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030-1053-95-200
PRIVATE SEWAGE SYSTEM County: St. Croix Wisconsin Department of Commerce Safety and Building Division Sanitary Permit No INSPECTION REPORT 538811 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Hanson, Mark & Melinda St. Joseph, Town of 030-1053-95-200 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 8 G`J 23.30.19.198b20 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic r , Benchmark /.49 lbb Alt. BM e, 6A_ 3 Jr 7 - q qty. Bldg. wer o lad, zs E,~; ; Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet 5 TANK TO P/~ WELL BLD . Vent to Air Intake ROAD gHttut" S Septic Sa Dt ttom Ct Jfi 75 z 7 Header/Man. Q > go ' D . (0 FZ. S~ Aeration Dist. Pipe %,A C.2_ 4 Holding Bot. System 7 -7 . O tA Final Gr d PUMP/SIPHON INFORMATION M Manufacturer Demand St Covei 414-- GPM Model Number 4t-tee.. 47 . 5 ~ y TDH ift Friction Loss System Ft ~I / ~c f 'T's Forcemain en ia. Dist. to Well l• 4,75 SOIL 7 ABSORPTIO SYSTEM BEDITRENCH Widf Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS $ *,V e SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer, ~r L INFORMATION CHAMBER OR Type Of System: _I ~ UNIT Model Number Go~wevL~iis ~,72`t+ DISTRIBUTION SYSTEM Z1' !Z 1- I = 3 T _ Header/Ma~fold Distribution x Hole Size Ix Hole Spacing Vent to Air l takr, i1 Pipe(s) \ ~ Length3 jq. 4 Length~_ Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth f xx Seeded/Sodded xx Mulched Bed/Trench Cen r Bed/Trench Edges Topsoil os E] No Yes Nc t COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: / Location: 1458 Ridge Run New Richmond, WI 54017 (Gov't Lot 3 23 T30N R19W) NA Lot 7 Parcel No: 23.30.19 198b )0 F ' L ~aJ 2~ F; I 1.) Alt BM Description = 2.) Bldg sewer length - amount of cover Use other ls de for additional inforYes mation. No i / Date 4 Insepctor's S' nature Cert. No SBD-6710 (R.3/97) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No. (ATTACH TO PERMIT) 538811 0 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Hanson, Mark & Melinda St. Joseph, Town of 030-1053-95-200 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 23.30.19.198b20 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution ix Hole Size Ix Hole Spacing Vent to Air Intake I Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil 0 Yes ❑ No El Yes [ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / Location: 1458 Ridge Run New Richmond, WI 54017 (Gov't Lot 3 23 T30N R19W) NA Lot 7 Parcel No: 23.30.19.198b20 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? ❑ Yes ❑R No Use other side for additional information. Date Insepctor's Signature Cert. No SBD-6710 (R.3/97) Con vnerce.wi.gov Safety and Buildings 7f' ion County 201 W. Washington Ave., ox 7162 b sconsin Madison, W 15372 Sanitary Permit Number (to he filled in by Co.) i erce ~ o is N tuber f Sanitary Permit Application State Transacts" accordance with s. Cbmrn. 83 202), Wis. Adm. Code, submission ofthis form to the apte g -rumen unit is required prior it) obtaining a sanitary permit. Note: Application forms for staed PO TS arc Project Address (if d;fferent Jan ng address) suhmineri to rite Department of Commerce. Personal information you provide tI I for sect ary t u ses in accordance with the Privacy Law, s- I5.(}4 I (m , Slaw. //G/ t i, t~ lip cation Information- Please Print All Information Property Owner's Name 'I l} O 5 Parcel N (yl°)v~A 001A NSI, O~~ ©30" 10 U0 Property Owner's Mailing Addess N/iy & N 2pCO UIV7r Property Location l 1 \ v 1 dgyG OF pFF is /CE 70 1 J y G I~ W I~ V b - G GOVr Lot City Starr Zip Cork Phone Number a Section 3 r ] Q(cUncle one) Mltld 1 _ T Q M. R E or W I1. Tyype o Building (check all that apply) Lot H Subdivision Name m' 2 Faintly Dwelling Numl,et' of })cdroons ❑ Public/Commercial Describe Use 'r2LlL,/Y1ea Block U State Owned Descrihc I Ise CSM Numhcr village of ❑ Town of - t) - `C i L M. Type of Permit. (Check only on box on fine A. Complete line R if applicable) A. - ❑ New System 54eplacement System ❑ It Tank Replacement Only ❑ Other Modification to Existing System (explain) I.