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HomeMy WebLinkAbout020-1412-10-000Wisconsin 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)]. 'ermit Holder's Name: City Village X Township Preferred Builders Hudson, Town of :ST BM Elev: Insp. BM Elev: 8M Description: fit. ~- I GST I"ANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Z Pb~ ~o~ Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ,~~ i ...,7Z Z~ ` Z°I I Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufactur Demand GPM del Number TD Lift Friction Loss S ead TDH Ft Forcemain Length Dia. Dist. to well SnIL A6SORPTION SYSTEM county: St. Croix Sanitary Permit No: 463368 0 State Plan ID No: Parcel Tax No: 020-1412-10-000 Section/Town/Range/Map No: 10.29.19.2593 ELEVATION DATA STATION BS HI FS ELEV. Benchmark rj'~ ~~ JOS ~ ~ 99 • ~ Alt. BM elf o j~5 /oy 35 Bldg. Sewer SUHt Inlet ~ ' /~ SUHt Outlet ~., ~ 5 ~• ~~ Dt Inlet `, Dt Bottom ~ ~ Header/Man. d ~ , r C f T . 7 ~ ~' Dist. Pipe ~a• 2 C l77 ~ ~• .~C J Bot. System //' ~ ~ ~ Final Grade .7 /~•~ St Cover ~' `~ /e BED/TRENCH DIMENSIONS Width ~ ~ Length ~ No. Of Trenches ^ PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth 2 CZ, 7 ir. SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:.-. n .~ ~~ -' INFORMATION CHA OR ~ J-~* ~ Type Of System: ~~~ ~~~ ~ J / C7 ~~ UN T Model Number ~ fv~ c ~ DISTRI6UTION SYSTEM 1-7 ~t1_. ~i4 -lil#'a,[ Header/Manifold ~~ i! Distribution Pi e(s) x Hole Size x Hole Spacing ' Vent to A' Intake z ~ /~ ~ ~ p \ ~ ~ i i S ~ ~_, - Length Dia pac ng Length D a S(~II •!:nVER v Drnea~ru Cvc4cmc Anl~• vv MnunA (lr Ot_(;rade 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 discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 630 Wildflower Lane Hudson, WI 54016 (SE 1/4 SW 1/4 10 T29N R19W) Burkhardt Prairie Lot 1 Parcel No: 10.29.19.2593 1.) Alt BM Description = ~~`~ G~ ~h a . hS ~- 2.) Bldg sewer length = Z.~ - amount of cover = ~~ // Plan revision Required? ~,] Yes ~lo ~ Use other side for additional information. ~ ~ ~ ~I I~ lO Date In Actor's 'nature Cert. No. SBD-6710 (R.3/97) gUt(~ RE~E vE~ MAR 3 0 2005 ST. CROIX COUNTY ZONING Safety and Buildings Division ~-)Y'4 ` ~ ' 201 W. Washington Ave., P.O. Box 7082 ~J ~ 5 ~D~S'~~ Madison, WI 33707 - 7082 Sanitary Permit Number (to be fill d in by Co.) Oe artment of Commerce (fig) 261546 ~ 3 3 ~O Sanitary Permit Application State Plan LD. Number N In accord with Comm 8321, Wis. Adm. Code, personal information you provide ~ maybe used for aocondary Purposes Privacy Gw, s 13.04(1 Xm) ,,Pronject Addr/ess~ , ~iffu t tnailinng ado ~ I. Application Information -Please Print All Information ~-C~ v ~' ~'O~X~ C~' 0 20~- / - p- O l~ 's Name+, ~ ~ r/~~ Parcel N t N Block N Pr expy ~n~M ' 'o Address Properry Location ~ <~~ I ~ ~ ' ~2 State ip Code Phone Numbe ~., Section ~ (circle ) T ~N R~E ~ IL of B ding (check all at apply) / ~,/i~~ ° ; o vv , -~ 1 or 2 Family Dwelling - Numbu of Bodrooms .