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HomeMy WebLinkAbout040-1308-00-166 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM county: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No:A543 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)]. Parcel Tax No Permit Holder's Name: City Village X Township 040-1308-00-166 Elzin a, David &Catherine Troy, Town of Ins BM Elev: BM Description: Section/Town/Range/Map No: CST BM Elev: P 6 �,, 24.28.20.1985 TANK INFORMATION ,I , ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic 1 7— Benchmark b / /Z6 g� IA.) � Alt.BM 2 �( J C Aeration Bldg.Sewer Jr-q 7 cyl - Holding St/Ht Inlet � .Z ay 7•7 St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. en Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. /_• '77 , Aeration Dist. Pipe W/_ fl- 7. Holding Bot.System S. / d� Final Grade 3, /6 D PUMP/SIPHON INFORMATION Manufacturer Demand St Coverer /��• 8 GPM Model Number TDH Lift Friction Loss System Head Ft - Forcemain Length Dia. Dist.to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No.Of Trenches IT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 9b Z �e,� SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacture�N �1 INFORMATION CHAMBER OR Q' Type Of System: Zy UNIT Model o.,. t_ and ,n. a eZ_ J DISTRIBUTION SYSTEM 7$ 2.�.a--ZZ Header/Manifo� Distribution x Hole Size x Hole Spacing Ve56 )Int ke Pipes) `, �\ Length Dia Length Dia \ Spacing w CoMe SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over xx Depth f xx Seeded/Sodded ulched Depth Over / P To soil __ Yes No Bed/Trench Center �• `� Bed/Trench Edges P es 7NT. '-'±I� [ COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: / / Parcel No: 24.28.20.1985 Location: 320 Lindsay Rd HHy ds n,WI 548g16(SE 1/4 SE 1/4 24 T28N R20W) Troy Vil age 6th dition L��66 / , ce Cry �— Cis✓�--- J/'c/CC-� �� 1.)Alt BM Description 2.)Bldg sewer length= 13 -amount of cover 6 w. r-- Plan revision Required? Yes No �t�L I lO UU' z 5 Use other side for additional information. �' �- - - Date Insepctor's ignatu Cert.No. SBD-6710(R.3/97) 0 8✓f/- _ 47 _ . i J - lerw r _ _ 1 i _ _ County oti�trcattla C E 19/i .y„ Services Division �. 3 1400 E Washington Ave nary Permit Number(to be filled in by CO.) s nn 1q P.O. Box 7162 " $ UL 15 2'>1<&son,WI 53707-7162--`_ ` ST. ROIX G 5anitar�V'�QAfi6n State Transaction Ivum er In accordance with SPS 383.21(2),Wis.Adm.Code,submission ofthis form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Address(if Brent than mailing address) the Department of Safety and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacv Law,s. 15.0 1)(m),Stats. L Application Information—Please Print All Information Parcel# �� Property Owner's Name / 1 Property Location G / Property Owner's Mailing Address _ ovL Lot r �d )I�� 1 4;V4 '/,S /4, Section City,State Zip Code Phone Number 's (circle one) L N R,2,�LE or W K 11 Type of Building(check all that apply) Lot / Subdivision Name 1 or 2 Fa ily D elling-Number of Bedrooms V �/ Block# ❑Pub iI c/Commercial-Des' be Ilse ❑arty of ❑State Owned-Describe Use ❑ Village of CS11�I Number —A IS44L ®Town of III.T pe of Permit: (Check only one box on Hite A. Complete line B if applicable) A F1 New System El Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain} ❑ permit Renewal Permit Revision ❑Change of ❑Permit Transfer to New List Previous Permit Number and Date u d $• Plumber Owner - / Before Expiration IV.T of POWTS System/Component/Device: (Check all that ap ') Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ 4found 24 in of suitable soil ❑ Mound<24 in.osuitable i ❑Pretre D Lice( . lain) qK Holding Tank ❑Other Disp 1 Component(e, i V.Dis ersal/Treatment A Information:Design Flow(gpd) Design Soil Application Dispersal Area Required(st) Dispers���Propo Rate(gpdsf) Capacity in Gallons Total of lfanutacturer Gallons Units i, New Tanks Em. sting Tanis Ai U ❑ ❑ ❑ ❑ Septic or xolaing Tank tti' c IL r'� 'l, ❑ ❑ ❑ ❑ Dosing Chamber VII.Respons' ility Stateme t-I,the undersigned,ass a respons' ' for install of the POWTS shown on the attached plans. Plumber MP1liPRS Number Business Phone Number Plumber' ame( nt) / Plumber's Address(Street,City,St e,Zip Cod �X l, ountv/De artment Use Only Pernut F Date Issued wing tlgent Si tyre Approved ❑ Disapproved - S tv ' El Given Reason for Denial '�,, I IX.Conditions of Approval/Reasons for Disapproval �U�X�d— C,t?�I Attach to complete cans for the system and submit to a County only on paper not less than 8 112 x 1 t inches in size t� 7CoJpds�a � f', - Property Owner L,J,, - Parcel ID#. �� —/��J��^�� _ /// Page L--;) of�� Boring# ❑ Boring ® pit Ground surface elev. G6.!J ft. Depth to limiting factor­ AQ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft 2 in. Munsell Qu.Sz. Copt.Color Gr.Sz.Sh. ff#1 :-ff#2 S o - a 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/ft z in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 02 ❑ Boring# ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil ApNication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft 2 in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. ff#1 ff#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-8330(RI 1/1 1) Wis.Dept.of Safety and Professional Services SOIL EVALUATION REPORT Page L of . Division of Safety and Buildings in accordance with SPS 385,Wis. Adm. Code 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:vertical and horizontal reference point(BM),direction and Parcel percent slope,scale or dimensions,north arrow,and location and distance to nearest road. - - - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)). / Property Owner Property Location v Govt.Lot__,- 1/4 1/4 T N E(or b Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# City S Zip Code Phone Number ❑City ❑Villag Town Nea est Road I 1A ( ) New Construction User Residential/Number of bedrooms Code derived design flow rate 11&r GPD ❑Replacement // El Public or commercial-Describe: Parent material ��n�rl Flood Plain elevation if applicable ft General comments 95'8 and recommendations: Boring# Boring /I pit Ground surface elev.� �2/n _ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence 3oundary Roots GPD/ft Y in. Munsell Qu.Sz. Cont.Color Gr.Sz.Sh. * ff#1 * ff#2 7 R 4 4 Boring# Boring ® pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence 3oundary Roots GPD/ft 2 in. Munsell Qu.Sz. C nt.Color Gr.Sz.Sh. ff#1 * ff#2 AZ q 9 *Effluent#17 BOD >30<220 mg/L and TSS>30 <150 mg/L uent#2=BOD <30 mg/L and TSS <30 mg/L CST Name(Plea nt) Signature CST Number Address - Date Evaluation Conducted Telephone Number SBD-8330(RI 1/11) I ifT I -- - - _ IL \ I I _ ' : : I I : _ I _ I _ i : �I F � , _ I --- -- -- -- '` ' --- I I t � I it T I I I , i - County .r. +y Safety and Buildings Division ' 201 W.Washington Ave.,P.O.Box 7162 Sanitary Permit Number(to be filled in by Co.) Madison,WI 53707 7162 State Transaction Number 'tary permit Application Wis.Adm.Code,submission of this form to the ate governmental unit