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HomeMy WebLinkAbout020-1433-04-000 /Visconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Cr oix Safetv and Building Division S INSPECTION REPORT sanitary Permit No: 430673 0 GENERAL INFORMATION R * (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Beer, Robert Hudson Townsh' 020 - 1433 -04 -000 CST BM Elev: Insp. BM Elev: BM Description: l e Section/Town /Range /Map No: 99-S . S f 11.29.19.2692 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Be mark / Z v c Qe Ctf '� t Dosing �^ U �—� Alt. ST Aeration ✓ Bldg. Sewer 3 Holding ! St/Ht Inlet 17 o TANK SETBACK INFORMATION St/Ht Outlet �— TANK TO P/ Wf-LL BLDG. Vent to Air Intake ROAD Dt Inlet own Septic �� , Dt Botto t 1 Z 1 2, � Dosing VQA. *_0'V) Header /Man. 0�7, Z '1 Aeration - -__ Dist. Pipe Ll Holding Bot. System d 4 1 41 71 Z Z , /o Fin " Grade PUMP /SIPHON INFO ATION WA,0 - � Y�(�td S S S 2. q 9 Manufacturer / , , Denw*d0k St Cover GPM 7 S I1 • D 90 Model Num C 3C) e4ve 1 -6 f JA.i. l._ (� L S _ Z TDH Lif Cf /� Frictio System d TD Ft f I Forcemain Lengt Dia. Tisf SOIL ABSORPTION SYSTEM BED /TRENCH Width i Length 7 No. Of Trench PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 9 SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING aufactyfer:� INFORMATION Typ f System: UrI�C g f L I oa (CHAMBER OR � Number: Model Number: w I DISTRIBUTION SYSTEM Bader /Ma ifold Distribution x Hole Size I x Hole Spacing Vent to Air Intake Pipe(s) h Q c Length Length 0 Dia Spacing J S� SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only :PJ• //'ti Depth Over Depth Over xx Depth of xx Seeded /Sodded xx ul ed Bed/Trench Center Bed /Trench Edges Topsoil Yes No es No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 30 /� Inspection #2: / Location: 1067 Daniel Drive Hudson, WI 54016 (SW 1/4 NE 1/4 11 T29N R19W) Mound View Estates Lot 4 Parcel No: 11.29.19.2692 1.) Alt BM Description = C/" l/�(/ 'oC- �K-f� SZ f�` - 2.) Bldg sewer length = 12 JQr - ro, haw U "j amount of cover = `� Plan revision Required? Yes [ _ No u Use other side for additional information. SBD -6710 (R.3/97) Date insepctor's S nature Cert. No. \ - P \ u o. � � I o � _ a o u . V4 � J Op Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 l T C' ✓a N' tisconsin hl?adison, WI 53707 - ® Sa ry Permit Number (to be filled in by Co.) Department of commerce (�$) F I f Sanitary Permit Applicatio Sta Plan I. D. Number In accord with Comm 83.21, Wis. Adm. Code, personal informatio you pr�AN 3 0 20 may be used for secondary purposes Privacy Law, sl5.04(1 (m) y -Proje Address (if different than mailing address) Ft01X GOUN I. Application Information - Please Print All Information ZONIN Property Owner's Na me arcel if Lot A Ft # i Property Owner's M ailing Address Property Location Imo_ e T City, State Zip Code Phone Number s ` V 'A'!� —v 'k.Section f S�yU / 3 &G - v 2 (circle on T �� N; R Ecr II. Type of Building (check all that apply) _ 1 or 2 Family Dwelling - Number of Bedrooms �_ S t Subdivision Name CSM Number ❑ Public /Commercial - Describe Use -State Owned - Describe Use S�- _ __ 11City_11VitlageXownship of . /ig: /_5-A4 III. Type of Permit: (Check only one box on line A. Co mplete line B if applicable) O _ 14-33 _ Z)4 —CV0 - 2 fo qZ A. - �` New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑Permit Renewal ❑ Permit Revision ❑ er Change of ' ❑Pmit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T ype of POWTS System: (Check all that apply) _ �� Non - Pressurized In- Ground J Mound > 24 in. of suitable soil El Mound < 24 in. of suitable soil v At- Grade El Single Pass Sand Filter 1 ❑ Constructed Wetlan ressurized In ii'dD ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Fhter� { ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ D tp kine ❑ Gravel -less i ❑ Othe; V. Dispersal/Treatment Area