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HomeMy WebLinkAbout020-1376-75-025Wisconsin 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)I. Permit Holder's Name: City Village X Township Emerson Homes Inc Hudson Townshi CST BM Elev: Insp. B Elev: BM Description: = t~ 3 ~ TANK INF012MATION ~ ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic ~- Z~ Dosing to _ ~~ Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic I 3 3 'k ~ ~ Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Dem nd GP Model Nu er TDH Lift fiction Loss System Head TDH Ft Forcemain ength Dist. to Well SOIL ABSORPTION SYSTEM /t~.l ~ D,~.~...I~o,< N-rr~.v~ cam. County: $t. Cr0lX Sanitary Permit No: 429975 0 State Plan ID No: Parcel Tax No: ~- SectioNTown/Range/Map No: 14.29.19. STATION BS HI FS ELEV. Benchmark Alt. BM ~ Bldg. Sewer rj"ZQ ~ `~$~3fo SUHt Inlet S`fb .ro' SUHt Outlet s .9.0 I~-~~ / Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System , SD / 9s• ~ Final Grade o3.s~ ~. ~~ / 99•Y~ St Cover 2. a~• ~ / BEDITRENCH DIMENSIONS Width ~ Length ~ /Yt "S.~ D ~ No. Of Trenches C2. PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKES REAM LEACHING CHAMBER OR Manufact rer• `- Type Of S stem: V~ I r ~~ ,~--- UNIT Model um~igr. DISTRIBUTION SYSTEM / "` ! S " -~E• ~tr.._ P/L Header/Manifold II Length ~~ Dia ~ Distribution Pip (s) Le Dia Spacing x Hole Size x Hole Spacing Vent to Air Intake S~ -~ SOIL COVER x Pressure Svstems Onty xx Mound Or At-Grade Svstems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched BedlTrench Center Bed/Trench Edges Topsoil ~~] Yes ~~ No ~~] Yes I`.,l No COM ENTS: (Include code discrepencies, persons present, etc.) Inspection #1~~f~~~3 Z~~s Location: 960 Fraser Lane Hudson, WI 5401~~6pppp(SW 1/4 NW 1/4 14 T29N R19W) NA Lot 1 1.) Alt BM Description = tom., S.T~ ~s~T""`' ~.~r 2.) Bldg sewer length = ~ t - amount of cover = ~"-(- , Inspection #2: -tl"-~T='~ Parcel No: 14.29.19. Plan revision Required? Yes No ~-li-~-~-~~ ~ ~ OS„ ,~,p,U,Z ~~ Use other side for additional information. ',-'~!^"~_! 1 ! ~ ~ _ _ ____ _-__. ___ __J SBD-6710 (R.3/97) Date Insepctor's Signature _ - _ / _ `'I~_ _- ! ' Cert. No. Q ~ ~ o /r~_~ ,s ,.~„ Safety and Buildin Division C~tY 5 ~ ` ~ 20l W. Washington Ave., P.O. Box 7082 ~~ ~ S'CO~~,~ Madison, WI 53707 - 7082 Sanitary Ptxmit Number (to be filled in by Co.) De artment of Commerce (608) 261-6546 2°) ~ ~..~ Sanitary Permit Application State Plan I.D. Number [n accord with Comm 83.21, Wis. Adm. Code, personal info `' ma be used for d Pri 0 ~ E D dd i d y secon ary purposes vacy Law, s 5. 4(1 V Project A ress ( f ifferent than mailing address) I. Application Information-Please Print All Information ~ ~~ MAY 0 9 2003 (, ~1 ` Property Owner's Name Lot # Block # ~~ SST. CROIX COUNTY ~# I Property Owner's Mailing Address lion 9 0`... ~~ ~%,~ut,% S ti 1~ City, State Zip Code Phone Number , ec on ]^ ~ ~,/D/ / circle one) II. Type of Building (check alt that apply) rw. ~1 ~ 2 Family Dwellin -Number of Bedrooms Subdivision N e CSM Number g ^ PubliclCommercisl -Describe Use ~'/ 9 S2 S ^ State Owned -Describe Use ('2 ~ 3 ~ K g~ -~ - f ~/t t~S ^City ^ V illage ownship of ~. I Q. III. T ype of Permit: (Check only one box on line A. Complete line B if applicable) A' New S em yst ^ R lacement S rem ep ys ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System B• ^ Permit Reaewai ^ Pettnit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T of POWTS S stem: Check all that a 1 Non Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constnrcted Wetland ^ Pressurized In-Cnound ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Uait ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V. Dis ersal/Treatment Area Information: -/tsU Design Flow (gpd) Design Soil Application Rate(gpdsf) Disperse Area R uired (sf) Dispersal Area Proposed (sfj ystem Elevation Do ~ ~ d 9s y~ VI. Tank Info Capacity in Total Number Manufacturer Pcefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank ~- ^,_, ~ ~ / Aerobic Treatmera Unit Dosing Chamber VII. Responsibility Statement- I, the nndersigoed, assume responsibility for i tallation of the POWTS ahowa oo the attached plans. Plumber's Name (Pri nt ) Plumber' Si r P PRS Number Business Phone Num b e r J ~j~/A~ ~ / Va! ~/ //~ ~~ ~~ ~ ~{ ~~f~'~/j ~j/ r 7/~ ~~~V ~ / P umAddress (Street, City, State, Zip ) ~ ~ ~~~ VIII. Coun /De artment Use Oni Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater Date issued Issuing gent Signature o Stamps) ^ Owner Given Reason for Denial Surcharge Fee) ~ ZS~ r ~ ~ IX.~ Conpditions orf ApprovaUReason/s~for Disapprov'al~~ ~ Cs ~ ttti 0~ ~ ~ ~ ~- ~ 1, I.dr CJ9„`h J t'~ ~ ~ ~ U ~ / ) ~ ~?o ~~ ~ ~ ~s~ ~ w~~~te.-~5 d.F.~.e~u~e~ .~:.. 1-~ . tJ . L . ~av ~ti a~ S'0}1 ~~ ~ Attac7l-kompkte picas (ter the Couaty Daly) for the tyttem oa paper cot hxs rhea 81/2 s 11 lecher is s8x ~ l.~ n .~c~-tom - .~.-~0(C) r SB 8/02) ~~ '{•~ py~~~e,w~~-n~ ~ann ~ ~;yQ,[,vtnti~-' / ~- ~, ~ N~ k.~~ as ~ "~-i 9s Z S Wisconsin Department of Commerce SOIL AND SITE EVALUATION ~ ~" ~ ~ ab ~S ~ \ Division of Safety and Buildings ~SO~/Page ~ of Bureau of Integrated Services in accordance with Comm 83.09, Wis. Adm. Code ~V. C}/p. Attach complete site pia~1 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 ~ . ~1' U I percent slope, scale or dimensions, north arro ndiocatio~aa nce to nearest road. Parcel I.D. # R { APPLICANT INFORMATION - Ple re ~ i ioi~ evi ed by Date Personal information you provide may be used for sewn 'Ikla¢oses (Priv Law, s..15.04 (1) (m)). ~ ~ `~ ?,~ Z Property Owner ,, 4 ~'~~)~/ fr"!] Property Location ,(; ~ ~1~~ S~ €f Govl~+, L t S(~ 1/4~~ 1/4,S ~ c~1 T "~. G~ ,N,R ~ G~ E (or) ~ J Property Owner's Mailing Address i :` `~ ~ , ;-rr;~; Lot #; Block# Subd. Name or CSM# City State Zip Code ...Phoney; `' Nearest Road .. ^ City ^ Village [~ Town 1-~L~dSc`~r I UJl I S`~~1~ `t,.t~~ > -~v'~. ~°'f ~-v ~Q.s~ ;~. I ~+-u Z ~_r- ~~Q L " New Construction Use: ~ Residential / Number o e rooms ~~ Addition to existing building Replacement Public or commercial -Describe: Code derived daily