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HomeMy WebLinkAbout020-1456-13-000 r Wisconsin Department of Commerce Count PRIVATE SEWAGE SYSTEM St. Croix Safety and Build; g Division INSPECTION REPORT sanitary Permit No: 499219 0 (ATTACH TO PERMIT) GENERAL INFORMATION s a e P 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: Miller Homes of Hudson, LLC I Hudson, Town of 020 - 1456 -13 -000 CST BM Elev: Insp. BM Elev: BM Description. Section/Town /Range /Map No: /X.O L104 CST 14%4A / 11.29.19.2929 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic � � Z� Benchmark 3 � D3 r� � . � + Dosing Alt. BM f Aeration Bldg. Sewer 1 Holding SUHt Inlet + .ss' C11. qs TANK SETBACK INFORMATION St /Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD jDt Inlet i Septic O� 1 Dt Bottom Header Man. ' Dosing - Aeration Dist. Pipe k � {,v /7• Holding Bot. System !Final Grade PUMP /SIPHON INFORMATION 1 �(o.2ri Manufactu er Demand ISt Cover S� ��,( yC �T•6 �' W- ' fn Model Number � r/ TDH Lift Fricti oss System Head TDH Ft Forcemain Le h Dia. Dist. to Weil SOIL AB RPTION SYSTEM Z3 R NCH Width t Length No. O Tre ches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 Z +/ _ • � SETBACK SYSTEM TO l � V BLDG IWELL LAKE /STREAM LEACHING Manufactr INFORMATION CHAMBER OR Typ ystem: � / UNIT Model mbgr� 4t5;6 DISTRIBUTION SYSTEM Header/ anifold Distribution ,x Hole Size x Hole Spacing Vent to Air Intake 0 / Pipe(s) Length Dia 1 1-en h SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Deprh of xx Mulched Bed/Trench Center Bed /T r 7 � ddecl rench Edges Tep�il Yes 1 1 No Yes No. O E TS: (Inclu e c e dis repencie persons present, etc.) inspection #1:�_` Inspection #2: / V�"'� O 1 T29 11.29.19.2929 �n L atio 1048 Labarge Road Hudson, WI 54046 (NW 1/4 SE 1/4 1N ill 1 1.) Alt BM Description= 4 �- t 5T. twoe• S + 2.) Bldg sewer length = Z9 + 92sS EI .y y' 12. 02 q /1• amount of cover = > N S'" �• ' •�� 13-0 ^ 70'`lli 3) LVQ% . p ' Q � �"c�Q c� Y 9 �• s � Plan revision Re ui5�d?c$-' Y s No ll ` Use other side for additional information. /UWJ. O / Date Insepctor's Signature Cert. No. SBAti710 R+3/97) DALd Safety and Buildings Division County t 201 W. Washington Ave., P.O. Box 7162 j�. ✓G I FN Viscons i n Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266 -3151 �p2/ I Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you pro �^ A' may be used for secondary purposes Privacy Law, s I5.04(l)(m) t Address (if different than mailing ad ass) I. Application Information - Please Print All Information i t Property Owner's Name Parcel # Lot # Block # 64 10 �I ,Ma, /l, ll 6S LL OCT : l3 Property Owne Mailihg Address Property Ucation ST, CRU'lA t ry ?, �l (1f City, State Zip Code Z - 27<r,? , " Y4, 5 y4, Section Soh 5 Z (eircle ) T _ N; R� E o� U. Type of Building (check all that apply) 111 or 2 Family Dwelling - Number of Bedrooms S f �G r'4Vl Subdivision Name CSM Number ❑ Public/Commercial - Describe Use ` n r 5o ity '' t s 1 El State Owned - Describe Use c.y i.LI< 7 T. XTownship III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System y El Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New" *�_ Before Expiration Plumber Owner _ 1 4, 3 G I% s U),4kZ34Z - - N -fit IV. Type of POWTS System: Check all that apply) t!