Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
020-1447-11-000
Wisconsin department of Commerce PRIVATE SEWAGE SYSTEM safely 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)]. 'ermit Holder's Name: City Village X Township Bast, Kernon Hudson, Town of :ST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION /~ TYPE MANUFACTURER ~ ,ti~~ CAPACITY Septic W ~ Y~ d .l ~ZS~ F,'1 ~~ ~ Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent toAi~l~take ' ROAD Septic ~+ t ~ ~~ ~ ~V ZZ ~ ... Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Len Dia. ist. to Well colt nRSnc2PTIf~N SYSTEM county: St. Croix Sanitary Permit No: +' 515177 p` State Plan ID No: Parcel Tax No: 020-1447-11-000 SectionlTownlRange/Map No: .29.19.2842 ELEVATION DATA STATION BS HI FS ELEV. Benchmark D . 9S ~~ ,~,~ /~ Alt. BM g~ ~ 55 Bldg. Sewer . g~~~5 St/Ht Inlet 7.3 y3. bZ SUHt Outlet ~, 5S ~~. ~ / T Dt Inlet ~~ ` Dt Bottom .~ Header/Man. $.~~ ~JZ ~ 5 Dist. Pipe $.~5 ~z-~ Bot. System 9~~ ~~~ Final Grade ~, ~ ~~ r ZC J St Covey-l~ ~ '1 .~ ~` r6 ~ SEDITRENCH Width / Length No. Of Trenches Pt7 DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS C,'7 ,~„~ 4•• Z rG~~ ~-~._ `~ ~,~ ~~~'~ SETBACK SYSTEM TO P!L BLDG WELL LAKE/STREAM LEACHING HA OR Manufacturacr• , ~,~.,ra~Q~- ~ INFORMATION Type Of System: d ~"~ ~ 75C ~$ / ~~tS ~' C UN 7 , Model Numbe ~ ~ ~ ~ 1. QJ~ a a,n. 2~. . c nICTRiRI IT1f11U CYRTFM L:~Ls..~il. / ! A1n'1>Li~ Header/Manifolds Length ~ Dia ~~ ~j i Distribution Pipe(s) ` Length 1 Dia \ \ Spacing ° x Hole Size ~ x Hole Spacing \ Vent to it In ke 3~~ ~la+~ Cf11t r _fl\/FR ., n..,~~.~.e c..~to..,~ n.,i" vv Mnnnri nr At_C;rada Systems Only Depth Over i Depth Over xx Depth of xx SeededlSodded xx Mulched Bed/Trench Center ~ ~~ Bed/Trench Edges ~ Topsoil ~ Yes 0 No Yes ~] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / /_ L t' n• 674 P' T'm r Lane dson WI 54016 (NW 1/4 SW 1/4 14 T29N R19W) Coyote Ridge Lot 11 Parcel No: 14.29.19.2842 ok oca to Ine I Fri 1.) Alt BM Description = ~ 2.) Bldg sewer length = ~ 3 A, -amount of cover = ~ / NP~ d/t G p ~ ~~~5 ~J~ rTG SSC.~Y _ a ~ ,~-s ~~-- r- i 1 ~_ _- _- --_-- - --- _-----~ ~ -- ---- ---- -- - - - Plan revision Required? ^ Yes [~ No i /' iZZ[ Q f ~ f ~~ Use other side fcr additional information. ,__.___. __. __ ~ ; ~_____ _ ... / _7 I --- - ---- _ I (f-/ - - _ _- -- -- Date Insepctor' Sign a Cert. No. SBD-6710 (R.3/97) ~P - n ~%tn ~ t~r>tlmerce.wl.goV Safety and Buildings Division Countyv 201 W. Washington Ave., P.O. Box 7162 T ~~ci ~ Madison, WI 53707-7162 Srtaitary permit Nu~er (tn be Shed in by Co.) Co„vr me 5~5 7 Sanit P it A li tion.--= State Transaction Nnmber ary erm pp ca In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate ~euep-mental ,/ TT" unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Address (if different than rrmrling address) submitted to the Department of Commerce. Personal information you provide ttffiy be used for secondary ses in accordance wiW the Priva Law, s. 15.04(1 xm), Stats. I. A licatioa Information -Please Prim U rmatioo y .~ ~i~r r~. ~i~+! Property lhvne r s Name ~ ~ Parcel # ~ / //~~ /[.~ nIO.J lUAST ~ ~ o /~ r // ~~ Properly Owna's Matlmg Address Property Lot~tion / -~ } G O 'Z 8 L .orcE' ~ ~.~~ ~ r 7 Govt. Lot C City, State Zi Code PIANNIN p ~'~ r ~ ~/~/ ''/., ~_'/., Section 1~ Sa ~J I .SyO /.S ~~C ^ 7T 7,~ (circle ones,, T ~ 9 N R r' II T f B ' . ; ~ B ~W . ype o u ing (check all that apply) pk, ~ Lot # 1 or 2 Family Dwelling -Number of Bedrooms ~ /~ Subdivision Name ~o~JR" v~ BI " ! K~/O~! 67 ^ PublicfComarercial -Describe Use ~ ~~~ ^ State -Describe Use CSM Number 8-ititts[gC'8f / ®Town of /~/ur0,t'ow! ~„J ~ e~ III. Type of Permit: (Check only on a on line A. Complete line B if applicable) `~' New S smm y ~ ^ Replacement System ^ Trcatmeat/Holding Tank Replacement Only ^ t~Eher ModiScation to Eadsting SYstem (explain) B- ^ Permit Renewal t Revision ^ Change of Plumber ^ Permit Transfer to New List Previous Permit Number and Dam Issued Before Expiration Owner 5~5~1-7 L O~ ~ ~ - ~~ IV. a of POWTS S stem/Com onent/Device: Check all that a 1 ^ Non-Pressurized In-Ground ^ Pressurized In-Ground ^ At-Grade ^ Mound > 24 in. of suitable soil ^ Mound <24 ia. of suitable so' ^ Holding Tank ^ Odrer Dispersal Component (explain) ^ Pretieat~nt Device (explain) ~ r) a~ V. Dis rsaUTreatment Area Information: ~ Design Flow (gp1~ Design Sod Application Ra gpdsf) Dispersal Area Required (s D' Area Pro rspetsal posed (s / System Elevation Goo .7 s 87.9 5'.7.5 VL Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units S ~ New Tanks E i ti T l x s ng aa cs ~ c U ,°~^ ~ ° ~ .