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HomeMy WebLinkAbout020-1454-00-092 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 3 ( ATTACH TO PERMIT) 487937 0 GENERAL INFORMATION 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: Bast, Kernon Hudson, Town of CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No: i 00 60\ \ 36.29.19. TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic , 1 � 3 / Z �� Benchmark 4 Alt. BM a Aeration -dg. Sewer (9.31 7740°9 Holding St/Ht Inlet 764 9'(° St/Ht Outlet TANK SETBACK INFORMATION 7.3z6 510• (pa TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet •, Septic 75 / �,(L J p /g / _ Dt Bottom Dosing f1 �� O — Header /Man. 777 z 2 ----r--rr—r----- Aeration / Dist. Pipe 1 /3 Holding — Bot. System 1.131 !' q5 • /( d - Final Grade PUMP /SIPHON INFORMATION 3.90 ✓60 Manufacturer Demand St Cover r 3 � � / . C� S GPM e,i Cot A. do Model Number a TDH (Lift Friction Loss System - - - TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length ' No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. 'Liquid DIMENSIONS 3 '&7.5 Z v1 �� I d Depth �. SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: (t'� j )% ddJ n j J INFORMATION CHAMBER OR Type Of System: n /, / UNIT ��ve �`o -AL I/6 , / n / ,\ / /� Model Number: Q /� DISTRIBUTION SYSTEM lJ '1 J V 17 / / ectc Z'W b+cQ Header/Manifold, 1 / Distribut'on x Hole Size x Hole Spacing V ent to Air Intake \ Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over 1 Depth Over xx Depth of xx Seeded /SQQ xx Mulched Bed /Trench Center 1Jr l i4 Bed/Trench Edges \ Topsoil Yes I__ ' No ?Yes 1 ] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 839 Riley Lane Hu.son, WI 54016 (SW 1/4 NW 1/4 36 T29N R19W) Cottonwood Ridge 2nd Add Lot 92 Parcel No: 36.29.19. k- f: ,''Av 6 �, t E z 6 - f� . 1.) Alt BM Description 146 � °�, COJ e�0 2.) Bldg sewer length = / O / - amount of cover = 1 - - T C Plan revision Required? forma Yes I I No �� 11 1 L- _ � 7 Use other side for additional in `LI (. ` ` ' _ i Date Insepcto i . Signatur, Cert. No. SBD -6710 (R.3/97) Z,eu f Safety and Buildings Division County LL 201 W. Washington Ave., P.O. Box 7162 ,S T cpai ( N M WI 53707 - 7162 Sanitary P it Number (to be filled in by Co.) 608 6 -3 1 3 �- Department of Commerce State Plan I.D. Number Sanitary Permit Ap 1 • : tion In accord with Comm 8321, Wis. Adm. Code, personal info r . • ...vide may be used for secondary purposes Privacy Law, t . ri r m) Project Address (if different than mailing address) 1. Application Information - Please Print All Information ,: 8,� Property Owner's Name ,� •^ ""-Y) � e / ' ., ' Parcel 8 � ' "l Ot 8 Block 8 i, ro y Owner s Mailin ress Pro tion TV L t2r /- � .f ( ` Sid , A, /JW Y., Section ii .,..-74, City, State Zip Code j Phone Number (/(f 'T �,, ^ T Qi.� N; Rr Q E o V� II. Type of Building (check all that apply) aD 5,,,,,(,,,,,,,.