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' Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safetya.ad Building Division INSPECTION REPORT Sanitary Permit No: 514909 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Edgar, Wesley Star Prairie, Town of 038 - 1047 -10 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: A k 6 5 11.31.18.198D TANK INFORMATION K, ELEVATION DATA TYPE MANUFACTURER „ CAPACITY STATION BS HI FS ELEV. Z•5 Septic Benchmark Alt. BM N6141,,6 WeeAr, a > 000 Aeration Z> ' , 3 I6 c o Bldg. Sewer Ile Holding c•`J St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet 4 .74 1 '�• $ TANK TO �P /L t WELL BLDG. Vent to Air Intake ROAD Dkntm d•+i` f � t � . 7 se i 3 z �"sa (� 2 •{. tto / 0 7.3 9S, Z 8 1.Z 11 z �'Sa ZI' Z �' /a ;ti Aeration ist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Dema St�CoveL Model Numbe TDH L Friction Loss System Head TDH Ft Forcemain Lengt Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length INo. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYS M TO P/L DG LL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type Of S CHAMBER OR UNIT Model Number: DISTRIBUTION SYSTEM Header /MM Id ` Distribution ` x Hole Size x Hole Sp i Vent to it Intake Pipes) Length Dia Length I'l Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded Mulched Bed/Trench Center � Bed/Trench Edges \ Topsoil \,,, Y xx es [A No \Yes C] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 1252 Old Mill Road New Richmond, WI 54017 (NW 1/4 NE 1/4 11 T31k R18 metes & bounds t ^ Parcel N 11 31 18.198D 1.) Alt BM Description 2.) Bldg sewer length = Y GO - amount of cover Plan revision Required? ❑ Yes No 7 (, Use other side for additional information. L Date Insepctor's Sig ature Cert. No. SBD -6710 (R.3/97) commerce.wl.goV Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 seo n s n Madison, WI 53707 -7162 Sanitary Permit Number (to be filled in by Co.) Dspatttnsnt or Commarc. 5/ , c l Sanitary Permit Application State Transaction Numher In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form tot ap 1 5 R L ;(� governmental unit is required prior to obtaining a sanitary permit. Note: Applicatipp.fp state-ow ned Project Address (if different than mailing address) POWTS are submitted to the Department of Commerce. Personal information you provide__ may a use7f'�" 1 Z rn L p secondary s in accordance with the Privacy Law, s. 15.04 1 �-� m , Stats. �� IC W JI&16A �o C I. Application Information - Please Print AI ormati r� Property Owner's Name �) Parcel # .. � 08 03'9- 16 Property Owner's Mailing Address Property Location / Q ` J Z 0 8 , 7H �!' . ST. CROIX COUNTY Govt Lot C y o City, State Zip Code �} k y4, - -A, Section D, y , 6,eSr T W T 5 5 7 y T R ior® le ) R. Type of Building (check all that apply) t' ` Lot 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name Block # ❑ Public /Commercial - Describe Use ❑ City of ❑ State Owned - Describe Use rM Number El Village of Town of $724 R &AIklE III. Type of Permit: (Check only one b6x on line A. Complete line B if applicable) A. ❑ New System Replacement System ® Treatmer,Holding Ta Replacement Only ❑ Other Modification to Existing System (explain) B. ❑Permit Renewal El Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System/Component/Device: (Check all that apply) ❑ Non - Pressurized In -Grand ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ;4olding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. IN real /Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation 1 156 ,44- A*- VI. Tank Info Capacity in Total # of Manufacturer Gallon Gallons Units o New Tanim Existing Tanks U Septic or Holding Tank A _ 6) O $ D t K S Dosing Chamber VII. Responsibility Statement- I, the undersigned, asswne responsibillity for htstallation of the POWTS shown on the attached plans. Plumber's Name (Prue) Plum 's S' nature MP/MPRS Number Business Phone Number p J SC/-f/n ,(�T` �a3 740 7/, -7(0 �0 P6 µ0 umbe r's Address (Street, City, State, Zip Code) 5 0; W 40f'of VIII. Count /De partment Use Onl Approved disapproved Permit Fee Dat ssued Issuing a ignature �` en Reason for 1 $ 57J .46 t `�t _e 2 7 5 ` IX. Conditions Conditions of Approval/Reasons for Disapproval r r A ts Z) gdei/.e n M.�t. P re rho l� z, lfte� u,rcci , G 1 5-. a. S k 3D ✓�4 D �. rJ� Attach to ro nnlete. Mono for the avrf and mhmtt to the Cmutt anly an now ant lem than R 1 x t t tachea to W7.e I� Page I of 5 4$� PROPEQty oij ifc�ia /�r� raN�s ICA. X /STIN T ta 8006AL S. 6a o.eE g ALr en D 111EWfA / W ELL SO W C L L. S ET d AU't A SM El. = 100.00 ToP or Z' MAWAo[.E 14U'• @ 4 j ttt 10046 : Bo TTDrn or s,a�Nb �1 V LL OL i 1fD�D1OV6 Tc l QF 40064_7 Fxisr�N(� 800GAL Sc_DTi� TgrIJ![___Fo/2 2800 GILL, ECOPY DRAW Flop D21W�njc� 8Y W ESLC Y �,,OAA Ik_ _ l{7_ O_TH �JO n 1 C,2$ET wr s VOP s MFRS ZZ3 760 r - - Page 1 of S 4 + /� PRo�EQTy L,'N N. v AyuoE- 1. 8y p ��4 ov (o Tai KS 1 RED Ex�ST� isrinita Am) AL d.r N. wE4L 2 ' S ET d pCh $(A EL. =00-00 ToP or Z' rj1 6 eo 1�1 9 N6 _ Ov � lel OL i 01 IV Tc Al ScDTiC 7 _._FoA Z$OD GAL, � 7 TAI C. DRAwuVe � : ! q;-Zoo� A� w�nrc� cx WESLc �ontrQSET" W r SyOZs jont�,�S�T W r T3/AV, ► I?W MFRS ZZ3760 Safety and Buildings t commerce.wi. OV 3824 N CREEKSIDE LA g HOLMEN WI 54636 TDD #: (608) 264 -8777 isco nsin www•commer g Department of Commerce www.wisco isconsin.gov n.gov Jim Doyle, Governor Jack L. Fischer, A.I.A., Secretary June 19, 2008 CUST ID No. 223760 ATTN. POWTS Inspector JOHN F SCHMITT ZONING OFFICE SCHMITT & SONS EXCAVATING ST CROIX COUNTY SPIA 586 VALLEY VIEW TRAIL 1 101 CARMICHAEL RD SOMERSET WI 54025 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 06/19/2010 Identification Numbers Transaction ID No. 1553242 SITE: Site ID No. 738969 Wesley Edgar Please refer to both identification numbers, 1252 Old Mill Rd above, in all correspondence with the agency. Town of Star Prairie St Croix County NE1/4, NW1/4, S11, T3 IN, RI 8W Lot: 038 - 1047 -10 -000, Subdivision: CSM No. in Vol. 2108; Pg. 362 FOR: Description: One Bedroom Holding Tank System / Replacement construction /3 tanks Object Type: POWTS Component Manual Regulated Object ID No.: 1187847 Maintenance required; 150 GPD Flow rate; System: Holding Tank Component Manual, Version 2.0, SBD -10855 (N.03/07) The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. 