Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
030-2131-21-000
✓isconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 430132 0 GENERAL, (FORMATION (ATTACH TO PERMIT) State Plan ID No: Personal ir�forma)on 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: N0' ` V3 - ,?j _ WV 7 Dan Lan Homes St. Joseph Township l,(�J v �(/�/ CST BM Elev: Insp. BM Elev: BM De ription: Se ion/Town /Rang Map No: �l�• t:� -b lS 4"b ✓ 23.30.20. D TANK INFORMATION E EVATI N DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Ben mark u /as Z. 02 lOD •a Dosing -7s-'D Alt. B / Aeration Bldg. Sew ` M1;,I..q 0 g� a Holding Ht Inle n 04 Go n "a of /5. 2, - TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WEL B LDG.� Vent to Air Intake ROAD Dt Inlet W n6v`�1 p Septic I p�' i Dt Bo V�I�t •'e � IT - 7 9 Z ..O Dosing !/ D Header /Man. Aeration Dist. Pipe Holding Bot. System Tkeinc � Final Gra PUMP /SIPHON INFORMATION M S f Manufacturer f Demand St Cover T{ c�rd Y►�aL�Z GPM Q - ✓t S �i%� ' S • 77- Model Number M TDH Lif Friction s � System H� T t 4- _Ft Forcemai I Len th Dian N Dist. to W I OI ABSORPTION SYSTEM ��! ��oG✓S' BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 f �- 3 � " SETBACK SYSTEM TO 7 � ' P/L IWELL LAKE /STREAM LEACHING Ma rer 7 INFORMATION \ CHAMBER O � 1 � J Typ Of S A (V I Model Number: DISTRIBUTION SYSTEM erK Header /Manifold Distribution x Hole Size z Hole Spacing Vent to Air Intake Pipe(s) i' 1. —�_— Length Dia Length Dia Spacing l�J SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over L Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center T/r Bed/ Trench Edges Topsoil �j [ 1 Yes i No Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / t /y / U / Inspection #2: Location: 135 Heritage Trail Hudson, WI 54016 (NE 1/4 SW 23 T30N R20W) Settler's Glen Lot 21 Parcel No: 23.30.20. 1.) Alt BM Description =�r ��' Gam /S`�/Y12 aA.� /-U- YlZ4.A 5&4 2.) Bldg sewer length - amount of cover =� J Plan revision Required? Yes No Use other side for additional information. JI "BD -6710 (R.3/97) �i� Date � IJ U ' � ' {-S // � � In7e's Signature� / � Cert . No Safety and Buildings Division "Y rte/ Cyr- ` 201 W. Washington Ave., P.O. Box 7162 Madis iseonsin on, W 1 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) (608) 266 -3151 Department of Commerce State Plan LD. N Sanitary Permit A lic IVED In accord with Conan 83.21, Wis. Adm. Code, information you provide ( Brent than address) mailin may be usod for secondary Purposes Pti Law, sl s.tYt(lxm) Address r i ' ! E 1. Application Information - Please Print All Informatt u 11��" Parcel 4 Block # Property wner's Name ZONING OFFICE �' Property wMai ling A�_g ss S y Location a ( F/ (' 1 H .e 7 N✓� �., 'h, Section $ City, State Zip Code jjPho��ne Number e 55r� Z W' ^ 3 b T DN; R E ot�) ll. Type of Building (check all that apply) Al , �j Subdivision Name CSM Number AIVL X or 2 Fancily Dwelling - Number of Bedrooms R/- 5 t�1"t�es L�01 ❑ Public/Commercial - Describe Use 6 w CGt'r'L�� ❑City_ ❑Village Township of ❑ State Owned - Describe Use it[. Type of Permit: (Check only one box on Ilne A. Complete line B if applicable) A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System Y List Previous Permit Number and Date Issued B. ❑ Permit Renewal Permit Revision - C1 Change of ❑ Permit Transfer to New -7 Before Expiration Plumber Owner "+'3o 13 Z U/3D1 0 J 1V. Type of POWTS System: Check all that a 1 // ❑ N - Pressurized In- G round ❑ Mound ? 24 in. of suitable soil [I Mound < 24 err. of suitable soil ❑ At -Grade ❑Single Pass Sand Filter Constructed Wetland ❑ Pressurized )n- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Fitter ❑ Leachi1v Chamber ❑ D Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dis ersaLrFreat ment Area Information: Dis rsal Required aired Dispersal 1 Area Proposed (sf) System Elevation v Design Flow (gpd) Desi Soil Application Rate(gpdsf) Pe e9 s (� / 7 �7 $70.46 `10.8 VI. Tank Info Capacity in Total Number Manufacturer Concrete Constructed Steel Glass Plastic Gallons Gallons of Units / Ncw Existing Y Tanks Tanks Sc tic or Acrobic Tmatrnc- Unit Duaing Chambcr rb l. Res nsiblll Statement- 1, the under ed, asa ere nslbW for }nstaUatlon of the POWTs shown on the attached plans. Vl Plu the (Print) PI SS' MP RS Num ��� Z Busute� Ph o ne N umber ono L � AJ � /"�,� l3 Plumber's Address (Street, City, State, Zip C V111. )Count /De artment Use Onl Sanitary Permit Fee ( ludes Groundwater Date sued suing Ag t Signature (N s) Approved ❑Disapproved Surcharge Fee) El owner Given Reason for Denial SD IX Conditions of ApprovaUReasons for Disapproval .,, / _ / S y ' ��--� �� a'�` �.