� h� rjtL.n , S Non - Pressurized In- Ground ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ' -❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dis ersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (st) Dispersal Area Proposed (so System Elevation (� t - + �T t �ro• •Z- R (.x-04 9 ©, so' VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units ncrete Constructed Glass New Existing y Tanks Tanks Q l d IL '{�� ' Septic or Holding Tank uv Aerobic Treatment Unit Dosing Chamber VI1. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number aorta t f t tq Z Z�"p -3 C,o 7 1�- 7 �D • 2� Plumber's Address (Street, City, State, Zip Code) /D A-A A t , JQ f Vs ®- 601 r 1 1 , b / VIII. Coun /De artment Use Onl Approved a�Own Pig Sanitary Permit Fee cludes Groundwater Date Issued Is ing nt Signature (No ps) Surcharge Fee) e r Given Reason for Dem IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: 1 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 the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) 4, b��co. /� d L A I z z - s--6 u ` " vla-.& co r` man Ot s,z_ �5� --s- p o D �/, G • TbT � I �� �' � � � I ; j ETA K� r FV611 / i 3 "1 1 I 6 �r 4 L fi 411 7. 3 V* \ AO 3 e � � �-/G� - TbT..I ��- , ' � 3-1 � A) L IN 7(k 6 co 171 lltill 9 q 'I 63 IV ------ V1 7. 1 2.So e A 4 - t y , �' w�,ll � �l =I� °�? s ee � � �/G� • TbT.I <� � � 'Lir N A►c 01 RECEIVED ..,,..m 1875 Wisconsin Department of Lan rce S IL EVALUATION REPORT page 1 of 4 Division of Safety and BuiJA 2 i d a"dilince �h mm 85, Wis. Adm. Code A.C.E. Sal & Site Evaluations Attach complete site e 'x,11 inch e. Plan must County C(ODC include, but not limit di hence po t M), erection and parcel I.D. percent slope, scale �Fo�v�@dd locatio and distance to nearest road_' Pendin from 020 - 101340 - 000 Please print all information. R D e Personal informetion you provide may be used for seamdary purposes (Privacy Low, s. 15.04 (1) (m)). Property Owner Property Location J Miller Homes Govt. Lot NW 1M SE 19 S 11 T 29 N R 19 W Property Owners Mailing Address Lot # Block # Subd. Name or CSM# 868 Kelly Road 13 Sunset Hills First Addition City State Zip Code Phone Number I City J Village i/ Town Nearest Road Hudson WI 54016 715 - 531 - 0714 Hudson I LeBarge Road 1J/ New Construction Use: Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD I Replacement Public or commercial - Describe: Parent material Glacial outwash Flood plain elevation, if applicable na General comments and recommendations: Recommend installing two trenches at TX 87.50' using twenty eight (28) 11" Standard Bio- Diffuser Chambers at elev. = 91.50'& 90.50' F-1 Boring # Boring ✓f Pit Ground Surface elev. 92.18 ft. Depth to limiting factor >112 in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -5 10yr3/3 none sl 2fsbk mfr as 21m 0.6 1.0 2 5 - 34 10yr5/4 none sil 2fsbk mfr cw 2fm 0.6 0.8 3 34 -58 10yr4/6 none Is 0 sg ml aw 1fm 0.7 1.6 4 58 -112 10yr6/4 none s 0 sg dl - - 0.7 1.6 H#4 contains approx. 10% gravel & Cobbles scattered throughout horizon. ❑ Boring # Boring 1/ Pit Ground Surface elev. 92.15 ft. Depth to limiting factor >118" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-6 10yr3/3 none sl 2fsbk mfr as 2fm 0.6 1.0 2 648 10yr5/4 m2d 7.5yr5/8 sil 2fsbk mfr cw 2fm 0.6 0.8 3 48 -56 10yr4/6 none Is 0 sg ml aw 1fm 0.7 1.6 4 56 -118 10yr6/4 none s 0 sg dl - - 0.7 1.6 7 T Redox. concentrations described in H ocated in lower ' of horizon at interface with coarser Is. Comm 8530(3)(a)3 applied to discount presence of red x. features. H#4 jontains approx. 10% gravel ed throughout horizon. * Effluent #1 = BOD ? 