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030-1093-10-400
i Mcorisin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix c SafA d Build ty ^ing Division � Sanitary Permit No: :- INSPECTION REPORT 515263 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1) (m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Haver) , Jason & Lisa I St. Joseph, Town of 030 - 1093 - 10-400 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range/Map No: 1 � �5 32.30.19.340630 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 5k4 •t z jZ 5 � Benchmark J , 4M. J Alt. BM Aeration Bldg. S er Holding St/Ht Inlet S$ TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 7�6 x /� �� ., /,� } Dt Bottom .` Dosing /�/� cx, Header /Man. ( 1 1 - - 5 46 Aeration Dist. Pipe 4 ?. Holding Bot. System Final Grad PUMP /SIPHON INFORMATION M 6 3 , -`Z •a Manufacturer Demand St Cover� GPM f-'f �1f�ca. �+0 l ► / T' Model Num 7 q JAS TDH Li Friction Loss S ead TDH r� � $ f Forcemain Leng ffi Dia. Dist. to Well I Z - Q 3 - � SOIL ABSORPTION SYSTEM -T x' # - !J 14 BEDITRENCH Width Leng No rench / PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 . T ew�1 / . Q/\ , SETBACK SYSTEM TO P/L BLDG WELL - J LAKE /STREAM LEACHING Manufacturer:. - �,� l / INFORMATION CHAMBER OR P'7a►t" TYpe f % Y (f �kl ►r 75 CJ �� ��-- —,76 Model N ele 4 f DISTRIBUTION SYSTEM J /umb 4- J /5.. , Header /Manifold / / Distribution x Hole Size Spacing Ve x Hole n tak T t to Air In J Pipe \ � � ✓ (`� Length - Dia Length Dia Spacing SOIL COVE x Pressure Systems Only xx Mound Or At - Grade Systems Only Sodded xx Mulched Bed/Trench Topsoil Depth Over ` Depth Over xx Depth of xx Seeded / Center �✓ Bed/Trench Edges �� �• r `ACS Efl No `�„`Ses No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: J J Inspection #2: / Location: 477 Perch Lake Rd. HHudso , WI 016 (NE 1/ NE 1/4 32 T30N R199W) NA Lot 3 Parcel No: 32.30.19.340630 1.) Alt BM Description = r � � `+^ Gtr C4. IP . r- 2.) Bldg sewer length = Cl Z G W �t►�a,! - amount of cover 4/ ,J 7 al ,n4wte_ Plan revision Required? Yes No Use other side for additional information. SBD -6710 (R.3197) Date Insepctor's S nature Cert. No. --,- � �, T � ". 4 r - commerceml.gov Safety and Buildings Division Coun M � a 201 W. Washington Ave., P.O. Box 7162 5� j /' , o . x sco n s n Madison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce 15 Z Sanitary Permit Applicatiou.-1.0, Sta Transaction Number In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the app 1 !q/' ` unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing addre$s) submitted to the Department of Commerce. Personal informati you ondary 77 P�,cc Lt h - A l�! rcl p urposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. /� I. Application Information - Please Print All Informatio Property O Name Parcel # 5 r QS461 MAY 17 2010 o 3,6 _1 0 13 -10- Yo0 Property Owner's Mailing Address ST. CROIX COUNTY Property Location 14 �� Oak �- f PLANNING & ZONING OFFICE Govt. Lot City, State Zip Code Phone Number / 1 A , It/ L y,, Section ?j Z_ P e d s A N L&., . ; 'yo 117% ; L 1 - t9 / d 3 ircle one) II. Type of Building (check all that apply) Lot # T _ 3 (� _ N; R f 7 E or W Subdivision Name TI or 2 Family Dwelling - Number of Bedrooms v U 1 /5, Block# ❑ Public /Commercial - Describe se �~ ❑ City of ❑ State Owned - Describe Use CSM Nu j t ❑ Village of / - T e3 a ! ` Town of 5Y. III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. IKL El Re Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) vv999 ___ New System Y P Y g P Y g Y ( P ) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumberl ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV Type of POWTS System/Component/Device: Check all t hat app Non- Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in, of suitable soil ❑ Mound < 24 in. of suitable soil �t El Holding Tank ❑ Other Dispersal Component (e - — flFie rea lain) A-3 V. Dis ersalffreatment Area Informatio : 3 'X i00 Design Flow (gpd) Design Soil Application f) System fl i va er6ry VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units New Tanks Existing Tanks I o a BF3 mid E U is U P. eptic o Holding Tank Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. ,7� ber Name (Print J � Plumber's Signature / M P Number Business Phone Number < /6�'s a. (��s e%z I WZ Zvzl Plumber's Address (Street, City, State, Zip Code) VII ount /De artment Use Onl Permit Fee Date Issued Ise Disapproved 'ng Agent S gnatu i S S &',V � $ IlU �/ � 1 tMti VV ta nk , a*f0kk*&*aeon for Depi I . (7 J • �/ •Zy 20 0 ( j L��/Y!/� �gpaditw s w" O al 1LQ as per management plan provided y p u ���_ 2. All setback requirements must be maintained ! f �� S j as per applicable code /ordinances. Y � r � s�Z�� ` Attach to complete plans for the system and submit to the County only on pa er not I - ss than 1/2 x 1I inc in siz SBD -6398 (R. 02/09) Valid thru 02/11 v W ' q Nil n 4 t P / A '.p N A El 0 � o r � CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: �Q ,So,✓ l7a V F.e1+, Owner's Name: Qajo A'. 1�d vf,G1y Owner's Address: f� Z Lc 04 k S { / L► �SG N, I/li J Legal Description: /l��_ LAG ���. 3 Z _T Zo N /�! q L Township: - r r County: Sf• 4!A_ Subdivision Name: Lot Number: 3 Parcel ID Number: Q 3 ' /a '- Va o Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross - Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenanc Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer /Plumber: f - License Number: 2-2-2-977- Date: J -/ to Phone Number tF7L- 2V Z/ Signature Designed pursuant to the In- Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD- 10705-P (N.01/01). Page 1 i S ll Absorption S}�s gm Cross Section ft wiz � ft 4" Schedule 40 PVC Vent Pipe With Vent Cap �� Leaching _ W,Y , Chamber System Elevation J' ft S ft S ft n/V T&,-7 Soil Absorption SVAtem Plan View (� (9 0 ft 3 ft . i s ft Leaching Trench 7 Chambers 4" Dia. Trench 2 Header Vent Or Observation Pipe wa Trench 3 Leachina Chamber Sgeclficatlons Manufacturer And Model G�i.� ,`CK r EISA Rating Zv. y sq ft per chamber Soil Application Rate - - 7 gpd /sq ft j v U gpd Design Flow + I _ Soil Application Rate + 2 0 - 0 EISA = 3 Chambers 3 rows of chambers each. Page of Ci G c C`I N of c , . � � I A VIP h cY y � c _ n I Wisconsin Department of Commerce SOIL EVALUATION REPORT Page / of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County �-t� X Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Q - /0 , 73 - D -!400 Please print all information. viewed b Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property 0w J ) rty Location ASv� v�iC/ T r[313city Lot /V£ 1/4�£ 1/4 S 3 L- T 3 U N R 9 E (or)6? Property Owner's Mailing Address ► % Block # Subd. Name or CSM# y z cp 0A 0 - f -. d-TM / a '/ /� " City State Zip Code Phone Number ❑ Village ® Town Nearest Road l kdSaAv �. J'VO /4 ( ?/� ) 9 -, 6 10 3 ti' . -:J' r /I! Rd ew Construction Use: Residential / Number of bedrooms Code derived design flow rate (p00 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft. General comments : �� , j�t.£•.�GLt ' f — 9�. t/ ,c'�I l� 9 , y f and recommendations: 57 tom-^ 7 _:31t 2 3 3 / 3 2 90 7' Boring # ❑Boring > 9,3 Pit Ground surface elev. 9Z ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDffF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 l - /a I 0`1,G S6< to G 03 P:1 Boring # ❑ Boring p a Pit Ground surface elev. ft. Depth to limiting factor 9 � in. Soil Aeplication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Q s .1 - Z .3 - 3 U x /Y .- Sid I 1s 6 /t QS / -L -3 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 N lease Print) Signature CST Number E w S ZLZ877- Address Date Evaluation Conducted Telephone Number Yb?J - 3 Y - /O Y72- - Z ) / Property Owner Parcel ID # Page a of F-51 Boring # El Boring ® pit Ground surface elev. 0 . 