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A [s� O A I o 0 � 0 a, A + Document Number Document Title St. Croix County Conventional POWTS Affidavit Name — (Owner) Typed or printed being duly sworn , states, under oath, that: He /she is the owner /part owner of the following parcel of land located' l in St. Croix County, Wisconsin, recorded in Volume , Page Document Number St. Croix County Register of Deeds Office: Recording Area t t Name and Return Addre A parcel o land located in the /4 of the _ /4 of Section � N 6 T N — R W, Town of , St. , Wisconsin, bein dui described as follows include lot 5 �� Croix Count — tY g Y 7 (� �DSQ� number, subdivision/CSM o � detailed legal description): O D / 3 0 Q _ ®� 1 0 W �/Gt� �! ° Parcel Identification Number (PIN) As owner of the above described property, I acknowledge that a conventional in- ground private onsite wastewater treatment system ( POWTS) was selected, rather than an at -grade or mound, to serve this - bedroom residence. This POWTS was sized for design wastewater flow of _&� gal /day with a dispersal area determined using a Maximum Soil Application rate of 0.3 gal /fe /day (per Comm 83.44). This soil application rate is indicative of slow wastewater infiltration, thus occupants are recommended to be conservative in water use /discharge to the POWTS. There is no implied warranty or specific longevity on the effectiveness of this conventional POWTS, whose projected lifespan is dependent upon proper maintenance of the system. If this POWTS should fail at any time in the future, the system will need to be inspected by a licensed plumber or POWTS maintainer to determine if it must be replaced according to state code requirements in effect at that time. A future replacement area has been designated within the property's boundaries. I acknowledge that I will make this information available to any future parties interested in purchasing this property. Dated this day of AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )ss. St. Croix County. ) authenticated this day of Personally came before me this day of the above named TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be (If not, the person(s) who executed the foregoing instrument and acknowledge the authorized by § 706.06, Wis. Stats.) same. THIS INSTRUMENT WAS DRAFTED BY Notary Public, State of Wisconsin (Signatures may be authenticated or acknowledged. Both are not My Commission is permanent. If not, state expiration date: necessary.) Date: "°THIS PAGE IS PART OF THIS LEGAL DOCUMENT — DO NOT REMOVE" This information must be completed by submitter: document title name & return address. and PIN (if required). Other information such as the granting clauses, legal description, etc. maybe placed on this first page of the document or maybe placed on additional pages of the document. Note: Use of this cover page adds one page to your document and $2.00 to the recording fee. Wisconsin Statutes, 59.517. ST CROIX COUNl AA IL Plan ning zoni FAX MEMO DATE: 1 dI To: CodeAdminisuati " FAx NUMBER: �� y 715 - 386 -4680 Land Information r FROM: / �7/Yvt �2•�� -� Planning 715 - 386 -467 FAX NUMBER: 715 -386 -4686 Real P erty PHONE NUMBER: 715- 386 -4680 7 6 -4677 R cling NUMBER OF PAGES, INCLUDING COVER SHEET: - 386 -4675 RE: )Aj ,�,Q 7 ST. CRO /X COUNTY GOVERNMENT CENTER 1 101 CARM/CHAEL ROAD, HUDSON, W/ 54016 715386 FAX PZ @CO. SAINT- CROIX.WI.US WWW.CO.SAINTCROIX.WI.US v Document Number Document Title St. Croix County Conventional POWTS Affidavit Name — (Owner) Typed or printed being duly sworn , states, under oath, that: He /she is the owner /part owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume , Page Document Number St. Croix County Register of Deeds Office: Recordin Area A parcel of land located in the '/4 of the _ of Section Name and Return Address T N — R W, Town of , St. Croix County, Wisconsin, being duly described as follows (include lot number, subdivision/CSM, or detailed legal description): Parcel Identification Number (PIN) As owner of the above described property, I acknowledge that a conventional in- ground private onsite wastewater treatment system ( POWTS) was selected, rather than an at -grade or mound, to serve this _ - bedroom residence. This POWTS was sized for design wastewater flow of gal /day with a dispersal area determined using a Maximum Soil Application rate of 0.2 gal /ft /day (per Comm 83.44). This soil application rate is indicative of slow wastewater infiltration, thus occupants are recommended to be conservative in water use /discharge to the POWTS. There is no implied warranty or specific longevity on the effectiveness of this conventional POWTS, whose projected lifespan is dependent upon proper maintenance of the system. If this POWTS should fail at any time in the future, the system will need to be inspected by a licensed plumber or POWTS maintainer to determine if it must be replaced according to state code requirements in effect at that time. A future replacement area has been designated within the property's boundaries. I acknowledge that I will make this information available to any future parties interested in purchasing this property. Dated this day of AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )ss. St. Croix County. ) authenticated this day of Personally came before me this day of the above named me known to be TITLE: MEMBER STATE BAR OF WISCONSIN the person ac s) who executed the foregoing instrument and acknowledge the (If not, same. authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Notary Public, State of Wisconsin (Signatures may be authenticated or acknowledged. Both are not My Commission is permanent. If not, state expiration date: necessary.) Date: "THIS PAGE IS PART OF THIS LEGAL DOCUMENT — DO NOT REMOVE" This information must be completed by submitter: document title name & return address. and PIN (if required). Other information such as the granting clauses, legal description, etc. maybe placed on this first page of the document or maybe placed on additional pages of the document. Note: Use of this cover page adds one page to your document and $2.00 to the recording fee. Wisconsin Statutes, 59.511. 