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014-1046-20-100
i j. A~7 I N~ N m~ m I ~ o w co ~ ~ N N N N n~ ~ O O O ~ ry ~ ~ c fp ~ ~ 3 ' v N N -+ (O fD ~ N ~ o ~ o I N N N 3 i ~ W C~)i N I I I I I l I A ? p O N N 0 0 N N N Al m ~ O p 70 ~ y Z ~- O. C y y ~ N ~ ~ o N N fD O ~ N tD (O H ~ ~ m ~ n - n .-. N '~ ~ c in a r ~ m ~~ a ~ lD ~ '' 7 ?~dCO ~ N ~ ~ N N ~ O ~ O a m w m ~..C n y ~2 O ~ 7 O tOA ~O N N N a m ~ o m~ ~ ~O+. Q ~ N (D ~ ~• ~ O O N ~ N ~ Q ~ C ~ .r ~ Do ~ n~~v 2~ D N A O y N "' ~' N~ ~ y~ ~ m w' ~- o cn ~, z C n m °o ~ 3 ~O ~ ~~ ~o m D S O ~ y 0 7 ~. Z{p N 3~'ym m_ c ~ m v~ m,~->> N N .C.~ ny AN N N('~ O fD 7 N y p ~ aw'~fD ?~ ~~o ma~onoycntn~ 3 ~~~y m a °' Zm' -., a -a m m y, s. ~~° ~~~°~ m o ~,co ~ ng w o o ~ a ~, O 7 ro cfl O O S~ O ~- n cn p _ ~ ~ ~ co ~ ~ ~ ~ `~ I ~: o,~' ~ ~ ~ I o N _ _ ~ 7 m ~ M m °- a ~ a ~, N C~`O W ~ (O (O _N O ~ ~ ? co °° D ~ I 'o ~ ~ c O O O m ° ° o m m n ~ ~~ ~ A D D o w l a I fD N W 3 7 A C m I ~_ ~ I 0 A ~ a ~ O O 3 N :C7 '00 W y N T c a I O I I I I I I I I I ~' ~ n fU v ai O 3 c`+ m ~ o- ro ~~ ~ m y O ~ ~ ~ d N n ~.m ~ ~ ~ d/ ~ N 7 C N 3 ~ O ~ m ~'A~ v ~ ~ ~ o. `o c ° 3 ~ ~ ~ ~- O O ~ fl c, m n ~ c m ~ N Q ~ ~ m 0 cD .~ fD C m (D 7 N C' j' N p Q' V !p C7 7 C1 O C K C n ~` N p n n o? a~ n~= a m aao nv N N N "O• ~ C +~ O `~ ~ o QfD ~ 3 ~ aim ~ w m m sm fD.f v .°«~•~ z Q N ~ 7 (~D 7 N _. O fD fD Q N ~ O y O" f0 p tp ~ N ~ j 7 0~ 7 j U) n fD O H O ~. N a 0 7 '< n a N n d ~ m w °'OC o O~ a ooi m ~ o n0~ rt -, x c co ~ m `7' ~ ~ v ~ N ~ ~ ~ o a m -fDO °_'~ ~0~~ m ~ a ~' r. ~ O 7 (D <n O O S~ O *- n ~ O ~ ~ y o o is n ~ ~ ~ I ~ `~ c 'o `•; d ~ m m ~ - W ~ c m ~o a a OT N O ~ j A o o ~ °~ W N j ~ O O O C~II A O O ~ ~ O O O ~ ~ v v o °- ~ ~ ~ d m ~ ;-• cn O D D o W n fD N 41 N A y C 01 v m N ~ °' 3 O ~•' 3 y ~ fD A W j O CD o_' T c a ~ O C ~ :" a .. A 0 m m .a -i (p p Z ~D ~_ ~ :A ~ 7 Z W N Z A T7 z~ m cL A d A~ 0 R O A'+ 0 eO c 1• 0 ~• 0 ~• O A A 0 0 ~o h ,b N Oq N ~ d ~' V N 3~~ d ~ ~ ~ o ~ ~'~a ~^ ~ ~ ~ ~ ~ \ 1 a ~ A~ Q O N ~ ~ j~ • N ~ ~ ~ rryll M _ cn A O ~° n O QD ~ ~~ O ~' D oo '~" O C N ^~ Q N 3 ~ °+ !ter • A O iU N (~ N O H ~ ~ ~ N A ? n _a ,'p .« A z O .. ~ 7 z W N z A ,T) z ~ m ~ A O A ~C A ti N O O b A h M ti _M N ~ A ti V b N Al Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) 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 Salse ,Bob & Brenda Forest, Town of CST BM Elev: Insp. BM Elev: BM Descriptio ~~~~~~T~~~~ r•~ C\/A TIA~1 r1ATA F11Yn IIY f'VRIYII111VIY TYPE MANUFACTURER CAPACITY Septic r (Sf'I /l U / UU O Dosing ~ ~~ ~~ Aer n m~//L~~-ftiC:IGu Hol (~Z(1 TANK SETBACK INFO MR ATION ~~~1/G~ ~'.~ TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration C Holding PUMP/SIPHON INFORMATION ,S/ ~/ Manufacturer Dem. GPM Model Number ITDH (Lift (Friction Loss (System Head ITDH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM V V V v A ~ i v ~~ vr\ ~ n county: St. Croix Sanitary Permit No: 138 State Plan ID No: Parcel Tax No: 014-1046-20-100 Section/Town/Range/Map No: 22.31.15.338A STATION BS HI FS ELEV. Benchmark J ~ ` J ~ 3 / / `, 5 / d Alt. BM - f Idg. Sewer ,u-~t ~~ ~ ~- a ~ 13 . ~ Sit i ; ~~ ~:~'7>~ ;~ SUHt Outlet Dt Inlet f ~(t.~~_ ,` ~-~:: ~ ~. :., ' ti e /~ ~tE!--'ti Dt Bottom ~ ~at~ )rte,; Header/Man. Dist. Pipe Bot. System Final Grade St Cover f . ,,~,.~ ~ . y3 y ~ . ~, `~ ( ,,;; 1 BED/TRENCH DIMENSIONS Width ~ /. Lengtf' _ / i '/] 5 No. Of Trenches PIT DIMENSI NS No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO „l,, G: P/L BLDG WELL LAKE/STREAM ACHING C MBER OR Manufacturer: Type S stem: %G ~,r~'~1,~ / IT Model Number: r11CTRIR1171(7N SYSTEM ._1-r, /1 /7/0 ,/1 yn,ni n e ~"' Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing S[~II CnVFR v Dracm~rn Svc4nmc (lnlu yr Mn~~nrl f)r At_(;rade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded ~ BediTrench Center Bed/Trench Edges Topsoil Yes ~ No ~ Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~a / ~~ / Location: 2969 210th Avenue Glenwood City, WI 54013 (NW 1/4 NE 1/4 22 T 5W 40 acres lot /~ ,~` 1.) Alt BM Description =T~ o f `~OG~ G{` = 9~' S~ / ~~ r C '"~-~ "`' L 2.) Bldg sewer length = ~~ ) i - r„ ~ ,,~ ~~ ~ fl~'G:~v Yvtt.--r~c;..~:, ~~~-l L4x:z;,y,,;t, Z~- G ~ tl,~ ~ti,di~ (,(.lC~ ~L _ r!' rs.-.. - amount of cover = J ~' ~ /~ ~ ~ ~ ~~ ~ ~ ~ ~~-~~ ~ ~fi Z~LI ~~.~~ Plan revision Required? [] Yes ~ No Use other side for additional information. ____.__._ __- J ~ _ - Date Insepctor's Signature SBD-6710 (R.3/97) ~ ~ ~ ~ ~~ ~-L Inspection #2: / / Parcel No: 22.31.15.338A r~~a~~ l ,,,_ : cam- ~ Cert. No „f ~l 4 ~` . c~,yet ~~f !~~-. Mulched Lj,C 03!17!09 aLTE 14:39 F03: 715 388 4888 ST CRS CO ZONI\G ~ ao2 r^"-, rY ry p ~ Y ' ~"} I h d i _.. c.....x cc;:c., , frwa~V,vrn n accgr w t Chapart 12 Si. Croix County Sanitary Cir'rra-tc+s ~.' - ~ ~° f~LANNiNO 8 ZdNiNO t~PARTM6NT ~j,, Ps;eors~ information you provide maybe used for secci k„~,; ~urpeses (Privacy Law S 04{1){m)] 15 ST. CRC~iX COUNTY QOY~P.NMEhT CENTS R 1 . . . ~ i at Carrichaei Road ~' Hudson, WI 54x16-7710 (715 3$6-4680 Fax 716 388-41186 com ate tans for the fem on a r r~ol less than 8-1l2 x 11 inches In size. -`-" n Chor4 .r rnulc~nn ,,, ~..;,..,.;. ~:.,.,~_~.:..~ C Permit # /~ _... .y.,...,,..,...., r /~ Ilcath-~~ J;rturvnaiirn • Wirsase Prlnt all Information ~~~IUELL •rop¢rty Gur.;er i:arrs~ ~' ._., tr ~""'~p"' r ' ~ P ~ ~ ~,,, t~t~i/4NL iia, sic 2 Z q-c.S ~~^^ (~ ~1 r~ ~ 4 ®/ S V" .~ 2~~9 ' ~ N. R F. l4f Prgperty Owner s A,1;;aling Address N b /6'`'~ Z ~ of um er ---- Block Number --.._._._ - Av c. T cROtxcollNTY . State %d ~ / Zip Code S Phrxte tai r,bdiviaion Nama or C8M Number ~~~ ~ o/Z 75-2 ~ -3 yv -_ o u : { orta; ^ 1 qr 2 Family Uweliing • No. of Bedroor,s~ ~ r~~- KY QViHags own of ~ ^ Put>fic/Commercial {describe use): Linn ,. ~ t/v ~ ~~~~ S7' , ^ St t e-owned a Neanepl Rca~ `-' f, TYps of Parmlt; !;Ghazk only one t>rx qn Sne A Check box on Itrt6 B !t appiioaisio) 2-10 ~ t<'e- ~ 1.O Repair ~ecomection .^Non•plumbiny . ^ Rejuvenation cel ex Num {s ~t a7~ '~ ~~~~"' ~d~ Sanitation ~./ -r ta:rrniti i~lumoer ~ /~ ~~ ^ Date 1SSUAd ®j '=i l P S t ~ s e an itr~ ermit wao oravious isetrrr+d 7 IY . r..~.~, - -. _. IY. Tynr nt ontyT a..r_...: ~nw3CL :: b';~. ^ Non~{rressurized in-ground [~ Mound a 24 in. sultabic loll Mound 5 24 in. suitable soil r'1 PAS„nti a+n ~I sa~,c F+rtsr ® Constructed YJet:aid Q ?eat Filter n r_w~ ~ t C`~ Hreasudzec' In-ground CI No,dina Tack p Singe Pasts O c)thar C ^t ado ~~~~ G P,eroRic Treatment Unit ^ Recircu~l!ng .,~ ~....,,....