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020-1283-30-000
N ^ O O 6 0 4 O o o m o m "� r d L COO 01' Y Q C w Zt N L E 3 L) 0 CL v_v •O O N 'O Z Z Z .� O LL C O)N LL c N a) o Y o c� I � ,3 I N 'O X E <1 w Q +c M O. 3 Cl) 'S uJ Z ° Z ;; O O C° a m a m ca v O z o y o N FZ- E c a v rn Y O N O_ 0 U 7 $ a) to 0?•�i O^' C O N O L= N L 0 d V 0O C C QQ p Z Z Z O N N = zz � E 15 m W _ N d ° �o E N m L _ m c 0 W y L y 0 'oc�' a` Oath � o $' a` E Cl) Unman a v) v) N o 00 0 0 0 0 •�Ny � aa (L = aaa �+► :. = R (n J U m o o } $)) 0) } N N �V yco N � O V-_ O O O O E G M .. O O .5' O O O O m •� p� a m N Os _d a z in o d ¢ in q 313 y3y� y O O 46 m N C •N O 06 0O CO CO E :� C C O M CO 0 N I? Z O .0 .0 c 2 a ° N y C C, U NY O � of F" a c `m m c v N O 0 N O C W " >- >- +O•+ pN\j U O y L I y �6 M O N c c c_ a) m N O 2. FBI N -O ++ 3 m m L �'•• a+ 7 ~ O 7 y ^ O o T T m U a) 3 O N m E • 0 N m LL LO O Z U) a' ' to 0 N O Z g '7 O Ud I E ee ` CL L L a a Z • � m a) c m y c r� r A vat 0U)) V I0cou Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT sanitary Permit No: 574382 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: Felland, Pete & Sara I Hudson, Town of 020-1283-30-000 CST BM Elev: Insp.BM Elev: BM Description: Section/Town/Range/Map No: l 6 �„�,(� L)j 20.29.19.1366 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark , ( Cf 9 2 /a Alt.BM e In .;,1„t kt- Go ,�. w 3.10 l S.3 Aeration Bldg.Sewer Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. en a In ke ROAD Dt Inlet Septic 75 � � ft0 �� / � Dt Bottom � Dosing Header/Man. '7' <15 Aeration Dist. Pipe 71 Z• 9 i' 7. 3 91 - 4- Holding Bot. System^ 8•Z 410 • 7 Q i� g.3 90 . �L. PUMP/SIPHON INFORMATION Final Grade 3 .3 7 Manufacturer Demand St C ver GPM r� Model Numb TDH ft Friction Loss System Head TDH Ft Forcemain Length Dia. Dist.to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width i Length No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 178 Z, le 11,� � SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufactuy INFORMATION CHAMBER OR ='I— Type r Of System r /l 'S / /LQ //) _ UNIT Model Numb r. DISTRIBUTION SYSTEM e C- ZZ xZ= Header/Manifold if IDistribution x Hole Size x Hole Spacing Vent to Air I t Pipe(s) � E Length �� Dia Length Dia\ Spacing ` ✓�GGG"'' 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 ' (4 es 0 No l es [ No COMMENTS: (Include code discrepancies,persons present,etc.) Inspection#1: / / Inspection#2: J / Location: 449 Virtue RoadeHUdson WI 54016(NW 1/4 NE 1/4 20 T299N R20W) Willow idge East II Lot 1133 Parcel No: 2 19 1 i 1.)Alt BM Description= N •�Jr GonlJn�- �`+��- ''`J�I �""^'` �`S 2.)Bldg sewer length= 41 ��f`5��/� �" •�� Ga J-2� -amount of cover= Plan revision Required? D Yes )il(No 7 Use other side for additional information. - "ignature Date Insepct Cert.No. SBD-6710(R.3/97) PLOT PLAN PROJECT Sarah Felland ADDRESS 449 Virtue Road Hudson 54016 NW 1/4 NE 1/4S 20 /T 29 N/R 19 W TOWN Hudson COUNTY ST.CROIX SYSTEM ELEVATION 91.8/91.2 4.5' below grade DATE 9/16/14 BEDROOM 4 CONVENTIONAL >00C IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1200 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 890 # of chambers 44 kk BENCHMARK V.R.P. Top of nail in power pole ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark Virtue Road All piping shall be SDR 30/34,within 10' Scale _ 1 /4" 1 0 of tank,piping shall be Schedule 40. Well 30' Property Line 40' 4 Bedroom house 15' ST B-3 10' 60' Valve 6% Slope B-2 Manhole is to be raised to 40 above grade,a filter is to 20, B-4 10' be added to the outlet opening B-5 60' 95' 40' 40' 96' 2-3' X 90' cells with>3' spacing 60 Vents 120' Property Line 20' B-1 Vent >6„ Quick4 Standard 60' of Cover Leaching Chamber 97' h 20.0 ft2 of Area of end caps 4' Long 12 Grade at System Elevation 34" B.M. 90' Cty Rd A ,�� County Safety and Buildings Division p 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be fiIled in by Co.) dtsaTt;`Wl"53707- 2 M ��e 57X382 �. covN�ME I s`�'\'N\TW Permit Appfta . StafeTransactionly In accordaoce�W 38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit A is regnked prlror to obtaining a sanitary permit. Note:Application form for Aato-owned PO WTS are submitted to Project Address(if dilfcrem the mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary in m da=with tin Privacy Law,s.15. 1 m,Stats. ��1, ...