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HomeMy WebLinkAbout020-1353-43-000 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT Owner Do,v l r.K4 r& R • Property Address ,4LEx A-AIE City /State grA Oswo &) Legal Description: Lot Block Subdivision/CSM # 04-A" SE 1/4 A/ w %<, Sec. 3 G , T 9N-R11 W, Town of 1--kt40s0A PIN # 2 o - /35 -t SEPTIC TANK — DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer '°' Size ST/PC/?Co/ — Setback from: House 3 9 Well 3S `P/L ? - 6 Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system': 1 ?e u K Width 3 - Length l3. 7C Number of Trenches .2 Setback from: House // 7 ' Well 9 ` P/L Vent to fresh air intake / S ELEVATIONS: Description of benchmark X/.t. ..� G ' OA IC Elevation loo-, D o Description of alternate benchmark r. K Wiz aj /' �ow� I.e u ct Elevation io y.o. Building Sewer / °. 5 a ST/HT Inlet /0 /- 3 ST Outlet /0 /. PC Inlet PC Bottom Header/Manifold 9 • �/ Top of ST/PC Manhole Cover / 0 /- 0 7 Distribution Lines ( ) ( ) ( ) Bottom of System (X-) VD • 816 (/) 7'0, ©° ( ) Final Grade (A) 5 2r3 (6) �'`•/. Sp ' ( ) Date of installation / /4 /d! Permit nu ber 313 ?f•7 State plan number , Plumber's signature icense number 22 Date 7 /3 /o ( Inspector Complete plot plan Q f NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW eeNcHnIARK- ''..Q1111 rtoo? r // // LowCf ktlidt 41-1.1:- /O'4 0.2. '"Y "Jc'"42 R e- i, 6 ,L,„ `p'.- 4- NIj,g <to Sewere 4pt.tr J P2 Po ET) -'� IA r , SY" / o �orf C.4), € €? 51, d / . A / d ct7 c -h,er .7 \ Qg , /1 ' ` l "- PdL 3 l kFF<uci 4 „.,e \ . \ 1 /4140 Ch'/i4 rr`r L1 er \ Je 5 --0., / 2' , \ \ - \ 53, q \ \ I g n0(14/ 77'<s NAr« ,N 6 �`V. INDICATE NORTH ARROW \ • /* Wsoa in Department of Commerce PRIVATE SEWAGE SYSTEM count : Safetland B uildings Division INSPECTION REPORT SYt. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 383987 Permit Holder's Name: ❑City ❑ Villa a ( Town of: State Plan ID No.: 3aierl, Donn Hudson T CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.: a , „/ 020 - 1353 -43 -000 /D n hZ G as�C TANK INFORMATION ELEVATION DATA TYPE / MANUFACTURER CAPACITY STATION BS N.61) HI FS ELEV. Septic (, J ` e r . r (t/ 1 Wier) (Z � O Benchmark y G 9 /D d Q.,.',. Alt BM 3.7 7 /4 y 7 Z Aeration Bldg. Sewer -b y. 9 y (o 2 - 9S - ---- -. -- D • ing Ht Inlet . �` St 2.9 ( /0/, 75" TANK SETBACK INFORMATION / Ht Outlet 3 . Zo (.04y1 TANK TO P/ L WELL BLDG. Vent to ROAD Air Intake / rrs -r t NA —..� I Septic > 7,5 3 9 q� Dosing -------- NA Header /Man. / 3. yG (- z 3 * 4 /3.3? 94 3♦ Aerati N Dist. Pipe K - { - 35 . � ' /.3y olding Bot. System PUMP / SIPHON INFORMATION .. Final Grade `. Ma . - • rer Demand 3t cover ;9/ j e A r S � /a y le Model Number GPM TDH Friction stem I TDH / Ft Loss e • - F remain I Length I Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED /REN8 Width I Length r No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIO ( 3 - 9_5 3 I DIMENSIONS M j r r. SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM LE A ING ,, ,� INFORMATION Type Of a N umber: System: (ibv1 \) (Z >› G �� 0.. ' ss.',44„/./ DISTRIBUTION SYSTEM Header / Manifold Distribution Piipe(s) u� x Hole Size x Hole Spacing Vent To Air Intake Length + . 4 ' Dia. 4 '' Length [ Z _. 