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HomeMy WebLinkAbout020-1452-14-000Wisconsin 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)]. 'ermit Holder's Name: City Village X Township LaCasse Development Hudson, Town of SST BM Elev: / Insp. BM Elev: BM Description: ~$~ . ~ ~ . ~ / ~~ VIM.#'; ~ C TANK INf=['fRM~TInN EL V TION DATA TYPE MANUFACTURER ~-' L' S ~' P CI Septic t ..~ ~ V~-~ , ~ ~O Dosing Aeration Holding TANK SETBACK INFORMATION . en o irnae eplc ~ ~of ~ 3Z~ osmg era ion o Ing PUMP/SIPHON INFORMATION anu ac urer eman GPM o e er i nc ion oss ys em ea orc eng ia. .7VIL ADJVRr' 1 IVIY J i J 1 GIYI //lf _ \" \ a~Fia~C~C.JK~wwlle.nrt county: St. Croix Sanitary Permit No: 488126 0 State Plan ID No: - ---~~ Parcel Tax No: 020-1452-14-000 Section/Town/Range/Map No: 13.29.19.2902 STATION BS HI FS ELEV. Benchmark `~.~5 D •} ~•of Alt. BM l~..a.~- 3 . °° ~ o I , ~5 Bldg. ewer ~ ~~ Q~. t t net g20 , i~ ~- t ut et .3 96-3~ net 0 om ea er an. ~ ~ ~ I~ I Is . ipe ~.p~ ~. ~ 0 (p , l~• I o. ysem ,fp 1 ~' D ina ra e S'~ / Ob • 2D over 1 ~a Z / o DIME IONS ~ f Q ~ ~C~9 Z~ INFORMATION q CHAMBER OR ~ ~ UNIT ~1r • ~~ _ S ~ UIJ 1 I[16U 1 IVIY J i l l CIYI / ~ Il Length Dia pipe(s) Length Dia pacing - ~ ~ S~ / Jvu. vvv~r~ x rressure aysterns only n,c rvi~ww .,.~ ~.~-.,~a..` ~~~•~~~~~ ~-•••~ Bed/Trench Center IBed/Trench Edges (Topsoil I Yes ~ No I Yes No CO M TS' (Include code discrepencies, persons present, etc.) Inspection #1 • !y7 G~%lCFrispection #2: ~7~ Location: 940 Sadie's Lane Hudson, WI 54016 (SrW _/4 NnW_ 1~/4..1,~3 T29N R19Wr) Bluebird Meadows~L~ota1~4, Parcel No: 13.29.19.2902 1.) Alt BM Description = '(o s~- ~~~' ~+~^~`~^ `~" U`~'" 1 s ~" ~ ~ " 2.) Bldg sewer length = 3 ~„ r (~~ ~ ~ ~ ~ -amount of cover = ~2" {- a~ 'nt"""`^ ~ ~ °5 ~'~"~"~~ 3) 1,~~-Q •w~C c1~s~~ r~1R.dl ~.7~ th~ec~,r, d~a~'~- .__ - - Plan revision Required? ~] Yes ,~ No ~ Z i I ~ !~ ~~ Z I! Use other side for additional information. ~_ ~- ---- - - -_- -------tre . SBD-6710 (R.3/97) .. e" a0l'~ ~~ e and Buildings ivision County 201 W. Washt Ave., O. Box 7162 ~ 53707 7162 /SCO/l Sl/~ p~ p ~'1ldi~o F~ Sanitary ] ennit Number (to be filled in by Co.) (608)266-3151 Department of Commerce Q 2/ l0 Sanitary Pe 't ~~i~~ea ' State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. ode n ormatio pro maybe used for secondary purposes Privacy Law, s15.04(1 m Project Address (if different than mailing address) I. Application Information -Please Print All Information , ~ 9'{0 ~D i ~ s i'_An~~- Property Owner's Name Parcel # Lot # f ' Block # ~ .~ ~ ~ .~~ Property Owner's Mailing Address operty Location '7 ~,~ ~ City, e Zip Code Phone Number ~`~ ~`' ~'~`' Section/ ~ - ~ (circle ~ ~ I T e f Buildi h k ll th l T N; R E or . yp o ng (c ec a at app y) ~ Sra.~ , ~ 1 or 2 Family Dwelling - Number of Bedrooms _ S , Subdivision Name tanber ^ Public/Commercial -Describe Use ~ - 3 ' ~ e ,1 ^ State Owned-Describe Use ~ ^City ^Vill a Township of III. Ty p e of Permit: (Check only one boa on line A. Complete line B if applicable) Ur Z D _ ~ - ~ - p~ ~ 2 90 2 ,~ ,~+ A. ~1 New S stem y ^ Replacement System ^ TreatmenthIolding 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 Non -Presstrriz~in-Ground ^ Mound >_ 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized I n Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treament Unit ^ Recirculating Sand Filter ^ , ~ / Recirculating Synthetic Media Filter ,kY Leac in ham Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersaUTreatment Area Information: ~ S .F- Design Flow (gpd) Design Soil Application Rate(gpdsf) tspersal Area Requi (sf) Dispersal Area Proposed (sf) System Elevation ~ r Vi. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Uni la( Concrete Constvcted Glass New Existing ~ ~ Tanks Tacks Septic or Holding Tank _ .S Aerobic Treatment Umt Dosing Chamber VII. Res nsibility Statement- I, the undersigned, a ume responsibility for installation of the POWTS shown on the attached plans. Plum r' Nam (Prints Plumber's Si MP/MPRS Number Business Phone Number ' °~ ~ J ~~ / Pl ber'~ Address (Street, City, State, ip Code) VIII. Coun /De artment se On Approved ^ Disappreued._, j "~ 'x; Sanitary Permit Fee (yrlcludes Groundwater Surchar e Fe ) ~~ ~ Date Issued Issuing Agent Signature o Stamps) ` ^ en Reason r Denial g e 7 ~` IX. Conditions o prova ""--~ -f SYSTEM OW ER: 1 Septic tank, effluent filter and . dispersal cell must all be serviced /maintained as per management plan provided by plumber. 2. All setback requirement$ must be maintained as per applicable code/ordinances. •~•••-r~•~ r••••s i••• ••~ ~~•••••a~ ougt,.ur me system on paper not ras scan au~ x i - inenes in ales SBD-6398 (R. 01/03) ~ ~~~~ ~-9-..~'~ ~~: ~..~c- , __. ~._.__ , l ~;,~48~J ,~/~~i~S ! ,G,if ~x Ste; ~ ~?~[/~~ _________ . / 1 ,% y~ -sC~ /f ~1'~ES r ~~~ , Li ~ ~~~C~C~~-~~~ 1J~~~ ,~y ' ~ ~. ®~ v f ~_ a 7 1 .~s~ ~~ ~~ ~/iJ.L ~'/ / a ^/t~ ~, _. ____.~ _--- _ Y . ~~,~~-~,r-;H~~f .'~a -, -- i, ,,s'~ I g5 ~ 8; ~ .~~;3-~'~ ~.~~. ~,.;c'. ~s aJ y- /(~~1 ~~ sE~ /.~ T~79~- ~'/~'~J a;:ra4t i~ __ ._ _ ~S~~i~ s ~~f~.~~ \\ ..rte 7', ___ ~._-- Dx' iiG~Jr1~ ~- ~~ ~~~~ ~ ~~J,~1/ 1 n~ ~,~, > .~ ~~,v~~Gn~h'-°~ - ,. ~ o~ ~ ~-'t~P / ;jai' -,F/,/D4.0 / ~~ z~G'~ -sCf ~ _ ~~~e ~~~1~ ~~~~ ~ G~~rkXs ~,1~/~ - ~- 3X ~~s' `~ i!~~~~C~~-L/~,~~~ `r~ //OU,SK ~~// ~S ~~.t~~ J ~~ / 7 ~~ ~ .t..... _....... _.../.__.. _..__....... _. .~~ ~t ~ tit -- _ -i - - _ __._ ~ 8~ I~ ~'' gs ~ 8~ ,,,,~ ,~,,,,e„e,Q o, Sri . 1 `f' ~ ~ s ' rf~ ~' h~ ~ 1494 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's Soil Service, Inc. County Aitach complete site plan on paper not less than 8'/z x 11 inches in size. Plan must St. Croix include, but not limited to: verfxzl and horizordal reference point (BM), direction and parcel I.D. percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Pending Please prn-taH iniormatiop. ewed By Date Personal information you provide ray be used far secondary purposes (Privacy lbw, s. 15.04 (1) (m)). ~ ~ ~ . Property Owner Property Location LaCasse Development , Inc. ? Govt. Lot na SW 1/4 NW 1!4 S 13 T 29 N R 19 W Property Owners Mailing Address] Lot # Block # Subd. Name or CSM# 573 Cty Rd " A" 14 na Bluebird Meadow City S{ate:..Zip.Code PhoaeJ+ttimber..__ _J Gity J Village ~ Town Nearest Road Hudson ~ WI ~ 54016 ~ 715-381-5405 Hudson McCutcheon Rd VJ- New Construction Use: !