~~evjou~s Permit Number and s R. ❑ Pem,it Renewal Permit Revision ❑ Change 0f Plumber ❑ Permit Transfer to New f' P Berere Expiration Owner / 1 V. Tyie of POWTS System/Component/Device: (Check all that a~ - Non-Pressurized In-Ground ❑ Pressuized In-Ground ❑ At-Grade r ❑ Mowrd > 24 in. tfsu;table s0;1 ❑ Mound < 24 in. of suitable soil 0 Holding "tank U Other Dispersal Component (explain) Pretrealmenl Device (explain)_. V. Dis ersal/Trea tent Area InWrinatton: - DX-sign Flo(gpd) Design Soil A;s lication Rat gluist) Dispersa; Area Required (s - Dispersal Area Proposed x l) System Elevation q J_m_~ _J 1 Vi. Tank Info Capacity ;n 101,11 Hof Manufacturer Gallons Gallons Units o v u Net, Tanks Existing Tanks n ~a~ N c y o R Y a in yr ri U a, Septic or Holding Tank Dosing (hatnber VU. Responsibflity Statement- 1, the undersigned, assure responsibility for installation of the POWTS shown on the attached plans. PlumbeT•s Name (Print) 1 ml is Si re MP/MPRS Number Business Phone Number Plumber's Address (SS~ticet, City, State, 7ipCode) 0-7b /\~3 1Q;DJ Ow 1AY31-1c. VIl1. aunt /De artin it Use Only Approved ❑ ae~rtfvo Permit Pce Date Issued Issuin cot Sign, ~jetGive eason for Der 1 4~ ~t IX. CondilbVStt.(Opq easons for Disapproval / r 1. Septic tank, effluentfikerand ,3) ✓r 4e lI~- G~ G"~►~+~~ dispersal cell must all be servk:es / maintained a''s per management plan provided by plumber. ~S D ~ l.~~'• 2. Atsef back requirements must be maintained _ a~idab1+ectide / orlNnmrces. ~_y rPP ~ ~rr~ . Attach to complete plans fur the srsteor and submit to Ilse Conuly only on paper not less 111.11 a "1 x I 1 inches in size S13D-6398 (R- 01/07) Valid thni OI/09 0 0 op/00 ~ta~/~l~ ~ ~ c~ ~ v►~ - ~t GP ~Q 1 i s C3om~~ ~o t,) ~f v- - ? 1 a Uhf ~t pI ® 1 i 00 0 op/0 A4me. A ivv ~,bmot,~ aNd S~'O"~~ ~ i ~ IOU. t-f ~k~v bu k CVv n2 '6~.1~ }V ~ ~3' w 1 Po~S 97 ya ~~Y f 1~~ 1 r ~ r r r J CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: i mp~1~ It NO p~so ti t~ r'l Ylt Owner's Name: nn Owner's Address: %A Legal Description: S T Township: J y County: crtfyi~- Subdivision Name: Lot Number: ! Parcel ID Number: Q~Q~ (_y~3 J a Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan t Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber: l rvN A I A n License Number: a D I o Date: Phone Number Signature Designed pursuant to the I -Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-1070'5-P (N.01/01). Page 1 I ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Ch'vndr/Bttyer 131kk N I) J P ID NJ U 0 Mailing Address p d Property Address (verification required from Planning & Zoning Department for new construction.) city/State t!.K9 1 ~ Parcel Identification Ntttt~ber _ o~ D- l Ug,3' g s a 0 0 LEGAL, DESCItIPT'ION Proper ter L€scation /4 , `f4 , Sec. ~ 3 , T 3 Q N R ~ VII, Town of c~ ~ l~' - J Subdivision C, S 1'Y, Lot it , Certified Survey Map # _`7L 7ZY ~ Volttme ,Page # Warranty Deed # `7 V 7 4/ '70 , L'altjnae , Pale Spec house yes no Lot lanes identifiable yes no SYSTEM MAINTENAN+CIE AND +0►"' GERTIFI~A " Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in tithe waste disposal system. Owner maintenance responsibil t es are specified in §Cornm, 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by else o-ser and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necesst ry), tithe septic tank is less than ! /3 full of sludge. Mom, the undersigned 'nave react 't~rments and agree to maintain the private sewage disposal with the 0 standards set forth, herein, as set fs the i rtif'acation statin that Y rntrstrce and the Dcparttnent of Natural Resources, Slate of Wisconsin. f3 your septic system has b-opq intained must be completed and returned to the St. Croix+County Planning & Zoning'Departament within 30 days of the three yea'#` ►s~atson date. Ywe certify that all statements on this form;"e. fte to the best of my/our knowledge. I/we at*t/are the owner(s) of the property described alcove, by virihtie of a warranty t sded in Register of heeds (3ffice. Nu>a bar of bedrooms 3 s :eTAT ~ 8 t 31 11 PP~..ICA NT(S) DATE **'Any information that is raisrepresented spay rttsttlt in the sanitary permit being revoked by the Planning.& Zmaing Department. Include with this application a recorded war anty daedE fiomu the Register of Deeds Office and a copy of the cert' red survey map if reference is made in the warranty decd. (REV. 08105) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to cert'f that I have inspected the septic tank presently serving the me i~ I Lv~~, n, t~ p p-Ij 011~ residence located at: Sec. W Town of St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good con ition, and it appears to be functioning properly. Last time serviced ~ V Did flow back occur from absorption system? Yes No line. (if no, skip next Approximate volume r length of ti e: gallons minutes Capacity: W)) -T Construction: Prefab Concrete Steel other Manufacturer (if known): Age of Tank (if' known) : (Sign u e ) r ~61~ ►'h~P-f S~/j (Name) - Please Print (Title) ~ ~ ! V (License Number) 1 (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle)'.. Name Y`n btil A QA Signature