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040-1277-50-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. CCOIX Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: 0225 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village Township Parcel Tax No: James & Mary Reed TOWN OF TROY 040-1277-50-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 16.28.19.1547 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION SUHt Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM [Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) gth Dia Length Dia Spacing 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 0 Yes No ® Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: nspection #2: Location: 393 EAGLE BLUFF DR f~ s~ 11 _ 1 / 1.) Alt BM Description = COG 2.) Bldg sewer length = - amount of cover = Plan revision Required? 1 Yes ® No 2 S Use other side for additional information. 19 ✓ Date Insepc/ignagtur- Cert. No. SBD-6710 (R.3/97) EtVED REC 44 0 County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN O In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT ~X GO tVPerson I information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER ~ LOPMEN (Privacy Law. S. 15.04(1)(m)) 1101 Carmichael Road MI~Nt~ Hudson, WI 54016-7710 (715)386-4680 Fax (715)386-4686 Attach complete plans for the system on paper not less than 8-1/2 x 11 inches in size. County Sanitary Pe ~ Z C ❑ Check if revision to previous application Application Information - Please Print all hrf ati n Location: 1 roperty Owner Name /f G!) 1/4 170-JIt/4, Sec /(p ' 7 / N, R W Property Owner's Mailing Address Lot Nu Block Number `l 7-f LCD/n 67--7 /S Ak ity, State Zip Code Phone Numer Subdi ' ' Name or CSM Number I Type o uilding: (check one) C k Q 5 $ f' 4- [pity ❑ Village 5FVW-n of ❑ 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Public/Commercial (describe use): 0,^= ❑ State-owned Nearest Road 1. Type Check only one box on line A. Check box on line B if applicable) GZ nGC Parcel Tax Number(s) ' A) 1 /~ir Reconnection .❑Non-plumbing 0 Rejuvenation Sanitation 0 -/Z 77- V Ilk Permit Number Date Issued 15 ~~ry Permit was previously issued 1-10 O IV. Type of POWT System: (Check all that apply) 12-1-Non-pressurized In-ground ❑ Mound 2 24 in. suitable sal ❑ Mound 5 24 in. suitable soil ❑ Mound A+0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In-ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating Dispersal/Treatment Area Information-. 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade ' / Required Proposed (Gals./day/sq.ft.) (Min.Anch) Q~ 9 Elevation Goo v --57 -96,1- -6.7 - - _ I. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks 11 AA Concrete structed glass Tanks Tanks W 1 ~ dr F} /00 2C7 2 00 / i maser C . ❑ ❑ ❑ ❑ e -/ad ❑ ❑ ❑ ❑ ❑ 11. Responsibility Statement 1, the undersigned, assume responsibili r" r ir/reconnenction/rejuvenatiorrTnstaliation of non-piumbing for the POWTS shown on the attached plans. A license is not required for terralift rep r or the i tallation of non-plum ' nitation system. Plumber's Name (print) Plumber' Signatur -MMPRS No. Business hone Number 7C~ e &c-67-/ 7/ Z IP - 77107 Plumber's Addres (Street, Ci St ip Code) 3(10 J" 1-4,4e e 605ccd 6 LJ/ . S 01~ III. County Use Onl Disapproved Sanitary Permit Fee Date Issued Iss;uin atujApproved w n e # X. Conditions of roval/Reasons for Disapproval: ~~jO of OWNER: 1 Jt' i,'ieptbc tank, effluent fluter tend` dispersal call must all to SONKes / maintained 4 (S~ LJ as per management plan provided by plumber. 2. Al'sefl gk,teyNirements must„ba maintained bLt U~. 3 (r G✓`c.~'~ as per applicable code / 6nil6ancss. Rev: 8/05 I P~Glr PLAN pA~ ~ tYp4VN~Q ~oar;,Cttr►x.~,~s I E 17 =YO, .1~ X~i901V LoT tS &A~-E Rt~u F _ 0 y~ t l~i►zEn uarNE ~fkiyy o K~,Jw~; G oum SURF ' lQPa nMt- 1~►' LA4t1SE G ~F~~.~ rx wt 21'iA 'fU.Aw_4--tttn'~T suit ~t cQrnY t .%S~ ~JlstonlStel- 50t ppy WW1 PACK►10C NO COMM W, 5MACK PR( eM5 Q v- ttftND ZOKIW- Lot 4 t1 t5~ pro be o/ h q7, R 4 y ~,~►r ta- fi 03, f 1 F6,- H-lo ~ ~ q. 8 Y fi_ a jYt, ~ , v uve~ q'7~ jTN•ttYJ ! 6 c A-S sin csr mVmo : b3-Z4-OZ» Zz4v 3z - vnt~:. io-~-oo - - i p~ . 