7 ft. Depth to limiting factor > 9 S 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 / ° ' /O !U .c %a.- S.' K .�..� v *•c,. Q S ate•- - Z - • 3 lG - Z D l c Si C 1 / 7 1 ' Z • ,3 3 3a �eo 's6K / ✓-�' . - Y . ' 7 / Z Boring # 0 Boring s� Q [� pit Ground surface elev. y 7 !J ft. Depth to limiting factor �7 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 I *Eff#2 25" f / �� 1C iii ✓ /L Q S �rn �' 3 a -3r o �y�� s•'c J��-6�' �.� as -�' • Z- . 3 9 -6 7.5'?1-Y�4 �' o s ..,.� w '1 !. 2- S L - 7 s��y�y S o s �.-,1 -- 7 4 Boring ❑ Boring # Ground surface elev. ft. Depth to limiting factor in. Pit 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 * Effluent #1 = BOD > 30 220 mg/L and TSS >30 150 mg /L * Effluent #2 = BOD i 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 - - ► ,� R TY 0 L j cl a M a Ll co h Z Cl 0 �1 It N ./ -lz a b r N N N 0 IS ^t � � n INGROUND SOIL ABSORPTION MANAGEMENT PLAN PURSUANT TO COMM. 83.54, WIS. ADM. CODE General This system shall be operated in accordance with Comm,82 -84 Wis Adm. Code and shall be maintained in accordance with its component manual [in- ground Absorption Component Manual for POWTS Version 2.0 SBD- 10705 -P (n,01/01) and SSWMP publication 9.6 (01/81) and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic tank or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm. 83.33, Wis Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed and watertight upon the completion of service. Any opening deemed unsound ,defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis Adm Code. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of the triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maxium scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Dept. of Commerce. Pump Tank The pump tank shall be inspected at once every 3 years. All switches, alarms and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Soil Absorption System No trees or shrubs should be planted on the absorption area. Plantings may be made away from the cell's perimeter, and the area shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration, Traffic (other than foot or for vegetative maintenance) on the area is not recommended since soil compaction may hinder aeration of the infiltrative surface within the system and snow compaction in the winter will promote frost penetration. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 4 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component shall be immediately repaired of replaced with a component of the same or equal performance, If the dispersal area fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by biologically clogged absorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. Replacement in a suitable area nearby is also an option at which point a diversion valve will be installed between the old and new systems to allow dispersal cell rotation at a schedule to be determined at the time of cell replacement. r rN c a o l7 �wQO� L- _ v L D — p a Y' U Of O waw3.4q �S a l�+ a C N to w Q 4 w 7 V LIM Zi is . N ro as w ti 0 4 5 .ve4 io O.N. Via a �O a vow L sx la d "d Q`� VT aav S W 5 a 0 a in s o A © v ¢ a T u vi m G- CD �I �m E rm� Y.ae �H= aQ'z�ai " a a O dq�e � i o I ®rg V ... o ,s 1 -6 M o c cz a 3L .. st v 1 OL CL `3 0 a 3w c ? YS s > 1 of L- " a. O O _ 3 L4 1 t �a C F' :. E ad+m m 1 v Q c d 3 1; o Q s z 1 gig. a fl, a ffi a a w� 1 jd f.J O fp R � a a� C 1 N � 1 � 1 cFt e0 T, ■ 0 u aa _ = 0 £ m 1 IL 44 v u N w� VI N V h C ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CER FORM Owner /Buyer Q OL '76 r-� o't/�•Cf Mailing Address Y LL Oa K 5 f-t ci Property Address y �fR ch �- a �L ��1 77 jo A2_ (Verification required from Planning & Zoning Department for new construction.) VQ City /State / �SOti �!! - Parcel