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HomeMy WebLinkAbout020-1395-41-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and BY,ilding Dision 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 Stein, Paul Hudson Townshi CST BM Elev: ~ Insp. BM Elev: BM Description: Csv . O (7D • O ~ CST' g~~ (= pU'L, TANK INFORMATION ~ ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic ~ 2~v0 Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic r 2 S .~ ~ ^. / 2 o r--- Dosing Aeration Holding PU SIPHON INFORMATION Manufacturer errand G Model Num r TDH Lift on Loss System Head TDH t Forcem Length Dist. to welt County: St. CroiX Sanitary Permit No: 430683 0 State Plan ID No: Parcel Tax No 020-1395-41-000 Section/Town/Range/Map No: 25.29.19.2435 STATION BS HI FS ELEV. Benchmark Sn ) o~ •~ dU.O ~ Alt. BM ~ti7~ 3.3 `~$,IS ~ Bldg. Sewer ~ j ~Q T~ ~ ~~o • qo SdHt Inlet L , ~D i Y~f-~ SUHt Outlet ~, q 9 ~,, Dt Inlet Dt Bottom Header/Man. ~ , S Dist. Pipes l 8.t{Z, 8•`f'Z ! 3.08•t Bot. System q.j9 `~ • s-p ~ Q2.00 Final Grade `~• 3o q~.2o' St Cover ~~ SOIL ABSORPTION SYSTEM tr~73~ P.~..:z1~.4 r ~ a...I~~ /aL~~. n ~. R CH Width ~ Lengt No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ r.~ ` Z ~• I 1 ~ J G SETBACK INFORMATION SYSTEM TO /L B D G L WELL LAKE/STREAM LEACHING CHAMBER OR Manufactu r pp~~ - r ~' l sr.~ ` ~ ~ ~ 1 Type Of o~~ 2 S • ~ ~~ -.. ~~~ ~~ UNIT . . . -- G_ Mp~iel Nurr)4e `~ ` DISTRIBUTION SYSTEM l ~.1-'ir[~1~+~++~ 1 eade Mawiield Distribution x Hole Size x Hole Sp cing V to Air Intake ape(s) M~' ~- Length ia~ L Dia Spacing SOIL COVER x Pressure Systems Onlv xx Mound Or At-Grade Svstems Onlv Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil r Yes No Yes No QQM ENT~_(fnclude c discre enc'~~pers;o present, etc.) Inspection #1:?~~~ Inspection #2: ---f--T'-' ~GC~ F+' l60 1~- Location: 717 Regal RidgJe,,,H~udso~,nI~ WI 5401~,6A(N 1/4 SW 1/4 25 T29N R19W) Scenic Hills Lo 41 Parcel No: 25.29.19.2435 1.) Alt BM Description = ~°~' S`t/l ~'1 ~ U 2.) Bldg sewer length = ~~ ` ~ ~ -amount of cover = ' ~ . ~. u ~ (~ ` n~ S; na~~ v e/ „a ~ << ~ ~~S~w~~ •~ ~~ ~~ ~ 1 I n evasion e uired . ' Use other side for additional in Y No T ~ formation. ___ ~~~ ~~ .R.l~M• _ .. _ _ _ _. _ _ _ ~I _ _ i l SBD-6710 (R.3/97) flat _ - /I ~I Insepctors Signature Cert. No. F~~~EIVED FFR 1 :? ~nnd Safety d Buildings Division ~unh' ` • . T. CRO X ~'C~i4~J~` Was ngton Ave., P.O. Box 7082 , ` ls~jOn ZONIN OFFICE Madi n, WI 53707-7082 8) 261546 Sani Permit umber(tobefiltedin Co. t~ ' ~ID De artment of Commerce 3o ~$ 3 Sanitary Permit Application State Plan I.D. Number -^ In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ' may be used for secondary purposes Privacy Law, s 15.04(1)(m) "Project Address (if different than mailing address) I. Application Information -Please Print All Information Property Owner's Name Parcel # Lot # ~ Block # -" ~ 20-1325- ~-~ .