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651324 042-1012-90-001
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: Mike Zurn (MV Trust) City Village Township TOWN OF WARREN CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER 110 rush �«r CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL to Air Intake ROAD Septic 4DG.Vent Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand PM Model Num r TDH Lift ion Loss System Head IT!Z Ft For ain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: 651324 State Plan ID No: Parcel Tax No: 042-1012-90-001 Section/Town/Range/Map No: 05.29.18.78A STATION BS HI FS ELEV. Benchmark 1,30 po.o Alt. BM Bldg. Sewer St/Ht Inlet St/Ht Outlet Dt Inlet`�- Dt Bottom Header/Man. g� Dist. Pipe Bot. System -40 3 6 1�.45, -3ZI I 9zgs' Final Grade s. gb gs Lf2' St Cover ��{{ r�tft last trL, Act 4.S� BED/TRENCH Width Length No. Of Trenches —7 PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 7� �2_ ] (2) SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufact r INFORMATION Type Of System: r S �p r I f � ZBB CHAMBER OR UNIT Model Number: r` ui DISTRIBUTION SYVI)M Header/MI U., stribution x Hole Size x Hole Spacing Vent�to Air Intake Pi (s) Length a Le th aci �r? 1166 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 ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Location: 1047 115TH AVE Inspection #1: 11/1H I Inspection #2: 1.) Alt BM Description = 2.) Bldg sewer length = f amount of cover = 1�o�IP1eaQ r Plan revision Required? ❑ Yes �" No �� `,// 2- Use other side for additional information. 7( SDate Insepctor's Signature - 6P( (R,,�n 4 el cLcQ °r-�P %c` �Q CAa- - a, . c - Q6 Q . � � 2 Cent. No. Z© il$_7 9;,4 �ti Safety and Buildings Division -------------- County -- 201 W. Washin ton Ave., P.O. Box 7162 9 Sanitary Permit Number (to be filled in y Co.) Madison, Wl 53707-7162 3Zq Sanitary Permit Application State Trans actionNumber In accordance with SPS 383.21(2), Wis. Adm. Code, subnussion of this form to the appropriate governmental unit ---— is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies, Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 1.5,04 C 1)(m), Stats. I. Appitcaffon Information -- Please Print All Information Property Own is Nance Parcel H t 1h.1t' naa- 3S4- nums Property Owner's Mailing Address Property Ln i n W r�> + Govt. Lot rf f� section J] City, State Zip Code Phone Number r� nb h 1 �iyQ (circle an T q N, R � E o1� II. Type of Building (check all that apply) Lot # or 2 Family Dwelling-- Number of Bedrooms-3 Subdivision Name ❑ PubIidComfnercial —Describe Use NR Block/4 ❑ City of ❑ ___ N Slate Owned —Describe Use ❑ Village of CSM Number _ — KTownof�\Ir)yyye—,Y4 III. Type of Permit: (Cheek only one box an Itne A. Complete line Rif applicable) A. ❑ New System Replacement System ❑ Treattnent/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B• 0 Permit Renewal ❑ Permit: Revision ❑ Cflarlgc tlfPlumber ❑Permit Transfer tc New List Previous Permit Number and Date Issued Before Expiration Clwncr stem/Com onent/Devfce: Check all that apply) Non -Pressurized In -Ground ❑ Pressurized In -Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil Q Mound < 24 in. ofsuitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treat ent Area Information; 2 x (,[, 2 y SQ 2 Design Plow (gpd) Design Soil Application Rate(dpdsf) Dispersal Area Required (sl) Dispersal Area Proposed sf) System Elevation i Lil S 4 C] , 7 6�ila. 57 C 5c� , a , e�ti �13 VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units �tV%,,/r L6L 7 t r New Tanks Fxistlna Tanks CIA - w � � sept%or Holding Taak Q Dosing Chamber — VII. Responsibility Statement— I, the undersigned, assume responsibility for installation of the POWTS shown on the attached Plans. Plumber's Name (Print Plumber's Signatu MP/MPRS.