HomeMy WebLinkAbout020-1388-06-000Wisconsin Department of Commerce
Safety and wilding bivision
PRIVATE SEWAGE SYSTEM
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
La Crosse Develo ment Hudson Townshi
CST BM Elev: Insp. BM Elev: BM Description:
~~
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic
zvv
D '
Aeration .--~'~
°__
olding
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD
Septic y r ~ ~ r /
Dosing _ _ - - _ _ _ -- --
Aeration
Holding
PUMP/SIPHON INFORMATION
anufacturer
Model Number r`'~
TDH Lift ion Loss
Forcemain" Length Dia.
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length
DIMENSIONS ~ ~
z
SETBACK SYSTEM TO
INFORMATION
Type Of System:
DISTRIBUTION SYSTEM
1~
f;N%
N
rr/
1 Head TDH Ft
st. to Well
~ r S Cct
No. Of Trenches
3
P/L BLDG WELL
ELEVATION DATA
county: St. Croix
Sanitary Permit No:
395293
State Plan ID No:
Parcel Tax No:
020-1388-06-000
STATION BS HI FS ELEV.
Benchmark
~~~
.s
ov
Alt. BM
9
Bldg. Sewer
'UZ
9:~3
S t Inlet
S t Outlet
/a. ~Z
90.
Dt Inlet
Dt Bottom
Header/Man.
Dist. Pipe M A l~'Y U -0'I
Bot. System
L ~ t 1. ~ D
Final Grade /wJ
rL (v?. 9
/ • f '~
Z • CY
St Cover fr
~, z 9 _ z
33 ~-i ~ ~ ~
C
lo-r`~r~ ±33 ~ ~ (~
Of Pits
ING
HA B OR
Depth
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
r~
Length Dia Pipe(s) { ' / '~ / /
Length ~ Dia Spacing~~ ..i .~- 7 3,~ /
SOIL COVER v Praecura Svs4amc [lnly xx Mnund Ar At-Grade SVStemS Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
Yes [] No
~ Yes ~ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/~_/~ Inspection #2: / /.
Location: 963 Sadies Lane H~u/dson~ WI 5~4J016 (SE 1/4 NE 1/414 T29N R19W~ Field Haven Lot 6 Parcel No: 14.29.19.2380
1.) Alt BM Description = ~/~ oT ~"`^'~^~1r„~~:,n- - ~'~~ ~i2'~ ~ riv~o~ ~~i~e ~~a~ tUa_5 i~CVrvt~
2.) Bldg sewer length = Z/ ~ r CST
~ ~ 5 Gt4C 4,~ TIC (JI'll~rr l6~
- amount of cover = > ~/ b M dk z cv~s ~Ys frr~~~ / / _ /
;~ O65tr r/w~ie+- roipC s iN. b f~//a~ ~~ L.~ OK ~y ~ 7utrC~ Q 4 i~L.S7~aP ~~d Qr l~~I ~ht
Plan revision Required? ^ Yes j No
Use other side for additional information. D d
SBD-6710 (R.3/97) ate Insepdor' Signature/ l Cert. N,o.
P4 T'~nfJ~ ~/i/~ ~t `y,~r SGt,w~,C >`/CVQ,p~M-
// ~
`:~
~~ .~ ~ ~5
~, ~~~~~~ s~~~ ~
(~KQ.
,Prp~o~ r~
$y
K
~~ tip` b`~-
~~
r
l
I
i
D,rt~P~r'ttf ~ ~~~ ~
_ ~--~
~3 ~
aw, z ~ g ~` ~ ~~wS~~J
,ha'<< ~~
L~ ~
~~
\,,Qe
~~w~.