-.-~,,.-~---~ _ ty f:~,fffMflTry}w.A'w~f ITS ~.s..r.ti~.p -. - 1. Ues Flevrr d a, steel Area 3. D spe~-sal Area d, snit AnnlFt^nrhnn pate ~ ~ ....,..+ nµ:v ,,.--------i ~ (Sp) ~~sp ~_ __.,,.. ., , . ,,. ,..ro,e,~t ~,rlorxriun r. nnSi tirade /~O Requir®d ,` Propassd ~~ (Gals.~day/sq.;t~ ,,v4,a I:rchj V D 3 ~Eleva6on ~~ ~]! II :.J . _- i _ 3 ~ 3 ~ i ~ ~ 1 / ~ 7 ~a3 . . TAnk Information arabty Gal ns of # o Martutaeturer refs • on- teal Fittar• Plastic Mew Existing Qaitons Tanks Concrete struG~ed glass ~ ~ Tanks Tanks ~ ~ ~ ^ ^ ^ Q ^ O D ^ ^ ~. Raaponaibpity Statement the undersigned, assume responsib'Jfty for repair/recannenetion,'reJuyenationl~nsteiation of non-pium4ing for the POWTa shomr an the attached plans. A kxsnae IS not required for letxalift r air or the Enst8liation o? non- umbi sanitation s elem. PI mbet"s Name {print PI is Sig lure (no stamp ); MPIMPRS No. Business Phone Number - r E /~1y. / 4r/ ' ~ C~ ~ .. .r ~ t ' / ~L~ Zlv7~~5 'lIS~24..$'-• y//S Plumber's Address {Street City Slats, Zip Code) '~ ~ X~ /.~cr1'/~~./y-~- ~/vrr ~'-rte-CI' L i S `/c~ r ill. irlo~at Uw t~rti~ Sanitary Permit Fee a Isau Issui gBnt Sign {Nos s) A{pxoved Owner Giv nltiel t Ue~ 4 ~ ~~ C a~ J ~ ~~ ~G r errt+ fte on X. Condlllans of ApproveUReaeDns far pleepproval: r SYSTEM OWNER: 3~ ~rL~,~w+ ~-' ~ 5 d~ C G~ Y 1. Septic tank, effluent finer and ` _~, _ L dispersal cell must all be services /maintained (~.,~. Gin. lt)1 ~,` ~i0 Q as per management plan provided by plumber. ~ L~ 2. All setback requirements must be maintained ~~t ~ `ter QY tie Per appaicable CodO / ordinances. --~~~I vrti. ~~ ~~~i C~ ~~ ~ ~~ ~ ~ ~~v c i~3 1 ~~~~~ Glh -b n ~ - a 1~~~~- ,fry U ~ ~ ~~~~ ~~~~ k ~° h ~ N ~ N ~' ,~~ C ~ ~. ~~ ~. c~~4 ~- ~ u i Cp PY ~ D -~ Z 7 ~ N a N `'~ ~ ~ J W ~( p~~ \ "~ ~ ~ ~ ~ ~ ~Q `~ ~~ ~~. ~~ ~. -~ ~J G~ G'~~ ~\~_ \ C Q ~`- C, ~~`.~''~ J ~N ~~._.- 'si~ N Northland Plumbing Inc. E1556 State Road 64 Boyceville, WI 54725 (715) 643-2520 Business (715) 643-2131 Fax Septic System Visual Inspection And or Nell & Water Test Property Address: `~a BS~~~c-w~A s~ cS~G- Inspection Date .3 -3 a - o~ 2 9(0 1 2/4 .V d.~. ~~ ~ w / Sib/2 Conventional ~ Mound Type of system At-Grade Holding Tank Observations Other °'' A visual inspection indicates that the septic system and all components are located the proper distances from the dwelling's foundation, well, and property boundary lines. The tank(s) have been pumped and were physically entered and were completely inspected and is/are free of any structural defects and are functioning properly. The tank(s) were pumped but not entered and appear to be free of any structural defects and appear to be functioning properly. The tank(s) and drainfield inspection revealed the following structural defects:- ~ The tank(s) were not pumped, but from readily observable features, it appears to be functioning properly. Determinations A visual inspection indicates no evidence of system failure at this time. The system is adequately sized and is not disapproved for current use as per WI Admin. Code, Comm 83. A visual inspection indicates the system is functioning, but failing. Repairs are needed as follows: A visual inspection indicates that the system has failed and is disapproved for current use. Water-Well Inspections Well is up to Code Well is up to Code ....- Wat Sample HAS been taken. ..- - ~ Water Sample NOT taken. Water Certification Water Test Results sent separately The undersigned cannot guarantee the continued acceptability of the private sewage disposal system due to unpredictable factors, which could later determine the life or code compliance of the system. The undersigned cannot guarantee the continued acceptability of the private well and water system due to unpredictable factors, which could later determine the life or code compliance of the system. z ~ 795 ~rP/~.sr Inspector's Sig ature License # Type of License held St. Croix County Occupancy Affidavit for a single POWYS servicing Two Dwellings via Private Interceptor Main _ ~~t.Tfl1Ar Sf~'i-'SEGr'1 Name - (Owner) Typed or printed being duly sworn ,states, under oath, that: 1. He/she is the owner/co-owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume ~3~J Page Document NumberC 'Z7b St. Croix County Register of Deeds Office: A parcel of land locat d in the'/ of the ~~'/ of Section 2,~ , T_ 3 ~ N - R ~~ W, Town of ~-C~i~'~~,'~' , St. Croix County, Wisconsin, being duly described as follows (include lot number and subdivision/CSM or detailed legal description): ~-~` ~ ~~ o F f her Nw ~/5/ of f/~ ~ N C ~/y 111111 IlIII I I I II I 1111 ll lull I II 1114111111 Il l{ I ll l 892224 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 04/01/2009 02:40PM AFFIDAVIT EXEMPT A REC FEE: 11.00 PAGES: 1 { -~ Name and Return Ad~dress // ~ ~1Z~L-E~ 'W 1 ~ ~ i 01 -- l b Q-to- 2$-4 cz7 Parcel Identification Number (P[N) As owner of the above described property, I acknowledge that a Private On-site Wastewater Treatment System (POWYS) serving the primary residence is sized for ~ bedroom(s) with a design wastewater flow o~ gallons/day. (DWF calculation based on 150 gpd /bedroom @ 2 persons bedroom). Two dwellings will be connected to the POWYS via Private Interceptor Main Sewer (PIMS) in compliance with Comm 82.30(12). A maximum of tp occupants are permitted. There are currently a total of~occupants in these residences, therefore the POWYS can be considered code-compliant at this time. However, I understand that if the number of occupants exceeds the maximum for POWYS design, the system will be undersized to accommodate any increased wastewater flows and/or contaminant loads and maybe subject to premature failure. I also acknowledge that I will disclose this information to any parties interested in purchasing this property in the future. ted this ~ ~ day of ~ , ~_. ,~ 1~ ~'ia AUTHENTICATION Signa~t tt•e(s) authenticated this day of _, TITLE: MEMBER STATE BAR OF WISCONSIN (If not, Authorized by § 706.06, Wis. Stats.) IIS INSTRUMENT WAS DRAFTED BY {Signatures may be authenticated or acknowledged Both are no[ necessary.) ACKNOWLEDGMENT STATE OF WISCONSIN ) )ss. St. Croix County. ) Personally came before me this ~_'~~day of (~~( ~~ ~- the above named TT ~ L /b r~~ ` -.G ~I to me known to be the person(s) who executed the foregoing instrument and acknowledge the same. _ ~ C/i ~ / L ~„• ,,~, ary u , State p iscorlsii><' ,• ~ ~~ My Cornrnission is permanent ~ knot, static i~Scpiratlon date: (. ~ • ,,, Date: ~- ~ - ~-8~_3-, ' ' _•~ . . "THIS PAGE IS PART OF THIS LEGAL DOCUMENT- DO NOT REMOVE" This information must be completed by submi[ter: document title. name & return address. and P[LV (if required). Other information such as the granting clauses, legal description, etc. may be placed on this first page of the document or may be placed on additional pages oJthe document. Note: Use of this corer }a~f ads one page to your document and 82 DO to the recordine fee Wisconsin Statutes, S9.SI7. -.. _ ~f i{~~ . ~~'~~~~ s~~aE g:tift c~a• aF°fg[.