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Home My WebLink About008-1041-50-100Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENER~i4L INF~JRMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 'ermit Holder's Name: City Village X Township Bledsoe, Robert Eau Galle, Town of ;ST BM Elev: Insp. BM Elev: BM Description: / a'b ~jt(~ 1 GS S TANK INFORMATION TYPE MANUFACTURER CAPACITY R: s Septic ~ ~'h1o„~• 3 ~,}..~ /~~~ Dosing P~ ~~ !y ~ G o,~o o ~ ~~ ~ Holding TANK SETBACK INFORMATION TANK TO P/L /1~of WELL BLDG. Vent to Air Intake ROAD Septic yrJ / 7 Z ! b' Z 1 / Z ~ , Dosing L~ .7 Z)b/ Z/ / Z , 1 ._-- Aeration Holding PUMP/SIPHON INFORMATION ~ Manufacturer ~ / A ) Demand ~ ~ ~ GPM Model Number ~' 1 ~Q Z~ ~! ) TDH Li Via,) ~ Friction Lo~ ~ System H3 t3 T ~~~ Sg Ft Forcemain Length ~ Dia. z Dist. to Welt / Z / b tD - SOIL ABSORPTION SYSTEM ELEVATION DATA county: St. Croix Sanitary Permit No: 487966 0 State Plan ID No: Parcel Tax No: 008-1041-50-100 Section/Town/Range/Map No: 14.28.16.210A STATION BS HI FS ELEV. Benchmark 5 ~ (~ ~~ 5 ~~ /O"b Alt. BM ~ To ~ ~~ ~'• o+~ t.J co cn.~. Z . n~ ~ d ~ . S b Bld .Sewer io.l~ 95. v3 SUHt Inlet SUHt Outlet ~.. ~ Dt Inlet ` ~ Dt Bottom /y, s5 9 /, o s Header/Man. ~ 37 /a/ . Z3 gist, Pipe y~ ~~, ~ Bot. System 5 . IS iuD , ~ 5 Final Grade 3~`( iaZ.Z.. stc~Jr 5. ~ ~9~ 9 ~ BED/TRENCH Width f Length / No. Of tench PIT DIMENSIONS No. Of Pits Inside Dia. Liquidid\h DIMENSIONS ~ -~~j hhhh h.7e .JJJ7 ~ ~~ \ SETBACK SYSTEM TO P/L B LDG WELL LAKE/STREAM LEACHING Manufacturer: ,~ MA IO CHAMBER OR INFOR T N st Type Of Sy em: ~ ~ TZ I I ,7 7 / ~ ^ /~' UNIT Model Number. ~ ` ~ DISTRIBUTION SYSTEM Header/Manifold ~ ,/ ~ Distribution /y ~ ~/ ~ Pipe(s) ` x Hole Size ~ / ~ x Hole Spacing / V t to Air Intake ~~ C.aJ Length Dia ~ 2 t Length Dia Z Spacing ~ ~ SOIL COVER v Praccnra Svsfams C)nly Yx Mnund Or At-Grade Systems OnIV Depth Over / Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center I ~ TS Bed/Trench Edges Topsoil , ~ ~ yes ~~ No .'~fbs ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: `~ !! ~ZL ! b ~ ~ _ Inspection #2: / /_ Location: 2509 County Road N Woodville, WI 4028. (NW 1/4 SE 1/4 14 T28N R16W) NA Lot 1 rra`'J ~~ Parcel No: 14.28.16.210A 1.) Alt BM Description = ~ P ~ ° ` Ov ~a`~ 1 ~~ Gw°~~ ~ ~ ~ o`~^~'~ ate' G~~~,11~_ 1 ~ ~ ~ ~C 2.) Bldg sewer length = 3a ~ ter Jl~~ - amount of cover = j ~ -T--- Plan revision Required? ~ q] Yes No I I `~ ~ z>oTac~l Use other side for additional information. ~__ i I Date SBD-6710 (R.3/97) ,. ~s ~k i ~GJ~I VV I , Cert. No. Safety and Buildings Division County 201 W. Washi OII y- ~/7 0/ ,~~0~~~ Madiso WI rritary Permit Number (to be filled in by Co.) ( 8)266-3151 y~~ De artment of Comm t:e Sanita a Applic ion - ~ ~ ~ Plan LD. Number s.{ ~Z6 $ In aooard with Comm 83.21, Adm. oaal inf ation ou pmv~de / may be used for spoon urpos acy Law, sl .04(1) (%KOIX COUNTY ~e~t Addleea (if different than malting addreea) ZONING OFFICE rmation ti i t All W ti Pl P L A li Sa ~ on orma on - ease n o ca r pp _ property Owner's Name Paroel # Lot # Blook # Property Owner's Mailing Address Property I.ooation el ii sa 9 tea. tea. N see6on ~5! ~ ~. ~~. City, State Zip Code Phone Number , ..> l O ~//L L E" L/ -r syaa 7/.s" G 98 - X08-5 ~ ~ N, R /G ~ lo~) ~ Z r T IL Type of BtWding ( eck all that apply) - its ~~; a`^"'~- Subdivision Names CSM Number ~ ~1 ~ 2 Family lhvelling - Number of Bodrooms 3 blia/Cammesmial - Daoribe Use ~ ^ P u // /+ ^ State Owned - Describe Use i n?f ~ ~ p ~ ~~~ ~ ~9_ ~sTownship of ~u A L~ IIL Type of Permit: (Check only one boz on line A. Complete line B if applicable) A' ^ New System ~Replaoement System ^ Treatmmt/Holding Tank Replacement Only ^ Other Modifioatian to Existing Syatear B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New Lest Previous Permit Number and Data Isauesd Before Expiration Plumber Owner / C~ / / IV. T of POWfS stem: Check all that a 1 ^ Non -Pre~suriud Tn-Ground Mound ? 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pala Sand Filter ^ Construotod Wetland ^ Presaurizod In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Resoim Sand Filter ^ /~ Reeirculatin Synthetic Media Filter ^ Iaaohing Chamber ^ Dri Line ^ Gravel-leas Pipe ^ Other ( lain) V. Dis rsallTreatment Area Wormation: Design Flow (gpd) Design Soil Applicetioa Dispersal Area Required (sf) Dispersal Area Propasexi (af) rem Elevation SD /. d D . tQ ysa ?5° ySa lzbo /ao. Y roe/ 9~ y rorrc~ VL Tank Wo Capacity in Total Number Maaufaeturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Cexlsttuottxi Glass New Tedcs Existing Taub w ~ / ~~~"~` 006 -- OGG ~ ESER G~onita~r~ '~ Aerobic Treatment Uuit DasugChembar `66 _ `do n •e VIL Responsibility Statement- I, the tmdersignad, assume responsibility for hiatallation otthe POWT3 dawn on the attacheal plain. Plumber's Name (Print) Plum Si store ~ MP/Itll!1tS Number Busineu Phone Number Eir.~r E~K~ ~ ~yi z is ~7a -sr~ ~ Plumber's Address (Sheet, City> State, p ) .? 98 Sr. wr. a?S tit .J,o ~/ Z VIIL pint /De artment Use Onl Approved ^ Sanitary Permit Fee includes Groundwater Date Iasuin t Si Stem ' Surcharge Fee) ~ ~ ~~ • ~ `~ ' ~ / Zi ~ G I J er ea for Denial { IX. Conditions of Approval/Reasofls for Disapproval 3 ~' ~ S t,(~ ,sv~ Y„~v b ~-. ~, b ~ ~X I U SYSTEM OWNER: II 1, `Septic tbnk, effluent filter and G,1p ex ~- ~~ ~ ~ ~"~~ . dispersal cell must all lie services /maintained as Par managertlsnt plan provided by P• 2. All smock ~ must be mair>~d errs Pa- dada / orditlattces. Attaeh twmpkte pleas (to the Couuty poly) for the system oa paper oat less there sus : 11 mcaa m srse ~-~ SBD-6398 (R. 01/03) ~i ~, v N D ~"I 1 1 ~_ a ~ ~ t ~ b 7 Q ~ G V Q w ~ ~ a ~ / 1 ~v- ~ / ~ r ~ ~ ~~ a y y ~ I ~° Q v ~ a ~ ~ .~ ~ ~ ~ ~ y ~ ~ y v lit ~~ ~ t ~ i ~I a r 4 ~ it ~Q v ~ W ~ V ~ ~ r ~~~ ~'~Q~ ~~ !~ j ~' ~ ~l v ~ I M ~ ~ / ~ v v +. ~ v q I 1-j~~ ~ Q ~ Q O V ~pp ~ ~ I V ~S ~ ~/ V Q o Z V ~' ~ y I ~ j. O Q o ~ h ~ J ( // ~~ z ~`o k^~ oo ~ d ~ ~ ~ ~o v ~' ~ \ .x ~k ~ ~ ° ~V~ ~ I a v~,~~ ,~, hey ~ ', n ~ ~ ~ ~J Q- 0 0 3 ~~ V ti~ ~~ 00 ~o s ~~ ~.i ~, ..~ ...1 ~~ Q . s ~. a ~: ~ ~ s ~~ 0 ~ o v o Z V c ` ~ ~ 3 ~ p `- O y Q` h v ~ ~ , , , k ~ ° ~ ' Z p v o ~ \ . {v ~ ~ ~ -. ~2 ~ A ~ ~ Z ~ .k ~k ~ V ~ ~~ ~ a ~ ~ l ~ ~ I / y 1~ y (- .' Q ~ ~ ~ ~ ~ o ; a Q ~i ~ ~ 3 t ~ `' ~~ . ~ ~ ~~ ~i a ~ L r ~~ V ti~ ~ ~ ~ w ~ f 1 ~ v a a aJ i __ __ ~. ~ ~~ ;~ ~~ ~ /~ ~ x ~ ~~ ~ ~ ~ ~ ~ W ~ ~ ~~ `VV ~ ~ M y '1 d` ^'i ~ ~ ~ ~ ~ v a R ~ -~ ;~ J o ~. a `z oY ~~ o° o l> `2` V Z a ~ ~ ~ ~ ~ b ~ I h y ~ ~ \ ~ ~~ a_ ~G ~Q W ~J c 0 0 3 ~~ v ti d ~~ ao ~o commerce.wi.gov i ^ isconsrn Department of commerce Safety and Buildings 4003 N KINNEY COULEE RD LA CROSSE WI 54601-1831 TDD #: (608) 264-8777 www. commerce.wi. gov/sb/ www.wisconsin.gov Jim Doyle, Governor Mary P. Burke, Secretary October 25, 2005 CUST ID No. 3412 HERB J PELKE PELKE PLUMBING N6298 STATE HWY 25 DURAND WI 54736 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 10/25/2007 SITE: Robert Bledsoe & Jayne Helgevold 2509 County Road N Town of Eau Galle, St Croix County NW1/4, SW1/4, S14, T28N, R16W ATTN: POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 5401.6 Identification Numbers Transaction ID No. 1208444 Site ID No. 706388 Please refer to both identification numbers, above, in all corres ondence with the a enc . FOR: Description: Three Bedroom Mound System Object Type: POWTS Component Manual Regulated Object ID No.: 1046780 Maintenance required; Replacement system; 450 GPD Flow rate; 25 in Soil minimum depth to limiting factor from original grade; System: Mound Component Manual -Version 2.0, SBD-10691-P (N.O1/O1), Pressure Distribution Component Manual -Version 2.0, SBD-10706-P (N.O1/O1); Biofilter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: DEPARTMENT 0 OF SAFE Reminders `~_ • This system is to be constructed and located in accordance with the enclosed approved plans and with the SEE CORRES "Mound Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD-10691-P (N.O1/O1) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems VERSION 2.0" SBD-10706-P (N.O1/O1). • Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area. Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal are prohibited. • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption area. chs. NR 811 & 812c • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the POWTS installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stat HERB J PELKE Page 2 10/25/2005 • Comm 83 22L) A coRy of the approved plans specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department which may include local inspectors. Owner Responsibilities: • Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). • ' Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. • Comm 83.55 The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stars 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence maybe made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, ,_ Charles L Bratz POWTS Reviewer II ,Integrated Services (608)789-7893 , 7:45 am - 4:30 pm Monday -Friday cbratz@commerce. state.wi.us Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 WiSMART code:'7633 cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 ~6 . / ,~ 9 .._. Private On-Site Wastewater Treatment System (POWYS) Index and Title Sheet Owner: GIo.QE~r ~~~osoe' t• .TAY./E /V`ELL~E'iJas.O Project Name and System Type: ~~~'Ased +~~t~•dato - -3 ~.c. ~a4.ro ~aurs Location: ~?Sd 9 ~o ~Io. iV ~ Street Address Legal DescriptiQn_ r~~~ o.~ ~",su ~7iIL6~', ~Sr. Cox moo. Township/County Contents: Page 1: /.vo~x ,o.ra ~r« .SNerrr Page 2: G't a r ~,~~ Page 3: `/toss - .5~~ ri../ A,~o ~,.,~ y~~ .~ /I ~,,~o N Page 4: ~.oe- 1,o r~~r,.~ L.~y.,, r ~~ ° ~~ . ~'~ C~ Page 5: ~~-PT/6 ~ .~.r ~~~.Yo C.r'.oyo~~ Cirosf • .~~~ r...~ ¢,, 'r G, ~} '' ~ Page 6: ~ o .r~ ~ 'a~.,r~="~ r~. s Page 7: ~Os/rs oa..~r.e 's ~,~./a.~a ~,o./~vs~irE./r .o~../ ~ ~",~,~~ cor ~ «~~c ~~ Page 8: ~~ ~;nrc; ~ ~J ~r r~ ~~ ,~ rr 'ONp .Page 9: Attachments: ,~o ~ ~ ~'vvLN.v rio.~ ~~.~.., r ~i rE.~ /~,i~,/ rc.~,.,~~ ~ /./.~e. Plumber/13esig~rer: /D`E~LB ~~'~.~~' Signed: -~' -1~ Credential Number: /ya0- v's//2 Date: /o- 8- aS' ~~ y G1SE0 SBQ ' /D L 9/'P ~ a.v0 ~o rlPo.vt'~v r /~A~/aAL v £a Jii,J d, D G1 Ss•,o = SGO - /0 7'Ol -i° ~~~il~tsw~ ~ .skis r~iau r..,r Lo~Pa/~.rr /^7A•.~NA6 ~~ !/E~t si..v a.o ~ ~ ~•ti H.W ~ ~ I .I w - - ~ ~ ~JM I~ I . . n. rt rt n n rr n . .. w .~ ~ ~ o ~ ~ v ~"~? ~----~-~ to ` f{ r~~ .o a p` ~ N N ~' l o p t -e 'r° 0 ~~ ~~ b r x h ~ ~~ s .~ d~ ~~ . ~ M ~~~ , ~' ~ r.o ~ ~ ` ~• ~ .a Mp b ~ ' -~r (, ~ N ~ t~' Ra t n ~ s ~` ~ ~ ~ ~ ~ ~ ~ ~ ~ k t ~ r ` .. .. O b A ~a ~a o. p fD 0 Fe ~~ ~ ~t.. '~` N~. pps~i ~ Q~ V' ~ ~~ ~~ •- • • • A ~ H •o .. -ti ho .. ~ti~ ~~ .: Uf ~N, W '!,'. a . ~ ~` . . .~. n o . ~ N. ~ O ... o' .. ti0 %~ 3 d .: ~ ~ ` ~ • .. C~ 7 :; } ; i : _ j ~ . ~ .~ ' H- .x . . ~ ~ , • 0 ~ ~ ~ 7 e` 1- C . t~ (~ M I~ e ~ ?. lti .~ ti ~ q a ~ e ~~ ~ ~ x~ x . ~ o ~ ~ ~ i ` ~ ~ ~ •`' w h t~ o ~\ w ~ ^_ k w ~ h n ~~ a n ~ 0 (~ a "1 '~~ w ~ ^ n C 3 .Z o h s ~ n t/' C a ~.. ~`~ . R ~ ~ ~ ~'a ~ ~ ~ n~ ° r b w. . ~ .~ ~. ~0 ~t W ~ C . •q i o q• ~Y .3. ~ . Z h 1 ~v~rcyr.M• -r1 „7 -rJ •,d Y Cy R R RR Z • ~ • ~. •) ( ~ • I , ~ `~ Ci f7 i7 "r7 • 0p ~' ~ , ~• O Page S Of 9~ SEPTIC TANK E' PU1~IP CHAMBER CROSS SECTION AND SPECIFICATIONS ..s Sc.r. yo. - ~ 4" CY VENT PIPE 12" MIN. A$OVE GRADE E WEATHERPROOF ?' /p' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AYR INTAKE WYTH CONDUIT MANHOLE COVERS W/ PADLOCK ~ fi.~~svdo - ~i WARNING LABEL G ~q,oar " ~E~..~ .,..~~ y ~~~._ 4 " MIN . 18 " IN . •. ~"i` .~'~` INLET i- ~ . WATER TIGHT SEALS . ZgQEC. .T ~ '~ GAS- ~ ~ TIGHT ~ ~ ~ • Fic rE~c ,q_~oo A i ` SEAL , ~ ppROVED . JOINTS WITH APPROVED __~_. i ; ALM APPROVED PIPE PIPE 3` -~- ~ ON 3' ONTO OI{TO SOLID C ~ • SOLID SOIL SOIL' PUMP OFF ELEV . ~ a.o FT. -~-- ~ OFF '~'~' RISER EXIT D PERMITTED ONLY • • IF TANK MANUFACTURER HAS APPROVAL 3" APPROVED $EDDING UNDER TANK CONCRETE .PAD SPECIFYCATYONS SEPTIC./ DOSE TANK MANUFACTURER: ~/ESera ~o./cRCrer TANK SIZES: .SEPTIC DOSE ALARM MANUFACTURER: MODEL NUMBER: SWITCH TYPE: Pt1~MP MANUFACTURER: MODEL NUMBER: swlTCH TYPE: /ooo GAL. ~ oo GAL.. S ~' ~.yo.yaus ~lttE//,eL4,~r /D'ypto~,or~C, _ _SL/ ,~'D /7EilLUaf REQUYRED DISCHARGE RATE ,?d, y GPM NUMBER DOSES PER DAY: ~`;,~ (/8,~) 8.7. / f /B. 7 DOSE VOLUME YNCLUDING • FLOWBACK: /oo, ~ .GAL. CAPACITIES: A = r .gip YNCHES = _ 33~ ' GAL. B = 2 INCHES _ 3.3. G GAL. /G. 8 t.ocs. i^~~.v C = `(~ INCHES = /0®.8 GAL. D . = ~_ INCHES = /.~Y.. y GAL . PUMP E ALARM WYRING AS PER ILHR 16:23 WAC VERTICAL ~DYFFERENCE $ETWEEN PUMP OFF AND DYSTRY~UTION PIPE iio FEET + MYNIMUM NETWORK SUPPLY PRESSURE •. ~,s FEET +-its -FEET FORCEMAYN ~~X /.s FT/100 FT. FRICTYON FACTOR /.~8 FEET . ~ ~ TATAL DYNAMIC HEAD = FEET INTERNAL DIMENSYONS OF PUMP TANK: LENGTH S3" ; WIDTH 78~~ ; DIAMETER - LIQU YD D~A~ 3~ " ~. SD33 O Y J33 T pical Application" I Sum /Effluent um Ca acities SW/SD/VS33 • to 48 GPM (3.0 I/s) Heads SW/SD/VS33 • to 26 h. p.9 m) Elertrical SW/SD/V533. 115V,1e,10.0 FIA, 60 Hz Motor SW/SD/VS33 - 1/3 HP shaded pole w/thermal overload 1550 RPM Minimum Raommended SD/VS33 =12" (304.8 mm) Sum Diameter SW33 =18"(451 mm) Automatic Operation SW = ode-angle float switch (manual available) SD =Diaphragm pressure switch VS = Vertcal float swNch Materiels of Construction Cast iron and en ineered ihermoplastc Impeller Thermoplastic vortex Discharge Size 1.1/2" NPf (38.1 mm) SoOds Handling 3/8" (12.8 mm) Power Cord 10' , S1iW,120' o tionai) Superior Features • Cgrban/Ce~amic jechanical seal • Oil-filled motor w/automatic reset thermal overload • Uses single rpw ball bearing construction • Piggyback plug available for easy maintenance and replacement r ~~ 6 20 ~ ~ ~ 3 °10 pl 0 ~, GaF 9 JYVaU 1 1 Typical Apprcation" Su /Effluent um Capacities SW/SD/VS50 • to 44 GPM (2.8 I/s) Heads SW/SD/VS50 - to 24 ft. (1.3 m) Electrical SW/SD/VS50 - 115V, le, 8.0 FIA, 60 Hz Motor SW/Sp/~IS50 •1/2 HP shaded pole w/thermal overoad 1550 RPM Minimum Recommended SD/VS50 =12" (304.8 mm) Sump Diameter SW50 =16" (451 mm) Automatic Operation SW =Wide-angle float (manual available) SD =Diaphragm pressure switches VS =Vertical float switch Materiah of fomirofion Cast iron and en ineered thermo lastic Impeller Thermo lastic Iwo vane semio en Discharge Size 1-1/2" NPT(38.1 mm) Solids Handling 3/4" (12.6 mm) Power Cord 10' , S11VY,(20' o tonal) Superior features • Carbon/Ceramic mechanical seal • Oil-filled motor w/outomgNc reset thermal overload • Uses single row ball bearing construction • Piggyback plug available for eery maintenance qnd replacement 40 30 ~ 20 10 n Capariry-U.S. G.P.M.O 10 20 30 40 50 - f 0 L1ers/Second A 1 2 3 Q.~~~back Switch A,` .:. 9 -:' 20 30 40 SO 60 10 GPM W~rsconslnDepartmentofCO~roe,~ SOIL ION REPORT Divisbn of Safety and BuIkllnps ~ _~ (`~~ Pape _L of cco wicn y6pw+m, vvis. Ham. was G, lar~~st l l a a s th n /2 11 Inches s Att h t it l County Sr ~Aa/ ~ p . ac comp e e s e p an on p s a include, but not limited to: veRical and h I refers po ,~ection and ~I Paroel I.D. //x i h I d t t i di ~ - ~~ ' ` ~~ " ~~ ons, nort o percent slope, scale or dimens arro d o rlaaoa . ance t on an s (fi/ Please print a!! lnfolma n. gT. CRS G pFF~G~ ON .Reviewed by Date Personal inforrnatbn you provide may be used for secondary pu N sec (Pm , s. 15.04 (1) (m)). !/ Z ds Property Owner Property Location GE sob ~ .J ~ Govt Lot ~ 1/4„S~/.1/4 S ~5/ T N R ` {~o Property Owners Melling Address lot # Block # Subd.-Alamo or CSM# ~?So9 Lo.~ tr ~~~ Cityy ~ State p Code Phone JJumber ~ ~R flape ,®Town Nearest Road ~+-- N !1 ^ New Construction Use:~Residential / Number of bedrooms .3 Code derived deslpn flow rate 5/Sa GPD Replacement ^ Public or commercial -Describe: Parent material LdESS ova sc ~ t"iLL Food Phain elevation if applicable .JA it - General commends ~ /~~/D Pawl T"S o os.~ ~ Arv~J ~ELorlMLiJO .SYS. Et. a F /oo, y ' o./ 99, y~~ rv° and recommendations: / / ~CConNdr./D /4/lA.~Da~/I.