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032-1041-00-200
I Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St" Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 579085 GENERAL INFORMATION 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 Township Parcel Tax No: David Richard TOWN OF SOMERSET 032-1041-00-200 CST BM Elev: Ins BM Elev: BM Desc iption Section/Town/Range/Map No: 14.31.19.201 E TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark W? V Alt. BM P, L JV► C (LICLG n Aw&fierf Bldg. Sewer l02. !oV F) 525 Holding o ~ St/Ht Inlet St/ t Outlet 2. ✓ TANK SETBACK INF ATION , 2 10T. 14 TANK TO BLDG. Vent to Air Intake ROAD Dt Inlet Septic T/ 1 * DHM of m jDU4-(t.1- , O 1(c Dosing 5150 f L ea er/ n. J [Holding eration Dist. Pipe Bot. System 12f`] ~ / J / PUMP/SIPHON INFORMATION Final Grade ,O ~U,FI Manufacturer Dem St Cover PM Model Number TDH Lift Frictio s System Head TDH Ft j G` 1 91W Forcema' ength Dia. Dist. to well 0 J SOIL ABSORPTION SYSTEM f' BED/TRENCH Width Length No. Of Trenches ^ PIT DIMENSI NS No. Of Pits Inside Dia/ ILi*id Depth DIMENSIONS L SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: a IVY, INFORMATION CHAMBER OR / V Type Of ys 1 ! UNIT ~--~f ~Model Number: y FUN BUTTON SYSTEM p `J L lluk A) / !Header/ n'rfold Distribution x Hole Size,,., x Hole Spacin~ Vent Air Intake 11 Pipe(s) ft rl Y -4 Lengt Dia Length Dia Spacing 'v (JI SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only JDDepth Over xx Depth of ~ xx Seeded/Sodded xx Mulched B enter Bed/Trench Edges Topsoil ® Yes No Yes 0 No COMMENTS: (Include code iscrepencies, persons present, etc.) Inspection #1: 16 Viol Inspection #2: Location: 2143 60TH ST cm fr~~l VW~rll td _ ,e ! P-e CST un" - V 1 ~l 1.) Alt BM Description = ,itX e6~~ Q r ~ap 2.) Bldg sewer length -amount of cover = Lj 015_0* Jl.~ C Plan revision Required? 0 Yes No ID Use other side for additional inform on. ~i L VWjj~v u SBD-671 0 (R.3197) Date sepctor's Signature Cert. No. . 3~S County Safety and Buildings Division CROIk 4 ~ ' r• p ~~ELOPMENT 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) a. y UN~N Madison, Wl 53707-7162 Sanitary Permit Application State Transaction Number In accordance with SPS 38311(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit 4 is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS arc submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary urposes in accordance with the Privacy Law, s. 15.04(1) in ,Stmts.' Z 1T3 (POX".. 51 1 L Application Information - Please Print All ration i Parcel # Property er's N,7 0-3z- 00 Property Owner's /'Mailing Addr Property Location +b 16 2- / 7 3 - 70 --/-1 ~ Goxvlt. Lot ~ L City, State Zip Code Phone Number / Section VO Z Y7-3 o- T / N; R /(circle on~ II. Type of Building (check all that apply) Lot # ❑ 1 or 2 Family Dwelling - Number of B lie ms Subdivision Name Block # ❑ Public/Commercial-Describe Use ❑ City of CSMNumber ❑ Village of ❑ State Owned -Describe Use q f- \S~- t.s.~ / ♦~04~ Op 6t J3 - ❑ Town of III. Type of Permit: (Check on one box on line A. Complete line B if applicable) A. ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) .ts f~c l~ UV , le K f ` ° O f~ B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued/ Before Expiration Owner Y• ~Q qs - Z 2 ~'3 6 Y >r IV. Type of POWTS S em/Com onent/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 Component (explain) ❑ Pretreatment Device (explain)V. Dis ersal/Tre ent Area Information: Design Flow (gpd) Design Soil Application Rate(gp f) Dispersal Area Required (sf} Dispersal 5red (sfj System E ation~ <<j t~ 0. 7 t)ri/ , / 4 7->, VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units C) U L y New Tanks Existing Tanks a a. U in ; +~n iw C7 R 4V - A Septic or Holding Tank D Y, 12610 '2- Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print Plumber's Signature MP/MPRS Number Business Phone Number Pr~C~l~t ~e l/ 23 /3 / ~S-Z 4~7~Z~3 Plumber's Address (Street, City, State, Zip Code) 3yk-112- ave ff> VIII. Coun /De artment Use Only Permit`Feeee Date Issued Issum nt Si Approved 14. O~son Denial $ ' v 9 , I DL Condi ' ~teasons for Disapproval 1 tank, eftiusrt ter and dispersal eetl.must all be sery"s /maintained as p`r maniiipment plan provided by. plumber. ~ ~ . @nt~r.t;~e'iaslittt2it N pK app=0W / 4►dow"lly Attach to complete plans for the system and submit to the County only on paper not less than 8 vz z 11 inches in size OWNS F~ Page 3 of 3 Name ~ U i , (i Brian Parnell Address 21`/3 G CST 231314. Date A Benchmark 1~ A Benchmark 2 ❑ Soil Boring _ i Suitable Area 1" = 40' Scale _ I} I { I I i ~ I I ~ i I i i~ ~ 1 R I I i 1 I I I I I I I l i i 1 w1 I! I I i I i G /`-Lie I I{ d I j l j l ~ i j { I j I~{ 1 1 1 j j~ l{{ { i l l i i i l i l l l ~ l i J-v 1 I l{ I ! I I l!~ i i i l i l~ I a i I j ~ I I ' I { I 1 ' I ~ ' 1 i I { 1 l i i l! l i l l l l i ~<<~~ { I I I ! l i I i~ I I I ) I i I I I i' { I f~ 133 y- I I I , I r I I! I ~ ~ ~f ~T~ ~ { -A) r7Z I ~ 1 ~ I I ~ I ~ I ~ { X ~ ~ ~ I I I j I I zl 1 ~ ~ ' , I I ~ i I { 1 i I I I 11 i l{ 1 I 1 { I ~ l i I l i ~ k I l I ~ l l i I I l i i O i l I I ~ I ' 1 4I ' I I I 1 I I I CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE ~ I. Project Name: Q Q 1 r r Owner's Name:/v/ r Gh Owner's Address: Legal Description: Township: So M eIVev-- County: Subdivision Name: Lot Number: Parcel ID Number: Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing Page 4 System Cross-Section Page 5 Filter Specs Page 6 Maintenance & Management Plan Page 7 Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Designer/Plumber: License Number: 2- f3~ Date: Phone Number ~S Y~~ 32G3 Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 0 Page 3 of 3 Name tr~ cc Brian Parnell Address 21 - G fi4 s~ CST 231314 _ Jprz Date A Benchmark 1~ A Benchmark 2 ❑ Soil Boring Suitable Area F = 40' Scale I to 4- e I i ~ R ~ i ! I 1. -T ~ C33 y- _ I ! ! lt- Ila 6 ~ ~ X t I PA Wx /41' vL -4 E r i 2 bf 4I c , Y1 1,6-,4 Ge S /S j ~ 3y~ Jar a S e l F ~ Lv ~ O' 6 f ~ l Gv.G.c iLr ~Y~-Lr (e r s ~c~ j 'el I7~ y - D. 62 lt-t .1-1 p 2 f 91d- v r - - - SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Pap---Pt-- Project Name: 2 No. of CellsF Per Cell ft Cell Width ~CJ Total No of % 12 - it Cell Length ~D sq ft EISA Per Cell it Cell Spacing a0 sq ft Total EISA Manufacturer Model W PrsA Rating InfRiwor EZ1203H-5ft 5A' 25.0 EZ1203H-10ft 10.9 50.0 Gravelless Leaching Unit Manufacturer. Gravelless Leaching Unit Model: l z " CIS Typical Cross Section Finished Grade ft Observation Pipe with approved cap or vent Mme' aisi•iitfi:x~x?iai<`>'cZca`•;::'.`,i'• - - ,_;_y Soil Backfill to s:<:-•':::%:<:::.:;;:==%:-;=c_>:u;:::;;. t..;~ 7!j' t Geotextiie Fabric t Infiltrative Surface 12 in Q p Limiting Factor in Slotted and Anchored Vent! _ _ _ Observation Pipe with Cap ■.Owl.....f...w..ww..s....■ ...■..............■....■■w...... PlumbedDesigner Signature: 0,- Alz/V, f,111 6-11 ~-t -e License: Date: wnl~ Ithm INSTALLATION INSTRUCTIONS PZH PL-525/PL-625 FILTER INSTALLATION INSTRUCTIONS s center filter wn opening akffiff Step 1: Step 2: Step 3, (A) Locate the outlet of the septic tank. (A) Before installation, place the (A) Glue the filter housing on the (8) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe. if necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the is positioned so the filter can be housing, making sure the filter removed from the tank for cartridge is properly aligned and maintenance and service- completely inserted in the housing. MAINTENANCE INSTRUCTIONS i low c f'-::~r•;~^'» . z ~ .max Step 1: Step 2: Step 3: I ocate the outlet of the septic flank (A) Remove tank cover and pump (A) Insert the filter midge back DO NOT USE if necessary. Into the the housing making sure e PLUMB i i (B) Pull the filter out of the housing. the filter is properly aligned WHEN FILTER IS REM (C) Hose off the fiber over the septic tank and completely inserted. tlSf= RUBBEF G~VES~ Make sure all solids fall back into the (B) Replace septic tank cover WHEM GE EANINEr FtG~ ER septic tank. POINTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE iNFORMATtON SYSTEM SPECIFICATIONS f '~ln K /Lf Owner a, a lrcd a `c u Septic Tank Capacity 70e o~ Z , 6 ai Cl NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer too 7>-,F 13 NA Number of Bedrooms ❑ NA Effluent Filter Model L 3`Z 0 NA Number of Public Facility Units D"NA Pump Tank Capacity al ❑ PIA Estimated flow (average) DO a)/d Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) 016 al/day Pump Manufacturer 0 NA Soil Application Rate a al/d Pump Model 0 NA Standard Influent/Effluent Quality Monthly average` Pretreatrartt Unit I~ NA Fats, Oil & Grease (FOG) 530 mg/L 13 Sand/Gravel Filter O Peat Fitter Biochemical Oxygen Demand (BODJ 5220 mg/L U NA 0 Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 nng/L. EI Diisirrfection © Other. Pretreated Effluent Quany Monthly average y _ Dispersal Cell(s) 0 NA Biochemical Oxygen Demand (BODg) . 530 mg/L JD- in-Ground (gravity) ❑ (n-Ground (pressurized) Total Suspended Solids (TSS)" S30 mg/L ❑ NA © At-Grade 0 Mound Fecal Coliform (geometric meant) 510' cfu/100mi 0 Drip-Line 0 Other: Maximum Effluent Particle Size Ys in dia. Q"NA Other: 0 NA Other © NA Other 0 NA `Vahss typical for domestic wastewater and Septic tank effluent. Other. ©NA MAINTENANCE SCHEDULE Service Event Service Frequency inspect condition. of tank(s) At least once every: f month(s) (Maukkn urrn 3"years) 0 NA Pump out contents of tank(s) When combined skidge.and scum equals one-third (Ya) of tank volume © NA Inspect dispersal cell(s) At least once every: 0 month(s) (Ma:dmurrm 3 yews) 0 NA ear(s) Clean. effluent fifer At least once every: Q month(s) ❑ NA :aspect pump, pump controls & alarm At least once every: 1 month(s) 0 NA 0 Year(s) 7eterais and pressure test At least once every: ❑ month(s) 0 NA ❑ earns) 0 month(s) At least once every. year(s) ❑ NA Other 0 NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal calls shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer POWTS Inspector, POWTS Makdainer, Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal ceg(s) shall be visually erected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The pond'eng 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 tank equals one-third (Ys) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator'and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not (irriited to the servicing of. effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shelf be performed by a died POWTS Maintainer. A service report shah be. provided to the local regulatory authority within 10 days of completion of any service event. 