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HomeMy WebLinkAbout020-1398-19-000I Wisconsin 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)]. Permit Holder's Name: Bast, Kernon City Village X Township Hudson Townshi CST BM Elev: /~ l , p" _` L o Insp. BM Elev ~ l~Iv1 Description: ~i ` n ~J ~yYl ~,l (~y~~` TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~ a ~~ Dosing w ,w ; ~ (,) -_ --- ~~, Aeration ` Holding __ TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent it Intake ROAD Septic U / , ~ t / ~ _ Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Numbe TDH Lift Fri Loss System Head T Ft Forcemai ength Dia. ELEVATION DAT county: St. Croix Sanitary Permit No: 420677 0 State Plan ID No: Parcel Tax No: 020-1398-19-000 Section/Town/Range/Map No: 22.29.19.2479 STATION BS HI FS ELEV. Benc mark ' // 111~ff' - D ' it 1 r] I Bldg. Sewer ~ ~I St/Ht Inlet o Sc,~Y~ ~, .r5~ G. 29 st/Ht o~~ut~t ,ScN Sfe 5.7D G ~ t "] Dt Inlet ~ '-~_ Dt Bottom r s ~f ~ ~ Header/Man. p ~ ~ 17Y~ C1 3 , Disc. P_,J2B., 2 Y. S'~ ~ • 't Bot. stem I ~~,~ Z-.Z Final Grade st c~l ~ Z.1 ~ 94. 7i SOIL ABSORPTION SYSTEM 2 X (I b}~(- I [-/ / `ftLLi~.L_.. BED/TRENCH Width ~ ~ Length ~ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ ,~ ~ ~ SETBACK SYSTEM TO P/L BLDG WEL LAKE/STREAM LEACHING Manuf~~/ L _~Y ~~/ INFORMATION T f S CHAMBER O TY2 ~C ype ystem: /Q ,^ ~ ' ~ - ~ ~ , / UNIT Model Number: ~ ,. DISTRIBUTION SYSTEM Header/Manifold Distribution ~ x Hole Size x Hole Spacing /' Pipe(s) R~ .~ y ~r / v ~ ~~ ~_ ~ ~~ Length Dia_ Length Spacing Dia Q SOIL COVER ~ x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over ~ Bed/Trench Center ~Cf ~ ~ Depth Over Bed/Trench Edges xx Depth of Topsoil xx SeededlSodded ~ Yes ~:%~%~% No xx Mulched u Yes 0 No COMMENTS: (Include ~ode~d si crepencies, persons present, etc.) Inspection #1:~/ / Q 3 Inspection #2: / / Location: 839 Ross Rd Hudson, WI 54016 (NW 1/4 SE 1/4 22 T29N R19W) Pheasant Hills 1st a-dldln. Lo 19 Parcel No: 22.29.19.2479 ~ ~ ,y 1.) Alt BM Description = S`i-~ CUV~~ ~ a-a ~// / k~n,6-~ ItAt~,/a~_~''e~L~f i4'~~ bw" 2.) Bldg sewer length =Z. O vd G{ ~Gfc~ /~~h.~c/7ic-piZ~ •~G~C,u'~'~ f G~ ~ ~ - amount of cover = ~ 3 I ~~1./ Plan revision Required? ', ;. i Yes I;; ' No Use other side for additional information. SBD-6710 (R.3/97) Date I Insepctor's Signat re Cert. No. n d c~+. r- V n to Airlntake Safety sari Bttildit~gs Division COY _ . ~ ~ 201 W. Watdiagton Ave.. P.O. Box 7003'l f l: ~ ~ ~scons~n - .~ -~ ~ ~~ De artment of Commerce Sanitary Permit Application ~ ~ ~ ~`'' Permit NmBbv ars Adm code 21 il ~ 83 m d ond r~ ~-~ y ~ . ~ ( ~ . . . , , p w aeeot t D cateelt if lte~risim y D o ~ ~ pm be aced for Law s1S_ 1 ~ L Apps Inforaasdiort - Please Print AH ti w Stan: Piam I.D_ Nnmbar Property Oa-aer's Na me ~, ,j . ... r ~ ~ ~~ ,~ ~_ L ~ u Pmpaty Oamar's M aili~ Address ~tY I.ot~tioa , 2~1~ i '''; ~ i'~I~, ~ r ~~ ~ code Lat Numbs Blod~ Number Subdivision Name CSM Number Q.~'ype of ( ali tba~t s~pp~y.) / ~h/ w G ve ~/ 82 ~- ~PiK OtSc~r -- 1 or 2 FacaBy DweHiag - Nnodxr of Bedrooms ~ V y~ n Public/(~ma~cid - Descn'be Use Z/S~,E .