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HomeMy WebLinkAbout032-1046-40-101Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT (ATTACH TO PERMIT) GENERAL INFORMATION Personal information you provide may be used for secondary purposes [Privacy Law, I.1 04 (1)(m)], Cit 9 e Township Permit Holder's Name: y Chris Dordal TOWN OF SOMERSET CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MAC �A aii� e.�TonlH! IKICnRMATION PUMPISIPHON INFORMATION SOIL ABSORPTION SYSTEM DIMENSIONS •1 Q5� SETBACK SYSTEM TO INFORMATION Type Of System1: � DISTRIBUTION SYSTEM Header/Manifold Fst l Qv I ` Unip f liiiiiiiii INNER CAPACITY 2�-�- Z55 Qi SOIL COVER x Pressure Systems only \ Depth Over � Depth Over ged/Trench Edges � 1% \ Bed/Trench Center,o� 1 (� COMMENTS:GG(include code discrepencies, persons present, etc.) L Location: No Address Available d C 1.) Alt BM Description 2.) Bldg sewer length - amount of cover Plan revision Required? Yes No Gj IZ Jt) Use other side for additional informatiion.\ Date SBD-6710 (R.3/97) ELEVATION DATA STATION Benchmark Alt. BM Bldg. Sewer SUHt Inlet SUHt Outlet Dt Inlet Dt Bottom Header/Man. Dist, Pipe Bot, System Final Grade St Cover /�_ 6 `t *III-LU\hk No. CHAMBER OR UNIT Size I O•� ►o• 47 ,, 05 1 a3.15 xx Mound Or At -Grade Systems Only '� lJ xx Depth of xx SeededlSodded � Mi Topsoil as No IIII William \Inlspection #1: Inspection #2: V Ev\e to Air Intake � 3 S Cert. No. Safety and Buildings Division 1 P.O. Box 7162 Z02� 201 V�: Washington Ave., Fig 21 I Madison) 53707 7162 A r ty C� Sanitary Permit Number (to be ftllrA to rG� �:. i- (j1X i..OUnty. ' - State TIa-nSaetrOn I`1DII1DG1 °u°` lization _ /1 �` ataxy permit App oov Cntal unit diffezent than mailing In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to owmned OWTS are submitted m Project Address a sanitary Permit Note: APPlicatior' forms for state- e used for secondary rovide 1 `',� L//� G /// is required prior to obtaining ! the Department of Safety and Professional Servies. Peisonal information you / T :,, .a> privacy Law, s. 15.04(1) m), Stats. C' A r 2; j��o � roperry vwuo. � ..._-- C zip Code Phone Number ity, state 7 SS C r}% �✓ Lot n, Type of guiidi (check all that apply) �� or 2 Family Dwelling —Number of Bedrooms Block #t ❑ PubliclCommercial —Describe Use CSM Nu/mbe ❑ State Owned — Describe Use W / Permit: (Check only one box on line A. Complete line B if applicabl III. Typ e Treatmnt/H olding Tank Replacement Only A. System ❑ Replacement System ❑ ❑ Chanae of Plumber ❑ Permit Transfer to New g. ❑Permit Renewal ermit Revision Owner Before Expiration �__r, vu that ana1S) - U ;w LLZ Property I.Ocarf011 Is do Govt Lot _--- j ----- Me o N; R �E W TV. T e ofPOW'TS S stemJCom onenvIII � --- Ground � At -Grade ❑Mound > 24 irt, of suitable soiNL�l ln-Ground ❑Pressurized izt ❑ Pretreatrnent ❑ Holding Tank ptber Dispersal Component (explain) ___,rr.o9rroentAreaTnformatio : Dupetsal? �. n;snersalAzeaR u' ed(sf) Deign Flow lgPul VI. Tank info iepuc or iioia>aE •� Rosin$ Chamber VII. Responsibili P1 A, a. 12 Plumbers Address /1 I ipacity in Gallons the State, Zip Total # of crayons units ` r ` �ApProved ❑ Di prov d S �" � Ovyi�rtiiven on for Denial royal IX Conditions of A roval/Reasons for Disapp SYSTEM 0)V�I�IefiR effluent filter and 1, Septic tank, lumber. dispersal cell must he Ian I d d bytp as per management p p o Au setback re uirements Must