� ! t ►/(/,►+J L iication Information—Please Print All Information P � D ad ��8�N -- property Owner's Mailing Address I GovLLott a /3( to Cm,g Zip Code Pbooc Number /.,�yti S.M. f/v, 1 le D t� T�N, � E DL Type of Building(check all tha=(Y7� # 2 Family Dwelling-Number of Subd ivision Name �Q�4Gti.vwer� BI / ❑PubliciCommercial-Describe Use []City of ❑State Owned-Describe Use CSM Number Village of _ of z Zz+-ZZ. G wt�Oc — III.Type of Permit: (Cbec ly one box on line A. Complete line B if applicable) A. New System lacement System ❑Trca�evt/Holdutg Tank Replacement Only ❑Other Modification to Existing System(explain) B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner Z 714 Z7e) I8 9 7 IV. of POW I'S S stem/Com nent/Device Check all that apply) -Pressurized In-Ground ❑Pressurized in-Ground ❑At-Grade ❑Mound 2:24 in.of suitable soil ❑Mound<24 is of suite a soil �- ❑Holding Tank ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dis rsai(Irea of Area Information: 3 Design Flow(gpd) Desigt Soil Application Rate(gr Proposed Dispersal Area Acquired(sf) Dispersal Area (sf) SXsunf{ qp� VL Tank Info Capacity in Total #of Manufacturer C Gallons Gallons Units � � �T .2 _ New Tanks Existing Tanim `u .6 I / / v3 03 iz C� C Septic or Holding Tank DO5in Chwber VII.Responsibility Statement-I,the nisdersign4, s ive responsibility for installation of the POWTS shown on the attached plans. Pig's Name(Print) Pl s Signature MPIMPRS Number Business Phone Numbs Plumber's Address(Street,City.State,zip t VIII.CouatvMe arfinent Use Only proved g�esappreve Permji�t�F,.e/,e�/ Dau sued I' I Issuing t Sigtattoe erEiNen Reason a D.W a 1 f J ' 9 1`1 7 DL Conditii Se ns for Disapproval I /Q ptic tank,effluent finer ward dispersal cell must all be servlcss/malri& as per management plan provided by plumbs. I At GK requiremerft must kpe rr l Mied as per ?erdi whoes. Attach to compiete plain for the system and submit to the Comfy only on paper not Ins than 8 trt x 11 inches in sine SBD-6398(R. 11/11) Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 9/17/14 Owner:Sarah Felland Location: NW 1/4 NE 1/4 S20 T29 N,R19W 441 Virtue Road Hudson 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 4-6. Maint;ec and Cont' gency Plan 7. Filter Spons t 8-10. Soil Signature License n 226900 PLOT PLAN PROJECT Sarah Felland ADDRESS 449 Virtue Road Hudson 54016 NW 1/4 NE 1/4S 20 /T 29 N/R 19 W TOWN Hudson COUNTY ST.CROIX SYSTEM ELEVATION 91.8/91.2 4.5' below grade 9/16/14 BEDROOM 4 DATE CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1200 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 890 ## of chambers 44 BENCHMARK V.R.P. Top of nail in power pole ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE WELL *H.R.P. Same as Benchmark Virtue Road All piping shall be SDR 30/34,within 10' of tank,piping shall be Schedule 40. Scale = 1 /4" = 10' 30' well Property Line 40 4 Bedroom house 15' ST B-3 10' 60' Valve 6% Slope B-2 Manhole is to be raised to 40 above grade,a filter is to 20' B-4 10' be added to the outlet B-5 opening 60' 95' 40' 40' 96' 2-3' X 90' cells with>3' spacing 11 Vents 60' 120' Property Line Vent 20' B-1 >6„ Quick4 Standard 60' Leaching Chamber 97' of Cover h 20.0 ft2 of Area of end caps 4' Long 2 34" Grade at System Elevation B.M. 90' Cty Rd A Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber 5.6ft^2 pair of end plates To be >1' above grade Finish grade elevation Vent _/ Typical Installation � gg° /9 Grade Vent 3' 4„ 3, X30/34 Septic Tank 5' Long 1 5' S' Long. III 36" Grade at System Elevation Grade at System Elevation Spacing 5' 2-3' X 90 ' Cells Same on other end Observation tubeNent At end of cell A 22 chambers per cell B System elevations: A-91 .8' B 91.2' ST. CROIX COUNTY SEPTIC TANK MAINTENANCE 1�iGREEMENT AND OWNERSHIP CERTIFICATION FORM � J Owner/Buyer ----- Mailing Address -- Property Address (Verification required from Planning&Zoning Department for new construction.) City/State Parcel Identification Nuraber �C-934 �tTU LEGAL DESCRIPTION Z_ Q T�N RLI W Town of Property Location M `/� , �r/4 , Sec. , , Subdivision �1 �' _ —' — - , Lot Certified Survey Map# _ __ , Volume��_ , Page#_^l Warranty Deed# � _, Valtune_z Page#�SU Spec house yes no Lot liner; identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION improper use and maintenance of your septic system could result m its pr;mature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner,ii 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 wasie 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&Zon.ng 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 inspecion arid pumping(if'necessary),the septic tank is less than 1/3 full of sludge. I/we,the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth,herein,as set by the Department of 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 Plannuig& 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 k aowledge. I/we andare the owner(s) of the property described above,by virtue of a v✓�ranty deed recorded in Register of Deeds Office. Num r of bedrooms J .......... SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being r,-:voked 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.08/05) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Tank Manufacturer. �c.Q S � �ielaze-❑ NA Permit# tic ❑ Dose ❑ Holding Volume: (gal) Tank Manufacturer: NA DESIGN PARAMETERS Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (gal) Number of Public Facility Units: %-NA Vertical Distance Tank Bottom(s)to Service Estimated(average)Flow: (gal/day) Horizontal Distance Tank(s)to Service Pad: C�p� Specific servicing mechanics must be provided I vertical is>15 feet or Design (peak)Flow=(estimated x 1.5): O (gai/day) If horizontal