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038-1180-10-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 538751 0 GENERAL INFORMATION State Plan ID No: Personal information you provide r*y be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Mager, Darin & Nanc Star Prairie, Town of 038 - 1180 -10 -000 CST BM Elev: Insp. BM Elev: BM Description: Section /Town /Range /Map No: /Op �jwi i C, ST 15.31.18.896 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER Qr S CAPACITY STATION BS HI FS ELEV Septic Benchmark �Q.�S [ '' l u. / AItG iJl�* -�. /• (p /6 .� .7 Aeration Pe ' � � Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet Ie Z TANK TO � P//L � WEL} BLDG. Vent to Inttk f�OAD Dt-I -nfet Ap 1 (o , 24 1 /DO . Z L Septic / DL iaE m OJ Dosing 5� � Z Header /Man. 9 �� S b � — 3 3 Aeration Dist. Pipe 7,01 99 - �S Holding Bot. System Final Grade PUMP /SIPHON INFORMATION 3. Zj /Q j , Z Manufacturer Demand St Cover fg P v` GPM �Z G0U /' /6-y Model N TDH L Friction Loss System He TDH Ft V " ' Forcemain Length Dia. Dist. to Well Vc, ( a e, od yy� A � 0 SOIL ABSORPTION SYSTEM BED/TRENCH Width f Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Deh DIMENSIONS 3 pt Fg �- Liq Z let&e' �� SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACHING Manufacture /+ INFORMATION Type Of System: CHAMBER OR (� � 6 "e • O.1 t,.X- g AJ i UNIT Model Number w Q -0 DISTRIBUTION SYSTEM Header /Manifoy Distribution x Hole Size x Hole Spacing Vent to Air J P Length / Dia T Length Dia Spacing r b SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only S •� Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center 1�N Bed/Trench Edges Topsoil \ - . N�Yes 9 No Yes No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 1142 212th Avenue New Richmond, WI 54017 (NE 1/4 SW 1/4 15 T31 N R18W) Apple River Bend 1st Add Lot Parcel No: 15.31.18.896 1.) Alt BM Description = Ca�'v" E � Co U t od W J 5 G re S 2.) Bldg sewer length = - amount of cover — - — Plan revision Required? Yes No Use other side for additional information. L.9 ll SBD -6710 (R.3/97) Date Insepyrr'sSigna ie�� Cert. No Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 538751 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). Permit Holder's Name: City Village X Township Parcel Tax No: Mager, Darin & Nancy Star Prairie, Town of 038 - 1180 -10 -000 CST BM Elev: Insp. BM Elev: BM Description: Section /Town /Range /Map No 15.31.18.896 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil a Yes R No Jl Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 1142 212th Avenue New Richmond, WI 54017 (NE 1/4 SW 1/4 15 T31 R1 8W) Apple River Bend 1st Add Lot Parcel No: 15.31.18.896 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ❑ Yes R No 1 Use other side for additional information. Date Insepctor's Signature Cen No SBD -6710 (R.3/97) mmerce.wi.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 St. Croix 1 Madison, WI 53707 - 71C itary Permit Number (to be filled in by Co.) ment of Commerce r 53 'F75/ Sanitary Permit Application 'ate Transaction Number 14— In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental Project Address (if different than mailing address) unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are submitted to the Department of Commerce. Personal information you provide may be used for secondary Same purp oses in accordance with the Privacy Law, s. 15.04 1 m nn '' I. Application Informati — Please Pri Il �t✓e- Property Owner's Name / Parcel # Darin & Nancy Mager 038 1180 - 10 - 000 Property Owner's Mailing Address Property Location 1142 212 Ave. City, State n Number Govt. Lot 6 0 New Richmond, WI. L ij ZONING F1° - 248 -7383 NE �/4, SW /4, Section 15 (circle one) 11. Type of Building (check all that apply) Lot # T 31 N; R 18 E or W El or 2 Family Dwelling — Number of Bedrooms / 32 Subdivision Name � f'� ^ 5y Block # Plat of River Bend 1" Addition El Public /Commercial — Describe Use po r 3 Na ❑ City of ❑ State Owned — Describe Use CSM Number ❑ Village of Z Na El Town of Star Prairie ;��. t(5 w;N�• 2Z�ZZ Gk,L9( III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System )(Replacement System ❑ Treatment/Hold Tank R Only ❑ Other Modification to Exist S ystem ( explain ) Y P Y g p Y g Y ( P ) B. El Permit Renewal El Permit Revision ❑Change of Plumber ❑ List Previous Permit Number and Date Issued Permit Transfer to New Q Before Expiration Owner 3262-91 IV. of POWTS System/Component/Device: Check all that appl Non - 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 (e lain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Information: 44 filtrator "Q standard chambers & 2 pr. endca s, Pol Lok PL - 525 effluent filter Design Flow (gpd) Design Soil Application Ra a gpdsf) Dispersal Area Requir d (sf) Dispersal Area Pro (sf) System Elevation 600 gpd J 0.70 gpd/sq. ft. 1/^ 857.15 sq. ft. � 891:%6 sq. ft. 99.00' �- VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o 'd New Tanks Existing Tanks a 0 Y A ✓ lolc 57,75 a U E C41) w a Septic or Holding Tank 261 1261 1 Weeks Cdficrete X 0 I I Weeks Concrete X Dosing Chamber Na Na Na I Na VII. Responsibility Statement- I, the and rsigned, ass a responsibili fo stalla ' n of the POWTS shown on the attached plans. Plumber's Name (Print) Plumbe s Signature MP/MPRS Number Business Phone Number James K. Thompson S-- MPRS 30021 (715) 248 -7767 Plumber's Address (Street, City, State, Zip Code) 340 Paulson Lake Lane, Osceola, WI 4020 VIII. Court /De artment Use Onl Approved m Permit Fee Date sued Issui Agent Si , er GNen RBaset3 for Denial I � ` 5 , °a 1 2- 1 11 IX. Conditions of Approval/Reasons for Disapproval SY5TEM OWNER: 1. Septic tank effluent finer and dispersal cell must all be services / maintained as per management plan provided by plumber. 7- Al( a"k•Mqu rements must.be maintained ae per appftw code Y ordit►e sm. Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD -6398 (R 02/09) Valid thru 02/11 Conventional POWTS Index & Tilte Sheet Project Name: Mager 4 bedroom Replacement Conventional POWTS Owners Name: Darin & Nancy Mager Owner's adress: 1142 212th Ave., New Richmond, WI 540 Site address: Same Project Location: Subdivision: Lot32, Plat of River Bend 1 st Addi Legal Description: NE1i4 swim, Sec. 15, T.3 IN., R. 18W., Town of Star Prairie, St. Croix Co., WI. Parcel ID #: 038 - 1180 -10 -000 Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Dispersal Cell Sizing Calcualtions Page 4 System Cross Section Page 5 System Management Plan Page 6 Filter Specifications Page 7 Treatment &/or Filter Tank Cross Section Page 8 Parcel map Page 9 Septic Tank Maintenance Agreement Page 10 Certification for Utilization of existing septic tank Page 11 Waranty Deed Attachments: Soil Evaluaiton Report Mater PI ber Restri ted Service: James K. DLOInEson, De 't. of Comm. Credential 930021 Signa Date: Page 1 Of 11 Design pursuant to In- Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD- 107W.. -P (N.01 /01) Soy eilal .o anP, f b CJ 'Con ne// /C>/O//98. ♦ LsXi3 Etr�ye e /e�' • 4-ca.lec/ c. -5 6a.,ee , e (/ \ D-oln 4f ") -Cy m�G/' Q // za '4oe /feud �.'c Cmanc� 5S /st� dCli q E %SIScJYy 5Kti� /s T 3 /r(., /S�•. Tn, a 5f,,> 5r; , C''roik Proposed wtto �4 SI<Qd C�,c. efr z�ly�P 4jeaK cre s`c a � B u.�.l•¢ , 0 Proposed !!a l �t ♦ QS�I. 1 : 6 EXisbing Sri �Q 0 / / Q / io3 z3' f� ♦ < 1 o� d ♦ io3 06' Prop65td d,s,ocrSa -/ ee/ /1. 12 x 90 w �6 &wo frc "C gs a - f 3 y 90'ecc�-- • Spa c 6n Cwlfer; Ea�� � �•eMGl 7� l'G+3.3 f o {11 .x•, �' /fJ'ty�'�'" ♦ 5��� ce u e� � be = y9•ct�: / oj Ao � ✓l 0 4PP�e cla6 /e 5 /oP - l+roK J c� S ySfern a r'�A• O $o,% edG /Lcct�ionP�f b�, 0 Connell ♦ LTX.SrII�y �+e e /ev` 177/Z .11 SK�c /5 T 3 /t1.,.P 56 , Cro7X Q% tA) �. pal• # o,�B- / /� ° /o - t:� pooposedwtco E14s�i �coo�°� 56ttd Conc. e {e Z�l9oY cJca-�'s�o�cre.tc 0 PropoxA -G � def3 i1,r, ammo fe- n.1 Vc ♦ � Qs�/�o � EXisting / / G R �siden�G \ Ex di -%c a// a 6 a ',x 6A 0 i P�opascd d ;sp4rso•/Cf. a-6- ?0 Wes( 6tw )o {/'c h'm ti- 3 X ?d - fack. e Spaceja lo Co4rtfer Eaac-4 •6i enc/t & "V316 1 a- .1a ko. bt-o- io.? Ao * 4 - tkroK SySfema�e'll• �nc.