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 or other chemicals . that may impede the treatment process and/or damage the dispersal o"(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when sort conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the,ceff(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the purnp tank removed by a Septage Servicing operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore-normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or- park over, or otherwise- disturb or compact, the area within 15 feet down slope of any mound or at-grads sort mar area. Reduction or elimination of the following from the wastewater streams may improve the performance and prolong the fife of the POWTS: antibiotics; baby wipes; cigarette butts; condorns; oottort swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation -drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. 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 properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shalt be disconnected and the abandoned pipe openings sealed. • The contents of all ranks and pits shall be removed and properly disposed of by a Septage Servicing Operator- • After pumping, all tanks and pits shall. be excavated and removed or their covers removed and the void space filled with soil, gravel or mother 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 soli absorption system. The replacement area shout be protected from disturbance and compaction and should not be &►f kN* upon by required setbacks from-existing and proposed structure, lot.lines and.well& Failure to protect the replacement area will result in the need for anew soil and site evaluation to establisha suitable repfaosnnernt area. RW=ametrt systems must comply with the rules in effect at that fine. ❑ A suitable replacement area is not available due to setback and/or soil !invitation. Barmng advances in POWTS technology a.holdkV tank may be Installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement' area. Upon faflnue 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 fadari POWTS. ❑ Mound and at-grade sore absorption system may be reconstructed in place following removal of the bionat at the Infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNING» SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR MtSR1FFIC~YT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS. NMU NTANwER Name r-i lci( PWA a ? Name Phone 71-5 Z `f ~r > Z05 phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REtiRlLATORY AUTHORITY Name Name Phone Phone ' T10 This document was drafta~_ csmr.iance with chapter Comm 83.22(2)(b)(1)(dMM and 83-640), (2) & (3), Wisconsin Administrative Code- START UP AND OPERATION Page of For now construction, prior to use of the POWTS cheek treatment tank(s) for the presence of painting products or other chemicals . that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored -the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore.normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal -cells. Do not .drive or' park over, or otherwise- disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics, baby wipes; cigarette butts; condoms, cotton' swabs, degreasers; dental floss; diapers; disinfectants; fat; foundation -drain (sump pump) water; fruit and vegetable peelings; gasofne, grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. 4BANDONMENF When the POWTS fails and/or is permanently taken out of service the following steps shalt be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 8333, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings seated. • The contents of all tanks and pits shall be removed and property disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shat. be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. -ONTINGENCY 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 D 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 compaction and should not be infringed upon by required setbacks from-existing..and proposed structure, lot lines and wells. Failure-to protect the replacement area will result in. the need. for a new sod and site evaluation to establish- a -suitable replacement area. Replacement systems must comply with the rules in effect at that time. Q A suitable replacement area is not available due to setback and/or soil Limitations. Barring advances in POW TS technology a. holding tank maybe installed as a last resort to replace the failed POWTS. 0 The site has not been evaluated to identify a suitable replicement'area. Upon failure of the POWTS a soil and site evaluation must be perforated 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. 0 Mound and at-grade soil absorption systems may be reconstructed in place following removal -of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <wARM G> > SEPTIC, PUMP AND OTHER TREATMENT TANIKS MAY CONTAIN LETHAL GASSES ANDIOR INSUFFICIENT OXYGM. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT-OR IMPOSSIBLE. UVITIONAL COMMENTS 'OWTS INSTALLER POWTS MAR TARR R Name ctrl ~~/1 Name Phone 745 Z Y7-- 3 2- 03 Phone :EPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORI'T'Y Name E Name Phone 54. a. Phone -,cQ L 71 -5 -V3' (O - 4(o 1051 "his document was draftee __-p&arnce with chapter Comm 83.22(2)(b)(1)Id)&(f) and 83.54(1), (2) & (3), Wwwrisin Administrative Code_ 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 following residence: (Street address) / V3 6115 /1 located at: /yam %4, 5 GU V4, Section y , Town --3 1 N, Range__~_y W, Town of .SU51nerSef , 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. f i Most recent date of inspection or service Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: 20d gallons minutes Tank Capacity: 16ODeol Construction: Prefab Concrete Steel Other Manufacturer (if known): Gy 2 e /LS Age of Tank (if known): Permit number (if known) Z 2 8' j~ -'r- -7 ---I -C (Licensed Plumber Signature) (Print Name) 0 ? P3 /f (Title) (License Number) MP/MPRS (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 ST CROIX COIINTV SEPTIC TANK MA WINANCP AGREEMEMT AND OWNERSMP CERTIFICATION FORM QWIlairIIyET 2,Q U ~ . Mailmg Address 2 Property Address ( _l9 ,na e ti S a gnu e (Veafic:attoa regtmed from Planning & Zoning coas8ruction ) City/State S61'h erJc,~ Parcel iderthficationNumber l~2 - l6 / I`0<526 0 _ES_ C'IOI~T /47 Property LocationAO" NR/ 1 Town of S6~h Plr~ Subdivision Lot= Certified Survey Map # Volume _ Page # Warrauty Deed-# Volume _ Page # Spec house yes no I Lot Jinn ideatifiable no SYSTEM WANCE AND QV_MM,CE. R'T~I' C~~ON Isproper use and wee of your septic system could result in its I r I me failure to IanMe vvasum,proper maintenance consists of purnpmg out tine septic sank eveay &m years Or sooner; ifnee&d, by a Iiceoscd What the system can affect the function of the septic tank as a pump You Pm into UtatuM stage in the Waste di~ resPousrbilities arc specified iu §Comm. $3.52(1) and in Captor 12 St Croix ~ a0cnartce The property ovrner agrees to submit to St Croix County Plxwwg & Zoning D a carom Iona, signed by the owner and by a master plumber, joiuneytom phambM res dcftd plumber or a licensed pnmaper vati&ng that (I) the on-site i='as~ disposal system is m proper operating condru m =&Or (2) athar boa c tan less than 1/3 full of sIudge_ P~~ rzfne y), septic I/w-e, the undersigned have read the above reqoirements and agree t D maintain the private sewage deposal system with the s cedars set forth, herein. as set by he Department of Comm =e and the Department of blat mW Resources, Stara of Wisconsin. Cem- x ratan stating that your septic systear has been ma>atammd maast be completed and named to &e St Czoix County Plauniag & Zoning Depa: regent within 30 days of the three year expk= nn date_ L"we certify that aII statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the Property described above, by virtue of a warranty deed recorded M Register ofD=& Offim dumber of bedrooms SIGN CANT(S) R Ill D.A.TE Azy mforutation that is misrepresented may result in the sanitary PMmit being =evoked by ate Pkmzmg & Zoning DTNMW ut _:ace mite this application a recorded wairmly deed from the Register ofDeeds Office and a copy of the c atified survey map if e~.eQQ 151JMde in the warranty deed. - r Wysconsin,Department of Industry, Labor and Human Relations PRIVATE SEWAGE SYSTEM County: Safety and Buildings Division INSPECTION REPORT ST. CROIX GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: P GEt Ngldgri bjiCHELLE ❑ City ❑ Village R Town of: State Plan o.: some-wat CST BM Elev.: =/<-'3 BM Description: Parcel Tax No.: r TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 2;.4 r Benchmark /O ,Uu .c,o Dosing / Aeration Bldg. Sewer ~ `f 751 3, d Holding St/Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet q ' 5, /o o TANKTO P/L WELL jBLDG. AiVernIt to ROAD Dt Inlet ntake Septic , BYO NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer 5~ Demand Model Number GPM TDH Lift Lriction Head m TDH Ft Forcemain Length Dia. Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH EWi Length No. Of Trenches PIT No. Of Pits Inside Dia. Li uid De th DIMEN ION a' S S DIMEN I N Q P TEM TO P/L BLDG SETBACK WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O CHAMBER System:}?_, Model Number: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only LBed-/ pth Over [Bed pth Over r xx Depth Of xx Seeded / Sodded xx Mulched Tr ench Center.' /Trench Edges' Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code disge Vies, persons present, etc.) LOCATION: Somerset.I4.31.19W, NW, NW, Lot 4, 60th Street f~ M Plan revision required? ❑ Yes E No Use other side for additional information. d r SBD-6710 (R 05/91) Date spectoK Signature Cert. No. Li4booa"i~Human Relations Industry, SOIL AND SITE EVALUATION REPORT Page ~of~ Qivision of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code UNTY Attach complete site plan on paper not less than 8 1: in size. Plan must include, but not limited to vertical and horizontal reference t tire a4 % of slope, scale or CE L