is>150 feet. speclttc instructions to be provided on back. In Situ Sal Application Rate: < (gal/day/fe) Effluent Filter Manufacturer: ❑ NA Standard(Domestic)Influent/Effluent Monthly average Effluent Filter Model: Fats,Oil&Grease (FOG) s30 mg/L Pump Manufacturer: Biochemical Oxygen Demand (BOD5) 5220 mg/L ❑ NA Primp Model: Total Suspended Solids(TSS) s150 mg/L High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer. A (B006) >220 mg/L ❑Mechanical Aeration ❑Peat Filter TSS) >150 mgA- / ❑Disinfection ❑Wetland Pretreated Effluent Monthly average ❑Sand/Gravel Filter ❑Other. (BoDS) 530 mg/L Soil Absorption System (TSS) 530+ p mg/L Ground(gravity) ❑In-Ground(pressure) p NA Fecal Conform(geometric mean) 510 At-Grade ❑Mound Maximum Effluent Particle Size 'e in dia. ❑ ❑Drip-Line ❑Other: Other: NA Other. ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) hen combined sludge and scum equals one-third('h)of tank volume ❑When the high water alarm is activated Inspect condition of tank(s) At least once every: ❑ month(s)ear(s) (Maximum 3 years) ❑ NA At least once every: month(s) (Maximum 3 Years) ❑ NA Inspect dispersal cell(s) ery: years) At least once eve �,m ar(s) ) ❑ NA Clean effluent filter �'� l �ears) ❑month(s) NA Inspect pump,pump controls&alarm At least once every: ❑year(s) ❑month(s) NA Flush laterals and pressure test At least once every:. ©year(s) Other: At least once every: ❑month(s) NA ❑Years) Other: NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifi 'ons: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). Tank inspections must include a visual inspection of the tank(s)to identify any missing or broken hardware, identify any tracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The soil absorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one-third(X)or more of the tank volume,the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 113, Wisconsin Administrative Coder All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of:512 months,shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. GMW-005(02/05) Page of START UP AND OPERATION 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 absorption system. If high concentrations are prior to use. detected have the contents of the tank(s)removed by a Septage Servicing Operator(pumper)P or restoration of power under these I Start u r due to pump P rural hi hwater levels prior to startup o P. P dose causing an above no one large d 9 may fill abo 9 in o Pump tanks y it absorption system 9 P conditions is not recommended, as the excess wastewater will be discharged to the so Y overload that may result in the backup or surface discharge of effluent and damage to one pQe to the pump this or contact a Plumber contents of the pump tank removed by a Septage Servicing Operator(pumper)prior or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. the life of the treatment Reduction or elimination of the following from the wastewater stream cm a improve tt shc performance on swabs, degreasers, dental floss, tanks and sal absorption system: adds, antibiotics, baby wipes, g diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps,medications,oils,painting products,pesticides,sanity napkins,solvents,tampons,'and water softener brine 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 s.Comm 83.33,Wisconsin Administrative Code`. • All piping to tanks,pits and other soil absorption systems shall be disconnected and the abandoned pipe openings seated. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator(pumper). • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space tilled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compact ion and should not be infringed upon by required ed setbacks from existing and proposed structure,lot lines and wells, Failure to protect the replacement area will result the rulesen for a new soil and site evaluation to establish a suitable replacement area. 'Replacement systems must comply 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 r abilitated and barring advances in POWTS technology,a holding tank may be installed as a 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 last resort to replace the failed POWTS. it❑ Mound and at-Wade soil of absorption systems systems may comply reconstructed the in in place effect atothat�m rem of the bfomat at the infiltrative WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT ESCAPE OR RESCUE UFE. OF AATANK AYIN STANCE. DEATH MAY NOT BE POSSIBLE ADDITIONAL INSTRUCTIONS: i POWTS INSTALLER POWTS MAINTAINER. � f . Name Name. Phone Phone `�XJ%02 r .