The URL can be used to link to this page

Home My WebLink About020-1349-11-000t Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)1. Permit Holder's Name: ^ City ^ Village ^ Town of: Kenall Jeff Hudson Township CST BM Elev.: q9 • ~ s ~ Insp. BM Elev.: q , qs' BM Description: w~ = c s`r' s (z" P vc. P` TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic alSO Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/ L WELL BLDG. vent to Air Intake ROAD Septic ~. ~~ / - ~.(,~ ~ - NA Dosing NA Aeration NA Holding PUMP /SIPHON INFORMATION Manuf Model Number GPM ELEVATION DATA County: St. Croix Sanitary Permit No.: 353293 State Plan ID No.: .---._.. Parcel Tax No.: 020-1349-11-000 v1G ~ ~ `~'~ / yi /d~87 STATION BS HI FS ELEV. Benchmark#2 p ' ~ qq- 9,5- ~ Alt. BM ' g " a,,~ •~- 0(~ Z a ~ Bldg. Sewer St/Ht Inlet ~6~ w Z ~(o•c{'~1 St/ Ht Outlet ~ g 4 ~-.6 ~ Q(Q . 28' Dt Inlet - ----- Dt Bottom Header /Man. 8 r,; 4 8 `('Z 9S; S'3 Dist. Pipe ~ f3,`f ~Y~ 8 S ~ S• S 'F S,~O Bot. System 9, Y4 9• }9 9 `~ ~ , Final Grade q~, S--O St cover (n ~ (H , o ~- ~l . S'~ r TDH I Lift I ran ,item I TDH Ft Fob I Length I Dia. I Dish SOIL ABSORPTION SYSTEM (~1 ,. Q,,,. , Q-- - -//f~ rt v T n/l fY_ WVJIO REN Width ~ Len ~ No Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIM N I N 3 ~ S~ •ZS Z., DIME I N SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING s ~ ~W re~~ SETBACK INFORMATION TypeO ~''~ r ( ~ "' ( ~~ CHAMBER OR UNIT M e Number: ~ System: ~ p a L DISTRIBUTION SYSTEM Header/ Manifold a Di tribution Pipe(s) x H e Size x Hole S n Vent To Air Intake r Length` Dia. gth Spacing 7 ~.~ SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Dept Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: y}/ 21 /av Inspection #2: ~-~- Location: 743 Blue Jay Lane, Hudson WI 5401 (SE 1/4 SW1/4 26 T29N R19W) - 26.29.19.187 Browns Ridge -Lot 11 1.) Alt BM Description = ~ ~, ~~ ~~ rc~.' ~ac>~ ~,ee~~ 2~ U 4 3 2.) Bldg sewer length = .. ~ I ' ~=8 -amount of cover = Plan revision required? ^ Yes ~No Use other side for additional information. SBD-6710 (R.3/97) 0~ Z t oo ~ ~ ~ ~ ~ -- Date Inspector's Signature Cert. No. a38Wf1N llWa3d Jas=1tJlINb'S ~ H~13~IS aNd S1N3WW0~ '1dNOlllaall - ti `~SC011S%11 SANITARY PERMIT ~ Department of Commerce In accord with ILHR 83. s m. Code'' rr~~ ..'~ • Attach complete plans (to the county copy only) for the , o ~6b[t less than 81n x 11 inches in size. ~~ • See reverse side for instructions for completing this app ' _ ion ~ ~ ~ ~~ ~~1X ~~ Personal information you provide may be used for secondary purposes ~%'~ '~ , [Privacy Law, s. 15.04 (1) (m)]. '''~ Safety and Buildings Division 201 W. Washington Avenue P O Box 7302 Madison, WI 53707-7302 ,o nty~ Sanitary Permit Num er 3r3 Z~ 3 eck if revision to previous application to Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PR{NT ALL ~ TI ~ `~~ "-'- Propert Ow erName ~"~ ~,l' ~'~;~-P,&•op~ ~o on 1 /4, S 2.6 T 2~ , N, R j~ '~ (or~/ Property Owner's Mailing Address L Lot Number Block Nu ber y3 / ~~. !l r4 City, State Zip Code Phone Number Subdivision Name or CSM u ber II. P F B ILDING: (check one) ^ State Owned ^ !t~ Nearest Road Public 1 or 2 Famil Dwellin - No. of bedrooms _~ ^ Vil age i/ / Town OF f9fl.