HomeMy WebLinkAbout032-2153-50-000 Asconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
574313 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes[Privacy Law,s.15.04(1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Robl &Simon, Michael D. &Jennifer Somerset, Town of 032-2153-50-000
CST BM Elev: Insp BM Elev: IBM Description: Section/Town/Range/Map No:
Z Y-7-2 n 15.31.19.1328
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark 3 o
Dosing , Alt. BM &0
Aeration 1 61h_ro Bldg.Sewer (y o
Holding t/H Inle
S t Outlet d
TANK SETBACK INFORMATION Jam• B 0
TANK TO P/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet /
Dt Bottom i
s L / 30 g a
Dosing Header/ n.
�d-
Aeration Dist. Pipe
v 8
Holding Bot. Ste' 2
Final Grade
PUMP/SIPHON INFORMATION ?/ (p
Manufacturer /j^l� Demand St v Z37
GPM A '
Model Number �Q -
TDH Lift Friction Syste TDH Ft
Forcemain Length Dist.to Well
SOIL ABSORPTION SYSTEM (o dram�
BED/TRENCH Width 1 Length / No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO FN L BLD WELL LAKE/STREAM LEACHING an etnr
INFORMATION Ty f System: CHAMBER OR Model Number: Tvlr'
v�aK,�if ,4
DgLSTRIJ3UTION SYSTEM S -5 Q4--t
Header ani�Id Distribution t W/ � G'y,y p x Hole Size x Hole Spacing Vent Air Intake
Pi
e(s)
t'l Length Dia N Length U' �/ Dia Spacing_
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only
Depth Over j Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center L ed/Trench Edges Topsoil Yes
-1 No Yes No
COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2:
Location: 592 217th Ave.SOMERSET,WI '5t4025(SE 1/4 NE 1/4 15 T31 N R1 9W) Shadow Pines 1 st Add Lot 3 Parcel No: 15.31.19.1328
1.)Alt BM Description= I 1.9 0 ' " V—U nAvu -
2.)Bldg sewer length
-amount of cover= 1
Plan revision Required? [J Yes ['I o
Use other side for additional information. kure Date Insepctor's Signa Cert.No.
SBD-6710(R.3/97)
PLOT PLAN
PROJECT Mike Roble ADDRESS 592 217th Ave Somerset Wi 54025
SE 1/4 NE 1/4S 15 /T 31 N/R 19 W TOWN Somerset COUNTY ST.CROIX
MPRS Shaun Bird 226900 DATE 7/13/14 BEDROOM 3
CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 650 # of chambers 32
BENCHMARK V.R.P. Top of nail in 3 birch trees ASSUME ELEVATION 100' Filter BEAR Filter
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 85.2/84.7 4.5' below grade
512' Property Line
Vent All piping shall be SDR 30/34,within 10'
of tank,piping shall be Schedule 40.
ALOng Quick4 Standard
Leaching Chamber Scale is 1" = 40'
with 20.0 ft2 of Area
5.6ft^2/pair of end caps unless otherwise
"
3493
Grade at System Elevation note
86' h.Z
5' 90' B-5 88' B-4 jo-
qSO ��
clo
Pro 3
Bedroom ¢ 45'
House �" p
15' _3
Poo
2-3' X 66' Cells with 3 Spacing
y0
6% Sf Cyw
0
Slope
O l� nts A 1 'q
B-1 35 B_ — I V
M. 3
130' fi� S
o'
