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HomeMy WebLinkAbout008-1030-10-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM county: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTACH TO PERMIT) 574308 0 GENERAL INFORMATION 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: Jacobson, Greg K. & Ma ry I Eau Galle, Town of 008-1030-10-000 CST BM Elev: Insp.BM E1ev: BM Description: Section/Town/Range/Map No: O0' !/0 1� C� � -Sr�"1 11.28.16.153 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HIS FS ELEV. 7 D3�� /�� • J Septic -- Benchmark Dosing Alt. BM ' C. ,�� ��� �'(__ /4-1" Aeration Bldg.Sewer Holding St/Ht Inlet S7-Al iL SUHt Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic , Dt Bottom Dosing He /Man. Aeration j1-ti,n L4 Dist. Pipe Holding Bow t. System ��j L PUMP/SIPHON INFORMATION Final Gr e J / ' Manufacturer 1 Demand St.0 ✓ �' r' GPM Model Number �J ��c�� I � �� -mil • b_ TDH Lift Friction Lost, Syste Head TDH Ft � � 12<< 0. 7 1 - '- S Forcemain Len? r Dia. it Dist.to Well �+ 2 > Iu,Lr Yea' SOIL ABSORPTION SYSTEM BEDITRENCH Width Lengtb o.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LE HIN Manufacturer: INFORMATION CHAM OR Tye O�System: /! f/ LINI Model Number: / 1 rg_;, i Una DISTRIBUTION SYSTEM (�yr_S+c%�C � «j�• Z' "-kit z, Header anifo d_ IDistrbution x Hole Size x Hole Spacing lVent to Air Intake Pipe(s) a ? '' r, Length Dia Length 7 � Dia Spacing ��" 3� 3,' -7 SOIL COVER x Pressure Systems Only xx Mound 9 r At-Grade Systems Only Depth Over Depth Over J"Mw*of 1xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil /` C G- '� �[LYes No Yes No COMMENTS: (Include code discrepencies,persons present,etc.) Inspe ' n(#1: / 1 I T Inspection#2: / / / Location: 484 Cty. Rd.B Woodville,WI 54028(NE 1/4 NE 1/4 11 T28N R16W) 40 abre�Lot JO�'C4Xd Parcel No: 11.28.16.153�� 1.)Alt BM Description= '° S ' , V 2.)Bldg sewer length= S �j U� - :_ -amount of cover= ,ti 1 EZ LI t"7th K. 0 0 — T Plan revision Required? [ Yes VNo — fUse other side for additional information. SBD-6710(R.3/97) Date Insepctor's nature Cert.No. F 4 1 700. pro Welk o > Qoo-p+ +o Pia der -}-y L; e o?O a -Fo >Qraf)w e'p I v 45.60 $ - r f. jo O L TANV —n 13 571. 3 s L,c) e 2 a i x S to a So TZ VJ _ , Doe— i . F i 1�5,4w_ ,ray County I ,/e- Safety and Buildings Division �`e �PG�t' o, 201 W.Washington Ave., P.O. BOX 7162 Sanitary Permit Number(to be filled in by Co.) Madison#X0tJJ y �� Permit Application State Transaction Number In accordance with SP�38 .Adm.Code,submission of this form to the appropriate governmental unit ` `� L is required prior to obtaJ ry permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if different than mailing address) the Department of Sa ;a rofessional Servies. Personal information you provide may be used for secondary purposes in accordan etq�rtli the Privacy Law,s.15.04(1)(m),Stats. N I. Application irmation—Please Print All Information fJ Property Owner's Name Parcel# Lr -e d-- e.4 4LP �� �, Sc 06P G U X109 66 Property Owner' ailing Address Property Location c 3� q / ` e i U/� Govt.Lot t - ` :7 City,State Zip Code Phone Number /e J �^� ' /a, Section G lrcle one) T�N; R or JZ11.Type of Building(check all that apply) Lot#Block# 1 or 2 Family Dwelling—Number of Bedr s Subdivision El Public/Commercial—Describe Use � �atQ ❑City of ❑State Owned—Describe Use / / CSM Number ❑ Village of 6- Co 3 Town ofFk III.Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑New System Re lacement System y p y ❑Treatment/Holding Tank Replacement Only ❑Other Modification to Existing System(explain) B. El Permit Renewal ❑Permit Revision El Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner IV.Type of POWTS System/Component/Device: Check all that apply) U - /(a e ��T ❑ Non-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade 5t Mound 124 in.of suitable soil ❑ Mound<24 in.of suitable soil ❑ Holding Tank ❑ ther Dispersal Component(explain) ❑Pretreatment Device(explain) V.Dis ersal/Trea ent Area Information: Design Flow(gpd)J Design Soil Applicatio ate(gpd f) Dispersal Area Requ d(sf) Dispersal Area Pro sed sf) System Elevation LIs© VI.Tank Info Capacity in Total #of Manufactur r L Gallons Gallons Units D P U N New Tanks Existing Tanks r �; E re Septic or Holding Tank e, i � Dosing Chamber S� I � VII.Responsibility Statement- I,the undersigned, sume responsibili o installation of the POWTS sho the attached plans. Plumber's Name(Pn t) Plu is Signature /MPRS Number Business Phone Number "ate .� �� -��(G Plumber's Address(Street,City, e,Zip Code) VIII.C""nty/De artment Use Only pproved ❑ pp Permit Fee �/2i ed Issuing nt Signature rove $ � ❑� n eason for Denial W-6 IX.Condit it"OArw pasons for Disapproval 3 OU fir 5epttc'tank,effluerit filter end J r dispersal ceff must ah be services!mairWned PA.— Lp asr per management plan provided by plumber. k,;! q is mast b*Mairdsk ed Attach to complete plans for the system and submit to the County only on paper not less than 81/2 x 11 inches in size I SBD-6398(R. 11/11) • �h MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Jacobson Replacement Mound Owner's Name: Greg &Mary Jacobson Owner's Address: 484 Cty Rd. B Woodville, Wisc. 54028 Legal Description: NE1/4, NE1/4, S11, T28N, R16W Township: Eau Galle County: St. Croix Subdivision Name: Lot Number: Block Number: Parcel I.D. Number: 008-1030-10-000 Plan Transaction No.: Page'1 Index and title Page 2 Data entry Page 3 Mound drawings Page 4 Lateral and dose tank Page 5 System maintenance specifications Conditionally Page 6 Management and contingency plan Pa e 7 Pump curve ands p specifications A P R U` V E[)h Page 8 Plot Plan DEP ENT of Colo Page 9 Soil Ealuation Report 7 ! 63 SEE CORRESPONDENCE Designer: Joe Stang License Number: 223475 Date: 06/1 V1 4 Phone Number: 715-684-5166 Signature: Designed Pursuant to the Mound Component Manual for POWTS Version 2.0 SDB-10691-P(N.01/01), and both SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS(01/81)and Pressure Distribution Component Manual Ver.2.0 SBD-10706-P(N.01/01) Version 7.0(R. 03/2012) Page 1 of 9 Mound and Pressure Distribution Component Design Design Worksheet Site Information (R or C) R Residential or Commercial Design Note: Sand fill(D)calculations assume a 300.00 Estimated Wastewater Flow(gpd) Table 383-44-3 in-situ soil treatment for 1.50 Peaking Factor(e.g. 1.5= 150%) fecal colifonn of<=36 inches. 450.00 Design.Flow(gpd) 7.50 Site Slope(%) 96.40 Contour Line Elevation (ft) 17.00 Depth to Limiting Factor(in) 0.40 In-situ Soil Application Rate(gpd/ft2) Distribution Cell Information 80.001 Dispersal Cell Length Along Contour(ft) = 5.63 Cell Width(ft) 1.00 Dispersal Cell Design Loading Rate(gpd/fe) 1 Influent Wastewater Quality(1 or 2) Are the laterals the highest point in the distribution Y Pressure Disribution Information network? Enter Y or N (C or E) a Center or End Manifold 2.82 Lateral Spacing (ft) If N.above, enter the elevation (ft) 2 Number of Laterals of the highest point 0.156 Orifice Diameter(in) 3.19 Estimated Orifice Spacing (ft)= 9.01 ft2/orifice 2.00 Forcemain Diameter(in) 50.00 Forcemain Length (ft) Does the forcemain drain back? 88.00 Pump Tank Elevation(ft) Enter Y or N 4.55 System Head (ft)x 1.3 8.16 Forcemain Drainback(gal) 9.58 Vertical Lift(ft) 72.01 5x Void Volume(gal) 0.79 Friction Loss(ft) 