MP,/MPRS Nov-11-2010 10.45 AM St. Croix County Plan/Zoning 715-386-4686 1/2 POWTS OWNER'$ MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner K N Irv A W~O~ Septic Tank Capacity ID~ Q al Cl NA Permit,# Septic Tank Manufacturer t)btn N WPB 0 NA DESIGN PARAMETERS Effluent Filter Manufacturer Poll, Lb M NA Number of Bedrooms ❑ NA Effluent Filter Model R L -;)S M NA Number of Public Facility Units ❑ NA Pump Tank Capacity al NA Estimated flow (average)ba gal/day Pump Tank Manufacturer NA Design flow (peak), (Estimated x 1,5) ~u al/da Pump Manufacturer NA Soil Application Rates . al/day/ftx Pump Model NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit NA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter 0 Peat Filter Biochemical Oxygen Demand (BODb) 5220 mg/L ❑ NA 0 Mechanical Aeration M Wetland Total Suspended Solids (TSSJ 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Bioohemioai Oxygen Demand (BODa) s30 mg/L IWIn-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L 0 NA ❑ At-Grade 0 Mound Fecal Coliform (geometric mean) s104 cfu/100ml 0 Drip-Line 0 Other; Maximum Effluent Particle Size )a in dia, Q NA Others ❑ NA Other: ❑ NA Other; C3 NA *Values typloal for domestic wastewater and 6eptlo tank effluent, other; 0 NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every; 3__ a M month(s) (Maximum 3 years) Ca NA ear(s) Pump out contents of tankla) When combined sludge and scum equals one-thlyd (Y) of tank volume ❑ NA Inspect dispersal cell(s) At least once every: 3 E) meaartthl! r s) (Maximum 3 years) C1 NA 1S ls Clean effluent filter At least once every: Q on W 0 NA Inspect pump, pump controls & alarm At least once every: C] month(s) NA C3 year(a) Flush laterals and pressure test At least once every: ❑ momh(s) NA ❑ ear(s) Other; ❑ month($) At least once every: ❑ earls) NA Other: III NA MAINTENANCE INSTRUCTIONS inspections of tanks and dispersal cells shall be made by an Individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, Identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface, The dispersal oell(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 an the ground surface may Indicate a failing condition and requires the Immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum In any tank equals one-third or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing operator and disposed of In accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of s12 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, OMW (4/01) Nov-11-2010 10:45 AM St Croix County Plan/Zoning 715-386-4686 2/2 1 START UP AND OPERATION Page - of - For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s), If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the Infiltrative surface. During power outages pump tanks may fill above normal highwatsr Isvels. When power is restored the excess wastewater will be discharged to the dispersal call(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Da not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 16 feet down slope of any mound or at-grade soli absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS; antibiotics; baby wipes, cigarette butts; condoms, cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; all., painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS falls and/or is permanently taken out of service the following steps shall lie taken to insure that the system Is properly and safely abandoned In compliance with chapter Comm 83.33, Wisconsin Administrative Code. • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed, • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void spsoe filled with soil, gravel or another inert solid material CONTINGENCY PLAN If the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system; A suitable replacement area has been evaluated and may be utilized for the location of a replacement soft absorption system. The replacement area should be protected from disturbance end compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells, Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area, Replacement systems must comply with the rules in effect at that time. 13 A suitable replacement area is not available due to setback and/or soil limitations. Marring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. 13 The site has not been evaluated to Identify a suitable replacement area. Upon faHura of the POWTS a soil and alto evaluation must be parformsd to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. O Mound and at-grade soil absorption systems may be reconstructed in place following removal of the blomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. C C WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ONTER A !SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCRS. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name y„ 1 D Name Phase 1~ ^ - d Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name 15 Kh@ ' S Name U U N Phone Q a~ Phone j " ^ This document was drafted in compliance with chapter Comm $3,22(2)(b)(1J(d)&(f) and 83,54(1), (2) & (3), Wisconsin Adminlstrativa Code, Soil Absorption System Cross Section -T.-_ r.-. ~b 4" Schedule -40 Final Gracie PVC Vent Pipe . , With Vent Cap S ft Leaching i Chamber r System Elevation =i- . ft Soil Absorption S}~stem an View tV 8r ft 3 'ft Leaching Trench 1 Chambers 4' Dia. " Vent Or Observation Pipe Trench 2 Header I Trench 3 Leaching Chamber Specifications - Manufacturer And Model _ l t,k -SJPt'`NAp n EISA Rating sq It per chamber Soil Application Rate, J-_ 9polsq ft gpd Design Flow Sail Application Rate C EISA = _33 _Chambers a rows of chambers each. Pane of pL~S25 Effluent Filter - Effluent Filters., Polylok J~jc. Page 1 of 2 Polylok Inc. 3 Fairfield Blvd Wallingford,. CT 06492 Call 4 Free: $88-765-9565 Emar '1: po ly lok.corn You are » Hera' 1.1o me a Product Details .......I EFFLUENT FILTER, Raising the bar in fitter technolc d :uJ arrbEiNT' ' adl PL-525 Effluent Filter Description ! Effluent Filters Polylok, Inc is pleased to add its new commercial filter to its existing line of effluent ! T quality ;Extend & LOkTM filters, The PL-525 is rated for over 10,000 GPO (Gallons Per Day) making it one of the largest commercial filters in its class, It has 525 linear feet of 1/16" filtration slots. Like the I Risers & Riser Covers Polylok PL-122, the new Pol lok PL-625 has an automatic shut off ball installed with every filter, When the fi:ter is removed for cleaning, the ball will float up and temporarily shut off Distribution Boxes anC the system so the effluent won'i leave the tank. No other filter on the market can make that !Accessories CIati-n! Pumps, Basins, Pump Ordering Information i and Step Systems Request a Quote Related Products u Seals / Gaskets Features Baffles, Sanitary Tees I Deflectors • Rated for 10,000 GPO (Gallons Per bay) + 525 linear feet of 1116" filtration j Reber Spacers Enlarge for details • Accepts 4" and 6" SCHD, 40 pipe + Built in Cas Deflector Handles and Receiven • Automatic shut-off ball when filter is removed • Alarm accessibility + Sins • Accepts PVC extension handle Landscape I Drainage The PL-525 Effluent Filter should operate efficiently for several years under normal Forms Clampa 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 Butyl S optional alarm, the owner will be notified by an alarm when the filter, needs servicing, i Butyl881a11tS Servicing should be done by a certified septic tank pumper or installer. Concrete Concrete Accessories Maintenance Instructions: Pressure Filters 1. Locate the outlet of the septic tank. Odor Crontrol Product 2, Remove tank cover and pump tank if necessary. i Rebar.Lok and CMU 3. Do not use plumbing when filter is removed, 4, Pull PL-525 out of the housing. Accessories 5. Hose off filter over the septic tank. Make sure all solids fall back into septic tank. Reber Safety and IQ C: 6. Insert the filter cartridge back into the housing making sure the filter is properly - , aligned and completely inserted. j Decorative Landscape 7. Replace septic tank cover. PL-525 Installation; Ideal for residential and commercial 1° waste flows up to 10,000 Gallons Per Day (GPO). Technical Spec iPtcatiot Installation Instructions: FRelated Product 1. Locate the outlet of the septic tank. i Pump, Filter and Sun 2. Remove tank cover and pump tank if necessary, i Filt Fll r la Riser 3. Glue the filter housing to the 4" or 6" outlet pipe, if the filter is not centered under Smer F!lt@rTM Panel an the access opening use a Polylok Externd & LokTM or piece of pipe to center filter. artrlter Control 4. 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CL cu U oy y • • O 3' z ~f\ •SL'28T 3 60 Tti.SO 3.00,SI.00S 8V3H OIL 0:3Wf1SSH 6.\ C3,.IS,02•SN> _ z . S3'JVd c 1❑1 1N3WN83ADO 30 3NI1 1SV3 3Hl Ol Q33N3M3338 388 S'JNIbV3H 00'E •338 AdO3 00 •E T • 338 038 HV00=60 EO0z/tE/T0 Q80338 808 WAI3038 lot , 3Q33Q 030 KU3.8LSI938 Fr9am • g "RIT L VX OStltt 3EIVd LL '[OA S•tiLLOG 4. 4.1 U 2 7 4 9 P 5 1 1 ?