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HomeMy WebLinkAbout020-1388-01-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety~and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal infirmation you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township LaCasse Custom Homes Hudson Townshi CST BM Elev: Insp. BM Elev; BM Description: W~ pl /t "'r'f~ dh 1 I Dfl~ d (DU. U '~ ~ ci Zth3~~ rs~ - ~-~..e v TANK INFORMATION ELE ATION DATA TYPE MANUFACTURER CAPACITY Septic ' ~~ U Dosing AA .~ Aeration Holding ". ~--_ TANK SETBACK INFORMATION TANK TO P/L was ~ WELL ,- BLDG. Vent to Air Intake ROAD Septic / _ ~~ j l.l~ / ~ ~ J ~ , Dosing ~ - Aeration Holding PUMP/SIPHON INFORMATION Loss n SOIL ABSORPTION SYSTEM ,~ O e-.~t fm.~.-~-~--~s~,,..~L / County: S{. CfOIX Sanitary Permit No: 420576 0 State Plan ID No: Parcel Tax No: 020-1388-01-000 ~-~~, ~.,-I-c~~~1 STATION BS HI FS ELEV. Benchmark t o ~'7 . y' t,Cb ~ Alt. BM ST ~V 9~`~7 Bldg. Sewer s~6 /Ub~' ~orri r~G~~ _ rnc~- -F ' ~ y SUHt Inlet 5.~a q~ 3 SUHt Outlet ~ Z: D Dt Inlet /~ / Dt Bottom _/ Header/Man. Dist. ipe of ~^'"7 , ~ssv ' O~ ~~- qs Bot. System / $ , (gyp Final Grad "~ ~ O St Cover _2 ys • 6'1 ///',lawn ~,rr ~,~,,, .T,~ti4~1. BED/TRENCH DIMENSIONS Width ~ ~ '~ Length Z ~~' No. Of Trenches ~ PIT DIMENSIONS r--~` No. Of Pits Inside Dia. Liquid Depth ~ ~, SETBACK SYSTEM TO PiL LDG WELL L 1STREAM EACHING Man cure ~ INFORMATION _ HAMBER OR ~ T Of S t ys em: I ,.L, ~,J d Model Number: ~~r UISTRI6UTIUN SYSTEM i Header/Manifold ] Distribution ~ ) ~ ~ x Hole Size x Hole Spacin // d ' V Pipe(s) / 2, r V j l~ ~ ~--- Length ig Length Dia p ing SOIL COVER x Pressure Systems Only xz Mound Or At-Grade Systems Only g Vent to Air Intakes ~y ,~...- 7 ~ o ` ``. ~fc>f 6v ~~2c. Depth Over ~ Depth Over xx Depth of xx Seeded/Sodded xx Mulc ed Bed/Trench Center ~ ! ~ .: Bed/Trench Edges Topsoil (-~ Yes ~~ No ~ Yes If Na COMMENTS: (Include Code discrepancies, persons present, etc.) Inspection #1:~/ ~ ~/ OZ. Inspection #2: / / Location: 964 Sadies Lane Hu~~+d+s~on, WI 54016 (SE 1/4 NE 1/4 14 T29N R19W) Field Haven Lot 1 ~ Parcel No:,,,,1..1l4.~~29.19.2375 1.) Alt BM Description = ~''l.o ~;~~-' `'`-, S~ ~ "=; ~~ ~SGN°~ or-'s7 ~ grow ~~ ti~ 5~ [ ry "'{ ~ ~ 0 1 ,10n ~S ~t~~ ~ ~ IQ gs ~-- 3d°Jo . 2.) Bldg sewer length =3' ` ~03~ s J, nu/l'1.On 7i ~ ~ ~°~~~ , - amount of cover = ~`~~ ~u~Gt~/ ~ J'-~7,vs-P~ D~ ~"~ ~~S f 31^'d (~lgiyr~, ~y--U~•MJyv~ Plan revision Required? ( Yes ~ o ~'N ~ ~ T ~ ~ ~ ! I I Use other side for additional information. ~a-~1 ~ _ ~___J ___-_________ _ ,_____ ~~ `~ _ ___J Date Insepctor's Sign ture Cert. No. SBD-6710 (R.3/97) /~~~ ^ ~ _/ ' ~,Q~ G f ~ ~~ ~- ~ ~ ~ ~,~, ,~ yak ~~~~ ~ ~ i-~ ~~// ~ - ~~ - , ` 1© a-~ri ~~~ p~~W ~ ~~~~ ~ ~ ~~ ~~s r ~u. ~ 1 ~~ lr c Safety and Buildings Division County ' ~ ~ 201 W. Washington Ave., P.O. Box 7162 ~ ,~CO~S,n Madison. VVI 53707 - 7162 Sine Address , De artment of Commerce -Z2-O ~ .