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HomeMy WebLinkAbout042-1059-50-525 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety .N.nd Building Division INSPECTION REPORT sanitary Permit No: 479243 Le,�" 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)j. Permit Holder's Name: City Village X Township Parcel Tax No: Nelson, Gary Warren, Town of 042- 1059 -50 -525 CST BM Elev: Insp. BM Elev: T Description: Section ( rown /Range/Map No: /0 6 Y✓1 1 21.29.18.331 F1 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic / Z (0 0 Be 5 ark � 6�.y 107q 1 Aft. BM Aeration Bldg. Sewer "31 97�1 Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet 16. 1(o "17. 7P TANK TO P/L . WELL BLDG. Vent to Air Intake ROAD Dt Inlet � Septic A4 //, I Dt Bottom ` `+ Dosing Header /Man. %. , 4 Aeration Dist. Pipe Holding Bot. System /Z� q `7?5• 52 PUMP /SIPHON INFORMATION Final Grade / / , 3 Manufacturer Demand St Cover 161 - Uo Model Number TDH Friction Loss System H TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width / Length j� No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS C �j re %__ SETBACK SYSTEM TO r � P/L BLDG � WELL LAKE /STREAM LEACHING Manufacturer: n INFORMATION Type Of System: r 5Q � �� r �� CHAMBER OR : d – o Model Number: 1JQ_ 49 DISTRIBUTION SYSTEM ( Z'S d" Z3 = &A0 f utrl)\ Header /Manifold !� Distribution x Hole Size x Hole Spacing Vent to Air Intake ♦ _ L_— Pipes) i ___1 Length Dia Length N 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 Mulc ed Bed/Trench Center °� Q Bed/Trench Edges Topsoil \es ] No es J No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:__7 ! f Inspection #2: Location: 1112 80th Avenue obert WI 54023 ( 1/ SW 114 21 T29N R18W) NA Lot 9 'P_y Parcel No: 21.29.18.331 F1 1.) Alt BM Description = Ccl6YN �z �.►6J��5 2.) Bldg sewer length - amount of cover k 6ignature Plan revision Required? Yes No Use other side for addition in ormation. Datein for Cert. No. SBD -6710 (R.3/97) t Safety and Buildings Division County Ivi m 201 W. Washington Sconsin Madison, W1 3707 1 '' snit Permit Number ( be filled in b Co.) Dep artment of Commerce (608)26 -3151 Z�3Gtl, Sanitary Permit Applieatio ; I , to PI n I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information y u provide may be used for secondary purposes Privacy Law, s15.04(I)( ) ST. CR01 X COU ojeet dress (if different than mailing address) ING OFFI E I. Application Information - Please Print All Information Property Owner's Name / Pprcel if Lot *� Block # Property O is Mailing Address Property Location City, S to Zip Code Phone Number �Z V`° -5 14J V'° Section ;:21— �C 1 Z9 _ r E or cle) II. Type of Building (check all that apply) a4 1 or 2 Family Dwelling - Number of Bedrooms N !,. t_ J Sttbdrvisioti acme CSM Number ❑ Public/Commercial - Describe Use ❑ State Owned - Describe Use 4 ❑City ❑ illage;! Ir o ship of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. 8.N w System ❑Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System B. ❑ Permit Renewal XPennit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: Check all that a pply) J9 Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ P r ❑Aerobic Treatment Unit El Recirculating Sand Filter El Recirculating Synthetic Media Filter El Leaching Cham El Dri Line E1 Gravel ipe ❑ Other (explain) V. DispersaVl7reat ment Area Information: Design Flow (gpd) Design Soil Application Rate(gpd Dispersal Area Re " Dispersal Area Proposed (sf) System Elevation s V____ VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank _ Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, ume responsibility for installation of the POWTS shown on the attached plans. Plumbe s ame 'nt) Pl Plumbe s Si MP/MPRS Number Business•Phone Number umber's Address (Street, City State, Zip ode) " VIII. un /De artment Use On pproved ❑ approve Sanitary Permit Fee includes Groundwater Date u Issuing t Signa Surcharge Fee) caner t Reason for IX. Conditions of Approval/Reasons for Disapproval 6"TI M OWNER: 1. >sgft tints, dom t t1Ner and depaaal cap naat aN ba Wideea mairaaln.d as tie► ffWUG~ plan Provided by palrttlter. 2 M silbeck rags* n W is mNa be maintailted M'Pir OPIC bta coda J ordinances. Attach com etc lane to the Coup onl for the stem on a not less than SU2 x 11 i i Pl P ( tY Y) sY P Pu' nchess n size SBD -6398 (R. 01/03) i �A�1MIW0 M�� yQ na tsum 491 "Uqo mWkAq Yd bgn v014 � W4 V*0 N b , %stn+sm - to mn Onwnsim"I rte $A .Z dll a ,� obw lkisoovAp a4 a I l =© 5 e,,P .