~ 3 ~ Es L,~E ~~ t~ s3 i 7
Sanitary Permit Application Safety & Building; D
`~seonsin In accord with Comm 83.21, Wis. Adm. Code
See reverse side for instructions for com
letin
this a
li
i 201 W µ'ashingto
PO B
Department or commerce p
g
pp
cat
on
Personal information you provide may be used 1'or secondary purposes o
Madison. N'I 53?0
(Privacy Law, s. 15.04(I)(m)( (Submit completed form w counn
state ~
Attach com lete tans (to the count co onl )for the s stem, on a er not less than 8-!/2 x ! 1 inches in size
Counp
J C~
' State Sari ary Permit Number ^ Check if revision to previous application
S2 3 .
State Plan I. D. Number
1. A lication Information -Please Print all Information
Progeny Owner Na
me LOCatlon:
~
~~ ~ ~
~~A~ A ~
~ Property L
o
cation
A
gi~'A~d~dr'es~s
Progeny Owner's Ma^ili~n hh
~~
(,
~~ I /4 4~~/q, S f 7 T~~~,N,
S ~ Lot Number 81ock Nur
•
C'~ry State
/ /
Zip Code P.~erre7~(uinber-.
Subdivisi~e or CSM Number
11 Type of Building: (check one) ~~
I or 2 Family Dwelling - No. of Bedrooms:~ ^ City
_
O Public/Commercial (describe use): ~^~'•r~~~ village
'
Town of
~ State-owned ./~ _ Q ` ~ s ~ :' ''AT
" ,
,
III
Type of Permit: (Check only one ox on line A. Chi;t;k~box on f=`itte: if ap~kcabl~~..
M1 Nearest Roa
r
A)
l New System
2. ^ Replacement A
3
^
R
'' ~
L
.
.,
t,place
q. ~7 n to
~ Parcel Tax Number(s)
B) S stem Tahic;Orrl Ex`t i S stem
T
^ A Sanita Permit was reviousl issued Permit mbe~_
.r •- ~~~ Date Issued
IV. Type of PO WT S
stem
Ch
y
: (
eck all that apply) •~_..m°,o..--
~Non•
r
ss
i
d
020--~ ~3g$
CX
p
e
ur
ze
ln-ground
~i..Ser/ ^ Mound ^ Sand Filter
^ Pressunzed In-ground ~
b ` ~ ^ ...
v-opp
^ Constructed Wetland
c
Noldin Tank
O .At•grade / g ^^ Single Pass
^ A
^ Drip Line (~• Zg, (q .
/ ~
ero c Tr tment Unit.--r/!LZ~-o~'~circulating
r ^ Other:
Z31
V Dis er al/'1'reatment Area Information:
I Design Flow (gpd) 2. DispersalArea
Required 3. Dispersal Area
ProposedS3~ 4. Soil Application
Rate (Gals./day/sq. ft.) 5. Percolation Rate
(Min./inch) 6. System Elevation 7 Final Grade
Elevation
~~ °~ ° ~ GJ
~s
~ / ~yJ~G
VI Tank
Capacity in
Information Gallons Total
Gallons N of
Tanks Manufacturer Prefab t
/
Site Steel Fiber• Piasuc
New Existing Con• Con-
glass
Tanks Tanks Crete s tructed
V11 Responsibility Statement ~
1, the undersi ned, assume res onsibilit for installation of the POWTS sho n the attached tans.
Plumb c rin) Plumber's Sig tur n sta
~~p{/~(/J ~~ M MPRS No. Business Phone/Number/
Plumber's Address (Street, City, St te, p Code) Q~S 7~S- ~(~ ~ ~~~^
~ ~~ ~Y~o
VI11 County/Department Use Only
^ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued
Approved ^ Owner Given Initial Adverse Surch ge Fee) ~ Issu g Agent Signature (No stamps)
Determination ~,,~~ ''~ ~ ~ 1' ~t t
IX. Conditions of Approval /Reasons for Disapproval: ~/
tiE' Spa.. ~ d ~ ~~~~+~s 5~~...~ w ~~~:. ~•,' ~ ars,Q~ .N~LQdI
l~ D.~ WOK/~Z ._. ~- ,~j~,~,,t,u,.~,,, ,l~.~fita ~C,~1/, ~] .
