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016-1014-40-001
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division 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 Cindy Warner TOWN OF GLENWOOD CST BM Elev: Insp. BM Elev: BM Description: moo. `� o� S TANK INFORMATION TYPE MANUFACTURER CAPACITY terry Ae;a+e8- 35 esS Holding ❑�s� l Z � 5� TANK SETBACK INFORMATION 21-,' 4.,, TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Holding 2c9 pnciny t8'rl Hol� ding PUMP/SIPHON INFORMATION nuf cturer Demand GPM Model Number TD Lift Friction L s System Head T Ft Forcemain Length Di Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: 651283 State Plan ID No: Parcel Tax No: 016-1014-40-001 Section/Town/Range/Map No: 07.30.15.112A STATION BS HI FS ELEV. Benchmark Alt. BM Corocrc£T-C PAP W) 0oUtA- Vs J 2.7N 97. ZC, Bldg. Sewer 91.59 St/Ht Inlet $.sI clI. y9 n+� D-t-9 m HB.ader/ . Final -Grade.. St Cover BED/T H Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits inside Dia. Liquid Dept D NSIO S1 1 1 SETBA K SYSTEM TO P/L 131"DG WELL LAKE/STREA!V�I LEACHING anufacturer: 77 INFOR TION CHAMBER OR 1 UNIT T e Of System: Model Nu er: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) w Length Dia Length Dia Sp SOIL COVER x Pressure Svstems Only xx Mound Or At -Grade Svstems Only Depth Over Depth Over . e-f xx Seeded/Sodded Mulched Bed/Trench er ed/Trenc Topsoil ❑ Yes ❑ No Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1662 280TH ST 1.) Alt BM Description = P'DT-t'. 1) V .P 5f?j-sc. -rAOK 6vt L-JPS0 2.) Bldg sewer length = 3a -amount of cover - s '�+ 1) ��'� H°`'''I�' 74'�14 q;00 2�� � DP ��J£"'�- - i coQZY Plan revision Required? ❑ Yes [ No Use other side for additional information. t SBD-6710 (R.3/97) Date Insepctor's Signa ure Cert. No. RECEIVED b�;,�. �� ry 1 r7 ��r�:�tr�r � � �. 1 � a SIr � �'� 4,r�ti SAN-2023 -205 09/08/2023 5 _ Permit Number (to be 1 it 1t~d in b� Co 4 Via email P t )- - 2 �" State Transaction Number ` T 11 2�� ro ��� �. dtn C'Od _ SLIbIt�t i�� ik)i1 F1' t11 r C'orin to the appcopna .e �,overnr�3� ti U1I unit is rreLI � rC �i prI01 rtl ����r�aa.t �rro } lrar y � r� [� �r � � � �, � �� permit. hd{}r� ��'� F�'��� iti�,�w �t+ r,t� I ikr ��,.rl�� 1•I�a•�1 � � �',�..�•'� �hr� �trf�rr� itr�'�i t� rsc � parimerit yand � , ���.irr�l�ir i�tin � ���r ��r��% idc r�a�. 1used I'0r t���•,�nd,rr+�. �r 111c as' Pay .Vff 4,)' r i t f�)n Baas flareJ t� , CfLrVr %rat SE 'A NE V9, Section 07 1 . "Fpe of 11141jild Irr (,chick all fast appj ) � I or 2 Fam i I y r% eI Irn — N Lim bct o1"Bedroor-r, . � � � I Subdt ° pylon Name e � q Proposed '� — 7 fA ri _. �— CSM Number D V III age Of Y, 0 Town of F" pe 411TOAVI .V t r'mit. (Check either ' c%s or *1111(t W I I" '1POIlitsisfe Ott ling. A, CheLck, one box (in Line It. Complete line C it � � F � �t�r�7 � �C��4r 't��.}�.irli��rer�5r7 fit} I�:�isllrt !'����� •�t��n� ��r�l�t���r��a�rtt _'�. ® � stem e xluirt) El ;r , w ® 1 "t PrL, I US F1��rn1 it L,ni ker M�Iii Rat Issued 1��.��1 �.r !�vi�a�� ��p�.rt�� �tx�'I�r�b�.s I•r�r7�.lii�`� apt rti����. f���.n�r Fy Ptranon '. Dilisi rs a, I.!l.reaIit)ctiI.Are il ate V effluent '`'�'� ���� � � �3i r �t�ra r� F ��t� ��I:` �"r I, A -pe r,-al , .!a Rc�jkttre,,,, � �� � C�i �p��r:���L ti; � f °�: � o i�P k�ed (s�� �� � te rri Elevation �� 11atit)In ����� lr�ry� �����1 I�kn� �l�nit� 'J New Twik I- mtks 2 �Iscptic or Ftiu1di rig, .r mik 500 Chamber �t poll i hi l i ry S to lrtne" t� I the a ndt r5i stir d. as �a.rr�r >r'r pr 4��M 1 I,'Co kr� l I ti ro r� r ite [ IIAV I �� rN (Ike l'i 1 �� v�. V. ,�^F Pl Uniher s Dent: (Frith) 11 ijrn r s S li ar Nt 11:" t P R,S i' Uwber 4 USirtess Phone Number ti VI. Cate.atiD ari.niciii,, L7ac 0a,ly _ Ft� ftrti t hL� E-Lite Issued Issuing A g.erit �. Appr ved Disappro� r r i{ 8s r "/zoI zo 03 h 1 � SYSTEMOWNER: 2 44 1 SepfiC tank, effluent filter and dispersal cell[L MA-60 c� a� ire ✓' I � � 1 mU t be Serviced / maintained as per management plan provided by plumber, q) 6445 G � a, DOLAA S , All setback requirements rnust be maintained P1t0L^4-,-P—, s per applicable code / ordin ri w—e . Alinch up t o'm r,l�_� it ji1.1 io , 1.,,, s'il-v ,a'.Ii-ri i .i m.l ,, trrml le, Vi ( jru ntj a..rTYi % �i l+ td,1 E't" w� P11.0 4II1.1J is 44 12 16 1 1 i lWhCN Ilk .ir4t CONCRETE, HO,LDING TANK DESIG Smgle Tank Optlic'.10 INDEX AND TITLE SHEET c- bedroom Residerril�--1 1-fold'in Tar,,;� j a (D,yv r Cindv "Narner I-e-gLil Desctiption S E 1/ 4 N E 1, /4, S ec - 07, F-3 C, N,, R F Townshv Gknvvocd County