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HomeMy WebLinkAbout032-2176-07-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 567207 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: T.I. Magnuson Enterprises, Inc., c/o Tim Man I Somerset, Town of 032-2176-07-000 CST BM Elev: Insp.BM Elev: BM Descri tion: 10,! � �� � �� l�/ /G _ ,O_ 2 Section/Town/Range/Map No: 7 f r Y (�/l� 11.30.19.1492 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic /000 Benchmark 3 3./ 3.q lb'7'L . 2 UC.�.�iJ / -•ZSi� Alt. BM g074 Aeration Bldg.Sewer S Holding S t Inlet 46,1 W--,-a 3 TANK SETBACK INFORMATION t Outlet /02.. 01 TANK TO P A WELL BLDG. V�ent to Air Intake ROAD Dt Inlet �- Septic ' S^\1 � C j � Ain _ Dt Bottom / f Dosing U J Header/MarG I I. /� Aeration Dist. Pipe x y I Ad Cf 7. Holding Bot_Slrstem I I h u'"--S PUMP/SIPHON INFORMATION Final Grade �f�SxS iv% g,. ioS Manufacturer GP and St Cover Model Num 1 , /07.(, TDH Lift Fri n Loss System Head H Ft /-_7 Forcemain Length Dia. ell G i 61 3 SOIL ABSORPTION SYSTEM 07 e_A BEDITRENCH Width / Length / No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS O 9 SETBACK SYSTEM TO I P/L BLDG JWELL LAKE/ST EAM LEACHING Manuf�rjerrer:�t � INFORMATION CHAMBER OR /J 7J Typ f System: -75 p UNIT Model Number: DISTRIBUTION SYSTEM eader anifold j J Distribution x Hole Size x Hole Spacing ent t Air Intake (� / e(s) �.... r--- Length Dia ngt Dia Sp in SOIL COVER r x Pre re Systems O Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center [ Bed/Trench Edges Topsoil 0 N 3 Yes 0 No I g Yes No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: -7 q Inspection#2: Location: 1618 83rd Street New Richmond,WI 54017(SE 1/4 SE 1/4 11 T30N R19W) Lakeside Estates Lot D/� Parcel No: 11.30.19.1,492/� 1 1.)Alt BM Description= `� i°� V� �L" s!�I �'� C.0 4 d W 2.)Bldg sewer length=-'1­ !6 / -amount of cover �5 U Yes wl��o Plan revision Required?Use ❑ e other side for additional information. SBD-6710(R.3/97) Date Insepctor's Signature Cert.No. of ORIGI ,6woeir`. l !w\ Klunnine&,. ���t✓K P r FU'1-t4 13t9 y-oy`, 1 ee- - AJ�� •l`�ho,���.�cSccQ %o O Gc,I"Se��-ic Wtti� S� ©(Y(0 10©.o a �� Tod o j V06 -roe C4 poc py, Z- nS'-JVL� G�tIL✓ri'-- /b I� kQv le-S �Lof ,�v- CIL)_11 Industry Services Division County 7- r? ` Y) 1~ 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.) p} :2 y P.O. Box 7162 5i!o-7Z D :::::::Madison, WI 53707-7162 anitary Permit Application State~ransaction " In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit FA 'ent than mailing address) is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Pr.Q _t Addre er the Department of Safety and Professional Servies. Personal information you provide may be used for secondary CQO purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. I. Application htformation - Please Print All ation . Property Owner's Name Parcel # T W1 /Ma n Lk S v k" TT. 033-)-) /;%.o ?00 Property Owner's Mailing Address ^ /0 A ~ ( ~ Q e 7 Pr Location A /a,;;4 l/-S~fm 1 l~ b Id~t/ c c n1 Govt. Lot City, State Zip Code Phone Number , 5& , /l 1 / 7^ ~ /a, Section gr f am/ o -:7,f / 7 eucle one II. Type of Building (check all that apply) Lot # T N; R E "L'/ .1 2 Family Dwelling -Number of Bedrooms (7~ Subdivision Name Sl~~ ~S l a~Jr 6 a Block # F.0-16 ❑ Public/Commercial - Describe Use ❑ City of ❑ State Owned - Describe Use CSM Number ❑ village of 71 N wl / 7 I )a'`fown of Vh l°/-~$C Ill. Type of Permit: (Check o one box online A. Complete line B if applicable) A. New System El 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 1-' A (k. i- ~ IV. Type of POWTS System/Component/Device: Check all that a 1 q f X 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/Trea ent Area Information: N Design Flow (gpd) Design Soil Application Rate(g f) Dispersal Area Require (sf) Dispersal Area Proposed (s System Elevation 9's-0 7 .9 q..:) 45.0 q~, 9 Q:trt G. I VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units o New Tanks Existing Tanks / v c v a 01 Ad v~ w w Septic or Holding Tank ~t -/Coo (,(,1I S~U• Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation ofthePOWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Number Business Phone Number :5,jEf t ('s ; cr.Ccc~~ MP 4211,,2p ors ~~8~58~ Plumber's Address (Street City, State, Zip Code) IV '705_3 Lovwt Rd. 3 B wr ~ir76 VII Coln epartment Use Only Permit Fee Date ssued ssuing Agent Si na Approved ❑ Disapproved ❑ Owner Given Reason for Denial r' {7 GG~iZ1 IX. Conditions of Approval/Reasons for Disapproval /s `/,Q s Q}t SYSTEM_OWUE~K: / 1. Septic tank, effluent filter and G'Sj ~0 - , S< QQQiy-1 lnt_4- dispersal cell must be_serviced I maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable er l rr<e ans for the system and submit to the County T on paper not less thqn 81rz x I in ros i iae SBD-6398 (R0313) b-" a v G Ulf 3 .G_7 k~ S~P~ ~sf~,~s dow c.L)U) e (r Ti VY\ M into vQLkS 0 V. ORl { ~~~_f Ir I~ V ~l i 9 d~ O u. c I I Z- 57 a-/PQ/ Jl©L(/U _ ~U Dom' Sl~/~l~lZ-sue / tiE:6 ofsf _S-c- /l /3- 60 /I tk) } o v,^ -e- (jt-r,w.~eQ i0.. Ve`+ \ JSIp~' By lD oSe- /000 co", wj~ sas~ Ao(.~ l o k F~ li-<~- - r oV-' /Oy Slo~.~ o 141 O 135- 8A /09. -rot of -Toe o y plc P p ~9o sip Cl \S' l61~ ORIGINAL L(.St 3 - LnpeLTlro+L~ O'~2hirle If i 30„ I i 36 -~'I 3 Bc,,j Nom = yso p b ~Sd 6. A - . 7 1 oa d i of /)e e e~ y Ch~~-,ln-ers (rya ° 1 9. (°~~e~ c hai,►,ber-,.33, ( ot, 3 3y C'ha l ews x ~ ' ~Ph ~ tiaw.10-ems /3Coff' etia h~ s 'ej CCS~ y 1nl I~rcta a uc ck 4 Chavh Wisconsin Depart o er SOIL EVALUATION REPORT Page f of 3 Division of Sal uildi in accordance with Comm 85, Wis. Adm. Code Courtly 7- Attach complete, site plan on paper not less than 81/2 x 11 inches in size.. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and i .3 I I p 7~ a percent slope, scale or dimensions, north arrow, and location and distance to nearest road. , J;/ 10 Please print all information. Revle Date Personal information you provide maybe, used for secondary purposes {Privacy Law, a. 15.04 (1) (m))... 9 1//3 Property Owner Property o n 71 ( I Vl'~ Qt Lk S O to Govt. Lot c~ /4 S T ®N R q E (or W Property Owner's Mailing Ad ss Lot # BI k# b . Mete or CSM# 1,18 gar S f. 7 L u~c 5,de E-540e-5 C' State Zip Code Phone Number 0 City Q Village own Nearest Road ec J Ric Ino GF) ({6/~) 9 -7 y So M et- r ct- S~ - New Construction Use: <Residential /Number of bedrooms 3 Code derived design flow rate SV GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material Flood Plain elevation if applicable ft. General comments 7., all C'GI~M ~r~s ,3t~" Liep 0,1 Co nfo c(r- .14 3 `'All, < and recommendations: G7n (x n T/D/v.*L GCSE 3, 1 our "k Z"rt /fra fo r C h~ he be ~-s . TV 6R"-D use oA 3 Boring # 0 Boring M Ground surface elev. ft. Depth to limiting factor > 76 in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fe in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring 0 Boring FD-1 Pit Ground surface elev. ft. Depth to limiting factor 7 5- in. Soli Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP61fe In. Munsell Qu.'Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 -3 A 1A ~ e tJ I) A 5 7 * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print Signature CST Number Address ate Evalua ' Conducted Telephone Number U-l l e but /3 /+nn n~~n mnn inns 5i 71.2 Property Owner l 10^ / -1000{ A U SO ~ Parcel ID #03--)D ~ 74 ~ 7000 Page of a Boring # 11 / g Ground surface elev. Z • ft. Depth to limiting factor / d in. LAY Soil Nation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in.~y Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •011#2 L a , ~o IU O Y SL t i" J - O g (L J- L'i ivy o \l s l.6 Boring # ❑ Boring 9 Pit Ground surface elev. ! ft. Depth to limiting factor 8 6 in. l M Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfiF / in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. n ` 'Eff/#1 •Eff#2 1 9 loyt~ -5 OC S h Cx) 2 to 40 3 q-8 to - s + J • 7 .t ~I Z Boring # El ng p ~l Ground surface elev. Q~ I ft. Depth to limiting factor ~w in. 7) P Soil Apolkation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPEXF In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 0 s 3 LA) to S L ~rn5 O Lo C. _9 o ~2 S • Effluent#1 BOD6 > 30 < 220 mg/L and TSS >30 < 150 mg/L • Effluent #2 = BODE < 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-8330 (R.m/oo) PIS Lc-ke Stc~~ ES 10.1 5 ~6w -3 S.T; JScr,tnt-e (ate cove 7a ~ ST. (f R0 K UAJ TnL o f _ _'n.