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HomeMy WebLinkAbout020-1441-72-000 Wisco,�sin Department of Commerce PRIVATE SEWAGE SYSTEM County: * St. Croix Safety and Building Division • INSPECTION REPORT Sanitary Permit No: 430257 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 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 Parcel Tax No: k Bast, Kernon Hudson Township CST BM Elev: Insp. BM Elev: BM Description: iz, / Section/Town/Range/Map No: /00 0 _ /O0- G / i A — 36.29.19. TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ' I / - �Z , Benchr��a aG �� j �� /0(t- p✓ / O D- D Dosing w ' !O � Al BM G r ' `t% 0 14 2 -all_d A- - e li maixfCttu 42 n , .y36 /ba C Aeration Bldg• Sewer - 30'q .'7S 16_ I Holding ® t Inlet t 40+-6, -1 ,a-� P C t. 0 ts•g St/Ht Outlet TANK SETBACK INFORMATION 1' Z' 94 5/ TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet , J i— ,lam Septic (O S�/ 1 . / Dt Bottom p �� — Dosing w"SI �'�J�'�" eade /Man. , / Q � ^ � _ n / � G 5-''Cl/ Aeration 1 _ Dist. Pipe �S XXUi�/ /! (. 7 • - V( Holding ` ?s Bot. System /O. ys- 1vq Final Grade PUMP /SIPHON INFORMATION . 9'9 ZS Manufacturer '.. PM Demand St Cover / /" v--) s 9 V j 3 -2( / 0 / : ' 5 - 2 Model Numbe — TDW{Lift Friction s System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM / 1/72/ 1 —o S • ` . ( _ 1T-) A , fled - BED/TRENCH Width j.•' Lengthy No. 0 r ench PIT DIMENSIO S No. Of Pits Inside Dia. Liquid Dep DIMENSIONS 3' III 7 49 I Igr1,44 SETBACK SYSTEM TO P/L L BLDG WELL LAKE /STREAM LEACHING Manuf rer , INFORMATION CHAMBER OR / TO K �J Type Of Sys ._ .. a :/ `I / ' / ' U NIT Model Numb2_ r DISTRIBUTION SYSTEM �� plt d C. r Header/ManiVd Distribution g / x Hole Size x Hole Spaci Vent to Air Intake - Frp-yt,.� Length (J Dia Ll 11 Pe 9 n (_ �a' //g a 5 / / / �5 SOIL COVER 7 (+(/ Pressure Systems Only xx Mound Or At -Grade Systems Only -S es.L._ 4 Depth Over / Depth Over xx Depth of xx Seeded /Sodded xx Mulched � Bed/Trench Center , Bed/Trench Edges Topsoil Yes j,- ] No iz.'i Yes i No 1 COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: e i / - /1)3 Inspection #2: / / Location: 672 Mary Jo Court Hudson, WI 54016 (NE 1/4 SW 1/4 36 T29N R1� � 6V Cottonwood Ri.. - 1 dd Lot 72 Parcel No: 36.29.19. I/ 1.) Alt BM Description = atg "^' 4 5•y�w. s ...P ^ : d,,,,-f--0 k c �I ,�o - eC. 2.) Bldg sewer length = ] a y w a , ; evi - G yy ru.s.A., - 6 , - amountofcover)3/ ,e c4,d S , 7 LEA . •-, 3& ,, , / S . i_o ( dam aPP i s Plan revision Required? Yes No 1 1 Use other side for additional information._ 103 _ _ � 41,. -(,&1.(--6 ' - (t - -- SBD -6710 (R.3/97) Date Insepctor's Signatur )rt. No. ys - S 4 " g3.6 (atteow, a I( a'� q 2n l 7 Safety and Buildings Division County ` NNV4sconsin 201 W. Washington Ave., P.O. Box 7082 ,$ 7 ( --LQ- Madison, WI 53707 - 7082 Sanitary Permit Number (to be filled in by Co.) De • artment of Commerce (608) 261 -6546 '.2 5 Sanitary Permit Application State Plan I. P .Nu n r In accord with Comm 83.21, Wis. Adm. Code, personal information you provi• may be used for secondary purposes Privacy Law, s15.04(lXm) Project Address (' different than mailing address) I. Application Information — Please Print All Information � l� , r ' r • Property Owner's Name Parcel # Lot # .10c ` � ►' ap ' . 