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Home My WebLink About020-1452-12-000Wisconsin Departmenfof Commerce P IVA E YSTEM Safety and Buildg Divisi ~n R TE SEWAG S 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, Town of CST BM Elev: / Insp. BM Elev. ~ BM Description: ~ ~ , ~~ ++~ t k .- "' ~ a- B ~ TANK INFORMATION ELEVATION DATA TYPE ~ M~~ASC'TURE,R ^~' ~~({{+ , ~ CAPACITY Septic ~ ~~ i Z~O Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ + f _~ ..~-- Dosing Aeration Holding PUMP/SIPFfON INFORMATION Manufac rer Demand GPM Model N ber TDH Lift ~ Friction Loss System Head T H Ft i Forcemain Length ia. Dist. to well SOIL ABSORPTION SYSTEM ~j 21 r~~, (~ l~{~c~, County: St. Croix Sanitary Permit No: 488035 0 State Plan ID No: •~ • ~' '~'~` Parcel Tax No: 020-1452-12-000 Sectionlrown/Range/Map No: 13.29.19.2900 STATION BS HI FS ELEV. Benchmark , (~ `'~ ~ 'oI'n~ q ~~ ~ ~ r / Alt. BM ~ ~4. ' Z I (.Sb ~ Bldg. Sewer ~, 9 .SS / SUHt Inlet S~ 2` ~l 3, t St/Ht Outlet . z q3 2~~ Dt Inlet Dt Bottom Header/Man. q. Z qZ~ ~~~ Dist. Pipe •r'O QZ. ~~ / Bot. System i~'SZ • p 1 Final Grade ~ ~ ~/~~ St Cover ~ 1 W~'~ Width t Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ? J Gt ~1 ~ llL. SETBACK SYSTE M TO P/L BL G WELL LAKE/STREAM LEACHING Manufacturer. INFORMATION CHAMBER OR !.. Tye O~ Jystem: ~~ ~ ~ ~~ ~` UNIT Model Number. d / DISTRIBUTION SYSTEM Header/Manifold ~t Distribution x Hole Size x Hole Spacin Vent to Air Intake t,.~ i Pipe ----- - h Di S i L „„ SS Length D a pac ng engt a SOIL COVER x Pressure Svstems 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 ' '? No ~"l' ~ I C M ~TS' nclud code di cr cies, persons pre ent, etc.) Inspection #1;~/~ ~ Inspection #2: ~-TT ~ L ~ t~~' 9~25~ee Hud~V4~6 (s~W 1/4 13 T29N R19W) Blueb'rd Meadows Lot 12 Parcel No: 13.29.19.2900 1.) Alt BM Description = ~~~ '~""'~ I~' 2.) Bldg sewer length = Z 1 - amount of cover = 3G ".E- . ~~ ~ ~ S~-Y ~) Plan revision Required? f ~, Yes ~ No ~(~11' "' Use other side for additional Information. T- __ ; D b~ ~ _~ ~~~ ---- ~ Date Insepctor's Signature SBD-6710 (R.3/97) ~~ 1 Cert. No. ~ ,.. _~ • Safety d~ But County ` 201 W. W Ave., P.O. Box 7162 1 ,~~~~~,n Madis3'~6`~ ~d~~ (608 nary ermit Number to be filled in by Co.) ~~' De artment of Commerce ~ a3; Sanitary Permit Appliea 'on s e Plan I.D. Number ' r 200" In accord with Comm 83.21, Wis. Adm. Code, personal informa on you~vide ~ J may be used for secondaz ) U~ G~ ~~'' ur oses Privac Law s15 (1)( P t Add if diff y p p y , . m ro ress ( erent than mailing address) NT I. Application Information -Please Print Alt Information $T. _ , i~ Property Owner's Name Pazce t # Block # - -~ c l~ Property Owner's Mailing Address Property Location , ~4, ~~4, Sectron ~ City, S ~ Zip Code Phone Number ~ ~4 ~ circle ~N R~E ~ II. ype of Building (check all that apply) ao ~ S ~ ; or bdi S i i N ] or 2 Family Dwelling - Number of Bedrooms v t s on ame ~ ^ Public/Commercial -Describe Use ~~~ ~+;~~ 1 ~1C?L(~ ^ State Owned -Describe Use , - - ^City_^V' I e,1~Township of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) Q ~j . I S Z - lZ - [?170 2, CQ A' New S stem y ep y ^ R lacement S stem ^ TreatmendHolding Tank Replacement Only ^ Other Modification to Existing System g, ^ 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 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 ersaVl'reatment Area Information: s 2 Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation VI. Tank Info Capacity in Gallons Total Gallons Number ofUni Manufacturer P ~ LS2 / ~ ~ ~ Prefab Concrete Site Constructed Steel Fiber Glass Plastic New Existing • -~ ~, Tanks Tanks Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, a ume responsibility for installation of the POWTS shown on the attached plans. Plum r' Nam (Print) ~ Plumber's Si aY MP/MPRS Number Business Phone Number ' ~ ~ 3 s `~ s s 3> lumbers ddress (Street, City, State Zip Code) ~~ ~ ' U~ , .