+_s°<SC". Fc3Ft~a ~ - ts11:~ ~t~fT ctAf~f f~~rf3 [ .s - _ N 3iQC.ard BZe~e~t,P~i_'~. alma ti~erd E. F3P_c-~ artd v~ f!F ...' g t~ernace B omt)erg, V a Fern i c~ F. B lc:;Bher~ ;. ~ 0 ° $$t~$ Guta~larreas rn Br~nrla Sa1seQ, a eTJarcie~ri o®rson '. 19L folla.+,^.ng d~•s~-nhzd teal d-slasC ul ~t . _~..r~D1X C(p31i1); si8r~ 4f ~Visrort.,,tt' re~e=5 SFAtE ~~~D Fi1-. 76L-y-.Jx+SG't.~(a L7.~F.ri• A'P.~..ISE JJ+:IS r^sEri~:'?a ~" ~'2t~n_cCysc ~ ~~ 72(0 - _~S 7A- Sj, Th,~ East One-Ha L ~ (E z) o P tree for th~.;es t (~xar ter (~ <~ . o~ tk~e northeast QL)arter (A+rF:r), ~~ L~~'~`~-•~~ L~1~13~~~~y11 ~~'~+ f Z The East One.-Half: (Er j of the Sou throes t (fir ter (S~~ ) oc the f~artheast Quarter i\~), part OL~A--iOLb-20-000 Al.l In ~ecti..n qty-tti.c) (22) , Townsh.bp Thirty-one ~ ~""~"~°`"~"° 4...4 (31) f~f , Range Fifteen (15~) k . ~ ~ . This (rs) ;es rc:) -Q~-"-- oarr~3 rhos _ Reward Blcxn*an..r r~r.-^_ ~, a/k/a _~ Howard E. Bla-aberg AfJ. f-I[NTICr1T10N si riarure(s) Howard Blomberg, a k/a Howard E. B~J.oomberg and Bernice 81oa:berg, a k/a Ul Vn:~~-~/-L s authPn:' tc this -~-~a~ of I;i y8 /l _ .e~ J nti .~ ~~~' .Rivard TI"CL~~ ML•MBEl2 ST~.T~ BtiCi QF WiSCOM$IN (1! roc. _ aurhorizea by §706.06, Wis. Stars.) THIS INSTRU)~tENT WAS ORAf-EO BY Francis X. Rivard Glenwcod City WI 54013 (Signatures may be authenticated or acknowledged. Both are not neieSiar}'.) hcrnesread propr:n}•. ~~ . aa, ,.r _~ ~ ~ ~~ ~~_ f,~98 Bernice F. Blomberg (SCAL) AC KNOLirLCf~GML-TST St3~te o< <'lfisccnsin, 55 - Cau m }: Perwnall}• came be Core me this da}• of IQ ~hn aMvn ne m.•.1 to me knaµ-n to be the person _ who executed aFe foregoing instrumeni and acknowledge the same. Nota:y Pr:blic, ---- --- !.tp corr+mission is permznene. (1( nix Count; 1Ves ;:;ate expiration da:c _. 19_ • wnmcs n: vrsnns mgmng ~n anj calr,¢nj sF.a::!d he iyncd ar pnmcd iacln.v ihcv • xm:rs. - STA-rE 9AR OF wtSCON5IN Wiscans~n ~c~ 0an*. Co , irc QUIT CLAtsi DEED Form No. 3 - 1992 bR1}.%u6r¢6. dJs ST. CROIX COUNTY TONING UCI' AS GUILT SANITARY Owner ~,a-q 9 ~'~'t.~t~1 ~+gc.,$F.c4 Address ;J,:~ ~-h B~c~ City/State _ ~mE~~r~ ;/ ~ ~-y'~3g Legal Description: Lot ~ Block Subdivision/CSM # `~ '/..: '/, A)L , Sec. ~~ , T,~N-RAW, Town of ~• `~' ~ '~ _ ~-+ _• ._ ~ ~~r~~~ E-...__, "^ • ~ ;~, •t =Rarx ;~ , ~q j.,,, ~CJit';NG~F~IGE ..,, . SEPTIC TANK -DOSE CHAMBER -- HOLDING TANK INFORMATION: -~ /NG ~ ~ , Tank manufacturer ./I` ~~y~ ~ ST/PC ~ Setback from: House Well ~ P/L ` ~ n Pump manufacturer Model ~ ~~ E=Pt7 .S' Alarm location _ ~,qsL-~,,,,,~, .~ (HOLDING TANKS ONLY) Setbacks: Service road _ Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: Width ~ r Len 7,$~` ~ ~ Number of Trenches Setback from: House ~._ Well ice, -~ p/I, ~_ Vent to fresh air intake ~,~ ' ELEVATIONS: Description of benchmark `' : '/ d ~ ~ `" ~~C Description of alternate benchmark Building Sewer ~ , /~? ST/~' Inlet ~d%~3 ST Outlet • /016 .-~t~- PC Bottom ~'s % zs~ Header/Manifold / , ~/ Top of ST/PC Manhole Cover Distribution Lines () / p z , o ~ ( ) Bottom of System ( ) / D /. 3 0 ( ) Final Grade ( ) () ' ~ ®~ Elevation ~G'~ ~~ ~~c Elevation ~ . jC PC Inlet Date of installation ~/ / Permit number c~~~'(~ State plan number Plumber's signatur t License number ~~~z/ ~ Date Inspector ~o C ~/ /~ 6G ('o~. NOTICE: Plcasc provide the following: • A plan view sketch showing everythinb within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark,. if applicable. ~„~~~ 2~t ~- •- - r~ v ...- PLAN VIEW ~~ i~ ~~ __-- ,:, a~ ,' ~~ ~1 ~ `~ __.__ ~ - ~~~ Il 0 © ~~ ~, ~ _ _ ~ ~C~ ~~ I C ~ 2, ~ ~ to ~, ~ ~, ~~z,~ ~ ~ INDICATE NORTH ARROW E NOTICE; Plcasc provide the following: A plan view sketch showinb cverylhinb within 100 feet of the system. Two horizontal reference points to center of septic tank manhole cover. Show alternate benchmazk, if applicable. ~'1 INDICATE NORTH ARROW Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Sa>•ety and Buildings D'evision • INSPECTION REPORT 'GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). Permit Holder's Name: p Cit p Village Town of: SALSEG, BOB & BRENDA FO~2EST CST BM Elev.: Insp. BM Elev.: BM Description: lob IDS o~v~'?.'~~lr 7;n~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~y/Nl;d /'•,e fi 1(~Cj osing ~ ~©v Aeration Holding TANK SETBACK INFORMATION TA TO `~/ L WELL BLDG. Vent to Airlntake ROAD Septic ~~~ a` (o, ~ „ NA Aeration ~ NA Holding PUMP /SIPHON INFORMATION ~, Manufacturer ~ Ov~Ct Demand Model Number ~Po~ Z•1 GPM TDH Lift~6.7 Lriction ~ /~ Syetem~, TDH~~,GI~t Forcemain Length ~ Dia. Fii ~f Dist. To Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: ST. CROIX Sanitary Permit No.: 315989 State Pian ID No.: Parce! Tax No.: 014-1046-20-000 A9800377 STATION BS HI FS ELEV. Bench r 'Z. 87 1 at• ~ ~ Bldg. Sewer ~?,.'7 , r 'fit / Inlet p ~ ~' St/ Outlet t Inlet Dt Bottom ~ 7_ ~ . Z Header /Man. (,~ ~, p / Dist. Pipe , ~ (~Z. p Bot. System f ,~'~ ~ ~ (. Final Grade /. r.e r o/•a.~ • ~Y~O ~1 ~ ~ I /'~ BED /TRENCH Width Length ~ No. Of Trenches PIT No. Of Pits Inside Dia. Li Depth DIMEN I N DIMEN I SETBACK SYSTEM TO P/ L BLDG WELL LAKE / ST - M LEACHING Manu INFORMATION Type O ll~0 ~ I ~O ~ ER OR UNIT tuber: Systc u ~ DISTRIBUTION SYSTEM ~ ~, ~ ~ ~,, i -! .,~.._~/,-~,, Header /Manifold ~ Distribution Pipe(s)i x Hole Size x Hole aSi~g Vent To Air Intake Length Dia. Length ~ Dia. C~ Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) • LOCATION: FOREST 22. 31.15.338,NE,NE 2969 210TH~AV;1~ ~~ AC~.~~, - 0~ t;~ ~D~D~~ ~ovt~~~ dY~ ~'YO vS ~ 2~ ~b ~ r >w ~~,~.~,~ . Plan revisi on ~e~ ~r~? ^ Yes ~ No Use other side for additional information. ~ ~ 9~ ~ SBD-6710 (R.3/97) Date Inspedar' ignature rt. No- SANITAi~Y PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code Safety and Buildings Division Bureau of Building Water System 201 E_ Washington Ave. P.O.Box7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County S" than 8 v2 x 11 inches in size. ~ • See reverse side for instructions for completing this application state sanitar~ermit~~ n The information you provide may be used by other government agency programs to previous application ^ Check if revisio (Privacy Laws. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION- PLEASE PRINT ALL INFORMATION Property O er Name ~ P pert Location N R ~ ~E (Or 1 i4 ~ ~ t /a ~ S~ T D ~ , , GU , Property Owner's Mailing Ad ess / ~ Lot Number Block Number ~-- ~ Ci ,State Zip Code Phone Number Subdivision Name or CSM Number IL TYPE OF BU DING: (check one) ^ State Owned ~ ^ city ' '~ ~ own o i Nearest Roa~& ~ Public 1 or 2 Famil Dwellin - No. of bedrooms _ d I C.E=S f l C III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) ~~ 2I, jr` 2Zp~~ 7 J7 a 7 _ / ' 1 ^ Apartment /Condo f ~ C `~ 2 ^ Assembly Hall 6 ^ Medical Facility /Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise:Sales/Repairs 11 ^ Restaurant/Bar/Dining 4 ^ Church /School 8 ^ Mobile Home Park 12 ^ Service Station /Car Wash S ^ Hotel /Motel 9 ^ Office /Factory 13 ^ Other. specify IV. TYPE OF PERMIT: (Check only one box online A. Check box online B, if applicable) q) 1- ^ New 2_ r~.Replacement 3- ^ Replacement of 4, ^ Reconnection of 5. ^ Repair of an System ystem Tank Only Existing System Exfstfng System B) ^ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE Of SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ^ Seepage Bed 21 (Mound 30 ^ Specify Type 41 ^ Holding Tank 12 ^ Seepage Trench 22 ^ In-Ground Pressure 42 ^ Pit Privy 13 ^ Seepage Pit 43 ^ Vault Privy 14 ^ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading- Rate 5. Pert. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Galslday/ . ft.) (MinJinch) Elevation ~~ ~ `~ ,, 2 Q , 3 Feet eet VII. TANK Ca acit INFORMATION in dllOnS g TOtdl # Of r Manufacturer s Name Prefab. Site Con- l Fiber- Plastic Exper. , N E i i Gallons Tanks Concrete Stee glass App ew x st n strutted Tanks Tanks Septic Tank or Holding Tank E}~ r-L; ^ ^ ^ a ^ Uft Pump Tank /Siphon Chamber ~'fl~' '~' N! L ^ ^ ^ ^ ^ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. Plum er's ame: (Print) Plumb is Sign ture: (No Stamps /MPRSW No.: Business Phone Number: Plum is Address (Street, City, St e, Zip Code . -' ~ ' ~ .~ ST d ~ ~ IX. COUNTY /DEPARTMENT USE ONLY ^ Disapproved Sa ary Permit Fee (Includes Groundwater ate Issue Issuing A ent SI re No am pproved ^OwnerGivenlnitial ~~}}A~., Surchargeree) ~G ~ ~o ~/p /, Adverse Determination > p V / X. CONDITIONS ®F APPR®ViAL / REAS®NS FOR DISAPPROVAL: S8D-6398 (H. OS/94) DISTRIBUTION: Original to County, One nrpySo: Safety & Buildings Oivuion, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be .renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal-Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years- 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.- III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufactt rer's name, indicate prefab or si s:e constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only i'tanks received experimental product approval from DiLNR. VIIL Responsibility statement. Installing plumber is to fill in name, license numuer with appropriate prefix (e.g. MP, etc.), address arn~ phone number. Plumber must sign application form. IX. County/ Da~partment Use Only. X. County /Department Use Only. Ccampiete p:;~:~s a~,d specifications not sma '~- ~an 8 1/2 x 1 1 incl F~; !?i..'st be submitted tt~ the county. The plans must inciude'r,F ~uLuw~r,c;: ;~ plot plan, drawn to scale or with comp :s=> cir;rensi.~rr>, ~ccation of holding tank(s), septic :7~ '' i~ Ali<? .. mac:': 1~(li lu' I':1, J~ +-ill .>t'we; vVE'll~; ihLicf t ,t<. S2!+i(_c!: >t .,:+r;, and iai• es; pl;nlp Or siphon iank_., ,,'.I ~'.(';ltil~0 ~ C;UX:""_~, :'J':l ui.;~Vi it1 i"i Sy/$t.°.rr15; (eplaCf'IT?r'!~;. -:~,( ..sf ~::3',~ <1~1U• ~IIC' 1(iC.iLIOn Of tf?4.' bUllding iE.'rVPd; ~) ~ :J~"~v.. l_~i ~i is ,.: _r!JCc~i el~Vu~l!)I" -""e~K~ rOlni;; ~~ -~-~lpi .~~r~ r t~:~i01~5 for ,, .,(lpS and :OntCUIS; dOie VOIUme; e~~v~UOn difrereneas; friction ;oss; pf.i;ni, perforri~ance curvy; pump me Lei ar,c pump mt~nu faclurer; D) cross section of the soil ~~bsorption system if required by tfre county; E) soil ~es~,4a_Y .~,~ a 1 1 ~ form; ar,d F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin i>ct 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. , The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. . ~ - ~ ~ ~scons~n Department of Commerce July 08, 1998 CUST ID No.227618 TOM GUSTUM N13450 937 ST NEW AUBURN WI 54757 RE: CONDITIONAL APPROVAL , APPROVAL EXPIRES: 07/08/2000 SITE: Site ID: 15227 ST CROIX County, Town of FOREST NWl/4, NE1/4, S22, T31N, R15W BOB SALSEG RES SEPTIC SYSTEM FOR: Safety and Buildings 15837 USH 63 HAYWARD WI 54843-8107 Tommy G. Thompson, Governor William J: McCoshen, Secretary Identification Numbers>., Transaction ID No. 117173 Site ID No. 15227 Please refer to both identification numbers,' above, in all correspondence with the agency. Description: REPLACEMENT MOUND Object Type: POWT System Regulated Object ID No.: 33083 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. This plan approval is fora 450gpd mound. The following conditions shall be met during construction or installation and prior to occupancy or use: • This plan action is subject to designer comments on the plan • Correspondence Note: " • Maintain well setbacks per Comm. 83.15(4) & 83.10(1). • Combination 1000/600 septic/ dose tank being utilized manufactured by Midwestern Precast. • The orientation of the mound system must be such that the mound's longest dimension is perpendicular to the P~Q, direction of maximum slope. G"on~li 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. All permits required by the state or the local municipality shall be obtained prior to commencement of DEPARTMIf construction/installation/operation. DtVIS-ON SAi Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address R on this letterhead. Sincerely TO BRA LAN REVIEWER Integrated Services (715)634-3026 , M - F 7:45 AM TO 4:30 PM TBRAUN@COMMERCE. STATE. WI.US DATE RECEIVED 07/01/1998 FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 BALANCE DUE $ 0.00 F w ~ MOUND SYSTEM DESIGN Residential Application INDEX AND TITLE SHEET Project Three bedroom septic Owner Bob & Brenda Salseg Address 107 Emerson Ave S Bloomington MN 54431 Legal Description NW NE S 22 T31 N R15W Township Forest County St. Croix Subdivision Name N/A Lot No. N/A Parcel ID Number Plan ' OF... W/ ~. ILQ;'' ~; THOMAS D. ~'N GUSTUM Z 1201 ZAfc~~.. /(( SiGNE transaction Number 117173 Index and title sheet Page 1 Mound calculations Page 2 Mound drawings Page 3 Pres. dist. talcs. and laterals Page 4 TDH and pump tank drawing Page 5 P{ot P{an Page 6 Pump Curve Page 7 Designer Tom Gustum License Number SignaturecL J~ Phone No. Date 6/29/98 D1201 715-658-1344 Notice: Tampering with this file by unauthorized persons is prohibited. Deliberate modification will result in disciplinary action under x.145,10, Wis. Stats. Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Y.T.S. ~ionally ,OVED Of COMMERCE :n rwo su .S O DENCE SBD-10462-E (R.05/98) Page 1 of 7 ' . MOUND SYSTEM DESIGN Complete red boxes as necessary. 1000 gpd maximum design flow. Inch-pounds Metric Residential or commercial? r (r or c) (y or n) ~~ Replacement system? Creviced bedrock site? n (y or n) Slope 4 Wastewater flow rate 450 gpd 1703 Lpd Depth to limiting factor 16 in 40.6 cm In situ soil infiltration rate 0.6 gpd/ft2 24.4 Lpd/m2 Contour line elevation 99.7 ft 30.39 m Use standard fill depths? x OR Design depth? ~in ~cm Place X in box to use standard depths (24 and A+4 inclusive) OR specify design fill depth. Center or end manifold Lateral spacing Number of laterals Forcemain length ~(c or e) Hole diameter 0.00 ft Use 0 lateral spacing for trenches. Estimated hole space 1 Pump tank elevation 90.0 ft Forcemain diameter ~~ 0.25 In 0.125, 0.156, 0.188, 0.219, 0.25, 0.281, or 0.313 inch only. 4.00 ft Not a final calculation. 85 ft Outside bottom of tank. 2.0 In 1.5, 2, 3 or 4 inch only. 2.067 in Actual I.D. SYSTEM SOLUTIONS Inch- ounds Metric Estimated daily flow 450 gpd 1703 Lpd Absorption cell Design load rate 8 area 1.2 gpd/ft2 375.0 ft2 Linear loading rate (LLR) 6.00 gpd/ft Design width (A) 5.00 ft Cell length (B) 75.0 ft Depth of cell (F) 10.0 in 34.84 m2 74.4 Lpd/m 1.52 m 22.86 m 25.4 cm Sand filter Upslope fill depth (D) 20.0 in 50.8 cm Downslope fill depth (E) 22.4 in 56.9 cm Basal area required (gpd/infiltration rate) 750.0 ftz 69.68 m2 Supporting components Topsoil depth 6.0 in 15.2 cm Subsoil depth at center 12.0 in 30.5 cm Subsoil depth at cell wall 6.0 in 15.2 cm End slope tce length (K) 12.30 ft 3.75 m Up slope tce length (J) 9.40 ft 2.87 m Down slope tce length (I) 12.60 ft 3.84 m Total mound length (L) 99.60 ft 30.36 m Total mound width (W) 27.00 ft 8.23 m Project: Three bedroom septic Transaction Number: 117173 HOLE DIAMETER CONVERSIONS 1/8 = 0.125 1/4 = 0.250 5/32 = 0.156 9/32 = 0.281 3/16=0.188 5116=0.313 7/32 = 0.219 D K/ Page 2 of 7 MOUND PLAN VIEW 27 ft 8.23 m W observation PIPS (h~Pi~) I =down slope dimension =absorption cell (AxB) J = up slope dimension ~ =plowed area (LxW) K =end slope dimension MOUND CROSS SECTION lateral topsoil .~ G ~~ invert 101 87 ft _ elev. 31.05 m ~ sys. 101.37 ft elev. 30.90 m / ~ ~F ASTM C33 C Sand Fill y 99.70 ft contour 30.39 m elev. subsoil cap D = upslope fill depth plowed layer E = downslope fill depth F =absorption cell depth G =subsoil + topsoil depth at cell wall H =subsoil + topsoil depth at cell center 4 % -----> slope A = 5.00 ft 1.52 m B = 75.0 ft 22.86 m J = 9.40 ft 2.87 m I = 12.60 ft 3.84 m K = 12.30 ft 3.75 m typ. obs. pipe ((anchored securely) 6" (152 mm) D = 20.0 in 50.8 cm E = 22.4 in 56.9 cm F = 10.0 in 25.4 cm G = 12.0 in 30.5 cm H = 18.0 in 45.7 cm ~~ ( ~ v~ l~ Note: Absorption cell media will consist of aggregate and pipe with laterals centered across Ax6 media. The cell media is covered with geotextile fabric. Designer notes• Project: Three bedroom septic Transaction Number: 117173 Page 3 of 7 ~ _ 99.60 ft 30.36 m TDH and Pump Tank Drawing Total Dynamic Head Operational head Z. ft 0.76 m Vertical lift 15.97 ft 4.87 m Are laterals the highest point in the Friction loss 0.80 ft 0.24 m system? Yes "x' here. L..__~J Total dynamic head 19.27 ft 5.87 m If no, what is the highest elevation Dose Volume downstr~rn of pump? Dose is > 10 times lateral volume Forcemain drain Lateral void volume 12.5 gal 47.3 L back to tank? {"x" one} Minimum dose 125.0 gal 473.2 L Yes Drain back 15.7 gal 59.4 L No Dose volume 140.7 gal 532.6 L Typical Pump Chamber Layout In combination with state approved treatment tank. Tank construction as per Comm 83.20(3) WAC. approved manhole cover with ~~ weather proof n ~~~ warning label and locking device grade levels junction box ~~ 4" vent pipe ~ ( electric as per NEC 300 and -"'I Comm 16.28 WAC wall of pump chamber or combination tank A alarm on pump on B pump off elev Tank manufacturer Pump tank capacity Pump tank volume 85.9 ft C 26.2 m D 3 " (75 mm) of bedding under tank gal grade levels disconnect Pump manufacturer Pump model number Hydromatic ~C~ a ~l osp-33 ~ CC o A E~~ 'v~ B Alarm manufacturer S~J Elec~~ ~ ~ C Alarm model number 101 'p D aftemate . outlet location 18" (46 cm) min. ~- apPr°ved ~ outlet jant Provide 1/4" weep hole or anti- siphon device ~ necessary Grade levels -pump tank manhoe = 4" (10 cm) minimum above finished grade -vent = 12" (30.5 cm) minimum above finished grade 85.0 ft Pump tank elevation 25.9 m bottom of tank Inches Gallons 20.0 339.3 2 34.0 8.3 140.7 8 136.0 ~~ ~l Project: Three bedroom septic Transaction Number: 117173 Page 5 of 7 I` ~~ I~~ L ~N 3 ,` 2." pvL Fo«~ ~~,; ~. ~boo-6~~ ~~60 ~,.o a16~ A~~ .8a 6 u~~ ,~-t~J~ ~.~.~(g ~i~~- Pf~ ~ ~~f a~ Nlr> NE S~~ 7"31 ~t/ ~!~~ ~ pr~p~~ ~tJ/oc m ~~ ~ . ~' ~~'''~ = ~~ lIX~. o " 70 ~O o F ~ " P~'C P~ per, X 56;~ ~or;~~S ~I~aC.KhoG c, ~~~ 0/Zoo t~/zq,/~Y S~~u l L /; y~ j!'1 QcT7" flc~s~c ~~ s A•~~ ~S' ~b~ ~e~~J T B~ r "09 ~•'sfv/ c rd ~i ~t ' • ..at r Pump Characteristics Pump/Motor Unit Submersible Monuol Modals OSP33M1 OSP33M2 Automatic Models OSP33A1 OSP33A2 Horsepower 1 /3 Full load Amps 1.8 4.6 Motor Type Split-Phase R.P.M. 1750 Phase 0 1 Volloya 11 S 130 Hertz 60 Operation Intermittent Temperature 140"F Ambient NEMA Design B Insulation Class F Discharge Site 1-1/1" NPT Solids Noodling S/8" Unit Weight SO lbs. Power Cord 18/3, SJTW, 10' std. (10' opt.) 18/3, SJTW 20' std. Materials of Construction Hondla Steel lubricating Oil Dielectric Oil Motor Housing Cast Iron Pump Coring Cast Iron Shaft Steel Mechanical Sboft red Seal Foces: Carbon/Ceramic red Body: Brass Spring: Stainless Stwl Bellows: Bunn-N Impeller Bros:. Upper Bearing Single Row Ball Beoring lower Basing Single Row Ball Bearing Bose Cast Iron Fasteners Stainless Steel ,. S . ... Performance Data 32 w 21 0 Q W x U ~ tti a z 0 a o e 1/"t MP U 0 10 20 30 40 50 60 