0 bow Property Owner's Mailing Address Property Location k 9 V8 A/11-0--a i e h. iu •"Y. S O-S4, section C ift ity, State C/��lJ �'� ` � Zip Code . .. Phone Number ..._-. ( -T 5 / o / � /7/$ - 07 :0 T (N; RJ E to II. Type of Building (check all that apply) a, PB.� Su/4 C� gl or 2 Family Dwelling - Number of Bedrooms (139-04&C) /`�� • Subdivision Name CSM Pei Public/Commercial - Describe se A4d, ❑ State Owned - Describe Use sL 7 /' S g' 1/2 ' & I �� w i ❑ tlla o_w ^ nship o f IIL Type of Permit: (Check only one box on line A. Complete line 13 if applicable) A. )(New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B • ❑ Permit Renewal 0 Permit Revision List Previous Permit Number and Date Issued ❑ Change of ❑ Permit Transfer to New Before Expiration Plumber Owner IV. Type of POWTS System: (Check all that apply) )(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 In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter &Leaching Chamber ❑ Drip Lin; ■ vel -less ' ipe ❑ Other (explain) V. Dispersal/Treatment Area Information: 4flitl / l)* /M Design Flow (gpd) Design Soil Application Rat- 1.. Dispersal Area ' equired (sf) Dispersal Are-. Proposed (sf) System Elevation 75-0 ..• 7 L6 7/ /D 8 95; 70 VI. Tank Info Capacity in Total Number Manu ,l Prefab Site Steel Fiber Plastic ,' J Gallons Gallons of Units e0 Concrete Constructed Glass New Existing Tanks Tanks _ Septic or Holding Tank /65-0 1 656 ) � Aerobic Treatment Unit L � Dosing Chamber VII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. PI ante (Print) Plumb. Sign ' re , 11"; ' PRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Cod 1 A / / I ' , i �. / ®C� VIII. eounty/Department Use Only Ir 7 pproved 0 Disapproved Sanitary Permit Fee includes Ground 'ter Da Issued uing Ag t Signature (No Surcharge Fee) ' ) ^ �O • i� E92 / 3 // / ❑ Owner Given Reason for Denial JJJ ��� 6 �" 4 /ILe/Q IX. Conditions of Approval/Reasons for Disapproval 0 O , , /, . (�avn��/ � � t A 3 .mod GPJa - 1/s 4-e • io 01' -b4110 ■ (-0/ ,u �la U/ e9 / 3 0. , ,-. , 42,/,073 , ems, y itaai 40.14.4_99 :.:�i , 6 4 14 17" eompkte plans (tot Coaa o (pa sys em r not less than 8l/2 x 11 lashes la size 7. BD -63 • -- , O 1 3 6____:__________raL.,vt- r) 1 I - I7 d r4f-J. )` go 1 - ig ii t- 2f. = �� 11 e 4 e- b 0 e 4 ) . - - I ¢ - ,7 ie I: /act ' x C/ 544 y wad k-awA- PI El 0 giii 9 = .7 y. 6 ) - f , 0/ 4 c v? " 5 dte4}4)? _______/.....____.______._.---- I < ____ ÷ ---6 ' -7, � 1 ,_ 1 ! ■ _ P .,.i 1 q (1)13 it17(x___ WO II tWagtiri=115721— fa-/Ce d 110 -+D -%il-`1 4 ‹ - , s, No ot,„ &Lie . r H v �, �., b id€( 7So"sy c -, 7 / / p %(-- IP /30tiee ; p &-�p ; /'E/Wo,t. /3457 3 _ODA/N� — sfEE72 /3,0 vise /A- BARtrE RP • HHVVPSo , v/. S Aft Ce ` Wisconsin Department of Commerce SOIL EVALUATION REPORT / of 3 Division of Safety and Buildings In accordance with Comm 85, Wis. Adm. Code County ST' c2 0/ X- . Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. S.ee 4e-/6 w 4 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all Information. /41-1.44— Date Personal Information you provide may be used for secondary purposes (Privacy Law. s. 15.04 (1) (m)). !