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014-1040-10-300
Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)], Permit Holder's Name: City Village Township Kyle Johnson TOWN OF FOREST CST BM Elev: Insp. BM Elev: BM Description: CxA l L to+Tze, --- 7 ("s-r-B 1M41-- TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic l Dosing do 0-0 �7� rj'g TANK SETBACK INFORMATION Vent to Air Intake wo MWERIWA oil= WA IWA =I IrA 1WM 606.Al PUMP/SIPHON INFORMATION 3-3/1nn Manufacturer I L't Demand 0 be GPM q2 If Model Number IS-P TDH Lift Friction Loss System Head TDH Ft 1, M 1- bS 1 '. 1�.55 Forcemain Length Dia. Di st. to Well _ n Or -1V15+all SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: 651262 State Plan ID No: Parcel Tax No: 014-1040-10-300 Section/Town/Range/Map No: 19.31.15.289D STATION BS HI FS ELEV. Benchmark z ozr IL90OrD Alt. BM oP 0� VovtivgT-na of T�FT 4A"4� g .D Bldg. Sewer g•5 qy.� St/Ht Inlet St/Ht Outlet Dt Inlet Dt Bottom Header/Man. DD• I Dist. Pipe 91.1 Bot. System 91, Final Grade St Cover 7D f BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS3 No. Of Pits Inside [,I+a. Li Depth DIMENSIONS )5- 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 t--oII Air Intake Pipe(s) < �I3Z 100�_ Length Dia Length 2 Dia Spacing SOIL COVER x Pressure Systems Only �xx Mound Or At -Grade Systems Only All, Depth PIV15r Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/ ench Center 1BeeT_r`eNfth E ges ❑ Topsoil Yes No Yes ❑ No ❑ COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 10/jo Z97,3 �`�'` Inspection #2: Location: No Address Available 1.) Alt BM Description = 5P 14 �u4bq D� �e16}c4cl 2.) Bldg sewer length = qD' 1"1) (,K--► L i5 - amount of cover = cv.vtv L:r� F [0 UT__ Nd YWII I�VIIT D� ���40.11D� �Qdl�i 4 I.9 I &Qfj ` OKI Plan revision Required? [:]Yes XNo Use other side for additional information. Date SBD-6710 (R.3/97) ��5 1 v I 5] nsepctor's Signat re Cert. No. y ; `} \,J 0 ' $ r AUG 2 1 202 I Industry Services Division 4822 Madison Yards WayCW Madison,-Madison,-W1 537 '" P.O. Box 7162 Madison W1 53707-7162 County , SAN-2023-18( - iitary Permit Nrimber (t(be filled in by Co.) S'M/ gZ a t"Y' i • �i meritApplication' In accordance with SPS 383.21 2 Wis. Ad,11. Code submission of this form to the appropriate overnmental unit ( )>g 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 purposes in accordance with the Privacy Law, s. 15.04(l)(m), Stats. State Transaction Number O t./ I Projecl.,,Address ifferent than mailing address) 2(a . I. Application Information - Please Print All Information Pro erty Owner's Name KV te." Parcel # 30J Prope4 Owner's Mailing Address Property Location Tl;'D ?Aotk Avzz Govt. Lot _ 'fd, '/4, Section I q T N R E or City, State --k ILI- )Igr Eiv Zip Code 15q� Phone Number ,� q6� 7--ILI 5 J 11 'l' �e of Building check all that apply) Y1 g ( pp y} or 2 I;ainily Dwelling - Number of Bedrooms _ Lot # Subc ivision Name 11PUblic/Commercial -Describe Use F]State ONVned - Describe Use Block 4 �— City of Village of own of _ CSM Number DoC: %477?_ III. Type of POWTS Permit: (Check either "New" or "Replacement" tend other applicable on line A. Check one box on line B. Complete line C it A lic e. A. blew System Replacement System F10ther Modification to Existing System (explain) DAdditional Pretreatment Unit (explain) B' Holding Tank In -Ground (conventional) t-Grade oulid Z� � Individual Site Design Other Type (explain) C. Renewal Before Expiration Revision [::]Change of Plumber ElFransfer to New Owner List Previous Permit Number and Date Issued I q IV. Dispersal/'Treatment Area and Tank Information: r K t7S yw, Design Flow (gpd) Design soil Application Rate(gpd/so Dispersal Area Required (So Dis ersai Area Proposed (sf) System Elevation u,('— C1 7.3a Tank Information Capacity in Gallons Total Gallons # of Units Manufacturer jj ,4ex— 1—•� �' w c a, U " cin to V) V 'h LZ U (n c1d New Tanks Existing Tanks Septic or Holding Tank � VA W'i Eit2gK7 YJ Dosing Chamber �01 I (� V. Responsibility Statement- I the undersigned, as a responsibility for installation of the POWTS shown on the. attached plans. Plum er's Name (Print) b(ACL VL, Plum Signatu MP/MPRS Number Business Phone Number 7 7 q6 I Plum er's Address (Street, Ci , State, Zip Code) VI. County/Department Use Only j Approved r en1 COwn=;�eason fo Permit Fee S Date Issued 2 ZZ� Issuing Agent Signature ("onditiOns o Approv Reacnnc for Tlicanrtirn�iol ` c `�"'� —vim W 31/ J `��/w■,1 ' '���////■(/■,A/�/1'_ 1 �J//J�n��I////�1` l/\� PCJ v�. � TEM OWNER. YOWN -t�s 1. Septic tank, effluent filter and dispersal cell _ � mu t b serviced / r aintain d per qj Aox 1 rvu�tat� mare re nt lan �rovid d b lumber. :� i� bplumber. i S "rr . �� tbecl� rqulremnt mint b malrltalnr L as of applicable code / ordir ance l ACX- Qom- Ap4atV;+ Am-,o 6O2-4A fV— 0-t-s ikttach to complete Flans for the system and submit to W County only on paper not less than 8 1/2 x I I inches in sire tk-+()I63. SBD-6398 (R. 03/21) System PLOT PLAN PROJI1C`r Kvle Johnson ADDRESS TBD 210th Ave Deer Park. WI 54007 NE 1/4 NE 1 /4 S 19 /T 31 N/R 15 W TOWN Forest COUNTY ST. CRGIX SYSTEM ELEVATION 99.2' 1.4 Sand lift HATE 7/25/23 BEDROOM 4 CONVENTIONAL AT -GRADE CONVENTIONAL, LIFT HOLDING TANK MOUND Xxx SEPTIC ,TIC. TANK ,ANK SIZE �, 1200 Gallons Y.I.FT TANK SIZE DOSE. TANK SIZE 801 Gallon HOLDING TANK SIZE. LUAU RATE 1.0 ABSORP'I'IUN AREA 500 # of ChambersNone IL BENCHMARK V.R.P. Top of Nail in tree 24" above Grade ASSUME ELEVATION 10U' Filter Lifetime BOREHOLE WELL 11. R. P. same as benchmark 21 Qth Ave Scale 1 "=40' o' ao' 8o'.,1` y'A) J Pro 4 Pro Bedroom Accessory House Building Well is to meet all WDNR Setbacks C.0. Wieser Combo Septic Grading to be, done to divert runoff away from system COPY B.M.