~' 03 / Sanitary Permit Application Sanitary Permit Number i ' ~~U S~~ de ormation you prov In accord with Comm 83.21, Wis. Adm. Code, personal im ^ Check if Revision ma be used for ses Priva Law s15. 1 m I. Application Information -Please Print All Information State Plan I.D. Number A' Property Owner's Name Parcel Number ~Zo - /3 ~ O l -- ~~ ot,>, Property Owner's Mailing Address perty Locxdon / ,J ~ ; S ~ TOt N, R! E City, State Zip Cade Phone Number Lot r Block Number •--~ ~,~~ bdivisio ame CSM Number II. Type of Btn7tiing (check all that apply) ~ ~ ;ty s 7 ~~ or 2 Family Dwelling -Number of Bedrooms r7lage ^ Pubiic/Commerciai -Describe Use ~ owaship G~! - a ,G ; ' ,' ~' 3 (oclsT . ~ `- ^ State owned ~ fi~ st Road ~(} / ' r Y , ~ ~ U ~ ZC ~~,;,;.""~" ` III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) `,' 1 ~ew 2 ^ Replacement System 3 ^ Replacement of 6 ^ Addition to For Couuty use ste Tank Onl Exis ' stem B. ^ Check if Sanitary Permit Previously Issued Permit Number Date Issued IV. Type oP Permit: (Check all that apply)(numbering scheme is for internal use) ,S~ ~ t ~` 44~Non -Presauized 1n-Grwmd 21^ Mound 47 ^ Sand Filar 50 ^ Consnncted Wetland j~ ,3/ /'~l' 22 ^ pressurized In-Ground 41 ^ Holding Tank 48 ^ Single Pass 51 ^ Drip Line ~ / ~~~ f~ 45 ^ At-Grade 46 ^ Aerobic nt 't 49 ^ Recirculating 30 r V. D' tment Area Informat ion: / Design Flow (gpd) Dispersal Area Dispersal Sod Application Percolation Rate System Elevation Final Grade Required Proposed Rate(Gals./Days/Sq. (Min./Inch) ~ /..- ~~/ Elevation O / ~ 7 ~ gg ~'= 9/~ v ~ - VI. Tank Info Capacity in .Total Number Mamtfacturer Prefab Site Steel Fiber plastic Gallons Gallons of Tanks / Concrete Construcud Glass New Existing ~ ~ /4'~~ ~r Tanks Taoka Septic or Hokliag Tank ~' ,.,, _ ~ Dosing Chamber VII. Responsibility Statement- I, the tmdersigned, assume responsibility for tion of the POWTS shown on the attached plans. ~ ~y~ r' MP RS Number Business Phone Number - ~~y ~ ao 3~ ~ ~~s-a ~ Phmrber's Address (S t, ity, Sta e) /J ~~ I ~~~lL ~~~' S~cx~ VIII /De atrtment Use Onl Approved ^ Disapproved ~~Y Permit Fee (includes Groundwater Da Issued m Signa o Stamps) ^ Owner Given hritial Adverse Surcharge Fee)~~ ~ ~• ~~ i ~ ~ I D ' G~~~~ /, /-/~ G~ Determination 17i:. Conditions of Approval/Reasons for Disapproval~~„ R 3 i ~~ ~~w c~ ~t,~ti1.~~ ~~ ~~ ~ ti~sy ~ / ~~ ~ ~ ~ ~~ ~ Z d/~~ ~ ~,, ~ /~., , ~c0 au~~A~t. rvtu.a.