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Home My WebLink About020-1452-04-000Wisconsin Department of Commerce Safety anU Building Division PRIVATE SEWAGE SYSTEM 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 LaCasse Develo ment Hudson, Town of CST BM Elev: ~ Insp. BM Elev: o BM Description: ~/~ ~ D D - ~ Q . ~ TANK INFORMATION TYPE MANUFACTURER CA PACITY Septic v~, ~ ! / ~Y.~/~~/ / ~,2 ((/ D Dosing 0 (~ ~ Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic 3~' ~~ 3l~ Dosing Aeration __ Holding Pl1MP/SIPHON INFORMATION ~~ 1 //~1.~~ Manufacturer Demand GPM Model Number TDH Lift Friction Loss Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM L BED/TRENCH Width ~~ Lengt~ / DIMENSIONS ~"~,' INFORMATION IBUTION SYSTEM LDG O I JV ELEVATION DATA county: St. Croix Sanitary Permit No: 488054 0 State Plan ID No: Parcel Tax No: 020-1452-04-000 Sectionlrown/Range/Map No: 13.29.19.2892 STATION BS HI FS ELEV. Benchmark~~ / ~ ~ l~7 ~D~ 1 ~ Alt. BM ~ ~ O"a o ~ ~ Bldg. Sew ~~ Z~ ~~ ~~.~~ t Inlet ~O~ / ~~~ Z ,p~ / b I~ 7 S Ht Outlet z- y' Dt Inlet ~r ~ Dt Bottom eader/ an. ~ ~ ,~+ Dist. Pipe ~ ! Y G(.,¢. / 3.~ 9 . ~~ Bot,--stem ~ ~'/'3.3~ Final G~~ ~ % (t.. ~~ ~ .0 DO ` St Cover l c~~s ,~ ly -r.o f s ~ ~aa' ~f~' ~' d Pits CHAMBER ., - Inside Dia. Liquid Depth Mang 7 ~ n Model Number: [~ ~.-, .~~ m Heade anifol~i Distribution / Pipe(s) (_ 'f x Hole Size x Hole Spacing ~-_'""_ Vent t~ e~ h D acin th Dia S L ia Lengt g p eng cnu rn\/Fv . n-~..~...... C....a....-.. A..1.. .... 11A.,..n.d Ar A4_Rr~riu RveTeme only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil I, Yes ij No Yes ~ o COMME 941SSadl es Laerl9,e Hudsonr WI n54016 (SW 1/4 NW 1/4 13 T29N R19W) Blutebird Meadow/~7~/7/~/ 1/ InsPartcel No: 13.29.19.2892 / t'( 1.) Alt BM Description = 1 app '7 ~~ ~~'`/ ~~ ~~ 2.) Bldg sewer length = ~~ ~ ~ ~i.(-l~ ,( ,~ ~~~~ DFZ~ - amount of cover = ~ y ~ ~ ~ tX(15~' Plan revision Required? (~ Yes ~'-x~o - L Use other side for additiona't'Tnformation. °?~ d b S J ~ Date Insepctor's ignature Cert. No. SBD-6710 (R.3/97) Safety and Buildings Division County ` m m 201 W. Washington Ave., P.O. Box 7162 ~seons~in Madison, WI 53707 - 7162 Sanitary Permit Number to be filled in by Co.) De artment of Commerce (608)266-3151 a Sanitary Permit Application State Plan I.D. umber In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ~ A may be used for secondary purposes Privacy Law, s15.04(ixm) Project Address (ifdi nt than mailing address) I. Application Information -Please Print All Informatio p C ^ C ~ ~~ Property O er's Name Parcel # Lot # Block # - JAN 2 ~ 2006 Property Owner's Mailing Address property Location ST. CROiX COUNTY ,~ ~ y City S Zi Code '•%KkL~-~•. Section /-~ , p 1~ " ~ ~ Type of Building (check all that apply) N; R f E ~1 or 2 Family Dwelling - Number of Bedrooms Jr!v/ ~a-~L~ ~ Subdivision Name ~dmitl7er - ^ Public/Commercial -Describe Use ` ~ ~ ^ State Owned -Describe Use ^City ^Vill ownship of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) `~' New System ^ Replacement System ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System B• ^ Permit Renewal Permit Revision ^ Change of ^ Permit Transfer to New ~~ Previous Permit Number and Date Issued Before Expiration Plumber Owner ~ ! / 3 ,l / / C/fp IV, T of POWTS S stem: Check all that a Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Reciroulating Synthetic Media Filter Leaching Chamber ^ D 'p ine ^ Gravel-less ipe ^ Other (explain) V. Dis ersaUTreatment Area Information: s Design Flow (gpd) Design Soil Application Rate(gpdsf) ispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Stee! Fiber Plastic Gallons Gallons of Units Concrete Conshucted Glass New Existing Tanks Tanks Septic or Holding Tank _ .