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HomeMy WebLinkAbout026-1126-42-000 r Wisco) ` Department of C� ce PRIVATE SEWAGE SYSTEM County: St. Croix Safety a wilding Division INSPECTION REPORT Sanitary Permit No: 453021 0 GENE.,AL 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: Sita, Joseph & Marjorie I Richmond Township 026- 1126 -42 -000 CST BM Elev: Insp. BM Etev: T D escription: Section/Town /Range /Map No: CST BM Elev: Insp. BM Elev: / ( � 'S_� 12.30.18.803 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. f 160 AI Septic Benchmark 3•5s Dosing Aeration Bldg. Sewer \ Holding SUHt Inlet J O J TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Z16 > I /A_ - /' / // / Dt Bottom (� Dosing + �►'J/� J ' / // / Header /Man. Aeration -- Dist. Pipe Holding Bot. System 7 PUMP /SIPHON INFORMATION Final Grade 3 •�S 1 60 Manufacturer , Demand St Cover \ GPM Model Number 3e CS TDH Lift Friction Frictio Loss System ead TDB q ,q ` J� Forcemain Length / ia. Z/o I Dist. to We SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No. Of Tren PIT DIII�ENSIONS No. Of Pits Inside ia. Liqui epth DIMENSIONS / /�� SETBACK SYSTEM TO � P/L BLDG 1 WELL LAKE /STREAM LEACHING Manufacturer: �� /'/ INFORMATION CHAMBER OR f" d L. , j Type f System: � N A UNIT Model Number: Zo > d DISTRIBUTION SYSTEM 6J 3 6 Header /Manifold fl I D iptr(bj do x Hole Size x Hole Spacing Ven to Air Int�kf 1,f Pi e s I�V Length I Spacing Dia r Length Dia \ \ SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over J Depth Over xx Depth of xx Seede /Sodded xx Mulched Bed/Trench Center 1f0 ®/�n Bed /Trench Edges Topsoil � I Yes No Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: Location: 1454 166th Av nue New Richmond, WI 54017 JSE 11/4 NW 1/4 12 T30N R18W) ater's Edge Lot 42 I Parcel No: 12.30.18.803 1.) Alt BM Description Anature 2.) Bldg sewer length = y - amount of cover = Q Plan revision Required? Yes No �7 X �( 7q 7� Use other side for additional information. FJ J Date Insepcto Cart. No. SBD -6710 (R.3/97) I Safety and Buildings Division County 201 W. Washi ., legion Ave., A ve. P.O. Box 7162 � irscon n Madison, WI .53707 —7162 Sanitary Permit Number (to be filled in by Co.) i L Department of Commerce (608) 266-3151 0 Sanitary Permit Application Stare Plan I. W. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide , nay be used for secondary purposes Privacy Law, sI5.tt4(l)(m) Project Address (if different than mailing address) I. Application Information — Please Print All Wornution . — 1 A Property Owner's Na me . Parcel A Lot B ya Block a Property Ow s M siting Address Property Lma RU t r 3 hr �n .S � N uJ � 'A .,Section City, State Zip Code _ Ptrtint NutnDisr ` 7 �. � � � circl . TYpe of Bttii (check ail that apply) T _ b ( N: R�E orQy I or 2 Family Dwelling - Number of Bedrooms Subdivision Name CSM Numb er t 'U PublictCommencial - Describe Use Ci State Owned - Describe Use (:� �! Cl S UCity ^ L_�Village _ o hip of t I III. ape of Peraait: (Check oWy one box on Use A. Complete line S if applicable) A. New System Replacement System ❑ TreatmenUHoiding Tank Replacement Only U Other Modification to Existing System B • ❑Permit Renewal � Permit Revision L_I Change of n Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System. ( Check all that apply) Non - Pressurized Ito- Ground U Mound > 24 in. of suitable soil Mound < 24 in. of suitable soil U At -Grade I_) Single Pass Sand Filter U Constructed Wetland U Pressured In- Ground i__) Holding Tank ❑ Peat Filter L.] Aerobic Treatment Unit U Recirculating Sand Filter i U Recirculating Synthetic Media Filter 0 Leaching Chamber U Drip Line i Gravel -less Pipe L_1 Other {explain) V • Dispersalffreaunent Area Information: a, Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (s0 Dispersal Area Proposed (sf) System Elevation oQs 7 Qa� qG�s Vl. Tank Info Capacity in Tots{ Number Manufacturer Prefab Site Steel Fiber Plasti Galhom Gallons of Units Concrete Constructed Glass t New Existing Tanks Tanks is ar tokling Tank WOO t herCk Treatment Unit ly ©i.t2v�C0� Ming t"hartrtxr c . t VII. RtapottSibility Statement- i, the mWeirslpixl, ponsibility for ' _ of the POWTS shown on the attached plans. Plu is Na me (Print) Ptu s Si Lure MPRS umber Busi»ess Phone Number a V e re "aws ( Plumber's Andre ss (Street, City, State, Zip C e) S u ) S I VIII. �il)e t use QW Approved 0 Disapproved Sanitary Permit Fee (includes Groundwater r 27o sui Ag Si gna rr ps) Surcharge Fee) ❑Owner Given Reason for Denial IX. Conditiotu �' AppwvaUReasans for Dlsapptwvai .. I SYSTEM OWNER: j 1 Septic tank, effluent filter and , dispersal cell mss t all b service / maintained i i as per management plan provided by p lumber. 2. All setback requirements must be maintained as per applicable code /ordinances. i Attach amsplem th= (to the Com ty oaiy) for tae symkm on paper not Im than a ll2 x 11 brcbes in size J II - i } 3 to�4 d. ht ` S i a f 3 o A) i2(� t rsj �r� il�C?i . �v A S� 1�'7Y1 f)a rca.t2 Z D * 1 -),O S'-f�L . N ^tir 3 -S -may �os3 j f Sc � R �* r i 00 9tr - v s z-' a 4o' �D b B� r�C� 3 1 O q u �►r� D �� of �,�?C?. -e rgc3 V t - o - � � / ,s Li �- 5 v ndre p�� A LL 3 � 1 �o 4" Cl VENT PIPE 12" MIN. ABOVE GRADE • EATHEONPROOF APPROVED 25' FROM-DOOR, WINDOW OR FRESH AIR INTAKE WITH CONDUIT MANHOLE / POCK &R / - WARNING LABEL 4" MIN • M s, [ 1-4 LET - s WATER TIGHT SEALS GASTIGHT A SEAL APPROVED u" I ; ALM JOINTS W/ CT Or CI PIPE ' PIPE 3' ONTO 3' ONTO °r� g —I ►� , t`' ON SOLID SOIL r SOLID C { ' RISER EXIT SOIL PUMP OFF ELEV . FT. �- --- T' OfF PERMITTED ONLt D IF TANK MANUFACTURER HAS APPROVAL 3 APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE TANK MANUFACTURER: ? � aS �r�_ m�f; NUMBER DOSES PER DA X : ____� � TANK SIZES SEPTIC /�_ GAL. DOSE VOLUME INCLUDING , it DOSE GAL. FLOWBACK: ! GAL. ALARM MANUFACTURER: S�. �`�, .