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030-2106-60-100
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 538874 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: Benschine, Bruce St. Joseph, Town of 030-2106-60-100 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: /OC> M I G~ 06.29.19.890A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. % ZZ i69. /d C, Septic n/I r Benchmark D r ~ ~ Alt. BM rla~ /7! 4CA. ` Aeration "-4 ( Bldg. Sewer Holding 4„ / St/Ht Inlet I of %j 1 t6 F"I " A 1~ TANK SETBACK INFORMATION / St/Ht Outlet 7,(02-1 is 1. ~Z TANK TO P/L WELL BLD9. Ven to Air Intake ROAD Dt Inlet Say „ D~~.►~ 4V-_ G, W, 3 Septic O a 71 15 ► Dt Bottom , 9, 74 q4 5 ior. F t .T C, r ,7 1 Lk- Header/Man. 7 SS J ✓d r• -237 Ae ion Dist. Pipe Holding Bot. System Sa 99.72 PUMP/SIPHON INFORMATION Final Grade 3.15 4S.72- Manufacturer Demand St Cover GPM 11. ` Ccs n ~z, AB, 7% Model Number 1/6 TDH Lift Friction Loss System Head 7T-" H Ft l `7' 37 Forcemain Leng Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width j Length i ' No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufactur r INFORMATION CHAMBER OR ' I Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifol6„ / Distribution x Hole Size x Hole Spacing Vent to Air Intake g 4--6 d Pipe(s) Nll~ \ 5 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 w Bed/Trench Edges ` Topsoil s 0 No Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 363 117th Avenue Hudson,, WI 54016 (SW 1/4 SE 1/4 6 T29N R1 9W) Evergreen Ridge Lot 12 Parcel No: 06.29.1 90A 1.) Alt BM Description= 66je,4 - 61 Gcs-j-e~ v-p V r I(. 2.) Bldg sewer length = ""K150~11~ ~ ~ ~ / / ri f _ - - amount of cover = J r.j Plan revision Required? ;a,r Yes 'T[ No El Use other side for additional information. J J Date Inse or's Siqy lure Cert. No. SBD-6710 (R.3/97) i Commercemi.gov Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 St. Croix t(IDR91 sco n s i n Madison, WI 53 707-7 1 62 Sanitary Permit Number (to be filled in by Co.) n t of Commerce 5 3 -8' State Transaction Number /t~/1T Sanitary Permit Applicatio V In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form top e governmental Project Address (if different than mailing address) unit is required prior to obtaining a sanitary pepuit jam;. A lication forms for sta wned~ POWTS are 7 submitted to the Department of Commerce. Personal vi e e d for ~ condary Same ~f / a purposes in accordance with the Privacy Law, s. 11.04(l)( 1. Application Informatio Please Print Ml Information Ave- Parcel # Property Owner's Name NNI OC T 2 7 011 18-2106-60-100 Bruce & Liv Benschine Property Owner's Mailing Address C,r ` G", UN ,r Property Location / p C~ 363 117"' Ave. Iii A,'~a NG r_:)MG Gr -lC1 l/ 0 / d Govt. Lot City, State Zip Code -PMIV Number NE %4, SW ''1A, Section 6 Hudson, WI. 54016 715 -377-0335 (circle one) IL Type of Building (check all that apply) Lot # T 29 N; R 19 E or W ❑ 1 or 2 Family Dwelling - Number of Bedrooms D4 12 Subdivision Name Block # CSM Ole ❑ Public/Commercial - Describe Use 14~ Na ❑ City of ❑ State Owned - Describe Use CSM Number ❑ V, lage of Vol. 14. Pg. 3939 Town of St. Joseph Lk L-J l,qo-/j o l-1f 6e III. Type of Permit: (Check only o fie box online A. Complete line B if applicable) A ❑ New System Replacement System ❑ Treatmem/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New Before Expiration Owner IV. a of POWTS System/Component/Device: Check all that a 1 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Componen ain) ❑ Pretreatment Device (explain) V. Dis rsal/Treatment Area Informati n: 42 !dgltrator "Q-4" Standard Plu chambers & 6 endca s, P 1 Lok PL-525 effluent filter Design Flow (gpd) Design Soil Applicatio sf) Dispersal Area Required Dispersal Area Propos d (sf) System Elevatyon 600 gpd 0.70 gpd/sq. ft. 857.15 sq. ft. 870.60 sq. ft. 11 99.50' VI. Tank Info Capacity in Total # of Manufacturer o Gallons Gallons Units b U y New Tanks Existing Tanks d c aU y wC7 Ll. Septic or Holding Tank 1,200 1,200 1 Midwestern Precast X Dosing Chamber Na a Na Na t,/ lStr ; t VII. Responsibility Statement- I, the unde gned, ass a responsibility N' Ilation of the POWTS shown on the attached plans. Plumber's Name (Print) lumbe s Sign MP/MPRS Number Business Phone Number James K. Thompson MPRS 30021 (715) 248-7767 Plumber's Address (Street, City, State, Zip Code 340 Paulson Lake Lane, Osceola,' 54020 VIII. un /De artment Use Only Approved ❑Dis Permit Fee Date Issu d Issuing A Signature ❑ Own G' Reason for enial $ /D Z7 IX. Conditions of Approval/Reasons for Disapproval t SYSTEM OWNER' 3) 42 , v ` 1. Septic tank. eftluent filter anal r ' ~4. l ~cc 4 a dispersal cell must all be services I maintained jf pr' IA t as per management plan provided by plumber. 2. AN setback requkements must be maintained I as per app&*ft tote / ordbliulces. Attach to complete plans for the system and submit to the County only on paper not less than S 12 x 11 inches in size SBD-6398 (R. 02/09) Valid thru 02/11 ♦ Exi S ~~f 9 ra ✓,c e (~z 34 3 11719 Ave. ~w,dson, w i. Q l-o~ /.Z, / 5F~3 439 swys~rl; 5ce 4,T..z9K, 5t . CrO4 Co LO i. bf::~ 3. o5/Q cres. S,rsExm E1tJa~.'dr~S: ,Yj•Xri)q S.T. owE(~"~= /o/.~~ ~/d. s~~ou~_ /o8 Ex•'s~i(G'~//q^cncl~ ~kvs~ 97 of ~Y90!' 