ae po.~
Na-- 1
~~bo ~.~~
- ~s ~,~- ~~ -, ~yo,
,~ -ioo z
~5~ . yi sa
ioa ` ,vb-,--~ -~
Brea-9sss ~T~°~
o u~-^
ff a~`-
13c•. ~~-e- ~,
%y ~ ~ ~~`
~.
s
/ ~
20 357
C
~~- ~
%oo ~ fD '
~- ~s ~-~-~ r~ -~~yo,
~~ -iao z
~~
ff a~-
_ yob f ,~~ -~-~ 13 ~-~-
~ ,,
`"~/
I~,~ p t~-,-~~.
"~, .
Zo35~
~seonsi~rDepartment of Commerce
Division of Safety and Buildings
SOIL EVALUATION REPORT
Page ~ of
In accoroance vwm t.omm tsa, vvis. rwm. was
Plan must
11 inche
in size
8 1/2
l
t l
th
At
l
t
it
County Sf CrUi
.
x
s
an on paper no
ess
an
e
e s
e p
tach comp
include, but not limited to: vertical and horizontal reference point (BM), direction and parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
Please print all information. R iewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ , ~ ~•
Property Owner Property Location
l~(.ls~ .~ ~ Govt Lot S~ 1/4 NE .1/4 S I y T 2~i N R 19 E (or)~(
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
5 ~ C Rd . A ~ r(eld eve
City State Zip Code Phone Number [] City ^ village ®Town Nearest Road
'N udSon w i y ~ l t ~ t5) 3$I -5y o ~ud5on I'Y~c } n
® New Construction Use: ® Residential / Number of bedrooms 3 ' `~ Code derived design flow rate
^ Replacement ^ Public or commercial -Describe:
Parent material Du-,~-wcc S G~ Flood Plain elevationrf applicabl
General comments SyS ~ ~ G / c v . 9/. so _.
and recommendations: ~J. ~f. e!e V• 9'/• So
.~l(~O ~ GPD
~\'ti ~ ~~' ft.
ST CAOIX
-~ zOhI1NGOFFICE
~r
Bonng
Boring #
® Pit Ground surface elev.9~/•3C) ft. Depth to limiting factor ~ I $ In. ~ _
Soil IK;ation Rate
Horizon Depth Dominant Color Redox Descxiption Texture Structure Consistence Boundary Roots GP D/fP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
D-12 ~0 ~ ~ -- Si l Zrr~ ~~r t S l ~ ~ . 5 • $
2 -2 -32 I ~ ~ y 4 -- SZ 2rr~Sb m~ ~ 5 •5 • ~'
3 32-118 10 ~~I~ - rnS ps ml - -' , 1 1.2
Q~•~~
33•(, ~t'o4~L
Boring # ~ Boring
® pit Ground surface elev. 9'~i • $d ft. Depth to limiting factor ~_ in. Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft'-
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
I b -I l0 ~ 3 - 5' l 2m c ) v -I` • 8
3 I~U(, t~ rye -- m ml - •~ ~• Z
* Effluent #1 = $ODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and t~5 < 3() mg/t.
CST Name (Please Print) Signature CST Number
~C~'~ _ ~<h r~ /1 Pr o ~
Address Date Evaluation Conducted Telephone Number
2//'~ ~m ~-~ ~'nr~,-~e~, l.~ ~,' ~ -fy2r~ 3 -/-a/ Cpl S~Z~7~`IOC~
~~
Property Owner ~ CGSSe Parcel ID #
Page Z of 3
Boring # ^ Boring
® pit Ground surface elev. 9y S'~ ft. Depth to limiting factor I Z l in. ~I lication Rate
Horizon , pepth Dominant Color Redox Description Texture Sbvdure Consistence Boundary Roots GP D/fl?
in. Munsell Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'Eff#1 *Eff#2
I o-rp ID x313 Sid Zm ~s I v-~ . 5 .8
2. 10-22 I ryly - 5~ 2m b m--~( CS - . 5 . `~
3 22-IZI 10 r ti~~ nn S OS m l - -' . ~ /' 2
.~
^ Boring # ~ Boring
^ pit Ground surface elev. ft. Depth to limiting factor in.