~~,~.c ~ ~~ D~ti~-nort-~ ~ ~~d P~ `' ,a c~i.a~-c~-~~- x not hxa than lien x, it ffi alse l~~~~''"°'t~~ /~ ~ Wisconsin Depar6nent of Commerce SOIL EVALUATION REPORT Page I ofJ Division of Safety and Buildings _- ' m accoroance wlm Comm asa, vvls. Ham. was i Pl n m st h i 1/2 11 i h county CrQ u n s ze. a x nc es an 8 Attach complete site plan on paper not less t include, but not limited to: vertical and horizontal reference point (BM), direction and Paroel I.D. O 20 `/.3$~- O~ '~~ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print aN information. Revie by Date Personal information you provide may tre used for secondary purposes (Privacy Law, s. '15.04 (1) (m)). '' 2 Property Owner Property Loca ~ ~p ~,s Govt. Lot 5 114 tJE 1 /4 S l y T Z c1 N R Iq E (or) Property Owner's Mailing Address lot # Btodc # Subd. Name or CSMf/ 5~3 C 1 ~~e1d. City State Zip Code Phone Number ~ City ^ Vllage [Town Nearest Road of l J (~t5 )mil-5 So C f [~ New Construction Use: ®Residential / Number of bedrooms 3 - `( Code derived design flow rate ^ Replacement D Public or commercial -Describe: Parent material d v -E-w a.S h flood Plain elevation if applicable _ General comments S ~/ Sfc -+1 G l e u e r ~- r e a c h ~ q. p p Lo w~ ~^ f- r~ ~•~ -.~ and recommendations: ~ ~, f, e J { v, U 1' P ~r- kr+ ti~~ q /. v U c.v w ter' re n.c i" &`~n 4 - j~r~1 ST CR~.;lx mf inr~ I Boring# ^ Boring zONitdGOrFi+~>~. ®Pit Ground surface elev. Q/ O y ft. Depth to limiting factor ~ 1 ~ in. ~`,,, Soil lication Rate Horizon th De Dominant Color Redox Description Texture Structure Consistence Boundary Moots GP D/~ p in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 J - 1 S ' / ~ ~ S 1 ~-~' • ~ 3 2a -all ~ 41m -' m s D m ~ - ~ . -~ I. 2 $ ° 2 - s _. 4~ 3,(~`~ ~: ~ 2 Boring # ~ Boring ~ pit Ground surface elev. 4~ y~ ft. Depth to limiting factor ~ in. Soil licetion Rate Horizon Depth Dominant Color Redox Description Textun: Structure Consistence Boundary Roots GP DIff'- in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 p-( ,, 5.1 2mGb mfr CS I v ~ . 5 - ~' 2 J ~ -31 ~ ~ yl ^' 2 -~- c s - . 9 3 3!-Ili JD 4I - mS m~ - ~ ~•Z ~~ ~. ~ ~ 0 `~ 7(p• "Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Emuent 4FZ =thus < su mgru ana r as ~ ou mgrs CST Name {Please Print) ~ Signature CST Number ~m LCl'YY] l~Pr ~-- ~-~ ~' 2533o`j address Date Evaluation Conducted Te~phone Number 2113 80~ ~4- ~o ~P c~ ~~ 5`~C~Z~ 3 - ~ - ° ~ C~~512y~- y oc~3 Property Ouvner ~ CC~.S~vP Parrel ID # Page 2 of ~ _ 3 Boring # ^ Boring ®Pit Ground surface elev. 9h! z 0 n Depth to limiting factor /I 3 in. Soil lication Rate Horizon Depth Dominant Cobr Redox Description Texture Structure Consistence Boundary Roots GP D/fi? in. Munsefl Qu. Sz. Cot>L Color Gr. Sz. Sh. *Eff#1 *Etf#2 I a- ~ 3 - 5~1 Jv.~' .s . ~ Z y J y --- L S s c S - . ~ J. 2 3 2 -11 ~ ~4 - ms Os I _ ~ . ~ ~. 