5 0., N M l-n S c~ ~rac~C~{D /~duCl ~7~GVo✓~`cf2 o; aV~y' E~ a.F Glca..~ ~s!'S. ~roposel c+;sp~s~/C~//.~e~C3~f~ege~asa E 3'z ~l7 ~ by T-., F.•/~a..~w- yq-Y "S-ta.., dc+d /v.s y 2 e l eet do b{ = 99.60: EX/34/"U d we.ll~ ~ - o v o A o p U `p v O ~ D o ~ ~ Q ~ ° ~ Proposes E l Va 1ue Pro asce~v-7res~u~$6-1 `i 1` ~ 'N _ \l ■13v ~CSfdfa'I~L ~ly \ ~ ~ 1~;5(ws~Pctl. ~ \ \ ` \ S~sEe.rt in~C'( rte DecX B3~\ = 97.o/~98oi. t-rEnK 5-e Bch Ev CoC4'n~ . QQ 7-ag-Oge 46 S~~. • 4:t Sr d, Conventional POWTS Index & Tilte Sheet Project Name: Benschine 4 bedroom Replacement Conventional POWTS Owners Name: Bruce & Liv Benschine Owner's adress: 363 117th Ave., Hudson, WI 54016 Site address: Same Project Location: Subdivision: Lot 12, CSM Vol. 14, Pg. 3939 Legal Description: NEi/4 SWt/4, Sec. 6 T.29N., R. 19W., Town f St. Joseph, St. Croix Co., WI. Parcel ID 030-2106-60-100 Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Dispersal Cell Sizing Calcualtions Page 4 System Cross Section Page 5 System Management Plan Page 6 Filter Specifications Page 7 Filter Tank Cross Section Page 8 Parcel map Page 9 Septic Tank Maintenance Agreement Page 10 Certification for Utilization of existing septic tank Page 11 Waranty Deed Attachments: Soil Evaluaiton Report Mater PI er LRestriade: James K. Thompson, Dept. of Comm. Credential #30021 Signature: Date: 2d// Page 1 Of 11 Design pursuant to hi-Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD-10705-P (N.01/01) ~ So./ eda/CCavon~/~ ♦ EX/ sin qra do elks L ~ace~,Ci d ~nsc~t/'aer 117 343 11749 Alt. p W",Cso4, cJ 1 ~1 lo6g, cso I ` 439 SwY~rIEf~; .Sce, G,T. •z9K, T • off' y~..?vsS/'~, St . CrO4 Csi U)/. be;~ 3. o~Q cres. J,rs~ rn El cda~i'or~ 5 ,CS,~ : Tap o{/off 5fru(' _ /60.60: ~,~sL,ilq S.T. owE(~'~= e.lt4 c 97 pro/,loscd,~c~ ckds= 99• so N M ~ F-n~SL.td ~r4-de-fyty /'ec~ucGd ~~v'a✓~c1e CC,ee 6.P 6~ CA 4-1 bAeS. -D o~ ~oposeler,sp~s~/e~//.Fi~C3~Ere.i~saE 3'X q7 4 y Tn F.'/~ 6a- -0-1/ °.Sta, A-5 14- Ex/ n~ eie~t,6n be 99•6o: we.l~ d ~ -o ~ o A c y- c1 U ``O v ~ O YS o 86l Value L ~;ly[p~P~-sss eFf/w~d.~` , ~ \ ` D; s{~ 5 c~ il. ~6S~deptt, \ \ S'✓raCC CIC .Y4'1 DecX \ \ 83\\ ~ = y7.o~i9B.ai.' \ 7 ~~,~r4LaN `{t~9K Ea Cv~4'n~ . ►vl~ • ToocF/off S~+'~'• ~ • t`~ t ,fib d: ~Assu mcd t (c,, P~.z off' r~ Benschine 4 Bedroom Dispersal Cell Sizing Calculations 1. (4 bedrooms)(100 gallons estimated flow)(1.5 design factor) = 600.00 Gpd design flow 2. Infiltrative capacity of native soil = 0.7 gpd/sq. ft. 3. Absorption area required: 857.15 sq. ft. 4. Absorption area as proposed: 870.60 sq. ft. (42 chambers + 6 end caps) Infiltrator "Quick 4" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4" end caps = 5.10 sq.ft, EISA 857.15 sq. ft. - (6 endcaps)(5.10) = 826.55 sq. ft. 826.55 sq. 1/20.00 = 41.33 chambers required Number of trenches: 3 @ 14 chambers per trench (42chambers total) Trench width: 2.83' Trench length: 58.00' Trench spacing: 9.00' on center Total system area w/ 6' trench spacing: 21.00'x 58.00' Pg. 3 of 11 Soil Absorption System Cross Section ft /ago 1-070 ft 4" Schedule 40 Final Grade PVC Vent Pipe With Vent Capes ft Leaching - ► Chamber 9f Std ` ft System Elevation 2.03 ft 6-600 ft ft Soil Absorption System Plan View S8 ft ft ft Leaching Trench 1 Chambers 4" Dia. I Trench 2 Header Vent Or Observation Pipe ~ Trench 3 Leaching Chamber Specifications Manufacturer And Model /4%a.,~ EISA Rating .W.0 sq ft per chamber Soil Application Rate 0. gpd/sq ft tol~_ gpd Design Flow . 0.7 Soil Application Rate + Ae3.d EISA Chambers 3 rows of chambers each. Page 5I of Conventional Septic System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82-84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD-10705-P (N.01/01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with bottom of tank to be 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1 /3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October-March) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a two-year schedule by use of diversion valve. Effluent to be diverted from new cell to old 19' x 36' dispersal cell at 4 year anniversary of diversion valve installation. Older dispersal cell to be utilized for a 1 year period. Effluent dispersal to be alternated between cells on a two year rotating basis thereafter. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715) 248-7767 or the St Croix County Zoning Department at (715) 386-4680. Pg. 5 of 11 ~ ~ Y rrJ • Filters PL-525 EFFLUENT FILTER ( Polylok, Inc is pleased to add its new commercial filter to its existing line of quality effluent filters. The PL-525 is rated for over 10,000 GPD Alarm Accepts PVC (gallons per day) making it one of accessibility the largest commercial filters in its extension handle class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the new Polylok PL-525 has an automatic shut off ball installed 525 linear feet with every filter. When the filter is of 1/16' removed for cleaning, the ball will filtration slots Rated for over float up and temporarily shut off 10,000 GPD the system so the effluent won't leave the tank. No other filter on the market can make that claim! Accepts 4" & 6° SCHD. 40 Pipe PL-525 Maintenance: The PL-525 Effluent Filter should operate efficiently for several years under normal conditions before requiring cleaning. It is recom- mended that the filter be cleaned every time the tank is pumped or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be Gas deflector done by a certified septic tank Automatic shut-off pumper or installer. ball when filter is removed 1, Locate the outlet of the U.S. Patent No# 6,015,488 septic tank. 5,871,640 2. Remove tank cover and pump tank if necessary. PL-525 Installation: 1. Locate the outlet of the 3. Do not use plumbing when septic tank. filter is removed. Ideal for residential and com- 2. Remove the tank cover and 4. Pull PL-525 out of the housing. mercial waste flows up to pump tank if necessary. 