~6 fdD ~X/1T/~J< /VaLD/./f T`A~/k dON! /NSipE f/1!/~Qie< w/,{DDS TO /S~ ,FJe,~~ r~ ~LpA! ALL /,~.fJD~ PEUOl6/.J! /.PTO ^/6i,/ cS!/oP/L ri~N~'• a p . .~ Boring # Bonn ®Pit Ground surface elev. 99. y ft. Depth to IimiUnp factor ~ (n. Soil Nation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fl' In. Mansell Qu. Sz. Cont Cobr Gr. Sz. Sh. •Eff#1 'Eff#Z 8- / ~ s- s roc s~~ r ~ _ _ a Boring # ^ Bonnp / ,Y / Pit Ground surface elev. p9. 9 R. Depth to limftinp factor ~G in. ~~ p~~ Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fP in. Mansell Qu. Sz. Cont Cobr Gr. Sz. Sh. 'Eff#1 'Eff#2 I o - .~ ~ l ~%~ ~ ~? o .c S S ~' ~ 3 ~ S .1 sYR S/` ~ G 6k //~~ Ti ~ r • Effluent #1 = BOD > 30 < 220 mg/l. and TSS mp/L ' Elfluerd #Z = BOD < 30 mpiL and T55 < 3u rrip/L .CST Name (Please Print) i re CST Number ~ ss rT ~ 97 . .Address Date Evaluation Conducted Telephone Number a 3 .9/rc ~r ~a ~ l o ~~ ~S ...... M,~ ~„r..,.,, 2J ~t +4 .~ ~.. r' Property Owner_ ~1~`DSO E ~ /y'El ~EVat,O Parcel ID # .:;r .<, r~ Pafle -~.°f~-- Boring # . ^ Borg ~ ® pit Ground surface elev.~ft. Depth to gmiting factor' a-? ~. Soq Ikatlon Rate Horizon Depth Dorrdnant Color Redox Description Texture Structure Consistence Boundary Roots GPD/IP in. MunseU Qu. Sz. Conk Cobr Gr. Sz. Sh. 'Eff#1 " !Eff#2 / _ J ~ v ~' s 3 ~ ~' - ~ 3 S- a Yic s 3 S~ l 6 ~' "' s--.f ~r• of 'sy~ s~~ ~ c / a6 Bonny # ^ boring ^ pit Ground surface elev. ft. Depth to limiting factor ~• Soq lication Rate Horizon Oepth Dominant Cobr Redox Descriptbn Texture Structure Consistence Boundary Roots GPD/fP (n. Mansell Qu. Sz. Conk Cobr Gr. Sz. Sh, •Ef#i1 'Eff#2 Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to Iimiting factor in. Sop lication Rate Horizon Depth Dominant Cobr Redox Description Texture Structure Conslstence Boundary Roots GPD/fP in. Mansell Qu. Sz. Conk Cobr Gr. Sz. Sh. 'Efgi1 'Eff#2 • Effluent #1 ^ BODE > 30 < 220 my/L and TSS >30 _< 150 mg/L • Eftluer~ #2 = BODE _< 30 mg/l. and TSS < 30 mgll. ,~ ~~; ,, ~. The Department of Commerce is an equal opportunity service provider employer. If you need assistance to access services or need material in an alternate format, please contact the de~i~nt at 608-266-3451 or TfY 608-264-8777. .SBD-~30 (807/00) ~ . "a r" Property Owner RJ 1~'Dta E ~ /D~~c-1 ~EUOt,O l_~ '~, ~ _ /,""~ ~ ~+^ ,v Parcel ID # _ ~ ~ ~ E '~ Pape _~of~_ Boring ~l . ^ ~~ ~``;~-, ® Pit Ground surface elev. S~ y ft. Depth to limiting factor a-~ k~ . goN Ibation Rate Horizon Depth Domlr-ac~t Color Redox Description Texture Structure Consistence Bouhdary Roots GP D/fP (n. MunseU Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'Eff~1 " !EtflR2 J _ .. J ~ v ~ s 3 a i+ - ~ .3 s- amass - ~ s,~ 6 s--.3 ,r• ~ z c I 6° ,, Borinfl # , ^ ~~ ;:: ^ Plt Grpund.surface elev. tt to RmiGny factor In. Depth . , SoY Ibation Rate Horizon Depth Dominant Cobr Redox Descriptbn Texture Structure Consistence Boundary Roots GP D/fP in. Mansell Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'Efflll •Effr~2 Boring ~ ^ Boring ^ Pit Ground surface elev. ft. Depth to Ilmitlnp factor In. SoU tication Rate Horizon Depth Dominant Cobr Redox Descrlptbn Texture Structure Consistence Boundary Roots GP tNPP In. Mansell Qu, Sz. Cont. Cobr Gr. Sz. Sh. •Ef>#1 •EfGf2 • Eftiuent a'i1 •80D~ > 30 < 220 rr~/L and TSS >30 < 150 mp/L • Effluernt #2 = BODE _< 30 rrg/l. and TSS _< 30 n'm/l. The Department of Commerce is an equal opportunity service provider emp)~ys'r. Ifyou need assistance to access services or need material in an alternate format, please contact the de~~ at 608-266-3151 or TTY 608-264-8771, r. ii T 4 ,~ .. ~, ~o ~~ ~R i ~~ a ~a g ~ r V ~ W n z ; w q ~ ~r ~ ~ ~ , ` x W ~ ~ ~ ~ ~ ~ ~ ~_ ~ l ;~ " Q o~ ~ l ~ ~ ' a' o A ~ Q ` ~~ "~ r ~ L ~ , . I z° < 1 / ~~ ~~ z , , ~ ;c ~ ~ ~ 0 O 1 ~ ~~ ~ r ~ ~ ~ ~ ,a r ~ R ~ ,a ~ ~0 ~~ ~ . { ~ ~ ~ ~_ ~ :; c ~ ` ~. a ~o ~ $ °~~, ~+ a~.n ~ "' ~i ~~ ~ o n ~ ~' A a ~! ~ O ~ , Z ~ ~ ~ ° E-~ w ~ o z ~T a. v cn y ~~j n rNj 'T1 O "d O ~ ~ c~'1 H -~-1 • :~ vi O t~1 ~ ~. ~ H ~ ~p 1'V ~ .~~. ~ 1 O `~ 0 H r e ti L c (Q POWTS OWNER'S MANUAL AND MANAGEMENT PLAN FILE INFORMATION Owner sad' ~' ~"~ d os o Permit # DESIGN PARAMETERS Number of Bedrooms 100 room „~ ^ NA Number of Commercial Units - NA Estimated flow (aerage)* 3a o aUda Design flow (peak), estimated x 1.5* „ro aUda Soil Application Rate /. O aUda ft Influent/Effluent Quality (NA^) Monthly Average** Fats. Oi18c Grease (FOG) < 30 mg/L Biochemical Oxygen Demand (HODS) ~ 220 mg/L Total Suspended Solids (TSS) 5 250 m Pretreated Effluent Quality ^ Monthly Average*** Biochemical Oxygen Demand (HODS) < 30 rng/L Total Suspended Solids (TSS) < 30 mg/L Fecal Coliform (geometric mean) <10 cfu/100m1 Maximum Effluent Particle Size 1/8 inch diameter *Wastewater Flow Verification and Calculations: (Other than bedroom based) ** Values typical for domestic (non-commercial wastewater and septic tank effluent. * * * Values ical for retreated wastewater. cvcTFM SPF.CiFiCATIONS Se tic Tank Ca ci /aao DNA Se tic Tank Manufacturer ~-,s~,c. DNA Effluent Filter Manufacturer ~~4,~dG ^ NA Effluent Filter Model /4 /oo DNA Pum Tank Ca ci dD DNA Pum Tank Manufacturer e~s~"•t ^ NA Pum ufacturer Y,o ory,~rra O NA Pum Model S~ .s"o ^ NA Pretreatment Unit NA ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: Manufacturer: Model: Dispersal Cell(s) ^ In-ground (gravity) ^ In-ground (presstu~.ed) ^ At-grade 'Mound ^ Dri -line ^ Other: ^ Leaching Chamber Manufacturer Model Laying Length/Chamber Soil Application Rate_gpd/ft2 Area Req. ftz Infiltrative Surface/Chamber-ESIA Rating ftx Minimum Number of Chambers ^ A egate Desi Flow/Loadin Rate= min Materials: all materials must comply with WI Adm Code COMM84 and be installed per manufacturers specifications and a royal letters. i-~crriv !`i2iTFRiA ^ "Wisconsin At-grade Soil Absorption System, Siting, Design &. Construction Manual" (Converse et.a1.1990) ^ "Wisconsin Mound Soil Absorption System: Siting, Design & Construction Manual" Converse, J.C. and E.J. Tyler. Publication 15.22 ^ "Design of Pressure Distribution Networks for Septic Tank-Soil Absorption Systems" Publications 9.6 ^ "Design of Conventional Soil Absorption Trenches and Beds". RJ. Otis - ASAE Publications 5-77 and "Design Manual - Onsite Wastewater Treatment and Disposal Systems". EPA 625/1-80-012 October 1980 ^ SBD - 10570-P (8.6/99) "At-Grade Component Manual Using Pressure Distribution" ^SBD - 10567 P (8.6/99) "In Ground Absorption Component Manual" ^SBD - 10705-P (N.O1/O1) "In Ground Soil Absorption Component Manual" Version 2.0 ^ SBD - 10628-P (N.6/99) "Recirculating Sand Filter System Component Manual" ^ SBD - 10656-P (N.6/99) "Split Bed Recirculating Sand Filter System Component Manual" ^ SB?J -10572-P (8,6/99) "Mound Component Manual" SBD - 10691-P (N.O1/O1) "Mound Component Manual" Version 2.U ^ SBD -10595-P (8.6/99) "Single Pass Sand Filter Component Manual" ^ SBD - 10657 P (8.6/99) "Drip-line Effluent Disposal Component Manual" ^ SBD - 10573-P (R 6/99) "Pressure Distribution Component Manual" SBD - 10706-P (N.O1/O1) "Pressure Distribution Component Manual" Version 2.0 ^ Drip-line Effluent Dispersal Component Manual for Multi-flo Onsite Wastewater Treatment Units 7 RT.T IiT ~jHjjr L ~jr Hl~ V~ Al\L 1~1A1\A\JL• 1,aaJl~ a MAINTENANCE MONITORING SCHEDU LE Service Event Service Fre uenc Ins ct condition of tank(s) At least once eve ^ months 3 ear(s) (Maximum 3 .) Pum out contents of tank(s) When combined stud a and scum oats one-third (1/3) of tank volume Ins ct dis rsal cell s) At least once eve ^ months 3 !