In formation: Ofl Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevatiot I F 7 VI. Tank Info Capacity in Total Number 1 Manufacturer Prefab Site bteei 14ber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding 'Tank Aerobic Treatment Unit Dosing Chamber�� Rod —' V II. Responsibility State ment- I, the undersigned assume responsibil for ' ll ation of the POWT _S_shown on the attached plans. Plutnber's Na me (Print) Plumber's Si gnature P/ PRS Number f Business Phone Number Plumber's Addre ss (Street, City, State, Zip Code) VIII. Count /Department Use nl O F IX Approved ❑ Disapproved San icary Permit Fee (in udes Groundwater Date Issued Issui A t Signature 'o Stamps) Surcharge Fee) ❑ Owner Given Reason for Denial . Conditions of Approval /Reasons for Disapproval f SYSTEM OWNER: 3 C� "AkA t o ,� c� p 1 Septic tank, effluent filter and t± � dispersal cell must all be serviced / maintained S� as per management plan provided by plumber. °7 2. All setback requirements must be maintained as per applicable code /ordinances. Attach complete plans (to the County only) for the system an paper not less than 81/2 x 11 inches in size �Z- SBD -6398 (R. 01 /03) i \ rA� a � o Q �1 C\� I lk V / r wrwsconsin Department of Commeroe SOIL EVALUATION REPORT Page L of � _ Division of Safety and BUP tgs in accordance with Comm 85, Ws. Adm. Code Cow Attach complete site plan on paper not less than 8 112 x 11 Incites in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all inforn►adon. _ e Date 1»' /j ? Personal information you provide may be used for ecorwry � p iv!cy,�• s. 14.04 I/ J Property Owner Prooertly Location R tC f'f g i Govt Lot "J'N 1/4 N 1/4 S 1 1 T 29 N R IT E( W Property Owner's Mailing Address Lot # Subd. Name or CSM# i t 50 C R-c _ A' Mov r'A Ulerr deg City State Z1p Code Number ❑ ❑ Village [$Town Nearest Road ® New Construction Use: Residential I Number of bedrooms 3 - y Code derived design flow rate AriS'01-6-6 O GPD ❑ Replacement ❑ Pubic or commercial - Describe: - Parent material S L ___ Flood Plain elevation if applicable ` w G r 9/ a ft. General comments 5�5 m ie j e v, 1 7 0 ' `,' e' 9 • °` y� and recommendations: S �z - 5 -. I , � � ✓n.2d -4� A' — f ' 1 2- , ;W- '� p Boring Q Boring #] Pit Ground surface elev. _ /� 1r7� ft. Depth t0 limiting tailor _ in. Sol A Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsei Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 6 I 6 f NZ - - g� I 'Z >-k mi - CS I v — .5 jka - 3 q3. 1 9z. F2-] Soiing # El Boring QQ Ground surface elev. h 1 tt. Dept tD limiting factor 12 Z in. pit --- Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft? in. Munsei Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eft#1 'Eff#2 I 0 -11 to 2 Si r �r Z 1 1- 20 I 21nn Lk 3 -1 lb yl — I s C, ml / - Z: `' '73.2'' az G ' 3(,-,l a- t' A- 'Ai - 7 - Effluent #1 = BOD > 30 < 220 mg/L and TSS >30:5 150 mg/L ' Effluent #2 = BOD < L and TSS _ mg/L CST Name (Please Print) pignature CST Number Address Date Evaluation Conducted Telephone Number P113 90'; 4Z20 S- c � Property Owner Parcel ID # _ - - -- Page 2 Of " Boring -- ❑ Boring a # Pit Ground surface elev. ft• Depth ii 9 taclor 2 in. Soil AlDvlication Rate Horizon Depth Dominant Color RedoxDescription Texture Structure Consistence Boundary Roots GPDftf in. Munseti Qu. Sz. Cant Color Gr. Sz Sh. 'Eff#1 *011#2 2 r4r- C� I J I� r4 S' I 2m5bk mCr C S X13 � ti, 1L D`► E] Boring E] Pit F-1 Boring # Ground,surface elev. ft. Depth to IinNMig factor in. Sol ication Rate .,. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlftz in. Munseti Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 '81#2 Boring Boring # Ground surface elev. __ ft. Depth to limiting factor — — in. ❑ Pit Sol tication Rate F Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIff in. Munseti Qu. Sz. Cont Color Gr. Sz. Sh. •Eff#1 'Etf#2 ' Eftiuent #1 = BOD, > 30:S220 mg(L and TSS >30:5150 mglL " Effluent #2 = BO0 < 30 mgiL 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. SBD- 8330(R.07/00) f S PAGE ,3 OF_ NAME: 13 e e r" LOT #LEGAL DESCRIPTION:S Il TL�,N,R,LO E(or)10 SCALE: g vA 1 ELEVATION: BM 1 DESCRIPTION: +,e of 4 SI e G/ 4 d ® + BM 2 ELEVATION: 99 Sa S� 1 BM 2 DESCRIPTION: D ew SYSTEM ELEVATION �o Gacw < r 9,7, 0 0 SYSTEM TYPE: (o vi u e rL cA- -D i Ole 6 �� q / t \ c� \ v SIGNATURE: DATE: A, w 'K ) EF1 1 A . i Mlp CR.SS YLCTIGN AND S +CATIC?�S___ 4" CI VENT PIPE 12" MIN. ABOVE G:JADE ?' 25' PROM DOOR, WINDOW OR WEATHERPROOF FRESH AIR INTAKE JUNCTION BOX APPROVED W CONDUIT MANHOLE COVER r:NISHE r2RADE W/ PADLOCK E 4 " Cl RISER - ---- WARNING LABEL ,t e ll � I N. 6" MAX, -N 14Z T 1 -- ---�+. E� WATER 'TIGHT SEALS ' GAS -,� 7 TIGHT ' PPROVEO ��'FROVEO A D IAL JOINTS WITH , IQE 31 JALM APPROVED PIPE 3tY't'0 SOS T�1 i "''- ' ON j 3' ONTO iOIL C ' ' 1 SOlIO SOIE, PUMP O FF ELEV. FT. t�Or: � � �� RISER EXIT ._ -.... 1 D PERMITTED ONLY IF TANK MANUFACTURER 3" APPROVED BEDDING UNDER TANK HAS APPROVA? CONC.RETE PAD SP ECIFICAll"_N5 SEPTIC DOSE TANK MANUFACTURER: G✓. - ?rUMBER DOSES PER DAY: �I TAN2! 5i2ES: SEPTIC ' GAL. DOSE VOLUME INCLUDING DOSE g GP,i„ FLO'ivBACX. I. .r GAL. ALARM MANUFACTURER: i:vC:?ES .. . � .GAL. ----- CAP:9C i TI E S : A : � MODEL NUMBER: SWITCH TYPE: B = 2 - INCHES = GAL. P P MANNUMB - MOD EL _ ����/�� C 2 � INC = E� NuM$ : .---.. SWITCH TYPE: REQUIRED DISCHARGE r RAT GPM PUMP & ALARM WIRING AS PER ILHR 16.23• WAC VERTICAL DIFFERENCE BE. P OFF AND ISTPIBUTZON PIPE FEET + MINIMUM NETWORK SUPPLY PRESSURE . . — FEET FQRCEMAIN X�p FT /3J0 FT. FRIG FEET T. ON FAC i 0P. '% 7� FEET TOTAL DYNAMIC HEAD F EST :NTERNAL DIMENSIONS OF FUM? TANX: LENG - 4 WIDTH ,rj? ; ,ETER �~ ;IGICED: '/8& WEGEREK KIL TESTING PAGE 74 Goulds PftS ~ it Submersible ,. �- Effluent pump ,i387 EPO4 1 EP05 A"LICATIONa • Ftebners: 900 sates • Fuly submelped n s �si�ed tar ttw • a steel, g WN od fold Cant iron ' diluent stems d! Wo ouo at ckng to had dklent st vqk end durebdmr. • Hontiea components, e! Nobr tae�rsr. ThOrmoplae• • �s MOtAt". A�raAONe for W�ON& and it mor N+o Ir"N Mtedle • AY b1+ surrtP ' EF04 SIr�M a minuet op�tlOS• Aftatle 10 1 W tAdf aWment Dom Wetertlefiater 116 Or2' V, d0 H4, 560 ` modlle fM polyp, ROM. bun In overtned Wth Flat Awltbh bM1 end ■ Festu Coble: Sewm d* wbwstk reset, pnw of the hetery. rated oil' and e,Ater nelstern. 0lIQAT16NC • EP06 Sin It Ohre: 0 5 FIAT= NP, • 1e �, • 115 V, 94 41550 RPM, twbb'WWUUpl Per &W bar S bulk g l n ovlftsd with EPO4 I aarIVY hee ng ute rovc rout m1�' n+ermc- ' ,'• : u to 55 GPM. ' bordc 10 foot 0 � deiipn > nd iorvh 166 To wo purrs atom ABEACY LBT1Nil r�hl bads: uA to 21 fw wJtn thnN pMrp tlm+n+Cing machmu m mbCom • M« I ait. h' W. plug. Opaonat 20 toot ■ EP W lmpolla: Thermo- � � eM &*Am. *. deelgIn Bl . sues PPron4 Oro ding plug 'mptQred pwwft i, br and In T %w m numbers T " (�aderd on Pop, a Cu � } ro: � R ugged 104 No•C) condnuoc� tha • "" F �irs�o ' o cormeto n mwa= >�telrteee eta Ma7ft MT • 4& of runfilnp *n dertreoe to p��� M P m*: go ewdntumn0 walky, wmeoGPM. ..r I • T'W h"& Mp fa Al fat • M��il e�iet NPT �. + ' e ` 1 rc a do i� "lent ' -~ g n 0� • o 0 Ia auft K"I. PAO so 1: nw�► I The Standard Inhil i1trator" Chamber The Standard Infiltrator Chamber 1 °Overlap at Latching Mechanism 12" o > In c 75° Effective Length Chamber End View PosiLock End Plate Size (W 'X L x H),....,..,., ',,...34" x 75" x 12, (85crn c6x 31 cm) 12 , ® ©®� o Storage Capacity :..:77.5 gal (293 L) Oo�� ©o @ 0 O O O ® O Weight ..............:...........26 Ibs (11.8 kg) 34^ ` I Louvered Sidewail Height .........6" (15 cm) INFILTRATOR SYSTEMS. INC. STANDARD LIMITED WARRANTY INFILTRATOR SYSTEMS. INC., ("Infiltrator') STANDARD LIMITED WARRANTY FOR SEPTIC PRODUCTS (a) The structural integrity of each