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HomeMy WebLinkAbout042-1024-40-200 § to ° 0 2 E 0 ) 0 c n % $i�%ta o� 22to \ c Q7 a §) q E Eiq 0 4) (P ms s �. c /G $k(}/ ; eEbc= ■ a Eci ® 222822E moo• /,a2 kk�) -oo> z ; 2$CL o 22 0� o 0 -rs- 2 LB . 5; ' (aoc\ <�20D0 « � § � CL CD § % © # § k } U) k 7 2 2 ) ) ƒ\ � � � k 9 } k \ k \ CL m = ) LO .. 0 R ) E E a a 2 2 & 2 a E % Z C d Cl) b k % k $ a a a R - \ r Cl) 2 j v 2 8 8 2 0 $ / >- I Q Q § E $ o o @ a ) <kJ ) ■ � § � ° � § o o a ■ @ q 2§ a -- 0 E a q& ( D § I E / 7\ C f C ) I f 7/ � & q § 8 / E § 2 2 £ 3 ) / � ■ � a EL E to� / 0 a & k . Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 420709 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: Nelson, Gary Warren Township 042- 1024 -40 -200 CST BM Elev: Insp. BM Elev: T Description: Secbon/Town /Range /Map No: CST BM Elev: Insp. BM Elev: 09.29.18.138A30 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet SttHt Outlet TANK SETBACK INFORMATION 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 BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. 7 uid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG IWELL 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) Length 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 Yes [� No ❑Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 1021 110th St Roberts, WI 54023 (SW 1/4 SW 1/4 9 T29N R1 8W) NA Lot 2 Parcel No: 09.29.18.138A30 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes E No Use other side for additional information. SBD -6710 (R.3/97) Date Insepctor's Signature Cert. No. Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Cr Safety and Building Divi fon INSPECTION REPORT sanitary Permit No;--- 420709 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: f Nelson, Warren Township 042 - 1024 -40 -200 CST SM Elev: p. BM Elev: BM Description: Section/Town/Range/Map No: 1 0c) . T 09.29.18.138A30 TANK INFORMATION ELEVATION DAT TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark b-n 7 05 / 07 CC loo d Dosing i-t Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet J TANK SETBACK INF St/Ht outlet y 0 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic r `_ Dt Bottom Dosing r }� s 7 O / HeaderlMan. Aeration Dist. Pipe Holding Bot. System 7 Final Grade PUMP /SIPHON INFORMATION b S Manufacturer V4 ED / / De and St Cover Model Number / �� ` �i TDH Li Fri ti n Loss System Hea T H Ft T sa s Y Forcemain Lengthy I Dia.W r i I Dist. to Well \ SOIL ABSORPTION SYSTEM l ONS BED/TRENCH Width�� Length No. Of Trenc r PIT Dl ENSIONS N6. Of Pits Inside Dia. Liquid Depth DIMENSI ETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manuf ctur r: c ,� \16 rvvkh� INFORMATIO Of Sys�err�:� -__ CHAMBER OR . Jd / UNIT Model Number: DISTRIBUTI Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake I I ( Pipe(s) �-- -- 7 Length_ 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 _ 5 �� Bed/Trench Edges Topsoil ^� Yes No � Yes ,m��a�J No 1117 COMMENTS: (Include code discrepencies persons present, etc.) Inspectio (#1: / / 0 3 Inspection #2: ! / Location: 1021 +11 0th St Roberts, WI 54023 (SW 114 SW 1/4 9 T29N R18W) �Lot2 Parcel No: 09.29.18.138A30 1.) Alt BM Description = V ►jl OV1 — ]e� ` yy2��N+Lp�' 2.) Bldg sewer length =4930 A (_ �� 1,�a YS W (*1 - nShj 1 Q 8 d U0 1 (\S JYA 7RA • - amount of cover = \ 3U " (,y 1 � Sic M l D A nd d/,W Plan revision Required? Ye Lial No Use other side for additional formation. /0 SBD -6710 (R.3/97) Date Ingepctor's Si nature Cert. No. Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 r/SCOOSIO Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by .) 4e artment of Commerce (608) 266-3151 6 Sanitary Permit Application State Plan LA. umber P In accord with Comm 83.21, Wis, Adm. Code, ersonal information you provide may be used for secondary purposes Privacy Law, sl5.04(1)(m) Project Add ess (if different than mailing address) I. Application Information - Please Print All Infc rma R E CEIVE D roperty Owner's Na a Parcel # Lot # 81ec1F�l SEP 0 8 2003 Property ner's M ailing Address Property Location ST. CROIX COUNTY m13 Y - 3v ZONING OFFICE t-A < f ti,, Section � C ity, State 1 Zip ode Phone Number 1. (circle 2w) II. Type of Building (check all that apply) T N; RB or Subdivision Name CSM Number A 1 or 2 Family Dwelling - Number of Bedrooms ------ ❑ Public /Commercial - Describe Use ❑ State Owned - Describe Use ' C? t ❑City ❑vill geo Towns hip of