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040-1110-40-150
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No. 538817 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Nelson, Brian Lisa Troy, Town of 040-1110-40-150 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No ~e ~e ~r ~y~r~ 28.28.19.445A10 TANK INFORMATION EL VATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic tJ Benchmark ~4 l a~f, ' 8.I b~ Oo / Alt. BM Dosing .1 LCA_ Aeration wu b Bldg. Sewer t Holding a b &I-, Inlet P~ S TANK SETBACK INFORMATI N St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom c Dosing 1 f A,, 7 ; Header/Man. • l0 9 Aeration J Dist. Pipe Iv •~o ~ 57. SFI Holding Bot. System 7.3 97 7. .9 Final Grade PUMP/SIPHON INFORMATION as • i Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft i Forcemain Length Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS /a Goy. a Aeu-d I SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer INFORMATION CHAMBER OR Type Of System: uL I 75 UNIT Model Number: AL (~_v DISTRIBUTION SYSTEM / /l/~ e}- _ / (JA,' 'S Header/Manifold, Distribution x Hole Size x Hole Spacing Vent to Air Intake \ \ Length It> Dia Pipe(s) ~ D i a Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only G Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched BedlTrench Center Bed/Trench Edges ` Topsoil Yes No ` Yes Nn I i,. COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2 I Location: 138 Bjerstedt Lane River Falls, WI 54022 (NE 1/4 SE 1/4 28 T28N R1 9W) NA Lot 1 Parcel No~28,28.19 445A10 1.) Alt BM Description = Cina..~ ~g G-L O.1 r. 2.) Bldg sewer length = Cp,vt . ~•~-c.~ - amount of cover = 1 T~l Plan revision Required? ❑ Yes No %TIUI Use other side for additional information.-___ Date Insepct s Signal Cert No SBD-6710 (R.3197) I, commerceml.goV ings Division County RECU[jj~rgton We., P.O. Box 7162 S T C 70 f sconsi n son, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.) Depar[meM of Commerce 15 ' ' -7 er A 60 State Transition Nur Sanitary I A;1 In accordance with s. Comm. 83.21(2), Wis. Code, mbukissiit64 "T Mini to a appropriate governmental unit is required prior to obtaining a sanitary eefitlifeN(FfJ0t6 &A esQl'6i f state-owned POWTS are Project Address (ifditfer t dress) submitted to the Department of Commerce. Pe1`StIYti11" M olma on you prove a may be used for secondary purposes in accordance with the Privac Law, s. 15.0 1 m , Stats. 1. Application Information - Please Print Information / 6)6- rg Property Owner's Name / Parcel # '4v- 15D Qr)0-n V~Moij 040-1110 Property Owner's Mailing Address 1 T Property Location y~e A 1 I 31 B tr $ Tcd 1 Lr) Govt. Lot Cr '{•v~ J City, State Zip Code Phone Number , 1 E Section IS4ozz, (circle one 1ve F411 47 TO&N; R _EorJ II. Type of Building (check all that apply) Lot # 19 1 or 2 Family Dwelling - Number of Bedrooms 3 I Subdivision Name eta (g r1A t_ Bloc ❑ Public/Commercial -Describe Use _ ❑ City of ❑ State Owned - Describe Use C'StMiNumber ❑ Village ofT Z N Ce,[ l-s Lj t Vol i 3 SSL I Town of 1 Y Or III. Type of Permit: (Check onl one bog on line A. Complete line B if applicab ) A. ❑ New S stem ®R lacement S stem ❑ Treatment/Hold Tank Re lacement Onl ❑ Other Modification to Existing S st ex lain y eP Y Treatment/Holding p Y ~g Y ( P ) B ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New Li us Permit umber afidWW Is Before Expiration Owner (:716 L,) IV. Type of POWTS S stem/Com onent/Device: Check all that a I KNon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound ? 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (exp i t) ❑ Pretreatment Device (explain) V. Dis ersal/Trea ent Area Information: Design Flow (gpd) Design Soil Application Rate sf) Dispersal Area Required ( Dispersal Area Proposed f) System Elevation 4 5o 1 0, goo qvo q S. r V. 5 VL Tank Info Capacity in Total # of ManufaLcturer Gallons Gallons Units o New Tanks Ddsting Tanks ~,l q B o GM1 Jc p j.P _ 1~ U rz w c7 a Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- L the undersigned, assume respons ility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Pl is Signature/ MP/MPRS Number Business Phone Number Cat I 9a0 55-4 bs1 -44,52 -8S9-% Plumber's Address (Street, City, State, Zip Code) W QgnJ 210 -14 &1 dai FQ113 .r 540 VIII. Count /De artment Use Only I $ Issuing A t Signature proved isapgroved Pe-nit Fee Ob Date Issued G ❑ lven Reason for erual ~ ~ g ~L ~ ~ IX Conditty wf At NaUReasons for Disapproval 1 Septic tank, Eeffluent filter and plu !e t J dispersal cell must all be services / maintained t as per management plan provided by plumber. r r ASP` 4 S AM ✓er 6,6 A -s 2. AN so6ack requirements must be Maintained / o comp e p ns or the system and submit to the County only on paper not less than 81/2: 11 inches in size I SBD-6398 (R 02/09) 1 srd 71 i~ V~- SN~ft Y~' rJTt he Fi='t CkIAMIGv. 11 {Ye`r/.h 1 Puc , r _ 1 ~ i Lr ~l. P, ~ Ti~ ~ .~~4,"f ~ rJ' lt~Lti.'