5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the tank. Make sure all solids fall 4 or 6 outlet pipe. If the filter is not centered under the back into septic tank. access opening use a Polylok 6. Insert the filter cartridge back Extend & Lok or piece of pipe into the housing making sure to center filter. the filter is properly aligned and 4. Insert the PL-525 filter into completely inserted. its housing. 7. Replace septic tank cover. 5. Replace the septic tank cover. P1. L bt /l 1.. 432 D m n n mz7 (A D D O mnN O_x i m z D y D~ -i ~mZ rmD rn O rnzr Dr N>m 37 2„ z T 6„ o r m -0r a r n D = m D rn _ OZ 18° MIN. ~C < D c o _ r 37" I 22 ° N m J ~1 m o m n A D D D ~A ~l N z- r DI N A m m r On D m X17 0 Z D C FT~ rTT D ----I /u , A r- c,n O > F- D D D f r Z C_ o -I z~ FILTER CANISTER DETAIL scALE:3j4° _ , REV NO. DRAWN 8Y:SWT MIESERCURGRETE Z SEPTIC MANUAL W3716 US HWY10. WAIOEN ROCK, N1 54750 DATE: JANUARY 2008 ° REV. JAN. 2008 800-325-8456 FILE: SHEET 13 Pi. l /l -Ln V CL11U iv vi Lue fuaL u Owner: Bruce Benschine 363 117th Ave. Hudson, Wi. 54016 M 117TH AVENUE M S 89'52'23"E 466.60' ft) l2_ UTILITY EASEMENT ~ I 0) JOO' i W i C) ~ H (0I r SETBACK...... /NE ' N 3.035 acres CID W Z ' W 132,186 sq. ft. r , W O ~Z I h !y f Ct p 1L ® 7T 12 W 1 Ct l :U (fka Lot 6) C :N I O MOUSE N UJ 1 i z to ) I WI 206.89' 265.00 S 89053'1 6"W S 69'83'16"W S00°20'2I'F 3.00' NOO °20'21 "W Legend 3.00' Aluminum county section corner monument found. ° 1"X24" iron pipe weighing 1.68 pounds per lin. foot set. 3.010 acres 1" Iron pipe found. 00 131,122 sq, ft, h Ui: Bearings referenced to the ~ I East-West 1/4 section line q i ~f assumed S89°52'22"W . ~ 101: 3C (L®11 v W N I 's co n= NI "4 QQ PI Note: This CSM is a sale , or exchange of land be- Z; CU V (fka Lot 10) c o 1 tween adjoining owners. UiI N N 0-1 j Town and county approvalW I 1 is not required. The 1Y 1 0 o ~I North line of Lot 11 has (D I I I been moved three (3') LLI Z N feet South to accommo- date building setback W sErBACK LINE ~ ~ requirements. ; ~ ~ ~ I w a ' 0\" P Z t /00' Sc I o UTILITY EASEMENT I Wl/4 CORNER SECTION 6-29-19 S89"52'22"W S 89 52' 22"W 265.03' 3/38.79' I _ S89°5222"W 2046.05' SCALE IN FEET /00' M RIVER ROAD 'Se9'5d20"vl6 O I O 2;0 - - - - - - - - - - - - - NOO °20'2!"W This instrument drafted by: 33.00' 4002683 Vol. 14 Page 3939 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/e Zdoc a,6 Ae Tras Mailing Address 1.363 Property Address (Verification required from Planning & Zoning Department for new construction.) City/State Parcel Identification Number -.210eo 407QV LEGAL DESCRIPTION Property Location 54J '/4 , /f E5 , Sec. (p , T ; _N R_/f_W, Town of 56 - TORP . Subdivision Plat: Pfet , Lot # Certified Survey Map # 4.288/7 , Volume Page # 39__ _ Warranty Deed # 837960 (before 2007)Volume , Page # Spec house 0 yes 0 no Lot lines identifiable 0 yes 0 no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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 §Comm. 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 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. l/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 Commerce 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 form 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 warranty deed recorded in Register of Deeds Office. 7:Slf~ATURE f bedroo s _ 0 OF APPLICANT(S) 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. 09/07) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the followin residence: (Street address) 343 11AAC• located at: /16- '/4,.50 1/4, Section Town__Ay__N, Range /P W, Town of 56. ~s~/✓~ , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service ? ZO/f Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: /C Construction: Prefab Concrete i,/ Steel Other Manufacturer (if known): N'rga,et ri tCr3L_ Tank (if known): vea.~s Permit umber (if kno ) dC. a4tf es Xicensed Plumber ignature) (Print Name) (Title) (License Number~PRS (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 %I 83-7'960 KATHLEEN H. WALSH RE6ISTER OF DEEDS Document Number QUITCLAIM DEED ST. CROIX CO., MI RECEIVED FOR RECORD Bruce G. Benschine and Liv M. Benschine, husband and wife, 11/02/2006 10:30AW quit-claim to the Bruce G. Benschine and Liv M. Benschine QUIT CLAIN DEED Revocable Trust, Bruce G. Benschine and Liv M. Benschine, Co- EXEMPT # 16 Trustees, Laila Rewolinski, First Alternate Trustee, Kristine REC FEE: 11.00 Benschine, Second Alternate Trustee, and Keith Benschine, Third TRANS FEE: Alternate Trustee, each, respectively, with full power of sale or COPY FEE: C FEE: encumbrancing, the following described real estate