-- bdivision Name M Ntt[rt be r . ^ PublidCommeroial -Describe Use ~~ l~ l / r ^ State Ownod - Desrn'be Use . ^Ci Village i f III. T ype of Permit: (Check only one box on ltae A. Complete IIne B if applicable) A' New S em yst ^ Replacement System ^ TreatmendHolding Tank Replacement Only ^ Othu Modification to Existing System B• ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Numbu sad Date Issued Before Expiration Plumbu Ownu IV. T e of POWTS S stem: Check all that a 1 Non -Preuuriud !n-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in, of suitable soil ^ At-Grade ^ Single Pass Sand Filtu ^ Constructed Wetland ^ Pressurized In-Gro ank ^ Peat Filter ^ Aerobic Treatment Uait ^ Recirculating Sand Filter ^ Recirculatin Synthetic Med'n Filte Leachin Chambu ri Line ^ Grevel- s Pi ^ Oth ex I ' V. DIs enal/I'reatmeatArca In / Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Pro s System Elevation . ~ ~5o e ~ ~ ~ y ~ 93 .sz~ VI. Tank Info Capacity in Total Numbu Manufacturer e b Site Stoel Fibu Plastic Galbns Gallons of Units Concrete Constructed Glass Ncw Existing Tanks Tanks Septic a Holding Tank O ~ .- (}(~ t'.~ ~•'t--'~-~-~J1 Aerobic Trcatmea Unit ~ ~ J Y DOfing Chamber VII. Res onsibllIty Statement- I, the unders(gned, assume res oaslbllity for installatloa of the POWTS shown oa the attached plans. umbu'i Name (P ' ) Plu 's Si ature MP/MPRS Numbu Business Phone Number p~p~ o ~S - i hunbu's Ad cgs Stree Ci State, Zip C e ( 1 ' VIII. ou /De artment Use Onl pproved ^ Disapproved Sanitary Pumit Fee includes Groundwatu Surcharge Fx) ~ 2 '~ `~~~ Dat Issued 3~ suing Agent S' cure (N s) STEM ~~i~Given Reason Cor ial D ~ " "`lJ D 3{ Q ,,,, ,~ G~~~''~t%~r I d~persal ce I must all eselyce~~r>~~I~tained ~ y ~vEJ~4,~th~ ~ L as per manes ement Ian rovdded b ~ .~ ,(„d/~~~.~-yl ~4. //~_~~~~7° ~- / L~ `~' maintained t b ~ e 2. setback requirements mus rasp r ere pplic ble code/ordi ances ~ e~ ~ ~/~-g~ rjy~ ~OyU75 . ~ I cl 1 = ~ ~ ' ~ ~ ~ / v~. .~an,o s a Zug. -o~ 7 ~ lo~,~J .S~.d y I ate, r~.~ ~J ~o -~ „3 3 - ,~'~ ~~ ~u ~- -1D~ /~; o o ~.~ u~~ v ~~ - f ~ ~- / `~v~ _ Sao ~ ~° ~ , ~ ~~ ' a = , ~-~c ~, iC _ ~ ``PUS' ~ 9 9~5~ Aso ~` ~ .7 = ~ ~3 ;' ~ 9, ~ = 3 3, ~ S 3~-~~ 3Yx1y,f_ ~~y,y yo ~ ,~ ~ ~~ ~. n~~_ /-~._ ,'v i ~-y~ tip- ~ P syn. 93.so i ~r'~'I v~ ~ /~/~~,a035~ ~ 3: so ~ N~ UU.~ _~a~ r /coo ~.~ u~t v~~- 1 ~ ~- ~`~v~ ~ ~ao~ °7° ~ ~/So , 7 i y3 3y-qy ;'~y,i= 33,~s 3Yx1y-~= ~~~,y e, ,N , ~~y~ ti~~ ~.~- P- SY .~` , 93,so lam( G~ ~~aao3s~ ~ 3: so Wiscc°nsin Department of Commerce SOIL EVALUATION REPORT r Division of Safety and Buildings • in nrrnrri~nro with rnmm Ate. VVic A.i... r...~.. Page ~ of . - - - - County Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertigl and horizontal reference point (BM), direction and Parcel I.D percent slope, scale or dimensions, north arrow, and location and distance to nearest road. . Q ZU - / /2 ^ ~~ --~~ Please print all information. viewe by Date • Personal information you provide may lie used f .15.1)4 (1) (m)). G(,(/y ~ J 1 V ~ 3 4 3 Property Owner roperty Locatio ~ 253 ovt. Lot ~ 1/4~~~ 1/4 S ( T 29 N R (~' E (or~ Property pOwner~~'s11 Mailin~g'Ad Tress ~ Z ~ r- ot~ Block # SugSl.fName or CSM ~ ( ~ ~ . V i.