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HomeMy WebLinkAbout032-2009-50-200 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division Sanitary Permit No: INSPECTION REPORT 556304 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: Sindear, Marian J. Somerset, Town of 032-2009-50-200 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: /OC> lryl ctl- 02.30.19.5028 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic r 5 i Benchmark Ian Alt. BM t+ 78 9`7. 0-7 ' m O Aeration Bldg. Sewer C1 1, A/ Z Holding St/Ht Inlet 9/ ZS TANK SETBACK INFORMATION St/Ht Outlet c/'~ 9b -7 7 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic I R Dt Bottom *7 YJ Dosing Header/Man. 141 T""05 Aeration Dist. Pipe P4.15 Holding Bot. System /3.C JS.R9 Final Grade C1 2- PUMP/SIPHON INFORMATION T • Z b Manufacturer Demand St Cover GPM .7 cy~ 07 fr \ Mod er TD Lift Friction Loss System Head TDH Ft Forcemain Dist. to Well SOIL ABSORPTION SYSTEM BED/TREDNS Width3 Length N 7f Trenchre~C PIT DIMENSIONS No. Of Pit Inside Di Liquid De tph DIMENSIONS !6 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type , ,S^yste~m 1 45~ -7~ UNIT Model Number: DISTRIBUTION SYSTEM Aea l H7lIt r 4- to Header/Mangold / Distribution x Hole Size x Hole Spa g Vent to Air Intake 9 Pipe(s) S Length Dia A4 Length~,r Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only a o Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes No es 0 No COMMENTS: (Include code di crepencies persons present, etc.) Inspection #1: Inspection #2: Location: 1742 HillcrestDrDrive New Richmond, WI 54017 (SW 1/4 NE 1/4 2 T30N R19W) NA Lot 1 Par el No: 030.19.50 1.) Alt BM Description = I ] I"^ U~" Q 5+ew ~~A c 2.) Bldg sewer length = a - amount of cover = ~a tt _ o Plan revision Required? ❑ Yes *No - Use other side for additional information. Date Insepctor's Si ature Cert. No. SBD-6710 (R.3/97) ~x County RECEIVED Safety and Buildings Division S %af H 201 W. Washington Ave., P.O. BOX 7162 Sanitary Permit Number (to be filled in by Co.) Madison, WI 53707-7162 JUL 31 201?. 55~30q PLANNI State Transactio Number ~~`ary Permit Application In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit ~Tl is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(l)(m), Stats. I17#Z #i 7llc,!'e&- &%jr I. Application Information - Please Print All I ation I Property Owner's Name / Parcel # MAR ~ AVJ 0 3Z 2x0 50 Property Owner's Mailing Address Property Location l• 56Z In E T'LeR AVe Govt. Lot fs,) City, State Zip Code Phone Number 1/4, SE , /4, Section on l~ lV.) 7~ f r V ~S- /b 04 I 1 p(circle E o1Q) I,. Type of Building (check all that a pply) Lot # T N; R 4I(1 or 2 Family Dwelling -Number of Bedroom ~ Subdivision Name Block # ❑ Public/Commercial - Describe Use Z'4e_f ❑ City of ❑ State Owned - Describe Use / G'LCSM Number 11 Village of Z 4;04.- Q / /!//J/ Z77lZTownof S01V\ERf19_11" III. Type of Permit: (Check only one b Ax on line A. Complete line B if applicable) A. ❑ New System WReplacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) ❑ Permit Transfer to New List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber Before Expiration Owner IV. Type of POWTS System/ omonent/Device: Check all that apply) 9-Non-Pressurized In-Ground ❑ Pressurized hi-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Trea ent Area Information: Design Flow (gpd) Design Soil Application Ra gpdsf) Dispersal re sf) Dispersal Area Pro sed (s System Elevation VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o o v New Tanks Existing Tanks w U v w~~/dfzSZSy'Yy ~R~ a U v~ ~ iw C7 P, Septic or Holding Tank fy~y^ I v CJ~N f7~ Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP PRS umber Business Phone Number SErp ~c U 2! Z3211 Z 715 7~55-Zy 61 Plumber's Address (Street, City, State, Zip Code) 17 U- p- 5 7040 in 7~ _ A171- ~ s8 17 VIII. Count