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HomeMy WebLinkAbout040-1318-00-052 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 563898 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: Creative Homes Construction, LLC Troy, Town of 040-1318-00-052 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: G 11.28.19.2127 I 6M TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Z., Benchmark /oats Y. 6 5 Dosing Alt. B L1, 7 Aefa4ien Bldg. Sewer 3, (V'5 rI Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. ent t Air Intake ROAD Dt Inlet W e,54-- ~ 7 MA- ?3 Dt Bottom 1 V J 3. 3 70.7 Dosing ,1J z f /0~ ,53 ~ i Header/Man. Aeration 7~ Dist. Pipe U b /GAD . ~ Holding Bot. System f / 7, 3 / PUMP/SIPHON INFORMATION ' JZD Lod- 6"1 Final Grade 3 /6/• t~ Manufacturer 2U-e l GPM Demand St Cover 7 [ '4.-7 99. 3 Model Number 13 t / Z' ~lJ / it ~ .35 7. a ,n o TDH L' Friction Loss System Head TDH 4 /3.3 a- 3. 3 S lForcernim Lenc th / Dia / Dist. to Well N~ SOIL ABSORPTION YSTEM BED/TRENCH Width Length No. Oench PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION I J, CHAMBER OR Type Of System: A Ij~ UNIT C/U`~ Model Number: DISTRIBUTION SYSTEM Header/Manifo!911 x Hole Size x Hole Spacing Vent Air Intake Pe(s) ~i L/ Length Dia z 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 Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yss No Yes No T, A COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 16 /_3 Inspection #2: ck.- 16-9 Location: 721 Crest Curve Hudson, WI 54016 (NW 1/4 NW 1/4 11 T28N R1 9W) Hills of Troy Lot 52 Parcel No: 11.28.19.2127 v 1.) Alt Description = I / L' C 6 it,,- 2.) Bldg g sewer length = 3 ~ ~ ti J - amount of cover = Plan revision Required? Yes No~ Use other side for additional inform ati 6 SBD-6710 (R.3/97) Date InsepctAignatur Cert. No. 1 CiPE.Sr ~u~cJE Q0. L6r S1 Lo r S.Z L6r S3 ~u,~DE tlELa/E~) L/ZFi~T"/uE /~,YE ~a•lSt~•sc t/a.J 7a1 I I Lsr vr,7 /VrLLS of / /t61~ rV / ~8N /9LJ /VA/ DAI ~6~ of ~o~ Sr: L~/x Lo. ® 33Ls 6 A~t,OcE D a~oSE/.""I/~ / = yG , ~ D = f~rSr /3.7 x3,~a Las' I I -SOS 383 y3 .SFrao~.rs r~Er I I 103.7 ~ /dc soi Y, I/P£ /ESE~2 /Opp/~60 I GOM'Q° f,O.JK I / MSC • C o B ~ /OL5.0' C/oy8.3 a,C /yy /ate DBE _ a Air Sa,v. yo Lor s~' ~ I s9 I a I ~ X 7S moo' D/s 3'a/,gu rrowJ LEZ L B a7 8 x 99' o r.~o 00wr5 9>.~ ~',st 9 97.7 G~ rau.L D/~E /.✓vE~i E~E~ = 99.9 ~ . r t I O r1 ~G GS j'aP lYS L / If (14 7Y. ?S s-T ~ia~y J - Ga rfie►a.J .ddEi4 County Industry Services Division .j f ilaiX 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.) P P.O. Box 7162 r~ Madison, WI 53707-7162 Permit Application Slate TransaccttionjNumber In accordance with Wis. Code, submission f his farm to II>~ mmental unit Application forms for state-o ined to Project Address (if different than mailing address) is required prio to ran~rofessional permit. Note: the Departme a eServies. Personal information you pi Jd e ndary u ce ivac Law, s. 15.04(1 m), Slats. .54 •A. 'rfTl' 1. Application -information - Please Print All Information 721 646-sr ei/ no C .40 Property Owner's Name UA&I Ur CO Parcel # ' ~ ~Nry 0Y6 -/3/8-do -6S.Z C/lE r/uE ors6 ~o.JSS7caGT/o~tl Property Owner's Mailing Address Property Location 21 Z-7 d LO E~cG E" /dam S4/rE y/O Govt. Lot City, State y~ Zip Code Phone Number /VA/ y,, -VAI y,, Section W,00 ,daRY / S /a.S" GSA p - 6800 T %,M N, R 1 Ic,res ne II. Type of Buildi g (check all that apply) 7 Lot # 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name O/C Block •7 rocs -0 mar ❑ Public/Commercial - Describe Use ef ❑ State owned -Describe Use CSM Number 8-vi#age of ~ / 0-Town of l2a y ~y -75 0 .-CA I- I Ill. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ICI New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) mit Transfer to New List Previous Permit Number and Date Issued B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber F10121 Before Expiration / Type of POWTS S stem/Com onent/Device: Check all that apply) O r ,,V r IV. ❑ 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) Z V. Dis ersal/Trea nt Area Information: Design Flow (gpd) Design Soil Application R gpdsf) Dispersal Area Require sf) Dispersal Area Pro sed (sI) S anon yso /H85 99.3 97.7ca,►rar~t ,s-p I o 0 ~/SO 117-15 Vl. Tank Info C pacity in Total # of Manufacture Gallons Gallons Units a V 4 H New Tanks Existing Tanks nei5 ~ ~ . U ~n 2 o 2 w C7 a: ~ C i . ' / (r. a cn Septic orWokkiLglank X060 OGO W/ESEAI Ga,JGdETE Dosing Chamber OO . ! 0 V11. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Si ture MP/" Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) G G.?98 Sr, //,y o?S A~Qw Vlil. County /De ar'tment Use Only proved 11 Permit Fee Date t sued Issuing nt Signature ❑ O en Reason for enial ~ IX. ConditWV Reasons for Disapproval 3 Lo t j T°or.