flow CS ~ gpd Recommended design loading rate bed, gpd/fl` r ~~ trench, gpd/ft2 Absorption area required ~S 7 bed, ft2 7~ ~tr/ench, ft2 Maximum design loading rate ~ ~ bed, gpd/ft2 , trench, gpd/ft2 Recommended infiltration surface elevation(s) ~ ~- / ~ ft (as referred to site plan benchmark) Additional design/site considerations l~i'~-- ei~- ~~ ~ S ' y Parent material ~U~z,~su S ~"\ Flood plain elevation, if applicable / ~ ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system ~S ^ U S ^ U ~$ ^ U S ^ U ^ S U ^ S SOIL DESCRIPTION REPORT ~~.,~.~_n~9n Atc ~~ ~m ~'~ Boring # ~ ,, Ground ev. - Uft. Depth to limiting factor i b(~ in. Boring # Ground elev. q~~ft. Depth to limiting factor 1l D in. Horizon Depth Dominant Color Mottles Structure i t C B d R t GPD/ft2 in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. ons s ence oun ary oo s Bed ,Trench I '~ (/~ Id ~ C~ J~ ~~ ~r~ I l~~ ~ . z Cv r - ~ ( ~. r ~ 5 - S ~ ~ 3 ~- /© I _-- rns o m ~ ~ s _ ~~ Remarks: I 0--r & ~® ~ ~-_ c ~ I'7Yk~ CS ' ,~5-3~ ~~ 4 -'~ S a l b~ ~ -- ~ ~ 3~-Ifd ~' 'mil I c.5 - - -7 • ~' / . 0 , ~® , Remarks: ;ST Name (Please Print) S' ture Telephone No. ~2~ ~~ --~ 7~~5~-~ ~7- Ih0 ~ 4dress f~ Date CST Number PROPERTY OWNER S!~CJ ~ ~ SOIL DESCRIPTION REPORT PARCEL I.D.# Boring # J .,/" Ground elev. ~. ZC3 ft. Depth to limiting factor min. Boring # ~f Ground elev. att. Depth to limiting factor ltd in. Boring # 5 Ground ele . 93t. Depth to limiting factor ~,in. Boring # Ground elev. ft. . Page ~ of .~„ Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench O~2n ~ ® (~ ~ ~" I ~ ~ ~ ~ V ~5 . 2. t i ~' s i I ~ - ~ .~ ; - 3 -~< < --- s l c s ~ .1 ' . ~ `fS :~ gr-S. Remarks: ~ ~- ~'-- ~~ b~.- c ~ ' ~ ~- `" b k m-~r c S - . ~ ' ~ ~ l- IL+ ~~ ~~ C ~ ~/ .~ ~' Q ~q. i S. Z Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD fly in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench ~ -+5 I Z ~-- S ~ ~ Z rr>G.bk IrnFr cS v~ ..~ 2 Y~- ~- 1 Z IL m~ ~ 5 - . S; 3 =+ `~~ m ml cs ~'.~ Remarks: Depth to limiting factor 'n' Remarks: SBD-8330 (R.9/98) PAGE ~ OF~ NAME ,~~ L~~ LOT#~~ LEGAL DESCRIPTIOI~~,% '/.2w'/<,S I yTZYN,R /~I E (or) ~~ SCALE: 1 "= l~ BM I ELEVATION ~ ~~~ ~ ~-~ BM 1 DESCRIPTION ~ ~ofr ~ ~ puc Pub- ~ a ~ ~ w/F/a~ BM 2 ELEVATION ~ , ~ 7 BM 2 DESCRIPTION ~b~-~~~~ p2 ~~f-~, ,~ 1~= lu~ SYSTEM ELEVATION ~S ~ ~~U ALTERNATE ELEVATION ~ 5• ~~~ CONTOUR ELEVATION ti 64 T ~~ ~- `~ d l~'''~serr ~e.P ~~ Tw,~,. ~ laS =~~-~t~. j4-/oo z y ~ = qs- y° l~_ ~ . g9. ?7 ~- a- u~~ ~ A~ Iv ~ ~ l `' /1~ I~~~ ~,~ 7y ~ N~ ~ °~ ~ ~~- ~ cs~~ ~- ~ ~ ~ ~ s l~~ ~~UL ~ f,~ ~, syC?) ~~~ -- ~~ V r;y ~~ N-/o~--5 ~ ~y~-~~ sygsyo~ ~+ ao 3s a5a ~~-S~-r SQ-~' ~,~ Tom,,. ~. j4-/o© ~ / ~/ yS, ~D I 'S , ~ ~'^ ~ /~ f C~~.. ~-~ ~ /~ 7~ v~ ~- ~..~-~ ~~ ~ s ~. ~ ~.