HomeMy WebLinkAbout040-1308-00-150
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division Sanitary Permit No:
INSPECTION REPORT 561076 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: F City Village X Township Parcel Tax No:
McCue, Mark T. Troy, Town of 040-1308-00-150
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No.
~v / Y l C 5 24.28.20.1969
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic % y~ ,S f Z 56 Benchmark ' 71 / 19
~YL,v- ~e !b ' ~•'S Alt. BM~ l~ CG -cti ✓s(p /U3.3
Aeration Bldg. Sewer
Holding St/Ht Inlet
Z5
~~ll
TANK SETBACK INFORMATION St/Ht Outlet - T' S /c~a • ~h
TANK TO P/L WELL BLDG. Vent oAir ritake ROAD Dt Inlet
Septic NM- 26 i Dt Bottom \
Dosing Header/Man. 4
t0 • lJ
Aeration Dist. Pipe -7.15 ~t 7d
Holding Bot. System (
7• co ~_7(O
PUMP/SIPHON INFORMATION Final Grade 35 A
!
Manufacturer Demand St Coves 1 Ga- J• S 7 63 .3
GPM 4- /
Model Number
TDH Lift action Loss System H T FH Ft
main la. Dist. to Well
Force
SOIL ABSORPTION YSTEM
BEDITRENCH Width Length / No. Of riches PIT DIMENSIONS No. Of Pits Inside Di= Liquid Depth
DIMENSIONS 3 76 7-1/ / G
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION T e f System: CHAMBER OR 67 z /o "j
7 S UNIT Model Number:
DISTRIBUTION SYSTEM
Header/Manifojd Distribution x Hole Size x Hole Spacing Vent to Air Intake
L~ Pipe(s)
\ G oCS
Length b Dia / Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over / Depth Over xx Depth of eeded/Sodded xx Mulched
Bedrrrench Center L([ Bed/Trench Edges Topsoil xx S
Yes H No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: I /
Location: 308 Lindsay Rdr.- Hudson, WI 54016 (SE 1/4 SE 1/4 24 T28N R200WI Troy Village 6th Addition Lot 1/50 _ Parcel No: 24.28.20.1969
t'`^5 T ~O G{GS 6
1.) Alt BM Description = ~ - C l~ C k.
2.) Bldg sewer length = 3 5~. Tc J - /6
- amount of cover = i G ~l e- o L
a
,Z 6r~
Plan revision Required? ❑ Yes No q -7 1-71 ~V ~7S
Use other side for additional information. ( / ` -
Date Insepctor's nature Cert. No.
SBD-6710 (R.3/97)
S
I'M
` s \
/17/13
RK McCUE
18 LINDSAY ROAD
rDSON, WI 54017 0 z OR
•
1` w
1/4 SE 1/4 SEC: 24v ~Z➢s \
28 NR20W
)WN OF TROY
t
,'NCHMARK #1 100 ~ 1~ 40
?,NCHMARK #2 101.3
[STEM ELEVATION 97.33 -
JBDIVISION -TROY BURNE VILLAGE
.ISER 1250 SEPTIC TANK \ \ , '
/ POLYLOK 525 FILTER
)T 150
ALE 1"-40'
~ ~ i 0c~
commerce.wi.gov Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 ST. CROIX
' s'W O n c' n Madison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce 0-7
Sanitary Permit Application State Transaction Number
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental Alk
unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address (if different than mailing address)
submitted to the Department of Commerce. Personal information you provide may be used for second 308 LINDSAY ROAD
purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats.
