model Number --~" TDH Lift ion Loss System Head TDH '\ Ft J Forcemain Length Dist. to Well SOI~.A~SORPTION SYSTEM ~ (cam) ~ f,~ n.w,_~nrr .~~aJL ELEVATION DATA county: St. Croix Sanitary Permit No: 453145 0 State Plan ID No: Parcel Tax No: 020-1407-05-000 Section/Town/Range/Map No: 10.29.19.2552 STATION BS HI FS ELEV. Benchmark ~ , / ~ ~~ ~ I ~ . It. B ~ s. O~ 2~ ) I~I•g3~ Bldg. Sewer 3•~8 I I -'t'b St/Ht Inlet ~ 0 R~ `f6 ~ St/Ht Outlet s, ~ 3 • 3 3 r Dt Inlet Dt Bottom Header/Man. '// I • `f~ r Dist. P'pe 9 . fo0 .~a ~ l3.~ Bot. System Ip , ZZ lo.2Z I J ~Z~ / Final Grade 5 ~~ , ~ ~ ~ t st Cover 2 •~t7 01.3 ~ ENCH idth t Len r ~ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth D(MENS ~ U g$, Z SETBACK SYSTEM TO P/L LDG WELL LAKE/STREAM LEACHING Manuf c~ turer ( .f--. /~4 INFORMATION CHAMBER OR _ 1-~~-r (J~ L'C ~ ~ Type Of System: ~~o ~ ~~` l.P"v" • ~ .,, C' J ' ~~ ~ ~ I~ UNIT . _ ~ . . . Model Nui ber / DISTRIBUTION SYSTEM Header/Manifold ~ ~F Distribution Pi e(s) x Hole Size x Hole S Vent to Air Intake / p , I ~ Len th Dia g p Len Dia Sac 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 No Yes No - COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: OJ[~/'~--f Location: 707 Ziepher Lane Unknown (SE 1/4 SE 1/4 10 T29N R19W) Sheperd Park Lot 5 1.) Alt BM Description = ~{~ 5' ~~ ~'~-• ~~ ~~ `~ ~~~~_ ~C:~u~x~~/[ 2.) Bldg sewer length = 23 ~ ~ ~ ~ ~w" ~~ I ~ rt ~,~' ~~ `- am(ou~nt~ofNcover = Ig 3) ~'1~-~C ~t ` I ~ ~ Tj ~'v~ ~ {~. LK D ~ F I~Z _S~'_ -r.._--T ---_-. _-___ _.. Plan revision Required? a Yes ~ No I~~ ~ Use other side for additional in formation. ! ~ ~~ 16~ I ~ ~ _ - __ -_ SBD-6710 (R.3/97) Date Insepctor's Signature Inspection #2: --F----t arcel No: 10.29.19.2552 ~° ~r~ c- ~~ ` ~! __ __ __ Cert. No. Safety and Buildings Division County _ ~ 201 W. Washington Ave., P.O. Box 7162 f' , ~scons~n Madi~n, WI 53707 - 7162 Sanitary Permit Number o be filled in by Co.) Department of Commerce (~) 266-3151 5 Sanitary erlnlt Appli tio~~~,~I~~~ State Plan I.D. Number PIED In accord with Comm 83.21, Wis. Adm. Code, personal inf Lion you provide may be used for secondary purposes Privacy Law, 5.04(1 ( ~~R 2 1 ?OOr~ Project Address (if d' ent than diaili ess) I. Application Information -Please Print All Information a~~.c~zo!:c:our~~r~~~ 707 z ~ Lam/ ~p~ Property Owner's Na me --~ ~ N_ .._ 1 # Lot i! Block // \ ~ ~ Cs J Property Owner's M Address + ~~ sE s~/N 9 ~i~ ~' ~.1, . , i4 X14 { Sechon /~ ' ' r City, State Zip Code Phone Number y f ~ -~ ~~ (circle _ II . Type of Builtlmg (check all ply) ~ , ~ ~ - / CSM N bdi i i N b S , Q+71 or 2 Family Dwelling -Number of ms v um er u s on a~r~ k dl h e er S ^ Public/Commercial -Describe Use ~ ^ State Owned -Describe Use - ^City Village ^'1'ownship o III. Type of Permit: (Check only one box on ' A. Complete line B if a 'cable) ~ ~ - - p - . 