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030-1094-10-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 552328 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: Gates, Jacqueline St. Joseph, Town of 030-1094-10-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: /0Q /3 m i 32.30.19.343A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. S Septic Benchmark 160 I• posing-- i Alt. BM IF::. I L11- j 217 - 4,;7 Aerst o'n W ;ems,` Bldg. Sewer Ex; Hek}irtg ~ 1 _ ~7G St/Ht Inlet ~ .O 93• (C, iJ`•J St/Ht Outlet TANK SETBACK INFORMATION $.3 SZ. 7-4 TANK TO PWELL DG Vent to Air Intake ROAD Dt!Met Septic y Sa y 67,E ? aJ~r T-41 I Z, 403 7 tf Header/Man. /4.65 9,0 q9 Aeration Dist. Pipe 1D, 13 010.9 Holding Bot. System 11. IZ~ ~i .9 a~. PUMP/SIPHON INFORMATION Final Grade ' S -1 Z`I Manufacturer Demand St Cover / GPM F:1 GoJ 33 417,10 Model ber TDH Friction Loss System He T Ft 172. 10Z Forcemain Length Dia. Dist. to well '72, ~ ~ D •'7 ~p 5U SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 tP~ :4A I ~j ` ~ _ SETBACK SYSTEM TO t~ P/L JBLDG WELL LAKE/STREAM LEACHING Manufacturer INFORMATION Type Of System: CHAMBER OR Z•n Gd s -~}0 2-5 36 /,OZ / IA- UNIT Model Number: DISTRIBUTION SYSTEM , v 410.6 / (0 P1 toc3/ Z Header/Manifold / Distribution ` Ix Hole Size Ix Hole Spacing Vent to Air Inta e Pipe(s) \ ` Q -7 4 1 S 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/ xx Mul ed Bed/Trench Center ~j Bed /Trench Edges ` Topsoil !;~Yes No ` s 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 497 County Road E Hudson, WI 54016 (SE 1/4 NE 1/4 32 T30N R19W) NA Lot 1 1 / Parcel No: 32.30.19.343A 1.) Alt BM Description= 0.11 2.) Bldg sewer length - - amount of cover = Plan revision Required? Yes No Use Use other side for additional information. VI-4 SBD-6710 (R.3/97) Date Insepcto s Signs Cert. No. 4~'vro~ County 2 f~' Safety and Buildings Division St. Croix : r 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) %All P R IVED 5 5 2 3 23 ermit 1 ' State Transaction Number 2012 In accordance with SPS 383.XM, Alts- . Adm. Code, submissioo the appropriate govemme al unit is required prior to obtaining a sanitary permit. Note: Applicatite 1'.1111311111 Qre sub fitted to Project Address (if different than mailing address) the Department of Safety and Professional Services. Personal iondary ses in accordance with the Privac Law, s. 15.04(1 m , SSame ZA= n~ 1. Application Information - lease Print All Information 74 r17 'G Property Owner's Name / parcel # Jacqueline Gates 030-1094-10-000 i Property Owner's Mailing Address Property Location 497 Co. Rd. E Govt. Lot City, State Zip Code Phone Number SE '/4, NE _''/4, Section 32 Hudson, WI 54016 (715) 549-9211 (circle one) T 2430 N; R 19 E or W II. T of Building (check all that apply) t # 1 or 2 Family Dwelling - Number of Bedrooms 3 1 Subdivision Name CSM Vol. 8, Pg. 2147 Block # ❑ Public/Commercial-Describe Used' Na ❑ City of 11 State Owned -Describe Use CSM Number El Vill a of CSM Vol. 8, Pg. 2147 17-9 1d'Town of St. Joseph 2 U (.5 t- 164-/6 CL, Lie~ III. Type of Permit: (Check on one box on line A. Complete line B if applicable) ❑ New System Ei eplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to 7sti% Sy em (explain) B. List evibus Permit N ber and ate Issued Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New Before Expiration Owner !2 :7 q IV.. ~T a of POWTS System/Component/Device: Check all that apply) ge!4 W'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 lain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Informa 'o :.5/- In trator "Q4 Plus" standard chambers & 4 endcaps, Wieser Concrete filter canister w/ Pol Lok PL-525 effluent filter Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (s Dispersal Area Propose (sf) System Elevation 450 Gpd 0.70 Gpd/Sq. Ft. 642.86 sq. ft. 660.40 Sq. Ft. Syst( 1 90.00, VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units 0 7 v New Tanks Existing Tanks ` w c v M A- Pa Ih k JZ5 a U in rn P. 0 a. Septic or Holding Tank Filter canister 1,000 ST 1,000 1 & 1 W eser C ncrete X Dosing Chamber VII. Responsibility Statement- I, the and signed, ass me responsibility for ' on of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber' Signature MP/MPRS Number Business Phone Number James K. Thompson ' MPRS 30021 (715) 248-7767 Plumber's Address (Street, City, State, Zip Cod 340 Paulson Lake Lane, Osceola, WI 54020 VII oun /De artment Use Only pproved tsapprov Perini Fee Date I ued Issuing ent Signature er Given Reason for De i $ ,,.J • b i'sV Iz- IX. Condi# WMS"easons for Disapproval 1 septic tank, effluent finer and dispersal cell must all be services / maintabo as per management plan provided by plumber. 