1. Application Informs ' -Please HUDSON WI 54016
Property Owner's Name / Parcel #
MARK T. McCUE I&JO40-1308-00-150
Property Owner's Mailing Address MAY 17 2013 Property Location 9
3727 SUNRISE DRIVE E Govt. Lot 1 50
City, State `749 T. Phone Number S_ y, S_ Y ,,circle 2 _
INNETONCA MN 55345 (circle one)
T'$_ N; R 20 E or VQ
II. Type of Building (check all that apply) Lot #
I or 2 Family Dwelling - Number of Bedrooms 4 W ) Subdivision Name
Block # TROY AMN*f VILLAGE
❑ Public/Commercial - Describe Use N/A ❑ City of
❑ State Owned - Describe Use CSM Number ❑ Village of
2 66 Town of TROY
III. Type of Permit: (Check on one box on line A. Complete line B if applicable)
A. .New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
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 a 1
$(Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/Treat nt Area Information:
Desim Flow (gpd) Design Soil ADplication Rate(gpd Dispersal Area RR,quired rcf) Dispersal-Area Proposed f) System Elevation
600 ~.7 857.14 900 97.33 1 L'
VI. Tank into Capacity in TOW- ' # of Manufacturer
2
Gallons Gallons Units D 9 V T
New Tanks Existing Tanks /1 a
U v~ ti v~ ii C7 n
Septic or Holding Tank Xi ZeSO , WELSE9 1, x
Dosing Chamber
VII. Responsibility Statement- 1, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Si ature MP/MPRS Number Business Phone Number
l 225410
Plumber's Address (Street, City, State, Zip Code)
321 WISCONSIN DRIVE, NEW RICHMOND, WI 54017
VIII ount epartment Use Only
.wCy
Approved ppro Permit'Feee Date sued Issuing ent Signatu 00 ven Reason or Denial $ / J3
IX. Condit easons for Disapproval
1. `septic tank, effltOnt filter and
;dispersal ceB:must all be sir*es I maintained
as per management plan provided by plumber.
2..M s slack rsgOnettts must bwominWruid
Wipe It ocde 1 o►dinaflt
Attach to complete plans for the system and submit to the County only on paper not less than 8 1/i x 11 inches in size
SBD-6398 (R. 02/09) Valid thru 02/11
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name:
Owner's Name: Mark T. McCue
Owner's Address: 3727 Sunrise Drive E
Minnetonica MN 55345
Legal Description: S E 1 /4, SE 1 /4. Sec 24, T28 N R20W Town of Troy
Township: Town of Troy
County: St Croix
Subdivision Name: Troy Burne Village
Lot Number: 150
Parcel ID Number: 040-1308-00-150
Page 1 Index and title
Page 2 Plot Plan
Page 3 System Sizing & Cross-Section
Page 4 Filter Specs
Page 5 Maintenance Information
Page 6 Management Plan
Page 7 St. Croix Cty Septic Tank Maintenance Form
Page 8 Warranty Deed
Page 9 CSM or Plat
Attachments: Soil Test & House Plans
Designer/Plumber: Countryside P & H License Number: 664713
Date: 05/03/2013 Phone Number (715) 246-2660
Signature
Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01101).
Page 1
I
J ~
)5/17/13 r~
MARK McCUE
308 LINDSAY ROAD
JUDSON, WI 54017 61
;E 1/4 SE 1/4 SEC. 24 oe v Z , 5
T 28NR20W
TOWN OF TROY
BENCHMARK #1 100 40 X
BENCHMARK #2 101.3
SYSTEM ELEVATION 97.33
SUBDIVISION -TROY BURNE VILLAGE
WEISER 1250 SEPTIC TANK
CGS
W/ POLYLOK 525 FILTER
LOT 150
CALE 1"-40'
s,'
Lof /
SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT Page
Project Name: ,O-- a-ri c/Z / ,M.C c r-
-No. of Cells Per Cell
ft Cell Width Total No of lyl 2y-/64
ft Cell Length s~ sq ft EISA Per Cell
_ ft Cell Spacing g d O sq ft Total EISA
Manufacturer Model Laying Length EISA Rating
Infiltrator EZ1203H-5ft 5.0' 25.0
EZ1203H-10ft 10.0' 50.0
Gravelless Leaching Unit Manufacturer: 21-7
Gravelless Leaching Unit Model: 12,03 hf"
Typical Cross Section
Finished Grade ft
Observation Pipe with
approved cap or vent
*rrrrrrra~--- ■
Soil Backfill
in ■ ■
Geotextile Fabric
lo'
4wzl Infiltrative Surface
12 in
r e~~ 0 it V
Limiting Factor
A10 in Slotted and Anchored Vent/
Observation Pipe with Cap
■■a=rrrrrrrresaarrrrsaR!.*rrraarrrrrr■rrrrrrrraarrrrrrrrr•rrrarrrrrarrr■
Plumber/Designer Signature:^
License '457",- ?2 <S fe/® Date: ^ o
'WP
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer 1 Z-►~ 1 c- C'ec-irc
Mailing Address
Property Address~`t~
(Verification required from Planning & Zoning Department for new.construction.)
