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040-1306-31-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT sanitary Permit No: 569600 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: Rose, George& Laurie I Troy, Town of 040-1306-31-000 ion/Town/Ran e/Ma No: Sect p CST BM Elev: Insp.BM Elev: BM Description: 9 m, 1 6 r 08.28.19.1858 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURE CAPACITY STATION BS HI FS ELEV. Septic ' 1 =•n, 2 Q� Benchmark /6.r,4 /� �.✓ 1�. ..- F:f�.w I�esirrg' Alt. Bn�; - Ca (o,ZS . t 5 Qe6 > - 1 Q Aeration Bldg.Sewer q., W 1 I Holding St/Ht Inlet /6 ,6 / ,/ TANK SETBACK INFORMATION St/Ht outlet A.15 c77.41 TANK TO PT6� WELL BLDG. Vent oA�l take ROAD DtInlet f � Septic 70 / /4,/ / �_ Dt Bottom � Dosing / `� Header/Man. A ZI 1 C 7 Aeration Dist. Pipe 'Z •7— /(a- Z ` ,- Holding Bot.System /2-7 y7 , 7 1 PUMP/SIPHON INFORMATION Final Grade Z Manufacturer Demand St Cover G.-Z-5 d Z 5 GPM v�t�. Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain en Dist.to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS (A� 7— lGd�- SETBACK SYSTEM TO ``dd P/L jBLDG WELL LAKE/STREAM LEACHING Manufacturer--r—f N� INFORMATION / CHAMBER OR Type o0�System, '� / �6 / �� UNIT Model+Nu er: DISTRIBUTION SYSTEM J Header/Manifo;d Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) L 4 I-ngth Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded -Mulched Bed/Trench Center 4. 3 Bed/Trench Edges 1 Topsoil ` Yes Lj No Yes i_ No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: Location: 423 Jordyn Lan H dson,WI 4016(NW 1/4 SE 1/4 8 T28N R19 Sunset View Lot 31 Parcel No: 08.28.19.1858 t- 1.)Alt BM Description= a )C-.`" 2.)Bldg sewer length= 9/ -amount of cover Plan revision Required? 0 Yes No / T Use other side for additional information. 4hrissepccior's -Date Signat a Cert.No. SBD-6710(R.3/97) ti ^ b J (60- Iz M a x X \y - K a 41 �O o r v� Q? j�, J R � ^9a ��p • �1 Q v Q � v � v 0 Q k z v - W h Z �� o � v v PAID �d s - � County Industry Services Division i; edo/X '1?) 1400 E Washington Ave Sanitary Permit Number(to be filled in by Co.) :� Sp OF}2�1 P.O.Box 7162 143b N� - Madison,WI 53707-7162 V.�� MUNITY©EVEL ba $atary Permit Application State Transaction Number In accordance wi 383.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit 1L� is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s.15.04 1 m Stats. J-12 1. Application-information—Please Print All Infor on J Property Owner's Name Co Parcel# �7Eo!¢GE LAu 1,r d`7D d Property Owner's Mailing Address A / Property Location ,-772 L/S aJ Aae. Goasr /V Go of City,State Zip Code Phone Number ,VE y,, SE ''-A Section 8 LAKE EL/yo �� .� f�i2 6S/ 3S7�.?GL3 (circle one T a78 N; R /9 tow iI.Type of Building(check all that apply) Lot# 24 1 or 2 Family Dwelling-Number of Bedrooms 3 (31 Subdivision Name , 6k 04 Block J UnJSEI [/�E!✓ �E!