HomeMy WebLinkAbout020-1077-80-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
(ATTACH TO PERMIT) 556337 0
GENERAL INFORMATION State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
McDonnell, Patrick M Hudson, Town of 020-1077-80-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
/atj < 6r 28.29.19.3158
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURE CAPACITY STATION BS HI FS ELEV.
Septic Be~ncchmark 166
I'J. tte F t / vL~O l a to Y-5 mY, 5
Dosing Alt. BM
o la 5Z5 F,• t Ce ~f 5
Aeration Bld . S wer Z -b' 16.79 4 7. -2 /
rJ~r ,17 9$:33
Holding _ St/Ht Inlet
q/5 -75-3:5
TANK SETBACK INFORMATION St/Ht Outlet /Z
`9Jr~
`J„3$
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic > 5a 30 / 36 f Dt Bottom
Dosing A Y a _ Header/Man. /d g 1 3 toy
Aeration Dist. Pipe
10.8 `!'3 _CRS
Holding Bot. System B
9 `Z, C,
PUMP/SIPHON INFORMATION Final Grade (o, C, 1/ is
Manufacturer Demand St Cover
Model Nu er
TDH Lift Rickqq Loss Sy -He'ad TDH Ft
y
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width 3,74(o engthZ No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. T uid Depth
DIMENSIONS (e / _ '
/
SETBACK SYSTEM TO P/L BLDG ~WELLL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type Of System: CHAMBER OR I rQvl_ty-
J UNIT Model umb r
A4
DISTRIBUTION SYSTEM
t// ZZ
40
Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake
.1 DiaPipe(s) ~ LT Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over q Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center 1 Bed/Trench Edges Topsoil
Yes No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: / /
Location: 515 Cty. Rd UU HHud on, WI 5544016 (NW 1/4 NW 1/4 28 T29N R1 9W) NA of 1 Parcel No- 28.29. 3156
1.) Alt BM Description v.n'/~- d J y~J
2.) Bldg sewer length
- amount of cover = / a
7 4 0,A-
Plan revision Required? H Yes o L r~
f
Use other side for additional information.
SBD-6710 (R.3/97) Date Insepct Sig re Cert. No.
Safety and Buildings Division County
! 0 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
Sp ri Madison, WI 53707-7162 ~5 (ip 33
•Y . _ to Transaction Number
e2), ermit Application tJ A-
In accordance with SPS 38 . ts Adm. Code, submission of this form to the appropriate govern menYaTunit
is required prior to obtaining a sanitary, pert: ~Ndte Application forms for state-owned POWTS are submitted to Project Address (if different than trailing address)
the Department of Safety and ~rafossibnal Servies. Personal information you provide may be used for secondary
u ses in accordance with the Privacy Law, s. 15.0 1 (m , Stats. r
1. Application Information - Please nt All Information
Property Owner's Name Parcel #
- bbd
OZO • 07 •
_
Property Owner s Mailing Address Property Location 6 zztz Govt. Lot
p
City, S to Zip Code Phone Number t~ 1 y. y4 Section_
(circle one
T,_ N; R - 2 E or>
lz:=-
II. Type of Building (check all that apply) Lot #
Subdivision ame
I or 2 Family Dwelling - Number of Bedrooms
Block #
❑ Public/Commercial -Describe Use ❑ City of
CSMNumber 11 Village of
11 State Owned -Describe Use
19 Town of
III. Type of Permit: (Check only one box on line A. Complete line B if applt ^ Ale)
A' ❑ New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
List Previous Permit Number and Date Issued
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New
Before Expiration Owner `
IV. Type of POWTS S stem/Com onenttDevice: Check all that a I
Non-Pressurized In-Ground C1 Pressurized In-Ground 11 At-Grade 11 Mound > 24 in. of suitable soil El Mound < 24 in. of suitable soil G'f%CN*%JOG
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/Treat ent Area Information:
Design Flow (gpd) Design Soil Application Rate sf) Dispersal Area Required (sf) Dispersal Area Proposed System Elevation
3 ,
VI. Tank Info Capacity in Total # of Manufacturer
Gallons Gallons Units a v u y
New Tanks Existing Tanks /dk ~ZS c 2 y U
a
a` U in H vi U. 0
Septic or Holding Tank ( ~S
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume respo bility for installation of the POWTS shown or the attached plans.
Plum er' ame (Print) Plumb is Sign MP/MPRS Number Business Phone Number _elsl
Plumber' Address (Street, City, late, Zip C de)
'Of
VIII. Coun epartment Use Only
Permit Fee Date ssued Issuing ent Signat e
Approved
iven Reason enial
IX. Condift%",A easons for Disapproval 3
1. Septic tank, effluent Piker and t
dispersal cell must all be services / maintained
as per management plan provided by plumber,.
