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HomeMy WebLinkAbout022-1006-80-155 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 552357 0 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Yang & Moua, Xao & Susan Kinnickinnic, Town of 022-1006-80-155 CST BM Elev: Insp. BM Elev: BM Description: Sectionrrown/Range/Map No: I G- 03.28.18.45D TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing 5d Z• lag :5 AZ ~~rQ Alt. BM ~a O : 1 60J-CA- EFatl6ff Ao 'a k- Bldg. Sewer 7.6 Holding 6~ St/Ht Inlet X z 971?. 3 TANK SETBACK INFORMATION St/Ht Outlet ` TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic //6 Sy Dt Bottoms 7 Dosing / ft / 54 J d / Header/Man. Z Aeration Dist. Pipe Z c Jr(, V Holding t Bot. System 7-:3 4M - -Z- $ . PUMP/SIPHON INFORMATION Final Grade -T#-. / 51 Manufacturer / Demand St Cove q ` GPM ` J Model Number 36 16 12~ TDH Li Friction Loss System He TDI3 • t 0. Z% ft-~ Forcemain Length Diaz. • Dist. to Well 5 SOIL ABSORPTION SYSTEM BED/TRENCH Width Length/ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ! z 1/64 A SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:` ~ INFORMATION CHAMBER OR Type Of System: O J UNIT Model Number I-q DISTRIBUTION SYSTEM OJ Ak 444 11116 5 4- Z 9F = 7 4 o Air take Header/Manifold I ) Distribution x Hole Size x Hole Spacing Vent to `S I Length ~i Dia Pipe(s) Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over I Depth Over xx Depth of xx Seeded/ odded xx Mulched Bed/Trench Center Z Bed/Trench Edges Topsoil \on Yes 0 No Yes Q No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: Location: 1287 Cty. Rd. N Rob rts, WI 54023 (NE 1/4 SE 1/4 3 T28N R18W) NA Lot 8 Parcel No: 03.28.18.45D 1.) Alt BM Description = 2.) Bldg sewer length jb -amount of cover = ~ ~f > ate, Plan revision Required? 0 Yes ko d Z ' L ~1 Use other side for additional information. a L -4- ~4,~ Date Insepctors Si ature Cert. No. SBD-6710 (R.3/97) commerce.Wl.gov Safety and B 'ldings Division County 20 ingto ve., P.O. Box 7162 S'_ CrOe i sco n s i n n, 53707-7162 Sanitary Permit NyiZ r (to be filled in by Co.) Department of Commerce RR 6 L~ 3 J Sanitary Perml p do *a SjFtPT=saction Number In accordance with s. Comm. 83.21(2), Wis. Ad n. Code, 'submission of t,~s to th appropriate governmental unit is required prior to obtaining a sanitary hermit. ote~pTolldh" 6ir tate-owned POWTS are Proje ddres different than mailing address) submitted to the Department of Commerce. Personabi be used for secondary purposes in accordance with the Privacy Law, sA5.fAWWW# 1. Application Information - Please Prin 1# ormation LTff A) Property Owner's Name Parcel # C <"r 4 2.Z - 1006, - T-0 - Property Owne s Mail g Address Property Location ( ~/S 1 /z7 /G/4 rec. ,e Govt. Lot City, State Zip Code Phone Number 4:_::- .5 C p Section 3 ~GG✓ Gl+ k- c` 4e~ :CY V 1? (circle one) T R fC11r~ # 11. Type of Building (check all that apply) Lot N; g' Subdivision Name ~or 2 Family Dwelling - Number of Bedrooms ok 1 Block# N A 0 / ❑ Public/Commercial - Describe Use 9 ❑ City of 141 ❑ State Owned - Describe Use CSM Number , ❑ Village of K Own of Sl 6 7 9 3 P' fem., r c~ i4~ ~ e- III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ~Alew System El Replacement System 11 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 Before Expiration Owner IV. Type of POWTS S stem/Com onent/Device: Check all that apply) ,O-Non-Pressurized In-Ground ❑ Pressurized In-Ground At-Grade ❑ and > 224 inof suitable soil ❑ Mound < 24 in. of suitable soil El Holding Tank ❑ Other Dispersal Component (explain) 15 C~~v~ "CJ Pretreatment Device ex lain /7 64Z-a. V. Dispersal/Treatment Area Information: i "41 Cdf, 426/ :o) 4A41f-wil~IJ S Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation ,/,00 CSZv rs~o f c"a Tl,9 T2 5Y. VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units S ~ I/l d 5 z o, o New Tanks Existing Tanks/„ ~ w o U, ~ y 7r av r-4 y v~ w5 a ti or Holding Tank Dosing Chamber e-OL-z VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature GW/MPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) 7 /c) _ 5.5# G VIII. oun /De artment Use Only Permit Approved El Disapproved Fee Date ssued / ssuing Agent igna ❑ Owner Given Reason for Denial $ y / 76'• ~Z J / Z IX. Conditions of Approval/Reasons for Disapproval i/ 3 Sc..e rtt 117_<1 4o k), stn,. SYSTEM OWNER: CGG~77•}~ ! 1 Septic tank, effluent filter and 12 A l dispersal cell must all be serviced I maintained 61 as per management plan provided by plumber. maintained 2. All setbauk c o om t or the system a submi the County my on paper not les than 81/2 x 11 inches in s' e _ ~;0~ f sW`G~ S /L U C1 as per applicable co efor8~~1~aN'~' Al~jj P/i~ad 2j- 9~s(_! Owl 0 r( &M ,115 h~ p/~h, C u ~ T SBD-6398 (R. 02/09) Valid thru 02/11 J f f J,^~ J {1 C ~Qf~s~ J1 eE (~'C~2 Q'~ - i'ko~ u Zvi - P CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: y Owner's Name: a o Lj~., G ct S'u c G4 c. c Owner's Address: 12 7 Y dUa c~, ~r Legal Description: L ~~~(•S %y 3 r2 b? Ltd- ll~ Township: County: ST Cv~ Subdivision Name: Lot Number. Parcel ID Number: d 22 - l ova -a l S -S~ Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber. G*~,`/c.e ~✓c Cf~~, License Number. ZZS/Sb Date: W/2 Phone Number 71-S-- 2- 6F- "2- Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01101). Page 1 0.11 V: © o -Jo 14 s N~ N s In, r °Q o N o e 0 r a ~ R W n Cl n ~ ~ Q 1j i r ~ ~ g Al ~ roj~clr: `9 S Q L er- C r S 4 e ~s scope- Gf~ 70r s 3 7-2- r2 T LC S e~cc r~ T ~ 3' G 4 W --2 T kny Tv, T~~h P r / Utz Goo _ a i Pf P401 bwox INSTALLATION INSTRUCTIONS INcJs•c.',ra`aa°a ADionof FoM,*hc. PL-525/PL-625 FILTER PL-525/PL-625 FEATURES & BENEFITS Features & Benefits: cK • Rated for 10,000 GPD • PL-525 = 525 Linear Feet of 1/18" Filtration PL-625 = 625 Linear Feet of 1/32" Filtration 411 all PL-525 PL-625 .Accepts 4" and 6" SCHD. 40 pipe The PL-525/625 Effluent Filter should operate efficiently a Built in Gas Deflector for several years under normal conditions before 9Automatic Shut-Off Ball when Filter is Removed requiring cleaning. It is recommended that the filter be cleaned every time the tank is pumped or at least every .Alarm Accessibility three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the .Accepts PVC Extension Handle filter needs servicing. Servicing should be done by a certified septic tank pumper or installer. RECOMMENDED PRODUCTS Polylok PVC Filter -r Extension Handle as r 1* . w• Awl 1 ~ f Risers & Riser Covers Extend & LokTM Riser Safety Screens Filter Alarm Panel and Polylok risers bring your Polylok Extend & LokTM Polylok safety screens SmartFilterTM Control septic tank cover to grade. is a simple, easy to use prevent tragic accidents Switch This allows locating and solution that can extend from happening by children Polylok filter alarm panels servicing your filter easier the inlet or outlet pipe and and pets falling into open and switchs provid a visual and time saving by elimi- make filter and/or baffle septic tank entrances. and audible notification of nating digging to find tank installation a snap. impending filter and tank entrance. Fits 3" and 4" pipe. servicing. For a full list of Polylok products please visit our web site at: www.polylok.com r Ue PUMP C AMISEa_CROSS SCCTION J .ND Sr CI Ar01►IS' VCMT CAN M'C.I. V[WT ►IPC 7"r WCArmsit PROOF "P, OVto Locki G • a ts' FROM DooR. ruuCTloy ~Ori e.R tov~~ . --r wiuuow oit iCC;N Ii'KIY. . • AIR IbITAKC _ , _ • . • . I , . • • 6RAOC • CONDUIT IV pig. le'KHI.' - - - % IAILCT ; • , AIRTIGVMT KAL , " I 1 4►PRQVLO JOIYT A ,I 1 .I I PKDVLO Jo w/C.z. ►I~E I III wic.t. PIPE CXTCNOIIA 3` I II » [XTWDIure ; AUTO EOLW SOIL : A I ONTO so"D i • •~t I OW• G~t~c f Y ff ruM1 o ..1• ~ of calcRCTt kasK + New. 3 ~•u • RISCR • CIIIT PCRAMC0 CWL.1 W.TAWt p1AWPACTUACIt" 1%S &"N A►PROVAI. wa~wawct . • oowA SCPTIC ! S PE G I F T GA7lAL1S _ Y ' 1 0050 TAblit #"UfACT"gA: WW TANK 61ZC: iA1.