/ELo%E.JT' ❑Publ is/Commercial-Describe Use ❑-`icr�„ ❑State Owned-Describe Use CSM Number of + ,LP P 13-Town of �lloy 111.Type of Permit: (Check only dne box on line A. Complete line B if applicable) p"Z A' New System y El Replacement System ❑TreatmenttHolding Tank Replacement Only ❑Other Modification to Existing System(explain) B. 11 Permit Renewal ❑Permit Revision ge of Plumber List Previous Permit Number and Date Issued ❑Chan ❑Permit Transfer to New B 4 efore Expiration Owner, IV.Type of POWTS System/Component/Device: Check all that apply) L, pn_ Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑At-Grade ❑ Mound?:24 in.of suitable soil ❑Mound<24 in.of suitable soil 4 ❑ Holding Tank Other Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dis ersaL/Treatment Area Information: Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sr) Dispersal Area Prop f System Elevation / ,DSO .7 6 osed ,Y3 G�/9,a2 ✓ 9S1- 4t 10 A,1 Vt.Tank Info Capacity in Total #of Manufacturer N Ako j Gallons Gallons Units .n S u°v , New Tanks Existing Tanks v c U Septic or Wok4a&'Fmrk 1 /GOO �Op 0 /f fEA �OAIGaErE ✓ 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's Si MPAMIRS Number Business Phone Number RI/SY4 71s V-S-,?�� Plumber's Address(Street,City,State,Zip Code) Ca A? Sr 114 o y a?.S u e:hW,0 4)-T 5"y7?4 VIIH oun /De artment Use Only Approved ❑ D' Permit Fee Dat Issued issuing ntSignature ❑ ne en Reaso or Denial $ 75' A IX.Condi y{ cp�eya�s�an@s�for�Diisapproval �H'4 y •q.tW 1R��I�IVR�1�III\�C(R7 ;dispersal c4must all be services/maintained a pa management plan provided by plumber. — tp tui eats mug bwmUftined Attach to complete plans for the system and submit to the County only on paper not leas than 8 112 x 11 inches in size SBD-6398(R0313) Private Onsite Wastewater Treatment System Index and Title Page //__ pow,-O/ Project Name: L7EoAz r 0 LAURiE'dos E •� �•t I.r�Roaao �owTS ��ANA tic Owner's Name: GED QdE f�Aa�t/E `1osE Owner's Address: W 73 9 L is ao.✓ Avg �o��r �/ K E�.yo ssoya AV, SE t Legal Description: E s£ 8 ,? �/ / �✓ Municipality: Town Verge, Cry of �oY - County: �r ciao/X Subdivision Name: Yvrse-r vier �E� Lot Number: 3/ Block Number: Parcel I.D.Number: Page 1 Page 2 or d"z A,✓ �✓���oss .�EcTie.J f R� lJiEw Page 3 %ANA' `�u�rP G'iYilAss �idoss•.S�c r�o.J - Page 4 �v�ro /'"Fo,` 4 X �uit dE Page•5 �otiJ}'S OtJ�✓EiL S /19A1U.oL f hrA�/ALEi9►ENr /�lA.✓ Page 6 Page 7 �14 f'E2 �A�iDr6,✓,yw�LE io Page 8 y/1 Page 9 ��iAGX/'1FNf ` Lr.rdl��AT/nom/ /4E�oILY . vis c v� Name of Designer: 7-W EKE License Number: IV- 231 6L Signature: Date: Designe Pursuant to the Following POWTS Component Manual and Comm 81-85: In Ground Soil Absorption COMPO Gent Manual for POWTS (Ver. 2-0) SBD-10705-P (N 01/01) n� �1 \ ♦ N M NO o♦ .k NO ! J S, w T � 1♦ a v Y 44 h \ V► W a � � it it cx Z r , o, QO AA s � V � °v •� 1t aLYY ��` J♦ 0 of � M p d W -� k o Q k PageL 3 Of 7 SEPTIC TANK V PUMP CHAMBER CROSS SECTIOW AND SPECIFICATIONS 04 X".f o. 4" CI VENT PIPE 12" MIN. ABOVE GRADE 9 WEATHERPROOF /p** FROM DOOR, WINDOW OR JUNCTION $OX APPROVED FRESH AIR INTAKE WITH CONDUIT MANHOLE COVERS /.v�:Ne►o < <% oecow W/ PADLOCK d,eROE WARNING LABEL ' 4" MIN. is,, LIN. ENLET I ' WATER_ TIGHT SEALS GAS . - ' ATIGHT i VAPPROVED SEAL 1 JOINTS WITH PPROVED B i ALM APPROVED PIPE I PE ON PUMP OFF ELEV. 9 10 FT. OFF RISER EXIT D PERMITTED ONLY IF TANK MANUFACTURER HAS APPROVAL 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS EPTIC_ / DOSE ANK MANUFACTURER: sE,c �a.