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030-1026-40-200
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 552371 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: Nagel, Steven & Kat St. Joseph, Town of 030-1026-40-200 CST BM Elev: InspBM Elev: BM Description: Section/Town/Range/Map No: ~a 06.29.19.104E20 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER RIMS CAPACITY STATION BS HI FS ELEV. Septic Benchmark ' V 100. Dosing Alt. BM z(Q f old 7;11~_ ss5 9s: rr Aerutron Bldg. Sewer Holding St/Ht Inlet / TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD DH"Iet 4-11 Z Septic Dosing ' SD! / / - Header/Man. 60 3l~ ~S rl.y3 ~'9. z3 Aeration Dist. Pipe - ~1. (p $ a(o Holding Bot. System b~ PUMP/SIPHON INFORMATION Final Grade 7, g5 / 53 / Manufacturer Demand St Cover// 2(o k w GPM I8 CdJt~_ Z7_ ~T- Model Num~ier v. Li 6o4- A)ej S. iz ~Z . 5~ TDH Lift Friction Loss System Head TDH Ft _ ~ 0~~- ac~ 91.5 j/ Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width i Length, / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System:II / / : (F Co u~,,,x r S~ 5'~- 2 b UNIT Model Number. J- 50'x, DISTRIBUTION SYSTEM ;Aes /S+/Sf/5~ /Z~- 57v1a HeaderMlanifold~ Distribution \ x Hole Size x Hole Spacing Vent to Air ntake Length Dia _ Pipe( ngth N,., Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mu shed Bed/Trench Center Bed[Trench Edges Topsoil Yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1138 37th Street Hudson, WI 54016 (NW 1/4 SE 1/4 6 T29N R19W) NA Lot 4 Parcel No: 06.29.19.104E20 1.) Alt BM Description = EZ Ga e a Z(o' 2.) Bldg sewer length = f ` / ; ^ S I ~ n / \ 1 e~ I - amount of cover - Plan revision Required? ❑ Yes No Z I Z 1 Use other side for additional information. f SBD-6710 (R.3/97) Date Insep ors Si ture Cert. No. commerce.wi.gov - k ely and Buildings Division County V . Washington Ave., P.O. Box 7162 f W, s V o n s ?dlsoo, W l 53707- 7162 Sanitary Permit Number (to he filled in by Co.) .514 tiepartmern of Commerc J 2 State Transactim Number Sanitary Permit APPlira o ht accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission ml'lfiis f m to they riate gnvcmmental unit is required prior it) obtaining a sanitary permit Note: Aphlicati nrr»s tot t d POWTS are Project Addres. (if different than mailing address) submitted to the Department of Commerce. Personal infirrmmioil yot provide may f econtlary Purposes in accordance with the Privacy Law, s. 15.04 I (nt , Slats. « .0 y a4-1--~ I. Application Information - Please Print All Information _ ^JI: jR Property Owner's Name Parcel # T„ Nib h16 :fa) Property Ow 39 37 Q ner's Mailing Address Property Location `D ^ b _ i~-I (;ovt. Lot City. State Zip Code Phone Number I I a° Section / v'r.`~L')/(J S1v!~._~I']'U~ TN: R1 circlFoonW) It. Type of Building (check all that apply) Lot # I or 2 Family Dwelling Number of Bedrooms Subdivision Name Block # ❑ Public/Commercial Describe Use s City of !1 J U State Owned Dcscrilx Use CSM Number 7 Village of - - g P 2,30 -VT"-- of ~_Jn h Ill. Type of Permit. (Check only one box on line A. Complete line R it ap licable) A. ❑ New System eplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) Q - List Previous Permit Number and Date q1sued Permit Renewal U Permit Revision C'hange of PlumbePermit Trailsler to New Before Expiration Owner L.JZJ~ t/I! 1V. Type of POWTS System/Component/Device: (Check all that apply) , - Won-Pressurized In-Gerund U Pressurized In-Ground U At-Grade ❑ Mound ? 24 Ili. ofstntable soil U Mound'" 24 in. ofsuitable soil U Holding-rank U Other Dispersal Component (explain) _ - ❑ Pretreatment Device (explain) A.. _ - _ -3 'deq V. Dis ersaVTreatment Aren lafonnation: T S - ' OAC /7 y C-1 /V 10 _ azt/ Design Flow (gpd) Design Soil Applic ion Rate(gpdsl) Dispersal Area Required (st) Disnersal A4 n--Po ed (sl) System evasion V1. Tank Info Capacity, in tonal N Of, Manutdcturcr Gallons Gallons Units NetvTanks Existing Tanks ~t c u u " y o u v ~ ~o a U in rn iz. U 4. Scptic or Holding Tank rinsing Chandler V V UY VI 1. Responsibility, tatement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Prim) Pl S Signal - MP/MPRS Number Business Phone Number Plumber's Address (Street, City, State, ZipCo0e) &IJ Vfll. nnl fUe>'artrne t Use Unly Apprmcd ❑ Disapproved Permit Fee Date Issued , Issuing Agent natur C1 Owner Given Reason for Denial VJ/ ~~~iy1~La IX. Conditions of A rr va1/Reasmts for DisapprovalS ~t!t!t" SYSTEM OVG~1EoR: Gt,L~cli 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained ~ J k1alo dt~12~ 4&V-ZGo as per management plan provided by plumber. 