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HomeMy WebLinkAbout022-1087-50-200 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 569547 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: Shaw, Daniel &Mary T. Sobota Kinnickinnic, Town of 022-1087-50-200 CST BM Elev: Insp.BM Elev: BM Descripti n: Section/Town/Range/Map No: pb �,s r 30.28.18.469E1 TANK INFORMATION ELEVATION DATA TYPE MAN FACJURER CAPACITY STATION BS HI I FS ELEV. Septic Zn, Z / /ate Benchmark /07.3 LZZ ;5 73 Dosing ( Alt. BM / P 42 �3 a A (A p, R TOf i Bldg.Sewer { a��S ✓l Holding St/Ht Inlet 17 i 73 g7.5 TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent t Air Intake ROAD Dt Inlet e 1 :5/ Dt Bottom 21• 1 -Z Dosing Sl, Z / Header/Man.T I an. 3.(.v 16 ,-7 Aeration Dist. Pipe l tt' 4. a A<�. Holding Bot.System -ID /O y.5 /OZ.9 Final Grade 2.,,�/ / �`• 5�5 /6/: PUMP/SIPHON INFORMATION �'�` 7 1104 ta 'Z Manufacturer Demand St Cover �, GPM_ 4- .• v �3-Lo Model Number 5 f TDH L{ 6 Fricti6 L7s / System He adl TDHI� �t Forcemain Length 1 Dia. 0 Dist.to Well 577 SOIL ABSORPTION SYSTEM -5 BED/TRENCH Width I Length 7. No.Of Trenches PIT IMEq NSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS 13 f`ekA. ��- SETBACK SYSTEM TO /L JBLDG WELL LAKE/STREAM LEACHING Manufacturer: 1- INFORMATION Typ Of System: / �[ �A CHAMBER Model ER OR �aC� L, G6 ST A) u1n Ji�lC J .- DISTRIBUTION RYSTEM /a V t) Header/Maniftld e&4K if Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) A Length -7 Dia _ 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 xx Mulched Bed/Trench Center I C)�,p Bed/Trench Edges Topsoil Yes M No es 0 No � COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: / nod- ��i-fa��� f•�a�.( �� Location: 190 Hwy 65 River Fal s,WI 54022(NE 1/4 NW 1/4 30 T28N R1 8W) NA Lot 3 Parcel No: 30.2 18.469E1 1.)Alt BM Description= r'•`U �iOJt� 7, Ar 2.)Bldg sewer length= � / -amount of cover= 7Q P1��^^�'�'^-" k ItA 5J 3(p" 2^1 6u:IL cQ:n.Ct $t we.-, Plan revision Required? ❑ Yes No 5 �!S Use other side for additional information. 7 t(r� L� -- Date Insepcto Signatu Cert.No. SBD-6710(R.3/97) fi i i. IC Pro�ore f ���. �J"yam � /a�a.f•'.mss /4 f�cSc: d,►-cep.b,as" �_�' S , y IN -�- 1,., _ Y � r o -- - y .06.t A I E y b r1 0.: c* s C6 t F � � � o. w. Mv� pert � h � F , OwM t4� N1.�ry s ot4 r qp yj, 6- v w me:.,- CA4J Twdy_4 k,"e/< — A d drers 9 f Hy CJ Dee♦ Or tw /ParedIr-O a'�' �A7t�`l�Zpp /�'•+�e./.C.D_o�.21D87Z�04 ' � � HY ejf'_ w s.0 k Q rp IA CL Li fa IV � w Safety and Buildings DiVision t 201 W.Washington Ave..P.O.Box 7162 Sanirary Permit Number ito tic fitted in(w C:k� i :z Madison,W! 53747-7162 Permit Application State Transaction Nar In accordance with S 3. (.2.),Wis.Adm.Cody submission of this ft>rm to the appropriate gavertrmentat unit �� �ST I'�'� is required prior to o `fag a sanitary permit. Note:Application forth,for state-owned POW'TS are submitted to Project A the Department of 5 and Professional So ivies. Personal information you provide may be used for secondary Co, u ases in accordan -with the Privacy Law, :.113. f Xm7.Stats. A� / 1. Application In rination-Please Print All Information Property Owner's Na � -y parcel 9 i Property Owner's Mi iffing Address Property Location 1 1,1 t� Govt.Lot city,State 4 ip Codc Phone Number Sect ion a rt J� n �; I _ - le cone C c tJ' 1' l V t /� T b?8' : R t a�'tV H.Type of Buildi mg(check all that apply) Lot N I or?Family Dtv !ling-plumber of Bedroom. Subdivisioe Alantr Q , - (�j� Blade PubliclCohintrerei i-Descnbe Usa ❑City of 't t SM Number-ND k D Villaeesof L 0 Mat,Owned- bo:Use III.Type of Perm (Check only one box on line A.Complete riot B if applicable) 66i 16 T A' [3 New Syst on V-Replacement System Treatment,'Holdine Tank Replacement On er ModItication tc_£xining Symetvi(eNptaini B. $ertuit Permit R� Change of Plumber Q Peatrtk-Tr .