~.!~.~7L ~'' o sa owned~~~s ~Tiic~t/~/i~ ~,r/r'T,G T/~ 7t~~S Ne~erest Rod .2- ~ ~ F v III. `1}Pe of Permit: (~ ~ one biooc on tine A. Numberlag is for its~l use.) (Comp kbe Bne B, if appBc~e.) A. 1 20 Replacaaeut System 3O Replaoemeatof 6^ Addidoo m Far Caaotjr use S Taus; S B' OCheck if Saainry Permit Previously Lsstsed Permit Number Dace Lsated ri._ ~~e ~ POWT System: (t~teck av thsut apQty. Nmtbering is far intervd use.) EiSA- rq ox ~~~~,~,~, o a o Q a w ~ a ' ~ roc~e sam lamer s om 44 Hi Moond 4~ Noa -Pruwriaod Ta-crowed al f~' / ~ ~ I // ' ZZ ~ Prrsau3xed In-G~oond 410 Holding TsNt 48 ~ Sigglc Pass 510 Drip Line '- 45 ~ At-Grade 4G ~Aembic Trams flair 44 ~ Rp~.ir 30 ~Olher V. t Area InfarnAat ion: Design Flow (81d) Dispersal Area Dispasd Area Sol! Appliralion Pecoo}ation ltae System F.k+rarion ~ Find Grade `i Requirod Proposed tta~c~ls-~r~9-lit-~ thcm.rlttcb) G ~ / x,,1.9 °evat;°" - ~ ~ ~ ~_ Z 9~,y ~ ~ ~-~r t'7 6 o.~ s~ . YL Tank Info ~Hy is T Nntt~er Mamfawuer Prdd~ Site Saxl Fiber Drastic Gdlor~s Gdioas of Tama Conaewe Constnrcmd Gbns trees t Tanks Tads seen` a Tad; ZOG - Gt/a'~,CS l/ VII. Responsibility Statesmmt- I, tTsc mdersigoed, assasne issta8etien at the PO~YTS silta~wa as tba; attaR6od plasa. Pbmtber's Ida me (~ 6ogerty P{umbing & Perk Pbaaber's Si ~ SRS Numba~ Btu Dime Number zz // ~' 7„ =- ~ y9--36j'~ Phattber's A ss treat, } j J -' ~ Spooner W{ 548Q1 - C~zL-- wSF- D~.~Z/o6 vtu. t~ Apxovod ~ Owcter Givat laiod Adwase sanmry Perutit Fee Daue'ssued sm~) Deeermimtioa a a ~ ~> ~ l0 0 3 ~ u~-~-~-~- I7t. Cane of Approvai/Reasans for ~ L ar/J' i~S .~ `SJLc~G, ~la~ W~~~ Ca~~na-~~~ csr !o~-dr;~,.~-s~anf ~ ,v~~~.°"'~ ntltre~ ~P~ ply i~ the Cor~f ouy) Fsr the s~ens as paperset kiss tLu E1B: S lfeches i• sine v 3 ,~~~~ s~-~~~/~Co-~ . ~3. y3 -i - _._a_ '~' ' -- hiss ~.~,~ -- ~~ (' ~I a ~ I Z , s~ N % ~ ,, ~6~', 0 ~C N 4 ~ ~ :~ y .u . ~ v w ~ l n xu ~ `-- ~~ _`~ ~\ ~~ i ~ '. s° ~r .s N vo ~ ~ 1-+ 3 ~ ~ ~ lwl ~ ~ ? W ~ --' 'O ~~.m ~C 3 N l 1e i. A A -~ • .i ~ -- - O b ~ o, ~. ~ ,~ .; 5 - ~ j~ . ' t~ ~ ;~ co a- • w rn • ~ : p. ~ 1 ~p o ~• ~ ,.: .: ~ :.•~ ~ ~ s •~ ~ ! - d .~' ~ , ... N ~ ' -' ,t-~ -, N a, ,- ~.,y4j . Q ~ . _~ -_~. ~ _ V ~~ ' -Y s• ~ - ~ _' gip.' _ ~ ~~ i ~ ,: `. .. ~ ~ W ~ ~ ~ ~ s.:~~`°~ O Ca 'r, . - • =•. i \~ \~ ~ ~\ w _, ' ~ ,,` ~ ~s~ .• ~ ` ~. N ~ ~ ~` Y, ~~ II ~ _. ~+ ~ `* 5 ~ ~ y. ~ o ti ~ - ~ •, - - ~ ~ N :~ ~ a ~~'. M ~" -- 11 Q'' co g .-r cP t/1 ~"! CD O ~• O ~ ~ r y ~~ ~~ o ,''`~, dQ ~+ F-~1 '~ ~-4 ~"~ O '~ c'~ ~ eQ° ...,. ~~ ~~® ~~ ~~~ G~c~~t+y ts7 ,_ ~ F+ . Op~p~ O~ ~O~ '~ ~ ~+ -ec. Z. Z m ~ NAME ~ G S T LOT# ~ ~ LE L D . RIPTION ~JW ~~~ 14 ~S Z Z T~ 4 ~j~,$, ~9 ~.(or2~ SCALE: 1" = GI O ~ BM 1 ELEVATION OG • O BM 1 DESCRIPTION ~ ~ • '~-zcj " BM 2 ELEVATION 9~. ~0 BM 2 DESCRIPTION o ~~ 5 ee Qoc~. (9 ~~ .~ y, SYSTEM ELEVATION _~D q y. $o G~oW~ ~ 93. ALTERNATE EI-EVATIONd~pgZ. nU ~ocae~ 9F `6b T CONTOUR ELEVATION• ~~.Gd ~ `j9.O d _ ~ ~°~ ~o ~,k ~, ~~csi ~ oa ~~; ~°~ ~ 6~. ~ ~ s boy ~ ~~ ~6 ~ s~,rnZ ~u PAGE 3 OF .3 ~ ~- 5~' /O o , ~7 v, S~-~i ~ ~zt rn ; Z ~ ~~/ F#1.S~~~I~' ~ C,o~ ~~ SIGNA ~ Z ev'' ~'' ~~~ DATE 3 -Z ~ ' °Z 0 ~~ w' - .. Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT ....~........ ...:i1. rte.....-., oc \A/:.. Ad... r...~.. Page ~ of ,,,~ 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: vertipl and horizontal reference poi percent slope, scale or dimensions, north arrow, and location ~ ~ nd dis~t~~~d. Parcel I.D. ~ZO' /;~~ ~ 9 -~Uv Please print all information. Revi ed y Date Personal infomration you provide may be used for secondary purposes Privacy~t~~ s. o5.~i (~~~ ~~j` ~ ~/ 6 3 Property Owner Property Location ~ ~ FLU ~ ST. OUfy~~ Q~ /45,E 1/4 S ZZT ~ N R ~~ E (or)1~ Property Owner's Mailing Address oc # Subd. Name or CSM# 9 ~ ~ I ~{~t c~So /t ~- r v n City State Zip C e Phone Number ^ City ^ Village ~ Town Nearest Road u ~Q Sa r1 ~v l ~ o / ~ ( / ) 3 b ' ~ ~ ~So t/Q SS Q ~ r [~ New Construction Use: ® Residential /Number of bedrooms 3 • Code derived design flow rate ,s6 ~ji Q ~ GPD ^ Replacement ^ Public or commercial -Describe: Parent materia{ a C~~Sin Flood Plain elevation if applicable ~/~- ft. General comments ~j ~ rY~ 2l-e v~ ~ ~ ~~ w { ,~ d and recommendations• ~~- PZ ~`f- t°~~v~ ~~rzr~o ~wQ~ 9i ~d ~ ~ -~ ~ a t - g 2 C,; n.+ewt~ - n..~ Boring # ^ Boring ~ O~ ~ ®pit Ground surface elev. ' ft. Depth to limiting factor in. Soil Appliption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence .Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ~'(2 ~ al Z .S,' Zrrt vin ~ u~ ~ S • ~ /~ [~. O~ , ~ D s z q2 ~ / ~• " ~- ~" z Boring # ^ Boring ® pit Ground surface elev. C~ O ft. Depth to limiting factor --t-1~-- in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture SWcture Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 /d ~e~ ~y/G `_ rn~ a ~ 1 - ~ Z g2. _ ~v ~f' ~ ' Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BODS < 30 mg/L and TSS < 30 mglL CST Name (Please Print) ~gnature ~--~___~~ -~~ CST Number J Address Date Evaluation Conducted Telephone Number SBD-8330 (R07/00) ~.y' ., Property Ovmer ~ S / Parcel ID # /~~ // Page ~ of 3 © Boring # ^ Boring [~ pit Ground surface elev. ~ DU ft. Depth to limiting factor /// in. Soil Applig6on Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont Color Gr. Sz . h . S *Eff#1 'Eff#2 ~, ~ ,, y ',fin p lf( o /y~Cv ~- 1M S p S l -- ~ o" - r,~e 0,~7 a ram 38- 2 ~,, ~, ^ Boring Boring # ^ pit Ground surface elev. ft. Depth to limiting factor in. Soil Appliption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring # ^ Boring ^ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 'Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) i .i ~ " t ~ ~ PAGE 3 OF .3 NAM ,,, ~ S 7 TOT# I q LEGAT DESCRIPTION ~JW ~~~.t 14 ,S Z Z T~ 4 ,N,R, I9 E(or)i~ SCALE: 1"= ~~ O ~ BM 1 ELEVATION /U~ • O BM 1 DESCRIPTION~~;`; ~~~~ ,~ '~ BM 2 ELEVATION 9~. ~U BM 2 DESCRIPTION -Eo p o ~ %1 S-I pe I ~o~ - ~ ~/~. SYSTEM ELEVATION ~D qy. $o /~ow~ ~ 93, ~~ ALTERNATE EI-EVATIONdvp fZ• nU ~vw e ~ 9!