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HomeMy WebLinkAbout020-1376-47-000 (2)Wisconsin Departrient of Commerce PRIVATE SEWAGE SYSTEM Safety end 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 Sen busch, Joet Hudson Townshi SST BM Elev: Insp. BM Elev: BM Description: / 0 I C ~~ ~~ rl C\/A TIAAI 1"\ATA IHIVr~ IIVr'VRIYIHI IVIV TYPE MANUFACTURER CAPACITY Septic ~ n ~ !` d- Dosing ~ Aeration Holding TANK SETBACK INFORMATION TANK TO P/L t7 WELL BLDG. Vent to Air Intake ~ ROAD Septic ' r U l a U I ~ I ~~ , Dosing s Aeration Holding PUMP/SIPHON INFORMATION Manufacturer `~ GPM Model Num TDH Lift ' ti oss System Head TDH Ft Forcemai Length Dia. e Snll ~RSnRPTInN SYSTEM VVV rr\~w.• /r\ county: St. Croix Sanitary Permit No: 405040 0 State Plan ID No: Parcel Tax No: 020-1376-47-000 STATION BS HI FS ELEV. Benchmark S. ID5 , OD ' SiD~ naCt Z • ~ ti 3 Bldg. Sewer ~ ~ ~~ ` SUHt Inlet ~ • ~ /,r~. `` ~~ SUHt Outlet q q !~p- l~ Dt Inlet Dt Bottom Header/Man. ~ .~`2 ~ ~ , 0 rl l D' ipe I Q• ~' ~ ~ (p~~ Bot. Syst h V• 1 Final Grade ~.3 ~ Z ~ V St C r.1 C BED/TRENCH DIMENSIONS Width ~ , Length No. Of Trenc PIT DIMENSIONS `/ No. Of Pits Inside Dia. Liquid Depth SETBACK SYSTEM TO P/L BLDG WELL i LAKE/STREAM EACHING HAMBER OR Manufacturer: INFORMATION Type~f^S,yste/m~:'~ W ~' ~V`c-v ~- ~-y~ ~ ~VI ~/ I / UNIT Model Number: r11CTRIR11T1nIU SYCTFM 4Jv"i,AK/ Header/Manifol/d / 5 / ~ Length Dia Distribution r _ Pipe(s) . ~ Length Dia it ~3~c~g / x Hole Size ~ x Hole Spacing ~- i Cnll CnVFR ,, o.e~~...e c..~te...~ only rr Mnnnrl nr Ot_(;rade Systems Only Depth Over i X Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center '~ ~ BedlTrench Edges Topsoil ;Yes ~~j No Imo] Yes [ ] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/~~ Inspection #2: / / Location: 963 Florence~Lapnbe Hudson, WIn540~16y(SW 1/4 NW 1/414 T29N0R-19W) Sweet Gr"a'ss)Farm~Lo/t~49 Parcel No: 14.2~9.19~.g231~0/~~ 1.) Alt BM Description = "-.L s~~t~~ "~"" A~~I~-'t- ~`~h~-~r r~w~rn.~'~'o ~ a-rc.~G~~ ~ S~o~-r6~f~~~ D i ~~i~/ a ~ I ®pw, ~ l~.o~(- d..v~ccvlra~n~e1 0~,- ,o e~.c~`~~ ~1e~', b-w~.~~t.CN~n 2.) Bldg sewer length = a$ ~a., L . -_~ ~~ -amount of cover = ~ G~"~"r, ~ ~ 3,5~fi Use otherls de for additional Inl Yes .. o ,~ ~ /~ fM ~ (l~p formation. - _ .~' _ ~ - - -- -- - ~ -- - Date Insepctors Sig ture Cert. No. SBD-6710 (R.3/97) 1 (%l~'h 6.tir L ~i.J 't Vent to Air Intake Safety and Buildings Division 201 W. Washington Ave.. P.O. Box 7162 County ® `+~O~~I~ Madison, WI 53707 - 7162 Siu A De ~ tment of Commerce - -O L ~ ~ ~6 3 '- Sanitary Permit Application ~o ~a fo In accord with Comm 83.21. Wis. Adm. Cade. personal information you provide , ^ Check if Revision ma be used for Priva Law, a15. 1 m I. Application Information -Please Print All Information Stau Plan I.D. Number Property Owner's Name ~~ Parcel Nutn 1 -'L - I . 'E~~ oZa -l3~ -~f ~-rr~o - ~ C Property Owner's Mailing Address ~ ~ ~~ ~ ~o~~ n It f ~ ~ y. ~ '; ' tJ Sf lf; S N. R l~ City, Stau Zip Code Phone Number ~ Y Lot N ber Bloek Piu~ber g ZON1NG pFF~CE Sub vision Name CSM-I~luenber~ .