--uo N List Previous Permit Number and Date Issued i Before Exp lian Owner � f TV.Type of POMTS S stemtCom onent/Dev ice: (Check all that a l ) _.. f ' Rtic+n-Pressurized In-Ground 0 Pressurized In-Ground Cl At-{`trade 0 Mound? Pg 1 of Private On-Site Wastewater Treatment System(POWTS) . Index and Title Sheet Owner: 1' tL���%�� �,� J kayj Project N e and System Type: 2'C 1 Ct ( fit A/L p f-,� Location: Street Address Legal D�ript' •, X- vtPli�{YtL C Township/County Contents: Page 1: __! t"- C Nftd Page 2: It f Via Page 3: i1 Page 4: rii �iav e� Page 5: ( � 141' tie Page 6: PA44`i'C p m / rZ-,)" Page 7: 61 it, ✓l Page 8: ��'�� At., l /i(—k L64 Page 9: t Atta ents: I ,I l? OWA&``S Pl a gner: Signed: Credential N amber: Date: t Pik �0.x Rw-e^L.I�IJ M p I I 1� iP P�,,e,�ose of Pte- lI'hc afN J-p-t Alort+ Yj A a WewG� T Pi.es- i, W. CAC Nleery S ota r �c; � �3 �WNCit digs L ki e k y� � —�-Address � 9 f K y 6s '� � 4'?-• DaA f'xrcal J /Ibv�,I�' �t34? Pa re��.L�•D_o.2;,/087,Z000O H y A N NC �, y ro s F A r0 3 Q \ 4z S Qv Q/.4 p/�,, �'o� ,-Tre e ,'r: pve f o 1.o'f p4,.�, c�1., eJ- t , f" Ft o Esc v d f '.A? 70 fh� P��l•.a� re.n.�'! /cs,.«r rT �T"f- � it �JI , 4t .Mrs or t'44 L ccr„tr .'h s�s tc d e p 744 �typl<<�/ ede� tre.,chJ 4X i��s� CO_a/j�rt. s%S�t��l! ek '-' ,q a at Re y / /7��Gw4 ��� Itr� /11ATrv� �' Qf /.�aCH A 1 rY!✓Vale 'h•i�j k rz� 0~� / /�~mil . S LL V-14 ;L. C ei 4 - a (Y aY q G,/Y Al 2, G /ht ,/Tla�v�f � �CJp� /yf�/�Ia/Ca- S e a/s q CL p �rs� Page�O <n Z, Steed 90 (No Scale) P/-47:r rear P.Pe� " Approved Locking Manhole Covers- With Warning Labels Atta h 9 c ed d 7r t�y1Ke Weatherproof Approved Junction Box Vent Cap —� 12" Minimum 4" Minimum G �;'�",�r,►�tn; ,urn Quick 18" Minimum ; , Disconnect t rx 1 /4" Weep �g Baffle Hole P A {' ar gf pNoved FAI B ejk%✓4/ev t On ' C t� Br. P Ae *APPROVED o, Off Coyer- y , JOINTS WITH APPROVED PIPE D 3' ONTO Conc. �lecK SOLID SOIL 1 4C_ /�' s 3" of Bedding Under Tank-� d'u.� �wwn f�clrld+^g•r vil se.�a a1t`.,dt�+ �i r-c�i 7„S' Number of Doses: ,�- 7Per Day Gallons Per Day/ ofi-Doses• &V Gal )o�.s Volume of Backflow:�s��`! Gall��s Tank Manufacturer: e14 Total Dose Volume .. . . . . . . . .. /G/ Gal Ions Tank Size-Septic/Pump: 14%vo UV Gal ons nl arm Manufacturer: S 1' zE A 7 µs Model Number: /-,>"— P. Capacities: A 2--)— inches or 367 Gal Ions Switch Type af� + B 57 inches or� GalIons Pump Manufacturer: C-4 + C 2 inches orb+Gallons Model Number: + D inches or�_Gallons Minimum Discharge ate: aC7- p Total . . . . .= inches orb a l 1 ons vertical Difference Between Pump Off and Distribution Pipe: ` / Feet Minimum Required Supply Pressure: . . . . . . . . . . . . . . . . . . . . . . . . S--Feet /-�b Feet of Force Main x O Ya.Friction Factor/100 Feet: + e e t _Inch Diameter Force Main Total Dynamic Head:. . .=,;Z-'°gFeet Iniernal Tank imensions: LengthlSom; Width efl%?, Liquid Depth /!r/c � „ f�is.eGr CY2 ,A- 8ii. ar -- Efth tft iun t� 1 1 3871 EP04 EP05 APPLICATIONS •Fasteners:300 series =no erged in high ■Motor Housing:Cast iron Specifically de igned for the stainless steel oil for for efficient heat transfer, ffollowing use 'Capable of running lubrication and efficient strength,and durability. llowi Effluent use ms dry without damage to heat transfer. ■Motor Cover.Thermoplas- •Homes components. Available for automatic and tic cover with integral handle •Farms Motor. manual and float switch attachment •Heavy°duty S imp • EP04 Single phase:0.4 HP; mama operation. M.Au nip a Points. 115 or 230 V,60.Hz,1550 •Water transf r Float Switch assembled and ■Power Cable:Severe duty •Dewatering RPM,built in overload with p of the factory. rated oil and water resistant. automatic reset ■Bearings:Upper and lower SPECIFICATH N • EP05 Single phase:0.5 HP, heavy duty ball bearing 115 V,60 Hz,1550 RPM, Pump:EP04 built in overload'with ■EP04 Impeller.Thermo- construction. • Solids hand)ng capability: automatic reset plastic Semi-open design 1/4"meximu • Power cord:10 foot with pump out vanes for AGNCY SING • Capacities:u to 55 GPM. standard length,16/3 SJTO mechanical seal protection. •.Total heads: ip to 24 feet with three prong grounding 0 EPOS Impeller Thermo- • Discharge s' :11/i NPT. plug.Optional 20 foot . (CSA listed model numbers •Mechanical eal:carbon- length,16/3 SJTW with Plastic enclosed design for end in"F"or"AC".) rotary/ce