in St. Croix PC AGES- 1 County, State of Wisconsin: Lots 11 and 12 of Certified Survey Map recorded in Volume 14, Page 3939, formerly known as Lot 6 and Lot 10, Evergreen Ridge, Recording Area located in the SWY4 of the NE%4, of Section 6, Township 29 North, Name and Return Address Range 19 West, Town of Saint Joseph. C. L. Gaylord Attorney at Law P. O. Box 46 River Falls, WI 54022 ) 030-21013-60-100 and 030-2107-10-000 (Parcel Identification Numbers) This is homestead property. Dated this Z5 day of October, 2006. (SEAL) (SEAL) *Bruce G. B nschine _ (SEAL)y J (SEAL) " *Liv M. B~enschine- AUTHENTICATION ACKNOWLEDGMENT Signature of STATE OF WISCONSIN authenticated this day of 2006• PIERCE COUNTY Personally came before me this 13r4- day of October, 2006. the above named Bruce G. Benschine and TITLE: MEMBER STATE BAR OF WISCONSIN Liv M. Benschine, to me wn to be the persons who (If not, executed the foregoing i st ment and acknowledge the authorized by § 706.06, Wis. Stats.) same. L. Gaylord, Nota Public, State of Wisconsin My commission is permanent. THIS INSTRUMENT WAS DRAFTED BY C. L. Gaylord -Names of persons signing irxan hould be ' typed or Attorney at Law acity-s printed below their signatu res:k. P. O. Box 46 ' N O Tt. _q River Falls, VVI 54022 1 of 1 INFORMATION PROFESSIONALS COMPANY FOND DU LAC. WI 800-6552021 py,it Or Oct-14-2011 02:48 PM 5t. Croix County Plan/Zoning 715-386-4686 1/3 3 womnow : rnoi °S~`' SOIL AND $17E EVAL.UAYI P • • w otMOW a Wkrnw in acCord with ILHR 83.05 ' ~ t u Attach complete site plan on paper not lose than 8112 x i i lnchee in •p4ar► must ~ CE41:. • oil[ not limited to vertioai and horizontal reference point (13M), direollon and a ope, scale or dimensioned, north arrow, and location and dietanoo to nearest road, rh. ^ t-► p BEY APPLICANT INFORMATION-PLEASE PRINT ALL INFO RMATI N k Sr PROPERTY OWN1A40 LQT SW a 4` 1N4,5 T 29 NR 19L°f) W PROPERTY OWNERS MAILING AMIRLSS NAME OR CSA1 # ~ 6 Ever reen xi 1153 Majawlay-13r. CITY, STATE ZIP CODE PHONE NUMBER CITY ILLAtIE WN NEAREST ROAD sots Wr. 54016 1 71h 549-6449 D New ()onsWWon Use 12d Wdentfial I NurMw of bedrooms 3 [ 1 Addltion to existing bulkM9 (j Replacement I I Public to oomm rcW descrit>a Code derived daffy flow On gpd Recommended design loading chCMad, gpoltt2_.s .._1 , OP 2 Absapilon area mquIred _ 643 lad, 42 m33 trench, ft2 MMmum design loading raW -L7-_bCd, gidfi2_J__bench, Rommmended infllUation surface elevation(s) Q7. an-°° nn- it (as referred to site plan benchmark) Addltional design / Me conslderalms _ Perertt rnaker~ , cut: FloDd plain elevation, if applicable OR -T SY&M S. gUI br."BISm 00NVWn0NA. MOUND IN-GRMNO PRESSUR9 AT-GRADE. V8 U I KIU U []nsul le fcr m fA fs 0 U [is DU ER S C1 U k18 ❑ U U SOIL DESCRIPTION REPORT Depth Dominant Color N101 W Texture Structure Consistence Boundary FrAa GPD/ft7d 13oring Horizon in. Munsell Qu. 3z, Cons Color ar• Sz• Sh. Seri 131 1 0-12 0 r3 3 none si r mvfr .5 .6 2 12-88 7.5yr4/4 rxona is Osg ml na .7 .8 Ground alev. , 1 1m g , Itln factor Remarks: Boring ~ 2£ .6 1 0-8 10 r3 3 none 1 2msbk mfr gv 2 2 8-20 10yr4/4 nom~e sic1 losbk mfr OV if .2 1.3 3 20-86 7.5yr4/6 none Oo s Osg ss na na .7 .8 Ground ' elev. tot - I u fang factor „ I R=Uks: CST Nome:-•+Piun Print C L. Steel thaw: 715-246-620D Address: 1554 200th. Av • New Richmond. W154017 CST Number. nM WS ( Signstum p°~: 4-2a-99 Oct-14-2011 02:53 PM 5t. Croix County Plan/Zoning 715-386-4686 2/3 arOt pRppeffff WNER Florars eckworth SOIL DESCRIPTION FiEPQR7 pap pARaiLI.D. 10- depth Daminant Color won Texture structure 00rGstence ftn:by Roots GPD Thanch Boring # Harizon in. Munseli Qu. Sz. Cont. Color Car. Sz. Sh. Bed 1 0-10 10yr4/3 none r .5 .6 3 if .5 .6 2 10-21 10 r4/4 none si 2tagr mvfr Ground 3 21-10 7.5 4 none Co a Dag ml r►a na .7 .B elev. 103_ ft, Depth to mffg ling i factor 4-1 Remarks: Boting # 1 2msbic mfr taw xf .5 ! .6 1 0-12 10yr3/3 n 4 2 12-23 10yr4/4 none siel losbk Mfr gw lt~ .2 .3 3 23-94 7.Byr4/4 none co s 055; m~. na na .7 1 .S Ground elev. ~ i loo -4t' Depth io 4 limiling factor ? +QAH 1 narnad e: Boring # I 0-9 10yr4/3 none l 2msbk mfr gw 2f .5 .6 1 5 2 1 9-16 1ttyr4/4 gone sliml 2mabk Mfr 9w if .4 .5 3 16-39 7.5yr4/6 none oa a Osg mi na tna .7' .8 GTaund Oev. ~ 1(kZ.~ tl, i Depth I W E llenhng I WIN 1 , Remarks: Boring # I i Ground ` elev. DepthAto Remarks: ssas3aoli~.asazt Oct-14-2011 02:53 PM St. Croix County Plan/Zoning 715-356-4656 3/3 STEEL'S SOIL SERVICE 1564 20I8 Gary L, Steel Florian Weck~vorth Ave. New Rlchm 54010 OSTM2298 SAM* S6-729N-919N (715 MPRSW-3284 town of St. soiseph 7~5)2 246.8200 lot #6- grem Ridge N r 111=401 BM., trop Of SE lot stake ! 61. 100.00 Alt. BK. = top of lot 5&10 lot stake 0 el. 103.45' 0C6 ~o N* Ok a Gary L. Steel. 4-24-99 2269 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 2 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations Attach complete site an on County pl paper not less than 8% x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. 