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HomeMy WebLinkAbout040-1304-07-000 Wisconsin Departmert of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 563849 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Renta, Pedro & Susan Troy, Town of 040-1304-07-000 CST BM Elev: Insp. BM Elev: BM Descd ti Section/Town/Range/Map No: / 66 G6 08.28.19.1813 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER//,., CAPACITY STATION BS HI FS ELEV. Septic 3 I Z Sd Benchmark ` 9 W r ~.St.~_ 't i Alt. B Aeration Bldg. Sewer ✓~A r / Holding 00, St/Ht Inlet w C'M TANK SETBACK INFORMATION St/Ht Outlet /•5 4 • Z 4~? • 79 TANK TO P/L WELL BLDG. ent it Intake ROAD Dt Inlet SoJ Ji 60~1(r 94 6. Septic 6 / AA- / a 9 / v / Dt Bottom Dosing Header/Man. •5 Aeration Dist. Pipe 4's 7~~7a Holding Bot. System J 7,1O I 9p7 a Grade v PUMP/SIPHON INFORMATION Final •:S ~O/ •(O Manufacturer Demand St Coe d PM fir; l Co J Z-6 Model N er - 7-1,1 W TDH Lift Friction Loss System He TDH Ft , b ! Z 7. 9 S• Forcemain Length Dia. Dist. to Well c $ i ~7 • !v SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS IR` 113 SETBACK SYSTEM TO v P/L BLDG WELL c~ LAKE/STREAM LEACHING Manufa urer INFORMATION CHAMBER OR ( !tea Type Of m: Z7 21f A).4,-- UNIT Model Number, DISTRIBUTION SYSTEM f Z6 4-Z6 do- Zo a Header/Ma~ / Distribution Ix Hole Size Ix Hole Spacing Vent to Air Intake Length 7 Dia 7 Pipe(s) Li-S 1 - Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only l~^^ Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center 2 tel. Bed/Trench Edges Topsoil Yes No Yes FAI No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 447 Sunset Drive Hudson, WI 54016 (NE 1/4 SW 1/4 8 T28N R1 9W) Sunset Valley ~Loo~t..7 Parcel No: 08.28.19.1813 1.) Alt BM Description e~b t•~Iitat'~'~ ~"'~""'3 d 2.) Bldg sewer length - amount of cover Plan revision Required? ❑ Yes No G / Z f„ Use other side for additional information. o (J _ w SBD-6710 (R.3/97) Date Insepctoes S/ture Cert. No. J hhss a cr ` 4 46 Y t VJ } N 68 o 0 _ Y County , e an B i sion S " ; F 201 n n v .0. Box 7162 Sanitary Permit Number (to be fill in by Co.) ` p ja 707-7162 ' ~StONF~'~ Sanitary Permit Application State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the approp overnmental unit N is required prior to obtaining a sanitary permit. Note: Application forms for state-owned PO ubmitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provideg~ay be use V ndary purposes in accordance with the Privacy Law, s. 15.04(1 (m , Stats. tl '9 51( h 1. <1 1%0 I. Application Information - Please Print All Information Property Owner's Name ST C Parcel # oe1:tr/L.4,n 4- L45:" s-!7 e2 if 1-%4-6774co PPropertf Owner's Mailing Address N~ Property Location Govt. Lot City, State Zip Code Phone Number &A- 11. j~ ~4, Section n J ' -7Q(D T~ N; R E o II. Te of Building (check all that apply) Lot cycle o 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name / ' dy A_ Blo Q- - Z4 ❑ Public/Commercial - Describe Use I~ ❑ City of CSM Number 11 Village of ❑ State Owned -Describe Use &-1 own of 3 D iCeA 5 2Z CL" "e-r--5 Lac III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. Ld <ew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner P,'( o✓ `u IV. Type of POWTS System/Component/Device: Check all that apply) P<On-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil CLIAI-Lern ❑ Holding Tank er spersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersal/Treat ent Area Information: Design Flow (gpd) Design Soil Applic ion Rate( t) Dispersal /oAr/Are,,, Required (sf) Dispersal Area Propose sf) ysynp,~,~pv}'ry 3+ / -42 12 4C Ov . _ r~?jj 77 d~ ~O VI. Tank Info Capacity in Total # of Manufacturer 2 C Gallons Gallons Units 2 c ° New Tanks Existing Tanks j) G o ) Y p , p / Q 5z .o J P. U Vi U V~ R. C7 Q.~ Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installa ' u of the POWTS shown on the attached plans. Plumber's Name (Print) PI e s Si re MP/MPRS Number Business Phone Number C/o f Plumber's Address (Street, City, Sta Zip Code) 04 r VI oun /De artment Use Only Approved isappro Permit Fee~p Date Issued Issuin ent Sign I ~il IX) J ivenReason o nial $ 7" ' Z 3 DL Condi TNlll4A1Vd f1l iteasons for Disapproval 'tank, eMusnt filter and dispersal citt,must all be services I maintained tit per managetnent plan provided by plumber. 2.• its requirements must be:maitltained is per cAde t Of&Wi0~ . Attach to complete plans for the system and submit to the County only on paper not less than 8 12 x 11 inches in size SBD-6398 (R. 11/11) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Renta Sewer Owner's Name: Pedro & Susan Renta Owner's Address: 808 Heggen St Hudson W i. Legal Description: NE1/4SW 1/4 S8 T 28 N R 19 W Township: Troy County: St Croix Subdivision Name: Sunset Valley Lot Number. 7 Parcel ID Number: 040-1304-07-000 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber. Keith Knudtson License Number. 648443 Date: 07/18/2013 Phone Number (651) 470-1737 Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01101). Page 1 <'v Q4 C~ c~ A" A 1- -i ml~ Z w .fir - ~ { 1 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2 FILE INFORMATION SYSTEM SPECIFICATIONS Owner eJ r. t) :5G G Septic Tank Capacity 1 zs O gal ❑ NA Permit # Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer k 106-- ❑ NA Number of Bedrooms L~ ❑ NA Effluent Filter Model sZ ❑ NA Number of Public Facility Units (VA Pump Tank Capacity gal '*;-NA Estimated flow (average) 1160 gal/day Pump Tank Manufacturer ;i IKA Design flow (peak), (Estimated x 1.5) !o gal/day Pump Manufacturer CIA Soil Application Rate 6.'_7 gal/day/ftz Pump Model xfi Standard Influent/Effluent Quality Monthly average* Pretreatment Unit A Fats, Oil & Grease (FOG) :_30 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) :5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dis rsal Cell(s) -TAI (kjrL Q,J:c~Z ❑ NA Biochemical Oxygen Demand (BODS) 530 mg/L in Ground (gravity) ❑ In-Ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) :_10° cfu/100ml ❑ Drip-Line ❑ Other: Maximum Effluent Particle Size Ye in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every' ye 3 ❑ onth(s) (Maximum 3 ears) ❑ NA ar(s) y Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ NA Inspect dispersal cell(s) At least once every' ❑ prionth(s) (Maximum 3 years) ❑ NA 3 year(s) Clean effluent filter At least once every: /r Pponth(s) ❑ NA year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) A ❑ year(s) 'D month(s) NA Flush laterals and pressure test At least once every: ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of :_12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Z of START UP AND OPERATION Page • For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or: must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. p~ T 1A"//jrj~1 aluat' a o ing ttank be a ai a '~fZD44115 rrEr OR A/6✓ CaNSTR(lCTtON ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS e POWTS INSTALLER POWTS MAINTAINER Name ~Jdl0,~ Name Phone tv5 / - 4-76 „ 1-7 -3 -7 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name sT. CID ( ou& 2D~l~cl Phone Phone -7 / S- 3 g' _ (0,f 0 This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3). Wisconsin Administrative Code. Page 2 of 71- START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or: must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. / T aluat' a o ing~ank be a ai e . 