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HomeMy WebLinkAbout038-1194-70-000 /* U 4sconsin Department of Commerce PRIWATE SEWAGE SYSTEM Count6t. Croix Sajet;; and k%uildingsDivision INSPECTION REPORT 7 GENERAL INFORMATION (ATTACH TO PERMIT) Sanita33(ftg2ro.: Personal information you provice may be used for secondary purposes [Privacy Law, s 5.04 (1)(m)J. t 1 r' Name: ❑ City ❑ V' State Pl a n ��'Y:�d'��, �'1��� � @°f'owns ip n ID No.: CST BM Elev_ Insp. BM Elev.: BM Description: Parcel W- 1.;194 -70 -000 TANK INFORMATION ELEVATION DATA.sn TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark r Dosing Z„rfl Aeration Bldg. Sewer 9 - r i Holding St / Ht Inlet ^� /. $0 9 7 -� � TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P / L WELL BLDG. A Intake ROAD Dt Inlet Septic s p { 3 6 f — NA Dt Bottom n. Lo (. 3a Dosing NA Header / Ma 9 Aeration NA Dist. Pipe , S 9/ `f3 o. r Holding Bot. System .35- PU / SIPHON INFORMATION Final Grade /V 57. S� / nufacturer Deman Cover Mode umber GPM TDH Lift L Iction System TDH t i H F emain Length Dia. ell SOIL ABSORPTION SYSTEM ( es BED/TRENCH Width Length I No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth IMEN I N 8 -q'S I I DIMENSION SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu acturer: SETBACK CHAMBER r mod Number: INFORMATION TypeO System: �g 32 53 OR UNIT w, DISTRIB N SYSTEM 6 ) G L Heade old Distribution Pipe(s) x Hole Size x HOle Spacing Vent To Air Intake f Length Q.L Dia. !e 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 I ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc. Insoection #1: CG/ IS /ol Inspection #2: - Location: 1329 220th Avenue, New Richmond, WI 54017 (NE 1/4 NW 1/4 13 T31N R18W) - 1331181012 Pine Acres -Lot 17 9. �,- 1.) Alt BM Description 2.) Bldg sewer length = - amount of cover = Plan revision required? Y N0 c :J Use other side o i lr add ti 0rm n. �Z ' Inspe I ` SBD -6710 (R.3/97)� Date A � Inspector's Si na re Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 Visconsin Madison, WI 53707 - 7162 Site Address De artment of Commerce 0 Sanitary Permit Application Sanitar Permit Number In accord with Comm 83.21, Wis. Adm. code, rsoaal provide ` Pe information you ❑ Check if Revision ma be used for purposes Privacy Law, s15. I. Application Information - Please Print All Informatio ���, - S ole Plan I.D. Number Prop Owner's Name 20 02 Parcel Number e Property Owner's Mailing Tim ress CC>U ' Property Location ST CF'` O ZCiviN" J L -A QA: S 3 T J N, R / 9E city, State Zip Code Phone Number Lot N r Block Number Su ' ision Name CSM Number ,�,�.. U. Type of Building (check all that apply) ❑City A l or 2 Family Dwelling - Number of Bedrooms ❑Village ❑ Public/Commercial - Describe Use ownship /L,V••�+� ❑ State Owned Nearest Road 4 — /�e 0 �J - 3 CRO III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) A For County use 10 N Replacement System 1 3 ❑ Replacement of 6 o y a m Tank Onl m B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) 44 JNon - Pressurized In -Groube 210 Mound 47 ❑ Sand Filter 50 11 Constructed Wetland 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. D' rsal/'Iteatment