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HomeMy WebLinkAbout020-1439-31-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 567217 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: Hanson, Robert J. Hudson, Town of 020-1439-31-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: / IJG,tiJ JO 25.178.19.2757 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 5 / Z c5a Benchmark AD ' 5z s Alt. BMC PaL4, /C r V Aeration Bldg. Sewer Holding SUHt Inlet St/Ht Outlet TANK SETBACK INFORMATION A3,75 TANK TO P/L WELL BLDG. enttO~ntake ROAD Dt Inlet Septic , S6 - r~ Z~ 7 C~ Dt Bottom ~ /u J \ O 7 74 -5 9Z. Z b .0 NHoldin .j Header/Man. Dist. Pipe Bot. System PUMP/SIPHON INFORMATION Manufacturer Demand St Cover u ' GPM P'Je - ~•7'S ~S Model Number 4,3 257- -7 TDH Lift Friction Loss System Head TDH 6-7 Forcemain Length Dist. to Well SOIL ABSORPTION YSTEM A 0:5 /fS, 95 BED/TRENCH Width Length No. Of Trenches NS No. Of Pity. IngidE pia._r _ • L i9uepth / ~!J DIMENSIONS 3 µ ` j~./ I GG►~Lv ~7 VV SETBACK SYSTEM TO P/L BL G WELL LAKE/STREAM LEACHING Manufacturer: ~~11 INFORMATION f System: CHAMBER OR yi/~e•i Type f / UNIT Model Number: r' O ~v4 5 ` DISTRIBUTION SYSTEM ` Q S Header/Manifo' O / Distributio x Hole Size p Nv x Hole Spacing Vent t, Air Intake 33 Pipe(s) \ L S P Length I Dia Length Dia Spacing 5 i- _ I ' SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over ~JD, p hOver xx Depth of xx Mulched Bed/Trench Center er a ch Edges ` Topsoil Yes No es No COMMENTS: (Include code iscrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 910 Highlander Trail Hudson, WI 54016 (SE 1/4 NE 1/4 25 T29N R19W) Indigo Ponds Lot 31 Parcel No: 25,21.19.2757 1.) Alt BM Description = 11:~_~ C~`,{, / 2.) Bldg sewer length = Z( - amount of cover = f 1-- c~0 1e U Plan revision Required? Yes No Use other side for additional information. ~X ~'4 SBD-6710 (R.3/97) Date Insepctor's S nature Cert. No. FfO-f pa,~ IA - IrlA~yo Von A-& ~©t -3 ; t , th et". I-)6er+ I Q~ s ©t1 I ~ln MLA c~Q K- III fir, 1'e 1 )140 !V~ WELL- BA, (no. ®o + Jln c 0l c OV -rod, a Pct ~;5 L~~ a~ 10 Clk Sa ~ \ ~f6 sb t 97,7 i q/o c~.l-De -S~t ect County 5/ (J/ Industry Services Division 3 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.) 0 i0.X-M P.O. Box 7162 7 Madison, WI 53707-7162 / 12 ~J Non Number ermit Application State Tran In accordance with S 3,Z1( m. Code, submission of this form to the appropriate governmental unit / V is required prior to obtaining a sanitary permit. Note: Application forms for state-owns POWTTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provid ed for seconds q V N~9~/~h e>✓~r T/ purposes in accordance with the Privacy Law, s. 15.0 1 m , Stats. 7 1. Application Information - Please Print All Info a §n ~Ll#so, Parcel # Property Owner's Name 3-E Q 6er f cLLtso I-t p VU 2013 0,)6-4'-13q_31-606 'If Property Owner's Mailing Addres/s~ CRO/X Property Location I7-)G/ COow), Govt. Lot City, State ~7- Zip Code Phone Number 'i•, A Jr-'- Section s 7/5-- '17 7- 0 -5675 (circle one T 9 N; R I ~ E or IL Type of Building (check all that apply) Lot # R'1 or 2 Family Dwelling - Number of Bedrooms 3 Subdivispion Name ~n cQ I , p ~O S ❑ Public/Commercial -Describe Use K erg ❑ City of ltia~se. 1a..