~01Ji OQITi VOWNC s*LARI MAYIIfACTYR[R: ST CC e 11iC4MQ1AI6 &ACKIj.AMh 5 W►~t•pi A0006 UU AOCR: /G / CArAiiTltris Aar 3 Pau 011 S • "~µLO~ SWITGM Ty/t: - IJOItI M E/Z C lIR ~ V ...WCMti qll WA L01 PUMP KAl1Y►AGTIIRCR: Za+LGCer Ca.. e.W(Mr►~ 9A .dt.drLLO~ job- MOA4L AIYIIAi•KS ~3 OR ••i`4AI•L0 Ajf~ $WITCH T1iP[i N- L : ' 1'11NR A1~Id µ,AAM ARr TO 6L. MIYIMWA D►iCMA~it VAn... 0.....0M R piJ /►iIATC CIRCNITi ►ECT 1 ; t. VCRTICi1L a/ItRWtE OCTW[CAI MIl~r OFF Mta OIiTRIWTIOM AC.. i + NIu1MU14 IJCTWo1tK futNLy NlttiSURC ; , • • FL9T , l2. f'c t~Z'i?J ♦ --0 fLtT Or roacC MAIM X o~ x j~l"TNMI N1CT+OII:• ►iCT . "TOTAL. O'.IWAMIC NCAQ' s w 3 , Fi•RT . INTERMAI. DIALUM0W6 0/ TAUK: 14610TM.:~...,+.. IoWIDTN..~.. j~,IQUIO OErTH ....•u• .•I.MAl~1• w •+w• TOTAL DYNAMIC HEAD/FLOW 1-- UJ UJ W PUMP PERFORMANCE CURVE PER MINUTE MODELS 53/55/57/59 EFFLUENTAND DEWATERING 20- 1 MODEL 53/55/57/59 °Q 6 w Feet Meters Gal. Liters 9 5 1.5 43 163 Q 15 10 3.0 34 129 z 4 15 4.6 19 72 10 Shut-off Head: 19.25 ft.(5.9m) I- 0 I- 009897 2 3na s3/1s 5 4 0 11/2 -111/2 NPT 0 3 718 10 20 30 0 50 GALLONS OO LITERS I 0 80 160 a FLOW PER MINUTE ~ i ~ i CONSULT FACTORY FOR SPECIAL APPLICATIONS • Variable level float switches available • Variable level long cycle systems available • Available with special cord lengths of 15', 25', 35', (50'230V only) 10 1/16 • Alarm systems available • Duplex systems available 33/32 I i SELECTION GUIDE SK858 1. Integral float operated mechanical switch, no external control required. 2. Single piggyback variable level float switch or double piggyback variable level float switch. Refer to FM0477. 3. Mechanical atemator "M-Pak" 10-0072 or 10-0075. 4. See FM0712 for correct model of Electrical Alternator. "Easy assembly" 5. Variable level control switch 10-0225 used as a control activator, with (pump & discharge pipe Electrical Alternator (3) or (4) float system. not included.) Single Seal Control Selection Listings Model Volts Phase Mode Amps Simplex Duplex CSA UL M53155 & M57159 115 1 Auto 9.7 1 - Y Y N53/55 & N57/59 115 1 Non 9.7 2 3 or 4& 5 Y Y • BN53 115 1 Auto 9.7 Y Y • BN57 115 1 Auto 9.7 • - N Y • BE53/57 230 1 Auto a.& • - Y Y OPTIONAL PUMP STAND P/N 10-2421 D53/55 & D57159 230 1 Auto 4.8 1 Y Y Reduces potential clogging by debris E53155 & E57/59 230 1 Non 4.8 2 3 or 4 & 5 Y Y Replaces rocks or bricks under the pump • Single piggyback switch included. Made of durable, noncorrosive ABS o cnunoN Raises pump 2" off bottom of basin All installation of controls, protection devices and wiring should be done by a qualified licensed electrician. All electrical and safety codes should be followed including the Provides the ability to raise intake by adding sections of 1Y2" most recent National Electrical Code (NEC) and the Occupational Safety and Health or 2" PVC piping Act (OSHA. • Attaches securely to pump For information on additional Zoeller products refer to catalog on Piggyback Variable Level • Accommodates sump, dewatering and effluent applications FloatSwitches,FM0477;ElectricalAltemator,FM0486;MechanicalAltemator,FM0495;Sump/ NOTE: Make sure float is free from obstruction. Sewage Basins, FM0487; and Single Phase Simplex Pump Control/Alarm Systems, FM0732. RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. © Copyright 2010 Zoeller Co. All rights reserved. 