Loading...
HomeMy WebLinkAbout040-1012-50-000 AR7d11>vzl County Safety and Buildings Division t * p $ 201 W. Washington Ave., P.O. Box 7162 St. Croix _ P Madison, WI 53707 j2 Sanitary Permit Number (to be filled in by Co.) -ST. CROIX COI.lN"I GLOP ENT s j ~"'~sstoKa~ N1MUNl7Y {7~ V" ~ Cf O Sanitary Permit Application ~azeTransacti°°Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit a is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. Same 9r49 I. A lication Information - Please Print All Information Property Ownerame Parcel # C Y, d , 19 r s D Fred M ers 040-1012-50-100 Property Owner's Mailing Address Property Location 594 Hi Ride Dr. City, State Zip Code Phone Number Govt. Lot NW /4, NE 1/4, Section 04 Hudson, WI 54016 (715) 821-1185 (circle one) II. Type of Building (check all that apply) Lot # T 28 N; R 19 E or W 91 or 2 Family Dwelling -Number of Bedrooms 3 2 Subdivision Name 4k a>a ~ t Block # 11 Na El Public/Commercial - Describe Use a Na City of El State Owned - Describe Use CSM Number El Village of Vol. 6, Pg. 1625 ;?Town of Troy 3 l~;>Sa 1 III. Type of Permit: (Check only on box on line A. Complete line D if applicable) ~06 Air, A' XNew System ❑ Replacement S System El Treatment/Holdin Tank Replacement Only ❑ Other Modification to Existing System (exPlain Y g ) ❑ Permit Transfer to New List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber Before Expiration Owner P k& IV. Type of POWTS S stem/Com onentlDevice: Check all that apply) Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil C ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis rsaItTreat nt Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation 450 Gpd 0.5 gpd/sq. st./day 900.00 sq. ft. s ' ft. 96.00' -7 IV VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units New Tanks Existing Tanks LL w c Y A a U rn w U p. Septic or Holding Tank 1,000 Na 1,000 1 Wies r Concrete X Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number Dale Hudson MP 220853 (715) 684-3378 Plumber's Address (Street, City, State, Zip Code) 820 Main St., Baldwin, Wl 54002 VIII. un epartment Use Only Approved Permit Fee Date I sued Issuing 06 t Signature [4.airapppo' eason for De ' $ r5 ' Lb to z 1s IX. Condi!►"fpeasons for Disapproval 1.: Septic tank, effiuentMer and / dispersal cefl.lnust all be servk:es / maintained J as per management plan provided by plumber. 2. Aa setback requirements must qe maintairied (f as per epplcable code / ordinances. Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x I I inches in size SBD-6398 (R. 11/11) f'`~fJ~ Kit~9e ~ ~ki3t,i~y~r'~.arE P/kv.' o. w. ss7. ~ 9 ' ~ ~d 22 ~ ~ flu-dso~-, u~ ! SS'016 ~-s p APPrvX. /ica~an a n 1rtL, Cs,.~(dc~ 1(ZS eX:r . res•rrknce. ll ~ulyyyE~'y See. y rtc, .SE• C~o~Gr., 64r1~ 20.D/aC~s w ~~Z .Lot/ t(t~-~llca-~~d~.~T~.,~lsSsc.►4c.o~elu/.~=/~.lx: E"XiJ~~+arSk<<J---~ - - - wa~o'e-cry p~ruy~y 3 Ledreo-m I ell .t Qes~~ence g 1 ,uric Sl 9y, 30' ,I I praPa seal d;sPu'~Cc/% ~k`re.c (s~ t~~n~.es e~ 3 r(,,3 xCid at 7 'c•, ewoE~~/~s ia- Conventional POWTS Index & Tilte Sheet Project Name: Myers 3 Bedroom Conventional POWTS Owners Name: Fred Myers Owner's adress: 594 High Ridge Dr., Hudson, WI 54016 Site address: Same Project Location: Subdivision: Lot 2, CSM Vol. 6., Pg. 1625 Legal Description: NWii4NEii4, Sec. 04, T.28N., R. 19W., Tn of Troy, St. Croix Co., WI. Parcel ID 040-1012-50-100 Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Dispersal Cell Sizing Calcualtions & Chamber Cross Section Page 4 System Cross Section Page 5 Septic Tank Cross Section Page 6 System Management Plan Page 7 Filter Specifications Page 8 Parcel map Page 9 Septic Tank Maintenance Agreement Page 10 Waranty Deed Attachments: Soil Evaluation Report Mater Plumber: Dale Hudson, Dep't. of SPS Credential #220853 OA1,01 - , All Signature: al,- Date: / Page 1 Of 10 Design pursuant to In-Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD-10705-P (N.01/01) ~ .50.% ec~G/ua~o•~~E ss7. 6 S ' ~a <<a(/Y(c c~J~Oro~o. S Approx. /ica.- o f 1 v fi Litz eS,►Tvo~ G ~G2S er cxisE:.~ its:dince. U ,/uJyy~EYs; Sce. 5; T'?8~; 7W, .0,477oK 6ev~7 20.0 aclcs !-,ot ~ Lo t ~ cl~ d~rb. AssK..•tc.~lc/w; =/~.az' EXiJ~~ 3kcc/ ^ _ _ w~~r~e ~ru5~y p~c1o osed u~,-cseT c_a,cre•~c uaD -M~ ~ _ R~/.G in ~ GcC~ 0~ L~BnX~ Ao~y ~ 9Q Sir' p~ S.zSC/uen E F: to 7. fti`de Q _ . bciaS~./.lsd of ou;E/tt , - _ - - fTO J Oc'& • ll_ ~ e1/ ae ~tS~G~41CG 82 ti ,L4Jt'~t SG. 9y, 30' ~i'oPosed d,s/ocrs4./cc//. ~rec (3~t~ari~s4~ 3xG31'S,a~lca of 7On Ca.er~/~SI~{/L~ra15~ "0_./'~p/us bti.SPcff/'c.r~c.C . F~l:•/t.-a~i ✓t Cace e tv 6e 96.0.' a~ io 2 MYERS DISPERSAL CELL SIZING CALCULATIONS 1. (3 bedrooms)(] 00 gallons estimated flow)(1.5 design factor) = 450.00 Gpd design flow 2. Infiltrative capacity of native soil = 0.5 gpd/sq. ft. at 3. Absorption area required: 900.00 sq. ft. 4. Absorption area as proposed: 917.40 sq. ft. (45chambers total) Infiltrator "Quick 4 Plus" = 20.00 sq.ft. EISA per chamber, "Quick 4 Plus" end cap/pair = 5.80 sq.ft. EISA 900.00 sq. ft. - (3 pair end caps)(5.80) = 882.60 sq. ft. 882.60 sq. ft./20.00 = 44.13 chambers required Number of trenches: 3 (a, 15 = 45 chambers total Trench width: 2.83' Trench length: 63.00' Trench spacing: 7.00' on center Total system area w/ 7' center spacing: 17.00'x 63.00' ffQl//Ck4rM STANDARD CHAMBER 52° - Quick4 Standard Chamber 48" (EFFECTIVE LENGTH) 8 r= =J rl_~ - 12 I~= LII I III I _-I I = i _ Ism 8 I I MIN& JEW- 34" - SIDE VIEW SECTION VIEW u ti ort n Cap 1. f---------------- 