HomeMy WebLinkAbout040-1316-08-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
563873 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:
Orella, Dominic & Trish Troy, Town of 040-1316-08-000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No:
101,1161 8-1 G 05.28.19.2064
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS / HI FS ELEV.
4 1 X62
Septic Benchmark t 3 ••q aS b ~~l ~
pesml~ - ~v~ ~ Alt. BM / L
r •
/ r
Aeration Bldg. Sewer /,~iy
Holding St/Ht Inlet • a /N, 64
TANK SETBACK INFORMATION St/Ht Outlet 1
~c . 7
TANK TO P/L WELL BLDG. ent to it Intake ROAD Dt Inlet \
At g%
Septic / ^ Z' 1 Dt Bottom \
Dosing 1117 Header/Man. /'I'D • Z
~P
Aeration Dist. Pipe 1717.- Z
It, Ir 43 Holding Bot. System ki Z 91.143
PUMP/SIPHON INFORMATION Final Grade 3 • Z- 161• Im
Manufacturer Demand St Cove
GPM ~ .C...• ~ • ~ ~ .
Model Nub
7e
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 14t
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: _ 15
IU4 Model Number: / -
/ ✓ UNIT
DISTRIBUTION SYSTEM 2Z
Header/Manifolc it Distribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s) ~Qb
Length Dia Length Dia Spacing \
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only ZZ)
Seeded/Sodded xx Mulched
Depth Over Depth Over xx Depth of r
Bed/Trench Center 3 ~Qg dBedrrrenchEdgps Topsoil
Yes NYes No
irm_ G
COMMENTS: (Include code discrepenci s, persons present, etc.) Inspection #1: Inspection #2:
Location: 533 Autumn Blaze Trail Hudson,,WWII 54016 (SE 1/4 SW 1/4 5 T28/N R1 9W) Cedar Woods Lot 8 Parcel No: 05.28.19.2064
1.) Alt BM Description
2.) Bldg sewer length
- amount of cover
L are. aQ-Q-~
Plan revision Required? Yes No ato
Use other side for additional informati5n.' UJ
SBD-6710 (R.3/97) Date Insepct71nature,~/' Cert. No.
/ r t
/w" pip--
13tH``'- t^~~sk-2__.~Q3-' ~-.--'°-po Sv;✓t~«S~/
,i
C , ':.ALL
~e k 0 V
\ ` Nf4(A
i
COPY
1
_
commerceml.gov Safety and Buildings Division County,
201 W. Washington Ave., P.O. Box 7162 7. c 6 x
sco n s i n Madison, WI 53707-7162 Sanitary Permit Number (to be filled in by Co.)
Department of Commerce 5 61 7S S 7
Sanitary Permit Application State Transactign,44umber
In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to 4us' e governmental
unit is required prior to obtaining a sanitary rmit. Note: Application forms f P WTS are Project Address (if different than mailing ad ress)
submitted to the Department of Comme sonal information you provide may be ary
ur oses in accordance with the Priv L s
afsy 4 (1)(m), Stats.
1. Application Informatio I nt nformation -
11 J1 7 7
Property Owner's Name [ f Parcel # t
Oo r_ c 0>11
eR~/ oya-~3~6 ~Q8_
Property Owner's Mailing A ress -VIV7)MA Property Location
7I %Io G /J G CO ii+' Govt. Lot 9
City, State Zip Code Phone umber S y, Section V
Ca G go-o"C' M17 S SO l` crrcle on
II. Type of Building (check all that apply) Lot T .+~8 N; R E of~
8 Subdivision Name
1K I or 2 Family Dwelling - Number of Bedrooms
C~D_
6k ad . ~4 Blo e rt
El Public/Commercial -Describe Use
❑ City of
tt~_
❑ State Owned - Describe Use CSM Number ❑ Village of
y~ / II ,KTown of /
III. Type of Permit: (Check onl one box on line A. Complete line B if applicable)
A.
New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner E a-)
IV. Type of POWTS System/Component/Device: Check all that apply) O
Ik Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dis ersal/Treat ent Area Information:
Design Flow (gpd)
/I A Design Soil Application Rate(gpdsf) --al Area Required (sf) Dispersal Area Pronosed System Elevation
o d, C Dig _ ~/X0 befog C
VI. Tank Info Capacity in Total # of anufacturer o4- 'J LJ, I
Gallons Gallons Units a c $ E
New Tanks Existing Tanks O / y c r2
/FGA f a U v y v a C7 a
Septic or Holding Tank
Dosing Chamber V
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number
/emu a /tom- ZZS'y'/o /S 2
Plumber's Address (Street, City, State, Zip Code
VIII. Count /De artment Use Only
Approved ❑ isapprove Permit Fee Date Issued Issuing nt Signature
❑ (::wner Given Reason fo eaial
$ '775.0° 1)14 /3
IX. Condi~I %lWeasons for Disapproval
1. teptic tank, of Wrtt filter and
dispersal cell,Must all be services I rhak tamed
as per management plan provided by plutr W.
