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1 Wisconsin Dep rtmentofCommerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 515089 0 GENERAL INFORMATION 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: Polen, Thomas & Dawn I Springfield, Town of 034 - 1055 -30 -000 CST BM Elev: Insp. BM Elev: BM�scription: Section/Town /Range /Map No: ;' {' C". r`f�. ' ' 25.29.15.387 TANK INFORMATION ELEVATION DATA 1 7 62 160 TYPE MANUFACTURER • ' CAPACITY STATION �B raZ FS ELEV. Septic t, '� , Z �� Benchmark l.✓ `� ? �� �: /rive Dosing Alt. BM C.o,,,,, 6 a PLO $ F,11,,, 5 . 61 9 3 • `i ( r Awm l Bid . Sewer A14- N ei Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL ent to Air Intake ROAD Dt Inlet Septic Zo , '75 / 7 ,7 1a, / Dt Bottom 17. a , , . U J Dosing f - 75 V / 1 / 100 Header /Man. 4 D �/� w • o,4 Aeration Dist. Pipe u, 5 ?7,54P Holding Bot. System 5.l$ 97. 3Z. PUMP /SIPHON INFORMATION (' Final Grade 3.T� 1`r'�•�T lJ.SZ Manufacturer i Qom GP and St Co�Ger �• Model Number TDH Lift Friction ;os System Head TDH 4 , 1 2- f3. b 5 Forcemain Length Dia it T ist. to Well 76 SOIL ABSORPTION SYSTEM 7o aF C�>sS CwJ� X69 � yt, 6 BED /TRENCH Widt C Length No. Of rent s I PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 17AJ �—�` SETBACK SYSTEM TO P/L JBLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type Of System: CHAMBER OR UNIT Model Number: m a o 7ri l yZ /bC� DISTRIBUTION SYSTEM WC54 Header /Manifold e Distribution � /� // � ESize Hole Spacing � r I V en Air Intake G pO G Lengt Dia � .,7 Length / is A 5 Spacing 3L �' Z � SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over / I Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed /Trench Center 7Z Bed/Trench Edges Topsoil -Yes LJ No Yes I fJo COMMENTS: (include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: 7 / Z- / _ 0 1 Location: 3256 75th Ave. Wilson, WI 54027 (SW 1/4 NE 1/4 25 T29N R15W) 40 acres Lot ; • - Parcel No: 25!d9.15.387 " {J 1.) Alt BM Description= 2.) Bldg sewer length = ❑ , `�#Sigure Jam/ amount of cover= lO L- tz/�v� Z-1 eci ` • r V Plan revision Required? Yes No Use other side for additional informati — - - SBD - 6710 (R.3197) -- Date In Cert. No. I Countya�� � Safety and Buildings Division St. Croix *iconsin s 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) Madison, 6- 3151 7162 Department of Commerce 608 266 - 3151 �� s OS State Plan I.D. Number State Sanitary Permit Application Trans id. In accord with Comm 83.21, Wis. Adm. Code, personal information you Qrovide Project Address (if different than maM maybe used for secondary purposes Privacy Law, ^T(m)RECEIVED I. Application Information - Please Print All Informatio 3256 75` Ave. Property Owner's Name JUN 2 9 2009 Parcel # Lot # Block # Tom Polen 03 Property Owner's Mailing Address ST CROIX COUNTY Pro rty Loc tion / J N 10606 Cty M PLANNING & ZONING OFFI E Y City, State Zip Code Phone Number S NE 'A, Section 25_ Colfax, WI 54730 715/232 -9317 T 29 N; R 15 W II. Type of Building (check all that apply) / 1��, V Subdivision Name CSM Number i X 1 or 2 Family Dwelling - Number of Bedrooms FOLIr � ❑ Public /Commercial - Describe Use ❑ State Owned - Describe Use City_ Village XTownship of Springfield III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System Replacement System Treatment/Holding Tank Replacement Only Other Modification to Existing System B Permit Renewal Permit Revision Change of Plumber Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV. Type of POWTS System: Check all that apply) .S' .0 OYI 2F Non - Pressurized In- Ground X Mound ? 