~ Residential / Number of bedrooms 4 Code derived design flow rate 6UU ~ru J Replacement J Public orcommercial - Describe:na Parent material Stream terraces and pitted outwash plains Flood plain elevation, if applicable na General comments 9~ ' S S and recommendations: Conventional system, system elevation 4r75ft. Trenches spaced and depth to code 4.75ft below grade. l (~ Boring # ~ Boring :J Pit Ground Surface elev. 101.10 fl. Depth to limiting factor 120 in. Soil Application Rate i ti R d D Texture Structure Consistence Boundary Roots GP D/ft' Horizon Depth in. Dominant Color Munsell p on ox escr e Qu. Sz. Cont. Color Gr. Sz. Sh. *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 r-a .4 .6 3 30-47 7.5yr4/4 none cos 2msbk mfr cs na .7 1.6 4 47-120 7.5yr4/6 none ms osg ml na na .7 1.6 uif" RS. o r ~z.3~ g.3b Boring # Boring d Pit Ground Surface elev. 101.10 fl. Depth to limiting factor 120 in. Soil Application Rate i l C tion cri R d D Texture Structure Consistence Boundary Roots GP D/ft2 Horizon Depth in. nant or Dom o Munsell p e ox es Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-17 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 17-37 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 37-56 7.5yr4/4 none cos 2msbk ml cs na .7 1.6 4 56-120 7.5yr4/6 none ms osg ml na na .7 1.6 S'~' . S "Effluent #1 = BODS> 30 <_ 220 mg/Land TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mglL anq 15ti < su mgrs CST Name (Please Print) Signature: 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 715-684-5680 Page 3 of 3 STEEL'S SOIL SERVICE INC. David J. Steel 994 200`" St. CST-POWTSM LaCasse Development, Inc. Baldwin, WI 54002 L1C. #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 14 ~ 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' ~ Benchmazk 1;`le. 100.00Ft of 3/4" pvc pipe '~- l'7~' Alt Benchmazk Ele. 100.00Ft op of 3/4" pvc pipe .~- ^ =Borings Boring Elevations B1 = lO1.lOFt B2 = IO1.lOFt B3 = 99.70Ft B4 = OO.OOFt ~0 w~~ ~~ ,/,,,~~ ,/' - ~. r ~~~ _~ ~ ~'~ ~° ~~ o~ 3S/ ~~ s~~ ,~~ C 1UT' ~ w- ~" ~ ~/ ~ j7~ zy, ~h ~o ~- ~~~,,,~ ~~ 9~ _ ~7_ _c_~~ry~ _ ~ ~ 4, ~ ~ U V UU~ ~ ~ ----~~ p ©~ ~ ~ p ~ i ^ . ~. ~~ ~~ . ~ o ~ .EE ~Ei; ! ~ ~ ~ ;.~-,os I ~ ~ze a s ;3 c~ X ~ I C / ZZ3~ '~ w ~ ~ ~ ~ (1~ W n ~ "'~ } X co m ~ ~ X°D i n ~ ~ ~ _ ... ~ ( s o ~ p ~ :.t i t 0 "~ i I J( t ~ ~ ~ ~ ~ W E ~ ~ X o taE~ '1 X ~ N N ~ ~~ X ~ y ~ ~o N _. ~ _ .. N . ~ ~~ .~.r ~ rw~. `° X : ~ ~ i~w N n -+I T~ 39Vl~IIVBa ~ v w~ ~ ~ ~a1M AE w ~ !~ ~ ~: ~P ~ n .,i ~ ~ N /~ 1~ ~ Op m's's ~ f ~ ~~ • M '_+ i ~W ~ ~ iV W ~ O ~h ~ V / ~ ~ ~ X 3~ ~, I a .~ y~ j 0 .... .... .. .A4' ~_ __ ~, i a F ~ . , ,,, c~ •,~ ~ G~ m ' ~ ~ '~ N. °~ ~ ~ ' a~ ~ iO ~ ~ I a t o :--~ ~ ~~ ~~~ X ~a _~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN =11.E INFORMATION f~'~`f3t,po,fJ~~i~,,,,,~f~/~~ „~~~ .....~..,,.r~ r..,.~~. , ~ .,....,. Owner > i~ Permit # DESIC3N PARAMETERS Number of Bedrooms ^ NA Number of Ptablic Facility Units ~ NA Estimated flow (average) 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 IFOG) s30 mg/L Bioohemical Oxygen Demand (BODb) s220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent duality Monthly average Biochemical Oxygen Demand (BODE) 530 mg/L Total Suspended Solids (TSS) 530 mg/L [~NA Fecal Coliform (geometric mean) s10° cfu/100m1 Maximum Effluent Particle Size Ya in dia. ^ NA Other; O NA "Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Page ~ of Septic Tank Capacity •-,: ~ ~<~; sl ^ NA Septic Tank.Manufaoturer ~ ~~ .