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HomeMy WebLinkAbout030-2141-00-005 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 561070 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: Bird, Shaun R. St. Joseph, Town of 030-2141-00-005 CST BM Elev: Insp. BM Elev: BM DescriptjiSection/Town/Range/Map No /bp I m G5-r 36.30.19.2055 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER . ~vfr CAPACITY STATION BS HI FS ELEV. Septic -:Po- D Benchmark (3 e- r f ~ ("1.1 L AI .6C 1~p . 3. ~dTi Aeration Bldg. Sewer Z .-7 '79 • , Holding St/Ht Inlet 3 3.~ TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 96 /JAr 1 Dt Bottom Dosing OF LI.J Header/Man. 9rZ 5 Aeration Dist. Pipe . S7 Holding Bot. System , Final Grade 9 PUMP/SIPHON INFORMATION 5 , Manufacturer Demand St Cover GPM S Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIM%<NS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS (e 7, 3 SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type fSystem:w~ rO nL CHAMBER OR yr` Q, At+~IX). UNIT Model Number: ^ rl (aikJ . 14 dj Jyt - •S!S + DISTRIBUTION SYSTEM ISJe3 7 Header/Manifold Distribution Ix Hole Size Ix Hole Spacing it Intake 4,,.i Pipe(s) -7 Length Dia Length Dia Spacing` SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Dept of xx Seeded/Sodded xx Mulched Bed/Trench Center G Bed/Trench Edges ` Topsoil 3• / Yes E] No ~ Yes No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: ection #2: Location: 818 126th Ave Hudson, WI 54016 (SW 1/4 NW 1/4 36 T30N R1 9W) Natalie's Ridge Lot 5 Parcel No: 36.30.19.2055 1.) Alt BM Description 2.) Bldg sewer length = - amount of cover = 23 avg. Q Plan revision Required? ❑ Yes _]WNo ~-7 Use other side for additional information. SBD-6710 (R.3/97) Date Insepctors S' ature Cert. No. PLOT PLAN PROJECT Shaun Bird ADDRESS 1432 120th St. Neew Richmond Wi 54017 SW 1/4 NW 1/4S 36 /T 30 N/R 19 W TOWN St. Joseph COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 5/10/13 BEDROOM 3 CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 46 BENCHMARK V.R.P. Top of power box ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 96.3/96.2 4' below qrade B . M. * 126th Ave Scale is 1" = 40' unless otherwise Rentention Pond a noted 5' 105' ' 94' Cells ith >3 spacing Vents 45' B-2 B 0% Slope 30' Well is to meet all ST setbacks required by WDNR 20' All piping shall be SDR 30/34, within 10' Pr 3 of tank, piping shall be Schedule 40. ho e Vent >6„ Quick4 Standard of Cover Leaching Chamber with 20.0 ft2 of Area of end caps 4' Long ;~_5.6ftA2/pair 14" Grade at System Elevation Property Line County Safety and Buildings Division 201 W. Washington Ave., P.O. Box 7162 o X Sanitary Permit Number (to be filled in by Co.) Madison, WI 53707-7162 5& 16 70 Permit Application State Transaction Number In accordance with 3 is. A ode, submission of• this form to the appropriate govern mental unit is required prior to tng a semi tt. Note; Application forrrts for state-owned POW'1'S are submitted to the Department of o essional Servies, Personal information you provide may be used for secondary Project Address (if dfflerent than mailing address) _urposes in accordance with the Privacy Law 15.04(1)(m), Stets. I. A lication Information - Please Print All Informatio Property Qwner' e ' Parcel # Property Owner's Mailing Address Y J v p7 5 7-... Z L U sT 3 2013 Property Location R zo5's J City, State Zip Code ph r _ Govt L ) ✓~L~c~~~ 1. jl, Z _'/a,~✓~cJ'/a, Section / role one II. Type of Building (check all that apply)) Lot # T..1 O . N; It7 E o or 2 Family Dwelling - Number of Bedro Subdtv/rsivn Name Q~ hArYU_ B /v- ❑ Public/Commercial -Describe Use 0.~ ❑ City of- State Owned - Describe Use CSM Number ❑ Village of -cSt~ Z 3 C Town of'~ L7 S III. Type of Permit: (Check only ne box on line A. Complete line B if applicable) k. w System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) i1. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner /6 / ICV. T e of POWTS System/Component/Device:. Check all that apply) ~ ` ' Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soft ❑ Mound < 24 in. of suitable soils„ L~ Holding 'Tank ❑ Other Dispersal Component (explain) 5 ❑ Pretreatment Device (explain) V'. Dis ersal/Trea ent Area Information: Design Flow (gpd) Design Soil Application Rate (gp Dispersal Area Required (st) isPersal Area Proposed-V* 3 d {st} System Elevation _ Jry J All. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units ~~q o New Tanks Existing Tacks er 23~ a n v, w C7 a. Septic or Holding Tank ~ i nosing Chamber VII. Responsibility Statement- I, the undersigned, assume r ibility for installation of the PO's TS shown on the attached plans. - e4 Plumber's N t (Print) Plumber's S• a MP/MPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) VIJ[I. oun /De artment Use Only Approved ❑ app Permit `F-eeee~ Date Issued Issuing rt Sign- C1 roan Reason )er►ial IX. Condi 1.'rpR easons for- Disapproval d..Me.~./U r8✓ nG e.J Nd T: 'septic tank, effluent finer and ( y dispersal cell must all be services 7 maintained Asper management plan provided by plumber. w~ ' '`'tom`b t~Ka / ~ ~r~""'~~v~ 2, ;A tse~=aclt raqulrements must bo maintained tss per appAcatile coda / ordinrices: ? 0 & Attach to complete plans for the system ands coif to the County only on paper nut l then 8 1/2111 inches in size 10, SBTI-6398 (R 11/11) PLOT PLAN PROJECT Shaun Bird ADDRESS 1432 120th St. Neew Richmond Wi 54017 SW 1/4 NW 1/4S 36 /T 30 N/R 19 W TOWN St. Joseph COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 5/10/13 BEDROOM 3 CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 46 BENCHMARK V.R.P. Top of power box ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL * H. R. P. Same as Benchmark SYSTEM ELEVATION 96.3/96.2 4' below qrade B . M. * 126th Ave I tl Scale is 1" = 40' Rentention Pond unless otherwise noted 5' 105' B-3 2-3:X 94' Cells with >3' spacing Vents 0 45' B-2 B 050 Slope 30' Well is to meet all ST setbacks required by WDNR 20 All piping shall be SDR 30/34, within 10' Pro 3 of tank, piping shall be Schedule 40. Bedroom J nt house Quick4 Standard Leaching Chamber with 20.0 ft2 of Area 5.6ft^2/pair of end caps 34" Grade at System Elevation a Property Line Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 5/10/13 Owner:Shaun Bird Location: SW1/4 NW1/4 S36 T30N,R19W 814 126th Ave St. Joseph 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 8-10. Soil test Signature License number #226900 PLOT PLAN PROJECT Shaun Bird ADDRESS 1432 120th St. Neew Richmond Wi 54017 SW 1/4 NW 1/4S 36 /T 30 N/R 19 W TOWN St. Joseph COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 5/10/13 BEDROOM 3 CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 46 BENCHMARK V.R.P. Top of power box ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION 96.3/96.2 4' below qrade B . M. * 126th Ave Scale is 1" = 40' unless otherwise Rentention Pond noted 5' 105' B-3 2-3:X 94' Cells with >3' spacing 0' Vents 45' B-2 B 0% Slope 30' Well is to meet all ST setbacks required by WDNR 20' All piping shall be SDR 30/34, within 10' Pro 3 of tank, piping shall be Schedule 40. Bedroom house Vent >6" Quick4 Standard of Cover Leaching Chamber with 20.0 ft2 of Area 12" 5.6ft^2/pair of end caps 4' Long Grade at System Elevation 34' Property Line Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber To be >1' above grade 5.6ft 2 pair of end plates Finish grade elevation Typical Installation 100.0' Vent /'CI Grade Vent 3' 4„ 3' X30/34 Septic Tank 5' Long 1 5' S' Long 1 Grade at System Elevation 36" Grade at System Elevation Spacing 5' 2-3' X 94' Cells Same on other end