HomeMy WebLinkAbout038-1215-80-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County:
Safety and Building Division St. Croix
INSPECTION REPORT Sanitary Permit No:
561055
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide maybe used for secondary purposes [Privacy Law, S.15.04 (1)(m)i.
Permit Holder's Name: city Village X Township Parcel Tax No:
Sorlien, Mark D. & Patricia Star Prairie, Town of 038-1215-80-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No
► ` ✓►`vt` 11.31.18.1189
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
dI
Septic •1 Benchmark
/A) b, 17 QrN be, V/..., r 2tq~ :5
, 35 747.
JAS
Dosing.. C.~O✓K. IC p ' ~'jf~ Alt. IIVl ~1D f /L• w
n w ~J
/b /L Bldg. Sew r - 17
'i C J ~9. 7
Holding St/Ht Inlet
A08 7
TANK SETBACK INFORMATION St/Ht Outlet \
TANK TO P/L WELL BLDG. Cent t it Intake ROAD Dt Inlet `
Septic > -76 Dt Bottom
Dosing Header/Man.
! zoo Aeration / /7 15~' 6
Dist. Pipe
Holding
Bot. System
'87. 5 d~
PUMP/SIPHON INFORMATION Final Grade q
Manufacturer `
Jl /t Demand' St Cper
eV GPM dam ✓ .Z 9 p - (40
Model Number
TDH Lift fl-tor Friction Loss System H TDH 16
Q
f "i'
/
Forcemain L ;gth~ / Di Dist. to well >/76
SOIL ABSORPTION SYSTEM )b• Zb G
BED/TRENCH Width Len th No. Of Trenches
DIMENSIONS / 7~ r96 PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth a
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer
INFORMATION
TypeO System: ~ CHAMBER OR
UNIT Model Num r:
DISTRIBUTION SYSTEM 2 a-ZZ -4,3 S
[Header/M;anif,)d i / Distribution x Hole SizVIntak
Pipe(s)
ength Dia Length Di'` Spacin g
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
De th Over - w.-
Bed/Trench Center L Depth Over Depth of xx Seeded/Sodded J Bed/Trench Edges Topsoil Yes No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2:
Location: 2215 124th Str It New Richmond, WI 54017 (SE 1/4 SW 114 11 T31 N R1 8W) River Place Lot 28 Parcel No: 11.31.18.1189
l ~nd/-D - I
1. Alt BM Description = PU ,
2.) Bldg sewer length = IL
85
D dt-
- amount of cover 6^ 1 1
o
#%A fe_ iIA i-L 0,_
-
Plan revision Required? ❑ Yes ~(No 9 Z ~ ~ / ..y~
13
Use other side for additional information.
-
Date -
SBD-6710 (R.3/97) Insepcto ignature Cert. No.
'i
77
,r
i
C~
i
5; 1ttv.,G~ lath
1
County
Safety and Buildings Division 5 f ~
2 01 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
P S' Madison, WI 53707-7162~j ~n
1°~~_ _ ✓ Yom/ ~
10"N~
rtary Permit Application State Transaction Nntrlke~
In accordance with 38 Wis. Adm. Code, submission of this form to the appropriate governmental unit N "~C` 12
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different th address)
the Department of Safety and Professional Servies. Personal information you provide may be used for secondary 2 Z 16 12
purposes in accordance with the Privacy Law, s. 15.04(1 (m , Slats.
1. Application Information - Please Print All Informatio e~ v c a
Property Owner's Name Parcel #
r~ It 7//-tC/a ~Qr /!~h 03?-1215-80- 600
Property Owner's Mailing Address Property Location
22 / 5 2, Govt. Lot
Zip W 1/., Code Phone Number 5 G 'A, -
City, State Section ~
kr / cycne
•PW / !t /uatfc LCD -S ~a e' le o
T 3~ N; R E o
II. Type of Building (check all that apply) Lot # 2
,011"or 2 Family Dwelling - Number of Bedrooms Subdivision Name
Block P/d c t
❑ Public/Commercial - Describe Use
❑ City of
C,
CSM Number ❑ Village of
❑ State Owned - Describe Use 71 Y~
/ ,'Town of
~L l ~j Z2-f- CIA ~,,Loe
III. Type of Permit: (Check on one box on line A. Complete line B if applicable)
A. KNew 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 System/Component/Device: Check all that apply)
on-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil Aa--5 6A4.4 ws
❑ Holding Tani: ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/Trea ent Area Information: ejot-d
Design Flow (gpd) Design Soil Application Rate(gp Dispersal Area Required (sf) Dispersal Area Proposed (s System Elevatio
(~~v 8 -70, ~s? SDI `V
VI. Tank Info Capacity in Total # of Man ufacturer
d V
Gallons Gallons Units y
New Tanks Existing Tanks ~
Septic or Holding Tank I, I 1~e ~ ai c V25 J5 0 A!