2 AN as4 ack req ~ trn tba
as .,C d& /order.
Attach to complete plans for the system and submit to the County only on paper not less than 8 112 x 11 inches in size
SBD-6398 (R. 02/09) Valid thru 02/11
1
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: ~d /?j, j~~ /'C • ~
Owner's Name: 62 /;j ih / G 7r,
Owner's Address: 82 71 %Yoe 9 Pr! f d~ yl "OF CD-ff4gG 61--m"euen &2a.
Legal Description: .S,0Lr- 4~--c s(~ '~f SCG /6/I S ! 28 f ttl
Township:
County: ST C6~t~C
Subdivision Name: 6-aer
Lot Number: ~d
Parcel ID Number: 1319 noe om
Page 1 Index and title V/
Page 2 Plot Plan
Page 3 S stem Sizing & Cross-Section
Page 4 Filter Specs
Page 5 Maintenance Information
Page 6 Management Plan
Page 7 St. Croix nce Form
Page 8 Warranty Deed ✓
Page 9 CSM or Plat L,--'
AW-hments: Soil Test & House Plans
Designer/Plumber: ' Q Q W/P j~4^ License Number: A~0 -22 ~~D
Date: Phone Number T1$-2- 24,x0
Signature
Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01/01).
Page 1
Ban lYh~ K I v2 '
-of 1o P
13cnc1 rnti~ 2__ 1Q3_' '1 !<p of 5vcvt5vl~k-
1110
' ` 533 'Au+-jw, n ze, Trar
/ I ac~y~ D Te06
4-0'
/ 9~L ; G COI `o ~•9cFf'~ ~f~ G'dU~ r
i
y~ \
S \
ry lb'j
\4o \
A a N
S,cr L ~,t111' \
. Poi l ~GY11 ~ \
Aliv
14~
EZflow 1203H - GEO
ESTABLISH NATIVE BACKFILL
6
VEGETATIVE COVER " MIN. COVER
s
OR PER CODE
1
11,
FILTER FABRIC
~1 4" PERFORATED
: 1 PIPE
12" EZflow -t~
BUNDLE (TYP.) T36" MIN.
RENCH
WIDTH
NOTE:
PRODUCT CONFIGURATION AND INSTALLATION Et
DEPTH MUST COMPLY WITH APPLICABLE
REGULATORY REQUIREMENTS. a/ t, +N ri LTR TOR
INFILTRATOR SYSTEMS INC.
4 Business Park Rd. Old Saybrook CT 06475
(600) 221-4436
EZflow 1203H - GEO
Dm-by. EMB Dale: 08/0712013
Scale: Hmro scut Checked by. DFH Sheet 1 of 1
Leaching Chamber Specifications
Manufacturer And Model
EISA Rating 5d sq ft per chamber Sail Application Rate gpd/sq ft
gpd Design Flow Soil Application Rate + 50 EISA = 20 Chambers
2 rows of chambers each.
Page of
\
WW WW 311A 95_b9-9Z2-009 OIOZ 'Nv 03SIA38 cj
:8nOd-1SOd '31V0 otob k8vnNvr 31Vo 09149 NA >1 08 N3aIVw Ot AMH Sn 9LL£M lb~(1NdW OLLd3S z
X321 13131M W o
=21nOd-38d ,0-,t=,4 t 31VOS 3WS A8 NMVMa 313111a~ 21YV-09zkcnM N V__ \
J
? ~ Z
w w O
D m H
a o z
U
a: z Q
J
LLI Or Z j~ W Z N° a U-) rA m W DC
LY U
U W O J J F- O Z J O
Z Q o O m o qk< Z z a it a w °w m a
o
z x cli Q ° > M m
W O OQ <-Q J OM N > rO p m v~C> 0
Q
i m z> z I- a.
Q acp mcwilWw O Z O \ zv~i
U M N
0 0 d a f0 ~~pp Q Q Q ow 0D J F- O (n Z Y n o Q cx.
