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HomeMy WebLinkAbout040-1320-00-004 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 556311 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: Grismore, Elmer A. Troy, Town of 040-1320-00-004 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: O1S t GST- 13.28.20.2151 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER. s CAPACITY STATION BS HI FS ELEV. Septic 'Z j Benchmark Aj C-CC'j C:,a.15 i Z66 A-7 111.7 Aeration Bldg. Sewer 3• ~5 / Z3 . is Holding SUHt Inlet G /1%. a -3 TANK SETBACK INFORMATION SUHt Outlet * y5 X17 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic / A'^ 33 Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Y • 3 /0 3 . Holding Bot. System PUMP/SIPHON INFORMATION Final Grade 14 2-7 16 '_1 Manufacturer Demand St Cover GPM LD" !5 - 53 Model Number J- / t -7. Z. /!J 5 TDH Lift Friction Loss System Head T Ft ►z 9.3 /a Z• Forcemain Length ia. Dist. to Well f_ /a . 7 / 0 1 I F SOIL ABSORPTION SYSTEM 1-7,77- 1 Z 4. C3 2.'% 16~ 9 BEDITRENCH Width Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 $Z ? SETBACK SYSTEM TO P/L J BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR L L Type Of System: ~Q a j UNIT Model Number: Co r.Je ,vim. DISTRIBUTION SYSTEM Ant, A)a j- Y p 4- I- r 6 S Header/Manifpld I Distribution x Hole Size x Hole Spacing Vent to Air Intake SC, 4' (1P Pipe(s) Spacing so J•1-~ G S Length Dia Len9 th ` Dia \ 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 5 Bed/Trench Edges Topsoil\ ~ ✓ Yes FE-] No F° Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 287 Croix Ridge Dri a Hudson, WI 54016 (Unknown 13 T28N R20W) Cove Ridge Lot 4 IParcel No: 13/~ 8.20.21 = , Ge J .5- 15 J-, V_, ~ ~ t7G !l' - 760 di $ - J 1. Alt BM Description 51 " (e I aG~w e p l~ l l 1'¢G`J r.~ t!~ t ~o o . 2.) Bldg sewer length = !5o P J - amount of cover = '4 L O ~Q a 6 ,.ti Plan revision Required? 0 Yes No q -~3 Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's Si ature Cert. No. PLOT PLAN PROJECT TravGrismore ADDRESS 1612 Stone Pine Ct. Hudson Wi 54016 SE 1/4 SE 1/4S 13 /T 28 N/R 20 W TOWN Troy COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 8/8/12 BEDROOM 4 CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1200 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 1230 # of chambers 60 BENCHMARK V.R.P. Top of survey iron ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 102.4/101.2/100.0 5' below qrade Croix Ridge Drive All piping shall be SDR 30/34, within 10' of tank, piping shall be Schedule 40. Well is to meet all setbacks required by Scale is 1" = 40' WDNR unless otherwise noted Property Line Pro 4 Bedroom House /G Property Line 2 Vent D 6„ Quick4 Standard S ~~Pover Leaching Chamber with 20.0 ft2 of Area 6 10.2ft^2/pair of end caps ~ 0 4' Long 12 Grade at System Elevation 34" B-3 55' r'J 0 110' 20 aca vw 108' ents B-15' 1 18% Slope 0B-2 3-3' X 82' Cells with 15' >3' spacing 95' eommerce.wl.gov Safety and Buildings Division County, / I Afiftab con 201 W. Washington Ave., P.O. Box 7162 JT ✓Ul S ~ Madison, WI 5 3 707-7 1 62 sanitary rerm:c Number ([o be fined in by Co_) Ieparlimrn of Com 4w, 3 t W PPlieation 1, ' ' State Transactiq Number Sanitar~~ In accordance with s. Comm. 83.21(2), Wis. Adm. Codsslon of this form to the appropnategovemmental unit is required prior to obtaining a sanitary A. Note: Application forms for state-owned PO~IVTS are Project Address Of different than mailing address) submitted to the Department of Com~~~`~`Personal information you provide may be used for secondary u oses in accordance with the Privac Law, s. 15.