Dosing Chamber I p Q~j
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
P mber's Name (Print) PI er's Si re MP/MPRS Number Business Phone Number
y~,
!L 7 s ~/5- ZG 5 5~// s
K t j. 1 vt rS 1 -1
Plumber's Address (Street, City, State, Zip Code)
2q l3a t~ Q~ ~'Cf tt/ ~S a~3
VIII. -County epartment Use Only
Permit Fee Date sued Issuing nt Signature
Approved tsapprove
r(
'en Reason for vial $ V~
IX CondifReasons for Disapproval +
P/c,
840tsdi dollIrium all be.servlc I n~Itil~rrssi. d- f CG/Lo e` r,✓' ~~'~n-'
A§ 06 iti.drW#@ffteltt plan provided by plumbbt 5
*W-4 bodli _A~f~wta~,mttslbm:,nraintt~iq¢
rortiod a .1
Attach to complete plans for the system and submit to the County only on paper not than 8 1/2 z 11 inches in size
SBD-6398 (R. 11/11)
f t
Page 1 of 5
SYSTEMS I NC
Environmental Onsite Wastewater Solutions
Leaching Chamber Design Spreadsheet
Project Name: Sorlien
Owner's Name Mark Sorlien
Owners Address 2215 124th St
Star Prairie, WI 54026
Legal Description SE + sw + Y. Sec 11 T 31 N, R 15 w +
Township Star Prairie
County Saint Croix
Subdivision River Place
Lot# 28
ParcelID# 038-1215-80-000
Table of Contents
Pg°
1 Cover page
2 Calculations and Drawings
3 Management and Contingency Plan
4 Plot Map
5 Lift Chamber
total # of pages: 5
Designer Name: Michael J. Myers
License 267985
Date: 9/9/2013
Ph. 715-265-4115
Signature:
Design Methods Used
"IN-GROUND SOIL ABSORPTION COMPONENT MANUAL FOR PRIVATE ONSITE WASTEWATER TREATMENT SYSTEMS" (Version 1.0) SBD-10705-P (8.6199)
091 Infiltrator and the Infiltrator logo are trademarks of Infiltrator Systems, Inc.
SYSTEMS INC
- Spreadsheet provided under license to Infiltator Systems, Inc by: 3bAdvisement N12486 220th St, Boyceville, WI 54725
i ` • ' Page 2 of 0
SYSTEMS INC Calculations and Drawings
Site Conditions Infiltration Elevations
Site Type: Private • Trench #1 Trench #2 Trench #3
%Slope 7 % Contour Elev: 89.89 89.89 Ft
# of Bedrooms 4 Infiltration Elev: 50 8 Ft
Depth to limiting factor 98 inches Limiting Factor Elev: 81.72 81.72 N/A
Soil Application Rate: 0.7 gal/ft^2/day Treatment and Dispersal Zone: 5.78 5.78 N/A
Effluent Quality Etf #1 _ Cover Material Required: 0 0 N/A In
Design Flow: 600 gal/day Finished Grade Over Cell: 89.89 89.89 N/A
Max BOD 220 mg/I
Max TSS 150 mg/I Distribution Cell
Choose chamber type:
Septic Tank Infiltrator Quick 4 Standard I
Manufacturer: Wieser Concrete # of trenches: Z
Volume Chosen: 1200/800 Chamber Length: 4.00 Ft
Effluent Filter Selected: Polylock Chamber EISA: 20.1 Ft2
Note: Access opening of sufficient size to be provided to allow removal of filter. Endcap EISA: 5.1 Ft2
Opening to terminate at or above grade. Required Infiltrative Area: 857.1 Ft2
Actual Infiltrative Area: 874.5 Ft2
Total # of Chambers: 43
Cross Section of Septic Tank Total # of Endcaps: 4
Combined Length of Cells: 176.0 Ft
12" Min Grade
Cross Section of Cell
18" Min Cover Material Observation Pipe
(if required) Final Grade
All joi nts to -
be Watertight D3034 or Ground
ZEffluent Sch40 Contour
Filter Pipe
Leaching System
Chamber Elevation
3" Bedding Under Tank
Lenq Ih
0 0
Width
r~r 5ch 40 4" I'Ip P
PVC Poe
Infiltrator and the Infiltrator logo are trademarks of Infiltrator Systems, Inc.
Spreadsheet provided under license to Infiltator Systems, Inc by: 3bAdvisement N12486 220th St, Boyceville, WI 54725
Page 3 of 5
In4round System Management Plan pursuant SM 3ri>S,Sj w. A. C.
