HomeMy WebLinkAbout026-1143-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
I INSPECTION REPORT Sanitary Permit No:
• 488208 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID N -
Personal inforynation 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:
Fireside Enterprise LTD I Richmond, Town of 026- 1143 -10 -000
CST BM Elev: Insp. BM Elev: ` BM Description: Section/Town /Range /Map No:
Cam.O 1 IC0.0 C,s'( wc 1 20.30.18.1042
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
`" P�� sas l>�•
Septic Benchmark , l ,
l�.s ��--5 � 3 • � /d3•Sa � • �
Dosing Alt. BM4 3 Sr
Aeration Bldg. Sewer 0D • r
olding St/ Ht Inlet ?- ZD
9s• 30
TAN SETBACK INFORMATION S t /Ht O ut l et ,s, 9f
BLDG TANK TO P/L WELL Vent to Air Intake ROAD Dt In
ep Ic , b B ottom
osing Header/Man. tl • s
A eration Dist. Pipe - Is I /
T , q3• �S
Uri n Bo t. system ' • fib
c1 `
F inal G � ,qo 9�•�0�
PUMP /SIPHON INFORMATION
anu ac urer eman ° 33 (off
u r
GPM �•
V oclel Mmoer
I rIC n L OSS I syst em Reaa
r-orcemain
l3) da-
DIMEN IONS ,3 & S 2
INFORMATION J CHAMBER OR ..40S
UNIT IvIudul 11011113M.
t t' Pipe(s) 0 '
Length Dia Len p
x Pressure Systems Only xx Mound Or At - Grade Systems Only
Bed/Trench Center Bed/Trench Edges Topsoil Yes i No Yes No
C M T$: (Include de discrep ncies per ons pr en etc.) Inspection #1: ' t Z� (o Inspection #2: T
(� 4 c on: 1029 14 th Ave New Richmond, - - (NE 1/ SW 1/4 20 T30N R18W) Waldroff Meadows Lot 1 Parcel No: 20.30.18.1042
a 2
1.) Alt BM Description
2.) Bldg sewer length
-
amount of cover = fa { 1 s
Plan revision Required? Yes No .6
Use other side for additional information. / __
I- Date -1 _ - �nsep rsSig t - Ce . - No-
SBD -6710 (R.3/97)
CROIX C OUNTY
PLANNING &. ZONING
xxxxxx
Tuesday, March 27, 2007
Fireside Enterprise LTD
1029 144th Ave
New Richmond, WI 54017
Code Adminisrratiar Regarding septic inspection for Fireside Enterprise LTD.
715- 386 -4680
Location of Property in St. Croix County:
Land Information
Planning Municipality: Richmond, Town of
715 - 386 - 4674_.:_:::: Subdivision or Plat: Waldroff Meadows
Real Prg rty
Certified Survey Map:
715:506 -4677 Lot: 1 �
Rycling Address: 1029 144th Ave
115- 386 -4675
Dear Applicant:
A septic inspection of the above reference property was conducted on August 11,2006.
This property is located in the NE 1/4 SW 1/4 of Section 20, T30N R18W, Waldroff
Meadows (Lot 1 ), Richmond, Town of, St. Croix County, Wisconsin. At the time of the
inspection, this septic system was found to be code compliant for a 3 bedroom home.
If you have any questions regarding this, please contact our office at 715.386.4680.
Sincerely,
Ke i au
Zoning Specialist
cc: file
ST. CROIX COUNTY GOVERNMENT CENTER
1 101 CARMICHAEL ROAD HUDSON, Wi 54016 715386 - 4686 FAx
P CO. -SAIAIT- CROX.W/.US W"'W. C0. S A I N T--,-- R CIX.IV.U"S
Safety and Buildings Division Co
` m m 201 W. Washington Ave., P.O. Box 7162 unty
iseonsin Madison, WI 53707 — 7162 Sanitary P it Number (to be filled in by Co.)
