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020-1378-11-000
,, ~~9I2G ~j/~L~,~~' S'~'. CItUIX COUNTY 'LONiNG ll ~ I'AR'I'MENT . AS BUILT SANITARY REPORT ~3~26Z owner /L!/'tG2 ,e o oe S/~~ti ~•QV~~O . ~I/i ~ ~°S City;',State i'GLt ~i'~`Z,O ~Iti. sS ~tZ ~ ~~~. • ~~r-/`'~t~E~ I,r.~al bescHption: U ; i~ 0 8 2003 , 236 i_.vt _~ Rlock Subdivision/~~ ~4,V ; ~~i i'~I '/~/Vl~'/~ ~, Sec.l ~- , T?~N-R~W, 'Town of D.So.~.~ . ~ 7~l • •f1'~ SEI''I'IC 1't1,NK -- DUS + CIIAMI3l{;It -- BOLDING TANK INTOIt.MATION: No w~~ wle5~ 1 x,50 ~ }/~-~• Tank ;ttanufacturer Go~uG~G~~ Size ST/PC / Setback from: House 3y Well F/L y~ i titnif ~rianuiacturer Modei Alar~tt (ocativtr (ttULi)1NG TANKS ONLY) Setbacks: Service road _ 1~Ieter location Aiatnt location Vent to fresh air intake Water Line SOIL AIZSOIZI' 1'IUN SYS'T1M: 3~0~'~~vS~P T~'E-~~c, ~P-~S Tyi,e of system. Width ~ Length ~~ Number of Trenches Z Setback from: Clouse ~~ ' Welt ~P/~L ~_ Vent to fresh air intake > ~ d LLI~V~I,TIUNS: Tor ~Ffi~~c. llescription of benchmark ~ ~ ~- hescription of alternate benclvnark C S T ~5 Building Sewer ~~ 3' y~ STlIi'T Inlet ~ ~ 3 ' / ~ ST Outlet ~~ a • 78 PC Inlet 1'C I3ottvtn Header/Manifold L)istribution Lines ( ) ( ) S~ E Top of ST/1'C Manhole Cover t3otfom of System ( ) ( ) ( ) I~ final Grade O O ( ) ~ ~ /s T' X03 ~ ' o y 3 0~, z- bate of installation / / Permit number State plan number i I'lut±-~ber's signature _ License number ZZ G 3~S [inspector .,ti~_K- -' ~r/d/~ S ~ ~J 7~q~,~s~ ~,~,,,,~GL /dU-v r Elevation Elevation ~6a ~~°G ~l~- Date / / co~+ia~ ~t~t di.n •~ Ulbricht & Associates I f ~ ~ ~ ~ ~ ~# (fl '°^~ m ~ o V I ~3' ~, 8~ ~p W ~ m D~ ~ t!~ -~ ? r" ~ ~ ~ ~~b r- . r° ~~ ~w O y ~``` ~.. D Q ~ ~U '~ ~ =34a a~~- ~tAoj ^~~ J~~~ '- '' ~ ~.. N Cf,# s, h ~ ~ F R..+~ °a ~ ~ ~~~ ~ ~ ~ '"~' '~ "~ 9~.. ~_ In N L'"`; -.. ~~ -~ _~.. 4 -~ ~ ~ v ~ ~ ~ ~ ~ ,~ ~ ,, ~ ~ te a , Y 'V 1 `~ E ~ --~ .~, -~ -r} W ~ ~ N f;~ ~ ~a'~ ~ ~ ~ ~ 4~ ~ ~ ~~ ~ ~`~~D~ ~ ~' ~ o~ v ~~ ~ w ~'' .N .~ ~~ N ~ Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSS~'ECTi'OIV REPORT GENERAL INFORMATION (AT-rACH TU PERMIT) Personal information you provide may be used for secondary purposes fPrivacv Law, s.15.04 (1)(m)l. Permit Holder's Name: City Village X Township Mielke, Earl Hudson Townshi CST BM Elev: Insp. BM Elev: BM Description: ~M~ t J°O.~ T~ t' ~ ~~ «~. hc•t TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~7-c. :'S ~~ 1 Z ~ G Dosing - ; t f ~• Z~b awl (~ ~o~ _.... Aeration .. Holding ~ % __, _.._. TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ','' 4 t/ N v ~ -, ,~ ~~ r Dosing Aeration f, Holding PUMP/SIPHON INFORMATION Manufacturer Demand _.__. ._.__... GPM Model Number TDH Lift Friction Loss N~2.tf.. °-- - - .. TDH Ft Forcemain Leng Dia. Dist. to Well ) vv..- r.vvv..~ ~ .v~. v ~ v . ~m ~ ~ ~~ r c....~ca-s--~ y ~.•. •- - County: St. CroiX Sanitary Permit No: 430202 0 State Plan ID No: Parcel Tax No: 020-1378-11-000 Section/Town/Range/Map No: 12.29.19.2350 ELEVATION DATA STATION BS HI FS ELEV. Benchmark Cj.~{v lU9f{Ci ~~O.c.O Alt. BM Bldg. Sewer ~ 3 Z r a`> ~ G (j SUHt Inlet ~~z~ lo3J~ St/Ht Outlet k,~~ rb ^-~.c~ /oa.8' Dt Inlet Dt Bottom Header/Man. Dist. Pipe T~ ra ~;, L w 5 t: I J I ~ tl•t 9'~, ?..~ 4~. Bot. System ;~ c ,~ ~ iZ • tq l~z•z~ q'7.1/ 97.E Final Grade -~ St Cover ~ y.,; ~~ ~+' `~.s+ 13~~ I.~~~ 9.~,~1 59,~~ BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS ~ ~/' SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING anufacturer: INFORMATION CHAMBER OR Type Of System: C~ rv z w ~ ~ ~N, , tl ~ r ~ ~+ ~=' ~ U IT Model Number: ~ DISTRIBUTION SYSTEM ~-~ 8C~ 1 ~ c~,,.~{ ~ r- ~,~, ~~1 , Header/M~nifold Distribution x Hole Srze x Hole Spacing Vent to Air Intake c l > y~ ,J Length Dia `1 ' pipe(s).. _ _..~> _ Length Dia Spacing ~" ---_ _....-.~ ~ -- ~._ ` __. ~Gr SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over ~ Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center ~ ~ ~` Bed/Trench Edges Topsoil ~~ Yes ~i No Yes [~~ No v- COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~° / 2 / ~~ ~ Inspection #2: / / Location: 1037 Moonbeam Ridge Hu~s~Wl 54016 (NW 1/4 SE 1/4 12 T29N R19W) Moonbeam Ridge Lot 11 Parcel No: 12.29.19.2350 51 1.) Alt BM Description = I-(~5~f ~cr~, ~~.~~ s~ 1 Gr~jG/t ~k' Jc~ i' n ~ s~WC~ 1~ ~p ~ /,~ ~~ qn~l 7~.0 2~ 2.) Bldg sewer length = .3+-I r d T S /_ /1 (I - f _ „ , ) /~Q~ . , . ,1 ~~~.. ~ r _I . 1/2~d-3 -amount of cover = ~ ~ G7`` ,~-} / ~~ ~-r/t "J~E'X.~~a Q~1X/L/ ~-Cf~ a :~ I I i i I Plan revision Required? I Yes I "I No ifb T Z ~rJ3 J ~ __ __-- ~ i-~ ~ ~~~ Use other side for additional information. L__- ~_--1_ SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. `.C~~~iIV~~.. 0 Safety and Buildings Division 201 W W County / / _ Y • v ~ ~ ,~ . ashington Ave., P.O. Box 7082 /T l.~/ /~ ,~~O~S,n Madison, WI 53707 - 70$2 Saniffiry Permit Number (to be filled in Co.) Oe artment of Commerce (608) 261 yid Z ~ Z Sanitary Permit Applieati ~p State Plan LD. Number to accord with Comm 83.21, Wis. Adm. Code, personal informatio provid r /" / may be used for secondary purposes Privacy Law, s15.114(1 Project Address (if different than mailing address) Q ~ I. Application Information -Please Print Ail Information ~'l.' 8s O ~~~ RECEIVED ~ . Property Owner's Name ~~~ ~~~1~~~ _ ~ Pazcel # 8fock # ~~ Property Owner's M/a'il~' g A1ddress G g~ ~ " ' J ~ C ~ ~( Prope/r ty, Locati~o+nG vt L li ~iL ( ~1 . i;;=~0i ~, :UUNT1" l /'Kl J Z Z /y ' Ci fate !~, '/., Section ,~ 1 ~~ ] ~~~,~ ~ i `~ vt/ ~ , ~ ~ ~ ~ ~ ~( ~ ~l v ~j ~'! /G (Circle T N R 7 ~ II. Type of Building (check al! that apply) ; E o t of 2 Family Dwelling - Number of Bedrooms Subdivision Name CSM Number ~ h O~ n~d, . S " /S ~ ^ PublidCommtxcial - Describe U ~ rr i! ^ Sffite Owned -Describe Use ~ ^City ^Vitlage ownship of_~~~ III. T ype of Permit: (Check only one boz online A. Complete line B if applicable) A' {~lew S em yst ^ Replacement System ^ Treatment/Holdiag Tank Replacement Only ^ Other Modification to Existing System B • ^ Petmn Renewal Before Expiration Permit Revision ^ Cheuge of Pl b ^ Permit Transfer to New List Previous Permit Number and Date issued y3 aZD Z ~' 7 um er Owner ~ 3 IV. of POW I'S S stem: Check all that a 1 ~on -Pressurized ln-Ground ^ Mound >_ 24 in. of suitable soil ^ Mound ~ 24 in. of suitable soil ^ At-Grads ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized ln-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Fiher ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersaUTreat t Area Information: D~ F~(gpd) Design Soil Application Rate(gpdsf) ' 1 Dispe,LSal Area Required (si) ( C VJ Dis ~ Proposed (sf) Sst~ vation~~ i / c1 o6 7 ~ ~ 9 ~. VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Stcel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Tanks Existing Tanks t / (,(' Septic or Holding Tank Aerobic Treatment Unit r ~~ Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached pleas. Plumber's Name (Print) Plu ber's Signature P/MPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code) VI . Coua IDe artmeot Use Onl Approved ^ Disapproved Sanitary Permit Fce (' eludes Grotprdwater ~ (ftJ Surcluuge Fce) u [ss ' g A Signature ps) ( ^ Owner Given Reason for Denial ` '` ~ ~' ~ Q 3 ~-- iX. on d it C ions of ApprovaUReasoas for Disapproval J~ e t ,, ~ ~~. od d ~C ,ct T l~"~~+w~ ~ ~~ ~l C ~, ~ `~, " ~ , ~ ~i4~e'~'~ `` ~ ~- v Z y - / 2 Z t ~ tack E~mpktt plan (tb tie County only) for t-hes,ysteml oa paper not kss ~ft 81/Z :11 Caches is siu [t~i/~ i nn inner U~.Bt~tCi-tl' & >~15~(J~~AT~S~ fit). 