epartment Use Only Approved isapprove Permit Fee Date IIss Qd J Issuing nt Signatu iven Reason Denial $ #;767 / IX. Condi '12easons for Disapproval 1: peptic tank, *Mubnt lifter and ✓J A- Iftoersill cell trust all be servIces I mpintained alQ per management plan provided by plumber. Co ka 1440# kKfequkemw is must be,maintainOd n F* Opkililo cods / Wdd1 ; Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD-6398 (R. 11/11) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE" Project Name:11RI f~1.S srN~LE A-lZ Owner's Name: Owner's Address: 1873 Pec- 2 Ave 5`1 MZWk -$~:'NLLS W/ Legal Description: ICE 11q 5 E S Z T 30 R 1 a lr✓ Township: -50"RSi --r County: 0 Q0 oL Subdivision Name: Lot Number. Parcel ID Number: Page 1 index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 8 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber n-efF -Fplf-- License Number. 1WPRS ZZ.-Szgz Date: -713))12- Phone Number "7 1 S - °755- 21-1 lo( Signature ' / Designed purtsaurt to the Sol Absorption Component Mena for PO TS version 20 sao-10705-P (M.01101). Page 1 If gL ;46 D (~M ~e1 ~ ,C7r~,L~ S~a .1WA%1t i w 3 ,Q i s'9 , c t Soif AbsorpV 3ysto Cross Section 8/ ft 4' Schedule 40 Final Grade PVC Vent Pipe ft 8- With Vent t Ca ICJ Leaching _ Chamber 65 - ~ ft f- System Elevation _ ft ft Soil Absorption SVStem Pian View ft ~3' ft Vent Or Observation Pipe Leachmg Trench 1 Chambers 4' Dia. Trench 2 Header Leaching Chamber SPeelfications QJ ~~L q Manufacturer And Model KN-tl(-QlYhv) EISA Rating sq ft per chamber Soil Application Rate ~7 gpd/scj ft gpd Design Flow A7 Soii Application Rate EISA = __;32- Chambers 2 rows of ~ chambers each. Page of ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 1L1F1(Z~0 iE~IBC IE-tkZ Mailing Address X73 FteR Au4 ir- 0 R©Ix i--P\u S , kl i 5 yo Z~l Property Address ) (Verification required from Planning & Zoning Department for new construction.) City/State K~i~( Parcel Identification Number LEGAL DESCRIPTION Property Location I~G '/4 , SO , Sec. 2 , T ab N R 19 W, Town of 5QX~E RS[s-1" Subdivision Plat: , Lot # Certified Survey Map # , Volume , Page # Warranty Deed # (before 2007)Volume , Page # 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 the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on thi orm are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a 71' my deed recorded in Register of Deeds Office. Number of bedrooms AV4 S G AT RE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 09/07) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner ~16 Septic Tank Capacity ~~00 al C7 NA permit - Septic Tank Manufacturer 0 NA RESIGN PARAMt:TERS Effluent Fitter Manufacturer y aK ❑ NA Number of Bedrooms D NA Effluent Filter Model 0 NA Number of Public Facility Units ANA Pump Tank Capacity al V NA Estimated flow (average) at/day Pump Tank Manufacturer _ ANA Design flow (peak), (Estimated x 1.5) G al/day Pump Manufacturer _ NA Soil Application Rate y~ ai/da /fits Pump Model - Of NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit -NA Fats, Oil & Grease (FOG) s'30 mg1L ❑ Sand/Gravel (=alter ❑ Peat Filter Biochemical Oxygen Demand (BOD,) 5220 mg/L ❑ NA 0 Mechanical Aeration 0 Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other, Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA 1 A. Biochemical Oxygen Demand (BODS) 530 mg/L "Ir -Ground (gravity! ; ❑ In-Ground (pressurized) Total Suspended Solids {TSS) 530 mg/L ❑ NA 0 At Grade ❑ Mound Fecal Coliform (geometric mean) 5104 cfu/100mt ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ya in din. ❑ NA Other: ❑ NA Other: ❑ NA Other: E3 NA Other. ❑ NA * Valuas typical for domestic wastewater and septic tank effluent. MAiNTMANCE SCHEDULE Service Event Service Frequency inspect condition of tank(s) At least once every: 13 month(s) (Maximum 3 years) ❑ NA