34 SIDE VIEW TOP VIEW FRONT VIEW Quick4 Standard Chamber Nominal Specifications MUItIPM End ,Cap Nominal Specifications Size (WxLxH) 34"x52"X12" . Size (WxLxH1 34"x16"x12' 48" Invert Height''' 8" or 1.25" Effective Length Invert Height 8y Pg. 3 of 10 Soil Absorption System Cross Section /u/. o' ft 4" Schedule 40 Final Grade PVC Vent Pipe With Vent Cap 170' ft Leaching Chamber 9l0. O ~ ft System Elevation ft 41 ft S/' ft i Soil Absorption System Plan View ft 1 ft ft Leaching Trench 1 Chambers 4" Dia. Vent Or Observation Pipe Trench 2 Header Trench 3 Leaching Chamber Specifications Manufacturer And Model i/Zr~•for'~C~-y'j0%S G/XA,,,,bc~ EISA Rating AO -0 sq ftper chamber Soil Application Rate 0-S- gpd/sq ft S~ gpd Design Flow - 0.57 Soil Application Rate - .7-0•0 EISA = 4 Chambers 3 rows of lS chambers each. Page ~t of ~"-0°°'~" 311 9St8-SZ~-008 ZIOZ 'Ndf a3SIAI2J o \ anod-lsod 091*9 VA 'NOOH N301VW Ol AMH Sn MCM Z 31v0 aloz AavnNVr 31vo 3ynNyW OIld3S LLJ a 10d-3ad ,0-,1=,4 l 31voS 3WS A8 NMVLIO 313d n009 13531M dW-OOOIdW o\ W w cn ~ J H Q o > co LLJ j d w Li LJ C~ n O O o O W O a d m N C/1 CL _ O V) v C) LL) w J J FW- J a n O p NO\ ~p < < < Q I- v (n O m O ~k Q _Z N D w~ Q Z~ m e W t0 M ~ Z J= 00 :2 m F- z e wWN OW <<U Q 00 N O i-i( ZO 3 O v o O IL C7 Op : e m J< W °N M O e ?.o V) < O O U? _UUpppdMJ W I <WN W d O QZ co ~ Y a< ° : u) f- m W L'i 1l U Z < d _O W N d a -1 't Lj N ~ Q~ O C, F-: 1 N N }}N w Q F--• f"- uj \N ..oga(0JLLJ ~aU ~?N F- OU Z NSO 0 Z~ -I U) N J.. O- =N~ OU) U X= 0 O~ WM <FO Gi ..O ~Oi "3p~ o<Y opw < ZZ < W wU °w F-Ln z °ao oQw w°-J ?`ate a QN _N~ Q z3m U §x W~mm ° ZO< Z U ~O W F- J J_j Z > Z OO W O Z Z J 2 OJ < UO FQ- U w 0 z 2 U w X W J p w U0C~ N HW> I QWO < -J J U mW Q Z < O w cn U 050 2 „6£ p Z e LIj a NO =o 0 a w a a O a w I ~ / \ n N N LLJ SHO / U I Q 1 „e~ do W ~ m I y ~ W W I N O < > < I ~ O U U J L x v W \ `t SHE „b 0 a „lb do w I W 0 O ~ N W J C „Zb < „98 l9 a w a N Y 2 a In-Ground POWTS Dispersal Cell Management Plan Pursuant to Dep't. of Safety & Professional Services 383.54, Wis. Adm. Code General The In-Ground septic system shall be operated in accordance with Dep't. of Safety & Professional Services 382-384 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD-10706-P (N.01/01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Questions on the operation or maintenance of the system should be directed to the installing plumber, Dale Hudson at (715) 684-3378 or your County Zoning Inspector at (715) 386-4680. Septic Tank The operating condition of the septic tank and outlet filter shall be assessed at least once every year by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of the annual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. The addition of biological additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Dep't. of Safety & Professional Services, Safety and Buildings Division. No chemical additives should be added to the system. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings shall be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or other component. No individual should ever enter a septic tank as dangerous gases may be present that could cause death. Dispersal Cell Observation and vent pipes within the dispersal cell shall be checked for effluent ponding annually. Ponding levels shall be reported to the owner. Persistent ponding of 3" or more will be deemed to indicate an impending hydraulic failure requiring semiannually monitoring. Effluent quality: The sewage effluent generated at this site may not exceed the high strength effluent concentration levels as established by the Wisc. Dep't. of Safety & Professional Services. Influent quality entering the dispersal component of the POWTS may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L, FOG. Contineency Plan: If any portion of the system becomes defective, the defective component shall be immediately repaired or replaced with a component of the same or equal performance to keep the system in proper operating condition. If the dispersal cell component fails to accept wastewater, the existing dispersal trenches will be replaced by installation of a new dispersal cell. Pg. 6 of 10 T Technical pecifications. . PL-525 EFFLUENT FILTER (C'OMJk EOgCIAIII)i-- 6112' BALL CHECK T - i EXCEPTS G SHD W FOR INLET EXIIN11ON 1,.57 14.35 ; 1OUTLET BUSHING EXCEPTS SCH 40 8 6` SCH 40 810 4 I.J j 44 &23 ` ✓ I 33.102 G > - - PL-525 FILTER HOUSING 1834 PART NO. - 30142-525 MATERIAL HOUSING - POLYPROPYLENE OUTLET BUSHING - PVC 6.5 BALL •HDPE I I LL- r- S=ET EXCEPTS FLOAT SW TOH - 10.23 - EXCEPTS I`SCH 40 .98 C fORHANDLEEXTENRON 10.84 530' OF It! 8' SLOTS 62e r 7 - - SOCKETEXCEPTS 8,04 9.58 BALL PUSH ROD OPENING I 7.09 I ~ ~r OPENNG 2o.71 I y i io~ .I of 1902 .2244 I I j I I PCtYLOK PL-525 FILTER CARTRIDGE PART NO. • 30141.525 MATERIAL • PC+LYPRCPYLENE I i - 1f ~ i 2 ~i ola. e, P~. 