HomeMy WebLinkAbout032-1046-60-001 (2)
Wisconsin Department of Commerce County:
PRIVATE SEWAGE SYSTEM St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 597332
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
NA-
Permit Holder's Name: City Village Township Parcel Tax No:
MORUD, MARTIN & MAUREEN TOWN OF SOMERSET 032-1046-60-000
CST BM Elev: Insp. BM Elev: BM Description: 5 0 Section/Town/Range/Map No:
'c 16.31.19.235
TANK INFORMATION ELEVATI N DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic O Benchmark 7
Alt. BM r
Aerayl Bldg. Sewer 8 5
~`7 J
H Ht Inlet
i~ • ~
TANK SETBACK INFORMATION U tOutlet S q A/ J/
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic ~r DtBottom
Dosing Header/Man.
A Z 92.7
Aer ion Dist. Pipe
Holding tot. System
PUMP/SIPHON INFORMATION Final Grade
Manufactur PfFhand St Cover gle)
GPM
Mo I Number
TD Lift Friction Loss em Head TDH Ft
Forcem Le Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK S STEM TO P/L B ELL LAKE/ST
INFORMATI Ty Of ste CHAMBER E OR Model Number:
DISTRIB N S M
Header/Manif d D tribution x Hole Size T7 Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length a Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Cent Bed/Trench Edges Topse -
~Yes Yes ❑ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 434 210TH ST C~GVI(`,~ N LaIW OIn, ` 1
1.) Alt BM Description = St Caves
2.) Bldg sewer le
Plan revision Required? ❑ Yes o
Use other side for additional informati n. '
SBD-6710 (R.3/97) Date Insepctor's i ature Cert. No.
~~vrPl.RTI yT`~
i; r ~Gw\
~ t ~k.• County
Industry Services Division St. Croix
sR1 MAY 16 2017 laoo E Washington Ave
z S yI S. CROIX COU P.O OX 7162 Sanitary Permit Number (to be filled in by Co.)
+OMMIJNRYDEVELOP EMadison, 537 7-7162
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,
Sanitary Permit App11~~. 'Star,TransaelionNnmber
In accordance with SPS 383.21(2), Wis. Adm. Code, submission ofthis form to the app_ unit
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POw _ ' Project Address A/i
the Department of Safety and Professional Services. Personal information you provide may be used
purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. (if different than mailing address)
434 210"' Avenue
1. A lication Informat on -Please Print All Information
Property Owner's Name
Mound, Martin & Maureen Parcel #
032-1046-60-000
Property Owner's Mailing Address
434 210th Avenue Property Location .
City, State Govt. Lot
Somerset, WI Zip Code Phone Number SE 1/4, SW Y4, Section 16
54025
circle one)
II. Type of Building (check all that apply) Lot # T 31 N R 19 E or
® I or 2 Family Dwelling- Number of Bedrooms 1
Subdivision Name
❑ Public/Commercial - Describe Use Oi Block #
❑ State Owned -Describe Use ❑ City of
CSM Number ❑ Village of
® Town of Somerset
III. Ty a of Permit: (Check only one box on line A. Complete line B if a plicable)
A. ❑ New System ❑ Replacement System
❑ Treatment/Holding Tank Replacement Only ® Other Modificjtion to Exin$tin S stem ((explain)
C NNif C / ao F r7 S ri
Si ~~c~CT~r arc`
B. Permit Renewal ❑ Permit Revision ❑ Change of
Before Expiration ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Plumber Owner
572863, tz/15/2014
IV. T e of POWTS System/Component/Device: (Check all that apply)
® Non-Pressurized In-Ground
❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil
El Ho mg n --❑TOther Dispersal Component (explain) - El Mound < 24 in. of suitable soil
❑ Pretreatment Device (explain)
V. Dis ersal/Treatment Area Information:
Design Flow (gpd) Design Soil Application Dispersal Area Re uired s
600 Rate(gpdsf) 1200 q Dispersal Area Proposed (sf) System Elevation
0.5 1200 90.70', 90.10, 89.50'
VI. Tank Info Capacity in
Gallons Total
# of 2
o
New Tanks Gallons Units Manufacturer U
Existing Tanks o y 2 2
G U v ti n U C7 0..
