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040-1205-40-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 552356 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: Co io, William & Grace Troy, Town of 040-1205-40-000 CST BM Elev: Insp. BM Elev. BM Description: Section/Town/Range/Map No: / D 0, v /,0 a - v (10 _ W-~ZL2~ 16.28.19.958 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark o ~ o y,ss ~o y A ~ . ~ Dosing Alt. BM Nuj VVk, L-6 . Aeration Bldg. Sewer &j ys,es Holding St/ Inlet St/H Outlet TANKS BACK INFORMATION TANK TO WELL BLDG. ent Air Intake ROAD Dt Inlet j / Se tic ' Dt Bottom 5O I tel. 2 ~j ~,Z D Dosing 3S , eader/ a . d S cti e for P S 97' Aeration Dist. Pipe Holding Bot. t ~halvn v5 t~ Sal R s PUMP/SIPHON INFORMATION Final Grade kv-,I S'k-'l SI]' S /Dd-4S Manufacturer Demand St Cover / J GPM Model Number Z cl' 3 Y)W,ti TDH Li ~ / Friction Loss Syst~rp d Ft TC~ I I , (7 b 9i l l7 Forcem in Le t 14- Dial 0 Dist. to Well75 i SOIL ABSORPTION SYSTEMS 3 CAT~__~j BEDITRENCH Width I Lengthx 3 No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/ BLDG WEL LAKE/STREAM EACHIN Manu tur r; INFORMATION CHAMBER O 1 w1 UV T Of '~J I O UNIT Model Number: E -A77_11i DISTRIBUTION SYSTEM 643 eade anifold Distribution IF Fc/ Ix Hole Size Ix Hole Spacing Vent to it In-take PEP11 Pipe(s) )(3 A Len X 3 Dia Length 52 Dia Spacing SOIL COVER ressure Systems Only xx Mound Or At-Grade Systems Only Depth Over I nALV Depth Over xx Depth of xx Seeded/Sodded xx Mulched BedlTrench Center I I- Bed/Trench Edge Topsoil ❑ Yes ® No ❑ Yes No COMMENTS: (include code diiScrepencies, persons present, etc.) Inspection #1: ,6-/2 / 112, Inspection #2: / / Location: 558 Omaha Road Hudson, WI 54016 (NE 1/4 NW 1/4 16 T28N R1 9W) Glover Station A44 Parcel No: 1MAW, 1.) Alt BM Description _ 2.) Bldg sewer len th = r~ Z - amount of cover = 7q7 S'cy vu / &"s l q UQ~4 'i h Plan revision Required? ❑ Yes No l;] Use other side for additional information. I i SBD-6710 (R.3/97) Date Insepctor's Sig ature Cert. No. County Cleo ~,,.•~'°r~ Safety and Buildings Division r 201 W. Washington Ave., P.O. BOxl2~ SanitaryPermit Number (to be fill d in by Co.) S p Madison, WI 53707-7162 - Q1 t - ate nsaction Number a FT1_ it Application In accordance ith SPS31 e, submission of this form to the appropriate governmental unit t permit. Note: Application forms for state-owned POWTS are submitted to Project Addres (if different than mailing address) is required pri ~n the Departmen o and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04 1)(m), Stats. U , 1. Application Information - Please Print All Information Parcel # Property Owner's Name Property Location Property wner's Mailing Address if S 55 D&6~ Govt. Lot City, ate Zip Code Phone Number Section circle one WI / ~ T Q!4 N; R 17 E o0 II. Type of Building (check all that apply) Lot # Subdivision Name I)-1 or 2 Family Dwelling - Number of Bedrooms Block # ❑ Public/Commercial - Describe Use I if ❑ City of CSM Number ❑ Village of ❑ State Owned - Describe Use Town of t III. Type of Permit: (Check onl line A. Complete line B if applicable) A El New System .'Replacement Syste ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System (explain) List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New /O 26 I Before Expiration Owner ~(7J IV. Type of POWTS S stem/Com onent/Device: Check all that a I 5Non-Pressurized In-Ground ❑ Pressurized In-Ground At-Grade Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil t/~ ❑ (explain) El Holding Tank ❑ Other Dispersal Component (explai (2 Pretreatment Device S X V. Dispersal/Treatment Area Information: r 33 Design Flow (gpd) Design Soil Application Rate(gpcl8f) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation 7 (l~j ilZ~ 9 y. 7 VI. Tank Info Capacity in Total # of Manufacturer o v Gallons Gallons Units v N .0 10-- E ~oI'y~o~ B"Sr a n a Septic ks Existing Tanks f / ~Y X or Holding Tank 1000 /000 a6 Dosing Chamber ! 1 /1510 VII. Responsibility Statement- I, the undersigned assume responsibility for installation of the POWTS shown the attached plans. Plu ber's Name (Print) Pl` be Signature MP PRS umber Business Phone Number ly Plumbr's Adre~ Street, Ci , State, Z. ode) 6 43C VII ount /De artment Use Onl Permit Fee Date ssued ssuing A nt S' nature Approved El Disapproved $ ~ ~ ~ t~ ~ 0 ~ El Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval ~ SYSTEM OWNER: 1 Septic tank, effluent filter and Q 1 Kl~ dispersal cell must all be serviced /mail tmberd. S'IS~ -T as per managemAetntat~ypltan provided by pt fined / ~/(j~ IlCable GUC1e?~~ ~~~~s for the system and submit to the County only on paper not less than 8 112 x 11 inches in as per app ~J (Y~' / - Cr km SBD-6398 (R. 11/11) Sl~i+c fc ~ ¢`vr So F't ~ er i-f ' j`~ a ~ Sr a 1C E.i~a/~ 4 Qi'"t re1cce +,ortS oaten) d' levr art t L,'s L ~s :.vim. eE lcl+rc~ u f ven t: ' `s 74 0 O o TesvirJT YChf .Z ".,r ~~.he4Gf 'ge.(O 8~f ~ Vcy fs, ~ QYe e ~('iC'f~c.e.r 2 ~r vk'7c' /D f i•C+~ cJ' / a isi 1,gt{. ! l,.G~l~lJ.~a 7` G. s ~pr/C TQ ii CL.r f S S_ 7't c /~7t`C r ~r ~K l r~ 7- c n S. S a,n~i c, nt.r It t ~ C o47i"~~• 5 .o,,; a~ra,k 43e XY.S7~e.-:;, Cr 4S, St-1' a~ '~c~.v y"rchc~csr e._C,4 70 Q 1 1 r~ p r t 1 ~ / , ~~Q G oy deG7C. j lOS; 7 ~ IPp ~ iY ~Cuhh ~a ri /?oc~.SC 1 t~ T f~ , s s~s ~ c r ii~s r~lle d in / ~ ~ % ~,:r r cjoar7' ~'s 7-4 e s~ ti 7'¢!t is 4 bf ~<s7' / 2O• "c CC t~ f oe.~li, C N j0 rerpa I+~ ~ 4 h ~ t ~ Q 7` i ~ ~.S ~ e~-a~L7 4 ~~e~• j ~r! S' ~ LZ C . Pg of Private On-Site Wastewater Treatment System (POWTS) Index and Title Sheet Owner: n ~64, 1'6) Project Name and System Type: `byte, G!'L°~1 G~1S' Location: C4 d3, X 1J,~ Street Address ~ w 7, 25, g l Dc ription ~~C yo rc Township/Cou ty Design Criteria (Check one): Holding Tank Component Manual: In-Ground Soil Absorption Component Manual: ❑ SBD-10571-P (6/11/1999) ❑ SBD-10567-P (R. 6/1999) ❑ SBD-10855-P (3/2007) Version 2 SBD-10705-P (N. 01/2001) Version 2 Contents: Page 1: if Page 2: Page 3: t 4i2litkylozz Page 4: 6~0 g 5eC'~1D Page 5: T Page 6: (14 A kr U Page 7: Alntuf 7 AI Page8: VA111 Page 9: Attachments: Plumber/Designer: 71~ kt Signed: V&,,P~Lq Credential Number: Date: 54)1~k f_ W 1 L 4 I ry M t GR.f C'f' Cc, G C'~t c~ ~ ~ ~ d a7 T`O~ ,y 7-w-,p - s-r r«o; C'ry ce~, +"*,"S, moted) ~~~"toN7~lY' ~1~.0rraF' I s~s~_i1+C~t1 jC~verQl~q,o~ ~7 Q ~ 't'o H? U7' YCh~ I(S ©C~, hCM Cl ~ P.