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HomeMy WebLinkAbout040-1294-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No 53885 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: Selliris, Anthony & Toni Troy, Town of 040-1294-10-000 CST BM Elev: Insp. BM Elev: JBM Dription: Section/Town/Range/Map No: 6 • -V / a u 0 16.28.19.1686 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 5- Benchmark D ~U7 Dosing -7 Alt. BM R3.Z Aeration Bldg. Sewer Holding St/H Inlet .~o St/Ht Outlet TANK SETBACK INFO TION TANK TO P/lT WEL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ~ l b'b ► ~ f \ ► Dt Bottom Dosing p~yl eader/ 3 - Aeration Dist. Pipe„_ ~ v a4 Holding t. S stem -'d 2, Z0, Oy Final Grade C2 PUMP/ HON INFORMATION W 2- bQ~J Manufacturer Demand ouer UY~ DI, S 3 GPM, Model Number Tr aft-X'ez D I TDH Lift, I riction„Ltoss 74 System H TDHa` Ft 1 W"k-A ~u X0 Dist. t well S Force ain ngt ~Vy i If ,(v` ►v, jleli~ 2 Nor I llJ '-v SOIL ABSORPTION SYSTEM 30 .lht S5 BED/TRENCH Width / Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 2~ I fi SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM ACHING M~nNtactuye~-~ INFORMATION HAMBER O ~,Jli~{td~7 Ty Of System: UNI Model Number. DIS IBUTION SYSTEM N (,1 w s ead r/ anifgld q() Distribution t / x Hole Size x Hole Spa Vent Air I ta- f kg, A J 11 I` Pipe(s) t2 ~11~-'~► Length V Dia `rt 11-ength- O Dia Spacing_ ew- §CUJ~WER-Tg 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 C ter _ / , / Bed/Trench Edges Topsoil ~ `.f [E Yes 0 No 0 Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~I Inspection #2: / / Location: 380 Cedar Court Hudson, WI 54016 (SW 1/4 NW 1/4 16 T28N R19W) Piney JWos 2Drcel N•.1~6/86. 1.) Alt BM Description &Ze-/ 2.) Bldg sewer length - amount of cover OlrJU f/'!7 S Plan revision Required? [i es [R No Y e other side for addition a w _I Da a Insepctor's Signature Cert. No. SBD- ~ oU 1 t' LtC 1~ < ~-F OL a tiv RECEIVED crD 13 7111 _ y ifibb. commewce.wl.gov -~Sa ety and Buildings Di ision unty - aim ~consin 20b1~'c1A~b Box7I62 epetdnon! of Commerce PLANNIN~bJ 62 Sanitary Permit Number (to bt; filled in by Co.) ?43,5 8 Sanitary Permit Application State TransactiogN tuber In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application fortes for state-owned POWTS are Project Address (if different than mailing address) submitted to the Department of Commerce. Personal information you provide may be used for secondary u oses in accordance with the Privac Law, s. 15.04(1)(9% Stats. 1. Application Information - Please Print All Information 3 Property Owner's Name Parcel # ' Property Owner's ailing Address Property Location City, Stat 5 0 Govt. Lot Zip Code PhoneNumbcr 41L,,> section rcle one II. Type of Building (check ail that apply) Let T N; R _ fi oq V or 2 Family Dwelling - Number of Bedrooms _ Subdivision Name - Block# LL ❑ Public/Commercial - Describe Use J El City of-- ❑ State Owned - Describe Use . CQ - / + CSM Number ❑ Village of _ W~ w (/001 ~J own of - - III. Type of Permit: (heck only one box on line A. Complete line B if applicable) A. w System - Y ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber El Permit Transfer to Now List Previous Permit Number and Date Issued Before Expiration Owner r~ IV. T e of POWTS System/Component/Device: Check all that a I ~t~ ` ~ ---------pp y) ~ pressurized In-Ground 11 Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in, of suitable soil ❑ Mound < 24 in. of suitable soil t - r ❑ Holding Tank ❑ Other Dispersal Component (explain)^________ ❑ Pretreatment Device (explain)--_efiXj -^r I V. Dis ersal/Trea nt Area Information: Design Flow (gpd) Design Soil Application te(gpdsf) Dispersal Area R iced (s f) Dispersal Area Proposed (s System E vati n VI Ts Info , Ca acit in ( P Y otal # of Manufacturer Gallons Gallons Units ~y New Tanks Existing Tanks `1. 