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HomeMy WebLinkAbout020-1052-40-050'Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Persorial information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Jendre~ack, Richard Hudson, Town of CST BM Elev: Insp. BM Elev: BM Description: gab G3+M t G ~ TANK INFORMATION TYPE MANUFACTU ER ~ ~ CAPACITY o00 Septic ; ~ ~ ~~ ~ 75~ J t'~ ~ ~t~ ~ Sz Aeration Holding TANK SETBACK INFORMATION Z~ ~b D~c+~, TANK TO P/L C r WELL BLDG. ~0~. Vent to Air Intake ~Oc~~+R-- ROAD Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH L' t Friction Loss System He TDH Ft Forcemain Length Dia. Dist. to Weil Cnll ARCnDDTInAI CVCTFM ELEVATION DATA County: St. Croix Sanitary Permit No 506172 0 State Plan ID No: Parcel Tax No: 020-1052-40-050 Section/Town/Range/Map No: 20.29.19.196010 STATION BS HI FS ELEV. Benchmark ,~ ~ ,6/• /~ AIt.BM, 1~ ,•y 7 Jdz,TZ Bldg. Sewer St/Ht Inlet ?~ 55 ~ 0 ~ 7J St/Ht Outlet ~ ~ ~~ I Dt Inlet Dt Bottom Header/Man. /b •S.S •~ • 7 5 Dist. Pipe /~. ~S ~/ . ~ 9'O ~ M 5 81.35 Bot. System / ~ • too ~4 . S oW Final Grade `.,Ct.+.) ~~, 55 ~ ~ 7 5 St Cover, ~~ ~/ ~ ! ~2.7Z ~,,, T 1 ~ 1. j,S Bpi • (p~j BED/TRENCH Width ~ Length ~ ~ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. ~- Liquid Depth DIMENSIONS 'j a. / 0 5~ 7 `f` 3 /~~ _ ,, _ _ J~ I v..w ~ •, ~_ SETBACK SYSTEM TO P/L BLDG WEL L LAKE/STREAM LEACHING Manufacturer: -~ '~ .~ I f , ~ ~ CHA ER OR 1G~N V INFORMATION Type Of System: ~ ~ 16 ~ /~ ~ LIN Model Number: u c~~ o C Z7 Z ~ ~ a~ nieTDtnIITInA1 cVCTGM e_ __r~ V.'_I_ lt.1 ~-•1G ir)~ -'SF~ Header/Manifold ~ ~ Distribution x Hole Size x Hole pacing Vent to Air Intake ~ ~ ~ ! Pipe(s) i \ S `' Di Dia Length pac ng a Length enn rnvGD ,, c.,..a......- n.. i.. ., ne..~~.,rl nr er_rrarlo Svcfwms only ~~~ ~ ~-/ ~ Depth Over i ~ Bed/Trench Center Depth Over ~ ~ Bed/Trench Edges ~ xx Depth of Topsoil ~ xx Seeded/S dded Yes No xx Mulc\hed \ Yes No ~~ COMMENTS: (Include code discrepencies, persons present, etc.) Location: 826 Dorwin Road Hudson, WI 54016 (SE 1/4 SE 1/4 20 T29N R 1.) Alt BM Description = ~~• ~'~ C'O J -~.JL_ 2.) Bldg sewer length = GNP ~f-t~`t Inspection #1: / / Inspection #2: / / 19W) NA Lot Parcel No: 20.29.19.196 10 o~~ p~ ~,~.~~ ~,~~t~ GI,~~: ~~ ~-' Lo a v~- n ,~ * ~~ commerce.Wi,gov Safety and Buildings tvtst unty ~ ~ G ~ ~ M 201 W. Washington Ave .Box 7162 , ( ot 1C !C ^ f ~ n ~ ] ~ Madison, W 153707-7I nary Permit Number (to be filled in by Co.) t)eVpartVmeVrtt o^t Gomm^erce ~j p ~ ) `7 Z Sanitary Permit Application State Transaction Number In accordance with s. Comm. 83.21(2). Wis. Adm. Code, submission of this form to the appropriate governmental ~~ unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are d f Project Address (if different than mailing address) ary or secon submitted to [he Department of Commerce. Personal information you provide may be used u oses in accordance with the Privac Law, s. 15.04(1)(m), Stats. ~~ ~ $ Zlp O C~ t.J t v., 1. A lication Information -Please Print All Inform Pro ny O er's N• me / ~~ ~ re ~ ar Parcel # 4 - l 5 -~d ~ D~ZS Property Owner's Mailing Address IYIQY Property Location / / 9, / _ ~ ~, I~ {~ ~ ~ / ~ C Govt. Lot Ci .State Zip Code Flt y,, ~''~ ~/, Section ~~~ t r S t;//t~ ~ J CC• Y etrcle one T ~ N; R ~ E o~W~ 11. Type of Building (check all that apply) Lot # , ~~, ~ nr 2 Family Dwelling N~imher of Bedrooms ''^" ~~~~ Subdivision Name Block # ^ PubticiCommercial -Describe Use ^ city or ^ State Owned -Describe C'~se CSM Number ^ Village of ' 3 ~ Town of ~i S!'