�` CAPACITIES: A = I9,S INCHES =GAL. MODEL NUMBER: B ? INCHES = Yl d. GAL - SWITCH TYPE: S��x� ' G = INCHES = 1 GAL. PUMP MANUFACTURER: � " -- c r t7 1 ct `� MODEL NUMBER: INCHES = _ GAL SWITCH TYPE: v l QS D ^ 1 �`� -- REQUIRED DISCHARGE RATE lbD GP PUMP & ALARM WIRING AS PER ILHR 16.23 WAS VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE . f�-' FEET + MINIMUM NETWORK SUPPLY PRESSURE - •.• - 2.s FEET + /D FEET FORCEMAIN X ��FTI100 FT. FRICTION FACTOR , FEET 5 TOTAL DYNAMIC HEAD = __ -5 FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH ; WIDTH ; DIAMETER LIQUID DEPTH > 0 5_3 s i • 1 A rr r T 77 r _ .1.. + r •t C" J r :! tr r l " +' r ' ;tllrlliiilwarlrriwaswlirww r •�', ; a. a� !=i+�ir . • +Mt Ma! wa a !a MarJriwaa'7wr I NN a r-> 'Ys- :�aws�eaaaaarl� Bar�rlw !■ a*�a�+�= �aaiarsrlr� ■ �rrlwr=i�iilw�i �•ar��iir=�''!!'a�r =�it�i� ■+naiwla a L Mum moil ra aar�lawia�wwaaa a! lawrrwa„�rtirra �elaraiar N1'► iiaw 'iawlrat:\walMiiatlila mu IN l�►lrla lr!talri�t�,�g ia � all uaaaaa wi��re .�la �• wa►aawlsrw! ' �l►� �- '��,!�'�"*�"�wa+►'!urwa►rwlaaaa ! / , �' .. �� �Sw�r, ■rsr.•�r�aaalaawlar!! ..�+rlri.f ate■ �'`wr'���t�a�saa,�aawiw ?'"w� %t►`1w��i�#i!r W40 i!!!ia ,,. , F r ,. r a�aal l�.7►b...."�� \1►�1wl�lwr,`la�a i!!17 ! al a � \ AI: Ai ,, �`� + raaiil►�iil��ai!A�'���� -, rJ, laaaran- ,naraiaa��..rlalw aaraaMrala ■ ra aara+ araaw�larrlwa�raa'ir�rar!!! f i � Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 S - r, 0, r`0 ; isconsl n Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 266 -3151 1. o2 Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Address en dress) I. Application Information - Please Print All Information 11-4 Property Owner's Na me REC 1 # Lot# a Blocs# ` \\ �~ ti v�(y r, S i� C) (D~ (0 -baa 3 Property Ow er's M ailing Address C� MAR 0 9 2Rtepe L cation i:)r % J UU't 1, N U) 1 k,Section 1 City, State Zip Code Phone N ber F ZONING O CE ` -7 � 7 (circl > H. Type of Building (check all that apply S N ; T __� N; RE of 1 or 2 Family Dwelling N Number of Bedrooms Subdivision Name CS tt�rtber Q Public /Commercial - Describe Use S 1 F/ � ❑ State Owned - Describe Use jC 9 ^ S ❑City_❑Village* wnship of ` III. Type of Permit: (Check only one box on line A. CVplete line B if applic le) A. New System ❑ Replacement System ❑ Trea t/Holding Tank /acement Only ❑ Other Modification to Existinf ys Change of ❑ P mit Transfer to New Lis r pe to Issued amber O er t C) V \ table soil ❑ ound 24 in. of suitable soil ASand Filter alding Tan k ❑ Peat Filt ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter er ❑ D p Line Gra less Pipe ❑ Other (explain) Dis r 1 Area Re s Required Dis al Area Pro posed S m Elevation Pe 4 (fl 1 s � (0 ste Y Manufacture refab Site Steel Fiber Plastic i 1 J s Co ete Constructed Glass -- .mss ,^s re v\ c v �.csponsibility Statement- I, the undersigned, ume responsibility for instpRokLon of the POWTS shown on the attached plans. PI ber's Na a nt) Plumber's a MP MP Number Business Phone Number �s e ti►,-� AC -S 715 L7S Plumber's Addre ss (Street, City, State, Zip Code) k Pta -- C)t-i VIII. Count /De artment Use Onl ,Approved ❑ Disapproved Sanitary Permit Fee incl �O udes Groundwater Date Issued Issuing ge Signature ( S ps) Surcharge Fee) � 7 �� El Owner Given Reason for D 'al IX. Conditions of Approval /Reasons for Disapproval SYSTEM OWNED 9 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. F Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) �� hit � ,`` � �. `c ' x' ` „� r r i Il i I I III 1 M S �'I o7 t'la V, /� " , /Q VOSv2 :TA n�a foii�2. ���C�. ,•, E y l � Ia -Ta 13 q )� a w, r �y Q �` ; ., p W Ck `. -e rS y e �d 7 Al �s� ► `f `7� 7� M O A U / ST C rllc) lx 1N : -,,,S e es rcxl2 $ {� O a•lo — I ! o� b sV o, AGO O � a5 � S ,�, � r�.�eo -l:`r -J�s aa- � y � � S y 1 lo(�`� h � � .� • 3 `� / �t� Noy �o s37- �! 9f� Y Y / s z- P BI 60 — Z1 6 q BM4 �� 4� e, r S E N �T3 // tg ci 3 1 tF iu Yyt �2 i v) 1L 7a 1 t l YYl of) LO Norl- i -�� .Q ► 5 � rca.s2 � 0�1' O a.�O -- � � o� �0 ��(,a �bo 3 s-, C�v ;o ns � c� � `3 l it r g l ` 'f bo' t b Wisconsin Department of Industry, SOIL AND SITE E V A L U" R E �, ; Page 1 of � Wi _ Labor and Human !Relations DI ion oi afety & Buildings in accord with ILHR 83.0 r� �- C e � is. Ad C NTY f, �� Attach complete site plan on paper not less than 8 112 x 11 inches in siz n muRin Jude, txti a0 r t. Croi not limited to vertical and horizontal reference point (BM), direction and off Slope, scalef Lv EL I.D. # dimensioned, north arrow, and location and distance to nearest road. --1 , �� p,4ty' " ndin APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATI �(,0o F�Or` EWEDBY DATE o 1N I 15 ' PROPERTY OWNER: R LOCATI G 1]A 1 /4,S 12 T 30 N,R lg �(or) W Derrick Con t. n PROPERTY OWNERS MAILING ADDRESS LOT # SUBD. NAME OR CSM # W 1505 Hwy #65 42 1 na I B e &Z G 6 CITY, STATE ZIP CODE PHONE NUMBER FICITY EIVILLAGE J'OWN NEAREST ROAD New Richmond, WI. 54017 115) 246 -2320 Richmond 140th St. [ *oVew Construction Use [X ] Residential / Number of bedrooms 4 [ ] Addition to existing building I ] Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate •7 bed, gpd /ft .8 trench, gpd /ft Absorption area required 858 bed, ft 750 ft ench, ft Maximum design loading rate .7 bed, gpd /ft .8 trench, gpd /ft Recommended infiltration surface elevation(s)_ 96.50 ft (as referred to site plan benchmark) Additional design / site considerations na Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem I [it 11 U EIS KI U [it S O U CIS ®U ER S❑ U ❑ S K1 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence BcAlary Roots : Bed GPDIft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Trertfi 2 1 8 - 22 10 r 4/4 none sil 2csbk mfr ow Ground 3 1 22- 60 elev, 9 9.8 ft. 4 60 -90 7.5 r 4/6 none cos 0SQ ml na 7 ' . Depth to a/ limiting f factor �' 't- Remarks: Boring # „_. 