~. ❑ State Owned - Describe Use CSM Number ❑ Village of 3 LJ O J G t LL S w 20 G~...1 ors aci. RTown of -H U_J S o V, Ill. Type of Perinit: (Check only a 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 ~-c ( IV. Type of POWTS System/Component/Device: Check all that a 1 'Jz_ 14 a0 S Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil 6,k ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) V. Dis ersaVrrea entArea Wormation: / Design Flow (gpd) Design Soil Application Rate( gp Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation g n lie ✓ e S /o~oo ` tNart c racOc e1,1 CO k VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units u 4 N New Tanks Existing Tanks na a w YG lob Sz5 ~ w~ a Septic or Holding Tank w I .Se r.5 Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber' rgnature MP/MPRS Number T Business Phone Number JV1 n Ile Z_5_,, Plumber's Address (Street 1 , State, Zip Code) /V 7~Cf / la 8' .S r/A 0a VII oun /De artment se Only Approved isapprove PernL►~itFee Date su / Issuing tSignature ❑ O rven Reason for D 1 S " 75 60 ~w / 44t IX. Condilirasons for Disapproval 1 1. 'peptic tank, effluent filter nd 3 dispersal ge8,must all be servicesI maintained as per management plan provided by plumber. 3. AD adgeck iequuements must be.maintalned 8$ ble Code / ordinances: 1",6 L✓t 1~.. Std G Dr` Attach to complete plans for the system and submit to the Coudiy only paper not less than 812 :11 inches in size zo n r rr.p 7 I0 and f-,- z w,`L ( ~ L( i'S fz✓~ SBD-6398 (R0313) G, 51,110 ~~C'G - ~'n^'1~ I s re ~I~rGcY' CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: V..%S8 Owner's Name: Q 610 ax N-a a Owner's Address: g/ d Legal Description: /V/I E Sec_ ZS [ Z9 /9 f Township: r/ x$ ev~._ County: 54-. Glo• Subdivision Name: Lot Number. 3 Parcel ID Number. 0 " /Y 3 S - 3) - OD o Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Piat /n~ Attachments: Soil Test & House Plans Designer/Plumber. /7 4A,e, 14C.46&- License Number. ZZa 2_9 Z Date: Phone Number Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 20 SBD-10705-P (N.01101). Page 1 plot Pic " 11)faetSc>6t- 1 IQ~50h r' 2 n ~ 44e~cesoea_ AY ct, r-.Q A II U A) D WELL- , 10c).00 k Zm. (01,0c) , o-f JA- Pcc_ t';~PS a ~~s-~o b -,o~, -opasec~ Faso . cpA« Ta k Box ~ ~ f / w P~1y l o k sus F>tt~ / a~Aesl lu 0133 t 3 efts u-s ~G o ~ r~u«k y e►.~b~~ o 97,7 g/ D I Cul-De-SQL s I, ahele, ' e. Vv S o &A tf~ e If\ IA l~ Sys~~vvL S~Z•~ T F'pur Do 1~,1-~ " ~sa ,peg- !,7"~ ►~Q~cQ i~r~ ~c /a 00 ~',~eecP~G4, ~,5~ vC ueclC 41 S7~Cc4rae a~~ Cho m eA'S DO ~.Gf"o9CC`Gpac.,b.ly-- , y Cell, 1 / i Soil AbsQrptlon System Cross Section 4 ft -.2-T -.?ft 4" Schedule 40 Final Grade PVC Vent Pipe With Vent Cap ft Leaching ft Chamber ~f- J System Elevation ft aft ft Soil Absorption System Plan View ft aft i ft Leaching Trench 1 Chambers 4" Dia. Trench 2 Header Vent Or Observation Pipe Trench 3 Leaching Chamber Specifications n 1 h's.~or" Qv; Manufacturer And Model EISA Rating Za sq ft per chamber Soil Application Rate d. Sgpd/sq ft gpd Design Flow + 5 Soil Application Rate 24 EISA = fob Chambers 3 rows of ZO chambers each. Page of F- LU Y Wa O 9-j= CL L.LJ E ~ Q N 1 11 CL N Fw-~ Ef) -~r Lu= mZo ~o : NL~ ~N J=M~~ M g ~ ~ Z~ZUoZ O i3k O Cl) ~a CL Oa OQ H U O ~a ~d OQ F d NE o U M CJ vi O r CO W M W M > u O U co U U CO N M M Ci Lq OO 6M C11 -co u u J u~ N rL- Ln O ti r Cs N u L ~ U z r O N u Cn O Z L1J V c O N U C] ULU ~X Zio LLJ (!J H U o I- J w U W W U = QO ~cn LL O U' Z m Z W C/ J > co LO O d U) C'4 CL LC) W Z W N , ® vLi¢ I-~t JZW zF'o -'o O=p ZWLL u-M CL=_ Q > LO LLI LUW COQQUmJ Z Z f- J LO - W Q NI2LU -j p Ln~Hpi--= 0 LO CL a2m0co II o E'd 0 0 0 11111111111111111111111 1011 II I co O LQ U _ r r- N O _ r, E N w E N U 11 U D C O LQ co N N o sf U aj (h N co co CO aWORM1 u CD U rid 1~ U ra r /-y I OB~AI9~AR 1 cc CD CD c0 N N W O u U Q N w a O m m U Q N lil!IIiI~~ ~!IIIIIQ it N "It coo• C N O S m ~ ~ lV- zo Woe U LL ovZ o \ / ~ rn Q Ow CV ~CD O 2 m y w 1- O CL N D U a = Q w U Q O W W W O Of ~ cn I-- LU 00 Of z r= U u U J C = W P wLO0 U 04 N v } O 2 `3 CL J ~ w J m J J 0 O Q ' LL LL W J- of JFa-- 1¢- a¢~~oo 0 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner fnS®~ Tank Manufacturer: ~A~f25PP ❑ NA Permit # S~Septlc ❑ Dose ❑ Holding Volume: /_~57a (gal) DESIGN PARAMETERS Tank Manufacturer: JQ NA Number of Bedrooms: G~ ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (gal) Number of Public Facility Units: Ar NA Vertical Distance Tank Bottom(s) to Service Pad: 0 (ft) Estimated (average) Flow : b~ (gal/day) Horizontal Distance Tank(s) to Service Pad: 106 (ft) Specific servicing mechanics must be provided if vertical is >15 feet or Design (peak) Flow = (estimated x 1.5): (gal/day) if horizontal is >150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: (gal/day/ft) Effluent Filter Manufacturer: D /y /o k p NA Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model $-a 5- Fats, Oil & Grease (FOG) s30 mg/L Pump Manufacturer: Biochemical Oxygen Demand (BOD5) 5220 mg/L ❑ NA WNA Total Suspended Solids (TSS) .5150 mg/L -Pump Model' High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer: ,~,c, (BODO >220 mg/L )ANA I ~A (TSS) >150 mg/L ❑ Mechanical Aeration ❑ Peat Filter ❑ Disinfection ❑ Wetland Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other: (BODO 530 mg/L Soil Absorption System (TSS) 530 mg/L I"NA Fecal Coliform (geometric mean) 510" Oln-Ground (gravity) ❑ In-Ground (pressure) ❑ NA E3 Maximum Effluent Particle Size t/8 in dia. ❑ NA At-Grade El Mound ❑ Drip-Line ❑ Other: Other: ~WNA 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) ❑ NA year(s) Inspect dispersal cell(s) At least once every: ~ El month(s) (Maximum 3 years) ❑ NA 11 ..1R year(s). Clean effluent filter At least once every: month(s) El NA 13 year(s) Inspect pump, pump controls & alarm At least once every' El month(s) XNA El year(s) Flush laterals and pressure test At least once every:. ❑ month(s) (rNA ,year(s) Other: At least once every: ❑ month(s) - ❑ NA ❑ year(s) Other: ❑ 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 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 treatment tank equals one-third ('/3) 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 orpressurized 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) START UP AND OPERATION Page of 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 be4scharged 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.Goda: • 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 RESMT. _ESCAPE`OR RESCUE FROM,THE-tNTERIOROFA PANKMA-YNOT:aE4PQSSiBtE. - ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER. Name t-7 Emme Phone "r 23 SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name SO-42/ CR row Name L757-, -W-O/ ZaN1NG- Phone Phone