0 U ~ _ ~ ° r ~ &w C7 0. Septic or Holding 'rank _ W ~T ! j _ V a~ m v~ Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume r o bility for installation of the POWTS shown on the attached plans. Plr's ame (Print) Plumber's Si C MP/MPRS Number Business Phone Number Plumber's A~~ tree[, City, State, Zip Code) , VIII. oun epartment Use Only 5.66 Approved sa proved Permit Fee Date I {ucd / Issuing nt Signatur e OwnerGi a Denial $ 4ql IX. Condit1 81 iM►OMMeasons for Disapproval - 1. Septic tank, effhlilint filter and dispersal cell must all be services / maintained as per management plan provided by plumber, 2. Ali at tack requlfements must.be.lnakttained all par M*kable coda / ofdinaxes. Attach to complete plans for the system and submit to the county only on paper not less than a 112 x 11 Inches in size SBD-6398 (R. 01/07) Valid thru 01/09 PLOT PLAN PROJECT ADDRESS SW 1/4 NW 1/4S 6 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX 9/12/11 BEDRO CM 4 MPRS Shaun Bird 226900 DATE CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE •5 ABSORPTION AREA 1230 # of chambers 60 BENCHMARK V.R.P. Top of pvc pipe ASSUME ELEVATION 100' Filter BEST Filter ❑ BOREHOLE O WELL * H. R. P . Same as Benchmark Plans Designed Using SYSTEM ELEVATION 95.6/95.5/95.4 3.5' below qrade Conventional Powts Manual Version 2.0 267' Property Line Vent 342' Property Line >6„ Quick4 Standard-W of Cover Leaching Chamber with 20.0 ft2 of Area 5.8ft^2/pair of end caps 4' Long 12" Grade at System Elevation Depth below grade not to exceed 3411 3.5' at northern portion of cell, system will be installed level, and be at 2.7' below grade at end of cell Pro 4 Bedroom B.M. * house B-1 10' 15' 65 B-3 ST Well is to meet all 40' setbacks required by WDNR 90' 3-3' X 82' cells with >3' spacing B-2 Vents 0' East cove road ~r Cover Page Shaun Bird Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715-246-4516 Date: 9/13/11 L Owner: 412 Location: SW1/4 NW1/4 S16 T28 N,R19W Lot 11 Pine Woods Tro Y Y System type: In-ground absorbtion system (conventional) Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Section 4-5. Maintanance and Con 'ngency Plan 6. Filter Specifications She Signature License number 4~doo ,2/,~~~PLOT PLAN PROJECT 4A~C_ S ADDRESS SW 1/4 NW 1/4S C4 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX M 4 MPRS Shaun Bird 226900 9/12/11 BEDRO DATE CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 1230 # of chambers 60 BENCHMARK V.R.P. Top of pvc pipe ASSUME ELEVATION 100' Filter BEST Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark Plans Designed Using SYSTEM ELEVATION 95.6/95.5/95.4 3.5' below qrade Conventional Powts Manual Version 2.0 267' Property Line Vent 342' Property Line >6„ Quick4 Standard-W of Cover Leaching Chamber with 20.0 ft2 of Area 5.8ft^2/pair of end caps \ 4' Long 12" Depth below grade not to exceed 3 4" Grade at System Elevation 3.5' at northern portion of cell, system will be installed level, and be at 2.7' below grade at end of cell Pro 4 Bedroom B.M. * house B-1 10' 15' 65' B-3 ST Well is to meet all 40' setbacks required by WDNR 90' 3-3' X 82' cells with >3' spacing B-2 Vents 0' East cove road Cross Section of Quick 4 Standard-W Leaching Chamber Typical cross section for 2 of 3 cells Quick 4 Standard-W Leaching Chamber with 20.0 ft2 of Area per Chamber 10.1ft^2 pair of end plates To be >1' above grade Finish grade elevation Typical Installation 99.1 Vent Grade Len 4' 4" 4' ~~30/34 Septic Tank 1" 4' Long 5' 4' Lonrade at System Elevation 3 4at System Elevation 3 4Spacing 5' 3-3' X 82' Cells Observation tubeNent Same on other end To be located on end of Cells %A B System elevations: C A_95.6 B 95.5 20 chambers per cell C___95.4 Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of the cells. 