$( ear(s) (Maximum 3 .) Clean effluent filter At least once eve ~/ months ^ ear(s) um controls & alarm Ins ct um At least once eve ^ months 3 ear(s) ^ NA , Flush laterals and ressure test At least once eve ^ months 3 ear(s) ^ NA Valves At least once eve ^ months ^ ear(s) NA Other: At least once eve ^ months ^ ear(s) ^ NA Paue 7 of START UP ` 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 sha11 not occur when soil conditions aze frozen at the infiltrative surface. OPERATION • The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity and quality of the wastewater stream will affect the performance and longevity of your.l'OWTS. The installation ofwater-saving appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water softeners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface whenever possible. Note: this does not include laundry waste, showers, dishwater, etc. This system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetable/fiuit peels and seeds, bones, and food solids such as those produced by a gazbage disposal should be minimized. Toilet tissue is the only paper that should be discharged into the system. Other non-biodegradable items such as baby wipes, tampons, sanitary napkins condoms, cigazette butts, dental floss, and cotton swabs should not enter the system. Chemicals such as petroleum products, paint, disinfectants, pesticides, antibiotics, solvents, etc., should not be flushed into the system as they can seriously damage your POWTS~ and contaminate your drinking water supply. Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components. Compaction of snow over the' dispersal unit may cause it to freeze up. ^ Valves Valves shall be operated in the following manner: Alarms Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service POWTS, There is normally a 1 day reserve under regular operating conditions, however water should be conserved until any problems with the system are corrected to prevent back-up of sewage into the dwelling or surfacing. INSPECTIONS Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule): Septic Tanks Component Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any backup or ponding of effluent to the ground surface. Access openings used for service or assessment shall be sealed and/or locked upon completion of service. Any defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with ari effective locking device to prevent accidental or unauthorized entry into the tank. When the combination of sludge and scum in any tank exceeds one-third (1/3) or more of the tank volume, the entire cortents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with Chapter NR113, Wisconsin Administrative Code. The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's . specifications. Provisions are to be made to retain solids in the tank. Filter cleaning maybe necessary at more frequent intervals than stated in the maintenance schedule to keep the system operating. 'Pump Chamber/Treatment Tanks Component The inspection must include a test of all electrical equipment such as pumps, alarms and floats. A visual check must be made for leaks, backups, surfacing, missing or broken security devices and other hardware and the condition of any filters. Any service needs or repairs shall be promptly taken care of. ^ In-Ground Gravity Component Dispersal Cells The inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any • evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory authority. Poriding at depths greater than 75% of the height of the component may indicate overloading or impending hydraulic failure necessitating more frequent monitoring. Page $ of 9 ~j Mound, AtAGrade, In-Ground Pressure The inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory authority. Ponding greater than 75% of the height of the component may indicate overloading or impending hydraulic failure necessitating more frequent monitoring: The pressure distribution system is provided with an opening at the end of each lateral to be used for flushing. The laterals should be flushed at least once every three (3) years. Pressure checks of systems with multiple laterals should be done to ensure that equal distribution of effluent is occurring to promote the longevity of the system. REPORTS Reports for maintenance, inspection, and monitoring shall be submitted in accordance with COMM 83.55 Wisconsin Administrative Code. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure that the system is properly and safely abandoned in compliance with Ch. COMM 83.33, Wisconsin Administrative Code. - All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. - The contents of all tanks and pits shat: be removed ~d proxrly di~osed of by a Septi~ge Se:ti wing 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 other 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 infiinged 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 from existing and proposed swcture, 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. p 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 site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank maybe installed as a last resort to replace the failed POWTS. Mound and at-grade soil absorption systems maybe 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 CONTIAN 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 FROt~i THE INTERIOF- OF A TANK N:AY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name E.QCt 6~,~rd /yo.3y/L Phone ~/.S G 7.?-5.~66 SEPTAGE SERVICING OPERATOR m er .~ woad Name Phone POWTS MAINTAINER Name it6 f'~.~t' ~'-LKat' 6u~r~irt Phone 7/,S' G 7•? ~ S,?ld LOCAL REGULATORY AUTHORITY I Phone 7/S 38~ • yL 8o I K:\WPDATA\E}I\POWTS OWNER'S MANUAL.Joc Page 7 Of I Maintenance The interval for servicing septic tanks is set by state and local code. Throughout the United States there is a wide difference of opinion on what this interval should be, but most regulatory agencies suggest two to five years. The Zabel'" filter, which does not increase the frequency of servicing for the tank, should be cleaned when the septic tank is normally inspected and pumped. However, our filter is virtually self-cleaning. The continued action of the anaerobic organisms on the Zabel filter causes lodged particles to disintegrate and fall to the bottom of the tank. !f your. filter contains a SmartFilter"' alarm, you wil! be notified by an alarm when the filter needs servicing. Remove the tank and pump the 1 necessary to pr any solid: escaping to the when the f While holding tl the access open cartridge with fr careful to rinse all 'Note: It is not n 'spotless' The b erdes in the pretre be left on the filter. maybe d. Firmly pull the filter h and slide the cartridc of the 'Note: A tee handle ma to be used it the lifter Is below ground level to Contact Zabel for into handles Insert the back in the sure the fit completely Replace ~~~~ /.Vi MADE IN USA The product(s) shown are covered by one or more of the following patents: •U.S. 5,762,793, 5,580,453, 5,591,331, 5,759,393, 5,683;577, 5,582,716, 5,779,896, 5,593,584,5,795,472,5,736,035, 4,710,295, 5,382,357, 5,482,621 U.S. Des. 386,241, 349067, 4605501,5098568, Des. 309007, Australia: 134440; Canada: 2,135,937; Israel: 111574; New Zealand: 264824, Olher Patents Pending Call for a free ZABEL ZONE An Onsite Wastewater Magazine 1-800-221-5742 • Website http://www.zabeLcom To service the filter: 'Servicing any zabel filter should only be done by a certified septic tank pumper or installer. Locate the outlet of the septic tank. A100/300•I•M,61499 ~ ,. F ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIl' CERTIFICATION FORM ' OwnerBuyer Mailing Address Property Address ZSog ~~ ~~ ti ~~1~•~IQ wz syoZ~ Zs~ C~n~ (Verification required City/State lit~Op~i1G~ w Z ~ct N (its oo O ~ & Zoning Department for new construction.) Parcel Identification Number ~~- ~ ~ ~ _ s~ -' /Gb LEGAL DESCRIPT''LOIlN //'' ~ Property Location ~W r/4 ,~J~ '/4 ,Sec. ~ ~ , T ~~ N R~W, Town of ~~ lGr (I~-. Subdivision '-~' Lot # Certified Survey Map # DDL. `~,Zrj~~ ,Volume $ ,Page # a'3~~ Warranty Deed # ~ °~ 1 ~ , Volume ~S~ ,Page # Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 3~oS Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Plamiing & 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. ~3 of bedrooms SIGNATURI/ OF APPLICANT(S) to /(o / oS 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) v~1..