` 2 4� ,�� Subdivision Name CSM K Nu I or 2 Family Dwelling -Number of Bedrooms S � ❑ Public/�Commercial - Describe Use f D�f id a94• `` ❑State Owned - Describe Use ❑City_ ❑Village 1 )Townsh p o cc),2 , M) 111. Type o ermit: (Check only one box on line A. Complete line B if applicable) A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. Renewal Permit Revision List Previous Permit Number and Date Issued ❑ Permit Rene ❑ ❑ Change of ❑ Permit Transfer to New Before Ex P iratfon Plumber Owner ■ IV. T of POWTS S tem: Check all that a . , 1Ma - •' , 1 ',111 < �1 tlf w 4 on - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Al -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter *caching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) , V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil A plication Rate(gpdsf) Dispersal Area Required (s() Disper Area Proposed (sf) System Eleic tion VI. Tank Info Capacity in Total Num Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Uri' , 1 1 a (i: Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank . *.- i /A , o ! v Aerobic Treatment Unit Ir Dosing Chamber VII. Responsibility Statement- I, the undersigned, me responsibility for Installation of the POWTS shown on the attached ports. Plumber's Na,, Print) Plu 's Si re MP/MPRS Number Business Phone Number Ie)V 77- 38b fad ti Plumber's Addres (Street, City, State, Zip Code • 0 - - AL. a.— r b`b VIII. County /Departme t Use Only Approved ❑ D. Sanitary Permit Fee (ii cludes Groundwater Date Issued Issuing gent (No Stamps) Surcharge Fee) ( s- '- ❑ • iven Reason or Denial 7f C( tl �,n� // IX. Conditions ; A prov I/ l _ SYSTE ■ e r NER: 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained as per management plan provided by plumber 2. All setback requirements must be maintained as per applicable code /ordinances Attach complete plans (to the County only) for the system on paper not leas than 11/2 s 11 inches In size • SBD -6398 (R. 01/03) , .P 8 . 6 7 Riot P7t. aikl _Si. le &inc rss• . . . ..T/?/. .ei', ..... • r �►!! _ ... � . 41A i1- ... _ n:)_. uu.m, e„ 1e ... • „ ' 07- 00. 10 , u u.S' /V ///- geNL nn�� + efru Gi I pit • c 13 d ! "f'/ • 3 V" PV .�. :_�Aii, 1 u. 3 V'' PV( l-ev- )(4.0 4 3 1 i 1. i r TU 9 0 A p,...? • R - irdavel, r k+tia • 3 k 67' S') a \ s \ ■____. So' . \ \ A----• 1 Ac,(.) E w)p -lux, Fi it-fn \ . . I a QP DRu,, Pohl • 2 vn P/0 t Pli, (1 /kl _Si'. le &i nc& r .s. • /..4 ..P 13 6 7 . • • /f , _ t I 7 �` _.........1 � 'lL- _ gym. _. �um „�e,, — �►�' !1 ��Qrj Co°NOU SOU g, d - . � � ' -_ 7)/ /�/ • I g4N 3 , niotz,� I �' , RI+ QPNCLI rnp)c- K . 1 .A PV u 3 y PV( R - 0-1, f ► �+ $ . ,` 0 . `�, So ' \ . Iak,V _colt.. lip, w)p -Iuu F; it-fn 1 \ \ • y Ql oRoc,n, '&..4\> 2 • , I scon$ln SOIL EVALUATION REPORT #1637 Department of Commerce in accordance with Comm 85, Wis. Adm. Code Page 1 of 3 Division of Safety and Buildings Steel's Soil Service, Inc. County Attach complete site plan on paper not Tess than 8% x 11 1 � size. Plan must St. Croix include, but not limited to: vertical and horizontal referen •- •, o • ' • irection and percent slope, scale or dimensions, north arrow, and location a' • �•nrn e to nearest road. Parcel I.D. pending Please print all information. R revved By Date Personal information you provide may be u;=.. . v-.1�7..7.• .n ,.'i+. • 4 vary . s qb (1) (m)). r uM O 13, - , - Property Owner roperty Location Bast, Kemon govt. Lot na SW1 /4, NW1 /4, S36, T29N, R19W Property Owner's Mailing Address A N R 1 3 MI5 U5 -ot # Block # Subd. Name or CSM# 948 Labarge Rd. 92 na Cottonwood Ridge 2ND Addition City State ; ip Coii• L MirW City Village Town Nearest Road Hudson WI 54010 1 ZONING 1- 7775 Hudson 1 Cty Rd N 4 New Construction Use: Z1 Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement Public or commercial - Describe: na Parent material Ridges and drainageways of /44 cner h,,e4 Flood plain elevation, if applicable na ft. General comments Conventional system, system elevation 96.30ft. Trenches spaced and depth to and recommendations: code 4.00ft below grade. 