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 "Holding Tank Component Manual for Private Onsite Wastewater Systems" SBD- 10571 -P (R.6/99). • 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. • The activities relating to evaluation and monitoring POWTS components afer the initial installation of the POWTS in accordance with an approved management plan shall be conducted by aperson who holds a registration issued by the department as a registered POWTS maintainer. • The existing POWTS shall be properly abandoned per Comm 83.33, Wis. Adm. Code. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions ofSec. 145.20(2)(d), Wis. Stats. • Comm 83.22(7) - A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include loca inspectors. Conditionally AP ROY�D DEPARTMENT OF COMMERCE _....e,n.. ce..-Iv AND BUILDINGS Page 2 6/19/2008 Pa JOHN F SCHMITT S Owner Responsibilities: • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s.Comm 83.54(1). • In the event this POWTS or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • The owner is responsible for submitting a maintenance verification report acceptable to the count' for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 60.00 Fee Received $ 60.00 Balance Due $ 0.00 Gerard M Swim POWTS Plan Reviewer, Integrated Services (608)789 -7892, Mon - Fri, 7:15 am - 4:00 pm WiSMART code: 7633 jeny.swim@wisconsin.gov cc: Leroy G Jansky, POWTS Wastewater Specialist, (715) 726-2544, Friday, 7:00 A.M. To 3:30 P.M. SCIWWTr & SONS EXCA VA TING INC. � t Nnr M6 VALLEY VIEW TRAIL SOMERSET, WI S402S 715- 549 -6651 HOLDING TANK FOR- WESLEYEDGAR ADDRLYS 473 208T A VE SOALERSET WI 3402S LEGAL- NE X NW Y SA, 731N, Rig TOWNSHIP.- SOMERSET COUNTY ST, CROIX CONTENTS Page 1 Plot Plan Page 2 Holding Tanks Page 3 Service Contract Page 4 &5 Management Plan Attachment 1 Soil Evaluation Report Attachment 2 Tank Verification Holding Tank Component Manual (Version 2.0) SBD- 10855 -P (N. 03107) r By: 1,c V// MFRS: 223760 Date: June 12,2008 SEE CORK SPONU�Nt Pageo2—Of J L u Y Y = t C q a 0 e � r- L q d U 0 N� ~ 01 t c M C" V u H q p> O^ N c N -2 c -0 N A �E d G• X O r y ac >Q 4 Y�J 00 t . 41 J C Q 3 d M N CL M >i � q . L t w/ d 4 Z ui � N w E " ` J W Q -- • N U W N p , Z Z . p °o. W CC � _ • H LLI .� o a X90 -.: �. 06 N J V W N at c N F- d U N c Y c T_ _a 0— .. a d F d ti CS Z "� CO z z . a� °n ° y v a `w Y X Z > 3 � OW h b 0 1 4 a nd o ate' <a i as O z a S � a i Z N 0.4 p oD _ c b a F F L. �+ D L " c a. 2 a ' `` ►= � X t W L � q � `O d 08/09/08 101N 07:52 R.4X 715 888 4888 9T CRX CO PLANNING id) 001 HOLDING TANK SERVICING CONTRACT Contract Date J - 06 This contract Is made between the Holding Tank Owner(s) Name(s) and Pumper's Name WE5L,EY FD O A R I C HR IS 'HoPPF- We acknowledge the installation of a holding tank(s) on he follow ng property: (Provide legal descriptions:) M I /— e 1 L c S` /D/ 7 1 I -------------------------------------- - - - - -- 1. The owner agrees to file a copy of this contract with the local governmental unit that has signed the pumping agreement required in Comm 83.52(1)(c)l. Wis. Adm. Code and the approved Holding rank Component ManuaL This agreement will also be filed with the St. Croix County Zoning Department. 2. The osmer agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have aeceas and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can service the holding tank(s) with the pumping equipment The owner further agrees to pay the pumper for all charges incurred in servicing the holding tanks) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the local governmental unit that has signed the pumping agreement and to the County, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a. The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volume in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to f le a copy of any changes to this service contract or a copy of a new service contract with local govermnental unit and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) Own is Signature(s) Subscribed and sworn to me on this date: r" Today's Date �! 9-K- Pumper's Name (Print) Pum Si tur14 Notary Public S ature r �,5 / 5- 3L9 -doIJ Pu per's Registry on Number Commission Expiration JUDY K. TANNER Notary Publio -State of Wisconsin Page 4 of 5 Holding Tank Management Plan This Private Onsite Wastewater Treatment System ( POWTS) has been designed, and is to be installed and maintained according to Comm. 83, Wis. Admin. Code, the Holding Tank Component Manual for Private Onsite Wastewater Treatment Systems (Version 2.0) SBD 90855 -P (N.03/07), and the St. Croix County Private Sewage System Ordinance. 1. This POWTS has been designed to accommodate a maximum daily flow of _ 4�0 _ gallons of domestic wastewater per day. 2. The owner of this POWTS is responsible for system operation and maintenance, Including all provisions in the attached Holding Tank Servicing Contract and Maintenance Agreements. 3. Each time the wastewater in the tank reaches 90% of the tank(s) capacity or a level of 12" below the inlet ( at which time alarm will activate), the pumper listed in the current Servicing Contract must be called to empty the tank contents and dispose of them in accordance with NR 113, Wis. Admin. Code. At each pumping the pumper should visually inspect the condition of the tank, risers and the manhole cover(s) and verify that any required locks are present. Inspect alarm every year. 4. The owner may not remove any of the wastes from the holding tanks, or cause such wastes to be removed by any person not authorized to do so under Ch. 281, Wis. Stets. The discharge of wastes from this holding tank to ground surface, including intentional discharges and discharges caused by neglect, constitutes a falling private sewage system and may result in issuance of correction orders by the county. 