~ s Type of Building (check all that apply) / `~ (~Q~ss~~ ~ ^City 1 or 2 Family Dwelling -Number of Bedrooms 7 ~~s.SP~eatrl~ ^Village / ^ public/Commercial -Describe Use ~T'ownship ,~ ~,1 ^ Stau Owned Nearest Road rt .7 III. Type of Permit: (Check only one box on lice A (numbering scheme for internal use). Complete line B if applicable) A. 1 ~ New 2 ^ Replacement Sysum 3 ^ Replacement of 6 ^ Addition to For County use sum Tank Onl Eris ' sum Permit Number Dau Issued B. ^ Check if Sanitary Permit Previously Lcstred IV. Type of Permit: (Check all that apply)(ntunbering scheme is for internal use) .~ ~a.-Q d4-`l~• , g4~Noa -Pressurized In-Ground 21^ Mound 47 ^ Sand Filur 50 ^ Constructed Wetland ~ ^ pn ~.{}m~ 41 ^ Holding Tank "~48 ^ Single Pass 51 ^ Drip Line 45 ^ At-Grade 46 ^ Aerobic Trea ent U ~t 49 ^ Recirculating 30 ^ Other , D' tment Area Information: ~ - 3 ~ V . Design Flow (gpd) Dispersal Area Dispersal Area oil Application Percolation Rau sum Elevation Final Grade /Days/Sq.Ft.) (Min./Inch) IIevadon osed Rate(Gals d Pro i R . p re equ ~ ~ 7 i~ , 3 VI. Tank Info Capacity ~ Total Number Manufacturer Prefab Site Steel Fiber plastic Concreu Constructed Glass Gallons Gallons of Tanks New Existing Tanks Tanks Septic or Holding Tack ~ - >'~ Dosing (:hanfber _ aj~ VII. Rt;xponsibt7lty Statement- I, the tmdearsigrred, responctbility for installation o the POWTS shown on the attached plans. Plumber's ame (Print) ^ Plumber' Signa MP/IvIPRS Nttmber Business Phone Number ~ _ ~ 3 ~~ 1 Pl s Addtess (Street, City, S u, Zip e) ~ }t!~ ~ ~ -r-~ VIII. Count /De artment Use Onl Sanitary Pernut Fee (includes Grotrndwaur Dau Issued Issuing Agent Signature (No Stamps) ~pproved ^ Disapproved Surcharge Fee) ^ Owner Given Initial Adverse ZZ~ ~_ ~ ~ ~ Deurmination IX. Condi~~ti~~o~~n~~spp of ARprovaUReaso for Disapproval ~ u~cu~n,'~a,t~n.D cad ru-` C ~ C,e~ ~ vr~ci.vl(.~S ~ SJe~sx.c~-s ~ , r~'' _.W`a.. c " - - _ l l Sit clew.,. n., />pt uMn~N~AMEN~I ~ , Attsidt comp plans (to the Co~mh od7) for the system on nor lean than 8112 x 11 Inches In sire SBD-6398 (R. OS/O1) ~° J 1 1~ "/ t~ - ~ ~, '~ ~ ~ .~ ~. ~~ _ G ~ ~~ fi ~ ~~ \~` O ~ \ I III M ~ - ~ v ~~ ~ ~ -~ ~ ~~ ~ ~ ~~- ~~ ~ ~ ~~ ~~ p~ ~~, ~ ~L ~ •1 ~"`--~~~ Z `~ 1 ' a'' \~ 3I ~ ~l \ O 00 ~ ~ R~ ~ ~~ ~ `~ 1 ,~ ~ _ _ ~~ ~~ ~ ~: c; - ~:`~ ~ ~ 0 ~ r `~ ~ ~~ 1 ~`~ ~ ~~ \ ~~ ,~ Z \C\ tl r ~'~~ \ ~ ~ ~ - ~~ ~~ ~~ Inv -/ ~~ ~ ~ r ~~ ~~ ~~ \ ©~ M ~~ ~ ~~~~ ~ ~~~ ~~ ~ k ~ ~~ ~ ~~ _1~ ~~~ ~~ ~ ~~ ~~1 ~ ~,~ {\ (~~~ ~ ~ ~ ~ \O ~ _~ ~~ ~~~_ -~ \cc~~~~, ~0 ® e ~~~~~~ ~~~~ ~ ~~ ~~ ,~ ~~~ ~ \~ ~~ ~ fi ~ ~~ ~~ ~M~ _~ .~ ~ _ ,~ .~ W ~l 3 0 c ~ 2 ~ ~ R ~ \ ,,,~ ~, ,~~~ a'.~ ~b/ ~ ~ ~~ ~ -"~- T ., 4 ~.~„.~~ ~~rr~y~~~ . .7 wisconsirfDepartment of Commerce SOIL AND SITE EVALUATION Division of Safety' and Buildings Page , of Bureau•of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County / include, but not limited to: vertical and horizontal reference point (BM), direction and s ~• C ~ t percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION -Please print all in I Reviewed by Date Y f Y Personal information you provide maybe used for secondary pure s~( Yv~cyLavu; s. 13.04 (tJ (m)). ~ 2(Q ~Z Property Owner p ~ I ` _ s\ C. tUl)-I- { `~.. ` ~`, ,~ /' Property!,Location Govt. Lot':.(-t~ 1/4,(~(.