�N,u-.ymber Business Phone Number v t/J r5" o Yl`]7rJ Plumber's Address (Street, City, Sta e, Zip Code) 40\ VIII. Coun /De artment Use Only Approved lsapp Pcrnfitt Fee Dato IssueJd. Issuing Agent Signature s lfl/26 aeon for Den J J (202 IX. Conditions Approva SYSTEiM1OwNER: �/�3t'u'`J 7r ..APO q�'s 1A�7�t'r@V� I,r+�"""q'a Qt12� 1. Septic lank. eRueni filler and dlspersal.call muse be serviced f mat,dained as per marageowl. plan pro'ded by plumber. 2.All sethnk requirements must be mairbirad as per appllrahk code 1 ordinances, lvua.cil to compiere plans for file system and subfult to free County only on paper not less than 8113 x 11 inches in size SBD-6398 (R. 11/11) ■ D V JPN Md� ems" x AdOO --C,l X51 I C,uFF'S E>AVK-�fO& S6i�->VIC,& QMA LJT y FIi- s 7'-- J-404 20 7/off STR.EET ( ,AMERDN. Wf 54i ?2:� W I U C. 2207c3 Pf-f. 7:L5- 4 R-42jt PROJECT NAME. Lk, P, OWNER NAME. �I t- llL lr OWNER ADDRESS: �.� I i AVk. LIC, * . � 7 PLUMBER C' SIGNITURE DESIGNER SIGNITURE: -~, DATE: r 3 Page / of POWTS OWNER'S MANUAL & MANAGEMENT PLAN FILE INFORMATION Owner's Name: yy DESIGN PARAMETERS Number of Bedrooms: ❑ - NA Number of Public Facility Units: - NA Estimated Flow: (gal/day) Design F!ow = (estimated x 1.5): 14 8c) (gal/day) l:i Situ it Application Rate: 017 (gallday/ft2) IN F L U l NTIEFFLU ENT QUALITY - Standard (Domestic) influent/Effluent Monthly average Fats, Oil & Grease (FOG) 530 tnglL ❑ Biochemical Oxygen Demand (BOD5) �220 mg/L Total Suspended Solids (TSS) �150 mg/t. NA - High Strength Influent/Effluent Monthly average Fats, Oil & Grease (FOG) >30 rn d/l Biochemical. Oxygen Demand (1301),) >220 ingil_. '['otal Suspenede Solids (TSS) %150 mg/L NA ❑ - Preteated Effluent Monthly average Biochemical Oxygen Demand (BOD9) <30 rng/L Pq Total Suspended Solids (TSS) <30 mg/t. NA Fecal Colifonn (geometric mean) _!�101 - Maximum Efflitient Particle Size vR in. dia. ❑ NA ❑ - Other: C Parcel ID # SYSTEM TYPE Soil Absorption System Type: X in -Ground (gravity) ❑ - At -Grade ❑ - Other: Pretreatment Unit: 0 - Mechanical Aeration - (ATU) ❑ - Other: Co. Permit # ❑ N) 0- In -Ground (pressure) 0 - Mound 0 - Drip -Line ❑ - Sar,&Gravel. Filter ❑ - Wetland 0 - Disinfcction ❑ - Peat Filter SYSTEM COMP0 N l " l'S Tank Manufacturer - - Aseptic 0 Dose 0 Tank Manufacturer - ❑ NA Volume: gal- X NA Type - 0 Septic 0 Dose 0 Holdin-g�' Volume: Effluent Filter Manufacturer ` .] r �r') ' ► `z t- ❑ Model # S'r� ` 16 - �( F� , Pump Manufacturer - Model # Servicing Distances: Vertical Distance Tank Bottom(s) to Service Pad: Horizontal Distance Tanks) to Service Pad: Specific servicing mechanics must be provide if vertical is ? 15 feet or if Horizontal is2!l50 feel. Specific instructions to be provided on back. MAINTENANCE SCHEDULE Service Event Service Frequency When combined sludge and scum equals one-third ('I3) oftank volume. Pump out contents of tank{s) ❑ When the hi h water alarm is activated. -- M th(s) Z Year(s) X (llriaxitnum 3 years} ❑ N condition of tank(s) Inspect hump- contra'-, & alarm(s) Flush laLral> and pressure test Other At least once every. an (Maximum 3 years) ❑ At least once every: Month(s) ear(s) At least once every: Month(s) Year(s) At least once every: Month(s) Year(s) At least once every: Month(s) Year(s) At least once every: Month(s) Year(s) ❑ NA Ot NA CkNA 14 NA Other: MAINTEN-ANCE IN`,I'RUCTIONq Inspections cell re made by an in_ . idual carrying one of the falioe%licenses ar certifications: hl 4tcr Plumloci. HG -.i�. � wel l . l S In ?, `>OWTS Maintainer; `�ej 4 Servicing Operator (pumper). iliclude a ..saal Inspc�. 