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HomeMy WebLinkAbout040-1316-07-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St, Cr oix Safety and Bu#ding Division INSPECTION REPORT Sanitary Permit No: 514839 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: Walrack, Dan & Tiffany Troy, Town of 040 - 1316 -07 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: (�j V►� ��j 05.28.19.2063 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic r 1 5 o ! Z_(0 Benchmark 7 ct 107 Q �Cl 4 �. 5 Z Alt. BM 4 2.6 Aeration Bldg. Sewer A 2.35 /zZ . Z'S Holding St/Ht Inlet Q � . k /11 . G 3 TANK SETBACK INFORMATION St/Ht outlet 7E' Z , ! l9. Z 3 TANK TO P/� WELL BLDG. Vent to Air Intake ROAD Dt Inlet a.k Septic 4S .� Dt Bottom �.. 7 Dosing Header /Man. Aeration Dist. Pipe r G Holding Bot. System a PUMP /SIPHON INFORMATION FiM' 3 Manufacturer Demand St 1, e A GPM 7 • �5 1 2 I 5 Model Nu er 1 , 17 TDH Lift Friction Loss Syst ad TDH Ft - 7 , 0 1 Forcemain Teng171 ia. Dist. to Well -' 9`i SOIL ABSORPTION SYSTEM 14A VZ,p, 1 A.0 BEDITRENCH Width i Length I NQ. Of Trenches PIT DIMENSIONS No, Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO PiL JBLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR i� M Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM AA 1$+ i + g Header /Manifold / Distributio x Hole Size x Hole Spacing Vent to Inr Pipe's' �— ` \ 3f n Length 2Z Dia 1 1-ength ` Dia Spacing e. .n. SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth o� xx Seeded /Sodded T Mulched es [] No Bed /Trench Center Bed/Trench Edges Topsoil Yes � No �: Y COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 1 1 Inspection #2: / ! Location: 537 Autumn Blaze Trail Hudson, WI 54016 (SE 1/4 SW 1/4 5 T28N R19W) Cedar Woods Lot 7 Parcel No: 05.28.19.2063 1.) Alt BM Description = y � `-'� �Z �t • 5 ° I 5 r7' • z 1, .� C�• 2.) Bldg sewer length = r ICJ SLte Q I Z`I U 3 - amount of cover = 'y 7 Plan revision Required? Yes No Z3 -l_i� y�"( � j 1 Use other side for additional information. �_ SBD -6710 (R.3197) Date InsepctoIgnature Cert. No. commerce.whgov Safety and Buildings Division County 261 W. Washington Ave., P.O. Box 7162 S4 e 0-10 J s co n n Madison, WI 53707 -7162 Sanitary Permit Number Number (to be filled in by Co.) Department of Commence Sanitary Permit Application state Transacti N u mber In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you pr9QJeay be us r s da p urposes in accordance with the Privacy Law, s. 15.04 I m , Slats. / uMM r Q 1 7 15 I L L Application Information - Please Print All Information T 11 Property Owner's Name Q A-/-J a.- Tl rrA r\1 V &AJ A L A cP i Property Owner's Mailing Address Prope Location za�3 J ( Q P K,,Q 4-A U MAR 19 200 Govt. o City, State Zt Code Phone lumber y,, � /, Section _ ,p 5 /_ J Z.3 ST. CROIX COUN cucle one C2j v" OFFIC N ; It E orb 11. Type of Building (check all that apply) V Lot # �.4 or 2 Family Dwelling- Number ofBedrooms $.u�dnne ! Block # C DPitt ritJJ S ❑ Public/Commercial - Describe Use � ❑ City of El State Owned - Describe Use CSM Number ❑ Village of Z - 'own of �k-- L w Z 2 III. Type of Permit: (Check only one box 6n line A. Complete line B if applicable) A. P. S stem y ❑Replacement System ❑ Treatment/Holding Tank Replacement Only C1 Other Modification to Existing System (explain) 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 S stem /Com onent/Device: Check all that appl Non - Pressurized In -Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. ofsuitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Component (explain) ❑ Pretreatment Device (explain) V. Dis ersaVrreatmentArea Information: Design Flow (gpd) Design Soil Application Rate(gpd Dispersal Area Required (sf) 0 ; 1 ga);roposed (sf) System Elevg(ion c90 o S (A I �. Q JJ VI. Tank Info Capacity in Total # of anufacturer Gallons Gallons Units u 0, 9 H Y New Tanks Existing Tanks `� V Septic or Holding Tank Dosing Chamber 1 ' VII. Responsibility Statement- 1, the unde igned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Si ature MP /p�llumber Business Phone Number U t�/L rya �2G q 7 �l5 z 7� Plum ePs ddress (Street, City, State. Zip Code) L L ✓- 1S Vlll. Count /De artment Use Onl Approved ❑ isapp�oe Permit Fee Date ued Issuin gent Signa e $ ❑ O even Reason enial ' IX. Conditi easons for Disapproval t 1. Septic tank, eftluw4 filter and dispersal cell must all be servtcet± / maintained as per management plan provided by plutnber. 