~ ~ i C7 `~ C / a rn w . Septic or~FIeltiiog.~anlc aao - /.70 0 ~ L//ES .c ~o.~,lc.crr ~- D~~n~t,ram~r Vll. Responsibility Statement- I, the ander~gaed, assn®c rYSpoasibility for iastdlataoa of the POWTS shows on the attached phtaa. Plumber's Name (Print) Plumber's ~ re /~ MP/D~RS Number Business Phone Number Plumber's Address (Street, City, State, Zip Cock) L 8 Sr. wy o?S ue .ro Lf I Sy7.~L VIII. Coun /De artment Use Onl ~ ~Approv~ Permit Fee Da te ssu Issuing A t Signature s -` / ~ ~ ~~ van Reason aial l i1X. Condi~'~~Qteasons for Disapproysl ~ (~ 1 it~,~,,, /~~ J1Rw 110~tZoc ~~ 1 Se tic tank effluent filter and 3, B rdU ~ , . _ . p , ` ~~ ~ , dispersal cell must all be servkes /maintained ~ ~ ~ r ~ r~~ o n.. as per management plan provided by plumber. 2. IUI setback requirements must be maintained ' J ~ ~ /i s ble od f oMina ~ / ~ a c e nees. taec~t'~ c~ dV~. @ ~. ~ ~ p..~a ..,. y.C ~~ tiro suo~~ w qe a.eOmy Oory ua paper a ~ Z les m sae S ese~~ I ~ G`Y ~ ~ ~,` ,,M.ro,Gc,(A/ r i~. o . ~7 ~.~.~ ~ ~ ~~.c,, wee ~~~ ~_ 3 SBD-6398 (R. 02109) Valid thru 02111 COUNTY ZON7CNG OFFICg ~ RECE EV- D ~- ~ * ~ ~ en OEC 0 9 2009 $ + ST. CROIX COUNTY PLANNING & ZONING OFFICE Date of installation //-,?3.~y o9 Permit number State plan number Nq Omer /~E~„b,,, ~asr - .3 c err/ /,c 1~~,.~ddress G 7y ~/•~r ~.vQ~~c L.~~~' Legal Description Plumber signature License number Description of benchmark /oa.o - r-os o< / ' srsrl ~i.~r Elevation loo, o ' F..C.- 9S **NOTE: -Use field readings and include benchmark reading for each group. of readings. s~rrc ~ aoLnz~ ~: 4/tO~oL -f~wr.~. Q Y s/owt~" = L . B ~ ~!r' i% ~s J Manufacturer ~i~-sE.c o.~ca r~ Size /,~so Elevations: Inlet 7..3 9.~ ~s Outlet 7. ss 9,~. y' Lid Observation pipe y' Manhole cover a Final Grade Setbacks: Building /Z T Well isa' P/L >,s~s ' Holding tanks only: road Vent to fresh air inlet Alarm manufacturer Model Field benchmark P[J!!P TIC: - .r~A Manufacturer: Size Elevations: Inlet Outlet Force main if through riser Pump pad. Top of manhole cover Pump off On Final grade Field benchmark Pump manufacturer Model ~ilarm manufacturer Model Gallons per cycle Setbacks: Building Well P/L SOIL AASOIRPTION SYSTBlt: /.~.~'i c t'as re.a y9N1o~c Bed Trench ~ Mound Other ( specify type ) y «'A~R«s (.~ xs~i-/z, Width or diameter- Length or depth 9y, 90' Number of Trenches, beds or pits- a Distance between soil absorption units S Type of cover Gravel depth below lines or around pit Spacing between-lines Distribution system (explain): Pressurized systems: Force main diameter Length Manifold diameter Number of laterals Diameter Elevations: Manifold Designed liquid level if pit Field benchmark: r Page 2 - As-built For trenches, beds or mounds: Beginning Line or Absorption area .(one} Ground surface 9d.c ` Top of pipe -~''~r.~.xr') Bottom of system 9~s/. ~s'~ Line or Absorption area (two} Ground .surf ace 9l o Top of pipe ds sa. ~7 Bottom of system .` 9/, ash Center Snd y'!.1 ~ - 9~- (~9i 3s~ R! ~ (Q•..~S•> Line or Absorption area (three) Ground surface Top of pipe Bottom of system Line:.; or Absorptior- area (four Ground surface Tap of pipe Bottom of system Setbacks: Building Well P/L Vent to fresh air intake N~'ICS: Drawing to be scaled on blank or graph paper. Signature of the plumber and the name of the owner and the date .are to appear on the drawing. r q h u ~~ a ~ a~ k b,~ ^ o ,~ h M L ~ ~ ~ ~ , ~ ? ~ a i o r ~ ~ ~ ~ n n ~ ~ h ~ .o ~ ~~` ~ -v y ~ ~ - O O ~ .G n ~ H H r, al ~ x ~ r x 0 ~ a A , o H .. e ~3 `'"z` ~~ ~ k a ~- ~ ;; ' ~ ~ i ~ o vg ~' ~, ~ p ~ ~ o v ~ ~ ~ 0 n4 ~f7 ~` ~ u b ~ ~ 1a ~ ~M ~ '~ ~ "~o.`' C2'` v ` ~ h u ~~ ; t Q. q ~~ ~ ~ ~ ~ a ~ ,~ 1 0 ~~~- ~ a wd A ~ ,~ q '`" ~, " ~ ~ ~ ~ ~ ~ * ~ a ~~ '` ' ~ `4 A r i; ~ - ~ ~ o ~ N z ° w ? q ~ ~ a ^ e o L ~ ~ ` h M ~ _ ~ L .,~~, o ` a L e ~ a 'm ~ ~ ~ ~ ? ° O c `t L a ~` o t A O V ~ p `t ~ ~ ~ ~Z ZN TT ~~ ~ A ~ ~ ~ S ~ t ~ ~ A ON X ~ ~ VU e ~^ o `` ~ ' ~~ a ~ a ~ m t p ~ .Z' .. Z O Cf3 . ° ~ as 4 ~ '~-Z{ O 't 9 ~ ~{ Cep v N ? ~ ~ rtAj i a, A ~' a ~; ,~= h w 0 , 0 a a ~ ~ ~ ~ ~ ~ Q. N a ` ~ P ~ `` k O ~ 'o\ ~` O 4 ~ ~ n 0 ~ w R N v ~ '~" D .