~ `6a CONTOUR ELEVATION ~~ GU ~ `j9~d d g -ec, Z Z i 1 SIGNATURE ~- ~ -- DATE ..~ -Z G "dam .~ .,-~ ~. POWTS OWNER'S MANUAL & MANAQEMENT PLAN P~ ~ of ~-' FlI.E MIFORMATION Owner ~ _ m - ~ ~`~~ Pemnit # aO~O ~' 1]PCtfSN PIIRAYFTERS Number of Bedrooms ^ NA Number of Public Facility Unrts NA Estimated flow (average} ~ al/day Design flow (peak), (Estimated x 1.5) p~ aUda Soil Application Rate _ aUda lft2 Standard Influer-t/Effluent Qua1'ity Monthly average' Fats, Oil & Grease (FOG) 530 mg/L tiochemical Oxygen Demand IBODS} 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand ISODS} 530 mg/l_ Total Suspended Solids (TSSI 530 mg/L ^ NA Fecal Coliform (geometric mean( 510` cfu/100m1 Maximum Effluent Particle Size Y8 in dia. ^ NA = ^ NA 'Values typical for domestic wastewater and septic taNc effluent. SYSTf3111 SPECS:ICATIONS Septic Tank Capacity ~~~ al ^ NA Septic Tank Manufacturer ~-r~,~f ^ NA Effkient Filter Manufacturer ~ ^ ~- Effluent Fitter Model r.. dd DNA Pump Tank Capacity ~ b ~ Pump Tank Manufacturer Q ~- Pump Manufacturer L'~ ~NA Pump Model }~J NA Pretreatment Unit ^ Sand/Gravel Fitter ^ Mechanical Aeration ^ D'isirifection D Peat Fdter ^ Wetland ^ Other. Q NA Dispersal Ce01s) `~ tn-Ground (gravity} ^ At-Grade ^ Drip-Line ^ ~` ^ tn-Ground (pressurized) D Mound ^ Other: Other: ^ NA Other. ^ NA Other. DNA enAav t rnwry~t a~.nrriui..~ Service Everrt ~~ FcY Inspect condition of tank{s) At least once every: ^ ~~Isl IMa~dmum 3 years) ~¢ earls( ^ NA Pump out contents of tankls} When combined sludge and scum equals one-third IY$} of tank vokirtte DNA Inspect dispersal cellis} At least once every: ~ D ~sl s) lMax&twm 3 years) ^ NA Clean effluent fitter s N ~~ ~~ At least once every: 1 Z D n~thls} ^ NA Inspect pump, pump controls & alarm At least once every: p ye~~{sl ~ CIA D month(s) [j NA Flustr laterals and pressure test At least once every: ^ yexls) Other: ^ month(s} ~j NA At least once every: ^ year{s} , tether: ANA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an indivkiual carrying one of the following fic~nses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of tfie tankisl 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 pond'mg of effluent on the ground surface. The dispersal ce{lls} shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3} or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent fibers, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, 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. L~~~~ ~~~~~~~ ~ s~ • Page Z--'of Z UP AND OPERATION a of paintaig products or other chem~als For new construction, prior to use of the POWTS check treatment tanklsl for the present that may impede the treatment prods and/or damage the disperse cetlls). ff high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infitrative surface. During power outages pump tanks may fdU above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(si in one large dose, overloading the cell(sl and may result in the backup or surface discharge of effluent. To avoid this situation have the cattents of the pump tank removed by a Septage Servicing Operator prior to restormg power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore nomtal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers: dental floss; diapers; disinfectants; fat; foundatwn drain (sump pump) water; fruit and vegetable peel'mgs; gasoline; grease; herbicides; meat scraps; medications; oil; painting product's; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm $3.