HomeMy WebLinkAbout026-1149-13-000 r� 12�'� I`f2 S } •J
mentofComm ce PRIVATE SEWAGE SYSTEM County: St. Croix
Division
INSPECTION REPORT Sanitary Permit No: 420620 0
()
,L INFORMATION ATTACH TO PERMIT State Plan I� D No
reformation you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
rlolder's Name: City Village X Township Parcel Tax No:
annin , Chris Richmond Townshi 026- 1149 -13 -000
,ST BM Elev: ,Insp. BM Elev: BM Description: Section/Town /Range /Map No:
(arc 6z �t�o . o CST .* ( 36.30.18.1113
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Bench r
3.39 -30 do.a'
Dosing Alt. B
Aeration Bldg. Sewer
S• 2( � ar0 . 2�
Holding St/Ht Inlet
•9� Q• S}
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic } Sol L.0 f Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe IAN
Holding Bot. System .d) �IS• Irk/,
Final Grade A s
PUMP /SIPHON INFORMATION „� �,�; ; ,. N� , 3 • �� 99 9
Manuf cturer Demand St Cover
M 3•�� �o .4G �
Model Nu ber
TDH Lift Friction Loss System Head TDH Ft
Force k, Length Dist. to Well
SO! ORPTION SYSTEM Z
RENCH idth Length +� No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIME 3 ••/► 2
SETBACK SYSTEM TO P/L I BLDG IWELL LAKE /STREAM LEACHING KJOM fa `
INFORMATION CHAMBER OR
2
Type Of System: i ll �� t UNIT Model Number: ( �I
DISTRIBUTION SYSTEM
Header /Manifold t t Dibution x Hole Size x Hole Spacing Vent to Air Intake
s) t
Length Dia Dia Spacin
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
0 Yes 0 No [1] Yes [A] No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:*O/ / ?JW Inspection #2.
Location: 1277 142nd Street New Richmond, WI 54017 (NW 1/4 NW 1/4 36 T30N R1 8W) Torey Pines Lot 13 parr_ral No- 36,30,18, 1113 -----,
1.) Alt BM Description = 5.T. W.�` • r
2.) Bldg sewer length = •— S5' 1
3 ` amount Of cover j0 i'T L... C +V" �� • �S (p • $ Z
J vt�nf.ra slti:
Plan revision Required? [N Yes ;K No S �, �•-�
Use other side for additional information. , NG
SBD -6710 (R.3/97) Date Insepctors Signature Cart. No.
Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7082 ,
r h4consin Madison, WI 53707 Site Address
Departmerit of, Commerce _W/ Y ( IZ T �2 +
Sanitary Permit Number
Sanitary Permit Application Lbo (2_0
In accord with Comm 83.21, Wis. Adm. Code, personal information you provide E _Check if Revision
may be used for secondary purposes Privacy Law, sl5.04(1)(m)
I. Application Information - Please Print All Information State Plan I.D. Number
Property O er's Name cel Number O ZG. - ^ Qt1O 1 3)
RECEIVED
Property Owner's Mailing Address P perty Location
6s F,/ DEC 13 2002 -A U/tk; S,_S T,5 N, E
City, State Zip Code hone Number Number Block Number
ST. CROIX COUNTY
ZONING OFFICE vision Name CSM Number
&A�
II. Type of Building (Check all that apply.) ❑City
❑ 1 or 2 Family Dwelling - Number of Bedrooms ❑ Village
❑ Public /Commercial - Des 'be Use ❑Towns -.
❑ State Owned z9 1 � - Nearest Road
III. Type of Permit: (Check only one box on line A. Num ering is for internal use.) (Complete line B, if applicable.)
A. New 2 ❑Relacement S 3 ❑ Replacement of 6 ❑ Addition to
System Replacement Tank only Existing System
For County use
B ' ❑Check if Sanitary Permit Previously Issued Permit Number Date Issued all
IV Type of POWT System: (Check all that apply. Numbering is for internal use.) — l0�
44W Non - Pressurized In- Ground 21 ❑ Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland
22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line
45 ❑ At -Grade 46 ❑Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑Other
V. Dispersal/Treatm Area Inf ormation:
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade
Required Proposed Rate(Gals. /Days /Sq.Ft.) (Min. /Inch) Elevation
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New Existing
Tanks I Tanks
Septic Holding Tank / to 0 —%
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Pl is Signature MPAIEE Business Phone Number
E " It �. 2zi
Plumber's Address (Str_ge t, City, State, Zip Code)
3) 7- / , to ��`f �,t. Ul svao
VIII. County /De artment Use On I
Disapproved Date Issued Iss ' gent Si tur (No Stamps)
) (App Permit F inclu '
Groundwater /
A pp roved ❑ Owner Given Initial Adverse Surcharge Fee) r-� Y �
Determination
IX. Conditions of Approval/ easony for D' p ov `
rem • � - aQ,�s at 6 tt
Z'� tt
J _ u tta co et (to C -py�- tyy the s to ar less than 8112 x 11 inches in size
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POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity /060 a l ❑ NA
Permit # zO (a 2.0 Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer Z ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ' 4101" ❑ NA
Number of Public Facility Units aNA Pump Tank Capacity a l ZNA
Estimated flow (average) %Dt? gal/day Pump Tank Manufacturer OINA
Design flow (peak), (Estimated x 1.5) S-0 gal/day Pump Manufacturer ONA
Soil Application Rate S g al/day /ftz Pump Model 99'NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit )CNA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L 13 NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD 530 mg /L In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (g eometric me an) 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(s) At least once every:) ear(s) s) (Maximum 3 years) 13 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: 0 yea I)(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: ❑ month(s) ❑ NA ZI year(s)
Inspect pump, pump controls & alarm At least once every: 0 month(s) 13 NA
❑ month(s) ❑ NA
Flush laterals and pressure test At least once every: ❑ year(s)
Other: At least once every: ❑ ye ar(s) (s) ❑ NA
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.
