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HomeMy WebLinkAbout040-1148-50-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division t 0 INSPECTION REPORT Sanitary Permit No 430538 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Dierbeck, John & Mary I Troy Township 040 - 1148 -50 -000 CST BM Elev: Insp. BM Elev: Descriptio Sectionrrown /Range /Map No: 10L). BM D ( i yt 13.28.20.578C TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Z D /O - C2 Dosing Alt. BM g 0 7 Aeration Bldg. Sewer Holding St/Ht Inlet - 7,13 TANK SETBACK INFORMATION 7a w 1 I S Cad St/Ht outlet �• yo Tq. o TANK TO P/L WELL JBLDG. Vent to Air Intake ROAD Dt Inlet Septic h ; h Dt Bottom Dosing Header /Man. 9,y7 Aeration Dist. Pipe > _ r c nc G Holding dot. System SvLCc `(C-,a� /t — o lv.y Final Grade PUMP /SIPHON INFORMATION - 7, 3/ 9533 Manufacturer Demand St Cover 7-7 !O 1 Model Number GPM µ+ 4 --n'Tp p — Q " TDH Lift Fr t' s y hb H Ft 9 d— j :%eu W e Forcemain Length Dia. s ell SOIL ABSORPTION SYSTEM %7.a�iz ,1 J be ;k BED/TRENCH Width ', Length No. fT'renehes� 0 � RYA PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ¢ 7 / � i k SETBACK SYSTEM TO I P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: �J N o {� ih UNIT Model Number: C Z� r't3V��,► B IW.v� Suu71'V � � , J� DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pi L Dia 1 Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only ver Bed/Trench h Center Bed/Trench Edges Z xx Depth of xx Seeded /Sodded xx Mulched es No Depth COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Location: 252 South Cove Road Hudson, WI 54016 (Government 13 T28N R20W) NA Lot GL 4 Parcel No: 13.28.20.5780 1. Alt BM Description = (�6 dtt7� s� I lows �w,� �� 3•'� P C - t rt 01,1/,.1 E' u.Ctt 8� 2.) Bldg sewer length = j(p vt" � ' cCL �► fl - amount of cover 1 G5v e l I I'1.C.Q -t9vJ Plan revision Required? Yes No . 1j(� Use other side for additional informatXn lv__;_ SBD -6710 (R.3/97) Date Insepctor's Signature Cert Nu Safety and Buildings Division County N VIscon sin 201 W. Washington Ave., P.O. Box 7082 �C — . C o I x Madison, WI 53707 — 7082 Sanitary Permit Numbs to be filled in by Co.) Department of Co mmerce 3fl Sanitary Permit Appli ti State Phut LD. Number In accord with Comm 83.21, Wis. Adm. Code, pasooal in mamas you provide may be used for secondary Purposes Privacy Law, I5.00(�V U Z �0 3 Project Address (if different than tailing address) L Application Information —Plena Print All Information ST. CROIX CUuNI r FFICE I ' �-s2- �o+�Ttt IAVb ►trim. Property Owner's Name Parcel N s�) Lot N Block x Property Owners Mailing Address Property Location 4 / // City, State �yJ Zip Cade Phone Number Y., Y., Section /3 CC 0C T V N R r E� II. of Building check sit that 1 aA TYPe g ( app S _ 4 5• Subdivision Name (SAf Number AI or 2 Family Dwelling Number of Bedrooms ❑ PubliclComm rcial- Describe Use ❑ State Owned - Describe Use 2- 3 - S c ❑City [IV llage �t'owmship of �O III. Type of Permit. (Check only one box on Use A. Complete line B if applicable) \ A. New System ❑ Replacement System, ❑ TrahnmtMolding Tank Replacement Only ❑ Other Modification to Existing system B. ❑Pamir Renewal ❑Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Pettit Number and Date hued Before Expiration Plumber Owner IV. of POWTS Check an