1 Safety and Buildings Division ou t t< 201 W. Washington Ave., P.O. Box 7162 iscon 1,� Madison, WI 537Q7 - 7162 Sanitary Permit Number (to be tilled in by Co.) De partment of Co mmerce _ (608) 266 -3151 — �� State Plan I.D. Number -7 � Sanitary Permit Application In accord with Comm 93.21, Wis. Adm. Code, personal information you pr e ma be used N _ Y for secondary purposes Privacy Law, 315.04(I)( Project Address (if different than mailing address) L Application Information - Please Print All Information RECE1�i Property Owner's Na me Parcel # Lot Block N e • sS' %.�® NO V 1 5 2005 1°t.J _ /,S Property Owner's M ailing Address 7 3- Property Location �c�je Y r •�� ST. CROIX COUNTY City, State Zip Code ti ' w t ?!,3' 38G DY4'� (circle • o ) ! U. T _ � _ -- T it _ E or ` ype of Building (check all that apply) bk ad �,Oou_ 14L%,-- N; R _ _ 4 _ I ❑ 1 or 2 Family Dwelling - Number of Bedrooms M Subdivision Name CSM Number 1 12 Public /Commercial - Describe Use n/1 ❑State Owned - Describe Use � Ll�_ ^ 1 �? �Z� t .,��- }� nCity_ ❑Village KTawnship of �.•� I. Ty of Perm it: (Check only one box o n line A. Complete line — B if applica \l 6 IVb _ W _ New System ❑Replacement System ` TrearmentlHolding Tank Replacement Only J Other Modification to Existing System B. 0 Permit Renewal Permit Revision El Change of L Permit Transfer to New Z'ist Previous Permit Number and Date Issued Before Expiration ' — Plumber Owner ,___1__,�7W4 I �'. Tvpe of POW System: (Check all that apply) 1Z N - Pressurized In- Grou ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At Grade ❑Single Pass Sand Filter ❑ Con.;tructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank Peat Filter ❑ Aerobic Treatment Unit r 2 Recirculating Sand Filter ❑ Recirculat Synthetic Media Filter Leach' Chamber Drl L' ❑ rre ❑ ravel -le Pipe ❑ Other (exp V. Dispersal/Tre Area -- Design Flow ( iW)_T_M_si 9i Application • t { Dispersal Area Required (s Dispersal Area Proposed sf) System Elevation +� t ell VI. 'Tank Info Cap oral Number umber Manufacturer Prefab Site Steel Fiber (plastic Gallons Gallons of units Concrete Constructed Glass New Existing Tanks Tanks septic or bolding Tank - - 4 Aer, bic Treatment Utilt [ To,uig Chamber '�- ---� -- +-- V11. Responsibility Statement- I, the undersigned, assume respo nsibilit y for JAq of the POWTS shown on the attached plans. Plumber's Na me (Print) Plumber's Si gnature MV. PI2S I umber Business Phone Number Plumber's Addre ss (Street, City, State, Zip Code) VIII. Count Department Use Only Sanitary Permit Fee includes Groundwater Dat Issued Issui 4 Approved isapprove ( gentSignanue o S Surcharge Fee) / _ I ,._ e l0(� IX. Conditions of Approval /Reasons for Disapproval 1 SYSTEM OWNER: t.. Septic tank, effluent lifter and j dispersal cell must all be services / maintillned r 06 P MWOOSrrteM plan provided by plumber. 2. AN Ulback rs** ntents must be rn~wl Oil per spprl "c6 tt I adi WV". Attach complete tans to the Count only) for system P P { y Yl h . stem on paper not less than 5112 1 inches in size S13D -5398 (K. 01/03) 4o 7` Z� LJ��.�.a l7% /� ��+c ✓ .� TA.. A/ dI !'kv \—= B�� 10 �� sc�.�C�- � � -sd• ' 3 p /a6 w a _ der 0 3 I aye D Y. 9•%�a l C -,S T" r7"" des d: � Wisconsin DepartmentofCommem[i ALUATION REPORT Page / of 3 Division ofSafatyand Buildings tfffum 8 Wis. Adm. Code UUlI f . Attadl complete site p lan on papa inches in . Plan must �' 5 e ro ix include, tut not limited to: vertical 'nt (BM drection and Parcel i.D. percent slope. scale or di acid use to nearest Toad. Q 3 L rJ o/ � E Please prir U0 Date PeisonW information You Pmv+de may be used for secondary purposes (Privacy Lair. s. 15. (1) (m)). Property Owner Property location M i Ke F a ss ioo GovL Loo 1 9 1/4 S T N R E (or) W Property Owner's Matting Address Lot # Block # Subd. Name or CSW 75 Pac^ep, ,o,ri ve /5 Wa/nuaMil /Farm T,iibu-Ae State Tap Code Phone Nunnber ❑City ❑ Village R'`t'own Nearest Road Nudsan I Lv/ 1 510 (V ( ?i5) 3 6 - o9o z `i �aY 1 S Co. 4 /over New Construction Lion (se, Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement Public or commercial - Describe: _ Parent material _ f it Flood Plan elevation if applicable tt. General comments and recommendations: rrwyd S UQ�Y!!1' Area Spot Tested suitable for -- 0 a convendonal inground system (P.O.W.T.&) i Le 13 5 1 1 _ , Q Boring #, a Boin9 ® Pit Ground surface elev. /01 & Depth to limiting factor 7 im Soli Application Rate Ploriaon Depth Dominant Color Redox Description Texture SMx*re Consistence Boundary Roods M. Munseti Qu. Sz ConL Color Gr. Sz Sh. *FM *EfW#2 / o_ /3 IbY - I rn - W 9 3m G 3 a p s/ i t 3 f bx, i a W '4 'SFb -55 5 — 1 Mf i 2,1r .7 /• F2_1 � 9s-•q �•sY - sl Gb _ lv�fi - - -- � BoFiry # D Boring ® Pit Ground surface elev. n Depth to MW ing farxor ln. Sad _Rate Ho(fzon Depth Dominant Redox Description Texhre Structure Consistence Bounder Roots GPM in. Munsell Qu. SL Cont. Color Gr. Sz Sh. 'EM1 l -13 mfr- CS 3M .. 2 - i b K- -F s 3 SYi2 wc t 51 K /'Vi Yf-i aw — - x/I Ire • tBiluent #t = BOD > 80 < 220 no& and TSS *0 < 150 mgtL • Mont #2 - SM < 30 � and TSS _< 30 m9 L CST Name (Prise - - �� ,41 i-F - � Address Die Evaluation Conducted Telapl>ooe Nutntw l2 / A ve J kL �t1J4 ter-- i,Jr / o - 17 05 - 71 S' ?7.2. U'k!:fIcht & Assodates C'�r"vate Sewage CO nst!l'Ian �ti 2812 1OrhAve. =� g Valley, tAVl 54767 ORI G N AL 1 i o • Q � S�QLLWV3 ` nc�_ N � N! � 10� • C?$ 0 C sjy • cLZ l Q�• 001 d � All w oi lo8 • r .%�3.�..L. . oo• oQr = I � �'oJ+�?�nS �o aQr 1st --a�1- �Nd�oa La-7 . S,c� o�•+3ncJ n� <zi can o� isconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix safety and BUilding D "•vision T Sanitary Permit No: INSPECTION REPORT 479445 �?l 0✓1 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: Baypoint Development Troy, Town of 040 - 1303 -00 -015 CST BM Elev: linsp. BM Elev: BM Description: � / ^ Section/Town /Range/Map No: () ' (6 z. 3 a S� 22.28.19.1750 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / l6 v Benchn; _ 57 7 U Dosing )� Alt. BM Af 1 1 Aeration (J Bldg. Sewer (� i -z6 303 Holding SUHt Inlet . 7 TANK SETBACK INFORMATION St/Ht Outlet TANK TO r t P/L W� BLDG. Vent to Air intake ROAD Dt Inlet f _ Septic ! 