2. All setback requi(ements must.be.maintained 5
as / w~.-
Attach to complete plans for the system and subm to the unty only on paper not less than 8 in, z 11 inches in size
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CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: ~ =/Z
Owner's Name:
Owner's Address:
Legal Description:
Alh
Township: ~a g~ L
County:
Subdivision Name: ,U
Lot Number:
Parcel ID Number:
Page 1 Index and title
Page 2 Plot Plan
Page 3 System Sizing
Page 4 System Cross-Section
Page 5 Filter Specs
Page 6 Maintenance & Management Plan
Page 7 Septic Tank Maintenance Form
Page 8 Warranty Deed
Page 9 CSM or Plat
Designer/Plumber: ~¢LJ License Number:
Date: Phone Numbers ~!g/- 79/
Signature
Designed pursuant to the In-Ground Soil Absorption Component Manual for POWrS Version 2.0 SBD-10705-P (N.01101).
Page 1
~~s~~
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-0-s-7 ~ = ~~~6'• „~J C~✓2s*„6,CL°S
3X~
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1
Soil Absorption Svstem Cross Section
ft
4° Schedule 40 Final Grade
PVC Vent Pipe
With Vent Cap
Leaching
Chamber ft
System Elevation
._f f
Soil Absorption System Plan View
ft
ft
-J-/ft Leaching Trench 1
Vent Or Observation Pipe r Chambers
4" Dia.
Trench 2 Header
i_eachina Chamber SpecMeations
Manufacturer And Model
EISA Rating sq ft per chamber Soil Application Rate gpd/sq ft
gpd Design Flow : _ Soil Application Rate EISA =,-.,7//= Chambers
2 rows of chambers each.
i Page of I
r~o
, ~aK~,n~ INSTALLATION INSTRUCTIONS
fnnova6onsinPrecas4Drainage Zabel'
& WasfeMrafer Products p p~~ ct p y,~,
PL-525/PL-625 FILTER
INSTALLATION INSTRUCTIONS
Center filter
with opening f a i Lil
eg
wZ • .
Additional pipe or°
Polylok xE~ rad Lok-
- :for GE nt2r:~n9. GCue
Step 1:
Step 2: Step 3:
(A) Locate the outlet of the septic tank. (A) Before installation, place the (A) Glue the filter housing on the
(B) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe.
if necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the
is positioned so the filter can be housing, making sure the filter
removed from the tank for cartridge is properly aligned and
maintenance and service. completely inserted in the housing.
MAINTENANCE INSTRUCTIONS
L K,"i
Step 1: Step 2: Step 3:
Locate the outlet of the septic tank. (A) Remove tank cover and pump (A) Insert the filter cartridge back I
DO NOT USE PLUMBING 10", if necessary, into the the housing making sure
WHEN FILTER IS REMOVED (B) Pull the filter out of the housing. the filter is properly alighed
(C) Hose of the filter over the septic tank. and completely inserted.
USE RUBBER GIwOVES Make sure all solids fall back into the (B) Replace septic tank cover
iNHEN C~EANIt~G FILTER cantir tank
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page Zof _
FILE INFORMATION SYSTEM SPECIFICATION
Owner 4 Azd)eT Septic Tank Capacity al ❑ NA
Permit # Septic Tank Manufacturer J ❑ NA
Effluent Filter Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Model ❑ NA
Number of bedrooms ❑ NA Pump Tank Capacity al ANA
Number of Commercial Unit ❑ NA Pump Tank Manufacturer m- NA
Estimated flow (average) gal/day Pump Manufacturer in NA
Design flow (peak), (Estimated x 1.5) -3 gal/day Pump Model Z NA
Soil Application Rate , `7 al/da /ft Pretreated Unit
Influent/Effluent Quality Monthly Average* ❑ Sand/Gravel Filter ❑ Peat Filter
Fats, Oils & Grease (FOG) <30 mg/L n Mechanical Aeration ❑ Wetland
Biochemical Oxygen Demand (BODs) <220 mg/L ❑ Disinfection ❑ Other:
Total Suspended Solids (TSS) <150 m L Manufacturer
Pretreated Effluent Quality ❑ NA Monthly Average" Dispersal Cell(s)
it In-ground (gravity) ❑ In-ground (pressurized)
Biochemical Oxygen Demand (BODs) <30 mg/L ❑ At-grade ❑ Mound
Total Suspended Solids (TSS) <30 mg/L ❑ Drip-line ❑ Other:
Fecal Coliform (geometric mean) <104 cfu/IOOmL
Maximum Effluent Particle Size '/s inch diameter * Values typical for domestic (non-commercial)
wastewater and septic tank effluent.
Values typical for pretreated wastewater.