CAPACITY-U.S. G.P.M. Total Nead (feet) 4 8 12 16 20 24 ZS GPM 1/3 HP 60 55 48 39 28 7 0 Dimensional Data 3~7/tl - 63/4---- -- --5-1/tl~-~~ 4-1/4 l' _~ 3 1314 t~ -- I i 11-3/4 11 1. AI! dimensions in inches 1-1/2NPT y. (omponenldimensions moy nary ± 1/8 inch 3 Nol (or ronslrudion proposes unless certified 4. Uuncmmus onJ weights we upproxmwte 5. Wn roserse the right to ~ make revisions .o our products and their specifications without notice 12 1/e /a elP V I AYRORA HYDROMATIC Pimps, Ins. ~ 7 / ~~( ~, 1840 Bonet' Road, Ashland, Ohio 44805 f (419) 289-3042 Wisconsin D&partment of Industry, Lakwr and,Human Relations SOIL AND SITE EVALUATION REPORT Page 1 of 3 ' - 111 QGliV1V Wllll ILI 117 VJ.VJ, ..IJ• /1V~~~. vvVv COUNTY but Plan must include 11 inches in size 8 1/2 t l th t it l h l A St. Croix , . x an on paper no ess an e s e p ttac comp e not limited to vertical and horizontal reference point (BM), di~c,Si~ and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance are~st;road`"~ ~,.. 014-1046-20 ~ -' ',.-"° ~ ``• APPLICANT INFORMATION-PLEASE PRI ~,,I~L INFO MATION•: R IEWED BY DATE , dd PROPERTY OWNER: w.,' ``-'~]~/~~ FRc~PERTY LOCATION Howard Blomberg ;~ '' `L1L9Ui'f. LOT ~ 114 ~ 1/4,S 22 T 31 ,N,R 15 {~ (or) W PROPERTY OWNER':S MAILING ADDRESS '-'s, t' 1 ~~ i~'~ -"" `~~ t_OT BLOCK # SUBD. NAME OR CSM # 2026 295th. St. ~ ,, ~ na na CITY, STATE ZIP CODE r.4-P ONE NUi~$~¢~n: ~ '~ TY OVILLAGE MOWN NEAREST ROAD ~'1`.~~6~® F~nerald, WI. 54012 210 h. Ave. [ ]New Construction Use [ ~ Residential / Nu ~ ~f j~drpo~ri~ ~' A; 3 [ ]Addition to existing building [,x] Replacement [ ]Public or commercial des~rit~~a1.,,~-° Code derived daily flow 450 gpd Recommended design loading rate • 5 bed, gpd/ft2 •6 trench, gpolft2 Absorption area required 375 bed, ft2 375 trench, ft2 Maximum design loading rate • 5 bed, gpolft2 •6 trench, gpd/ft2 Recommended infiltration surface elevation(s) 101.03 ft (as referred to site plan t~enchmark) Additional design /site considerations system el based on contour line of el . 99.70' Parent material glacial drift Flood plain elevation, if applicable na ft S =Suitable for system CONVENTIONAL ~ S ®U MOUND ~S ^ U IN-GROUND PRESSURE ^ S ®U AT-GRADE ^ S L9 U SYSTEM IN FILL ^ S ®U HOLDING TANK ^ S L'~ U U =Unsuitable for s stem SOIL DESCRIPTION REPORT Boring # 1 Ground elev. 98.9 ft. Depth to limiting factor 16" Boring # 2 Ground I elev. 98.5 ft. Depth to limiting f~~s] Depth Dominant Color Mottles T t Structure Consistence BoLUxial Roots GPD/ft Horizon in. Munsell Qu. Sz. Cont. Color ure ex Gr. Sz. Sh. y Bed Trt?nch 1 0-10 10yr4/2 none sil 2msbk mfr cs 2f .5 .6 2 10-16 10yr4/4 none sil 2msbk mfr gw if .5 .b 3 16-28 7.5yr4/4 c2d 7.5yr5/6 scl 2csbk mfr gw na .4 .5 4 28-40 7.5yr4/4 c2p 7.5yr5/8 scl lcsbk mfr na na .2 : .3 Remarks: _ _ 1 0-9 10yr3/3 none sil 2msbk mfr gw 2f .5 ~ .6 2 9-19 10yr4/4 none sil 2msbk mfr gw if .5 ~ .6 3 19-50 7.5yr4/4 c2p 7.5yr5/8 sl 2csbk mfr na na .4 .5 Remarks: CST Name:--Please Print Gary L. Steel Phone: 715-246-6200 Address: 1554 200th. Av .New Richmond WI 54017 Signature: ~ Date: 6-10-98 CST Number: m02298 .,- " PROPERTY OWNER Howard Blomberg SOIL DESCRIPTION REPORT PARCEL I.D. # 014-1046-20 Boring # ~::.<:.: <:~ .... 3 Ground elev. 100.0(61. Depth to limiting factor ~~ Boring # .:.~. .~::::: ~... . 4.:' Ground elev. 100.0(61, Depth to limiting factor 23" Page ,? of _ ' ~.., i H Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPDIft or zon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Trends 1 0-10 10yr4/3 none sil 2msbk mfr gw 2f .5 .6 2 10-17 10yr4/4 none sil 2msbk mfr gw if .5 .6 3 17-22 7.5yr4/4 none sl lcsbk mfr gw na .4 .5 4 22-48 5yr4/4 c2d7.5yr5/6 scl lcsbk mfr na na .2 .3 Remarks: 1 0-10 10yr3/3 none sil 2msbk mfr cs 2f .5 ~ .6 2 10-19 10yr4/4 none sil 2csbk mfr gw if .5 .6 3 19-23 7.5yr4/4 none sicl 2csbk mfr gw na .4 .5 4 23-50 7.5yr4/4 c2d 7.5yr5/6 scil lcsbk mfr na na .2 .3 Remarks: Boring # 4:iii}i:4iiiii:^: }:::::ii}::Cj::~; 4>~ Ground elev. ft. Depth to limiting facror Remarks: Boring # .;<:< 4i. ..~. L?:\ Ground elev. ft. Depth ro limiting factor Remarks: SBD-8330(R.05/92) r STEEL'S SOIL SERVICE Gary L. Steel CSTM2298 Howard Blomberg MPRSW-3254 NW4NE4 S22-T31N-r15W town of Forest N 1"=40' BM.= top of 2" pvc pipe C el. 100' Alt. BM.= top of 2" pvc pipe ~ el. 97.55' 1554 200th Ave. New Richmond, WI 54017 (715): 246-6200 OwnerBuyer Mailing Address Property Address .-2 ire .~ /. ~ s~/2 City/State Pazcel Identification Number ~ ~ ~ - ~`t~ ~la = Z D LEGAL DESCRIP,.T/~ION Property Location/UL~ '/.,,~~'/,, Sec. ~Z . ~~N-Rf~W, Town of ~ Subdivision N `-4 .Lot # ~. Certified Survey Map # .Volume ,Page # Warranty Deed # .~~~~ ~C7 3 ,Volume Page # 4 ~ Q Spec house ^ yes ~ no Lot lines identifiable ^ yes ^ no ~~ SYSTEM MAINTENANCE 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. The property owner agreesto submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeymanplumber, restrictedplumberora licensedpumperverifying that(1) the on-site wastewaterdisposal 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. Uwe, 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 Zoning Office within 30 days of the three year expiration date. /-~'ly ~ ~~~~ DTI l/S IITO SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION 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. ~~ SIGNATURE OF PLICANT DATE ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM (Verification required from Planning Department for new ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed afi~~{~3 DOCUPAENT NO. STATE BAn OF WISCONSIN FOiLt[ 3 - 14'!32 QUiT CLAIM DLE13 Howard Blomberg, a/kJa Howard E. Blant~e~ arm __ ~e'rnice Blom-berg, aka Bernir~ F. Blcrnberg~ __ quit-claims to _ Brenda Salk. ~ marri~~~s~n the foliowing described real estate in St. CroiX _ Cc+unty, State of Wisconsin: TRIS SPACE RESERVED FOR RECORDING DATA The East One-Half (E~) of the Northwest Quarter ~!~} of the Northeast Quarter (NFL), AND The East One-Ha1F (E~) of the Southwest Quarter +() of the Northeast Quarter (;dFfz), All In Secti„n Twenty-two (22), Township Thirty-axye (31) N, Range Fifteen (15) W. ' 8-EREI~T" This homestead prot~ert}•. ~. (is) (15 not) ~---~ Dated this -_T ~- day of ~~ '~' _ . A.D., 19 9$ / i" - _ G -' s~ ~~ij ' (SEAL) ~CS~n ,z, /~. -,~-~-t-~E~~"-.~~~~'- (SEAL) • _ Howard Blombe~, aj~ Bernice Blomberg-,_a/k/a `~ _ Howard E. Blomberg (SEAL) Bernice F. Blomberg _ (SEA!