~ ~6 r0 `f"x' 4 1. Septic tank, effluent filter and dispersal cell must all be services / maintained e - 'ec~ as per management plan provided by plumber. quirw m ntafnt$d At tli~ Attach to complete plans for the system and submit to the County only on paper not less than 8 to x I I inches in size SBD-6398 (R0313) o axlttF~, DIVISION OF INDUSTRY SERVICES 10541N RANCH ROAD ' 9~ HAYWARD WI 54843 Contact Through Relay s P www.dsps.wi.gov/sb/ 9 1 S? www.wisconsin.9ov °s aLS sroN Scott Walker, Governor Dave Ross, Secretary August 27, 2013 CUST ID No. 231346 ATTN. POWTS Inspector JOHN HERBERT PELKE ZONING OFFICE PELKE PLUMBING ST CROIX COUNTY SPIA N 6298 ST HWY 25 1101 CARMICHAEL RD DURAND WI 54736 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 08/27/2015 Identification Numbers Transaction ID No. 2290301 SITE: Site ID No. 793722 Creative Home Construction Lot 52 Please refer to both identification numbers, 721 Crest Curve Rd above, in all correspondence with the agency. coNo Town of Troy St Croix County AP NWl/4, NWl/4, S11, T28N, R19W DEPT OF Lot: 52, Subdivision: Hills of Troy PaOFESSI FOR: i Description: Mound, 3 bedroom residence +p~ViSION OF Object Type: POWTS Component Manual Regulated Object ID No.: 1441445 Maintenance required; 450 GPD Flow rate; 17 in Soil minimum depth to limiting factor from original grade; System(s)-..: Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01101, R. 10/12), Pressure Distribution Component Manual= Ver. 2.0, SBD-10706-P (N.01101, R. 10/12); Effluent Filter SEE CID, The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: Key Item(s) • In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. In addition, the owner must insure that the operation, maintenance and monitoring duties as described in section VIII of the mound component manual are complied with. A copy of this information must be given to the owner upon completion of the project. • This system is not designed for and may not be sited on a concave slope. • The bottom of the distribution cell shall be level per the Mound Component Manual. The "D" dimension shall be a minimum of 19". The maximum finished slope of the mound surface shall not have a slope ratio steeper than 3:1 per the Mound Component Manual Reminder • The orientation of the mound system must be such that the longest dimension is oriented along the surface contour per SPS 383.44(6)(a)2. JOHN HERBERT PELKE Page 2 8/27/2013 • Limit activities in the area 15' beyond the down slope edge of the mound per Mound Component Manual. • Surface water drainage shall be diverted away from the system area per Mound Component Manual. • Materials shall conform to the requirements of SPS 384.10. No fixture, appliance, appurtenance, material, device or product may be sold for use in a plumbing system or may be installed in a plumbing system, unless it is of a type conforming to the standards or specifications of chs. SPS 382 and 383 and this chapter and ch. 145, Stats. • Maintain well and waterline set backs per SPS 383.43(8)(1). Consult the Department of Natural Resources for well setbacks and other regulations and exceptions. • Insulate building sewer per SPS 382.30(11)(c). 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 construction/installation/operation. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. I Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Fee Received $ 250.00 ii6) Fee Required $ 250.00 Balance Due $ 0. 00 _7 _ntegrated Services WiSMART code: 7633 5) 634-5150, M - F 8:00 a.m. - 4:45 p.m. pat.shandorf@wisconsin.gov cc: Pelke Plumbing & Well Drilling Inc Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with "SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to the Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. JOHN HERBERT PELKE Page 2 8/27/2013 • Limit activities in the area 15 beyond the down slope edge of the mound per Mound Component Manual. • Surface water drainage shall be diverted away from the system area per Mound Component Manual. Materials shall conform to the requirements of SPS 384.10. No fixture aPPfiance appurtenance, material, device or product may be sold for use in a plumbing system or may be installed in a plumbing system, unless it is of a type conforming to the standards or specifications of chs. SPS 382 and 383 and this chapter and ch. 145, Stats. • Maintain well and waterline set backs per SPS 383.43(8)(1). Consult the Department of Natural Resources for well setbacks and other regulations and exceptions. • Insulate building sewer per SPS 382.30(11)(c). 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 construction/installation/operation. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Fee Required $ 250.00 ~~6ylFee Received $ 250.00 Balance Due $ 0.00 i 1pra, icia ;LShandorf WTS Plan Revi wer Integrated Services WiSMART code: 7633 (715) 634-7810, ax- 715) 634-5150, M - F 8:00 a.m. - 4:45 p.m. pat.shandorf@wisconsin.gov cc: Pelke Plumbing & Well Drilling Inc Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm Note: Effective January 1, 2012, all codes under the jurisdiction of the Division of Industry Services (formerly Safety & Buildings) will be modified. Code references with prefixes starting with "Comm" have been replaced with "SPS" to recognize the relocation of the Division of Industry Services from the former Department of Commerce to the Department of Safety & Professional Services. Additionally, all IS (formerly S&B) codes have been renumbered and addressed in a "300" series. For future reference, the Wisconsin Commercial Building Code will be addressed by SPS Chapters 360-366. Private 4nsite Wastewater Treatment System hadex and Title Page PsojeCtName: CA"rlae /S~arE ~o.✓J'.~utr/a.J- iYaud,o s°awrs LJWJx.tl. SNaiie: ~/~EA'f/dE /1~`c1.-~E ~nJSJ'~tacr~e.J owncesAddress: 707 ~arr.ME.~u .O.tidE JaLzif y/6 oo.O.B~.cy /liN SS/.~S - G S/ ~ e?89- G86G _ • ...,fit ROVED VICES 7p PV. r '1 11 r *Al S Town, She, ' C#y of o Comdr: Sf l,~o/x ioaName: /b~i~~s f LotNutnber: Sa B1oclcNumribea: D E Parcel. I D_ Numbea: O D - I YAW -00 - o s'iz l_= Page, 2 A1or Z. PW 3 C/Ioss ria.J Ae"I l1i~'t✓ of u.✓O Page 4 6"/PE ~A rE~r.►t 1A1'a~ - p~ ~ .fE.orr~ ~,y.✓.r ~Qur~ ~.~,s~ry.~E~ ~itoss-SEario.~ Peas Pap 6 ~u.•~i° ~E'iLfO act /ir/f0 Pia DotJTS 4/,l~JE~ S ,yA,JuA4 /l.Q ~~t.+yr~/r' ~lA•✓ Page 8 page 9 rE2 1i✓fo .r !-~o.✓ - LiewsoN ber: Name ofDedgwer: o A E-tr~ Date: ~8- ao13 sipatuc S 81-85: Degped to the Following POWT3 ComponetCt Manual and ,05,4 ,J4AL f1E/L s/6a ? D .f~D -/DL 9!-~ 4I1eI oa~B el'o~►Paae~.,.r DI~e! ~f'TAt1//'1EN~'S % ~D/L Et/~AtuA7'/mn1 ~E~~'~ri /6 r Sl g / L'a r s~ L° r ~u~JDE dELa/LD) .~3 L!/lF,~ruE /~HE ~d~sr~Ka trawl 7.7 6, ESr ✓r !l0 I I ,Car S.? ~i~cs of j'rraY ' of ~o~ Sr. Li~a✓X Lo, D,4j 230 D oPoSEO / c ya . 1=7 x3.~a'L4 AL L SOS 383, y3 ..frrd,4 C.S rYET ®L y,OdC 3037 l/P£ G 6 fed ",g CLo'd La/DE) /ESEa /oao/`aa ~ lc~`s,6o rD~~ I / MSG iop r Q r •c G x 75- Pots ,0/s ra 8 ~ /Bu r/or! LEZ L d7;8 x 99 d4 ,4 ~otvrs 9) ~ at, 977 Lcw )a~.G ~O~C J QPE /.ruE~t Etrr 99.9 ~ r ~ r ® Q 9G.Cs j'oo /yaL Al I/ F-- /3.?' ~G s/f,IclD La,",,J 4AJr,4 IN V o` I h I t [-,k 44 ' v 40 W4. o a 10 4 ~t x 1 ~ a o0 (m s It V co m o • M • • • - • - • • • • • n o v ~ a t~ i v~ • ~ L ~ h ~y ~ o o b 3 b c W M r £ II v V x X uj Il P+ L Z o Z \ v j O a I ~ a O 0~ V Lk V% v P4 11 a A p i H azn~c~+ x Page, f Of -SEPTIC TANK PUMP CHAMBER CROSS SECTION'AND SPECIFICATIONS ..t ;tsar. 4" Cl VENT PIPE 12" MIN. ABOVE GRADE WEATHERPROOF .2: /p" FROM DOOR, WINDOW OR WITH CONDUIT MANHOLEDCOVERS FRESH AIR INTAKE W/ PADLOCK E ~®scow WARNING LABEL .y-__.._...4" MIN. 18" [NLET t _ WATER TIGHT SEALS (f Est GAS- 77 TIGHT i ► VAPPROVED or /o A SEAL JOINTS WITH f' PPROVED ic rE.t -.L- ALM APPROVED PIPE i IPE 3' B ON _ 31 ONTO 1170 SOLID f SOLID SOIL OIL' C PUMP OFF ELEV. %?6 FT. OFF ' RISER EXIT D PERMITTED ONLY IF TANK MANUFACTURER HAS APPROVAL 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS ;EPTIC.I DOSE / DANK MANUFACTURER: 1,1Ayr zt Go.J, 4- NUMBER DOSES PER DAY: S__ y. i . DANK SIZES: SEPTIC oao GAL. DOSE VOLUME INCLUDING 813 DOSE Goo GAL.. FLOWBACK: 9_y .GAL. iLARM MANUFACTURER: ~t.T.E: ~~1(o ris CAPACITIES: A = ,e?„ O.S- INCHES = j , GAL. MODEL NUMBER: _ ~K ~r B 2 INCHES = 3 GAL. SWITCH TYPE: 'AMP MANUFACTURER: 0 64te.2 C = INCHES = ,t. y GAL. MODEL NUMBER : S/ SWITCH TYPE: D = goo INCHES = .3y GAL. 'EQUIRED DISCHARGE RATE as°8_ GPM PUMP 9 ALARM WIRING AS PER ILHR 16.23 WAC 'ERTICAL-DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE 7.9 FEET • MINIMUM NETWORK SUPPLY PRESSURE . . .33 FEET • FEET FORCEMAIN`X f~_FT/100 FT. FRICTION FACT' OR .T FEET TATAL.DYNAMIC HEAD = 7._FEET :NTERNAL DIMENSIONS OF PUMP TANK: LENGTH XJ a : WIDTH 7 Al DIAMETER ~ LIQUID DUTH 34 P`. G of g TOTAL DYNAMIC HEAD/FLOW g W PUMP PERFORMANCE CURVE PER MINUTE MODEL 151/1521153 EFFLUENT AND DEWATERING So 14 153 MODEL 151 152 153 12 40 ! Feet Meters Gal. Lters Gal. Liters Gal. Ltter6 ! i o 5 1.5 50 189 69 261 77 291 i 10 152 10 3.0 45 170 61 231 70 265 35- 15 4.6 38 144 53 201 61 231 o e 25 151 20 6.1 29 110 44 767 52 187 'Ilk 1 25 7.6 16 61 34 129 42 q125 6 30 9.1 - - 23 87 33 35 10.7 22 15 40 12.2 - - - - 11 42 4 X ` Shut-oft Head: 301L (9.1m) 38 ft. (11.6m) 44 ft. (13.4m) 10 ti 0145088 2- Model 151 Models 1521153 0-- i s 10 20 30 40 50 60 70 80 90 100 GALLONS 67132 67132 - LCfERS 0 '408D 120 180 200 240 280 320 360 3718 488 y' 3716 4518 FLOW PER MINUTE 014508A Fl 1 1 _ 3718 3718 3 7/8 3718 d'.-`... 