HomeMy WebLinkAbout026-1000-20-050 I
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
K afAty and Building Division
INSPECTION REPORT sanitary Permit No:
515053 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:
Amundson, Gerald I Richmond, Town of 026-1000-20-050
CST BM Elev: Insp. BM Elev: BM Description: Sectionrrown /Range /Map No:
/ Q(� �J m 1 G'5 T 01.30.1 .2A05
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER ;.,- CAPACITY STATION BS HI FS EL V.
Septic Benchmark
( MOO '
0
Dosing O l ak 5 Alt. BM�
Aeration Bldg. Sewer
ti
Holding St/Ht Inlet 9. : q: �7
St/Ht Outlet �• 3% 97' Z Z
TANK SETBACK INFORMATION
TANK TO P/L WELL LD Ven to Air Iptak ROAD Dt Inlet
Septic - 50 /� 1 1 / Dt Bottom
Dosing J � Header /Man.
Aeration Dist. Pipe
Holding Bot. System �0 �
Final Grade
PUMP /SIPHON INFORMATION G' SOS �Y ✓�J
Manufacturer Demand St Cove 5. 1 Q ,y(
GPM �` LpJ J 7
Model Num r
TDH Lift Friction Loss System Head I T )H Ft
r6r66main Length Dia D
. ist. to well
SOIL ABSORPTION SYSTEM
BED /TRENCH Width O Length No. Of Trench s PIT DIMENSIONS No. Of Pits Inside Dia. Liquid De th
DIMENSIONS 3 g� 3
SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR G /Z 9 - A Type Of System: 7U 3d W� UNIT Model Number:
we � a
DISTRIBUTION SYSTEM �4�
Header /Manifold �/ Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length /p Dia / Length ` Dia Spacin n
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only 45
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center 3 8 Bedrrrench Edges Topsoil .� Yes E] No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: /
Location: 1469 Cty Rd K w ichmond, 1 54017 (NW 1/4 NE 1/4 1 T30N R18W) NA Lot Parcel No: 01.30.18. 05
�r O L� r q„�
1.) Alt BM Description = I Jam_ �� d r�' 1G 5 }{�J� �+� a, b A — j
2.) Bldg sewer length
- amount of cover 4 -D Cc. s -
30 4a- `�'°�
Plan revision Required? 0 Yes )<No
Use other side for additional information. ✓�I ✓� _"
Date �Ihsepctoes re Cart. o.
SBD -6710 (R.3/97)
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comnierce t i.gov Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 J
WI Of� Madison, WI 53707 -7162 Sanitary Permit Number (to b filled in by Co.)
5
Sanitary Permit Application State T on Number
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental
unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address if different than mail' address)
submitted to the Department of Commerce. Personal information you provide may be used for secondary C/
purposes
in accordance with the Privacy Law, s. 15. 1 m , Stats. ED L Application Information - Please Print All Informs
Property er's Name Parcel # 6 -
aab
O
Property Owner's Mlailing Address Property Location
�—('�
' a C I Y` / ST CRM COtl1M Govt. Lot `
City, State Zip e W '' /., N r- 'V,, Section
N
� LOX r rr� (circle one)
.Q t J t [ 71 lD 3 T 3 N, R 1 G
II. Type of Building (check all that apply) Lot # O
M 1 or 2 Family Dwelling - Number of Bedrooms q N f� Subdivision Name
Block # 0 1-
❑ Public/Commercial - Describe Use & Pw A
N � City of
❑ State Owned - Describe Use CSM Number L Village of
'of �
IIL Type of Permit: (Check a on line A. Complete line B if applicable)
A ' New System M R Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain)
ystem�
B. El Permit Permit Revision Change of Permit Transfer to List Previous Permit Number and Date Issued
Renewal Before Plumber New Owner
IV. T ype of POWTS S m/Com onent/Device: Check all that appW
R Non - Pressurized la- Ground Ll Pressurized 1n- Ground JJ At -Grade Ll Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil
Holding U Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/Treatment Area Information:
Desi Flow (mod) / Design Soil Application Dispersal Area Required ( Dispersal Area Proposed 7" System Elevation
p 45. 9
DmgHow Wdy Design Soil Application
VL Tank Info Capacity in Total # of Manufacturer ,
Gallons Gallons Units
New Tanks Existing Tacks
Septic Holding Tank ! SO 1 A 50 I QS r-SAO
Dosing Chamber El 1:1 TT
VIL Responsibility Statement - 1, the undersigned, assume r sibility for installation of the POWTS sh % " the attached plans. ,
r"bef Name ) PI bet' Sign MP umber Business Phone Number
r S
Plumber's Address (Street, City, State, Zip Code)
tqL0 I IY, S ' e N,k w Rl n� W o !