5. Anytime a defect is identified or malfunction occurs, it shall be reported to the person(s) identified in the User's Manual for this POWTS. Repair or correction of such failure or malfunction shall comply with Comm. 83, Wis. Admin. Code. 6. No one should enter a holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. 7. In the event that this POWTS falls for and cannot be repaired, a code compliant replacement holding tank may be installed in the same location (a new sanitary permit is required for such a replacement). 8. If this POWTS is replaced, or its use is discontinued, it shall be abandoned in accordance with Comm. 83.33, Wis. Admin. Code. Page 5 of 5 File Information Owner VJjF Egon Design Parameters Number of Bedrooms ❑ NA Number of Commercial Units WNA Estimated flow averse p gal/da Design flow (peak), Estimated 1.5 /50 gallda System Specifications Number of tanks Holding Tank # 1 Manufacture /Ca acit E k S C P. '9T)0 g al ❑ NA Holding Tank #2 Manufacture/Capacity ,= F J000 g al ❑ NA Holding Tank #3 Manufacture/Ca acit ROZ gal ❑ NA Alarm Manufactuer TON / C T -TE ❑ NA Alarm Model # - 7/n - 1 ❑ NA Alarm Type EeGU le ❑ NA Maintenance Schedule Service Event Service Frequenc Inspect conditions of tanks At every pumpin Pump out contents of tanks When wastewater reaches 90% of tank volume Inspect alarm At least every year POWTS INSTALLER POWTS MAINTAINER Name 3 - a y j1 .5cgolirT I Name TcH 5 c)4 n1 17 r Phone 7/S - Sil?-66,rl I Phone 7i5 - - 7& 0 - DY f6 I SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name 1 64 (CIS OpAE Name -5T- C / X uvvr ZoawN(, l Phonel 7 - q & - 7 i? lPhonel 7IT- 3 ie( —4`64M " SOIL EVALUATION REPORT #-3, �► isc�ons�n Page 1 of 3 Department of Commerce in accordance with Comm 85, Wis. Adm. Code Division of Sail and Buil�rrgs Scltmit Sort Testing, Inc. Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County St Cron( include, but not limited to: vertical and horWx tal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. 038-1047-10-M P W"w PAM a/1 kdhfwa9kwL Reviewed By Date Personal inkmolion You povide may be used for secondary Purposes (Priva:y Law. S. 15.04 (1) Property Owner Property Location Edgar, Wesley 8r Patrice Govt Lot NE1/4, NW1 /4, S11, T31N, R18W Property Owner's Mailing Address Lot # Block Subd. Name or CSM# 473 208th Ave. I I GSM Vol 2108 Page 362 City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road Somerset I WI 1 54025 715 - 247 -5345 Star Prairie I Old Mill Road ❑ New Construction Lhw ® Residential / Number of bedrooms 1 Code derived design flaw rate 150 GPD ®Replacement ❑ Public or commercial - Describe Parent material Pitted Outwesh Plain (Chetek Flood plain elevation, if applicable na R General comments and rec' m pe rietin - m This site is restrided by the 50' well sefta and drainage ways and ditches along the driveways. A hokfiM tank appears to be the only feasible option. F-11 Boring # El Bing ® Pit Ground surface elev. 100.70 tt Depth to limiting factor 25 in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistenm Boundary Roots GPD/ft in. Munsep Ou. Sz. Cont Color Gr. Sz. Sh. - EfIS1 - Eff#2 1 0-11 10yr3/4 none sl 2fsbk mvk cs 2m,2f .6 1.0 2 11 -25 10yr4/6 none sl 2fsbk mfr Cs 2f lvf .6 1.0 3 25-34 7.Syr4/6 � ' 6 / 6 Is imsbk mfr gw if 7 1.6 4 34-48 7.5yr5/6 c211t X6/ 6 f5l Om mfi 9W .2 .5 5 48-60 7.56/5/4 c 2d 7.56/6/8 7.5 2 vfSI Om mfi — .2 .5 ❑ El Boring , 2 eorurp # ® Pit Ground surface elev. 95.67 R Depth to limiting factor 26 in. Soil Application Rate Horizon Depth Dominant Color RW= Description Texture Structure Boundary Roots GPD/W m- Mansell Qu. Sz. Cont. Color Gr. Sz Sh. .Eff#1 , EW2 1 0-6 Driveway Gravel — — — 2 6-20 F18 — — 3 20-26 10yr3 /4 none Sil 2fsbk mfr a 2f,ivf 6 g 4 26-32 lOyM /4 l� 8 SI 2msbk mfr 9W .6 1.0 5 32-41 106/4 /6 c2d 756/6/6 SI 2msbk mfr 7.56/6/1 9 .6 1.0 6 41-63 7.5yr4/6 n2d 106r6/6 grSI imsbk mvfr cs .7 1.6 7 63-77 7.5yr5/4 cld 75yr6/8 fsl Om mfi 7.5 — .2 .5 ' Etrluent #1 = BOD 5 > 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 Thomas J. Schmitt , 227429 Address schmitt Soil Testing, Inc Date Evaluation Conducted Telephone Number 1595 72nd Street New Richmond, WI 54017 5/28/2008 715-247 -2941 stn -8330 rrLmrooe - - - - Page ,2 of 3 - . ' � Ccuaducted by: _ _ - Conducted For. Schmitt Soil Testing Inc. Name: Wesley B. & Patrice M. Edgar Thomas-J..-Schmitt,-CST-227429 _ Address: 473 208th Ave. 1595 72nd St. City, State, Zip: Somerset, WI. 54025 New Richmond, WI.54017 Phone- 715-247-2941 _ Subd.Name: CSM Vol 2108 Page 362 sip Siteb Address: Lot No: Daft —�- _ Legal Description: NEIA NWIA S11 T31N R18W - -® Backhoe rt - -- -- - _ _ - P Township, County: Star Prairie, St. Croix County A - Bench Mark E1. 100.00' Top T manhole cover on septic tank A Alternate Bench Mark - E1: f 00:66' bottom of siding on house - - / 1 4 rec. ;S res4'i,c�e* 6y / e / - - G7 i �C X's /v►, y d / ;.ti°/, �c�/f Gt h � `7e S� "ell Scale 1" —40' - _. _S c,f / /��y An,& c l olral 7 Xe 7`Ie 6.7/ Ius.�/ s y ysf�,' op� b tv i WA - - Arc1MS Viewer Paged of ry " 3 167.8 co i �,1 g 100 ` 525/273 Cp TN STAR PRAIRIE 11 f ! 10 CO 10024 98r '195 Y; N 1 � CD 1 �� ' ti1 I I 110024 http: / /Www.landinfo.co.saint -mi wi. website/L"OrtW/ARCIM!