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HomeMy WebLinkAbout020-1010-20-200Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) 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 Baum artner, Patrick & Barbara Hudson Townshi CST BM Elev: ( Insp. BM Elev: ~ 0 BM Description: P~c 1 = ego . o 0 ,a _ ~ 1~ 1/V~ TANK INFORMATION • v TYPE MANUFACTURER CAPACITY Septic ~(SC--~fL.. ZS~ Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ' ( ~ I -~^ Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufactu r errand G Model Numbe TDH Lift n Loss System Head TDH Forcemain ength Dist. to Well SO ABSORPTION SYSTEM I ~L ~ ... oaf ,. X ~/ ELEVATION DATA County: $t. CrDIX Sanitary Permit No: 430440 0 State Plan ID No: Parcel Tax No: 020-1010-20-200 Section/Town/Range/Map No: 10.29.19.43A10 STATION BS HI FS ELEV. Benchmark 5. D S f I ~ .O ~ Alt. BM .~O O~.g~ Bldg. Sewer ~.30 ~ .2.S' SUHt Inlet p, pp~ SUHt Outlet 1 Dt Inlet Dt Bottom Header/Man. q, 2s 16.30, Dist. Pipe i ~+ , R f . o $';(00 ~ Bot. System ~ (. ~ d •2 ~i ~ ~ Final Grade ULc St Cover (2~ . ; r:~ ~ r wun ~.v. -Ea~c RENCH idth ~ Length ( No. O Trenches PIT DIMENSIONS No. Of Pits Inside ia. Liquid Depth DIME SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Man factu r. INFORMATION CHAMBER OR ~ Type Of System: 'rn 1 ~ q 1 ~ ,~^ UNIT Model Number. f DISTRIBUTION SYSTEM Header/Manifold ~ Lengtlf~_ Dia~ Distrib Length Dia Spacing x Hole x Hole Spacing Vent topp,Air,ntake 7v SOIL COVER Y Pra~sura Svsfamw [)nlv YY Meund Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes ~ No ~ ~ Yes ~ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: ~~ ~ 3 Inspection #2: "- / Location: 1005 Cty Road A Hudson, WI 54016 (SE 1/4 SW 1/4 10 T29N R19W~NiLgt 1 ~ ~ P-ar ~ o: 10.29.19.43A10 . of ~~ `4, --G'~n`,~/ . I oo ~~~u~ 1.) Alt BM Description = 1 Em ~O~lMOC ~~, _ ^ /) ~ ~.~ ~~~~ ~. ~y~~ ~~ . 2.) Bldg sewer length = 9 ` ~ ('yVJ(,~,~,i~•+{ . -amount of co_ ver = ~ 8 k+• ., Plan revision Required? ®Yes No d ~ ~ ~' Use other side for additional informs ion. ~*.!1 Cam- ~S ~ Atheh compkte pleas (to the Cauaty Daly) for the system oa p not less rhea ~~-.~- SBD-6398 (R. 08/02) ~~ ~ ~ eS 0~'t Safety and Buildings Division County ,,. ` m m 20i W. Washington Ave., P.O. Box 7082 GIZOt J( x ,SCO~S'In Madison, WI 53707 - 7082 Sanitary Permit Number (to be filled in by Co.) De artment of Commerce (608) 261-6546 30 Sanitary Permit Application State Plan [.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privacy Law, s 15.114(1 xm) P ro 'e ct Addr (if different than mailing address) ~ j ~ I. Application Information -Please Print All Information ~ ~ (ZD aQ /~/~SwJ, ~ f 5~{Q I (7 Property Owner's Name (~ !~ j ~ ~ pflt~pal # Block # UU3 P~tiY~-K~ ~ 13 13~4f~'vv~ b dZo ~a Property Owner's Mailing Address ~~ . ~,!~ OI x ~; JRt6pFrtY anon ~/~ _ ~ONWGC?F, IC= ]~ ~~~ S i ~~ City, State Zip Code Phone Number ect on / ~ '~ / fo ~ ~ 0 u ~ ~ 7 ~..~ 37 Z 5~ ~ s circle one) '/ T ~ N R~E W -~ / II. Type of Building (check all that apply) ~ $~ ~/~ non ~1 ; or 6 ~ _ ~1 or 2 Family Dwelling - Number of Bedrooms ~ .