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HomeMy WebLinkAbout020-1411-09-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION w ~ (ATTACH TO 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 Ho ,Sean Hudson Townshi CST BM Elev: Insp. BM Elev: ption: BM Descri 0 0 . U U /'~ ca .~ L I~ G r v r~ GU -~ N~~1~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ .~e ~t.K.~ / U 00 Dosing L~~S Q,oc.~ Aeration ~~` __ _.., Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~V ~ ~~ .~ ~ ~V / ' j J / Aeration Holding PUMP/SIPHON INFORMATION Manufa urer Dema GPM Model Numbe TDH Lift ctio s System Head TD Ft Forcemai Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM County. ---- -~ St. Croix Sanitary Permit No 430353 0 State Plan ID No: Parcel Tax No: 020-1411-09-000 Section/Town/Range/Map No 13.29.19.2579 ELEVATION DATA STATION BS HI FS ELEV. Benchmark _s .3~ /v 5.3 you . ~~~ Alt. BM ~ -Q~ / V ~ -3 Bldg. Sewer 3 ~ ~S /0/ G~ St/Ht Inlet 5 _v Ivo•z3 SUHt Outlet g~.~ Dt-I t~+e t Z e 5. ~.3 q ~j . (07 gg ~~ ~~ StT~Z.- Gw ~ ~~++ rj.~ l A 7~-(,~( Header/Man. Dist. Pipe S "7.7Y, -,. 7.'~~ 9~.s Bot. System rSJ $ S 9G .~' Final Grade S: ~ loa.3 St Cover BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ ~1' , ~ Z ~ -~- SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manu turer: _ I ~ INFORMATION CHAMBER OR ~ ~~ LO ~ 3~e~ Type Of System: ~/1/ L~ N 1.~ v1<~ ~~ C~b.O~` f ~ ~ S~ ~ ~V NO ~ NIT I Model Number: DISTRIBUTION SYSTEM ` ~ L c~e.~n'~c~tY ; n Ti'"` Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake ~ Pi e s w.._.__..,..__,_._.. ~ p O ~'~~__, _ __ __ - _...__~-~ "" -"~ 1~~ 1 JV Length Dia Length is SpacRrg SOIL COVER x Pressure Systems Oniv xx Mound Or At-Grade Systems Onlv Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched BedlTrench Center ,Y V ~ Bed/Trench Edges Topsoil ---~.. ~ Yes [~ No ~Ji Yes _ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~ / Z /~ Inspection #2: / /~ Location: 810 Hillside Trail Hudson, WI 54016 (NW 1/4 SW 1/4 13 T29N R19W) Alexander Meadows Lot19 Parcel No: 13.29.19.2579 1 J Alt BM Description = "~~a Pjp{ ~f S j p~(~j..~~ ~G 1J~ SeISU +r..y p~,..~ ~-l. l 5 2.) Bldg sewer length = Z~ u .~~ ~j~ a., L - amount of cover = _~ ~ o7'r i,,,, ~, l( ~ o nSM-t !r{ ~ "`'"'` 6 iw __ -_ -- __ -- ~ 23 0 Use otherls de for additional inform on, No ` ~_ i ~/I ~ !% ~,_ f -/ Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) '~ A D~-~~... G~j `~/vc~ '7~a.,s 7~ Z~ U.sc.a.. ~p ~.~.,,~ ,po c IC -c~~ 5 S p G `--~(~ Jam'' p ~'.ar~- L~ cv..~ --.~ c v~ So v..`~~ .. ~ v.~- ~--~ hoLL>r2.~?IQ~Y' ~ Cbrt,~ : r ~,.~ , n ~ ~ONr~' /J l~Y ~~e .,e lev cam- ~ OAS t~r~ w-e.~ a~/e ~~ ~~e-r'r-n ; N e ~„~. ~~S~e-~_ ; 'S ~.e ~vw ~e /U I .`7 ~vn~o~.r ~/~oWn/ pn Safety and Buildings Division County ~ ,~ 201 W. Washington Ave., P.O. Box 7162 v isconsin ~ . Madison, WI 53707 - 7162 Sanitary Pt Nttmbe (to be filled in by CoJ De artment of Commerce (~$) 266-3151 3 Sanitary Permit Application s~ce ~ LD. Number In accord with Comm 83.21, Wis. Adm. Code, personal norm y may be used for secondary purposes Privacy La , s15.