HomeMy WebLinkAbout592147 020-1133-00-000Wisconsin 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
Richard & Jodi Nelson I TOWN OF HUDSON
CST BM Elev: IInsp. BM Elev: BM Description:
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
Aeration
Holding
TAME[ c1=TRArK INFORMATION
TANK TO
P/L
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PI IMP/RIPHON INFORMATION
Manufacturer Demand
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcema,n Length Dia. Dist. to well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
County St. Croix
Sanitary Permit No:
592147
State Plan ID No:
Parcel Tax No:
020-1133-00-000
Section/Town/Range/Map No:
18.29.19.642
STATION BS HI1 FS ELEV.
IBldg. Sewer
SUHt Outlet
Dt Inlet
Dt Bottom
Header/Man.
Dist. Pipe
Bot. System
Final Grade
BED/TRENCH
DIMENSIONS
Width
Length
No. Of Trenches
PIT DIMENSIONS
No. Of Pits
Inside Dia.
Liquid Depth
SYSTEM TO
P/L jBLDG
IWELL
LAKE/STREAM
CHAMBERLEACHING
OR
UNIT
Manufacturer:
SETBACK
INFORMATION
Type Of System:
Model Number:
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size x
Pipe(S)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade System:
Depth Over Depth Over xx Depth of xx Seeded
Bed/Trench Center Bed/Trench Edges Topsoil
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:
Location: 920 WILLOW RIDGE RD
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
to Air Intake
Only _
iodded xx Mulched
I] Yes [ No [] Yes No
Inspection #2:
Planer so de for additional information. No I J L — — — _ _ CertL No
Use other
Date Insepctor s Signature
SBD-6710 (R.3/97)
RECEIVE Safety and Bylildirigs C,iivlon
... . 201 W. Washington Ave., P.O. Box 7162
Smutasy Permit Number (to be filled in by Co-)
c '. . • T Madison, WI 5371,7162
INV. OCl Q 2G 16 SIN
I
.. - 3
at/�� /
`
pphcat
State Transaction Number
In accordance with SPS 38321(2), Wis. Adm. Code, submission of this form t PYBYXYN K588 RJ
is required prior to obtaining a sanitary permit Note: Application forms for su=-Qwnoa ry w 13 m c buunuucu w
Project Address (if dlfferem than mailing addre
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary
VV 1z
f�� p` QG
ses in accordance with the Priv Law s. 15.04 1 m), Stats.
Parcel #
L Application Information — Please Print All Information
property Owner's Name '
Rt,
t7-0_
Property Owner's Mailing Address j
Property Location
(�C
" /
Govt. Lot
SE %, 5F Y., Section
Z�tp~Code
Phone Number
City, State
` o � V1 10
J<
sJ
i q (circle onew)
T 2 N; R E orLD7J
II. Type of Building (check all that apply)
�t Number of Bedrooms I
# //
ri✓�
Subdivision Name
or 2 Family Dwelling —
p (,6 C
vJ IL.to �k! '` !`
6iL �5QQ r S�b1�i1�Po�
Blocky
❑ Public/Commercial — Describe Use {
❑ City of
I
❑ State Owned — Describe Use
❑ Village of
Town of
CSM Number
15Tti 6Q11 ON ELLS W 2 � + Z (+
2,1 C hA m b� rS
III. Type of Pe it: (Cheek only one box od line A. Complete line B if applicable)
N�SYStrm❑
Replacament System
❑ Treatment/Holding Tank Replacernent Only
❑ Other Modification to EzisdnB System (explr
B.