Owner's Responsibility:
The component owner is responsible for the operation and maintenance of the component. The
county, department or POWTS service contractor may make periodic inspections of the
components, checking for surface discharge, treated effluent levels, etc. The owner or owners
agent is required to submit necessary maintenance reports to the appropriate jurisdiction and/or
the department.
Septic Tank:
Septic tank(s) are to be inspected routinely and maintained by department approved individuals
when necessary in accordance with their approvals. The use of chemical/biological "treatments" is
not required or recommended. If such additives are used, make sure they are approved by
Department of Commerce, Safety and Buildings Div.. Effluent filters are to be removed & cleaned
as necessary, with provisions to keep solids from passing the septic during removal. No more
than 1/3 of the usable tank volume may be occupied by sludge/scum. 3 year inspection: If tank
has greater than 1/3 volume sludge, tank contents must be emptied and disposed of in accordance
with NR 113 Wisconsin Administrative Code by an approved individual. If the inspector does not
recommend pumping of the septic tank, then the owner must be notified of when pumping should
be done as to not exceed 1 /3 sludge volume. Septic tank should be routinely inspected to be
watertight and of good repair.
Absorbtion Cell
The absorbtion component must remain free of ponded surface water prior to pump operation. If 4
inches or more water level is detected in the observation pipes, the owner must be notified of
possible problems/failure. The designed daily flow capabilities of the component should never be
exceeded. Trees and any other deep rooted vegetation should never be planted, or allowed to
grow anywhere on the component. Activities OTHER than mowing/maintenance (i.e. excessive
walking, pets, vehicles, etc...) could compress the component and reduce it's absorbtion
capabilities and/or possibly cause it to freeze in winter conditions.
Performance Monitoring:
Performance monitoring must be done at least once every three years following the installation or
at the time of a problem, complaint, or failure.
Contingency Plan:
If the septic tank or other components therein (including floats, alarms, etc) become defective, the
defective tank or component must be replaced immediately to ensure that the system can operate
as designed. If the absorbtion component cannot accept wastewater or ponds wastewater to the
surface, the component must be repaired or replaced in its current location by removing the
clogged bacterial mat, aggregatelleaching chamber cell, and distribution piping within the cell and
replacing failing components in order to return system to proper working order as required. If repair
is not feasible, a new system is to be constructed in a designated replacement area
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Lift Station Information & Calculations
Total Dynamic Head Calcs.
Discharge Rate: 6.18 gpm
Forcemain Length 30 ft
Forcemain Diameter 2 in
Friction Loss from Forcemain 0.032
Vertical Lift15.11 ft
Total Dynamic Head (TDH) Ift
Dosage Volume Calcs.
Does forcemain drain back to tank?~
Dose: 60 gal
Forcemain Volume 9.60 gal
Total Dosage: 69.60 gal
Tank Information
Tank Manufacturer Wieser Concrete Inches Gallons
Tank Capacity 800 gal A= 21.5 442.9
Tank Gallons per Inch Water Level 20.6 gaUin B= 2.0 41.2
Bottom of Tank Elevation 73.39 Ift C= 5.5 113.3
Pump Manufacturer/Model Goulds PE41 P1 D= 12.0 247.2
Total= 41.0 800.0
Pump Curve Pump Tank Diagram
waterkght: M*"4 cow
4 kith wik warn" Lkei
NOW
Mmm~n
f Grade
Nkernake
Dede6
Locakrn Rbcheal per
Came 16.28 and
WC Siw req.
weep Hole h
or Ankr5ow
berre 9
G
V
Selected pump requires a minimum operating rating of: 0 feet of head pressure at 6.18 GPM
ITT GOULDS PUMPS
Residential Water Systems
APPLICATIONS MOTOR
Specially designed for the following uses: General:
• Mound Systems • Single phase
• Effluent/Dosing Systems • 60 Hertz
• Low Pressure Pipe Systems • 115 and 230 volts
• Basement Draining • Buih-in thermal overload protection with automatic reset.
• Heavy Duty Sump/ • Class B insulation.
Dewatering • Oil-filled design.
• High strength carbon steel shaft.
SPECIFICATIONS PE31 Motor:
Pump - General: • .33 HP 3000 RPM
• Discharge: 11/2" NPT • 115 volts
• Temperature:104OF (400C) maximum, continuous when • Shaded pole design
fully submerged. PE41 Motor:
• Solids handling: 1/2" maximum sphere. • .40 HP 3400 RPM
• Automatic models include a float switch. • 115 and 230 volts
• Manual models available. • PSC design
• Pumping range: see performance chart or curve. PE51 Motor:
PE31 Pump: • .50 HP, 3400 RPM
• Maximum capacity: 53 GPM • 115 and 230 volts
• Maximum head: 25' TDH • PSC design
PE41 Pump:
• Maximum capacity: 61 GPM AGENCY LISTINGS
• Maximum head: 29' TDH
Pump:
• Maximum capacity: 70 GPM
• Maximum head: 37' TDH CM is
Tested to UL 778 and
CSA 22.2108 Standards
By Canadian Standards Association
METERS FEET File #LR38549
40
PE51 MODELS: PE31, PE41, PE51
35 KP33, .40, .50
10
z Gin Goulds Pumps is ISO 9001 Registered.