ar(e) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3} of tank volume ❑ NA Inspect dispersal call(s) At least once every, , E3 month(s) (lVi2xirium 3 years) E3 NA ~ , ear(s) ' Clean effluent filter At least once every: ❑ month(s) 0 NA ©month(s) Inspect pump, pump controls & alarm At least once every: Z- year(s) © month(s) ~lA Flush laterals and pressure test At least once every: p year(s) Other. At least once every: ❑ year(s) Other: ptA MAINTMMCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following Gdenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintalner, 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 scum and to check for any back up or ponding of effluent on the ground surface, The dispersal call(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any pondint of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a fairing condition and requires the )mmedlate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y,) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing operator and disposed of in accordance with chapter NR 113 Wisconsin Administrative Code. Ali other services, including but not lirriited to the servicing of effluent filters, mechanical or pressurized components, pretreatmen units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GhAW Page of START UP AND OPERATION For now 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 andlor damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to. the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to- restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb. or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS. antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of sarvice the following steps shall tie taken to insure that the system is properly and safely abandoned in compliance with chapter Comm $3.33, 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 shall be removed and properly disposed of by a Septage Servicing; Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the;void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: -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 thereplacement 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. E1 The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption. systems may be reconstructed in place following removal 'of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNiNG> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY R SULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY RE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER E--~ Name Nam ACF P hone - 7 Z q 7 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY LITkORt`C ` ' !77~d Name Name lle 0t -0-0 Phone Phone ` 1j,-- (.n- This document was drafted in compliance. with chapter Comm 83.22(2}{h)(1)(dl&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner ~i(f1PR1~j Septic Tank Capacity J~}QQ al ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer 13 NA Number of Bedrooms ❑ NA Effluent Filter Model ❑ NA Number of Public Facility Units j, NA Pump Tank Capacity al O NA Estimated flow (average) aVda Pump Tank Manufacturer ANNA Design flow (peak), (Estimated x 1.5) y a al/da Pump Manufacturer NA Soil Application Rate gal/day/ft' Pump Model j~ NA Standard Influent/Effluent Quality Monthly average* Pretreatment Unit CVA Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (13006) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetlard Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other; Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (80135) 530 mg/L -Ground (gravity) ❑ in-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 510` cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ya in dia. ❑ NA Other: ❑ NA Qther: ❑ NA Other: ❑ NA *Valves typical for domestlc wastewater and septic tank effluent. Other' ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ m ont}(s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one-third of tank volume ❑ NA Inspect dispersal cell(s) At least once every: O month(s) (Maximum 3 years) ❑ NA ear(s) Cleave effluent filter At least once every: ❑ month(s) ear(s) ❑ NA Inspect pump, pump controls & alarm At least once eve 0 month(s) NA ry: -gear(s) ❑ month(s) Flush laterals and pressure test At least once every: p year(s) ~`4 Other: ❑ month(s) At least once every: ❑ year(s)~A Other: PIA' MAINTE=NANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following lidenses 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 scum and to check for any back up or ponding of effluent on the ground surface, The dispersal call(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any pondin4 of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulat}on of sludge and scum in any tank equals one-third or more of the tank volume, the enth contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113 Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatmen units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (410.1) III o G o 0 0 0 Nil Iw_ U O L[1 U N O N I- m V U CO N M c 6q N N N CN U u O u U Oi M N O OD A1111- IN III Q U, U 1 ~ i N co U O ~ CO L6 ~y I OP~YAR i ! CO CO CO U N ti C6 u W O U d' Q cn LU G_ cn m O IFiIsm 11 Iloilo U cr cn co 04 N ~F- H Z w O U l~ Q U3 o m O \ N Cl LU ooi v Co ti -I S, co LLI cn - a N m LLJ U0, ¢ o C7 co LU LL1 W w d N Z 2t.) 0 co U -j ~ rn d U N w w d CO ~ J 0 0:5 Li LL J Z C`~ J J J~HOJFa- F¢ d d m 0 O 0 ~t O o 0 N l1~ O M ch ~ M O M LO co CO r-I O CC) O O H Z ILU- t=X X~ W N LU CDu W J J W Z c=r) C O m y O W W LU U C7 ] Cn J Z Lu CD C3- U:) _ C5 N C.7 m -J ~Lc~ Z~ ® p N w-J _ mot' _ ~ pp o O Lrl> ~ucr7 =aC6 ,r z N 1--- W LO ~ Q J o-celve' 3M 3 2017 Wisconsin Department of commie ,i . SOIL EVALUATi I F Page of Division of Safety and B~ zoto* oFF i PLAN in accordance with Comm 85. Wis. Adm. Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest mad. 6 z=2 w . Please print all information. Dais personal information you provide may be used for secondwy purposes (Priveay Law, s. 15.04 (1) (m)). Property, r Property t ocafim Govt. Lot AIZ 1/4 114 T N R E (or~ Property Owner's Matting Address Lot # Block # Subd. Namf or uaw 11/4 1 Zip Code Phone Number ❑Y ❑ Village ®Town O New Construction Use:, Residential ! Number of bedrooms Code derived design flow rate GPD 0 'Replacement O Public or commercial - Describe: -7~- Parent material D2ZJ&a~z Flood Plain elevation if applicable ft. General comments, and recommended=.- Boring S ((O~~ # Boring (n Pit Ground surface elev. ft. Depth to limiting factor in. Sol Applicadw F-4 -OZ Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPQff In. Munsell Qu. Sz CqnL Color Gr. Sz. Sh. 'Eff#1 OQ - q 1,14 1 it - W © Boring # ° Boring ® Pit Ground surface elev. ft. Depth to limiting factor in. Soi! Application Rats Horizon Depth Dominant Color Redox Description Textixe Structure Consistence Boundary Roots GPD/fi= In. Munseti Qu. Sz Cqk Color Gr. Sz. Sh. 'Eti#1 'EfF#2 s ~t A/ q 3 R 4 EftKint 4 4 b = BOD > 1220 mgn- and TSS 1-30:5 150 mgA- PI(Mt #2 = _ 30 nV& and TSS 5 30 mglL CST Anse / Signature (ST Nutlber Address Oate Catdiu~d Telephone Number Panel ID # Page ~of .5 property owner 3 11 BO"M jo Pit Ground surface elev. ft. Depth to VMMV factor 's Soil Application Rate E Horizon Depth Dominant Color Redox Description . Textue Structure C nsistence Boundary Roots GPOM In. Munsell Orr. Sz. Cont. Color Gr. Sz. Sh. `EIW1 *Ef F#2 4 4 Q 9 4 4 1 11 it ❑ Pit Ground surface elev. ft. Depth to g factor in. ~ AxWmdon Rds F-] # ❑ng Horizon Depth Dornirrarn Color Redox Desdiption Texture Structure Consistence Boundary Roots GPDVfE In. Mursell Qu. Sz. Cont. Cola Gr. Sz. Sh. '8101 "EM2 Boring # ❑ Bonng Ground surface elev. tt Depth to WW" factor. ❑ Pit Sol Application Rete Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GOOM In. Mutsell Qu Sz. Cont. Color Gr. SL Sh. *M 'E11102 Eftent #1 = BAD, > 30 1220 rngn. and TSS >30 < 150 argil ' Effluent #2 = BC06 < 30 rnol. and TSS 30 m9L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 609-264-8777. san.aswtie.doot /873 I p~ 5"l 9~ ~ 8g 86 Z-1 k)4// ' 0 3 s'9 0 .