1'fZD4d1('3 Tti✓1, VbP- AJ6'✓ rbtJSTR(I~ D ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS f POWTS INSTALLER POWTS MAINTAINER Name ~i_ A Ly~~ r~ Name Phone 1- 4-76 - 1 -7 -3 -7 Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name o u L tot (f1 J Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.5401, (2) & (3), Wisconsin Administrative Code. Y: a law Jim sa: aillimakac , 3P~f+c~sg oae~~cP~reiet~a~ . {va~z ~ ~-Itl~DS-P{lI~ - TAbkLSysismDcskp stp&Tmdc T _ T I!- - ~ Denim -4 -c.s~ ]i~aon~eal'f~t~ ~ - T 3: Foce Scar T 3 ase~aa a~das~erecied.. = bw = - c Isr gild= Regula fo 9TIV POWTS r - I 8011 On System AISLOn A zei ft 4' Schedule 40 Final Grade PVC vent Pipe WNh Vent Cap Leaching ♦ ft Chamber - Elevation Ali Abso on System Plan View 3 ft hPt P~ Leeching Trench 1 Chambers 4' Dia. n Trend 2 Header ent Or (ervatlon Pipe Trench 3 china Chamber SR2giNalm Manufacturer And Model JZ~~- ~t „*4 a Sd ~ 7~e1rS EISA Rating Q 6 sq ft per cumber Soil Application Rate , & gpolsq ft 4_ gpd Design Flow + .6~-- Soli Application Rate t a EISA = e_ Chambers 3 rows of chambers each. Page of ° Filters r f;V -525 EFFLUENT FILTER 1r 1L-525 Filter is rated for 10,000 GPD (gallons per day) 1116" Filtration Slots it one of the largest filters its class. It has 525 linear feet 1.`16" filtration slots. Like the 'E k PL-122, the Polylok -525 has an automatic shut - ball installed with every filter. the filter is removed for ing, the ball will float up and porarily shut off the system so e effluent won't leave the tank. M Ft of r other filter on the market can a 1/1b a , FUMbon a than claim. Relled for over 10,= GPD PL 525 Maintenance: ~ x~- SCHD. 40 Pipe a, The PL-525 Effluent Filter should operate efficiently for several years - under normal conditions before requiring cleaning. It is recom- mended that the filter be cleaned every time the tank is pumped or . ~w at least every three years. If the installed filter contains an optional s e! Can ~ard- alarm, the owner will be notified ~ovvs an! cin be by an alarm when the filter needs servicing. Servicing should be done by a certified septic tank SF e~tlfled for re-,~dentiall use pumper or installer. BaN When Mar is 1. Locate the outlet of the 5 ~'PGat~ent No# 6,015,488 OC Removed septic tank. I< 2. Remove tank cover and pump I tank if necessary 3. Glue the filter housin to PL-525 Installation: g 3. Do not use plumbing when the 4" or 6" outlet pipe. If s filter is removed. Ideal for residential and coin- the filter is not centered 4. Pull PL-525 out of the housing. mercial waste flows up to under the access opening t 10,000 Gallons Per Day (GPD). use a Polylok Extend & 5. Hose off filter over the septic Lok or piece of pipe to tank. Make sure all solids fall 1. Locate the outlet of the center filter. See page back into septic tank. septic tank. 19-21 for Extend & Lok 6. Insert the filter cartridge back 2. Remove the tank cover and informations into the housing making sure pump tank if necessary. 