In accordance with SPS 383.21(2), Application forms for state-ownedl' S are submitted to Project Address >f different than mailing address) is required prior to obtaining a sanitary Permit Note:App vide ma for secondary the Department of Safety and Professional Servils personal information you provide sea in accordance with the Prrra , I. A lication Information-Please Print All Informati Parcel# Property Owner's Name �l(/ O`� �j Q 40 130-9 L Property Location (, ial�) Property Owner's Mailing Address �Fl pp�Y Govt Lot Phone Number ,t,� -�,� '/,, A Section Zip Code •I` (circle one City,State T N; RE f II. Lot#Type of Building(check all that apply) Subdivision Name G 1 or 2 Family Dwelling-Number of Bedrooms �� � C✓"gC Bloc ❑City of C1 Pub lic/Commercial-Describe Use CSM Number ❑Village of 0 State Owned-Describe Use �Town of Z lv 2Z G a III.Ty t: (Chec only one box on line A. Complete line B if applicable O M ification to Existing System(explain) A New System ❑Replacement System ❑TreatmentlHolding T eplacement y ist Previous Permit Number and Date Issued B. ❑permit Renewal ❑Permit Revision ❑Change of Plumber ❑ t e Before Expiration I stem/Com o nt/Device: Check all that a 11!11111 �L Non-Pressurized In-Ground ❑Pressurized In-Gro und ❑At-Grade Mound>-24 m.❑o pretrealtment Device Mound<((explain)4 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component(explain) V.Dis ersaUTreal ut 11 Area Information: s Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation Design Flow(gpd) Design Soil Application Rate(gpd Total #of Manufacturer c VI.Tank Info Capacity in ` c Gallons Gallons Units New Tanks Existing Tanks d l 5z c cg H U tL Septic or Holding Tank Dosing Chamber MP/MPRS Number Business Phone Numb VII,ILesp risibility Statement-I,the undersigned,assume res sibility for instill n o er f the POWTS shows on the attached plans. Plum r' ame t) Plumber' Si Plumber's Address tree' City,State,Zip Code) VIII.Coun /De artment Use Onl Permit Fee Date sued Issuing t Signature Approved isap7vie. Reaso n for-Denial ✓ IX.Condi I eaSons for Disapproval 1 peptic tank,effluent filter and dispersal ce8 must ali be servlces(majntn d as per management plan provided by plutytber. 2. All se ?ack requirements must be a.l P appliclibte code I wdinanas. Attack to complete plans for the system and submit to the Conory only on paper not less than 8 iR x 11 incites in size CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: ,l12W 7��� — Owner's Name: Owner's Address: Legal Description: Township: County: Subdivision Name: Lot Number: Parcel ID Number: Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing Page 4 System Cross-Section Page 5 Filter Specs Page 6 Maintenance&Management Plan Page 7 Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat 5 Designer/Plumber: License Number. Date: Phone Number Signature Designed pursuant to the In-Ground Soil Absorption component Manual for POWTS version 2.0 SBD-10705-P(N.01101). Page 1 88�s<s -W / <;D�ir/` l�•Bs�L A gq� I � &12 �m �� ' ��/ �9�,� Sell kbsoMon SwtW Cross 890600 - �ft Firui Grade 4'Schedule 4D PVC Vent C pe ft 1�Vent Cap f----" Leaching Chamber --® �--- m System EWjaIjon Soil Absoroi<lon goft'n Plan View qe it OREM& ft 1 Leaching Trerud�9 't Vent Or ObsWvafian Pipe Chambers 4°Die Trench 2 Header Leachilm Chmftr 80Mift521101ts Manufacturer And Model ElSA Rafing rZ.sq ft per chamber Soil APpUc ation Rate gPdISi ft gpd Design Flow 4 Soil APPiipf+on Rafe EISA= Chambers t rows of chambers each. Fagg Of ,V11 K rim. INSTALLATION INSTRUCTIONS raw A zwmr PL-525/PL-625 FILTER INSTALLATION INSTRUCTIONS oer faber with apardng s. oft y.d'tf A "x'^'f ``"N"J cc Y -y'S� •A K s §'`r i , •S3F r { S! gr,.t ��� <: Step 1: Step 2: Step 3: (A)Locate the outlet of the septic tank. (A)Before installation,place the (A)Glue the filter housing on the B Remove tank cover and pump tank fitter housing on to the outlet pipe. outlet pipe. ( ) (B)Make sure that the housing (8)Insert the filter cartridge In the If neo3ssary. is positioned so the fitter can be housing,matdng sure the filter removed from the tank for cartridge is properly aligned and maintenance and service. completely inserted in the housing. MAINTENANCE INSTRUCTIONS b � i .., �,.s�;.t� y"-•. °" � `a- *- }' � Cam. fi �?'� 7 "+..fin. .�'y4 1"� � '�•C"���,z ' �`'.r � ! Y r` 1.. r �� c.�Y Yx •il�FO. l'.�♦� ,.w��,r',s Step 1: Step 2: Step 3: Locate the outlet of the septic tank. (A) Remove tank cover and pump (A)Insert the filter cartridge back if necessary. into the the housing rnalang sure DO a (B)Pull the Alter out of the housing. the finer is properly aC�ghed WHEN FILTER IS REMOVED and completely inserted. (C)Hose off the Alter over the septic tank (g)Replace septic flank ever rr "` VES-:: ' Make sure alt solids fall back into the USE R1 E GLQ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page la-or_ FILE INFORMATION SYSTEM SPECIFICATION Se tic Tank C aci al ❑NA Owner Se tic Tank Manufacturer -� ❑NA LPe Effluent Filter Manufacturer o NA DESIGN PARAMETERS Effluent Filter Model - ❑NA ❑NA Pum Tank Ca acit al NA Number of bedrooms ONA Number of Commercial Unit 6NA PUMP Tank Manufacturer Estimated flow(avera e) aI/da Pump Manufacturer NA Desi flow( eak), (Estimated x 1.5) g al/da Pump Model �N}°` Soil Application Rate -7 al/da /ft Pretreated Unit Influent/Effluent Quality Monthly Average* o Mechanical ravel Filter o Wet and <3U m* L ct Mcc:hanical Aeration ❑Wetland Fats, Oils &Grease(FOG) g/ p Disinfection o Other: Biochemical Oxygen Demand (BODs) <220 mg/L Manufacturer Total Suspended Solids(TSS) <150 mg/L Dispersal Cell(s) Monthly Average vit o In-ground(pressurized) Pretreated Effluent Quality ❑ NA X'In-ground (gravity) Biochemical Oxygen Demand(BODs) <30 mg/L p At-grade ❑Mound Total Suspended Solids(TSS) <30a � m - ❑Drip-line ❑Other: Fecal Coliform(geometric mean) <10 cfu/100mL Maximum Effluent Particle Size '/s inch diameter Values typical for domestic(non=comritereial) _._._.-�vastcwater-and septictankeF#tuent. ** Values typical for pretreated wastewater. - MAINTENANCE SCHEDULE Service Event - Service Frequency Inspect condition of tank(s) At Ieast once every ❑months 0 ye s) (Maximum 3 rs) ?um out contents of tank(s) When combined sludge and scum equals one third(%)of tank volume Inspect dispersal cells At least once eve o months to a s) (Maximum 3 rs Clean effluent filter At least once every o months w year(s) Inspect pump, pump controls &alarm At least once every o months' p year(s 2 NA Flush laterals and pressure test At least-once every o months o yea rs) Other: �At�Ieastl nce eve �Omoonn ths �E3e r(s) NA Other: nce eve ths (s N A 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 tank(s) 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('/a)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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mechanical or pressurized POWTS components,pretreatment components,and any other maintenance or monitoring at intervals of 12 months