3 °F3 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer James & Mary Reed Mailing Address 1475 Winton Rd., Mt. Pleasant, SC 29464 Property Address 393 Eagle Bluff Dr. (Verification required from Planning & Zoning Department for new construction.) City/State Hudson, WI Parcel Identification Number 040-1277-50-000 LEGAL DESCRIPTION Property Location NW %4 , NW 1/4 , Sec. 16 , T 28 N R 19 W, Town of Troy Subdivision Plat. Plat of Eagle Bluff Lot # 15 Certified Survey Map # N a Volume N a . Page # N a Warranty Deed # (before 2007)Volume Page # Spec house Oyes Ono Lot lines identifiable Qyes[:]no SYSTEM MAINTENANCE AND OWNER ERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 113 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 Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on tl~Wform are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a w anty deed recorded in Register of Deeds Office. u e of be room 4 10/15/15 I NATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No. 404909 0 I 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 Baidzicki, Ed Troy Township 040-1277-50-000 CST BM Elev: h Insp. BM Elevi IBM Description: 0) 11 (00 Waj vs~_JA~ -OM C', TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION# t11SH FS ELEVSeptic Benchmark -16) Dosing AI BM weo-,+5 3.3U Aeration Bldg. Sewer 3. -1122.-73 Holding St t Inlet /Z-2-a3 St/ t Outlet TANK SETBACK INFORMATION g l,Z(- (a3 TANK TO P/L WELL BLDG. Vent to Air~take ROAD Dt Inlet W" v Septic J r ! ( 10 Dt Bottom JS Header/Man. Dosing Aeration Dipe Holding Bot. System -7.1 Zvi Final Gra e PUMP/SIPHON INFORMATION t z m-o 5.73 1DS. a Manufacturer Demand St Cover GP~ Model Nu er i TDH Lift FS Loss System Head TDH Ft i Dia. Dist. to weu Forcemai Length SOIL ABSORPTION SYSTEM - 2 I iL- BED/TRENCH Width 1 Length No. Of Trenches PI I SIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS t'2 10 try I/- Vi SETBACK SYSTEM TO P/L BLDG ELL LAKE/STREAM LEACHING anuf Eek INFORMATION C, CHAMBER OR Type fSystem: UNIT Model Number: DISTRIBUTION SYSTEM S a-,d C40. Header/Manifol~ Distributprx~. x Hole Size x Hole Spacing Jens t Air Intake I~ j df Pipe(s) VI: ~~i(~I 7 1 Length Dia Length Dia Spacing v SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over epth Over xx Depth of xx Seeded/Sodded xx Mulched D Bed/Trench Center Bed/Trench Edges Topsoil Yes No 11 Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: (1 Inspection #2: Location: 502 Omaha Rd Hudson, WWI, 54016 (NW 1/4 NW 1/4 16 T28N R19W) AG BLUII~F Lot 15 Parcel No: 16.28.19.1547 v~ NSW Gal 3 ~ .4o. w c4h5 ts4-c4 G~~~- 1.)Alt Description= dtSJJ~~,,,,,t S3C. r ~05 2 2.) Bldg sewer length amount of cover 'A 4~5 _<4- ~oQvtn to,~'(nn ~f Arr,m LOV .tea-r,.,~c e`v~ >•S•y~#-h.o'f?t zap. eCo-wx • C~armhers ~ h ,s~d~. Plan revision Required? Yes , v! No Use other side for additional information. G~> 7 Date Insepctor'ss)Signature Cert No SBD-6710 (R.3/97) b F~'S~ r ~ s (s n C~ a`v~ s r' nor Mass, v y-) V" " U Safety and Buildings Division County , t m 201 W. Washington Ave., P.O. Box 7162 Nvisconsin Madison, WI 53707 - 7162 Site Address Depar Inent of Commerce Y~ J~ 02 Sanitary Permit Applications Permit Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide WC--heck if Revision LD V may be used for secondary purposes Privacy Law, s15. 1 m 1. Application Information - Please Print All Information State Plan I.D. Number Property Owner's Name Parcel Number oVD -/a7? -30 Property owner's Mailing Address Property Location X c5 CLA,,~ / )_gyl& ?/V ~ A4 S4 S T R E City, State . Zip Code Phone Number Lot Nun r Block Number ` Subdivision Name N 0033 ~i, 11. Type of Building (check all that apply) Jt the ❑chy X1 or 2 Family Dwelling - Number of Bedrooms ❑Village ❑ Public/Commercial - Describe Use ~-7 Township ❑ State Owned 3D/ x p op/ Nearest Road DD III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable A. ~t7j- 2 ❑ Replacement System 3 11 Replacement of 6 ❑ Addition to For County use Tank On] Existing- stem B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check an that apply)(numbering scheme is for internal use) Z 9 - o i 3i f j~ l~ r 44 (q Non -Pressurized In-Ground 2111 Mound 47 ❑ Sand