'T 2. All setback requirements must be maintained m P o et system and submit to the County only on paper not less than 3 1/2 x 11 inches In size SBD -6398 (R. 01/07) Valid thru 01/09 ...�.. .h,�y . ......... I i i r� L-A- A-� � i r y A-L 2Krz L o+ 7 C ec yr a {fit m y r v _ w l0 PO4 J�tl 0 0 6 � bu y ��dpol� A j�1/(fLG 1� Rcopy �< i i t 4 G o 4- - 7 C e-oe4 -7l. r -h2 a Y $y jpj�e f D-ora x L �d 6 dpe9l� d lirJ (�G G I 3AI11,9Z I r O / �s�.' o ' N U a �o o N O O ik 461.13 `mss N07 09,tlw Lr F-- ,� "- a) / a L. < O N / j �' / 0 0 'M z as rn Lo A � VK ,:� iLZ L 3 „8t LON 1 8 L' 3 „8tr,80. LON ,ZS' L LZ 3 „8 *,80. LON �«gb�80o [ON f (M „LS,Z L. LOS) o J Ip d N y O f J a u I 01 L L d d Z f NQ 0 U_ Z N c ~ . I I � WN N Z F- N C} LJ LL , Q a >� � Q � z U-1) C14 �-' D o 0 0 c LL ° n w `= s 1� W a t p��3 c04 Ix i x M LLy r, � Z LV J J3 o� vi L - Of ~o 13: Wsconsin Department of Commence SOIL EVALUATION REPORT Page I of 3 Division of Safety and Buildings in accordance with Comm 85, Ws. Adm. Code County ST. CROIX Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. 040 - 1022 - 70 - 000 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Im Revie by 3 1?16-3 Personal information you provide may be used for seconds nA (m)) ­31 d4b Property Owner ProqertyLoc5U1 G & L LAND DEVELOPM NT, INC. Govt 1/4 SW 114 S 5 T 28 N R 19 E (or) Property Owner's Mailing Address IAA A 1 Lot Block # Subd. Name or M# W 12491 890th Aven 1 t 7 Cedar Woods City State Zip Code hone OD( ICE Village ■Town Nearest Road River Falls, WI 54022 (! 711 Z 0 New Construction Used Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement E] Public or commercial - Describe: Parent material sandy outwash Flood Plain elevation if applicable IAA ft• General comments Conventional In- ground Trenches -- 0.7 loading rate and recommendations: a Boring # 0 Boring 0 pit Ground surface elev. 103.70 ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff #1 *Eff#2 1 0 -6 10YR2/2 1 2fa &sbk mvfr cb 3vf -co 0.6 0.8 2 6 -17 IOYR2 /2 - sil 2ma &sbk mfr cs 2vf -co 0.6 0.8 3 17 -24 7.5YR3/2 / sil 2f -mabk mfr cs 2vf -co 0.6 0.8 4 24 -38 7.5YR3/3 A 2f -mabk mfr gs 2vf -m 0.6 0.8 5 38 -60 7.5YR4/3 grs Osg dl gb lvf -f 0.7 1.6 L 6 60 -100 7.5YR5/4 W s Osg dl -- -- 0.7 1.6 I Horizon 3 has some gr; few cobs. 2 Boring # Boring 101.70 99 ❑ Q pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I *Eff#1 I *Eff#2 1 0 -8 10YR2 /2 1 2fgr &sbk mvfr cb 3vf -co 0.6 0.8 2 8-1 10YR2 /2 1 2fa &sbk mfr cs 2vf -co 0.6 0.8 3 17 -37 7.5YR3/2 sl 3fabk mvfr S'C'I' 2vf -m 0.6 1.0 4 37 -63 7.5YR4/3 grs Osg dl gs lvf-f 0.7 1.6 5 37 -99 7.5YR5/4 s Osg dl -- -- 0.7 1.6 Horizon 5 has some cos; few cobs. * Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) ture CST Number Mary 10 Hollister Hollister's Soil Testing & Desi Wt S 224832 Address "' Date valuation Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 03-08-08 (715) 426 - 1775 Property Owner G & L Land Development, Inc. parcel ID # 040- 1022 -70 -000 Page 2 of 3 Boring ❑ Boring # E] pit Ground surface elev. 97.10 ft. Depth to limiting factor 90 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -6 10YR2 /2 -- 1 2fgr &sbk mvfr cs 3vf -co 0.6 0.8 2 6 -18 10YR2/2 _ I 3fabk mfr cs 2vf -co 0.6 0.8 3 18 -30 7.5YR3/2 -- A 2f- ms &abk mfr cs 2vf -m 0.6 0 • 8 4 30 -45 7.5YR4/3 -- s Osg dl gw lvf -f 0.7 1.6 5 45 -90 7.5YR5/4 -- s Osg dl -- -- 0.7 1.6 few cobs /one stone El Boring # lJ Boring pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 F-1 Boring # pit Boring Groun surface face elev. ft. Depth to limiting factor in. Soil A plication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30:5 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777. SBD- 8330Test (([01 /00) Ili L • Plot Plan for Site and Soil Evaluation Page 3 of 3 j' � LA A V,, tpPlv.