or less 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. START UP AND OPERATION For new construction,prior to use of the POWTS check treatment tank(s)for the presence of painting products or other chemicals that my impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tanks(s)removed by y-a septage servicing operator prior to use. Page �11 of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. I 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 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: I 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 rb required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area wi. 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. ❑ 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>> 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 INSTALLE POWTS MAINTAINER Name Name Phone _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATO Y AUTHORITY Name Name Phone Phone —_ This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) &(3),Wisconsin Administrative Code. Lo Ile tot K o 7 2-5 wl ; I r �,�I LQJ 3 AAACHO N 1n. lh r i ., . w..• t9 lz ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing .Address 2 �/s Z `,,�A; Property Address p (Verb cation required from Planting Department for new constructi ) / ll<_ /"X/ Parcel Identification Number City/Statee �.._ _ f`AI t�F ;C'RJPTION, Property Location,--5'Z -5-4"_ V4, Sec. �, W, Town of Subdivision �.� l � <�-- , Lot # ��6 CertMed Survey Map # Volume , Page # Warran ty Deed # ('a , voluipe 3 ZD , page # Spec house ❑ yes (y/no Lot lines identifiable yes ❑ no STEM 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. The property owner agrees to subunit to St. Croix Zoning Department a certification farm, signed by the owner and by a masterpluraber,journeymanplumber,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 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 throe pyar expiration da e. SIGNATM APPLIC DATE OMME CERTIFICATION I(we) certify that all statements on this form are true to the best of my (our) knowledge. I (we)am(are)the owners)of the propeq&4pribed above y virtue of a warranty deed recorded in Register of Deeds Office. /A SiC3AlA F APPLZGt�� v L. ��' DATE *•**** Any information that is mis-represented 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 a copy of the certified survey map if reference is made in the warranty deed li illll 11 II l Ill lilt 8221664 State Bar of Wisconsin Form 1-2003 Tx:4181651 WARRANTY DEED 994367 BETH PABST Document Number Document Name REGISTER OF DEEDS ST. CROIX CO., WI 04/03/2014 11:26 AM THIS DEED,made between Tribella Properties,LLC EXEMPT#: N/A REC FEE: 30.00 ("Grantor,"whether one or re), TRANS FEE: 157.50 and David J.Elzinga and Catherine E.Elzinga,husband and wife as PAGES• 1 survivorship 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,State of Wisconsin("Property")(if more space is Name and Return Address needed,please attac a endum): River Valley Abstract&Title 1200 Hosford St. Suite 201 Lot 166, Plat of Troy Village Sixth Addition in the Town of Troy, St. Hudson WI 54016 Croix County,Wisconsin. File: 400358 040-1308-00-166 Parcel Identification Number(PIN) 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. Dated April 2,2014 LORRIE L. DEMARS Tribella ro erties,LLC NOTARY PUBLIC STATE OF WISCONSIN (SEAL) - *Jo (SEAL) (SEAL) * * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )ss. authenticated on • ST CROIX COUNTY ) * Personally came before me on April 2,2014 TITLE:MEMBER STATE BAR OF WISCONSIN the above-named Joseph Klewicki,Managing Member of (If not, Tribella Properties,LLC authorized by Wis. Stat.