2. AD setback requirements must be maintained as per sppticable code / ordnaricea. Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD-6398 (R 11/11) ~~%eda/cca><ion Pi~ ell • /Oc ,ora(o Eby e Ica/e: / = S/O S cue%oe ~at~s ~foeo. v a \ Lod ; CSM k/w o SE%yAEyy .SeC. 3.2, T. 30?., o ~ w Ew~G• /,oho q.~sc~&c- /q u~y T . o~' .5~. Toseok, V a' 3 a~ out/eE "'wee-6 9Z.3S /.)a./. A'0.30 - loSW- /o- oL'1i be/ow s ysE.e~t pp.~~ ~ Are-4L v 00 IC b 83 4~saz' BI` ~d" .r.a., kr/c. carte: Assc,.ncd Clev = "cc-cc' ~ ~ wre3Er 9~~ 1•~9G/a' 95.77A~ f.4rea eu:t 4ccelne94 drivec..)ay i~ tn-L(QiEibn. a K •rcA 0 J L ~ E'Xi"s~i.~q 've 1 O~QUC 1 \ 1 --J PrOP05f-C( d~5 O-e-!/ Two (2) trenc.k Z ?e a.tar,C6G'ua/e~ lO/u s" St`ru,dard G6.a,.~b~s/,1~-Er~rtc~. /Jic~oSe.o/ 1-nk/e-af6v 3u~F cc e%vA- ~6e = 90.c,19; d7 Conventional POWTS Index & Tilte Sheet Project Name: Gates3 bedroom Replacement Conventional POWTS Owners Name: Jacqueline Gates Owner's adress: 497 Co. Rd. E, Hudson, WI 54016 Site address: Same Project Location: Subdivision: Lot 1, CSM Vol. 8, Pg. 2147 Legal Description: SE1/4 NE1/4, Sec. 32, T.30N., R. 19W., Town of St. Joseph, St. Croix Co., WI. Parcel ID 030-1094-10-000 Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Dispersal Cell Sizing Calcualtions Page 4 System Cross Section Page 5 System Management Plan Page 6 Filter Specifications Page 7 Filter Tank Cross Section Page 8 Parcel map Page 9 Septic Tank Maintenance Agreement Page 10 Certification for Utilization of existing septic tank Page 11 Waranty Deed Attachments: Soil Evaluaiton Report Mater lumber Restric ed Service: James K. Thompson, De 't. of Comm. Credential #30021 Signatur f, Date: Page 1 Of 11 Design pursuant to In-Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD-10705-P (N.01/01) Ex~~f,' rode e1 u/~'un • 101' P' ~°`fbYe X971&. ,1d. E O ~woCSon, r,J/. S5r0/~ ~r Lot CsM dc~ B, z/~/7 cr ~ o sr %y/IPyy ,SeC. 3,2,~Tr.'3o4y L~Xi~}~• uv0 L)K. St11tiG K. 19 Gc9.~ T /S 2oJ Slope 41 h Oc Are-iz 83 q~s~' ~6I` ~3d• \ - _ - - - - l3.~7' n PKas1C~ Teo e~* ~e06-d- 1 K _ 9S•o' man /loft C~ct~I LZsstuncd zle~?= "Cc'cc" i• wieSew' ' ~h ~ r32 daJut F'it~~ [yHi3tf~ 96-77 ~Area ew-t•t°4cedino'c driveL-) y LLLL...~~~~ o~,'c~,-ne/ QSs~oer~a.?Ce.// ~ f1c~fK~nq o •r,+, ga4Vn dt- Ejj(iS~w'nw Cl ~ 4 ~ decd i Prop osec! d;s soi(C4// Two z tre,zc es a t 3`X 6~, r~ ,,4/fra~Y"o-(AAA , Stt~dard ~.~•,•~b~s~e-,-tr~rrc~. /Ji~Jose,o/ n / ~.n {~'uc c crFsc cc e-le t` -6o 6 C = 90. c49: q, ~ dr ll DISPERSAL CELL SIZING CALCULATIONS / 1. (3 bedrooms)(100 gallons estimated flow)(1.5 design factor) = 450.00 Gpd design flow 2. Infiltrative capacity of native soil = 0.7 gpd/sq. ft. ✓ 3. Absorption area required: 642.86 N. ft. / 4. Absorption area as proposed: 660.40 N. ft. (32 chambers total) / Infiltrator "Quick 4 Plus" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4 Plus" end cap = 5.10 sq.ft. EISA 642.86 sq. ft. - (4 endcaps)(5.10) = 622.46 sq. ft. 622.46 sq. ft./20.00 = 31.13 chambers required Number of trenches: 2 @ 16 chambers per trench Trench width: 2.83' Trench length: 66.00' Trench spacing: 9.00' on center Total system area w/ 6' trench spacing: 12.00'x 66.00' Pg. 3 of 11 Soil Absorption Svstem Cross Section 93. so'- 9G. Go ft 4" Schedule 40 Final Grade PVC Vent Pipe With Vent Cap ft Leaching - ► Chamber 9p, d ft System Elevation x.83 ft 6.6 ft Soil Absorption System Plan View ft 2.8 3 ft { (,.O ft Leaching Trench 1 Vent Or Observation Pipe Chambers 4" Dia. Trench 2 Header Leaching Chamber Specifications Manufacturer And Model ~n /fi r "©-fl p/as":5 I EISA Rating .20.0 sq ft per chamber Soil Application Rate 0.7 gpd/sq ft 416-6.0 gpd Design Flow _ 0.7 Soil Application Rate : X0.0 EISA = ~3 Chambers 2 rows of chambers each. Page of Conventional Septic System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82-84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD-10705-P (N.01/01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with bottom of tank to be 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1 /3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October-March) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a two-year schedule by use of diversion valve. Effluent to be diverted from new dispersal cell to old cell at 4 year anniversary of new system installation. Old cell to be utilized for a 1 year period. Afterwards, effluent dispersal to be alternated between cells to allow use of each cell for a two year period. Contineencv Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715) 248-7767 or the St Croix County Zoning Department at (715) 386-4680. ® - ~-~Filers PL-525 EFFLUENT FILTER ( I Polylok, Inc is pleased to add its new commercial filter to its existing line of quality effluent filters. The PL-525 is rated for over 10,000 GPD Alarm (gallons per day) making it one of accessibility Accepts PVC the largest commercial filters in its extension handle class. It has 525 linear feet of 1/16" filtration slots. Like the Polylok PL-122, the new Polylok PL-525 has an automatic shut off ball installed 525 linear feet with every filter. When the filter is of 1/16" removed for cleaning, the ball will filtration slots Rated for over 10,000 GPD float up and temporarily shut off the system so the effluent won't leave the tank. No other filter on the market can make that claim! Accepts 4" & 6° SCHD. 40 Pipe PL-525 Maintenance: The PL-525 Effluent Filter should operate efficiently for several years under normal conditions before requiring cleaning. It is recom- mended that the filter be cleaned every time the tank is pumped or at least every three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the filter needs servicing. Servicing should be Gas deflector done by a certified septic tank Automatic shut-off pumper or installer. ball when filter is removed 1. Locate the outlet of the U.S. Patent No# 6,015,488 septic tank. 5,871,640 2. Remove tank cover and pump tank if necessary. PL-525 Installation: 1. Locate the outlet of the 3. Do not use plumbing when septic tank. filter is removed. Ideal for residential and com- 2. Remove the tank cover and 4. Pull PL-525 out of the housing. mercial waste flows up to pump tank if necessary. 5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the tank. Make sure all solids fall 4" or 6" outlet pipe. If the filter is not centered under the back into septic tank. access opening use a Polylok 6. Insert the filter cartridge back Extend & Lok or piece Of pipe into the housing making sure to center filter. the filter is properly aligned and 4. Insert the PL-525 filter into completely inserted. its housing. 7. Replace septic tank cover. 5. Replace the septic tank cover. i A W11 431" n m'D m N O nn m N N O x_ O - n A n m Z A F M' Z _A A N r Z p r TNi > n rnAr i nnr N n IV N 6„ o m 37~ 2" Z !m W z nm r C7 J S I ° z m 4.~ U) I i\ ° j 0 18„ MIN. 't I< ' A O r O Z N \ m O 37" 22 m O m (7 A ~ A A z> r r j A y N -1 I m z' A r j ~ n D m~O ZD z c r7-1 rT; D -i ; D - m I r O m 1 I n• > D > D j -4 i c- o FILTER CANISTER TAI` SCALE:3/4" = I REV No. _ of - y, Z; DRAWN BY:SWT ZI SEPTIC MANUAL W3716 US HW'Y!0. MAIDEN ROCK. W. 54750 DATE: JANUARY 2008 iL_J REV. JAN. 2008 800-325-8456 FILE:SHEE- 13 4=90 CERTIFIED SURVEY MAP fUA) W Located in part of the SE4 of the NE4 of Section 32, T Town of St. Joseph, St. Croix County, Wisconsin. ,~6•J~~~~r= FILED OWNERS ,•~.`;y JAMES p'C1 19893 Ronald E Lori Thoennes Michael E Tamera Koenig ALLE C. S EP ~ r Route 2, Box 318N IVY PagiftOfDeft & ow Co,VVI Somerset, WI 54025 r QIIDS r Wi +rr r. Cf► 0 ~qM NE Corner of d1SSection 32 N SCALE IN FEET County Section 200 100 0 200 Monument unplatted lands owned by others Bearings are referenced to the - east line of the NE} of section o 32 assumed to bear NO101914511E. North line of the SEA of the NE} H` S89°45' 12"W 536.41 n ~/V'76049141" hay 453.89' B 7 , W E G K C----- FI o 277.35' 1 Vol. 563, Pg. 432 Mme. 133'33' small-tract g M M~ l~ N19hir Y R N M a /W a 3 $.0p N P §0 13.16 I N89°14'25"W N 5' o ` 2 ztu . r 12 500.00 } m w ~66' Private Roadway Easement 0 T~ S f X, d R ~v W 341 481 O J 309,2q, I OD c1/ x s 76049'41. E ( to rn G a1 732.4 0.99. 7 1 a 11 4- dTz Temporary Cul-de-sac Cul-de-sac to be removed Tf road Is N extended. I 1 .ol~ 3 monumented west line.of C.S.M. I y cuo" a in _ 3 ' volume 1, page 96. t; PO co rn i c in ' 5.93 w CL i^ 7 pp ' iA - •1" ° N 1 I V O 01 . m 4 o OI N a O ? 