Identification Number G 3 U - 10 7,3 - w - V}o O LEGAL DESCRIPTION Property Location /V L E '/4 , /�' £ ' /4 , Sec. 3 , T 3 0 N R I e ! W, Town of J D •SF Subdivision Plat: p v , Lot # _3 d �o l 6�Zof 2 - ° o l J� Certified Survey Map # ,Volume ,Page # Warranty Deed # _ l 12 761 "31 y / Z0 (before 2007)Volume , Page # Spec house yesVno Lot lines identifiable&es i 7 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 maintepance 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. I /we am /are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. P ert Number of bedrooms 4/ j n SiGNMITURE OF APPL T(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** i 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) I POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Q Sa✓ au r Septic Tank Capacity I Z SO a l ❑ NA Permit # �/y 2� Septic Tank Manufacturer s ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model aFlo ❑ NA Number of Public Facility Units 2"NA Pump Tank Capacity a l [-IA Estimated flow (average) l O g al /day Pump Tank Manufacturer 13-NA Design flow (peak), (Estimated x 1.5) 4L}U U g al/day Pump Manufacturer g'NA Soil Application Rate - 7 al /da /ftz Pump Model L]- A Standard Influent /Effluent Quality Monthly average* Pretreatment Unit A Fats, Oil & Grease IFOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ETA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Othe Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L J kLIn- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L &NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. 9151A Other: ❑ NA Other: "A 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: 3 ❑ month(s) (Maximum 3 years) ❑ NA IZ year(s) Pump out contents of tank(s) When combined sludge and scum equals one -third %) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA _- year(s) months) Clean effluent filter At least once every: f ❑ year(s) ❑ NA Inspect pump, pump controls &alarm At least once every: ❑ month(s) E3 NA 0year(s) Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA Z fTyear(s) Other: At least once every: p m onth(s) E3 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) /Vza, ":* 917337 cA;4sinDepartmentofCommer SOIL EVALUATION REP Page 1 of 3 Div�i3*n of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County S 7-� Attach complete site plan on paper notless than 8 1/2 x 11 inches in size. Plan must Include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. view Date )a Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location - M - �)MZS Rk)b ': SUhJ �� GGIA -W i`lEE 1/4 A3e 1/4 S T . N R 19 E (or W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# I Lj L-D Csr'4 City State Zip Code Phone Number ❑City ❑ Village ® Town Nearest Road TQiZTUE Ltd ).-V i I SqtJ9 I (-) IS) 2.S - b S o 3 I NCH 21 New Construction use: 2 Residential / Number of bedrooms 7 Code derived design flow rate GPD C3 Replacement E3 Public or commercial - Describe: Parent material GAL f'ce.t Pr(- 0 Flood Plain elevation if applicable General comments and recommendations: p r 8 0 - MM 1 C) V- ❑ Boring Boring # Pit Ground surface elev. 23 • 'J ft. Depth to limiting factor l 0 in. 9 77 � SoiV lion Rate Horizon Depth Dominant Color Redox Description I Texture I Structure I Consistence 8ouitdAry Dots . �•.(JPD /ftz in. Munsell ` Qu. Sz. Cont. Color Gr. Sz. Sh. ~ 1 - Eff#2 0 -9 z`Fsb� wt cS , s . e Z 0 - q )D`!2 3 - si1 Zwt �tp -lo � S`�1t31y - S�bl- O S4 m � - .� 1.