Soil lication Rate
Horizon Depth Dominant Cobr Redox Description Texture Structure Consistence Boundary Roots GP D/f~
in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 "Eff#2
^ Boring # ^ ~~
^ pit Ground surface elev. ft. Depth to limiting factor in.
Sal ficatbn Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/if
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 'Eff#2
* Effluent #1 = BODS > 30 <_ 220 mglL and TSS >30 < 150 mglL ' Effluent #2 = BADS < 30 mglL and TSS < 30 mglt.
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.
SBD-8330 (R.07lW)
PAGE~~OF .3
NAME ~ C'aSS e LOT# ~ LEGAL DESCRIPTIONS ~ '/.A/~'/4 S/~/TZq N R Jg E (or)~V
SC~A~LE: 1"= y~
/BM YELEVATION BOO • C~ /
BM I DESCRIPTION N a ~• 1 r n /p" Cio r cl c<< r C~ o s~ r- - -r- x
BM LEVATION 9~. S ~ j ~/ ~
BM2DESCRIPTION~pol; 3/~/~Ca,~Qrr p•oe. w/F'/A,
SYSTEM ELEVATION 9 ~' S~
ALTERNATE ELEVATION 4 ~• sd
CONTOUR ELEVATION ~ 5~ , 9S. p C3
t
4~
3 - fs acs v
.1 POWTS OWNER'S MANI.IAL 81: MANAGEMENT PLAN
„tti G~~uCARMATION
,Owner ~ p~ C,q.S 5 6 1
,Permit # ~ ~ Z9 3
nccr~v DADAMit:'Tii:RC
VYH~Y~~ • . ~.v r .~ - ~---
Number of Bedrooms
^ ~•
Number of Commerdal units ~ NA
Estimated flow (average) gal/day
Design flow (peak), (Estimated x 1.5) fo CJ9 gal/day
Soil Application Rate ~ , ~. gal/day/ft2
Influent/Effluent Quality Monthly average*
Fats, Oil 8t Grease (FOG) <_30 mg/L
Biochemical Oxygen Demand (BODs) <_220 mg/L
Total Suspended Solids (TSS) <_ 150 mg/L
Pretreated Effluent Quality ^ NA Monthly average* *
Biochemical Oxygen Demand (BODs) <_30 mg/L
Total Suspended Solids (TSS) <_30 mg/L
Fecal Coliform (geometric mean). <_104 cfu/100m1
Maximum Effluent Particle Size % inch diameter
SYSTEM SPECIIFIC:A1 wNs
Septic Tank Capacity Z$U al ^ NA
Septic Tank Manufacturer I~t ^ NA
Effluent Filter Manufacturer ~. ^ NA
Effluent Filter Model y}. - t~j ^ NA
Pump Tank Capacity gal ANA
Pump Tank Manufacwrer ~' NA
Pump Manufacturer f~NA
Pump Mode! p~NA
Pretreatment Unit
^ Sand/Gravel Filter
^ Mechanical Aeration
^ Disinfection
Manufacturer
^ Peat Filter
^ Wetland
^ Other: `ANA
Dispersal Cell(s)
$[, In-ground (gravity)
^ At-grade
^ Drip-line
^ In-ground (pressurized)
^ Mound
^ Other:
* Values typical for domestic (non-commercial) wastewater and septic
tank effluent.
* * Values typical for pretreated wastewater.
MAINTENANC;t ~c,tttuuLZ
Service Frequency
Service Event
Inspect condition of tank(s) At least once every ^ months t~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 tSlryear(s) (Maximum 3 yrs.)