�zAxrE NUMBER DOSES PER DAY: S,/ ANK SIZES: SEPTIC I000 GAL. DOSE VOLUME INCLUDING Re./ t y./ DOSE Goo GAL.. FLOWBACK: 9.?.Z .GAL. LARM MANUFACTURER: S.T.E. dc,a/,,,dNS CAPACITIES: A = _,,71 _ INCHES = .?s7.0 GAL. -�— MODEL NUMBER: At -,r ! . SWITCH TYPE: ,�,�� .;r . IC, 7� 6ALf. B = .,...? INCHES = .3�3,5_GAL. IMP MANUFACTURER: Zodrez" %"'y C = ST INCHES = 9,7..Z GAL. MODEL NUMBER: /s/ SWITCH TYPE: D = _ 75 INCHES = 12 7 GAL. SQUIRED DISCHARGE RATE GPM PUMP E ALARM WIRING AS PER ILHR 16.23 WAC ERTICAL"DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE FEET MINIMUM NETWORK SUPPLY PRESSURE . . . . . . . – FEET aits' FEET FORCEMAIN `X /o FT/100 FT. FRICTION FACTOR 3– FEET TOTAL DYNAMIC HEAD = `. 9 FEET Af ITERNAL DIMENSIONS OF PUMP TANK: LENGTH J-3// ; WIDTH 78 ; DIAMETER LIQUID DEPTH"" 3� , e 7 TOTAL DYNAMIC HEAD/FLOW ' 2 LL PUMP PERFORMANCE CURVE PER MINUTE MODEL 15111521153 EFFLUENT AND DEWATERING 50 14 45 153 MODEL 151 152 153 1z ao Feet Meters Gal. Liters Gat. Liters Gal. titers $ 10 152 — 5 1.5 50 189 69 261 77 291 10 3.0 45 170 61 231 70 265 15 4.6 38 144 53 201 61 231 c8 1 151 20 6.1 29 110 44 167 52 197 0 25 7.6 16 61 34 129 42 159 5 20 30 9.1 – – 23 87 33 125 35 10.7 – – – – 65 1s 40 12.2 - - 11 42 4 10 Shut-off Head: 30%(9.1m) 381(11.6m) 44 fl.(13.4m) 0145M 2 5 Model 151 Models 1521153 10 20 30 40 50 80 i0 80 90 100 GALLONS 87132 67132-- Ln'rRS 0 40 80 120 160 200 240 280 320 360 3116 - I_ 456 340 3718 4 518 FLOW PER NNUTE f .. 0145M 37re 3718 ti,_ 37re ® i 3718 i •Timed dosing panels available. •Electrical alternators,for duplex systems,are available and i supplied with an alarm. j •Variable level control switches are available for controlling ! M single phase systems. •Double piggyback variable level float switches are available j for variable level long and short cycle controls. _ •Sealed Qwik-Box available for outdoor installations.See 1,11116 I j t2 ire 4 I •Over 130°F(54°C)special quotation required. 4ISM 5 31B ... .._- . -.. SK24" SK2064 15111521153 MODELS control Selection Model Vohs-Ph Mode AMPS Sim hex Duplex N151 115 1 Non 6.0 1 2or3 BN151 115 1 Auto 6.0 Included 2or3 E151 230 1 Non 3.2 1 2or3 BE151 2301 Auto 32 Included 2or3 n u N152 115 1 Non 8.5 1 2 or 3 Easy assembly BN152 115 1 Auto 8.5 Included 2or3 ( not included.) t E152 230 1 Non 4.3 1 2 or 3 BE152 230 1 Auto 4.3 Included 2or3 N153 115 1 Non 10.5 1 2or3 BN153 115 1 Auto 10.5 Included 2or3 E153 230 1 Non 5.3 1 2 or 3 BE153 230 1 Auto 5.3 induced I 2or3 1. Single piggyback variable level float switch or double piggyback variable level float switch. Refer to FM0477. Reduces potential clogging by debris. 2. See FM0712 for correct model of Electrical Alternator E-Pak. Replaces rocks or bricks under the pump. Made of durable,noncorrosive ABS. 3. Variable level control switch 10-0743 used as a control activator,specify duplex Raises pump T'off bottom of basin. (3)or(4)float system. Provides the ability to raise intake by adding sections of 1W or Z'PVC piping. o caunoN Attaches securely to pump. Accommodates sump,dewatering and effluent applications. NOTE:Make sure float is free from obstruction. For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. 