( (1rr)C ® Project Address (if different than mailing address) I. Application Information -Please Priut Ail It>formutiou S EP 0 S 2003 g O O E j P~ Property Owner's Na me Parcel Ar Lot X Block X ST. CROIX COUNTY Z ONING OFFICE _ (~oZ ~ - ^ d Property Uwner's M a" g Address Property Location ~!4 S ti ~ u S Ci S , ec on /,~ , , ( ty, tate Zip Code Phone Number i `~-~ (circle ) ~ ~ ~ I I T f B ildi h T ,~ N; R E or . ype o u ng (c eck all that apply) ~ , C / lJ~ 1 or 2 Family Dwelling -Number of Bedrooms ~' / Subdivision Name GSM--Nttmber ^ Public/Commercial -Describe Use s ^ State Owned -Describe Use " ` - '^City_^ViUa a Township of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' ~ New System ^ Replacement System ^'Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System B. l l Pcnnit Renewal ~") Pcnnit Revision ^ Change of C) Pcnnit Transfer to New List Previous Permlt Number atxi Date issue[i I3clurc lsxpiruiun Plwntxr Owner I V. T e of POWTS S stem: (Check all that a 1 ) vt f a) Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil (_I Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculadng 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 (sf) Dispersal Area Proposed (sf) ystem Elevation ~- ~5 ~ d 7 VI. Tank Info Capacity in .Total Number ~ Manufacturer Prefab Slte Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank _. ~L' ~~/ T Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assun[e responsibility for Installation of the POWTS shown on the attached lens. Plumber's me (Print) Plumber' Sl nature ~ MP/MPRS Number Swinew Phone Number Plumber's Addre ss (Street, City, State, Zip Code) ~ ~r> _ ~ -S ~ i VIII, Count /De artment Use Onl `Approved _ ^ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Surch F ) Iss ' ,gent Signature (N tamps) t ( ^ Owner Given Reason for Denial arge ee Z~'~' 1X. Conditions of Approval/Reasons for Disapproval (~, SYSTEM OWNER: 3J N 't'`~w~ •.r' l ~~ ~ 1 Septic tank, effluent filter and J ~ ~ ~ dispersal cell must all be serviced / maintained ~ "~ as per management plan provided by plumber. t~ tom. ~ 2. All setback requirements must be maintained as per applicable code/ordinances. SBD-6398 (R. O1/03) +.w~u wwy,e,e p,aos lw me t,0un[y ONyJ Ior lne 6y8teO1 OD papor not te46 than til/Z x 11 inehp to ttxf --- - _- - / ~~-- ~/~ ' i K i ~ - ~ ~ d n J~ ~'' i i i ~ ~ ///~ ' - ~ }_- // / .. __ ~ 1 +- _ .. l , i ~ W I ' a-._-_ ~K Inc r ~ % '~ ,.% '~ ~- ~-~ +--- r~" ~, _~_ -~- -t -~- - :---- --- } --~-- -+---- .- t 3, t-- ;~ ~ i I t + r - r -- ~ ~ ~__ t-_++-- rt- -~---}---_-- - ..~x - -+ ~~' ~~ f ~~ ~ ~ - 1 +- 7 L ~7",/~ i t ~ y.__ ~-_ - +- + _ - ~ ~ .- - .- ' j~ tr. /' ~.~~-~J~--~, ~~r-+511.-~r-.EG~s~-r----~- }-~ -r- •-.__..~----~--*-- '----r-- -~-- ---t----~- r-----~ - ~- J ,/ -----+ r t r +--- ~*- - -!- +---r r- ~- t- ~-- r- --+ --r----- - ~-_-- r- ---r--t-- ///~~~ /{ ~- ~ ~-- ~ ~ ~~ - '. ~. i i' ~--~- ~ I ~~ ~ i ~ i ,~///~ X ---~-- ~ \ -- i ~. I 1- ~ ~ ~ i ~ ~ ~ ~ ~ ~ i ~. .__- ~ ~ r- ~-_~- r + - -, ~o~ ~~~ ~~.t, °~f' ~cf ~~v~S ~.9~s'.CL~-~ , /~it~ ~S'~,b2~ 7~~~/~..~~1 F / ~J oD ~T'~ .S1.Edd( ,0~/[ - ~ f"3~•E~ /".C~~ ;, Y~` a ~'' ,~y'iiA- ii ;~ 2 ~~ ~~~ ~~ Z~~ -7 33' / ~~-~ y / ~ i / \ %~ 3 ~~ ~ ~ ~ goy ~~. ~ 5 ~~, ~~ , -~ ,/ ~ wind ~ 6~ ~~n ~ C ~I -~ ~ A-. \ % ~ (Q ~ Co ~~ ~ ~.. /~a ~` ti ~\ ~~. L .