1 0 -8 10 r 3/3 none 2 8 -22 10 r 4/4 none sil 2csbk mfr aw lm .5 .6 5 Ground' 3 22-32 7.5 r 4/4 none s1 2csbk mfi if elev. 4 1 32-90 7.5 r 4/6 none cos osg ml na na .7 .8 9 g ft. Depth to limiting factor +90" Remarks: CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200 Address: 1554 200th. New Richmowl, WI 54017 Signature: Date: 6_29_2000 CST Number: m02298 PROPERTYOWNER Derrick Const. , Inc SOIL DESCRIPTION REPORT Page - 2 — of _3_ PARCEL I.D. # Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundlary Roats Bed Ti�ctt 10 r 3/3 none 1 2msbk �- €:<' 2 8 -20 10 r 4/4 none rnf r rTw 1 rn y Ground 3 20 -34 7.5 r elev. 99 ft. 4 34 -9 0 7.5yr 4 6 none COR as g MI na na Depth to limiting factor +90" Remarks: Boring # 1 0 -16 10 r 2/2 none • S� t< 4 2 16 -32 10 r 4 .S` Ground 3 32 -90 7.5 r 4/4 no elev. 1 t ft. Depth to limiting factor Remarks: Boring # 1 0 -9 10 r 2 na no no >'S 2 -22 7.5 r 4/4 none sici 2 •� Ground 3 22 -34 7.5 r 4/4 none sl elev. 4 4 -90 7.5vr 4/4 none nq M1 n;4 nn 100. 3t. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(R.05/92) STEEL'S SOIL SERVICE Gary L. Steel Derrick Construction, Inc. 1554 200th Ave. CSTM2298 SE NW'j S12- t30N -R18w New Richmond, WI 54017 MPRSW -3254 town of Richmond (715) 246 -6200 lot #42- Brushy Mound Lake This soil evaluation was conducted to satisfy a zoning requirement, it may or stay not be suitable for your use. The location of the test may or may not be as shown as permanent lot lines mere not established at the time the test was conducted. 1 =40 . �.= top of 1° pvc p ipe C el. 100.00 t. BM = top of 1 pvc pipe C e 011 0 40 i k t� �. ' Gary L. Steel 6 -29 -2000 1 4 EZ1203j t f - 4 - 1 , -+� _ � � i +s `'�.62a" * *! 12 i !! we V •! rr of J ' * w s !! t � �!' irk JtY. t ! *w!`!!t►ww, I ..) Plot VlWd � q. uF�,� 7 , tar ♦� � . • us . v, t r = rr, �Mlrlgpk1 ' • to � t! l� �nr � e of ��, rr�, � t ------ .• _ .. ____ —_.._ � tR � L!, �. „f p f t t? &,1 s � i . , �1 t,�� s r i �t t.. e , '�nt .►..� 'r""— __ ---�__ GZ) T p�+re a'tde 44 S 6 ! t2rarh,' s r._ 901 ow .!x }} m Arcar +•arw cr »fin F Sa11 tMi!( ' *olvs,,,o 4 'sw f , 36 '+� j f®4Y e�her3 (t,? J °f� q. of , •'atgy k rert � * 'Q.jt3- O..lO,xr.�h� t3 tlt{idh- 43 CPS Ag n Trench gat r _ - 5 ,#Noq up - Crr r ar r ## t POWTS OWNER'S MANUAL & MANAGEMENT PLAN, ° ` Of •• - Took Mar r _ Owner ntl 11 \Ct r r r �2. ( �, s �1 tern D Z / sew t ueae n lid it o NA Tank Maw t> 6MI PAR11 a Doss 0 t tQ Prot. Od mmtm of 0 RA f fA � M a * (� l� Y�c C7 0 f rtA Murnber of Pubf Fa i tlr U nits © -`� � � Es'dn'r�d faver+�? flow 0 N A Dadgn fpwQ flaw -- (Emijrnated x 1.51 Q purrp modal Sod fbsae t %it t3 NA Sle Wwd Oruaft IAaotrtltiy atrerartOs D Pest t�ittar Fats. Oil A Grease (FOG) 530 mgn Fftw d NA on 0 Wattsnd 8iac�arrricN Oxygen barb 0013 520 t:3 f7� D t�that: TOW Suspended Salida t't3�i1 st 50 OVIL ;A MOW montN1► Overalls M� t D NA ygen Owmand (BOW Sao "V& O ln- Ground omse�xed) Sotida f SS) 530 a*& 0 NA t1 At- (arada Q Mound farm figs ff"") :S'W cft#lOowd ❑ Oth r: Pattirde Sire Y in dia. D NA © 0 NA ❑NA DNA `Valtrss t fat dorrreatrc vnwawwaw arid s to rk sffhlerrt. Mallf!lTERaAl11GE Sfr!