VEIL Conn /De artment Use Onl
proved DiMPRELVed I Permit Fee Date Issued Issuing A& Signature
_ ownertr Denial S q75.
d p 1.� 3a o
UL Cond"O"mWeasons for Disapproval 4-o ILe
t, Septic tank, effluent filter and f V
dispersal cell must all be services / maintained
as per management plan provided by plumber.
2. AN setback requirements must be maintained
as pw aWW" code / ordinances.
Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 inches in size
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SBD -6398 (R. 01/07) Valid thru 01 /10
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County ST. CROIX
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.
percent slope, scale or dimensions, north arrow, and location and distance to nearest 02(0
road. Please print all inform ad R e by Date
r2DCI %YdV b Personal information you provide may tie used for seconciftl�wiaw, s. 15.
bkj:� utj
Property Owner p � Property L C.-
GERALD AMUNDSON APR 7 Govt. Lot NW 1/4 NE 1/4 S 1 30 N R 18 E (or) W
Property Owner's Mailing Address ST C ptpgy. of # Block # Subd. Name or CSM#
1469 CTY RD K &Z 17 ACREA5
City State Zip Code Phone Number (' City (' Village (* Town Nearest Road
NEW RICHMOND WI 54017 715 - 246 - 4413 RICHMOND CTY RD K
(� New Construction Use: (i Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
Replacement C Public or commercial - Describe:
Parent material PITTED OUTWASH Flood Plain elevation if applicable N/ A
General comments and recommendations:
Boring � Boring
1 g o Ground surface elev. ft Depth to limiting factor 96 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/%
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Ef1#2
1 0 -6 1Oyr3 -2 n/a L 1fsbk mvfr gs 1 V .4 .6
2 6 -16 1Oyr4 -3 n/a Is Ofsg mvfr gs 1 V .7 1.6
3 16 -31 1Oyr5 -4 n/a Is Ofsg mvfr gs n/a 7 1.6
4 31 -66 1Oyr6 -8 n/a fs Ofsg mfr gs n/a .5 1.0
5 66 -96 1Oyr5 -8 n/a Ifs Ofsg ml n/a .5 1.0
11
Comments:
F 2 Boring # Boring
pit Ground surface elev. 9 8 ft. Depth to limiting factor 6 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -10 1Oyr4 -2 n/a sl 1fsg mvfr gs 1 v .4 .7
2 10 -21 10yr5 -4 n/a Is Ofsg mvfr gs 1vf .7 1.6
3 21-48 1Oyr5 -6 n/a fs Ofsg mfr gs n/a .5 1.0
4 48 -61 1Oyr5 -8 n/a Ifs Ofs mvfr gs n/a .5 1.0
5 61 -96 1Oyr6 -8 n/a Is Ofs mvfr n/a .7 1.6
tt
[ Comments:
* Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg /L * E #2 = BOD 5 < 30 mg /L and TSS < 30 mg /L
CST Name (Please Print) Signature CST Number
CALVIN POWERS 220573
Address Date Evaluation Conducted Telephone Number
1969 185th AVE, NEW RICHMOND, WI 54017 Apr 27, 2009 715
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2 4 11
8 Bottom
36
12 -I /2" DiA. (tYF•)
VoldVo{ume Soil interface Area In fill El
Void Coefficient in Aggttgue given at 57.4%. Sidewall (2 Sidawalls) 2. I &gain _
O of 4" pipe a 4.625 inches
12ia - 3.T4
2s lzs;n !ft
Bottmn 2.00
Void volume per linear ft. - 3.14 • { / ft tft = 0.1 17 ft'
12in •
Total Soil Interface Area 5.14 SQ. .
O.D. of cettterrylinder a 172.5 inches
Void volume in aggregate of center cylinder -(3-14 • 6.25ta 3.la • .3I25m
�12in/ft) 2 tT27;; -,ft—) �' S7a =..422 fN
O.D. of outside cylinder I2 inches Projected Trench Area
Void volume in Outside Cylinders - 2.3.1 6i. .574: •901 ft' Sidewall Height a 12 in. *2 = 2.00 Sq.Ft,
tt2ss�/li�
Bottom = 36 in. = 3.00 Sq.Ft.
Void volume at bottom between cylinders n 24in bin ( ! 'in
R i =0215 ft' Pro ectt:d Trench Area SAO Sq.Ft
[2a� /ft 12vnttl)� j
Void volume at outside bottom comers (1 /2 of void volume between cylinders) 0.215 ! 2 - 0.108 re
Total void volume = 0.1 17 + 0.422 + 0.901 + 0.215 + 0.1 011 = 1 -763 cubic ft ! ft
Gallons per ft - 1.763 X 7.48 - 1.3.2 eatlons Per linear„ [t
(t
3 L
EPA Aggregate
Trench System
EZ1203H E, f Ow
Ring - Industrial Group
65 induAdol Park Rd.