Filter 50 ❑ Constructed We 22 ❑ Pressurized In-Ground 41 11 Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At-Grade 4611 Aerobic Treatment unit 49 ❑ RecizT " 30 ❑ Other V. tment Area Information: G/1-S 0 1, T~ Design Flow (ad) Dispersal Argo Dispersal Area Soil Application Percolation Rate System Elevation Final G Required ✓ Proposed / Rate(Gals./Days/Sq.FK) (Min./Inch) / , 9~ 7 -8 Elevation 957 D/ ? - 7 r a . FZas /0~, I-YI02-2,09' VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tanks Tanks Q, Septic or Hokting Tank 01- A L13 )off Dosing Chamber VII. Responsibility Statement- 1, the undersigned, respoavbility for tion of the POWTS shown on the attached plans. Plumbe 's Name (Print) PI s Si 7' RS Number Business Phone Number Z7~~ umber's A&tress (Street, City, S ,Zip VM,Column /De artment Use Only Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Dace Issued Issu' ent Signature o Stamps) IYT Fee) ❑ Owner Given Initial Adverse - D Surc Determination ' IX. Conditions of Approval/Reasons for Disapproval 1 Sy.o_.e.. ~?~~vntic~' Ctnt~t;c.~r~~ `s-k~C !~►..~?'~~°'~~~i.r,~ I i Attach complete plow (to the Comty a*) for the system on paper not less than SM x 11 inches In size SBD-6398 (R. 05101) PLOTPLAN PAGE W. yo ~t I = zm KtY OWNER_J -0,1- ~ c t r 0 L lti1 ~TNE ~N rSC`,~tl ~>v oT 15 EAGI-F Rt,U F F, G uflrl+C ►~c °~Stn1 - ~-50L DORWG W/ PACYJa ;ly VlMY L_l l1I AI \ l NO COMM 65 %TACK PROPUM5 p - tt ftiND $o>e t ~G- ~5D UO 'A i { a _ q7, a O 133 i V ~ i i 1 H-/0 ~~l 1~-1a i n~~7 AJE fL 7, (N' ' t jYr't 1 ~nl - s1GNEn c5r z2-LA 9 32 UM,UN P. , iZL~Ap 'R£VlSE~ : b3-Z8-OZ 5£c VAM • 10-2.10-00 Wlsconsln Dope ent of Commerce SOIL EVALUATION REPORT Page of 3 Division of Safe and Buildings In accordance with Comm 85, Wis. Adm. Code County cam- ~ n Attach complete site plan on paper not less than 8 112 x 11 Inches In size. Ptan must - ' ` Ktk T Include, but n t iimited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope scale or dimensions, north arrow, and location and distance to nearest road. QH 0-- 12-77-50-060 Please print nformatlon. vlew by Date Penonsl Info ellon you provide may be used f r eecon .04 (1) (M)) I Property Owner P arty Location 114 ^J Vi 114 S + T N R ICI NJorrW Property Owner's Malling Address 002 L # Block # Subd. Name or CSM# 'Dj 5 - FJ1~LE BLI~[^~ .5ua~. City State ZJp Code Phoor IfVG 0 ~y\ City ❑ Village Town Nearest Road HunsolJ ~i 5 Dlt~ I 65AG-Ls &UFF oXOG New Consbvctlon Use: % Residential/ Number of bedrooms Code derived design dow rate GPD J❑ Replacement ❑ Public or commercial • Describe: Parent material - `5,ARZM1 M _ (ALIXA65 d Flood Plain elevation if applIcable A- fl• General comments and recommendations: A k)EW AREA Fp °-T4t5 LOT HAD -M gF f 5Ttsrjl-1,5 R ED AS LOT L4A)r Lv-AST l_.iNF) CHAX-c-z F{ZUM OKr lr\~AL 1'eSr. (5ui-M-5T DATED )0-21o-00.) 2ER• 5LLiTA61E FOK !tJ-GICWA7D COk)0eK7ho ^L SYSTEM M Boring # Boring nPit Ground surface elev. - 104, 94 ft. Depth to limiting factor -I q5 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF In. Munsed Qu. Sz. Cont. Color Or. Sz, Sh. 'EN#f 'Eff#2 I 0-6 0 1 L 6 Z -?-q I I y 2 L _ 0• 29-32 in Ya 3 - L - L4 0,6 4 Y-- V 3 St) 2 - r~~xr - OS 5 to fc ~b - - 0.? l•Z (r a -bq 0 ite 3 S - I Z 7 471 51 1<3/y s Os cti ` 0,7 .Z `71-95~ IOa1K'5 & / ON 9~ y S Osg dl r O,"7 Z Boring # Pit Ground surf ce elev. _I01. SR ft. epth to Ilmlting factor In. licatlon Rate Horizon Depth Dominant Color Redox Descrfpfion Tamura Structure Consistence Boundary Roots GPD/IF In. Munsell Qu, Sz, Cont. Color Gr. Sz. Sh. 'E"I 'Eff#2 - I 0 3 ti -z5 0 -/A y it 25-1f(o ° G I -at 0 1-2- /416-6 Lit've _ s Os --ml 0--1 t.