0 Copyright 2008 Zoeller Co.All rights reserved. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page S af 7 .FILE INFORMATION SYSTEM SPECIFICATIONS Owner ljEoRbE f �Aui[iE �oSE Tank Manufacturer: GoeJeAg'r6 ❑ NA Permit# Jg Septic ❑ Dose ❑ Holding Volume: /Dop (gal) DESIGN PARAMETERS Tank Manufacturer. `J/,rseic eo, 4111,crE ❑NA Number of Bedrooms: 3 ❑ NA ❑Septic S'Dose ❑ Holding Volume: 600 (gal) Number of Public Facility Units: tK NA Vertical Distance Tank Bottom(s)to Service Pad: /D/ (ft) Estimated(average)Flow: moo (gauday) Horizontal Distance Tank(s)to Service Pad: 90/ (ft) Specific servicing mechanics must be provided if vertical Is>15 feet or Design(peak)Flow=(estimated x 1.5): f/sp (gal/day) if horizontal is>150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: 7 (gauday/fe) Effluent Filter Manufacturer: Es r ❑ NA Standard(Domestic)Influent/Effluent Monthly average Effluent Filter Model: Gf-/o Fats,Oil&Grease (FOG) s30 mg/L Pump Manufacturer: Zo ELLE,t ❑ NA Biochemical Oxygen Demand (BOD5) s220 mg/L ❑ NA • Total Suspended Solids(TSS) '5150 m91 Pump Model: High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L - Manufacturer ZNA (BOD5) >220 mg/L ❑ NA ❑Mechanical Aeration ❑Peat Filter (TSS) >150 m /L ❑Disinfection ❑Wetland Pretreated Effluent Monthly average ❑Sand/Gravel Filter ❑Other. (BOD5) <_30 mg/L Soil Absorption System (TSS) <_30 mg/L ❑ NA Fecal Coliform(geometric mean) <_1e " 0In-Ground(gravity) ❑In-Ground(pressure) [3 NA ❑At-Grade El Mound Maximum Effluent Particle Size '/a in dia. ❑ NA Cl Drip-Line ❑Other. Other: ❑NA Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) When combined sludge and scum equals one-third('A)of tank volume �tJ When the high water alarm is activated Inspect condition of tank(s) At{east once every: 3 �year(sjs) (Maximum 3 years) p NA Inspect dispersal cells At least once eve ❑month(s) (Maximum 3 years) ❑ NA O every: 3 S year(s) Clean effluent filter At least once every: /3 ®month(s) ❑ NA ❑year(s) Inspect pump,pump controls&alarm At least once every: ❑month(s) ❑ NA 3 9 year(s) Flush laterals and pressure test 'At least once eve ry: ❑month(❑yeaarss))r( ) NA 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(Ys)or more of the tank volume,the entire contents of the tank shall be removed by a Septage Servicing Operator(pumper)and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code, All other services,including but not limited to the servicing of effluent filters,mechanical or pressurized components,pretreatment units, and any servicing at intervals of<_12 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. START UP AND OPERATION Page / of 7 For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process-and/or damage-the soil absorption system. If high concentrations are detected have the contents of the tank(s)removed by a Septage Servicing Operator(pumper)prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended,as the excess wastewater will