2SSZ. A' I~New S stem y ^ Re lacement S stern p y TreatmendHoldin T g Replacement Only Other Modification to System B. ^ Permit Renewal ^ Permit Revision ^ e of Permit Trans to N t she it and ed Before Expiration Plumbe Owner _ I V Type of POWTS System: (Check all that a ly) , , / L7 Non -Pressurized In-Ground ^ Mouad > 1A in. of suitable soi Mout-d < 24 in. of sortable soil a ingl nd Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holdin ank Peat Filter ^ Aerobic Treatme nit eci and Filter ^ Recirculating Synthetic Media Filter ~Ja Leaching Chamber ^ Drip L ^ Graver-less Pipe er zplai V. Dis sal/Treatment Area Information: C GL ~ . S' ' Design Flow (gpd) Design Soil Application Rate(gpdsfj Dispersal Area Req (sf) Dispersal Area Pro ystem Elevation . 7 ~S . / ~•~ y'?. J ~ VI. Tank Info Capacity in Total umber Manufa rer Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existin tJ ~ ' \ _ Tanks g Tanks , r „ _ Z ~~ 7 t'Fr J Septic or McIQIPig'1'Zc zs-o ~ / Gd.~,~' .t _ VII. Responsibility Statement- I, undersigned, aecnma respons' iliCy for installation of the shown on the attached plans. Plumber's Na me (Print) Pharr 's Si cure MP/MPRS Number Business Phone Number Plumber's Addre ss (Street, City, e, Zip Code), Fogerty Plumbin & k T . ~ G f~,_ yO2 ~ ~/O g r estte~c== < s - o - 37 VIII. Co Approveds ~/ira Qj Sanitary Permit Fee (includes Groundwater Date Issued Issui Agent Signature (No Stamps) ^ O r Given Reason for Denial Surcharge Fee) 2.~ '- ~ ~ 1Qi;. Conditions p rov al SYSTEM OWNERi - ~ 1 Septic tank, effluent filter and ~~ ~ "' dispersal cell must all be serviced /maintained ' as per management plan provided by plumber. ~°'~ Q~~ l?f~ ~~ ~ 2. All setback requirements must be maintained ~' as er a licable code/ordinances V r G~- tPJ~l~t ~` ~ k p pp ,~ cr ~ ~""'6 Attach complete plans (to the Connty only) for We system on paper not less than 81/2 x Il inches in size ~.~-(,~/ ~~~, 1--~5 tS~~ ~0~~( Fo~Arty Plumbing #221180 2~?88 McKenzie Rd. S~,ovner, WI 54801 (715) 635-9609 ~, ~G/~i`7' ~i~T ~~o oy // ~ \ _`~ /io . ~ ~"'~. . ~ j ., I Y I /~ , t _~ 6/ c-- ~~'S ~ --T ~T~~ -. sC/JL+~ / "' - S D ~ / =amez-,r~6 = Finav~ LaT CO.P/~~ ~o~ W ~' S v' r'7~7 ~ ~.~ o fs~4~T~,~-r• ~srEw c c-/ z g7~ ' L , 93.3 ~ ~ y/s ~ V . - COPY // ~ iio . ,-~,. ~~ ~~ W y ~~ ~~ a -~. ., ~z /~ r ,s A I /~ .~ Fo~'rrty Plumbing #221180 2~~~8 McKenzie Rd. S~;~en~r, WI 54801 ,,.~~(715) 635-9fi0 ~ ~ %'~ 5 i B` ci c_ z 6/ ~- /~'S ~ -.-~ ~T~~ - 7e ~ sCIK~ / " = S~ . QrtL d ~`/ s,awn~ jO/ of/Y ° R~ lAO.p ~~~ ~- / 1S ~! =gSGT- tiaJ ~ . ~~~.~ 11 ~ io ~ ~iezrr/G ~ = a~ 6sT cvv-/~ ~~~ o stsr~w c c-! 1 g7~ ~ L , 93.3 ~ ~' f/ V . <~ ~l~ ~ ~ ~ ~~~b PAGE~OF 3 ~~~ S ~" LOT# J~' LEGAL DESCRIPTION SF ~ S = `4 ~ /C~ T Zcl N R / l Elor~ SCALE: 1"= y0 BM 1 ELEVATION lUC)~ G BM 1 DESCRIPTION~~ G ~- /trr ~1--~P I ~c.