24,Y L- 17th Ave
Cocmty
Safety and Bul d rigs Division < r o c
201 W.Wad*Vton Ave.,P.O.Box 7162 Sanitary Permit Number(to be Bad in by Co.)
unitary Permit Application stameTsamarxionxtanber
L. ' .., fv
In aexard>ar�vvNa SPS 38321(2).viis.Adm.c ode.admission of ibis faro►to too appropriate govemmeatal im►t `��
is required or to a sanitary p®nit. Note:Application forms for stow-owned POWYS ace submitted m Prcpa Address Cif diftc t dum ms g )
the DeQntroat of Safety and ProSeasional Service. Personal information you provide may be used for seconda<y C5 n _
in 11000"11110C 11000"1111011000"11110C wi&the Law,s.15. 1 m -
Stats. fir"
L g Information-Phase Print All Information
Property Owmes New 00, P°
�`'O Property location
-Property own ry
er'� ^ 1 7Y' /'7 v (a
Govt Loot S:Stsoe Phone Numbs -y. '/., Section
ESC/ T_3/ N; R Fg55
II.Type of BuNbC(cheek sU that apply) #
err 2 FamrBy Dwelling-Nomber of Subdivision Name ll
ocktl // l.-�-
❑PubliQKAai cc al-DescnOW Use S ❑City of
L
❑State Owned-Describe Use CSM N�nmber ❑v�apc� ,y
of
33 Type of P (Check only one box an line A. Complete line B if applicable)
A System ❑Replacement system ❑Trsatmeat/Holding Tank Replace Only ❑Omer Modificaion m anti g System(explm)
List B. ❑Permit Ronawai ❑Permit Revision ❑Chanpe of Plumber ❑Permit Transfer 10 New Previot�t Permit Naanba and Date Issacd
Before Expiration I I owner
j`r, om nent/t)evice: Cheek all tart apply)
Non p�p�ed ❑Preasurired ta-0roww At43wde ❑ >24 in suitabk ❑Mound<24 is of suitable soil
❑Holding Tads ❑Other Dispersd component( Device(°xplffi)
V.Diu reatn nt Area Information:
Design Flaw C> Design Sot?Appliatian Area Required(st) Ares Proposal(st) System Elrvstion
4.
VL Tank Into Capacity 7° Galles units
t3
New Todca its Tads a a
Septic or&&An Tads lan
Doting cbut<
VII. gubment-t, for ieata4tios of the POWTS Aawa ea&a a
s Name( i MPM1PIt5 Nnmber Business Phone Nmnber
or)
Plumber's address(Sired,city.State,Zip n a
VHVC"MftM!!!eRt Rt use only '
❑
Disapproved Permit Fee Date Issued Lvsuing
APPS M ❑Oamr Given Reason for Denial s U� / f
UL c easons for Disapp
1.Se tic tank,effluent filter and 3 )/
dispersal cell must ygeLviced maintained y�, �/� L�� 2vriy,
as per management plan provided by plumber.
2.All setback requirements must be maintained = S�( yt (fGzG'►� fY�jp�p L��V
as per a licable code/ordinances. / v
Atrad to ooapYte phao for de ardent sad=6x&to de nay on"p- a"kka)F71 Wks is am_
�chi /I Avis /ti � n .�,+��R�,1/
wly O had v
SBD-6398(811/1114 4 .`�
� t
Cover Page
Shaun Bird
Bird Plumbing Inc.
1432 120th St.
New Richmond Wi 54017
715-246-4516
Date: 7/13/14
Owner: Mike Roble
Location: SE 1/4 NE 1/4 S15 T31 N,R19W592 217th Ave Somerset
In-ground absorbtion system(conventional)
Manuals Used: In-ground absorbtion system (version 2.0)
Page#
1. Cover Page
2. Plot Plan
3. Chamber Cross Section
4-6. Maintanance and Contingency Plan
7. Filter Spja ) heet
8-10. Soil Signature
License n 00
PLOT PLAN
PROJECT Mike Roble ADDRESS 592 217th Ave Somerset Wi 54025
SE 1/4 NE 1/4S 15 /T 31 N/R 19 W TOWN Somerset COUNTY ST.CROIX
MPRS Shaun Bird 226900 DATE 7/13/14 BEDROOM 3
CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK
MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE
HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 650 # of chambers 32
BENCHMARK V.R.P. Top of nail in 3 birch trees ASSUME ELEVATION 100' Filter BEAR Filter
❑ BOREHOLE O WELL *H.R.P. Same as Benchmark
SYSTEM ELEVATION 85.2/84.7 4.5' below qrade
512' Property Line
Vent All piping shall be SDR 30/34,within 10'
of tank,piping shall be Schedule 40.