7o,,-io ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Fred Myers Mailing Address 594 High Ridge Dr., Hudson, WI 54016 Property Address Same (Verification required from Planning & Zo mg Department new construction.) City/State Hudson, WI Parcel Identification Number 40-1012-50-00 LEGAL DESCRIPTION Property Location NW 1/4 , NE '/4 , Sec. 04 , T 28 N R 19 W, Town of Troy Subdivision Plat. ~'SM Lot # , a Certified Survey Map # Volume 6 , Page # 1625 Warranty Deed # (before 2007)Volume Na , Page # Na Spec house 0yes0no Lot lines identifiable El yes[] no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the 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 statements on ' 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 w ant deed recorded in Register of Deeds Office. Number of bedrooms 3 /0~& ~ (9 l_l ! SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) p~.9ofi~ 01- .1 A < J G'~1 Ow ►w zz px w c~ 8 o a' ' ~ r rtN PiN W LZ v w (on v) - y r:n f~ 1 iti ~ ty ry. 1 , { 1 1 1 -A 6 f N ia' © ciSMJ 1 ~'V {,~fC \ I,,x`":, ral~" N iff~N <7 M eMtJ ry~yji ~i~ .9 ,..t'x t ~„1 N7 f 0 y~ •d 1 bd M 1 1 K%°a~ 'S S W p C a x ig - ~ Q 1 ~C O w (on ~ :r. m > O `J „ 'If'~~8 aN P-"os ~ 1.11 j n HN S..=n Lo € a < < o ~ O F O ~ 4 }nw.m]ULO. ~\o -,E, x bra <Q ~ (t-J q: i a q 7 q~ 1 1"N JQ W x jj VI I 1 - _ - - • ~ r1` RECEIVED D 2407 Wisconsin Department SOIL EVALUATION REPORT Page 1 of 3 Oap~uleCC6 Sp6 ~ 2015 A.C.E. Soil & Site Evaluations A.C.E. in accordance with Cernn~r.8C-Wis. Adm. Codf COUNTY County Attach co Mr(ve L fo7lh 8'/2 x 11 inches in size. Pla St. Croix include, hd o: Ical and horizontal reference point (BM), directio percent slope, scale or dimemsions, north arrow, and location and distance t( Parcel I. D. 04 101 -50-100 Please print all information. Revie By Date Personal information you provide may be used for secondary purposes (Privacy Law, s. " Z s Property Ownei Property Location Fred Myers Govt. Lot NW 1/4 NE //4 ~tll 4 T 28 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Nam or CSM# 594 High Ridge Dr. 2 na CSM Vol. 6, Pg. 1625 City State Zip Code Phone Numbei City Village ✓ Town Nearest Road Hudson WI 54016 715-821-1185 Troy Old Hwy 35 New Constructior Use: Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement Public or commercial - Describe: Parent material Glacial Outwash Flood plain elevation, if applicable na General comment, and recommendations: Soils suitable for conventional dispersal cell at 0.5 gpd. Recommended linfiltrative surface elevation to be 96.00'. Boring # Boring i✓ Pit Ground Surface elev 100.21 ft. Depth to limiting factor >94" in. Soil Application Rat Horizon Depth Dominant Redox Description Texture Structure Consistence Boundar Roots GPD/ft; in. Color Qu. Sz. Cont. Colo Gr. Sz. Sh *Eff#1 ff#2 1 0-11 1Oyr3/3 none sil 2mpl dh cs 2vf,fm 0.0 0.2 2 11-18 1Oyr4/4 none sil 2msbk dh cw 2vf,fm 0.6 0.8 3 18-43 7.5yr4/6 none Is Osg dl gw 1vf,fm 0.7 1.6 4 43-72 1 Oyr5/4 none s Osg dl gw 1 vf,fm 0.5 1.0 5 72-94 10yr516 none s Osg dl - - 0.7 1.6 H#4 contains 1/8" - 1" bands of Osg dl 10yr5/4 Ifs spaced at Tnte als hroughout horizon. Loading rate adjusted to reflect reduced permeability o horizon associated with banding. 2 ] Boring # Boring F ✓ Pit Ground Surface elev 99.50 ft. Depth to limiting factor >96" in. Soil Application Rat Horizon Depth Dominant Redox Description Texture Structure Consistence Boundar Roots GPD/ft' in. Color Qu. Sz. Cont. Colo Gr. Sz. Sh *Eff#1 *Eff#2 1 0-11 1Oyr3/3 none sil 2fgr dsh cs 2vf,fm 0.6 0.8 2 11-25 1Oyr4/4 none sil 2fsbk dsh cw 2vf,fm 0.6 0.8 3 25-40 7.5yr4/6 none Is Osg dl gw 1 vf,fm 0.7 1.6 4 40-75 1 Oyr5/4 none s Osg dl gw 1 vf,fm 0.5 1.0 5 75-96 1Oyr5i6 none s Osg dl - - 0.7 1.6 CPO It II H#4 contains 1/16" - 1/4" bands of Osg dl 10yr spaced at10" - 18' ervs throughout horizon. Loading rate adjusted to reflect reduced permeability horizon associated with banding. * Effluent #1 = BOD ? 30 < 220 mg/L a TSS >30 <~150 mg * Effluent #2 = BODS< 30 mg/L and TSS < 30 mg, CST Name (Please Print) Signa re: CST Number James K. Thompson / 5.-- 3692.3CV4f Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 8113/2015 715-248-7767 + Property Owner Fred Myers Parcel ID # 040-1012-50-100 Page 2 of 3 3 ] Boring # Boring Pit Ground Surface elev 100.71 ft. Depth to limiting factor > 103" in. Soil Application Rat Horizon Depth Dominant Redox Description Texture Structure Consistence Boundar Roots GPD/ft' in. Color Qu. Sz. Cont. Colo Gr. Sz. Sh *Eff#1 *Eff#2 1 0-9 1Oyr3/3 none sil 2fgr dsh cs 2vf,fm 0.6 0.8 2 9-19 1Oyr4/4 none sil 2fsbk dsh cw 2vf,fm 0.6 0.8 3 19-30 7.5yr4/6 none Is Osg dl gw 1vf,fm 0.7 1.6 4 30-78 1 Oyr514 none s Osg dl gw 1 vf,fm 0.7 1.6 5 78-103 1Oyr5/6 none s Osg dl - - 0.7 1.6 if C/ ❑ Boring # Boring Pit Ground Surface elev ft. Depth to limiting factor in. Soff Application Rat Horizon Depth Dominant Redox Description Texture Structure Consistence Boundar Roots GPD/ft' in. Color Qu. Sz. Cont. Colo Gr. Sz. Sh *Eff#1 *Eff#2 ❑ Boring # Boring Pit Ground Surface elev ft. Depth to limiting factor in. Soil Application Rat Horizon Depth Dominant Redox Description Texture Structure Consistence Boundar Roots GPD/ft' in. Color Qu. Sz. Cont. Colo Gr. Sz. Sh *Eff#1 *Eff#2 * Effluent #1 = BOD 5 30 < 220 mg/L and TSS >30 < 150 mg * Effluent #2 = BOD 5< 30 mg/L and TSS < 30 mg, The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) A.C.E. Soil & Site Evaluations ~ .So.% edG/ua~~~~ ,X ~ipprvX,/ica~~noF 1~1 sof,, w! Ss~o/6 a~ . c/ U ,/uJyy~Ef'y See. ?t .3~. Cro;r fir., w! 649 20.o~ac*rs w t/ •zo-6Z Lott c! ,'ca/c dkr~. Assk.ncdc/w'=/li~.~ ~►-fL. Lit 4.~,ce y9,z.8 ' EjriJ~i+.~ Skc~✓ - - - wa~d4~6 ~~u s~~. 