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HomeMy WebLinkAbout020-1452-07-000Wisconsin 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 iPrivacy Law, s.15.04 (1)(m)). Permit Holder's Name: City Village X Township LaCasse Develo ment Hudson, Down of CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~~,~ yd Q,°s~. ~ ~ ~d ,1 ~ Z~.~ ,~- ova Aeration +^ .,w._._.~..,_~ Hoiding (~„~~~,,,,_ TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ r ' ~~ t ~~ ~ ~ ~ J ._._ Dosing Aeration r'' d^' Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Numb .-'' TDH Li ..` Friction Loss _..--~ ayste"m Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. CfOIX Sanitary Permit No: 463300 0 State Plan ID No: Parcel Tax No: DZO- ~FS~~?-ODU Section/Town/Range/Map No: 13.29.19.E STATION BS HI FS ELEV. Benchmark w; ~~;,~ 5; II ~ ~ y'O X65• ~ Alt. BM ~,, 7Z ~o~. ~ rr~ Bldg. Sewer ~ ~ b~ ~~~ St/Ht Inlet g Z~ e79 ~ ~1 g St/Ht Outlet ~ ~ Z q~ // Dt Inlet ~ ~ Dt Bottom ~ ~. Header/Man. 9 -3,1 ~~ • Dist. Pipe ~ ~~ l ~ ` ~~ Bot. System /a ` 3 $ ~ ~ , .."/ Final Grade ~ I D ~~ • 7~ St Cover ~, ~ 5, ~ I f b3 ~ ~ I BED/TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS J ~ Z .2\ ) ~ ~ ~~ ~ `_ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacture ~ ~.~~~~ OR CHA INFORMATION Type Of_System: ~ , ~ ~ MIBI T Model Number I~ISTRIBl1TION SYSTEM GJ c~r1.~ ~~ ~ (o Tod o~.~ Header/Manifold ~/ / Distribution Pipe(s) x Hole Size x Hole Spacing Vent to Air Intake th ~ Di ~ acin ~ th ` Dia \ S L \ Ut ~^ ~ ~- Leng a g p eng CA'111 f`f1VFR ., o...«...~ e.,~*o.,,~ n.,i.. .,,. Mnnnrl nr At_(:rarla Svsternc Only Depth Over / L ~ Depth Over B d/T h Ed xx Depth of To sdlf xx Seeded/ dded , xx Mulched " ' . Bed/Trench Center ~ renc ges\ e p ~ Yes ', ' No No Yes COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Location: 814 Dove Court Hud on, WI 54016 (SW.1/4 NW 1/4 13 T29N R19W) Bluebird Meadows Lot 7 1.) Alt BM Description = , 2.) Bldg sewer length = 3~ -amount of cover = ~ i -- -_- Plan revision Required? Yes ~,I No ~ Zi - ~ 05 ~ Use other side for additional information. i _ ~E' I ~~ Date SBD-6710 (R.3/97) Inspection #2: i i~__ Parcel No: 13.29.19. ___ _ _ i __ ___. ~~ 3 ~ 75 Insepcto s Signa re Cert. No. Safety and Buildings Division County ` ~ ~ 201 W. Washington Ave., P.O. Box 7162 ' ,sconsrn Madison, WI 7 62 (608) 2~ ~~ p Sanitary Permit Number (to be filled in by Co.) De artment of Commerce 3 3~ Sanitary Permit Application fate Plan LD. Number l` ~ In accord with Comm 83.21, Wis. Adm. Code, personal inforn~ati yplt~¢~v'~,1 `r may be used for secondary purposes Privacy Law, s1~.04(1 ) jest Address (if different than mailing address) I. Application Information -Please Print All Information +, ~ `'± ' ~ ~ CJ/~/ ~"" Devi CT: ; , Properly r'sName ,-.~ ~~,~ F~G~ ~ ~~"' G ~F # Lot# T Block# - - ~' ~ ,' ZoN~N ~ P~ ---- Property Owner's Mailin Address -3 ,~ % % City S Zi C d Ph N b ,, ., Section /3 , p o e one um er , S ~ / (circle doge,) ~~ N R~ E' ~ T f B ildi k h ; r, or . ype o u ng (c ec all that apply) ~ ~ S ~; ~~ I or 2 Family Dwelling - Number of Bedrooms Subdivision Name t~SM-~lunltsEr- ^ Public/Commercial -Describe Use ~ $ ^ State Owned -Describe Use ^City ^ 'age 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• ^ 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 ^ Singte Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatm ent Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter Leaching Chamber rip Lin ^ Gravel-less Pipe ^ Other xplain) V. Dis ersaUTreatment Area Information: Design Flow (gpd) sign Soil Application Rate(gpds i ers Area Required (sf) ispersal Area