that appl Non - Pressurized In-Ground ❑ Mound 2:24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At4kade ❑ Single Pass Saari Fiker ❑ Caatructed Wetland ❑ Pressurized Ia-G ound ❑ Holdimg Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Fiker ❑ Reckculatia S tb.hc Media Fiker ❑ Lesching ❑ Drip Line ❑ Gravel-1 ss Pipe ❑ ( lain V. Dis rem t Area Information: Design Flow (gpd) Design Soil Application RaWgpdst) Mspc=l Arca Required (sf) Dispersal Area Proposed (af) S Elevation VL Tank Info Capacity in Total Number Mamubcturer Prabb Site Steel Fiber Plastic Gallons Gallons of Units Concrese Constructed Glass New Existing Taub Tado Septic or Hording Talc gv Aerobic Treatment Unit Dodag Chamber VII. Responsibility Statement - 1, the undersigned, assume tespo slbility for installation of the POWTS shown on the attached plans. P ber's Name PHtm a Si MP/MPRS Numbs Business Phone Number Plumber's Address (Street, City, State, Zip ) 4 - A S , JAI . /- 6,1DSC> 1 VIII rtment . Cous a UUseOnl V Approved ❑ tmentved Sanitary Permit Fee includes Gtotmdwater Date Issued Agent Si Staamps) Surcharge F.) ❑ Owner Given Reason for Denial 2 5-0 — �-y� v — X . 1 DL Conditions of Approval/Reasons for Disapproval L SYSTEM OWNER: 1 Septic tank, effluent filter and S 5tL� dispersal cell must all be serviced 1 maint tal ed � �Q� e� G�taC��°►^S as per management plan provided by plumber. 2. All setback requirements must be maintained T C,,_ 1) • �/q Z I as per applicable code /ordinances. Ji �XS Att-h complete plant (b Ow Coaaty aaty) fir tie syslem a paper lets mina :11 taehea b als SBD -6398 (R. 08/02) ►�E�rc s 0 >�/►�no.J q PVC �tFNUr�x / ,�► E P►P p taiE5E45crr cTiw ES �.�+ 3 R °c�f3ae /ac G� 4w A•t� t �t��rnT �`s��� � e,,,FJr �•�E PLOT It CROSS SECTION PLANS IAPPA 6805. EXCAVATMrG IM CREn T ENCNFS ��pRt .. PRA�CT � - So"rIt �ovl� oq0 • � �o`�o� WN OE O 'Sr L'Qo ix &Pc" G ,a.j C 4jp S .a 00 Q d �E • /r � C�� :R oA-0 S C��ALE S N6� 1 /� Ew — DresE� ..�n�.► Po ©bS�Q�I rkT, 0,#j o 2 slowed: VEN r e-/AP U cENSE: N cs�G DATE: / /iMC►MAM �XI ISOd� y�pl. eptM JO P�E Gf{rkMh� TEST", BV: The Standard Ini ilti for Chamber 1' Overlap at Latching �" T Etc ff 6 0-�0», �t�v Pie Sac Est fir "`; to SrDE. View 75' CO PY Effective Length �IE�J'C 2 ��- "�P1►Jj°R10� q,, PVC PIP&6 �.� 3 R�cElMri /'So eon WIESE4Se�T�GTiwIC �I, •Z at A•t o &*r<Et r- �,eryt bite � �� ...P� d • - 5"", A'.1E PLOT & CAM SECTION PLAM DE ZAMA OPM. exCAVATM INC UW C fb�r18ot T �NO�S p � V Rjf pR , , , f .. PIF"CT moo' 8 � � P �pa WN of O -5r- L' o IX 64M AIrle s�• � 4 9 L �. K, !J f 1. (� A ES Alo S SCALE P Air 06.544 k-rj ow) oft SIGNED: VfN r e-A UCENSE: aw Abwc 1�4rs 6e DATE: /Y� r wi a�n 9iG ° i� 6o df y Ale 'ge A io P.Af c srr a ,gnu TEST" BY: The Standa d Ini i1b ator Chamber " 1' Overlap at Latching TF�JcH Bo �� d ��► oiq Sovc�EsY 1r m� 0 s�v V yew 75' Effective Length POWTS OWNER'S MANUAL & MANAGEMENT PLAN fags _I of . FILE NrdONAATION �� � MC p � C� n Capacity 1250 DNA dJ t � ic Parnuit d 3 0 Manufacturer Wieser O NA DES16�1 PARAMETERS Manwfacturer Zable O NA Number of Bedroom 4 O NA EffNnMt Fdter Modal A -1800 O NA D NA Number of Public Facility Units *3ddA Pump Tank Capacity Estimated flow IaVaragel 400 Pump Tank Manufacturer m NA pesign flow Ipeakl, IEnimeted x 1.51 600 w&dw PUM Manufacturer M NA Soil Application Raw . 