~Q+.N Q h4i~C.. BvtH Very tr k QYC e 74 ct 6-,o7`/01 &C cr a 4- f u. C C a C Q i s 9'SG+7~' pi-, cc~ : c s l aulc~ t11' 6! E.. ~ Sa.ma dtt` ~~ie /IK/a~~ *~co47t'1C'y% 5b S I t?t.;r7f a~ra,ka 3e syst° :f 1 j' C~ 4SiSf1' a~ "t't.~,o r"«^G.ae~C S ~ f'a c Ir ~ X 70 Q ibIDD1600vt Al 4 ed-'la L:,1heFrc A7nZ 1 p pcll~~-, YRP '~1r septic t y k c~ ✓cf. f'/ G~ Ho•,sc. cy ~'ec.J~~ ~ j E _ _ p~j , f n ~f 1 I ~,1 st~s-fc~rt wQr shf`t¢Ilec~ /n 7I7Et~ hcfQar'~' ~s $c, ~ ~,le to ver, r f! e /Fee S'-, "l rCS?` VCPoil7' F x~ lts. TIT 0)'t 6x tl ct t//aswr ~'n s',' ~ e. Cb.ts - S'ec fio+,. ~7~ D%Str,6c~,tloa Ce1 f ~G r P~ Y SL" to i o 43 Pe 5% 4:h. sc~cd4o pvc /e~ P~dti o7'' ~u,c.K 'f' in f•~f+'~1/faryY~ iQsiysfe•',^ Syst~,3 K Jl~_ 7`I-ea c~CJ'~ ed e~ ceifGj~O ~/0 ~~~u,~K 7 Gene ~'S ® r 0 6scc-ri t,oA, P/p S / r P-&Vl de !*s.h isiti o / 3 4 Seg. )1/ tl 47 ft. f vC~s Maf fv dtif' Tcdr /C'. l ~ Cob ~tiY elm e LL C,~si. y~awr G(~- ~ r oAr • J PPS' C C t rys fr.^ e( S~-Yr ~tc-w Serf%On A-A CN•T s-/ s i.s/G Z,4.L c cL L,4 r/0I✓5 R 6,3 dlk.74 -l PAGE! 4 pace ~'o Approved Locking Manhole Covers With Warning Lane?S Attached, rr 1 ~ t r ilr Yrr G: Weatherproof Approved Junction Box ~ Vent Cap ~-1) f fi' 4' Min4m ! 'MUM 't 4 i 9 p i .•'dA *A y I Quick, u _ I~ ~ ~ No i e Baffle t~ e it L3 33 ftt' 1£'k f ( ~nj I I ! x ttr~7~:►!&;.c~4 -APPROVED f ;off lS"E ~ Js` 1!f!I J0AC YG!r ra JOMTS WITH I , / ; tI ONTO f r c j yn S ©1 ! 3" of LR(,dlldi no }Undp Td,... r Nu,t':,`er of Doses: Per Day u,alons Per Day/i of Doses: ,Q: r-1i^r 8a4k ITr Tank Manufacturer: 1 ~ r ga)- Dcse Volume: ........~+,L4~_~~Iic .5 and Sipe-Se;sticlPump:•'-It70Dj/ 5~`ioin s Model Number: Capacities: A a0 inches or~ G:- ?u Jr• /dB _ _ • !o #u.._1TCr''_.....adL(.ACy r,,-4 :l~ciel Number'. F/~D 51 nches or S 13 S ,C or !,f7 tlll111!f'1 ul SChdr`~? dtP_ ; ~Otd f - - - - - `ier-TiCal Difference 8etxeer, Pump Off and Distribution Pipe: Feet ±inimum Recuired Supply Pressure: Feet ~y 1 r~C !'e Li~i1 7 I"v! rill Lj2 t'L I1Ch 7iameter Force I-lain T ota i Dynarn l c He ad: A Feet gFeet 'i~c~; Tur=k ,°,;e,,,, s. L t 1 EP04 3871 EP05 APPUCAT10NS • Fasteners: app series • Fully submerged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer, following uses: • dry of running lubrication and efficient strength, and durability. • Effluent systems without damage to heat transfer. ■ Motor Cover. Thermo ias- tic cover with integral handie • Homes r components. Avaitat for uhnatic 811141 • Farms a1 and float switch attachment ONFIXIIIIIIIIN • Heavy duty sump • EP04 Single phase: 0.4 HP, mew ~~i points. • Water transfer ` 115 or 230 V, 60.,Hz,1550i a> ppw~ Cable: Severe duty • Dewatering RPM, twill in overload with automatic reset. stire rated oil and water resistant. SPEC*WATMU • EP05 Single phase: 0.5 HP, • B111wh4 : Upper and lower 115 V, 60 Hz, 1550 RPM, FEATiIIIIIES heavy duty bail bearing III Pump: EP04 built in overload with construction. • Solids handling capability: automatic reset ppl NOW SeImilwN mi-open Thermo- design sig14' maximum. • Power cord: 10 foot with A®ta Y LISTING • Capacities: up to 55 GPM. standard length, IN SJTO pump o vanes for mechanical sea] eal pro protection. • Total heads: up to 24 feet with three prong grounding 49- l , • Discharge size: 11/2" NPT. Plug. Optional 20 foot 0 'EP6ti W"fer. Thermo- • Mechanicsl seal: carbon- length, 1613 SJTW with Plastic eada:ar'dn for (CSA listed model numbers • improved performance. end in F" or "AG".) rotary/ceramic-stationary, three prong grounding plug BUNA-N elastomers. (standard on EP05). ■ Caaft and Ike: Rugged • Temperature: thermoMasticdesign provides 1041(40°C) continuous superior strength and 140°F (WC) intermittent, corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. 10I } • Capable of running , - dry without damage to s 30 components. Pump: EP05 8- • Solids handling capability: a 25 3/4 maximum. w I • Capacities: up to 60 GPM. U_ 6 20 'Ap • Total heads: up to 31 feet. • Discharge size: l'rz"NPT. 5- • Mechanical seal: carbon- > rotary/ceramic-stationary, ° BUNA-N elastomers. 4- ki-71 1 • Temperature: ~ 3 10 104°F (400C) continuous l 1400F (6(rC) intermittent. 2 i 5 1 .~P c~ I 00 10 20 30 40 50 GPM s L i 1 1 1 3 _ o 2 4 6 s 1 o 12 m~/h CAPACITY Q 19,95 Goulds Pumps, inc. Effective Mav. 14W; POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pag1A, of jRMATION SYSTEM SPECIFICATIONS Septic Tank Capacity /000 al ❑ NA nit # Septic Tank Manufacturer l c~ ,e se>^ t Effluent Filter Manufactu pol % k ❑ NA ESIGN PARAMETERS ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model Number of Commercial Units NA Pump Tank Capacity D O gal/day Pump Tank Manufacturer mice NA Estimated flow (average) Design flow (peak), (Estimated x 1.5) 0 gal/day . Pump Manufacturer CS 2a ~ VNA Soil Application Rate _ auda /ftz Pump Model Ile 0 NA Monthly average* e• Pretreatment Unit NA lnfluent/EffluentQuallty ~ ~ [3 Sand/C~ravel Filter ❑ Peat Filter Fats, Oil & Grease (FOG) 530 mg/L C3 Mechanical Aeration ❑ Wetland Biochemical Oxygen Demand (BODb) 5220 mg/L ❑ Disinfection ❑ Other. Total Suspended Solids (TSS) 5150 MgIL Manufacturer Pretreated Effluent Quality ❑ NA Monthly average" Dispersal Celt(s) /,i 1,,,~,e a b 530 mglL )d In-ground (g y) ❑ In-ground (pressurized) Biochemical Oxygen Demand (BOD) M-grade ❑ Mound Total Suspended Solids (TSS) 530 mg/L ❑ Dri dne ❑ Other: Fecal Colifortn (geometric mean) 510` cfu/100m1 Inch diameter Vakm t~rakcal for domestic (non-cornmerclo wastewater and Maximum Effluent Particle Size Y. tank eftl lent. sepue Values M71cal for pretreated wastewater. oh .S"y' ale 2 r•o ~ o! ~ ~,',e'4,! C'A MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every 3 ' ❑ months year(s) (Maximum 3 yrs.) When