~ VIII. Conn /De artment Use Onl Approved ^ Sanitary Permit Fee eludes Groundwater Date Issued Issuing Agent Signature o Stamps) ^ Owner Given Reason nial Surcharge Fee) ?~) /"" _.--- IX. Conditions ppr v R 1 ~ ._p-- SYSTEM OWNER: 3~ Q~'Ccs•..~.N,s-G JZM~,6a~Q~ B.t,~ ~~.~q 1 Septic tank, effluent filt er and dispersal cell must all be s i 5°'` Q ~ ~~ ! erv ced /main[ ine " ' as per management plan provided b l 2 y p umber. . All setback requirement s must be maintained as per applicable code/ordinances. 4:omp4eu puns tto me a,ounly onry),tor the syscem on paper ant cess than alll x 11 inches in sixe SBD-6398 (R. 01/03) ~----- .--/\ ~_~ \ ~ ~~ ._ ~~ ~~ ~ r ~~. r U r, ~~ 0 ~~ ~, G~~y ,~ ~1 .,~ ~ a.~ s-~~~ .~ ~~ ~. r, ~. r ~'~ °~ ~`~ ;' N (i~~ P . \j \\ ~ ~.~ S ~~ ~~ ~ ~ c K \~ / ~ , ~~. N ~~ ~ __ W ~ ` ~~ ~~ tj ~ ~~ ~ ~\ Z ~ ~ a ~ 11 ~ r' ~~~ ~~~~ z~ ~~~~~~ a o ...h ~ ~ ,. ~~ ~~ ~~ ~~° ~, ~~ , so !~ ~, o n~ ~(] ~`~~ Z u A, ~~ ~~ 0 ~> \ ~_ s ~\ ~ ~y'o ~ \ `~.l W N c ~~ W ~i~ h, ~~ hV \~\` O ~~ ~, ~„` \, ~-- s ~`~ ~N ~ ~ ~j ~~ ~, , ~ ~ ~ ~ ~ ~ ~ ~~ ~" ~ ~ w ,~~~~~ ,. , ~ ~~ z ~~ ~ ~ w ~°~` ~~ ~~ ~~ ~ ~~ ~b ~ , o )o Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT in arrnn-lanrv with Rnmm R.ri Wic Adm_ Code 1492 Page 1 of 3 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: verlicaland.lnrizontatJf~.f~rence~nt (BM), direction and parcel I percent slope, scale or dimensions, rgrtffar~owrer(dlgc,~Lpq~nd dance to nearest road. p ding P/ea~e print all nforrta~ion. Date ewes By Personal infom>atlon you provide may beused,tprse~condary purposes (Privacy Law, s. 15.04 (1) (m)). , ~N • ~~` Property Owner Property Location LaCasse Development , I ~c. Govt. t.ot na W 1/4 NW 1!4 S 13 T 29 N R 19 W Property Owner's Mailing Add ss ~ Lot # Block # Subd. Name or CSM# ~ ~ ~ -'~" ~~` """" "°'~ 573 Cty Rd " A" 12 na Bluebird Meadow City State Zip Code Phone Number ~ City ~ Village ~/' Town Nearest Road Hudson ~ WI 54016 715-381-5405 Hudson McCutcheon Rd New Construction Use: ~ Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement ~ Public or commercial - Describe:na Parent material Stream terraces and pitted outwash plains Flood plain elevation, if applicable na General comments and recommendations : Conventional system, system elevation 93 50ft below grade. 3 . .60ft. Trenches spaced and depth to code ,.} . _ ek. /W'r Boring # J Boring ~ ~ Tom' 1 ~r ,,~/ vQ ~{ Pit Ground Surface elev. 97.10 ft. Depth to limiting factor 20 in. Soil Application Rate Horzon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft: in. Murrsell 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 10-25 10yr4/4 none sicl 2msbk dfr cs na .4 .6 3 25-79 7.5yr4/4 none Is osg ml cs na .7 1.6 4 79-120 7.5yr4/6 none cos osg ml na na .7 1.6 ~ ql• Boring # ~ Boring ~'f Pit Ground Surface elev. 97.10 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft= in. Munsell Qu. Sz. Coat Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-14 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 14-32 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 32-120 7.5yr4/4 none ms osg ml na na .7 1.6 T ~- ~(. ~i. ~,~~ * Effluent #1 = BODS> 30 <_ 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mglL and T55 < 30 mg/~ CST Name (Please Print) Si ature: CST Number David J. Steel ~ -tom 248956 Address Steel's Soil Service, Inc. Date Evaluation Conducted Telephone Number 994 200th St., Baldwin, WI 54002 8/20/2004 715-6845680 ~S ` Property Owner LaCasSe Development , Inc. Parcel ID # Pendi Page 2 of 3 Boring # J Boring 1/ Pit Ground Surface elev. 94.70 ft. Depth to limting factor 120 