chamber and end plate manufactured by Infiltrator (collectivety referred to as "Units J, when Installed and operated h a Ieachfield of an onsite septic system in accordance with Infiltrator's installation instructions, is warranted to the original purchaser ("Hdderl against defac- tive materials and workmanship for one (1) year from the date upon which a septic permit is issued for the septic system crxitalning the Unite; provided, • however, that d a septic perk is not required for the septic system by applicable law, the one (1) year warranty period wFl begin upon Ute date that installation of the septic system commences. In Holder order to exercise warranty rights. Ho must natty Infllt fat in writing at its corporate headquarters in Old Saybrook. Connecticut, within fifteen (15) days of the aYeged defect. IMhtrata will supply replacement Unts for those Units tletermined by Infiltrator to be defective and covered by this Limited Warranty Infiltrator liability speclfically excludes the cost of removal for installation of the Units. SYSTE INC (b) THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT TO THE UNITS, INCLUDING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. (c) The Limited Warranty does not extend to incidental, consequential, special or Indirect damages. Infiltrator shah not be Fable for penalties a Gquidatetl Environmental OnSite Wastewater Solutions'" damages. including loss of production and profits, labor and materials, overhead costs or other losses a expenses incurred by the Holder a any third parry. Specifically excluded from Limited Warranty coverage is damage to Me Units due to ordinary wear and tear. alteration, accident, misuse, abuse or neglect of the Units; the Units being subjected to vehicle traffic a other conditions which are not permitted by the installation instructions; failure to main- 6 Business Park R • P. O. BOX 768 fain the minimum ground covers set forth in the Installation instructions; the placement of improper materials into the system comining the Units; failure of the Units a the septic system due to improper siting, Improper sizing, excessive water usage, improper grease disposal or improper operation a arty Old Saybrook, CT 06475 other event not caused by INIIVator. This Limited Warranty shall be void'" the Hilda m fails to Comply with all of the turns set forth in this Limited Warranty. Further, in no event shah Infiltrator be responsible for any loss or damage to the Holder, the Units, or any third party resulting from installation or shipment, 860 - 7000 ^ FAX 860 - 577 -7001 a from any product liability claims of Holier a any third party. For this Limited Warranty to apply, the Units must be installed in accordance with all site conditions required by state and local codes, all other applicable laws and IMltrator's installation instructions. (d) No representative of Infiltrator has the authority to change this Limited Warranty in any manner whatsoever, or to extend this Limited Warranty 1-800-221 No warranty applies to any party other than the original Holder. The above represents the standard Limited Warranty offered by Infiltrator. A limited number of states and counties have different warranty requirements. ww w. i nflit ratorsystems .com Any purchaser of Units should contact Infiltrators corporate headquarters in Old Saybrook, Connecticut prior to such purchase, to obtain a copy of the applicable warranty and should carefully read that warranty prior to the purchase of Units. Infiltrator Systems does not recommend installing onsite systems under pavement. Chambers must be installed according to manufacturers instructions. Failure to install according to manufacturer's instructions will void warranty. Infiltrator Systems recommends the use of septic tank filters and laundry filers with all onsite septic systems. System