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HomeMy WebLinkAbout030-1053-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 563842 0 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Iverson, Robert C. & Gail M. Revocable Trust St. Joseph, Town of 030-1053-90-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: X00 65 T 23.30.19.198A TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. ~ / //6 Leo Septic es~/ 73,n ' ' bOO Benchmark $ ` ' ~u V w L\A Dosing ` Alt. BM U D , / La~nJ1Op Soo ,QJ GO J ~ Z , b Bldg. Sewer Pb ► t. k, SZ Holding St/Ht Inlet TANK SETBACK INFORMATION TANK TO P/L I(VEL~ BLDG. Vent t it Intake ROAD Dt Inlet AN J Septic /u x / Dt Bottom 16.1Z CM Z Dosing / Header/Man. D ~`f 8 Z.ci's 167, Aeration Dist. Pipe 1.'3 / 67 . 11 Holding Bot. System 3. / b (o PUMP/SIPHON INFORMATION Final Grade 1 I $ /O 7 Manufacturer Demand St Cover / Ur~ zo ei( _ GPM Z-6 A0 c Model Number Zs.~., '7 Q ~~oV~ Z • ~ /OS, TDH Lifl9 Friction Loss System Head TDH c7 (v. Sts ! CQ J~ Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. xy PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS -7 5 z16 1___.___ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Model Number: Type f 6System .J w- a y 5a / UNIT DISTRIBUTION SYSTEM bje51r - Header/Manifo~ Distribution 7 x Hole Size x Hole Spacing/ Vent it Intake Pipe(s) Length_~ Dia / Length 3 $ 6 Dia /r Z-5 Spacing Z' J Z SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded ix x Mulched Bedrrrench Center Bed/Trench Edges Topsoil Yes Q0.,°• No Yes ~ ~ I l~~ Q Q f~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1426 Hidden a Trail New Ric mond, WI 54017 (Gov't Lot 30N R1 9W) metes & bounds L Parcel No: 30.19.198A V,,P I 1.) Alt BM Description = ~e~ aq,, ~IO`~ ~S 2.) Bldg sewer length = /V R - amount of cover Z Q~ Plan revision Required? Yes Use other side for additional information. SBD-6710 (R.3/97) Date Insepctors S' nature Cert. No. L (d Jor/8 vC~f~~~.f"on~ir ~Xr SL'rre a /etla 6 ,c n e fit' Sys e.,r, 5 CO-~~~ colrrg4.ery. A4ddan 00-A / 38113-r 3a 3 z, 38`-3 f 1 f1n~ ,~5~ L~itScJ' 'oY:CfG~d ars~jSGC7 ~4 36=5,' 38 3c~7 Go►~ c~ r ScJ Z3 e~nl~lrsr~~~ .s.rj.~?c. ~,f T. 3~~1; ~''.19~, off' , ill ~o ~ sx s' e FFlu 5~ . ds ~ r s{ • cevzr , u lE s,~ a,~ tLt • Pte' 030 /0,53 -90-'k-,O Sc~ F' i, s -,e c, a sic ~a ('esidente er ~ well louafed oe? G -?1 Otla.~'~ta:~+.e (c~f1^;z~1Q r'j ° _ c{'') a.sE[t 83 rtSotG ! sr! - 1 QUA _ L lE,. { i V, e- fDL` is ssccrteaf `s!,- r Jl! "~s f.Lv ! ~ 5lcfat RP S r Ce'F.~*•tGt I 5 Core wz~. c jktC.`n+ I'I a f}OSf1~ ~oc% old 4.f 24~ .33.;r S?~.4~3 c...y' du ```~,ti f f , ~g'~ 1 1/f J 7.5'x~u'o~':S~aa.."safce.lt. -T~rec ~3~G`„ft; ~u~crrr cc~, l~ c fr~/5 4 f X 38 S7,ay/rd ~~r7 { t t S S~+u e C c~ a:6 , . fl3.' ~n l I r v Surrcr ce 2lsv -fo be = /o~+. St! ¢ a b~ ~e ,gas s-e' ter: commerce.wi.gov - Safely and Buildings Division County - „ r 201 W. Washington Ave., P.O. Box 7162 W_ f x (Madison, WI 5371?7 - 711,U2 Sanitary Permit Number (to he filled in by CA),) - - Depnrtmoont of Commerce 1-Y _•_j.. aani,tai-y PPee,Tl 11 floe 4,&~ '~i StnteTransactinoNumher In accordance with s. Comm. 83,2l(2), Wis. Sion of this fnrnt to the appropr~t. ovc:rnmet 001 unit is required prier to obtaining a rani. rn' rte: ,c:alion 1'nrms fo-0,mate-own .s T5 are Pmject Address firdifTerent thatimailingaddress) submitted to the Department of Comn rsnnal rmation you provide may4]iP`uSCd f< ndary t'--// t Ja/(.~u J ~erNfl_ o al' u ores in accordance. vrith the Privat f (m `SIRIS, T .ti. ~ 1. ~ff►itcation Information- Please Print All Information - - G- - (IK5 Properly Ovmer's Name ~ - - - - Parcel # CJLXi1 /e 0 030°/053-11o - al) Propeer/ty Ow 's Mai Iink Address Property Location 9A) 11 City, State Zip Cnde Rhone Number y,, Section 113 p(circle one].- W1 T _Job N. R F Or/to ) 11, l'ype of Bitliding (check all th2t apply) Lot # te I r,r 2 Family Dwelling Nwliberof'Serlmoms Suhdivisi+rn ~A Block # ❑ Public./C"ornmercial Describe. Use O city of C.5M Number _ Village ref [ ] State owm:d - Dcscrilx Use ,9 Town of III. Type of Permit: (Check ox olt . A. Complete line Rif applicable) - O New System Replae lent System Tremment/Holding Tank Replacement Only O Other Modification to Existing System (explain) e _ R. ❑ Permit ttCnowal O Permit Revision Y List Previous Permit N ber and Date Issued i Change of Plumber O Permit Transfer to New Before Fxpinnion Owner - 7 vNK,v~cv tV. Type orPOWT_S System/Component/Device: (Check all that 11)01 ~-_-r-- / El Non-PreSsm ized In-Ground O Pressurized hnd,iround O Ai-(hadc 2 ndound =•24 in. a ;Nuilablc snif 'Mound < 24 in. "01.1.1,V1 sn, /~r / O Holding -tank U Other D~isper'sal Component (explain)__ O Pretreatment Device A (expLtia) 5-r zr~ 79 1 .o it V. UispersalfTreatrnent Area lotormation: pad-kV Design Flow (gpd) Design Soil Application Ote(gytds) penal i rea Ret)uircc (st) Dis Ma Area Proposed (s f) System F,levation 300 - - L C~ I -v '1 e® by ~6b c~ 106-SO Vi. 