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Wisco3sin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 514991 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: Washick, Kenneth J. I St. Joseph, Town of 030 - 2100 -20 -000 CST BM Elev: Insp. BM lev: BM Descrip n: S No: ^ 1 � r7 f7Y� 1 (, 's f 32.30.19.817 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ,� 2 I®D. Dosing Alt. BM Snr a Aeration h _ �c (� Bldg. Sewe Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION "g TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet 7 n7'0 Set Dt Bo tom / c Dosin 2 r/ a._ c n ' —^ S 3 S 9�• — Aeration Dist. Pi / Holding B ot. Syste 2. R y `1l fi . G� /•o (,�� Fi Grr de Q 0,170 ' PUMP /SIPHON INFORMATION �� �IZfP�CLQ r S 3. ( Manufactur Demand St Cover GPM L Model Numb A 2 — 9 9 .'0 TDH Lift Friction Loss System Head IV TDH Ft -3 q0 . 0 3 Q , s &tvrh F Lengt Dist. to II , [Dia. 3 —r law SOIL ABSORPTION SYSTEM p. 3 BED /TRENCH Width , Length No. Of Trenches PIT DIM S S No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 7a ' SETBACK SYSTEM TO / P/L BLDG WELL LAKE /STRE /LEACHINP Manufactur INFORMATION Ty Of System: (CHAMBER PR 23� r � > f � / Model Number: w DISTRIBUTION SYSTEM 3 Y3 M _Qadt Header /Ma ifol istribution / x Hole Size x Hole Spacing Vent to Air Intake �q Pipes) �� ( �- Lengfh Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over 1 Depth Over xx Depth of xx Seeded /Sodded rulched Bed/Trench Center / Bed/Trench Edges Topsoil Yes E No 0 Yes No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / 2 / Inspection #2: Location: 404 126th Avenue Hudson, WI 54016 (SW 1/4 NW 1/4 32 T30N R19�jW))) Ridge Meadow Lot 2 Parcel No: 32.30.19.817 1.) Alt BM Description 2.) Bldg se - �� wer ad length - I } yu4�(,� �>b�� `7" ?rm010-4 "- - amount of Plan revision Required? ❑ Yes W �9� �5 Use other side for additional information. L L _ J_ 40_i L — _ ��?. _ � _i Date Insepctor's Signatur Cart. No. SBD -6710 (R.3/97) .Wiscc, ;t.rtmentofIndustry,. PRIVATE SEWAGE SYSTEM County: La and Hu i ld i Relations INSPECTION REPORT ST CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284347 Permit Holder's Name: ❑ City ❑ Village ff Town of: State Plan ID No.: DELTA CONSTRUCTION, INC. ST. JOSEPH CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: f ry.J 030- 2100 -20 -000 14 k TANK INFORMATION ELEVATION DATA A9700113 TYPE MANUFACTURER CAPACITY STATION BS HI I FS ELEV. Septic i , Benchmark° Dosing `� r_1 . ' W o o ,. Aeration Bldg. Sewer 55 C7 '7 Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet s TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake i Septic NA Dt Botto Dosing 7a5° ° ,�'x ; NA Header /Man. 9r 3-2 Aeration NA Dist. Pipe y q/ Holding Bot. System .31' PUMP / SIPHON INFORMATION Final Grade ,Vl / 8560' Manufacturer w =Deman g6 ,5 Model Number ;� o 3� �- n- TDH I Lift 5(1 I Friction System�� TDH &.11 Ft Forcemain Leng ,, ' Dia. a F I Dist. To Well' , SOILABSORPTI STEM a70 4 BED/TRENCH Width Length No- Of Trenches PIT No. Of Pits Inside Dia- Liquid Depth DIMEN I N ° 5s" DIMENSION SETBACK SYSTEM TO P / L I BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O f / CHAMBER Model Number: System: '7 5 /4 7( 0 OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia 1 Length Dia. Spacing I I 1 i 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/Tr nch tenter Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST JOSEPH.32.30.19,SW,NW 404 126TH AVENUE LOT 2 I Plan revision required? ❑ Yes rj No Use other side for additional information. - SBD -6710 (R 05/91) Date (an ¢�aor'sSi9nature Cert. No 8 STC - 104 T RECE� AS BUILT SANITARY SYSTEM REPORTS c' 1997 OWNER j��.l �5�`• S T OFOX npFlCE ADDRESS ,2 Z L SUBDIVISION / CSM # LOT # -2 SECTION ?2 T „?,0 N -R / W, Town of S7. ST. CROIX COUNTY, WISCONSIN I PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM O 1,10 I i A I / r I p I - l i f i f n INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. commerce .wl.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 St. Cr Mi n s i n Madison, WI 53707 -7162 Sanitary Permit Number to be filled in by Co.) epartment of Commerce Sanitary Permit Application State Transaction umber, J In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appr i govern P roject Address (if differe mailing address) unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owne WTS are submitted to the Department of Commerce. Personal information you provide may be used for se Same p urposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. I. Application Information — Please Print All Informatio Property Owner's Name RECEIVE Parcel # Kenneth J. Washick 030- 2100 -20 -000 Property Owner's Mailing Address Property Location 404 126' Ave. ST. CROIX COUNTY Govt. Lot City, State Zip Code SW ' / <, _ NW -/,, Section 32 (circle one) Hudson, WI 54016 (715) 549 -6124 T 30 N; R 19 W II. Type of Building (check all that apply) Lot # t, El or 2 Family Dwelling — Number of Bedroo s 3 2 Subdivision Name Block # Ridge Meadow El Public /Commercial — Describe Use Na ❑ City of ❑ State Owned — Describe Use CSM Number ❑ vi age of Na Town of St. Joseph III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System eplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. El Permit Renewal El Permit Revision El Change of Plumber El Permit Transfer to New List Previous Permit liumber and Date Issued Before Expiration Owner '1 7 IV. T e of POWTS System/Component/Device: Check all that a I Non - Pressurized In- Ground ❑ Pre ized In-Gr d ❑ ade ❑Mound > 24 in. of s table soil El Mou < in. of suitable soil g ip 7 p��� PLUS L6,gc f ��'9177, S .n-r ��ao.4-z ea /�•.