`•� -tom' `-��'� `� '�, , A h complete plain (to the ounty only for the systc o per not than YlR s 11 I,nehn In ` SBD -6398 (R. 01/03) t J Se-cs / -� r � s dam. o 4-o - - w Ott f l� tA xv �5 vtit� „ ol� — e-3 �p 1� tit el r L � lo• o� iti w�1 J 1 � o Z 4 7 o 'yON boo r � R - ` i ZA �� X C21 i)� D VA ¢.k f G v ( � 0 vk , *- l } t ®o v /erg dL6t11r (( M S4MvsQ, tOwt ��•�.�� 7sg•S � • z. '� #-A" o •, � ,ya, o+cwK Qo Li �a b �� fie_ �'i .�. �.��k�»;� �•.� 1y,, � S set �... ,�•o�r+��.a r I FROM CERTIFIED SOIL TESTING FAX NO. 715 233 0388 Jun. 14 2002 05:52Ah9 P2 WE�,TkE0.PRc:vF l.00KruG GO�/sR � I 1 � fcrA�N d 6 Q�tt:K. Ot�GOwtviGT --•� j �h to o p y `` j7/,7%7,1,7, s1� tau 1.ti. a VY b a CrT !1 T'J �CiFF1. AL � I � 1-: \ � �►,. : �. O W� 4 a.. `t' � III � � t' ' ` ij i O&P A I j I C4rit:.reE'rc SEP TIC E G1�1'CA'1�15 �! DOSF £ f'1 A. Q U FA, Cr Q R 7- R: �JW"�6`<R OF DDSCS'. -� ,� v ^.� i z�—o �sb T..�:x sJz� ; tiAt_Lpt.tS .00SC VOLUME I20 i.�Astir1 ltftil?IIFALTtSft.CR; S .i �' 4.�v,� tR1GLS5o5NG: ^00ZL QUP116EK: \ o t t `-� CAPACITIES; A= 3o I C)K SWITCH TyPL: � 5 x Z 1tiCH£S.?R ^^G KAIJUFACTIJRCR: �T�i VN✓I'T(� ca 7 lULKFS OR .,.+_. t MOC£L 1JUMbi1t: '�� 3 b+. � INCHES GR � °2. � Z . G�•._...;; SWITGI•i TbPE: %,-ti QJv`"`r MJ TT£�_ PUAP AAW ALARM ARE TO 8L M041 MUM pi5CHA,1t&E R A T'C 3d ,_GrM INSTALLZO O►J SEPARATC Clk" VL0.TICAL DiFFEXCQCZ &Z .frW PUMP OFF A1.1n 013TIU4UTIOW PIPE.. /-7 vccT } m.IUI,-,UK kLTWORK SUPP1.l PA.C&SUR£ . . . . . . . , . . D FLCT + £CET OF FORCC t - %0k04 X / � 9 r ^ /gpytFRICTIQil FACYCIL. Lo FEET TOTAL. WdWAMIC. FICAp /60 FEET l JUTERQAw DIMr- Witiows OF TAWK: LF.WCPTN ORIGINAL 1930 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Certified Soil Testing Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D. Please orint RE&8 D R iewed Date Personal information you provide n ay be used for secondary purposes (Privacy w, s. 15.04 (1) (m)). ! 3 Property Owner NOV 0 4 2 003 Property Location Lang, Dan I Govt. Lot NE 1/4 SW 19 S 23 T 30 N R 20 W Property Owner's Mailing Address ST. CROIX COUNTY Lot # Block # I Subd. Name or CSM# 221 East Myrtle Street I ZONING OFFICE 21 Settler's Glen City State Zip Code Phone Number __j City _�j Village yj Town Nearest Road Stillwater MN 1 55082 1 651- 439 -3430 St.Joseph I Heritage Trail V 11 New Construction Use: 16 Residential / Number of bedrooms 4 Code derived design flow rate 600 GPI Replacement Public or commercial - Describe Parent material loess over sandy outwash Flood plain elevation, if applicable NA General comments and recommendations: install deep trench system w/ 0.7 gpd /sq ft loading @ system elevation of 90.8 Uh S f�^ 9AE - S w 3 �� Boring # __j Boring Pit Ground Surface elev. 96.8 ft. Depth to limiting factor > 116 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. - Eff#1 - Eff#2 1 0 -8 7.5YR 3/1 - sit 2 f sbk mvfr cs 1 m .5 .8 2 8 -23 7.5YR 4/3 - sit 2 m sbk dsh cs 1 m/c .5 .8 3 23 -28 7.5YR 4/4 - sit 2 m sbk dsh cs 1 m/c .5 .8 4 28 -60 7.5YR 4/4 - Ifs 1 m sbk mvfr cs Inn .5 .9 5 60 -116 7.5YR 4/4,3/4 - s 0 sg dt - - .7 1.2 4 common gy si co is on peds in horizon & 3; gr, cob, occasional st and occasional stratified mcos in horizon 5 Sx � F 0 Boring # � Boring Pit Ground Surface elev. 97.0 ft. Depth to limiting factor > 112 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 7.5YR 3/1 - sit 2 f sbk mvfr cs 1M .5 .8 2 8 -16 7.5YR 4/3 - sit 2 m sbk dsh cs 1m /c .5 .8 3 16 -30 7.5YR 4/4 - sit 2 m sbk dsh cs 1M .5 .8 4 30 -112 7.5YR 4/4,3/4 - s 0 sg dl - lm 7 1.2 common gy si coats on peds in horizons 2 & 3, gr, cob, occasional st in horizon 4 Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L LEffluen — 5 _ mg /L and TSS < 30 mgt! CST Name (Please Print) S ture CST Number Henry F. Grote 222774 Address Certified Soil Testing Date Evaluation Conducted Telephone Number E. 4366 353rd Ave., Menomonie, WI 54751 10/27/2003 715- 233 -0398 r f Property Owner Lang, Dan Parcel ID # Page 2 of 3 F3 ] Boring # _ Boring 94 Pit Ground Surface elev. 96.5 ft. Depth to limiting factor > 120 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 -7 7.5YR 3/1 - sil 2 f sbk ds cs 1m .5 .8 2 7 -21 7.5YR 413 - sil 2 m sbk dsh gs 1 m/c .5 .8 3 21 -41 7.5YR 4/4 - sil 2 m sbk dsh cs 1m .5 .8 4 41 -50 7.5YR 4/4 - Ifs 1 m sbk dsh cs 1m .5 .9 5 50 -120 7.5YR 4/4,3/4 - s 0 sg dl - - 7 1.2 t I I common gy si coats on peds in horizons 2 & 3; gr, cob, occasional st and occasional stratified mcos in horizon 5 F -1 Boring # Boring 1j Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD ' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ❑ Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots ' 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 < 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. S13D•8330 (R.07 /00) Certified Soil Testing L �� NYd- Sw • 23 -Zd- t° w Z-0 4-0 z31.,s4� C q(.