GMW (4/01)
I
Page of
START UP AND OPERATION 4 '
For new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products or rather chemicals
that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are'detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is
properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ 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 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)11)(d)&If1 and 83.5411►, 12► & (31, Wisconsin Administrative Code.
Page Z of Z '
START UP AfYD 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 seryice 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:
)CU 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 - " ' Name
Phone Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name -S-1
C` pri q
Phone Phone
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.5411), (2) & (3), Wisconsin Administrative Code.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity g a l' ❑ NA
Permit # Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA
Number of Public Facility Units ❑ NA Pump Tank Capacity a l ❑ NA
Estimated flow (average) g al/day Pump Tank Manufacturer ❑ NA
Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer ❑ NA
Soil Application Rate allda /fts Pump Model ❑ NA
Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ❑ NA
Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD 530 mg /L ❑ In- Ground (gravity) ❑ In- Ground (pressurized)
Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound
Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
❑ year(s)
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: 0 Yea � j(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: ❑ m )
❑year(s ) ❑ NA
Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA
❑ year(s)
Flush laterals and pressure test At least once every: 13 y ear(s) month(s) ❑ NA
Other: At least once every: ❑ month(s) ❑ 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.
GMW (4/01)
I
ST CROIX COUNTI
SEPTIC TANK MAINTENANCE A -TREEMENT
AND
OWNERSHIP CERTIFICATIO, �1 FORM
Owner/Buyer
Mailing Address _60 a 'Z S7� i
Property Address 1 DL :1 1 a a "! i _ .
( r quired from Planning Department for new 4sonstructiov ---_
City /State % wr /- ��.s�, Parcel Identification Nut ibex y
LEgAL DESCRIPTION t
Property Location %,, r'fk, %., Sec.,,_, T ,�O N -R ._W, Town of
Subdivision d r e 1 f A , Lot # 3
Certified Survey Map # , Volume — , Page #
Warranty Deed # 7 <n f `Z Z - L Volume 26 0 Z- Page # A
Spec house O yes O no Lot lines identi; fable U yes 0 no
SUMM MAIMMANCE
Improper use and maintenance of your septic system could result in its pa tnaturc failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed b1 a licensed pumper. What you put into the system
can affect the fumetion of the septic tank as a treatment stage in the waste dispo A system.
The property owner agrees to submit to St. Croix Zoning Department i certification form, signed by the owner and by a
master plumber, journeyman plumber, restrictedplumber or a licensed pumper ven lying that (1) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if neces iary), the septic tank is less than 1/3 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain th( Private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of N Eituml Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and return rd to the St. Croix County Zoning Office within 30
days of the three year expiration date.
du
SIGNATURE OF APPLY ANT DAT
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my i our) knowledge. 1 (we) am (are) the owner(s) of
the property de cribed abov -by virtue of a warranty deed recorded in Register ; rf Deeds Office.
SIGNATURE OP CANT' � Z //0/07
DATE
• *• * *• Any information that is mis- representedmay result in the sanitary pennii 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 refereno is made in the warranty deer{
i
wisponein Department of Commerce SOIL EVALUATION REPORT Page _J.__ of 3
.Division of Safety and Buildings
in accordance with Comm 85. Wis. Adm. Code
� County -� _ C r UI
Attach complete site plan on paper not less than 812 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 information. a by Date
Personal information You provide may be used for seaorrdary purposes (PrNsw Law. s. 1504 ( (m)). ' ' • &0 (o
Property Owner Property location
• e Govt. Lot ti w 1/4 /V to t f 1 /4 S T �j N R/ E (ore
Property Owner's Mailing Address Lot # I Block # Subd. Name or CSM#
3
City State Zip Code Phone Number ❑ City Vdlage & Nearest Road
/y10
New Construction Use: ® Residential / Number of bedroom . Code derived design flow rate gfYJ / (0e) 0 GPD
❑ Replacement J ❑ Public or commercial - Describe:
Parent material T7 j I - Flood Plain elevation if applicable Y a `- I ` ft.