~ ~\ \ ~ SQ _ _ ~\ ., ~ v~ \ .. L~.P.J~hLAc{ ~.Fi°t IC ~i1r~5' ~L~G^~ fA'/- t)~ly~.~ lt,~tG+C~S\ ~~ //'' J 1°Ra~resca H;'K~~ ~ ,~ ~, /~ ~~~ ~~ 1047 Wisconsin Department of Commerce ~ SOIL EVALUATION REPORT page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Steel Sal Service County Attach complete site plan on paper not less than 8%: x 11 inches in s¢e. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and r L percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. Q jQ -/I r I - D 9.-OO~ pending Please print al onnation. R By Date Personal information you provide may be used r secor~p ,~ ~W~iira~ fir, s. 15.0 (1) (m)). 3 Z~ O Property Owner Pr rty Location LaCasse Development , Inc. ~ ~ G Go _ Lot NW 1 /4 SW 1 /4 S 13 T 29 N R 19 W Property Owner's Mailing Address ~ 4 2002 L # Black # Subd. Name or CSM# 573 Cty Rd "A" sT. CROIx CouNrY 9 na Alexander Meadows City State Zi a ~~iri~~~gCE City Village ~;` Town Nearest Road Hudson WI 54016 715-381-54 Alexander Rd. /~ New Construction Use: VResidential /Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement Public or commercial -Describe: Parent material Glacial Drift Flood plain elevation, if applicable na General comments and reco mmendat ions: system elevation 98.20 ft, trenches spaced a nd depth to code 3.50 ft below g rade `~ t /F ~ `T'~ ~ "~" ~ ~ry / ' ' 1/~M` 'Gf~ ~ A / / GcJ ~ 72 d ~ 1 li tZwt Rdtl~ Boring ~oQYitit i ~ Boring # M Pit Ground Surface elev. 101.70 ft. Depth to limiting factor 96 in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft= *Eff#1 'Eff#2 1 0-6 10yt'3/2 none sil 2msbk mfr cs 1 f .5 .8 2 6-15 10yr4/4 none sicl 2msbk mfr gw 1vf .4 .6 3 2-51 7 5 r4/4 none ~ls 2msbk mfr w na 9 ~ . y s g . 4 51-96 7.5yr4/6 none ms osg ml na na .7 1.2 ~ ~ 2 ~, 7~ „ ~, °~(o , ~, z (pb ~/~ ~ N ~orizon # 3 has strat~ed layers Boring # Boring /, Pit Ground Surtace elev. 101.70 ft. Depth to limiting factor 96 in. Sod Applicaton Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bourxtary Roots GPD/ftz 'Eff#1 'Eff#2 1 0-9 10yr3/2 none sil 2msbk mfr cs 1f .5 .8 2 9-27 7.5yr4/4 none Is osg mvfr gw 1 of .7 12 3 27-45 7.5yr4/4 none sl 2msbk mfr cs na ~ .9 4 45-96 7.5yr4/6 none ms osg ml na na .7 1.2 ~fZ`~ 7g ~~ lae ~~~ ~ fob `` ~~ N - trrwem ~~ = rsuu ~ su < l~u mgiL and l SS >:it) < ~ bU mglL * Effluent #2 = BODS <30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature: CST Number David J. Steel ~ ~ - 248956 Address Steel Soil Service Date Evaluation Conducted Telephone Number 1564 CR GG, New Richmond, WI 54017 8/1/2002 175-246-5085 Q ~,j-!~' alr-~ Property Owner LaCasse Development , Inc. Parcel ID # Pending Page 2 of 3 Boring # Boring /; Pit Ground Surtace elev. 09.50 ft. Depth to limiting factor 96 in. Soil Appl~ation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP 1 0-6 10yr3/2 2 6-15 10yr4/4 3 12-51 10yr4/6 4 51-96 7.5yr4/4 'Eff#1 *Eff#2 none sil 2msbk mfr cs 1 f .5 .8 none sicl 2msbk mfr cs na .4 .6 none scl 2msbk mft cs na .4 .6 none syls 2msbk mfr na na .5 .9 horizon # 4 has stratified layers Boring # ~ Boring /; Pit Ground Surtace elev. 00.80 ft. Depth to limting factor 96 in. ~ Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlftZ 'Eff#1 *Eff#2 1 