~.530PAGC 365 STATE BAR OF WISCONSIN FORM 2 - 1998 WARRANTY DEED Dtx:umettt Nttmber T6fa Dteed, made between Todd J. 8uclcosr and Arun Maria • sutcicoa, husband and sri£a . Gramor, and Robert T. Bledsoe and Javna M. Haloavold txo aiat3la parsons as iaiat tenaata Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin: Part o£ the NFT1/4 0£ SW 3/d o£ Section 14, Tour-ship 28 N. , Rainga 16 Wast, t3eatsribad as follows; Lot 1 of Carts£itad Survey Map filed August 16,1991 in Vol. 8, Page 2390, Don. 472579 627~[?6 K.A't'HLEEN H. WALSH REGISTER OF DEEDS ST_ CROIy. CO_ , WI RECEIVED FOR RECORD 07-31-2(100 l0:OD AM YARRAIiTY DEED EXElIPT ll CERT COPY FEE: COPY FEE: TRANSFER FEE: 352.50 RECORDING FEE: 10.00 RAGES: 1 Arta Nana and Retvm AQdrus ~V f-1--~' ~ ~-F- ) a-3 3 Palcel [demificaion Number (PIN) Tl•is is homestead property. (is) (is nm) Exceptions to warranties: eaaernants , rosdt+aya and rsatriotioas of rt®oord bated this -!_~~! ~- day of _ , * AUTHENTICATION Signatures} authenticated this day of TITLE: MEMBER STATE $AR OP WISCONSIN (If trot, authorized by § 706.06, Wis. Stets.) THIS INSTRUMENT WAS DRAFTED BY Michael H. Foreaki Attornav Eau Claire, ~Iistsonsin (Signatures may be authenticated or acknowledged. Both are not necessary.) / ~1 ~ ~CSL~G~f/~-- * Todd J. Su/cylc~oN / ~r / , l~/I.i 1J ~.Gl~c~c~_ * Ann Mario Sut:.lcoa ACKNOWLEDGMENT STATE OF W[SCON$!N ) ss. St. Croix Coon P y came before me is day of above named Todd J. 8 ow and Ann Maria Suolcow to the known to be the person who executed the f im= ir~str/rsn-Mt~r+ c mowledged the same. j~ * Traav* Ttarnar J Notary Publ c, State of Wisconsin My Co . "ssi is (If not, state expiration date: C~ •) •Names of persons siting in any capacity must bt typed tx primed below their sigtadlre. NOf9f',I PIIbflC WARRANTY DEED STA7'EEBO M No 2-19~980NSiN ~Slt2Y O~ ~{/[appnBlfl Ptodttea0 with ZpFoan*~ by VatWaa Ne. ta0Q5 t'Mlean tt6la Road. din<en Townahb, ttYddpan ~5, (900) 3e3-9005 Aebmry ftidsel N Fwacki ItM Ave. Feu Cldm wl St17(/1-W27 Pho,r~~ t713) a]i]O]V Fex~ (7151 a75-II12 Parcel #: 008-1041-50-100 Alt. Parcel #: 14.28.16.210A 008 -TOWN OF EAU GALLE Current ~X'' ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O =Current Owner, C =Current Co-Owner ROBERT T BLEDSOE O - BLEDSOE, ROBERT T C - HELGEVOLD JAYNE M HELGEVOLD JAYNE M 2509 CTY RD N WOODVILLE WI 54028 Districts: SC =School SP =Special Property Address(es): * =Primary Type Dist # Description "` 2509 CTY RD N SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 2.570 Plat: N/A-NOT AVAILABLE SEC 14 T28N R16W PT NW SW BEING LOT 1 OF Block/Condo Bldg: CSM 8/2390 2 5 RE . 7 AC S Tract(s): (Sec-Twn-Rng 401!4 1601/4) 14-28N-16W Notes: Parcel History: Date Doc # Vol/Page Type 07/31/2000 627306 1530/365 WD 07/23/1997 950/119 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/09/2000 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.570 23,600 81,900 105,500 NO Totals for 2005: General Property 2.570 23,600 81,900 105,500 Woodland 0.000 0 0 Totals for 2004: General Property 2.570 23,600 81,900 105,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch #: 513 11/02/2005 11:11 AM PAGE 1 OF 1 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 E N O 3~ n M ~ ~ ~ ~ ° ~o c .fir.'. 3 '~ '~ '~ ~ 0 ~3 ~~ a °;Pm y ~°o ~ • ~ ~• ~ y ~ ~ ~ C N ~ H ~ N C y ~~ d ~ ~ N O ~ G 1 IAA N ~~ ~ D~ ~ O 7 fN ~ O r. N y ~ Vi ~ R I ~ tn~D a:~ f~ m c~ a, ~' W o. ~ C I ~ _ o. ~ a o o Z !, N I ~ I A I `O i 0 O ~ 0 ~ ~ ~ ~ y t0 f0 < --' ~ ~ O C V1 3 :-r c• ~ ~ I 0 0 0 1 I o = .~ o < ~ 2 I .. N v ~ v o 0 ~ = cc m ~ N = N ~ W p• 7 fD ~ C p O Z •' C Z 2 ='~ ~ D n °* ~ ' I ~ o ~ I ~ ~ ~ ~ d x I c I W ~. I Z p ~ ~-itn A ? ~ O A ~ O N ! 7 ~ O ~ .. ~i C ~ W ~ < l D a ~ z ' ~ ~ ° ~ .p ~ I o r: I ~ I N i m ~ I v I A W 01 I ~ I n n a ~ ° ° a r. ~ ° m - I , v n ' c m o I z a p a N ~ y ~ ~ ~a m ~ ~ m ~ a a i ~ ti I ~ o ~' I ? . ~'• o I '~ ~ °+. I C I ~ b ~ I ~ A ~ ~ I <n O ti p I o g ~ n ! c ~ ~ . o ,~, I `~ Alt. Parcel #: 14.28.16.210A 008 - TOW N OF EAU GALLE Current ~X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Parcel #: 008-1041-50-100 11/02/2004 11:39 AM • PAGE 1 OF 1 132,500 Valuations: Last Changed: 10/09/2000 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.570 23,600 81,900 105,500 NO Tax Address: Owner(s): ' =Current Owner * BLEDSOE, ROBERT T ROBERT T BLEDSOE HELGEVOLD JAYNE M HELGEVOLDJAYNE M 2509 CTY RD N WOODVILLE WI 54028 Districts: SC =School SP =Special Property Address(es): * =Primary Type Dist # Description * 2509 CTY RD N SC 0231 BALDWIN-WOODVILLE AREA ~i " SP 1700 WITC / ~ 0 ~ ~ ~ ~~ Legal Description: Acres: 2.570 Plat: N/A-NOT AVAILABLE SEC 14 T28N R16W PT NW SW BEING LOT 1 OF Block/Condo Bldg: CSM 8/2390 2.57 ACRES Tract(s): (Sec-Twn-Rng 401/4 1601/4) 14-28N-16W Notes: Parcel History: Date Doc # VollPage Type 07/31 /2000 627306 1530/365 W D 07/23/1997 950/119 2004 SUMMARY Bill #: Fair Market Value: Assessed with: Totals for 2004: General Property 2.570 23,600 81,900 105,500 Woodland 0.000 0 0 Totals for 2003: General Property 2.570 23,600 81,900 105,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch #: 513 Specials: User Special Code 010-GARBAGE Category SPECIAL ASSESSMENT Amount 138.00 Special Assessments Special Charges Delinquent Charges Total 138.00 0.00 0.00 ,' ~ ~ • ~ i~ ~ ~~_ N v ~N a CO ~ ~ ' ~ C 2422 2433 i 2428 N 2447 ~ I 2460 2465 2464 2475 8 ~ 2474 _ L 2484 V ~ N 2512 N ~"~ 2546 2549 2555 ~s ~/ 2581 V N j ~ W J J V 2837 ith 286, 2~ ~_ J V • ~ s 2509 C ~ _ 2531 -• 2530 ~ 2533 ' ~ 2559 ~~ -9 ~~ a-, R Z 2581 • 2582 ~~ ~ ~ - ~ . ~ j • 1 ` ~ V WW ~ N V r W N r • >t w e~~eJ _ ,, j~ .~S ^ O W `~, 'I `DEPARTMENT OF INDUSTRY, ~'' LABOR AND HUMAN RELATIONS REPORT ON SOIL BORINGS AND PERCOLATION TESTS (115) (ILHR 83.0911) & Chapter 145) SAFETY & BUILDINGS DIVISION P.O. BOX 7969 MADISON, WI 53707 LOCATION: SECTION: TOWNSHIP/ib9liPdhe'F~RtiTi': LOT NO.: BLK. NO.: SUBDIVISION NAME: ~~ ~/ St,~~/ 1 /T~$ N/R l~ E to - W ~'~,~, G-a. 1 e.. !~ COUNTY: WNE BUYER'S N E: MAILING ADDRESS: '` w e '1 e 1 ICF ,-,~ NO.BEDRMS.: COMMERCI~AL,DES RIPTION: L~Residence ~ /V A QATIIUf]• C= Sito euif~6ln fnr evMUm 11= Ci4o unu~i4ahlo fnr evctem DATES OBSERVA I TUN, MAUI ,,~~,,~~ PROFILE DE CRIPTIONS: ER OLATION TESTS: ^New L_I-Replace (' ~j/ N~ ~/.tGo ~ ~a$a-~-y/ CONDVENTIONA_L: MODUND: ~ IN-GROUND-PRESS~IRE: SYSTEM-IN-FIj.L OLDI TaA~j : RECOMM DED SYSTEM:loptional) DESIGN RATE: If Percolation Tests are NOT required ~ If any portion of the tested area is in the A' J under s. ILHR 83.0915-(b-, indicate: ~ Floodplain, indicate Floodplain elevation: /\/f{ PROFILE DESCRIPTIONS BORING TOTAL D PTH TO GROUN DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- r ~ y s ~ ~~ ~. r~ ~ y !o` Bi Srl rs y" .~.,5~ ao" ~, ~~ /~'li7D °,;~~ v ~~~- ~ ~ ~ of B- ~ ~ ~ ~:3. ~ 11 9~,,t3j s~175 S~C B>1 /,1 ~Gio p pr~ ~ Gy Mot B- ~ ~, ~ / J ~~ ~~ /I ~ 1~1 S~ ~ -T~ ~~ ~t~~ ~ ~ ~~1~1/"t~D O h~ t g y /~lo' VS ~ ~ p . 1 i t B- ~ 3~ (~ li /O ~~ /0,/, 8~ Sal Ts ~~~ ~~, s,~ ~ ter- at~ ~ 9~ ~o B-~j 'Z ~ r rr J~ 5"iBl ~'i~ TS ~7'~,Bn ~,`1 ~r"'1N'~ pl-•~ r •7 Hof lam" C~ ~ v ~ B- ~ b ~ ~~ ~r ~ q`i QI ~i(l~S ~" i8h 5~~ "`''/YIFD G~r-~j Mof " L ``~ Do G o PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD1 PERIOD2 PER D PER INCH P- P- P- P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all e of land slope. _ SYSTEM ELEVATION l~~ `~ 3 3 . -~ - C,T ~I :~~ ., - - _ ~. r_ ....__ -~ i--~ ~\ ~ E a , ~ ; e. ~ __ ; E~ se ~~ s~ ,~_ ~ _ g y" o E ~~ ~ L ~_..... r Bi ~y_. _ __ ~ - e" F 1=xs~i~ ~ ~ 4 - . Ii ~~ `. I ~. I - ~. escribe w r~ hori- ~' s and the direction nt N ~ ~ ~ ~n 2 ~~ ~~ ~ ~ ~~~ i ._ ~~__ ~.M ~ Uk'~ IrOb.(~o >o`~-tivv~T~ ~~~~ Cnr.'. ilq TN 1`rr tae a uc1n~~~ €cl ~a~ :-3ra , yu€~~ ,,, .. ir;: ~ . Cramp€et:e ~ey~a 2. The use seci:ion a'nc=,' -~,'~-e€~ dais is a r£asi~ier€ce € ~ ~€:ae€~;iat ~Srcljet;fi, 3.. MAXI"1t=i~~l ra€lbec t1~ ~ 'trial us£1 Natar€raed; 4. Is,~ ~~ r ys°-, ~. Copl.,°-> the su'€ ., ~ ~ ~o ..a..