2, .ill setback requirements must be maintained as per applic0teyt0d 11 AG09he slstern and sobmit to the County only on paper not less tAan a V2 x I incbcs in site S13D-6398 (R 01 /07) Valid flint 01/09 \lk CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: i Owner's Address: St Legal Description: - Township: County: Subdivision Name: Lot Number: r~[ Parcel 10 Number: 3G .l Uri~~ l~ -l Page 1 Index and title Page 2 Plot Plan Page 3 S X stem Sizin , & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page Warranty Deed Page 9 CSVI or Plat Attachments: Soil Test & House Plans Designer/Plumber. ' l, h~Csi Date: License Number. ~ C Phone Number Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01). Page 1 I 0#0 M4 y I~PMGI, Mbn)C. (~Mn~e~ S'ib~t„5 A~1)Vf Elec. ~►NP E~OV=~~~~ ~WP l~ ~ M) I ISM N Vplve G4R°~ 3 Q P ~ ~ Mpu ~TnNk 3xs~ (v Jv i Soil Absorption System Cross Section `~yl d ft 4 oft 4" schedule 40 Final Grade PVC Vent Pipe 89 With Vent Cap , Leaching Chamber ~_ft System Elevation 3 _ f 3' Soil Absorption System Plan View _ft { I - - {t Leaching Trench 1 Chambers 4' Dia. Trench 2 Header " Vent Or Observation Pipe r?nch 3 Leach'ina Chamber Specifications - Manufacturer And Model -1 it V,~-( EISA Rating . c o sa ft per chamber Soil Application Rate • gpd/sa ft _~.C ~_S V gpd Design Flow • Soil Application Rate _ EISA J = Chambers 3 rows of (7 _ chambers each. Page of _ PL-525 Effluent Filter - Effluent Filters-, Polylok Lic, Page 1 of 2 s zte', titre A- I Polylok inc. 3 Fairfield Blvd, Wallingford. CT 06482 Call Toll Free: $88-765-9565 Email: palylok,com You are Here: 1lOrrte > Product Details 'lt' EFFLUENT FILTER Raising the bar in filter technolo - - - .r'uJ 'a'couNfia'Pia PL-525 Effluent F ilter ;i4 k5!11ti71w ~anp~rMnensoamm~dn ni~ne~vlu'l~mdlvmEb! Description Effluent Filters !s Polylok, Inc Is pleased to add its new commercial filter to its existing line of quality effluent Extend & LokTm filters. The PL-525 is rated for over 10,000 GPO (Gallons Per Day) making it one of the largest commercial filters in its class. It has 525 linear feet of 1/16" filtration slots. Like the Risers & Riser Covers Polylok PL-122, the new Polylok PL-525 has an automatic shut off ball installed with every filter, When the filter is removed for cleaning, the ball will float up and temporarily shut off i Distribution Boxes anS the system so the effluent won't leave the tank. No other filter on the market can make that 1 Accessories Vil claim. Pumps, Basins, Plump I and Step Systems r: Ordering Information Request a Quote 1 Related Products _ _ . :7. • ;:r w. ;...Seals 1 Gaskets Features ! Baffies, Sanitary Tees ~ Deflectors • Rated for 10,000 GPD (Gallons Per bay) + 526 linear feet of 1/16" filtration j Rebar Spacers Enlarge for details a Accepts 4" and 6" SCHD, 40 pipe + Built in Bas Deflector Handles and ReceivOn • Automatic shut-off ball when filter is removed • Alarm accessibility { Signs + Accepts PVC extension handle I Landscape I Drainage The PL-525 Effluent Filter should operate efficiently for several years under normal Forms & Clamps conditions before requiring cleaning. It is recommended that the filter be cleaned every I .•.....T s , •...~...ps time the tan% is pumped or at least every three years. If the installed filter contains an 1 Butyl Sealants optional alarm, the owner will be notified by an alarm when the filter, needs servicing, Servicing should be done by a certified septic tank pumper or installer. Concrete Accessories Maintenance Instructions: , Pressure Flit are Odor Crontrol Product 1. Locate the outlet of the septic tank. 2, Remove tank cover and pump tank if necessary. 1 Rebar-Lok and CMU 3, Do not use plumbing when filter is removed, ! Accessories 4• Pull PL-525 out of the housing. 5. Hose off filter over the septic tank. Make sure all solids fall back into septic tank. ~MRebar Safety and ID C. 6: Insert the filter cartridge back into the housing making sure the filter is properly " aligned any{ completely inserted. Decorative Landscape 7. }replace septic tank cover. PL-525 Installation: Ideal for residential and commercial waste flows up to 10,000 Gallons Per Day (GPD). Technical Speci;ficatiol Installation Instructions. Related PtPdUG 1. Locate the outset of the septic tank. i Pump, Filter and Bun i 24" x 12" Riser 2. Remove tank cover and pump tank if necessary, Filter Alarm Panel an 3. Glue the filter housing to the 4" or 6" outlet pipe, If the filter is not centered under SmartFilterTM Control the access opening use a Polylok Extend & LokT11 or piece of pipe to Center filter. f 4. Insert the PL-525 filter Into its housing. h ttn' ~~~ulx'tx t d n1r r 9 9 0 E'° N W N l l' 6 00Z itu~tr ri,~tsaila sacrt~l~t•nrlrte~t fTl='i ti l a uut, ia. 2010 9:12AM No-3066 P. 2 r Q ~ ~ C ~ ca r U7 ~mO-P X z m > OA R' t' m ca I~R Z co : °wx0 cn csa Ci a n CO cn Ilia 0 o ~ oa ~ F 3 rn _ :a. L ODcr, N IV b CTI .4..