~~ l l ~-IS ~- /5 Gl 3 ` ~ lctr,-,t oe. w lll. T ype of Permit: (Che only one box online A. Complete line B it applicable) A. ^ New System ~-Repiacement System ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System (explain) B• ^ Permit Renewal ^ Permit Revision ^ Change of Plumber ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner ~~ l,.,r~~_ ~~ IV. T e of POWTS S stem/Com onenUDevice: Check all that a I OLNOn-Pressurized In-Ground ^ Pressurized In-Ground ^ At-Grade ^ Mound > 24 in. ofsuitable soil ^ Mound < 24 in of suitable soil ^ Holding Tank ^ Other Dispersal Component (explain) ^ Pretreatment Device (explain) V. Dis ersal/Trea ent Area Information: '" ~ f" p IPr Design Plow (gpd) Design Soil Ap+lication Ra~(gpdst) equired (sf) Dispersal Ar~ Dispe~sal A~ea Proposed (st) Syste E{e [iqp~~„ ~ ~~ t Vl. Tank Into Capacity in Gallons Total Gallons # of Units ) M ufa curer !/ q /~ / y ~ y G ~ ~ V New Tanks Existing Tanks / -, e JtiCp~(Lt3j,+~t d o o. v U ~ 3 'v, y to .~ m w C7 R a. Septic or Holding Tank ~ /D~b D ] 1 t Dosing Chamber Vll. Responsibility Statement- I, the undersigned, assn responsibility for installation of the POWTS shown on the attached plans. Plu bet's Name (Frio Plumbe ature RS Number M Busine~P~~u tee! !/~` ~ Plum is dress (St eet, City. .Zip Cod c r-- : ~ ~a~ ~~ ~ 6 ~~ ~ f ~ VIII. Coon /De artment Use Oniy ~pproved Permit Fee Date Issued Issuing Age 'nature ySD . ~ s fy o-, even Reasot rDenial J J' A/,, IX. Condit~,#-~~N~teasons for Disapproval ~~~reh C ~ S 1 ~ a~S /~r~'~ C „[ „~(,~ ~~j~ ,V` 7~ ~l~( t ( / Gj 1. Septic tank, tsffluent filter and ( t ~ , ~ :dispersal cefl must all be services / mainfalned 3) ~_ _ ^ s ~ aQ~ o~ G~,~,4~p ~, as er m J ` ' p anagement plan provided by plumber. ~ 2. AU se~baok [equiremeMa roust be main~lned 5 a~5 '- r-• -rr~n t62Mm'ptlTC~lnR!lrf6pMte system anu submit to the t.~ounty o_nlty on paper nor tess utan a ua z r t mcues m Brae //'~ ~~ U L ~I 5 b~e,~.~ ~Gnn ~ Gl. ~ 4 ~.OL SBD-6398 (R. Ol/07) Valid thtu 01/09 ~ G o ~C.~ o S~l~r S a ,~ a rS ~~' / I~tLC ~ r r~ i ~., I t^~v~ ~ JS - Safety,and Buildings Division County ` 201.W. Washington Ave., P.O. Box 7162 SI ~ SCO ~On' ~ 53707 - 7162 Sanitary Permit Number ( e filled in by Cp.) ! / (608) 266-3151 De artment of Commerce ,,, , . Sanitary Permit Application State Plan I.D. Num In ace d with Comm 83.21, Wis. Adm. Code, personal information you provide y be used for secondary purposes Privacy Law, s15.04(lxm) Project Address 'different than mailing address) I. Application Informah n -Please Print All Information Property Owner's Name Parcel # Lot # Block # Property Owner's Mailing Address P nY Location ~ Section '~~ ~~ City, State , Zip Code Phone Number , ~ '~ (circle one) T N; R E or W Type of Building (check alt the apply) II . Subdivision Name CSM Number ^ I or 2 Family Dwelling -Number of Btdrooms l -Describe Use r bli /C i ^ P u c ommerc a ^ State Owned -Describe Use ^City_^Village ^Township of III. T ype of Permit: (Check only one bo on line A. Complete Line B if applica e) A' ^ New System ^ Replacement S m ^ Treatment/Holding Tank R lacement Only ^ Other Modification to Existieg System B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ it Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber O er IV. T of POWTS S stem: Check all that a ^ Non -Pressurized In-Ground ^ Mound > 24 in. of suitable it ^ tub < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding T Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ De ine ^ Gravel-less Pipe ^ Other (explain) V. Dis rsallPrestmeat Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsfJ Di teal A Required (st) Dispersal Area Proposed (sf) System Elevation VI. Tank Info Capacity in Total Nu anufadurer Prefab Site Steel Fiber Plastic Gallons Gallons of nits Concrete Constructed Glass New F,xisting Tanks Tanks Septic or Holding Tack Aerobic Tmatment Unit dklSlag t'dlanlblr VII. Responsibility Statement- I, the aade tgaed, assume responsibility for i e POWTS shown on the attached ph-as. Plumbe~ s Name (Pent),, , (( Plum 's Signature M ~ Busines Phone Numbed ,(~ G/~V ~~- / ' S J / t umber's Address (Street, City, S ,Zip e r ~~ f /~~~ S U tJf VIII. Coun / De artment Use On ^ Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater D to Issued Issuing Agent Signature (No Stamps) Surcharge Fee) ^ Owner Given eason for Denial IX. Conditions of Approve easons for Disapproval \ 1 .; _i, . I ~:. , Attach complete plain (to the Conaly only) for the system on paper not laa a!lA,~;7;,11 inches iq¢j~e. ;tt,. ~, ,, SBD-6398 (R. 01/03) GG {~ e(~c~ f'vs- .~p Fvdl~.~.df.in /~e~orf ~oV' `. ~tCUef.~r~ ~L~~I L.,~1,L.V\'~j~~'!~r`7 ~e~q(~'e~ do k' ~ 1~U~ ~ 1 }}^^~~ ~ } - .,~ goo ~-~. YO L''+Y~ It ~ ~ ~ P ._ has fi -- r----- o ~_ ~~.~r~ ~ ~ ~ ~ ~~~ t c~ e, ~ ~. ~l e y_ a7" 1 1 ~-! l~le ~ ~s~~ a~ ~ ~~~r 1'iossr ~ N Rt? ~ s tX/ cee~ta~i.- o ~' houS e, ~~~ a a 0 h W--~-~ ex.~~h~,nS ~e1pay ~ p~'ts P ~/ !!!! ~ ,Q~( ~1~a ~~( Sc~~~c~ ~ ~e~~be[~-ioa ~~~~~~~, ~ pM~ as;f : ti t~ee~ E/. ~ loo. ~ `~ S~~/~, t,'h ~ ~ of.~ 7'~, S PJY~a/ f-~?~ 3 ~~~e~ CG, a, /p, 1•~f~,sr ~et-- .~-~ ~ a ~ o ~ 7J ~! ~ ~/~ ~ t i ~~~ ~\\ ~~ ~~"' ~-~_ U 4j ~~~4 ~ ~ '~' ~.. 3 ~~~'t~e~ ~~~~ ~S CkA~,~ e~'~ `~o~a ~~e~~~ ~l~v.~fi~~``-~9-ql~~ „ ;~. ~ `' ~,~ ~ alt ~ ~~ ~ ~J,~ . ~C e ~ ~^>r -Sa~ ~ y d lu.d-fi`az /deport rotes 11 11 3~~ ~ QiC~~d ~~1~dre~a,~~'~l~~ia~d `Te~q~-~eJ dck ~ ~- ~"~ ~ ~ ~~ ~ ~~ ~X.S~`.~ ~~of~'nc °~c~,- c~ : h t da !~ l~~e ~ 7~a~ at ~ e~~; -~ T- 9~~ ~~ `~~6~ r.{ ~{~ ~ s ~ Cet.t~ry- o f' houS e. ~~ ~G~tle. fiYl_ ~ ~~T'"E" ~ZX c"~7` k! ~l crp, dtrs.ens i ol~t ed~ ~ s r a. ,~ 0 6 ~'~? ~I~~/Q~ .~ a v h ex.'sr~'h~, S ~cpay ~ ~.'tsI ~~ b~ ~ ~~dene ~ ~ Cab d ~ ~~~ s ~~~ .. ~~,... r P ~~ ~ ~ ~\o~ ~ ~ .d y' a i -L --~~I ttrex e~~~ ~ ~'S C~~-~,~ erg `~o~a, ~ { ~~ev~C~. ~~e~.a~t3~~'-~9-q1,~ ~a~~~ wen ~ Wisconsin Department of commerce SOIL EVALUATION REPORT Page ~ of 3 Division of Safety and Buildings m accvraance wr<n t,omm ao, vvts. nam. was ~~ sfi ~ 6 o i~ l~ Attach com lete site lan on a er not less than 812 x 11 inches in size Plan must p p p p . include, but not limited to: vertical and hor¢ontal reference