•Z 133 B / ❑ Boring # ❑ Boring 1 ® pit Ground surface elev. ' ft Depth to limiting factor 7 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 tJ -10 t0`l4Z 3! Z - SH Z-fs M'ff - 0-S- 2 fib- b l 2 31 — Si I - LM S bk M, 0-, 66 -1 lt - 1.S`12 A 7 t dbc' 0 S9 1M if Effluent #1 = SOD, > 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) Yignatu CST Number Arthur L. Wegerer 01 -85 -.3 220254 Address W e g e r e r Soil Testing & Design Service Date Evaluation Conducted Telephone Number 421 N. 1-lain St. River Falls, WI 54022 x/_19 =0J 715 -425 -0165 - Property Owner ��1ti1 1't_t,�Z Parcel ID # p'� N G page Z of - 3 Boring # ❑ Boring ® Pit Ground surface elev. 1W4. S ft. Depth to limiting factor 12Jq in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure ucture Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz, Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 c� tp�t 3lZ si 1 c'sb m`F c --s ', Z 4 -� I�`12 � sit Zh,sbh m�'►- c_1,�., -S -�3 _ 2t) `1- S`l23�y SGT- O ❑ 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/ft In. Munsell Qu. Si. Cont. Color Gr. Sz. Sh. 'Eff#1 "Eff#2 n Boring # ❑ Boring L_J ❑ 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 /ft= In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2 Effluent #1 - BOD > 30 < 220 m /L > < a 9 and TSS 30 150 mgfl. Effluent - _ nt #2 - BOD < 30 mg /L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service rovider and employer, If P ou nee Y d assistance to access services or need material in an alternate format please contact the department P p nt at 608 -266 -3151 or TTY 608- 264 -8777. S13D -1330 (R.6J00) Il i I I PLOT PLAIT Page of 3 Scale 1 CLC RM CI Z 1 L►J LT 11R�. f��j � I $,l I lRDra P1PN` - lob - � 101�.p' (3N 1'l)� PVC PLPE C�ft -s . - - <tiL) -- K i �- l� -p� 715 - 425 -0165 220254 � CST Signature Date Telephone No. CST No. Job PTO. P"arcel #: 030 - 1093x0 -400 03!0112005 07:33 AM ST, CROIX AGE 1 OF 1 Alt, Parcel 6..,+ 0 W'qp I F SAINT JOSEPH Current' " ' _ -'`� `ST'CR NTY, WISCONSIN ZO I G � �F Q ,,F.„I,� Creati 13�!t "• #• Sales Area Ap X C�(JOW" N NM T CENTER 0 Tax Ad dies _ . - Owner(s): Hudson,g4OtI ®f0 JAMES L & DEBORAH G JUNKER * JUNKgPl1 386 - 4686 $;}1 tg��ESi) 487 PERCH LAKE RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description ' 477 PERCH LAKE RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: 4.682 Plat: 1294 -CSM 15/4111 SEC 32 T30N R19W NE NE SE N BEING LOT 3 Block/Condo Bldg: LOT 3 CSM 15/4111 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 32- 30N -19W NE NE Notes: Parcel History: Date Doc # Vol /Page Type 06/15/2001 648350 1660/341 QC 03/10/2000 619517 1495/154 QC 07/23/1997 1204/389 QC 07/23/1997 1198/386 CC mo ... 2004 SUMMARY Bill #: Fair Market Value Assessed with: 5558 84,400 Valuations Last Changed: 07/08/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.680 83,000 0 83,000 NO Totals for 2004: General Property 4.680 83,000 0 83,000 Woodland 0.000 0 0 Totals for 2003: General Property 4.680 48,800 0 48,800 Woodland 0.000 0 0 Lottery Credit Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ",E!? 848$81 AUG 9 200 6 JUN 2 0 29001 ~ 3 2 I �r > 4 S oo,.vA L � I?P'S fife c r iNVEY MJ%iil�" LOCATED IN PART OF THE NE1 /4 OF THE NE1 /4 AND PART OF THE $w1/4 OF THE NE1 /4 OF SECTION 32, T30N, R1 9W, TOWN OF ST. JOSEPH, ST. CROIX COUNTY, WISCONSIN. CURVE DATA TABLE (ALL LENGTHS ARE IN FEED OWNER Curve Radius Central Chord Chord Arc Tangent Bearing JENNIFER HALLET Number Length Angle Bearing Length Length Tangent in Tangent out C1 5789.58 00 0 10 1 01" N75°23'07.5 "W 16.87 16.87 S75 °1 8'07 "E S75 0 28 1 08 "E PREPARED FOR' C2 202.50 58 0 47 1 37" N34 0 21'48.5 "E 198.80 207.79 N04 °58'00"E N63 0 45'37 "E 1416 --3 3 1 JIM C3 5639.58 00 °16'26" N76 °1 7'29"W 26.96 26.96 N76 °25 N76 6"W 1 /'/2 2 S TREET S TURTLE LAKE, WI 54889 04 169.50 85 0 4744" N47 °51'52 "E 230.75 253.81 N04 0 58'00 "E S89 0 14'16 "E C5 396.00 30 °4938" N75°20'55 "E 210.50 213.06 S89 °14'1 8 "E N59 °56'06 "E SCALE IN FEET 1"= 200 M(� RACUTCED LAHnD 200 0 200 O �a_IED@_vO_4NG_[3__. N1/4 COR. NORTH LINE OF THE NE1 /4 `- w Z SEC. 3 N8 °5 7 _� E52 N N69 ° 5736 ° E 76 _ / �� NE CO R. 1893.16' r 271.16'— - - — 338.13 160.07' EC. 32 U " S8 ° 14' 16 "E 14.61' O 'C N R U N01 E /'— 186.70' 127.91' — w. 36.49'/ a� Z ' t /� w W ...... ........ i� w W in f 64 ACRES .49 ACRES d 6 ¢ X O a i O.H.W.M. 818.4 w t o POND III m u.. a � :��I w cv Q O '� : OT 4 0 Z Z) Io L 3 7. 90 ACRES co 321, 5 SQ. FT.) INC. RAW to u) ui ( Q ���i r"''`0) 4.682QCRES O % 7.063 ACRES 00 m� cv o n a , _ 11' 11 (203,942 SQ. INC. R/W . i j7,646 SQ. FT.) EXC. R/W � O C5 °• a N o 3.991 ACRE_ o o ; , - (173,848 SQ. FT.) EXC. RND a a,� o I Q o r RJ; i C. i 33.04' : 442.70' m 1 W y ,°� o o ©; Iii i * N87 °4748 W 475.74' o (� �� M W LOT 2 ° �' �' Q e cm no, S' V N 2 �8 d: '�° Cat 1 5� v o�0 4.133 ACRES BENCH MARK: TOP OF -� �� CL g° [o, i N IRON PIPE, ELEVATION Q v i I H� a Z ^ 3.815 ACRES (t 80,041 SQ. FT.) INC. RAN 831.4 Z o N N c �� i �, i ►. (166,201 SO. FT.) EXC. RAJ U -' A' ' • o �} ro 5 j �i �'i .Z N85 °02'00"W X02 '(2" i oo a o i W i 6 17.0ot ��\ ,Nd 6�9 a ; c+i .66 66' JOINT N IVEWAY EASEMENT 88 S o �� CD NOTE: f d 328.35' ,` i O aj LOTS MAY BE SUBJECT co 9 0 53 1 52 "W 378.55' ✓ I y �� TO FUTURE SPECIAL �? ASSESSMENTS FOR ANY ,� L ' UPGRADES AND - -- � IMPROVEMENTS TO THE I Swc,)l ' & 9 LOT 1 ROAD. o co cy x'01 11.452 ACRES W o (498,840 SQ. FT.) INC. RAJ ^ Z Z 9.879 ACRES W (430,320 SO. FT.) EXC. RAN O Z SOUTH LINE OF THt' • - • • .. , -j .El /4 OF THE NEi /4 c N7 �D 42„w �$.`6• 13 O N89°51'10"W 642.60' ,+ LE .. EN - 4? G D � IN FOUND ALUMINUM COUNTY �.. '� _ r T q \ ` ?8 �• ' "�. ' SECTION CORNER MONUMENT FOUND 11 IRON PIPE j wQt5Q O SET 1" X 24" IRON PIPE, WEIGHING 1.13 LBS: PER LINEAR FOOT • • . • • • • • • • • • • • • ROADWAY SETBACK LINE (100' FROM RIGHT -OF -WAY) — --- — 75' SETBACK FROM THE ORDINARY HIGH WATER MARK (O.H.W.M.)� ~ cf) co ,-- PROPOSED DRIVEWAY : (0 EXISTING FENCE r 1/4 COR. THIS INSTRUMENT DRAFTED BY: WILLIAM KANE JOB NO. 6006 -01 DATE: 05/17!2001 SEC. 32 VOL. 15 PAGE 4111 * 9 1 2 7 6 9 1 State Bar of Wisconsin Form 6 -2003 912769 SPECIAL WARRANTY DEED BETH PABST REGISTER OF DEEDS Document Number Document Name ST. CROIX CO., WI RECEIVED FOR RECORD 03/04/2010 02:50PM THIS DEED, made between State Bank Financial, a Wisconsin baakig SPECIAL WARRANTY DEED corporation EXEMPT hi REC FEE: 11.00 ( "Grantor," whether one or more), and Jason R. Haverly and Lisa R. Haverty, TRANS FEE: 176.70 a h . PAGES: 1 husband a wife, as survivors marital property ( "Grantee," whether one or more). Grantor for a valuable consideration, conveys to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ( " (if mom space is Edina Realty Title needed, please attach addendum): 400 South Second Street, #115 Part a(tM Northeast. Q%orter of the NanbtW Qu rtw (NE y. of NE Y.), and psrt of the Soathesut WI 54016 -1974 Quarter of tie Northeast Quarter (SE % of NE %N of Seedoo Thirty -two (32), Tm"p Thirty (30) HUC1S on , North, Range Nineteen (19) West, St Joseph Township, St Croft County, Wisconsin, further 2 O described as bliewu: Lot 3, Certifled Survey Map recorded In Volume 15 of Certified Survey Maps oa File # Page 4111, as Document No. 648881, Previously described incorrectly in Sherilrs Deed recorded as Document No. 899M as Part of the 030- 1093 - 10.400 Northeast Quarter of the Northeast Quarter (NE Y4 of NE Y.), and part of Me Southeast Quarter of the Northeast Quarter (SE Y. of NE Y.), of Section Thirty -two (32). Township Thirty (30) North, Range Parcel Identification Number (PIN) Nineteen (19) West, SL Joseph Township, SL Cron: County, Wisconsin, further described as follows: This is not homestead property. Lot 3, Certified Survey Map recorded In Volume 15 of Certified Survey Maps on Page 4111, as DocumentNo.65881. (it) (is not) Grantor warrants that the title to the Property is good, indefeasible, in fee simple and free and clear of encumbrances arising by, through, or under Grantor, except: any easements, conditions, covenants, restrictions and reservations of record, and any municipal or zoning