~l F R S F T tia s Sit. l 17~~a U,ck N LJ f . ~ rotr- l~~-ta:, _ 3 Lied Ho~,~ i r ~ ~ ' 6rnu~c~ ~le~, low? s t-A ~Q ~ 1490 ~ A~ ~ i 7 j33 ate- Ta~A of t'{~UC ~t~p e G 13M. pp.o~ iaYd Top a~ l PLY- 4 %xr r ~cx NOAv-es- z e ~ b1O W L L- w POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Tank Manufacturer: ! , t Permit# tN)eSCa-- ❑ NA 6- P~1' r_01 ' CrSeptic ❑ Dose ❑ Holding Volume: joo d (gal) DESIGN PARAMETERS Tank Manufacturer: gr NA Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (gal) Number of Public Facility Units: eff NA Vertical Distance Tank Bottom(s) to Service Pad: 4 j} (ft) Estimated (average) Flow : CC7 (gal/day) Horizontal Distance Tank(s) to Service Pad: ~i~(ft) Design (peak) Flow = (estimated x 1.5): (gal/day) Specific servicing mechanics must be provided if vertical is >15 feet or y) if horizontal is >150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: "'7 (gal/day/fe) Effluent Filter Manufacturer: Po/,t 0 k ❑ NA Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: Fats, Oil & Grease (FOG) 530 mg/L Pump Manufacturer: Biochemical Oxygen Demand (BODS) s220 mg/L ❑ NA 4 NA Total Suspended Solids (TSS) 6150 mg/L Pump Model:.- High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer: (BODO >220 mg/L NA WAA (TSS) >150 mg/L ❑ Mechanical Aeration ❑ Peat Filter W Pretreated Effluent Monthly average ❑ Disinfection ❑ Wetland ❑ Sand/Gravel Filter ❑ Other: (BODE) r30 mg/L Soil Absorption System (TSS) 530 mg/L WNA Fecal Coliform (geometric mean) s10e Xin-Ground (gravity) ❑ In-Ground (pressure) ❑ NA Maximum Effluent Particle Size %s in dia, [I NA El At-Grade ❑ Mound ❑ Drip-Line ❑ Other: Other: ❑ NA Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) When combined sludge and scum equals one-third of tank volume ❑ When the high water alarm is activated Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) p NA year(s) Inspect dispersal cell(s) At least once eve ❑ month(s) ry' year(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: 3 ❑ month(s) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) NA ❑ 'year(s) Flush laterals and pressure test At least once every:. ❑ month(s) 9XNA year(s) Other: At least once every: ❑ month(s) Other. El year(s) ❑ NA ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). 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 a check for any back up or ponding of effluent on the ground surface. The soil absorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any pending 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 treatment tank equals one-third (X) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) 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 30 days of completion of any service event. GMW-005 (02/05) 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, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent. and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. 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 treatment tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge. 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 s. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks, pits and other soil absorption systems 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 (pumper). • 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 the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. ❑ 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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF ATANK MAY NOT BE POSSIBLE. -`r ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER . Name h Name Phone Phone SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY A THORITY Name kolt! Name 57 b-1 O t2/ Phone 'tt5 -has Q (T% Phone f S- 3 This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owne Buyer 1 1 WI ' " 1 r X d T Md MYO-1'1 ~/1 E~ Mailing Address Ito I T eci S - - ~~~eLl ?'j CLV%► c4 L'y ( 5 4~ j 7 Property Address ~ I Z ,-j: I 5'f" AlPW R C i!w7[5nc-j VAJ 1 5 4 (Verification required from Planning & Zoning Department for new construction.) City/State t\ eVJ V1 Mc~>1 Parcel Identification Number 3 2. Z t 1 Igo -7 O O O LEGAL DESCRIPTION Property Location _Nf- y< ~ /4 Sec. ~_,/Tj N RW, Town of 56rv\ e r S e+ Subdivision Plat: L-A ke's i 1 ~SY 4 Lot # . Certified Survey Map # Volume . Page # Warrant)Deed # (p 9 2.ycL1 (before 2007)Volume lq.