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HomeMy WebLinkAbout020-1452-03-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (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 LaCasse Develo ment Hudson Townshi CST BM Elev: ~ Insp. BM Elev: ' BM Description: ~ ~ 0~ . D 40 . c7 gr~,t ~ aF P~ = e S TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~ S d"0`~7 Dosing Aeration Holding i TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~ S , ~ ~ ~~ Dosing Aeration Holding PU~IPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss em Head H Ft Forcemain Length ia. Dist. to Well SOIL ABSORPT-I"6N SYS ~- ~~,Q~ ELEVATION DATA county: St. Croix Sanitary Permit No: 463180 0 State Plan IDID N-~ Parcel Tax No: Section/Town/Range/Map No: 13.29.19. STATION BS HI FS ELEV. Benchmark Alt. BM ~ok-~- r ~ ,D~ ~~• l2 ~ Sldg. Sewer $o ~ 9.3 r q~F pro SUHtlnlet 'D,~ 2•~i J St/Ht Outlet o,gS q3.~- Dt Inlet Dt Bottom Header/Man. ~- Dist. Pipe I I, (p i ~ 3.oL Bot. System IZ , t ~' Z.ZS'' ~j_ I q~•d'~ Final Grade ~ilD .©Z ~ St Cover /TRENCH DIMENSIONS idth I ~ Length / p~ ~• 8 No. Of Trenches ~2 PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING M ct er:t ' ' INFORMATION CHAMBER OR t~'~o{ Type Of System: , Q t 1 UNIT Mo umbe by . zQ + ~ C.~ ~ ` DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole S Vent to Air Intake ~^^ Pipe(s) Length Dia Length Dia cing ~--~' ...- 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 j No COMMENTS: (Inclu cod di re encies, persons present, etc.) Inspection #1:~. dZ/. /~S Location: 803 McCutcheon Road Hudson, WI 54016 (SW 1/4 NW 1/4 13 T29N R19W) Blu~-ebir~ndl Bluffs/ILot 3 ~w~ 8~~•~ S~ ""~ I6tJ.R.~ ~ -•-" Spam ~C y .K~a4Q. . 1.) Alt BM Description = TU 2.) Bldg sewer length = .- 5-l0 ~ -..amo--u,^,nnnt of cover = ~ S": o Plan revision Required? es [~ No r r ,~ ~ ~ ~ Use other side for addition tnfor `7 . ___ I _____._I SBD-6710 (R.3/97) ~l '` /J Date ti~ ~ +" Inspection #2: "Y--~-f-~ Parcel No: 13.29.19. -- - -- - _- - -- , - -r- i I Insepctor's Signature Cert. No. Safety and Buildings Division County ~ ~ 201 W. Washington Ave., P.O. Box 7162 ~~~ ' 1SC0~~,~ Madison, WI 53707 - 7162 Sanitary Permit Number (to be Bled in by Co.) De artment of Com a (608) 266-3151 2 / San' rmit Application state Plan LD. Nt~tnber / ,l/ In accord with Comm 8 1, t Ac}tjt. Code, per y4ia / may be used fors d riva Law 1 ~ Project Address (if di Brent than mailin addre s) , g s I. Application Information - Please P ' ati * L004 ~ ~ u ~; f Prope Ow ner's Name Parcel # Lot Block # 7 Y CROIXC~~ ST 3 CE . / ~ d~ Property Owner's Mailing Address operty Location City S e Zi C d Ph N b , p o e one um er r ~- trcle ) T ~ N R~E ~ II. Type of Building (check all that apply) ~~/ ; o / Q ~I or 2 Family Dwelling - Numberof Bedrooms ~ L~Gt~p'~,Z~l,Q ,~ZCQ/j,/ Subdivision Name C'.5114-1U~eF-- ^ Public/Commercial -Describe Use .S ~ C ~ ^ State Owned -Describe Use ^City ^Vill ~'ownship of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' New S stem ^ Replacement System ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System B• ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T of POWTS S stem: Check all that a 1 Non -Pressurized In-Ground ^ Mound? 