~ 3S Property Owner's Mailing Address Pr o p erty Location ~~ JJ ~~ ~L,t ti Y S ~~ ~~ Cit t St , ., ec on ti y~-~'~ y, a e Zip Code Phone Number I r (circle o)~ T~ N R~E or ; II. Type of Building (check all that apply) ~ ~ S wt~ i i i - ~1 or 2 Family Dwelling -Number of Bedrooms 5 Subd v s on Name tmf6e r ^ PublidCommercial-Describe Use ^ State Owned -Describe Use 3 X •~ ~ ^City_^Vill e,~ITownsnip of 2 _ III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' New S tem ys ^ R Iacement S tem ep ys ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System B • ^ Permit Renewal ^ Perrttit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T e of POWTS S stem: Check all that a 1 ,Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized ln-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter Leaching Chamber ^ Drip Line ^ Gravel-less Pi ^ ther in) V. Dis ersaUTreatment Area Information: -'!~ Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation 7. "~ ~~ , ~ ~ ~~ ' ~' VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Stoel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic a Holding Tank „_ Aerobic Treatment Unit Dosing Clamber VII. Resp risibility Statement- I, the undersigned, ssume res onsibility for installation o[ the POWTS shown on the attached plans. Plum' er' am P~) ~ Plumb 's ~ MP/MPRS Number Business Phone Number -~ i s- ss = ~ ~ Plumber s Address ( eel, City, State, Zip Code) '"' ~.CJ ~, ,; VIII. Coun /De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued I sui Agent Signature o Stamps) Surchazge Fee) ^ Owner Givem Reason for Denial ~ ~ ~ ~ I i 3 IX. Conditions of ApprovaVReasons for Disapproval SYSTEM OWNER: 1 Septic tank, effluent Filter and dispersal cell must all be serviced /maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances Attach compkte plans (to the Coaaty only) far the system on paper aot kss than 81/Z : 11 Inches is siu SBD-6398 (R. 08/02) ~~/s~,~ EGG ~d.~~ ~/~~.~~ L'~~ /1l~ ,s's"~18 N .Ley 5~/ ~~ ~ „_ --/~ .sue ~ ~ju/vSr~.J i W I~ i~,~ _~~ ~~ a~-- 9 ~~ .~~,~s',~zs~?~s ~ apY L~~~ ~~~ .~'s"~/ 8 ~d~Q'ti ~~~ ,Il/~5.~7/~?~~ ~vH~v~~ ~~~ ~// ~~c ~ ~; ~~~~~ .5 r a '~l „- ~~ ~ sc,rJr~ ~. ~~fllc ~„il~- ,~~C~.~ dL~~eit~ ~ ~ t3rr m ~'~ ~~ r-- -T a~ i I I~ ~._ . 9 /~//Li. Vlfiscxrnsin Departrnent of Commerce ~ • SOIL EVALUATION REPORT Page ! of~ Divisioty of Befell/ and Buildings to accoroarrce vmn wrnrn aa, vns. fwrrr. woe t m i Pl 81/2 11 i 11 ~ T• C- r0 i ~ us ze. an x s Attach complete site plan on paper not less than inducts, but not limited to: vertical and horizontal refers nl and pendent slope, scale or dimensions. north arrow, a ~ areal mad. Parcel I.D. . 0 ~~ - (,3 1 ~ - ~ ' OU ~ ~ !~ Please print aN i , .; ,,. ~ Date ., ry ~t~~, s. ~ij4 1) (m)). 1?ersonal information you provide may be used for n r ! q 0 Property Owner - ~ i ~ ~~ P location ~?~ ~. ~w 1/4$w 1/4 SZ S TZ ~ N R / Q E (~1~ era>MaiSrtg Address %• Property Ow/n . ~ \ lLO~t't!F-., Block # Subd. Name or CSMI/ . S - '~ : G U Ff ~ S'P i ~ Wv~T-c tD T Z. .C fy~ ~ ; i City State Zip Cade Ph Number , .