*I_� B"1 Area 15' Below Mound is to remain undisturbed , 97' op 97.8' 8` 9` 190, B - 3 2% Slope 4;�2 v'1- j August 14, 2023 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 2025-8-14 Plan Review: PWTS- 082301090-C Shaun Bird 1432 120th St New Richmond, WI SITE: Johnson 210th Ave St Croix County Town of Forest N E % N E % S19 T31N R15W FOR: Conditionally APPROVED DEPT. OF SAFETY AND PROFESSIONAL SERVICES DIVISION OF INDUSTRY SERVICES -04&� R4494f SEE CORRESPONDENCE Description: 4 Bedroom-600 GPD 20" to limiting factor- Effluent Filter - Mound Component Manual — Ver. 2.1, SBD- Maintenance required. 10691-P (5/22-5/27) Pressure Distribution Component Manual —Ver. 2.1(May 2022-2027) Verify proper dose is achieved and system is not being over dosed. The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: Reminders The site shall be properly prepared prior to plowing. Any grasses longer than 6" shall be cut short and removed. To avoid matting, any leaves or loose organic matter shall be raked up and removed. Cut trees and shrubs flush to the ground and leave stumps. Avoid operating equipment on the Mound site. If necessary, use only tracked equipment, during dry conditions, with minimal passes, to avoid compaction. • Components and soil removed from an existing drain field shall be properly disposed of so that there is no risk to public or environmental health. • A sanitary permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec.145Z0(2)(d), Wis. Stats. • A state approved effluent filter is required. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. • A cow of the approved lans s ecifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the De artment which may include local inspectors. Owner Responsibilities • The current owner, and each subsequent owner, shall receive a copy of this letter. Owners shall also receive a copy of the appropriate operation and maintenance manual(s) and be responsible for ensuring that POWTS is operated and maintained in accordance with this chapter and the approved management plan under s. SIPS 383.54(1). In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, , 7&J A a, a, / /T c " V I le-,, ye Joshua Rowley POWTS Plan Reviewer, Division of Industry Services (715) 634-5124 Joshua.rowlev@wisconsin.gov Cover Page Shaun Bird Conditionally APPROVED Bird Plumbing Inc. DEFT. OF SAFETY AND PROFESSIONAL 1432 120th St. SERVICES DIVISION OF INDUSTRY SERVICES New Richmond Wi 54017 1 715-246-4516 SEE CORRESPONDENCE Date: 07/25/2023 Owner: Kyle Johnson Location: N E 1 /4 N E 1 /4 S 19 T 31 N, R 15W 210th Ave, Forest Manuals Used: Mound Component Manual Version 2.1 (May 2022-27) Pressure Distribution Manual Version 2.1 (May 2022-27) Page# 1. Cover Page 2. Mound Plot Plan 3. Mound Cross Section 4. Pipe Cross Section/Pipe Layout 5. Pump Chamber Cross Section 6. Pump Curve 7. Filter Specifications and cross section 8-9. Maintance and contingency plan Attachm�♦�, Shaun Si Signatur License Page 1 of 9 System PLOT PLAN PROJI1C`r Kvle Johnson ADDRESS TBD 210th Ave Deer Park. WI 54007 NE 1/4 NE 1 /4 S 19 /T 31 N/R 15 W TOWN Forest COUNTY ST. CRGIX SYSTEM ELEVATION 99.2' 1.4 Sand lift HATE 7/25/23 BEDROOM 4 CONVENTIONAL AT -GRADE CONVENTIONAL, LIFT HOLDING TANK MOUND Xxx SEPTIC ,TIC. TANK ,ANK SIZE �, 1200 Gallons Y.I.FT TANK SIZE DOSE. TANK SIZE 801 Gallon HOLDING TANK SIZE. LUAU RATE 1.0 ABSORP'I'IUN AREA 500 # of ChambersNone IL BENCHMARK V.R.P. Top of Nail in tree 24" above Grade ASSUME ELEVATION 10U' Filter Lifetime BOREHOLE WELL 11. R. P. same as benchmark 21 Qth Ave A,1 Scale 1 "=40' o' ao' 80'.,1` y'� J Pro 4 Pro Bedroom Accessory House Building Well is to meet all WDNR Setbacks C.0. Wieser Combo Septic Grading to be, done to divert runoff away from system B.M.*I_� B"1 Area 15' Below Mound is to remain undisturbed , 97' op 97.8' 8` 9` 190, B - 3 2% Slope 4;�2 v'1- j Mound System Cross Section and Plan View j t i i A w t i t 1 1 f 1 t i t r I +tea a now am ONO "Mo w .rrr rrr rrr am G r aw a so" r arr err �a arir aaf wwr w a. .rrr w r.w r airr a. r r ai K L T - T 1 — Topsoil ASTM C-33 Clean aggregate 4 in. sch. 44 pvc 0 Cap Material sand fill Y, to 2 /z in, dia. observation pipe r ►1�1�1111�1r���►��1titis �.... . ..�.rt1�1�►�111►1�ti111ti �1�1�1ti1��ti�����11ti1���ti�t���,�ti���:��.�,.