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020-1355-01-050
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 579000 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: Hornung, Raymond & Elizabeth Hudson, Town of 020-1355-01-050 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: I D ' CST 61v\ 2- 21.29.19.2067A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER L , C ACITY STATION BS HI FS ELEV. 41 F Septic Benchmark W ~ E3E~. ~X~S~n Jd DD 1.D I b2, l0I , O' Alt. BM Aefatiom A oc 52 / Bldg. Sewer Xf5 rN k~ld►w9 / StN-*lnlet TANK SETBACK INFORMATION Stfhftflutlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Qwffle~ Septic Dl;-~ Dosing l2jt ' f3 I eader/ an. A~erattim W Dist. Pipe q L1,-7 Bot. System B.ZS 93.75 Final Grade PUMP/SIPHON INFORMATION Manufactur GP a St Cover y 25 I h o 15 f Mod Number V e c ~u .7 5 . Z TDH Lift Friction Loss System Hea TDH Ft Forcem 1111Length Jia. ist. to well SOIL ABSORPTION SYSTEM -7 -7 BED/TRENCH Width LengtFL, No. Of Trenches PIT DIMENS NS No. Of Pits Inside D/ ia. Liquid De 1R DIMENSIONS lot / p SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: 2 INFORMATION CHAMBER OR T pe OfUy Sste D ~ ] UNIT Model Number: , J I Zo 3-H ~o DISTRIBUTION SYSTEM p ~ Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake tt (s) ~ LI~dS Length Dia Len Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil T Yes ] No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 801 Grant Avenue Hudson, WI 54016 (SE 1/4 SE 1/4 21 T29N R19W) Homeplace Lot 1 Parcel No: 21.29.19.2067A 1.) Alt BM Description 2.) Bldg sewer length ,b bt )ls t AIA U 6 ems' -amount of cover =L/X~S~ IV~►~ bV~-t V't2T+rC (\A i~ @ fiMt c~ '^SAet.'ti°n+ L/ ! 51rw-~- FS @ iv It'. L i S Plan revision Required? ❑ Yes No ~J 205 Use other side for additional information. fi J Date s Signature Cert. No. SBD-6710 (R.3/97) PLOT PLAN N Project Name: Hornung Replacement Septic System Legal Description: SE7/4, SE1/4, S21, T29N, R19W P.I.D: 020-1355-01-050 Subdivision Name: HOMEPLACE Lot 1 SCALE: 1" = 40' Township: HUDSON Parcel Size: 1.459 Acres County: ST. CROIX System Elevation: T1=93.60' Existing 56.25' Infiltrator H-10 Trench Slope: 1% T2=93.60' Existing 56.25' Infiltrator H-10 Trench A, BM1 Elevation: 100.00' To of NE Lot Corner Iron T3=93.60' Proposed 70' EZ Flow Trench BM2 Elevation: 101.00 To of Foundation T4=93.60' Proposed 70' EZ Flow Trench ~ Backhoe Pits: 4 inch Sch 40 -ASTM D2665 NOTE: See page 15 for a complete plot of the parcel. 4 inch 3034 - ASTM D3034 i ~O a 1~ L 581,4 101 sL5 ~Q IQ00 6 AI $ ~ cXj 5 ~ PY ~1 C h~ a7 G P f` r ,~Jl Page 2 mmm~ ~erryr RECEIVED County 1 ivision St. Croix 11400 E Washington Ave Sanitary Permit Number (to be filled in b Co. p JUN 2 2 201 ` by ) X COUNTY Madison, WI 53707-7162 + ST. CROI 5 )D !N11TY DEVEI OPMEN1 _ 7 0 t Sanitary Permit Application State Transaction Number ✓ In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit I V is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address (if different than mailing address) purposes in accordance with the Privacy Law, s. 15.04(1)(m), Slats. Same y 1. Application Information - Pease Print All Information Property Owner's Name Parcel # Raymond & Elizabeth Hornung C~) 020-1355-01-050 Property Owner's Mailing Address Property Location 801 Grant Avenue Govt. Lot City, State Zip Code Phone Number SE 1/4, SE 114, Section 21 Hudson, WI 54016 circle one) T29N R19Eor 11. Type of Building (check all that apply) Lot # ® 1 or 2 Family Dwelling - Number of Bedrooms I Subdivision Nam j Homeplace ❑ Public/Commercial - Describe Use, lock # ❑ State Owned - Describe Use ❑ City of CSM Number ❑ Village of ry O W/7) a~L ~ ® Town of Hudson 2,C,1 1 1 X III. Type of Permit: only one box on line Complete line B if applicable) A. ❑ New Syste ® Replacement System] Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal El Permit Revision E] Change of ❑ Permit Transfer to New List Previous Pe it Number and Date Issued Before Expiration Plumber Owner IV. of POWTS Syste Component/Device: (Check all that apply) ITYIJ Non-Pressurized In-Ground, Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of sui 1 0' Holding Tank ❑ 0ther Dispersal Component (explain) ❑ Pretreatment Device (explain) , r V. Dispersal/Treatment Area Information: Design F w (gpd) Design Soil pplication Dispers ea Required (sf) Dispersal ea Proposed (sf) System El ati l 450 Rate(gpds 643 700 93.60 d ~ 0.7 VI. Tank Info Capacity in Gallons Total # of L, °o Gallons Units Man acturer - w 6 Y New Tanks Existing arks ( 2 o a? 7 P. U v y w C7 P. Septic or Holding Tank 320 1000 v 1320 2 Wi ser/ Wieser ® ❑ ❑ ❑ ❑ Dosing Chamber ❑ r-1 ❑ ❑ ❑ VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plum Si ature MP/MPRS Number Business Phone Number John Schmitt ( I ~ 223760 715-760-0486 Plumber's Address (Street, City, State, Zip Code) 616 150th Avenue, Somerset, WI 54025 VI I. ounty/Departiment Use Only Approved I „ ❑ Disapp Permit Fee t<~ 6aI Issue Issuing Agent Signature er Given Reason for Denial ~ 7, e4 IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: rl~r) 'lti~ 1. Septic tank, effluent filter and dispersal cell must be serviced / maintained I as per management plan provided by pl,.;r-;-,r. 2e t ietl 6s~st' g8 s to t e ounonly on paper not less than 81/2 x 11 inches in size Attach tpggomnle~'NNF~' SBD-6398 (R03/14) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Hornung Conventional In Ground Owners Name: Raymond & Elizabeth Hornung Owner's Address 801 Grant Avenue Hudson, WI 54016 Legal Description: SE1/4, SE1/4, S21, T29N, R19W Township Hudson County: St. Croix Subdivision Name: Homeplace Lot Number: 1 Block Number Parcel I.D. Number 020-1355-01-050 Plan Transaction No. Page 1 Index and title Page 2 Plot Plan Page 3 Existing Septic Tank Specifications Page 4 320 Gallon Filter Tank Specifications Page 5 Filter Information Page 6 Valve Information Page 7 System Sizing & Cross Section Page 8 EZ Flow Information Page 9 Sidewinder Chamber Specifications Page 10&11 Management and contingency plan Page 12 Existing Septic Tank Certification Page 13 Septic Tank Maintenance Agreement Page 14 Warranty Deed Page 15 CSM or Plat Attachment Soil Evaluation Report Designer: John Schmitt Licnese Number: MPRS 223760 Date: 2/20/2015 Phone Number: 715-760-0486 Signature: In- round Soil Absorption Component Manual Version 2.0 SBD-10705-P (N. 01/01) Page 1 PLOT PLAN N Project Name: Hornung Replacement Septic System Legal Description: SE114, SE114, S21, T29N, R19W P.I.D: 020-1355-01-050 Subdivision Name: HOMEPLACE Lot 1 SCALE: 1" = 40' Township: HUDSON Parcel Size: 1.459 Acres County: ST. CROIX System Elevation: T1=93.60' Existing 56.25' Infiltrator H-10 Trench Slope: 1% T2=93.60' Existing 56.25' Infiltrator H-10 Trench A BM1 Elevation: 100.00' To of NE Lot Corner Iron T3=93.60' Proposed 70' EZ Flow Trench BM2 Elevation: 101.00 To of Foundation T4=93.60' Proposed 70' EZ Flow Trench ~ Backhoe Pits: 4 inch Sch 40 -ASTM D2665 NOTE: See page 15 for a complete plot of the parcel. 