- 0.1
30 PE41 1 FT
o
25 PE_31
x '
S2
20 '
0
i
10
I i
5'
i
0 00 10 20 30 40 50 60 70 GPM -8-0
0 5 10 15 m3/h
CAPACITY
R
IWAlwonsfn SOIL EVALUATION REPORT #87
Department of Commerce in accordance with Comm 85, Wis. Adm. Code Page 1 of 3
Division of Safety and Buildings Northland Plumbing, Inc.
County Attach complete site plan on paper not less than 8% x 11 inches in size. P!too ust St. Croix
include, but not limited to: vertical and horizontal reference point (BM), dire
percent slope, scale or dimensions, north arrow, and location and distance neek4Wqd. Parcel I.D.
038-121
Please print all information. ,S'16P eviewe y Date
Personal information you provide may be used for urposes (Privacy Law, s. Q P vin))
Property Owner Party Loca n
Mark Sorlien Govt S/1 /4, S 1/4, S11, T31 IN, R18W
Property Owner's Mailing Addm4p Lot # I ck # S bd. Name r CSM#
2215 124th St 28 River Place
City State Zip Code Phone Number ❑ City ❑ Village ❑ Town Nearest Road
Star Prairie WI 54026 Star Prairie 124Th St
❑ New Construction Use: ❑ Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material Outwash Flood plain elevation, if applicable fl.
General comments /
and recommendations: w G ~a
F -1 E] Boring
1 Boring #
Pit Ground surface elev. 89.89 ft. Depth to limiting factor 98 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consisten Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Effi" 'Eff#z
1 0-11 10YR3/2 A 3sbk ds a 3f .6 .8
2 11-18 10YR4/4 sil 2sbk dsh Cs if .6 .8
3 18-64 10YR6/8 s Osg ml fs .7 1.6
4 64-74 10YR5/6 scl 2sbk mfi cs .4 .6
5 74-98 10YR6/4 gr cos Osg ml cs .7 1.6
D Y'
1
❑ Boring 51
F2 Boring # ❑ Pit Ground surface elev. 90.27 ft. Depth to limiting factor 102 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consiste Boundary Roots GPD/ft=
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 -Eff#2
1 0-9 10YR3/2 sil 3sbk ds cs 3f .6 .8
2 9-17 10YR4/4 A 2sbk dsh CS if .6 .8
3 17-66 10YR6/8 s Osg ml CS .7 1.6
4 66-72 10YR5/6 sCl 2sbk mfi cs .4 .6
5 72-102 10YR6/4 gr cos Osg ml a .7 1.6
s~ it
* Effluent #1 = BODS> 30 < 220 mg/L and T >30 < 150 Effluent #2 = BODS <_30 mg/L and TSS <_30 mg/-
CST Name (Please Print) Si ature: CST Number
Michael J. Myers 267985
Address Northland Plumbing, Inc. Date Evaluation Conducted Telephone Number
2943130th Ave Glenwood City, WI 54013 8/3012013 715-2654115
SBD-8330 (807/00)
Property Owner Mark Sorlien Parcel ID # 038-1215-80-000 Page 2 of 3
F3 Boring
Boring # Pit Ground surface elev. 92.11 ft. Depth to limiting factor 98 in.
Soil Application Rate
Horizon ' Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I *Eff#1 `Eff#2
1 0-9 10YR3/2 A 3sbk ds cs 3f .6 .8
2 9-18 10YR6/2 sil 2sbk dsh cs if .6 .8
3 18-26 10YR5/6 scl 2sbk mfi cs if .4 .6
4 26-69 10YR6/8 s Osg MI CS .7 1.6
5 69-76 10YR5/6 scl 2sbk mfi cs .4 .6
6 76-98 10YR6/4 gr cos Osg ml cs .7 1.6
p i
V O
L)
* Effluent #1 = BOD5> 30 < 220 mg/L and TSS >30 <150 mg/L ` Effluent #2 = BOD5 < 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.
SBD-8330 (11.07100) Northland Plumbing, Inc.
Property Owner Mark Sorlien Parcel ID # 038-1215-80-000 Page 2 of 3
F3 ~ Boring
Boring #
pit Ground surface elev. 92.11 ft. Depth to limiting factor 98 in.