~ O NA Effluent F11ter Manufacturer ~ Q NA Effluent Filter Modal ~ - DNA Pump Tank Capacity al fYNA Pump Tank Manufaoturer ~ Nn Pump Manufacturer' >~ Na Pump Model ~ P~~ Pretreatment Unit ^ Sand/Gravel Filter O Mechanical Aeration ^ Disinfection ~ O Peat Filter ^ Wetland ^ Other: ~~+~~ Dispersal Cellls) ~In-Ground (gravity) ^ At-Grade ~ O Drip-Line O Ni~. ^ In-Ground (pressurized) ^ Mound 0 Other; Other - DNA ~ Other: ~ ~ O Nl~, Other; q N/~ Service Event Service Frequency Ins act condition of tankls) p At least once every: month(s) ' lMaxfmum 3 years) aar s , , , Q NG~ Pump out contents of tankls) When combined sludge and scum equals one-third (Ys) of tank volume C] N~ Inspect dispersal cell(s) At least once every; ^ monthlsl ~ (~ earls) )Maximum 3 years) O Nr-. Clean effluent filter At least once everyr O month(s) , ~ ~ earls) ^ NA ! Inspect pump, pump controls & alarm At least once every; month(s) O earls! ~ NA _. Flush laterals and pressure test At least once every: O month(s) c:: ~ O earls) ~ NA other At least once every: ^ month(s) ^ earls- ~ NA Other. O NA MAINTENANCE INSTRUCTIONS ~ '° " "' inspections of tanks and dispersal cells shall be made by an individual parrying one of tho following licenses or cortificaUona Master Plumber, Master Plumber Restricted Sewer; POWTS inspector; POWTS Maintainer; Soptage Servioing Operator. fare, inspections must include a visual inspection of the tankls) to identify any missing or broken hardware, identify any oreoks or leaks measure the volume of combined sludge and scum and to check for any back up or ponding of affluent on the ground surface. Tha dispersal cell(s) shall be visually Inspected to check the effluent levels In the observation pipes and to cheok for any pondln~ of affluent on the ground surface. The ponding of effluent on the g-ound surface may Indicate a falling oondition and requires the immediate notffication of the )peal regulatory authority. '- ~- Whan the combined accumulation of sludge and scum in any tank equals one-third IYsI 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 wfth chapter NR t 13; vVisconsln Administrative Code, All other services, including but not limited to the servicing of affluent filters, mechanical or pressurized components, pretreatment units, and any servfcing at intervals of 512 months, shall be performed by.a certified POWTS Maintainer. A service roport shah be provided to the local regulatory authority within 10 days of completion of any s®rvice event. OMW 14/ut1 Pafle ~, of START UP AND OPERATION For now construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or, other chemicals that may impede the treatment process and/or damage the dispersal celllsl. If high concentrations are 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 fs restored the axoaaF wastewater will f;~ discharged to the dispersal callla) In one larva dose, overloading the oelllsl and may rosult In•the backup o- Wrfaoe discharge v eftluent. To avoid this altuatlon have the oontenta of the pump tank removed by a Septage Servicing