Quick4 Standard
of Cover Leaching Chamber Scale is 1" = 40'
with 20.0 ft2 of Area
12" .6ft 2/pair of end caps unless otherwise
5
4 Lon g Grade at System Elevation noted
34"
86'
88'
15' B-5 B-4
ST 25'
Pro 3
Bedroom 45'
House 90,
15' B-3
2-3' X 66' Cells with 3' Spacing A 1100
6%
45' Slope
Vents
B-1 35 B-2
B.M.* 30'
130'
0'
217th Ave
Cross Section of Infiltrator Quick 4 Leaching Chamber
Typical cross section for 2 of 2 cells
Quick 4 Standard Leaching Chamber
with 20.0 ft2 of Area per Chamber
5.6ft^2 pair of end plates To be >1' above grade
Finish grade elevation
Typical Installation 89.7'
Vent Al Grade rnt
3, 4„X30/34 Septic Tank 1"5' Long 5' ;J3
Long
3679 Grade at System Elevation Grade at System Elevation
Spacing 5'
2-3' X 66 ' Cells
Same on other end Observation tubeNent
At end of cell
A
16 chambers per cell B
System elevations:
A-85.2'
B 84.7'
POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page—Of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner " ` / -y� Tank Manufacturer. _ ❑ NA
Permit# ;J �e tic ❑Dose ❑Holding Volume: lbov (gal)
DESIGN P ETERS Tank Manufacturer: ANA
Number of Bedrooms: ❑NA ❑ Septic ❑Dose ❑ Holding Volume: (gal)
Number of Public Facility Units: NA Vertical Distance Tank Bottom(s)to Service Pad: (ft)
Estimated(average)Flow; (gal/day) Horizontal Distance Tanks)to Service Pad:
Design(peak)Flow-(estlmated x 1.5: Specific Ong mechanics must be provided If vertical is>15 feet or
9 ( ) �J�J (g aY) If horizontal is>150 feet. Specific Instructions to be provided on back.
In Situ Soil Application Rate: 7 (gaVday/ft') Effluent Filter Manufacturer:
❑ NA
Standard(Domestic)Influent/Effluent Monthly average.. Effluent Filter Model:
Fels,Oil&Grease (FOG) '30•mg/L pump Nyn rer:
Biochemical Oxygen Demand (BODs) s220 mg/L ❑ NA NA
Tote) Soft SS ''150 Pump Model: .
High Strength IrnluentlEffluent Monthly average Pretreatment Unit
(FOG) >30 mglL - Manufacturer.
(Boos) >220 mg/L --Zr'NA
' ❑
SS) >150 m Mechanical Aeration [3 Pee Filter
0 Damec5on ❑Wetland
Pretreated Effluent Monthly average ❑
SandlGravel Filter ❑Other.
(BODs) '30 mg/L Soil Absorption System
(TSS) s30 mg/L
Fecal Coliform eomebt mean .5W" �nd(gravity) ❑in-Gramd(pressure) ❑ NA
Maximum Effluent Particle Size ')6 in dia.. ❑ NA ❑DriGrade ❑Mound
❑Drip-tine ❑O>her.
Other: Other: ❑ NA
MAINTENANCE SCHEDULE
Service Evert Service Frequency
Pump out contents of tank(s) en combined sludge and scum equals one-third()J)of tank volume
❑When the high water alarm is activated
Inspect condition of tanks At least once every: ❑month(s) (Maximum 3
P ( ) ery: s) years) ❑ NA
Inspect dispersal cells) At least once every: mo'h(&) (Maximtan 3 years) ❑NA
Clean effluent filter At least once every: 1 moms) ❑NA
Inspect Pump,pump controls&alarm At least once every: 0 month(s) NA
Flush laterals and pressure test 7 At least once every:. month(s) NA
.❑yews)
Other: At least once every: [3 month(s) NA
Other:
L13 NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and sod absorption systems shall be made by an individual carrying onne of the following licenses or certification:
Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper).
Tank Inspections must include a visual inspection of the tank(s)to identify any missing or broken hardware,identify any cracks or leaks,
measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The soil
absorption system shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent
on the ground surface. The ponding of effluent on.the ground surface may indicate a failing condition and requires the immediate
notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any treatment tank equals one-third(%)or more of the tank volume,the entire
contents of the tank shall be removed by a Septage Servicing Operator(pumper)and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code
All other services, including but not limited.to the servicing of affluent 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 shad be provided to the local regulatory authority within 30 days of completion of any service event.
GMW-005(02106)
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other
chemicals or sediment that may impede the treatment process and/or damage-the soil absorption system. if high concentrations are
detected have the contents of the tank(s)removed by a Septage Servicing Operator(pumper)prior to use.