Soil Application Rate
Horizon Depth' Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft'
in. I Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2
1 0-9 10YR3/2 sil 3sbk ds cs 3f .6 .8
2 9-18 10YR6/2 sil 2sbk dsh cs if .6 .8
3 18-26 10YR5/6 scl 2sbk mfi cs if .4 .6
4 26-69 10YR6/8 s Osg mL_ _ cs .7 1.6
5 69-76 10YR5/6 scl 2sbk mfi cs .4 .6
6 76-98 10YR6/4 grcos ; Osg ml cs .7 1.6
v
I
Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 <150 mg/L ' Effluent #2 = BOD5 < 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.
SBD-8330 (&.07/00) Northland Plumbing, Inc.
S~Yy~ ~w+'r~ X11 't'31t~S~E~w~ l
S Gxa ~,sc. t'av as -t'~
. ~ ~ m ~ tJ 6.31 `F ` ~ a TT ~ 1Z~ .f s.! ~if~ +t? :..J~ s ~ ~.lA ~~hQ r
QC,2*4'
83 92,rr"
l 31
sCAL F
r~
i'~ g ILI,
~tt~ C< st ~ ~`~9.~ 5
}v~""'~"~vTa County
re Safety and Buildings Division S¢ , C~e
a~ S < 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.)
p Madison, WI 53707-7162 _
S Permit Application State Transaction Number
k
'ty In accordance with SP 3 2 •i in. Code, submission of this form to the appropriate governmental unit Al
is required prior to ob ary pe 't. Note: Application forms for state-owned POWTS are submitted to Project Address (if differ nt than mailing address)
the Department d Prof Servies. Personal information you provide may be used fyrsecondary
/1j Jl7 purposes in acco wi vac Law, s. 15.04 l)(m , Slats. f Z 2 1 12
~J
1. Application nfornation - Please Print All Information ICJ ol le- D D w~
Property Owner's Name j Parcel #
r14r r ~i'it sat_: J. ~JoJ-/* c~3S- /215 -840 co o
11
Property Owner's Mailing Address , O I~ Property Location 07
OOG Govt. Lot /
City, State / 116 11/4!1 Zip Code Phone Number ~ .$5 1/4, _TW 1/4, Section
/ / S T cirele on
360 7
'lo
3 / N; R zi7) 4
II. Type of Building (chec all that apply) Lot #
l or /2 Family Dwell inNumbe r .70 r ~s Z CJ Subdivision Name
j`2~`L~Lx ,JCi ~ l C`%'Jn ' ~ Block# /ver- 101aEC-G.
❑ Public/Commercial - Describe Use h 1 ~,-~T~rrr yt ❑ City of
❑ State Owned - Describe Use CSM Number ❑ Village of
Town of C~ Y er t% C/ C,
III. Ty mit: neck only one box on line A. C mplete %e B if applicable)
A. New System ❑ Replacement System ❑ atment/Hol 'ng Tank Repla~rr~►~r y ❑ Other Modification to Existing System (explain)
List Previous Permit Number and Date Issued
B. ❑ Permit Renewal ❑ Permit Revision ❑ Chan Plum r ransfer to New
Before Expiration e
IV. Type of POWTS Sys tem/Comonent/Device: Check all t t V) 0"
~➢lon-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade Mound > 24 in. of sui le soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) treatment Device (explain)
V. Dis rsaVIrreatment Area Information: ' D 1Xf 60' Z, dDesign Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Req fired (sf)
Dispersal Area ed (sf) yttem Elevation
?50 to / /~5'0 12.61, 5-Pro /o s.~c
VI. Tank Info Capacity in Total # of Manufacturer ,
Gallons Gallons Units r, o
New Tanks Existing Tanks
W Po l (,,Ie- -r,, n`. U v~ v vi is C7 rY
Septic or Holding Tank ~g ~l~ SGr t~H+ L
Dosing Chamber
VII. Responsibility Statement- I, the undersign , assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) PI ber's Si ature MP/MPRS Number Business Phone Number
/5-2 5_ //S
Plumber's Address (Street City, State, Zip Code) 9 ^ Z/ Z
5rY- a77Y
2 ~3 0 C',! mss"
e artment Use Only
VIII. oun
ty-
Permit Fee Date Issued suing Age Sign
pproved 11 Disapproved $ (N/
❑ Owner Given Reason for Denial ! 75, /
l 2 C~ C
IY,Ag "im pproval/Reasons for Disapproval 3 S L✓ yt /f ~ J 7 2- y (i ~t
1. Septic tank, effluent filter and Z Z DDD 5 wax 300 l~ ww ( .J~~~~! J
dispersal cell must be.serviced / maintained{ PS IS (11C~(1L
as per management plan provided by plumber.