7-O w.. Dt Bottom Z �. Dosing / Hader /Man. {/ ya Aeration I ✓� S�� I Dist. Pipe Holding Bot. System (E1 6, ` FpW.Grade PUMP /SIPHON INFORMATION 11 Manufacturer Demand St Cover GPM Model Number 3 TDH Li ft Frictio Los System Hea � TD r 6 Ft � � - b 5r � p 3,'75 17 Forcemain Le nth / Dia. /' Dist, to well SOIL ABSORPTION SYSTEM FPIT DIMENSIONS BEDITRENCH Width i Lengt� / No. Of Trencfjes No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 7 SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM e" LEACHING Manufacturer., INFORMATION CHAMBER [7 t 4.. Ty ? f System: —� a UNIT` Model Number. DI IBUTION SYSTEM ..r T eader/ anifold Distribution t "'' �. �, r-r ' z Hole Size x Hole Spacing Vent to Air Intake � r Pipes) L ne gth 6 Dia Length Dia Spacing ' - SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over /r Depth Over xx Depth of T /Soddedl xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes ( No I—Q Yes No COMMENTS (Include code discrepencies, persons present, etc.) Inspection # -�- /� Inspection #2: 1 3 Location: 649 Tribute Parkway River Falls, WI 54022 (NW 1/4 SE 1/4 22 T28N R19W) WalHill Farm /opf[15 Parcel No: 22.28.19.1 1.) Alt BM Description = to Z * �& ' "- V t/k� 2.) Bldg sewer length = zp Vat-aj e2i ,tom.. 3 - amount of cover = a� Plan revision Required? ' s 1 No Use other side for additional information. a[ 1 6kz , Insepctors Sig Cert. No. SBD -6710 (R.3/97) It , /1 •�� _L = p a- 4 1- 7l & 3 LIT �llti -r V GL�tX� Safety and Buildings Division _ County is r J 202 W. Washington Ave., P.O. Box 7162 J �' Y "x f sin Madison, WI 53707 - 716 Sanitary Permit Number (to be filled in by Co.) Departmo o mmerce u (608) 266 -3151 Sanitar mtar rate Plan I.D. Number y Perm><t Appl><catttoln In accord with Comm 83.21, Wis. Adm. Code, personal information you pr ' e may be used for secondary purposes privacy Law, 315.04(1 )( 11,14 Project Address (if different than mailing address) I. Application Information - -Please Print All Information A(, ? II n.J ok- P /�� RE CEIV � , Property Owner's Na me Parcel 1/ Lot Block A I / er ti -- N O V Property Owner's M ai ling a 1 5 2005 Property Location 75 7 Ire Y , •c/e ST. CROIX COUNTY City, State Zip Code ; 'a _ '4,Section C i 1 I T of Buil — T ��`_ N; R E ar 1. Type g (check all that apply) ak Ab ou_ o P let%A— f ❑ 1 or 2 Family Dwelling - Number of Bectrooms Subdivision Name CSM Number L Public /Commercial - Describe Use - - �`_ ��`�_ •�� b � A State Owned _ Describe Use . w Z Z 7 7 G��. ❑City ❑Village KTawnship of ,r - - -- _ 111. Type of Permit: (Check only one box o n line A. Comp line B if app licable) 61{b _ /363 _ _ `� � - New System _� New e ❑ Replacement System W Treatment/Holding Tank Replacement Cnly� Other Modification to Existing System B. ❑ Permit Renewal Permit Revision L Change of U Permit Transfer to New Z'tst Previous Permit Number and Date Issued Before Expiration' Plumber Owner � 1/ 7W -X5 14' TW of POW System: (Check all that _4 l _ V. N - Pressurized In- Grou ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil LJ At- Grade ❑ Single Pass Sand Filter ❑ Contructed Wetland ❑ Pressurized In- Ground 11 Holding Tank '7i Peat Filter L Aerobic Treatment Unit -' Recirculating Sand Filter �� f<et;irculating Synthetic Media Filter X Leachin Chamber ❑ Dri Lane ❑ rave - Le ss Pipe ❑ Other (expla V. Di s pe rsal/Treatm ent A rea Information: ��— + Design Flaw (gptl) Design Soil Application t °(gpdst) Dispersal Area Required (s j Dispersal Area Proposed st) System Elevation X4 _- • Y O I 5��' ea"f, VI. 'T'ank Info � Capacity in T Total Number Manufacturer Prefab Site SwelTFiber i Plastic New Gallons Gallons of Units Concrete ! Constructed i Glass Existing � Tanks Tanks �nJ �y¢Q #4 AZ P-,� i I , ieptic �11.ldit � air ibic Treatment unit V11 Responsi St atement - 1, the undersi assume respo nsibility for ' r ll atioli of t he POWTS shown on the attac plans. LPIunllheer's Na i n , e (Print) Plumber's Si gnature M '_ PRS Number I Business Phone Number i � Plumber's Andre ss (Street, City, State, Zip Code) i �_ VIII. Cou /D epartment Use Only - -- Approved tsapproved Sanitary Permit Fee (includes Groundwater Dat Issued Issui gent Signature o Sta t I Surcharge Fee) / X �// _rven Reason nial ff. Conditions of :4.pproval /Reasons for Disappror - i SYSTEM OWNER: 1., Septic tank, effluent filter and j dispersal cell must all be services / maintidned as par MENVsment plan provided by pksnbsr. f 2. AI setback N** merits must be maN*MnW l W par appMos* code / crdbancas. Attach complete plats (to the County only) for the system on paper not less than 8112 x 11 inches in size �� SBD -6398 (R. 01103) CC 4e 7` �� L✓e %uo��l� /� �a✓'Nt Tl�l�l/ d��Yd �/ w v. o r oc1 a cG \ w 6 dY:y•�a � �"s T ��s►�� g�p�"� � oe,� C OPY 4o Z�' /-9 /.tf d�TYa �l 1 w a a � oc1 3 as 'e, Ala# w 3 t ydk.fA- GD — Q 0 N 2 3 m ° 'D eo o ^ I v I i 0 N ai 0 ° V p a N? `C O • f, OD Q N p y W ►+, c m c w o° co w O 9 3. ° 3. v ' b \ 1 ' cc < O u Q O m o o I 3 N y .� Cn �� zcoz cnD cnZCn W ate:. cn D co D co D co D �' a o CD a (W a co c° o m O Q O O o f I ° � c o 0 0 0 f y c .xT. cr R M OOO 0 to C to 0 r < `� y c c 3 c c 3 co dJ N1 T �^ d Q Q v v v o , ' I m (D� m m� A N mil 1 1 1 1 (v I N i N z I O I O O 3 � C CD CD to N N CD ? j c c 3 m ff a CD CD CD -1 N :3 M 1 A Z CD M A Z N N to a cD * W Z I 8F N� 3 m o I y Z �_ 2 I � I an 3�W°:1 O O ^; 0 7� K) o 01 p�j O r a O ^; 0 7 d G1 R C �p N 7c d N 0 yr N a c N 7r N O to N> O - c o �,�LvxL.�'< y om ��N xym �, -4 G ° a �5.o 0 0R m �CD 9-2 o -0 s3.o 0 om m gym' °O- ° CD ZA 3 M W�.xa ac OF o'D O � 3 W� xa ay Ov p � O O � pt .0 N � O pl •< N � >> N >>n�a < CA 3 am �?.3 ° fl y 3 acco v 3 a 5' n fi O O 01 rA CD ? N C w O O d (1) G Er 0 C 01 K cc 3 ° a r o n aW ° �' co 3 ° D ca �0� ° od. c °o-O.�>cn n ov. c rn ° oC OLX 3 3 0 oWa ° x � o� y cD 3 3 I a o ° X o 0 3 F Cr o �.� c m o o m x -7 vm < ;w c CD ' ft D) ° y fD fn N fD K CD �+ y- 0 N o O �p y N 0 3 (D f ( 0 ° N 0 0 3 cD N fD y 0 N N ° . Ch m C > QQ0 3 N ° 3 t G fD A a < fD A - fi N 0 0 b u+ I m < N o o o o 0 ~ � i n �J � f/ Y d �°.