24 in. of suitable soil — Mound < 24 in. of suitable soil At -Grade Single Pass Sand Filter _ Constructed Wetland Pressurized In- Ground Holding Tank Peat Filter _ Aerobic Treatment Unit _Recirculating Sand Filter Recirculating Synthetic Media Filter Leaching Chamber Drip Line _ Gravel -less Pipe ❑ Other (explain V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Appl'cation Rate(gpdsf) Dispersal a Required (sf) Dispersal Ar a Proposed (sf) System Elevation 600 i n 0.4 / ��( 600bed 1500basel 611bed 1504basel 97.3' i VI. Tank Info Capacity in Total Numbe Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Concrete Constructed Glass New Existing Units Tanks Tanks or Holdin Tank 1200 1200 1 Weiser Concrete X Aerobic Treatment Unit 800 800 com o X VII. Responsibility Statement- I, the undersigned, a1sume respgdsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber' Si store MP RS Number T 715/96 2-4155 usiness Phone Number Kent Hoke NW224199 Plumber's Address (Street, City, State, Zip e) S� -70 7 200 Bremer Ave., Suite D , Colfax, WI 54730 VII .Coun /De artment Use Onl Approved El Disapproved Sanitary Permit Fee (includes Groundwater Date Issued suing A nt Stamps) Surcharge Fee) / 2 � ) ❑ Owner Given Reason for Denial (l/ IX. C&MCWcM pal/Reasons for Disapproval 3 Vj�,Q 1 Septic tank, effluent filter and dispersal cell must all be s ervl /maintained �: L.D? A, as per management plan provided by plumber. 2. All setback requirements must be maintained / n , " as per applicable code /ordinances. / � J �t�r �o �" 'bao • � Attach complete plans to the County onl f e system on per not less than 81/2 ifelies in size y VIA S - d ' VneVW r SITE PLAN SE,NE,25,29N/R,15 W 3 Springfield township sh �� St. Croix county 7 � TGM6CUr• 1 Lv e Q4clVtt f J LEGEND 1 BM: 100.0' flagged nail at orange spot on power pole X pits t a grade c/o clean -out contour No Comm 83 problems e 0 Scale P — 40' except where indicated � t 1. 1 Sa 4� 0 2P Lv/ 1 System Elev. 97.3' on contour 96.8' Li P-16 nDuSe chr art of 113AC a i _ _ I P 01-. z Oct q45 2 "mac F' d ,r f • G� project: POLEN of 8 page 6 Safety and Buildings 141 NW BARSTOW ST FL 4TH commerce .Wi.gov WAUKESHA WI 53188 -3789 Contact Through Relay i www.commerce.wi.gov /sb/ www.wisconsin.gov Department of Commerce Jim Doyle, Governor Richard J. Leinenkugel, Secretary June 22, 2009 CUST ID No. 224580 ATTN: POWTS Inspector LORETTA LARRABEE ZONING OFFICE L & L PERC TESTING ST CROIX COUNTY SPIA N2089 CTY RD Y 1101 CARMICHAEL RD MENOMONIE WI 54751 HUDSON WI 54016 CONDITIONAL APPROVAL Identification Numbers PLAN APPROVAL EXPIRES: 06/22/2011 Transaction ID No. 1678738 SITE: Site ID No. 748879 Tom Posen Please refer to both identification numbers, 3256 75TH Ave above, in all correspondence with the agenc Town of Springfield St Croix County SE1A, NE1 /4, 525, T29N, R15W FOR: Description: Mound, 4 bedroom Object Type: POWTS Component Manual Regulated Object ID No.: 1229751 Maintenance required; Replacement system; 600 GPD Flow rate; 32 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - VQ rsi�SBD- 10691 -P (N.01 /01), P ressure Distribution Component Manual - Version 2.0, SBD- 10706 -P .O1 /O1 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD- 10691 -P (N.01 /01) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems VERSION 2.0" SBD - 10706- P (N.01 /01). In the event this soil absorption system or any of its component parts malfunctions so as to cre a t%lth hazard, the GO property owner must follow the contingency plan as described in the approved plans. In adz e must comply with the operation, maintenance and monitoring duties as described in section S IB �onent manual. A copy of this information must be given to the owner upon completion the pYj;4 l All holding/treatment tanks are to comply with Comm. 84.25(7)(a). Maintenance information must be given to the owner of the tank explaining that periodic c (ni of the filter is required. Access to the filter for cleaning must be provided per Comm 84 product approval o itions. A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. 