(4(1 m), Stats. I. Application Information - Please Print All Inform n $ - ',,L r Property O Ine a d^ n ti a a-. Parcel # t` J fV,~ f Ot/O 3-20 Property O/ s M g Address Property Location /b/2- 57 17 Govt. Lot City, tate Zip Code Phone Number r 1A Section --F (circle one 1A I T N; R 01,) E W II. Type of Building (check a that apply) Lot # 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name p 4~ Block ~ t O r Cad ` D v ❑ Public/Commercial - Describe Use 1 ❑ City of ❑ State Owned - Describe Use CSM Number ❑ Village of Town offZ Za a- 26 4- Zb III. Type of Permit: (Check onl one box on line A. Complete line B if applicable) A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner O w: ej,_ IV T e of POWTS S stem/Com onent/Device: Check all that apply) -Pressurized hi-Ground ❑ Pressurized In-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 ersaf/Treat ent Area Information: 1gn Flow (gpd) Design Soil Application (gpdsf) Dispersal Area Required (sf) Dis ersal Area Proposed (sf) Syste Elevaho -79/ Z1XX4)a VI. Tank Info Capacity in Total # of Manufac er Gallons Gallons Units o ° New Tanks Existing Tanks C°c n U to rn w C7 CL. Septic or Holding Tank / Dosing Chamber VII. Responsibility Statement- I, the undersigned, ass esponsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumbe lgnature MP/MPRS Number Business Phone Number .5 0, F Plumber's Address Str et, City, State, Zip Code , ZY> Q VIII. Coun /De artment Use Only Approved isappr Permit Fee Date Issued Issuin gent Signatur 1 iven Reason o nial $475. v 13 l~ IIX. Condi&R pWK*,Reasons for Disapproval 1. $eptic tank, efflubnt fifter and dispersal cell must all be services / maihtahed as per management plan provided by plumber. 2. Atl se6ack tequiretitents must. be, fnaintaltWd n Pei q*klible code / ofdh0ik Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 inches in size SBD-6398 (R 02/09) PLOT PLAN PROJECT TravGrismore ADDRESS 1612 Stone Pine Ct. Hudson Wi 54016 SE 1/4 SE 1/4S 13 /T 28 N/R 20 W TOWN Troy COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 8/8/12 BEDROOM 4 CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1200 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 1230 # of chambers 60 BENCHMARK V.R.P. Top of survey iron ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 102.4/101.2/100.0 5' below qrade Croix Ridge Drive All piping shall be SDR 30/34, within 10' of tank, piping shall be Schedule 40. Well is to meet all setbacks required by Scale is 1" = 40' WDNR unless otherwise noted Property Line Pro 4 Bedroom House Property Line Vent >6" Quick4 Standard of Cover Leaching Chamber with 20.0 ft2 of Area 60' 12„ 10.2ft^2/pair of end caps 4' Long Grade at System Elevation 34" B-3 55' EIA S 110' 20' ' 108' ents B-15' 106' 18% Slope 30 B-2 3-3' X 82' Cells with 15' >3' spacing 95' BM.* copy Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 8/8/12 Owner: Tray Grismore Location: SE1/4 SE1/4 S13 T28 N,R20W 287 Croix Ridge Drive Troy System type: In-ground absorbtion system(conventional) Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Section 4-6. Maintanance and Contingency Plan 7. Filter Specifications Sheet Signature License number 26900 i PLOT PLAN PROJECT TravGrismore ADDRESS 1612 Stone Pine Ct. Hudson Wi 54016 SE 1/4 SE 1/4S 13 /T 28 N/R 20 W TOWN Troy COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 8/8/12 BEDROOM 4 CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1200 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 1230 # of chambers 60 BENCHMARK V.R.P. Top of survey iron ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL * H. R. P. Same as Benchmark SYSTEM ELEVATION 102.4/101.2/100.0 