� - - Plowed Surface Ft Contour Slope Direction GENERAL INSTALLATION: The mound area is staked out along the design contour. Existing vegetation is mowed and raked off the site. The mound basal area (L x w) is plowed with a moldboard or chisel low. Plowing not proceed if the soil is wet enough at the plow depth to form a V4 inch soil wire p g may when a sample is rolled between the palms of the hands. ASTM C-33 quality sand is placed immediately after p . lowin Sand is laced with a tracked machine keeping 12 or more inches of sand under the tucks o plowing. is laced overhead b a backhoe. Special care must be used when placing sand of less than one foot p � P . thickness to minimize compaction of the lowed surface. After the topsoil cap is placed, the entire mound p p is seeded and mulched to promote vegetative growth, limit erosion and protect from freezing. "I'he observation i es are slotted in. the lower 6 inches and s ured Pp in place with rebar or a closet flange. 0 10107 lgi Page � of Pressure Literal Layout Two Laterals — End Manifold Manifold Force Main Distribution Network Specifications Lateral Diameter In. Manifold Diameter . Orifice Diameter �1 2 In. X (Orifice Spacing) L(Lateral Length) 2. M �Manitold Length)fit. Force Main Diameter '' In. Force Main Length _ IOiD--- at. Lateral 'urn -up _,�.—..�► �---- 'I'�c•eaded r Cleanout Plug Long Sweep 90 Bend Pressure System Construction Laterals are constructed of Schedule 40 PVC pipe. e. Orifices are drilled perpendicular to the pipe with a sharp drill bit and face down. a r -readed Lateral turn -ups terminate with a th cleanout plug and are enclosed in a 6-8 inch diameter lawn sprinkler valve box accessible from finished grade. I Of Page C' * 0 • 03/05 Igi ' I I �pecifjcaboils p 'Per-forman.ce Septic,wl)ose ank, Cr-oss Seetion.An.d Pum pump manufacturer' are -manufacturer r Model N11mber (hM] , �irik. Modul IN)'urnbar hz W-2 pump n Manufekcturor Lie "rotal Twik Capacity Alarr Alarm Model Numbe), &fdx. Miry Delipth I or ��Iwitch Type "-�7 (-JW Wilier Maiiufficturer Minimum Pump f wformance Required 4%. Gy P M Ft TD11 Outlet I.Ivlanhole Min. 4" bove Grade Witli T,00king Do -vice. Inlet Manhole < 6" Below Cn*de Seuled Watertight 'w"' 17inished Grade law INIIggy 46,01 Tbtal Dynamic Head--(FDT1),-- Feet j3jVy4tjQn Distal Pre9sure Network Loss /I Force Main Loss ;Seoul-ely Mounted Weather-proof Junction Box Vent Min. 12" Above Grade With Vent Cap Manhole Min. 4" Above Cyrade With Locking Device, %NOW I 4 4 Outlet Filter Inlet Baffle lit, t Disconnect Means 1 tea`tA. X4 4 4 17 1/4 to, weep tilt 110 4, 0 of 11; Ito, H Ir b Off Elevation C '►rl I to -7 Bottom 4 4 D ['11evatioll :7TF74T4F%1Y;1 1111.Y 41 11.1 4 4 It 4 1 t 4 4 to•0 .1, . 1, It W I : f V $ 1 I V ) 6 1. 11 4;i�� 4, 1 a of' 4.'4 ': 4$4:46!, �#* I P 4 0 4 'S 4 4 q I I 4, 1 f It - a. L. 2 -1 --,� IL I i 1. A• a I A. I GENERAL INSTALLATION: The suptioldose tank is budded aud back filled in accordance with the *AV (nanufact'arur's product approval specifications, Maximlim depth of buiy as spoomod by the munufucttirer inay not be excee4led without prior approval. Manhole covers exposed to grade have an effective locking device (padlock) installed, Piping at the inlot and -outlet is of approved material, coMiected to the tank with wRterfight fifftings, and luid on stabl soil to preveat sealing or Saggi9 1 'File force 111a'n is S100yed with 4" Sch. 40 PVC to bridge Ilie tank ng. exuavaticill fil�ld the sioevo is sualed wateitight, 'Blectrical service, complies with NEC 300 and Comm 16-28. 02/05 U' P age 'S 0 f 280=SERIES 1/2 hp Submersible EffluentlSu p Pumps The Liberty 280-Series provides gi cost effective "mid- range" pump for on -site waste water systems, liquid waste transfer and commercial heavy-duty sump pump applications that require higher head or more flow, Designed around Liberty's unique "Uni-Body" casting, the 280-Series will provide years of reliable performance, AtIM90al*Fcaturc; 9 Vortex style Impeller permitting passage of solids up to 'A" • 416 stainless steel rotor shaft • Permanently lubricated upper and lower ball bearing • Epoxy powder coat finish All fasteners - corrosion -resistant stainless steel • 1 ? Discharge • Stainless steel bottom screen - easily removable • Maximum fluid temperature:140" F. 280-Series cord Lengths Model 101 251(-2) 35'(-3) _50`t-5}_Y 280 Standard Optional Optional Optional 281 Standard Optional Optional _ Optional 283 Standard O tional O tional N/A 287 Standard O tional NIA NIA 10` cord length standard on all models. For optional lengths, add "-2, -3 or -8" suffix to model number. Example: for model 280 with 35' cord, order 280-3 Motor Specifications /2 hp 60 Hz 3450 RPM Oil filled, thermally protected (PSC) Permanent Split capacitor 8.0amps 015V) 4.0 amps (208I230V) 10 _'�■ ■■■A■■■■■Miami N■Nr■■■■■ ■WI ■o■■ ro■E■l�or■MIMMEMIN ■■rri94% ■■■o01111011111011111■ ■E■■ ■■�,�ME■■ ■■r■■■ soon . ' Niglio ,��r ■■ MOONS ■Orr■ miss rr■Nos 1111111111110110 ■■■Orr■ ; ■■■ Orr■ 1►�INo�I■■■N0So on Nos ■ r ■■E.�o■■■lI■IS■■■ , . Mmm i INN■■ ■ r moll■ ■■ ►M■ ■■ ■r■■ ■Orr■ ■■■oss m ■■ r■INS■ r ► r r ■ ■ ■■■ ■r�Nr■ ■ ■ ■■■ ■ rt■■■■ ■■■■101r ■■Error■soon■r■ ■ ■■■■ ■ ■�►. , Dimensional Data: Weight. 