1 Boring # Ei Ground surface elev. 100.30 ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Texture Structure Consistence Boundary Roots GPD/ft in. Munsell 1 0 -18 10yr3/1 none sil 2msbk mfr cs 1vf .6 .8 2 8 -20 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 20 -35 7.5yr4/4 none scl 2msbk mfr cs na .4 .6 4 35 -100 7.5yr4/6 none grs /ms osg ml na na .7 1.6 ----- YrCk ( t 2 Boring # D Ground surface elev. 100.30 ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Texture Structure Consistence Boundary Roots GPD/ft in. Munsell 1 0 -10 10yr3 /1 none sil 2msbk mfr cs 1vf .6 .8 2 10 -24 10yr4/4 none sicl 2msbk mfr cs na .4 .6 3 24 -36 7.5yr4/4 none sl 2msbk mfr cs na .6 1.0 4 36 -100 7.5yr4/6 none grs /ms osg ml na na .7 1.6 cd 9 - ' ° * Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD 5 < mg/L and TSS <30 mg/L CST Name (Please Print) Signature: ( — CST Number David J. Steel �,y -- _ 248956 Address Steel's Soil Service, Irss, —•- Date Evaluation Conducted Telephone Number 994 200th St. Baldwin, WI 54002 4/11/2005 715- 760 -0347 SBD -8330 (R.07 /001 Property Owner Bast, Kernon Parcel ID # Pending Page 2 of 3 3 Borin # ❑ El Ground surface elev. 99.10 ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 1 0 -10 10yr3/1 none sil 2msbk mfr cs 1vf .6 .8 2 10 -24 10yr4/4 none sic' 2msbk mfr cs na .4 .6 3 24 -39 10yr4/4 none sl 2msbk mfr cs na .6 1.0 4 39 -65 10yr4/ none grs /ms osg mvfr cs na .7 1.6 5 65 -100 7.5yr4/6 none grs /ms osg ml na na .7 1.6 Boring # ❑ ft. Depth to limiting factor in, Ground surface elev. P 9 Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots _ GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Boring # ❑ ft. Depth to limiting factor in. ❑ Ground surface elev. P 9 Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD 5 < 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. SBD -8330 (R.07 /001 Steers Soo Service. Inc. ` . 3of3 STEEL'S SOIL SERVICE INC. David J. Steel Kernon Bast 994 200 St. CST - POWTSM SW1 /4,NW1/4,S36,T29N,R19W Baldwin, WI 54002 Lic. #248956 Town of Hudson, St. Croix Co. Cell (715) 760 -0347 Cottonwood Ridge 2ND Add. Fax.(715) 684 -3449 Lot, 92 This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. Legend N 1 " =40' • = Benchmark Ele. 100.00 ft Top pvc pipe • =Alt t Benchmark Ele. 99.90 ft 0` Top of 3/4" pvc pipe �l ❑ = Borings ;11.;05 G ` ice _ = Boring Elevations /04-- i- B1 — 100.30 ft /-0-e°2-- 6/ Gt t B2 = 100.30 ft l 1. B3 = 99.90 ft B4 = 0.00 ft .\ Vol r 0, 4 4 N l 6y ' i o 7 5/� 1 - i , If x 4.... ..... ■ .::::1. :: ii + i , ii i r � +r rr / / k fi ri •'ij� r i , � l l f i � � z " �,J�f, / , / r 4 , , 2 : ... •.. / 0 ?s' • ! p f •�� 10lj I� ,, 1 4 . 4 , y�1 % /� f� % � +' « «�'� / t f ' . x to • Q i t i f / rr f, / // +I i: " • ♦'' ri «fit . �J / /f � JJ�� r ir r «• e�1/1 l 1 11�J�'f f /� '� % ��!•rr� t i / +�lr «lf� r �i �j / f 41 U t// / « « « i• F#d1 s /!f 1 f /1 / ;,/J / t J /�', * + «'ci « «trii..iirriiif / /I ` n p Z • / /,//,,, , p;•y +yip% rf /lf / I.I!! #lf /f � DF // / / +I t ii , .! l iififffifi! ! ! j f I * / /I MI / / / /Nf srip<► s. + ff /f !' Pi / / «t +•.Vi ««t « «, - f1l / /Ifll ii'j A • �� / //II H/f �� �� /. + «i�'t' ff / �• X p 0. � r III/ //i/ + • a :.W/ /r / > N IS �� sir "ll r *. ` j` ::::.. .. .