~.1 i/4,S / ~/ T2 cl ,N,R /y E (o~ Property Owner's Mailing Address ? ~ ~ ~ ~ ~ ~ ~ Lot # '~ ,lock# Subd. Name or CSM# t ~ C a r~ u~ee I ~ ~ ~ ~ wee- rois5 phone Number City State Zip Code - ` [~ Town Nearest Road ge ^ City ; _' ^ Villa } (~' ~y ~ 1 ~ ~~~`7^1,LL U`3~'; ~~~n ~U 1 ~ ( g / l~vG~ rjG n ~a/c it Cam. ~~* r`-~. ,. New Construction Use: Residential /Number of bedrooms: ~`-~ Addition to existing building ^ Replacement Public or commercial - DescPlbe Code derived daily flows ~ ~ gpd Recommended design loading rate • ~ bed, gpd/fl2 ~ trench, gpd/ft2 Absorption area required ~s7 bed, ft2? trench, ft2 Maximum design loading rate ' ~ bed, gpd/ft2~rench, gpd/ft2 Recommended infiltration surface elevation(s) ~S' 3 ~ ft (as referred to site plan benchmark) Additional design/site considerations ~ d /~ Parent material ~ Flood plain elevation, if applicable ./Ga`T' ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system ^ S ^ U ~ S ^ U ~] S ^ U ~] S ^ U ^ S ®U ^ S ~] U E Boring # .~,; Ground elev. ft. Depth to limiting factor 1(.g_in. Boring # ,ffi Z Ground elev. q~`Lft. Depth to limiting factor II`1 in. w~~ u~~a,.n~r ~ ww n~rvn ~ Horizon Depth Dominant Color Mottles Structure i t B d Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Cons s ence oun ary Bed ,Trench t o-~ i 1.312 s, I I malok c~ I v y . Z~- 3 Z ~ -y~ ply ~~ ~ Z k ~; - . ~ ; . ~ °Is ~ Remarks: I 6-~ Id r31z 5~l ~ m-~r lv~ . Z ; .3 Z -~I Z 1 r y ~4 ---- ~~ ~ c 5 - -~ : ~ ~ Remarks: CST Name (Please Print) S' cRure Telephone No. G ~ ~G dYf u ~i'" ~ - ? / S-Z y7- ~/UUff Address / /~ Date CST Number /I~ ~~ ~ ~~'''1~i'S'e-~' WI. S7G~r C-~-LI GG ZS33G SOIL DESCRIPTION REPORT PROPERTY OWNER PARCEL I.D.# Boring # 3 .~ Ground elev. ~~_ft. Depth to limiting factor 11 (o in. Boring # L~ Ground ^^~~lev `i`T~ft. Depth to limiting factor 1 Jt~ in. Boring # Ground elev. `9.88 ft. Depth to limiting factor 11-1 in. Boring # Ground elev. ft. . ~`` ~ . Page 2 of 3 Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench ~ -~~ i0 ,-3)2 ~ I I m-~r ~ I u-~ ~ 2 ~ ~ 3 Z ~83~ c`I~`I " I ZmQbk ~~r cs -- .5 ; . 3 3~--~~ - ~ y~ _ .L ~ Remarks: ~ - 5 I~ ~~Z --- 5~~ bk mfr" LS ~~ . Z ~ . 3 Rio t `~/cam ,s ~ ~5 .~ ~ - ~ Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots PD/tt2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench i -1 l 3 2 --- S; I 1 r LS ~ v ~. 3 ~ i-n~ ~ ~ ~tl~ i z~s m~ ~ .-~ ; ~ ~ Depth to limiting ' factor in. Remarks: Remarks: SBD-8330 (R.9/98) .; / i PAGE~OF~ NAME $'fCSC~-L- LOT#~~ LEGAL DESCRIPTION~'W '/,GG~'/4,S/y TZ~(,N,R/9 E (ory~ SCALE: I"= )CJU BM I ELEVATION ~UQ - C) BM I DESCRIPTION-fnp p~Z`^prc P,p~ ~7'~w~~la~ BM 2 ELEVATION ~ ~, BM 2 DESCRIPTION ~,~ a S 2 "(~JC.Tp~t_~t/F~u,~ SYSTEM ELEVATION ~~ ~ /~ ALTERNATE ELEVATION ~~• w CONTOUR ELEVATION ,4~~ ~- I ~-~I ly \~ •a o X33 . • d ' DATE ~- i G~ POWTS OWNER'S MANl1AL 8t MANAGEMENT PLAN Paee ~ of FILE INFORMATION Owner ,, Permit # n 5 D O DESIGN PARAMETERS Number of Bedrooms ^ NA. Number of Commercial Units ~ NA Estimated flow (average) gal/day Design flow (peak), (Estimated x 1.5) gal/day Soil Application Rate gal/day/ft2 influent/Effluent Quality Monthly average* Fats, Oii ~ Grease (FOG) s30 mg/L Biochemical Oxygen Demand (BODs) x220 mg/L Total Suspended Solids (TSS) s 150 mg/L Pretreated Effluent