~ ~ Y i l ~' ~~ I~~~ c~, ~„~w~~` ~- ~ 9 ~ z s ~~- 7~ ~ N~ ~~~ ~ C- ~~~ -- ~~ 1 ao35 ~y qs y~~ ~OWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of Z FILE INFORMATION Owner ~' ~ ~~ Permit # 2 c~ DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units "~VA Estimated flow (average) dtJ al/day Design flow (peakl, (Estimated x 1.5) ~j Qa gal/day Soil Application Rate r al/da /ftZ Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand IBODS) <_220 mg/L ^ NA Total Suspended Solids (TSS) <150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand IBOD51 530 mg/L Total Suspended Solids (TSS- <_30 mg/L ^ NA Fecal Coliform (geometric mean) 5i04 cfu/100m1 Maximum Effluent Particle Size YB in dia. ^ NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity ~d ~ al ^ NA Septic Tank Manufacturer ~C.c~ ^ NA Effluent Filter Manufacturer ~ ^ NA Effluent Filter Modet --%a ~ ^ NA Pump Tank Capacity al NA Pump Tank Manufacturer 1~NA Pump Manufacturer [~NA Pump Model ~ L~NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: CIA Dispersal Cellls) '[~In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground Ipressurized- ^ Mound ^ Other: Other: ~A Other: NA Other: A snerNrc~uerurF cr_u~nru F Service Event Service Frequency Inspect condition of tankls) At least once every: ^monthls- (Maximum 3 years) yearlsl ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third IY31 of tank volume ^ NA Inspect dispersal cellls) At least once every: ^monthls) (Maximum 3 years) ~ yearlsl ^ NA Clean effluent filter At least once every: ^ monthls) ~,l jd yearls) ^ NA Inspect pump, pump controls & alarm At least once every: ^ month(s) ^yearlsl NA Flush laterals and pressure test At least once every: ' ^monthls) ^ year(s) ~ NA Other: At least once ever y~ ^monthls) ^yearlsl L~FNA Other: C~bNA 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 tankls) 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 cellls) 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 focal regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY31 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 local regulatory authority within 10 days of completion of any service event. Page ~ of y START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tankls) 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 will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or: must be taken, to provide a code compliant replacement system: ~A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. alua ' a o ing tank iv~ T b ~ e a~ a ~RDN18 TIC ~R- N~ CoNS'T72c1c~1.ON ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER U" Name / / ~'_ Phone v\ ~ POWTS MAINTAINER Name ~ Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name ST. ~ l d~/N ZD~II~ Phone ~/S- 3~(A_ (p (~ This document was drafted in compliance with chapter Comm 83.22(211b11111d1&If) and 83.54111, 121 & 131, Wisconsin Administrative Code. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP C~~RTIFICATION FORM OwnerfBuyer _ Ely! ~.~'Sa .~ ,/yo ~t es ~ L, C Mailing Address ~~ 3 ~~o ~ en c e ~ e /~~ of rd h , l.J ~ .~ yD ~ (o Property Address T„ (Verification required from Planning Deparizrtcni for new City/State ~~Soh l..~ ~ Parcel Identification Number LEGAL DESCRIPTION Properly Location S~ 1/a, ~ '/., Sec. ~ T a ~l R `~ W, Town of /5l~~rb>- Subdivision . S w f e ~ 4 ~c.l's ,Lot # ~~ ~ Certified Survey Map # -71 t'..