Septic or Holding Tank 320 1250
1550 2 Wieser Concrete both w/ ® ❑ ❑ ❑ ❑
525
Dosing Chamber Poly]ok 525's
Dosing
Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. ❑ El El
Plumber's Name (Print) Plumbek ign e
John Schmitt MP/MPRS Number Business Phone Number
223760 715-760-0486
Plumber's Address (Street, City, State, Zip Code)
616 150th Ave. Somerset, WI 54025
VII1. Count /De artment Use Only
Approved ❑ Disapproved' Permit Fee Date Issued Issuing gent Signature r
Ow en Reason for Denial $ r = % •
IX. Condit ~b _r
i > ` IDisapprovaI
~'Stt Wlll IT".* IlflMi'Rx~s trt4'"~ ~=royo 1 p t,~
*p$r,;yWA M! plan A!'o"rkled by plwnbe=. V
2. as per ropkx6h be nand' fired f.~.. ~ t' ~5 ~ ~ .lc' t-E; / I C;.~"~.~ r.
narlass.
Attach to complete plans for the system and submit to the County only on paper not less than 8 U2 x l l inches in size
SBD-6398 (R03/14)
PLOT PLAN N
Project Name: Morud 4 Bedroom Septic System
Legal Description: SE1/4, SW1/4, S16 T31N, 019W P.I.D: 032-1046-60-000
Subdivision Name: NA Lot NA
Township: SOMERSET Parcel Size: 40 Acres Parcel SCALE: 1" =40'
County: ST. CROIX
System Elevation: T1=89.50' Proposed 80' EZ Flow Trench
Slope: 11% 12=90.10' Proposed 80' EZ Flow Trench
BM1 Elevation: 100.00' To of 2' PVC pipe
BM2 Elevation: 99.48' To of 2' PVC i e T3=90.70' Proposed 80' EZ Flow Trench
~ Backhoe Pits:
4 inch Sch 40 -ASTM D2665
TANK SCHEDULE 4 inch 3034 - ASTM D3034
S1 Pro osed 1250 allon se tic tank w/Pol lok 525
S2 Pro osed 320 allon se tic tank wJPol !ok 525
NOTE: See page 11 for a complete plot of the parcel.
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CONVENTIONAL COMPONENT DESIGN
INDEX AND TITLE PAGE
Project Name: Morud 4 Bedroom Septic System
Owners Name: Martin & Mary Maureen Morud
Owner's Address 434 210th Avenue
Somerset, WI 54025
Legal Description: SE1/4, SW1/4, S16, T31N, R19W
Township Somerset
County: St. Croix
Subdivision Name: 40 Acre Parcel
Lot Number: NA Block Number
Parcel I.D. Number 032-1046-60-000
Plan Transaction No.
Page 1 Index and title
Page 2 Plot Plan
Page 3 System Sizing & Cross Section
Page 4 Septic Tank 1 (S1) Specifications
Page 5 Septic Tank 2 (S2) Specifications
Page 6 Filter Information
Page 7&8 Management and contingency plan
Page 9 Septic Tank Maintenance Agreement
Page 10 Warranty Deed
Page 11 CSM or Plat
Page 12 Accessory Structure Affidavit
Attachment Soil Evaluation Report
Designer: John Schmitt Licnese Number: MPRS 223760
Date: 5/15/2017 Phone Number: 715-760-0486
Signature:
i`
In- round Soil Absorption Component Manual Version 2.0 SBD-10705-P (N. 01/01)
Page 1 of 12
PLOT PLAN N
Project Name: Morud 4 Bedroom Septic System
Legal Description: SE1/4, SW1/4, S16 TMN, R19W P.I.D: 032-1046-60-000
Subdivision Name: NA Lot* NA
Township: SOMERSET Parcel Size: 40 Acres Parcel SCALE: = ao
County: ST. CROIX
System Elevation: T1=89.50' Pro osed 80' EZ Flow Trench
Slope: 11% T2=90.10' Proposed 80' EZ Flow Trench
BM1 Elevation: 100.00' To of 2' PVC pipe T3=90.70' Proposed 80' EZ Flow Trench
BM2 Elevation: 99.48' To of 2' PVC pipe
Backhoe Pits:
F4in1h ch Sch 40 -ASTM D2665
3034 - ASTM D3034
TANK SCHEDULE
S1 Proposed 1250 allon septic tank w/Pol lok 525
S2 Proposed 320 gallon septic tank w/Pol lok 525
NOTE: See page 11 for a complete plot of the parcel.