4 inch 3034 - ASTM D3034 i Z I11 FQJZO L P®t, L© t; SLR 'N vd o GX~STi~1lo I©poC,AL 55r it, 3 10 f ~G m AO .ry I-, G f~ Page 2 SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Project Name: Raymond & Elizabeth Hornung Gravelless Leaching Unit Specifications Manufacturer Model Laying Length EISA Rating Infiltrator EZ1203H-5ft 5.0' 25.0 EZ1203H-10ft 10.0' 50.0 System Sizing EISA Rating per Foot of EZ Flow 5 ft2 Soil Application Rate 0.7 gpd/ft2 450.0 gpd Design Flow _ 0.7 Soil Application Rate = ~ EISA = 128.6 Feet of EZ Flow F72trenches 70 feet long each 2 No. of Cells 7 Per Cell 3 ft Cell Width 14 Total No of 1203H 70 ft Cell Length 350 sq ft EISA Per Cell 3 ft Cell Spacing 700 sq ft Total EISA Typical Cross Section Finished Grade 99 ft Observation Pipe with approved cap or vent _.e. Soil Backfill • 36 inch Geotextile Fabric ■ 12 Inch O I~ O Slotted and Anchored Vent/Observation Pipe with Cap 93.60 ft Infiltrative Surface >36 inch 89.47 a®rrrr■rar■rrrrrrr■srrr■■r■r■rr■s■r■rr■rr■■■re■rr■■rr■■■r■srrsr■ Plumber/Designer Signature: License MPRS 223760 Date: June 21, 2015 Page 7 D Z N D M m 61 86" D Z C D 42" n z M M N ~ v 0 ~ I i lffup 41 0 4' CAS 41 M N -I > 1 M 3" 36" 4" ( I. v < ID Wm D UP 38" r 0 0 4" CAS \m / N N V I M M c C ~ C rn ° .1 ° D ;a > e M ° 39" v < o D OrL> D N mDr D OmD -I M C D 0 rn 1I Xr f7 2 D Z 0 M C D0 D r = r Z Z ° Rr~* x z D Or c m m m -i 0K m w> DMZ DOZ v -9D 0-PD pm~rr*tmy0 0>- Z N Xr mZ ZrA 0C1 n OZ D Z rvz O c0 vx Sao v r~ °m >rrn> -0 ~0 X0 =v~~c~ 0..(,) ~ 0-4 mm cam D N r--IZ 0 ~Z0 rncDi>O fir- -1 Or F N oz ON \c Z n=X cn~c I c rnmzrn~ rnvm~ N z1~ <m =o ~o =N~ D ZZ OD DO OD Dy --I DD-1 cor --i 1KP O-VN M v n v y z D N M cn cnN p m to vM Cc) C:) o m o c v N oho N A M O c w 14 p. 0 C-) C) k 'i D o 000 0 -!l O n< z oc v, cn z ri c 0 m m ~ AA- cn n r v m z o 00 0 ~O -V O z z ~m 0 rn -Im rn m v m z H ? nm m t*i O D U) r- OpoO m z r- v W-n D m D 0 ;o ;a 8 m -0 Z C cn Z D 0 W sD v -n 0 Dv D D .~.p1 O~ Paper v O C Z O N co -V n r O z m ~A p O 0 D =o o o m~ ; o n z ; r c rn co H °z o Z m m ~ z ~ r M \ m WLP100 MR DRAWN BY: SME SCALE: 1/4"=l'-O" PRE-POUR: 0rn1 SEPTIC MANUAL MIEGER COOCAETE DATE: JANUARY 2010 DATE:. POST-POUR: W3716 US HWY 10 MAIDEN ROCK, WI 54750 ~ \Z ° REVISED JAN. 2010 800-325-8456 FILE: WIP1000-MR tb 95ed v z X N D A m X t > AS c 58 REQD N 0 4" -n 0 46j" m 50" m Z X D O m D O U) UP 484" m i I I I 4" CAS 43" LL O \ x m 3" 1 cn m 51" I < 0 rri UP 48" N 4" CAS LL 61 0 W 7Ty 1. 46' o N r v m m O c .'T) a m r. N m D z N I D I mm D r c Dn O r r (A z o0 x D c -mi m m D _ g v ~N x3 N D ^ D G)~D r~j2rn WAN z m x- _ C~ x m Z O`3z D aZ prpzr!ly0C OD- Cv v D 0 v 5~ 0 v (n v Oc0 OOZrIr Arz (nom mp :d Co m -u ° m0 =x -►D Nm 0 m (n D mop A>o -1 ~ ~ ~ (n X: z Z5 N F) Q ;ozc --I c mz(n m W z En U Zz z vci NzP I r~ A r-a 01.. 3 ITI N z 00 (Q (n C-) 0 x v D O Mm a) -1m 0 00 a a v p N (A z (n o to m D D ~ c,, rn v~ o ?1 o v a n O O (na -n I m N c o v D z m c r m-m-Im mW w -0 D V-41 ca c D Z =rz r0 Oa 0 m o 0 O H 0 ~C~ m %o 4-1, 70 Z rv 0 ;o -10 -n o~ N O o m G) >J D O ~ Z o D cn m m rr r r,1 n 00 N W N p r fJ p rrl X c 0 o 0 mr ;o O m O z r 0 m < 3 0 y D H m r r-'11 ry* N m v (n W320 MR m DRAWN BY. SME SCALE: t320/ =1'-0' PRE-POUR: ° SEPTIC MANUAL REV. 3 \ z W3716 US HWY 10 MAIDEN ROCK, N 54750 DATE: JANUARY 2012 DATE.. 12 POST-POUR: ° REVISED JAN. 2012 800-325-8456 FILE: 1320-pR kTM lnc. L YA 0 bel' PL-525 Effluent Filter Za Innovations in Precast, Drainaiz & Wastewater Products A Division of Polylok Inc. PL-525 Filter The PL-525 Filter is rated for 10,000 GPD (gallons per day) making it one of the largest filters in its class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the Polylok PL-525 has an automatic shut-off ball installed with every filter. When the filter is removed for cleaning, the ball will float up and temporarily shut off the system so the effluent won't leave the tank. Features: 116" Filtration Slots • Rated for 10,000 GPD (gallons per day). Alarm Switch 10,E GPD (optional) • 525 linear feet of 1/16" filtration. • Accepts 4" and 6" SCHD 40 pipe. G~ Accepts 1° PVC Extension Handle • Built in gas deflector. • Automatic shut-off ball when filter is removed. • Alarm accessibility. Rated Gfor PD • Accepts PVC extension handle. PI-525 Installation: Ideal for residential and commercial waste flows up to 525 Linear Ft. 10,000 gallons per day (GPD). of 1/16" Filtration Slots 1. Locate the outlet of the septic tank. yx 2. Remove the tank cover and pump tank if necessary. Accepts 4" & 6" - 3. Glue the filter housing to the 4" or 6" outlet pipe. If SCHD 40 pipe the filter is not centered under the access opening use a Polylok Extend & Lok or piece of pipe to center filter. 4. Insert the PL-525 filter into its housing. 5. Replace and secure the septic tank cover. Certified to NSF/ANSI Standard 46 PL-525 Maintenance: The PL-525 Effluent Filters will operate efficiently for p.n several years under normal conditions before requiring cleaning. It is recommended that the filter be cleaned every time the tank is pumped, or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be done by a certified Gas Deflector septic tank pumper or installer. 7A'tomatic 1. Locate the outlet of the septic tank. Shut Off Ball 2. Remove tank cover and pump tank if necessary. 3. Do not use plumbing when filter is removed. 4. Pull PL-525 cartridge out of the housing. 5. Hose off filter over the septic tank. Make sure all { solids fall back into septic tank. 6. Insert the filter cartridge back into the housing making sure the filter is properly aligned and completely inserted. Polylok, Outdoor Zabel l & Si & Best filters s Alarm accept extend tall Easily installs 7. Replace and secure septic tank cover. the SmartFilter® switch and alarm. into existing tanks. Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Toll Free: 877.765.9565 Fax: 203.284.8514 www.polylok.com Page 5 6/21/2015 American Manufacturing Company Bull Run Valve Home About 1 Site Map V Order Info_ Training Videos Contact Drip Systems Nil Treatment Controls Products Downloads n r a ice 4z- 'WATER-TIGHT ACCESS CAP i.a RI SER CAP ADAPTER RI SER TUBE VALVE DIRECTI ON The Bull Run Valve TM is designed to split flows to septic HR ND LE fields or systems. In addition to the advantages of 4" OUT PORT longer life and easier installation it is the most public 4" OUT PORT health safe alternating device available for wastewater disposal applications. The use has absolutely no contact with wastewater due to the valve's leak-proof and external operating characteristics. The change over from one drainage field to another can be accomplished 4" IN PORT in less than a minute by simply turning the valve without digging or contact with wastewater. The Bull Run Valve is available in 4" sch 40 pvc and is suitable wherever septic disposal systems are used - in commercial, industrial, an residential applications. OPERATING THE VALVE F VValove Field Field The direction control handle should be rotated No. I ield periodically to direct effluent to one or the other No. 1 No.2 of two septic fields. After removing the screw cap at the top of the riser tube, the valve handle s can be turned with the valve key furnis hed. Valve PPositioned on . an No. 2 BULL RUN VALVE during during Complete Valve Kit Odd Years Septic Septic Even Years Contains Tank Tank 1. Bull Run Valve body 2. 28" Valve Key 3. Riser Cap Adapter ITEM DESCRIPTION 4. Watertight Access Cap BRV4 BULL RUN VALVE 4" BRVBULK BULL RUN VALVE & KEY ONLY BRVCIRISER BULL RUN VALVE RISER W/ CAST COVER BRVKEY28 BULL RUN VALVE KEY 28" BRVCIRISER - 4" BRVKEY36 BULL RUN VALVE KEY 36" ADJUSTABLE TO 28" HIGH BRVKEY48 BULL RUN VALVE KEY 48" Page 6 Mtp✓lwww.americarmnsite.can/americaNcatalcxybrv.html 1/3 Installation Instructions for ZUTM EZflow Systems in Wisconsin EZ flo TRATOR Wisconsin Department of Commerce, Safety and Buildings 5. The Absorption area (SF) necessary for a given site shall Division, has reviewed the specifications and/or plans for this : be sized based on maximum daily sewage flow (GPD) and product and determined it to be in compliance with chapters the Permeability for the site. If certain criteria is met, the Comm 82 through 84, Wisconsin Admin. Code, and Chapters EISA sizing can be used in Wisconsin, resulting in a 40% 145 and 160, Wisconsin Statutes. All sites must meet the Site smaller drainfield. & .Soil Conditions & Locations & Isolation distances as noted in local regulations. 6. Place EZflow bundle(s) in the EZflow configuration ap- proved by system design permit specified for the particu- The approved products are 1203H (3-12" bundles with pipe in lar site. The top or center-most bundles containing pipe center bundle in 5' or 10' lengths) and 1203HP (3-12" bundles are joined end to end with an internal pipe coupler. Any with pipe in each bundle in 5' or 10' lengths. additional aggregate only bundles that may be required, should be butted against the other aggregate-only bun- A single pipe bundle contains a four inch perforated pipe sur- dles and do not require any type of connection. rounded by EPS aggregate and is held together with poly- ehtylene netting. A single aggregate bundle contains aggregate 7. The top of each GEO cylinder contains a filter fabric pre- only and is held together with polyethylene netting. manufactured in between the netting and aggregate. The fabric is inserted to prevent soil intrusion. The installer Materials and Equipment Needed shall make sure the the GEO is positioned upward and is • EZflow Bundles in contact with the fabric contained in the adjacent cylin- • EZflow Geotextile Fabric der before backfilling, • EZflow Internal Pipe Couplers • Pipe for Header and Inlet 8. The EZflow Drainfield Systems should be installed in a • Backhoe/Excavator level trench in all directions (both across and along the trench bottom) and should follow the contour of the ground Installation Instructions surface elevation (uniform depth), with all continuous The instructions for installation of EZflow products are given adjoining 10-foot cylindrical bundles placed end to end, below. This product must be installed in accordance with state with central bundle distribution pipe interconnected, rules defined in chapters Comm 82 through 84, Wisconsin Ad- without any dams, stepdowns or other water stops, ministrative Code, and Chapters 145 and 160, Wisconsin Stat- utes, as well as the local health department's current design 9. The trench top shall be graded such that water will not manual. pond. Backfill should be seeded or sodded immediately after completion to reduce erosion. 1. After the local health department has determined sizing, configuration, and layout for the EZflow systems, stake 10. EZflow EPS bundles are flexible and can fit in curved or mark with paint the location of trenches and lines. Be trenches as may be necessary to avoid trees, boulders, or careful to set correct tank, invert pipe, header line or dis- other obstacles. tribution box and trench bottom elevations before instal- lation of pipe bundles. 11. EPS aggregate is lighter than water, therefore, it might be expected that natural buoyancy forces would tend to 2. Remove plastic EZflow shipping bags prior to placing cause EZflow assemblies to float out of ground when bundles in the trench(es). Remove any plastic bags in the ponding occurs. Field experience has shown, however, trench before system is covered. that this is not a problem when systems have a minimum • of 6" of soil cover as recommended by manufacturer. 