2. All setback requirements must be maintained 300
c o co ete plans for the system and submit to the County only on paper not less than 8 12 111 inches in size
SBD-6398 (R• 11/11)
co
Page 1 of 4
91490fil to] "Dal
SYSTEMS I NC
Environmental Ons+ie mistrewater golufions
Leaching Chamber Design Spreadsheet
Project Name: Mark Sorlien-conventional
Owner's Name Mark Sorlien
Owners Address WOMINVA 2_2/55 /.2y?'IC ,y/-
j
Legal Description I~ sw ",V ]II. 1/, Sec 11 T 31 N, R 18 ! ww
Township Star Prairie
County Saint Croix
Subdivision River Place
Lot# 28
ParcelID# 038-1215-80-000
Table of Contents
Pg_
1 Cover page
2 Calculations and Drawings
3 Management and Contingency Plan
4 Plot Map
total # of pages: 4
Designer Name: Michael J. Myers
License 267985
Date: 3/30/2013
Ph. 15-265-4115
Signature:
Design Methods Used
"IN-GROUND SOIL ABSORPTION COMPONENT MANUAL FOR PRIVATE ONSITE WASTEWATER TREATMENT SYSTEMS" (Version 1.0) SBD-10705-P (RAM9)
° Infiltrator and the Infiltrator logo are trademarks of Infiltrator Systems, Inc.
SYSTEMS INC
Spreadsheet provided under license to Infiltator Systems, Inc by: 3bAdvisement N12486 220th St, Boyceville, WI 54725
W .....e............«....=..4..,».v+...~y~t.....,.1...~.r+..,.~....~.. w.. ................v.-..............v,-..-....... ~~~~h~
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page _L_ of 3
Division of Safety and Buildings
in accordance with Comm 85, Wis. Adm. Code
County
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must p
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 road.
Please print all information. ewes by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Govt. Lot SE 114SW 1 /4 S 11 T 31 N R 1 (or) W
Property Owner's ailing A dress Lot # Block # Subd. Name or CSM#
1373 C-ty- Rd n n
City State Zip Code Phone Number El City ❑ Village Mown,.- Nearest Road
Hudson, WI. 54016 (715 ) 381-5405 Star Prairie
® New Construction Use: [Z Residential / Number of bedrooms 4 Code derived design fl t GPD
❑ Replacement ❑ Public or commercial - Describe:
Parent material outwash Flood Plain elevation if app ft
General comments S .9e,N~ )
and recommendations: G
trenches @ el. 106.00', or to code dep Z C9 11
1.91
M vA14• 2`--~---
F] Boring f'1~tLL •
g # Pit Ground surface elev. 109.30 ft. L Depth to limiting factor O
❑ Boring in. Soil Application Rate Ic4d
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fg
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-12 10~m3/3 none it 2msbk mfr cs 1m .5 .8
2 12-27 10 4/4 none sil 2msbk mfr 9W 1m .5 .8 b
3 27-57 7.5 4 4 none sl 2msbk mfr 9W if .5 .9 b
_ 2 bk mfr if .5 .8 (p -aw na na 7 1.2 •
Boring # E] Boring
2 ❑x Pit Ground surface elev. 108. 9Oft. Depth to limiting factor 1 30 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
none sil 2msbk mfr cs 1m .5 .8 • b
-1 0-12 10yr,313 _ mfr 1M .5 .8 jo
25-58 7 5 4 4 none sl 2msbk mfr if .5 .9
4 58-72 7.5 4/3 none sil 2csbk mfr 9W if .5 .8
72-13 7 5 4 4 none cos os ml na na •7 1.2
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Signature . CST Number
Gar L. Steel 02298
Address ate Eed Telephone Number
1554 200th. Ave., New Richmond, WI. 54017 6-26-2001 715-246-6200
Property Owner La-CaSSe DeV _ . II1C. Parcel ID # Pncji nq Page 9_ Of
❑3 Boring # ❑ Boring
U pit Ground surface elev. 109.50 ft. Depth to limiting factor 1 30 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
sl 2msbk mfr 9W 1m .5 .8 . (P
11-41 7 4 6 none ms Os mvfr 1m .7 1.2
_ sil 2csbk mfr gw 1f .5 .8
3 41 51 7, , none
4 51-13 7 5 4 4 none cos Osg ml na na •7' 1.2
F-1 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.
F-1 ❑ Pit Soil A lication 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
` Effluent #1 = BODS > 30 < 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.
SBD-8330 (R.6/00)
L
I '
STEEL'S SOIL SERVICE
Gary L. Steel 1.554 200th Ave.
CSTM2298 LaCasse Dev.,Inc. New Richmond, WI 54017
MPRSW-3254 SE' SW' S11-T31 N-R18W (715) 246-6200
town of Star Prairie
lot #28-River Place
This soil evaluation was conducted to satisfy a zoning requirement, it may or may
not be suitable for your use. Ihe location of the test may or may not be as shOMrt
an pernmust lot liners were not established at the time the test wars conducted.