Cit) /State a-t-A050Lj, I Parcel Identification Number
LEGAL DESCRIPTION
Property Location '04 '/a , Sec. Z4 , T Z4~ N R 70 Val, Town of
Subdivision / >n-4-►c ut L~ La ` , Lot # ISO
Certified Survey Map # , Volume , Page #
Warranty Deed # 1 q , Volume , Page #
Spec house yes 46 Lot lines identifiable Ono
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper
maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into
the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St: Croix County Planning & Zoning 3. J+eparirtrent"a-certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
less than 113 full of sludge.
Vwe, 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 exp' ation date.
Uwe certify that all statements on this fo a true to the best of my/oar knowledge. I/we am/are the owner(s) of the
property desc d above, by virtue of a warranty eed recorded in Register of Deeds Office.
-Numb a ed oms
SIGNATVkE OF AP LICANT(S) DATE
'Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department.
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if
reference is made in the warranty deed.
(REV. G&M5)
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page cf
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner MARK MdCUE Septic Tank Capacity al ❑ NA - 1250 Permit # -
Septic Tank Manufacturer WEISER Q NA
DESIGN PARAMETERS Effluent Filter Manufacturer POLYLOK ❑ NA
Number of Bedrooms 0 NA Effluent Filter Model 525 ❑ NA
Number of Public Facility Units 121 NA Pump Tank Capacity gal H7 N A
Estimated flow (average) 400 Pump Tank Manufacturer KI NA
gal/day
Design flow (peak), (Estimated x 1.5) 0 gal/day Pump Manufacturer ® NA
Soil Application Rate al/day/ft2 Pump Model 0 NA
Standard Influent/Effluent Quality Monthly average* Pretreatment Unit 8 N,a
Fats, Oil & Grease (FOG) 530 mg/L 0 Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BODE) s220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection 17 Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) d N,~
Biochemical Oxygen Demand (80Db) S30 mg/L M In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L Q NA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) 510' ofu/100ml ❑ Drip-Line O Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ Nok
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: 3 00 maarn~(s) (Maximum 3 years) 13 Nit
Pump out contents of tank(s) When combined sludge and scum equals one-third (Yt of tank volume ❑ NEB
Inspect dispersal cell(s) At toast once every: 3 0 month(s) (Maxknum 3 years) 13 Nit
year(s)
Clean effluent filter At least once every: Q month(s) ❑ NA
141 10 year(s).
Inspect pump, pump oontrois & alarm At least once every. 13 month(s) ❑ N/,
N/A D earls)
0 month(s) ❑ NA,
Flush laterals and pressure test At least once every: N/A ❑ year(s)
Other: At least once every: Q mori (s) [3 N~,
year(s)
Other: 0 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' surfao 3,
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 itie
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one-third (Y) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 11:3,
Wisconsin Administrative Code.
Ali other services, including but not limited to the servicing of effluent filters, mechanical or pressurrzed 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.
QVuL
START UP AND OPERATION Page Z of
For new construction, prior to use of the POWYS cheok treatment tank(s) for the presence of painting products or other chemic all
that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the content:
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 Maintalner 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; coil;
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:
s 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 Vold 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:
C) A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorptkn
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 A ill
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.
0 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.
l►wO alua. ' .ri
►k
❑ 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 NC T
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
EName OUNTRYSIDE PLUMBING & HEATING, INC Name AUL KOEHLER
Phony t7l5-245-2660 Phone 715-246-2660
SEPTAGE S VICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name POWERS LIQUID WASTE MANAGEMENT Name :5t, i ( 24DAI1A
Phone 715-246-5738 Phone
~5-~,~ (p .