# ,� Sbnka EvOt ( 3 V@g p4 ❑ NA Inspect COrKW*M Of t rrirfsl At bast once e ever r: 3 When caarnad add WW ate WPASIS =*-"*d of tank 0 NA pump out c ontarrts of tarts? E3 When 00 hqh *NOW ab fnetl poexbram $ f DNA Inspect W At s} At beat once ever. DNA At beet tsrroe Owwr- . D enotrftdsf 0 NA E3 0104 erect .purnp. lip cOnI Ols & alarm bast once mery: 0 NA vearW Fkah larterab and Prue test At bast once e+rary: (3 El ftwat4s) o NA At Imest once evw r` CI CI -NA WANTERAFAM V#gyRVCTKNlS one of " followar8 or a icatiom cells shall ba made by an �. O stet' tPu►1�i. InspectIona of tanks and dispersal Master Pkxnber. Master PlunlAw fiestrictsd Sewer; F'OWTS inspector. men hasd Wardit any Cracks or Tank kupecdons must include Is vbUsl tectiat of the tgre an to ideniiftl for � of effluent on the ground leaks. measure the vckmw of combined sludga and so= and a d+ack for lea beck w or and to check for any sr arface. The agxw afi w staag be vbuay bapacted to t�e the affls brads in the � f condition artc pw dhv of effluent an the grotrwd surface. The pow of � on the gt� stsdar� rt'aY nxrjkm the kmwfAme notific lim of the local regubtary &AtrsadW odd 1 Y3 1 or more of the tank volume; Ov e q uals When the axonbined sr cs mulabor3 of sb+dW wW srxrrt lo airy treatment tank of in accordance wkh chapter Nft 113 entire contents of the tank shag be removed by a She Sat4i+*V Bator an d 4spamd Wisconsin Adrnirfttrative Coda. pr uriaa+d c , nts, pretrestrnen of effia rent titters• or AN other, services, irtdudisag but not limited to the a pOWTS faAauntsiner us#its. and any sar Ack* a t intervals of 512 nwx0m, shall be Performed by of any ssrvid:s +ant° A service report $W be Woarided to the local regulatory sudw tll vtktsn 10 dolts of � rt Gmw t2M2 S7'AR7 top qNp OpSAT1011# . III °a te. Prior to use of Oft f►OWTS doivx* page he" that �Y impede the � � t twit for the Presence of pain of the tank(s) the sod d4Pwsat tret(s}, tf v tra aeiverrt$ or othe Systm" start up slmA not oCCer When aer'rir3"$ prior to use. we deumft i W*V ceded Power ' � are foam et the s11ftrar 'ye sur Pump tanks of dis#rse+bed daPW%at cWW in one nor mal tsowrer is to To avoid #his rRlon does and MW awalaad " ► exce Power is the ofitu!a�rrt Pu"V or os � � of the pump isrtlt rear In the bhp or aurfaccm mvtrcft to restore no Do nest drive #evs#a + the tank f'itegbar car i T1AiTS airw to assist in Operator p rim veNcies 'Over tanks pip 75 feat down" dope of anY Mound or from at � Do not drive or park Q,,. or oUrary disturb or L, the alga the area. wastwastw f err ' baby . cif to atr+s°n► n'r°1' "Wavae the PWfO WW Pain*q - ice) �. fruk and V taatlpn swat; ors: dental ifaes the left of the Pesticides; mss. and ' ; o ice► aW aafel'it � in a►x-e wnhwath, the "Owk slaps shed be taltan Ad to tl a i tanks S3. IRtec A r**W= m t the system is a to arrd Pits stmN be and the a The +giants of a# tanks acrd p({s � be �° ° see#ed. • ra►ms+aad and proper##, o f by a Servicing op.,.., tanks gravel a a"p� and rernorsd or the covers muoved and the vof ��Y pum agape Mad with If to rPovn and cannot be TSPM d the foiovvwp n have bean, or must