ordinances and i real estate taxes for 2010. Dated February 25, 2010 TATE B (SEAL) (SEAL) * * Kevin R. a President (SEAL) � (SEAL} + + ad Hill, Vice President AUTHENTICATION ACKNOWLEDGMENT Sign tares) STATE OF WISCONSIN ) ) ss. authenticated on LA CROSSE — COUNTY) Personally came before me on February 25, 2010 * the above -named Kevin R. Leslie, Executive Vice President, TITLE: MEMBER STATE BAR OF WISCONSIN and Chad 0114 Vice President, of State Bank Financial, (If not, to me po"Iwb% the person(s) who executed the foregoing authorized by Wis. Stat. § 706.06) aA1l aa ged the same. s THIS INSTRUMENT DRAFTED BY: * t c Stewart L. Etten, Ruder Ware, LJ-&C. Public, State of ?VYWONSIN P.O. Box 8050, Wausau, WI 544024WSO � tisFfi**Ciit)'(expires• ) (Signatures wa be authenticated or ad us Both are pet ry.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATION BE CLEARLY IDENTIFIED. SPECIAL WARRANTY DEED 0200.3 STATE BAR OF ' wt FORM Na 6_2W3 'Type mime below signatures. r �i►rrr nuN „tp� IWO -PRO- Lsgw Pons. • (800)565-2W . k**r&wm wm 1 of 1 Parcel #: 030 - 1093 - 10-400 05/1812010 04:06 PM PA 1 OF 1 Alt. Parcel M 32.30.19.340B -30 030 - TOWN OF SAINT JOSEPH Current XX ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co -Owner 0 - HAVERLY, JASON R & LISA R JASON R & LISA R HAVERLY 426 OAK ST HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): "= Primary Type Dist # Description * 477 PERCH LAKE RD SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 4.682 Plat: 4111 -CSM 15 -4111 030 -2001 SEC 32 T30N R19W NE NE SE NE BEING LOT 3 Block/Condo Bldg: LOT 3 CSM 15/4111 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 32- 30N -19W NE NE Notes: Parcel History: Date Doc # Vol /Page Type 03/04/2010 912769 WD 07/02/2009 899278 SD 0210812007 844147 WD 06/15/2001 648350 1660/341 QC more... 2010 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/08/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 4.680 83,000 0 83,000 NO Totals for 2010: General Property 4.680 83,000 0 83,000 Woodland 0.000 0 0 Totals for 2009: General Property 4.680 83,000 0 83,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 p JawoaE) u01joag JGMOJL 9£d l punoil - P! 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Staff finds that the proposed project meets the spirit and intent of the St. Croix County Zoning Ordinance and Shoreland District with the following findings: 1. Filling and grading less than 10,000 square feet in area less than 300 feet from the OHWM on slopes less than 25 percent is allowed with a land use permit in the Shoreland District pursuant to Section 17.29(2)(c) of the St. Croix County Zoning Ordinance; 2. The filling and grading required for excavating the foundation of a single- family dwelling, the driveway, and POWTS are located within 1000 feet of the OHWM and subject to Shoreland zoning requirements. The proposed driveway, single - family dwelling, and POWTS meet all required setbacks and dimensional standards provided in the St. Croix County Zoning Ordinance; 3. The applicant submitted an erosion control and storm water management plan featuring retention areas for roof runoff from the garage and house. With conditions to install appropriate sediment control measures e.g. silt fence or sediment "logs" below the construction area, to maintain erosion control measures until self- sustaining permanent vegetation is established on all disturbed areas, to prohibit the use of phosphorous fertilizer to establish and maintain a lawn, to implement the storm water management plan, and record a maintenance and monitoring agreement against the property for the infiltration basins, negative impacts to the water quality of the wetland will be minimized; 4. The shoreline of the pond is currently unimproved. With conditions for maintaining the current level of native vegetative cover along