30 < 220 mg/L an TSS >30 < 1 mg/L uent #2 = BOD <30 mg/L and TSS < mg/L CST Name (Please Print) ignatur . CST Number James K. Thompson �J 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceo , WI 54020 1227/2004 715 - 248 -7767 Property Owner Miller Homes Parcel ID # Pending from 020 - 1013 -40 -000 Page 2 of 4 r 31 Boring # Boring Pit Ground Surface elev. 96.07 ft. Depth to limiting factor > 109" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -5 10yr3/3 none sl 2fsbk mfr as 2fm 0.6 1.0 2 5 - 14 10yr5/4 none SO 2fsbk mfr ew 2fm 0.6 0.8 3 14-20 10yr4/6 none Is 0 sg m1 aw 1fm 0.7 1.6 4 20 -109 10yr6/4 none s 0 sg dl - - 0.7 1.6 d- 90 -SID �o� bF • ta2 .S`� H#4 con ins approx. 10% gravel & Cobbles kaftered throughout horizon. ❑ Boring # Boring _j Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots QP : in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ❑Boring # _j Boring _j Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD / in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 • Effluent #1 = BOD 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD 30 mg/L and TSS <30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 -264 -8777. ■ Sa ;l �ylu/ua�;nn P;� " � E IG ✓a� iai+ -*El .56"l q f'imel.14e A i Su.n f' //sf�- bi¢aldti`�or, Sec. /.z, 7 of M dSm Q•�' "� /81s 9� o' Benc.� arK: To o % r bar. Assumed elegy =/oo.c» i i P / , 4 YAM, le , 8t P�eposcd Tocan rQoad trAF w ® Filters PL -525 EFFLUENT FILTER( ) Polylok, Inc is pleased to add its new commercial filter to its existing line of quality effluent filters.The PL -525 is rated for over 10,000 GPD Alarm (gallons per day) making it one of accessibility Accepts PVC the largest commercial filters in its extension handle class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL -122, the new Polylok PL -525 has an automatic shut off ball installed 525 linear feet with every filter. When the filter is of 1/16" removed for cleaning, the ball will filtration slots Rated for over 0 float up and temporarily shut off 1 0,00 G PD the system so the effluent won't leave the tank. No other filter on the market can make that claim! Accepts 4" & 6" SCHD. 40 Pipe; PL -525 Maintenance: The PL -525 Effluent Filter should operate efficiently for several years under normal conditions before J requiring cleaning. It is recom- mended that the filter be cleaned every time the tank is pumped or at least every three years. If the installed filter contains an optional t alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be Gas deflector done by a certified septic tank Automatic shut -off pumper or installer. ball when filter 1. Locate the outlet of the U.S. Patent No4 6,015,488 is removed septic tank. 5,671,640 2. Remove tank cover and pump tank if necessary. PL -525 Installation: 1. Locate the outlet of the 3. Do not use plumbing when septic tank. filter is removed. Ideal for residential and com- 2. Remove the tank cover anu 4. Pull PL -525 out of the housing. mercial waste flows up to pump tank if necessary. 5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the 4" or 6' outlet pipe. If the tank. Make sure all solids fall filter is not centered unoer the back into septic tank. access opening use a Polylok 6. Insert the filter cartridge back Extend & Lok or piece of pipe into the housing making sure to center filter. the filter is properly aligned and 4. Insert the PL -525 filter into completely inserted. its housing. 7. Replace septic tank cover. 