..1r~✓.s .r7 n ~ EL 17 CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: ~j rl a'_ n I y r' ~C 0,-J Owner's Name: Owner's Address: 3 Pi Q j5~~ h tV{Y 0i tw~1.1 Legal Description: `-r I Cf (,J Township: Trd~ T t County: 5 rep y Subdivision Name: Lot Number. Parcel ID Number. )40-1)10 -40 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: A License Number. p~o~OS.S41 Date: Phone Number C. $7 ' 99.x- Pi59~ Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 `;.CALL i - a . ~ 61Gp 5 CU 9Y w f D a F>; s1;r. 7,r• t iS7Acc-1Y~N D7VERTF-ZVA .VE N 7atl 9 F-Z F ?N1``~FILC NC-l~/ WIF S 6`` COiCC G%(f dD Finrl~ CRAMeLg G' b4 B5 ~l%~ S~ l7 ra lY 8' ENC N T R ~>uGN Con7'oii„~S q ~,r RPprn,~ EL q7. Ip Flow u n t7s II o 0 0 0 0 0 a II co U E O Ln U _ I~ O N N M O N U _ Ln O O CG E NCN u C U N U ~ O CO l(7 E I JWA.MMMG ~l Houllifflouill uluuuuuo I wed E CO ~y 10PIOA~AN1 U O O I CO U N c6 N W O u U 6 N Y ~ C Co ¢ N m U CS rn co N to m j N U ca N O U H Z U) 9 CD C/3 o O O Cnn H v w o N GO O ~ H 07 O d NO OJLL~ Lu O CL C, LU W to Q~ ¢ cv> O (D W LL' w ¢ U- p F- Cf U LL WCA m Z O Lf> Q W Cv> r o> J LO CO CL W JN~ LL ~1 du~r uw LL ~ d Z ~ RJR N M m u d ..fir: O O Q LL LL a s O O O e~ o ~ o N LO O _ r CID cl~ r O M ~ N C7 co LO O co CD - O Lq r Z o ~ H Z cz~ XW Lu Lu = Z U i H LLI Z C/3 J m Z = cD CL Lu J w 0 LL- C~ U.J C5 J Z LLI O C~ ~ U:) Cl- fZ N m , Lo Z~J ® r F O O =D LL7 ~uc? 20c0 L z LAD N F- W Lr) ~ Q I POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner r j ~ n S ~ Septic Tank Capacity 0- p - 6-5-20 al ❑ NA Permit # Septic Tank Manufacturer ,1eS f tecl NA DESIGN PARAMETERS Effluent Filter Manufacturer L ❑ NA Number of Bedrooms J7 ❑ NA Effluent Filter Model Sa ❑ NA Number of Public Facility Units $L NA Pump Tank Capacity gal ANA Estimated flow (average) 4V50 gal/day Pump Tank Manufacturer Or NA Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer ~n NA Soil Application Rate gal/day/ft' Pump Model ~f NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit ~!INA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) <_220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) :0 50 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BODS) 530 mg/L )tIn-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) :530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) :510' cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA ear(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA EL year(s) 37 month(s) ❑ NA Clean effluent filter At least once every: ❑ year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) NA ❑ year(s) Flush laterals and pressure test At least once ever ❑ month(s) ~A' A y' ❑ year(s) - 7 - Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of :0 2 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) 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 or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result 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) water; 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 and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be perforrrjed 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> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Gro X Phone Phone "71:~ _ This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address 11-3-g ors L, Property Address (Verification required from Planning & Zoning Department for new construction.) City/State 400-' is 1 Parcel Identification Number 0- LEGAL DESCRIPTION Property Location IV FL'/4 , Sf '/4 , Sec. 79,T,;98 NR 1 ~W, Town of Troy Subdivision Plat: , Lot # Certified Survey Map # -,Volume ( _3 , Page # Cj Warranty Deed # (before 2007)Volume , Page # Spec house ❑ yes 4 no Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Numbe of bedrooms 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. 09/07) • 0~ 1543PAGE 15 STATE BAR OF WISCONSIN FORM 11 - 1982 4E3,::Z 994fJ LAND CONTRACT KATHLEEN H. WALSH Individual and Corrpfpporatc WHERE O REGISTER OF DEEDS (TO BE USED FOR ALL TRAN $23,000 15 FINANCED AND NSOTHERNNONCONSUMER ST. CROIX CO., WI DOCUMENT NO. ACT TRANSACTIONS) RECEIVED FOR RECORD Contract, by and between Dwayne S. Carlson and 09-15-2000 9:30 AM Jeanninne Y Carlson husband and wife as survivorship LARD CONTRACT marital property ("Vendor, EXEMPT I whether one or more) and Brian T. Nelson and Lisa M. Nelson, CERT COPY FEE: husband and wife as survivorship marital property COPY FEE: TRANSFER FEE: 665.70 (`Purchaser", whether one or more). RECORDING FEE: 14.00 Vendor sells and agrees to convey to Purchaser, upon the prompt and full performance PAGES: 3 of this contract by Purchaser, the following property, together with the rents, profits, fixtures and other appurtenant interests (all called the "Property"), in St. CroiX County, State of Wisconsin: THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS Part of the Northeast Quarter of the Southeast Quarter Edward F. Vlack (NE 1/4 of SE 1/4) of Section 28, Township 28 North, Davison & Vlack / Range Nineteen (19) West, Town of Troy, St. Croix 200 E. Elm Street County, Wisconsin, described as follows: River Falls, WI 54022 Lot One (1) of Certified Survey Map recorded in Volume 13 of Certified Survey Maps, at page 3561, as Document No. 592573, St. Croix County, Wisconsin. 040-1110-Lt0-000 PARCEL IDENTIFICATION NUMBER Subject to an easement for ingress and egress over that portion of Lot One (1) of said Certified Survey Map as shown on said Certified Survey Map. This is not homestead property bEk (is not) Purchaser a fees to purchase the Property and to pay to Vendor at Vendor' s residence 15 , 9 5 9 _ the sum of S 22$1, 844.00 in the followiny manner: (a) $ at the execution of this Contract; and (b) the balance of $ 205,887 • 11 together with interest from date hereof on the balance outstanding from time to time at the rate of seven (73o percent per annum until paid in full, as follows: Monthly payments of $1,383.83 beginning September 1, 2000, until paid in full. imo Following any default in payment, interest shall accrue at the rate of 12 % per annum on the entire amount in default (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire principal balance). omt dl+t~~axr~aca~~~Qac~l Payments shall be applied first to interest on the unpaid balance at the rate specified and then to principal. >0x1arXXXXX>C1c1Fxre4M¢:plmd there may be no prepayment of princlpal without permission of Vendor.