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WisconsigDepartment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety anti Buildin;,P Division INSPECTION REPORT Sanitary Permit No: 499199 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: Koats, Richard I Warren, Town of 042 - 1055 -50 -100 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: c f ° / (p R) ✓� z 20.29.18.306E TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Co t a $� Alt. l�j AeFetien Bldg. Sewer 95. Lo F; � Pv �� lc L. 5 ZS . Ick Holding St/Ht Inlet ----- ---- -- TANK SETBACK INFORMATION St/Ht Outlet \ TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet \ weal° � Septic 7 V i 7 751 _ Dt Bottom Dosing j -7 7-5 `f5 / _ Header /Man. 6 35 9 V, a 5 Aeration Dist. Pipe / , 3� y f , -a S Holding Bot. System � x.15 q�3 Final Grade as� PUMPISIPHON INFORMATION 5 , 3S ri S -zSs X Manufacturer Demand St Cf�ver / au � GPM C� l.aJ1� 5.6 at Model Number n TDH Lift �.� Friction Loss System Head TDH Ft t5 . Z 6.5 IZ, 5,T Forcemain Length r Dia. I/ I Dist. to Well 7s 3t Z 7 SOIL ABSORPTION SYSTEM BED/TRENCH Width I Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS � 75 � SETBACK _ PETE M TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMB T OR Model Number. Type S m: { W/ 7 7L DISTRIBUTION SYSTEM LJC5} -- Header /Manifold �/ Distribution / x Hole Size x Hole Spacing Vent to Air Intake Length Dia Length Dia Spacing Gov 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 / 555 Bed/Trench Edges Topsoil ` 4 yes No Yes 0 No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: / / /3 / Inspection #2: Location: 1059 Hwy 12 oberts, WI 54023 (NW 1/4 NE 1/4 20 T29N R18W) NA Lot 2 G6 , 5CL Parcel No: 20.29.18.306E �� p e� 1 ate- �°� 1.) Alt BM Description = o A 2.) Bldg sewer length = &47— ti b�cwd`o I 0 '1 V' - amount of cover = 7 41�ZI I Plan revision Required? El Yes XNo Use other side for additional information. Date Inse ore's Sig re Cert. No. SBD -6710 (R.3/97) I Safety and Buildings Division County 201 W. Washington Ave. P.O. Box 7162 C N Visconsin Madison, W1 53707 — 7162 Sani ermit umber (to be fi led in by Co.) Department of Commerce (608) 266 -3151 qqqlqq Sanitary Permit Application State 1 I.D. umber /� In accord with Comm 83.21, Wis. Adm. Code, personal information you prove ! / `� may be used for secondary purposes Priva y Address (if different than mailing address) I. Application Information — Please Prin nformat n Property Owner's Name OCT 0 9 zuub Par &l # t # lock RLC&ARD vt T Q Property Owner's Mailing Address Property Location ` City S /Q J �p Code Phone Number N W /<, Ag' /,, Section 7V/ ®W 5 is ` /�5� /.. Tr N; R Ea IL Type of Building (check all that apply) 'V Y,1 or 2 Family Dwelling — Number of Bedrooms < ubdivisiion CSM Number ❑ Public/Commercial — Describe Use Y/ 5- ° m O / ❑ State Owned — Describe Use City ❑Village flTownship of"17- 111. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System Replacement System g Replacement y g y ❑ Treatment/Holdin Tank R lacement Onl Other Modification to Existing System B. 11 Permit Renewal ❑Permit Revision 11 Change of ❑ List Previous Permit Number and Date Issued Permit Transfer to New � � � �� _ �/� Before Expiration Plumber Owner IV. Type of POWTS System: Check all that appl - ❑ Non — Pressurized In- Ground ; Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Fil r ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber Drip L' e 1 0 Gravel -less Pipe ❑ Other (explain) r` /i V. Dis ersal/Treatment Area Information: ( k O k SGr� Design Flow (gpd) Design S it Applicatio Rate( s Dispersal Area Require (sf) Dispersal Area Proposed (sf) System E ation bOO 4� - .31-D I 02-� yzwol eu oD I VI. Tank Info Capacity in Total Number anufacturer Pr ab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks T Septic or Holding Tank O S Aerobic Treatment Unit Dosing Chamber 75 x VII. Responsibility Statement 14 the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) PI is Signature MP/MPRS Number Business Phone Number JAlor.s. i 911L,A1(r Plumber's Address (Street, City, State, V Code) /`/V 3 uJo M 4/ r/ 5 7� wiwe A✓w - 6 - d 4 VIII, oun epartment Use Onl pproved ❑Disapproved Sanitary Permit Fee includes Groundwater Date Issued I ing Agent igna a (N ) Surcharge Fee)� ❑ Owner Given Reason for Denial (J V IX. Conditions of Approval/Reasons for Disa _ L STEM OWNER 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained r �/✓�� � � as per management plan provided by plumber. 141"/_ _0 S -J 2. All setback requirements must be maintained 3S Per applicable c0%,&g ftW;,. (to the County only) for the system on paper not less thsa 81/2 ill inches in size SBD -6398 R.01 /03 S � ON I I N 3 I o n _ / T n Q � r o � � t ca ON 0 S r eb o . Q tC A n s ti r f • Safety and Buildings PO BOX 7162 commerceml.gov MADISON WI 53707 -7162 TDD #: (608) 264 -8777 isconsin www.w www.coe.wi.gov/s / isconsin.gov Department of Commerce Jim Doyle, Governor Mary P. Burke, Secretary September 19, 2006 CUST ID No. 220673 ATTN.