5. Replace the septic tank cover. Quick4 STANDARD CHAMBER 52 -- Quick4 Standard Chamber — 4 8 ° - - -- - - - -- -- FFFECTIVE LENGTH) I I i _ 3 _ a - - . 34" - - - -- ... -- SIDE VIEW SECTION VIEW I I I I MultiPort End Cap j 16 I - 34 _ _ -' >II'i '✓IEV "- - TOP VIEW i FRONT VIEW ` Quick4 Standard Chamber. `Nomina['Spec fications M ultiPort End Cap Nominal Specifications 1 Size (WxLxH) x52 "x12" � ize(WxLxH) 34 "x16 "x12" Effective Length r 48" avert Height 8" or 1.25" Invert Height - 8" I I i NFILTRATOR SYSTEMS INC STANDARD LIMITED WA RRANTY ,;11 IC SCf)IG Der n, I s .,,,l Ot �I ,I Sl+rl i r r II ]I 1 a IV PFrnd II n q 1 II gI1, C'on ter r . ' • - Lh,t, � ' - l I-C WA IN iRAN� ,[ qA OF MEPCH AN F A AB I Ex LIIV 1l SYSTEMS INC � J NC I II ; I .. , �✓A .�S MER(,H F AR ()N I NI 1 i � � ., n n F. 1 rnr,I III Environmental Onsite Wastewater Solutions ' I.. f ( 5. 0 tl - I0 n i,•r n o Ie an mr n d,o fl '� BUSIneSS Park Road " P.O- BOX 7 6 till! o1,C e , 1 r. t Old Saybrook, ST 06475 r h, aL v In., JvdrnalV .,I ,II hP vo if l, Hotr r' ;, 860 577 -7000 • FAX 860- 577 -7M' 1 "'It 1 , ], I � 800 -221 -4436 ._ _ ,i r1r. -<,Ii naO C.br rvr ,,nilrl I I - - I ,1.N i.1 In "1 , ,'. ),1. .5(l.488, 5 336 7 , 5.40 1 , 1 1 6 . 5. 4M 4 59 . < 1 0 n F 1 0!!,w oalenls Pend ng IradelTa of I,II I r.i 01 ;iy ,1l.Ir o 1, r4 Ii rll ). .vs;t1'1_1 Inl. 11:0 ...v. IA -i.O. CO'r11 Contour Swivel Connection . vicrnt t ItY .r'�. .. ,• r, Y,.' i Iry +., ,) ,• - aECrCLEpcea=A ' ��^ ' I r-arv.; of Infillratr Sc 'ems Inc. � 2003 InIiIlraUx Svs , °, r� Int i'�r- r POWTS OWNER'S MANUAL & MANAGEMENT PLAN �LE I NFORMATION So Owno( Page SYSTEM SPECIFICATIONS 1 �'erm :i x Septic Tank Capacity DESIGN PARAMETERS Septic Tank Manufacturer -- Numoer f 3 .� o Bedrooms Effluent Filter Manufacturer l- f Numoer f ❑ NA /�- o Public Facility Units Effluent Filter Model Estimated flow (average) NA Pump Tank Capacity �- a r,, Design flow (Peak), (Estimated x 4 00 alFda Pump Tank Manufacturer a. Soil Application Rate b al /da Pump Manufacturer Standard Influen o. 7 t /Effluent Quality al /da /ft Pump Model Fats, Oil &Grease (FOG) M onthly average • Pretreatment Unit ' l _. Biochemical Ox S30 mg /L Ygen Demand (SOD ❑ Sand /Gravel Filter Total Suspended Solids (TSS) 5150 mg /L ❑ NA C3 ❑Peat Filter Mechanical Aeration ❑Wetland i"re!reatee Effluent Quality mg /L ❑ Disinfection Biochemical Oxy gen average ❑ Other: Ygen Demand (BOD 530 mg /L Dispersal Cell(s) Total Suspended Solids (TSS) 530 M In Ground (gravity) ❑ I ' g/L n- Ground (pressurr_ec Fecal Coliform (geometric mean ❑ NA 13 At•Grade I S10' cfu /100m1 ❑Mound F'Aa,,,mum Effluent Particle Size ❑ Drip -Line Y in dia. Other. viper ❑ NA Other: _ ❑ NA Other: as t Yp 1 c 81 for domestic w a stewater astewater and septic tank effluent. f.'AINTENANCE SCHEDULE Other: Service Event _ nspect condition of lank(s) Service Frequency At least once every: O months) rump out contents of tank(s) ear(s) (Maximum 3 years) When combined sludge and scum equals one -third sped dispersal cells) IY,I of tank volume At least once every '� ❑ month(s) _ Clean effluent filter - 9 -- y ear(5) (Maximum 3 At least once every; _ Z ❑ month(s) years) . Inspect pump, pump controls & alarm .2 ear(s) _ At least once every: ❑ month(s) m ' sn 'laterals and pressure test ❑ year(s) _ of e At least once every- ❑ month(s) _ ❑ year(s) rj At least once every: ❑ month(s) ❑ year(s) r . MAINTENANCE INSTRUCTIONS _ inspections of tanks and dispersal cells