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HomeMy WebLinkAbout020-1452-01-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Xion , Xao-Dee Hudson, Town of CST BM Elev: Insp. BM Elev: BM Descriptio~/ny:~ / c ~~ ~~t\ ~ t.s~7 ~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~ Aeration Holding TANK SETBACK INFORMATION TANK TO ~P/l~ WELL BLDG. Vent to Air Intake ROAD Septic S/ ~ i 1,/L / F ~ q~ ~1 V ~q 1 1 r Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Numbe TDH Li Friction Loss em Head TDH Ft Forcemain Dia. Dist. to well SOIL ABSORPTION SYSTEM ELEVATION DATA county: St. Croix Sanitary Permit No: 479242 0 State Plan ID No: Parcel Tax No: 020-1452-01-000 Section/Town/Range/Map No: 13.29.19.2889 STATION BS HI FS ELEV. Benchmark cl ` ~ /(~/•~ ~Qa A~BM~~ r.~ ~~ tt--cc ,,.~ Z. t, ~e 7 ~ B Bldg. Sewer 1Z ,41 q7, ~q , SUHt Inlet !3.9 9S_ 9 SUHt Outlet ~~ ~ ~' Dt Inlet ~ Dt Bottom ~ i Header/Man. ~ ~, 35 f `/~ c / 5 . T 7 Dist. Pipe r~..4~ I S ~ 3 ~( Bot. System /'~ 3 7 T Final Grade 9 `-7 /~ , St Cover ~ t ~~ ~ Z /~! ~ ~~ BED/TRENCH Width / Length C°L 0. Of Trenche.~ PIT DIMENSIONS No. Of Pits Inside Dia. liquid Depth DIMENSIONS ~ ~ ql Z (~'e~ ~ \ \ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufactura~„= ~ l y INFORMATION Type ~ ~ , ~' A J ~~ ~~' CHAMBER OR UNIT ~, ` ~ Model O ~~ J~ r O J~ ~ ~ \p DISTRIBUTION SYSTEM Header/Manifold ~ ~ Distribution Pipe(s) \ \ ` x Hole Size \ x Hole SpacirLq \ th ~ Dia Len Spacing 1 th ` Dia Len g g SOIL COVER v Prn~enro Cve-nma n.,i.. YY Mn~~nd nr of-Grade Systems Only Number. ~ V 2 Gc~, c~ %bd- Ve to Air Intake n`~ac ~~ e Z~ c Depth Over t nt d/T h C B Depth Over BedlTrench Ed es \ xx Depth of soil To xx Seeded/Sodded xx Mulc ed renc e er ~ r e g p \ ~es U No ~;" Yes [~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Location: 821 McCutcheon Road Hudson, WI 54016 (SW 1/4 NW 1/4 13 T29N R19W) Bluebird Meadows Lot 1 1.) Alt BM Description = ~~,e'~ C'~~~' ~~ ~Ot~Q.,1 2.) Bldg sewer length = $cJ -amount of cover = / a ~ Plan revision Required? [ ]Yes ? ~/ ~ O G, Use other side for additional information. _ u // Date SBD-6710 (R.3/87) Inspection #2: / / Parcel No: 13.29,19.2889 I~~ Sri Cert. No. ~I'~[~ anti buildings Division ~ ~ounzy ~ ` ,~ ~ 101 W. WYt rutt~tai true P.O. Box 7161, '~ Viueif 4', =7q7 - 716: ~ 5a,~utary Permit umbe~to fjlled in by Co.) /S+~O,/~S/~ ~~~) z Department of Commerce 7 Z~ Sanitary Permit Applicatio' EIV 1.D. N,nn>,>~e[rL In accord with Comm 83.21- Wis. Adm. Code. ,tersonai inhira7;ifinr; n " ` vide A~l~ ____._. .. ._.._... -_r._..__ may be used for secondary purposes Privacy Law ,>.ti4(t m) JuA' n ~ 9 1. ,ipplicution Information -Please Print AU lnfurmatiutr ~_ - - ST. C'~YO1VX [ Co i..r i Project ddress (if different than mailingaddr~ss) ~ ~Z~ ~Gt..vV°e.~eor` urv y ~ I'ropaYy Owners N am e / E Ntuce tf - Lot k Block $ ,, ~~ ~ Property Owner's M aiting AJdress Property Location / ,~~`!°-'~ ~'G ~o"t~'~ -,`~'',i~ City, S tate ~ Zip Code; ~_'~~~ !'hone Number ,5~._ ~/,, ~((yL._%y Section _..~3 ._._ ~ ~ ~'- "._ ' ' '1' ~ N; R B o Il. t ype of $uilding (check all that apply) i ~~ ~k aD (~ 1 or 2 Family Dwelling - Number of Bedrooms Subdivtston Name E'9M-Number ~~ ~~ PuolielCommercial -Describe Use _ [ f CJ State Owned -Describe Use ~~_~- (P~ LS L-~~ 7 2 ,~.. 7 Z (~City_[~ Vill e~ownship of l II. 'Type of Permit: (Check only one box ou Imp A. Complete line 13 if applicable) A. ~ -r--- ....