§706.06) to me known to be the person(s)who ec t t oregoing instrument and Xknowledged the THIS INSTRUMENT DRAFTED BY: *torrie .DeMars Fran Iverson 1200 Hosford St. Suite 201 Hudson WI 54016 /Notary blic,Stai e of consin ` My C ission(t' anent)(expires:March 20,2016 d. B ) (Signatures may be authentic ed cknowledgeoth are not necessary.) NOTE:THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ©2003 STATE BAR OF WISCONSIN FORM NO.1-2003 6typarmmCWnat�ti W%7 Page 1 of 1 CAl�1�►�NT.i�L t3�.i1>✓Ls�PM�T ca��'' / ;�� � _ LOT 1 btu, ' G '-rower ST. CRD�X CDUl>wTy ,W,scua�l 8Nl =� 1W OF Z3�`u S.Rbti i�►f�s 1G6 g1 s �Os \l 38.44' F i Z }gip J p t � O i C B1666 8166A ELEV. 892.0 ELE 94.0 Cbg4 8 is ,� f8g6� B 166C ® B167C ELEV. 897.2 r0 201.42' ELEV. 895.1 NLO).8 s� _2)g-ko.�!_ - - - - - - - - -— pq-a8-c3 t r� 155 1. 3 AM 40/! M ado i► gloom MI 04 1 t 1 (i�gY1J►Jl , 1 1 ' t I I ` ' i Iii fl ►Iit- — J(i i � � ' c- v u I t lL try J L JL- - - - - - i ----+ •-----� , T• ( ( SA02V 9>00M!+„M-�N39 t _ at IL cq t t i t 1 t xo►-,� „0,4 1 1 I 1 i t 1ltrt- - ssr�i, rB�r�t>7 �wlltr2,1 1 ( 1 i >i W�oac3V3M 1 i c 1 ~ ' 1 1 2163 tioOld 1 1 f �4 4NI1137 cmaol8 m i "7'O xL"61 s SmaL1 21001:.oz _� 43WV21d QNVM 1 - 1 ' 1. 1 m 1 1 1 I (NO)lil -1- - L- - - - - - - - - - 1 - - - - - - - - - - - - - i It �- -------------- 1- r---- ----- ------------- -J t 1 1 t t L u W 1 IXi3 , o i i t t ! Lu t t , ( 1 1 J 1 1 F t i no't t 1 0 1 1 1 `----------IT- 'T- ul 1 1 f d LL x.5 - t sr < 1 t ( t 1 r t i t 1 ( 1 - 1 wrUn9 _ N!-11IR3 1 i 1 j 1 - i f i t Fs t t t 1 ( - 1- •- --------- ------- ---------------- ------------------- -------------------------- -a f 1. , Wlsoonsin Department of Commerce SOIL EVALUATION REPORT Pere_ 1 of 3 Division of Safety and Buildings In accordance with Comm 85,No. Adm. Code County S7•C�� Attach complete site plan on paper not less than 8 1/2 x 11 Inches sizo. I V C Y.;;- include,but not limned to:vertical and horizontal reference point(B ),dir C percent slope,scale or dimensions,north arrow,and location and c stance to nearest road. _ Revle ed by Date Please print all Information. O(✓j 9 2� 3 0 Penonei Inronnalfon you provide may be used for seCondary purposes(Pr-scy Law,S.15.01 )(mil• Property Owner l' QIOTY .r E i/d 5 1/4 S ;LAJ T ;LY N R w Property owner's Mailing Address Lot tt Block tt I Subd.Name or CSMX I I U O P� EIGD 5T N G SW-M 100 Inc(o -" T{� V t LL-A 6,E �ADcA City State Zip Code Phone Number Cl city C]Village ®Town Nearest Road 61.Awe 4 49 10 0737-7 -t" L-tA)D5AY ROAD New Conswction Use:X Residential!Number of bedrooms _ Code derived design flow rate_ S?QQ _GPD ; ❑Replecament ❑ Public or commercial•Describe: Parent material_ A LL-r--U 1A L Flood Plain elevation it applicabie General comments andrecommendations: CUAJtJS.%MCl.0AL Z/J-CoKOULNA Tl2i'al�Git� 0.1 LOAD1Nro RATE Boring Boring tt pit Ground surface elev.`�q�_'t. Depth to limiting(act or 7I�Z n. Soil icalion Rats Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDO in. Mtnsell Qu.Sz. Cont.Color Gr,Sz,Sh. 'E(ftV1 EtttfZ za 25-P m cis d.5 0. Z 3 - 51 Z -mato d7 -rn D,S D•9 (u v2 03 1.2 WS - 5 - s o.?s_ ti d t ; P-12 I Z-` ��co Hogluhl ttA 5 0-12%1 Gle• 1�. I ' I � ) Boring n Boring tt ! is L ! Pit Ground surface eiev. L (t. Depth to iimltlnS7 factor q� in, Ication Rate ) 1 Horizon Depth Dominant Col Redox Description Texture Stricture Consistence Boundary Roots GPDOF i n. Munsep Qu.Sz. Cont.Color Gr.Sz.Sh. 