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Wrscogsk Department of Commerce PRIVATE SEWAGE SYSTEM county: St. Croix
,Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 483959 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:
Thorsen, David S. Warren, Town of 042 - 1104 -30 -000
CST BM Elev: 95 Insp. BM Elev: BM Description: Section/Town/Range/Map No:
�6 20.29.18.575
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic (,U Benchmark
l� 3.S gyp. 54
'f { ��✓ 2 (0 r' Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet �.
St/Ht Outlet `,
TANK SETBACK INFORMATIO "7. 2,r
TANK TO 1 /L L WELL BLDG. Vent to Air intake ROAD Inlet
n r
-1215
Septic J v l Z Z J Q wT 1� 7 a d 0
Header/Man.
�
Aeration V Dist. Pike
Holding Bot. Syste m 5' O k
S Ye a 0.
PUMP /SIPHON INFORMATION Final Grade
�j 3•S So
Manufacturer Demand St Cover
GPM
Model Number GiL
TDH Lift Friction s P Head TDH Ft ,v 97 D
Forcemain Length Well S� /
SOIL ABSORPTI N SYSTEM 23
BEDITRENCH Width I Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 2 ! t4-
SETBACK SYSTEM TO P/L BLDG WEL LAKE /STREAM ( ACHING M n actu F"" 14
INFORMATION MBER O
Type f System: / ' ��
Model umber:
DISTRIBUTION SYSTEM S " (�
Bader nifold Distribution ' _ - 7 x Hole Size x Hole Spacing Vent t it t_a / ke
1 (4 4 Pipe(s)� / /
Length Dia Length Dia Spacing 3 s ��
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only 4 D
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center / Bed/Trench Edges Topsoil
0 Yes 0 No I ❑ Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: - 7/ /I D � Inspection #2: ! /
Location: 1094 89th Avenue Rpberts, WI 54023 (NE 114 NE 1/4 20 T29N R1 8W) Pleasant Acres Lot 3 Parcel No: 20.29.18.575
1.) Alt BM Description = 0 t- S
2.) Bldg sewer length= � 5 n )/Qi
- amount of cover =
r � Plan revision Required? Yes �. No L j I F—
Use other side for additional information. �U
SBD -6710 (R.3/97) Date Insepctoe Signat
a Cert. No
III
r
T PLAN
PROJECT David Thorsen ADDRESS 1094 89th Ave Roberts Wi 54017
NE 1/4 NE 1 /4s 20 /T 29 /R 18 W TOWN Warren COUNTY ST. CROIX
MPRS Shaun Bird 226900 DATE7/25/10 BEDROOM 3
CONVENTIONAL XXX IN -GRO D RESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000/261 LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 925 # of chambers 46
BENCHMARK V.R.P. Bottom of siding ASSUME ELEVATION 100' Filter BEST Filter
❑ BOREHOLE O WELL * H. R. P. Same as Benchmark
Well is to meet all SYSTEM ELEVATION 88.5/88.1 7.5' below qrade
setbacks required by
WDNR Hwy 12
Scale is 1" = 40'
unless otherwise
100'Plans Designed Using noted
Conventional Powts Vent
Manual Version 2.0
>6 „ Quick4 Standard Low -
Vent Profile Leaching
5'
Failed Drainfield of Cover Chamber
U —T with 20.0 ft2 of Area
4' Long 2.8ft ^2 /pair of end caps
Grade at System Elevation
75'
34"
20' Valve (' le) Weeks 261 Filte tan
25 ,
S 2- 3' X 4' ells wit >3' spacing
45' �'t' >25' e '
B -3 B.M.* 40' 10,
5t7o Slope Existing 3
BedroomHouse
3
S�
B- 96 '
5 Vents
y
89th Ave
e.V -4 90V Safety a nd Buildings Division County ^ 201 W. Washington Ave., P.O. Box 7162 At
Madison, WI 53707 -7162 Sanitary e�itNumber (to be filled in by Co.)
Cotnrnel+t=e S 5
State Transaction Number
Tiumber
Sanitary Permit Application N j
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate govern mental
unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Project Address (if different than trailing address)
submitted to the Department of Commerce. Personal information you provide may be used for secondary
u oses in accordance with the Privacy Law, s. 15, l m , Stets.
I. licstion Information - Please Print All Informati Parcel #
Property owner's Name
Property Location / G
property Owner's Mailing Address Of ` aJ
D 7 [ � ST. cHOlx COUNTY Govt. Lot �
Zip Code /v /. %.,'�. Section Z
City, State role on
1 U 0 — / T�N; R _ E W
Lot #
II. ype of Buildlttg (check all apply) Subdivision Name
Family Dwelling - Number of Bedroo — CIO 9 j�
Block # /
❑ Public/Commerciai - Describe Use r- ❑ City of
CSM Number ❑ Village of
❑ State Owned -- Describe Use — Town of
�,✓ Zia -2�3 C_l•�a. �—
III. Type of Permit: (Check only one ox online A. Complete line B if applicable
A El Other Modification to Existing System(cxplain)
❑ New System lacetnent System ❑ Treatment/Holding Tank Replacement Only
B. [I Permit Renewal C1 Permit Revision List Previous Permit Number and Date Issued
❑ Cha a of Plumber ❑ Permit Transfer to New
Owner
Before Expiration . G
IV. T e of POWTS S stemlCom enent/Device: Check all that apply)
- Pressurized In- Ground (I Pressurized In- Ground ❑ At -Grade ❑ Mound >_ 24 in. of suitable soil [I Mound < 24 in, of suitable soil
❑ Pretreatment Device (explain)
El Holding Tank ❑ Other Dispersal Component (explain) _ ` J !