emaintained a snbi as per Sl3D-6398 (R. ] 1/1]) � ❑ cin' of �rage ofovwmn of ❑ Other Modification to Existing SYsrem (eXPI�) List Previous PennitNrrmber and Date ]slued c Mound,e 24 in. of suitable soil — Manufacwrer l u =_ a. for installation of the POWTS Tho �A the � ched 22 Date Issued Issu � Agent 5rgrraa 3l3 �ZoZ� � n� < • 46 is ayonpapernotlT UOI ,,� 4 1 PROJECT Chris Dordal Soil Test and System PLOT PLAN ADDRESS 8832 Humboldt Ave S. Bloominaton Mn 55431 et NW 1/4 SW i�4S 16 /T 31 N/R 19 W TOwN Som_ e—rs 2/20/20 SYSTEM ELEVATION 99.2/98.8/98.4 4' below grade DATE CONVENTIONAL LIFT CONVENTIONAL %� 1255 gallons LIFT TANK SIZE MOUND _ SEPTIC TANK SIZE 1216 HOLDING TANK SIZE LOAD RATE • 5 ABSORPTION AREA IL BENCHMARK V.R.P. To " pipe ❑ BOREHOLE O WELL *H.R.Pa same as benchmark St. Scale = 1 /4" COUNTY STCROIX. 4 BEDROOM HOLDING TANK DOSE TANK SIZE # of chambers 60 ASSUME ELEVATION 100' Pro 4 Bedroom House 3-3' X 82' cells wi All piping shall be ASTM SDR 30/34, within 10' of tank, piping shall be ASTM 3 Vent Filter Lifetime Filter ({JCOP1f 5% Slope 5' \ Vents10� 101' 103' Property Line >6„ Quicic4 Standard Leaching Chamber of Cover with 20.0 ft2 of Area 2" 5.6ft^2/pair of end caps 4' Long 1 at System Elevation � is ,), 2020 FEB 21 SOI EVALUATION REPORT wiisoorwin Department of Commerce ). Atli Division of Safety and Buildings St in accordance With'do m 85, Wis. Adm, Code CommU paper less than 8 112 x 11 inches in size. Plan must Attach complete site plan on include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. onal information you provide may be used for secondary purposes (Privady Law, s. 15.04 (1) (m))• Property Locati r;;M ly owner / Govt. Lot /V- C` Lot # Block # 0Replacement commentsParent material General System Residential I Number of bedrooms PublicRr commercial - Describe: Boring 4LPit Ground surface elev. ,�,,,t;�,r, �pepth I Dominant I in. Munsell Redox Description Qu. Sz. Cont. Color C'ST—aQc) —(•I r Page of County Parcel LDi ► •� i by fit',Jh&t. 13/3 /242we )114 S 0 T c rt,r1 Name or CSM# vv Village 2 Code derived design flow rate Flood Plain elevation if applicable System n, crest Roads GPD Depth to limiting factor _L--- Texture Structure Consistence Boundary Roots Gr. Sze She n f n /1 ,� ti'41 2 Z' 2� • 'f Z, 8 Vring / �% Depth to limiting factor in. Ong # t Ground surface elev/D ' ft Texture Structure Consistence Boundary Roots Horizon Depth Dominant Color Redox Description Gr. Sze Sh. in. Munsell Qu. Sze Cont. Color • Effluent #1 = BOD. > 30 < 2� �- and TSS >30 <_ 150 CST Name (Please Print) �I Bird Plumbing, Inc. Shaun Bird Address 1432 120th St, New Richmond, WI 5401 •Etf#1 'Eff#2 � lam' 'Eff#1 'Eff#2 ,� l� J 140 ' Effluent #2 = BOD. `_ � �• and TSS < 30 mglL CST Number 226900 Telephone Number Date Evaluation Conducted 715-2464516 Property Owner ❑ Boring # Boring ®.Pit Horizon Depth Dominant in. Munsel Parcel ID # Ground surface elev/� ft Color Redoxf(Cont. ption :[ Qu. Sz. Color r Boring # ❑Boring ❑ Pit Horizon Depth Dominant in. Munsell Depth to limiting factor 4 in. Texture Structure Consistence Boundary Roots Gr. Sz. Sh. % /! �nolication Rate 'Eff#1 'Eff#2 � � L ft, De th to limiting factor �n• Soil Ground surface elev. p olor Redox Description Texture Structure Consistence Boundary Roots 'Eff#1 Qu. Sz. Cont. Color Gr. Sz. Sh. Boring Boring # ❑ Pit Horizon depth TForninant c in, Munsell Ground surface elev. n• Redox