❑ Permit Renewal
❑ Permit Revision
El of Plumber
❑ Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expmwon
Owner
IV
Com nenVDevice: Check all that apply)
on -Pressurized Infi o ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound a 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
I
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (tecplain)
V. Dispersairrrea en t Area Information: 1 Al '
Design Flow (gpd) Design Soil A licabon Dispersal Area Required Dispersal Area Proposed (sf) System Elevation
VL Tank Info
Capacity in
Gallons
Total
Gallons
# of
Units
Manufacturer0
/^/
u
0
3 G
New Tanks
Existing Tanks
! / I ✓ "
a U
rn
in
Septic or Holding Tank
Dosing Cb mber
VEL Responsibility Statement- L the undersigned, assume responsibility for installation of the PORTS shown on the attached plans
RS her Business Phone Number
Plumber's Name (Print) Phrmber's Signature
2Z3 2. 715 316
Phlmber's Address (Street, City, State, Zip Code)
e) J,5 5���
VM. Counn2RMartisent Use Onl
Permit Fee Denc Issued Issuing Agent Sign
90> S lb
Sp° 1� �i
DL Conditions of Approval/Reasons for Disapproval -9) ^ A �X' My --�Ot�
SYSTEM OWNER: 1"l - va.' ibl'A�J f� 1J
e1
1. Septic tank, effluent filter and 1, CST dC ,� n' I� NJSW �
dispersal cell must be serviced /maintained 1 (Y Ain -P "
as per management plan provided by plumber.
2. All setback requirements must be maintain
a not than a : 11 iacbes size
ni
LTI
13c c it;
6
gg,the system gad sabmh the Cosa oo y on p perot Tess C &7 1 D D r 1
t1 S� 3M 3 i � b1 P
SBD-6398 (R. 11/11)
RILJ,�O 4 -ToU I NOD IL)
f�e'l K<,r- (Ai S iR -,-M i Z-q AJJ k i g W
Lvr 2-S DJ(LLDLc) RAY-C 2/uo AWE
To 1nJkU`�Soi J
y
/1
MM-S
�Uc
IVL
15Z w i FSO2
3
L,
A aa)c�-a wd- 43
Cugij ' sr
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4
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name:
Owner's Name:
Owner's Address: 66_,111 A S+l woob j )go 1 bR
\A=1)81 K-/ AA 14
5SiZ5"
Legal Description: _ '�%y I/y ,��� T ZC1 J yt/
Township,
County:
Subdivision Name: VV�(.(,�W (X,E Z�� POP,
Lot Number: 33
Parcel ID Number. o2® ^ %/&5-0 0 -- 0,06
Page 1
Index and title
Page 2
Plot Plan
Page 3
System Sizing & Cross -Section
Page 4
Filter Specs
Page 5
Maintenance Information
Page e
Management Plan
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: lk FF 6Y- License Number: M _Z3Zy 2-
Date: 104S116 Phone Number �"_ qql -34s6
Signature J/3/10
Designed pursuant to the In -Ground Soil Absorption Component Manual for POVdTS Version 2.0 SBD-10705-P (N.01/0' j.
Page 1
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INSTALLATION INSTRUCTIONS
PL-525/PL-625 FILTER
i25/PI_-629 FEATURES & BFNEFUSr -
_ s
PL-M PL-M
PL- 525W5 EM"A Fiber should operate effida ly
;everal years under normal conditions before
iringcleaning. tt is recommended that the fitter be
led every time the tank is pumped or at least every
years. if the installed filter contains an optional
n, the owner vvnit be notified by an alarm when the
needs servicing. Servicing should be done by a
fled septic tank pumper or lnstallm
FeaWres & Benefits:
* Rated for 10,000 GPD
e PL-525 = 525 Linear Feet of 1/180 Filtration
PL-626 = 625 Linear Feet of 1/32" Filtration
*Accepts 4" and fi SCHD. 40 pipe
a Built in Gas Deflector
* Automatic Shut-M Bad men Finer is Removed
e Alarm Accessibiitty
eAccepis PVC Extension Handle
,OMMENDED PRODUCTS
am i Riser Conners
ook bring YOLW
be tardk Cover to gmde-
3 s jam locating and
AdM MN iUter easier
by eMM-
I9 rligghV to WW tank
rance.
Extend & l,,okT'=
Poh4ok Extend & WkTa
Is a skrwle, easy to use
soMai that can extend
Me Wet or oestlet pipe and
make Mar andlor ba is
insWki lon a strap.
Fets 37 and 4' pipe.
Riser SafieW SWOOM
Powok raft" saaens
prevent tragic acciderds
from happenrig by chkhen
and pats failing iro open
sepac tank entwc a&
Poiy K PVC Mar
won Handle
FftwAlw= t and
sm2rwmar- k;DtlUM
awftch
PoVok iW aiarm panels
and swat M prvrld a vetoed
am audubis rat k2tion of
Ong Fitter and tank
sen4di g_
Fora foil list of PoM& products pie vet our web site at r po ylok -c6m
_ POWTS OWN1rI.t'S MANUAL AND MANAGEMENT PLAN
FIIX V40RMA130N
Owner WIAWO -A -LEO.