03 -2106-60-100 Please print all information. =ied Date Personal information you provide may be used for secondary purposes (Privacy taw, s. 15.04 (1) (m)). Re Property Owner Property Location Bruce & Liv Benschine Govt. Lot SW 1/4 NE llS 6 T 29 N R 19 W Property Owners Mailing Address Lot # Block # Subd. Name or CSM# 36317th Ave. 12 CSM Vol. 14, Pg. 3939 City State Zip Code Phone Number I City _f Village 6el Town Nearest Road Hudson WI 54016 St.Joseph 117Th Ave. New Construction Use: 01 Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD 6011 Replacement J Public or commercial - Describe: Parent material Glacial Outwash Flood plain elevation, if applicable Na General comments and recommendations: Evaluation completed as addendum to Steel report verifying soil suitability to allow installation of replacement system deeper than allowed by original soil evaluation report. F6 ]Boring# - Boring f Pit Ground Surface elev. 106.56 ft. Depth to limiting factor > 138" 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 1 0-10 10yr3/3 none sil 2fgr dsh gw 2f 0.6 0.8 2 10-18 10yr4/4 none sicl 2fsbk dsh cw 2f 0.4 0.6 3 18-27 7.5yr4/4 none Is Osg dl cw 2vf 0.7 1.6 4 27-64 10yr5/6 none gr s Osg dl aw, - 0.7 1.6 5 64-138 10yr6/4 none strat. s I Osg dl - - 0.7 1.6 47, * Effluent #1 = BOD? 30 < 220 mg/L a d TSS >30 < 50 mg/L * Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signat e: CST Number James K. Thompson 11- 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 10/27/2011 715-248-7767 Jai/ QdQ~Gt0.~pn~i~ EX% $ ~i g /~✓4 ~1 tl ca./c : 27 77 117 34.3 1170 AVc. p p 1fic: sort, w4 •F- 1 ~~1 /.off /.Z, C-4.v1 / Y3,9.3.9 ,S WA/ se a G, T•Z9K, St - CrUiX Aa. 3f 030 -Z/o6-la0-kt7 6e;.y 3 oyQ cres. S,rsEc m E/ cda~'dr~ S I Ex's-~~~t•-o,~c.I,e1<vs~ g7oi'899.0%. P~o,x~SCrfnc~ eft~s= q-7,!5 o' v ~ntShed ~~'tde-(r, ty /'eductd ✓'Vc ~✓(a-x. C'e✓y -,e :s 8.u'3e;iincc6ei.?x F ^(I -e A-0P sed ~lrspcfs~/~~~.7; eA' (3j CJ-,5 a E j rJ.a.nbvs ~u ~c.,c~. Tr, /f,a~,i~Sc.,-{ace ~xisEl~~ N e 1e~t 1r, b~ = 99•so: o o v ~ A o ' V rJ ~ ~ o ~ o iyw, E 18S ~I 1 vc.lue ~GR$( /~7~yl olllo~.5z5 laLd.F•` \ EXiSE?nc -XI ~ 7 B•S' 7~.ry, Eo ~uC4'n~. • ~ z ~ ~ di 4•~~ i1CJ~ lufnu~ : Y.OOf ~D~ S Of'~ocv~dP+Fic;ti. E'/tt/~ = //p, y Asa"os ae (c,, O f~D ry ~p y ~ • C N 3 y w ~ O O O IF- Z C O W W r O W 0D ~ m 0 N W n O PO K) [.3 --o Z _ N N Q 3 N S ~O 0 O i?d O N n CO -1 O O O O O CD 0 0 a C.0 m < D a w _!~y m m cn a ~ ~i co -0 N co 3 o C) N CA) 0 D "IOWA W CL Q N to - c(OO coo = ° a CL o m h. O O _C < m Nv yy0)~ to N`m N O d cr v q A f° w m a d m = coo co CL w N 3 - a M w z (0 CD a z --i z D m o m O 5 0 0 ? O N N• C y ll~~d O N j, 'a N a) CD C W ~p O d d 3 z CD O O O 2 cp n 7 M w flJ a O CCl)C 1 O W CD < O a z O 3 a ;U 3 j z CA) sa N co T C l o~ z S y N lip, A N O J A O ~ O O CA O A v O ! O C ~ ti Parcel 030-2106-60-100 05/08/2007 11:49 AM PAGE 1OF1 Alt. Parcel 06.29.19.890A ' 030 - TOWN OF SAINT JOSEPH 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 BRUCE G & LIV M TR BENSCHINE O - BENSCHINE, BRUCE G & LIV M TR 363 117TH AVE HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description 363 117TH AVE SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 3.035 Plat: 3939-CSM 14/3939 SEC 6 T29N R19W SW NE FORMERLY LOT 6 Block/Condo Bldg: LOT 12 EVERGREEN RIDGE NKA LOT 12 CSM 14/3939 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 06-29N-19W SW NE Notes: Parcel History: Date Doc # Vol/Page Type 11/02/2006 837960 QC 03/22/1999 599766 1412/162 WD 08/27/1998 585886 1351/629 WD 2007 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/13/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.035 76,000 275,200 351,200 NO Totals for 2007: General Property 3.035 76,000 275,200 351,200 Woodland 0.000 0 0 Totals for 2006: General Property 3.035 76,000 275,200 351,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ~ ~ M R s FILED - U L5 .1U.. AUG 2 5 2000 s ` SEP - 117 6 KATHLEEN H. WALSH Register of Deeds 11 USt. Croix Co., W1 U NTV ' V 1 CEP T-" F I ED SUP V E Y MAP Located in the Southwest quarter of the Northeast quarter of Section 6, Township 29 North, Range 19 West, Town of St. Joseph, St. Croix County, Wisconsin, being Lots 6 and 10 of the plat of Evergreen Ridge. Owner: Bruce Benschine 363 117th Ave. Hudson, W i . 54016 117TH AVENUE M S 89'52'23"E 466. 0' ~ 12 UTILITY EASEMENT /00' N C7 m lit • Q) i s~ co ..............................-.3.035 acres.............SET14W~ .....LINE.............. N W 132, 186 sq. ft. 3 W~ ~0 Z~ o' N !L ®7r 12 w ~ i • i cl: i (fka Lot 6) U Lli ca L 0 HousE p L11 I LU i 2 co ) i 206.89' WI 265.00 ' SOO°20'21' E S 89 53 16 W7 s e9 53'16 'W 3.00' N00°20'21 "W Legend 3.00' Aluminum county section corner monument found. ° PX24" iron pipe weighing 1.68 pounds per lin. foot set. 3.010 acres d ~ 1" Iron pipe found. CD n p 131,122 sq. ft. J i Bearings referenced to the ~ CY) i East-West 1/4 section line p I Q assumed S89°52'22"W . i0): ; ILvit I1 v W O co n= Ni Note: This CSM is a sale N rn (fka Lot 10) rn m M or exchange of land be- v . tween adjoining owners. Ui N N i Town and county approvalUJ i i is not required. The Q i 00 00 -i North line of Lot 11 has 0 1 Ct: been moved three (3') W : Z N r ' NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW G D ~8 0 30` INDICATE NORTH ARROW ST. CROIX COUNTY ZONING DEPARTME R c,, t-9/ AS BUILT SANITARY REPORT y t u.K•~,' ` sr c, X g9 Owner-; 9 A Property Address f 3~ ~3 l / 7 204Z AMY City/State OFFACj~ Legal Description: Lot Block Subdivision/CSM # 3GcC t/a 31C t/a, Sec. ,6, T21N-Ra W, Town of PIN # 0 30 - oZ 166 -A 