4. Owner agrees to limit greases, garbage, and water conditioner discharge into the sy:>tem. 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system. 8. Discharge into system is not exceed those required as per Comm. 83 VContln ncy Plan If system fails, determine cause of failure, use alternate area and install new ested replacement area. Install system at a lower elevation, by removing chambers, removing bioniat, and install new system. Option#3. No adequate area is suitable for replacement area, and system elevation cannont be lowered. Install holding tank as last resort. 3. Replace any other failing components as needed. Plumber: Shaun Bird 715-246-4516 St. Croix County Zoning 715-386-4680 Pumper Tom Mondor 715-246-5148 Shaun Bird #226900 Wig N , Cn 00 0 -_J m ' -A ~z - Q~ ~a v Wisconsin Department of Commerce SOIL EVALUATION REP R Page I Of 3 Division of Safety and Buildings in accordance with Comm 85, M. Adm. Code 401110 TPAIV CROIX Attach complete site plan on paper not less than 81/2 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 ordimensions, north arrow, and location and distance to nearest road. O- /ajs/~ 10 - ew Pre"o pdn ~E® Date Personal information you provide may be u for se (Privacy Law, 15.04 (1) (m)). ' Properly Owner PertY Location ■ V Ec 1 OM Q 3 2~~~ , Lot SW 1/4 NW 1/4 S 16 T 28 N R 19 E (or) W DIVINE CUSTOM Property Owner's Mailing Address y~( L I L # Block # Subd. Name or CSM# 51W 1#t ~ s . ` 1 Piney Woods City State T.3p Code L=0akwftr-- []C4 Village • own Nearest Road A Q ( ) East Cove Road 0 New Construction Use] Residential / Number of bedrooms 3 or 4 Code derived design flow rate 4 0 or 600 GPD ❑ Replacement ❑ Pubic or commercial - Describe: Parent material outwash Flood Plain elevation if applicable -Mn ft. General comments Conventional In-ground trenches 0.7 loading rate system el 95.84 pumping may be requried and recommendations: Test was conducted with Leroy Jansky, State of Wisconsin Wastewater Specialist due to site had been disturbed. -50,9 E. eovF Fil Boring # ❑ Boring Q Pit Ground surface elev. 98.84 ft. Depth to limiting factor 85 in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Efi1 •Eff#2 1 0-2 10YR312 - sl 2fgr mvfr as 2vf-f 0.6 1.0 2 2-14 10YR3/4 - sl 2fsbk mvfr as lvf-f 0.6 1.0 3 14-85 7.5YR4/8 - s OSg ml 0.7 1.6 Horizon 1 is horlwn 2 has 15% gr. n Boring # D Boring 98.14 75 S pit Ground surface elev. ft. Depth to limiting factor in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD fF in. Murseil Qu. Sz. Cor►t Color Gr. Sz. Sh. 'EfWl 'EfW 1 0-5 10YR312 - 1 3fsbk ds as 2vf-m 0.6 0.8 2 5-9 10YR2/2 - 1 2fabk ds as lvf-m 0.6 0.8 3 9-14 10YR3/3 - Is Osg ml as lvf-f 0.7 1.6 4 14-36 10YR4/6 - s Osg ml as lvf-f 0.7 1.6 5 36-75 10YR5/4 - s Osg as 0.7 1.6 6 5-80 10YR3/4 - sil 1 mpl mfr 0.4c 0.6 Horizons 1,2 &3 is fill; horizons 4.5.&6have some gr and pockets of cos. ' Effluent #1 = BOD > 3D 1220 mg/L and TSS >30 150 mg/L ' Etlluent #2 - BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Pmt) S' nature ~i CST Number Mary Jo Hollister fb-~'s b,- 224832 Address Date Evaluation Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 04 - 24 - 06 (715) 426 - 1775 Prows riY Owner Divine Custom Homes ParW ID O~f/I j29y-/(J~-©Ad Page 2 of 3 Boring 3 Boring El Pit Ground surface elev. 99.14 ft. Depth to limiting factor 92 in. Soil Ap*aWn Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont r Gr. Sz. Sh. 