7� Dia. A/A Spacing % /1/4 /1/4 7 l6 d 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 Center Bed / Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons presen etc9S peCtlon #1: / 3 /rr/ Inspection #2: / Location: 866 Alex Lane, Hudson, WI 54016 (SW 1/4 NE 1/4 36 T29N R19W) - 3629192043 Cottonwood Ridge -Lot 43 y .) w� // , Le" ,;■_ S I L41 1.) Alt BM Description = L* clop, 2.) Bldg sewer length = yo' - amount of cover = > �/z °' ( g 1 ( 3 3' D1�tP lVDC7�Ow V �„�5 (hS�o �P� r 6-4t,14. /JCC� tg..C� , d. Plan revision re ❑ Yes p No , , / / /�� Use other side for additional information � ®,� 6 �„. $ nature /,.... tc ] Ins SBD -6710 (R.3/97) Da a Pe ctor' Cert No. 1 ,,fie: 67737.3. cit g64 4L LANK . Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave. `sr+on f j See reverse side for instructions for completing this application PO Box 7302 Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce [Privacy Law, s. 15.04(1)(m)1 (Submit completed form to county if not state owned. Attach com.lete .lans to the coun co. onl for the ste . ,ilntr..• 8 -1/2 x 11 inches in size. Co State Sani . • P mmit Number ❑ Check if 'r' vious ap ° off• of m tale Plan I. D. Number I. Application Information - Please Print all Information `�-r1 + i i I�' ation: ner Property Ow Name f Q JW N ,D0A.14 S Gt F /2 A l q R 1 id A it a /4 /4, S , T N, RFIE or a/ Property Owner's Mailing Address 1 tuber Block Number Si CROIX ' "` 3 City, State Zip Code Pho ` • 'NG OFFICE 4 .. ivision Name or CSM Number f � t�iVt,�,cv IQ /J /t - ,I COQ d I ci II. Type of Building: ( check one) 9 a City CI Village ' t 1 or 2 Family Dwelling - No. of Bedrooms : `r ,Town of il OSc.)N ❑ Public/Commercial (describe use):_ ❑ State -Owned Nearest Road / ex LA-706 C2) 3 t X TS. I-f 1 kJ1kcIA., . S Parcel Tax Number(s) Illll ` Al - 4?s ? - Y3 III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) .3(0 . ?. . /9. 20 3' A) 1. 3114NIew 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only ExistinSystem B) Permit Number Date Issued ❑ A Sanitary Permit was previously issued _''�^^ Q.Q7,11 �",�p IV. Type of POWT System: (Check all that apply) ' . 4 - [ ` ' - ❑ ' Sand Filter ❑Constructed Wetland Non- pressurized In-ground ❑ Mound ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade ❑ Recirculating de ❑Aerobic Treatment Unit g ❑ Other: V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (Gals /day /sq. ft.) (Min /inch) Elevation JO , 6 - 00 Si o? /_a O . 00 e 9 l . oa VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete ' strutted Tanks Tanks . ❑ ❑ ❑ ❑ /,2Ca /a6a / L), E S�n� ❑ ❑ ❑ ❑ ❑ I VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. 1 Business Phone Number /MRS No. s a io m sS ' : MP Plu //ale ,7-41#1`11< t Plum /`1 t "_ l 313'6 ' �SO J1'i/�r( E � �2Y`1 ��I � g' ' Plumber's Address (Street, City, State, Zip C e) L / 7 r - - AI k //44.0 S°- Cwt 5y©/ IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued 1 s 'ng Agent Signature (No stamps) Surd e Fee) n,.6 l Approved ❑ Owner Given Initial Adverse g ) Lw Determination 225 - � tO t X. Conditions of Approval /Reasons for Disappr 12 ,� D_ (S Apo i Q� �4r .