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HomeMy WebLinkAbout032-2157-10-000 (4)County Industry Services Division St. Croix p $ 1400 E Washington Ave Sanitary permit Number (to be filled in by Co.) P P.O. Box 7162 S _ Madison, WI 53707-7162 Sanitary Permit Application State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address (if different than mailing address) purposes in accordance with the Privacy Law, s. l5. 1 m Stats. 882 1671h Ave I. Application Information — Please Print All Information Property Owner's Name Parcel # Daniel & Kari Rae Sikkink 032-2157-10-000 Property Owner's Mailing Address Property Location 882 167t° Ave Govt. Lot NE'/., NE'/., Section 12 City, State Zip Code Phone Number New Richmond, WI 54017 rcie one T30N R19Eor� H. Type of Building (check all that apply) Lot # Subdivision Name ® 1 or 2 Family Dwelling — Number of Bedrooms ID 11 The Highlands Block # ❑ Public/Commercial— Describe Use ❑ City of ❑ State Owned — Describe Use ❑Village of CSMNumber ® Town of Somerset all. Type of Permit: Check only one box on line A. Complete line B if applicable) A. ❑ New System 0 Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner 42995 fV. Type of POWTS System/Component/Device: Check all thatapply) ® 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 (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation 750 Rate(gpdsf) 1071 1125 93.80' 0.7 VI. Tank Info Capacity in Gallons Total # of Manufacturer '� 2 U New Tanks Existing Tanks Gallons Units o o U B 2 :? H rn i2 w 0 C. Septic or Holding Tank 750 1000 1750 2 Weiser Concrete/Weeks ® ❑ ❑ ❑ ❑ Dosing Chamber El I ❑ El ❑ VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) 9 MP/MPRS Number Business Phone Number John Schmitt223760 nX;re/ X(J 715-760-0486 Plumber's Address (Street, City, State, Zip Code) 586 Valley View Trail, Somerset, W154025 VIll. County/Department Use Only ❑ Approved ❑ Disapproved Permit Fee 1 Date Issued Issuing Agent Signature ❑ Owner Given Reason for Denial $ UC. Conditions of Approval/Reasons for Disapproval Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x I I inches in size SBD-6398 (R03/14) CONVENTIONAL COMPONENT DESIGN esi,i�.;,;•y,�l;lic�ation INDEX AND TITLE PAGE Project Name: Sikkink 5 Bedroom Replacement Septic System Owners Name: Daniel & Kari Rae Sikkink Owner's Address 882 176th Ave New Richmond, WI 54017 Legal Description: NE1/4, NE1/4, S12, T30N, R19W Township Somerset County: St. Croix Subdivision Name: The Highlands Lot Number: 11 Block Number Parcel I.D. Number 032-2157-10-000 Plan Transaction No. Page 1 Index and title Page 2 Plot Plan Page 3 Existing Septic Tank Specifications Page 4 Existing Tank Certification Page 5 Existing Effluent Filter Information Page 6 Proposed Septic Tank Specifications Page 7 Proposed Effluenrt Filter Information Page 8 System Sizing & Cross Section Page 9 EZ Flow Information Page 10 Management and contingency plan Page 11 Sanitary System Ownership/Address Form Page 12 Warranty Deed Page 13 CSM or Plat Attachment 1 Soil Evaluation Report Designer: John Schmitt Date: 9/5/2023 Signature: 7I Licnese Number: MPRS 223760 Phone Number: 715-760-0486 Page 1 . t isconsin commerc Department of Commerce February 16, 2010 WEEKS CONCRETE PRODUCTS RAY WEEKS 1832 215TH STREET NEW RICHMOND WI 54017 SAFETY AND BUILDINGS DIVISION Plumbing Product Review P.O. Box 2658 Madison, Wisconsin 53701-2658 TTY: Contact Through Relay Jim Doyle, Governor Richard J. Leinenkugel, Secretary Re: Description: SEWAGE TANKS, CONCRETE Manufacturer: WEEKS CONCRETE PRODUCTS Product Name: SEPTIC, HOLDING, OR PUMP Model Number(s): 1000 (49 IN. L.L., 21.76 GAL/IN., 84 IN .MAX. DEPTH OF BURY 511 G.P.D. WHEN USED AS A SEPTIC TANK BASED ON A 3 YR. SERVICE INTERVAL FOR RESIDENTIAL WASTEWATER;. TANK DIMENSIONS = 84 IN. L X IN. W X 49 IN. H ) Product File No: 20100040 The specifications and/or plans for this plumbing product have been reviewed and determined to be in