c-stationary, three prong grounding plug Improved performance. BUNA-N elic tomers. (standard on EP05). ■Casing and Base:Rugged •Temperature thermoplastic design provides 104°F(4.0°C continuous superior strength and 140oF(60°C intermittent corrosion resistance. • Fasteners:NO series METERS Fear stainless stei I. 10 I i • Capable of rL nning dry,without c amage to s 30 components i Pump:EP05 s • Solids handling capability: 0 7 i Y4 maximu W • Capacities:u)to 60 GPM. x s 20 •Total heads: ip to 31 feet. g i • Discharge si e:11r�"NPT. z 5 • Mechanical :carbon- 9 15 rotary/ceram c-stationary, -+ 4 BUNA-N a 0;mers. c •Temperature 3 ao 104°F(40°C continuous I i 140°F(60°C intermittent. 2 i s 011(" 10 . 20 30 40 5o GPM 0 2 4 e S 10 12 m3m r CAPACITY 0 1995 Goulds P ps,Inc. EffecNe May,1995 83871 PpWTS OWNER'S MANUAL $ MANAGEMENT PLAN Page . F INFO ON SYSTEM SPECIFICATIONS owner S ;rUS4 ho Septic Tank Capacity gal Cl NA Permit# Septic Tank Manufacturer 4 f i es�t- O NA DESIGN-1:0=Bed ERS Effluent Filter Manufacturer PO f /o k D NA Number p NA Effluent Filter Model 0 N Number of Comm ' t Units p NA Pump Tank Capacity 66 gat DNA Esltanat flow{ ) d Pump Tank Manufacturer ;tg C r ❑NA Design flow{pea .(Estimated x 1.5) yda .Pump Manufacturer 0 NA Sod Application R tie s L-9 ayda Pump Model 0 NA lnilu�►t!E#fluent ty Monthly average' Pretreatment Unit a NA F p Sandt ts.Oct&Grease (FOG) Sap�- C�ravel Faber ❑ Peat Filter Biochemical xygen Demme (8OD6) :52W a91 D Mechanical Aeration ©�d Total uspended Solids OW. ) s15t1 G nufa tyrer Manufatctur'er Pretreated Effkmr t Quality • DNA Monthly average" Dispersal Cef!(s) Biochemical )"w Demand (BODs) :m mg/L D In-ground(gravity) D In-ground(Pressurized) Total E uspended Solids (TSS) s30 mg1L D At-grade D Mound Fecal cc fform(geometric mean) 51W c Wflooml D Dri D Other Maximum Effluen Particle Size Y"diameter ( ICIBQ wastewater and •- vak es for w*reeted wastewater. MAWENANCE S HEDUI ice Event Service Frequency Inspect condition f tank(s) At least once every D months D years) (Maximum 3 yra-) Pump out con of tank(s) When combined sludge and scum equals one-third(Y3)of tank volume Inspect dispersal (s) At least once every D months year(s) (Maximum 3 ym.) Gleam effluent r W- At Wag once every �mo �sy Inspect pump, p controls$alarm At l�once every jCO3 e ars) fl NA Flush laterals anc pressure test At West once every D months D year(s) ❑NA Other. At least once every D months D year(s) D NA Other: At(east once every O months D year(s) 17 NA 1ri�' - heeeay..ws..lit s �x,�'p Aflfep- dsee vtry,yyr�ts,tveYtto.. .s d t rt MAINTENANCE i STRUCTIONS Y,- c/e.►r, rt/drr- every P#41 to i voi ar & P•'—LA—PP-4 d-r•1ho inspections of tar ks and dispersal cells shall be made by an individual carrying one of 67e following licenses or certifications: M Plumber,Master Plumber Restricted Sewer, POWTS Inspector,POWTS Maintainer;Septage Servicing opera r. Tank inspecl�ns must k#ide a visual Inspection of the tamlc(s)to ident#!y MY missing Or Woken hardware,iden- any cracks or leaks,measure the volume of combined sludge and scum and to check for any beck up or poM"of a ent on the ground surface. The dispersal cogs)shad be visually inspected to dwic k the effluent levels in the obsetvatio pipes and to check for any ponolng of effluent on the ground surface. 'The ponding of effluent on the ground surface ff ay indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combir ed accumulation of sludge and scum in any tank equals one-third(Y,)or more of the tank volume,the entire contents o the tank shall be removed by a Sel fte Servidng OPerabor and disposed of In accordance with ch.NR 113, Code. The servicing of ffluent filters, mechanical or pressurized POWTS components.pretreat9ment components, and any other maintenan or monitoring at intervals of V months or less shall be performed by a certified POWTS Maintainer. A service report hall be provided to the local regulatory authority within 14 days of compIetion of any service event START UP AND C PERATION. For new constu tion,prior to use of the POWTS cimcik