~ Q q ~ '~~ h ~ ((ww` _1 A ~ Lj ° '~ ~ h "1 4 '~ A ~ ~ a ~ O O ~~ ~~ ~ ~ ~ a ~ ~ ~ ~ ~ a ~ ~ ~ h ~C •'~ w a ~ w P L c~1 ~ ® C ~ ~ '1 '~ a ~ ~ +D Z `~/ 1 O a o ~ ~~ ~ o ~ `1 o ~ ~ O v A ~. ~ A ~ N ~ 1 ~ N e 0 a ~ s .iC cA. ~ -q A o O ` y ® ~ ~ , ~ ~~K ~ ~~ ~ O o n ~ ~ P, 6 ~ 1 / Z h ~ N a a r ~~ a ~AA •l A a ~ h h A a ! ~ ~~ `\ h t0 ~ v V Ir~ 1 Gp t b I ~' ~ ~ ~ O h 7 O O y 1 i ~ ~ ~ ~ ~ ~/ \ ." ro ti ~. a 1 ~ ~ h Q ~0 ~' a_ Lo r /l Co r. rt f l i~OrQ', ~ 7 y ~~E li•,•,~,~ L,v,,~ ~/ rj",' o/f /7nOSa.~ .Sr. tRoix Lo, ~/-,~3~.t y a Property Owner ~E~rwRer/ kf.oSx' • .3 iert ~ ~e~.w.arParceJ ~ ~t o9~~iy ~~~ a ~ # ~ goring ~ ~ Pit Grorxrd surface elev. 9g.e R Depltr to ~g fardor '/la hr . Soti - Rate Horizon Depth Domirdurt Radar Description Texhue Str~hxe Consisienoe Boundary Roofs in. Qlhnrsea Qu. Sz. Cora Color Gr. Sz Sh. 'EffiF'I 'E1flIrL y ~ T. s'rc y/y s/ .t ~k ~ '' s o is rJ /~- ~ /b y7- io rc sly - s.c _ ~ _ ®Pit Ground sruface ele+r. G10 d ft. Depth bo 6rrw"ting factor ~/y2 'er. a#°~ - Sal Rafe Haizcn Depth Domin~rt Color Redox Description Texhu~e Strudune Consistence Boundary Roots t in. IlArxrseM t1u. Sz Coat. Color Gr. Sz Sh. 'Et~1 I o- 9 oYa 3/i ~ / .? ~ d ~ as .7 . T /. 2 9- a 7,src - - s/ ~ ~ s 1 . o ~# ^ ^ Pit Ground surface elev. >t Depitr to hniUng factor ~r, soi Ram Ftorizort Depth OominaM Color Retbx Description Texdxe Strucdxe Cor~berrce eotsrdary Roofs GPD/IF irr. MrmseN Qu. Sz Cont Color Gc Sz. Sh. *~ ~2 Eflkrerrt #1 = BDDs > 30 < ~0 mgA. and TSS >30 < 150 rtgll_ ~ = BOD < 30 < ~ 'rhe Det~tment of Commerce is an equal oppordmity service provides and empbyer. If you need assistance to access services or need material in an alternate format; please contact the meat at 608-266-3151 or TTY 608-264-8777. seo-a;3ocRmar, ~I v 0 ~I i O ~ \ ~( ~ i V ~ Z '~V/ V 0 C ~ ~ ~~ !7 w ~4 ~ \ a p r ~ 1 ~~? ~~ y e ~ ~" J `O ~ d .Y L ! ~' V V o Q p,0 ~ O ~ ty i• ~ `a ~ ~ ~ e ~' V .~ a , V O y r V ~ ~ 1 y ~ V ~ ~ (~ N ~ j y f~ V V iV ~~~. ~ ~ ~ ,~ L a ~~ Q O V Q \~~- \J ~ M~~~~ W~~~ 0 f~C~.+.~ 0 Q A W ~ ~ V \ a ~~ ~ ~ ~ ~ ~: i N ~. 0 V R _~ T` Y ~ n 'dam V ~ V •7 a ^` ~0 \ 1 ` ~~ tt N~ ~ x ~ ~ ~ d0 `1~ ~k \ ~ a ti ~ k ` ~; ,~ ~ ~ a n -fi ~ Z ~ .. "~ R ~ ~ t ~~~ 'I' V V 0 b a ~ h ^~ v ~ ~ M d, v 7 2 .. = ` M ~ V Q V h ~ d ~ t b~ _~ ~~ n ~ ~ y -~_ '~ -~ h ~; ~M W 0. ~I D ~I v i L I V Z ~~ T ~ 4v~ v ~, C ~ i ., ~ 2 ~ ~L y ~~ .a ~ ~~ ~~ ti~ a p ~~ ~ ~ ~ w ~ ~ ~ n / o ~' ~ o~: v ~ IY ~ ~ ~ h ~ ~ Q ~~ ~ ~ ~ ` N aQ ~, e ~ ~ ~' ~~ M~ h ~ ~. ,, ~ o p~ ~ ~ ~ v o ~ ~ ~, o ~ 0 ao ~ ~ o v .~ G D v ~ Z M \ i 41 V ~O ~ '~ a ~ `~ b W .a I~ V ~ ~ ~ ~ ` N l1 ~ ~ ~ ~ v e-,' o 0 ~I W 0.p a ~'' I R ~ ~ ~ _~ a- T y ~ ,,, a V '' ~~ ~~ ~~ r nu N~ ~ x ` ~ .~ `k \ ~ ~ x o a ti \~ k M ~ ~ ~ ~ M ~ V -~` e ~ ~ '~ -==- W `~ V y v ~ ~ ~ M I ~ v ~ V ... t M V 4' V .'., ~ @ b } ~ ~ o o Apr ~cY `h V~ H K ~ ~` C ~ 'Q ~ d d 1 ~ ~" ~, 0. . ~ =__ --~ Wfsoonairroepshnentoftbnrnatoe SOtL EVALUATION REPORT ~~ 3 ~~ *~ aooadarroe~r Camr~i;, wis,. Adrn. code ~fiaa~apl~esispiananpapernotla~~an8i2x11rnches~sm~PJlannasc ~ Sr, ~so.x &x~de.batnotii~iertmc.rer~rai and irorixon~i re+Fererraepotnt(>DYj, dr+er~ion and pencefltsiope;scaleara;nna,noesow,anatocr~onas,as~noetone~troaa. ~ ~ OZ~- 5~~7-. //-~ e pant as ~n 6y o~ Properlyisc~or, /~~~.~,loa l.~Asr. NOV 0 2 009 ~~ w ~Sw ~ /y T d9 ~ R /9 :cam ~~ Lot# Block# SuMi Name ar CSMiE NG&ZONINGOFFIG~ G.ayerE GcjDl~ ~P Phone Number _ ~ I~~+~rge ®T~ Nemeat Road ~ Newao~nx~ion ~I~I~dan~ItNumbercFbadroo~~___~___~~ira6a Cao ~p ~~ ^ ArbioarconMn~-Desaia~ Panartmalartai O>>u ru"stir Flood Plafn eisu~on ~appipble ./A ~ QafIB18~ OopMrrB(~.4 ///G /l o r.,~0 /.la cJrS f ./ f r Z Lo A.Oi~.+L ite rt" ~ fE~/ • 9P / ~ 6ZE•co,yvtNo S. Ec , - 9.T. S /o/N~ y'•it cFS l'o iS6 /L~.~seac/J '~"' ~ /7A/~/ Tiia SYSrFro ro nJaie rX f 4lCS r iiS rtieN - As ~ols~,QaFj /t6co.-i.-scuv 3- 6.2 ~ t'aF.~c.vt's rn ,/~ //I ne U / ®Pd t~rorrrrdsrsEaoeelerr. 8, s' $ Deo~ to irrt7~ >l~n ~ ~ ~ ~~A ' " tior~+on Darniaant Redooc DeecripGorr Textrne Sh'uclure Come !may L~~ ~ ~ d- /6 ir. 3 Z ~- ~ r r .Pcr~= G /. O 3 8- yo 7. s Yom. S-/ - c s /f'-.y /.y S~ 7 .7 ~ G. o rrt ~ c.rc .~ -3 ~:-.. tlanon Deptlr ~ [lomirrant Redgrc Deerxip~on Tie -~-- - ------9 ----- - -~ woe y Rno~ ~ Rals GPD~ ~- fir. S`z Gard. Caior Qr. Sz Sh_ +~ .~ .~-/.JO /o Y2 S/ - rs f c S S rf -- - 7 /.li '~nt~f= >30<2~~-andTSS>30_< ~E~rd;R2=80D <3pmgA.sdT$$<30mgll- t.ST Name (PlBase Priaq CST Number /cN.4~L /. .sse-rr dd Y97 /'' ~ T ;Eirataa6on Corduded Telephone Niunbar ~~ .3 //~/!LL/A ~'- _ ~S; GAK ~LiRI~LE W1. .S / //~ -~i _n 9 7~ c~ Q 74/_ 1+.