` O i %� e; fo 0 1 o `O r . >2, IA v / , <.:; cti / ; . /t 0 n u .•-r 0� 4.• •• _ ‘t to r i 1.... 0 0,0 / / X y ",..$::: ori y, •.• _140 .« . Phi node ,4 .._..:: :::.. .....4. 04 i ?. yy- Ns 1 .• #* • e.eee� • '�f « « «� « + + « « «t�,t ' Q O • mot. a , ,e, • i ;';'tiS:' //e" i- Os • ifilf </ — x r.te...*, .„ „ op, + / / O �� v� f t. co N NPq O � :•:v' ":i i i;::: is I or • / 0 .: / e O L r : i G / / • - / N ,r X 4/5- M ; U co OX iQ / 1 ii;.°.. L yaGV UtLJ c¢ /�,• /0 0In Z , • ,J • al Pi t;:' � vO f . • • I Ci" : 0 x "L x X � /,, x r 9E N01103 • e 1 S3 .iAy`� /ie J! : % :! , ` r1 % /_�%f /! // r 1 / / ! Nfli o tn X ° at rn � �' • /� \� __ o �` + ■ C 1SJ.S 3�' J..I.NfI • XIOaG i%- — I A / t� . `LAC' fa,. 1 P�� ... nG ...- .� .�.. -n nr.t m iv In POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner �e1 Al 0 N Q.As Septic Tank Capacity a (j gal ❑ NA I ` 1 � Permit # ctg3- . 937- Septic Tank Manufacturer W F 4 (f ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer Zm L) ❑ NA Number of Bedrooms L i i ❑ NA Effluent Filter Model Number of Public Facility Units A-100 ❑ NA I3 NA Pump Tank Capacity r, gal 19 NA Estimated flow (average) 375' gal /day Pump Tank Manufacturer " NA Design flow (peak), (Estimated x 1.5) GOO gaf /day Pump Manufacturer — Cr NA Soil Application Rate . 7 gal /day /ft Pump Model ANA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit Fats, Oil & Grease (FOG) 530 m /L NA 9 0 Filter 0 Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/1 ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) 0 NA Biochemical Oxygen Demand (BOD 530 mg /L It In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100mI ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: Other: ❑ NA ❑ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) q year(s) (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(s) At least once every: ❑ month(s) glyear(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: 1 ❑ month(s) ❑ year(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ year(s) NA Flush laterals and pressure test At least once every: El month(s) Other: ❑ year(s) NA At least once every: ❑ month(s) NA Other: ❑ year(s) CS 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 (1/ 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. lt, 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 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: ,121 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. ❑ 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> > 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 Name eN mez Name j�. Vb4 t? Phone $ 4— ba Phone )11 (' 10 :)0 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name � . 154 c. L' Ot '. Name 51 , (1t)> ?1/4.1 Phone y bI)C Phone 3 (? 9 L U b This document was drafted in compliance with chapter Comm 83.2212)(b)(1)(d) &(f1 and 83.5411), (2) & 13), Wisconsin Administrative Code. wu•=co e►e .AL /1 b9/'79820 09/14/05 07e02ealT1 P. 001 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERT FICATION FORM Owner/Buyer __ e r Mailing Address • / • I' 74/50,d Property Address a°,3 ;l (Verification required from Planning & , sin: /i ,artment for new construction.) Ir City /State Parcel Identifi..ation Number LEGAL DESCRIPTION Property Location . % , ,/JLU ' , Sec. 