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, alt tanks and pits shalt be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. If the POWTS faiis and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant replacement system: A suitable replacement area has been eva~ated and may be utilized for the locatan of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction ~d should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluator to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ~, The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEP71C, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFRCULT OR IMPOSSIBLE. ~ ~ #221180 ~" . _ ... 5..~.. (715) 635- _ ~ POWTS INSTALLER POWTS MAl ~ Name I (~{~~~ Phone S'- -- ~~ Name Phone - ~ - d ' SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORfTY Name Namelj I ~.~ 1 X trt~u~~ Phone Phone ~'(~ -•' ~ '' This document was drafted in compliance with chapRer Comm 83.22t2j(b)l1Nd)>41fl and 83.54!11, (21 & t31, Wisconsin Adminisuatrve Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer !~[ ~~ /3.~T Mailing Address ~'~ ~~`/1~,~£" ~ 1~~*,Dlo.~ cr-~ .~S~mIG property Address ~-3 Z /.G'~fS .~/: T /~I.YO~: ~ (Verification required from Planning Department for new CitylState Parcel Identification Number a Zo -~~4~ /9-vuv LEGAL DESCRIPTION property Location ~ %4, ~_ '/., Sec. ~~ TAN-R /9 W, Town of l~~G~~ Subdivision ~fi.~~~~ ~,~tin ~ s-t .Lot # _ ~ 9 Certified Survey Map # `-""--- ,Volume ..Page # -i Warranty Deed # L 7 S/ e ,Volume - /S ? / ,Page # ~3 ~ Spec house ^ yes C~no Lot lines identifiable [9~yes ^ no STEM 1~'IAIN'TENANCE 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeymanplumber, restrictedplumber or a licensedpumperverifyingthat (1) the on site wastewaterdisposal system is is proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain rho private sewage disposal system v~nth the ~~'~ 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. Cmix County Zoning Office withm 30 days of the three year expiration date. / /l ~/ D~3 S AT[JRE OF PLICANT DATL OWNER CERTIFICATION I (we) 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 descn'bed above, by virtue of a wamanty deed recorded in Register of Deeds Office. / //~/n3 ATURE APPLICANT DATE ****** Any information that is aus-represented may result in the sanitary permit being revoked by the Zoning Department. ****** ** Include vrith 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 1 ~5c3~~~ P ° S~~e~~y~~,,33 . sraTE ~ ~1.