$-7 -4'930 `i State Bar of Wisconsin Form I - 2003 ]KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS Document Number Document Name ST. CROI X Co., WI THIS DEED, made between John R. Low and Randi C. RECEIVEIrl FOR RECORD Railsback Low, husband and wife 02/14/2005 01:35PH ("Grantor," whether one or more), and Mark F. Hanson and Melinda A. Hanson husband and WARRANTY DEED wife as survivorship marital property ("Grantee," whether one or more). REC FEE: 11.00 TRANS FEE: 1215.00 FEE: : Grantor, for a valuable consideration, conveys to Grantee the following CCPFEE described real estate, together with the rents, profits, fixtures and other PAGES: 1 appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): Lot 7 of Certified Survey Map recorded in Volume 17 on page 4450 as Document No. 707745 together with private road easement from town road and being a Recording Area part of Lots 1 and 2 of Certified Survey Map Name and Return Address recorded in Volume 5 on page 1346 and part of Title One Premier Group Government Lots 2 and 3, Section 23, Township 30 706 19th Street South North, Range 19 West, Town of St. Joseph Hudson, Wisconsin 54016 030-1053-95-200 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: Roadways, Easements, and Restrictions of Record. Dated 3 Z04S" (SEAL) (SEAL) John R. Low * ndi C. RaAlsback Low * (SEAL) (SEAL) * AUTHENTICATION ACKNOWLE terra Conxnisaion D0123948 Signature(s) STATE OF F~O )Expiru Am 09, 2006 ) ss. authenticated on COUNT ) Personally came before me on F_e jlGD,5' the above-named John R. Low AND * Randi C. Railsback Low TITLE: MEMBER STATE BAR OF WISCONSIN to me known to be the ner on(s) who executed the (If not, foregoi g instrument and acknow edged the same. authorized by Wis. Stat. § 706.06)y, THIS INSTRUMENT DRAFTED BY: * e a e. r Michael H. Forecki, Attorne Notary Public, State of ~t Eau Claire, Wisconsin My Commission (is permanent) (expire (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1-2003 *Type name below signatures. Attorney Michael H Forecki 3452 Oakwood Hills Pkwy Ste I, Eau Claire W1 54701-7928 Phone: (715) 835-3029 Fax: (715) 835-4112 T5588710.ZFX Title One Prem~r Gror1A, Produced with ZipFormTM by RE ForrnsNet, LLC 18025 Fifteen Mile Road Clinton Township, Michigan 48035, (800) 383-9805 www.zipform.com 730'S I Parcel 024-1000-60-000 08/05/2011 09:37 AM PAGE 1 OF 1 Alt. Parcel 04.28.17.4 024 - TOWN OF PLEASANT VALLEY Current ❑ ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner 0 - THOMPSON, GREGORY GREGORY THOMPSON 3240 STALOCH PL STILLWATER MN 55082 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description SC 2422 SCH D ST CROIX CENTRAL G/ SP 1700 WITC J Legal Description: Acres: 26.180 Plat: N/A-NOT AVAILABLE SEC 4, T28N, R17W, SE NE N OF INT HWY 94 Block/Condo Bldg: EXC E 45 FT. OF N 384 FT. TO HWY. TOWN- SHIP PLEASANT VALLEY. Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 04-28N-17W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 828/54 2011 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 04/29/2009 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.180 22,200 101,300 123,500 NO AGRICULTURAL G4 23.000 4,400 0 4,400 NO Totals for 2011: General Property 26.180 26,600 101,300 127,900 Woodland 0.000 0 0 Totals for 2010: General Property 26.180 26,600 101,300 127,900 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 2249 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations Attach complete site plan on County p paper not less than 8/: x 11 i hes in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference (BM), direction and percent slope, scale or dimemsions, north arrow, and I d j dice to nearest road. Parcel I.D. 030- 53-9 -200 Please print all inform on. Reviewe y Date Personal information you provide may be used for secondary pu vwy 4-4m))- Property Owners , o erty Location Mark & Melinda Hanson Govt. Lot 3 19 1 S 23 T 30 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1458 Ridge Run Road 7 CSM Vol. 17, Pg. 4450 City State ~j W)Xmber J City Village 0 Town Nearest Road Hudson W1 1 54016 1 7G OFF46-4427 St.Joseph Ridge Run Road 11 1 New Construction Use: 0 Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement J Public or commercial - Describe: Parent material Glacial Outwash Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for conventional POWTS dispersal cell with 0.7 gpd/sq.ft./day loading rate. Proposed system elev.