• POWYS Inspector CHARLES L WEBSTER ZONING OFFICE WEBSTER SOIL TESTING & DESIGN SERVICES ST CROIX COUNTY SPIA N5815 770TH ST 1101 CARMICHAEL RD ELLSWORTH WI 54011 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 09/19/2008 Identification Numbers ' SITE: Transaction ID No. 1319910 Richard Koats Site ID No. 718264 1059 Hwy at Please refer to both identification numbers, Town of Warren, 54023 above, in all correspondence with the agency. St Croix County NW 1/4, NE 1/4, S20, T29N, R18W FOR: Object Type: POWTS Component Manual Regulated Object ID No.: 1097481 Maintenance required; Replacement system; 600 GPD Flow rate; System(s): Mound Component Manual - Version 2.0, SBD- 10691 -P (N.01 /01), Pressure Distribution Component Manual - Version 2.0, SBD- 10706 -P (N.01 101) The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with the component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: • This system is to be constructed and located in accordance with the approved plans, and the "Mound Component Manual for Private Onsite Wastewater Systems Version 2.0" SBD- 10691- P(N.01 /01). 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 f 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. Sincerely, Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 Robert Kanter POWTS Plan Reviewer, Integrated Services (608)261-7735, Monday -friday 8:OOAM - 4:45PM WSMART code: 7633 robert.kanter @wisconsin.gov cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 Webster Soil Testing Et Sewer System Design Cb►ari* a Km. m 'A,ist, x, owes 85815 770 Stmt, Et&Mrth, �45" 54011 Telephone: (715) 273 -3430 Fax: (715) 273 -4181 WI Licenses: MP220673, ST220673, ST 261669, PE18803 POWTS Index Sheet Page 1 of 8 1 1 2 n( Mound System for a 4 Bedroom Residence Property Owner/Project Name: Richard Koats NW 4 NE 1 14 S20 T29N R18W Town of Warren, St.. Croix City, WX Contents Page 1 of 8 Index Sheet Page 2 of 8 Plot Plan Page 3 of $ Plan View Cross Section Page 4 of 8 Distribution Pipe Layout Page 5 of 8 Pumping Chamber Layout Page 6 of 8 Pump Performance Curve Page 7 &8 of 8 Management Plan SCO111 L t WEBMR Component manuals used: Name: Mound Component Manual for POWTS --- --�` =�- Version: 2.0 SBD- 10691 -P Date: January 30, 2001 Name: Pressure Distribution Manual for POWTS Version: 2.0 SBD - 10706 -P Date: January 30, 2001 . ,., �. ..� .�, �� � `r, 1� 4.i• �+ � � -w�� A F N ^� � � J[. (y Sp _ � ' � Y; ' ... 6'L � a T 4 . .� sl I to h r lb �•o- It �- •tN e o s� �^ 3 � � n t > 1 t _ S' P ry p L ;A, c A O� 04 ro [ S � � � r8 ri � p � � S S• 7' m NO ? O Q• O Page Of a Approved Synthetic Covering Distribution Pipe Medium Sand - H - G Topsoil - -_ -- _ =_= F Elev `t J 3 .7_ % Slope Bed Of 2' -2% Force Main Plowed Aggregate From Pump Layer Cross Section Of A Mound System Using F r, s 1 � g J A Bed For The Absorption Area p.5' Ft. A Ft. H /- O Ft. Linear Loading Rate =` C GPD /LN FT B 7 Ft. Design Loading Rate= 0 • 3 oGPD /SO FT j ' I - Ft. i \ ,4,, Ft. Tllrca A4d 1 K Ft. Ty,� lcj/ �1t / cn w 34 Ft. L ArObservation Pipe K l � ` } -_ -- — __ -- A I - --- _ -------- -�_ - - - - - � Distribution Bed Of �2�- 2 i Pipe Aggregate I 2 - 0 i w e md�h 1 Observation Pipe,, I tai,chor sccur d Irr b -P- d k-, c ; 0 �, P C- ? 4 d�Cr g_Lif ccJ/O� / lS�e Elie baf�ovn G,hczcs f /atfeo/ 6e scca1fQ� dhc�izk�• Plan View Of Mound Using A Bed For The Absorption Area Page Of - ��� � e�• ,.�,;� , a��� � t�� � 1�_�.��C�. ��� Perforated Pipe Detail End Vier+ Perforoted A PVC Pipe � o``oo`ocG` �\ J Holes Located On Soiiom, Se t d / of d %l Are Equally spaces vif J J + 1 DistrlJJtlon Pipe r defid � �\ p 7 Ft. Distribution Pipe Layou $ Ft. �'?• frhr c c ' luw`�Y, r, re -��,f X 3 Inches CT ,, .4� z '. S� t,»,- v 3� Inches Hole Diameter Inch Lateral Inches) Manifold Inches Force Main " Inches # of holes/pipe � al c e e.rs 6 aX "e4C/ A Invert Elevation of Laterals 93 7 St. I J P,� e " Place 1st hole / from ead o'dsn :be�t� °.�el� with succeeding holes at 3 , Qo . intervals. ' Co ni �!A)�.•�� �C'Qti � TJ h � /�4.+s ck j �r6er -� 4la 1.or Su 9 0 (No Scale) ri�s refit p." e, oJ'� Approved Locking Manhole Covers P �/ With Warning LabelS Attached a? %r ' ri - r1Ke Weatherproof hpprc'ied ----r - /p -t Junction Box vznt Ca= 1 1 2" Mini / ' 4" Minimum Fea/ C�r)o/Q iK.r+9 /:r,inctrn i tt 1 Quick 18" Minimum _ DiscoAhect 7 Baffle Hole Alarm 6+ 6� x On B � p A e � C *APPROVED Off A . D EIJ' 83 `� of coy e} to JOINTS WITH f P`°. °",° do APPROVED PIPE 3' ONTO Cons.. SOLID SOIL j i 3 " of Bedding Under Tank -� Number of Doses: 9 Per Day Gallons Per Day /ff oFDoses: /O! -I5' Gallo ns 1 Zo ' / Volume of Backfl ow: � .)+ /1- Gal F. Cn Tank Manufacturer: r�e5e` C hC v - .1_ Total Dose V - f. Tank Size-Septic/Pump: ! a6`v 7S0 Gallons alarm Manufacturer: L.evc/ Model Number: t?L- Capacities: A 3<'-> inches or 1<6'1- Gallons Switch Type: + B a inches or 34 Gallons Dump Manufacturer: + C __7 inches or /13 Gallons Model Number: /a + D inches or 1 a Gallons Minimum Discharge ate: Total .....