I.D. # FP dimensioned, north arrow, and location and o nearest APPLICANT INFORMATION-PLEA NT AtL INFORMkftoO REVIEWED BY DATE PROPE9TY OWNER: PROPERTY LOCATION GOVT. LOT 1/4 1/4,S~ T N,R i(or PROPERTY OWNER':S MAC G ADDRESS LOT BLOC # SUBB~. NAME OR CSM # L .1 CITY TATE ZIP CO HONE NUMBER C)TY ❑ I LAGE 0 N NEAREST R OAD zz) New Construction Use Residential ! Number of bedrooms [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate __,_~bed, gpd1ft2-,2 -trench, gpd/ft2 Absorption area required bed, ft2 ,G trench, ft2 Maximum design loading rate 7 bed, gpd/ft2__,,~trench, gpd/ft2 Recommended infiltration surface elevation(s) 915 ft (as referred to site plan benchmark) Additional design / site considerations Parent material Flood plain elevation, if applicable ft F uitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK Unsuitable fors stem S ❑ U PR S ❑ U 1 7 .®S ❑ U L) S E1 U 1:1 S 0 U ❑ S RrU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD/ft in. Munsell Qu. Sz. Copt. Color Gr. Sz. Sh. Consistence Boundary Roots Bed Trench _77 Ground elev. s h2v~ ft. Depth to limiting factor > 5rl Remarks: Boring # ' l Ground / elev. ft. Depth to limiting factor Remarks: CST Name:-Please Print Phone: Address: Signature: Date: CST Numb 1~2 z/ PROPERTY OWNER ~f SOIL DESCRIPTION REPORT Pageof= Air PARCEL I.D.} Depth Dominant Color Mottles Texture Structure Consistence Bour>dary Roots GPD/ft Boring # Horizon in Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends r Ground ' elev. ZIZAk Depth to limiting factor DIP - Remarks: Boring # ? S y7 r /vz Ground elev. - - Depth to 677- J"~ limiting factor Remarks: Boring # i s 'i~zyy i,9 Ground elev. ~ ZA~ k - _ - ~ - - - - Depth to limiting factor W Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) PROPERTY OWNER T /,~r `a (.3ls~raaA J SOIL DESCRIPTION REPORT Paget~~j of PARCEL I.D. # /,j Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots Bed Irend Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed T 411 Ground ? A . elev. Depth to limiting factor Remarks: Boring # round elev. Depth to limiting factor Remarks: Boring # j; r ~ s f Ground elev. f - /,22 1 Depth to limiting factor t W Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-6330(R.05/92) J ~a~SJ»KK-Z'la9" o~L1 '~'~IOnI 4TS;TC ~f y8~!3~ dot 1~,~ B~ 2C,9 i a a S -77 36 Z- ,OIL i ° m a o r°oV Q o y li m Q "0_ m rn u, o ~ I ~S I 0~ c~ 0 6 o c Z c°(D ILL c m 3~~x I Q ~Lo~ I M ~ N z y rn w E U) = O z 4) 4) It Cl) Z a co 0 E z m z S ° o y H a) z E v ~ ch I N Q1 C a7 N •w4a d L 0O oa)d ° z co z N z ~l ~ d a V co t0 E E N ~ t0 Y !y a 04 CL ff d V ° o m v d ~ D Lo G e a bap Zv> a ° C aaa z IL E o N c°n rn to a N O O = O N D d m d~ in 0 O O C a) y C U, a5 W 3: Lo O 8 OO O H C C d 00 1 cli N C_ _O C C 2 CO O <t 7 N CO N U 'O 00 c~ M E E co a) Z c a • O M r U) N O O z c L (n Q a L: (L • d 5 ,V d rw c m c r A 0(L M 'o 2 0 U)0 Parcel 032-1041-00-200 04i28i2005 03:52 PM PAGE 1 OF 1 Alt. Parcel 14.31.19.201 E 032 - TOWN OF SOMERSET Current X' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner RICHARD, DAVID P & SHELLY K DAVID P & SHELLY K RICHARD 2143 60TH ST SOMERSET WI 54025 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 2143 60TH ST SC 5432 SCH D OF SOMERSET SP 1700 WITC Legal Description: Acres: 3.220 Plat: N/A-NOT AVAILABLE SEC 14 T31 N R19W PT NW SW BEING LOT 4 Block/Condo Bldg: CSM 10/2889 3.22 ACRES EZU-1163/208 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 14-31 N-1 9W Notes: Parcel History: Date Doc # Vol/Page Type 08/11/1999 608357 1448/165 WD 07123/1997 1198/193 WD 07/23/1997 1114/369 WD 07/23/1997 800/495 LC 2004 SUMMARY Bill Fair Market Value: Assessed with: 10021 202,700 Valuations: Last Changed: 07/12/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.220 49,100 122,800 171,900 NO Totals for 2004: General Property 3.220 49,100 122,800 171,900 Woodland 0.000 0 0 Totals for 2003: General Property 3.220 49,100 121,100 170,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 502 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ii I e i STC - 104 AS BUILT SANITARY SYSTEM ORT v OWNER ADDRESS 6 SUBDIVISION / CSM LOT SECTION /z / T ~TN_R Town of ST. CROIX COUNTY, WISCONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 13s/ ~ '~D marl 0 dC. 7 j A i ,Lk INDICATE NORTH ARROG~ Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARK' ALTERNATE BM: ~n o't' S'/! ~•1~ ,a L-7~. SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: z&dc Liquid Capacity: Setback from: WellA_ House /=;2 Other Pump: Manufacturer Model# Size Float seperation Gallons/cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: Length S-<-' Number o f trenches Distance & Direction to nearest prop. line: Setback from: well:- House _~X Other ELEVATIONS Building Sewer ST Inlet. ST outlet i PC inlet PC bottom Pump Off Header/Manifold Bottom of system 76~s~ Existing Grade Final grade Zp/ DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt ti. W,yconsin,Departmentof lndustry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST. CROIX Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: tjTCHELLE ❑ City El Village ©Town of: State Plan o.: P GEtltMAlr1Y Nam CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 00 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark /o I 16o f Dosing Aeration Bldg. Sewer o 5- `{7,~ 1 3.d~ Holding St/Ht Inlet -,3 / 1 /(,d 6y TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Airi to ntake ROAD Dt Inlet rl Septic NA Dt Bottom Dosing NA Header/Man. 9.