~ ^ V~iage ~ Tawn Nearest Road ~STi: L ~ war 1'h iti , fSo ~Z ( ~()'~ •q'a _ . ~~ _v . S , •n ~ lP c~ ® New Construction lJse: ® Residential / Number of bedrooms _ 3 " `{ Code derived design flow rate ~.SO ~(o O O GPD ^ Repiaca:ment ^ Public or commercial - Descnbe: Parent material _ DU fca.Ja-8 (~ Flood PlaNr elevation if ~ ~ General canments S ~ S ~ ~, t I c iJcr, f , b n - ~' ~ 9 2. sz~ .. Lrj w -e^" Z • a U and recommendations: ~ l.. ~ ~. l •e. ~ r` - . P 9/• SQ w w t ,~ `~' ~- Q I tpi Rit Ground surface elev.9G . ~ R Deptl- to limiting lador ~,~,~,_ in. Sal tication Rate Horizon De th Dominant Co Redox Description Texture Stntcture Consistence Boundary Rarts GP D/f~ p , in. _ Munseil Qu. Sz. Corrt. Cobr Gr. Sz. Sh. 'F~1 'Eff#2 I O-I lb - S' ~ 2 ~' c l v-~ . ~J , ~ ~ `~ ~ ~ Bonng # ®~~ Ground surface elev. 9 S- ~ 0 ft. Depth to limiting factor ~ ! Z in. ~ Rai Horizon Depfl'i Dominant Cobr Redox Descxipfion Texture Structure Consistence Boundary Roots GP D/iP in. Munsell Glu. Sz. Cont. Cobr Gr. Sz. Sh. - 'Etf#1 *Eff#2 1 0 -~z ~ - k ~ ~ ~ ~~ . 5 2 L2- ~~ a 2 k rr?~r' es - .4 3 3 -I IZ ~ .. ~ - - . -7 I -. 2 ~ ~ . Q~ ,1 * Effluent #1 = 9oD_ > 30 < 220 moll and TSS >30 < 1 50 moll ' FJtluent #2 = BOD . < 30 mglL and TSS < 30 mgll CST Name (Please Print) S' re CST Number ~c1. vy~ ~ 1~,~ wok e. r ~c~~ c, ~' ZS ~ ~0 9 A~ress ~ Date Evaluation Conducted Telephone Number-_ /l Zl(3 Ba~S~ , erne ~ /. t/ S~/[72S ~-~ l,~ 7!S'-2~{7-'fUaX _ t Property Owner r k~ ~ j Parcel ID # . Page z ~~~ , a ring # ^ Boring ® Pit Ground surface elev. ~ G 0 ft. ~Pth to fnniting ~~' ) l l~ in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Stnicbure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont Color Gr. Sz Sh. 'Eff#1 'Eff#2 1 ~-io ID 5i k ._ ~ I~~ '~ ' $ 2 ip 4 I ~~ 5icl -~ c - ~, ~s",~ c/ _. Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. ~~ ic~tion Rate Horizon Depth Dominant Color Redox Description Texture Struchne Consistence Boundary Roots GPD/i~ in. Munsell Qu. Sz. Cont Color Gr. Sz Sh. 'Eff#1 'Eff#2 Boring # ^ Borrc~g ^ Pit Ground surface elev. ft. .Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant Cobr Redox Description Texture Strudw'e Consistence Boundary Roots GP D/ff in. Munsefl Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'Eff#1 'Ef~2 'Effluent #1 =GODS > 30 ~ 220 mg/L and TSS >30 <_ 150 mglt. ` Effluent #2 =GODS < 30 mglL and, TSS _< 30 mglL 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 608-2648777. S8D-8330 (R07p0) PAGE ~ OF~ NAME 14 r K -e- ~ ~ LOT# N / LEGAL DESCRIPTION Nw `/<Sw'/4 S ~'T z 9 ,N R lq E (or) '~ »- v y Y~-~~0.( ~n t ~~~~ SCALE: 1 - BM 1 ELEVATION lOU • O BM 1 DESCRIPTION•/o~ o ~ ~2_D_~ ~~~e BM 2 ELEVATION q q. So 1 " BM 2 DESCRIPTION~,p a -~ ~ Z ~ v Ac.. ~Qt SYSTEMELEVATION~P 9Z•s° Gow«9Z•~v ALTERNATE ELEVATION ~a~ Q/.6d ~~~'' 4~ ~ ON 9S sv j ~. U U CONTOUR ELEVATI ~ ' ~ •~ 4` ~ ~ ~ . \ ~ / \~ \\~~ -----T // / ~ - ~ ~~ ~ C J i _ ~ ~ •~ ~ , ;~ ~`~ X ~ ~~ ~ ~ ~~~~ ~; ~,`~-~ - ,, . `i , 4j !;. ~, ~ , ~ -.,, 10! .a ~'~,,„ ~^,, 237 ~ :~ ~ 104 i /~ X kp ~, i \~ ~, Y/~ -":j ~ ~~ ^ 1006 ' x / ~ ,, 103 .8 ~ ~' ~1 / ~ H,-'D 9 i 0 .9 / i 1014. ~., \ iii ~ B- i , , f ~ ` ,1 1 ? ~ ~~ ~ ~ 4 ,~' S ~ 1 1~2 x \ ~ `~~\ . ,y y~.i.~ ~ V / B~ '.:~ .. ~~ ~ ~ 1~ ~ ~ ;~ ~ ~~ j ~ ~77~ / . o, ~ ' ,.A ~~, ~ V ~~~ ~~ ; ~ ; ~ j ' ~ I t 0 X ~~;,~ ~~~~ ~~ ~ ~~-~, ~ ~` ~ ~~~i !'