(~!t~ Subdivision Name CSM tuber y ^ Pubtic/Commereial -Describe Use ^ State Owned -Describe Use i 2 ^City ^Village )l~fownship of (•fthdfOy III. Type of Permit: (Check on e x on is A. omplete line B if applicable) ~ _ ~ r-- A. ~ New System ^ Replacement System ^ Treahnent/I-Iolding Tank Replacement Only ^ Other Modification to Existing System B• ^ Permit Renewal ^ Permit Revision ^ Change of [] Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber C>wner IV. T of POWTS S stem: Check all that a 1 Non -Pressurized [n-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filte Leaching Chain r ^ D ' L'ne ^ Gravel-less Pipe ^ Other (explain) V. Dis ersal/Treatment Area Informatton: '~j ~ ~1/ / Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation ~ ~ ~7 ! /'` VI. Tank Info Capacity in Total Number Manufacturer Prefab Steel Fiber lastiC Gallons Gallons of Units Concrete Constructed ass New Existing Tanks Tanks Septic or Holding Tank ~ ~~ Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assu responsibility for tallatton of the POWTS shown on the attached plans. PI b Name (Print) Plumber' gnatu M /MPRS Number Business Phone Number ups ~ ~i.s!- aG ~~ - ~ Plum 's Address (Street, ity , State, Zip e ~ / , / / f L ~! / ~ VIII. Dun /De artment Use Onl Approved ^ Disapproved Sanitary Permit Fee includes ound~vater ate sued [ ing Agent ignature S mps) ^ Owner Given Reason for Denial Surehazge Fee) ~~ ... (((/// ~ ~, 3 03 IX. Conditions of ApprovaVReasons for Disapproval 3 ~d ~ ~Q,,4J ? G~,~.n~- .S SYSTEM OW NEFt: ~ ~/ ~~ ~t,~¢ , (~,pQ yy~ lpp "•~yj~~ S2- OO •- effluent filter and ~yntivt. ~3 tic tank 1 Se ~~~h~-~~` ~ ` ~ , , p '~' ed /maintained l b ~ e servdc dispersal cell must al as per management plan provided by plumber. SBt PJ • 2. All setback requirements must be maintained ~ sys~ ~ ~CG~a/ UU, <;~~ .. ~ as per applicable code/ordinances. 3 3 .. ~ trnv,~. /O '~..o~, stn ttiaea .: ~ / - ~1 - J0o Z~ <_J ~~ l `' y~ N o' ~ T- a - ~~ ~-`~ ads ~~ ~ as ~~ - ~a ,, ~° > , ~~ ~ I ~P ~ ~~ ~~ .~ ~~ ~i ~~ Xa ,~ ~~~ ~ ~-e.~ ~~ - t~~ ~' c~. ~ ~ D ~sT ~ ~ ~ ~ b ~ s~s~ ~~ ~J~o~', ~~ .- ,~~-1 ~y~ 90 ~ ww'N ~o" ~ '~1 ~ y~,so ~ ~~~-~` . lo~~~ ~ _ ~ - l Q ~ Z. ~~ ~~ ~~ ~~ ! 1 ''- y~ n S~ ~- ~ ~y, ~, ;, ~ ~ ~~s ~ `,~~ ,~ ,~ a ~ ~~d~ f lie ,Q,~-t ~e-~u,~ ~~y. ~ ~ CST eh.~ ~ ~ ~~ ~G ~~~. yL' ww-^ ~o" ~ PAGE 3 OF~ ,~~ Ny I~~ n LOT# ~ T EGAL DESCRIPTION S~' ~Sw iq ,~~U T z 9 N.R. / `~ Ecor~ SCALE:I"= ~/D BM 1 ELEVATION ' rOO •O BM 1 DESCRIPTION }gyp o-~ l `~EUG ~'a-e BM 2 ELEVATION Y9~ ~d BM 2 DESCRIPTION do P ~ .~' l ~~ PSG ,0 ~'~'~- SYSTEM ELEVATION ~aP q S• Z O lbw ~t ~ `T s• O0 SYSTEM TYPE ~'rnn u c.n,-~-Pv .tio~,~ CON'T'OUR ELEVATION q,9. ~O a- lpr, . o ~~ • ~ ~ I _ ~ ~~ ~~ 5 ~~ ~~ ,,.~ ~w~ ~~ -~L-- SIGNATURE N -Wisconsin Department of,Commerce SOIL EVALUATION REPORT Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County ~r I Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must c..~T include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. ~2.0'"~d Please print all information. viewed by Personal information you provide may be used for 5.04 (1) (m)). l Property Owner perty Location Property Owner's Mailing Address -` 2-~2v ,;nlo~ ~-~. w econd -__aw.