Permit #
DFMGN PARAACVrl tS
Number of Bedrooms 10Q
❑ NA
Nwr9w of Corrmmrcisl Units
S-, NA
EstirtiaW ROW (average)•
500 PLIday
Design How (peak), estimated x 1.5•gal/day
Soil Applicaekin Rate
6 py4gy
Infl f2l t Quality (NA❑)
Monthly Ave age"
Fats. Ott dt Grease (FOG)
5 30 mg/L
Biocl l Oxygen Demand (BODS)
5 220 mg/L
Tool Suspended Solids (TSS)
5 250 nWL
Pretreated Effluent Quality E3
Monthly Average•••
Biochomicai Oxygen Demand (BODs)
5 30 mg/L
Total Suspended Solids (TSS)
Fecal Colifatm (geometric mean)
5 30 mg/L
<10 cfiil100ml
Maxirmum Effluent Particle Size
118 inch dWnmftr
•WaaW"ter Flow Verification and Calculations:
(Other than bedroom based)
' Values typical for domestic (non eoam cv ial waseewater
and septic tank a muent
***Vghws twical for mvirexted wastewater.
S'V.STi'M 9PRI IF[CATIONS
Scritic Tank act
$ Ad 0 NA
c Tank Mam&cnttCr
CS'C'k. 0 NA
Effluent Filter Manu&cturer
NA
Effluent Filter Model
0 NA
Pum Tank
NA
Pump Tank Manufacbm
PuuV Manufacturer
Z NA
LUR Model
NA
Pretreatment Unit NNA
❑ Sand/Gravel Filter C3 Peat Filter
❑ Mechanical Aeratia ❑ Wetland
C3 Disinfection 0 Other:
M:Ctattacduer. Modal:
Dispersal Cell(s)
V in -ground (gravity) p❑ bVv d (prod)
[3 At -grade Mound
C7 Other.
❑ ng Chamber Manufacttucr
ModLel (�U( K Laying LengthlChamber.
Soil Application RateArea Raul.
Infiltrative Surface/Chamber-ESIA Rating_ Rz
Minimum Number of C W=bers
❑ Awagaft Design Flow ' Rat- min
Materials: sit materials mmat comply with WI Aden. Code
COMM84 and be awalled pares gx=fieatlons
am appmval letters.
❑ "Wisconsin At -grade Soil Absorption System, Siting, Design & Construction Manual" (Converses etal.1990)
0 "Wisconsin Mound Soil Absorption System: Siting, Design & Construction Manual" Converse, J.C. and E.7. Tyler.
Publication 15.22
❑ "Design of Pressure Distribution Networks for Septic Tank -Soil Absorption Systems" Publications 9.6
❑ 'Design of Conventional Soil Absorption Trenches and Beds". R.J. Otis - ASAE Publications 5-77 and "Design Manual -
Onsite Wastewater Treatment and Disposal Systenns". EPA 62511-80-012 October 1980
0 SBD - 10570P X6") -At-Grade Compoment Manual Using Pressure Distnbution"
ASBD-10567-P (R.6/99) -In Ground Absorption Component Manual"
❑ SBD-10705-P (N.01101) -In Ground Soil Absorption Comet Manual" Verdian 2.0
p SBD-10629-P (N.6199) -Recirculating Sand Filter System Component Manual"
❑ SBD-10656-P (NAM) "Split Bed Recirculating Sand Fitter System Component Manual"
❑ SBD-10572-P (R.6/99) "Mound Component Manual"
❑ SBD-10691*-P (N.01/01) "Mound Component Muusual" Vemioa 2.0
C3 SBD - 10595-P (R.GN9) "Single Pass Sand Enter Con4wncut Manual"
❑ SBD-10657P (R.6M) grip -line Effluent Disposal Component Manual"
® SBD - 10573-P (R 6/99) "Pressure Distnbutiom Component Manual"
❑ SBD-10706-F (N.01101) -Erasure DUMbudan Component M,am al- Version 2.0
❑ Dri1l-line P,ffiuent Dispersal Component Mannal for Multi flo Onsite Wastewater Treatment Units
� ;rya;rw:�:n�ce�,��:aa��ars.r[H:�►�,r;�:rw
MAINTENANCE MONFI'C3RING 9C WULE
so —via Event
Service
caeaditaan of a
At lean once every
0 months
s 3
ow coutimis of 01W
When combined sludge
and scan equals one-third
113 oftwk volmw
a
At lest once
At least once every
months
❑ monita
s 3
❑ yeazos
Clean efib mt ffitsr
Inspee EME controls & alarm
At least once 01
❑ umamths
a NA
Ptah laterals and teat
At least once
t I" at .w.w. pup ru
monibs
rl Innntin
a NA
t—i vasr(sl ❑ NA
• • A , - -
Syataas MA up don not occur when soil conditions are frown at the infiltrative natsce.