~ ~p -71 5 YR 3/4 S 0~9 M1 - 0.7 1. z 7 7 - 10 Vf-3 - g nnsbl 1. g 0,7 Z Effluent 41 = BOD > 30:5 220 mWL and TSS >30 < 150 Eftent #2 - BOD 5 30 mg1L and TSS S 30 mgll CST Name (Please Print) lgnature CST Number /AA S0 HOWL s E zL 4 9 37- Address Date Evaluation Conducted Telephone Number W9fl?5 69o;"`AVE, vF- FAL s WI 59022 0 -Z$-OZ ?IS y26-1-17S I Ilk Paroal ID # Page Z_ of 3 Property owner ❑ Boring a Ong # I ,t¢~ Depth to limiting factor > qb in. Pit Ground surface elev. j0 h. soil Horizon Depth Dominant Color Redox Description Texture Ea Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color L a6 34~a Z- - I Z a L y 3 - L. CS z~4-co 0 ~r 0 1z-33 ~3 - - CS Z -m d 3S -S8 ! o J -m Sb ui Lac -rn 0% I ~ 4 s ~lo►C ~ _ V1 s ,m 1 0. I, Z 0 ,-7,11 [~torLtZA~ 7 4i ft 5 4 i00S mt-AINCt_ >~>~va 5MN~s• ❑ L~ Boring # Boring In. Soil icatlon Rate ❑ pit Ground surface elev. ft, Depth to limiting factor Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots •E"GPO/MEff#2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. t I Baring ❑ Boring # Ground surface elev. ft. Depth to limiting factor m' SON leatlon Rate ❑ o pit Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots '092 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Effluent #1 = BOOS > 30 1220 mglL and TSS >30 < 150 moll. Effluent #2 = BOD, < 30 mglL and TSS < 30 mg1L 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. S6i7•Q>4 (R bW) Ddr- I I.~ eNn: ! ~ ~ y0 o~ c r to K.` PRU'~RiY 0m Q L i,I LA-Ill£ 0. 0 LoT & G-E t=F 6 o nJ *11R: su~rwc Sex-1110,111,Z!,"Itill "bill] 50L PORING W/ DPCM NO COMM 63 5elDKK PRCMeM5 Q - ~t~ND Bo,etntG- UuT L6- y --rp~ I fi I Ca$~. W\1 6.q i I o ! o 4- ~ ~ tou.S4 ~y 2 LOT_ j I nrA x c ~7r 1 t OrJ c - 5IGNEn C5r Rt L.WED : b3-Z8-OZ 2ZNY 32 `v 5C 14, ' vnrt: _ to-2b-0o - _ - y.ac.~s~w.sasrs~aac71t.:.S i+...• lit HOLLISTER'S SOIL TESTING Mary Jo Hollister wgS75, (A0" Avenue River Falls, WI 54022 (715) 426-1775/ Date .gT. C►~ol x our-T~ Zbn) I Lo-t 15 eAcA-r-- BI-UFF j~JJ~W yDll 1~Su~~ TtAU For THIS l_L1 BU-T_ F-tE►e~ W~f?~ S ~ Issues t~5 FI~V Itit~S TCK A 54sT M, lu~i3~ti_ ADD w~ ~ 6 c~ uT ~r~ this ~cT tv ~ u A P)c P-tAGr AwNV b/0, C -Tb 6E"C w /k~ M Ttt~ fi So I LS , w DSc oU ~rL~ -T N rt' ~-t I.,OW~tZ ~-F(X-~ j,~?~►~ Jul ~T ~1;,~ Oti L-CT )S ~ ~ JV'1bJ ED '-t-t~ E ~~R AfiD ©UkD 62R-DEC Sbt Ys S WE: 6'0E /WW f, U-V I ~ rt+t~ L0U)r--2 IF you )A~JC AtJY-Q-OE61_c JrH,, tKs Mau., -Jo L, ~ o ~ ~1 "'-i` , ~ ~ 1 I \ / I \ ~l ~ ~ ~ ~ ~ ~ v ~ ~ ~ ~ ~ m ~ ~ N ~ ~ L N C Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 consin Madison, wi 53707 - 716 Site Address /i De artment of Commerce ~'3da Sanitary Permit Applic Sanitary Permit Number In accord with Comm 83.21. Wis. Adm. Code, personal' I n ou ov &Y ❑ Check if Revision may be used for secondary purposes Privacy 1 1 m 1. Application Information - Please Print All Information = State Plan I.D. Number 4 Property Owner's Name t ~ ? JZ Parcel Number 16. Z P, Click 'E Arlaotgf;:7.4- & V0 Property Owner's Mailing Address e rt Property Location (.(,l 14 N(Ak!4; S I (A T;2 2) N. R E C~ ~J I' City, fitate Zip Code N bec- r Lot Number Block Number Subdivision Name CSM Number 33 S L9 00 II. Type o uilding (check all that apply) / ❑ar pal or 2 Family Dwelling - Number of Bedrooms 0~ r ❑Village ❑ Public/Commercial - Describe Use ;ATbwnship ❑ State Owned ' p - O Nearest Road leap do 2 a-G~-~ d3a III. Type of Permit: (Check only one box on line A (numbering scht ,o! for internal use). Complete line B if applicable) A For County use 1 New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to in Tank Only Existing System B. ❑ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type of Permit: (Check all that apply)(numbering scheme is for intemal use) 44,k Non -Pressurized In-Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In-Ground 4111 Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line fL ~i Z) 45 ❑ At-Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. D' ersaUTreatment Area Information: 10 3 1 11 ` 0 Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevatio Final Grade Ml- P sed Rate(Gals./Days/Sq.Ft.) (Min./Inch) Elevation 1~ l2~ R r-3= yd ss, 7-Y-t 9 5r VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank O _ a b Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for ' 9stalladon of the POWTS shown on the attached plans. Plumber's Name (Print) Pltunber' i RS Number Business Phone Number Plumber's Address (Street, City,, Zip ) S~Y66 VIII. Count /De artment Use Onl Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Approved ❑ Disapproved Surcharge Fee) El Owner Given Initial Adverse Z z S. d U Z I D L Determination Q 1X. Conditions of Approval/Reasons for Disapproval 1. Effluent filter to be installed and maintained per manufacturer's recommendations. 