'l'ank info f apacity in rntal ( M nufacturer Gallons Gallons Units o u Nrw Tanks Existing Tanks ' c m W A io a` t) rn r~ rn W t7 1. Scp,m nrttold p Tank _ ilosingC"11 ar uu - Y~ v T' - _0 w v o ou 6o M VII. Responsibility Statement- I, the undersigned, assume r_espon_sihility for installation of the. POW'TS shown on the attached plans, Piumber'S Name. (Print) P1ur s 5 V" Ire - MP/MFRS Ntlmbet Ilusiness Phone Number - ~1~AYSEIF __-l -I bei's Address ($hcet, Ci, Zip Co de) VII C4~tngv/~e tttp tr ettlh t [1sP (dniy - -V Approved U Disapproved Permit Fee{ Date Sued Is,,; mg A Signat e O Owner Given Reason for Dccninl 7 GCS- IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: 3 7L f~ ~C 1. Septic tank, effluent filter and fJ1iVyy(/t'!' i dispersal cell must be serviced /maintained G as per management plan provided by plumber. ~~l 1(M (NtQdiob -y% _..2.._A1LsetlZack.req ' p Q - l Q per applicable cobtt, ttaj6A'f~h,.frt Maus Fn,-ehe s+xten• and ~c,rt+.y r.,,,/,; .nnu;~ crnh nn pa/ycr nilfrcSt trr~a7t$ r/2 [ 1/1,.1,ncA s,n//y~c'_ t /•t ` -~/Nty(~ Jr~ I j~'~./ ~GINYK'/Il~ t-O ~l. t ' OC i'~f~JCiJI J! _ i3 -639R (R I /t v rd tl,nr Q l /0<>' / ~ Z lv S~ Y 0 N V S .,PIA hR EPTO DIVISION OF INDUSTRY SERVICES 3824 N CREEKSIDE LA oy ~N~ HOLMEN WI 54636 3 D Contact Through Relay P www.dsps.wi.gov/sb/ S `cw www.wisconsin.gov A~O~sSIOIN S~ Scott Walker, Governor Dave Ross, Secretary June 20, 2013 CUST ID No. 222904 ATTN: POWTS Inspector JAMES W BOUMEESTER ZONING OFFICE BOUMEESTER & SONS EXCAVATING INC ST CROIX COUNTY SPIA 1070 STATE ROAD 35 N 1101 CARMICHAEL RD HUDSON WI 54016 HUDSON WI 54016 CONDITIONAL APPROVAL Identification Numbers PLAN APPROVAL EXPIRES: 06/20/2015 Transaction ID No. 2259281 SITE: Site ID No. 791893 Mary Gail Iverson Trust Please refer to both identification numbers, 1426 Hidden Oak Trail above, in all correspondence with the agency. Town of Saint Joseph St Croix County Government Lot 2, S23, T30N, R19W FOR: Description: Mound / Two Bedroom / Sloping Site Object Type: POWTS Component Manual Regulated Object ID No.: 1433486 Maintenance required; Replacement system; 300 GPD Flow rate; 24 in Soil minimum depth to limiting factor from original grade; System: Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01101, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01101, R. 10/12); Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: Reminders • This system is to be constructed and located in accordance with the enclosed approved plans and with the component manuals listed above. • Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area. Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and CpNDITi dispersal are prohibited. APPR • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption DEPT SON area. chs. NR 811 & 812c PROFES p4VIS1©N OF 1ND • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the POWTS installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stat SEE JAMES W BOUMEESTER Page 2 6/20/2013 • SPS 383.22(7) A copy of the approved plans specifications and this letter shall be on site during construction and open to inspection by authorized representatives of the Department which may include local inspectors Owner Responsibilities: • SPS 383.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. SPS 383.54(1). • SPS 383.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. SPS 383.54(4) shall be considered a human health hazard. • SPS 383.55 The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 Fee Received $ 250.00 lG Z':? L l~ Balance Due $ 0.00 Charles L Bratz POWTS Reviewer II , Integrated Services WiSMART code: 7633 (608)789-7893 , 7:45 am - 4:30 pm Monday - Friday charles.bratz@wisconsin.gov cc: Edwin A Taylor, Waste Water Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm YnG~ a.~t; I MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Iverson 2 Bedroom Replacement Residential Mound RECEIVED Owner's Name: Mary Gail Iverson Trust JUN 10 2013 Owners Address: 456 Park Lane, Hudson, WI 54016 INDUSTRY SERVICES Site Address: 1426 Hidden Oak Trail, New Richmond, Wl Legal Description: Gov't. Lot 2, Sec. 23, T. 30N., R.19W. Township: St. Joseph County: St. Croix Subdivision Name: Na Lot Number: Na Block Number: Na Parcel I.D. Number: 030-1053-90-000 Plan Transaction No.: Page 1 Index and title Page 2 Data entry Page 3 Mound drawings Page 4 Lateral and dose tank Page 5 System maintenance specifications Page 6 Management and contingency plan Page 7 Pump curve and specifications Page 8 Site Plan Page 9 Attached Soil Evaluation Report Designer: Jim Boumeester License Number: 222904 Date: 05/28/13 Phone Number: (715) 386-90.20 4 ► ALLY Signature: !