= inches or. 7�o Gal Ions Verti Difference Between Pump Off and Distribution Pipe : /o -4S Feet }/ di nimum Required Supply Pressure:. ......... +7_s 70 Feet of Force Main x o_ 97 Friction Factor /100 Feet: +p eet b'y7 ��- Inch Diameter Force Main d Total Dynamic Head: ... = /7 -7Feet ntzrnal Tank Dimensions: Length / & ; Width ; Liquid Depth Jam " .% f«r�.^�,^ /r...�e %1 m�r•'p <ids x°.°r c''A? d,,' Ey - � •5 � ulF m K 7 �� P , M ? EPO4 I EP05 APPLICATIONS Fasteners. 300 series Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the • stainless steel: grade turbine oil for for efficient heat transfer, following uses Capable of running lubrication and efficient strength, and durability. r Effluent systems dry without damage to heat transfer. ■ Motor Cover. Thermoplas- Homes components. or au Available for and tic cover with integral handle Farms manual operation. Automatic Motor and float switch attachment - EPO4 Single phase: 0.4 HP, points. Heavy duty Sump - models include Mechanical • 115 or 230 V, 60 Hz, 1550 ■ Power Cable: Severe d Water transfer float Switch assembled and RPM, built in overload. with rated oil and water resistant. • Dewatering reset at the factory. automatic reset. ■Bearings: Upper and lower • EP05 Single phase: 0.5 HP, h eavy ball be aring SPECIFICATIONS e d ba 115 V, 60 Hz,1550 RPM, FEATURES vY �y 9 Pump: EPO4 built in overload with ■ EPO4 Impeller Thermo- construction. • Solids handling capability: automatic reset. plastic Semi -open design 'A" maximum.. . • Power cord: 10 foot with pump out vanes for AGENCY LISTING • Capacities: up to 55 GPM. standard length, 1-6/3 SJTO mechanical seal protection. Cp. CmdIanswWaftAnwWon • Total heads: up to 24 feet. with three prong grounding. rm - •Discharge size: l' /z" NPT. plug. Optional 20 foot Impeller m EP05 pellet The o (CSA fisted mode! numbers Mechanical seal: carbon- length, 1613 SJTW with plastic enclosed design for end in "F" or "AC ".) rotary/ceramic - stationary, three prong grounding plug improved performance. BUNA -N elastomers. (standard on EP05). ■ Casing and Base: Rugged • Temperature: - - thermoplastic design provides 104 °F (4.0 °C) continuous superior strength and 140 °F (60 °C) intermittent, corrosion resistance. • Fasteners: 300 series - METERS i FEET stainless steel 10 • Capable of running I dry,without damage to s 30 components. I j Pump: EP05 $ 25 • Solids handling capability: 0 7 maximum. W I . • Capacities: up to 60 GPM. s zo l • Total heads: up to 31 feet. Discharge size:.1 /" NPT. Z 5 ' • Mechanical seal: carbon- c 15 rotary/ceramic- stationary, a 4 BUNA -N elastomers. c • Temperature:. 3 10 l 104 °F (40 °C) continuous 140 °F (6WC) intermittent 2 5 i QeP�r 44 of = j o � 1 1 0 0 020 l 30 40 50 GPM 1 7- 7 / e � o 0 2 4 s 8 10 12 m3m CAPACITY ©1995 Goulds Pumps, Inc. Effective May, 1995 83871 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 7 of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Q / Septic Tank Capacity _0 P at © NA _S Permit # Septic Tank Manufacturer DESIGN PARAMETERS Effluent Filter Manufacturer ❑ IA::+ Number of Bedrooms ❑ NA Effluent Filter Model 3" a ❑ INA. Number of Commercial Units ONA Pump Tank Capacity ,T gal ❑ Nr. ' Estimated flow (average) (% O da Pump Tank Manufacturer L �Y ,M -e Q NA Design flow (peak), (Estimated x 1.5) t U Pump Manufacturer 67-1 1 ', /d Q NA Soil Application Rate ay nt' Pump Model / +'o ❑' Month NA Influent/Effluent Quality � Vie Pretreatment Unit ❑ Sand/Gravel Filter ❑Peat Filter Fats, Oil &Grease (FOG) 530 mg/L ❑ Mechanical Aeration ❑ Wetland Biochemical Oxygen Demand (BOD 5220 mg/L ❑ Disinfection ❑ Other. Total Suspended Solids (TSS) 5150 mg/L Manufacturer Pretreated Effluent Quality ❑ NA Monthly average" Dispersal Cell(s) Biochemical Oxygen Demand (BOD 530 mg/L ❑ In -ground (gravity) ❑ In -ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ At -grade XMound Fecal Coliform /1o0m1 (geometric mean) 510` cfu ❑ Drip-line ❑Other Maximum Effluent Particle Size Y. inch diameter values typical for domestic (non-oommendaq wastewater and septic tank effluent. �+ values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ❑ months )Kyear(s) (Maximum 3 yrs.) Pump out contents of tanks) When combined sludge and scum equals one -third (Y of tank volume Inspect dispersal cell(s) At least once every ❑ months )4 years) (Maximum 3 yrs.) Clean effluent filter * At least once every 3 ❑ months )Kyear(s) Inspect pump, pump controls & alarm At least once every ❑ months ❑ year(s) ❑ NA s-A/r- e V'! Flush laterals and pressure test At least once every ❑ months ❑ year(s) ❑ NA 11/� Other. At least once every ❑ months ❑ year(s) 3;NA Other. At least once every ❑'months ❑ year(s) )KNA ea0,,"— df e% r Je,NV e7fif phcC very 3ye�Pr. AC1 