~ 9g Aeration NA Dist. Pipe q c q qG Holding Bot. System /L) 7-;- q7 ~ 2 PUMP/ SIPHON INFORMATION Final Grade /o/. /S- Manufacturer Demand Model Number GPM TDH Lift Friction Syestem TDH Ft Loss Forcemai n Length Dia. Head Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS is S DIMENSIONS _7 SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK INFORMATION TypeO R >c7 CHAMBER Model Number: System: }:11,4., V r r v~> fJ j; `t OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake 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 L)"o Bed /Trench Edges ` Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code disc e n ies, persons present, etc.) LOCATION: Somerset.14.31.19W, NW, NW, Lot 4, 60th Street r 9a -u.la q. Plan revision required? ❑ Yes NJ No Use other side for additional information. SBD-6710 (R 05/91) Date spe'ctor's Signature Cert No. SANITARY PERMIT APPLICATION ~~~■Z COUNTY In accord with ILHR 83.05, Wis. Adm. Code 7hSec T ^AR PERM -Attach complete plans (to the county copy only) for the system, on paper not less than of ~S b 8% x 11 inches in size. k if revision to pr ious application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPER OWNER PROPERTY LOCATION T21 , N, R 419 J~(or)&& PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # C1fY STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER II. TYPE OF BUILDING: (Check one CITY NEAREST ROAD VILLAGE ) ❑ State Owned @TOWN OF: A ❑ Public 4 1 or 2 Fam. Dwelling-#of bedrooms,a PARCEL TAX NUMBER(S) Ill. BUILDING USE: (if building type is public, check all that apply) 1 ❑ Apt/Condo 20 Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor Recreational Facility 30 Campground 70 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 in line A. Check line B if applicable) A) 1. E4 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5.0 Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 M Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 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 Feet Feet 76 VII. TANK ;N ACITY Site allons Total # of Prefab. Fiber- Exper. INFORMATION isting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks structed -1 D I El Septic Tank or Holdin Tank 6D Lift Pump Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installati of the onsite wage system shown on the attached plans. Plu be s Name (Pri Plumbe s Si at ps) LMP/MPRSW No.: Business Phone Number: _ l I /Z Plumber's A dress Street, City, State, Zip C e): IX. COUNTY/DEPARTM T U 61t ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate sue Issuing A nt Si ure (No S ps) Surcharge Fee) Approved ❑ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398(R.08/93) 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 the 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 & 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 in 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 in ##1-7. VII: Tank information. Fill in the capacity of every new and/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% 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, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) ~ i -Sze ISM, i Cdr PAGE OF CrUSS Secrtun p ep SyJern Fresh Air Inlets And Observation Pipe ( Approved Vent Cap Minimum 12" Above Final Grade 20- 42" Above Pipe _ 4" Cast Iron To Final Grad• Vent Pipe Marsh Hay Or Synthetic Covering win. 2" Aggregole over Pipe Distribution J- - Teo pipe 0 0 0 0 0 B" Aggregate Beneath Pipe o Perforated Pipe Below Coupling Terminating At Bottom Of System P/~pPosef~?'In~,.' 11grac~t ton SOIL FILL DISTRIBUTiOf.) PIPE APPROVED SjMT)4ETIC COVER e2"OF J~6GR~GAT~ '~-~R AR'SU HA `j9„ OF STRAW (o OF !2 -2 /Z AGGREGATE ELEV. o6= FEF-T__ 1 DISTRI5%JTI,3M PIPE TO BF_ AT LEAST INCHES BELOW ORIGIUAL GRADE AML) AT LEA.ST20 IAICHES BUT MO MORE THAI) H2. IAICHES BELOW F11VAL GRADE MAXIMUM ®F.PrW of EXCAVAT100 FROM OKI&*Jat 6KAoF- WILL BE MCHES MINIMUM Mf" OF EACAVATI oM FROM CW\1(AWAL GRAPE WILL BE LL- INCHES SIGUED: LICEMSE. AJUMBER: a DATE: S~ Wisconsin epartment of Industry, SOIL AND SITE EVALUATION REPORT Page of Labor a ' Human Relations Mi ision of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 iin size. Plan must include, but not limited to vertical and horizontal reference;~nt`1B ljjai eF i % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location andsdf*60o o nearesf'ro 'i' 'y REVIEWED BY DATE APPLICANT INFORMATION-PLEAS-.P)l0NT ALL INFORMATION PROPE OWNER: PROPERTY LOCATION GOVT. LOT 1/4 1/4,S /,/T N,R ~(or)ffl PROPERTY OWNER':S MAILING ADDRESS LOT BLOC # SU. NAME OR CSM # CITY TATE ZIP CO `~-o,~HONE NUMBER C ❑ I LAGE [ZTOWN NEAREST ROAD B New Construction Use Lo Residential I Number of bedrooms [ ] Addition to existing building Replacement [ ] Public or commercial describe Code derived daily flow -S~Sd gpd Recommended design loading rate ~ Z ed, gpd/ft2_,.P trench, gpd/ft2 Absorption area required 3 bed, ft2 trench, ft2 Maximum design loading rate 7 bed, gpd/ft2-,trench, gpd/ft2 Recommended infiltration surface elevation(s) 978 ft (as referred to site plan benchmark) Additional design / site considerations Parent material 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 stem J1 l S ❑ U S❑ U As ❑ U As ❑ U ❑ S S U ❑ S Lai I SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Copt. Color Gr. Sz. Sh. Bed Trench / 2 A? Ground elev. 14ft. 61- Depth to limiting factor Remarks: Boring # 1 l / Ground' 1 S elev. _ /4/./f ft. Depth to limiting factor > gG Remarks: CST Name:-Please Print Phone: Address: Signature: Date: CST Numb PROPERTY OWNER SOIL DESCRIPTION REPORT Pageof_ PARCEL I.D. Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Clu. Sz. Pont. Color Gr. Sz. Sh. Bed Trench 4 149 Ground " elev. Depth to limiting factor > Remarks: Boring # Ground elev. Depth to limiting factor Remarks: Boring # s - Ground elev. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) ~•v//1~3'.ltT Y v ~1 s~GC7S~ ~~~J.~Jr~E'~ ,x oC©~yionl ©~s; ~r i 450 35~ 36' 1,:5-5,s'Y .l s /t ,jz, 1 JktJ- 19-95 THU 05:31 HM S&i. !-AND -URVEYIW.. 386 2007 P, CERTIFIED SURVEY MAP Located in the NW} of the SW} of section 14, T31N,•R19W, Town of Somerset, St. Croix.County, Wisconsin. N c NOTE fj.~ W 4 1" Iron Pipe found N03940112"E, 0.93' S y of computed position. Mike Germain d w N 51 fi"AVenue Somerset, WI 54025 V ~ q LO q t •e vi C- 0 1 1 L T ! `_1 • 9363 Se oti on 14 _ Corner of N86051112"N 484.40, ' 151.40 5' 3.22 Acrea.lnc. R/W j1 140,368 Sq. Ft. N I-I! 3.00 Acres EAC. W G~! t Vol 130,682 Sq. Ft. R/W ~'c a ~ ~ 2PIt'46"W ct I _ { --33.00' 11 66.00 0 451,34' 58704811411E 484,34' L~1 Si N87°48'1411 484 A I W I 451,36' Z I F.) 001 11 14611E Q I LOT a I ~v 4 222Acres Inc. R/W • h Sq. Ft. 9 0 1 Imo, 3.00 Acres Exe, R, /W lv! 130,681 Sq. Ft. n I- I !4 r~ ~4Y N07 44'14"W 464134' Ln `~^-.XE 431.34' w as,oo' r v 3 Z' L~~ ! as • LOT ? r r ~ I qI v 3.21 Acres Inc, R/W 140,236 Sq. Ft. N a 3.00 Acres Exc, R/W •681 q. Ft. L~ 1 ~ -33.00' J lul + 431.!4' S87°481141,E 484.34' 3 0T Z j ~i Pro. "736 SW Corner of Mum Seotion i4 ~ Aluminum County Section Monument Found • 1" Iron Pipe Found 0 111 Iron Pipe set, weighing 1.68 lbs per linear toot Scale in Feet Existing Fenoeline -1*1 r~ L- 1001 Setback line 50 100 200 400 This instrument drafted by Michael Erickson Job No. 94.104 526637 CERTIFIED SURVEY MAP Located in the NWi of the SWi of Section 14, T31N, R19W, Town of Somerset, St. Croix County, Wisconsin. NC 3 NOTE ~yW <8> 1" Iron Pipe found N03°40'12"E, 0.93' OWNER o 0 of computed position. Mike Germain +D cn r- 785 205th Avenue d o o Somerset, WI 54025 V N 03C d3 L_ L to i0 N O Q t L. dj O O 4- L_ O O d E LOT 1 CC_ N N S. L11. m ~ I 97 2303 flat? ;'95 Wk Corner of N86°51'1.2"W 484.40' Section 14 451.40 ;r?t:';:a ("Ct!'- , -33.00' LOT 5 ~ .;;F7i°: __Yi;aj~c,i~'•': i-,:=.•„0 3.22 Acres Inc. R/W a Co 7 N v 140,368 Sq. Ft. C14 i' rnnih[ca (-I c N o 3.00 Acres Exc. R/W k )I lrJ1 U) 130,682 Sq. Ft. 7- I I i s 2°1146W ii;ur 0 day-,; ' `I I --33.00': 66.00 0 sS):ai val data 9 1995 .JI y (r)I 451.34' Z o ;g_orUV ? al KpTHI~ENNwH W S87°48 '14"E 484.34' Re~,s1er 01 Deeds oW C7 I $l.C(OlX~O. Vd1 U T -I I N87°48' 14"W 484 34, a; s 451.34' I c~ W I w OI °p -33.00' N02°11'46"E X11 Gj H I z X01 a 66.00' J I Q' :LOT 4 C I ~0 A L- 3.22 Acres Inc. R/W a m m 140,236 Sq. Ft. N N m 00 01 0 3.00 Acres Exc. R/W a 9 LUI lO 130,681 Sq. Ft. Ln I- "w 484.34' _214 ►'H gVEIVUE N87048'14 i 451.34' W 11 33.00' i LOT 3 ~ C I 01 3 I d 3.22 Acres Inc. R/W 0 C~I r " 140,236 Sq. Ft, z° r~ _L' y+fo. 41 a N o 3.00 Acres Exc. R/W N 130,681 Sq. Ft. 4r.tr. I''j -33.00' ems, 14, ~ ~ R'. C~ 1 ` 451.34' LUl S87°48 4Q7 '14"E 484.34' 3 1-I Q i 163S 6' M. I LOT UPSON, Wis. 1 ~ - s. rya. < may' e_ I N V '~i'y~~f`b ctl `tJ ry z~C~ LEGEND SW Corner of Aluminum County Section Monument Found Section 14 • 1" Iron Pipe Found 0 1" Iron Pipe set, weighing 1.68 lbs per linear foot scale in Feet r--Existing Fencel i ne 100' Setback line 0 50 1,00 200 400 This instrument drafted by Michael Erickson Job No. 94-104 VOL. 10 PAGE 2889 it SURVEYOR'S CERTIFICATE I, Allen C. Nyhagen, registered Wisconsin Land Surveyor, hereby certify, that by the direction of:Mike Germain, I have surveyed, described and mapped the land parcel which is represented by this Certified Survey Map; that the exterior boundary of the land parcel surveyed and mapped is described as follows: A parcel of land located in part of the NW1/4 of the SW1/4 of Section 14, T31N, R19W, Town of Somerset, St. Croix County, Wisconsin; further described as follows: Beginning at the W1/4 Corner of Section 14; thence S0201114611W, along the west line of the SW1/4=of said section, 938.91 feet to the NW corner of Lot 2 of Certified Survey Map recorded in Volume 1, Page 236 at the St. Croix County Register of Deeds Office; thence S8704811411E, along the north line of said Lot 2, 484.34 feet; thence N02011146"E, 579.08 feet; thence N8704811411W, 484.34 feet to a point on the west line of the SW1/4 of said section; thence N0201114611E, along said west line, 66.00 feet; thence S87048114"E, 484.34 feet; thence N0201114611E, 285.80 feet; thence