~g1~la'~eXJy Document Number WARRANTY DEED This Deed, made between Mahe A. Shimon, a siag#e Qerson, ` I Grantor, and Kennon J. Bast and Donalda J. SpeerBast, husband and Wife, Grantee. Granror, 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): (See Attachod Exhibit "A") Recording Area 62?51 O Kti i'HLEEN H. WAL5H FEL-ISTER OF DEEDS ST. CFOIX GO., WI RECEIt~EO FOR RECatD aE-oas--2~ 3:0o PII Ir~I1TY 6EFb IT.'OPY FEE: COY .FEE: TkAllSEER FEE: 656.00 RECORDIRIi FFE: ~ 15.60 pR6'ES: 3 NamemdR~~A OGLAND Zi)z, Estreen & Ogland p•O. Box 359 Hodson, Wl 54016 ozo-los9-ao~aoo Parcel Identification Number (PIN) Tb'ts h not homestead ptopaty. Oi) (is not} Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. Dated this ! ~ 4~` day of 200!1 tea.. ~i~,,~`W ,.;~ • M A. SY®ttn « + AUTHENTICATION ACKNOWLEDGMENT Signature(s) Marie A. Shimon, a single person, STATE OF WISCONS[N ) )~ County ) t ~ j~. auth r 1 K/- y~' d~ y of July 2~ Petwnall rime befae me this of ~ :.• Y ~' tfie above named • ~stifY! ~ _. TI ~I'ATE 8AR OF WISCONSIN to me known to be the person(s) who executed the foregoing su § 706.06, Wis. Stats.) instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY • Attorney Kristian Oeland Notary Public, State of Wisconsin Hudson, WI 54016 My Commission is permanent (If not, state expiration date: (Signatures may be authcoticatod or acknowledged. tiotb are tat ttecessary.j . •) • Names of persons signing in arty amity must be typed or printed below thew sigtreturc. rro""a~wn rroNwianN~ t:omv~r. Fong au L•4 Va STATE 1sAR OF W tSCONSIN eoD~e6s2o¢I WARRANTY DEED FORMNa2-1999 ~Y vot~ 1531PAGf 434 EX~IIBIT "A.. A PARCEL OF LAND IACATED'IN THS NORTHW85T QUARTER OF~+'PHE SOUTHEAST QUARTER (NW 1/4 OF~SS 1/4) OF SECTION TfiENTY TWO (22), TOWNSHIP TWSNP7C NINE (29) NORTB, RANGE NINETEEN (19) WEST, MOBS FULLY DBSCRIBBD AS FOLLOWS: Commmtcing at the Bast Quarter corner of said Section 22; thence•North 0 degrees 02 minutes 57 seconds Sast along the Nast line o€ the Northeast Quarter of said section a distance of 40.00 feet; thence North 89 degrees 57 minutes-16 seconds West 750.00 feet; thence Nesterly 450.47 feet along the arC of a 905.17 foot radius curve concave Southerly whose long chord bears South 75 degrees 47 minutes 19 seconds West 445.83 feet; thence South 61 degrees 31.isinutm 54 seconds West 135.86 feet to the point of beginni~; thence continuing South 61 degrees 31 minutes 54 seconds Weat 150.12.Eeet; thence Southwesterly 297.89 feet along the are of a 740.00 foot radius curve concave Southerly whose long chord bears South 49 degrees 59 minutes 58 seconds Nest 295.88 feet;. thence South 53 degrees 22 minutes 28 seconds Bast 409,87 feet *`thence Sarah 0 degrees 15 minutes 46 seconds Bast 667.10 feet to a point-on the South line of the Northwest Quarter of the Southeast Quarter of said Sectiaa 22; thence North 89 degrees 57 minutes 16 seconds Nest 1269.89 feet along said line Co the Southwest corner of said northwest Quarter of the Southeast Quarter; thmce North 0 degrees 16 minutes 35 secanda West along the North-South Quarter Section line a distance of 1296.23 feet; thence North 89 degrees 