Quality O NA Monthly average** Biochemical Oxygen Demand (BODs) s30 mg/L Total Suspended Solids (TSS) s30 mg/L Fecal Coilform (geometric mean) s 10' cfu/ l OOmi Maximum Effluent Particle Size % Inch diameter SYSTEM SPECIFICATIONS Septic Tank Capacity al ^ NA Septic Tank Manufacturer ^ NA Effluent Fliter Manufacturer ~ ^ NA Effluent Filter Model ^ NA Pump Tank Capacity gal .ANA Pump Tank Manufacturer ,i~'NA Pump Manufacturer ~f NA Pump Model ~ NA Pretreatment Unit NA ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: Manufacturer Dispersal Cell(s) ~ In-ground (gravity) ^ In-ground (pressurized) ^ At•grade O Mound ^ Drip•Iine ^ Ocher: * Values typical for domestic (non-commercial) wastewater and septic tank effluent. * * Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ~ ^ months year(s) (Maximum 3 yrs.} Pump out contents of tank(s) When combined sludge and scum equals one-third (Ys) of tank volume Inspect dispersal cell(s) At least once every ~; ^ months ,~. year(s) (Maximam 3 yrs. ) Clean effluent filter At least once every O months Gd year(s) Inspect pump, pump controls 8t:alarm At least once every ~ ^ months ^ year(s) 1~'>;NA Flush laterals and pressure test At least once every O months ^ year(s) NA over: At least once every ^ months ^ year(s) ~NA Ocher: At least once every ^ months O year(s) ~NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Maste Plumber Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servidng Operator. Tank Inspections must Include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually Inspected to check the effluent levels In the observation pipes and to check for any 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 (S~) or more of the tank volume, the entire contenu of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with ch. NR 113, Wisconsin Administrative Code.. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatement components, and any other maintenance or monitoring at Intervals of 12 months or less 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. START UP AND~OPERATION For new conswctton, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemical chat may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents nt ,~,,, ~ ~ny~.~ rn~++ovn~ w ,~ canrw? ~arvi<1nv onerztnr nrtnr r.n ~icP System start up shat not occur when Boll condltlons are frozen ac the tnflttratlve surface. Page~_ :,f During power outages pump tanks may HII above nortttal htghwater levels. When power Is restored the excess wastewater will h~~ discharged co the dispersal cells} In one large dose, overloading the cells} and may result Jn the backup or surface dlscharl;e ~~r effluent. To avoid this situauon have-the contents of the pump tank removed by a Septage Servicing Operator prior co restoring; power to [he effluent pump or contact a Plurtfber or POW`i'S Matntalner to assist In manually operating the pump cuntrob to restore ncrmal levels wlthln the pump lank. Ga not drive ar park vrhlclres over tanks and dispersal cells, po not dt1ve or park over, or otherwise disturb or cc~mYact, the ari ~ wlthln 15 feet down slope of any mound or at-grade soil absorption area. Redt~ctlon or elimination of the followir+.g