655 O'Neil Road * Fludson, W,l 54Q16 7 i 5-386-8 i 85 ' PROJECT INDEX ~LnN IU # OWN[sR ~~ L /vI '~ Reg..besigners of Engineering Sy% F-ivafe .Sewage Ca~~sullants i DATE ~z`'~Ci ~ 3 --0.3 - ~ L ~E PF~ONE ~~~` ~~~~ ~UUr2r_•.ss ~(o S C ~~ l%~ /2yy~,c~ ,~D - ~~..t'o,~ S5`D/ ~ LEGAL DESCRIPTION L©~ ~ jl ~' /~!d Q,v ~,Q~,,,,,_ 1~iti d zo ~ ~3 ~ I ~ ~~ v-aa .v ~, s ~, s~ . /? ~-- z y' /c'~~ 'T'OWN OF ~UI~SD.~ COUNTY 'S r' `/e0/~~. LocAL nuTr~oRITY/ SUPERVISION _ 57~~ ~-D%7~ G)`~ ~•v: ~ ~ PROJECT DESCRIPTION: ~____._ ~ ~ ~~S . ~ Silk,. l,~ ~,( ~~~ ~ ,~f%til~a ~~OT I~ ~~.~ ~ m~'R'M D vp2 ~3 QRIGINP,L ~6 ~3,~-2~-- Zl~~i~'i' Ulbricht & Associates ~ ~- Private Sewage Consultants 2812 1 Qth Ave. Spring Valley, Vlft 54767 NtP,PS ~- .~z~3 ~S Z/- °~ Fg.l INFILTRATOR SIZING WORKSHEET Pg.2 SYSTEM PLOT PLAN Pg.3 CROSS SECTION OF SYSTEM, WITH ELEVATIONS. Pg . 4 ~~ ,~ ~~ ~~ Pg.5 OWNER MANAGEMENT PLANS & ZABEL FILTER SPECS Z a ti ~~ ~ ~ ~~ ~ ~ ~ ~ n ~~~~ t ~~ ~~ ~ d ~ .~ ~ , -~ _ ~ ~~ ~~ ~' 6`` "'ft Y ~.._..~- ~t a .` a ~~ ~h h ~~ `~ C °~ .: ` ~ ~ ~` _, ~ (`~'~/~~ y [ i. ~~'° ~ "'~ °~. ~., ~ ~. Z a .~ °°°--~ ~' T~ t d ~. v . - f3,~- ~ Toy ®~ E/,~~'fc 7~~~.sok'~~ ~° ~~Dx ~ ~ 2taZ ©0.0~ No • G°~~ ~N _------ ~~ `: ~~ ~ I's'~~~ ~xD~a~~~~~~ -~ Il~~ /fit ~ ~ 3 ~ ..._ r ~ ~ 1 sl -i i ~~~T~'``~ ~ -~ ~ ~ ~; i ~ 11 xit q~--- ~ ~ ~ ~ 1 / ' . i~ ,~ 3 ' ~* - i ~ b 5 ~5 ~ `-"` ~ -` ~~~ ,, ~_ ~8 ~:~ ~~ ~, /Aj Y~ V ~°~' f ~, ~~ ~..~ 25 9' ~,~D~ ~,~.~~ s7'`IC~UGTllln~ ti~ j!l%~T~ ~~~~~ << ~ ®____ ~ ~~ j, -z I -af Q ~~ ~. ©~ 4 V THiS POWT SYSTEM SHALL INCORPORATE PER COMM. 83.44(2}c A PROPER ZABEL e~°~. "I ~I n / Y~-~1 ~/~ ~/N. ~ 2 ., __. ~ ,~ ,, ~. ~y;,. ~~____.. T~~~ ~~ .i .~ S~~T~~ ~/~v, 9 S. ~' - ~--- C,~/cv~/fT,~ , ~p U~ %us~ ~'c T/ov ~d r~ 1/I/ Sc~, ~o ~~~~ 9iP~4f~~= /0 3, ~ • Cho SS Sic Tiot,~ ~~ ,~ 7~E'~ ~- ~s y' ~~~+IAcr 1"~/ ''SiflE-ty/,u~;Zo ~~~yp~~L 3 cv~~f,~, ? ~. ~ S,Q ~',T ~;,a/~~o i f~~ -_ t .1 3~ 1 `i,, ., A~~~ ~,U~~7XtTd~ T~ ., oR _____._ ~~ G =jr~ ~, ~"N~~ls << j3rbpi~~"uS~ SE'S I~ y ~ ~~~ r~ AP~~L~~ v~ti T cg/° Uti' ~~S~1EcT/ov p~~ 1lii Sc~.; , ~o ~~~~ "~--, fliv~S/f~~"D 9~~~~ /a/, D ' T~~~ ~~ d ~ Jj ,. . ' PAGE 8 REVERSE SIDE ©WNER's MAINTAANCE OF SEPTIC SYSTEM POWTS {landowner) is reponsible for proper operation and maintenance of this system. Regular periodic inspections and servicing is necessary for the safe healthy operation of this system. The owner is required by code to submit all necessary maintenanceJinspection reports to the controlling authorities. SPECIFIC CONTACT AGENTS ~~* tiLlJl X ~~~ * Governmental authority/ inspectors: ~ ~1 ti ~-~' vJG~_ ~~~ ~ ~~~~ *.Licensed installer, responsible for providing an operation/ maintenance "Users" manual: ~t S • 7? ~.-~ 3 LIZ--- ~ - Z~I~~tLt~i I.' ~P~S ~- ?~ 3~S * Licensed servmce / inspection agent other than installer: ~f _ ~i ~ Ll 3 * Electrician, for pump, electric controls, wiring units: IMPORTANT OWNER MAINTENANCE RE UIREMENTS i. Winter traffic (sledding, shoveiring, etc.) across the area shall not be permitted, or frost can/will penetrate into _ the cell, freezing up the system. Discontinuos use in the winter (a vacactian trip, resulting in no water use) can also lead to freeze ups. 2. Water conservation needs to be exercised! Or system can be hydrolically overloaded and destroyed. This system was designed for a maximum wastewater flow of ~~ gals. daily. 3. POWTS are not designed to accomodate wastes from a garbage disposal unit, or any other unnatural sources of waste. Any introduction of such waste materials will overload and destroy this system. 9. If a power outage occurs, or a pump fails, it may result in a temporary overload of effluent being pumped into the cell, which may adversely impact the cell (leakage). It is recommended that a licensed pumper empty the dosing tank, allowing the pump to return to dosing the correct amounts, Consult your installer immediately for advice. ~. Neglect of the vegetative cover (the cells insulation & erosion preventive} can lead to f_ai3.txre. Compaction or heavy traffic also can destroy t he system- It IS NECESSARY TO REGULARLY WATER THE VEGETATION OVER A SYS'T'EM!! Effluent in the system beneath IS NOT sufficient alone t0 maintain a grass cover. 5. Peri ~- • TES i ~ N~GtI A~E~- ~-pP~o v~ - ~o ,q-p//~olp ,~,~Ce~ss i ry ~~ A' ~UM~ SYS7'~'tiI `; ~EG~'lISC ~~ ~U l7SE' ~~,~U~T/o,~ • Wisocrosin De~kstent of Commerce SOIL. EVALUATION REPORT P~ ' Page ~ at J Division of Safety and Buildings in arcardarsce with Comm 85,1Arts. Adm. Code Cody Attach cxxriptete site plan art paper not Less than 81/2 x i t inr~es in size. Plan must ~, include, but not tirn'sted #o: vertical and horizontal reference point {BM}, direction and pernent slope, scats ~ dirnensians, Werth arraaw. and location and distance #a nearest road. Paroel ~ ' l 7 0 ~ ~~ Please print al/ Information. ft viewed Date / Pbraenai information yoee provWe mey be wed for secondary WNPvses t~~f' ~. s. t 5.04 if? frn))- ~ / d Q3 ~P~Y M f ,(~,C~ Property t.acatian ~~ L ~ `~~v`'4 GrnR. t.c~f ~/W 414~~ 1!4 S / T L/ lV R /~ ~ {or} W Property t}wtter's Malting Address ~ ~~ ~ ^ Lot # Bioclc #l Subd. Name or CSt~t# g~ S C ~~ ~ v // oO.v~3Eyft-r State Zip Code Phone t+tumber ^ City ^ tllHage (Town Nearest Road --__--_ New Constttx~iott Use: ~..Residen6al f Number of bedrooms ~ Cade derived design Qow rate ~ GPD Replacesttent ~ Pubhc or catnmeraal - Descnbe: _. _-.~. I Parent material oU C`C91`Y'v °n it igbte ~ _ ft. Get~i vorrrnerrts and ~7 0 ~~ 133 = ~~~ ~S r-~~ir- ~~P 2 2 2003 P~~ y ST. CF201X COUNTY ~---~1 ~ ^ ~~ O~~ NING OFFICE / !(/~!