— SEPTAGE SERVICING OPERATOR UMPER LOCAL REGULATORY AUTHORITY G. Name / F uru / /: Phone one ;7),., C✓ r drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections This document was draft Comm 83.22(2)(b)(1)(d)s(f)and 83.54(1),(2)8(3),Wisconsin Administrative Code. FILTER CARTRIDGE INSTRUCTIONS STEP I Dry At the 1111W case oat*the 8W Of the outlet pipe to ensure t is centered under the wAmw opening. It not,then either insert more pipe into the tank through the outlet or solvent weld(glue)additional pipe onto the outlet pipe- s':EP 2 While the CASO is still dry fitted an the outlet pipe,measure the length of%-inch pipe needed to brace the filter to the tank end wall If utillizing the optional supplemental side support.It side support method.is not utilized, proceed to stop four. �TF P I For inst;allations utilizing the optional supplemental side support: solvent weld the%-inch pipe onto the fM*y case. ff side support method is not utftod,proceed to step four. - Solvent weld the filter case onto the outlet pipe. Insert the filter cartridge into the case, Pressing down until the flier kicks into the bottom of the case. If a VRS switch is utilized:insert into the filter and lock by turning clockwise 9(•. Maintenance 1. The effluent filter should be cleaned every time the septic tank Is serviced. 2. Open the outlet access opening to Inspect the tank and toter. 3. Pump the septic tank completely,making sure to remove the sludge layer on the bottom of the tank and not just the scum and effluent, 4. Once the effluent level has been lowered below the invert of the Outlet Pip*,firmlY Pull up on the fitter handle to dislodge the cartridge from the case. S. Slide the cartridge up and out of the case for cleaning. 6. If a VRS swk6 connected to an aiarro is present,the switch should be removed by turning counterclockwise 900 and cleaned with water only. 7. While holding the cartridge on its side(large flat surface facing down)over the access opening,rinse off the cartridge with water only,making sure all 9"o Material Is rinsed back into the tank. 9. If VRS switch is utilized,replace by insetting into filter and turning clockwise 90•. ,3. Insert the toter cartridge back into the case,pressing down until the filter locks into the bottom of the case. 10.Replace and secure the access opening an the tank. %'WW.be9Mndft-M1n 877-NIFILTERS(653-4583) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK 1'1i i.s is to certify that I hav inspected the septic tank prese;it 1. c ruing the S� y jli ' 2-1/0 residence locate<j S ection T=-/ N, R _w, Town ;f Upon inspection, I certify that I have faiincl the tank and baffles to be in good condition, and it a functioning properly. ppears to he 1.a1st time serviced: f T V ---- 1" j-d flow back occur from absorption system? Yes No (If no, skip next line) Approximate volume or length of time: gallons mini�tc�s '�ipacity: Construction: Prefab Concrete Steel other 19 Iilufacturer: (If Atje of T (If known) .:/j y��fs�— -- .gnature) (Name) Please print ixt-le) (License Number) Date fc:;rm to be completed by licensed plumber (s. 145. 06, Wisconsin .Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: - Iii accepting the above statement regardinshexisting septic tank condition, I certify that the tank to kW' . f my knowledge will conform to the requirements of ILHR 83 . Code (except for_inspection openin over outlet baffleSignature MP/MPRS 2441k� U. 2 8 5 8 P 616 6PIc'R4- 1 7 STATE BAR OF WISCONSIN FORM 1 -1998 KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO.. WI RECEIVED FOR RECORD Document Number This Deed, made between Scott R. Olson and Geri Lee Olson, 08/04/2005 02:15PM husband and wife,Grantor, and Peter W. Felland and Sara L. Felland, WARRANTY DEED husband and wife:!, Grantee. EXEMPT # Grantor,for a valuable consideration conveys to Grantee the following described real estate in St. Croix County State of TRANS FEE: 11.00 TRA FEE: 972.00 Wisconsin(the"Property"): COPY FEE: CC FEE: �lE as survYvorship marital property PAGES: 1 Recordin Area Name and Return Address PETIIRN TO: METRO LEGAL SFR\r'r`. INC. 330 SOUTH?N' J-TE 150 MINNEAPOLIS.'."!: ) - !-ZZ17 020128330000 Parcel Identification Number(PIN) This is homestead properly. (is) (is not) Lot 113,Willow Ridge East II in the Town of Hudson,St.Croix County,Wisconsin Together with all appurtenant rights, title and interests. Grantor warrants that the title to the Properties good, indefeasible in simple fee and free and clear of encumbrances except Dated this 22 day of July, 2005. (SEAL) (SEAL) Scott R.Olson Geri Lee Olson Metro Legal Services SEAL (SEAL) —EDIRET 470262 A (SEAL) 483404 WD 374635 AUTHENTICATION ACKNOWLEDGMENT Signature(s) W E N D Y S W ATZ I N A State of Wisconsin, RTATP r-)P: `,;!.ZLi")NiCIN } ss. St.Croix County authenticated this day of Personally came before me this 22 day of July,2005 the above named Scott R.Olson and Geri LagijMon.husband and wife to me known to be the perso. who executed the TITLE: MEMBER STATE BAR OF WISCONSIN foregqllng inst7iment and ackno d e same. (If not, l authorized by§706.06, Wis. Stats) l )-q— THIS INSTRUMENT WAS DRAFTED BY Notary Public,State of isconsin Coldwell Banker Burnet/Robert Nicholson 1301 Coulee Road My commission is elfna an (. (If not,state expiration date: Hudson,WI 54016 Y 5-35030 ) (Signatures may be authenticated or acknowledged. Both are not necessary.) "Names of persons sioning in any capacity must be ty2ed or erinted below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co,Inc. WARRANTY DEED FORM No. 1 —1998 Milwaukee,Wis. 1 543 AC. T .