1 Private On -Site Wastewater Treatment System (POWTS) Mound and Pressure Distribution Component Design Replacement Residential application Index and Title Sheet RECEIVED JUN 1 1 2000 Project Name: POLEN SAFETY & BUILDINGS Owner: Tom Polen N10606 Cty. M Colfax, W1 54730 Location: 3256 75 Ave. Legal Description: SE,NE,25,29,N/R15W Township /County: Syrineld township, St. Croix county Contents: Page 1: index and title Page 2: general information & lateral diagram Page 3: mound drawings Page 4: dose tank Page 5: pump information Page 6: site plan Page 7: management plan Page 8: contingency plan Attachment: soil test to state plan deflection worksheet Designer's name and license no.: Loretta Larrabee license# 1872 -007 Address: N2089 Cty Rd. Y Menomonie, WI 5475 lSC ' / , Oi Phone: 715/664 -8184 : •'� " "o'd'i% Cell: 715 /505 -1628 _: *'• �� 's '_ E— lanlperctestin�wwt.net 1 8TH E ` Designer's Signature:,� �t p``8; 2009 I the undersigned submitted these plans under my authority .�� ¢jr Mound component manual for POWTS Version 2.0 SBD- 10691 -P (N.01 /O1), and Pressure Distribution manual — Version 2.0 SBD- 10706 -P (N.01 /01) Y i Page. 8 �� 13� r. GENERAL INFORMATION Replacement Site Four bedroom home, 600gal DWF ' e nd fed system w/2 laterals 6% slope system area dispersal cell design loading rate 1.0 0.4 soil application rate linear rate 6.38 31" limiting soil factor orifice sq /ft.11.37 1200/800 Wieser tank with Polylok 525 septic filter effluent quality #1 LATERAL LAYOUT DIAGRAM (not to scale) End Fed System Number of laterals 2 orifice dia. 5/32in. (0.156) Lateral dia. 1 %2" orifice spacing (X 42in. (3.5') Lateral length (P) 91.0 ft. orifices per lateral 27 Lateral spacing (S) 3.25ft. lateral discharge rate 14.58gpm Manifold dia. 1 V2 in total system rate 29.16gpm Forcemain dia. 2.0 in D * *see page 7 of 8 Mis. Construction for turn-up detail turn -up end on laterals at manifold for access of lateral at both ends for servicing _Valve box Pressure lug finish gra de P first orifice next to fitting X manif S 3.25' (39" Orifices located on bottom of lateral t� Last orifice next to fitting 1.62' (19'/2" Force main 2" dia. project: POLEN page 2 of 8 PLAN VIEW OF MOUND (not to scale) J= 5.0' D= 0.50' ( 6 ") K= 8.0' required bed 600sq.ft A= 6.5' E= 0.89' (10 3/4 ') B= 94.0' proposed bed 611sq.ft. I = 9.5' F= 0.83' (10 ") L= 110.0' required Basel area 1500sq.ft. W= 21.0' G= 0.50' ( 6 ") proposed basel area 1504 sq.ft. H= 1.00' (12 ") observation pipe @ 18.8ft. Observation pipe I ' J w O A 21.0 ~� 6.5' g I B 9.5' L 110.0' Mound Cross Section View (not to scale) Finished grade elev. 99.13' 1 Lateral invert elev. 97.8' H lllll 2 11!! Dispersal cell elev. 97.3' IlIIlI11 /lIIIIIIIIIIIIIIIIIIII - - - -- 4 dispersal cell +2" -- ---- -- -- --- - - -- - -- f- laterals -- --- --- - - -- - - - -- - - -- - Aggre ate bed 6" - -- - -- -- - -- - -- - -- --- - -- - - - -- 3 - - -- - - - -- - -- - -- - -- - E -- -- -- -- -- D - -- - - -- -- - -- - - -- - -- - -- -- - tilled layer tilled layer contour 6% site slope lev. 96.8' Numeral Key 1 topsoil cap 2 subsoil cap 1.5ft. min. 3 ASTM C33 sand 4" min.dia. observation pipe 4 synthetic cover over cell with 1 /4" slots, 6" min. height 5 aggregate T closet flange