2 Borng # ^ ~~ ^ pit c~rouna surface elev. n. uepu~ w ~Hmm~y ~acwr "'• Soil 6cation Rate Horizon Depth Dominant Color Redox Descxiption Texture Structure Consistence Boundary Roofs GP D/ff in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Eff#1 *Eff#2 Boring Boring # Ground surface elev. ft Depth. to limiting factor in. ^ Pit Soil ication Rate Horizon Depth Dominant Redox Descx~tion Texture Structure Consistence Boundary Roots GP D/ff in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. *Etf#1 *Eff#2 * Effluent #1 = BOD$ > 30 _< 220 mg/L and TSS >30 _< 150 mg/L * Effluent #2 = BODg < 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. SBD-8330 (R.07/00) Property owner La Cc~55P Parcel ID # Page 2 ~ 3 ~ # ^ pi Ground surface elev. 9h! Z 4 ft papth m leniting factor /~ 3 in. Soil Rate Horizon Depth Dominant Cob Redox Description Texture Stnx~ure Consistence Boundary Roots GP I in. MunseU Qu. Sz. Copt Cobr Gr. Sz. Sh. 'E~ ' 1 - l 3 - 5~1 1~~' .S •~ Z yly ~-- LS C 5 - , ~ 1. Z 3 Z ai ~ r4 -- ms ~s 1 _ ~ . ~ i. 2 o ~~# ^ ^ Pit Ground surface elev. tt Depth to limiting factor in. Sod Rate Horizon Depth Dominant Cobr Redox Desciption Texture Structure Consistence Boundary Roots GP D/fF in. Munsell Qu. Sz. Cont Cobr Gr. Sz. Sh. 'Eff#1 'Eff#2 a ~dn9 # ^ Boring . ^ Pit Found surface elev. ft Depth to limiting factor in. Sod Rai Horzon Depth Dominant Colo Redox Descriptbn Texture Structure Consistence Boundary Roots GP D/fr; in. Munsell Qu. Sz. Cont Cobr Gr. Sz. Sh. 'E~ ~~ 'Effluent #1 = BOD$ > 30 < 220 mg/L and TSS >30 < 150 mg/L " Effluent #2 =GODS < 30 mgA.. 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 608-264-8777. ssos~so ~x.ovoo> - . PAGE~OP .3 NAME L.a~0.5 .e LOT# ~ LEGAL DESCRtPTIONs~ '/<~u~'/a S /y T Zq N R /9E (or)~V SCALE: 1 °_ BM I ELEVATION /D(~ • U ~ BM 1 DESCRIPTION ~~ 6~ y Ncuoad aT o c #~ w/F~a °J -' {"• K BM 2 ELEVATION 9 ~'. 5 3 ~ ~ ~ ,~ BM2DESCRIPTION ~'oPo-F'3/~l Co~re~r A~'Ae w!/`/d1 SYSTEM ELEVATION upP rr ~j.o a tow • ^ 5s~'•Ol~ ALTERNATEELEVATION~~cr-9/•~y l~owar4O~4o CONTOUR ELEVATION 9/.OrJ Q3~ oy~9s. ao w k 5~ ,~~ u'i ~ ti~~" ~~H s~ ~~",~ r ~ ~, . ~~ ~"` ~ // ~~ A ~~ ~~7 \`~ ~ ~ ` 1 t \ (t~ A Z pr. ? 9/•00 5° ~ ~~'~ t3 ~ 3 ~ ~~p,2 '. 00 b. L.t., 8 '~/ ~ ~~` - a ~ ,, y 7, S3 T~,~ 3/y U ~~~ ~ 7 = l ~. ~ q ~ T- a : 88 ~ D ~2 S~ ~-1- ~ a= 1~ ~ ~~ a l ~-~o 2~ ~- s ~~~ / L ,~ l~ N~ ~~ /pod c/ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION Owner ~ ~~~ Permit ~ '~d 5- DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ^ NA Estimated flow leverage) ~ al/da Design flow (peak), (Estimated x 1.5) O al/da Soil Application Rate t allda Ift~ Standard Influent/Effluent Quality Monthly average Fats, Oil & Grease {FOG) 530 mg/L Biochemical Oxygen Demand IBODS) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand IBOD51 <_30 mg/L Total Suspended Solids iTSS) 530 mglL ^ NA Fecal Coliform (geometric mean) <_10" cfu/100m1 Maximum Effluent Particle Size Y8 in die. ^ NA Other: ^ NA "Values typical for domestic wastewater and septic tank effluent. ^^AI~tTGwl A111/~C Cf~YCf1111 C SYSTEM SPECIFICATIONS Septic Tank Capacity ~Q ~ Q al ^ NA Septic Tank Manufacturer ~ ^ NA Effluent Filter Manufacturer ^ NA Effluent Filter Model .