()FBRRTION
The property owner is responsible for fire operatiott and mait►tcnance of the 1'OWTS and submission of raquirtd reports. 'Thu quantity
and quality of the wastewater scream will affect the pw%nrmmce and longevity of'your POWTS. The installation of water -saving
appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine of waste
In water
softeners, iron nernoval units, other clear water teaumut devices and foundation drains should be
dwImSed to the ground sinface
whenever possible. Mote: this does not utchuie laundry waste, showers, dishwater, etc -
This s3 m to handle domestic st�ettgth wastewater, however the disposal of food based greases and oils, vegetable�t
peels and seeds, bones, and food solids sttch as those produced by a Prbage disposal should be mimed. Toilet tiasuze is the only
paper that should be discharged into the system. Other non-biodegcadabie mms such as baby wipes, tampons, sanitary
sue, dgm dz butts, deantal floss, and cotton swabs should not enter tiro system Chemicals such as petroleum prvdueb, Wit
r pides• antibiotics• solvents, ex, should not be 8ushod into the system as they can serionaly damage your POWTS
and male YOM drnslang water supply -
Maintain a regular steady flow by spreading IffundrY washing trough out the week Avoid vehicle auffic over all system components.
Compaction of snow over the dispersal unit may cause it to f =W up.
❑ Valves
Valves SMU be operated in the following manner.
Q Alarms
Alarms should be heated on a regular basis by the home owner. If an alarm sounds, contact an individhssl licensed to Smvic c
PORTS, Them is normally a 1 day reserve under regular operating conditions, however water should be consa�ed until any
problems with the system are corrected to prevent back-up of sewage into the dwelling or surfacing.
Uils—
Inspection shall be made by an individual carrying one of the fonowmg licenses or certifications: Master Plumber. ster
Plan ber Rolrictted Sewer, pOWfS MaWainrer or Septage Servicing Operator (per the attached Mamt
enum C Septic Tasks Couiponent
Tank inspections must include a visual inspection of the tank to identify ainy missing or broken hardware, identify any tawaics
or leaks, merssure the volume of combined sb*e and scum and to check for any baclatp or pcm dung of effluent to the ground
anrfsce. Access openings used for service or assessment &hall be sealed and/or locked upon completiion of service. Any
deli cts shall be promptly cmu tad. Exposed Openings grater than 8 inches in diameter shall be secured with an effeCtivc
locimtg device to prevent accidental or umuthormed entry into the tank.
When the c Wation of sheedge and scum in any tank exceeds one -thud (1/3) or mare of the tank volume, tie e8fim conteurts
of the tank shall be removed by a Sepmge Servicing Operator and disposed of in accord me with Chspftr�113, Wiacoaeio
Administrative Code_
The outlet filter(s) shall be inspected and cleaned to remove any acctantniated solids according to
s
specifmations. Provisions are to be made to retain solids in the tank. Filter clean g may be necessary at more
fi+equutaat integvAl& than stated in the maiuWasace schedule to keep the system operatin&
C1 Pump ChamburlTreatnaai Tanks CoMhoruut such as primps. alarms and fists. A visual chectc BMW be
The inspection mid include a test of all electrical equipment Of anyfiitau,
made for leaks, backups, surfacing, musing or broken security devices and other hardware and the
Any service needs or repass shall be promptly taken cue of.