This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.72(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Page of START UP AND OPERATION For new construction, prior to use of the POWTS check. reatment 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 be4scharged 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 (purnper),prior#orestoring 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 product's, ,pestici des, 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 t~ SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY WESULT:-ESCAFE~QR-RESCAJE.fRGMI-TH TEPJOR-OF-AIANK1A-Y'NOT9VE-POSSfBt~E - - ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER. Name Pe i,1 L4 I Name G~h $p.. ~ca n t t_c~ Phone / - 7 7 Phone, -7f 5) 3 579/1 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY I' Name ~uvSow jpts2r C ro Name car ~ Of 76,A IP6- Phone Phone (j/iO -3 !?,g ~(6 eo 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 Owner/Buyer -Robert c So r~ Mailing Address / hec~1'Te z Xue & J k o ~ CO1. 5-(f ODD Property Address O` (Verification req ired from Planning & Zoning Department for new construction.) City/State Parcel Identification Number D" % X13% , 6D A LEGAL DESCRIPTION o Property Location S~ , NZ:_~_ 1/ , Sec. ~ 5' , T _2_~_N R11 W, Town of As 3 Subdivision Lot # Certified Survey Map # , Volume , Page # Warranty Deed # 71 , Volume , Page # Spec house ❑ yes Ono Lot lines identifiable ❑ yes &tY6' 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 §Comm. 83.52(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 Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County 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 dee recorded in Register of Deeds Office. Number bedrooms J5/ i 3 A RE O PL ANT 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. 08/05) i 8 0 5 7 3 8 6 Tx:4042693 STATE BAR OF WISCONSIN FORM 1 - 2000 956719 BETH PABST Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI THIS DEED, made between Rosamji, LLC, a Wisconsin Limited Liability 05/18/2012 2:34 PM Company, Grantor, and Robert J.^ e Hans Jr. and Stacey A. Roering, EXEMPT#: NA unmarried person, as joint tenants, Grantee. - REC FEE: 30.00 Grantor, for a valuable consideration, conveys to Grantee the following TRANS FEE` 210.00 described real estate in St. Croix County, State of Wisconsin (the PAGES: 1 "Pro rty"): . Lot 31 Plat of Indigo Ponds, Town of Hudson, St. Croix County, ~Vis sin. Recording Area Name and Return Address: Land Title, Inc. 2200 West County Road C, #2205 Roseville, MN 551 13 LT-T 0 _376-64a- Together with all appurtenant rights, title and interests. 020-1439-31-000 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 Roadways, Reservations; Restrictions, Easements and Rights of Way of record. Dated this 27th day of April, 2012. Ro•, nji, LLC * Sandra M. Gehrke, President * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) E,....• S-f. CROIX COUNTY. ) ss. authenticated this 27th day of April, 2012 R Y Personally came before me this 27th day of April, 2012 the 0 .001 bove named Sandra M. Geluke , (lie President of Rosamji, LLC * a Wisconsin Limited Liability Company, to me known to be TITLE: MEMBER STATE BAR OF WISC NSJN V•:p2 ie person(s) wh e, t foregoing instrument and PU acknowledged the s te. (If not,5 authorized by § 706.06, Wis. Stats.) •TATE OF THIS INSTRUMENT WAS DRAFTED BY *Kelly J. Nelson Notary Public, State of Wisc nLin Larry S. Mountain, Attorney At Law My commission is pennanet t. not , tate expiration date: ) 4/13/2014 (Si_natures may be:mthen(icated oracknowledged. Goth are not necessaiv.) *Names o(pcrsons sienine, in any capacity must be typed or printed below their signtue 1 of 1 WARRANTY DEED STATE BAR OF WISCONSIN FORA No. I-2000 1 ~ ~ .rte W% @nyw - i0ai< Lf • 1~7~ NO O1MELJNG C 30 SO-,ow o Unt Sy. 3.r V~ 4, 31 `d . 