�t El Holdin Tank ❑Other is ere Co o e e lat ea ent Device ex ain i 7Fi &t V. Dispersal/Treatment Area Information. * C,76 Infiltrator "Q-4 W" chambers 20.0 sq.ft EISA / chamber + 4 pair end caps 5.8 EISA = 1,543.20 sq. ft. Design Flow (gpd) Design S ' pp ication dsf) Dispersal ea equtre s D a 450 gpd 0.3 in -situ soil 0,500.00 sq. ft. 1,543.20 sq. ft. 89.00',90.00',91.00',92.00' VI. Tank Info n Total # of Manufacturer Gallons Gallons Units y c v New Tanks Existing Tanks _ c� `c wU c U P. Septic or Holding Tank 1,000 1,000 1 Weeks Concrete X Dosin chamber 800 800 1 Weeks Concrete X VII. Responsibility Statement- I, the and reigned, ass -one responsibility fo stal on of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber' Signat MP/MPRS Numbe7 usiness Phone Number James K. Thompson / -- s-- 30021 248 -7767 Plumber's Address (Street, City, State, Zip Code) 340 Pa lson Lake Lane, Osceola, WI 54020 -5413 VIII. oun /De artment Use Onl pproved El Disapproved Permit Fee 64? D it Issued suing Agent Si attar A i e ❑ Owner Given Reason for Denial Conditi s of A�provaUReasons for Disapproval S 3 (�Pd l� SYSTEM NNER: ,C TA'/�X- S 7� 1 Septic tank, effluent filter and lQ/Q/ S `rt M�1 !iY! dispersal cell must all serviced / maintained �� �G _&t7U 1�na as per management p provided by plumber. (/ 2. All setback requirements must be maintained d4941j.___ as per applicable W=0NOWplans for the system and submit to the County only on paper qO less than 8 In x 11 inches in size SBD -6398 (R. 01/07) Valid thru 01/09 e.ya /uat.'6r7/0,`E �uhS car ' A EX�s�" 1�de e/er/ E ' :, 8w eft Q j0 r� • /tro y Sf�fC ;x a.ri 6er'. E /er�E ,bath., o = 4v.42 — .92•x6 St c i - z •.rE Jfan cJas E,Y.<3E7n /,� �k/ s cvy see. 3 2 < -FoSe�oLi 5£�G7�ix�o' . may So% Couv E /. 'M Z/' O P� �p 2JC27 -zD-� t-I EXi,Stin IV s t�rY 3 6 gr in Res:denee 98 83, 0 976 �,kre.Ec 99 �' s Ian iA q �. /o ca t�iYM o F � taK 8izr,a, y eFFvuerE /'ne. 0 1 pp- Qr►'14;n• ;' � /O pp- 9 71 i eF�/ t "� • y9 d2 verSrar-, �—. ; cSarC�- .d�5•Er;bu-E.o, bo�, AA,"o �ctds yy y - Y / 9 L1.h s�ciJ u� Zn Y .ode EXi�t ny �nede ¢lec/ E,r 8�8s P ('o>tcrc fl . Pro � � a c , a. c S7.Cic0 -.fZ men cJas/i.c.E� � C'arscr'� Scp(�c. - -r s wy�n�ay� sce. 3.2, A. 7'30/(. .P• /9cv. T,c� !t /t.b.,,y.: Too {s.T. 5e • tTosc 66 - ce K(?O. Mow , fo% Ciu r. E/. °9.� V' 0 ,a/ o jo vcn- zo -an e, J E,Ed�� b cdr s tv 3 ds.ur �,sedence 98.83' 0 i 9y. � I I s IoF'e � "� % Cm,✓•el�� Feral z "{once toy "8/tz.ai-6y eF,uuea /�l. i 0 0 {+ o �� _ ; 997-3' Slope rf�o/Jrck. /CJC4.U(n7 � , 1 O'Z rtz u.Ef — �� Val ✓c r --I.J; cSarC@,�C,.d�sfr;bu�.o box 97 uJtsds s ' /1 d/aut; ca fie. /ed� Be c • o I 3' 9s�, y i .seacrsa. /eeJ /4tiz;rss' -- - e 26 / D l ro�osec✓d l��¢�S�c./ eL. // ` � �� / //d .5I0/OP LJ) - J Cv' n �«cr(J.vcic4S of 3, 7 Z f, /trai'uc S�cr� ce ,ode ai , Ii I as �� L - - - lk 4 o C C S r _ ? I C 0 O 0 �" � Ken Washick Pump Chamber Calculations 1. Force Main: Diameter 2 i Length 150' Flow rate 60.00 gal. /minute ± Friction loss 10.50 ft. (150')(7.00 ft. /100ft.) 2. Total dynamic head: Min. supply pressure 0.00' c � YP Vertical lift 4.57' (elev. off high elevation at force_m_ain invert = 93.09) Friction loss 10.50' z „ , �. � q`7A � I( Total dynamic head = 15.57' 3. Pump selection: Manufacturer: Goulds � ��,f Model number: WE03L "� �5 ►n°j r /"""� 'T "�i S a -a'W"J - Pump will discharge 50.0 gpm @ 15.57' TDH 4. Dose chamber: Manufacturer & capacity: Weeks Concrete 800 gal. 37.00" (a, 21.76 gal. /inch (805.12 gal. actual) Sizing calculations and float settings: A) One day holding capacity: 18.00" = 391.68 gal. B) Alarm setting: 2.00" = 43.52 gal. C) Dose volume + flow back: 5.00" = 108.80 gal. Max. dose = (450.00 gal.)(20% Design flow) + (24.45 gal. flow back @ 150') = 114.45 gal. D) Reserve storage: 12.00" = 261.12 gal. TOTAL: 37.00" = 805.12 gal. Dose Tank Information Locking cover with warning label and locking device and sealed watertight Electrical as per NEC 300 and --♦► Comm 16.28 WAC 4 in. min. Disconnect _ Tank component is properly vented F- Alternate outlet location Forcemain diameter Wieser Concrete Manufacturer 2 in. Capacityl 805.12 Gallons Volume 21.76 gal /inch A Weep hole or anti - Dimension Inches Gallons B siphon device A 18.00 391.68 C B 2.00 43.52 Pump off elevation (ft) C 5.00 108.80 T 96.43 D 12.00 261.12 D � Total 37.00 805.12 Do elevatio 3" Bedding un er tank. 95.43 Alarm Manuafacturer SJ Electro Systems Alarm Model Number Tank Alert Pump Manufacturer Goulds Pump Model Number WE03L Conventional Septic System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD- 10705 -P (N.01 /01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with bottom of tank to be <_ 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. 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. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed 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 the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Pump Tank The pump (dosing) tank shall be inspected at least once every two 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 Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October - March) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a two -year schedule by use of a diversion valve. Valve to be switched diverting effluent from dispersal cell currently in use to resting cell on a two -year cycle coinciding with septic tank inspection and maintenance. Contineencv 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. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715) 248 -7767 or the St Croix County Zoning Department at (715) 386 -4680. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/bfi�er q° ��Gt.�2 5�i, ce Mailing Address �D S/ /1 G�� , /�c c o�S�I &J/ Property Address (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification Number 0 - ,Z./e�e )-, W - &b LEGAL DESCRIPTION Property Location 360 1 /4 , 1� t /a , Sec. -32 , T .36 N R_�Y_W, Town of St - Sose1a4 ' Subdivision , -,— Lot # -Z Certified Survey Map # �g , Volume , Page # _ Warranty Deed # 8 - , Volume , Page # Spec house no Lot lines identifiable es SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 1� -0 Ci SIGNA OF APPLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) RGOULDS PUMPS Submersible Effluent Pump 3885 PROSURANCE AVAILABLE FOR RESIDENTIAL APPLICATIONS. APPLICATIONS ■ Shaft: Corrosion - resistant Single phase: ■ Bearings: Upper and Specifically designed for the stainless steel, Threaded • Built -in overload with lower heavy duty ball bearing design. Locknut on three phase automatic reset. construction. following uses: models to guard against • All single phase models ■ Power Cable: Severe du • Homes component damage on feature capacitor start rated, oil and water resistant. • Farms accidental reverse rotation. motors for maximum Epoxy seal on motor end • Trailer courts p Y • Motels ■ Fasteners: 300 series starting torque. provides secondary moisture • Schools stainless steel. •' /3 and '/2 HP — 16/3 STTOW barrier in case of outer jacket • Hospitals ■ Capable of running dry with 115, 208 and 230 Volt damage and to prevent oil • Industry without damage to three prong plug. wicking. Standard cord is 20'. • Effluent systems components. • 3 /4 -2 HP —14/3 STOW with Optional lengths are available. ■ Designed for continuous T bare leads. ■ 0 -ring: Assures positive hree phase: SPECIFICATIONS operation when fully • Overload protection must sealing against contaminants and oil leakage. submerged. be provided in starter unit. Pump •Solids handling capabilities: •'/2 -2 HP —14/4 STOW with bare leads. 3 /4 " maximum. MOTORS AGENCY LISTINGS • Discharge size: 2" NPT. ■ Fully submerged in high- ■ Designed for Continuous • Capacities: up to 140 GPM. grade turbine oil for lubrication Operation: Pump ratings are Tested to UL 778 and • Total heads: up to 128 feet and efficient heat transfer. within the motor manufacturer's CSA 22.2 108 Standards TDH. recommended working limits By Canadian Standards ■ Class B insulation. can be o erated continuous) ci us Association • Temperature: a file #LR38549 without dams when full 104 F (40°C) continuous 9 Y 1401 (60 °C) intermittent. submerged. Goulds Pumps is ISO 9001 Registered. • See order numbers on METERS FEET reverse side for specific HP, ao 130 SERIES: 3885 voltage, phase and RPM's ET5H - {- available. 120 SIZE: 1 /4" SOLIDS 35 __ RPM: 3500 & 110 __ -� Y___ - 1 1750 FEATURES 30 100 � - —► 5 GPM_ I - 5 FT i ■ Impeller: Cast iron, semi- ° a 90 + -- - open, non -clog with pump -out 25 80 - - fi -- ----- vanes for mechanical seal 70 - t - i -- - r - - r- protection. Balanced for ; 20 60 smooth operation. Silicon ° uvEO -- r 0 1 5 so bronze impeller available as t0 t an option. � ao Ea H 0 - - --- - -- � - I ■ Casing: Cast iron volute type 30 w A4__ h for maximum efficiency. 5 - -- 1 2 NPT discharge. 10 - ■ Mechanical Seal: SILICON CARBIDE VS. SILICON ° ° 0 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 GPM CARBIDE sealing faces. 0 5 10 1s 20 A 30 35 m; /hr Stainless steel metal parts CAPACITY BUNA -N elastomers. Goulds Pumps © 2002 Goulds Pumps ITT Industries Effective October, 2002 www.goulds.com 83885 2145 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 4 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations Attach complete site plan on paper not less than 8' /Z x 11 inches in size. Plan mus St. Croix include, but not limited to: vertical and horizontal reference point (BM C ), direction an I I D percent slope, scale or dimemsions, north arrow, and location and distance to near 030- 2100 - - 000 Please print all information, evi ed By Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). lJ / (� y 7 _0 I Property Owner RECEIVED roperty Location Kenneth J. Washick ovt. Lot SW 1/4 NW 1/4 S 32 T 30 N R 19 W Property Owner's Mailing Address L Dt # Block # Subd. Name or CSM# 404 126th Ave. SEP 1 8 ZOOS 2 Ridge Meadow City State Z Code Phone Number J City J Village 1J/ Town Nearest Road Hudson I WI 016 -��4 St.Joseph 126Th Ave. I New Construction Use: W1 Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD d Replacement —J Public or commercial - Describe: Parent material Glacial Drift Flood plain elevation, if applicable na General comments and recommendations: Site suitable for conventional replacement system. Mound system recommended with 6" of sand fill placed on 97.00' contour. See Memo page for additional site considerations. Boring # I Boring Pit Ground Surface elev. 95.03 ft. >108" in. Soil Depth to limiting factor 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 I *Eff#2 1 0 -7 1 Oyr3 /2 none sit 2fsbk dsh cs 2vff1 m 0.6 0.8 2 7 -20 1 Oyr4 /4 none sit 2msbk dsh cs 2vffl m 0.6 0.8 3 20 -31 7.5yr4/6 none gr sl 1 fsbk dh cw 1 of 0.4 0.7 4 31 -54 7.5yr4/4 none Ivfs 1 msbk mvfr cw 1 of 0.4 0.6 5 54 -108 10yr4/4 none Ifs,ls,s Osg ml - - 0.3 0.6 H #5 consists of many 1" - 4" stratified bands of 10yr4 /41fs, 10yr4/6 Is & 10yr5/6 s. Loading rate adjusted to reflect reduced permiability of horizon associated with textural changes. No redox. observed. Boring # I Boring 16 Pit Ground Surface elev. 94.49 ft. Depth to limiting factor > 113 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 1 0 -8 1 Oyr3 /2 none sit 2fsbk dsh cs 2vff1 m 0.6 0.8 2 8 -23 1 Oyr4 /4 none sit 2msbk dsh cs 2vffl m 0.6 0.8 3 23 -31 1Oyr5/4 none gr sl lfsbk dh cw lvf 0.4 0.7 4 31 -50 7.5yr4/4 none sl 1msbk mvfr cw 1vf 0.4 0.6 5 50 -64 1Oyr4/6 none sl,ls,s 1msbk mfr cw - 0.4 0.7 6 64 -113 1Oyr5/6 none Ifs,ls,s Osg ml - - 0.3 0.6 H#6 consists of many 1" - 4" stratified ds of 10yr 4Ifs, 10yr4/6 Is & 10yr5 /6 s. Loading rate adjusted to reflect reduced permiability of horizon associat d with textural changes. No redox. observed. * Effluent #1 = BOD 5 > 30 < 220 mg/ and TSS >30 < /50 /L ffluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signat e: CST Number James K. Thompson 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 8/27/2008 715 - 248 -7767 Property Owner Kenneth J. Washick Parcel ID # 030 - 2100 -20 -000 Page 2 of 4 ]Boring # - Boring ✓ Pit Ground Surface elev. 97.72 ft. Depth to limiting factor >110" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -7 10yr3/2 none sil 2fsbk dsh cs 2vff1 m 0.6 0.8 2 7 -22 10yr4/4 none sl 2msbk dsh cs 2vff1 m 0.6 0.8 3 22 -36 10yr4/6 none Ivfs 1fsbk dh cw 1vf 0.4 0.7 4 36 -62 10yr4/6 none Ifs,fs,s Osg ml cw - 0.3 0.5 5 62 -110 10 r5/6 n Ifs Is s Os ml - - 0.3 0.6 y none g H#4 & 5 consist of 1/4" - 4" stratified bands of 10yr4 /41fs, 10yr4/6 Is & 10yr5/6 s. Loading rate adjusted to reflect reduced permiability of horizon associated with textural changes. No redox. observed. 4] Boring # J Boring 1/ Pit Ground Surface elev. 98.55 ft. Depth to limiting factor >104" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -9 10yr3/2 none sil 2fsbk dsh cs 2vff1 m 0.6 0.8 2 9 -18 10yr4/4 none sl 2msbk dsh cs 2vff1 m 0.6 0.8 3 18 -36 7.5yr4/4 none grsl 1msbk dh cw 1vf 0.4 0.7 4 36 -67 7.5yr4/6 none Is /sl 1 msbk mfi cw - 0.4 0.7 5 67 -104 10yr5/6 none Ifs,ls,s Osg ml - - 0.3 0.6 H#4 & 5 consist of 1/4" - 4" stratified bands of 10yr4 /41fs, 10yr4 /6 Is & 10yr5 /6 s. Loading rate adjusted to reflect reduced permiability of horizon associated with textural changes. No redox. observed. ❑ Boring # Boring 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 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5 > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD <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) A.C.E. Soil & Site Evaluations PROPERTY OWNER: Kenneth J. Washick SOIL AND SITE EVALUATION 2145 Page 3 of 4 PARCEL I.D.# 030 - 2100 -20 -000 A.C.E. Soil & Site Evaluations REPORT MEMO This soil evaluation did not reveal a limiting factor as indicated by the lack of redoximorphic concentrations or depletions. However, an overall interpretation of the site, soil morphology, current soil moisture content, early failure of existing ose conventional dispersal cell and the presence of mound on the adjoining property, have resulted in 9 p P 1 the conclusion that while a code compliant in- ground dispersal cell can be installed, a mound system is better suited to the site and will provide a better longer term solution to onsite waste management. The existing dispersal cell was found to be located in code compliant soils and can therefor be left in place and retained for future use with the installation of a diversion valve. E,r/6 4ncde c %t/ Erg ss�.:�,q Bte�, p e tc�c i . Pia y Rani d CKam her. Eie / ad j , 6t6. o x.42'= 92• lean Gt�as/1ic.E�jO�•oJO. E�t''c� /,� �'-Q \ /ot,Z oF�d�Cp7en.doul, � � scPbrc � swi�i�u�y xc, 3a, L95..63 X ,4C /r /�•%S.irf.: /ooa {S.% Sb. ToSt�oCi 5�. GaixC'o. /1la4Ao% Coµv E /.'9� O �/ , a o3o- z/cn- .2D-an � EXi,Sti� dew c k 3 b ed M Ra_sidence r 98 83' I o I �nareEc 9,9 C/ 0 ^� Con ✓ alb 7� j (, a _ entaa n. 73 y /off eF�/ /4 i jq o 97 - 97. -v' I e /erg; = 9i. 20 'f . • o � Ale ' 835949 KATHLEEN H. WALSH REGISTER OF DEEDS State Bar of Wisconsin Form 3 -2003 ST. CROIX C0., MI QUIT CLAIM DEED RECEIVED FOR RECORD Document Number Document Name 10/04/2006 12 :35PM QUIT CLAIM DEED EXERT # 8M THIS DEED, made between Sharon A. Washick, a single person REC FEE: 11.00 Also Known as Sharon A. Roos TRANS FEE: ( "Grantor," whether one or more), COPY FEE: CC FEE: and Kenneth J. Washick a single person PAGES: 1 ( "Grantee," whether one or more). Recording Area Grantor quit claims to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin Name and Return Address p]:TUItN pOCUMcN'fS TO: ( "Property") (if more space is needed, please attach addendum): ~ Ift & Abstract Company Lot 2, Ridge Meadow in the Town of St. Joseph, St. Croix County, Wisconsin. 201 Ul"mAy Avenue Vibst SMW 214 North 14 9Nk Poll, onrlesots 55 g P g 1 This deed is given pursuant to the Judgment of Div rce �etween the Grantor and I S SS Grantee, which Judgm nt was granted on , as Case Number _ 030 - 2100 -20-000 Parcel Identification Number (PIN) This is homestead property. not) Dated l (O 4• p1r, 14 (SEAL * *Sharon A. Washick , AKA Sharon A. Roos (SEAL) (SEAL) * AUTHENTICATION ACKNOWLEDGMENT Signature(s) n authenticated on STATE OF rt ) ss. COUNTY ) * a� TITLE: MEMBER STATE BAR OF WISCONSIN Personally came before me on (If not, the above -named Sharon A. Washicl , a single person authorized by Wis. Stat. § 706.06) Also known as Sharon A. Roos to me known to be the person(s to a ecue fore oing THIS INSTRUMENT DRAFTED BY: instrument and acknowledged th Michele Elizabeth Johns NOTARY PUBLIC - MINNESOTA Attorney Kristina Ogland N Hudson, WI 54016 * FIRES JAN. 31 2010 Notary Pu , State of My Com ' sion (is permanent) (expires: 1 i 1 0 (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. QUIT CLAIM DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 3-2003 * Type name below signatures. INFO -PROTM Legal Forms 800. 