be--discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator(pumper)prior to restoring power to•the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance a'nd 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. SPf383.33,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 shalt 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 e SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ADDITIONAL INSTRUCTIONS: I POWTS INSTALLER /� POWTS MAINTAINER. Name ,'o , Arl-x4' ay/. Name -7oiY.J lEIKE ClEl.XE Phone 71,5- L,V-"44 Phone 7j5- 67a = $a6d SEPTAGE SERVICING OPERATOR PUMPER - WAI c.rJow.) LOCAL REGULATORY AUTHORITY Name Name sp- �/tcfiX Lo, Zo.di•J� O�<ic E Phone Phone 71 38L- yd80 �I LLI :2.E- k 0. T 11 LT I V C1 C R' 0 4- � f 2Ey CL a qq�� cl L$j ti C W r LU I} g L1.6 i3 a O LU q td > u � aEm v , 91-a >r _ 0 > 0 mw= CY m _ o osa,. L N c fl O Y O N y � � L 01� m v� " j ig ro y N C Ln .• •� Y .` U C .- y 'O l0 .2 L � u d fJ•- N 3 a 'a: m L' d+ Y !t E n v vo 3 n v ca O V H N M v $ c v a LA c a' ® � � � �$• ate, �" N v 0 r c Q y a Y D�tA s c w v ..o L c o C � y 4� Q' ;°. vmi rs i .� '!La^•'., ''�.'''G.G�'x..i:.'_:'a v � aNi ' C y w a t v yy Y" yJ 'G y oj EL ac> o �1 0 %n m ) `•� O M ..�.. O L V y_. I{ :e.aa:;rsac: .R.. r7 , o v •o � 3 �a c _0 LL O . 79 OC s�;� [A N O � p� py� Iwi � a w •N d « .. 2-5 E v o eo t aoNo> � u = a, di ai ( f � � oao � air E it �y { a•OLy CO y P� to 0 31 "?7 x: �...._'•.....- r Cl -V ,1 i.l O G V .. 7;.g v C I � i ti ti � h U1O 9 _ 1 . ,.., r'°i .a� 40 ci 0 -E aN o aO u a m 1 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM ),Owner/Buyer L A 6, 67e e. a ?�Mailing Address L 1'.5 �e S7SO Y ) )(Property Address v (Verification required from Planhing&Zoning Department for n conatrucaon.) �CitylState P(A d.S o 0— W Z 4�Parcel Identification.Number O L4 O t 3 O t`, 3 I c o a LEGALU§!_CRIMON NVV_ 4 Property Location N !4, E l<,Sec. ,T_a R N R_l C _W,To rn of Subdivision ViPAAJ Lot# Certified Survey Map# , Volume ,Page# Warranty Dees! # / 3 q , Volume Page# Spec house yes no lot lines identifiable 0 no SYSTEM M_AXNTENANCE AND OW ER CERTIFICATIO?V 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,ifneeded,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(l)and in Chapter 12-St.Croix County Sanitary Ordinance, The property owner agrees to submit to St.Croix County Planning&Zoning Department a certification form,signed by the owner and by a master plumber,journeyman plumber,restricted plumber or a licensed pumper verifying that(1)the on-site wastewater disposal system is in proper operating condition and/or(2)after inspection and pumping(if necessary),the septic tank is less than 1/3 full of sludge. Uwe,the undersigned have read the above req*etnents 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. Uwe certify that all statements on this rtn are true to the best of my/our knowledge, Uwe am/are the owner(s)of the property described above,by virtue of a wan t3 deed recorded in Register of Deeds Office. Nu ber of bedrooms SIGNA OF APPL (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) u, , / vi A \ b 0 --! \0> > C o -A Ike 9 < ce) m trn co tom: �<2 C'') vi s g\� 152.87 ` 244.