�N'� Property Owne 4 � I" = 40ft Legal Description uav -7 P CU-�AK VJWDS (except where noted) sue' /4 ors Z W s s, -cZg 14� -�tiw� o� o = Backhoe pit T�,n4� 5T C�A� c�n�. l�ttY �tSCK%t�l,�F�t1, North can 4 P OD Ak R 114 Site Location: F r a- tl rF4- b y 6 0A L 1 4, c 67 uick4 Q STANDARD CHAMBER I N 52" Quick4 Standard Chamber 48" (EFFECTIVE LENGTH) 12" 1111111112 8" /641v, 34" SIDE VIEW SECTION VIEW © /0,3 MultiPort End Cap A 0 16" 12" 34" SIDE VIEW TOP VIEW FRONT VIEW M _ .v r ,�� y,•".I "4.T:'V d' uV �` i t `��N�,i Y t �a��� &` �'"?` asb`a . �� �'���, r Y f :. � '�✓ v� + t -'� t "� ��:. �. '�&�gr4' w INFILTRATOR SYSTEMS, INC. STANDARD LIMITED WARRANTY (a) The structural integrity of each chamber, and plate, wedge and other accessory manufactured by Infiltrator ( "Units °), when installed and operated in a leachfidd of an onsite septic system in accordance with Infiltrator's instructions, is warranted to the original purchaser ("Holder) against defective materials and workmanship for one year from the date that the septic permit is issued for the septic system containing the Units; provided, however, that If a septic permit is not required by applicable law, the warranty period will begin upon the date that installation of the septic system commences. To exercise is warranty rights, Holder must notify Infiltrator in writing at its Corporate Headquarters in Old Saybrook, Connecticut within fifteen (15) gji • . days of the alleged defect. Infiltrator will supply replacement Units for Units determined by Infiltrator to be covered by this Limited Warranty. Infiltrator's liability spedficaly excludes the cost of removal and/or installation of the Units. Q (b) THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT SYSTEMS INC TO THE UNITS, INCLUDING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE. (c) This Limited Warranty shall be void if any part of the chamber system is manufactured by anyone other than Infiltrator. The Limited Warranty does not extend to incidental, consequential, special or indirect damages. Infiltrator shall not be liable for penalties or liquidated damages, including loss of Environmental Onsite Wastewater Solution production and profits, labor and materials, overhead costs, or other losses or expenses incurred by the Holler or any third party. Specifically excluded from Limited Warranty coverage are damage to the Units due to ordinary wear and tear, alteration, accident, misuse, abuse or neglect of the Units; the Units being subjected to vehicle traffic or other conditions wMch are not permitted by the installation instructions; failure to maintain the 6 Business Park Road • P.O. Box 768 minimum ground covers set forth in the installation instructions; the placement of improper materials into the system containing the Units; failure of the Un or the septic system due to improper siting or improper sizing, excessive water usage, Improper grease disposal, or improper operation; or Old Saybrook, CT 06475 my other event not caused by Infiltrator. This Limited Warranty shall be void if the Holder fails to comply with all of the terms set forth in this Limited 860- 577 -7000 •FAX 860 - 577 -7001 Further, in no event shall Infiltrator be responsible for any loss or damage to the Holder, the Units, or any third party resulting from installation or ship- 800221 _4436 ment, or from any product liability claims of Holder or any third party. For this Umned Warranty to apply, the Units must be installed