/k4anFMrn. �-7DTAT— c inn ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the V J is L E y residence located at: N JE 1 /4, NW '/4, Section I I , Town 3 L_ N, Range f e W, Town of S j 48 PRA I R r , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of service S -Zno Did flow back occur from absorption system? Yes_ No (if no, skip next line.) Approximate volume or length of time: gallons minutes Capacity: &QD Construction: Prefab Concrete x Steel Other Manufacturer (if known): C t P,,00jWcrs Age of Tank (if known): t ' 94 l�� Ar�S 041 j) J oN N .Sc -gnl IT7 (LiOlsed Plumber Signature) (Print Name) yV( Z Z 3 76 0 (Title) (License Number) MP /MPRS f�'l Z - ZOD�' (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) I NVi sconsin SOIL E ATION REPORT #1597 Department of Commerce in acco nce m 85, Wis. Adm. Code Page 1 of 3 Division of Safety and Buildings Schmitt Soil Testing, Inc. Attach complete site plan on paper not less than 8'/ x 11 inches in mu County St. Croix include, but not limited to: vertical and horizontal reference point (BM), irecti percent slope, scale or dimensions, north arr and location and �«ew to n t road. Parcel 1. . Please grin all inR&G &V E D ev' By 038- 7 -1 R�' Date Personal information you provide may be for secondary purposes (Privacy , s. 15.04 (1) (m)). f✓ 1is p$ Property Owner roperty Location Edgar, Wesley & Patrice Govt. Lot NE1 /4, W114, S11, T31N, R18W Property Owner's Mailing Address ST. CROIX COUNTY of # Block # Subd. Name or CSM# 473 208th Ave. ZONING OFFICE CSM Vol 2108 Page 362 City State Zip Code Phone Number City []Village ❑ Town Nearest Road Somerset I WI 1 54025 715 - 247 - 5345 Star Prairie Old Mill Road ❑ New Construction Use: ❑ Residential / Number of bedrooms 1 Code derived design flow rate 150 GPD Replacement ❑ Public or commercial - Describe Parent material Pitted Outwash Plain (Chetek Flood plain elevation, if applicable na ft. General comments and recommendations: This site is restricted by the 59 well setback and drainage ways and ditches along the driveways. A holding tank appears to be the only feasible option. Boring # Boring ❑ Pit Ground surface elev. 100.70 ft. Depth to limiting factor 25 � 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 •EfW 1 0-11 10yr3 /4 none sl 2fsbk mvfr a 2m,2f .6 1.0 2 11 -25 10yr4/6 none sl 2fsbk mfr a 2f,1vf .6 1.0 3 25 -34 7.5yr4/6 cif 7.5yr6/6 Is lmsbk mfr gw if .7 1.6 7.5yr6 2 4 34 7.5yr5/6 c2d 10yr6 /6 fsl Om mfi - -- 10yr6/1 9w .2 .5 5 48 - 60 7.5yr5/4 c2d 7.5yr6/8 vfsl Om mfi - - -- .2 .5 7.5yr6/2 F2 ] Boring # Boring Pit Ground surface elev. 95.67 ft. Depth to limiting factor 26 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 0-6 ----- - - - - -- Driveway Gravel - - - - - -- 2 6 -20 ----- - - - - -- Fill -_ -- __- - - - - -- - - - -- -- - -- - - - - -- 3 20 -26 10yr3 /4 none sil 2fsbk mfr cs 2f,lvf .6 .8 4 26 -32 10yr4 /4 c11010vr6 8 sl 2msbk mfr gw -- .6 1.0 5 32-41 10yr4/6 c2d 7.5yr6 6 ' sl 2msbk mfr w - -- .6 1.0 7.5yr6/1 g 6 41 -63 7.5yr4/6 m 110yr6/6 grsl imsbk mvfr CS - -- .7 1.6 7 63 -77 7.5yr5/4 c1 7 7.5 n2/ 8 fsl Om mfi - 2 5 Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD s30 mg/L and TSS <_30 mg/L CST Name (Please Print) Signature: CST Number Thomas J. Schmitt 227429 Address Schmitt Soil Testing, Inc. Date Evaluation Conducted Telephone Number 1595 72nd Street New Richmond, WI 54017 5/28/2008 715 - 247 -2941 SBD -8330 (R.07 /00) Page,2 of 3 Conducted by: Conducted For: Schmitt Soil Testing Inc. Name: Wesley B. & Patrice M. Edgar Thomas J. Schmitt, CST 227429 Address: 473 208th Ave. 1595 72nd St. City, State, Zip: Somerset, WI. 54025 New Richmond, W1.54017 Phone: 71 5 -- 247 -2941 Subd.Name: CSM Vol 2108 Page 362 signature - 4 1 , Siteb Address: Lot No: Date $� fD �S Legal Description: NE 1/4 NWl /4 S 1 T3 IN RI 8W M Backhoe pit Township, County: Star Prairie, St. Croix County A Bench Mark El. 100.00' Top of T manhole cover on septic tank A Alternate Bench Mark El. 100.66' bottom of siding on house 1 4rec. i'5 res�.,6 � 0 tjlay's, ClAcl�s a/a d� s crhf� f lip Ste' '�✓e`I Scale 1" = 40' S 6�c� , f'`L'���% layrfs c� �OC�Q� 7 y L' Nc I ( r A 1 �''A i 1 �Rl /nn Y Ok yo AMMS Viewer Page,3 of 3 167.81 3q� Grs� �' 100 4 525123 y �95K TN STAR PRAIRIE 11 a YQ `+y 03 100 1 46012 lg . 95 cn N � J 100.24 ti http: / /www.landinfo.co. saint - croix. wi. us/ website /LRPortal/ARCIMS/MapFrame .asp ?PIN= 5/22/2008 06'09/08 NON 07:52 FAX 713 986 4686 ST CRX CO PLANNING Q001 n.,. Jys Pool 9 I Nnr HOLDING TANK SERVICING CONTRACT QiAI -30_3a Contract Date / I - 0 6 This contract is made between the Holding Tank Owner(s) Name(s) and Pumper's Name WLSLF -Y FDOAR CHRIS HoPPiF We acknowledge the installation o (a) holding tank(s) on he following property: (Provide legal descriptions:) 1Y1 I L C B A r- LQ K,r-i-lftt0iViQ. W21 Si-1017 77. 1 --------------------------------------- - - - - -- 1. The owner agrees to file a copy o; this contract with the local governmental unit that has signed the pumping agreement required in Comm 83.52(1)(c)l. Wis. Aden. Code and the approved Holding Tank Component Manual. This agreement will also be filed with the St. Croix County Zoning Department. 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access and to enter upon the property for the purpose of servicing the holding tank(s). The owner agrees to maintain the access road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to pay the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the local governmental unit that has signed the pumping agreement and to the County, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agrees to include the following in the semiannual report: a, The name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volume in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreement will remain in effect until the owner or pumper terminates this contract. In the event of a change in this contract, the owner agrees to f le a copy of any changes to this service contract or a copy of a new senice contract with local governmental unit and the County named above within ten (10) business days from the date of change to this service contract, Owner(s) Name(s) (Print) Owner's Signature(s) Subscribed and sworn to me on this date: U/ <' Today's Date Pumper's Name (Print) Pum Si tuck Notary Public S ature X ( " 5 r Pu per's Regist a on Number Commission Expiration JUDY K. TANNER Notary Public-State of Wisconsin t3 U 2 10 8 P 3 6 2 - 71z,ssE-E-3,9 I KATHLEEN H. WALSH STATE BAR OF WISCONSIN FORM 2 - 1999 REGISTER OF DEEDS WARRANTY DEED Document Number ST. CROIX CO. • WI This Deed, made between Arthur Kempen, a single person, RECEIVED FOR RECORD 01/13/2003 09:38AN EXEMPT # Grantor, and Wesley B. Edgar and Patrice M. Edgar, husband and REC FEE: 13.08 TRANS FEE: 227.70 wife, COPY FEE: CERT COPY FEE: PAGES: 2 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area (See Attached Exhibit "A ") Name and Ret r Y�t`f(NA OGLAND ESTREEN & OGLAND 304 Locust Hudson, WI 54016 038- 1047 -10 Parcel Identification Number (PIN) This is homestead property. (is) CkX0Q Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this I Z- day of December 2002 * * Arthur Kempen * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) ss. St. Croix County ) authenticated this day of -- Personally came before me this _ day of December . 