Pump tanks may fill above normal highwater levels prior to startup or due to.pump failures. Start up or restoration of power under these
conditions is not recommended, as the excess wastewater will berdischarged to the soil absorption system in one large dose causing an
overload that may result in the backup or surface discharge of efflaent.'and dernage'to the system. To avoid this sit6ation have the
contents of the pump tank removed by a Septage Servicing Operator Oumper)prior to restoring power to the pump or contact a Plumber
or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
Do not drive or park vehicles over tanks or the soli absorption system. Do not.drive or park over, or otherwise disturb or compact,the
area@ within 15 feet down slope of any mound or at-grade soil absorption.area.
Reduction or elimination of the meowing from the wastewater strew may improve the performance and prolong the life of the treatment
tanks and soil absorption system: acids, antibiotics, baby wipes,-cigarettedixft, condoms, cotton swabs, degreasers, dental floss,
diapers, disinfectants, fats, foundation drain(sump pump)d'sscharge,fruit and vegetable peelings, gasoline, greases, hides, meat
scraps,medications,oils,painting products,pesticides,san' napkins,solvents,tompons,'and water softener brine discharge.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly
and safely abandoned in compliance with s.Comm 83.33,Wisconsin AdMinistrative.Code`.;
• All piping to tanks,pits and other sal absorption systems 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(pumper).
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil,
gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replacement system:
A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system.
The replacement area should be protected from disturbance and compaction and should not be infringed upon by required
setbacks from existing and proposed structure,lot lines and wells. Failure to protect the replacement area will moult in the need
for a new soil and site evaluation to establish a suitable replacement area. -Replacement systems must comply with the rules in
effect at the time of their permit issuance.
❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be
rehabilitated and barring advances in POWTS technology,a holding tank may be installed as a last resort
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a
last resort to replace the failed POWTS.
❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the.biomat at the infiltrative
surface. Reconstructions of such systems must comply with the rules in effect at that time.
WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK
SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY
tR^,r RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE.
ADDITIONAL INSTRUCTIONS:
POWTS INSTALLER POWTS MAINTAINER.
Name Name
Phone _C,. Phone '� - �
r
SEPTAGE SERVICING OPERATOR PER LOCAL REGULATORY AUTHORITY
Name &— ,_ Name�7`� 1�;. 1,
Phone J 12 Phone
This document was drafted by the staffs of the Gruen Lake, Marquette and Waushers County POWTS regulatory agencies in compliance with sections
Comm 83.22(2Hb)(1Md)&(f)and 83.54(1),(2)&(3),Wisconsin Administrative Code.
+� F�L
TER CARTRIDGE INSTRUCTIONS
STEP 1 Dry at the ARM'tare awls the eed of the etttlet Pipe�ensu►e it is
tank through under e o tlet or aMnieA• If�then v Mesert more pipe htto the
though the outlet a solves**wrd )sddfEfonal 0 onto the outfit length
STEP 2 needed to stir dry Anted on the outlet pipe,measure the
of 314-inch$Ppe
Waft the Aker to the tank end wen if utfftnq the
p�to �° Ort'If side w+Ppo t method.is not utilized,
5- F.P 3 For fetstdatfotes Ut Wng the optional
s*h0wd, OW the to step pip&,onto the later cxe�suPP� is not
Sowent WOW the lter use onus the outlet r
urttldge kdo the coq,pressing down until the outlet 0". Insert the faker
the case. locks IWA the bottom d
y
If a VRS switch clockwise 90•. is utilized:insert into tits fitter and i*clk by turning
Maintenance
1. The efpuettt Aker should be cleaned*Very time the septic tank is
sereieed.
2. Open the outlet access opeeNng to ingest the tank and aw
S' i mp the tank cw"pi@Wy,making sure to remove the sludge a
layer on the bcft m of the tank and net Just the SCUM and likm,nt. Y
<. Onu the eM ww*level has been lowered below the invert of the a
outlet pipe.Amdy Pun up on the Alter handle to dislodge the
cartridge from the case.