~~sas6 VOL 16 PAGE 4277 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD CERTIFIED SURVEY MAP 04-09-2002 4:30 PM LOCATED IN THE NE 1/4 OF THE SE 1/4, THE NW 1/4 O SURVEY MAP THE SE 1/4, THE SE 1 /4 OF THE NE 1 /4 AND THE SW 1 gQPYFFEE. 33008 OF THE NE 1 /4 OF SECTION 2, T30N, R 19W , TOWN OF -PAGES: J? SOMERSET, ST. CROIX COUNTY, WISCONSIN.z H J SCALE IN FEET ~00 LEGEND °~ZZ W 2 ~a ~ W O 50 100 200 COUNTY SECTION CORNER La :I- MONUMENT, FOUND, (TYPE ~``.,~`'`o cno = SE 7/4 OF NOTED). ~ ~ z ~ f- THE NE 1/4 3 6 w w Sw 1/4 OF VI Wm w= THE NE 1/4 1 1/4" (OUTSIDE DIAMETER) C) I o x 24" IRON PIPE WEIGHING waWvvl l w p _ 1.68#/LINEAR FOOT. SET. m w o a z UNPL A T TED L A_ND_ E 1 /4 CORNER N I S - - SECTION 2 POINT OF 3 N z 1 ~`~°00' 00 „ BEGINNING T30N, R 19W 324 45. E / (1 1/4" (OUTSIDE DIAMETER) IRON N 89-13' S3" W 1 5214.96' PIPE) Id-- - N:rEA --_s W 1 / 41 CORNER .69' SECTION 2 19W w =N T-WEST 1 /4 2 1/2" z LOT _ ~.jn SECTION LINE OUTSIDE 00 't 11-11- 3.010 ACRES , DIAMETER) a q\" DIAMETER) 131,117 S.F. IRON PIPE) o o z1o m Vi Z1 m~ UNPL A T TED LAND ~ r C Z -L lfi r\ Cn W - m JVE 1/4 OF THE SE 1/4 ~a 3I Z BUILDING _ wEC-`~°o r SETBACK LINE SEPTIC f I~ I TANKS I_ I o / Q I I GATE R A A C'' 84. \ CZy/ GR~'~~ / 4 I I 155.02 37' C3 L , S 86°00' 00" W N 2°00' 00" W C 1 N1L! / Flo s AfW 1.14 HE SE i4 i UNPL A T TED L A ND1 f T APPROVEDi Planning Zoning and Parks Cmittee A ES D . F LK I NS S-2246 JOB #00-2496 ST. CROIX COUNTY, CFILKINS G I STERED LAND SURVEYOR APR 0 9 20021 DEN ENGINEER I NG COMPANY 113 WEST WALNUT STREET RIVER FALLS, WISCONSIN 54022 If not recorded within 30 dais of approval date approval sha I he DATE : JANUARY 16 , 2002 null end void ~t"REVISED: JANUARY 28, 2002 REVISED: FEBRUARY 25, 2002 ~~t!!F",~~ L REVISED: MARCH 27, 2002 CURVE TABLE CURVE RADIUS CENTRAL ARC CHORD CHORD TANGENT TANGENT NO. ANGLE LENGTH LENGTH BEARING IN OUT C1 267.00' 28:32:12:: 132.98 131 131.61: S 83°43 54.0 W S 69°°27' 48" W N 82°00 00 W C2 267.00' 101 145 47.51' 47.45' S 74°33' 40.5 W S 6927' 48" W S 79°39' 33 W C3 267.00' 18°20' 27 85.47' 85. 10' S 88°49' 46.5" W S 79°39' 33" W N 82°00' 00" W C4 533.00' 12°00' 00 111 .63' 111 .43' N 88°00' 00.0" W N 82°00' 00" W S 86°00' 00" W THIS INSTRUMENT DRAFTED BY JAMES D. FILKINS PAGE 1 OF 2 Vol. 16 Page 4277 72+10 740 r KATHLEEN H. WALSH A U 2 4 15 P 4 0 2 REGISTER OF DEEDS ST. CROIX CO.. NI TERMINATION OF DECEDENT'S RECEIVED FOR RECORD PROPERTY INTEREST 09/22/2003 10:00AM DECEDENT'S NAME TERM OF DECEDENT PRO GEORGE W. SINCLEAR EXEMPT # ADDRESS OF DECEDENT AT DATE OF DEATH CITY STATE ZIP REC FEE: 25.00 TRANS FEE: 1742 Hillcrest Drive, New Richmond, WI 54017 COPY FEE: DATE OF DEATH SOCIAL SECURITY NUMBER CC FEE: PAGES: 8 December 5, 1998 393-34-9779 PRESENTATION OF DEATH CERTIFICATE I certify that I have viewed a certifi opy of the decedent's death certificate. 1~aiAteel-l • W6L" 03 Recording area REGISTER OF DEED'S SIGNAT E DATE Name and return address: EAGLE VALLEY BANK, N.A. Interest in property is terminated under (please check appropriate statute): St. Croix Falls Branch x s. 867.045 which pertains to property in which the decedent was a joint tenant,` had 2206 Glacier Drive a vendors or mortgagee's interest, or had a life estate. `(You must provide a copy of the PO Box 1106 document establishing joint tenancy or life estate.) St. Croix Falls, WI 54024 s. 867.046 which pertains to (1) property of a decedent specified in a marital property agreement, and