MAINTENANCE INSTRUCTIONS 14 -P; e c /er- �t /�r► eyery A011 to �v - l�a. y I°r /!"'' v, du.r -the Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer, Septage Servicing Operator. Tank inspections must Include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreatVment components, and any other maintenance or monitoring at intervals of 12 months or less shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event START UP AND OPERATION. For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. Pao :System start up shall not occur whe:7 so l condhions are frozen at the infiltrative surface. During power outages pump tanks rr.ay fit above normal highwater levels. When power is restofed t-ne ex�e wastewater will be discharged to the dispersal cells) in one large dose, overloading the celi(s) and mom° �::- backup or surface discharge of effluent. To avoid this situation have the contents of the pump taro =" a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Pk nnber or P'C'V t S 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 cther*ise 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 perfon f wine sn of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental `toss: dam_' disinfectants; fat; foundation drain (sump pump) water, fruit and vegetable peelings; gasoline; grease; herbicides =: scraps; medications; oil; painting products; pesticides; sanitary napkins, tampons; and water softener brine. ABANDONt4 r)4T When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is property and safely abandoned in compliance with ch. Comm 83:33, Wisconsin'Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: • A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. • A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. • The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. X Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. <<WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER C,C(` POWTS MAINTAINER ?� Name Name Phone -Phone SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name Agency S t C r x '`a Phone Phone 71.E -3,? — + �� Q This document was drafted by the stiffs of the Green take, Marquette and Waushara County Zoning and Sanitation agencies. This document meets :he minimum requirements of ch. Comm 83.22(2)(b)(1)(d)&(0 and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not guarantee the performance of the POVM. GMW (2/01) ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer Rle -Nal KoA %S Mailing Address /0 S79 / - / W Y w / Property Address /05 // Y /Z Qd Bps W/ /� (Verification required from Planning & Zoning Department for new construction.) City /State P019W 7s UP Parcel Identification Number Q 2 LEGAL DESCRIPTION 3 0 Prope Location N w 1/ L 1 /a S c. D T 9 N R ,� W Town of W /4��ET/ Pe y , `� _ e __, Subdivision , Lot # ZZV Certified Survey Map # 7� a T 0 I , Volume � , Page # Warrant Deed # 9 3 3 ,Volume OU ,Page # Spec house yes no Lot lines identifiable ye no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my /our knowledge. Itwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number o moms _ SIGNATURE OF APPLICANT(S) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) t via 3 Wisconsin Department of Commerce SOIL EVALUATION REPORT ,,,,,,..+.►r"" ') age of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County $' p i Attach complete site plan on paper not less than 81/2 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. O Revie by Date Please pr rsed C� q Personal information you provide may be for sivacy L , s. 15.04 (1) (m)). / Z / b Property Owner Property Location 8 , -� d , �U P- i� o d S E P 2 G of V (/1/ 1/4 1/4 G' T N R Property Owner's Mailing Address Lot # Block # CSA# d T. CROIX COUNTY P /o - 11,5 - �. � s s City State Zip C P El City ❑ Village Town Nearest Road 6 day W-T -5 0 ( `F'!.a ) 74 - 3 4 10 W"? t' ❑ New Construction User Residential / Number of bedrooms 4 Code derived design flow rate o C? GPD KReplacement ❑ Public or commercial - Describe: 6 ,?, t /' Flood Plain elevation if applicable ��` � Parent material ft s s ^r f q 1,f Cs General comments �-- and recommendations: Boring c� 7 F I Boring # Pit Ground surface elev. ! �'t ft. Depth to limiting factor in. Soil lication Rate Consistence Boundary Roots GPD/fP Horizon Depth Dominant Color Redox Description Texture Structure Co "Eff#1 °Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. f H- 4- 11,4 a El Boring a Boring # t�I Depth to q ,may pit Ground surface elev. ! 