III. Type of Permit: (Check onl one box on line A. Complete line B it applicable) A. XNew System ❑ Replac ent System Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal Vermit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: (Check all that apply) N - Pressuri I n- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil, ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter Leaching Chamber ❑ Drip Line Gravel -less Pipe ❑ Other (explain) V. Dis ersal/Treat ent Area Infor ationc ' Design Flow (gpd) Design Soil Application fa e sf� Dispersal Area Required (so Dispersal Area Proposed (so System Elevation VI. Tank Info Capacity in o I Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units �j f Coo Concrete Constructed Glass New Existing / Tanks Tanks r ✓ Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber _ I il L. S VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumbe ' Na a (Print) Plumber's Si na a MP /MPRS Number Business Phone Number ✓) Plumbers Addre ss (Street, City, State, ip Code) VII ount /De artment Use Onl Approved ❑ Disapproved Sanitary Permit Fee (includes Gropndwater Da Issued Issuing A t Si Stamps) (Ila J Surcharge Fee) C ❑ Owner Given Reason for Denial 5� / IX. Conditions of Approval /Reasons for Disap roval Attach complete plans (to the County only) for the system on paper not fts than 81/2 x 11 inches in:lu �`�� SBD -6398 (R. 01/03) v� a C 1� f I PAGE of PUMP CNAM15CR CROS5 SECTI A FJC) SPECIFICAT(OKS V E WT CAP 4� VENT PIPE WEATHERPROOF /►PPItOVLC LOCKING rF7 I JLIQ aox MA►JHOLE CovGR WIrK 25' FROM DOOR, Tr WAWING LABEL WINDOW OA FRLS14 I1. MIU, AIR INTAKE — i i.RADC I y" Mlu. — T c 0 ki D U I T - - - - - - - - - m- � 1 8'MIIi. PRov;D - - -- IAILCT -T AIRTJ. 1iT SCAL I LEI V I APPROVED JOIUT A ` i i I APPROV' DE01�:' W/ PIPE CXTENO uG a' I II ALARM ExrEUDllac, s' 0►JTO SOLID SOIL I I I O►J70 SOLID SO' d I I I I f O . C I f_LCV. FT OFF PUMP b 0 GOUCRL "TC CLOCK RISCK EXIT PcRmiTrED OIJL`J IF TA1JK MAQUFACTURCR HAS SUCH APPROVAL 5EPr1c f 5PEC.IFICAT101JS DOSE ) TA►J►(S MALIUFACTURER: "' C IJLLM.L`C:R OF DOSC5: - PER DAM TAWK SIZE: -- GALLOWS DOSC VOLUMC /CDs ALAKPA1 MA►JUFACTUR,GR INCLUOI►JG DAGKFLOW: GALLON! WUM61K: " "q/ 'Vw /�� -� // CAPACITIES: A= c � 1►JCNCIOK s"g� GALLOU; 5`,41TCH TYPE: � � - • -- B =_ I ►lCNES OR 3 yZ GALL01.;' P JMP MAUUFACTURCR: _ G n IWLNES OR LALLO�;:, ` MOOrL UUMDEK: !�1 : L - 0- INCHES OR L7� GALLDU SWITCH TVPC'> �- ,�. /`n fly %� 1.1 PUMP AUD ALARM ARE TO DC h11►JIMUM DISCHARGE RATE PM 3s` G INSTALLED OW SEPARATE CIRCUITS g / VERTICAL DIFFEKEWCE DETWEEU PUMP OFF AUD D15TRIpUTlow PIPE.. _ FEET / + MIr.11MUM NETWORK 5UPPLy PRESSUR . . FEET y ��J } _ Of FORCE MAIfI X /io nrt,FRtG;IU�I �ACrow...��_ FELT TOTAL Oy1JAMIC HEAD - ,C6'2,fl_ FECr IETER►JAL nIME1J51oUJ OF TAWK: LEI I _j1r(ID'(H - �LIQu10 DEPTH _ ti �IGIJEDI�. .�� LICEIJSC �JUMI�LR: c DATE: Performance S ubmersible Effluent Curves P u mp s METERS FEET - 00 25 MODEL 3885 so SIZE 3 /4 Solids W 1 15H E10H 70 1 20 yy 60 p •WE07H• — 15 50 1 WE05H 40 10 30 WEOOM y WE031. 5 i Kz/ _ 0 0 0 10 20 00 t n0 50 60 70 80 90 100 110 .120 GPM 0 10 20 30 m'/h CAPACITY [CGOULDS PUMPS, INC. S8*CA FA" *W 1M 13W O METERS FEET 120 ---- - M 0 D EL 3885 35 — - — - SIZE 3 /4 " Solids 110 WE15HH 30� 90 26 60 it 70 601 _ j 0 60 � • WE08HH t5 40 14 1 1 10 20 _ 5 10 0 L 0 0 10 20 30 40 0 60 70 80 90 100 110 120 GPM 0 10 20 50 m'/h CAPACITY • 1986 Gould$ PUMPS, Inc. EMOOVY0 July, 1985 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of 1-55 Division of Safety 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 Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Govt. tot 11� 114 S T N R (or Pro pert O is ailing Address Lot # Block Subd. Name or _apd#!; City Sta Zip Code Phone Number El City ❑ Village JA Town Ne rest Roa ( ) New Construction use: 54 Residential / Number of bedr Code derived design flow rate ��JZt GPD F Replacement Public or com e l t e : Parent material G Flood Plain elevation if applicable ft. General comments E� O $ 1 03 IvA and recommendations: ST GN�16 �FFiCE F/ I Boring # ❑ Boring Pit Ground surface elev. �_ ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 44 ,3 s Boring # ❑ Boring ® Pit Ground surface elev. Depth to limiting factor ? &FJ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Cal 7 S� 5 ' * E uent #1 = BOD > 30 < 220 mg /L and TSS >30 _< 150 mg /L ffluent #2 = BO s < 30 mg /L and TSS < 30 mg /L CST N lease Mr / Signature