compliance with chapters Comm 82 through 84, Wisconsin Administrative Code, and Chapters 145 and 160, Wisconsin Statutes. The Department hereby issues an approval based on the Wisconsin Statutes and the Wisconsin Administrative Code. This approval is valid until the end of JUNE 2015. This approval is contingent upon compliance with the following stipulation(s): This tank must be designed to withstand the pressures to which it will be subjected. The manufacturer must keep at the manufacturing plant a set of plans and specifications bearing the department's stamp of approval. The plans and specifications must be open to inspection by an authorized representative of the department. When this product receives wastewater from dwellings and is used as a septic tank, it will produce an effluent quality with a maximum monthly average value for BOD5 of greater than 30 mg/L and less than or equal to 220 mg/L TSS, or greater than 30 mg/L or less than or equal to 150 mg/L TSS, and F.O.G. of less than 30 mg/L. Approval is issued for this product as being equivalent to a floor outlet water closet when the fixture drain is installed in the vertical position. The design meets the intent of s. Comm 82.32 (5) (c) and 84.20 (5) (n), Wis. Adm. Code, which requires water closets to discharge through a minimum diameter 3" drain pipe or fitting and the bowl to conform to ANSI Standard Al 12.19.2M. The intent of the code is met since this product provides the same functional performance as water closets that meet ANSI Standard Al 12.19.2M. BEDDING: Bedding material shall be used to provide a uniform bearing surface. A min. of 4-inch base of sand or granular bed on top of a form and uniform base is recommended. The tank should not bear on rocks. Sites with high ground water tables should have specially designed bedding. Soils should be compacted under the tank. This approval supersedes the approval issued on 4/21/2005 under product file number 20050106. This approval letter shall be incorporated with your previously approved plans and/or specifications approved under product file number 20050106. As of May 15, 2008, a copy of a successful water tightness test report for this product must be AVAILABLE FOR INSPECTION AT THE MANUFACTURER'S PLANT prior to this product being used as a POWTS holding or treatment tank in Wisconsin. The department is in no way endorsing this product or any advertising, and is not responsible for any situation which may result from its use. Sincerely, Jean M. MacCubbin, CST Engineering Consultant --Plumbing Product Reviewer Commerce; Safety & Buildings Div.; PO Box 2658; 201 W Washington Ave.; Madison WI 53703-2658 Phone: 608-266-0955; Fax: 608-263-7456; E-mail: Jean, MacCubbin@wisconsin,gov SBD-10564-E IN.10/97) File Ref; 1%va.Doc PAGE 2 of 2 The interval for servicing septic tanks is set by state and local code. Throughout the United States, there is a wide difference of opinion on what this interval should be, but most regulatory agencies suggest two to five years. The Zabel filter, which does not increase the frequency of servicing for the tank, should be cleaned when the septic tank is normally inspected and pumped. However, our filter is virtually self-cleaning. The continued action of the anaerobic organisms on the Zabel filter causes lodged particles to disintegrate and fall to the bottom of the tank. If your filter contains a SmartFilter® alarm, you will be notified by an alarm when the filter needs servicing. Step 1: Locate the outlet of the septic tank and remove the tank cover. Step 4: While holding the cartridge over the access opening, rinse off the cartridge with fresh water, being careful to rinse all septage material back into the tank. Step 2: Remove the tank cover and pump the tank if necessary to prevent any solids from escaping to the the drain field when the filter is removed. Step 5: Insert the filter cartridge back in the case, making sure the filter cartridge