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HomeMy WebLinkAbout030-2131-11-000 Wisconsin Depa ,tment of Commerce Count PRIVATE SEWAGE SYSTEM St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 506180 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: Johnson, Glen I St. Joseph, Town of 030 - 2131 -11 -000 CST BM Elev: Insp. BM Elev: 7F Description: Section/Town /Range /Map No: — 7' 16 1 (25 - 2 1 C-5T 23.30.20.1065 TANK INFORMATION ELEVATION DATA in TYPE MANUFACTURER WA 5 CAPACITY STATION BS HI FS ELEV. J Septic � F tQ 1L56 Benchmark �• 3 lbij R7. /6 Alt. BM d a SZS •� Z Aeration Bldg. Sewer Holdin suHt Inlet 9.93 ?A f TANK SETBACK INFORMATION St/Ht outlet 17 Z 5 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic J i Dt Bottom 1 p y Z5 (PtJ 7 $� Dosing Header /Man. q, '79 Aeration Dist. Pipe 93 Holding Bot. System 4 -3 PUMP /SIPHON INFORMATION Final Grade Manufacturer Demand St Cover a GPM �'I�► Z• v 9g' Model Num' r �, rl 4P7 TY f3 TDH L t Friction Loss System TDH Ft I �V Forcemain ia. Dist. to Well SOIL ABSORPTION SYSTEM If BED /TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No Of Pits Inside Dia. Liquid Depth DIMENSIONS \ SETBACK SYSTEM TO V P/L BLDG WE LAKE /STREAM LEACHING Manufacturer INFORMATION CHAMBER OR g'` l 440 Type Of System t k J Z� I -7 UNIT Model Number 6_6 . n /v DISTRIBUTION SYSTEM A).Rl.,, ZZ Header /Manifold #! Distribution x Hole Size x Hole Spacing Vent to Air Intake t u Pipe(s) Length 5 Dia T Length \ Dia Spacing_ J d SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only e Depth Over I IDept h Over Txx epth of xx Seeded /Sodded xx Mulched I Bed /Trench Center V Bed /Trench Edges �` oil � N Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / Inspection #2:____/__/. Location: 1431 Pioneer Circl Houlton, WI 54082 (NW 1/4 SE 1/4 23 T30N R20W) Settler's Glen Lot 11 Parcel No: 23.30.20.1065 G 1.) Alt BM Description 2.) Bldg sewer length = - amount of cover = C ! j 2 l 'i Plan revision Required? Yes > No J Use other side for additional information. Date InsepctoWture Ceit. No. SBD -6710 (R.3/97) I __ __ _ ._ _. R . , . i ���� ��Z � ;, 1 �� � �` tL co mmerce .wi.gov Safely and Buildings Division - - -- County 201 W. Washing(on Avt.. P.O. Box 7162 � ` Madison, Wi 5370 ? -7162 Simitary Ptrm���i (w b Ole in y Cup+rinr.rst at 1O /�� F Sanitary Permit Application Stut trans "actionNumt�er In accordance with s. Coma 83.21(2). Wis, Advs. Code, submission of this form to the appropriate governmental j i;rin is required ltnor is obtaining a sanitary permit Note: Applicaiwn forms ! etale« owned PO AIV Ojecl Address(,fd,.`feren( than tnaiiingaddress) subtstilteti to the Uepanrt)ent of Commerce I'etsonal information yuu provide rna) ix used jhew ndaly �x ,srx ,` �cc dunce w ith the P t L s, 041 State. i A I Ilicatioll tnformaUon — Plea Print All inform n rl 9uPe t� ti)umer'� hen —.�� — ' -- - -_ _— /-� xrcel r f'rotxr' O,'s i ng n - ltdress AP y Locatton < lx COUNTY _ ___.. t. Lot I I c ity Stale `-` i P ode Phone Nurtibtr I r, I 4 &1 1/., � ' 4 ,.! Secnoa, 23 i ( � ry � l l fi . , T �. R 1 1 1 C- r, u YPe of B all that apply) I Lot f Ur 2 Fant�ly Dw'ellug '14 r is 9 Subdivesron Nymne PubliclCommrrc,ul I 7�"JTLP'7`I � Clty of J State Uw ncd - Dcsw ibv Lisa C c 't-a CSM Number ❑ �'sifa�e ut' _ __ _ i own of rC —_ --- E31. Type of Perm it: (Check gnty one box on lin A. Coml)lete lin 8 if atenlir.able `� —� --- -- ----�- — __...__— VDO tvew S stCm � y ❑ Rsislacemant Sywem ❑ 1 reatmc.uH Repiti m i:Oidy [ Other Modititatiun to Existing tiystent (explain) f ? Pe � List Key ious Pernik Number and Date issued i mut Renewal ❑ sion Change of Plumber d Permit TrartFfer to New E � llt:forc � Own iV. 