combined sludge and scum equals one-third (IS) of tank volume Pump out contents of tank(s) Inspect dispersal cell(s) At least once every ❑ months ear(s) (Maximum 3 yrs.) Clean effluent filter At least once every 3 ❑ months ,year(s) Inspect pump, pump controls & alarm At least once every ❑ months ❑ year(s) ❑ NA r e de q( Flush laterals and pressure test At least once every O months ❑ Year(s) ❑ NA S. e e c% Other At least once every ❑ months ❑ year(s) ❑ NA Other At least once every El months ❑ year(s) ❑ NA Vftce- yer t~4S• 4"C l eCern ~a d t~ I`f M P;- f Ccaor,"0- dy OIC",/x~r y P 4/4'1"1 C/wh~9ad +he wlbftl - MAINTENANCE INSTRUCTIONS y"W c / e l j" Fr / r every t/ to g oft following licenses or Inspections of tanks and dispersal ells shall be made by an individ jai wrying one POWYS Maintainer; Septage certifications: Master Plumber, Master Plumber Resuic ted Sewer, POWTS Inspector. Servicing Operator. Tank inspections must indude 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 fo eanffluyntback or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the in the observation pipes and to check for any pondhv of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (X,) or more of the tank volume, the and disposed of in accordance with ch. NR entire contents of the tank shall be removed by a Septage Servicing operator 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components, pretreattment components, and any other maintenance or monitoring at intervals of 12 months or less shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event START UP AND OPERATION of aiming products or other For new construction, prior to use of the POWTS check treatment tank(s) for the presence painting 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. Page of 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; 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 ch. Comm 83:33, WisconsinAdministrative Code: • Ali piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • 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 shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and 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 soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POW TS technology a holding 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 failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ 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. <<WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT 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 MAINTAINER Name Name Phone -Phone SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY I Name Agency if ~ Le DJ?, 0~~3 D ,~GaPhone _ Phone - I E This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies. This document meets the minimum requirements of ch. Comm s3.22(2)(b)(j )(d)&(f) and 83.54(f), (2) & (3), Vftoonsin Administrative Code. Use of this document does not guarantee the performance of the POWTS. GMW (2/01) ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer p Mailing Address Property Address (Verification required from Planning & Zoning Department for new construction.) City/State S Parcel Identification Number LEGAL DESCRIPTION Property Location &L V. , Sec. , T N R W, Town of '/4 , - Subdivision , Lot # Certified Survey Map # , Volume , Page # r~ Warranty Deed # Volume , Page # Spec house yes no Lot lines identifiable E )s 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. $3.52(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 sef 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. Uwe certify that all 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 in Register of Deeds Office. Numb, er of bedrooms J S GNA F APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) v0!- 1730 PAGE 615 STATE BAR OF WISCONSIN FORM 1 - 2000 ' 6 5.5 1 1 2 WARRANTY DEED Document Number KATHLEEN H. WALSH REGISTER OF DEEDS This Deed, made between Rickey DeWayne Funk and ST. CROI X CO., WI Deanna Rene Ftlnk, husband and wife RECEIVED FOR RECORD Grantor, 10-02-2001 12:30 PM and William D. Cocain and Grace L. Coe io WARRANTY DEED husband and wife as survivorship marital property EXEMPT li CERT COPY FEE: Grantee. COPY FEE: TRANSFER FEE: 960.00 Grantor, for a valuable consideration, conveys to Grantee the following RECORDING FEE: 11.00 described real estate in St. Croix County, State of PAGES: I Wisconsin (the "Property") (ifmore space is needed, please attach addendum): Lot 4, Glover Station, Town of Troy Recording Area Name and Return Addry4ETtM To: MTMOM GROW. VC 706 1WH STREET SOUTH HUDSON. VA 54MG 040-1205-40-000 Parcel Identification Number (PIN) Together with all appurtenant rights, title and interests. This is homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Roadways, Easements, and Restrictions o£ Record. Dated this 28th day of September 2001 - * *Rickey DoWa a Funk ~.f-'ULQ• L- * * Deanna Rene Stink T AUTHENTICATION ApplY P(/e ACKNOWLEDGMENT ZO STATE OF WISCONSIN Signature(s) ) ss. n, St. Croix County. ) authenticated this day of Personally came before me this 28th day of September 2001 the above named Rickey DgKayne Funk and Deanna Rene Funk TITLE: MEMBER STATE BAR OF WISCONSIN (If not, to me known to be the person s who executed authorized by §706.06, Wis. Stars.) the foregpifig in men d eknowledged a same. THIS INSTRUMENT WAS DRAFTED BY * l Xai4 V Palm Michael H. Forecki, Attorney N ary ublic, State of Wisconsin Eau Claire, Wisconsin My Commission is permanent. (If not, state expiration date: (Signatures ma be authenticated or acknowledged. Both are not necess December 12 O *Names of persons signing in any capacity must be typed or printed below their signature. WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1-2000 ttomey Michael H Forecki 1830 Brackett Ave, Eau Claire WI 54701-4627 Phone: (71'5/) 835-3029 _ Fax: (715) 935-4112 Michael H. Forecki T4594463.ZFX 4 S ~U II Pmoucad with ZlpForm- by RE Fa rna)OM, LLC 181325 Fdtmn Mia Road, CfiMon Township, Mic/Npan 48035, (900) 383-9805 RECEIVED Wisconsin Department of Corn erce Melly 0 .qI11 FOIL EVALUATION REPORT Page / of CZ Division of Safety and Building FUix Com 85, Wis. Adm. Code ST County GU -5'-t Attach complete site plan on pgWNW1W&&j@N4WWFhlQWe in size. Plan must include, but not limited to: v M), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. c> Please print all information. Reviewed Date Personal information you provide maybe used for secondary purposes (Privacy Law. s. 75.04 (1) (m)). `V-711 Property Owner Property Location W 64, ` //j (X ,r:P, Co i (7 Govt. Lot 1 /4 M9414 S I ~ TQ N R ~ o &W Property Owner's Mailing Address r Lot Biotic # Subd. Name or 661rMt SEA Orr~Q f7 tt ~C[ ~~QY~r .