~w~ WED . Designed Pursuant to the FETY AND 4L SERVICES Mound Component Manual for POWTS Version 2.0 SBD-10691-P (N. 01/01, R. 11/12), and both SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81) and JSTRY SERVICES Pressure Distribution Component Manual Ver. 2.0 SBD-10706-P (N. 01/01, R. 10/12) Version 7.0 (R. 11/12) Pagel of 9L. zPOND : SENCI Mound and Pressure Distribution Component Design Design Worksheet Site Information (R or C) R Residential or Commercial Design Note: Sand fill (D) calculations assume a 200.00 Estimated Wastewater Flow (gpd) Table 383-44-3 in-situ soil treatment for 1.50 Peaking Factor (e.g. 1.5 = 150%) fecal coliform of - 36 inches. 300.00 Design Flow (gpd) 8.00 Site Slope 105.50 Contour Line Elevation (ft) 24.00 Depth to Limiting Factor (in) 0.60 In-situ Soil Application Rate (gpd/ft) Distribution Cell Information 40.00 Dispersal Cell Length Along Contour (ft) = 7.50 Cell Width (ft) 1.00 Dispersal Cell Design Loading Rate (gpd/fe) 1 1 Influent Wastewater Quality (1 or 2) Are the laterals the highest oint in the distribution Y Pressure Disribution Information network? Enter Y or N (C or E) E Center or End Manifold 2.50 Lateral Spacing (ft) If N above, enter the elevation ft 3 Number of Laterals of the highest point. 0.125 Orifice Diameter (in) 2.00 Estimated Orifice Spacing (ft) = 5.00 ft2/orifice 2.00 Forcemain Diameter (in) 40.00 Forcemain Length (ft) Does the forcemain drain back? Y 97.50 Pump Tank Elevation (ft) Enter Y or N 6.50 System Head (ft) x 1.3 6.52 Forcemain Drainback (gal) 8.50 Vertical Lift (ft) 36.86 5x Void Volume (gal) 0.54 Friction Loss (ft) 43.39 Minimum Dose Volume (gal) 0.00 In-line Filter Loss (ft) 24.72 System Demand (gpm) 15.54 Total Dynamic Head (ft) Lateral Diameter Selection Manifold Diameter Selection in. dia. options choice in. dia. options choice 0.75 1.25 x x 1.00 x 1.50 x 1.25 x x 2.00 1.50 x 3.00 2.00 x 3.00 x Gallonslinch Calculator (optional) Treatment Tank Information 501.84 Total Tank Capacity (gal) 1000.00 Septic Tank Capacity (gal) 51.00 Total Working Liquid Depth (in) Wieser Concrete Manufacturer 9.84 gaVin (enter result in cell 1349) Dose Tank Information Effluent Filter Information 501.84 Dose Tank Capacity (gal) PoI Lok Filter Manufacturer 9.84 Dose Tank Volume (gal/in) PL-525 Filter Model Number Weiser Concrete Manufacturer Project: Iverson 2 Bedroom Replacement Residential Mound Page 2 of 9 Mound Plan and Cross Section Views T 1/10 B J Observation Pipe A W . - B z 0 L Mound Component Dimensions ft A 7.50 ft E 19.20 in H Elft ft K Efift B 40.00 ft F 9.25 in z ft L ft D 12.00 in G 0.50 ft J W 300.00( ) tzDispersal Cell Area 753.29 (ft) Basal Area Available 7.50 (gpd/ft) Linear Loading Rate 4.00 (ft) 1/10 B Obs. Pipe Placement Mound Cross Section View Aggregate Dispersal Area Finished Grade 108.27 (ft) ♦ H G j I F , 107.00 (ft) Lateral (ft)-► - Dispersal Cell 106.50 Invert Dispersal Cell Elevation D Q: A { r 4 , 10 ,50 (ft) Contour Elevation 8.0 % Site Slope Geotextile Fabric Cover Shading Key I r Dispersal Cell See lateral details on [1] ® Topsoil Cap 1.5 ft Page 4 for number, size, Subsoil Cap o and spacing of laterals. ~7(T .j.~ Laterals are equally ASTM C33 Sand :5 Tilled Layer c T Lateral 0, ft ; rmicai `"y F spaced from the a. , r•: ft~.} distribution cell's Aggregate centerline in the -i- A distribution cell (AxB). Project: Iverson 2 Bedroom Replacement Residential Mound Page 3 of 9 End Connection Lateral Layout Diagram ate sc~;r ;;Wthr A 6c drrunsion Turn-upvdbaallvalvsorcloanoutplup t P g N Clat rals :at#4rn "l 14-X--+l H014,s d644 on tM bottom of OW lateral S etnsa4 speced Fome mien eonamion wa too d moss to manioW at 4m point. Laterals &forcemain Sch 40 PVC per SPS Table 364.30-6 Number of Laterals 3 Orifice Diameter 0.125 in Lateral Diameter 1.25 in Orifice Spacing (X) 2.03 ft Lateral Length (P) 38.57 ft Orifices per Lateral 20 Lateral Spacing (S) 2.50 ft Orifice Density 5.00 fe/orifice Lateral Flow Rate 8.24 gpm Manifold Length 5.00 ft System Flow Rate 24.72 gpm Manifold Diameter 1.25 in Total Dynamic Head 15.54 ft Forcemain Velocity 2.52 ft/sec Dose Tank Information Locking cover with warning label and locking device and sealed watertight Electrical a$ per NEC 300 and SPS 316.300 WAC Disconnect 4 in. min. Tank component is properly vented :Forrcwx Alter nate outlet location main diameter Weiser Concrete Manufacturer 2 in. CaRacityl 501.84 Gallons Volume 9.84 gal/inch A _ Weep hole or anti- Dimension inches _Gallons B siphon device A 32.59 320.69 B 2.00 19.68 C Pump off elevation (ft) C 4.41 43.39 98.50 D 12.00 118.08 D Total 51.00 501.84 Dose tank elevation (ft) Bedding un or tank. 97.50 Alarm Manuafacturer SJE Rhombus Note: Switches Alarm Model Number [SJE 1011421 containing mercury _ may not be used in Pump Manufacturer Zoeller this system. Pump Model Number BN 151 Pump Must Deliver 24.72 gpm at 15.54 ft TDH Project: Iverson 2 Bedroom Replacement Residential Mound Page 