�`� ,,,�� rJ �� o l,�f�'�.,�/� r�'.S�'•',�y d _ �C� `�l,�l,�J.c�y�� %f y� �' �'A �rV! /r. • l r 4 r' jf , Vv Lj Lk 5 t1l L� `Q V V , FF F �l S1 j ; p „ 3 2 �_. _ f'� k ill 1-14 W YIZ Wcty asst! Builds ,s �i sine �c auruy 4consin 201 W. Washington Ave., P.o. Box 7162 Madison, WI 53707 - 7162 De artment of Commerce (608) 266 - 3151 Sanitary Permit Number (to be filled in by Co.) Sanitary Pe < p ica OR CEIVE® tau Plan I.D. Num r In accord with Comte 83.21, Wis, A r MY be used for seconda ° # don provide /V Y PWP� sl 40)(m' i ' i• AApiicattioss Information - Pteeae Pr#ttt AU tntorsnatioo -- �ur rr)ect Address (t different than mailing addresa> Y � C� Tr,'th cc>�e pew ! Property Owner s Na me - I ZONING OF CE ucel # lock a 1 I Property Owner's M ailing resa Pro cation "-- City, State Zip Code Pttane Nu[nber — `� • 4.5 n fcircle one) II. Type of Building (check ant that apply) J W V-4.f- 1 7' � ,?c`f N; R�F. or W ✓ P K1 or 2 Family Dwelling - Number of Eledrootrs Vft 1 Subdivision Name C5M1i Number Wl - i -J Public /Coinrnerciai - Describe Use State Owned -- Describe Use �� —. - -- -. - �'� - - -- --- - --� -� - - -- --. _ {:_fCity OVellage�Towrnhi of III. Type o Check only one box on li ne A. Com plete line B if applit a ble) _ - -_" -- - ----� A. - r -._ _.__w New System Replacement System L� Treatment/Holding Tank Replacement Only `7 Other Modification to Existing System - �--- -- i B ertnit Renewal Q Permit Revision Change of I t] Lil st Previous Permit Number and Date s^ Before Expiration Plumber i O it Transfer to Yew ; Issued ry• TYAe of YU - L a i (_ Check all that - (X_Non Pressurized M- Oroutkl LJ Mound ? 24 in, of suitable soil t7 Mound < 24 in. of suitable sui, ❑ At -Grade (_. Single Pass Sand Fitrxr - L : Constructed Weiland C Pressurized Ir.- Ground ❑ Holding Tank U feat Filter Arrobic Treatment Unit l✓ Rccirculatin; Sand Filter j u Recirculating S nthenc Media Filter Leaching Chamber r V. Dis gal /Treatment Area Informa on: - then (explain) >� ^ 4*TAre,9 - Design Flow (gpd} Design Soil Application Rate( Disper � -- roposed (s �yyteAE le vation 2, Z I Tank Info Capacity in � -— __..,. .___ P Y Tarel Number Martufa�turrr Prefab Site Steel Frber i Yla�ti I Gallons Galion of Uwtx I - I Concrete Constructed Glass I New Existing I ; i Tank$ Tanks 3optic or Holding Tank j Aetubic Treament Unit I Dosing Charnber _'11. Res tt4 # bit #t Sta ternent - 1, the u ndersi g ned, P ' - -- - _ _ ___,� __ - fined, ssume rr resr ' , ._a of the POWT slrown an the attached taus. _ Plumber's Na rrre (Prins) Plumber's Si gnaruee N. Number Business Mono `umFrr .___ - - - -- I Plumber's Addre ss (Street, City. State. Zip Code) -_- -- VIII ` Pu rtment Use Oal A � t SaniraryPer_mit Fee (inr odes �srour a{t;• - -_ - -- - --- __ pproved �] Disapproves 1) to sued Is ingC Agent ignu Surcharge Fee)G i( i 0 Owner Given Re ason for Denial ,360 + d ovaIlReasons for Di III ! eptic tank, effluent filter and j dispersal cell must all be serviced / maintained a s per management Plan provided by plumber. c AI sew requirements must be maintained © �� /)S � ! as per applicable code /ordinances. �'" l- Attscls tax ell cos (t the Count oat, ar the s stoat ors pp ------ - PI p1 y y per not leis tban g1:1 z ! 1 inches la size l F. Wisconsin Department of Commerce RECOVER E ALUATION REPORT P a ge / - of Division of Safety and Buildings m 8 Wis. Adm. Code Attach complete site plan on Pape not less than 8112 x 11 inches in e. Plan must to r0 / X include, but not limited to: vertical d "nt (BM direction and Parcel t.D. Percent slope. scale or dim north l a�`id dis nce to nearest road. 3 d 3 0 0/5 FFICE Please print a M Date Personal infomnation you provide may be used for Secondary Purposes {Privacy law. S. 15.04 (1) PMP "OWW Property Location M l" Ke Fa 55 ino Govt Lot 1/4 1/4 S T N R E (or) W Property Owner's Mailing Address Lot # Biotic # Subd. Name or CSW 75 pgcrter2 P-lve l5 Walnu -1 Hillftlrm T✓ib44 Uy State Zip Code Phone Number ❑ City ❑ Village )F`l'own Nearest Road HudSOe) Wl I 5WA01& ( ?/5) 3 6 -69x2 I 'i kDY Sp, Glover New Construction Use Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement 7 Pubic or commercial - Describe: _ Parent material � `I _ Flood Plain elevation if applicable , —~ ft. General comments and recommendations: 7 , " MA4 shy B U J Area Spot Tested subMe for 07l Le 13 ' — a conventional inground system (P.ONT.S.) vt � Opting # ❑ Sons F cG ® Pit Ground surface elev. /0'0.30 ft. Depth to limiting Wor > / in. Sad Rate Hmimn Depth DominantColof Redox Desaiption Texture Structure Consistence Boundary Roots GPM fn Mused Qu. Sz Cont. Color Gr. Sz. Sh. •Elf# t I 'EfM2 / o-13 to Y - I m-W 9 3 t.4 . 2 13 DY9- — iGl 2'f 6r, m* i vF 3 a5 p Ate/ i I 3 -� bx YY4 a w 3 \j� ­q -55 10 Ye- 5 /(0 i s n'If i s VV 2 d ,7 /.(0 . t o 2• soft 7 ate# ° ® Pit Ground surface elev. 10 q ft. Depth to knifing factor > 88 in. Sod .Rate HwIzon Depth Domirant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsetl Qu. Sz Corti. Color Gr. Sz- Sh. 'Etf#1 'Efr#2 l — 13 /c if '32 Q 2'm r M fir- CS 3M & 2 -2"7Y* s i t 2 Itf 6r- -f- i Ci S IVF -L / 3 5 -�/ S �'cl bK MY -F i aw _Y4 b /.0 Sew b • Efluent #1 = BOD > 30 < 220 mg& and TSS >30 5 150 nv& ' Effluent #2 = BOD < 30 mg& and TSS 5 30 nVIL CST None (Please print) – – – 61VIV t3� iT Address Data Evaluation Conduced Telephone Number 2$IZ- l pT� - A V E Sfgli� au i p - 17- 05 -/ 5:X 772_ , 6 t ASSO; fatc s . "iv«te Sewage Consul - 312 1 O,h Ave. Valle V T 547 7 ORIGINAL, L _ LbT / 5 Property Owner x 55 t Parcel ID # Page 2 of 3 a Boring # ❑ BMV ❑ Pit Ground surface ele ft. Doh to ftkk 9 factor in- Sod Rate Horizon Depth Donunard Redox Texture Structure Consistence Boundary Roots GPDIff in. Munse Sz. Con. Color Gr. Sz. Sh. 'Etf#i 'Eff#2 B OIL l o —pel joyp 2 /2 — / mfg' Z `f' C l 2 m Ib Q 5 .�-� Co 3 -73 !✓R 3 , 1 5c — S/ . . 7 Borm ❑ #s ❑ Pit Ground surface elev. ft. Depth to knifing fader in. Soil App Rate Horizon Depth Dominant Cola Redox Description TexWm Stnxxure Consigerce Boundar Roots GPDffE in. Munsell Lau. Sz. Con Color Gr. Sz. Sh. 'Efr#1 'Eff#2 F — ] BWM # ❑ Boring ❑ Pit Ground surface elect. ft. Depth b kr&V factor in. Horizon Depth Dominant Color RedoxSod Rate Description. Texture Shudure Consistence Boundary Roots GPDtt! in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Efr#1 '01#2 Efftuent #1 = BOD > 30 1220 mg& and TSS 1-30 <150 mglL ' Effluent #2 = BOD < 30 mgR and TSS _< 30 mgfL 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. s9na33VQtA ) I L-� T 5 PAZ ,S of FO urQ C> �o r 40 02 NCR "T-f�os CL lop O F S vgveya s -vv 60TTpnl1 -72' rdA(7£ O P D 3 1 a 3 4 36 too' /00.10 ! i 2 { o N �s So. k-OT (,- // 1 ioura. V�iTT Z) X33 � .d3 T W201 Washington Ave., P.Q. Bax 7162 O adison, Wl 53707 - 7162 Sanitary Permit Number (w be filled to by Co.) L e�artment of Commerce (608) 2ti6 3351 Sani tary Permits Appliea on /+ 1� tale Plan I.D. N um r -- — — In accord with Comm 83.21, Wis. Adm, t`. RECEIVED r MY be lised for secondary purposes '� don Y ou provide t: ciject Address (i differ ent than mailing address � Pl- t s1 4(1 m' Applicrbteoa InPgrmaion - Pteaae Pri� perty owner's Na me 1 ZONING OF CE ucel A lock p !Property Owner's M ailing ddress y` _ ^ � Pra ofty acatian -7 City. State Zip Code Phone Nuber •r �' � '�• 5 'o't _ AA xe;_ , Sy � ?, m (circle ant) I T Type of Building (check all that apply) V / 1 T �y N; R^ f—F of W 1 or Famil Dwell J Y nY - Number of 13edrex�ms ��r'1 � %1 .