sizing is determined by government regulations. For technical assistance, installation instructions or customer service, call Infiltrator Systems at 1- 800 - 2214436. U.S. Patents: 4,759,661; 5,017,041; 5,156,488; 5.336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,588,778; 5,839,844 Canadian Patents: 1,329,959; 2,004,564 Other patents pending. tnfiftrator, Equalizer and SideWinder are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc. is a registered trademark in Mexico. Contour, MicroLeaching, PolyTuff, SnapLock, ChamberSpacer, Posil-ock, OuickCut POWTS OWNER'S MANUAL. & MANAGEMENT PLAN Page FILE INFORMATION SYSTEM SPECIFICATIONS Owner %G r e� Septic Tank Capacity ,� i O NA Permit # 3 fl 6 Septic Tank Manufacturer O NA DESIGN PARAMETERS Effluent Filter Manufacturer O NA Number of Bedrooms Y O NA Effluent. Filter Mode( ea O NA Number of Public Facility Units A Pump Tank Capacity al q NA Estimated flow (average) Q� al /da Pump Tank Manufacturer i p NA S ep Design Now (peak), (Estimated x 1.5) eo ; C © al /da Pump Manufacturer ,. / 0 NA Soil Application Rate al/do lftt Pump Model O NA standard lnfkmWEffluent Quality Monthly aversge• Pretreatment Unit q Fats, Oil & Grease (FOG) 930 mg /L 0 Sand /Gravel Filter O Peat Filter Biochemical Oxygen Demand (BOD a2Q mg /L O NA Q Mechanical Aeration O Wetland Total Suspended Solids ITSSI 5150 mg /L O D(ainfection C3 Other: Pretrested Effluent Duality Monthly average Dlepersa( Coll(s) p NT Biochemical Oxygen Demand (BOD.) 930 mg /L ?!Un- Ground (gravity) D In- Ground (pressurized) Total Suspended Solids (T5S) s30 mg/L O NA O At -Grade O Mound Fecal C 0 11fomn (geometric mean) S10` ofu /10orni O Drip O Other: Maximum Effluent Particle Size Ys in dis. O NA other: A other: O NA Other A * v @Iu" typical for dornestie wastewater and septic tank effluent. Other: MAINTENANCE 8 WpULE ffiuvitae Event Service Frequency Inspect condition of tank(s) At least once every: 3 s s (Maximum 3 years) ❑ NA Pump out contents of tank(@) When combined sludge and scum equals one -third 14) of tank volume O NA Inspect dispersal cell( At least once every 3 i atme) this) mad rt 1m 3 years) O NA Clean effluent fEter At least once every: O NA inspect pump, pump controls & alarm At least once every: rlonth(s) A �' "� O earls! Flush laterals and pressers test At least once every: --- O earls! s! NA Other: month($) At least ones every: O ar(s) NA Other: NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licensee or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Se a Swvicin Op Tank insp preg g pe ep one 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 di spersal cel(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding Of effluent on the ground surface. The ponding of effluent on the ground surface may Indicate a failing condition and requires the immediate notificat(on of the local regulatory author' 9 ry Rye When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Ssptage 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 filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of !912 months, shall be performed by a certified POWTS Maintalner. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. •apoa 6A1te1181U1WPV U191JO09 '(B) S (Z) 'I OVS Pug 19VIP)I I MM)ZZ'SS WUM 401042 4VM 9au90m ul P014011) "m Wow"aop sN41 9u04d suoud ► 1 �,� / C�??1� etueN oweN AMOH1nV Aaol.Vin03H 1V001 lumvind) tIO ONIOIAU39 JVV1.d3S 9u04d r�r- -� .G ' G euo4d _N aX? ���'� 'l�,'r7 ewg IdINIVINIVW S1MOd U311VISNI ILMOd S1N3WWO01VNOUI(MV '31slssodWl vo 11noisum 38 Am xwi V do vord31N13H.L W01l3 Nm3d V do 3 osu '11nS3a AVW H1VI0 '830NV1sWnom ANV MGM )INV1 1N3W1V3UJ. 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MAINTEN'ANCI? AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer c h �✓ ,Q� r Iftiling Address l SD � r op Lc'� -S� Property Address e o� v C (verification required from Planning Department for new O aasttvction ) City/State - ` Parcel Identification Number D20 — ��ss.