4 of 9 Mound System Maintenance and Operation Specifications Service Provider's Name Jim Boumeester Phone 715 386-9020 POWTS Regulator's Name St. Croix County Zoning Dept. Phone 715 386-4680 System Flow and Load Parameters Design Flow - Peak 300 gpd Maximum Influent Particle Size 1/8 in Estimated Flow - Average 200 gpd Maximum BOD5 220 mg/L Septic Tank Capacity 1000 gal Maximum TSS 150 mg/L Soil Absorption Component Size 300 fe Maximum FOG 30 mg/L Type of Wastewater Domestic Maximum Fecal Coliform >10E4 cfu/100 ml Service Freeguencv Septic and Pump Tank lns t and/or service once eve 3 ears Effluent Filter Should inspect and clean at least once eve 3 years Pump and Controls Test once eve 3 ears Alarm Should test month) Pressure System Laterals should be flushed and pressure tested eve 1.5 ears Mound Inspect for ndi and seepage once eve 3 ears Other Miscellaneous Construction and Materials Standards 1. Observation pipes are slotted and materials conform to Table SPS 384.30-1, have a watertight cap, and are secured in as shown in the mound component manual. 2. Dispersal cell aggregate conforms to SPS 384.30 (6)(i), Wis. Adm. Code. 3. All gravity and pressure piping materials conform to the requirements in SPS 384, Wis. Adm. Code. 4. Tillage of the basal area is accomplished with a mold board or chisel plow. 5. The mound structure and other disturbed areas will be seeded and mulched to prevent soil erosion and help reduce frost penetration. Lateral Turn-up Detail Finished Grade 6-8" Diameter Lawn Threaded Cleanout Sprinkler Valve Box Plug or Ball Valve Distribution Long Sweep 90 or Two 45 Degree Bends Same Diameter as Lateral Project: Iverson 2 Bedroom Replacement Residential Mound Page 5 of 9 Mound System Management Plan Pursuant to SPS 383.54, Wis. Adm. Code General This system shall be operated in accordance with SPS 382-84 Wis. Adm. Code, and shall maintained in accordance with its' component manuals [SBD-10691-P (N.01101, R. 11/12), SSWMP Publication 9.6 (01/81), and Pressure Distribution Component Manual Ver. 2.0 SBD- 10706-P (N. 01/01, R. 10/12)] and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with SPS 383.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8-inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Slats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Department of Commerce. Pump Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Mound and Pressure Distribution System No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October-February) dictate that the mound be heavily mulched as protection from freezing. Influent quality into the mound system may not exceed 220 mg/L BODS, 150 mg/L TSS, and 30 mg/L FOG for septic tank effluent or 30 mg/L BOO., 30 mg/L TSS, 10 mg/L FOG, and 104 cfu/100 mL for highly treated effluent. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system is provided with a flushing point at the and of each lateral, and it is recommended that each lateral be flushed of accumulated solids at least once every 18 months. When a pressure test is performed it should be compared to the initial test when the system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution within the dispersal cell. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 6 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. C nntinuencv Plan if the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component(s) shall be immediately repaired or replaced with a component of the same or equal performance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or by removing biologically dogged absorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. See Page 5 of this plan for the name and telephone number of your local POWTS regulator and service provider. PreUl tpent Units The information and schedule of mananagement and maintenance for pretreatment devices such as aerobic treatment units or disinfection units are attached as separate documents and are considered part of the overall management plan for this system. Project: Page 6 of 9 Nov-11-2010 10.45 AM St. Croix County Plan/Zoning 715-386.4686 1/2 PQWTS OWNER'$ MANUAL & MANAGEMENT PLAN Pane _,,._.of F11.15 INFORMATION l3YSTEM SPECIFICATIONS Owner p p 1 S N Septic Tank Capacity 1 ()Q U al 0 NA Permit # v Septic Tank Manufacturer W .