S��, Su.bdivision Nan',,e Prociosed-:L`SM 11 umber front 016-1014-40-001 Trar)Sa:dlon IU Number wb� Index and t1le she,el Page Holdirig t�i,,* specifications, 1-1 a j e I -Ate plan P a e Main-, marl and cowi!'igem' plan 4 Tank Cross -Section P a c-, 5 Hold piii(i Propose'_'j U p a III k-2 Attac d Saii Skt,�Eva uation Report p a 8 hone No '1 41 Signaftire r 1 2" )ate Li�-.,ense NU C" E:I M ')0853 L Designed pursuiant'j'.'ra Holding Tank Ccm,',,onent Manual For I 10%,V'J'S N 2--1) May 2022-2027' Version 7,1 (07122') Page 1 of 8 CONCRETE HOLDING TANK DESIGN Single Tank Option INDEX AND TITLE SHEET Project Warner 3 bedroom Residential Holding Tank Owner Cindy Warner Address 1662 280th St. Glenwood City, WI 54013 Legal Description SE1/4NE1/4, Sec. 07, T30N., R15E. Township Glenwood County St. Croix Subdivision Name Proposed CSM Lot No. 1 Parcel ID Number from 016-1014-40-001 Plan Transaction ID Number Index and title sheet Page 1 Holding tank specifications Page 2 Site plan Page 3 Maintenance and contingency plan Page 4 Tank Cross -Section Page 5 Holding Tank Agreement Page 6 Proposed CSM Page 7 Attached Soil & Site Evaluation Report Page 8 Designer Dale Hudson Signature License Number MP 220853 Phone No. (715) 248-7767 Date 08/24/23 Designed pursuant to: Holding Tank Component Manual For POWTS (Version 2.1) May 2022-2027 Version 7.1 (07/22) Pagel of 8 HOLDING TANK SPECIFICATIONS E3 Number of bedrooms I Non-residential estimated flow (gpd) 2000.0 Minimum holding tank volume required (gal) 2500.0 Proposed holding tank capacity (gal) Wiese concrete Tank Manufacturer W-3000 Tank model number Rhombus SJE Alarm manufacturer Tank Alert 101-01 H lAlarm model number Tank Dimensions and Data X for round tank 53.0 Liquid depth below inlet invert (in) 4.0 Maximum depth of soil cover (ft) 71.0 Height (in) Outside 186.0 Length (in) Dimensions I 93.0 Width (in) Only Tank Anchor Calculations 20610 Ibs Weight of tank and cover 1.50 1 Safety factor 45915 Ibs Weight of anchor required 45.9 in Soil cover req. for anchor or 11.3 lyd3 Concrete counter weight HOLDING TANK CROSS SECTION manhole cover with locking device and finished vent cap junction warning label grade box ---> 4" min. 12" min. �23 in. Manhole and vent locations T conduit > vent pipe 18" min. blind plug to seal outlet tether weight --------------------------------------- t ---------- 12.0 in. service alarm on T Electrical as per 41.0 in. NEC 300 and SPS 316 Note: All tank joints, and joints between tank openings and piping are sealed watertight. All pipe and vent materials comply with SPS 384. building sewer inlet 3 in. bedding under tank. Tank is anchored as necessary to negate buoyancy. Project: Warner 3 bedroom Residential Holding Tank Transaction Number: Page 2 of 8 HOLDING TANK MANAGEMENT PLAN This Private Onsite Wastewater Treatment System (POWTS) has been designed, and is to be installed and maintained according to SPS 383, Wis. Admin. Code, the Holding Tank Component Manual (SBD-10855-P N. 03/071 R. 01/12), and the St. Croix County Sanitary Ordinance. 1. This POWTS is designed to accommodate a wastewater flow of 60.0 to 500.0 gpd. 2. The owner of this POWTS is responsible for system operation and maintenance, including all provisions in the attached Holding Tank Servicing Contract and Maintenance Agreements. 3. Each time the wastewater in the tank reaches 90% of the tank(s) capacity or a level of 12" below the inlet (at which time the alarm will activate), the pumper listed in the current Service Contract must be called to empty the tank's contents and dispose of them in accordance with NR 113, Wis. Adm. Code. 4. At each service event, the service provider should visually inspect the condition of the tank, risers and manhole cover(s) and verify that the alarm system functions and manhole locking devices are present. Discrepancies are reported to the owner in a timely manner for corrective action. All corrective actions shall comply with the county sanitary ordinance and SPS 383 and 384 Wis. Adm. Code. 5. All service events or inspections of this POWTS shall be reported to the county within 30 days. 6. The owner may not remove any of the wastes from the holding tank(s), or cause such wastes to be removed by any person not authorized to do so under Ch. 281, Wis. Statutes. The discharge of wastes tank to the ground surface, including intentional discharges and discharges caused by neglect, constitutes a failing POWTS and may result in issuance of correction orders or a citation by the county or state. 