7 adhis / Pump Model D NA Standard kofluett/Effkrent OuaEtY Monthly average' Pry Unit DNA Fan, Oil A e ngage IFOGI 00 ing& o Swd/Gmvd Filler O Put Filter giochennical Oxygen Demand (90Ds! 5220 mgfL •O NA O fllechaeical Aeration O we"Id Total Snspwww Solids Mw 51 so MO& D Disinfection O Oliver prwesw Effluent Ef cent O.usW Monlw were" OaPersal CelNsl O NA Biodwnical Oxygen DwvwW 1900 00 nV& O ln-c red fgrev" O kWkound (pressoraed) Total Suspended Salida Mw x80 f*& O NA O At -Grade O Mound Fecal CoGform 49so netric mean) x10• ciWl O orwUne O Other: Maximum Effluent Particle Silica Yes In nor. O NA 611w. 0 NA Odwr: 10a1A dies° R NA • Vskm typical for doinaft wwwwatar and septic tank of lucent. ®NA MpW iiMIANCE SCHEDULE Service Event Servbe Fre4wncll O inspect condition of tank(:) At Mast once eVary: 2 0 years) O NA pump out contents of tanklsl when combined sludge and arum equals a�athitd IYaI of tank volum O NA Mspect dispersal 0911181 At Meet once every: 2 a q vM IM P alouse 3 1 O NA At Mast once every: l• 1 DNA Chan effluent fitter . Inspect per, pump controls A alarm At Mat once every: O) 1 ! m ®NA Fbslt laterals and Pressure wet At Mast once every►: O el 0 moruthlsl NA Odwr: At Mat once ovary: odw - NA MApdTENANCE NIItiTIWCTION'S or owdficadon inspections of tanks and dispersal cells shah be made by an Wiwi" carrying one of the following fioenees s: Master pkmlber. Master nwnbw Restricted Sewer POWTS Mepecwr POWTS Maintainer S's~ Servicing Oparater• Tank inspections must include a visual inspection of the tanklsl to identify m y at broken ��' ida11 nt► a rxscks of Mika. up or p04 masers the vokrme of combined sludge and scum and to dwck fa any back a0 of stlknent on the surface. MvaM in the observation ponding The dispersal W shah be visually meted to fleck the affluent , af a and to dneok and my of efpuent on the ground surface. The ponding of effluent on the ground surface may Indicate a faiNnug condition and requires dw krmsdiate notification of the bad regulatorY audwrity. When the combined accurnukM n of sledge and arum in any tank equals one -ftd IYsI or more of the tank vokMne. the attire contents of live tank shay be removed by a Sptp Servicing Operator and disposed of in accordance with dopter NR 113, Wisconsin Administrative Code. All other services. including but not limited to the servicing of effluent fihas, maohaniCal or PMUMW eoomponents, pretreat w" units. and any s rvk** at intervals of 512 nronths. shall be pwfomwd'bY a 0 - dfwd POWTS Maintainer. A service (Spot shag be provided to the local roguMtory authority wMM 10 days of conpletion of any eerwce everts. GQAW 1011 Palle -� of . START UP AND OPERATION use of the POWTS check treaennent tanklsl for the presence of painting products or other chemicals For new Impede t Prior and/or damage the disparsa ceg(sl• If h� concentrstuons are detected have the contents of the tank(s) removed by that may impede the matmeht operator Prior to use. ' a ppta9e System start up shall not occur when ON conditions are frozen at the infdtrativs surface. 