~ ~ Pit Ground surfar~ elev. ~ tt. Depth to rtrr~tir>g far#or ` ~~ a<». soil Rate Hori-aott Depltr Oamararst Ftedox Desa~tan Texltxe Sfrudure Car~enca Bound ary Roots GP iMf In• Mtmsed tZu. Sz. Cant, Color Gr. Sz. Sh. *Eff#i 'Etixi2 o- i'z ~o YR ~! - iL l S 3 f . Z . 3 • 2 /D L / ~ . S ~ L Ct. • Z ?~S - S ~. ~z'3o ~ fQ Pit Grotmd surface elev ft Depth th limiiirg far~y in . . . Sod Rude Horizon Depth Dominant Cd Radox Desuiption Texture Strtwdare Consistence Boundary Roots GPDIfF in. Mrmseg thr. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 I . !z io s LO ~iL O. ~.~ cs / ~ ,, ~~ Z a h; ~Si L f ~- v CS / . Z . 3 ~ ---_ ~ L ~ Q ~ ~ - canxarc a r = DW ~ JU ~ LLU m91L an0 i `.iy- >3U < l5V rriglL " t„Ailleni i€L = 13C?i) < :it! mgtl. ana i ' < 3t7 mg/t_ CST Name (Please Pratt} ignabxe CST7VIXiiber ~~ zZ c~ 3 ~ s Address Date Evaluation ed Telephone Number Ulbricht ~ Accnriatae ~!~ . 2 G - .2~0 3 7!S • ~7 ~ • 3 Y~ SeWA(lA i':nnci iltante 2812 10th Ave. - - ----~ ~~_ Wiring Valley, WI 54767 1~ ~ ~/2 ~o f ~ `/ Faroei tD tF ~D~'~~~- Z- 3 Page of ~~ l~=J ~j ~~ ~ ^ t3orirx7 ' D I ~-Pit Ground surface elev. ft. Depth to Irtniting tads I6 !l ~ - ___. ~-i Rate Horizon Depth Dorr:inant Redox Description Texture Strudrxe Consistence &wrrda~ry Roots GP D,~tt` &r. Munsed Qu. Sz. Cor-t. COtor Gr. Sz. Sh. •EtHlf 'f=>T#2 l o• ll ~o ~,~ 3 ~L s ~ ~ . i • 3 Z D -- ~~ L 2-f~' ~ - S 3 z • ~a ~ ~' ~FSh v - ~•5 ~ S .~ ~ ^7 ( Z s o ~ .o - ~, ~, ~^ ~~ ~~~ ^ Pit * Ground surface elev. 1t. Oep~r to timiting factor in. Sod ication Rate Horizon Depth Dominant Redox DesaipGon Texture StrucAxe Corrsisterrce Boundary Roofs GP DItt? in, tiAtrnseil l~ti. Sz. CoM. Cobr Gr. Sz Sfi. 'Etfg1 'EtF#"t ^ Fit Ground surface elev. R. Uep1h to . .. or kr. ~~ # ^ ~~ Sod Rate Horimn Depth Domfnant Color Redox Desofiptiots_ Texture Consistence Boundary Roots kr. Munsed Qu. Sz. Cont. Color Gf. Sz "Etf#S 'Etf#2 .~ ^ Pit Ground surFace elev. it. Depfh to 9 factor in. . Sod Rate ~~ # ^ ~~ tiotizOri Depth Dominant COI Redox Description. exture Stnrdrxe Consistence Borrtxfary Roofs GPDIt~ ~. AAunseN flu. Sz. Cont. Color Gr. Sz. Sfi. 'Ett#1 'Et~l2 ' Ettttrerrt #1 = BfuJ6 > 30 < ?2f1 mglL TSS >30 < f 54 mglL ' EtBuerrt #2 = Bt~U6 < 30 mglt. and TSS < 3U mgli. rj,~~ l mop ®~ ~'/~~-C?~l~ 7~'~~,S~o~`~~ ~-- ~. ~°x 2Caz /o 0,0 ~ No G~'~ , ~ N~-- _-- ~~ ~~'~~~ a ~~ 11~ .~- ~ Gov ~ - ~ ~ ~ ~~ t~ l- %~ ~ ~ -i ~, ~ ;~ ~ t -~,~Qi~' I1 ~~,~ s~~uc~/~~.a q~~b ~~ ~ ~ ,~, • `r------ ~ _ 1~ %j ; ` ..~' ~~ ~ ~ ~, '! M~,2' ~~ ~!~ t 1 !'y 0~ ~°~ l ~~ ~' .~ ~~~ ~~_.. l~~~~ f p, ~ ; t ®~ .~ ~______® r ~~,~,b 0 ~~ ~~'°~~ ( \\ Safety and Buildings Division 2 ' County _ d,, 5 / • C~or ~ 01 VY. Wasfiington Ave., P.O. x 71 isconsin Madison, WI '53707 - 7 d,D ~7/ ^ tie Address ~~~ C ~trl~ ~,~ Department of Commerce Qq~,lp Sanitary Permit Application Safi Permit amber In accord with Comm 83.21, Wis. Adm. Cade, personal information yon provide •~3oZoZ ^ Check tf Revision ma be used for seco sea Privac ,-s15, m I. Application Information -Please Print All Information ~ '~ '- ~_~ State Plan I.D. Number ,~,, Property Owner's Name Parcel Number ~~/2~ M/~~ ~~ ~a~c. ~ :, o~' ~3~8• //• o~v Property Owner's Mailing Address ; C,//__c y _ Property Lo``catLLion C~ tiW~JL,~~S~Z T~~ N.R/! Lr City, State Zip Code Phone Ntunber """`""" Lot Nttmber ~ / Block Number ,~ivOSo ~ ~/ / s~~/~ 7~s • 3~(O Subdivision Name // MDD~v /,~~~~-! II. Type of Building (check all that apply) ~ g,~Q~ „~,~,~ ^City ~1 or 2 Family Dwelling -Number of Bedrooms S • ^Village ^ Public/Commercial -Describe Use ~ownship V ~Q ~ ^ State Owned ~ Neatest Road III. Type of Permit: (Check o one box on line A (numbering sch a for internal use). Complete line B if applicable) A' 1 `New 2 ^ Replacement stem 3 ^ Replacement of Addition to For County use '. S stem Tank Onl tin S stem B • ^ Check if Sanitary Permit Previously I d Pertnit Number IV. Type of Permit: (Check all that apply)(nu Bring ache a is for internal use) 44 Ton -Pressurized In-Ground 21^ Mound 47 ^ Sand Filter Gi Constructed Wedartd 22 ^ Pressurized In-Ground 41 ^ Holding Tank 48 ^ Single Pass SI ^ Drip Line 45 ^ At-Grade 46 ^ Aerobic nt 't 49 ^ Recirculating 30 O r V. Dis ersaUTreatment Area Informat ion: -(gyp $~ ~ .O Design Flow (gpd) Dispersal Area Dispersal Soil lication Percolation to System Elevation Final Grade ~ Required Proposed Rate(G Days/Sq.Ft.) (Min.Rnch) s Elevation ~ ~5~ ~~ t~ ~ ~~ /~ P ~,~ VI. Tank Info Capacity in .Total Number Mamtfac r Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Cottstntcted Glass New Existing ~ ~ ~~ Tanks Tanks Septic or Holding Tank _ Dosing Chamber VII. Responsibility Statement- I, the ersigned, assume reapon4ibility for installation of We PO shown on the attached plans. Plumber's Name (Print) PI bee's Si nature •M~P/MPRS Number Business Phone Number Plumber's Address (Street, City, State, Code) VIII. Coun /De artment Use Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issu' Agent Signature (No Stamps) • ^ Owner Given Initial Adverse . Surcharge Fee) ~ ~ ~---- - Determination G . ~ 3 IR. Conditions of Approval/Reasons for DisapprovaLl//~ ~ ~ ~ ~Q / j/'~ t p~^LY `~ ~ ~~RJ~l1~C_¢,Q®L / V~l~~l~.~S~ a-d !! a _~ -r-^- r•-••- .......~ ........y vw~, ^vr wo s~s^em vn paper nor ^esa wan aa^~ : is nlenq m iR! SBDy6398 (R. OS/Ol) /vt ~Uti ~.s ~ ~9~ l 1 a ~~ I` 1 1 i ~i OD - --~ ~ n m~0~ ~ N ~ n ~ ~ mD~~ ~ ~ ~. ~° -° can ~~m O =. m~D r~~ ~~ d~ ~t ~` ~f°} ~~ t1 \lN V - _Z +v,\ s ` (~ vV ~ V ,~r O~ ~ yJ ~ t; ~'~ ~ ~ i ~ ~ ~ '~ - ,, ~ ~~ ~, ~~a _ `"~ -~ I ~~ ,~ y t ~~ '` ~ b ~ ~ s ..,- .s ~. ~ T O i o ~ ~'1 ~~ ~ y c~ Xi ~_` a pc, ______...W_________~.. __ ~ I~ ~__ __ _~ --~ a'x ~~~ ___ _ _. __. ____ -~ b . _ ... ~~ ~ ~ ~ ~ ~ ~ b ~, ~ .:.J...: ` -v t ~ ~ ~' ~~. +,.a ~~ i., ,r~ ..~,~ ..~ ~ -._ ~ ' ~ ~r~ ~- ~ ~ ~, ,~~ . ... ~,~ I~ Ui~BRIGI~I' & ,~-~~17G#AT~~ Gp. 655 O'Neil Road -Hudson, WI 540 f 6 715-386-8185 • PLAN IU ~ PROJECT INDEX Reg..beslgners o(F~,prry,g Syste Frivale Sewage ConsuNanls i HATE o~`-~ ~ 3 -a._.3 owNER ~fi•'R L /`'l~'EG ,E'E` PHONE ~~(~ - -~//O naoPESS ~(o .~ C ~,q~a /jam- /~ygt,y ~!~ Jf7,~.1'0.~ Sy0/ ~ LEGAL DESCRIPTION L~~' ~ /l -' /~'1ts O.v I~~~.,_ n~N o ~ ~ ~3 ~~ ~ .~" ~ ,~ ~, s ~, s~ . ~Z ~-- z f ~~~ w TowN of I~~OSd.J LOCAL AUTHORITY/ SUPERVISION $'~• Ltpj )[ PROJECT DESCRIPTION: -_-_____ COUNTY 's r" ~/eOl `,~ /t/-eLtr GD.vS]'%~C7`% D,c> - 5~~'G ~~ /~',f ~ti ~' X02 .G/ i~ir,~s ~c a ~ fir- Zl~~i~'i' Utbricht & Associates ~ ~- Private Sewage Cpnsuitants 2812 1 Qth .Ave. Spring Valley, Wt 54767 S _-- z3 - o~ Pg.l INFILTRATOR SIZI Pg.2 SYSTEM PLOT PLAN Pq"3 CROSS SECTION OF Pg.S OWNER MANAGEMENT Pg. 6 l ~PTInNAT.I r~nncc VG WORKSHEET SYSTEM, WITH ELEVATIONS. ~~ ~~ ~~ PLANS & ZABEL FILTER SPECS .. ~ b ~ m ~.