3. This product must have geotextile fabric that meets re- quirements of s. Comm 84.30 (6) (g), Ws. Adm. Code, installed directly on top of the product and extending down along the sides of the product to a point at least six 1203H-GEO inches from the bottom of product. Geotextile Barrier Material 4. When installed in a trench, the trench should be dug to a width of 36 inches. This not only saves labor in excava- 12' tion, but also provides better load-bearing capacity after backfilling is complete. • Page •8 -D c: r E z C') x IM U) co 70 i\ c T_ A co 0 x rn o o g ca i° cl m a V) - =6 E COD o T~. b 0g ~R o~~C _ ~ O b O _ CA > CL z. C: CO N C O C.U G'Y M_. C 1] Rf N > O5 N p rn c p 0. O 0 O U v J co la i E O: r= t~ V [n E 05 Q • • • • ~N ~i a I 4 14 k4 - a { 17 W d / W \ / Co- Ra c ;5 A L- 3: 20 m t E co g~ w 'y$ atu~ m J d _ i • I Page 9 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page _of FILE INFORMATION SYSTEM SPECIFICATIONS Owner: Raymond & Elizabeth Hornung Tank Manufacturer: Wieser Concrete ( NA Permit # Septic E Dose L_ Holding Volume: 1000 gal DESIGN PARAMETERS Tank Manufacturer: Wieser Concrete NA Number of Bedrooms: 3 NA T Septic 1: Dose E Holding Volume: 320 al Number of Public Facility Units: F NA Vertical Distance Tank Bottom (s) to Service Pad: ft Estimated (average) Flow: 300 gal/day Horizontal Distance Tank(s) to Serivice Pad: ft Design (peak) Flow = estimated x 1.5: 450 gal/day Specific servicing mechanics must be provide if vertical is>15 feet or if In Situ Soil Application Rate: 0.7 gal/day/ft2 horizontal is > 150 feet. Specific instructions to be provided on back. Standard Domestic Influent/Effluent Monthly average Effluent Filter Manufacturer: Polylok NA Fats, Oils & Grease (FOG) 530 mg/L Effluent Filter Model: 525A-100 Biochemical Oxygen Demand (BOD5) 5220mg/L NA Pump Manufacturer. R 'NA Total Suspended Solids (TSS) 5150mg/L Pump Model: High Strength Influent/Effluent Monthly average Petreatment Unit Fats, Oils & Grease (FOG) 530 mg/L Manufacturer: Biochemical Oxygen Demand (BOD5) 5220mg/L f-%/NA Mechanical Aeration Peat Filter NA Total Suspended Solids (TSS) 5150mg/L Disinfection r Wetland Petreated Effluent Monthly average r Sand/Gravel Filter Other: Biochemical Oxygen Demand (BOD5) 530mg/L Soil Absorption System Total Suspended Solids (TSS) 530mg/L NA f✓ In-Ground (gravity) f"` In-Ground (pressure) Fecal Coliform (geometric mean) 5104cfu/100m1 r At-Grade mound NA Maximum Effluent Particle Size: % in dia. N r Drip-Line Other: Other: Other: NA MAINTENANCE SCHEDULE Service Event Service Frequency When combined with sludge and scum equals one-third of tank volume Pump out contents of tank(s) When the high water alarm is activated Inspect condition of tank(s) At least once eve : 3 m ea is f"✓ y (Maximum 3 ears) NA month(s) Inspect dispersal cell(s) At least once every: 1.5 year(s) (Maximum 3 years) NA r month(s) Clean effluent filter At least once every: 1.5year(s) NA Insect um month(s) p p , pump controls & alarm At least once every: 17 year(s) NA r month(s) Flush laterals and pressure test At least once every: r year(s) NA month(s) Other: Ca trenches T1 & T2 Use T3 & T4 for 5 f✓ Year(s) NA Other: Alternate Trenches Alternate Trenches every 1.5 years 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 Insepector; POWTS Maintainer; Septage Servicing Operator (pumper). Tank inspections must include a visual inspeciton 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 a check for any back up or ponding of effluent on ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicated a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumualtion of sludge and scum in any treatment 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 Admininistrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, petreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. (Rev.2/05) Page 10 START UP AND OPERATION Page of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil 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 extended power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose and may overload them resulting in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) discharge; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide the opportunity to obtain a sanitary permit for 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 the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. ❑ 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. ❑ 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: TR OXYGEN TO SUPPORT EATMENT TANKS AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES AND LACK SUFFICIENT LIFE. UNDER CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM HE INTERIOR OF ATANK IS VERY DIFFICULT. ADDITIONAL INFORMATION: POWTS INSTALLER POWTS MAINTAINER Name: John Schmitt Name: John Schmitt 'Phone: 715-760-0486 Phone: 715-760-0486 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name: Marko Septic Name: St. Croix County Zoning Phone: 715-749-3404 Phone: 715-386-4680 This document is intended to meet minimum requirements of Ch. Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not guarantee the performance of the POWTS. Ppge 2b3) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently servin the following residence: (Street addressor Grant Avenue at: SE 1/4, SE Town i/4, Section 21 29 N Range 19 Wlocated , Town of Hudson St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service June 18, 2015 Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: 1000 Construction: Prefab Concrete X Steel Other Manufacturer (if known): Weser Concrete Age of Tank (if known): 16 years oid Permit number (if known) 344539. John Schmitt ( ensed Plumber Signature) (Print Name) MPRS 223760 (Title) (License Number) MP/MPRS June 20,2015 (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 Page 12 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Raymond & Elizabeth Hornung Mailing Address 801 Grant Avenue/ Property Address Same (Verification required from Planning & Zoning Department for new construction.) City/State Hudson, WI Parcel Identification Number 020-1355-01-050 LEGAL DESCRIPTION Property Location SE SE '/4 , Sec. 21 T 29 N R 19 W, Town of Hudson Subdivision Plat: Homeplace 1 Lot # Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume Page # Spec house Oyesdlo Lot lines identifiable Byes[]no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 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 Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all ments this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, virtue of a 1 rranty deed recorded in Register of Deeds Office. Number of b room 3 S NATURE O PLICANT(S) E DATE ~ * * *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) Page 13 " t u { I.904 acres 1 2 584 acres ) . excl, temp cul-de-sac O ° c t a PROPOSED FUTURE R.