- ~ ~ ^ NA Pump Tank Capac"rtY al ^ NA Pump Tank Manufacturer ^ NA Pump Manufacturer ^ NA Pump Model ~ ^ NA Pretreatment Unit ^ Sand/Gravel Filter O Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ^ NA Dispersal Celtls) ^ In-Ground (gravity) ^ At-Grade - ^Drlp-Line ', ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ Nq Other: ^ NA R~I,~~~ ~ L~~~"~~~va. v Service Event Service Frequency Inspect condition of tankls) At least once every: ^ ea~ls)Is) (Maximum 3 years) ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third lY3) of tank volume ^ NA Inspect dispersal cellls) At least once every: ^ yearl )Is1 (Maximum 3 years) ^ NA month(s) ^ NA Clean effluent filter At least once every: yearls) ^ monthls) ^ NA Inspect pump, pump controls & alarm At least once every: ^yearls) ~ ^monthls) ^ NA Flush laterals and pressure test At least once every: ^yearls) Other: At least once eve rY~ ^ month(s) ^yearls) ^ NA 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 tankls) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum acrd 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 local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third !Y3) 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 512 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 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 cellls). If high concentrations are detected have the contents of tl"ie 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 celllsl in one large dose, overloading the cellls) 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 fife 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 safe{y 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 alt tanks and pits shaft 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 wilt 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. ^ 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 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 Name Phone .- ~ ~~ POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) EGULATORY AUTHORITY Name Phone LOCAL R Name ~ ~j---G Phone (r~ ~- 3 O ~ '- ~G ~5 This document was drafted in compliance with chapter Comm 83.22(2)Ib)(1)Id)&(f) and 83.5M11. (2) & (3), Wisconsin Administrative Code. S'1' C1tOIX CUUN'1'1' SI?1''I'1C '1'A1~IC MAIN'1'LNANCL AGltl?1?ML~i~'1' AND UWt~I?RSlltl' CI?lt'1'IP1CA'1'ION l~OltM Owner/Btryet' ~l~t~g5 fP~ ,e-~ ~ ~~~~~~~~-- Meiling Address _ ~ 73 _~C y ~.~~ ~a 6~r I'roharly Address (Verification requited Bout 1'lanuing Ucpattntcnt fitr new cnnsUuclion) CilylSlutc~~~s~~ _ I'nrcc) Iclcnlitic:-ticrn Nuntltcr~Z~ /,~~~~~~-~~Q SCllll''I'ION /Y• Z~7. ~~1. '2.375 LI~GAL llr Properly Location _~~ t/,, ~ y~, Sc~. ~_, 'I' 2.5 1~1-IZ~~W, 't'own of /"1 SuUdivision c~`l~P. ~.