[ /n r 1 ~ D•~ ITT MM/./AMMI.~ P~ope~lyOwnet_ /~E/l.~o./ .c~A.S7- parcel ID3r Pane aZ of _ 3 ® P8 C~lorard salsas elev. 9s G . it tI~ t~ inking lector 'iod in. _ ~ tia6e Horimn Oepfh Domi~arK Redaoc Desaipion Te~drse Slnrcfine Caredeienoa Botrxia~r liools (~ Odl~ in. Qu. St. Cont. Color GY. Sz Sh_ '~1 '~ / o -.to ior~e - s / ~ .~ ~~ Y . 7 .?a -.? 0 3 - s/ ~ . G d 3 7- ~ o s/ - ~aAd. s ~ s6 .~ - G . D dR~/. S. Lo - o ore S/ '" S - - .G ~ ~l y ®~ ~~ ^ ptt Graardsulaoeelev 9G. 9 ~ ~. Dept, b lirnilrrg factor > /ao ~ n, soi tzebe Horanon Depth Denirrant Redaoc Dton Texfuna Shrelrne Conrdmerrae Borndery Raois GPD~ irr. MinseO Qu. Sz. Cat Color Gr. Sz Sh. ~1 '~ ~ d - oY - 3 B- o ): 3' 2 - y yo-boo ~orc s/y _ yi~ a~# ~ ~ - ., ®~ hound errfaoe elev. 93.6 ~ Deplfr !a im'prg factor 5~.? or. Sol lie Horizon OepBr Danmark Ttedar Desaipion Te~dure SUrrc~ne Consisberroe ®otardary fools m. YiageY ~. Sz Cat Color Gr. sz. s-h. ~ +~ D - o .t .r - / ~ s~.~ n y e7 .27- o rc s/ - S, / s6 ,, _ G 8 .3 ~ /- y a rR s/2 Si / s~,E ~ c S `.#1=80D6>9p<~pn~andTSS>9D_<150mg11 'EflluenE~=BOD _<30 s tr19IL end TSS a 3Q rrigll. The Depa~bmerit of Commeax is ~ ecpml opportaeity sexvice provides and employer. Ifyon ~ assistasae to services or Hoed aoabaiai is ~ abbe , please oombact fherOmeat at 608-266-3151 a• TT'Y 608-26d-8777. .: ~: ,, +~ sen-e+soo~.avao~ ~~~,~ ~ Ptopeiiyawnet ~Eiln~o./ ~,Q,S f-- Pascal lt3# Q ~~~ ^ ~~ ®Ptt Grortrtdsr~Faoeelev. 9s: G ~ R Dean to rm~.,o >ioa ~. Page a2 of~„_ Hormott Depth Oortrbneuvt - - Redarc Deeai~at Terdure - - .. a --- -- Carrsisbenoe Sotrndety Roots soa GP Rasa DlfE~ in. Qu. S`a. Cord. Color Gr_ S`z. Sh •~ • / o -ao /ort - s / ^ ~~ ~/ . 7 ,?0 -.7 ~ a 3 - a ~ ^ . G d 3 o s~ ... t asd. s -~ t ^ - . d .r. ~o - O dr S/ - S . li 1 Harmon Depth t Darrrirtarrt l A Redaor DeeQip6ort Texbuns Ca~sbenoe BorrrMay Roots Sod GP' Dll~ ~e n. ~ itteeq Qu. St. Cord. Color Gr. Sz Sh_ 'E~t "~ ~ p- dy 3 B- o ): s' 2 y yo-boa iorc s/~ .- MiC ^ ~9 ~ ~~ ~ ®~ Grand swtaoe eiev_ 93. d ~. t ~ ~9 moor 5'.? ~~ ~ HorFmrt ~ Da~tt Redox Desaip5ar Texhre Strrrchrte ConsbsffinOe Borprday Roots sod Rabe is lYasrseN t1u. Sz. Cont. Cabr Gr_ sz. Sh. 'C~1 '~ D - a .c - / s~k ~ . 9' ,7 ,?7'- a rt s/ s~ / s6 ~ - G , 8 3 3y- y d rc s/L . - Si / r6k ~ c s - y r '. it ~ ° B0D6 > 30 _< 2a0 rn®iL end TSS >30 < 150 rrplL ' Efpuerlt dR2 ~ ®ODS < 30 ~- end TsS t 30 nlglt. The De~mem of Commerce is an eriaal ~* service p~ovidec aqd employer. Ifyon need assistaave to access services or aced a in art albernale , please contact ,.' ~ 608-2b6-3151 ~ TTY 6d8-264-8777. ~~ ~' sat>~soQrovoor "~ ~_ 1 ~ -o ~ z-~ ~ -d H ~ ~ O O c4sl ts1 ~n •.. ~ a r~ ~ ~, a ~ A A ~ o H •• ~ ~ ~ t x ~ ~ ~ ~ ~ ~ o e ~ o v a '' ~ o ~ O a Z ~ ~ ® ~ ~ ~ n ~ \\ ~D ~, ~ o ~ ~~ ~ i ~ \ ~~> t ~ M `~ "` a ~ ~ o ~ ~~a a ` a '~, ,~ Yl~ ~ A\ ~`C ~~ O ` D C o \ ~ a ~ o a ~ 7 9 ~ i o ~ N p ~~~ ~ ~ 1 h ~ ~ ~ ~ A ~ ~ ~ ?~ n ~; ~ ~ ~ ~ ~~ ~ , N ~ ~ li w a ~ 3 ~ n' ~ Z , ~ ~ O z r ~s ' ~ a ^ !r s~ 'o ~ h "1 l ^ ~ h ~ O O a ~ ` ~ " : ~a 0 a 4 ~ i _ L ~~ ,~ O 0 ~ ~ ~ A ~ a ~ ~ ~ ~ ? o ~ c `t ~ L 1 a a 0 r A t o ~ ~ ~ ~~ ~'~ v ~ ti ` ~ ~ \ h ~ ~ o ~ `i ~ .~ w / ~[ Qi ~ ~~ ~ ~~ ~ ~ ~ ~ ~ ' t' . ~ ~ "V + \ _/L o ~ 11 0~. ~o~ Private On-Site Wastewater Treatment System (POWYS) Indez and Title Sheet Owner: E~ o~ ~ sr Project Name and System Type: ~E~r,~a.r ~asr- ," ,Ba, /.~t~o4.~a dogs Location: G 7y ~/.~E D /iY,JE~C L.o./d Street Address /Y~ .Sil ~y~9 ~ ~9 l/ ~o c' // ~oYo 1'/ 6c%OlF Legal Description, G Ow,~ of /f~,osd~„ S ~.vo~x Co. - Township/County Contents: Page 1: /,~®Ex r ~i r~E .y6~r Page 2: ~6 r DAB ~ C.ra.rr - S.-c r<..~ Page 3 : ~a w r'1 Od.~ .~ `s ~rs.~,u.. ` ~ /!i./.t s ~.y ~..~ r Pa.t.J Page 4: Page 5: - Page 6: Page 7: ' Page 8: .Page 9: Attachments: ~a<c ~yos ~.. r<..r ~~~e.s r Plumber/Ber: Joy./ G'~z~ Signed: Credential Number: ~!~ d 3 /3yG - Date: /o -.z 7- 0 9 ~/i ; ~ i1/1 n , ~ i in n ~P eerrter~roetttrigov Safety and Buildings Division Courtly ~ 201 W. Washington Ave., P.O. Box 7162 y- ~jroil• Madison, WI 53707 7162 ~ Sanitary PamitNnmber (to be flied in by Co.) :~ 5 5 ~ ~ Sanitary Permi# Application ~: ~` ~ StateT ~~ Ia acoor~nrx with s. Comm. 8321(2), Wis. Adm. Code, submission of this form m the aPpm unit is required prior b obtaining a sani~ry permit. Note: Application forms for state-owced POWYS are Project Address (if fluor matliag address) submitted to the Department of Commence. Personal infornmUion you provide may be used for secondary ~ /~~ ~~. in accordance witlr the Priva Law, s. 15. I xm), Slats. ~ ~ ~ ~ r I. A tion Information - formation ,, `a' D, ~p~y hr's rr?a~me / ~ Parcel # ~E/l.