00 F (LOGO ioo~ EX i OPENING smow ELEVAIM MY 1 ~ ~~'"~~MI~+ • fit` M-OGZIdM `3-11-4 9518-SZ2-008 OIOZ 'Ndf 03SIn38 o \ :8nOd-1SOd 31V0 OIOZ 18VnNVf 31V0 O9L*9 IM 'NOOa N301dW 01 AMH Sn 9LL£M z n3a 31381 lu 1313'M i`dnN`dW OIld3S w o 3WS 1 8 NMVHo \ 1l = :anOd-3ad „D-,l= l 3lVOS 8W-ogztcr M N F- J Z Z W W w~ Q O z O I- c U Q W 0 w M: Q ¢ Z V) w 0 xm m w OC 0 0 0 z En o m LL. j 0- LL oW C) (X 0: V O w v Z ~ in O v °zi z z m~ H Fd o o Of F- w OQ a='U ~ 0M a o 0 z o z w p Q e 0_00 mV) JWW C9 0.. D W O \ ° U O v° w ce o U O0, a ~pNppp QQ WOfn pp J~ ° > C C z Y I"1 Q a a -\O W ~r7J 1 awfn O WW Z p¢ U N < Q F- ~ m W ~ Q Q _ F e d 'Z> rok Q O ~r Q U-) N a ~ ~ 0. J~ I a F- N Q Ld °o p Q W O z Gi ~ V) N N N L W 00 W Q V U.J O Q = (n 2 0 Z Y M W m..,n-'t _jLd- F' 1 -N z 00 zo N -i ~?J MNH OZW U Y J O QJ \ W (n FH D- (n Gi..oEwo ..30~ 0¢Y Dow a Qwa w mF op D J p~~~`lzmm C) O0F-0Dm 0 U) ON _ ¢ 0 (n_j o xx WU ~a0oaw~?0wca- a,t8 <~o U 0oU o z-Jz a(n n'~ 3mU~~m~ zo< Z U 20 <1 a ~ J J o 0 a Y W z p Z Z _ y'z v) U H C-) W N I I Q H N Q H U W V LLJ 0 Z O W Uj W w Cfl D I W cr SHo „b I: LLJ N -j 04 ,92 do w WQ U M w cn o a > 92 > CIA N d w 0 I o W W U SVo O ~ L L ~ d p, 1 W Y l N W „o-V do I o w "J N J U Z_ z 4038 < ~a sv „has N Y Z Q F- I t r 1275 SOIL EVALUATION REPORT 1 of- Division Department of Commerce Page Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Steel Soil Service County Attach complete site plan on paper not less than 8'%x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D. Plea ~eviewecl Date Personal information you proa may tRfm r&VFl -Qses (Pri y taw, s.15.04 (1) (m)). / DA / Property Owner Property Location ROSAMM, LIZ 1 3 .2003 Govt. Lot na SE 19 NE 1/4 S 25 T 29 N R 19 W Property Owner s Mailing Address Lot It Block It ~Subdd. Name or CSM# 2141 Cty Rd. C ST. C1 COUNTY 31 nag Indigo Ponds City State J City J Village 0 Town Nearest Road New Richmond WI 54017 715-248-7071 Hudson Highlander Trail IJi New Construction Use: 0 Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD I Replacement I Public or commercial - Describe: Parent material Sream terraces and pitted outwash plains Flood plain elevation, if applicable na General comments and recommendations: system elevation 99.90 ft, trenches spaced and depth to code 6.00 ft below grade ,le" d"v M 0 9 Boring # Boring 1e Pit Ground Surface elev. 99.00 ft. Depth to limiting factor 110 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/02 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-12 10yr3/2 none sil 2msbk mfr gw 1 c .5 .8 2 12-37 10yr4/4 none sicl 2msbk mfr gw 2f .4 .6 3 37-50 10yr6/4 fld7.5yr5/6 sicl 2msbk mfr gw na .4 .6 4 50-110 7.5yr4/4 none Ifs om mfr na na 4 .6 ~2 /iWr1 J L_2._ Boring # I Boring ~Q S r 10 1 7 CdyjflAJ'Z/ Y' Pit Ground Surface elev. 99.70 ft. Depth to limiting factor 110 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Etf#1 *Eff#2 1 0-4 10yr3/2 none sit 2msbk