� Subdivision Name M Number i Public , 'Commercial - Describe Use 1, � _i State Owned -- Describe Use of — - __ _ �_— I �C sy (JVillagerownsttip III. Type of Check gnly arse bgx an Il l - le A. Comp to line B if applica .. _ _ T New System [I Replacement System i t-' TreatmentI >Idin rank Replace nt Ot 13 p y ! ] Other Modification to Existing System i B • ermit Renewal C Permit Revision Chant of Pe' rm it'r ; tnsfer to New I List Previous Permit Number and Bate Issued j I Before Expiration I Plumber wnor i I IV. Type of yC) I S Sy stem Check .11, that apl yly) / l,Non - Pressurize[! la- Groutul L1 Materiel > 24 tn. at'suttabte soil t_ M T- -- _ ��� -- 4 in. of stutable sal: At Grade 1_; Sing P4.1% Sand Hirer Constructed Wetland i Pressurized Ir.- Ground ❑ holding Tank lJ Peat Fil ',.; Aerobic Treatment Unit Rocircuiatin.) Sand Filter u Pecircuiatuill Synthetic Media fitteArm eaching Chamber I iher (explain) V. Dis real /Treatment Area Inn: -' u� I Design Flow (gpd) Design Soil Application Rate( 1 Dis r r ' _. -- pe Are ropased (s • ystern Elevation 3 3 as vv Zao _?_ ._— __ . T ----- — r — - - -- �'I. Tank Info Capacity in Total >vurnber Manufa�turcr � Prefab Site r Steel - Eber � ber Ylasfi;: Gallons Gallons of Units Concrete Constructed Glass New Existing �_ _ Tanks Tanks � he c or Holding Tank Aerobic Treatment Unit posing Chamber VII. Res p o nsibility Statement 1, the un t� gt[ed r , . x+sume re pcimi hihty for Na tion of the POWT show» on t attached plans _�. Plumber's Na me (Print) Plu r s Si gnarule M11; kS Number B iness P1wttc \nmtKr Plumber's Addre ss (Street, (lily, State. 9P Code) Ai� t VIII• _ ,/ �a rtmen t Use -- -- -�- r J Disapproved I oanitary Perzti[ Fee (inc udas Gtourww II ate ssut+i is tng Agent 'i�rw re ( ips) G I Surcharge FCC)�/� /l / Q j �� Owner Give Reas for Denial ` I o valfllteasorw for Dis St ic tank, effluent filter and dispersal cell must all be serviced/ maintained a s per management plan provided by plumber 2. All setback requirements must be maintained as per applicable code /ordinances. Attach complete plans (to the County out, ar the systenn on paper not less. than 81;2 x 1 I inches in size - �y ��,`�`� 1'Jey��o.✓�f 1�,� f� ��:,.vd 40TI�I .� 3Q 4 I le z i s I � � pOy it y i a� -z. q % c V�. i N SEPTIC TANK & PUMP CHAMBER CRw5S S ECTION AND SPECIFICf 4" Cl V ENT 'PIPE 12" MIN*' ABOVE GRADE & WEATHERPROOF 25' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER W1 PADLOCK & FINISHED GRADE 4" Cl RISER ---- WARNING LABEL _ - - .��._._._ 4 " MIN . 18" IN. 6" MAX. INLET 's _71 WATER TIGHT SEALS GAS- TIGHT .APPROVED A SEAL JOINTS WITH %PPROVED — --- ' 'ALM APPROVED PIPE WE 3' B ' ON 3' ONTO )NTT SOLID � SOLID SOIL zOII PUMP ELEV . FT. ,--- + p 0:-F 66 RISER EXIT D PERMITTED ONLY IF TANK MANUFACTURER HAS APPROVAL 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE , / TANK MANUFACTURER: NUMBER DOSES PER DAY: 4 TANK SIZES; SEPTIC 1 Q GAL. DOSE VOLUME INCLUDING DOSE GAL. rLOWBACK: / GAL. ALARM MANUFACTURER: Le1)clshL M CAPACITIES: A = INCHES = `? j GAL. MODEL NUMBER : 'D LV SWITCH TYPE: tVN& _ %c B 2 INCHES = q a GAL= PUMP MANUFACTURER: G c C = INCHES = 1p0 GAL. MODEL NUMBER: SWITCH TYPE: MILL D = INCHES = ato GAL. REQUIRED DISCHARGE RATE ' GPM PUMP & ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE !o- FEET } MINIMUM NETWORK SUPPLY PRESSURE . . . . . 2.5 FEET + FEET FORCEMAIN X - �,66 FT /100 FT. FRICTION FACTOR . , ' FEET Z6 �tl - TOTAL DYNAMIC HEAD - � 47 FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH ; WIDTH F- DIAMETER LIQUID DEPTH ,38 � � L a e. 1 P r r .TED _,,r - : �����,.... LICENSE NUMBER: t�a� �, '� Dl.TE 1/88 [qGOULDS PUMPS Submersible Effluent Pump 3871 EPO4 EP05 APPLICATIONS • Fu11y submerged In high ■ EPOS Impeller. Thermopias ay Bearings: Upper and lower Specifically designed far the 9 turbine oil for tic enclosed design for heavy duty ball bearing following uses: lubritaation and efikient improved performani e. construction. • Effluent systems heat transfer, and Base: Rugged • Homes Available for automatic and thermic design provides AGENCY LISTING • Farms manual operation, Auto - superior strength and corrosion cwd1 as ln stadw Association • Heavy duty sump matic models lndude rea+cyrnce, • Water transfer Mechanical FIW Switch ■ Motor "ousing: Cast iron (CSA listed model numbers end • Dewatering assembled and presot at the for efficient heat transfer, in "F" or "C ".) factory. strength, and durability. SP ECIFICATIONS 4 MOW Cover: Thermoplastic Goulds Pump h So 9061 Aegistered. • Solids handling capability: FEATURES covet with integral handle and 'A,' maximum. fJuat switch attachment points. N EPO4 Impeller: Thermopias• 0 Power ale; Severe duty • Capacities: up to 60 GPM. tic Semi -open design with rated cN and water resistant. • Total heads: up to 31 feet, pump out vanes for mechanical • Discharge size: 1 NP7. seal protection, • Mechanical seal: carbon - rotary/ceramic stationary, BUNA -N elastomers. • Temperature: 1041(40°C) continuous 1401(60 intermittent. MErens Feel _ • Fasteners: 300 series stainless steel. 9 30 ...." """"".,� ;; .... , j —. .—s GPM • Capable of running < dry without damage to 8 2.s rr components, 7 Motor: ' • EPO4 Sing phase: 0.4 HP, ._;._ 115 or 230 V, 60 Hz, 1 350 s I RPM, built in overload with 1 automatic reset. a a 15 _.. \ • EP05 Single phase: 0,5 HP, c Enos 115 V, 60 Hz, 1550 RPM. F. built in overload with . automatic reset. , EPO4 • Power cord: 10 toot standard length, 16/3 gro�nding h plug. p Optional 20 o L 11 0 1 o 2 0 _ . . 30 d0 50 GPM foot length, 16/3 SJTW with three prong grounding plug 6 '— - — ---- (standard on EP05). 