• aO? 6 03'18'_07•�r pn � O �. 121 id 1ICS vIU M • r w 50752 So FT s72$O $o FT a r+ 1 165 AC / / 005 AC / 10 0 me 1.s" & It _ w • ' � 120 3 . 63498 SO FT ' 1.458 AC. tf2 dr. 11 / 45099 so. FT + e r a IV 66739 So FT', d f,4Ft AC a M t.532 AC. _ W _ •�'J.�. 2462.34 � t _. Tiff. LINE OF TfiE� SE t/4 OF s+s1+r! !Q FT F SEC 17 ' � • 1.ROO AC, 13 44070 So Fr r • 44934 90. FT � ✓' �5 1,070 AC. r ` 44 634 SO...FT. ' 1 420 SIC. • �� � soots s4. FT i4 1.I SO AC. J,,, r A; t. C. "'43 r Wiscwnbin Department of industry, SOIL AND SITE EVALUATION "',M Labor and Hufnan Relations L'I(j� Page�_of `Divtsion of safety and Buildings in accordance with s. ILHR 83.09,Wis.Adm. Code A? AfA 1 Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include,but not limited to: vertical and horizontal reference point(BM),direction and TC*-.0 i )c percent slope,scale or dimensions,north arrow,and location and distance to nearest road. parcel I.D.# 8'3 3 APPLICANT INFORMATION-Please print all information. Review Date Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). Property Owner Property Location r e DcA fi� cN Govt.Lot 1/4 lo' v7 O�Tq ,N, Avqd E(or Nl Property ei's Me ling Address Lot# Block# Subd.Name or SM# a0a A vd $7, /r s I 1,42,Ylqeo City State Zip Code Phone Number ❑ City ❑ village ® Town Nearest Road fd dSo.o Iza r 6'YOl6 (P )S5-1-1166 �p ®New Construction Use: ❑Residential/Number of bedrooms Addition to existing building ❑Replacement ❑Public or commercial-Describe: Code derived daily flow. 6��D gpd Recommended design loading rate 7 bed.gpd412_r_�trench,gpd4t2 Absorption area required ay,�! bed,ft2 S�;_? trench,ft2 Maximum design loading rate - T bed,gpd/f12—.--&-'—trench,gpd/t2 Recommended infiltration surface elevations) 710. -1-5- ft(as referred to site plan benchmark) Additional design/site�c/o/nsiderations Parent material Al/.0 Z'c a X 'Qj 5-•'tt Flood plain elevation,if applicable it S = Suitable for system Conventional M In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system [3S [:] U-. U ®S ❑ U (�S ❑ u ❑S ® U ❑s ® U SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Structure GPD/ft2 in. Munsell Qu.Sz.Cont.Color Texture Gr.Sz.Sh. Consistence Boundary Roots Bed ,Trench 2 - G GJ l4 Ground I 4 9 eV •. ' fi�'e�t• Depth to f limiting ; factor Remarks: Boring# �2 VA /4,46 4 A 4J is 3 yy 1dRy . e- S s GJ r ^ Ground �elev. Depth to limiting factor q—in. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number /s 7e PROPERTY OWNER .0elre SOIL DESCRIPTION REPORT Page_ of 3 _ PARCEL I.D.# Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 ry in. Munsell Ou.Sz.Cont.Color Gr.Sz.Sh. Bed ,Trench Mc / o-;t S J ' k Ur s Ground g •9 'Y .UG•Il s i U elev. Depth to limiting factor � in. Remarks: Boring# *- * 1 ; s Ground elev. �a '•• Depth to fn Lo limiting factor, Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary .Roots GPD/ft2 in. Munsell Ou.Sz.Cont.Color Gr.Sz.Sh. Bed ,Trench Boring# 074itr &� Y • � y 10- v I hcj A.4 1n Acd Ground /elev. Depth to (limiting 2 1 Ctdr Remarks: Boling# Ground elev. ft. Depth to. limiting factor i"' Remarks: SBDW-8330(R.08/95) 3 V J f'✓e�o s K �� �/ Ile s Co / cu IN cY,,�l� i Ir ped l e� Wiscdnsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labw and Human Relations INSPECTION REPORT ST. CROIX • Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitar284270 Permit Holder's Name: City Village M Town of: State Plan ID No.: DELTA CONSTRUCTION HUDSON C T BM E ev.: , Insp.BM E ev.: JBIVIDescription: Parcel Tax No.: .!9S/66 1 95,cz /YI, .0Z o0 o"I ,tom 020-1283-30-000 TANK I FORMATION ELEVATION DA Aq7nfiniq qld_3z`i�7 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic dwe,s4r r1 � 2C�a Benchmark 5.-30 . " Aeration Bldg.Sewer Holding St/e Inlet /S TANK SETBACK INFORMATION St/L4 Outlet X 9.2.14 TANK TO P/L WELL BLDG. Ve stake ROAD Dt Inlet Septic 3 ' /,,¢ NA Dt Bottom Dosing NA Header m. 77 y/. f3 Aeration �~ -'� NA Dist.Pipe 9 y7' 43 Holding Bot.System ' , 90' _19 5 D PUMP/SIPHON INFORMATION Final Grade Manufacturer Demand - (, �1 9"e,/,0 Model Number ------ ' GPM TDH I Lift Ion Ft Loss ForSwd-inj Length Dia. Dist.Towell SOIL ABSORPTION SYSTEM BED/TRENCH Width Jr i Length7S , No.Of Tenches PIIT �.._.I No.Of Pits Inside Dia. Liquid Depth SYSTEM TO P/L BLUG WELL LAKE/STREAM LEA► Manu aRurer: SETBACK AMBER Model Num INFORMATION Type /Ir ,u C-rrGt d System: 4-re' 3 5�0'�, 3cl OR UNIT DISTRIBUTION SYSTEM Header/ Distribution Pipe(s) x Hoe Size x Hoe Spacing Vent •'*intake Length �7 Dia. Length �— Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Depth Over Depth Over xx Depth Of eded/Sodded Iched Bed/Trench Center Bed/Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes COMMENTS: (Include code discrepancies,persons present,etc.) NL As 6U;.A:A _ -_f.Q(')41 LOCATION: HUDSpON.20.29.20,NW..,NE. 449 VIRT/UE RO D SGJ ��r?�•>Y,�t,,..: � r�- �' n?w'.-��•. {: oL�-: '�r.� a�� �r.7� �J� l J �e,� �c�,4 Oe%•ti,(a 0-h) a La Plan revision required?