De artment of Commerce (608) 266 -3151 O
Sanitary Permit Appliea State Plan I.D. Number
In accord with Comm 83.21, Wis. Adm. Code, personal info ation you e
may be used for secondary purposes privacy Law, s15. Project Address (if different than mailing address)
I. Application Information - Please Print All Information - 44 -- 2
II I q j dub
Property Owner's Name
/ Parcel # Lot # ( Block #
Property Owner's Mailing Address
Property Location
- T cR01X
City, fate I 7p_1 ode Phone Number OUNTY y, �( Y�, Section
�._ — circle
T ' N; Ro
II. Type of Building (check all that apply)
1 or 2 Family Dwelling — Number of Bedrooms
S ubdidsion Name
� ❑Public/Commercial —Describe Use l
❑ State Owned — Describe Use ❑City ❑ 71age ,(Township of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. XNew System
❑Replacement System ❑ Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System: Check all that a pply)
Nori Pressurized In- Ground ❑ Mound >_ 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter El
Constructed Wetland [I Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter ,X Lcaching Chamber ❑ p Lin E] Gravel -less Pipe El Other (explain)
V. Dispersal/Treatment Area Information: _ 2
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
9 .
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units Concrete
p Constructed Glass
New I Existing P
Tanks Tanks
Septic or Holding Tank
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assum esponsibi6ty for installation of the POWTS shown on the attached plans.
Plumber' ame (Print) Plumber' Si =MP/MMPRS Number Business Phone Number
PiulnbeCs Address (Street, City, State, Zip Code)
VIII. Coun /De artme' t Use Onl
J°j Approved ❑ Di sa Sanitary Permit Fee includes Groundwater Date Issued J Assu i n Agent Sign (No Stamps)
Surcharge Fee) `
El r en Reason for ial a
IX. Conditions ffAppi
SYSTEM 3) 0o -�t` ( q t)t qnn -c:# A
Septic tank effluent filter eand \�Q�
1 Se ,Q,
P � c � 9
dispersal cell must all be serviced / maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained 't J Qj cam,. duN
as per applicable code /ordinances
S
Attach complete plain (to the County ouly),for the system on paper not less than 812 x 11 inches in size
SBD -6398 (R. 01/03)
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III
•Wisconsin Department ofCommerce SOIL EVALUATION REPORT Page Of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County
Attach complete site plan on paper not less than 81/2 x 11 inchN in size. Plan must
include, but not limited to: vertical and horizontal reference poi ), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location a is to nearest road.
Please print all informatio Rev wed by Date
Personal information you provide may be sad fo ME ® L w, e. )). JU
Property Owner party Location
�; , 006 Govt. of � 11" �' 1/4 S T ? N R (or
Property Owner's Mailing Address Lot # Blo # Subd. ame.or
}� T . CROIX COUNTY
City State Zip C e Phone Number ❑City ❑ Village �) Town Nearest Road
New Construction Use:f E Residential / Number of bedrooms Code derived design flow rate S`0 GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material Flood Plain elevation if applicable ft.
General comments / 7
and recommendations: ��r, Ei .
n Boring # n Boring
t f I ® Pit Ground surface elev. - 2 7_ ft. Depth to limiting factor 71 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Efr#1 *Eff#2
a a
a,+9Z -7
1
Boring # Boring
® Pit Ground surface elev. ft. Depth to limiting factor } in.
Soil Applica tion Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/if
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Efr#2
, /
o Z.
* #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/- * uent #2 = BOD < 30 mg/- and TSS < 30 mg/L
CST N (PI Pri ) Signature CST Number
Address 1 Date Evaluation Conducted Telephone Number
_
i
Property Owne i �ior'r Parcel ID # Page of
531 Boring # ❑ Boring
Pit Ground surface elev. ft. Depth to- limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/tF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2
7t 7 ¢ 4 '
7 ! s s - —
F Boring # ❑ Boring
❑ pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/W
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* 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 /00)
r J i
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y �
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3
I -
Mico nsip De SOIL EVALUATION REPORT Page I of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code minty
Attach complete site plan on paper not less than 81/2 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 road.