~ ~ -~ Aerobic Treatment Uait ~ r Dosing Chamber VII. Res nsibility Statement- I, the undersigned, assume responsibility for iastallatioa of the POWTS shown on the attached plans. Plum r' N ( ~nt) Plumber' i MP/MPRS Number Business Phone Number _~ _ ~ --r Plumber s Address (Stree~XiJty, State, Zip Code) ~_ G VIII. un /De artment se On pproved ^ Disapproved Sanitary Permit Fee (includes Groundwater Surcharge Fee) Issued I tng Agent ignature (N ps) ^ Owner Given Reason for Denial _ ~ ~ r0 v IX. Conditions of ApprovaUR/~essoas for DisapproJval ~~+ ,~ ~ (i!/hta~~ ~6' C.E~ ~~ T~/ Gl L~GC ~ w"7~tir~~ ~' ~~.F'~/1/~ ~ 6~'~'~'j~'~~+C.~ `-lJ r' , G~~ -~ ~~So~ti ~Q U~~ ~ ~ sys~~l e+~wcn wmpeu pram tw me i.aimry onry~,ror toe system on paper no[ seas maa airs : t t mcnn m sve SBD-6398 (R. 01/03) x"73 ~ ~~ ~~s~ ~J~ s~~~ ~ ~'-~ ~~~?l`.s r~ ~~ T~~c sw/y-/i/~~/- s~//c///3 -Tv~i/-~~S'i~rJ ~~ose~ .~l ,,~~,~//~1 ~'~ ~ -- /~ a~-3iy'Pv~ ~E -~~~oo ' ~ = ~6 SG,'~/~ C,~l~- a ~~9y~ ~~~ ~~~ ~ ~~~~ ' l~l ,~,~'' 3 . ~~~~ 73~ go' ~' 33`~ Wisconsin Department of commerce SOIL EVALUATION REPORT Page~of 7/ Division of Safety and Buildings rn accoroance wrm Comm ua, vws. Ham. Voae County Attach com lete site lan on er not less than S 1/2 x 11 inches in size Plan must a p p p p . indude, but not limited to: vertical and horizontal reference point (BM), direction and p~ I,p, percent slope, scale or dimensions, north arrow, and location and distance to nearest road. _ P/ease print all i»formation. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (t) (m)). Properly Owner Property Location - - ~ "~ C Govt. Lot _S 1/4 1/4 S f N R ~or) W roperty Owner's Mailing Address Lot # Blodc Subd. Name or 6SNph~--- ~ ~~ - ~ City S Zip Cade Phone Number City Vltage ,®Town Nearest Road / ( ) ~ -S __ __ New Construction User Residential / Number of bedrooms Code derived design flow rate ~G`l~ GPD ^ Replacement ^ Public or commercial -Describe: Parent material ~ ,yx- Flood Plain elevation if applicable ft. Generalcomments / .~ and recommendations: ~5~~ ~1 ~J? 3 ~ ~/~Ss~~~,~F~,Es~ ii,~a' 1 1/ 1 ~L;;~l[[~_JJ Boring # ~ Boring ~ pi( Ground surfaceelev.1~~~ft. Depth to limiting factor ~`/~5`d in. Soli lication Rate Horizon Depth Dominant Color Redox Desription Texture Stiucture Consistence Boundary Roots GP D/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Ef~F1 'Eff#2 . S/ 3 - C ~ a ~ -- 7 s 4 ~ ~ f- ,~ - - 7 ~ ^ Boring # ~ Boring Pit Ground surface elev. ?L~ft. Depth to limiting factor] f~ in. Soli licetion Rate Horizon Depth Dominant Color Redox Description Textun: Structure Consistence Boundary Roots GP D/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eft#Z ~~ 5~ / T ~ ~ s Q ~-- 4 ~ - r - ¢ Q * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mglL * Eftiue t #2 = BOD < 30 mg/L and 15S < 3U mg/L CST Name (PI ) ~. l Signatu CST Nurr~er Address \/ ate Evaluation Conducted Telephone Number Property Owner Parcel ID # Page of ^ Boring # ^ Boring ^ pit Ground surface elev. ft. Depth to limiting factor in. Soil A licaflon Rate Horizon Depth Dominant Color Redox Description Texture Sirudure Consistence Boundary Roots GP D/ff? in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. "Eff#1 "Eff#2 Boring # ^ Boring ^ pit Ground surface elev. ft. Depth to limfing factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ff' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiflng factor in. Sal ic~tion Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/tl? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 "Eff#2 * Effluent #1 =BODE > 30 < 220 n~lL and TSS >30 < 150 mg/L * Effluent #2 =BODE < 30 mg/L 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 wntact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R07/00) Safety and Buildings Division 201 W W hi Comity ~ ' ® ~ ~ . as ngton ~ ~ y ~seons~n Madison, 537 608 6 Sani Permit Number (to fill in by Co.) De artment of Commerce ) 6-3 5 ( O Sanitary Permit Applieatl ,1 AN State lan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal infonnatio you provide ---~--- may be used for secondary p Law, s15.04( m) gT, CROIX COON prod Address (if different than mailing address) I. Application Information -Please Print All I ~ , Property er's Name Parcel Lot #~ Block # ~" Ja/' ~ 6Zb-/`l$Z- b~-boo ope Owner's Mailing A dress Property Loca ti n o ~ ~ ' / ~ ~ City State Zi Code Ph N b %•, Section f.~ _ ~, , p one um er circle ~C~ T~N ~ Z II. Type of Building (check all that apply) , ~ ; E o ~. p / ~ wt• ~~ ~ ~ 5u ] or 2 Family Dwelling -Number of Bedrooms Subdivision ne CSivrl o ^ Public/Commercial -Describe Use ^ State Owned -Describe Use Z Q ~J~- C~ ~ S ~-t.J ~ i- ~?~ /~ ^City ^ V" cage ~Tpwnship of II III. Type of Permit: (Check only one boa on line A. Complete line B if applicable) A_ '~ New S stem y ^ Replacement System ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System B• ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Ovi+ner ]V. T of POWTS S stem: Check all that a Non Pressurized In-Ground ^ Mound>_ 24 in. ofsuitable soil ^ Mound <24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Reciroulating Sand Filter ^ Recirculating Synthetic Media Filter Leaching Ch ^ Gravel-less Pipe ^ Other (explain) V. Dis ersalfi'reatment Area Information• Design Flow (gpd) Design Soil Application Required (sf) Dispersal Area Proposed/(st) System Elevation •~ • } / VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Stcel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass NeV" ~'~°~ vz5 P / I f a T ks T k e ~/ z. t. e an ac s Sepdc or Holding Tank .C~ Aerobic Tresanent Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, a ume responsibility for installation of the POWTS shown on the attached plans. Plum er' ame Print) Plumber' Si ur ~ r MP/MPRS Number Business Phone Number ~ Pl tier's A dress (Street, City, State, Zip Code) i ~~ C ,~ VII nun /De artment Use On Approved ^ v Sanitary Permit Fee (includes Groundwater Date Issued Issui gent Sign tamps Surcharge Fee) Owne en Reason for ial DO / /3 d 1X. Conditions of pprovaUReasons for Disapproval (n~ ,"~ ~v..f ~, 3~ 4J~~~~-~• 5 ne_~ ~,ot...~ - i SYSTEMO~f;~IER: 1~"- ~ tic ,fflu rtt tNl!er and ' 1 S _ , u~ , ° ep . e ~ :,e ~ p,,,~~p,~_ 1M,a ': e'en-a.n.cQ... 4.G/~ dispe~~ •!I must ell (1e serv(ces !maintained ~ as per r , ,gettlellt plan provided by plumber. V Z. AN Setback regNil~Nrletdi RIIJit lie trlsintslned M per applicabb 06d~ / ordnMtoee. uiacv cumpicu yu® ~w wx a.vuvry vnry),lvl' to Eyltenl OD PtPEi' not I!!3 taAn al/L I 1 t IoC6tl In flZe SBD-6398 (R. 01/03) ~i'UlJS~ ~~ S-~d/~ i ~ _~~~ J7'~/D.SOi/ /~ ~ So; ~ T ~s -~~ Q~s ~f~-~ ~t _. ~ ~~~~ ~ wr--~/ 0 usE .~ ~78~ ~~~i~~~ ~~ So . /~~ 1 37~ T~~yS~ ~y; k~ ~ps~ ~~ s7Di~ ~~~~ P.ivs .<.~Y:t3 ~iJ~-,~IUJ~y ~ SAC ~~- ~v79/~ 7~ /~ 6fOSdnJ j / ® .LSD/ /~,he~? ~ao a~ %y~Je~,~x ~l 99, 8 °y~ qys ~f~-~ ~e f _. ~~ 37~ ~P~~ w~~~ D BUSS ..~ CA,4tG~ ..28 ~ , ~~ _ 3 _S~,pi.~ s ~~.s% ~~ ~ ~~ ~ ~ ~~ . / ~r -7.00 ,~ 1484 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page t of 3 Division of Safety and Buildings in accordance with Comm 85. Wis. Adm. Code Steel's Soil Service, Inc ,~ 1 County Attach complete site plan on paper not less than S'/: x 11 inches in size. Plan must St. Croix indude, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I D percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. . . o - /NSZ-6'f-m~Pending Please~pri~t,at/t~--~ip,~-~i-• °°-~ ' ~ wed By Date r i 9 x :~.