~d ~~ 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) _ ~ ~ ~ D _ ~ 3 ~ _`/_ ~~ 1 ^ Apartment /Condo '' '" - :,~-;ta ~ ~ °~ Z - Z 2 ^ Assembly Hall 6 ^ Medical Facility/ Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise: Sales/ Repairs 11 ^ Restaurant/Bar/ Dining 4 ^ Church /School 8 ^ Mobile Home Park 12 ^ Service Station /Car Wash 5 ^ Hotel /Motel 9 ^ Office /Factory 13 ^ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. ~ New 2. ^ Replacement 3. ^ Replacement of 4_ ^ Reconnection of 5. ^ Repair of an -_____System ________System _ Tank Only______________ Existing System _________Exlstfn~System B) ~ A Sanitary Permit was previously issued. Permit Number 37 3Z ~ 3 Date Issued f- JQ.- Z,pcy V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ^ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 12,8 Seepage Trench 22 ^ In-Ground Pressure 42 ^ Pit privy 13 ^ Seepage Pit 43 ^ Vault Privy 14 ^ System-In-Fill ~g ~(~ ~ G~c.>~c.~5 VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft. Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ~1 ~ Elevation 3 9 ~~ ~ ~ TH 0 Feet ~. Feet J 72, ~/ , 7 ` ~lo VII. TANK INFORMATION Ca aut in gallo s Total # of Manufacturer's Name Prefab. Site con- l s Fiber- Plastic Exper. N E i ti Gallons Tanks Concrete tee glass App ew x n s strutted Tanks Tanks eptic Ta k 0`DC~ -~ OUn ~ ^ ^ ^ ^ ^ L ^ ^ ^ ^ ^ ^ i VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumbe 's Name: (Print) Plumbe 's Signature: (N Stamps) MP/MPRSW No.: Business Phone Number: T,~~-- c~,~ z2 ~5 ~ z~s _ ~~Z - ~z~~ Plumber' Address (Stpreet, City, State, Zip Cod,,e~j• IX. COUNTY/ DEPARTMENT USE ONLY ^ DisapprOVed Sanitary Permit Fee (~ncludesGroundwater ate ssue Issuin ent Signature (No Stamps} C~Approved ^ Owner Given Initial Surcharge Fee) ~ ~ ~ Z D / Adverse Determination O ~- X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: ' ` '' >~ sy s~~--- /~nS~~ ,~a-~ ~~ ;~ s/-al/ ~ ~ ~ o" ~~--- a --,~~ r~ ~/ ~p •-~~ w ~>C~.e~ ~~o><~;~ ~~~,, SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Divis on, Owner, Plumber 0~,~~~~/ .~.~`' INSTRUCTIONS A sanitary permit is valid for two (2) years. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If-you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3151. - To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to_be installed. It. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon-and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VI11. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County /Department Use Only. X. County /Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. ~ViSCOnS%n SANITARY PERMIT AI Department of Commerce ~ ,~- ' ~ rd with ILHR 83.05, W' I • Attach complete plans (tot ~gottr'fty copy~on e syst ,,i than 8 vi x 11 inches in si `; ' ~.. ,,.' M. ~,.~~ ~ • See reverse side for instr etit~ns for~orn~3ti~tMg this`~p ication Personal information you provide aye useyl~3se4oi•~dafy~~u[`~ose~ (Privacy Law, s. 15.04 (1) (m)]. ¢ -~ - -.. ~'"" ~ Safety and Buildings Division ~ 201 W. Washington Avenue 4d ~ ~ P O Box 7302 `# Madison, WI 53707-7302 s ~.0 :~ Sta ~ itary Permit Number /" i301X ^ ~ if revision to previous application COU S an I.D. Number 71-,nllar, no I. APPLI ATI N INF R T1 N - RL~A RI LL INF. MATT N ~ --!' Pro ert Owner Name ZCr'~l I ~ p -•-Y Z ~` Ptoperty~lo~a io /~~ Q -.t rya tiff` i T Z~ , N, R (or) `e ( l ' / Property Owner's Mailing Address 1. A~ - ~. ~...- ...../"~i Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Nu er II. TYPE IL ING: (check one) ^ State Owned ^ !t p Village ~/ Nearest Road Public 1 or 2 Famil Dwellin - No. of bedrooms ~_ Town OF fT I11. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(~)4 ~~ ~~~ OZ,Qj + 1 .~ ~ ^~ ~ - "' ~= o Zb • 29. l'9 , 1$ $ ~ ss 1 ^ Apartment /Condo c, 2 ^ Assembly Hall 6 ^ Medical Facility /Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise:Sales/Repairs 11 ^ Restaurant/Bar/Dining 4 ^ Church /School 8 ^ Mobile Home Park 12 ^ Service Station / CarWash 5 ^ Hotel /Motel . 9 ^ Office /Factory 13 ^ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) q) 1. ~-New 2. ^ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5, ^ Repair of an __ _System ________System ___ __ Tank Only______________ Existing System ________ Exlstm~S~fstem B) ^ A Sanitary Permit was previously. issued. Permit Number ,Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ^ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 12 ~ Seepage Trench 22 ^ In-Ground Pressure 42 ^ Pit Privy 13 ^ Seepage Pit / 43 ^ Vault Privy $ ~ ~ ~ ~ 14 ^System-In-Fill G ~; ~. t~ VL ABSORPTION SYSTEM INFOR A N: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final Grade. ti El on eva Required (sq. ft.) Pro osed (sq. ft.) (Gals/da /sq. ft.) (Min./inch) ~ t 3d Fe ~ ~S 3 ~ F ~ y~ ~ ~ ~ e eet j - ~ 7 Z , - 7 _ VII NFORMATION Capaat in allo s g Total # of k Manufacturer s Name Prefab. Site con- steel Fiber- l Plastic Exper. .A Gallons s Tan Concrete g ass pp New Existin strutted T nks Tanks Septic Tank or Holding Tank (~C3Q ^-~ ~t~d0 ,~,~ ~./~ Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print Plumber's Signature: o Stamps) MP/M~ No.: Business Phone Number. Plumber' Address (Street, City, State, Zip Code):. ~~a27 t1 ~ti ~l ` r ~ ~ Z IX. COU TY /DEPARTMENT USE ONLY ^ Disapproved S nitary Permit Fee (Includes Groundwater ate SSUe Issuing Agent Signature (No Stamps) '~A rOVed pp ^ Owner Given Initial Surcharge Fee) ~ ~ Za lg'~~ ` ~' Adverse Determination J . o X. CONDITIONS OF APPROVAL /REASONS FOK uISP-rlrKUVA~: SBD- 639H (R.11I97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber a INSTRUCTIONS ~ '' 1. A sanitary permit invalid -for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved 6y the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system fs to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7; VII. Tank information. FiIF in the capacity of every new/or existing tank, list the total gallons, number. of tanks and manufacturer's name, indicate prefab or site constructed and tank material- Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County /Department Use Only. X. County /Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal.and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on.a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. TIMM EXCAVATING Route 1 Box 192 WILSON, WISCONSIN 54027 (715) 772-3214 (715) 386-5443 MPRS #3224 WI MPCA #696 MN JOB ~'P r 1`- /7.~f~'c.~~ _ SHEET NO. '~ff ~, OF may,` CALCULATED BYP~ r..+ ~ /y' ~ DATE ("' ~ ~~ ^ ~"~ CHECKED BY DATE SCALE / '' ~ L/V , PRODUCT 2051 ~ tnc., Groton, Mass. 01471. To Order PHONE TDIL FREE 1-BOP2256380 God [ iwc I~ -- ---I- - QI _. _ ~ ~ ~ - -- -~ Z - - ~ ~ ~ ~~ g - - -- Z o- -- -- - - -- - 1 qtr w _ -- -~- -- - -- ~- -- - ' \ -- ~- ~- i, ~ C~ ~ e ~ ~e Wisconsin Department of Commerce SOIL AND SITE EVALUATION Divisjon of Safety and Buildings ~ --° ~eureau of fhtegrated Services %1r1 aCOOr:'derlc~~h s. ILHR 83.09, Wis. Adm. Code 'G '?