also to (2) survivorship marital property. (You must provide a copy of the 32-2009-50-000 & 32-2009-60-000 document establishing survivorship marital property.) PARCEL IDENTIFICATION NUMBER Presentation of recorded document establishing joint tenancy, life estate, survivorship marital property, vendor Interest, or mortgagee interest in real estate. This document number is 279580 volume 412 , page 17 of (check one) Records X Deeds This document number is 280289 volume 413 page 495 of (check one) Records X Deeds Description of the real estate. Include only the extent of ownership (or vendor or mortgagee's intereso in land at the time of the decedent's death. If the extent of land is exactly the same as on the document, a copy of that document may be attached to describe the real estate. Attach tax bill(s) for year immediately preceding death, if applicable. (See directions.) The legal description of the property and the persons receiving the property are as follows: (if more space is needed, attach pages.) n See Attached. Description of personal property (if any) being transferred. You may list savings accounts, checking accounts and securities on attached pages. Indicate person(s) receiving property. DECLARATION: I (We) declare that this document is, to the best of my (our) knowledge and belief, true, correct and complete and is in conformity with the provisions and limitations of the Wisconsin Statutes. (if more space is needed, attach pages.) Name and address of Persona Receiving Property to Decedent Signature Notarized Date Marian J. Sinclear spouse _ 1742 Hillcrest Drive q111163 New Richmond, WI 54017 This document was drafted STATE OF WISCONSIN, County of '00K by: , (print or type name below ••''~-3 Subscribed and sworn to before me on Qllq l03 •~'Y M~iRd person(s). Steven J. Swanson, Atty. . 9 s St. Croix Falls, WI 54024 Signature of notary or other person authorized to administer an oath NOTE: SEE DIRECTIONS. as per s. 706.06 706.07 Wisconsin Register of Deeds it Vs" G Association Form HT-110 Print or a nam at- o (a A v~ Version 1/2001 tYP e: 8 y ; Title: Notary Public Date commissio dl . .Od INFO-PRO 1$O0,M ,2021- ' www.infoprolorms.com U 2415P 4 0 3 ATTACHMENT TO TERMINATION OF DECEDENT'S PROPERTY INTEREST Decedent: George W. Sinclear The decedent held a joint tenancy interest with Marian J. Sinclear, his wife, in the following described real estate: a) The Northeast quarter of the Southeast quarter (NE1/4 of SETA), Section 2, Township 30 North, Range 19 West, St. Croix County, Wisconsin. b) The Northwest quarter of the Southeast quarter (NW1/4 of SE1/4), Section 2, Township 30 North, Range 19 West, St. Croix County, Wisconsin. Iii Parcel 032-2009-50-200 07/31/2012 02:47 PM PAGE 1 OF 1 Alt. Parcel M 02.30.19.5028 032 - TOWN OF SOMERSET Current ❑X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner 0 - SINCLEAR, MARIAN J MARIAN J SINCLEAR 1873 PEER AVE ST CROIX FALLS WI 54024-8144 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description ' 1742 HILLCREST DR SC 5432 SCH DIST OF SOMERSET SP 1700 WITC Legal Description: Acres: 3.010 Plat: 4277-CSM 16-4277 032-2002 SEC 2 T30N R19W NE SE,NW SE, SE NE, & SW Block/Condo Bldg: LOT 1 NE LOT 1 CSM 16/4277 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 02-30N-19W Notes: Parcel History: Date Doc # Vol/Page Type 09/22/2003 740740 2415/402 TI 2012 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/12/2010 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.010 25,000 133,600 158,600 NO Totals for 2012: General Property 3.010 25,000 133,600 158,600 Woodland 0.000 0 0 Totals for 2011: General Property 3.010 25,000 133,600 158,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 09115/2005 Batch 05-14 Specials: User Special Code Category Amount i Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00