29 lbs. Height:13" Major Width:10" (model 287) Minimum Sump Diameters, Model 281, 283...14" Model 287 VMF...101, Factory switch Model 2819 283 Model 287 settin s VMF Turn on level 1311 9 5" Turn off level 7" 4.0" The Model 283 features a fully adjustable wide-angle float. Differential adjustments can be made easily by tethering the float to the dis- charge pipe or other mounting point. Vertical float model 287 is not adjustable. M ode! 280 Model 281 Model 283 Model 287 VMF-Series Manual, Wide angle no switch float switch Wide angle float switchg Verticalma - with quick- a with series netic float for smaller pits -- disconnect piggy -back} will operate in plug a 1011 diameter sump SSP� �► CERTIFIED c us Certified Speoffiostions ors subject to champ without notice. C Ur Liberty Pumps . 7000 Apple Free Avenue o Bergen, Now York 14415 • Phone 804-543..2550 Fax (585) 494-1839 Ywww.libertypt mpS.com Copyright 0 Uberty Pumps, Inc. 2017 All rights r©served. LLIT 200O R05/17 r- 0 4.52L0 I NI ) .01 Gap between Lose and Serpentine �A 91 I.1921 So POWTS OWNER'S MANUAL 8 MANAGEMENT PLAN Page _,or...... FILE INFORMATION Owner ____ Kyl ao bCSYL Permit # )ESIGN PARAMETERS Number of Bedrooms ❑ NA Number of Public Facility Units 13 NA Estimated flow (average) INN gal/day I Design flow (peak), (Estimated x 1.5) gal/day Soil Application Rate d ai/da o Standard i nfluent/Effluent Quality Monthly M n v average* Fats,' 011 & Crease (FOG) -530 mg/L Biochemical Oxygen Demand (BODs) !220 mg/L ❑ NA Total Suspended Solids (TSS) :5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODE) ,530 mg/L Total Suspended Solids (TSS) S30 mg/L *NA Fecal Collform (geometric mean) 5104 cfu/100ml Waximum Effluent Particle Size 36 in dia, ❑ NA }ther: ❑ NA "Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Event linspect condition of tank(s) At least once every: IPump out contents of tank(s) When combined sludge and scum equals one-third (%) of tank volume q NA At least once every: 7� ❑ onth(s) (Maximum 3 years) ❑ NA ear s SYSTEM! SPECIFICATIONS Septic Tank Capacity a ❑ NA Septic Tank Manufacturer ❑ NA Effluent Filter Manufacturer y ❑ NA Effluent Filter Model 1' ❑ NA Pump Tank Capacity al ❑ NA Pump Tank Manufacturer ❑ NA Pump Manufacturer ___Lj ❑ NA Pump Model ❑ NA Pretreatment Unit A ❑ Sand/Gravel Filter ❑ Peat Filter ❑ Mechanical Aeration ❑ Wetland ❑ Disinfection ❑ Other: Dispersal Cell(s) ❑ NA ❑ In -Ground (gravity) ❑ In -Ground (pressurized) ❑ At -Grade ❑ Mound Drip -Line ❑ Other: Other: ❑ NA Other: ❑ NA Other: ❑ NA hnspect dispersal cell(s) Clean effluent filter Inspect pump, pump controls & alarm Hush laterals and pressure test Service Frequency O month(s) (Maximum 3 years) DNA 3 �►ear(s) At least once every: ❑ month(s) * ear s ❑ NA At least once every: ❑ month(s) IXWeart ❑ NA At least once every: ❑ month(s) ❑ ear(s) ❑ NA At least once every: Cl month(s) EJ years)_ D NA ❑ NA MAINTENANCE INSTRUCTIONS !Inspections of tanks and dispersal cells shall be made .by an individual carrying one of the following licenses or certifications: Master 1Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank Inspections must iinclude a visual inspection of the tank(s) to identify any missing or broken hardware, Identify any cracks or leaks, measure the volume of n0ornbined 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 gn3und 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 (%) or more of the tank volume, the entire contents of i.he tank shall be removed by a Septage Servicing Operator and disposed of In accordance with chapter NR 113, Wisconsin AdmInistrative Code. III other services, Including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, lend any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. - '{t)trq'r8� pue Wv(P)(0(q)Q)u'E8E SdS jaldgq� gjIm noueljdujoo ul pjDjj'Rjp S17m jusujnoop s�u.L 'epno enIJV�jsluluap�{ u�surs.sslfVl ��) '� ��) "" � euogd — ,L L AIWOHIMf Auo.Lwino ouo q d rllr i w, OuoLid I^e 'rt II Y y A Buie i - - - - - - - - __..---�pyY4�rlyy�iI� ► A ■ l 1 i S N t S I MO d !K _:- NBNIVAI'M SiMOd _ _—_ _._ --•-- S1Ni WWOO WN01110CIV a`IEjtSSodWI 18o .L"1n�1��t 2FA A`cltlil MV1. V do tiolt1LNl'3H1 WoAA NOSbad noNio ANV �IACM �N�'1. 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CRO #: °l .� �� NTY, ��`S`�"��"s"�� ... OWNERSHIP/ADDRESS FORM Office Use Only Created 2/2021 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 ProDerty Files Scanned weblink. _` �. 'N' R 3UY I N_�FOR�1l� -T 7 N . {. -01R owner/Buyer KY16 .. ... .... . Mailing Address , W-M Fe-l" City/State/Zipr .� Phone Number (required) i P5. 5 Email Address (required) `7 Parcel Identification Number (found on the property tax bill) tifM:LCAESCRIPT N Property Location Y. 1/4 , 1/4 , Sec, ; T N R w, Town of Subdivision Plat: , Lot # , Certified Sur► eY Ma � # � �' � Volume � 2- �3 S^Z -. .. .. ...... .Page # Warranty Deed # .115'3 �� � before 2005 Volume #i } Page , Number of bedrooms Spec house 13 yes no Lot lines identifiable kes Q no New Property Addres 4�t- (Staff Initials) s � � (Verification of new address F262 (Date) quired from community Development Department for new construction.) This form must be submitted with a[! 