O.Sft. min. n. infiltrative surface project: POLEN page 3 of 8 COMBINATION SEPTIC TANK / PUMP CHAMBER (too Scale) 4. ,Approved Locking Manhole Cover APProved Cap, With Warning Label Attached Weatherproof Approved _ Warning Label Junction Box vent Cap - -� iu •2 11 1e�k 12 Minimum • ' tt� Final Grade -\ t 4" Minimum Quick 18" minimum Disconnect 1/4" Weep Baffle- Hole t Approved Joint w /4z' sA40 phpe t A Extending 3' t Onto Solid Soil Alarm B On Approved point I w /4" S` IPip N, B Elm I C Extending 3 Off LS' Onto Solid Soi D Conc. Block 3" of Beddi Under tank—/ -}� _ 20"lo Oki F. 120.0 c o- 1 1 5 _l19ts _Pp and Alarm Are On .Separate , C i rc4is � I B3, a t; M• Uo� d /� -59 n t Tank Manufacturer: 9 2 9 5.,L '-- 30. Tank Size-Septic/Pump: oo / goy �� Ga 1� ans Alarm Manufacturer: Model Number: -� Capacities: A / 9 inches or y22 -S4 Gallons Switch Type: Mec h o��n ;c o�` + B z inches or_j�Lq�Gallons ' Pump Manufacturer: + Cinches or / / L. � o Gal Ions Model Humber: S to --yp la + D o nche! `k-ur 2 a2,i/a Gallons . Minimum Discharge Rate: 3O Total.._._= 3 inches or g� Gallons Vertical Difference Between Pump Off and Distribution Pipe: 1 3.0 Feet vh .aq Minimum Required Supply Pressure:. '& :i. ►: . , .. , .. _ .... +,L4,55 Feet �5 Feet of Force Main x :1 124 Friction Factor/l00 Feet: 2 Inch Diameter Force Main Total .Dynamic Head: ... = J S, S I Feet �rnj� A t r,1 PQS y S 8 S - v I SE -40H Series 4/10 HP Submersible Effluent Pump - High Head, 3/4 Solids I I FLOW - LITERS /MINUTE 0 50 100 150 200 250 35 10.0 30 C onstruction 25 s.o Motor Housing Epoxy Coated Cast Iron Impeller Material Polycarbonate LL zo 6•0 W Impeller Type Closed Vane 0 W 15 o Volute ABS a = 4.0 = Power Cord SJTW -A 10 Nitrile with Carbon 2.0 Mechanical Shaft Seal and Ceramic Faces 5 Fasteners Stainless Steel 0 0.0 Shaft Stainless Steel Upper - Sleeve 0 10 20 30 40 50 60 70 Bearings Lower -Ball Bearing FLOW - GALLONS /MINUTE U �� r1YllY a`�"`f* c 11.65 e 1.5" DISCHARGE 9 30 O 9.00 3.91 I I SCREEN TO PASS 3 /a" SOLIDS Specifications 7r509 3614/1 115 1.5" FNPT 13.0/1000 70.0 64.0 55.0 41.0 32.0 13.8 20' 24.0 230 1.5" FNPT 6.5/1000 70.0 64.Q 55.0 41.0 32.0 13.3 20' 24.0 115 1.5" FNPT 13.0/1000 70.0 64.0 55.0 41.0 32.0 13.8 20' 24.0 230 1.5" FNPT 6.5/1000 70.0 64.0 55.0 41.0 32.0 13.8 20' 24.0 SITE PLAN SE,NE,25,29N/R,15 W Springfield township EY ' s } ' "5 St. Croix county 1+Vin` g4avk t J �f t5 4 i LEGEND 41 ma_k , e �oalo� m5� `tiY I BN/1: 100.0 tlagg,ed mail at orange spo Oil pmver pole }� pits s`. a grade �' c/o clean -out k — contour No Comm 83 problems j � e } 6 ,W % r Scale P -40' except NQ where indicated t' ��`' I . I 5T-__1 , � i System Elev. 97.3' on contour 96.8' - 4M part of 113AC � y y( Wietr.• •in..t • q3.3 ' � � i', r ��r• `t PVC • l � w F << _^ C q0- +CIO RX project: POLEN - -�!—�' -- - - �Ce li page 6 of 8 Mound System Maintenance and Operation Specifications Service Provider's Name: H & H Plumbing LLC Phone: 715/962 -4155 POWTS Regulator's Name: St. Croix County Zoning Phone: 715/386 -4680 System Flow and Load Parameters Design Flow — Peak 600gpd Maximum Influent Particles Size 1 /8in Estimated Flow — Average 400gpd Maximum BOD5 220mg/L Septic tank Capacity 1200gals Maximum TSS 150mg/L Soil absorption component Size 611 bed Maximum FOG 30mg/L Type of Wastewater Domestic Maximum Fecal Coliform >1OE4 cfu/100mL Service Frequency Septic and Pump Tank - - - - - -- -Inspect and/or service once every 3 years Effluent Filter------------- - - - --- Should inspect and clean at least once every 3 years Pump and Controls ---- - --- -- --Test once every 3 years Alarm---------------------- - - ---- Should