1 n ~ N Obi If1 ~ ~ i n ° °f o w U I _ 33 feet on each side and adjacent to the line between lots 3 6 4 is reserved for road extension if neccessary. V F9° 3 331 ~l ~ SEP t 149 ' ST. CRO CUuIW Y ' /rRICS Plr^ti~ur, ' 370.65' M~ 933.71' AAD C~MIWt tT-f N89056 57"E 1304.56' N South line of the NEI EJ Corner of Section 23 C.S.M. vol.-3,-pg. 900 111 Iron Pipe This instrument drafted by Fran Bleskacek Proj..No. 88-25 SHEET 1 OF 2 SHEETS VOLUI! E 8 - PAGE 2147 n p j/ ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/fir ~ Q s Mailing Address Property Address 5a-no•e (Verification required from Planning & Zoning Department for new construction.) City/State W Parcel Identification Number 030-14YFI /0 6W LEGAL DESCRIPTION Property Location '/4 , hC-'/4 , Sec. 32-, T 36 N R /9 W, Town of Subdivision Plat: Lot # Certified Survey Map # , Volume 8 , Page # 2Z!jI Warranty Deed # 761 eA92 (before 2007)Volume Z563 , Page # S0.2- Spec house ❑ yes Q"no Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 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 Planning & Zoning Department within 30 days of the three year expiration date. 1/we certify that all statements on this form are true to the best of my/our knowledge. 1/we am/are the owner(s) of the property described above, by virtue of 7arranty deed recorded in Register of Deeds Office. Numbe of bedrooms NATCRf OF A ICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 09/07) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address> EAkdScl" 41)1 SY016 located at: SE' '/4. ham, Section _,2,_ Town 3,6 N, Range~W Towrr of 5~ . ~:re5VX , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they,,) appear(s) to be functioning properly. "Most recent date of inspection or service Did ilo%v back occur frolll absorption system? Yes v-' No___ (if nip, skip next line.) .-approximate volume or length of time: gallons 4s- minutes Tank Capacity: Construction: Prefab oncrete P-1 Steel Other- _ 'Manufacturer (if known): u~i e_SQ-►~ ~ar,c~ee :fie of Tank (if known): ermit number (if known) / X37 .icensed Plumber Signature) (Print Name) _ %ernP,~7(5 93C,0-2/ (Title) (License Nurn-rber) ti2PRS (Date) form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. ! 45.00, A,' 1sconsin Statutes) or licensed disposer (NR 113 Wisconsin Alrr, inis[Fall ve. Code) Elev. y '2C~0 U 2 5 6 3 P 5 0 2 76144B2 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 Jerome J. Zentner and Patricia M. 05/03/2004 01:30PK Zentner, husband and wife Grantor, and Silas M. Gates and WARRANTY DEED Jacqueline J.-Gates, husband and wife , Grantee. EXEMPT # Grantor, for a valuable consideration conveys to Grantee the following described real estate in St. Croix County State of REC FEE: 11.00 Wisconsin (the "Property"): COPYSFEE: 1116.00 CC FEE: PAGES: 1 Recording Area Name and Ret'urn.Address 030J094 10 000 Parcel Identification Number (PIN) This is homestead property. (is) (is not) Lot 1, of Certified Survey Map Vol. 8, Page 2147, filed September 1, 1989, as Document No. 451190, located in part of the SE'/. of the NE'/. of Section 32, T 30 N, R 19 W, Town of St. Joseph, 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 day of April, 2004. (SEAL) (SEAL) ftL J rome J. ntne Patricia M. Zentner (SEAL) (SEAL) * AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, WENDY SWATZINA } ss NO St. Croix County authenticated tt-FT,Ed" If At~S ('Q N S I N , Personally came before me this day of April, 2004 the above named Jerome J. Zentner and Patricia M. Zentner, husband and * wife to me known to be the person who TITLE: MEMBER STATE BAR OF WISCONSIN executed the foregoing inst ment and acknowledge the (If not, same. authorized by §706.06, Wis. Stats) THIS INSTRUMENT WAS DRAFTED BY Q. I t~C1kZ Coldwell Banker Burnet Notary Public, Sta of Wisconsin 1301 Coulee Road Hudson, WI 54016 My commission 's'permanent. (If not, state expiration date: 4-25992 L) ~ b (Signatures may be authenticated or acknowledged. ) Both are not necessary.) Names of persons si nin in an ca aci must bet ed or rinted below their si nature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co, Inc. 2281 SOIL EVALUATION REPO Pa e 1 of 3 Wisconsin Department of Corrrrrr r 9 Division of Safet and A.C.E. Soil & Site Evaluations y g in accordance with Comm 85, Wis County Attach complet~pla paper not less than 8/= x 11 inches in size. Plan t ~ St. Croix include, but not t : vertical and horizontal reference point (BM), direction nd percent slope, scale or dimemsions, north arrow, and location and distance to ne t road. 