$w L'f / o 27 City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road 7-P0- led ❑ New Construction Use:M Residential / Number of bedrooms U0 A'*1 Code derived design flow rate GPD Replacement ❑ Public or commercial - Describe: Parent material _ / T% Flood Plain elevation if applicable /V - fl General comments Thl`y reS t ¢/cv,~e 7 O Y e r, 7' /i in, V tl'--c f'fS and recommendations; a y 6~ R c ~g 1 p * `r r- c> x~~ i ~ti xcc ; / ! t/~ 7` Ec r C' Lj c ~c c~n.~ e J CS 7' o s7 s-/-f Aw F-/1 Boring # Boring Pit Ground surface elev. T7. ft. Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munseli Qu. Sz. Cbnt. Color Gr. Sz. Sh. *Eff#1 *Eff#2 d a 6 Jd 13 .2 ~ ,l 0,6 alk im r, 16-.2 T 4/4 S oS' w ©.7 6 02 4' Boring # ❑ Boring Tl v ira.r~d a Pit Ground surface elev 1. Depth to limiting facfAr in. Soil Application Rate Horizon Depth Dominant Color Redox Descnp ion Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 I C, L& y'~73/3 - i . ` h a s 240 0. 0-8 z _17 I&t'R+/6 Zwm' 4l >er a s l,-o 0.6 . O 7SrK4! S l 1d w, fr c w 1 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30:S 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print t Signature CST Number 44 0 6- 7 3 Address Date Eva Conducted Telephone Number ~3C~ . nj~S`rs/S- 770-Jl~ Sr ~C'!lSGvur~`F? lll.1"-S--f0lf ,S/371S. Z7-4- 3 TAG 7-w,,p r r,.o,-X a e / .Z D. 0'fa - o,~-- 40 - C> 00 SC0.le, r,y~~= ~'~'F't Cexce~t.'ohsK,teeL taN~/ dt ~o/ to UT VCA-t #.Z r ~i hc~Cf ,be~ow 2h aC B~t~ Vin tr X.Cye e ff lam„ f Q. 6 alit ~o~ 14C cr d e t jo ~'7 7"' l1 L° hYJ • 'F v The, li'9c< , Q! lC I~ ~.'s, 7`~c 3^ t~aT''e 7 a I~ ~y 9,J- 7~t., -ae aGS fC ~du~~iNC o1~ ~~t~04f/l°~: SC .j a f `r 3 1 e. as.'s!s a~' *~,,o r're.,c ~ese' ea%-c 4 ..j~ x 7o f 'O Cki oydeC~_/s~oS. ~J How'c. 7 v T,'s s~sj`rt war /n~~~,srQ~~ea~ iC,-;x 4~e.MC~ tv Y! ' f. C- SorCr /IvC GV, 7' F/CS'u ~ts. 7- e .scD7'~,c y~[Z kir 26~v /20,~c~c}1 /`f cv~i, CH ~0ra~a t~~ Ih Cq hs 7~~Q 7` !rt ,S ~.~-~O ~y t~~ ~'r! S! G. Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 112840 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: Funk, Ricky I Troy, Town of 040-1205-40-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 100.6 PIA I c( Q 16.28.19.958 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. d ~r s .f Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet 7Y `9`7 7 TANK SETBACK INFORMATION 4yx- 1wPita St/Ht Outlet 7 '773/ TANK TO P/L WELL BLDG. Vent o Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. `?T0 f2, Aeration Dist. Pi 9, F 7 9Z,?3 y- Holding Bot. System y ~r ACS s Final Grade PUMP/SIPHON INFORMATION J 15 2 9S.%2 Manufacturer Demand St Cover GPM Model Number d TDH Lift Friction Loss Sys m Head TDH Ft ` _ Forcemain Length a. Dist. t ell SOIL ABSORPTION SYSTEM BED/TRENCH Width 0 Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS y , I- D- SETBACK SYSTEM TO V P/L BLDG WELL LAKE/STREAM L CHI Manufacturer: INFORMATION CHA OR Type Of System: _ n NI h Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(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 1xx Seeded/Sodded xx Mulched Bed/Trench Cent r Bed/Trench Edges / Topsoil -33 Itn' - Ed Yes N No ® Yes [E No COMMENTS: (Include code discrepencies, persons present, etc.) Inspecti n #1:// p 8 Inspection #2: Location: 558 Omaha Road Hudson, WI 54016 (NE 1/4 NW 1/4 16 T28N R1 9W) Glover Station/M" Lbf'4 1 Parcel /No: 16.2,8.,19/.958 1.) Alt BM Description = N© j , ~G `~~y~ e 4~/ 4 " L ~G 2.) Bldg sewer length = c r/ -amount of cover -yw -A-Aa .rte Plan revision Required? ❑ Yes FE-1 No 44- SBD-6710 Use other side for additional information. (R.3/97) Date In is Signature Cert. No. p vi, ~ O N O N 4 0 I Oq b m uNi qb c N U N C ? E~ o c I m c~ o MO 00 E €~c, N L w CU Cc C M O ~ CO o (D v z :3 0) ' I 'E O C CL co C Cl) LL E 'v y~ yYv Q r v I a3i M p I Z y ~ W Z ! O N C Cl. 7 Zr y N U 9 co m N W d m Z E -~z c a c c 0 z 2 c c d d Z z o c 3U~ m t- E F° LL v _ N O 7 C6 co C O O y 0 N y M CO V C • Al d r- N O C O Q Z m Z z N c O N o H E m m - o cn Mn CD c d ~ CD o o G O > rn Cp N _O a N p FL > O O ~v Z O O 3aaa II IL co co U C 7 p fn ! O co co Z y J V ~V = N N 0 0 m o o p a E cc m C a ° f0 ~ W tU ~ O O co N ~ ~ Q ~ fn l4 li 1~ C ! O v 0 U') H Ct O j e- M n O O O N C CO C a CD N N co O _ i.. C N CO N O N c6 M U) Z C N O m a0 O CD ~o O N N O R U ~ N T co E L • 2 rn H fn O v~ d ~a E a v I o. d i E c c r A 0 at I0 Ui0 DEPARTMEM1!T OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUI INGS LABOR & HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION I P.O. BOX 7969 BUREAU OF PLUMBING MADISON, WI 53707 Town re Plan I.D Number. assigned I MADISO WI 537T28N-R19(U El CONVENTIONAL ❑ALTERNA*TIVE Store U - ThU, Holding Tank D In-Ground Pressure ❑ Mound Lot 4 Geoveh Station NAME OF PERMIT HOLDER. JADDRESS OF PERMIT HOLDER: INSPECTIO D TE. R ck Funk 1330 S. Main, Riven. F" , Wi 54022 L5._ $ ~f 30 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN REF. PT. ELEV.: CST REF. PT. ELEV. Name of Plumber IMP/MPRSW No.. county Sanitary Permit Nurrtbe!. Thomo A. Clang 3231 St. cuix `a$ SEPTIC TANK/HOLDING TANK: MANUFACTURER LIOUID CAPACITY. TANK INLET ELEV.. TANK OUTLET ELEV.. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED. OYES ONO OYES ONO BEDDING. VENT DIA.. VENT MATL HIGH WATER NUMBER OF ROAD: fROPERTY WELL BUILDING. VENT TO FRESH ALARM FEET FROM INE: AIR INLET. OYES ONO AYES ONO INE,4REST DOSING CHAMBER: MANUFACTURER BEDDING 11,101111) CAPACITY PIMP MODEL. PUMP/SIPHON MANUFACTURER WARN I NG LABEL LOCKING COVER PROVIDED PROVIDED. OYES ONO OYES ONO OYES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL. NUMBER OF PROPERTY WELL JBIALDING VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET PUMP ON AND OFF) _ L_~YES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH )IAMETefI MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) MAIN CONVENTIONAL SYSTEM: WIDTH LENGTH N!,l I UISTRPIPE SPACINGCOVER INSIDE DIA -PITS LIQUID BED/TRENCH TNCHES MATERIAL' PIT DEPTH DIMENSIONS GRAVEL DEPTH FILL DEPTH UISTR PIPE UISTR PIPE DISTR. PIP MATERIAL: NO DISTR NUMBER OF PROVER Y WELL. BUILOING V NT TO FRESH BF LOW PIPES ABOVE COVER FI F:V INLf I ELEV END PIPES FEET FROM LINE AIR INLET: 11 1 1_ N EAR EST-~ OUND SYSTEM:- Mound plowed pgrpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OFSYSTEM aim fu T own upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- meets the criteria for medi ' TIONS MEASURED. DYES NO SOIL COVER TEXTURE ANENT MFl HKE HS OBSERVATION WELLS } DYES ONO OYES ONO DE OVER TRENCH BED DEPTH OVER TRENCH BED UEPiH OF TOPSOIL SODDED SEEDED MULCHED CENNTTE ER EDGES DYES ONO OYES ONO DYES ONO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH LENGTH NO. OF LATERAL SPACING GRAVEL DEPTH BELOW PIPE FILL DEPTH ABOVE COVER BED/TRENCH TRENCHES DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL NO DISTR DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING ELEV ELFV. DIA ELEV. PIPES DIA ELEVATION AND DISTRIBUTION INFORMATION HOLE SIZE HOLE SPACING DRILLf U CORRECTLY COVE RMATER IAL PLANS VERTICAL LIFT CORRESPONDS TO APPROVED OYES ❑ O OYES ONO COMMENTS: PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: JBUILDING. FEET FROM LINE: ^n l x ~i DYES ONO OYES D O NEAREST 310 I~ Sketch System on Retain in county file for audit. qr.< erS SIGNATURE TITLE I J' Zon ng Admtivt.i6t a tan ILHRSB66710(fl. 9t82) SANITARY PERMIT APPLICATION oo~ 75" ILHR In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT # MEW 7 I ~g -Attach complete plans (to the county copy only) for the system, on paper not less than STATE PLAN I.D. NUMBER 8% x 11 inches in size. -See reverse side for instructions for completing this application. PETITION 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. FOR VARIANCE ❑ YES ❑ NO PROPERTY WNER PROPERTY LOCATION ,~0'/a, S T ,0N, R /49 E (o W PROPERTY OWNER'S M LING ADDRESS LOT NU BER BLOCk NUMBER SU DIVI ION NAME 5 11 Lo U~1A C TAY, STAT ZIP CODE PHONE NUMBER 71 CITY ` NEAREST R0 D, LAKE OR LANDMARK U G^ VILLAGE : j TOWN OF: II. TYPE OF BUILDING OR USE SERVED: 0410_10?0=410 Number of Bedrooms if 1 or 2 Family OR ❑ Public (Specify): III. PURPOSE OF APPLICATION: (Check only one in #1. Check # 2,3 or 4, if applicable) 1. a. rNew b. ❑ Replacement c. ❑ Replacement of d. ❑ Reconnection of e. ❑ Repair of an System System Septic Tank Only an Existing System Existing System 2. ❑ A Sanitary Permit was previously issued. Permit Date Issued 3. ❑ An Existing System has been inspected and soil conditions meet minimum requirements. 4. ❑ The System is shared by more than one owner/building. Attach Common Ownership Agreement to County Copy. IV. TYPE OF SYSTEM: (Check only one in #1 and only one in #2) 1. a. lQ Conventional b. ❑ Alternative c. ❑ Experimental 2. a. ❑ System- b. ❑ Holding c.0 Pit Privy d. ❑ Vault Privy e. ❑ Mound f. ❑ IGP In-Fill Tank V. ABSORPTION SYSTEM INFORMATION: (Check one) ( ju--,Lt~ f 0.2 1. a. ❑ Seepage Bed b. ❑ seepage Trench c. ❑ Seepage Pit 2. PERCOLATION RATE 3. ABSORPTION AREA 4. ABSORPTION AREA 5. SYSTEM ELEVATION 6. WATER SUPPLY: (Minutes er inch): REQUIRW(S are Feet): PROPOSED (Square Feet): 7 6 o~, ~2 Feet s Private ❑ Joint ❑ Public VI. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New xisting Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank I S S El 1 [71 0 Lift Pump Tank/Si hon Chamber + 1- ❑ ❑ ❑ VII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the private sewage system shown on the attached plans. Plumb is Name (Print): Plu a Signature: (No StI^ ps) MP/MPRSW No.: Business Phone Number: ~P It )AZP- It 715' gds P umber's Addres Street, City, S e, Zip Cc e): Nam esigner: 44b . "Pr 604 l0O it; VIII. SOIL TEST INFORMATION CMified it Test r (CS ) 2Name CST # - K/i G -e i CST' A1;1gRESS (Str , City, State, Zip Codg) t Phone Number: IX. COUNTY/DEPART NT USE ONLY ❑ Disapproved Sanitary Permit Fee Groundwater ate Issuing Agent Signature (No Stamps) ~ r-> /2o, S harge Fee Approved ❑ Owner Given Initial Adverse Determination ~h, X. COMMENTS/REASONS FOR DISAPPROVAL: 7b 3 ( S 30 6La SBD-6398 (formerly Plb-67) (R. 03/86) DISTRIBUTION: Original to County, One Copy To: Bureau of Plumbing, Owner, Plumber INFORMATION & INSTRUCTIONS FOR COMPLETING A SANITARY OERMIT, APPLICATION TO THE APPLICANT: 1. This 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. A new permit may be needed if there is a change in your building plans, system location, estimated wastewater flow (number of bed- rooms, etc.), depth of system, or type of system; 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. Private sewage systems must be properly maintained. The septic tank(s) should be pumped by a licensed pumper whenever necessary, usually dvery.2,to 3 years; 6. If you have questions concerning your private sewage system, contact your local code administrator or the State of Wisconsin, Bureau of Plumbing, 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 where the system is to be installed; II. Type of building or use served: If public is checked, indicate type of use (i.e. 10 unit apartment, 30 seat restaurant, etc.). Fill in number of bedrooms if building is a one or two family dwelling; 111. Purpose of application: Check only one in ##1. Complete ##2 if permit is for tank replacement, reconnection or repair; IV. Type of system: check all appropriate boxes depending on system type. Check experimental only if project is in conjunction with University of Wisconsin; V. Absorption system information: Provide all information requested in ##1-6; VI. Tank information: Fill in the capacity of every new and/or existing tank, list the total gallons to be installed, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, lift/siphon chamber and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR; VII. 