~ Yl a l ,„ , U ll "~ City State Zi Code Q Pho ~~;,w?!be~FF~~;~ ^City ~ Village ®Town Nearest Road (~ New Construction Use: ~. Residential / Number of bedrooms ~~ Code derived design flow rate ~ (o D GPD Replacement Public or commercial -Describe: Parent material T ~ ~ gc Flood Plain eleev//at//ion if applipble /U ft, General comments 5Y.7~E'~"'~ 2~-~~ • /z~ !S~ W it ~7/~ ,Q,~` ~ ~~ and recommendations: / ~~ v%/~~ ~v ~ ~~, Boring # ^ Boring ® pit Ground surface elev. ft. Depth to limiting factor __LLLL_ 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. 'Efi#1 'Eff#2 ~ O- © 3 2 Si! Z ~r c g I v~ . J . $ (G - `' Si k {fir cS ~' , -- l l ~ Ims O, m l ~ . -1 ~.2 Boring # ^ Boring Pit Ground surface elev. ft. Depth to limiting factor I I C~ 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 ( d-15 --- ~~ ~S l v ~~ . 5 .8 3 x`'(05 ~ . - S L 2 S~ m-~ c~ - • 5 . `7~ ~ l~ p I ~l -- m 5 ~ _ - ~ (. 2 ~ a ~„ Gl~, - cmuenr ~~ = ts~us > su ~ uu mgiL ana I JS >su _< '15u mgiL~ • Effluent #2 =GODS < 30 mg/L and TSS < 30 mg/L CST Name (Please PrinO ~gr)ature CST Number `` ~ ~'. lt;' ~' c - . ~~ - ~ ~ Address _ ' ~ Date Evaluation Conducted Telephone Number : , /(r SBD-8330 (rtm/00) ~- -~ Property Owner Parcel ID # ti Page ~ of Boring # U Boring `-' C]~ ®' pit Ground surface elev. -I ~ ft. Depth to limiting factor ~ ~ ~ in• Soil Application Rate t istence C Boundary Roots GPD/ftz Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture ure Struc Gr. Sz. Sh. ons 'Eff#1 'Eff#2 ©--(2 Z c.S ~ ~~ ' S 3 ~ -(~~ -1 y c~ -- - ~ r I ~~ `- - . ~ . ~ . 9 ~ . 2 U Boring Boring # ^ pit Ground surface elev. ft. Depth to limiting factor in. Soil Appliption Rate tion scri D d R Texture Structure Consistence Boundary Roots GPD/ftz Horizon Depth in. Dominant Color Munsell p e ox e Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ^ Pit Soil Application Rate tion i D Texture Structure Consistence Boundary Roots GPD/ftz Horizon Depth in. Dominant Color Munsell p escr Redox Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 'Effluent #1 =GODS > 30 < 220 mg/Land 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) Property Owner ~ ~ t IJ~ Parcel ID # Page ~ of ^ Boring Boring # Pit Ground surface elev. ~~ ft. Depth to limiting factor ~ ~ in• Soil Appliption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDfftz •Eff#1 •Etf#2 in. Munsell Qu. Sz. ConL Color Gr. Sz. Sh. ~ ©-t2 Z G5 (~ ~Vt , 5 Z t-F t -~ ~` _ ~ ' 3 -toy -- t_ r ~~ ~-- . ~ ~~ -I `f c~ -- _- - • __l ~ . 2 a Boring # ^ Boring ^ pit Ground surface elev. ft. Depth to limiting factor in• Soil Appligtion Rate l C tion Descri d R Texture Structure Consistence Boundary Roots GPD/ft2 Horizon Depth in. or o Dominant Munsell p ox e Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eft#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 =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. sso-uw trt.a~rool ~ _. , PAGE~OF~ 7~TA MF /~/~ V l ~ U~ 'C /~ T OT# ~ LEGAL DESCRIPTION s~%~,~ /(~ T ~T,N,R. I~-f E(or~ r SCALE: 1 ~~ = yo BM 1 ELEVATION BOO • Q BM 1 DESCRIPTION -~® o-~ % ~~ O~c ~, ~P BM 2 ELEVATION 9q S. Q BM 2 DESCRIPTION ~, p 6 -~ l ~O,/c ,O D-P ~ ` ~ ~ SYSTEM ELEVATION ~~T ~I~ . S ~ I SYSTEM TYPE ('off u'e ~,-~~ a V~f - ~- ® - CONTOUR ELEVATION 9~~ S-d 3 ~9~y 9~ s~ g m Z' B~'` ~ ~~~ ~~ ~~~ TURF ~r'_--- DATE ~'' -~' ~~U~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of 2 FILE INFORMATION Owner Permit # DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ^ NA Estimated flow (average) ~ al/da Design flow Ipeakl, (Estimated x 1.5) gal/day Soil Application Rate ~ al/day/ftz Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BOD5) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODE) Total Suspended Solids ITSS) 530 mg/L 530 mg/L ~NA Fecal Coliform (geometric mean) 51 ` /100m1 Maximum Effluent Particle Size YB in dia. ^ NA Other: ^ NA "Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHE~III_E SYSTEM SPECIFICATIONS Septic Tank Capacity ~~d al ^ NA Septic Tank Manufacturer ~ ^ NA Effluent Rlter Manufacturer , ^ NA Effluent Filter Model ~-- -~~ Q ^ 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: A Dispersal Celllsl ^ 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 tankls) At least once every: ^ month(s) (Maximum 3 years) earls) ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third (Y3) of tank volume ^ NA Inspect dispersal cellls) At least once every: a ~ year( -(s1 (Maximum 3 years) ^ NA Clean effluent filter n('~~ ~ At least once every: ~ y °nls~(s) ear ^ NA Inspect pump, pump controls & alarm At least once every: ^ month(s) ^yearls) ^ NA Flush laterals and pressure test At feast once every: ^ month(s) ^yearls) ^ NA Other: At least once every: ^ monthlsl ^ year(s) ^ 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 cellls) 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 1 O 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 celllsl. 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 cell(s) in one large dose, overloading the cell(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 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 P N If the POWT ails and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant replaceme 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 alua ' b e ai a ~fZp~lB i?~ ~~- ng tank p ^ 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 Name Phone '~S _ _ POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name ST. C l b ZD/lif l~ Phone '7/S- 3g'(o_ (p (~ This document was drafted in compliance with chapter Comm 83.22(211b1(1-Idll~lfl and 83.54111. 121 & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK 1ViAIlVTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Mailing Address Property Address dO y~r,t~, s~sy D u.~.~.P.~J~ (Verification required from Planning Department for new conshuction.) City/State /~'i~!