~__ i ~ New System l hJ Replacement Systur i. J "1'reauncnt, i [c: twn~ Tattle Replacement Only ^ Uther Modification to Existing System ~• ^ Permit Renewal ~ PermiC Revision I ~ Change of ! ~ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration ~ Plumber !Owner i IV. T to of POWTS S stem: (Check sll that a r ~I ~ ~ ___ Nv7i -Pressunzed Cn-Ground ^ Mound > 24 in, of suttuvlc soil J tvIound <24 in, of swtable soil ~J Ht-Grade l~ Single Pass Sand Filter 0 C:msu~,cWd Wetland l-i I'russunicd ln-Ground C. w luldwg'I'ank l I'4;u Filter ^ ACrol)iC'Prwtment Unit ~~ ltoclrculttting Sattd Filter ^ i i~ 'arculaUng SynU,vhc Nlcd,u I~iitcr ~l,e:uchu~~,,u,;cc, (~ Drp ,.u,.: ~..J Gravel-IC9S Pi ^ Olher (explain) V . Dis ersuUl'reatment Arcu Information: Design Flow (gpd} Design Suil Application Rate(gpdsi j Dispersal Arca Itequired (sf) Dispersal Area Proposed (sf) Syatotrt 8levation . +. ~~ e? a VI. Tank Info Capacity in Total ~ Number anufacturer ~ Prefab Site Steel Fiber plastic Gallvns Gallons i ufUnits Concrete Constructed Glass New Existing "I'milcs .Tanks '. Sepuu or Holdi.tyq lank ~ ~i--~-'-"+'"-"" ~ ~ ' / Aerob,c Troaunent Utur Dosmu Chamber .,..+.,. -..----r-. ---t--_ ~_ _ __ , -*-- - VII. Respo sibility Statement- I, the undersigned, ssume responsibility for iastallatioa of the POWTS shown oa the attached plans. i'lumver's ame (P ' t) c ,Plum is Si at ~ MP/MPRS Number Business Phone Number I r ' j i (uanber s Add s (Street, City, 'talc, Lip ode ~ _.__ ~_~~ ~^ ~ VII ,nun /lle rartment Use Onl HNNruvcti ~ ~; tyi r `?anitary Permit 1's;u tincludas Groundwater Date ssu Issuing tSigtlatutq ' ,,1s;?ttuge ~ ee r ~ ~J t) "van iteason or Denial 3~ ~ l~ ~ ~o (~5 lX. Conditions of Approval/Reasons for Disapproval -' SYSTEM (71AINER: ~ 7i I /~ ~>>.. i~ct~ti /WJw~ ~ ut : m. Q pn 1. Septic tWtk, eAM~tt fNter and ~ r - i ~ ' dispersal cell must all he services / nta~r,.d pY i ~; ~~~' a'~-. a - 3 ~, t as per management plan provided by pktmbar. 2. AU setback requirements must be maintained J i as per applicable code /ordinances. Attach complete plans tro the County only} Tor the system vn paper not kes Wan 81/2 x t 1 inches in sis<e ' `~ ~t3D-639 (K. O1/U:S) X,~ ~-,~~E. x~~~ /~s3 vl~ov~ ,9~~ ~~~°~~ /~lrl~ ~i~~ ~~se~ ~~.y, ~~ ~ ~-~~~ y~ ~~_ 378' /}-~~'s 11 Wit/ asp ' ~.G~ ~ ~~ ~ ~~ X,9~ d-,t~rE x~©,~~ -~ .sue%y-,~/~J%y - sEc /.3 - 7~ 9it/- ~l9uJ aroSeoJ .,~ ~B~//~~~~ ,rv.~:/ ~,~ ~'~ -.{L /795 A ~~~,~,~ ~~ /=yo s~~ 33 .aml-~ /ma s<~,Q ,~2~y~ ~ T ~~.~.~,rs ~E/~s- ~ .3X~i ~~ ~~~ 378' ~~~~ ~~~ ~~ 1~}~ o?S-3 ' COPY ~~8 ~ °~~g ~~pf Wisconsin Department of Commerce $~~ 0 ~ ~ Page ~ of~ Division of Safety and Buildings R m accaraanr~ vwm nor n o~, vvis. Twin. ~.vuC ~ ~ ' Attach lete site lan on er not less than 81/2 x 11 inch m ao in size nas~ 2 s p p pap co ~~ indude, but not limited to: vertical and horizontal reference point and M), dir~ Pa I.D. percentslope, scale ordimensions, north arrow, and location and istans~ CQ~N~ F c _ p . Please print all information. ~iyGOFFIC ZO N by Date Personal Information you provide may be used for secondary purposes (Pri 5.04 (1) (m)). ~ ~~ 0 Property Owner Property Location ~ Govt. lot 1/4 1/4 T 9 N R ~or) W P party Owner's Mailing Address Lot # Bio # Subd. Name or CSMIi City State Zip Code Phone Number ( ) City Vllage Town Nearest Road " New Construction Use:, Residential / Number of bedrooms Code derived design flow rate l~ GPD ^ Replacement ^ Public/ or commeraal -Describe: Parent material -~,~ ,~l-„i,~~ Flood Plain elevation if applicable ft. General comments ~ , ~ ~~ / !