~E S1T~ iS SlI1T~R13L.E f=C~Fi ~ t-iC}I_C}31Vt"s TAiUK CJ111LY IF AtvL QTR S`~S~t'E_ ', _ i= #~" ~~~L~ ~17T r3,~SE C}Ih SC~Ii~ C;C1(i4Gl~i`I~I~S; . PC~~AS~ usa~ Che ~ ; ~ . r;.tt clras show€€ i1r:r .~;€~ e+~~€•itiray ~rofite e9escri~stic~ras ~ncf ccarra~l£a~in_y ~Ehe pto~t plan; 7. laJ1AKE ~, ~~i~~~ di~anra ;~£ze~a€<a:y ~;ir€~ your s:est Icrcat:iclns. ~1;~ati~irag to scale is prefer€~ed. A sr~parate steer€t may u~ :ase<f if r~rasirerf; 8, f~~rake sure yclur tae,acY;r~;aark an<f slertical elr:a <4t it:1r~ r~:fer~erace paint are £atearly staown, and are pet~rr€anerat; 9. Go€raplete ali apprcaprlai:e 1}oxes as to dates, names, adcirc=sses, (load plaid data, fsercolattn€~ tent: exerrap- titan, if anpr£apriate; `t t}. lfth£> inforn3aCian {;u.' G .cad tslain, e4eva~tiara} Braes not ag~taty, place }~.~t. ara ~tlae z€pp€~otla~iat:e boxF ~ 1. Sl~n ~tlae ~fcar€ra ar~ri ~la_a ~ ~~;~r€~r1i a£Idress anci yaur certification ntsrxakle~ry 12. make iec~ii~le ccltai£as anct ei=arika€.1t£: as r£;gtlire£:3. J'<LL St~1L TESTS 1ylt.,'S-6` f3~ 1LEC~ t~ITH Tf-~~ LC3CA~ ~TF!{~FtlTl' ~f~'1Tt-Iltt! :3CJ CJfieYS C}f~ C;(~`IPLtTlt~ild. ~~®JlATtf~NS tJE Tip £~!L T`1°~ Srai! S€z{aarat£zs and 'Textures ~ ' r Symts~ls Si: ~- v~tf)nE; It3L'£;r ~~~3 ~'~''S Seefresck Cats - Cofalale ~ ~~~~ .sari -- ~i{r1C~5~tCFn£', . ,~ car _ Gra~1=;€ {u€arle€" 3 } t~S - ~rn£tstorae °; _ Sand E-~G~~a H;~la C..,~ °~r;~ater ~;~ _ C,caarse Sa:,~~ f'erc; -- rat.rcca '~a°~ [Tt('d S -_- ~v~fi3d€Lit17 uc11C.~ ~~a .._. G^a'81i _ ~ ;- ~. i_ € ...._ cC;l - Sa+ncly ~.€~d'u` l~.t:1;1rT1 ~,,«+ ulG} ._.. i('y {~,~c€;,i ~"J;1rCl ~j lY3G~ ~- ++ s s€c - Sj19y Clay fff -- fevr,`, t;ne, 'fa€nE c -- Clay c-c --- c:art~neorar cc ar'e p£ .._ i~c;at n~ri1 -- t~flaray, naetliur~a €~ -- ~J3£ac~ d - distinct: €a _ _ p~ ° r~ ~ ~: r~ I-f~r~tL _... €~, ;. ~€~ le~,ai~ ~ ~iX {<:; 1y -t'a9 5t~ki t£?tit+_€r°as .. ~..; anda2er '~ ~.. v'a S!£ .;,{!5~~£35i~i' ~ ~i ~~ -- ~' r:'la€"tL DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS DIVISION INDUSTRY, P.O. BOX 7969 LABOR AND. PERCOLATION TESTS (11J) MADISON, WI 53707 HUMAN f~ELATIONS (ILHR 83.0911) & Chapter 145) LOCAT N: SECTION: TOWNSHIP/ fihHAM~'t13Rtt~i': LOT NO.: BLK. NO.: SUBDIVISION NAME: N~ ~/ Sc~'/ 1 /T~.$ N/R 1~ E lo) W E~~~ C~~.11 ~ ti COUNTY: WN BUYER'S N ME: MAILING ADDRESS: USE ,,-~,,~~ Residence NO. BEDRMS.: ~ COMMERCIAA1L DES RIPTION: JV~~ __ ,~~,~~ ^New L`_'rReplace ur+ i is vesstesvw ~ wrva mEauc RO NS: TS: ~'` ~j/ NA / e er~nir_. c~ c:.e .~~c•sti~e s... ~..~rn.., ~ ~_ cc.e ~~..~~~;,~hie f.,. e..crar„ Y(~ C~ a ~7 ~ ~ S al y ON^VENTIONA_L• MOUND: IN-GR~OUND~PRESSURE: SY~S~TEM-IN-FILL OLDI T~A~f : RECOMM DED SYSTEM:(optionall If Percolation Tests are NOT required DESIGN RATE: J /~ If any portion of the tested area is in the A t J under s. ILHR 83.0915)Ib), indicate: ~ /-) Floodplain, indicate Floodplain elevation: /~J~J'1 PROFILE DESCRIPTIONS BORING TOTAL D PTH TO GROUN DWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IAJ, ELEVATION OBSERVED EST. HiGHE~T TO BEGROCK IF OBSERVED (ScE ABBRV. ON BACK.) B- ~ ~f y s ~ ~~, ~, ~ / ro"~i 5rl rs ~" ~s~ moo" r..C:L ~p ~`'~ Y ~ ~.M ` Mo ~ ~L" I. C aT ~r y„ ~~ S, i 75 y'' ~n S, I ~tJyD ar9 ~ Gy 1'-Vc B- 3 ~ 1 ~S ~~ ~ '' `I' ~ f31 S;, 7~ ..7" ~~ S; I %+n~ o r9 + g 7 /k~ B- ~ "~~ B- tj ~ I ~ ~~ ~7 5"~ 1 S~ 1 Ts -7 `~ ~n L~o I /~,y~~ Dr7 r 7 ~ta'f i ~ " ~ ~ C I_ '~" v f Q , ~ y ~~ !_i i S (rts ~ " L3~. 5: / "`/,,,t~D ati-5 Mof- PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-IN CHES RATE MINUTES NUMBER INCHES AFTER SWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 P R PER INCH P- P- P- P- P- F'- 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 tiA __. _ _ _ _ r April 23, 1991 Division of Safety and Building Bureau of Plumbing P.O. Box ?969 Madison, WI 53707 Dear Sir: ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY COURTHOUSE 911 FOURTH STREET • HUDSON, WI 54016 (715) 386-4680 An on site investigation of the William Peavey property, located at the NE 1/4 of the SW 1/4 of Section 14, T28N-R16W, Town of Eau Galle, St. Croix County, revealed no suitable soils for an onsite sewage disposal at this location. Should you have any questions, please feel free to contact this office . Sincer ly, James K. mp`s+n°'~pw~ Assista~~~E Zoninct Adm, cj ~, ,.~ inistrator ~ .~~ ,~ , FORM - STC - 104 AS BUILT SANITARY SYSTEM REPORT OWNER TOWNSHIP ~1 ~ ~ ~~~ SECTION~T -2 ~ N-R W °~ tc rf ADDRESS ~._~~ C~ C,«,~ ~ ST. CROIX COUNTY, WISCONSIN t~lJ ) / ~~~ ~/~ SUBDIVISION LOT LOT SIZE PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM ~! ~~. I "° ~~, Gwl, lI X0%0,'7 ~ ,B, M 1~~ 0 1~ ~r~-~ ~I r ~-= Sd ` S Ca ~~ INDICATE NORTH ARROW BENCHMARK: Elevation and description : po~to... car e ~,d'~ Alternate benchmark SEPTIC TANK:Manufacturer: Liquid Cap. Rings used: Manhole cover elev: Final grade elev: PUMP CHAMBER Manufacturer: Liquid rapacity: 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: Trench: Seepage Pit: Width: Length Number of Lines: Exist. Grade Elev. Area Built Proposed Final Grade Elev. Fill depth to top~of pipe: No. feet from nearest prop. line:Front Side Rear Ft. No. feet from well: No. feet from building HOLDING TANK Manufacturer: LU~lsc~ Capa~ No. of rings used:~_Elevation of bottom Elevation of inlet:_T~j i No. feet from nearest prop. line:Front , No. feet from: Well ref ~ , building~~~ , Alarm Manufacturer:_~~~ ~ ~~-,-~ ~ < ~].ty: 0~2»~ G~ tank : 8 ~ . ~a Side, Rear Ft. nearest road T-c~w/a /D / ~~ INSPECTOR• DATE: PLUMBER ON JOB: Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM tabor and Human Relations INSPECTION REPORT Safety and Buildings Division GENERAL INFORMATION ~ ~ (ATTACH TO PERMIT) NF.d SW~ Sec.14_T28-R1fi.Co. Rd. N Permit Holder's Name: ^ City ^ Village ~] Town of: William Peavey Eau Galle CST BM Elev//.:~~ Insp. BM,pnE'~~lev.: BM Description: ~~/_ TANK INFORMATION TYPE MANUFACTURER CAPACITY Sept - Dosi n _ A .~_.._._~__. Holding TANK SETBACK INFORMATION - TANK TO P/ L WELL BLDG. vent to Airlntake ROAD Se tic NA NA . _~ .__ A NA Holding ^-~j ~ _ 7 C~~ a , ~ PUMP /SIPHON INFORMATION Manufacturer Demand Model Number GPM TDH Lift Lriction System TDH Ft Forcemain Length Dia. I-f Dist. To Well SOIL ABSORPTION SYSTEM ELEVATION DATA STATION BS HI FS ELEV. Benchmark ~ a/. ~ ~ ~ Bldg. Sewer ~~ ~/-I-It Inlet ~, ,2, BF•~S"` .StxHt Outlet Dt Inlet Dt Bottom Header /Man. Dist. Pipe Bot. System Final Grade BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I N DIMEN I N SYSTEM TO P I L BLDG WELL LAKE /STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER Mode Num er: System: OR UNIT DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) o~ C~~ ~ ,~ U Plan revision required? ^ Yes [a~IQo Use other side for additional information. ~ o~ SBD-6710 (R 05/91) Date Inspector's Signat County: St. Croix Sanitary Permit No.: 149104 State Plan ID No.: Parcel Tax No.: D Cert. No. -~ _ _ Cep11TeRV DFRMIT ADPI ICOTIAN '1-1 ~~LHR . In accord with ILHR 83.05, Wis. Adm. Code couNTY STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ~ /~ ~~ 8i~ X 11 IfiChe3ln SIZe. Check frevisi nt re iousapplication " ~Se@ reVerSe Slde for InStrUCtIOnS for Completing thlS 8ppllCatlOn. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. 591-40413 PROPERTY OWNER PROPERTY LOCATION WILLIAM PEAVEY NE '/a SW '/a, S 14 T 28, N, R 16 or) W PROPERTY OWNER'S MAILING ADDRESS _ LOT # BLOCK # 2530 COUNTY ROAD B N A N A CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER WOODVILLE WI 54028 715 698-2361 ~~~ I1. TYPE OF BUILDING: (Check one) ^ State Owned D viLTMLAGE ~ NEAREST ROAD Count Trunk N NUM f b ~ F D lli d ® ^ ( ) PA AX rooms 1 or 2 we ng~# o e Public am. 111. BUILDING USE: (If building type is public, check all that apply) 008-101-50 1 ^ Apt/Condo 2 ^ Assembly Hall 6 ^ Medical Facility/Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise: Sales/Repairs 11 ^ RestauranUBar/Dining 4 ^ Church/School 8 ^ Mobile Home Park 12 ^ Service Station/Car Wash 5 ^ Hotel/Motel 9 ^ Office/Factory 13 ^ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) i. ^ New 2. 