655 -2021 www.infoproforms.com IofI L 'v. v. frt • 4 1 a , PG. 318 NORTH LINE OF THE SWI /4 OF THE NWI /4 4 O 0 O) O P LOT 6 1) 1n O n N 4 ��• S O i 4� SW 18'14"E 523.05' 278.00' 245.05' 32 F v LOT 2 z LOT 3 3.07 ACRES 0 3.11 ACRES _ . 135,373 SO. FT. 133,913 SO. FT, dp C 0_ 2.96 AC. EXC. ESMT. LOT 4 128,773 SQ. FT. m 3.47 ACRES Ri 151,168 SO. FT. Ci � v � B DE- AC UP \ .0 362 \ ✓ ` � S \ - — — 1 578 2 0 L )1 LOT �. `✓7�. G, PG. I73? s NOTE:' ��£ "" Air) ci1J`a . . .. n m o ■_ 0 e . 2 § § ; 3 ° Q k � § _ 0ƒ E f/ 0 m 2 $\ S �- e w E Q% i { //\ Q = ƒ » 2 : z w / , \ 0 7 I \ \ \ ) / / CD C) 2 § = o \ \ 0 6 a E E 0 % / & A § 0 © ® C � ® E 3 $ E / ƒ i = A o © �$ j \ � ® % $ / i k/ g 0 c ~ � 0 0 0 \• -n ■ E � E 2 l go g PO / 7 7 \ CD I 2 J \2I m * ( ¢ } CL I 2 0 2 2= z \ ■ > E g o 0 . / 2 §- G8; ƒ j\ k ° k OIQ 3 / _ cn � 8 ; { z E � k m \ / § 0 CL § $ $ I § z 2 z » » I � $ � � rq«± ƒX C, § S%\ ƒ 77' E § R // o R I \ƒ}f 0 ) M CD ( �k3 y _o CD ( I E& m2 / 0 LO 77 CD \ 0 » ) § \ a } . 4 ` V E STC - 104 RECCNEO o AS BUILT SANITARY SYSTEM REPORT�` 1997 OWNER ST AY v E zcNiw ADDRESS ��G' 1 t� �^ SUBDIVISION / CSM# /OYen�lT/ LOT # - SECTION _?Z T -R Town of 5� �j� e�2 ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM Ae o \ O l i i 1 � r r f ' . ALT INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 59 F I 7,7. BENCHMARK: ALTERNATE BM: `- SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: � Liquid Capacity: Setback from: Well s'o House / 7 Other Pump: Manufacturer "/_,-"/,/ Model# w1_r Size Float seperation 15"' Gallons /cycle: - Go Alarm Location i ati c h "an t SOIL ABSORPTION SYSTEM Width: I Length Number of trenches _ Distance & Direction to nearest prop. line: > 7y Setback from: well: ? ��o ' House //,f Other '-/ our , e. Ctlp� !' ELEVATIONS fT�b I�dWN 'I °�R� T o Building Sewer fJ, 7 ST Inlet: f'o, pS' ST outlet: J - PC inlet ?.f PC bottom Pump Off f6, 7,5 Header /Manifold 9/.3Z� Bottom of system Existing Grade 96,y Final grade 9s DATE OF INSTALLATION: 71 - Z,3 f PLUMBER ON JOB: fTi9,s�`N LICENSE NUMBER: INSPECTOR: 3/93:jt 11 XM ##I /, 9 7,� ��•7 -Wisc 'rtmentoflndust'ry,` PRIVATE SEWAGE SYSTEM count Labor anod Hunian Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No -: GENERAL INFORMATION 284347 Permit Holder's Name: ❑ City ❑ Village 15 Town of: State Plan ID No.: DELTA CONSTRUCTION, INC. ST. JOSEPH CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 030- 2100 -20 -000 TANK INFORMATION ELEVATION DATA A9700113 TYPE MANUFACTURER CAPACITY STATION 85 HI FS ELEV. Septic, z � Benchmark Dosing < .fir D� y � i "-✓ Aeration (` Bldg. Sewer 5S U•'7 Holding St /Ht Inlet i - 65' TANK SETBACK INFORMATION St/ Ht Outlet q, RS " TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Q . s Septic (Z' NA Dt Bottom Dosing NA Header / Man. 9�- 3oZ Aeration NA Dist. Pipe 91. Holding Bot. System 21 ' PUMP / SIPHON INFORMATION Final Grade ' V / / 956(' Manufacturer Demand Model Number OEO GPM �- r, DH Lift 56/ Friction Systern TDH 6�! Ft Forcemain Length „' Dia. 1� U Dist. To Well SOIL ABSORPTION SYSTEM RED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 5 DIMENSION SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manuacturer: SETBACK CHAMBER INFORMATION Type Of y Moe Number: System: � 7,5 //3 7l5 0 OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing 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 ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST JOSEPH.32.30.19,SW,NW 404 126TH AVENUE LOT 2 i I Plan revision required? ❑Yes [J No ; -, Use other side for additional information. :/ a SBD -6710 (R 05/91) Date A n or's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ld I 5 f Z I/ Safety and Buildings Division I� "■�.nln SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. ®.�' • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs E] Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. 404- �� /# + R ,AYC State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner ame Property Location S v4 a 1/4, S T 3a , N , R E (ollo Property Owner's Mailing d ire s Lot Number Block Number �D �r City S�tatt Zip Code Phone Number Subdivision Name or CSM Nwnber 1 ( ) `cJ 11 . TYPE OF BUILDING: (check one) ❑ State Owned it Nearest Road Public 1 or 2 Famil Dwellin - No. of bedrooms s� pf Town OF 1 - ) 'k ,L y`. 111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Numbers) 30I. W' 19• 1 [] Apartment / Condo d — P /mod —2D D 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1. jJ New 2. ❑ Replacement 3, ❑ Replacement of 4 ❑ Reconnection of 5 ❑ Repair of an System System _ Tank Only_ Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other _ 11 OSeepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: s roY� 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (MinAnch) Elevation IV 1 6 Y-3 , 3 ' Feet Feet Capacit VII. TANK in Ca allo g Total # of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass plastic New Existing structed Tanks Tanks Septic Tank or Holding Tank Of ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber Q7� �.G El ❑ 1:1 1:1 E] VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the o sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: No Stamps) W /MPRSW No.: Business Phone Number: V /J a /E) t �,•L r 1 9 7 — 6 'Plumber's Address Street, City, State, Zip ode): IX. COUNTY/ ElEPARTM ENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Inc udes Groundwater D ate Issu Issuing Agent Signature (No Stamps) f� Approved ❑ charge Fee) Owner Given Initial l J Adverse Determination 7 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SOD -6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1 _ A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. IL Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.),. address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. DAVE F4GE PLUMOM RTY � �. � � � � �� PKk Testes f. PN�►ber �° ° a V f .S (� rte- H --A y M F � =SI 54023 . • : i ROBE Phone 749-36 Z,7 L J I4c�zEs O s i j SALE /' = So �- ? 