is properly aligned and completely inserted in the case. Replace the septic tank cover. Step 2: Firmly pull the filter handle and slide the cartridge out of the case. (a Residential Applications Certified to ANSUNSF Standard 46 Copyright 2014, Polylok, Inc. All rights reserved Product(s) covered by one or more U.S. and/or International patents. Other U. S. and International patents may be pending 1-877-765-9565 / www.polylok.com page 4 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)882167th Ave located at: NE 1/a, NE 1/a, Section 12 , Town 30 N, Range 19 W, Town of Somerset , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? (if no, skip next line.) Approximate volume or length of time: Tank Capacity: 1000 Construction: Prefab Concrete X Steel Manufacturer (if known): Weeks Age of Tank (if known): 5/20/2003 Permit number (if known) 429995 Yes No gallons Other John Schmitt (Licensed Plumber Signature) (Print Name) MPRS 223760 (Title) (Date) minutes (License Number) MP/MPRS Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 Page 5 Jw-OSLdIm :3�1-J 99t8—SZ�-008 :anOd-iSOd 00/00/00 :31V0 09L4S M 'NOON N301VW 'OL AMH Sn 9LL?�bfVbW 01d3S w dOM :A9 NMVHG 8nod-38d :31va n38 .0-L a�VOs 3130BUDO 13531 8W-05LdIM cl w LU Li N z J in Y J cr H Q O � 0 N m w co O w J O d W Q oCL cc U w o w m ,�I l/ I Q O w�Ncapm aa K a N HQ¢ >a w LL Q =OO JU Z C wO W ZjD_ O O U I J O0) W W o rJ�LL Q W mw�N \ ww w Y o nN Cf)m F N_CO o F=w HLj W O z YG 0 ¢ a d �w WO WN WNF- LLI } Wa NJ �C� Z Y \ihc N�¢J>N OQ O Fa- ~ YOa U w= 0OW FaO z N N N J N W Z J O O O N N d Za 2 J W m\ X O w O Q O O = 2 a 3 O= Z Q Z O w V W? Q Q N U ���`'z2� -_j5 � ao ao fir- Ua 2o_ Za00aw�wa' �= FNO O no(-) o Yvwi o Y oQ w mU�xom�w3 w� L'i J a z z z C'l 0 o a o a � p - - J m J H U H U J Q W N I Q I H N Q U ,L a36 n038 Sd „i N H z W W CY W w rr N N I U N a O W W U X W w O Ld - w O H O W U a z a w Page 6 P0LYA0N0kX---lnc. Innovations in Precast Drainage " Zabel" & Wastewater Products V A Division of PoMok Inc. PL-525 Filter PL-525 Effluent Filter The PL-525 Filter is rated for 10,000 GPD (gallons per day) making it one of the largest filters in its class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the Polylok PL-525 has an automatic shut-off ball installed with every filter. When the filter is removed for cleaning, the ball will float up and temporarily shut off the system so the effluent wori t leave the tank. Features: • Rated for 10,000 GPD (gallons per day). • 525 linear feet of 1/16" filtration. • Accepts 4" and 6" SCHD 40 pipe. • Built in gas deflector. • Automatic shut-off ball when filter is removed. • Alarm accessibility. • Accepts PVC extension handle. PL-525 Installation: Ideal for residential and commercial waste flows up to 10,000 gallons per day (GPD). 1. Locate the outlet of the septic tank. 2. Remove the tank cover and pump tank if necessary. 3. Glue the filter housing to the 4" or 6" outlet pipe. If the filter is not centered under the access opening use a Polylok Extend & Lok or piece of pipe to center filter. 4. Insert the PL-525 filter into its housing. 5. Replace and secure the septic tank cover. PL-525 Maintenance: The PL-525 Effluent Filters will operate efficiently for several years under normal conditions before requiring cleaning. It is recommended that the filter be cleaned every time the tank is pumped, or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be done by a certified septic tank pumper or installer. 1. Locate the outlet of the septic tank. 2. Remove tank cover and pump tank if necessary. 3. Do not use plumbing when filter is removed. 4. Pull PL-525 cartridge out of the housing. 5. Hose off filter over the septic tank. Make sure all solids fall back into septic tank. 6. Insert the filter cartridge back into the housing making sure the filter is properly aligned and completely inserted. 7. Replace and secure septic tank cover. 