~Z-T .Volume / 7 .Page # `~.5~© ~] ~-~9~~1 Warranty Deed # o ,Volume U? Page # ~ b~J`r Spec house ~ yes ^ no Lot lines identifiable dyes ^ no SYSTEM MAIlTENANCE Improper use and maintenance of your aeptie system could result is its premature failure to handle wastes. Pmper 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 teak as a treatment stage in the waste disposal system. The property-owner agrees to submit to 5t_ Croix Zoning Department a certification form, signed by the owner and by a master plumber, joumeymanplumber, restrictedplumber or alicensed pumpcrverifyingthat (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 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Offrce within 30 days of the three year expiration date. ' ~_ ~---- ~.~i i o 3 SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements oa this form are true to the best of my (our) knowledge. I (we) am (arc) the owner(s) of the property described above, by virtue of a warranty decd recorded in Register of Deeds Office. -S' ~'~ 0 3 SIGNATURE OF APPLICANT DAT£ *"**•" Any infozmatioa that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. *'***` •• Include with tttis app[icatian: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made u~ the warranty deed d WdBZ ~S0 E0/S0/Z0 00LS9~ZSLG ;]NIltihHSX3 1102lN sconsi Department of Commerce ~ SOIL AND SITE EVALUATION Division of Safety and Buildings Bureau of Integrated Services in accordance with Comte-83•x@9;-1Qlis. Adm. Code ~. County Attach complete site plan on paper not less than 8 1/2 x 11 inches m size I°I~n must ~;,~ include, but not limited to: vertical and horizontal reference point (BM), ec'#ion ar>fl,....., S~ • ~ rU ercent slo a scale or dimensions, north arrow, and location and dis ' ce,to nearest': [oad~.,;~. ~ • P P ~ ~? Parcel LD. # r' APPLICANT INFORMATION -Please print all inform~tictn, fF ~ ° ` Reviewed by Personal information you provide may be used for secondary purposes (Privacy L'6,tv", 6:,15.04 (1) (rim)),,.', Property Owner PropBRy'C:oca o~a~. Page ~ of \~U'k.~ir~'I -~~.. ~ Govt. Lot s(~,J <, 1/4~(,rf 1/4,S /y TIC, ,N,R ~ ~ E (or)~d1I Property Owner's Mailing Address Lot'# BIOCk# , `$ubd. Name or CSM# ) 3 ~3 A-~+uk e Tr. -j~#-_~ . -~~ Swe~~- C-~ras City State Zip Code Phone Number ^ City ^ Village ~ Town Nearest Road NI icl5nn 11n)I I St-IU1ln (~15 )S~lq-(~73~ /f~~SG ~ ~F~•z-~r- La n ~ ® New Construction Use: Residential / umber of bedrooms 3 - ~ Addition to existing building ^ Replacement ^ Public or Comm cial -Describe: Code derived daily flow ~~ y gpd Recommended design loading rate bed, gpd/ft2 ~ ~ trench, gpd/ft2 Absorption area required S~ bed, ft2 ~~ tren ft2 Maximum design loading r ~ 7 bed, gpd/ft2 8 trench, gpd/ft2 Recommended infiltration surface elevation(s) ~~'/~ ft ( referred to site plan benchmark) Additional design/site considerations Gf • ~~' ~ ~ ~ S if applicable :/I/ ~ ft lain elevation lood Parent material , p S = Suitable for system Conventional