Q In-tiround CitavitY Component biap005al Cells
The inspection &hall include re cm dit the l�.vels of pamding if any in the obearvatim ttdhas Bird a visual inspection for any
evKWUCe of sure seepage or discharge. Any discharge to the ground surface mast be PIOMFOY reported !o den roPlatKy
amity_ pooling at daps ilk Om 75% of the bd& of tits COUPOUCA may indicate overloading oe i m�
hydraulic i) Rm necesnaung more hequent mom& tPtnge of
® Motmd, At -Grade, In-Gtmtntd PMUM
The inspection shall include recording the levels of pondmg, if any in trig observation tubes and a visual WWrfim for any
evidence of surface seepage or discharge. Any discharge to the goateed stuface must be promptly reported to the repl" toy'
audgreaterrity. Pording greater than 75% of the height of the component may indicate overloading or Wpaxbng hydmljc fifty
M=Sskafins more frequent Monitoring.
used for flushing The hutarals
The pressure distribution system is provided with an opening at the end of each lateral W be
should be flushed at least once every three (3) years. Pressure checks of systemwith mule laterals should be done to
ensure that equal distribution of entreat is occurring to Promote the longevity of the system.
Reports for maintenance, inspection, and monitoring shall be submitted in accordance with COMM 83.55 Wisconsin Adrttinistltve
Code.
�ti ! �I�_ 1 --q
Where the POWTS fails and/or is pcmnnently taken out of service the following steps shall be taken to euurre that the s3►tNern is
prey sad safely abandoned in compliance with Ch. COMM 8333, Wisconsin eve Code.
All piping to tanks and pits shall be disconnected and the ab ea Boned pipe openings scaled.
The contents of all tanks and pits shall be removed and properly disposed of.by a Septage Servicing OPMUM.
. After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void apace Shed with
soil, gravel or otbet inert solid material.
CONTiNGLNCY PLAN
If the POWTS fags and cannot be repaired the following measures have been, or must be takes, to provide a code coWpihmt
replacement system
❑ A suitable replacement area has been evaluated and may be utilized fat the location of a replacement soil absonXion SY$ttm
The replacement artier should be protected from distturbo= and compaction and should not be infringed Won by
required
setbacks from cmtimg and proposed structure, lot limes and wells. Failure to protect the tephounent area will resu t in the
treed for a new soil from exis ft and proposed allucaut,, lot lines and wells. Failure to protect the replacement area will
result in the treed for a new sail and site evaluation to establish a suitable replacement area. ReplaseUMA systems mast
comply with the rules in effect at that time.
® A suitable replacement aura is not available due to setback and/or soil lindutions. Barring advances in POWTS tec?mo1W a
holding tank nay be installed as a cart resort to replace the failed POWTS.
® The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a sail and site evahwim
must be performed to locate a suitable replacement arm if no replacement area is available a holding tank tray be installed
as a last resort to replace the failed POWTS.
❑ Mound and at grade soil absorption system tnay be reconstructed in plate following removal of the biorrat at fire infiltrative
surface. Reconstructions of such system must comply with the rules in effect at that time.
<..�WAR"G» SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTIAN LETHAL GASSES
AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT
TANK, UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE
INTERIOR OF A TANK MAY BE DIFFICULT OR WOSSIBLE-
ADI>l MMAL COMMWrS
POWPS INSTALLER POWTS 1HlAlIN'PAINER
Nature � �FI= v K Blame
Phone --( t $ - -7 S,5 2 �) (o / Phone
ryl
SEWTAGS sERFiC94G OPB,RATOR 1t.iDCAI. REGCJLATORY AUTHGBIt
lvaoae �� Lx
SD
Pbom
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer t &\k0A + JO k% IN) e- \ 5bh
Mailing Address S, 1 ok ka 4 1,0 ` I wdo►�'^ry, �ov 5�� �S
Property Addres 7-�o W �&w R1 RID4
(Verification required from Planning & Zoning Department for new construction.)