4. Insert the PL-525 filter the filter is properly aligned into its housing. and completely inserted. 5. Replace and secure the septic 7. Replace septic tank cover. tank cover. i • 157.43 r..._..........~._ ..~...._._~...r.- OUTLOS' 1 U25 A _ ~ _ , 27.2M ST. o LOT 7 1.5ft ACM 65,624 Sf. L8$11.0 PIES s~ Ir1ARlC BEWH r TOP Of 1 1/4" " PM P" - ELEVAT~is87_54 !DRAINAGE EASE MEW ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM S'ci 5 cry Owner/Buyer Mailing Address 4=4 j Property Address s~T .a>' _ n (Venfion required from Planning & Zoning Department for new construction.) -c Qt4, City/State N o GU ,t Parcel Identification Number O !k/O 473 - 67 0420 LEGAL DESC. Pl~t~ ION Property Location , j aJ14 , Sec. , TAYN R~W, Town of / Subdivision Plat: 4 T U~ r` e , Lot Certified Survey Map # , Volume , Page if Warranty Deed # (before 2007)Volume , Page # Spec house Oyescs o Lot lines identifiable M S[]no SYSTEM MAINTENANCE AND OWNER URTII+'ICATION 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 §SPS. 383.52(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. 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 Safety And Professional Services and the Department ofNatural 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 o a warranty deed recorded in Register of Deeds Office. N %q'qf bed~it~s I SIG1 ATME W 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. 04/12) IIIIIIII I l l l l l l l l l l i l l l l l l l l l l l State Bar of Wisconsin Form 7-2003 0 1 7 0 1 8 3 Tx:4139975 TRUSTEE'S DEED 982590 BETH PABST Document Number Document Name REGISTER OF DEEDS ST. CROIX CO., WI THIS DEED, made between Arthur N. Feyereisen and Marilyn E. Feyereisen 07/18/2013 4:33 PM as Trustee of The Feyereisen Revocable Trust dated December 28, 1995 EXEMPT#: NA ("Grantor," whether one or rryore), REC FEE: 30.00 and Pedro A. Renta, Jr. and Susan D. Renta Revocable Trust dated J TRANS FEE: 150.00 December 8, 2010 PAGES: 1 ("Grantee," whether one or more). Grantor conveys to Grantee, without warranty, the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in Recording Area St Croix County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): Name and Return Address River Valley Abstract & Title 1200 Hosford St. Suite 201 Lot 7, Plat of Sunset Valley, St. Croix County, Wisconsin. Hudson WI 54016 File 2810830 040-1304-07-000 Parcel Identification Number (PIN) I Dated July 17, 2013 (SEAL) (SEAL) * Arthur N. Feyereisen, Tr tee * Marilyn E. evereisen, Truste (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) authenticated on MARS ) SS. • ST CROIX COUNTY ) NERARY t- STATE OF ANC WIRCaNi * Personally came before me on July 17, 2013 TITLE: MEMBER STATE BAR OF WISCONSIN the above-named Arthur N. Feyereisen and Marilyn E. Fe ereisen Trustees of the Fe ereisen ocable Trust (If not, to me known to be the perso s wh xecuted the foregoing authorized by Wis. Stat. § 706.06) instrument an acknowl me. THIS INSTRUMENT DRAFTED BY: * Lorri . D~Mars Fran Iverson 1200 Hosford St. Suite 201 Hudson WI 54016 /orackjoi(owle Publ c _ e of Wisconsin L mmission (is permanent) (expires: March 20, 2016 ) i r to be h ntit~ . Both are not necessary.) (S gi ah res n ) h ,tut e dged NOTE: TIIIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FOR,I&I SHOULD BE CLEARLY IDENTIFIED. TRUSTEE'S DEED © 2003 STATE BAR OF WISCONSIN FORM NO. 7-2003 * Wy lame below signatures. Wisconsin Department of Commerce 0 C T 2 2 TION REPORT Page 1 of 3 RECEI4fiM Division of Safety