= 91.75'. Existing dispersal cell elev. =92.40'. Boring # J Boring If Pit Ground Surface elev. 99.27 ft. Depth to limiting factor >129" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-10 10yr3/2 & 4/4 none Is fill na na as 3fm,2c na na 2 10-19 10yr3/2 none sil 2fgr ds cs 3fm,2c 0.6 0.8 3 19-28 10yr5/4 none sil 2fsbk mfr cw 2f,1mc 0.6 0.8 4 28-48 10yr4/4 none sl 2msbk mfr cw 2f,1m 0.6 1.0 5 48-74 10yr4/4 none slAs mix 1msbk/Osg mvfr/ml aw 1fm 0.4 0.7 6 74-129 10yr5/4 none s Osg dl - - 0.7 1.6 Profile of H#6 from 107" - 129" observed by use of hand auger through bottom of soil pit. Q1 -7AC it Boring # J Boring G ?.ti tmPit Ground Surface elev. 97.17 tt Dep h to ing factor >113" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-10 10yr3/2 none sit 2fgr ds cs 3fm,2c 0.6 0.8 2 10-20 10yr4/3 none sit 1 msbk ds as 2fmc 0.4 0.6 3 20-31 7.5yr4/4 none sl 1 msbk dsh cw 1 vf,fm 0.4 0.7 4 31-40 7.5yr4/6 none Is Osg ml cw 1vf,fm 0.7 1.6 5 40-113 10yr4/6 none s Osg dl - - 0.7 1.6 l~ p I * Effluent #1 = BODS> 30 < 220 mg/L ad TSS >30 < 40 mg/L * Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signatur : CST Number James K. Thompson 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 6/13/2011 715-248-7767 Property Owner Mark & Melinda Hanson Parcel ID # 030-1053-95-200 Page 2 of 3 3] Boring # Boring 601 Pit Ground Surface elev. 99.06 ft. Depth to limiting factor >139" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-7 1Oyr3/2 none sil 2fgr ds as 3fmc 0.6 0.8 2 7-21 1 Oyr4/3 none sil 2msbk mvfr gw 1 vf2fm 0.6 0.8 3 21-30 7.5yr4/6 none sicl 2fsbk mfr cw 1fm 0.4 0.6 4 30-70 1 Oyr4/6 none Ivfs Osg mfr cw 1 fm 0.4 0.6 5 70-79 1Oyr4/4 none sicl 2fsbk mfr aw - 0.4 0.4 6 79-139 1Oyr4/6 none s Osg dl - - 0.7 1.6 Profile of H#6 from 105"- 139" observed by use of hand auger through bottom of soil pit. J /1 Boring # J Boring F-1 r / Pit Ground Surface elev. 'Ift. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Q D& in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ❑ Boring # _I Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD5> 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 TTY 608-264-8777. SBD-8330 (R.07/00) A.C.E. Soil & Site Evaluations fl ~ .5oi/ e ✓a/ucL~r~,-~~17; f AeX%s& jbrade- eft/ lie cJ/, 6-KI7 a.raq, Lot 7 C.srr~ e%~ ~7~. y~S~sl? 0 O E° v ~ Lo t ,3, SeC ~,Z.3, i. Cdr(. sue. TA (10 • Lo 0,36 -/o.s"3 be 3, /z a ire s EXiJfinq cuC(~ :WY y 5epvc . ~~d 36adrce,y7 6°y"a~ 143Erc~cl ~Evr es,detce Concljb'o.7 un~rtdciJy, deLx / Bc„~ch n ~K : 13~•~, of / 42- c9gpt / d Sep6e /r n /e eat ! 11' \ O 1 e7ll e F oXiSfi~f 5 T 6yl 1 ce C Cxdl. le 0-11 f6Y-- ' B3 1 So t~. ~~Lihe (nct .'he 68, P~ 3 C{3 6sconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor ahd Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284201 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: LOW, JOHN ST JOSEPH CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header/Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. Fi Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I N LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION TypeO CHAMBER Mode Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched pt /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST JOSEPH.23.30.19W, SE, NE, RIDGE RUN Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. SANITARY PERMIT APPLICATION Bsafureau of Buetyand Buildinildig WaterlSystems 201 .O E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. C'rc~ I • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ CheckL"'f ievisitfn to~ ii 'application lPrivacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location 1/4 " 1/4, S T N; R%C E (oQ Property Owner's Mailing Address Lot Number~ Block Number [J' City, State Zip Code Phone Number Subdivision Name or CSM Number :vim ('l!~ . )2Y.6'. 531~lv II. TYPE OF BUILDING: (check one) ❑ State Owned E' it _ Nearest Road iage Public 1 or 2 Family Dwelling - No. of bedrooms _ ❑ ro n OF .3_~75 Z ~~1 v-a 111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo - } <~Z 0 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining 4 ❑ Church/School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1 ❑ New 2. ❑ Replacement 3. ❑ Replacement of 4. F] Reconnection of 5., Repair of an System System -------------Tank Only - Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 1 Seepage Bed 21 ❑ Mound 30 E] Specify Type 41 E] Holding Tank 12 Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade C Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation 9 1 U Feet Feet VII. TANK Capacity INFORMATION in gallons Total # of Prefab. Site Fiber- Ex er_ New Exlstin Gallons Tanks Manufacturer's Name Concrete Con Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank 1 41 ❑ El n ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 11 ET I ❑ ❑ Vill. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumbb 's Name: (Print) 2PIumbe ' ign ure: (No Stamps) ~7~MP/MPRSW No.: Business Phone Number: Plumber's Address (Str et, City, State, Zip Code): IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Si ps) 4Approved ❑ Owner Given Initial ~l Surcharge Fee) ! ~Z r Adverse Determination /S X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber I ~ ~ SyaI7 ~ Pod IVIA ' Ti, yz 54 I S-p 1 ~ ya 6N ~ I l00 wif consin Department of industry, SOIL AND SITE EVALUATION Labor and Human Relations Page of Division of Safety and Buildings in accordance is. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inche i PI unty include, but not limited to: vertical and horizontal reference poin ( dire s'rr L^ O percent slope, scale or dimensions, north arrow, and location a anc e~q rest r01 Paitel I. D. # - ►o5 --36 APPLICANT INFORMATION - Please print all inf tior*: Ell iewed by Date Personal information you provide may be used for secondary purposes (Pri s. 15.04 ( Property Owner erty -,TO~ Low n E 1/4 M E 1/4,S T 31D N,R 1 E (or) Property Owner's Mailing Address Bloc k# Subd. Name or CSM# 1459 y 13 y6 City State Zip Code Phone Number ❑ City ❑ Village M Town Nearest Road ~ ern LJt 5%1'7 (7,S ),24-S36Y $a" v% e- Qvij ❑ New Construction Use: Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow S D gpd Recommended design loading rate bed, gpde 1 S trench, gpd/ft2 Absorption area required (.43 bed, ft2 5(S~. trench, ft2 Maximum design loading rate! 7 bed, gpd/ft2 -V trench, gpd/ft2 Recommended infiltration surface elevation(s) 95. `AA ft (as referred to site plan benchmark) Additional design/site considerations Parent material Q I A Gi 4 L O V+ W A S, ) CO G,21 Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system S ❑ U [ A S ❑ U IBS ❑ U ®S ❑ U ❑ S ® U ❑ S K U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Ioya 3) L 1 F 6 ",V fr a F ~q ;t 12-20 01M $13 .L dMs w.fr Ground 20-32 10 f, q14 L m 5 F elev. w .3 May 32-40 7.5 4/q IS L, K rn i`r w I v F . 5 , le Depth to - 7'S -j 9, 4/ L W - 7 ,O limiting _ ,5 R $1116 fa_ctor in. Remarks: Boring # AA 11 Ground elev. ft. Depth to limiting factor in. Remarks: CST Name (Please Print) Signature Telephone No. T04% >1 ar xamylj~ 715 - 2y 9 - 3S V2 Address Date CST Number a a 007 St. 5to r Pr % , '~VI <N ea I_ l l owl 4.1 VA I ' I -I _ ` _ - - - I I I I L ' i I I I I ~ I I I ' I ,I I I I - - - 4- 1 - - o SIoQ ~ IL -1- L- t-- -i -r - - 1 g t. T r w . v~ t -1 - - - f - T, IL4 _ ~~~j,►1 L Isle e,c. an / - . --t-~ - - C CiFtr R Nt ~C Dn_~ _ ~ I I j ! ~ li r I ~ ~ I I i -f- I I ~ I I ( I I 1 j- 114 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the residence located at: ~ _V., Sec. . ? )_N, R_% j' W, Town of On,n St . Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? Yes / No (if no, skip next line. Approximate volume or length of time: le n gallons minutes Capacity: Construction: Prefab Concrete 4° Steel Other Manufacturer (if known): Age of Tank (if known): (Signa ure) (Name) Please int (Title) (License Number) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except for inspection opening over outlet baffle). y Name ~ Signature MP/MPRS 6 SE STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER (7,-7rj/i v r•" MAILING ADDRESS k , t PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE PROPERTY LOCATION, f - 1/4, i' 1/4, Section ~ _ , T va N-RAW TOWN OF ST. CROIX COUNTY, WI SUBDIVISION , LOT NUMBER CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has-been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 S T C - loo This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/ contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. owner of property Jchjn Location of propertyf-,_1/4 hJ f_ 1/4, Section Z:3 ,T ,.D N-R~ y W Township Mailing address Address of site Subdivision name Lot no. Other homes on property? Yes-_A No Previous owner of property Total size of property Total size of parcel Er - Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? Yes ~No Volume f--~`- and Page Number 500 Z as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. l/2l/ e2`~ and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. ' t ~GcI Signature of Applicant Co- plicant Date of Signature Date of Signature ewcUMENT NO. WARRANTY DEED I) 1N1i lR/1Ct RESERVED •OII RECOROINO DATA STATE BAR OF WISCONSIN FORM 2-1983 424339 774 FAR 503 -1 XEGISTERS 0MCE Audol h B Low and Norma G. Low, ST. CROIX Cut Wis P....... . . Wd. for Record t b_j tL. i day of Av_„ 11 ,_A.Dk 191.7 e~nveysand warranr~ to _..J, Low-and.Rand - Raj1sbacX------ 3.55 P AL -A i ~►oar....itusbi~st..aid.~tifa,.oint.tenamts..vriti rlghta-.a 01 i RurYiYUB111P...............••..