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 715-245-4250 Fax cdd@sccwi, ov 1101 Carmichael Road, Hudson, Wl 54016 wwwsccwir.,gov State -Bar of Wisconsin Form 1-2003 WARRANTY DEED Document Number Document Name THIS DEED, madebetween Kristin. D. Rosen-- ,� CG rare tor," whether on a or more), and , Kyle Johnson, a single, verson _ .._.... ("Grantee," whether one or mare), Grantor, for a valuable consideration, conveys to grantee the following described real estate, togeth6r with the rents, profits, fixtures and other appurtenant interests, in. St. Croix County,. torte of Wisconsin ("Property") (ifmore*space is needed,. please, attach addendum) Lot .Three (3).of Certified Survey'Map, as recorded in Volume 22 of Certified Surrey Maps, Page 5352,, as Document No. S43 7.72; LOCATED IN the Northeast Quarter (NE %) of the Northeast Quarter (NE X} and the Southeast Quarter (SE Y) of the Northeast Quarter (NE %).of Section Nineteen (19), Township. Thirty-one (31) North, Range Fifteen (15) W6st, Town of Forest, St. Croix County, Wisconsin. .1153100 BETH PABST REGISTER OF DEEDS ST. CROIX CO., VIII RECEIVED FOR RECORD 05/ 13/2022 10:48 AM EXEMPT#: REC FEE 30.00 TRANS FEE 330.00 PAGES: 1 **The above recording information verifies that this document has been electronically recorded & returned to the submitter Recording Area. Namc and Return Address Kyle Johnson 2114 Cook Drive Somerset, WI 54026 014-4040-10-300 Parcel Identification NurnbcT (PIN) This is, not homeste ad - 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: Zoning ordinances, rights-ef-way., all easements, covenants, conditions, reservations and restrictions, and general real estate taxes and assessments levied in the. year of conveyance. Dated: MAY 9 2022 istie D. Rosen AUTHENTICATION �,ti��1111*trri .t% ` n reanTA authenticated. on A' 4 � y TITLE: MEMBER STATE BAR OF W� (If not,- L authorized by is;Star. § 706.06) "mi'S INSTRUMENT DRAFTED BY; Tony R. SchraderAttorne ?l 5 235-3403 File No. ST-22-062 t2 ACKNOWLEDGMENT STATE OF WISCONSIN j � ss, COUNTY OF ST. CROIX ) Personally came before -me on t aboyeqmmed Kristie D. Rosen to me known to he the sv o c vhuted. the foregoing instrument and S awe. No&ry*Fublic, State of Wisconsin My Commission (is anent) (expires: 6/I7/2022) (Signatures may he authenticated or acknowledged. Buth.ure not necesury.) N91'E: THIS IS A S'C` NDARD FORN]. ANY NIODIFICATIONS TO, r 1S DORM SHOULD QF CLEARLY ivENTIi± IED0 WARRANTY DEED -Z003 STATE BAR OF WISCONSIN FORM NO. I-2003 *Tyne name below signatures: St. Croix County 1153100 Page 1 of 1 1111 II III (II � II ocI :899600 Tx:5177863 1170163 BETH PABST REGISTER OF DEEDS Document Number Document Title ST. CROIX CO., WI RECEIVED FOR RECORD St. Croix County 08/18/2023 09:09 AM EXEMPT #: Accessory Structure Affidavit REC FEE 30.00 Kv(el 0'06Yof) PAGES: 1 N xrie ---- (Owner) Typed or printed He/she is the legal owner of the following parcel of land located in St, Croix County, Wisconsin, with their deed or document of ownership interest recorded as Document Number 1153/00 St. Croix County Register of Deeds Office. Recording Area Name and Ii�—Iurn Address This property is described as follows (include lot no. and subdivision/CSM I =?, Z/ .0 or detailed legal description): Parcel Identifie n Number (PIN) 11 -r3 l/l( q1SW PT 6 �/0 -300 ('06) L-0+3 7 FA(,) a6 /7 sae -i 97'//)OR: 0 See attached deed copy for legal description As owner of the above described property, I acknowledge that the Private Onsite Wastewater Treatment System (POWTS) serves an accessory building on this lot and is sized for a future (3 ) bedroom home, or a design flow of gpd. This accessory building may not be used as a residence on this parcel. I also acknowledge that I will disclose this information and stipulation to any future parties interested in purchasing this property. D� AUTHENTICATION ��� � •'•• �••• �� ACKNOWLEDGMENT Signature(s) S OTAR•: sTATCOFWISCONSTJ • • : )ss. authenticated this day of St, Croix County. ) ? e�onally came before me this day of U , ��% • ��.��+•� 1xi above named TITLE: MEMBER STATE BAR OF WISCONSrN 111"IM1111�(� to me known to be the (if not, person(s) who executed the foregoing instrument and acknowledge the authorized by § 706.06, Wis. Slats.) some. THIS INSTRUMENT WAS DRAFTED BY: St. Croix County Community Development (Signatures may be authenticated or acknowledged. Both are not necessary.) '00TOf' Notary Public, State of Wisconsin My Commissi n is cmanent. If not, state expiration date: Date: 34:�'� St. Croix County 1170163 Page 1 of 1 Ind Roar Ysuked CoOng K, & 3� DA 6.S� A_I & rl �l(�---- rll ' WiscontWrn o sional Services L DivisionPlndu§w��rviX SOIL EVALUA 5:L- 2�02- .jft 2 0 2023 County In accordance with SIPS 385, Wis. Adm. Code Attach com lete sitaplan,q s th n 8 1/2 x I include.. ST Croix p �p less 11 inches in size. Plan must but not I'm' ed -, fire point (BM), direction and percent slope,Parcel I.D. scale or di Ll I U1 evu, u, id I....atten and distance to nearest road. 014-1040-10-300 Please print all information. RevOved by, Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(1)(m)). Kv_!� Property Owner Property Location: Kyle Johnson Govt. Lot: NE 1/4 NE 1/4 S19 T 31 N R 15 W Property Address Lot # Block # Subd. Name or CSM# TBD 210TH AVE 03 CSM 22-5352 City State Zip Code Phone Number ❑ city ❑ Village F01 Town Nearest Road Deer Park I WI 154007 1 (715) 529-5482 Forest 210TH AVE X New Construction Use.