7. No one should enter a holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within these tanks may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. 8. In the event that this POWTS fails and cannot be repaired, a code compliant replacement holding tank may be installed in the same location (a new sanitary permit is required for such a replacement). Con- nection to municipal services would also be considered at this time if they are deemed available to the property. 9. If this POWTS is replaced, or its use discontinued, components no longer in use it shall be abandoned in accordance with SPS 383.33 Wis. Adm. Code. 10. If there is a problem with, or question about this installation, the following persons may be contacted: a. Installer ......................... Boldt's Plumbing & Heating Phone: (715) 684-3378 b. Service Provider ............... Power's Liquid Wate Management Phone: (715) 246-5738 c. Co. Zoning or Health Dept. St. Croix County Zoning Phone: (715) 386-4680 11. Project: Warner 3 bedroom Residential Holding Tank Transaction Number: Page 4 of 8 1831 4" CAST -A -SEAL 4" CAST -A -SEAL \ J FILTER OR J BAFFLE TOP VIEW V) c Q w ry . e. Mks INLET - OUTLET Lo 3„ � m 1e %n TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS WLP2500 TANK SPECIFICATIONS D 0 0 n DIMENSIONS: bi o WALL: 3" a_ a_ BOTTOM: 5" COVER: 6" o i MANHOLE: 24" I.D. PRECAST CONCRETE RISER HEIGHT: 55 1 /4 O.D. LENGTH: 183-1 /4" O.D. WIDTH: 101 1 /4 O.D. J w BELOW INLET: 43" O.D. V) Of o LIQUID LEVEL: 36" WEIGHT: TANK - 15,527 LBS. COVER 9,300 LBS. a_ o INLET AND OUTLET: o 4" CAST -A -SEAL BOOT OR EQUAL m o N o INLET AND OUTLET BAFFLE AND FILTER: Q w WISCONSIN, SEE DETAIL #10 Q J (OTHER STATES SEE CHART) 0 W LIQUID CAPACITY: 69.44 GAL/IN W HOLDING TANK: OUTLET HOLE PLUGGED (_0 ACTUAL CAPACITY: 2,639 GALLONS C oo Ln 0 LOADING DESIGN: 8' 0" UNSATURATED SOIL w00 �o TANK CAN BE USED AS: N SEPTIC/ HOLDING/ PUMP OR SIPHON W� I COVER: MIX DESIGN #8 (NO FIBER) 00 TANK: MIX DESIGN #9 (SMALL FIBER) W N 00 D CUSTOMIZED TANKS: FOR CUSTOM TANKS CONTACT WI ESER CONCRETE DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: o z Q N U W SHEET N0. OF 1 co 0 CD Sr. CR N ry SANITARY SYSTEM File #: Office Use Only OWNERSHIP/ADDRESS FORM C•eatea212a=1 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. Owner/Buyer Mailing Address City/State/Zip _ OWNER/BUYER INFORMATION Cindy Warner 1662 280th St. Glenwood City, WI 54002 Phone Number (required) Email Address (required) (715) 928-0366 BooBooCindy@HotMail.Com Parcel Identification Number 016-1014-40-001 (found on the property tax bill) Property Location SE 1/4 p y Subdivision Plat: NEW SYSTEM: LEGAL DESCRIPTION NE 1/4 , Sec. 07 , T 30 N R 15 W, Town of Glenwood un ME AM, A I I MV, � Lot # Certified Survey Map # v , Volume , Page # Warrant Deed # 810982 & 1139002 (before 2006)Volume 2920 , Pa e # 500 Y g Number of bedrooms 3 Spec house 0 yes E no Lot lines identifiable E yes 0 no OFFICE USE ONLY New Property Address � 4 p y (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 715-245-4250 Fax cdd@sccwi.gov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.aov DOCUMENT NO. STATE BAR OF WISCONSIN FORM 5-I982 PERSONAL REPRESENTATIVE'S DEED Cindy L. Warner, as Personal Representative of the estate of Michael Warner ("Decedent"), for a valuable consideration conveys, without warranty, to Jeffery A. Klaustermeier and Janine J. Klaustermeier, husband and wife as survivorship marital, Grantee(s), the following described real estate in St. Croix, St. Croix, St. Croix, St. Croix, St. Croix, St. Croix, St. Croix County, State of Wisconsin (hereinafter called the "Property"): Parcel 1: A parcel of land being located in the SE'/ of the NE'/ of Section 7, Towmship 30 North, Range 15 West, in the Town of Glenwood, St. Croix County, Wisconsin, described as follows: Beginning at the E'/ corner of Section 7; thence S89'01'33"W, along the East-West '/ line, 1319.11 feet to the West line of the SE'/ of the NE'/of said section; thence N0001014011E, along said West line, 1317.37 feet to the North line of said SE'/ of the NE/; thence N89'00123"E, along said North line, 1320.53 feet to the East line of the NE'/ of said section; thence S00114121"W, along said East line, 433.38 feet; thence S89001'33"WI) 592.64 feet; thence S00O14'21 "W 558.56 feet; thence N89001'33"E 592.64 feet to the East line; thence S00'14'21"W, along said East line, 325.90 feet to the Point of Beginning. The parcel shown on this document is being added to the parcel shown on the document recorded as Document No. 865368 on December 10, 2007 in the St. Croix County Register of Deeds Office, described as the Southwest Quarter of the Northeast Quarter (SW '/ of NE 1/) of Section Seven (7), Township Thirty (30) North, Range Fifteen (15) West, Town of Glenwood, St. Croix County, Wisconsin, to create one parcel, and this transaction is thereby exempt pursuant to Section 13.1 B. 3. of the St. Croix County Code of Ordinances, Land Use and Development. 