(~yz rL © NA DESIGN PARAMIsTERS Effluent Filter Manufaoturer Qu ~ C3 NA Number of Bedrooms 13 NA Effluent Filter Modal sa~ A NA Number of Public Facility Unite 10 NA Pump Tank Capacity S U al ANA U alld Pump Tank Manufacturer iD NA Estimated flaw (average) Z Design flow (peak), t5stimated x 1.5) Pump Manufacturer u-Q VP it M NA tJ~ al/day 7=0 NA Sail Application Sava at/day! z Pump Model N Standard Influent/Effluent Quailty Monthly average* Pretreatment Unit M NA 00 mg/L Cl Sand/(,travel Filter 0 Peat Filter Fats, 011 & Crease (FOG) Biochemical Oxygen Demand (BOD51 X220 mg/l- a NA Q Mechanical Aeration Cl Watland Other; Total Suspenders Solids ITS$) :150 mg/1, C1 Disinfection Q NA Monthly average Dispersal lainfsinfection ) E3 Q In-Ground (pressurized) Pretreated Effluent Quality s80 mg/~ r3 in-Ground {gravity) Biochemical Oxygen Demand (BOD11 Q inGro n &Mound Total Suspended Solids (TSSI 530 mSIL Q NA 1:3 lather: 19104 cfu/100ml L7 prip~Lna Fecal Colifarm (geametr)o mean} Others Q NA Maximum Effluent Partlcle $tns Ys in dia. ANA at. Q NA A NA Oth GI NA Other: Other: *values typloal for domestic wastewater and 99ptlo tank affluent MA IN`fENAN F i3CHROULE Service l requanOv Service Event Month(s) (Maximum 3 years) ID NA At least Once every: ear e) 17 NA Inspect aandttian of tank(sl When combined sludge and coos squats ansathlyd {Ysl of tank va use pump out contents of tank(s) Ga month(s) (MmelMum 3 years) © NA At least Once every: o~ 0ar(s Q NA Inspect dispersal 081191 t QmonthM At feast cr►ae every: . ! aar sl p NA Glean effluent filter 0 month(s) At least once every: ysaris p NA Inspect pump) pump controls & alarm C1 hlanth(s) Flush laterals and pressure teat At least once every: o~ earls) © Q NA i,0 ear.al s) other: At least once every: E3 NA Other: or arerat certifications: MAINTBNA1raCl:IN;3TR(JGTIOtuS carrying one of the following lloengegV tar ppWTS MaintaineUAW Bgrylctng Operator. Tank teaks, inspections Of tanks and dispersal cabs shat) be made by an Individual Master Plumber; Master Plumber Rastriotsd Sewer; k(s) to identify for any a Inepeo missing or SIMOIn hardware, identify a n of the of effluent an the ground surface. and to check for any hack up or pondtng I pipes and to check for any pending inspeatta must me of combined sludge 4 and scum and to ia visual measure th the voluFn the qfflusnT levels in the observat The dispersal Ollie) shall be visually inspected ending of effluent an the ground srface ay Indicate a felling condition and raquiree the of effluent on the ground surface. Th p immediate notification of the local regulatory authority. any tank equals ons°th)rd or more of the tank volume. the entire by a Sept ga i3ervECirtg Operator and disposed at in accordance with chapter NR '11'5, when the combined accumulation of Was and scurn In contents cf th® tank shall be removed certified )'C►mechanical yrWTS pressurized components, pretreatment Wisconsin Administrative Cade, Maintainer. not limited to the aervIcing of effluent filters, All other $8rulaes, including but performed by event, units, and any servicing at intervals of 512 months, shallowithin 10 days of completion of any sue' oMw solo)) A service report shall be provided to the local regulatory authority '0000 aAgaJZelulwpy u!suoasl (E) s (21 (Wbs'se Pue (d! !(p)f 1!!gl()i:4'E6 wuJOO Azde40 431M 00uegdwoo ul pe41Up 90M luewnaop e14J. 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(e)liea lesJedsip eyz 04 P00JO4061P aq II1M Je;gMGMM GVV0X9 ay; peJ0490J al J9mad uogM •slaAal Jainnn46ly II1wJdu aAoga 111; Aaw c4uea dwnd aeBaano JaMod Suuntl -vve,pns eARVJIII;Ul atli ie USZO4 9Je sUail!pu00 1108 U94M Jnonn IOU ije4s do aims LumeAg 9zuaiu0o ey; eney pezoazep aJe 9U0lzeJZUeauoo 'ean oz Jolid JoleJedo Suiapues e6ezdas a Aq PSAOW91 (6)111183 941 da 4614 dl '(SHISO Imedsip eta aftwep Jo/pue $$avoid IUSU4198JI 941 spedw! Aew;I4; Blooiwaqu Jo4ao Ja ownpoJd Bupulad }o aouasaJd ay; =4 (s)nue; W W wm a 4vaqu SIMOd ayz do am of Jo!Jd 'uolzonJasuoo Mau J0 ,l ;o - ssed NOI1VUBdO (3NV do 15IV1S Z/Z 989b-98£-91L 5uiuOZ/ueld 41unoD xioj:) ;S Wd 5v 06 060Z-66-AON PUMP PERFORMANCE CURVE MODEL 151/152/153 TOTAL DYNAMIC HEAD/FLOW 50 PER MINUTE 14 153 EFFLUENT AND DEWATERING g 72 MODEL 151 152 153 = 70 152 Feel Meters Gal. Liters Gal. Ulan; Gel. U19M 10 5 1.5 50 189 69 261 77 291 10 3.0 45 170 61 231 70 265 e 25 757 15 4.6 38 144 53 201 61 231 a 20 6.1 29 110 44 167 52 197 25 7.6 16 61 34 129 42 159 ~5 J T 30 9.1 23 87 33 125 77-41T 4 35 10.7 - - - 22 ss 10 40 121 - - 11 42 ShuFoB Head: 30 fl. (9.1m) 381L (11.Bm) 44 iL (13.4m 2 5 014MBB 0- 10 20 30 40 50 K' 80 9) 11 D GALLONS UfFRS 40 1 1 3E SW ROW PEN MINUTE 014 Model 151 Models 1521153 Z~.ZZQ,,o~Y1./rl:AiMUnl~iSt~(gr~,,e /ry'r/~~gd CONSULT FACTORY FOR 0 SPECIAL APPLICATIONS 67132 $114 3718 45M 327132 4549 • Tuned dosing panels available. • Electrical alternators, for duplex systems, are available and supplied with an alarm. ' 7~ 3 rnz • Variable level control switches are available for controlling 974 327A2 single phase systems. • Double piggyback variable level float switches are available I + far variable level long and short cycle controls. • Sealed Qwik-Box available for outdoor installations. See FM1420. • Over 130•F. (54•C.) special quotation required. + 1511152/153 Series ++,v,e I ' 121A I I 1511152H53 YODELS _ control saleallon -C' Yodel VdWPh Mode Am simplex Duplex i 43• s tra N151 15 1 Nan 