* In the event of any prepayment, this contract shall not be treated as in default with respect to payment so long as the unpaid balance of principal, and interest (and in such case accruing interest from month to month shall be treated as unpaid principal) is less than the amount that said indebtedness would have been had the monthly payments been made as first specified above; provided that monthly payments shall be continued in the event of credit of any proceeds of insurance or condemnation, the condemned premises being thereafter excluded herefrom. Purchaser states that Purchaser is satisfied with the title as shown by the title evidence submitted to Purchaser for examination except: Purchaser agrees to pay the cost of future title evidence. If title evidence is in the form of an abstract, it shall be refaced by Vendor -Tll the full purchase price is paid. Purchaser shall be entitled to take possession of the Property on date hereof 19 • Cmw Out One. STATE BAR OF WISCONSIN Wisconsin Legal 11J nk t.n.. inc LAND CONTRACT - Individual and Corporate Form No. It - 1982 M,I.. - Wis. 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 serving the following residence: (Street address) 139 ~;er5~ G. ,•J2- located at: AJi~ '/4, 5E t/4, Section 2Town Zg N, Range 7 W, Town of , St. Croix County Wisconsin. Upon inspection, I c tify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or le th of time: gallons minutes Tank Capacity: /4607656 Construction: Prefab Concrete Steel Other Manufacturer (if known): ;4.)e64- Age of Tank (if known): )z UeQ('S Permit number (if known) ait )12 (Licensed Plumber Signature) (Print Name) M V g y (Title) (License Number) MP/MPRS 1o 'V (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 Labor and Human Relations_-Y' SOIL AND SITE EVALUATION Diviton of Safety and Buildings Page of I 3 in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than g 1/2 x 11 inches in size.. Plan must. :nciude, but not limited to: verticai and horizontal reference County Percent slope, scale or dimensions, north Point direction and - ~ arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION -Please print all information. P na Personal information you Provide may be used for seconds N Reviewed by Pf0 Purposes (Privacy All. s. 15.04 (1) (m)). Date Perty Owner • ~ ~ Property Location pt" 1 a r ~ S Govt. Lot Property er's Mailing Address )V C_ 1/4 C, 'E 1/4,S Z T N,R Lot # Block# Subd. Name or CSM# Z 9 (or) W I s.~ c.u< I t M Rj _ City State Zip Code Phone Number. ~t Gt W I b9oZZ. 71 S) 9L5_G9~ El City El Village Town 'Nearest Road r6 ~rt t Lrl New Construction Use: Residential / Number of bedrooms ❑ Replacement 3 _ Addition to ❑ Public or commercial -Describe: existing building. Code derived daily flow 450 9Pd • Absorption area required t)p bedz Recommended design loading rate 6. ~ bed g~ft2 Q , ft~_trench, ft2 . to trench, gpd/ft2 Recommended infiltration surface elevation(s) To 1,~ rrr~r Maximum design loading rate 0 , bed, gpd/f2 0~ • ,;,,t trench, gpd/ft2 Additional design/site considerations ft (as referred to site plan benchmark) Parent material T I Rood plain elevation, if applicable ►V J4 S = Suitable for system Conventional Mound ft U = In-Ground Pressure AT-Grade Unsuitable for system S ❑ U S ❑ U System in Fill 7Hi-Tank ng ~S ❑U ®S ❑U ❑S-®U S ~,U SOIL DESCRIPTION REPORT 30ring # Horizon Depth Dominant Color Mottles Structure in. Munsell Qu. Si. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots GPD/ft2 0 -17 I 0 ` Bed , Trench Z, l7-Z 10 Z ` I ~s ~ r C S u 7 O,.f 0, 3iound -Z S rn i c. 5 1 v i' 0 , S ; 6 ,1p elev. 3 zg-4g i v t 9;/ z 14 0, a ls z~s6~. C5 )epth to 54-~G 7.5 4~ 4 p 0.7 ' 0• miting actor Qb in: ' Remarks: ro v % oring # 1 Z 1 o S. 3 5T -2ra 11 cs 14 o.s ;o.t. ound mfr C r I o.s o,G g 3 Lq s YQ.L 3 raft. 5 G4.g8 ~ 2 ~ f5 I ~e rn ~ Cs ~ p s;o.6 pth to Ting for n, r1 1 S~ Lin. Remarks: o tll 4 T Name (Please Print) Si4,nature a/ I'tG1ie / ' ~YII ~ Telephone No. joss . y -2 .S 4 ZS~ - 217 ~ Z S Y 5 Date CST Number ~ v a o 4 30PERTY OWNER t,vc.. 'A-e tQ4I10"J SOIL DESCRIPTION REPORT Page Z of 3 %RCEL t.D.# orin # Horizon Depth Dominant Color Mottles... Structure. ' . z ' • g Texture Consistence Boundary Roots . In. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 7J 1 011 l0Y m~ 1J~ 0, lb-192 10r 3 Yri -F; c t A n~ 70, g .,ound 3 47 7 .5 Y S% Z S T r C S I v :O, (o .v. (b (.11 4 47,38 IS ? IL f ( z 4~ k A-P i c d, G -1q) YV14 fs sbk I. Dpth to iiting f cto~ ,o in. Remarks: ON I -i,4 oring # cs_It i 'rc - ~l S; 1 fS1 n, c a.~ :o,G Z II • Z4 1 e Y R 3 L 5% 't~sh Yh G t v U. s. za a ,S ti~ - 5, ( z f~~1. rrfr c S o<S ,G round 4 i3-5o S ,a 1 2-~S~i~ GS d (pj4 S So-9G 7.~YQ s ! . S~a1,,. C7~ ;0•G yI . apth .to r niting ctor Remarks: o~ r s Nof . Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary. Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3oring # 34 To 0,_( S 5 4 !round 4ev. )epth to miting actor. Remarks: wwQ A.k.4,6,t, becaUx. 