40 63 QlSid~nct 82 ~~K 5~ 9y, 30, R~ 3 0~3 ~ ~ I ti ~o (U o 0 0 h c N N 0 0 ~ N O y X N CD 3 y o c o ~(D E o t~ a) CD c y a 0 2 E m c D a U a7 E 7 o aS Lt ASH oC --8;0 z Z c Z Eg c z `tea v v 76 lL o ° N V LL O m (6 N 0 (D 3 v a~ 0 3 v a -01 E Q U N Q r c I C ~ y ~ II o 0 I w z E E rn z 0 0 Z 00 IL m a co 0 0 0 Z a C v j :3 z a ° c 0 o c o E 2' E '2 v m Cl) v 2 M N N N .7 N N (D y a) ~ y d ~ y v C C y a) ~ C a) a O N 0 d 0 0 c ~ a c 0 o C w r N C w- Z F- o Z U) Z o z z d d E c N N 0 cc co U) Iz d = .y ca C, M w C C M 06 M V1 C y O y d N f[I .0 00 O W d N O a) u 0 0 a E Z5 N 0 a E N E N Nr 00r 3 v~ v~ U) _E 3 O O a co Z E a co z 0 R j° a a a y y a a a N a •N = rn rn = rn rn J U M W } M a) 0 } U) 0 o (D N = W O w N r M M E 0 N m 0 0 D :3 m ~ a ml a V) co M D a aa) LO Q>- in m ~ d y m o _ Q Z V) V 7 a~+ 0 V 7 M 0 O C N C C f~yA C O a Z = N CO Z o a) j N U O Q y f0 O d a 0 ~S y a c 72 c G N i°n > `o m N> o E a m 0 r- m 7 N N (A 0 7 W ci 0.0 ayi C y c~ co t=xi p ° y c c m ao CO > co Oki ~L (n 1 O d' I- H M O z C Y fn R~ M O z a Uj w R € a € a a ` a te U (L E ` .c c r A vat 0UU 0UL) ST, CROIX COUNTY ZQNING DEPARTMENT AS BUILT SANITARY REPORT Owner Property Ad es 11 _ 35 ~ { City/Stat l ~-J.1 l ~ 1 Legal Description: , Lot Q ; Block t A Subdivision/CSM # Ste'/4 aE '/4, Sec. H , T zS N-RILCW, Town of a_o PIN # ,rr SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION: JC i Tank manufacturer bkkt1: ,,1tv NA N Size ST* Setback from: House Well i 0o Pump manufacturer ~3 - A Model rv Alarm location iy A (HOLDING TANKS ONLY) Cv Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: C` i1OCi-'AlQVI6_,,. Type of system: act .j _ Width Length t n ' Number of Trenches 2 Setback from: House Well o o P/L qc~ Vent to fresh air intake 1 Cv 1 ELEVATIONS: Description of benchmark IN Elevation OCR. C Description of alternate benchmark --y:LIP 23 Elevation i 'I Building Sewer 99,16- ST, Inlet ?U 3 ST Outlet PC Inlet PC Bottom Header/Manifold q . ~ Top of ST/PC Manhole Cover Distribution Lines k (Z) 5 ( ) Bottom of System 9q oA ( ) Final Grade O - S (t) L- ( ) 0`, J , cl 9 Date of installation Permit number 3 5 7State plan number ' 7 5 N R ~1 / Plumber's si ature License number Date Inspector Complete plot plan Or i 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 - `~I i r .ice ~ ~ ~ ~ ~ r J i v 7 ~ G ~ D r G~ 4 \i INDICATE NORTH ARROW r Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division County INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 344657 Permit Holder's Name: ❑ City ❑ Village W Town of: State Plan ID No.: Ray, David & Nancy Town of Troy CS BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 00 , © , v a6 4_ ~ ~a-~' < /fz-~1_- 040-1012-50-000 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark . 2 tf Dosing Alt. BM ?j. q5-- Aeration Bldg. Sewer c19. 16 Holding St/ Ht Inlet .zor TANK SETBACK INFORMATION St/ Ht Outlet 3Y Cr+10 Vent iri to ROAD TANKTO P/L WELL BLDG. A irl ntake Septic NA Dosing NA Header / Man. 96 Aeration NA Dist. Pipe qc: (O} F olding Bot. System 12• °Z s ZZ 3- Z-% 9 - -I PUMP / SIPHON INFORMATION Final Grade ~~5° .o 0 Man r _9gw6-ncT' St cover 5 Sb 0J. Model Number GPM TDH Lift Fr' n Sye TDH Ft oss Forc Length Dia. H Dist. To We(, SOIL PTION SYSTEM 2 ENCH Width t Lenqth _ I No. O Tr riches PIT No. Of Pits inside Dia. Liquid Depth DIMENSION y DI EN I N SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O CHAMBER S~ t Q ~ f OR UNIT Model Number: System: (J DISTRIBUTION SYSTEM Header / nifold Distribution Pipe(s) x Hole Size Ix Hole Spacing Vent To Air Intake Length U--lDia Length Dia. Spacing i3 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only [Depth Over Depth Over xx Deptfi Of xx Seeded 1 Sodded xx Mulched d 1 Trench Center Bed /Trench Edges Topsoil E] Yes E] No Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: inspection #2: Loclliion: 571 Hi hway 35, Hudson, WI (SW 1/4, NE1/4, Section 4 T28N-R19W) - 4.28.19.50D t~ C~ 39 W z` > -(Q, C&,,, NO Plan revision required? ❑ Yes No Use other side for additional infor ation. a-9 cm SBD-6710 (R.3/97 Date Inspector's Signature Cert. No. i ADDITIONAL COMMENTS AND SKETCH ' SANITARY PERMIT NUMBER: g i i i 3 f K a w; _e a e h h s y i E rt s i 3 } } j ~ .tee.. E 3 F t y k t 1 s A, f Safety and Buildings Division Bow302ngtonAvenue Aiiconsin SANITARY PERMIT APPLICATION 201 Department of Commerce In accord with ILHR 83.05, Wis. Adm. 10 Madison, WI 53707-7302 9 • Attach complete plans (to the county copy only) for the syste er not a ~O nt a than 81/2 x 11 inches in size. v C(Z \ X x^'`^r > Ste nitary Permit Number • See reverse side for instructions for completing this applica o7t ~j i Personal information you provide may be used for secondary purposes p Chec f revislo'n t-p us lion (Privacy Law, s. 15.04 (1) (m)]. State PlAn I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Pr rt y Owner N me ropert Location t i4 1/4; S T , N, R (o W Property Ow is Mailing Address Lot Number Block Number City State Zip Code Phone Number Subdivision Name or CSM Number ~l (~15>~~b(o~Z(3 1~ Scrn l -T II. TYPE BUILDING: (check one) ❑ State Owned ❑ ItY Ne rest Road Public 1 or 2 Family Dwellin - No. of bedrooms Tolwn OF 35 Ill. BUILDING USE: (If bilding type is public, check all that apply) Parcel Tax Number(s) Z 1 Apartment/ Condo o~ l 0 LZ - 50 Cr1rD A$, g5,# 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 Q Restaurant/Bar/Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel /Motel 9 Q Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2. Q Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. Q Repair of an System System Tank Only--------------- Existing System _________Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Weepage Bed , 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 eepage T ch aZ 3 X 75 6 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13E] Seepage it 43 ❑ Vault