Area Information: Des' (gpd) Dispersal rsal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade Flow Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation ys o - 3 - 3"2,5 - 72 C/ -/° VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tanks Tanks � Tank Tanks Septic or Holding O APOO Dosing Chamber VII. Responsibility Statement - I, the undersigned, assume responsibility for ' on of the POWTS shown on the attached plans. PI is Name (Print) Plumbe S' lure RS Number Business Phone Number kl� �- s7 lumber's Address (Street, City, S te, zip VIII Count / Department Use Onl Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Approved ❑ Disapproved Surchar a Fee) ❑ Owner Given Initial Adverse m e1�y Determination IX. Conditions of Approval/Reasons for D' pproval � — Q4,v l5 d6+^ vet J So l 1�9 UAW CIS t G.ti Alt. 4 ,,w, - 2 S Attach complete plans (to the County ody) for the system on paper not less than Un x 11 inches in size SBD -6398 (R. 05101) 3 -4 r7 ,4 im Lj 7A.AJ- /too � Bea = g7.(a7 Tl� t-Io � X 3 ►3 0 132 z2p ` E.' Sanitary Permit Application Safety & Buildings Division � 5 In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington O Box 302 ®.S� ®n5�� See reverse side for instructions for completing this application Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned.) Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 1 I inches in size. County Sta S itarvPer Number Cl Check if revision to previous application State Pl an I. D. Nu I. A pplication Information - Please Print all Information Location: Prope / Owner Name Property Location 1/4 PIMA, S T JXor) Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number II, Type of Building: (check one) 0 City R 1 or 2 Family Dwelling -No. of Bedrooms: ❑ Village ❑Public /Commercial (describe use):_ rown of ❑ State -Owned 5 Nearest Rome 7 � b �/ Pazcyl,Nurp ^--j cm III. Type of Permit: (Check only one box on tine A. Check box on line B if applicable) 3.3 1 , . 1 A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to Syste System Tank Only Existing System $) Permit Number Date Issued ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) ANon- pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At -grade �/ ❑ Aerobic Treat nt nit ❑ Recircul ing 13 Other: r V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3, Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) Elevation D 3 7� 3 7 7 /, t y &. 5 -- VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks /000 ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ VIII. Responsibility Statement I, the undersigned, assume responsibility for installation of the POWTS show on the attached plans. Plumber's Name (print) Plumber's nature ( P RS No. Business Phone Number 13,01 y` u� i�� nos ): 035- 7 Plumber's Address (Street, City, Sta , Zip Code) C� .AGM IX. County/Department Use Only ❑ Disapproved Sanitary Pennit Fee (Includes Groundwater Date Issued Iss ing Agent Si ature (No stamps) JiQ Approved ❑ Owner Given Initial Adverse Surcharge Fee) Determination ZZS CIO 2 �� �- X. Conditions of Approval /Reasons for Disapproval: -1E AA( QM. 1� � E- 'V SBD -6398 (R. 07/00) Kn /7 13, ' ! y -/o ,��a 6 35. - /oo 7 -!! 