'EfWl 'EfW22 1 0-5 10YR3/2 fsl 3fsbk ds as 3vf-m 0.4 0.8 2 5-17 l OYR 6 - ( fs dl as 2vf-f 0.5 1.0 3 17-28 7.5YR2.5/3 is Osg dl as lvf f 0.7 1.6 4 28-32 7.5YR3/3 - is Osg dl as lvf-f 0.7 1.6 5 32-92 10YR3/4 s Osg ml 0.7 1.6 All horizons have some gr. 1-5%; horizon 5 has some bands of 7.5YR2. 5/2 cos ater observed at 9 - F-1 Bones Boring Pit Ground surface elev. ft. Depth to limiting factor in. SolApWcation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPN; in. Mur"l Qu. Sz. Cont. Color Gr. Sz. Sh. 'E1001 'EfW Ground surface elev. ft. Depth to limiting factor in. F-]Borlng# Rp"it""" Soil imtison Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDHF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'EfWl 'EfW2 ' Effluent #1 = BODE > 30 : 220 mg/L and TSS >30 5150 mg/L ' Effluent #2 = BOD6 < 30 mglL and TSS < 30 nV& 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. S1313-8330Taat (R.07KI0) Plot Plan for Site and Soil Evaluation Page 3 of 3 Property Owner t5►vus-: Cuw~ AMEs I»=. Legal Descripion 40~ pimsy wooers (excq where noted) su'14 aF-mp- MVA see, 16, 12911, V,Aw -ruuw m 0 = Jac oe pit Tuy ma. cm%x CAUW04 101S -01 119, North SANK 6 A aF a~ ~~rl 6'~C~ ►°pObt Db~~ t 133' qa.t4' f vfiw vl site Locatto ~ o i "t Y, sue- i1 / State of WlsoonsM Leroy G. Jansky Department of Commerce INSPECTION ~Partment of Commerce safety s BWldtngs Division REPORT 13 69 Spruce Street Bureau of FWd Operations Chippewa Falls, WI 54729 Inspection Date .(715) 726-2544 A•K1 A- '1 2-dd fia Permial lnvlam etlon you provide may be used frn ssoondsry pwpoaee (PftM tAVr; s.15A4(1)Y* Name of Premises Address or Legg Description "ITownship County IJtvbv~ Ct~►S~p.~ ~°r''~S LOT 11 f'INIEYw&o,9 I Sw►- f~- Ifa-Z Tito ST. C12pfX i Master Phanber Name and Address Master Plumber Firm Name and Address Plan I.D. No. I Sanitary Permit No. /8oN Tester Licensed Person's Name(s) and License Number(a) Owner's Name and Address --I _SCb11l, *P L- At TE... ~.._.._.F►!_T . t,1 --lw!+v..' T41~-lr ._A _ fr _ I 1 _ _I_r. l_ I _ _ i . _ _ -l - i _ ! i _ _ I I ! I ~ I _ F►~i~5tsnJ ftss fem. jx! VA 0, I Pot Tr- 4 I I , cod,: r~ i Td ,fah Ne- ~ ,g- ► ~ 71,~~ f III-I II it i i ~dl 2Ui-t~5 I" I/.f ! ~•?.I ~4• ~l~/ I!~ ~r I i 1 f. i f !CA .I 3 f I►o~~ 4s'i` Co• 5 y~ts$, M•:/ . /a;- jY "~~.,ty~~'`3 4~►~ ~ ' Ei _ I i i' ~7~ ~ZI nr ~ I~~r~~~ •Sr ~s~, INS "sV.~Ik ~STf e~8s y ; I ~i ~b( I I ~ I I!~ I~ I I I I ' I I( I F i I i~ I f+~~ I I~~ f I i I I►~ I I I~' ~ i ~ I_ I i I I~~I ~ I ~~,.IIIi_1 ilIIIIIi~ 1 ~ , ► ~ i I I . ~ t I . I II.Illlli?11►►~ ~ i ~ Page ' Of Signature of Responsible Licensed Person (only one needed) Check all SID to of Plumbing I Private age Consultant Original: Copies to: that appiy) seasraa #Liox l District 0 S&B 0 Plumber 0 Owner 0 Co ty&ocal Insp. (gar II IIIIIIIIIIIIIIII Illllllll III 8036311 State Bar of Wisconsin Form 2-2003 Tx:4026300 WARRANTY DEED 941251 BETH PABST Document Number Document Name REGISTER OF DEEDS ST. CROIX CO., WI 09/08/2011 5:03 PM THIS DEED, made between Donald 0. Rodahl and Joyce J. Rodahl, EXEMPT#: NA husband and wife REC FEE: 30.00 TRANS FEE: 180.00 ("Grantor," whether one or more), and Anthony J. Selliris and Toni G. Selliris PAGES: 1 husband and wife as survivorship marital property i ("Grantee," whether one or more)'. Grantor for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant Recording Area interests, in St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): All American Title LOT ELEVEN (11), PINEY WOODS SUBDIVISION IN THE TOWN OF TROY. 1610 Maxwell Dr #120 Hudson, WI 54016 040-1294-10-000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptions to warranties: easements, restrictions, and rights of way of record, if any. Dated 1-2. 