V. rsal/Treat Dis nt Area Information 5 : stem Eleva to
De si Flow (gpd) Design Soil Applica Rate(gpdgt) Dispersal Area Required�§f) Dispersal ea Propo (sfl Y O J �
Capacity in Total # of Manufacturer E c
VI. Tank Info +'
Gallons Gallons Units � d U
Existing Tanks
New Tanks 8 s a V w p"
_ ��! --
Septic or Holding an � *�
Dosing Chamber
VII. Responsibility Statement I, the undersigned, assn aponsibllity for installation of the POWT MPIMPRS 00 the Numbeached plans. ess Phone Number
plum er Name (Print), Plumbe ' ature
Plumber's Address (Street, City, State, Zip Code
VIII. oun /Dep artment Use Only issuing A ignature
Permit Fee Date Is ed g
pproved Disapprove $ zJ - C �72
teen Reason for ial
IX. Condit -f-A sons for Disapproval
$splia tank, tltiltlfM filter and
dispersal cell must all be sery ices / maintained
ft per management plan provided by plumber.
Z., A# ootbii k requirements must be maintained
Attach to compkte p na or t e system and submit to the County Daly en paper not less than S V2 x It Inches in size
t
:q
SBD -6398 (R. 01 /07) Valid thm 01109
r
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County 3� j . C Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must I
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. 4#Z w
Please print all information. Revi ed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 7 ZL
Property Owner Property Location
Cam.- - T t- 0 r j t Lot# t 1/4 >� 1/4 ) T .2 , 9 N R E (or
Property Owners Mailing Address Block # Su bd. Name or CSM#
o $ ?�� —
Cily State Zip Code Phone Number ❑ City ❑ village Town Nearest Road
W ti I 00,3 I ( I A- re z
❑ New Construction Us Residential / Number of bedrooms _ Code derived design flow rate yJ Z7 GPD
Replacement ❑ Public or commerce 7'
Parent material 7 E,2,hwl1N(r � QFF levation if applicable
General comments
and reconwriendations:
System Ty pe O evation
F T1 �� # �BOrir1g
pit Ground surface elev. ft. Depth to limiting factor !/� in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color ` Gr. Sz. Sh. n 'Eff#1 •Eff#2
L a r S� �- !
Ir
Fg� # Boring
pit Ground surface elev. S� �� ft. Depth to limiting factor - �C�� - "'.
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
�I
' Effluent #1 = BOD > 30 < 220 mg1L and TSS >30 < 150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) S' re CST Number
Bird Plumbing, Inc. Shaun Bird 226900
Address Date Evaluation Conducted Telephone Number
1008 192nd Ave, New Richmond, WI 54017 �– — 715 - 246 -4516
Property Owner _ Parcel ID # Page of
113-1 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/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
7 1-1 Y
qD
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor )n• Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2
E Ong # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil Application Rate
Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I - Eff#2
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/_ ' Effluent #2 = BOD < 30 mg/_ 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 (8.6100)
Property Owner _ Parcel ID # Page of
Boring #
F131 Boring 01
.pit Ground surface elev. ! � � ft. Depth to limiting factor � / 7 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
tt
9a
a 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 I GPDIff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
F-1 Bor,ng # Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil ligtion Rate
Horizon 1epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
Effluent #1 = BOD > 30 < 220 ng/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.
Sa - 8130 ee.c/aoi
Soil Test Plot Plan
Project Name David Thorsen Shau ird
Address 1094 89th Ave
Roberts Wi 54023 C M #226900
Lot 3 Subdivision PleasantAcres pa 7125/10
NE 1/4 NE 1/4S 20 T 29 N /R W Township Warren
Boring Q Well PL Property Line County ST. CROIX
BM or VRP Assume Elevation 100 ft. Bottom of Siding
System Elevation 88.5/88.1 *HRpSame as Benchmark
Hwy 12
AL
Scale is 1" = 40'
unless otherwise
100' noted
Vent
5 Failed Drainfield
75'
20'
B- 0' 50'
25'
ST
45' >25' Well
95' 25'
B -3 B.M.* 40' 10'
5% Slope Existing 3
BedroomHouse
B- 96'
95'
89th Ave
Cover Page
Shaun Bird
Bird Plumbing Inc.