011 . 900 SPrd rC tl--4Z 75 I l j O /, va LoT "�� 1 r l x' +k3 My I ! 1 i I I i I I I j I i I H lc rawr r °� w: A l. ,,;*.- {� •ii ' Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building water s 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. j • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. 4 �f �.. l r f � �f-� ,Q-�: �� i ? (?" ��� . State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Ownerdame Property Location 1/4 c 1/4,S " .2 T di , N, R E (O WWD Property Owner's Mallln cIdre s Lot Number Block Number City Statg Zip Code Phone Number Subdivision Name or CSM NN ber 11. TYPE OF BUILDING: (check one) ❑ State Owned 'ty Nearest Road E] Public 1 or 2 Family Dwelling _2' - No. of bedrooms - El ro w a n OF _6 gf Ill. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number s) 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1.171 New 2 ❑ Replacement 3 ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an ______System ________System _____________ Tank Only______________ Existing System ________ Existing System B) ❑ A Sanitary Permit was previously issued- Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 B'Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 []Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: f�+ s rc 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min.linch) Elevation .-3 ' Feet Feet VII. TANK Capacity gall Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank or Holding Tank —" !± I G<.1 d` ❑ ❑ ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber G l%C% I' � /�' I ❑ I ❑ I ❑ I ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the o site sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: No Stamps) b?P /MPRSW No.: Business Phone Number: e. lumber's Address (Street, City, State, Zip Code): Alt IX. COUNTY / DEPARTMENT USE ONLY ❑ [-]Owner Sanitary Permit Fee (_ ,, ff�� udesGroundwafer ate ssu Issuing Agent Signature (No Stamps) surcharge Fee) 7 — X Approved Owner Given Initial ✓/J Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD -6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority_ 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. AS BUILT Job Number Name Date PA( G F -� s PUPf%P CHAtAbZR CROSS SEC T IO?J AMC) SPECIFICATIOUS VEAIT CAP 'i"C.Z. VENT PIPE _T WEATHERPROOF APFROVED LOCKIAIG Z5' = ROPA DOOR, JUMCTIOIJ BOX MANHOLE COVEF 4i WWDOW OR FRESH IZ "MIU. AIR WTAKE GRADE I I I y" MIIJ. FE COKIDUIT _ _ _ _ 11� IAILET PROVIDE 7 AIRTIGHT SEAL *� A I � I ! ALARM e II I I o *APPROVED i ow JOINTS WITH ELEV. FT. APPROVED PIPE I - -j 3' ONTO PUMP OFF D SOLID SOIL CONCRETE BLOCK RISER EXIT PERmarl[D OKILy IF TAK1K MAMUFACTURER HAS SUCH APPROVAL SEPTIC f SPECIFI DOSE TANKS MANUFACTURER: -- a e/CS IJUMBER OF DOSES: Z PER DAy TAWK SIZE : _ "e9 GALLOKIS DOSE VOLUME ALARM MAWUFACTURER: _ _, IMCLUDIMG 6ACKFLOW: yD GALLONS MODEL KIUMBER: CAPACITIES: A= Z ►uCNE50R J°`� GALLOWS SWITCH TyP[: /2S )e CUeN B= IUCHESOR _ GALLONS PUMP MAMUFACTURFR: _ c�orrC�S C= /y IAICHES OR 2 1- 2 GALLOU5 MODEL DUMBER: Gr/4!J 3L D- y IMCHES OR w GALLO SWITCH TYPE: MOTE: PUMP AMD ALARM ARE TO BE MIKJIMUM DISCHARGE RATE 45 GPM INSTALLED OU SEPARATE CIRCUITS VERTICAL DIFFERE DETWEEN PUMP OFF AND DISTRIBUTION PIPE.. -2- FEET + MIKIIMUM METWORK SUPPLY PRESSURE , , , , , . , _ , Mt - FEET + "� ,sD Z%- F T ✓✓ FEET OF FORCE MAIN X- /oortFRICTION FACTOR.. FEET TOTAL DSWAMIC. HEAD = FEET IMTERMAL DIMEIISIOMS OF TAK1K: LEKJGTH ;WIDTH - ;LIQUID DEPTH L SIGtiJED: '7 LICEMSE KIUMBER: D ATE: r Goulds Submersible Effluent Pump 388 CANADIAN STANDARD ASSOCIATION S h APPLICATIONS • Three phase: 1 /2 HP - FEATURES Motor: Fully submerged in 1'/2 HP 200/230/460 V, high -grade turbine oil for Specifically designed for the 60 Hz, 3500 RPM. Class B impeller: Cast iron, semi- lubrication and efficient heat following uses: insulation, overload open, non -clog with pump- transfer. - • Homes out vanes for mechanical seal Designed for Continuous Desi • Farms protection must be protection. Balanced for g provided in starter unit. Operation: Pump ratings are • Trailer courts smooth operation. Silicon • Motels • Shaft: threaded, 400 series bronze impeller available as within the motor manufacturer's option. an o Schools p . stainless steel. recommended working limits, Hospitals Casin • • Bearings: ball bearings � can be operated continuously • • Industry upper and lower. g� Cast iron volute Power cord: 20 foot without damage. • type for maximum efficiency. • Effluent systems standard length (optional 2" NPT discharge adaptable Bearings: Upper and lengths available). for slide rail systems. lower heavy duty ball bearing construction. SPECIFICATIONS Single phase: 1 /3 and 1 /2 HP Mechanical Seal: Silicon Pump: -16/3 SJTO with three carbide vs. silicon carbide Power Cable: Severe duty • Solids handling capabilities: prong plug. % - 1' /z HP sealing faces. Stainless steel rated, oil and water resistant. S S maximum. -14/3 STO with bare leads. metal