N8605111211W, along the south line of Lot 1 of Certified Survey Map recorded in Volume 8, Page 2363 at above said office, 484.40 feet to the point of beginning. Above described parcel is subject to right-of-way for town road (60th Street) and all easements of record. I also certify that this Certified Survey Map is a correct representation to scale of the exterior boundary surveyed and described; that I have fully complied with the current provisions of Chapter 236.34 of the Wisconsin Statutes and the Land Subdivision Ordinance of the County of St. Croix in surveying and mapping same. Each parcel shown on this map is subject to State, County and Township laws, rules and regulations (i.e., wetlands, minimum lot size, access to parcel, etc.). Before purchasing or developing any parcel contact the St. Croix County Zoning Office and appropriate Town Board for advice. VOL. 10 PAGE 2889 ~r: S T C - loo 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 property ti)W 1/4 1/4, Section T 31 N-R-~-W Township Mailing address ao5~ Address of site uo'*, a, subdivision name Lot no. Other homes on property? Yes- ~-No, p Previous owner of property ITT Total size of property 3.a)L Total size of parcel 3 'L _Z O_Cv,!n- Date parcel was created ~'a5 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? >~,-Yes No volume and Page Number 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. 5 at"9 0 1 , 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. a ce 8 0 1 Signature o Ap licant Co-Applicant STC-105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MAILING ADDRESS Qw-A, PROPERTY ADDRESS (location of septic system) Please obtain from the Planning Dept. CITY/STATE \ PROPERTY LOCATION 'O 1/4, 5 w 1/4, Section , T 31 N-R W TOWN OF , ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER - CERTIFIEDSURVEYMAP , VOLUMEIAO", PAGE 37 / , LOT NUMBER 9" 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 mainta' ust be completed and returned to the St. Croix County Zoning Officer within 30 days of the three 'ye exp r i n date. SIGNED: DATE: ~j lQ 9S St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 c State Bar of Wisconsin Form 2 - 1982 WARRANTY DEED 526801 . _ • DOCUMENT NO. REGISTER`S OFFICE ST. CROIX CO., W1 Rec'd for Remr,,I Walter E Germain and Debra C. Germain, husband and wife, MAR 16 1996 4 3:00 P.I conveys and warrants to Michael J Germain and Michelle M Germain, husband and wife, as Register of Deeds survivorship marital propprty, THIS SPACE RESERVED FOR RECORDING DATA NAME AND RETURN ADDRESS the following described real estate in St Croi x County, State of Wisconsin: (Parcel Identification Number) (See Attached Exhibit "A") p ANA`)' FEE, is not This homestead property. W (is not) Exception to warranties: Easements, restrictions and rights-of-way of record, if any. 95 1 Dated this day of March '19-. (SEAL) -s (SEAL) * * Walter E. Germain 0 (SEAL) a. X1411\ (SEAL) If, K * * Debra C. Germai AUTHENTICATION ACKNOWLEDGMENT Signature(s) Walter E. Germain, Debra C. STATE OF WISCONSIN SS. Germain ~ County. authenticated this ~ day of March 19 95 Personally came before me this day of 19 the above named Kris t abgland * TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Stats.) to me known to be the person _ who executed the foregoing instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Kristina Ogland I, Attorney at Law _ Notary Public County, Wis. i (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date: necessary.) - - 19- II 'Names of persons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. FORM No. 2 - 1982 Milwaukee, Wis. ii - • - VOL-1114PaA72 EXHIBIT "A" A parcel of land located in the West One-half of the Southwest Quarter (W1/2 of SWI/4) of Section Fourteen (14), Township Thirty-one (31) North, Range Nineteen (19) West, except the following parcels therein: 1. Lots 1 and 2 of the Certified Survey Map filed in the St. Croix County Register of Deeds Office in Volume I of Certified Survey Maps on page 236 as Document No. 332995. 2. Lots 3 and 4 of the Certified Survey Map filed in the St. Croix County Register of Deeds Office in Volume 3 of Certified Survey Maps on page 746 as Document No. 353786. 3. A parcel of land in the Southwest Quarter of the Southwest Quarter (SWI/4 of SW1/4) of Section Fourteen (14), Township Thirty-one (31) North, Range Nineteen (19) West, Town of Somerset, described as follows: Commencing at the Southwest corner of said Section Fourteen (14); thence North 2011'20" East (assumed bearing) 691.00' along the West line of said Southwest Quarter (SW1/4) and the centerline of an existing town road to the point of beginning; thence North 2°11'20" East 404.65' along said West line of the Southwest Quarter (SW1/4) and said centerline of existing town road; thence South 87°48'40" East 438.00'; thence South 2°11'20" West 404.65'; thence North 87°48'40" West 438.00' to the point of beginning, subject to an easement for existing town road right-of-way on the West 33' of said parcel. Parcel contains 4.07 acres, being 177,237 square feet, more or less, including town road right-of-way and 3.76 acres, being 163,883 square feet, more or less, excluding town road right-of-way.