$6' 50.21 ® N 1 00'40 41 447.8 z � Z 0 ---L-----------i orww►ce - + qt EASEMEN7 b i N OO.04'31 347.31' uj N f ce) vi a �� a co i ° °�' f E- +s +� f z f o to f k W 1111111 IIIIIIII 11111 8223571 Tx:4183065 State Bar of Wisconsin Form 1-2003 994735 WARRANTY DEED BETH PABST REGISTER OF DEEDS Document Number Document Name ST. CROIX CO., WI 04/11/2014 1:55 PM EXEMPT#: NA i THIS DEED,made between B&L Land Development,Inc.,a Wisconsin REC FEE' 30.00 C'nrp nration TRANS FEE: 179.70 i ("Grantor,"whether one or more), PAGES' 1 and George A.Rose and Laurie A.Rose,husband and wife as survivorsbip marital property ("Grantee,"whether one or more). Grantor,for a valuable consideration,conveys to Grantee the following described real Recording Area estate,together with the rents,profits,fixtures and other appurtenant interests,in St.Croix County, tate of Wisconsin("Property") if more ace is Name and Return Address ty ( P Y'�)(� P needed,please attach addendum): River Valley Abstract&Title 1200 Hosford St. Suite 201 Hudson W1 54016 Lot 31, Plat of Sunset View Development in the Town of Troy, File: 400282 St.Croix County,Wisconsin. 040-1306-31-000 Parcel Identification Number(PIN) Dated: April _,2014 This is not homestead property. (is)(is not) Grantor warrants that the title to the Property is good,indefeasible in fee simple and free and clear of encumbrances except: Easements,restrictions and rights-of-way of record,if any. Conditional that the residential single family home, to be built on this lot, be built by Waters Edge Construction, Inc. A Wisconsin corporation. B&L Land Development,Inc.,a Wisconsin Corporation (SERI.) (SEAL) *Ly WT.R'eatherholt President/Treasurer (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGME NT Signature(s) STATE OF KENTUCKY )ss. authenticated on JEFFERSON COUNTY //J i 1 1 * Personally came before me on April 'l J , . the above-named Lyle T.Weatherholt, TITLE:MEMBER STATE BAR OF WISCONSIN ' President/Treasurer of B&L Land Development VER, :.�',,'••= N (1f not, to me known to be the person{ )who execute e'fot� of authorized by Wis. Stat.§706.06) , ` instrument and acknowledged THIS INSTRUMENT DRAFTED BY: ^ F2 0 Iverson St. Suite 201 Hudson W154416 Notary Public,State of Kei ucky ea ar G�} he My Commission(is permanent)(expires: 'of I } (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE:THIS IS A STANDARD FORM. ANY MODIFICATIONS'rO THIS FORM SHOULD BE CLEARLY IDENTIFIED. `WARRANTY DEED O 2003 STATE BAR OF 1'1'ISCONSIN FORM NO.1-2003 Type name below signatures. St.Croix County 994735 Page 1 of 1 vI as Apmr'"w,v.iiti-i 10)mms,iXxd S*a i oza( SNULV.1%3T3 i1012aLxi VIM J9dS iviJxuJ n eM u .ivwmsa on eve :uamu N 4H MOLLDf UISMOD 39(19 SU31VA1 wine s I �wg M I Jill 0 as t e ----------� ' E l;ii�i e i e a e ? B Z O p f� LLt �j ! I z G ° P i z 0 J LL Ng, II Bg 6-Ift-"t Hd _Ml IM11NOUVaNnol S.'Nor 41oz 03ds Yltlh TS1 RZ JVjD7R)VMW.LHOl'l!'Al'oll0AlllnK-1VUX301SR'd :Dim 39yj :13ma oZ' ..................... .....................................-----_...