Operator prbrao rostorin~ power to the effluent pump or contact a Plumber or POWTS Maintainer to assist In manually operating the pump' controls tc restore normal levels within the pump tank. _ Do not drive or park vehicles over tanks and dispersal calls. Uo not drive or park over, or otherwise disturb or, compact, the area, within 16 feat 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 tr~~; POWTS: antibiot(ca; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental. floes; diapers; dlilntectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicide;;;meat. scraps; tmedlcatlons; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. At3ANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall ba taken to insure that the systern 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 Septaga Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled wiu~ soil, gravel or another inert solid rnatorial. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures. have been, or must .be takan..to provide, a code complian replacement system: .,..... ~, :,,:. ,,, , . A suitable replacement area has been evaluated and may be utilized for the location of a replacement sell absorptio~~ system. The replacement area should be protected from disturbance and compaction and should not be infringed upon b ~ required setbacks from existing and proposed structure, lot linos and wells. Failure to protect the replacement area w. result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems rnu: , comply with the rules in effect at that time. ^ A suitable replacement area Is not available due to setback and/or soil limitations. Qarring advances in .POWT: 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~svil and sits evaluation must be performed to locate a suitable replacement area. If no replacement area is available, a holding tanr 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.. «WARNINQ» _ _. 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 CIRCUMSTANCE8:'bEATH MAY.RE8ULT. AE$CUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSI6LE. ADDITIONAL COMMENTS PO WT8 INST. i~ Name ~ ~ ' _ ~ ' Phone ~ : ~ - POWTS MAINTAINER . Name _ ..r -, . :, ; Phone SEPTAOE 8ERVICINO OPERATOR PUMPER) LOCAL REGULATORY AUTH RI • Name Phone Nams .r ~, 1~ ~., ,~ ' ' Phone ; : :,,. , . , This document was draped in compliance with chapter Comm 83,22(211blltildl&(f) and 83.54(1), (21 & (31, Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT .AND . OWNERSHIl' CERTIFICATION'FORM Owner/Buyer ~..aG.4~ti e, i~,p ~~o ~~,P,4~~ Mailing Address Property Address (Verification required from Planning & Zoning Department for new construction.) L City/State ~~ SGw_ t, ~ ~ Parcel Identification Number OZc~ - !~S 2 -/~-Oa"0~. 2qd L) LEGAL DESCRIPTION Property Location 3 ~,~5 '/4 , ~'/4 ,Sec. ~_, T ~N R~W, Town of -~t,0$o/V Subdivision (~~~_(~,~ ~.~.~.