1/16" Filtration Slots 10,000 GPD Accepts 4" & 6" SCHD 40 pipe Outdoor SmartFilter® Alarm Polylok, Zabel & Best filters accept the SmartFilter® switch and alarm. Alarm Switch (Optional) A^cepts 1" PVC tension Handle Rated for 10,000 GPD 525 Linear Ft. of 1/16" Filtration Slots Certified to NSF/ANSI Standard 46 Gas Deflector Automatic Shut-0ff Ball Extend & LokTTM Easily installs into existing tanks. Polylok, Inc. 3 Fairfield Blvd. Wallingford, CT 06492 Toll Free: 877.765.9565 Fax: 203.284.8514 www.polylok.com Page 7 U LO 7 7 U m C C m ~ rn « — LL 0 U Q cF -U a c O W 0 o W ii Y O c o N w N Q C m U � O N � r� E W +(n 'cn - Q c U a) N Z 0 D{='M �o C3 W z � � Q N U) v 0 V) L $ U colC C C: C E a) 10 3.2 2 <L co a - a) on = W Z > Z W O U U UWj Z U) Of U m > O w C7 h U t O hm C m N C 4 U �C J Q 'c crT U. E 0 Fm, — r � con H W Lu CL Z :. 'y O m U 1 e w a— 0 € S U)3m m amm (zir m U .g d rn �m�r 0 U m � N .Q a- O m on ca L U C .. w O J m c Q m ' C m 0 ° a C C e 0 0 .0 � c I c m m 0 0 I U rn a I a M 0) I c O t—Lo I O M u T I 0) Qi N .Q �' I � f0 L IL i a� I— N a) L � � I = a' U CO Z�^ c v s JZU) m a) Liz w a. a. t PAGE 3 OF 4 coi C 0 U c C O E i m U In M (+M > C I - m I I n a� o N i I o I I I w a v :3 E a MI NCoo) Cool w w LO U') N a a on on c c 0 7 mo O t!j 0 .0 N I_ X O 0 0 5 � on a= a✓ I- ti M I I L U C a Q C0 w on a 0 a` I I M Page 8 Installation Instructions for E ZTM EZflow Systems in Wisconsin FI ........................................................................................... Wisconsin Department of Commerce, Safety and Buildings 5. The Absorption area (SF) necessary for a given site shall Division, has reviewed the specifications and/or plans for this be sized based on maximum daily sewage flow (GPD) and product and determined it to be in compliance with chapters the Permeability for the site. If certain criteria is met, the Comm 82 through 84, Wisconsin Admin. Code, and Chapters : EISA sizing can be used in Wisconsin, resulting in a 40% 145 and 160, Wisconsin Statutes. All sites must meet the Site smaller drainfield. & Soil Conditions & Locations & Isolation distances as noted in local regulations. 6. Place EZflow bundle(s) in the EZflow configuration ap- proved by system design permit specified for the particu- The approved products are 1203H (3-12" bundles with pipe in lar site. The top or center -most bundles containing pipe center bundle in 5' or 10' lengths) and 1203HP (3-12" bundles are joined end to end with an internal pipe coupler. Any with pipe in each bundle in 5' or 10' lengths. additional aggregate only bundles that may be required, should be butted against the other aggregate -only bun - A single pipe bundle contains a four inch perforated pipe sur- dies and do not require any type of connection. rounded by EPS aggregate and is held together with poly- ehtylene netting. A single aggregate bundle contains aggregate 7. The top of each GEO cylinder contains a filter fabric pre - only and is held together with polyethylene netting. manufactured in between the netting and aggregate. The fabric is inserted to prevent soil intrusion. The installer Materials and Equipment Needed shall make sure the the GEO is positioned upward and is • EZflow Bundles in contact with the fabric contained in the adjacent cylin- • EZflow Geotextile Fabric der before backfilling. • EZflow Internal Pipe Couplers • Pipe for Header and Inlet : 8. The EZflow Drainfield Systems should be installed in a • Backhoe/Excavator level trench in all directions (both across and along the ' trench bottom) and should follow the contour of the ground Installation Instructions surface elevation (uniform depth), with all continuous The instructions for installation of EZflow products are given adjoining 10-foot cylindrical bundles placed end to end, below. This product must be installed in accordance with state : with central bundle distribution pipe interconnected, rules defined in chapters Comm 82 through 84, Wisconsin Ad- : without any dams, stepdowns or other water stops. ministrative Code, and Chapters 145 and 160, Wisconsin Stat- utes, as well as the local health department's current design 9. The trench top shall be graded such that water will not manual. pond. Backfill should be seeded or sodded immediately after completion to reduce erosion. 