66" 53" z 86" m N ~ ~f n f1 II 11 3" I ~ 1 57" I rr/ ao -n 8~ \ 6° r " rn m~~ ~ I I ~ I 10 I I I I N < I I < m m I D 11 II Z x 51" u+ W N ? D ;u O m c m r, D m Z N c m 0 I ZN m N 0 D Z Z Z 0 0 0 D vD O S: rln m m O Z~ 0 D Z 0 ~ c: a) r 2 g c) a) :E V1 z WN A tl*i Z Z rlx G7 0 O-Z D:Z mama ZmDoo>a m -u O rtn 0 SC~a (A0 ScOS o A -~If-Z m (n -4 m n IW*I 2 N > D mop mDn p =2~~0~o u) (I) N C-) ;u Z In r- r N Ln 0Z1cn r< Z?(n MZOD rnI r ~mmrnm(Z) m N r0 O D Z O ~N ~tnM ND ~r -{O CnO~ N v 0 N v g > mm < . 4 mm a) -iN O o m O O (n i < o NO 0) (A C) -n Mr- Ln 0 cnm~ IDD r00w -1171 D p Z 9z c DD mmm m0 co 0 A D O D m0 SrZ~O~ n n m c ZZ D>~O W o I ID - O (n D :3- v O ?7 Op ~ C7 -I A Z O m cm F om C) ,z^ pi m N N (n -i 0 "O u M C )AD Z V/ J m = O< m N ~v ~ D C7 O rrl -I O m r m m O Z A r 0 --4 c m c z O m m m (A m m -1 ~ m z m z N m \ O = W1250 750-MR scALE:1/4• _ 1' REV NO. DATE: 0 rn MHER callIETE DRAWN BY:SWT Z SEPTIC MANUAL W3716 US HWY10. MAIDEN ROCK, WI 54750 DATE: JANUARY 2007 O \o REV. JAN. 2007 800-325-8456 FILE: W1250 750-MR 1 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity al ❑ NA 3 Septic Tank Manufacturer ❑ NA Permit # 5752, fl - E3 NA DESIGN PARAMETERS Effluent Filter Manufacturer Number of Bedrooms ❑ NA Effluent Filter Model i ❑ NA Number of Public Facility Units F~-NA Pump Tank Capacity al ❑ NA Estimated flow (average) pp gal/day Pump Tank Manufacturer tom; Q jPr ❑ NA Design x 1.51 600 a/ da Pump Manufacturer 46e E3 NA flow (peak), (Estimated Soil Application Rate • al/da /fe Pump Model B~ E3 NA i Standard Influent/Effluent Quality Monthly average" Pretreatment Unit A Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (SOD,) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Watland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other; Pretreated Effluent Quality Monthly average Dispersal Cell(s`L-1aSed ❑ NA Biochemical Oxygen Demand (SOD.) 530 mg/L $4n-Ground (gravity) $14n-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L i NA ❑ At-Grade ❑ Mound Fecal Col(form (geometric mean) 510` cfu/100ml ❑ Drip-Line ❑ Other: Other: ❑ NA Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA other. 13 NA ''Valves typical for domastic wastewater and septic tank effluent. Other: 0 NA MAINTENANCE SCHEDULE Service Event Service Frequency ❑ month(s) (Maximum 3 years) ❑ NA Inspect condition of tank(s) At least once every. i3 ear(s) Pump out contents of tank(s) When combined sludge and scum equals one-third of tank volume ❑ NA ❑ month(s) (Maximum 3 Years) ❑ NA Inspect dispersal cell(s) At least once every:-year(s) • ❑ month(s) p NA Clean effluent filter At least once every: ear(s) ❑ month(s) d NA Inspect pump, pump controls & alarm At least once every: Wyear(s) 13 month(s} ~dNA Rush laterals and pressure test At least once every: ❑ year(s) Other Omonth(s) V-NA At least once every: ❑ year(s} ~,C NA' other: MAINTENANCE INSTRUCTIONS inspections of tanks and dispersal cells shall be made by an individual P WTS Maintainere Sept following liven es oper torcatT~M Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, uent any pondin£ surface measure the volume combined vsludge and scum and to heck he c effluent levels in the observa iongpipes alnd to h ck foground The dispersal cell(s) shall be visually inspected to 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. more volume, tank the When the combined accumulation of sludge and scum S tank ) and d'sposed}ofrin a cordance with chapter NR~113 contents of the tank shall be removed by a Septag Servicing Operator Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatmen units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GNAW (4/4t ) •5j a Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(sl 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 chapter Comm 83.33, Wisconsin Administrative Code: + All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. e The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or 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: P -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. 