shall be ` Master Plumber; Master Plumber Restricted ewer; POWTS Inspector; POWTS Maintainer; Septage Servicin made by an individual carrying one of the following licenses or easctions must include a visual inspection of the tank(s) to identify any missing or broken g Operator measure the volume of combined sludge and scum and to check for any back u The dispersal cells) shall b hardware, identify any cracks cr _ �( ei erfiuen[ on the ground surface, y ins of effluent on the ground surface observation p anon Pipes effluent on the ground pc -":: e visually check the effluent levels in the observation pipes and to check for an Of efflu to notification of the local regulatory authority, Y Pe, y, = may Indicate a failing condition and requires u when the combined a ccu contents of the tank halllbe removed by and ig a Se tacum in an Wisconsin Administrative Code, Y tank equals one-third (y or more of the tank volume, the ent P ge Servicing Operator and dispo$ed of in accordance with chapter NP All other services, including but not limited to the servicin units, and any servicing at intervals of S12 months, shall b g e of effluent filters, mechanical or pressurized component A service report shall be provided Performed by a certified P s, P Ided to the local regulatory authority POWTS Maintainer, ority within 10 days of completlon of any service event. OF AND OPERATION Page ? of For new, construction, 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 tank(s) removed by a septage servicing operator prior to use. Svstem 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 cischarged to the dispersal cell(s) in one large dose, overloading the c�ell(sf 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 N thin 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; oii painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT Chen 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 a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance 'and compaction and should not be infringed upon by required setbacks from existing and proposed stt'ucture, lot lirres and wells. Failure to protect the replacement area wiii 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, T alua b e ale r- ,044181Te� �� N/�1✓ CaNST1zc1 Dank ❑ 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 INSUFFICIENT 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 DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name j lle- E t ,0elt) l — Name Phone I �t 7 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name S • ' Name ( Phone Phone This document was drafted in compliance with Chapter Comm 83.22(2)(b)(1)(d) &(f) and 83,54(1), (2) & (3), Wisconsin Administrative ode. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 5 ; Mailing Address ( (, /} �CL� c �l g O / Property Address © (Verification required from Planning & Zoning Department for new construction.) City /State JL /' Parcel Identification Number A ?fo • 1 0r S4 LEGAL DESCRIPTION Property Locatio> '/4 F '/a , Se c. ( , T 2 ( N R Town of Subdivision S. , Lot # Certified Survey Map # 7? S / S , Volume / a , Page # ,-S Warranty Deed # ?y Zo '5;ra , Volume 27 , Page # 5' 17 Spec houst yes no Lot lines identifiab ye no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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 alreatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification 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 