24 in. of suitable soil ^ Mound <24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurize In-Gr and ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter Leaching Chamber Drip Line ^ Gr 1-less Pipe , ^ er (explai V. Dis rsaUTreatment Area Infor lion: t't S - Design Flow (gpd) Design Soil Applicati te(gpdsf) Dispersal Area Required (sf) Disp al Area Propo ystem Elevation ~~, 3 3 ~ VI. Tank Info Capacity in otal Number Manufacturer Prefab Sit Steel Fi astir Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank ._ Aerobic Treatment Umt Dosing Chamber VII. Reapo ibility Statement- I, the undersigned, ass a responsibility for installation of the POWTS shown ou the attached plans. Plumbe 's e ~ t) ~~ Plumbe s Si ~ MP/MPRS Number Business Phone Number _ I - S .jr5 Plum Br's Address (Street, City, S ,Zip Code ~p VIII oun /De artment Use On Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater Dat Issued suing ent Si a Stamps) ^ Owner Given Reason for Denial Surcharge Fee) ~U ~ ~ ~ ' `~ ~ ~ 3~ Y ~~li{/Y!/1~L IX. Conditions of ApprovaUReasons for Disapproval ~t/L7%~ y~.(ti ~~G~z ~ ~ ~/~~~ 1.W.~ ~ SYSTEM O E : / ~~~yy,~. ~'3„S~Z ffl t filte i t k ~rn`~ ~~~~~ (. ~pQr~'.~"T7'uG~;Y~2.7~ib !LQ-Pol c uen r and an , e 1 ept c dispersal cell must all be serviced J maintained? ~ /~~~~ S~S ~ ~ZD ~~ ~ ~~~ as per mans C. ~~ ~ ~ ~~' setback requirements must be maintained ~ ~ r 'n nce~. ~ d 2• ~S' to,~ nttaca compteu pts~ tto the t:ounty onlf) for the system on paper not less than 812 x 1 heb in si SBD-6398 (R. 01/03) ~iP-SF•o~,r J f ~ - \ ~~n ~~~,~ ,~~~ ~pso.~ GUS ~o~G °S"~J~9- ~1//~/5~ -sr c ~3~ y~9rS~ ~i g wi ~aso~ ~~~ ~a,~eS~Q ~EII o ~t~ /~6~rs~ = 76 sC~--r / ~~ ' ~..~ / Q Y ,a ~ $ o ~/.Q~s ~~y~~3 _ --,~ - i 3a' ,t~~;~n~c,~ '~ .3i8 -_ ~---_ ~o,at "v~~J~~ ~~ti ~ ~ ~ O 1 N J S~m ~~~ ~ l~ca~.o ~ ; t- - -~-- ~=~ ,~, ~ ,~.~ /~~~ ~/~Szv,,=~,' f l ',~f /~i ~~ .~ 'lam Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT in accordance with Comm 85. Wis. Adm. Code 1483 Page 1 of j Steel's Soil Service, Inc. County Attach complete site plan on paper not less than 8'/: x 11 inches in s¢e. Plan must St. Croix indude, but not limited to: vertical and horizontal reference point (BM), direction and Par D percent slope, scale or dimensions, north arrow, and location and distance to nearest road. . Pending Please print al! information. Rev' Dat Personal inforrnalion you prov(de may b~s~.T_ ___„.-. __:'- "~Pn ~ Law, s. 15.04 (t) (m)1~ Property Owner ! ? Property Location LaCasse Development , I lc. ~ Govt. Lot na SW 1/4 NW 1!4 S 13 T 29 N R 19 W Property Owner's Mailing Addr ss ' ~ `-~ ~ ~ ~ ~ ~ ` Lot # Block # Subd. Name or CSM# 573 Cty Rd " A" 3 na Bluebird Meadow City ,State lap Cods Phone Number J City ~ Village ~/f Town Nearest Road Hudson ~~"'Wf`~"3401~"`"`" 1~5-381-5405 Hudson McCutcheon Rd li/ New Construction Use: ~rf Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD _j Replacement J Public or commercial -Describe: Parent material Sream terraces and pitted outwash plains Flood plain elevation, if applicable na General comments and recommendations: Conventional system, system elevation 94 .65ft. Trenches spaced and depth to code 6.0 low rade. ~~ Boring # ~ Boring 0 65 100 in. i~ Pit Ground Surface elev. 10 . ft. Depth to limiting factor Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-8 10yr3/1 none sil 2msbk dfr cs 1f .6 .8 2 8-12 10yr4/4 none sicl 2msbk dfr cs na .4 .6 3 12-38 7.5yr4/4 none sl/Is 2msbk dfr gw na .6 1.0 4 38-100 7.5yr4/6 none cos osg ml na na .7 1.6 5.35 =~ ~~, ~ ~6 . ~ ~/ , . 6<~ ~a ~ ys 2 Borin ~ Boring # J g Pit Ground Surface elev. 100.65 ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fP in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-10 10yr3/1 none sil 2msbk dfr cs 1f .6 .8 2 10-24 10yr4/4 none sicl 2msbk dfr cs na .4 .6 3 24-63 7.5yr4/4 none sl/I 2msbk mfr gw na .6 1.0 4 63-100 7.5yr4/6 none cos osg ml na na .7 1.6 ~S,3S~ ~~~~'~ * Effluent #1 = BOD~> 30 < 220 mg/L and TSS >30 < 150 mg/L ,.