Pr pos (sf) System Elevation ~ I ~Lt/ f VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber plastic Gallons Gallons of Units ~_lj ~`/ " Concrete Constructed Glass New Existin ''' ( ~ Tanks g Tanks Septio or Holding Tack Aerobic Treatment Umt Dosing Chamber VII. Resp nsibility Statement- I, the undersigned, assn a responsibility for installation of the POWTS shown on the attached plans. Plum er' am ' t) ~ Plumber' i MP/MPRS Number Business Phone Number ~ 3 s lumbe s Ad Tess ( eet, City, State, Zip Cod ~~ VIII. Coun ,De artment Use Onl ~A roved pp sa ~~ Sanitary Permit Fe includes Groundwater Date Issued Issui Agent Signature (No Stamps) ~J (h~v iven Reason r Denial Surcharge Fee) 2 J~ ~- • O ~ ~US _ J 1X. Conditions Approv R al SYSTEM OWNER: 1 Septic tank, effluent flltel' arld 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. nrtacu comptece ptam fro ttce county nary) for lrle syahm on paper not las than 81rz x 11 inchn in size ~~ SBD-6398 (R. 01/03) a SZ-3 ~ 4 Y ~~ ~ ~ G ~~~ ~~ 1 '/ _.. 0 ~ _ _ A'. ~'~J~',J~ / ~_ vt~ `'` ~~ ~, ~ '~ / ~ ~~,/ ~arCKp?- ~ of ~/y'i~ ~°pK . ~.;.c 99.x' ~ / Gnu ~ .~.~ / ~ / --yo set .S~e ,~ s,~-,~ ~,~sK- i~~r~~/ ~;~ ~S y,, G~K i.~_ ~- ..~~r~ ' s©~ ~,,~ ' ~~f 1 ~ C~~' ~~/k5 Y CpP ~ ~~~E ~u~J,~tO~i~~.~r 1~L 7 ~ ~ `} e ,, 1 t e ~ ~~ ,I 11 1 ~ a~~ " ~asonl a w~ ~ ,// r~ - ~`/i Q~~= / ~ ~~ ~ ~ / ~` ~ ~ d~~~ ~, ~~ ~ - ~° 6F''3~y I!°f~L' ~'~rit- .~c/00,0 / ~Jct/ ~~.~~~?- ~, ef -3/y'i~e ~"pK - ~~,c 99,x' ~ / 2 ~ ~~ I ,~ °-/D sc~.r/ ~/ ~` ~-.~~~a so ` ;~ ~~ ~~~ ~~ C-'u l !~F ,S,ye { Z~ Wisconsin Department of Commerce Division of Safety and Buildings 1487 SOIL EVALUATION REPORT P t f 3 in accordance with Cnmm 85_ Wis_ Adm_ Code age o 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 include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. " Parcel I.D. Pending Pleas„~,/r ,Ot.~7/(j~-fplr~,~._,...n..~ R sewed B,y Date Personal information you provid~ may be ifo~spf~On', dayl~p~!~pos~s (PrivaO~ Law, s. 15.04 (t) (mU~ • ~aF Property Owner ~ ? Properly Location LaCasse Development , In'. ~ • ~~ i ~~ ;,:; Govt. Lot na SW 1/4 NW 1l4 S 13 T 29 N R 19 W Property Owner's Mailing Addre s Lot # Block # Subd. Name or CSM# 573 Cty Rd " A" ~ 7 na Bluebird Meadow City fate Z.fpCo~ PhohetVumber~ ~~ _f City _J Village ~ Town Nearest Road Hudson ~ WI 54016 715-381-5405 Hudson McCutcheon Rd ill New Construction Use: ~ Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD J Replacement ~ Public or commercial -Describe: Parent material Sream terraces and pitted outwash plains Flood plain elevation, if applicable na Generalcomments //'' and recommendations: Conventional system, system elevation 99.55ft. Trenches spaced and depth to codf~ 3.00ft elow grade. ~~~~ ~r~.~S ~o t~s Boring # ~ Boring ~ , off Pit Ground Surface elev. 102.55 ft. Depth to limiting factor 120 in. / ~ ~ od Application Rate Horizon Depth Dominant Color Redox Description Texture Stnucture Consistence Boundary Roots GP D/ft2 in. Munsell Qu. Sz. CoM. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-9 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 9-20 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 20-77 7.5yr4/4 none Is osg mvfr gw na .7 1.6 4 77-120 7.5yr4/6 none cos osg ml na na .7 1.6 99• '~ ~•~Z. Boring # J Boring /j Pit Ground Surface elev. 102.55 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-10 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 10-23 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 23-120 7.5yr4/4 none Is osg mvfr na na .7 1.6 2 * Effluent #1 = BODS> 30 <_ 220 mg/Land TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) ign