't'o CO- Gr. o o wnw oring # round ev. epth to niting ictor in. Remarks: . . . :BDW-8330 (R. 08195) ~-a7 4s, Z9I. Ig c~ h m P d 0 s u ' rn atl (1 cwt ~q~w~~";A a ~gl ~m 2 U IT t' AL 5V57EM '~GKGz N d't Prapw'~'i l~w< -1L x -I--~ ,t t Y rG y Y- k - -`j. r+- a ~c yc 1l ,a.s~ °PfiN ~6S Co-+n ~'~cid t3Ft ESURVEYO~...5PI E ATGRAVE-EL IOD.00 470.1° Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM CountyST. CROIX Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanita"St477"' Personal information you provice may be used for secondary purposes [Privacy Lap, s.15.04 (1)(m)]. ~D Village ❑ Town of: State Plan ID No.: Permit Hold is N Lk CARL! BRYNE CST BMFlev.: Insp. BM Elev.: BM Description: Parcel b-0~1110-40-100 ELEVATION DATA EA9900001 3 TANK INFORMATION TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ez.rte Dosing ~j,h~ Aeration Bldg. Sewer S 33 D 6.8~ Holding St/ V( Inlet TA ETBACK INFORMATION St/Outlet s, 9a' /D/.25'' TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake 2 94 NA Dt Bottom Septic 7 o Dosing NA Header / Man. Aeration A Dist. Pipe -f!Hfj:7 S6 Hold' g Bot. System PUMP/ SIPHON INFORMATION Final Grade S (0,02 ~O QS~ Manufacturer Demand -bz~ o-r:- rz~ ,M, s 3. ~ 03.63' GPM 078 r C.1~o- Model Number TDH Lift Friction eaem TD Ft C' ~cc.E 3 OS• Forcem Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED / TRENCH 7idth 2 Length No. Of renches PIT Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSI N LEACH cturer. SETBACK SY5TEMT0 P/L BLDG WELL LAKE/STREAM LEACH INFORMATION TypeO n~W / 5i~ 3 d CH Model Number: System: R UNIT DISTRIBUTION SYSTEM Header / Distribution Pipe(s) x Hole Size x Hole Spacin Vent To Air Intake Length Dia. Length ia. Spacing SOIL COVER x essure and Or At-Gra ystems 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.) btu LOCATION' TROY 28.28.19,NE,SE 138 BJERSTEDT LANE - LOT 1 e -1a iu'ct ~-e-~ - --"-D j D , Plan revision required? es No 3 Z Use other side for additional information. Date Inspector~SS nature Cert.NNa% CRn_R71 n !R A/Q7\ i n /I r / i l 4 ~w _ _ tin (/1.liLfG/ . c (D q 3: 0 N 0 dq N a. O a ~ e r, s o .3 0 N 0) H ~ O N O N f4 ~ N O C N + > U O co z c o = Z w U. O O Q N a m v ~ X I i'' Z y a i rn w ~ E I' c ' a w a m 00 00 CO 04 NN z Z a U O Z d c Q U Y w O 0 2 a z c 72 "0 0) }U~ v o M _~J N a 'U I CL U) CL c O N L M.0 C • N U N .CD O C C O C U) U O O~Q Z 1- Z o N Z c ~ ~ Cl) 4 CL co N N y~ ~ O C CL E ns O O O IL m z •~V LL a a a I O to 0) 0) N O fn J V c a) 0) (D 0) O) J } O m LO 0 C) .0 O N .-0 N 0 04 1~~1~ N O co E Vim' N a rn rn M n 0 y fV 00 y Q t"r y N O O O N N C LO - O 'ca Q T p'0j C E N N 1.0 00 ~r p O O N G U d O O O r~yi o a 3 K E E N N N V O O C O O M V N 4. F- o v a _ &d ~ N Q1 FN N T U) a) 'O H C_ M • 7~ 4 Ou LO (0 N O rA O O U y O N F- U M O Z N Z -7 to O r \ k w d a v °=t a L L: CL CL C rr~~ L Lo1 o 3 C U a~~ O N 00 VVisconsn Department of Industry, SOIL AND SITE EVALUATION Lab4rand Human Relations Page I of 3 ibivision of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and ST. Ypi percent slope, scale or dimensions north arrow, and loca 'on U and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information. Re ' ed b Date Personal Information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). S( U Property Owner Property Location 01 v) a-r I S w Govt. Lot IV C 1/4 S F 1/4,S 2 T-a,N,R (or) W Property O er's Mailing Address Lot # Block# Subd. Name or CSM# City State Zip Code Phone Number El City ❑ Village ~ Town Nearest Road I`S W1 f 4022 715) 4Z5 =G9.7s' ra New Construction Use: Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow 4Jro gpd Recommended design loading rate 6. bed, gpd/ft2 Q. ly trench, gpd/ft2 Absorption area required 00 bed, ft2 750 trench, ft2 Maximum design loading rate 0 bed, gpd/ft2 Q, //J trench, gpd/ft2 Recommended infiltration surface elevation(s) To &I a'/zr».~wv( ft (as referred to site plan benchmark) Additional design/site considerations Parent material Tt I I Flood plain elevation, if applicable rV J4 ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system P, S ❑ U CK S❑ U 0S ❑ U ,®S ❑ U ❑ S o u ❑ S IK U SOIL DESCRIPTION REPORT 3orin # Horizon Depth Dominant Color Mottles Structure GPD/ft2 g in. fvlunsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench I o-f 9 l 0 3 S" l ~5 C S V f Z 17-Z f0 Z S: Z n1 i c, 5 1 ~ ~ 0,5- :0.6 around Z8-dg 1 ~ S';1 2~~ b ~ mT C S t v t 0 , ~ ~ D• ~v elev. 0144ft. A 8.5f Z ?aL4 I s -z 61, m41 c 5 0.7 :o.8 )epthto 54-14 7.5 ~ ~S ► ~s1~. 0,'0.6 miting actor i A -In. Remarks: root ~vu.a Nlx r: Hof ain 5 3oring # C., C V4 0 10.4 c ;off 2 l 17 I v kQ v 5;- z rn~ is "4 3 97-52 -/,SMZ 4 - 6"( z k rnfr C „ o,s n G around 3Lp SY(LZ S z~ yx•~~ Cs 0.~ I 0 2,s4t 4 - , )epth to miting actor ~ ~ rnh 5 I NVJ s m. ~ ~Y_in. Remarks: o c.~ DST Name (Please Print) ~ Signatures Telephone No. Car / 1~Gcse '71.5 4ZS- -Z17 ~ Address Date ' CST Number ~0 4-Z-Ste, T -7 0,2-0 SLS 4 ' SOIL DESCRIPTION REPORT 3ongwoWNER LQC&~pr CCAA IS0~ Page Z of 3 %RCEL I.D.# v oring # Horizon Depth Dominant Color Mottles Texture Structure Roots 2 . in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence Boundary Bed , Trench 31 1 ®-Y6 l 0 Y 3 a~ o, `Z ~G as I O Y 3 S7 Z 4 4_ Yn G l 4 round3 z i5l k. tr c s I vl ,1; 0. L :pth to siting ; 'tor 4~ in. Remarks: rac)- fru.yvra~j 1~ rto~,~o-~ oring # 10 Y&- Z 11 24 ) kR 3 5 ; Z~sti~ m~ i c t v ~a a ,spa s I z ~sb1, ~,f~ ~ s Os r),L round 4 335a S~2 2 sb~ CS d •~;O,~v 6 e apth to niting ctor Remarks: Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary. Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3oring # 34 To rra( S 'round ; 4ev. ~n )epth to , miting actor ^in. Remarks: ~wwQ ctc~wc ,a, Oflkw- 'to CO- C4012 oring # round ev. ,ft. epth to E niting actor -'n. Remarks: ;BDW-8330 (R. 08195) a7 ALAN -I~-1~fA_YX~-CA RLSoN Lo-T 5.71LAc 40/ Zat. ig' ro cA P d f-A u -•f - _ .r .r._ 5 rnati\ p cwt W 1ak~"~ti~ - Ig2 o t31 M-A I 114 IT) AL SVSTtM n,-02 v- - - - - `~G'"G` N IM A. JL PL jo- L7 -.6 °PsN A84 D6S C~,, ~~old i ~fi SURY ~D Spr jcE ATGRAVF EZ.I00,00 r 470.'0 Parcel 040-1111-30-000 07/25/2007 09:20 AM PAGE 1 OF 1 Alt. Parcel 29.28.19.450 040 - TOWN OF TROY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - CARLSON, DWAYNE & JEANNINNE TRST DWAYNE & JEANNINNE TRST CARLSON 157 CARLSON LA RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 157 CARLSON LN SC 4893 RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE SEC 29 T28N R19W 40 AC SW NE Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601/4) 29-28N-19W Notes: Parcel History: Date Doc # Vol/Page Type 08/17/2000 628376 1535/306 QC 2007 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 07/21/2004 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 38.000 5,400 0 5,400 NO UNDEVELOPED G5 1.000 100 0 100 NO OTHER G7 1.000 10,000 95,100 105,100 NO Totals for 2007: General Property 40.000 15,500 95,100 110,600 Woodland 0.000 0 0 Totals for 2006: General Property 40.000 15,500 95,100 110,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 130 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ST. CROIX COUNTY ZONING DEPARTMENT AS BUILT SANITARY 0P6RT Owner ur J ohs Property Ad ess B a c L City/State L~,, L! S LA) S 4 o L ti- Legal Description: Lot Block - Subdivision/CSM # - 3 N F- 1/4 s P 1/4, Sec. 2&., T S N-R I k W, Town of I ,~T _ : }P # 04 ~ -1)10 - 46 -10 d SEPTIC TANK DOSE CHAMBER BOLDING TANK INFORMATION: 1000 Tank manufacturer Size ST/PC&! o / Setback from: House Well P/L Pump manufacturer lv Model Alarm location w , (HOLDING TANKS ONLY) rb f Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: i nf,' I t,. , d L4, fi Width 3 r Length 7 _s Number of Trenches 2 Setback from: House 37' Well 2 P/L Vent to fresh air intake 7 3 ELEVATIONS: Description of benchmark 'rvr u s.., Elevation 100, o Description of alternate benchmark Elevation Building Sewer I o , BL ST/HT Inlet 101 s ST Outlet 1 01. 2 PC Inlet W ~aL, 4 I PC Bottom w Header/Manifold Top of ST/PC Manhole Cover o s G Distribution Lines (I) 141 .0 (z) q5- Bottom of System 'i 9, 7 1 (2) R $ . G 3 ( ) Final Grade I OZ. 04 O ) 0 / ( ) i Date of installation 3 /a1 /11 Permit number 3-'? Q 7 a State plan number Plumber's signature License number G Date 3 h d /a, Inspector Complete plot plan 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 v 3 L n a° L U I INDICATE NORTH ARROW ' Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y' Safety and Buildings Division count ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitargt?r` ► Personal inffoormation you provice may be used for secondary purposes [Privacy L , s.15.04 (1)(m)]. CARLS 0" MIYNE I +kb)Fl village ❑ Town of: State Plan ID No.: CST BM lev.: Insp. BM Elev.: BM Description: Parcel ~'4~P-;1110-40-100 TANK INFORMATION ELEVATION DATA A9900001 3 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic i f G~ Benchmark 0 -C Dosing ,~j,~ Aeration Bldg. Sewer 1, 33 D 6. Y6 ~ Holding St/ I~ Inlet g~6S Q/.5~~ TA ETBACK INFORMATION St/Outlet 57.90' /D/.2~'' TANK TO P/ L WELL BLDG. AirI to ROAD Dt Inlet Airlntake Septic 2 NA Dt Bottom Dosing NA Header / Man. L' 2 /o/ Aeration Dist. Pipe Hold' g Bot. System 7¢~ PUMP / SIPHON INFORMATION Final Grade S p2 p Manufacturer Demand o , J,S(o o,3.G3~ Model Number GPM S - 0,73 r TDH Lift Friction em TD Ft ~d~°o C. 3 ~ oS sG Forcem Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED / TRENCH Width Length No. Of renches PIT Of Pits Inside Dia. Liquid Depth DIMEN I N DIMEN I N SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHI cturer: SETBACK INFORMATION Type O CH BER Mo el Num er: System: n St.1. 3 UNIT DISTRIBUTION SYSTEM Header/ Distribution Pipe(s) x Hole Size x Hole Spacin V nt To Air Intake Length Dia. Length ia. Spacing SOIL COVER x essur and Or At-Gra ystems 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.) ~ P LOCATION: TROY 28.28.19,NE,SE 138 BJERSTEDT LANE - LOT 1 3 Plan revision required? es No Z h r side for additional information. Use of e ~ s 3 w Date Inspect S mature Cert. N . OT~-67 R.~~C~ i3+`~.,7~ ~~.~c2~~LJc-C-C~CV .~,?,~GtgreC~~9~./+o~QL~l~1,~~d~"'~F /h'J~J'1 ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: y Safety and Buildings Division SANITARY PERMIT APPLICATION 201 E. Washington Ave. `~.7vons►n In accord with ILHR 3.05 Wis. Adm. Code P.O. Box 7969 Department of Commerce 8 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. J . Croly, • See reverse side for instructions for completing this application State Sanitary Permit Number Jp)4 -7 4;~- The information you provide may be used by other government agency programs ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location o"Iso►J X114 5 _ 1/4,5 aB T,?8 NR 11 E(Or :21, U Property Own is Mailing Address Lot Number Block Number 7 a~ldiayv Lw ~ d- City State Zip Code Phone Number Subdivision Name or SM Number tiviv Falls -50-z'~ (71,5, )425-G9a ,S a o t3 G II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest oad FIF Public 211 or 2 Family Dwelling - No. of bedrooms ° village Tro e~crS~ t I III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number Ag- g- ! Q 1 ❑ Apartment/ Condo 040- /1/ 1*) -40 -10 a 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ 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. :K New 2_ ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an System System______ Tank Only -_____---_____Existing System Existing System ❑ 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 12KSeepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area All. Loading Rate 5. Perc. Rate f System Elev. 7. Final Grade 0 l Required (sq_ ft.) Proposed (sq. ft.) (Gals/day/sq. ft_) (Min./inch) (i bd, Elevation 50 7 50 G 3 p 9 4~ Feet e,ci,X j Feet 4 1 -7. 