~ n T114? ~N Cj N n + W Cil O NY ~ II I uct, 14. 2010 9 12AM No, 3066 P, 3 rp~ cr) CO. CZ- C-rl C- r 90 C-A r m m0 c M, ~ lCl) J t c.~ ca ° p 0 a a o III oil ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address Property Address 83 9 7 ' (Verification required from Planning & Zoning Department for new construction.) City/State 1'Y Gr (L` 5~~ Parcel Identification Number LEGAL DESCRIPTION Property Location'/a ,'/o ,Sec., T cJ N RAW, Town of Subdivision 's IV Vol U r 3 , Lot # . Certified Survey Map # , Volume , Page # A 380 Warranty Deed # 7D ~ZJ Volume 2- Page # -31-7 Spec house yes no' Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read v nts and agree to maintain the private sewage disposal "stem with the standards set forth, herein, as set by the ce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has ed must be completed and returned to the St. Croix County Planning & Zoning'Departmmt within 30 days of the three don date. Uwe certify that all statements on this.., o ;true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warn dea rCOorded in Register of Deeds Office. Number of bedrooms - SIGN OF APPLICANT(S) DATE ***Any information that is misrepresented may ro"U in ft sanitary permit being revoked by the Planning & .Zoning Department. Include with this application a recorded warranty'dp~d 4om the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) Nov-11-2010 10 45 AM St. Crolx County Plan/Zoning 715-386.4686 1/2 PO1/WTS O WNER'$ MANUAL, & MANAGEMENT PLAN Pegs - or FILE INFORMATION SYSTEM SPECIFICATIONS Owner, I Sept)o Tank Capacity a ko lral° 0 NA Permit # Septic Tank Manufacturer i ~ S11 f x ~ Wit ri 0 NA DEStON PARAMETERS Effluent Filter Manufacturer ~ol L~1~ 0 NA Number of Bedrooms ® NA Effluent Filter Model L' S~ S M NA Number of Public Facility Unite 121"~A Pump Tank Capacity al NA Estimated flow (average) 3106 gal/day Pump Tank Manufacturer NA Design flow (peak), (Estimated x 1 5) S V al/da Pump Manufacturer NA Soil Application Rate sudsy/ftz Pump Model NA Standard influent/Effluent auailty Mont iy average"' Pretreatment Unit NA Fats, Oil & Grosse (FOG) 00 mg/L 0 Sand/Gravel Filter 0 Peat Filter Biochemical Oxygen Demand (BODE) X220 mg/l. 0 NA 0 Mechanical Aeration 0 Watland Total Suspended Solids (TSS) 5150 mg/L lO Disinfection ❑ Other. Pretreated Effluent Quality Monthly average Dispersal Cell(s) lO NA Biochemical Oxygen Demand (BOD51 2930 mg/l [N In-Qraund (gravity) A In-Ground (pressurized) Total Suspended Solids (TSS) 530 mall, 0 NA 0 At-Grade 0 Mound Fecal Coliform (geometric mean) 29104 cfu/100ml 0 Drip-Line C] Other. Maximum Effluent Particle Size Ya in dia, Q NA Other: ❑ NA Cher: 13 NA Dther: M NA "Values typloal far domestic wastewater and septic tank affluent. Other: 0 NA MAINTENANCE SCHEDULE Service Event Service Frequency A k'honth(si Inspect condition of tank(s) At least once every. i ear(s) (Me>arnum 3 years) q NA Pump out contents of tank(s) When combined sludge and scum equals onaathird t3/a) of tank volume 0 NA Inspect dispersal call(s) At least once every: month(s) (M ftum 3 years) C3 NA 0 ear s Clean effluent filter At least once every: t r I 0 month (s) p NA 13 ears) Inspect pump, pump controls & alarm At least once every: 0 m nTr (s) NA Flush laterals and pressure test At least once every, © oakls Is) NA Othar: At least once every: Q month (81 NA Other., INA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal calla shall be wads by an Individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator, Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and soum and to check for any back up or ponding of effluent on the ground surface, The dispersal oell(al shall be visually Inspected to check the effluent levels In the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent an the ground surface may indloate 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 (YO) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordenco with chapter NR 113, Wiaconsin Administrative Cede. All other services, Including but not I "reed rn rho servlcIng of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing a intarvals of 2912 mont s, s II 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, QMW (4/01) Nov-11-2010 10:45 AM St. Croix County Plan/Zoning 715.386-4686 2/z START UP AND OPERATION Page of For new construction, prior to use of the POWT& check treatment tank(s) for the presence of pointing 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 prlor to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large does, 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 sell 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 wraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine, ABANDONMENT When the POWTS falls