3- ft. lim factor ,� 7' in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots *Eff#1 *E in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Effluent #1 = BOD, > 30 220 mg/L and TSS >30 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS <_ 30 CST Number CST Name (Please Print ) ignature 6 C1 <)-t /Qs We,bs7�7",- Date Evaluation Conducted Telephone Number Address - > v / 71 � - - 3430 IJ f'r n, L rL. h n ls' tb �S :a T X � o a• Efl I V g �/ o No � � f coo F•t- t �* �, _ - � '�+,. n v f t a IIN - ;w �-j Itz T R x •� n� a- k �� 2 n r ° 3 - � � W U 2 0 0 8 P 5 9 6 s'rNrr nAR OF WISCONSIN FORM 3 - 1998 QUITCLAIM DEED t_= __9 Z�1� A� 1:3 C=� KATHLEEN H. WALSH REGISTER OF DEEDS Docwmrot Nw1ber ST. CROIX CO.. WI This Deed, made between RECEIVED FOR RECORD 10-11-2002 4:15 Ph Lisa Ann Koats Granlor. and REC FEE: 21.00 TRANS FEE: COPY FEE: Grantee. CERT COPY FEE: Grantor qijtlt Claims to GFatilee lite following destylbed real estate in PAGES: I S t . C r 0 1 x Cotinty. State of Wiscoissioc Awa Lot 2 of CSM 6/1528. being part of NW NE of i Naffm and Fletorn AckWe" See 20/T29N/R[8W, Town of Warren I Richard Dennis Koats 1059 Highway 12 Roberts, W1 54023 042-1055-50-100 A Parcel $deorlification Hurriber fl"114 This - i s homestead property. (is) (is not) Together with all appurtenant rights. title and Interests. Dated this day of (SEA1.) (SEAL) Lisa Ann Koats Ric Dennis Koats (SEAL) (SEAt.) AUTHENTICATION ACKNOWLEDGMENT State of Wisconsin, County. aothenticated this __ day of Personally came before rne this c" day a tl-m above named * Schleif Gherty TITLE MEMBER STATE BAR OF WISCONSIN to (if not. me known to be the person A2= who executed lite foregoing authorized by S706.06. Wis. Slats.) Instrument arid acknowledge lite same. THIS INSTFIUMENT WAS DRAFTED BY Gherty and Gherty, S.C. 328 Vine Notary Public. State of Wisco My colm"issio" Is Hudson, W1 540 16 permane". (if not. state expiration date: (Sigimutres may be authenticated or acknowledged. Both are not neces"ry.) In ay -p-Ity most be typed-pinted below t1wir signattdre. STATE BAR OF WISCONSIN Wtst:tmii. Legool Blaotk Cc, � W4 QUIT CLAIM DVED FORM Not. 3 - 1992 M111.0.6100. Wis • Parcel #: 042 - 1055 -50 -100 10/09/2006 04:11 PM PAGE 1 OF 1 Alt. Parcel #: 20.29.18.306E 042 - TOWN OF WARREN 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 RICHARD D KOATS O - KOATS, RICHARD D 1059 HWY 12 ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1059 HWY 12 SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 5.200 Plat: N/A -NOT AVAILABLE SEC 20 T29N R18W NW NE LOT 2 OF C.S.M. Block/Condo Bldg: 6/1528 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 20- 29N -18W Notes: Parcel History: Date Doc # Vol /Page Type 10/11/2002 693836 2008/596 QC 07/23/1997 978/186 WD 07/23/1997 793/135 07/23/1997 713/499 2006 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/19/2002 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.200 49,100 185,100 234,200 NO Totals for 2006: General Property 5.200 49,100 185,100 234,200 Woodland 0.000 0 0 Totals for 2005: General Property 5.200 49,100 185,100 234,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 104 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 V !02,a 451 CERTIFIED SURVEY MAP Q Located in the NW 1/4 of the NE1 /4 of Section 20, T29N, R18W, Town of Warren, h r St. Croix County, Wisconsin Surveyed for: Richard Hayhurst Rt. #1 Roberts, WI 54023 NORTH 'LINE OF THE NE 1/4 SECTION 20 U.S. HIGHWAY o ' ,. 11 12' 1 S89 55 39 E _ 379.98' 540.44' M N I/4 CORNER_ _ m S89 "E S89 0 55 ' 39 " E _ — NE CORNER SECTION 20 275.76 264.68' T29N, R ISW POINT OF BEGINNING �o 2 HOUSE 217507 SO. FT. 21656. . FT EXCLUDING RIGHT -OF -WAY EXCLUDING RIGHT -OF -WAY 226605 SO. FT. 225301 SQ. FT. INCLUDING RIGHT -OF -WAY D�, INCLUDING RIGHT -OF -WAY N w \ O x w ~ m LL K) O, .n 6� -!0, &1 CERTIFIED SURVEY MAP O Located in the NW 1/4 of the NEl /4 of Section 20, T29N, R18W, Town of Warren, (� St. Croix County, Wisconsin Surveyed for: Richard Hayhurst Rt. #1 Roberts, WI 54023 NORTH 'LINE OF THE NE 1/4 SECTION 20 U.S. HIGHWAY o "12" _ — S89 5_5 39 E _ 379.98' 540.44' io N 1/4 CORNER_ _ S89 * 39 "E S89055 "E _ _ NE C ORNER SECTION 20 275.76 264.68' T29N, R18W POINT OF BEGINNING 2 1 \O HOUSE 217507 SO. FT 21656 . FT EXCLUDING RIGHT -OF -WAY EXCLUDING RIGHT -OF -WAY 226605 SO. FT. 225301 SO. FT. n' INCLUDING RIGHT -OF -WAY 0 N INCLUDING RIGHT -OF -WAY W Q xW W M 0 W 1C) O O~i ZCf CD M 0) x to a CD it 00 (y) 1 °° C Z ? o ti , FILED W a W 1,- a JUi . 3985 O = W O W F- m O N a V �o CO W o ° w � t w lWwl�r 0 ° � o O emt O L' O O W N Z O Z, W Q i U- O W CY ° LEGEND W z °° COUNTY SECTION MONUMENT' Z \_ W O I "X 24" ROUND IRON PIPE Q J WEIGHING 1.68 LBS /LIN. FT. SET W W 0] Z. U 0 ROUND IRON. PIPE FOUND to O 1" ROUND' IRON PIPE FOUND ACCEPTED FOR LINE ONLY APPROVED JUN 0 51985 St. CA00( COUNTY COAirm"04MV2 PAWj fEi �"• %'' 276.54' 03100 4WA1A4 jW Z. N87003'35'TW. - _ 269.001 N83 42 59 8 IV 8p016 - 0.4 C. 81 N. W. R. R. Volume 6 Page 1528 d DEPARTYAENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDING 'LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON -SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: Wk, NE4 -R194 ® CONVENTIONAL ❑ ALTERATIVE (If assigned) �g > 2 of T v arren ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: David 6Jendt Box 334, Hammond, WI 54015 