U-N\~*in m~ mW(n dV W +lJ Q- O Q Q
LO C14 UJ \wN NNNa WWJWCO WQU Z~ oa Wx cn 0z Y2
N W ~..IA. w> N F- xU > O\ O~
c- n N l~i CD?!~ O N Z Fn
cn OZ~ U Y -J in a WU pW to
ly }}~WW.Ot_ I- oaw Oow Q Q R< W x mF o O
J Z7~>ZUO~OOO 0UN Oy~ Q ~ o fn~0 Zla XX wU
°aooawZOwoQ~Ca9 Q~3O U OOU a Z~ Z
z om N~
m~~Mfl ZOQ Z Y
z
o z z ° v
J
a
w
i
Q
N
Q w
U w
,6£
d 0O Z
W
m
w
'r
I W
1\ ce
x w $Vo N
° ,9F do i
Lr a U
~J' m
V)
o Q > "9£ Q
V) CL
W~
a
I x
V) w
ce
O
SV0 j, F
`r x9 r~ 04 do w
I o
0
W
a ~
W N
J Q
Z_ LL
O
Z
(117321 2
.,ti8 $V JZ9 w
a
V)
Y
Z
Q
H
Inc. INSTALLATION INSTRUCTIONS
`y
n:,cvatio+!sinYrecar,,Jrrnagt„~.` Zabef' a
k PL-525/PL-625 FILTER
~ Was!cwa?r ProEr;Cs A tNvision of . oyia k~c.
PL-525/PL-625 FEATURES & BENEFITS
Features & Benefits:
s Rated for 10,000 GPD
• PL-525 = 525 Linear Feet of 1/18" Filtration
PL-625 = 625 Linear Feet of 1/32" Filtration
PL-525 PL 625 • Accepts 4" and 6" SCHD. 40 pipe
The PL-525/625 Effluent Filter should operate efficiently " Built in Gas Deflector
for several years under normal conditions before .Automatic Shut-Off Ball when Filter is Removed
requiring cleaning. It is recommended that the filter be
cleaned every time the tank is pumped or at least every *Alarm Accessibility
three years. If the installed filter contains an optional
alarm,. the owner will be notified by an alarm when the .Accepts PVC Extension Handle
filter needs servicing. Servicing should be done by a
certified septic tank pumper or installer.
RECOMMENDED PRODUCTS
li Polytok PVC Filter
Extension Handle
J
MCA
ill, 6
Risers & Riser Covers Extend & Lok- Riser Safety Screens Filter Alarm Panel and
Polytok risers bring your Polylok Extend & LokTm Polylok safety screens SmartFilterTM Control
septic tank cover to grade. is a simple, easy to use prevent tragic accidents Switch
This allows locating and solution that can extend: from happening by children Polylok fitter alarm panels
servicing your filter easier the inlet or outlet pipe and and pets falling into open and switchs provid a visual
and time saving by elimi- make filter and/or baffle septic tank entrances. and audible notification of
nating digging to find' tank installation a snap. impending. filter and tank
entrance. Fits 3" and 4" pipe. servicing.
For a full list of Polylok products please visit our web site at: www.polylok.com
LU
Y LU
U a
w~ =Qw FLU
o W C) U)3;:v ~v 22
N~ WU mZ0 ~O iG fii O~
2 (n J 2 f
Q Q ~ Q O
U) o U) Z = Z Z
Q a 0 a p Q o
H U O ~a ~n
O Q
U NO U
O
cli
r CO U M OMO
M C 7
C J
O U M U M U
CO N M
00 CD LO c e. C7 06CO
N u ~ ~
N U
ul~l O r-: u
r (O
N
O U
U.,
r ~
~ O
N
U)
F-
0-CD
Q
U 0
U)
W Q U
U) X Zto
co w =
U) L N o
LU F-
w U Of LU U
= U O J
U <LL
J O 0 W
m Z W
~ U
a
o >
ca N = LO N 0a
a LU Ln
U.J C,4
U
® ,iQ H J Z a
Z F- o J o o= p E-L
LU U- Cf) 0- U)
Q > 2 LO m
Www C?04
0Q0
tau LC)Z~ZWQ
NHWU) _JM
Ln of H o
JQQO::) Lo
d~~_0Cfl
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of y
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner
ya!2ZZ -7.1 'e- i
7o--,'.r G~ Septic Tank Capacity ~b gal 13 NA
Permit # Septic Tank Manufacturer
Wi~4SGl" ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer RI ❑ NA
Number of Bedrooms y ❑ NA Effluent Filter Model 1 ❑ NA
Number of Public Facility Units it NA Pump Tank Capacity a~ jleL,NA
Estimated flow (average) cS8 al/day Pump Tank Manufacturer kNA
Design flow (peak), (Estimated x 1.5) gal/day Pump Manufacturer
Soil Application Rate L al/da /fts Pump Model ANA
Standard Influent/Effluent Quality Monthly average` Pretreatment Unit GV NA
Fats, Oil & Grease (FOG) 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (BOD6) 5220 mg/L ❑ NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg/L ❑ Disinfection ❑ Other:
Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA
Biochemical Oxygen Demand (BOD6) 530 mg/L 14 In-Ground (gravity) ❑ In-Ground (pressurized)
Total Suspended Solids (TSS) 530 mg/L ❑ NA ❑ At-Grade ❑ Mound
Fecal Coliform (geometric mean) 5104 cfu/100ml ❑ Drip-Line ❑ Other:
Maximum Effluent Particle Size Ya in dia. ❑ NA Other: ❑ NA
Other: Other:
❑ NA ❑ 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: ❑ month s) I& ear(s) (Maximum 3 years) 13 NA
3
Pump out contents of tank(s) When combined sludge and scum equals one-third (Y,) of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: ❑ month(s) $year(s) (Maximum 3 years) ❑ NA
Clean effluent filter At least once every: A ` ❑ month(s) ❑ NA
~ year(s) ~
Inspect pump, pump controls & alarm At least once eve 13 month(s)
ry' ❑ year(s) ANA
Flush laterals and pressure test At least once every: ❑ month(s) 04NA
❑ 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 (Y) or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 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 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service ever(i.
GMW (4/01)
Page _ of
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.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement aria is available a holding tank
may be installed as a last resort to replace the failed POWTS.
❑ 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
POWTS INSTALLER POWTS MAINTAINER
Name C4%,? Ass, G X411 Name C0.0"7
Phone Phone 71S- 2ye_ `ems
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name s' 7~i • Name 64, C('o x- Co u,..
Phone 7~.1 7 Z Phone 7/5 37& ' 4 217')
This document was drafted in compliance with chapter Comm 83.22(2)(b)0)(d)&(f) and 83.5411), (2) & (3), Wisconsin Administrative Code.
ST. CROIX COUNTY
SEPTIC TANS. MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
ClwnerlBtlyer ~ t 1 t W o t t- l t_ ~.a.k-4
Mailing Address t ` r _x x ! ~ , ~ .
Pmperty Address ,.t l,..i t..# c t .
Verification required from Planning & Zoning Department for new construction.)
City/State C~> t Parcel Identification Number 0 " t-t> t t0 -0 -0
LEGAL, DESCRIP7'l'O
4
Property Location, i!q rla , Sec, , T " N R. W, Town of {
Subdivision Lot #
Cerfifted Survey Map Volume, Page #
Warranty Deed # Volume , Page #
Spec house yes no Lot limes identifmble yes : no
SYS'T'EM MAINTENANCE AND QWNEIt CEItT]<k'ICATIUN
Improper use and maintenance of your septic system could result in its prettmture failure to handle wsstes. Proper
maintenance consists of pumpirag out the septic tank every three yams or sooner, ifneeded, by a licensed pumper. Wbat you put in€o
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 §Cormn, 83,52(1) and in C-bapter 12 - St. Croix County Sanitary Ordinance.
?'Lie property owner agrees to submit to St. Croix County Ptaruting_& Zoning Department a certification fom sizued by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (l) the on-site
wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is
] Cann 113 full of sludge.
I/we, the undersigned have react the above requirements and awe to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Nature Resources, State of Wisconsin.
Certification stating that your 'septic system bas been maintaitaed roust be completed and returned to the St. Croix County Planning &
Zonj ag iDepartinent witbin 30 days of the three year expiration date.
Uwe certify that all statements on this fo re true to the best of my/our knowledge. l;wve amlare the owner(s) of the
property described above, by virtue afa warranty ed recorded in Registcr of Deeds Office.
Nun erofbedrooms
SIGNATURE OF APPLICANT(S) DATE
***Any infornuttion that is misrepresented may result in the sanitauy permk being revoked by the Planning & Zoning Deparitnent;
Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified s zvey map if
reference is made in the warranty deed.