parts, BUNA -N Epoxy seal on motor end • Discharge size: 2" NPT. Three phase:' /2 - 1'/2 HP elastomers. provides secondary moisture • Capacities: up to 128 GPM. -14/4 STO with bare Shaft: Corrosion - resistant barrier in case of outer jacket • damage and to prevent oil Total heads: up to 123 feet leads. On CSA listed stainless steel. Threaded TDH. models - 20 foot length design. Locknut on three wicking. • Mechanical seal: silicon SJTW and STW are phase models to guard 0 -ring: Assures positive carbide -rotary seat/silicon standard. against component damage sealing against contaminants carbide - stationary seat, 300 on accidental reverse rotation. and oil leakage. series stainless steel metal parts, BUNA -N elastomers. • Temperature: METERS FEET 104 °F (40 °C) continuous 90 SERIES: 3885 140OF (60 °C) intermittent. - -- — -- - -- -t- _ -t - -- SIZE: 3'4" SOLIDS • Fasteners: 300 series 25 80 e RPM: VARIOUS stainless steel. - - — - -- . — - � 5GPM _ . _ — — • Capable of running dry 70 Et 5FT without damage to 0 20 -- -_ components. = 60 _0 eel Motor: 15 50 •Single phase: '/3 HP, 115 Z -- — - " -__ -- — - — — or 230 V 60 Hz, 1750 RPM; 0 40 ' HP, 115 V, 60 Hz, 4 /2 3500 RPM; ' HP - 1'/2 HP, R to 3 0 /2 230 V, 60 Hz, 3500 RPM. 20 eo Built -in overload with 5 - automatic reset. to Class B insulation. -- OL 00 10 20 30 40 50 60 70 80 90 100 110 120 130GPM I I I I p 10 20 30 m CAPACITY (0 1994 Goulds Pumps, Mc. Effective May, 1994 11 133885 Safety and Buildings Division �� ■er=r■ SANITARY PERMIT APPLICATION Bureau of Buildin water System! 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number r7 �L 3 The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner Name Property Location %Lr B'hSl 1i4 W 1/4,571 Tap , N, R If E(orjfV Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name orreSfd4 No nber / ) / / 6 -� II. TYPE BUILDING: (check one) ❑ State Owned it� Nearest Road Public 1 or 2 Family Dwelling [3 VII age - No. of bedrooms — Town OF o / Z T Ill. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number s) 1 ❑ Apartment/ Condo 19 30 r 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 112 ❑ Service Station/ Car Wash 5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. Vj New 2 ❑ Replacement 3, ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an System ________System ______ _______Tank Only System ______________ Existing y ________ Existing System B) . ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Propo ed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation Ca aut � d If „ 7 /00, a Feet 0 Feet VII TANK in g allons Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existin structed Tanks Tanks Septic Tank or Holding Tank ,❑ ❑ ❑ ❑ 1 ❑ El Pump Tank /Siphon Chamber El 1:1 11 El ❑ ❑ VIII. RESPONSIBILITY STATEMENT 1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No S mps) f1Af/MPRSW No.: Business Phone Number: 9. F1ZT d 792 �s6 Plumber's Address (Street, City, State, ip Code): 21r 7z Pr ©�- IX. COUNTY DEPARTMENT USE ONLY ❑ Disapproved San' ary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) Surcharge fee) X Approved []Owner Given Initial & �7 Adverse Determination 2l O 9 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: L Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. - Il. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. . VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), j address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic. tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. I GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. DAVE FOCJRN PLUMM $ o `a° uc�•e�T� Roq*�W IN 54023 Phone 744 A /1. _ /3,r1 TOE Of SuRvE��o� f r R °� �►- sSun�� �c+a� o ,�= fjcrir' = { 4Nj GOT t�/V1E�S O LoT � I w / 0 �G /✓ I I� yoG � ssY' fiy X K X rk3 �y 1 so I v 4 Do eo la i i i toa nRelationsos� SOIL AND SITE EVALUATION REPORT Page_of� Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but S z rrmj not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. A3O ,2 DD —,ZQ APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION s GOVT. LOT Sw 1/4 Id 1 /4S ,Z T N,R l y E (rqV PROPERTY OWNER':S NJBILIN ADDRESS LOT # I BLOCK # SUBD. NAME OR CSM # /Zr t CITY TATE ZIP CODE PHONE NUMBER []CITY []VILLAGE MOWN NEAREST R04 m tag) / i L 7 —'� V1 New Construction Use [/I Residential / Number of bedrooms f [ J Addition to existing building j I Replacement [ ] Public or commercial describe Code derived daily flo gpd Recommended design loading rate bed, gpd /ft .Z ^ trench , gpdm Absorption area required bed, ft S,0 trench, ft Ma)umum design loading rate _ — bed, gpd /ft trench, gpd/ft Recommended infiltration surface elevation(s) /D0. D `rim )e ft (as referred to site plan benchmark) Additional design / site considerations Parent material s'c C Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable for sy stem O S ❑ U ❑ S [Z U m S ❑ U O S 4 [is o U ❑ S U SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundivy Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench W z S 7.S-- LS ,)IS g s Ground ,3 - s- Y s 4 7 y elev. / ,03 ft. Depth to limiting factor > Q6 Remarks:- „£L --W itXrZ ,Acres 7v 7Za<M ZA&QX ©.