1. After the local health department has determined sizing, configuration, and layout for the EZflow systems, stake 10. EZflow EPS bundles are flexible and can fit in curved or mark with paint the location of trenches and lines. Be trenches as may be necessary to avoid trees, boulders, or careful to set correct tank, invert pipe, header line or dis- other obstacles. tribution box and trench bottom elevations before instal- lation of pipe bundles. 1 1. EPS aggregate is lighter than water, therefore, it might • be expected that natural buoyancy forces would tend to 2. Remove plastic EZflow shipping bags prior to placing cause EZflow assemblies to float out of ground when bundles in the trench(es). Remove any plastic bags in the ponding occurs. Field experience has shown, however, trench before system is covered. that this is not a problem when systems have a minimum • of 6" of soil cover as recommended by manufacturer. 3. This product must have geotextile fabric that meets re- quirements of s. Comm 84.30 (6) (9), Wis. Adm. Code, installed directly on top of the product and extending 1203H-GEO down along the sides of the product to a point at least six inches from the bottom of product. — Geotextile 'VJ Barrier Material 4. When installed in a trench, the trench should be dug to o a width of 36 inches. This not only saves labor in excava- tion, but also provides better load -bearing capacity after ' backfilling is complete. : 36" ...................................................................... ................. Page 9 PAGE 4OF4 In -ground Gravity Management Plan IMPORTANT: The owner of this in -ground gravity system shall be responsible for its perpetual operation and maintenance pursuant to requirements of SPS 382-384, Wisc. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall be considered a human health hazard if not maintained in accordance with this approved management plan. Furthermore, all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in accordance with SPS 383.52 (3), Wisc. Admin. Code. Maximum Dispersal Area Operating Limits: Design Flow = 750 gpd; BOD5 <- 220 mgL"; TSS :5150 mgL"'; FOG <- 30 mgL"' Inspection Checklist INSPECT EVERY 3 YEARS o type of use c age of system o nuisance factors (i.e. odors, user complaints, etc.) o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.) o material fatigue (i.e., leaks, breaks, corrosion, etc.) o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes) o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.) o extent of ponding in distribution cell prior to dosing o dosing irregularities - if applicable (i.e., pump re -cycling, float switch settings, etc.) o electrical components - if applicable (i.e., wiring, connections, switches, controls, timers, alarms, etc.) o distribution lateral or lateral orifice plugging (measure lateral distal pressure — compare to design specification) o surface discharge of effluent or sewage back-up into structure served Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary) o Septic and dose tank(s) shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis. Stats. when the volume of solids in the tank(s) exceeds one-third (1/3) the liquid volume of the tank(s) or as required by local ordinance. Disposal of contents shall be pursuant to NR 113.. Wisc. Admin. Code. o Effluent filter(s) shall be inspected every 3 years and shall be cleaned when necessary to remove any accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12 months. System maintenance reports shall be submitted to the proper local government unit in accordance with SPS 383.55 Wisc. Admin. Code. Report any component failure or malfunction to: Name of individual or company. Schmitt & Sons Excavating, Inc. Phone: 715-760-0486 Local government unit: St. Croix County Community Developement Phone. 