'Ce�pe of PU `VTS ntlDevic Che all t hat a 1 jNo,rr'rcasurized In Ground f'rasaurired In•Crround a J. G (� Mound 4 in, afsgltublr. s tt Moun r 4.n. of suite L -1 Nold ni;'rank (] Oti,e, t)is real f'pnt • i>e ponent(expi;,in)'��n.. - �21�r� 2'�`C.M7�+rca1� ovice ex i / ( D __J I Dispersalf freattnent area informa -- - -- 7::� Design Flow (gptf) aesiltn SoiE Applicaiiun Rare{gt�ds TDisi)ersal Area Rcquir+dl (sl) Dispersal Area Pro d (sf)i vats Elevatmn 1 7VI. Tank Info apacitr in Total M of Manufacturer i 1 i Gallons Gallons i Unia / C i New Tanis l w �epiic or Holding T.n♦, �__. �..- ------ - c�G�L� ` ,� _ r�� �'C 2 -lnscrg C;hantber '� i Vii. Responsibility Statement- 1, tale undersigned, assume re sLwnsibility for iastallatlop of the POW TS 14pa on the attached plains. r i / timber's !came (Prtntl i Plurni�er "s S iptarure P WRS Number Business Phone Number ' fumGer's .lddress {Street, City, Statt, 2q) ' � f ♦'ill. at lD epartttsent Uss Onlr h' p�rraved Disapproved ~ rsermitTee GZ Date 1 sued - Issuing Ay(ent ignature CC ss,,, Given Reason for U 73 6 / — 7 - W!8"NEKppr ea s Disapproval 11 Septic tank, effluent filter an Z r dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. A l l s etback requirements must be m aint a ined de 6 6 F, AkOA a t a as per app stable co rieigde plant to r tree aypHn ni 3a it to fire Con aaly pea paper u<!ea tit a s in a of eh in sue !� SIM -639$ (R. 1 +07 Valid thty 01/09 �� q f°UYYJI�Lc� .� r a loor var PV i� 1V �i 00 0 9- a Cad S' -T,,, Gl m , l a /I CG C 4�4, -• cl s b p� G 0 9- D Wisconsin Department of Commerce """'* UATION REPORT Page of 3 Division of Safety and Buildings in accordance with Comm 85, 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 not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location an arest road. Please print a I info (fpEWED Reviewed by Date Personal information you provide may be used fo secondary purposes (Privacy Law, s.1 .04 (1) (m)). 6 Property Owner M AY LIJUI Pro arty Location Go Lot ,F/s� 1 /4� 1/4 S Z T N R E Property Owner's Mailing Address ST. Lot Block # Subd. Name or CSM# O v City f State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road r Ol New Construction Use: W Residential /Number of bedrooms 3 " y Code derived design flow rate _ Q GPD ❑ Replacement r ❑ Public or commercial - Describe: _ ` _ __ _ Parent material _ (�C Y I cz S Flood Plain elevation if applicable ��G Lill, �Q.3 Q ft. General comments p � / and recommendations: S Y e ( u / loz j ( �a v t-- V 4 / �4r-le� e� [ n Boring Boring # Ep C/'18 pit Ground surface elev. ft. Depth to limiting factor � J � in. � Soil lication 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 I o - 3( /rt'z �� i' ^ z 3 3, S; ( -�—' - 55 " 70 C S I , 4 Y Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor is in. Soil Application 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 O Effluent #1 = BOD > 30 1 220 mg/L and TSS >30 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please 'pt) ( ature _ CST Number Q' C w' Syt i _ S3 / Address n / Date Evaluation Conducted Telephone Number A (�` C • �uJ rr29/ / e j/• � 7 S���jZ ,S 7& a "aZ Property Owner �y� ��� Parcel ID # �� r l /7rs /� Page of _-,,> FS1 Boring # ❑ Boring pit Ground surface elev. ft. Depth to limiting factor in. Soil Application mate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I -y0 �- G , Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil licetion 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 