1<iti] to identify any missingoriXn Tare, identify any cracks or leaks, nit l fp t5 t[' :1 3lned sludge allCi :•Llitl i:J a check for any back ill' r fluent on the ground surface. The dispersal cell(s) shtl ily inspected tot` v �fflue,1. 'Ltve15 rl the n!,,. 11� k for any discharge of effluent. on the ground sus'�a.:�. i i�:e discharge o� v:-.rcc may iltdicate a taking enl ,ii;on and requires the immediate notification of the local regulatory author-1v When the combined accumulation of stud: � x, d ,, jr.in any treatment tank equals ape -third ('/3) or more of the tank volun the entire contents of the tank shall be removed by a Sclr `.Irvicing Operator and disposed of in accordance with ch. NR 113, Wis ".. Code. All other service, including but not limited to -h >.y: icing of effluent filters, mechanical or pressurized cosnprrnents, prell � , rt units, and any servicing at intervals of <_ 12 montlls, shall be performed by a certified POWTS 1v4aintainer. to the local reaulatory authority within 30 days of completion of any service event. A Service report Shall be provided (ACP7.DF - 106 (R01110) pg. I 13 START UP AND OPERATION Page Al of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil 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 extended power outages pump tanks may fill above normal high water levels resulting in an excessive wastewater discharge to the dispersal cell(s) that may cause a surface discharge of effluent once power is restored. If this were to accrue, contact a Septage Service Operator to remove the contents of the pump tank or contact a Plumber of POWTS Maintainer to manually operate the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil 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; fats; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oils; painting products; hair; pesticides; sanitary napkins; tampons; and water softener brine or foundation drain (sump pump) discharge. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is property and safely abandoned in compliance with ch. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks, seepage pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and seepage pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and seepage pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN XIf the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a compliant replacement system. A suitable replacement area has been evaluated and may be utilized for the location of a replacement so' The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and pre posed structures, lot lines or wells. Failure ofprotect 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 the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a replacement of last resort. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a replacement of last resort for a failing POWTS. ❑ Mound & At -grade soil absorption systems may be reconstructed in place following removal of the bio-mat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING Treatment tanks and holding tanks may contain poisonous gasses and lack sufficient oxygen to support life. Never enter a treatment tank or holding tank under any circumstance death may result. Escape or rescue from the interior of a tank is very difficult. ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINE NameC�`C O V ku Q. V Nam4 Phone 5 V 4) O` ' 7�Ci Phone OdL� s Y S ` tea- ) SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name Name S-f (�l I Gj Phone � Phone Note: All sections of page I & 2 of this document must be completed to be excepted including identifying the POWTS Installer, Maintainer, Pumper and Local Authority. (ACPZDF-106 (01/10) pg. 2 �� - ll� �c `19,96 V JPN '1 `' WdQ � ►Ls% x�j (kx 5l u GI©�� n1 ! C7 I'll "y .� �� `-1 Oyu �r 5 �?j `t ,-4" (�X-N6NINZ:�5 - ys sect f, r ,bb ) "A_�, K�L 9 1q�'I'K�- z-►-rn Soil Absorption Systern Crass Section 4" Schedule 40 PVC Vent Pips Wrth Vent Cap Leaching Chamber ftt r // ---- 7 6 Final Grade T7 Q ft System Elevation Sail Absorption_5ystem Plan View ft ft 1lIlflf1 IfIIIIf1IIIIIIIIfIf IIIII' Vent Or Observation Pi Leaching Trench I aambers. IIIIffNIllffflllllllllll 1flff III Iffllf ■ Leaching_Ghamber Specifications Manufacturer And Model 1 h ��'� `•�'- `'n , EISA Ratin-ac:Z-0 sq ft per chamber. Soil Application RateQ �? gpd/sq ft (`}SQ gpd Design Flow : C7 . Soil Application Rate �_ EISA = a�Chambers 2 rows of chambers each. Page of S 0 O Quick4 High Capacity Chamber MultiPort EndCap 16' 34' FRONT VIEW Typical Trench View fr - 48' EFFECTIVE LENGTH SIDE VIEW NATIVE 8A(KFiLL TOPSOIL HI COVER 13Y rL DESIGN f = 15' 16 r 11.5' INVERT � 34' } -- SPACING PER CODE (W WZEIRENGII �� ry aTt s Yr tiryaec t cr #Y aSt+CM 7y `� w 4e . •. _ WIN 4; Size 34"W x 53"L x 16"H (864 mm x 1346 mm x 406 mm) Effective Length _ 48" (1219 mm) Louver Height 12.2" (310 mm) Storage Capacity 62 gal (235 L) Invert Height 11.5" (292 min) TOP VIEW INFILTRATOR WATER TECHNOLOGIES STANDARD LIMITED WARRANTY (a) The structural integrity of each chamber, endcap and other accessory manufactured by Infiltrator ('Units'), when installed and operated in a leachfield of an onsite septic system in accordance with Infiltrator's instructions, is warranted to the original purchaser ("Holder") against defective materials and workmanship for one year from the date that the septic permit is issued for the septic system containing the Units; provided, however, that if a septic permit is not required by applicable law, the warranty period will begin upon the date that installation of the septic system commences. To exercise its warranty rights, Holder must notify Infiltrator in writing at its Corporate Headquarters in Old Saybrook.. Connecticut within fifteen (15) days of the alleged defect. Infiftrator will supply replacement Units for Units determined by Infiltrator to be covered by this Limited Warranty. Infiltrator's liability specifically excludes the cost of removal and/or installation of the Units. (b) THE LIMITED WARRANTY AND REMEDIES IN SUBPARAGRAPH (a) ARE EXCLUSIVE. THERE ARE NO OTHER WARRANTIES WITH RESPECT TO THE UNITS, INCLUDING NO IMPLIED WARRANTIES OF MERCHANTABILITY OR FITNESS FOR A PARTICULAR PURPOSE (c) This Limited Warranty shall be void if any part of the chamber system is manufactured by anyone other than Infiltrator. The Limited Warranty does not extend to incidental, consequential, special or indirect damages. Infiltrator shall not