~ * Effluent #2 =BODE <30 mg/Land TSS <_30 mg/L CST Name (Please Print) tune: L5 r rvumoer David J. Steel ~~~ 248956 Address Steel's Soil Service, Inc. ate valuation nducted Telephone Number 994 200th St., Baldwin, WI 54002 8/20/2004 715-684-5680 Property Canner LaCasse Development , Inc. Parcel ID # Pending Page 2 of 3 Boring # _:~ Boring ~f Pit Ground Surface elev. 97.25 ft. Depth to limiting factor 100 in• Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Coat Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-16 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 16-23 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 23-100 7.5yr4/4 none ms osg mfr na na .7 1.6 ^ Boring # J Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ^ 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 in. Muruell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BODS> 30 < 220 mg/Land 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. 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. Page 3 of 3 STEEL'S SOIL SERVICE INC. David J. Steel 994 200`" St. CST-POWTSM LaCasse Development, Inc. Baldwin, WI 54002 Lic. #248956 SW1/4,NW1/4,S13,T29N,R19W Bus.(715) 684-5680 Town of Hudson, St. Croix Co. Fax.(715) 684-3449 Bluebird Meadow, Lot 3 This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of this test may or may not be as shown, as permanent lot lines were not established at the time the soil test was conducted. Legend 1" = 40' • =Benchmark Ele. 100.00Ft Top of 3/4" pvc pipe = Alt Benc k Ele. 99.45Ft T of 3/4" pvc ipe ^ = orin¢s 1 = 100.65F B = 100.65Ft B3 - 97.25Ft B4 OO.OOFt ~ 2 ~ ~3 _~u~.. ~ ~_ - ~~~ ~ ~ ~-` ~- ~~~~ a f.!° i 7U ~y, ~3~ .~ ~' ~5. ~~s s ~ x~ a N ~- ~ ,~ p x A ~ W \~ ~ .oi rrr ,~- x ® - , ~ O~ X ~ ca,' c„ • „_------ ~ - ---k __ _____~ i ! ' W ~N r~ ~N pi x W ~ ~~ N / ~ ~/ ~ ~ rn N x ip j Git t I I ~; ~ ~~ o ~ ~ ~ N W ~N N x tp W V~ :.. x W N i~ I~I:~ . . ~" ~1 I • ~i ;: ~ ~~ :~ ~ ~. ~ ~ ! ~o i 1:~~-~ __,~, W x~ 1 Al L ~ , ~ X ;. x ~~ !~~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN,..,.:.... Peae~-.cl~ FiI.E INF 0~.,.......... `-permit If v - ~ 7 (~ 3 i ~~ n1I~~1 AAAA\ACTL'OC Number of Bedrooms ~ O NA Number of Public Facility Units ~NA Estimated flow laverage- al/da Design flow Ipeakl, (Estimated x 1.51 ~?;' al/da Soil Application Rate al/da /ft2 Standard InfluentlEffluent Quality Monthly ave rage' Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L [~NA Total Suspended Solids (TSSI 5150 mg/L Pretreated Effluent duality Monthly ave rage Biochemical Oxygen Demand (BODE) 530 mg/L Total Suspended Solids (TSS) 530 mg/L DNA Fecal Coliform Igeometrlc mean) 510' ciu/t00rttl TMaximum Effluent Particle Size Ye in die. ^ NA Other; p NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SP~crricA r rvrra J Septic Tank Capacity al 0 N" ~ ._ Septic Tank Manufacturer Ft " ~ ~ ` " ^ N' Effluent Filter Manufacturer " `" " " ^ N~~ Effluent Filter Model Q N~,.1 Pump Tank Capacity at ~`N'~_~ Pump Tank Manufacturer ~ ~~~' Pump Manufacturer ~ ~' NA Pump Model ' D Nk Pretreatment Unit ~N~'. ~ Sand/Gravel Filter O Peat Filter O Mechanical Aeration O Wetland O Disinfection ~ Other: Dispersal Cellls) ^ N!, .f~`In-Ground (gravity) D In-Ground (pressuriz.ed) D At-Grade D Mound ^ Drip-Lina D Other, Other; p NF. Other Q NA Other: DNA MAINTENANCE 5Ct1EUULt: 7 Service Event Service Frequency Inspect condition of tank(si At least once eve rY~ D monthls) `` (Maximum 3 Years) earls! ,~ „ DNA When combined sludge and- scum equals one-third .