---_......... . i ;i RETURN TO • . the following described real estate in St. CZbiX County, - _ - I Sate of Wisconsin: i Tar Parcel No: ~ Lot 2 of the Certified Survey Map filed for record in the office of the Register of Deeds for St. Croix County, Wisconsin on September 13, 1983, as Document jI No. 387721 in Volume "5", Page 1346 of Certified Survey Maps, which Map covers land conveyed to grantors herein by Richard D. Simon and Angeline Simon, his wife, by warranty deed recorded in the office of the Register of Deed for St. Croix County, Wisconsin, on January 30, 1987, as Document i No. 421867 in Book "767" Page 387,which is marital property of the grantees i herein; and a part of the land conveyed io grantors herein by Raymond H. Simon and Delia E. Simon, his wife by warranty deeds respectively recorded rv i in the office of the Register of Deeds for St. Croix County Wisconsin on August 14, 1948 in Book No. "295", Page 68, and on November 4, 1950 in Book No. 4 "295",. Page 589, which is non-marital property of the grantees herein. i 1 -'T This homestead property. (is) (is not) Exception to warranties: Dated this Stn day of ........_....Apr... . - - - - - - - 19..a~... - (SEAL) (SEAL) guolph E ow . = - (SEAL) . '(SEAL) Norma -G. -Ld - ' AUTHENTICATION ACHNOWLBDGUBNT ~I~ Signature(s) STATE OF 90MX as. BAM-S$Y.. County. authenticated this ---.---.day of_.......................... 19...... Personally came before me this 8.211.......... day of ARril____________________________ 19-117... the above named -••Rudcalph.R.--Law..and.IliormB.-G...LaYL........ ...husband--and-wife.......................................... TITLE: MEMBER STATE BAR OF WISCONSIN (If not- authorised by 1 706.06, Wis. Stats.) to me known to be the person .11.......-- who executed the me forego) instrum . ` i a, 7 OWNER PLAT TER RUDOLPH LOW JOHN LOW R. F. D. 4 R. F. D. 4 NEW RICHMOND, WISCONSIN 54017 NEW RICHMOND, WISCONSIN 54017 3$+ryF 0fir1 IW N 1h (f) x o m z D O v) (A 0 m o N. 50 20 511' C) D r c') E. 182.75' T- m m O D Z • W >:u H1 ® O • o O O Z Z m g iF v~ro Om C w w- z (A~ D -I cn 3~3 1 mO m~ m z :u 02 o 'o 90 4-I~j D O 0 Z _ Z O 06X -u 0 n Ir ~S o~ m~ OS-~ 0zzZ m D c) a C> F \ o Co z o O D D r om ° vm z o ID c Oa Z' n o v n 40 m n Z' 0 ? mmCD T n iy 1\) k Dr-mi co mo 0D0 T O OO C~ 0 G) C -n c: o U m m co n~ i y au O X X c z z o r O m z m a D nwi ~m o u-'i °0z0O z O m (A V) ca 2 --1 z S. 29' 33" o m n 'I 0 D> -n c- - 60.10 O 0 0 Co ro m O m a ~p N N 'y Z 0 CCD M Z~ r- T m- _ cn D 0 m O o z z .gy 320 m mm z r N) (A r D UJ A C g _ :U QD `J coOm rn a Asc O z m m z c~~,, FAQ X W ;o OD 0 0 D D D W c~ 0 O O O G) 0 m m 0 k w~ Z (A rri Z U U) D `90 A' 34.09' _ I n 4 -N m 115.34' 1 ~ m --i : Lo 1 N 0°-45'-56" W t N. 00 45' 56" W. 237.85' f Q z z3 w m - Z WOZ o m m m co y 71 -100 0 _xm I m in m y ib- m C ArP N I W ,P 1 RAVED ~ ~C ~ ~~1 N r N ° Ir Fr ° v o o z SEP1E D jL 61983 OD N ~N D = c la o 3198'-' , a) A"" p, co W cn $T, C~tO ao O v o 'o o c~ ~0hf4 ,t Nd~« PREtIFNSlYE p,COUltTY rn 1D 03 n, rW'a" , ,Q y ° xoN1No coM PIA Io 0 (A 0 Z m O e0 0 D D r o O m O W N 0 WfSconsin Department of Industry, SOIL AND SITE EVALUATION Labor and H;,pan Relations Page of Divi~n of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and 5or, C Ir percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # - IO5 -30 APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location o v% N Low Govt. Lot A SS 1/4 M E 1/4,S a3 T 3C) N,R I E (or) Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# 14 5 City State Zip Code Phone Number ❑ City ❑ Village M Town Nearest Road V.m WX 54o17 (715 )Q46-$362 51;t. S ose v, ❑ New Construction Use: Residential / Number of bedrooms Addition to existing building ❑ Replacement Public or commercial - Describe: Code derived daily flow J' D gpd Recommended design loading rate 7 bed, /ft2 gpd ~ trench, gpd/ft2 Absorption area required {a ~1 3 bed, 111:2 ~ V . trench, ft2 Maximum design loading rate----7--bed, gpd/tt2 _L $ trench, gpd/ft2 Recommended infiltration surface elevation(s) IS. ft (as referred to site plan benchmark) Additional design/site considerations Parent material Q 4G; a L p v+ W A S Co C .,;L*) Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U Unsuitable for system N S U SA S ❑ U E~:S ❑ U 9 s ❑ U ❑ S ®U ❑ S XU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench L i F 6 r hnvi Fr a F 4 5 Ground 3A 1 6 m $ w elev. 3 M6 1. K sn Fr w I F • to Depth to 7.5 90/9 5 - L W 17: A limiting so-so R s (a 5 s7 is R ; n. Remarks: Boring # s AAA cm~~ -At ft.. a d Ground elev. ft. , Depth to limiting factor in. Remarks: CST Name (Please Print) " Signature Telephone No. r'r► ar 715 - 24 g - 3SQR Address Date CST Number d -10611% St. Statr N-064-ie, %A '1 . 11- a- `~D11 r.