~ _~ and recommendations: sq~;•., ~~ ~'" a'f- (~7 / Boring # ~ Boring ®Pit Ground surface elev. _ tt. Depth to limiting factor ~ in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fl? in. Munsell Qu. Sz. C t. Color Gr. Sz. Sh. *Ef#k1 *Eff#2 q 4 s ~ S' s a 9 4 9 Boring # ~ Boring / Pit Ground surface elev. _~~ ft. Depth to limiting factor _~1~~_ in. ~/ Soil licaflon Rate Horizon Depth Dominant Color Redox Descxption Texture Structure Consistence Boundary Roots GP D/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 `Efi#2 3 -3 ~ D ~! 4 ° t m ~~ _ ~sw > ;iu < ~u ngn. ono r s~ >3tr < ~ 5u mgn. nt ~ = is < 3tr mgrs ana i ~ ~ su mgrr_ CST Na P ' ) ' Signature CST Nurnber Addre s Date Evaluation Conducted Telephone Number '~'~ s _ _ Properly Owner _ ~~~ .~"E ,~/~~.1 G~ Parcel ID # Page ~-~ of ~_ ^ Boring # ^ 8oring pit Ground surface elev. ~_ ft. Depth to limiitirrrg factor.>~~ in. Soil liption Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/f~ in. MunseN Qu. Sz. Corrt. Color Gr. Sz. Sh. "Eff#1 "EtT#2 9 R a a ^ Boring # ^ Boring ^ pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fl? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 "Etl#2 ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Stnuxure Consistence Boundary Roots GP D/fF in, Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 "Eff#2 "Effluent #1 =BODE > 30 < 220 mgll. and TSS >30 < 150 mglL "Effluent #2 = BODE a 30 mglL and TSS < 30 mglL The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-$777. 9BD-8330 (R.07/00) ~.,~. X~ ~ ~~~ xJO~~ /~s~ d1~o.~,~ ~~t ~`~ ~u ~l~lii/ ~``s,~G ~~~~~ ~~e~~ I ss' ~i ~ 3G' BO ~- ~'e~ ~ ~ je/tJ4 7a ' ~~-E~c \. \~ i C.fe1~a lZ ?aP~-8,n :~- ~'ra 'I .~ sB~c~/ iy/~i~?- .d,,c l :~ ~~~ /o/-- ,FC JQ~7 9s- ~ ~.`~ ,~.~,~.s /l=y~'s~~ -~3~DS~~ 3r8' ~©t ~ 3 ~ /~/,~,~ c~/ % ~N1yl aS3 ~®t ~" ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~~ C~ ~ ~ ~ ~! ~r'1- Mailing Address ~ l~~ l~'Q'~v t'T~ ~- ~C.~A,~ '~~ ~~ b Property Address ~ ~~l ~, (V`erification required from Planning Department for new construction)~`~ City/State ~t ~~1 ~~ ~ Parcel Identification Number 6 ~- l ~5 Z - 0 / -- ~~ LEGAL DESCRIPTION Property Location S ~ '/,, ~ '/,, Sec. l,3 . T~N-R~W, Town of Subdivision 0~ Lot # i Certified Survey Map # Volume _, Page # Warranty Deed # ~ q~~ ~~ .Volume Z~ ~ Page # 3 d ~ Spec house ^ yes ~ no Lot lines identifiable,t~ yes ^ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewaterdisposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than I/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 tlce 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 f th ee y ar ex iraNon date. / / SPC A A DATE OWNER CERTIFICATION I (we) certify that all statements on this force are fete to tlce best of my (our) knowledge. I (we) am (are) the owner(s) of the prop Ascribed above, by virtue of a warranty deed recorded in Register of Deeds Office. / /' d G A C NT DATE ***** Any information that is mis-represented may result in tlce 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 POWTS OWNER'S MANUAL & MANAGEMENT PLAN,...,. Pape~„ot~ FILE INFORMATION Owner ~~~ ~d7E~• Ysvdl~' Permit # DESIGN PARAMETERS Number of Bedrooms Q_NA Number of Public Facility Units ANA Estimated flow (average) al/da Design flow Ipeakl, (Estimated x 1.5) ai/da Soil Application Rate al/da /ft2 Standard Influent/Effluent Quality Monthly average " Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/l_ ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODE) 530 mg/L Total Suspended Solids (TSSI 530 m~/L ~l NA Focal Coliform igeometric meant 510° cfu/t00rnl ~Maximum Effluent Particle Size Ya in die. Q NA Other: p NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPeC:IrltiH r wrva ~ Septic Tank Capacity ~ ) al ^ Ni' Septic Tank Manufacturer =~ ^ N' Effluent Filter Manufacturer ` ~`` •`• ^ NFL Effluent Filter Model - ^ Nl; Pump Tank Capacity al ~NH ~ Pump Tank Manufacturer ~B. N! Pump Manufacturer ANA Pump Model ~ ~Fi I Pretreatment Unit ^ Sand/Gravel Filter O Mechanical Aeration ^ Disinfection ^ Peat Filter O Wetland Q Other: ~' 1 Dis areal Cell(s) p In-Ground (gravity} ^ At-Grads ^ Drip•Lina ^ NF' ! O In-Ground (pressurized) Q Mound Q Other, Other: ^ Nf~ Other: Q NA Other ^ NA MAINTENANCE SCHkuuLt 7 Service Event Service Frequency inspect condition of tank(s) At least once every: ^ month(s) " (Maximum 3 years} ,~' earls) •~ ^ NA Whan combined sludge and scum equals one-third (Y,l of tank volume DNA Pump out contents of tankls) Inspect dispersal cell(s) At least once every; ~ month(s) `` ` (Maximum 8 years) j~ year(s) Q NA ._i ^ monthta} ^ Nt•. Clean affluent filter At least once every: ~ year(s) _; ^ monthlsl ,INF. Inspect pump, pump controls & alarm At least once every: ^ ear(s) _ Flush laterals and pressure test At least once every: O saris) caner: At least once every: O monthta) p earls) j~NA 0thor. (7 NA MAINTENANCE INSTRUCTIONS inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer, Septage Serviaing Operator. Tank inspections must include a visual inspection of the tankls) to identify any missing or broken hardware, identify any oraoks or leaks, measure the volume of combined sludge and scum and to check for any baok up or ponding of effluent on the ground surface:, a"he dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to cheek -for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing oondition and requires ttr~ immediate notification of the looal regulatory authority. When the. combined accumulation of sludge and scum in any tank equals one-third (Y,1 or more of the tank volume, the entire contents of the tank shalt be removed by a Septage Servicing Operator and disposed of in accordance with Chapter NR 113, Wisconsin Administrative Code. ' "' " ~ r All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWT5 Maintainer, A service report shall be provided to the local regulatory authority within 10 days of completion ofi any service event. t3MW larv ~ . :~..~. Page ~, of ,~ START UP AND OPERATION . For new construction, prior to use of the P.OWTS check treatment tank(s) for the presence of painting products or other chemicals ti~at may impede the treatment process and/or damage the dispersal cell(sl. 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 era frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwatar levels. When power is restored the excess wastewater will by discharged to the dispersal cell(s- in one large dose, overloading the oell(i) and may result ln•tfN bwkup M sutfllos discharge o1 effluent. To avoid this situation have the contents of the pump tank removed by a Septaga Servioin~ Operator prbrao rostorin~ 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 arv~ 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 thy 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 lie 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 shah be disconnected and the abandoned pipe openings ealedi,.r, ..