Clean effluent fliter At least once every ~ months ^ year(s)
Inspect pump, pump controls at:alarm At least once every ^ months year(s) i~NA
Flush IateraLs and pressure test At least once every ^ months year(s) ~ NA
Other: At least once every ^ months year(s) f~NA
other: At least once every ^ months ^ year(s) ANA
MAINTENANCE INSTRUCTIONS
Inspectioru of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Mas
Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspectio
must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure t
volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground su nd ng ~ ffdtuent~on
cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any p
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 (Ys) 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 ch. NR 113, Wiscon
Administrative Code.
The servicing of effluent filters, mechanical or pressurized POWTS componenu, 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 conswction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemi
that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the come
nr ~s,a rank(s'~ ramovpd ~Y z SentaRe cerviCinR operator prior to use,
P~~e _ of„_
System start up shall not occur when soli conditions are frown at tits Intlltratlve surface.
t)uring power outages pump tanks may fill above nomul hlghwater levels. When power fs restored the exeeu wastewater will be
discharged to the dispersal cell(s) In one large dose, overloadlr>8 the call(s) and may result In the backup or wrface discharYe ul
effluent. To avoid this situation have the contents of the pump tank removed by a SsptaEe ServklnF Operator.prior to restoring
power to the effluent pump or contact a Plumber or POWI•S Maintainer to assist in manually operatlrmg the pump controls to
restore ncrmal levels wlthln the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not dove or park over, or otherwise dtsWrb or compact, the area
wlthln 15 feet duwn slope of any mound or at•grade soli absorption area.
Reduction or elimination of the following from the wastewater str'earn may Improve the performance and prolong the lik of c'me
POWTS: antlblotla; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental Aoss; diapers; dlslnfectanu; fat;
foundation drain Isump pump) water; (mutt and vegetable peelings; ~uoNne; grease; herbiddas; meat scraps; medications; oil;
wlntlnR products. aescicldes; saniean~ napkins: tampons; and water softener brine.
A>~AN DON EM ENT
When the POWTS tails and/or is permanently taken out of service the following steps shall be taken to Insure that the system is
proprrly and safely abandoned in compliance with ch. Comm 83.33, Wisconsin Adminlstratlve Code:.
• All piping to tanks and pIu shag be disconnected and the abandoned pipe opsnfngs sealed.
• The contents of all tanks and plu shaft bo removed and prc+periydlsposed of by a Septage Servking Operator.
• Ahe- pumping, all tanks and plu shall be excavated and removed or their covers removed and the void space filled with
soil, Q~~avel or another Inert solid matrrlal.
CONTINGENCY PLAN
!f the POWTS falls and cannot be repaired the lollowtne measures have been, or mtut be taken, W provl4e a code compliant
replacement system:
O R sulUble replacement area has been evaluated and may be utilized for the location of a replacement soli absorption
system. The replacement area should be protecte4 from disturbance and compaction and should pat tx Infrfrteed upon by
required setbacks from existing and proposed strucwn, lot tlrtts and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to estabNsh a suitable replacement area. Replacement systems must
comply with the rules In effect at that time.
O A suitable replacement area is not available due to setback andlor soli llmlatlorts. 6arrtng advances in POWTS technology
a holding tank may be Instaped u a last resort to replace the falisd POWTS.
O 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 focau a suitable replacement area. If no replacerrlsnt area h available a holding tank may
be installed as a last resort w replace the failed POWTS.
O Mound and at•gradr soil absorption systems may tx retons~tructed In place following removal of the biomat at the
Infiltrative surface. Re<onswalons of such rystems mtrst.comply with tfte rules In effect at that dme.
< <WARNING> >
SEPTIC, PUMP AND OTKER TREATMENT TANKS MAY CONTAIN I.ETHAI GASSES AND/OR 1NSUFFICItsNT
07(YGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREEATMENT TANK UNDER ANY CIRCUMSTaNCES.