� -- � ��siyR�T�Ox Property Location s' «J �,� L= ' /., Sec. ,/,.,� TN 9 W, Town ofli�s — Subdivision � �?dc� ,ut� ` �� $ 7e Lot # , �- � Pa e # Certffii ed Survey Map # _, �. Volume — . Volume `7�� , Page # e-, a ° 2 Warranty Deed # -- Spec house ;� yes 0 no Lot lines identifiable g yes 0 no �av trtwr N AWENANC .� peruse and maintenanceof your septic system could result in its premature failure to handle wanes. Proper maintenance vista of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the systeaz caw a cot fu 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 arsater plwnbc4ja eyomplumbaa testcicted plumber or a incased pumper v� tbat (1) the on -site wastewaterdisposal system is is p operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned bave read the above requirements and agree to maintain the private sewage disposal system with the standards set forth` herein, as set by the Department Commerce and the Department of Natural Resources, State of Wisconsin- Certification tic stem has been maintained must be completed and returned to the S't. Croix County Zoning OMoe within 3a statigg that your sep s ystem days of tb throe year expiration date. DATE SIG 'TUBE AF APPLICANT I (we) certify' that all statements on this form are true to the best of my (our) knowledge- I (we) am (arc) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds OtI"ice. SIC3NATLtRB OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked b the 2antag Dcpartrncnt. +" Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey tnap if referenoa is made in the warranty deed DOCUMENT NO , WARRANTY 1111 r� r �Q�1<Q A .:� y STATE OF WIEOONEIN —FORM 9 v 0 0 0 5 6 T= R AM NIMM Fog ISMIDEG DATA Tess m)ePPP[JRs,Made by Leonard J. Beer, also RLGISTERS OFFICE }mown as Leonard Be er, a si n,gl a man L ST. CROIX CO.. WIS. Recd for Record tt is_6th __ g d St . Croix county, Mwoosin, hereby conveys and warrants day of_ APT_U____ A.D.19_7 to at_ $:34 A M. and wife as Joint tenants i Vnt S EETEEE TO of St.- Croix County, Wubonsin, for the sum One nollar and other valuahle on - gidera. ion the following tract of land In S t r r n i x County, State of W The Northwest Quarter of Section Two (2), excepti g therefrom: Commencing at the Northwest corner thereof: thence South 159.6 feet: thence Easterly 40 chains to a point on the East line of said Northwest Quarter (NW, which is 121.3 feet South of the Northeast corner thereof: thence North to said Northeast corner; thence West on the North line of said Northwest Quarter (NWT) to the point of beginning: also The Southwest Quarter of the Northeast Quarter (SW k of NE4); the Southeast Quarter of the Northwest Quarter (SEA of NW'), except a parcel of land described as follows: Commencing at the Northwest corner of said Southeast Quarter of the Northwest Quarter (SE4 of NWT); thence East on the North line thereof 815 feet to the place of beginning: thence South 33 feet: thence East 100 feet: thence North 33 feet: thence West on the North line thereof for 100 feet to the place of beginning; also an easemen for roadway purposes 20 feet wide on the West side of said excepted parcel: also a right of way easement over the roadway as now traveled in a Northerly - Southerly direction over the Northeast Quarter of the Northwest Quarter (NEB of NW;',), all in Section Eleven (11); all of the above located in Township Twenty -nine (29) North, of Range Nineteen (19) West. also The Southeast Quarter of the SouthwestQuarter (SE4 of SW') of Section Thirty -five (35), Township Thirty (30) North, of Range Nineteen (19) West. Subject to easements and highways of record, and containing 275 acres, more or less. r s s PaLl L4f4 , 2AW ACM r �. ♦ , L . VVV • 1 t • * r * • Mwe " x r : i I