~ ~ ~ ` ~ COUnty Attach complete site plan on paper not less~than 811/2 ~~~ iPte~s' size' QI~ must Page ~ of 3 ` "-"' St . Croix include, but not limited to: vertical and horizontal refereiiA~;pAitat.: M), dir~cfior~and percent slope, scale or dimensions, north farrow, and location and distance ne rest road. 1:,~ ~(?..-.- Parcel LD. # APPLICANT INFORMATION - Plgase print 8n i~le~mat~on~`F~'J Reviewed by 2 _ Date Personal information ou rovide ma be used for ec~nda aw ~i5. 4 1 m O g e~ Y P Y ~ ,,, ry~~~l~~~hf~ ~ () I )) C? Property Owner `~ ,.:,r'~ Property Location Richard StOUt '` ~` ~ `°;°.E~( ~~ ~s~'` Govt. Lot s~ 1/45 1/4,S ~G Ta'~ ,N,R ~~ E (or~ Property Owner's Mailing Address "-~' "' Lot # Block# Subd. Name or CSM# 1353 Awatukee< Trail 11 Brown's Ridge City State Zip Code Phone Number ty ^ Village ~{ Town Nearest Road Hudson WI 5401 6 (71 5 549-6731 ^ ci Hudson Meadow Lane [~ New Construction Use: Residential /Number of bedrooms 3 Addition to existing building ^ Replacement ^ Public or commercial -Describe: Code derived daily flow 4 5 0 gpd Recommended design loading rate • 7 bed, gpd/itz • 8 trench, gpd/ft2 Absorption area required 6 4 3 bed, ft2 5 6 3 trench, ft 2 Maximum design loading rate • 7 bed, gpd/ft2 • 8 trench, gpd/ft2 Recommended infiltration surface elevation(s) ~Y.~ir~Yw.+ 9S• -~~ /4~.~7J~r.~O ft (as referred to site plan benchmark) Additional design/site considerations Parent material Glacial DepO s l t Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system [~ S ^ U ®S ^ U ®S ^ U ®S ^ U ^ S ®U ^ S ~] U SOIL DESCRIPTION REPORT Boring # 1 Ground Iev. %~• Depth to limiting factor 9 6 in. Boring # 2 Ground lev. ~v~Oft. Depth to limiting factor 9 $_in. Horizon Depth Dominant Color Mottles T t Structure Consistence Bounda Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color ex ure Gr. Sz. Sh. ry Bed ,Trench 1 0-1 10 r3/2 Sil 2mabk mfr cs 1F .5' .6 2 15- 8 10yr4/4 Sil 2mabk mfr ss .5;6 3 38- 6 10yr4/6 Ms os ml .7 .8 y. 3 ,f ' Remarks: 0-1 10 r3 2 Sil 2mabk mfr cs 1F .5..6 2 15- 8 10~r4 4 Sil 2mabk fr 3 38- 4 10 r4 6 M 4 44- 8 10 r 4 L t Qy 3 ~~ 9G" ' Remarks: :.ST Name (Please Print) Signature Telephone No. t~G~~~l~~m ~°t~tia~ r `~,o~! f~~ ~~~~,,,d,~i''_',_.--- (71 5) 3 8 6 - 31 21 Address Date CST Number 1070 Scott Rd Hudson WI 54016 ~ 9~ ~~~~'d~'' PROPtRTYOWNER Richard Stout SOIL DESCRIPTION REPORT PARCEL I.D.# Boring # 3 Ground elev. rJ9.3d ft. Depth to limiting factor ~_in. Page o ,of _ Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ~ Trench 1 0-1 10 r3 2 Sil 2mabk mfr cs 1F .5'.6 2 18-3 8 10 r4 4 Sil 2mabk mfr cs .5; .6 3 38- 6 10 r4 6 Ms os ml .7~.8 RY. 3 ~~ 9l~~~ Remarks: Boring # 1 4 2 18 Ground elev. /DQ!°n Depth to limiting factor ~~in. Boring # 5 Ground elev. ~~n. Depth to limiting factor _~.~in. Boring # Ground elev. ft. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench 1 0-14 10 r3/2 Sil 2mabk mfr cs 1F .5'.6 2 14-4 10 r4/4 Sil 2mabk mfr cs .5;.6 3 44-9 10 r4/6 Ms os ml .7~.8 J Remarks: Depth to I I I I I I I I I I ' limiting factor in. Remarks: SBD-8330 (R. 07/96) ~row~ sr ~=~.9 ~ ~ e7' /! L-- ~ L P.~,2-Po f ~ ~ ~ ~' ~ N N God ~,~- vF.~ u/_~pZLBYNQ.y ~ / .~M~ .Sm ` ~ g~ ~ ~ S~~ PG 3 •,~- ,~~ 7_ 'B Y .~ ii ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~ ~' ~ ~ ~~e.. rt u~x Mailing Address Property Address (Verification required from Planning Department for new City/State S~-y- ~ zr: _ ~~' ~ Z - 3 ~ 1~ ~ Parcel Identification Number a Z ~ ~ j ~. ~ z - c.