{ ~ 'o ~© --~ ~. M r` ~1 '~ ~' ., 0 n t~ ~ b ~' ~ ~ ~N z a ~~ ~ ~b O w b -~ ~• ~ ~ ~ ~ ~d ,~ ~ o ~~ c ~ ~~ o ~ ~ ~~ ~~~y -~ ~ ~°~ y ~ ~ y ~ ~`~•, ,, ~ n~ ~ ----~ 0 __. __\ ~x - s N~ ~, W O O ~1 .~ 0 -~ R~r oQ y 0 ~~ ~' Cry C U °~ ~~ ~~ o.;~ ~~~ w ., ~ ~~~ ~~ _~ ~, ~ ~ ~ ~~ ~. ~. ' ,r ~~ - ~~ ., ~. ~~.. - ____ . ~ .__ _. .__ _~ 1 ~ ~ ~ ~ ~~. ~ ti ~ m~ ~ ~:;~ ice, ~ a~ ~ = ~ ~ ,, 7 ~ ~ ) { N~ ~ ~: ~ ~` __ __ ~ ~ _,__ -G --- - _--~ ,,J ,; ~ d~ ~- ~~~, x~ ~ .~._ , .~--_-._,~._....s ~ ~~ _ V ~~. .,~ ~v „ ~i ~° ~ ~~ ~ ~~,. _~ ~ , ~ ~ ~ ~ >. .4W .w~._.::~~_._ . o ~ ~ v~ Y ~"" lT' ~- :.. ~_ ~~.- ~~ ~ i ......y~...v_,y.. ~ ~~. 1` ~e ~~ '~ r~ a ~.,. r~ it ~ `~ tJ "\ '~` ~`~ ~~ o ~ ~-~ <h 3~~' /z ~~ ~\ ~~ ~. J ~ ~ Q ~ m c=~N~ ~ ~ O Cil~~ ~°-~~ ~Qao a.a~~ ac _, ac cn0~'w "~1 t m /~PPrPav.~ off, l1~~7~ ''' .- 1~~ ~tiv. ~ (,. ~` T~' ..~ ~9Pp~~~l~ U~tiT c~/° U.v' •,vsp~-c T~ov ~~~ Ir~i _. if M '' ~~~~ 5~..~0 ~Pv~ yiP~1>~" 9~~ _ '_ C T~~~ ~ ,~ .~ _ ~. i ~iN. ~2 ,, -(~ - j _. ~'~o ss Sic T~o~ oC TiP~~vG~ls ~' .~ ~c ~~ . Zr,S /.v (~-' l~U~i L ?~'~}- 7lo~'S oR r3 i o pi f~uS~ AC'S - ~ i`{~~,, c~ f~Ac r rt/ "si~E~v/,~~~ ~~,yo~~C 3 'x G 'a " t ov~ w~~ 3 ~, ~ SQ. ~T ,fv~~'vv~j ~rt~.~fcfr~f ~ S~'~ Tr'~.c~ M 3~ . ,, K ~~~~ iv~~rX~To~' •~.~... ~r~i ~9Pp~~~h v~,v 7- cf jd U,v ~,vsp,EcT~ov p~~ sc~. Qo ~ ~ y~T~,~ ~%~~, ~~ o -~ F~N~ s~~-~ ~--,~ t - '' ~ '~ T~P~ti c~ ""5 _ . . • PAGE 8 REVERSE SIDE OWNER's MAINTAINCE OF SEPTIC SYSTEM POWTS (landowner) is reponsibie for proper operation and maintenance of this system. Regular periodic inspections and servicing is necessary for the safe healthy operation of this syste~a. The owner is required by code to submit all necessary maintenance/inspection reports to the controlling authorities. SPECIFIC CONTACT AGENTS S~•Gcojx ~1~`/ * Governmental authority/ inspectors: ~ ~~ ~ ~ 0~~~_ 3~Zv ' ~l~~O * Licensed installer, responsible for providing an operation/ maintenance "Users" manual: * Licensed servmce / inspection agent other than installer: ~3 ~li ~-i3 ~ * Electrician, for pump, electric controls, wiring units: IMPORTANT OWNER MAINTENANCE REQUIREMENTS 1. Winter traffic (sledding, shove ring, etc.) across the area shall not be permitted, or frost can/will penetrate into the cell, freezing up the system. Discontinuos use in the winter (a vacaction trip, resulting in no water use) can also lead to freeze ups. 2. Water conservation needs to be exercised! Or system can be hydrolically overloaded and destroyed. This system was designed for a maximum wastewater flow of ~~ gals. daily. 3. POWTS are not designed to accomodate wastes from a garbage disposal unit, or any other unnatural sources of waste. Any introduction of such waste materials will overload and destroy this system. 4. If a power outage occurs, or a pump fails, it may result in a temporary overload of effluent being pumped into the cell, which may adversely impact the cell (leakdge). It is recommended that a licensed pumper empty the dosing tank, allowing the pump to return to dosing the correct amounts. Consult your installer immediately for advice. 5. Neglect of the vegetative cover (the Bells insulation ~ erosion preventive) can lead to failure. Compaction or heavy traffic also can destroy t he system It IS NECESSARY TO REGULARLY WATER THE VEGETATION OVER A SYSTEM!! Effluent in the system beneath IS NOT sufficient alone t0 maintain a grass cover. 6. Periodic inspections by the owner. n.- ~,;~ ~......,... _ /~ ~ y~i2 ~ M i /lE' ~FT~/2.So.~ , iQ-S>~E•v aEVE~oP.yF.~ ~ (~ yyZ f E'~~/ >4~ - sv ' ~ ~ 3 wisoonsfn Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code minty •ST G/Q d~• 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 p~ I,p, 6 0 percent slope, scale or dimensions, north arrow, and location and distance to nearest road. ""-~ ~ Re 'awed by Date Please prf tall Information x Personal IMormadon you provide may be u for secondary prxposes (Privacy l.aN. s. 15.04 (7) (m)). -Ir~~o3 Property Owner „ ; ,, Property Locati ~~RL M ~ ~'i E . °; b Govt. Lot N~ 1/4 S~ 1/4 S 1~ T Z N R ~~ E (or) W P Ay Owner's fling Address i Lot # Block # Subd. Name or CSM# ~~oS C~,~}RG/E RY~~/`~ ~~~` ~` ~ oowt3~~41'~ ~ R~~'GE _. City Stet Zip Code Phase Number ^ City ^ Vllage Town Nearest Road ~ p sa,/ ~/ s yo/~ ) ~ ' 36~ ~vOSo .v ~H'9R1iE' ~ Ant (~ New Constrirction Use: .Residential /Number of bedrooms Code derived design flow rate GPD ^ Replacement ^ Public or commeraal -Describe: Parent material /D ES$ d ~~ Si'}N0~ Flood Plain elevation if appGpble N/ T ft. General corrrnerds ~ ~T'w~'~ and recommendations: Svr'Ti1-~/E j~I~ ~a~v vE~ % ~o~v ~q-c • ,~,~~,¢ TESTED i~vf,~Pov~v P C~. cam. ~ S . ~- j3:ov~~~ uSE~(° ce l/s . # Boring ~ a p • D > /lo Pit Ground surface elev. ft. Depth to IimNing factor in. Soft lotion Rate Horizon Depth Dominant Redox Description Texture Stnx~rxe Consistence Boundary Roots GP D/fF in. Mu-setl Qu. Sz t.ont. Color Gr. Sz Sh. •Etf#1 ~~ Z ! • ~z io k - S~ /~J/~~ ~-fiP c4> /~ • Z • 3 S•/D ~D S S D,S ~ /• Z L s Lf ~r. 9~ p Boring #~y ~~ 7 2 t2Y Pit Ground surface elev. ~~ ` ~ ft. Depth to limiting factor ~~ in. ~ ~~ ~ Horizon Depth Dominant Cdor Redox Description Texture Stricture Consistence Boundary Roots GP D/fF kr. Mrmsetl QU. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 • • /~ ,e ~• s L LS 2fSh cs C S -- -- • s . '~ 9 1 • Z ~j. o ~°6 ,D'a Effluent #1 = BOD > 30 < 220 mglL and TSS >30 < 1 50 mgll. 'Effluent f/2 = BOD < 30 nglL and TSS < 30 mglL CST Name (Please Prirrt) Signatue CST Nixriber a ~ /b ~ •c~ ~ ~ z~3 5 Address Date Evaluation Concluded Telephone Number _- Private Sewage Consultants 2812 10th Ave. Spring Valley, WI 54767 M y Ovrt~er - _ Parcel ID !t L D ~ ~ /~ PAflA ~ of ~. ~, pit Ground surface elev. ~~' R. Depth to limiting factor /Ov in. ~ ~e Horizon ..Depth Dominant Cdor Redox Description Texture Stnrctrxe Consistence Boundary Roots GP D/fF in, Munsep Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff1f1 •Eff#2 ~ d • ~L i~ 3 ~- ~- Z~S bK nM~f'2 3 ~- ~ s • Z ~ r .---~- f' Co ~-- SQL S w -- ~ • Z . 3 o ~d r , -s - ~zP. S D ~. o ~„~ # o 'Boring ^ Pit Ground surface elev. R. Depth to firruHng factor in. ~~ ication Rate Horizon Depth Dominant Color Redox Description Texture Stnx~ure Consistence Boundary Roots GP D/ff in. MunseA Qu. Sz. Cont. Color Gr. Sz Sh. •Eff#1 •Efflf2 ,. ^ Pit Ground surface elev. ft. De to Nnwting factor in. ~~ # ° ~^~ Sod Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GP D/fF in. MunseM Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Efitt2 ^ ~~ ff ° ~n~ ^ Pit Ground surface elev. R. Depth to IimiGng factor in. Sob ication Rate Horizon Depth Dominant Redox Descri Texture Stnx~ure Consistence Boundary Roots GP D/ff in. MunseA Qu. Sz. Cont or Gr. Sz Sh. 