�^J1t t/1.t��q \ 0'' - mitt t. _ .. "r . i PLOT it CFWSS SECTION PLANS ,; 7 Po s cp ZAPPA bHOS. EXCAVATU�i INC yg`"P ° °`" • I1.Uh eINQ UNIT .. u - k e s/vt.44 • , C .t 2r� is 2 GE /o'-! - PROJECT — — - -\ T l 11 \. k) -• naN.t/ £ SL. 8A A1 1t / - 5'crd�/o be 8�otm �I <<X ��hv.L , 30 /- Os o � c. ,. v.4P . ' -J o 2 / \ 6-4 i .6v7T 2 A Dr > • G /2s06.AL• V7 V� `�\ ft � ..51- C2o.x Zoom.,,) TT,- mow.)r2a -*rric T K ''� �j) \ 6,J, 7 •�.4& A ICoo /-IL r 1 ; �. i o co v' /, ID P3 5Ac .r,FGu . • Feq,pai V1 ., \ \ . grc-- i_,/,k)e - • CI R 1 ,X' s —.la' • Gr i i • SE,ULNnirt►?K / /vAn L /'J f ' - /33 OBE EGE�_ /oo." vr ,� 1 3, 75 --- - ! .' L +sPT / ■ N � , . N° 1- a l,. p M 0 1- „° i) 7 1 Olre �iPL [Lett. /OD.00 . © Q $CAut 1 , . , SIGNED: G�k 1 .44 T>♦ig Az4 0651AN / ATiJ,v c',61) uceNSB: x,2 5 7 DATE• `vl 1 /3`b( /1IN /� ' JF r /�JtSH � vQk4r - FN45 6 . 1 I / • ilk C14 yo e �.: ; Sadt B�tNq ICY: �I+X1 AN“ A. 9G" Aaovv .Zff 4s� rI hrii . .. : ~' /{ To CINl S H GQhjz • Side View E &EVA170A'91"1414 6o n - w.-. rf S0 ,4 1T End View 16 � � v < 4 15° ON 11/ • , fl!I j _i • ' 14 7S" AI 14 34' .. ►I S „ J 14 4 CR j-)i - APAc!TV Alo lOEI. o _ ...PL.B Si. • PLOT ii CRABS SECTION PLANS P2oQ ZAPPA EROS. EXCAVATING INC u �� siC) ,�`�t PLUM NO UNIT .. . t+ �'E'?,t‹.� /0'...4 _ PROJECT �; -■ 1i..4J I £ 5 8A - IEr?L C ° </" 5�,�� /a oU c d 41-�EX ...hvi ., -(` Bo' /-h i/ s oN `77:0/u6". t-J, o / \ K Sz,Liek> 4 „vE 4v7rcviC...d /QtDa,‘ - sue c ,Pox Lo,,,,, y 'i \(1 Cw .) c2t=rE 'EPric K ' d GviTy ZI-8L A- i (oo r,L7-2 A ■ `a ` S, P∎eq, rrr \ \ ,, �� v' 4 . , \- \ vl ___>,,,,... , . ,, \ ---4-A i . si,„„4„,,..,,,e, xi,,,,.. /AJ r ' A,— g 3 ♦ w_ .1111.1•11M .-Y 04 �eE £L.4✓. /oo. o ' ; • ``1'3 7S -- !, 0 1 L N �n ► SpE�Tton,l�f - ., 116 1T5 • • 1 , � 3 1 6 400-im/ 1 ( w • E . - 41 7 s{ bloc 1.-It. C LE . /O0. ` 1 Q t CA LE S , t . SIGNED: / L c`_• . • -1 065 Viii - i�v 44-e LICENSE: 2,240 6 DATE: ° 0 / ` v . /Kkic� �,Hin a' A6044 v +st �vRk41` . F.u 6,R�4E . 4 ii " N 6 N yo P �� ; saL TEsT!wq By: • 10 ' /N15H GQhpE • Side View t l .E 'l q7 on) - 77?FAl c H A mo Y. 1' ' So, c "TEST End View = a l II , - �� 1S ` X 15° :z --- 9.S'' I 1 34' • .I r Wisconsin Department of Commerce I � SOi t� SITS' 1lALUATION 1 - Division of Safety and Buildings .. . Page of - Bureau of Integrated Services in accordar►ee With s. 4..HR 83:Q ,Wis. Adm. Code • .( {' . ... Attach complete site plan on paper not less than 8 1/2 x 1/ i ric t ies in size. P lan Ta z County C include, but not limited to: vertical and horizontal referenc e.point (En . irection and t . C (,)' 4 percent slope, scale or dimensions, north arrow, and loca distance to rteart3S ;r ad. � � 3 Parcel I.D. # APPLICANT INFORMATION - Please print all'infdrn f / Revi wed by Date a Personal information you provide may be used for secondary purposes (I'rlvcy s. 15.04 (1)(m)rt_ i i c , U 0(6/-7 ' ( �C 1 Property Owner w ' , Prope Location Govt. Lot s F 1/4 1/4,SL 6 T 2 c ,N,R 1 E Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 1 35 . 3 - A u c x \ukee Tr Li 5 Qc 6 Loccd Rt(13e) City 1 State Zip Code Phone Number ❑ City, ❑ Village N ffir Town Nearest Road Ht. iCjtl 1 1 WI 1 6 I ri t..0 )5 --1q -( 0131 -1 -i- 1d` 1 CG4-{®h u..),..,-," of - . 0 -New Construction Use: VI.Flesidential / Number of bedrooms ,. L I Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow t,4(1 gpd Recommended design loading rate 7 bed, gpd /ft • Er trench, gpd /ft Absorption area required S51 bed, ft 1 ) trench, ft 2 Maximum design loading rate . 