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Parcel #: 032 - 2117 -50 -000 08/01/2007 04:38 PM
PAGE 1 OF 1
Alt. Parcel #: 15.31.19.1075 032 - TOWN OF SOMERSET
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 - PLOURDE, CHARLENE S
CHARLENE S PLOURDE
2176 59TH ST
SOMERSET WI 54025
Districts: SC = School SP = Special Property Address(es): ' = Primary
Type Dist # Description ` 2176 59TH ST
SC 5432 SOMERSET
SP 1700 WITC
Legal Description: Acres: 3.080 Plat: 2445 - SHADOW PINES 1 99
SEC 15 T31 R1 9W PT NW NE LOT 18 SHADOW Block/Condo Bldg: LOT 18
PINES
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
15-31N-19W
Notes: Parcel History:
Date Doc # Vol /Page Type
11/13/2001 661938 1761/206 EZ
12/27/2000 635883 1570/184 WD
2007 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 07/14/2004
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.080 57,400 141,300 198,700 NO
Totals for 2007:
General Property 3.080 57,400 141,300 198,700
Woodland 0.000 0 0
Totals for 2006:
General Property 3.080 57,400 141,300 198,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 12/29/1997 Batch #: 554
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
395298
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purpo
as [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Plourde, Charlene I Somerset Township 032 - 2117 -50 -000
CST BM Elev: Insp. BM Elev: BM Description:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing
Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L JBLDG IWELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number.
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
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 1 77eeded /Sodded x x Mulched
Bed/Trench Center Bed/Trench Edges Topsoil
❑ Yes EM] No ❑ Yes ❑ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 2176 59th Street Somerset, WI 54025 (NW 1/4 NE 1/415 T31N R19W) Shadow Pines Lot Parcel No: 15.31.19.1075
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Plan revision Required? ❑ Yes ❑ No
Use other side for additional information.
Date Insepctor's Signature Cart. No.
SBD -6710 (R.3/97)
I
1 C7
3/
Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162
seonsin Madison, WI 53707 - 7162 Site Address
Dep artment of Commerce Sanitary Permit Number
Sanitary Permit Appli
c ., 3�S"� LJ
1n accord with Comm
83.2 1, Wis. Adm. Code, perso vtmation you provyl ❑ Check if Revision (J
may be used for secondary ses Priva w`�15. 1
I. Application Information - Please Print All Informa o / r State Plan I.D. Number
YA
Property Owner's Name CD 01 Parcel I u D , I q / O')
6 S D-
Propey Owncr's Mailing Address ^`- Property Location
rt
ti s
A A;S T- N,R
Ity, State Zip Code 8 ldtnl� �� lot Number � Block Number
L t Subdivision sion Name tuber
S
U. Type of Building (check all that apply) ❑City
1 or 2 Family Dwelling - Number of Bedrooms ✓k�—� ❑Village
❑ Public /Commercial - Describe Use 4 ;d - r—.— hip
❑ State Owned Nearest Road }�
M. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable)
For County use
A
1 $ New 2 ❑ Replacement System 3 ❑ Replacement of 1 6 ❑ Addition to
S stem Tank Ordy I Exis ' S stem
B. ❑ Check if Sanitary Permit Previously Issued
Permit Number Date Issued
IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use)
44 C� Non - Pressurized In - Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wedand
22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 1
45 ❑ At -Grade 46 ❑ Aerobic Tr eatment Unit 49 ❑ Recirculatin 3000 or
V. D' ersal/Treatment Area Information:
Design Flow (go) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade
Required Proposed Rate(Gals. /Days /Sq.Ft.) (MinAnch) Elevation
L S /
Tank Info 4 Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank
Dosing Chamber
VII. Respopsibility Statement- I, the undersigned, a responsibility for installation of the POWTS shown on the attached plans.
Plumber's ame tint) ` Plumber' Signa MP/MPRS Number Business Phone Number
J --:S / s --
Plumber's Address (Street, City, State, Zip e)
VIII. County /De artment Use Onl
Approved C1 Disapproved Sanitary Permit Fee (includes Groundwater Date ssu Issuing S' nature (No Stamps)
Surcharge Fee)
❑
Owner Given Initial Adverse
Dete rmination _ - -- -
CPM WRMI? i r#&BE'4tYsUKVWB YARi4tMMggg �gMLufacturer's recommendations.