•S� `•v c. l 1 I.5� AM •Q � L � Lt Th2 v :F 0 bs ,N SA.cx - o (2 C O, o qA a.4 v.t. Q_ t9 wt Q-s 1•: � .. �,,� `° 7S a • S •�- OKt�K•S 0 Li t , 3 POWTS OWNER'S MANUAL u MANAGEMENT PLAN Pa of FILE INFORMATION SYSTEM SPECIFICATIONS Owner f Septic Tank Capacity gal ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA, Effluent Filter Model d0 ❑ NA Number of Commercial Units 2 Pump Tank Capacity gal ❑ NA Estimated flow (average) Q gal /day Pump Tank Manufacturer - ❑ NA Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer /pL ❑ NA 00 v Soil Application Rate 7 gal/day/ft' Pump Model 30 ❑ NA Influent/ Effluent Quality Monthly average* Pretreatment Unit ❑ NA Fats, Oil 8i Grease (FOG) :530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter :_220 mg/L ❑ Mechanical Aeration ❑ Wetland Biochemical Oxygen Demand (BODs} ❑Disinfection ❑Other: Total Suspended Solids (TSS) :5150 mg /L Manufacturer Manufacturer Pretreated Effluent Quality ❑ NA Monthly average ** Cell(s) Biochemical Oxygen Demand (BODs) :_30 mg /L 0411n (gravity) ❑ In- ground (pressurized) Total Suspended Solids (TSS) 1530 mg /L n At -grade ❑ Mound Fecal Coliform (geometric mean) :_10 c€u /100ml ❑ Drip -line ❑ Other: Maximum Effluent Particle Size % inch diameter * Values typical for domestic (non - commercial) wastewater and septic tank effluent. * * Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every 3 ❑ months years) (Maximum 3 yrs. ) Pump out contents of tank(s) When combined stud and scum equals one -third ()6) of tank volume Inspect dispersal cell(s) At least once every 7,13 ❑ months years) (Maximum 3 yrs.) Clean effluent filter At least once every ❑ months year(s) 04 ^5 NAG Inspect pump, pump controls 8Z.-alarm At least once every Z 3 ❑ months ear(s) ❑ NA Flush laterals and pressure test At least once every ❑ months ❑ year(s) NA Other: At least once every ❑ months ❑ year(s) NA other: At least once every ❑ months ❑ year(s) NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (A) 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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent fllters, mechanical or pressurized POWTS components, pretreatement components, and any other maintenance or monitoring at intervals of 12 months or less shall be performed by a certified POWTS Maintainer., A service report shall be provided to the local regulatory authority within 10 days of, completion of any service event. 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 dispersal cell(s). If high concentrations are detected have the contents _C ..L- -A k- , &e te• mrviirino nnnritnr nrinr to IKP. Page of System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; Desticides; sanitary napkins; tampons; and water softener brine. ABANDONEMENT 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 ch. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replagepent system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. • The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. • Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules In effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMMVURIF.. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name A li �/`L PGal 4 — Name Phone zk&154 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Namel Agency 61), )c ek Phone I I Phone ?(S= WAIF ' q-Wo Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 S iseonsin Madison, Wl 53707 - 7 Sanitary Permit Number (to be filled in by Co.) (608) 266 -3151 1 -13 v 3 Department of Commerce State Plan I.D. Number Sanitary Permit Application IJ A In accord with Comm 83.21, Wis. Aden Code, personal inform may be used for secondary purposes Privacy Law, s 15. 1 )( r- R E C EIVE (ifAifierent than mailing address) T�U41 I. Application Information - Please Print All Information Property Owner's Name P 1 # Lot # Block # 1..