~G ~~ Parcel Identification Numbe D D-/~/~ -/U -Qo 0 r - a0 LEGAL DESCRIPTION Property Location .5,~ %4 , S~ %4 , Sec. ~ T ~N R~W, Town of ~~` Subdivision ~ 4 Lot # 1 Certified Survey Map # ~ ,Volume ,Page # Warranty Deed # 7s 3 ~ / y ,Volume S-OO Page #, ~~C~ Spec house yes no Lot lines identifiable ~ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in § Comm 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County 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 requirements and agrce 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. Cmix County Zoning Department within 30 days of the three year expiration date. SIGNATURE OF APPLICANT 3 /min DATE OWNER CERTIFICATION Uwe certify that all statements on this form are true to the best of my/our laiowledge. Uwe am/are the owner(s) of the pro ~~,~~ttescribed abo , by virtue of a warranty deed recorded in Register of Deeds Office -~ 1 SIGNATURE OF APPLICANT DATE ****** Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department. ****** Include with this application a stamped warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made iu the warranty deed. Parcel #: 020-1412-10-000 03/30/2005 03:23 PM PAGE 1 OF 1 Current X' ST. CROIX COUNTY, WI5GON51N Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): * =Current Owner * PREFERRED BUILDERS INC PREFERRED BUILDERS INC 2700 CAMPUS DR PLYMOUTH MN 55441 Districts: SC =School SP =Special Property Address(es): * =Primary Type Dist # Description " 630 WILD FLOWER LN SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.080 Plat: 0137-BURKHARDT PRAIRIE SEC 10 T29N R19W SE SW LOT 1 BURKHARDT BlocklCondo Bldg: LOT 01 PRAIRIE Tract(s): (Sec-Twn-Rng 401/4 1601/4) 10-29N-19W SE SW Notes: Parcel History: Date Doc # Vol/Page Type 01/29/2004 753014 2500/400 WD 2004 SUMMARY Bill #: Fair Market Value: Assessed with: 50467 57,100 Valuations' Last Changed: 06/06/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.080 44,200 0 44,200 NO Totals for 2004: General Property 2.080 44,200 0 44,200 Woodland 0.000 0 0 Totals for 2003: General Property 2.080 44,200 0 44,200 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 1~ ~ 2500p yp0 4 STATE BAR OF WISCONSIN FORM 2 - 1999 Document Number WARRANTY DEED This Deed, made between James D. Henry and Allen C. Nyhagen, a/k/a Allan C. Nyhagen Grantor, and Preferred Builders, Inc. Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, Sta of Wisconsin (if more space is needed, please attach addendum): Lots I, 3, and 4, Burkhardt Prairie, located in part of the Southeast 1/4 of the ou est 1/4 of Section 10, T29N, R19W, Town of Hudson, St. Croix County, Wisconsin; being Lot 2 of Certified Survey Map recorded in Volume 16, Page 4407. Recording Area 7~3~ 1 4 KATHLEEN H. MALSN REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 01/29/2004 04:38PIi MARRANTY DEED EXEMGT # RfiC FEE : 11.00 _ TRANS FEE: 556.20 COPY FEE: CC FEE: PAGES: 1 Name and Return A s LA;1~ T L~, INC. ~J ''~.'!ir 2G0 C~ r::.; _ .:zZ~ai~sg2 FILE I:v. Part of 020-1010-20-300 __ _ Parcel Identification Number (PIN) This is not homestead property. p~) (is not) Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. Dated this ~~ day of July 2003 s s AUTHENTICATION Signature(s) Jams D_ Henry and Allen C. Nyhagen, a/Wa Allan C. Nyhagen (~ ~ authenticated thisi~T day o/f'~..