2. All setbacks to system and residential structure must meet applicable code requirements.
3. Property is zoned Ag- residential - only one principal dwelling is allowed on this property.
4. Floodplain mapping = Zone "C"
I
Attach comptete ptaw (to the County only) for the system on paper not km than 81R i 11 inches In size
SBD -6398 (R.. 05101)
AMA
-�_41 - --
-
.�
� s
p 3
I
w
'
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division,pf Safety and Buildings Page 1 00
Bureau'of;p Services in accordance with s. ILHR 83.09, Wis. Adm. Code
"
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. man mus4 County
include, but not limited to: vertical and horizontal reference point (13w,,direction and } . St. Croix
percent slope, scale or dimensions, north arrow, and location and Otanoe to near t road.
rcel I.D. #
APPLICANT INFORMATION - Please print all information. Re " wed Date
Personal information you provide may be used for secondary purposes (P ivac�Law,A,.Rf�4p)
d
Property Owner EPTog fttocation
Richard Stout ,. �+ �jC W 1 /4NE 1 /4,S 15 T31 N,R 1 E (or )(W
Property Owner's Mailing Address f Lot # Weeim . °Subd. Name or CSM#
1 353 Awatukee Trail , l! t Shadow Piffles
City State Zip Code Phone Number �I Nearest Road
Hudson Wi 54 1 6 i? 1 5 49 -6731 � City ❑Village ' Town
S omerset
Ea New Construction Use: Residential / Number of bedrooms _4 Addition to existing building
❑ Replacement HPublic or commercial - Describe:
Code derived daily flow 6 0 0 gpd Recommended design loading rate ,7 b , gpd/f? trench, gpd /ft
Absorption area required 8 5 2 bed, ft 750 _ trench, ft Maximum design loading rate bed, gpd /ft gpd/ft
Recommended infiltration surface elevation(s) 2CQQ ^4:et —g4n ft (as refe d to site plan benchmark)
Additional design /site considerations
Parent material COC2 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 system ® S ❑ U 10 S ❑ U U s ❑ U E� S ❑ U ❑ S KI U ❑ S U U
SOIL DESCRIPTION REPORT AU01
Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft
in. Munsell Ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench
1 1 0 -6 10 r2/1 -- is IAubK mvfr Cs if .7
2 6-8q 10yr4/6 -- ms osg ml Cs -- .7 :.
Ground
elev.
92 ft.
Depth to
limiting
factor
Remarks:
Boring #
1 0 -6 1 0 r2 1 -- is 1 mvfr Cs if .7 t
2.,' 2 6-8E 10 r4 6 -- ms osq ml Cs --
t
Ground
elev.
91 e ft.
Depth to
limiting
factor
8 6 in. Remarks:
CST Name (Please Print) Signatur Telephone No.
Address Date CST Number
PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D.# `
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
3 1 0 -5 10 r2 1 -- is 1 m
...................
2 5-8P 10 r4/6 -- ms 0sq ml cs -- .7;.
Ground
elev. C
91 . -5-0-- ft.
Depth to
limiting
factor
--8-6
Remarks:
Boring #
1 0 -6 1 0 r2 1 -- is 1 M mvfr — CS 1
4 2 6-86 10 r4/6 -- ms osq ml cs -- .7 .
Ground
elev.
92. ft.
Depth to
limiting
factor
-8-6—in. Remarks:
E
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring #
-- M6
k 2 14-86 10 r4 -- --
Ground
elev.
89. ft.
Depth to
limiting
factor
8 6 in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
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POWTS OWNER'S MANUAL a MANAGEMENT PLAN Page of _
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner _ Septic Tank Capacity al ❑ NA
Permit # Septic Tank Manufacturer ❑ NF.
DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NP
Number of Bedrooms
0 NA. Effluent Filter Model ❑ Ni-
Number of Commercial Units NA Pump Tank Capacity N�
gal (�
Estimated flow (average) gal/day Pump Tank Manufacturer 5 N
Design flow (peak), (Estimated X 1.5) gal /day Pump Manufacturer [2
al /day /ft Pump Model .5 Ma
Soil Application Rate g
Months average lNr
Influent/Effluent Quality y * Pretreatment Unit
Fats, Filter E Peat Filter
Fats, Oil at Grease (FOG) s30 mg /L ❑ Mechanical Aeration ❑ Wetland
Biochemical Oxygen Demand (BODs) s220 mg /L ❑ Disinfection ❑ Other:
Total Susp Solids (TSS) 1 5150 mg /L Manufacturer
Pretreated Effluent Quality ff NA Monthly average ** Dispersal Cell(s)
Biochemical Oxygen Demand (BODs) :_30 mg /L 0 In- ground (gravity) ❑ In- ground (pressurized)
Total Suspended Solids (TSS) _ :30 mg/L ❑ At -grade ❑ Mound
Fecal Coliform (geometric mean) :510 cfu / loom s ❑ Drip -line ❑ Other:
Maximum Effluent Particle Size A inch diameter
* Values typical for domestic (non - commercial) wastewater and sept
tank effluent.
* * Values typical for pretreated wastewater.
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every 3 ❑months _D8'year(s) (Maximum 3 yrs. )
Pump out contents of tank(s) When combined sludge and scum equals one -third (PS) of tank volume
Inspect dispersal ceil(s) At least once every 3 ❑ months CVyear(s) (Maximum 3 yrs.)
Clean effluent filter At least once every ❑ months dyear(s)
Inspect pump, pump controls ax.alarm At least once every ❑ months H year(s) )ANA
Flush laterals and pressure test At least once every ❑ months ❑ year(s) ja NA
Other: At least once every ❑ months ❑ year(s) AS-NA
Other: At least once every ❑ months ❑ year(s) 25 NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Mast
Plumber; Master Plumber Restricted Sewer; POWTS Inspector, POWTS Maintainer; Septage Servicing Operator. Tank inspectior
must include a visual Inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure ti
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. entire
When the f the com
tank hall be accumu
s ludge and
a sc In any tank
Operaor e nd disposed vo
ed of in accord n e with ch.NR 11
contents o 3, W scons
f the to
Administrative Code.