� 3 d0 I � I srt /pp Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance r e County Attach complete site plan on paper not less than 81/2 x 1 inches" iii a. I n t include, but not limited to: vertical and horizontal referen point (BM), dire n Parcel I.D. percent slope, scale or dimensions, north arrow, and loca n and iutce to gearto _ , 331 ! J Please print all informat� n. ytewed b Date Personal information you provide may be used for secondary pu " K (k). Prope Owner IF 4V Govt. Lot 1/4 114 S T N R (or) W Properly e s Mailing Address Lot # I Blo # Subd. Name or CSM# g - City to Zip Code Phone Number ❑ City ❑ Village 01 Town N15arest Road 124 tit ),3te, j o New Construction User Residential / Number of bedrooms Code derived design flow rate ll�_ GPD ❑ Replacement Public or commercial - Describe: Parent material 6u7 "'I' sr/ Flood Plain elevation if applicable ft. General comments and recommendations: M Boring # ❑ry Boring Pit Ground surface elev. ft. Depth to limiting factor y //.9 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Efr#1 *Eff#2 -8 6 / e Q � Boring # ❑ Boring pit Ground surface elev. . /' Depth to limiting factor >//,r6 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Efr#2 4 4 rJ i 7 4 9 * Efflyent #1 = BOD > 30 < 220 rng/L and TSS >30 < 150 mgA_ * pent #2 = BOD < 30 mg/_ and TSS < 30 mg/L CST Nam ase ' Signature CST Number Address Date Evaluation Cond ucted Telephone Number Property Owner Parcel ID # — /DS�I 'Sri - 7 s' Page_ of Boring # � OB � oOng pit Ground surface elev. ft. Depth to limiting factor .7 /�Sd in. Soil ftplicabon 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 *Efflf2 6 a 4 ., _ a a F] Boring * ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Applicetion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDffF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eft#2 F Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil 8pplication 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 * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 150 mglL * 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 4151 or TTY 608 -264 -8777. SBD -8330 (R07 /00) Property Owner. Parcel ID# Page 2 — of El Boring # ❑Boring Pit Ground surface elev. Depth to limiting factor .> in. Soil Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Coat Color Gr. Sz. Sh. *Efr#1 -Etf#2 - d 4 4 a a F-1 Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor In. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Efr#2 ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor In. Solt Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Efr#1 *Efr#2 * Effluent #1 = BOD, > 30:E 220 mg/L and TSS >30 <_ 150 mg/L * Effluent #2 = BOD, < 30 mgr. 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 -3,151 or TTY 608 -264 -8777. SM4330 (807/00) i e�57m 6� B I, q � � I I � ' 1 CERTIFIED SURVEY MAP L. Newel and Dorothy M. Jones Family Trust Located in part (?f the Southwest %4 of the Southwest %4 of Section 21, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin, being Lot 6 of that Certified Survey Map recorded in Volume 18, Page 4811 of St. Croix County Certified Survey Maps. N - BEARINGS ARE REFERENCED LEGEND TO THE SOUTH LINE OF THE SOUTHWEST 114 OF SECTION 21, 0 INDICATES 1' O.D. x 18' IRON T 29 N, R 18 W, ASSUMED AS PIPE SET (MIN. WT. -1.13 LB.A.F.) N 89 °36 36" W. O INDICATES P IRON PIPE FOUND 0 SOIL BORINGS (PROPOSED SEPTIC SYSTEM)�j SCALE IN FEET 1 . =200 - 0 SECTION CORNER MONUMENT (AS NOTED) ' (R =) RECORDED AS 100 0 100 200 A DRIVEWAYLOCATION OWNER S ADDRESS 1134 80TH AVENUE ROBERTS, W/54023 VD _ 1 � UNP_LA 710 LANDS NORTH LINE LOT 6 S 89 °36'36" E 4 ' - 212.00' A 213.00' O A A A E•QT__ LOT 9 - LOT 10 ti 109,228 SQ. FT w i 109,289 SQ. OR 2.508 AC. G R 2.509 CE=RTIEIEO SURVEY Sri z (102,232 SQ. FT. (1 Q. FT F' ZI OR 2.347 AC. OR 2.349 AC. Q MAP 'n t,, EXCLUDING _ ° `� v EXCLUDING N Lu N TOWN ROAD ; TOWN ROAD o Go RI F WAY) $ RIGHT OF WAY) Cr &' PACE 3648 0 �Q� ti����o N ca LOT 4_ z ��¢ `* SOUTHWEST CORNER S 00° S89 ° 36' 6 "E 66 0 S ETBACK UN QP ' SECTION 2 T T 29 R W SECTION 21, T 29 N, R 18 W o 11 40° ��' 33 00' 33. S 00 °1 u� 50.Op �' ;' (FOUND COUNTY BERNTSEN (FOUND COUNTY BERNTSEN 50.0 r t 0 ALUMINUM MONUMENT) ^ 212.00' I ALUMINUM MONUMENT) 179.00_33.0' 0- I _ 211.35' - M '- -- — — — �O! _ 3 3.00_178_35' _ 212.50 80_TH_ A VE_NU_E _ 3 3.00' . N8§ °36'36 "W ` ; - 33.00' 423.35 - M 89 °36'36" W 38900' - ;•33.00' r S_O_UTTH � LSWI14- n _ — -- — — -- — 212.00' " _211.24' - _ _ N 89 °36'3g" �! 