Observation tubeNent At end of cell A B 23 chambers per cell System elevations: A-96.3' B 96.2' POWTS OWNER'S MANUAL & MANAGEMEN7 PLAN Page of FILE INFORMATION SYSTEM SPECIFICATI(..)NS Owner 7ufadui /K~" ~tj Septic Tank Cermit # -al ❑ NSeptic Tank Mer D W DESIGN PARAMETERS Effluent Filter Manufacbarer Number of Bedrooms O D NA a NA Effluent Filter Model Number of Public Facility Units NA A Pump Tank Capacity Estimated flow (average) al NA al/da Pump Tank Manufacturer NA Design flow (peak), (Estimated x 1.5) c al/da Purnp Manufacturer Soil Application Rate NA Standard Influent/Effluent Qualit al/da /ft2 Pump Model NA Y Monthly average" Pretreatment Unit Fats, Oil & Grease (FOG) <30 mg/L NA Biochemical Oxygen Demand (BODs) X220 m /L ❑ Sand/Gravel Filter ❑ Peat Filter 9 DNA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L O Disinfection Pretreated Effluent Quality Monthly averse Other: Biochemical Oxygen Demand (BODs) S30 m /L g 41'n-Ground Cell(s) ❑ NA Total Suspended Solids (TSS) <30 mg/L ) 'Urn-Ground (gravity) ❑ In-Ground mg /L 11 At-Grade {pressurized} Fecal Coliform (geometric mean) s104 cfu/100m1 D Mound Maximum Effluent Particle Size Drip-Line D Other: in dia, p NA Other: Other: - - El NA © NA Other. Values typical for domestic wastewater and septic tank effluent. ❑ NA Other: MAINTENANCE SCHEDULE ❑ NA Service Event , Inspect condition of tank(s) Service Frequency At least once every: ❑ month(s) Pump out contents of tank (s) - ears (Maximum 3 years) ❑ NA When combined sludge and scum equals one-third (A) of tank volume Inspect dispersal cell(s) - DNA At least once every: ❑ months) Clean effluent filter -~kyear(s' (Maximum 3 years) ❑ NA _ At least once every: / ❑ monthts) Inspect pump, pump controls & alarm s, ❑ NA At least once every: El moat monthts) Flush laterals and pressure test ❑ year(s NA At least once every: ❑ month( s) Other: 11 year(s) NA At feast once every: ❑ monthts) _ Other: ❑ year(s) NA MAINTENANCE INSTRUCTIONS NA Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servii:ing Operator. Tank include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cricks or leaks ure e v Master combined sludge and scum and to check for any back up or ponding of effluent on the ground wirface. The dispersal inspections must visually inspected to check the effluent levels in the observation pipes and to check for any measure the volume of The ponying of effluent on the ground surface may indicate a failing condition and requires the cell(s) shall be regulatory authority, y i g es th ig of effluent the ground surface. When the combined accumulation of sludge and scum in any tank equals one-third or immediate notification of the local the tank shat( be removed by a Septage Servicing Operator and disposed of in accordance Administrative Code. (3) more of the tank volume, the entire contents of All other services, including but not limited to the servicing of effluent fillers, mechanical or res f with chapter NR 113, Wisconsin 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 c p sur zed components, pretreatment units, ompletion of an!, service event. START UP AND OPERATION Page of For new construction, prior to use of the POWTS' check treatment tank(s) for the presence of painting products or other chemicals tha 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 Itackup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Orerator 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 scrap, ; 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 shalt be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septagr; 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 ffect at that time. X.Asuitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a Idling tank may be installed as a last resort to replace the failed POWTS. O 