~«_ LEGAL DESCRIPTION Property Location ~ C '/4, Sc~ %4, Sec. '~ ~ . T Z S N-R / ~ W, Town of f~~.~5 cr-rr Subdivision [~ ~~ Lot # i f Certified Survey Map # Volume ,Page # Warranty Deed # (~~ C~~l [;~~_"~ ,Volume / X13 Z ,Page # S~„ /~_. Spec house ~ yes ^ no Lot lines identifiable ~,I yes ^ no SYSTEM MAINTENANCE 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 licensedpumperverifying that (1) the on-site wastewaterdisposal 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. Uwe, 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 tic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of they year expirati9n date. / i7 /~ DATE 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 described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT // 7/ oc) DATE ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed srATE BAR OF ~5CUN31Nf 58 `~- t~ This Deed, made between Gary D Nelson and Jillietrne J. Nelson. husband and wife Grantor, and Jeffrey R Kenall a married person Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin (The `Property"): 604617 Y.A'THLEEN H. WflI.SH REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 06-09-1999 9:30 PN Wi'I~tiWTY DEED EXEtlPT R CERT LDPY FEE: COPT FEE: TRANSFER FEE: 106.50 RECORDING FEE: 10.00 PAGES: 1 EAGLE VALL~CY BANK, N.A. 1301 Coulee Rd., Unit 2 Hudson, Wl 54016 ozo-lon-ao ar tnalmz~o Parcel Idemification Number (PII~ This is not htattestead property. Lot I1, Plat of Brown's Ridge Addition in the Town of Httdson, St. Croix County, Wisconsin. This is not homestead property. Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any Dated tltis ~ day of May, 1999. AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ~~~~... ~~ ) ss. authenticated this day of LENS ~1~2/- • ~d• X County ) - Plotarr ru°t"'^'mt~Tw ~ 2~ I Q r)~l Personally cazne before me this / 7 day * *,t;t_('om+r~sston ><v ~'~ - of May, 1999, the above named Gary Nelson and Jilbenne J Nelson husband and wife TITLE: MEMBER STATE BAR OF WISCONSIN (If tat, authorized by § 706.Q6, Wis. StatsJ THIS INSTRUMENT WAS DItAFCED BY Attorney Krlstina Ogland Hudson, WI 54016 (Signatures may be authenticated or acknowledged. Both are twt reccssary.) //* Gary D. a ~Dn * Jillience J. N to me known to be the person(s) who executed the foregoing insttvment and acklpwledge the same. - ~ ~~t--n ^ Notary Public, State of Wisconsin My Contni ssion 's petrnanent. (If not, state expiration date: ig '/,_.) *Names of persons signing in any capacity should be typed or printed below [heir signatures WARRANTY DID STA18 DAA OF WISCONSIN FOAM No.1.199a INFORMATION PROFES910NAL3 COMPANY FOND DU IAC, wl aao853-YPat _._ .__ 80'~,EE --3„~Z,8Z.OOS O' ,ab'saoi a'LZ68 ,00 9 3 v> a,si.oos ~ - N of ~, ~ ~ S ~s~ ' 1- ~ 's~~' '~ ~Nww ~ ~ ~ I aow ~ ~ `~•O y ~ 98`'8r ~'jl~n£os,~ i ~ N JO=~ I ~ Si~ £tiJ I ~~Z~t- ~ I w ° ~ o ~ ,89'i6b 3„Ob,60.00N s ~ ., a / ~¢~~W i°~N~ ~ ~ yZW=¢ ^~ ~" ~ln m °Z° 2 ~ Nn ~O Ay~¢N 1~ > z fn ~wi I~ .. .ter ti Q F~- ~- J~rZ--i I n- U. p~ w.,,J,, pwq~X~~ ~ O ° ~ Q W ~ I ~ ~ ° N ?. ~ ,08'TbS 3„Ob,60.00N W w~rF-~ ~ ~~ Q. ~ ¢°wJ~ I W ¢ .-~ y W~ F- ~ J Q Z '~' .~ Q~QW~ I V~` = o! W_ ~ ao ~w> aZ ~ : _ _ _ ~. ~ 3 w ~p=gNaZH ~ N^ ~ ~ W ~ P4 """-Wr '~-~ ~ O QOZQQZL7 f '- ~ 0~ W 1 ~waac~-n~°° U i ~ ~ F-o~A~M H ~ a~ 3 ~ J ~ ,EZ'6ES 3.,Ob,60.00N ~ ~ z a r o a I~ ~ ,L£'~8Z ,98'~SZ Z