1836. y8- -- " ' q7 - N 89 36' W 423.24' SE CO — — ' — RNER I , I JOINT DRIVEWAY LOT 6 1� 66 EASEMENT, CERTIFIED SURVEY _IVlq_P t -' - N e9°36•36" w 2sas.22' - (R = S 88 °42'19" W 2649.28) VOLUME 6, PAGE 1575 (R = N 90 '00'00' KI ,'�,� UIVPL.ATTED LANDS \SG�NS ti /. • LAURENge Mil Hy • *`• S 1713 ; tt FEB -9-2UA 09:42 FRUM:QUALilY SLHLLUFvllrrta ; i— ( j Jf1N- gl lb: S3 �FR011:QUALI7Y SE AL MRTING (715)381-9978 _ _ T0:,7494007 _ a , -- - + : CERTIFIED SURVEY MAP L. Newel and Dorothy K Jews ramify Trust z;:: Gkmed M pw of Aw Awhww, l % ofilm Soulhwea % and 8awhwo Ye C co'thc Suallhwst 9 Rf &olon 21. Tvwaldp 29 Borth, AaW 18 Weil, (j � Taws of Werrtn, St. Croix Couo*, Jl'iwontin, bring U f qll) l C-t•lille4Surwy Map reav*d U YvIsme M. Pop 36M of � � Q Sr Choir County Cerl Jscd Siw-ty Apr. N, � as � „�......,,.. o 00'11 E GIs 2r 4 r r lira VIA I' i L Z 1. ° •wr2r• `� H i m .4 a m UL Ida < t �� I •' s.r�esl•e arnxwttisrr � Q r' g ee. ar NO $ n�or � 00'2»1 W $110' '► x i 9 21 fig Lj l 1 : r►us Ud rALMO,oa FM AYJR"L u,tscw SHE ET t OP 2 I e o ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address yL fSZ2_� Property Address (Verification required from Planning Department for new construction) City/State U 2 Parcel Identification Number LE GAL DESCRIPTION Property Location ,_5'� '/4, 1 /4, Sec _, T�,N- R_2Z_W, Town of Subdivision Lot #. Certified Survey Map # _8�/j , Volume , Page # �8 Warranty Deed # Volume �sT,�S' , Page # aj Spec house J�6 yes ❑ no Lot lines identifiable o es ❑ 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 master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site waste water 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. I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St, Croix County Zoning Office within 30 days of the t ee year expiration date. SIGNA eP LICANT 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 owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIG U 0 APPLICANT 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 POWTS OWNER'S MANUAL & MANAGEMENT PLAN... , . Page _Z_ of FILE INFORMATION 9 SYSTEM SPECIFICATIONS Owner Septic Tank Capacity Rol 0 - Ni ' ' Permit # Septia'�nK Manufacturer 4. �° O Nr DESIGN PARAMETERS Effluent Filter'Manufacturer' " O N�, Number of Bedrooms to NA Effluent Filter Model O NA Number of Public Facility Units ONA Pump Tank Capacity gal NA Estimated flow (average) gal /day Pump Tank Manufacturer� Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer A _ Soil Application Rate al /da /ftr Pump Model eNA I Standard Influent /Effluent Quality Monthly average* Pretreatment Unit NF Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5220 mg /L 1:1 NA [3 Mechanical Aeration O Wetland Total Suspended Solids (TSS) 5150 mg /L O Disinfection 17 Other: Pretreated Effluent Quality Monthly average Dispersal Cells) ❑ N! Biochemical Oxygen Demand (BOD,) 530 mg /L in- Ground (gravity) O In- Ground (pressurized) Total Suspended Solids (TSS) 5,30 mg /L ONA ❑ At -Grade © Mound Focal Coliform igeometric mean) 510' cfu /1001111 ❑ Drip -Lino Q Other: Maximum Effluent Particle Size Y in dia. p NA Other: ❑ Ni Other, 0 NA Other: ❑ NA *values typical for domestic wastewater and septic tank effluent. Other: D NA MAINTENANCE SCHEDULE i Service Frequency Service Event manthisf (Maximum 3 years) 0 NA Inspect condition of tank(s) At least once every: aar(sl Pump out contents of tanks) When combined sludge and scum equals one -third (Y of tank volume El NA 0 _ onthlsf (Maadmum 3 years) O Ni, Inspect dispersal cell(s) At least once every: ta`year(s) Clean affluent filter At least once every: El month(s) 0 Ni, years) _1 O month(s) Aa Ni. Inspect pump, pump controls & alarm At least once every. q y ear(s) ❑ month(s) ,, 12 Ni, Flush laterals and pressure test At least once every: ❑ earls) Other. O month(s) D NA othe At least once every: Q y ear(s) Other, Q NA MAINTENANCE INSTRUCTIONS 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 surfacr;. The dispersal cells) 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 tho immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third %) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of