in accordance with all she conditions required by state and local codes; all other applicable laws; and Infiltrator's installation Instructions. (0 No representative of Infiltrator has the authority to change or extend this Limited Warranty. No warranty applies to any party other than the origi- nal Holder. The above represents the Standard Limbed Warranty offered by Infiltrator. A limited number of states and counties have different warranty require- ' ments. Any purchaser of Units should contact Infiltrator's Corporate Headquarters in Old Saybrook, Connecticut, prior to such purchase, t obtain a copy of the applicable warranty, and should carefully read that warranty prior to the purchase of Units. U.S. Patents: 4,759,661; 5,017,041; 5,156,488; 5,336,017; 5,401,116; 5,401,459; 5,511,903; 5,716,163; 5,58W8; 5,839,844 Canadian Patents: 1,329,959; 2,004,564 Other patents pending. Infiltrator, Equalizer and SideWinder are registered trademarks of Infiltrator Systems Inc. Infiltrator is a registered trademark in France. Infiltrator Systems Inc. is a registered trademark in Mexico. Contour, Contour Swivel Connection, MicroLeaching, PolyTuff, SnapLock, ChamberSpacer, Posil-ock, QuickCut, QuickPlay RECYCLEPPAPER and Quick4 are trademarks of Infiltrator Systems Inc. 0 2003 Infiltrator Systems Inc. Printed in U.S.A. Q011203HP -0 Private Onsite Wastewater Treatment System Management Plan Y 9 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 Numb of Bedrooms Design Flow - Peak (gpd) Estimated Flow - Average (gpd) Septic Tank Capacity (gal) Soil Absorption Component. Size (W) tp,uc e e Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank omponent Soil Absorption Component Design Flow - Peak (gpd) 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 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 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. Y 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 cont f h q to o 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 usual) temporary, but is difficult Y p rY� t or impossible to repair until weather conditions improve. In n p general, soil compaction over this component wil � i reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and d earlier, organic clogging of the soil. 2 I . I Management Plan for a Septic Tank and Soil Absorption Component 9 p p P 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. P LO - E R-9 6,-> 7 /s-- 2, 7 3 --�- co 1u c 2 6 c- 7/5 4 7 2 I 3 ! liilll lilli i!!ii IIlil IIIlI IIII1 IIII 111111 Ili! liil * 8 6 3 3 0 3 1 State Bar of Wisconsin Form 1 -2003 863303 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS Document Number Document Name ST. CROIX CO., WI RECEIVED FOR RECORD 10/31/2007 09:45AM THIS DEED, made between G & L Land Development, Inc., a Wisconsin WARRANTY DEED Corporation EXEMPT It ("Grasstor." whether one or more), REC FEE: 11.00 TRANS FEE: 427.50 Dan Walra-ck and Tiffany Walrack, hltaabnd and wife PAGES: 1 ( "Grantee," whether one or more). Grantor, for a valuable consideration, conveys to Grantee the following described real Recording Area estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ( "Property ") (if more space is Name and Return Address needed, please attach addendum): River valley Abstract & Title, Inc. 1200 Hosford Street, Suite 201 Lot 7, Plat of Cedar Woods in the Town of Troy, St. Croix County, Wisconsin Hudson, w134016 File k 2696422 0404316-07-000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except: Easements, restrictions and rights -of -way of record, if any. Dated October l 1, 2007 G & L and Development, Inc. (SEAL) (SEAL) * * Glen M. Wiese, President (SEAL) (SEAL) AUTHENTICATION - ACKNOWLEDGMENT Signature(s) J STATE OF WISCONSIN } authenticated on ) ss. St. Croix COUNTY ) * Personally came before me on Octobe 2007 TITLE: MEMBER STATE BAR OF WISCONSIN the above -named Glen M. Wiese (If not, to me known to be the person(s) who executed the foregoing authorized by Wis. Star. § 706.06) i t ack wrl s me. THIS INSTRUMENT DRAFTED BY: Attorney Doug Berg Notary Public, to of Wisconsin 1200.NosfocdStreet,.Suitt 20.1...Hudscut, -Vd 54016 My Commissio (is permanent) (expires: ) (Signatures may be authenticated or acknowledged, Both are not necessary.) NOTE:THMSXSTANDARD FORM. 'ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ® 2003 STATE, BAR OF WISCONSIN FORM NO. 1 -2003 • Type name below signatures. 