General comments sXsle ✓ti el-e u . �a d° rf.5' o Gc w rr L, v
and recommendations:
j'1JL 1 2 2002
I Boring # ❑Boring
® Pit Ground surface_elev. 9�' Z6 ft. Depth to limiting factor I t[� 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. 'Eff#1 •Eff#2
I O —tl l 3�2 5i 1 2 . . k rY,�r cS v� 5 g
5i( zalahk_
3 i ry — its OS4
Boring # ❑ Boring
F ®pit Ground surface elev. 99'1U ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft=
in. M unsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 _t 2 - 10 12. 2 n ,o,�►� r r c:S l J 5
2 iZ -2o I 2m I� v-4r- C5.
3 zo -too tb 41 — Si_ 9
75 1L) I F . 4/6 SL 3m3l rrr�i
. 2. �-3 . 2
Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 _< 150 mg/L ' Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature � CST N umber t
Address Date Evaluation Conducted Telephone Number
Property Owner n vc--I{rr" LL C Parcel ID . # Page C._ of
Boring # ❑ Boring JdO od
i Pit Ground surface elev. IL Depth to limiting factor �_ in. Soil Applicatio Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfftz
In. Munsell Qu. Sz cunt color `. Gr. Sz. Sh. •Eff#1 'Eff#2
1 C H Z 13Nr31Z +S' 2 m r c-
Z 12 -2q fir- GS — .5
3 tf -75 to I6 5 d rn
7] Boring
Boring # ❑
❑ Pit Ground surface elev. ft Depth to limiting factor in.
Bail Application Rate
Horizon Depth . Dominant Color Redox Description..., Texture - Structure Consistence Boundary Roots GPD/111
In. Munsell Qu. Sz. Cont color Gr. Sz. Sh. •Eff#1 'Eff#2
T 1
F-1 Boring # ❑ Boring _
❑ Pif Ground surface elev. ft. Depth to limiting factor in.
Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture . Structure Consistence Boundary Roots GPD1ft
in. Munsell Ou. Sz. Cont Color Gr. Sz. Sh. 'Eff #1 'Eff#2
Effluent #1 = BObs > 30 < 220 mg/L and TSS >30 < 150 mg/L Effluent #2 = BOD < 30 mg/I. and TSS < 30 mg/L
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SBD1770 (t07/00)
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• PAGE 3 OF 3
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NAME � � e -s LOT# � j LEGAL DESCRIPTION 41(, 41(, X �� ,S 6 T �t .N.R. X E(or
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BM 1 ELEVATION loo o
BM 1 DESCRIPTION Sap o P c - -Ae-
BM 2 ELEVATION 99, yO
BM 2 DESCRIPTION 2 6e o l I ,p /, Q C
SYSTEM ELEVATION
ALTERNATE ELEVATION .,li
CONTOUR ELEVATION /0 99 O , 9 e a
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SIGNATURE DATE �� °
z07 2E' 162
79M 2. 3Z3
SPECIAL, WARRANTY DEED KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
This Deed, made between, 12/06/2002 11:15AN
AMES INVESTMENTS CORPORATION, BM if
A MR4NESO'TA I.i1r Y ED LIABILITY Co MpANY R&C FEE: 11.00
TRANS FEE: 104.70
COPY FEE:
CERT COPY MM t
Grantor and PAGES: 1
THIS SPACE RESERVEO FOR. REC0R0*u, DATA
CHRISTOPHER L_ HENN,ING AND NICOLE M. N ANO RETU ADDRESS
H _ C SBAND AN WIFE , . --
C7I'&Tit @e,
WITNESSE'TH, That the said Grantors for a valuable
consideration conveys to Grantee(s) the following
described real estate in ST CROIX County, State of Wisconsin:
ACH ON P � A , T OF TORE PINES II IN THE TOWN OF
D ST. CROIX Y, WISCONSIN. 026
-1101-
This IS NOT homestead property.
Together with all and Singular the hereditaments and appurtenances thereunto belonging;
And above named grantors warrant that the title is good, indefeasible in fee simple and free and clear of
encumbrances except any easemtnts, Testrictions and reservations of record, municipal and zoning
ordinances, and will w,arrantand defend same.
Dated: December 3, 2002
(SEAL)
_ . E WODA, MANAG>:R (SEAL)
(SEAL)
(SEAL)
AUTHENTICATION ACKNOWLEDGMENT
S(grteture(s) autbonticattd:
Statt Of WLSCONSIN )
County. ST. CROIX ) SS.
TrrLE: MEMBER STATE BAR OF WIMCON[SN Personally came before me on )
December 3, 2002
.,...._ the above named
THIS INSTRUMENT 7'E
MENT WAS DRAD'BY, JEFF SWODA •' �--, 'c','�•j
River traffey Abstract r ° _ Q t° rson(s) who executed the
Hudson, '%V! 54016 r y forego t asui ackr10w1ed9ed 1he same.
"d 1866 -EE2 SIL HOHQH dirb :Zi 20 60 08a
8 AQftES y \ I Z i I LI ��lr LOT 0
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PROPOSED sERnFlgo - 10p 00
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8 ACRES' K "
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