'Eff#1 •Eff/t2 ....L~ ~, ~. ~° ~ w a ~ ~ ~ c a ~ ~; ~ y o ~~ ~ j ~~ ~~ ~o~ -~~ ~3 cti ~ ,~ . ~- ° v _~ N -~_`®' _ " r~ `~...w. ~..; ~ ,~ ,~~ .~o ~~ ~, ~.. ,r a -.~ 00 ' O ~c _____ 1 .~ _. W ~r 0 l~ N d G ..~ o Q d d_ 0 o_ , ~ ~ .~ ~ -- ~ ~ q _a S'I' CItUIX CUUN'I'Y SEI'~'IC 'L'ANK MAINTENANCE AGREEMENT AND UWNERSIIIP CERTIFICATION FORM Uwner/i3uyer ~~~' 1 r ~ ~ L ~~ Mailing Address C ff ~}'/~G i~ Property Address r O J (Verification required from Planning Department for new City/Start' yo/~ Parcel Identification Number ~~~ ' /~7~' ~~~ ~~ ~ ` LEGAL UESCRICTIUN ~i z Z ~~ Proi~erty Location N~ '/,, S " '/,, Sec. ~ , T ~ N-R ~ ~ W, Town of `S~ ~ Subdivision ~D~Nl3~A'~t /~ID~~ ,Lot # l~ Certified Survey Ma1- # o ume ,Page # // g Warranty Veed # ~ g ~`~ y ` , Voiwne l ~~ a ,Page # ~~~ Spec house Oyes d no Lot lines idenliftable~ yes O no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its pretnalure failure to handle wastes. Proper maintenance consists of pumping oat the septic lank every three years or sooner, if needed by a licensed purnper. What you put into the system can affect the function of llre septic tank as a treatment stage in the waste disposal system. 'I~he properly owner agrees to submit to St. Croix Zoning Department a certification form, signed by llte owner and by a master phrmber,.iourneyman plumber, restricted plumber or a licensed pumper verifying that (1) the ou-site wastewaterdisposalsysrem 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. Ihve, 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. Certi[ication slating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 da s of the three year expiration date. ~- 7 /~Zi ~3 SIC3NA~URE Of MCLICA DATE OWNER CERTIrICA'I'ION ' t (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) Am (are) the owner(s) oC roperty described above, by virtue of a warranty deed recorded in Register of Deeds O[rce. ' ~ ~~ SIGNA'I~UILE Of ACPLICA DATE ****** Any information that is rnis-tepresentedmay result in the sanitary permit being revoked by the Zoning Department. ****** /~/ /~~ ~ ~ (7 SON ~ ~„ ** include rvHlt ihts appftcalion: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map iC reference is made in the warranty deed w ~ ~~ U 1960P ti84~ STATE BAR OF WISCONSIN FORM 2- 1999 6 8 8 4 4 9 Document Number W~ d-NTY DEED RA7HLEES i!. MALSH REGISTER OF DEEDS ST. CROIX CO., WI This Deed, made between P. C. Collova Builders, Inc., a RECEIVED FOR RECORD Minnesota Corporation, 08-28-2002 9:30 AM Vg1RRAlITV DEED Grantor, and Earl L. Ia14^ °-a "'---y * aRcPlke, husband and wife _ ' EXEIfPT N ~ REC FBE: 11.00 TRAMS FEE: 186 00 . COPY FEE: Gratttee. ~OPY F$E: r Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Lott 1 oonbeam Ridge in the Town of Hudson. St. Croix County, Name and Retum Address nstn. DAVID J. ESTREEN 304 LOCUST ST. HUDSON, W154096 o2o•ls7s-1 I-ooo Parcel Identification Number (P1N) This is not homestead property. (ft;) (is not) Exceptions to warranties: Easements, restrictions and rights-of--way of record, if any. Dated this ~ ~" ~ day of Augus! , 2002 AUTHENTICATION Signature(s) P. C. Collova Builders, lac., a Minnesota Corporation, by P.99C. Collova, President authenticated this 1 ~ day of August ~ 2002 ~_1 ~_~=~G + Kristtna Oaland ~ TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stets.) 'fl[IS INSTRUMENT WAS DRAFTED BY Attorney Kristine Ogland Hudson, WI 54016 _ (Signatures may be authcnticatcd or acknowledged. Both are not necessary.) • Names of persons signing in any capacity must be typed or printed below that WARRANTY DEED . C. Collov uild~s, Inc. '*"P. C. Collov4; President r ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. County } Personally came before me this day of the above named to me known to be the parson(s) who executed the foregoing instrument and acknowledged the same. Notary Public, State of Wisconsin My Commission is permanent. (If not, state expiration date: •) ~latare. Informatan Profaf~ionW Company, Fond du l,w, WI BOD~65a.2021 STATE BAR OF WISCONSIN FORM No. 2 -1999 r *R019 P C COLLOUA HLDRS, INC PHONE N0. •715 549 5911 Jun. 22 2001 09:58AM P1 i ~ us ~ W ~ ~~ ~ .~' v ~ uu'' .\ 636'-~-- -,,~ \~ \\~ ~~ ~' .- Y _~__.~~,~ , ~ # -f . ~ , ---- tia ,~ ~ ~ i ~ , ~ ~ ~ } \ f~l _,~ j /' LV'V1 1 ~ F E EL.JEV. ~ 10.0 ~~ ~ ~ 1 _- ~` err' X 9;8,7 •~, r ~ ~ , '~ ~ ~ , _ . ~ - - ~ ---------E--- ~.,,,, ``--~ ~''• ' / ~ o W ALL°°u~~~' I .r ~ N ~~ ~ ./ • + X 93 .3 ~~ ~ ~ ~ N X 9 7 I l ~ tN tJ `.,~``,.~ - J `--,- ~ 6 . 2.8 ~' .,~ ~ / ` \~~ `\ , ~ 933.2 i ~ --~ att ,r. Mur u ~ .ti ~ s. - -~ ~ ~ i ~ ,T,.4( t . • $ '`. cf '~~ ; ~ ~w (2. E ~ l t •- ~ ~~`' ~ ' ._ ~. ~~ tl ~ ~` 30.0 ~ ~ t ~~ \ ~ / ~ K..~ ~ 1~'1 r~~r~` / // /~f // 2 / • 1'` . / .' X 92 ~ ~~ Z8 ,` rJ »-.~..~ ~ l / ;N ~ J f ~ ~ `~ _ _ • ~ `''~. 1 MI a lD d a \H.1N.L. ~ `( ~~-...--,.._~t~lltl~/ /~ '`- ~~"~ ~KJ~~ "' ~ T'rT ~~T v [////y ~/I ~ ; v r .. ~J \ ~`" -- ~._ ~~ ~~e li.~ ~ l /~t 4 ~'~ .,.1 /* Wieoonsin Department of conxnerce St~fety m1d Eiuildings Division GENERAL INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Personal intorrnatkxl you provice may be used for secondary purposes [Privacy Law. x.15.04 (1)(m)]. Permit No er s Name: ^ City vi la ^ Town o ' Collova, Hudson Township UT BM E ev.: Insp. BM E ev.: BM Description: TANK IN FORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION ounty: St. Croix Sanitary Permit No.: 384277 State Plan 10 No.: Parcel Tax No.: 020-1378-11-00 ELEVATION DA TA I d ~ a9 • ~• $O STATION BS HI FS LEV. Benchmark t. BM ~~ Bldg. Sewer St / Ht Inlet St/ Ht Outle Dt Inlet Ot Bott m Header Man. Dist. Pipe Bot. Syste Final Grade Cover TANK TO P/L WELL BLDG. vent to Air Intake ROAD Septic NA Dosing NA Aeration NA Holding PUMP /SIPHON INFORMATION _ Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Forcemain Length Dia. I-f Dist. To WeH SOIL ABSORPTION SYSTEM BED /TRENCH Width length No.Of Trenches PIT No. Of Pits Inside Dia. liquid Depth IMEN I N SYSTEM TO P / L BLDG WELL I I LAKE /STREAM LEACHING Manu adurer: SETBACK CHAMBER INFORMATION Type OR UNIT Mo a Num er: System: DISTRIBUTION SYSTEM x x Length Dia I Length Dia Spacing I I ( SOIL COVER x Pressure Systems Only xx Mound Or At•Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Include code discrepancies, persons present,l~dection #1: / / Inspection #2: / Location: 1037 Moonbeam Ridge, Hudson, WI 54016 (NW 1/4 SE 1/4 12 T29N R19W) -1229192350 Moonbeam Ridge -Lot 11 1.) Alt BM Description = 2.) Bldg sewer length = -amount of cover = Plan revision required? ^ Yes ^ No Use other side for additional information. Date Inspedofs Signature Cent NO S8D-6710 (R.3/97) ~ ~~ (~ ~ Safety and Buii~iings DiF'isian ».. C~r /~.