�, WlarK' 7'e,o o /af s -�vfe • QIE. e.,rj AZ Se,o�e r✓a^� Moshe% e��•., DISPERSAL CELL SIZING CALCULATIONS 1. (4 bedrooms)(100 gallons estimated flow)(1.5 design factor) = 600.00 Gpd design flow 2. Infiltrative capacity of native soil = 0.7 gpd/sq. ft. 3. Absorption area required: 857.15 sq. ft. Infiltrator "Quick 4" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4" end cap (pair) = 5.80 sq.ft, EISA 857.15 sq. ft. — (2 pair endcaps)(5.80) = 845.55 sq. ft. 845.55 sq. ft. /20.00 = 42.28 chambers required 4. Absorption area as proposed: 891.96 sq. ft. (44chambers total) Number of trenches: 2 @ 22 chambers per trench (44chambers total) Trench width: 2.83' Trench length: 90.00' Trench spacing: 9.00' on center Total system area w/ 6' trench spacing: 12.00'x 90.00' Pg. 3 of 11 1 Soil Absoratlon System Cross Section 102.75 ft Final Grade 4° Schedule 40 PVC Vent Pipe 6.00 With Vent Cap ft Leaching --� Chamber e ft f— System elevation 83 6.0 Soil Absorption System Plan View 40,0 ft 2.83 ft i 6.00 ft Leaching Trench 1 7 Ventbservation Pipe Chambers 1 11HIMI III III I M1 111111111111111111111111111111101 111111111H1111 III I 11011111, 4' Die. Trench 2 Header Leaching Chamber Snecificafiions Manufacturer And Model Infiltrator Q -4 EISA Rating 20.00 sq ft per chamber Soil Application Rate 0.70 gpd /sq ft 600.00 gpd Design Flow + 0.70 Soil Application Rate + 20.00 EISA = 42.85 Chambers 2 rows of 22.00 chambers each. i Page of �1! Conventional Septic System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD- 10705 -P (N.01 /01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with bottom of tank to be <_ 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. 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 a biannual 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 outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical 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 Department of Commerce, Safety and Buildings Division. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October - March) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a two- year /1 -year schedule by use of diversion valve. Effluent to be diverted from new dispersal cell to old cell at 4 year anniversary of new system installation. Old cell to be utilized for a 1 year period. Afterwards, effluent dispersal to be alternated between cells on schedule to allow use of new cell for two years and old cell for 1 year. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715) 248 -7767 or the St Croix County Zoning Department at (715) 386 -4680. �.� °�'�/ EFFLUENT FILTERS POLYAOX "The PL -525 has 525 linear feet of 1/16" slots. It has an automatic shut off ball. When the filter is removed for cleaning, ball will "'arm Acc.pls PVC g, accessibility ( <___y e:t ension henNe float up and temporarily shut off the system 1( so the effluent won't leave the tank. No other $2 linear feet filter on the market can make that claim!" liltratbn Huts Rated for ever ,e 10.000 GPO Accoprs 4" SCH0 40 Pip. r I� ,N I e Gas delledor Automatic shul.off bell when tilt., 7 ' is removed "The PL -122 has over 122 linear feet of 1/16" slots. Rated for 1500 gallons per day, and „'na 1,2" PVC can be manifolded together with other PL- Al.rm 122's to double or triple the GPD. It has an Switch 122 Linear h. automatic shut off ball that stops flow when of 1, 18 inch the filter cartridge is removed for cleaning. Filter Slots Comes complete with it's own housing, no Fitter Housing gluing of tee or pipe and no extra parts to withY &4" Pipe Adapter buy. 1" Gas Deflector Automatic Shut -Off Ball When Filter is Removed From Tank Order # Model # Description List Price PK -525 PL -525 Effluent Filter System 203.50 PK -122 PL -122 Effluent Filter System 62.50 6 -10 alp/ aA / /dw Ael;c 41 �ri//,AL edit *;Vl ad'� �v �?� uS�cQ '09S7 cl ���� G�oN�14i�f/Z Olv f9 I � I � I I I � ! I 1, 4sIr A a" io 3� z WEEKS CQ ICP-" i r �' ' ~ =, RAY L� WEEKS y ` i8n 218th St. W Riohmond, 5417 Of NE114 OF THE SWI14 ANO IN PART OF THE NWI/4 OF THE SE114 Al l. I,% ck:C TION 1-5, T31N, RIBW, TOWN OF STAR PRAIRIE, ST. CROIX COUNTY, WISCONSIN Fro HST-0 4WE LOT 27 LOT 26 LOT 39 LOT 28 LOT OT 24 LOT 4 LOT 23 LOT 37 LOT 30 7 K LOT 22 � . LOT 36 IT LOT 31 LOT 35 cif LOT LOT LOT 34 ono ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerAAtp n �c Q. Mailing Address _ Property Address (Verification required from Planning & Zoning Department for new construction.) City /State /� _ / �� Parcel Identification Number 031 - 118D LEGAL DESCRIPTION Property Location 1 /4 , J) Lt.J 1 /4 , Sec. /S , T ,3 LN R l8 W, Town of 51�' Subdivision Plat: Aw le- iC ,"4/ ,cr Qe i / —� �c/,'zc�- , Lot # Certified Survey Map # a , Volume , Page # Warranty Deed # (before 2007)Volume , Page # Spec house'�eAo Lot lines identifiable 1 es ❑� 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. Nu r of bedrooms l SIGNAT OF APPLICANTS) 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) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) TIZis is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence. (Street address) I tV� a/a �.4� Y �e Ae� ,o,, cD/. located at: 4e5' ' /4, Sc,J '' /4, Section _ls , Town _3/ _ N, Range I_ W, Town of S Azi, - ;e- , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of 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.) 