in. $pd Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. CoM. Color Texture Structure Gr. Sz. Sh. Coruisterxe Boundary Roots 'Eff#1 *Eff#2 1 0-12 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 12-30 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 32-120 7.5yr4/4 none ms osg ml na na .7 1.6 ^ Boring # J Boring _] Pit Ground Surface elev. ft. Depth to limiting factor in. Sod Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots P *Eff#1 *Eff#2 Boring # Boring _f Pit Ground Surface elev. ft. Depth to limiting factor in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5> 30 < 220 mglL 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. 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 12 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 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 ~- ~ i ~ Alt Benchmark Ele. 100.20Ft op of 3/4" pvc pipe ~ ^ =Borings ~aj Boring Elevations ~`-~ `'`" `_ ~ B2 = 97.lOFt B3 = 94.70Ft ,c rIi B4 = OO.OOFt . ,/ ~/~ ~ so ~ x ! I v N I I `° ~' W `~ ~~-- x : ul I ~ . ~ : ~ 3l~rN1V!!~~ a ANN h ~ .~- ~, X (~ N ~ t0 I ((~~~ ~ G~~ id ~ ~ ~ ~ ~ O N W ~ uU O ~ i ~~ ~ ~ Ia ~ ~1 I~ I~ i p, l O ~~ ~° I . I x /~~~ 7 ~' x ox ~ r Q ,,.,, ~ ~_. ~ ~ ~ L - ~~ ~ 9 9 ~ i w~ ~x '• s~ - -- --• ` •~ n s- ..... ....... ~ ~ ~p • ~ ~ ~'~ ~ ~ ~. ° ~.'3 .,~ ~ ~ x , ~9Q'p ~ a0~ _ w a ~. - . ~I. cp i O x ~ ~ Q OD ~ !~'! ~ i x .. x 'N ~ x N f0 ~ ~ j x POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of FILE INFORMATION Owner Permit DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ~-NA Estimated flow (average} gal/day Design flow (peak?, (Estimated x 1.5) d gal/day Soil Application Rate gal/day/ft2 Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODS) <_220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average __ Biochemical Oxygen Demand (BODS) 530 mg/L Total Suspended Solids (TSS) 530 mg/L Ji~NA Fecal Co{iform (geometric mean) 510' cfu/100m1 Maximum Effluent Particle Size Ye in dia. ^ NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity G gal ^ NA Septic Tank Manufacturer _ s ^ NA Effluent Filter Manufacturer ^ NA Effluent Filter Model ^ NA Pump Tank Capacity gal .~ NA Pump Tank Manufacturer ,J~NA Pump Manufacturer 18' NA Pump Model ,~ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ,{)ANA Dispersal Cell(s)_ In-Ground (gravity) ^ At-Grade ^ Drip-Line _ __ __ ~ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ lyq Other: ^ NA w11AU1rCwlAwlnc C/NJCn111C IYI/111Y 1 GIYAIYVL vv1 IGarv,.~- Service Event Service Frequency Inspect condition of tankls- At least once every: ^ earls-(s) (Maximum 3 years) ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third {Y3i of tank volume ^ NA Inspect dispersal cell(s) At least once every: ^ month{s) (Maximum 3 years) .~ .~ year(s) ^ NA Clean effluent filter At least once every: ^ month(s) year(s) ^ NA Ins ect um pum controls & alarm p p p, p At least once eve ry~ ^ month(s) ^ years} J~NA ~(s) ~ (;3~NA Flush laterals and pressure test At least once every: year~s Other: At least once every: ^ month(s) ^ year(s) ^ NA Other: ^ NA 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; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tankls) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cells} shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local 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 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 <_12 months, shall be performed by a certified POWTS Maintainer. A service report shaft be provided to the local regulatory authority within 10 days of completion of any service event. page ~ 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 cellfsl. If high concentrations are detected have the contents of the tank(sl 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 