~ BM 2 ELEVATION Cf 9 ~ U BM 2 DESCRIPTION~~ N t~~r'-~e~ ~ocr SYSTEM ELEVATION X110 ALTERNATE ELEVATION q ~ ~d CONTOUR ELEVATION Vlo`7~a D~ ~~ ,~ ;~ ~_ ,, ,, ~a N SRc. /~ I~ - -i -- 1 ~~l ~e t%~ __~ n~ St~,Q~ ¢"2 L z, gfi t1h~V~v~. ~-e6r~~: ~~ r Q~3 /~ ~ •j /1e 9s' ~u~~ SIGNATURE ~~~ --~G --~"'._~ DATE 7 ~ 2~~ ° Z .~ ^„ , VViscensirt Department of Commerce SOIL EVALUATION REPORT Page ~ of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Couf' ~~~ " ~ r6 C Attach corrrplete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must ~ indude, 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 l.D. p2O .- 1~}0 } .. tS o'p~ ~ 2 S5Z Please print all information, Reviewed by Date Petsorrai information you provide may be used for seco (Privacy taw. s. 15.04 (1) (m)). ~ I ( cuC/ 3 I, Property owner CEIV' ~ Location ® e~ n~1'1 ~vr• L S~: 1/4C~ 1/4 S ~ Q T 2~ N R ~ E (or) Property Owner's Mailing Address qy$ ~ ~r 1~~ 2 2 20 Lot # Block # 25 Subd. Name or CSM# ~h ~c~ ~.~ . City State Zip Code OIX 0 ^ C~ ^ ~Ilage ~ own Nearest Road ~• New Construction Use: [.~' Residential / Number of bedrooms 3/41 Code derived design flow rate yS' C) _ GOO GPD blic or oorrtmenaal -Describe: Replacement L~ Parent material Q V 1 W C.' .S Flood Plain elevation if applicable N ,/~ ft. General comments S~ JC~-e ~.~ -e(t v ~ ~ ~~~(~ and recommendations: Boring # ^ Boring /J-) n~~ I 17 -J LX,( Pit urouna surrace elev. r ~. r ... n. uaµu~ w mwwry racwi - n~. Soli Appligtion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. 'Eff#1 "Eff#2 ~ ~;-- 11~ Z _ ~ S;1 Z k m~ ~ ~ 1 v . 5 . g Z [~-y 2 ~ ~ I _ " 1 2r-~k mfr ~ S - , g Z-112 l m l ~- ~ •~ /• Z `t3•ta~ s~,~ 93. ~v Boring # ^ Boring 4.9, fir) _. I "~ c..J 1 L~ Pit urouna surrace erev. - ~r. uepur ro ~u~uwry ~aww - ~ u~. Soil Application Rate Horizon Depth Dominant Cokx Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Cokx Gr. Sz. Sh. 'Eff#1 *Eff#2 1 a-12 ~~ 2 5~ 1 z c5 I v . 5 - 8 2 I Z -~ (~ --~ i~ b r c 5 - ~ 8 3 -)Z~) I 0 r ~-I to `- ~ - _ - -1 ~ . Z ' Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 =GODS < 30 mgiL and TSS < 30 tng/L CST Name (Please Print) ~ ignature CST Number ~ ~~-~=~- v z s 3 3 o q Address Date Evaluation Conducted Telephone Number Zu3 ~-o~ S~. sowlers~f cal s'~Jv2S ~~~ zy~ yoo8• Property Owner ~ ` Parce11D # ~~ ~ r Page ~ of Boring # U Boring / Pit Ground surface elev. q ~~ ~o ft. Depth to limiting factor 1 ~ ` _ in. ~I Appligtion Rate l C Redox Descripti~ Texture Structure Consistence Boundary Roots GPD/ftz Horizon Depth in. or o Dominant Mansell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ~ ~-i 5 ~5 -`~Z I G. ~- Z I ~ ~ ~I ~ _ 5 'f I ~- ~ i 1 ~ mfr rr-~-~~ c S ~5 (~ - . ~ . 8 S ~Z-~~~ ~ ~ - r~ _ `" . ~ 1. 