13 A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. EI 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. O 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~~~ C✓ [ j C',` Name Phone s-_ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ST' Cvv r c, 4 / Phone phone ( _57 3 8 6 _ Yro ~l0 This document was drafted in compliance with chapter Comm 83.22(2)(b)(ti(d)&0) and 63.54(1), (2) & (3), Wisconsin Administrative Code. May-10-2012 02:18 PM St. Croix County Plan/Zoning 715-386-4686 1/1 ST. CROIX COUNTY SEPTIC TANK MA n ENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM 19muycr Mailing Address 7 41 ve w,, A11 .e C i-V Q., 4 s~. ~l C7 (7 Property Address /ay-7 G T I'V ~j (Verification required from Planning & Zoning Department for new construction.) Vl ) City/State Parcel Identification Number [02-z- /009 -go- LEGAL DESCRIP'T'ION Property Location /V , .5 6: 1/4 ,See. , T~2 'N R l rW, Town of k '4 e- /c k i~ G Subdivision Plat: Lot # -7 "o Certified Survey Map 2-1- - 1007, Volume 2-3 . Page # Warranty Deed # SG 3 1 ~ (before 2007)Volume , Page # Spec house 0 yesAno Lot lines identifrable4yes ❑ no SYS'T'EM 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 responsibilittes are specified In §Comm. 83.32(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. Uwe certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office, Number of bedrooms Z U SIGNATURE OF PL (CANT(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) PS II IIIIIIIIIII I IIIII IIIJIIIIIII I 8056777 Tx:4042281 State Bar of Wisconsin Form 2-2003 956315 WARRANTY DEED BETH PABST Document Number Document Name REGISTER OF DEEDS ST. CROIX CO., WI 05/14/2012 1:00 PM THIS DEED, made between Cher Yan Toua Lor a/k/a Lor Toua and EXEMPT#: 3 Tria Lor, anoint tenants REC FEE: 30.00 ("Grantor," whether one or more), and Susan Moua a single person and PAGES:2 Xao Yana a single person as joint tenants with rights of survivorship - ("Grantee," whether one or more). Grantor for a valuable consideration; conveys and warrants to Grantee the following described real estate, together with the rents; profits, fixtures and other appurtenant Recording Area interests; in St. Croix County, State of Wisconsin ("Property") (if more Name and Return Address space is needed, please attach addendum): Xq.5 ~~a3If7 That part of the Northeast Quarter of the Southeast Quarter (NE 1/4 of the SE 114) of f!a /tar r t/ ~1 1jrek Section 3, Township 28 North, Range 18 West being a part of Outlot 1 of Certified Survey l Map recorded in Volume 18 of Certified Survey Maps on page 4691 described as follows: X HC/ I 5 da-2, Lots 7 and 8 of Certified Survey Map recorded in Volume 23 of Certified Survey Maps on page 5497 as Document No. 867938, St. Croix County, Wisconsin. 