°1) Page # Spec house OyesW Lot lines identifiable Plyes[]no 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. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of 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. I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty ed recorded in Register of Deeds Office. Number of bedrooms SIGNATURE O PLICANT(S) DATE O TE ***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) U 2 7 3 3 P 3 2 5 7~s3i~ c~j KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI STATE BAR OF WISCONSIN FORM 1 - 2000 WARRANTY DEED RECEIVED FOR RECORD Document Number 01/19/2005 10:00AN THIS DEED, made between Copar Development, LLC, a Minnesota WARRANTY DEED Limited Liability Company, Grantor, and TI Magnuson Enterprises,Inc., a EXE-WT # Minnesota Corporation Grantee. REC FEE : 13.00 Grantor, for a valuable consideration, conveys to Grantee the following TRANS FEE: 585.00 described real estate in St. Croix County, State of Wisconsin (the COPY FEE: "Property"): CC FEE : PAGES: 2 SEE ATTACHED EXHIBIT A Recording Area Name and Return Address: Land Title Inc. 1900 Silver Lake Raod Suite 200 New Brighton Mn 55112 a* ,q "7 q 23'?~~- 01 Together with all appurtenant rights, title and interests. 032-2042-80-000 Parcel Identification Number (PIN) This is not homestead property. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Dated this 10th day of January, 2005. Copar Developmen , LLC * Thomas D. Hanson, Chief Manager * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF MINNESOTA ) WASHINGTON COUNTY. ) ss. authenticated this 10th day of January, 2005 Personally came before me this 10th day of January, 2005 the above named Thomas D. Hanson, the Chief Manager of * Copar Development, LLC, a Minnesota Limited Liability TITLE: MEMBER STATE BAR OF WISCONSIN Company, to me known to be the person(s) who executed the (If not, fore goin instrument and acknowledged the same. authorized by § 706.06, Wis. Scats.) ~ THIS INSTRUMENT WAS DRAFTED BY *Annette D. Theis Notary Public, State of Minnesota My commis ion is permanent. (If not, state expiration date: Larry Mountain, Attorney, 1900 Silver Lake Rd #200, New 3 /1 ) Brighton, MN 55112 (Signatures may be authenticated or acknowledged. Bath are not necessary.) ■ ■ *Names of persons signing in any capacity must be typed or printed below their signature r AN NETTE D. THEIS NOTARY PUBLIC - MINNESOTA WARRANTY DEED STATE BAR OF w1 My Comm. Expires Jan. N31, ' 2005 a FORM No. 1-2000 U: 2 7 3 3 P 3 2 6 / EXHIBIT A J Lot 7, Lakeside Estates, St. Croix County, Wisconsin, together with a 66 foot wide access easement as shown on the recorded plat. I ST. CROLK-K, NT Y Planning & Land InfoLand Use rmation Resource Management Community Development Department September 25, 2013 File#: LU88043 ~I I T. I. Magnuson Enterprises, Inc. c/o Tim Magnuson 1618 83rd Street New Richmond, WI 54017 Re: Land Use Permit, Filling & Grading < 10,000 sq. ft. in the Shoreland District 1618 83rd Street, lot 7 of Lakeside Estates Parcel #11.30.19.1492, Town of Somerset Dear Mr. Magnuson: This letter confirms zoning approval according to the plans you have submitted for filling and grading an area of approximately 4000 square feet within 300 feet of the Ordinary High Water Mark (OHWM) of East Twin Lake to construct a driveway, single-family dwelling, detached garage, and private on- site wastewater treatment system (POWTS) on the property referenced above in the Town of Warren. Staff finds that the proposed project meets the spirit and intent of the St. Croix County Zoning Ordinance and Shoreland District with the following findings: 1. Filling and grading an area less than 10,000 square feet