0 ; 4 6 8 to 12 m /h CAPACITY Goulds Pumps ® 2000 Goulds Pumpc ITT Industries EMealve February, 2000 63871 r — STANDARD CHAMSEH Quick4 Standard Chamber�� i (EFFECTIVE LENGTH ) T ri ( r / SIDE VIEW SECTION VIEW MuitiPort End Cap IL r — - - - -- __ - -, SIDE VIEW TOP VIEW FRONT VIEW �r x 3r �` .� 1 r Qtiiick4 Standard Chamber Nominsl S ecitica cions' T , Size W ,-� —�- ---� Ott MuitlPOrt End Cap Nominal Specificattona *� x L x H�34" x 5 x 12 �' Size (W'x L H ) ` "�� 34' x 16' x 12" Effective Length X48" invert Height 8" or 1.25" Invert Height 8" IN F_ I T—R A TOA$Y�T EMS, IN LIMIT WARRANTY ial h0 t' ;r" r.g t sys; Orb -n ;n:mhar; end plate, wadga a d .l. �x, a"';essory mur",Ywn3rvd oy I Itl afx t'Units "), water na13I11d W'l OIX- filers .R a IHaLr soil .rt an cn uC GAofr ry lem in as 'dance w,th I fi t woe, irsv.,claB, is wafrardnd le {hn viguufl pufcl-�y t•HCkJa'I lxialnsl dalec!rve n a,en )ts ano w,xkmansr�.p tt,, ono year Iran the date tttaS Rte :c{V-c penril rs issued la ibe scp;fc syala-n ext ina ' 140( Crovsled, hc»ve -1 Irrer II a Eft(31a: 0'31-1 iS not fe+ltlired by appl;�rble law. the warranry P. 3 y1 yiG begin apou ;n' dale that, sia days of Nalron ul the ''pair, ern cdnrniancas. 7c rc e 's war, an rights, Holder must nolily rGllrata n -4in11 at a5 Corpnra'e Headynodcf s in C!d .,aybrtibk. Carnrx:trut w+thm litleen 051 he arl+r deh}cl h*ralcf whl supply leplacfxnen -its for Units deiemrinco by nrBlralor to be c'"rod by this umlled Wanan, , frr c iiw .s rk M ue arty sc: IuaIN Facludes the cost Ct , firtwel a ri rn inslallatror . u( the Units rim ibl 7 ff L h.IT[U ✓AAR6 APJTt AN 11,AI MS SUBPARAGRAPH SUBPARAGRAPH I,t) AFL r i l ILF6: ARE PiG ULHFJ', WAAFAN7k:> 4YI1H farS?£CT �/�\ //�� INC t 11 laN.l;i, LllpiM rJ MPUED WAFRAMIL OF ME(K:HArtiTA J11TY LI ?FINE rO�i1 Afil I�ULAF+ PURPOSE. SYSTEM l i V sh 61 d 3io r y part 3f ltua -bar le ys{enr - n�lxlorba oY '+ 1 ore olhr l nfrl[ or. The Lvr terrJ warranty OMS a t xlfno I r is r- dent con tc;.,e t I, "ae al u dr a i u ,y .. inlet ar a nca t a h r pn ail a IxJ�x]nle(i damage t c k,dirq; loss : Environmental OnsftB Wastewater Solutions- lur x1 1 3 arkt p ufl lalu� ndsr al .,ve, oaU - . 1psws o Le vy - cmrf f uy e e IiOkk. any a3ird Carty. SI tr'Irrn fy dr. - I f c t t- t ,y y N ant r o aT a darnag' la r e U x am ysww. a to v Trssrry w'r, cf r , :utoraiicw aukk{frl f ptly, hr o+ niy�ibCl lho '.:n Is ivti y kh"rta 5 i - oeFnck { - ti C or Done. a"crihuns wN -r are no+ per 1 1'r, d ny the 1n ai'wo ;nsto"Aars. law­ 1" a-airnal 1 Ina 6 Business Park Road - P. Box 768 m n rnum glau d set forth 0 the in tat+ali'n rnst'r,,p..s, the p:acafnert of in malerrals into: the system Lantanirg IM Uruts. failure of ou I�1 Units a m se e p -' yst_ due to ,MFA(Wr WIN or r)(11,0110' ,0110' slang, e"ceSq,,a water usage, -100µ3e1 grease disposal, or improper cperal.!A; or Old Saybrook, CT 06475 ary Cther event not crrusen oy InfiUratCr. This Luniled WarrarlY S ^aA Ce •.cvd ',f tt» NWder talk to umpN with all of the fcvmS sal funh in tYiis Llmilsd Wd fanly 860- 577 -7000 • FAX 860 -577 -7001 Fwlhar; in rro sybnt sm.11 wilba{O. 1" reSpCr3Sibia fa arty I(3ss or (tdlileg" to tae HG1t1P,r, {he th01S, G? any third pad y resutitng from in>lat'alidn or ship /► A w mbnt Or { rDm airy prat' I taciHty ,Idims UI t{ok',w a any Ihird ;3ady Fcr this Llrn:tyd Wananty IC apply, the I,r i1s must be irlstaaeo 0 acmdarrce 800`221 -"36 with all site centlif ,ns w -rtired by ~tale a rcrd rd bcal es; aY olhsr applicable laws; anJ 1nf*ral01,% "s1e4a{lon nstvetlaL;. till M1kt repxesenlali.re 61 Intiftrota tras il» auftrc,rily to chanyH Or e>;lartn tniS Lruterl wprrar rty No ,m - dy eprA*S to any party uthur flan the a:gl- nal Holder, Thr? atX)va reorot m!s ltla Slsuwar i L nt:lari tga - dy uNwa:f by r 1. a;a. A n+ ktkl n+,mher T,t ,.ta-as ar.O ccxmties i+pye Q-flareni w n - IY : 3t =ire- tux+te. Airy puNna'M f Unns Sn Id <:Jn13t.t '.nnuatv,, C_Pornlb r'IoaO({Jarrar$ rn O;d :iaytNn.N:. ( ;onrreCl¢:ut, poor la SIIGh pJ CjWfo,r to pblai (zW of " a"'li"'bi' wa- Tanly, ar.d s'"Id .; fulN :sad Traf war, only pnci lc thr purcha5e ut ivirb. n a U.S. Patents: a,�59,6E7; 5,077,041:5,15E,488; 5,33',017; 5A07,t!c; S,r�G1,45',l; 5,51 I J03; 5.776,7G3; 5,588,77H; 6,839,844 Canadian Patents: 1,329,959: 2,004,564 Other patents pending. iIlUtfalot. EQUalizel and SldeWincler are registered trademarks 0 hilittrator Sy tbrnS Ire. !nli3;ator is a rc{g:atered IrarJomark in France, In!rtrator Systems !nc. 10 a regiStafad trademark in Mexico. Contour, Contour Swve, Ceniie,tfon, fvUuaLdachinp PoiyTuH, Snapi-Ock, Chamber£pacor, Posit-ock, QuickCut, QuickPlav R£CYCLEOMPPA r y Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County 57 Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must 4 jN include, but not limited to: vertical and horizontal reference point (BM). direction and Parcel I.D. ti0l� percent slope, scale or dimensions. north arrow. and location and distance to nearest road. P `b Please print all information. 11 b Da Peso" trdor obw You Provide vW be used for secondary wxPos« (PriwacY Law. 5.15 04 (1) (m))• hr D ^ C( 3 b 3 1 Propertyowner - rOP A9 Property Location 1% p Q3E�Te i C / d /9�I' N All O 49 5 1/4 S T� N R // 4(or)W Property Ownefs Marling Address Lot # Block # Subd. Name or CSM# . ( 0 o t 5 C * i LL Awe • 15 wALNO r K i l l FA IeAf � CKY --CMWR State Zip Code Phone Number ❑ city ❑ Village (A Town Nearest Road b�ov� HT; MN SS-07(p ( &sr zyk• ro�� T-,e so. �IouER 0 pa New Conshtctiori u ' M Residential / Number of bedrooms 3 Code derived design flow rate 0 lJ D GPD �► ❑ Replacement ❑ Public or commercial - Describe: � t o Parent material /D eS S ©Uk _7 Flood Plain elevation if applicable A tt F . General commends and recommendations: eW .,f rL� S��r/A� /Q �r(v�j,e© �,�� l Cv • T S 1 /1 � ;�� Z- ti FT] Bora�g # !� ®p Ground surface elev. ��. �� n Depth to limiting factor 7 . � / rrr. Sol Application ate �- Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW b In. Munseti Qu. Sz. Cont. Color Gr. Sz Sh. 'Etf#1 '011#2 .� 0 •/ /o yR 31 G zfshk w 2 ' s fr_ 2 fS h / • s %A 3 Si L /f c S -- z• 3 D Borkv * ® pit Ground surface elev. ft. Depth to limiting factor in. Sol A ppkabon Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Rods GPDff � In. Mtmseli Qu. Sz Cont. Color Gr. Sz Sh. I 'Elf#1 *01#2 n o• L z dS17 w 2 `F • S N z 5 -- ---- -- S� / a � • �f • (�e '0 " - - . Z. t • Etlkient #1 = BOD > 3o 1220 mg& and TSS >30 < 150 rrwA ' Effluent #2 = BOD < 30 ffgt and TSS 130 mglL csT Signature Name (Please Print) R • Zl iz R i c k T % zZ 3 S Address Ulbricht & Assgciates Data Eva Conducted Telephone Number Private 5� i • y— 02 00 1 f • 77,;1.3 41q Z- 2812 1 Oth Ave. Spring Valley, WI 54767 P/N5 FO 40R x . 