S12 months, shall be performed by a certified POWTS Maintainer, A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. (3MW iQJp t Page of 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 chemical's* that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(&) In one large dose, overloading the cell(#) and may result in•the backup or surfs" discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prlouto restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually - operating the pump' controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells, Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides ; ; scraps;. medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the systorn is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings fealpd • 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 takan,.: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. 11 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.---,­­­ 13 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. Il 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. 00 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 P OWTS INSTALLER POWTS MAINTAINER r Name Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORI Name Nama Phone r his aocument was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.540), (2) & (3), Wisconsin Administrative Code, , SA ,, wj Iluildings Division County l W Waslur ,11un Ave., P.O. Box 7162 itu itary Plan Hermit Number (to b filled in by Nviscons ),' ` .N u artmant or Commerce REC EIVED `� 7`IZ� 1 C �r hD, to nWb : S anitary Permit Ap n n �' i In accord with Comm 83.21, Wis. Adm. Code, personal iNur anon }Ovitlb 205 - may be used for secondary purposes Privacy Law, s .04(Ixm) Iroject Address (if diffmri than mailing address) ST. CROIIX 0u � i. +t plic utiou Information --Please Print All infurulation ONING OFFICE 1 Property Owner's Name Parcc111 Lot # Block # Property a 's M ling Address M Property Location v/, � Y +, Section �__ City ";Late Gip Code � Phone Number, ci or off} II. 'I ype of Building (check all that a ) DiC Subdivision Name S§M_M9ber 1 or 2 Family Dwelling — Number of Bedroom ❑ Public /Commercial — Describe Use U State Owned — Describe Use Z t Z' f5 ❑City_U iliage ownshipof mplcic laic !3 i pplicable) 111 ,Type of Permit, (Check o nly one b on lair, A. A New Svstcm � ! Rclrlucotncut Syst ��,� 'I'reu ur,vr itilcr ; v, l'wtk Replacement Only I _? rhhcr MWIlieatiat to Gxtrumg ayr� — List Previous Pemttt,Numbar04 Date 1111111M I] permit Renewal U Permit Revision 1 Change u ❑ Permit Transfer to Now : Before Expiration ` Plumber Owner IV. T lc of POWTS S stem: Check all that appl Nor; — i'ressunzed in- Ground :1 Mound ? 24 in l Suitab soil dcuod 4 in. of suitable soil J At- Grade U Single Pass Sand Filter Constructed Wetlano �� Pressurized In- Ground 2lo ig Tank i Filte ❑ Aerobic "i reatment Unit keeireulating Sand Filter ❑ Recirculating Synthetic Media Filte: Leach. f ua Drip L,r,c L.; v less Pipe U Other (explain) V, Dis ersaffreatment Area Information: Design Flow (gpd) Design Soil Application Rat p s ispersa Area Required (sf) Dispersal Area Proposed (sf) System Elevation � V - VI' Tauk Info Capacity in tal ( Number ! Manufacturer Prefab Site Steel Fiber Plastic I Gallons silond of Units Concrete Constructed Glass 1 New 4xisting bp� ' 4 �� t "tanks Tanks Semis or Holding Tauk F — ^ ~~ �crobic Treatment Unit :ins :n�e::},amber VU kcsponsibility Staters - 1, the u nderstgii ed :os!sun respoaubMily for installation of the POWTS shown th allttched plans Businuea Phone Number 1 Ylunib r "5 urns ('riot? �lumbar's ihn c , MI /MARS Number ZY I - 2 2 i r 1 tuiti ur's A ress (Street, ity S ate, 'Lip C c) VI .Coon /De artment Us40n Sanitary Perm i i +.c i nciudes Groundwater D Iss d Issuing t Si RpT,rur ��! iswurtv,;w, � „large re:. , ��'S IX. Conditions of approval /Reasons for Disapproval SYSTEM OWNER: 1. Septic tMtk, eftettt Mar Wid dispersal cell must all be services / rrtdrtWrted as per management plan provided by plumber. 