•O -W.. LINE j PONOING t DRAINAGE 441 W ` EASEMENT. _.rys " 6 6' HIGHWATER ' "+.'•1 W ;n 6 ELEV = 920 9' 188,042 square feet I 6 = .ww ' r b~ ryD { 4,317 acres) O U LL d c L 50' SETBACK FROM PROPOSED rn +J W `r s ro y) FUTURE R.-0 -W. LINE ! Q Z (SEE SURVEYOR'S NOTES) a _ tL I F 4t`°a Uy C? O Ci ( ~ 5? 72 2 vp ° W 00 ~ ~ [r ~ t3y ~ m va 730 (r) ` w o o W 8" 0~ 20'X 6b' joint 2 V L0 W s 33 Ixf driveway easement V p square a NAIL Asa d 60°('JO ' . 101,174 2.323 acres )et W ` [ j L UTILITY E.ASLMENTI' = 923.08' 10, o n 11 /01 0©ry W I No pole or buried cables are be placed st u . bT .0 1 ° installation would disturb any survey sta F 90`7 00'00or~~L a° 9 99 CD ° obstruct vision along any lot line or suet 20' X 66' joint ~00- disturbance of a survey by stake by anyo driveway easement 8(7 ' utT . c~0 e LO violation of Statute 236 32 (2) of the We uSO~ Statutes Utility Easements as herein set T 4 I for the use ofpublic bodies and private 1 19 48- - 9"~ N~ 65 ( utilities have the right to serve the area - 9 O, W I 136,241 square feet !v 90,206 sgu a feet 567 {3128acres) SEPTiC G (2071 esO n p o n 50 5~' J rye existing dwelling U) Z ~ L 0 61, C> '0 10 z 2 ti~ S a8° 34' 38' E 300 90 - - ,O N W O 87,652 square feet Z Z DRAINAGE EASEMENT w w T O 2 (2.012 acres) m O - i 379 80' R= 30 W W a \ )*23'51"W 881.24 DEDICATED TO THE PUBLIC Tan.=29.a3 ' 4 to `r' Tan=3o se ° 23'51"W Two SET 14 v rr() r± N 89° 23' 51" W 1.319.1Q I3.~L~C .=~'I~s ROAD LOT I OF LOT I OF \ ° T t CF, R TINED S'URGFY MAP LOT I j C A'R77FIED SURVE MAP, PLAT OF VOLUME 6, PAGE IbSQ- VOLUME 3, PAGE 862. loo' I Do' ( BADLANDS PRAIRIE Cufty 1 ~ ~ _ E DATA f+)R TCti1PORARY C[!1: DF;-SAC' ( O LOT NO RADIUS DELTA CHORD-- Cf fORD ARC TANGENT • ear •ntwu r C:lw~!_Ttl DC A D tAtr:C SCALE IN F i Wisg9411`1 Department of Commerce Division of Safety and Buildings SOIL AND SITE EVALUATION Page - - of -3- in accord with Comm 83.05, Wis. Adm. Code A.C.E. Soil & Site Evaluations Attach complete site plan an paper not less than 8'h x 11 inches in size. Plan must County include, but not limited to., vertical and horizontal referee direction and percent slope, scale or dimensions, north arrow, to nearest road. St. Croix \ Parcel l.D.# APPLICANT INFORMATION - P/ nt all i ornra~ti f. - 6 90 00t) Personal information you provide may be used dory P =y t eiy, a 04 (1) (m)). Reviewed BY Date Property Owner h P Location o - - - rty Miller Sam rs ) Lot SE 114 SE 1/4 S 21 T 29 N,R 19 W - , ~1 n9- roperty Owners Mailing Address -L~ ST CROix tvt Block # Subd. Name or CSM# Box 151 Trout Brook Road .-,1 ~t;fVTY 1 f NA Home Place City State Zi opm" \ City [ ) Village [,d Town Town Nearest Road Hudson WI 54 6 5)386-2 'L Hudson [ Grant Avenue New Construction Use: C; ] Residen rooms 3 L JAddition to existing building [ Replacement Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpdr .8 trench, gpd/ft' Absorption area required 643 bed, fns 562 trench, ft, Maximum design loading rate .7 bed, gpd/fl2 .8 trench, gpdtW Recommended infiltration surface elevation(s) 95.00, ft (as referred to site plan benchmark) Additional design / site considerations Parent material outwash s & E.- Flood lain elevation, if applicable NA ft S--Suitable for system Conventional Mound In-Ground Pressure AT-Grade 1. System in Fill Holding Tank U=Unsuitable for system S❑ U z S0 U 0 S❑ Ll ❑ S L:7 U ❑ S ©U ❑ S r- U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure Consistence GPD/ftz Boring# Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz Boundary Roots Bed Trench 1 1 0-8 IORY2/2 None sl 1 thin pl mvfr as 2f 0.4 0.5 _2 8-12 IOYR3/3 _ None sl 1 thin pl - mvfr cs 2f, lm 0.4 0.5 Ground 3 12-23 10YR414 - None sl 2msbk mfr - cw 2f 1m 0.5 0.6 elev + 100.32 it 4 23-38 7.5YR4/6 None gr. Is o sg ml cw if 0.7 0.8 Depth to 5 38-123 1 OYR5/4 None s & gr. o sg ml - - 0.7 0.8 limiting - - - factor Remarks: 2 _ 1 0-10 - IORY2/2 - -None - sl 1 thin pl mvfr as 2f 0.4 0.5 2 10-14 1 OYR3/3 None s1 I thin pl. - mvfr cs 2f, I m 0.4 0.5 Ground r--- 3 14-24 10YR4/4 None sl 2msbk mfr cW 2f, im 0.5 0.6 elev 99.35'it 4 24-36 7.5YR4/6 None gr. Is osg ml cW if 0.7 0.8 Depth to 5 36-116 10YR5/4 None s & gr o sg ml - - 0.7 0.8 1 _ _ imiting - - - - - factor Remarks: CST Name (Please Print) Sign lure: Telephone No. James K. Thompson / 715-248-7767 Address A.C.E. Soil & Site Evaluations Date CST Number Ref # 340 Paulson Lake Lane, Osceola, WI 54020 5/3/99 3602 1013 I tiROpoviOwwx Milia, s.. SOIL DESCRIPTION REPORT PARC& ID tK o2atos¢ Page of 3 Horizon - ~ - - - _ _ A.C.E. Soil & Site_Evaluations ~ Depth Dominant color Mottles Texture Stru cture sistence BoundaryRoots in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trench 3 l I 0-8 1ORY2/2 None sl 1 thin pi i mvfr as 2f 0.4 0.5 + - - 2 8-13 10YR313 None sl 1 thin pl ! mvfr cs 2f, lm 0.4 0.5 elev 3 13-25 10YR4/4 None sl 2msbk f mfr I cw ! 2f, Im 0.5 0.6 25-35 7.5YR4/6 None is os ml f_._- - gr. g cw If 0.7 0.8 Depth - limiting 35-120 10YR5/4 None s & gr. o sg u ahl - 0.7 0 8 - factor - - - - f - - >120' i Remarks: 4 1 0-9 1ORY2/2 None sl 1 thin pl mvfr as 2f 0.4 0.5 2 9-15 IOYR3/3 None sl 1 thin pl mvfr cs 2f, lm 0.4 0.5 Ground - - - - - - elev 3 15-27 10YR4/4 - None sl 2msbk mfr cw 2f, lm 0.5 0.6 99.6Z ft 4 27-34 7.5YR4/6 None gr. Is osg ml cw if 0.7 0.8 Depth to limiting 5 34-119 10YR5/4 None s& - gr. osg ; ml 0.7 0.8 factor > 119' Remarks: 05 1 0-13 IORY2/2 None sl 1 thin pl T mvfr as 2f 0.4 0.5- 2 13-18 10YR3/3 None sl 1 thin pt mvfr cs 2f, Im 0.4 0.5 Ground d elev 3 18-33 10YR4/4 None - sl 2msbk i mfr cw 2f, lm 0.5 0.6 99.09ft 4 33-46 7.5YR4/6 None gr. Is osg ml cw if 0.7 0.8 Depth to limiti ng _ 5 46-115 10YR5/4 None s & gr. o sg ml - - 0.7 0.8 factor ___i ->115' Y Remarks: - - I - - Ground elev i Depth to Wiling factor . Remarks: pj . Sc~.Pe : r X10 P. -t • lcca~t,c~(~ga. ■ L.o C:A.4.U1: ~ ~vt / off' ,ola~ d~' yolucL SEysFSr`~, Sec. ~Kalsr,,. ■ ~ R 19 cJ; 7,-t. p~ 39699' w n h~q G n CO) O 3 T n d CD 0 M -0 ~ CD I m ~ ro ~ ` 1 • m o N a t ii c-I N C < o. c a i.