frorn the wastewater stream may Improve the performance and prolong the life of the POWTS: ant(biotics; bevy wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; dlslnfecUnu; fat; foundation drain (sump pump) water; fruit anti vegetable peelings; gasoline; grease.; herbicides; moat scraps; medications; oil; palntJn~ croducts: aestkides: sanitary napkins: tamtzons; and water softener brine, AKANDQNEMEN? When the POWTS fails andior is pemzanentiy taken alit of service the following steps shall be taken to Insure that the system is property and safely abandoned In comp0ance~ with ch. Cornet 83.33, Wiscons(n Administrative Code: • All piping to tanks and piu shall be disconnQCted and the abandoned pipe openings sealed. • The contents of af{ tanks and pit's shall be removed and property disposed of by a Septage Servicing Operator. • After pumping, all t<3nks and piu shall be excavated and removed or their covers removed and the void space filled with ~c+il; gravel or another Inert solid material. CON~'INGENCY PLAN If the PUWTS falls ar<t ~3nnot he repaired the following measures have been, or must be liken, to provide a code compliant replac ent system: ~P, suitable replacement area has been evaluated and may be utlltred for the loc;atlon of a replacement soli absorption system. Thr replacement area should be protected frorn diswrbance and compaction and should not be Infringed upon t,~ required setbacks from txlsting and proposed ,structure, lot Ilnes and wells. Failure to protect the replacement area will result In the need for a new soil and site evaluation to eswb(Ish a suitable replacement area, Replacement syster~ts enlist comply with the rules in effect at that tltne. o A suita>le replacement area is not avallabfe due w setback and/or soil limitations. Barring advances in POWYS technology a holding tank may be installed as a last resort to replace the failed POWTS. D The site has not been evaluated to ident(fy a suitable replacement area. Upon failure of the POWTS a soli and site evaluation must be performed to locate a suitable replacerr-ent area, tf no replacement area Is avallabfe a holding tank may be installed as a last resort to replace the failed POWTS. Mound and at•gradr soil absorption systems may bt recortstrvcted In plate following removal of the biomat at the Inflluatlve surface. Re<onswc~ioru o(such rystems must comply with the rules in effect at that time. < < WAiEtNING> > SEPTIC, Pt1MP ANb t~7rt~ER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFIGI~NT OXYGEN. DO NOT ENTER A SEPTIC, PUMP UR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATW i~AY RESIiLT~. RESCUE 4F A PERSON FROM TtrdE INTERIOR Of A TANK MAY BE DIFFICULT OR iMpdCC1Rl i ApDt710NAL COMMENTS POWTS lNSTA L , Name __ ~ ~ 1 - ' ~= ate Phone , ......._ __._._.. - - P01kTS MAINTAINER Marne ____ -- Phone _______.___~ SEPTAGE SERVICING OPERATOR (PUMPER) LOCPIL REQItLATORY AUTHORITY _ Name I ~ A~ene;, , Phnnv +- ~~ ^. __.......~,...,.~. Phone ~X ~ ~~ .. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer _ J o e ( .Se r e_ ~~, s,~ ~ -_ Mailing Address l~ Zj~ /1/~~-e f~r~~~,? S~- .