Description. Qu. Sz. Cont. Color Depth to limiting factor in. IIIIIIIi Texture Structure Consistence Boundary Roots Gr. Sz. Sh. ' Effluent #1 = BODS > 30 < 220 mglL and TSS >30 < 150 mglL Soil 'Eff#1 ' Effluent #2 = BODS <_ 30 mglL and TSS < 30 mgll. to access Rate 'Eff#2 'Eff#2 The Department of Commnran is mate format, pleaseservice contactphe department at 608-266Y3151eoa TTY 608e2tJ4-8777 services or need matenal PROJECT Chris Dordal NW 1/4 SW 1/4! Soil Test and System PLOT PLAN ADDRESS 8832 Humboldt Ave S. Bloominaton Mn 55431 III liiiiiiiiiiii Oil 16 /T 31 N/R 19 W TOWN Somerset SYSTEM ELEVATION 99.2/98.8/98.4 4' below qrade 2/20/20DATE CONVENTIONAL )00( CONVENTIONAL LIFT 1255 gallons LIFT TANK SIZE MOUND SEPTIC TANK SIZE HOLDING TANK SIZE LOAD RATE • 5 ABSORPTION AREA 1216 BE*HMARK V.R.P. Top of 3/4" pipe ❑ BOREHOLE !� WELL *H,R,P, same as benchmark St. COUNTY ST. CROIX 4 BEDROOM HOLDING TANK DOSE TANK SIZE # of chambers 60 AS ELEVATION 100Filter Lifetime Filter Pro 4 Bedroom House 30 20' 3-3' X 82' cells with >3' spacing 50' All piping shall be ASTM SDR 30/34, within 10' of tank, piping shall be ASTM F891 Vent 0 �,iB-120' 5°Io Slope 5' \ Vents10=\ 101' 103' Property Line >6„ Quicic4 Standard of Leaching Chamber with 20.0 ft2 of Area 5.6ft^2/pair of end caps 4' Long 12 Cover Grade at System Elevation �.Ai� , aoao '_�� -,,,,;; , G-:,`? Safety and Buildings Division 201 W: Washington Ave.; P.O. Box 7162 1 ,� 6 `lQ�Q Madison�l 53� 7-7* 2 11 ���;tv Mary Permit Application m In aceo � ' PS 383.21(2), Wis. Adra Code, submission of this form to the appropriate gov ental unit is required prior to obtaining a sanitary permit Note: Application forms for state-owned POW'I'S are submitted to the Department of Safety and Professional Servies. Personal information you provid be used for secondary oses in actor ee with dte Privac Law, s. 15.04{1) m ,Scats. L A lication formation — I'fease Print All Information Property Owner's e ype of Bu or 2 Family heck all t —Number ok ❑ PubliclCotnntercial —Describe Use O rJ�i ❑ State weed —Describe Use 2 �:ei- CQ,I,L� �J 12�-� G IIt. T rm ( only ne box on line A. ' I�ccv System ❑ eplacement System CC Lot # // �/6g line 1�f a t LJ�' 1 }'(//�� Sanitary Perm%tt NuQmb'er%(�to be fillc;d m by Co.) State Transaction Number address) arcel #i �' "J o l ��� �' ? �� Proqoperty Location �� , � , � 9� 3 3 �- r 1� �� , . '/+, Section (�scle o� lJ Cig� of 61 � ❑ Village of P `s � own of s� G%� ` � C P J �d'ke� � Only ❑Other Modification to Existing System (explain) _'' List Previous Permit Number and Da B. ❑Permit Renewal ❑Permit Re 'on h o be Permit Transfer to New Before Expiration � �F�l a.�" e of PO S S Co onen vice: C all fh 1 on -Pressurized in -Ground ressutiu In -Ground t- e ❑Mound > in. of suitable soil ❑Mound < 24 in. of suitable soil etreatment Device (explain] ❑ Holding Tank ❑Other Dispersal Component (explain) 3 L V. Dis ersallTreat ent Area Informatio Design Flow (gpd) Des Soil Applicati e(gPdsf) Dispersal Atea Required (sf) Dis Area Pro sed (sf) System Elevation VL Tank Info Capacity in Total # of Manufactu Gallons Gallons Units G '_' .,°j New Tanks S T� , '/ ^ ° '� v � � � 1 U m ' in rsa-nr� F��.