2002 the above named Arthur Kempen, a single person, * TITLE: MEMBER STATE BAR OF WISCONSIN �,�'`...A / .Ir�own to be ' the person(s) who executed the foregoing (If not, rJ". s ent and acknowled d the same. authorized by § 706.06, Wis. Stats.) i ` : Q~ ; M THIS INSTRUMENT WAS DRAFTED B$ ° * ` * ' may" a r (� 1 a hoc /a � Attorney Kristina Ogland � tl -Notary Public, State of Wisconsin Hudson, Wi 54016 ,• .P. ••; My Commission date: (Signatures may be authenticated or acknowledged. Both are not n ?Q;y.P F * Names of persons signing in any capacity must be typed or printed below their signature. information Professanais company, Fond du Lac, wl STATE BAR OF WISCONSIN 900.855.2021 WARRANTY DEED FORM No. 2 - 1999 EXHIBIT "A" V 2.10 8P 3..63 PARCEL 1 Commencing at a point on the East line of the NE'/. of NW` -of Section 11, Township 31 North, Range 18 West, which point is 203.80 feet North of the SE comer of said NE % of NW % and the point of beginning; thence N68 106 feet to an iron pipe stake; thence North 100 feet; thence East at right angles to a point directly North of the point of beginning; thence South along the East line of sal NE % of NW'/ to the point of beginning, St. Croix County, Wisconsin. TOGETHER WITH the right of ingress and egress as described in Judgment In Vol. 515, Page 35, Doc. No. 323506. PARCEL2 A parcel of land located in part of the NW' /. of the - NE'/, of Section 11, TownsNp 31 North, Range 18 West, Town of Star Prairie, St. Croix County, Wisconsin described as follows: Commencing at the North Quarter conger of said Section 11; thence on an assumed bearing along the North/South Quarts' line of said Section 11, S001 a distance of 961.68 feet to the point of beginning of the parcel to be described; thence S87 a distance of 16.49 feet, this being the Northeast comer of that parcel described in Warranty Deed 'recorded in Vol. 482, Page 166 per a Circuit Court Judgment recorded in Vol. 515, Page 35 in Register of Deeds Office In said County; thence S32 1'55"E -a distance of 144.77 feet;. thence along the right of way of Old Mill Road as presently located, S51 °00'33"W a distance of 40.03 feet thence N81 VW a distance of 51.36 feet to the Southeast comer of that parcel described In Warranty Deed recorded In Vol. 482, Page 166 per a Cir A.* Court Judgment recorded In Vol. 515, Page 35 in the Register of Deeds M6 6 In said County; thence N631 a distance of 15.33 feet to the trnie NordVSturth Quarter line of said Section 11 per State Statute 59.73; thence along last said: Quarter line, N00 5 56'53 "E a distance of 133.73 feet to the point of beginning. I . ` 0 o / Lo� § f • FF Cz / 7 7([ o ° 7 9 \ o - s ± c � + - Q m E n t 2 r , Q Q \ m £ ® ° 2 2 § % !\/ 2 2 @ R k§ k 2 @ w e� CD m m A L CL 0 k § � , � § CD � { § w E : 0 r @ CD & a V T V @ ■. @ ( 0 0 o o § .. 22 2 s CD § % \ ( A § CD ■ CO) , i § e & ƒ v v a � S= R§ z Q w f � z E 0 \ ° k \ . ƒ 7 / . ƒ =r § i \ i 7 a f § � 2 z ■ G ¥ z o � ƒ ■ T § 2 : 0 } 2 7 m m % r g °t /> E�� \ , i §;0 a ; %%77 � CD §5 ƒ y ®- 2 ]%( \CD a RE ƒ m 'n s k0 CD / §/ \ $ E % Parcel #: 038 - 1047 -10 -000 11/21/2006 10:40 AM PAGE 1 OF 1 Alt. Parcel #: 11.31.18.198D 038 - TOWN OF STAR PRAIRIE 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 WESLEY B & PATRICE M EDGAR O - EDGAR, WESLEY B & PATRICE M 473 208TH AVE SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description SC 3962 NEW RICHMOND SP 1700 WITC Legal Description: Acres: 0.000 Plat: N/A -NOT AVAILABLE SEC 11 T31 N R11 8W PT NE NW COM 203.8 FT N Block/Condo Bldg: OF SE COR NE NW, TH N 68 DEG W 100 FT, N 100 FT, TH E TO A PT N OF POB, TH S TO Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) POB ALSO PT NW NE DESC AS COM N 1/4 COR 11-31N-18W NE NW SEC 11;TH S 00 DEG W 961.68' POB;TH S 87 DEG E 16.49';TH S 32 DEG E 144.77' TH S more... Notes: Parcel History: Date Doc # Vol /Page Type 01/13/2003 705569 2108/362 WD 02/16/2000 618368 1490/257 WD 10/04/1999 611461 1460/600 WD 613510 1469/250 WD more... 2006 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/13/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.000 13,300 42,100 55,400 NO Totals for 2006: General Property 0.000 13,300 42,100 55,400 Woodland 0.000 0 0 Totals for 2005: General Property 0.000 13,300 42,100 55,400 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 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT —$ Owner Address City /State 5 I f , Legal Description: i Lot Block Subdivision/C # ` ' ' A � ��, /a /a Se ;T � W Town of r SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFO TION Tank manufacturer a Size ST/PC Y O,01 Setback from: House Zewell 22 S P /L Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: / Width 3 Length S Number of Trenches Setback from: House _ Well .5o` P/L T' Vent to fresh air intake ELEVATIONS e Description of benchmark Elevation G d Description of alternate benchmark Ste' Elevatiog !