7 bed, gpd /ft • a trench, gpd /ft Recommended infiltration surface elevation(s) _ ue/P -Pr 90.90 G-ow•-r 9 0. 1 /0 ft (as referred to site plan benchmark) Additional design /site considerations ,e4-4 • upp-cr 9b.L0 liar "r- 8 6 � in {-•e CCr-ect 1 • 5-. 6, 404di'nc Rp Parent material E kn. t - t�LR.11 Flood plain elevation, if applicable 4(4 U ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system [Is ❑ U ©S ❑ U J I1 S ❑ U ® S ❑ U ❑ s II U ❑ S ©_U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 1 U Iasi Y , 3 (Z f)L l 'ytk Oacr C-5 t C. . . 5 '1 12,3 tei r 4 t4 f�' l 2_. met c 5 — 1 � °� t 'rYYLb��C YY 6 Ground ,3 31-12F( tbN rt tins 033 ml LS - • 1 . r elev. y 76gt. Depth to limiting factor I 7.5c in. Remarks: Boring # 1 0 is y r 3IL _ `__' Si_ I rnatic tnn +r cS ■ 9- 5 Z 12--LIZ 104r y (t1 Si 1 2.rrribk 114 c S — 1 :. g 3 Utz -13o to ii �p — orts 4-3 mt c. s – .1 ; - y Ground _ elev. 0,40 ff. Depth to t0$ ,a \o\ `�- --- _ limiting 91. 115. 2. , factor /3oin. Remarks: CST Name (Please Print) Signature Telephone No. A .ct. 5 uu - _ -r /1 ■ C - /r51 2 `f 7 7 -4- / - G1D Fr - Address Date CST Number 4 1 0 ' Ceder 5 f--. # `f &m,--K of / w/ 5ctv2-5 4- /-/5-`19 25 3.309 PROPERTY OWNER 51004— SOIL DESCRIPTION REPORT Page 7- of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench cbyr 312- I ma . fi r C_ S 1-f A;• 5 1 0 -29, Ivyr414 I Z -c ktiL v .ln Ground 3 21 10 yr 5111) Si 3rndt1 me-r+ c_`) 9 c yaf. 51/4,14 I I( - 41lD MS oSc rr 1 Depth to limiting 6, 100 g' factor o l'r I n in. qtP Remarks: Boring # I o 13yr31 -- St. lmnbk mC'r CS Z 2 ` 10 LIN Sit _rr mf' c .1 3 48-0 M yr 41 ■1 . Ground elev. Depth to Z// 0� limiting (o' 01'1 factor 12.9 in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # 1 01h0 toy r 31 Z 1 table r1-v { rr - LS I 5 5 ' 2 1ln. y t C) N, `{ 1'1 2 tY Sl t 1oh( fn (t c S 1 v - 5 . to ....................... .......................... 3 40-(0 ipyr 514 milr me-Ct 6s — . 5 �o Ground "T ia-I Iovr y14) MS Cr-Si • - i . K elev. - 9 /.9p ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) NAB 3 °-.3 , Z-f- hWt ��2Qq e , nay I i'r . fs''oc,k tim ( elegy, tQa.B naf I : #.6 RK SPA ;- go.zo 141 cle0. C.°6'4r- $Y,20 ✓�d r .1.■.. L.- f-- 3 Z • n • • p 0 � Q if- •0 Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567-P (R.6/99). Table 1: System Design Specifications Sanitary Permit Number Number of Bedrooms cl� Design Flow - Peak (gpd) (gyp Estimated Flow - Average (gpd) 4 013 Septic Tank Capacity (gal) • lt Soil Absorption Component Size (ft2) " !' . _. 1� V � _ 7 Type of Wastewater D • mestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component n ,p Design Flow - Peak (gpd) 12S S� c�4+z — a�s p� ikis.Lt Maximum Influent Particle Size (in) 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks the septic tank shall be disposed under s. 281.48, Stats. The contents of he sep osed of in accordance with p NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the se• • k and outlet filter shall be assessed at least once every 3 years by inspection. The . - r. sball be cleaned as necessary to ensure proper operation. The filter cartridge shoul• not be removed unless provisions are made to retain solids in the tank that may slough h off the filter when removed from its enclosure. If the • Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 Management Plan for a Septic Tank and Soil Absorption Component Plantings of deep- rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. 