~;? • The contents of all tanks and pits shall be removed and properly disposed of by a Saptage .Servioing Operator. • After pumping, ail tanks and pits shall be excavated and removed or their covers remgVed aftd the void space filled with soil, gravel or another inert solid material. CONTINC3ENCY 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: ;.g:;~-r ~ ;~ ;,,,, .. .. , ^ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soft absorption system. The replacement area should be protected from disturbance and compaction and should not be Infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitably replacement area. Replacement systems must comply with the rules in effect at that time. ^ A suitable replacement area is not available due to setback Arid/or soil limitations, Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS.-~--~-~-~~- ~ --•- - O 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 OXY4EN. 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 DIFFICU4T OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLE _ POWTS MAINTAINER ~.~ ''" t~r'~^:!}~~.:~ \.:~~h> „ ,~ Name Name ! Phone / --_ _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name .~~:• Phone ~~~ >_ ~, ti ,.,;, this document was drafted in oompliance with chapter Gomm 83.22(2)(b)(11(dl&(fl and 83.64f 11, (Zi & (3i, 1Msoonsir- Administtatlve CoQe. U. 2 7 7 y P 3 0 1 79~~~~ ~~ KATHLEEN H. wALSH State Bar of Wisconsin Fotm 2-2003 REGISTER OF DEEDS WARRANTY DEED 5T. CROIX CO. , wI RECEIVED FOR RECORD Document Number Document Name 03 /31 / 2005 10 : 00AM WARRANTY DEED E71Eh~'=. THIS DEED, made between LaCasse Development, Inc.. a Wisconsin Corporation REC FEE : 11.80 TRANS FEE: 254.70 ("Grantor," whether one or more), COPY FEE CC FEE: and Xao Xione and Dee Thao, PAGES : i ("Grantee," whether one or more). Recording Area Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant Name and Return Address interests, in St. Croix County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): Lot 1, Plat of Bluebird Meadow in the Town of Hudson, St. Croix County, Wisconsin. n ~ 1 f1 t-- /1 C _I7 r 2~ Psrt of OZO-1017-30-000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Exceptionsto warranties: Enasements, restrictions and rights-of--way of record, if any. Dated ~ ~~~ -V~ /~ ~ * *L Casse Development Inc. (SEAL) (SEAL) * AUTHENTICATION Signature(s) authenticated on TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by Wis. Stat. § 706.06) THIS INSTRUMENT DRAFTED BY: ACKNOWLEDGMENT STATE OF~JV.~-- ) ~' I r ,, ,mil ) ss. l ~Tc,V~lJ 1~ COUNTY ) Personally came before me on~r)~~J_J/ the above-named Casse Develo went Inc. a Wisconsin Corporation ,~_ fL to me lgtown to be the pe on(s) who executed the foregoing instru nt and aclcaow dee the same. Attorney Kristine Os:land _ Hudson, WI 54016 Notary Pu~c,'State of U/~! My Commission (is permanent) (expires: (Signatures msy 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 ®2003 STATE BAR OF WISCONSIN FORM NO.2-2003 * Type name below signatures. , - INFO-PROTM Legal forms 800-655-2021 www.intoproforms.com y~ ~a ~6 ~k,~~ l®~ ~~ ~ ~ las a~~ ~,~~?i'`-G~ ~ ~ , r' /~~`-'K ~~~ ra ~ v ~a:~ ac~~a~~aoc ~~, dap Cd1~ n d - - +1 "+-l~ i~ +Nn ME OF E -------- '' x °' sw~ia of r~ w~ia '~ ._._.