80.16 Minimum Dose Volume(gal) 0.00 In-line Filter Loss(ft) 26.93 System Demand(gpm) 14.92 Total Dynamic Head (ft) Lateral Diameter Selection Manifold Diameter Selection in. dia. options choice in. dia. options choice 0.75 1.25 x 1.00 1.50 x x 1.25 2.00 1.50 x x 3.00 2.00 x 3.00 x Gallons/inch Calculator(optional) Treatment Tank Information E!38.00 0.00 Total Tank Capacity(gal) 1000.00 Septic Tank Capacity(gal) Total Working Liquid Depth(in) Wieser Manufacturer 7.11 gal/in (enter result in cell 1349) Dose Tank Information Effluent Filter Information 650.00 Dose Tank Capacity(gal) Best Filter Manufacturer i7.001 Dose Tank Volume(gaUn) GF1.0-810x18 Filter Model Number Weiser lUlanufacturer Project Jacobson Replacement Mound Page 2 of 9 Mound Plan and Cross Section Views 1/10 ;: 3 J Observation Pipe n'.' w;�. . �;;�•r+r+r+f r r::r';r,i�;�=t=:r=f=i=:r.i•i�,'r+' r=r= . ' x;r••.�;>�;r;�;r;r;r;�;,�=rjr r'r'r*r•r•r'r•r•r•r•r•r• r•r•r• . ' r,=*`r••'r:r,.r:r�t;r?r•`r�r;r;r;r�r:r;,;r,,,r'r;r;,r;,r�r;,r;r,r;r;,,,,r=r• . W B. �J. I . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . L Mound Component Dimensions A 5.63 ft E 24.07 in H 1.00 ft K aft ft B 80.00 ft F 9.50 in z 12.76 ft L ft D 19.00 in G 0.50 ft J 7.04 ft W 450.40 (ft) Dispersal Cell Area 1471.48 (ft) Basal Area Available 5.63 (gpd/ft) Linear Loading Rate 8.00 (ft) 1/10 B Obs. Pipe Placement Mound Cross Section View Aggregate Dispersal Area Finished Grade 99.78 (ft) --► �ffffl}1 f ff1}}11f11f f}}}}f� F Dispersal cell 98.48 (ft) Lateral 97.98 (ft)—111 — Invert Dispersal Cell :D = i Elevation E : : 4 s 4 96.40 (ft)Contour Elevation 7.5 %Site Slope Geotextile Fabric Cover Shading Key 2- Dispersal Cell See lateral details on Topsoil Cap a _ 1.5 ft +tea•.>•.. .,. ..,. .'*.•.+ Page 4 for number, *r+r*r+r*r'r*r*r r*r*r Q Subsoil Cap � o * ,�* r*r•r size,and spacing of ASTM C33 Sand := ��:�"'` *�;� F laterals. Laterals are ® Tilled Layer = m 0.5 ft equaffy spaced from the � 1e.y*1•yayala r*r+r*r*r*r*r r>r.r. r =;>'.ay.�y,.***>*�>�.****_> 5 distribution cell's © 1:':r:'.•": Aggregate $ r=r*.**r'r•>•> •r+r•r+rr centerline in the A-* distribution cell(AxB). Project: Jacobson Replacement Mound Page 3 of 9 End Connection Lateral Layout Diagram i Laterals centered over the A&B dimension 0=Turn-up iodball valve or cleanoutplu9 ,1 P All laterals are identical k-X I Holes drilled on the bottom of the lateral equallg spaced S Force main connection via tee or cross to maniFold at ana Point. Laterals Morcemain Sch 40 PVC per SPS Table 384.30-6 Number of Laterals 2 Orifice Diameter 0.156 in Lateral Diameter 1.50 in Orifice Spacing (X) 3.27 ft Lateral Length (P) 78.48 ft Orifices per Lateral 25 Lateral Spacing (S) 2.82 ft Orifice Density 9.01 fe/orifice Lateral Flow Rate 13.461 gpm Manifold Length 2.82 ft System Flow Rate 26.93 gpm Manifold Diameter 1.50 in Total Dynamic Head 14.92 ft Forcemain Velocity 2.75 ft/sec Dose Tank Information Locking cover with warning label and locking device and sealed watertight Electrical as per NEC 300 and--► SPS 316.300 WAC 4 in.min. Disconnect Tank component is properly vented E Alternate outlet location Forcemain diameter Weiser Manufacturer 2 in. Ca acity 650.00 Gallons Volume 17.00 gal/inch A Weep hole or anti- Dimensior Inches Gallons B siphon device A 20.62 350.54 C B 2.00 34.00 P♦ ump off elevation(ft) C 4.72 80.16 88.91 D 10.90 185.30 D Total 38.241 650.00 iF 'Dose tank elevation(ft) 3" Bedding un er tank. 1 88.00 Alarm Manuafacturer SJE-Rhombus Note: Switches Alarm Model Number Tank Alert 1 —T— containing mercury may not be used in Pump Manufacturer lGoulds this system. Pump Model Number 3887 EP05 Pump Must Deliver 26.93 