022-1006-80-155 and 022.1006-80-150 Said deed is given to confirm the conveyance between the parties and to correct the fact Parcel Identification Number (PIN) that the original conveyance dated October 25, 2010, recorded October 28, 2010 at 12:36 This Is not homestead ro c p.m. as Document Number 925623 was by Quit Claim Deed and should have been b p p Warranty Deed. R (SO• by (is) (is not) Exceptions to warranties: easements, restrictions, and rights of way of record, if any. Dated C~•~'~~~aY P~Uy - -(SEAL) _ s O B~ (JL_ * Cher Yang 4 (SEAL) A M. * * Tria Lor _ ♦ ZIMMERM4N s AUTHENTICATION ACKNOWLEDGMENT STATE OF > ACKNOWLEDGMENT Signature(s) I F C~ OF WIS ) ss. '~►~`~`1' authenticated on Cf-o COUNTY ) - Personally came before me on * the above-natned Cher Yana, and TITLE: MEMBER STATE BAR OF WISCONSIN Tria Lor (If not, to me known to be the person(s) who executed the foregoing authorized by Wis. Stat. § 706.06) instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: Maxfield E. Neuhaus - Attorney at law Notary Public. State o~~ t;.1; 5 ~r.Si-. River Falls, WI 54022-0138 My commission (is permanent) (expires: I -,n- -Ing ) (Signatures may he authenticated ur acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATION TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED 01003 STATE OAR OF WISCONSIN FORM NO. 2-2003 *Typc name below signatures. INFO•PRO "'www, itfofxobrms.com 1 of 2 1 Dated: OS/ V%©/z , 2012. Toua Lor aWa Lor Toua ACKNOWLEDGMENT STATE OF Al S & COUNTY OF SS ors Personally came before me this day of -jet Y _`.~2012, the above named Toua Lor wWa Lor Toua to me known to be the person who executed the foregoing instrument and acknowledged the same. SHANDON WALKER Notary PublIC - Notary Seal State of Missouri, Jasper County my commission Expires April 20, 2015 Notary Public _ commission # 11175641 State of /~I~aS~wr My Commission Expires 20 2 of 2 I Y RECEIVED Wisconsin Department df Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Bbildings S E P 0 ~n ;,WAance Comm 85, Wis. Adm. Code du~ co ROIX Attach complete site n on ` t 12 x 1 inches in size. Plan must include, but not limibuto rerkd W0" point (BM), direction and Parcel I.D. 022 - 1006 - 80 - 155 percent slope, scale or rmensions, nor - arrow, a lion and distance to nearest road. tf S Please print all information. v' c Personal information you provide maybe used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location SUSAN MOUA xkp Y*1J, Govt. Lot NE 1/4 SE 1/4 S 3 T 28 N R 18 E( ) W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 1291 C.T.H. N 8 CSM 23-5497 022-2008 City State Zip Code Phone Number vdage ■ own Nearest Road Roberts, W1 54023 ( ) C.T.H. N E] New Constriction UseEj Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD D Replacement Public or commercial - Describe: Parent material glacial till Flood Plain elevation if applicable NA ft. General comments Conventional In-ground trenches - 0.4 1oadinrate pump (/h S~ and recommendations: 0 ^ So'C.~ l,,Y g Z, Property Address: 1287 C.T.H. N fri Ls Boring # El Boring 0 Pit Ground surface elev. 93.08 ft. Depth to limiting factor 55 in. Sol d Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *EfF#1 •Eff#2 1 0-6 10YR2/2 - sil 2fabk&gr mvfr cw 3vf-m 0.6 0.8 2 6-12 10YR2/2 - sit 2f-mabk mfr cs 2vf-m 0.6 0.8 3 12-24 10YR314 - sil 2fabk mfr cs lvf-f 0.6 0.8 4 24-41 10YR3/6 - sil lfabk mfr cs 0. 0.6 5 41-55 7.5YR4/4 - sl lfmsbk mvfr aw 0.4 0.7 6 55-60 10YR812 - vfs Osg ml 0.5 1.0 2 Boring # El Boring 95.68 55 a El Pit Ground surface elev. ft. Depth to limiting factor in. Sol Application Rate Boundary Roots GPD/fP Horizon Depth Dominant Color Redox Description Texture Structure 7mds in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 -Eff#2 1 0-5 7.5YR3/3 is 2f-msbk cb 2vf-m 0.7 1.6 2 5-12 7,5YR3/3 - Is if--msbk cw lvf-m 0.7 1.6 3 12-27 10YR3/2 - 1 2fabk mvfr cw 1vf-m 0.6 0.8 4 27-50 10YR314 - sil 2fabk mfr as lvf-m 0.6 0.8 5 50-55 7.5YR4/4 - sl if-msbk mvfr ai 0.4 0.7 6 55-6 10YR8/2 c2d 10YR" VIES Osg ml 0.5 1.0 ,~S Effluent #1 = BOD > 30:5 220 mg/L and TSS >30 < 150 mg/L • Effluent 02 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) CST Number Mary Jo Hu ert