This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1). (21 & (3), WiscorrAn Administrative Code.
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\o m WLP1250-MR WIENER CODCAETE DRAWN BY. SME SCALE: 1 4"~i'-0" PRE-POUR:
m ~ SEPTIC MANUAL W3716 US HWY 10 MAIDEN ROCK, WI 54750 DATE: JANUARY 2010 DATE:. POST-POUR:
`O REVISED JAN. 2010 800-325-8456 FlLE: "2b0-18
s
I
II ~ INSTALLATION INSTRUCTIONS
a bx na Zeta
Afh+isto"of.°oylakG+c. kh PL-525/PL-625 FILTER
3r WiSrewa:erProCucs
PL-525/PL-625 FEATURES & BENEFITS
Features & Benefits:
• Rated for 10,000 GPD
• PL-525 = 525 Linear Feet of 1/18" Filtration
PL-625 = 625 Linear Feet of 1/32" Filtration
PL-525 PL-625 *Accepts 4" and 6" SCHD. 40 pipe
The PL-525/625 Effluent Filter should operate efficiently • Built in Gas Deflector
for several years under normal conditions before „Automatic Shut-Off Ball when Filter is Removed
requiring cleaning. It is recommended that the filter be
cleaned everytime the tank is pumped or at least every • Alarm Accessibility
three years. If the installed filter contains an optional
alarm, the owner will be notified by an alarm when the .Accepts PVC Extension: Handle
filter needs servicing. Servicing should. be done by a
certified septic tank pumper or installer.
RECOMMENDED PRODUCTS
Potylok_PVC Filter
Extension Handle
x,
Filter Alarm Panel and
Risers.' Riser Covers Extend La(ETM Riser Safety Screens
SttlattFltterT"' Control i
Polylok risers bring your Polylok Extend & LokT'4 Polytok safety, screens switclt
septic. tank cover to grade. is a simple, easy to use prevent tragic accidents pot lok fitter alarm panels
This allows locating and solution that can extend' from happening. by children y servicing your filter easier the inlet or outlet pipe and and pets falling. into
open and switrfls provid a' visual
and time saving by elimi- make filter and/or baffle septic tank entrances. and audible notification of
hating digging to find tank installation a snap. Impending filter and tank
entrance. Fits. 3" and 4" pipe. servicing.
For a full list of Polylok products please visit our web site at: wwrw.polylok.com
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State Bar of Wisconsin Form 1-2003 Tx: 4111463
WARRANTY DEED 974663
BETH PABST
- ~
Document Number Document Name REGIS . TER OF DEEDStiw •
ST. CROIX--C WI .
03/07/2013 2:55 PM
THIS DEED, made between Troy Uevelo m nt Corporation EXEMPT#: NA
("Grantor," whether one or more), REC FEE: 30.00
and Mark McCue, a single person TRANS FEE: 120.00
PAGES: 1
("Grantee," whether one or more).
Grantor, for a valuable consideration, conveys to Grantee the following described real Recording Area
estate, together with the rents, profits, fixtures and other appurtenant interests, in
St Croix County, State of Wisconsin ("Property") (if more space is Name and Return Address
n e , ease attach ad ee dum): River Valley Abstract & Title
1200 Hosrford St. Suite 201
Lot 150, P at of Troy Village Sixth Addition in the Town of Troy, St. Hudson WI 54016
roix unty, Wisconsin. File: 2810551
L
040-1308-00-150
Parcel Identification Number (PIN)
This IS NOT homestead property.
(is) (is not)
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except:
Easements, restrictions and rights-of-way of record, if any.
Dated February 15, 2013
Troy Develop Co ration
(SEAL) (SEAL)
* Courtnie Kirvela Vice Pre 1 e t
(SEAL) (SEAL)
*
AUTHENTICA~~tQlNttrtrr~~~ ACKNOWLEDGMENT
Signature(s) ~``~~cZ~E• ` G~M~~~~4; STATE OF WISCONSIN )
` • ' ) ss.
authenticated on = v • O R.r = ST CROIX COUNTY )
* N• . A~ flat ~V ` Personally came before me on February 15, 2013 ,
TITLE: MEMBER STATF.W .ISCQ` - the above-named Courtnie Kirvelay. Vice President
If not, Cf. ~NIS.%\11 to me known to be the persons ho xecuted the foregoing
authorized by Wis. Stat. § 70b!66j1`"
instrument acknowledge e.