~o,/ sr 620 - /~fL~7- /l - ob0 s Ma~mg Adare~~ Property Locatmn /, z ~SyL 9y~ L ~E Q,o. ~ ~ ,,,,~.,~ ~:uu~~, , FIE C Govt Lot City, State Z' Code Phone Number ~'v., s~/ ~~ semen ~l ? 9 N T R ~ II T f B ' h k ll ~ ; ~ . ype o u tng (c a ee that apply) Lot # ~1 or 2 Fatm'ty Dwelling-Notrdter of Bedrooms y / Subdivision Name OK~ ~5 Blodc# C-OYUT~E" .OG~ ~ Public/Commencial - Describe use ~ ~~_ ~f ^ State Owned -Des«rbe use CSM Number ~ef 1 Z ~~e, t~ Z2~-Z3 Town of uDso./ Kww.- III, T ype of Permit (Check one boa o® line A. Coro Gne B if appUca `~ ~N_~ Stem ^ Replsarneat System ^ T oldiog Tank Only ^ Other Modification ~ Ex~mg SYS<em (e~cPlain) B. ^ Permit Rrnevvat ^ Permit Revision ^ Chaos of PI Permit Transfer to New List Previous Permit N~ aml Dam Issued / rv. of PoR+TS S Coro bDevicts: Check all ffiat a Non-Pressurized In-Ground ^ Pressuriad In-Ground ^ At-C»ade 24 in. of suitable soil ^ Mound < 24 is of suimbie sor7 ^ Ho~ierg Tank ^ Other Dispersal Cor[~onent (explain) ^ Pldreatment Device (exphun) V. Dis UTreatmeot Area Information: Design Flow (gpd) Design Soi! Application gpdsf) Area Required ( Area Pro posed System Etevatiar ~ o Asa 8» 9ys VL Tank Info CapacUy is Total # of , Gallons Gallaos Units L ° :i Akvn Tacks Existing Taal-s ~ ~ g ~ ~ ~ ~ zd LtJ Za ~- / C a rn ii t5 i% Sepne a itividi~~'ask ~ 00 -- .~ 00 ~ ~ E'SE2 Lo./G.t ! ~ ~s VII. Responsibility Statem~t I, tie ^adersigaied, asat<nx resp~sibltity for h[stallatioa of tic POWTS shows oa tie att[reied plaaa. Plumber's Name (Print) ~ ' Plumber's MPli Number Busi~ss Phone Number .~/ o ~/ E[Kt / ~%"--~C-Z~ .?3/3S'6 /s L7.7-S,tG6 Plumber's Address (Street City, State, Zip Code) /1/ G,? 98 Sr wr..?S ~ue',oao ~1,.Z" sy73G VIII Coun IDe rtment Use Oi Approved Permit Fee s ~7 d6 ( Date I l D ~~ 9 .Issuing S' Reason • j IX. Condit~~l~~Reasoes for Disapproval 3~ ~/~ r ' - ~ /QP ~ f` ' J ~ ( ~ /\ tk C e~. Gc.. a . e , . ow d[~. L Septic tank, effluent filter end / dispersal cell must ail be services /maintained ~ / ~,,,~~ ~~ ; ~~ ~ r 1 ~ r [' 0. `O'ff + . as per management plan provided by plumber. ' ' ' 2. fill setback requirements must be maintained as per applicab~ code / ordinatlcas. .. wapmc lns.as wr ~ s7aca a~a s~v~[ w i!C 1.09Y1y oB1y Oa @~t1C[' M[ [~ lain 8 IR S 11 ~larS>Q Srie sBD-63ss fit. o2ro9~ vaud tmu oyl l ~I 4 0 '~ f V Q ,~ ,.. ti 1.. 0 I V R ~. ~ d I I 4 W o Cs __~~ y O O `T v N ~~ N i ~ t a 1 M ~° e ~~ a ~ ~- ~l \ ~ ~ v ~S V ~ i ~ L ~ o ~ ~ v ~ ~~ ''' O v a V ~o ~ -~~ M ., ~ ; M "e ~ v®~~\ ~ o~.~~ o ~ ~! b Y t v ~~n; ~~ ~ QV~ ~\ '~ ~ v h a o. 1 ~ T a. V y ~~ A b O ~ ` N~ w~ M ~~~ ~~ 6~ L 4~ ~: W a ~; ~v v ~ ~ ~ M~C ~ ~ 4 ~ ~ 2 V ~ ~ n y :- a :o ~~ ~~ ONV ,a ~ T .~ a ~ ~ V ~ ~v~h r~ V 1 `aI W ~. ~ _ ~ a v q \ .x ~ ~f a ~ b \ k ti K ~ \ ~ v V ~ V 0 ~ v Q i~ ~° ~ - lC \ M b y v ~ M ~I 4 D ~1 a Q ~ ~ n I ~ ~ O V "a ~ ~~ I °. m e~ S~ by ~ ~ y °~ ~~ v ~' N ~~ N 1 i ~ a Q ~ 4 ra M y c c c 4 ~ i 1 ~ \ S v o ~ ~ a o ~ V v ~ ` O \~ `a O Q` ~C" O ~ '~ ~ V O ~ ~ M \ ` y ~ ~ v 'v ~~ N ~ ~ o ®~--- ~ ~ a o ~ e . c ~ z a ~ ~ o ~~ V f 1 }~ v w ~J ~' ' ~ ~ v ~ b A ~ v t ~j Q p ` X ~ ~~ 11 ~ ~ r ~~ y ~ ~~ ~ ~. 'O ~ ~'~p '',y "~ N~ ~ L v i I i -- ( Y- -- 0 ~ ~ ~ M J 4 ~ ~N ~, ~. n ~y __=J Z O N ~ ~ s o, ~ ~ ~1 O .J ,a ~: V a ^~ 1_' `7 ~ ~ ~ K k T °~ ` ~ ~ V ~ ~ ~ v 0 ~ ~ ~ h 1 O ~ (\~ mil' J V ` v y ~ ~ ~ \ 1 ~ d ~~ ~; 3 A ~ ~ ~ ~ M 0~. ~o~ Private On-Site Wastewater Treatment System (POWYS) Index and Tile Sheet Owner: JC E-.c,~o.~ ~,a rr . Project Name and System Type: ~Eir.~oa ~.os r _ y- ,a'n. /„~ Ana ~~a ~o ors Location: ~~~~F~ Q,o, Street Address ~/~/ s~/, ~5~~,a9, ~ /9 ~/ Lor // ~oYer~ ~.oc~ Legal Descrip~ti-on / r6cJ.J of ~/Oso~/, ~r GRoiX ~o. Township/County Contents: Page 1: /,vaEx r L i r~~ ~,ve-ter Page 2: ~er 0,..~ ~~ C.ra.rr- Sic ri.d Page 3 : ~D w tt Oy.y En. `.~ ~.s./us L r' /li./.~ t ~.Y ~..il' dtw.J Page 4: Page S: Page 6: Page 7: ' Page 8: Page 9: Attachments: laic ~lJ.OL 4.. r~..~ ~s~/ate >-' Plumber/I3~g~er: 7~H~ ~~t.~'E ~ Signed: Credential Number: /;J~'- asi~y6 - Date: /o ai- a 9 ~-tE Lo,JdE,~ rio.J.I[. ~oklrS ~oiyPo,~t.~r~„/..ec.~ S6 /J -/oSL7-!