__. aw, s. °, P G . _ s~ . Grz;!ix r;~r PhonedfilHitltti' ~_ ' /~) ~4 -~ o Page ~ of !k Date ~~~ r a~~ 3/6; vt. Lot $ r 1/4S(,J 1/4 S ~(~ T Z N R I E (or)~ t # oc # Subd. Name or CSM# nS-~ 1~urk r~ -~ C- (~ ~~ Ci Village ®Town Nearest Road ° -"7r cQ ,SG '^ I GT~I b4- New Construction User Residential 1 Number of bedrooms '~-y Code derived design flow rate ~JC} l Co(Sp GPD ^ Replacement II ^ Pu_ublic or commercial -Describe: Parent material _ ~U't ~ Flood Plain elevation if applicable /~/ ft, General comments s~~ /C ~ ~~~ ~ ~ ~ ~~- ~ ~G w 2 r Qs- U U S/~„ l ~ ~-- and recommendations: ~1" J I C GZ~C.C~t~ ~~7~E'a' [lA -~ _ n Boring ~-~- ovnng ~ ® Pit Ground surface elev. /00•/ d ft. Depth to limiting factor _~~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlftz in. Munsell Du. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 ( O_I Z L0 z ~ , sfr 2 r~r^ c5 (v~ , 5 Z _ ~ 1 ( °` 5il 2 c~ , 5 3 3g-Gb ~~ - mS G ml - - .~ /.~ D Boring # ^ Boring 0 Pit Ground surface elev. /A~-O~ ft. Depth to limiting factor /C~l) in. Soil Appliption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ( Z ~-I 2 iZ-Z5 (0 3 I z I to ~' (_5 Z ~ rr~r rr~~r c-s cS l v ~ -' . 5 , ~ . $ (_ Z r_re._. _...,...... ,.. - ~....,5 - .,,. _ ~., ~. ~y, ~ a~ ~~ ~ ~~ Gov ~ ~ o~ mcy~ - r=muent rtz = F3UD5 < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) 'nature j ,,~ CST Number ,~' ~i i. t, _ly~'y~;o~ I SB1)-Ri1n rammm Property Owner ~~~~- Parcel ID # i Page ~ of 3 U Boring `" Boring # ®, pit Ground surface elev. ~`9 S° it• Depth to limiting factor ~ in• Soil Application Rate tion scri D d R Texture Structure Consistence Boundary Roots GPD/ftz Horizon Z Depth in. 0-13 I - Dominant Color Munsell (0 32. ~v p ox e e t2u. Sz. Cont. Color -' _' Si 1 Gr. Sz. Sh. i r cS c. I~~ i *Eff#1 . 5 'Eff#2 . ~ . $ ~~ ~~ - ~ ~, sue' -' ,~ ~ U Boring Boring # ^ pit Ground surface elev. ft. Depth to limiting factor in. coil Appliption Rate tion Descri d R Texture Structure Consistence Boundary Roots GPD/ftz Horizon Depth in. Dominant Color Munsell p ox e Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 U Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ^ Pit Soil Application Rate tion scri D d R Texture Structure Consistence Boundary Roots GPD/ftz Horizon Depth in. Dominant Color Munsell p ox e e Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 'Effluent #1 =GODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) PAGE 3 OF~ r; M Ny ~~x r T OT# T AL D RIPTION S~ ~Sw ~ ,~~U T Z 9 ,N.R. / `~ E(or~ SCALE:1"= yU BM I ELEVATION ' ((~ . D BM 1 DESCRIPTION }~,p p-~ / ``Q~G f,'p.e BM 2 ELEVATION ~y~ ~U BM 2 DESCRIPTION ~oP ~.~' ~ ,.~~G p,`~-C. SYSTEM ELEVATION dap R S• 2 U L~w.e r `~S• O0 SYSTEM TYPE ('rnn u c ~,~--yu .~.o~.~ CONTOUR ELEVATION ~9. S7~ a- lf?o - 0 ~-~• . / d I _ ~ ~ ~ ~ ' DATE (1 ~~~ ~ - G Z POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of 2 FILE INFORM ON Owner %~, ; Permit # ~ 1 DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ^ NA Estimated flow (average) ~ al/day Design flow Ipeak-, (Estimated x 1.5) ~''j gal/da Soil Application Rate s al/da /ft2 Standard Influent/Effluent Quality Monthly average" Fats, Oil & Grease (FOG) _<30 mg/L Biochemical Oxygen Demand IBODSI <_220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOOS) <_30 mg/L Total Suspended