• e Building Sewer 2 ST/HT Inlet - 7 ST Outlet PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover 6 Distribution Lines O 9�, -2 (} ( ) Bottom of System ( ) J?3, 5 ( ) ( ) Final Grade ( ) 2 6 ( ) ( ) Date of installatioul l #ermit nuf 4er S/5' State plan number Plumber's signature r. - '" License number � Date /4 / 9 / 1P Inspector Complete plot plan NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW 01) l l Zo 1' q 6)0 51� INDICATE NORTH ARROW Wisconsin Department of Commerce Count y PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No -: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 353157 Permit Folder's Name: ❑ City ❑ Village W Town of: State Plan ID No.: Town of Star Prairie CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.: 1 v6.0 f "• 038- 1047 -10 -000 TANK INFORMATION U ELIVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark �• ((�� O Dosing Alt. BM Aeration Bldg. Sewer,�� c� Holding St/ Ht Inlet g 1 TANK SETBACK INFORMATION St/ Ht Outlet S TANK TO P/ L WELL BLDG. Air I to ntake ROAD Air Septic ) -30' > �� NA m Dosing A Header /Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer ' qgmd St cover Ct 7,G Model Numbe GPM TDH Lift Friction stem TDH Ft Forcemain gth Dia. Dist. To SOIL ABSORPTION SYSTEM -31 8@0 TREN H Width f Len th t No f renches PIT No. Of Pits Inside Dia- Liquid Depth DI EWSI DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O f CHAMBER Model Number: System: �.O � �^ OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length 9ia. Spacing I S g SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #l: 1 11`{ 1gcj Inspection #2: r Locati pending, Somerset, p (NW /4, NE 1/4, Section 11 T31N -R18W) - 11.31.18.198D Plan revision required? ❑ Yes 10 No Use other side for additional information. I z I I 9 °' r I s 2 SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: F e E � 3 e ....... 7 r 6 a � E i 9 e�. s 3 # t E ; s.. „..,.F eAm� .,..... w E e s ., .. 3... _. a °a s 3 e _ . F 8 P � 4 � E 3 a t d ®m m� e �- E s n j .w�. �� a E 1 . ....ee > 4 S < 3 # w _ e € .... ,_W.... € } t e i a � _ e � � u � � . } e a. t I w Safety and Buildings Division SANITARY PERMIT A7 tf�A 201 W. Washington Avenue Wisconsin , IQN P O Box 7302 Ds artment of Commerce In accord with ILHR 83.0 die , P Madison, WI 53707 - 7302 • Attach complete plans (to the county copy only) for the �rh, on I#p,Q1'�ot less County �� n than 8 112 x 11 inches in size. rp I • See reverse side for instructions for completing this ap Iicatior ' State Sanitar rmi�Nu�be - r Personal information you provide may be used for secondary purposes i S% CpO, ^ Jr t[o] if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. 2N / � UIyT Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT AL I F R;55 f8N Property Owner Name \ ; '. eryrLoc�t n T 3 , N, R� E (or W Property Owner's Mailing Address Lot u er Block Number 2 City, State _ Zi Code Phone Number Subdivision Name or CS Number (7 �- 11. TYPE OF BUILDING: (check one) ❑ State Owned o it Nearest Roa Public r 2 Famil Dwellin - No. of bedrooms 2 V ow a n OF �r 111 BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 E] Apartment/ Condo D �/ 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV TYPE OF PERMIT (Check only one box on line A. Check box on line B, if applicable) A) 1. ❑ New 2 Replacement 3. ❑ Replacement of 4. E] Reconnection of 5. E] Repair of an _____System ----- System ------------- Tank Only______________ Existing System ________ Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 []Holding Tank 1 hj4.SQepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade Re uired (sq_ ft.) Proposed (sq. ft.) (Gal ay /sq. ft.) (Min. /inch) q EI vation l 5 d 5 / 3- 10 Feet ' 72 ,6 Feet Ca acct VII. TANK in allo Total # of Prefab. Site Fiber- Exper. INFORMATION New Existing Gallons Tanks Manufacturer's Name Concrete st Con- ed steel glass Plastic App Tanks Tanks 2L + Septic Tank or Holding Tank 1:1 El ❑ 1:1 11 1:1 Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for in tallation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber' S t re: (N ) I MP/MPRSWNo.: Business Phone Numb r: Plumbs A dress ( t et, City, St e, Zi . ode dl i IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) ®A pp roved ❑ Owner Given Initial Surcharge Fee) Adverse Determination '�eZS•� X. CONDITIONS O F AP RO AL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber a INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4_ Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form SBD -6399 9 p P q Y ( ) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line 6 if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. Vlll. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 81/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 f for number fr I r hie h n A 41 included he creation o surcharges (fees) o a o regulated ated actices w ca 983 Wisconsin ct c uded t g( ) g p effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau'of Integrated 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. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and 154• percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 38'–te 0 OM APPLICANT INFORMATION - Please print all information. Re iewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). (- Property Owner Property Loca ion 67 Govt. Lot (� 1/4 ' 3 1 1/4,S T N,R E (o W Property Owner's Mailing Addreftf Lot # Block# Subd. Name or CSM# OL.2 FL City State Zip Code Phone Number ty ❑ Village Town - ❑ Ci Nearest oad F w Construction Use: residential / Number of bedrooms Addition to existing building placement El Public or commercial - Describe: derived daily flow .50 gpd ��/�,, Recommended design loading rate bed, gpd/ft I trench, gpd /ft Absorption area required 3@Q bed, ft ft 2 Maximum design loading rate ^ S bed, gpd /ft . ( v trench, gpd /ft Recommended infiltration surface elevation(s) 93 -o as referred to site plan benchmark) Additional design /site considerations Ga /w .^ , Parent material G2 Flood plain elevation, if applicable ft S = Suitable for system Conventional I Mound In- Ground Pressure AT -Grade System in Fill Holding Tan U = Unsuitable for system ;KS ❑ U JV S U S❑ U ❑ S U ❑ S �U ❑ S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench " -12 11 -0 S S Ground CT Depth to limiting factor ? 