Privy 14 Q System- -Fill VI. ABSORPTI M INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate ;Elev. . y e 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gal day/sq. ft.) (Min./inch) L 0 Elevation ~Dco ISO r7 6.1. a (Z) N - 5 . Feet , Q Feet VII. TANK Capacity glloacctn s Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank o*44sWing-lank 1,900 10 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installationof the onsite ge system shown on the attached plans. Plum er's Name: ( riot) Plumber's Sign 0: tamps) MP B iness hone Number: Plumber's Address (Street, City, State, Zi Cod m ru.e IX. COUNTY/ DE ARTMENT SE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing Agent Signature (No Stamps) ($A pproved n Owner Given initial ~ , / Surcharge Fee) 9'3 / 9 6L' Adverse Determination ON ITIONS OF APPR, O•rV ~ / ~tEAS NS FOR I PPROV,~1L: SLAV," &190~4~ SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber L ! 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 8 if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII_ Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX_ County/ Department Use Only. X. County/ Department Use Only. Li Complete plans and specifications not smaller than 8 1/2 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. r Page 1 of 1 SITE PLAN David Ray SW,NE,4,28,19W St. Croix county Troy Township L so o ~ ^II / % ' Sack A. Bowman MP 5875 ' 14 LEGEND U- c 'D EM; 100.' top-lof I1k" PVC pipe 0®-BM: _.98.86', nail in box >~!Tder tree !-borings Sole 111-40' except where indicated ~ ~ • g r) Proposing 2 trenches 3ft. by 75.6ft. Hi-Cap Infiltrators o qSystem Elev. 95.50' • ~L o -'t-k 12 o0 ~A--k w f Zo ad y " s~4o f I i wisconsinDepartment ofCommerce 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 hori mntal peg (BM), direction and St. Croix percent slope, scale or dimemsions, north a atidn tance to nearest road. Parcel I.D.# APPLICANT INFORMATION - e print it i` 040-1012-50-000 Personal information you provide may be seconc r (Pri%4cy s. 15.04 (1) (m)). R Dat Property Owner Property Location David & Nancy Ray Govt. Lot SW 1/4 NE 1/4 S 4 T 28 N,R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# OlX 571 H . 35 South t COOR NTV City Sta'g` ,dip /YPt Vftpber, ❑ City ❑ Village ❑Town Nearest Road Hudson WI < Y 4 715-3 Q ~ Troy Highway 35 ❑ New Construction Use: ❑ R t r of bedrooms 4 ❑Addition to existing building ❑ Replacement ❑ Public or commercial describe Code Derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd/ft2 .8 trench, gpd2 Absorption area required 857 bed, ft2 750 trench, ft 2 Maximum design loading rate .7 bed, gpdfftz .8 trench, gpd/ft2 Recommended infittration surface elevation(s) 95.50' ft (as referred to site plan benchmark) Additional design / site considerations Install trenches using high capacity infiltrators. Parent material Outwash s & gr. Flood lain elevation, ff applicable NA ft S=Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U=Unsuitable for system ® S❑ U N S❑ U ® S0 U ❑ S❑ u ❑ S 2 ❑ S® u SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPDIft2 Boring# Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz Sh Consistence Boundary Roots Bed ;Trench 1 1 0-9 1Oyr4/2 None sl, 2fcr Mvfr as 2f 0.5 0.6 2 .9-21 1Oyr4/6 None sl 2fsbk mfr cs if 0.5 0.6 Ground 3 21-31 7.5yr4l6 None Ics Osg ml gw - 0.7 0.8 elev 100.60 It 4 31-48 7.5yr4/6 None it. S & gi Osg ml gS - 0.7 0.8 Depth to 5 48-106 1Oyr5/4 None St. S Osg ml - - 0.7 0.8 limiting factor >106' - Remarks: Z 1 0-18 1Oyr3/2 None SI 2fcr Mvfr as 2f 0.5 0.6 2 18-29 10yr3/4 None SI 2fsbk mfr cs if 0.5 0.6 Ground 3 29-47 105yr5/4 None SI 2msbk ml aw - 0.5 0.6 elev, 100.56 ft 4 47-71 7.5yr4/6 None it. S & gi Osg ml gs - 0.7 0.8 Depth to 5 71-108 10yr5/4 None St. S Osg ml - - 0.7 0.8 limiting factor >108" Remarks: CST Name (Please Print) Signatur Telephone No. James K. Thompson 715-248-7767 Address A.C.E. Soil & Site Evahiations Date CST Number Ref# 340 Paulson Lake Lane, Osceola, 54020 7/14/99 3602 1072 PROPERTY OWNER: .David -&Nancy _Ray SOIL DESCRIPTION REPORT 1072 Page 2-- of 3 PARCEL I.D.# 040-1012-50-000 A.C.E. Soil & Site Evaluations Depth Dominant Color Mottles Texture Structure nsistence Boundary Roots _ ir orizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench. 1 0-10 10 r4/2 None sl 2fcr Mvfr as 2f 0.5 0.6 3 y 2 10-21 1 Oyr4/6 None sl 2fsbk mfr cs 1 f 0.5 0.6 Ground elev 3 21-36 7.5yr4/6 None Ics Osg ml gw - 0 7 0.8 100.18 ft 4 36-50 7.5yr4/6 None St. S • Osg nit gs - 0.7 0.8 Depth to 5 50-103 10yr5/4 None St. S . Osg ml 0.7 0.8 limiting - - factor y >103" - 516 4 2 Remarks: - - - - 4 1 0-9 1Oyr3/2 None sl 2fcr Mvfr as 2f 0.5 0.6 2 9-21 1Oyr3/4 None Sl 2fsbk mfr cs 1f 0.5 0.6 Ground elev 3 21-34 105yr5/4 None sl 2msbk ml aw - 0.5 0.6 97.24' ft 4 34-60 7.5yr4/6 None St. S & et Osg ml gs - 0 7 0.8 Depth to 5 60-98 1 Oyr5/ None St. S Osg ml 0.7 j 0.8 limiting - - factor >98": lor~- Remarks: - - 1 0-15 1Oyr4/2 None SI 2fcr Mvfr as 2f 0.5 j 0.6 2 15-27 1Oyr4/6 None sl 2fsbk mfr cs If 0.5 0.6 Ground elev 3 27-36 7.5yr4/6 None Ics & gr. Osg ml gw - 0.7 j 0.8 97.18' ft 4 36-50 7 5yr4/6 None St. S & Osg ml gs - 0.7 0.8 Depth to 5 50-95 Oyr5/4 None St. S Osg ml 0.7 0.8 limiting - - factor 2 ..y >95"_ - z Remarks: - Ground elev Depth to limiting r - factor Remarks: - - - - v 0 3of.3 . d u,n e r• : S c~a.Qe 1 X10 , N o,c! 8 Ka.nc y Pay ■ so. ~ o bsu ~o~or s71 iwy.3s~ fence Gn%roP/n ,L.oca.ceon = 5W~y t) E-4 see. y T2B1r., R. 19&0:1 n. o10 Troy, SE.. G'r o i~C (.m y W 1. 