50 stinutea 17 seconds East 651_01 feet; thence North 0 degrees 11 minutes 41 seconds West 22.40 feet to the Southwest corner of the Certified Survey Map recorded in Volume 7 of Certified Survey baps, page-1891; thence North 89 degrees 50 minutes 17 seconds Bast along the South line of said Certified Survey a distance of fi51.09 feet to the Northeast corner of the Northwest Quarter of Southeast Quarter;~thence South 0 degrees 15 minutes 46 seconds West along the Bast line of said Northwest Quarter of t'he Southeast Quarter a distance of 129.94 feet to the point of beginning. ALSO subject to that part of a 66 foot wide easement reserved for future township road included is the above describes} parcel, said easement being 33 feet equidistant and at right angles to the following described reference lines: REFERENCE LINE NUMBER 1 Cosmeacing at the Bast Quarter corner of said Section 22; thence North 0 degrees 02 minutes 57 seconds East along the East line of the Nortaeast Quarter of said section a distance of 40.00 feet to the point of beginning of the following described reference line: Thence North 89 degr~ 57 minute's 16 seconds Went 750.00 feet; thence Westerly 450.87 feet along the arc of a 905.17 foot radius curve concave Southerly whose long chord bears South 75 degrees 47 minutes 19 seconds West 445.83, feet; thence South 6I degrees 31 minutes 54 seconds Ne$t 285.98 feet; thence Southwesterly 247.89 feet along tine arc of a 740.00 foot radius curve concave Southerly whose long chord bears South 49 degrees 59 minutes 58 seconds West 295,88 feet; thence South 38 degrees 28 minutes OT seconds West lOU.00 feet; thence_Southwesterly 381.99 ~ ., ~0~.1531PAGF 435 Exhibit "A° - Page 2 feet along the arc of a 427.00 foot radius curve concave Northerly whose long chord bears South 69 degrees 05 minutes 43 seconds West 369.38 feet; thence South 89 degrees 43 minutes 25 secoc-ds West 545.65 feet to the end of said reference line. REFERENCE LIMB NONBER 2 Comarac-eing at the Bast Quarter corner of said Section 22; thence North 0 degrees 02' minutes 57 seconds East along the,•EasC line of the Northeast Quarter a distance of 40.00 feet; thence NortY- 89 degrees 57 mini~tea 15 seconds Weat 750.00 feet; thence Westerly 136.81 feet along the arc of a 872.17 foot radius curve concave Southerly whose long chord bears South 85 degrees 42 miautea S7 seconds West 136.67 feet to the point of beginning of the following described reference line: Thence North. 269.97 feet; thence Northwesterly 350.77 feet along a 500.00 foot radius curve concave Southwesterly whose long chord bears North 20 degrees 05 minutes 50 seconds West 343.62 feet; thence North 40 degrees it m3.nutea 41 seconds West 70.00 feet; thence Northwesterly 158.48 feet along a 227.00 foot radius curve concave Northeasterly whose long chord bears North 20 degrees it minutes 38 seconds Weat 155.28 feet: thence North 0 degrees 11 miautes 41 seconds Nest 500.06 feet to the end of said reference lice. 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