5' below qrade Croix Ridge Drive All piping shall be SDR 30/34, within 10' of tank, piping shall be Schedule 40. Well is to meet all setbacks required by Scale is 1" = 40' WDNR unless otherwise noted Property Line Pro 4 Bedroom House Property Line Vent ALo Quick4 Standard Leaching Chamber with 20.0 ft2 of Area 60' 10.2ft^2/pair of end caps 34" Grade at System Elevation B-3 55' S 110' 20' 108' ents B-15' 106' 18% Slope 30' -2 3-3' X 82' Cells with 15' >3' spacing BM. 95' . Cross Section of Quick 4 Standard Leaching Chamber Typical cross section for 2 of 3 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber l0.lft^2 pair of end plates To be >1' above grade Finish grade elevation Typical Installation 110.0 Vent Grade Vent 4' 4" 4' X30/34 Septic Tank 4' Long 1 5' 4' Long 191 3479 Grade at System Elevation 3411 Grade at System Elevation Spacing 5' 3-3' X 82' Cells Observation tubeNent Same on other end To be located on end of Cells %A B System elevations: C A-102.4 B101.2 20 chambers per cell C100.0 I ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer 7 M, 0 ~t Mailing Address 161 Property Address e 7 Cro 1',4- XA " ~ z (Verification required from Planning & Zoning Department for new construction) City/State ` Parcel Identification Number. (2yo f 3 Z O r Cb- LEGAL DESCRIPTION Property Location e ti" . '/4 '/4 , Sec" _Q-) . , T Z N RZ 0 W, Town of Tro ciSubdivision _ , Lot # . 01 Certified Survey Map # Volume Page # Warranty Deed # , 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 313 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. 1/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue o a warran deed recorded in Register of Deeds Office. Number-of be oms NATURE 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. 08/0S) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS c ~ Septic Tank Capacity 1~~ all ❑ NA Owner ~ Septic Tank Manufacturer ❑ NA Permit # ::::~j - //Z. Effluent Filter Manufacture ❑ NA DESIGN PARAMETERS ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model bIA Pump Tank Capacity gal N Number of Public Facility Units Estimated flow (average) - al/da Pump Tank Manufacturer Design flow (peak), (Estimated x 1.5) al/da Pump Manufacturer Soil Application Rate al/da /ftz Pretreatment Unit NA Pump Model Standard Influent/Effluent Quality Monthly average" Fats, Oil & Grease (FOG) <_30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD5) <_220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) <_150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD5) 530 mg/L bgtn'-Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) <_30 mg/L ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) <_104 cfu/100m1 ❑ Drip-Line ❑ Other: Other: ❑ NA Maximum Effluent Particle Size Yin dia. ❑ NA Other: NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA ear s Pump out contents of tank(s) When combined sludge and scum equals one-third of tank volume ❑ NA At least once every: ❑ month(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) ear(s) At least once every: month(s) ❑ NA Clean effluent filter ear(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) 11 NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) 11 NA ❑ year(s) Other: At least once eve ❑ month(s) NA ry❑ year(s) Other: NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third 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. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment 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. Page of START UP AND OPERATION For new construction, prior to use or the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the To avoid this situation have the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: + All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • 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 the replacement area will result in the need for a new soil and site evaiuation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. <<WARNING>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name Name Phone Phone 7/ J--~~" d- j SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name ✓c i Name Phone '7/_j7- 1 Phone F~-- Z//-;? ~ This document was drafted in compliance with chapter SPS 383.22(2)(b)(1)(d)&(f) and 383.54(1), (2) & (3), Wisconsin Administrative Code. a1V RLTER CARTRIDGE INSTRUCTIONS Installation STEP I Dry fit the filter case onto the end of the outlet pipe to ensure it is centered under the access opening. If not, then either insert more pipe into the tank through the outlet or solvent weld lue additional i e onto t pipe. P P he outlet STEP 2 While the case is stiU dry fitted on the outlet pipe, measure the length ~ of 4-inch pipe needed to brace the filter to the tank end wall if utilizing the optional supplemental side support. If side support method is not utilized, proceed to step four, r4. TFP .3 For installations utilizing the optional supplemental side support: solvent weld the 3h-inch pipe onto the filter case. If side support method is not iRq utilized, proceed to step four. Solvent weld the filter case onto the outlet pipe. Insert the filter cartridge into the case, pressing dawn until the filter locks into the bottom of the case. - 1 If a VRS switch is utilized: insert into the filter and lock by turning Yr % a r clockwise 900. 1,.'71 Maintenance 1, The effluent filter should be cleaned every time the septic tank Is serviced. 2. Open the outlet access opening to inspect the tank and filter, 1 3, Pump the septic tank completely, making sure to remove the sludge y layer on the bottom of the tank and not just the scum and effluent. 4. Once the effluent level has been lowered below the invert of the outlet pipe, firmly pull up on the filter handle to dislodge the cartridge from the case, s. 5. Slide the cartridge up and out of the case for cleaning. 6. If a VR5 switch connected to an alarm is present, the switch should be removed by turning counterclockwise 900 and cleaned ' with water only. 7. While holding the cartridge on its side (large fiat surface facing { down) over the access opening, rinse off the cartridge with water c, tri i only, making sure all septage material is rinsed back into the tank. ~ 8. If VRS switch is utilized, replace by inserting into filter and turning clockwise g0*. 4. Insert the filter cartridge back into the case'' ..r. Pressing down unfit the filter locks into the bottom of the case. 10. Replace and secure the access opening on the tank,' l:' :1\:. ri "r..:JAl.r.• -{i.-{. t{'rRf'i.Aw :+V,il . www beamnsitexow 877-MLFILTEIkS (653-4583) 2 Wisconsin Departmentof Commerce U~ g 707 SOIL EVALUATION R Page of Division of Safety and Buildings 10 i c da9 10 . mm 85, Wis. Adm. Code Four G& .,tY Attach complete site plan on paper rpt** an 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel 1.15 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. t9 1 _ Please print all information. Revie by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). $ 3 / Property Owner Property Location /,e f CA fr r Q/ Govt. Lot S~ 1 /4 1 /4 //3f Z 8N R (or y~P Property Owners Mailing A ess Lot # Block # Subd. Name or CSM# 6'. - L D A 2- City State Zip Code Phone Number ❑ Cri'Y Village Town arest Road _ E-1 ( ) New Construction Use: Residential / Number of bedrooms Coda derived design flow rate GIRD ❑ Replacement ❑ Public r commercial - Describe: Parent material (lli~.t.