Please print all inforntadon. Reviewed by Date
Personal irdormation you provide may be used for secondary purposes (Privacy Law. S. 16.04 (1) (m)).
Property Owner Property Location
Govt Lot / t) j e� 1/4sW1/4 S ZU T N R r g E (or
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
.
City State zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road -
( New Construction Use: Residential / Number of bedrooms - y Code derived deslgr►fl rs a z- / loo O Q GPD
Replacement ❑ Public or commercial - Describe:
Parent material U '-�� CL S Flood Plain elgvatiors if applicl
General comments S j/ S4e vir-\ e ( J • 9 y- FS U (: L
and recommendations: f , 21-'2 v ,
F -1 � # ❑ Boring xcwlNr C`
Bori
® Pit Ground surface elev. ft. Depth to Irtrnbn " i . I 2
$oil Application Rate
Horizon Depth Dominant Color Redox Description. Texture Structure Con` iiii ry Roots GPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *901 •Etf#2
1 U -$ 450 2 c I . .
2 1 3-W JD L rrPr c5 —
Boring # Boring
Pit Ground surface elev. ft. Depth to limiting factor in. Soil Ap&mlion Rate
Horizon Depth Dominant Color Redox Description Texture _ Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'EfW1 `E11#2
2 s
2 / — Sl 2 mfr c 5 rn, • 9
- wo MS OSQ m 1
Effluent IM = BOD > W < 220 mg& and MS >W 150 mg/L ` Effluent #2 = BOD < 30 ng& and TSS < 30 mg/L
CST Name (Please Print) ignedue CST Number
__ Z 9
Address Date Evaluation Conducted Telephone Number
L_
I 1
4'
Property Owner (, J� r6 Parcel ID # Page of
F-31 Boring # ❑ BorN
® Pit Ground surface elev. 8. Od R Depth to limiting factor J68 in. soy Rath
Horizon Depth Dominant Color Redox Desaiption Texture Strtjdure ConsWer ce Boundary Roots GPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *E 'E1f#2
c5 j .5 , 8
St_ CS — '
MS U I
Boring # ❑ Boring
a pit Ground surface elev. - 92-2-bft. Depth to limiting factor 1 6 4 4 in. soy Application Ram
Horizon Depth Dominant Color Redox Desorption Texture Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Efi#1 TRW
I p 5' rr,�r v� .8
2 L 1.9
F-5-1 Borft # ° -
Pit Ground surface elev. ft Depth to Irtniting factor _ 1 �� in.
r-Efff#1 tion Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Efr#2
a --
Sil 2 -Fr c
2 g_ SL Cr c- -�
3 _ - 1
' Effluent #1 = BOD > 30 220 mglL and TSS >30 150 mg/L ' Effluent #2 = BOD a 30 mglL and TSS 5 30 mglL
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 60 9-266 -3151 or TTY 608- 264 -8777.