5 Slide the urbW*up end out of the case fbr cleaning.
6 If
should be rwn&AW by a VRS II Itch conneded to an alum is present,the switch
With water only. 9 90•and cleaned
7. Win*hoWytg tit cartridge esn Its skis(br'ge Net surfau fadng
down)over the sexes opanittg,rk:te off the mrb'Wg*wlth weber k ;
anY,retsftitng aura an septa"wwtwW ks rioted bads into the tank.
3. If VRS swlt h is utklzed,rgpbu by knutitq into Alter and
rn . .4
tuing dodmvbm 90'. .,.!•
9. Insert the filter cartridge ba&Ntbo the cwoe, �r
the Altar locks into the bothwn of the ease. ,,n d own until
10.P"lau and sOMM the aexesa opening flit the tonkk.
!:71D•<:hA^-•+tt'!C:ak'rr:AteeT -1v6'••r r..:at.et'LI:%t'..k7t.:w•.
WW%L ft-m= (653-4583)
ST. CROIX COUN1,Y
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
s uyer
Mailing Address-
Property Address J 2 J 17 ' -
(Verification required from Planning&Zoning Department for new construction.)
City/Stated Parcel Identification Numberv�
LEGAL DESCRIPTION
Property Locatio x/4/,6/_ '/a , Sec. J , T 3/ N R/W, Town of
Subdivision � ;,�, � -� — , Lot# �?
Certified Survey Map# '(Aumec� ,Page#
Warranty Deed# –7 tune/ Page#
Spec house yes no Lot line,, identifiable (Ee9sno
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 ofpunrpmg out the septic tank every three years or sooner,-0 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 Comity Sanitary Ordinance.
The property owner agrees to submit to St.Croix County Planning&Zon:mg 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 road 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 Planning&
Zoning Department within 30 days of the three year expiration date.
Uwe certify that all statements on this form are true to the best of my/our k:aowledge. Uwe am/are the owner(s)of the
property described above,by virtue of a warranty deed recorded in Register of Dmis Office.
7szItOF
PPLICANTS ��
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.08/05)
PROPERTY OWNER Richard Stout_ SOIL DESCRIPTION REPORT Page of3_ -
PARCEL I.D.# t
Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2
in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed Trench
3 1
0-115 1 0 r2 1 -
2 15-&5-,1 Oyr3/4 -- sil 2 rnms mfr cs -- .5; . 6
Ground 3 35-89 Oyr4/6 -- ms osq ml cs -- .---7) .8
elev.
8 8-6 Qft•
Depth to
limiting 2,
factor
89in.
Remarks:
Boring#
1 0-1 10 r2 1 -- �4ntK Mfr 18
4 2 16-48 10 r3 4 -- si1 m
3 48-SO 10yr4/6 -- ms osg ml cs -- . 7 '. 8
Ground
elev.
87 . 20ft.
Depth to
limiting
factor
90 in.
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed Trench
Boring # 1 0-6 1 0 r2 v 'i
5 ,' 2 6-89 10 r4 6 --
Ground
elev.
8 9 .-M—ft-
Depth to
limiting
factor
8 9 in. Remarks:
Boring#
Ground
elev.
ft. '
Depth to
limiting
factor
in. Remarks:
SBD-8330(R.07/96)
l
wcon apartment of Commerce SOIL AND SITE EVALUATION 1 3
biir�ion of fety and Buildings Page of
Bureau oVtegrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must Cgunty
include,but not limited to: vertical and horizontal reference point(BM),dip6ction and S t. Croix
percent slope,scale or dimensions,north arrow,and location and distan6etq iearest Parcel?,,D.#
APPLICANT INFORMATION- Please print all information►. , R� , evi6we y Date
Personal information you provide may be used for secondary purposes(Privacy LaW,S.15.04(1)(m�J:h i`' 0')
Property Owner PropeOpLoiWiion
Richard StoutCf �� f. G !LPIt, F1GI 1/4,S1 5 T31 N,R1 9 E(off
Property Owner's Mailing Address Lof Name or CSM#
1 353 Awatukee Trail �Shadow Pines
City State Zip Code Phone Number ❑ City ❑ Village jj Town Nearest Road 1]Hudson I Wi 154016
[R New Construction Use: ®Residential/Number of bedrooms 4 Addition to existing building
❑ Replacement ❑Public or commercial-Describe:
Code derived daily flow 6 0 0 gpd Recommended design loading rate •7 bed,gpd/ft2•8 trench,gpd/112
Absorption area required R S R _bed,ft 2 750 trench,ft Maximum design loading rate , 7 bed,gpd/ft2 —trench,gpd/ft2
Recommended infiltration surface elevation(s) See plot plan n ft(as referred to site plan benchmark)
Additional design/site considerations
Parent material COC2 Flood plain elevation,if applicable ft
S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank
U = Unsuitable for system [2 S ❑ U [as El [2 S ❑ u u S ❑ U 1:1 S [ U ❑S 9 U
SOIL DESCRIPTION REPORT
Boren # Horizon Depth Dominant Color Mottles Structure GPD/ft2
9 Texture Consistence Boundary Roots
in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. Bed ,Trench
1
0-12 1 r 2 t+t1
2 12---- 4 10 r3/4 -- is lm mfr cs -- . 7 , . 8
Ground 3 34- 0 0 yr 4/6 -- ms osq ml cs -- . 7 . 8
elev.