2 tee-PI tes wt 3 X 7S' B S i, ~ 6 3 e~ ■ ,moo A a z A~ca tree, ve~`= 48.8G; ~ 3enc{.rrtar~~ _ k~~~. ~~acle n;E or lyi" P.u,c p,pedn low d;nq S-4e =/o93fe eb:~ t r oL . -x: 7K I .1Z 71' K 04 330 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ' ~(b-j Mailing Address sfil [Ju j uT-').Z w ~24 01 (D Property Address 1V1 (Verification required from Planning Department for new construction) City/State Parcel Identification Number 04 6.1 U 2 • So • o co LEGAL DESCRIPTION Property Location SW %a, V4, Sec. , T 2 -Rj~a_W, Town of rat _ Subdivision , Lot l#~ Certified Survey Map # Volume, Page # Warranty Deed # S9 H04 , Volume 13~ to , Page # ~-Z (4:~ Spec house ❑ yes ( Ino Lot lines identifiable [ryes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a 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 masterplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 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 s has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 T"f the three year expiration te. A 'P DATE SR A OF OWNER CERTIFICATION I (we) certify 11 statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of th operty describe abov , by virtue of a warranty deed recorded in Register of Deeds Office. / q o Q D / S N A 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 PIP- 5 91404 iaL 13 i ?2 • Document;Jumber WARRANTY DEED RE01'9' ''i -Iii brr ICE ,T. CRGIK CO., %Y! j This Deed, made between Ervin A. Hal sdorf and . Eloise V. Has sdorf, husband and wife, Grantors, and David yCIU 1 1 1998 i ma A. Ray, husband and wife as survivorship i. A. Ray and Nancy } ~ ' vital property, Grantees. 9 30 witnesseth, That the said Grantors, for a valuable (LJi.rj ea r of n..d. - - consideration convey to Grantees the following described* real estate in St. C'.r)ix County, State of'Wiscorlsin: ,F or tract of reat estate located in the NE'/. of Recordin Area That certain parce, , rand o Name and Return Address ; Section 4, Township 28 North. Range 19 West, Troy Township, St. Croix FSTREEN' County, Wisconsin, further described as follows: Beginning at a point on AVID the east right-of-way line of S'T ri "35", said point being 1082.2 feet south a 304 LOCUST Sl. the north line of said Section 4; thence S00 34'W with said rig DSUN, Wl 5ST. distance of 734.6 feet; thence S89-26'E a distance of 19.7 feet, thence HUU S00°34'W with said right-oi-way a distance of 95.4 feet; thonce N89*00'E , a distance of 660.3 feet, thence N00°34'E a distance of 330.0 feet: thence S89°0C'W a distance of 680.0 feet to point of beginning. Tha above 040-1012-50-000 . ~ ~ I described parcel containing 5.11 acres, more or less (Parcei Identification Number) L (This deed is given ir satisfaction of that Land Contract dated 8-15-78, recorded 8-22-78, in Vol. 579, Page 547, as Doc. No. 351055. Register of Deeds' office, St. Croix County, Wisconsin.) TRANSFER FEE This is nut homestead proper iy. Toget .er with all and singular the hereditaments and appurtenances thereunto belonging; And Ervin A. Harsdorf and Eloise enH3rsdorf warrant that the title is good, cumbrances except easements` covenantsnconditions in fee simple and frr::3 and clear of I and restrictions, and will warrant and defend the same. f Gated this day of Nove ber, 1998 - *Ervin A. HarsdoOf ! - - *Eloise V. Harsdorf * ACKNOWLEDGMENT STATE OF WISCONSIN Signature!?1_~._ _ • P I tdLG COUNTY Personally came before me this L M day of November, 1996 1998, the above named Ervin A. Harsdorf and Eloise V. authenticated this - day of Harsdorf to me known to be the persons who executed the for ing instrument and ackno4' ge the safe, Signature int name S~I_ E ~LL m. GI ype or pr Type ~+~~r~nR rwme T . - 111, TITLE: MEMBER ST:'.TE BAR OF W!`:C:ONSIN Nr,_ary ?Vc-W e of Wisconsin zoo (If not '•.is. Stats! Mycortmlon rbire~ _Z~' - authorized by §706.W Wrres of `,se'sor.s ;;caning r-, airy capacity should be type,; or printed below THIS INSTRUMENT WAS '.RAFTED 3" T tae:r sgmmres. C. L. Gay'.ord, Attorney a' Law ` R',,rer Falls, Wl 54022 be aulM~-'A.-.!ed or acknowledged. 8 are nM necessary.) ;,',natures may kdorrr~ p,dess,onals Gor ^-Y Fond J. Lac WSows,n BO1655.-,~21 r Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST. CR IX Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 338819 Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: RAY, DAVID & NANCY TROY CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 040-1012-50-000 TANK INFORMATION ELEVATION DATA A99 U,vv/:) 311 919,' TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATIO St/ Ht Outlet TANKTO P/L WELL Air intake LDG. to ROAD Dt Inlet Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. Systg/n PUMP / SIPHO INFORMATION Final G ade Manufacturer Demand Model Number GPM TDH Lift Lriction System H TDH Ft Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN 1 N SYSTEM TO P/ L BLDG WELL LA STREAM LEACHING Manu acturer: SETBACK INFORMATION Type 0 CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length ia. Spacing SOIL COVER x Pres!