21 I 1 i/11 (SEAL) L'_ V g j- (SEAL) * Donald 0. Rod hl (SEAL) (SEAL) * J ce J. Roda UTHENTICATION ACKNOWLEDGMENT tgitu're( STATE OF IIV ) d ) ss. authenticated on • ~0 i X COUNTY) Personally came before me on } the above-named Donald O. Rodah and Joyce J. Rodahl ITLF X:,MBEk TATS, BAR OF WISCONSIN 14 (If not, to me known to be the person(s) who executed the foregoing authorized by Wis. Stat. § 706.06 ~HARLENE A. LARSON instrumen • ac wledged same Notary Public - , 0 4 424-1 THIS INSTRUMENT DRAFTED BY: State of Wisconsin Maxfield E. Neuhaus - Attorney at Law Notary Public, State of River Falls, WI 54022-0138 My commission (is-peauaneat) (expires: _ / 1 ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATION TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED 02003 STATE BAR OF WISCONSIN FORM NO. 2-2003 *Type name below signatures. INFO-PRO"'w Jnfopmlonns.cam 1 of 1 FKT LOT 13) mar n+ t „W (TONE CSR N88'65 T' 43" E 1302. 44# 33 X- 7 MGT. 10,06 z Awl ml 1s'ir Q DO' fAAd. /~GW P~rE 41 T,..I d,•.............. , 1 0 1 1 MW WT IRON #W03' WE Q. 04' "ON a T rR+aM SEE , , ~ ~ yr+.a r r LOT 0T1 I 1. 73 ACRES 75,;456 SO. OrT. v; • l C4 c) 9 LOT *3r• 43-E ORES 1. PT ACRES ~ ' 7~• ~ ~ c: tt a. FT. 33,909 9Q, F ri M :V. At r~rj.. W ITS.' `t [r► ; ' ` "-r PUBLIC ROAD TO BE NAME L OT 1. ~i~ ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Q Vl r 1 U r I t V I S Mailing Address U d vue tv 4~Aso~ Property Address S C~ d OC) \~e_ (Verification required from Planning Department for new construction.) City/State 1 U d SUS 1V I Parcel Identification Number LEGAL DESCRIPTION Property Location K , K , Sec. , T .-N R W, Town of ~lv Subdivision S Lot # CertifiedSurvey Map # , Volume , Page # Warranty Deed # , Volume , Page # Spec house yes Lot lines identifiable yes no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle waste . 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 ma' tenance responsibilities are specified in § Comm 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Zoning Department a certification form, sign by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site tewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is 1 ss than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage dispos 1 system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, Stat of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Department within 30 days of the three year expiration date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the o er(s) of the property describe ove, by vi e f warranty deed recorded in Register of Deeds Office SIGNATURE OF APPLICANT DATE Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning epartment. Include with this application a stamped warranty deed from the Register of Deeds Office and a copy of the certifi d survey map if reference is made in the warranty deed. '.Arr=ns1n Department of Commerce SOIL EVALUATION REPORT Page of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code - County M lX Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must Include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. ? r percent slope, scale or dimensions, north arrow, and location and distance to nearest road. ,1jC V-110 -(~(y Please print all information. R sewed by Date Personal information you provide c,.; s..o.v, Property Owner ` Property Location C3 N 9tIJ-D J CE R,o Dfit ~A L Gevt:-Lot :S 1j 1/4 NUJ 1/4 S I U T Z$ N R )9 E (o W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# IPl kZrt . WVbD g S°I-7 01*1 V--S1,JO Oz- LA-" e 1 - r~t Sta te Zip Code Phone Number El City ❑ Village ® Town Nearest Road UkUL Ft~uS bj S4oii (-)tS) 4ZS- LNZ 'TIZ41 jzf t az-o . New Construction Use: & _Residentlal /"Nuffi6e-roTBedroom 3 Code derived design flow rate GRD tr r;`,'r [3 Replacertnent---'-=--.4-_] Public or commercial -Describe: Parent-r legal Flood Plain a ation if applicable - 1g . ft 5' r n G 'pKeral gdmments nd recdmmendations: Rr-GCE' S `fsl-el w/ -2 n;° t -LS l l~ yC L Q Z 161 `C12113v`T1 b ~j 'p) 0 es _ r?C - o • S # ❑ Bo y Pit Ground surface elev. ~-1 ft. imiting factor Soil Application Rate Horizon Depth Dom► a ox escription ure Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 O -B 10 `112- 31Z. SI1,1 Z436 b 3 32_63 1C)'f rZ ` - o s g M C S • S .9 , S y -I Z to -t rz-y! ~1~ 1. S K YZ S S I p Vn M V-qk • 0 . Z a Boring # ❑ Boring pit Ground surface elev. Depth to limiting factor ;p 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 Z ~-~9 l~~rZ 3l - S> I 2msbk wi.`Ft- CI,J . S .i3 3 19-5 8 i 0'J 2.3 6 S t2.5 /S s i cSb ~c yrt 'fi►- - - z 3 - ' Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signa re CST Number Arthur L. Wegerer 4, 01'3 220254 Address W e g e r e r Soil Testing & Design Service Date Evaluation Conducted Telephone Number 421 N. Hain St. River Falls, (1I 54022 l-L l01 --(1' 1 715-425-0165 J Property Owner d'D/=~ L - Parcel ID # 1Vp 1 }"1 G Page Z, of F~] Boring # ❑ Boring 3 ® Pit Ground surface elev. 100• ft. Depth to limiting factor 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 a l0`~12 31Z is O SS yy ` Ct.S t, Z Z ~ Z 1 ZDy tZs ! G ~ ~-S c~ s4 r1 I e s - - S . 9• s Z ~ X37 ~ - l v •Fs k m v ~'r- ~ s ~ , ~ , L4 3~-s3 s~R V/y~~~ ~.541~. spa )vas o~►. Yq - F ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor 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 F-1 Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BODE < 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. SB0.8330 (R.6/00) 4 ` t PLOT PLAN ' Page 3 of 3 Scale 1' = SO' Z6~.lb I Lor ~ 1 I O a o U r rq N V c ss' 1D0.0' ~ 10p - F7 D~3T• ~~IWNS lv L'1.. lip, s' l~ 8.1 ,I -8,10 mi+-'2 EE s ~ SS• ! ~tq S cur d-t~ per ulz B~zQ Lo T lp 81_'1.1 ~2.1u ((('''~/~~U :0 ~.Oh~ lO-`Z`PSLC.~ 31c~"DLH_-P_v_C-P_i P-~?s1/ Z_1 ~t _pJ 715-425-0165 220254 t_3 jg _ CST Signature 'Date Telephone X10. CST No. . Job NO. Parcel 040-1294-10-000 04/09/2008 09:52 AM PAGE 1 OF 1 Alt. Parcel 16.28.19.1686 040 - TOWN OF TROY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - DIVINE LLC DIVINE LLC C - DBA DIVINE CUSTOM HOMES DBA DIVINE CUSTOM HOMES 484ECOVE RDN HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 508 E COVE RD SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 1.730 Plat: 09-018-PINEY WOODS SUBDIVISION SEC 16 T28N R19W SW NW LOT 11 PINEY Block/Condo Bldg: LOT 11 WOODS SUBDIVISION Tract(s): (Sec-Twn-Rng 401/4 1601/4) 16-28N-19W SW NW Notes: Parcel History: Date Doc # Vol/Page Type 12/30/2005 815354 2951/441 LC 07/23/1997 418/476 2008 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/23/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.730 80,000 0 80,000 NO Totals for 2008: General Property 1.730 80,000 0 80,000 Woodland 0.000 0 0 Totals for 2007: General Property 1.730 80,000 0 80,000 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