1008 192nd Ave
New Richmond Wi 54017
715- 246 -4516
i
Date: 7/25/10
Owner: David Thorsen
Location:NE1 /4 NE1 /4 S20 T29 N,R18W 1094 89th Ave Warren
System type. In- ground absorbtion system(conventional)
Manuals Used: In- ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. Chamber Cross Section
4 -5. Maintanance and Contingency Plan
6. Filter Specifications Sheet
7. Utilization of Existing S ptic Tank form
8 -10. Soil Test
Signature
License num r K26900
T PLAN
PROJECT David Thorsen 1 29/R DDRESS 1094 89th Ave Roberts Wi 54017
NE 1/4 NE 1 14S 20 / 18 W TOWN Warren COUNTY ST. CROIX
7/25/10 3
MPRS Shaun Bird 226900 DATE BEDROOM
CONVENTIONAL XXX IN -GRO D RESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000/261 LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 925 # of chambers 46
BENCHMARK V.R.P. Bottom of siding ASSUME ELEVATION 100' Filter BEST Filter
❑ BOREHOLE O WELL H. R. P. Same as Benchmark
Well is to meet all SYSTEM ELEVATION 88.5/88.1 7.5' below qrade
setbacks required by
WDNR Hw 12
Scale is 1" = 40'
unless otherwise
100'Plans Designed Using noted
Conventional Powts Vent
Manual Version 2.0
> 6„ Quick4 Standard Low -
Vent Profile Leaching
5'
Failed Drainfield of Cover Chamber
with 20.0 ft2 of Area
4' Long 2.8ft ^2 /pair of end caps
Grade at System Elevation
75'
34"
20' Valve (if possible) Weeks 261 Filter tank
B- 0' 0'
25'
S' ST 2- 3' X 94' cells with >3' spacing
45' >25' Well
95' 5'
B -3 B.M.* 40' 10'
5 0 10 Slope Existing 3
BedroomHouse
B- 96 ,
95'
Vents
89th Ave
Cross Section of Quick 4 Standard Low Profile Leaching Chamber
Typical cross section for 2 of 2 cells
Quick 4 Standard Low - Profile Leaching
Chamber with 20.0 ft2 of Area per
Chamber 2.8ft ^2 pair of end plates To be >1' above grade
Finish grade elevation
Typical Installation 95.0'
Vent AC Grade �► 1 Y , e n t
4' 4" � �30/34 Septic Tank
4' Long 5 3 4" Grade at System Elevation 3 4 Grade at System Elevation
Spacing 5'
2 -3' X 94' Cells
Same on other end Observation tubeNent
To be Located on ends
A
B
23 chambers per cell
System elevations:
A
B`_88.1
Maintenance and Contingency Plan for a Septic System
Maintenance Plan
1. Septic Tank is to be pumped once every 3 years.
2. Effluent filter is to be leaned once a year. Please note: a larger filter is being installed In
order to extend the maintenance interval of the filter.
3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of
the cells.
4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system.
5. The owner agrees to save this plan.
6. Do not plant trees nor park nor drive over system.
7. Watershed is to be diverted away from system.
8. Discharge into system is not exceed those required as per Comm. 83
ing y Plan
p ' #1. system fails, determine cause of failure, use alternate area and install new
e ed replacement area.
Option #2. nstall system at a lower elevation, by removing chambers, removing biomat,
"and in ew system.
Option#& No adequate area is suitable for replacement area, and system elevation
cannont be lowered. Install holding tank as last resort.
3. Replace any other failing components as needed.
Plumber: Shaun Bird 715 - 246 -4516
St. Croix County Zoning 715 - 386 -4680
Pumper Tom Mondor 715 -246 -5148
Shaun Bird #226900
i
ST. CROI K COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTMCATION FORM
OwnerfBuyer �D a J _JLC ��e ^
Mailing Address l `f g � a F 1 ,c�� <5 ` l�
Properly .Address
(Verification required from Planning & Zoning Department for new construction-)
City /state Parcel Identification Number 0 I D L i t " 3�j
EGAD, DESCRIPTION r-
t 1a , Sec. L T N R W, Town of � 176 N✓
Property Location �_ 1 /a , � '
Subdfv on 1 '� -c.�� avv� �;� -- - - , Lot # -
CertiSed Survey Map # , Volume , Page #
Warranty Deed # Volume /� i , Page #
Spec louse yes
Lot lines identifiable yes 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 fiu chon of the septic tank as a treatment stage m the waste disposal system Owner maintenance
responsibilities are specified in §Comm 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
Tire property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a mas ter plumber. �ournayman ' plumber, restricted plumber or a licensed pumper vw&fiflg that (1) the On-site
wastewater disposal system is in proper operating condition and/or (2) alter inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
Uwe, the undwegued have road the above requirements and agroe to maintain the private sewage disposal system with the
standards set forth, heroin, as sot by the Department of Comnnerca and the Department of Natural Resources, State of Wisconsin.
County P St. Qroix Coup
Certification stating that your septic system has been maintained mast be completed and returned to the 1aIImnS &
Zoning Department within 30 days of the three year expiration date.
I/we certify that all statements on this form no true to the best of my/our knowledgo. l/wo am/art the owwer(s) of tbc
property described above, uty deed recorded in Register of Deeds Office.
I
Number of b
- 7 J
_�)_ - GNATURE OF APPLICANT(S) DATE
** *Any information tbat is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *'*
Inchidc 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.
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ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
Phis is to certify that I have inspected the septic tank presently
serving the A p r Spiv✓ reside ce located at:
Section I l> T N, R I W, Town of
6 sa r $ Upon inspection, I certify that I have found
the tank and baffles to be in good condition, and it appears to be
functioning properly.
mast time serviced:
3
Did flow back occur from absorption system?