Oakland. TM .18060
State FU NMtpt EZ1203H-vsl
J SHEET: t of t 11 -27-01
4
POWTS OWNER'S
MANUAL &MANAGEMENT PLAN Pa t of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner ��
S p Septic Tank Capacity a l 13 NA
Permit # Septic Tank Manufacturer r5' ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer PoL t ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity al ❑ NA
Estimated flow (average) Q 0 gal/day Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) 1 gal/day Pump Manufacturer ❑ NA
Soil Application Rate # 5 ai/da /ff Pump Model ❑ NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter O Peat Filter
Biochemical Oxygen Demand IBOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pr_ etmated-Effluent_Qualitv-- - - - -- --Monthly merage •spersal-Gell(s)----- - -- -- _ --
Biochemical Oxygen Demand (BOD 530 mg /L in- Ground !gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ NA tAt - Grade ❑ Mound
Fecal Coliform (geometric mean) 510 cfu /100ml ❑ 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
Inspect condition of tan may ❑ month(s) (Maximum 3 ears) ❑ NA
tank(s) At least once ev ery : ear(s) y
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) year(s). (Maximum 3 years) ❑ NA
❑ monthlb)
Clean effluent filter At least once every: , year(s) ❑ NA
Inspect pump, pump controls &alarm At least once every: ❑ year(s) ❑ month(s) ❑ NA
❑ month(s)
Flush laterals and pressure test At least once every: ❑ year(s) ❑ NA
Other. ❑ month(s)
At least once every: ❑ year(s) Q NA
Other:
❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shell 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 teaks,
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.
i _
Pag
START UP AND OPERATION v o�
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 tanks) 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 lar9e 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 fife 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 falls and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
repkacernent 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 wilt
result in the nears 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 perforrtned 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. Reconstruct of su ch syste 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 c t-S' Name
Phone 'IL 1-25 Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name �(` C 'k in
Phone Phone s j g" 0 1 (0
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.
ICI
v of v�
START UP AND OPERATION Page
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 rformance and p rolong the fife of the
Pe P 9
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; medlcations; oil;
painting products, pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails andfor 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.
0 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 falls and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
repQwement 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 lnfringed upon by
required setbacks from existing and proposed structure, lot lines. and wells. Failure to protect - the replacement area wilt
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.
0 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.
0 Mound and at -grade soil absorption systems may be reconstructed in place following removal of the blomat at the
infiltrative; surface. Reconstruct of su ch syste - must comply with the rules in effect at thatt;me.
< <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 U. 1 ,k V_S Name
Phone 5`13S Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name ` C
Phone Phone t S 3 ! "-
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1l(d) &(f) and 83.54{1), (2) & (3), Wisconsin Ad n'linistrative Code.
ST. CROIX COUNTY
b SEPTIC TANK MAINTENANCE AGREE
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer -,� r YY1(k t) Lc) v\-
Mailing Address _) l �r N .P tL Oil Jr •i_ �� u
Property Address S ek yv�SL
(Verification requited from Planning & Zoning Department for new construction.)
City /State Parcel Identification Number
LEGAL DESCRIPTION l
Property Location ' /a , N £ '/a , See. T 3_Q)_ R W, Town of
Subdivision u , Lot #
Certified Survey Map # Volume , Page #
Warranty Deed # - 29 �� , Volume � Page # ! ��
Spec house yes O Lot lines identifiable ® no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its prearature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed per. 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 §Comm. 83.52(1) and in Chapter 12 - st. Croix County 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 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agreetDinaintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Natural Rte, State of Wisconsin.
Certification stating that your septic system has been maintained must be completed and retuned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
Uwe certify that all statements on this form an true to the best of my /our knowledge. Uwe am/are the owner(s) of the
property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Number of bedrooms
SR�kAttJRE OF APPLICANT(S) DATE
** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *"*
Inchlde with this application a recorded warranty deed from the Register of Deeds Of and a copy of the certified survey map if
A mice is made in the warranty deed.
(REV osros)
DOCUMENT NO. WAitRANTY DEED
8TATS OF WI CONSIN — FORM t
-, tlt1 THIS SPACE RESERVED FOR RECORDING DATA
(
V
THIS INDENTURE, Made this . day of_ ...- Ju........- A. D. 19...x.
Norman 1�'1. Iornbostel and Maureen K.
`
b etween • :- -.:. ... .._ ... _... ..._- •; � - � (t �. v.:;.
Hornbostel,. Y1l° wife
__........ ..._.......
22nd
.._ .