- A Residential/ Number of bedrooms 1-4 Code derived design flow rate 600 GPD F-1 Replacement ❑ Public or commercial — Describe: **Shed with 1 bedroom living quarters and future 3 bedroom home** Parent material Loess over loamy till (VIasaty sil) Floodplain elevation if applicable NA ft. General comments and recommendations'. Recommend minimum 16" sand -lift POWTS mound on 98.00 contour with 0.4gpd/ft2 loading rate. LF = 20" (Redoximorphic featur **Deep plow (10-12") recommended to break up weak-platey soils in B2 & B3* !L� Boring # F] Boring MR pit Ground surface elev. 98,00 ft. Depth to limiting fact r Q20in, FZnil Annlirqfinn Pqtp Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft 2 *Eff#1 *Eff#2 1 0-9 10YR 3/3 SO 3mgr mfr cs 3m-vf 06 0.8 2 9-14 1 OYR 4/3 sil 2mabk dsh gs 2 m-vf 0.6 0.8 3 14-20 10YR 4/4 - sil 2mabk dsh-dh gw 2m-vf 0.6 0.8 4 20-37 7.5YR 4/4 f2f 10YR 4/6 8c 10YR 5/2 Sl 1 csbk mfr-mfi gs 1 M-Vf 0.4 0.7 5 37-50 5YR 4/4 f2f 7.5YR 5/8 8t 7.5YR 6/1 Sl Om Mfi 0.2 0.6 Boring # F] Boring Pit Ground surface elev. 97.00 ft. Depth to limiting factor in. .0,n1l AnnfirqtInn Pqtp Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 1 0-8 10YR 3/3 sil 3mgr ds cs 3m-vf 0.6 0.8 2 8-12 1 OYR 4/3 sil 1 mabkm') ds-dsh gs 2m-vf 0 .4c 0.6 3 12-21 10YR 4/4 - Sil 2mabk dsh gw 1 m-vf 0.6 0.8 4 21-33 7.5YR 4/4 f2d 7.5YR 5/8 & 10YR 5/2 f2f 7.5YR 5/8 & 7.5YR 6/1 SI sl 1 msbk 0M Mfi mfr-mfi gs 1 MM 0.4 0.2 0.7 M 5 33-46 5YR 4/4 old I = i i MA CST Name (Please Print) Signature CST Number Ryan Bechel (Advanced Environmental LLC.) 4-4--'.5�09 1330832 Address Date Evaluatiort"Conducted Telephone Number W1 1932 560TH AVE, Prescott, WI 54021 07/06/23 (651) 327-0074 bbu-0,5,ju tNu4vjn) 3 Boring # ❑ Boring 0 Pit -Ground surface elev. 98.00 ft. 1 Depth to limiting fact 20 i C %il Llnnlirnfinn Rata Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 *Eff#1 *Eff#2 1 0-8 10YR 3/3 - sil 2mgr mfr cs 2m-vf 0.6 0.8 2 8-13 10YR 4/3 - si! 1 mab -1 TOdsh gs 1 m-vf 0.4c 0.6 3 13-20 10YR 4/4 - sil 3mabk dsh-dh gw 1 m-vf 0.6 0.8 4 20-31 7.5YR 4/4 f2d 7.5YR 5/8 a 10YR 6/1 sl 1 csbk dh gs 1 f-vf 0.4 0.7 5 31-48 5YR 4/4 f2f 7.5YR 5/8 8t 7.5YR 6/1 sl 0m mf - - 0.2 0.6 4 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Anil Annliratinn Rata Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDIFt2 *Eff#1 *Eff#2 5 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Cnil Onnliratinn Rata Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDIFt2 *Eff#1 *Eff#2 * Effluent #1 = BOD, > 30 s 220 mg/L and TSS > 30 s 150 mg/L * Effluent #2 = BOD, > 30 s 220 mg/L and TSS > 30 s 150 mg/L Designer: Ryan Bechel O 2023 Advanced Certified Soil Tester- 1330832 Environmental LLC. ADVANCED, Designer of Engineering Systems: D 2263-7 All rights reserved. E N V I R 0, N N-1 E N T A SC*ALF 020' I I � -`� 1 40' lM > Planted trees 4—J M 0- C: In -field drainage I route (Avoid) F Shop with }� � 1BR living Future 3BRII �— Q----Juarters Home K, (approx.) Current grade 96.35 *All property lines not Benchmark SYSTEM NOTES drawn are > 1 00ft from Septic Tank: system* ti Soil Boring N "Well to be located >50ft Fromsoil treatment area & >25ft from tanks** to north P.L./ Ln 210TH AVE C/L 0) B2 9 7. 00 l J �,, d A Tree line L ±1901 + - i- --t - �- T-jo + 0 _W0TBV12 = 99.00 to east e op1" PVCpiI __ /-I '�\ P.L. 0 J_ + (21 above grade) + + + +rt BMI = 100.00 JWOOD§ Top nail in 26 11 split hardwood (24 above grade) Certified Staternent: This system has been designed and evaluated in accordance with State and Local codes. The soil treatment area must remain protected from disturbance and/or compaction before and after construction. NO WARRANTY IS MADE THAT THIS SYSTEM WILL CONTINUE TO FUNCTION INDEFINITELY. System must be properly maintained. Review your system's management plan for information on proW care and maintenance. Pump Tank: Soil Treatment Area: -Recommend minimum 16' sand -lift POWTS mound on 98-00 contour with 0.4gpdt2 loading rate "Deep plow (10-12') recommended to break up weak-platey soils in 82 & 83** -Depth to restriction = 20' (Redoximorphic features) -Contour = 98.00' -Slope = 2% Distr-ibution: -System will require pressure distribution LOCATION MAP (not to scale) 210TH AVE I C;11 SITE CD 1`1141-TARED FOR: Kyle Johnson Site Address: TBD 210TH AVE Deer Park, W1 54007 PID: 014-1040-10-300 20.78 Acres Legal: Lot 03 CSM 22-5352 NE 1/4 NE 1/4 S19 T31N R15W Town of Forest Scale: 1" = 40' Date: 7/6/23 SCC ArcGIS Web Map 6/26/2023, 3:27:33 PM 1.31227 0 105 210 420 ft ConservationEasement Lot and Units Park General Common Element Flood Hazard Areas Drainage Easement Lot Tax Parcels 0 30 60 120 m outlot ZONE A Public ROW Unit Limited Common Element Subdivision/CSM Boundaries ZONE AE VVDNR. SCC CDD. SCC CDD and SCC Highway Dept, SCC CDD, FEVIA, SCC CDD Web AppBuilder for ArcGIS SCC CDD I'vVDNR. SCC CDD I SCC CDD and SCC Highway Dept I FEIVIA, SCC CDD I CDD and NPS I National Geospatial-intelligence Agency (NGA), Delta State University: Esn I VVI Dept. of Natural