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP /MPRSW No.: County: Sanitary Permit Number: Henry Nechville 3258 St. Croix 119430 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV: WARNING LABEL LOCKING COVER PROVIDED ❑ YES ❑ NO [:] YES ❑ NO BEDDING: VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES ID No ❑ YES ❑ NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: P PUMP /SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF PUMP ❑ YES ❑ NO NEAREST --- 00- SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED /TRENCH WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID TRENCHES: MATERIAL: PIT DEPTH: DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: AIR INLET: NEAREST ---- 110- MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER I TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED /TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV: ELEV: DIA.: ELEV: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO I 1 ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ YES ❑ NO ❑ YES ❑ NO NEAREST ---- 10 Sketch System on Retain in county file for audit. Reverse Side. SIGNATURE: TITLE: SBD -6710 (R. 06/88) Zoning Administrator ®ILHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code CouN STATE SANITARY PERMIT # — Attach complete plans (to the county copy only) for the system, on paper not less than / / / /,3 8% x 11 inches in size. ❑ Check if revision to previous application —See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION — PLEASE PRINT ALL INFORMATION. PROPERTY OWN R PROPERTY LOCATION /(J 1 '/4 A14 :'/4,S .5?6 T q, N, R 3 E o OR PRPPERTY OWNER' M LING ADDRESS LOT # BLOCK # ,/ CITY STA E ZIP CODE PHONE NUMBER SUBDIVISION E OR CSM NUMBER rT 11. TYPE OF BUILDING (Check one) CITY NEAREST ROAD El $tat@ OWned ILLAGE ❑ J 1 Public L or 2 Fam. Dwelling -#� of bedrooms __ PA T NUMU ( 111. BUILDING USE: (If building type is public, check all that apply) .� L 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Home 10 ❑ Outdoor Recreational Facility 11 El Restaurant/Bar /Dining 7 Merchandise: sales/Repairs ❑ 3 ❑Campground 4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash 5 ❑ Hotel /Motel 9 ❑ Office /Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line Bit applicable) A) 1. ZNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit ## — Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 E Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 1 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) ELEVAJI Feet KK 6 6_TG VII. TANK / S ' ite ..+ . Cn allons Total # of Prefab. Fiber- xper. INFORMATION New istin Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass Plastic App Tanks Tanks structed Se tic Tank or Holdin Tank i- Y - Qv f ' Lift Pump Tank/Siphon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on t ttached plans. Plumber's Name (Pri t): Plumb 's Signature: ( o Stamps)_ MP PRSW No. Business Phone Number: Plumber' Address (Street, City, State, Zip Code): IX. COUNTY /DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater a e Liu Issuing Agent Signature (No Sps) IL Approved ❑owner Given Initial oi�^ �� Surcharge Fee) C �� A rm tin `1l7 X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS ' 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped a pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code.administrator or the State of Wisconsin, Safety & Buildings Division, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing addre�k. Provide the legal description and parcel tax number(s) of where the system is to be installed. 11. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. , GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. S8D4M8 (R.11/88) APPLICATION FOR SANITARY PERMIT STC -100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ------------------------------------------------------------------------------- Owner of property t_)nU)(cL of a)Wjr4hc W"f Location of property U UA /4 _ �V�1 /4, Section _ �O , T_<:;�> -R_W Township WQ"' ez) Mailing address Kj� Address of site Subdivision name Lot number Previous owner of property N hCrrall-, Total size of parcel Date parcel was created L",L_ 5 - /g8S ;� / Are all comers and lot lines identifiable? 