treatment tank(s)for the presence of painting products or other chem*:als that m y impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have th contents of the tanks)removed by a septage servicing operator prior to use. Page y! of System start ups all not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be 1 discharged to the dispersal cells)in one large dose, overloading the oell(s)and may result in the backup or surface discharge of effluent To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or pa rk vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or:elim nation of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: a n9blobcs; baby wipes;cigarette butts;condoms;cotton swabs;degreasers; dental floss; diapers; disinfectants; fat; bundatl6n drain(sump pump)water,fruit and vegetable peelings;gasoline; grease; herbicides; meat scraps; medicati s; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONt4 F When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to Insure that the system is property and safely abandoned in compliance with ch. Comm 83:33,Wisconsin`Administrative Code: • All piping I o tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The conte is of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After puml iing, all tanks and pits shall be excavated and removed or their covers removed and the void space filled withoil, gravel or another inert solid material. CONTINGENCY PL kN If the P S falls and cannot be repaired the following measures have been, or must be taken, to provide a code compile t replacen ient system: A suitable placement 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 infringe I 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 replaceme it area. Replacement systems must comply with the rules in effect at that time. • A suitable eplaosment 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 he not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evalua ion must be performed to bate a suitable replacement area. If no replacement area is available a holding tan may be installed as a last resort to replace the farted POWTS. • Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltra' e surface. Reconstructions of such systems must comply with the rules in effect at that time. «WARNING>> SEPTIC, PUMP M D OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMN ENTS POWTS INSTALLER POWTS MAINTAINER Name if ' Name Phone -Phone SEPTAGE SERVICIN OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name I 0A e 1` L Agency `'s°t 0 r4-),,K' Phone �� '�� Phone .3�, .' yr°V This document was dra by the staffs of the Green Lake,Marquette and Waushara County Zoning and sanitation agencies. This document meets ;he minimum requirements of ch.Comm 83M(2)(b)(1)(d)&M and 83.54(l).(2)&(3),Wisconsin Administrative Code. Use of this document does not guarantee the performance of the PO4VTS. GMW(2/01) ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I ha e inspected the septic tank presently serving the FI n S © `14/4 SQ be, 14 residence located at: I/4, 1/4, Section , Town N, Range W, Town off 1CiLLhi4'1'ii1\i( , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my luiowledge, will conform to the requirements of Comm. 84.25, and it (they) al pear(s) to be functioning properly. ost recent date of service ' W4 3 D'd flow back occur from absorption system? Yes No�c (i no, skip next line.) proximate volume or length of time: gallons minutes C pacity: C nstruction: Prefab Concrete K Steel Other TV"anufacturer (if known): Age of Tank (if known): 9t., g *' % ILI (Licensed Plumber Signa e) (Print Name) s PJ 7 y (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) ST.CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT ''AND WNERSHIP CERTIFICAMN FORM owner uye Mailing Address Property Ad (Verification required from Planning&Zoning Department for new construction.) City/State IV, Parcel Identification Number C LEGALDF,SLRWn0N pap t of, A Property Location :ra , 'l4, Sec. ,T �P? N R W,Town Of Lh�[�LN Subdivision , Lot#�- Certified Survey Map# �� �9 , Volume