~ /~ifa. tJ~- 1_ot ~f Ccrtfficrl Stttvcy Mttl-/~~ _ _, Vc-luntc , 1'ngc ~l tivnl'I'Al[ly vCCll ~E _ _ (D ~~ ~ ~ g `7 , Voltultc ~~ 1'ctl;c ~~ _~ Spec 1-ousc D yes [~' no Lul lines iclcnli(inltlc ~ yes U no SYS'1'LM MAIN'1'I~NANCL [mproperusc and maiutenauccuf yutlt scpttic syslcnt caul+l result in its ptcutalute t~ilme to handle wastes. Propermainleuauce couslsls of putrtplug out the scpllc lank every three years or suoucr, if needed by a ficcnse+{ puntpcr. What you put into the system eau atT'ect the function of the septic teak as a hcattucut singc in ttte waste disposal systau. + The property owner agrees to submit lu Sl. Croix 7.oning I)cparhttcnt a cetlitiealion forte, signed by the owner and by a ntasterpluutber, jounteytnau plumber, restricted pluntbcr or a licensed puntpcrvet ifyingthat (1) lbc on-site wastcwat~erdisposal system is in proper operating condition and/or (2) alter inspection and puny-ing (if necessary), (he acetic tank is less than 113 fuel of sludge. 1/wc, (hc undersigned have read the above rcgrtitcntcnts and agree to nraiulai^-the ptrivatc sewage disposal systetu with the standards act forth, herein, as set by Iltc Dcpatlntcnt of Crnnutctcc attd Ilrc Ucpatlmctrt of Natural Rcsottrces, Stale of Wisconsin. Certification slattug that your septic system has beta nraintaiucd roust be conrplctccl and tctuurcd to the St. Croix County Zoning Oftice wllhin 30 days a three ye r expiration date. Illl~~~~ Si ATUItL~ p API'LICAN'I' DA'I'LY O~'VNI;R CI!,IL'I'fIaICATION I (we) cattily that all slatcn-cnls on Ibis tinnt etc Itue U+ the best of u+y (rnir) knowledge Rte rr rty described hove, by virtue of a wananly decd retarded iu Rcgtsler of l)ccds Uflice. s[CiNA°I'UItLt 'PLlCAN7' 1 (wc) ant (are) the awucr(s) of /i~i~ia~ UATE *'"**** dirty iuforntatton /Let is ntis-tcprescntcel stay result in the sanitary pennil being revoked by the Zoning Departmcut. ****** ** Include. tvlt[r thls apptllcatiott: a slantp>cd watratrt}' dcee`: Ctoiri•tite [Eegisicr ci` `c.?cccis oflice_ - _ _ _ - - _ ~_ . _ _ ~--e=c~~y c;J`tis ':ccrti~cd sitcYc~%nta~~ if reference"is'tnadc' ~t tdJc w.grt:uf~~,ct^~d - _ - _. . - --- - - - - - - -- - - - • ~o~ 1612Paf,E 414 ` I STATE 8AR OF WISCONSIN FORM 2.1999 II WARRANTY DEED Docmnenl Number This Deed, made between John W. Moravec and Mary A. Moravec, husband and wife, __ -__ ___ _ _ . ___ ____ Grantor, and LaCasse Developtnent, Inc._ __.__ _.__.__ Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix _ _ County, State of Wisconsin (if more space is needed, please attach addendum): 6112 of SEI!4 ofNEl/4 of Section 14-29-19, St. Croix County, Wisconsin. 641954 YA'THLCEN H. WALSH kEGTSTER OF DEEDS ST, CRfIIX CQ, , WI RECEIVED fOk RECORD 04-G3-2GGi 2:30 PN WP,RRANTY DEED EXE?fDT q ' CEkT COPY FEE: COPY FEE: TRRNSFEA FEE: 924.00 RECGRDING fEE: 10.00 PAGESI • 1 Recording Area Name and Return Address The RiverBank 880 Sixth Street North Hudson, WI 54016 020.1020-70.000 _,_ _ __ Farce aionNumber(PIN) Phis is homestead property. Gs) P~a130 Exceptions to warranties Easements, restrictions and rights-of-way of record, if any. Dated this ~p day of _ March 200t -~_. ~. * J n W. Moravec - -- - -- - ~}r + Mary A. ravec _.