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SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT
Project Name: Martin & Mary Maureen Morud
Gravelless Leaching Unit Specifications
Manufacturer Model Laying Length EISA Rating
Infiltrator EZ1203H-5ft 5.0' 25.0
EZ1203H-10ft 10.0' 50.0
System Sizing
Flow Rate 600 gpd
EISA Rating per Foot of EZ Flow ft2 Soil Application Rate 0.5 gpd/ft2
600.0 gpd Design Flow _ 0.5 Soil Application Rate = F-57 EISA = 240.0 Feet of EZ Flow
F trenches 80 feet long each
3 No. of Cells 8 Per Cell
3 ft Cell Width 30 Total No of 1203H
80 ft Cell Length 400 sq ft EISA Per Cell
3 ft Cell Spacing 1200 sq ft Total EISA
Typical Cross Section
Finished Grade 100 ft Observation Pipe with
approved cap or vent
Soil Backfill
36 Inch Geotextile Fabric
'3 ft
12 inch O II > aft Slotted and Anchored Vent/Observation Pipe
_ ' with Cap
If _ _
90.70 ft O 89.5 ft
I / Infiltrative Surface
>36 inch `90.10 ft/
Plumber/Designer Signature:
License MPRS 223760 Date: November 18, 2014
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The PL-525 Filter is rated for 10,000 GPD (gallons per day) snaking it one of the largest filters in its class. It has
525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the Polylok 1?1 525 has an automatic shut-off ball
installed with every filter. When the fitter is removed for cleaning, the ball will float up and temporarily shut off
the system so the effluent won't leave the tank. r
Rated for 10,000 GPD (gallons per day). alarm Switch
- (Optional)
525 linear feet of 1 /1.6" filtration. 10,000 GPD
Accepts 1"
Accepts 4" and 6" SCHD 40 pipe. , e`'
Extension 1 tandl
c
Built in gas deflector.
Automatic shut-off lull when filter is removed.
Alarm accessibility. Rated 10,(x)0 for
GPD
Accepts PVC extension handle.
Ideal for residential and commercial waste flows up to 52; Linear Ft.
10,000 gallons per day (PD). of t/ te"
P 1 G Filtration Slots
1. Locate the outlet of the septic tank.
2. Remove the tank cover and pump tank if necessary.
Accepts 4" & Ei"
3. Glue the filter housing to the 4" or 6" outlet pipe. If SCHD 40 pipe
the filter is not centered under the access opening use a
Polylok Extend & Lok or piece of pipe to center filter.
4. Insert the PL-525 filter into its housing.
5. Replace and secure the septic tank cover. j 4 t w
The PL-525 Effluent Filters will operate efficiently for
several years under normal conditions before requiring
cleaning. It is recommended that the filter be cleaned
every time the tank is pumped, or at least every three
years. If the installed filter contains an optional alarm,
the owner will be notified by an alarm when the filter
needs servicing. Servicing should be done by a certified Gas Deflector
r
septic tank pumper or installer. Automatic
Shut-Off Ball
1. Locate the outlet of the septic tank.
2. Remove tank cover and pump tank if necessary.
3. Do not use plumbing when filter is removed.
4. Pull PL-525 cartridge out of the housing.
5. Hose off filter over the septic tank. Make sure all ►
solids fall back into septic tank.