2. All setback requirements must be maintair►ed ' as Per aoolicable code / ordinances. x_ 111/2 es Attach complete pia:u (to the County only) for iGC system an paper not teas than 81/2 111 inch in size S E U -6398 (K. U 1 /U3) n 3 p u id C'Al �e i/oN9k .! Gf rr ll y I 3 n 1 �o ��.jpfLA I I I R C��v VD Wisconsin Department of erce SO EVALUATION REPORT Page of Division of Safety and Building Q 2�� M accordance with 85, Wis. Adm. Code M County Attach complete site plan on per 1 @ 1 inch in size. Plan must include, but not limited to: ve 1 and (BM), direction and Parcel I.D. percent slope, scale or dimens ns, no and location and distance to nearest road. Please print all information. vie Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ' - 1 �d ( Property er Property Location r - ` Govt. Lot 1/4 1/4 S T 9 N R le E (or Prope owners Mailing ress L t # BI # s � � s ym, ZZ CRY state ZIP Code Phone Number CI c ity 0 Village 0 Town Nearest Road New Construction UseA Residential / Number of bedrooms — Code derived design flow rate _ GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation If applicable ,A ft. General comments _ and recommendations: Boring # E] Boring pit Ground surface elev. ft. Depth to limiting factor Ld--Q�_ in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff° in. Munsell Qu. Sz . Color Gr. Sz. Sh. 'Eff#1 •Eff#2 dd � c g s - Boring # ❑ Boring pit Ground surface elev. ft. Depth to limiting factor �('L in. Sop Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Munsell Qu. Sz. Pont. Color Gr, Sz. Sh. 'Etf#1 'Eff#2 J e 6 4 4 Q g E t #1 = BOD > 30 220 mg/L and TSS >30 150 mg& ' Effluent #2 = D 1 30 mg& and TSS < 30 mglL CST Sig CST Number Addrdss �� Date Eval Corxfucted Telephone Number ZL L � �ZL� Property Owner _ Parcel ID # Page of 3 Boring # Boring Pit Ground surface elev. it. Depth to limiting factor in. i, Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff In. Munsed Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 3 -,aSZk Pd i O 6 q R ry 4 4 , Elork , g # ❑ Borin ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon Oepth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPDlff In. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 F-1 �g # ❑ g ❑ Pit Ground surface elev. ft. Depth to limiting factor wr. Sod APplication Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPDRf in. Munsed Ou. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 Effluent #1 = BOD > 30 <_ 720 mglL and TSS >30 < 150 mg& ' Effluent #2 = BOD 1 30 mgll- and TSS 1 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. seesaw (RAN) M � CL DtL N N FEB -9 -21 J4 09:42 FRUM: QUALi I Y btr tai Ui+ irwa t� tS r d �bbv JNN=21 1b :53 �FROII.QUALITY 5EALGOATING (715)381-9978 TO :,7Q94W7 F 4 CERTIFIED SURVEY L. Newel and Dorothy K Joe-to F*mW Trost �;:: !,.�taed /A pwrr of rl4r �Satukwral k Qlrhe Sowrhwcsl '!, and SaahmW % C } rI Ac Sum0amr % vfSn/ion 11. Tawfablp 14Nerth, Ramps 18 Wel, Tmm of Warren, a. Croix Cowry, Wl Ovin, br ing /. $ of Aw � Q CerfOl ed Surmy Map mcardrd in Volume /J. Pup 364-N y/ � Sf. (ioir Vauuwry C ati fled Survey Uapi. MOM 4 f I �� n00.1 •teltsr �Ir J 2l a nl�e�� #� jIe I r ti K I ; 4 UL 1 � �► v= I $I ron 8W Mix L4 L � , '�� • .arse � � �`'' \ 1 Jill ' : nwna� u►orur►�oor rreua�uas SHUY f OF 2 e O CERTIFIED SURVEY MAP L. Newel and Dorothy M. Jones Family Trust ` Located in part (?f the Southwest %4 of the Southwest %4 of Section 21, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin, being Lot 6 of that Certified Survey Map recorded in Volume 18, Page 4811 of St. Croix County Certified Survey Maps. 1 \1 . BEARINGS ARE REFERENCED LEGEND TO THE SOUTH LINE OF THE SOUTHWEST 114 OF SECTION 21, p INDICATES 1 " O. D. x 18' IRON T 29 N, R 18 W, ASSUMED AS PIPE SET (MIN. WT. - 1.13 LB.1L.F.) N 89 0 36'36" W. • INDICATES 1' IRON PIPE FOUND L SOIL BORINGS (PROPOSED SEPTIC SYSTEM) SCALE IN FEET 1" = 200' SECTION CORNER MONUMENT (AS NOTED) (R =) RECORDED AS 100 0 100 200 . DRIVEWAYLOCATION V" OWNER'S ADDRES D 16 C U" 113480TH AVENUE ��$� , / ROBERTS, W1 54023 11 �p� • �� _(1LYP_I.ATT_EA LAW-S NORTH LINE LOT 6 S 89 °36'36" E 42 212.00' d 213.00 0 A p LOT 9 LOT 10 109, 228 SQ. FT. 109,289 SQ. - ih OR 2.508 AC. ;n OR 2.509 CERTIFIED SURVEY z (102'232 SQ. FT. 3 (1 Q. FT. 1 OR 2.347 AC. c OR 2.349 AC. 