2 S~-~ 93• a ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate ~g# t C l Redox Description Texture Structure Consistence Boundary Roots GPD/ftz horizon Depth in. or o Dominan Mansell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#'I 'Eff#2 Boring Boring # Ground surface elev. ft Depth to Wmiting factor in. ^ Pit Soil Applicati~- Rate l t C i Redox Description Texture Structure Consistence Boundary Roots GPD/ttz Horizon Depth in. or nan o Dom Mansell Qu. Sz. Copt Color Gr. Sz. Sh. 'Eff#1 'Eff#2 `Effluent #1 = GODS > 30 < 220 mgR. arxi TSS >30 < '150 mgll_ ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mglL 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 (r;.mroo> r "~ PAGE~OF 3 ;~,~~c_s r TOT# J~ T EGAT, DESCRIPTIONS ~ S -14 ,S I~1 T Z~'/ .N.R. lrl Elor~U '~ SCALE: 1"= CIO BM 1 ELEVATION /(~ • U r~ BM 1 DESCRIPTION r~ -~- //.~ ~I--~~ ~ iQoc~ ; BM 2 ELEVATION ~~~U i~ BM 2 DESCRIPTION ~,~ ~ J~1 l ~ ~ca ~ ~ (~ o~ SYSTEM ELEVATION ~~~ 10 ALTERNATE ELEVATION q 3 ~l o CONTOUR ELEVATION ~4 ~~'d Q~. N ~~a la ~~ _ -} - ~ ~„ 1 f p - p gfi tiC1~4.'J21tr ~}2~izf.`/~ Q~3 SIGNATURE ~ Y ~ --- -°`"~ DATE l~.,s=~ ~ ~o~ ~ E~ ^'~o~ ~ c ~ °~ ~ - ,~ ~ ~ ~ p o d#~ o~ ; N N ~ t `~ N ~ ~ ~ ~ M a. -~ ? O a ~ •~ Q., U W t U at ~` w ~,,,, r~ `+-+ II o - ono ``~` ~ p' o °' -~ f ,~,-,~ I ~, W .~ . ; •~ ~ ~ s z ~ .~ N ! . '~,. s. 1 V ,.~ ~ - '~, ( '_ -~ .'~ = ... U - •_, ,. +~'- - _ -~ T~'' ~ , a . r --~=: - - ~ : i i ^ti ~: y-0 _ ~ ~ ~ II ~ 11 II i ~ j a`i ~ ' ~i ~ a? _ ,, ~' ~ ~ ~ v -~ o ;, 0 0 H U t~v .~ O "d O ai •3 U b m O U 0 Q~ .~ Qr G"+ O t'VW Ib VVVIYCti .7 IVIAIYVFIL of IYIMIU/yv~^~~a•^~^ ^ ^-^'~ CII F INFARMeT1AN Owner ~- ~_ Pemnit ~ S3 t ~S~ ncslr_Ie aeweN-~S Number of Bedrooms ^ NA Number of Public Facility Units ~NA Estimated flow (average) Oa ~ aUday Design flow (peak), (Estmated x 1.51 pp aUday Soil Application Rate __ ,, aUday/ftZ Standard Influent/Effluent Quality Monthly average` Fats, Oil & Grease iFOGT Gi0 mg/L Biochemical Oxygen Demand (BOD5) X20 mg/L ^ NA _ Total Suspended Sol'xis (TSS) _<150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODE 530 mg/L • Total Suspended Solids (TSSI 530 mg1L ^ NA -. Fecal Coliform (geometric mean) 51 O' cfu/100m1 Maximum Effluent Particle Size Ya m dia. ^ NA Other: O NA "Vahies typical for domestic wastewater and septic tank efftuerrt. cvc~su soc-~`~1[`~TIONS rayo / w Septic Tank Capacity d ~ ^ NA Septic Tank Manufacturer ~ r-~- ^ NA Effluent FNter Manufacture` _ ~ ^ NA Effluent Filter Model _ ~ ~ a ^ NA Pump Tank Capacity al ~ ~` Pump Tank Manufacturer ~ NA Pump Manufacturer CT ~- Pump Model ~ DNA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeratwn ^ Disinfection ^ Peat Fiher ^ Wetland ^ Other: A - Dispersal CeNls1 _ In-Grand (gravity) ^ At-Grade ^ Drip-L'me ^ NA ^ In-Ground (pressurizedi ^ Mound ^ Other: Other: ^ NA other: ^ NA Other. ^ NA MAINTENANCE sCtit17u1x Service Event Service ~ Inspect condition of tank(sl At least once every: ^ month(s) (Maxillulm 3 years) ~ ~(sj C] NA When combined sludge and scum equals