test monthly Pressure System --------- - - - - -- Laterals should be flushed and pressure tested every 1.5years Mound -------------------- - - - - -- Inspect for ponding and seepage once every 3 years Other---------------------- - - - - -- Initially filter should be checked yearly to determine service schedule Miscellaneous Construction and Materials Standards 1. Observation pipes, 4 "min. dia. are slotted and materials conform to Table Comm 84.30 -1, have a watertight cap and secured with water closet or 3/8" dia. bar as shown in mound component manual. 2. Dispersal cell aggregate conforms to Comm 84.30 (6)(1), Wis. Adm. Code. 3. All gravity and pressure piping materials conform to the requirements in Comm 84, Wis. Adm. Code. 4. Tillage of the basal area is accomplished with a mold board or chisel plow. 5. The mound structure and other disturbed areas will be seeded and mulched to revent soil erosion and help reduce P P frost penetration 6. Lateral Turn-up to finish at grade or above, enclosed in a 6 -8" diameter lawn sprinkler valve box or similar product. lateral turn -u consists of a long sweep 90 or two 45de ee bends same diameter as lateral P ( P g P gr ) 7. Lateral Turn -up on end of distribution laterals after the last orifice. project: POLEN e 7 of 8 P Pag Mound System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General This system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code. And shall maintained in accordance with component manuals and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manholes risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8" in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s.281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis Adm. Code. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slip off the filer when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personal shall advise the owner of when the next service needs to be done to maintain less than maximum scum and sludge accumulation in the tank. Pumu Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Mound and Pressure Distribution System No trees or shrubs should be planted on the mound. Plantings maybe made around the mound's perimeter and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations dictate that the mound be heavily mulched as protection from freezing. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system is provided with a flushing point at the end of each lateral and it is recommended that each lateral be flushed at least once every 18months. When a pressure test is performed is should be compared to the initial test when the system was installed to determine if orifice clogging has occurred, if clogging has occurred orifice cleaning is required to maintain equal distribution within the cell. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner and any levels above 6" considered impending failure requiring additional, more frequent monitoring. Continaencv Plan If the septic tank or any of its components become defective the tank or components shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank or its components become defective the defective components(s) shall be immediately repaired or replaced with a component of same or equal performance. If the mound fails to accept wastewater or discharges wastewater to the ground surface, it will be repaired or replaced. Increasing basal area if toe leakage or by removing biologically clogged absorption and dispersal media and related piping and replacing components as deemed necessary to bring the system into proper operating condition. See page 7 of this plan for the name and telephone number of your local POWTS regulator and service provider. project: POLEN page 8 of 8 Mound Deflection Worksheet Tom Polen Four bedroom - 600DWF Formula 8 4.5ft. divided by 88ft. = 0.051136 0.051136 times 100 = 5.11% deflection Formula 9 5.11 times 0.00265 = 0.01354 plus 1 = 1.01354 1.01355 times 90ft. = 91.2195ft Required 91.5ft cell length Proposing 94ft. cell length project: POLEN ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Mailing Address A D if Property Address ..