and/or is permanently taken out of servioe 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 disconnseted and the abandoned pipe openings sealed. • 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 falls and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: 1 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 POWTS 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 alto 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 blomat 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 ANDIOR INSUFFICIENT OXYGEN. DO NOT IINTER 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 MAINTAINgN Name l e, Name Phone 1 _ U Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUT ORITY Name ~An)tie~~ Name INJW Phone l s °y S jb)S Phone r) L -All This document was drafted In acmpliance with chapter' Comm 83,22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (E), Wisconsin Administrative Code. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certif that I have inspected the septic tank the presently servin Sec.- residence located at: T- _J" ~ N, R_ W, Town of ~i County, Wisconsin. S<~ Ah Upon inspection, I certify St• croi: baffles to be in that I have found the tank anc good condition, and it: appears to be functioning properly. Last time serviced o~ Did flow back occur from absorption system? Yes line. NoA_ (if no Approximate volume or , skip next ,Capacity: 1 (,11U th of time gallons minutes Construction: Prefa ' Concrete Manufacturer (if known): Steel Other Age of Tank (if known) : e Sc K ~s (Sign ure)L J I M Ou {.P (Name) Please Print (Tit 1 e ) - --Lice nse Number) (Date ) 't o+~ Form to be completed by licensed plumber licensed disposer (NR 113 Wisconsin Administrative6C Wisconsin Statutes) or ode) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) C ' ertification: In accepting the above statement regarding existin septic tank condition, .1 certify that the tank g requirements of IL 83 to the best of my knowled e outlet baffle). Wis., Adm. Code (g will conform to the except far inspection opening over Name 1 by Signature MP,/MPRS 2280 O page 1 of 3 SOIL EV1~ REPORT A.C.E. Soil & Site Evaluations o t of Comm 85 WjS A Wisiscc n of S e y and Bml accordance with Comm di~ G~ st County St. Croix bite la han S'/2 x 11 inches in size. Plan must Parcel I.D. ach com{> P . orizontal reference point (BM), direction and 0 -1026-40-200 y in de, but not lirri Pe nt Sloped . ~ ns, north arrow, and location and distance to nearest road. Date Reviewed I ease print all information. on you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Pe Property Location NW 1/4 SE 1/4 S 6 T 29 N R 19 Property Owner Govt. Lot Steve & Katy Nagel Lot # Block # Subd. Name Cor CSM# SAVol. 8, pg. 2380 Property Owner's Mailing Address 4 City _j Village ✓J Town Nearest Road 1138 37th Street City State Zip Code Phone Number J St.Joseph 37Th Street WI 54016 715-386-7345 GPD Hudson 450 3 Code derived design flow rate Use: _url Residential / Number of bedrooms New Construction Public or commercial -Describe: na Replacement o pal on, if applicable Parent material Glacial Till ' pA yv-4 S te. Recommended General comments d/s4ft./day loading and recommendations: Site suitable for conventional POWTS dispersal cell ith 0 .4 gp j o 4 trenches at recommended elevation of 8 >1 18" in. Soil Application Rate Boring # Boring Ground Surface elev. 93.40 ft. Depth to limiting factor GPDIft2 _yJ Pit Consistence Boundary Roots E 1 Texture Structure . Horizon Depth Dominant Color Redox Description Gr. Sz. Sh 0 Munsell Qu. Sz. Cont. Color mvfr as 2fmc .6 0.8 in. 1 0_6 10yr3/2 none sil 2fgr 2fmc 0.6 2 0.8 2fsbk mvfr cw 6-11 10yr3/3 none none sit sicl 2msbk c" 2f,1mc 0.4 0.6 mfr 0 7 3 11-17 1Oyr4/4 2f,1m 0.4 sl 1 msbk mvfr 4 17-36 7.5yr4/6 none 1 csbkl0sg mvfr 91 1 0.4 0.7 36-65 7.5yr4/6 none / sl/Is 0 7 5 mvfr - - 0.4 Y none Is/sl 0sg/1 csbk oading rate reflects most restri bit found Is. g 65-118 10yr4/6 ~J1 hi h sand content and is. L ctiv orizons #5 & 6 contain an unsorted mix flight sl with a ve Within these horizons. >1 16" in. Soil Application Rate Boring Boring # ~ Pit Ground Surface elev. 9_ 3.63 ft. Depth to limiting factor GPDIft' Consistence Boundary Roots *Eff#1 *Eff#2 Texture Structure Horizon Depth Muns Dominant ell Color Qu. Redox Sz. Cont. Description Color Gr. Sz. Sh. 2fmc 0 6 p'$ in. 1 0_6 10yr3/2 none sil 2fgr mvfr as 0.8 2 6-21 10yr3/4 none sll 2fsbk mvfr cw 2fmc 0.6 1fm 0.5 1.0 Ifs Osg ml cw 10yr4/6 none 3 21-31 4 31-73 10yr4/6 none s/Ifs Osg ml cw 1f 0.4 0. 