13 SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION: Tank manufacturer _ Size ST/PC 167061 Setback from: House,?3 Well P/L ~ Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: e Type of system: Width 3 Length Se7 Number of Trenches Setback from: Housed Well P/L 5~ Vent to fresh air intake f- 70 ELEVATIONS: Description of benchmark 1 Elevation ,O 0 Description of alternate benchmark T~ CAI-Ir Elevation IA9, g V Building Sewer ST/HT Inlet /L ~ e 50 ST Outlet J4/. PC Inlet 7 PC Bottom Header/Manifold Top of ST/PC Manhole Cover Loa, ( ) Distribution Lines I 6f) , 1 7 815-3 Bottom of System ` l - 7~ d ( ) Final Grade /7 ~6~'. / ( ) Date of installatio n/ rmit number 33N83 I State plan number Plumber's signature License number ' f - ~a 15-ADate Inspector Complete plot plan r" Wisconsin Department Commerce PRIVATE SEWAGE SYSTEM Count Safety anfi.Buildings Division y: INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: ST. CR IX Personal information you provice may be used for secondary purposes [Privacy Law, s.mo4 (1)(m)]. 3 3 3 V', 9 Permit Holders Name: E] City ❑ Village Town of: State Plan ID No.: BENSCHiNE, BRUCE CT . JOSEPH .a i CST BM Elev.:. Insp. BM Elev.: BM Description: Parcel Tax No.: 1A.4~ 1 7 (of ~i4r.~ 030-2106-60-000 TANK INFORMATION ELEVATION DATA A99001 0 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. eptic b1,1 '~G►o ~~ze f- C Z Benc r4 1 o..7tj //off ' [ o t~ Dosing J. L-0 -7 Aeration Bldg. Sewer ~•aZ ; ~Da Holding Inlet Z.o/ fdf ~~j3 TANK SETBACK INFORMATION lyl Outlet q.3G1 •0 & c/ TANK TO P/ L WELL BLDG. Air " ake ROAD Dt Inlet Int e 4 U p~ 3?i NA Dt Bottom Dosing _ NA Header/Man. Ap 78 Aeratio NA Dist. Pipe io.» too. /7 Holding Bot. System >,o a3 qp. o/ a .o PUMP/ SIPHON INFORMATION Final Grade 7,Up ~0 /c Manufacturer Demand " L6 2- b(o /06, 29 Model Numb GPM TDH Ift Friction *aa.Dis. TDH Ft Forcemai L tTo well SOIL ABSORPTION SYSTEM BED E idth Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK 'e; INFORMATION Type O CHAMBER Model Number: Syste : OYI 70f OR UNIT h E4 aci DISTRIBUTION SYSTEM yo Header /Manifold h Distribution Pipe(s)~~~ ^I x Hole Size x Hole Spacing Vent To Air Intake Length -Z_ Dia 14 Length • --Bfa. Spacing _~('J_ Cliff qh,r Cozc- SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of Tx Seeded /Sodded 7xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: ST. JOSEPH 6.29.19,SW,SE 363 117TH AVE - EVERGREEN RDG LOT 6 D, grji/~i ~cwe~, 18wuat,( q•.-L. na'Cj' Kktt iiw¢ t-, c-iwuG&~aj f~,~t 7v) 5,W cf rv7 Plan revision required? ❑ Yes Eff"No Use other side for additional information. 1,5_1116~- SBD-671(R.3/97) Date Inspector's gnature ert No. Visconsin Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707-7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitar Permit Number 3el Personal information you provide may be used for secondary purposes heck if revision to previous ap ication [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Proper R, 1, A ty Owner Name t - Property Location c~ 6(,f,(114 5,E:1/4,5 T a i, N, R f 9 E (or)9 Projrt y Ofwner's Mailing Addret/ Lot Number Block Number City, State Zip Code Phone Nu►rtbpr Subdivision Name or CSM Number of I, _h I A~ P, 'IV II. TYPE'OF BUILDING: (check one) ❑ State Owned _3 C] itr Near fist Road ❑ VII age Public ' 1 or 2 Family Dwelling - No_ of bedrooms Town OF 5 7A D~ 1111. BUILDING E: (If building type is public, check all that apply) Parcel Tax Number(s) / w L L - 0 tD • 1 ❑ Apartment/ Condo - - 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. W New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. Q Repair of an Syste2________System_____________TankOnly______2_ w -Existing System ZO System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued 1140 V. TYPE OFSYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 Q Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 Q Holding Tank 12 Seepage Trench oZ - 22 ❑ In-Ground Pressure / 42 ❑ Pit Privy 13 ❑ Seepage Pit Ca X S7 ~ _ 43 E] Vault Privy 14 E] System-In-Fill r 8,5 VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. WElev. 7. Final Grade t Required (sq. ft.) Proposed (sq. ft.) (Gals/da sq. ft.) (Min./inch) 7 Elevation 5-22, V - Feet ~ Feet VII. TANK Capacity INFORMATION in gallons Total # of Prefab. Site Fiber- Ex per- Gallons Tanks Manufacturers Name Con Steel - glass Plastic App New Existing Concrete strutted Tanks Tanks Se is Ta w+f, flflZJ"r7ti'R~ /006 j Lift Pump Tank /Siphon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber' natur (No S ) /MPRSW No.: Business Phone Number: Z/r 114-1-( 1ZV aS- a G 9 y,. _ Plumber's Address (Street, Ci te, Zi de` C//1 N t Y~6 IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued Issuing Agent Signature (No Stamps) Approved ❑ Owner Given Initial low0 p® surcharge fee) Adverse Determination C(~/ X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11197) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber ~a t x~ 4 " ' b►r Wiscons f~Department of Industry, SOIL AND SITE E V A L U A T I ~R~O R T Page 1 of 3 Lalx~ and Human Relations r : rrr Division of Safety & Buildings in accord with ILHR 83-05 ilk. 4 , Ode" OUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in siz Flan must i + St. Croix P CEL I.D. # not limited to vertical and