4 Approximate volurne or lengAh of time gallons minutes Tank Capacity: 4 dO Construction: Prefab Concrete Steel Other Manufacturer (if known): Age o Tank (if known): Permit umber (if kn n icensed Plumber Signature) (Print Name) (Title) (License NumberMPRS (Date) Form to be completed b /licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) R 9!2008 1 0q . C' VOL 13SOPA07'O �L 592404 WARRANTY DEED REGIST OF DEEDS ST. CROIX CO., WI Document Number RECEIVED FOR RECORD 11 -25 -1998 9:15 AM 4 351882 VARRANTY DEED EXEMPT D CERT COPY FEE: Return Address COPY FEE: First National Bank of New Richmond TRANSFER RECORDING FEE: 10.00 PO Box C PAGES: 1 New Richmond, WI 54017 Parcel I.D. Number: 038- 1180 -10 -000 022 11Rn �)n nnn M & G Inc. a Wisconsin cor oration conveys and warrants to Darin J. Ma er and Nancy D. Mag er, husband and wife as survivorship marital prope the following described real estate in St. Croix County, State of Wisconsin: Lot 32, Plat of Apple River Bend First Addition in the Town of Star Prairie, St. Croix County, Wisconsin. This is not homestead property. Exception to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this 7-6 day of November, 1998. TR;VJSFER 2 r M & G, Inc. F By L UL— :: - (SEAL) Michaet J. Ge 'n, President AUTHENTICATION Signature(s) Michael J. Germain, President, M & G, Inc., authenticated this ? c, day of November, 1998. t Kristin Ogland TITLE: MEMBER STATE BAR OF WISCONSIN THIS INSTRUMENT WAS DRAFTED BY: Attorney Kristina Ogland Hudson, WI 54016 Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services 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 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. # DzB — 118D —ID —Clnc( APPLICANT INFORMATION - Please print all information Re 'awed by Date m Personal infoiation you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 7 I * / & /9 b Property Ow Owner Property Location r Govt. Lot — 1/4 1/4,S T ,N,R X(or)9 Property Owner's Mailing Address Lot # Bock Subd. Name or CS G "k City Sta Zip Code Phone Number ❑ City ❑ vil ® Town Nearest Road ( ) New Construction Use: go Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow : j/� gpd Recommended design loading rate - r bed, gpd/W 6 trench, gpdJ* Absorption area required C V bed, ft trench, it 2 Maximum design loading rate bed, gpolfl • � trench, gpd* Recommended infiltration surface elevations) ft (as referred to site plan benchmark) Additional design/she considerations Parent material QW& AjuZ Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holding Tank U = unsuitable for system S❑ U 14 s❑ U M S ❑ U [4 s F U ❑ s ®U ❑ s Lou SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground 3 AdJ . elev. - Depth to limiting factor Remarks: Boling # s 13 7: _ • Ground c elev. qq LQ3.2ft• 1 Depth to limiting factor Z21in. Rem rks: CST Name (PI Print Signature Telephone No. s Add Date CST Number Dominant Wor NMI - :• • .ornlnsnt Cu l O rE l Munvell II .. �� ��rrrr■�r V 4 ' �a << i 1 3 ,,, \ 0 2 CD � j 2 � \ to @ � o K 0 A � p � ( � § � . § � ƒ 0 z / $ k Z ) � \ � 7 � «_ $ � � \ \ E ® § . z / f § z � ) z C . � � k k 7 / / .N © % 2 C -� § ) / D �� k k Q k k I z 0 k// \ 0 .. g E E > 2 LO) \ J ! g §f 2 z 0 D a )` R ( k ) a b � - m 2 2 2 .0 � § 2] v N k CO - ) _ LO m o § § & e 8 8 G I B _) o E Q// [ \ c a. v G ) k 4 ƒ ƒ 2 ■ , . § k 2 & E O Cl) § 2 a && c a I k 8 a o = d co o e = � o k a) ` c -in- @ 2 a a= , 2 § 6 § § ) 3 ) f § v - 3 § b k 7§ o z$)� a 2 a , 2 (D , f E 0) o k k WS/ aojeajsiuiwpy SuiuoZ luelsissy aasu 3 po 'Alai auiS '089tb (5 LL) Ie aaijjo ino 1aeIuoa aseald 'sigj SuipiuSai suoilsanb Aue aneq nog( jI - awoq wooipaq (£) aaagI a joj jueildwoa apoa aq of punoj seen walsAs aildas sigl 'uoipadsui aqj jo awil aqj Iy - uisuoasiM 'AlunOD xiaD "IS 'aiaiead MIS Jo unnol 'pua8 aani�l olddy Jo Z£ 1 'M9LN L£1 'S L uoiPaS J o ' /MS a4; jo 1 Yt3N aqj ui paleaol si /qaadoid sigl '966 L 1 1 7 Z aagopp uo papnpuoa seen Apadad paauaaa;aa anoge aqj }o uopadsui aildas d :aj!w aeaQ uisuoasiM 'Aluno:) xioa:) -IS 'apie.ad ae }S jo unnol 'puag aanll alddd }o Z£ jol'anuaAV gjztZ ZvLl le pa;eaol -auk 0 7g W aoj uoijaadsuj a1;daS :311 SZObS IM 'Iasiawos U1eW £OL uiewja!D aj!w :u:Ry AIleaN L weal xewa 9661 '9l iagwanoN 089V-985 (9I.L) OUL-9LM IM 'uospnH P Ieg4 W L l floss ■�� N r M �� 1 u31N301N3NNU3A0J Jl1 noo XIOuo '.is 331:1:10 ONINOZ NFSNOOSIN1 AINnoo *-Ls ' S.I.