6.0 1 2 or 3 6N751 1115 1 Auto 6.0 Included 2 or 3 El 51 230 1 Non 3.2 1 2 or 3 BE151 230 1 Auto 3.2 Included 2 or 3 SK2444 SK2064 N152 115 1 Non 8.5 1 2 or 3 &N152 115 1 Auto 8.5 Included 2 or 3 E152 230 1 Nan 4.3 1 2 -or 3 BE152 230 1 Auto 4.3 Included -2 -or 3 N153 115 1 Non 10.5 1 2 or 3 BN153 115 1 to 10.5 Included 2 or 3 E153 230 1 Nan 5.3 1 2or 3 SELECTION GUIDE BE153 30 1 Auto 5.3 Included 2 or 3 1. Single piggyback variable level float switch or double piggyback variable level float A CAUTION switch. Refer to FM04T7. All installation of controls, protection devices and wiring should be done by a qualified 2. See FM0712 for correct model of Electrical Alternator E-Pak. licensed electrician. All electrical and safety codes should be followed including the most recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA). 3. Variable level control switch 10-0715 used as a control activator, specify duplex (3) or (4) float system. RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL 70' P.O. BOX 18347 kJAWLouHIP 70: 8RRoad Manufacturers of.. 27 LouisWBe►c40261 ZLU17Y/~L/" /#AF /9c~S hap1/www.zoellereom ~/IP l0 1(5SO2) F v(b02) n4~6 928.PUMP 24 0 Copyright 2004 Zoeller Co. All rights reserved. ® .JOr~~ (1~fGtfi~ivr'7~r'~ n4sc *4.o V ceryl 5C.-le ash- '5 c 5y54 oorlr5ere-y. 6~'''~ Q /1'tra.^ Z"v'~r'.sern f.Jra1CJ - d'~•- eyrat -ct? f)fD5-r a ,tee .c . ; wTrscl C~u»cfeke ; ao~/sue 3 ,y -'s ¢ 38~1 3A. f6 1, 0rwsw)5rzc 23 e~mh:n~ s, fraC. ~f 7!`3Z9r1; e. /9~-', T • t!~ /ao~Lo,E'J~.[-SZs'eFf'/a~,~ ~ J'~.s7`ds~j0`~ G's~iXfu, c. 5c..,4• Q30 - /c,5,3 em loe Yea residence ar- u.relt IcCa.•ccd ar? l{e.bpr•:ng ttra~a, ~ Fes: _ c ~ ,~itiC~Wr~"C• Maryrri4le{ ` ! j jQ rf(pllt C7fiuf^~ xYtdts-C~s ~~f r~' t e E.cri15E/'c;„L LY1. r err ~ " "~RL fat ~~~.,l~.ss~cn¢d *•f, rt ~ ~~4.. ~u;fd~gSiw~' ~b r o ct / ~ ~ ti m.- 6461 c /y t !l o Cf ~ i ~ 51o~'C 'S%'~a;Q~ `~~•.~e ~c~ ~ ~ ¢r~ttx~Y tlut,G is, f f propased r~?'crwrd rc E291 33X 53' d'v~ J 7.Jr'XTSJ Cf ~S dU'JGJ .--Gi7, C:S`,,! ~iJ'tlt t~ __~3` lac rrcr ~/'s ~t / /rg',"t 31.t S',?',~ o/r't; Ee S SPa c e cl rz N ttlq ^•fl.3,'~"n 1 +a~~eB r acy¢!¢u: f0 be042ul Q Err vz ins sca ` C'rrn~'o U-e- Pq $I W15COnSln Department of Commerce SOIL, EVALUATION REPORT -f~V LUPW 2327 Division of Safety and Buildings Page 1 of 3 in accordance with Comm 85, bftdm'- C A.C.E. Soil 8 Site Evaluations Attach complete site plan on n 8%: x 11 inches in size. Plan )County St. Croix include, but not limit a oMal reference point (BM), dr ecboi percent slope, north , and location and distance to 2,13 Parcel I.D. lea ntall information, sr cR R 0-1053-90-000 Personal infomialion you provide may be used for 0/ Date arY pirposes (Privacy Law, s.15.04 (1 OVN~Y / _ - ~ ' W elj Property Owner Property Location Ma Iverson Govt. Lot 2 19 1/4 S 23 T 30 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 456 Park Lane na na Na City State Zip Code Phone Number _j City _j Village N' Town Nearest Road Hudson Wt 54016 (715) 441-0087 St.Joseph 1426 Hidden Oak Trail - Construction Use: 16 Residential / Number of bedrooms 2 Code derived design fl rate 300 GPD J Replacement J Public or commercial - Describe: 'Parent material Glacial Till Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for mound system with 12" of ASTM-C33 sand placed on105.50' contour. Infiltrative surface elevation to be 106.50'. <1 2-CM G' ac?n .S 1d s y✓ -500 r W Q I-t`w" Boring # I Boring lei Pit Ground Surface elev. 106.09 ft. Depth to limiting factor 30" in. Sol Application Rate Horizon Depth Dominant Color Redox Des n Texture Structure Consistence Boundary Roots GPD/fe In. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 ff#2 1 0-8 10yr3/3 none 1 2fgr mvfr cs 2fm,1 c 0.6 0.8 2 8-18 1Oyr4/4 none Is Osg ml gs lfmc 0.7 1.6 3 18-30 1 Oyr4/6 none s Osg ml cw 1 fmc 0.7 1.6 4 30-49 7.5yr4/4 c2d 7.5yr4/6 sl lmsbk mvfr - 2fmlc 0.4 0.7 ' L 1 Boring # -J Boring I-----~ 0 Pit Ground Surface elev. 102.91 ft. Depth to limiting factor 24" in. Sol Applies Rate Horizon Depth Dominant C*r Redox Description Texture Structure Consistence Boundary Roots GPD/fe in. Munsell Qu. SZ. Cont. Color Gr. Sz. Sh. "Eff#1 •Eff#2 1 0-6 1Oyr3/3 none I 2fgr mvfr cs 2fmc 0.6 0.8 2 6-24 1Oyr4/4 none Ifs Ogg ml gs 2fmc 0.5 1.0 3 24-48 1Oyr4/6 f2f 7.5yr5/8 sl lmsbk mvfr cw 1fmc 0.4 0.7 4 48-56 7.5yr4/4 c2d 7.5yr4/6 scl lcsbk mfr - - 0.2 0.3 * Effluent #1 = BODg> 30 < 220 mg/l an TSS >30 < 10 mg/L - " Effluent #2 = BOD < 30 mg/L and TSS S.30 mg/L CST Name (Please Print) ignatur. . CS Number James K. Thompson _ 3602 Address A.C.E. Soil 8 Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 64020 5/23/2013 715-248-7767 1 3 Property Owner Mary Iverson Parcel ID # 030-1053-90-000 Page 2 of 3 Boring # J Boring ! Pit Ground Surface elev. 103.93 ft, Depth to limiting factor 33" in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Coneistem