'ra a I.D. 030-1094-10-000 Please print all information. Date , Personal information you provide may be used for secondary purposes (Privacy Law, s. 15. (1) 151.: Property Owner Pr Jacqueline J. Gates Go SE 1/4 NE 9 S 32 T 30 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Na a or CSM# 497 Co. Hwy. E 1 CSM Vol. 8, Pg. 2147 City State Zip Code Phone Number J City J Village 0 Town Nearest Road Hudson WI 54016 715-549-9211 St.Joseph Co. Hwy E New Construction Use: y~ Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD i~ Replacement I Public or commercial - Describe: Parent material Glacial Till Flood plain elevation, if applicable na General comments and recommendations: Site suitable for conventional POWTS dispersal cell with 0.7 gpd/sq.ft./day loading rate. Recommended system elevation to be 90.00'. Boring # I Boring ✓f Pit Ground Surface elev. 93.57 ft. >108" in. Soil Depth to limiting factor Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-12 1Oyr3/2 none sil 2fgr ds cs 2fmc 0.6 0.8 2 12-33 1Oyr4/4 none sil 2fsbk dsh cw 2fmc 0.6 0.8 3 33-40 7.5yr4/6 none Is Osg ml cw 1fm 0.7 1.6 4 40-107 1 Oyr4/6 none gr s Osg dl - - 0.7 1.6 AQA 71 Horizons #3 & 4 contain/► app x. 20% gravel & cobbles. Boring # I Boring Pit Ground Surface elev. 95.94 ft. Depth to limiting factor >1 10" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-10 1Oyr3/2 none sil fill 2fgr ds cs 2fm,1c 0.0 0.0 2 10-19 7.5yr4/6 none Is Osg ml cw 1fmc 0.7 1.6 3 19-26 1Oyr4/6 none s Osg ml cw 1fm 0.7 1.6 4 26-110 1 Oyr4/6 none gr s Osg dl - - 0.7 1.6 It /67 Hori n #4 contai a rox. 20% gravel & cobbles. * Effluent #1 = BOD? 30 < 220 mg/ ana TSS >30 150 mg/L ffluent #2 = BOD5 <30 mg/L and TSS < 30 mg/L CST Name (Please Print) 'Sign re: CST Number 3602 James K. Thompson i7k Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, Wl 54020 3/28/2012 715-248-7767 Property Owner Jacqueline I Gates Parcel ID # 030-1094-10-000 Page 2 of 3 3 ] Boring # Boring ~e pit Ground Surface elev. 94.87 ft. Depth to limiting factor >110" in. Soil Application Rate F Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-8 10yr3/3 none sil 2fgr ds cs 2fmc 0.6 0.8 2 8-29 10yr4/4 none sil 2fsbk dsh cw 2fmc 0.6 0.8 3 29-37 7.5yr4/6 none Is Osg ml cw 1fm 0.7 1.6 4 37-110 10yr4/6 none gr s Osg dl - - 0.7 1.6 1 Horizo #4 co tains approx. 20% gravel & cobbles. ❑ Boring # J Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPM' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # I Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS <30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) A.C.E. Soil & Site Evaluations ~i%eda/ua~bn ~i~ EX E,' 9 ra de eJu/'vn /O= S cc~/i ne GateS ~ro%o, O `/cco~Son, c40/. -5-1104- ot / Cs M doh B, . z./5/7 ~ o Sf/y/It~yy .ScC. 3,z, T.3od, W EXi~S~' /,~r1o9.~Sc(~dz. /9 u~y T . o/' Sf. ~oSerok~ v o- 3 a~ ou~/r.~ ~'ad~= ~z.s5," ~aa/. ~03o-lo5W--io-az Vi of ~S 2oJ S/ope \ v ~~7 c 6c/ow Sys~~n ~pD~~1`~ ?d, ~ ~•~95.0' .ra.,d.! 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N O d O w f~pm<a, o A3 p.N N 00 O p o 3 N y 7 fD N a CD Cn CD o CD A En O °w C a t o (Do ~ Op h ~ I C 0. cco V I L O N C i 72 . I ~ I i i I, c z LL c II ~ ~ I Q 3 `Y) CD z H O Z O V z 0 M CO O a m o I co + o . Z c w r 7 c d Z 2 Z cn c E -0 I "0 N M N 01 c m N N •wail a L o 0 o N Q z co z N z w c N N N 1}y~ O ~ a~+ i (7 c C) It U) C G C a -0 M N Z j fn M (A E N o O 0 o o o O O O Z O •N m a a a N IL I w rn o y CO a) M 0) jr U Z :z o o O 0 01 O +T O N N C O O p E N c a v I o' co i CJ 'a ~ a~'i m ~ d Q U) Q ~t 4) 0 3 ~ H c C: E O o p' M F- W c U d 00 00 ,It - V W CI- N Lp d -Q) N O 17 N C M N U y V K N M 0 O w M c N 0 co CD p ~ I I w a L: a w 1 E u '2 c a+ c _1 A U a o N 00 r ?~T~ Form - S T C - 104 AS BUILT SANITARY SYSTEM REPORT OWNER ~i/oE,vuES TOWNSHIP S7 ~ms~P.E SEC. J~ T 90 N-R2-W ADDRESS ST. CROIX COUNTY, WISCONSIN SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•LHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM GJ~Sf ~"i(oPc~(TY ~.v.c~f ,4va Du•rL.Ef (fk1114)0u7_ Aq,P.,ItD AiR TirC C soR 5,0,f C1, _'AA1 Ir VeAAr_ ,~.pos- S.rEfvs ~.T ~ • TXPc~Oto C.