be liable for penalties or liquidated damages, ncluding loss of production and profits, labor and materials, overhead costs, or other losses or expenses incurred by the Holder or any third party. Specificaly excluded from Limited Warranty coverage are damage to the Units due to ordinary wear and tear, alteration, accident, misuse, abuse or neglect of the Units; the Units being subjected to vehicle traffic or other conditions which are not permitted by the installation instructions; failure to maintain the minimum ground covers set forth in the installation instructions, the placement of improper materials into the system containing the Units: failure of the Units or the septic system due to improper siting or improper sizing, excessive water usage, improper grease disposal, or improper operation; or any other event not caused by Infiltrator. This Limited Warranty shall be void 4 the Holder fails to comply with all of the terms set forth in this Limited Warranty. Further, in no event shall Infiltrator be responsible for any loss or damage to the Holder, the Units, or any third party resulting from installation or shipment, or from any product liability claims of Holder or any third party. For this Limited Warranty to apply, the Units must be installed in accordance with all site conditions required by state and !oval codes; all other applicable laws; and Infiltrator's installation instructions (d) No representative of Infiltrator has the authority to change or extend this Limited Warranty. No warranty applies to any party other than the original Holder. The above represents the Standard Limited Warranty offered by Infiltrator. A limited number of 3, BRUSH SPECS: #12 GA. ST, ST, 316 WIRE FILLED WITH YELLOW ,017 POLY STAR 0 SINGLE STEM, SINGLE SPIRAL WITH VINYL TIP ON EACH END OF BRUSH PART# STF-110 gmetiluffew 'INYL WIRE ENDS ATE: 05/23/06 MATERI-AL STEP TRIM BRUSH REV: DRAWN BY: JASON MAY APPROVED BY: DESCRIPTION: 4 INCH�c � r EFFLUENT FILTER FiJLT ST C G to v r Y SANITARY SYSTEM File #:offceUseOnly OWNERSHIP/ADDRESS FORM Created212021 Community Development Department will utilize this information to provide the property owner with information regarding operation and maintenance of your new or replacement sanitary system! This information will be provided as part of our ongoing efforts to protect public health, your well, groundwater, surface water, property values, and county resources. Once approved, this completed form and educational information will be sent to you by email. If you would like to view your issued sanitary permit online, you can do so by using the Property Files Scanned weblink.. OWNER/BUYER INFORMATION Owner/Buyer _ I4 t IL.o_ 211. rv1 Mailing Addre: City/State/Zip Phone Number (required) Email Address (required) Parcel Identification Number (found on the property tax bill) NEW SYSTEM: LEGAL DESCRIPTION Property Location � t/4 , , i,1/4 , Sec. � T N R�W, Town of Subdivision Plat: L.f]�(.x.