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. Fill in designer name if applicable; VIII. Soil test information: CeVtified soil tester's name, certification number, address, and phone number. IX. County/Department Use Only; X. Comment area for use by county or resaon given when application is disapproved. 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; dosing or pumping chambers; 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. GROUNDWATER SURCHARGE On May 4, 1984, 1983, Wisconsin Act 410 was signed into law. This legislation is more commonly known as the groundwater protection law. This change in statutes was the result of over 2 years of steady negotiation and public debate. The groundwater bill Groundwater included the creation of surcharges (fees) for a number of regulated practices which Wisconsin's can effect groundwater. The surcharge took effect on July 1, 1984. All of the water that buried treasure< a is used in your building is returned to the groundwater through your soil absorption o system or the disposal site used by your holding tank pumper. The monies collected through these surcharges are credited to the groundwater fund adminis- tered by the Department of Natural Resources. These funds are used for monitoring ground- f water, groundwater contamination investigations and establishment of standards. Groundwater, it's worth protecting. SBD-6398 (R.03/86) y . 9 v ' N to Tai t 3~~1 h C6vered w1 f'~~ar b `,r~i~ l 2 k S srtevn, ~ I eV 9~ ~yb 93 o ebb I T ~ (ro FOSS JC ` 0' Q C~ i Q f3~ om~e vwc, ~c I ►Sd'to ~d fjEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDING INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION SECT ON: TOWNSHIP/ LOT NO.:B S BDIVISION N E: /TQ*R!c(E c W MAILING AD ESS: COUNTY: s QW4f!T6/QUXjB'S NAME. J 1) L _1.1 M I /.3" 4 4.~. y~1 4o r, USE DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESC PTION: PROFI T NS: PERGOLA ON STS: I ~UResidenee 3 ~1New ❑Replace L V RATING: S= Site suitable for system U= Site unsuitable for system j CONY ZONAL: MOUN IN-GROUND-PRESSURE: rE]S YSTEM-IN-FI OLDING TAN RECOMMENDED SYST M~optional) ou s❑u sE u osCO_. l_<~ If Percolation Tests are NOT required DESIGN RATE: If any portion of the tested area is in the / under s. ILHR 83.09(5)(b), indicate: CIiCJl 4--d II'loodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO R UNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. IGHES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- ,5., C ;I 11A21-A2 > % 7 d d /Z ems's 26 9 ~o cI r 9(~ 8 5 f'S 010 6 CS + 'Lil- B- . b > 7 2 B- , 76 9'~f Osl > 7& s ~3/ s Cs PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 P RI D2 P R 003 PER INCH P_ _ / s /Ga s !e 1161 P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensio s f s itablgsoil areas. Indicate scale or distances. Describe what are the hor)- zontal and vertical elevation reference points and show their location on the plo~ %W*the surface elevation at all borings and thgdirection and percent of land ope. SYS M ELEVATION C/ a B 3o n-~ F_3 0 , a r _ o i 13 D 6-113 Q a /5'e 1, the undersigned, hereby certify that the so tests reported on this form were made by me in accord with the pr cedures and methods specified in the Wisconsin Administrative Code, and that the data recorde and the location of the tests are correct to the best of my knowled a and belief. z6o NAME (print): TESTS WERE MPL ED ON: ti I ^ An rot J JC ADDRESS: I a CERTIFICATI N NUMBER: PHONE NUMBER (optional): G~ 3 CST rSl N ~TUR ' f DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - 1 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 lp~ Aw Location of Property 1 14, Section T 9;~N-R__ W Township l a Mailing Address Address of Site /;4r~ Subdivision Name Lot Number Previous Owner of Property ~J Total Size of parcel v.'T. Date Parcel was Created Are all corners and lot lines identifiable? Yes No Is this property being developed for resale (spec house) ? Yes No Volume /10 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 refer- ences to a Certified Survey Map, the Certified Survey Map shall also be required. - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PROPFRTV OWNER CERTIFICATION I (We) ce tijy that at statement6 on thin banm ane tAue to the best ab my (ouA) knowledge; that I (we) am (aAe) the owneA (d) o j the pnapeh ty dens n bed in thus in4 mati,on bonm, by viA tue o j a waA&anty dee n c nded in the O b bice o j the County Register ob Deedsa~s Document No. < and that I (We) Pita entty own the pnopob ed .6 to ban the.6ewag e dies pays system (an I (we) have obtained an .said easement, to nun with the above de~scA bed pnopenty, ban the consttnuct on o_i, system, and the same has been dut recorded in the Obb~,ce ab the Co ten ab Deeds, as Document No. SIGNATURE OWNER SIGNATURE OF CO-f&NER (IF APPLICABLE) ATE SIGNED DATE SIGNil D H z N H a STC - 105 r a H SEPTIC TANK MAINTENANCE AGREEMENT o St. Croix County x c7 M OWNER/BUYER I H ROUTE/BOX NUMBER L% 1~i-v+ Fire Number .CITY/STATE- ZIP jY/9 PROPERTY LOCATION:Ix, S tf 36, Section, T N, R Town of G , St. Croix County, Subdivision (7/6 i'7 , Lot number. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists 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 treat- ment 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 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 veri- fying that (1) the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if nec- essary), 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. 