© es ❑ No Use other side for additional information. SBD-6710(R 05/91) Date Inspector's Signature Cert.No. STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ;)-ck.7~a G v.r~'c7f~~c,~1~',•,~/ ADDRESS ,'?Q 6~ ;2-.e ,,j SUBDIVISION / CSM# LOT # SECTION bZ Q TAN-R r;~ W, Town of t~✓~of~a~ ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM U vtu 12GI( _ .l Q x I 1 O INDICATE NORTH ARROW f Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. e a , BENCHMARK: e P S' ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: aze Setback from: Well 7S House g,2 Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: g~ Setback from: well: ~S House Other ELEVATIONS Building Sewer ST Inlet: ST outlet: PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: -G~1s PLUMBER ON JOB: LICENSE NUMBER: 1-21? INSPECTOR: T 3/93:jt Division rllr~i~ iilt~ Safety o and Butildin g Water System! - v■`~■~ SANITARY PERMIT APPLICATION Bureau 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. 5 ` cv, tr•1c • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law; s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location ~"a T .rte ,~1a 114 /C40- 114, S T a N, R /t? E (or) Property Owner's ailing Address Lot Number Block Number a ®G ;~j $7 1 /,/S City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE F BUILDING: (check one) E] State Owned ❑ ityillage Nearest Road Yo Public JR] 1 or 2 Family Dwelling - No. of bedrooms wn of Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 0 FJIF M. (3 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. [g New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Exlsting 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 Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill - VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade / Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation Gt !V ~✓rO 7 d Feet Feet TANK Capacity VII. in gallons Total # of Prefab. Site Fiber- Exper. NFORMATION Gallons Tanks Manufacturer's Name Concrete Con- steel glass Plastic App New Existin structed Tanks Tanks A Septic Tank or Holding Tank x l r~D[ K1 7~ 9 ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: ( Stamps) MP PRSW No.: Business Phone Number: r . LI p('. 7 J ^ .Z l Plumber's Address (Street, City, State, Zip, Code): IX. C UNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing ent Signature (No Stam Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-6396 (R. 05194) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1 _ A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrt,tive Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation _ 5. Onsite sewage system?s must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety anc Buildings Division, 608-266-3815- To be complete and accurate this sanitary permit application must include: I, Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line 11 if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system nformation. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g."MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Safety and Buildings Division y; v.■■„■■■, SANITARY PERMIT APPLICATION Bureau of Building water systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. - 7 Gyro • See reverse side for instructions for completing this application State Sanitary Permit Number The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location `--tg~i ?`k r, al t/~ r°r .t! Va 1/4 V 1/4, S j T . N, R rQ E (or) L•-` Property Owner's ailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE F BUILDING: (check one) ❑ State Owned ❑ qty Nearest Road q Village Public 1 or 2 Family Dwelling - No. of bedrooms Town OF C-~ v~ CCU Parcel Tax Number(s) III. BUILDING USE.: (If building type is public, check all that apply) 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. [~t New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an _ System________System_------- ______Tank Only- Existing 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 Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation G 00 TS Q 7 t f ~sr Feet Feet TANK Capacity VII. NFORMATION in gallonTotal # of 's Name Prefab. Site Steel Fiber- Plastic Exper. New Existin Gallons Tanks Manufacturer Concrete strutted glass App. Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ Vlll. RESPONSIBILITY STATEMENT t, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: ( Srtamps) MP PRSW No.: Business Phone Number: Plumber's Address (Street, City, State, Zip, Code): r IX. C UNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signature (No Stamps) Surcharge Fee)~_.-- Approved ❑ Owner Given Initial -IlIX Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: y SBD-6398 (R. 05/94) DISTRIBUTION: Original to county, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS r 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labmr and Human Relations INSPECTION REPORT ST. CROIX Safety and &uildings Division (ATTACH TO PERMIT) Sanitary Permit No-: GENERAL INFORMATION 284270 Permit Holder's Name: ❑ City ❑ Village Town o : State Plan ID No.: DELTA CONSTRUCTION HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: .951 C& 915, PLO-°CIA.:..