and Buildings 'r~em. Code t,~y ST. CROIX Attach complete site plan on paper include, but riot limited to: vertical and horizontal reParcel I.D. percent slope, scale or dimensions, north arrow, and locea rbad. Please print all information. R Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). WIWI- 0 6 Property Owner Property Location ■ ARTHUR & MARIYLN FEYEREISEN Govt. Lot -INE 1/4 SW 1/4 S 8 T 28 N R 19 E (or) W Property Owner's Mating Address Lot # Block It Subd. Name or CSM# 420 Townsvalley Road 7 - Sunset Valley City State Zip Code Ph" Nurnber OCO []Ydlage ■ own Nearest Road Hudson, WI 54016 ( 71) 386 - 2122 T 14poy 1 Townsvalley Road 0 New Construction UseE) Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD 0 Replacement Public or commercial - Describe: Parent material outwash/sandstone ble NA fL General commerce BM 15 7 '7 B 4 6 Conventional Iiigi esiby installer A" AX and recommendations: ~ ` / ' ' M ^ PB- Boring # 1] Boring / El Pit Ground surface elev. 888.03 ft. Depth to limiting factor >86 in. Soft Application Rate Horizon Depth DorninaM Color Redox Description Texture Structure Consistence Boundary Roots GPD/tl= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. -EfWl -Etf#2 1 0-4 10YR2/2 - I 3f-mgr mvfr cb 3vf-co 0.6 0.8 2 4-18 10YR2/2 - I 3f-mabk mfr ci 2vf-m 0.6 0.8 3 18-30 10YR3/4 - sl 2f-msbk mfr cW 2vf-m 0.6 1.0 30-36 10YR3/4 - s & Os dl cW 2vf-m 0.7 1.6 5 3 86 10YR4/4 - fs Osg dl - - 0.5 1.0 IS B Boring # [I Boring 889.71 >108 Pit Ground surface elev. ft. Depth to limiting factor in. Sod Awkation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff= in. Munsell Qu. Sz Cont. Color Gr. Sz. Sh. 'Eff#1 *01112 1 0-5 10YR2/2 - is 2fgr ds cb 3vf-m 0.7 1.6 2 5-11 10YR3/4 - Is & gr Osg dl at 2vf-m 0.7 1.6 3 11-22 10YR4/6 - s & gr Osg d) &S lvf-m 0.7 1.6 4 22-108 10YR5/4 - s Osg dl - - 0.7 1.6 5 - " Effluent #1 = BOO > 30:5 220 rr1glL and TSS >30 < 150 mg& ' Effluent 02 = BOD < 30 mg& and TSS < 30 mglL CST Name (Please Print) C CST Number Mary Jo Hollister J fiO&J&^- 224832 Address Date Evaluation Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 01 - 13 & 07 - 08 - 04 (715) 426 - 1775 • Property Owner FEYEREISEN, Arthur (Lot 7) Parcel ID # (Pending) page 2 of 3 C Boring # Boring 891.96 >112 E] pit Ground surface elev. ft. Depth to I MbM factor in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Shucture Consistence Boundary Roots GPD/IF in. Munsell Qu. Sz Cont. Color Gr. Sm Sh. *0101 '0102 1 0-7 10YR2/2 - Is 3fgr ds ai 3vf-m 0.7 1.6 cs 2vf-m 0.7 1.6 2 7-13 I0YR4/4 - is lfsbk ds 3 13-22 10YR3/6 - cs & gr Osg dl cs lvf-m 0.7 1.6 4 22-62 10YR4/4 - s & gr Osg dl gs - 0.7 1.6 5 61-112 10YR5/4 - s Osg dl - - 0.7 1.6 Boris # H Boring Pit Ground surface elev. ft. Depth to limiting factor in. Sod Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/IF in. Munsell Qu. Sz. Cont. color Gr. Sz. Sh. *Eff#1 " EM12 Boring # S Boring Ground surface elev. ft. Depth to limiting factor in. Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPDAF in. Munsell Qu. Sz Cont Color Gr. Sz. Sh. 'ElF#1 'E1102 • Effluent #1 = BOD5 > 30 < 220 ng/L and TSS >30:5 150 mg& ' Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330Test (R.07/W) I 1~ ~ I 11 V FAaZa I tY OVY1~2: FEY I.~G~M: ! 5~D ~ LaT 11 _AK_ Y OF N q TK019 5t C ~ s CA-50L BOM W1 VAMVf S NO COMM B5 "ta PtMM 1.5016 1}CRES 3 7C d~ B /SHOT ORING is 8 x.44000' 70 89I.ss2 LOT 7 cQ~d B-P7A s .0 5r , S T BORI / 89.3. D : s .795 i i F 14.'b F WAS - X Ro.