N
1"=40'
BM.= top of SW lot stake @ el.100.00'
alt. BM.= top of 1" pvc pipe @ el. 108.60'
Av
1
nil' 9 7
r~
Gary.L. Steel
6-26-2001
644.89 322.sa a @ duo if 9 o
LOT 13 I 02 C7 I I O3 _ -
® 1.548 ACRES I I ! t
67,492 80 Fr Z I LOT 22
to
w e
• I 1.514 ACRE
i S F
~ 85 942
. ~ ~ so Fr a~ .
626.79
~ 1 a ~ • i
■
~G/''
87
® II I I l LOT 12 II I I ®
PI 1.615 ACRES ; II I ;"i3
& 70,326 80 Fr II Cs I LOT 23 I
I p AREA TO MEANDER LINE
I I 1.659 ACRES r
II I I I 71,390 60 Fr
619.69' I I I MEANDER LINE
NUMBER W
( I ~
• I $T ~ r6pE 3ge•42.
of
1.a ACRES ° 0t
_ ® 0) '
N 86,950 80 FT ~ ~ AREA ~BOEANDE ESLINE
e ■
/ 78,926 SO FT I m
570.33'
257.44t 8 TO I 1 0
• l ~ ~ ~ ® 74E41
e~4• ~ I `10
/r LOT 23 tl ~m-----------------
LOT 10 ^ AREA TO MEANDER LINE
1.544 ACRES
87,271 SO FT tpi ; 2.098 ACRES
A 88,761 80 FT ~I
• O / fj : p o I ~
86g,7T FLOOD tAIN LIMITS
so I l i 4j4•&2• 884
272.W
LOT 26
AREA TO MEANDER LINE
i : 2.184 ACRES
O ORES 1 95,141 80 Fr / i
18 SO Fr
Q~
LOT 27 "er m~
/ / AREAcFO MEANDER LINE 1.811 ACRES
78,908 SO FT /
i C4
X
.a ,
LOT 28
AREA TO MEANDER LINE N
- .19
412 0 SO Fr C O'
c
MEANDER LINE ~I ( 5
m NUMBER •2' ' 882
8w=15'E 404.22' art - - - - - -
1~yf1• ?Za- 927.50 LOT 29 ! I1 l-
~A N I
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ' of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner 2 L Septic Tank Capacity gal ❑ NA
Permit #
(O Septic Tank Manufacturer ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer Z S ❑ NA
Number of Bedrooms ❑ NA Effluent Filter Model v ❑ NA
Number of Public Facility Units Pump Tank Capacity gal A
Estimated flow (average) ~dV gal/day Pump Tank Manufacturer ❑ A
Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer ❑ NA
Soil Application Rate gal/day/W Pump Model ❑ NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit NA
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) 5150 mg/L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average SPV6 ell(s) ❑ NA
Biochemical Oxygen Demand (BODS) 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 Ye i dia. ❑ NA Other: ❑ NA
Other: ❑ NA Other: ❑ NA
*Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA
❑ year(s)
Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA
Inspect dispersal cell(s) At least once ever ❑ month(s) (Maximum 3 ears) ❑ NA
y' ❑ year(s) y
Clean effluent filter At least once every' ❑ month(s) ❑ NA
❑ year(s)
Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA
❑ year(s)
Flush laterals and pressure test At least once every: '0 month(s) ❑ NA
❑ year(s)
Other: ❑ month(s)
At least once every: ❑ year(s) ❑ NA
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 (Y3) 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 2 of
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 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 POWT fails and cannot be repaired the following measures have been, or. must be taken, to provide a code compliant
replace system:
mesuitable 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.
aluat' a o mg tank
T
be ' e ai a ~fZDI-t't¢3 TTF~ ~D~- I~l$1~✓ ~NS7RtJ~ Dr`J
❑ 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 ~ dZ-17-16,4AIN t0&,111h!d//PICT'' Name
Phone Nlk,C M C"]~S- _W~ Z f ,57- L// Phone
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Name ST. C26 l d u Zo~JI~
Phone Phone
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.5411), (2) & (3), Wisconsin Administrative Code.
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORA/I
JwnerBU)'Cr
2b!ol /~iv~ora. r. cS' kl~f; c 5vlld
Vlailitlg Address Aer 1-oke ^A/
-
Propert}Address /2,1
(Verification required from Planning Zoning Department for new construction.)
wluc,nm City/State :e, A-/ Parcel Identification Number 639-
LEGAL 12 B- doO
DESCRIPTION
Propert% Location 14. Sm.) a , Sec. f T 9/ N RAW, Town of 5ia r f ra;~~
Subdivision Plat. I Nac~ , Lot # 2-8.