7"• ✓�gr, a too 13'S 13.3 X ! Q C 04/12/2001 Z: 171 252231 ARTANDERSON REALTY I PAGE 01 I cq,lr SOIL AND SITE EVALUATION Page 1 of jj f 80ty and Buildings in socord with Comm 83.05, Wis. Adm. Code Attu comptbta see plan on pa8et not ie■s dwn 8 x 11 Inches in slza. Plan must County _ irx*uda, but roc tirrrlrsd m: vchild and horizontal reference Point (BMA, dimc*m and �L I •' , __.... _ ._._ .. __.. pafcwtt Mme, stole or drrramsism, tonic erro•+, and location and diswice to nearest road. Parcel fbAi APPLICANT IWOI - PIsA #e print al! inforf"10007. Re BY Date pwm infanrow+ rou prowwo ors be and ftw www h" purvMes (Prl`wy L", 9. 15.04 (1) (m)). -- P PtopenY �� Lot 114 114 S _ 13 T� 31 . ,R L,pices 1 Hills DyVe xt�t _ — Su j. Name or CSW - — Property Owners Maikq Addreee P Lot x B _ Pine ACM C Vilepe 'faw Nearest Road — to Zip code PhaneNunrber 220 TH. Ave. ye New Constraction Residential I Number of bedrooms 3 .. _ ❑Addition to 6"00 btufcGnQ--- Rep4cament Public or commercial deboribe nded deal n loading rate ? ,be d, gP� $ tom g pdW Code p gu }� 450 gpd Recxnmrrle g 7 bed, dW _, •t3 ... tr ench, gpdff � d 4 bed, � 56 trench, it= Muimum design loading rate iJD Abaorpt(bn a� requNtr ._•�� ..—.� v s ' 5 ft (as referred to site plan benchmark) ReCtxrlrrwnded Nnfitreion surface e1e abort() – . 4 Addidonal design I sib considerations ft Pencil b Flood plain elevation, if applicable le V wUnsultable - &uitabl0 for system Conventional Mound In- Ground Prewure AT -Grade System In FIR Homing Tarp` for system 0 0 u [A S . u ® 5 0 u s C7 u s ou SOIL D C IPT10N REPORT Depth Dominwd Color Mottles structure C onti ste Boundary Roots GPDff Boring# Horizon in• Munself Qu. Sz. Cunt Color Texture Gr. SL Sh, eed Tiefroh I 0-10 1 0 YX 313 --- - -- ------ --_ l Imsbk mvft sa if 4 S gw ] of .4 -5 w__.- 1 msbk mvfr 0 414 1 10-20 I YR I .-- Ground 3 20-57 7.SY gw .7 . 8 R4 /4 _.��_�...__._ -_ Cs osg mJ � 103.0 ft 4 57 -95 10YR5 /6 Cs osg nnl - - -- - --- .7 A 8 S -- e S a cy ` Z' De ip S to 7 / 0 y�C /iv - J _ w ang Cv tf/4 Q cr Z facbr i Remo": 1 0-11 10Y R3 /3 -- - - - - - -- ► I m sbl myfr as i —4 ! ,5 mvfr 1vf .4 .5 Z 11 -21 loYli4 /4 i s SN' Ground 3 - 21 - 7,5YR4/4 ------- - -- - -- Cs osg ml gw elev ; ____ __._..r� Cs o s ml 4 59 -9 IOYRS _ 1.03.0 ft. 4 /6 _ S i Depth to — tactor >94" Remarks: EWAd ame (Please P&O Signature: Telephone No. cque Hawkins �rt� `� �,� C/ D09 CST Number f;<d#I v �esC N�� 1 4/8/00 z 390 Wimmsin Department of Commerce SOIL AND SITE EVALUATION Page 1 of 3 Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north arrow, and location, and distance to nearest ro - Parcel 1,D.# APPLICANT INFORMATION - Ple a p;* ah information L Pendtn Personal information you provide may be used for ary purples (Privacy Law,'a. 15.04 (1) (m)). Reviewed By Date Property Owner a ! roperty Location Lakes & Hil Dev el opm ent Gtvt. LP4 4 W 114 NW i /4,S 13 T 31 N,R 18 W Property Owner's Mailing Address 1 tad L t # Biock # Subd. Name or CSM# - _ Pine Acres City St to Zip Code Phor Gi Village Town Nearest Road /�v 7 f•�.