~P ' I 1...E ~/D ~..JF4 ~ildfFGE I ~{LSi~%v c I INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used J/4,/_ /,cJ /v" ~.uE TfE Elevation of vertical reference point: /mod' Proposed slope at site: SEPTIC TANK: Maqufacturer: (~iES o~iP Liquid Capacity: /6900 o,K.. Number of rings used: 3 Tank manhole cover elevation: /©S o5/~ Tank Inlet Elevation: 10611"3.3' Tank Outlet Elevation: /O /s' Number of feet from nearest Road: Front 10 Side Rear, 3/ 7 feet .From nearest-property line Front 10 Side 10 Rear, a feet Number of feet from: well , building: '419, (Include this information of the above plot plan)( 2 reference SEE REVERSE SIDE septic tank) PUMP CHAMBER Manufacturer: U quid Capacity: Pump Model: Pump/Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: ~,~E✓, /da .7a ` Trench: Width: Len$th: .5.~~ Number of Lines: Area Built:lS -g " Fill depth to top of pipe: Number of feet from nearest property line: Front, O Side, O Rear, all t Number of feet from well: Number of feet from building: SS ` (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation vr bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of fef,t from building: Number of feet from nearest road: Alarm Manufacturer: i Y Inspector: Dated: Plumber on job: License Number: /,t 33 9S 3/84:mj i qpa~ tiH DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON-SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 State Plan I.D. Number: SE, NE , 32 , 30 , 19W [CONVENTIONAL ❑ ALTERATIVE (Ifassigned) Town of St. Joseph ❑ Holding Tank ❑ In-Ground Pressure ❑ Mound L M F PERMIT HOLDER ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Ron & Lori Thoennes Rt. Box 318 N, Somerset, WI 5 0254- Il"4d a106 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: o(= t..,~l~ 113 ~odrGO~ Name of PlumberMark S MP/MPRSW No.: County: Sanitary Permit Number: Za a Bros. Inc. Q~ S ~~q `3 7 SEPTIC TANK/HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV.: WARNING LABEL LOCKING COVER I PROVIDED: PROVIDED: "lit 1i` ' 1 y 4d~~ld G`I I r i U 3-93 S ❑ NO El YES O _LE BEDDING: y VENT DIA.: VENT HIGH WATER NUMBER OF ROAD: PROPERTY WELL, BUILDING: VENT T FRESH / d) ALARM: FEET FROM LI AIR INLET: ❑ YES NO L-. ❑ YES ❑ NO NEAREST DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL: PU / PHO MANUFACTURER: WARNING LABEL L CKING OVER PROVIDED: P ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO NLOET:RESH GALLONS PER CYCLE: PUMP AND CONTROLS OPER O A NUMBER OF 7 PROPERTY WELL: BUILDING: -N I (DIFFERENCE BETWEEN FEET FROM LINE: AIR PUMP ON AND OFF ❑ YES O NEAREST LENGTH: DIAMETER: MATERIAL AND MARKING: SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) 2- (Q CONVENTIONAL SYSTEM: sYs~ WIDTH: LENGTH: JY~N DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: LIQUID BED/TRENCH 7 ES: ~ tMATERIAL: PIT DEPTH~_ DIMENSIONS M _ F GRAVEL DEPTH FILL DEPTH D TR. PE DISTR. PIPE DISTR. PIPE MATERIAL: NO. DISTR. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: t ABOVE COVER: ELEV. INLET: ELEV. END: PIPES: FEET FROM LINE: _ v LS AIR INLET: I v q G a r ~7°f P v c, NEAREST `J 1 7 7 MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH/BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: : FILL DEPTH ABOVE COVER: BED/TRENCH WIDTH: LENGTH: NO.OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MAR PBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑ E ❑N p31 ❑ YES ❑ NO NEAREST--1111" ~4 10 k it i 0`4 lOh t~~6 j r,kt 'li l ~r LOS (6 I Retain in county file for audit. Sketch System on , TITLE Reverse Side. SIGNATURE: i . t~ SBD-6710 (R. 06/88) ILA ° d - SANITARY PERMIT APPLICATION v. Cou DILHR In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ l a2 -7 8% x 11 inches in size. Check if revision o previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROP RTY OWNER PROPERTY LOCATION o / .tFo ~.t/ ES S!5 " '/4 iv'E'/4, S T 30, N, R E (or PR PERTY OWNER'S MAILING ADDRESS LOT # BLOCK # AI A CI STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSMM NUMBER NEAREST ROAD 111. TYPE OF BUILDING: (Check one) ❑ State Owned VILLAGE ; 5r osEQ!-! e • T/`'~• . ❑ Public 1 or 2 Fam. Dwelling-# of bedrooms ARE TAX NU B R() N QQ III. BUILDING USE: (If building type is public, check all that apply) 3 y 3 !-7 1 ❑ Apt/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 in line A. Check line B if applicable) A) 1.WNew 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 - 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 14 12 Seepage Trench 22 ❑ In-Ground 420 Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 12. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. EFINAL LEVATION GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) 'e7lS0 /.S 1' * (P-7 / s A, . 9.:{ 3 10.q. 97 Feet Feet VII. TANK CAPACITY Prefab. Site Fiber- Exper. in allons Total # of Manufacturer's Name Prefab. Con- Steel glass Plastic App INFORMATION New Existing Gallons Tanks Concrete structed Tanks Tanks Septic Tank or Holdin Tank eoo ©n~ 1E5G L] E] Lift Pump Tank/Si hon Chamber Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber' Signature: (No Stamps) MP/MPRSW No.: r siness Phone Number: 9S 9. ,S r6 _ Asa ZAA-0A S 33 Plumber's Address (Street, City, State, Zip Cod / /`l-~t~ S oiV LJ/ s GJ/ /S lP -t~ 5;7- A/ IX. COUNTY/DEPARTMENT USE ONLY El Date Issued Issuing Agent Sig'naatttuureey(No Stamps) ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Surcharge Fee) Approved Owner Given Initial c a (f J Adve e Determination X. ONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety s 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 .1 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 6D8-266-3815. 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 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; close 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. SBD4;3N (R.11/88) r " APPLICATION FOR SANITARY PERMIT STC-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 -Q'13tyA G ~1 : f t(~C1~/V L S Location of property S 1/4 1/4, Section , T W N-R(q W Township < " (lab S~ t~ Y Mailing address _ IcS`^63 S0 t-2SC1 WS ~`1UZS Address of site H u c~bt~ Subdivision name f Lot number nl(= Previous owner of property D J P(NM~ CLSNI(' Total size of parcel Ito ~C iZ t 5 Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house)? -X-Yes No Volume 716.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. ---------------------------------------------------------7--------------------- 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 warranMP-81 ed in the Office of the County Register of Deeds as Document No. ; and that I (We) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Regi r of Deeds, as Document No. _aL - - Signature of wner Signature of Co-Owner (If Applicable) kt,CA i~ Date o gnature Date of Signature . uuC..UMl.r1 r NU WARRANTY DEED *Nd INA•..c RruaaY{,O IAR OCuwows V.,• • STATE ~i AF' 71'ISCONSIN FUILNII -1M1 1CW 01 OF= _ ST. am Me wr John A. Cesnik and Jeanne Tierney "ied for Romd II •.Cesnikl.husband and wife as Joint Nov. S, 1987 tenants I d 8:30 A AA' cuuer)'+ and w...-minta to . RoA$~.d N. Th0 Thoennes, •an - undivided. 1/2 interestnas~survivor hip iI~1lrrelOrr~ marital..property.and Michael. J. Koenig and Tamer A. Koenig,,..an.-undivided 1/2 interest as survivor hip V marital..property..(between COuples,.as tenants inj~dFf and Thomas. L. Dorafeld and Debra.K...VanDellen',. to as tenants. in Ccammon.(between couples and Dprz~te y r~ and VanDellen,-title.as.to he following described real estate in Hants in . COm1II Croix . ,tare of W*cunsiCroix (;mtrty, 3Ek of the NE of "E", t . Section 32-30-19 EXCEPT that Tax vanes! `h ':vunty Trunk Highway and except that 'Parcel north parcel b as: I Beginning at a point where the west line ofsaid SEkcofNEkand the :,outh boundary o.' County Trunk Hi hwa r.long the west line of said SE g y nE" inter:;ect; thence south right angle 500 feet; thence np~th NEB 250 feet; thence east at a • Said highway; thence westerly alongpthelsouthiboundarywthereofetoothe point of beginning. he ' I I PIN-1 - S 0 1 is not ; i~ Thu homcytcad prnl : t}•. (is) (is not EXCOptiatl to warranties: easements restrictions and rights-of-way of record, if any. 1,a,vl this _ 30th. ~I day of . October '1987 (SEAL) ~ / Sohn A. Cesnik _ Au_, c. ,,tom C;;~,~+ Jeanne Tierln" Cesnik (a>rALt IS RA (EAL# AuTIISNTICATION AgKNOWLEDOURNT ;i vT:►T1r OF L'.'IaCLiA;;I\ authenticated that St • Croix' r sa day of ...Cuunty. ) . )3.... QC tODrel+all)!catwe.before the is ......3o....da i • I.. 19.. the above named . 31EMBER . John A. Cesn ik, ..r..n..e.. TITLE STATE BAR o 1 ~ Jreanfie "Tie y.. F nlc u~. Cesnik.. (I f not. i . authorized by 'fos.ofi,'Wii. SIAts.). I fit: ly .I 4t to me known to fic the person s T`5 INSTRUMENT WAS ORAFTtp BY fob°uln6 • ln who eXCCUtld the t + ^ y, r+lttc the t , r> o. p ctrn~. ct..r►►►t..'