6. Insert the filter cartridge back into the housing making
sure the filter is properly aligned and completely inserted. PoIN,lok Zabel & Best filters accept Easily installs
7. Replace and secure septic tank cover. the SmartFilterc_b switch and alarm. into existing tanks.
Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 7it11 Free: 877.765.9565 Fula: 203.284.8514 www.polylok.com
-ae 6
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page _of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner: Martin & Mary Maureen Morud Tank Manufacturer: Wieser Concrete NA
Permit # 7-' Septic ! Dose- Holding Volume: 1250 gal
DESIGN PARAMETERS Tank Manufacturer: NA
Number of Bedrooms: 4 r... NA Septic- Dose Holding Volume: 320 gal
Number of Public Facility Units: NA Vertical Distance Tank Bottom (s) to Service Pad: ft
Estimated (average) Flow: 400 gal/day Horizontal Distance Tank(s) to Servvice Pad: ft
Desi n (peak) Flow = estimated x 1.5: 600 gal/day Specific servicing mechanics must be provide if vertical is>15 feet or if
In Situ Soil Application Rate: 0.5 gal/day/ft2 horizontal is > 150 feet. Specific instructions to be provided on back.
Standard Domestic lnfluenVEffluent Monthly average Effluent Filter Manufacturer: POLYLOK NA
Fats, Oils & Grease (FOG) s30 mg/L Effluent Filter Model: 525
Biochemical Oxygen Demand (BOD5) :5220mg/L NA Pump Manufacturer: NA
Total Suspended Solids (TSS) s150mg/L Pump Model:
High Strength Influent/Effluent Monthly average Petreatment Unit
Fats, Oils & Grease (FOG) s30 mg/L Manufacturer:
Biochemical Oxygen Demand (BOD5) 5220mg/L ?J NA Mechanical Aeration Peat Filter ANA
Total Suspended Solids (TSS) 5150mg/L Disinfection Wetland
Petreated Effluent Monthly average Sand/Gravel Filter Other:
Biochemical Oxygen Demand (BOD5) 530mg/L Soil Absorption System
Total Suspended Solids (TSS) s30mg/L +VNA tir In-Ground (gravity) In-Ground (pressure) NA
Fecal Coliform (geometric mean) 5104cfu/100m1 At-Grade Mound
Maximum Effluent Particle Size: % in dia. N Drip-Line Other:
Other: Other: NA
116 MAINTENANCE SCHEDULE
Service Event Service Frequency
When combined with sludge and scum equals one-third (1/3) of tank volume
Pump out contents of tanks When the high water alarm is activated
month(s)
Inspect condition of tank(s) At least once every: 3 ly year(s) (Maximum 3 years) NA
month(s)
Inspect dispersal cells At least once every: 3 3Y year(s) (Maximum 3 ears NA
month(s)
Clean effluent filter At least once every: 1.5 w year(s) NA
month(s)
pump, pump controls & alarm At least once every: year(s) i~ NA
Inspect
month(s)
Flush laterals and pressure test At least once every: year(s) NA
month(s)
Other: At least once ever : year(s) NA
Other: Maintenance is the same for both tanks
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master
Plumber; Master Plumber Restricted Sewer; POWTS Insepector; POWTS Maintainer; Septage Servicing Operator (pumper). Tank
inspections must include a visual inspeciton of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on ground surface. The
dispersal cell(s) 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 indicated a failing condition and requires the immediate
notification of the local regulatory authority.
When the combined accumualtion of sludge and scum in any treatment tank equals one-third 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
Admininistrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, petreatment 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 30 days of completion of any service event.
(Rev.2/05)
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Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other
chemicals or sediment that may impede the treatment process and/or damage the soil dispersal cell(s). 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 extended power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will
be discharged to the dispersal cell(s) in one large dose and may overload them resulting in the backup or surface discharge of effluent.
To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the
effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal 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; foundation drain
(sump pump) discharge; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products;
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 83.33, Wisconsin Administrative Code:
• All piping to tanks, pits and other soil absorption systems 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, 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.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide the opportunity to obtain a sanitary permit for
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 proposed structure, lot lines and wells. 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 the time of their
permit issuance.
❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be
rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort.
I
❑ 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: TREATMENT TANKS AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES AND LACK SUFFICIENT
OXYGEN TO SUPPORT LIFE. NEVER ENTER A TREATMENT TANK OR HOLDING TANK UNDER ANY
7 CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK IS VERY DIFFICULT.
ADDITIONAL INFORMATION:
POWTS INSTALLER POWTS MAINTAINER
Name: John Schmitt Name: John Schmitt
Phone: 715-760-0486 Phone: 715-760-0486
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name: Owners Choice Name: St. Croix County Zoning
Phone: Phone: 715-386-4680
This document is intended to meet minimum requirements of Ch. Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
Use of this document does not guarantee the performance of the POWTS.
(Rev. 2/05)
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i
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer Martin & Maureen Morud
Mailing Address 6711
o r wd
Property Address 4 4 10th Ave' .
(Verification required from Planning & Zoning Department for new construction.)
City/State Somerset, WI Parcel Identification Number 032-1046-60-000
LEGAL DESCRIPTION
Property Location SE 1/4 , SW '/4 , Sec. 16 'T31 N R-19 W, Town of Somerset
Subdivision Plat: NA 40 Acre Parcel
, Lot # NA
Certified Survey Map # , Volume , Page #
Warranty Deed # (before 2007)Volume , Page #
Spec house C7yesMno Lot lines identifiable Elyes]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 §SPS. 383.52(1) and in Chapter 12 - St. Croix Count), 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 113 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 Safety And Professional Services 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.
1/we certify that all statements o 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 sarranty deed recorded in Register of Deeds Office.
Number of bedrooms 4 f
SIGNATURE OF APPLICANT(S) - 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. 01/12)
I I E 1111 Ili
IIIIIII(
8 IIIIIIII
8272768
Tx: 4223426
Document Number Document Tide 1005353
St. Croix County BETH PABST
REGISTER OF DEEDS
Accessory Structure Affidavit ST. CROIX CO., WI
RECEIVED FOR RECORD
12/12/2014 10:37 AM
Martin C. & Mary Maureen Morud EXEMPT
Name - (Owner) Typed or printed REC FEE: 30.00
being duly sworn. states, under oath. that: PAGES: 1
He/she is the legal owner of the following parcel of land located in St.
Croix County, Wisconsin, recorded in Volume Page Document
Number 983115 St. Croix County Register of Deeds Office, Recording Area
being duly described as follows (include lot no. and subdivisiort/CSM or N-ame and Return Address .
Martin Morud
detailed legal description): 5301 Edina Industrial Blvd az
-40-Acre-parcel,-S£,114. SW 1/4, Section 16, Town 31N, Range 19W Ntinneapolis, MN sS439'
Parcel Identification Number (PIN),
032-1046-60-060-
As owner of the above described property, I acknowledge that the Private Onsite Wastewater Treatment System
(POWTS) services both an existing principal dwelling and an accessory building on this lot and is sized for a (_4j
bedroom home, or a design flow of _(QQ gpd. This accessory building may not be used as a second residence on this
parcel. 1 also acknowledge that I will disclose this information and stipulation to any future parties interested in
purchasing this property.
Dated this day of `xcel"Vwly
i. A
* Yl D Y yr *
AUTHER T iV ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
_ )ss.
St. Croix county. ) ~t ~`~p~✓
authenticated this day of~~ Personally came before me this _ da5'•of
Irk the above named
• ro me known to be .
TITLE: MEMBER STATE BAR OF WISCONSIN the person(s) who executed the foregoingsinstrument and acknowledge the
u n 1, I V
(author same. V~~ }
authorized by # 706.06, Wis. Stars.)
THIS INST UMENT WA DRAFTED BY d` ` I ? ri~~ ~ c ~
Hp// •zs.~.•y~~.y
Notary Public ate C lIl
(Signatures may be authenticated or acknowledged. Both are not My Com isS[on rs per[anent~lfti s4r[ci~t~ date:
s,.
necessary.) Date: .
I
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