111 restored the excess wastewater will be During Pow outages pump tanks MW fill above normal highwater levels. When power discharged to the dispersal CAW in one klrge dose, overloading the ceN(s) and may result in the backup or surface discharge of effknent. To avoid this situation have the contents of the pump tank removed by a S904211e Savant Operator POW to r estoring power to the effkieht ptrnp or contact a Pkrnber or POWTS Maintainer to assist in "WWAy operating the Pump controls to restore normal levels within the pump tank. Do not drive or Park vehicles over tanks and d' drive or park over. or otherwise, disturb or compact. the area area. within 15 feet down slope of any mound and Prolong the we of dN Reduction or elimination of the following from the wastewater stream may i ft , d diapes; disinfectants; fat; POWTS: antibiotics; baby wise; cigarette butts, condoms: cotton agreasers • fruit and vegetable pa�ga% gasoline; grease: herbicide.: meat scraps; medications; oil,- foundation drain (sump Pump) water, t ampons ; and water softener brine. painting products; pesticides; �� ��' ABANDONMENT taken out of service the following std shall lie taken to insure that the system is When the POWTS fags and /or 19 P wan* ch C 83.33. Vlfiscot>sin Administrative Cade: properly and $afely abandoned in to tanks and Pita shall be disconnected and the abandoned pipe OPSWO 9a wait- • All piping disposed Of by a Servicing pperator. • The contents of all tanks and Pits shall be renoved and property • After pumping, all tanks and Pits shag be excavated and removed or their covers removed and the void space filled with soil, gravel or another Inert sore nhateial- CONTINGENCY PLAN sure. haw been, or must be taken, to provide a code compliant if the POWTS fags and cannot be repaired the following mea re placement system: d for the location of a replacement sod absorption �[ A suitable replac "Ott area has been a pm ated and may be utilize a Compaction and should not be infringed UpUpon by system. The replacement eras sho uld be structure from distur MW and wells. FARM to protect the replacement area Will required setbacks from existing and prof am. Replacement systems must result in the need for now S an a aft e valuation . to establish s suitable roP comply with the rules in k and/or soil gmitations. Barring advances in POWTS Q A suitable replacement area is not aysikhble due to setbac an technology a holding tank may be instaW as a fast resort to replace the feted POINTS. to identify a suitable replac~ am Upon failure df the POWTS a $ON and site Q The site has not been wabated locate b a sutsbk,replaownnent am. If no replacement area is available a holding tank k mn instated W as a last to replace tine failed POWTS. may s �� msY be ��� in place f removal of the bieromat at the Q Mound and at-grade soil absorption much com ply wide the rules in effect at that time. infiltrative surface. Reconstruc of such system < <WAMWG> > S MAY CONTA LETHAL GASSES AND/OR WSUFffIC1ENT OXYGEN. DO NOT SAC. PUMP AND OT• PUMP OR OTHMI TRE ATMW TREAT TANK IN TANK UNDO Ally CNRCUMBTANCEB• DEATH MAY RESULT. RESCUE OF A ENTER A SEPTIC g� pgR80N FROM THE OR OF A TANK MAY BE DIFFICULT OR MAPOSSN3LE• ADWTIONAL COMMENTS pOWT8 MAINTAINMI POVV'fS NYSTALLER Name o t Ben Mor an Name oth ) Phone 715 - 386 -2 Phone 715- 386 -2850 LOCAL REfiULATORY pUTHORRY gEpTAGE SERVICING OPERATOR (PUMPER) St Croix County Zoning Of f e Name Name Tri County (Ben Morgan) Phone 715- 386 - 4680 Phone 715-386-21 V A�lrtratiw dodo. Thft docume nt was drafted in cOnVOW ce with chapter Comm 83.22(20111140(f) and B3.541f1, (Z) 8 I31. DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR HUMAN REDLATIONS PERCOLATION TESTS (115) MADISON W 53707 G - tDT (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHI MUNICIPALITY: OT NO.:BLK. NO.: SUBDIVISION NAME: y 1 / 13 /Tz8 N /R E �Y - _ 14 a, P1 60 COUNTY: MAILING ADDRESS: 3 $ ?