point (BM), direction and- percent slope, scale or dimensions, north arrow, and location and nce nea t ro parcel I.D. O a p " ~d •~' (? - 0.5-4 Please print a!J fniormatlon. R ~ ~' Date Personal information you provide may be aced for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~/ ~f S 7 ~ Property Qwner c `j ~i:y ~ek ~ r e RECEIVED d ~ k Pr perty Location p . L.ot .S ~ 1!4 S~F 1/4 .ZU T Z 9 N R ~ / t-(or) W Property Owners Mailing Address ~ ~ o e ~ r-.. ~ ~ ~ APR 2 7 2 0 0 7 ~ # Block # - snba,-0lartfe or CSM# v z .~ F''1~~1 City State Zip Code Phone Number City ^ Vllage Town Nearest Road 1 l-ludspti U/.I' ,,,~~}©~ ST.CR I COIZN~Y (Ti,~) S~ ~- a f ~wd~6~ Da-~w,yi R d New Construction Use Residential / Number of bedrooms .3 M yh Code derived design flow rate ~.,a d GPD (Replacement ^ Public or com mercial -Describe: /V79 ) / it Parent material ~/ a c, ~ I ~r ~ ,~ / Flood Plain elevation if apdicable .p[~ / General comrnertts Y e e ez~, rri ~- ~ ~ t' rr Cti cLGB ~-v s"/'~ /t'~ C4i n and recommendations: ~ ~C~ ~' G-^ ~ ' ~ t01^ ~ ' ~~ ' f r Q 4 ~ µ r V r t ~e OL~ ~p Fq r . . K J~ ~)f'Y chi wCli at l ~ d.y 6CkS r s` d ~ ~a h ~.~c~ oy H, or a. dclove vhr~i~k/ ~.vA /e y-o ~ e~' .it fo ~l,e .rdy ~ /dj~<'1'v .~-,d f eti,'d !. 7g a-tcehc~ ,3lre ~`ra tH SfiST`P~.-, wVwl Gl • eP k~,-E.- .3 `I ~ cc,/ok 4 t~yi ]r-S- ~4 4 6~d~Uah, sy s>~e.n 4,0 «,l o! r e ¢ ~._.. L P 4 S ~ ti."c ~ 4 _ uh~t - Boring g Boring # l ~ S e~1 pit Ground surface elev. ft. Depth tolimiflngfador~~pU in. Soil A icalion Rate Horizon Depth Dominant Color Redox Description Textuee Structure Consistence Boundary Roots GP DAF in. Mansell Qu. Sz. Cont Color Gr. Sz. Sh. "Etf#1 "Eff#2 a ~ ~ - 36 7.sy sf6 e OS v s e. w ~ O. / >~ ~-~ ~s~ /~ .~- os ~ 1 v o Boring # I^~ Boring ,IEY pit Ground surface elev. ~~~ ~ ft. De to limiting factor ~ / ~ ~ in. Soil iption Rate li~-izon Depth Dominant Color Redox Description, Texture ~ rudu."e C.^nsietertce Seundary Roots GP D/1F in. Mansell Qu. Sz. Cont. Color r. Sz. Sh. "Eff#1 •Eff # 2 P - ~ ~ - ® 7.S 3~ - cos s d c w / a- 7 ~- 3 ~,l 7S~ df>~' - ~ s ~ ~ o. " Efl9uerrt #1 = BODS > 30 < 220 rr>!q/L and TSS >30 < 150 mgJL 'Effluent #Z =GODS < 30 ngn. arts t ~ _< Ju ~~ -- CST Name (Please Print) Signature ~ CST Number ct. d ~-- !>: S 1'1le ~s t~ ~1 6~~~~-~" ~ a.,o 6 7 3 Address Date Evaluation Conducted Telephone Ntmtber u ,~' ~/.~' 7 i `~ >~ ~ Sfi,~ ~' //sc~o r ~~ C.~~'.3'~ l! 4~ 17~b 7 7/S = x,73 - 3~ 30 ~,,... ~„~ m,V,w,,.. ~Q P L Property Owner ~ + i C ~ J ~ ~ ~ e 4 ~V e~ d ~ k Parcel I D # ~' ~ ~' ~ p3 °~ ~ Q~ ®`~~ Page ~ of a ~~~ # ^ Boring dd > pit Ground surface elev. ~-1' -oC, ft. Depth to limiting factor ~~D ~ in. Sal ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP DliF in. Munseil Qu. Sz. Cont. Color Gr. 5z. Sh. 'Eff#1 'Eff#2 I 0-/0 /!~ ~'~.~~~ ~.- S ~ .Z ~' r ~,., ~~ a_ s ~ m cam. ~ l- C7 4fU 6/b ~ ~ y ~ a_~ 1. ^ Boring # ^ Boring ^ pit Ground surface elev. ft. Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant Color Redox Description Texture Stnx*ure Consistence Boundary Roots GP DHt? in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#'I 'Eff#2 ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Sal A iCation Rate Horzon Depth Dominant Color Redox Description Texture Stnxture Consistence Boundary Roots GP D/tF in. Munseil 4u. Sz. Cont Color Gr. Sz. Sh. 