(Y:1 of tank volume- ~ NA Pump out contents of tankis) Inspect dispersal cell(s) At least once every: D y~ar(sjlsi ~ (Maximum 3 years! ^ NA_ Clean effluent filter A-S ~~~~ At least once every: ^ monthls! year(s1 D Nt, ~ _~ D monthls} S3:Nf. inspect pump, pump controls & alarm At least once every; ^ ear(s) _i ~ ^ monthls) - ~ , . ~NF~ Flush laterals and pressure test At feast once every: O ear(s) 1 Other: At (east once every: O monihlsi Q aerial DNA Other; DNA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWT5 Inspector; POWTS Maintainer; Septage Servicing Operator. TanK inspections must include a visual inspection of the tankis) to identify any missing or broken hardware, identify any creaks or leaks, measure the volume of combined sludge and scum and to check for any baok up or ponding of effluent on the ground surface. 1"he dispersal cellts) shall be visually inspected to check the effluent levels in the observation pipes and to check -for any pondint; of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires thu immediate notification of the Iooal regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY,) 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 Gode. ' "' `'~~ { - " All other services, including but not limited to .the servicing of effluent filters, mechanical or pressurized compvneMs, 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 10 days of completion of any service event. (3MW Ia107 r:.,~,. START UP AND OPERATION i; +-,-.;. Pape ,~, of For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting product$ or, other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high conoentrations are deteoted have the conXants 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 cell(s) In one -large dose, overloading the oall(a) and may result ln~tM bsokup ol" surftloa dlaoharge of affluent. To avoid this situation have the oontenta of the pump tank removed by a Saptage Servioing Operator prior:to restoring power to the effluent pump or contact a Plumber or POWT$ Maintainer to assist in manually-operating the pump' controls to restore normal levels within the pump tank, Uo 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 scream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floes; diapers; disinfectants; fat; foundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides;;;maat; 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 systerr7 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 aealedt,t. • The contents of all tanks and plts shall be removed and properly disposed of by a Septag8 .Servioinq Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers remOVed aid the Void space filled with soil, gravel or anothor inert solid rnatorial. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, ,to provide. a code compliant replace ent system: .;3.~ ,::~, .~~ ~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 musi comply with the rules in affect at that time. D A suitable replacement area is not available due to setbaok andlor soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS.~°~~-i-~~~ ---~--•~~~ / ~sit h not bean lusted to i ntify a unable re camen area. Upo ure oft POWT 'I and site e/jfei~ati m st be rfor d to i ate a suitab cement area,. placeme a is available a holding tank ay be stall d a last res replace the failed POWTS. ........::... . .~ D 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,thet time. < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL. GASSES AND/OR INSUFFIGIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. ~ DEATH MAY RESULT, RESCUE pF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ., ADDITIONAL COMMENTS " ti~~ rt:rftd;a .