1,- Yes No Is this property being developed for resale (spec house)? Yes v No Volume s and Page Number /r as recorded with the Register of Deeds. ------------------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. ------------------------------------------------------------------------------- PROPERTY OWNER CERTIFICATION I(We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. �i�`,� ©yam/ ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in thel Office of the County Register of Deeds, as Document No. 0 ). �)'."O Signature of Owner ign tune of Co -Owner (If Applicable) 79 _ 2za-�Z/spy Date of — Signature Date of Signature r - ��•(,i -c� �¢�''�R1N^� AND SAFETY &BUILDINGS DEPARTMENT OF REPORT ON OIL Bo (1 �{ DIVISION INDUS.7RY; 1 P.O. BOX 7969 LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707 HUMAN RELATIONS (H63.090) & Chapter 145.045) — NSIIIP� / pp OT NO.:BUC• NO.: SUBDIVISION NAME: LOCAl'InN. <;EC'fION:- WAtQT�� — NVj 1/4 fL1� Tz� N /Rr•� (o A COUNTY OWNE 1 ' R 24Z �o�E1�TS W1 S�o - s-r- Lkblk IL AY�O� I DATES OBSERVATIONS MADE US —_ S: A STS: -- -._ NCLBECIRM5.: COMM A PTION: ❑ReP 3, /�f35 4 L Z' /� ,New lace APhIL 7 Residence (INK � A —. _ -- _. - -- —�--- A M E Qy P>wt 59 SOILS ZSt�� �pI�S RATING: S- Site suitable for system U= Site unsuita f or system ros MOUND: IN-GROtJ� �� E: SY TE "IN� -FILL U T„r1UlJAL �onal) [�U CTS ❑U D QS S U if any portion of the tested area is in the TE: /� � If Percolation Testsar Ij T req.j e,A DESIGN RA SS Ftoodplain, indicate Floodplain elevation: A - ndr? ss _Hf33.Ot3(5)1b), indicate: 'V ,1 C- - ` ttt ttt PROFILE DESCRIPTIONS _ _FT IIORINC; TCITAL - P T R rV6'1�� INCHES TO BEDROCK I OBSERVE D (SEE ABBRV. ON BACK B- L N TEXTURE, AND DEP h -� O BSERV UMBER DEP'J'1 1 Mrt, ELEVATION 7 L d K 2.66' L AKI o ��. s tjcl L r6 -za M 4 S w /cob S 1 B- 3 , � 95.1 f Nor.tL > 60 — z8 -4o r�c:� S f 9R 40 -6.ct Cs f G12 W �o BhS,L ro -zS StL 25 -41 CS B- 4 6.0 �a bq' IJcN� > 60 �r 6ot cs rt G12 �-- -� - - Z4 -66' CS B- PERCOLATION TESTS Ce T - DROP l WATER LEVEL-INCHES RATE MINUTES TEST DEPTH WATER IN HOLE TEST TIME I PER INCH NUMBER AFTER SWELLING INTERVAL -MIN. ' T ___ _ � C 4 ZL t,f tt. z — 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 contal 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 lanri slope. SYSTEM ELEVATION 9 9?� NO�IZOh1Ti4C T���. �. ��,� V' , •S Nin 1 ._ — D 783.0' 1 r, ACeA 0 / -- rtr 4 s Z _- p _ rs 1 p , ,r r I SYsi r P I P a Ash A 7 [ n i iIGAL tf.tcu JylaRk rS SW Go2uE� OF [n iyc(2ET� PAa $GwtNt1 L.c�& Aouse: err LET I, the undersigned, hereby mortify that the soil tests reooried on this form were made by me in accord with the procedures and methods specified in the Wisconsin correct to the best of my knowledge and belief. Administrative Code, and that the data recorded and the location of theJ ests are COMPLETED ON: NAME (print)' �Q�Q IL Z / --- CERTIFICATION NUMBER: PHONE NUMBERInpironui � �j ,Z _DR E §S \,. I 46 7 S _T ST S I N A T U R E ny cn L<x:;d Auilm,11,, Pcnpc.rty Owntn and Soil Teste,, fit\ /FR ae - / DOCUMENT NO. I STe. 1 BAR OF WISCONSIN FORM 1 -19821 HIS SPACE RESERVED FOR RECORDING DATA 43030 aooK I I3 x,35 _ _— - - -- -- -- - kEGISTERS OFFICE This Deed made between . Ric_hard..Joh!a -- Hay.huXSt..and ..... S CROIX CO., WI& P�box ki.Gxace__ ayhuxs_t_,_._ sus_ b_and.. aad. wi. £e ............................. W& for Record this 7th i . Grantor, day of __ -- A.D. 1917 Oct - - - -- f: and ---- David __D_ _Wendt -. and.. Martha_ J_._- Wendt _,__husbanA.an,d...___..__. 8:30 A �! Haifa,_ surviv ors. hip_- mar- it-al-_ pxaPer_ ty------------------------------ - --- • ----- - - - -- ftwww !� -- --- - - - - -• --- .-- --- ---- -- - - -- -- ---------•------------------- ---- ----- ------------ - - - ---- Grantee, Witnesseth That the said Grantor, for a valuable consideration...... -------------------------------------- - - - - -- --- - - - - -- - - - - - -- - -- conveys to Grantee the following described real estate in -.St-.-Croix --------- County, State of Wisconsin: r River s P 1'afi; i�'�iscensin 540 Part of Northwest Q uarter of Northeast ' ' Q Quarter of Tax Parcel No_ ----------------------------------- !� Section 20, Township 29 North, Range 18 West`s described as follows: Lot 2 of Certified Survey Map filed June 5, 1985 in Volume "6 ", Page 1528. lC O TIP �I �I This ....... is..uot---------- homestead property. �I (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; l� And_ grantors.. Richard. _John.•Hayhurst_aud _Deborah ._ G - race - Hayhurst..................................... warrants that the title is good, indefeasible In fee simple and free and clear of encumbrances except !� easements, covenants and restrictions of record, if any, j { and will warrant and defend the same. i' S � . day of .----•-•------•---------------- •------ •--------- - - - - -- ..__... -- 1981 - - - -• (� 1 S Dated this _______ ____ _ _ __ _ _ ____ � - - - - P it ---- ----- ----- --- ---- -- -- ---- (SEAL) - ----- - - - ---- - .................... SEAL) RIC JO HAY * ------- - - - - -- - ------•--•-•-----••--- •-- •------- •••---- •-- •- - - -••. * - - -------- - - - - -- (SEAL) J j! ---- - - - - -- --•-----•---------•--- -- ----------- -- --- -- ----- -- - - -- .�o��--- `"rl4ict �FSEAL) I * DEBORAH GRACE HAYHURST I AUTHENTICATION i I ACKNOWLEDGMENT I ! I Signature(s) -------------------------------------------- - - -• -- ------ -- STATE OF WISCONSIN SS. i -- - - - -... -------- - - - - -- - - - -- - - - - -- - - -- -- -- - - - - -- - - - -- St. Croix County. --- - - - -__ -dQ of �I (' authenticated this -------- day of_________________ , 19 - - - - -- Personally came before me this -- •--- .