3t , T N R aj / p W, Town of Subdivision r I : , i 44 A te , Lot #. Cerdfled Survey Map # , Volume _ , Page # Warranty Deed # 4, /0 f , Volume 73? , Page # 314 Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFIC tTJON Improper use and maintenance of your septic system could r.:sult in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or. sooner, if n the system can affect the �, by a licensed pumper. What you put into of the septic tank as a treatment sta;ge in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St Croix County P12 acing & Zoning Department a certification fomn, 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 j a rter inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 1/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 arc the De r Certification stating that your a c system Department of Natural Resources, .,fate of Wiacoosin, septic ystem 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 an statements on this form are true to the bet of my /our knowledge, Uwe am/are the owner(s) of the property descn - above, by virtue of a warranty deed recorded in Re.gisfer of Deeds Office. Nail .erof Si �'' E OF APPLICANT(S) /0 / DATE os T ** ' ny information that is misrepresented may result in the sanitary 1 emit being revoked by the Planning & Zoning Department * ** 1tclude with this application a recorded warranty deed from the Regis`er c f Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) U 2739P 31fi - 7aE•112, ‘3 KATHLEEN 11. WALSH REGISTER OF DEEDS ST. CROIX CO.. MI STATE BAR OF WISCONSIN FORMA 2 2000 RECEIVED FOR RECORD Document Number WARRANTY DEED 01/28/2005 03 :15PN THIS DEED, made between Neil L. Wilcoxson and Mary Jo WARRANTY DEED Wilcoxson, husband and wife, Grantor, and Kernon J. Bast and Dcnalda J. EX # REC Speer -Bast, husband and wife, Grantee. TRANS FEE: 12.80 Grantor, for a valuable consideration, conveys and warrants to Grantee TRA FEE: 9212.98 the following described real estate in St. Croix County, State of Wisconsin: COPY FEE: CC FEE: PAGES: 2 SEE ATTACHED EXHIBIT A Recording Area Name and Return Address: Edina Realty Title, Inc. 400 S. 2id St. — Suite 115 Exceptions to warranties: Hudson, Wl 54016 Easements, restrictions and rights -of -way of record, if any. 456780 1 1— 1'— 0-0 0 020-1110-30-000... 020- 1109 -55 -050 Parcel Identification Number (PIN) This as not homestead property. Dated this 28 1 et. y of January, 2005. 1 .1 A i A 4 1 Y 40 (• Ctf O it L. Wi cox'. - * Mary Jo i oxson * +n * • • s AUTHENTICA sp QLibAO ACKNOWLEDGMENT Signature(s) �° t JC Q,�gln STATE OF WISCONSIN ) s .2, ST CROIX COUNTY. ) ss. authenticated this 28th day of January, 2005 Personally came before Die this January 28, 2005 the move ove named Neil L. Wilcoxson and Mary Jo Wilcoxson, TITLE: MEMBER STATE BAR OF WISCONSIN Imsband and wife to me known to be the person(s) who (If not, a {ecut : e fore ing instrument and acknowledged the same. authorized by § 706.06, Wis. Stats.) ' i / THIS INSTRUMENT WAS DRAFTED BY 'Chen : rown Peterson, Frain & Bergman — Steven H. Bruns Notary Public, Share of Wisconsin 50 East Fifth Street, St. Paul, MN 55 101 N. commission is permanent. (If not, state expiration date: /11/2007 ) (Signatures may be authenticated or acknowledged. Both are not necessary.) "Names of persons signing in any capacity must be typed or printed below their signature