gpm at 14.92 ft TDH Project: Jacobson Replacement Mound Page 4 of 9 Mound System Maintenance and Operation Specifications Service Provider's Name Joe Stan Phone 715-6845166 POWTS Regulator's Name St. Croix County Zoning Phone 715-386-4680 System Flow and Load Parameters Design Flow-Peak 450 gpd Maximum Influent Particle Size 1/8 in Estimated Flow-Average 300 gpd Maximum BOD5 220 mg/L Septic Tank Capacity 1000 gal Maximum TSS 150 mg/L Soil Absorption Component Size 450.4 fl? Maximum FOG 30 mg/L Type of Wastewaterl Domestic Maximum Fecal Coliforml >10E4 cfu/100 mL Service Frequency Septic and Pump Tank Inspect and/or service once every 3 years Effluent Filter Should inspect and clean at least once every 3 years Pump and Controls Test once every 3 years Alarm Should test monthly Pressure System I Laterals should be flushed and pressure tested every 1.5 yea rs Moundl Inspect for ponding and seepage once every 3 years Other Miscellaneous Construction and Materials Standards 1. Observation pipes are slotted and materials conform to Table SPS 384.30-1, have a watertight cap, and are secured in as shown in the mound component manual. 2. Dispersal cell aggregate conforms to SPS 384.30(6)(i),Wis.Adm. Code. 3. All gravity and pressure piping materials conform,to the requirements in SPS 384,Wis.Adm. Code. 4. Tillage of the basal area is accomplished with a mold board or chisel plow. 5. The mound structure and other disturbed areas will be seeded and mulched to prevent soil erosion and help reduce frost penetration. Lateral Turn-up Detail Finished •�������������• Grade 6-8"Diameter Lawn Threaded Cleanout Sprinkler Valve Box Plug or Ball Valve Distribution . . ./. . . . . Lateral Long Sweep 90 or Two 45 Degree Bends Same Diameter as Lateral Project: Jacobson Replacement Mound Page 5 of 9 Mound System Management Plan Pursuant to SPS 383.54,Wis.Adm.Code General This system shall be operated in accordance with SPS 382-84 Wis.Adm.Code,and shall maintained in accordance with its' component manuals[SBD-10691-P(N.01101),SSWMP Publication 9.6(01/81),and Pressure Distribution Component Manual Ver.2.0 SBD-10706-P(N.01/01)]and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with SPS 383.33,Wis.Adm.Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers,access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective,or subject to failure must be replaced. Exposed access openings greater than 8-inches in diameter Shall be 5mred by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s.281.48,Slats. The contents of the septic tank shall be disposed of in accordance with NR 113,Wis.Adm.Code. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm,the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment,maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However,if such products are used they shall be approved for septic tank use by the Department of Commerce. Pump Tank The pump(dosing)tank shall be inspected at least once every 3 years. All switches,alarms,and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Mound and Pressure Distribution System No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter,and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic(other than for vegetative maintenance)on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations(October-February)dilate that the mound be heavily mulched as protection from freezing. Influent quality into the mound system may not exceed 220 mg/L BOD5, 150 mg/L TSS,and 30 mg/L FOG for septic tank effluent or 30 mg/L BOD5,30 mg/L TSS, 10 mg/L FOG,and 104 efu/100 mL for highly treated effluent. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system is provided with a flushing point at the end of each lateral,and it is recommended that each lateral be flushed of accumulated solids at least once every 18 months. When a pressure test is performed it should be compared to the initial test when the system was installed to determine if orifice dogging has occurred and if orifice cleaning is required to maintain equal distribution within the dispersal cell. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner,and any levels above 6 inches considered as an impending hydraulic failure requiring additional,more frequent monitoring. Continency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank,pump,pump controls,alarm or related wiring becomes defective the defective components)shall be irmediaely repaired or replaced with a component of the same or equal performance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface,it will be repaired or replaced in its'present location by increasing basal area if toe leakage occurs or by removing biologically dogged absorption and dispersal media,and related piping,and replacing said components as deemed necessary to bring the system into proper operating condition. See Page 5 of this plan for the name and telephone number of your local POWTS regulator and service provider. Pretreatment Units The information and schedule of mananagement and maintenance for pretreatment devices such as aerobic treatment units or disinfection units are attached as separate documents and are considered part of the overall management plan for this system. Project: Page 6 of 9 ITT 0oum Pum" Wastewater s compotams TOM OW YL Of wvaww a�os . , lbapeler 5 53 2 Base 10 6 10 46 62 3 P1mV Casing 8 15 36 55 4 Medur"Seal 20 21 46 5 Bd emkxjs 7 25 0 33 6 04bp 6 Y 30 — 11 4 7 Power Cofd 5 8 08 Fied Motor 4 MoWHouskW' 3 9 St t t0 Mo6 cmw 2 METERS FEEr 10 -- — I 9 +-28FT E 7 251 u61 2O i 5 3 EPOS 10 z 2 ' 7 EP04 5 0 0o 10 20 3a 40 so GPM L 'L 0 2 4 s to t2 nWh 3 , ?e�0`-•f y w elk > qoa-p+- o +o Pra Per+7 L; a ap�' +° Prbeeefp } s $OoT rovwg .ln� AS.too 8 t Qy 60 je O L TANk 7-0 t,.t,1►'a�',� 2 _ 1VaG - �5� a i t to Pto�e�� �-�•n� 4 =s i s o G,�ec, � �l\.a�� 'Smc ab ^ y$4 �+ ca iy Y � 4oLY' LN D Oi e�v>>�� v,�:•K R 1 1 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer e- 4 k14 Mailing Address qgz q, Property Address If An e (Verification required from Planning&Zoning Department for new construction.) 1 City/State �wc, , ` ( `_ parcel Identification Number jjG G 3� lG_ 6 o U � I LEGAL DESCRIPTION Property Location N�!'/4 , �'/4 , Sec. 1 , T Ik!k N R 1 G W, Town of &/Nt A-` Q Subdivision Plat: , Lot# Certified Survey Map# , Volume , Page# Warranty Deed# ���1 - y (before 2007)Volume JbI.3 , Page# Spec house❑yesElno Lot lines identifiable❑yes❑no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner,if needed,by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in§SPS.383.52(1)and in Chapter 12-St.Croix County Sanitary Ordinance. The property owner agrees to submit to St.Croix County Planning&Zoning Department a certification form,signed by the owner and by a master plumber,journeyman plumber,restricted plumber or a licensed pumper verifying that(1)the on-site wastewater disposal system is in proper operating condition and/or(2)after inspection and pumping(if necessary),the septic tank is less than 1/3 full of sludge. I/we,the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth,herein,as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St.Croix County Planning&Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on thi orm 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 warr my deed recorded in Register of Deeds