(REV. 08105)
I
it flliil{{11{liiil{Ifl{I{li { li{
8 1 2 2 3 5
State Bar of Wisconsin Fora) 1-2003 7x,:4098316
WARRANTY DEED 971227
BETH PABST
0ocament Number Document N`'mc REGISI E.t2 O DEEDS
ST, CROIX CO,, WI
THIS 1)EEI), made between G & L, [.,and Development, Inc., a Wisconsin 01/11/2013 12:13 PM
EXEMPT#: NA
corporation FtEC FEE: 30.00
("Grantor," whether one or more), TRANS FEE: 283.10
and Dominic K. Orella and -Trish C, Orella
PAGES: 1
T ("Grantee," whether one or more).
Grantor, for a valuable consideration, conveys to Grantee the following described real according Area
estate, together with the rents, profits, fixtures and other appurtenant interests, in
St. Croix County, State of Wisconsin ("Property") (if more sp ce is Name and Return Address
needed, please attach addendum):
I~SA'ritte Services, 1.1-C
Lot 8, Cedar Woods, St. Croix County, Wisconsin. s6a5 Manorial Avenue
Stilttvtder. MN 55082
Pile No 120139
040-1316-08-000
Parcel Identification Number (PIN)
This j1C''t 1. homestead Property.
(is) (is slot)
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except:
This property is subject to Covenants and Homeowners Association By-Laws.
Dated r] F
G & L Land Development, Inc.
-.(sr-.A1.)
(SEAL)
Glen M. Wiese, President
(SEALr~_•
* * Lola M. Wiese, Secretary
AUTIIEN-TICAT'ION AC'KNOWLE DGMI.NT
Signature(s)
STATE: OF Ss(1'~zL.
authenticated oil
COUNTY
Personally came before me on ,
TITLE: Ml-MBI'-P STATE BAR OF WISCONSIN the above-named Glen M. Wiese as President and Lola
M Wiese as Secretary of G & L Land Development, Inc.
(If not'
authorised by Wis. 5tat. § 706.06) to me known to be the person(s) who executed the foregoing
instrument and acl:nowl ge the same.
Gam` ELIZAStTH G, VANEYLL
THIS INSTRUMENT DRAFTED BY: f ~-nomrgrabttcyatmnesare
Mr Commhsbn t~pires Sag. 31, 2017
Baiers C. I leeren, FSA Title Services LLC Nattily public, , ate.a innesota
5645 Memorial Avenue, Stillwater, MN 55082 My Commission (is permanent) (expires: )
ttii8natures ntsty hr authenticated nr arknneledged, Both are not necessary.)
\O•I'F: TIIIS IS A STANDARD FOR►1. ANN' iNIODIFICATIONS TO TIIIS F0ItN7 S1101tI.1) 13E{ CLEAR N ID1:\TEFI1{D.
WARR:1NTl' DEED s? 2003 STA'tP, BAR OF WISCONSIN FOICNI \0. 1-2003
• 'I )pc name below signatures.
oocN Bl94s3
COUNTY PLAT OF CEDAR WOODS
il(lplilFAi- Ci 7wE satl[xrEYT t/4 AAO VaJ1f Of 1110 S,ynimi(SJ v. OR T!E (a w V~ SKw•
SOUtMASi Vt. M SE(2%IM S T0vr511/ kt po.M pAN.E tt SIEST, U9 EANS Ik iMC ~ I~'(I- 3,~,m
aut Lyp ~S710 I k x man V. of IM NO*T +(V Vx, AWPAAJ M 1T4 p0 JM4csr 11. Of ,NS .woe ax N ! L9 3 P-r pv+
y VF 0l UCT"%. 10"dw "W ntloe E.4 Vk%T.
is Au; TWA OF otm cowtt~(ww
N6941'10:'E 1321.12
OUTLOT i
Xt~46 a7a.ma zc i ftt"fTa e~;txaL u.8osa3` g g/® tiQ e
TIM Deep J t n s% .
g'IS/ ~9.
wog: awpt ts.w:Nt o .t«m.nur waw,.n 5..28°
~ ~ ,tan,,,otK nwcw aawl... ~
tv.~G..<'.WpNfMe.i 1...e Kp u'11. vJ peYU'bt„, !Lm
LOT 11
5'20^19 : § 1t L,xe: 1O ! (
LOT 9
L LOT 12
v v 1 .S' L- 1l :.z . > 1
uAI-Pta"'a PC \ I T f ) f ! p'
w..,. lute ~ .,,ps,s ,fs,,4 ~s, i 1 I"'•°.,.lr~~ ~i ~ j
LOT 13
Ka tmx>w.r.z: KC P
- +trof0.T .ne[ova.i+Nq..¢ . 1 \ ~ Sp., ti ~ 1.yp +rsw !
w:uw, w wn ~
a-
•vrxmcia 3 fi! L07 7 Z s.a. bT ..v
°y $1 aaws (LOT 14 ('1
C 11 von ~ }'>ti I9.D60 M.
y t
s `n r J r- OUTLOr t ! t,i «Y«
b.w
LOT B iw .aw \ ? I s I L07 15 14
sp, t a:a »z y yr, 1 a.u~.