Solids (TSS) <_30 mg/L ^ NA Fecal Coliform (geometric mean) 510° cfu/100m1 Maximum Effluent Particle Size YB in dia. ^ NA Other: ^ NA "'Values typical for domestic wastewater and septic tank effluent. ~~nrwrTewrnw~rc erucnr u c SYSTEM SPECIFICATIONS Septic Tank Capacity ~~ al ^ NA Septic Tank Manufacturer ,(~,Q~ , ^ NA Effluent Filter Manufacturer ^ NA Effluent Filter Model ~~ ^ NA Pump Tank Capacity al ^ NA Pump Tank Manufacturer ^ NA Pump Manufacturer ^ NA Pump Model ~ ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ^ NA Dispersal Cell(s) ~In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA Service Event Service Frequency Inspect condition of tank(s) At least once every: ^ month(s- (Maximum 3 years) earls! ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third IY31 of tank volume ^ NA Inspect dispersal cell(s) At least once every: /~ ^ yea~(s11s) (Maximum 3 years) ^ NA Clean effluent filter At least once every: monthls) yearlsl ^ NA Inspect pump, pump controls & alarm At least once every: ^ monthls) ^ year(s) ^ NA Flush laterals and pressure test At least once every: ' ^monthls) ^ year(s) ^ NA Other: At least once every: ^ month(s) ^ yearlsl ^ NA Other: ^ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tankls) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY31 or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Page Z of 2 START UP AND OPERATION ' For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cellls). If high concentrations are detected have the contents of the tankls) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cellls) in one large dose, overloading the cellls) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or: must be taken, to provide a code compliant replac ment system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need•for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ~~ T - ~~c a o in an aluat' g~ be ' e ai a ~~01-~18 TC~2~. ~~ IJ>~ ~NS772(I~TIO ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER ,n n Name Phone - ' ~ ~ ~ POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name s^~-, t/' ( G V 20/l~l N Phone ~/S- 3~(O- (O C7 This document was drafted in compliance with chapter Comm 83.221211b1111(d1&Ifl and 83.54(11, 121 & (31, Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP C'::RTIFICA'I'ION FORM OwnerBuyer P~`~~.-tl;, IL (~q-y ~~. b,~->~1~NR- Mailing Address 1~3b 1~2~q-AJbL~ D~I~'~ ~~~-m~ ;w~ S~~~Z Property Address %o D~ C C~:v ~ rLA (Verification required from Planning Department for new ©r~ ~ uJ( 5~-rd i ~ ~ City/State 1-FV A S c,~ ~ ~ i Parcel Identification Number :. % ~ CJ -_ f %~ ~- ~Q= LEGAL DESCRIPTION Property Location 5 ~ '/., Subdivision 13t)~.~Ll~t /~ S~ '/., Sec. ~b . T Z~ N-R I~~' _W own of _ Certified Survey Map # ~ 6l ~ ~~ ~ ,Volume f (. ,Page # Lot # ~ at GSA, ~~ '7 Warranty Deed # 2'-f'1 ~ Volume ?