-Cott, $ ST•G�tJ1X BR1�R oA`ICS ���� -OARS �FT� N 1�'t (v SS�a I USE DATES OBSERVATIONS MADE NO. BEDRMS.: I COMMER IAL DESCRIPTION: I PROFILE DESCRIPTIONS: PERCOLATION T7. Residence 7�1 >v , A" IRNew ❑Replace q — S- 9Q) 1V - A . RATING: S= Site suitable for system U= Site unsuitable for system CONVENTIONAL: II� MOUND: IN- GROUND-PRESSURE: SPS TEM -IN -FILL OLDING TANK: RECOMMENDDED SYSTEM: (optional) E s 5u O S EIu ®S E1u EI S EA EIS a If Percolation Tests are NOT required re DESIGN RATE: CL q N$ S Z If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: o• GRL /SL4 r p?)Y F i ndicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROU NDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- > 86 Qr, S Nori►L > $b f B- Z 83 QS.o > g3 i B- 3 g S ':�2 9.-S '� > S Z `� B - 4 aV lo�.Z > gy � Z .y B- S 83 °lS.S > g3 30 / B- PERCOLATION TESTS TEST DEPTH , WATER IN HOLE TEST TIME D I WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PERT D2 P PER INCH P _ P- P- ISM = S L 30"t - tic S P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation — at�all borings and the direction and percent of land slope. �pT�}� CF C 8 l fit, P"O M j=l SYSTEM ELEVATION 6 = ' 3 ti�.j>.'nm' E $ :. L .i t F ; ? 1 ,. T3 _ 30 E g1 ep , SCPCL.(�Z7 I It = �iO I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): A O TESTS WERE COMPLETED ON: 1 4- S -90 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): cs i ouo S (a I , ) ) S -VZS- 8i6 S RIVER FALLS WI 54022 CST SIGNAT RE: 715 - 425 -0165 z2a DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. C, ff DILHR -SBD -6395 (R. 10/83) — OVER — INSTRUCTIONS FOR COMPLETING FORM 115 - SOD - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use section must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; 8. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number;' , 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols st — Stone (over 10 ") BR — Bedrock cob — Cobble (3 - 10 ") SS — Standstone gr — Gravel (under 3 ") LS — Limestone 's — Sand HGW — High Groundwater cs — Coarse Sand Perc — Precolation Rate med s — Medium Sand W — Well fs — Fine Sand Bldg — Building Is— Loamy Sand > — Greater Than 'sl — Loamy Sand < — Less Than '1 — Loam Bn — Brown 'sit — Silt Loam BI — Black si — Slit Gy — Gray cl — Clay Loam Y — Yellow scl — Sandy Clay Loam R — Red sicl — Silty Clay Loam mot — Mottles sc — Sandy Clay w/ — with sic — Silty Clay fff — few, fine, faint 'c — Clay cc — common, coarse pt — Peat mm — Many, Medium m — Muck d — distinct p — prominent HWL — High water level, surface water Six general soil textures BM — Bench Mark for liquid waste disposal VRP — Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. Thesanitary permit must be obtained and posted prior to the start of any construction. f i SOIL DESCRIPTION FORM Attach Soil Prot ile Location Map a Su arato Shoot) Clj T 'Ba !J Nm s 'D�y 11►pL"12 S LINEAR LOADING RATE: 0 PURPOSE: tV A LVA S- S ED'�JtM S `'! S SLOPE: DESC RIPTION BY: ASP S 6 V uT"J DATE. (— S l q q O CURRENT LAND USE: woo t s COUNTY /STATE: S� C U1X Cc)UNYy L�J VEGETATIVE COVER: Q�u G"s S LOT DESCRIPTION: 1:5\ OF G'L- SAC 13, T Z41 1J- [ Z10W DRAINAGE CLASS: E>< C�gslU b R -h .4$ LOCATION: TW OS ) d I _ - rV4 - QLt GALLONS PER S . FT. PER DAY: 0 PARENT MATERIAL s / EPTH: GLf<< pvRnlliS SOIL SERIESt ly! HORIZON DEPTH MATRIX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CLAYSKINS/ PORES ROOTS PII BOUNDARY REMARKS moist Gr. Ss. Sh COATINGS y /t/ - S ) M Sb1t ri► V H Cw - 3 in CLS Z �_z.s 7.SyR S// - ) S 1 �Tshlt my ►� C`'` cos ►n l 1 s i s rn v H 3m a-S �.SYR Y! - - ):s ) m S) h. m U 3 Zs_8s .s yR yi O - 1 b`9� Z! ) 5 5 . In v'F1 •S k Y! S ) In Selz )n\) mvp blip-z / i — l s fit 7n u'Fr 3 k, �S o s rn I OTHER SITE FEATURES /NOTES: LIMITING FACTORS /DEPTH: Signature Date CST M L WRIZON OEPT11 MATRIX COLORS MOTTLES TEXTURE STRUCTURE CONSISTENCE CCOAi1NGSS/ PORES ROOTS P1 BOUNDARY REMARKS in. nnisl Gr. Ss. Sh OTHER SITE FEATURES /NOTES: nhGE_ oF_ Signature Date CST # LIMITING FACTORS /DEPTH: 1 =•`?Fl�i La - Cd HIMeS n . ;7 '36 667-- ac t OCT -31 F'RI 02;57 ?M HERITAGE DEVELOPMENT FAX T. 051 481 1518 ?, 02/02 1 -03i 7. =VFlPM ;Land <i atl NnmRS Inc. i�t$ 38d (1 78 y! • Z/ A 3$6 --o3Z3 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CFRTTFICATION FORM V , UwrterlBuyer eih � f� n h � V (. � I l e � Mailing Address D PD zt Go cToz Vim CIE' Property Address O (ove A d,,i � Q (V'erificattoA required from Planning DcpsrSmeat for new construction) City "State Trrly. VUT i - 5 . 0 Parcel Idantificatioti Number �� Q I,)'<GAL DTSC'RIPTION Propctty Location t /, A, Scc. �3 , T 2&N R ZV W, Town of -� D Subdivision Lot # Certified Survey Map # �- -- —� . Volume . Page # , Warranty Deed # 1 t D P 2 9A V -0lunw ...� Page # Spec house ❑ yes C1 no Lot lines identifiable 0 yes I$ no �STittNVll't♦rAiMt'�'tyeNC� , hVr oper and maintenanceofyow nt se p tics y aleeou tdresultisitsprematurefa ijutetobaad tewastes.Prop consists of pumpi put the septic tonic eYey thmG yearn or sooner, if needed by a licensod 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 &9"'s to s to St. Croix Zoning Dapulmcat a certification fotm, signed by the owr>cr and by a masterP +�,lot►tneyatanplumber, restricted plumber or a UceasedpurgperYw*inI; that (1) the on-site q rastewYterdisposal system is in proper operating condition and/or (2) after inspection and pumping (ff necescsty), the septic tank is less than 1/3 fiW of sludge. I/W the tandersitacd have read the above requircanntts and agree to tsuintain the privata se w ago disposal system with the standards setfortlt, harem, as set by the Department Of Commerce and the Depatlmentof Natural Resources, State of Wisconsin, Cettilleatioa stating that your septic system has been =ktained must be eomplered and returned to the St. Croix County Zoning office within 30 days of the dues year expiration date. AP ICAN'C '�--- DATB OWN .A FRTIRICATro� I (we) certify dIst all statements on this fern are true In the test of my (our) kmowlcdge, I (we) am (are) 1110 o.vner(s) of : U 1 4 property descri above, by vi of a warranty deed recorded in Register of Deeds offrce. l+IA1 APP ICANT L0 3 �j DATE Amy information that is tnis- represonted may result in the sanitary permit being nvoke,3 by the Zoning Department.' *• «•* ** Include with this applicalloa: a stamped warranty deed froth the Register of Deeds office 2 copy of the certified survey map if reference is made in the warranty deed 11- 7 G_; _ f,f +1; L 5'....