Page# Warranty Deed# / 0 / �v l , Volume , Page# Spec house yes (✓ Lot lines identifiable -9 110' SYS'T'EM hLAINT ENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failurc to handle wastes. Proper maintenance insists of pumping out the septic tank every three years or sooner,if needed,by a licensed pumper. What you put into the system c affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilitie are specified in§Comm.83.52(1)and in Chapter 12-St.Croix County Sanitary Ordinance. The 1 oroperty 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 di osal system is in proper operating condition and/or(2)after inspection and pumping(if necessary),the septic tank is less than 1/3 1 Lill of sludge. Uwe the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set orth,herein,as set by the Department of Commerce and the Department of NaturalResources,State of Wisconsin. Cttfifications,tating that your septic system has been maintained must be completed and returned to the St Croix County Planning& Zoning Deputment within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s)of the property d bed above,by virtue of a warranty deed recorded in Register of Deeds Office. Number o beds ms 3 I fiNATURE OF APPLICANT(S) DATE ***Any inf Lion that is misrepresented may result in the sanitary permit being revoked by the Planning&Zoning Department.*** Include with his application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey neap if reference is in iade in the warranty deed. (REV.08/a 0 989395 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI CERTIFIED SURVEY MAP RECEIVED FOR RECORD 11/21/2013 08:41 AM EXEMPT *: LOCATED IN THE NE 1/4 OF THE NW 1/4 OF SECTION 30, T28N, R18W, REC FEE: 30.00 TOWN O KINNICKINNIC, ST. CROIX COUNTY, WISCONSIN, PAGES: 2 INCLUDI G ALL OF LOT 3 OF THE CERTIFIED SURVEY MAP RECORDED IN VOLUME 20, PAGE 5152, DOCUMENT NO. 817161. W 1/4 CORNER OWNERS &SUBDIVIDERS SECTION 30 DANIEL SHAW & MARY SOBOTA BEARINGS REFERENCED TO THE T28N, R 18 (ALUMINUM CAP) 1 EAST-WEST 1/4 SECTION LINE OF SECTION 30, T28N, R18W, RIVER 65 ER FALLS, WISCONSIN 54022 ASSUMED TO BEAR N 88'19'42" W. LOT i' 1.281 ACRES 14jO�p°�' �$l Ii 55,790 S.F. `52 �,,°. SCALE IN FEET i LOT 2 C.S.M. VOL. 20__ PAGE 5152 `" z 0 40 80 160 DOC. NO. 897161 A, -r2 rho Co d s4s° 80 �� LEGEND LOT3,C.S.M. N VOL. 25____ ,p �- co 4,53°o6_ F'�' N COUNTY SECTION CORNER D��.-NO.817161 0 3'� ® MONUMENT, FOUND � N 2 3/8" o.d. IRON (TYPE NOTED). O 00 H S3 9 �, " 9b IRON FOUND. rAgS 6 - .� ,\ _ ^�• N PIPE, FOUND LO s 9 :Ste•-�� O p �O ` • (1 1/4" o.d. UNLESS 3 I POIN OF 3J C,yb VIL �;. �'/ \ OTHERWISE NOTED). BEG 11 NING Q p N 1 �4j6y�o �oylO� 1 1/4" o.d.) x 24" IRON PIP `V ` o� WEIGHING O 1.68 LBS./LINEAR rn eh O \ o FOOT, SET. 00 2 See \•\ /r w Z i �F— - - FENCE. z Pipe BUILDING SETBACK LINE AS A Note t\,e�o9 °J�� / _ _ _ _ _ SHOWN ON C.S.M., V. 20, O 1 \/ LL1 P.5152, DOC. NO. 817161 w o� ♦/ o (100' FROM R.O.W.). ® � J� rz 7r N WELL. 0 r, ,r��s� / °6=`_"�'tiC / ® ® 1 SEPTIC OBSERVATION Z \ J/` / x PIPE. 1> 30° • ^ PREVIOUSLY RECORDED 6hi �s`�?�¢7•. � S 3?e Ryes ^row�e. (80.38') INFORMATION. SOIL BORING PERFORMED X993 ?> ® BY CHARLES WEBSTER I \ \ ON APRIL 27, 2013. 99S J \ E 1/4 CORNER tai +\ SECTION 30 qtr 0�y \ S 3 Pipe Note: ® T28N, R 18W \�'}\?g A 1" o.d. iron pipe was found MARK SURVEY\ ��_7 JP��� \ ?X S 56°43'24" E 1.55'from the MARK" NAIL) \ ��► `\� \ /Y found 1 114" o.d. iron pipe. rainwewrnnnu \ \ \ \ ?S.9 ANIEL P. KUGEL _ 4„ S-2684 = DANIEL P. KUGEL S-2684 JOB - REGISTERED LAND SURVEYOR IVER FALLS, = OGDEN ENGINEERING COMPANY 1234 SOUTH WASSON LANE WI RIVER FALLS, WISCONSIN 54022 o J $l.)R DATE: AUGUST 20, 2013 REVISED: SEPTEMBER 13, 2013 THIS INSTRUMENT DRAFTED BY DANIEL P. KUGEL PAGE 1 OF 2 1 of 2 Vol 26 Page 5984 ► 8196319 State Bar of Wisconsin Form 1-2003 TX:4163112 WARRANTY DEED 989394 BETH PABST Doct ulent Number Document Name REGISTER OF DEEDS ST.CROIX CO.;WI THIS DEED.made between Charles G.Luick,a single person 11/21/2013 08:35 AM EXEMPT#. NA REC FEE: 30.00 TRANS FEE: 27.00 ("Grantor,"whether one or more),and Daniel B.Shaw