Boundary Roots GPDffe in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-8 10yr3/3 none I 2fgr mvfr cs 2fm,1 c 0.6 0.8 2 8-24 10yr4/4 none Is Osg ml gs 2fmc 0.7 1.6 3 24-33 10yr5/3 none S Osg ml cw 2fm,1c 0.7 1.6 4 33-46 10yr4/4 c2d 7.5yr4/6 SI 1 msbk mvfr gw 1 fmc 0.4 0.7 5 46-60 7.5yr4/4 f2d 7.5yr5/8 SI 1 csbk mfr Boring # -I Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Sol Application fiats Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Q Boring # J Boring J Pit Ground Surface elev. ft. Depth to limiting factor in. Sol Application Rate _GPDAF Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = SOD 5> 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, SBn-8330 (x 07/00) A.C.E. SON & Site EvaWab" ~ A s ca. e : / "s~o /Ytafy .~da/.so~/or°Io 1lelJ C.~msrA; 0/, M/7 W;c'scr~oricre e ooo/szz7 Go✓ E• &?WScJJSZC 23 r- 3 M., eAPCJ. ,A'/6e,--65.7-0of-tt-ct sL" gc-4-,/a/a de.o~. of a~ /Oc./ 030-1oS,3-90-ocn Vic residence or ~PC!6 s well /aCa.fcdoe; vP Pro x~ oUw'kcad~elaG£r;e i . - `'Ce w2~ K;c~u w; rC • May .t tad ~ ` / ~ ~ ~ 6e Atovt d ;o1~ tv rrtd r d3 C3E/KG 0 1 r 0. ~ Xp -d rt ~ ~ `y C7 ~,4.•. t W encraY vac. i+:ro, Qe,~-7' 1 vta,~~bors Al v ~raPose~ ~'/occ./d 4-E2S~ 33 ;r SB.d3 w/ d ve- . 'a',SPusr✓C~/. (s~d,~fi:6u ~i °Y 7s'x5/0 7fof r'o la~c~a/S 4~/yt/ r3d 5 7,u k "a, '"i`CtS Sa,Ce c✓ of ~CVq ,t•o3,'Sn /bra ~vPSw~Fuce a/ev; o6e=/oG.SO a~/.I- Q 60 dt /OS;SO' C'a»'~OGc-f ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer C Mailing Address Is-le Property Address /ggjj~ 1'd1GU kN Oak Tto. ( ~e~ ►c~rnonc~. WT -54617 (Verification required from Planning & Zoning Department for new construction.) City/State 1 J t if Parcel Identification Number 103 0 -IDS 3- qU - ~vo I~ 030 - LEGAL DESCRIPTION 6~ -2, f 1/4 , Sec. 3 , T _,J&_N R__Lq__W, Town of s¢ JOSe Property Location Subdivision Plat: , Lot Ce Tied Survey Map # Volume Page # K Q(`W anty Deed # ~2 Z l 3o (before 2007)Volume , Page # Spec house 0 yesz/no Lot lines identifiable 0 yes 0 no , SYSTEM MAINTENANCE AND OWNER CERTIFICATION C Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. 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. Numbe Of bedrooms IALB SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 09/07) II II I ili181111{IIIIIlIIINII 8015535 State Bar of Wisconsin Form 3-2003 Tx :4011923 QUIT CLAIM DEED 929030 BETH PABST Document Number Document Name REGISTER OF DEEDS ST. CROIX CO., WI THIS DEED, made between Robert C. Iverson and Mary Iverson, also known as 12/20/2010 2:12 PM Mary Gail Iverson EXEMPT#: 16 ("Grantor," whether one or more), REC FEE' 30.00 and Robert C. Iverson and Mary Gail Iverson as trustees of the Robert C. and Ma PAGES: 2 Gail Iverson Revocable Trust, dated November 1, 2010 ("Grantee," whether one or more). Grantor quit claims to Grantee the following described real estate, together with the Recording Area rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach Name and Return Address addendum): Jennifer A. O'Neill O'Neill Elder Law, LLC Prairie Pointe Professional Center 900 Crest View Drive, Suite 220 SEE ATTACHED ADDENDUM. Hudson, WI 54016 See Attached Addendum Parcel Identification Number (PIN) This is homestead property. (is) (is not) Dated November 1, 2010 (SEAL) (SEAL) Robert C. Iverson (SEAL) (SEAL) * M Iverson AUTHENTICATION ACKNOWLEDGMENT Signature(s) Robert C. Iverson and Mary Gail Iverson, husband and wife. STATE OF WISCONSIN ) a e ica> on tuber 1 010 ) ss. COUNTY ) I A0 JEM er A eill Personally came before me on the above-named 'Hf LE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by Wis. Stat. § 706.06) to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: * Jennifer A. O'Neill - O'Neill Elder Law LLC Hudson, Wisconsin Notary Public, State of Wisconsin My Commission (is permanent) (expires: ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. QUIT CLAIM DEED C 2003 STATE BAR OF WISCONSIN FORM NO. 3-2003 Try name below signatures. 1 I ADDENDUM TO QUIT CLAIM DEED ~I GRANTOR: ROBERT C. IVERSON AND MARY IVERSON, ALSO KNOWN AS MARY GAIL IVERSON, HUSBAND AND WIFE. GRANTEE: ROBERT C. IVERSON AND MARY GAIL IVERSON AS TRUSTEES OF THE ROBERT C. AND MARY GAIL IVERSON TRUST PIN: 020-1128-60-000 030-1052-60-000 030-1053-90-000 LEGAL DESCRIPTION: Parcel 1 (Homestead) Lot 20 of Park View Estates 151 Addition located in Section Seventeen (17), Township Twenty- nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin. Parcel 2 (Bass Lake Cabin) Part of Section Twenty-three (23), Township Thirty (30) North, Range Nineteen (19) West, Government Lots 1 and 2, described as follows: Commencing at the East Quarter Corner of Section Twenty-three (23); then South 1700 feet; then West 1981.40 feet; then North 21 oEast 66 feet; then North 33oEast 120 feet; then North 340East 181.5 feet, then North 680West 216 feet to the Point of Beginning; then South 68oEast 216 feet; then North 340East 12 feet, then North 25oEast 79 feet; then North 22oEast 19 feet; then North 460West 45 feet; then North 740West 171.10 feet; then Southwesterly to the Point of Beginning, St. Croix County, Wisconsin. 