~~ll~y 2003 .fYi~ ~ Ca.f,,al~c., * ames D. Henry ~ Allen C. Nyhagen, k/a Allan C. Nyhagen ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. County Personally came before me this _ day of the above named TITLE: (If not, /(~Df~/J~j1~/iG 0~'/~/Y~~O~(Jt~ to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. authorized by § 716 6, WIS. Stats.)tP~~, ~~/~/O (I , - _-_- THIS INSTRUMENT WAS DRAFTED BY // • _ _ _ _ ___ _ _ Attorne Kristine O land y g ~_ _ _ _ Notary Public, State of Wisconsin Hudson, WI 54016 My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) _ , _ •) • Names of persons signing in any capacity must be typed or printed below their signature. ~rAormation Professionals company, Fora du lac, wI STATE BAR OF WISCONSIN aoo~ss-zozf WARRANTY DEED FORM No. 2 - 1999 s ~~ 1 { .i '~' n. . ~'1 f i' ,''I mosrl,aot H19B ot.~losv' 110003! dO t/tM9 3LL ~ 3f1 HIlN 311 Q131V 90P1N W r ~p Q W~ a ~ ~ ~,d W ~ ~~~°~x~ {~ pp~~ F5 Z¢Q¢ O <~ ~ O ~ $ ~ ~ ~ ~ ~ 0 ~ f71 O ~ W q~ ~~~~~s~~~~s 31L =z ~ m ~; ` Ul~t mo~ go oa®~~ I W {LL I r W ~W~n ~~~~ W I ZLL o~~~r~~~~~~~ i OfO ~Sm~~~w~~Www`~ i N b i • b~ b• ~~~ AS~1_ 4 _ °o ~~~~~~~ ~~g~~ W za ~sssgsgssssg ... Oz ~~~mmmm~~~~~ ! W ~m I ~ W Z ~b&F3cT~~S~i~ic'~io li. ~ z i OZ I I ~o ~, a 3 ~ (W'j 13 I~ N }~ a I~ I~ = F" ~ z° Flo E" Z W ~~~~ ~~ g CC O Q ~~ J Wu~ ,n i I Z r O ~, W ~o ! 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I~N OZ ~ i j~ _ <7Z y IW~%y 1 I7 1 ttll H8 NUU JF~tZ I-~- O IvU - - - - -- •• • • ~ • ~••~.~ ~~ Y~i.ao r tt i ~ u 1 Ht F'UlNT OF BEGINNING. y` DATED THIS_ ~ I ~~ . _~ ___________DApY OF_ _ _ 2002. 1 R~ ~i -'7,-02 __ _ ~ DOUGLAS ZA R S 2145 S & N LA SU VEY G, INC. 2920 ENL~E STREET SUITE 101 HUDSON, WI 54016 <715) 386-2007 ~~ a~ wi~c© 2 y DOUGLAS J. cP~ ZAHLER 5-2145 HUDSON, WiS. ~Uritl " UTILITY EASEMENTS ND PALE OR BURIED CABLE ANY SURVEY STAKE, OR OE DISTURBANCE OF A SURVEI WISCONSIN STATUTES. UTIL BODIES AND PRIVATE PUBL BENCHMARK TOP OF IRON PIPE ELEVATION=917.60 (S89°48'42"E) nnMnn nc,~.,pl N89°50'S5"E j 345.69' V l1V IYLS[r.1 u u ~:~' 144.70' ------- 4• 20' DRAINAGE 45' 45' I ~ '' - --~Q' ~ - ~,~ `EASEMENT ~ _ ,.... ; .Q~.\o... ....... ~ on ~~ ~ ~ ~ N • ao4 ~... ~ .:.~~ ~` ~ .... ..... ~ f- .- - --- -- ~• ' Q' ' ~ to BENCHMARK TOP OF 100' ~-~--•~- , - . . - . ' . - . ' , ~- . - ~ ~ IRON PIPE ELEVATION=92 \'\~-~~ ~ ~S1 `O',' ;' ~I I LB.O. =824.0 ~~3 ~ I 2.080 ACRES o f I LOT 2 ~,~ r X11 ~ (90,624 S4. ft.) o~ ~ 2.017 ACRES ~~ GPI ~ ~~ Qi j c°n~ ( (87,872 sq. ft.) ~!~% @~I I ; I I ~ ~}~ Q~ I L.B.O. =824.0 ~ r-25' DRAINAGE EASEMENT / I 10'~ / I ,,~ G I ~I ; a j :...........I 1...... .... ~~~3 ~~ h ~~ ~I ° I X56 ~ ~I ~I ^ ~ o ~ 58'03"E 291.00' C ~~$°OrO ~3 ~I ~I g ~ N89°58'03"W 291.00' -~ Ga, ~ I C so.12' ~; ~~ c j ~~ ~; ~ Z I :................... ........ 2~ I I ~I zi .I S° I ~ a' v~ ~I ~ L.B.o. =82a.o N LOT 4 ~s/ • I ~ o ~ - ~ 2.339 ACRES / ~~j, ~ LOT 3 n (101,906 sq. ft.) / ' 2.311 ACRES I ~I ~ (100,662 sq. ft.) o / / / . o / i