'Oil • Timed dosing panels available. - -i - • Electrical alternators, for duplex systems, are available and supplied with an alarm. • Variable level control switches are available for controlling single phase systems. • Double piggyback variable level float switches are available for variable level long and short cycle controls. 1- s I I • Sealed Qwik-Box available for outdoor installations. See 1111116 ~j 1 i 12 t18 FM1420. * i1e T • Over 130°F (54°C) special quotation required. I - 415116 5 t rlnLie -J._ - - - ~ ~ sK2444 SK2064 15111521153 MODELS ! Control Selection Model Volts. Ph Mode , Amps ' simplex Duplex N151 115 1 Non 6.0 1 2 or 3 BN151 115 t Auto 6.0 Included 2or3 E151 230 1 Non 3.2 1 2 or 3 BE151 230 1 Auto 3.2 Included 2 or 3 "Easy assembly" N152 115 1 Non 8.5 1 2 or 3 (pump & discharge pipe BN 552 115 1 Auto 8.5 Induded 2 or 3 not included.) E152 230 1 Non ~4.3 1 2 or3 BE152 230 1 Auto 4.3 Induded 2 or 3 N153 115 1 Non 10.5 1 2 or 3 BN153 115 1 Auto 10.5 Induded 2 or 3 E153 230 1 Non 5.3 1 2 or 3 BE153 230 1 Auto 5.3 Included , 2 or 3 1. Single piggyback variable level float switch or double piggyback variable level V - t float switch. Refer to FM0477. Reduces potential clogging by debris. Replaces rocks or bricks under the pump. 2. See FM0712 for correct model of Electrical Alternator E-Pak Made of durable, noncorrosive ABS. 3. Variable level control switch 10-0743 used as a control activator, specify duplex Raises pump 2" off bottom of basin. (3) or (4) float system. Provides the ability to raise intake by adding sections of 1'/2" or 2" PVC piping. IA cnuTloty Attaches securely to pump. - - - ' Accommodates sump, dewatering and effluent applications. - NOTE: Make sure float is free from obstruction. For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. 0 Copyright 2008 Zoeller Co. All rights reserved. POWTS OWNER'S MANUAL AND MANAGEMENT PLAN ,ILE INFORMATION SYSTEM SPECIFICATIONS owner ~/lEiPti o c S .tuc rim Se tic Tank Ca aci 06p al ❑ NA )ermit # -Septic Tank Manufacturer ❑ NA ASIGN PARAMETERS Effluent Filter Manufacturer ESf ❑ NA lumber of Bedrooms 100 d/bedroom) Effluent Filter Model 47-/o ❑ NA dumber of Commercial Units Pump Tank Capacity Goo al ❑ NA :stimated flow (average) ao gal/day Pump Tank Manufacturer A)147." A ❑ NA >esign flow (DWF), estimated x 1.5 aUda Pump Manufacturer Zo6tc-rt [3 NA pail Application Rate Pump Model ❑ NA Z,6 day ft' Pretreatment Unit ;UNA nfluent/Effluent Quality (NA❑) Monthly Average ❑ Sand/Gravel Filter ❑ Peat Filter Fats. Oil & Grease (FOG) < 30 mg/L ❑ Mechanical Aeration ❑ Wetland Biochemical Oxygen Demand (BODS) 220 mg/L ❑ Disinfection ❑ Other: Total Suspended Solids (TSS) Manufacturer: Model: 5 150 m Soil Absorption Component retreated Effluent Quality ❑ Monthly Average ❑ In-ground Biochemical Oxygen Demand (BODS) < (gravity) ❑ In-ground (pressurized) 30 mg/L ❑ At-grade XMound Total Suspended Solids (TSS) < 30 En Other. Fecal Coliform (geometric mean) mg/L El Drip-line <10 cfu/100m1 ❑ Dispersal Units - Manufacturer laximum Effluent Particle Size 1/8 inch diameter ❑ Aggregate Cell(s) Model .alculations: Soil Dispersal (EISA) or DWF Application rate = Area Required _ (Ag reeate Trench Width) _ # Units or Total Length of Aggregate Trench(s) ESIGN CRITERIA ❑ "Design of Pressure Distribution Networks for Septic Tank-Soil Absorption Systems" Publication 9.6 (SSWMP Manual) ❑ "ICC Flowtech Mound Component Manual" Version 1.2 ❑ "EzFlow Mound Component Manual" Version 8/20/2007 ❑ SBD - 10854-P (8.1/12) "At-Grade Component Manual Using Pressure Distribution" Version 2.0 ❑ SBD - 10705-P (N.01101) "In Ground Soil Absorption Component Manual" Version 2.0 SBD - 10691 P (N.01/01) "Mound Component Manual" Version 2.0 ❑ SBD - 10657-P (R.6/99) "Drip-line Effluent Disposal Component Manual" SBD - 10706-P (N.01/01) "Pressure Distribution Component Manual" Version 2.0 ❑ Other - AINTENANCE MONITORING SCHEDULE - MAINTENANCE AND MANAGEMENT Service Event 13 ^ow r#s Service Frequency Lm /ins ect tank(s), inspect dispersal cells , clean filter At least once eve : 9 13 months at 3 ears ❑ Other - s ect um & um controls, alarm, pretreatment unit At least once eve : ❑ months 0 3 ears ❑ NA ush and pressure test laterals At least once eve : ❑ months ®3 ears ❑ NA 'ART UP AND OPERATION: For new construction, prior to use of the POWTS check treatment tank(s) for the presence of . inting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations detected have the contents of the tank(s) removed by a septage servicing operator prior to use. -stem start up shall not occur when soil conditions are frozen at the infiltrative surface. e property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity J quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation of water-saving pliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water 2eners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface enever possible. Note: this does not include laundry waste, showers, dishwater, etc. is system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetable/fruit -Is and seeds, bones, and food solids such as those produced by a garbage disposal should be minimized. Toilet ti ssue is the only )er that should be discharged into the system. Other non-biodegradable items such as baby wipes, tampons, sanitary napkins idoms, cigarette butts, dental floss, and cotton swabs should not enter the system. Chemicals such as petroleum products, paint, Page 7 of 9 disinfectants, pesticides, antibiotics, solvents, etc., should not be flushed into the system as they can seriously damage your POWTS and contaminate your drinking water supply. Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components. Compaction of snow over the dispersal unit may cause it to freeze up. INSPECTIONS & MAINTENANCE: Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule). Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and check for any backup or ponding of effluent to the ground surface and test all electrical equipment such as pumps and alarms. Any defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with effective locking devices to prevent accidental or unauthorized entry the tanks. When the combination of sludge and scum in any tank exceeds one-third (113) 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 NRI 13, Wisconsin Administrative Code. The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's specifications. Solids washed from the filter shall be retained in the tank. Filter cleaning may be necessary at more frequent intervals than stated in the maintenance schedule to keep the system operating. Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service POWTS, There is normally a I day reserve under regular operating conditions, however water should be conserved until any problems with the system are corrected to prevent back-up of sewage into the dwelling or surfacing. ABANDONMENT: When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure :hat the system is properly and safely abandoned in compliance with Ch. SPS 383.33, 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 other inert solid material. CONTINGENCY PLAN: If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide t 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 render it unusable. Replacement systems must comply with the rules in effect at the time of replacement. rl 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 area 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>> >EPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTIAN LETHAL GASSES AND/OR INSUFFICIENT )XYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. )EATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR MPOSSIBLE. 1DDITIONAL COMMENTS 'OWTS INSTALLER POWTS MAINTAINER dame „7Dy,0 Name O W E EL~6 Lv~,g6~ws 'hone 7/S 6y,? _.57444 Phone / ~7a- S.T EPTAGE SERVICING OPERATOR (Pumper) wj LOCAL REGULATORY AUTHORITY lame [Agency T. Litai o t OFD/G 'hone Phone 7'/S' jW4C - $/d J00 Page $ of 9 d Oaf ~s;< ~ sou s 14. Q ! V fl L6 4L(5 Y A E ~e} W Lt Q 0 4- i Li G C G ~1 ' , fU fl+ Z 0 a c « v I'M- q C y -0 •~~TT~~ ~ ~ G r N g c ~O 13~ °u 3 C O j tv. i O L z w s v E ui d 3 x W s m i+ ■-t~j c o rn•o-ti o o~ 01.5 m 0 T N C ~ acv > //0 u y d ~S[} tg~ ib (L) LU M m 0 9 Vl Ip .•L 1~ cc maj u a t V m d r M _/I i~/7 ~6 G E w0.. i e+ N d v 4F mOLa a) s to $o" E -C 4-0 y~~ C Y. ~ ~ d N ~ ~ Y~ d t' mY o - - v 92 c °r~' a z E ~v U n v v a' d c t p,'a o E g r a a a v 3 : yd C aaa >n 0 z Q ~ T u v"ii ~ c. ~ f't . ` s m Q ~ o F.r'1 12 N O .2 2-c.o ai o ,a a .c . :1 1 3 1~1 ~n N o'O tJ C H g a_ ^ v m o ^ a `o m w ! 3c «.0v -rL 0.1 -9_... = aY'O C C His y^ Q7 i. »'0cEE aZVIca ,Y A $ r, O C m~TOi Vf~e-L E a = a P r y y c "wC: ~m i4i C~ O use E u E y £ } s"n CL -2 c ul c a J i y G ,y0.. N m 2 a v o , i + Vi ~i 41 t Wislept. of Safety and Professional Services SOIL EVALUATION REPORT Division of Safety and Buildings Page _ / of in accordance with SPS 385, Wis. Adm. Code Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Revie by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location G /Cd T JE o~s6f Govt. Lot Al 1 /4 V4)114 S T N R If JL(orvl Property Owner's Mailing Address Lot # Blodc # Subd. Name or ftin_ o Lo itcE ,A/!/d6 ~u/rE /o S•2 111"s aF rlloy City at Zip Code p one Number l @Village ®Town Nearest Road ~/oaDeu~ ,T (LS/ ) a?8 - 800 Ito Z'uno- zm Qo. New Construction Use: Residential / Number of bedrooms Code derived design flow rate 3/1f-40 GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable fl General comments and recommendations. °r~S : ~3o~~~rc s EvA~WgTEp Fem. A0,0/ r/"101- /,"FoAlyWr/o.J to o~ti.