MAINTENANCE SCHEDULE
Service Event Service Frequency
Ins ect condition of tanks At least once ever ❑ months -2f ears Maximum 3 rs
Pump out contents of tank(s When combined sludge and scum equals one third '/3) of tank volume
Inspect dispersal cells At least once eve ❑ months-_-;' 0-year(s) (Maximum 3 rs)
Clean effluent filter At least once ever ❑ months Ll year(s)
Inspect um um controls & alarin At least once ever ❑ months ❑ ear(s) WNA
Flush laterals and pressure test At least-once ever ❑ months ❑ ear(s) .@ NA
Other: At least once eve ❑ months ❑ ear(s) a NA
Other: At least once ever ❑ months ❑ ears ANA 777771
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 ('/3) 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 ch. NR 113,
Wisconsin Administrative Code.
The servicing of effluent filters, mechanical or pressurized POWTS components, Pretreatment comPonents, and any other
maintenance or monitoring at intervals of 12 months or less 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.
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other i
chemicals that my impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have
the contents of the tanks(s) removed bya septage servicing operator prior to use.
Owner: Page _of
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal high water levels. When power is restored the excess wastewater
will be discharged to the dispersal 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 soft absorption are.
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; '
s• medications;
oil
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONEMENT
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 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 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 limes and wells. Failure to protect the
replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area.
Replacement systems must comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and 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 coinP1Y with the rules in effect at the time.
<<WARNING>>
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASES 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
Phone Name
Phone
SEPTAGE SERVICING OPERATOR (PUMPER)
Name LOCAL REGULATORY AUTHORITY
Phone Name
Phone] J
START UP AND OPERATION Page Z OT
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents
of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(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 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 evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
available a holding tank
evaluation must be performed to locate a suitable replacement area. If no replacement area is
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 INSTALL5A POWTS MAINTAINER
Name / Name
Phone Phone I ~j
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name
Phone Phone j -a
`his document was drat; ::_-c' ance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
ST. CROIX COUN'T'Y
SEPTIC TANK MAINTENANCE AGREEME
AND
OWNERSHIP CERTIFICATION FORM
Owmer/Buyer
Mailing Address
Property Address
(Wacation required from Planning & Zoning Department for new construction.)
City/State - Parcel Identification Number
LEGAL DESCRIPTION
Property Location Xl&) V4 , V,, Sec. 12, I'-,;;4 N R W-, Town of
io-abE~t vIC` Cf Lot #
.y
n
Certified Survey Map # , Volume , Page #
Warranty Deed # , Volume , Page #
Spec house yes Lot Tines identifiable no
SYSTEM MAIlVTENANCE AND OWNER CERT MCATTON
Improper use and mainumance of your septic system could result in its prematur e failure to bundle wastes. Proper
maintenance consists of pumping out the septic tank every tlaee 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 ow=ner 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
,vastew•ater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
ess than 1/3 full of sludge.
Uw e, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
`TatmaI Resources, State of Wisconsin
=t4_dard set fortb- herein. as set by the Department of Commerce and the Department of'
ve izcaton stating that your septic system has been maintained must be completed and returned to the St Ckoix County Planning &
Zoz u'--~ De; artment within 30 days of the three year expiration date.
1-m certift- that aH statemeuss 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.
N '-umber of bedrooms
SIGNATURE OF APPLI DATE
Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department
rue with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
s-ece is made in the warranty deed.
iRT,Z )
VOL 2379PAU632 73Ei3-7S ( r
STATE BAR OF WISCONSIN FORM 2 - 1998 KATHLEEN H. WALSH
WARRANTY DEED REGISTER OF DEEDS
ST. CROIX CO., WI
Document Number RECEIVED FOR RECORD
This Deed, made between Leo A. Draveling and 08/19/2003 11:30AM!
Monica J. Draveling, husband and wife, WARRANTY DEED
EXEMPT •
_ Grantor, REC FEE: 11.00
and Patrick M. MCDone , a singe person, TRANS FEE: 501.00
COPY FEE:
CC FEE:
PAGES: 1
Grantee.
Grantor, for a valuable consideration, conveys and warrants to Grantee the following
described real estate in St. Croix County. State of Wisconsin:
Recurding Aran
Name and Return Address
First Federal Capital Bank
ATTN: John Sias
H1ACV_-0_r)' 'SCI o1Lo
020-1077-80
Parcel Identification Number (PIN)
This is homestead property.
(is) (is not)
I
Part of NW 1/4 of NW 1/4 of Section 28, Township 29 North,
Range 19 West, St. Croix County, Wisconsin described as follows:
Lot 1 of Certified Survey Map filed may 5, 1997 in Volume 11,
Page 3250, as Document Number 558889.
i
Exceptions to warranties:
Subject to easements, reservations and restrictions of record.