__- 020-1283-30-000 TANK I FORMATION ELEVATION DATA p TYPE MANUFACTURER CAPACITY STATION B5 HI FS ELEV. Septic rn dwie,5"Ct~-S 2G'J Benchmark S'~0 Dosi t t-, • I r(. - Aeration Bldg. Sewer Holding St/FjR Inlet TANK SETBACK INFORMATION St/ Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic Z~ 11,4, NA Dt Bottom Dosing NA Header s. K77' y/. -3' Aeration - _ - NA Dist. Pipe Holding Bot. System 77' QO , _SD PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Ion Ft Loss ead Forc rn Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED /TRENCH Width i Length , No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION 75 - DIMENSIONS LEAQ#A Manufacturer. SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM INFORMATION Type O /3?.,,u, ~CIIAMBER Moe Num . System: _ rc v c'ks 39 OR UNIT DISTRIBUTION SYSTEM Header/Me ie'd Distribution Pipe(s) x Hole Size x Hole Spacing Vent Tv 77 sir Intake Length 7 Dia. ~f Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Depth Over Depth Over xx Depth Of x eeded / Sodded x Iched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes COMMENTS: (Include code discrepancies, persons present, etc.) yL_ /45 R (ea LOCATION: HUDSON.20.29.20,NW,,NE 449 VIRTUE RO D S fn~~ C1 9L, 1 l~ ~ ~ ' • ~ly{.dVJ ~ _ r+. ~,L".. _:1 ~,.~.r~.r~ ~.f-"~•'V ~/I IE~S~% Plan revision required?® es ❑ No p Use other side for additional information. 7 O SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ' r a Safety and Buildings Division ~~■~■,fR SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. I • See reverse side for instructions for completing this application state SanitaryPermitNuml5 r The information you provide may be used by other government agency programs ❑ Check iitt~revision ~too previous application (Privacy Law,.s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Property Owner Name Property Location ,e,C cc r! S a r'a .J W1 /4 1/4, S o2O T 9 , N, R/W 16E (or) Property Owner's Mailing Address Lot Number Block Number g aG d City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road Village Public Eff 1 or 2 Family Dwelling - No. of bedrooms Town OF ,rf e III. BUILDING USE: (If building type is public, check all that apply). Parcel Tax Number(s) 1 ❑ Apartment/ Condo ®a 4 ' / ~3 3 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, fig.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 U&Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 E] Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation 4'.Sd 1 15" a -1 irr v~ Feet Q' , g Feet VII. TANK Ca ng aaclt i llons Total # of site INFORMATION Gallons Tanks Manufacturers Name Prefab. Con- Steel Fiber- Plastic App- New Existin strutted Tanks Tanks Septic Tank or Holding Tank X ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se ge system shown on the attached plans. Plumber's Name: (Print) Plumber's Signatur (N Stamps) P MPRSW No.: Business Phone Number: 44,11.4 ~cl~a n1 aY wr ~3 a .3 - j~ / Plumber's Address (Street, City, State, Zip C e): IgO 7 d -S'a o /<Y/& ro IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issue suing Agen Signat a (No mps) Surcharge Fee) Approved ❑ Owner Given Initial 1-V Q-A 1~ Adverse Determination 0 X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD-6398 (R. 05/94) DISTRIBUTION: Original to County, One copy To: Safety & Ruildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit -nay be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrz tive Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority- 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety anc. Buildings Division, 608-266-3815- To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. I1. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line 13 if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber into fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 112 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. J6)w Sad 7oc~~el~1s~,.J 1 3 v ~.n•t S,.T~ +~~r.~ e? Ile S } u .S a ITS -a; ~atv Wiscont;in Department of Industry, SOIL AND SITE EVALUATION 0 Labor and Human Relations Page 1 of 3 'Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Adm. Code MIA l Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and S TC k-0 <<~ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # (7 ;2 4- X3--3 APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location rG e DCA'j'4 Q,J Govt. Lot 1/4 'Cr1/4,S 40 T ,;?9 ,N,FYf,Lae E (or g-' Property ner's ailing Address Lot # Block# Subd. Name or CSM# a06 a'ad .sT //3 « 4-City State Zip Code Phone Number Nearest Road l%G~-ds0.