[� Lot # C(TfiffieO Survey Map # —� Volume , Page # wX e dt# l V {before 2005}Volume _ Page # Number of bedroom New Property Address (Staff Initials) Spec house 0 yes 0 no Lot lines identifiable ❑ yes 13 no OFFICE USE ONLY (Verification of new address required from Community Development Department for new construction.) (Date) This forma most 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 su; vey 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 cdd2sccwi.gov 1101 Carmichael Road, Hudson, WI 54016 www.sccw,gov Slate l.3ar of Wisctmsin form 3-2003 QUIT" CLAIM DEED Docurnrnt Kumhcr II -)ovum ,: lame HITS 1)kV,D_ made betsseen Michacl D, Z_urn and Victoria I, Zurn h tr.LIurtcl Mid ss i fC {"(Itr'antt r.' sshcIIIe1 c)I ie t)r111 1c), and Michael D. ZLlrn Mid Vicwrn I 7.ttrn, a. 1 nlSt t+ `Ilu: L1 V ZLit II I rust ('Vramec," sshrthcr nine tir morel. Gramor quit claims lu (.it'antee the ]'nllnwirtk descr•iIsed real cslatc. t ,:Mier wish the rcros. prrofiIs.. ImureS and (uhcr appwt�nant interesls, in SI t ;;i1x Ctxiruy, Suite of Wl;L:onSin c ("I'rc p rc_, 'if mnr4)�,s�t is '..'ctfctl. pTlease attach addcn:lum Sec Addendum A, amtched. Dated * S i t�ttat ure•(S , alilhentlC'ated Ui1 AUTHENTICATION I I -LE: MEMBLiZ S'IA I L BAI1 OF 1is'ItiC'C)NSIN ( If niit, authorized b} WiS. Slat.: 706.00) 8219339 Tx:4180010 993930 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI 03/24/2014 1:09 PM EXEMPT#: 16 REC FEE: 30.00 PAGES: 2 k,L'i'1dir- lamc Lind I',; i ;J'.rr.., -- — (lirtr: J. ; P A "IX� JG7y 042-1012.90-U00 Parcel IdentiPicautin Num)ll"r (PI I Ili +s homalcad sFAI.I t�' 1—/ '.Michael D.t-- I III`; \rl Rl 11h`J f ,w 1 TLD BY: iril V I. :trk0il I �,tl)1)1. (1)iV A & J[itlnsori, P.,A _ it•ili ti1;is..cll, Suilc 200, HUdSUri, t11 �;4010 (:s) (is not) EAI -) '1:�1v:lu I lu:li ACi N0WLEDIG111['N' 1 SI.1Tf:01 11ISCONSI\ I r COUNTY ) o p'ci,,o ills c;tiiic heltire me ern "-7cs,," _- /0 2- n� hr a1 n;tiuL,f Mlcliacl i) /urn acid klusLaitd ilI)d %Nile to me known to he the L+crSein(s) who cm7cuted 11Y[ ' 'r n: instruntcnl and aknosrledged the sirne. y A Pz m t( NoiaK, Puhlic, Stott~ of Wisconsin MJ C'tlmrnis,,ion f.iS pernutimit) (crpirL�S: ALLYU 7 17 ( i�n,tEnrr� ni:r% I'v aiir`n. r'I !,',I • r ac6u-m ledge(]. Muth are not neceysarr.) \01 F.: (Ills IN Sf"ANDAND 10101. s\1 "ii ?I'll I( 1I It1's"' 10 1"IIIN 1:0101 SII(ll"1 ) Ill: ("I I:ARI.I. IDI-AtIFIVD. ctll"1I I.AIN1I)V1.1) .k,IAILB\LkIII 4slti('tlltitY 1011\1 No.3-2103 • T+ pc ntunci-n ;�uics St. Croix County 993930 Page 1 of 2 ADDENDUM A Legal Description for Michael D. Zurn and Victoria 1. Zurn NW '/4 of SE'/4, Section 5, Township 29 North, Range 18 West, consisting of 40 acres, more or less. St. Croix County 993930 Page 2 of 2 Wisconsin Department of Safety and Professional Services ❑ivlsion of Industry Services SOIL EVALUATION REPORT C S T in accordance with Spy 383, Wis. Adm. Code County � Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must Include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Reviewed by Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m))" Property Owner Property Location y Govt. Lot j Ili 114E 114 S TA Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1 Of -ILI 4 Date I io/-w�262, 3I N R i" t r) City �ANa"tate Zip Code Phone Number ity Village Town Nearest Road ® New Construction usem Residential ) Number of bedrooms _ Code derived design flow rate V GPD Replacement Public or commercial - Describe: Parent material ? t��. \��W <,— Flood Plain elevation if applicable ft. General comments and recommendations: r�G Boring # 51 Boring r t r Pit Ground surface elev. ft. Depth to limiting factor in. Soil A llcativn Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfF In. Munsell Qu. Sz_ Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 -,1 �---� i w.sk �n Iv ` y 13, 07 C� at 93,o �Z �g Boring 1 !1 Boring # Ground surface elev. �� ft. Depth to fimiYing factory %� in, 1�pit Soil AoDlication Rate ! Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff In. Munse;l Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'E2 Cal �- Y �7 ©I C: <] 1�1 'Z� `Yi S. X- I ul 0. 11 0,6 —29 Effluent #1 = 13LH] 7 30 C 220 mg1L. and TSS >30 < ILIi11:Ln[ rlt - MUU, t Jd I I IUIL di lu 1 vv 11 CST Name (Please Prig� 1 � Signatu a ~� _CST� ber r r Address Dat aluation Conducted Telephone Number aau-o.�av env rr 4 j) ];1 I Boring # ❑ Boring / /l N Pit Ground surface elev.��t. Depth to limiting factoG 4. Soil Application 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# Z v 3 --- S 1 L ,.y •W --- S - r p- �.. ..- -- 0, 7 1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Hon 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 Grou <1ev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Descr on Qu. Az. Color Texture Structure Gr. Sz. Sh. Consi ce Boundary Roots GPD/Ft2 '°Eff#1 '°Eff#2 * Effluent #1 = BOD, > 30 5 220 mg/L and TSS > 30 5 150 mg/L * Effluent #2 = BOD, > 30 5 220 mg/L and TSS > 30 5 150 mg/L ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EX I S1 I Nti (: SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) l04'- [IS A\6 . located at: Nw `/4, S/a6 ', Section 5 , Town 2 9N, Range__J�UW, To wn of WA-2REnl , St. Croix COUnty Wisconsin. Upon inspection, I certify that I have found the tank(s), to the beast of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Did flow back occur from absorption system? Yes No�— (if no, skip next line.) Approximate volume or length Tank Capacity: Construction: Prefab Concrete Manufacturer (if known): Age of Tank (if known): Permit number (i own) (Livens lumber Signature (Title) (Date) of time: gallons Steel Other (Print Name) minutes (License Number) MP/MPRS Form to be completed by licensed plumber (Dept of Safety and Protti"' ik iiial. Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licen�td (NR 113 Wisconsin Administrative Code) Rev. 2/2012 n� 7� 71 bb .--I�()u - cI r dr-y NIP .)ql a IN ■IiN■ MEME Township 29N - Range 18W (0/ (,'t)parlkhi 2018 Mapping SOIL11I0119 Q- LL UJ SEE PAGE 49 UNILIMI7ED6TA. F ''.._ usA AEw1 - ROBERT d ��. CONNfE GERALD& JUDV HUNTING { q ru "S N" FISH & a DERRICK TR Lr . CLUB INC �.t. pµ IWWILDLIFL .• U ' i{ 14S aK , MUELLER 154 251 -H .. " ,. +tics 23 .I ...—._.....-,..,.- STATE OF m J ...... �EFFERYT +r , ...._ _ j ewer W13COWSIN BEER "� 'cac JOHNC UHNA Q N R +.o.• _ 66 MIDHEEEE MICkEL50N 449 DCNALLI 1HO MAS & FRAHCIS BM SEE 140 I EN MAlON EY •J GREENFIEL❑ `a Y77 -I -; a il.1. r'( I• :' .,EFFkEY6 kENNETHd .0 GEAAi¢A KEN GAR INC �I JCHN C 153 MICKELSON 3 14 i REI NICOLAI 160 AH L>>i, LL rr NTwA PAMEIA ;^+, RONALQ :m.-m. THOMAS& CONwIE RHK. -- Tf.^ ' REDMON NE INK F ';. M.![ELER FRANCIS FARMS ... ._., ,.• rr. ue TRUMEY rl TRUST .o MALONEY 'r DSi Erd INC RHII .. .. L NnfNe. MATHE 3O3 YAIt 160 FARMS ISO IRFDFRcCK INC - --�-'RCENEL SO S�•y ( :TR I �.. iA• UNITED VA H NN 1 # ' a[ x.i RAY".ILNU F. :n.,4S STRATE RHK KAMM +.n '.7N r'MD TsI,A PATRICIA �1;(WOLD 1 GORDON STRATE LLC FREDERICks STATES OF FARMS BROTHERS BURL .., SELISK! 1a5 —TRUESDILL LLC : 15O S &J - AMERICA INC LLC VAN SEEK cuMP _ i• TON TE10 200 JOHN50N 159 160 I' ISO 161) 235 ..-• ,: RII5MAR d RHK_. R 1 BUR L -, FARM$ DIANE = MMT RDENF FARM WECHYILLE S INC NIECH VAN OEEk SFEY€Na SCOt17 JDAN �E`.- -',RRA INC MCk ENNA rREDER CK a '- ,•60 + 80 1qS y AArcKEN CAMP LLC BROWN GAviba I` -_. -- - ' y' y NICKENMA Si LEGATE •�,,n, wsD ,.. ,... ,. -paqj •I Cy .. ` of 1 - 12D eu N'e•. — - RODU EAU D. e aI I EwNETH � A PAME A ¢ DAVID & DIANE , p _.. ;iEAN &. TORKELS6W- GILLIS DEL ORES FARMS RO ULE Au uND M9E>tE. JOAN E Hew Nn _ u1 n 72 6ROWW ea w = m DONKA _ - + ;.