'Efflit Eft#2 J. 57 04 10 111AC Z• 5--`� o v ZJz — L. -M cis GllnJ m .5 �•g q-jq 3/� !_ K d Zvi- r D.2 ! 'i y R_35 y 3J - 5 1 �! - 1 Effluent N =BOO >30_<220 mg/L and TSS>30< ISO mg/L 'EMusni 02=800, 30 30 mg/L and TSS<30 nVL CST Name (Please Print) Signature �CS � � t n1 JO HOPI_ S1-F- Address Date Evaluation Conducted Telephone Number t t W9875 e4o�~AVE, t y2.b-i"t7.s W S Sit o 2 Z 4-Ff�0 3 C.� 5 p90PEA11 0, 1Eii COMWGMT-A1-Qr�-SOIL DESCRIPTION REPORT Page Z'ot 3 PAW&J.Ma (AE.tr RIG) /"IEIJT co,e� - FROM OYi\�Wf�L_ Bo,rtW�'S LOT 140(c COWL0'TED B. LOWS FIL<EN S,CGD�� ENC�IN�FRlN6 0"M Dominant Color I Motlees (Texture I SWc Lure I ��� Roots GPO/ft mn nt gog Nonzon� gin. I Munsell ChL SL Ca Color Gr. SL Sh. fled iTwxn 2fsbk mf gw 3vf 0.5 10.6 A 0-11 - B1 11-17 10YR 4 I --- sil 12msbk mfr Ics 2vf 0.5 10.6 B2 17-28 7.5YR 4/6 I --- gcbsl � 2m-csb mvfr cw 2vf 0.5 10.6 Grotrid i 869.SR C1 28-52 lOYR 6/6 --- s IOs ml c lvf 0.7 0.8 Dow to C2 52-83 10YR 6/6 -- gs ml --- lvf 10.7 0.8 t�1# Remarks: Boring# 2vf 0.5 0.6 1 0-18 IlOYR 3/2 --- sl [1��msbk mfr Igw 27 2 18-30 lOYR 3/2 -- sl I2m-cs mfr cw 2vf 0.5 0.6 1 30-54 LOYR 4/2 --- sil 2msbk fr cw lvf- 0.5 `.0.6 Ground �y 2 4-66 lOYR 5/6 --- sil 3mabk mfi cs lvf 0.5 0.6 874.5 ft 1 6-72 10YR 5/ --- Igsl lcsbk mfr w Ilvf 0.4 0.5 ro W"" 2 2-85 .5 ' 4/6 --- s Os ml --- lvf 10.7 0.8 to= _ IbI.F� Remancs: Horizons Al and A2 appear to be fill La Bonng ) A I A -9 �OYR 3/3 I --- 1 (2msbk Imfr law 2vf- 0.5 0.6 33v1:I� B -16 OYR 4/4 --- Icl 2msbk mfr cw 12vf �.4 0.5 AM OYR 5 6 --- s Osg ml w lvf .7 0.8 ;qpM C 1 ��-43 / C2 3-80 OYR 5/6 --- s Os ml lvf .7 0.8 I o Gmibrig tartar > 80" Remarks: Boring# A 0-9 lOYR 3/3 --- 1 2msbk mfr aw 2vf4 0.5: 0.6 332: B 9-12 lOYR 4/4 --- sl 12msbk mfr cw 2v - 0 GrotYd C 12-84 --- - e� fr 893.81E Dow to �� i > I I I I Remarks: \)I LLAGIG7, TI•D`I , ST. CRD� CO ' �,��SGOrJS1� (, TW OF X \ k% G� " 238"SR�ti �o \ 38.44' 166 Z 0 J a i B166A L,B 1668 .0 ELE 94.0 4 /$96i B166 ® B 167 C 5 .2 201.42' 7 &lk K W C �r��m � �q� 1 Lo - - - - - - - - - -- — pq-o8-c3 CC�J71�IJ\�tL D�vEU71'N�F-�T Cotta. /�;y0 � � U)T I101, TIZCY V ttLfl�C;e:� -(pw1�; CF pjN1 ! Or TRoV, S�.L��X COl11�Ty, �l Q h r - 38.44' « W� J b1� 167 , � Z 0 �$W J iD N M .-N . O Z 81678 B1666 ELEV. 890.2 �� ELEV 0 A� B1 A ,a9 B166C ELEV 887.4 ® B 167C ELEV 897.2® ® 218.15' ELEV. 895.1 EL,E, yy•g97• f'� V�- �e��-tJ 09-OS-c5 PROPERTY OWNER CUKMIJkZu`C'Kl. 'Z:>ky • SOIL DESCRIPTION REPORT Page?of 3 PARCEL LD. is l-1Q)!y C. Consistence Bound Texture Horizon Boundary y Roots Depth Dominant Color Mottles Structure GPD/ft # ��j in. Munsell Qu.Sz.Cont.Color Gr. Sz. Sh. o-ll 1r"7\Z 3!•L G� _ Bed Trends g� 1 �.`Fsb►z s a� s .t, Ground 3 Zq-L04 S�11Z 3! elev. Depth to limiting i factor tt'' > t Remarks: �s b►� �Qsh e s . S ::.,.D.. .., rz sic/ Gt, o S 9 Ground i elev. �°i�•7 ft. Depth to —— limiting factor >LO6' Remarks: or g # .... o,to Ltd`-t o- 3 !z — G s, 1 3 22-1�9 �.S �t2 3 f �. S � �1- U S °� o�I — .1 •� Ground elev. I 5964 ft, ! Depth to limiting factor >l of?'' Remarks: 3oring# around ,lev. ' it. )epth to imiting actor Remarks:_ Wisconsin Department of Industry, SOIL AND SITE E V A L U A T l ?*R E P O R T Page I of 3 Labor and Human Relations Drvi on of Safety&Buildings in accord with ILHR 83.05*jg Adm.-Code' COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in sizq Pl4n must include but ST• GZ-o�k not limited to vertical and horizontal reference point(BM),direction and�.