Dated this /_3 day of August 2003
(SEAL) (SEAL)
* 1ZQ A. DRAVELT /
(SEAL) Ct,rlri_ (SEAL)
* MONICA J. DRAVELING
AUTHENTICATION ACKNOWLEDGMENT
Signature(s)
State of Wisconsin,
St. Croix County. J
authenticated this day of Personally came before me this 13 day of
August 2003 the above named
Leo A. Draveling and
Monica J. Draveling,
*
TITLE: MEMBER STATE BAR OF WISCONSIN to
(If not, me oe person S who executed the foregoing
authorized by §706.06. Wis. Stats.) i owledge th e same,
THIS INSTRUMENT WAS DRAFTED BV }P
~U5
Stephen J. Dunlap i;
TAMARANotary Public, State of Wisconsin
Hudson, Wisconsin Z My commission is permanent. (If ot, state expiration date.
(Signatures may be authenticated or ackn d. oth are n CO /A/ 7 )
necessary.) 4j y
" Names of persons signing in any capacity must tx typed or pl ~1Set5w,l~tare.
E BAR OF WISCONSIN Wisconsin Legal Blank Co,. Inc
WARRANTY DEED FORM No. 2 - 1999 Milwaukee, Wis.
,VcrrlvF-o
SEP 0 5 2012
YlriscorrsimD p~ )NtNG~FF~~ E SOIL EVALUATION REPORT Page Of
oldsion of dmgs
in accordance wUh Comm 85, Wis. Adm. Code
County
Attach complete site plan on paper not less than S W x 11 inches In site. Plan must
Include, but not limited to: vertical and horizontal reftwence point (BM), direction and Parcel I.D.
percent slope, scale or dimensions, north arrow, and location and distance to rreerest road. U 7 7 7 -66t) , 3 5
Please Print all inAwm don. AMIS
PemwW 3n wwoon You p~~ may be used tow samndary pmpom (Privacy t aw. s.15.04 (1) (m)). r7~d - I LI
Property Location
PmpwV?wner Govt. Lot
A/ V a q) iNt iM S N R E (or~
Properly Owner' arTmg Address Lot # 1 8,7 SuIxi or ~CSW
oar
❑ City EYVMage Town Nearast Road
Stake Zip Code Phone
4 ~ (
❑ New Construction User Residential / Nu mtw of bedrooms c s3_ Code defired design flow rate - S GPD
Replawnent ❑ Public or cormrer" - Describe:
~~e Flood Plain elevation if applicable j , R
Parent material
Gertueraloomments
and MoDmalw1clations: sj
G s < ~
Boring
F71 lt~t r Shay f Gc
Boring # ❑ l
Pit Ground surface elev. QR. !J It. Oepth to bnftl g factor in. Soli iicafion Rye
Horizon Depth Dominant Crr Redox Deso"on Texture Structure Consistence Boundary Roots
In. Munsell QU. Sz Color Gr. Sz. Sh. •EWI 'Efl#2
4 4
A 1 11, /,W
4' 4
❑ Eodng
8arblg # ® Pit Ground surface elev.-~ ft. Depflr to tirnft favor 8 in. Soil Appilicallon Rde
Horizon Depth Dominant Color Redox Desaiptiou Texhse St ctixe Consistence Boundary Roots GPON
In. Munseti Qu. Sz Color Gr. Sz. Sh. •M VIM
.41
d
q
A22 Z~
4 a
el6ant #I a
• _ = RVL and M :*30 im mglL • _ < and M _S 30 mgll.
Signature l~'i HNmber
C*T /
,
Date evaluawn Tatsphone M xnbw
Adclia6 J
*[n] Parcel ID # of Page,
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Pit Ground stataoe elev. ,<i ~ 8. Depth to funifin9 tador in. Sod Rate
Horizon Depth Dominant Color Redox Description Texture Structure Corte Boundary Roots GPDW
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❑ Pit Ground surface elev. ft- Depth to factor h Sop Application R,de
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' Effluent #1 = SOD, > 30 220 mg& and TW >30 150 mgll ` Mont #2 = BODE _ 30 mglL. and TSS w 30 mVIL
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need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
G Parcel ID # Page ~ of
Property Owner 2
Boring
a Bow # Pit Ground surfaceelev. ft. Depth Gmifing favor rn Sal nation Rate
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Horizon Depth Dominant Color Redox Desaiption G,% Sz Sh. `F*EM TIM
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lid 4
a soift # ° Boring
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Role'
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In. Munsd Qu. Sz. Cont COIM Gr. Sz Sh
❑ Boring # Boring ❑ Pit Ground surface elev. fL Depth to Gmr6ng facto °L
Soil Rate
GODff
Horizon Depth Dominant Col Redox Description- Texture Structure Consistence Bouruiary Roots
In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. `Qf!#1 `Efi#2
• Effluent #1 = BODs > 301220 mg/L and TSS 41) 5150 mgtL ` Effluent #2 = BODE_130 mglL and TSS 30 mgiL
The Department of Cammeme 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-SM.
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