�_ = - - MCKENNA VANOUS i MUELLER JL "I NIFER LLC SCHIY LTE INC seen CO IIG - ED 'DAVID d DIANE p Z r Ia a 340 FR1J5,' 2 J5'U eY21€ MUELLER 237 TRUST 72 315 JEFFERY , MCKENNA E7AL c>c . __. rcM1g 160 SEER 1 ', 119 _ pg aac ^i L3AV, Rir MANE:p AN v,o _ CIlL15 i3g7 • IYEI'ol X a MCKENNA ''U " TORKELSON Ee NA s .$' H OA. - . - / N 7 id9 N .. WALEER a Ml1ELLER FARMS JCH N+I CR' WARR- INC C 1 .. .. - DARTL d +� E GEHE -- - df NG K R w;i AI NF'Ar, ELSA LLC CARFENTER MUELLER aDIAI,l 74 Cl) u PLACID LAND v HAR4'EY *H[c'. F(,-- a, E - STEFti.+Rr CRANE HOLDINGS 159 FA.M LIM Pi Its RODE 79 W CCMPANY'LLCI+mac JGNE9 U 1'td —.• e # ✓+_� "- p LLC 139 - rr1 ,.. •• EWEN E}ERiASAAb RAC UKACE AL DR ONi 9{ JAAI.ES & 1 NATIONWIDE .,y,• NG&fA 8J U LLJ IRO t '' S .wr[R 8� IG P RAT DN iIALrU'i 11, LIMITED JERRY & uE .. .. -�1 ' cev a "i .. '' PARTNERSHIP N1COLLE Ha Lk D .E•E 4Rp in ' 1. _ VARK ' Eo AL GRACE& GARY a 9 TRUST nAMLIN FERL& ETLIV rr sy E H{ vI FARMS IN(. 57 „2 C MAN D 8. 4 r w nagas 1T _.. CO .a+A... z q MYII:GM nn a - ram. - r ° GILLIS •. .. I ".: s .� .• ,.. - „ J JAMS W & FARMS INC - FARM - yy • .-. � -4R JET 1Y.. PROPERTIES MARK A RUTH 129 DR _ Ae d 'EIKEN9} PHILLIPLEECC FL41Ra GDONA ESE . i e; NE NELL ERT UDY RRRICK . PEGGT REV TR L64 67 �• 6J PRDP3z T ER OFWILLC HAM,. IIss 160 DERRICK LV TR 4G MASL. ; L KI�LINC OG BURN TR . a LLC - e i usr fis xs ^^�� f/�1 E f' ��e n:a ✓- 1 I HAML N GGUDa.As apOHAED LO4 �Har� 1 -•,'" _ f s FQ -' PATRICK S = yW9AN iE0 E ED1E / }'8pT5 nE Rs¢NI " s 'F. • L1R NA d �_- O b RO WEw ANDERSON ".: .. �..... bryry pSAMP GF ✓ .v..R 176 .r' CRANE 1 MARGARfI ANN HOLDINGS DE RRiCK '' " RL ,EE SHERRI -.E n u[.N'.PINKE _ "' DERORAH :. w DELANpER • K Cl r. HUD SON un •n an .r, ROBERT & '.'. t .. a t LLC tag y A k ix BD 152 V �' IUNCASTER ! wsu A I I TT, I J F T8 a �' n.IM AEr R �C•`e �$ `, w R A, y �� 1Ni, y 1 J s iA - c roc ROBERTSMATERIAL 'WYMAN BOSBIEa 1 1 IHRKE T� _`r py� '1 COUNTY N URNER PORW ES L eaa �w 14D nre M Pay � ' GLEN&TR. LA 15 . CT FARMS INC H zo f.� MARKs' p1A T V;,, '" (.1 CORPORATION' WIESE 172' 200 LLEST 11 0 + KOFACZ .. + A 91, 65 �5 SIREN DA EI IA KRAUTLEE Hryf EA ANDREW ._ HQLD(♦G ',n =STATES & ROSE 6C A L' {� IR ¢�E I GfRALU DRI$CDLL TnUSTH. H 11Y1 e.r .Mi S.EIr. .., v...a CDLLC 'u :i TRIYCetd gppE51LL E4 In •TRAM TRAILER laD qa.. S 1 DEAN& �'•DP1,. ('g LENDA - .'PEARL HANSEN s., PIArz 196 5 iN STATE Of 1 WISQONSIN ❑NR I✓.288 J, 940 1000 11Gi; SEE PAGE 17 1200 1300 1400 1500 THE ROBERTS LIONS CLUB 00 Proudly serving the Community of Good Neighbors since 1959. Sponsor of Roberts Good Neighbor Days the first weekend after Memorial [lay. Also, sponsor of Cub, F',;),/ and Girl Scouts, T-Ball, Little League, Flag Football and various pi ograms at St. Croix Central High School. Active participation In b'.'isconsin Lions Camp RNAI for blind, deaf and ment illy, h,-) 1 id:capped, www.robertstionsclu bxom k,;,,b,11,4AC-1;� MoIx COUNTY P1'1§1'R A N S M W RU 11 twWT OWNER jVv 2-%,tW PLUMBER 1 , TOWN OF � i• r • �0 3 2 q 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 the permit, please contact the county authority. �.AUTHORIZED ISSUING OFFICER - DATE 1'14)262-3 THIS PERMIT EXPIRESr UNLESS RENEWED BEFORE THAT DATE POST IN PLAIN VIEW VISIBLE FROM THE • , FRONTING • DURING CONSTRUCTION SBD-06499 (R11/20)