~ Flood Plain elevation if applicable General comments s and recomrnendations: System Type ~:Z/jjio, System Elevation ~ro, I Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor In. M Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 - s s J 3 is . 5 v Boring # ❑ Boring ® Pit Ground surface elev. C s D ft. Depth to limiting factor ! v in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. -Eff#1 •Eff#2 1 - / S 3 s" . J I Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 ' Effluent #2 = BOD 130 mg/L and TSS < 30 mg/L CST Name (Please Print) lure CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date aluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 540 715-246-4516 Property Owner _ Parcel ID # Page of Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate ® Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 4*Eff#l 'Eff#2 I D~ S C' L 3 , ice- ~l hi l1 0 Boring # Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mg/_ ' Effluent #2 = BODS < 30 mg/L and TSS < 30 nVL The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (8.6/00) Property Owner _ Parcel ID # Page of Boring # Boring Pit Ground surface elev. ft. Depth to limiting factorL in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr.•Sz. Sh. 'Eff#1 'Eff#2 I o- l S . - Z _ , S L Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil ication Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 i i Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mgA- ` Effluent #2 = BOD5 < 30 mgA_ and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBa8330 QLWOD) Soil Test Plot Plan Project Name Tray Grismore Shau rd Address 1612 Stone Pine Ct. ` Hudson Wi 54016 CS #226900 Lot 4 Subdivision Cove Ridge Date /12 SE 1/4 SE 1/4S 13 T 28 N/R20 W Township Troy Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. top of survey iron System Elevation 102.4/101.2/100.0 *HRpSame as Benchmark Croix Ridge Drive Scale is 1" = 40' unless otherwise noted Property Line Property Line B-3 55' 110 110' ' 108' B-15' 106' 18% Slope 30' -2 15' BM.* 95' Ole 1.688 ACRES 73,531 S.F. n j"" 44 /-tI, ~ / 1 cn « or © " tr i So r« 4 s, y' z 2.000 ACRES •'~~`'~~'~`~Qap~'.~. 87,133 S.F. R=800 5 C. " 1.674 ACRES--- a c•~a / 72,834 S.F.! ~a Oi......_..........",..................... Z:C 412.55' LO 188.39' :0 224.16t 158.14 0 0oq7 I Arm$ w OA's nr%f ~ II I IIIllillllllillllllll 1111111 State Bar of Wisconsin Form 1-2003 8 0Tx:4044941 WARRANTY DEED 959061 BETH PABST Document Number Document Name REGISTER OF DEEDS ST. CROIX CO., WI THIS DEED, made between Kevin P. Mergens, a single person 06/28/2012 1:58 PM EXEMPT#: N/A ("Grantor," whether one or more), REC FEE: 30.00 TRANS FEE: 426.00 Elmer A. Grismore III and Andrea L. Grismore, husband and wife, as survivorship marital property PAGES: 1 ("Grantee," whether one or more). Grantor, for a valuable consideration, conveys to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is Recording Area needed, please attach addendum): i Lot 4, Plat of Cove Ridge in the Town of Troy, St. Croix County, Alliance Title, LLC 3600 Minnesota Drive, Suite 175 Wisconsin. na, MN 55435 040-1320-00-004 Parcel Identification Number (PIN) 287 Croix Ridge Drive, Hudson, WI 54016 This is not homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except: roadways, easements, restrictions and rights of way of record. Dated June2' , 2012 (SEAL) (SEAL) * K vin P. Mere en (SEAL) (SEAL) * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) authenticated on ) ss. 01 I~ COUNTY ) * Personally came before