~ ° r. v ° G) y m cn (A j C/) zt 12 zt N O N O O 'S 1 N N Q (a N 3 N I O O C CD CD O O O O N j O 3 v 6 (\I N N O O N 'r7 d C o C D a N Qro < ` Q ro i 3 ° ° C. ccoo rn c l~~+ C co co n CD ccoo co QO '04 N o . r a N N "WA. o O O O cn ~r 0 E o_ p ( f~A f~A f~A C3) O o 0 N o 0 0 m O O : A .%r N '0 ro o 0 CD ro N W ro CL I z l~ o O I = D a ET 7 O o o CA I N ~y CD = M c m W a n 3 v E Z m m (p "1 CA I O w " o ? croi =i `G c M a Lz0 I 0 U) N W M M (D G 1 ' Z o 3 c O " m CD N Z CD A W ~ I Q a I N C o a I CD N i I V y c I I kj 0 °b a A O N O ~ O O. • ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY REPORT V Owner 4 ,~°°L_ - r ,E E61E0 Property Address a l 6 0A MT K_ 1 10 q 1999 City/State K 0 DS n ST cox ZoN Legal Description: " "'"rt~~a~ Lot Block Subdivision/CSM # '/a, Sec. z- T 2-7 N-R,~ Town of v ' PIN# t SEPTIC TAN DOSE CHAMBER HOLDING TANK INFORMATION: Tank manufacturer Siz ST C Ct?' l Setback from: House 32 Well P/L Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: CWidth S Length Number of Trenches Z Setback from: House 'S I ' Well / ZO 7"- P/L 3 3 Vent to fresh air intake s ELEVATIONS: C, CC ~/f Elevation/ Description of benchmark TC r I' / le T ,4 /e 1 Description of alternate benchmark `t a t~ c F E t C C K F e -,x1i-,A T 1,,A1 3,-Y5- Elevation c::P/, ?U _ ZS S Building Sewer f,ST/HT Inlet ~ST Outlet `7, 3, PC Inlet PC Bottom Header/Manifold Top of ST/PC Manhole Cover ~3, 7 Distribution Lines Bottom of System O I CA S= t~ ~(0 O Q Final Grade Go . zS' =O (y,2S~L ( } Date of installation --71Z91 q Permit number State plan number Plumber's signature r License numberZl!!~a3(tO Date Inspector _ bn L7 _ ~0 N„ lk- 66 p~ 4- Complete plot plan or NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW Ln AIP f 5 d5 of71Z1k, O - r• V NOTE , 7`IA (If fa it com C31~ II /dCs !r L t -J 41 < F ~AtiAGE `C; --'T C } T ti L l~fz~UE ~~tY LOT ~ 1 r N1 l` INDICATE NORTH ARROW NOTICE: Please provide the following: II • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW M #TE 1V,0T-1Atjr,44QA,6 it cc ty% 14 CE k z C, 14 be- vE wAY LOT ~ i INDICATE NORTH ARROW i i Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST7 _CRC IX Personal information you provice may be used for secondary purposes (Privacy Law, s.15.04 (1)(m)]. 344539 PerrRt}d I Nam~AM ❑ City_UDSION Town of: State Plan ID No.: CST1B"1MllEEleev.:- Insp. BM Elev.: BM Description: H Parcel Tax No.: lot- ^ Air- 020-1355-01-000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark s 4 Z /oS, S U0, d Dosing J1 LL , g5 DO Q IT Aeration Bldg. Sewer' 96 Holding St / Ht Inlet lo. 3 Z R , r-O TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Vent to Airlntake ROAD Dt Inlet Septic 32 NA Dt Bottom Dosing NA Header / Man. E !e S 7 Aeration NA Dist. Pipe W ~ . er 97- F 32 Holding Bot. System ~ Z, vs- X1 7- PUMP/ SIPHON INFORMATION Final Grade 35" qf. 5(;~- Manu a r 03 Model Number GPM TDH Lift FL ricti Y TDH Ft ead Forcemai ength Dia. H Dist. To W71 SOIL ABSORPTION SYSTEM TRENCH Width Length _ No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth IMEN L • ZS DIMENSIONS SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manuf c urer: S, ` INFORMATION Type O CHAMBER Mode Number- System: 143 OR UNIT 1cc lD DISTRIBUTION SYSTEM Header/ Manifold a Distribution Pipe(s) x Hole Size x en o Air Intake Length / Dia. Lengt Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over u Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed/ Trench Center & 6 Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 21.29.19.2067,SE, E 801 GRANT AVE - HOMEPLACE LOT 1 2 (Ater, edu~+IV - tat v~ I~ `t, ,.O 4n.n t Geu*/ d~ > `i g(1}~i ~ S4JIat~ 32~ Ina4 Plan revision required? ❑ Yes MNo Use other side for additional inform ion. ~ C q 1 S 2 b SBO-6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: s" . d 3 i Osconsin Safety and Buildings Division S NITARY PERMIT APPLICATION 220118 Washington Avenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7302 • Attach complete plans (to the county copy only) for the system, on paper not less county than 8112 x 11 inches in size. cni • See reverse side for instructions for c mpleting this application State Sanitary Permit Number 3_YrYsq Personal information you provide may be used for econdary purposes Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. Stale Plan I.D. Number 1. APPLICATION INFORMATI N - LEASE PRINT ALL INFORMATI N Pro e y Owner a e WE 9 roperty ocation 1/4 S 1/4, S Z T 40 , N, R 6T E (ol Py Ow ts; ailing ddress Lot Number Block Number City Stat V I, 1 Zip C Pho a Number a or SubisioriName o CSM N mbe 1. TYPE OF BUILDING : (check one ❑ State Owned City Nearest Road Village 16-e4kT Pu A"r blic 1 or 2 Famii DwelliL of bedTown OF fl:A N 111. BUILDIN USE: (If building type is ublic, check all that apply) Parcel Tax Number(s) O(/ ~ 1q. sTO+G~ 1 ❑ Apartment/ Condo 1) Zo . 3 :5 -c- ~ 1 - V C~ 2 ❑ Assembly Hall 6 Medical Facility/ Nursing - 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 Merchandise: Sales/ Rep 11 ❑ Restaurant / Bar / Dining 4 ❑ Church/School 8 Mobile Home Park Service Station / Car Wash 5 ❑ Hotel/ Motel 9 Office / Factory : specify IV. TYPE OF PERMIT: (Check onl one box on line A. Che( A) 1. New 2. ❑ Replac ment 3. E] Repl; is n of 5 ❑ Repanof stem System --System - Tani, y y -q_----- B) A Sanitary Permit was pr viously issued. Pern._ _ Date Issued 7WZ/ V. TYPE OF SYSTEM: (Check onl one) Non-Pressurized Distribution Pressurized Distribution Experrn._ Other 11 ❑ Seepage Bed 21[3 Mound 30 ❑ Specify Type 410 Holding Tank 12 tA Seepage Trench I, EAo+ 22 In-Gr and Pressure 42 ❑ Pit Privy 13OUSeepage Pit j#tjF tT an. 43 ❑ Vault Privy 14❑System-In-Fill 3140 sipf- V1. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade t,,11 s~ Required sq. ft.) Pro 167 osed sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation & 7X "`.a 3 r 3S Feet 99r feet q 0 Capacity VII. INTANK FORMATION in gallon. Total # of Manufacturer's Name Prefab. Site Steel Fiber- Plastic Exper. I Exist in Gallons Tanks concrete strutted glass App. New Tanks Tanks Septic Tank r W` jiQQ ❑ ❑ ❑ ❑ ❑ Li ump Tank /Siphon Chamber 11 11 ❑ 13 13 ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) PlumberSignature: amps MP/MPRSW No.: Business Phone Number: OA ~ Plu0mbe„"rr's Ijddresstr~eret, City,`Ste; Zip Cod i IX. COUNTY / DEPARTMENT USE ONLY / ❑Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issu e i ur oStamps) .r Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: SBD- 6398 (R.