• CROIX COON "I'Y ZONING DEPAR "I'MEN .4 AS GUILT SANITARY RE110It'1' A'TF'VED Owner Address 1 jy I f4o$ 37 CROIx City /State ,> �•.;,` CoU►v71'Y Legal Description� Lot Block Subdivision/CSM It '/• ,> '/, —I , Sec. 4:5 TAN -RAW, Town of ' - PIN # SEPTIC TANK — DOSE CLAMBER — BOLDING TANK INFORIVIATION: 15 31. 1 g. Z Tank manufacturer Size ST/PC le& / Setback from: House L Well P/L / Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: Wid /2 Length �_ Number of Trenches Setback from: House Well P/L - Vent to fresh air intake ' ELEVATIONS: Description of benchmark „�� Description of alternate benchmark Elevation Elevation Building Sewer ST/HT Inlet ST Outlet- L4/L- PC Inlet PC Bottom _ Header/Manifold Top of ST/PC Manhole Cover /, 9 Distribution Lines ( ) e Z Bottom of System ( ) q� 7/ ( ) ( ) Final Grade ( ) 1,2 7 /_ ( ) ( ) Date of installation &� l Pc snit number - ,Z - 20.2 9/ State plan number r Plumber's signature License number '/- / Date/ Y / Inspector complctc plot plan •� Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Count • ,Safety and Buildings Division y ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitari.: Personal information you provice may be used for secondary purposes [Privacy Lty, s.15.04 (1)(m)). Per& its I�kCName: � j a[ g o Elev 1 v..: CC wn of: State Plan ID No.: CST BM Insp. BM Elev.: BM Description: Y Parcel b�,3W-�1180- 10-000 tve� L — , ro t% i TANK INFORMATION ELEVATION DATA A9800479 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic VJ (QS 1 ooD Benc ma k I' 63 (qg(,3 /coo Dosing dam l eiS'. Aerati Bldg. Sewer Holding St Inlet 6 lc: ,/,67 TANK SETBACK INFORMATION a+V Outlet w TANK TO P/ L WELL BLDG. Atake ROAD Dt Inlet Se tic Sa' �+� q ► 8' q NA Dt Bottom Dosing rN Header /Man. $��( c-?'�.7�. Aerati n Dist. Pipe g( 99. 617 Holding Bot. System `1,9a q8 PUMP / SIPHON INFORMATION Final Grade Manufacturer - Demand W , S' l oo?- Model Number GPM TDH ift Friction S s TDH Ft FOrce a Dld. Dist. To Well SOIL ABSORPTION SYSTEM BENCH Width Length No. Of Trenches PIT No.O Liquid Depth D N 1 N 12 SSA DIM EN I N nufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM L G Ma CHAMBER mod Number: INFORMATION Type Of - � OR UNIT System DISTRIBUTION SYSTEM Header / M// Sc}' nifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length V� Dia. 4' Length Dia. A Spacing 9c-4 0 t I - Z-7-Lck SF� SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil E] Yes E] No E] Yes E] No COMMENTS: (Include code discrepancies, persons present; etc.) LOCATION: STAR PRAIRIE 15.31.18,NE,SW 1142 212TH AVENUE to Plan Sv requlreti? ❑ Yes YNo r7 Q Use other side for additional information. SBD 6710 (R.3197) Date Inspe . 's Signature Ce No. Safety and Buildings Division SANITARY PERMIT APPLICATION 2 01 W. Washington Avenue %6onsin P O Box 7302 Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. ' • See reverse side for instructions for completing this application State Sanitary Permit Number 3ZoLj i Personal information you provide may be used for secondary purposes ❑ Check if revision to previou§ application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property wner Name Property Location 114 - T m j 114, 5 T , N, R jip IV (or Property Owner's Mailing Address Lot Number Block Numb N! 3 City, tate Zip Code Phone Number Su bdivisi on Nam or C M Nu ber r ( ) . TYPE BUILDING: (check one) ❑ State Owned - No. Nearest Road Public 1 or 2 Family Dwelling No. of bedrooms ❑ Ig Town OF III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) Q38- 1 ❑ Apartment/ Condo 0-T,? _ 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, Ig New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ 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 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit Z >< 55 