►ao Komi r z' Property Owner's Mailing Address y Location Q 5r r y. G -` t,., Section City, State A , 'IG Zip Code Phone - Phone Number t� C Q S 1 � v �' �•�� T N; 1 11. Type of Building (check all that apply) Subdivision Name CSM Number or ? 2 Family Dwelling - Number of Bedrooms � o4e N ❑ Public /Commercial - Describe Use El Owned - Describe Use K GM W � ❑>ityl To p of 111. Type of Permit: (Check only one box on line Complete line B if applicable) A. New System El Replacement System ❑ tmenUHolding Tank Replacement Only ❑ tion to Existi ng System B. ❑ Permit Renewal ❑ Permit Revision ❑Chang ❑ Permit Transkr to New Prev N E YMM Before Expiration Plumber Owner 1V. Type of POWTS System: Check all that app l X Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ M 4 ' suitable soil ❑ At -Grade ❑ Single Pass Sand Filter C1 Constructed Wetland ❑ Pressurized In -Ground ❑ Holding Tank ❑ Peat F' ❑ Aerobic Treatment Unit El Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip vel Pipe (explain) V. Dis rsaVTreatment Area Information: L Design Flow (gpd) Design Soil Application Rate(gpdsf) al Area R s pos (sf) System Elevation DD 07 57 3 `� 9S ° V1. Tank Info Capacity in Total 09umber Manufacturer Prefab Site Steel Fiber Plastic Gallons Gall of Units � 14-1,1116 to Constructed Glass New Existing � • /� Tanks Talcs Septic o O ` Aerobic Ttcauncnt Unit Dosing Clamber O Y VII. Responsibility Statement - I, the undersigned, n ty for installation of the POWTS shown on the attached plans. PI s Name (Print) Plumber'�Sture MP/MP Number F ;;�one Number Plumber's Address (Street, City, State, Zip C 5610 9 4 r ,✓o�rn�u>� �,�/�' d4/7 Vlll oun /De artment Use Onl Approved ❑Disapproved Sanitary Permit Fee (includes GroundwAter Dat Issu Issuing Ag t Signatur o tamps) Surcharge Fee) ❑ Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disap j ar Q� ✓�� , u S S ivas V14 Q/?�4��,� Q� Y12 2 � ° Y r s ttach compfete pl (to the County only) for the systc o paper not less than 81/2 x I 1 idghes in atxe a4 SBD -6398 (� R � 3 ) ,y �1r�2� -cam 1�jruTl d'3• SZ . - ' 08/02/2003 08:48 FAX 7152 52592 T L SINZ PLUMBING_INC_ 40 002 Sr CROIX COUNTY SEPTIC TANK MAWENAPICE AORSEMEN'T AND OWNERSTIIP CERTf'rICATION FORM X Owner/Buyer LAW 6t 1 Y "'?', Mailing Address 2. C M_vr -} -1 S M t' e S S O F� C Property Address tom' rz-& 1 (Verification required from Planning Dcpamnent for new coostrverion) City /State ��' e;�1� lJ� Pared Identification Number t L EGAL VEStRr10 OW - 2032- 10— tCO(32.1� Property Location — %. Sec. a3_ . T_ L5O -Ia—W Town of Subdivision Lot # C21 Certtiled Survey Map # _ Voluino Page # Warreaty )deed # 32(1 — Volume 2Zq . Page # 6 S .4F 17/03 Spec house 2ylu ❑ no Lot tines identifiable [9"pes ❑ u0 SYSTFM MAW 1'ENAxt Improper use and mainteuaereof your septic system could resnit in its premature far7ure to handle wasm. Proper maint consists of pumping ow the septic tank every three years or soow, if needed by a Uceasedpumper. Wbat you put into the system can effect the fraction or the septic tank as a tmetment stage in the wuu disposal system. The property owner agrees io submit to St. Croix Zoning Department a eetti5catioa form, signed by the owner and by a o=asoerpiumber. jou=ymaa ptttmbcr, nruietedplamber erns licensed pumper verifyiog that (1) the as -alto wasocaaterdispoaal system tin m proper operating condieioa aadior (2) after inFpeetioa and pumping (if aeecssary), the septic tank is 1= thin 113 toll of sludge. 11wc, the aadcw4ned bavo read the above mquistimetcts and agree to maintain the private sewage disposal system with the standards set forth, herein. as set by the DepasImew of Commerce sad the Department ofNatwai Rcs otttvca, State of Wisconsin. Cortiflcutioa rtating that your sep6e system bas been maintained ,must be coutplcted and rcw=4 tv the St Croix County Zouiug Office witbio 30 days of the three y ar expiation date, nn x It-,, , 6 SICYNA'ITI E OF APPLICANT DATE O Alf Y'I3 CERTlFICATT{�N I (we) certify that aU aratemcats on this form arc true to the best of my (our) knowledge. 