-of slope,scale or PARCEL I.D.# rV r dimensioned,north arrow,and location and distance to nearest road. ' APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY _ DATE PROPERTY OWNER: PROPER ' LOCAT't©N Cb11371.tJ T M T- eot p 4 SE 1/4 SE�,, i4,S14 T Z-b ,N,R '2.0 E( W PROPERTY OWNER':S MAILING ADDRESS. OT*...�BLOCK#, Ste.NAME OR CSM# CITY,STATE SZSIP CODE (HON)NUMBER I ❑VI�GE WTOWN VNEARESTS BLKL►u� ,r'1N [X],New Construction Use Residential/Number of bedrooms L/ [ ] Addis n to existing building Replacement [ ] Public or commercial describe cle,� Code derived daily flow 60o gpd Recommended design loading rate - bed,gpd/ft2 $ trench,gp ft2 Absorption area required 9 S8 bed,ft2 -1 SO trench,ft2 Maximum design loading rate --1 bed,gpd/ft2 • trench,gpd/ft2 Recommended infiltration surface elevation(s).690-S (I 3T* TSLEuOWn) It (as referred to site plan benchmark) Additional design/site considerations S EE tluoTr 1M I N 5'TtRL�2 0" Parent material Lo Q-ss ovt"1Z GLA-S—I t'rc- 0kJ'T4J g H Flood plain elevation,if applicable N A It S=Suitable for system 60NVEMIOML MOUND IN•GROUND PRESSURE I AT-GRADE SYSTEM IN RLL HOLDING TANK U=Unsuitable fors stem ®S El ®S ❑U 79S ❑U ®S ❑U MS ❑U ❑S I$U SOIL DESCRIPTION REPORT ��r n # Horizon Depth Dominant Color Mottles Structure GPD/ft 9 Texture Consistence Bourxiary I Roots in. Munsell Qu.Sz.Cont Color Gr. Sz.Sh. !:ii:3p\ ;Y Bed ITw& � x ] �-�I Lp�►Z 3lz — si 1 z�sbk o�Sh cc.v -- ,s •E, Z 11-3 2 l�`iR alb _ S;� Z�sb►� ash cs _ .s .b Ground 3 3Z_toi} �.SY2 3ly - S gM v 99 41 ,$ elev. 8°t6.9 ft Depth to limiting factor > Remarks: Rg # slf Zmsbl- chk Cg •S , 6 3 16-105 S�t R Sty — S d GI� O S9 0l ] — _ •S3 Ground elev. 891.8 ft Depth to limiting factor > t OS Remarks: CST Name--Please Print Phone: Arthur L. We erer 715-425-0165 ergerer Soi Testing & Design Service-P.O. Box 74 River .Falls,WI. 54022 Signature g 4_Z c9 7 _ \3 9 Date: `Z_ t' CST Numbe 220254 PLOT PLAN Page 3 of 3 CALE S/1 S o ' SAP Ll IN LuT X36 i� � put L.L1 1w G \ S trr a `7 8_131 d t3 139 C- �•$� 3.�3q LS S�vH.E2 847.Ib' 8 13gq one Z'+ $°t(, 3r1 — �+-. 6e6•Sy, ory Z4 l 12Lh! p I� IIVVlNbt7 c- tGl tpe� _ SIAI ►ti� A tcl�4- ett ►B . qq-Z-47-139' Z20Z.5� ( 715 ) 4 .5-O-1 x5 CST Signature Date Signed Telephone No. C Parcel #: 040-1308-00-166 03/07/2014 08:28 AM PAGE 1 OF 1 Alt. Parcel#: 24.28.20.1985 040-TOWN OF TROY Current EX ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type #of Units 02/10/2004 00 0 Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner O-TROY DEVELOPMENT CORP TROY DEVELOPMENT CORP 11806 ABERDEEN ST NE STE 290 BLAINE MN 55449 Property Address(es): *=Primary *201 MUIRFIELD TRL Districts: SC = School SP= Special 320 LINDSAY RD OR Type Dist# Description SC 4893 SCH DIST RIVER FALLS SP 0100 CHIP VALLEY VOTECH Notes: Legal Description: Acres: 1.419 SEC 20 T28N R20W PT SE SE; BEING TROY VILLAGE 6TH ('04)LOT 166 (1.419AC) Parcel History: Date Doc# Vol/Page Type 02/10/2004 753934 09/100 PLAT Plat: *=Primary Tract: (S-T-R 40'/.160'%) Block/Condo Bldg: *09-100-TROY VILLAGE 6TH ADDN 146/168 24-28N-20W SE SE LOT 166 2013 SUMMARY Bill#: Fair Market Value: Assessed with: 236823 65,800 Valuations: Last Changed: 11/09/2009 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 1.419 75,000 0 75,000 NO Totals for 2013: General Property 1.419 75,000 0 75,000 Woodland 0.000 0 0 Totals for 2012: General Property 1.419 75,000 0 75,000 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