2. System shall be installed exactly 44 inches below uniform contour line to ensure proper location within soil profile. 3. Additional borings shall be evaluated on the edge of the proposed septic system prior to any installation to verify that soil conditions are . consistent and suitable for the proposed design. The paperwork shall be submitted prior to or at time of inspection Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in We SBD-6398 (R. 05101) c4& !17""' ~a 00 n-p - ' is l y 30.7 V P a T`f ' x 0 - - N )a ~h~, a b~~ ~ _ - -a= -3 = 9d~~so1 T H= 9~y T 1 ~Id~,~! T f~ cv--Is-OZ Xevim Sr. C IZOIX COLLAN awl N (s T iRemEWtD MV r-i em NDI;M AAA NuTk:t~ RN Apz%"r oa EMS." , AFTW-'M 014 6 Tti:F-- FKO F 1 LE Alter -f1-~~ }}bl.E- pt P R • WE a~SJ AME 1t1'E mqut tzm 7 $ ANy QL1xrM om S j C A lL . `VANKSt AAA" M, Wisconsin DspaNnsnt of Canneree SOIL EVALUATION REPORT Pape I of DMelon of BatNy_rind Buildings In accordance with Comm 85. Wis. Adm, Code ' County Sf CAD\X Aflach complete she plan on paper not lose than 81/2 x 11 Inches In size. Plan must Include, but not Wed b: vertical and horizontal reference point (BM), direotlm and Parcel I.D. percent skim. sosle or dimensions, north arrow, and location and distance to nearest road. Please Print all Information. Reviewed by Date Personal Inlonnaeon you provlds~nsv be used for woondary purpoeee (Pdvwv law, e. 15.04 (1) (m)). Property 0wher Property Locallon 6RAKLE5 5. C•ODY, , enottot NW 114 Ajwi 1M s 16 T 7.1 N R Idf JbW W_ Property Owner's Melling Address Lot 8 Block N Stkd. Name or COMB 1FBO'q ~1.~E1CDrcEA! 5i. NE S'A1'M I 15 - eAC"Lr- StufF City sWe zip ode hone r ❑ City village Town Nearest Road BLAr%A1 Mn1 15* 4 163 Z57-1Z6.9 wNSUALLMY Xto. New Construction Use: 09 Resldsndal I Number of bedrooms ~T Code derived design flow rate 6 tab GPD ❑ Replscama d ❑ Public or commercial - Describe: Parent materiel 'SAMMMISkytf Flood Plain slavallon it applicable Al&^j ti General conwo is ax 6,01 - 12-7,50, CONJ E~J'T l t1/,>* L "I K>i: NcN~ 5 and reco imaridadons: z-K -,gkr - 4 Zfe.t~ EWnp ® ~ M t9 PII Ground surface elev. 360-11 M. Depth to limiting NOW '>7 In. soil Awool Fiats Horizon Depth Dominant Color Redos Descriplon Texture Structure Consistence Boundary Roots In. Munsel Qu. 6z. Cant, Coin Or. Sz. Sh. •E"I 6121182 1 0-7 toY ,r./L 1 3- rnt r es uf4 0 -7-11D 10'4K* - 1 I fh r CL6. 5f .5 61 3 10-1 1014r X4/-5 641 1 m S As s z-(-M Z✓ 01 b 4 Ib-A IovK V-5 '1 2 I , e- 5 0 M.- - .5 0 5 -30 to it 31F-1 sl 3f5b dsh a$ af~ ,s 0.9 0-360 3/y 4 61, sti1 f 561( d s o. o.t 3(p.a)2 It)V 'S/ N 7d 6h S11 ~h QS 1~' z. 16 110 -4it G.3 41,-"72 0 1w Ills - 056 dl - 0.7 1, 2 Boring # Pit Ground eurfaae elev, 92-2-55 fl, Depth to Iknlltno facer In. 801 Application Role Horizon Depth Dominant Color Redox Description Texture SIfwwre Consistence Boundary Roots GPM In. Munsell Qu, Sz. Cant Color or. sz. Sh. TERM 'ERN2 I o i cs o.s a 2 -18 v Z/ 1 f ! Fr C 0.5- 0.2 3 I- o ~3/z 5-0 3 Ynd S6 cb 0-5- 0. 1 :5 rn e 5 8 Lt M-35 -9 1O V .3, 11 24 Vt~ QS _ 0.5- O. -S ) Id 4/4 ~ fo s i 1 rn f r acs I f-n+ 0 • . U. 7 31-75 53-w y y - O~ 0.1 1, Z O ? 147-- -105-401 • EM uwd Ni w SOD > 30 220 mWL and TS3 -v30 =150 Mok • Enluont 02 r BODE ao mg L and Ttla 30 not CST Name (Please P*d) Signature CST Number Z T Address Date Evaluation Conducted Telephone Number IdfO-k`"AUF, 1U rALls 1601L SyOZz o-21. 0 (11s 1121-1-7 ~.~1saGo: of-1S*42 Pt+pattll Owen FEYEREfSEN pO~ a 0 pop -,A3.4-Z1_ EE ~ri4 0 ❑ ~q ® pit Oeound gUft a WW. 959.2 R Owe1 b *am tadlr in, Biail REM A t =*W Dom 00"* Mt color Aetdott 0aatstpwt Tors" sludi m 0. 