-----.i. o -------------- .................................... ...... .......................................... ............ ............... ----------------------------...... .......................----------------- .................. J:: ........................................................... I ii W11-111-111 Hd 91015 1 —S-wa 96t KVId 13A3I MIVW i,Ioz Dads G,' " -lYLLM30SAd i m mu..O., on-AIDWA-u•rlyl "I HYd :Ljxojd Nomfilusmoo ROM sualvm 9-9 -44i----- 4-7-- LEI ..................... ................. ------------------- ....................... Property Owner M ` �N'�J7 N1Y Parcel ID# E J�1)V G Z ❑ Borin Page of Boring# g 1O6\ ® Pit Ground surface elev. ft. Depth to limiting factor -;' C1 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. •Eff#1 •Eff#2 6�5 DT ►vt`� e w Z-� .S -g � Boring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil Application Rate GPD/ft2 in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'E(f#1 'Eff#2 • ❑ Boring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in, Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz In. Munsell Qu-Sz. Cont.Color Gr.Sz.Sh. •Eff#1 'Eff#2 Effluent#1 =BODS>30<220 mg/L and TSS>30<150 mg/L •Effluent#2=BOD3<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.6/00) Wisconsyn Department Comr ECEIVED SOIL Division of Safety and B (dings EVALUATION REPORT Page of LimensigW,AR ® �'a �Iance ith Comm 85,Wis. Adm. Code County Attach complete site pl per inot less than 8 1/2 x'11 inches in size.Plan must include,but not limited galGho6id{jl refere a point(BM),direction and percent slope,scale or Parcel LD.P P FdGrE tion and distance to nearest road. Please print all information. Rev' wed by ''Date Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). ` ZZ Property Owner Property Location `S Z -y�,� 1/4 SE 1/4'S e�• T Z.8 N R �� E(d��W Property Owner's Mailing Address _,# Block# Subd.Name or CSM# Sox 3 3 _, — S rvs - vii,,, 7 �--\) City State Zip Code Phone Number ❑City ❑Village Town Nearest Road t3�tSR Lv i I 5<< U 0 (�I S )�8S_33 S I T tZ-�`-1' ►-= New Construction Use:® Residential/Number of bedrooms - Code derived design flow rate S C) - �p(3O GPD ❑Replacement ❑ Public or commercial-Describe: Parent material G LAC) `ZZ- Flood Plain elevation if applicable General comments and recommendations: 3 ,NL 'E-�ot'm►Nt o1= S (,C) J U-4;4U-1 F 1-1 Boring# Boring CQ&Q- �o�vo c.o � ® Pit Ground surface elev. 'q ft. Depth to limiting factor v in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Cu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 'Eff#2 1 _1Z �0`iR z L Z — Si 1 Z`�sb�C %n-t �� .S -C-1 ,fie .lo 1o��zql6 — vS3 — •� t' Z irk � 1 t F—?J Boring# ❑ Boring ® pit Ground surface elev. �� ``3 ft. Depth to limiting factor 7 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD 1ft2 j in. Munsell Cu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 'Eff#2 -`Z tip`-12Z1Z — i Z�SbFz Z ti-3 Z �T3-1 1t '/Y1Ty -S — .S •� �, 3 3Z-47 i o-1 fZ y v sg Y1 1 — . -1 , , z bil i� tt Effluent#1 =BODS>30<220 mg/L and TSS>30_<150 mg/L 'Effluent#2=SODS<30 mg/L and TSS<30 mg/L CST Name(Please Print) Signa re CST Number -Arthur L. YWegerer 03 Z 1S -�� 220254 Address W e g e