°- red - IGmes nC -. ,71S 2e6 6678 aF V 19021' 2oa STATE BAR OF WISCONSIN FORM 1- I m WARRANTY DEED KATHLEEN N. kALS6 Docammt Number ST`� ICROIX CO., DE EDS This Deed, made between Gary &a velq a Kathleen Savela, RSCSI YED FOR RECORD husband a nd wife - — 06 -03 -2002 9236 AN VARVI11EED 8 ' D Grantor, and John J. Dierbeck and Mary C. Dierbeck, husband and EXOT wire REC FESt 11.00 TRANS FEE: 323.66 COPY FEEL CERT COPY FEEL Grantee. PABESt 1 Grantor, for a valuable conslderadon, conveys to Grantee the following described real estate in St Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Anea Part of Govemrnent Lot 4 of Section [ 3, Township 28 North, Range 20 Nluac etd Return Address West, 5t. Croix County, Wisconsin described as follows Commencing 488.7 feet North and 66.0 feet East of the South Quarter comer of said Section 13; thence Nly on the Ely line of Cove Road 3'0.0 feet; thence N48 °40'E 210.5 feet: thence S43 292.0 feet; thence S6 ( °l5'W on the Nly line of the Town Road 408.0 feet to the point of teomirg. 040-1148-5o 5�$c- cation Number Tkit homestead property. (al) it nc Exceptions to warranties: Easements, restrictions and rights -of- -way of record, if any. Dated this - 31 day of Nay , 2002 — T • ltleeg Savela AUTHENTICATION ACKNOWLEDGMENT Signature($) STA OFWISCONSIN ) as. County ) authenticated this - day of Personally came before me this day of May 1 2002 the above named tL hON, Gary Savals and Kathie Le a Savela husband and wife TITLE: MEMBER STATE BAR OF WIS — (lfnot. m o t be the person(s) who chiecIpted the foregoing authorized by § 706.Ob, Wis. Slats.) knowledgedtb THIS INSTRUMENT WAS DRAF ?Y Anorner Krtstiga Ogland _ Notary Public, State of Wis Had son, `' My Commission is perman%txwn state expi� { (Signatures may be authenticated or acknowledged. Both are nat necessary.) •) • Names otpenons signing in any capacity must Sc typed or printed below then signature. HawaGrn Fiores,lanWsC ewy. Fuca d, tee m STATE BAR OF WISCONSIN emasszott WARRANTY DEED FORM No. 1.1999 I 2 564.83 / \ \v im rC " • 1 � � 48 3 p- % 3 432.31. 6 1 i O E i 749 N LOT I - _ _ 4 _ � � P '" LOT I O 576 F 50 l / 2$, 426.41' 5 3.81 - 4 904 / a s . Q . 1445.70 N 751 I o 1 ` �; ' 0 0 6 24558 Z` J S 7 6 C LOT 7127.8 752 753 576 D 2y 5 LOT 2 Q 576 f 248.80 �,• ' Q 67 / 246.80 37 ` c 453.33' _ — r i � c - 3 694 2591 o 36 I� I 69,3 o cs 275.so 3.9 578 D 578 E 692 20 C I (' 34- 0 i `may r �, v GR 28 9.3o 33 690 32- _ M_'"/VT L O T 6 89 0 - -- o� m 2 ; _ 313.70 3 688 o I � 578 C 578 B I i. 340 •. 3Q � � � 687 0 olj -r►i / 36220 I / 5 78A ' n 1740 3 9 .656 -�--� 3 g5 .62 659 A 659 695 - _ 317.35 �p 70 4 661 38 — - — — 301.72 S 1 4 COR. SEC. 1 3 ut= r #Ul MEN f OF I "P ORT - Oft Oft SOIL BORINGS AND SAFETY &BUILDINGS - IN . RLUMANA "° PERCOLATION TESTS 115 DIVISIC H a HU RELATIONS • � � p•4. OOk >gs9 G vu - \.bT 1 .1 U LHR 83.0911} & Chapter 146} MADISON, WI 53707 L 1 W M ICIPALITY: .: SU 0 I N NAME: '4 t 3 / Tzs N/R zo E (o `�- 4y — \hx. 4 R 1 1� 6 09 COUNTY: A N 3 q 8 ?