'v MAP N EXCLUDING .r N EXCLUDING W N TOWN ROAD v TOWN ROAD o RI F WAY) $ RIGHT OF WAY) o -0 VQll1M�_13, 6. y �� , PACE '(' `� M J E 3648 0 �a� LOT _4 z 100' SETBACK LlN p�' SOUTH 114 CORNER SOUTHWEST CORNER S 00 ° 11'4 p• �yS833 - 0' 33 66;00 3 00.11'40" SECTION 21, T 29 N, R 18 W (FOUND COUNTY BERNT SEN r 09 ALUMINUM MONUMENT) 50.00 (FOUND COUNTY BERNTSEN 50.00' ALUMINUM MONUMENT) 179 ��� 33.00'• g 211.35' – — -- — — — $y- •33.00_178_35 _ z12 .5 80_TH AVENUE —� 33 .00' N89 °36'36 W >-33.00 423.35' ;•33.00 ^ — — -- - M N 89 °36'36" W 389.00' 212 00' - � SOUTH LINE _� SWI /4 A `- — -- — _ _ _2 - ) - N 89 °36'36" W /I 1836.98'— � N 89 °36' 36' W 423.24' y SE CORNER — — - ti LOT 1_ 66' JOINT DRIVEWAY LOT 6 t I EASEMENT. CERTIFIED SURVEY MAP cn ; -a1 - N 89'36'36" W 2649.2r - (R = S 8842'19'W, 2649.287 _VOLUME 6, PAGE 1 575 (R = N 90 '00'00' Kq �,� t�NPL_ATTED LANDS `S pONS�� IAURENq e M(}R RHY • / - 1713 : 7k ',lj4j c JO4 16:53 �FROI�I ;pUiit.I TY SEALCOAT I NG (715)381-9978 CERTIFIED SURVEY MAID ct' L Navel sad Dorothy K Jsaa Pamir Trnot a :.: t.,�ddM�►l q /� w�l � ��rr< �,w�.w x .Ad aa>+►t,�,a � fi � N , . (!'►kr Suv wies/ N of smlan 21. Tawny► 29 Monk Aaw r8 Wal. I Tawff of Warrd^ S. Oft CQNOa 1Ylocok klfW U S a IIwY Q C. C tr($d &vwy Map mawrhd in Polipm /i. AW J60 (f ,� ., SK (J1rir C'cwxy Cafyilyd Stwty Illrpr. � \ � ;rn o I r y , 1 1I N wi1 '4E 0112&' MINA x� ZI SIR! a ; � I • �wo� �o $ S S �Ra „� � H im SJL r I a.r�nri I wvw J7 "C G ~� 11tH if NO O a r f i Is w Mi a$, -� fig +� � ,•.,� .....,.. M I f Q vas � o ,i ` V►b '� rl s t fAASOu SHEET I Or-1 Q lk � � � nwiw►auff�urnwrccnrouin r ti of the ; �outhwe.st '/, of Section 21. 1opwnship 29 North, Runge In West, T 0 Win of Warren, St. Croix C'ounty, Wisconsin, being Lot S ofthat ray -Cy' Certified Survey Map recorded in Volume 13, Page 3648 of tf `' St. Croix County Certified Survey Maps. 33I il n _ 6 3' it rn 10 0 .ti 1 rr C ' g 2 w ,., m I m� a' --''< 1 N 00° 11'40" E 515.23' "� y " . 1001 WESTuNE LOTS fi y i V� 7 ZZ px- z i S 00'23'24"W 515.23' w 482.23' Cos yy 1 n m y • . • t rn � H ^'' '50.00 A82.23'- 432.23' R' 'N 89'76% W S 00'23'24" W 515.23' EASTUNE l o r6 Z— 50.00" . 228.03' Q" N f; 278.03' ti p g A ` s o j I I S 00 0 23'24" W 311.03' c ' //�" i • ��,� °'� �•'.�h 33I � � � -' b3' I Z m , b + ,it } Uri * ��` O C r, (� v, v, g 204.20' y, i. , �.► ern � � �•► (� ( .'Cn I � y o - w ° • i t THIS INSTRUMENT DRAFTED BYJERALD L LARS01) SHEET 1 OF 2 Wisconsin Department of Industry SOIL AND SITE EVALUATION RE P O R T Pa e of Z Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, ��ril1. IC COUNTY , J Attach complete site plan on paper not less than 8 1/2 x 11 inches in siz must�clee, but not limited to vertical and horizontal reference point (BM), direction and 6 0 slope, scale ot� €" ARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. `� AP APPLICANT INFORMATION - PLEASE PRINT I III y 0 B DATE ST � :',� / PROPERTY OWNER: s- E T p PR TION O T L 1/4 1 14,Sa T a ,N,R W PROPERTY OWNER':S MAILIN A DRESS L _@I.QCK # ,3U . NAME OR CSM # o �.� 03 �Rl STATE 21P CODE ONE NUMBER GE MOWN ] NEAREST R D New Construction Use D4 Residential / Number of bedrooms QmQ=CX31 (J Addition to existing building j J Replacement (J P dab Code derived daily flow 50 gpd Recommended design loa ing rate �l . S gibed, gpd/ft ( o lench, gpolft Absorption area requir bed, It 1 , trench, 0: mum design loading rate s z bed, gpd/ft . trench, gpd1ft Recommended infiltration surface elevation(s) 9 .;a .,eecA 9 • ft (as referred to site plan ben mark) , Additional design / site considerations A. 4 tin Parent material el C Flood plain elevation, if applicable /1t fi4 It rU= itable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FlLL HOLDING 7TK suitab le for s stem u s O U W S O U u s O U as Cl U 9S 13U O S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed re(dI v.. 1 -13 /o sr / k F� s `:z 21 N 2 I -,;291 jogg 3)e, 51 L2 to sbk YYJ FIZ IG s 3 4 Ground 3 , 5 ° R A © Q) 5x 2 M 5 b k rA F R A 5 VE . elev. ft 5c, Depth to limiting factor P-3 " Remarks: t 5- 010 t'A c � - A cyylsr Boring # vx Ground elev. ft . Depth to limiting factor Remarks: CST Name.—Please Pr v _ Phone: j 3 - 83 Address: A S� $— Signature: 'Y Date,, j CST Number. S PROPERTY OWNER Almpd d-bo &A/ —Tot* SOIL DESCRIPTION REPORT Page of i� PARCEL I.D. # Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft Boring # Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Y Bed rerx k a Ground 3 I -95 .7 S ® Co S 0 -SCA M L A S l V-F , P elev� ft• - 143 56 �) !o © 1 D fn Fi — — 3 Depth to limiting factor Remarks: ��% e ci Boring # a o f JOUR al 3,rIf �. to e. 44 m sb1: M F(z 145 zv Ground . C K 9 ft 5 AI l Depth to Jam' �8 2 3 'y limiting Remarks: Boring # ,�-• J �. ,�y� C S � s / 0 vJ2 Ground 3 v ;5' YY1 M Ff q� ft Depth to limiting factor Remarks: Boring # v. 0/ 0•- /o