8 9_Z-9-ft.
r
Depth to
limiting
fain. Ste. -2 � f�
Remarks: oL7h
Boring#
yvt.i4
es
1 2 14-35 10 r3 4 -- YVilbrN __
x� i
°---- 3 35- 1 10yr4/6 -- ms osg ml cs -- . 7 . 8
Ground
elev.
8 7 _64-ft-
Depth to
limiting
factor
91 in. Remarks:
CST Name (Please Print) Signature Telephone No.
4A i:�4e_011—
Address Date CST Number
�`1rG ,x�`I�+G ®Q CJ
✓Y
�� $�
9
Il^ �` t C� �
,! b
� ��
S 0
d \
C'
� e
�i ��
8 nr► I
•���'
c � '
,_ — — -_ -�- � GG�- -- --' — ---
� _--
//y/y/MME, jJ/ '"•e •''' it'll
• �7�I
A.
MOW
• ♦ O•�ii♦•viii• ♦• 955.B
�:•.i':�'�:�:�i as a�♦•iii♦`i i i•%i i�.�.�♦ii;.�.♦':n��!J I / '.::O••�♦4:'.a':��i•'�•,i• ♦••'<<O�.:� - y s...
�� �.••..:• • ... ♦♦iii•„ ' �•i i•:� •♦♦..♦• •♦♦.�♦•♦ ♦ ��.iT�o♦�.��i.�i�.�.".�.���i,
915.5
4/ i
s a
EA\fXCLUDO
a
AREA
1311. 2
v
• FT. 938.8 3.01"A
3. ACR
SQ
ES
JOTAL ...,
•♦ r° 44 8
FT
3.'105 AC9ES
El
Ev El
947.4
953.0 g 4 007
i�.��_ _jam•/ _ �� y.•����,
/�� - �••��� • '• • ' _ _ % // lair" �/// //
2 00
` v.
FA
;:;;•,•
a� •:.,
• .�-oioo./ .hoc♦ %� � � ���
oo'000 ♦�� ♦♦ / ///s r
aioio<os,
mo
j // � �/ • .
w,w WRIP
0ITION
w Am oa
I \1 '9,
f• $E anno LOT 2 �\ trc�A��[[
285 ntx` NO. 521879 � R�t,CFY[O
10 PAGE 26M t 1
am Am
LO M 1 P 2G02
ST CAOIX
afEa+• 3` NUDITY f-,
• - Awr N.
/Y RR
km
Z
1 807 PAGE 820
ENO. 436226 � ;�r
iir ar>v
&A MW*A=M iAYr}RM
let o% War
MAM se
sw•a.�.r w.r�►rw w.w
M
10fR Ilf 01f1f3 f Wa ff N11r > Wm wA
tiw of, lw O�M/01 v S Mfff1R�f011f10 w f
pYN W��lplfv000MW flafa111 - 1M mma
a MM�s fega MY
ffLf!