Yes No (If skip next line)
Approximate volume or length of time: gallons minutes
:rapacity: !�
Construction: Prefab Concrete Steel Other
manufacturer: (If known):
Age of Tank ( f known),:
(Sig re) (Name) Please print
(Title) (License Number)
Date
Form to be completed by licensed plumber (s.145.06, Wisconsin
Statutes) or 'Licensed Disposer (NR 113 Wisconsin Administrative
Code)
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR 83, . Adm. Code (except for
inspection opening over outlet baffle
Signatu
MP/MP �� ��C/ ��
tG
VOL 1461 PAGE 268
61 156
STATE BAR OF WISCONSIN FORM 2 - 1998 KATHLEEN H. WALSH
Document N r WARRANTY D REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made between Rosemary Thomason, a stnele nerson RECEIVED FOR RECORD
10-05 -1999 2:00 ph
Grantor, conveys and warrants to David S Thorsen and Amy S Thorsen 11RRRAMTY DEED
husband and wife EXEMPT N
CERT COPY FEE:
COPY FEE:
Grantee. TRANSFER FEE: 273.00
Grantor, for a valuable consideration, conveys and warrants to Grantee RECORDING FEE: 10.00
the following described real estate in_ 5j _ .Qr _ oix County, State of Wisconsin (The PAGES: 1
"Property"):
Recording Area
Name and Return Address
a - 19c0co
042- 110430.000
Parcel Identification Number (PIN)
This I s homestead property.
Lot 3, Pleasant Acres in the Town of Warren, St. Croix county, Wisconsin.
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this A $ day of October, 1999.
67 A
s *
Rokemary Thompson 0 -
ACKNOWLEDGMENT
STATE OF WISCONSIN )
AUTUENTICATION ) ss.
f . 60 ('/ County )
Signature
Personally came before me this / day of October ,
authenticated this day of October, 1999. 1999, the above named IQOSeMGLI cw TA&/no -rorl
tv me known to be the
person(s) who executed the foregoing instrument and
* Kristin Ogland acknowledge the same.
n
TITLE: MEMBER STATE BAR OF WISCONSIN
*
(If not, Notary blic, State of Wisconsin
authorized by § 706.06, Wis. Slats.) My Commis on is permanent. (If not, state expiration date:
THIS INSTRUMENT WAS DRAFTED BY
Attorney Kristin Ogland
Hudson, WI 54016
(Signatures may be authenticated or acknowledged. Both are not
DIANE M. BARRON
necessary.) Notary Public
State of Vsconsin
+ o signing in an capacity should be d or
i Names of persons s g ng y p ty type printed below their signatures p
W ARRA 1TY DEED STATE BAR OF WISCONSIN
FORM No. 2 - 19M
INFORMATION PROFESSIONALS COMPANY FOND DU LAC. W 800. 855 -2021
THE NE 1/4 OF SECTION 20
8 W, ST CROIX COUNTY, WISCONSIN
BEGINh
NE CORNER OF I
UNPLATTED LANDS 1
•- - - -- SECTION 20 T29N 1 66' j- UNPI
- -- N 89 °23_10 "E V2625.l7'. - - - -_ - -_ _ -- --- ^----- - - RlBW ^ —� J S�0 °I115�'l
M 33.00
SOUTHERLY RIGHT -OF- , „ t0 -
N 89 960.59 WAY LINE cn i 0 °41 50 !99.23' M "
27Q°Q$ 50
s 0° 190.02 190,02' O �o° S 89 ° 57'35 "E p Mo 11
�O O 0 190.02
0 0 `r0• 00' ° 0 ° � s o- 166.23' °�� POINT
O••
N89 O'35'E 0°' I
- - - -- ------- - - - - -� _- -------- - - - - -- - - - - ------------------ 1 ' - - - - - -- 33' 33'
BUILDING SETBACK 6 6' I
w LINE
to 0 I
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f N T °19 94.76 a 190.00 190.00' o- 177 O F O' ! �+
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- �-- M 844.66 cn I z
7ACRES 03 N 89 65E.56 M
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ST. °CROIX COUNTY, WISCONSIN 37
The C horizon is 0 to 15 percent coarse fragments. deteriorate and has reduced the content of organic
The subsoil is strongly acid or medium acid, and the matter in the surface layer,
substratum is slightly acid to strongly acid. Most areas of this soil are cultivated. The soil is
k Jewett soils are near Santiago and Sattre soils and suited to oats, alfalfa, and a limited amount of corn.
Jewett, sandy substratum. They have a darker A hori- Controlling erosion and maintaining tilth and organic
zon than Santiago soils. They have a B horizon that matter content are important factors of good manage-
formed mainly in reddish till rather than in the outwash ment. Capability unit IIIe--1; woodland group 2o1.
sediment typical of the Sattre soils. They have a C JsA— Jewett silt loam, sandy substratum, 0 to 2 per -
horizon that contains less sand than Jewett, sandy cent slopes. This soil is on benches and large drainage-
substratum, soils. ways of ground moraines. It formed in reddish sandy
JeA Jewett silt Ioam, 0 to 2 percent slopes. This loam till underlain by sand and gravel. Most areas are
soil is on till plains of ground moraines. Most areas are oblong and range from 10 to 60 acres in size.
oblong and range from 10 to 40 acres in size. This soil has a profile similar to the one described as
This soil has a profile similar to the one described as representative of the series, but the substratum con -
representative of the series, but the surface layer is tains more sand and gravel and the surface layer is
dares` and the silt mantle is slightly thicker in most darker colored.