1.1.39002 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 09/ 14/ 2021 08:37 AM EXEMPT*: REC FEE 30.00 TRANS FEE 384.00 PAGES: 1 **The above recording information verifies that this document has been electronically recorded & returned to the submitter RETURN TO St. Croix County Abstract & Title Co., Inc. 575 N. Knowles Ave., Suite #B New Richmond, WI 54017 Tax Parcel No: 016-1014-40-000 (past of) The Personal Representative by this deed conveys to Grantee all of the estate and interest in the Property which the Decedent had immediately prior to Decedent's death, and all of the estate and interest in the Property which the Personal Representative has since acquired. Dated this day p of September, 2021. 4-4(SEAL) * Cindy L. arner Personal Representative AUTHENTICATION Signature(s) authenticated this September 8, 2021. TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED Byd6) St. Croix County Abstract & Title Co., Inc. by Samantha Olson at the direction of the Grantor. SO/ 21-S27148 .................. (Signatures may be authenticated. or acknowledged. Both are not necessary.) *Nanics of persons signing in any capacity should be typed or printed below their signatures. ACKNOWLEDGMENT STATE OF WISCONSIN COUNTY OF y'�jJ") �C I ss. Personally came before me this of - 2021 ......... . ..... .. . ..... ... the above named Cindy L. Warner, Personal Representative of the Estate of Mich el Warner, to me known to be the person(s) who executed -r, g ins T nt and acknowledge the same. . Notary Public C ty, Wis. My Commission is permanent (If not, state expiration date:) `���i�t�ttll►��rrri r N 0 ,dam, l">1't a PERSONAL REPRESENTATIVE'S DEED St. Croix County 1139002 Page 1 of 1 p U 29 2 0P 500 State Bar of Wisconsin Form 3-2003 QUIT CLAIM DEED Document Number I I Document Name THIS REED, made between Frank Warner alkla Frank H. Warner and Donna Warner alkla Donna J. Warner, husband and wife ("Grantor," whether one or more), and Michael Warner ("Grantee," whether one or more). Grantor quit claims 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): Southeast Quarter of Northeast Quarter (SE 114 of NE 114) of Section Seven (7), Township Thirty (30) North, Range Fifteen (15) West. 4B 1 ell S3 4B KATHLEEN R. WALSH REGISTER OF DEEDS ST. CROI X Co, , v I RECEIVED FOR RECORD 11 / 02/ 2005 10:15AN 9U I T CLAIM DEED EXEMPT # 8 REC FEE TRANS FEE COPY FEE, EO FEE: PAGES: 1 Record ing Area Name and Return Address Thomas A. McCormack 1020 loth Avenue Baldwin, WI 54002 016-1014-40 Parcel Identification Number (PIN) This is not homestead property. ibis} (is not) Dated 0 01, 12005 SEAL SEAL AUTHENTICATION Signature(s) authenticated on TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by Wis. Stat. § 706.06 THIS INSTRUMENT DRAFTED BY: Thomas A. McCormack Baldwin, WI 54002 * Frank H. Warner (SEAL) � � G��t,�Y1�i-- (SEAL) * Donna J. Warner ACKNOWLEDGMENT STATE OF WISCONSIN } ST. CROIX COUNTY` Personally came before me on .� D the above -named Frank Warner alk/a FraO 14. Warpergod ,' , Donna Warner alkla Donna J. WarnerAL : to me known to be the ;per n(s) o ex :the oregaifig instrument d acknowledd the s e. Notary Public, State of WISCONSIN My commission (is permanent (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATION TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. QUIT CLAIM DEED STATE BAR OF WISCONSIN FORM NO.3-2003 *Type name below signatures. 