WARRANTY DEED STATE BAR OF WISCONSIN FORM No.2-2000 • { U 2739P 317 EXHIBIT A Parcel 1: A parcel of land located in part of the SW ' of the NW 'A and part of the NW ''A of the SW V, of Section 36, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin; more particularly described as follows: Beginning at the W ''A corner of said section 36; thence N0096' 10 "?3, along the west line of the NW ''A of said section, 1248.49 feet to the north line of Lot 1 of Certified Survey Map recorded in Volume 3, page 669 at the St. Croix County Register of Deeds Office; thence N63 °02'59 "E 148.42 feet to the north line of said SW 'A of the NW ''A; thence N89 °26'58 "E, along said north line, 1182.70 feet to the east line of said SW ''A of the NW ''A; thence S00 °21'37 "W, along said east line, 350.04 feet to the north line of Lot 73 of the Plat of Cottonwood Ridge First Addition recorded at said office; thence S89 °26'58 "W, along said north line, 10.00 feet to the west line of said plat; thence S00 °27'24 "W, along said west line, 2096.76 fee. to the centerline of County Trunk Highway "N" and a point on a 1999.00 foot radius curve, concave southerly, whose central angle measures 7 °10'30 ", whose chord bears N84 °30'41 "W and measures 250.16 feet; thence westerly, along the are of said curve and said ces terline, 250.33 feet to the point of tangency, thence N88 °05'56"W, along said centerline, 83.64 feet to the point of curve tare of a 2700.00 foot radius curve, concave northerly; whose central angel measures 3 °17'53 ", whose chord bears N86 °26'59.5" 1'7 and measures 155.40 feet; thence westerly, along the arc of said curve and said centerline, 155.42 feet; thence N04 °29'56 "E 244.01 ' eet to the point of curvature of a 167.00 foot radius, concave westerly, whose central angle measures 34 °24'12 ", whose chord heirs N12 ° 42'10 "W and measures 98.78 feet; thence northerly, along the arc of said curve, 100.28 feet to the point of tangency; thence N2 9 °54' 16 "W 274.22 feet to the easterly extension of the north line of Lot 1 of Certified Survey Map recorded in Volume 12, page 3456 at said office; thence N89 °' 12'45 "W, along said easterly extension, along said north line, and along the westerly extension of said north line, 670.44 feet to the west line of the SW 'A of said section; thence N00 °37'50 "E, along said west line, 496.89 feet to the point of beginning. AND Parcel 2: A parcel of land located in part of the SW '/. of the SE '/4 of Section 36, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin; described as follows: Beginning at the South 'A Corner of said Section 36; thence N00 °27'O5 "E, along the north - south' 'A line of said section, 1216.78 feet to the centerline of County Trunk Highway "N "; thence S76 ° 47'47"E, Flong said centerline, 1354.82 feet to the east line of said SW 'A of the SE ''A; thence S00 °07'02 "W, along said east line, 897.02 feet to the south line of the SE ''A; thence S89°33 '25"W, along said south line, 1326.80 feet to the point of beginning. 1 y_ / / Q 1, / Z 1.1.1 1.1.1 ° . ! I . Q ir i- 8 . 1 _ . Qt. • �y / .• 1 • J ' ' / • ' � z o /,. , '' � $ I Q\ 2 A a SO ‘ aV I ' ©1/4. \ \ 0; ,\ & / N ♦ \\ / �M l�lOS o ♦ ,� ♦ v O ff ,\ \\ �, .... Jew _ . c 3" i b �. 4 4,‘ . rI N \Z)C, I 1 Rhousat14/.4 as,=-,N‘,-, 1. l•- - 11/ eFsvg 5 . 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