9ox"y ftm O~IIp OIL tmnOwl 8: Carox C w or. 8m OL '8w low A 0-5 IOYR 3/2 oil 2f gr mvfr ew 3vf-e 0.5 0.8 111 5-21 IDYR 5/3 oil 2mabk mfr gv 2vf 0.5 0.8 82 21-40 IOYR 5/6 ail 2mabk mfr ev 2vf- 0.5 0.8 C 40-78 10Y)t 5/6 to 068 tnl lvf 0.7 1.2 p37 8iark~gM ❑ 9driAa ® pit C9ymm MAaOO Mwa 929.4 R Dow 00 lop" "Nor 82 - in. Andildilion Mateo 1192801 Doom DD"* Ws cow Rooms 13 iatrl0io I Too" 811119"a C "Wisim mm "Um" mcm in, L%Mo l ow u Cont. Color Gr. $a Sk •~Nt Al 0-6 lOYR 3/1 ail 2mgr mfr to 3vf-m O.S 0.8 6-119 1 YR 3/2 ail 2f-mebk mfr a lvf-m 19-47 IOYR 4/4 all 2mabk mfr IV ivf-m 0.5 La 47-64 10YR 5/4 la On mfr to lvf-m 2-1 LL. 64-62 10YR 6/6 a Oag ml ev --0-7 .0 OZ 8289 IDU 3/4 f2d 5 YR 4/4 le Om mfr ev 0.5 0.7 • eq 88 P 38 doV*+g ~ Pit Grow+dnurlaos erav. 923.4 h. Dom b *w" fam► in. Sell blmwn P-40 No= Dom owwwnt cow am ft Daseroun Tast♦as Bova" conaitr+aa so~ Raab im MW" W s Caen. COW Gr. SS. oft, -aws -ll n 0-4 IORY 3/2 ail 2m8r mvfr co vf- 0.8 0.3 1 4-10 10YR 3/3 al If-mebk ofr 8v 2vf-m 10-18 lOYR 5/4 01 lmabk mfr gv 2vf-m 0-4 0-6 18-42 LOYR 4/4 - 18 0 m mfr ev lvfwn 0- 5 0-7 zi. 42-57 10YR 5/6 el Om mfr gv lvf-m 0.3 57-78 IOYR 4/6 lie Gm mfr 8w lvf-m 0.5 0.7 C3 78-88 IOYR 5/6 e Ogg m1 0.7 1.2 Emit Nh ■ 81001 s 30.1 ?m MOIL and TU v30.S 180 mWL ' EftWa J ■ 80C, 5 30 m0L and That S 30 MOIL. The Oepament of Commerce it an equal oppotwnity swvice pravidnr and empioger. If you need asWmnco to soma services or noel matmial in an altamote formak please contact the daparament at 608-266.3151 or TTY 608-264411M. sroaesoas,en I Wisconsin Department of Commerce SOIL EVALUATION REPORT Page I of~Z Division of Safely.and Buildings in accordance with Comm 85, Wis. Adm. Code County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Reviewed by Dale Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location CHAt2L-e5 S, COOK Gevt-t-ot NW 1/4 NW 1/4 S 16 T Z$ N R Iq N(@l'i W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# II90(3 A6GKbC-E)L1 -ST., NE Su \T>` 106 1S - FflGt~ 8ttiFF City State Zip Code Phone Number ❑ City ❑ Village NTown Nearest Road i3uA1A)a✓ Mnl 5-149 (`763)757-7`568 ~ftoy T0UJ SVAt_t.eY T-D. New Construction use: W Residential / Number of bedrooms Cp~Tderivveedd design flow rate CJb GPD ❑ Replacement ❑ Public or commercial - Describe: Parentmaterial SAbQCq0A Floo lain elevalitAXapplicabie MA. ft. ; General comments Z X 50' q27. 501 (i and recommendations: 2_K - qZ(o.00 ) CoN-~ I 6N J 'E11)JCt~ S' tJ Boring : r FtCi ® Boring #*a;;~.~ t V1 Pit Ground surface elev. 930.1 \ ft. Depth to IimSip f c(or >7(a in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture- 6t* u ®r, Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color ,Gf. Sz. Sh. 'Eff#1 'Eff#2 r t 0--7 10 \1222-/Z - 3 r 0 *%q f r 65 0-5 01 Io V►221- 1 s I r 0-b 3-F 0•5 0.8 2 \1 3 In-Ib OV►'t u~3 St 1 l T sb) 5 C5 24-ol 0,2-. 0,5 4 Ib-Iq loVYC3/3 s11 Z 1 (A 5 -3o Iby~3Jy - s1( 3-Es110 K 3512 cls 7- f-rn .s U " b 3o-3b to ~/d u e o~ Sit 3~sbK d as I = 0.~ 0.8 12 3fa-u2 \ovf~3r' oil ut toy b f sit 1 5 ALh Q5 if O,zr 0.3 Li Z.--7 b, B b b 0,7 1.2 s os5 dl - F Is Boring # ~ onng ~21 pit Ground surface elev. 2 7.53 ft. Depth to limiting factor in. Soil Application,11ate ' 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 0 1 I - sb m~~r CS A- Os d. ~g~ l Z -I$ 0\re - I 5b)< mfr C5 3C-W\ 0•57 0. 3 I -z o\4r,- 5-11 3 Mel d 5h C, 10 Z-C- 0.5- O, 65 _ 0-5- ~f 24-35 10 \1192/14 S-11 m I 35-4q 10 v -3/ sl Z~ m QS 2--m 0.5- O. 10 R `I/y 16 a -1o / 511 y sbl Mfr aw I F-rn 0. S U. l 7 --75 3 7 ~5Yr y y •5 D~ m C Tr- m 0.-1 Ir Z rn 1 0. -I I . Z Effluent #1 = BOD > 30:5 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD 30 mg/L and TSS < 30 mg/L CST Name (Please Print) i ature CST Number Address Date Evaluation Conducted Telephone Number a 7 s (0q0 "A U E, RI U l-A L1--5 (.JS _51-j()77- U -2-(o -00 015) 42-b - l'] ? 5 f 'Ole. 7 L~~ 15 y Property Owner Cf)f) C1iA ALES Parcel ID # Page of Boring # Boring F-cl pit Ground surface elev. q 32.7 ft. Depth to limiting factor y $ 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 I 0- to - St 1 3m r m4 fr as 3d(rm 0r5 0)1? - t1 Z/z s Zm ~ f oLs 2-rn 0%S Qg 10 11? 2 y << 3 M-lq 10 YfeJ3 lai5bl< r 0.b Z-- m 0)2 0.3 19-25 o \I 25111 - S t 1 c 5 C. 2T- m 0%2- O,3 25-4Z . -)q s d 5 0 .5 o, Z- 5 rz3 - s i r 31 ul 1i m (7~ 7 1 z 7 48-53 10gRylo 5 5r 059 cll 0,7 1.2 lo-ik Lt c3 5(1 d - Z IOV ~ s b 7.5\0V ( F Boring # Boring Jrs) pit Ground surface elev. q Zq' b I ft. Depth to limiting factor '7-A_ 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 0-~i IoyR~l► I 3~~ m~1-F a~ ~~~-F 0.S b 2 -I Ib~l►Z3~3 St\ I 1 GS Z 0,3 3 1 -2~ Ib41231 St.