0 10 r5/4 none trat. grs 1 csbk/Osg dl - - .7 1.6 5 73-116 Y 4" - 12" spacing. Loading rate reflects Horizons #4 contains an unsorted mix of s and Horizon also contains - bands of 7.5 4l6 yr Ifs at red d perm bitty associated with textural changes and banding. /L and TSS <_30 mg/L " Effluent #2:= BOD _30 mg CST Number Effluent #1 = BOD 5> 30 < 220 mg/L a TSS >30 < 1 mg/L 3602 Signatur . CST Name (Please Print) Telephone Number James K. Thompson Date Evaluation Conducted Teleph 8-7767 Address A.C.E. Soil & Site Evaluations 3/27/2012 340 Paulson Lake Lane, Osceola, WI 54020 < <vaiuauons 780325 U 2 6 9 8 P 3 9? KATHLEEN OF DEEDS ST. CROIR CO., VI STATE BAR OF WISCONSIN FORM 3- 2000 RECEIVED FOR RECORD QUIT CLAIM DEED 11/18/2004 12:30PM Document Number oUIT CLAIM DEED This Deed, made between Priscilla A. Zeller, EX9F # 3 a single person REC FEE: 11.00 TRANS FEE: Grantor, COPY FEE: and Steven F. Nagel and Katy J Cnnl_ey-Nagel, CC FEE: hrrshand and u1ifo PAGES: 1 Grantee. Grantor quit claims to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Part of the NW 1/4 of SE 1/4 of Section 6, Township RecordingAtea 29 North, Range 19 West, St. Croix County, Wisconsin, 141 and Return Add", described as follows: Steven H. Bruns, Esq. 50 E. 5th Street, Suite 300 Lot 4 of Certified Survey Map filed July 22, 1991 St. Paul, MN 55101 in Vol. "8", Page 2380, Doc. No. 471735. Together with all appurtenant rights, title and interests. 030-1026-40-200 Parcel Identification Number (PIN) **This Deed is given to extinguish any interest of This is homestead property. Priscilla A. Zeller created by the filing of Warranty (is) (is not) Deed Document No. 721106 containing an erroneous legal description** Dated this :2 ✓-A M-W day of October 2004 * * lla A. Zeller * * AUTHENTICATION ACKNOWLEDGMENT STATE OF ~ jRXINNES9TA Signature(s) ) ss lrb-*- County ) authenticated this day STEVEN H. BRUNS Personally came before me this day of October , 2004 the above named * iAypopahBiphaJUL31,2005 Priscilla A- Rpller- a single pArRon TITLE: MEMBER STATE BAR OF WISCONSIN to me known the person _ who executed the foregoing (If not, instrument know a he same. authorized by § 706.06, Wis. Slats.) j THIS INSTRUMENT WAS DRAFTED BY s Steven H. Bruns, Esq., ID No. 1008013 Nota~y Public, State of Wiscausi4- ^IA nGC 50 E. 5th Street, Suite 300, St. Paul 55101 My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ) *Names of persons signing in any capacity must be typed or printed below their signature. QUIT CLAIM DEED STATE BAR OF WISCONSIN FORM No. 3- 2000 AS BUILT SANITARY SYSTEM REPORT OWNER SQ //ar TOWNSHIP Sf. J.~s•~ SECTION( 9 N-R / ADDRESS Sex zQ Z ST. CROIX COUNTY, WISCONSIN SUBDIVISION_S/h. LOT LOT SIZE f L S ~fC PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 1 ~ aa'x s2 JI R yo • " /9L fd. I L; ~NX3Z\ e0 sz &•M T•r Sty. __.INDICATE NORTH ARROW BENCHMARK: Elevation and description: l 00 Alternate benchmark SEPTIC TANK:Manufacturer: W- <<!3 =-y- Liquid Cap. Rings used: _,_Manhole cover elev: sn Final grade elev: S o Tank inlet elev.:_~.,Ij( ---Tank outlet elev.: 704( No. of feet from nearest road:Front4_1 Side , Rear Ft.,L5/-d"' From nearest prop. line:Front , Side , Rear_,k_Ft. S No. of feet from: Well 42- Building: (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER • Manufacturer: Liquid Capacity Pump Model: Pump/Siphon Manufact.,: Pump Size Elevation of inlet: Bottom of tank elevation Pump on elev.: Pump off elev.: Gallons/cycle: Alarm: Man.: Switch Type: Location Distance from nearest prop. line: Front_, Side_, Rear_Ft. Distance from: Well Building SOIL ABSORPTION SYSTEM Bed: A;L~_Trench: Seepage Pit: Width:-Li-Length-Y~- Number of Lines:-,~-Area Built Z O Exist. Grade Elev. J,~.sd Proposed Final Grade Elev. S,V..r Fill depth to top of pipe: No. feet from nearest prop. line:Front , Side, Rear_)~,-Ft., _'5 _No. feet from building y3 / No. feet from well: HOLDING TANK Manufacturer:.////~ Capacity: No. of rings used: Elevation of bottom tank: Elevation of inlet: No. feet from nearest prop. line:Front Side Rear Ft. No. feet from: Well , building , nearest road Alarm Manufacturer: INSPECTOR: 10, DATE: PLUMBER ON JOB: LICENSE NUMBER~~ 6/90:cj Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: 'Labor and Human Relations INSPECTION REPORT St. Croix Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION NE SW Sec.6 37th St. Lot 4 149255 Permit Holder's Name: ❑ City ❑ Village 0 Town of: State Plan ID No.: Sam Miller St. Joseph CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 030-10264-200 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic es~ ,r p J Benchmark 104,76 t 6,125 40 1 60 ' osing G1(o. r O , o(v Aeration Bldg. Sewer r Holding St/~t Inlet 71V elf" TANK SETBACK INFORMATION StIX Outlet 7a/' TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Airlntake Septic >Sa/ ?5 3O~ NA Dt Bottom Dosing NA Header44M~- 9 sa, .6.5 Aeration NA Dist. Pipe 99' ' Holding Bot. System /3' PUMP/ SIPHON INFORMATION