one-third (Y31 of tank volume ^ NA Pump out contents of tank(s) inspect dispersal cell(s) At least once every: ^ month(s) (Maxitrwm 3 years) 3 year(s) ^ NA ^ monthlsf ^ NA Ctean effluent filter At least once every: ' • ~ year(s) ^ nwnth(s) -~(A Inspect pump, pump contro{s & alarm At feast once every: ^ y~(S- ^ month(s) Q NA Flush- laterals and pressure test At least once every: ^ year(s) Other:- At least once every: ^ month(s) ^ year(s) _ j~ NA ather: ~~p` MAINTENANCE INSTRUCTIONS Inspectwns of tanks and dispersal cells shah be made by an andnvidual canying one of the folbwillg 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 combkled sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(sl 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"a~g of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY31 or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent fikers, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within~l0 days of completion of any service event. • 2 3 . ~aHT UP AND OPERATION For new constructie~, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s)- If high concentrations are detected have the contents of the tankls) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose. overbading the cell(s) and may result in the backup a surface discharge of effluent. To avoid this situation have the contents of the pump t~k removed by a septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist :tn 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 replacement system: A suitable rep! been evaluated and- may be utiCrzed f~ the location of a replacement soil absorption system. T r lacement area om disturbance and can on and should not be infringed upon by required se xrs ng and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ^_ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ~, 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 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/OR INSUFFlCIENT OXYGEN.-DO NOT Ellli'ER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. _ , e.. #221180 _ ®n e Spooner WI 5~~ (715) 635-96~ ~ POWTS INSTALLER Name ( (~{~t ~ Phone `]/,S~ ~v3 _ ~ ~9 POWTS MAINTAINER Name Phone f- SEPTAGE SERVICWG OPERATOR (PUMPER) LOCAL REGULATORY AUTHORRY 7~f ~, !- Name Name -171 ~.~ l' x ~' 1 `•""" Phone ~Oce ~~ ~ r This document was drafted in compliance with chapter Comm 83.22(211b)1111d1&(f) and 83.54(1), (2) & (31, ~~~ administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer .~~??.dor/ ~~ST Mailing Address ~ J ~~/ L,~~r~.E ~ T~~~~ w~ f~olG Property Address City/State "" W ~" (Verification required from Planning Department for new construction LEGAL DESCRIPTION Parcel Identification Number eZo - I~(o~-- oS- c~ ~ 2S~Z~ Property Location ~_ ~/., ~_ y,, Ste, lp , T~~N-R!~«~, Town of lL~uj~se,t~ Subdivision Certified Survey Map # Lot # Volume _ .Page # -- Warranty Deed # _~ss~'~ Volume _/y3G ,Page # .