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 J 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: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. 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. V1. Absorption system information. Provide all information requested for numbers 1 through 7. VIL 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. ` Safety and Buildings Division Visconsin SANITARY PERMIT APPLICATION 201 W. Washington Avenue P O Box 7302 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7302 • Attach complete plans (to the county copy only) for the system, on paper not less county than 81/2 x 11 inches in size. CJYD • See reverse side for instructions for completing this application State Sanitary Permit Number WX537 Personal information you provide may be used for secondary purposes ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number i I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N Property Owner N,~Ame Property Location r 514 M SE1/4 SE _ 1/4,5 L/ T Z~ N,R Iq E(O W Property Owner's Mailin Address Lot Number Block Number City, State Zip C de Phone Number Subdivision Name or CSM Number 7-7 9 Home P-14c.-C II. TYPE F BUILDING: (check one) ❑ State Owned it Nearest Road Public 1 or 2 Family Dwelling - Na. of bedrooms _31 Er Town OF III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) `"t'd 1 ❑ Apartment/ Condo 13 5-s'-- O d c.?. 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 ❑ 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) A) 1. lsti New 2, ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of S. ❑ Repair of an System System Tank Tank Only _____--____-_-Existing System _'______Existing System _ 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 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 Holding Tank 12 „Seepage Trench LEACH 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit ,f IN.FW A(7,b /Z X 3 X ,5'6, ZS ivy 14[]System-In-Fill 3 f SQ~'T S/pE wrNLEp /~-TaT~ VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Requl ecl sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min-/inch) E vation / o I -S <o S7 Z-- Feet Feet VII. TANK Capacity gallons Total # of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted T nks Tanks + E c e tic Tank ~ l4 r-P- ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ 11 ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: ( tamps) MP/MPRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip C)de): Io?O U O'Ed l0(aF , Dr4 & LIDO W IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit F (Includes Groundwater ate Issued lssuirigAg4h Signature (No tamps) Z Surcharge Fee) Approved ❑ Owner Given Initial 2 s G Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.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. II. 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. Vlll. 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 8112 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- l r , a i y 1 kjj j J? Nye Fv Vl C'V to r- Z- e C~ ~ fq - Q3 r, ao x 4 • a vv N -1 m x U, 0%) 1 LAf (IN Q 1 1 N r c 7 _ n v 1 m~ m ~n 3 M ~w o n. XJ Cr, [Z. y `isv -u ~ p s Cl) CD o a N ~ -=a x ~ y ~ e v ~o u o I'17 4 ' i t`, Y i I T n co 0-1 v 4 Y ~f v I- cq CD 61 lp -0 c c1 (n (D CL _ C 3 (D tb ° m ca (D rL G p- O•QO c _ 1 ° 6 vi N ~ccn~ (D ° CD w i w 070 0) w ~ N " = n (D~ o o co to 1 x, o `l `C D _ S { Or D CD x a ° i Ie I I ~ s c I~ _ Wisgorisin Department of Commerce SOIL AND SITE EVALUATION Page -.-1-- of --3 Division of Safety and Buildings in accord with Comm 83.05, Wis. Adm. Code A.C.E. Soil & Site Evaluations Attach complete site plan on paper not less than 8'/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal referenge-pw 9W direction and St. Croix n eta to nearest road. percent slope, scale or dimensions, north arrow, a 16011 op iGe Parcell.D.# APPLICANT INFORMATION - Ple nit all i forM4 020-1056-90-000 Reviewed By Date Personal information you provide may be used fo dary p ri y Laws, 04 (1) (m)). , r v ? . j j,e.Q,~,,,.~;H , i7 - Property Owner h~ rty Location Miller Sam r4 s Gn Lot SE 114 SE 1/4 S 21 T 29 N,R 19 W 099 Property Owner's Mailing Address . 11.0 -LDt Block # , Subd. Name or CSM# ST CRaX Home Place Box 151 Trout Brook Road NA ; GUNTy City State Zi 9 P OPprE _J City J Village jown Nearest Road Hudson WI 54 6/ 5 386-2 Hudson I Grant Avenue New Construction Use: C%. Residen Brooms 3 _]Addition to existing building [ Replacement Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2 Absorption area required 643 bed, ft2 562 trench, ft' Maximum design loading rate .7 bed, gpdr .8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 95.00' ft (as referred to site plan benchmark) Additional design / site considerations Parent material Outwash s & gr. Flood lain elevation, if applicable NA ft S=Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U=Unsuitable for system Zs D u ❑ S0 U E] S❑ U E, S❑ U j ❑ S❑ U I ❑ S N U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPDt t2_ Horizon Texture Consisten Boundary Roots Burin9# in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. II Bed Trench 1 1 ( 0-8 l ORY2/2 None sl I thin pl mvfr as - 2f 0.4 i 0.5 2 8-12 10YR3/3 None sl 1 thin pl , mvfr cs 2f, lm 0.4 0.5 Ground 3 12-23 10YR4/4 None i 2msbk mfr cw 2f, Im 0.5 0.6 elev - - 100,32 ft 4 23-38 7.5YR4/6 None-~-gr. :-ls _o sg ml cw if 0.7 0.8 Depth to 5 38-123 IOYR5/4 None I s & gr. o sg ml - - 0.7 0.8 limiting ~ - - i factor - r ~3 Qy,~ ~i~t .q~1 ----f- 4 ->123" Remarks: 71 - as 2f 0.4 0.5 1 4 0-10 lORY2/2 None sl 1 thin pl mvfr 2 10-14 IOYR3/3 None A I thin pl mvfr cs 2f, lm 0.4 0.5 - Ground 3 14-24 1OYR4/4 None sl 2msbk mfr cw 2f, im 0.5 0.6 elev ' 99.35' ft ~ ~ - ~ ~ - ~ - ~ 4 ' 24-36 i 7.5YR4/6 None gr. Is o sg ml cw if 0.7 0.8 Depth to 5 36-116, 1OYR5/4 None s & gr. o sg ml - - 0 7 0 8 limiting - + t factor >116" s l b~ Remarks: - - - - - CST Name (Please Print) Sign ture: Telephone No. James K Thompson 715-248-7767 Address A.C.E. Soil & Site Evaluations Date CST Number Ref # 340 Paulson Lake Lane, Osceola, WI 54020 5/3/99 3602 1013 VIII . OROM-1,YOWNER: Miila,sam SOIL DESCRIPTION REPORT Page 2 of 3 PARCEL LD.