Mound n-Ground ressure AT-Grade System in Fill Holding Tank U = Unsuitable for system ®S ^ U ®S ^ U ^ U ~ S ^ U ^ S ~ U ^ S ,® U snu nt=scRtp N REPORT Boring # Ground elev. ~ft. Depth to limiting factor 1 I (~ in. Boring # Z~ Ground elev. 99.91~ft. Depth to limiting factor 1 I Z in Horizon Depth Dominant Color Mottles Structure i B d R t GPD/ft2 in. Munsell Qu. Sz. Cont. Colo Textu~ Gr. Sz. Sh. Cons stence oun ary oo s Bed ,Trench Z I ~y . I k m-~'~ c - ~' -~ -Its y ~ I rs ~ ~ ~~ , Remarks: ,~ ~ ~ 0-t 5 /0 1 5~ I mablL mfr C ` 1 ~' • Z ; ~ 3 .3 y Z-n 10 r y ~o m5 f - - ~ ~ . ~ Remarks :ST Name (Please Print) Signature .b~ Telephone No. y~a./~n ~ ~Ww~a ~~ ~/.S =Z~f7- OCR 4ddress Date CST Number Z / ~3 ~~ ¢"~~ Sa w.,e r S~ Gc/ ( G' Z ,~"~ y` -CO ZS",3 ~G PROPERTY OWNER ~~-~-- PARCEL I.D.# Boring # 3 Ground elev. 99~tt. Depth to limiting factor ~Zin. Boring # `~ Ground ev. n. Depth to limiting factor JI `~ in. Boring # Ground ele 99 .. Depth to limiting factor 11 ~ in. Boring # Ground elev. ft. SOIL DESCRIPTION REPORT Page ~ of Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench I o-17 Id r3l- -- 5`! ImGbk ,~ c Ivy .Z ~ . 3 ~ _~~ v r ~, ~ c.s . ~ ~ g Remarks: l 0--1~} /D i 311 S+'~ I c v-~ _ 2 ~N39 1 U c `-~ `J , ~ bk ~ c ~ - ~ 3 9x14 )p r `II t:.Q - mS ~ ~ - . ~ ~ . 8' Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/fl2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench I D-!~ r3 ' ~ I I bk c5 Ivy ~Z ~ -3 Z ~~- ~ t ~t ~F S ~ I ~ ~ c 5 - . 5 ; . Depth to Q limiting factor 'n' Remarks: Remarks: SBD-8330 (R.9/98) PAGE~OF~ NAME S~~ v -~- LOT# ~~ LEGAL DESCRIPTION~iJ '/4 UW'/4 S t ~TL~ N R 1`~ E (or)(~V SCALE: 1"= ~~)y, r BM I ELEVATION (CCU • O BM I DESCRIPTION }_~~ (~ Puc ~;be ~ ~h~s~hl=~ BM 2 ELEVATION (Q(> . Z 3 BM 2 DESCRIPTION-lz~y vl l~i~~ ~~e lath vs~~ SYSTEM ELEVATION ~1Lv. l~, ALTERNATE ELEVATION ~ ~• ~~ CONTOUR ELEVATION ~(J//4 I ~ ~ - ~_/ G DATE L/~ G~~ OU TM13 HSTM1hEP1P OWFTm BY FDWM~ FIMRN+~ JOB NO. 041 i'EVlsm 6T-W _ ~ ao s ,cs9xs ~ 99S 9NR x~1M1' . .F ~ N ~~ a~ ~ O Nv W J o--~ g ~O~ Op~~+ ~o:~~ ~ ~ ~ ~ 0 VZ~O ¢-~i~I 8 a O 0 q ~ °o LL Z c 0) I ~ ~ ~~ Zg ~~ ~ < ~` ~ €Z ~a5 a ~'2 F~ 3 ; ~3 ~ ~~ C =h 3<~ c f3~ ~ ~~~ ~~ ~~ ~ J C4 ~ o ^ g ~ Z ~ ~~ 3 1 y+ 0 3" x ~i >y ~ ~ ~~ o a ~ x I I ~ I I ! - 1._ ~1 ~ ~~ ~d 3 s-' _ ~ ~~ .- H.; :a~. ~~ 119.BH' O^~ NIO~ ~APC41o gt~E 3 1 I • O W fA q LL W S iD ~av ,. oan ~ a ~ wz~ ~~ ~ QWm \ w M ~ z N m ~°`Nw ~:? 3 ~~ ~. ~zzoN ~~O~w O~Ka~ WW~W~ 0 V.~V~z ~ N ,v, w W W3o~ ~W T~~ T i ie ,/~ ~LLVI Oz~ a ~o~~ a~~u ?33~ ~~N~ ~W'~~W voZ,g° ~HaO z ~ss~va 333 1~d00 @0'ET 333 ~3$ dvli x3A2If15 Q3I3I1?130 KdST ~~@ E~Z/@E/i~0 a~100321 803 Q3AI3038 IA ''00 XIO?~0 '.LS Sa33t] 30 2I315I~8 _ HG~vx 'H ~7H,LVH LOStt 3JVd Lt '10A S Z S 6 T t ,/'~~-. ~~ Q~ a~ O' ~' ,~ 3_\ ~: 0 c ~ ~ O Q ~ J M N N ~ .n V ~ (( ~,~~ lJ~ r I a o~ ~J~ O a Q v 0 z ~~ Q~ i as ~~ \ ~i i ~ ~6 ~ ~ I 8~`s y\ ,~z. J. ~ W I°'- ®3 v Q ~ ~YR J p- F. ~,~ i (l5 ~ ~- r~ tt 1~~ On ~~ ~~ `~i ~ ~9Z ~I W N• ~' tU ~1 Z a ~~ ~' H O ~9~~8Z~ ~~ ~~ ~ -- ~S;'sSos~ ,~~` ~' ~ n- I~ ~~ 1 p ~ c~ i ( ~ j ~1 O~ t d~ W~ a~ C7 ~ M cv v ~,. rAA Y' t ~ a O ~~ ~L11 N ~~ C= o(~ i d~ ~~~~ ~'~~~ ~~ ~~ ~F-L ~ a c . -0 3 E ~ c°c N ° c o O~ UZ O, ~ ~ c~ ~: m ~~ao N '3 m 01U E ~d c o O ~ U ~O N ~ o~ . Q aE c~ tia w ~°~ ~~ ~ :~~~ ~~ o~~ ~ ~~ (h t~ •` .C O O ` Q :O ~ OU ~ U.L.