2 of 2 I Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * = Current Owner * IVERSON, ROBERT C & GAIL M ROBERT C & GAIL M IVERSON 456 PARK LA HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 1426 HIDDEN OAK TRL SC 3962 NEW RICHMOND SP 8040 BASS LAKE REHAB DIST SP 1700 WITC Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE SEC 23 T30N R19W GL 2 THAT PART OF GL 2 Block/Condo Bldg: DESC AS FOLLOWS COM E1/4 COR SEC 23 S 1700'W 1981.40'N 21 DEG E 66'N 33 DEG Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) E 120'N 34 DEG E 181.5'N 68 DEG W 216' 23-30N-19W TO POB S 68 DEG E 216'N 34 DEG E 12'N 25 DEG E 79'N 22 DEG E 19'TH N 46 DEG more... Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 867/473 07/23/1997 749/430 07/23/1997 745/115 2004 SUMMARY Bill Fair Market Value: Assessed with: 5176 208,300 Valuations: Last Changed: 07/08/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 0.000 162,400 42,500 204,900 NO Totals for 2004: General Property 0.000 162,400 42,500 204,900 Woodland 0.000 0 0 Totals for 2003: General Property 0.000 83,200 33,000 116,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch Specials: User Special Code Category Amount 040-OTHER ASSM'T SPECIAL ASSESSMENT 453.82 Special Assessments Special Charges Delinquent Charges Total 453.82 0.00 0.00 989ti-98>; (s LL) xe j • Oe9ti-98E (9 LL) O LLL-9 LOb9 IM `uospnH ..r,. peon{ Iaeyoiuaaeo LOLL _ H31N301N3WN»3AOJA1Nf1OOXIOaO'1S n.~.~~ " 33I330 OAIINOZ R177 „ ~ NISN03SIM - AlNnoo XIOa31S `r ti Q o ! a-0i y C ~ ~ O "7 Iii c w O O) 'r C O N O .t„ C r°v E=y3~~ ~o f0 O > ao c m 0) FM i a~aico~a~y o -i= 3 0 w- ~ cv cL I 0 E o c 3 I 4) .2 E y m0rn F n i,a m > o.cC'. 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Plan must include, but St. Croix not limited to vertical and horizontal reference point (BM), direction.and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location nd distance jp nearest.road:•, 030-1053-90-000 APPLICANT INFORMATION-PL A PRI U': (I E D Y oD TE [_FOR 'A. ON PROPERTY OWNER: PROPERTY LOCATION Robert Iverson - _ GOVT. LOT NW 1/4 SW 1/4,S 23 T 30 N,R 19 k(or) W PROPERTY OWNER':S MAILING ADDRE t:,0UNTY 1, LOT # BLOCK # SUBD. NAME OR CSM # 456 Park Ln. INrc)FFIr na na 1426 Hidden Oak trl. CITY, STATE ZIP CODE.;% PHONE NUMQFfa'" } ❑CITY ❑VILLAGE UFOWN NEAREST ROAD Hudson WI. 54016 Jl;;1 -j St. Joseph Hidden Oak TrI. ] New Cons ructio Use [x ] Residential / Number of bedrooms [ ] Addition to existing building jxj Replacement Public or commercial describe D ?ULtlIS SG'uuirr-- NO er i y flow 300 gpd Recommended design loading rate .4 ed, /ft2 2 gpd ~~trench, gpd/ft Absorption area required 250 bed, ft2 250 trench, ft2 Maximum design loading rate .4 bed, gpd/ft2 .5 trench, gpd/ft2 Recommended infiltration surface elevation(s) 106.50 ft (as referred to site plan benchmark) Additional design / site considerations na ssytem el. based on contour line of el. 105.50' Parent material lake t rrarp Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK U=Unsuitable fors stem EIS ®U E7S ❑U ❑S ®U ❑S ®U [is @U ❑S QU SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trer>ch 1 0-6 10yr3/3 none 1 2mgr mfr cs lc .5 .6 2 6-30 10yr4/4 none sl lcsbk mfr gW lm .4 .5 Ground 3 30-56 10yr4/4 c2d 7.5yr5/6 scil lcsbk mfr na na .2 .3 elev. 104.85. Depth to limiting factor 30" i Remarks: Boring # 1 0-8 10yr4/3 none sl lcsbk mfr 9W 2m .4 .5 2 2 8-40 10yr4/4 none sl lcsbk mvfr gW lm .4 .5 3 40-55 10yr5/4 2d 7.5yr5/6 sil M na na na np .2 Ground elev. 103.9ft. Depth to limiting factor 40" L I Remarks: CST Name:--Please Print Gary L. Steel Phone: 715-246-6200 Address: 1554 200th. New Richmooi, WI 54017 Signature: XI-r Date: CST Number: m02298 7-8-98 PROPERTY OWNER Don Iverson SOIL DESCRIPTION REPORT Page'2_of 3_ 030-1053-90-000 PARCEL IA Depth Dominant Color Mottles Structure Roots GPD/ft Boring # Horizon Texture Gr. Sz. Sh. Consistence Boundary in. Munsell Du. Sz. Cont Color Bed Trench 0-6 10yr3/2 none 1 2mgr mfr cs 2m .5 .6 3 2 6-32 10yr4/4 none sl 2csbk mfr gw if .5 .6 Ground y c2d 7.5yr5/6 sil lcsbk mfr gw if .2 .3 3 32-4 7.5 r4/4 106.45ft c2d 7.5yr5/8 cos/si lcsbk mfr na na .2 .3 elev. 4 48-84 7.5yr4/4 . Depth to limiting factor 32" Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor LLL Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD-8330(8.05/92) STEEL'S SOIL SERVICE Gary L. Steel 1554 200th Ave. CSTM2298 Robbrt Iverson New Richmond, WI 54017 MPRSW-3254 WIWI S23-T30N-R19w (715) 246-6200 town of St. Joseph I N 1"=40' BM.= top of SE lot stake @ el. 100' Alt. BM.= top of mid-lot survey stake C el. 107.80, i y L4 19 )°1 r to 0"1 Gary L. Steel 7-8-98