m i k M Fe- CS 3vIc . S L 1+S W Ground / ft . Depth to limiting factor r! _ - -- - -- _ Remarks: Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page ,�; of 5 Labor acid Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY 'Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but' - Cam''` not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Ale we-1 2) ro �JC GOVT. LOT SL -� 114 5'r0114,S , 2t T Qcj AR 1 $ IWW PROPERTY OWNER':S MAILING AD SS LOT # BLOCK # I SUBD. NAME OR CSM # 8© '- .S 94 AT e 4 I , 11 CI ,STATE ZIP CODE PHONE NUMBER OCITY OVILLAGE CWOWN NEAREST ROAD MAW 41- j>q New Construction Use )< Residential /Number of bedrooms p o ? .3 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe r Code derived daily flow 0 gpdecomtnense� design loading rate bed, gpd/ 2 trench, gpd/ft I Absorption area required bed, ft , � trench, ft Maximum design loading rate bed, gpd/ft trench, gpd/9 Recommended infiltration surface slevation(s) - ft (as referred to site plan benchmark) Additional design / site considerations Parent material svc e=� Flood plain elevation, if applicable It S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT GRADE SYSTEM IN I'll HOLDING HOLDING TA U= Unsuitable fors stem P S Cl U ®S O U US O U RI S❑ U 9S 1:1 U [IS O U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Coat Color Gr. Sz. Sh. Bed rends iD .2 m sb� M FR 3v+ <. ;.. - 3 Ground 3 j1 loa 3l 0 .L ft. 4 1 340 70` S M L 19-5 Depth to ' :5 k d C 3 Y' limiting factor Remarks: Boring # µ I © -/ v S"L 2 rh PP_ C 3W .5 r ? 4 °a2 'l 314, S6 m Fie a s f-' <. 3<:x�v 3 122-R 2,' I S w+ VYIv 2 S 1v� Ground I r elev� .r! C ° 0 s Yvt 1.. 0-s . ft Ij rvi -57 o s r 1,7 Depth to limiting factor Remarks: CST Name: — Please Prin A ddress: o ` / �` Phone: 71 � _ -2 .-y ` ,1 -< 3O ' `� S .�r Signature: f c. --,` Date: CST Number. PROPERTY OWNER �I- t a �ota�u ��CSYI DESCRIPTION REPORT Page of PARCEL I.D. Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GFD /ft . Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ranch W1 AP- GS • ; : } Ground 3 7; 51- 1 C'_ S� m p : C S I i , Aj . 5 elev l ft. 5` 7 o Yh L Depth to limiting fact Remarks: Boring # _ Ground elev. ft Depth to limiting factor Remarks: Boring # Ground elev. ft Depth to limiting factor Remarks: Boring # vs Ground elev. ft . Depth to limiting _ factor Remarks: Robert Heise N4769 430th St. Menomonie, WI 54751 1 (715) 235 -8369 April 25, 1999 Lot # 5 Recommendations Note- The amount of information required was not sufficient on the soil and site evaluation form. The information provided below shall supplement will report. 1. System #1 will require (2) trenches. Loading rate .5 (bed) .6 (trench) based on S.B. #4 Recommended elevation Trench #-1 el. 96.4 Trench # 2 94.6 2. System # 2 Loading rate .5 (bed) .6 (trench) based on S.B. #1. If the installer has the approval to install the turtle shells at- a greater depth, this - would allow loading r ate to-change accordingly. Some excavation may be required as not to exceed maximum depth over the proposed system. Recommended system el. 95.3 3. System #3 Mound system loading rate based on S.B. #6 .2 (bed} .3 (trench) Horizon # 5, Massive structure, I determined as the most limiting factor. Recommended system el. 102.0 Parcel #: 042- 1059 -50 -525 06/10/2005 01:53 PM PAGE 1 OF 1 , Alt. Parcel #: 21.29.18.331 F -1 042 - TOWN OF WARREN Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 12/03/2004 00 0 Tax Address: Owner(s): * = Current Owner * L N &D M(LE)FAM TR %DARYL JONES JONES, L N &D M(LE)FAM TR %DARYL 1134 80TH AVE ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): " = Primary Type Dist # Description * 1112 80TH AVE SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 2.508 Plat: 4888 -CSM 19 -4888 042 -04 SEC 21 T29N R18W PT SW SW & SE SW BEING Block/Condo Bldg: LOT 9 LOT 1 CSM 11/3039 CSM 18 -4811 LOT 6 (5.016 AC) NKA CSM 19 -4888 LOT 9 ( 2.508 Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4) AC) 21- 29N -18W SW SW Notes: Parcel History: Date Doc # Vol /Page Type 12/03/2004 781610 1914888 CSM 08/16/2004 771727 18/4811 CSM 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 03/03/2005 Description Class Acres Land Improve Total State Reason Totals for 2005: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 1 2 8 15 P. 0 0 3 KATHLEEN H. WALSH STATE BAR OF WISCONSIN FORM 7 - 2000 REGISTER OF DEEDS TRUSTEE'S DEED