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. Q Mound and at-grade soil absorption systems may be reconstructed in place following rtamoval 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/OH,, INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DpWATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER _ Name LL e 161 r F Name ~ 7, 7/✓ ' ~ - Phone SEPTAGE SERVICING OPERATOR PUMPER Name LOCAL REGULATORY AUY'HORITY 11 Name Phone 1 Phone / This document was drafted in compliance with chapter SPS 383.22(2)(b)(1)(d)&(t) and 383.54(1), (2) & (3), Wisconsin Administrative Code. FILTMK LARTRIDGE IINSTIRUCTIONS ~'rw z bry r1t tlrr casrr , Cantered under tiw tiaee,rSy otrwrrrl ig.Yl } tl~ftitl 011th1f, ~rl After Ojos ter eerr:uru it is I" through the outlet or erolvered wahi ttlan pups. tl~luo 1h6 Oddd j,ii9uha,l 1}rt Inure lrflra i}rto tke 1 plwu UirYu t'be rtutfret :H'o 1:C~ ~ Whl{rr Urns rvaw 1sx +stlti rlr ut+rti~ineh plpr: n Yt4md 9t1 tits ntlt9t3t trine, rrraa3urv time IasMytfr ulrHwri►f Y adt~nn Calf tdder Ctvivorl de ~~ie Laid well If UtliFelnp .he "440 t* bra Rr° to 1'uUt. p#rurt }nawad Is nut Utui nd, F'vr- ial rlidtluras'Warmly tlra virtlurlal 611pplfsYrrerrtn) tcaruahk wrafd Ilia >I6. ihak lul{ea o►,ka the f1w ct►srr• sappnrt rrrakrttld in trot Utilized, pradeed to e-lea (.U, if biidt ~ eupirurr: cartridge ihft ttr the tameW v..rx S t Wahl the l tgi" cure urtrr tits aUtiirt gips Xlvu,rt krre Nfhrr prarlsinrl dOY " allYli tilt rasu. t11Ci tiftwr far:kc 1►rtn the br►ttnror IF a AS xwlt'ch if, cal M' liutkwlse atilir d: irr lido tires iirtter' and ivraC try tUrhing 1. '1'hrn eYrltiarrt tiftar rtlrnuid br deahud uvury time the C%Vptlr tllnlt !5 5erviCgd • 9, l7p i►u►rern tket cutlet +ur"res a aparHr,ty to 1nop t the tw4c mid fft., tp tirw snpurtrrnlr cu►r►plurt►rly, Ibrydr t►►t rnerkigll surm to rwreaV'e the dug" r the botkar►r eri'(hIs t;,iwk and not Just the sr%Urrr uhd ei9ltlunt. d, Orrin t4sm aWltwht: l►rvat flees Won tow wvd huh;W th, i}n+ttrt of t'iru - u t plum, frrr►dV pull rip err the elrtw• halsefte U, drsigdhe the ss Ctrrtrwwo fnwo tilt matt. , 5. Shde the rurtridted in, and otw: of the ctrsrr ti,►r daartirry. U, V a VAS swltsth e:a hhectad tv are trfrrrhl k N'rWittit, the swr/itth shi,ufd bu nrasovad by tarninry r:ryitrrtardM*VVisw 3Lr" r Whit Water Only, OW dtsithrid I. Whfie lt1NtYN}g the t~I'y 40 blS bids ~ g dozen) aver the y are Mit suri4ra iwdary r. t"'s upnntrlgr MOO ON IN caltAdoa whit w,*,,r ordy, nnarrlriu sure all mrrptagx: "Oterval Iti r s a. Jf VRS switch Is utifterd, replw,* by 111481VAIItut ttfteyr' ndlia tanl . ai L•urMU►g dnckwiya BU°, 9, Xhs,ert trier 11 liar corbidev beek lrrkt► the lilt-at, lr ckm 8►to the Lnttoun the liieu i'ibt( duWrr until biz a, rrl' itrW fmse►. 14.14uglate rind suture thrr +ttrui;b uflxhfpU or, tize tjtiR. r.: r, .>n:.r.,...,e~,•yw ; aw,:'vr:riartr ,1,' r.l a lr4t'i67 :.raFlnrav.. W WVALb9*r4UWtO-item. 877-MWLTUI (6 531451j3) I ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer it <z c{ i , Mailing Address Property Addres~r~' 14 (Verification required fro o . - g ning Department for new construction.) City/State - Parcel Identification Number .LEGAL DESCRI'PTI(:rN j Property LocataionSc,.) Sec 0 N 4' OS Sub R W, Town of Subdivision - r`-- Lot # CertMed Survey Map # Volume Page if Warranty Deed # Z Z _ _ _ _ Volume Page # Spec houOP6 yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFIC_ A~ TAN Improper use and maintenance of your septic system could result in its premature failure What you put into handle wastes. Proper to maintenance consists ofpumping out the septic tank every three years or sooner, if needed, by a li-,ensed pumper. the system can affect the function of the septic tank as a treatment stage in the waste disposal sYstf rn Owner responsibilities