horizontal reference point (BM), direction and o p~ slope, scale or / dimensioned, north arrow, and location and distance to nearest road. a rp^ p t rT'"a REV W BY DAT APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATI N"`, PROPERTY OWNER: )iT,LOT SW 114;\ 1/4,S 6 T 29 ,N,R19 -&or) W Florian Neckworth PROPERTY OWNERS MAILING ADDRESS L '~LQC~C ~ NAME OR CSM # 115 McKirmley Dr. 6 Eger reen Ridge CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE RkOWN [NEAREST ROAD Hudson, WI. 54016 ( 715 549-6449 S Joseph Core Dr. :k] New Construction Use [x] Residential / Number of bedrooms 3 [ ] Addition to existing building ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2 Absorption area required 643 bed, ft2 563 trench, ft2 Maximum design loading rate .7 bed, gpd/ft2 .8 trench, gpd/ft2 Recommended infiltration surface elevation(s) 97 . n0-94 . nn_ It (as referred to site plan benchmark) Additional design / site considerations alt- area= 101-001-99-001 Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK tU=Unsuitablefors stem IRS ❑U CAS ❑U CRS ❑U KIS ❑U ZS ❑U ❑S ®U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 0-12 10 r3 3 none sl 2m r mvfr gw 2f .5 1.6 2 12-88 7.5yr4/4 none is Osg ml na na .7 .8 Ground elev. 100 . fit. Depth to limiting factor ~Y +88" Remarks: Boring # 1 0-8 10yr3/3 none 1 2msbk mfr gw 2f .5 .6 2 8-20 10yr4/4 none sicl lcsbk mfr gw if .2 .3 3 20-88 7.5yr4/6 none co s Osg ml na na .7 .8 Ground elev. 101 . (1)tt• Depth to limiting factor .191 Remarks: CST Name:--Please Print Gary L. Steel Phone: 715-246-6200 Address: 1554 200th. Aviv., New Richmond. WI 54017 Signature: Date: 4-20-99 CST Number: m02298 le A~ PROPERTY OWNER Florian Weckworth SOIL DESCRIPTION REPORT Page _?,70f 3 PARCELI.D.# 030- aIDG'-(!~zk~ Depth Dominant Color Mottles Structure GPD/ft Boring # Horizon in Munsell Cu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bax xiary Roots Bed Trench 1 0-10 10yr4/3 none 1 msbk m r gw .5 .6 2 10-21 10yr4/4 none sl 2mgr mvfr gw if .5 .6 Ground 3 21-10 7.5 r4/4 none co s Osg ml na na .7 .8 elev. 103.0 ft. Depth to limiting factor +1041, ~k Remarks: Boring # 2f .5 .6 1 10-12 10yr3/3 none 1 2msbk mfr gw 4 2 12-23 10yr4/4 none sicl lcsbk mfr gw if .2 .3 3 23-94 7.5yr4/4 none co s Osg ml na na .7 .8 Ground elev. _ i nh - Qt• Depth to limiting factor Remarks: Boring # 1 0-9 10yr4/3 none 1 2msbk mfr gw 2f .5 .6 L5 2 19-16 10yr4/4 none sicl 2msbk mfr gw if .4 .5 3 16-99 7.5yr4/6 none co s Osg ml na na .7 .8 Ground elev. 107.0 ft. Depth to limiting factor Remarks: Boring # Ground elev, ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) STEELS SOIL SERVICE Gary L. Steel Florian Weckworth 1554 200th Ave. CSTM2298 SW4NE4 S6-T29N-R19w New Richmond, WI 54017 MPRSW-3254 town of St. Joseph (715) 246-6200 lot #6-Evergreen Ridge N 1"=40' BM.= top of SE lot stake C el. 100.00' Alt. BM. = top of lot 5&10 lot stake C el. 103.45' rt2r, y D1e ~C6 k St pct` 3 3,' _ gt~ Qr M Gary L. Steel 4-20-99 *66onsin SANITARY PERMIT APPLICATION 201E W nn~gto~ ve. In accord with ILHR 83.05 Wis. Adm Code P.O. Box 7969 Department of Commerce Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. ~hU/ X • See reverse side for instructions for completing this application State Sanitary Permit Number y y by programs ❑ Check if revision to previou ap~J The information you provide may be used b other government agency vo pKca tion [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D N r 1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Property Owner Name _ 11I11i Property Location Ce .3w1/46 C 1/4, S Lo T Zy , N, R 0 Property Owner's Mailing Address Lot Number ' f Block Number d,31 . F_ , ~l City, State. Zip Code Phone Number Subdivision Name or CSM Nu ber_ 1Il-73l-35331C7j5)5t4c1_5(&_3 I1. PE BUILDING: (check one) ❑ State Owned ❑ 't~ earest Road ❑ VII age Public 1 or 2 Family Dwelling - No. of bedrooms I - - r Town of III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number( s) 1 ❑ Apartment/ Condo 030 (O.zq. 01- O 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. t2 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ 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 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trenc_ha-c/ChamboaL 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit y fn 1-'S SG. .2S 43 C] Vault Privy elic" 14 E] 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 5o Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation 156a - 5 5 7 ,1, Ll q0 r Feet q t4. 5 Feet VII. TANK Ca city hallos Total # of Prefab. Site Fiber- Exper INFORMATION g Gallons Tanks Manufacturer s Name Concrete Con- Steel glass Plastic App- N ew Existin Tanks Tanks strutted Septic Ta orkbklicg_T~utr- bw /D Q ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumb is Sig /(IAr No Business Phone Number: Idrao~~ 35 -715 3- 199 Plumber's ber's Address (Street, y, State, Zip Cod / IX. COUNTY / DEPARTMENT USE ONL ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssue Issuin gent Signature (No Stamps) XApproved E] Owner Given Initial Surcharge Fee) ~j7 /g Adverse Determination .7 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6398 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber t yon 3 /00 /V Off' 0 l A- /0(,., S 3/• 8-` N a' DAP. 3-~ ~7S y 3o3y ~ 8-K 8-3 A-l Wisconsin Department of Commerce ND SITE EVALUATION Pa l of Division of Safety and Buildings . Page Bureau of Integrated Services ,iq rdar=I s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not le -81/2 )or N~ shze.'; , must county include, but not limited to: vertical and zontal referefhf~), direlp6on~ G~ percent slope, scale or dimensions, north farrow, anq '5gtion and distance t' t road. Parcel I.D. # { 3998 4,.