~._ O o ~ 2••E 1 x .X x --- x Boa-~ x ~. j _..,~ i N M~ ~ ~ O!O!! ~ .d. ~ ' Z. II • ~ ~ .r ~7 ~ N -~~ o • I y a~ `~ `~ / ~ ~ ° ~' ~ x Q ~~, J ~ '' ~i p i i/ ~ ;: _ ~• ~ ~ r ~ ~ t0 d ~ ~O~ / ~ 1~ o • ~ ~ ~ x~ o d. o, ~ ~ a- I h ~ n e~ ~ ~ ~0 tai ~ N N X ~ ~ N ~ I h ~ ~} N '- ~ d' I ~ o X °' . / ~~ I ~ ~ 3 [~,~ x '/ ~, I. _ ~ ~°' •E• ~ xo ~~ 0 .: , .., .........' - , 7 1Tp~ ~ ~ ~ ~ ~ ~ . ._w. WIESER cunenEr~ www.wieserconcreie.com ~'©Q~.~/ . ~y ~s1 ys .~~... ~~ ~~, o f ~~ ~~' G~~ k i9. ~ _ ~~g, ~ ~~q //. 4 ~~ l sq©,~ -.~ X9y . ,~~d ~l ~'~~s ~~~ ~ ~~ C~l ~s Maiden Rock, WI (800) 325-8456 Portage, WI (800} 362-7220 Fond du Lac, WI (800) 641-5937 Spooner, WI (800) 336-3416 Parcel #: 020-1452-01-000 Land Improve Alt. Parcel #: 13.29.19.2889 020 -TOWN OF HUDSON Current ' X I ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 10/06/2004 00 0 Tax Address: Owner(s): * =Current Owner * XIONG, XAO XAO XIONG THAO, DEE DEE THAO 1653 LEONE AVE ST PAUL MN 55106 Districts: SC =School SP =Special Property Address(es): * =Primary Type Dist # Description * 821 MCCUTCHEON RD SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.140 Plat: 10/34-BLUEBIRD MEADOW 020/04 LOTS 1/14 SEC 13 T29N R19W PT SW NW BEING BLUEBIRD Block/Condo Bldg: LOT 01 ' MEADOW ( 04) LOT 1 (3.140AC) Tract(s): (Sec-Twn-Rng 401/4 1601/4) 13-29N-19W SW NW Notes: Parcel History: Date Doc # Vol/Page Type 03/31/2005 790909 2774/301 WD 08/20/2004 772236 2641/399 WD ~nn~ ci ~nnnneQV Bill #: Fair Market Value: Assessed with: Valuations: Description Class Acres 0 Totals for 2005: General Property Woodland Last Changed: 03/07/2005 Total State Reason 0 0 0 0.000 0.000 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category 06/10!2005 11:30 AM PAGE 1 OF 1 0 0 Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 1481 ~~ Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 ' Division of Safety and BulldlllgS , in accordance with Comm 85, Wis. Adm. Code Steel's Soil Service, Inc. County , ' Attach complete site plan on paper not less than 8%: x 11 inches in srze. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM}, direction and parcel LD. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Pending Please print all information. Reviewed By Date Personal information you provide may be used for secondary purposes (Pdva;.y l.aw, s. 15.04 (1) (m)). Property Owner Property Location LaCasse Development , Inc. Govt. Lot na SW 1/4 NW 1/4 S 13 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 573 Cty Rd " A" 1 na Bluebird Meadow City State Zip Code Phone Number _ {City ; J Village Town Nearest Road Hudson ~ WI 54016 715-381-5405 Hudson McCutcheon Rd _/_ ;New Construction DSe~ ~~ Residential /Number of bedrooms 4 Code derived design flow rate 6UU l Replacement I Public orcommercial -Describe: Parent material Sream terraces and pitted outwash plains Flood plain elevation, if applicable na General comments and recommendations: Conventional system, system elevation 101.95ft. Trenches spaced and depth to code 3025ft below grade. uru Boring # .~ Boring Pit Ground Surface elev. 105.20 ft . Depth to limiting factor 100 in. Soil Application Rate i i tu T Structure Consistence Boundary Roots P D~ Horizon Depth in. Dominant Color Munsell pt on Redox Descr Qu. Sz. Cont. Color ex re Gr. Sz. Sh. *Eff#1 Eff#2 1 0-5 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 5-13 10yr4/4 none sicl 2msbk dfr cs na .4 .6 3 13-24 7.5yr4/4 none sl 2msbk dfr cs na .6 1.0 4 24-71 7.5yr4/4 none ms .osg ml cs na .7 1.6 5 71-100 7.5yr4/6 none cos osg mf na na .7 1.6 ^ Boring # ~ Boring /~ Pit Ground Surface elev. 105.20 ft. Depth