El Boring # ❑ Pit Boring ❑ Ground surface elev. ft. Depth to limiting factor in. Soil A pplication 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 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD 130 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. SWUM QW00) A q e c,l J , 2 e e e rn a I'VI i'A /fix VVL X b m g -Z q uj L 3 SEPTIC TANK F?:MP CHAM CAt;55 $ECIZON AND SPECIF -CA TIONS 4" C.I VENT PIPE 12" MIN. ABOVE GRAVE WEATHERPROOF ?'25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER FINISHED GRADE W/ PADLOCK € W 4. GI RISER ARNING LABS - il ._.._ 4 it M T N . 18" I N . 6" MAX. L NLE'r ! E i WATER TIGHT SEALS GAS' TIGHT FA ' PPR01►EO A SEAL OINTS WITH PpROV'EU -- ALM A PPROVED PIPE 'IpL 3' ON ' ONTO INTO SOLID ' OLD SOIL FOIL PUMP OFF ELEII FT. --�- � OFF RISER EXIT RMITTED ONLY TANK .ANUFACTUREP. HAS APPROVAL 3" APPROVED BEDDING UNDM TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE 47 TANK MANUFACTURER: 1 �..F�. NUMBER DOSES PER DAY. TANK SIZES: SEPTIC VAS0 UAL. DOSE V OWME INCLUDING DOSE GAL. FLOWBACK: 1 GAL. ALARM MANUFACTURER: L. tixj: jm%Lm _ CAPACITIES: A = INCHES = LI GAL, MODEL NUMBER: b L- SWITCH TYPE: rf 8 Z INCHES = �. GAL. PUMP MANUFACTURER: C = INCHES = GAL. MODEL NUI SWITCH TYPE: Me-LC, D - INCHES - Ott GAL. REQ IRED DISCHARGE RATE L4 0 GPM PUMP 8 ALARM WIRING AS PER T LHR 16.23 W A4 VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE . JQ_ FEET + MINIMUM NETWORK SUPPLY PRESSURE 2.5 FEET + FEET PORCEMAiN X �,WO /100 FT. FRICTION FACTOR . ' FEET TP'."AL DY NAMIC HEAD - FEET NTERN1AL DIMENSIONS OF PUMP TANK: LENGTH _. _ ; WIDTH Y--" ; DIAMETER LIQU TS£TTS � 8 '' I Q1 &,4L pee J SIG ?viD: �� LICENSE NUMBER .QLa_ v DATE 1; 88 RGOULDS PUMPS Submersible Effluent Pump �r 3871 EPO4 EP05 APPLICATIONS • Fully submerged in high ■ EPOS Impeller: Thermoplas- ■ Bearings: Upper and lower Specifically designed for the gra de turbine oil for tic enclosed design for heavy duty ball bearing following uses: lubrication and efficient improved performance. construction. • Effluent systems heat transfer. ■ Casing and ease: Rugged • Homes Available for automatic and thermoplastic design provides AGENCY LISTING • Farms manual operation. Auto- superior strength and corrosion CmdwSWWardsAssodirtim • Heavy duty sump mastic models include resistance. • Water transfer Mechanical Float Switch ■ Motor Housing: Cast iron (CSA listed model numbers end • Dewatering assembled and preset at the for efficient heat transfer, in "F" or "C ".) factory. strength, and durability. SP ECIFICATIONS ■ Motor Cover. Thermoplastic Goulds Pumps is I50 goat Registered. FEATURES cover with integral handle and • Solids handling capability: float switch attachment points. 1 /4" maximum. ■ EPO4 Impeller: Thermoplas- III Power Cable: Severe duty • Capacities: up to 60 GPM. tic Semi -open design with rated oil and water resistant. • Total heads: up to 31 feet. pump out vanes for mechanical • Discharge size: 1 1 /2" NPT. seal protection. • Mechanical seal: carbon- rotary/ceramic-stationary, BUNA -N elastomers. • Temperature: 104OF (40°C) continuous 140°F(60 intermittent RAFTERS FEET • Fasteners: 300 series 10 stainless steel. g sow --, .._ • Capable of running dry without damage to s -� 2s FT components. 25 ,. ;.... _.. . 7 Motor: • EPO4 Single phase: 0.4 HP, v s 20 115 or 230 V, 60 Hz, 1550 RPM, built in overload with 5 automatic reset 4' EPOS • EP05 Single phase: 0.5 HP, c 115 V. 60 Hz, 1550 RPM, *- _....._. .__ -_._ built in overload with .. EPO4 automatic reset. 