0 E I/WE, the undersigned, have read the above requirements and agree z to maintain the private sewage disposal system in accordance with x the standards set forth, herein, as set by the Wisconsin Depart- 10 ment 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 DATE St. Croix County Zoning Office P.O. Box 98, Hammond, WI 54015 715-796-2239 or 715-425-8363 Sign, date and return to above address. ~ooK ~~.Q fiat ~ 7~. i •,baCUMENT NO. STATE BAR, OF WISCONSIN FORM 11-1982 THIS SPACh RESERVED FOR RECORDING DATA ~I ~I LAND CONTRACT j 437277 I (TO and Corporate (TO BE USED FOR ALL TRANSACTIONS WHERE OVER $25,000 IS FINANCED AND IN OTHER NON-CONSUMER REGISTERS OFFICE _ACT TRANSACTIONqL__- f - - _ - - - ST. CROIX CO., WI i ~i Dennis R. Schultz' and Recd O Record Contract, by and between ' ppaa i C. M. Bye, each in their --own right----------------------------------... , . 'MAY~.6 19U0 - I I~ - . ('Vendor", whether one or more) and....Rickey DeWayne Funk and at 8:00 AM - Deanna--Rene.- Funk... lnarital__suryiyourship property ("Purchaser", whether one or more). Vendor sells and agrees to convey to Purchaser, upon the prompt and full per- $,_Repist w of Dseds formance of this contract by Purchaser, the following property, together with the I rents, profits, fixtures and other appurtenant interests (all called the "Property"), - I in ..................St: ..C]:QiX.-----------------------._------ County, State of Wisconsin: RET C. M. Bye URN TO P. 0. Box 167 River Falls, Wisconsin 54022 j Tax Parcel No i i Lot X64, Glover Station Subdivision, located in the NW-1/4 of Section 16, Township 28 North, Range 19 West. I! Land only. This is not homestead property. t1W (is not) I Purchaser agrees to purchase the Property and to pay to Vendor at ..a__place reasonably directed _ I the sum of 22, 000._00 in the following manner: (a) 4, 000.00 at the execution of this Contract; and (b) the balance of $..._x S,000-0u ................I together with interest from date hereof on the balance outstanding from time to time at the rate of 97 per cent per annum until paid in full, as follows: Interest only payment on January 1, 1989 Entire contract due January 1, 1990 r 4 l i i Provided, however, the entire outstanding balance shall be paid in full on or before the.......... lst.......... day of .1anuiaxy.• 19.9.Q.. ( the maturity date). Following any default in payment, interest shall accrue at the rate of .____1 0__- % per annum on the entire amount in default (which shall include, without limitation, delinquent interest and, upon acceleration or maturity, the entire I principal balance). Purchaser, unless excused by Vendor, agrees to pay monthly to Vendor amounts sufficient to pay reasonably antici- pated annual taxes, special assessments, fire and required insurance premiums when due. To the extent received by Vendor, Vendor agrees to apply payments to these obligations when due. Such amounts received by the Vendor for payment of taxes, assessments and insurance will be deposited into an escrow fund or trustee account, but shall not bear interest unless otherwise required by law. Payments shall be applied first to interest on the unpaid balance at the rate sp Icified 1nd then to principal. Any (eft) amount may be prepaid without premium or fee upon principal at any time after .._.y 19.8 1zl~anxlaBlrbsnxal~msglo~onemlSCmktpod~pafil~ali>hlsnrspt~8ixidssfiDaIllXfi~~ In the event of any prepayment, this contract shall not be treated as in default with respect to payment so long as the unpaid balance of principal, and interest (and in such case accruing interest from month to month shall be treated i as unpaid principal) is less than the amount that said indebtedness would have been had the monthly payments been made as first specified above; provided that monthly payments shall be continued in the event of credit of any proceeds of insurance or condemnation, the condemned premises being thereafter excluded herefrom. Purchaser states that Purchaser is satisfied with the title as shown by the title evidence submitted to Purchaser for examination except: easements, restrictions and covenants of record. i i Purchaser agrees to pay the cost of future title evidence. If title evidence is in the form of an abstract, it shall be retained by Vendor until the full purchase price is paid. ~I C Purchaser shall be entitle to take possession of the Property on ..............May .13 1 19 88 I~ 'Cross Out One. ~I _ KCM=CeR"M 00 FORM No. 4-- STATE BAR OF WISCONSIN StOCI( No, 1301 BOOK PACE 472 Puiebaser promises to pay when due all taxes and assessments levied on the Property or upon Vendor's interest in it and to deliver to Vendor on demand receipts showing such payment. Purchaser shall keep the improvements on the Property insured against loss or damage occasioned by fire, ex- tended coverage perils and such other hazards as Vendor may require, without co-insurance, through insurers approved by Vendor, in the sum of nla but Vendor shall not require coverage in an amount more than the balance owed under this Contract. Purchaser shall pay the insurance premiums when due. The policies shall contain the standard clause in favor of the Vendor's interest and, unless Vendor otherwise agrees in writing, the original of all policies covering the Property shall be deposited with Vendor. Purchaser shall promptly give notice of loss to insurance companies and Vendor. Unless Purchaser and Vendor otherwise agree in writing, insurance proceeds shall be applied to restoration or repair of the Property damaged, provided the Vendor deems the restoration or repair to be economically feasible. Purchaser covenants not to commit waste nor allow waste to be committed on the Property, to keep the Property in good tenantable condition and repair, to keep the Property free from liens superior to the lien of this Contract, and to comply with all laws, ordinances and regulations affecting the Property. Vendor agrees that in case the purchase price with interest and other moneys shall be fully paid and all conditions shall be fully performed at the times and in the manner above specified, Vendor will on demand, execute and deliver to the Purchaser, a Warranty Deed, in fee simple, of the Property, free and clear of all liens and encumbrances, except any liens or encumbrances created by the act or default of Purchaser, and except: easements, restrJctions__and__coyenan_> s.. of- record:------•----------------•--..