-.. Personal information you provide may be usi:d forteeond~iypar~eses (Privacy Law, s. 15.04 (1) (m)). i . / I yl Property Owner Property Location LaCasse Development , Ir1c. ~~^ `a +.~ r~ 1 ~ ~ ~ `! Govt. Lot na W 1/4 NW 1/4 S 13 T 29 N R 19 W Property Owner's Mailing Addrm~ss Lot # Block # Subd. Name or CSM# 573 Cty Rd " A" 4 na Bluebird Meadow City ~ ~ City J Village y_J Town Nearest Road Hudson ~ WI 54016 715-381-5405 Hudson McCutcheon Rd /~ New Construction Use: ~j Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement ~ Public or commercial -Describe: Parent material Sream terraces and pitted outwash plains Flood plain elevation, if applicable na General comments and recommendations: Conventional system, system elevation 97 5ft. Trenches spaced and depth to code 3.7 tt below grade. Boring # J Boring 120 H Pit Ground Surface elev. 101.50 ft. Depth to in. limiting factor Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stn~cture Consistence Boundary Roots GP DIft= in. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-13 10yr3/1 none sil 2msbk dfr cs 1f .6 .8 2 13-30 10yr4/4 none sicl 2msbk dfr cs na .4 .6 3 30-49 7.5yr4/4 none sl 2msbk mfr gw na .6 1.0 4 49-120 7.5yr4/6 none cos osg ml na na .7 1.6 ~l ~ 9~• r D / Boring # J Boring . Pit Ground Surface elev. 101.50 ft. Depth to limiting factor 120 in. Soil Applicator Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GP D/ft= in. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-11 10yr3/1 none sil 2msbk dfr cs 1f .6 .8 2 11-33 10yr4/4 none sicl 2msbk dfr a na .4 .6 3 33-42 7.5yr4/4 none sl/Is 2msbk dfr gw na .6 1.0 4 42-60 7.5yr4/4 none cos osg ml a na .7 1.6 5 60-120 7.5yr4/6 none cos osg ml na na .7 1.6 t II ~~ * Effluent #1 = BODS> 30 <_ 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/Land T55 < 30 mg/L CST Name (Please Print) ignature: CST Number David J. Steel 248956 Address Steel's Soil Service, Inc. Date Evaluation Conducted Telephone Number 994 200th St., Baldwin, WI 54002 8/20/2004 715-684-5680 ,S Property Owner LaCasse Development , Inc. Parcel ID # Pending Page 2 of 3 Boring # J Boring p- Pit Ground Surtace elev. 99.95 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-9 10yr3/1 none sil 2msbk dfr cs 1f .6 .8 2 9-18 10yr4/4 none sicl 2msbk dfr gw na .4 .6 3 18-37 7.5yr4/4 none sl/cos 2msbk mfr gw na .6 1.0 4 37-120 7.5yr4/6 none cos osg ml na na .7 1.6 // ~~~ ^ Boring # ~ Boring 1 _J Pit Ground Surface elev. fl. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Murrell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ^ Boring # --~ Boring _J Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Descripfron Texture Stnrcture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BODS> 30 < 220 mg/L and 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. Page 3 of 3 STEEL'S SOIL SERVICE INC. David J. Steel 994 200th St. CST-POWTSM LaCasse Development, Inc. Baldwin, WI 54002 Lic. #248956 SW1/4,NW1/4,S13,T29N,R19W Bus.(715) 684-5680 Town of Hudson, St. Croix Co. Fax.(715) 684-3449 Bluebird Meadow, Lot 4 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 soil test was conducted. Legend ,~~ 1" = 40' ~ ~~ Benchmark Ele. 100.00Ft `~ Top of 3/4" pvc pipe r- ~ ~~ Alt Benchmark Ele. 99.80Ft op of 3/4" pvc pipe -~' ^ =Borings Boring Elevations B1 = lO1.SOFt B2 = 101.50Ft B3 = 99 9S>''t B4 = OO.OOFt i ~ws~~ ~~ 37L ~~~ ~, ~6~, ~d{~` 3, ~,~ , ~~~~ ~~ ? ~~r ~~ ~ ~a Y ~~ ' ~, ~' ~/n M n [L~ ~- 7 V L1~Ll~J~QU~~UQ~ V ~ `---~ ~ ~ ` ~ ~ ~ ~ N - 10V'fiE9S M.L~i54~0~5 i 9 I -X---^- - ~ X ~ ~ i ^ i -i-~' ;/-. v ,w, r--' .9 8 w ~~ v ,~.~ ff! ~ a X ~x ' ~ ~ N ~ v { t _ s ~ ~ r _ -+ ~r ~T t r : ~ ~~.. ~~~~~ ~ .u~wa~v~~ .