within 300 feet from the OHWM on slopes less than 25 percent is allowed with a land use permit in the Shoreland Overlay zoning district pursuant to Section 17.29(2)(c) of the St. Croix County Zoning Ordinance; 2. The filling and grading will consist of excavating for the foundation of a single-family dwelling, driveway and turnaround, and the POWTS, which will be located within 300 feet of the OHWM of a lake. The proposed driveway, single-family dwelling, and POWTS meet the 75' setback from OHWM and other required setbacks and dimensional standards contained in the St. Croix County Zoning Ordinance; 3. The applicant's contractors must implement an erosion and sediment control plan. With conditions to install appropriate erosion control and sediment control measures e.g. silt fence or sediment "logs" between the construction area and the lakeshore prior to beginning excavation, to maintain erosion control measures until self-sustaining permanent vegetation is established on all disturbed areas, and to prohibit the use of phosphorous fertilizer to maintain a lawn, negative impacts to the water quality of the lake will be minimized; 4. The lake shore is -100 ft. from the north side of the proposed house and the owner will be required to maintain vegetative cover within a 35' shoreline buffer zone; Phone 715.386.4680 Government Center, 1101 Carmichael Road, Hudson, WI 54016 Fax 715.386.4686 www.sccwi. us/cdd www. facebook. com/stcroixcountywi cdd @co.saint-croix. wi. us Community Development Department Page 2 5. A storm water management plan must be approved that will specify areas designated to infiltrate the first 1.5" of runoff from impervious surfaces (-4000 sq. ft. total). Approval of a land use permit will include a condition that an affidavit documenting the stormwater management plan be recorded against the property; and 6. The Wisconsin Department of Natural Resources staff was sent a copy of the application on September 13, 2013 for review. An appropriate infiltration system for runoff must be a condition of county permit approval. A DNR grading permit will not be required for land disturbance less than 10,000 sq. ft. and outside the 75' OHWM setback. Based on these findings, approval of the land use permit is subject to the following conditions: 1. Prior to commencing construction, the applicant shall submit a stormwater management plan for review and approval by the Community Development Dept. (CDD). It must include specific details for and location(s) of infiltration devices that provide a minimum capacity of -500 cu. ft. to handle stormwater runoff from roof and other impervious surfaces totaling -4000 sq. ft. 2. The applicant shall record an affidavit referencing the approved stormwater management plan with the Register of Deeds prior to commencing construction and before the pre- construction meeting (affidavit form enclosed). 3. A pre-construction on-site meeting must be scheduled with CDD staff to verify placement of erosion and sediment control measures and that the stormwater affidavit has been recorded. The applicant will be responsible for directing contractors to implement storm water management and erosion control plans, which include installation of silt fencing, straw waddles, and/or sediment logs between areas of exposed soil on the construction site and the lake or neighboring property to control contaminated runoff. Photos will be taken to document pre-construction site conditions for enforcement purposes. 4. The applicant shall obtain all applicable permits and approvals required for construction of the driveway and house. The sanitary permit has been issued for the POWTS. The applicant will need to provide a copy of the erosion control plan to the town's building inspector for compliance with Uniform Dwelling Code requirements. 5. The sanitary permit issued for installation of the POWTS will require compliance with all conditions of the land use permit and contractors must be made aware of the conditions regarding erosion and sediment control. 