to limitingfactor 100 in. Soa Application Rate Horizon Depth in. Dominant Color Munsell Redox Descdption Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary R0°~ 'Eff#1 P D'ft"Eff#2 1 0-8 10yr3/1 none sil 2msbk dfr cs 1vf .6 .8 2 8-18 10yr4/4 none sicl 2msbk dfr cs na .4 .6 3 18-30 7.5yr4/4 none sl .2msbk dfr cs na .6 1.0 4 30-71 7.5yr4/4 none ms osg ml cs na .7 1.6 5 71-100 7.5yr4/6 none cos osg ml na na :7 1.6 'Effluent #1 = BODs> 30 <_ 220 mglL and TSS >30 < 150 mglL `Effluent #2 = BODS < 30 mg/Land I s~ <su mgrs CST Name (Please Print} Signatur : CST Number David J. Steel ~ 248956 Address Steel's Soil Service, Inc. Date Evaluation Conducted Telephone Number 994 200th St., Baldwin, V41154002 8/20/2004 715-684-5680 ~ Property Owner LaCasse Development , Inc. Parcel ID # Pending Page 2 of 3 Boring # - Boring /; Pit Ground Surface elev. .101.00 ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 'Eff#1 *Eff#2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 1 0-4 10yr3/1 none sil 2msbk dfr cs 1vF .6 .8 2 4-17 10yr4/4 none sicl 2msbk dfr cs na .4 .6 3 17-30 7.5yr4/4 none sl 2msbk mfr cs na .6 1.0 4 30-64 7.5yr4/4 none ms osg ml cs na .7 1.6 5 64-100 7.5yr4/6 none cos osg ml na na .7 1.6 Boring # ~} Boring j Pit Ground Surface elev. ft. Depth to limiting factor in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture. $trudure Consistence Boundary -Roots in. Munsell Qu. Sz. Cont. Cotor Gr. Sz. Sh. *Eff#1 *Eff#2 Boring # ~ Boring ,~ Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz: Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots *Eff#1 *Eff#2 * Effluent #1 = BODS> 30 < 220 mglL and TSS >30 < 150 mg/L * Effluent #2 = GODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. if you need assistance to access services or need material in an alternate format, please contact the devartment at 608-266-3151 or TTY 608-264-8777. Page 3 of 3 L ' • STEEL'S SOIL SERVICE INC. 994 200 St. David J. Steel Baldwin, WI 54002 CST-POWTSM LaCasse Development, Inc. Bus 7i5 684-5680 Lic. #248956 sWl/4,NW1/4,S13,T29N,RI9W Fax (715) 684-3449 ~1 Town of Hudson, St. Croix Co. Bluebird Meadow, Lot 1 This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of this test may or may not be as shown; as permanent lot lines were not established at the time the sail test was conducted. Legend 1"=40' • =Benchmark Ele. I OO.OOFt Top of 3/4" pvc pipe ~ =Alt Benchmark Ele. I OO.SOFt Top of 3/4" pvc pipe ^ =Borings Boring Elevations B 1 = l 05.20Ft B2 = 10520Ft B3 = 101.00Ft B4 = OO.OOFt ~~ ~~ ~-o "`'~ ~.. i ~- ~ --- ~ .~ ~ r, ~i ~ x ~ ; I i X X 1QQ'--F: X csi l o . ,~ i ~ i o~ Zn "' ~ ~ m .i N ~ ~ I ~ ~ w v '~ ~ x a ~ I I t ~ ~- ' ~' ~ v `~ ~ ,..~ ~' ~ : ~" ~ i ~ a r : M N m ;. ~ i ~ .. .i e~ ~ ~ tai ; X 'DO s ~ ,; ! ~ a' O ~ ~ ~ v ~ a . ~ Oro .. a 1 ~ ~, ~ ai , i i ~ ~ f ~ ~ ~o ~ ~ .~ 1 X . ' T 170' ~ - ~ 8T ~ ~ M ~ O W~ ~ x r:.~ '. / 4 it -k m is .i '"rf N i! !~ ~ . ~ a its ao °' ~ ~ H ~r x ~ ~ t+~ N , ~z n ~ ~ :x~ ~a N ~ ~ x ' ~ ~: ~ l 7/ SOIL EVALUATION REPORT in accordance with Comm 85. Wis. Adm. Code 1481 Page 1 of 3 Steel's Soil Service, Inc. County pl p paper not less than 8'/: x 11 inches in s¢e. Plan must Attach com ete site Ian on St. Croix include, but not limited to: vertical and hor¢oMal reference point (BM), direction and Parcel I D percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. . . Pending Please print all Information. 