2 VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tan or Holding Tank p oO f 'I~,y, y ❑ ❑ 1:1 1:1 E] Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plu ber'sSignatue:(Nostamps) M MPRS No.: Business Phone Number: .yf C at-1 F. Neese I) f 0.55 715 25 075' Plumber's Address (Street, City, State, Zip Cod 10 12 5 (I ` 51, A f 1141 ~S 4e IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved San'tary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) X Approved ❑ Owner Given Inttl Surcharge Fee) al D Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-63% (R 11196) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner, Plumber I INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe 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. 111. 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 PLDT ~L1~1.1 DWAY NE CA RL SON • Scat 40 157 CARL50N 1_N LSCALEMM-_VRP1#1RP IZIVEK.I<ALL~ \41 -5103z1 LOT 1 5.7110 gcRiS _ IDESINUD Grc~ M PR 5--~ Z 0 55q _ r d Q o w~LL 3 8dr~ NOME N 4 sak 1000 Gpt ry~D{✓rS7Egp p~FGSJ SEV~ic. 82 o~ B I Q 'a'te ~ ~ d g pvc QO ►+fI_TO P S~1~VE'Corc - PIKE aTGR -vE EL. 160-00 A)-FEgNA7E AREA p .d a9 B5 SYS7E11 To 0G 2 TRENCHES WITH 12-EA H10 C,pWW.V s~v v~~~►D~R IN 1LT~{a~JO»--CNAH$~R5 EL, TgEMC6 µ j 100.0 "'t 99.//0 lIQPQov~P V E,%T C,* F, S ci. 4 0 45- 141GMCAI?,4CITY _ 51PF-WINPER _CAA MBE2 i ' g''P~rf MIN G". a I q Per 3 EL-100.0 9 9, i6 ~I D 1 t h Lprt C04nGt ~pLLw 470 . 10 ~ T n 6 jam.-s'r~l't L rV . . Wisconsin Department of Industry, SOIL AND SITE EVALUATION Labor and Human Relations Page I of 3 Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and ST, C,YOt percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # F h Irv APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location pW ar I $ w Govt. Lot N r- 1/4 S r 1/4,S 2 T Z N,R (or) W Property O is Mailing Address Lot # Block# Subd. Name or CSM# 15 7 C 150 •j L n - Cs rr t (je -A ✓-1 )1f1p.-P_-1 City State Zip Code Phone Number rK ❑ City El Village ~ Town Nearest Road - w l b4o-n ( 7) 5) 4L5=~9.?r re ~t ? N T it" ® New Construction Use: Residential / Number of bedrooms J'T Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 4150 gpd Recommended design loading rate Q. r bed, gpd/ft2 -0b trench, gpd/ft2 Absorption area required 00 bed, ft2 750 trench, ft2 Maximum design loading rate 0,-i;- ,.S bed, gpd/ft2 0./ trench, gpd/ft2 Recommended infiltration surface elevation(s) Tc h, ft (as referred to site plan benchmark) Additional design/site considerations Parent material 7'1 *11 Flood plain elevation, if applicable W .4 ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system Xs ❑ U CKS ❑ U ;K S ❑ U JO S ❑ U ❑ S ®U ❑ S J& U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD1ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 0-17 )v 3 I I- S; I ~5 ~ ( cS O.f 0,Z 17-Z )0 " Z S; ( Z s rn pp i c 5 t v f 105- d ,6 Ground 3 28-48 1 U\ - S.' Z mT r C s I v t , p, t/p elev. i~ ft. q 8-5q ~aL4 v Is z-~~b~ C5 0.7 0 8 Depth to 59-14 i's l~-,j/„ OO,lo limiting factor 746 in. Remarks: row vau t~ci'~ Mot~z~~ / S Boring # 1 ~0 Si~ 1 ` C I ,4 ©,S .O, la Z Z { -27 Iv~Q3v 5; Z ~ )14TH CS ►~4 o.s G.b 3 7- ?,s~eZ 4 S • f Zf 1, rA Y- C I o.s o. (o Ground 9 aM 11 S1( (L43 elev. t c s ft. 5 44-9S IS 2 A -~S I } e h. Y1J - p. S o, G Depth to limiting factor > 98 in. Remarks: o o~ '0 w 4 ism CST Name (Please Print) Signat a Telephone No. C(A(l 21S 4Z.S'-217 Address Date ' CST Number 10 4-L S, Yvt L 7- 7 o a 0 4 PROPERTY OWNER n a Cw `bo-) SOIL DESCRIPTION REPORT Page Z of 3 PARCEL I.D.# o. Boring # Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots - in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench 3 t o~~ Ivr 3 - mr tio~ Q,~o.G` z ~G-aa t o 3 S; Z i L, yn 4,; c 11)4 n~f o, 6 Ground 7 J' Y Si f/ z 5 ~i. T Y C S ! v 7 d. S, G, !v elev. Is~t. 4 4,38 7,S 2 (51,~ ► c c;. v. Depth to 58-1a) 76 Yt1 fs f s b m E - L. limiting factor in. Remarks: rocl- f,wN,,ta~s t'~oti~o- Boring # 1 10-o I 2 S; 1 ~~1 ►ti, c 5 a,g ;D, Z 1I l- Z4 t O '?a 3 Z, 5; -t~sh Yh , G 1 v X4'8 ,S k (1 - S' 2 f~~~ Vr, ✓ t S - 0 C),te Ground 4-50 Sv2 2-~56~ f C-S d .7 'O, to elev. 6YJ 4 . S 150-96 Depth to limiting factor > RG in. Remarks: 20~ ~r!t4 yJU,-V ~s Noa 5 Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 3q To ,~Ut' S Ground elev. ft. Depth to limiting factor Remarks: dd L ~w1ti1 a,C.t_y,G~ b«au~C G T'~4.vNiR~ CO~'~^ GYa p Boring # Ground elev. ft. Depth to limiting factor 'n' Remarks: SBOW-8330 (R. 08/95) p 3 0~3 PGA H r La7 I 5.7J~ A ► : 4oJ Is s_ h ro u~ v a- d u -f yn X82 ~ AL m I 3 114 IT ► AL SVSTSM , 2 va`- - - x--- R- - jGnGg- N61 Prey.*) ~ - lbws V . ~K y t x ,c ~ r t t yyy X V- A 84 1l of SN a6S C®tin -~~zid _131401 TOP SURVEYo SPIKE ATGRADE EL. 10000 -_roP.