~e,,~ t, ,Lot # Lc~. Certified Survey Map # Volume ,Page # Warranty Deed # ~~"ZZ3(.P ,Volume 210 `fj ,Page # 3`l~_ Spec house yes. no Lot lines identifiable ~ 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. I/we, 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. I/we am/are the owner(s) of the property. described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms ~L- _ SIGNATURE OF APPLICANT(S) ~/ ~ / ®l~ DATE - ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) .. ^~. ~~~ ,~ A Weyerhaeuser Business 1~h f~lnrne Job Number Sheet NORTH CENTRAL REGION Brad Overby 4530 West 77th Street, Suite 200 Edino, Minnesota 55435 Phone 952.896.1115 ~ Fax 952.896.1117 of ~,i~l~nl feprestntative .._---_--------------- By - --- ----- ----- Date ~, 26~I1.,' 3S9 .STATE BAR OF WISCONSIN FORM t - 2000 WARRANTY DEED Document Number This Deeti, made between Ronald G. Raymond, Loretta 8. Raymond, husband and wif® Grantor, and LaCassa Devalo meat, Inc a V~isconsin carporatioa Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in st . Croix. County, State of Wisconsin (the "Property") (if more space is needed, please attach addendum}: Southwest 1/4 of Northwest 1/4 of Sectioa 13, Township 29 North, Raaga 19 PJast, St. Croix County, w2 Together with all appurtenant rights, title and interests. Recording Area ?72236 KATHLEEN H. NALSH REGISTER OF DEEDS ST. CROIX CII. , 4FI RECEIVED FOR RECORD @6!28!28@4 11:55AlY YARRAIi'1'Y GEED EXERT # RfiC FEE: I1. @8 ?RAJiB FEE: 2258.8P1 CQPY FEE: CC FSE: PAGES: 1 Name and Retu Tess 3 C ty Ro Hu om~--~2 54015 ~- f.1~~-~.. tr~~u oza-soil-ao-ooo 4azce! identification Number (PIN) 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 enctunbrasaces of record Dated this da of Au at ZD04 . *Ronald G. Ra AUTHENTICATION signature(s) TraeY ~-. Turner otary authenticated this day of 0 ~ i * TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §7Q6.fl6, Wis. Slats.) THIS INSTRUMENT WAS DRAFTED BY Redmon Law Chartered (.Richard Lau) 2219 Vine 3t., Suits 204, xudson, WI (Sianatures may be suthcnticated or acknowledced. Both arc not neccssarv.) o-t.e.~t~ ~ r -~ /C~- m ~xd * Laratta Pl. Ra oad ACKNOWLEDGMENT STA F WISCONSIN ) ) ss Y ~ County--~~ ~~~-1- Personally came before me this day of Aueust ZOa4 the above named Ronald G. RaYatond and Loretta B. Raygoad hu an n w f to wn to he e n who executed th wledged the same. Notary Public, State of Wisconsin My Commission i~erntanent. (If not, state expiration date: "Names of persons signing in any capacity must he typed or printed below their signature. WARRANTY REED STATE BAR OF WISCONSIN FORM No.1-2000 ~~ Redmon Law 2217 Vine St Ste 204, Hudson W15401(r58ti4 Phone: (715J 386-0100 Fax: (715),386-0700 Redmon Law Chartered T4926305.ZFX Produced with Z)pfoma"' by RE FormsNet, LLC 18025 Fifteen Mile Road, Clinton Township, Mlchipan 48035, (8001383-9805 ~e.zigjgrm.com i '~'' ~~ ~ ~r~ ~~~~~~~ ~ A ~..._~...,..,...... ~- ~ LA~1~ t ca 4 ~~ t L ~~ I ~~ t , ,~ ~~ ~ ~ :° ~ ; \ i ~~ ~ ~~ .. _~~pp, W ss~. ~s ~~ ~~ ~~ [~ ~~ i !~ ;~~, i~"'' !~ }i^~ r wr+~ f ~r '..'r ~""~~ illl +e~ ~w+ ~ ~r~ r~ ~~ ~~ ~~ ,~ ~ ,. ~ ~ 1 » s » • » . » . • .. t • • » » . » .. i . » .. f~. i .. • . »~.. . a ~ • w~ ~w~ ~~~ ++ arm ~ +l N89'44'43'W 3i~8.S1' ..s • .r~Y 4 '~ ~~ ~'' ~'.., ~` ....... ~ . » . , ........ ~,,..•~ • •' itAltUG4»tASEM~F.NT C • .. DRAfitAQE Ens D H.W.L. ~ 93 H.1ilf»L.. ~ 931.i -~ __ /..,- \1 ~~ ^ ~ '"'~ ^ 11~,~~ ~Q. mss, L.A.~?. ~ 933.1 f'~?.48' 3z~.m ~ sf~cM t~sa~ YoR aF ~ ,u,u~~NU~ ~cQU~nr E~.E ~T1 M 934.4 ~'~~.. ~ ~' ~ ~ ~~ ~~ 1 ~.~NE 'TABLIE ~~ ~~ ~lR~1NJ~-G~ ~AS~1~A~1+~T ~