� VII. Responsibility Stateme I, the undersigned, a e responsibility for installation of the PORTS shown on the attached plans. Plumber's Name (Print) Pl s Signature MP/MPRS Number Business Phone Plumber's A� ess (Str City; State, Zip ` � � �� - � ounty a arhnent Use Only Permit Fee Date sued Issuing. ntSignazure Approved ❑ Di S �� ven Reason for Denial � � ` 1X. Con � easons for Disapproval �� '�` � � � 1. Septic tan ,effluent filter and dispersal cell must be servic; c', / main.lained �, as per managerrlent plan prov,,led by plumber. 2. All setback requirements must b�, maintained as per applicable code/ordiuu:,czs. Attach to complete plans for the system and submit to the County only on paper not less than R r2 z ]1 inches in siu SBA-6398 (R. I1/ll) �p� C� �✓ .° � � R> w v c. 11 System PLOT PLAN PROJECT Chris Dordal ADDRESS 8832 Humboldt Ave S NW 1/ 4 SW 1/ 4 S 16 / T 31 N/R 19 W TOWN Somerset 10010/9916 4' below grade 1 /16/20 SYSTEM ELEVATION DATE CONVENTIONAL %a%( CONVENTIONAL LIFT 1255 gallons LIFT TANK SIZE MOUND SEPTIC TANK SIZE HOLDING TANK SIZE LOAD RATE .R•7 ABSORPTION AREA $91 IL BENCHMARK V.P. Top of NW lot stake ❑ BOREHOLE Q WELL *H.R.P. same as benchmark >5' St. Property Line 36' 24' B-4 Vents 30 18' B-3 3 0' B-2 B-5 Bloominoton Mn 55431 COUNTY ST. CROIX BEDROOM 4 HOLDING TANK DOSE TANK SIZE # of chambers 44 ASSUME ELEVATION 100' 210' 71' B-1 2-3' x 90' cells with >3' spacing 0' All piping shall be ASTM SDR 30/34, within 10' of tank, piping shall be ASTM F891 4°10 Slope 5 0' Vent 30' Filter Lifetime Filter Pro 4 Bedroom House >6„ Quick4 Standard Leaching Chamber of Cover with 20.0 ft2 of Area 5.6ft^2/pair of end caps 4' Long 12' at System Elevation Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 1 /16/20 Owner:Chris Dordal Location: NW 1/4 SW 1/4 S16 T31 N,R19W 2131 40th St. Somerset Manuals Used: In -ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Secti941 4-6. Maintance and CorStigp'ncy Plan 7. Filter Cross Signature�� — s.f License number #226900 System PLOT PLAN PROJECT Chris Dordal ADDRESS 8832 Humboldt Ave S. Bloomington III I Mn 55431 NW 1/4 SW 1 /4 S 16 /T 31 N/R 19 W TOWN Somerset COUNTY ST. CROIX 1 /16/20 BEDROOM 4 SYSTEM ELEVATION 100.0/99.6 4' below grade DATE CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK 1255 gallons LIFT TANK SIZE DOSE TANK SIZE MOUND SEPTIC TANK SIZE LOAD RATE .7 ABSORPTION AREA 891 # of chambers 44 HOLDING TANK SIZE IlkBENCHMARK V.R.P. Top of NW lot stake ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark >5' St. Property Line 36=� 24' B-4 Vents 30' 18' B-3 30' B-2 B-5 210' 71' B-1 2-3' x 90' cells with >3' spacing 0' All piping shall be ASTM SDR 30/34, within 10' of tank, piping shall be ASTM F891 4%Slope 50' Vent 30' Pro 4 Bedroom House >6„ Quick4 Standard Leaching Chamber of Cover with 20.0 ft2 of Area 5.6ft^2/pair of end caps 4' Long 12 at System Elevation Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber 5 002 pair of end plates Typical Installation Vent Grade A/30/34 Septic Tank 5' Long _ Grade at System Elevation Spacing_ 5' System elevations: A 100.0' B 99.6' 3 5' Long To be > I above grade Finish grade elevation 104.0' Went 1" at System Elevation 2-3' X 90' Celts Same on other end Observation tube/Vent At end of cell A B 22 chambers per cell POWTS OWNER'S MANUAL & MANAGEMENT PLAN ILE INFORMATION Owner ,� hPSIr�W POReMFTERS Number of Bedrooms✓ ❑ NA i Number of Public Facility Units �NA j Estimated flow (average) G G al/da I 1 Design flow (peak), (Estimated x 1.5) �� } gal1day i Soil Application Rate ai/da /ftz ,Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (6005) <_220 mg/L ❑ NA Total Suspended Solids (TSS) <_l50 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODs) 530 mg& Total Suspended Solids (TSS) <30 mg/L ❑ NA Fecal Coliform (geometric mean) s104 cfu/100ml iMaximum Effluent Particle Size la in dia. ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. I i Page of l SYSTEM SRECIFICATIONS i Septic Tank Capacity _ S"` al ❑ NA Septic Tank Manufacturer X o ❑ N4 Effluent Filter Manufacturer �� ' ❑ N4 Effluent Filter Model I r' ON' Pump Tank Capacity al ❑ NA' Pump Tank Manufacturer ElN Pump Manufacturer N/,I Pump Model NA' Pretreatment Unit NA� ❑ Sand/Gravel Filter ❑ Peat Filter ❑ Mechanical Aeration ❑ Wetland I. ❑ Disinfection ❑ Other. Dispersal Cell(s) ❑ NAC` ❑ ln-Ground (gravity) ❑ In -Ground (pressurized) ❑ At -Grade ❑ Mound :1 Drip -Line ❑ Other: I Other. ❑ NA!' u Other: ❑ NAIP Other. ❑ NA IAIN7ENANCE SCHEDULE Service Event Service Frequency linspect condition of tank(s) At least once every: ❑ o ts(s) (Maximum 3 years) ❑ NA . (Pump out contents of tank(s) When combined sludge and scum equals one-third (X) of tank volume ❑ NA 1 linspect dispersal oell(s) At least once every: ❑ month(s) Maximum 3 ears) years) ( Y ❑ NA / ❑ month(s) ❑ NA Vean effluent filter At least once every: ( ear(s) p NA ! nspect pump, pump controls & alarm At least once every: Y marts}s) ❑ m NA I:lush laterals and pressure test At least once every: ❑ yeaarr(s))ts) Dther. ❑ month( NA At least once every: ❑ yeaarr(ss)) ether NA.� MAINTENANCE INSTRUCTIONS (Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Macata�r (Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must linclude 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 Dondinq of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the loca' Iegulatory authority. I I,A/tten the combined accumulation of sludge and scum in any tank equals one-third or more of the tank volume, the entire contents of :he tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter KID 113, Wisconsin Administrative Code. INN other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, land any servicing at intervals of 512 months, shall be performed by a certified POVVTS Maintainer. A service report shall be provided to the local regulatory authority %evithin 410 days of completion of any service event. START UP AND OPERATIONor ducts or other chemicals tit For new construction, ptoruse Ofocesss antd/or damage tEie dispersaltce I{ )s} if high conttationps arendete� tied have the contents of tr may impede the treatmentP 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 surfaces es um tanks may fill above normal highwater levels. When power is bar p or surface dischargeed the excess eof effiu6n1t During power outages pump over to Ithfe discharged to the dispersal cells) in one large dose, overloading v tank ysa S tage Servicing Operator prior to restoring p To avoid this situation have the contents of the pump controls to restore normal le Is effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the Pump within the pump tank, the area within Do not drive or park vehicles over tanksand soil ersalrptillls area not drive or park over, or otherwise disturb or compact, 15 feet down slope of any mound or at-g��� and prolong the life of the pOWT: Reduction or elimination of the following from the wastewater stream may improve it,e performance dis'urfectanth; fat foundation �r4 antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; dlaPmedications; oil; painting prod lam; (sump pump) water, fruit and vegetable peelings; gasoline; grease, herbicides; meat scraps; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT shall be taken to insure that the system is Pro ! etlY When the POWTS fails and/or is permanently taken out of service the following steps and safety abandoned in compliance with chapter Comm 83.332 Wisconsin Administrative Code:, isconnected and the abandoned pipe openings sealed. • AN piping to tanks and pits shall be d • The contents of all tanks and pits shall be removed and property disposed of by a Septage Servicing operator. • oved and the void space filled with'sw'I, After pumping, all tanks and pits shall be excavated and removed or their cavern rem 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 i repI ment system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption systeim. e ` replacement area should be protected from disturbance and compaction and he repuld�mentbe rareawiwill result upon bin the need The setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement must comply with the rule:/ in for a new soli and site evaluation to establish a suitable replacement area. Replacement systems effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technotogK 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 evatua>�on O�Splacement area. {f no replacement area is available a holding tank may be install as must be performed to locate a suitableII a last resort to replace the failed P ❑ Mound and at -grade soil absorption systems may be reconstructed in place fallowing removal of the biomat at the infilt, dive surface. Reconstructions of such systems must comply with the rules in effect at that times e<1NARNING» SEPTIC! PUMPAND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANDJOR INSUFFICIENT OXYGEN. DO ENTER A SEPTIC, PUMP OROTHER OR OF A TANK MAYBE NNF UNUCK DIFFICULT OIMPOSSIBLE MT�C . C� MAY RESULT. RESCUE PERSON FROM TH Name 0 Name 1 This dacxmnerrtwas drafted incompliance with chapter 5P5 sns.ielcllu)l � �(d)&{f) and 3836,54(1)1 (2) & (3)1 VUlscw►sW Admin'tstfBtiVe Code. '9 C.� (V a Q Q z ST• CROTX COUNTY SEPTIC TANK MAINTENANCE AGRBPMt NT AND I OWNERSHIP CERTIFICATION FORM: ' W►e It1: LIty/State 5�0 .�,� w sr LJ 1 Parcel Identification Nlunber ��AX. DESC�tXpT'ION Property Location Av w r, 1 5 %% 1/41 Sec. _L, T JLN RILW, TOM of )0M P ls e-t subdivision _ G .5 /�) ,Lot # Certified Survey Map # `o ftZL Volurae �G J Page # L �7 S1ZL Warranty Deed # , Volume , Page # Spec house yea no Lot ]in% Ideatifiable yea no 6YSTEM MAINTENANCE ANI? OWNER CERTIFfCATION 11� I• 1 / � 1 • . 1 II • • I A I •Ir: • • • /1 . .• f Elm • • 1• amintensnre consists of pumping mntbc septic tankevmythrecycars affect 11• 1• 1 1 thesepticas a treatment cage • • sooner, 1. • . IM•• II: I.1• •. I rea•11. ••1system 1•,.•§Cornm and 12 St • I County Sanitary OTdinan". 7U property SL • i • 1 / • signed master I • 11• /• : 1 I agrees to suball't 1 CroixCounty11 I- • plumber • Zoning Planning• 1 111•verifying 1 :the on -site y a owner 1 and . 1I •H • 1 • • .: • • .11I • I Y 1 proper ► • :I •11 • • 1 1 • • 1and/orjaspcedon and 1 1 /1 • 1 • accessary), theseptictank . _A 1.1 of Mudge. with the I agree to maintain private sewage disposal 1 _ undersigned I I • 1 • • 1 11 . •: 11 / ••I/ Iw 1•:• Il�f1 above i•. •11 1, 11/., l/ 1 • .. • • • / :I►• •, III• 1. 