0 Replacement 3. ^ Replacement of 4. ^ Reconnection of 5. ^ Repair of an System System Tank Only Existing System Existing System B) ^ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ^ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ®HOlding Tank 12 ^ Seepage Trench 22 ^ In-Ground 42 ^ Pit Privy 13 ^ Seepage Pit Pressure 43 ^ Vault Privy 14 ^ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION 450 Feet Feet VII. TANK CAPACITY in allons Total #of e ' N M f t Prefab. Site Con- Steel Fiber- Plastic Exper. INFORMATION New istin Gallons Tanks am urer s anu ac oncret glass App Tanks Tanks structed Se tic Tank or Holdin Tank 200 2000 1 Weis r n r Lift Pum TanWSi hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumbs ' Signature: (No Sta ) MP/MPRSW No.: Business Phone Number: BENNIE HELGESON ~ E ~ 3215 715 772-3278 Plumber's Address (Street, City, State, Zip Code): W 1229 770TH AVENUE, SPRING VALLEY WI 54767 IX. CO TY/DEPARTMENT USE ONLY ^ Disapproved Sapitary Permit Fee (includes Groundwater urcharge Fee) a e ssue Issuing Age t Signature pproved ^ Owner Given Initial ~ v~ o ` A v rmin i n X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-639ti (formerly Plb-67) (R. 11/813) DISTRIBUTION: Original to County, One Copy To: Safety 8 Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary perrr~it is valid for two (2) years. 2. Your sanitary f~errriit may be renewed t;efore the expiration date, and at the time of renewal any new criteria in the 'vVisconsin Administrative Catfe will be applicable. 3. All revisions tc: 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: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. t, II. Type of building being served. Check only 'one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for al/ septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8'/z x 11 inches must be submitted to the county. The plans must include the following: A) piot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The rsusnies colle<;ted through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD-fi33N ;F; ?1r8c~1 ~ ~~ .~ 3a ~ s :;~ ., ~ =~ ONSITE SEWAGE SYSTEM ~~~~~ co ~® REU1T10NS gEPARTMENT OF il~s0i105~ RY, LABOR AND ~~ I SEE CORAE r - -- - - ~ N - ~ __ t, 0 Eli o os~~ ~~ C~..l _ Hal~~~ T~~ N ~ ~~~ ~ ~ g.M~yy~~~ tJ~R.P ioo.oo f ~ ~ 1301 a w~ of ti' ~he \~~e ~t0,;., ~ 1~1«.cc i (~OC~S2 S.cQrrt~ \. ~/ ^ r- h 8~~de d' _ u~ ot~i &>~~. ~--- 3heA F ..~~_ i I~~ t -1- ~ ~ -c I~o~~'. ~S' ~ Min . 1Jer.~ "Fo ~t-es4~ ~~r ~r~}ake ~ ~~~ /~B,AC.tbc~N TH£ EXtS7"il.lG S~PTt~ S~sTt.:.nn a s PiC1Z 11..1-1 R $ 3. O i (, Z 40 ~= MAX. BCTIN~E.tt TNT ,$E;RVtcE ~eav 15ttb T}tE ~fpLpln-C-~ TAMS ~~VICC- MAN NOI.E . ', HOLDING TANK CROSS-SECTION AND SPECIFICATIONS .. 1 9~-1 ~9 4 Approved Vent Cap 4" C.I. _ Vent Pipe l / 1.- 18".Min Approved Locking Manhole Cover with Warning Label 4" Min Water Tight Seal Approved Joint w/ C.I. Pipe Extending 3' Onto Solid Soi Weather Proof Junction Box 12" Min Final Grader, Approved Joint Alarm Sy~tch ~O~~~na c~ 3 •, ~'~'i~c;v Co B~r~btt~ ~ SPECIFICATIONS TANK Manufacturer: Tank Size :_~ ALARM Manufacturer: Model Number Switch Type:• NUMBER OF BEDROOMS: (~ ~e Ser :.x~c~ GallolIns /I o t l~ ~~ OWNER' S NAME : ~:% ~ ~,,,,~ .~ ADDRESS: ~ L~ , LEGAL DESC IPTION: ~4f ;~~, Sec. ~, T.~SN, R ~W TOWNSHIP/MTT~rrivcrs~ir~~L T i : ~ ,~ G Q((.~ COUNTY : ~~(_ ~ ~ Q ~ ~ SIGNED : _ ,:~ '~ LICENSE NUMBER : ~ , -3~~5'' DATE : _~~,,, ,~ ~ y q/ • ; yes~a ~~.c. mrlar -~...... Stock No. 26273 CERTIFIED SURVEYMAP NO. VOLUME , PAGE --. PART OF THE NW. I/4 OF THE SW. I/4, SECTION 14, TOWNSHIP 28 NORTH, COUNTY I WISCONSIN' TOWN OF EAU GALL E, ST. CROIX , NORTHWEST CORNER OWNER SEC.I~, T28N, R16W WILLIAM PEAVEY '~ FOUND I~~ IRON PIPE ?330 C. T. H. 'N ',,, a WOODVILLE, WI r ~ i o .i ~o _ "1 ,y • V .r, N UN PLATTED N LA/y0S ~~ 1 M PT OF BFG. ~~ ~,~ _ ~ 2,3i"E. 38736• I 5.82°/2~34~~F -~ ~ ~_ ~ o ~ ' ~--- 340. !8~ - ~ ~ ~ '~ s.ee~ _ N ~ WE57 /< CORNER =? 3a~E. . ,V i SEC.14, 7?8N, R16W ~ r nr ~ rtc[. FOUND I" IRON PIPE =0 h s ~[0. g h .. ~I ~ P s N of M p I QI W = JI r L=i.R' •N 0 -i V N 0 u W YI k 0 W 2 N W 3 ; 2 O ~~ o ~+ 1- o ~, O O W i v z ~ W Q W W m W p a~ H ~ uW 2 ~¢~ W N m a W N ~~ N ~1 ~ ~" ~ O ~, ~ Q~ o J~ 2 al ~I ~, W~ N u~ 7 • J./' 7.?• LOT N M01/S[ h ~~SV'wNER N 0 N 3 N O 0 N O U) `~ ~~ O= 2. Q~ JI A/7~N~N TOTg1, =12/09 SOFT./?,374 c.1 0~ R. W/NOMI( L lRRN FOUNp, D •...' l W N0. sN[o S.89° 14~59~~W. 146.29 NPLPt~~o U. ~-•SOUTHWEST CORNER SEC.I4, T28N, R16 W FOUND 3/a" RE-BAR SCALE = 1'1 = 100' .__ inn' 300 GG 01 $N[0 ZJO• o~~• 6` 9° A $ ~~ W~ ~~ F-, Q~ J~ a, 21 ~, .f~~~f f f ~fa~e~ * :' DONALD M. ;~` ' CLARK ^ 's c S•1580 ~ .' MENOMONIE, ~~[~11~~~,ftffff - f~OLD1i~G TANK ~~RVICIf~G CONTRACT Contract Dale This contract is made between the --------------------------- HoldingTank Owner(s) Name(s) and i Pumper's Name I ~~~~ ~~ am ~e~ Vpy I LJG(- h'~5S ~~~(/~y' ~r!/~~~ We acknowledge the in~taliation of (a) holding tank(s) on the following property: (Provide legal description:) /~ S W 4k Sec / y _ To ~t/n _ ~Q ~ ~u//P S r- ~rd / ~C~ Coo` i. The owner agrees to file a copy of this contract with the Local governmental unit hereinafter called the "municipality", which F signed the pumping agreement required in Ch. ILHR 83.18 (a) (b), Wis. Adm. Code and with the County of f • `.~~ r k 2. The owner agrees to have the holding tank(s) serviced by the pumper and guarantees to permit the pumper to have access anc enter upon the property for the purpose of servicing the holding tanks}. The owner agrees to maintain the all-weather acct road or drive so that the pumper can service the holding tank(s) with the pumping equipment. The owner further agrees to F the pumper for all charges incurred in servicing the holding tank(s) as mutually agreed upon by the owner and pumper. 3. The pumper agrees to submit to the municipality which has signed the pumping agreement required by s. ILHR 83.18 (a) (b), N Adm. Code, and to the county, a report for the servicing of the holding tank(s) on a semiannual basis. The pumper further agre to include the following in the semiannual report: a. The-name and address of the person responsible for servicing the holding tank; b. The name of the owner of the holding tank; c. The location of the property on which the holding tank is installed; d. The sanitary permit number issued for the holding tank; e. The dates on which the holding tank was serviced; f. The volumes in gallons of the contents pumped from the holding tank for each servicing; g. The disposal sites to which the contents from the holding tank were delivered. 4. This agreernentwsll-remain in effect until the owner or pumper terminates this contract. In the evens of a change in this contra the owner agrees to file a copy of any changes to this service contract or a copy of a new service contract with the municipa and the County named above within ten (10) business days from the date of change to this service contract. Owner(s) Name(s) (Print) ~ Owner's Signature(s) / I i ~~, Jr j o r, ~C~ v~ J C' I - ---~ -- Subscri I 1 I ° r ! _ .' ~• ~ ,. _~ ~s. 'I C /CAA •C S $' -.