Final Grade sd /0/"z Man turer DemandS? ' 104 SOS 0~. del Number GPM TDH Lift Friction SVsteO TDH Ft oss H Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length, No. Of Trenches its Inside Dia. Liquid Depth DIMENSIONS `ld —DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION TypeO Q_c4f CHAMBER Mod umber: System:e OR UNIT DISTRIBUTION SYSTEM Header fh~arrifctitd-' Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake i Length _ Dia. Length z 7 Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Topsoil ❑ Yes C] No ❑ Yes ❑ No Bed /Trench Center Bed /Trench Edges (1) 1 COMMENTS: (Include code discrepancies, persons present, etc.) Plan revision required? ❑ Yes Ly'4o Use other side for additional information. o' 1431 SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. SANITARY PERMIT APPLICATION l ` In accord with ILHR 83.05, Wis. Adm. Code COUNTY/ _2 STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for compl ting this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE DINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION SQ ~i jAw F Y45 Gt( S T -2.1, N, R / y E (ort7 PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # z z y So Y CITY, STAT ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER Ala X500,% .r- &/v/ 31'4.Z-7 t, 47 L. 3-50" El ITY VILLAGE : NEARESTQAD II. TYPE OF BUILDING: (Check One) ❑ State Owned ❑ M : t .fos h 3 " ,54 r~ .L- ❑ Public M 1 or 2 Fam. Dwelling-# of bedrooms 3__ 'PARCEL TAX NUMBER ) 111. BUILDING USE: (If building type is public, check all that apply) / b 30- 10Z for z-00 1 ❑ Apt/Condo i 2 ❑ Assembly Hall 6 ❑ Medical Facility/Nursing Home 10 ❑ Outdoor P~---' - 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 4 ❑ Church/School 8 ❑ Mobile Home Park 5 ❑ Hotel/Motel 9 ❑ Office/Factory IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable)! A) 1. 9 New 2. ❑ Replacement 3.E] Replacement of 4.E] System System Tank Only B) ❑ A Sanitary Permit was previously issued. Permit - " V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimenta 11 Seepage Bed 21 ❑ Mound 30 ❑ Specit Q' U 12 Seepage Trench 22 ❑ In-Ground 13 ❑ Seepage Pit Pressure 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: C z 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5 -o,=M tt_EV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) train./inch) ELEVATION _!~O 210 . L ZS~ . G D P. 9 7• G D Feet 00.6 0 Feet VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name oncrete Con- Steel glass Plastic App Tanks Tanks structed Septic Tank or Holdin Tank C r &K I F1 Lift Pump Tank/Si hon Chamber. El I El El 1:1 VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumbe 's Signature: (No Stamps) MP/MPRSW No.: Business Phone Number: lumbe Address (Street, City, State, Zip Code): a.uJ k; S D IX. CO NTY/DEPARTMENT USE ONLY ❑ Disapproved S tary Permit Fee (Includes Groundwater Date Issued Issuing ent Sign re o Sta ps Approved ❑ Owner Given initial rcharge Fee) f{ .tom Adverse D rmin i n /-Q ~ 9 ' X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS , -1. A sanitary permit is valid for two (2) years. . 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. ill. Building use. If building type is Public, check all appropriate boxes that apply. lV Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate b:x depending on system type. VI. Absorption s/5-:tern llnforn aVon.. Provide all information requested in 41-7. V; 1 Nana er `jr +ati~;n F of every new and/or existing tank, list the total gallons, number of IF- ,arks and EsFasii frfi._ turer's name. Indicate prefab or site constructed and tank material. Complete for all septic, and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from OILHR. Vlfl Flesptnr,sO? ;lity ^ta*e!rent. Ins-Ninq plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc address ar,d ph(-me number. Plumber must sign application form. iX. County/Department Use Only. X. County/Department Use Only caiiur; ++ot smaller than 8'/ x 11 inches must be submitted to the county. The plot plan, drawn to scale or with complete dimensions, location of '+er treatment tanks; building sewers; wells; water mains/water service; tanks; distribution boxes; soil absorption systems; replacement system n g B) horizontal and vertical elevation reference 9 ) . points; C) complete rspecii+cai,o is s(:!r ^Orrps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-6398 (R.11/88) l S T C - 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner/contractor,(spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property Location of property_4[41/4 ,,Gr/1/4, Section !Q , T2~P N-R / Township a Mailing address _ z9Yi2g-Z__ o Gt/S / Address of site A /j, S Sea-,pTow" <.4 p subdivision name L',s 17). 