1 11 11 1. /""1 /1: r i' 1 11 /' VIM 7 // •1 /''1 1 1 1 • 11 • t/ ••1. 1"/:•IN ••vAthin tdays /the three year expiration date. Uwe certify that all stabernenb on this form are true to the best of my/our k.aowledgc. Uwe atn/aro the ownrt(s) of the property described above, by virtue of a wariartty deed rewrded in Register of Dcelis Office. Number of bedrooms .• i . I wAa&wIth this :11 M I►1 . • I lilwwoty 1:'► 1111 the Register of Deeds11 .11 : Copy OL ACV M 1 is made1 tho warrmty •..• (RE!V'. 08l05) DATE Scanned with CamScanner rr u } m m LOZ qd 31310 O o N 6O12J390130 jo3pO21d SSD�mMJOJ 3Hl 0 0 a 0 0 0 e � o p C � �r Q > W b W= F— o Z O" � n dIZ '31ViS 'AJ 2f38N1N'3NVN 13R1S 3SflOHWbdd N21900N =w Q J � W i Z �n In z i�aroa�a 1 O SS3ll1HQ� N �yN U N o zo 'o �r °s t2. 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Labor and Human Relations Divib.on of Safety & Buildings in accord with ILHR 83,05, Wis. Adm. Code FPARCEL Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but I.D. # not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or �,) dimensioned, north arrow, and location and distance to nearest road. REV W BY DATE APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION J PROPER OWNER: ` PROPERTY LOCATION " � %� GOUT. LOT 1/4 1/4,S T % AR C (orj�V LOT # BLOC # SUBD. NAME CSM # [PROPERTY OWNEFP:S MA LI ADDRESS CITY VILLAGE �jiOWN NEARES ROqD CITY STATE ZIP CODE PHONE NUMBER ❑ ���`/S '600 D(1 New Construction Use �f Residential / Number of bedrooms ( 1 Addition to existi g building 1 Replacement [ 1 Public or commercial describe Code derived daily flowgpd Recommended design loading rate c bed, gpd/ft2.,.o trench, gpd/ft2 Absorption area required 45 bed, ft2 . 4� trench, ft2 Maximum design loading rate _bed, gpd/ft2 , , trench, gpolft2 as referred to site plan benchmark) Recommended infiltration surface elevation(s) �%9' 7 ft ( Additional design / site considerations ft Parent material Flood plain elevation, if applicable S =Suitable for U =Unsuitable Ground elev. ft. Depth to limiting factor Boring # Ground elev. VD PRESSURE ❑U AT -GRADE �S ❑U SOIL DESCRIPTION REPORT Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft ged Trench Depth Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.374 tl �jD Z Remarks: �. .7� Remarks: PROPERTY OWNER �� . iJ6/ �� SOIL DESCRIPTION REPORT PARCEL I.D. # Page of Boring # Ground elev. lJpMF4l ft. Depth to limiting fact Dominant Color Mottfes Texture Structure Consistence Boundary G P D/ft Roots Bed Trench Depth Horizon in. Munsell Qua Sz. Cont. Color Gr. Sz. Sh. U200 Ground elev, ft, Depth to limiting factor Boring # Ground elev. /a�ft. Depth to limiting fact Boring # Ground eIev. ft. Depth to limiting factor Remarks: / _3 Remarks: II S�f Remarks: Remarks: SBD-8330(R.05/92) Remarks: SBD-8330(R.05/92) tr/ d_�%.J�/7/ I ST if gL 000 1083007 BETH PABST DEEDSREGISTER OF I I00 00 ST CROIXCO.WI loin I � � COMA FOR RECORD m �q Ia 06/13/2019 12:43 PM CERTIFIED SURVEY MAP (L011" 9 I I o d l VOLUME: 29 651 C.� �G�i/ L VO , Qg C�C_2269 07 R Im PAGE: 30. — EC FEE: 30.00 _ PAGES: 2 --N00038'47"W 2701.93'-- - 40TH STREET w " 47 ' Noo�3843198' N03847W 33tw) rn w - m 127,98' 210.00 2363,95' w 37.99' m N00°59'02"W 3 FD 72o 127.96' Gin in ©X( z0 (210000?) 4'm — I v mO O'rl 0n 0N -n 57 i o m n O F') F) O m A t�i� 1J D ---� O o m D G7 vCi m OC M A m y m VV Y.II ^ 1 0l O � Z Z Rl ..