~. I M6\d< 5 C5 Z-F O,Z- 0,3 4 2'7-35 toyi2:V4 1 -~sbl 0.W ,Z- 5 35-45 ►0444 sal 0m 0,0 04-1- L6-7q to\w,4h, S b t)q d1 1 m 0 '1 1.2- E Boring # ❑ Boring 11 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/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS 5 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-8))0 (RAM) y PLOf PLAN PAG~_ 1J~~ PROPFp1Y OWaP: ' (2o o K c t i. ~L~ I ~G~NCI; = yU ' LrCik Vr : LoT i S. EAGLE LV FF 13M= - Y OF LlA) LaATl1ZT1°R see_ 2 WA3 0 V N LR p-E " p e- m ouAm 5 c cocas F-1=501L PORING W/ PPCKNa su%Q FACe NO COMM 65 SNACK PROPLrM5 Lc) LA ~~~i Et.gZ •bl Aug yl 6 40 SLof Z ISO Q ~ 1_ j 'i' El. Zti.53~ LV-_ p~LuFF >,or is vwv~ 57itT1~.1 _ 51 AW C5f SAC. Ib VAiC: I0-4,-Oo i , N N M i ! ! B' 1 iC 8- 15D f J t 1, i l% ~ 1 j ' ( r 67P37 ~1 ~ r, ~ J! t f QOWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity o~ al ❑ NA Permit # D Septic Tank Manufacturer ❑ NA DESIGN PARAMETER Effluent Filter Manufacturer Z ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity gal ❑ NA Estimated flow (average) gal/day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) C000 al/day Pump Manufacturer ❑ NA Soil Application Rate i o~ al/day/ft' Pump Model ❑ NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) :530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (130135) :5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) :5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODS) :_30 mg/L Kin-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) :_30 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) :_10° cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ emonth ar( ►(s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA year(s) Clean effluent filter At least once every: ❑ month(s) ❑ NA years) Inspect ump controls & alarm At least once every: 0 month(s) [I NA pump, P ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or-must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name Name Phone l 5 L Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY t Name Name Phone Phone lS This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.5401, (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTAINANCE AGREEMENT AND OWNERSHIP CERTIFICATE FORM OwnerBuyer_E/D AND NANCY BALDZICKII Mailing Address (I ll X LK J (o/ ( #3~ i 11LI~ ~o D~+~- ,.00336 Property Address (Verification required from Planning Department for new construction) City/State _HUDSON ,WI Parcel Identification Number LEGAL DESCRIPTION Property Location NW_'/,, NW_'/4 Sec._16_T 28 N-R 19 W, Town of Troy Subdivision EAGLE BLUFF Lot# 15 Certified Survey Map# , Volume Page Warranty Deed#-665427 Volume 1792 Page_416 Spec house yes -x-no Lot lines identifiable x__yes no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result 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 masterplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on- site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1 /3 full of sludge. 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 th Department of Commerce and use 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 10 days of the three year expiration date. SIGNATURE OF APPLIC T DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. a,--ro - 0 2s SIGNATURE OF IC T DATE Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department***** ss 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. STATE BAR OF WISCONSIN FORM I - 1998 6EsS42ALSH WARRANTY DEED REKATHLEEN H. GISTER OF DEEDS ST. CROIX CO., WI DooornertNMW 1 792PIK,E416 RECEIVE) FOR RECORD Corporation, a Minnesota Corporation 12-17-200! 