~,s ~ Jd/~ ~Esj- aF 9 L-o S" 6r />.oa r 11dtzl-cret. F/_1 Boring # ® Boring Pit- Ground surface elev. 97. 7 ft. Depth to limiting factor ,?O in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ff#1 02 p.0-9 3 ~o :?7 iaY.~ y ~.?d/arc ras s/6 .f / .T7• G SYit c.?a~ e rt S ~ s/L .s ~ Boring # ® Boring it ❑ Pit Ground surface elev. 9,7 ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence oundary Roots GPD/ft 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. _ ff#I ff#2 .1 0- aril 3 / - s,/ /9- f a R orR s.rfs~ S -1/0 * Effluent = AF WL ,B D >13U230 and TSS >30 < 150 mg/L * Effluent #2 = BOO < 30 mg/L and TSS < 30 mg/L CST Name (Please Signature CST Number 1 3 Fairway St. O /Al alli U a , Dat valuation Conducted Telephone Number (H) 715-834-8610 (G) 715-977-4383 SBD-8330 (1111/] 1) • G /1 c~'S l' `i~icvE • 'r+ H ca 7d 7~7 7.? H iri t=1 ttn 94 u r z th ~ H H O ~ z I - o o Op .33o w c~ b ~ilo~°EaTY 97 7 ~u~s foR /08 F f>!°i•> 1 EAST- 6EfanE fog A SLlcyr /T CnAOu,I[cY l'•~..t.Js SearN ~ QEdit.✓ co^JC941-1' SLeP£, /S ~✓EE.p~A, O Go•✓G.f d SLod! I ~°Q• Cs To~° of 97.7 ~ 1 T I /V ,l o .za > ya D ?Z 2 i Lor- S/ L®r S.? a 3Ves f-/d,7 y /itcw Zvi/E 9s) kgLAC/~C l"o~ .0/t>.> F I 1 0 %l, Wisconsin Departmerietijt~~ntroe Lk@I~12EPORT Page 1 of 3 Division of Safety and Buildings in aecordan with Caw a-_ a - omm 85, Wis. Adm. Code t. County ST. CROIX Attach complete site plan on paper not less than 8 1/2 11 inches in size. Plan mwst include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. rP.rr`.Pnt clnrP, snnlP or diimansinns, north arrow, and lootion and distance to nearest roac# 5 Please print all inform tion.' e Date Tt)~ 11~' 1 ( r , Personal information you provide may be used for secondary Caw, s:'P51~(~f (m)).' C ((/y~'~ Q6 Property Owner Property Location LEONARD & MARGARET DELAURIERS Govt. Lot NW 1/4 NW 114 S I1 T 28 N R 19 ©r0 Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 706 Coulee Trail N52 Hills of Troy City State Zip Code Phone Number [-]city [:]Village Town Nearest Road Hudson, WI 54016 ( ) Troy Coulee Trail 0 New Construction UseE] Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD El Replacement 0 Public or commercial - Describe: Parent material loess over till Flood Plain elevation if applicable NA ft. General comments Mound System 1.59 ft. sand fill 0.6 loading rate and recommendations: (If pre-treatment system - 0.59 ft. mound sand 0.8 loading rate) A Boring # El Boring l I I Q Pit Ground surface elev. 1072.90 ft. Depth to limiting factor 17 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 04 10YR3/2 - sil 3fgr mvfr cb 2vf-m 0.6 0.8 2 - 4-12 4 Al sil 2f-ma&sbk mvfr as 2vf-f 0.6 0.8 3 12-17 10YR3/4 - sil 2fabk mfr as 2vf-f 0.6 0.8 4 17-26 10YR3/4 mlf 10YR4/6&1 R6/1 sil If--mabk mfr cs lvf-f 0.4c 0.6 5 26-30 7.5YR4/4 f2f 7.5YR3/4 sl Om dh 0.2 0.6 Horizons 4& 5 have some gr between bound- ary. B Boring # 11 Boring 1074.20 19 0 pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-4 10YR3/2 sil 3fgr mvfr cb 3vf-m 0.6 0.8 2 4-11 10YR3/2 sil 3fa&sbk mfr as 2vf-m 0.6 0.8 3 11-19 10YR3/4 sil 2fabk mfr cW 2vf-m 0.6 0.8 4 19-25 10YR3/4 flf 10YR4/6&10YR6/1 sil 2f-mabk mfr cw lvf-m 0.6 0.8 5 25-30 7.5YR4/4 c2f 7.5YR3/4 A Om mfr 0.2 0.6 Horizons 4 & 5 have some gr between bound- ary. * Effluent #1 = BOD > 30:5 220 mg/L and TSS >30 < 150 mg/L * E ent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature CST Number Ma Jo Hollister 224832 Address WDte Evaluation Conducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 09 - 06 - 05 (715) 426 - 1775 Property Owner DeLauriers (Lot N52) Parcel ID # (Pending) Page 2 of 3 Doring # Boring ,1C ~ 0 pit Ground surface elev. 1078'00 ft. Depth to limiting factor 24 in. Soil Application 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 0-4 10YR3/2 sil 3fgr mvfr cb 3vf-m 0.6 0.8 2 4-10 sil 3f r&abk mvfr as 2vf-m 0.6 0.8 3 10-24 10YR3/4 1 sit 2fabk mfr as 2vf-f 0.6 0.8 4 24-28 10YR3/4 m1f 10YR4/6&10YR6/1 sil 2f-mabk mfr as Ivf--f 0.6 0.8 5 28-33 10YR3/4 m2d 7.5YR4/4 sl Om mfr lvf-f 0.2 0.6 ❑ Boring # F] Boring pit Ground surface elev. ft. Depth to limiting factor in. Soil Application 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 Q Boring F-1 Boring # Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330Test (R.07/00) Plot Plant for Hills of Troy Page 3 of 3 Town of Troy, .Sk Croix County, Wisconsin Lot sz I"=40ft Legal Description A1W /4 OFTttSNW,./,, -See-.11,Tzga} 2 ft; contours R 19 ti., 7 wt4 OF TROY Backkoe pit t i I I t R-"C I I I ~ t I I ~ t L4ARKa I Tap 1 Y4 ` EENVq 1074 z9 I 1 \ R-97C 4 TS I I t o_ r t R-9M j I ®EL 107~?A ~ o t t - /1 I I ' ~p S R-99 T OFM MARK- *NCH 4" ELEV 101 PPE 1074.45 E! ATION ' WIDE SHARED F C ~A i Plot Plan for Mills of Troy Page 3 of 3 Town of Troy, St. Croix County, Wisconsin Lot s4 I" = 40 ft. Legal Description Pj,/LI ar i ~ .