City/State r
qq1i I Parcel Identification Number a 2 O _1 t 3 3 —00 —dQ 0
A o1 So 1I) � w�
LEGAL DESCRIPTION
Property Location '/4 , '/a , Sec. 1'6 , T 2_1 N R 19 W, Town of vX
Subdivision Plat: W tlUnw zi* Z'", A4A OZS7 , Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # I L0 Z9 �P (before 2007)Volume , Page #
Spec house DyesC&O Lot lines identifiable ❑ yes Elno
ENANCE AND
r Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §SPS. 383.52(l) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Safety And Professional Services and the Department of Natural Resources,
State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix
County Planning & Zoning Department within 30 days of the three year expiration date.
I/we certify that all statements on this m are true to the best of my/our knowledge. I/we am/are the owner(s) of the
property described above, by virtue of a wa my deed recorded in Register of Deeds Office.
Number of
J / 2I/ l�
DATE
***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. ***
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. 04/12)
LOCATICXl MAP
Wis. Dept of Safety and Professional Services SOIL EVALUATION REPORT
Page —,L of
uIYI5lull UI Jmcly
ance with SPS 385, Wis. elm. Code
TF/�"
Attach complete site plan o ss t 112 x 11 inches in size. Plan i��i
County
include, but not limitedf� nd h ntai reference point (BM), on a
Parcel I.D.
�o
o
percent slope, Scale orWs,�1.0 orth arrow, and location and dis q nearesr��
/ 0
eV
Date
Please print all information. sr �Q
4'
C�N
1(/
Personal inlormalion you provide may be used for secondary purposes (Privacy [ I�ir� . 15.04 rr)).
' `" ✓
J
Property Owner
r Location
/
,./�OitE J E!/ER fc�J
Govt Lots 1 t4SE 1 /4 S Td 9 N R
9 (o
Property Owner's Mailing Address
Lot # Block # Subd. Name or
33 IAJ
City State Zip Code Phone Number
-B-Eity 4�]Y+Nege ®Town Nearest Road 1120.
!c!af�rYo�o (JI 1 J'Y717
9.?0
lLor✓ rd-
® New Construction Use: ® Residential / Number of bedrooms _ Code derived design flow rate ySd
GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material Or, r/ /A.r.✓ - Flood Plain elevation it applicable N.Q
ft.
�u✓O Pol�TS� G ��s/ � LaADi✓L l� � ram, rfEfs t.!!it ✓1N
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To Or
and lotions:
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1 L Ve,4
Boring
I
1 1 �n� # M ., r:rrvind mirfvinp Alev. 9�. a ft. Depth to limiting factor > 7G in. c,.a ennliratirvt Rate
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
Qu. Sz, Cont. Color
Texture
Structure
Gr. Sz. Sh.
onsistence
Boundary
Roots
GPD/ft _
fl#1
ff#2
O-
O Yx aZ
—
I
,-
I__I Boring
Boring # 9 Pit Ground surface elev. 98, y ft. Depth to limiting factor 76 in. Soil Application Rate
Dominant Cobr
Redox Description
Texture
Structure
onsistenoe
Boundary
Roots
GPDM '
Horizon
Depth
in.
Munsell
Qu. Sz. Cont. Color
Gr. Sz. Sh.
fT#1
ff#2
r
Effluent #1 = BOO s > 30 < 220 nV& and TSS >30 < 1
CST Nanjp (Please Part)
riA ,z
Address
/S"0 3
- Efluent #2 = BOD < 30 mg/L and TSS < 30 rrtg/L
CST Number
7—Evaluation Conducted
1-� -Y7o/ s
i
one Number
SBD-8330 (Rl 1 / 11)
Property Owner �it%D/t fl✓ �EUElt So,J Parcel ID #
❑ Boring
F—? BOn� # (571 ., C.rcuu,d surface eJev. 99. 8 ft. Depth to limiting factor >7G in.
Page -' of &
GnR enn6r-Minn Rate
�•
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❑ �ng
n Boring # n r4mi rout crnfarr elev. R Depth to frnitin9 factor in.
cap en..iratinn Rate
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Depth
in.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz Sh.
onsistence
3oundary
Roots
GPDAt '
1
N#2
u Boring
Boring #
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Sod cation Rate
Horizon
Depth
in.
Dominant Color
MunseM
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
onsistence
Boundary
Roots
GPDIft
f2
. Effluent #1= BOD 4 > 3o < 220 mg& and TSS >30 < 150 mg/L. - Effluent #2 = BOD e < 3o — A. and TSS < 30 mg&
The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. if you need assistance to
access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay.