0-10 10yr3/2 none sil 2msbk mfr cs 1f .5 .8 2 10-30 10yr4/4 none scl 2msbk mfr gw na .4 .6 3 30-60 7.5yr4/4 none sUls 2msbk mfr gw na .5 .9 4 60-96 7.5yr4/6 none ms osg ml na na .7 12 horizon # 3 has strat~ed layers * Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS <30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. ff you need assistance to access services or Borina # __ Boring _ _ _ Page 3 of 3 STEEL'S SOIL SERVICE David J. Steel 1564 Cty Rd GG CST-POWTSM LaCasse Dev., Inc. New Riclunond, WI 54017 L1C. # 248956 NWl/4,SW1/4,S13,T29,RI9W (715) 246-6200 Town of Hudson, St. Croix Co. (715) 246=5085 Alexander Meadows, Lot 9 This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of the test may or may not be as shown as permanent lot lines were not established at the time the test was conducted. ~~o~ ~- ~~~~~~~~ ~,~ ~~ W c5~-- h ~ nQ. X33 e~ £~ ti~.~9 2 ~~, ~ p0 ~Zo'rd- ~..~ y~~~ ~,,:~o, .q s l~enc~j/h6t~ l~ ~'.L. /Ga.~~- ~ L.10!•10 r~~i~~s~-~a~~, p~ T~ o-F' I~.L~' ~Vc Pi;aG. ~~ ~$orir~S X30 ('~_n c, l~~l[~E ~~ oh S' ~! ~ /0/•70~F~' /3~ % / o1.70r~ ~33~ ~s~i,-so ~r /3s~: g y, ga~~ 8- l-~ Z ~ i~~ C c. ZU 5~ N ~G ,2 ~. r . l ~r _. ~, fir 5/o~e ~` ~~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN. Page ~ of ~ FILE INFORMATION Owner 5-' Permit # p DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ~'NA Estimated flow laverage- al/da Design flow (peak(, (Estimated x 1.5) .~ al/da Soil Application Rate al/da /ft~ Standard Influent/Effluent Quality Monthly average' Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BOD51 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODE) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) 5104 cfu/100m1 Maximum Effluent Particle Size Ye in die. ^ NA Other: ^ NA "Values typioal for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity ~ el ~NA Septic Tank Manufacturer S- ^ NA Effluent Filter Manufacturer ~`~ ^ NA Effluent Filter Model O NA Pump Tank Capacity al f~'NA Pump Tank Manufacturer .~ NA Pump Manufacturer ,~ NA Pump Model 1$'NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Fiter ^ Wetland ^ Other: ®NA Dispersal Cell(s) ~ In-Ground (gravity) ^ At-Grade ^ Drip-Line O NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other. ^ NA Other: p NA Service Event Service Frequency Inspect condition of tank(s) At least once every: ^ month(s) (Maximum 3 years) ear sl ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third IY,1 of tank volume O NA Inspect dispersal cell(s) At least once every: `' ^ month(s) ` (Maximum 3 years) ..5 ~ earls( ^ NA Clean effluent filter At least once every: ^ month(s). ,~ earls) ^ NA Inspect pump, pump controls & alarm At least once every: ^ month(s) ^ earls) .i~NA Flush laterals and pressure test At least once every: ^ month(s) ~ ^ year(s) ~ NA Other: At least once every: ^ month(s) ^ earls) -= ,~ NA Other: .. ^ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certification:,: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Suvioing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or pending of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any pending of effluent on the ground surface. The pending of effluent on the ground surface