// • 07/ Property Owner E GEW8D P'operty Location "/E., of 5W / 4vp /VEIL 10/ DA) (;ION. Lot - - 1 /4,VN) 1/4 S 3• T 27 N R // p 4 (or) W Prope Owners Mankig Address JA 0 9 20 03 „+ Block # I Subd. Name or CSM# /Gify'P /Au9 PL,47' f / !e ery• . fflo y/. / � c 11/ Cfi )260006 4 11 d / 5 14 dd City State Zip Code Phstrattutrkwc bUNTY 3 C 81 lage 0 Town Nearesl'Road ' {{Up5o, i ( w/ 5 0/4 , ( ( 7 494firXICIL 9 Hvosa , N rei-New Construction Use: (Xi Residential / Number of bedrooms 3- y Code derived design flow rate y'-fJ — C O GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material /d4- SS ook-/Q .S4AJP, 19x7 Flood Plain elevation if applicable Ni-- ft. General cormlents end recommendations: • -� 7 /5 5J/778/ -- /, if e2 '(.' )rio.J 4.-- �it�1�P#PA / 4 /7 C , •� �sE/Z ❑ min Q / I Boring ® Pit Ground surface elev. - • • ZO ft. Depth to bulling factor 7 �/ in. r SoN Application Rate Hortaon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff i In. MtaseI Qu. Sz. Cont. Color Gr. Sz. Sh. 'BM 'Eff#2 / o _ /© yre .„3'y — L- 6cskt /Yh ?4 -.1`v 3 f . V . Co 2 6./2- / — 5/4 f,W A 4/2 cw /f . z . 3 3 .2S /, - " 5/1- 2-Af fi 4,5 /7 . s •9 . 7 z s / 2$ - Fa /o yx yt� --- ,rn f - d e cs . _ --- y /. Z . s 10 '� , /a XC s --- zP, 5 D, s ..� -- . 7 i z. M- 7 5 ,. ' _ q 2 .7f', / - 4U, ; 61.co Jg 3 • Z Boring ft 0 Boring f 3 y Z— 7 �Z , I Pit Ground surface elev. ft . Depth to knitting factor APPS Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fE In. Munselt Qu. Sz. Cont. Color Gr. SL Sh. 'EH#1 'Eff#2 / 6 .7 /o Vie s/y L /,Sh/C cif/ feel 3 - F - • K -_ 4. 2- 7./ / /oY/ /q - 5/L /f.Slr A.1 a.> 2 r • 2 -- • 3 3 /�. r �e - -- -S' /z. 2-An AC n�f/' 4 /f • • �' �� MA /0 Z $ /A " / 4 _' CS -, • 7 A 2 - s ‘6 /ow 57v —. ag ,gd. s x, 33 It .7 / - i'/2. Il fit/. . • Eff # = BOD. > 30 < 220 mg/t. and TSS >30 < 150 rnglL • Effluent 1/2 = BOD < 30 nlglL and TSS < 30 mg& • CST Name (Please Print) Ro /MR Zl /M.ei Gut 7— signature / 2 U 3 Z S Address Date Evaluation Conducted Telephone Number Ulbricht & Associates . !'5 2 e - /0 — �jt 7/S' 3 2G • V G55 O'Neil Rd. Hudson, Wis. 54016 t. A V5 J /I JIE ia'' -714 N�a�S� o� t�• / /ay•yc7• �- srf o�N� .00. / /oy .20 - H eiV7A.-ce__ 1---," 7 i dvJ,dy ` ti-` ply- . ,-71 4 /d /Ifcg.- • r r / 1 N f b1 i'` L \L uY K Ts - �� 0 3.0.1/0 f. go 6. Property, owner 4'L Witco K So o).0 • //b 9• o• t 2 3 Parcel ID # Page of 1 3 I B o r i n g * ❑ Boring d y I spit Ground surface elev. / ft. Depth to limiting fador y �� in. Soil Application Rate Horizon Depth I Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPO/ in. , Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. • •Eff #1 •Eff#2 aA9 /0 jg.- Y — L /i 4E /h, 9 vg 31 • •Y • •Co 2- /e - 4._Joye yV 5 /L /{slur i 2 c-5 / C , Z • 3 3 4 • a /B in 5/6 -- sit 21mi ,,- mtf' 4. s . — . s ...SP. •fo /01/2 SCE ,j. s d , s (I� . 7 i. Z • Boring # ❑ Boring ' ❑ Pit Ground surface elev. ft. Depth to limiting factor in cation Horizon Depth Dominant Color Redox Desaiption Texture Structure Consistence Boundary Roots Sod GPD/ff Rate In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. ' •Eff#1 . 'Eff#2 • • I Boring ° Boring # ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate • Horizon Depth Dominant Color Redox Description. Texture Structure Consist °ce- 8otrrdary Roots G nx In. Munsell Qq. Sz. Cont Color Gr. Sz. S4/ •Eff#1 'Eff#2 1 2 • • • • ❑ Boring Boring # Ground f surface elev. ft. I ❑ Pit Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Desaiption. Texture Structure Consistence Boundary Roots GPO/f? in. Munsel Qu. Sz. Cont Color Gr. Sz. Sh. 