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Pate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /' ch) Elevation >` "D Feet Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel Plastic p New Existin structed glass App. Tanks Tanks Sep Ic Tank -- — ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber I ❑ ❑ ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the dersigned, assume responsibility for insta tion of the onsite sewage system shown on the attached plans. Plum s Nam : (P Plumber' ature: Sta MP /MPRSW No.: Business Phone Number: Plumber's Address (Str City, !ate, Zip C ): S IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sani ary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps) A roved Ol / 4 8 L� pp []Owner Given Initial Surcharge Fee) � �U ���� I / 6 � �� Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: original to County, One copy To: Safety & Buildings Division, Owner, Plumber y /J .8.� `fit!- �,� af,�� s-�✓,�, / e .� /G�, o _ 0+ •� ,�,�c� �l.�ilt �� o� � ,�o»C� , a ,,; fil , /6S` Ste? �d ge Tt z� � p 6L s �� gi Wisconsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page of Bureau of Integrated Services 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 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 02 6 — 118D APPLICANT INFORMATION - Please print all information R by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Govt. Lot 1/4 1 /4,S T N,R ,8(orYQ Property Owner's Mailing Address Lot # Bock Sub d_. Name or CS # City Stat Zip Code Phone Number El city E] Vill e ® Town Nearest Road ) '� New Construction Use: Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate bed, gpd /ft 88 trench, gpd /ft Absorption area required bed, ft trench, ft Maximum design loading rate -7 bed, gpd /ft • `S trench, gpd /ft Recommended infiltration surface elevation(s) I ft (as referred to site plan benchmark) Additional design /site considerations Parent material 0r 4s / Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system S❑ U us ❑ U lK S❑ U [4S El U I ❑ S ®U ❑ S © U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ground 1 elev. / s- — 041 Depth to limiting factor in. Remarks: Boring # / s Ground elev. eft. Depth to limiting factor Z -Min. Rem rks: CST Name (Plea Print Signature - Telephone No. Address L Date CST Number �� � ,�'�� /Y,� l - s� %y sec /S = 7 �/$ lil y As of •� F%Knlc�✓ �f.,�ilt' l�i� a���wo��;r,.� ay.! /s�S, /OS`, So? /D 98 i a !I a� 3 t .. 93' Safety And Department i Commerce PRIVATE SEWAGE SYSTEM Count .. Safety nd Buildings Division ST . CROIX INSPECTION REPORT 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)). 320243 Permit Holder's Name: ❑ t Villa I Town of: State Plan ID No.: M & G INC. S, CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 038- 1180 -10 -000 TANK INFORMATION ELEVATION DATA A9800439 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet Air I Septic NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction I System TDH Ft Forcemain Length Dia. Fi Dist. Towel] SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION - T - y - pe - 07 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 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes [] No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: STAR PRAIRIE 15.31.18,NE,SW 1142 212TH AVENUE Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No. V i sconsin SANITARY PERMIT APPLICATION 20j E �� �n De sion Code In accord with ILHR 83.05, Wis. Ad m. P.O. Box WI Department of Commerce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 81/2 x 11 inches in size. s' • See reverse side for instructions for completing this application State Sani ryPermit N The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Ow Der Namp Property Location 1/4 1/4, S S T3 , N, R 40 Property Owner's Mailing Addryps Lot Number Block Number City a e ��'' Zip Code Phone Number Subdivis n N me o M Nu er II. TYPE F ILDIN (check one) ❑ State Owned ❑ it Nearest Road 3 ❑ Village El Public 1 or 2 Family Dwelling - No. of bedrooms Town OF s III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) ��� // - ~moo 1 ❑ Apartment/ Condo �� 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. Z New 2_ ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5, ❑ Repair of an ______System ________System Tank Only Existing System