~~lZg P ,Page # 2~° Spec house ^ yes 1~„ no Lot lines identifiable ~ yes ^ no SYSTEM 1VZAINTENANCE Impropez 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a masterplumber, journeymanplumber, restrictedplumber or a licensedpumperverifying that (1) the on-site wastewaterdisposalsystero is is proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of 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 Zoning Office within 30 days of the three year expiration date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION 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 deed recorded in Register of Deeds Office. ~~~_ a~ ,,.f,,... SIGNATURE OF APPLI ANT ~ /~Zy / 0 3 DATE ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** t{ViJSO~ ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed U 2~128P 026 I STATE BAR OF WISCONSIN FORM 2 - 2000 Document Number WARRANTY DEED This Deed, made between James D. Henry and Allan C. Nvhagen Grantor, and Patrick D. Baumgartner and Barbara J Baumgartner husband and wife Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Part of SE 1/4 of SW 1/4 of Section 10, Township 29 North, Range 19 West, St. Croix County, Wisconsin described as follows: Lot 1 of Certified Surve Map filed October 31, 2002 in Vol. 16, page 4407, oc. No. 696666. 742473 KATHLEEN H. KALSH REGISTER OF DEEDS ST. CROIx CO. , WI RECEIVED FOR RECORD 10/03/2003 01:00PIf ----__ MARRAHTY DEED EXEMPT # REC FEE: 11.00 TRANS FEE: 190.50 COPY FEE: CC FEE: PAGES: 1 Recording Area Name and Retum Address G': t: z c NS ,fr.4r ~ i3,a,.,,t 2Z.iz C~'~Sl`u. aw ~~•'~ 020-1010-20-100:020-1011-40-000 Pazcel Identification Number (PIN) This is not homestead property (is) (is not) Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. Dated this ~ ~ day of October , 2003 AUTHENTICATION Signature(s) James D. Henry and Allan C. Nyhagen * ames D. Henry c ~~_ * Allan C. Nyhagen STATE OF authenticated this ~~ of October , 2003 * Kristine Ogland TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stets.) THIS INSTRUMENT WAS DRAFTED BY __ Kristine Ogland, Anorney at Law 304 Locust Street, Hudson, WI 54016 (Signatures may be authenticated or acknowledged. Both are not necessary.) ACKNOWLEDGMENT ss. County ) Personally came before me this day of the above named to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. * Notary Public, State of My Commission is permanent. (If not, state expiration date: .) • Names of persons signing in any capacity must be typed or printed below their signature. INFO-PRO (80055-2021 www.infoproforms.com STATE BAR OF WISCONSIN WARRANTY DEED FORM No. 2 - 2000 • suRVEYr3n: DOUGLAS ZAHLER S6N LAND SURVEYING • E920 ENlOE STREET HUDSON, V( 51016 PRlPA/1ED POI! ALLEN NYHAGEN ~ J1N HENRY 1331 EVERGREEN DRIVE R1VER FALLS, Vl. 54022 SUIIVEYpPS CERTIFICATE ___r~ r~ I I I 9Iv i I I 1 I 1 4 DOIK,IAS J. 2A/S.ER, REGISTERED VISCONSIN LANG SURVEYOR, MfREBr CERTIFr~ THAT IN FULL COIPUANCE VITH THE PROVISIONS CIF CHAPTER 276 OF THE VISCONSIN STATUTES AND THE SUBO[VISION REGULATIONS OF THE TOVN OF HUDSON AND ST. CROIX COUNTY, ANO UNDER TIE DIRECTION Di ALLEN C NYHAGEN, 1 HAVE SURVEYED, DIVIDED AND NAPPED A PART OF THE SOUTHEAST QUARTER OF THE SOUTHVEST QUARTER OF SECTION l0, T29N, R19V, TOVN ~ HUDSON, ST. CRO1X COUNTY, VISCONS[I1, BEING LOT 2 OF CS.N. IN VOL.