-I U eZ R(Ior $ USE DATES OBSERVATIONS MADE Residence I . WNew ❑Replace y,- rj 91Z) Ps RATING: Be Site suitable for syeum W Site uttwitabb for system ONVEN A ; M fiJN ® IN• tl •FI L A I ACCOMM ND D lrW11TIOAdoptionatl S U CIS ❑U 0S ❑ - U S S l 2.`x79 r cU>vvelu`ntw�c. eta If Percolation Tests are NOT required DESIGN RA : a % _tr `$ Z [ FIbodplain, portion of the tested area Is in the S under s. ILHR 83.08(5)(b), indicate: p.tm SAL, �. Indicate Ftoodplain elevation: N 'tom• ELE PROFILE DESCRIPTIONS_ eORFNG ERD •i ' C M A 1 I NIX .'WEW X{R�, AND DEPTH NUMB: EPTH.d:N, VATION O ASSAY. ON'$ACK_ a �• 1 S6 > $b S L�e l'I�GLZ 2 0� Z B. z $3 10 1i S,o g3 1/ .. B. 3 %S g 9• S B- Y 101• Z - v > 8y fr B- ;, PERCOLATION TESTS TEST NL"ER INCHES AFTER SWELUN I L•MIN. RA MiNU E PER INCH P- N P P_ 1Jtt"CL' = S L 30tr t 4 L >p P• P• P- PLOT PLAN. Show locations of percolation tests, soil borings and the dimensions of, suitable soil areas. Indicate sale or distances. Describe what are the hori- zontal and vonical elevation reference points and show their location on .the plot plan. Show the surface elevation at all. borings end the direction and percent gt_iendsloprr cs�C' Ui>�: AAA "RGe Attic oii Q. 4 1'.S . SYSTEM ELEVATION - 2 6 = I . Y _ h AVS 'Co der i D t bR11��FtrC't.�W L: 7U Ii _. _..._. _.-4 ,.�_. __ __ _. ___ k3 S . we tt�c.ti " � _ 1 _ - 1 k I i sca Pcl- e I IL C r - __ . _...._._ _ ... _......_ - S em , 's 1, the undersigned, hereby certify that the soil tests reported on this form wort made by me in accord with the procedures and methods specified in the Wisconsin Adm,'nirtrati.,a Coda, and that the dace raeordad and the teeotian of tho to*** aro eorraot.to the bast of _V 4r.awl.d4. and lao1:�1. NAM (print l'. WaGr AND S W RE C MPLETEO ON: Y_ S-90 AOOR CERTIFICATION NUMBER: IPHONE NUMBER (optional): ca ouo S �� S -VZS- 0/( _S • S S A . RIVER FALLS WIC 54022 715-425-0165 DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester, DILHRSBO -6395 (R. 10/83) — OVER — y SOIL DESCRIPTION F" MpOSE: �V h t_�A TI~ R S tve:"R S S IM IPiTON BY L. W+`6�R ASPE CT: pAT .t S, 1 g g o . Tw11N>m.Jag: CawlY /S1ATE: ST Cl2UXK CtlQWW , l.-J }, y €4lrt iye 0MR: S L ot 0001M ON lz atr 4. L. Y S+~C.. l T7AM, 1- G e..r. Z�>< da$4I UZI-L/ I`j Gta PEA .PER DAY c7 - PARENT iE Al Gt.ttL'� sDIEfi L.1�11V �1(`�L 1iGR[1W1.. OEPIiI MATRCX COLOAS "MOTTLES TURN SIRNCTURE ::. GD4161 " CLAvtKCMS/ POAES ` Awls -' mi .90LII my Rwms I a�. VsOTt N6 o- 6 I t l SZ 'L / I s 1.. bk. )Y� V %- 3 fi ct, s Z 6 _z3 -).syiz Y/ -- 1 s M b vn v I. _ S ►�'1 `.t3ej 1NG Z o M v in ct.s Z - �_�.s '�.StiR C/ - IS 1 ms my H `L�J 2S -$3 s it vie t yug S CU. m 1 �— L� - I o 1 O �•I A 2.. / -� � S 1m U � c�.s h sbtt )n v h C w 1-S_8S •S-ilt y/ — }r�a:8 S o S Yr1 z - zG stiz W/ — 1 s l.In 5m , v y/ y s m 1 mia 5 !wlp- Z.l1 — 1 s b M v'�h 0.1S Z > - •Sy Yf - I I S V4 M v l- cK.. ag- sbtt Yly 5 O s OTWA SITE FEATUMSMOIES: �' -S--9 o oc,s - � (, LIMITING FACICRS /OEPIN: SiyntiuTy ate CST Y �--- I - F rv' EXHIBIT " At, Part of Government Lot "4" of Section 13, Township 28 North, Range 20 West, described as follows: Commencing 488.7 feet North and 66.0 feet,East of South Quarter corner of said Section 13; thence Northerly on Easterly amine of Cove Road 270.0 feet; thenc&'N48 210.5 feet; thence S43 292.0 feet, thence S61*15 "W on Northerly line of Town Road 408.0 feet to the point of beginning. St. Croix County, Wisconsin.