Places-, Included with this soil in mapping are a few small
fnoded with this soil in mapping are a few areas areas of Jewett, Pillot, and Sattre soils.
wl the soil is underlain by heavy loam or light clay Runoff is slow, and the hazard of erosion is slight.
low .A: and a few small areas of Jewett, sandy sub- Available water capacity is moderate, and permeability
foils and Sattre soils. Also included, mainly in in the substratum is rapid. Natural fertility is medium.
d ' lye's, are small areas where the surface layer Most areas of this soil are cultivated. The soil is
is..' bred and 20 to 30 inches thick and a few moderately well suited to corn and other row crops.
s - ssions where the silty mantle is 30 to 60 Maintaining organic matter content and soil structure
are important factors of good management. Capability
'+ slow, and the hazard of erosion is slight. unit IIs- -1; woodland group 2o1.
reas of this soil are cultivated. The soil is JsB— Jewett silt loam, sandy substratum, 2 to 6 per-
Ito such row crops as corn. Maintaining soil cent slopes. This soil is on benches and large drainage -
d organic matter content are important ways of ground moraines. It formed in reddish sandy
od management. Capability unit h--4; wood- loam till underlain by sand and gravel. Most areas are
01. oblong or irregular in shape and range from 10 to 120
ett silt loam, 2 to 6 percent slopes. This acres in size.
es and till plains of ground moraines. Most This soil has a profile similar to the one described as
Tong or irregular in shape and range from representative of the series, but the substratum con-
in size. This soil has the profile described tains more sand and gravel.
tive of the series. Included with this soil in mapping are a few small
th this soil in mapping are a few areas areas of other Jewett soils and Sattre soils. Also in-
1 is underlain by heavy loam or clay loam eluded are a few areas where slopes are less than 2 per -
as of Jewett, sandy substratum, soils and cent or more than 6 percent.
`knolls and along drainageways and small Runoff is slow, and the hazard of erosion is slight.
here the silty mantle is 30 to 60 inches Available water capacity is moderate, and permeability
hided are a few small areas where slopes in the substratum is rapid. Natural fertility is medium.
s than 2 percent or more than 6 percent. Most areas of this soil are cultivated. The soil is
w, and the hazard of erosion is slight. moderately well suited to corn, soybeans, oats, and
of this soil are cultivated. The soil is alfalfa. Controlling erosion and maintaining tilth and
brn, oats, and alfalfa. Controlling erosion organic matter content are important factors of good
g tilth and organic matter g e content are management. Capability unit Ile-2; woodland group
i s of good management. Capability unit 2o1.
group 2o1.
silt loam, 6 to 12 percent slopes, Lawler series
1-11 is on ridges of ground moraines.
elongated or irregular in shape and The Lawler series consists of nearly level and gently
15 acres in size. sloping, somewhat poorly drained soils in depressions
Profile similar to the one described as and drainageways of stream terraces and outwash
the series, but the surface layer and plains. These loamy soils are underlain by sand and
.r• gravel. Native vegetation was mainly sedges and other
this soil in mapping are a few small water - tolerant prairie grasses. The subsoil of these soils
few small convex areas where the soil is saturated with water for relatively long periods dur-
,, and areas where the soil is underlain ing the year.
imestone bedrock at a depth of 4 to 6 In a representative profile the surface layer is silt
d are a few small areas of Jewett
loam about 13 inches thick. In the u er art ' '
ils and a few areas where slopes and in the lower part it is very dark grayish brown. The
nD 6 percent or more than 12 percent. subsoil is about 26 inches thick. In the upper part it is
m, and the hazard of erosion is mod- brown and ra ish brown fri 1
as erosion has caused the tilth to and in the lower part it is grayish b own, friable, loam
mot-
SAFETY AND BUILDINGS DIVISION
Plumbing Product Review
commerce.wi.gov P.O. Box 2658
Madison Wisconsin 53701 -2658
s co ns�■ n TTY: Contact Through Relay
I t i lepartment of Commerce Jim Doyle, Governor
Aaron Olver, Secretary
June 3, 2010
INFILTRATOR® SYSTEMS INC. INFILTRATOR® SYSTEMS INC
GOVERNMENT AFFAIRS DEPARTMENT DAVID LENTZ
6 BUSINESS PARK RD 6 BUSINESS PARK RD.
PO BOX 768 PO BOX 768
OLD SAYBROOK CT 06475 OLD SAYBROOK CT 06475
Re: Description: LEACHING CHAMBER
Manufacturer: INFILTRATOR® SYSTEMS INC
Product Name: (was 20090165) QUICK4 PLUS STANDARD (MODIFIED) , QUICK4 PLUS STANDARD
LOW PROFILE (LP) LEACHING CHAMBERS AND END CAPS
Model Number(s): QUICK4 PLUS STANDARD, QUICK4 PLUS STANDARD LOW PROFILE (LP) INCLUDING
QUICK4 PLUS ENDCAP AND QUICK4 PLUS ALL -IN -ONE ENDCAP OPTIONS WITH TOP, END,
OR SIDE PIPE INLET CONNECTIONS USED SINGLY OR IN PAIRS AT ENDS OF CHAMBER
LINE, OR AS A MID - CHAMBER LINE CONNECTOR
QUICK 4 PLUS STANDARD, MODIFIED, DIMENSIONS: 52.0 IN L. X 34.0 IN. W X 12.0 IN H
QUICK 4 PLUS STANDARD, LOW PROFILE, DIMENSIONS: 52.0 IN L. X 34.0 IN. W X 8.0 IN H
[EISA for chambers with or without fabric = 20.0 sq. ft. /chamber, EISA for Quick4 Plus All -in -One
Endcap installed at the ends of a chamber row = 4.6 sq. ft. /pair of end caps, EISA for Quick4
Plus All -in -One Endcap nstalled in -line within a chamber row = 1.9 s . ft. /end cap; EISA for
p q P
Quick4 Plus Endcap installed at the ends of a chamber row = 1.4 sq. ft. /pair of end caps; Laying
length of chamber = 4.0 ft., Laying length of Quick4 Plus All -in -One Endcap installed at the end of
a chamber row = 1.1 ft., Laying length of Quick4 Plus All -in -One Endcap installed in -line within a
chamber row = 0.9 ft., Laying length of Quick4 Plus Endcap installed at the end of a chamber row
= 0.4 ft., Width — 34 QUICK n rd Height = 12 inches, QUICK4 Plus Standard
Low Profile Height inches; Max. depth of bur = 8 t QUICK4 Plus Standard Open Bottom
area = 9.8 sq. ft. /cham r, us an a ow Profile Open Bottom area = 9.68 sq.