_) AUTHENTICATION Si nature(s) H+ward Blomberg, a/k/a Howard E. B~oomberg, and Bernice Blomberg, a/k/a 4 '-' authenC to his ay of 19 98 at~A Rivard TITLE: MEMBER"ST.~TE BAR OF W15COVSIN (If not, _ auti.orized by §706.06, Wis. Scats-) =~ECiSTER'S nF'FiCE . e~cix ~~~, w~ ~~~ ~ 9 1998 S~ ~ P. M !t~S;s!>rl- at Dowd: i~ NAME AND RETUPN ADDRESS 202(0 - Z9ST~' S'T'. ~4fllZ part 014-104fi-20-000 ar n14-1r14fi-'~n-nnn P CEl IDENTIF~CATIGh NliMBER ACKNOWLEDGMENT State of Wisconsin, ss. Count;. }t-sortall}• came befor: me this day of 19 ,the above named to ~tne lc-nwn to be the person who executed the foregoing ~~~~+ and acknowledge the same- THIS INSTRUMENT WAS ORAF'ED BY _ _-_ - V T!_____~ y l 'M1 ~ 6 ~,_ ___. -- _ ~~Na -~ ;~ ~~~ '~+F~~1 F' ~i ii ~I Wi~,co~sin Department of Commerce Safety and Buildings Division 'GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) rsonal information you provice may be used for secondary puQrposes (Privacy L~y, s.15.04 (i)(m; ~~~ ~'Gd~ r ~~~~+'RT & BRENDA FO~~TRage Town of: T BM Elev.: Insp. BM Elev.: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding County: ST. CROIX Sanitary Permit No.: 315987 State Plan ID No.: Parcel Tax No.: 014-1046-20-000 ELEVATION DATA A98o0375 TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Airlntake ROAD Septic NA Dosing NA Aeration NA Holding PUMP /SIPHON INFORMATION Manufacturer Demand Model Number GPM TDH Lift Lriction System TDH Ft Forcemain Length Dia. H Dist. TO wen STATION BS HI FS ELEV. Benchmark Bldg. Sewer St/Ht Inlet St/ Ht Outlet Dt Inlet Dt Bottom Header /Man. Dist. Pipe Bot. System Final Grade SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMEN I N DIMENSI N SETBACK SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION Type O CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: FOREST 22. 31.15.338,NE,NE Plan revision required? ^ Yes ^ No (~ Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature Cert. No. ^~,E; ~~ Safety and Buildings Division ~~^~^~^~ SANITARY PERMIT APPLICATION Bureau of Building water systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County ~~ ~ than 8112 x 11 inches in size. ( • See reverse side for instructions for completing this application state sanitary Permit Number 3~ S5'~ 7 The information you provide may be used by other government agency programs ^ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State Plan LD. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION Prop y Owner Name . ~ ~ ~opert o tion S ~ T , N, R S-E (or~ -1/4 ~1/4 ~~ ~ LS L T , Property Owner's Ma ing Address Lot Number. Block Nu be Ci ,State Zip Code Phone Number Subdivision ame or CSM Number /~i~1..tr~ ~ ( ) II. TYPE OF BUIL ING: (check one) ^ Stdte Owned ^ oty ^ Vll age ~- Nearest Road ^Public 1 or 2 Famil Dwellin - No. of bedrooms -.~ , , own of t0 vz !~ III. BUILDIN USE: (If building type is public, check all that apply) Parcel Tax Number(s) '" 1 ^ Apartment /Condo 2 ^ Assembly Hall 6 ^ Medical Facility/ Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise:Sales/Repairs 11 ^ Restaurant/Bar/Dining 4 ^ Church /School 8 ^ Mobile Home Park 12 ^ Service Station /Car Wash 5 ^ Hotel /Motel 9 ^ Office /Factory 13 ^ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box online B, if applicable) A) 1. "New 2. ^ Replacement 3. ^ Replacement of 4_ ^ Reconnection of 5_ ^ Repair of an _____System ________System _____________ TankOnly______________ Existing System _________ExistingSystem B) ^ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ^ Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 12 ^ Seepage Trench 22 ^ In-Ground Pressure 42 Pit Privy 13 ^ Seepage Pit 43 ^ Vault Privy 14 ^ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) Elevation Feet Feet VII. TANK INFORMATION Ca acit in gdllOns TOtal ll # Of k Manufacturer's Name Prefab. Site con- steel Fiber- plastic Exper. ons Ga Tan s concrete glass App. New Existin strutted Tanks Tanks Septic Tank or Holding Tank ~f` G -{-~G -^ ^ ^ ^ ^ Ltft Pump Tank/Siphon Chamber ^ ^ ^ ^ ^ ^ VIII. RE5PONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite se age system shown on the attached plans. Plum er's jUame: (Print) Plumb 's Signature: St ps) MP MPRSW No.: Business Phone Number: //~ ,z t l S'~ ~ 3 ZS'Zt~ Plu er's Address (Street, City, tate, Zap ~o ~ v f --~ IX. COUNTY /DEPARTMENT USE ONLY ^ Disapproved Sanitary Permit ee (Includes Groundwater ate Issue Issuing entSig ps) - _Approved ^ Owner Given Initial //~ / Surcharge Fee) `~ ~~%~~~ Adverse Determination X.'~ C11O~$ND~-ITIONS OF APPROVAL / REASONS F R DID' VA . ~ ,G ~ 7~ ~ ~yrLc•~~ -,~~ ~ --__ SRD-(i398 (R. OS/y4) DISTRIBUTION: Original to County, One copy 70: Safety & RuilJings Divrion, Owner, PlumGer INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable- 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county priorta installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3815. To be complete and accurate this sanitary permit application must include: I. Property ov,~ner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County /Department Use Only. X. County /Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacementsystem areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can °~ effect groundwater. The monies collected through these surcharges are used far monitoring groundwater contamination investigations and establishment of standards. ' ~~~tJ c3 X~ ~d~ ~ ~~~~ ~r~ s G j y~ .o ~~„~~ L~ ~4 Pvt ~ lJ,q-~ '' rj'I ~J . ~~ ~z~ ~7 ,~~ ~~ ~s-5 Y ~ s;~ ~G~ '~ i ~ /~ ~a l ~ C,Q-T'i o •J ~t1 c~ ~y ~ ~ ~~~ 'T ~v,Js ~ p C~ _ ~T ~2~JY S L~ T-3/ I'lj /2/Sl~ ~02~ ~~~~ o~ f D -.~ ~` f~j vt N . D~,~~~ ~D 3 ~ ~~r~t ~~ s ~' l }° Zt d /~i2i ~~ Crt~ ~~~ c ~J.4~i~ ~x~, s~s ~z4o ~~ct m /3 i-y2 ~~ 7Z s'~ Y ~~~Z~4 SDP ~ ~' ~ ~' b( ~I ~I% I~ I@ ,Co ~ ~~,J ~ // r iU~" ~ ,~~ ~ S'zz, r .~ ~ ~a~ ~~~ ~' ~ - sr~ c2di~ 7sa ~,~ J S~'~`! ~ Nis ~~ $~g ,~ I ~~ .~ !~~_ ! ~ ~~ i ~~ ~~ ~~ ~v o ~~ ~ ~'' ~ ~ ~----1 c!c ' .~---a ~~'~~`~ `1 -~ .Pp1~~ ~~~~/M .3 i 1 r STC - 106 PRIVY INSTALLATION AGRF.EMRNT St. Croix County, [Visconsin PRIVY fNSTAI.LAT[ON AGREEMENT -COPY TO eE ATTACHED TO THE SANITARY PERMITAPPUCgTIpN Property Owner(s): QQ Reserved For Re<ordrnq Oata ~~ ~ J/lc.'~~A ~LZ S ~ fo' Mai in~~d~: ~y~, J _ l ' ~{ ,. Lot w ~~. ~ll~}. S ZZ T3 ~ N R S E o W Gty, Village. Township OI: Parce Ta^ Num r: ~ ~ '- O Y' O t.e a Description: ~~.!'r r4"+.tC-+rk~vF ~ (31(2 arrr m~ NM1 !l b'f-'1'~bG NG II4' k^'D tI~Z„ a~ Sv~l t/G- . OF-'[1rtL l~~ `(4,. <YN. )N ~ •ncinl Z2~ '~ lS .. no pwmotng will be installed in the privy. 