# 020-10$6-90 000 A.C.E. Soil & Site Evaluations • Horizon Depth Dominant Color Mottles Structure I GPD/ft2 Bounda Roots in. Munsell Qu. Sz. Cont. Color I Texture Gr. Sz. Sh. COnslstencel ry Bed Trench 1 0-8 IORY2/2 None st 1 thin pl mvfr as 2f 0.4 0.5 2 8-13 10YR3/3 None sl I thin pl mvfr cs 2f, lm 0.4 0.5 Ground _ - I ~ _ _ elev 3 13-25 10YR4/4 None sl 2msbk mfr I ew 2f, lm 0.5 0.6 I I I r.-1s - o sg - i ml cw if 0.7 0.8 99.38'ff 4 - 25-35 7.5YR4/6 None g - -t . - 5 -120 10YR5/4 None s g r. o s g MI 0.7 0.8 35 Depth to - -12 - - limiting - - r - t - - - factor ~ i 2 36 Remarks: i ! 1 0-9 IORY2/2 None sl l thin p mvfr as 2f 04 0.5 ~ 4 i ± 2 9-15 10YR3/3 None sl 1 thin P1 I mvfr cs 2f lm 0.4 0.5 Ground - - - __-t._. elev 3 15-27 10YR4/4 None sl 2msbk mfr - cw 2f, lm 0.5 0.6 99.62' ft 4 27-34 7.5YR4/6 None gr. Is o sg ; ml cw if 0.7 - 0.8 Depth to 5 34-119 10YR5/4 I None s & gr. o sg ml - - 0.7 0.8 limiting - - factor . _ + >119* ~ - - - R -----1- Remarks: i I 1 0-13 IORY2/2 None sl I thin pi j mvfr as 2f 0.4 0.5 05 2 13-18 10YR3/3 None sl 1 thin pl mvfr cs 2f, Im 0.4 0.5 Ground - - - elev 3 18-33 10YR4/4 I None sl 2msbk mfr cw 2f, lm 0.5 0.6 99.05' ft 4 33-46 7.5YR4/6 None gr.1 o sg ml cw if 0.7 - 0.8 - Depth to 5 46-115 10YR5/4 None s & gr. O S9 ml - - 0.7 0.8 limiting - - - factor y >115"- - i Remarks: Ground elev Depth to limiting - - - - factor I Remarks: z --c:_ Ito ` Sca.Pe : t ■ So:C 06sa~Ja.~,Z,~, p. ~ i o co-4,.d pr* LA,7 r) c 10., 5c / i 112 r~ ■I 13 oX isi ■ ~.o c-ate%on ~ ~ fat / off' ,o(a~ dre, ~p(ac~ ~ SEy~srys; See. z/, 29 ft., ■ R 19 rJ; i,I. lop 39s, 99 n O w~ G ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer_S 14 P" 114 11, L. JF72 Mailing Address B © X 4 r / Property Address i3bl . 1 (Verification required from Planning Department for new construction) City/State U 1) S f) Parcel Identification Number D - po p LEGAL DESCRIPTION Property Location SL %4, E %4, Sec. , T 711 N-R W, Town of 146'D .59) V . subdivision'`! M , Lot # 1_. s -~J Certified Survey Map # Volume ! . Page # Warranty Deed # S'9 T y ~o! , Volume ( G --,Page # Spec house )I yes ❑ no Lot lines identifiable M 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 master plumber, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to-the St. Croix County Zoning Office within 30 the three year expiration date. NATURE APPLICANT DATE .4'10 ~NER 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 pro . described above, b virtue of a warranty deed recorded in Register of Deeds Office. ~ G A O~ • YCANT 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 r+. _ . ~ t At, a. , . ` 4. "J ~ 5SS464 rot 1-361PAa114 a Document Number WARRANTY DEED This Deed, made between, - r Robert L Rohl Grantor, and, Sam E Miller ~IS1*tjrrlU + a single person Grantee. ST, C R0IX CO.. WI Witnesseth, That the said Grantor, for a valuable K/ rw %60 r cans~eratan of one dollar and other valuable consideration conveys to Grantee the below aescnbed real estate in OCT 0 G 1998 ' St. Croix County, State of n This is not homestead property. 7. 3o A ' Together with all and singular hereddaments arc appurtenances thereunto Re fer of ow*elal► 4, Or! belonging, r ti And Grantor F t~ f warrants that the title is good, indefeasible in fee sir-pie and free and clear of ~ . . encumbrances except Reconim Area t easements, covenants, and restrictions cf record, None and Return Address , ' y and will warrant and defend the same. San 1C. Miller K' [Parse lentificabon Number) PO Box 151 020-1056-90 Hudson to 54016 A parcel of land located in the SE '/4 of the SE ' . of section 2 I . T29N, R 19W, Town of Hudson, St. Croix ~ County, Wisconsin, described as follows: beginning at the SF corner of said Section 2 f ; thence N 89'23'5 I "W 1319.10 feet to the monumented West line of the SE ',,4 of the SE '4 of said Section 21; thence N00°51'33"W" 980.09 feet along said monumented West line of the SE '/4 of the SE '/4 to the North line of the South 30.,80ths of a the E'/ of the SE'/4 of said Se. ion 21 as called ow in that documentation found in Volume 838, Page 252 of the St. Croix County Register of Deeds; thence S39'37'1 9"F 626.85 feet along said North line of the South 30/80ths to the intersection of the monumented South line of the Certified Sur%e% 1--1ap tiled in Volume 2, Page 484 and the said North line of the South 30, 80ths of said E of the SE '/4; thence S89'23'1 OT 31.88 feet to a found 1" iron pipe being the SW Corner of said Certified Survey Map. thence continuing S89°23'101: 660.24 a feet to the East line of the SE 1/4 of said Section ' 1. thence S00°5 1'50"E 982.41 feet to the point of beginning. containing 29.725 acres including rigl of %a% t -8.006 acres excluding right of wa% I':y i►y Dated this day of 199 T A aFER 'Robert L Rohl 14 AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN y' COUNTY ST. CROIX t t Personally came before me thisz day of C-T- r the t above named Robert L. Rohl j t authenticated this _ day of , to me known to be the person(s) who executed the foregoing A ns . 7,n,,, and acknowledge Or. same, signature agrw~e C,~~ c.. f Ljlr 3 type or print name type or print name v1/14.u,ZC-T- tl r iTITLE' MEMBER STATE BAR OF WISCONSIN Lary Public County, (If not. P om issron is permanent (If not. state expiration date U - i 35 authorized by4706 06. VVts Slats) - 0 - t THIS INSTRUMENT WAS DRAFTED BY 4r 'N a pons . y ` signing in any capacity should be typed or . Robert F. 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CROIX COUNTY GOVERNMENT CENTER r"r:r 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 February 10, 2000 Home Realty Dave Anderson 602 3' Street Hudson, WI 54016 RE: Septic Inspection for Sam Miller located at 801 Grant Avenue, Homeplace, Lot 1, Town of Hudson, St. Croix County, Wisconsin Dear Mr. Anderson: A septic inspection of the above referenced property was conducted on July 28, 1999. This property is located in the SE'/4 of the SE'/4 of Section 21, T29N-R19W, Homeplace, Lot 1, Town of Hudson, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3) bedroom home. If you have any questions regarding this, please contact our office at (715) 386-4680. Sincerely, W'~ ~~~w Kevin Grabau Zoning Technician Ism 7-41 2~- 04 Cr~~~, ~i ~•gpq ,y7,aS~, i, .8y9 V 8 j ~ '4 5 a 8 ~ 'is ~ I W 01 _ _ V C ~ V n~ A 3S. -04 C yy yy •iTi ~ y 6g ^i ~yy Q A YO ~A .O M± Qom. 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