~. t "Y ~~~~~~~~~ ~ w. ~. naauiu~s~-tnvt:., r.v.:avw ..v~. r ` Madison, Vr'I 53707 - 71tS2 i ... v ~ v i - site Address / ~- Dsp~,rtm~nt Df Cammerc~ F i D3~r~ia ~$~~' ~@rltl~l~ r',p~~i~A.'C3011 ' su+ictrY~Psrmac hua~rcr 2~ Zz actset+d artdt ~Caaeutn 83.23„ ~Vis. A@m. Cade, perromd intormat(on you pravida ~ ',,~ Check if' R ba Privac Law til. 3 rtt --- 1. Appilaatlm l~ r Fxiat All ~Of7tltiti4C i 9b~te 1"1ar! 1.D, Nucsi:c ~ Property t?1w0ar'a 1:Vame Puooi Number ~' /~ ~ ~L~Y J~ Pnrtr il~+ner's alai ictit Addntt Cr er + i,~ication '~"~ { ~ ciy, State ?~ Coda ~ 8haae Nttstt~t+r + ~ Lot Atuatt~ Black Nwnbor rt 1 ~B~xiivuiaa l~'ame CSM Number E ~ ofG ~ ~~ s - sv y- s~ ~T~ ~r~D,.tJ~C~t Gr, ./~. ,`~o-~ ~,... I. Type er 8uttai~ t~t~ alt tPsat apply) i ~i7t:ity I 1 er 2 Futaity Dig - Ntaaaber t:i l8odrtuatns i ~~ i ~'t11tIaSs C7 PubliclCetnmesciai - I~ctiba t3so ~ __.____ 0 4, ~~ Ci State 4~nted , ' x Q;. ~-~-rp..~.~ c a-~co 3 a j r.~`~t~-7'~ ~._ Neartcr A~ i .e ~ ~~~-~---i ib } 13a. Type at I'erto~tltt (puck only eme beat wn lime A (tau~berinS ach+sane for internal urtt}. Comglete tine B lP sppii A. i New 2 ^ Re~lacx~ment 3yuem ' 3 G ltepiecemeat of . Pcr Coutur vre G 2.0 -! 3 ~~ - ~ - 00 0 r; C Addison A R , ~ 3.5 C3 1 a'i • v~ ! ~f . Svatem Zank and ; Exis~ S stew 8. ~ ~ Crieck if Switaty Parrett Psoviuusly Issued ~ 3'orioit Number I Data Issued l<V. Type of Fermin (Ciuek a!1 that apply}{nauuberlaS ttcbetacse is for intttrttat tme} a4~Nua ~Fresaurtsad Io-Qrouad 2101 Hotted 47 ©Sas:d Filler 50 ^ Coasav.tcd Ws~land S?'e n ~y,~ v ~ '22 G Prassut'ized Isi-Around ~1 i~l. FFoldit>y Taalc 48 u 5iegim Paea S i L~ Drip Lire 45 ~ At-Otasie 4b ©Aarebic T'reatmam. Jtsit 491_i Recirculating 3Q ~ Other ~ Va D im _ a+tnt Area Informat _~ tea: Daslgts Flaw (,5pd) Dieperettl~ Ragttired 5~~ Diapertiai Soil AgFliatrion t.} ,~ysi d S7`(~ Itxa E Percolat}on Rau (b4lta./Izich) Systa ~ Ftaal Grade , Eltvatic ~ ~Z ~ ~~ 3 ~ ~ ~ ~~~ ~`3~ q3.3 9 ~ yx, r~ ani'0 C !as .'Tool Nta~ber Mutufactauar Prefab Site Suai ~Fibcr Plastic , talailou t3a;lptu of Traits Coacrats . Cnmttructed I 'Glass j E l~env ~ ~ ,J ..a epric or Tuck - «~0 r` ~S'~e .~' ~ ~ ~ ~ s --yt rt-~--~---r--~---- tlesicq i { '~. R ilt i3tatemtWt- I, tin . aartmu tedbiWy toe a! the Pow1's shown oa cbe attached Fltttrber's Naee (PrlttO Plismber'zz i~aatro A~4 , it+tnbet Busiaase Pboas Nutuber 2 ~/ ~ ' ~ ~ ~~ le-.ayC Y .i~=--- GC.y!//' o?a7 Q D l S 3 C" ~Lji a s+s .~ ~ Pltttaixr'a AdRkasa (8ttsnt, City. State, Zip Code} ? ~~ ~d s ~ o ~~ ~~ • ~ ,~- 6 vl~. arttueus y~ ap~~ P''"' ~ m,-,~ Sanitary Pemi3t Fee tiac`,t~at lirosndwritsr IJatt. Iente Ie ABent Sigt>ature (No Stamps? i ^ awaer 4iven Itticsl Adverse ~ Sarehaxge Foe} ,Qp 2Z~ ~ ~ 7,~ ; ~~,,~",,, tx. canruttam a< Apps l+t-nri ror ,urea pravas ~ LS J1ild~bS -b~Q.. .~_ _~wM.J1AitN~ ~r~~ty[t?. G'efl~l.t"C~M~L~ _ / i . C".K.Q~V~¢Dt/ NV~W1,1~17~R~(,M~.Q! Gtr . ~. `w s~~~~~s ~a. ostai~ oa s . ~ ti;~ ~isLld~JG~ ~Cci~/Y'P~ ~`O~`l ~~O,,tI,GBdI~'y /s~~~tl~ %OCI~d 4 ~ ~a~S'o~IJ • / ~ ~~~ i ~ ~ov~ 9~~ Y p ~~ u ~ ;` ~ ~ '~ I ~ ~( ~s ., i / ~ w o~ ~~ a~ 0. ~ ~ y ~, ~ I j ~ I ~ ~ Ar --~I ' V a ~. • ,ate ~ a ~ o 'gm~ ~~ r ~ y F F v' ~ ~ ~ a ~, ~. ~_ ____.r~ ~ V r ~,,, L~~ i ~~" Chlla Gd- ;©~,`/~~.~ ~a `~ ll lyJ~y..~l,be.~ n-~- ~'~`d~~. %o~,~ a ~ hla. ~s-d..tJ rr ~ ~~ ~ Sc~~~ / ~~n~ v~ 9P~ ~'~ a-~~ - I f ~~ J ,~ ~ ~4 {~ ~5 ~ s i j ~~ n w ~ ~ °' 3 ~ ~ / ~~ ~ ~~ ~ ~' A r ~w '~~ /v a ~ ti'' 'pm3- ' ~~ ~ ~o ~~ ~ ~ ~ ~ , v' ~ ~ ~ ~~ _~-~- `_ l ~ ~-_ ~.J ~,t ~ L~~ i ' '~gce~tsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and ~-~-- percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # ~~ `h Page ~ of APPLICANT INFORMATION -Please print all information. Re awed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. t5.04 (1) (m)). ~ ~ I Prope Owner Property Location C~`1 V R Govt. Lot ~~ 1/4s ~ 1/4,S (Z T2 ! ,N,R ~~ E (or~ Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# ~-a ~ Z~ L I\ rn~Nb~t~ '2; oU~ City State Zip Code Phone Number ^ City ^ Village Town Nearest Road 1~v0 t'v W T- ~ ~ 16 (~"l.$) S" -fit p n1 c5cs New Construction ^ Replacement Use: ~ Residential /Number of bedrooms ~ - `~ Addition to existing building ^ Public or commercial -Describe: Code derived daily flow ~~~ gpd Recommended design loading rate ~_bed, gpd/ft2_~trench, gpd/ft2 Absorption area required _~bed, ft2~trench, ft2 Maximum design loading rate bed, gpd/ft2 ~ O trench, gpd/ft2 Recommended infiltration surface elevation(s) UDati(' 9 L~• 3 ~ LcswL f Q ~, 3 q_ft (as referred to site plan benchmark) Additional design/site considerations A-L'~'• ~ ~'~ C~ ~ ~`~"~ Parent material G V -~W'u S ~ Flood plain elevation, if applicable /(/-"~- ft S = Suitable for system .."..•~..•."..°. ..."".." ... --.--..~ ..--__._ ... _._-- u = Unsuitable for system [~ S ^ u 5~ S ^ U ~ ^ U CAS ^ u ^ S [~u ^ S ~ u Boring # Ground elev. ft. Depth to limiting factor \1l~ in. Boring # ~_Z Ground elev. ~~ft. Depth to limiting factor 110 in. Remarks: CST Name (Please Print) Signature Telephone No. S~hvr~-taker __~_~ __ C7~ 24?-~1v~ Address Date CST Number I3 ~~ ~I-. ~m2r~~, (~1~ ~y0~ ~ -7-oC~ 25330 JVIL YGVVf71r ~ w~~ nVr v~~ i {A~c ~,,,~ - r ---~ Horizon Depth Dominant Color Mottles Structure i d B R t GPD/ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Cons stence oun ary oo s Bed ,Trench ~ Q - (i (0 3 3 ~ ~\ w.r~ ~ I~.FCt ~. F ~. 6 ~Z. iz- y L I w` ~S .~ ' .~S t~tt ~ 2 ~ 6 ,~ ~ cis ~ ~ - L - Remarks: o I ~ s ~~ Zn.~~~-. ~~~ c.s - • ~ ~6 6 - s ~~ s - .~~~ °1.3.3 °t ~ l SOIL DESCRIPTION REPORT Page .~ of PROPERTY OWNER PARCEL I.D.# Boring # 3 Ground elev. ~~ft. Depth to limiting facto ~in. Boring # Ground ~ehev~.p~. Depth to limiting factor 1~ _in. Boring # Ground ele,~i. i `~ ft. Depth to limiting factor F~. Z9 in. Boring # Ground elev. ft. Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots ' 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench -11 b - ~^^5 © v~~ cs - ~-- ~ .~ 4~f- 39 ` Remarks: ~S-I o 6 - o ~ c.5 - ~ ~ ,~' r ' Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench v~ .