lure: / _ CST Number David J. Steel ~/ 248956 Address Steel's Soil Service, Inc. Date Evaluation Conducted Telephone Number 994 200th St., Baldwin, WI 54002 8/20/2004 715-6845680 ~~ i ~._ 1 < Property Owner ~~~ Development , InC. Parcel ID # Pending Page 2 of 3 Boring # ~ Boring If Pit Ground Surface elev. 94.55 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth DominantColor Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-10 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 10-17 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 17-30 7.5yr4/4 none sl 2msbk mfr cs na .6 1.0 4 30-70 7.5yr4/4 none ms osg ml gw na .7 1.6 5 70-120 7.5yr4/6 none cos osg ml na na .7 1.6 ^ 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. Munsell (2u. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ^ Boring # J Boring J Pit Ground Surtace 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 * Effluent #1 = BODS> 30 < 220 mg/Land TSS >30 < 150 mg/L * Effluent #2 =GODS < 30 mg/Land 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 swl/4,NW1/4,S13,T29N,R19W Bus.(715) 684-5680 Town of Hudson, St. Croix Co. Fax.(715) 684-3449 Bluebird Meadow, Lot 7 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 ti a the soil test was conducted. Legend kY ~ 1" = 40' '~ ~~ ,,.~ ~ Benchmark Ele. 100.0 t ~ , ~ ~~~~ ~~~~' ~~f °~ Top of 3/4" pvc pipe ~~ ~ ~ ( ~ /,~ l ~ 2 •• Alt Benchmark Ele. 99.85Ft ~Op of 3/4" pvc pipe ^ =Borings Boring Elevations B 1 = 102.SSFt B2 = 102.SSFt B3 = 94.SSFt i~~ ~ B4 = OO.OOFt "~ ~'~~ ~ N ~v /~ • ~.! .... Cl1 `` r :~-_ ~~ ~ ~Tiii ii're'~'~YV/ ~i ~ ~r,~~ rr ~~~ ~ ~~ ~~ X ~ ~ Q N ~ O • : ~ 1NSN3~1t3N ~ tO cn ~ N ~ ~auN ,oe w 1 N w (~,~ . ~ K N r l X a SON! ~t X ao~ ~N I ~ -1 ~ N N • ~ ~ ~ A A ~ :/ ;/ ~ ~ x ~~~ ~ .E1. / -- X w N •~ ~ . ~ X ~ ~ ~ ~ ~o - . ~ ~• _.. .•r ~ G~ ~ x N {' r ~ ~ `~ ~'~ \ J X N N 111 ,' ~ ~ W W 0 6i :~ II ~1 V ~ ~ A \r X ~ • ~ wX ~~~ ~ a ~. • , ~. A ~ 1 ~ X • i •~• N ~' X O M W r (r .i :r ~ ~ ~ ~ a ro ~ ~ X X ~~~i Fi. t ao~.v~ ~ovv^. X X ~ 1-/L ELL d0 ti/LMS c`°i+ N ! ~O ~JN~ti~^ POWTS OWNER'S MANUAL & MANAGEMENT PLAN,;,;., Page~ol~ FILE INFORMATION Owner ~ ; Permit N L" Art AAA wrAI'_'TG[]Q VI.VI V.~ • r...~.•r~...r•: Number of Bedrooms ^ NA Number of Public Facility Units j~NA Estimated flow (average) allda Design flow (peak), (Estimated x 1.51 al/da Soil Application Rate al/da /ft~ Standard Influent/Effluent Quality Monthly average * Fats, Oil & Grease IFOGI 530 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids (TSS) s150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODE) 530 mg/L Total Suspended Solids (TSSI 530 mglL l~ NA Focal Coliform igeometrlc mean! 510° cfu/100m1 Maximum Effluent Particle Size Yd in die. ^ NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPec~rrGA r r~rva ~ Septic Tank Capacity ~ ~ al O N`^ Septic Tank Manufacturer .z ~ '~ ~ ~ ,° ,' C7 N' Effluent Filter Manutacturer ~ ' ^ NJ's Effluent Filter Model O NA i Pump Tan1c Capacity al 1~ NA ', Pump Tank Manufacturer -® NE_ Pump Manufacturer ~ NA Pump Model ~ NA Pretreatment Unit ~ NF ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: Dispersal CeI11s1 ^ N<~ ~ In-Ground (gravity) ^ In-Ground (pressurized) ^ At•Grade D Mound ^ Drip-Lino Cl Other; Other: O NF, Other: ^ NA Other: ^ NA MAINTENANCE SCHEUUt.e Service Event Service Frequency Inspect condition of tank(s1 At least once every: O month(s) `' (Maximum 3 years} l~ earls},, ,:- ^ NF, Pump out contents of tankis) When combined sludge and scum equals one-third .1Y~) of tank volume- ^ NA Inspect dispersal cellls) At least once every: ^ month(s)'`'`- (Maximum 8 years? ~ J~ year(s) O NA ^ monthls) . ^ Nt.. Clean effluent filter At least once every: ,~ year(s) ^ ^ monthlsi ~ Nf- ~ Inspect pump, pump controls & alarm At least once every; p ear(s) ^ monthls! r: ~ ,l~ NFL Flush laterals and pressure test At feast once evory: ^ ser(a) Other. At Ioast once every: O monthls) Q earls) ^ NA Othor: C7 NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following lioenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector POWTS Maintainer; Septage Servicing Operator. TanK inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any craoks or leaks, measure the volume of combined sludge and scum and to check for any back up or Bonding of effluent on the ground surfacE. i he dispersal cellls! shall be visually inspected to check the effluent levels in the observation pipes and to Cheok -for any pondin~ of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the looal regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) 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 Cod®. ~ ~ '~ - " All other services, including but not limited to the servicing of effluent filters, mechan"teal or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service avant. C3MW IaJO ~ 1.`+''~~<~ Pape ~ of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tanklsl for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal ceUlsl. If high concantratlons are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions era frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restoreii the excess wastewater wilt be discharged to the dispersal cell(s) in one -large dose, overlcadinq the oell(ri) and may result-In~the backup or surtaw 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. Uo not drive or park vehicles over tanks and dispersal cells: Do not drive or park over, or otherwise. disturb or compact, the arcs within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the fallowing from the wastewater stream may improve the performance and prolong the life of file POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides;;:meat~ scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: All piping to tanks and pits shall be disconnected and the abandoned pipe openings ~ealod. r, .t~t~ The contents of all tanks and pits shall be removed and properly disposed of by a Septaf~e ,Servicing Operator. ~ After pumping, ail tanks and pits shall be excavated and removed or their covers remgyed and the void space filled witf~ soil, gravel or another inert solid material. CONTINC3ENCY 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 sell absorption system. The replacement area should be protected from disturbance and compaction and should net b® 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 effect at that time. D A suitable replacement area is not available due to setback and/or soil limitations. 4arring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS.-°~•~•s°~~ • ~~- D 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. ..,..,;:... , . D Mound and at-grads 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 lima. < < 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 CIRCUM87ANCE8. ~ DEATH MAY RESULT. RBBCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS ~,.r~,,; .is . , ~ ° ,*.~.r ~r rt}r.~~3 , ~~ .3~fi~ ,r , POWTS INSTAL E POWTS MAINTAINER Name Name i ' Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name ,,, ~ Phone ~~~ _f ~ .r,. ;..,. ?'his document was drafted in compliance with chapter Comm E3.22(211b1111id)&ff1 and 83.64111, (2) & (31, Wiaoon+rln Adminlatrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT -AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~->'1C.a~ge~ t~~J~.L.