cell(s) 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 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 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 tf 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. ^ 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. nnnrr~n~un~ rnnAnAFNTC 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 83.22(2-(bl(11(d-&tfl and 83.5411), (21 & 131, Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Mailing Address Property Address City/State ~~„~s~~ 1it ~~ LEGAL DESCRIPTION Parcel Identification Number D Zo - ~ ~ S Z - ~ Z-~ ~ ~9~~ Property Location~~,J '/4 , ~~ 1/4 ,Sec. /3 , T~~~N R~_W, Town of ~~~,,~ Subdivision ~~ -,B/ ,n ~~~,~~~~ ~ ,Lot # ~. ..._---- ~---- Certified Survey Map # Warranty Deed # ~1~2 2310 Spec housexyes no Volume ,Page # Volume 26~f / ,Page # ~~ Lot lines identifiable yes 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 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 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 virtu of a warranty deed recorded in Register of Deeds Office. Number of bedrooms SIGNATURE 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. (Verification required from Planning & Zoning Department for new construction.) (REV. 08/05) . J. Z6`f~~, 399 ~~a~36 ~` STATE BAR OF WISCONSIN FORM (- 2000 - - -- KATHLEEN H. NALSH 'WA-.RRANT~' DEED ~ REGISTER OF DEEDS Document Number ST. CROTX CU. , hFT This Deed, made between Ronald G. Raymond, Loretta 8. Ra~mondt,huaband aad wif® Grantor, and LaCasae Developmeat, Inc a Wisconsin cozyoration Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix. County, State of Wisconsin (tlte "Property") (if more space is needed, please attach addendum): Southwest 1/4 of Northwest 1/4 of Section 13, Township 29 North, Raagta 13 West, St. Croix Couaty, API Recording Area RECEIVED FOR RECORD @8128/2884 11:55At4 ~1ARRAli'CY OBfiD EXERT f RfiC FEE : 1 l . 88 ?RAJiS FEE: 2258.0P! C4FY FEE: CC FEE: PAGES: 1 Name and Retu ress 3 C ty Ro xu o:a~-;RI 54016 .fir ~.1~~-r~.,~ r 1 rG~u Together with all appurtenant rights, title and interests. o2o-iol~-3o-ooa Yazcel Identification Number (YIN) This not homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and cieaz of encumbrances except encumbrances of recoxd Dated this da of ~, Au st 2004 , *Ronald G. Ra AUTHENTICATION signature(s) Tracy ~. Turner ,Notar_y authenticated this day of ~~`atG "' ~~O 1 * TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §7Q6:06, 'Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Redmoa Law Chartered (.Richard Lau) 2217 Vine 3t., Suite 204, Hudson, PPI f5ignatures may be authenticated or acknowledged. Both arc not necessary.) *Loretta 8. Ra and ACKNOWLEDGMENT STA F WISCONSIN ) ) ss 0 county. Personalty came before me this day of August 20f)4 the above named Ronald G. Raymond and Lor9stt~B. Ray~tgnd to t~wrt to he e n who executed th o inetitls wiedeed the same. Notary Public, State of Wisconsin - My Commission i~petmanent. (If not, state expiration date: *Names of persons signing in any capacity must he typed or printed below their signature. WARRANTY DEED STATE BAft OF WISCONSIN RORM No.1-2000 Redmon Law 2217 Vine St Ste 204, Hudson W154016-5864 Phone: (71.5) 386-0100 Fax: (715), 38b-0700 Redmon Law Chartered T4926305.ZFX Produced with Z1pFOma'u' by RE FormsNet, LLC 98025 Fifteen Mile Road, Clinton Township, Michigan 48035, (800)383-88D5 www.zioform,com • j~ ! ~'a ~ 1 1.»~ R j f ~, ~ • ~. y r p s /J * ~ • ,~ ~ ~ ~ • ~ ~ • t • ~ f ~~ ~~ • ! ~ ,• ~ ~s i • ~• ~~ ! I ~~ ' R • w s s ~,~, ~ ~ ~ • ~' s M ~ .~ ~ ~ ~ ~ ~ ~~ ~~ ~ ~ ~,, ~ ~a~i ~~s • a s R ~ ~ ~ • ~! i s ..pj : • R r • ~ ,~ , w ~„~ } ~' 1 ~ ~ R ~ • '~ ~ # • R~ ~ ~• f !~_ • • ~ • • 3S~.9iX ~~ • ~ ~~ '~1+ ~ ~~~ ~ i~ ~ ~ ~~~~~ t 1