THIS INSTRUMENT DRAFTED BY:
* Lorr' L. D,eM S
Doug Berg Not Public at
f
1200 Hosford St. Suite 201 Hudson WI 54016 i Commi sio s permanent) (expires: March 20, 2016 )
(Signatures may be authen 'c or acknowledged. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORNI SHOULD BE CLEARLY IDENTIFIED.
WARRANTY DEED C 2003 STATE BAR OF WISCONSIN FORM NO. 1-2003
* ~)s# iame below signatures.
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Wisconsin Department of Commence SOIL EVALUATION REPORT Page
Division of Safety and Buildings
In accordance with Comm 85, Wis. Adm. Code j
5T. C -Rot
Attach complete site plan on paper not less than 8 112 x 11 inch is In si
include, but not limited to. vertical and horizontal reference point (BM). Pam?l 1.0 arc
percent slope, scale or dimensions, north arrow, and location air I distance to nearest road. -
Rs wed b Date
Please print all Information. O C T 2 9 2003
, I
Personal mlortnauon you provide maybe used for secondary pwposas ( raaCYuw.11.15.04(1)(M))
Property Owner T•d~f113+Y 1
4-- 114 Z I F F P- 114 S 2L4 T 2-1 N R `N
(20MTln1F_.jTAt_ DE EL0PMENT Cpf~P.
property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
IIi0O A RlEii(ZlEgm C.T. I-Su'li 100 ISO - TRO`{ Utt_t~c *"-AD1>3-
57 State p Code Phone Number. ❑ City ❑ village X Town Nearest Road
t_n►NE 55449 (743) 7 -T5(a$ Tlglov LiNl~f1`I 'KID.
GPO
New Construction User Residential I Number of bedrooms Code derived design Clow rate 00
p Replacement Lr] Pubic or commercial - Describe: -
'
Parent material rV I A Flood Blain elevation if applicabie it.
Cfr~ A t +
1
General comments
and reco mmendallons: Cotavg~4^0 )j Ak - SN-&A0 W.)D -itCENCt1E5 t
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0.7 CoAciw& T,?A-TF-
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goring # Boring O 1
A pit around surface elev. Depth to limiting factor ?Ljjfl_ _ in. Soil iraGon Rats '
Horizon Depth T' Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPO/ff
in. Munsell Cu. Sz. Cont. Color Gr. Sz. Sh. 'Etf#1 'Etf#2
- '
i 0--5 I ovlC Z-
5-11 pYI~~Z - 51~ -Lab d 66 Zjq-M, 0-5 ;
3 II-2-10 4 K.*1 - 7 5 0 dl 0 - 0.1 -1. Z
4 Z ..t5 lovl~3~ s11 d 0.1 •3 '
1 0.-1 I.Z
S - Iu~K3jIo S 0-fro L
lp 511 10, ab d eS 0. 0.'S
10
z-1 tovl~ s 0 - - 0.Z 1• Z.
Boring CftKIZON '3 WAS j3 To &r- tiorctLO -1 IFNAS ~.IOQIo 61e- ~
75 Boring # q00-.T tt. Depth to limiting factor in. r
Pit Ground surface elev. Sall AppicatIon Rate
Horizon Depth Dominant Col Redox Description Texture Structure Consistence Boundary Roots GPO/fF
in. Munsail Qu. Sz. Cant. Color Gr. Sr- Sh. 'Eff#1 'Eff#2 i
L c~ S LL V _Co . 5 i
I 0- 1OytCz/z - nn r J
• j:
2 14- iOVRz/z V ~ala~ d di Y -Co • S
0• i J
3 10-Za o - 7 2-- A\ alt- d~ a5 -M 17.5-
4_ a 3 - 5 d s -rn i. Z ty,
37-qlo V'11 - s o d 1 C,5 - o 1. Z r i
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_12Ap 0 v14~ s to d 1 C-5 - d.7 I•Z 1
7 I1L- IovK3/ 4 Wilms dl 0.? 1•7
n1gll
Effluent 91 = BCD > 301 220 mg/L and TSS >30 tSo mg1L Effluent #2 - BOD 130 mgA. and TSS 130
ml CST Name (Please Print) Ignature CS u 1
MAOU J0 H01-1-1,S-MR,
Address Date Evacuation Conducted Telephone Number ?