be A$Ysi �t area taken, to provide a code complfwn area Wmuld � the ction of a �t soil absorptfQn resrdt In 00 fined fora newer and pied �, iot tsreas and and show not be MfrhVW Upon by conVly with ilm ndes in effect at to a suitab#e t area the r'M�carnerd w" vnN [] q suiteb# �rw+t aYsttuns rn� am b "It a�bie due to Ci � a tank arty be instWed as a taut retort acs the failed PO advances in POWT'S has not been evu ustad to ' _ of o "� ed as a � ""Amt ft r�aOeai the � �°` no �t area the WT'S a Sol ng Seta L7 M ,� turd POWTS, va-rtsls a holding taritt abaor�ion C <1ArA ft Fiecorrstti er Of such syste � nxs 1Y With ills f� vaf of the ndms in 0160 at that *no. at the 89M A 0 ,, OTHMMRTMEMT TANKS MAY f.'QN1/1/d LET#lAt 5 MII QE A T Tyr tlXYfs#• 17Q l?T A� ASS• DEATH YAy S' .7. REWM OF: A STS Marne POWTS !s ~AWM a � Narne PrKxte i►TAtiE � ATnN ante mumpm tpCgl, i JtTORY A K"e Ntarre . Phone > 6� by the staffs of etas C,raon *lw Caerert 83.22i21(Wflj(tU&M -.d 83.W, lake � and .t21 Zre Zrq and n+a ' ir ►. a rative � aq in Coots. c WTW I Sm . with f ST CROIX CQUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer you U R4fi -3,c f E 5/ 7 - A Mailing Address 1 `� 77u^� ! '6/L(Y - f /VS77fN- IJK 1 /77Z<j Property Address (Verification required from Planning Department for new construction) City /State 12Y Lq04-0f461 k o t Parcel Identification Number. LEGAL DESCRIPTION Property Location l4, V4, Sec. 1 Z , N -R W, Town of A Q4 M-° Subdivision t�'47�t`LS Q t �L Lo # Certified Survey Map # Volume , Page # Warranty Deed # 75 Z Volume 7-V `) 9 . Page # A0 Spec house ❑ yesXno Lot lines identifiable )kyes ❑ no 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 masterplumbujourneymanpl*mber, restrictedplumber or a licensedpumper verifying that (1) the on -site wastewaterdisposal 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 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 a IGNA the thre yearxpiratio te. 1 ` � TURE OF APPLICANT 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 kroperty des ed above, by virtue of a warranty deed recorded in Register of Deeds Office. r�m� x / 1 SI OF APPLICANT 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 02/25/04 WED 15:21 FAX CJj002 I U. 2499 P 16 � -7!ffi �-- FEE, Document Number WARRANTY QEED- KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO.. WI THIS DEED made between Brushy Mound Partners, LLP, a RECEIVED FOR RECORD Wisconsin Limited Liability Partnership ( "Grantor') and J n� h M. Site and Malone E. Sita, husb and and wife, as survivorship marital 0/2500$ 1 0:00A?! property ("Grantee")_ WITNESSETH, that the said Grantor, for valuable consideration WARRANTY DEED conveys to Grantee the following described real estate in 'St. Croix EXEMPT # County, State of Wisconsin: REG FEE: 11,00 TRANS FEE: 148.50 Forty-two (42), P of Water the Township of Recordin COPY FEE aunty, Wisconsin Name and The First ion Bank of Hudson ATTN: Pat #016039291 PO Box 1$7 Hudson WI 54016 028- 112842 -000 (Parcel Identification Number) This t£_RQt homestead property. Grantor, Brushy Mound Partners, LLP, a Wisconsin Limited Liability Partnership, is an affiliate of Derrick Homes, LLC, a Wisconsin Limited Liability Corporation. Grantor develops land and Derrick Homes, LLC is a home construction contractor. Grantor agrees to sell this lot to Grantee on the condition that Derrick Homes, LLC will be the builder of the home for Grantee. If Grantee does not commence construction with Derrick Homes, LLC as the contractor /builder within two (2) years of the date of sale of this lot to Grantee, Grantee gives Grantor the Irrevocable right to re- purchase the lot for the same price as Grantee paid Grantor for it when Grantee bought it from Grantor. If Grantee desires to sell the lot to another purchaser before constructing a home upon this lot, Grantee gives Grantor the right of first refusal to re- purchase the lot for the same price as Grantee paid Grantor for it when Grantee bought it from Grantor. Dated this 23N day of January 2004. * ` Ro D ricl Michael R. St yens AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ST. CROIX COUNTY Personalty came before me this 23rd day of January 2004, authenticated this , day of 19 the above named Michael R. Stevens and Ronald L. Derrick, as partners of Brushy Mound Partners, LLP, a Wisconsin Limited Liability Partnership to me known to be signature the pe ns who executed the foregoing instrument and type or print name ackn w d e the same. HEfDt �. EtffZ � � authorized by' 706.06, Wis. Stats.) TITLE: MEMBER STATE BAR OF WISCONSIN fora (if not, type or print name Heidi L. Lutz State of WiS Notary Public St. Croix County, Wisconsin. THIS INSTRUMENT WAS DRAFTED BY My Commission Expires: March 26th 2006. Brushy Mound Partners *Names of persons signing in any capacity should be typed or PO Box 445 printed below their signatures. New Richmond, WI 54017 IY Y(YIY 7)y Y S g 3 = rY Y Yly y Y Ay ;^ g Y y q do �. 'AA &AAAA`�rt'C' =t�• = « « � Y ,r ;�, ��; RR AA &AA rrrrZ :aa8g 3 Y Yyy _ s i AA� ca - - -_. ?� • s_ Ma 6� t .72 asON a- \19 1 , 4991 x L lot ik C R �+ w�' cy ci g T � ' + , dP co ` •�, 1i *� , tip , j , � J� .�( , A NOR TN 114 CORNER UNPLATTED LANDS SECTION 12 -30 -18 FO'l),(V© ALUMINUM COUNTY IVIONUMEN T a OQ•• of fo "' 1 UNPLATTED LANDS f s o/ 42 2. g N8g'22'15 "E 378.15' - S87'13'12 "E 176.07' '" 8 _ _ _2 38 "E �\ -` __ - -- J _ - -_- � _ 9_29_ �,uEgyDFR Li. N 2 67.04' f'URPpg�cS OF T£NS/S SURWY F .. ............ .973% • ..2 ... • • �� ... ...• • • .................. J� ..-- h T 43 AREA TO SHORE: 125,361* SQ. FT. ,l4 + i. �� 2 Nas7r ar w 2.88± ACRES L O T 41 rrt AREA TO MEANDER LINE: o +k ; AREA TO SHORE: �, s ��, - 105,798 SO. FT. ,. 180,206± SQ. FT. 4 ¢ * • 2.43 ACRES a Ilk ,� 4.14± ACRES � o' H.W.L. �`���_ F.F.E. 984.7 AREA TO MEANDER LINE: �a 159,704 SO. FT. H.W.E. 980.7 3.67 ACRES— -- ` � L Q T 4 22 Q.Q �.._ —AREA TO SHORE .._..— .�_..� -. 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