6. The applicant shall maintain all erosion and sediment control measures until permanent, self-sustaining vegetation is successfully established on all disturbed areas of the site, including a 35' buffer zone along the lake shore. 7. No phosphorous fertilizers shall be used on the disturbed areas of the site, unless a soil test confirms that phosphorous is needed for establishing permanent vegetative cover. 8. Within 30 days of completing the project, the applicant shall submit to the Zoning Administrator photos of the stormwater infiltration devices and stabilized disturbed areas for documentation of compliance with conditions. Photos may be sent electronically via e- mail attachment. Phone 715.386.4680 Government Center, 1101 Carmichael Road, Hudson, Wl 54016 Fax 715.386.4686 www.sccwi. us/cdd www. facebook. com/stcroixcountywi cdd @co. saint-croix. wi. us Community Development Department Page 3 This approval does not allow for any additional construction, structures or structural changes, grading, filling, or clearing of vegetation beyond the- limits of this request. Your information will remain on file in the St. Croix County Community Development Department. It is your responsibility to ensure compliance with any other local, state, or federal rules or regulations, including obtaining a building permit from the Town of Somerset. Please feel free to contact me with any questions or concerns. Si , /i Pamela Quinn Land Use Specialist/Zoning Administrator Enc: Land Use Permit LU88043 Stormwater Affidavit form Cc: Todd Dolan, Building Inspector, Town of Somerset Mike Wenholz, Wisconsin Department of Natural Resources Phone 715.386.4680 Government Center, 1101 Carmichael Road, Hudson, Wl 54016 Fax 715.386.4686 www.sccwi. us/cdd www.facebook.com/Stcroixcountyw i cdd @co. saint-croix. wi. us ST CRO ,UNTY LAND USE PERMIT File#: 4a APPLICATION office Use Only Revised 6-2013 APPLICANT INFORMATION a J-~ S Property Owner: Contractor/Agent: Mailing Address Mailing Address: 5-7a 77, V r7 t.+.* 11L y 1~:. i} ii~ Daytime Phone: o - Q•i 4 1`V( Daytime Phone: Cell: (~l+w Cell: E-mail: NJ A I'`+(4 t ',~Z (V( f _s' > E-mail: SITE INFORMATION 0 % - ? r C, - T- IA t Site Address: -l 4 q ' _ R. (I W., Town of Property Location: SE' 1/4, SCIA, Sec. 0 , T. -3 032 Computer -a~-~ - Parcel 36 Lq_. 12~ LAND USE INFORMATION Zoning District (Check one): E3 AG. 13 AG. 11 13 AG. RES. A RESIDENTIAL 13 COMMERCIAL 17 INDUSTRIAL Overlay District (Check all that apply): JWSHORELAND 0 RIVERWAY 13 FLOODPLAIN O ADULT ENTERTAINMENT Type of Land Use Permit Request (Check one): 13 Animal Waste Storage Facility $550 D Wireless Communication Tower (Co-location) $550 13 Nonmetallic Mining Operation $550 13 Lower St. Croix Riverway District $350 0 Signage $350 P1 Shoreland $350 Floodplain $350 13 Temporary Occupancy $350 Grading & Filling, 12-24.9% Slopes $350 13 Livestock Facility $1,000 0 Other: 0 Permit processed in conjunction with a Land Division, Special Exception or Variance $50 State the nature of our request: / Q ( ~ 5•~ / 300t 4 Zoning Ordinance Reference Z~l C) a ru /V J SIGNATURE I attest that the information contained in this application is true and correct to the best ofmy knowledge Property Owner Signature: Date i 1 Contractor/Agent Signature: Date t' a 'OFFICE USE ONLY Complete Application Accepted: / I By: Fee Received: q /W /a $ 360-oO Receipt 715.386-4680 ST. CROIX COUNTY GOVERNMENT CENTER 715-3864686 FAx CDD@CO.SAINT-CROIX.WI.US 1 101 CARMICHAEL ROAD, HUDSON. W1 54016 www.sccwi.us/cdd o N 0 3 m o G `n > > g rr o N o z 0 L" -1 o °w. 3 c - 3 p= o CA `III 6 3 co N oi A- O 0 o N CL O p t~+ N 0 o p p N G n _ N y O CO N y t° Ir. a CD o c O o n z oo f orto O CA O c m w a rr "WA O O O l~l~711 O v O N CA (A 0 0 - ~f ~ a -0 v v' CD y Ch a) N ID N ~ rC C-7 m l~ oo H 3 cn y D o O - z N o ~ pl N • M CL O a C N w llI~VVV1 N M O co o po N p ~ h~ N N C C. N 3 o 3 a A. 3 3 (A CD z! y N O fR (O A 7 A Z p z 7 0.0 N n -4 O N O a3 W v m wo O f° 0 m C F U! z CD A C ~ w F n~ U3 0 O o a- n o: n y O N C CL w z a O w n~ x~ 0 can r-j o co A. CD CL W con v :E • b s a ss 33 a m N N N N O ~ w A S O O ro ti N ~q N ~p 69 0 ti Opp CD CD a °o CL r