1 • Power cord: 10 foot s standard length, 16/3 1 S1TOW with three prong grounding plug. Optional 20 0 00 10 20 30 aa. _ so GPM foot length, 1613 SJTW with three prong grounding plug (standard on EP05), o z 4 6 a to 12 ml /h CAPACITY Goulds Pumps ® 2 000 Go ulds Pumps ITT Industries Effective February, 2008 83871 POWTS OWNER'S MANUAL A M PLAN Nape - or FiLE INFORMATION �� 2� YSTEM SPECIFICATIONS Owner . _ , 6b Septic Tank Capacity �, �'" �j a l ❑ NA Permit 1f / —.-. ---- -- l0 ( 6 Septic Tank Manufacturer e�Se. ❑ NA 1 3..__. DESIGN PARAMETERS Effluent F ilter Manufactur 'Z0_6 �'e. 0 NA Number of Bedrooms ❑ NA Ef ! Filter _ f tart F e Mode} �..._...�.. _ DN A Number o f Public F Uni Q NA ^ Pump Tank Ca pacit y g o Est imated flow {average) - 4r 9 - 0} - g al /day PuMP Tank Manufacturer SE' ❑ NA De fl 1peek), x 1.5) el /ds Purrip Manufacturer G O �� ~T 0 NA Soil Application Rate ate i x P Model q NA /� um M de V. P_ � alltla /ft Standard Influent /Effluent Quality Monthly average* Protreaunent Unit _ _ O NA Fats, Oil & Grease IFOG) i s30 rng/L 0 Sand /Gravei Filter D Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L 0 NA U Mechanical Aeration 0 Watland Total Su spended Solids (TSS) 5150 mg /L 0 D isinfection 0 Othe Pretreated Effluent Quality Monthly average Die or Cell(&) // O NA Biochemical Oxygen Demand (800 s30 mg /L n- Ground (gravity) O In- Ground (pressurized) Total Suspended Solids (TSS) s30 mglL X-1JA iQ At -Grade O Mound Fecal Colifarm (geom etric mean} 4 u;100 0 Drip- 0 Other: Maximum Effluent Particle Size Y. in dia. w q NA Other:. O NA Other___ q MA J Qthar; 0 NA *Values typical for domestic wastewater and septic tank effltant. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tanks) At least once every: year] j (s) (Maximum 3 years? C NA Pump out contents of tank( When combined sludge and scum equals one -third (Y3) of tank volurne 0 NA Inspect dispersal ceil {sl At least once Avery: ❑ month(s) X year(s) (Maximum 3 years) ❑ NA year(a) 0 month(sl At least. once ovary: � � $, ❑ NA Clean eftiuent filter Inspect pump, pump controls & alarm At least once every: 0 year($) 0 NA Flush laterals and pressure test At least once every: d month(s) 0 NA 0 year(s) Other:_____,_._ .�.._` D mor►thia) .�_._.._._ At least once every: � -- Cl yearia) 0 NA Other: ---------- ----_— _ -_ C 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; POINTS Maintainer; Septage Servicing Operatcr, 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 celi(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 pending of effluent on the ground surface may indicate a failing condition and requires the immed }ate 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 f effluent filters, mechanical or pressurized components. g M p retreatment units, and any servicing at intervals of 112 months, shalt 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. I START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the diape1601 collfs). If high concentrations are detected have the contents of the tankle) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frot at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(*) in one large dose, overlo the ca ll(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the aumb tank removed by a Septaga Servicing operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Nlaintalner to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal calla. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts c9noome; cotton swabs; degreasers; dental floss, diapers; disinfectants; far, foundation drain (sump pump) water; fruit and vegetable "slings; gasoline; grease; herbicides; meet scraps; medications oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excpvated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN if the POWTS fails and cannot be repaired the following rneesurea have been, or must be taken, to provide a code compliant replacement system: Q A suitable replacement area has been evaluated and may be utilized for the location of a replacement soi! absorption systern. The replacement area should be protected trolls disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure lot lines and wells, Failure to protect the replacement area will result in the need for a new soil and site evalu comply with the rules In effect at that time, ation to establish a suitable replacement area, Replacement systems must D A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a lest resort to replace the failed FOWTS. N�Q The site as not en evaluated to Identify a suitable replacement area. Upon failure of the POWTS a soil and site 1V evaluation be performed to locate a suitable replacement ores. 11 no replacement area is available a holding tank may b tape s a last resort to replace the failed POWTS; C Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must Comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CO LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TA NK UNGRA ANY 0IRCUM111TANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE D WFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER t+ AA , INTAiNER N ��� e1� � • A� S_ �S, y.Mt��C+ot.� Nmme Phone '7 - SEPTAGE SERVICING OPERATOR (PUMPER) LO AL ULATORY AUTHORITY Name [, Phone This document was drafted in compliance with chapter Comm 83 ,32t2lib)I l )id)arsf) and 83 ,54(l 1, t 2 & (3), Wisconsin Administrative Cody. i ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND \ OWNERSHIP CERTIFICATION FORM � Owner /Buyer 1 n n i �7'I a±0 _ C 1'vlailing Address o 1 __p 7 f" Property Address GW rr _ . (Verification required from Planning & Zoning Department for new construction.) City /State _ " ow l Parcel Identification Number LEGAL DESCRIPTION Property Location J t/4 , Sec. T 90 N It a W, Town of . Sumivision Certified Survey Map # �, Volume __ _ , Page If _ Warranty Deed # - 3 35 , Volume G / , Pag e # S Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATQN: 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 respunsibihties are Rpecified in §Comm. 83.52(1) and in Chapter 12 - St, Croix County Sanitary Ordinance. The property owner agrees to subatit to St. Croix County Planning &'Zoning Department a certification form, aigncd by the owner and by a toaster plumber, journaytuan plumber, restricted plumber or a lic6mad pamper verifying that (1) the on -site wastewater disposal system is in proper operating condition andior (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 Commor(* and the Department of Natutal Resources, State of Wisconsin_ Certification stating that your septic system has been maintained must be completed and retamod to the St. Croix County Plarntitig dt Zuniu£, Department within 30 days of the three year expiration date. 1!we certify that all statements on this form are true to the but of my/our knowledge, l /we ain/are the owner(i) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number bedXqoms SIGNA OF APPLICANTS) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning &'Zoning Department. ; ** Include with this application a recorded wanimty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (RED'. 