� 220 TH. Ave. New Construction Use: R'Sidentia{ / Numbs o ooms 3 Addition to existing building -- ❑ Replacement Public otrsrbai escribe Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpdfff? 8 trench, gpdAF AbSOrption area required 643 bed, fF 562 trench, fF Maximum design loading rate .7 bed, gpd/ft .8 tr ench, gpd/fF Recommended infiltration surface elevation(s) 98.5 ft (as referred to site plan benchmark) Additional design / site considerations t Paren t material - - - - -- Flood plain elevation, if applicable -- - - - ---- ft ble for sys tem Conventional Mound In Ground Pressure AT Grade System in Fit! Nolding Tank uitable for system r ® s❑ u M S U ❑ s❑ U ❑ S U ❑ S Z 11 ❑ S® U SOIL DESCRIPTION REPORT u ,, Zavo 0 -k- Depth Dominant Color Mottles Structure GPD/ftz Boring# Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistent Boundary' Roots Bed Trench 1 1 0 -10 10YR3 /3 I - - - -- 1 lmsbk mvfr as if 4 .5 Y 2 10 -20 1 /4 -- 1 im sbk mv gw lvf .4 .5 Ground 3 20 -57 7.5 YR4/4 - - -- cs osg ml g - - -- 7 .8 elev , — _�. — - - -- I 0 ft. 4 57 5 Ic R5/ - - -- - - - -- - - - - -- es osg ml - - -- - - -- 7 ! 8 Depth to limiting S ` factor Remarks: _ - ------------------ 2 1 0- I 1 l OYR3 /3 I 1 msbk mvfr as I 4 .5 - I - - - -- -- - - - - - -- - - -- - - - - -- — - - - - -- -- -1 - - - -- -- 2 11 -21 10YR414 1 lmsbk mvfr gw lvf 4 .5 y Ground 3 21 -59 7.5YR4/4 ------------------ es osg ml gw - - -- .7 .8 1 2 elev - 10 - 0 ft. 4 5 -9 10YR5 /6 ------------ - - - - -- cs osg ml - - -- - - -- 7 8 Depth to limiting factor I - - >94" Remarks: -. -- CST Name (Please Print) Signature: Telephone No. Jacque Hawkins 1 1?7 - Add s �.� mi Date CST Number Ref # / J 0 v6 �t uc: 4/8/00 Z 7 390 PROP ERTY OWNER: Lakes & Hi11s Devel n lent SOIL DESCRIPTION REPORT Page 2 of PAkEL l.DJ Paneling Depth Dominant Color Mottles Structure GMT Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. onsistence Boundary Roots PD Bed Trench 1 0 -12 10YR3/3 ---- ------ - - - - -- 1 lmsbk mvfr as if 4 .5 2 12 -25 10YR4/4 ------------------ 1 lmsbk mvfr gw lvf .4 .5 Ground elev 3 25 -57 7.5YR4/4 ------------ - - - - -- � C osg ml gw .7 .8 102.F . 4 57 9 10YR5/6 ------------ - - - - -- cs osg ml - - -- - - -- .7 .8 Depth to limiting - - -- —— -- — - -- - factor o2.Z Remarks: 4 I if 1 � 0 -9 10YR3 /3 ---------------- 1 lmsbk mvfr 5 a .4 2 9 -22 10YR4 14 ------------ - - - - - - I lm mvfr I gw lvf 4 .5 Ground -- — — —� - —� elev 3 22 -56 7.5YR4t4 - - - - -- - es bsg - -- ' Ml 9 w — _7 8 ' 101.9 4 56 -80 10YR5 /6 ------------ - - - - -- cs os g ml - - -- I - - -- 7 ! .8 .8 Depth to limiting -- — -- - - - - -- - - - -- ----- -' - - -- - - - -- factor >8U Remarks: 5 — 1 0-10 10Y /3 � ------------ - - - - -- 1 llnsbk �mvfr as if 4 .5 y 2 T ! 10 -23� 1 0 Y R4 /4 ------------------ 1 I lmsbk m vfr gw lvf .4 .5 Ground I I elev 3 23 -54 7.5YR4/4 ------------ - - - - -- cs osg Ml gw - - -- . 