ft. /Chamber; Open Bottom = 2.8 sq. ft. /pair of Quick4 Plus All -in -One Endcaps installed at the
ends of a chamber row, 1.4 sq. ft. /single Quick4 Plus All -in -One Endcap installed in -line within a
chamber row, 0.8 sq. ft. /pair of Quick4 Plus Endcaps installed at the ends of a chamber row]
Product File No: 20100248
The specifications and /or plans for this plumbing product have been reviewed and determined to be in compliance
with chapters Comm 82 through 84, Wisconsin Administrative Code, and Chapters 145 and 160, Wisconsin
Statutes.
The Department hereby issues an approval based on the Wisconsin Statutes and the Wisconsin Administrative
Code. This approval is valid until h n f
pp d u t the d o August 2014.
This approval is contingent upon compliance with the following stipulation(s):
• This product must be installed in accordance with the manufacturer's printed instructions, product approval, and
plan approval. If there is a conflict between the manufacturer's instructions and the product approval and /or plan
approval, the product approval and /or plan approval will take precedence.
• When this product is installed in a dispersal cell that is sized based on the EISA rating stated in the regarding
block of the product approval letter, this product must receive wastewater having a BOD5 value between 30 and
220 mg /L and a TSS value between 30 and 150 mg /L.
• When this product is installed in a distribution cell that is sized based on the EISA rating stated in the regarding
block of the product approval letter, this product must be installed in individual excavations that create a row of
chambers that are horizontally separated from other rows in other excavations by at least 3 feet. The 3 -foot
measurement is measured between the closest outside edges of the leaching chambers.
SBD- 10564 -E (N.10/97) File Ref: 10024802.DOC
INFILTRATOR@ SYSTEMS INC.
Page 2
June 3, 2010
Product File No: 20100248
• When this product is installed in a distribution cell that is sized based on the EISA rating stated in the regarding
block of the product approval letter, the distribution cell design must allow at least six inches of ponding in the
chambers without backflow of wastewater into the drainpipe that discharges into the chambers.
• When this product is installed in a distribution cell that is sized based on the EISA rating stated in the regarding
block of the product approval letter, this product must be installed in a distribution system, which has the top of
the distribution cell at or below original grade.
• When this product is installed with geotextile fabric on the sides of this product in a distribution cell that is sized
based on the EISA rating stated in the regarding block of the product approval letter, the EISA rating with fabric
must be used to size the system.
• When this product is installed next to each other in a distribution cell that is NOT sized based on the EISA rating
stated in the regarding block of the product approval letter, the effluent distribution area is equal to the length
times the width of the chambered area. The use of geotextile fabric in this type of installation is optional.
• When this product is installed with geotextile fabric on the sides of this product in a distribution cell that is sized
based on the EISA rating stated in the regarding block of the product approval letter, the geotextile fabric must
meet all of the following specifications:
Geotextile shall be non -woven
Weight shall be 0.35 oz /sq yd to 1.5 oz/sq yd
Apparent opening size (AOS) shall be 20 -30 U.S. Sieve (ASTM D- 4751).
• For mound designs, see the manufacturer's propriety mound component manual for this product line.
• As of 611/2010, an optional location of observation pipes is recognized. Observation ports may be
located at opposite ends of the dispersal area, and 1/5 to 1110 the length of the chamber row measured
from the end of the row with a minimum of one observation pipe per chamber row. Where the top of the
end cap is configured to accept an observation pipe (QUICK 4 PLUS Standard and QUICK 4 PLUS
standard Low Profile models), the location may be at the ends of the distribution cell mounted through
the end cap.
This approval supersedes the approval issued on 8/10/2009 under product file number #20090165. This approval
letter shall be incorporated with your previously approved plans and /or specifications approved under product file
number #20090165.
The department is in no way endorsing this product or any advertising, and is not responsible for any situation which
may result from its use.
Sincerely,
Jean M. MacCubbin, CST
Engineering Consultant -- Plumbing Product Review
Commerce; Safety & Buildings Div.
PO Box 2658
201 W Washington Ave.
Madison WI 53703 -2658
Phone: 608 - 266 -0955; Fax: 608 - 283 -7456
E -mail: Jean. MacCubbin @WI.GOV
Wisconsin Department of Commerce Count
PRIVATE SEWAGE SYSTEM
Safety and Buildings Division
INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 353203
Permit Holder's Name: ❑ City []Village [:brTown of: State Plan ID No.:
Thorsen. Dave I Town of Warren
CST BM Elev. Insp. BM Elev.: BM Description: Parcel Tax No.:
042 - 1104 -30 -000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St /Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet
Air Intake
Septic NA Dt Bottom
Dosing NA Header / Man.