2 ~~5-30-63 L"ItS y2b-1'176 r
W98~5 AVE,~ ~uEtZ,FAtaS+ WI 5y02
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Property Owner CoA T1UEIJtAL QEVF1o~vIENT ParcellD# L~1~1O1tJG~-- Page L of 3 y
❑ Boring
15 ~ Boring tt v
pit Ground surface elev. `s•=~ it. Depth to limiting factor I OZ in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Ou. Sz. Cont. Color Gr. SL Sh. 'Eff#1 'Eff#2
ds Gf.t 3
, I - L r
1 d--7 1G'4IL4
Z _l Id, a vr<~ - _t% sb Qs . S 0.8
ku - 5 Q L Cs 0,-I 2
in
-3 Ilk 40 "-70 `I S S 5 c 5 - 0&7 I. Z ; v
0- 2 10 y d 1 0.7 t• Z e
Z TO ~9 " rUZOA ` 3 4 < tock GK,
.a
Boring
❑
Boring #
❑ pit Ground surface elev. It Depth to limiting factor in.
I Sal Ao lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPOM
in. Munsell du. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 Etf#2 ti
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❑ Boring
F7 Boring # Ground surface elev. it. Depth to limiting factor.-.- _ in. i
❑ pit Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPOMf i
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2
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Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODE < 30 mg/L and TSS < 30 mglL Y
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'l'he 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.
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VO COMM 83 SvfDPCK FWPaM5
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the ~itc eras "radcd after soil c~ aluatiol).S c
amy,leted tscc pa«c vkith final
\ stcm clc~ ations should not be a}t ctcd, atiollq
depth e(oa grade M ill need to be d
based on the ed
amount etermittb
ot, - ill.
cle\ ations cut o t should hav e remained coBMant.
1 0 Sao
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B 1508
E 900.5 <F~ \
- ELEV.
B 151 A
898.\
LEV.
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ELEV. 893.87
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LEV. S95'y
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Wisconsin Department of Commerce SOIL EVALUATION REPORT Page_ L_ot N-3
r
Division of Safety and Buildings i
In accordance with Comm 85, Me. Adm. Code Cour><y 1
ST.' C L
Attach complete site plan on paper not less than 8 112 x 11 Inches In size. Plan must I
include, but not Ilrnl(od to: vertical and horizontal reference point (BM), direction and P f
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. (PEA) I C-
1
Revla e by Date
Please print all Information.
I 7 I
Personal Information you provide may De used for secondary purposes IPrWecy Lew, s. 15.04 (1) (m)).
Property Owner Property Locatlon
GW*,- l 5 E 1/4 5S 114 S y T N R W
C0MTI NEIJTAL DE 1rt QIPM EM ~~p' Lot a Block a Subd. Name or CSMa
Property Owner's Ma81ng Address
11(W0 AIBEKZ 6T. E sutTE 100 150 _ -TRoj U t LLAC-C
City State Zip Code Phone Number, ❑ City ❑ Village JR Town Nearest Road
L.t~INE 55449 (7L3) '7--1568 Oy t_I,va,SR`I Rfl'
y (x+00 1
New Conslructlon User Residential / Number of bedrooms Code derived design now rate 'PD
t
❑ Replacement ❑ Public or cornmercial - Describe: - ft
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Parent material _ n~TW~`At I R L' QV I A i Flood Plain elevation i(epplicabie
` f
General comments `
and recommendations: CON*j UA 0)j )4N%_ SaJ-G►4p W3D _TKSOWES
b•~ cvROIN~ 1Ztt'tE 4~ ~ .