are specified in Comm, 83.52(1) and in Chapter 12 -,qt. Croix County Sani Ordi maintenance tart' nonce. The property owner agrees to submit to St. Croix County Plannin & Zoning owner and by a master plumber, journe plumber, g Department a certification fo j or a licensed pumper that the on-site wastewater disposal system is in proper o~ Aerating Condit condition plumber and/or (2) after inspection and verifying signed by the less than 1/3 full of sludge. pumping (if necessary), the septic tank is Vwe, the undersigned, have read the above requirements and agree to maintain the private ;sewage disposals stem j standards set forth, herein, as set by the Department of Co the Certification stating that your septic system has been mainta ned must bie completed Department and of N'returneaturadl R to the St esources, State of y Wisconsin. Zoning Department within 30 days of the three year expiration date. Croix county Planning & I/we certify that all statements on this form a true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty de recorded in Register of Deeds Office. Number of bedr G' ATURE OF APPLICANT(S) DATE ''"'"*Any irtfortnatian that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning De a Include with this application a recorded warranty deed from the Register of Deeds Office and a co of the ce p rtrap preference is made in the warranty deed. PY rtified s survey reap if if "REV. 08/05) i UNPLATTED L. N89°51'08"W ; 231.32 231,32 231.32 BLOCK DIST ~ 2079.5' SNCN MARK: T OF 1" IRON PIPE ELEVA'00N 940.1 l5' 15' JQ 1 ! 1 1 ! 1 ! ! Ili LOT 4 ~ LOT ~ LOT 6 1 ~y3y.~~00}/0 ACRES ~ X3.000 A~ 3.000 ACRE'S ! 30,682 SO. Fr. 130682 SQ. FT. + ! ~ ~ III MAW SO. F 1.8.0.w 940.: LB.0.= 940.' ! ! 'F4w ! ,DRAINAGE H.W.E. 916.0 rASEmmr or, S89'51'08" E 2084.21'~-....wwww..w~.. 126TH VENUE S now 1J~a~siwv~ ~sM~a DRAINAGE IIII IINN ~I II~Il~I~II~III ~~I~I~I~I.l~ll 81122.93' Tx:4089263' STATE BAR OF WISCONSIN FORM 3 - 2000 969022 Document Number QUIT CLAIM DEED BETH PABST REGISTER OF DEEDS THIS DEED, made between Citizens State Bank, a Wisconsin banking ST. CROIX CO., WI corporation, Grantor, and Shawn Bird, a single person, Grantee. 12/07/2012 1:23 PM Grantor quit claims to Grantee the following described real estate in St. EXEMPT#: NA Croix C unty, State of Wisconsin (the "Property"): REC FEE: 30.00 Lots 4 5 G, 11, 13, 20, 21, 26, and 27 Natalie's, Ridge, St. Croix County, TRANS FEE: 764.10 PAGES: 2 Wisco Lots are sold `as is' with all faults. Recording Area Name and Return Address: 'Title One Premier Group 706 19th St S Hudson. WI 54016 #18811 Together with all appurtenant rights, title and interests. see attached Parcel Identification Number (PIN) This is not homestead property. Dated this 7th day of December, 2012. Citi n tate Bank aj - kx..4~~ * Gene Haberman, Vice Chairman * * AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN ) Signature(s) ST CROIX COUNTY. ) ss. authenticated this 7th day of December, 2012 Personally came before me this 7th day of December, 2012 the above named Citizens State Bank by Gene Haberma, * Vice Chairman to me known to be the person(s) who executed TITLE: MEMBER STATE BAR OF WISCONSIN the foregoing instrument and acknowledged the same. (If not, authorized by § 706.06, Wis. Stats.) *Jay P field THIS INSTRUMENT WAS DRAFTED BY N VcOuission lie, State of Wisconsin My is permanent. (If not, state expiration date: Michael H Forecki, Attorney 8/7/2016 ) (Signatures may be authenticated or acknowledged. Both are not necessary.) *Names of persons signing in any capacity must be typed or printed below their'signQY red. PFNFIE'_ "Iotar I Public 7tei CI wlSco•.Sin 1 of 2 QUIT CLAIM DEED STATE BAR OF WISCONSIN FORM No. 3-2000 File No.: 1881 1 EXHIBIT A Lots 4, 5, 6, 11, 13, 20, 21, 26, and 27 Natalie's, Ridge, St. Croix County, Wisconsin. 