and Mary T.Sobota, PAGES: 1 husband and wife as survivorship marital property ("Grantee,"whether one or more). Grantor ffir a valuable consideration,conveys to Grantee the following described real Recording Area estate,together with the rents, profits, fixtures and other appurtenant interests, in Name and Renlrn m�� Address` St.Croix County,State of Wisconsin("Property")(if more space is I SO DOA 0. needed,p ease attach addendum): '\ �It A parcel of Is d located in the NE 114 of the NW 114 of Section 30,T28N.RISK Town of Kinnickinnic,St.Croix County, 0 I _(/ Wisconsin,d scribed as follows:Commencing at the E 114 comer of said Section 30;thence N88.19'42"W(bearings referenced to t e f Fa(.(5, WT S •0 Z 2 the East-Wes 114 section line of said Section 30,assumed to bear N88.1942"W)3005.85'along said East-West 114 section One; thence N01.4'18"E 1825.67'to the Point of Beginning;thence N56.35'26"W 172.14'along a north line of Lot 3 of the Certified Survey Map r Icorded in Volume 20,Page 5152,Document Number 817161;thence 533.24'00"W.60.18'along a west line of said Part of 022-1087-20-000 Lot 3;thence N62'00'33'W 114.03'along a north line of Lots 2 and 3 of said Certified Survey Map;thence S45'1 1'14'W 80.21' -------------- along a north line of said Lot 2;thence N50.21'58"W 210,35'along a north line of said Lot 2;thence 580014.46"E 352.62';thence N88.05'12"E 41.14';thence 556651'47"E 71.67';thence 332.44'27"W 96.85'along a northerly right-of-way line of S.T.H.65 to the Point of Beginning. Parcel Identification Number(PIN) This parcel c ntains 0.768 acre,more or less,being 33,455 square feet,more or less. Subject to all easements,restrictions and t covenants of record. This is humeslcad properl.y. (is)(is not) Grantor warrants that the title to the Property is good,indefeasible,in fee simple and tree and clear of encumbrances except: easements, restrictions and reservations, if any, of record. Dated WVzoL, aD r v�0 3. (SEAL) c:v (SEAL) * *Charles G.Luick (SEAL) _(SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF W/ - ) )ss. authentic fed on �1 4UnC4j_ COUNTY) Personally came before n1c on - * ...kA A 31„ •,, the above-named Charles G.Luick,a single person TIrrL;'L MI .K43tR STATE BAR OF WISCONSIN -- If n i o t to me known to be the person(s) who executed the foregoing uthgrized by;Wis7.Stet. 706.06 ENE-O instrument and acknowledged the'sane. Notary Public THIS LN TRUNIEN.T.DRAFTED BY: State of Wisconsin * — ---- Leo A.B skar'Rodli„Be'skarr Krueger&Pletcher,S.C., Notary Public,State of _ 214 N:+M iri'S't'reet!;River Falls,WI 54022 My commission(is..pP�t)(expires:__( (Signatures may be authenticated or acknowledged. Bolh are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATION'1'O THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRAi\'ry DEED ©211113 STATE BAR OF WISCONSIN FORA NO.1-21)(1.1 *Type naire below signalures. INFO-PRO'°Legal forms•(600)655-2021•mloprolum,s.com 1 of 1 1 ice. Wisconsin Del artment of Commeroe MAY 0 2 20 j jS0I L E TI ORT Page / of Division of Saf ty and Buildings in accordance with Comm 85,Wis. Adm. Code ST CROM COUNTY County St Attach corrw fete site plan on paper not less thin Sn/2 x 11 inches in size.Plan must include,but iot 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. O a jZ/o i 6 7..Z oQ Please print all Information. R Personal inWrnation you provide may be used for secondary purposes(Privacy Law,a.15.04(1)(m)). /3 Property Owner T— Property t on C A r I s ✓ r t p� -� C/� r u n e rs) N E 114 NM 1/4 S 3 T.4 CT N R W Property Owne's Mailing Address of# lock# Subd.Name or CSW P Ct cC-e 6;r tz- city _ State zip code Phone Number ❑V"" JST Newt�� /i','ve���a�,� �' �•02,.2 ( � ��, hoc�.� - r c N ❑ New Consb uction Use Residential/Number of bedrooms _ Code derived design flow rate S GPD Replaoeme t ❑ Public or commercial-Describe: Parent material 4 cress Flood Plain elevation if applicable ft• General oommiants .