1e,,,~ gy Date Persons information you provide may be used for secoridary Pins (Privacy Law, s. 15.04 (1) (m)). ~ . / Property Owner ., '1 ~ ~ ~ w ~v ~ ~ Property Location W I LaCasse Development , Inc. ~ Govt. lot nor SW 1 /4 NW 1 /4 S 13 T 29 N R 19 Property Owner's Mailing Address g Lot # Block # Subd. Name or CSM# 573 Cty Rd " A" ~~ ~ ; ~~- : k ~ ~ ~~ ~ 1 nor Bluebird Meadow City S to Zip Code Phone Number J City J Village ~ Town Nearest Road Hudson ~ I 5Ai0t6~ -~!r ~4t3+381-540 Hudson McCutcheon Rd HIV! .J New Construction Use: ~/ Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement ~ Public or commercial -Describe: Parent material Sream terraces and pitted ouiwash plains Flood plain elevation, if applicabl6~ 11 2 ~ General comments ' ' J and recommendations: Conventional system, system elevation 101.95tt. Tre es spaced and dep h to cod 02 below grade. ~ ~- ~ Boring # J Boring 100 in. Soil Application Rate Pit Ground Surface elev. 105.20 ft. Depth to limiting factor Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fP in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-5 10yr3/1 none sil 2msbk mfr cs 1f .6 .8 2 5-13 10yr4/4 none sicl 2msbk dfr cs nor .4 .6 3 13-24 7.5yr4/4 none sl 2msbk dfr cs nor .6 1.0 4 24-71 7.5yr4/4 none ms osg ml cs nor .7 1.6 5 71-100 7.5yr4/6 none cos osg ml nor nor .7 1.6 J o/• 9S Boring # :J Boring 1I Pit Ground Surface elev. 105.20 ft. Depth to limiting factor 100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft2 in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-8 10yr3/1 none sil 2msbk dfr cs 1vf .6 .8 2 8-18 10yr4/4 none sicl 2msbk dfr cs nor .4 .6 3 18-30 7.5yr4/4 none sl 2msbk dfr cs nor .6 1.0 4 30-71 7.5yr4/4 none ms osg ml cs nor .7 1.6 5 71-100 7.5yr4/6 none cos osg ml nor nor .7 1.6 `Effluent #1 = BODS> 30 <_ 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TS5 < 30 mg/L CST Name (Please Print) ignature: CST Numt~er David J. Steel __ 248956 Address Steel's Soil Servi c. Date Evaluation Conducted Telephone Number 994 200th St., Baldwin, WI 54002 8/20/2004 715-684-5680 Wisconsin Department of Commerce Division of Safety and Buildings Property Owner I-a~sse Development , Inc. parcel 1D # Pendi Page 2 of 3 Boring # ~ Boring 1/ Pit Ground Surface elev. 101.00 ft. Depth to limiting factor 100 in. ~{ Application Rate T t Structure Consistence Boundary Roots PD Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color ex ure Gr. Sz. Sh. *Eff#2 *Eff#1 1 0-4 10yr3/1 none sil 2msbk dfr cs 1vf .6 .8 2 4-17 10yr4/4 none sicl 2msbk dfr cs na .4 .6 3 17-30 7.5yr4/4 none sl 2msbk mfr cs na .6 1.0 4 30-64 7.5yr4/4 none ms osg mt cs na .7 1.6 5 64-100 7.5yr4/6 none cos osg ml na na .7 1.6 ^ Boring # ~ Boring Jj pit Ground Surface elev. ft. Depth to limiting factor in. Sod Application Rate i ti d D T t Structure Consistence Boundary Roots PD Horzon Depth in. Dominant Color Munsell escr p on ox Re Qu. Sz. Cortt. Color ex ure Gr. Sz. Sh. *Eff#1 *Eff#2 ^ Boring # ~ Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PD in. Murrsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5> 30 < 220 mg/Land TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151. or TTY 608-264-8777. I 7 x i- ' N p 0 ~ N X; I 'P ~ v I• ' N w ~ ~ ~ r I. x i O N t0 rn ~ h n N g6 ~' ~ L ~., W ~; ~ n ~ ~ r ~. J j X °~ m w I '" N ~ €~ l f~ ,l ' © ~ ~ tin o N X ~ o~ co I ~d o r o, I r r ro i N N V ~ ~ w ~ r I 0 n I ro • ro N ~ ( 1 x ~9 r ~ .. r -~ ~, N w . r~ ~ a ~ -~~ ~ ~ ~ '` ~ ~ ~ !! a m x m J I :. ~ / ~ ~ ~ ~ i- ~~ ~ ~ ~ ~i ~ `° b I ~. X ~+--A06 X x X + V