715-386-4680 Local government unit address: 1101 Carmichael Road, Hudson ZIP: 54016 Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin. Code. Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wisc. Admin. Code. No product for chemical or physical restoration of the POWTS may be used unless approved by the department in accordance with SPS 384, Wisc. Admin. Code. Contingency Plan In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to a plan submitted to the appropriate agency for review and approval. A failed in -ground dispersal component may be abandoned and replaced by a code -complying dispersal component in a pre -determined area of suitable soils. System Abandonment If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wisc. Admin Code Page 10 ST. CR01X -C=AUNTY SANITARY SYSTEM File #: eUse Only OWNERSHIP/ADDRESS FORM creat�eared Zlrozi Community Development Department will utilize this information to provide the property owner with information regarding operation and maintenance of your new or replacement sanitary system! This information will be provided as part of our ongoing efforts to protect public health, your well, groundwater, surface water, property values, and county resources. Once approved, this completed form and educational information will be sent to you by email. If you would like to view your issued sanitary permit online, you can do so by using the Property Files Scanned weblink. OWNER/BUYER INFORMATION Owner/Buyer Daniel Sikkink Mailing Address 882 167th Ave City/State/Zip New Richmond, WI 54017 Phone Number (required)701-793-7741 Email Address (required)dandksikkink@gmail.com Parcel Identification Number 032-2157-10-000 (found on the property tax bill) NEW SYSTEM: LEGAL DESCRIPTION Property Location NE 1Z4 , NE 1A , Sec. 12 . T 30 N R 19 W, Town of Somerset Subdivision Plat: NA , Lot # 11 Certified Survey Map # 682294 Volume Page # 19 Warranty Deed # 1146025 (before 2006)Volume Page # Number of bedrooms 5 Spec house 0 yes ■ no Lot lines identifiable E yes 0 no OFFICE USE ONLY New Property Address (Verification of new address required from Community Development Department for new construction.) (Staff Initials) (Date) This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications. New System: Include with this form 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. Community Development Department — Land Use Division 715-386-4680 St. Croix County Government Center cdd@sccwi.gov 1101 Carmichael Road, Hudson, Wl 54016 715-245-4250 Fax www.sccwi.gov Page 11 State Bar of Wisconsin Form 1-2003 WARRANTY DEED Document Number II Document Name THIS DEED, made between Benjamin M. Hayes, a single person ("Grantor," whether one or more), and Daniel Stuart Sikkink and Kari Rae Newquist Sikkink, husband and wife ("Grantee," whether one or more). Grantor, for a valuable consideration, conveys to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): Lot 11, The Highlands, a County Plat in the Town of Somerset. 1146025 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 12/29/2021 09:03 AM EXEMPT#: REC FEE 30.00 TRANS FEE 1,366.50 PAGES: 1 **The above recording information verifies that this document has been electronically recorded & returned to the submitter Recording Area Name and Return Address Partners Title 1380 Corporate Center Curve, Suite 317 Eagan, MN 55121 032-2157-10-000 Parcel Identification Number (PIN) This is homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except: easements, restrictions and reservations, if any, of record. Dated (I tL-�!,v� n EAL AUTHENTICATION Signature(s) Benjamin M. Hayes / authenticated on ?i( l *Kristina O land TITLE: MEMBER ST TE BAR OF WISCONSIN (If not, authorized by Wis. Stat. § 706,06) THIS INSTRUMENT DRAFTED BY: Kristina 021and, Estreen & Ogland 304 Locust Street, Hudson WI 54016 M. Hayes (SEAL) ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. ST. CROIX COUNTY ) Personally came before me on the above -named to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. Notary Public, State of My Commission (is permanent) (expires: ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS 1S A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED C 2003 STATE BAR OF WISCONSIN FORM NO. 1.2003 * Type name below signatures. INFO -PRO"" Legal Forma 800-065.2021 www iMoproforms com Page 12 ct r..,;� r.,� inn, 1 1 nRn�� P.