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❑ Boring ;
U goring a lQ`
A Pit Ground surface elev. '700.0 _ Q. Depth to limiting (actor 7 n Soil Ilcation Rats
Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD,"
Horizon
'EHa1 Etfa2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. i
D-5 I ON OZ SL I _ d Cb 3vfi m .5
z 5 -tt O VfLqZ _ 511 -Lab d 06 -m O. Sr ;
Zvq
3 II-z tovrc.~V 5 Q dl lL - ~7 !
z -JS l0vf_3/ ski d 0`z b.-5
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30- 7- lov►~3~(, 5
o NIK * 5~ 1 I tn~01b d CS 1A 0 • L D,-5 )
S O
7 2-1 t 0 `I iK r
❑ Boring CfrGIZON '3 "A5 i3 O &r-, M0rClZ.0-7 MAS X101710 lure I i
F-51 Boring Pit Ground surtece elev. Way N. Depth to limiting factor in. Soil • icadon Rate r
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Boundary Roots .E 1 Effii2
Horizon Depth Dominant Colo Redox Description Texture Structure Consistence GPD/tP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh.
1 0- I0yKNz - .Cm r d5 0. 3v -ea ,S O-y
2 - IOV le-`7 Z ~ L ^0.bll d Ci 1 ~ ~ (Q . 5 ~ ~ ' i
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3 10-ZJ o - ; ( z yh a~ a5 Y -M 0.5,
o.~ Lz
4 u- 0 3 - 5 S 1Y -m
d,-r t.z
s l `4! - s o d i c5 -
-IZ16 0,1K s 0, 1 C,5
7 hr.- IovrC~/ - w w;iK o d1 0.7 1 Z I i
Effluent #I = BOD > 30:E 220 mg/L and TSS 2-30 1 150 mgrL Ettluent X2 BOD 30 mglL and TSS ±30 mg/L. Number
_I CST Name (Please Print) Signature n r umber
9317-
Nl J H O L ST E
Number
Address to Evaluation Conducted Telephone
W`i875 b9a{hAUe, ;DIVE FAuS Wj 54022 ~~5-~~1-b3 ~'1lS yZb-1~7S ,
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LOT 1 3 1
Property Owner C0.A1Tl U F_tJ1AL QeV6 4 MF.N7 Parcel ID # _ N01A) Page of
/SI Boring # C3 Boring Co xv. Y
y
ft pit Ground surface elev. ` S- ft. Depth to limiting factor UZ in. Soil -Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPO/ff y
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
► 0-~ tovr~zll - L afmab ds at .S a
t y
z _1 0 14 7& ~t1 4? as in, . s o_
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4 60-70 10 Y S s ~ c 5 Q j 1. Z j Y
0-l710 4e-14/Li 4-4 dl - 07 1z
Z -M fiOKAZOA) s 3 4 H <iovk 6K.
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® Boring # ❑ Boring 1
Nj'pit Ground surface elev..$95-17ft. Depth to limiting factor in. (Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPO/ff
in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Eff#t Ef(#2 y
t t7_(o IeY 174 ---F4 v- Qa r~-*t, a.4 d,(o
M
a a. d y
3 -Ito X y - s D - y
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Boring
Bonng # Ground surface elev. It. Depth to limiting factor • _ in.
❑ pit Soil A ication Rate
Horizon Depth Dominant Colo Redox Description Texture Stricture Consistence Boundary Roots GPO/ff 4
in. Munsell Qu. Sz. Cont. Color Gr, Sz. Sh. 'Efi#1 'Eft#2
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Effluent #1 = BOD, > 30 1220 mg/L and TSS >30 1150 mg/L ' Effluent 92 = BODr 130 mg/L and TSS < 30 mg/L ~ I
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'rhe Department of Commerce is an equal opportunity service provider and employer. if you need assistance to access services or 1
need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777.
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NO COMM 83 5~Tf CK PPGNXM5
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B 150B \ ~S \
ELEY. 900.5 F<FG
- ELEV.
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B 151 A
hLEV. 898.\ o° - f
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ELEV. 893.87
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~EVIS~ED : 45 /S-/3