7 .8 + - -- + — — — 101.9 4 54 -83 10YR5 /6 -------- - - - - - - cs osg ml - - -- - - -- 7 8 ^� .T Depth to limiting - - - - -- -- - factor — -- �----------- �- - -- - - -- -- >83° Remarks: _ _ -- Ground � - -� - -- — - -��- - -- —} - — elev Depth to limiting — - - -- - -- -- -- -- - - - - -- - - -- - — factor Remarks: I -I 6 • B o x /d z- z 3�n7.t iF 23 J�Y/ U / 7 A N zZ Z9 7Z- �f� Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567-P (R.6/99). Table 1: System Design Specifications Sanitary Permit Number Z- Number of Bedrooms 3 Design Flow - Peak (gpd) 5'0 Estimated Flow - Average (gpd) c7 - 0 Septic Tank Capacity (gal) 6rsD r Soil Absorption Component Size (ft') }r 2 Type of Wastewater Do estic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) aup — ac. Maximum Influent Particle Size (in) 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years 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 (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the se d outlet filter shall be assessed at least once every 3 years by inspection. Th outlet filter all be cleaned as necessary to ensur p roper g2eratio The filter cartridge s not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge 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 an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole 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- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 r r • ` Management Plan for a Septic Tank and Soil Absorption Component Plantings of deep- rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. 3 S'I' CItOIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer P, C� . 11 aVA 6 W A S - :Y - ,v <.- Mailing Address Ov . 1 ? d- ir' Property Address 2 (Verification required from Planning Department for new construction) City /State Parcel Identification Nurnbcr 03�' LEGAL DESCRIPTION 13.x, . I 0 I Z Property Location N y,, -NA/ r /1, Sec. , T...3I N -R W, Town of S'5V O NA1 16' Subdivision Lot 11 —/7 Certified Survey Map It �— -- Volume Page 11 Warranty Dt ed # _ / / 3 �^ Volume Pa ge It Spec house yes Cl no Lot lines identifiable Kyes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof your septic system could result in its prcniaturafailure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewa(erdisposal 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. 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 Zoning Office within 30 days of the three year expiration date. SIGNATURE Or APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowlcdgd. I (we) am (are) the owncr(s) of Ac property described above, by virtue of a warranty deed recorded in Register of Deeds Office. A • APP IC � K �� DATE « * « * «« Any information flint is Fins- represenicd may result in the sanitary permit being revoked by flu Zoning Dep artment. ent. *« Include with (his applicatlorrt a stamped warranty deed from the Register of Deeds office 8 copy of the certified survey map if reference is made in the warrnnty decd F )fill No9- AI— WARRAlFYDI ?F,D MitmesulaUnilinm Blanks (1978) llulslad.t'-Lar Corporation or Partnership to Corporation or Partnership VOL 1517 PAGE 2 C' 24439 No delinquent taxes and transfer entered; Certificate of KATHLEEN II. I-MI -511 REGISTER OF DEEU3 Real Estate Value ( ) filed( ) not required ST. CROIX CO., 411 Certificate of Rcal Estate Value No. 119 RECEIVED FOR RECORD 06 -07 -2000 4:00 PH HURRAIITY DEED County Auditor EXPIPT R CERT