~ ~R. G~99~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page .,,~ of y FILE INFORMATION Owner tee,/ Est' Permit # DESIGN PARAMETERS Number of Bedrooms ~ ^ NA Number of Public Facil"tY Units ,_ ^ NA Estimated flow {average) do gat/day Design flow (peak), (Estimated x 1.5! Goo gal/day Soil Application Rate gal/day/ft2 Standard Influent/Effluent Quality Monthly average" Fats, Oil & Grease {FOG) 530 tng/L Biochemical Oxygen Demand (BODS) 5220 mg/L DNA 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 [~„'NA .Fecal Coliforrn Igeometnc meaty 510° cfu/100m1 Maximum Effluent Particle Size Y8 in dia. _ ^ NA Other: ~ ^ NA 'Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity ,/000 gal ^ NA Septic Tank Manufacturer L/6SE~ ~~~. ^ NA Effluent Filter Manufacturer Q 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 D Wetland D Other: ~NA Dispersal Cellls) j~ln-Ground (gravity) D At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other. ^ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ^ month(s) {Maximum 3 years) 3 ear(s) ^ NA Pump out contents of tanks) When combined sludge and scum equals one-third. (Y3) of tank volume ^ NA Inspect dispersal cellls) At least once every: ^ monthts) (Maximum 3 years) 3 ~ yearts) ^ NA -Clean effluent fitter At least once every: / y month(s) ^ year(s) ^ NA Inspect pump, pump controls & alarm At least once every: ^ month(s) D year{s) ~NA Flush laterals and pressure test At feast once every: ^ month(s) ^yearts) DNA ~~r' At feast once every• D month(s) ^ year(s) ^ 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 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 {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. Att 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. START- UP AND OPERATION Page ~ of 'S/ For new construction, prior to use of the POWTS check treatment tank(s) for the presence of nainr~~„ nr,,.~,....... __ _~__ _. that may impede the treatment nrnesae~ ~.,a~.,..,____ .. Page ~ of STARTUP AND OPERATION For new construcfwn, prior to use of the POWTS check treatment tank{s) for the presence of painting. products or other chemicals that may impede the treatment process andlor damage the dispersal cell{s1. 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(sl 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 manuaNy 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 sha{I 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: . ~j 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. ^ 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 replac~nent 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._ Reconstrugtons 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 OP A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFlCULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name ,~ £ /yf~ .73 d G ..Phone S C 7.?- ~6~ POWTS MA{NTAINER Name c~v./ ~d'L E' Airs Lcri'z~i,.a~ .Phone ,/S- L 7.J - S.?~ at SEPTAGE SERVICING OPERATOR (PUMPER) - G~./il'./ov.J LOCAL REGULATORY AUTHORITY Name Phone Name , G/toi)! Ce. Zo./n/! ~ F/GJ"~ Phone ~S 38~ _ ~` 8Q This document was drafted in compliance with chapter Comm 83.2212)(b)f1)(d)&1f) and 83.54(i-, 12) & 13-, Wisconsin Administrative Code. The ~ervlrl for serviang s~piic tanks Ls~~state and rocat one. Througha-ut the Un~ad Sues the is a vie ~ of as whalt this stx~id be„ b~ ~. r+egulata1r two th ive years. The ~a~bet" t wttii~i does not fire ~r~e~wy of servid~,g for the shotid~deaned w!~ the ~~o~i~pe~ d~ , Ea,r filter is ~ set-dearrir,~ The oor lion the ta:tlc. ~yraarroor~ns a ~"' a~m.you~ ram ~ alarm v ~ r senricw~g, To sertr~ the fitter: •.-~e~3'~' anY~6ef f~rslrortld rx~fYb~e dbrre b~-a dse~ic talc per arm t the overt of the taNc ~r1d pump the - Nrt+ett #~e ~tf _ - - ~- _ a~ .~ ~wwan ~~ . . nsprad4djs)st~e~aiar~sdb~-t~eor oiDis~p L. s . . r~ a ~ . 3 r~,~ s. ~ . ~ . . ~ e a . s. s e ~'r. s. s ~ ~ ~ Tre. a e e . s. .~ .~ .v zz ~ ~a .~ . s . r o. z s s~ r, ~ U.B. U~s.,86,2t1. OesB®~~ t3M~ i~ned~~jJ5.937; ~ tit57~3: Neat Z 261824, a8~a[ PateNs P~itg CaY thraieaeeZABEt.ZO~+tEA~tCJtt~e 1MarMag~e'f-830-221-;.