OIL a7-7
AM V=MAW"
i
fGli■ •1M iwt y �
feMaf�ioaav if ws EAR us v fs
s: v fsfs�lL to M saw a U =
w�i s w�sm�o fuu foe�ir�
a'°sR swaev i
fi..I rr ; b ,,,,17/r am
.rlr..d fwM.a W rb fN M d.r.r 1� pp
�.frt Yw�frl•rOr M r w.rw1Y.�M/r
4W1A w% M�IM�@ Mwf r MrM i.
nInn rwr=r •MiM d/ .ir lA lrw 1 l.i�..t
a~guano mmift be Amem
mom ummosswr
no simpossm sawd so ban 0 eft.
w as
«.uww:f++ff�r w.�wrwwr far LOT 2 C S.M.
8 PAGE 2364
me cnwiw
i
LNIMlY YON(SV
SHEET i OF 2
Parcel #: 032-2153-50-000 osi2sizoos 09:29 AM
PAGE 1 OF 1
Alt. Parcel#: 15.31.19.1328 032-TOWN OF SOMERSET
Current X ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type
00 0
Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner
O-GRAND PROPERTIES LP
GRAND PROPERTIES LP
712 RIVARD ST STE 300
SOMERSET WI 54025
Districts: SC =School SP=Special Property Address(es): *=Primary
Type Dist# Description *592 217TH AVE
SC 5432 SOMERSET
SP 1700 WITC
' I
Legal Description. Acres. 3.050 Plat: 08-095-SHADOW PINES 1ST ADDN 02
SEC 15 T31 R1 9W NE LOT 30 SHADOW PINES Block/Condo Bldg: LOT 30
FIRST ADDITION
Tract(s): (Sec-Twn-Rng 401/4 1601/4)
15-31N-19W NE
Notes: Parcel History:
Date Doc# Vol/Page Type
05/15/2003 721647 2243/150 WD
2008 SUMMARY
Bill#: Fair Market Value: Assessed with:
0
Valuations:
Last Changed: 07/24/2003
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.050 57,200 0 57,200 NO
Totals for 2008:
General Property 3.050 57,200 0 57,200
Woodland 0.000 0 0
Totals for 2007:
General Property 3.050 57,200 0 57,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: 12/04/1998 Batch#:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
Parcel #: 032-2153-50-000 07/16/20P AGE E 1 AM
P 1 OF 1
Alt. Parcel#: 15.31.19.1328 032-TOWN OF SOMERSET
Current [XI ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type #of Units
00 0
Tax Address: Owner(s): O=Current Owner, C=Current Co-Owner
O-STOUT, RICHARD O&JANET P
RICHARD O&JANET P STOUT
1353 AWATUKEE TRL
HUDSON WI 54016
Property Address(es): "=Primary
592 217TH AVE
Districts: SC=School SP=Special
Type Dist# Description
SC 5432 SCH DIST OF SOMERSET �!
SP 1700 WITC Notes:
Legal Description: Acres: 3.050
SEC 15 T31 N R1 9W NE LOT 30 SHADOW PINES
FIRST ADDITION Parcel History:
Date Doc# Vol/Page Type
02/24/2009 889438 WD
05/15/2003 721647 2243/150 WD
Plat: '=Primary Tract: (S-T-R 40%160%) Block/Condo Bldg:
08-095-SHADOW PINES 1 ST ADDN 02 15-31N-19W NE LOT 30
2014 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/12/2010
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 3.050 40,200 0 40,200 NO
Totals for 2014:
General Property 3.050 40,200 0 40,200
Woodland 0.000 0 0
Totals for 2013:
General Property 3.050 40,200 0 40,200
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: 12/04/1998 Batch#:
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
II IIINllllllllllllillll(III III
State Bar of Wisconsin Form 1-2003 8 2 4 1 1 2 6
WARRANTY DEED Tx:4197318
998177
Document Number Document Name BETH PABST
REGISTER OF DEEDS
ST. CROIX CO., WI
THIS DEED,made between Richard O.Stout and Janet P. Stout,husband and 07/03/2014 11:09 AM
wife EXEMPT#: NA
("Grantor,"whether one or more), REC FEE: 30.00
and Michael D.Rohl and Jennifer M.Simon TRANS FEE: 117.00
("Grantee,"whether one or more). PAGES: 1
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 needed,please attach Name and,Return Address
addendum): Lot 30, Shadow Pines First Addition in the Town of Somerset.
Sc,"p<
1 Nl
032-2153-50-000
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 reservations, if any,of record.