2- 4 64.es oya • ,ohs• so- � 0 1 . �o �(� . io • oaD a 4 /o / v/ o yo • �( ' o yO - /og(p �D • oar I i Cv�N V propertyoww Parcel ID # PEW of 3 EJ t Ground surface elev. S fl. Depth to hMWV WOr ? • kt Soil Rate t torizon Depth DorninantColor Redox Description Twdure Sbuch" Consistence Bouerxtar)t Roots GPDJW IM Munsell Qu. Sz- Cont. Color Gr_ Sz. Sh. `Ef #1 �E� o• Ho L 2_F ShX d-SA .2 . s Z c w 1 / . s s m r2o del A- �d noting El pit Gmund sarfaoe elev, ft. Depth to ilrniting factor in. i Rate Horizon Depth DominaM Color Redox Description Textrsre Skuck a Consistence Boundary Roots GPD ff' kc Munsen Qu Sz. Cora Color Gr. Sz. Sh. ; 'E # © Ground surface etev. ft. — pit Depth to factor in Sod A pfficAon We Horizon Depth DorninantColor Redox D ma"on. Texture ime Consistence Boundary Roots In. munseti Qu. Sz. Coat. Color . Sz. Sh. 'Eff#1 'EW i t Rning # tQr Boring i Fit Grouxrd surface elev. ft. Depth to inni" favor in. Soli ftWation Rate Horizon Depth Dominant cow Red= Texture Skutt" Gor>sister>oe 80undar<y Roots OPT In. Munsell Qu. Sz. cow Gr. Sz. Sh. 'Eff #1 'Eff#2 I ' Eftluerl #1 = BOD > 30 < 220 mgtl and TSS >30 150 mg1L ° Effluent #2 = BOO,, 130 mg& and TSS < 30 Mg& i The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or trend inaterial in an alternate format, please contact the department at 608 -266 -3151 or TTY 608-264-8777. s ®aa?so rt�umo> PLOT-PLAN WALNUT HILLS FARM. LOT # Pg. 3 of 3 d = Contour elevation lines. o = Backhoe Soil pits. Q = Benchmarks set, maRRED WITH FLAGGED .lathes. 1/2" steel conduit pipes. SCALE: 1 0 0 L d qo q D p , 1S ! 133 9 9 "O ©4K — �5 Sa -L5 d r3 A4 / 8D __- 1� S o • G-rs T G. . Ar S,w . to T CogNa-L, Go f sr cROIX COUNT TY SEPTIC TANK MAINTENANCE AGREEMENT AIv'D OWNERSHIP CERTIFICATION FORM L �rs1/ OwnerlBuyer M tG t Mailing Addres G . Property Address Lcrf 15 at 0f IAh h u� k i t t faraw OLA (Verification required from Planning Department for new can3tructi0n) CitylStatea 'n5 L Pazcel ;dentiftcatior. Ivumbcr O' l0' 1303 —OO — OIL_ 1 Property Location ._ t �•, _ , V4, Sec. as , T o� $ N•R Town of Y� Subdivision _ C l arm , Lit certified Survey Map p Volume ,Page # — . r._.._ W arranty Deed # 2 O 1 a Volume Paso # Spec house ® yes ❑ no Lot lines identinable & yes C no SYSTEM -MAIX=AbcL . Improper use and maintenance of your sepdc system could r e su lt t wi by a licensed re to hand What you put into the consists of pt:ntpinS out the septic tan; every' three Years or so on er, can affect rho h=tjon of the septic tanlc as a treatment range in the waste disposal system. De ar=ent a certification form, signed 'ny the Owner a ^d by a Zo ; o e "t The property owner agroas to su b m it to St. Croix nsng p master plumber, journeymaupluznber, restrictedplti mber or a ]iceasadpu:npe � t t t he 1 ss thanal /3 full of IN in proper operating condition and or (2) after inspection and pumping (' ty ), � sep st t andards $ undersi ned have read the above requirements and agree to maintain the private sewage disp l y yst e sin fa ifs ati a set f the set forth, herein as set by the pepartmct�t of eorrtmmerce and the Department of natural Resotu , stating that your septic system has bean rasiatained must be completed and returned to the St. Croix County Zoning office withza 3C days of tlu three year expiration date. S Ix /05 DATE SIGNA W OF CANT OWNER cErRT1FF1 nQ 1 (we) certify that all statemonu on this form are true to tine best of my (o'�:) icnowladge, 7 (we) am (are) tl c owners) ui the property described a ove, by virtue of a warranty deed recorded in Register of Deeds office' SIGNA OF fL CANT DAT Art 1nfO that i6 ZnSS •ropresente .eie.w tm d m ay result in the aani pennit being revoked by the Zoning Deparent.'"' "' y — Include W10 thin sppUcation: a lumped warranty a Ern �e R of its madein the warranry deed a copy of the certtf�e ) p • POWTS OWN ANI & ANA 2— IVY _AL . M PLAN Page � of FILE INFORMATION $1f TRM SPECIFICATIONS Owner Permit a fiiep0o Tank Capacity ,? d al 0 NA Septic Tank Manufacturer 0 NA DEGON PARAMf - RS Effluent Filter Manufacturer O NA Number of Bedrooms Y Q qNA Effluent Filter Model � 0 NA Number of Public Facility Unite, P Pump Tank Capacity �J al Q NA Estimated flow {average) Pump Tank Manufacturer r 0 NA a � e °9 �t� Design flow (peak), (Estimated x 1.5) " , aVd Pump Manufacturer O NA Sou Application Rate , 3 g a l/ . d 1 ti Pump Model O NA Standard inttuent/Effluent Quality Monthly averagoo Pr I reatment Unit TNW Fats, Oil A Grease IFOG) 530 mg /L P)(land /Gravel Filter 0 Peat Filter Biochemical Oxygen Demand (BOD,) 5220 mg/L 0 NA 0 Mechanical Aeration 0 Wetland Total Suspended Solids ITSSI 6150 mg /L 0 Dlstnfeetion C7 Other: Pretreated Effluent Quality Monthly average 01spereal Collis) 0 NA Siochemicai Oxygen Demand (BOD S30 /L r g s mg n G ound (gravity) Q in- Ground (pressurized) Total Suspended Solids (TSS) S30 mg /L NA Q At�Grads 0 oun Mound Fecal Coliform {geometric mean) 510 c " q p►ip -Line 0 Other: Maximum Effluent Particle Size K in die: 13 NA 0 OVA Other. 4 NA 0 NA "values typical for domestic wastewater and septic tank effluent Other, 0 NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 3 ear a) s (Maxbnum 3 years) O NA Pump out Contents of tankfs) When combined Sludge and scum equals one -third (Y of tank volume 0 NA Inspect dispersal cell($) At least once every: 3 ear GIs! (Mexlmum 3 years) 0 NA Clean effluent fiker At least once every: rat ts) C7 NA /• ,'lid' earls! Inspect pump, pump controls A. alarm At feast once every: �--- {Womb)$) U NA 0 IS) Flush laterals and pressure test At lean onca every: rrm (s) 0 NA 0 earls) Other: monthis) 0 NA At least ones, every: --- 0 earls) Other: a NA MAWMANCE INSTRUCTIONS Inspection* 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 tanklai to Identify any missing or broken hardware, Identify any cracks or leaks, m r grou surface. easu s the volume of combined sludge and scum oh k r back or ponding of effluent on the yrou g um and to . eo, for any up p 9 The dispersal collie) 