COPY FEE: COPY FEE: TRUIISFER FEE: 304.60 b RECURDIIIG FEE: is .o 0 Deputy PAGES: 2 STATE DEED'I'AX DUE IIEREON: $ RecordingArca Date: May 31, 20 00 FOR VALUABLE CONSIDERATION, Lakes and Flills, Inc. a Corporation under the laws of Minnesota Grantor , hereby conveys and warrants to P.C. Coltova Builders, Inc. Grantee, a Corporation under the laws of Minnesota real property in St Croix County, Wisconsin, described as follows: Lots 9,1 1,15, an 17 ine Acre St. Croix County, Wisconsin "The seller certifies that the seller does not know of any wells on the described real property: together with all hereditaments and appurtenances belonging thereto, subject to the following exceptions; Easements, covenants and restrictions of record. Lakes and Hills, nc. , . By: Itichard S Nels n Affix Decd Tax Slan)p Here Its: President STATE OF MINNESO'IFA Ss. COUNTY Or Ramsey The foregoing instrument was acknowledged before n1c this 31st day of May 1 19 99 by Richard S Nelson, President and the and of Lakes and Hills, Inc. a Corporation under the laws of Minnesota on behalf of the Corpo NOTARIAL STAMP OR SEAL (OR OTHER TITLE OR RANK) C) y.� DEBORAH L. TEICH SIGNATURE OF PERSON TA ING ACKNt;WL1iDGn1ENT NOTARY PUBM•MINNESOTA • MY COMMISSION Tax Statements for the real IxopeAy described in Ibis insounCot . +�• EXPIRES JAN.. 31, 2005 should he sent to (Include name and address or Grantee): MIS INSTRUMENT WAS DRAFTED BY (NAME AND ADDRESS): P.C. Collova Builders, Inc. Northwest Title & Escrow Corp. 705 County Road E Suitc #120 Iludson, Wise. 54016 3535 Vadnais Center Drive Vadnais Heights, MN 55110 58887 I I� c0 I N00'33Y7E � //� v I I I ?s> /c �/ .�, / i/ \ 1�3 \ 83 re ft. —_ 1.91 91 acres m� \ Z r� IS 15 F+I n 76,424 sq. ft. "� u // 9 �•. \\ — 031 1.75 acres W / 21 \ °�\ 3)0 /- �• ? NI 68,652 sq.ft. 1 0 6p. 1.58 acres ma yy2 J 0 o I J2a00' 0i 1 w 70,766 sq.ft. $ I Noo'SY17'e n 1.62 acres 4� �so•�n'�eP _ x zl g 22 l C I �g w; f 16 p .t, 'O - 70,332 sq.ft. /I 2 f cvl Iry 74,128 sq.R. ig / 'b' 1.61 acres //yo, �, � 10' CQ 1.70 acres �, ,or 23 w I I 3 20 � / / 76,324 sq.ft. I • 32a6a' 8 93,346 sq.ft. $ / 1.80 acres �y N0033 f7 k 1 9 2.14 ones �a' 10' � 10' 7 to zo• NlI .I 93,110 sq.ft. zo• NW QII Ih I 2.14 acres ~' 376 %' 66,730 sq.ft. –ill I 1.53 acres g �._ -, J- / OUTLOT 3 a � o �aamm9 �: t , 8 109,642 sq.ft. m �d \ o roo HWL 9ai.3 - =o 2.52 orne9 \ Q ` 307.61' % -- 230.67' 1 zp• 380.96' \ \ 15_ 14 a ' 13 1310.43�(meas.) 12 11 - 9 / 'T • --- N00 50 E 09''e e o� West line of NE 1/4 of NW 1/4 -- 1 Lo. ^a ^y of Sec. 13, T31N, R18W I 1310.45'(rec.) r9�o. JJJ <� 9`e PRAIRIE RICH z ( 3 \ oro w"yq� 3 En" i Z 3 b GRAPHIC SCALE N a o h Zn 0 300 � • i z rn q� CO z I Q: ° t1i Im( IN FEET) _ 1 inch 100 a ` p ` 1 5003229'W� 5 y 0 o ASSUMED BEARINGS REFERENCED TO THE WEST LINE OF THE NW 1/4 — _ —__ �_ �'--- r 3 0 ? OF SEC77ON 13, T 31 N., R 18 W., ASSUMED TO BEAR NOO`W'46*E. 132ND o p Z N F STREET_ Project No. 272.002FP � of Cbrranerce i`) $s ` � rQ �ALUA� � REPORT Pam I of 3 Div an of Safety and Buildings 2;,— iU, Comm 85, Adm. code S+. Croix Attach complete site Plan on pow not less than 812 x 11 undoes in sae. Plan must include. but not Nrnited to: vertical and hwoon l reference point (SM, dxechon and pared LD. p slope, scale m . ms north z any lotion arxl diustenoe neatest road- Date Please P n , s.18. (1) (rn)). peMnW k*M= tion you mW ee Property Owner fit .