me on Jun10 2012 , TITLE: MEMBER STATE BAR OF WISCONSIN the above-named-Kevin P. Mergens, Grantor (If not, authorized by Wis. Stat. § 706.06) to own t be the person(s) who execut . oing i ent and knowledged the same. Cy0 THIS INSTRUMENT DRAFTED BY: ~QTO)o el Redmon Law Chartered (Richard Lau) 401 Second Street, Suit 200, Hudson, WI 54016 Notary Pu e of Wisconsin L ~y ) My Commission (is permanent) (expirepi .1 (Signatures may be authenticated or acknowledged. Both are not necessary.) I~ NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. 1V2ANTY DEED © 2003 STATE BAR OF WISCONSIN FORM NO. 1-2003 ss~~ pype name below signatures. i ~-yyy I bi N vI T II ~ III ~ f Ul~ I G I G G I ? ~J Ilu! N FM A 01 I s x 1, L _ -H y _ d jFF- I i uJ ~ III .II I I. - °v Y1 ~Sa1.4'ory'Z lk g I 1y 7 ~ dn3L / V B'>3z F77, 9 ~ ~ I I ~ -a7 ^f 67 ~ M I - ~ N - I - O 8°r6 ? E-~r S U ro I A ro~z - E-~ I N _ `7 ns 1I ? I I I a ~ N 6. N g m~ g s 3 i 4 ~6SL2'~I I ,1r' y _ ~ _i~j' - ~ - . s i ~ z - ~ . " . a m J,~ ~ ~ ~ +'zs~- ILL4 ~nl Z"°IIL£2iyry ~-f tftl:l I ~~~e E a ~ - - ~ I, O O d ~ - 42si~n1 E<~E~ 'L'c~l - ~ 'I: ~ - = ILLf'v71F ~ ~Z`~ ~ilF.ltnl °IILf~LNlli t 1• 1 ~ ~ ~ s~ w~slwulP ti I r: ~C ~ „,ram g 9 ~ J LL d rg ~ ~N3 h3 ~ ~I n ~ I ~ ~~~II r ~ w ~ I j O ~ ~5 ~ I _ _ 3 ~ n,av_s ~ _ d 9~ A ~ I Ft - - - lLLfv~1 a °.n \ - - I I I o I I 'J I I ~ ~ ~4v~1 i ae2 ~ ~ i ~ I I ~ f ~ j dry I i I 2'IL:2W1'? Z~ILS b11. 9 ~ 1 _ ~ ~ ~ 3 I ~ la i I d~ ~~•p I Lt L[»~ a J 3 'I~ .BoG 3"/Yrl3"/rY2:~~ g Yl L ~ I n II _,t S ~3 f 113 j. ~ d~1 qB2 I U i I 1NV^ ,oy I z I i I I_ J i J I j II' I ~J I- TI o c4r J R f l l J 1 a I I~ L11~ a zr.Q N N ~ ~ _ - zl. ~ ~ IryI I a I 21:L1 I - I I ly{ - it I iC FT:1 I ~I i I I V. Wftconsin Department of SOR V,, EPORT Page 1 of 3 Division of Safety and Buildings ~q in 85, Vft . m a a A P A `n C county ST. CROIX Attach complete site plan on paper not 1 x 11 inches in®si~. A;0" include, but not limited to: land horizonhal BgM~a)~,,,d~ir~e,c,t~ion and Parcel I.D / percent slope, scale or dimensions, north arrow. and 7' -D? by " infontnatho . Re Please print all / 7 b !p Personal information you provide may be used for second wy purposes (Privacy Law, s. 15.04 (1) (m)). Property LOCatiOrt / ■ Property Owner BOMAR HEIGHTS, LLC (Buyer: Bruce Lenzen Homes) Govt. Lot - SE 11//4r . 1/4 d T 2 N R 20 ~ W Property Owner's MOM Address Lot # Block ~ Subd. Name or CSM# 6810 Brookhill Drive 4R - (Pending) city Slate Zip Code Phone Number Tl* ❑viNage ElTown Nearest Road Salt Lake City, UT 84121 ( 1 NK South Cove Road • New Cormin ctlon U960 Raldsrillel / Number of bedrooms Code dwiad deslpn flow rob GPD ❑ Replacement ❑ Public or commercial - Describe: ft Parent material till Flood Plain elevation 9 applicable »A General cornments 1~1 e-N) (r ot"-'S Conventional In-ground trenches 0.4 to ding rate 13&,,D and recommendations: bv' ~ Mcd.~ G6ob~ S To be designed by insta ak6cje . ~e r~U' AL- hoc 5a A Bork9 # O Pit Ground surface elev. - R Depth to knift factor 51 in. Soil N?g- Rate Horizon Depth Dominant Color Redox Description Texture Strtxabixe Consistence Boundary Roots GPDAf` in. Munsell Qu. Sz Cord. Color Gr. - Sh. 