Resources Division of Water I Wisconsin Department of Safety and Professional Services Division of Industry Services SOIL EVALUATION REPORT In accordance with SPS 385, Wis. Adm. Code Countv Attach complete site plan on paper not less than 8 1/2 x 11 Inches in size. Plan must include, ST Croix but not limited to: vertical and horizontal reference point (BM), direction and percent slope, Parcel I.D. scale or dimensions, north arrow, and location and distance to nearest road. 014.1040-10-300 Please print all Information. Reviewed by Date Personal irtfomlaon Y2M 2rovide may be used for seconds ur ses Prlvacv Law s. 15.Q4 1 m . Property Owner Property Location: Kyle Johnson Govt. Lot: NE NE '/4 S 19 T 31 N R 15 W Property Address Lot # Block # Subd. Name or CSM# TBD 210TH AVE 03 CSM 22-5352 City State Zip Code Phone Number ❑ City ❑ Village M Town Nearest Road Deer Park jWl 154007 (715) 529-5482 Forest 21 OTH AVE © New Construction USe: Q Residential/Numberof bedrooms 1-4 Code derived design flow rate 600 GPD ❑ Replacement ❑ Public or commercial -- Describe: "Shed with 1 bedroom living quarters and future 3 bedroom home" Parent material Loess over loamy till Vlasaty sil) Floodplain elevation if applicable NA ft. General comments and recommendations: Recommend minimum 16" sand -lift POWTS mound on 98.00 contour with 0.4gpd/U loading rate. LF = 20" (Redoximorphic lectures) "Deep plow (10-120) recommended to breakup weak-platey soils in S2 & 83" 1 Boxing # ❑ Boring [] Pit Ground surface elev. 9� R. Depth to limiting factor 20 in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh. Soil Application Rate GPD/Fe 2Eff#1 *Eff#2 1 0.9 10YR 3/3 - sit 3rngr mfr cs 3m-vf 0.6 0.8 2 3 9-14 14-20 10YR 4/3 10YR 4/4 - sit sil 2mabk 2mabk dsh dsh-dh gs gw 2m-vf 2m-vf 0.6 0.6 0.8 0.8 4 20-37 7.5YR 414 f2f 1 OYR 4/6 & 10YR 512 sl 1 csbk mfr-mfi gs 1 m-vf 0.4 0.7 5 37-50 5YR 414 1217.5YR 518 & 7.5YR 611 sl 0m mfi - - 0.2 0.6 2 Boring # ❑ Boring Pit Ground surface elev. 97.00 ft, Horizon Depth Dominant Color Redox Description Texture In. Munsell Qu. Az. Cont. Color / 0-8 10YR 3/3 - sit 2 8-12 10YR 4/3 - sit 3 12-21 10YR 4/4 - sil 4 21-33 7.5YR 4/4 12d 7.5YR 5/8 & 10YR 512 SI 5 33-46 5YR 4/4 1217.5YR 5M & 7.5YR 611 Sl Effluent ## BOD, 30 s 220 L and TSS > 30 s 150 CST Name (Please Print) Signature Ryan Bechel (Advanced Environmental LLC.) f;&j Address Date Evaluation W11932 560TH AVE, Prescott, WI 54021 07/06/23 Depth to limiting factor 21 in. Soil Application Rate x Structure Gr. Sz. Sh. Consistence I Boundary I Roots GPDIFt "Eff#1 *Eff#2 3rngr ds cs 3m-vf 0.6 0.8 1 mabk-1 mpl ds-dsh gs 2m-vf 0.4c 0.6 2mabk dsh gw 1 m-vf O.f 0.8 1 msbk mfi gs 1 m-vf 0.4 0.7 0m mfr-mfi - - 0.2 0.6 * Effluent #2 = BQD 5 30 m /L and TSS S 30 m CST Number 1330832 Telephone Number (651) 327-0074 SBD-8330 (R04115) 3 Boring # Boring 20 Pit Ground surface elev. 98.E ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh. Soil APpliqation Rate GPD/Ft� "Eff#1 'Eff#2 1 0-8 10YR 3/3 - sil 2mgr mfr cs 2m-vf 0.6 0.8 2 8-13 10YR 4/3 - sil 1 mabO mpi dsh gs 1 m-vf 0.4c 0.6 3 13-20 10YR 4/4 - sil 3mabk dsh-dh gw 1 m-vf 0.6 0.8 4 20-31 7.5YR 4/4 f2d 7.5YR 518 & 10YR 611 S1 1 csbk dh gs 1 fM 0.4 0.7 5 31-48 5YR 4/4 12f 7.5YR 518 & MYR s11 s1 Om mfr - - 0.2 0.6 oBoring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ftx •Eff#1 *Eff#2 5 Boring # ❑ Boring ❑ Pit Ground surface elev. �ft. Depth to limiting factor in. " Effluent #1 = BOD, > 30 s 220 mg/L and TSS > 30 5 150 mg/L ' Effluent #2 w BOD, > 30 5 220 mg/L and TSS > 305 150 mg/L _... __..._...... ... ... _ .. _. _...... Designer. Ryan Bechel Certified Soil Tester: 1330832 Designer of Engineering System, SCALE 20� 4. 0, In -field da �•. route (Avoi r . if l '/fjff i l ;eo 2023 Advanced ainage Environmental ! 1..C. ADVANCED : D 2263-7 All rights reserved. E N v I R o N M E N T A f f i � f �f r t f f �L f � � f Planted ! trees j � f _ f Q # Shop with 1BR living II Future 3BRI 1 quarters L. _ Horne E (approx.) Current grade 96,35 �...._ _._..._ _._. Es� ?,Ti+�i rrr;\ nPEN FIELD _. `All property lines not Benchmark drawn are > 100ft from Septic 'Conk: system* Soil Boring N Op�N �E�DPume Tank: Soil Treatment Area: 4koo wmW mrnim n 16' smd4rlt POWTS mwM on "Well to be located � SOft 9$.00 =lourt�, O�� rate " .� P� j0-`l t � tv weak � from soil treatment area & p** sws �, m*kim82 & >25f� from tanks** �=��'���} -Slope as 2% � to north P.L/ 210TH AVE C/L H 1 Distribution: .System will lure preu me dslntiorr LocAMN MaP (not to :o") 210TH AVE X r/ � �- �J� - 01011/ SITE x � � �- z... .....1. Tree 11011, i o tine 190, ~— PREPARED FOR: � BM2�= 99. � ~— to east Kyle Johnson .:.�.� site A�dress.. .. .._ _ . - .. . Ta i r` PVC ! � � P.L. + + �- -r p ' - - "b t - - - 4- - - T TBD 210TH AVE + (21rr move gfTa- -� +de) Deer Paris, W154007 BM = 100.00 PID: 014-1040-10-300 20.78 Acres 4WIC)o —�— +` Legal: Lot 03 CSM 22--5352 + + + * + Tep+nail in �16" spli hard ood NE 1/4 f a -- 'T T_ rt + + I- + -� 4- (24'` abov�efigrads19 T31 N R 5w Town of Forest Certified Swarm* This systov hos been aeaigm- aid @vakx sd in-coorbwos rrlt State and LOW codea. The sal Uvabn nt orso n rary protected from dvh�s and/or bstors and dtor won. Scale: 1" = 40' Date: 7J6J23 NO MAY IS AiADE TKAT hr<5 SYSTEM Yw.L COHTlI+ D Filhkil0�t I[�OEfM:1ay. 9ysterrr M&MA be properly mod. �tswiea Maur WeWre# rronagernerrt plan for iedarnwtion on proper acre and rnoir�6enan�aa. B2 / --- 4097.00 �����ia! VOL PAGE 5352 KATA�EA H . WALSH REGISTER OF DEEDS ST. CROIX Co, kI RECEIVED FOR RECORD 02/02/2007 12:10PH REC FEE : 13. 