LOT 5 ( LOT t,...n, r- K Y nap's c
>a,as! .r. 1 r.•sls :r. LOT 2 1 t
...r..... i° +'+z tp sn ~x3r~ a.~ F~+•. tlrnr_4c~lilis, k
x> . 1 8 i 4
V x LOT I I t
t ~ ate. ~/r'~,', l 1 ~ saaro2',rr see
rye rer AneA r,.e1E ~,r~ .e ~ ,k .r,' ~ 1 I t , ~ 1 a 20' a~
{161 L9 /LOT 17
0..25' T.P .567 ep..6e> ! Swa H6 Conir
7177,
1w S- 04"
a
N 2M.1Cdf1,'.
F 6r twn M 1..E u
- :Jr . . n 6w w. M _ iId_ 3P~558 `1 ° d EPA \ !
~ ~ J 'tew
OUTLOT 2
SCALE, r . iwo, 14
L¢t-s
EOEAT#k(SICHTiH CUi2VE ➢A7A va_TngsSV ,
SECTION 51,8, TZO*. P19W xv x " - -
' _ m3/ _ vY x> pGP Np
sw Vi LEGEND
SECTS SE VC ,N.,r,- ax ,«,rt.r. w6.w~ w,xr~. -0~f,...rn..wrC lea wi«N ,•,a. /i
SEC i.S _ J63 mt l11vN ff.,
J- r p•
W x., - ._aa r, a',.. w...ywy- d.
nr _ u) rA✓ ifnex rut
mw 114 E!E 114 F:,Yi•• ur rw wirR w~n✓t _.»rr'ai •..-Sal llati+q
w r i
SECC S SECTS er r,,,,r rr wx ur' sw srnrrr~ mvr«w 1>».ret _ a~rua oWr
_ .r...Y• wti .w..G
c w wr..• n✓ w.r
'w .....r ..w .r ...M .,.,~-..T S_HEEF 10 I
N
~ F
scs~ ~
~ f
~v W ~t v erl2~
sl'l'E PEA- Q '
IL
Wisconsin Department of Commerce SOIL EVALUATION REPORT page 1 of 3
Division of Safety and Buildings
in accordance with Comm j"VEV County ST. CROIX
Attach completes r n ss than 8 1/2 x 11 inches in size. Plan must
include, but not erti d horizontal reference point ( di ~~gg Parcel I.D. 040 - 1316 - 08 - 000
percent slope, r di rons, north arrow, and location andnn~ road.
Please print all information. ST CROIX Rev' ed b Dat
Personal information you provide may be used for secondary purposes (Privacy Law; C".044 (4COUNTY U J 'J
Property Owner Property Location
DOMINIC K. & TRISH C. ORELLA Govt. of SE 1/4 SW 1/4 S 5 T 28 N R 19 EE((or)❑W
Property Owner's Mailing Address # Block # Subd. Name or CSM#
533 Autumn Blaze Trail 8 Cedar Woods
City State Zip Code Phone Number [:]jlage ■ Town Nearest Road
Hudson, WI 54016 ( ) Autumn Blaze Trail
Q New Construction User Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
Replacement rl Public or commercial - Describe:
Parent material sandy Flood Plain elevation if applicable },lA ft.
General comments Conventional In-ground trenches -0.6 loading rate
and recommendations:
Boring # ❑ Boring
a Pit Ground surface elev. 101.18 ft. Depth to limiting factor 100 in.
Sal lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2
1 0-28 7.5YR2.5/1 sl 2fgr dl as 3vf-co 0.6 1.0
2 28-36 7.5YR3/2 - sil 2fabk mfr cs 2vf-co 0.6 0.8
3 36-49 10YR4/4 sil 2fabk mfr cs lvf-m 0.6 0.8
4 49-100 7.5YR3/4 s Os ml 0.7 1.6
few cobs; some gr.
i
2
F Boring # Boring 87
Q pit Ground surface elev. Inc. (0,q ft. Depth to limiting factor in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Eff#2
1 0-30 7.5YR2.5/1 - I 2fabk&g dl cs 3vf-m 0.6 0.8
2 30-34 7 5YR3/2 - sl 2fsbk&gr dl cs 2vf-m 0.6 1.0
3 34-87 7.5YR3/4 s Osg dl cs 1 of--m 0.7 1.6
Horizon 3 had broken band of 7.5YR2.5/2 sl.