08/05 i P Parcel #: 030 - 2131 -11 -000 05/08/2007 04:44 PM PAGE 1 OF 1 Alt. Parcel #: 23.30.20.1065 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - GLEN JOHNSON CONSTRUCTION INC GLEN JOHNSON CONSTRUCTION INC 634 COMMERCE DR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description ' 1431 PIONEER CIR SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 3.000 Plat: 2443 - SETTLER'S GLEN LTS 1/45 030/03 SEC 23 T30N R20W PT NW SE SETTLER'S GLEN Block/Condo Bldg: LOT 011 LOT 11 (3.000AC) Tract(s): (Sec- Twn -Rng 401/4 1601/4) 23- 30N -20W NW SE Notes: Parcel History: Date Doc # Vol /Page Type 09/02/2004 773335 2649/35 WD 04/29/2003 719301 9/58 PLAT 2007 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 05/31/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.000 79,600 0 79,600 NO Totals for 2007: General Property 3.000 79,600 0 79,600 Woodland 0.000 0 0 Totals for 2006: General Property 3.000 79,600 0 79,600 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 04/26/07 THU 08:06 FAX 715 386.4686 11003 - • LOT 8 � . &OW E :. a / h. 13o,ee0 so. Fr. ,:. LOT 9 � 3.000 ACM `� 130.E 90. FT. : r — 1a �• f t L.8 0- 905 .0 r.e )5.0 � .. r ........ ........................... 1 1 ............ i -' iN ` ........y. . .. .........�..... .4:. .) STORM WA's t A►A �t LOT 10 %VOO 3M ACM ►� • 4i.W.L. :903A j 130.711 So. FT. ; L.B.0.=905. .12 - ..�/ • ... / 130691 S0. FT. ,- B.O. =9o5.o v M.W.L:. =am . F 1 WATER LOT 1 S T-CM 3.000 ACRES y • �b :'RVINTION AREA 1 1 130.00 SO. Fr. A L.B.O.a90 0 0 E Nyy1M OF THE SE H.Vb • L. =903-0 y p i p le�" 94 1� i Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and parcel I.D. r percent slope, scale or dimensions, north arrow, and location and distance to nearest road. U 3 0 — , 2 / , / 1 Date Please print all �� .. �.v.__ R e y 3 r3�a ��. 3 Personal information you provide may be used for ary purposes( macYl a,ro. s.1 .04 (1) (m)). Property Owner P rty Location C OY r l G Lot N w 1/4 � 1/4 S 2 3 T 3 O N R 2f) E (or) Property Owner's Mailing Addiebs T Lotl# Block # Subd. Name or CSM# 1/trS %e City State zip Code Phone Numoer ❑ City ❑ Village ®,Town ij Nearest Road 550$2 ( ) 1 4 -'LLA t L4 w s 9 New Construction Use: Residential / Number of bedrooms ..� Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material o U 4L,� o 5 Flood Plain elevation if applicable fL General comments �y 5><�`n U q S 3 CJ and recommendations: © Borin g # El Boring � ft. Depth to limiting factor _ in. [Z] pit Ground surface elev. �� g Soil Application Rate [ R;riion ­ Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. •Eff#1 - Eff#2 f CO 2 — S1 1 2 k h4r C S i g 2 -30 1`-I Si d 2 vr� �'r c — '-I - 3 9 13 S I P - 1. S L J 1113 b m�r 5 — L4 _ ( y 115 m5 rn 2 Boring # ❑ Boring (y ❑ pit Ground surface elev. — r ?C _ ft. Depth to limiting factor in. Sail Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1 t in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 ( -12 1 '— 5i� r r c - J Z- I -y 2 10vrL41LI I 2rr Ll ry • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = B013 : < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) ignature CST Number Z533Cf� A4G Lh Date Evaluation Conducted Telephone Number Address T- ���erse� , l,J I 5`+425 r Property Owner Parcel ID . # Page • 2 o f � + 1 37 Boring #• r ❑r��1 B rn lYt Pit Ground surface elev. .19l> ft Depth to limiting facto in. Horizon Depth Dominant Color Redox Descri Soil Application Ra Texture Structure Consistence Boundary Roots GPD/ft In. M unsell Du. Sz. Conic Color Ge. Sz. Sh. 