.nt avidallyt'o1( tle Att.......... g land ...L'aw' Lundeen t 0 rney.. ..at Alice J .:Fl Is. (Signaturo•.; may he authenticated ur ,°t' ` 'u 'is St. Croix are not nuressar aci.m. cl l ed. [ nt i `I t' Will t v i•,-inn i. ptrtu:urc• ~ expiration d•tt+•: j - - June. l11~...... a. $.9 . arses o P•'raors .frA~7tt( • } .•ed r .;tnt•, ! to it to any caps+' ,.ii 1 t tY tCAHItA 'TY a v i r STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER __F~0V11k ROUTE/BOX NUMBER (S ® J 3 FIRE NO. I lCb: CITY/STATE J~'YY~L~~C"T l SL ZIP ~4 ~Z S PROPERTY LOCATION: s 1/4 N 1/4, Section *32- , T 30 N, R-i-q-W, Town of St. Croix County, Subdivision , Lot No. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a LICENSED 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 $3000 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 systems properly maintained. The property owner agrees to submit to St. Croix County Zoning 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 (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. 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 Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. _ SIGNED f DATE / ` u_ 81~ St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386-4680 Sign, Date, and Return to above add ress DE.PAATN1LNTOF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS iWOUSTRY. DIVISION P.O. BOX 7969 LABOR AND PERCOLATION TESTS (115) MADISON, WI 53707 HUMAN RELATIONS (H63.09(1) & Chapter 145.045) TOWNSHIP MHf te+f AcL+rY: OT NO.: LK. N177rz~~ 'Sc 14 /1'3%N/R/9&►( )W COUNTY: A ~T~ai x DATES OBSERVATIONS MADE INM BEEORMS.: rOMMERCIAL DESCRI T 1 OFIL'6L;~1~1P'I'fb S S: ~5 C~ l n AIRi~ New ❑Replace 50) 0- $ac~K PA4v_ .4 _ COir- - NtTkK_ ~hcz SAT16C T : So Site sufaalrte tareY010M U- Site unsuitable for system 01,1 0Y CAN q11 'A LL O DI G ANK: ECOMMENDED SYSTEM: (optional) -P. '10 =SOU Nalos ou .-I "S EA I [IS IDU if Owcolatfon Tuts are NOT required D N RATE- If any portion of the tested area is in the ~ A / /f ttRdet &NNA MIN, frtdlcete:,, f_+a'S+5 Floodplain, indicate Floodplain elevation: (Y PROFILE DESCRIPTION IWAL EI,IcVA710N A 1 ARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH TO BE ROCK IF OBSERVED (SEE ABBRV. ON BACK.) J3'gLLT~ Z4 "~Y{~,tbu ` ~ 1. !~,'RaL~~+'N ►~75 ~ l ~QQNC ~e+2. 101- 1617 -T~ > AD. 1-7 IB" z II, 41 al01'66 lYpAfc 7 11.42 rt„,ELI`Lrtl~ to'* $RQ'►A'i~1~C+~F.t2~J!'1~ ,e t~~t..~ = rt~''Ba~,L l~~' ~AtPyQH ►'f1 p- a,•z.~ /O. V5 > ,ZS "@R•~c~~4~ z~ aN r't1 }>r g. 16.7 S /t>.70 a e- C7 /bl.~ > B- - PERCOLATION TESTS D-ROP IN WATER LEVIL-INCHES TIES IME A TERS YWMMIIL ! INTERVAL-MIN. MAPER INCH MINUTES P. , So t zo > > <3 P.;Z. , b 5, >*k >14 lox Iv >I L v' A"f' lU ~ i t~ -Lj- 'WT PLAX; Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- tittisl <ancl vertical elevation r4ference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent )f taro slope. S7 " ELEVAT /02.76 . , , i 1414 M t ( { i r , L ~ 39; I r ; _ _ f , e 5 tN 1 i ~ 1 f i I a ~ Sc.r4l & ~ A L I It Q#4 WT &r , I 7 _ gar 1=30 -4 l., 1Ij LA ! B- i -Z J. f 4 1, *a uttders*", hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin 4t itrliriiMatiwe Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. TESTS WERE COMPLETED ON: Son IeUSc- l ` kJC II . _ ~u _ t t` s9 CERTIFICATIOPJNUMBER: PHONE NUMBER (optional): Sr fluhs6 r QI' ?48A a8~-4U$U CST SI ATURE: i '!TMWTIlON: Original and one copy to Local Authority. prrmerty Owner and Soil Tester. c,~~sr /A►C PLO 67 PLOT & CROSS SECTION PLANS /JENcrI N~/f f'K / S ZAPPA BROS. EXCAVATING INC PLUMBING UNIT ~jRrt /N /O' prNG~ PROJECT T~ 7r~ Et F v. /oo So e, ~ T ~ < s S TEo Q o -7 ell I 4z-r s,TE a Sr Jos o s o N a-/' Tt- Sa" ~s o 5~ C,~o.k Coy„vT y Q U ~«L u EuT L. ~ n/ E T© /-Fwx~, Q - - A'f/'v- OF s s cG~V -e -7- -~r,-1 ~dNf X03 pStoPoS~D .O/~rvr a...-A-y /l/« -ro B f CUT S /ooo (1~,Ac S'vtrc T N,< AA/0 GrPKDLD fia MFfT 0 /MsFX MOTH ~6(-tLt?f - SOS /nitlf5 \ iKOPosf<J nn G~AF~ , /'sPoLbSFp aS• ~ fkoAosca E SOuTr( \~t ~ PPo~Err~y NO SCALE FRESH AIR INLET AND OBSERVATION PIPE APPROVED VENT CAP MAXIMUM 12" ABOVE FINAL GRADE 4' CAST IRON PENT PIPE MAXIMUM OF 42" ABOVE ,4PPA /3/~o S ~.u c . PIPE TO FINAL GRADE _ SIGNED: T MARSH HAY OR SYNTHETIC COVERING LICENSE:P /l S 33 9 S MINIMUM 2" AGGREGATE DATE: Sc/ ,7 //gvt~ OVER PIPE DISTRIBUTION PIPE r TEE SOIL TESTING BY: ELEVATION BED 6" AGGREGATE • BOTTOM PER SOIL BENEATH PIPE PERFORATED PIPE BELOW TESTIS • COUPLING TERMINATING /0,,?-r70' FT. AT BOTTOM OF SYSTEM