~ Q nn Remarks: Depth to limiting ' factor 'n' Remarks: SBD-8330 (R.9/98) PAGE~OF~ NAME ~ (~ ~ (OUP LOT# 1 I LEGAL DESCRIPTION~IIcU '/~'/4,S iZ TZ9 ,N,R 7~! E (or~W SCALE• 1"- r BM I ELEVATION l b~' BM 1 DESCRIPTION'~Qo~ ~ ~ P~ P.OC ~a'F ~ ~/I`~u~ ~/---rte ~1 BM 2 ELEVATION q ~ - y l ~ ,. BM 2 DESCRIPTION ~~ ~ ~ Z~~~ ;~ Q ,Q~{~ ~~~ SYSTEM ELEVATIONV ppe ~ `r'~,3 y Gc3 w<C' `I-3~-3 ~ ALTERNATE ELEVATION u~®e.j1~/,0~ Ly~uer9~/~ CONTOUR ELEVATION .~/ ~~ Privat® Qf7site We~fte~water Treatment System Managemenanent .Septic Tank And Gravity in.Groufnd Soii Absorptrson Comp pursuant to Comm 83.54 Wis. Adm. Code ea ~~ ri$ for rttaintair~"tng the system w thin System IPOWTS} shall include (nformatian and prose the department, agent, the parameters of Comm 83 and ~, and the conditions of approval by or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. g4, Wis. Adm. Code, and the ln-Ground Th(s management plan complies with Comm 83, Sail Absorption Component Manual for Pr(vate Onsite Wastewater Treatment Systemsi SBQ- 1 tl587.R {R.6~S9}. Table 3: Maintenance Scnvau~e tns ct and/or service once eve 3 sera ln~saect once a year and mean at least once gate T-.nk The septic tank shall be maintained by a~i~ ~a~~ she( ~Qid~ osed of 1n ac~ordartce with under s. 281.48, Stets. The contents of the sep NR 113, Wis. Adm. Code (Servicing Septic or Holal egTrenct~ s,~Priv es~ar Pcrtabfe rs3ase intercepters, Seepage Beds, Seepage Pits, Seep g Restraoms~. The operating condition of the s and outlet fitter ~ ais ~ ~ sa sed at least ante every 3 years ay fnspecN~an. T e utfet~ t be removed unless prov ssAns are made to Groper open. The biter carMdge retain solids in the tank that may slough off the filter when removed from its anciasure. if the ,~Gi.atlEt", SI:iL.. C5f 1~V4~ ' ~ ~ Mound System Managamont Plan page 2 of 'r' Pursuant to Camm 83.34, Wts. Adm. Cade Th pflc~ k ohat3 b® maintalnaC by an ;ndeviduel carttiad to arvice iepttc tanks under [. ZSt,48, Stars. The cCntents of the eept~ tank shall ba dlapttad of in accordance wide NR 113, Wie. Adrn. Cade. The cporsting oendation at the apda tsnR and ouBst filter shat be assessed et least once every 3 years by Impaction. The ouwt t1Her aheA lee dasned as n~ee8ery ~ enaun proper aperatio:e. T'he fitter cartrtdga anould nOt be ramowd unless proviaione are made to retain saiida in the ttnk that may sough off the flltear when nxrroved from ire onctoaure. {t the filler is equipped with an tom. the ttttaar ainail be serviced If the alarm is actlvafed contlrtuoueiy, intarmfttent fllmr alarms may inaksa surge flown or en in+pendie,O oantiex+oua alarm. The eeptis+rink shall hew its c'vnterete rromoved when trie volurrN of sludge and scurrt in the taNc exceeds 1t3 the tqutd volume of the tank. if the OOntentas of the tank are not removed at tlee time of s triennial eerteaament, rnaintanance Personnel [hall advise the owner c+f when the next service needs tc be peritxmed to maintain Ieee than mexin+t-rr+ sr..rm end aludgs aoourttufsrbn in the oink. The eddkbn of blologicstl Or t.herrtlcal additlves to enhance atspt~ tank parfonrance erg Comment:. Sandy end Haurevsr, t# atxill products en used they ehait t» t~prawd for septic tank we 4t' the Departm Buliainga Dhriefon. e pump do.tnQj trtutk rhali be inepeoted at bast once avert' ~ yeas. Ar sw8oh.e, elarn+e. end pumps efislt t» feared b verity proper opentlon. If an affluent fitter hs +nataiwtr within the tank it er-eii be tnepected end senriGed as neoesaaN• o tree or should be pisnti On mound. Plantinge may be made e-cuntl the mound's perimeter, and the mound abet txi Neded and mulched as neceeaary to provent eroabn and to provide some prot-Odor+ from hoer penatra8an. Traffic (Other than for wpatatiw tneintanenae) on the mound b n8t raoornmendad alias soil conpeatian may hinder saretiar+ at the Inflltretlw eurfaq within 'the mound and snow COrnpaCddn in thr winter wEll promoW frost penetration. Cokf weather lnata6atlorta t~ber~ebruaryy dk~ate that the mound be haavYy muiehed for frost pretactlon. intlwnt quality Inba the meur!d system may not exceed ZZt3 mg~l. 8CQ8, 130 mp~l. 'rS$, and 30 ~~ FOQ. Influent lbw maY not exce4d maximum deai9rs flow spectNed ~ the permit for this lnetaliatlon, Yhi pn[wre dlatr~lfliOA tytlirm b ptoYltlad IlYtttt s AuahinQ poem at Vie srsd Of each lateral, alrrd k Ja rerarrtmende0 that oath lateral ba slushed of accumulated wilds at least ontx awry 18 moms. When a pressure testis perfomead It should be aort~pered tp the irtitlei rest when the system was lrtstdled `.0 Csterntlne ~ orifice clopping lies oecuRed end if arlfice ~eaninQ Ia requt++sd tD maintssi egt:al dietetbuflort within the dispersal oeff. Cba~vatlon pipes witltiin the dtspereritl cstl shell be checlcad tar effluent ponding. Pending teveia avail ba reported to me Ownsr. and any fevela above 4 inches eotuldered ae art impending hydrauUc fapwa r+lgviring eddttlOnel, marafregc:ant rn~tcrinp. ~tatn ahW be operated in aocordance with Comm 82.64 Wis. Adm. Coda, and shall rnainteinad in accordance with 3ta' component manual (S8f0.10872-P (fi. t31Sip)j and Iooel Or elate rules peetalning to system maintenance and maintenance ~~g• tVa one should ever enter a septic or pump tsnk etnGl dengeroua pease may be praaant that could cause deati+. 8epda and ppump ionic abas+danmetet shat bs in sCCO-dencs with Gomm 83.33, Wte, Adm. Coda when the tanks ens no Iorrpar wed a• PQ1k'~B corrtponeAte, Septic or pump tank manhole risen, aocaea riaara and oowra ahoufd ne lnepaated for water nghtneaa end soundnew. Access openinga wad tOr aerviq naafi aeweaalant shat! f~a sealed waterdght upon the aompiedon of servSCe. My apenk+il deemed unsound, dafactlw, or subject tv failure mwt be repleeed. Exposed accaea opaninga greeter then 8-inches in diameter shall t7e secured by an effective bdcirp device W prawnt sOCidental or unauthortaed entry into a tank or component. t~'tsi~ any Of its tx>mpaner.4 I»coma detectlw tl+a tank ar component shell ba ropairotl or nptaceo to keep the ayatent i!1 grapes operating Condition. If the doalnQ tank, Rump, pump Gorrttole, alarm ter related wlrirep becamas defeativa the dafactlve conepcnanl ahail be Immsdiatey repaired or ropiecad with s component: of the name ar equal perforn~tance. if the mound aete~ponent falls to aOCept wastewater or begins to diaCherga wastewater b the Around surface, it hdU fie rppesrad a: rapid In lid praaent bcatlon by IncreaeirlQ tai Ottla K boa IeakaQa octave or tril removG'tQ bioh~piCilfy Cio~ed adacrptian Anti dlsparaa! medfp, and stated piping, and repladrtp aid ~mponente ar dettutted necseaary to bring the ayetetn into pccpar opecatlrtg conditbn. Queationa an the operation or tnaiatenance ofthis ~ sy~C~effi should be . direatied to slim County Zoning office sit '1:g-3ldb- U6B 0 or to the lice.naed plumber w.ho installed, the s7stetre, . .