Office. Number of bedrooms /SICT4ARE OF APPLICANT(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.04/12) 1613PAGE 481 ro STATE BAR OF WISCONSIN FORM 2.1999 E'4_--Z:3L-'a Q WARRANTY DEED KATHLEEN H. WALSH DocnmentNumber REGISTER OF DEEDS ST. CROIX CD., WI This Deed,made between Edna Iverson,a single person RECEIVED FOR RECORD 04-05-2001 9:30 AM WARRANTY DEED Grantor, and Greg K Jacobson and Mary Jacobson,husband and wife EXEMPT to as survivorship marital property — CERT COPY FEE: COPY FEE: TRANSFER FEE: 2.85oa RECORDING FEE: 10.00 Grantee. — PAGES: 1 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): The Northeast Quarter(NE 1/4)of the Northeast Quarter(NE 1/4)and the East One-half(E 1/2)of the Northwest Quarter(NW 1/4)of the Northeast Recording Area Quarter(NE 1/4),all in Section Eleven(11),Township Twenty-eight(28) North-Range Sixteen(16)Wert. Name mid Re Address Thomas A.McCormack This deed is given in satisfaction of that certain Land Contract between the 1020 10th Ave. parties dated December 12, 1986,and recorded December 19, 1986,in PO Boa,W1 Volume 763 of Records,at Page 439,as Document No.420477,office of Baldwin,WI 34002 the Register of Deeds for St.Croix County,Wisconsin. 008-1030-10, -20 Parcel Identification Number(PIN) This is not homestead properly. Exceptions to warranties: Easements and restrictions of record,and exe t tis not) be created by the acts and defaults of the eP anY liens or encumbrances created or suffered to I'! grantees,their heirs,successors or assigns. Dated this day of /+nl a�c1G` 2001 * Edna Iverson AUTHENTICATION ACKNOWLEDGMENT Signature(s) ---- -- STATE OF WISCONSIN ) ss. St.Croix County ) authenticated this day of i L Pc�°�ally came before me this day of n�r t� , 2001 the above named • Edna Iverson r TITLE:MENIBER STATE BAR OF WISCONSIN - (Ifnot, _ to me known to be the perso" wlio c ecuted the:foregoing authorized by§706.06,Wis. Stats.) -- instrument fq acknowledg a Barn s' THIS INSTRUMENT WAS DRAFTED BY --- Thomas A.McCormack G✓tl� l �l/d..`�'t� J Imia 7 wjLz4uu2 Notary Public,State of Wbro In My Commission is perman not,sta e7:prcatron — (Signatures may be authenticated or acknowledged.Both are not necessary.) °� ,. r F--- ) •Names of persons signing in any capacity must be typed or printed below their signature, Inronnavon Proles,;;,ais company,fond du Lae,Wt WARRANTY DEED STATE BAR OF WISCONSIN 800-855-2021 FORM No.2-1999 RECEIVED , JUN 172014 Wis.Dept.of Safety and Professional Services SOIL EVALUATION REPORT Page 1 of 4 Division of Safety and Buildings ST.CROIX COUNTY 'OMMUt44ftl4D5W ($PMVIQ1Ws. Adm. Code County St.Croix Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.Plan must include,but not limited to:vertical and horizontal reference point(BM),direction and Parcel I.D. 008-1030-10-000 percent slope,scale or dimensions,north arrow,and location and distance to nearest road. Please print all information. Re ed Date t—� 71 Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). �j{i(/j��` ` Property Owner Property Location I El Greg&Mary Jacobson Govt.Lot NE 114 NE1/4 S 11T 28N R 16E(or) Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# 484 Cty Rd B City State Zip Code Phone Number City rjViIlage ■ own Nearest Road Woodville Wise.1 54028 1 ( 715-698-2040 Cty RD B New Construction LlseE] Residential/Number of bedrooms 3 Code derived design flow rate 450 GPD ElReplacement Public or commercial-Describe: Parent material Glacial Drift Flood Plain elevation if applicable f ft. General comments and recommendations: Mound system Contour El.96.4 aBoring# 11 Boring El Pit Ground surface elev. 96.4 ft. Depth to limiting factor 40 