1 (we) am (art) the odacris) of th roperty desert d above, by virtue of a warraary decd recorded in Register of Decda Office. SIGNATURE OF APPI -I DATE 00.00 Any information that Ls mis- rcpmetttod may result in the sanitary peretit being revoked by the Zoning DepartmeaL •• Ioelude with this applitetioo; a stampod warranty decd Cram the Register of Doc& *Mee e Copy of the cwtifcd survey map if mfereace is roado in the waamaty deed 1'd eBE =BO EO 60 unr 06/30/2003 11:18 FAX 7152352592 T ii,, SINZ PLUMBING INC [002 Jun Ju ud utj: pima rT� �ri� q7w` w IU D %f Sw 5 7 Zd L- L =79.96 58g 4a 57`'* 0 - 27'26'00" R= 167.00 - T Rm rz M 2,36 S� l � s i0 �r�oo�p �....... j S 1 " 0 +� prOOOaed kcuze �• — � s 303 � �Rt f y zA 4 1 ) j V co j may= /�✓ 75'0 Pk Al C � 11 W'24�/01 TUE 15:11 FAX 715 586 4686 ST GRX CO ZONING �dxr k POVVr?'S OWNER'S MANUAL a MANAUSI'llrMi r LAN 1 f1L -Ei INFORMATION SPECIFICATIONS Owner Septic Tank Capacity Zd`O I ❑ NA Permit # Septic Tank Manufacturer DNA DESIGN PARAMETERS 6luent Filter Manufacturer E3 NA Number of Bedrooms Q NA, Effluent Filter Model OD ❑ NA Number of Commercial Units A Pump Tank Capacity D gal ❑ NA Estimated flow (average) 0 gal/day Pump Tank Manufacturer v ? Q NA Design stow (peak), (Estimated x 1,5) (pOD gal /day Pump Manufacturer ❑ NA Soil Application Rate '7 221 /day /ft Pump Model N' Monthly average* Pretreatment unit NA 1nfluenV>rffluent Quality y ❑ Sand/Gravel Filter ❑ Peat Filter Fats, Oil at Grease (FOG) s30 mg/L Cl Mechanical Aeration ❑ Wetland Biochemical Oxygen Demand (BODO :5220 mg /L ❑ Disinfection ❑ Other: Total Suspended Solids ( TSS) 5150 22911. Manufacturer Pretreated Effluent Quality ' ❑ NA Monthly average* * Dispersal Cell(s) Biochemical Oxygen Demand (BODO :530 mg/L wrl ground (gravity) Q In ground (pressurized) Total Suspended Solids (TSS) X30 mg/l. ❑ At -grade ❑ Mound Fecal Conform ( mean :5 10' cfu/ 100ml ❑ Drl -Ilne ❑ Other: � Maxlmum Effluent Particle Size ib inch diameter * Values typkal for domestic (non - commercial) wastewater and septic tank effluent. * + values tyoical for pretreated wastewater. MAINTENANCE; SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every 3 ❑months earls) (Maximum 3 yrb. ) Pump out contents of tanks) When combined sludge and scum equals one -third (h) of tank volume null inspect dispersal cell(s) At least once every ❑ months year(() (Maxim 3 yts.) Clean effluent filter At least once every ❑months frYear(s) Inspect pump, pump controls ar.alarm At least once every 3 O months years) 0 N !=lush laterals and pressure test At least once every is months Q year(() A then: At least once every © months ❑ ye ar(s) 0 2NA other: At least once every ❑ months Q year(s) NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or ceruflcations: Mast Plumber; Master Plumber Restricted Sewer, POWTS Inspector; POWTS Maintainer; Septage Servicing operator. Tank Inspection measure must include a visual Inspection of the nd o ) check e for any bac p or ponding of effluent on the grou d cra cks 'ace. The dispe of h volume of combined sludge and scum c ell(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 immediate notification of the local regulatory authority. When the combined hall be removedsb luge and scum In any tank d a Septage Serviring Oper and disposed o in accordance e with ch. 113, Wisconsi contents o( the tank she be Y Administrative Code. The servicing of efnuent filters, mechanical or pressurized POWTS components, pretreatement components, and any other maintenance or rtionitoring at intervals of 12 months or less shall be performed by a certlfied POWTS Maintalner. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. ART AND OPSIEATION p roducts or other chemic; d ST UP truce of painting p ro For new construction, prior to use of rfie POWTS check treatment tank(() . If high concentrations are detected have the conten that may impede the treatment process and/or damage the dispersal cell((). nr rki, ranirfs'D romovPd 5Y x tentaat servicing orerator prior to use. 08"'p/01 TUE 15:11 Fkl 715 386 4686 ST CRX CO ZONING Z002 System start up shall not vcplr when soil tondttlont are frown at Ow Inl1trative fumca- During power outages pump tanks may fill above nomiai highwater kvets. When power is rawried the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overioading the cells) and may result in the backup or surface dischargr v? effluent. To ivold this situation have the Contents of the pump tank rerrwved by a Sepgage Servkfnll Operator.prior to restodrit power to the effluent pump or contact a Pwmber or POWTS Maintahner to asslat in manually operating the pump controls to restore ncrmal levels within the pump lank. Do not drive or park vehicles over tanks anti dispersal cells. Do not drive or park over, w otherwise dlswrb or compact, the are.