1 of1 State of Wisconsin County of St. Croix 1 hereby certify that this Instrument Is a full; true and correct copy of the document on file and of record in my office and has been compared by me. Attest 4a ,1, ''C 11 , 240 Kathleen H. Walsh Register of Deeds Mar 19 2008 9:32RM Dan Walrack, RCR Inc. 715.749.4181 P.1 ST. CRO IX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnWBuycr 1)0610 is I i �„ W a � fi G GC ,, 5 3?` Mailing Property Address - ,0; Ad A (Verification requited front Enanning iii Zoning Department for new construction.) City /State Pjji q W ;C Paroel Identification Number _ I311d "' 07 — QO Q LEGAL DESCRIPTION Property Locrttiol� ';:. w �; . Set:. : T N R W_ Town of Subdivision Plat: W 443 , Lot # . Certified Survey Map # Volume , Page # Warmaty Deed # � - 3Q (before 2007)Yolume , Page # Spec house yes(0w Lot lines identifiable X" no SYS'C,_ Eel M,AINIENANCE ANlll,Qw'NER C T ATION lmprgperus.- and nuintenartce of your septic system could result in its prum ature failure to handle wastes. Proper maintemince consists of pumping out the septic tank every three yetis or sootier, if needed. by a lic ettsed pumper. What ym put k0l) the system can affect the functioti of the septic tank as a treatnterk stage in ft waste disposal system. Owner enainterisacc responsibilities are specified in 4Comm. 83.32(1) stid in CbApter t 2'- St. Croix County Sanitary Ordinance. The proptwq oamer agrees to submit to St. Croix county Planning & Zoning DepYrrment a certification Form. signed by the owner and by a amster plumber, journeyman plumber, restricted plumber or a licensed pumpar verifying that (1) the on -site wastewater disposal system is in proper operating condition ancVor (21 after inspectidn and primping (ifnecossary), die septic tank is less thin 1, full of sludge. Irwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal ttyaoeiawith the standards set rorth, herein, as act by the Depsrtatent of Commerce and the Department of Natural Resources. State of Wiscartsin. Certification stating that your septic system has been maintained must be couvUted =4 reltwned to the St. Croix County Ptarming & Zoning D"ruitent within 30 days of the three year expiration date. Uwe certi that all statements on this farm are inns to tie best of mytour lumw ledge. 11we anvarc the owncr(s) of the property described vc, by virtue of a warranty deed recorded in Register of Deeds Office. Number DA70 OF APPLICANTS ** *Any information that is misrepreisented may result in the sanitary permit being revoked by the Planning 8r Zoning Department. *,• tnciude wids this application a recorded warranty deed froarrhe Regkwer of Deeds Office and a copy of the certified survey trap if rekrvnce is nude in the warranty deed - (REV. 08451 Z'd oewtc"IL )IIAWN '0 Au04WV aZV60 90 6t "M t Wisconsin Department of Commerce SOIL EVALUATION REPORT Page I of 3 Division of Safety and Buildings In accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8 '/2 x 11 inches in size. Plan must St. Croix Include but not limited to: vertical and horizontal reference point (BM), a ion 1 Parcel I.D. 040-1022-70 -000 Percent slope, scale or dimensions, north arrow, and BM referenced to n Please print all information Review y Date Personal information you provide s vary Law, s. /Z L$ Property Owner Property Location G &L Land Development, Inc. Govt. Lot SE �%. SW %. s 5 T 8 N R 19W E (or) W