Existin�5 stem B) [ Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 jo Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage 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 4. Loading Rate 5 1 I Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (,� k�L vv� i t levation j 1 7 / Feet VII. TANK Capacity (�1 �, �(, 0d in gallons Total # of er. �� �� Ex INFORMATION New Existing Gallons Tanks Manufacturer's Nai ✓� � Plastic APp Tanks Tanks 10 Septic Tank or Holding Tank — ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ Li I t__I ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, t e undersigned, assume responsibility for in allati n of he onsite sewage system shown on the attached plans. Plu b s Na e: ( t) Plum is rn (N t p) MP /MPRSW No.: Business Phone Number: 1 21 3 s Plumbe s Addre (street City, S a , Zip Cod ): IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature (No Stamps)' � Approvecl surcharge Fee) ❑ Owner Given Initial Adverse Determination Z X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -8388 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, plumber .� �� � z,�G �/� / s� — ,sw %y � sic /� r�ir✓ — �'i�� ,a r sxal7 ca mss' i j/orlF�E �AG1i9E �JkM/i}�i sly// W , Labor con en Human tn Sales ne Role of Industry SOIL AND SITE EVALUATION REPORT page / 3 ations Division of 3efety a 8uiidings In accord with II-HR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x t t inches in size. Plan must i `, �'!' r.. C R O 1' K not limited to vertical and horizontal reference point (8M), direction and % of slope, ARCEL D. # dimensioned, north arrow, and location and distance to nearest road. r APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION ' L REVIEWED BY DATE cam. PROPERTY OWNER: PRO LOCy1 Ci. `y k'i'G A/?D Sro v T G �f4 1 /4,S /�.� � N p /� PROPERTY OWN R':S MAILING ADDRESS ' ' E i 3 1 3 w.4 7 k�� TIP. WT sI Ic # # CITY, STATE , �S ZIP CODE PHONE NUMBER [)CITY NEAREST ROAD �� sow syof� (��s)sg4- (v731 r AD (�ew Construction Use 141 tesidenlial I Number of I6drooms .3 +o 11 Replacement YS o_ Public or commercial describe 1 Addition b existing buckling Code derived daily Flow ' o& gpd Recommended design loading rate - 7 bed 2 Absorption area r 2 ' gI try' gP� p e"red bed, fl trench, ft Maximum design baring rate ' 7 bed, gpolft ' g trench, WW Infiltration surface elevations) SE 3 ft (as referred b site plan , gpd/ mark) NJ Additional design ! site cons rations Parent material $CS I 1 9,M 7-- Flood plai elevation, Fl applicable n rUU7ns ble tot System CoNV�Ni❑ U L MOON N o 0 PRESSURE AT-G U SYS iN FILL FpL01�p ru�ecc uitable for stem Las f ❑ U p RO p U L p U O S fed' SOIL DESCRIPTION REPORT 4 '12 = ,voi ,PE�oHp�,vfJ�c� Boring # [Horizon Depth Dominant Color Mottles Texture Structure GPD /ft In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh.� Roots Bed y,� 3/y s. �.e s ,� f 17 , Ground elev. /o y, & tt. Depth to limiting factor Remarks: Boring # Z ..... Z cs 77 Ground 3 _ 5 elev. Depth to limiting factor Remarks: T Name: Please Print Address: Phone: !' g Signature: U16ficht rl - tl. � Private Sewsas Consultants Date: CST Number: r - jc 107 3.2- /0010 ' 3Z �S 3' �z to3,sso I� 3 0 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERS14I PCERTIFICATION FORM Owner/Buyer n � `�,,, Mailing Address P-0. 4-08 Property Address I I `f 'a t 3, H A V- (Verification required from Planning Department for new construction) City /State , ` Parcel Identification Number e ?,q - //o ,moo -Din LE GAL DESCRIPTION Property Location _ '/4, 5 &j '/4, Sec. 1,5 T -R Town of Subdivision 2L ?E 1�� J � ,Lot # _ Certified Survey Map # , Volume , Page # Warranty Deed # ��`- l �y� , Volume ��5 y , Page # 1 42 Spec house DO yes ❑ no Lot lines identifiable 14 yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, 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 Zoning Office within 30 days of th three ear a iration date. Q q il/IY� / SI NA E F APPLICANT DATE; OWNER CERTIFICATION I (we) certify that all statements on This form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the prope des ribed abAe, by virtue of a warranty deed recorded in Register of Deeds Office. �� p 7 SI NA APPLICANT DATE * " * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed VOL Y35 PAcdn9 STATE BAR OF WISCONSIN FORM 2 — 1982 II 586,3 II