�' �r.,rr�•e,rx+G. Boring # Ground elev. /O- 7j' ft. Ymkm Depth to limiting facto Remarks: CST Name:— Please Print Phone: S A ddress: Signature: Z ) ate CST Number: � s3 3 PROPERTYOWNER L7.eA 40/ SOIL DESCRIPTION REPORT P�e_,g�of n h PARCEL 1. D. # die -- 2100 ' �O Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft Boring # Horizon / in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench q•.vvv.:::.i.v:, 3 r _ ; � -Z .s' F Ground - 7 _ 3 L S CIS G NlzF� S S' 6 elev. V7—, Depth to limiting fact Remarks: 4d 7 1 44e--a- Boring # Ground elev. _ D S e G e- /oft. Depth to limiting factor > Remarks: Boring # :::: w> S m � . Ground elev. V AI , I 2 ft. Depth to limiting factor 7 _ !3p Remarks: Boring # ,u'•4 titiC Ground elev. DATE: ft. J0B PT: Depth to limiting .08 S: factor Remarks: SBD- 8330(8.05/92) f DAVE FOGEM PL.UMOM ucensed� T #3� to ROW O a Poaert�r W ROSE V1 I Ph me 749-3656 V f7 w a ,114 X y� 1a7Z i R-D,d, ;2p iS /oo O I� r ti i - NA CA aIL r IO � b i S T C - 100 This' application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ------------------------------------------------------------------- owner of property f /� z, �sj Location of property 1/41/4, Section 3 Z ,T N -R /9 W To �/ �eu�� Mailing address ��t �s S` /.6 Address of site Z/O � - C& 6,4c - rZ p /,E Subdivision name �� 1�1�,�0.� Lot no. Other homes on property? Yes L , , No Previous owner of property zoc 7, r� Total size of property Total size of parcel �_d Date parcel was created Are all corners and lot lines identifiable? y Yes No Is this property being developed for (spec house) ? Yes ,,,�- No Volume /,)/3 and Page Number ,.22 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register ister of Deeds as Document No. g'S"�c and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. Signat e of Applicant Co- Applicant L/- 3d- 77 '� Date of Signature Date of Signature M• " r • , S T C lOS SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER �w MAILING ADDRESS © &' z h, �l ml's � 1 4" Gv PROPERTY ADDRESS V ft / '� 9 (location of septic system) Please obtain from the Planning bept. CITY /STATE PROPERTY LOCATION 1/4, emu/ 1/4, Section 3z T 3 z) N -R TOWN OF ST. CROIX COUNTY, WI SUBDIVISION ° D , ��r� /!�_ i LOT NUMBER 2 CERTIFIED SURVEY MAP _ , VOLUME 2L_, PAGE 31ja , LOT NUMBER 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three expiratio date. SIGNED: DATE: - 7 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 WARRANTY DEED DOCUMENT NO. ri"'GISTEF , VI 12�.3rac�6Z2 o T caCr,. I a t This Deed made between THE McKINNON FAMILY TRUST, � EC IT 1996 20:00 A. 'd Grantor and DELTA CONSTRUCTION, INC., a Wisconsin corporation, Grantee, P4913 W of p Witnesseth, That the said Grantor, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin: (SEE ATTACHED LEGAL DESCRIPTION) RETURN TO: Barry C. Lundeen Post Office Box 469 Hudson, WI 54016 s Tax WN This is not homestead property. Together with all and singular the hereditaments and appurtenances thereunto belonging; And The McKinnon Family Trust warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances, and will warrant and defend same. Dated this 11th day of December, 1996. 'HE McKINNON FAMILY TRUST SEAL BY: William N. McKinnon, Trustee G (SEAL) Y: P yllis M. McKinnon, trustee STATE OF WISCONSIN ) ) ss. ST. CROIX COUNTY ) Personally came before me this 11th day of December, 1996, the above -named William N. McKinnon and Phyllis M. McKinnon to me known to be the persons who executed the foregoing in� and acknowledged the same. ell Barry C. Uundeen Notary Public, State of Wisconsi My Commission Is Permanent. Y THIS INSTRUMENT DRAFTED BY: Barry C. Lundeen MUDGE, PORTER, LUNDEEN & SEGUIN, S.C. 110 Second Street, Post Office Box 469 Hudson, Wisconsin 54016 a VOL �z1.`�PACf�� . 4 Waco" of land located in ~" t� Mn/ of section 32, T3011 P4rt Of 199, thO ol4St the IaNi /4 and the 861/4 of St. Croix Cpmtr, WiacOmin; described as follows CbmAmcirg at the 93/4 corner of said Section 32; thence U01 tUe •est line Of the WI/4 of•said section, 773.29 feet to a point as thm = aastiiasly right -of -WW Of the tans road (126th Avenue) be ing the m at 29 ; thence Mutiauiag 1101 along said west line, 531. tit: the nce 589006'12 north "s aicmg the th line of the MI/4 of the 1811/4 of said Notion, 249.99 feet; thence 901 265.02 feet; thence sawfts -14.8, 523.05 feet to a point On an 80.00 foot radius curve, conoava _o %, aWesterly, Whose central angle - •aaMUres 64 Whose chord bears M9 and oeasuses 84.97 feet theme northeasterly, a m* thm are of said curve, 89.58 feet; thence 8532'38 376.69 feet; thence X26 -2, 357.04 feet; tb,enpe 854 272.54 loot to the point of cuz+a ,%WO a 196.22 toot radius curve, concave southwesterly, MhaN ag tral aag�. s+easures 32 59", Whose chard bears 337 and W4asnreo IL -03 lest; thence southeasterly, along the arc of said curve, 111.53 rest t0 the point Of tangency; thence 821 "s, 50.00 feet to the point CC CUzWmtv= a 367.00 foot radius curve, concave Wester whose central ao�Le MGMWosee 47 ftf';12 0 , who" chord boars 802 and measures 295.26 tbwcs southerly, alaeg the are of said curve, 303.87 feet to the post at t�� 9-7f is 825 1X0.00 feet to the northerly right -o! of gal& to= Void (116th Avenue); thence N64 "9, along said right- of-ma. 105.00 feet to the point Of curvature Of a 507.89 foot radius curve, oasKve Bmth"IY, Whose central angle measures 37 Whom d and t� 1: P U r X82°42' 57.111 and •oasureo 326.51 feet; thence Westerly. along the we "r CC said curve and Maid right -of -Way. 332.41 loot to the point Of taaonncrt tbeeoe 878 8 N, along Maid sight -of -Nay, 345.00 feet to the point of CINZWa of a 455.00 foot radius curve, concave northerly, whoso ceeatssl -13 f measures 4200 ,050, WWho" chord bears 1180 7 "9 and saasus60 321 326-13 333.54 feet t0 the y me the arc of said curve and said ri ot point of tangency; thence 959 S2 "11, along said right -of -Way, s7� rt 12 �aad is e.�t to 1 easooaata o l record. 19.14 A�Cr+es (833, 608 E