~~~ Mailing Address Property Address ,~ t~ (Verification required from Planning Department for new construction.) City/State ~~i.,~ ~ S~-~ Parcel Identification Number d a b - l D ~ ~ " ~O - c v a LEGAL DESCRIPTION Property Location `~ c.~ '/a , ~1/ tv %4 ,Sec. l 3 , T ~N R 1 ~W, Town of ~/~, ~~ ,~~ Subdivision ~ L u ~ .~ a r-~ ~~~,~ L~ u~ S ,Lot # _~. Certified Survey Map # Volume ,Page # -~-' Warranty Deed # ~ T~-~~3~ ,Volume Page #. Spec house es 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 liy 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 Department within 0 days of the three year expiration date. 2 ~/2 7/~ 5 S NATURE 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 pr desc 'be above, by virtue of a warranty deed recorded in Register of Deeds Office . ~l ~r/d5 S NATURE OF APPL T 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. 'J 2 6 4 ] ,~ -3 9 9 3~s ~ . . ~ ~7~~ STATE BAR OF WISCONSIN FORM t - 2000 -- - - KA1'HLEEit H. MALSH WARRANTY DEED ~ REGISTER OF DEEDS Document Number S'~', CROhX CD. ~ 1tI This Deed, made between Ronald G. Raymond, Lor®tta B. RECBI~dED FOR RECORD Raymond, husband and wife 08/2812884 11:55A1i Grantor, wARRA1CC'Y DEED and Lat:asae Development, Inc a Wisconsin El(EfiRT ~ c ~oratioa RHC FEE 8 : 11.0 TRA}tS FEE: 2250.00 Grantee. COPY FEE: Crrantar, for a valuable consideration, conveys to Grantee the following CC FfiE ` PAGES: 1 described real estate in st. Croix. County, State of Wisconsin (t)te "Property") (if more space is needed, please attach addendum): Southwest 1/4 of Northwest l/4 of Section 13, Township 29 North, Range 19 West, 3t. Croix County, WI Recording Area Name and Retu Tess 4D16 r 020-1017-30-0.00 Parcel Identification Number (PIN) Together with all appurtenant rights, title and interests. This 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 eactunbrances of recoxd Dated this da of Au st 20D4 , *Ronald G. RaYm *Loretta B. Aa nd AUTHENTICATION Tracy ~-.Turner Signature(s) otary authenticated this day of ~E~ 1_ ~11~C~0 ~~ TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §7Q6.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTER BY Redmon Law Chartered (Richard Lau) 221.7 Vine St., Suite 204, Hudson, WI (Signatures maY be authenticated or acknowledged. Both arc not neccssarv.) * ACKNOWLEDGMENT STA F, WISCONSIN ) c ) ss I< ~ County--!) ~~~--1- Personally came before me this day of August 2004 the above named Ronald G. Raymond and ~.oretta B. Raymond hu an n wif to wn to he e n who executed th o 1~ wledged the same. Cu _ /!/v[ X1/1 Notary Public, State of Wisconsin My Commission i~erntanent. (If not, state expiration date: "Names of persons signing in any capacity must be typed or printed below their signatun:. WARRANTY DEED STATE BAIT OF WISCONSIN RORM No.1-2000 Redmon Law 2217 Vine St Ste 204, Hudson W154016-5864 Phone: (71.5) 386-0100 Fax: (715), 386-0700 Redmon Law Chartered T4926305.ZFX Produced with Z1pFOrmTM by RE FormsNet, LLC 16025 Fifteen Mile Road, Clinton Township, Michigan 48035, (800)383-9805 wrvw.ziptorm,com tQ 1 ~8,98T sQ. Fr. ~.~' DRAINAt3E EASE1~1"H! A o ~ c ~r~.V. ~ ~4 ,~ .v ~ Q C ~.~ ~ --~4 S` s H.W,I.• ~• 93$.4 .U~ 122.83' ~ • 3B4.9T` 1 f)B.ZE' ~ 1 QB.d~ ~9'49't?Q~ 743.34' ~~~~. ~~T 8 .E,I~iGH IMAI~Kt TqP p~ ~ QF 1" IRQM PIPE, ~,~~ ACr. ~' tI,EVAT'IQN 93~.iT i 15,2' 4 SQ•1 It}'~~~ 48 ~ . ~y ...•r ~ . as 1 ~I ,~~ ~ '" N8~'27''t7S" ~- _J ~ y ...... . ~ . ~ ~~ ,. ~~ ~ ~ 98,~i98 SQ• ~'~"• ~ 94 5~7 aQ• FT. .•' ,~ ''` ~ ~ ~•.s.o. ~ saaa C x ~,. ~ i~ ~ I ~:~ ~ a ~ ~ ~ ~ Q a .•• ~ ~, . 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