�,2 ;- 7S 'f'� (Verification required from Planning & Zoning Department for new construction.) City /State Y}Cp 1 Q _ Parcel Identification Number 10 SS — 3Q - co LEGAL DESCRIPTION Property Location .74' I/4 , N," %4 , Sec. , T ,Z N R W To ° --�_ a_ , Tow of �cl� Subdivision f} . , Lot # Certified Survey Map # �/. /� , Volume `, � � ,Page # �. Warranty Deed # ,X , I U LQ � ,Volume _ , Page # Spec house i s no Lot lines identifiable yes SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes, proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning &Zoning Department a certification fo owner and by a master plumber, journeyman plumber, restricted plumber or a licensed er ve � signed by the wastewater disposal system is in proper operating condition and/or after ' p �Ymg that (1) the on -site 2 less than 1/3 full of sludge. () inspection and pumping (if necessary), the septic tank is Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my /our knowledge. Uwe amiare the owners) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms SIGNATURE 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 warran deed from the Register of Deeds Office and a copy of the certified survey map if i reference is made in the warranty deed. (REV. 08/05) l Ifllll 11111 Iff1i lilll IIII1 fllll 1111111N1 sill i111 State Bar of Wisconsin Form 2 -2003 � g 7 1 6 6 3 1 WARRANTY DEED 871 883 Document Number Document Name KATHLEEN H. WALSH THIS DEED, made between Julie Bjornstad ( "Grantor," whether one or more), and THIS OF DEEDS ST. Thomas J. Polen and Dawn D. Polen, husband and wife as survivorship marital property CO. , WI ( "Grantee," whether one or more). RECEIVVED ED FOR RECORD Grantor, for a valuable consideration, conveys and warrants to Grantee the following 03/28/2008 1 WARRANTY DEED described real estate, together with the rents, profits, fixtures and other appurtenant EXEMPT t interests, in St. Croix County, State of Wisconsin ( "Property") (if more space is needed, REC FEE: 11.00 please attach addendum): TRANS FEE: 570.00 The South half of the Northeast Quarter (S '/z of the NE' /.) of Section Twenty -five (25), PAGES: 1 Township Twenty -nine (29) North, Range Fifteen (15) West, Town of Springfield, St. Croix County, Wisconsin. Recording Area Name and Return Address Tom and Dawn Polen N10606 Cty Rd. M Exceptions to warranties: easements, restrictions and roadways of record._ Colfax, WI 54751 034 - 1055 -40 -000 034- 1055 -30 -000 Parcel Identification Number (PIN) This is not homestead property. �) , 2008 Dated: /U��`y�C,� ) (SEAL) J , (SEAL) * ...,.__ -,. _.._.....�.._._._ .. * ulie Bjornstad S.