� S tc� Qc� J`ot- ia�v_ok 6c<�f�YS' and recommen ations: �O/e cs,•r 7`�e �bs n '7� q -ry,� rte,., ,, 4 lit C'-10 2 s'CA cs �L. l'G C C"�'f/+1 a// leac•d h c�,ar,,6ersQtl - qt. �c�f/r O7� /� to 3 �f N�aX:.s�kr�s, 7;- c, 4c-s 10 o" s-,�����d eve, K. tcs� a des /o a. -� -r - Boring 1 0 Boring 5/1 Pit Ground surface elev. �a 3"s ft. Depth to limiting favor 6 in. Soil lication Rate Horizon th Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW i . Munsell Qu.Sz. Cont.Color Gr.Sz.SK -Efr#1 "Eff#2 Il- oY�t /� — s 1 6 r a s 2 a. s o /e 7/ —f ' s rs s s — C:2-5 /_ O o-70 M ZA f Z-r-h -8 tt om Iry C2.0 O. D can t-eh Boring Boring ,��,�� , Pit Ground surface elev./a6 ft. Depth to limking factor in. Sol lication Rate Horizon De h Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW i . Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Efr#1 'E D G S �r q s d. / v - s Or �,, o, /,0 �i.0 CbtiS, 'Effluent#i1 =BOD >30:<220 mg(L and TSS>30:E 150 mg/L 'Effluent#2=BOD <30 mg/L and TSS<30 mg/L CST Name(Flease Print) a CST Number Cti Q / s we.�s tPf- r 1.t o 9-7 3 . Address Date E Conducted Telephone Number Property Owner h "�e� X � Parcel ID# ®r�-�/ p 19 7 000® Page of-� Boring# ❑ Boring Pit Ground surface elev. f O-C ft. Depth to NnittiirV factor l50 in. Soil Application Rate Horizon Dept I Dominant Color Redox Description Texture Structure Corsi Wwe Boundary Roots GPDKe in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'EfF#1 I -Eff#2 !� O' 7A Z 70 S C2 A' 1MI� V, OL / f ® Boring# ❑ Boring ,(" � pit Ground surface elev. al«3� ft. Depth to limiting factor �in. Application Rate Sod Horizon Dept Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu.Sz. Cont Color Gr.Sz.Sh. "Ef#1 'E d.9 z IPP O_ /C7 + 3 U• d�a y 71 _ T 0j-'46j CIP 73 C' art 4v.' ` ,6 rent r t, ►�t v., �t Boring F-1 Boring# Ground surface elev. ft. Depth to limiting factor in. El pit Soil Application Rate Horizon Dept Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 "Eff#2 Effluent#1 =BOD,>30<220 mg/L and TSS>30<150 mg/L •Effluent#2=BOD,<30 mg/L and TSS<30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or reed material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330(R.07/00) A s Z� �r P��pmse ✓ Pw-p_ �ih� 'Q q(�.t fw h b hi \ / kS t � �' � �O •rte o� s 1 � � R l.. P r ro n n _ PF�k..,c.aC �'-�, w. � �r���s c d, C�!�aat✓ � � � � � �'�� D 57AkW i b * "��✓A d dr�st / 9 f N y 6S- ©p Q �C rl Parce �� y.f`��va P�.�c/1"•P o•�t.2.1o87Zcw ' �, � 41 p L. tzs A zR q A A M i n Q Q rt p r n� i'� p r r ti e 4,:" i F Aa CL QQ 0 • r of n IL c, . kAj v � w eC s u y ; Fsa4 Ni ..,, �. d 'S`a ".C 'a 1 / M '\ i ` t / / NE E 2 Y� T ft "ate t f , k r a F ` =.3 • f AA z v IM RW �,�.: ,�.! 3� ,�'/ vA '{" v °,�.� .�iM+ .f�cK�a`.�i.�°��� ._\ �a 3 ,,, �v '' ✓e�:i, .., y u�� 3 F .. fps G Y a Fi'1 xiP TIZ c 3 h � , a y � $� r« to v a j is Y iJ y� . R Z CERTIFIED SURVEY MAP LOCATED IN THE NE 1/4 OF THE NW 1/4 OF SECTION 30, T28N,R18W, TOWN O KINNICKINNIC, ST. CROIX COUNTY, WISCONSIN, INCLUD G ALL OF LOT 3 OF THE CERTIFIED SURVEY MAP RECORDED IN VOLUME 20, PAGE 5152, DOCUMENT NO. 817161. W 1/4 CORNER OWNERS & SUBDIVIDERS I SECTION 30 BEARINGS REFERENCED TO THE T28N, R 18 DANIEL SHAW & MARY SOBOTA EAST-WEST 1/4 SECTION LINE (ALUMINUM CAP) HWY 65 OF SECTION 30, T28N, R 18W, RIVER FALLS, WISCONSIN 54022 ASSUMED TO BEAR N 88019' 42" W. i i 1 LOT 4 °h � h i ' 1.281 ACRES I loe 55,790S. `5� �,�o SCALE IN FEET i LOT 2 C.S.M. V_OL_._20_ W PAGE_51_52 0 40 80 160 DOC. NO_ 17161 co cv o LEGEND ° LO_13 N yo—L-2-01---- �W- 1 00 PAGE 5152 4,3 06- F A to COUNTY SECTION CORNER DOC.-NO.817161 �3,o�, 3 MONUMENT, FOUND N --- -- stp 2 (TYPE NOTED). rs, 6'J F o o; O 2 3/8" o.d. IRON 00 V�n 00 i 330 9- N��li .1 O PIPE FOUND. 45�8%�8-- ��`'� 2/p ^�� IRON PIPE, FOUND 0 Rso�3 5>•,�J,0 p �O ` • (1 1/4" o.d. UNLESS POIN OF J F 6 w OTHERWISE NOTED). BEGI NING °� pryO�./ 3 1 c�1, 0 �' 1 1/4" o.d.) x 24" ��(v 1' L� IRON PIPE WEIGHING O FOOT,SET LINEAR 00 1 ed See \'� / w Z i X --X FENCE. Z Pipe �0� ��, / iv BUILDING SETBACK LINE AS Note O.\�e �� / p I SHOWN ON C.S.M., V. 20, W -'- - - - P.5152, DOC. NO. 817161 #j/ � (100' FROM R.O.W.). �� s ,r / /* I ° R / Z _I x WELL. x SEPTIC OBSERVATION o PIPE. r i Z �� / <v \ S 3 • PREVIOUSLY RECORDED s'�°24• S 9 ^ � (80.38') INFORMATION. ►'� . .