mfr gw 1c .5 .8 2 4-35 10yr3/4 none sl 2msbk mfr gw 1f .5 .9 3 35-58 7.5yr4/4 none scl 2msbk mfr cs na .4 .6 4 58-110 7.5yr4/4 none sl 2msbk mfr na na .5 .9 I S• * Effluent #1 = BOD? 30 < 220 mg/L and TSS >30 < 150 mg/L Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signatur : CST Number David J. Steel 248956 Address Steel Soil Service Date Evaluation Conducted Telephone Number 1564 CR GG, New Richmond, WI 54017 5/3/2003 715-246-5085 Property Owner ROSAMM, L.L.C Parcel ID # pending Page 2 of 3 ] F Boring # Boring 1J/ Pit Ground Surface elev. 105.90 ft. Depth to limiting factor 110 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD1fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-5 10yr2/1 none sil 2msbk mfr cs 2c .5 .8 2 5-17 10yr4/4 none sl 2msbk mfr gw 1 c .5 .9 3 17-34 7.5yr4/4 none scl 2msbk mfr gw na .4 .6 4 34-110 7.5yr4/6 none cos osg ml na na .7 1.6 COS <35% coarse fragments = 36" & >35% - <60% = 60" below system ❑ Boring # Boring _f Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PD in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring # J Boring F-1 Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PD 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 = 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. L 3 f • Page 3 of 3 STEEL'S SOIL SERVICE INC. David J. Steel 1564 Cty Rd GG CST-POWTSM ROSAMJI, L.L.C. New Richmond,WI 54017 Lic. #248956 NWI/4,NE1/4,S25,T29N,R19W Bus.(715) 246-6200 Town of Hudson, St. Croix Co. Fax.(715) 246-9372 Indigo Ponds Lot 31 This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of this test may or may not be as shown, as permanent lot lines were not established at the time the soil test was conducted. Legend 1"=40' A = Benchmark Ele. I00.00Ft Top of 1/2" pvc pipe • = Alt Benchmark Ele. 10 .00Ft Top of 1/2" pvc pipe N ❑ = Borings Boring Elevations B I = 99.50Ft B2 = 97.70Ft B3 = 105.90Ft B4 = 00. Ft h 70f ~o ~3 ~ a3 ~s a ~ Aare Ite 1 13 3~° 81 S s 2 to 6~ 77d~~" Page 3 of 3 STEEL'S SOIL SERVICE INC. David J. Steel 1564 Cty Rd GG CST-POWTSM ROSAMJI, L.L.C. New Richmond,WI 54017 Lic. #248956 NWl/4,NE1/4",T29N,R19W Bus.(715) 246-6200 Town of Hudson, St. Croix Co. Fax.(715) 246-9372 Indigo Ponds term This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of this test may or may not be as shown, as permanent lot lines were not established at the time the soil test was conducted. Legend 1"=40' = Benchmark Ele. I OO.OOFt EREC-EIVED op of 1/2" pvc pipe Alt Benchmark Ele. 101.00Ft 0 2003 oP of 1/2" pvc Pipe N = Borings 7 Boring Elevations G oFF!cE BI =99.50Ft B2 = 97.70Ft B3 = 105.90Ft B4 = OO.OOFt 9 • ti o~ 7 1 S-~ J,1 As a3 6rF~ 3 5t' 11~- M /-Sol=es 1403• x,0 3 67o, to z Gl) At I (2.010 AC.) ?9R} 3p 1 - 0.087 AC. NAP.A.) ti Jr O CV' t T ~ J 9.41' j 1 f 143.i i O., , V lo~ .B.P.A.~~ 42 l f~/ i`j 59.57• su* - L 9 ~i . .i ` _ ~ ~ - , • ~ ' r it 88185 ,S.F ~~`9 ~c~czb` , ~ / /rL 7 w C (2.024 AC.) y 1 [N14 AC,--N-IMP A.~ D1 , c 50. ` ,-_.1 , ~ l 19275.9oS.F.4", (2.126 AC.)__ t'' ```x o 0M01 AC` N.B.P.A.~ t ` --r : ! r p /QD r, i . ` i r iii ` 1Y o' r i d l f j ~ I r P4 111.14 x'66 _ ~i~r.r .•f N W A 3 W` } ~ t 1bg to i ! z 9'S.F. 4s ' ~w w 1$-9 ti t (2.088 AC.~ 601, ! 5 } (1.243 AC. N.B.P.A. I.J 't 4 U) Wzn x.25/0 f PR 0PR~C ; ! t 480: 8s t p,sa = k j - =80'~ - 50'• - e~87216 L ` (2.002 AC.) - / ' t (1.139 AC. N.B.P.A.) i 2