-_, PG____~ CONTAINING 16.618 ACRESI DESCRIBED AS FOLLOVL COMMENCING AT TIE SOUTH QUARTER CORNER 0T' SAID SECTION 101 riIENCE ALONG TIE SOUTH LINE OF THE SOUTHVEST QUARTER OF SA10 SECTION 10, S89'14'SO•V A DISTANCE OF 1272.02 FEETI THENCE ALONG THE EAST LINE D< COUNTY TRUNK HIGHVAY •A• N00•p1'37•E A DISTANCE OF s22.31 FEET TO THE POINT OF BEGINN[NGI THENCE CONTINUING ALONG SAD) EAST UNE OF COUNTY TRUNK M1GIIVAY •A• N00.01'37•E A DISTANCE OF 903.03 FEETI THENCE KONG THE NORTH UNE DF THE SOUTHEAST QUARTER OF THE SOUTHVEST QUARTER OF SAID SECTION 10 N119.50'35•E A DISTANCE OF 31569 FEE77 THENCE S01.02'07•V A DISTANCE OF 1772 FEETI THENCE S51'79'76•E A DISTANCE OF 197.12 FEET TO A POINT ON A 80.00 F00T RADIUS CURVE CONCAVE TO THE SOUTH, SA10 CURVE NAS A CENTRAL ANGLE OF 77'59'07• A CHORD TWIT BEARS NBI.OS'f03•E ANO MEASURES IOOb7 FEETI THENCE NORTHEASTERLY ALONG THE ARC Cx' SAlO of CURVE foe.ee FEETI THENCE N29.23.18'E A DISTANCE OF 333A3 I'EETt THENCE ALONG SA10 NORTH UNE OF THE SOUTHEAST QUARTER OF THE SOUTHVEST QUARTER N89.3075•E A DISTANCE OF 509.% FEETI THENCE ALONG THE NORTH-SOUTH QUARTER LINE OF SA10 SECTION 10 S00'00•l2•E A DISTANCE OF IIAS FEETI THENCE ALONG THE NpiTNVESTERLY L[NE OF THE PLAT OF RIVER PARK MEApOVS S/1.5297'V A DISTANCE OF i1S9.27 FEETI THENCE S89'11'S0•V A DISTANCE OF 197.86 FEET TO THE POINT OF lN:GINNING DATED TH[S________________OAY OF__________. 2002. DOUGLAS J. ZAHILER RLS 2115 S t N LAND SURVEr[NG, INC 2920 ENLOE STREET SUITE 101 HUDSON, VI 51016 1719 786-2007 ~>sz: II •~~ ~~e f 4~ _~ Ab. {m~ ~;t6 °Z~ C ,, gs ~~N O ~ Y B i ~g g~~ EEd 5~fi fi ~~ ~~%€ ~~~~ W ~~i COUNTY PLAT OF: B U R KHAR DT P RAI R I E LOCATED IN PART OF THE SE 1/4 OF THE SW 1/4 OF SECTION 10, T29N, R19W, TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN; BEING LOT 2 OF CERTIFIE SURVEY MAP RECORDED IN VOLUME _, PAGE DATE .~\ . .'_~ ~...~P ..'.'.'.. ~~ M.W.! ~917.0~ / 1.`...: Q.~ ... o`er.'......^..'..~i UTIUTT EASEMENTS NJgP6G14ui~D_dG1f~1R1D~ ®1'~'Ifb~DD [~T ~4G~46 ------------------------ N~•60'66'E 6C OR011,NE OF THE 8E 1N OF THE BVV 1N MOO 6 ~PC~ _ LOT a j ~ 4.228 ACRES ~ ~~ ~s % % ~a A?1 i ~ ••• ' ~ ' ~ ~ 9' • ~ `coo . i i HO POLE OR SUIIICO dM.Ei A/1E TO DE PlACEO SUCH TWIT TIIE INSTALLATION VOULO DISTURS ANY SURVEr STAKE, OR OBSTNIICT VISION ALONG ANY LOf LINE OR STREET LINE. THE BISTWBANCE OF A SURVEY STAKE BY ANYdE IS A VIOLATION OF SECTION 236.72 K VTSCONSIN STATUTES. UTILITY CASEMENTS AS HEREIN SET FORTH ARE F011 THE USE OF PUSLIC BOGIES ANO MIVATE PUSLIC UT0.ITIES IMVDKi THIS R1GHT i0 SERVE TIIE AREA iV m I LOT: ~ ~ ~ Le.a .BS1A I ~ I 2.aeti ACRES ~ ~'~1 ~' ~) ~ ~ LOT 2 ~ 2.017 ACRES 1 ~ (87,872 aq. R) q' ~~ I I 1 ~ ' % I -•~ Ha ~29ORABIAOEEASO,noaT ' , .O..S1A I ~ E I ~ o~ ~~ ~ ~ ~ _ . _ r -- - ~D.->r - ~; 1 i .......» .. ........ I i (Ii 1 Z I . a; I ~ I I 1 I p I I I I I As~/s I I ! i Q IN ~~~.~ ~Y)/{„'+v ~ ry LOT 4 ~J 2.330 ACRES LOT ~ v ~ not.QOew.rL) 2.311 ACRES n oo,6e2 aa. rt.) Q d~ 1) ~.~. ~~. ~a •~° rw+~-- 3 - ~ TOVN TREASURER'S CERTIFICATE STATE OF VISCOIISIN) calla aF sT. caocxlss. 1 SS ~ 918 ,% ~- ~ i • / LOT 6t•% ~ ~ 2.132 ACRES (105,04;eq.