'Efi#1 •Eff#2 • 1 • . • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BOO. < 30 mg/L and TSS < 30 mg/L • The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608 -264 -8777. $ao.a»o (8.6/00) , DES % ' L 0 7 4-i >--e_____ 11 Nk0 't 0 _ 9. o i /, .......___=........ 1. ti ll w o Np , V► w I a D. r qs _ .e�T L O \. h q t fl °. N O 3 P NI \ ■ o ge-J,,- 3 ��` 410 1 -17 a i � a° 1 ii,„ t_df loo 7,04A- gso 5y.1-1, 9 2° 5r/8 e Qru /: A00 , rafol 54,21 /g/ a= 99 a Py°di 1 / . ? " 5 keJ ar� Rio /f,,b , << • 95 70 `sY • POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2 FILE INFORMATION ' SYSTEM SPECIFICATIONS Owner / L 07 7 --. Septic Tank Capacity /6561 gal ❑ NA Permit # 4 /3 0 .2 5 Septic Tank Manufacturer t it. „ ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer 7..... ❑ NA Number of Bedrooms . r— ❑ NA Effluent Filter Model A —100 ❑ NA Number of Public Facility UnitsA Pump Tank Capacity ga l NA Estimated flow (average) ,_r )O gal /day Pump Tank Manufacturer NA Design flow (peak), (Estimated x 1.5) 25-0 gal /day Pump Manufacturer ❑ NA • S011tion RAtg d 7 gal /day /ft2 Pump Model ❑ A Standard Influent /Effluent Quality onthly average* Pretreatment Unit ❑ A Fats, Oil & Grease (FOG 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L �I Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L NA //❑ At -Grade 0 Mound Fecal Coliform (geometric mean) 51 ° /100m1 ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA "'Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) Inspect condition of tank(s) At least once every: 02 Aa- year(sl (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell D. year(s) s) At least once every: El month(s) (Maximum 3 years) ❑ NA ■ p ❑ month(s) ❑ NA Clean effluent fitter At least once every: ,9 year(s) ❑ month(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ yearls) Flush laterals and pressure test At least once every: ®a��s1s) ❑ NA Y Other: ❑ month(s) ❑ NA At least once every: ❑ year(s) Other: ❑ NA 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 Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection 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 to check for any back up or ponding of effluent on the 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 indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. . 1 Page Z of ?/ START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the 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 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, overloading the cell(s) and may result 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) water; 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 and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, 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 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 that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. b; •• • . . . - • is11 Fr M al • - • . 