~~e cep ~ r .S'~C Pumper's Name (Print) ~~~~~ Pumper's Registration Number ~ v~~ ~- I Pumper's Signature I n to before me on this date: M My commissio ez ir2s: ~~ JJ SsD-75~a (N. 1v651 This instrument was drafted by the State of V~Jisconsin Department of industry, Labor and Human Relations, Bureau of Ptumbirtg. von 9~~ fA~f 45? Document No. Thls space reserved for recordlny 4~~~~$ HOLDING TANK AGREEMENT Date County or Local Governmental Unit fi~~'h ~ ~ ~~ ~ Ga/~~ This agreement is made between the I Holding Tank(s) Owner(s) I ~IJi/~i Qrn F ~a veY I ~ S 3 0 L'G . ~ We acknowledge that application is being made for the installation of (a) holding tank(s) on the following property, (Provide legal land description:) E~ f REGISTER'S OFFICE ST. CROIX CO., .WI Recd for Record I~i~Y 1 '~' 1991 at /8:30 A.M V C~n~Q Regtater of Deeds Return To or that continued use of the existing premises requires that a holding tank be installed on the property for the purpose of proper containment of sewage. Also, the property cannot now be served by a municipal sewer, or any other type of private sewage system as permitted under Ch. ILHR 83, Wis. Adm. Code, or Ch. 145, Stats. ,r~U As an inducement to the County of ~~ • l r~ t X to issue a sanitary permit for the above described property, we agree to the following: 1. Owner agrees to conform to all applicable requirements of Ch. ILHR 83, Wis. Adm. Code relating to holding tanks. If the owner fails to have the holding tank properly serviced in response to orders issued by the municipality to prevent or abate a nuisance as described in ss. 146.13 and 146.14, Stats. the municipality may enter upon the property and service the tank or cause to have the tank serviced and charge the owner by placiny the charges on the tax bill as a special assessment for current services rendered. The charges will be assessed as prescribed by s. 66.60, Stats. 2. Owner agrees to pay all charges and costs incurred by the municipality for inspection, pumping, hauling or otherwise servicing and maintaining the holding tank in such a manner as to prevent or abate any nuisance or health hazard caused by the holding tank. The municipality shall notify the owner of any costs which shall be paid by the owner within thirty (30) days from the date of notice. In the event the owner does not pay the costs within thirty (30) days, the owner specifically agrees that all of the costs and charges may be placed an the tax roll as a special assess- mentfor the abatement of a nuisance, and the tax shall be collected as provided by law. 3. The owner, except as provided by s. 146.20 (30) (d), Stats., agrees to contract with a person who is licensed under Ch. NR 113, Wis. Adm. Code to have the holding tank serviced and to file a copy of the contract or the owner's registration with the municipality and with the county. The owner further agrees to file a copy of any changes to the service contract or a copy of a new service contract with the municipality and the county within ten (10) business days from the date of change to the service contract. 4. The owner agrees to contract with a person licenseo under Ch. NR 113, Wis. Adm. Code who shall submit to ttte municipality and to the county a report in accord with s. ILHR 83.18 (4) (a) 2.. Wis. Adm. Code for the servicing on a semiannual basis. In the case of registration under s. i4o.tt~ (3) (d). Slats., the owner shalt submit the report to the municipality and the county. 5. This agreement will remain in effect only until the local governmental unit responsible for the regulation of private sewage systems certifies that the property is served by either a municipal sewer or a soil absorption system that complies with Ch. ILHR 83, Wis. Adm. Code. In addition, this agreement may be cancelled by executing and recording said certification with reference to this agreement in such manner which will permit the existence of the certification to be determined by reference to the property. 6. This agreement shall be binding upon the owner, the heirs of the owner and assignees of the owner. The owner shall submit the agreement to the register of deeds and the agreement shall be recorded by the register of deeds in a manner which will permit the existence of the agreement to be determined by reference to the property where the holding tank is installed. --- Owner(s) Name(s) (Print)„ I Owner(s) ignature(s) _~l_1 ~ r._~ r~._._/J~{__J?~r f..____..___.___ __~ ~-a~~r____. ~-e~'L~`"`~.~_u_ Subscribed and sworn to before me on this date: /' ~, , I I -` Municipal Official Name (Print) I Municipal Official Signature ~ t U 1 :~ ~~ Notary Public I ~ My co 'm" siorrexpires: ~ unicipal Official Title (Print) I C~~~~~/ ~ / ~ ~ '~ SBD-6123 (R. 10/85) This instrument was drafted by the State of Wisconsin Department of Industry, Labor and Human Relations. Bureau of Plumbing. APPLICATION FOR eANITARY PBRMIT This appl)catlon Eorm !s co be the property belny developed. the Pecmlt latuance~ Should owner/eontcactoc,(spec house), completed when the property appcopc)ate deed cecordlnq. ------------------------------- 9 T C - 100 completed in Full and signed by the owner(s) of Any inadegvacies will only result in delays of thla development be intended Eot ie:al• Dy than a satond form should be retained and !s sold and submitted to this otflce with the ---------------------------------- Ovnet of property v ~ - ~ ~--~ ~- Locatlon of property ~1/~ ~S L, v _1/~, 8ectlon T-~~=~-~`-R-"`--V Township C C> r~ ~ ~~~f^ C lU VVo~a ~f'y; l/L I~fi'~ S YCa ~' Melling address ~~~ (L Ilddsas^ of alts ~ubdlvlslvn name ~~ Lot nuaber ~L~° a -+ ,. ~ Previous owner of property ~ ~' Total sls• of parcel `fo~5 - -r Date parcel vas created ~~. ~ ~ 11c• ail corners and lot lines ldentlfiablsl _.-....._._Yes ~_)Jo 0 is thla pcopatty being developed for resale (spec house)?__Yes ~_No ~ Voluwa and Page Number ~_ as recorded with the Reylstar of Deeds. ~ S y .~.w--~.-.-~.~----------------~....~..-. ------------------------------------------------------- -- o PROPERTY OSrNER CBRTIPICATION Q ;iI<'a) cnrtl£y ti:s~t s22 gtateme~titB on this fozrn ace tzue to the best of wy (ovtl tnowledgel that I twe; am :aea? the owner;a) of the property daacrlbpd :n this In[otmatlon Iorm, by vlztue of a waczant des z corded !n the Oi!!ce oI the County Reyletet of Deeds as Document No. ~S ) and that I (Vt) .......,~,., .,..., Fti. .,*.,^~npa wlta Est the sewaaa lBOOSal aystetn (or I (we) have INCLUOS WITH THIS APPLICATION ?ll8 FOLLOVINCi A VJIRRANTY 0860 which includes a DOCUNBNT NUH88R, VOLUNS AHD PAC>i NU1486R, •nd q th• 88AL OY TH8 RSCIeTBR OF D88D8. In addition, a certified survey, it b avallabla, would be helpful so as to avoid delays of the reviewing process. IE .. the deed description te[etencas to a Ceitlfled Survey Map, the Certified Susvey ^ Map shall also be required. -t~ ,SCON: ~: ~ ,_ STATE BAR OF WISCONSIN FORM 1-1962 THIS SPACE RESERVED FOR RECORDING DATA . ~.•,_.-_._, ooCt:.MENT No. WARRANTY DEED ~~~ r ~~ '~-~+, ~~ ~ aar` ~~~ REGISTER'S OFFICE _ _ _ ST. CROIX CO., W Thls Deed, made between ...Ta1le_y.._Ros.~ue_tte__a.nd_. ---- ReC~d for Record Viola . Roque-tte, _husband. and _ wi-fe .as_ joint. --- - - i A~'R1a198 -_ - - - . i - _ tenan-ts -- -- -- _ Grantor, ~ 9 :45 A.J M -- . _. -, - -- -- and _ William._Peavey and._Jean -~'.eav~y~._husb~n- --_an ;,~' ~ ~~~ ~n ~ wife .as _survivorsh_ip_ marital. pro_per.ty_ ._ ---_-.-- - R~i~~~ ~~Mds ' _.._._ -- - - - - ---- -~ Grantee, - - V6litnesseth, That the said Grantor, for a valuable consideration . . llar--.an. d-_other. valuab.l e..-co.ns.i-de_ra_t a,on-_-___. o d One RETURN TO . . --- conve}•s to Grantee tl;e following described real estate in __-S.t=-.-Cr_o1X__.-___ County, State of ~~isconsin: west one-half (W 1/2) of the Southwest Quarter (SW 1/4) of Section 14 ~ Township 28 ~ Range 16. Tax Parcel No_ ___________________________________ i Q'RANSFER .~~ This _._1S...no.t-_..._-_ homestead property. pis) (is r.~~t) Together with all and singular the hereditaments and appurtenances thereunto belonging; --- -- - - _ - Ana_.._~ra-ntor- ------- --- -- --- --- warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except and will warrant and defer~I the same. ~'• - ----~ I9-89 .. A r.~ 1--- - --- -- -- - - ---.. IJaced this ._. ---- ~ ~-- --- ---- ------- -day of - -- -- - - - p r- _(SEAL) ~ . /-`-~~ --~ . 'L~ - . -- ---(SEAL) --- Talle Ro ette -- -(SEAL) `- ;- ~~----- - -- --- - ---- ---...------(SEAL) - - - - --- -- Viola Roqu tte - ---- -- - AUTHENTICATION ACKNOWLEDGMENT of Talley Roquette STATE OF WISCONSIN Si ature O ---- - an~ Via -a Roquette Sg• ----------- ----- --•-----------•---------------- ----- _______`:_;_f; ;ro_ ~: _ County. April - --.-.._.., 19.89- Personally came before me this __._- ~__-___..day of authenticated this ._._._day of_.._-_-._-_.. - t,T)ri l 19.-~'«__ the above named