~; ~ ' ~' bo~ ," ~m. ~`,_ ~ ac~sr i OWNEA9 CIERTIFIOAT! OF OEDIOATION AS OVNERS, VE IEREri CERTIFY TIMT VE CAUSED THE LANG DESCRIBED ON THIS PLA BE SURVEYED. DIVIDED, NAPPED AND DEDICATED AS REPRESENTED ON TH1Y PLAT. VE , CERT(i'Y THAT THIS PUT IS REQUIRED BY 527610 OR 527612 TO BE SUBMITTED i0 THE F0.LOVING FOR APPROVAL DR OBJECTIOK ST. CROIX COUNTI' PLANNING. ZONING AND PMKS COMMITTEE AND THE TOVN OF MIDSON VITNESS THE HAND AND SEAL OF SAID OVNER TH[S__~__~_DAr OF___~____20p2, M THE PRESENCE OF. ALLEN NYHAGEN JIM HENRY STATE OF VISCONSDI )SS COUNTr OF ST. CROUO PERSONALLY CAME BEFORE ME TH[S"______DAY DF____________2p___, THE ABOVE NAMED ALLEN NYIMGEN AND JIM HENRY TO ME KNOVN TD DE THE PERSONS VHp EXECUTED THE fOREG0ING INSTRUMENT ANO ACKNOVLEOGEO THE SALE. NOTARY PUBLIC,______________~VISCONSIN, NY COMMISSION EXPIRES_________________ __~;~ ~_ LOT AREA TABLE w~ ~I ~I 'I I g' LOT AF ACRES 1 2.080 z 2.on 3 2.311 4 2.339 6 H 2.132 8 4.228 L TOTAL 1b.405 /8 ~ 2.687 AVEFVIOE '~ CURVE DATA TAB: ` AIL IPINQTHB ARH D1 PPJ 6~4 4_ CENTRAL cfloRO CHORD NUMBER FU,DBJS ANGLE a LENGTH C1 187.00 91'66'01• M4.04K8.6'E 91.89 C2 60.00 16.04M0' N96'31'61'E 81.32 C~ 60.00 32'02'63' N2D'04'12.6•E 41.17 w eo.oo 77'69'09' NBI'06'to.b•E 100.67 r,..~. ...... .~.~~ ...~ .~..... C6 80.00 80.28'02• S18.41M7•F trto oA r ~ • ' d~~ au~~ o~~ ®v s~a~va i •--------------------------------------------- ~ I NORIN LlE OP T1E eE /M OP7FE 91N 1N • ~ ~~ F7087l4g0~ 721 1 \ M 9z+ / ~ ass~E ~ ~ -~ I 1 I ~... ......:.............. I _ - _ _ _ x seu ~..:.... ems,,. .~ cAnAOe I al I ATER / 1 w 827 x seas x xes 1 II ' ' ~ . I ~HfW. • B7 O 9~ ~ ~~ ~ / X Ts \ ie~ / // oo~C X sus ~ ® l ~ I I ~~`911Y'f 1 ~/ s ~ I :. / a~rlEo I I I I ~~ ~ 1 0. ast.o ~ ~'( / o I_..- x x.a rl °°,;~R~'e ~ ~ L Ti 8 _ ~~ Resl I '~ I II X n.a X slag ~ i .I / a 1 fl( III ~ ~ ~, 1 ( ~ ~ I ~ / ~/ % , i i I II x I I I X ~. _' 1 r...~ ,. a; ~ y I~ ~ - x 'I'~ - • xse o, ~, -- --~ - - ~ y~2i I Oi ~ X 9i!0.3 .......... / /... ••/ It.a7 ~ .../ x; "~ x~ ~ :sa wcRes~ ~" T x o. IUi i l y ;:: . ~~ ~ la.os AcaES' 1 ~ ~ ~ ~ i ~ / C a, ~ 7 AC B X less ~ ~ ~ ~ ~ 9' I ~ x sze..: (~ woes) / e2 ~ X II I ,~~ ~ / / //~ x. '~ / ~ X ses.4 ~ ~; I y~ ~ 3/ x 9e~ ~ x i ...~~~^~-i r ~ ~ _ ' sar i T /~`' I c. ~ i J .. 4 [ ate! i x~: ~ \ I j~ ~ Lo ~ ~ ~~ X - \\ ( 2.Ye ACR ~ / \\ (Z.6a ACR \ II X ~ / \~ ' _~ u 4. I I I ~~~ \ ,.,..f. I ~ X!P ..::::.:. x ~ I, :;~~ 1 \, ~, ~ 4.~ \~ w ~ ~ / \. ~~ SEC170N 10. TZI .,n~~ DI14.1 ~ ~_ °'e i /. $a ~~, LOT AREA TABLE LOT II ACREB 1 4A6 4 4.31 3 2.90 4 234 6 2.42 e s.z3 7 2.04 B 2.02 AVEWIO6 4.06 sv POWER u - EA6EMB'Ii R W voL. s~ 0. i ~t,QQo 9 ~~ SIC . d~ ~ 9~s ~'h /~~!~ ~ ~~ I I _ ~ ~ .:;:::.A ._ ~ O081M DRNE , ~ ~ ,o~ ,, 80llf1A1F8T P ~' NOTE 1.a0. 017lE LOW lIILOP~9 OPEnwAO ODAM~ i O90fI0N 10 :~;;.-~ ~ >K t ~9A9B.BdI WINDOW OR DOp 0.. - _SB9M4'60'W 1154.22 - - BXWRI IK ~ ~,~eu. ae `soun+ur.I~oFir~sw, ii 11j.so'~~ ~ s[~ o ~ 6 Nore s~aaveLwrolro~-orowN7+e IEBPONOIOlf1E6 RE9AfbNA MANI® 41.91' - 44'S0'E RE7B'If10N.MEAB 7®LOI1~ 014T191 ~ d~ ~ ~ BEe 00VB4ANf~FOR IAT OWN6M NOTE REOPpI816LREi NP1iQYB~(IW06101 THEH LOT. NOTES: NO 011MER OR PIEODEN~8WLLL 00 ANYIHNO WI.CF1 WOULD.JfETIFEPE WIlf1 OR CFNNOETE OPERA71O/.OF TI9AWRO~V®COAPREHHJBNl WAT6NOMNIAOEM/O N07E EAGI PARCB /iFIOWIV ON 7XB M11P^ 80L ER031OPI PLAN FOR T}fB PLAT.7NE f40UlOFA 01lf 8119JEC~TO 6TAle. OOUMYW4D 10V E NOT l.lA1lfEDlO6U..ONJ01101{ OBfIR1OIN10, UWa RLLl6AND I~LATION6l.l.. AITEANO, F.l.MO OR EXGAVATNq OR PLANIMID N ANY WEIIMO, MN~aIM LOf 9Qt, ACOIM