~w a Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) ~~S ~esd LOCATION: TROY 04.28.19.50 NW,NE 571 HIGHW Y 35 low 0 ley C- 7z, T tl Plan revision required? ❑ Yes 2.110 Use other side for additional information- 3119 SBD-6710(R.3/97) Date Inspector's Signature Cert No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: e E i e a e t S ~ i A~ f ~ ~ 4 f a 9 i e E d , r e d ~ r + t d s, e~ ~0 {mss. a = 1 y .tea _ f t ~ *Lconsin Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. .S • See reverse side for instructions for completing this application State Sanitary Per5glit Number ir to The information you provide may be used by other government agency programs ❑ Check if revisiioon to[JprSious application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Property Owner ame Property o ation \ ~~)f7 PhG P WI/ N:v4,S y T aS,N,R ~ E(or)W Property Owner's Mailing Address Lot Number Block Number City, State U Zip Cod Phone Number Subdivision Name or CSM Number II. TYPE OF BUILDING: (check one) ❑ State Owned Itr Nearest Read Public 1 or 2 Family Dwelling - No. of bedrooms 3 Town of / P-b NL,r ~ -1 - L4 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) ~2cj.I,ct. OD 1 C] Apartment/ Condo ( 0 12 ~a 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 Q Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash S ❑ 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. Q New 2. ❑ Replacement 3. Q Replacement of 4_ Reconnection of 5. Q Repair of an -.....System System 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 41 ❑ Holding Tank 12 ❑ epage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 Seepage Pit G~)Ik4f-t 15 43 Q Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INF RMA ON. 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation Feet Feet VII. TANK Capacity gallons Total # Of Prefab. Site Fiber- Exper- INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete stun- Steel glass Plastic App lcted Tanks Tanks Septic Tank or++eldtngiank ? i.l ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage s stem shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) rpRQLRSW Business Phone Number: s>M u 4R r 7/~ va u Plumber's Addrestreet, City, State, Zip Code N-7 Awk. N 4.kPJa,. W, IX. COUNTY/ D ARTMENT USE ONLY Q Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuin Agent Signature (No Stamps) WApproved E] J Surcharge Fee) Owner Given Initial I ;t So aJl~ ~ q Adverse Determination / X. CONDITIONS OF APPROVAL/ REASONS FOR DISAPPROVAL: -~Gvlw}Do I(•U,GM ~X,vj~' l5 f o l~~ A *wh-le, ~,+s~,e on 4", 'I ~c 0111 IA A, S80-6398 (RA I/M) DISTRIBUTION: Original to County. One copy To: Safet 6 i ings vision, Ow , plumber / Ael 1.11 a 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: L 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. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County / Department Use Only. Complete plans and specifications not smaller than 8 1/2 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. i i r 6d c~a~~~d 0 E - I~ G r ~ t b ~ z d z z D LS:: I W "r e P_ L M 7-1 T A L X I C~ I C • rtl C 24 - Wisconsin Department of Commerce SOIL AND SITE EYAtUATIOIif - Pap 1 of 2 Division of Safety and Buildings in accord with Comm 83:155, Adm. Code A Enw=nental By Desigr. Attach complete site plan on paper not less than 8% x 11 inches in size. Plary twst ,p-111t I, , include, but not limited to: vertical and horizontal reference point (BM), d rectbrv and ` , ` ;gyp dun $t. CiO1X percent slope, scale or dimemsiorls, north arrow, and location and distance to nearest road. parcel ~D.# APPLICANT INFORMATION - Please print all information. s 040-1012-50 Personal information you provide may be used for secondary purposes (Privacy law, s. 15.04 (1) (m)). R ie By Dakt o~► 1Vq Property Owner f)roperty f Ray. David & Nan, Dave & Nan 664 10 r M~(1!4 AfE 1/4 S 4 T 28 N,R 19 W Property Owner's Mailing Address Lot # %I Block # +S4:'Name or CSM# 571 I JIM None city State Zip Code PhoneNumber City ❑ Village ®Town Nearest Road Hudson Wl 54016 Troy Hwy 35 ❑ New Construction Use: E Residential / Number of bedrooms 3 ❑Addition W existing building Replacement ❑ Public or commercial describe Code Derived daily flow 450 gpd Recommended design loading rate -.-/bed, gpd/ft! 8 trench, gPd/W Absorption area required 643 bed, ft2 563 trench, ft? Maximum design loading rate •7 bed, gpd/flz .8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 88.21. ft (as referred to site plan benchmar Additional design / site considerations This bore hole is for the verification of the existing system tParent material Loess Over Glacial Outwash Flood lain elevation, if applicable Na ft ble for systemConventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank itable for system I ® S❑ U ® S❑ u I ®s ❑ U I M S0 U I ❑ S MU I ❑ S M U SOIL DESCRIPTION REPORT Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD1W Boring# in. Munseii Qu. Sz. Cont Color Gr. Sz. Sh. Bed ; Trench I 1 0-12 10yr3/2 - sil 2msbk mfr cs 2f .5 .6 2 12-20 1Oyr4/4 2msbk mfr cs if .5 .6 Ground 3 i 20-32 10yr5/6 - sil 2msbk mfr f cs - , .5 .6 elev 97.21 ft 32-38~ 7.5yr4/6 I = I is ~ 2msbk ~ mvfr i cs i _ ~7 .8 Depth to 5 38-142 7.5yr4/6 5 Osg ml 7 i 8 limiting factor >142 Remarks: I his bore hole was conducted so that a temporary hookup could be made to a mobile home. Original residence was destroyed in a fire. This temMary residence will be replaced with a new residence a new location at which time this system will be removed CST Name (Please Print) Signature: _ Telephone No. 715-246-2454 Thomas C. Nelson Address Environmental By Design Date CST Number Ref# 1432 120th Street, New Richmond, Wl 54017 3/18/99 227387 225 I A hL t*y i 7 IS* 193 110" STREET, NEW RKHMOMD, WIRON99 LA515WO IMOA-I►S M 4W 7iS-1~6-149 Dave & Nancy Ray NW /i , NV/4, SECTION 49 T 28 N, R 19 W Troy 'township, St. Croix County, Wisconsin Page 3 ca h r'~ (I~ In ~y A 1, M 3~ S k I ~ S ~ Q~ d~w c 1 ~s r~,ob r y4t SCALE 1" =40 To BM 1. Top of telephone pedestal ELEV. 100' 2 Nelson BM 2. Top of tongue to mobile home Elev 99.93 22 7 7 I ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK. This is to certify that I have inspected the septic tank presently serving the p~)o 1,~1powL residence located at: ' Sec. RW, Town of St. Croix County, Wisconsin. Upon inspection, I certify hat I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Fe~ 179 7 Did flow back occur from absorption system? Yes_- No,/ _ (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: Construction: `Prefab Concrete J teel Other Manufacturer (if known): \TU Age of Tank (if known): ( W+ ~l 1 iY► u ►h 2 LJ (Signs re) 1 p } (Name) Please Print i ')r. A-en ~ 11, n hP 11 j.1~'/t__I~aS I_li P d XQ 4 0 (Title) (License Number) 31 g (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name B61A rhp,Q Signs e MPR _.UA9Qvy i I~ &WIPhOC7 SYSTEM AFFIDAVIT KATHLEEN 599632 H Document Number REGISTER OF DEEDS ST. CROIX CO., WI ame & Return Addr ss RECEIVED FOR RECORD 1~----w- 03-18-1999 3:00 PM l~ U ~l S~1y~ ; ' liV 1 -sn I G, AFFIDAVIT EXEMPT # CERT COPY FEE: COPY RANSFER:FEE: 3.00 © G u ( a " T Parcel I . D . Number RECORDING FEE: 12.00 PAGES: 2 The existing septic system which serves the dwelling being added on to must be verified by an acceptable soil report or be inspected by a licensed soil tester for compliance with high groundwater and/or bedrock separation requirements as set forth in s. COM Chapter 83.10 (2) WI. Adm. Code. The results of that inspection must be made available to this office. If the existing septic system meets these minimum requirements, and is properly functioning, an addition may be added to the dwelling without updating that system. This addition must not, however, encroach upon the required septic system setbacks as setforth in s. COM 83.10 (1). Property Owner (a) a-U i 9 " g~ln Lo Property Mailing Address: -~lI S4 RU 5ay\, s IVY O ( S0 Property Legal Description: Lot # CSM/Subdivision Sec., TN-R_~_W, Town of See. o•.~r~cl~ I, as the owner of the above described property, hereby affirm that the septic system serving this dwelling meets the above referenced state private sewage system codes. I realize that this addition may cause the existing septic system to become undersized for a dwelling of the resulting size, and I will make this information available to any future parties interested in purchasing this property Signe Notary Public ;rib)wo and to befo e on t i te: Date: 3 - ` My mmissio expires: c zo 0 County Approval: /'yN M. qv Date: -)T A CGr VV VOL 1411 PAcE 488 591404 u0L 13 76 ?6 Document Number WARRANTY DEED j ~ -RE (r _6 FIC E This Deed, made between Ervin A. Harsdorf and ST. CROIX co.. wl Eloise V. Harsdorf, husband and wife, Grantors, and David A. Ray and Nancy A. Ray, husband and wife as survivorship NOV 11 1y98 marital property, Granteas. q:30 Witnesseth, That ti to said Grantors, for a valuable ;J_t J consideration convey to Grantees the following described Ra lel1w of a..de real estate in St. C~nix County, State of Wisconsin: That certain parcel of land or tract of real estate located in the NE% of ~ iand 2 R~ Section 4, Township 28 North, Range 19 West, Troy Township, St. Croce i County, Wisconsin, further described as follows: Beginning at a point on FSTREEN i the east right-of-way line of STH -35', said point being 10822 feet south of DAVID J. the north line of said Section 4; thence S00034'W with said right-of-way a 304 LOCUST ST. is distance of 234.6 feet; thence S89°26'E a distance of 19.7 feet; thence HUDSON. WI 54016 t S00°34'W with said right-of-way a distance of 95.4 feet; thence N89e00'E y~ 9 a distance of 660.3 feet; thence N00°34'E a distance of 330.0 feet; thence S89000'W a distance of 680.0 feet to pant of beginning. The above i.~ described parcel containing 5.11 acres, more or less. 040-1012-50-000 jParcel Identiftailmn NumW) I :r i it ' (This deed is given in satisfaction of that Land Contract dated 8-15-78, recorded 8-22-78, in Vol. 579, Page 547, as m Doc. No. 351055, Register of Deeds' office, St. Croix County, Wisconsin) j TRANSFER i This is not homestead property. Together with all and singular the hereditaments and appurtenances thereunto belonging; And Ervin A. Harsdorf and Eloise V. Harsdorf warrant that the title is good, indefeasible ! in fee simple and free and clear of encumbrances except easements, covenants, conditions and restrictions, and will warrant and defend the same. Dated this ~o* day of Nove. ,ber, 1998. A,-~ a ~ `Ervin A. Harsdorf 'Eloise V. Harsdorf ! AUTHENTICATION ACKNOWLEDGMENT Signature(s)____ STATE OF WISCONSIN PrUf_& CWNTY i.. Personally came before me this L-1-4 day of November, authenticated this _ day of 11998. 1998, the above named Ervin A Harsdorf and Elnise V Harsdorf to me known to be the persons who executed the i for oing instrument and ackno`• the sa e. Signature Type or print name Sig tt tome ~QI [n I TYpr 4104 TITLE'. MEMBER ST, ,TE BAR OF WISCONSIN , • (If not. N6tprry "At to of Wisconsin. authorized by §706.06, Wis. Stals.) {X cor~mi~ston il¢trals _ - Z~L -ZOO n THIS INSTRUMENT WAS DRAFTED B" ' lWeres of oe-vtw.a'Vkq - a^y cap" shook! be typed at pnnied below e ~ ► C. L. Gaylord, Attorney at Law trot signatures. t ; River Falls, WI 54022 c. (Signatures may be autherdicated or acknowledged. Both are not necessary.) Inrormebw pmhms,onals Col - . y Fond 0u lx Wmcwmn 700.65520:1 . w w • .v.rftra