—I of 1 COUNTY PLAT OF: THE HIGHLANDS DOGS 6 e 22 / if LOCATED IN THE NE114 OF THE NE114 AND IN PART OF THE SE1/4 smums mica OF THE NE1N OF SECTION 12, T30N, R19W, TOWN OF SOMERSET. ".Ck t ST. CRMCOUNTY, WISCONSIN. 6F Mw! 6C�T i co 6,4Sm. MA uucps ASiTw Lve P" o@P7 am ®G @vM9 Si -- --- mommi, A9W-w 170TH AVENUEZ IF&= Iasi �� Npml UNE OF laE! NEIµ6*FwizQ-- •lD. 1S 21SA• 33W N3rMWE 1W3.07 yr N30'35' -E w -_ -.tsroi\- - - - - - - - - - - - 151 (- LOCAnoN SKETCH �i / 15 F � �0 c .oa • 5 i +` . J NR. 1gI ®;J I ;30=861�a°1EFI '• �:� I 16 18 I I a00I ACRES N ' t3DO Nis 130 SD FT 30.).OSO tT _ A / O�T 3012 ACRES d 1121600Ft I H W.L=631.01r N0a^.152Tyr 30r OTl ^ fM RE=Sr1A >', fi 3316Y,` � / J 1a1.1v SECTION 12, T30N, R19W / AN. 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AL 6 NNe .e era a I - 8 r# .31Ac1E6 DtilvAlmp atwMwNAHr VW+D �1 POND H1,912SO R FABEFtMe wntal w.:NAOE uraFs. 30w AGES ; A y; ,1r I.N111{L1 �0 _ _ -- -- wA A,m OLLwrts. aIaAE QQ.'8.1 �JI ti °' 130,Cd SOR 3.0061CRES T A N on dl 9 ,� % lam SO FT 3 .,` i / __`FFEWL =�00 �nI I 3.003 NGIB S �- / O'' rvO,E BEEF m+ENUJrB mB.L1T OAt1ER8 I�I 130.SOB6DfT �'1j'1j A,o J �r�.3 QQ r1EswNaaReumex rwrrm+w.cc Mal ,''�L�'i Ln� /'j O�EI [7 BET,�tr,w ArfA9 utcATm aN rtFn Lor. tt'71r ee caeNAvre non nor avrcrels q�f�y / b � _ - Np,E �POt1BNLRiE9NPRE>.FNItW BIpBrOH ON I �, � •'J�.1 FFE.9,5.2 •djj r NHWL- 04 -ff � 2 SURVEYOR: �.t10 -���'w h 2122Z 2� 35 DOUGLAS J. 7N LER N•Td•iT! /.120.28' BOVTH LrNE OF TM Nt/2 OF LAND SURVEYING INC. 2920 ENLOE STREET LEGEND um �' L [� 4Iz i�WMM [017 77 i ri -THE BEtµ Of TIE IHt/i SUITE 101 --------------------- -- HUD•ON, VA 64016 Nellil, ALLwBSAlnn 00uNrT lEG 10H COn1E. A1OrA1LEM irIIrYrJ P.FrNxlr+E o�FAr anax aaM't' (716) 386-200 ----M -- -- ZONNO VIOL oN tpepet ENGINEER: 2 • rouro t•pYryi0c 0VArcrin Rory v,vE _ LT` i AUTH CON•ULTINO A860CIATEa BTOMI NATen RPtM+roH MCA 2920 ENLOE STRQT Sz O (✓DOt100Ix10 ONISOE OUNERR x tr LAW Maa _ _ ror,No amu,e. PER LNIFAn poor - RMOtA�r ne00rofD - er LIIY1Y[ACBItM etµ 0011. 14UMON�NIA.10 ,� U e E�� SEC wr,�0 (71 q E61.62Tf �"' +' °u rIo1E AU Ana Lm oprree uaw.aEHtt:o wm1 r ourarOE ovAEtrR B-1r --•.._ - Exrra re+oe of PREPARED FOR$ i5 Lars „Pe wlzoet6ttzur. nnrrewr roor �rcv. �-' wxaBEo wruE Nw.L. MQS WAIIA/ Ad WAVA"ON 7AH1en/ * F71 JANET P. BTOVT iNE•1NA'11,IKW TNAIL II MY,6 1AY OItW --- �� — lae NtA1YWA•tltIW9M HUDSON, 1M 640/6 SOALE IN Pitr I-. 10D gE �[B' 46 xxHr ltnrvti l+BHAcn* .^T6, Owi*m RWASIM OE/1Ef•E 1 0 160 EOo Bftl �'�' $ ' DIIAM iYL KEVIN REM •NES► 1 op ■ 400 ND, 11101112.04 Page 13 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division e INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)[. ermit Holder's Name: City Village X Township Grand Properties L.P. I Somerset Township ST BM Elev: ( Insp. BM Elev: BM Description: jco , a tso . a' — PAL = cs-r $ .-►• * I I11lvf% 117r WrNIVIMl Illlr TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL P BLDG. Vent to Air Intake ROAD Septic J v .2 / �. Dosing Aeration Holding L� PUMP/SIPHON INFORMATION Manuf cturer Demand GPM Model Nu er TDH Lift riction Loss System Head DH Ft Force ain Length Dist. to Well SOIL AA j, B-SORPTION SYSTEM _ r'. ""_ / CLCVAI1UN U/41P1 County: St. CfOIX Sanitary Permit No 429995 0 State Plan ID No: Parcel Tax No 032-2157-10-000 Section/Town/Range/Map No: 12,30.19.1353 STATION BS HI FS ELEV. Benchmark t Alt. BM Bldg. Sewer � rn �� • �� + St/Ht Inlet . 