~7$2 • IAI$bs~e I~~Jtiwrw.zab~cxxn Oct 19 2009 3:17PM TERM SPEERBRST 7153868660 p.l • 10/19/2809 14:20 7155499230 MCCORMACKCLASSICCOIVS 3T. CRQaX COUIVx'X SEPTIC TA,~IIC MAINTENAtiNC~ AGREFrMkNT AND owNERSHIP CFtt,~'~G,~TI4N .FARM Owrler/Buyar tdalling Address Property Address 8t Zoning CitylState Parcel Identi~icatian Number L~ ~ - ~ -L- -~-~- 1 - ~, Zg~Z) Property I,ocation~ /, ,~~ %, ,Soc. ~,, T °`-~4~ R~,W,'~own of ~j~~~S-~- Subdivision PAGE 02/02 Lot # ~. Certified Survey 1Vlatp # .Volume ~, page # Warrl~trty Deed # __ , Volutnc ,Page # _~.. -- Spec bousc yes nn Lot )fines idtattiliahte yes no SYSTEM MAINTENANCE A,~D,OWNER CFR~'1FIC,A, IOiY Improper trse and ttrilintcnaace of your septic aysEem could result in its premahtttt hihtre to pantile wasues. Proper tsa-inkennDCe comista of imr~r-£ out the septic tank every three ycarcs ar saotxr, if tu-edcd, by a lic:nttsed puntpcr. What yov put irit0 rho ayatom can affect the fLttctioa of the aepric tank t+s tt trcatmerst stage to the waste disposal system. Ovrr-er tm-lttteniance respottsibilitics ere speciAed is ~Cornm, 83..52(1) w,d in Chapter 12 - St. Croix County Ssnitoty Chdinancc. 7--o property owner agrees to subrnlt w 5t. CYoix County Planning de zo~tiug Departrnettt a certiftaation form, ai~ted by tpe owner and by s tnasterpiutober, jottrnryman plumber, t~estricted phm~lxr or a licdtacd pumi~er vetifpiug that (t) the on-site wastewater disposal systcnt is in lxoper operating catxiition and/or {2) after asspection sad pttrnpittg (i Pnecesasry), iltn septic tank is leas dwn lf3 full of slttti~o• l/vvC, ttto uadersigned have read the above raquiceaaaats and agroe M rnafttttdn t#ie private ac~VagO disposd system with the standards act forth, herein, as sat by the Depattmettt of Cotnttterec and tlx Deprttrmettt of Nahaal Resources, Slate oC Wiaconsla. (7ertitcatioua stYtieg that your septic system has heart maintained m~aet be wmpkDod aad returned to the 5t Croix Cotmty 1'laarritaa $t Zoning Dtpatttrtetat wlehin 30 days of the three year expiration date. Uwe certify that all srstetnettts nn this fat~t are lrue ro the perk of my/our lcnowlcdge, I/vvC amlare the ow~aer(s) o[tbc propergr d 'red shove, byvitiue of a a-atramy dc~d recorded in Register of Deeds Office. srvNA ~ ,~4, a4 DA7T ' J~ny httbrmatiett that is misrcpresemed ntary result m rile aantutry pcrtnit being rcvokect by the Planning dt ping Depa:tirteet• * •* Tn ode with this appiicatioo a recorded uarr:er+ty decd Rvrtt the RtQislor of Deeds Office ctrl a copy of ~ ccrtii+kd Harvey tuap i! refcrctxe fs made in the warrmry decd (Rjgv, ngros~ new constrnction.j ~ ~ V .;~ VZ`~8~ P. IZo STATE BAR OF WISCONSIN FORM 2- 2000 Document Number WARRANTY DEED THIS DEED, made between Kemon J. Bast, a married person, Grantor, and Kernon J. Bast and Donalda J. Speer-Bast, husband and wife, as Survivorship Marital Property, Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, State of Wisconsin: SEE ATTACHED EXHIBIT A Recording Area 750940 KATHLEEN H. MALSH REGISTER OF DEEDS ST. CROI% CO., MI RECEIVED FOR RECORD 01/07/2004 12:35PIf NARRANTY DEED E%EF1PT i 8M REC FEE: 13.00 TRANS FEE: COPY FEE: CC FEE: PAGES: 2 Name and Return Address: Edina Realty Title, Inc. 400 S. 2~ St. -Suite 115 Exceptions to warranties: Hudson, WI 54016 Easements, restrictions and rights-of--way of record, if any. 412540 20-1027-40-000 & 30-000 &20-00 Pazcel Identification Number (PIN) This is not homestead property. Dated this 6th day of January, 2004. * ernon J. Bast AUTHENTICATI rONICI eC~ Signature(s) _ G~ b~~C' 0 h~ authenticated this 6th day of Jag TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY ACKNOWLEDGMENT STATE OF WISCONSIN ) ST. CROIX COUNTY. ) ss. Personally came before me this January 6, 2004 the above named Keeton J. Bast, a married person to me known to be the person(s) who executed the foregoing instrument and acknowled Jth~e same. ~ ~, , tl.C~ i(~/t/`~ *Cheri Brown Notary Public, State of Wisconsin Edina Realty Title -Doug Berg My commission is permanent. (If not, state expiration date: 400 South Second Street #115, Hudson, WI 54016 3/11/2007 (Signatures may be authenticated or acknowledged. Both are not necessary.) 