00 COPY FEE : 3, 00 CERTIFIED SURVEY MAP 'AGES: 2 LOCATED IN THE NE 4 OF THE NE 4 AND THE SE 4 OF THE NE 4 OF SECTION 19, T31N, R15W, �W TOWN OF FOREST, ST. CROIX COUNTY, WISCONSIN Lu '- cl oo C> o LIEQEW : • , G AN 00 cn 40� - INDICATES SECTION CORNER MONUMENT -2295 = w (AS NOTED) i NEW RICHMONDSi ; p - INDICATES 1" X 18" ( OUTSIDE DIAMETER) YVI IRON PIPE WEIGHING 1.13 LBS/ LIN. FT. SET �.Q �-.* �� ��r. �d w t-- - - 50 ST. CROIX COUNTY BUILDING SETBACK LINE •+"' .i tJ LLJu -- - FENCE s u R� �o m o UNPLA77ED LANDS N Y4 CORNE#2, NE CORNER, SECTION 19, SECTION 19, ( ALUMINIUM CAP FOUND) 210TH AVENUE NORTH LINE OF THE NE Y4 _7 7 ( ALUMINUM CAP FOUND) 1b�'�8'E —��N891� 46"E 1348.08' 1 s o4r -- �--- 32.07 50' WIDE 674.03' DRAINAGE 3a. 9' fi37.71' EASEMENT • - _ — — _ _ • ............ N89006'570E 13 ..111. 74' — — \- ��� LOT 1 ; Z 1 461,910 SQ. FT. 5a WIDE DRAINAGE EASEIANT( 29 EACH SIDE OF (11].60 ACRES) j CENTERLINE OF DRAINAGE SrvALE ) INCLUDING RNV \ 418,253 SQ. FT. c� (9 6 ACRES ) •� � '' i S + EXCLUDING RNV 98 MANMADINTERI�IITTEENT POND 5 ( WATERING . HOLE FOR Q \ %N1 CAME) � Lai ILu N89 35 35'W 672.42 PE co 636.38' 1 3so ` 4' � Q LOT N w 460,945 SQ. FT (10.58 ACRES) INCLUDING R/W - LOT 3 r � � 435 789 s . FT. � � �j905,028 SQ_ FT , Q g g _(20.78ACRES) • / (10.00ACRES) INCLUDING RNV ( cn EXCLUDING RN 1 w 884,099 SQ_ FT. \ ( 20.30 ACRES } \ 1 6 3 EXCLUDING RM 1 i EXISTING Z +y DWELLING � 523. 27' FRCVW SWCM l TO CEAfTBWjAE OFESW SERTiC 871.p$' SOUT LINE OF THE NEY OF THE NFy VENT 835.30' 1.06' p SHED : a N88"27' Z 342.1Z' "' 35.76 OVO&FiS: PARCEL DESCRIBED IN. LQN1 & KRISTIE ROSEN ������© �Q��� DOCUMENT NO. 828070 � 2078 270TH STREET DEER PARK, WI 67 j J � f PREPARED BY: I � ' 250' 5w 750' GRA BERG SURVEYIMG AMC. EYs CORDER, SECTION 19, 1235 C.T.H. `E" ( ESTABLISHED FROM TIES OF NEW RICI MOND, WI. W17 RECORD) SCALE IN FEET 1' = 250! PHONE ( 715 ) 246-7529 THIS INSTRUMENT DRAFTED BY: GSI JOB NO.064)36 SHEET I OF 2 Vol. 22 Page 5352 Document Number 1 Document Tide St. Croix County Accessory Structure Affidavit Y(& - -T—ahaw N me — (Owner) Typed or printed Hashe is the legal owner of the following parcel of land located in St, Croix County, Wisconsin, with their deed or document of ownership interest recorded as Document Number , 1153/00 St. Croix County Register of Deeds Office. This property is described as follows (include lot no. and subdivision/CSM or detailed legal description): SeG I T3IN R IS G/ PT fE AlF 3 5 1, (',96) 4+3 &0. 7 Jr AC) a6 1 N4 See attached deed copy for legal description 1!11 i o�41001 Tx:5177663 1170163 BETN PABST REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 08/IS/ 2023 09:09 AM EXEMPT #: REC FEE 30.00 PAGES: i Area Name and Y-Iurn Address Parcel Identifica n Number (PIN) o1q-10vo'-10-300 As owner of the above described property, I acknowledge that the Private Dnsite Wastewater Treatment System (POWTS) serves an accessory building on this lot and is sized for a future UJ bedroom home, or a design flow of gpd. This accessory building may not be used as a residence on this parcel. I also acknowledge that I will disclose this information and stipulation to any future parties interested in purchasing this property. V ACKNOWLEDGMENT R •`� ST` -n OF W1 CQN IN • • � }ss. - authenticated this day of 56 Wix County. } S+ 10y�eonally came before me this _ day ofire L.-I W-3- i�� 8�,�� • above named J N' op wISG°,•��` TITLE: MEMBER STATE BAR OF WISCONSIN //�lIrI111111����, to me known to be the (if not, persons) who executed the foregoing instrument and acknowledge the authorized by § 706.06, Wis. S(ets.) game. THIS IIMTS`E•RUMENT WAS DRAFTED BY: St. Croix County Community Development (Signatures may be, authenticated or acknowledged, Both are not necessary.) Notary Public, State of fflaconsin My Commissi n is vcmianent. If not, state expiration date: Date: UO)X'COUNTY No. 6s12 6z . .......... .. ........ . . .. . ... . .. .... . ..... ..... .. . . ........ .. .............. .. . .......... IAS tid 7 . . D►�/ [�117.Y►[�a 004 AV -'rM-w-"h n 22,6?oo W N F 10 CHAPTER 145.135 (2) WISCONSIN STATUTES (a) The purpose of the sanitary permit is to allow installation of the private sewage system described in the permit. (b) The approval of the sanitary permit is based on regulations in force on the date of approval. f c The sanitary permit is valid and may be renewedor a � � Y ]P Y specified period. (d) Changed regulations will not impair the validity of a sanitary permit. (e) Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. (f) The sanitary permit is transferable. History: 1977 c. 168; 1979 c. 34,221; 1981 c. 314 Note: 1f you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. 1 r' I I I I � A � ' � ,� 1 , 1 ..... ..... SBD-06499 (RI 1/20)