Aeration NA Dist. Pipe
Holding Bot. System
PUMP/ SIPHON INFORMATION Final Grade
Manufacturer Demand St cover
Model Number GPM
TDH Lift Friction System TDH Ft
Forcemain Length Dia. Fi Dist. To well
SOIL ABSORPTION SYSTEM
BED/TRENCH width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIM DIM
SETBACK
SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manu acturer: INFORMATION Type Of CHAMBER Mo Number:
System: OR UNIT
DISTRIBUTION SYSTEM
Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
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 discrepancies, persons present, etc.) Inspection #1: / / Inspection #2•
Location: 1094 89th Avenue, Roberts, WI (NE1 /4, NE1/4, Section 20 T29N -R18W) - 20.29.18.575
1.) Alt BM Description=
2.) Bldg sewer length=
- amount of cover =
Plan revision required? ❑ Yes ❑ No (�
Use other side for additional information. I
SBD -6710 (R.3197) Date Inspector's Signature Cert. No.
ADDITIONAL COMMENTS AND SKETCH
SANITARY PERMIT NUMBER:
J.
- 4 -4 -
I
5
1
r
Safety and Buildings Division
SANITARY PERMIT APPLICATION 201 W. Washington Avenue
Wisconsin _ _. _ P O Box 7302
Department of Commerce n accord with ILHR 83.05, rn Coe ,
` Madison, WI 53707 -7302
• Attach complete plans (to the county copy only) for the s to 'on ap& not less'` '4ounty
than 8112 x 11 inches in size.E�n S)�
• See reverse side for instructions for completing this ap I ion S e Sanitary Permit Number
Personal information you provide may be used for secondary purposes —: r� Check if revision t previous application
ST
[Privacy Law, s. 15.04 (1) (m)]. �' ORO
COUNTY �5f to Plan I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT AL iNE0 5111111111AMMM
Pr rtyOwner ame Propert y Eip
S Zo T Z9 , N, R /� E (or) W
e W
Pro erty Owner's ailiV AddressBlock Number
City State F I Zip Code Phone Number Subdivisi n ame or CSPjNurl
T YPE OF BUILDING: (check one) ❑ State Owned It Nearest Road
❑ Village _ '
Public c 2 Family Dwelling- No. of bedrooms / / Town OF ✓192
111 BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s) t' -2.0.
1 E] Apartment/ Condo d YZ ' /Vlll - ?, ,c 0 a
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 Q Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) f�i ✓a .(,T'
A) 1. ❑ New 2. ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5_jd Repair of an
------ System ........ System ------------- Tank Only______________ Existing System ________ Existtilem
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distribution Pressurized Distribution Experimental Other
1112rSeepage Bed 1$'A,?0 21 ❑ Mound 30 []Specify Type 41 [:]Holding Tank
12 Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit t 43 ❑ Vault Privy
14 C] System-In-Fill � �-p� L�"— �.(,U�v�
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft.) Proposed ft.) (Gals/day /sq. ft.) (Min. /inch) I Elevation
', —C2 9V/ {/'Feet Q Feet
capacit
VII. TANK in Ca gallo Total # Of Prefab. Site Fiber- Plastic Exper.
INFORMATION New Existin Gallons Tanks Manufacturer's Name Concrete strutted Steel glass App.
Tank Tank
Septic Tank or Holding Tank Q 3 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ I ❑ 1 ❑ 1 ❑ 1 ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I he uncle 'gned, assume respon ' ility igr
jpfitallation of the onsite sewage systeqRshown gn the attached plans.
:(Print) s re: (No Sta m ps) Business Phone Number:
Plumber's Address (Street, City, State, Zip Code):
e G/ G
IX. COUNTY / DEPARTMENT USE ON
❑ Disapproved 5a w ary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signat re (No Stamps)
..
Wpproved ❑ Owner Given al j�
Adverse Determination Surcharge Fee)
nation !! 6-D l / , ?
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: �r =Q C
SBD- 6398 (11.11197) 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 a 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 by a licensed 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 and Buildings Division, 608 - 266 -3151.
To be complete and accurate this sanitary permit application must include:
1. Property owner's name and mailing address. 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 on 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 for numbers 1 through 7.
VII. Tank information. Fill in the capacity of every new /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 81/2 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 contamination investigations
and establishment of standards.
ST. CROIX COUNTY ZONING OFFICE
CERTIFICATION STATEMENT
FOR UTILIZATION OF AN EXISTING SEPTIC TANK
This is to certify that I have inspected the septic tank presently
serving the _(ut ��,-, residence located at:
AJ /V ;, Section 7,0 , T ��j - N, R __L Town of
A2r Upon inspection, I certify that I have found
the tank and baffles to be in good condition, and it appears to be
functioning properly.
Last time serviced: pr 9y
Did flow back occur from absorption system?
Yes _ !X No (If no, skip next line)
Approximate volume or length of time: gallons minutes
Capacity: /000
Construction: Prefab Concret Steel Other
Manufacturer: (If known):
:
Age of Tank If known
g ( )
0. & 11 — ("
�
(S1 nat r ) I (Name) Plea e print
(Title) (License Number)
/D ;,?9 -7�3
Date
Form to be completed by licensed plumber (s.145.06, Wisconsin
Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative
Code)
— — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — —
Plumber (applying for sanitary permit) Certification:
In accepting the above statement regarding existing septic tank
condition, I certify that the tank to the best of my knowledge will
conform to the requirements of ILHR 83, Wis. Adm. Code (except for
inspection opening over outlet baffle).