� g 3 G co (0, \?s ly 2OgA 8s" ^^ SOIL BORING PERFORMED ��- 9 BY CHARLES WEBSTER \ \ * '93• ON APRIL 27, 2013. I 998 J \ SEC/ON 30NER \s \ ���,� +\\ S 3 ° Pipe Note: T2ft R 18W y��� \\ st¢, A 1" o.d. iron pipe was found (STE �L "SU,VEY �\ \ 2),, S 56 043'24" E 1.55' from the MAR NAIL 6'3► \ \ iy found 1 1/4" o.d. iron pipe. \ 289 �\\a\Iauouln 0 Al °Ilniiip� \ h \ 92, lby ' DANIEL P. KUGEL = '$ANIEL P. KUGEL S-2684 JOB #13-3208 4', S-2684 = REGISTERED LAND SURVEYOR RIVER FALLS OGDEN ENGINEERING COMPANY 1234 SOUTH WASSON LANE '9 RIVER FALLS, WISCONSIN 54022 so R��a��,� DATE: AUGUST 20, 2013 "�����I I I f 111111111111111\\\\\\�� THIS INSTRUMENT DRAFTED BY DANIEL P. KUGEL PAGE 1 OF 2 f - CERTIFIED SURVEY MAP LOCATED IN THE NE 1/4 OF THE NW 1/4 OF SECTION 30, T28N, R18W, TOWN OF KINNICKINNIC, ST. CROIX COUNTY, WISCONSIN, INCLUDING ALL OF LOT 3 OF THE CERTIFIED SURVEY MAP RECORD ID IN VOLUME 20, PAGE 5152, DOCUMENT NO. 817161. SURVEYOR'S CERTIFICATE I , DANIEL P. KUGEL, REGISTERED LAND SURVEYOR, HEREBY CERTIFY THAT I HAVE SURVEYED, DIVIDED, AND MAPPED THIS CERTIFIED SURVEY MAP LOCATED IN THE NE 1/4 OF THE NW 1/4 OF SECTION 30, T28N, R18W, TOWN OF KINNICKINNIC, ST. CROIX COUNTY, WISCONSIN, INCLUDINC ALL OF LOT 3 OF THE CERTIFIED SURVEY MAP RECORDED IN VOLUME 20, PAGE 5152, DOCUMENT NO. 817161 AND IS DESCRIBED AS FOLLOWS: COMMENCING AT THE E 1/4 CORNER OF SAID SEC ION 30; THENCE N 88°19' 42" W (BEARINGS REFERENCED TO THE EAST--WEST 1/4 SECTION LINE OF SAID SECTION 30, ASSUMED TO BEAR N 88 019' 42" W) 3114.37' ALONG SAID EAST--WEST 1/4 SECTION LINE; THENCE N 01°40' 18" E 1717.03' TO THE POINT. OF BEGINNING, SAID POINT OF BEGINNING BEING THE SOUTHMOST CORNER OF SAID LOT 3; THENCE N 56°43' 24" W 86.84' ALONG A SOUTH LINE OF SAID LOT 3; THENCE N 33°18' 57" E 45.93' ALONG A SOUTH LINE OF SAID LOT 3; THENCE N 56 034' 01" W 80.92' ALONG A SOUTH LINE OF SAID LOT 3; THENCE N 33 013' 26" E 40.60' ALONG A SOUTH LINE OF SAID LOT 3; THENCE N 62°00' 33" W 82.91' ALONG A NORTH LINE OF LOT 2 OF SAID CERTIFIED SURVEY MAP; THENCE S 45°11' 14" W 80.21' ALONG A NORTH LINE OF SAID LOT 2; THENCE N 50°21' 58" W 210.35' ALONG A NORTH LINE OF SAID LOT 2; THENCE S 80°14' 46" E 352.82' ; THENCE N 88°05' 12" E 141 . 14' ; THENCE S 56051' A-7" E 71 .67' ; THENCE S 32°44' 27" W 96.85' ALONG THE NORTHERLY RIGHT—OF—WAY LINE OF S.T.H. 65; THENCE S 30°2441" W 9.93' ALONG SAID NORTHERLY RIGHT—OF—WAY LINE; THENCE S 47 044' 43" W 144.05' ALONG SAID NORTHERLY RIGHT—OF—WAY LINE TO THE POINT OF BEG INNIN . THIS PARCEL CONTAINS 1 .281 ACRES, MORE OR LESS, BEING 55,790 SQUARE FEET, MORE OR LESS. SUBJECT TO ALL EASEMENTS, RESTRICTIONS, AND COVENANTS OF RECORD. I CERTIFY THAT I HAVE MADE SUCH SURVEY, LAND DIVISION AND CERTIFIED SURVEY MAP BY THE DIRECTION OF THE OWNERS OF SAID LAND, THAT SUCH MAP IS A CORRECT REPRESENTATION OF ALL THE EXTERIOR BOUNDARIES OF THE LAND SURVEYED AND THE SUBDIVISION THEREOF MADE, AND THAT I H VE FULLY COMPLIED WITH THE PROVISIONS OF CHAPTER 236.34 OF THE WISCONSIN STATUTES AND THE SUBDIVISION RULES AND REGULATIONS OF ST. CROIX COUNTY IN SURVEYING, DIVIDING AND MAPPING THE SAME. DATE: AU UST 20, 2013 NIEL P. KUGEL 8-2684 JOB #13-3208 `���aa��atutttittup//uq/i�� REGISTERED LAND SURVEYOR CO IVS+���,y�y' OGDEN ENGINEERING COMPANY 1234 SOUTH WASSON LANE RIVER FALLS, WISCONSIN 54022 DANIEL P. KUGEL = OWNERS & SUBDIVIDERS S-2684 = DANIEL SHAW & MARY SOBOTA RIVER FALLS, 190 HWY 65 <9 NI �p �' RIVER FALLS, WISCONSIN 54022 �''���yillllllloaf lt 111 EXEMPTION VERIFIED UNDER SECTION 13. 1 B.3.a.3 OF THE ST. CROIX COUNTY LAND DIVISION ORDINANCE AND SECTION 236.45(2)(a)(4� OF THE WISCONSIN STATUTES. BY DATE COUNTY TREASURER'S CERTIFICATE STATE 0 WISCONSIN ) SS ST. CROIX COUNTY ) 1 , LAURIE NOBLE, BEING THE DULY ELECTED, QUALIFIED AND ACTING TREASURER OF THE COUNTY OF ST. CROIX, DO HEREBY CERTIFY THAT THE RECORDS IN MY OFFICE SHOW NO UNREDEEMED TAX SALES AND NO UNPAID TAXES OR SPECIAL ASSESSMENTS AS OF 2013, AFFECTING THE LANDS INCLUDED ON THIS CERTIFIED SURVEY MAP. DATE LAURIE NOBLE COUNTY TREASURER PAGE 2 OF 2