SBD41330 (8.07100)
PAGE,_S__OF
NAME LOT# LEGAL DESCRIPTION d/.C- ' /1cAA,SZOT faN,Rlr E (or)10
t
SCALE: I ,, = � (7
BM I ELEVATION ��[� • Q
BM 1 DESCRIPTION
BM 2 ELEVATION -/ • tD Z Z O
BM 2 DESCRIPTION }_ CO
SYSTEM ELEVATION qY• s 0 (
ALTERNATE ELEVATION 93 - (%* 0
CONTOUR ELEVATION q9. �d �' gG•F�y I
O ,
q q
9
r 01 b�
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• ��`• � d�n1
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page —/—of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner
Septic Tank Capacity ga l ❑ NA
Permit #
Zt� Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer 14 IA I ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model e- ❑ NA
Number of Public Facility Units lX-NA Pump Tank Capacity gal 13'
Estimated flow (average) gal /day Pump Tank Manufacturer ANA
Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer ANA
Soil Application Rate gal/day/ft' Pump Model 0'-NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ANA
Fats, Oil & Grease (FOG) <_30 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODO 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) <_150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD <_30 mg /L $ In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) :530 mg /L 1� NA ❑ At -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 tank ❑ months) s) At least once every: ear(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) 0-'year(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: months) ❑ NA
3 ear(s)
Inspect pump, pump controls &alarm At least once every: ❑ month(s) ❑ year(s) NA
Flush laterals and pressure test At least once every: ❑ year(s) ❑ m ) ANA
year(s)
Other: At least once every: ❑ month(s) J21-NA
❑ 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.
START UP AND OPERATION ,Page of
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 th6 contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions s 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
restore normal levels within the pump tank. the pump controls to
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.
❑ 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 INSTALLE POWTS MAINTAINER
Name A l Name
Phone
Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name
Name
Phone Phone
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
Owner/Buyer
Mailing Address
Property Address y' ,e
(Verification required from Planning & Zoning Department for new construction.)
City /State r �� Parcel Identification Number �� /l�/ = /f� -�C+ � /o` ±:
LEGAL DESCRIPTION
Property Location N/' '/4 '/4 , Sec TAN R_W, Town of �,1�
Subdivision /,j����ir7 S , Lot # � •
Certified Survey Map # , Volume , Page #
Warranty Deed # ��s , Volume , Page #
Spec house no Lot lines identifiable no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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. 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.
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 Planning &
Zoning Department within 30 days of the three year expiration date.
I/we certify that all statements on this form are 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.
Numbe dro s r
SI NATURE OF APPLICANTS) DATE
** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department * **
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 08/05)
1
625759 '
State Bar of Wisconsin Form 2 -2003 KATHLEEN H.
REGISTER OF DEEDS DEEDS
WARRANTY.DEED ST. CROIX CO., WI
Document Number Document Name
RECEIVED FOR RECORD
05/22/2006 10:30AN
WARRANTY DEED
THIS DEED, made between David J. Waldroff and Julie A. Waldroff, husband and EXEMPT i
wife REC FEE: 11.00
("Grantor," whether one or more), TRANS FEE: 149.70
COPY FEE:
and Fireside Enterprise. LTD CC FEE:
PAGES: 1
( "Grantee," whether one or more).
Reco mg Area
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate, together with the rents, profits, fixtures and other appurtenant Name and Return AddrM
interests, in St. Croix County, State of Wisconsin ( "Property") (if more space is ���-" ` a " ti's��
, pgdf d, please attach addendum): lw3c- 12 -2? ( G' 7 — () Lot , Waldroff Meadows. St. Croix County, Wisconsin. /5� ij 1 _ 64
026 -1143- 10-000
Parcel Identification Number (PIN)
This is not homestead property.
(is) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated Q �D?i 1
(SEAL) k (SEAL)
* *Da ' Waldroff
(SEAL) (SEAL)
* *Jul' A. Waldroff
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) David J. Waldroff and Julie A. Waldroff
husband and wife Z STATE OF )
authenticated on ) ss.
COUNTY )
*Kristina O land Personally came before me on
TITLE: MEMBER STATE BAR OF WISCONSIN the above -named
(If not, to me known to be the person(s) who executed the foregoing
authorized by Wis. Stat. § 706.06) instrument and acknowledged the same.
THIS INSTRUMENT DRAFTED BY:
s
Attorney Kristina Oland Notary Public, State of
Hudson. WI 54016 My Commission (is permanent) (expires: )
(Signatures may be authenticated or acknowledged.. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
WARRANTY DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 2-2003
* Type name below signatures. INFO -PROTM Legal Forms 800 - 655-2021 www.infoprofonns.corn
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