'Eff#1 'Eff #2 5 I 5 8 2 - /4 - C 's s - 3 - ml Boring # ❑ Boring ❑ Pit ' Ground surface elev. ft. Depth to limiting factor In. foil Application Rai Horizon Depth Dominant Color Redox Descriptlon.._ .. Texture _Structure consistence Boundary Roots GPD /ft= In, Munsell Ou. Sz. Conic Color Gr. Sz. Sh. 'Eff #1 'Eff#2 a Boring # ❑ Boring ❑ Pit - Ground surface elev. ft. Depth to limiting factor In. Soil Application Ralt Horizon Depth Dominant Color Redox Description Texture . Structure Consistence Boundary Roots GPD/W In. Munseil Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff #1 'Eft #2 - ' Effluent #1 = BODs > 30 < 220 mg/L and TSS >30 < 150 mall ' Effluent #2 = GOD < 30 mg/l, and TSS < 30 mg /t. 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, seamo (IL07M) i r PAGE 3 OF - - - S NAME a C r i a a A LOT# LEGAL DESCRIPTION PLO Y.�SF X .S 2-S T 56 N R Zo E(orl� SCALE: I"= �{O BM I ELEVATION U BM I DESCRIPTION (aP o - ( �Oyc e 13M 2 ELEVATION /00, U BM 2 DESCRIPTION UU D�D2 SYSTEM ELEVATION SYSTEMTYPE (onuen} c,via — CONTOUR ELEVATION V7 J - /co.c) 1 � SIGNATURE DATE ZZ G i 773335 k3 2 6 4 9 P 0 3 5 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO.. WI STATE BAR OF WISCONSIN FORM I - 2000 RECEIVED FOR RECORD Docu ment Number WARRANTY DEED 09/02/2004 12:15PK THIS DEED, made between St. Joseph Development Corporation, a WARREAXEIPT DEED Minnesota Corporation Grantor, and Glen Johnson Construction, Inc. Grantee. RfiC FEE: 13.00 Grantor, for a valuable consideration, conveys to Grantee the following TRAYS FEE: 254.90 COPY FEE: described real estate in St. Croix County, State of Wisconsin (the CC FEE: "Property "): PAGES: 2 SEE ATTACHED EXHIBIT A Recording Area Name and Return Address: Land Title Inc. 1900 Silver Lake Road Suite 200 New Brighton Mn 55112 Together with all appurtenant rights, title and interests. 030- 20 -20- 0000 Parcel Identification Number (PIN) This is not homestead property. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Dated this 31 st day of August, 2004. St. Jos h Development Co oration * Kellci St. Martin, Vice President * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF Minnesota ) WASHINGTON COUNTY. ) ss. authenticated this 31 st day of August, 2004 Personal) came before me this 31st day of August 2004 Y Y g the above named Kellei St. Martin, Vice President of St. Joseph * Development Corporation, a Minnesota Corporation to me TITLE: MEMBER STATE BAR OF WISCONSIN known to be the person(s) who executed the foregoing (If not, instrum t and acknowledg the s e. authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY *Nancy J entz I Notary Public, State of nnesota My commission is permanent. (If not, state expiration date: Greg Booth A ttorney 1 900 S ilver L ake R oad S uite 2 00 ) New Brighton Mn 55112 (Signatures may be authenticated or acknowledged. Both are not necessary.) ■ *Names of persons signing in any capacity must be typed or printed below their signature � NANCY J. LENTZ NOTARY PUBLIC - MINNESOTA My Comm. Expires Jan. 31. 2005 WARRANTY DEED STATE BAR OF WISCONSIN ■ LOT a &ODO ACRES 130,680 SO. F r. I 4• . `1 �• \ . LOT 9'. 3.000 ACRES 13006 SO. FT- I 14 I rev 4 L.B.O. =905.0 , ,. Fr. fi = 903.0 12 I H.W.L.= , t 05 .0 °'/ I I ............................. ..... ..................... ...................... i STORM WATER RErEN AREA I �I LOT 10 \�• � I 3.001 ACRES eT N.W.L. =903. I 130,711 SO. FT. L.B.O. =905. �. - - .art a. ���'wsse.�r • ' �_ LOT 3.000 ACRES I� / 130,691 SO. FT. I 187.20' L.B.O. =905.0 v H.W.L. =903.0 Fr \ _ s f ' _ STORM WATER LOT 12 3.000 ACRES ° \ �b RIMNTION AREA ( 1 130.699 SO. FT. L.B.O. =905. Z jE NW1 /4 OF THE SE1 /4 \ \ \ H.W.L. =903. J