ollister's Soil Testing & Deli ! [ / 224832 Address Date Evalua' ucted Telephone Number W9875 690th Avenue, River Falls, WI 54022 08-23-11 (715) 426 - 1775 Property Owner MOUA, Susan YAD '#W&- parcel iD# 022-1006-80-155 page 2 of 3 31 Boring Boring # Spit Ground surface elev. 96.38 ft. Depth to limiting factor 50 in. Sofl Application Rate Horizon Depth Dominant Color Redox Description Texture Stnxture Consistence Boundary Roots GPD1fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eft#1 •Eff#2 1 0-6 10YR312 sl 2f-msbk mvfr Cw 2vf-m 0.6 1.0 2 6-24 10YR3/2 VI~tQ sl If--msbk mvfr cs lvf-f 0.4 0.7 3 24-43 10YR3/6 rr sil 2fabk mfr as lvf-f 0.6 0.8 4 43-50 10YR6/3 fs Osg ml as lvf-f 0. 5 50-54 10YR613 fld 10YR4/6 vfs Osg ml 0.5 1.0 ❑ Boring # HBoring Pit Ground surface elev. ft. Depth to limiting factor in. SoN Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDtfF in. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. •Efr#1 •Efr#2 F-1 Boring # Ed Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/fF in. Munsei Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 Effluent #1 = BOD6 > 30 < 220 mg& and TSS >30:< 150 rng/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. saD-8333ameet (x.mroo) Plot Plan for Site and Soil Evaluation Page 3 of 3 Property Owner ga(A. 5R-c*AI LXAO yttnt~ 140ft Legal description Csn~ a3 ©zz - acce; (except where noted) "r g Ne Vy or- yri 5e /4..s~c. 4, rzgng, rzmJ 0 = Backhoe pit -row d - North APE r pa~~ss - + rZS 7 c. rtf. F IV JAJ Utz-~Qdb•-YU -j55 x 3 as a ~ a A u 4 G ~ J Ale, QL Q Q `PPRQ7c S`7J IL C D Pc$pV~G'!~D p1L1_ ~ S~N`t~ lOQOO~~'~NCE -l~iE y ~l.at.3$gf"~` ti " •r sbu-ct4 Pit- 'Col. ~L NEIGH goKlA1G L~~v~wt~Y Site Locadotc: 1 mac. ~ Parcel 022-1006-80-155 09/09/2011 08:17 AM PAGE 1 OF 1 Alt. Parcel 03.28.18.45D 022 - TOWN OF KINNICKINNIC Current ❑X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 01/29/2008 00 0 Tax Address: Owner(s): 0 = Current Owner, C = Current Co-Owner 0 - MOUA, SUSAN SUSAN MOUA C - YANG, XAO XAO YANG 1291 CTY RD N ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 1287 CTY RD N SC 4893 SCH DIST RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 3.354 Plat: 5497-CSM 23-5497 022-2008 SEC 3 T28N R18W NE SE BEING FKA LOT 3 Block/Condo Bldg: LOT 08 CSM 15/4117 EXC TO HWY DEPT 1903/130 FKA OL 1 CSM 18-4691 --NKA-- LOT 8 CSM Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) 23-5497 03-28N-18W NE SE Notes: Parcel History: Date Doc # Vol/Page Type 10/28/2010 925623 QC 07/30/2009 901106 QC 01/29/2008 867938 23/5497 CSM 01/28/2004 752811 18/4691 CSM more... 2011 SUMMARY Bill Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 05/14/2009 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 3.354 500 0 500 NO Totals for 2011: General Property 3.354 500 0 500 Woodland 0.000 0 0 Totals for 2010: General Property 3.354 500 0 500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 I Illilllllll'"" 41111IIII8 1111 IIII111l11f~1 8+67938 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., NCI RECEIVED FOR RECORD 01/29/2008 11:35AM CERTIFIED SURVEY MAP CERTIFIED SURVEY MAP VOL: 23 PAGE: 5497 REC FEE: 13.00 Cher Yang etal PAGES: 2 Located in the Northeast 1/4 of the Southeast '/a of Section 3, T 28 N, R 18 W, Town of Kinnickinnic, St. Croix County, Wisconsin, being Outiot 1 of that Certified Survey Map recorded in Volume 18 of RECEIVED St. Croix County Certified Survey Maps, Page 4691 VAR,F ~:.~~c~;ualrvr EAST QUARTER CORNER OT ' SECTION 3, T 28 N, R 18 W OWNERS' ADDRESS (Fo d Bentsen Aluminum Monument) CERTIFIED SURVEY MAP io99 C.T.H. "N" VOLUME 9, PAGE 2670 , ROBERTS, WI. 54023 _ N 87°o4 3$ E 4os.17' 66.oo'WIDEJOE DRIVEWAYEASkWENT 0 33' g' rw~ta~ "L/q ~~s c .OR ~t °c~ 3.212 ACRES IN 28°5548 20 OR 66 v1 00 W M a' 139,918 SQ. FT. * bg3. - - \ ~ `0 ~ao3 W. °I g \G gb5° $65 66~ o 33' 400 T lh>~ ~L \r 1 3.354 c 5 50' w \0 OR ° g w- \~A A 146,101SQ.F. \ \ 3.212 ACRES < o I g sT OR oo j y I cPo stn 1 9.918 SQ. Fr. R 7 .18 SI EXCL. R/W) ~8?