Property Owner's Mailing Address UEU 7, 7 zon Lot # Block # Subd. Name or CSM# W12491 890' Ave. 7 1 1 Cedar Woods City State ❑ City 0 Village 0 Town Nearest Road River Falls WI Zip - 8 1 Troy Coulee Trail / FF 0 New Construction Use: 0 Residential / Number of Bedrooms Code derived design flow rate GPD ❑ Replacement O Public or Commercial — Describe: Parent Material Flood Plain elevation if applicable ft. General comments and recommendations: B -1 was completed during the preliminary soil assessment on July 22, 2005. The lot lines were not clearly marked during completion of the final soil assessment. Sufficient area is available for installation of the POWTS, however the plumber prior to installation of the system must confirm the location of the lot line. ❑ 1 Boring # OBoring g 0 Pit Ground Surface Elevation 98.9 ft. Depth to Limiting factor >110 tn. Soil AoDlication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 1 0-8 10YR3/2 None SIL 2 -f-gr dsh as 3f 0.6 0.8 2 8 -23 10YR4/4 None GRSIL 1 -f -sbk dh aw 2f 0.4 0.6 3 23 -34 10YR3/4 None GRVS 0 -sg ml gs 2f 0.7 1.6 4 34 -110+ 10YR5/4 None GRS 0 -sg ml - 1f 0.7 1.6 Boring O Boring g OPit Ground Surface Elevation 97.4 ft. Depth to Limiting factor >120 in. Soil Aoofication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDtfe in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -13 10YR3/2 None SIL 2 -f -sbk Mfr Cs 2f 0.6 0.8 2 13 -22 10YR3/4 None GRL 2 -m -sbk Mfr Cs 2f 0.6 0.8 3 22 -32 7.5YR4/4 None GRLS 0 - Ml Cs 2f 0.7 1.6 4 32 -120 10YR4/4 None FS & GRVS 0 -sg ml Cw None 0.5 1.0 * Effluent #1 = BOD5 > 30<_ 220 mg/L and TSS > 30:5 150 mg/L * Effluent #2 = BOD 5 30 mg/L and TSS 5 30 mg/L CST Name (Please Print) Sign CST Number Mark Iverson 46672 Address Date Evaluation Conducted Telephone Number P.O. Box 155 Hammond, WI 54015 December 20, 2005 715 -796 -5664 Property owner G &L Land D evelopment, Inc. parcel ID# 040 - 1022 -70 -000 page 2 of 3 ❑ Boring 3 Boring # ppit Ground Surface Elevation 98.7 ft. Depth to Limiting factor >120 M. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /le in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -18 10YR2/1 None SIL 2 -f -sbk Mfr Gs 2f 0.6 0.8 2 18-31 10YR2/2 None GRSICL 2 -f -sbk Mfr Gs 2f 0.4 0.6 3 31-46 10YR3/4 None GRSCL 2 -m -sbk Mfr Aw 2f 0.4 0.6 4 46-65 1 7.5YR4/4 None S 0 -sg MI gw 2f 0.7 1.6 5 65 -120+ 10YR4/4 None S to GRVS 0 -sg ml - None 0.7 1.6 Boring # 0 Boring Wit Ground Surface Elevation ft. Depth to Limiting factor in. Soil AiDolication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDKe in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring # O Boring Wit Ground Surface Elevation ft. Depth to Limiting factor in. Soil Applicafion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDtft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 * Effluent # 1 = BOD > 30:S 220 mg/L and TSS > 30:5150 mg/L # Effluent #2 = 13013 :5 30 mg/L and TSS <_ 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or Need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 -264 -8777. Site DiagrarR Page 3 of 3 "P C 100.01 � Pipe A 98. B -2 ti LO 7 % ;1001 98.7' BM#2 - Top of 8 "x12" wood post Adh 9>1 101.4' Lot Lines BM# & Description Bench Mark Borin Location & Elevation House and well location to be determined Elevation B -1 g Owner: G & L Land Development Inc. Site Information: Completed By: Mark Iverson, PSS #197 W12491 890th Street SE1/4, SW114, S5, T28N, R19W 680 Larcorn Street River Falls, WI 54022 Town of Troy Hammond, W154015 St. Croix County 715-796-5664 Phone: 715-386-2928 CST# 46672 N "48 "E 7 � a 2' (C - 4 h a cn Ln f� Ln Il k We ' 4 fj o It I � �.! 4 IL o �n pact -�n m z N om Z p V 0 lmz A -IO Z O O Z0 0.. _ � p ox Z A A Z Om,:E ' n� O O 3 jZN K �ZAO� O� z (1) ( - ) W = rn O Z { I rMA1.1�CK BOOS ° MARK ANTHONY HOMES, INC. oCapyriglrt2006 C opyi�gaiuMSpl�ispdred '°W CO WIM affiftmft IS MC" SITE PLAN ° W' � OZ