� -i i0 m m N to O D' y `G lD O ---1 JC S N C OO O> wo � m m W - m � p AO 0 Oz z Z Nr� o o off' U O +p ZCNCO �C v Noz < n r I� ��� -vc-' Z� n �� a �. n p wr� mo m n n n � C 'S O < D co a _— m m e m m O p p < Z < O n< r Gl r W m m N00'38'47"W 210,00, a O m r 004 cn `L Y O ti m0, O I Z O9 O ri COO) m Z 0 _ � m memmuds v I I my 0 IOUO I rn au m O0 A V N O w m m D +'_ -ml --I o © D p NnG N m y o w O0 m 11 N o O m I z N m �� C O_ rn JO Z m Y rn N ~ A m C O N m n n v CC N v' O 0 N0000000 (� C Z � , ■ l CC))Z Z Loop UP mil/ /� Z m � ;U 77D7 I`.. IJI C) :� N y O ornicn n' o tm7 Oka _ s _=Z r- m ^i cn rn Sti, , �-�'i� wm O l0 1l N O - G N♦ 0 G C O O 0 TJ O v z z S00038'47"E 336.83' p m v m O o p (S02°30'43"E 337.20') to -�.� C — UNP /,a51 II D D L1,CVI`�1DS Q A I �� � c m THE EAST WEST 1/4 LINE OF SECTION z o / m z 16 BEARS S89007'44"E BASED UPON z o z THE ST. CROIX COUNTY COORDINATE � SYSTEM SHEET 1 OF 2 &19 - (OtC� 51 St, Croix County 1083007 Page 1 of 2 Document Number State Bar of Wisconsin Form 7-2003 TRUSTEE'S DEED Docwnem Namc THIS DEED, made between Sara H. Weiner as Trustee of the Sara H. Weiner Revocable Trust u/a/d 6/30/2011 ("Grantor," whether one or more), and Christopher J. Dordat ("Grantee," whether one or more). Grantor conveys to Grantee, without warranty, the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): That part of the NW 1/4 of the SW 1/4 of Section 16, Township 31 North, Range 15 West, Town of Somerset, St. Croix County, Wisconsin, including Lot I of Certified Survey Map recorded in Volume 10, page 2755, as Document No. 516370, described as follows: Lot I of Certified Sutvey Map recorded in Volume 29 of Certified Survey Maps, page 6651, as Document No. 1083007. Sara I-1. Weiner, u'ustee of the Sara H. Weiner Revocable Living Ttvst u/a/d G/30/2011I in executing this instrument, certifies and affirms ilia she is the duly appointed trustee of the Sara H. Weiner Revocable Living Trust u/a/d 6/30/2011 and that she has authority to execute this instrument on behalf of the trust. Dated (SEAL) ®1" INN t * Sara H. Weiner, * (SEAL) AUTH"TICATION -:>_ - Signature(s) authenticated on I < J...:si * TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by Wis. Stat. § 706606) THLS INSTRUMENT DRAFTED BY: Stephen Nash (license 44151567) tbo The Title Group Inc 3200 Main St. NW #280, Coon Rapids, MN 55448 REGISTER OF DEEDS IN CROIX CO., WI RECEIVED FOR RECORD 01/17/2020 09:10 AM EXEMPT#: REC FEE 30.00 TRANS FEE 201.60 PAGES: 1 **The above recording information verifies that this document has been electronically recorded & returned to the submitter Recording Area Name and Retunr Address The Title Group, Ina 3200 Main St, IN NY N280 Coon Rapids, MN 55448 032-iO4b-40-100 Parcel Identification Number (P[N) (SEAL) ACKNOWLEDGMENT STATE OF ►I 1 �`'1�i�_Sc2��- ) ) ss. 1 �/1 COUNTY ) Personally came before me on� (� ( (C1 ©01 the above-namedaWeiner, Trustee of the Sara H. Weiner Revocable Trust u/a/d 6/30/2011 C u to me known to b?) the person(s) who executed the foregoing Fi Notary Public, State of My Commission (is permanent) (expires: OI/31/2020 (Signatures Wray he authenticated or acknowledged. Both are not necessary.) NOTE: THIS [S A STANDARD FOithi. ANY MODIFICATIONS TO THIS FORI4i SHOULD BE CLEARLY tDENTIFIED. TRUSTEE'S DEED ®2D03 STATE IIAR OF WISCONSIN FORM N0.7-2003 * WE name below signatures. St. Croix County 1095740 Page 1 of 1