+ '` O ~ ~ ~ ~ . L N ' N c~~ 3~ c~ o a ~ N A = ~ N `.• N "[3 'L3 -O O cri to U Q O p U p'CS 4 ~ p~j c U Q ~ d c 0 N U U Q c tl ~t C~tl N N N ~E~~ Q~~~ ~~ ~ a i -~ o E rn ~ ~ ° . 7 i~ ~ O O U Z ~ Cp t]. ~~o.o Y ~~ m ~ d '~ .... c O +" ~ U O O Q~~ o~ ~ ~ aE ch Q o a~ ~ ,~ °' o ~ ~~ ~ ~ o- ~ ~ m ~ o sd c cc y'`" c_ o _~~ °'~'°3~ ~~ °' a ~ 60 ~O to "' U ti ~ 'O N ~ c '' Ry U L N ~ v i Q1 o ~~~~~ ~~ ~~ ~~ ~ a~ _ o-ooE~ ~ ~ ~a o ~ ~ a a ~` , < ,~ _-_~ >. DOCUMENT NUMBER `J 21y1P 38 Warranty Deed .~' g ~ STATE BAR OF WISCONSIN FORM 1--1982 KATHLEEN H. NALSH REGISTER OF DEEDS ST. CROIX CO. , WI RECEIVED FOR RECORD 02/14/2003 08:00AlI This Deed, made between Clinton L. Jones, a single person, Grantor, and Greg C. Emerson and Lisa M. Emerson, d/b/a Emerson Homes, Grantees, Witnesseth, That the said Grantor, in consideration of the sum of Seventy-two Thousand Five Hundred Dollars and other o~od and valuable consideration conveys to Grantee all of the Grantor's right, title, interest and estate in and to the following described real estate in St. Croix County, State of Wisconsin. IVletro Legal Services EDIRET 382842 A 240850 1~'D 1b8213 Lot 7 ,Plat of Sweet Grass Farm, THIS SP.(C~~15B~FOw7tHt;ORD1NG DATA I EXEMPT i REC FEE: 11.00 TRANS FEE: 217.50 COPY FEE: CERT COPY FEE: PAGES: 1 RETURN TO: ~/C..C ~,QQ~(,Q Sjoberg & T elius, P.A. 33ot /n~~e~ 2145 Wo lane Drive, Suite 101 xN~aS Wood ry, Minnesota 55125 ~• Pte, mfv Ph~e: (651) 738-3433 ~n~ Facsimile: (651) 738-0020 y~T`+~:~~ Tax Parcel No.: ~~,p_ ~37<0-'11/- DOt7. Town of Hudscn, St. Croix County, Wisconsin This is not homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; and Grantor warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except subject to all easements, restrictions, liens and reservations of record, if any, and Grantor will warrant and defend the same. Dated this 5th ~ay,.p~f ~r,p~uary, 2003 Diane n/I t~ v Notary Public State of AUTHENTICATION Signature(s) authenticated this day of , 20_ -- L ~~____._ Clinton L. Jones ACKNOWLEDGMENT STATE OF WISCONSIN ) SS. COUNTY OF ST. CROIX ) Personally came before me this 5th day of February, 2003, the above named Clinton L. Jones r S. i~ ~~-e- _ Title: Member State Bar of Wisconsin {If not, authorized by §706.06, Wis. Stats.) This Instrument Drafted By: Sjoberg & Tebelius, P.A. 2145 Woodlane Drive, Suite 101 Woodbury, Minnesota 55125 (Signatures may be authenticated or acknowledged. Both are not necessary.) to me known to be the person who executed the foregoing instrument and acknowledged the same. * , Notary Pu is S~. G~ ~~ County, lS CO~~S ~ My Commission is permanent. (If not, state expiration date: l~- ~9- ao-o /n F:\Cliems\2963\0302 Warranty Deed. WARRANTY DEED STATE BAR OF WISCONSIN Page 1 of.l FORM No. I -- 1982