► within 1 S feet down slope of any mound or at -grade $cat absorption area, Reductlon or elimination of the following from the wastewater swam MY improve the performartwce and prolong Ow We of the POWTS: antibiotics; bacy wlpes; cigarette buttsl condoms; cotes swabs; degmase ; 4MU1 AosEi dlapersj diatn(scainu; fit; foundation dratn (sump pump) water; fruit and vegeuble peeling 9"ne; grease; herbkides; meat scraps; mtdicatwns; oil; painting CrOdUC14: aesUcides; sanitary n .)okim: tampons, and wiswr softener br ", AVAN DON EM E.NT When the POWTS fails and /or is pemtanentlY taken out ofservlce the following steps shall be taken to Insure that thr. system is properly and safelY abandoned In comptiince with ch. Comm 83.33, Wisconsin Adminirtradve Code$ • All piping w tanks arid pits shall bt disconnectod and #sit sbwAorwd pipe openings "akd. The contenrs of aft tanks and plu shall be removed and property_ disposed of by a Septage Strvklns Operator. • After pumping, all tanks and plu shall be excavated and removed or their covers removed and the void space Abed with soil, gravel or another Inert solid matrrial. CONTINGENCY PLAN if the POWTS rafts Anil cannot be repalmd the following measures haY4 peen, or must be taken, to proAde a code compliant replacement sYSE , Xsysw A suitable replacement area has been evaluated and may be utilized for the loradOin of a nplaoemcnt soil absorouon The replacement area should be prowcud from diswrbance and compaction and sh&Ad not be infriNed upon ey requlred setbacks from existing and proposed $VVC +re, kx tine and wells, failure to protect the replacement Ore will result In the need for a new soil and rite evaluation to estabiish a sultabte repiacemem area. Replacement systems must comply with the rules in effect at tint time. P A sutUVIC replacement area is not available due W $tomCk• and/or soil titnkatlons. 8enting advances In POWTS wchnolefct a holding tank maY be Imulled es a taut resort to repl&Ce thr fatted POWTS. ❑ The site has not bttn cv =luatkd to Identify a SwItAM replaumerlt arm. Upon fafture of the POWTS a sell and site evaluation must be performed to locate a sulubie replacementarta. If n0 replacement area Is available a holding tank may be installed as a last resort w replace the failed POWTS. p Mound an tics p ys d ax- grade soil absorption s ;em may y be reconstructed In place following removal of the bivmat at the Inflluattve surface. Keconstructtorts of such systems must.cvmply wlth the ruks in effect at that time. < < WAANiNG > > SErrIC, (RUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICiENT OXYGEN. 00 NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT, 9ESGU4 OF A PERSON FROM TK% IM19RIOR OF A TANK MAY BE DIFFICULT OR tl.iD1'1ii1R1 F. , ADDITIONAL COMM LENTS POWTS INSTALLER POWTS MAINTAINER Name A/Z 6r L• Nau ne b TNv Phone TEPTAGE SERVICING OPERATOR (P%IMPERI W GULATORY RUTH Name Agency STLr/Lt Phnnt PAGE 3 OF 3 Zl LEGAL N •VL V a -j X 2 5 T 30 N . R . ZU 5��� �s G SCALE: I"= 7 BM I ELEVATION /JO. U BM I DESCRIPTION 170/' N1 BM 2 ELEVATION BM 2 DESCRIPTION ; - kQ D� Y vC. t SYSTEM ELEVATION k� Ccu� SO SYSTEM TYPE CONTOUR ELEVATION .0 1 - - - -- A-u- - v e)-3 c l5� Sy s SIGNATU E DATE ��Z r Wisconsin Department of Commerce SOIL EVALUATION 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 81/2 x 11 inches in size. Plan must rb l include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all in ormp by Date Personal information you provide may be used for sec Dridery purposes (Privacy Law, s. 15. X (1) (m))- Property Owner n Pr rty Location r kc�. 8 n ` Go Lot NC 1/4 5W 1 / 4 S Z 3 T 30 N R 20 E (or Property Owner's Mailing Addre Lot Block # Subd. Name or CSM# l-C�l 2 2 Se?yyevs �✓� City State Zip Code Phone Number _ _. e_ ❑ City [3 Village gown Nearest Road der ��N 5D$Z ((oOI )4 OS h 39 ZL} l y w New Construction Use: Residential / Number of bedrooms - 3 :: �Z— Code derived design flow rate � 60 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material o qlw 4 S Flood Plain elevation if applicable General comments �� /Pn�t elev. J042 and recommendations: r ;` -30 = . Zo k /W = Zo �� -S� s��t�- ��.