> Q '110 -21 p G a APPLICANT INFORMATION - P/ a print s c '~x fv ~ Re ' by Date Personal information you provide may be used for ry ( (1) (m)). Property Owner Location 10 rya W -e GcIG 'F Govt Lot S~ 1/4,U f= 1/4,S T~F -IC N,R /9 z0 E ("'+~J Property Owner's Mailing Address Lot Biodc# Subd. Name or CSM# City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Ro& w ! ,3Y0/1/, (71S) G ~'y St v If IfA Ca -e D New Constriction Use: aResidential / Number of bedrooms 3-V Addition to existing building ❑ Replacement Public or commercial - Describe: Code derived daily flow U 0 d gpd Recommended design loading rate ! bed, gpd/ll2 rtrerxit, gpd/il2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate bed, gpoltt~_trench, gpdAt2 Recommended infiltration surface elevation(s) 1 a 3o ft (as referred to site plan benchmark) Additional design/site considerations Parent material C~Ar- ~a ~ CiiL~4S ~ Flood plain elevation, if applicable It S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system 53 S❑ u la S❑ u tOs❑ u CK S❑ u ❑ s [9 u ❑ s tau SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/tt2 in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. r Bed , Trench 13 Ground 3 -z,6 rn elev. Ify>Oft. , Depth to limiting factor Fin. S F3 • ~ Remarks: Boring # 0 -t Z- o ~Z S ~N?4 C -S , - lo, r V-6 S< rna d C - pr, 3 yz 0 l 4"11 rns ,~r► / c,S , Ground elev. Q/. Oft. Depth to limiting factor "in. Remarks: CST Name (Please Print) Signatu Telephone No. 4Jo pi 4u w~a .ems ! ~iJ' as'7- yCr~~ Address Date CST Number 0 S I ,S',G Le' 5'G' I-S- G -/1- ~ S'33n PROPERTY OWNER SOIL DESCRIPTION REPORT Page, 02--, of PARCEL I.D.# Horizon De th Dominant Color Mottles Structure 2 Boeing # P Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3M 5, /,q 77 6-1v r3 Ground 3 93 Y/~ elev. Depth to limiting factor -"-in. 36 -72- Remarks: Boring # Ground elev. 4/-Y6ft. Depth to limiting factor :Rin. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # G- C1 /0y `3 s ' wro~i-- c 1~ 4~ rO~/ Ground elev. q,~yQft. , Depth to ; limiting g7 ,2" factor L -ly_in. Remarks: Boring # Ground elev. tt. ' Depth to limiting factor in. Remarks: SBD-8330 (R. 07/96) Azle 1,C-Qk" &n Ze%. /o~.o S~jY s 76r WA. e(~ v. -e f' ©rae , t~ <x -.r-, ---.~yU ' ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address a_31 . I°~-N y ~f7 /r 7 3/ 3 S 33 Property Address 36 ALI (Verification requited from Planning Department for new construction) City/State Parcel Identification Number O /Q Q LEGAL DESCRIPTION Property Location 6jQ r/,, _ y,, Sec. T2eLN-R1_W, Town of Subdivision Lot # Certified Survey Map # Volume Page # Warranty,Deed 7/,7 (c, Volume l ~~oZ Page # l Spec house ❑ yes 2/no Lot lines identifiable yes El no SYSTEM MAC X ANCE Improper use and maintenanceof 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. The property owner agrees to submit to St. Croix Zoning Department a certification fo master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying (1) the ste waste the owner and by a is in proper operating condition and/or (2) after inspection and pumping necess), the t system septic tank is less than 1/3 fuU of sludge. Uwe, 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 Commerce and the Department of Natural Resources, State of Wisconsin. Certiftcation stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNA (TURE OF APPLICANT 3 / JL/ q DATE O Y' ER CER K[CATI N I (we) certify that all statements on this form 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 warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT / L / DATE Any information that is mis-represented may suit in the sanitary permit being revoked b the Zoning Department. Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed VOL 1412mcE162 5997Cs6 STATE BAR OF WISCONSIN FORM 2'- 1998 KATHLEEN H. WALSH Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI This Deed, made between Richard LaCasse, a/k/a Richard W RECEIVED FOR RECORD LaCasse, a married uerson, Grantor, and Bruce G. Benschine and Liv M. Benschine husband and wife 03-22-1999 B:40 AM Grantee. WARRANTY DEED Grantor, for a valuable consideration, conveys and warrants to Grantee EXEMPT # the following described real estate in St. Croix County, State of Wisconsin (The CERT COPY FEE: "Property"): COPY FEE: TRANSFER FEE: 134.70 RECORDING FEE: 10.00 PAGES: 1 Record' Area Name and Return Address F-F LC - ~a Goss 030-2106-60 Parcel Identification Number (PIN) This is not homestead property. Lot 6, Plat of Evergreen Ridge in the Town of St. Joseph, St. Croix County, Wisconsin. Exceptions to warranties: Easements, restrictions and rights-of-way of record, if any. Dated this day of March, 1999. * * ichard LaCasse, a/k/a is and W. LaCasse * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) ss. 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