7-If Remarks: Boring # e l� 3 12 lupr'-p I m �� ,P .3 Q/ r` ✓ I Ground L l v �ft. Depth to limiting / factor ?gym Remarks: CST Na a (Please Print) Signature Telephone No. s.�� u,.� s 1- Address Date CST Number 7 AL 6 - 69 1 SOIL DESCRIPTION REPORT PROPERTY OWNER — 2 Page of PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ^� ,/� Bed ,Trench CZ _Izewl� Ground f 4 e,�ev. ( ' d ft. Depth to limiting $ �� factor 7 A Remarks: /���.-i ,,: ✓ ,Gd 7 Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # ; 13 Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. , Depth to limiting factor in ' Remarks: SBD -8330 (R. 07/96) 4 PLOT PLAN PROJECT Martv Chevalier ADDRESS 2028 77th St. Somerset Wi 54025 NW 1/ 4 NE 1/4S 1 1 /T 31 R 18 W TOWN Star Prairie COUNTY ST. CROIX ' MPRS Shaun Bird 226900 DATE 10/6/99 BEDROOM 1 CONVENTIONAL XXX IN -G PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 800 Gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .6 ABSORPTION AREA 254 # of chambers 8 IL BENCHMARK V.R.P. Base of Siding ASSUME ELEVATION 100' ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTE ELEVATION ZZ d Alt. BM Top of Survey Pipe @ 101.9 Vent > 12" Sidewinder High of Cover Capacity Leaching Chamber with 31.8 f ^2 per chamber 6' Long 16" 34" Grade at System Elevation Pro Well Please note: the existing • cabin has no basement and Private Drive to Old 8 , consists of only one level. Mill Rd. 10' 1 Bedroom 18' Cabin B.M. 25' Old Pit Well, Sandpoint 10 25 was pulled before testing T was done, pit is to be 10' filled in. 5' B -1 Alt. 40' M. 4% 50' Slope 10 1 -3'X 50' ' -3 Trench 0' 6' B -2 20 Priv y Vent o 30' 9� Property Line • Soil Test Plot Plan Project Name Marty Chevalier Shaun Bi Address 2028 77th St. Somerset Wi 54025 C M #226900 Lot ---- Subdivision -- - -- -- Date 10/6/99 NW 114 NE 1/4S 11 T 31 N /R W Township Star Prairie Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Base of House Siding System Elevation 93.0 *HRP Same as Benchmark Alt. BM Top of Survey Pipe @ 101.9 Pro Please note: the existing • cabin has no basement and Private Drive to Old 8' consists of only one level. Mill Rd. L10' 1 Bedroom 18' Cabin B.M 25' Old Pit Well, Sandpoint was pulled before testing 2 5' was done, pit is to be filled in. 5' Alt 40' 4% 5 , Slope 10' -3 0 ' a� B -2 20 , Privy Property Line SYSTEM ELEVATION AND SIZING CALCULATIONS Below Grade Chamber Soil Absorption Systems Permit Number 10/11/99 Date X "X° Gravity Distribution only 1 Pressure Distribution 3 ft Suitable Soil , Note 1: Bury depth as per manufacturer 16 in Chamber Height 2 8 ft Maximum Bury Depth 3 1 7 50 7- 1 gpd Estimated Daily Peak Flow 0.60 gpd /fe Wastewater Infiltration Rate 250.0 if Code SAS Size 40 % Down Sizing Credit 100.0 ft Reduction ( -) 150.0 ft Min. SAS Size 93.00 ft Proposed SAS Elevation Soil Surface Acceptable Finished Grade EL 4 (ft) Boring Grade Limitation SAS Elevation (ft) System Minimum Maximum Number Elevation (ft) Depth (in) Lowest Highest Elevation? 95.83 102.33 1 99.00 112 92.67 97.00 Yes 2 98.60 120 91.60 96.60 Yes 3 100.00 130 92.17 98.00 Yes 1. Depth of suitable soil required below the infiltrative surface for treatment. 2. Total height of chamber in inches. 3. Maximum bury depth as per manufacturer's recommendations. 4. Based on chosen system elevation, and chamber height. Top of chamber is equivalent to top of aggregate. The addition of fill for cover or the reduction of finished grade may be required to meet minimum or maximum code standards. SBD- 10553 -E (R.05/98) ST CROIX COUNTY SEPTIC 'TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM i Owner/Buyer ff_ 2527 (11W A o Mailing Address a 6 L L j i Ll d `z-- n �� f� Property Address l�' ��'` d Q G v�1 y:.��' (V erification req uired from n Department for new construc n N rW g eP ) City/State Parcel Identification Number i LEGAL DESCRIPTION Property Location /'✓V '/., AI F_ ` /., Sec. // . T�N -R�W, Town of S�w. ,� �a�(/L �t.it Subdivision Lot # Certified Survey Map # , Volume — / . Page # Warranty Deed # _�f �y� , Volume t`a Page # Spec house ❑ yes ono Lot lines identifiable J4 yes ❑ 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, restrictedplumber or a licensedpumper verifying that (1) the on -site wastewaterdisposal 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 f Ithe iration date. SIGNA F APPL DATE OWNER CERTIFICATION I (wefce iffy that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the p perty dd ab ve, by virtue of a warranty deed recorded in Register of Deeds Office. SI OF PLICANT DATE * * * * ** 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 Y�:! .1 i KATHLEEN H. WALSH STATE BAR OF WISCONSIN FORM 2 - 1998 REGISTER OF DEEDS Document Number WARRANTY DEED ST- CROIX Co. WI This Deed, made between Maril A. Grummons a /k/a Mary O. RECEIVED FOR RECORD Grummons, a single aerson 10 - 04 -1999 9:30 AM Grantor, conveys and warrants to Martin WARRANTY DEED EXEMPT # Chevalier and Brenda Chevalier, husband and wife CERT COPY FEE: COPY FEE: TRANSFER FEE: 84.00 Grantee. RECORDING FEE: 10.00 Grantor, for a valuable consideration, conveys and warrants to Grantee PAGES: I the following described real estate in St. Croix County, State of Wisconsin (The "Property"): Reco i Nart> Estreen & AND r -1 Z Ogland P* O. Box 359 Hudson, WI 54016 038- 1047 -10 Parcel Identification Number (PIN) This is not homestead property. Commencing at a point on the East line of the NE t /a of NW t /a of Section 11, Township 31 North, Range 18 West, which point is 203.80 feet North of the SE corner of said NE t /a of NW t /a and the point of beginning; thence N68 °W, 100 feet to an iron pipe stake; thence North 100 feet; thence East at right angles to a point directly North of the point of beginning; thence South along the East line of said NE t /a of NW t /a to the point of beginning, St. Croix County, Wisconsin. TOGETHER WITH the right of ingress and egress as described in Judgement in Vol. 515, Page 35, Doc. No. 323508. Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this day of October, 1999. * Maril A. G mmons a /k /a Mary O. Grummons * * ACKNOWLEDGMENT STATE OF WISCONSIN ) AUTHENTICATION ) ss. County ) Signature Maril A. Grummons a /k /a Mary O. Grummons, a single person Personally came before me this day of October 1999, the above named autherkticated this day of October, 1999. to me known to be the person(s) who executed the foregoing instrument and acknowledge the same. * Kristina Ogland * TITLE: MEMBER STATE BAR OF WISCONSIN (If not, Notary Public, State of Wisconsin authorized by § 706.06, Wis. Stats.) My Commission is permanent. (If not, state expiration date: THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Ogland Hudson, WI 54016 (Signatures may be authenticated or acknowledged. Both are not necessary.) * 8 7 7 5 6 2 2 Document Number Document Title 877562 KATHLEEN H. WALSH St. C POIX COU11t REGISTER OF DEEDS Y ST. CROIX CO., WI Holding Ta Agreement RECEIVED FOR RECORD, 06/27/2008 02 :30PM HOLDING TANK AGREEMENT State Plan Transaction Number - / SS3 EXEMPT t 4 V REC FEE: 13.00 2 Name — (Owner) Typed or printed PAGES: Being duly sworn, states, under oath, that: 1. He /she is the owner /part owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume /U,9 Pag Document Number St. Croix County Register of Deeds Office: Recording area A parcel of land located in the /4 of theA/1 /4 of Section Name and Return Address a ✓ / , �j �'/ N — R W, Town of t5 t C Ep<. a _ I �- ,,�, � , St. Croix County, Wisconsin, being x{73 ZogT �' q 17 duly described as follows (include lot no, and subd r 'ision/CSM or Sor "t SET W I a d S detailed legal al es cri ti p on): ee.. A-1��.�.•ec41 © l Oy7 — / 0 - OD Parcel Identification Number (PIN) Agreement Date: 4Z_�_W? We acknowledge that application is being made for the installation of (a) holding tank(s) on the above described property or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, a municipal sewer cannot now serve the property, or any other type of private onsite wastewater treatment system as permitted under Comm 83, Wis. Admin. Code, or § Ch. 145, Wis. Stats. As an inducement to the county to issue a sanitary permit for the above - described property, we agree to do the following: 1. Owner agrees to conform to all applicable requirements of Comm 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the governmental unit or the Department of Commerce to prevent or abate a human health hazard as described in s. 254.59, Stats,, the governmental unit (Town) may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.0703, Stats. 2. The owner agrees, pursuant to Comm 83.54(2) and Comm 82.40(3)(e), Wis. Adm. Code, to have a water meter installed in the structure. The water meter shall be installed by a plumber authorized by the Department of Commerce to make such Installations; with said inst, elation complying with State regulations and manufacturers specifications. The owner agrees to be financially responsible for the purc hase, installation, maintenance, and repair of the water meter, and agrees to allow the governmental unit or the Department of Commerce to enter the above- described property on a regular basis to read and /or inspect the water meter. 3. Owner agrees to pay all charges and costs incurred by the governmental unit or county for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. The governmental unit shall notify the owner of any costs that shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law, 4. The owner agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have the holding tank serviced and to file a copy of the contract with the governmental unit. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service contract, with the governmental unit within ten (10) business days from the date of change to the service contract. 5. The owner agreesto contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit to the county on a semiannual basis a report detailing the servicing of the holding tank. The governmental unit or county may enter upon the property to Investigate the condition of the holding tank when pumping reports and meter readings may Indicate that the holding tank is not being properly maintained. 6. This agreement will remain in effect only until the county office responsible for the regulation of private onsite wastewater treatment systems certifies that either a municipal sewer or a private onsite wastewater treatment system that complies with Comm 83, Wis. Adm. Code serves the property. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit this agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner that will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. Owner(s) Name(s) - Please Print Subscribed and sworn to before me on this date: Notarized ner's Signat ) Notary Pu ' Gover mental Unit Official Nam , Title - Please Print My Commission Expires �7 ( .9 ! o ' 'r�l! BNo Govemmen nit al Si na Draft by: � VIP Persona format' you a may be used for secondarV purposes (Privacy Law s. 15.04(1)(m)) "o- a "THIS PAGE IS PART OF THIS LEGAL DOCUMENT — DO NOT REMOVE" Of This information must be completed by submitter: document title. name & return address. and PIN (if required). Other information s granting clauses, legal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document. Note � Use of this cover pace adds one pace to your document and S2. 00 to the recordina fee. Wisconsin Statutes. 59.517. J EXHIBIT .,,A „___ U 2.10 8. P . _- -3. -6 3 PARCEL 1 Commencing at a point on the East line of the NE % of NW %-of Section 11, Township 31 North, Range 18 West, which point is 203.80 feet North of the SE comer of said NE'/, of NW' /, and the point of beginning; thence N68°W, 106. feet to an Irod pipe stake; thence North 100 feet; thence East at right angles to a point directly North of the point'of beginning; thence South along the East line of sW NE of NW'/ to the point of beginning, St. Croix County, Wisconsin. TOGETHER WITH the right of ingress and egress as described in Judgment In Vol. 515, Page 35, Doc. No. 323508. i