~,___..-_- '_ -- --- AUTHENTICATION ACKNOWLEDGMENT STATE OF WISCONSIN ) Signature(s) _.-.-..-__- - )ss. -- -. ... _ St. Croix County ) - - --- -- - autbcnticated this _ _. day of _ __ __.___. _ _...___. Personally came before me this ~ZJ _ day of March 2001 the above named John W. Moravec and Mary A. Moravec, husband an wi e, _ - TITLE: MEMBER STATF. BAR OF WISCONSIN t4>'~' (If nut. _ _ _ -.-_-- _ -- `,.aj~itr `~,.~ authorized fiy § 706AG, Wis. Stets.) ,R- ~. TIiIS INSTRUMENT WAS DRAFTED BY 3- -~ Attorney Krishna Ogland _ .__._ __,_ ~~^ ~`1i)t, . ~ Hudson, WI 54_0!6 __ ~_ _ _ __.____. b'1Y (Signatures ma)- he authenticated or acl.nowlcdged. Both are not necessary. ~ . _`_ r Name; of persons signing In any capacity must he lype~d or printeJ below their s~ >1u ~ STATE BAR OF WISCd WARRANTY DEED 1'OR,NNo.2-1999 be the person(s) who executed the Icr~' nowledged the same. Pu lie., Stu:' of Wisconsin t n,,tiior, to permanent. (If not, state expiration date: Z. iv~ ; - Inlormation Proless~ona~s Company, Fora au Lac, Wi W rr r • `.,-. - 8~ab55-2021 r1 ~ ~~-a =,, y7,S3~~.~ r- ~ T- a ~-- a al ~°' ~9~ 88 ~2 S, /o ~+-~'t 11 ~.~'~"`, ~y' ~,.,Q,,~ l~ - /o St s u~ ~~~ V L ,~ l~ ,9- -/~ ~~,-G-Q `~ N~' ~-0 /DD b cu-~~/ UNTY SEOTiON JMENTFOUNO J PIPE NI PIPE WEIGIiING 3.85 ~ FooT RNERS SET WITH t• X 24• .~HTING 1.13 POUNDS )OT. SACK (AS SHOWN) YEASEMENT E NE G WHICH WOULD V OF THE APPROVED _ EROSION PLAN FOR D TO BUILDING UPON, ATING, OR PLANTING IN TCHES, WATER >SS SEEDINGS. ..~ Q va v.a ~ xr_.:: .~, M~;t ~' -~. EL ~. DH AV E LOCATED IN PART OF 'THE SE1/4 OF THE NE7/4 OF $ECTI T29N, R19W, TOWN OP HUDSON, ST. CROIX COUNTY. WI I i l._._ ~ BENCHMARK TOP 2 > OF 1• IRON PIPE -- g ELEV 917.23 11 AND 'PED rHE .LNG F al al ~~, ~~ I Z I I * ~~ I a ~, I °~I®I ~IQI . ~I~I of I ~I~i ~i9 aT ~I ~ I ~I°I TO LNG, z _i = ~~ HOUSE I C~CG°~40G~OL~D ~MG°~MC~~7 [~QP as eon 909 pack ~~~ dOO4 ~ I dOO4 6 ~ MCCUTCHEON ROAD S89°3SK1'rU 6S8 ~ -- -1 ~ ~ --•-=t_~L_--•- ~ ~ 6 6' `~r \ DRAINAGE EASEMENT ~ V 1~' 1 ~ \- ~~ H.W.L. =932.00 '~ 1 \ C6 ~\ ~`, ~~ ~ 1 ~\ ~ .\ EXISTIr HOU: S 6~ ~ _ i ~ \ \' t9 y~ '6~ \ ;, '\ ~- \ cSj \ ~~ ~= ••\ 2.829 ACRES _ 123,228 SQ FT ~ ' \\ ~~ \ ~ ~ MINIMUM FIRST FLOOR .\ f-DRAI E EASEMENQ ~ ~ ELEVATION OF 938.00 •\ ~ ~ \ n ') POND NG AREA \ ~ ~' \\ ~\ ~` ~ ~ ~ ~ i '' 33' 33' I 2.368 ACRES I I j 103,157 SQ FT ~p MINIMUM FIRST FLOOR ~ O y ~ I ELEVATION OF 928.00 I M ~ N I r ~ v ~ ~ I N88°01'36"E 264.41' j ~ ~ ~ j I ~ ~ ;u I j j I I. I r` I I r •' I r ~ ip ~ • P>t 3t r ~ ~ ~ $ ~ _ ~ ~ Z Z I I „ T N I I r I T ~ , 33' 33' ~ N89°46'06"E 499.48 Ex EXISnNG CONCRETI TO BE 6 2.219 P 96,659 S89°27'5~