�NI`314A ICwY ARTERY Notary Public (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) ss. authenticated on COUNTY (/ it /I ) Personally came before me on �'a <c y , 2008, * the above -named Julie Bjornstad TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person(s) who executed the foregoing authorized by Wis. Stat. § 706.06) instru ent and acknowled ed the sa THIS INSTRUMENT DRAFTED BY: Louis J. Andrew Jr. Notary Public, State of Andrew Law Oflices, S.C. My commission (fit) (expires:) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATION TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ©2003 STATE BAR OF WISCONSIN FORM NO. 2-2003 * Type name below signatures. INFO-PRO- Legal Foam. (800)655 -2021 . Intoproforms.com 1 of 1 'Parcel #: 034 - 1055 -30 -000 06/05/2009 09:43 AM PAGE 1 OF 1 Alt. Parcel #: 25.29.15.387 034 - TOWN OF SPRINGFIELD Current 1X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner 0 - POLEN, THOMAS J & DAWN D THOMAS J & DAWN D POLEN N10606 CTY RD M COLFAX WI 54751 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 3256 75TH AVE SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A -NOT AVAILABLE SEC 25 T29N R1 5W 40A SW NE Block/Condo Bldg: Tract(s): (Sec- Twn -Rng 401/4 1601/4) 25- 29N -15W Notes: Parcel History: Date Doc # Vol /Page Type 03/28/2008 871663 WD 03/28/2008 871662 EZ -1 07/30/2002 685454 1936/437 PR 09/2011999 610579 1457/324 TI more... 2009 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 06/15/2007 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 24.000 3,850 0 3,850 NO AGRICULTURAL FOREST G5M 14.000 24,500 0 24,500 NO OTHER G7 2.000 9,550 5,800 15,350 NO Totals for 2009: General Property 40.000 37,900 5,800 43,700 Woodland 0.000 0 0 Totals for 2008: General Property 40.000 37,900 5,800 43,700 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 'P #: 034 - 1055 -40 -000 06/05/2009 09:44 AM PAGE 1 OF 1 Alt. Parcel #: 25.29.15.388 034 - TOWN OF SPRINGFIELD Current O ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - POLEN, THOMAS J & DAWN D THOMAS J & DAWN D POLEN N10606 CTY RD M COLFAX WI 54751 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description SC 2198 GLENWOOD CITY SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A -NOT AVAILABLE SEC 25 T29N R15W 40A SE NE Block/Condo Bldg: Tract(s): (Sec- Twn -Rng 401/4 1601/4) 25- 29N -15W Notes: Parcel History: Date Doc # Vol /Page Type 03/28/2008 871663 WD 03/28/2008 871662 EZ -1 07/30/2002 685454 1936/437 PR 09/20/1999 610579 1457/324 TI more... 2009 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 06115/2007 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 16.000 3,050 0 3,050 NO AGRICULTURAL FOREST G5M 24.000 42,000 0 42,000 NO Totals for 2009: General Property 40.000 45,050 0 45,050 Woodland 0.000 0 0 Totals for 2008: General Property 40.000 45,050 0 45,050 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount I Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 / 5 ��� / , , ; 3 % ; E 2. k { 7/ 7 o f to S Q. ` ~� + + f 2 « / @ G ( - - } \ \ ) / ) CD k ( E E \ \ \ / . g 2 U i © /§ƒ � ) cl - e e ® \ § § zt 7 _ ƒ R \ O § o CO) 0 0 0 ' � � � � \_ ■ �. . k k k CA .. \ 1 :99 CO) CO) CO) § § � % / J 7 7 � 2 � ( rT \ � § § 0 /k/ ƒ �- �/X - ' N }\\ 5 . CD (6 ■ § CD �m ®( C � % . � \& \ ( k c CD / 0 % \ z \ ƒ/ /z § . (D 0 : � � \ :E ® 7° n ■a c o , 3 :3 o R . 0 W � �» . ;_0 0 (n ) \ 0 $ - I t ; 0CD Oo \ §EQ \ 2 . m t 0 / cr 7 CL u 0 o 0- \ � ? \ (D \ » ) \ a # I r, PAID Wisconsin Department of s �691L EVALUATION REPORT P of Division of Sa accordarice with Comm 85, Wis. Adm. Code (� Attach com an 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. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all Information R Date Personal information you provide may be used for Law, S. 15.04 (1) (m)). Property Owner Property Locion at JUN 4, GovL Lot 5 1/4 NL1 /4 S ;L q, T � N R S E Property Owner's Mailing Address Lot # Blocic # Subd. Name or CSM# IV t 0 (Q Ci ID ST CROIX COUN7y N-4 4A Al. - 7 6 Ajxa CRY State OFFICE ❑ City ❑ Village =Town Nearest Road 3c (`1 L - 9W) I I '15 Aue. New Constru Use: ® Residential / Number of bedrooms �4_ Code derived design flow rate IoOO GPD f W vr" Replacement // ❑ Public or commercial - Describe: N A 0( f rent material /Ecs S oLe r ®c:twdsh Flood Plain elevation if applicable it y General comments and recommendations: tj V. Boring # Boring ® Pit Ground surface elev. `700 ft. Depth to limiting factor in. SoM Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP AF in. Munseli Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 '01#2 • - 1 O 4 K 3 1 `i c• 6 r. �r 1 Cb b 3 0 ^4 rZ 5 /6 121 r -f- 1 fib, 4 c ,S Boring # ❑ Boring z • ® Pit Ground surface elev. 74 f( ft. Depth to limiting factor 34_ in. Appl ication mate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff? In. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1. 0 u 3 /z s a orb k m '►- s xS -1 d), 4 0 b X. 12 -2-1 o V `�/ �L i aka s i ��. Effluent #1 = BOD > 30 220 mg/l- and TSS >30 150 nig/I_ Effluent #2 BOD < _ 30 mgll. and TSS < _ 30 tnglL CST Number CST Na Ms Lor Larrabee S191*" CSTM224580 Address Evaluation Conducted Telephone Number N2089 Cty. Trk.Y, Menomonie, WI54751 i ^ Z 4�4 715/664 -8184 Property Owner �G� �a f Jli Parcel 1D # Page_ of M �9 # ❑ Boring ® Pit Ground surface elev. 1S ft. Depth to limiting factor — in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft? in. Munsed Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 L /0 Yk 31 S i A 1,0 2. 1 7- s I P, "Al ` 1 .? t 46 k ta f � � 0,'� . b •R • 23 fw2 7. S Y "A, S 1 I J sb m t �^ - 45 . A4 Cj. (A -36 `7,S ` V ' C o ^' S sbk ❑ Bang # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to Itiniting factor in. Son Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW In. Munson Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 F-1 # Boring o Boring C1 Pit Ground surface elev. ft. Depth to Nmiting factor in. Sot Application Rate Horizon Depth Dominant Color Redox Desc dpdm Texture Structure Consistence Boundary Roots GP in. Munsen Qu. Sz. Cast. Color Gr. Sz. Sh. `Eff#1 `Eff#2 Effluent #1 = SOD. > 30 220 mgR. and TSS >30 150 mg1L • Effluent #2 = BOE 6 ;5 30 mglL and TSS a 30 mglL 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 60 8-264 -8777. ssD -8330 O )7/M SOIL AND SITE EVALUATION REPORT Pag 3 of 3 � g Cr is +lh5 S'n I Tom Polen F 6 s� SE,NE,25,29N/R15 ��Vin kav i Springfield townshi t St. Croix county W - f Loretta Larrabee CSTM224580 k 3 '2 u.- vl F�-9 r LEGEND I BM: lilt). fla-eed nail at orange ;hot on hosier hole 1 X — pits 0 —grade elev. contour ( t No Comm 83 setback problems Scale 1" — 40' except hv�s a e where indicated Part of 113AC { ��'� ( • �' T ea h J , f G� eytae link 7L 0 cn 0 0 3 m n C °' 3 3 CD M m o CD m 3 `•°, �'' Ili d 3 CD 0 o u ° U) o z ° cn o v w o O O A N N ro m p ro 0 co ? t � C) S ? 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Y!1l4 -Y i$M kT� •.• i r' I t W s 4 i 4 :r i �9ttt} 5 � ..., O 56 RUG -5 -2009 09:05 FROM:H &H PLUMBING (715)962 -4156 TO:17153864686 P.2 is fv\ PUG -5 -2009 09:05 FROM:H &H PLUMBING (715)962 -4156 TO:17153864686 P.1 FAX COVER SHEET H & H PLUMBING, LLC 200 BREMER AVENUE, SUITE D PO BOX 10 COLFAX, WI 54730 PH. (715)962 -4155 FAX: (715)062 -4156 TO: FROM: COMPANY DATE: N E: g zooLcQ O FAX NUM ER: TIME: gto- 4cp$lo I "H(0 Am PHONE NUMBER: # OF PAGES, INCLUDING COVER: 38 LO - Y (4 go a 1:1 Urgent ❑ Reply ASAP 1:] Please comment ❑ Please review Ej For your Information COMMENTS: ftoM p 0 t This message is intended only for the use of the individual or entity named above, and may contain Information that is privileged, confidential, and exempt from disclosure under applicable law. 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