~ 3 ~o ~c,~.c~son L.J~' -SYcT~(~ f ! ~ Property Address (Verification required from Planning Department for new consi City/State Parcel Identification Number LEGAL DESCRIPTION ..Q~-° - ~3~ - y~1_~ ~9 Property Location ~tJ y., .NtJ ~/4, Sec. ~, T,~_N-RAW, Town of hr~.d sorb Subdivision acs ~ e ~- ~~, ~ r ,Lot # ~9 Certified Survey Map # ,Volume ,Page # Warranty Deed # ~" ~~~~ ,Volume lg~~ ,Page # 3~ Spec house O yes IBJ no Lot lines identifiable ®yes O no SYSTEM MAINTENANCE Improper use and maintenanceof 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. The property owner agrees to submit to St. Croix 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 wastewaterdisposalsyscem is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than ~I/3 full of sludge. I/wc, 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 Office within 30 days of the hree year piration date. / ,r 1 / /~l ~ 7i GNATURE APPLICA T DATE OWNER CERTIFICATION I (we) certify that al! statements on this farm are true to the best of my (our) knowledge. I (we) am (arc) the owner(s) of the property described above, b virtue of a Warr y deed recorded in Register of Deeds Office. ' ~/ G/~z ATURB OF AP ICANT DATE ****** Any information that is mis-represented 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 a copy of the certified survey map if reference is made in the warranty deed .~' U 1877P 37S • ~ STATE BAR OF WISCONSIN FORM 2 - 1998 6'7 7 fb 6 0 ' WARRANTY DEED KATHLEEN H. MALSH REGISTER OF DEEDS ST. CROIX CO. ~ MI Document Number I RECEIVED FOR RECORD This Deed, made between TANET P STnIIT O 1T d S 04-24-2002 8:30 AM . ~ an T RICHARD O husband and w; fe WARRANTY DEED r Grantor, EXEMPT # !' and a.~I,~~pLCnrrcr~u ~,,.a g~y~na r REC FEE: 11.00 ~l ~ h ,~h d d c N~' cr TRANS FEE: 170.70 t~ . e~ a an ~n BiT. F ~uT COPY FEE: CERT COPY FEE: ~: '~ Grantee. ~~ PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following '' described real estate in $~} _ Crn i x County, State of Wisconsin: 'Recording Area '' Lot 49, Plat of Sweet Grass Farm, Town of ' Hudson, St. Croix County, Wisconsin. Name and Return Address ; ~' EAGLE VALLEY BANK, N.A. 1301 Coulee Rd Unit 2 ii ~, r Hudson, WI 54016 ~~ 020-1376-49-000 I' Parcel Identification Number (PIN) ~'', This i S riOthomestead property. ~i ii (is) (is not) ., .. ,_ . - - r ----- -_~ _-._L_ I I .r - NORTH UNE OF THE S1/2 OF ~E NW1/4 SECTION 14 ~-~ N8~oa4 "- - _ a, McCUTCHEON RO_A_D - - _ Ne0'4e'a0`E 10a4.0e' `/x°31 bl.~ MAjNANaRL~E40' •- •--•--- -_. I -.~ ` ~ ~~~+~ EMENT ~F ~ ~. ~ '~ -~ rn r,'~ ~ H ~! ~ T Yp r ~ g ~ .9j3.5 . ~OqC 1MIN BUILDING ELEV. s 017.a . i . . .: ~~ I 33' 33' 1~ ~ ~$~ .. .. ~ a ~ J .~- O I m ~~ / ~ I ~ ..._.. _ im i i' is m i . i ~i I ~ . ;1 C24 ~, . .: ~~ ~ ! A ~. v N ~ ' ~z ~ . . , ~~sn~ E -or-~i~ . ~. LOT 46 2.a4 ACRES 110402 8Q FT . . H.W.L. = 024, a. ~ . . 14' Ne0'46'a0'E LOT 47 2.aa ACRES i 11020 eo FR aaa.14' 7 64.08' LOT 48 2.aa ACREB 111020 80 FT LOT 49 2.a8 ACRE6 111348 6Q FT LOT 50 2.a4 ACRE8 Hone so ~ Nesa°aa'ao•e . i. . MIN BUILDING LOT 7f ELEV.: ~0,p 2.74 ACRES 11048a eQ F 11--.~~ ~~ J J ~i~ 11aa.1s' H.W.L.. 080.0 Q MIN BUILDING MIN BUILDING `{ ELEV. =0.91.0 ELEV. = 03o.a 'E 1000.0T MIN BUILDING ELEV. =031.0 ~ LOT 74 2.33 ACREB _ 1 o12e9 8Cf ~ MIN BUILDING y~' ELEV. = p30.a ry ' -~