~~ / Iota. ' ~ ~~_~- ~ ~~ ~ ~. ;~ , ; - _--_ , -_~._ _ ~ ~ I ~ ~ ~ ;~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pape ~ of c~ FILE INFORMATION Owner , Permit # ~ p DES{GN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ~NA Estimated flow leverage( al/da Design flow Ipeakl, (Estimated x 1.5) ai/da Soil Application Rate al/da /ft~ Standard Influent/Effluent Gluality Monthly average" Fats, Oil & Grease (FOG) S30 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODE) 530 mg/L Total Suspended Solids ITSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) 510' cfu/100m1 Maximum Effluent Particle Size Ya in die. ^ NA Other: ^ NA "Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity al ^ NA Septic Tank Manufacturer S" "7 , l~; Effluent Filter Manufacturer ~ -~ O NA Effluent Filter Model ;- , -~' ~ +A Pump Tank Capacity al ~- NA Pump Tank Manufacturer :~r~A Pump Manufacturer ,~ t1A Pump Model ~ ~ NA Pretreatment Unit ~~ -I~NA ^ Sand/Gravel Filter ^ Poat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other Dispersal Cell(s) ~ NA ~In-Ground (gravity) ^ In-Ground (pressurized) ^ At-Grade ~• ^ Mound O Drip-Line O Other; _ ~ Other: C.J riA Other: L_J ; iri• Other; ^ NA :;. ~, Service Event Service Frequency Inspect condition of tank(s) At least once every: .~ monthls (Maximum 3 years( ear of D P.l, Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ^ IiA Inspect dispersal ce(lls) At least once every: -~ ^monthls) " (Maximum 3 years) ti5 ~ earls- ^ I Iti Clean effluent filter At least once every: ~ ^monthls) ~ year(s) O FJF, Inspect pump, pump controls & alarm At least once every: ^ month(s1 ^ earls) ~f, ti _ Flush laterals and pressure test At least once every: ^monthls) ^ ear(s) ANA Other: At least once every:. ^monthls) ^ aerial ^ NA Other. O NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licences or certificatlcns: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identity 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 bo visually Inspsoted to check the effluent levels In the observation pipes end to cheok for any ponpinq of effluent on the ground surface. Ths ponding of affluent on the ground aurfaco may indioato a failing oonditlon and requires ctru immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IYsI or more of the tank volume, the en~irc contents of the tank shall be removed by a Septage Servicing Operator and disposed of In accordance with chapter NR 1 i 3, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretroatm ant 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 t0 days of completion of any service avant. GMW (4iG is ,. Page ~oi START UP AND OPERATION For new construction, prior to use of the POWTS chuck treatment tank(s) for the presence of painting products'or~other ch~~rnicu~s that may impede the treatment process and/or damage the dispersal celllsl. If 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 infiltrative surface. During power outages pump tanks may fill above normal highwatar levels, When power is restored the excei~ wastewater will b© discharged to the dispersal cell(s) in one large dose, overloading the oelllsl and may result Mahe backup Or aurfaoe discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septaga