may indicate s 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 IY,1 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 witft chapter NR 113, Wisoonsln Adminlstrative 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 S12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. aMw (arot- Pepe ,~ of ~, START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal celllsl. If high concentrations ars detected have the contents of the tanklsl 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 celllsl in one large dose, overloading the celllsl 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 pries 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. Oo 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 Coda: • 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 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. l7 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 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 INSTALLE ~ Name ~ ~ ; Phone POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name Phone / ~- ~ This document was drafted in compliance with chapter Comm 83.221211b11111d1&(f) and 83.64111, l21 & (31, Wiaooraln Adminfstntlve Code. (a7%3012005 11:16 FAX 1 715 2~7 3098 BELISLE EXCAVATING S'X' CROIX Ca'UN'CY SEPTIC 'TANK MAINTENANCE AGREEMENT AND aWNIaRSIi)F CERTIFICATION FOi'tM OwnertBuy~r Mt:ilinl; Addr~Ss Prt?prrty Address ~ ~ lCdl~ ~~_~~-._.___r.~-_ `7 ~ 1 ~ 2, ~ ~'' S~_- ~ ~~ 1 ls~~ Try ~ / ('v'erifice[ion regwred from Plt+nrzing Department for ~ 005 ~ 5~~~ ~ consnvction) CicyJState Ty~i~ ~ i Parcel Identification Number _ -- --- 1 ` ~~_ 'f,, Sec, „~,r, T~N'-R~.,...W, 'I'oWtt of .~~~--+^' i~rClFJerty LC74CISG17 , f~, _.,,,,_..., Lot # ,.. ~~.. Certified Surrey Map # _ ,Volume 23 9 Pa tr # ~ I g~ ~~~~rdtt~ ~~~~;~ ~ ~..~.._ ~38~ , vt,rttme g Spec house G yc3~ no Lot lines identifiable yes ©na SYSTIaM !'r1.~INTLN.4.1!~CI~ lmrropc: use cell rnaintananceof your septic system could result in its prernatatrc failuro to hondlC wastes, Proper rnaiatanance consists a: pumpinl; ous the septic rtt~k every thrca years or sooner, if needed by o licanacd pumper. Wttst you put iato tha system can affect the function of the septic tank ;ts a trcartYrtent stago in the waste dispasai system. 'i:`he prop~rt;y owner egrets co submit to St. Croix Zoning Depsrtme>*t a cerii~eation fvsm, eigpod by the owner and by a master pl umbe r, ; o ~~:rnc yrnan pl umber, restricted plumber or a licensed pumper vedl}ting that (L) the on-site wastEwater disposal systtru is in proper opernt,nE; CunditiUat a,tdlot (Z) after inspectiars Brad pumping (if necessary), the septic tsttk is less thaa 1/3 Aa11 of sludge. U~ve, the utrdersigned nave read the abavc requirCments anti agree to maintain tlt4 private sewage disposal system with the standards sat forth, hereua, as set by the Dcpartrc;tsnt of ~ummcrce and the AepatOaertt of NAttual Resources, State ae Wisconsin. Carti,ficatioa stating Char }'our scptir system has bzon maintained tztiust be completed and returned to the St. Croix Coanty Zoning Office vt~tthtn ~~ days of three year cxpiratioaa date, $:GtdATUR~ Ai'1'LICANT y DACE t~1'VNER CEI2Tl;'Fr~'ATIUN' ~,„ are the owner(s) of