~"/C Spec house ^ yes ~~ no Lot lines identifiable Q~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 ceriification 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 andlor (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. -= / / SIGN~-TLrRE OF PLICANT 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office, SIGNA OF A 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 ~Y~~.1436F~~~ 5~6 Document Number I WARRANTYDEED Jean Grantor, and,Kernori J Bast and Danalda J Speer-Bast husband and wife, as survivorship mazital property Grantee. Witnessetfi, That the said Grantor, for 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 singular 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 KATHLEEN H. WALSH REGISTER OF' DEEDS ST. CROIX CO., WI RECEFVED FOR RECORD 06-24-1999 b:30 Afl MARRANTY DEED EXEMPT N CERT COPY FEE: COPY FEE: TRANSFER FEE• 450.00 RECORDIMI'a FEE: 10.00 PAOESs 1 Area FIRST FEDERAL. SAVINGS 201 SOUTH SECOND HvDSON, WI 54016 Part of the NE'/a of SE'/4 of Section 10-29-19 described as follows: Beginning in the center of Scott Road at the NW comer of Lot 1 of Certified Survey Map, filed in the office of the Register of Deeds for St. Croix County, in Vol. "3", Page 651; 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' l3"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. Dated this L,~day of 1999 l.~ T.~ h ~r C/ Y f, n M Hendrickson AUTHENTICATION Signatures authenticated this day of s~ r S~J->r type or print name TITLE: MEMBER STATE BAR OF WIS (If not, authorized by~706.06, Wis. Stets.) THIS INSTRUMENT WAS DRA Robert F. Wall (Signatures may be authenticated or acknrn necessary.) ACKNOWLEDGMENT STATE OF WISCONSIN COUNTY ST. CROIX Personally came before me this ~Sday of ~-~-'~~ `%9 the above named Jean M Hendrickson to me known to be the person(s) who executed the foregoing instrument and acknowledge the s ipnalu 1 ff type or print name ~~~' 1 'C.Y1(' _ ~ . ~61 )'Y1 ~i~ f Notary Public County, . S ~ • o iX ~My c°mmis~v ~ permanent. (If not, state expiration date: CJ O~•) of persons signing in any capacity should be typed or below their Signatures. ~a ~, ~ " ~ ~6 ~ ,/,~~~a~~~ ~ d04 4 ~ ~ / ~s ~ ~1~ i ~ - / ~ ~ LOT 3 / / / 2.02 ACRES / / / 58,146 SQ. FT. ~ / ~ / /~ / / / ~ ~~ ~1d~ i / / ~ ~z~, / •~, ,/ ~o`-$ LOT 4 2.00 ACRES ~ 57,161 SQ. FT. fi `~ ~. ~. ~ ~~ ~ W .~ c--.; ~ "i i j ~ Q i ~~ ! N = ~~ i'~ N, i i\~` ~ \ 'Q7 y~• ®~~~ \ ~O ~ ~ _ ~ ~ -. `~ ~. a `~ ~. ' ~ .03' ACR 88, . FT. ~:~~ s 96 ~~ ~~ ~~~ ~z SBEI°31'39'E 200.08' 9~ ~%~ _36.74' 36.74'] ~ LOT 6 2.46 ACRES INC. ESMT . ~ ~ 107,098 SQ. FT. 2RES w SQ. FT. ~ 2.09 ACRE8 DCC. ESMT 90,931 SQ. FT. FENCEUNE IS 1'+F NORTEi \ OF LOT CORNEfi LOT 7 2.31 ACRES INC. ESMT 100,830 SQ. FT. _ 7.96 ACRE8 EaCC. ESMT 86,797 SQ. FT. ~~.. 6.~ a ACRES 224.487 SQ. FT. aEa