0 State Bar of Wisconsin 2003 INFO -PRAT"" Legal Forms • (800)655-2021 - infoproforms.com f kL- V �t/ a - Document Number Document Title St. Croix County Holding Tank Agreement Permit Number - Name — (Owner) Typed or printed being duly sworn , states, under oath, that: Lc0iQ a__�) Dnc 0 �v-+Eq?o CP l . He/she is the owner/part owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume Page Document Number 1139194 St. Croix County Register of Deeds Office: Recording Area A parcel of land located in the SE 1/4 of the NE 1/4 of Section Address Name an Warner Cindy 07 , T 30 N — R 15 W, Town of 1662 280thSt. Glenwood St. Croix County, Wisconsin, being Glenwwood City, WI 54013 duly described as follows (include lot no. and subdivision/CSM or detailed legal description): 016-1014-40-001 Parcel Identification Number (PIN) Agreement Date: July 21, 2023 We acknowledge that application is being made for the installation of (a) holding tank(s) on the above described property or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private onsite wastewater treatment system as permitted under Ch. SPS 383, Wis. Adm. Code, or Ch. 145, Wis. Stats. As an inducement to the county to issue a sanitary permit for the above -described property, we agree to do the following: 1 . Owner agrees to conform to all applicable requirements of Ch. SPS 383, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the governmental unit or the Department of Commerce to prevent or abate a human health hazard as described in s. 254.59, Stats., the governmental unit (Town) may enter upon the property and service the tank or cause to have the tank to be serviced and charge the owner by placing the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.0703, Stats. 2. The owner agrees, pursuant to s. SPS 383.54 (2), and SPS 382.40(3)(e), Wis. Adm. Code, to have a water meter installed in the structure. The water meter shall be installed by a plumber authorized by the Department to make such installations, with said installation complying with State regulations and manufacturers specifications. The owner agrees to be financially responsible for the purchase, installation, maintenance, and repair of the water meter, and agrees to allow the governmental unit or the Department of Commerce to enter the above - described property on a regular basis to read and/or inspect the water meter. 3. Owner agrees to pay all charges and costs incurred by the governmental unit or county for inspection, pumping, hauling, or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any human health hazard caused by the holding tank. The governmental unit shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all the costs and charges may be placed on the tax roll as a special assessment for the abatement of a human health hazard, and the tax shall be collected as provided by law. 4. The owner agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code, to have the holding tank serviced and to file a copy of the contract with the governmental unit. The owner further agrees to file a copy of any changes to the service contract, or a copy of a new service contract, with the governmental unit within ten (10) business days from the date of change to the service contract. 5. The owner agrees to contract with a person licensed under Ch. NR 113, Wis. Adm. Code, who shall submit to the county on a semiannual basis a report detailing the servicing of the holding tank. The governmental unit or county may enter upon the property to investigate the condition of the holding tank when pumping reports and meter readings may indicate that the holding tank is not being properly maintained. 6. This agreement will remain in effect only until the county office responsible for the regulation of private onsite wastewater treatment systems certifies that the property is served by either a municipal sewer or a private onsite wastewater treatment system that complies with Ch. Comm 83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 7. This agreement shall be binding upon the owner, the heirs of the owner, and assignees of the owner. The owner shall submit this agreement to the register of deeds, and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. Owner(s) Name(s) - Please Print Subscribed and sworn to before me on this date. - Cindy Warner Notarized Owner's Signature(s) Notary Public Governmental Unit Official Name, Title - Please Print My Commission Expires Dale Berends, Town Chair August 31, 2023 Governmental Unit Official Signature Drafted by: James K. Thompson rersonai information you proviae may oe usea Tor seconaary purposes Lrrnvacy Law S. -I5.u4(11[m)! "THIS PAGE IS PART OF THIS LEGAL DOCUMENT — DO NOT REMOVE" This information must be completed by submitter document title, name & return address, and PIN (if required). Other information such as the granting clauses, leagal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document. Note: Use of this cover page adds one page to your document and $2.00 to the recording fee. Wisconsin