Certified Survey Map # (p5(Q~? :7 Volume Page # Warranty Deed # ~-7~ (before 2007)Volume . Page
Spec house yes no Lot lines identifiable yes no
SYSTEM NJAINTENANCE 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. $3.52(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 andror (2) after inspection and pumpinL_= (if necessary). the septic tank is
less than 1 3 full of sludge.
liNve, 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 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 of a warranty deed recorded in Register of Deeds Office.
N mbe=NIL CANT(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 vvarranty deed.
(RED'. 08/05)
Parcel 038-1215-80-000 02/13/2013 07:44 AM
PAGE 1 OF 1
Alt. Parcel M 11.31.18.1189 038 - TOWN OF STAR PRAIRIE
Current 0 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
O - SORLIEN, MARK D & PATRICIA J
MARK D & PATRICIA J SORLIEN
2661 RIVIERA DR S
WHITE BEAR LAKE MN 55110
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ' 2215 124TH ST
SC 3962 SCH DIST NEW RICHMOND
SP 1700 WITC
Legal Description: Acres: 2.190 Plat: 08-068-RIVER PLACE LOTS 1/30 038-01
SEC 11 T31 N R1 8W PT SE SW LOT 28 RIVER Block/Condo Bldg: LOT 28
PLACE
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
11-31N-18W
Notes: Parcel History:
Date Doc # Vol/Page Type
08/09/2012 961424 WD
08/16/2004 771820 2638/565 WD
2012 SUMMARY Bill M Fair Market Value: Assessed with:
196159 68,500
Valuations: Last Changed: 09/13/2011
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.190 72,700 0 72,700 NO
Totals for 2012:
General Property 2.190 72,700 0 72,700
Woodland 0.000 0 0
Totals for 2011:
General Property 2.190 72,700 0 72,700
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
STATE BAR OF WISCONSIN FORM 1- 1998 8 0 7 5 6 9 5
Tx:4056685
Document Number WARRANTY DEED
961424
038-1215-80-000 BETH PABST
Parcel Identification Number (PIN) REGISTER OF DEEDS
ST. CROIX CO., WI
THIS DEED, made between Anthony Q. Hall and Lana L. Hall, formerly 08/09/2012 10:16 AM
known as Lana L. Delsart, husband and wife, Grantor, to Mark D. Sorlien EXEMPTO: NA
and Patricia J. Sorlien, husband and wife as survivorship marital property, REC FEE: 30.00
Grantee. TRANS FEE: 219.30
Grantor, for a valuable consideration, conveys to Grantee the following PAGES: 3
described real estate in St. Croix County, State of Wisconsin (the
"Property"):
SEE ATTACHED EXHIBIT A
Recording Area
This is not homestead property. Name and Return Address: 3
Together with all appurtenant rights, title and interests. e ,,y
Grantor warrants that the title to the Property is good, indefeasible in J`/
fee simple and free and clear of encumbrances except; U)
1
Dated this Z ~~Z
(SEAL) (SEAL)
* Anthony Q. Hall
i (SEAL) (SEAL)
* Lana L. Hall
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF ARIZONA
}SS.
COUNTY OF Maf-t
authenticated this Personally came before me this Jl • 13' ) a , the
above named Lana L. Hall, formerly known as Lana L.
Delsart, wife of Anthony Q. Hall, to me known to be the
* person(s) who executed the foregoing instrument and
acknowledge the same.
TITLE: MEMBER STATE BAR OF WISCONSIN
(If not,
authorized by § 706.06, Wis. Stars.)
THIS INSTRUMENT WAS DRAFTED BY - ffit SW 18. 2d14
Attorney Gregory Booth
1054 Centerville Circle
Vadnais Heights, MN 55127
Notary Public, State of Arizona
(Signatures may be authenticated or acknowledged. Both are--
not necessary.) My commission is per 1manent. /((IIfrnnot, state expiration date:
"Names of persons signing in any capacity must be typed or printed belo t 'r A ~ 14
signature. '
hmlptftM - Arizona
V kcopa County
U !IbA ntm. Expires Sep 18. 2014
TS File No. 17712
ROSA CRUZ
*my Notary Public - Arizona
Maricopa County
Comm. Expires sap 18, 2014 .
.r
1 of 3
STATE OF MINNESOTA )
ss:
COUNTY OF )
This instrument was acknowledged before me on 2012, by Anthony Q.
Hall, husband of Lana L. Hall, formerly known as Lana L. Delsart, to me known to be the,
individual described in and who executed the document, and acknowledged that he
signed the document as hi ee and voluntary act and deed, for the uses and purposes
therein menti ed.
Not lic CYNTHIA E KOEBELE
MotW Pubft-Mtrmesom
W ComtlWpn .in 8~; aota
2 of 3
' I I
Exhibit A
Lot 28, Plat of River Place in the Town of Star Prairie, St. Croix County, Wisconsin.
I
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3of3
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