2. No plumbing will be installed in the premises served by the privy unless a code compliant soil absorption system or holding tank exists, or a valid sanitary permit to install such a system has been issued. 3. A privy vault /pit shall maintain minimum setbacks as specified in Table 1. Tablel Well Building Lake/Stream Additional County Setbacks Open Pit SO Ft 25 Ft R",in. 75 Ft - Sealed Vault 25 Ft 25 Ft Min. 75 Ft 4. Privies for public buildings shall comply with ILHR 52.6, Wis Adm. Code. S. Privies used for one- and two-family purposes shall be constructed in such a manner so as to exclude flies, rats and other vermin. Doors should be self-closing and vault ventilators should terminate at least one foot above the roof. 6. A privy vault shall be constructed of watertight plastic, fiberglass, coated steel or monolithic concrete. Materials shall comply the intent with ILHR 83.20, Wls. Adm. Code. Counties may, by ordinance, establish minimum sealed vault sizes and type or construction within the guidelines of ILHR 83.20, Wis. Adm. Code. - 7. The privy shall be kept clean and sanitary. The contents of the pit or vault shall be disposed in accordance with NR 1 t 3, Wis. Adm. Code. 8. This agreement shall be binding on the owner, their heirs and assignees. This document shall be rec_otdsd br~tbe _ _ __ register of deeds in a manner which allows its existence to be determined b refere <e e r e privy is installed, y p~~~~~. ~~~,$ NOTARYPUEUC • t:.:.:i~:~:,TA HENNEPIN CGUfI iY Pnnte ner s Names ~a`"~r~~Ac L Jr~L-~.~a Subscribed and zwo n o before me on t is ate: - '~•D~~'[' 11!. SrArI~SE.L~„ _ 1 u,Lr( 1 ¢ - 1.~,°t,8 ~r s ignatu ~'~,~J~~ Notary PuO~i< My commission expires on:'O( ~j 1--E~ NOTE: This document was drafted by the State Department of Industry, tabor and Human Relations, Bureau of Building Water Systems. 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A ~ ti ti O A N ~ hp A to O A ti o'Ao o g ° ~ ~ 'a o - ,~, .. U: 2796P 1S2 Document No. 794th 1 S KATHLEEN H. MALSH REGISTER OF DEEDS ST. CROIX CO. , 1fI RECEIVED FOR RECORD 05/04/2005 10:30AM EASEISENT EXElPT • REC FEE : 13. 00 TRA)IS FEE COPY FEE: CC FEE: PAGES: 2 I I Return to: ~ ~~~[ n C,~1 S~dvL 014-1096-20-100 014-1046-20-000 Parcel Numbers DRAINFIELD EASENIffiNT Easement made this ~ ~ day of , 2005, between Brenda Salseg and Robert Salseg, her husband, Em ald, Wisconsin (hereinafter referred to as GRANTORS3, and Dean 5ickenberger, Emerald, Wisconsin (hereinafter referred to as GRANTEE). 1. GRANTORS are the owners and occupants of a tract of land described as: The East Half of the West Half of the Northeast Quarter (E '~ of W 3'i of NE 'ri) of Section Twenty-two (22) , Township Thirty-one (31) North, Range Fifteen (15) West, Town of Forest, St. Croix County, Wisconsin. 2. GRANTEE is the owner and occupant of a tract of land described as: The West Half of the West Half of the Northeast Quarter (W ~ of W ~ of NE '~i) of Section Twenty-two (22), Township Thirty-one (31) North, Range Fifteen (15) West, Town of Forest, St. Croix County, Wisconsin. 3. GRANTORS desire to convey the right, and GRANTEE desires to continue to operate, an existing sewerage absorption unit (mound system) and sewerage pumping pipe across a portion of the above described tract of land of GRANTORS. 4. Therefore, GRANTORS, in consideration of the sum of One and No/1OOs ($1.00) Dollar, receipt of which is hereby acknowledged, do hereby grant, sell and convey to GRANTEE the right to operate and maintain said unit and pipe in, on, and about the property of GRANTORS, more particularly described as: Commencing at the North Quarter corner of Section Twenty- two (22), Township Thirty-one (31) North, Range Fifteen (15) West, Town of Forest, St. Croix County, Wisconsin. Thence 589°03'17"E, along the north line of the Northeast Quarter (NE ~) of said Section Twenty-two (22), a distance of 700.06 feet to the centerline and beginning of a 50 foot wide sanitary easement, herein described: ~~ Thence S00°35'24"E, along said centerline, a distance of 100.00 feet, therein terminating. :~ 2~786P 1~3 The rights herein granted may be assigned by the GRANTEES in whole or in part. The easement contained herein is for a sanitary drainage purposes only, which may not be extended or changed. No plantings on the easement property are allowed and GRANTEE, his successors and assigns, shall be responsible for maintenance, cleaning and care of the system, and shall keep it in compliance with all applicable zoning and sanitary laws and regulations, including regularly scheduled pumping. GRANTORS shall not be responsible for any damage to the system from GRANTORS' adjoining property, whether from adjoining trees, plantings, barriers, or other characteristics or activities located on or emanating from GRANTORS property. To have and to hold such right and easement to GRANTEE, his heirs, successors and assigns, forever, provided, however, that said right and easement shall expire in the event said sewerage absorption unit (mound system) shall fail. For clarification purposes, "failure" of said system shall be construed to mean the necessity of replacing, rather than ordinary and necessary maintenance to and pumping of, said system. In the event of failure, GRANTEE, or his successors or assigns, shall be responsible to obtain and pay for cleanup and restoration of the easement property to the condition it was in prior to installation of the system, including but not limited to removal of the mound, piping and drainage. tile, in default of which GRANTEE, his successors or assigns, will hold harmless and indemnify GRANTORS, their successors or assigns, for any costs incurred by them, and in which event GRANTORS, their successors or assigns, shall have a lien on the land of GRANTEE, together with interest at the rate of 12~ per year, for any such costs incurred by GRANTORS or their successors and assigns in performing the cleaning and restoration of the premises, which lien shall be enforceable as though a mortgage under Chapter 846 of the Wisconsin Statutes. IN WITNESS WHEREOF, GRANTORS date first above ritt~en. / _ ~ ~~ C~-~e~an Sickenberger~' have hereunto set their hands on the Bren Salseg Robert Salseg Subscribed and sworn to before me this ~I,d day of ~, 2005. .~~ ~ ~l~ Notary Public St. Cro~i`~x County, Wisconsin My commission: J-as--05' THIS INSTRUMENT DRAFTED BY: Thomas A. McCormack Attorney at Law 1020 10th Ave. Baldwin, WI 54002 State Bar No. 01011884