S8134330 (R.l l/1 n
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PROJECT NAME: 2�4,cJ,O C Eta �EyER.sa.✓
PROJECT LOCATION:_ 5Z /,8.pN,,l'/�� r� �
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CST LICENSE Q:
SIGNATURE:
DATE:
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. I C:11,-L'20)3 09:21 FAX T15 377 47J7 REJAER--W ILL] AM.'i INT Ri "j
gou!,UU1
I herebi certify that this survey was Pref d by me -;r under my direct
4upervision, that it Is true and correct to —e best of my knowledge and
belief, and that I am a registered land surveyor under the laws of the State
o Iscons:n. 31.4
Douglas I. hl 2145 Date
ti
'VOUGIAS
* S-2145
11 ;-IUDSON,
suft �)4�
PREPARED FOR:
�- ANDREW SEVERSON
1500 OAK ST. � � � R
HUDSON, WI 54016 l:
RipGE Rp ,--
AD
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71�
�12 ,00,
CURVE DATA y�JZ51p.
RADIUS LENGTH = 173.22' � � al
CENTRAL ANGLE =15'21'39'
CHORD BEARING = S79'52'30"E i
CHORD LENGTH = 46.30' (46.33')
ARC LENGTH 46.44'
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or a, LOT 33
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0 FOUND 1-1/4' OUTSIDE DIAMMK IRON PIPE
r FOUND I'OUTSIDE DtAMFTER IRON PIPE ,� 1
( ) PRcYIOUSLYRECORDED DIMENSION �
FOR BIDDING ONLY '
NOT FOR CONSTRUCTION o
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FOR BIDDING ONLY E _ li
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State Bar of Wisconsin Forin 1-2003
WARRANTY DEED
bocumentNumber 11 Document Name
THIS DEED, made between Scott J. Staffon and Theresa A. Staffon husband and
wife
("Grantor," whether one or more),
and Richard C. Nelson and Jo ' and wife and Bruce H. Nelson
a married person
("Grantee," whether one or more).
Grantor, for a valuable consideration, conveys to Grantee the following described real
estate, together with the rents, profits, fixtures and other appurtenant interests, in
St. Croix County, State of Wisconsin ("Property") (if more space is
needed, please attach addendum):
Lot 33, Willow Ridge 2nd Addition in the Town of Hudson, St. Croix County,
Wisconsin
1006296
BETH PABST
REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
01/06/2015 8:00 AM
EXEMPT•# NA
REC FEE: 30.00
TRANS FEE: 177.00
PAGES: 1
**The above recording information
verifies that this document has
been electronically recorded
& returned to the submitter
Recording Area
Name and Return Address
020-1 33-00-000
Parcel Identification Number (PIN)
Th•. homestead property.
(is) is trot)
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except:
None
Dated Id'AmbIA—i " a 4
(SEAL) I (SEAL)
9�� 6 z
colt J. fon
(SEAL) Theresa A. Staffon (SEAL)
AUTHENTICATION
Signature(s)
authenticated on
ACKNOWLEDGMENT
STATE OF*1NN£-SGT-A- 1 15t_t606(4) )
/} ) ss.
Washington ���roik COUNTY )
* Personally came before lie on 1A - /1 `" / ,
TITLE: MEMBER STATE BAR OF WISCONSIN tine above -named Scott J. Staffon and Tlieresa A. Staffon,
(If not, husband and wife
authorized by Wis. Stat. § 706.Ob) to meEnt
n to be the person(s) who executed the foregoing
ins nand acknMdl�
ged the same.
t'
THIS INSTRUMENT DRAFTED BY: E R
Ina Kraemer NOTARY PUBLIC
Burnet Title -Scott Tranby, 5151 Edina Industrial Blvd, Notary Public, State of Wisconsin STATE OF ISGONSIN
#500, Edina, MN 55439/ 14-18286 My Commission (is permanent) (expires:
(Signatures Piny be authenticated or Acknowledged. Both arc not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORT[ SHOULD BE CLEARLY IDENTIFI
WARRANTY DEED 0 2003 STATE BAR OF WISCO, ISIN FORA NO, 1 2003
* Type name below signatures.
St. Croix County 1006296 Page 1 of 1