- Menaplrrwnt Plan for ~ t3eptio dank and Soil Abearption Component Plantinpt of deep-rootsd test and sttruot dlractly owr of within ~ hat of the corn~nent should be avoided linos root Intnrslan ir~ta the oomponant may abttrud virattewater f40Mi• Continpenoy Plan !s~ the event a:yetem faHun, a new aystam could be installed in an alternate area. Wt~ ttre Inatalletlon al a dlvarter valve, the existing system rouid alto ba nosed after a period of three to lour years, rt is that property owners reipor'Etibility to nwintaln the •itKnate ana fiya frofr+ any ~~'+0 of tna, shrubs, etc. In care of failure of the aripinal tyttam, the alterrwte ana wl~ be Waded. tf any tress, thrubt~ etc, have been planted on the alwmata ana, they will hsw to be re~rwwd at propet#y owraen •xperlee. it aYttarnslrs •raa it destroyed, then an ether altemattw syateme that an be used, in whloh, oouid suit In added expanN to the properly owner. Any tank sbandonment shall be done in accordance with Wits Cads 43,33, Any quaetlont rspardlnp the code, pisses cu~tatk your ioarl Zonir~ Office or contact the inttalltnq plumber. • P~?'~1 P C CDLLOUA BLLRS, INC PHONE N0. 715 549 5911 Fib. 01 2001 07:33AM P1 s~~ caalx c~ulv~rY SEPTIC TANK MAINTEN~INCE AGRL'L~MENT AND ~ QW1 h,~ • OWNERSI~III' CERTIrICATIQN FARM OwncrlBuyer ~. ~ . ~Zi { ~ a~,n Q ~ ~ n 5 ~N ~ Mailing Address `rQ~ ~v • lt' d . ~' yu ,Su•v !,v ~ ,5 ~_v ~ Property Addreas ! Q ~~ ~ , ~, ` {Verification required !Torn Planning 1Jopar~rnnt for ra±w construction) City/Stato N~.~ ~ /~ _ ~Y~'1 j i ~m.ccl Tderitlt3caliott Numbc;r LEGAL D ~ IZ~c~nr Properly Location %, ~ %,, Scc. ~, T a~ N-R~W, Town of ~ - Sabdivisian ~ Lot ~ ,~. Certltied Survey Map # Voittmc .Page # Warra~tly Deed # ~ ~ ~ . 'Volume ~~, Page # ,~ ~ L---• Spec House p yes ^ no Lot liucs identifable~yes ^ no Sl'SZ'EM MAIN"rRx~NCt+' Impwper ttse and maltiteacwcc of your septic system could result in its grernature•faihue to handle wastes. proper taalntertaucc eonsisbt of ptttnpittg out the septio teak every thrzc years or sooner, if needed by a 1i=e~cd pumper. what you put into the system can affect the function of the =optic talc az a treatment stage in rho tiraste disposal system. Tha P~p~Y awuer agrees to submit to St, CroiSC ZaniAg Depati4nent a certification fotm~ signed by the owner. and by a ~t0t'Pr.3 phrrstber, Ycstricteti plwuber or a ticansed putuper verifying that (I) We on-site wastcwaterdisposal system is itt proper operating condition audlac (Z) alter inspection aAd pumping (if accessary), tht: segtic tack is less than 1/3 full a! sludge. Va'a, iltt: ttndcrri=aod boon read the above requirements gad agree to maintain We private sewage disposa! system with l}tc standards set fottlt, he:+ein~ sa Eet by the Departtneat of Commerce and the Department of Natural Resources, State of Wiscansio. Ccrti~cation Mating tta~t Your septic sya<ecn has been maintained must be co feted and rchrrned to the St. Croix Co ~ mP only Zoning Otftce wltttin 30 ex itati date. F APPL,I NT ~ ! l~/ 0 DATE OWNLR CERTIRI -ATI()ty certify that sil atatcmeata on this form are true to the best of my {our) knowledge: I (we) ant (are) the owrnt(s} of de abo by viKue o warranty decd recorded in Register of Deals Otnee. GNA OF APPLICANT ~ ~ ~~ DATE •'ee+t Any lnfocmatiott fluff !s mis-represented ma result in the sanity Y ry permit being mocked by the Zonins Department. ••'••• •~ Cnetude wltL ltt{a applteattan; a staaipcd wastauty decd fsom the Register of Deeds otrtae a copy of the certified Survey map if refetancc is grade in the warranty dead • STATE BAR Ol: WISCONSIN FORM 2 . !999 DbcumentNumber V'b'ARRANTY DEED This Deed, made between ,Tames A. Fisher and Rosemary F, Campbell, f/Wa Rosemarv F Fisher, both single persons, .---- Grantor, and P. C. Cotlova Builders, Inc., a Minnesota C~oratioa, ------~ Grantee. - ~~`-' Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St, Crotx State of Wisconsin (if more space is needed, please attach addendum):o~ty~ Part of West 1/Z of SE1;4 of Section 12-T29N-R19W described as follows: Commencing at the NW corner of said SE 114; thence E 763.1 feet; thence S 1980 fees; thence W 103.1 feet; thence SWIy to a point 165 feet E of the SW conger of said SEI;4; thence W 165 feet; thence N2640.0 feet to Flace of Beginning EXCEPT Lot S of Certified Survey Map recorded in Vol. 14 of Certified Survey Maps, page 3788 an Doc. No. 616755, St. Croix County, Wisconsin. Recording Area 618SI~gg KATHLEEN H. WAl_SH kEOISTEFt OF DEEDS ST. CkOIX l:d., WI RECEI4IED FOR RECORD OZ-~9-g000 2:a?4 PN E ~TT1 DEED (A (i FE~Em FEEe TRAIRO:ER FEEe 851.70 :IHB FEEe 10.00 Name and Rehun Address DAVID J. ESTREEN 304 LODUST ST. ;_al HUDSON, WI 54016 ozo-lots•7o.o00 & ozo.lols-vo-ooo Parcel Identification Number (PIN) This is not ~ Exceptions io warranties: Easc;ments, restrictions and rights-of--way of record, if any. 0I) (" not) Dated this y ~a'V'day of February 2000 w r AUTHENTICATION Signature(s) James A, Fiaber and Rosemary F. Campbell, f/Wa Rose .. I~'iaher, both elnale ~~~^~.,._ r day of February Z ~`, 00(1 STATE BAR OF tWISCONSIN authorized by § 706.06, Wis. Slats.) es A. Fisber _ • Rosemary iF. Cam bell, flk/a Roaem mestead property. F. Fisher ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. County ) Personally came before rte this ~~ day of . ~ the above named to me known to be the person(s) who executed the foregoing Instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY Attorney Kriatina O$iand '' u son, Notary Public, State of Wisconsin~~~~-'-~~ (Signatures may be authenticated or acknowledged. (loth are not necessary.) My Commission is permanent. {If not, state expiration date: Names of persons signing in any capacity must tx; typed or printed below their signature, ~ ) WARRANTY DEED STATE BAR OF WISCONSIN Mrorrt~amn Proh.sNx~els company, fax! eu lae, WI FORM No. 2 -1999 ~~' FROt'1 P C COLLOVFI BLDRS, INC PHONE N0, 715 549 5911 Jun. 2~ 2001 09:5~M P1 ~ ~ v, "- ~ - ~"'- ~~ 4 . ~ '\ s ~ ~ 636' ~; ~~ ~\ ~, ~ ~,~ •~ -' ''_~i _ ~ '`~~ ~~ ~, ~ 1 ~~ •~ , i, ,- A ~~ ~ ~ ~ f \~ ~ ~f ! ~ t~ ,~~ y~ ~ se 1 ' `I F E ~I.LN.. 10.0 r `~'' f . C- t' ~ ~' X 9187 ~, ~ / ~ / ~ / •.,ti ~ ~ , ~, ~ ~f ~ X 93 .3 ! ~r~ ~`C m t Q L- `- L ~.8/! ~. MIN UI I t ~/ • ~ 1 -1-'_._ '~ ..~_~ 4 ~ - ~.~ ~ i..i~~#3 ,~ m -. ~ ~ tl ~ ~ ' ~~ .~. ~,~ ~ ~'~., 1 y~ ;1 M ~U DIN ~r \, ' ~ / y i, ~ • e 30.0 . ~~ry ~,. [~'y~~'',.-_ ~ _ , _.~__ ~ j it ~`~ -..., r-..,,_' _ _ ~~ ~,: j X 922,8 _.,,,_. ~ 1i.iN.1... ~ 4COi'G~ilN f/ /~