.part ley. of the first part, and lul�T 71
Gerald.. F�.....r�lrnzrads.on..and._ H'>~rxa _.G..._.Amundsnn.,.. Li
t.enan.tz._.1'u:i-th...ri, Lt
_. shi.P- s - ..T�.euv..:l�i�Y�rnnnd -- Y'Yi��nnsi.n..- • .. ..... .. .... _ .. _ ... _.. ? � -�.. --
e /�'
p.art_1jaF3_ of the second Dart,`=
Witnesseth, That the said part le -. of the first part, for and in consideration
� RE',TUtiiN TO .
of the sum ot:.-- .. -...
to. the_M__ in hand paid by the said part__! e 0 of the second part, the receipt
whereof is hereby confessed and acknoHledgcd, ha._V.e. given, granted, bargained, sold, remised, released, aliened,
conveyed and confirmed, and by these presents do -_._ zive, grant, bargain, sell, remise, release, alien, convey, and
confirm canto tile: said part __.... e5 }; the >erond i, t11E - 1X'.. _._ heirs and assigns forever, the following
described real estate, situated in the County of z: r _.-- 4'XQ04aK....... . .. .. and State of Wisconsin, to -wit:
the East six- hundred--tiu it ( (?n t 1 3 ) f et
Township 'Thirty (30) Nortri, Range: Eighteen (18) West
�•
too
(IF NFC:N:68ARY, e0N'rINIJ I. IJt':lC lei f'Tii� ^� (:)N
Together with all and singular the hereditamcnts and appni thereunto belonging or in any wise
r.
t,r r,t� +.��•er IHTI� ')r its ;md w)rlf•i� ever, of the said fart e ` _ of the
a ppera� aixlll,l.,y +•i :aa, a.. ..�.1.�, t �.
first part, either in law or equity, either in possession or exl)c+ -tansy of, in any -i to the above Bart >ained premises, and
their hereditaments and appurtenances.
To Have and to hold the said pretenses as above ri siribcd with the^ lictcditafnents and appurtenances, unto
the said part..,,. -Q Q. of tine ml p art, and to _ � lhr .r .' h In nand 1(1R1:'ti FR
And the sa id nr.,..eel,.- ri wf
,
,r for._.-_t.hf3S ae1V- s,_ ; ilai_x heirs, eXecutors anal dd gas, covenant, grant bargain, and
agree to and with the said part lF S of the second part tr ( r heirs and assigns, that at the tune of the
the are
i ensealin}; and delivery of ttles< presents ...... ..Y ............ .. .well scrzed of the premises above described, as of a • ,,.
good, sure, perfect, absolute and indefeasible estate of inlaeritanccr in the law, in fee simple, and that the same are
free and clear from all incurnbiances whatever, ._5?27c3_ - YlO GXCf t].On
.__.
and that the above bargained premises in the uact and :eaeeable posscssion of the said part -les of the second
part, heirs and assigns, against all and every person or persons lawfully dailrung the whole or any part
thereof, ........ will forever WARRANT AND DEFEND.
In Witness Whereof, the said part.,1_9.9., of the first part ha.. VE hereunto set ...... han .S._ and
seat .... t9 this---1 .._.._. clay of.. . j:Ul!Y _ -._ . - -- _ ...., T.)., 19. - -71..
(JNE}U gNl1 y 'AL 'i�) r qt]i,SP.NCL�' OF -
.� _ .. .(SFAL)
orman Iii. lIornbostQl
I
Paul 0. Swen y k1a teen A Hornbostel
er
State of Wisconsin, ( 12th
i S:t ..Croix ..... County. ( Personally �a{ne �e ore near thts ... day of J .U1Y... - _..• ...... A. D., 19 ... 71,
the above named Norman HO 1d ... ...... .. . . .... ..... .
...A rnb e hi Ho o t s wife
0l to me known to be the persona- $ wh C b et ted th' "} le e4 the same.
.1"_* t WAi DRAFTT:D 8 , .; } a,. a r Pau . I�W . '
M
qjatly Public, ...,�.� • ..�e.rS?IX . _...;.._... County, Wis.
�reb Realt A
y tom n (expires) � : 973. �e.. ......1
v
rrllaai4 .M .�ri.�..:S.�A
w .
$, �"n:�i�r. •4r9"Y*M..Mm°3w' -M 3T'9i::..""' ,. ..,. . «,._.. .:.: .: ,.{ „. .. .
.,
7 irnoMrkd ehat3 hA" plainly printed or typewritten thereon
t e�niaua' pi tl grankon, gErntEes, w t an t tarty requarbs tat for name of the 'person who, of govern-
wr' thereon in a legible manner.
meakal agency which, drJfted ouch instrument. Thal[ 6e printed, typewritten, stamped or itten g )
W TE printed. WIBCONNIN Wisconsin Legal Blank Company
WA1tRANTY DEED FORM No. 1 Milwaukee, wig. ( Job 29622 )