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 Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms /) / Za / ono ( N�� IG ATURE OF APPLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) 78 m4� �\ KATHLEEN H. WALSH ST. CROIX , WI RECEIVED FOR RECORD STATE BAR OF WISCONSIN FORM 1 - 2000 12 / 0 9/2004 09:05AH WARRANTY DEED WARRANTY DEED Document Number be EXEMPT ti This Deed, made between Celeste M. Bennett and s lCie REC FEE; 11.00 t�i Jool n 08ha TRANS FEE; 1974,00 Grantors, and Miller Homes of Hudson, LLC, Grantee. is COPY FEE.- Grantors, for a valuable consideration, convey to Grantee the following PAGES. 1 described real estate in St. Croix County, State of Wisconsin (the "Property ") (,if more space is needed, please attach addendum): Part of the NW% of SE' /. and the NE' /. of SW'/. of Section 11, Township 29 North, Range 19 West, St. Croix County, Wisconsin described as follows: Beginning at the NE corner of the NW' /. of SE' /a of said Section 1 I; thence West 2640 feet to a steel stake; thence South 613 feet to a steel stake; thence East 1320 feet to a steel stake; thence North 288 feet to a steel stake; thence East 835 feet to a steel stake; thence South 75 feet to a steel stake; thence East 485 feet to the center of Tanney Road; thence North to the point of beginning. j Recording Area ALSO All that part of the NE'/. of SE' /. and the NW %. of SE'/. of Section 11, Name and Return Address Township 29 North, Range 19 West, Town of Hudson, St. Croix County, Sam E. Miller Homes Wisconsin lying Wly of the following described line: Commencing at the E'IA P.O. Box 151 corner of said Section 11; thence S89 ° 30'00 "W along the North line of said SE' /., Hudson, WI 54016 1296.55 feet to the point of beginning; thence S07 ° 49'36 "W 296.01 feet; thence S00° 1 1'33 "E 107.11 feet and there terminating. 020 - 1012 -00 -000 Together with all appurtenant rights, title and interests. 020- 1013 -40 -000 Parcel Identification Number (PIN) Grantors warrant that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except: None. Mail tax bills to: Sam E. Miller Homes P.O. Box l9-r 1S'/ Hudson, WI 54016 Dated this day of December, 2004. Benne ei AUTHENTICATION r ACKNOWLEDGMENT STATE OF , J`Eit/ /.SC GPI -N 1) Signature(s) authenticated this day of ss. ST C',�� COUNTY j i TITLE: MEMBER STATE BAR OF WISCONSIN Personally came before me this 1 day of December, (If not, authorized by §706.06, Wis. Stats.4 2004, the a named Celeste M. Bennett and Keith D. Johnson to THIS INSTRUMENT WAS DRAFTED BY� a Y"`ptl��4�j� a the person e ho exec d the foregoing instrument apt Kevin K. Shoeberg, Esq. � ���� I- L �- KEVIN K. SHOEBERG, P.A. �TgMgRq i 1805 Woodlane Drive a N K• 1 tary Public, State of 42,'sC u,-7 S i l Woodbury, MN 55125 HERBST /j 2 y co mission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both NrfFessary.) ,J Gj •7 ) -Names of persons signing in any capacity should 15P, 4, ` r yst�" a C below their signature. WARRANTY DEED STATE BAR OF WISCONSIN FORM No. I — 2000 (R = N89°52'23'E ) S89 0 43'05 "E 26 37.46' X X x X X 344.58' 417.34' OT 13 LOT 14 $ 2.00 Acres 2.00 Acres 87,223 sq. fl w b Z � L ...... ............ foci' O Sk -- -- �� — - - -- -- -- -- 127.13' -- --- ^ q, 19 641.24' N89 °44'56W 803.71' — — - - -_ N 499.3T CO 99.30' 332.33' 1 Lo 471.55' � ° 191.55' - - -- -- - -- - -- 166.86 62. 48' \ N89 831.70' ....................... Cm 3\ .OT 20 - - - -- 2.00 ACRES 0 17,318 SO. FT. V 1 � N ' III