'Eft#1 *Eft#2 "Effluent #1 =GODS > 30 < 220 mglL and TSS >30 < 150 rrg/L 'Effluent #2 = BODS < 30 mglL and TSS < 30 mgA_ 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.07/0D) .~ k et~ ~'~ ~vl ~"v~z~uafi,'o~ I'~eport F°-^ 3a~ 3 l~-c~a--d ~TeHO~~'eJ dck ~ ~- ~~ po ~• w; h ~' d .~ 8oa ~'+ ~+ _~ i„tell ~ I ~flth ~ f ~ ~d r »~. f1oa~ v H RP ~ s ~ cor-pq.. b ~' ~ouS' 2.. o~ w ~~~o cc'y' .~ ~d.s- D ~~~ y eX.'rr~~n~ $. ~~~ody ~ p~.t~, ~~1 S-~~~~, 1,,~_ ~ 4 0~- C~.x cep7' w heve., d in.Qns- opp 6dJ ~= .,Z•aci: cd~cs se; ~ beMihq~ ~/1,'s pd~~-~f l~~' s~ dc~~~rl C~ ~,~ f ~s We,6.r tc r ~/ ! 7/O 7 BMA na;/; h t`ee~ el..~ /oo. U ®~ 9 ~v ~ F~R° J .Q ~o` ~~ s .~ d a V ,~y Z ~l S ~e -4 0 h w.ri, vawac> vv vi.i a SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owne uyer Mailing Address Property Address ~` ~ ~~;/~ GIJI , .~ 2''Ul b l le~J (~~r41,1 (Verification required from Planning & Zoning Department for new co ction.) ~~jj City/State ~~ S~~ ~ i , Parcel Identification Number ~~(~ °~~,~~ ' C~ ~~~ LEGAL DESCRIPTION nn Property Location ~ 1/4 , ~ t/4 ,Sec. ~, T d ~ N R~W, Town of %L ~ Subdi~Tision `~"~ 4 ,.Lot # ~ . Certified Survey Map # , ,~_ ~ ~ ~ ,Volume / Page # Warranty Deed # ,Volume ,Page # Spec house yes no 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. 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. Uwe 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 _~ SIG TURF F APPLICANT(S) ~/~ /~7 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} STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. ViALSH Document Number WARRANTY DEED STGICROIXO~DEEDI This Deed, made between Randv D. Dookins and Trina M. RECEIVED FOR RECORD Do~kiTTS husband and wife. Grantor, 08/29/2003 01:30PM and Richard M Jendreiack and Kristine Jendreiack, husband and wife, MARRAHTY DEED Grantee. EXEl~T # Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin REC FEE: 13.00 TRANS FEE: 752.70 (if more space is needed, please attach addendum): COPY FEE: (See Attached Exhibit "A") CC FEE: PAGES: 2 Recording Area Name and Rey,trn_ A~re~s ~~ 304 LocxiSt Street Hudson, WI 54016 020-1052-40-000 Parcel Identification Number (PIN) This is homestead property (is) Exceptions to wazranties: Easements, restrictions and rights-of-way of record, if any. Dated this ~ 1 ~ day of August , 2003 __ ----- * * AUTHENTICATION Signature(s) Randy D. Dopkins and. Trina M. Dopkins, _ husband and wife, ---- .rr•~..aa~.r,.• ,v of August , 2003 i d ---- - TI e~ ER,S~ATIv BAR OF WISCONSIN authorized by § 706.06, Wis. Stats.) ~ //~O * D. Dopkins * Trina M. Dopkins ACKNOWLEDGMENT STATE OF ) - ) ss. County ) Personally came before me this day of -- _- the above named to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY Attorney Krishna Ogland * Hudson, WI 54016 Notary Public, State of My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Hoth are not necessary.) .) * Names of persons signing in any capacity must be typed or printed below their signature. Information Professionals Co., Fond du Lac, wl STATE BAR OF WISCONSIN 800-655-2021 WARRAN'T'Y DEED FORM No. 2 - 1999 EXHIBIT "A" vot.2394 