Statutes, 59.43. Pg. 6 of 8 Ljepai-trn ent of Safety and Profess ion all Ser-vices Page 1 of Division of IndustrY Services JUL 11 2023 SOIL EVALUATION REPORT 111 2CCOFd a n ce VtL. _C County St. Croix Co. Attach Cnr�vew:e to plan on paper not less than 8 1/2 x 11 inches in size P121-1 MUSt Include, but rlu- IoN,,,,ited to vertical and liorizontal reference point (13M) direction and percent slope, Parcel I.D. scale or dimensions, north arrow and location and distance to nearest road 016-1014-40-001 Ref #2689 Please print all information. Reviewed by Date Personal information Y ors p r ov d e rrl,nY U se d for second- ry p u rp o s e ri v a y Later. s. 15,94 CljAm)), Property Owner Property Location Cindy Warner Gout Lot SE YA NE 1/4 S 7 T 30 N R 15 E (orb W Property Owner's Mailing Address Lot Block # Sjbd Name or CSM# 1662 280", St- 01 Na Prqpqqsed CSM City State Zip Code Phone Number Ej city D village 0 Town Nearest Road Glenwood it VVI 54013 t lenwood 70"' Ave L] New Construction use, Residential !N Umber of bedroot -n s ' 3 Code derived design flow rate 460 GPD 0 Replacement Pubiic or commercia I - Describe Parent material Glacia I drift — Flood Plan elevation if appliiicabte rya ft. t7 G ' I Its ano.' recommendations- Soil and site conditions are unsuitable for Mound PO WTS withQLA IndividualSAe Design and/or Interpretive approvais Boring # Boring Z Pit Gr&nd surface elev, 92 26 ft Depth do limiting factor 18" in. Snil Annllrnfinn Rafe Horizon Depth Ili. Dominant Color Munsell Redox Description Qu A7- Cont Color Texture sil Structure Gr. Sz. Sh. 1 fgr Consistence ds Boundary CS Roots 2vf,f GPDR2 "Eff#1 *Eff#2 0.4 0.6 1 0-7 1 0yr3/3 none 2 7-11 1 Oy r416 none Sill 2fsbk ds CW lvf,f 0.6 0.8 3 11-18 1 0Y 1-414 7.5yr4/4 7.5yr416 none f2d 7 5yr518 5yr5), d f27 8 sil sili 1fsbk mfr CW 0.4 0.6 4 18-28 I rnsbk dsh CW 5 28-41 heavy lcsbk dsh 04 0.sil . ........ . .............. Boring j I Boring El P it Ground surface elev 92.23 k Depth to limiting factor 22" in qn11 Amnlirntinn PMA Depth 1 0-8 Dom inarit, Color Munsell 1 Oyi-3/3 Redox Description Qu Az. Cant Color none Texture Sill Structure Gr Sz. Sh 2fgr Consistence i"Eff#1 FBoL1r1da'--.Y Roots GPDIFt2 0 E ff #2 0.8 ds Cs 2vf,f 2 8-13 1 Oyr414 none sil 2fsbk ds CW 2vf 06 0.8 3 13-22 7.5yr4i4 none Sl 2msbk dsh CW 2vf 0 6 1.0 4 22-42 7.5yr4/4 c2d 7 5YR5/8 sl 1 msbk dsh 1 Vf 0 4 0,7 - Lttluent 91 = 16IJU. > 6U �-:- ZZU Mg.-L and I bZ> > JU S 1W MgIL tmuent ;Fz = t5uL), > -5IJ S ZZV Mg/L aF10 100 -," JU � I UIJ !-flgL, CST Name (Please Print) signatwe CST Number James K. Thompson z 30021 va Address Date i luation Conducted Telephone Number L I I ( ,40 P�,- Lake Lane- Osceola, WI 54020-5413 June 22 2022 715 248 - i,167 SBCC-8330 (R04/15) ❑ 3 Boring # Boring Ground surface elev. 91.56 ft. Depth to limiting factor 23" in. Horizon Depth Dominant Color Redox Description In. Munsell Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots Soil Application Rate GPD1Ft2 *Eff#1 *Eff#2 1 o-8 1Oyr313 none sil 2fgr ds aw 2vf,f o.fi o.8 Z 8-13 1 Oyr414 none sil Zfsbk ds cw 1 vf,f 0.6 a.8 3 13-23 7.5yr414 none sil 1 msbk ds cw 1 of 0.4 o.6 4 23-38 1 Oyr514 f2d.7.5yr518 sil 1 csbk ds - - 0.4 0.6 El Boring 4 Boring # Pit � Ground surface elev. Na ft. Depth to limiting factor a" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1Ft2 In. Munsell Qu. Az. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-7 1 Oyr414 c1 f 7.5yr414 sil fill 1 thin pl mvfr ci 3vf,f 0.0 0.0 Z 7-13 1 Oyr313 m1 d 7.5yr414 sil 1 fsbk mvfr gw Zvf,fm 0.4 o.fi 3 13-22 1 ayr3/2 c1 d 7.5yr4/4 sil 1 msbk mvfr gw 1 fmc 0.4 0.6 4 22-33 1 ayr313 m2p 7.5yr418 sicl 1 csbk mfr gw 1 fm 0.2 0.3 5 33-46 1 oyr411 m2p 7.5yr4/8 si 1 csbk mfr - - 0.4 0.6 ❑ Boring 5 Boring # Pit Ground surface elev. Na ft. Depth to limiting factor 0" in. Soil Application Rate H r) r Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1Ft2 In Munsell Qu. Az. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 "i ° 7-7 1 ayr414 'c1 f 7.5yri14 sil 1 fgr mvfr cs 3fm1 c 0.4 0.6 2 7-12 1 ayr3/3 c1 d 7.5yr414 sil 1 fsbk mvfr gw 2fm1 c 0.4 o.6 3 12-24 1 ayr3/3 m 1 d 7.5yr414 sil 1 msbk mfr gw 1 fm 0.4 0.6 4 24-40 1Oyr3/3 m2p 7.5yr418 heavy Sil Om mf gw - 0.0 0.2 5 40-52 1 1 ayr3/3 c2p 7.5yr418 sil Om mft - - 0.0 0.2 * Effluent #1 = BOD, > 30s 220 mg/L and TSS > 30s 150 mg1L * Effluent #2 = BOD, > 30s 220 mg1L and TSS > 305150 mg1L i fi1 Boring # [:1 Boring g ® Pit Ground surface elev. 92.37 ft. Depth to limiting factor 0" in. Anil Annlir--4tinn F?ata Horizon Depth Dominant Color In. Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDIFt2 *Ef1#1 *Eff#2 1 0-9 7.5yr313 fif 7.5yr414 sil 2fgr mvfr cs 2vf o-6 0.8 2 9-17 10yr514 c1 d 7.5yr41fi & f2d 1 � W sil 1 fsbk mvfr gw - o.4 o-6 3 17-26 110yr514 m2p 7.5yr518 & m3p 1 o r6/2 SO 0m mfr gw - 0.0 0.2 4 26-36 1 oyr514 m3p 7.5yr416 & 10 t$I2 sic[ 0m mfr aw - 0.0 0.0 5 36-46 2.5yr314 none gr scl 0m dh - - 0.0 0.0 I A Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Anil Annliratinn Rate Horizon Depth In. Dominant Color Munsell Redox Description Texture Structure Qu. Az. Cont. Color Gr. Sz. Sh. Consistence Boundary Roots GPDIFt2 *Ef1#1 *Eff#2 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Anil Annlieatinn Rate Horizon Depth In. Dominant Color Munsell Redox Description flu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDIFt2 *Ef1#1 *Ef1#2 IL * Effluent #1 = BC D, > 30 5 220 mg/L and TSS > 30 5 150 mg/L a * Effluent #2 = BC D, > 30 5 220 mg/L and TSS > 30 5 150 mg/L r Warner Soil & Site Evaluation 1662 1651h St.; Glenwood City, WI 54013 Site suitability associated with area of soil borings B 1 - B3 The soil conditions at this location are marginally suitable for a mound POWTS. However, the size of the area and the associated slopes are not suitable for the construction of a mound. The site plan associated with this report shows a possible mound design that would require an Individual site design and State approvals prior to final determination of site suitability. Soil conditions throughout the proposed parcel and immediately north of the property are not suitable for a mound POWTS and do not appear to be a good candidate for an Interpretive Evaluation. r r Pg. 4 of 5 5114v oe4r S. cy, r4n (,< "Z7 16 I Cl-C ev �ff mahm u o 4 5�oir Codo! - S Ig 5- Wisconsin Department of Safety and Professional Services Page 1 of 4 Division of Industry Services SOIL EVALUATION REPORT In accordance with SPS 385, Wis. Adm. Code I County St. Croix Co. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, 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. 016-1014-40-001 Ref #2689 Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes Privacy Law, s. 15.04 1 m . Property Owner Property Location ❑ Cindy Warner Govt. Lot SE 1/4 NE 1/4 S 7 T 30 N R 15 E (or) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1662 280th St. 01 Na Proposed CSM City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road Glenwood Citv WI 54013 1 ( ) Glenwood 70th Ave. ❑ New Construction Use: ® Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD ® Replacement ❑ Public or commercial — Describe: Parent material Glacial drift Flood Plan elevation if applicable na ft. General comments and recommendations: Soil and site conditions are unsuitable for Mound POWTS without Individual Site Design and/or Interpretive Determination approvals. 1 Boring # ❑ Boring ® Pit Ground surface elev. 92.26 ft. Depth to limiting factor 18" in. Snil Annlirntinn Rate 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 0-7 10yr3/3 none sil 1fgr ds cs 2vf,f 0.4 0.6 2 7-11 10yr4/6 none sil 2fsbk ds cw 1 vf,f 0.6 0.8 3 11-18 10yr4/4 none sil 1 fsbk mfr cw - 0.4 0.6 4 18-28 7.5yr4/4 f2d 7.5yr5/8 sil 1 msbk dsh cw - 0.4 0.6 5 28-41 7.5yr4/6 f2d 7.5yr5/8 heavy sil 1 csbk dsh - - 0.4 0.6 2 Boring # ❑ Boring ® Pit Ground surface elev. 92.23 ft. Depth to limiting factor 22" in. Anil Annliratinn Rate 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 10yr3/3 none sil 2fgr ds cs 2vf,f 0.6 0.8 2 8-13 10yr4/4 none sil 2fsbk ds cw 2vf 0.6 0.8 3 13-22 7.5yr4/4 none sl 2msbk dsh cw 2vf 0.6 1.0 4 22-42 7.5yr4/4 c2d 7.5YR5/8 sl 1 msbk dsh - 1 of 0.4 0.7 w Ftth ipnt #1 = ROF) > :in < 22n mn/I anti TSS > -in < 1-n mn/I w FttiuPnt #7 = ROF) > -in < 22n mn/I anrf TSS > -in < 1 -f-i(] mn/I CST Name (Please Print) Signs a CST Number James K. Thompson 30021 Address Date valuation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020-5413 1 June 22, 2022 715 248-7767 3 Boring # ❑ Boring ® Pit Ground surface elev. 91.56 ft. Depth to limiting factor 23" in. Anil Annliratinn Rate 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 10yr3/3 none sil 2fgr ds aw 2vf,f 0.6 0.8 2 8-13 10yr4/4 none sil 2fsbk ds cw 1 vf,f 0.6 0.8 3 13-23 7.5yr4/4 none sil 1 msbk ds cw 1 of 0.4 0.6 4 23-38 10yr5/4 f2d.7.5yr5/8 sil 1 csbk ds - - 0.4 0.6 4 Boring # ❑ Boring ® Pit Ground surface elev. Na ft. Depth to limiting factor 0" in. Snil Annliratinn Rate 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 0-7 10yr4/4 