~ ~ e ❑ City ❑ Village ®Town /ecl~ ® New Construction Use: ❑ Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate bed, gpd/f' a ranch, gpd/ft2 Absorption area required ~y bed, ft2 v~ trench, ft2 Maximum design loading rater 7 bed, gpd/ft2 S trench, gpd/ft2 Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site considerations Parent material -C Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system CAS ❑ U CA S ❑ U ©S ❑ U 9~S ❑ U ❑ S ®U ❑ S 9111 SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench l s$ /a R a e 6-1 l Xeth r< A) 2 - e 14e Ground 3 Q- 9L S 4 t? 7 elev. 9 Depth to limiting ; factor Remarks: Boring # 36 /d S / tN"4?6 X/ Al GFy e4 4) 2a S 2 y 6 r AGJ ~O ~ S- 3 yy Id R ,Ilzl 0 4, 4.., e- s s 1 r- Ground elev. Depth to limiting factor min. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number PROPERTY OWNER ,O>°ITce- SOIL DESCRIPTION REPORT Page of T _ PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots QPQ/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ',Trench 3 / a -a A e S l b k tJ Zl r/V 2 gel__ i y 4.41-41 -C- l !n 6k J~f 41J u F Ground C~ 16 IR `-//-Yl dj,4w e- 3 S % Gl,) U elev. Depth to limiting factor in. Remarks: Boring # j -12 ,4 i .~e- Si Mab!f oWa 4J A4 J/ ,.S ~ -ic ! bK ! i ~ : S Ground elev. Depth to limiting facto in. 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# / ro 16 iQ 5,/ l JyiakR p74A- v-- S /d -i j, y< ti An I' a F 3 d /e y l G i 4A -7 Ground elev. L•l~ft. Depth to limiting f ctor ~in. Remarks: Boring # Ground elev. n. Depth to limiting factor in. Remarks: SBDW-8330 (R. 08/95) /~~.3vf3 pa.~tc~. ea A 3 J Q ~err•~ S,-T~ ~:vts'f..~ftG t s ~tj a ~ ~ti~~ q5 d ni a 0 xN ~v f 4•a- .00.085 ,00-095 .TE•602 .00-v02 .00 94T s A- 102 103 104 105 ~ 106 m 1.254 AC.' p 1.281. AG; 1.368 AC.0 1.308 AC. ~ 1.317 AC. tor) CY) C) cu N 9 m Cu m m 209.84, 206.62' ~ eG T v F 1S'Z P Ass ,,r .£8•SSS 2 8 2.3 2 y OVERLOOK •~d-FGD y £9' Td2 221 .66• 110 - i° cr) YF~ 122 a 1.233 AC. co ~p 107 ~n CD a '♦o 1.093 AC. a cn 1.267 AC. (0 u r, f1 rt 123 N N to s. )n • T6 . c0' SEZ z 90E 1.543 AC. 0) CA v _ . 00 Ob2 m m 121 1.165 AC. 01 II I ~r O 1.085 AC: g) e y y 8Z ' 89 Sb N m 108 N N `.S8'bTZ .00'SST E 3G0+•A~, p .~lW.:n„ - dE 120 'erZ to 124 O1 1.458 AC. n. to a 1.077 AC. nM 1 12 £L' 6S2 s' a 119 S 1.049 AC. No A r R:;~ 0 2'~ 1.532 AC. N p~' 0 101 N a 22 -r ' Q~_~, I ' 290 AC. to 8 ANN • 6 ` 113' C G ~~60 g~~~9• a' t ti^ W 1.510 AC 2p6 ROPE 'lA6 1.287 AC. Co A' 2.T1 p• w X32 . J ,p 114 Z p• a 1.078 AC. 115 k ~~9 5 AC 1T9 116 1 50 AC. 0. O G~~ 117 1.272 AC. N ~9 ,N yap : , r A 20 w WILLOW RIDGE EA - Bill Harwell - 386-8135 a` Orin Bjornstad 386-2087 Don Bjornstad' J k b T C; - 100 "This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property Location of propertyj_1/4,yy- 1/4, Section a0 T_9_-? N-R g/ t2d W Townships. Mailing address ~2646 9219-1d Address of site y Q l) T~~ d~ ~Q ~L~v,✓ Subdivision name s, Lot no. Other homes on property? Yes_e_No Previous owner of property a„-e o A-., Total size of property l . s-os~9 Total size of parcel gam` Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No Volume 11110 and Page Number -?,Fog as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. .!'31?5rT , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. Signat e of Applicant Co-Applicant 3-/v- r Date of Signature Date of Signature STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER DG~ fia o.ys 1rµ c t~e~ MAILING ADDRESS ;206' PROPERTY ADDRESS fi ;K Q &d cf cLQ ~ a r' (location of septic system) Please obtain from the Planning Dept. CITY/STATE ~Cu~ co,rJ 6,J PROPERTY LOCATION 1/4, zlF 1/4, Section -1Q , T 9 9 N R19 axao W TOWN OF d,~Ia ) , ST. CROIX COUNTY, WI SUBDIVISION W •`l/o ev J ~'dy z ~~sT , LOT NUMBER f (3 CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60%. of the cost of replacement of a failing system, which was in operation prior to July 1, 1978: St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three ye expiratiou date. SIGNED: t%D IJ /L4 DATE: 5 - 0 7 St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 534483 State Bar of Wisconsin Form 2 - I9W WARRANTY DEED REGISTER'S OFFICE DOCUMENT NO ! VOL 1142 PAS ST. CROIX CO., IIVI - - - - Redd lof Record 0CT 2 14-55 , B & H Development, Inc., a Wisconsin corporationL _ FA 9:00 A. M Delta Construction Company__-_ ~I RefllttardDeeds conveys and warrants to THIS SPACE RESERVED FDA PECOADINO DATA II I NAME AND RETURN ADDRESS I - - i Delta Construction Company i 206 2nd the following described real estate in - St. Croix Hudson, WI 54016 County, State of Wisconsin: ! (Parcel Identificati-n Number) ,t ra Lots 106 and 113, Willow Ridge Fast II in the Town of Hinson, St. Croix County, Wisconsin. This is not homestead property. } (is not) J Exception to warranties: Easements, restrictions and rights-of-way of record, if any. ! R I) 95 20 v+ I Dated this day of - ~t B & H Development, Inc. 1'y I ' I ~`1•. (SE 8,L) x - (SEAL) William C. Harwell ! " . I (SEAL) (SEAL) iI AUTHENTICATION ACKNOWLEDGMENT j~ William C. Harwell STATE OF WISCONSIN j~ Signature(s) ss. County. - authenticated this -~~da~y of 19 95 Personally came before me this day of j ` 19-- the above named via, i i ' Kristin Aland - TITLE: MEMBER STATE BAR OF WISCONSIN (If not, who executed the ! V > I authorized by §706.06, Wis. Stats.) to me known to be the person 4 ; j foregoing instrument and acknowledge the same.