I'r,~1602 A parcel of land located in the W%z of the SE'/. of Sec. 20, T29N, R19W described as follows: Commencing at the SE comer of Section 20; thence S89°04'06"W, along the south tine of the SEY., 1339.70 feet to the east line of the W % of the SE'/.; thence N00°52'45"W, along said east line, 1213.05 feet to the NE corner of that parcel of land described in volume 1487 of deeds, page 533 at the St. Croix County Register of Deeds Office; being the point of beginning; thence continuing N00°52'45"W, along said east line, 168.61 feet to the SE corner of that parcel of land described in volume 509 of deeds, page 126 at above said office; thence N88°04'39"W, along the south line of said parcel, 144.21 feet; thence N01 °55'21 "E 4.43 feet; thence N88°04'39"W 83.49 feet; thence S01 °55'21 "W 4.43 feet to said south line; thence N88°04'39"W, along said south line, 502.79 feet; thence S09°05'16"E, along said west line, 206.81 feet to the north line of said parcel of land described in volume 1487, page 533; thence N89°05'25"E, along said north line, 374.63 feet; thence N74°33'23"E 98.27 feet; thence N85°22'15"E 35.59 feet; thence S63°52'38"E 59.34 feet to said north line; thence N89°05'25"E, along said north line, 141.95 feet to the point of beginning. St. Croix County, Wisconsin. `~''~~ _`~ft%': System Management Plan ' Pu~`suant to Comm 83.54, Flis.Adm. Code -- ' 8ectic Tank - • The septic tank shafi~tie maintained by an individual certified to service septic tanks unCer s. 281.48, Stets. The patents of the septic tonic shall be disposed of in aaordance with NR 113. W is. Adm, Code. The operating pndiion of the septic taNc aced outlet biter shall be assessed at least once e~rery 3 years by inspeC.ian. Tne outlet fiit£.- slag he ~t:aned as necessary to ~~ P'nt~ open- The ~~ cac~idge should not he removed unless provisions are rrsaCe to reGat somas in the tank that may sough off the 18ter when removed from ~ ~~~. if the ;r7ter is equippeC wfih an - „ the yitet s,'tiap he serviced if . the Maim is aC3vated pntintau~y, t tl'ber alarms septic tank shalt have ~ patents removed when the volume off indkmte stage bows or an irresending t~trtnurous ann. the •_ the tank. >f the pnterns of the tank are not sludge and scan in the tank excesds 1/31he vchrme of • the'ovrner of when the next service needs ~ br~0"~ at the time of a triennial assessment, rnyntartance personnel sha8 advise the tank. The ad~ton of bio pe~nnsd f4 maiNain teas than maximturr st.,rm and sludge ac~rar~on in However. g suCr b9~ °f tom! additives to enhance sep~ tank perornrncs is gimpy rat required. 8ta~ngs are used they shag be approved for septic tank tree by the Departrnent pf ~ Safety and ' Rueeeo Tank . !+'~Y proPmerabon. g an bebiue~ gar is instated v~hirthe taynk k shag ~ mss. and pumps shag be tt'st$d b be Inspected and serviced as nom. At- rode ComDOnent and Presstire Distribution S stem ' o.trees.or s ru s s ou e p sate or a ove to grog on the component. Plantings map be made around the perimeter and the component shall be seeded and mulched as necessary to prevent erosion and to provide soma protection from .frost genetration. Traffic (other than for vegetative maintenance) on the component is not allowed. Cold