c1f 7.5yr4/4 sil fill 1 thin pl mvfr ci 3vf,f 0.0 0.0 2 7-13 10yr3/3 m1 d 7.5yr4/4 sil 1 fsbk mvfr gw 2vf,fm 0.4 0.6 3 13-22 10yr3/2 c1 d 7.5yr4/4 sil 1 msbk mvfr gw 1 fmc 0.4 0.6 4 22-33 10yr3/3 m2p 7.5yr4/6 sicl 1 csbk mfr gw 1 fm 0.2 0.3 5 33-46 10yr4/1 m2p 7.5yr4/6 si 1 csbk mfr - - 0.4 0.6 5 Boring # ❑ Boring ® Pit Ground surface elev. Na ft. Depth to limiting factor 0" in. Anil Annliratinn Rate 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 0-7 10yr4/4 c1 f 7.5yr4/4 sil 1 fgr mvfr cs 3fm1 c 0.4 0.6 2 7-12 10yr3/3 c1 d 7.5yr4/4 sil 1 fsbk mvfr gw 2fm1 c 0.4 0.6 3 12-24 10yr3/3 m1 d 7.5yr4/4 sil 1 msbk mfr gw 1 fm 0.4 0.6 4 24-40 10yr3/3 m2p 7.5yr4/6 heavy sil Om mfi gw - 0.0 0.2 5 40-52 10yr3/3 c2p 7.5yr4/6 sil Om mfr - - 0.0 0.2 * Effluent #1 = BOD, > 30 <_ 220 mg/L and TSS > 30 <_ 150 mg/L * Effluent #2 = BOD, > 30 <_ 220 mg/L and TSS > 30 <_ 150 mg/L 6 Boring # ❑ Boring ® Pit Ground surface elev. 92.37 ft. Depth to limiting factor 0" in. Anil Annliratinn Rate 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 0-9 7.5yr3/3 fif 7.5yr4/4 sil 2fgr mvfr cs 2vf 0.6 0.8 2 9-17 10yr5/4 c1 d 7.5yr4/6 & f2d 10 r6/3 sil 1 fsbk mvfr gw - 0.4 0.6 3 17-26 110yr5/4 m2p 7.5yr5/8 & m3p 10 r6/2 sil Om mfr gw - 0.0 0.2 4 26-36 10yr5/4 m3p 7.5yr4/6 & 10 r6/2 sicl Om mfr aw - 0.0 0.0 5 36-46 2.5yr3/4 none gr scl Om dh - - 0.0 0.0 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Snil Annliratinn Rate 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 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Snil Annliratinn Rate 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 * Effluent #1 = BOD, > 30 <_ 220 mg/L and TSS > 30 <_ 150 mg/L * Effluent #2 = BOD, > 30 <_ 220 mg/L and TSS > 30 <_ 150 mg/L Warner Soil & Site Evaluation 1662 165th St., Glenwood City, WI 54013 Site suitability associated with area of soil borings B 1 - B3 The soil conditions at this location are marginally suitable for a mound POWTS. However, the size of the area and the associated slopes are not suitable for the construction of a mound. The site plan associated with this report shows a possible mound design that would require an Individual site design and State approvals prior to final determination of site suitability. Soil conditions throughout the proposed parcel and immediately north of the property are not suitable for a mound POWTS and do not appear to be a good candidate for an Interpretive Evaluation. SCALE IN FEET 111 = 100' 0 100, 2001 OWNER CINDY WARNER 1662 280TH ST. GLENWOOD CITY, WI 54013 LINE BEARING DISTANCE Ll N85044'04"W 67,36' L2 N41004'15"W 94,49' L3 N85044'04"W 86,61' L4 N41004'15"W 126.64' L5 N61042'07"W —1--28.101 DETAIL "All OUTLOT1 S89001'33"W 592.64' 279,82' 279-81' 33.01' r 559,63' 6 6' ce m 06 06 LO WELL LOT 2 ° N 06 Ln 00 Ln a EXISTING D C= .j --,N89001'33"E 286.62' m © \1 58.77' J.. —23":129.61' 253.61' 33.01 co cn C) HOUSE 06 zo GARAGE C) CS- c:F -�r Lu Lul Z) SEPTIC TANK X uj B OG�� LOT 1 lZo M C) I C) V, rN 0 C) SEPTIC VENTNI 00 C) 0 z r" C) C) 01 T--i 286,62' 306.02' 126.81' 253.61' 126,80' 33.01 N89001'33"E 592,64' OUTLOT 1 k I J j 1 33 SHEET 2 OF 3 SHEETS Pg. 7 of 8 Matthew Traynor From: jule@boldts.com Sent: Thursday, September 7, 2023 2:22 PM To: C D D; Kevin G ra ba u Subject: Cindy Warner Holding Tank Permit Application Attachments: Warner Sanitary Permit Application Package.pdf; Warner_HoldingTank_Signed.pdf have attached the permit application for the holding tank on the Cindy Warner Property, 1662 280t" Street in Glenwood City. The original Holding Tank Agreement has been submitted to the Register of Deeds Office and the recording fee paid. They were going to give Kevin the original after recording. am happy to pay HT fee by credit card. Please let me know if you need anything else. Thank you so much for you help. Jule Hudson Boldt's Plumbing & Heating 715-684-3378 Baldwin 715-386-4445 Hudson Boldts.com OWNER Ciftiby Wftedef, PLUMBER �AL-C ttuQ$o/�( LIC.# z2oS573 TOWN OF C,t�n�v�oop SEC Nq ADAJ6 X 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.. (c) The sanitary permit is valid and may be renewed for a 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: If you wish to renew the permit, or transfer ownership of ^ C�rTDT7`77 C�rOl�7 I the permit' please contact the cauuty authority. ,c.. �71J 1)11 /V 1�71 11 ji� Vft 11111 A aUT� ORIZED ISSUING OFFICER — DATE 9Vzo)?ZZ3 TAIS ERMIT EXPIRESIVA I.0 SBD-06499 (RI 1/20) . . . . . .... . ... . ... . .. . .. 1. Y..M .. . . ..... . ... . ... ..