CST Number Address Date Evaluation Conducted Telephone Number " 4 / SBD -8330 (R07 /00) i Property Owner J Parcel lD # Page of F2-1 E] Boring Boring # Pit Ground surface elev. 1 _ ft. Depth to limiting factor in. 0 Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 67 - L ) i z 13" F-1 Boring # ❑Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # ❑ Boring El Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608- 264 -8777. SBD -8330 (R.07 /00) Y r J V SRI c. G - ` POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page j of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity g ❑ NA n Permit # Septic Tank Manufacturer O NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model A ❑ NA Number of Public Facility Units aNA Pump Tank Capacity a l ❑ NA Estimated flow (average) al /da Pump Tank Manufacturer 14 ❑ NA Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer ❑ NA Soil Application Rate al /da /ftx Pump Model L ❑ NA Standard Influent /Effluent Quality Monthly average" Pretreatment Unit J9 NA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Coll(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L *In- Ground (gravi_ty) (3 In- Ground (pressurized) Total Suspended Solids (TSS) S30 mg /L 5-NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 510 cfu /100m1 ❑ 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 tanks At least once eve onth(s) (Maximum 3 years) C3 NA p 11 every: ear(sl Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cells) At least once every: 13 month(s) (Maximum 3 years) 13 NA �5� ayear(s) Clean effluent filter At least once every: —, O month(s) ❑ NA ` year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA 0 ear(s) Flush laterals and pressure test At least once every: ❑ month(s) ANA ❑ year(s) Other: 13 month(s) ❑ NA At least once every: ❑ 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: Masten 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 (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 S12 months, shall be performed by a certified POWTS Malntalnor. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW 14/01) START UP AND OPERATION Page _sz2of 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 cells) 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. I • 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 r i need r new sot and site evaluation to establish a suitable replacement area. Replacement systems must result n the e d fo a e I p p Y 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 I in .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 INSTALL POWTS MAINTAINER Nam Name Phone , Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone f This document was drafted in compliance with chapter Comm 83.22(2)(b)0)(d) &(f) and 83.54(1), (2) & (3). Wisconsin Administrative Code. r Pam Quinn Subject: Gary Nelson- 420709- K.O'Connel Location: Lot 2 1021 110th St., Warren Twp. Start: Fri 9/5/2003 10:00 AM End: Fri 9/5/2003 11:00 AM Recurrence: (none) System inspection - change from mound to conventional POWTS ` Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7082 S , ��O�SI n Madison, WI 53707 — 7082 Sanitary Permit Number (to be filled in by Co.) Department of Commerce (608) 261.6546 1 -�� Sanitary Permit State Plan I.D. Number In accord with Comm 8311, Wis. Adm. Code, de /� �r /vs � 0 3 may be used for secondary Purposes 'vary Law, s15.04(lxm) Project Address (if different than mailing address) V I. Application Information - Please Print All Infor tion Property Owner's Name ST CROIX Parcel # Lot # - Bloc" ZONING OFFICE Property 's Mailing Address Property Location City, State Zip Code Phone Number Scr1 ' c � �' section G ircle PAO) I c I. a of Building TI N; R�E or&/ 0 /3 A79 — .30 Typ g (check all t t apply) A or 2 Family Dwelling - Number of � � Subdivision Name CSM Numbe ❑ PubliclComminial - Describe Use X �" ❑ State Owned - Descri M ty be Use X7 J D' ed ❑City ❑Village Township of III. Type of Permit: (Check only one box obqne A. Complete line RIf applicable) - A. .p New System ❑ Replacement System ❑ TreatmemdHol ng Tank Replacement Only ❑Other Modification to Existing SWm B. ❑Permit Renewal 11 Permit Revision List vi �PermqitF#m1WA ed ❑ ge of ❑ Permit Transfer to New leer t Before Expiration Plumfl Owner V F I ��o IV. Type of POWTS System: Check all that appl ❑ Non - Pressurized In- Ground 0 Mound ? 