€;,wA, see- It 1-170-S-4 2 ft. contours RIgw, 7mut,~ OF -T{Uj = Backhoe pit f I g -R-9 /081. IN, I TOP F 1 Y~ IRON P ELEVATIO ! D7T. Z-9 i / -4- R-97C~L '-52 eL I~'74DD' R-99B a a- i G" ' o -99/10 'OE f o CH MARK: \ BENCH MARK: Ik OF 1 1 /4 ~ g' TOP OF 1 1/4#f ELEV ION = 6ObR,gl q IRON PIPE ELE ATION = 10714 , qSt 66' WIDE SHARED /Rop ECEV1 a 1 72.00 r a ZZI " 00" W o' ST CURVE auk am am 90000' 00" 580.09' f 32v' 32.00' 2 . Or timmm GIPFPP EP IN 49R w fw~ * x11171 m a EEAIIIIIi A Mium i R 4XIS 17F it Imawm ID 69H ncD 54 a 1,031 LO Aft w .4,891 51 plB4 a 1.051 R: 1117EImIK 4Y 6R~EOi111 1i WRIER b ~ 11NIfNIF f 90MG~R T ~7001i11f lk VIiE17019 ~b 132.001 3240 7 9000' 00" 254800 66a ~ WIDE SHARED 90* 00' 00" 272.35' VV 76-00.4 rraTAf DIVISION OF INDUSTRY SERVICES o2y~r 10541 N RANCH ROAD y D ' HAYWARD WI 54843 3 S P Contact Through Relay S' www.dsps.wi.gov/sb/ A~ www.wisconsin.gov ~~SSfONAVS Scott Walker, Governor Dave Ross, Secretary August 08, 2013'Q CUST ID No. 231346 JOHN HERBERT PELKE PELKE PLUMBING N 6298 ST HWY 25 DURAND WI 54736 REQUEST FOR ADDITIONAL INFORMATION SITE: Creative Home Construction Lot 52 721 Crest Curve Rd Town of Troy Identification Numbers St Croix County Transaction ID No. 2290301 NW1/4, NW1/4, S11, T28N, R19W Site ID No. 793722 Lot: 52, Subdivision: Hills of Troy Please refer to both identification numbers, above, FOR: in all correspondence with the agency. Description: Mound, 3 br res Object Type: POWTS Component Manual Regulated Object ID No.: 1441445 Maintenance required; 450 GPD Flow rate; 17 in Soil minimum depth to limiting factor from original grade; System(s): Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01101, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01101, R. 10/12); Effluent Filter The submittal described above has been placed on HOLD and the review and approval is pending subject to receipt of the ADDITIONAL INFORMATION and/or revised plans requested by this letter. Upon receipt of the additional information and/or revised plans, the plans will be reviewed for compliance to applicable Wisconsin Administrative Codes and Wisconsin Statutes. The following must be corrected/revised and accompany the resubmittal: • The mound is partially outside of the tested area. Provide a verification boring on the northwest end of the mound. • Verify the slope in the mound area. It looks like there might be a concave slope in the dispersal cell and basal areas. This mound is not designed for a concave slope. Send your re-submittal into the address listed above, unless otherwise noted, and the department will review the resubmittal within 5 working days of receipt date. Please include a copy of this letter with your resubmittal. Designer shall identify plan revisions by a readily discernible means such as shading, highlighting, hatching or clouding the changed areas prior to plan re-submittal. Failure to do so may delay review. If the above requested information and/or plans are not received within 30 business days of the date of this correspondence, this submittal will be returned denied. No fees will be refunded, and a new fee, application form, JOHN HERBERT PELKE Page 2 8/8/2013 r and submittal of plans/specifications will be required should you desire to continue with this project. The code in ' effect at the time of new submittal.would apply. If you have any questions, after reading the above comments and related code sections cited, please call me at the telephone number below. Sincerely, Fee Received $ 250.00 L WiSMART code: 7633 Patricia L S dorf I POWTS Plan ReviewerUtegrated Services (715) 634-7810, Fax: (715) 634-5150, M - F 8:00 a.m. - 4:45 p.m. pat.shandorf@wisconsin.gov cc: Pelke Plumbing & Well Drilling Inc Edwin A Taylor, Wastewater Specialist, (715) 634-3484, Monday - Friday 8:00 am To 4:30 pm Zoning Office St Croix County Spia I ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer C-rge-4, V e- "m,..eu / Mailing Address CC Property Address 721 C r -e-S+ Cu r ve- (Verification required from Planning & Zoning Department for new construction.) Parcel Identification Number 040- /3 8-oD OS L City/State=4y co ,n . LEGAL DESCRIPTION Property Location ~l V4, A(W 1/ , Sec. T 28 N RjW, Town of 1 roV Subdivision Plat; i f s c 1 (roe/ Lot # Certified Survey Map # Volume (o Page # Warranty Deed # " I O 7i~v (before 2007)Vol une , Page #E Spec house yes 0 no Lot lines identifiable/ yes 0 no ' t SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §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 of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form ar a