9:44/5 rreb. sco /2- A/61V NS7RU ZtO ❑ 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 > > 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 BE DIFFICULT OR IMPOSSIBLE. • ADDITIONAL COMMENTS POWTS INSTALLER /� POWTS MAINTAINER 5 ,,,,y Name �ti Name Phone �C'_ a g Phone - SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name S T. Ct 96 (_C•V 201'J/'(J6 Phone Phone i /s— 3e4,„_ s ( ( p i r(> This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST CROIX COUNTY . SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer -.-ei1/4t/ Mailing Address 9 "6 .mil// � j !�✓-� s /r Property Address 67,E ® � ■ (Verification required from Pla ' : Department for new construction) City/State ,4V23'/ / Parcel Identification Number falA/4-7- LEGAL DESCRIPTION Property Location A- 1/4, , V4, Sec. 3 6, T o� �N -R W, Town of # . Subdivision e , Lot # /7? •S led Survey v : - • 11 - • - Warranty Deed # 7 a S , Volume )35 Page # 355 • • S. . . - - -- - • no Lot lines i • en i " • 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 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 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 o th ' year expiration date. ��✓ 7 /Z9 S TURE O'er 'PL CANT 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) the owner(s) of the prope described a ve, virtue of a warranty deed recorded in Register of Deeds Office. 7 /Z9/ D3 ATURE 0 ` 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 . - • • • s , o , \ ..... X 6 / , ..„ , . , L / i • ..„ ■ I 1 0 Z rm mm• 1 ..- - -- / I 0 0 ..■ i■ k , MM... / \ \ :a •=1. ‘ / ‘ (OWNED E3V C7TERG2 . ' EMMEN, =MEW MI ..■ / / s .. I „ I s, I ‘ I • 0. 1 d4 I 4 —' X 4 : 4 —• ■ . ' ; ••■■.....r omIN• — 0 ■11 .1■■ NM/ — .' ••■••■ . ) al=11111 III•1■ , 1.1= 1 ,■,■...011......• ,M1,■,... . s ,, k...,,, i s ...- za -,, , ....■ mwma / CO • ----7` 1 ,, • EP 0 I . • / Ikk't il / :. • : / I . il • 1 • \ . I ' • /// 1;14-1 N'e k, ..:.1 • . i , -• I —s # LOT / / (A tCg. • : , LOT 9 in ; X' ‘,„, , §k , - • - , \ --- • NXT'''ke , kkl - . ,,,, --- --........_ • A ,..ts . X (, X . ' k■t0 . - • / CO . / ba l ' Ok • • , — -- — • ' ok0 I ,l . • ...., • •, -,. . • •=k !:-k . ..... s 1441 kk. • o • cfri • • co X 0 • - t Ikkkk 6 ui . • -, •••4 • :.WI k,, • .■ . / LOT 7 411 4 • . - t?4 k • LOT 10 --// , • ko.' tkk . - §61 • • , .. _ . 11 4 , - t% • _____ , . Y 'N / _. , 0 • y k:N • , x 0 • §ef Iltt • , - . . 0 -0 blc-414 ,/ (.„ . . NI/A.replqb • _, - co 0 4 Ts/ • ',f 4,7!; • , / LA • • i 41/ / A . • , . \\\\ ,,,, 4,4 • • , i.„ . ,. .. •":// .4 ..., ., LOT 1 1 • .......„?. ,,,,,.,./ „.....„. ,,,..„,. • , . • ..., .-..„,/ 4:.,....„ , • 1 _ , -.. • CA LOT 6 ... . • 0 4 :4 .> . 0 , 4. .. / 4 ik'' .>,/' .t..' 8 • s 4 ";." ' /.. #., . , / tel. ' ■ ..-- / : <e ,..? / • /AA. _ 0 5 1. .... 0 x ,,, •. • „,./ ,,,,,,, .-. .•.'• / /.44:,/ 0 • .‘,. ,./„. (4 • • • v. -•,,, 0, ... .6, • ,,, 4 ,,,,,,/ ,/",./ . 4/ ..., ) • ,,.... „ : ,,,,:; ; , \ $'1" . ",,,-,,, , / ,,../. 4 ;4,, , : , . • . • . , , „.„.... .... _ x .... __ ,-, ' .;,.• -. • ,-- _ — . . '' --. --' '■ .,. .... .... _ • _ .9 /—/ Gel1 X cA " At. (-4 • -4- - - .._.‘ ■I •••4 • ul * X ' b 4 , • ,..)„,.& . • '..1 • . • ....... „. „ . • - ,‘ • 4".,,A.1.7- ; .-.0-.- . -8x ..,- 41.,,,.. • „:,.