( CAC CollO rr , -) Govt Lot N E -1/4 rtw 114 S 1 3 T 31 N Rig E (orel Prop" Owners Mailing Address w Lm f�a�c # Subd. Name or CSW 20 � c 4- o� – �T Roix �`1 �Irl ACYe Nearest Road th N1R ❑ C ❑ddb ©Town lad r r r, 220't AyS22C 3 — Code derived design tfowrMa �/SO O0 GPD [� New God t1se: i� Residential ! � — — ❑ Repleoement ❑ public or cortuoerdau - Desalm �i /!� ft parent material Uc� w 0 .S (^ Flood Play elevation if applicable General comments S ysle w\ e- be u . 7 0• ,SO and `¢ L. r`• e( U. 90• S v O i WC^S VYIoS' ty S 'rift -c� or-, S � Boring Boring # © © Pit Ground swface elev •� ft. Depth to 9 factor I Zg in. Sou Rate II GPD/fF Horbw Depth Dominant Red= Desa fon Texture Structure Consistence Boundary Routh *Eff#i 'EW2 in. Murrell Qu Gr. Sz. Sh Sc L 1 msbk mfr CS IV 2 • 3 m - 1 1.Z a ly - �Z�S ID tills mS Q rnl /. �(�•`� �3•`� F Boring # Boring (3 in. ® pit Ground surface elev. 47 •94 ft Depth t fader Sol AMyqp§M Rate Horizon Depth DW*MtCObf Redox Description Texbm Strudwe ('.cam Boundary Roots GPDNF in. Mural Qu. Sz. Cont. Color Gr. Sz. Sh. *M *Eff#2 I (.N -cj 16-4 Sc Im5 m cS 14 .2 • 3 L S ✓n 4r c5 — - 7 /. Z 3_ ►�- l31 16 4 mS Y-n Effluent #1 = BO[ > 30 < 220 mg#L and TSS >30 150 mg/L ' Ef&mt 92 = BOD < 30 mgjL and TSS _< 30 mg/L CST Name ( Print) 'G!— Z `l Address pate Evaluation conducted Telephone Number 2 � 1 t c, Owner — C - la I IO\/a parcel lD a piBo�in9 Ground s, e ►. .7- F ft. Depth to -�-- sea Rate Dom Redox Desaipr;ion Texhae She C.o Roots 'Ett 1 `EW2 HoruAr► Gr. Sz Sh. in. Mu CKL Sz. Coat Color 3 I O- I --, Sc, I rnsbk , �r EF L— I I nS ❑Boring# ❑ ❑ pit Ground sub" elev- 9 factor Soil Rate Texture S6uc�une Consistanoe Botu+dary Roots rpm Hoi¢an Depth Dominant COW D "EW "EW in. Munson !lu sr- Cont. COW Gr. Sz. Sh. I , -- � R a Boring # El sorft Ground surface elev. _ fL Depth to liirn!" factor in- ❑ pit Soil Rate Horizon De pmt Redax Description TOM" Structure Consistence Bound" Roots pDff in. Munsell (XL Sz. Cont. CoW Gr. Sz Sh. 'Ef�1 'Eff#2 • E1MMM#1= 800 30 220 a & and TSS >30:5 150 a & ' Effluent #2 = 80D < 30 aglt. and TSS :5 30 ffQ& The Department of Commerce is an equal o pp o rtunity service provider and employer. If you need assistance to access services or need material in an "m=te format, Plm mda the deWftnent at 60 8-266 -3151 or TTY 60&264 -8777. SOD-Wo cs.OM) PAGE 3 OF .3 NAME 0 16 qC LOT# / LEGAL DESCRIPTION N E'1 +kiu' /e S / 3 T 31 aR. r E (or)(9 SCALE: BM I ELEVATION 160 d BM I DESCRIPTION Aot,' l ; '7 ' 1 rV, { re c - r - BM 2 ELEVATION A 7 • Co 7 SeG• BM 2 DESCRIPTION -Lop 04 14ovse mA, -+,`o r SYSTEM ELEVATION 9O . 5'0 ALTERNATE ELEVATION qa So CONTOUR ELEVATION Ylf.0 gS,00 3 `c,.Oc 0 J ■ a 9 s.6 q ee l, a Al 6' SIGNATURE �'� - DATE �� FROM P C COLLOVA BLDRS, INC PHONE NO. 715 549 5911 Apr. 02 2001 02:20PM P1 { 1 V __ PINE ACM I..a•. IJ IJ � I � � uu uer!rrer .•,... .. 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