-. s��° �C° ,� d �Llm Z/ > z o a(tA Xd oring -s� ` �- _ �n a Boring# Pit Ground surface elev. ICx >.00 ft Depth to limiting factor `iso in. Soil ApplicationfRW Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 I o -�a iG 12� m- C-5 5� Z k Cs � y 3 p yl cos O I 2 �2 Boring # Boring ® Pit Ground surface elev. CX) ft. Depth to limiting factor i in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. i `Eff#1 'Eff#2 1 O lL (C) 3� 2 S I Z c- ,5 g z 12-55 ►� I�+ sic_ 2rY�sbk rY,tr �s a 3 55 - 1 10 r `-F/ (p — W3 ` Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 _< 150 mg/L ` Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number /darn S&,u N-, ksr 25 3 30� Address Date Evaluation Conducted Telephone Number 2l 3 ST Scrn 1cr5e� 1 l ��c�z5 �.�� rc12 LI 15) Z - 7 - GOOFS l l Property Owner Cay; t nP Parcel ID . # Page z of 1 Boring # ❑ Boring El pit 1V Ground surface.elev. k ft. Depth to limiting factor �_ in. t{ " Soil Application Ra Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fl' In. Munsell Qu. Sz- Cone Cobr Gr. Sz Sh. , EIf#1 •E(( #2 0-12 S; I 2 ma)ok rn Z (' -40 IC) 1 4 ILA S ?- rv-,5 b K , F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. fL Depth to limiting factor in. Soil Application Rai Horizon Depth Dominant Color Redox Descripbon.._ .. Texture _Structure Consistence Boundary Roots GPp /f1 In. Munselt Qu. Sz ConL Color Gr. Sz. Sh. 'Eff #1 •Eff#2 F-1 Boring # ❑ Boring ❑ Pit ' Ground surface elev. ft. Depth to limiting factor In. Soil Application Rats Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /W In. Munselt Qu. Sz. Cont. Color Gr. Sz. Sh. •Eft#1 'Eff #2 Effluent #1 = BOO;> 30 < 220 mg/Land TSS >30 < 150 mg/L • Effluent #2 = BOD, < 30 mg/t 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 TIT 608- 264 -8777. ssauro nL07M) i i PAGE 3 OF 3 NAME (�L r LOT LI LEGAL T)F.SCR IPTION 1/E `a. w t o o ZO SCALE: 1 "= BM 1 ELEVATION /QU. U DM I DESCRIPTION �a�' �► �/ C� r�� -� t I3M 2 ELEVATION 9� z� 4 r s PC, Z3_.____ _ I3M 2 DESCRIPTION -- SYSTEM ELEVATION �� �� •y° Ccw s 9 SO C SYSTEM TYPE ��nv�✓��-u►�c�l - _ -t " CONTOUR ELEVATION 9LI.0u —4-hry �p0 � gy SIGNATURE DATE �2 to qt s T.L. Sinz Plumbing Inc. E5609 708th Ave. A-'J � l S Phone: (715) 235 -2644 Menomonie, WI 54751 N r !��{ gVj /, Z3 T D /� Z� +� Fax: (715) 235 - 2592 www.tisinzplumbing.com �ivvv V% ST - �OSt�F� Se�b(e ►2s g' I-e ✓1 1 4 rr Tg, =(00 Sim 'q pIP'C �v SAeLt �,S D ,$w I B� &u{ Z �3Z e �B3 0 � 1 1 e' wr'go w r - y /( __f � SA�C 3o �p Zfi-t.�t� � - Ivu f,CCf FROM - : ~ CERTIFIED SOIL TESTING FAX NO. 715 233 0395 Jun. 14 2002 05:52AM P2 • YJI,l,TN�SiQRrk7t= _ �CK�uG �Ov�R jl, I C TICH Sac QittClt fGt�GLAi4itT�� 1 b" , i7r,777;,7 ,. 4 `° PtPG 3' P.0 p NnlSSupE�ED � � `a, ' yK �� i So I(.. 24" Y.L . �t 4 MT 3ria�tr'J �FF�I: � a� 3' o•r v PI!"f. Q N.tw- ru Let+ 3'� l � �+v : +� a wT t• a. 1 T' � ' • F PU P I �sv. 6caCK ) SEPTIC f _- iPEG.IF)'GA7'IQS 6)? poSF � �- TA11r•5 MA.►IUFACTURCR: - �~• \ �JW`ibUk OF Doyrs; -- dALLORtS • .DO5C VOLUFAE �Zo ALA`�rt rihUt1FALT1sRCit; S'1 L� . WC.LU%14CA 6l+LXF6.CoW - , /35 �.A � -ls ^ODEL WW4clt: 1 . t h4 C A 3 o IWCHZ5 0 K CA'-L l..l. SwITC.k TJPC: �_ �v.. bWl�,, 5- 7 _ juCHE. 0A "4.t4 ;,A:cc: s PutAp r'1AWUFACTURCR t ce 7 m il LOtt$ PIt 1 vALI.✓QJ, SWITCH TIdPE; � `Y M QT'C: PUAP AUD ALARM ARE 70 6C j t'111JIMtSM DI RAT'C 3 D GPM Lk -ED puS,E,P,QAnR�ATC CttCCu 's VERTICAL DIFFEXC)4CE &r I'WE[jj PUP& OFF AWD 016TRtWT1014 ?(PC.. IFECT + 11II. l UM 11I-TW0jtX SUPP4.y PAi&6UItC . . . . . . . . . . . rF.LT ••l �r CC ET 4F roOLCC 11AIM X / •- 9 �%*lCFRICTlQW FACT09. �'d FEET (' ~— TOTAL OtiUAMICL KEAD 8 '$ FEET � �. l l• GOi IUTERLIAt. DIMEWg,io s ' OF TAUK: LLWCPTN �;k1iD7 }� �... -�.�; LIQUIC) OILPT I4 -- Performance Wh Products Page: 6350 -1 �' Section: Performance Data Ppta Dated: January 2001 RPM: 1550 Discharge: 11-1/2"' Solids: 3/4" 12 40 9 30 W L^ L.I.. tz W Z J o SHEF30 3-- ' 0 0 Capacity -U.S. G.P.M. 10 20 30 40 50 Liters/Second 0 1 2 3 The curves reflect maximum performance characteristics without exceeding full load (Nameplate) horsepower. All pumps have a service factor of 1.2. Operation is recommended in the bounded area with operational point within the curve limit. Performance curves are based on actual tests with clear water at 70° F. and 1280 feet site elevation. Conditions of Service: GPM: TDH: I'F 14YDROMATIC Maw 21 03 07:52a p.3 1% 'MaM 09 03 05:33p 6!2 7A9 088] I sa tt I � G Qv �5 ° o C-, i7 z z z °t, Li _. .61i , } 11 coo Dmia ild NI5 Z Z Z62ZSCZSTL XVd LC :ii COOZ /LZ /90 Hay. 21 03 O7:52a P'2 flay a9 03 O5:39p 912 789 0891 P• I� Al -- tlzs t g r• � • too [A DO DNivala MI5 Z Z Z62ZSCZSTL YVd LC :TT COOZ /LZ /90 Jun 18 03 07x12a p_2 U 2278P 365 6x9 KATHLEEN N. NALSH STATE BAR OF WISCONSIN FORM 1 - 1998 REGISTER OF DEEDS ST_ CROIX CO., MI Document Number WARRANTY DEED 030- 2043 -10- 000/030- 2032 - 1000/ 030 - 2032 - 70000/030- 21733 -40 -000/ RECEIVED FOR RECORD 030 - 2032 pn- om /n_'i(] 9 0 3 ; - SoA= 06/17/2003 09:30AH Parcel Identification Number (PIN) WARRANTY DEED THIS DEED, made between St Joseph Development Corporation, a EXEMPT IM Minnesota corporation, Grantor, and Dan Lang Homes, a Minnesota REC FEE: 13-00 Corporation Grantee. TRANS FEE: 269. 