reacher install- ations require the component to be heavily mulched for frost protection. Influent quality into the at-grade system map not exceed Z20mg/L BODS, 130 mg/L TSS sad 30 mg/L FOG. Influent f1aR map not exceed the maiimum design floe specified in the permit far this installation. . ~~~p~edw~ta lateral be of eked ~~ at k3ast oc pornt at the eras of eac~ lateral. and b is ceco~nendgd that b teat when the ayatmn was ir~ ldeta'n ti orNks ~ p~ ~ be ~ n vr&hin ~ cam. Leaning is Observation pipes vi thin the dispersal cell shall be•checked for effluent ponding. Poadiag levels should be reported to the ovaer and any levels above 4 inches considered as an impending hydraulic failure requiring additional, mote frequent monitoring in acrordaace vith•Comm 83.52 (2). General •~ ~s system shall be operated is accordance xith Comm '82-84 FTis.Adm.Code and shall be . maintained in accordance with it!a component manual SBD 10570-P'(8.6/99)•aad.local and state tales pertaiairig to system maintenance and aaintenance reporting.- No one shou&i ever errter a saptfc or pump taNc ~ dangerous gases ~;-y be present that putd cause death Septicand -.~ PTS~~ ~ ahap be ~ ~" wolf Cortun 83~, 4Vis. Adm. Code when the tanks ale no kaget used as ~r ~~~s. ~xss risers and putts should be inspac~d for water tiQfd gtd somdness. Access . ~ ~ sha8 be sealed watertigtd upon the prrr of servke. -Any W>~9 deesrted ~ seamed ~ ~ to failure trntst be replaced. Exposed access o~arirgs ! than 8-irCtes h dPameter sha8 Sr.4.4~1fnt-Plan ~denfal or unauthorized entry ir~o a tank or component. . '~ tom' 9,on. bepma detective the tads or aunponent sh29 be repaired or repl~d b keep the ~ . ~~~~•p~ omrtrots. alarm or reed wiiiip bewares def~nre the detoGive cariportent sfml be .. ~- artep w8lt a parponent of the same or equal pedOCrtmr!ce- grade cam anent"fails t'o accept ~astevater o~'ir~3nsi'to iliac rge vastevater-to the t~o~d outface, it aa9 be necessary to iaatall ap aerobic pre-ersat:aat unit or ., .replace the component. Additional site aad•soii•avaluations say need to be done.aad eddit~ional pleas may'nesd to be prepared. and apppoved by the Department of Cotimerce,~ Befell and 8uildings~Diviaioa. ~ ~- _' f ~Queationa .a-boot the op~raeiou~or aaintenance of ~thia system sho-u].ri~be directed to: - srl` (~"o~~ --• The Conaty~Zoniag Office at _-_ ~ ,- _7~s. 3$~_ H~$~~ G The system installer ae __ 1~$_ ~2S- agSR W ,, The tank manufacturer at _ ~pp_3Z.S_$ S~, VVI~CS~'R . The effluent filter' manufacturer at app - 221 ~ S7~ Z, Zt'C'@t~„ N ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This ~ s t ce i that I ave ins ected the septic tank presently serving the ~~~ ~ ~° ~ ,Q ~ reside nce locate at: ~~ 1/4, '/4, Sectio ~; Town N, Range Town of ~ S~'j /~ , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of service Did flow back occur from absorption system? Yes ?C No (if no, skip next line.) Approximate vol e or length of time: Capacity: y1 Construction: Prefab Concrete ?~ Manufacturer (if known): Age of Tank (if known): gallons ~_ minutes Steel Other (Licensed Plumber Signa ) (Title) (Date) ~ C~~ (Print Name) ~~ ~~~ (License Number) M /MPRS Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code)