33 SUHt Outlet ry Dt Inlet Dt Bottom Header/Man. • � 93- �b Dist. Pipe 5elr9ystenl i' 2• (r t: t F.aIls�etere Qtf. �, Z 3.SID r St Cover � o 9 •3s ` NCH DIMENSTM Width Length No. Of Trenches (y��=S Z PIT DIMENSIONS No. Of Pits Inside Dia Liquid Depth SETBACK INFORMATION SYSTEM TO P/L JBLDG WELL LAKE/STREAM LEACHING CHAMBER OR UNIT Ma factur o�S FFKS Type Of S t�„ �. 110150 O I} -' Model Number: I if vlv 1 I�Iuv 1 Iv114 J I J 1 CIVI Header/Mani fofd t� Length Dia Distribution Pipe s Length Dia Spacing x Hole Size x Hole Spacing Vent to Air Intake ! •••••� •.• •-•• v PrpSCurp Svctamc flnl•. _ RA -..-A n. wa Depth Over jpep6over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes rah, No _ Yes No L;0MMF_NT5: (Include code discrepencies, persons present, etc.) Inspection Inspection #2: Location: 882 167th Ave Somerset, WI 54025 (NE 1/4((NE 1/4 12 T30N R19W) Highlands of 11 Parcel Nr: 2.. 0. 9.1353 1.) Alt BM Description = 5' ` 3) Sy �. l�'t+� Y 501 2.) Bldg sewer length = / - amount of cover - 1t Plan revision Required? Yes No Use other side for additional Information. SBD-6710 (R.3/97) Date Ineepctoes gnature f Imo• No, z4)8W I E Wisconsin Department of Commerce SOIL EVALUATION REPORT Page I of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County � / Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must �.�t include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel percent slope, scale or dimensions, north arrow, and location and distance to nearest road.�nd'n Please print all information. iew by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)) Z (p 3 Property Owner Property Locatio11 S 4 Govt. Lot (V E 1 /4 A) 1 /4 S I Z T 3o N R/ 9 E (or� Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# wwktkeeTr. 1l /qh 1 nc�S City State Zip Code Phone Number ❑ City ❑ Village N Tow Nearest Road HAwL5, c Ito] IStqn)[. l_c_715 �5y4-1o731 Somers+ I /707b AVe. g-New Construction Use:ER Residential / Number of bedrooms 3 - `aF Code derived design flow rate qSZ /1'00 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable General comments (�c l /�LtJ {t"p-}���, 1 sa and recommendations: �vskr -, Q) v q3' $� U�4�%Y 7 S ° fir} LIf Boring U 1 Yam,. rk/N?Y f © Boring # ® Pit Ground surface elev. `tn �7- 6 ft. Depth to limiting factor �-% in.: Redox Description Qu.Sz. Cont.Color �WIN�©®®® ■��� • ,�� • • psi©��® VBoring # ❑ Boring O 1 & pit Ground surface elev. 7- Od ft. Depth to limiting factor 1 in. Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. S Consistence Boundary Roots rGPD/ftz *Eff#1 I *Eff#2 1 0-9 10 31Z -- 5 2 CS ) Vr 5 7- q - 59 IO ylL4 Gs -- 31- Ib — 0 m1 (. 3•S i av - acv n v— auv I Qa -w 2 I VV Ind/1L CIIIUUM ff4 - DVL75 % Ju m91L ana 100 -- JU mg/L CST Name (Please Print) Signature CST Number tqdam Sc)%L)^ ,a-ker 25-3 ,3462 Address Y Date Evaluatlon Conducted Telephone Number Z113 90t� N4. S tjl .5g6zS- !a -36-a 1 (7/3)ZY7 V66Y ,MD-8110 (R07/00) 1� Property Owner I r),) � Parcel ID # i 3 Boring # ❑ Boring ® Pit Ground surface elev. Q� ft. Depth to limiting factor. 7 in. Page 2. of 3 Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ft2 'Eff#1 I 'Eff#2 1 0 —1 )0vr31Z _. ` Si ) 2 wxkhkr1r C5 I v 5 2 12 -14cm 1 —' i c.) "I -r- (- AID l Ur 4 1 in rn l -- -- �. ❑ Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Annlication Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ft2 'Eff#1 'Eff#2 Boring # Boring Ground surface elev. ft. Depth to limiting factor in. El Pit Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ft2 'Eff#1 'Eff#2 • Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TrY 608-264-8777. SBD.8330 (R.07/00) • PAGE_,3 OF_-S ►: u • J •► ► •.� SCALE: V = 410 BM I ELEVATION 160,C) BM I DESCRIPTION Q,"& ow �•;OT BM 2 ELEVATION BM 2 DESCRIPTIONo o,�'��{ SYSTEM ELEVATION ALTERNATE ELEVATION 92, Fa CONTOUR ELEVATION 5rQ Z- p l SIGNATURE DATE 12 -Z-f -a/ p l SIGNATURE DATE 12 -Z-f -a/