70 P Grantor, for a valuable consideration, conveys to Grantee the following CC FEE: . described real estate in St_ Croix County, State of Wisconsin (the PAGES: 2 "Property SEE ATTACHED EXHIBIT A This is not homestead property. Rmording Area Together with all appurtenant rights, title and interests. Name and Return Address: Land "Title Inc. 1900 Silver Lake Road Suite 200 New Grantor warrants that the title to the Property is good, indefeasible in Brighton Mn 55112 fee simple and free and clear of encumbrances except Dated this 2nd day of June, 2003, �- C St Josep Development Corporation, - -�/�P. /// (/ j (SEAL) (SEAL) * Kellei St. Martin, Vice President (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF MINNESOTA ISS. W A SS UNC. - MN COLYNTY_ authenticated this 2nd day of June, 2003 Personally came before me this 2nd day of .Tune, 2003, the above named Kellei St. Martin, Vice president of St Joseph -- -- Development Corporation, a Minnesota corporation to me # known to be the person(s) who executed the foregoing instrument and acknowledge the same. TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by 706.06, Wis. Slats.) THIS INSTRUMENT WAS DRAFTED BY Greg Booth Attorney 1900 silver Lake Rd Suite 200 New Brighton Mn 55112 Notary Public, State of MINNESOTA My commission is permanent. (If not, state expiration date: (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•MINNESol `'y My Comm Expl,as Jan. 31. 2005 Jun 11 03 09 :49a p - 1 17 -M - Corporation Minnesota Uni1'onn Conveyancing Blanks (1978) STATE OF Minnesota 3 SS Affidavit Regarding Corporation COUNTY OF Washington ) Kellei St. Martin being first duly sworn, on oath say(s) that: 1. He /She is- the Vice President respectively, of St Joseph Development Corporation, a Minnesota corporation, a corporation, the corporation named as Grantor in the document dated June 2, 2003, and filed for record , as document number _ _ in the Office of the County Recorder of St. Croix County, J4lmrtesBta� W,SG(�h..Si�! 2. Said corporation's principal place of business is at, , and said corporation's previous principal places) of business during the past ten years (has) (have) been at: 3. There have been no: a. Bankruptcy or dissolution proceedings involving said corporation during the time said corporation has had any interest in the premises described in the above document ( "Prermses ") b. Unsatisfied judgments of record against said corporation nor any actions pending in any courts, which affect the Premises; C. Tax liens filed against said corporation; except as herein stated: 4. Any bankruptcy or dissolution proceedings of record against corporations with the same or similar names, during the time period in which the above named corporation had any interest in the Premises, are not against the above named corporation. S. Any judgments or tax liens of record against corporations with the sari or similar names are not against the above named corporation - 6. There has been nolabor or materials fumished to the Premises for which payment has not been made. 7. There are no unrecorded contracts, leases, easements, or other agreements relating to the Premises except as stated herein: 8. There are no persons in possession of any portion of the Premises other than pursuant to a recorded document except as stated herein: Affiant s 4. There are no encroachments or boundary line questions affecting the Premises for which () (has) ( have ) knowledge. • Affant(s) know(s) the matters herein stated are true and make(s) this Affidavit for the purpose of inducing the passing of title to the Premises. B B y Kellei St. Martin Subscribed and sworn to before me this 2nd day of June, 2003. L4 C\ A SIG A URE F NOTARY UBL C OR OT R OFFICIAL TH15 INSTRUMENT WAS DRAFTED BY (NAME AND ADDRESS): NoTAR OR SEAL (OR OTHER. TITLE OR RANK) Land Title, Inc. 0 12415 55th St N NANCY J. L.ENTZ Suite A NOTARY PUBLIC - MINNESOTA Lake Elmo, Minnesota 55042 -' -Y My comta E-Pues Jan. 31. 2045 . ■