Servloing Operator prlot to restoring power to the effluent pump or contact a Plumber ur POWTS Maintainer to assist in manually operating the pump contrvi; :c restore normal levels within file 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; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides;, meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tai»pons; 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 83.33, Wisconsin Administrative Coda: • 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 Servioing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTtNCiENCY PLAN If the POWTS falls and cannot be repaired the lvlluwing measures have been, or must be taken, t0 provide a code Compliant replacement system: , , ,; A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and propvsud structure, lot lines and walls. Failure to protect the replacement area will result in the need for a new soil and site evaluation 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 fast 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 tans. 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 effaot at t~t~,t time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES, DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY SE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS MC+:: rr POWTS INSTAL E Name ~ • Phone ~ --- -~ POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR PUMPER) LOCAL REGULATORY AUTHORITY Name Name ' .~ Phone Phone - - , This document was drafted in compliance with chapter Comm 83.221211b11111d1&Ifl and 83.6411), 12) & 131, Wisconsin Administrative Code. ST. CROIX ~O[TNTY SEPTIC TANK MAINTAIN.~NCE AGREEMENT AND OWNERSI~ CERTIFICATE FOBM ~ / Property Address. r ~ , z~3s City/State , ~ ° Parcel Identification Number o20 - I',~ S - ~ ~ _p~ap ~ ) LEGAL DESCRIPTION PropertyTlocat~i^o''n!'++'~ 'f<, ~~' ~f< jSec. v~^~ ToZ 1~ R, Town of ~~r~~,d~(`~'! subdivision Jc~~/ (~ ~r [ ~,~ I,ot# `~ 1 _- Certified survey Map# ;Volume - Page V~aaanty Deed# ~ s~ ors 3 , Voluffie 25dg Page n3 ~ ~ 3'2r-- Spec house yes ~no Lot lines identifiable des no SYSTEM MAINTEI~I~4~CE Improper use and maintatance of your septic system could result 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 p~ into the system can affect the fattetion of the septic tack as a treatment stage in the waste disposal system. The property owner agrees to subm}t to- St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeyman plumber, restricted plumber or a lic~sed pumper verifying that (1} the on- sitewastewater disposal systemic th proper operatingcondition aadfor (2)-after inspectiegapdpumping (ifnecessary}, the septic tank is less than I/3 full of sludge. Uwe; the undersignedhavercadtheabove requirements and agreete maintain the private sewage disposal system with the standards set forth, herein, as set by th Department of Commerce and use the Department of Natural Resources, State of W' Certification stating that your septic system has bear mairttairted mast be completed and returned to the St. Croi /,, u~nt_y ,Z~o ' ce within 10 days of the three year expiration date. SIGMA