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I--_ - O I O I~D~yx, I I ~~x 1 i F g 1 I p I I B°R NRme I ! g I I I i @S I, I 1 I e I j~=='~==~'11~ F~~I 1` I 1 ay I ~a~ I x I I I I++ p0 I I I x I I I I ! I e I FCT - __r R - - _ g _a I I I II i6 f4 RlI j ~ i i 9J II j 9 ~ i % v I J I•-~.-J-__JI v 1 -r T r______I J i t i q I', I I b LIJ LIJ v ~9 -J I j S Ili I I Itl ~ I it r---- - i i ~~&S ooTT.lsunw uaoval (~y~ j 1 ~ I I Y I II ~~H I I b I I I :1 I~ F: i I I I ~rl ~ I wmw I ___'J V113 ,tMtlOY.I~MO 1 ~ I .mY a~ qq a.er I - YM uG .r w a. 8 6 x Wisconsin Department of Commerce VP OIL Ev"6 I/ N REPORT Page of Division of Safety and Buildings L in a Comm 85, Wis. Adm. County Attach complete site plan on paper not I n 8 x 11 inches irtPl# / x include, but not limited to: vertical a on ference point (BM), directo~~3 Parcel I.D. percent slope, scale or dimensions, rr and location and dice to nearest road. Q 30 Please print all information. cROMCO(A Revi ed by Date Personal information you provide may be used for secondary purposes (Privacy Low, s. 15.04 (1)'(m)). ~3 13 Property Owner > Property Location Govt. Lots 1 /4 l /4 1_36T.'.-' d N R E (o W /C Property Owners Mailing Address Lot # Block # Subd. Name or CSM# city State Zip Code Pone Number ❑ City ❑ Village To Nearest R Xew Construction Use esidential / Number of bedrooms- Code derived design flow rate JU GPD ❑ Replacement ❑ Public or commercial - Describ Parent material (7C.~.[/c{Q 1~ mlP.. c% c1 _~lood Plain elevation if applicable ft. General oornments and recommendations: System Type ~/hn•-c~c i? System Elevation F Boring # ❑ Boring pit Ground surface elev. , .~,4'c ' G ft. Depth to limiting factor 9 (0 in. Sal 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 Z J mti ' 0 Loo, S 1~S- rn^ , f J✓ 1 C7 4117 Fs Boring # n0 Boring RSL pit Ground surface elev!~ 37 ft. Depth to limiting factor 02- 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 P -9 3/L- S ems- Q/ -2 All Effluent #1 = BOD > 30 < 220 mg/L and 117SS >30 • Effluent #2 = BOD 130 mg/L and TSS < 30 mg/L CST Name (Please Print) CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 54017 715-246-4516 Property Owner _ Parcel ID # Page of a Boring # ❑ Boring "&Pit Ground surface elev. -40-0-~ ft. Depth to limiting factor 2 in. Soil A-pplication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/lf in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 n 0-/ 0 222 4/ Z -3 r c----1 fJs c 1-/) t7 14- C7 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 F-1 ❑ Pit Ground surface elev. ft. Depth to limiting factor in. 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 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 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. SBD-8330 (RAW) Property Owner Parcel ID # Page of E Boring # [3 Boring '.Pit Ground surface elev. 400- ft. Depth to limiting factor ~ in. -9-oil-Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/if in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 n le) 3 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 GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 a Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon 'lepth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPDM 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 = BOD, 130 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. SOD4330(RAMD) Soil Test Plot Plan Project Name Shaun Bird Shaun Address 1432 120th St. New Richmond Wi 54017 CS Lot 5 Subdivision Natalies Ridge Date 51,1226900 13 S W 1/4 N W 1/4S 36 T 30 N/R19 W Township St. Joseph ❑ Boring 0 Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of power box System Elevation 96.3/96.2 *HRpSameasBenchmark B.M. * 126th Ave Scale is 1" = 40' unless otherwise Rentention Pond noted 5 105' B-3 30' 