3 FROM : Zappa Brothers Inc. FAX N0. : 715- 386 -0323 Apr. 19 2001 11:14AM P1 • • ST CRO1X COUNTY SEPTIC TANK. MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM y D i T Q�►r err) ooind S= - - Owner/Bu er c� J / /r �•-- Mailin Address / � ea i` / C"7 aid . i is ro 'M J / / — 7 g Property Address • Nu 4. a o S 10 LAS (Verification required from Planning Department for new construction City /State / / Aci- o"" Parcel dentification Number 6420 -' )3 S3 — _ LEGAL DESCRIPTION Property Location St' %,, A" r /4, Sec. 3 6 , T .29 N -R 9 W, Town of /✓into ✓ • Subdivision C6 t-'ooJ ! C r , Lot # ^1 Certified Survey Map # i . , Volume _so , Page # Warranty Deed # S-22 Volume /S't(1 , Page # 6�2_.^.• Spec house ❑ yes ( no Lot lines identifiable IS yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper inaintenancc 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 master plumber, journeyman plumber, restricted.pluunber or a ficensedpumper that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNATURE OF APPL � — DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) thc owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. /23/ 6 SIGNATURE O APPLICANT ATE t +a Any information that is mis- representcdmay result in the sanitary permit being revoked by the Zoning Department. ••••yt " Include with this application: a stamped warranty deed from thc Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed • VI ,- .1J67PAGr 627 STATE BAR OF WISCONSIN FORM 2 - 1999 63537 'Document Number WARRANTY DEED H. WALSH REGISTER KATHLEEN O F DEEDS OF DEEDS ST. CROIX CO., WI This Deed, made between Joel W. Root and Kari J. Root, husband and wife RECEIVED FOR RECORD 12-18 -2000 9:00 AM Grantor, and Donn T. Baierl and Susan J. Baierl, husband and wife WARRANTY DEED EXEMPT N CERT COPY FEE: COPY FEE: TRANSFER FEE: 202.50 RECORDING FEE: 10.00 Grantee. PAGES: 1 Grantor, 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): Recording Area Lot 43, Plat of Cottonwood Ridge in the Town of Hudson, St. Croix County, Name and Return Address Wisconsin. EAGLE VALLEY WANK, N.A. 1301 Coulee Rd., Unit 2 Hudson, WI 54016 020- 1353 -43 Parcel Identification Number (PIN) This is not homestead property. Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. OE) (is not) Dated this S day of December 2000 C- • • Joot + - ..n12'1°411 + Kari J. Root AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) Q ) ss. • (- U ) `F County ) authenticated this day of Personally came before me this S 11 4z 7 day of December 2000 the above named Joel W. Root and Kari J. Root, husband and wife TITLE: MEMBER STATE BAR OF WISCONSIN N • (1 not, to me . known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. Stats.) irrstr nt anti �C ge the same. • THIS INSTRUMENT WAS D RA � FTE13 8 Y. ► F "' i �rlPn� Attorney e y K ristine O gland t Hudson, WI 54016 riot g Y Public, State of Wisconsin • lydj Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.). •' i %la 00 ) ,) * Names of persons signing in any capacity must be typed or printed below their signature. 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