DEATH MAY RESUtT. RESCUE 4F A PERSON FROM TKE tNTER10R OF A TANK MAY 6E DIFF1CUlT 4R
IMpf1CCIRl i.
ADarT10NAL COMMENTS
POWTS 1NSTALt,ER
Name t,E-r
Phone ~ ~- ~qq
POWTS MAINTAINER
Name
Phone
SEPTAGE SERVICING OPERATOR (PUMPER
Name
Phnn•
tACAL R)E4ULATORY AUTHORITY
Agency t;rO t L~"O sv //l~
n ~ (o
S'T' CIZOIX COUN`T'Y
SLI'7'IC 'PANIC MAIN'1'1?NANCT3 AGItI?1?MI?N'1'
AND
OWIJI?ItSIIII' CI?It'I'l1~ICA'I'ION I~OItM
Owuet/Buyer G.~4Cb ~~~ ~ ~) 1~,~,~.~ ~•
MAiling Address x'7,7 C.e~ . ~2d ~ ~d,S~~
Properly Address g ~ 3 ~AC~, /~3.5 l ,1 ~ t~_ _ ~~ . _ ~ .
crificalion ~ciluiicd lium Planning UcpaiUncnl for new conslnccli
City/Stole 1~u a ,.
°'''~-. I ,uccl lclalliliculiun Nunll~cr ~rilC' -- ~tJo2t7-7d- ~8d
LrGAL DrSC1211''I'ION
T'roperty Location ~_ '/,, ~''/~, ,~~~, ~_~ 'I'~~IJ-1t1~W, 'Town of _L~t,~,D Sb~I
Subdivisiat l.ol ~i
Certlfiell Survey 111np #
Vc~luntc
1':t6c it
Wt[rrAUty Decd ~~ ~ (/ c` U ~~
Spec house ^ yes [~ no
Lot lines illatliliul~lc ~) yes ^ tto
SYS'1'I;M MAIN'I'I~NANCI;
Improper use and mainlenauccuf yuui scplic syslen, audd ,csult in its pccmatuie lailwe to handle wastes. l'ropermaiulenaucc
consists of pumping out the septic lank evc,y thcec ycacs or sooner, if needed by a licensed punq,er. Wlcal you put into the system
eau affect the fiutctiau of the septic lank as a Iceatmcut stage in the waste disposal syslcm.
The property owner agrees to sulnnit to S1. Croix Zoning Depa,lmcul a ce,liticalion form, signed by the ovimer and by a
maslpr plumber, journeyman plumber, ,cslciclcd plund,cr or a licensed pnmpcr vcc ifying that (I) the on-silo waslewaterdisposal system
is in proper operating condition and/or (2) alter inspection and pumping (if ncccssaty), the scplic tank is Tess than 1/3 full of sludge.
1/wc, Ilw undcrsigncd have read the above icqui~ements and agree to mainlah- the private sewage disposal syslent with the standards
set forth, herein, as set by the UcparUncut of Cunm~erce and the I)cparlmcut of Natural Itesourccs, Stale of Wisconsin. Cettificalion
stating that your a ptic syslcm has been maintained nmsl be conydclcd and tcUuncd to the Sl. Croix County Zoning Olliccwitttin 30
de the hre car expiratlau date.
NA'I'U L~ Or APPI.ICAN'I' /-`' f
DA'I'LY
OVVNTR CI!;R'I'Il!/CATIO
I (we) cerllfy tl at all slatcu,culs on Ibis loon aic Uuc to the best of uiy (our) t:nowlcdge. I (wc) am (are) the owner(s) of
Ih ,crly dcscr' cd ovc, by vi,luc of a wananly decd cccucded in Itcgislcr of 1)ccds Otlicc.