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. *1-ff#1 02 1 0-7 10YR2/1 --- sil lmsbk mfr cs 3 0.4c 0.6 2 7-14 10YR4/4 --- sil lmpl mfr cW 2 0.4c 0.6 3 14-20 7.5YR4/6 --- sl 2msbk mfr cW 1 0.6 0.7 4 20-40 7.5YR5/6 --- sl 2msbk mfr cW -- 0.6 0.7 5 40 10YR7/4 Weak Cemented Sandstone ❑2 Boring# 11 Boring 96.4 20 El Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft I in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. -ff#1 * 02 1 0-5 10YR2/1 --- A lmsbk mfr cs 3 0.4c 0.6 2 5-11 10YR4/4 --- sil lmpl mfr cW 2 0.4c 0.6 3 11-20 7.5YR4/6 --- sl 2msbk mfr cW 1 0.6 0.7 4 20 10YR7/4 Weak Cemented Sandstone *Effluent#1=BOD 5>30:5 220 mg/L and TSS>30 <150 mg/L *Effl.Ioent#2=BOD <30 mg/L and TSS<30 mg/L CST Name(Please Print) Signature CST Number Thomas W.Gedatus 962178 Address Date Evaluation Conducted Telephone Number Stang Plumbing&Electric P.O.Box 263 Woodville,Wisc.54028 6/12/2014 715-684-5166 SBD-8330(RI 1/11) Greg&Mary Jacobson 008-1030-10-000 2 4 Property Owner Parcel ID# Page of F]3 Boring# Boring 94.1 17 Q pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Donsistence Boundary Roots GPD/ft z in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 ff#2 1 0-7 10YR2/1 --- sil Imsbk mfr es 3 0.4c 0.6 2 7-10 10YR4/4 --- sil 1 mPl mfr cw 2 0.4c 0.7 3 10-17 7.5YR4/6 --- sl 2msbk mfr cam' 1 0.6 0.7 4 17 10YR7/4 Weak cemented Sandstone ❑ Boring# Boring Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft z in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. -ff#1 02 Boring El Boring# Ground surface elev. ft. Depth to limiting factor in. Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft Z in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. * ff#1 *11#2 *Effluent#1 =BOD 5>30<220 mg/L and TSS>30 <150 mg/L *Effluent#2=BOD 5<30 mg/L and TSS <30 mg/L The Dept.of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format,contact the department at 608-266-3151 or TTY through Relay. SBD-8330Tmt(RI 1/11) N Sh� rScgt� Yo 700 �r > 400-p+ Qro et-Fy L' e > a a -�0 Proc ef� _ � Q g OT 7"or+r+ 6 S•d` h1 a6.�o 8Z g! y Q�G60\\n 8-3 � h 4o 200 -Q+ -T- 2, 8N, b to Pro 4 e 4L rA + c o ,4 ._ i4 A 2014 Property Record I St Croix County, WI Assessed values not finalized until after Board of Review. Property information is valid as of JUN 09 2014 10:25PM . OWNER CO-OWNER(S) GREG K&MARY JACOBSON 484 CTY RD B WOODVILLE,WI 54028 PROPERTY DESCRIPTION SEC 11 T28N RI 6W 39A'sNE NE PROPERTY INFORMATION Property Address: 484 CTY RD B Parcel ID: 006-1030-10-000 Municipality: TOWN OF EAU GALL€ Alternate ID: 7f.28.16.753 School Districts: SCH D BALDWIN-WOViLLE DEED INFORMATION Other Districts: WITC Volume Page Document# 774 636 Section Town Range Qtr Qtr Section Qtr Section 763 43 420477 11 28N 16W 1613 481 642130 Lot: Bl�o k:, Plat Name LAND VALUATION Valuation Date: 20120606 TAX INFORMATION Code Acres Land Value Improvements Total G1 3.000 33,000 183,000 216,000 Net Tax Before: .00 G4 34.000 7,000 0 7,000 Lottery Credit: .00 G5 2.000 100 0 100 First ollar Credit: .00 39.000 40,100 183,000 223,100 Net Tax After: .00 Total Acres: 39.000 Amy;Due Amt.Paid Wince Assessment Ratio: 0.0000 Tax .00 .00 .00 Mill Rte: 0.000000000 Special Assmnt .00 .00 .00 Fair Market Value: N/A Special Chrg .00 .00 .00 Delinquent Chrg .00 .00 .00 Private Forest .00 .00 .00 INSTALLMENTS Woodland Tax .00 .00 .00 Managed Forest .00 .00 .00 Period End Date Amount Prop.Tax Interest .00 .00 Spec.Tax Interest .00 AO Prop.Tax Penalty .00 .00 Spec.Tax Penalty .00 .00 Other Charges .00 .00 .00 TOTAL .00 .00 00 Over-Payment .00 PAYMENT HISTORY(POSTED PAYMENTS) General Special Date Receipt# Source Type Amount Tax Status Assess.Status Interest Penalty Total