OF APPt~ANf c DATE OWNER CERTIFICATION I (vve} certify that all statements on this form are true to the best of my (out) knowledge I (vwe} am (are) th er(e) of the property described above, ~ virtue of a warranty deed re~rdad in Register ~ Deeds e. ~ ' ~ ~y SIG aF APPLICANT TE :w~ess~ Any infciamatian that ismisrepresearted~y resuh in the saeitary permit beiErg revokedhy the zoning Depaztm~tssss* ~ hxclude with this applic~ian a stamped warranty dead from the Register ~ Deeds a~ffice a copy of the ~&a<tsarveymap ifreferm~ismade arthewarrmty deed U 2500P 031 STATE BAR OF WISCONSIN FORM 1 - 2000 Document Number ~ WARRANTY DEED THIS -DEED, made be een Hartm ., 'n Corporation Grantor, an Paul A. Stein and Laurie A. Schomisch Stei husband and wife, survivors property ran ee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (the "Property"): SEE ATTACHED EXHIBIT A Recording Area 7542>tQ>t3 KATHLEEN H. iiALSH REGISTER OF DEEDS ST. CROIX CO.. MI RECEIVED FOR RECORD 02/ 11 /2004 10: ~AIf . wARRAHTY DEED EXEMPT # REC FEE: 13.00 1'RAHS FEE: 247. S0 CDPY FEE: CC FEE: PAGES: 2 Name and Return Address: Land Title Inc. 1900 Silver Lake Road Suite 200 New Brighton Mn 55112 Together with all appurtenant rights, title and interests. 0'1~ -+595.4 i • i'jt,b Parcel Identification Number (PIN) This is not homestead property. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Dated this 9th day of February 2004. Hartman Homes Inc. ~~J ~ Gam„--'~- * Michael J. Hartman, President AUTHENTICATION Signature(s) authenticated this 9th day of February, 2004 TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Greg Booth Attorney, 1900 Silver Lake Road Suite 200 New Brighton Mn 55112 (Signatures may be authenticated or acknowledged. Both are not necessary.) *Names of persons signing in any capacity must be typed or printed below their signature ACKNOWLEDGMENT STATE OF Minnesota WASHINGTON COUNTY. ) ss. Personally came before me this 9th day of February, 2004 the above named Michael J. Hartman President of Hartman Homes Inc., a Wisconsin Corporation to me known to be the person s) who executed the regoing instrument and ackno edged the sa e. r Notary P lic, Stat of innesota My commission is permanent. (If not, state expiration date: WARRANTY DEED STATE BAR OF WISCONSIN y NANCY J. LENTZ ~, NOTARY PUBLIC-MINNESOTA My Comm. Expires Jan. 31.2005 ~ FORM No. 1-2000 ~. ,, U 2508P 032 EXHIBIT A Lot 41,~ Plat of Scenic Hills, located in the Town of Hudson, St. Croix County, Wisconsin. • / / ~g. . `~/ ~ ~ ~. L SOUTH UNE OF THE N1 /2 OF THE SW1 /4 Mf~]p~~GD L~i[r~D~ 68 ~t~ / ~ ~' \ ' , 98,886 SQ Ff ~ ~ / ~ ' f \ \ ~ \ v~ 2.270 ACRES N 90,2E •.. 674 SD Ff ~9 ACRES ~89°42'16"E 2630.40' ~r'P,~ ,-. ~ 2.07: \ ~~~, ,~~ ~~~~ ~~ ~~ `~~ Jar ll P~ ~ \ ~ \ • • ~ ~ ~\v/ ` ~ H.W.L. =991.9 ~ \ •' I ~ • ~ ~~ ~ H.W.L~= .: ~~ C29 100.13' . ~ ...-~ _ , 1002.0 ~. ~ \ ~ 586°58'14"E 336.83' • • . ~ . ~3~ ~ . Regal R1dge- . ~ . N86°58'14'W 336.83' dam Quinn (/wV r Subject: #430683 O'Connell/Stein Location: T of Hudson Scenic Hills Lot 41 Start: Tue 5/25/2004 2:00 PM End: Tue 5/25/2004 3:00 PM Recurrence: (none) 717 Regal Ridge -conventional