I T
Effluent #1 = BOD > 30:5 220 mg/L and TSS >30:< 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS 30 mglL
CST Name (Please Print) Sig CST Number
Mary Jo Hu ert ollister's Soil Testing & Design) 224832
Address Date Eval n Conducted Telephone Number
W9875 690th Avenue, River Falls, WI 54022 07 - 30 - 13 (715) 426 - 1775
Property Owner ORELLA, Dominic K.& Trish C. Parcel ID # 040-1316-08-000 page 2 of 3
33 Boring Boring 97.73 65
L~ E] pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-30 7.5YR2.5/1 sl 2fsbk&gr dl cs 3vf-co 0.6 1.0
2 30-42 7 5YR3/2 sl 2f-msbk dl cs 2vf-m 0.6 1.0
E g 3 42-50 7.5YR2.5/2 sl 2fsbk mvfr cs lvf-m 0.6 1.0
4 50-65 7.5YR3/4 s Osg ml cs 0.7 1.6
65-70 10YR4/4 flf 10YR4/6 scl Om mfi 0.0 0.0
❑ Boring # Boring
pit Ground surface elev. ft. Depth to limiting factor in. _61 A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDflft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 *Eff#2
Boring # H Boring
Pit Ground surface elev. ft. Depth to limiting factor in.
Sal Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ffz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = 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-8330Tea (R07/00)
Plot Plan for Site and Soil Evaluation Page 3 of 3
Pjroperty Owner DokINtCK K.4 TASK e--,
OP-S L-A 1"=40ft
Legal Description Lz 5z , aEt>Ap., w Qom, , (except where noted)
V- Y,f o f YNE _S04, s5. Tzg NJ R t4 tz of -rm%f s = BaCkhoe pit
-sr. CRoIX COtAX)TY WLZ>M 5Ir~
North
I
ha
a - -pe O S6u2d84oR StAK
~.lei r i1J 6FZOU~ a 103• NZ
n, ~ p
4?.~3
•e
=70f- £
10D.ao' ,oR g1
Site Location:
Parcel 040-1316-08-000 08/13/2013 08:53 AM
PAGE 1 OF 1
Alt. Parcel M 05.28.19.2064 040 - TOWN OF TROY
Current XX ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units
02/03/2006 00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner
0 - ORELLA, DOMINIC K & TRISH C
DOMINIC K & TRISH C ORELLA
533 AUTUMN BLAZE TRL
HUDSON WI 54016
Districts: SC = School SP = Special Property Address(es): Primary
Type Dist # Description ` 533 AUTUMN BLAZE TRL
SC 2611 SCH DIST OF HUDSON
SP 1700 WITC
Legal Description: Acres: 2.240 Plat: 10-100-CEDAR WOODS 040-06 LOTS 1/17
SEC 5 T28N R19W PT SE SW CEDAR WOODS Block/Condo Bldg: LOT 08
('06) LOT 8 (2.240AC)
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
05-28N-19W SE SW
Notes: Parcel History:
Date Doc # Vol/Page Type
01/11/2013 971227 WD
01/11/2013 971226 TD
02/28/2006 819453 PLAT
02/03/2006 817941 LC
more...
2013 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 08/24/2007
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 2.240 97,500 0 97,500 NO
Totals for 2013:
General Property 2.240 97,500 0 97,500
Woodland 0.000 0 0
Totals for 2012:
General Property 2.240 97,500 0 97,500
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch M
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings In accordance with Comm 85, Wis. Adm. Code
11
Attach complete site plan on paper not less than 8 '/z x 11 inches in si U.9 County St. Croix
Include but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. 04 -
Percent slope, scale or dimensions, north arrow, and BM referenced tefwarrst~ad.