12:00 AN Troy Dvelopeed, made between alARRAN?t DEED Grantor. EXEMPT II E rd F. Baldzi a d T &ly hE. FEE: and LOGY FF.E: usband and wife .A4SFc1 :EE: 299.70 RECORDING FEE: 11.00 Grantee. PAGES: 1 Grantor, for a valuable consideration. conveys to Grantee the following described real estate In St. CXOiX County. State of Wisconsin rn:•. m-t .ao.i (the 'Property Name and Rourn Address Lot 15 of the Plat of Eagle Bluff in the Torn of Edward and Tamra Baldzicki Troy, St. Croix County, Wisconsin. Sun land villas Subject to Declarations of Covenants, Conditions and 688 Unit Qin in Xi Road Restrictions for Eagle Bluff, recorded in vol. 1589 Shangh38 141 ai, P.R. China 200036 Page 516 , as Doc. No. 638946 , as appearing in the office of the Register of Deeds for St. Croix County, Wisconsin, and such other easements, 040-1277-50-000 restrictions and reservations of record, or in use, Parc« identiricaaon Number (PIM and the "Buyer" obligations contained in the This is not homestead property. Purchase Agreement for this lot. (is) Us nos) Together with all appurtenant rights, title and interests. Grantor warrants that the tide to the Property is good, indefeasible In fec simple and Ore and r•Icar of encumhrances except Dated this/ O1~29th,, day of November 2001 9ilf~ J-d? yof4K (SEAL) (SEAL) Charles S. Cook, President Troy Developlflent Corporat on (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Minnesota Signature(s) State of Whseenskh ss. _ Count authenticated this day of Perso y~came before me this 29th-- ~ day of November ~uu 1 , the above named Charles S Cook, President Troy Development Corporation _ TITLE: MEMBER STATE BAR OF WISCONSIN to Of not. me known to be the person _ who executed the foregoing authorized by 5706.06. Wis. Stata.) Instrument and acknowledge the same. f THIS INSTRUMENT WAS DRAFTED BY Troy Development Corporation Na y L lift Notary Public. Sua.oL~Dpsconsln Anoka County, Minn. Charles S. COOK r President My commission is permanent. (If not. state expi 2005 date: January 31 (Signatures may be authenticated or acknowledged. Both are not necessary.) N.me of InTgre ■IpanR In ,ny ulxx ny rr.rr Lx IneA er Qrux•d tr■low rM slRr ST ATL BAR AR OF WISCONSIN Mamun tpu al■nk Co., Ms. WARRANTY DEED FORM Ne. I - t998 M1w■utr■■, wr. r- N"Y L CUFT NOTARY Pl1Bl.ICr-faze MY COMMISSION EXPIRES JANUARY 31, 2005 c~> 1~3 U I N 1 LON, K 1 VW. I vmr yr I F%v , . ONE - m I I NW-SE NE-SE I 0 or p NW Sl a1 k 1~~ y-W~~ I _I ZI - - - I ~W I _ I I _ xN _ I SW-S' SAC I N < TOWNSVALLEY tON-NA 1 ROAD W EXCEPTION E F N SCALE IN FEET IJtl 5 150 300 450 I Sw-~ SE-NE Sw-n 17- 8 6 0 7 ]S;c4 I F. LEGEND SCALE: 1 2 W 25101 COUNTY SECTION CORNER MONUMENT, 0 MAGNETIZED "PK NAI ALUMINUM CAP, FOUND. BUILDING SETBACK L m . • IRON PIPE, FOUND (DIAMETER NOTED). 0 10' WIDE UTILITY E 401 1p ■ 3/4" REBAR, FOUND. DRAINAGE EASEMENT ACR S.F. 2" x 30" IRON PIPE WEIGHING 3.65#/LINEAR BUILDING SETBACK L O FOOT, SET. I's x 24" IRON PIPE WWEE I GH I NG 1.68#/LINEAR FOOT SET AT ALL OTHER LOT VARIANCE APPROVED 3► AND OUTLOT CORNERS. (R_ ) PREVIOUSLY RECORDS V. 1" x 24" IRON PIPE WEIGHING VIP ~ 1.68#/LINEAR FOOT, SET. Os N UNPL A T TED LAND N POINT OF BEGINNING N 88°59' 00" E 2616.30' NORTH 189.53' 1 .4 ' 578.17' \ SECTION 7 ^ ' 1308.15' DEDICAT \ \ I T28N, R 19W ; PUBLIC I % 19 _ 0.40( \ I y M'~ 1.286 ACRES 20 17,4 56,013 S.F. % 2.546 ACRES \ 110,899 S.F. OUTLOT 3 $ N 75 0 0 7 3 .00 00 G 4.425 ACRES a0 , Op N I ~ _ 00 80 20 _ \ 192,768 S.F. 2g4 W R-80' 6. I ~ _ 06 I I O \ BENCH MARK N 18 \ TOP OF 1" PIPE \ \ ELEVATION-927.00 NN " 1.182 ACRES Q (NAVD27) 2 1 1 N Z \ 2 51,478 S.F. 1 N 00 2.169 ACRES ; _ ~ S - - I . G / 94,485 S.F. w \ 5' 81 °0 0 0p" E i I i 77105. 0) 650 3 I \ \ e , 08.56 tc \ 202,91, ap BENCH MARK: 1 , - , - ~ ~ TOP OF 1 PPE ' \ 1 1; W ~o 1 ELEVATION-908.00 2ES 33 o I ; I (NAVD27) 15 ,.F. 16 I S M _ 369.68 1.47 r=7 7 ACRE ~ - L ; 1.055 ACRES uo 171 N 85°00' 00" E . ~,.,Ne 64,354 S.F. 1 ^ $ I3 _ r 45,953 S.F. = 4.277 ACRES klm 1 g [5,609 S.F. 0 1$ ti 909 N N __j g 22 i Z 2.008 ACRES ':-0 N ' O+. z do _ C34 7,492 S.F. . o_ . I~ o n~, 3 ° 100 dr C32- - $ 8 33' 33c,n I O+ ~ e o M - 100" ! .211-84' C41'- C63 _ C4 110111 E - C65 W C64 1 5 W W 3 _ r 0 - N 81 r'OAD w i5~e.o 40 88 o g 1 g ono w - -m M C51 - - ~31 57Z oo~ °11 $ $ 20 211.84 C5 20.000 - M I ao e e 4 53 3 o I 0 30 lg o 3 ° i 2 i 1.228 ACRES lam- % 31 o° 1299 ACRE 53,509 S.F. / 33 No N o .S 25 0 o = 56 ,580 1.202 ACRES ° $ N N Sao w e 32 rn 52,346 S.F. 1 NO rij sX 33 , $ s 75.x, _ co ; 29 1.79. 15 1.093 ACRES - L i y 0 ~ ~ m 00 "m d m co m O M ® n m m® m O CL m m® aai 000 - m® ® O n m M OE ® M a o ®0 Q m I 00 00 ® m m m m m r m :A I o a m M t m m ® ~1 U m I' V 'r r m N V) .J 1 ,y O o, a O o a ®a ® ® m I ® m 00 m I a- m o_ , o m m a ® co m ®a M ®-~Jnoo m m® a m® o (0 ®m o_ i