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 effluanr 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 (Y,) 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 !912 months, shall be perf irmod by s certified POWTS Maintainer. A service report sha!I be provided to the local regulatory authority within 10 days of completion of any service event. Page 2 0t t' - —% START UP AND OPERATION For new construction, prior to use of the POWTS cheek traattT►ant tankis) for the presence of painting products of other chemicals that may impede the treatment process and /or damage the dispersal ceNts). -if high concentrations are detected have the contents of the tank(Q 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 pu m p tanks may fig. above e n m r i hwater lavets. When power is restored the excess wastewater i will b., no h p, discharged to the dispersal call(s) in one large dot.q, Overloading the celliel and may result in the backup or surface discharge o f eftluent. To avoid this situation have the content* pt the pump tank removed by a Septage Serv icing 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 calls. 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 aiksorp.tion area. Reduction or elimination of the following from the westgwater stream may improve the performance and proiong the life of the POWTS: antibiotics; baby wipes cigarette butts; oopdoma; cotton swabs; degre asers; dental floss; diapers; disinfectants; fat: l grease; herbicides; meat scraps; medications; oil alien drain sum p ump) fruit and ve poeli s; g asoline; p found ( sump pu p _n8 � , " n painting products; pesticides; sanitary napkins, t almpc ,a, a nd water softener brine. ABANDONMENT When the POWTS falls 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 pas 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 um in aN tanks and its shall be excavated and removed or their covers removed and the void space fitted with R 8. R R 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 replacemen stem: OA suitable replacement area has been evaluated and may be utilized tar 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 propased 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 "0. 13 A suitable replacement area Is not ave1lablo due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be Installed aM a last report to replace the failed POWTS. D T as d site e tank 6 1 13 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 msast oaMply 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 UNDIII1f AAIY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY E9 tKOICOf T OIL tfMpMIBLE, ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name 0,N �ife dame Phone ?/ - �' ,� .� .,z Phone SEPTAGE S ERVICING OPERATOR PU PER) LOCAL REGULATORY AUTHORITY Name Name S7 , c� / N fi Ll Phone Phone This document was drafted In compkafice with chapter Comm $3,22(211b1(1l(4)&(f) and 83.54(11, (T) B (3), Wisconsin Administrative Code. f Parcel #: ,040- 1303 -00 -015 09/06/2005 11:47 AM PAGE 1 OF 1 Alt. Parcel M 22.28.19.1750 040 - TOWN OF TROY Current !X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - BAY POINTE DEVELOPMENT INC BAY POINTE DEVELOPMENT INC 757 PACKER DR HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 649 TRIBUTE LN SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 1.130 Plat: 2588 - WALNUT HILL FARM 1/75 040/03 SEC 22 T28N R19W PT NW SE WALNUT HILL Block/Condo Bldg: LOT 015 FARM LOT 15 (1.130AC) Tract(s): (Sec- Twn -Rng 401/4 1601/4) 22- 28N -19W NW SE Notes: Parcel History: Date Doc # Vol /Page Type 07/25/2005 801223 2849/631 WD 12/10/2003 748766 2471/591 WD 11/19/2003 747018 9/92 PLAT 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/23/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.130 69,900 0 69,900 NO Totals for 2005: General Property 1.130 69,900 0 69,900 Woodland 0.000 0 0 Totals for 2004: General Property 1.130 69,900 0 69,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 I STATtiB L" PM 3 WARRANTY DEED KArKL OF DEEM g Document Number ST. Cit0I8 ca., UI This Deed, made between BrightMS Developaaeut Corporation, a RSC6IYF.a FOR RECORD Minnesota Corporation Grantor, and Bay Pointe Development, Inc, a Wisconsin Corporation, Grantee. 07/28/2M IM 15AX Grantor, for a valuable constdaation, conveys and warrants to Grantee the WARRANTY OEM EAW ; t following deco bed real estate in St. Croix county, State of Wisconsin (if More space is needed, please attach addendum): Re M 1 t 11.00 COPY FEES Lots 15 and 52, Plat of Walnut Hill Farm in the Town of Troy, St. Croix County, CC Put Wisconsin. PAGES$ 1 Exceptions to warranties: Easements, restrictions and right -of way of ja Ar" record, if any. asd Reim Adds, Pointe Iuc. Ti Q40- 1303- 00x0)5&040-1303 Paw "axitloadoa NwA t (F" r This is not homestead property. Bated thiQ day of]uly, 2045. ikvetopmemt Corporate • • d �^ cKxowi.>i� AUTHEI4TICATiON STATE OF ) )sL Signadut(s) auftn icated this day County ) Of , Peawnally came before me thi day of the above named BrightKEYS * I meet Corporation, a Mianesota Corpomdon to rote knowm TME: MEMBER STATE BAR OF WISCONSIN to be the person wbo executed the fiftoxf aaotMiw��wwwwta GFOU 706.06, Wes Stets.) authorized by § aclmowledged tho sate. MALLOW IRt101rldOMt�tiFtt4 THIS tNSTRUMENT WAS DRAFTED BY • Notary Public, o isconsin 707 C.isn mercy Drive, Suite 410, Woo&Mt MN 55125 My Commission is permanent. (If not, stela expiation date: .;l I' . 2(*1 _ .) tx �udwaticated ar ea Hah .ro not •Napwm of pry Utz in any u4wity —a be "W or pd&W bk'Aow dwir •igan. WARRAM DIED bTATE I" OF WIlpMSIN FORM Nw 2 - 2m .w t x V M1 . 47.0 ��� O�i� io• 1037.14' N 85.46' 37'. L 478.5 38.83' \ t9�'•� 203.9 ` 4 � 46900 S.F. \1 1.08 2 1 �1 48115 S. F. II �+ I 4' I w I o w, I ►•' 48782 S.F I� 5 \ �\ LBO 964' C. 48169 S.F. 1 LBO = 965' 1.12 Ac. , 1.11 Ac. I �s\ ` N I � LBO = 9651 � 1 468 \ �\ � LBO = 967 1! — -- L_ — — J 1.0 0 . . Og 8 r�\ i N• v Z L 46& i i TO � RD 6 � Z/ __-- - - — — s 39 t 4 0 45670 S.F\ \ Z \.05 Ac \ Z\ 15 1 ' ' 1 528: r ,\ 49159 S. F. �\ 1.2 .\ 14 Sp '� \ �.� 1.13 A c. 13 \ ,�� \ - - --- 12 ® �\ \ �\ )n N 87'56'5 W 219.22'\ .o r y e , 794 S F 46.. I 10 \ ,, � � 1.07 Ac. 7 S,F\ 51673 S.F. \ � \450 2 1.19 Ac. — ""_ 4 S 1.0 Ac. s 168.42 143.76' 246.38' .4 N 88'25'46" W 672.35' 25' SHED ra W . .4