to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty dee recorded in Register of Deeds Office. Number o rooms u Zi?9 i~ ATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) 8 1 4 7 9 0 4 State Bar of Wisconsin Form 6-2003 Tx: 4120163 SPECIAL WARRANTY DEED 976926 BETH PABST Document Number Document Name REGISTER OF DEEDS ST. CROIX CO., WI THIS DEED, made between BMO Harris Bank National Association, successor by 04/16/2013 11:52 AM Merger with M&I Marshall & Ilsley Bank EXEM PT#: NA ("Grantor," whether one or more), and REC FEE: 30.00 Creative Home Construction Investments, LE,, a Wisconsin limited liability TRANS FEE: 2025.00 company ("Grantee," whether one or more). PAGES: 3 Grantor for a valuable consideration, conveys to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): Recording Area Name and Return Address See attached Exhibit A. o E I e ive o eDnv Cb~stf~ctMn vestments, IaLC~c. I 6 ria gl e Land T Stet . ~tt~ ~tv c a Rd . C, •u LS No to 082I~SCYtlIr~MIJ S~~ 1=t ~ ~~i ~ a~- See Exhibit A Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible, in fee simple and free and clear of encumbrances arising by, through, or under Grantor, except municipal and zoning ordinances and agreements entered under them, recorded easements for the distribution of utility and municipal services, recorded building and use restrictions and covenants, general taxes levied in the year 2013, and Permitted Encumbrances described on the attached Exhibit B. Dated February 28, 2013 BMO H S BANK NATIONAL ASSOCIATION, succes Ilsley Bank (SEAL (SEAL) * * B S. utze , President (SEAL) (SEAL) * *,By: AUTHENTIT ARY p'lllyrlr~ ACKNOWLEDGMENT Signature(s) ) STATE OF WISCONSIN authenticated on ss. MILWAUKEE COUNTY ) * rr,~r ; • r Personally came before me on Agil Al 2013 the above-named Gary S. Kautzer, ice President of BMO ' ' TITLE: MEMBER STATE BARR+ IN Harris Bank National Association (If not, to me known to be the person )who executed the foregoing authorized by Wis. Stat. § 706.06) M d ac wl a the me. THIS INSTRUMENT DRAFTED BY: Marvin C. Bynum 11, Godfrey & Kahn, S.C. * Carol Lee Hopkins Notary Public, State of Wisconsin My Commission (is-peFmaaan (expires: April 6, 2014 ) 9003373 2 (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. SPECIAL WARRANTY DEED ® 2003 STATE BAR OF WISCONSIN FORM NO. 6-2003 * Type name below signatures. i EXHIBIT A Legal Description Lots 2, 11, 13, 14, 15, 16, 17, 19, 24, 25, 26, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 48 52, 3, 54, 55, 56, 57, 58 and 59, Plat of Hills of Troy in the Town of Troy, St. Croix County, Wisconsin. Parcel ID Nos.: 040-1318-00-002 040-1318-00-011 040-1318-00-013 040-1318-00-014 040-1318-00-015 040-1318-00-016 040-1318-00-017 040-1318-00-019 040-1318-00-024 040-1318-00-025 040-1318-00-026 040-1318-00-032 040-1318-00-033 040-1318-00-034 040-1318-00-035 040-1318-00-036 040-1318-00-037 040-1318-00-038 040-1318-00-039 040-1318-00-040 040-1318-00-041 040-1318-00-042 040-1318-00-043 040-1318-00-044 040-1318-00-048 040-1318-00-052 040-1318-00-053 040-1318-00-054 040-1318-00-055 040-1318-00-056 040-1318-00-057 040-1318-00-058 040-1318-00-059 -I- EXHIBIT B PERMITTED ENCUMBRANCES 1. Any encroachment, encumbrance, violation, variation, or adverse circumstance affecting title to the Property that would be disclosed by an accurate and complete land survey of the Property. 2. Easements or claims of easements which are not shown by the public records. 3. Any lease, grant, exception or reservation of minerals or mineral rights appearing in the public records. 4. Subject to the building set back lines, utility easements, drainage easements and wetland areas as reflected on the recorded plat. 5. Subject to the terms and conditions as shown on the recorded plat of Hills of Troy. 6. Restrictive and protective covenants as recorded in Document Number 816569, amended by Document Number 841464. (These restrictions contain no forfeiture provision.) (Omitting any covenants or restrictions, if any, based upon race, color, religion, sex, sexual orientation, familial status, marital status, disability, handicap, national origin, ancestry, or source of income, as set forth in applicable state or federal laws, except to the extent that said covenant or restriction is permitted by applicable law.) 7. Subject to the terms and conditions of the Landscaping Easement in favor of Hills of Troy Homeowners Association, Inc. as shown as Document No. 816571. 8. Subject to the terms and conditions of Conservation Easement recorded on July 1, 2005 in Vol. 2834, pages 155- 173, as Document No. 799119, amended in Vol. 2937, page 68-77, by Document No. 813315. 11 7 LL W Q Z LL J wx J 00 J w co 0 Of) L. w Z w t . 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