~~ nrit ~~ POWTS INSTAL R t POWTS MAINTAINER . Name Name r ', Phone Phone St:PTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name ~ ' i Phone ,,. ,p , ,,~....,.. +his document was draped in compliance with chapter Comm 83.22(2)(b}It}(d)&tf) and 83.64(1), (2) & (3), Wlsoonsln Adminlatratlve Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSIiIP CERTIFICATION FORM OwnerBuyer ~.,~-Cg 5 ~ ~,~ ~ ~. ra ,P,.,,,.~- ~u ~. Mailing Address Property Address O (Verification required from. Planning Department for new ty (~~ Su~~, t il .C Parcel Identification Number ~~~~5 u ~ Ci /State LEGAL DESCRIPTION Property Location 5 ly '/4 , _~~'/< , Sec.13 , T Z-~ N R~W, Town of Subdivision ~ Gtr.. ~ ~ r .,~t.9~~n ~ ~~ s ,Lot # Certified Survey Map # ~I~ ,Volume ,Page # Warranty Deed # ~ ~ ~ ~ ~ ~ ,Volume ~- ~ ~/ ,Page #,_~2~. Spec house yes no Lot lines identifiable es 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. 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 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 Zoning Dep ent within 30 days of the three year expiration date. ~I~g/ a v~. SI ATURE OF APPLICANT DATE OWNER CERTIFICATION 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 escrib dab , by a of a warranty deed recorded in Register of Deeds Office ~/~~ SIGN OF APPLICANT DATE ****** Any information that is misrepresented 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 and a copy of the certified survey map if reference is made in. the warranty deed. ~! . 2641 ~'~ 399 STATE BAR OF WISCONSIN FORM l - 2000 WA]EtRANTY DEED Document Number This Deed, made between Rona2.d G. Raymond, Loretta S. Raymond, huaband and ovifa Grantor, and LaCasae Development, Inc a Wiaconain corporation _-_-- - _ Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix. County, State of Wisconsin (tire "Property") (if more space is needed, please attach addendumj: Southwest lf4 of Northwest lf4 of Section 13, Towaship 29 North, Raage 19 VQ93at, St. Croix County, wx Together with all appurtenant rights, title and interests. Recording Area 7?236 KATHLEEIi H. NALSH REGISTER OF DEEDS sT. cRalx cc. , MtI RECEI~dED FOR RECORD @8lZ0/2884 11:5SAC( YARR~T # EED REC FEE: 11.08 TRA}t8 FEE: ?250. @Q1 COPY FEE: CC FEE: P1iGES : 1 Name and Retu Tess 3 C ty Ro Iiu o 154015 a2a-1a1~-so-000 ['creel Identification Number (PIN) This not homestead property. (is} (is not) Grantor warrants that the title to the Property is good, indefeasib}e in fee simple and free and clear of encumbrances except encumbrances of record Dated this da of,_,^, Au st 2004 . *Ronald G. Ra AUTHENTICATION Tracy ~• Turner Signatures} p~otary authenticated this day of ~3' ~~-~~~1 * TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Slats.) THIS INSTRUMENT WAS DRAFTED BY Redmon Law Chartered (Richard Lau) 2219 vine 3t., Suit® 204, Audson, WI lSianatures msv be authenticated or aclrnowiedued. $oth are not necrssaiv.l o-t-2~cL ~ ~ r -e.. /Ca- m a~c.d *Laratta 8. Ra nd * ACKNOWLEDGMENT STA F WISCONSIN ) c ) ss V ~ County--~~~~~- Personal}y came before me this day of Auauat 2004 -the above named Ronald G. Raymond and oretta B. Raymond hu an an wif to wn to be e n who executed th o wledged the same. C'u _ /!/al ~l'! Notary Public, State of Wisconsin Mp Comrnission i~ermanent. (If not, state expiration date: *Names of persons signing in any capacity must he typed or printed beiow their signature. WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1-2000 ~~ Redmon 1.aw 2217 Vine St Ste 204, Hudson W154016-5864 . 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