'Ef #1 *002 1 0-5 7.5YR2.5/2 - sl 2fgr mvfr aw 3vf-co 0.6 1.0 2 5-12 7.5YR2.5/3 - si 2fsbk 111' es av1-w A 2fsbk mfr cs 2vf-co 0.6 0.8 3 12-20 7.5YR3/4 - 4 20--4 7J 4 - fflfP lvf=M 016 1:0 5 43-51 7.5YR4/4 - sl 2fa-mabk dsh - lvf-f 0.6 1.0 Bw* ❑ Boring 52 ❑9 ❑ Pit Ground surface elev. 4 W,'7$ ft. Depth to 1irrdl's1g factor in. Sod Applicakiri Rate Horizon Depth Dominant Color Redox Description Texture Stnjcture Consistence Boundary Rods GPDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. '01fi:1 '092 1 0-4 7.5YR2.5/2 - sl 3fa&sbk mvfr cb 3vf-co 0.6 1.0 2 4-15 7.5YR2.5/3 - fsl 2fsbk mvfr cw 2vf-co 0.4 0.7 3 15-34 7.5YR4/4 - sil 2fabk mfr as 2vf-co 0.6 0.8 4 3452 7.5YR4/4 - s Osg ml - - 0.7 1.6 Horizon 3 has some, one srnne- ' Effluent #1 = BOD > 30 < 220 ffq& and TSS >30:5 150 mg/L ' Effluent #►2 = E1095:5 30 mgA- and TSS < 30 nglL CST Name (Please Print) nature CST Number Mary Jo Hollister ~JC 224832 Address _ Dale Evaluation Caiducfed Telephone Number W9875 690th Avenue, River Falls, WI 54022 10 - 21 & 11 - 17 - 05 (715) 426 - 1775 t Property Owner BOMAR HEIGHTS, LLC (Lot 4R) Parcel ID # (Pending) Page 2 of 3 Boring # ®^0 50 • Pit Ground surfaceelev. Y14.1o q fL Depth to limiting fador in. Sol Applicabon Rate Horizon Depth Dominant Coll Redox Description Texlue Structure Consistence Boundary Roots GPDlfP in. munseu UU. x W14. %AM A •,2 w~ 1 0-6 7.5YR2.5/2 - A 2f-msbk mvfr cb 3vf-co 0.6 1.0 2 6-25 7.5YR3/4 - sl 2f-msbk mfr cw 2vf-co 0.6 1.0 3 25-41 7.5YR4/4 - sl 2fa&sbk mfr as lvf-m 0.6 1.0 4 41-50 7.5YR4/4 - sl 2fa&sbk dsh - - 0.6 1.0 Horizon 4 has many si cts. El in. FD Boring # pig Ground surface elev. 21. U3 ft. Depth to limiting factor 55 U Sol AppWation Rate Horizon Depth DorranaM Color Redox Description Texture Structure Consistence Boundary Roots GPDff in. Mundt Qu. Sz. Cord- Color Gr. Sz. Sh. 'Etf#1 'Eff#2 1 0-6 7.5YR2.5/2 - sl 2fsbk mvfr cb 3vf-co 0.6 1.0 2 6-I2__. /2 _ &I 2f--msbk mvfr cs 2vf-co .4 0.7 3 12-35 7.5 YR3/4 - fs1 2fa&sbk mfr cs 2vf-co 0.4 0.7 4 35-55 I0YR4/6 - fs Osg dl - lvf-m 0.5 1.0 Ong* Ea~n9 Ground surface elev. R l4. q5 ft. Depth to Urnov facto' 53 in. Soil Rate b @Fl ®@FflIR t fiRim- mon ommirm @040111" in. Munsel Qu. Sz Cord. Color Gr. Sz. Sh. NO% 'Eff#1 'Eff#2 1 0-10 10YR2/1 sl 2fsbk mvfr cb 3vf-co 0.6 1.0 2 10-29 1 _ sl 2f-msbk mfr cs 2vf-co 0.6 1.0 3 29-53 I0YR4/6 - fs Osg ml - lvf-m 0.5 1.0 ' Effluent #1 = BOD, > 30:s 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODs < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. saD-s 3ffem UL07M) Plot Plan for Cove Ridge Page 3 of 3 Town of Troy, S Croix County, Wisconsin (R>`~►o : os-ls-00 Lot 4 I"= 50 ft Legal Description s>FYg -m, seYyj Sic. l3. 2,f~ contours T2214, XZDvJ 4 = Backhoe pat c°VF ~ n 919.68969• o- pR~VF t BENCH MARK: TOP OF 1 1/4" a RON PPE 41 v~ 1: J21. 332 84D I: 14.95209' • I: 895.87608' 4 M O~ J MARK: SCALE:1 "=50` TOP OF 11/4" RON PPE •N I: 897.50190' BENCH MARK: TOP OF 1 1/4" IRON PPE 1: 918.33548' 5 B-5C 0 -1: 919.103 ' n Parcel 040-1320-00-004 04/09/2008 08:41 • PAGE 10F 1 Alt. Parcel 24.28.20.2151 040 - TOWN OF TROY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 07/31/2006 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - BLH DEVELOPMENT CORPORATION INC BLH DEVELOPMENT CORPORATION INC 502 2ND ST STE 204 HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description * 287 CROIX RIDGE DR SC 2611 HUDSON SP 1700 WITC Legal Description: Acres: 2.000 Plat: 11-008-COVE RIDGE 040/06 LOTS 1-13 SEC 24 T28N R20W PT NE NE; BEING COVE Block/Condo Bldg: LOT 04 RIDGE ('06) LOT 4 (2.000AC) Tract(s): (Sec-Twn-Rng 401/4 1601/4) 24-28N-20W NE NE Notes: Parcel History: Date Doc # Vol/Page Type 07/31/2006 830969 11/008 PLAT 05/02/2006 824187 WD 12/07/2005 813723 2940/194 QC 08/02/2005 802065 20/5033 CSM more... 2008 SUMMARY Bill Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/24/2007 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 188,500 0 188,500 NO Totals for 2008: General Property 2.000 188,500 0 188,500 Woodland 0.000 0 0 Totals for 2007: General Property 2.000 188,500 0 188,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00