24 in. of suitable rI \LUIneGravel-less 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holdin ank er ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ 1. caching Chamber ❑ Drip Pipe ❑ Other (explain) V. DisPersanreatment Area Information. t1 1 / Design Flow (gpd) r (sf) Design Soil Application Rat Dis I Requ Dispersal Area Proposed (s Syst kvadon i Tank Info Capacity in Total Number Manufa Prefab Site Steel Fiber Plastic Gallons Gallo of Units 6 Concrete Constructed Glass Exkting New Teaks Tanks Septic or Holding Tank _ Aerobic Treatment Una Dosing Chamber - VII. Responsibility Statement I , a undersign4 assume responsibility for installation of the POWTS shown on the attached plans. Plumbe5A Name (Print) Plum 's MP/MPRS Number Business Phone Number J Plumber's Address (Street, City, Sdft, Zip Code l VIII. un ibe artment Use Onl pproved ❑Disapproved Sanitary Permit Fce (includes Groundwater Date sued uing ent Signature o tamps) Surcharge Fee) �U 6 D ❑Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval Attncl complete plans go the County only) for ystem as paper mo less than 81 s 11 Inches to du SBD -6398 (R. 08/02) . v v � O Q � l Safety and Buildings `10541N RANCH ROAD HAYWARD WI 54843 TDD #: (608) 264 -8777 I \ , vAsiconsin www•commerc .wis ons Department of Commerce www.wisconsin.gov Jim Doyle, Governor Cory L. Nettles, Secretary February 19, 2003 CUST IL) No.224263 ATTN.• POWTS Inspector KIM A O'CONNELL ZONING OFFICE K.O. CONSTRUCTION ST CROIX COUNTY SPIA 504 3RD AVE 1101 CARMICHAEL RD OSCEOLA WI 54020 HUDSON WI 54016 CONDITIONAL APPROVAL # ZD �0 PLAN APPROVAL EXPIRES: 02/19/2005 Identification Numbers' Transaction ID No. 838033 -� , • �',. SITE: Site ID No. 655913 Gary D Nelson Please refer to both identification numb 1 J� 1 110TH St above, in all correspondence with the a+< Town of Warren St Croix County R�M� SW1 /4, SW1/4, S9, T29N, R18W FOR: New mound, 450 GPD Object Type: POWT System Regulated Object ID No.: 892276 t O RES G The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative C 5 and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: General Approval Conditions: • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Septic Tank Effluent for Private Onsite Wastewater Systems" SBD- 10691 -P (N.01/01) and SSWMP Publication 9.6, "Design Of Pressurized Distribution Networks For Septic Tank- Soil Absorption Systems." • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must insure that the operation, maintenance and monitoring duties as described in section VIII of the mound component manual are complied with. A copy of this information must be given to the owner upon completion of the project. Key Item(s) • A copy of this approval letter and index sheet shall be attached to plans that correspond with the copy on file with the Department. Changes to the approved plan must be submitted for review and approval. Failure to properly attach the approval and index page to plans that match the copy on file with the Department may result in enforcement action under s. 145. 10, Stats. Note • The designer proposes to install a state approved effluent filter to achieve the requirement of wastewater particle size Pursuant to outlet filter product approval stipulations maintenan ce information must be given to the owner of the POWTS explaining that periodic cleaning of the effluent filter is required. The access opening use o service the filter shall terminate at or above finished grade with a watertight cover. e KIM A O'CONNELL Page 2 2/19/03 Reminder • The orientation of the mound system must be such that the longest dimension is oriented along the surface contour per COMM 83.44(6)(a)2. • Limit activities in the area 15' beyond the down slope edge of the mound per Mound Component Manual. • Surface water drainage shall be diverted away from the system area per Mound Component Manual. • Materials shall conform to the requirements of COMM 84. • Maintain well and waterline set backs per COMM 83.43(8)(1). Consult the Department of Natural Resources for well setbacks and exceptions to the setbacks. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. S y, Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 Patricia L Shandorf POWTS Plan Reviewer, Integrate Servic s WiVJART,pdw763 (715) 634 -7810, Fax: (715) 634 -5150 , -F 7:45 am - 4:30 pm pshandorf@commerce.state.wi.us cc: Leroy G Jansky , Wastewater Specialist, (715) 726 -2544 K 0 Construction r MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: GARY D. NELSON Owner's Name: GARY D. NELSON Owner's Address: P.O. BOX 24 ROBERTS WI 54023 Legal Description: SW- SW- SEC9- T29N -R18W Township: WARREN v County: ST. CROIX Subdivision Name: �s Lot Number: 2 Block Number: Parcel I.D. Number: 042- 1024 -40 -200 Plan Transaction No.: Page 1 Index and title `t Page 2 Data entry T Page 3 Mound drawings / Page 4 Lateral and dose tank Page 5 System maintenance specifications Page 6 Management and contingency plan �J Page 7 Pump curve and specifications 4v Page 8 PLOT PLAN Designer: KIM A OCONNELL License Number: 224263 % A S Date: 02/14/03 Phone Number: 715 - 755 -3145 Signature: Designed Pursuant to the Mound Component Manual for POWTS Version 2.0 SDB- 10691 -P (N. 01/01), and SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST -SAS (01/81) �/ r Version 3.0 (03/01/01) Page 1 of 8 Mound and Pressure Distribution Component Design Design Worksheet Site Information (r or c) R Residential or Commercial Design Note: Sand fill (D) calculations assume a 300.00 Estimated Wastewater Flow (gpd) Table 8344 -3 in -situ soil treatment for fecal 1.50 Peaking Factor (e.g. 1.5 = 150 %) coliform of <- 36 inches. 450.00 Design Flow (gpd) 7.00 Site Slope ( %) 102.50 Contour Line Elevation (ft) 28.00 Depth to Limiting Factor (in) 0.50 In -situ Soil Application Rate (gpd /ft Distribution Cell Information 75.001 Dispersal Cell Length Along Contour (ft) = 6.00 Cell Width (ft) 1.00 Dispersal Cell Design Loading Rate (gpd/ft 1 Influent Wastewater Quality (1 or 2) Are the laterals the highest point in the distribution Y Pressure Disribution Information network? Enter Y or N (c or e) E Center o End Manifold 3.00 Lateral Spacing (ft) If N above, enter the elevation ft 2 Number of Laterals of the highest point. 0.125 Orifice Diameter (in) (e.g. 0.25) 3.50 Es #imated Orifice Spacing (ft) ft 1.50 Forcemain Diameter (in) 130.00 Forcemain Length (ft) Does the forcemain drain back? C Y 93.50 Pump Tank Elevation (ft) Enter Y or N 6.50 System Head (ft) x 1.3 11.93 Forcemain Drainback (gal) 9.50 Vertical Lift (ft) 67.44 5x Void Volume (gal) 4.02 Friction Loss (ft) 79.37 Minimum Dose Volume (gal) 20.02 Total Dynamic Head (ft) 18.12 System Demand (gpm) Lateral Diameter Selection Manifold Diameter Selection in. dia. __ options choice in. dia. options choice 0.75 1.25 x 1.00 1.50 X 1.25 x 2.00 1.50 x x 3.00 2.00 x 3.00 x Gallons/Inch Calculator (optional) Treat Tank Information 800.00 Total Tank Capacity (gal) 1000.001 Septic Tank Capacity (gal) 36.00 Total Working Liquid Depth (in) WEEKS Manufacturer 22.22 gal /in (enter result in cell B49) Dose Tank Information Effluent Filter Information 800.00 Dose Tank Capacity (gal) JZabel Filter Manufacturer 21.76 Dose Tank Volume (gal /in) [Al 00 Filter Model Number WEEKS Manufacturer Project: GARY D. NELSON Page 2 of 8 1 Mound Plan View 1 1/10 B J Observation Pipe i :: .. ... ... l O 0 A w . B ....................... ..... ..... ..... I 3 ...................... ............................... L Mound Component Dimensions A M ft E 13.04 in H 1.00 ft K 8.01 ft B ft F 9.50 in z 9.03 ft L 91.01 ft in G 0.50 J 4.86 ft W 19.89 ft 450.00 (ft Dispersal Cell Area 1 1127.37 (ft BasaLA rs&Aua+labW -✓ 6.00 (gpd /ft) Linear Loading Rate ✓ 1 7.50 (ft) 1/10 B Obs. Pipe Placement Mound Cross Section View Aggregate Dispersal Area Finished Grade 104.96 (ft) —► r H G 10 3.2 OK O 1 F Oispersai cell 103.67 (ft) Lateral 103.17 (ft) — Invert :.:.:. :.:.:.......:..:.:.:.:.:.:.:.:. Dispersal Cell ' Elevation D ......•..........d ' Q n4. 1 02.50 (ft) Contour Elevation 7.0 % Site Slope Geotextile Fabric Cover Shading Key Dispersal Cell See lateral details on Topsoil Cap c 1.5 ft Page 4 for number, Q Subsoil Cap o Q " " " "' a /J! /J / /Jl Q �"j size, and spacing of ASTM C33 Sand :6 I F laterals. Laterals are Tilled Layer 0.5 ft Typical Lateral equally spaced from 05 0 Aggregate o Q the distribution cell's -- A centerline in the distribution cell (AxB). Project: GARY D. NELSON Page 3 of 8 End Connection Lateral Layout Diagram Laterals centered over the A & B dimension i = Turn -up wl bell valve or clean outplu g f P All laterals are identical IF x —�I Holes drilled on the bottom of the lateral equally spaced 9 Force main DOnnection via tee or oross to manifold at ang point. Laterals & force main of PVC Sch 40 (per COMM Table 84.30 -5) Number of Laterals 2 Orifice Diameter 0.125 in Lateral Diameter 1.50 in Orifice Spacing (X) 3.50 ft Lateral Length (P) 73.50 ft Orifices per Lateral 22 Lateral Spacing (S) 3.00 ft Orifice Density 10.23 ft /orifice Lateral Flow Rate 9.06 §RM Manifold Length 3.00 ft System Flow Rate 18.12 m Manifold Diameter 1.50 in Total Dynamic Head . 