Name Signature MP
Ar
Wisconsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page --/-- of e�
Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and 6 , c
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
L-1 a_ �o - 30- 00C)o
APPLICANT INFORMATION - Please print all information Re iewed by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property ner Property Location
Govt. Lot f_ 1 /41)F 1/4,S ab T ,99 ,N,R / E (or)Z)
Property Owner's Mailing Address Lot # Block# Subd. Name or CSM#
C) ' - k, C 1
City State Zip Code Phone Number ❑ City ty Village Q Town Nearest Road
IS
rcS
❑ New Construction Use: gResidential / Number of bedrooms Addition to existing building
❑ Replacement El Public or commercial - Describe,.
Code derived daily flow 7 c' 5o gpd r Recommended design loading rate - - bed, gpd/ft trench, gpd/ft
Absorption are required bed, ft trench,•'�ft2 Maximum design loading rate � bed, gpd /ft2 trench, gpd/ft
PreS�►• � f
meffftcHn filtration surface elevation(s) 9 7 • T ft (as referred to site plan benchmark)
Additional design /site considerations
Parent material a c i o.) ";' i , Flood plain elevation, if applicable ft
S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
U = unsuitable for system ® S ❑ U ® S ❑ U ® S El ® S El ❑ S [> U ❑ S JR U
SOIL DESCRIPTION REPORT
Boring Horizon Depth Dominant Color Mottles Structure GPD /ft
g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench
byR - - --- 5
Gro 3 /s -ao - 7, 5 y 2 s /yr
R 7 1(, 415
Depth to S 6 -3� �'1:.
limiting S Y( s// J-. 5
factor (/
Remarks 15 -'1. Vi i# rk r- f
Boring # `
e-
6 S I ' U vt a v�.
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
CST Name (Please Print) Signature Telephone No.
- D I S --� \18 3 s Yk
Address Date CST Number
YOA 6
SOIL DESCRIPTION REPORT
PROPERTY OWNER Page of
PARCEL I.D.#
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench
Ground
elev.
ft.
Depth to
limiting ,
factor
in.
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # ;
Ground
elev.
ft.
Depth to
limiting
factor
in ' Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer �, )�., -'►
Mailing Address 1'01 -z
Property Address
(Verification required from Planning Department for new construction)
I
City /State Ar'4 -2 � ( _ Parcel Identification Number %� ii�y r •�o— Odd
LEGAL DESCRIPTION
1 . '/4 Sec. TZ � W, Town of
Property Location a /, , yep �_ N -R
Subdivision Lot #
Certified Survey Map # , Volume . Page #
Warranty Deed # 6 ll �6 3 , Volume // Page #
Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no
SYSTEM MAINTENANCE
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.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
mastorplumber, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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.
f Iiwe, 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 Zoning Office within 30
days of the year expiration date.
SIGNATffE OF APPLICANT DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owners) of
:9:2Z of a warranty deed recorded in Register of Deeds Office. /r) lZ9/ 9 9
DATE
« « « « «« Any information that is mis- represented 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
J
' h yon 1461•, 268
tS 1 1 X63
SrA18 EAR of WISCONM Font z - vas KATHLEEN H. NALSH
Doemunt REGISTER OF DEEDS
--- ST. CROIX CO., MI
This Deed, made RECEIVED FOR RUM
10-05-199! 2 :00 PN
Grantor, conveys aW warrants to David S. jagg ea and Air S. 71orsen. IIARRAM KED
husband and wife E)O:iPT 0
CERT COPY FEE:
Grantee. T FEE: 27100
Grantor, for a valuable consideration, conveys and warranes to Grantee RECORDING FEE: 10.00
the following described real estate in St. Qr County, State of %wonsk ('Ibe MEG: 1
"Property*):
Recording Area
Name and Return Address
4W s aid �s*r
w = syotl.
a l9 oO �o
042-1104-30-M
Parcel Identification Number (PIN)
This m hornestead property.
Lot 3, Pleasant Acres in the Town of Warren, St. Croix county, Wixousin.
Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any.
Dated this /S ! day of October, 1999.
♦ ♦ Thompson
ACKNOWLEDGMENT
STATE OF WISCONSIN )
AUTHENTICATION )Ss.
f 6)t X County )
Signature
Personally carne b efore the this / day of October ,
authenticated this day of October, 1999.
1999, the above named k a yhQ,2+nsO/r
to met m n to be the
person(s) who executed the foregoing instrurneot and
' Kristin Oglattd acknowledge the same.
TITLE: MEMBER STATE BAR OF WISCONSIN r
(If not,
authorized by 1 706.06, Wis. Stats.) Notary I%Nic, State of Wisconsin
My Commiss n is permanent. (If riot, state expiration date:
THIS INSTRUMENT v. „S DRAFrED BY ' s ib t
Attorney N c i stina Ogand
Hudson, VII 54415
(Signatures may be authenticatz-0 or acknowWged. Both are not
necessary.) DIANE =BARRON NoState
*Names of person, signing in any capacity should be rypcc' or printed blow their signntutrs
WARAA147Y iFrD S7 ATE Nna Ow WNCONISM
FORM W. 1- 1111
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