i (,ve; cea^:i~~ that ail staterncnts a,z this form at-c true to tht bast of mY (our) knowlodgC. Y (we} ( ) the prop ~ ~cst:ri~ed s vC, l7y via'Etis oC a warranty deed recorded is Register of Dods Off1CC, /~ Z~ SIGNAT'LJRE CF A l'1' icAPdT ~~ DAZ'>w ~:ny i„fonna,;on that is arils-rcprrsattted may result in the sanitary permit being revakt:d by the Zoning Deparrtmcnt, ""'*` *+~.::,. "~` rncluda with this appiieatian; a stam;aed warranty deed from the Register of Deeds office a copy of tho cottifiad survey map if roference is made in the waattnty deed U 2399P 187 I STATE BAIL OF~VISCONSIN FORM 1 - 1999 Document Number WARRANTY DEED This Deed, made between LaCasse Development. Inc.. Grantor, and Sean A. Hoaa and Nicole L. Hour. husband and wife Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin erty") (if more space is needed, please attach addendum): Lot 9, P t of Alexander Meadows in the Town of Hudson, St. Croix Wisconsin. X387 1 4 KATHLEEN H. NALSH REGISTER OF DEEDS ST. CROIX CO.. MI RECEIVED FOR RECORD 09/04/2003 09:45Ati MARRAHTY DEED EXEMPT iR REC FEE : 11.00 TRANS FEE: 221.70 COPY FEE: CC FEE: PAGES: 1 Recording Area Name~an~d R1e~turn A/d/d`ress~f ~~~ ~d 1~6~~ / ~Qsr~ ~ Lv~'" S~Ul,6 Together with all appurtenant rights, title and interests. 020-1017-50. 020-1017-70, 020-101&20 Parcel Identification Number (PIN) This is not homestead property (is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and rights-of--way of record, if any. Dated this ~ ~ day of Aut>_ust , 2003 * * ---- AUTHENTICATION Signature(s) authenticated this day of * I,aCasse Development, Inc., by: ACIINOWLEDGMENT STATE OF ~~/f1~~ ) ss. County ) Personally came before me this Z~?'~y of August , 20003 the above named s ;::ii1 ,,` '~ _ _ TITLE: MEMBER STATE BAR OF WISCONSIN ~~ ;``. b , ~- . ~~~~ (:U. ~G 4sS 2 Its r ~ S , (If not, _ ~ .r> i~ e~known be the person(s) who executed the foregoing authorized by § 706.06, Wis. Stats.) ~` -' i:.'~~ inst~rt~ment a~Id ~knowledged the same. ~"~' ~_ THIS INSTRUMENT WAS DRAFTED BY ~'^ ..~ ., ~ ' ~ _ r _ Attorney Krishna Ogland ,,, ~« ~~+,~'. Hudson, WI 54016 ,,`~Pc ~Notaixt~tb~lj~, State of [1.~75~'On S i %i;~r~ tt~yt~gfghltsston is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) 3 Jl 3~~(1[]G~ ii * Names of persons signing in any capacity must be typed or printed below their signature. Information Professionals Co., Fond du Lac, wI STATE BAR OF WISCONSIN 800-655-2021 WARRANTY DEED FORM No. 1 -1999 '"""`~ '°~°~ oou~,Yw-*~,-AL'.@XANDER MEADOWS WI IAIO 41,[IK J CM1. riN •.• ArbNbiNON 1q~rwr 1O0A7~MIMfO~l1~NYYfN Yl11~iWIK I111R O/llli l~lN O~TIi iWIKrNY MIRp MNw~N OEM M1N d MC~IOM ~i.liiN. MiW.70WM O! MpiON, R.OIIOR 001111Y. Mii00~M11L OOIIrRO'ODAOIINi YpFA~~ ~er~Tl L(~~ •rrW1011 ~V~ ~I.rtrr uOl rrA ~.~~ -wwv- :r..rr ~~'"a.~.r"':~~r..n tls7~. rwriwiima- m`wui i ucvs °am.e~ir r"OC, omw~ _ r r~o rws ~w•~.s `<.uo .a ono r_r I i •••••'n• ~T- ~ ~r . ,, ~ ~~ i W ~~ , ` ............................ n ~ .r ,~ r,..~rr.r~r r ...rro..r r~ .. ~rrmr »~r.rr rr r..r. r ~. ~ - ~~G y ~ ~.'~' .... ............ nm.......o F.6. ia. o..: ~ .yl ~~ iR.•~'~ aowrawMarN~iow~no+aaroao~o ~ '~. 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