~ ~ o „ W '50 .43 T ~ • -w 16149 348 G S'76 ~v1 LOT 5 ~1s~olvsl~ \'p G LOT 6 sgb ~ 111. 1 wvlt>rrr • SOUTHEAST CORNER M~ 3. SECTION 3, T 28 N, R 18 W * • -713 yt \a,\y (Foand Bentsen Aluminum Monument) 0 1-414x>D - May 1, 2007 W E LEGEND $ _ 0 Indicates i"O.D. x 18" Iron Pipe Set Scale in Feet 1 200 (Min. Wt. -1.13 lbs./lin. ft.) ' • Found i" Iron Pipe 200 100 0 200 Bearings are referenced to the East line 0 Section Corner Monument of the SE 114 of Semen 3, assumed (as noted) bearing S oo°2656"E. wA A& Indicates Soil Boring 1 This Instrument Drafted by Mark W. Peavey SHEET 1 OF 2 1 of 2 Vol. 23 Page 5497 A FF -7 Z55 63 3- 1. APR 2 6 ? r. Cr.• i I f;:3 VOL 18 PAGE 4691 KATHLEM H_ WALSH REGISTER OF DEEDS ST. CROIX CO., MI RECEIVED FOR RECORD 01 / 28/ 2904 09: 00AR - " • &CERTFEIFIED SURVEY riAP E. 13.00 FEE: CERTIFIED SURVEY MAP PAGES: 2 3.90 Cher Yang, Lor Toua and Tria Lor Located in part of the Northeast % of the Southeast Y4 of Section 3, Township 28 North, Range 18 West, Town of Kinnickinnic, St. Croix County, Wisconsin, being apart of Lot 3 of that Certified Survey Map recorded in Volume 15, Page 4117 of St. Croix County Certified Survey Maps. N NOTE BEARINGS ARE REFERENCED OWNERS' ADDRESS AN EROSION CONTROL PLAN WILL TO THE EAST UNE OF THE BE REQUIRED BY THE ST. CROIX. SOUTHEAST 114 OF SECTION A 1099 C.T.H. N' COUNTY ZONING OFFICE PRIOR TO T 28 N, R 18 W, ASSUMED AS ROBERTS, W( 54023 CONSTRUCTION ON THESE LOTS. S 00.2656" E _ EAST 114 CORNER SEC77ON 3, T 28 N, R 18 W SCALE W FEET 1.-200' CQ (FOUND COUNTY BERNTSEN ALUMINUM MONUMENT) 100 o too °SURVEY MAP_ i ' I . ~'y!fr ' CERTIFIED 1 1-2 N l~1~ P_L4~E¢_7_O_ GRAD=621.81' ` N 67°04'32' E 402.1T w n CA= 34°47'43" NORTH UNE LOT 3 10p \q~ a L= 377.62' CH= 371.84' % CB= S 31'2103.5" E ~ ~i S ~ (R= S 30'1(r09" V1t) TAN 9 1= S ~I 2 "d OVTLOT I ` \2~ W 1 TAN 2= S ~'5T12" E CONTAINS 286, 019 SQ. FT. z I jA ~ -Z OR 6566 AC. y o (279,836 SQ. FT. OR 6424 AC N 89°3304' E * Q r~ w EXC. ROAD RIGHT OF WAY) L yr to z f lR=see°tsrot•~ FO ~Op 8 y (OUTLOT 1 WILL BE USED z S~ p. AGRICULTURAL PURPOSESR liL ~t ~ OR AS GREEN SPACE} O{ $ 50, ? Q; N 952'46" E L91-3 167.70' 111.03' $ 3 NORTH UNE "b1- cstlg?I V - N as 45'27" E _ ' 1 NO ADDITIONAL LOT 3 Tjf-j F E sAa.AS 75.18' - f It Z. PLATTED LOTS ~~R Ny615Ag ._.•~~'~"M _ MAY TAKE ACCESS ~,~r/~`7 I ' 1++ I •Y~ w THE 66'WIDEGPORTION LOT 5 N7~1B4g 11 a~N 86 10127 - E ire I U OF LOT5 UNLESS 3 CONTAINS 176,624 SQ. FT OR 4. ALL STRUCTURES o (174,261 SQ. FT. oR4.o00AC. CONFIRM TO E(C. ROAD RIGHT OF WAY) P--` 1 w I + " APPUCABLE SETBACKS LOT 6 AND COUNTY ROAD 2 S A ~0 A~ Z STANDARDS o ARE Z w )IQ~° ACHIEVED.' it U3 r N V n ^431.02 - m I~ $ 39563' 35.39 SOUTH UNE LOT 3 366.31' Z 50 150 1 NOTE- S OT 6 CONTAINS 111,432 66'45.27" W 797.33 i m I SQ. FT. OR 2558 AC. I_QT 4 (101,400 SQ. FT OR CERTIFIED -S.URVeY MAP 2328AC. EXCLUDING YQLzUME 15. PAUE-411Z_ ROAD RIGHT OF WAY) LEGEND INDICATES 1-114' 0.0. x 18' IRON O PIPE SET (MIN. WT. - 1.13 LB.&F.) `gGONS~~ SOUTHEAST CORNER ' yJ _ SEC77ON 3, T 28 N, R 18 W • INDICATES 1' IRON PIPE FOUND (FOUNDCOUNTYBERNTSEN ENC ALUMINUM MONUMENT) a SOIL BORINGS (PROPOSED SEP77C SYSTEM) LAMUURPENO >R 0 SECTION CORNER MONUMENT (AS NOTED) IAI 1713 EL~ENVILLE, • -x-- INDICATES FENCEUNE C p; WL O (R RECORDED AS DATED. 1 ■ PROPOSED DRIVEWAYLOCATlON F4~o ENO NOVEMBER 11, 2003 REVISED: _ DECEMBER 22, 2003 THIS INSTRUMENT DRAFTED BY JERALD L CARSON SHEET 1 OF 2 PC Vol 18 Page 4691