•......------........--- . Purchaser agrees that time is of the essence and (a) in the event of a default in the payment of any principal or interest which continues for a period of ..30.... days follow ing the specified due date or (b) in the event of a default in performance of any other obligation of Purchaser which continues for a period of .30..... days following written notice thereof by Vendor (delivered personally or mailed by certified mail), then the entire outstanding balance under this contract shall become immediately due and payable in full, at Vendor's option and without notice (which Purchaser hereby waives), and Vendor shall also have the following rights and remedies (subject to any limitations provided by law) in addition to those provided by law or in equity: (i) Vendor may, at his option, terminate this Contract and Purchaser's t rights, title and interest in the Property and recover the Property back through strict foreclosure with any equity of redemption to be conditioned upon Purchaser's full payment of the entire outstanding balance, with interest thereon from ` the date of default at the rate in effect on such date and other amounts due hereunder (in which event all amounts previously paid by Purchaser shall be :forfeited as liquidated damages for failure to fulfill this Contract and as rental for the Property if purchaser fails to redeem) ; or (it) Vendor may sue for specific performance of this Contract to compel immediate and full payment of the entire outstanding balance, with interest thereon at the rate in effect on the date of default and other amounts due hereunder, in which event the Property shall be auctioned at judicial sale and Purchaser shall be liable for any deficiency; or (iii) Vendor may sue at law for the entire unpaid purchase price or any portion thereof; or (iv) Vendor may declare this Contract at an end and remove this Contract as a cloud on title in a quiet-title action if the equitable interest of Purchaser is insignificant; and (v) Vendor may have Purchaser ejected from possession of the Property and have a receiver appointed to collect any rents, issues or profits during the pendency of any action under (i), (ii) or (iv) above. Notwithstanding any oral or written statements or actions of Vendor, an election of any of the foregoing remedies shall only be binding upon Vendor if and when pursued in litigation and all costs and expenses including reasonable attorneys fees of Vendor incurred to enforce any remedy hereunder (whether abated or not) to ti,e extent not prohibited by law and expenses of title evidence shall be'added to principal and paid by Purchaser, as in- curred, and shall be included in any judgment. Upon the commencement or during the pendency of any action of foreclosure of this Contract, Purchaser consents to the appointment of a receiver of the Property, including homestead interest, to collect the rents, issues, and profits of the Property during the pendency of such action, and such rents, issues, and profits when so collected shall be held and applied as the court shall direct. Purchaser shall not transfer, sell or convey any legal or equitable interest in the Property (by assignment of any of Purchaser's rights under this Contract or by option, long-term lease or in any other way) without the prior written consent of Vendor unless either the outstanding balance payable under this Contract is first paid in full or the interest conveyed is a pledge or assignment of Purchaser's interest under this Contract soley as security for an indebtedness of Purchaser. In the event of any such transfer, sale or conveyance without Vendor's written consent, the entire outstanding balance payable under this Contract shall become immediately due and payable in full, at Vendor's option without notice. Vendor shall make all payments when due under any mortgage outstanding against the Property on the date of this Contract (except for any mortgage granted by Purchaser) or under any note secured thereby, provided Purchaser makes timely payment of the amounts then due under this Contract. Purchaser may make any such payments directly to the Mortgagee if Vendor fails to do so and all payments so made by Purchaser shall be considered payments made on this Contract. Vendor may waive any default without waiving any other subsequent or prior default of Purchaser. All terms of this Contract shall be binding upon and inure to the benefits of the heirs, legal representatives, successors and assigns of Vendor and Purchaser. (If not an owner of the Property the spouse of Vendor for a valuable consideration joins herein to release homestead rights in the subject Property and agrees to join in the execution of the deed to be made in fulfillment hereof.) Dated this 1. day of May--................•----•••--•-••-•--. 1988..._. (SEAL) SEAL) w Dennis R. Schultz C!_~_.!_"~.✓ (SEAL) t._.. (SEAL) C, M. By-e e AUTHENTICATION ACKNOWLEDGMENT Signature(s) Dennis R.....Schultz STATE OF WISCONSIN ss Bye C , - .County. thent' ay of__.__._MaY 1988-- Personally came before me this 3_~_ day of ;1-A_------- , 19S r the above named S a r t-------••- tuart J'--- rue er-..-•--•-••--•-.._.._...-•-----•-•••.---• !Slf al. :.=y..f`_K.~'llt........... TITLE: MEMBER STATE BAR OF WISCONSIN ______________YJr/9N!✓~ rJIC____............... (If not, -i.e~" authorized by § 706.06. Wis. Stats.) to me known to be the s v iho ;eltecuted t~te~ foregoing instrume L' L~pnoad4e;the v . THIS INSTRUMENT WAS DRAFTED BY ..y,y~%•1 ) YA,..Attorney•at Law ,gf ' P. 0. Box 167, River Falls, WI 54022 ............/r Notary Public iH". ....County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is permanen ; (,If not state expiration are not necessary.) 2~ 19) •Names of persons signing in any capacity should be typed or printed date: . , below their signatures. OMD . A