Dated
(SEAL) R °L �� (SEAL)
* *Richard O.Stout
(SEAL) (SEAL)
* et P.Stout
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) Richard 0.Stout Janet P.Stout
authenti ated o �? STATE OF )
)ss.
(,_ COUNTY )
*Attorney Kristina 026nd
TITLE:MEMBER ST TE BAR OF WISCONSIN Personally came before me on
(If not, the above-named
authorized by Wis.Stat.§706.06) to me known to be the person(s) who executed the foregoing
instrument and acknowledged the same.
THIS INSTRUMENT DRAFTED BY:
Krisdna OF-land,Estreen&Oeland
304 Locust Street,Hudson,WI 54016 Notary Public,State of
My Commission(is permanent)(expires: )
(Signatures may be authenticated or acknowledged. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
WARRANTY DEED C 2003 STATE BAR OF WISCONSIN FORM NO.1-2003
*Type name below signatures. INFO-PROTM Legal Forms 800-655-2021 www.infoproforms.com
St. Croix County 998177 Page 1 of 1
0i CO.,
.I ............... ....................N
.i!.i „ ..............
a' bi Jt fi f fi�
gg
•� 1 I
pJ a r
'(f 1 f
s
Oz 3.L l.LQOQS
WAS
� �'• I a t I r tJ i �� � �� lOOQ7'ti� �J� I ` I�
dim#.►toms
,rTril �,,Y� A ■ ' r� � { � I � i
tJ••rr 1 c� ��g � �I ;�� ! ;
1 iZ4 '
SO
4 Ike 21
I �
��� �� •1 p gg .sox�r AtJtirr[Y.0�75 '`'
r
f '
F�
I � .La717I7r �ltilfE�l� I � � O;
e► I g; '''�' °� . � '—_tea..��a'1 � I e
J
I i C?, CO
TID e 1 iR 1 r
1 , M, 8, tATM
L', �1 ' �ff77 !I
L)1, �I '1irpNM
_ 1
_.._.. .._.._.._ ._.._.._..—'t/i �rv.�ivt�n jj�� Sri'. _.. -s•' -- _. I � _ ._.I._.._..
AS AU X17 3WI 1SY3�k! �~ 1 ;—� � co"
moms
i XOZ 3.W.6m00s
b Mfr _, 14tvGl�S 1
—-—-—-—-—-
NOII'Ef
O ----------
CEf
El�
Haffner Construction
lass
—N LEV& p NNna
MAIN LEVEL
(775)248-3070
NOnCEI
Haffner Construction
Pro-Nerve
FOUNDATION
o A2
Parcel #: 032-1072-70-200 07/16/2014 08:36 AM
PAGE 7 OF 1
Alt. Parcel#: 26.31.19.354C 032-TOWN OF SOMERSET
Current 0 ST. CROIX COUNTY,WISCONSIN
Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type #of Units
00 0
T ddress: Owner(s): O=Current Owner, C=Current Co-Owner
MICHAEL D ROBL O-ROBL, MICHAEL D
C-SIMON JENNIFER M
SIMON JENNIFER M
1978 HWY 35
SOMERSET WI 54025
Property Address(es): *=Primary
Dis SC=School SP= Special
Type Dist# Description
SC 5432 SCH DIST OF SOMERSET
SP 1700 WITC Notes:
Legal Description: Acres: 4.490
SEC 26 T31 N R1 9W SE NE LOT 4 CSM 12/3511
EZ-IE-1527/342 626590 Parcel History:
Date Doc# Vol/Page Type
07/18/2000 626588 1527/333 WD
09/15/1998 587098 1357/181 TI
07/23/1997 1165/346 QC
Plat: *=Primary Tract: (S-T-R 40%160%) Block/Condo Bldg:
*3511-CSM 12-3511 032-98 26-31N-19W SE NE LOT 4
2014 SUMMARY Bill M Fair Market Value: Assessed with:
0
Valuations: Last Changed: 10/12/2010
Description Class Acres Land Improve Total State Reason
RESIDENTIAL G1 4.490 31,000 108,800 139,800 NO
Totals for 2014:
General Property 4.490 31,000 108,800 139,800
Woodland 0.000 0 0
Totals for 2013:
General Property 4.490 31,000 108,800 139,800
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: 09/2612005 Batch M 05-17
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00