+ 3!t1rNiV1lQ 3a1M ~Oe v' ~-- ; X • N O ~~ ,/ `~X w ~ N N r. .~ O X m ~ ~~ ~ X ,~ X , - ~ o Q i N `° o ~ o ~ X n ~ vl ^ ~~ .~ r r .~ ~ ~~ ~~~ ~ ~~ :I ' (W w ~A1 ~ N ' ~~ O' X ~ ~~ ~ N ~ 'v X ~. ~ ~ r f.. y .+~ ~ .\ ~ a ~ X ..' .~ ~,, ~~ N Xj ~ ~ ' ~~ ~ ~ v ~ ~-~ ~ ' ~ ,~ ~: ' ~ ~ A ~~ i N n X co ~n / ALL ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~.. , { C: ~ z 5 ~, t~ ,r^ ~ ~ ~ ~'r„~L, ~- ,L,~,; c. Mailing Address .-~ 7~ ~~ ~~ ~~ ~-~ /-~u~f S~~ L~ :; Property Address (Verification required from Planning & Zoning Department for new construction.) City/State ~~~.~ ~t,~-•~- ~~ ~ Parcel Identification Number bLa - /`~S Z - [Z~ - 25~~ LEGAL DESCRIPTION Property Location S ~; '/4 , lV i. ~ 1/4 ,Sec. 13 , T ~N R 1~'(_W, Town of j~ ~S~ „_ Subdivision i~ r~ r,~.. ]x, e y~~Q ~~;~ ,Lot # ~% . Certified Survey Map # Warranty Deed # Spec hou yes ono Volume ,Page # Volume ,Page # Lot lines identifiable ~j no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance. of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County 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 knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms y --~ SI NATURE OF APPLICANT(S) 1 /~i o ~ 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) 2s~1 399 STATE BAR OF WISCONSIN FORM i - 2000 ~ WA.RRANTI' DEED Documem Number This Deed, made between Ronald G. Raymond, Loretta s. Raymonds husband and wife Grantor, and LaCasae Development, Inc a Wisconsin corporation Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in st . Croix. County, State of Wisconsin (ttte "Property") (if more space is needed, please attach addendum): Southwest 1/4 of Northwest 1/4 of Section 13, Towaship 29 North, Range 19 West, St. Croix Cotsaty, A7x Recording Area Name and Retm 772236 _. KATHLEE~1 H. NALSH REGI51`ER 0~ !'-EEDS SY'. CROIX Ctl.. 1tI RECEIVED FOR RECORD @8/28/2@@4 31:55AK tfARRAN't'Y DEED El(EIlPT # RfiC FEE: 11.0@ TRA}i,5 FEE: 2250.00 COPY FEE: CC FEE: PAGES: 1 016 Together with all appurtenant rights, title and interests. 020-1017-30-000 Pazcel Identification Number (PIN) 'This 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 enctuAbxances of recoxd Dated this da of August 2004 . *Ronald G. Raym * AUTHENTICATION signatures} Tracy ~. Turner hLotary authenticated this day of 0~~~ TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Slats.) THIS tNSTRtAKENT WAS DRAFTER BY Redmoa Law Chartered (.Richard Lau) 2217 Vine 3t., Suite 204, H.udaon, WI fSianatures maybe authenticated or acknowled¢ed. Bosh are not neccssarv_l ~tte~c4.... ~ r -e.. /Ca- m inc. d *Loretta 8. Ra and ACKNOWLEDGMENT STA F WISCONSIN ) c } ss V ~ Cotmty--- Jk~ Personatiy came before me this L day of August 2 0 04 ttte above named Ronald G. Raymond and l~oretta B. R~y~Qn~, hu n an wif to wn to be e n who executed th o wledged the same. Gu ,IVi2~/1 Notary Public, State of Wisconsin My Commission i`permanent. (If not, state expiration date: "Names of persons signing in any capacity must be typed or printed below their signature. WARRANTX DEED STATE BAR OF WISCONSIN RORM No. 1-2000 `~ Rcdmon Law 2217 Vine St Ste 204, Hudson W154016-5864 Phone: (71~ 38b-0100 Fax: (715),38b-0700 Redmon Law Chartered T4926305.ZFX Produced with Z1pFOrm'*' by RE FormsNet, LLC 98025 Fifteen Mite Road, Clinton Township, Michigan 48035, (800j 383.9805 wavw,zioform.com POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of~ FILE INFORM' TION Owner , Perm ~ DESIGTN PARAMETERS Number of Bedrooms O NA Number of Public Facility Units l3~IVA Estimated flow (average) al/da Design flow (peak(, (Estimated x 1.51 al/da Soil Application Rate '7 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 (TSS) 530 mg/L ,J~ NA Fecal Coliform (geometric mean) .510° cfu/100m1 Maximum Effluent Particle Size Ye in dia. ^ NA Ocher: ^ NA *Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity al ^ NA Septic Tank Manufacturer S ^ NA Effluent Filter Manufacturer O NA Effluent Filter Model ^ NA Pump Tank Capacity al ~ NA Pump Tank Manufacturer ~NA Pump Manufacturer ~ NA Pump Model ~-NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ~A Dispersal Celt(s) y~ In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other. ^ NA Other: ^ NA Service Event Service Frequency lnspect condition of tank(s) At least once every: ~ ~rrttonth(s) (Maximum 3 years) ,e~y ear(s) ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third (Yal of tank volume O NA Inspect dispersal celllsl At least once every: ^ month(s) (Maximum 3 years) year(s) ^ NA Clean effluent filter At least once every: ^ month(s) year(s) ^ NA lnspect pump, pump controls & alarm At least once every: ^ month(s) ^ year(s) ~ NA Flush laterals and pressure test At least once every: ^ month(s) _ ^ year(s) I~NA Other: At least once every:. ^ month(s) ^ ear(s) ANA Other. ^ 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 Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third lY,) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. 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 S12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the focal regulatory authority within 10 days of completion of any service event GMW 14/O1) Page ~ ofd START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other char that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the cor of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater v discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result In the backup or surfrace dischar effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to real power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump contra 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 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 c POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat.. scraps; medication painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the syst" properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled soil, gravel or another inert solid malarial. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code coml replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorl system. The replacement area should be protected from disturbance and compaction and should not be infringed upo required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area result in the need for a new soil and site evaluation to establish a suitable replacement area.. Replacement systems r comply with the rules in effect at that time. ^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in P01 technology a holding tank may be installed as a last resort to replace the failed POWTS. ^ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding 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 infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO I ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE d PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER ~ POWTS MAINTAINER Name ~ Name Phone _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ,' " Phone Phone This document was drafted in compliance with chapter Comm 83.22(2)Ib)It)Id-&(f) and 83.54(1), 121 & (3), Wisconsin Administrative Code. START UP AND OPERATION P89e ~ ofd For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other Chen that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the con •of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above. normal highwater levels, When power is restored the excess