SI NA'I'UItL~ O APPLICANI' -'~--=~~1
llATL~
.••.~*
At-y information that is n,is-tcprescnlcd niay ,csull iu the sanila,y pcnnil bctng revoked by the Zouiug Deparlrnent. *'~~`**•
+• Include w[lh thls appllcallotr. a stamped wauanty decd from llic Itcgislcr of Uccds otTice
a copy of the ceclilicd survey neap if ~cfcrenec is made in the wanauly deed
v~tn 1612PA~.414
1 STATE BAR OF WISCONSIN FORM 2 - 1999
Document Number WARRANTY DEED
This Deed, made between John W. Moravec and Mary A_
Moravec, husband and wife,
Grantor, and LaCasse Development, Inc._ _ ___-_
Grantee.
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in St. Croix_ _ County,
State of Wisconsin (if more space is needed, please attach addendum):
E 1 /2 of SE 1 /4 of N E 1 /4 of Section 14-29-19, St. Croix County, Wisconsin.
641.954
f;a~rHt.CEN H. WAL5H
REGISTER OF DEEDS
5T~ CF;OIX CO., WI
kECEIVED FOk kECORD
G4-G3-2GG1 2:30 PM
WARRAhITY DEED
EXE?IPT N '
CEkT COPY FEE:
COPY FEE:
TRRRSFER FEE: 924.00
RECCRDiNG fEE: 10.00
PAGESt - 1
Recording Area
Name and Return Address
The RiverBank
880 Sixth Street North
Hudson, WI 5401b
020-1020-70-000 _.. _._ __
Parcel Identification Number (PIN)
Phis is homestead property.
Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any.
Dated this ~O _ day of March ____ _ , 2001
AUTHENTICATION
Signature(s) _ __ -_ _ - ..-
authenticated this _ day of _ _ _ _ ____
~. ~^^~~' : tel. ~- ~-
~ Marv A. raves ___-_-
ACKNOWLEDGMENT
STATE OF WISCONSIN )
ss.
St. Croix __ _ County )
Personally came before me this ~~~-day of
March 20UI _ the above named
John W. Moravec and Mary A. Moravec, husband and wife, _ _
TITLE: MEMBER STATE BAR OF WISCONSIN tg,ttl
(!f not. __ -. _ -_, --- ,.~itr
authorized by § 706.0(1, Wis. Stats.) a ,
~•~t~
THIS INSTRUMENT WAS DRAFTED BY 3 !
a
Attorney Kristina Ogland _,_._ _ _ =u- TTDt;
Hudson, WI 51016 _ _ _ _ _ _ _ yy~p fly
(Signatures may he authenticated or acknowledged. Both are not necessary.)?~_~.
Nanxs of persons sieving in any capacity must he typed or printed below theirs ~
SC~
WARRANTY DEED STA TE BAR OFWI
FORM No. 2 - 1999
he the person(s) who executed the foregoing
[o~rnowledged the same.
~ ---
pu lie., Sta' of Wisconsin
i m tiior: i~ permanent. (If not, state expiration date:
,...,~ ,o,~ cl.% ~)
!.! inlormatim Prolessbnais l.anGany. Fontl tlu Lac, W~
w. `r,,. , Bn0{55-2021
M
~~
!T, r
~ ~;, ,~ _ 11 W L 12'l K) \ ~ ~ `~ I tf rlRtlf ft; ~ I 1
%~' / ~ t~rlnn nc; ns, ref n \ I ~ ~ 1 (;a n nl f ~ I
1 / ~ '
/,~ / •y/ ~ e? f I ~ 11 I ~ II\ ~ 191' ., .~ ~ ~ °` I
~ z j
/ ,lE. 1 1 I I ~ ~ 'f . ~
~ -__.
. LOT--1 •' I ~ ' ~ ~ 1 ~o ~° ~ ) ~~ ' ;
.420 AQR~S._ t,;, ~ . E;. ;~.
l I r 264,'1 '' P ~ /
\ I
939.1'.19 ~` ~ I i ~ I I ~~\ fin' ~ I ~
~ ~! 9 i:i.' r' I
' I ~~ ~ ~r
~ ~ I -f 3 7' R"1
t I I I 1, I ) ~ ~ I
1 r
I) ~~ I~ ~ I I I 1' ~, W
[1 ~ \ I~ I ~ m I / / ~ t..