PdJD EIlOENIFNf9. WATER OFMNMIE DRCNF9. WA7E11 F BGTa6QOR MNIGMBNOOP PANWAYB, WATBi OULV67Ri, BFiM9OR 0RI199 OEVB.OP'NOAPIY LOT, OONMO~TE I 8®INOB' CF10o1COlWIV2ONN00PPICEANDT TOWN OF HABML SCALE NJ FEET 1' _ 60 OPOMIMY NNIH WATER MARK MID WEILMD LJMIfB E6TAOLI9FIED BY THE 6T. CROD10WNfY DONNCI OFRCE 9 OD 100 109pRW1 O y O N ~ ~ N fD O a UT Z A ca D a c O r. Z 0 -i v 3 3 3 Q ~ `, O m m C fD (D N Q.Q ZvQ d c O N ~. ~ '~~00. -n 00 j N ~ ~0~~~ to `~ C Q W O O qa~ ~ ~ U/ N.Dnv`G ~ ~ Q~~:~ ~ '°~O. (A fn >. O (p f cow w ~ao N ~ ~ O ~_ ~ n ~ V O O a m ~~WV~i ~~•~~ ~,OVa o nam 01~ai~G -O d m ~ ~, a °c S'' f ~ ~ m ^~ O v N ? ~ W ~ c co ~ a a c°ii can cn cn ~ ~ N N O O O fA ~q U! ~ ~ v v, A d ~ 3 d lD 7 w C ~ Z ~ O O ~c n > a"~ ~ ~ y ~ c ~. N N a (C5 O C a ~ ~ a O •" 3 ~! z f W G T C 7 a 3 d o ~ ~ 3 ~ ~ d C O N d IV Q O ~ ~ ~ ~ O ~ `O o O A N W O ~ O O 'o N o c 3 ;-• < W m o ~ rn d co ~ .~ ~ A O p. ~ ~ N A n _1 ,ZJ .r A Z O .. O m ~ ~ z A ~ O A d A~ IN C O O Cf ~• 0 ~` 0 ~• O A A n 0 N 0o N ~ w 'r v ~°., b 4 r ~ / .~ • , ' KATHLEEN H. IiALSH REGISTER OF DEEDS ST. CROIX CO.. WI PREPARED FOR: CER`T'IFIED SURVEY MAP LOCATED IN PART OF THE SE 1/4 OF THE SW 1/4 OF SECTION 10, T29N, R19W, TOWN OF HUDSON, ST. CROIX COUNTY, WISCONSIN; INCLUDING LOT 1 OF CERTIFIED SURVEY MAP RECORDED IN VOLUME 7, PAGE 2089. ~w ~ U~ ~ Zw ~ ~Oo~ r ¢J~u~ ~~Um QD~O C~7~wOw Zw0 pC=~~ t~O~Q - - f 6 9 6 6 6 6 VOL ~6 PAGE 4407 RECEIVED FOR RECORD 10-31-2002 1:30 PM CERTIFIED SURVEY MAP REC FEE: 13.00 COPY FEE : 3.00 SURVEYOR: DOUGLAS J. ZAHLER S & N LAND SURVEYING, INC. 2920 ENLOE STREET HUDSON, WI 54016 ALLEN NYHAGEN & JIM HENRY 1334 EVERGREEN DRIVE ~ i ' RIVER FALLS, WI. 54022 ~, Q ~ o~ a ~ I ~ ~I ~1 a~~~ M~n]I~~`u~C~D ~[y]D~ O nM]~n.]C~D ~ ~ ~4La4C~ i ~ ------------------------------------------------o---~ , 66 FOOT TEMPORARY ACCESS EASEMENT, TO BE EXTINGUISHF_D ON SOO 0012 E X41.05 COMPLETION OF PUBLIC ROAD. (SRg'46'42"E) NORTH LINE OF THE N89°50'55"E ~ 271.1 S' SE 1/4 OF THE SW 1/4 _ - - 9I0' ' ~ ~ ::345.by' c~ ~---- -- ~ 177.82' N01 °02'07"E ri oo'-: 1~~ ~`Sr i 12~~ SEPTIC- w~12' UTILITY 415.54' OT 3 ® ®H usE~ ~ s 9) ~ .y 12 ~-' i ~I Q' a~ ~~ ~~ i 00 ~ ~~ a' ~' - ~i Q i ~ ~ p; ~ n^~ ~~ N l/U i ~ ~ ~ N ~~ I ~ ~ O ~;Z~? ~ ~ ~' ~~ ~~ v~ ~ I ~' a~ i ~' i ~~ .9 EXISTING DRIVE TO BE REMOVED ~1 1369 CORNER SECTION 10 p~_ 4 O~ ~° °~~~ Mn~~r~~ I ~ ~ EASEMENT ~ ~ / '~ ~~ ~ M w -~- _/ - - L T 2' _ ~ I O FUTURE PU ROAD ~ ~ 5' POWER LINE / GARAGE w~.w ~ / / / ~ ~ 'oo, 35' / / ~~SHED /% / ~~~3 / %~ / / h~-l I ~~o ~ - - ~ ~ EASEMENT / / QOP ~~ ~~ G~, RECORDED IIV ~ , ~/ Q~ ~ ,~ ~,' O VOL_ 610~PG_50§ / / ~`'p~0 ~ a~p'~ OOH,' fi100 w ~ / / Q,~~o' .N .~.0 Qp ,, ~ ~ hti ~~ i ~ o~ o C~''~ N89°44'50"E 4 ~ ' 3 o d0~! ~ o QQ, OT 1 ~~y`? ~ ~~' ~1 / ~ ,ti \ a ~O ~,' i~ ~~~ d04 ~ ~ , N ~ O/~~ IN ~ ~ ~ ~. ~~ ~'~ 2.3'± ~ v ~. I zl ~I ~I ~+ O ~I ~I of I ~i 00 ~ O' ~' i o~ ~~ a~ Q Q~ i C~ O' a' ~7~ i C5 o~ i a~ i ~I o~ ~I I o~ j~ _ _ _ S_OUT_H LINE OF THE SW 1/4 - - I~ iS89°44'50"W 117.80' 1154.22' - SOUTH 1/4 I ~/ n r~ N89°44'50"E 2641.88' CORNER L5~ I~ v SEC-fiON 10 ~~,~~~,~~_ ~ LEGEND ST. Ci~Cll;~: i;0:~" '! FOUND ALUMINUM COUNTY ~~lannir~^ 7nr~~.-.•~ :nr! parG;c ~ ,,r~;rr~i'tee SECTION CORNER MONUMENT