~TEEL r--ORtaEn r- n~eE POST EL. 101.4E ~o 470, 12;'30;98 WED 08.34 FAX 715 686 4686 ST CRX CO ZONING [a 002 ST CROIX COUNTY SEPTIC -TANK MAINTENANCE AGREEMENT AND. OWNERSTUP CERTIFICATION FORM Own Buyer Mail Address . J~ Prop y Address 3 Lr 5'~G t P (Verification required Gam Planning Departmnt for new construction) City uto e-j 1 Parcel Identification Number ~/C 10 O LEG I., ,RESCRIPTCON Prop ;y► Location s V. V4, Sec. T N-R W, Town of i i Subc i,tion Lot Cert ed Survey Map # Volume 8 War inty Deed volume . Page # Spec :ruse 0 yes 0 no Lot lines identifiable El yes 0 no SYS ~Ml MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance coast of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. what you put into the system can a n' 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 fecm, signed by the owner and by a maste Iitniber, journeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on-site wastewaterdisposal system is in 1 per operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is leas than 1/3 full of sludge- Uwe, : undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set to , herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification statin vat your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days dz three year expiration date. SIGN '1 ]R$ OF APPLICANT / DATE U OW ~,R CERTIFICATION [ (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 pi city described above, by virtue of a warranty deed recorded in Register of Deeds Officc. ` zF G J %Gt, PURE OF APPLICANT DATE Any information that is mis-representedmay result in the sanitary permit being revoked by the Zoning Departrent. It ide with this applieadon: a stansped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed DOCUMENT NO. STATE 13AR OF WISCONSIN-FORM 11 LAND CONTRACT-Individual and Corporate 3 t c) ,~fJ D 1 1 ~ THIS SPACE RESERVED FOR RECORDING DATA r te, 6*A_ 4 1 CONTRACT, by and between Sppprt Carloon '11 - herein called Vendor, whether one or more, q -73 and ]DWayne--Caron S: 30 An/l n herein called Purchaser, whether one or more, Y WITNESSETH: That the Vendor, in consideration of the payments to be made and the ©r(~ - covenants and agreements by the Purchaser to be performed, as hereinafter set forth, ►etd hereby sells and agrees to convey unto the Purchaser, upon the prompt and full perform- RETURN TO ance by the Purchaser of the covenants and agreements of this contract to be by the Purchaser performed, the following described real estate in St. Croix County, State of Wisconsin: Tax Key # This is homestead property. The Southwest Quarter of the NoAheast Quarter (SWk of NEk) and the Southeast Quarter (SEk), excepting the East 30 rods thereof and also excepting a parcel of bland in the Southwest corner of the Southwest Quarter of the Southeast Quarter (SWk of SEk) 165 feet East and West and 144 North and South, all in Section 28, Township 28 North, Range 19 West. together with all buildings, improvements, fixtures and appurtenances, now or hereafter erected thereon, including all screen and storm doors and windows, attached mirrors, fixtures, shades, attached floor covering, hot water heater, furnace, oil tank and light fixtures which shall be a part of the real estate. The Purchaser, in consideration of the covenants and agreements herein made by the Vendor, agrees to purchase the above described premises, and to pay therefor to the Vendor at River Falls, Wisconsin , the sum of a Dollars, in manner following: $ 5Q0.0() at the execution hereof, the receipt whereof is hereby acknowledged, and the balance of $_49,500 00 , together with interest on such portions thereof as shall remain from time to time unpaid, at the rate of 6 per cent per annum, until paid in full, as follows: Said principal and interest shall be payable lot installments of not less tan $--400.00 per quarterly-payment , beginning on the day of April 1974 provided the entire purchase money and interest shall be fully paid within yp years from the date hereof. Purchaser further agrees, unless excused by Vendor, to pay monthly payments sufficient reasonably to anticipate the payment of taxes, special assessments, fire and extended coverage premiums and such other insurance premiums as Vendor may require, and Pur- chaser agrees to make such payments to the Vendor and hereby authorizes Vendor to apply the same in payment of such items. Interest on the first payment shall be computed from January 19 1974. e r Said payments shall be applied first to interest on the unpaid balance at the rate herein specified and then to principal. Any amount may be prepaid without premium or fee upon principal at any time, and interest shall be calculated at all times on the unpaid balance on the daily rate basis at 1/360 of the annual rate. In the event of any prepayment, this contract shall not be treated as in default with respect to payment so long as the unpaid balance of principal, and interest (and in such case accruing interest from month to month shall be treated as unpaid principal) is less than the amount that said indebtedness would have been had the monthly payments been made as fi{~t specified above; provided that monthly payments shall be continued in the event of credit of any proceeds of insurance or condemnation, the condemned premises being thereafter excluded herefrom. The Purchaser hereby states that he is satisfied with the title as shown by the abstract-title insurance commitment submitted to him for examination; the Vendor agrees to deliver the abstract-title insurance policy to the Purchaser when the full purchase price hereunder shall have been paid. The Purchaser agrees to pay the cost of later continuations of abstract-title insurance. (OR;The Vendor shall furnish the Purchaser thirty days prior to the date of ultimate closing, and the Purchaser shall accept as a sufficient showing of title, either (1) a title insurance commitment for an owner's policy of title insurance in the sum of the purchase price, the Purchaser to be named as the assured, to be written by a title insurance company, and guaranteeing the Vendor's title in the condition called for by this agreement, or (2) a merchantable abstract showing the Vendor's title in the condition called for by this agreement. If an abstract is furnished, the Purchaser shall notify the Vendor, in writing, of any objections to title within ten (10) days after receipt of such abstract, and the Vendor shall then have a reasonable time within which to rectify the title or furnish a title policy as above described. The Purchaser shall be entitled to take possession of said premises on 0.n *.