1 - 7 Lot no. ~ . Other homes on property? yes --No Previous owner of property /w g. u fQ,/' Total size of parcel ZS e S Date parcel was created 2 Z /S57/ Are all corners and lot lines identifiable? - ,X Yes No Is this property being developed for (spec house)?A Yes No Volumeff) and Page Number c9Q 7 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 & THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available', ;would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified survey Map, the certified Survey Map shall also-be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No.+Z2 , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly r ecorded in the office of County Register of deeds as Document No.e Zg~na~ture of ~apffi~cant~~ Co-applicant ~2- Date of signature Date of Signature f DOCUMFrIT NO. ~I WARRANTY DEED TM4 !PACE xrscwvm iron mccoaoaMe DATA II ii STATE BAR OF WISCONSIN FORM 2 -IOU 472239 i t REGISTER'S OFFI(-' Edward R. Hauser and L-rol A. Hauser - aka..Carol . Augus a ST. t.'ROIX CO., W _ ( Ree'd for Record i~ con~c,s ;md tl.,rruuts to Sam F. Miller a single person ii I 2.35 P M I~ 11 rn uyn *o St: Croix the following descritxd real estate in _-.county, 1 - State of Wisconsin: Tax Parcel No: A parmel of lard located in the NW; of SIN of Section 6-29-19 describe'! as follows: Lots 2, 3 and 4 of Certified Survey Map filed July 22, 1991 in vol.. "8", Page 2380. Tovether with an easement for ingress and ep:riess over, ttie u6 foot access easement as shown on said Certified Survey Map. Maintenance of the Easterly 100 feet of said acce::s ea^~ ,.e nY, ::hail tip nr'otated equally between the owners of Lots 1 mid 4 of :,aid 1 :'.:'ve.v I. 3n, their heirs, successors and assigns. 'll)e ourlermof Lot 1 ,f ->Pcertified :>urvey Map, their heirs, successors and. assiprls, sttall be responsible exclu ively for ' re:rairsng pc.r*,ion of said access easem.rit. a2 3 io riot homeatrad I,n Lcrtt. (is) (is not) F:xcepliau to warranties: easF.rterit3, restrictions, gild I'iP}!LS-Or-NIi3" of t! 4tr 1 d:t). Auta:ct ~1 ~t of (SF:A1.) <sral.l :,:::~il1t i?. I:zucer i✓;!r~; A. i_ii_l:;t:r, (.SEAI.► tSF:Af r AUTHENTICATION ACKNOW LE DG NIENT iin:.turcls) _ STATI: OF Wl.s •ONSIN ' c~. auth •n Gcated this dac of... 19 1 1 r n u: came me t;".% da)of al U-: l ti- the at`ove name i rti1w:u I i'.. 1U t'I° calvi A. :,.au:?et' T1'f1.E \IF:MVi .*I: ~T\TE BAROF• WISCONSIN - ( If not. autLr,ri~ed by ;(N;.Ot% \1'ix. Slats.) Qp ' to me know-i t mho cNec,ittrl the f e uir i tt.r-- n nd.: a ti a salve. t SiQnaturr Lc :u+t hcntir;ltc,l a P"I l'nunty. \\m tn:n or arkiii,wh,tirt•.1. ILA11 \l~ l'„mmi siettf r :I rr not t-ces<arc,l Q f. nt.t, ctaty eyl•iratio.t date' I4 .~-)3 .1 a •Yalm.~ of yen .ur rKta nr m any 1'*, it, rhm!d I,e i, i-I of h. mt.d h.dow their riv- r- WARRANTY DEED RTATB BAR Of WIBCONSIN ~t'iwti.wsia t.atd R16e1L Cw,. f.- J This instrument drafted by Fran Bleskacek Proj. No. 90-38 UNP Q LAM > ---~-KI~ Bearings are referenced to the o t1 S000111121E rr east-west 1/4 line of Section 6, o H 396.00' LQ! iei~tMt „11 assumed to bear S89o52'22°W z 0 A- 0 7 M. ° CO CO IN YQL: LL > ° ~ w to oppQ Q NO CO o to C" r ° ° (S00°05'21"E) E ; I i I I O e' o S000111121 N = 247.50' v, o 1== C M y W CO 0 x O n'1 N t0 = .7 In N (t o NE} of the SW} Cn o w y ° y ■ G O r to N N° n O Fh A -1 y o NJ NW} of the SE} a = ~i ~ CD C ~ to ~ y o 14 I N ,o r• C rt M ,y I r-• r- 7 N • I.••. r• A CL z 7 n en Cr C4 C) i o'i 6--~ rt o ° O Sr. C] ° I ~ *--a N 1 CD CD. 0 PO 1-h 0. cn I rs v to rt C-) ❑ N = O Q C2 N K c VI fD Iz d ~ S00°11' 12"E -n tri rv to f ° d 198.00' rn ► • ' 0 sr H rn On;;~C • 105.00' as o I N O N M 341 MO C = eei p'rC t71 T I o. b e J >l u~ 0 6 f o+ 1 -3 ft w ICI z CO :ti 4? " rt a CO I e+ "O o f l- a r 100, 0. o ~N, O .y j I $ O N N S00007'2911W 541.06': iO ;I a 2 0 M S0000712911W 365.16' 296.12' ° 508.06' e° = it r• z y I N I y I?y `J. M CO 0 = N N tt I-1 • O N O Ln,Ln I _ Z \ O r+ _ Q 00 O I N r - - rt C6 ei7 ° m• D m O L" O y ; S00007'29"W 586.81' r- o CL m _ ° 0 553.81' Ic/) ' w ° E o r ss' r Joint 'Drive 33 33' _ tLI x o ? ? ` O ~ i + N w o F-J n I oo r _I o 8 I 306.221 -4 Xi/ 240.22' f C;0 568.28' ~ N _ f! IA. _ Oo07' 2911 E 874.50' O _ - c 305.93 W - 601.57' - _ > I r N00007'2911E 907.50' 0 RIH SIREEI East line of the NW} of the SE} I (SO002115511W) I ~ 6, Lai.Mi. IN YQL.L L. EQ~ 196 o CO 0 ° N O M&L 1960 , 0 I 7 7 APPROVED PP~~ 1 '7j77 LQ, CGLL ~ ~ z 19~f ~Es~aM, IN YQL, 5L U L SHEETS 1 OF 2 SHE SHEET S7. CI7OlX CUi~TY (-'Otv1P*HC.N:S1\ A PARKS PLA14NM. ` , CyI1tM"TTfF AN- w SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County n OWNER/BUYERr~~ o ROUTE/BOX NUMBER Fire Number_ - :1 ' oy d , ZBZ CITY/ STATE ZIP PROPERTY LO CATION:4[.F--k,S, k, Section to TAN, R1-0' Town of ,~,Lusorr St. Croix County, Subdivisions