-w , • L\ O 1 . x 1:1 (ii ------- I../ ,-"• ' • -s•i_ -, IC J 2 1 3 5 P 3 5 5 7088x0 • WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO. , WI Neil L. Wilcoxson and Mary J. Wilcoxson, a/k/a RECEIVED FOR RECORD Mary Jo. Wilcoxson, husband and wife, conveys 02/07/2003 02:00PM and warrants to Kernon J. Bast the following EXEMPT # described real estate in St. Croix County, State of REC FEE: 11.00 Wisconsin: TRANS FEE: 2880.00 COPY FEE: CERT COPY FEE: PAGES: 1 Exception to warranties: all easements and restrictions of record. This is not homestead property. f es 4, f A Parcel Identification Number(s): 20- 1 r - 40 -000; 2 19 -20 -000; 20- 1109 - 10 - 000; and 20- 11 -90 -55 -000 A parcel of land located in part of the Southeast' / of the Name and R tam city Title Northwest 1/4 , part of the Southwest '/4 of the Northwest 400 South 2nd Street 1/4 , part of the Northeast V4 of the Southwest l/4, and part Suite #115 of the Northwest 1 /4 of the Southwest 1/4, all in Section 36, � jj son, WI 54016 Township 29 North, Range 19 West, Town of St. SIN Croix County, Wisconsin described as follows: Commencing at the South 1/4 corner of said Section 36; thence North 00 degrees 10 minutes, 01 seconds West along the north - south' /4 line, 1634.77 feet to the Northeast corner of a parcel of land described in Volume 526, page 259 at the St. Croix County Register of Deeds Office, being the point of beginning; thence continuing North 00 degrees, 10 minutes, 01 seconds West along said North- South /4 line, 1977.22 feet to the South line of the North 350 feet of said Southeast '/4 of the Northwest %; thence South 88 degrees, 49 minutes, 51 seconds West, along said South line and the Westerly extension of said line, 1324.14 feet; thence South 00 degrees, 09 minutes, 43 seconds East 2,096.73 feet to the centerline of County Trunk Highway "N" being a point on 1,999.00 foot radius curve, concave southerly, whose central angle measures 03 degrees, 00 minutes, 19 seconds, whose chord bears South 80 degrees, 02 minutes, 21.5 seconds East and measures 104.84 feet; thence Easterly, along the arc of said curve and centerline, 104.85 feet to the point of tangency; thence South 78 degrees, 32 minutes, 12 seconds East along said centerline, 712.54 feet to the West line of said parcel described in Volume 526, Page 259, thence North 00 degrees, 10 minutes, 01 seconds West along said West line 304.75 feet to the North line of said parcel; thence North 89 degrees, 49 minutes, 59 seconds East along said North line 523.00 feet to the point of beginning, all in Section 36, Township 29 North, Range 19 West, St. Croix County, Wisconsin. Dated this , _ day of J Gs —� 660, , 2003. tuipc,,ki L. ilcoxson Mary J. W o n ACKNOWLEDGMENT . � �.� ^.;::;.�,; STATE OF WISCONSIN ) , � ?SO PC/e147, r COUNTY OF ST. CROIX ) '71) 1A-- / Q /1144'4 Personally came before me this. day of 7 2003, the above • =med Neil L.'Wilcoldol� d Mary . � e Wilcoxson to me known to be the persons who executed th fo g oing instrum = • acknowledge the 4ime * L r � _ ! PRE Nota Public � 2 1 My commission expires: - h11 k9 0� . This instrument drafted by Robert F. Wall. WilcoxsontoBastWD03 -1 ; � WIS t e ' r g 6 < ■ m 1 _ O 's' mpNo A iiai %'s % %''s'c" X z t I I o 1 ! It /jij / ';,'.is.',^ 0 37 $ "1 sa I g %f % %' % ss' s '% x z pu • i / s Ir .; ' Oj / ` G':' %`ec.:%/ / ioE §, ggZ • a • f = ° O v 7 x ,, ' .. ..i ;;�;';, �Y / /i% `" ir E 2OE6.73' � % _ . ,,,. / r /� //, � � � � � ; _ 0,;%%%:( % r 4SSI•. ' 1 v O v NO IRE OFT* SE IN OF THE NNIH ,'4 +, ; ' • , . 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