The servicing of effluent filters, 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 chemic
that may Impede the treatment process and /or damage the dispersal celi(s). If high concentrations are detected have the content
of the tank(s) removed by a sentage servicing operator prior to use,
Page — of,
System start up shall not occur when soil condiilons are frozen at the Infiltrative surface.
During power outages pump tanks may fill above normal hlghwater 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 Servking Operator.prior to restorinti
power to the effluent pump or contact a Plumber or POWTS Malntalner to assist in manually operating the pump controls to
restore ncrmal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells, Do not drive or park over, or otherwise diswrb or compact, the area
wlthln 15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater weam may Improve the performance and prolong the life of the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; dislnfectanu; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasollne; grease; herbicides; meat scraps; medications; oil;
painting CrodUC13; aesticldes; sanitary napkins; tamoonsi and water softener brine.
ARAN DON EM ENT
When the POWTS fails and /or is pemtanently 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
replacement system:
g 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 roust
comply with the rules In effect at that time.
D A suitable replacement area is not available due to setback and /or soil Ilmitatlons. 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 repfacemelit area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suluble replacement area. if no replacement area Is available a holding tank may
be Installed as a last resort to replace the failed POWTS.
D Mound and it-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 MiAY RESULT", RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR
IMPAC IR1 F.
ADDITIONAL COMMENTS
POWTS I STALli,ji POWTS M AINTAINER
Name _ ': Na me
Phone Phone .._._
SE:PTAGE SERVICING OPERATOR JPUMPERJ LOCAL REGULATORY AUTHORITY
Name E FApncy
Phone P hon
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
/ l et
OWNERSHIP CERTIFICATION FORM
Owner/Buyer f1 Art, r I F /ca yr � ; �'ho�.� 7/_ ' 5 41
T �
Mailing Address ,, G _s ;,, -S¢ U Z
Property Address 7-17 SCI g
(Verification required from Planning Department for new construction)
City /State iJrrlG / 5G� ��� Parcel Identification Number 03
LE GAL DESCRIPTION
Property Location 'VVJ '/4, NE '/4, Sec. �, T 31 N -R Town of
Subdivision �� � •� cs , Lot # P6
Certified Survey Map # , Volume , Page #
Warranty Deed # Z_ RSA' , Volume 1_<76 , Page #
T '-
Spec house O yes X no Lot lines identifiable H yes O no
SYSTEM MAINTENANCE
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.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
/ days of the three year expiration date.
SIGNATURE OF APPLICANT ATI� E
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
th� property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE OF APPLICANT D TE
* * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * **
** Include with this application: a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
vol.1570PAG1184
' 635583
STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H. WALSH
Document Number WARRANTY DEED REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made between Richard O. Stout and Janet P. St out, RECEIVED FOR RECORD
husband and wife, _ — 12 -27 -2000 10:00 AM
- YARRANTY DEED
-- -- — EXEMPT N
Grantor, and Charlene S . Plo _ _ _._ CERT COPY FEE:
COPY FEE:
- -- — — — — TRANSFER FEE: 148.80
__.__- _. ---_ - -- --------- -- - - - --- RECORDING FEE: 10.00
- -- — . —_. — PAGES: I
Grantee. —
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in S t. C roix County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
Name and Rohm Address
Lot 18, Shadow Pines, Town of Somerset, St. Croix 1 1!'tA OGLANj
County, Wisconsin. 1-streerl & Oglan4:
P . (►. Box 359
JJntlsOn, WI 54016
032 - 2117 -50 -000 --
Parcel Identification Number (PIN)
This is not _ homestead property.
-- p{) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any
Dated this 1 j 4,4" day of Decem — 2000
-- ------- - - - - -- + Richard O. Stout - --
et P. Sto
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Rich O. Sto ut and Janet P . St out, husband and STATE OF WISCONSIN )
-- -- ) ss.
w
_ County )
authenticated this I �� y oI - -- 2000 _ Personally came before me this _ day of
the above named
+ Krislina
TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the person(s) who executed the foregoing
(If not, _ _ _ —._ _ —_ — instrument and acknowledged the same.
authorized by 5 706.06, Wis. Stats.)
THIS INSTRUMENT WAS DRAFTED BY + -
Attorne Kristina Ogland _ - Notary Public, State of Wisconsin
Hudson, WI 54016 My Commission is permanent. (If not, state expiration date!
— J
(Signatures may be authenticated or acknowledged. Both are not necessary.)
• Names of crsons signing in an capacity must be typed or printed below their sig nature. Wormetbn Praessfomis Company, Fond du Lac. wi
P' g g Y P Y > P P g aoo.665-2021
STATE BAR OF WISCONSIN
WARRANTY DEED FORM No. 2 -1999
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