the shoreline to preserve wildlife habitat and provide further filtration of storm water runoff from the site consistent with the standards in the Shoreland District, the natural beauty and ecology of the pond will be protected; 5. The St. Croix County Land and Water Conservation Department has reviewed the plans and recommends approval of the land use permit with conditions that an affidavit for the stormwater management plan be recorded against the Sr. CROIX COUNTY GOVERNMENT CENTER I 1 01 CARMICHAEL ROAD, HUDSON, W1 54016 71 X386.4686 FAX PZC�CQ. SA /NT CROtX. Wl. US W W W. CO.SAI NT -C ROIX. W I, U S pc n osp orous e i izer no a use un ess soi con i i v etative cover; and 6. a Wisconsin Department of Natural Resources has reviewed the plans and commented that a rmit will not be required for land disturbance less than 10,000 sq. ft. and outside the 75' OHWM s k. Based on t findings, approval of the land use permit is subject to the following conditions: 1. Th licant shall be responsible for implementing the erosion control and storm water ma ent plan submitted, and as provided in the conditions below. 2. The licant shall install silt fencing, straw waddles, and /or sediment logs between disturbed area the construction site and the pond's OHWM for control of contaminated runoff. 3. The itary permit issued for installation of the POWTS will require compliance with all Condit s of the land use permit and contractors must be made aware that all excavation must stay ou ide the 75' OHWM setback. 4. The a licant shall maintain all erosion and sediment control measures until permanent, self - su . ming vegetation is successfully established on all disturbed areas of the site. 5. phosphorous fertilizers shall be used on the disturbed areas of the site, unless a soil test confirms that phosphorous is needed for establishing permanent vegetative cover. The current level of native trees, shrubs, and groundcover along the shoreline shall be maintained. 7. Within 30 days of completing construction, the applicant shall execute and record an affidavit against the property with the Register of Deeds referencing the storm water management plan and required maintenance and monitoring for the rainwater retention structures, and provide the Zoning Administrator with a recorded copy of these documents. ithin 60 days of completing construction, the applicant shall submit to the Zoning Administrator tos of the completed project as viewed from all angles. The photographs must also show all st - water management measures and vegetation on the site. This ap oval does not allow for any additional construction, structures or structural changes, gradin filling, or clearing of vegetation beyond the limits of this request. Your information will remai n file in the St. Croix County Planning and Zoning Department. It is your responsibility to ens a compliance with any other local, state, or federal rules or regulations, including obtaini a building permit from the Town of St. Joseph. Please free to contact me with any questions or concerns. Sin +, Pamela Qu' Zoning Sp list/Zoning Administrator Enc: Use Permit osion & Sediment Control Plan Cc: odd Dolan, Building Inspector, Town of St. Joseph ve Olson, St. Croix County Land and Water Conservation Department rie Stoltz, Wisconsin Department of Natural Resources ST. CROIX COUNTY GOVERNMENT CENTER 1 10 1 CARMICHAEL ROAD, HUDSON, WI 54016 715- 386 -4686 FAX PZ @CO, 5-A1NT-CRO1X. W1. US W W W. C O. SAI NT-C ROIX. W L U S 014tus MTO IZSSIL'Apo- Hu— r.i',Ivmoa _t'Et'9[11yt5r_ EON ISIA3N yU�� 4OL NJlS30 IM H 'PROM etlo'I 4-d LLt, 00 tv . U31bN SS3'INn W V ` 331130IS31 L1934VH .o-.t =.wt3tv�s 8j15 s ZJ z W Z a cn a 1 •-- .r - � S s o oc h a c> o ? U z > — Z.z ZO Ll ? J U¢U z Z 53 W g - ° z 0 ° o 1; �ww a J zarv, 0 OZZ Q O m p .' 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