r e r Soil Testing & Design Service Date Evaluation Conducted Telephone Number 421 N. Main St. River Falls , WI 54022 `Z - �q -o3 715-425-0165 'f/isconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings ' Page -of_ •--�_ } in acorrdance with Comm 85,Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.Plan must County �` C include,but not limited to:vertical and horizontal reference point(BM),direction and Percent slope,scale or dimensions, north arrow,and location and distance to nearest road. Parcel I.D. _ - Please print all information. Reviewed by r� -tv�tiG Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). Date PPr erty Owner O P Property Location L Tz' r erty Owners Mailing Address 1/g S T Z� N P, E car 8�K 3 3 Lot Block Subd.Name orCSM# City 3 — I S U N Ste- V l State Zip Code Phone Number ❑City ❑Village Town Nearest Road Fra-1ew Construction Use:® Residential/Number of bedrooms =� -L. eplacement Code derived design flow rate l4 S (D _ VU❑ Public or commercial-Describe: Gr^D nt material G Lie) }r L d Ficcd Plain elevation if applicable N�1 comments u and recommendations: ;wjL'� , - �o'1'iZlwf G 1= +v -�j •u/ Jk Fj Bcring# F] Bcring El ® Pit Ground surace elev. a ' I ft. Depth to limiting factor ? �j v in. Horizon Depth Dominant Colcrl Redcx Description Soil Application Rate P I Texture I Structure I Cansistencel Ecundary Roots GPD/ftz in. Munsell Cu.Sz. Cont.Ccicr I Gr.Sz.Sh. 0_lZ 10`1 Z-[ I _ 'EfFr1 'Eff=2 i I tZ I � � � I I aBoring# ❑ Boring ® Pit Ground surface elev. �� t'3 ft. Depth to limiting factor cl in. Horizon Depth Dominant Color Redcx Description , Soil Application Rate F Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. 'Eff#1 'Eff#2 Z 1Z-3 Z lD'•-ifZ 316 S C)S9 '�1 1 - . -2 . z i 'Effluent#1 =BODs>30<220 mg/L and TSS>30<150 mg/L 'Effluent#2=Boo < CST Name(Please Print) - s_30 mg/L and TSS<30 mg/L Arthur L: ;tJegerer Stgna re CST Number �. 03 Z1S —31 220254 Address �1 e g e r e r Soil Testing & Design Service Date Evaluation conducted 421 N. 1-la i n S t. River Falls , U I 54022 \Z _ pI_p3 Telephone Number 715-425-0165 • � � t Property Owner ` y��Ul�N1��Jr Parcel ID# ����' J��)/U G Page of - Boring# E]Boring ® Pit Ground surface elev. )0),� ft. Depth to limiting factor CIO 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. •Eff#1 •Eff#2 -�, 1bKR- ztZ - s� 1 Z�F s b k ►vt`fl-- �w Z-� •S • �i Z 12 S 1 oy R 3/6 — S 1 ) ZtiI 5bk W) `E l- C.g — S .0 F-1 Boring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. •Eff#1 •Eff#2 ❑ Boring# ❑ Boring Ground surface elev. ft. Depth to limiting factor El pit 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. •Eff#1 •Eff#2 •Effluent#1 =BODS>30<220 mg/L and TSS>30<150 mg/L •Effluent#2=BODS<30 mg/L and TSS<30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format,please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330(R.N00) e PLOT PLAN Pa¢e of 3 Scale I ' = SO ' r— G� LuT 3 i 0 � v (7° SL'1� LL `(1 Fc�r'z 1 iv�-n S (M/N /v 0 s Ril - LL1-)oo o'oo�, 8`` L) 31 �Dtt4_ w C P1 P[-" w/Lq . �Z-lq-U3 715-425-0165 220254 O3 Z S 3 ) CST Signature / Date Telephone No . CST No . Job 1_`10.