45' B-2 45' 0~ 45' B-1 0% Slope Property Line . s 1318 L!PR9461E I~JAT N REPORT Wisconsin Department of Commerce Page 1 of 3 Division of Safety and Buildings Tom Schmitt jincorda?A%yith C m 85, Wis. m. Code > ~"'(j ~ County Attach complete site plan on paper not les: x 11 inches n size? Ptart must St. Croix include, but not limited to: vertical and r~t,(~ direction and percent slope, scale or dimemsions, nrth ~hd ~Ta~neares road. Parcel I. D. NG OFFICE 2/ co- C~ Please print all inform R lew y l D e Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Grand Properties, LP Govt. Lot SW 1/4 NW1/4 S 36 T 30 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 712 Rivard Streeet, Suite 300 5 Natalie's Ridge City State Zip Code Phone Number _j City J Village 1e Town Nearest Road Somerset WI 54025 715-247-5900 St.Joseph 80Th St. A6 New Construction Use: a Residential / Number of bedrooms 3 Code derived design fkmr rate 450 GPD J Replacement I Public or commercial - Describe: Parent material outwash over sandstone Flood plain elevation, if applicable na General comments and recommendations: Area is suitable for a mound system. System elevation is 99.4' based off of contour line established at 98.90'. Slope is 0% (flat). Depth to limiting factor is 33". Boring # Boring W Pit Ground Surface elev. 98.73 ft. Depth to limiting factor 33 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 -Eff#1 -Eff#2 1 0-15 1Oyr3/2 none I 2fsbk mfr cs 1vf .6 .8 2 15-28 1Oyr4/4 none sl 2msbk mfr 9w 1vf .6 1.0 3 28-33 1Oyr4/6 none scl 2msbk mfr cw .4 .6 4 33+ 1Oyr8/3 none vfs Osg cemented - - OA 0.0 Boring # Boring Pit Ground Surface elev. 98.92 ft. Depth to limiting factor 68 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz "Eff#1 •Eff#2 1 0-12 10yt3/1 none I 2fsbk mfr as 2vf .6 .8 2 12-23 1Oyr4/6 none scl 2msbk mfr 9w 1vf .4 .6 3 23-33 1Oyr4/4 none sl 2msbk mfr cvv 1vf .6 1.0 4 33-68 1Oyr5/6 none ms Osg ml CIS 1.6 5 68-82 7.5yr5/4 c2d 10 /1/6 vgrcos Osg ml as 1.6 6 82+ 1Oyr8/1 none vfs Om cemented 0.0 0.0 * Effluent #1 = BOD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD S.30 mg/L and TSS <,0 mg/L CST Name (Please Print) Signature: CST Number Thomas J. Schmitt , -/1,t/,- 227429 Address Tom Schmitt Date Evaluation Conducted Telephone Number 1595 72nd St., New Richmond, WI 54017 12/18/04 715-247-2941 Property Owner Grand Properties, LP Parcel ID # Page 2 of 3 3 ] Boring # Boring Pit Ground Surface elev. 98.68 ft. Depth to limiting factor 74 in. Soil Application Rate F Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots "Eff#1 'Eff#2 1 0-12 10yr3/3 none I 2fsbk mfr as 1vf .6 .8 2 12-25 10yr4/6 none scl 2fsbk mfr 9W 1vf .4 .6 3 25-30 10yr4/4 none grsl 2msbk mfr gs .6 1.0 4 30-74 10yr5/6 none ms Osg ml as - .7 1.6 5 74+ 10yr8/2 none vfs Om cemented - 0.0 0.0 F-1 Boring # I 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 *Eff#1 "Eff#2 ❑ 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 *Eff#1 *Eff#2 * Effluent #1 = BOD ? 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. Page 3 of 3 Conducted by: Conducted For: Schmitt Soil Testing, Inc. Name: Grand Properties, LP Thomas J. Schmitt, CST 227429 Address: 712 Rivard Street 1595 72nd St. City, State, Zip: Somerset, Wl. 54025 New Richmond, Wl. 54017 Phone: 715-247-2941 Subd.Name: Natalies Ridge 0 Y Lot No.: S_ i Legal Description: S~~ 1/4 /YAl114 S36 T30N R19W Township of St. Joseph, St Coix County Bench Mark El. 100.00' Top of 1/2" rebar Alternate Bench Mark El. 0, 1, 7 / Top of 1/2" rebar Slope= DA /ut) Contour Line EL~c 90 S 1" = 40' a f y~73 Q~ 120 03 Alp em A L Les Zo .54vuj-4 -1 V- This soil report was done to fulfill a zoning requirement. A preliminary plot map was used, no drainage easements or drivewav lncations were established at the time this soil and site evaluation was conducted.