ST. CROIX GO. NI Document Number RECEIVED FOR RECORD 06/03/2005 03:36PH Daryl L Jones TRUSTEES DEED EXEMPT # as Trustee of L REC FEE: 11.00 Newel Jones and Dorothy M. Jones Family Trust TRANS FEE: 156.00 COPY FEE: CC FEE: for a valuable consideration conveys without warranty to PAGES: 1 Gary D Nelson and Jillienne J. Nelson I Grantee, the following described real estate in St. Croix County Recording Area State of Wisconsin (if more space is needed, please attach addendum): Name and Return Address Lot 9 of Certified Survey Map recorded in Volume 19 Title One Premier Group on page 4888 as Document No. 781610 being part of Hudson, Wisconsin Lot 6 of Certified Survey Map recorded in Volume 18 on page 4811 and part of Lot 5 of Certified Survey File No. 8711S Map recorded in Volume 13 on page 3648 being part of the Southwest Quarter of Southwest Quarter (SW of SW's), Section 21, Township 29 North, Range 18 West, 042 - 1059 -50 -400 Town of Warren, TOGETHER with a joint driveway Parcel Identification Number (PIN) easement. Dated this 3rd day of June - , 2005 * *Da 1 L. J es Trustee Trustee AUTHENTICATION ACKNOWLEDGMENT I Signature(s) STATE OF WISCONSIN ) ) ss. St. Croix County. ) authenticated this day of Personally came before me this 3rd day of June - 2005 the above named �A K, Daryl L. Jones TITLE: MEMBER STATE BAR OF ONS m to me krwwn to be the person who executed (If not, ° the f 'Ong instrum t and acknowledged the same. authorized by § 706.06, Wis. t 4/ THIS INSTRUMENT WAS DR ky K See er Michael H. Forecki Attorne blic, State of Wisconsin Eau Claire Wisconsin ission is permanent. (If not; state expiration date) (Signatures may be authenticated or acknowledged. Both are June 3 ' 2005 not necessary.) *Names of persons signing in any capacity must be typed or printed below their signature. TRUSTEE'S DEED STATE BAR OF WISCONSIN FORM No. 7 -2000 Attorney Michael H Forecki 3452 Oakwood Hills Pkwy Ste I, Eau Claire WI 54701 -7928 Phone: (715) 835 -3029 Fax: (715) 835 -4112 Michael H. Forecki 8711S.zfx Produced with ZipForm- by RE FormsNet, LLC 18025 Fifteen Mile Road, Clinton Township, Michigan 48035, (800) 383.9805 I - 7 4E31Es1PJ VOL 19 PAGE 4888 KATRErM H. WALSH REGISTER OF DEEDS ST. CROIX CO., MI RECEIVED FOR RECORD 12/03/2004 01:10PH CERTIFIED SURVEY NAP REC FEE: 13.00 CERTIFIED SURVEY MAP COPY FEE: PAGES: 2 L. Newel and Dorothy M. Jones Family Trust Located in part of the Southwest T/4 of the Southwest Y4 of section 21, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin, being Lot 6 of that Certified Survey Map recorded in Volume 18, Page 4811 of St. Croix County Certified Survey Maps. N LEGEND BEARINGS ARE REFERENCED TO THE SOUTH LJNE OF THE INDICATES 1' O.D. x 18' IRON SOUTHWEST 114 OF SECTM 21, O PIPE SET (MIN. WT. - 1.13 LBA, F,) T 29 N, R 16 W, ASSUMED AS N 89 W. • INDICATES 1' IRON PIPE FOUND A SOIL BORINGS (PROPOSED SEPTIC SYSTEM) SCALE IN FEET 1"- 200' 0 SECTION CORNER MONUMENT (AS NOTED) (R -) RECORDED AS 160 6 160 26o A DRIVEWAY LOCATION $�.P,RQ1lk�1 @f1111''H OWNERS ADDRESS nk�23oMIpfaM+Rarkk6ommittea 1134 80TH AVENUE Q. ROBERTS, W1 54023 UNP.,LATT -ED LAWS Ihnaan�siarq,ec�wu,�� 3s�,oa,c.o�. NORTH LINE LOT 6 �3A{lel1 TRY1M1M1FMI'bi S 89 °36'36" E 425.00' null +�ndfKOid 212,00' A 213.00' LOT 9 LOT 10 1.QT _ 3 109,228 SQ. FT, ,,; 109,289 SQ. FT. F3 N OR 2.506 AC. Z OR 2.509 AC. (1 02, 2 32 QERT(FIEO SWWEY V OR 2. 4 7 AC . - (102; .3 4 9 Fr. OR 2.37 . Fj OR 2.39 AC. MAP y EXCLUDING EXCLUDING w N TOWN ROAD TOWN ROOD ag RIGHT OF WAY) S ' RIGHT OF WAY) E (� LQT_ _4_ Z ( 0 _ 100' SE7HACK LINE I; P� SOUTH 114 CORNER SOUTHWEST CORNER � ,ar Q. SECTION 21, T 29 N, R 18 W x'1140• pp•11'4� a (FOUND CO(pVTYBERNTSEN , W " ,•' SECTION 21. T 29 NR 18 W 80, 8 00' ALUWMAW MON 00' r . 50. I/MEN>7 SUM /NU MMONUM E N f 212.ar .ar.- _ 33.ar 178.336 212.50' 80TH A VEN UE z�0� _ 33 .00' W :- 33.00' ;.33.00' — ci —SOUTH —UNE -� SNnH 3 N 89.36'36' W 389.0(Y -212.00 - 2 - - N W x1636.98 - —0 r N 89 °36' " W 423.24' - sB CORNER < < JOINT DRN -WAY LOT 6 4 Q T 66 1 EASEMENT - N 89'36'38' W 2649.27 - CERTIFIED $S EY. MA -sl (R = s 6e'4r1s• w, 2"9.287 VOLUME 0 PAQE 1 575 UIYP( ATT €D LA1VD$ r i � ': • M Hy f: I S 1713 p � wI. � DATED: AUGUST 19, 2004 O L SNP •00 THIS INSTRUMENT DRAFTED BY JERALD L. LARSON SHEET 1 OF 2 Vol 19 Page'4888 f PO ra ,� LA / 0. a Ca ! s th JQ �AA 1 .c b t E � cA • u1 Q o i N • tr o AA 3 i I { t 4 c i