2 ft Forcemain Velocity 3.29 ft/sec Dose Tank Information Locking cover with warning label and locking device and sealed watertight Electrical as per NEC 300 and ----► - ` Comm 16.28 WAC Disconnect 4 in. min. Tank component is properly vented >' E--- Altemate outlet location Forcemain diameter WEEKS Manufacturer 1.5 in. Cap acityl 800.00 Gallons Volume 21.76 gal /inch A Weep hole or anti- Dimension Inches Gallons B siphon device A 22.52 490.01 C B 2.00 43.52 Pump off e levation (ft) C 4.25 92.39 -t T 1 94.17 D 8.00 174.08 D Total 36. Dose se tank elevation (ft) 3" Bedding un er tank. 93.50 Alarm Manuafacturer JSJ ELECTRO Alarm Model Number I HW 100 � — Pump Manufacturer IGOULDS Pump Model Number WE0311WE031 LL Pump Must Deliver 18.12 gpm at 20.02 ft TDH Project: GARY D. NELSON Page 4 of 8 Mound System Maintenance and Operation Specifications Service Provider's Name KIM A OCONNELL Phone 715 - 755 -3145 POWTS Regulator's Name r ST. CROIX COUNTY ZONING Phone 715- 386 -4680 System Flow and Load Parameters Design Flow - Peak 450 gpd Maximum Influent Particle Size 1/8 in Estimated Flow - Average 300 gpd Maximum BOD5 220 mg /L Septic Tank Capacity 1000 gal Maximum TSS 150 mg/L Soil Absorption Component Size 450 ft Maximum FOG 30 mg /L Type of Wastewater Domestic Maximum Fecal Coliform >10E4 cfu/100 mL Service Frequency Septic and Pump Tank Inspect and/or service once every 3 years Effluent Filter Should inspect and clean at least once every 3 years Pump and Controls Test once every 3 years Alarm Should test month) Pressure System Laterals should be flushed and pressure tested every 1.5 years Mound Inspect for ponding and seepage once every 3 ears Other Miscellaneous Construction and Materials Standards 1. Observation pipes are slotted and materials conform to Table Comm 84.30 -1, have a watertight cap, and are secured in as shown in the mound component manual. 2. Dispersal cell aggregate conforms to Comm 84.30 (6)(i), Wis. Adm. Code. 3. All gravity and pressure piping materials conform to the requirements in Comm 84, Wis. Adm. Code. 4. Tillage of the basal area is accomplished with a mold board or chisel plow. 5. The mound structure and other disturbed areas will be seeded and mulched to prevent soil erosion and help educe frost penetration. P p Lateral Turn-up Detail Finished ..••��•......••. ..............• Grade 6 -8" Diameter Lawn Threaded Cleanout Sprinkler Valve Box Plug or Ball Valve Distribution Lateral Long Sweep 90 or Two 45 Degree Bends Same Diameter as Lateral Project: GARY D. NELSON Page 5 of 8 Mound System Management Plan�� Pursuant to Comm 83.54, Wis. Adm. Code General f�G /� C (f �. F3 • ,�-7i This system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall maintained in accordance with its' component manuals [SBD- 10691 -P (N.01/01) and SSWMP Publication 9.6 (01/81)] and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall bed isposed of in accordance with NR 13, Wis. Adm. Code. The operatin condtion of the se tic tank and outlet filter shall be assessed at least once every 3 years by inspection. x]-x e c eaned as necessa to ensure proper operation. The filter cartridge should not be removed unless provior� are made to retain solids in the tank that may slough off the filter when remove om its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of a biennial assessmen , mamtenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Department of Commerce. Pump Tank e pump (dosing) tank shall be inspected at least once every 3 ye ars. All switches, alarms, and pumps shall be tested to verify proper operation. IT an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Mound and Pressure Distribution System No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October- February) dictate that the mound be heavily mulched as protection from freezing. Influent quality into the mound system may not exceed 220 mg/L BOD5,150 mg/L TSS, and 30 mg/L FOG for septic tank effluent or 30 mg/L BOD 30 mg/L TSS, 10 mg/L FOG, and 10 cfu/100 mL for highly treated effluent. Influent flow may not exceed maximum design flow Zk specified in the permit for this installation. The pressure distribution system is provided with a flushinn point at e end of each lateral, and it is recommended that each lateral be flushed of accumulated solids at least once every 18 months. When a pressure test is performed it ou a compared to the initial test when mysten, was I, istalled to dater, He ie Of op ifice as occurred and if orifice cleaning is required to maintain equal distribution within the dispersal cell. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 6 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component(s) shall be immediately repaired or replaced with a component of the same or equal performance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or by removing biologically clogged absorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. See Page 6 of this plan for the name and telephone number of yo local POWTS regulator an d service provider. S'r C201�G z0 nJ1 A.)4- N--FF. Project: GARY D. NELSON Page 6 of 8 • - MEMO '.�'!�■� CC ■ ■C�iCCCw ■ ■ ■ ■ ■ ■ ■■ ■ ■�"''� ■ ■r ■rr r ' ■■�'■i■iC�!ir��i�ii��i� ii�iii� , �i:� ��■ ■ ■� ■ ■■■ ■fir ►`� ■ ■ ■ ■w ■1n \� ■■ww ► ■►'�■■■■ WINE ■ ■r���. ���r ■►111 ■ ■■ . , r w�■ ■ ■ ■rr ■rwr■■w■ ■rr ■r■ w �■rrw ■ ■ ■ ■wr ■ ■■ 0 , ::' SIZE 1 /4" Solids WIN m MEW �'CI■CC�C�CC © ®CC ®C'iIC • ■ i�CCCS�■CCCCCCCCi�CC■ � 'i■w■■■■NOISOM■CCw■■■■■■■ ., ■ . , ••�� ■ ■.■■. ■.■r■■■..■. ■ r: ir■■CCi C■iiiiiriCM ■■ ■w►r■ ■ ■w■iw■■r ■ ■■r�■r■r■r ■ r , ■ . ■■■■■■n ■Now a ®C ®VCCCCC�■CCC. �w� ■ ■rrw ■ ■ ■w� ■ ■ ■■� ■ ■ Iw ■ ■ ■ ■1■�■ ,� � 1 , 0 � \V � "'; I y ' \ \ �` / (� `� G �y -- U �, � _., � a� � �� � � ,� ,� � `� � � �� � � ,� \� � � � ��� �:, G .�. � vv � 4 � Z � � � � ~ \ ,� ,� '�. .� �, L� I � ` \ ' •'� ��� ���� � � � e ��`�� a � I l I 1 r^ fi ��� � �� � �c o I 1 •Q I { 4 � � � �� !_ � � �, � � x i `� �. �.._�..c..-_ -- ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND 20NERSHIP CERTIFICATION FORM OwnerBuyer Mailing Address Property Address (Verification required from Planning Department For new construction) City /State `_, )_t tG/ 2 ? Parcel Identification Number n�2 : Zzlal �c� LE GAL DESCRIPTION Property Location '' /a, _:4L ' /a, Sec, T-,2 N -R,22 W, Town of Subdivision , Lot # Certified Survey Map # /5��� �� , Volume 1 �' , Page # T � Warranty Deed # , Volume { ���(/q , Page # Spec house f9 yes ❑ no Lot lines identifiable,( yes ❑ no SYSTEM MAIN`I'F,NANCE Improper use and maintenanceof 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 treamlent stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposa I 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. 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 Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained trust be completed and returned to the St, Croix County Zoning Office within 30 days of the three year expiration date. 4 S1G 44 8 _ F z APPLICANT DATE OWNF,R CERTIFICATION 1 (we) certify that all statements on this form are tntc to the best of my (our) knowledge. I (we) am (are) the owncr(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. d �so3 SIG�UE AP PLICANT DATE * * * * ** Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department."' ** 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 U 2 119 P 9 5 2 7�69s� • KATHLEEN H. WALSH STATE BAR OF WISCONSIN FORM 2 - 1999 REGISTER OF DEEDS Document Number WARRANTY DEED ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between Gordon A. Truesdill, 01/24/2003 08:30AN EXERT # REC FEE: 11.00 Grantor, and Gary D. Nelson and Jillienne J. Nelson, husband and wife TRANS FEE: 150.00 COPY FEE: CERT COPY FEE: PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Part of the NW '/< of SW '/< and part of the SW '/4 of SW '/. of Section 9, Nam jt* VILe1s-EY BANK NA Township 29 North, Range 18 West, St. Croix County, Wisconsin described 1 301 Coul Rd as follows: Lot 2 of Certified Surveti Map filed August 29, 2001 in Vol. 15, PO Box 70 Page 4157, Doc. No. 655060. ✓ Hudson, W1 54016 042- 1024 -40 -200 Parcel Identification Number (PIN) This homestead property. (is) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this day of January , 2003 * * Gordon A. Truesdill AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) ss. S+ Y 0 1 Y- County ) authenticated this day of �"� Personally came before me this day of January 2003 the above named Gordon A. Truesdill, * .0 TITLE: MEMBER STATE BAR OF WISCONSIN N. (If not, to me knovh be the " er�bh(3 executed the foregoing e. authorized by § 706.06, Wis. Stats.) instrumen '' sal — THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Ogland Notary P., Ye of Wisconsin Hudson, WI 54016 ' . My Com��i,,. � e�nt, If not, state a piration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) - — v ) * Names of persons signing in any capacity must be typed or printed below their signature. Information Professionals company, Fond du Lac, WI STATE BAR OF WISCONSIN 800-665-2021 WARRANTY DEED FORM No. 2 - 1999 f 1 132119 0 V,? - l t e V - va - 05`d ! X3. - / l� o C/a - /o P-q- 6 i A Alu- Dy ! a o - 10R t —bo -os 655060 KATHLEEN H. WALSH !fie/; %2 OF DEEDS ST. CROIX Co. wI 1� RECEIVED FOR REHRD 08 -29 -2001 9:00 AM C PY FEE: 3.00 a G' 'J /m R ORDIHG FEE: 12.40 Cel" , Gordon Truesdill Jr. Part of the Northwest 114 of the Southwest 114 and the Southwest 114 of the Southwest 114 ofSection�nship North, Range 18 West, Town of Warren, St. Croix County, Wisconsin. , APPROVE01 L ESEND: ST. CROIX C(1t)NTY _ /Pl 7 0 INDICATES / "X24 "IRONP /PEWEIGHING 1.13LBS./L1N.FT T. NI IR10.0'J INDJC4 TE9 PREVIOUSLY RECORDED DATA AUG 2 9 2006 J O O INDICATES TEST HOLE 1SEWERBI TEJ. I NDICA TES FENCE If not recoroeu wriiut ,,: ::,ys of approval date approval stiall be M W 114 CORNER SECTION 9, OWN R'S AIU/TC JJ ; N; til, (BERNTSEN ALUMINUM MONUMENT) �I h 1112 00 TH AVE. Ni'� —- GNPL T TED LA ROBE TS, W1 54023 2• 4 041 I (� /y 89.44'48 "E 484.00' 33' 33'1 4 78.60' - -� 6 6' 5.40' I ' 11 138Ii , b N I I Igo' -- LOT I ' 2.500 ACRES OR 106,900 SQUARE FEET MI t Q 2.464 ACRES OR 107, 317 SQUARE FEET EXCLUDING N ` '0 0 I I ROAD R1GHT OF WAY $89 48 4.00' ^ 4I NO %J W 1 �Zlin 8.67' 475.33' v � • �' CO Q i38� �.o W I.J. 4 g� I- N 2.301 ACRES OR / 0 2 / SQUARE FEET � I 1 0 2.267 ACRES OR 98,754 SQUARE FEET Q O FT^4C� �EXCLUO /N6 ROAD R/GHTOFWAY r g m I I VN188.5443 E60.86 °y y y i. w � � � 0.00' f/1l p 4T 100 ^ .I V ` X //./825000 QSE,yF Y .00, Z 3 NT I SI88 43 "W S88.54'43 "W 146.08' ►n i ��6` ~ ' LANDS UNPL TT p y 3 THIS INSTRUMENT DRAFTED BY SW CORNER SECTION 9, V �D LAURENCE W. MURPHY f 2 "IRON PIPE FOUND) W ►: 3 ku o N S CpN+��1► OUTLOT / _~ in 0.283 ACRES OR 12,342 SQUARE FEET Z O Z O 0.266 ACRES OR 11,594 SQUARE FEET O Z • 1M EXCLUDING ROAD R/GHTOF WAY Q Z FA" ku i t, h SCALE 1 "= 100' Q 3 o Q u� 0 50' /00' 150' 200' 250' 300' "Resvised this 14th day of ., 2001." DATED: JUNE 6, 200/ SHEET / Of Y VOLUME 15 PAGE 4157 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page —J-- of Division of Safety 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 refer pours erection and Parcel I.D. percent slope, scale or dimensions, north arrow, y6ibcation an isCanc o nearest road. 0 2 (' 2 � C/O '02 00 ' Please print all ' fprmation* I R iewed b Date , r, r .... Personal information you provide may be used fo secondary purposbs ?PkDy Law, s. 15.64 (1) (m)). V a eO d Property Owner Propeft y Location �. Govt: Lot 1/4 1/4 S T N R lq E (or Property Owner's Mailing Add es's Lot # Block Subd. Name o 'C)t1NTY 4NGOFFIGE [ cit y S t T te Zip Code ( one Number ` � City Village 9 Town Neares Road New Construction Use :jj� Residential / Number of bedrooms -- �— Code derived design flow rate r - GPD ❑ Replacement // ❑ Public or commercial - Describe: Parent material %i,�/ Flood Plain elevation if applicable ft. General comments and recommendations: Boring # 121 10 ❑ Boring pit Ground surface elev. ,�� 1 ft. Depth to limiting factor _ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD 1ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 3 S 3 Boring # ❑ Boring 0 Pit Ground surface elev. ZOIJ ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 / s S k s s 3 - * Effl ent #1 = BOD > 30 < 220 mg /L and TSS >30 _< 150 mg /L * Effluent #2 = B 5 < 30 mg /L and TSS < 30 mg /L CST Na P ase rnt) Signature CST Number Address Date aluation Conducted Telephone Number x _ _ - SBD -8330 (R07 /00) Y ` Property Owner L4sr,J „/1�il� S.J� �-/�C - Parcel ID # Page of 17 1 � Boring # ❑ Boring Pit Ground surface elev. /r�s' -�/ ft. Depth to limiting factor _ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cgnt. Color Gr. Sz. Sh. *Eff#1 *Eff#2 S 13 s IV Z 1 r S 1�i F-1 Boring # ❑ Boring ❑ 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 /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 F-1 Boring # ❑ Pit Boring ❑ Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or ' need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 264 -8777. SBD -8330 (R.07 /00) l 750 ,T s��3 90 ' ' ag ej i