- - - - -Se telitb.er ---------- - - - --- 19. __ the above + - - - - - -- ' --------------------- - - - - -- � ve named ._.... Richard -_ John-- Hayyhurst-- azrd__ -____ i I i� , * - -------- - - - - -- - - - --- - - - - - - ------------------------------------ - - - - -- -------- Grace.• H. a- yhuxst---------------------------------------- TITLE: MEMBER STATE BAR OF WISCONSIN -- - - - - -- ------------------------------------------- e (If not, ---------_---- ---------------- ........... ........ --------------------------------------------------- authorized by § 706.06, Wis. Stats.) to me known to be the person s__::___ c• , foregoing Instrument and ackno@!etlt the'k e r ' V j THIS INSTRUMENT WAS DRAFTED BY V% HEYWOOD , C_ AR_I_ & HURRAY � m "' by Samuel R. Cari --- -St. -- Croix:'' ; fIuds 01T;• - WI - -- Notary Public 5r4f?ifr .� - ount,1 ill (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (I4•.,Ii r 'State•• are not necessary.) �� �� 1 • p n r -,� date _ '��,;+r ! ll *Names of persons signing in any capacity should be typed or printed below their signatures. ,C 1 WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co. Inc. FORM No. I — 1988 Milwaukee, Wis. r .+ l STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St.-Croix County OWNER / BUYER h 1U n r +hc, )JE n UT ROUTE /BOX NUMBER R + I FIRE NO. CITY /STATE Rolae.r ZIP GUO'D hh �� A" � PROPERTY LOCATION: /J IJ Q /9 G' 1/9, Section C2� Q , %0 N, R_J_LW, Town of Z "AAayc_ , St. Croix County, Subdivision , Lot No.. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED SEPTIC TANK PUMPER. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County Residents MAY be eligible to receive a grant for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. I /WE, the undersigned, have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED A n� c' DATE � p ff St. Croix County Zoning Office St. Croix County Courthouse 911 9th Street Hudson, WI 59016 (715) 386 -4680 Sign, Date, and Return to above address INDU, S T R Y , tT Of REPORT ON SOIL BORINGS AND SAFETY &BUILDINGS INDUTRY, DIVISION LABOR AND PERCOLATION TESTS (115 MADISON WI 53 0 HUMAN RELATIONS (H63.090) &Chapter 145.E1451 L C/'.71?5N � - E7ITN NOT NO. BLK. NO.: SUBDIVISION NAME: NW 1 /4NC 1 / Tz9 N /R/axio -- COUNTY WNE /� •5-t- r!�y ILK IIAY►• oU - , - r I &v 24Z Fo"e% W# S4aZ US _ DATES OBSERVATIONS MADE MMERCIAL DESCRIPTION: FI 150CRIPTIUNN: [�_ R _ .sidence K ►J A K I �PEL 23, /�85 4 Pe# L• New ❑Replace P,oGE 59 S C1►LS taoC Aw ful JOILS ra RATING: S- Site suitable for system Ud Site unsuitable for system Y1TNA'C' MOUND: IN- -FILL OLDING TANK: RECOMMENDED SYSTE (optional) , ills [I a s au ❑ s ❑u a s [:)U Lo�►JE �I fIONAL 9h F ercolation Tests are NOT re uired DESIGN RATE: 4 If any portion of the tested area is in the A er s.H63.09(5)(b), indicate: /�,Q , CCjdSS .L l F loodp l ai n, NA indicate Floodplain elevation: r-r PROFILE DESCRIPTIONS BORING TOTAL U D A E •I CH C A A SOIL IT T KN , COLOR, TEXTURE, AND DEPTH NUMBER DEFTFN f�0, ELEVATION g E V TO BEDROCK IF OBSERVED SEE ABBRV. ON BACK.) B I �.6" sl..�6 Nr,NL- > 67 # 0 -►3 A Re% <aIL i3-2T LhSIL 2>-"o S I I 'i ! 6: • z (,.o� ��.&4 / 0/.1 > 6 b� ®,o o(K kK - �61L `5i kl- 6C 46A+Kt <, >F 6P, dAg L ►O - Mel! S w Cob ♦ ST �S.I 1� NokL > 6o Za -40 m eol S 4 9R 4o -&dt cs +sit w cs-►o A ^S,L iO -zs S 2S -41 C-S B. 6.0 S a •6q &I oriF_ 7 6D " 41.60* cY,+6k B- 6•a 9$ .zz' Noun >60' 0 -l1 d k B„SiL 11 -24 S,L 24- C'S. W1 6k, B. T PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEE-INCHES RATE MINUTES NUMBER AFTER SWELLING INTERVAL -MIN. PER INCH P_ _ 4.1 14oNe z >6 <3 it 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. SYSTEM ELEVATION 99.2 � .. � -z HottzosiXrAC iar. h. • nS o. ID W 783 0 t► i1 r ��cafE ►�=I� �eLroE.EMertY I NC QCA rrr r ! I Y 10h1 5, 5 S �h i r 1 '1 D a z S a I P f�3 c �� TrX4�f 'SY STCM J AU P ''- t c --► N eras, S4eP .__ a,:5 b nfaa • (y i•` .s'7..� L C n I � �: e l 6kw N &T Ve: rK�'L U MIARK 1 1 'SW .CONE@ � ©F Con►CQrTli PA 86mIND LcA� NaUs.; APPfdkiMX7t LY i5o' E.rST oS= 7//K LoT. 1, 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 are correct to the best of my knowledge and belief. NAME (print ): TESTS WERE COMPLETED ON: 14 -ow el G 3614 -s Ai�eiz, z1 /Is ADDRESS: —, CERTIFICATION NUMBER: JPIHONE NUMBER (opt ionai): 46 -7 S& ea r�S 14L, W s4 ©1 34a �,5� -4o» CST SI NATURE: DISTRIBUTION: 01 i Prail and one copy in Local Authority, Properly Owner and Soil Tester. L !1)S F4Fi- 5fin- h' Ifi Cr71R?) OVER - ' of "Intl slope? . SYSTEM ELEVATION , �OZ z AL s. } ib it - f .try ! v - !co`.r... - ;1 C -� N C GIN S, •f� �. f..A Y;-_ ' -,.':. �' �. +�4 1 - f _. n �ENICu MaQk �5 51ht G^CnEk- a�F Conc E PA A $GulNt - --- .. "'�" - '^ ^' •ti....ni.ltasxs_[epgrted . on this form were made by me in scrord with the procedures and methods speciluxl in tlw 4'V�:cunsui 4, "w1odQR -w-0 belief. v ca , z