Lot number_ ,-4 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' 's'ept'ic tank pumper. What you put into the system can•a ect t e .unct on of zne septic tank as a treat- ment-stage in the waste disposal system. St. Croix Count residents'-may f be eligible t ofrecieve a failing grantefor a maximum of 60% of the cost pl sys, whi-c 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 'sys't'ems agree to keep their system properly maintained. The property owner agrees to. submit to St. Croix County Zoning a M certification form, signed by the owner and by a mater 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. y 0 I/WE, the undersigned have read the above requirements and agree 0 to maintain the private sewage disposal system in accordance with the standards set forth, herein, as.set by the Wisconsin Depart- 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. SIGNE e - ! S ~/l DATE 1'2- St. Croix County Zoning Office 911 4th St. Hudson, WI 54016. 386-4680 Sign, date and return to the above address. .DEPAhTMENT INDUSTRY, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS .INDUSTRY, DIVISION LABOR AND PERCOLATION TESTS (115) MADISOP.O. BOX N WI 53707 HUMAN`RELATIONS (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNSHIP/MUNICIPALITY: LOT NO.: BLK. NO.: SUBDIVISION NAME: NE ~4 SW 1/4 6 /T 29 N/R19)Lx(or) W St. se ph 4 n/a n/a COUNTY: OWNER'S @L%W$l33CNAME: MAILING ADDRESS: St. Croix Edward Hauser 1616 Pinewood Lane, Hudson, Wi. 54016 USE DATES OBSERVATIONS MADE NO.BEDRMS.: COMMERCIAL DESCRIPTION: (PROFILE DESCRIPTIONS: 1PERCOLATION TESTS: :PI CM 1 1 3 n/a New ❑Replace Il 7-16-91 n/a RATING: S= Site suitable for system U= Site unsuitable for system r ONVENTIONAL: MOUND: IN-GROUND-PRESSURE: SYSTEM-I ® N-FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) S ❑ U [,IS ❑ U ®S ❑ U ❑ S QU ❑ S ®U conventional If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: 6 Floodplain, indicate Floodplain elevation: n/a deciaml' PROFILE DESCRIPTIONS page 49 sTB BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH= ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 1 6.67 101.45 none >6.67 0-.50bl.1. .50-1.25bn.sil. 1.25-2.42bn.s.l. B 2.42-5.42bn.l.s. 5.42-6.67bn.s.l. 2 7.00 100.20 none >7.00 0-1.00bl.l. 1.00-1.75bn.sil. 1.75-2.75bn.s.l. B- 2.75-7.00bn.stratified l.s. &s.l. 3 7.17 101.10 none >7,17 0-•92bl.1. .921.92bn.sil. 1.92-2.92bn.s.l. B- 2.92-7.17bn.stratified c.s. & s.l. B_ 4 6.67 101.20 none >6.67 0-.67bl.1. .67-1.59bn.sil. 1.59-3.42bn.s.1 B-5 7.09 100.60 none >7.09 0-.67bl.1. .67-1.34bn.sil. 1.34-7.09 bn.s.l. FB- TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD II PERIOD 2 PERIOD3 PER INCH P- P- P-see design rate P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 97.60 F f~ .t I 25'z _.0 3 f - - E F E , T 011 hAp _ r r ~ trr QQ~ ~ c~ _ m T }'}~i Ca C l I, the undersigned, hereby certify that the so t~?6 Q",ported on t ere made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded d t I f1~t s are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: Gary L. Steel 7-16-91 ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): 1554 200th. Ave., New Richmond, Wi. 54017 2298 5- 6-6200 CST ATAY: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DI LHR-SBD-6395 (R. 10/83) - OVER - r -TIONS FOR COMPLETING FORM 115 - SRO - 6395 To be a cr Irate sail test, your report must incaude: 1. Complete leaz 2. The use sectic clearly indi~ v 'his is a i ~sidence or commercial project; 3, MAXIM if «cial €ined; 4. Is this a r a, Compl:,, o~ E IS SL7- '~BLE FOR A HOLDING TANK ONLY I ALL OTHER 34. Lr i) CL ~ ~>ED ON SOIL CONDITIONS; 6. PLEASE r : ",own here for writing profile descriptions a-d completing the plot plan, 7. ltd :E _ ~3€ , tely locating your u,_ ' =r~ 'i to scaie is r~ -ferred. A 9, I al {aevata€€n referee€ce t - oven, wr < anent; 9, appsohr'< b"'a.'s o dates, names, addresses, flood pla n €ata, percolation Ft exenip- te; 10, rich as flood plain, elevatior€) does not apply, plac.° A, i°, the appropriate box; 11, :;ce your current address and you r certification nctr ~ 12. and distri 3ute as regniied, ALL SOIL TESTS 'J ST BE FILED ll~lTl-I THE ID.. :'[THIN 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL. TESTERS Soil Separ. Other Sy ,als BR Seco, cob rb(3 - 10") SS Sant;- e gr ~ ! (under 3") LS Lim? c<, 3 Perc - P,~rcol e Is L, id Bn - , 61 G i ; .p t - x;Ilckv. R rno t sic fff - few, fir€e, fa - cc commor pt nnrr€ Many, r€ .~c n - d - distinct p - prominent: HWL High vva' r' 1, x Q€xtaxtures sumac„ iisposal BM - Bench Marls V RP - Vertical -ice Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county orthe Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. t e J 4! 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