,~ ~ ~ i
~11 J ~ I1 \
LO Z X 939.y`~ ~ I ' I '~O 5
f °' ,.43~ACRES (\ I I ~-/ ;~.1 S~7 CRE _' . ~ z
- / / 1
j (2.13 AC S) 1 ._
~ ~ `~~ ~ ,' (2.13. ACRES) _~-~'~ ~ I
/, ` ~~
i /~ `~ _ -J-- I
r ~ ~ 1 ~
I X 94:3.491 , ~ ~ ~ _ ~ ~ ~ ~
I ~ . ;~
~~ 1 %~ ~
t \' 1
~~ ,
~~, ~" ,, ~\ ~ ~ ~~ ~ ,~ 215' ~ ... , ~ .
`\ ~~ ~ ~/ 93659! ! ~ `~~ ~ /~- `~ -- -934,958
.~ ~ \ ~\ ~
'~ 1
LOT 3 X 93~.1~1 I, I.
~~ ~ l 2.~5$ ACRES ~:
__ ~,
o ,~/ (2.96 ACRES) `~' ` ~. t I
L_._ w ~ ~' x ~ ~
~D ~ .... _ _ to c
~, ' _~--------- - yffl ryA 93.x.495
~ ~ ~ _. I k 933. ?~
~ ~ ` /' .qq~ ~~
,' ` ,, I
` ~~. 6 ACR S ~
` ~ ~ '~
`,1 ,~ ~1 ~ .~ ~.~ x 3ns,or ~ ~ f _
c 1 ~ ~ ~ ~ ~ l '~ ~(2. 2 .1 C~iES
* , ~~
~ ~~
~~~
~~
S00°OTES'W 1316.OS' µ 3o.oa µ
486.58' ~ ~ 7.84 32.53' I
523.77'
1283.52' ~~ ~ iv ~ ~ ~ I
D w .~--$ I
N
v D'J m ~ ~ • '~ -'
~ w t~~ ~~ ~ ~~ ~ ~ ~ ~ • ~ ~ ~~~-~
pm m 8~ ~ D .. ~~ 02
UJ N ~ / ~ "
~ ~ ~• ~ "
- -- -191.49' - - ~ - -134.06' -" " g0~'~9~ ~ ..~
'~ ~ S00°15'17"VV 326.55' y~ N ~ ~
41t a3
~•~ _
,, ~t 3N1~'1 S~IaVS ~•~ ~
N00.15'17'E 325.55' '" ~ ~ ~ ~'~ I'
;'~~ ~. -, ~ 131.30'-. .--•--194.25'- -•--- -~~~~ 2Z ~
N
V
_ ~ ~~ ~~ . I
~ i i
~~ " ~cDi ~ ~ ~ ~ ~ ~ I.
~~ ~n ~ ~ ~m ~ ~ ~ ~~~ I ~ i
N 0 ~ ~ ~-
v
`I ~ ~ t
/ j I
~.-
I
~~ 877.57' ~ I ~ 34.59'1
302.81' 277.99' 296.77
j ~ m N00°i'S'i TE 131 T.TO'
~ ~ ~ ---2sa5.4a---
n~
~ b o NJ~1 ° ~ 4`~CD ~Q[n~D~
Z ~ " OO ~~iCD ~ ~'l O`u~]C~G°3~
~ Q ---------------
-c~
~~o
~ ' UCi
N
n
~~
boo Uf'D
,r3~ / = tea ' ~ --~
~ r~ a = 9S, ~~- ' r
w.
~a S ~ ~~,,
lv
~~~ ~~~
~~ ~
~~
~/ ''
Y
~~V 8
~? `~ao as ~
d
8
3~~
x
a-aX~
~/
xg-3
~~
~3~a ~~~