+1+.~ nr193-. In case possession is to be obtained by the Vendor, he shall have a reasonable time after such date in which to remove any occupant. The Purchaser shall be entitled to remain in possession as long as he performs all covenants and agreements herein mentioned on his part to be performed and no longer. H.C.Miwler Company M LAND CONTRACT-INDIVIDUAL AND CORPORATE -STATE BAR OF WISCONSIN, FORM NO. 11 - 1971 07 5,173 d~ + ~25?3 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 11-30-1998 9:30 AM CERTIFIED SIXtVEY MAP EXEMPT 8 CERT COPY FEE: A^ CERTIFIED SURVEYMAP RECMINGFFEE: 12.00 PAGES: 2 DWAYNE AND JEANNINNE CARLSON Part of the Northeast 114 of the Southeast 114 of Section 28, Township 28 North, Range 19 West, Town of Troy, St. Croix County, Wisconsin. W114 COR. SEC. 28, r2BN, RISW. SUNDOWN kI LL S E//4 COR. SEC. 28, r2BN, RIO W, /COUNTY SURVEYOR'S MON.) tCOUNrYBURVEYOR,s MON.J LO/ 8 E W //4 LINE N '/7'29"E 3349.6' R/N89•1B'20"EJ 'M 291. /8' 4 69.890 4093.72' 495. 07 ' 76 07' 96 ~o 4 ~ ; C:JtT1Uf8~itir~'3wC '~'1;•• ~SICN; M zon;nS art. M o M :+oj r~!x~rd~d "o ~ ~'stl1ir. '.Ci 119Y¢ al o► Cl) oval date LOT2 ~ pfflvR! 4-ki'19i! kPN 0 N Z 'L uis Aod vote 2 Q 1.968 ACRES h Q ..1 239, a s o so..- r. ~I O ~ W O a Q z W W V LOT W Q h ~ 0P ~ 1p S. 716 ACRES 4 Q N a 249, 009 S0. Fr. y~ O 0. S. 623 ACRES ErYC. TOWN 0 / O Q. :y R.O.W. AN0 ✓0INT OPI~~ / N 2I Oft N ORIVEWA Y EASE MENr `ev 2 244,931 So.rr. ` III h y i i Q N89•36'33"WJ76.7d(2) b 6 b N ✓0IN r OR VEWA Y EASEMENT , x/33 WI v la ~ • ! R h N 69136'31 "W 470. /O' ~yT i ® ~I UN PL AT 77T ED LANDS di rob a3•*',,. ~o Rs.- - - SCALE J "z /SO' O 50' /00' /SO' 200' 290' 300' 400' Soo' `1% \9CO~S/ BIW' LEGEND ?'LAU E CEO o Indicates 1"x 24" iron pipe weighing ].13 lbs./lin. ft. set. 2 A f W RPHY - o ~lndicates fence. N %RIV R FALLS -x,44 R (10.0) Indicates previously recorded data. , wise, ? • This instrument drafted by Laurence W. Murphy LA NO . ~~>ttlt~~ Dated: June 19, 1998 "Revised this 28th day of Sept. 1998. ence W. Murphy Regist ed Land Surveyor Owner's Address: 157 Carlson Lane River Falls, WI 54022 SHEET 1 OF 2 Vol. 13 Page 3561 CERTIFIED. SURVEY.MAP DWAYNE AND JEANNINNE CARLSON Part of the Northeast 114 of the Southeast 114 of Section 28, Township 28 North, Range 19 West, Town of Troy, St. Croix County, Wisconsin. CURVE DATA CURVE CHORD BEAR/NG CHORD D/ST. ARC D/Sr. RAD/us CENTRAL ANGLE /ST TAN. BEAR. 2ND TAN. NEAR. 1-2 S09.45'38"W 66.//' 66.15' $86.76' 06'4/'/4" S/3'06'/3"W S06•24'59"W 3-4 N83'/5'//"W 84.77' 84.94' 362.82' /2.42'48 N76"13.47"W No$*36'3511W 5-6 S B3' /5'//"E 99.39' 99.59' 448.82' 12042-48" S 89.36'351'E $76•'13'47"E Description: That certain parcel of land located in the Northeast 114 of the Southeast 114 of Section 28, Township 28 North, Range 19 West, Town of Troy, St. Croix County, Wisconsin, more fully described as follows; Commencing at the West 114 corner of said Section 28, thence N 89°1729'E (assumed bearing on the East/West 114 line of .said Section 28) (recorded as N 89-18'20"F.) a distance of 4093.72r to the POINT OF . . BEGINNING, of the parcel to be herein described; thence continue N 89°1729 "E 761.07' on said line (recorded as N 89°18'20"E); thence S 00°16'15"W810.35'; thence N 76°5347"W 69.25; thence Westerly on a curve concave to the South, having a radius of 382.82', whose. chord bears N83 °15'11 " W a distance o11 84.77'; thence N89 3635"W 470.10; thence N 00`15'42 "E 448.53; thence N 23°01 '38 "W 351.55 , to the POINT OF BEGINNING, containing 11.684 acres or 508,955 square feet, being subject to that. joint a ntas-.shouwan d=-map being-.suhjerl.-in-EasemenLfnr town road R. 0. W. purposes as. _ shown on this map and also being subject to easements of record. Note: Each parcel shown on this map is subject to State, County and Township laws, rules and regulations (i. e., wetlands, minimum lot size, access to parcel, etc.). Before purchasing or developing any parcel contact the St. Croix County Zoning Office and the appropriate Town Board for advice. Dated: June 19, 1998 "Revised this 28th day of Sept. 1998." This instrument drafted by Laurence W. Murphy I State of Wisconsin) County of Pierce) I, Laurence W. Murphy, Registered Land Surveyor, do hereby certify that by direction of the Owners, Dwayne and Jenninne Carlson, I have surveyed and divided the lands shown hereon in accordance with official records, Chapter 236.34 of the Wisconsin Statutes and the Ordinances of St. Croix County and that this map and description are true and correct to the best of my knowledge and belief. ,,,~ppNlffrf % '44 40 LASIJAE E% -9 i• W U PHY Cr m 17{13 s R •FALLS,,i~ Wisc. FD LAND - 40Iftuso Laurence W. Murphy gistred Land Surveyor SKEET 2 OF 2 Vol. 13 Page 3561 I 1