wastewater w discharged to the dispersal cell(s) In one large dose, overloading the cell(s) and may result k~ the backup of wrfeos discharl effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prbr to real power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump contro 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 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 o POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides;. meat. scraps; medications painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the syste properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Serviaing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled 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 comp replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorp system. The replacement area should be protected from disturbance and compaction and should not be infringed upoi required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area result in the need for a new soil and site evaluation to establish a suitable replacement area.. Replacement systems n comply with the rules in effect at that time. ^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POV technology a holding tank may be installed as a last resort to replace the failed POWTS. ^ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and evaluation must be performed to locate a suitable replacement area.. If no replacement area is available a holding t may be installed as a last resort to replace the failed POWTS. _ O Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO h ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OI PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER ~ POWTS MAINTAINER Name Name Phone _ _ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ..~ " Phone Phone This document was drafted in compliance with chapter Comm 83.22(21(b)It)(dl&(f) and 83.54(1), (21 & (3), Wisconsin Administrative Code. °' Parcel #: 020-1452-04-000 01/13/2006 01:35 PM PAGE 1 OF 1 AIt.~Parcel #: 13.29.19.2892 020 -TOWN OF HUDSON Current ' X I ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 10!0612004 00 0 Tax Address: Owner(s): O =Current Owner, C =Current CaOwner O - LACASSE DEVELOPMENT INC LACASSE DEVELOPMENT INC 573 CTY RD A HUDSON WI 54016 Districts: SC =School SP =Special Property Address(es): * =Primary Type Dist # Description " 941 SADIE'S LN SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 2.250 Plat: 10/34-BLUEBIRD MEADOW 020/04 LOTS 1/14 SEC 13 T29N R19W PT SW NW BEING BLUEBIRD Block/Condo Bldg: LOT 04 MEADOW '04 LOT 4 2 250 C ) ( ( . A ) Tract(s): (Sec-Twn-Rng 401/4 1601/4) 13-29N-19W SW NW Notes: Parcel History: Date Doc # Vol/Page Type 06/28/2005 798770 2831/233 VRNC 08/20/2004 772236 2641/399 WD 7iln~ CI IMMARV Bill #: Fair Market Value: Assessed with: - - -- 94544 68,600 Valuations: Description Class Acres Land RESIDENTIAL G1 2.250 70,000 Totals for 2005: General Property 2.250 70,000 Woodland 0.000 0 Last Changed: 10/25/2005 Improve Total State Reason 0 70,000 NO 05 0 70,000 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 o ~ ~ o m ~ m a ~ m y fD fD N ~ ~' y ~ m n d ~ O u~zN co D a O z 0 O ~ ~ C m ~ O m N C (D (D 7 a a N N < ~ N O m ~' 0 m N 01 7 O 7 N O) O N v~ O o ~ °o ~. c ~ 3 ~ ~ ~ 3 3 o ~ ~ ~ n (0~7 d A y fD v m v ~ ~ m a a ~ A o ~ =' a cw m o ~' rn w m ~ ~ ~ c O O O w ~ O O d 'a ~" fD 1D :: N o 3 °-' °' .. D ~ o v ~ ~ ~ f0 y n N S C 7 3 N Q n f~ 7 O C a A A a 3 O '•' 3 ~! z G C 3 a 3 m c ~ ~ 3 ~ 'a m # o 0 a fv Q Q ~ J ~ ~ O ~ N p ~ O N O ~ ~ o O 0 N o e 3 :~ c .. A W C m v a w ~~' A ~ ~ ~ ~ .+ A Z O .. O ~ ~ ~ w Z A ~ Z ~ ~_ g A d '°,. m m p 0 m O ~1 0 ~• O ~• ~• r A A t. A N A N O O O~ Q w ~n aQ O A ~ ~ ~ ~°,, b