Reviewe y Date
Please print all information
Personal information you provide Wj=jhTdjQLjQondarv oses vary Law, s. 15.04 (1) (m)) Z 5
Property Owner RECEIVED Property Location
G&L Land Development, c. Govt. Lot SE /4 SW % s 5 T 2~ N R 19W E (or) w
Property Owner's Mailing Address p E C 2 7 2O0C Lot # Block # Subd. Name or CSM#
W12491 890th Ave. l• e J 8 Cedar Woods
City State Zip 0SOCROIX C1'6WY ❑ City ❑ Village 0 Town Nearest Road
River Falls WI 1 540')) 7-1 - 8 Troy Coulee Trail / FF
0 New Construction Use: 0 Residential / Number of Bedrooms Code derived design flow rate GPD
❑ Replacement ❑ Public or Commercial - Describe:
Parent Material Flood Plain elevation if applicable ft.
General comments and recommendations: B-1 was completed during the preliminary soil assessment on July 22, 2005.
CS 1 o v. 711 h aLv off- VFS 1 Q i! J 38. D . .X►re5~
f 0~70^-'K V, ca
a Boring # ❑Boring /
0 Pit Ground Surface Elevation 99.8 ft. Depth to Limiting factor >110 ✓ it,.
Soil AoDlication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell u. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
'1 0-10 10YR3/2 None SIL 2-f-gr dsh as 2f 0.6 0.8
2 10-17 10YR4/4 None SIL 2-of/m-sbk dsh gw 2f 0.6 0.8
3 17-26 10YR4/4 None L 1-co-sbk dh aw 2f 0.4 0.6
4 26-56 10YR4/4 None GRS 0-sg Ml aw If 0.7 1.6
5 56-110+ 10YR5/3 None VFS 0-sg ml - None 0.7 1.6
❑
Boring # ❑ Boring
.
2 OPit Ground Surface Elevation 92.5 ft. Depth to Limiting factor >120
Soil A lication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDe
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *E02
1 0-17 10YR2/2 None SL 1-m-sbk mvfr CS 2f 0.4 0.7
2 17-27 10YR3/2 None LS 0-sg Ml cw 2f 0.7 1.6
3 27-37 7.5YR4/4 None S 0-sg ml gw 2f 0.7 1.6
4 37-120+ 10YR5/4 None S 0-sg ml - None 0.7 1.6
* Effluent # 1 = BODs> 30:s,
0 5 220 mg/L and TSS > 30:s 150 to /E * Effluent #2 = BOD, 30 mg/L and TSS 30 mg/L
CST Name (Please Print) Signature CST Number
Mark Iverson 46672
Address Date Evaluation Conducted Telephone Number
P.O. Box 155 Hammond, WI 54015 December 20, 2005 715-796-5664
Property Owner G&L Land Development, Inc. Parcel ID# 040-1022-70-000 Page -!--of 3
Boring
Boring # >120 in.
C~1Pit Ground Surface Elevation 97.0 ft. Depth to Limiting factor
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-15 10YR2/2 None SL 1-f-gr mfr gw 3f 0.4 0.7
2 15-27 10YR2/2 None SL 1-f-sbk mfr gw 2f 0.4 0.7
3 27-39 10YR3/2 None S 0-sg ml cw 2f 0.7 1.6
4 39-120+ 10YR4/4 None S 0-sg ml - None 0.7 1.6
Boring
Boring #
E1Pit Ground Surface Elevation ft. Depth to Limiting factor in.
Soil ADDlication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
Boring # Boring
❑
a
EdPit Ground Surface Elevation ft. Depth to Limiting factor in.
Soil AgWication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent # 1 = BOD5 > 30!5 220 mg/L and TSS > 30:5 150 mg/L * Effluent #2 = BOD5 30 mg/L and TSS 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
Need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264.8777.
Site- piagram
0 ft. 24 ft. 40 ft, 80 ft.
Page 3 of 3
INN
N
V _r t -•.1 LJ k4
I .l I k7r ti
LOT 9
r
F 90,,
t- Y
t. - ~1 y
l~
LOT 8 9392'
94' li
5' -
95'
t
t, e 97 y, ~tiL
To 98' r
k r.
t- pops 99,
_ 7p ~2 B-1
0
,0 190, 8,
1
Z `
1
i r
Hof 1/2" Gpi
102.0
~BM#2 - p of 1/2"PVC Pipe
-X01.3'
r•. f
=Lot Lines
BM# & Description Bench Mark B 1 - Boring Location & Elevation House and well location to be determined
Elevation - 100' Owner: G & L Land Development Inc. Site Information: Completed By: Mark Iverson, PSS #197
W12491 890th Street SE1/4, SWIM, S5, T28N, R19W 680 Larcom Street
River Falls, W154022 Town of Troy Hammond, WI 54015
St. Croix County 715-796-5664
Phone: 715-386-2928 CST# 46672