WARRANTY DEED I � DOCUMENT NO. II ij - -- -- - 1 i - RICHARD n- qrPnT7rV j CY. C (IX Cp ji �i.41i s� �r nly6Farii� I) I SEP 0 1998 conveys and warrants to M &S, INC. i i Re istor of Deeds i , THIS SPACE RESERVED FOR RECORDING DATA j� NAME AND RETURN ADDRESS the following described real estate in St. ro i x County, j State of Wisconsin: I� Lot 32, Plat of Apple giver Bend First ` Z{/ S'VO�fo Addition, Town of Star Prairie, St. Croix ' County, Wisconsin. j �3�= 116 U =10- — 038 - 1 fln- 20 -oon II PARCEL IDENTIFICATION NUMBER V i i, TR��ISFER II � � I I i F E I I i L This i s not homestead property. (is) (is not) Exception to warranties: easements, restrictions, rights -of -way and covenants ii of record, if any. I II Dated this 31st day of August A.D., 19 i i� Richard 0. Stout (SEAL) (SEAL) li * II (SEAL) (SEAL) it �I t! I, AUTHENTICATION ACKNOWLEDGMENT State of Wisconsin i Signature(s) , " ss. I St. Croix County aurhPntirararl rhic 'I nF I n APPLE RiVil--l? BEND LOCATED IN FMRT OF THE NW1147 OF 7 HE swol, I-AF? I Of I t-IE svvl/- 0' 1, t- � I Ut I tft- :�)t I/', Ut 111L J U I I 1 -1 NE114 OF THE SWI/4 AND IN PART OF THE NWI/4 OF THE SEI114 4L 1. 1,%' EC TION 15, T�/N, R18w, TOWN OF STAR PRAIRIE, ST CROIX COUNTY, WISCONSIN. o . T, LOT 27 LOT 26 LOT 39 2 54 -c a E 4 6..G65 SO IT LOT ;85 LOT 28 'o, -...Z 1. F1 I IQ IT LOT 91. IQ IT IN 38 2 �2 AC, p T 21 8 -6 IT 1 1 E-c LOT 291" S� Fl/ . IL 12,9. . FT Ile oI 23 v � 1 71 1 LOT 37 �., ;11 11 al t 4�> 'go 11.7 Io a, -c q., ws so 5b /I LOT 30 01 _L �9 LOT' 22 ',,j .3 E I 'IT 5 LEGEND ED[ o LOT 36 a5'!4 37-� 384 9' E LOT 31 4 �I. E F FT -1-1 F Z I p —.1 E 5 16' LOT 20 c)f LOT 35 'TE I C1 �E 1X -z c rj, o LOT, LOT 32 �c 1 31. 11 I � 12� 2 1 SC j, 33 uj LOT 34 7 k 2� 15 NIJ I V - sconsin Safety and Buildings Division SANITARY PERMIT APPLICATION 2 1 B W shingtonAvenue Departtnent of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 e 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.'" ✓ 1 . r P r 0 See reverse side for instructions for completing this application State Sanit e mit Number Personal information you provide may be used for secondary purposes ❑ Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)). State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property Owner Name Property Location (Or W 1 /4 r-- 1/4, S T , N, R r r' Property Owner's Mailing Addres Lot Number Block Numt)er City tate f Zip Code Phone Number Subdivision Na a or CSM Number IL E F B ILDIN : (check one) ❑ State Owned it� Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms _J Town OF —/{ / - III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)�� s _ ✓1 ?�� 1 ❑ Apartment/ Condo 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. ID New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ------ -------- System Tank Only __ y Existing System Exlstl System ______ ____ _ ___ g y_________ n� 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 R] Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage 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 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.), (Gals/day /sq. ft.) (Min ./�r'1ch) Elevation - - Co C / Feet > Feet Capacit VII. TANK in Ca gallo s Total # of Prefab. site Fiber- plastic Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App. New Existing structed Tanks Tank Septic Tan /' a 1 /./� ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 1 ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the ndersigned, assume responsibility for inst4jilation of the onsite sewage system shown on the attached plans. Plumb s Nam ((Print) Plum ber'_5 ature: Starfrps) MP /MPRSW No.: Business Phone Number: Plumbers Addre3s Street, city, tate, Zip Cq¢e) IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater D ate I ssued Issuing Agent Signature (No Stamps) ❑ Approved E] Owner Given Initial surcharge Feet Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.1. DISTRIBUTION: Original to County. One copy To: Safety 4 Buildings Division, Owner, Plumber FAX ST. CROIX COUNTY ZONING OFFICE 1101 Carmichael Road Hudson, WI 54016 (715) 386 -4680 DATE: //- /G� - TO: Fax Number. Name: FROM: Fax Number. 386 -4686 Name: Number of Pages Including Cover Sheet IF COMPLETE AND LEGIBLE INFORMATION IS NOT RECEIVED, PLEASE CONTACT: NAME: TELEPHONE NUMBER: �� �� 0 Cl/