'Names of persons signing in any capacity must be typed or printed below their signature ~~ WARRANTY DEED STATE BAR OF WISCONSIN FORM No.2-2000 ~ 2`187P 12~ EXHIBIT A The NE '/, of the SE'/. and the NW %, of the SE '/,, all in Section 15, Township 29 North, Range 13 West, St. Croix County, Wisconsin, EXCEPT a parcel described as: Beginning at the E '/, corner of said Section 15; thence South 00 degrees 47 minutes 33 seconds East, along the east line of the SE '/, of said Section, 407.27 feet; thence South 89 degrees 08 minutes l5 seconds West 535.46 feet; thence South 14 degrees 10 minutes 34 seconds West 93.31 feet to a point on a 80.00 radius curve, concave southwesterly, whose central angle measures 25 degrees 34 minutes 33 seconds, whose chord bears North 54 degrees 32 minutes 33.5 seconds West and measures 35.41 feet; thence northwesterly along the arc of said curve, 35.71 feet; thence North 14 degrees 10 minutes 34 seconds East 76.12 feet; thence North 01 degrees 07 minutes 26 seconds West 400.07 feet to the monumented south line of Certified Survey Map recorded in Volume 1, page 2l7 at the St. Croix County Register of Deeds Office; thence North 88 degrees 51 minutes 13 seconds East, along said south line, 570.78 feet to the point of beginning. I. ' ' ~ RECEIVED ., ~ 3 " iKsaotra6loeperar~ldof diL ALUATION REPORT Paae ~ ~ «,o~s~,,end n~c ~ ~ zo~_ Plan nwst ~ ~~! no~~~~~ s¢e j>Bf08f>tS~OQ@.St:9I@Of ~ . .8[1d~Of~Oflallf~10@TR1ffBflf9St/r~. p~tCE~ 1.0. ~~'~'.~' ~ / j~ 3 ~ /I . Please prln# ali lrrfamafion. ~ ~ ~ Persaw t u t tde b t P S 04 i ~~_ f~j~ '~ (~ ~~ ~I , a/la e on you pov e used rtraty Ltw, s.1 t ) t/~l orssoaary prposes ( . ~ ~N fJ s0 ~ GT• Propeny0+~ ~CEiP~1lO~v r3fFS T_ Propcrtylcrabion cw,. roc Nw ,-asw,ra ~s~T Z 9 N +~ ~9 sdor~ w r o+~s r~ ~y Gi! • ,8>4R G..~- ~'`~ ' ~ ~ / e~ ~ sl,na. r~lne a cs~ a Coo y'o TE ,~ fD~~" " ~UD.SO ~ w . s dt (r 4 71 S 3 4~ '~7 ) 5 a ~Y ^ ®Taerr- Nel~st R~osd ff UOSo.•~ /3/P~J~w ~~ New ConsUUCdoll user[ ~ r Number of badrnoms ~ Code desi~l na!- rye Y.SO -- Ca 4"a ~o ~ Repaaeaer* ~ Pubic or oomneraai - De~scaibe: + _ S.~dt1?~Y B yT/.rl~t- SrL~.. f,~oa r~l- X11 ~ tae ~/ ~. la"`' • ~~ T~'ST~"D SvlTrt~3LE i'~~° ~tv i~yeov-u~ _ .. CAN U,2u.~fr'o,~ ~F-L ~ 4 • W . T' S „ ~.._., ,~ ~ {NOlRIti80.R1i~OB819,,. - . ><. _ ~ W ~ ~ - ~ ~. soy ~e Horimon Oepfh Dom~na-rt iisdooc Oesoripfon Texltr+a 8tru*re Caol~lenoe 8otndary li~oobZ in. MixeeN ~. Sz Cont. Color (~ Sz. S'tl. 'EIS, '~ ~ o. 7 ~ ~Y 3< ~ S ~,b/'I sbe cs 3 f . '7 1.2- z • S ~l2 y ~. s / ~ c s l~ ~. z lS • 7•S Y s D ~. c - l~ 2 o --- / ~~ ~ ~ Bexslg ~ ~ 7 ~, 1, _ ~ . ~- GS ~• Z . -7 /. 2_ c ----- ~aP . S D , ~. l ~ ~ t7VY ~ ~T • ~ (.Ll• mglt. and TSS 3p <, 50 m~1. ~ •I(. t' fi7W < 3Q ~- ~ T~ < ~ m~ - W ~ ~{iNi~ `~ ~ ~T-- ~t ~ b ~~ cGi" ~ z. 2 ce 3 z s IWdreas /,//~ 1 O/elys/Eon Conducted ~rTskphone~ N.u1`n/6~er ili...:~4a n w _ _ ' / ~ Ov ~ / - 003 ~~./•~~O\• V'S~~ Private Sewage Consultants p 2812 i 0th Ave. ~/N •S I~i2 Td ]'.~G ~F O 0 /Q~ Spring Valley, WI 54767 2 p . Io Z-7 . Z o • oa-a ZO •101,7 . 3D • 4'~ ~..o • ~©z-~ , yp • oar • ~ • f • ~ ~~/'~vD~v T3f~-5 T~ Property Owner ParcellD # ,~~ yo T~ ~;~~ ~, ~ ~- it Z ~ Page of 3 # ^ ~~ ~ Pit Ground surface elev. ~~•,Z ft. ~ rn,iting ~ in. Rde Horizon Depth Dorninsu,t Redox Description Texture Sinrcd,r'e Corn,oe Boru,dary Roots GP DA~ in. MunseQ Qu. Sz Cont. Color Gr. Sz Sh. 'EtfA`t 'EfI#2 z • I ~ • 5 GS .w,. G / I • d ~ .$ ~ ~ (. I , i~ ^ Pit ward surface elev. R Depth to ~tirg factor • rci. ~# ^ / Sol Rate Horizon Depth Dominant Redaa Description Text,xe Siruct~xe Consistence Roots GP OfiP in. M,atseA Qu. Sz Cart. Color Gr. Sz. Sh. 'Etf~1 'Etfl12 ~ ~ ~9 ^ ~ Ground surface elev. ft. Depti- ~ l6nNir,g factor in. Soil Rake Horizon Depth Dorrw-ant Redox Desaiption• Texture Shta~re Cor~sterwe Boundary Rods GP DRy in. MunseN Qu. Sz Cont. Color Gr. Sz Sh. 'Eff#1 'Eff~2 ' l #'(= BODs > 30 < 220 mglL TSS >30 < 150 mglL • C-1liuent ~ = BOD, _< 30 rrglL and TSS <_ 30 rrglL The Department of Commerce is an equal opportunity service provider and employer. If you need assistance W access services or need material in an alternate f t, please contact tjte dtpartrnettt at 608-266-3151 or TTY 608-264-8777. S( Co yo 7-E' ~ip~' ~~ ,m~ Q~ o ~ ~ a ®Ak totOtmdat~stev_ /~•I~-a n.....s._.e_L.__~~__ 7 Ftwiaa~ nePU~ ~~ ~ . --~ ----- ~ Sbi ~ in. o•` Mur~seq iby ~ tau. Sz (bnt. Color Ts~das t361JCttap Ocrgtelsnoe G`r. Sz. Sh. gp,K,dgpy, Roots E~PFllrt 'E1A9't •Et~ j LS ~»6 s cs 3 ~ -7 l•2 3 -3 .S S 0, S c ._._ a i o ~. # u ~~ liaimn ~ DomYrsnt R - ~ Rsls (n M tl sdco[ [JBSrr7pUon Textile t3trucfitns Cor~sla~loe Roots L'P DJIp . unae tlu. Sz. (krM. Ootor t8r:3z. 8h. .g~i t3ahg # ~ ttorlt~ ^ Pit Ground s~a~raoaetev. ft paplh lv tlmiBng fpt~w. h. tiorizott SoH Rate Depth Dominant Redotc DesaipBon. Texhxe Strurhre Dons BoarMery Roots in. tuhaisell (lu. Sz. tam trdot .. ix Ss. Sh._ "lit ~ 'E672 • ant #1= t3pDs s ~o c ~p ngq The Dcparhttent of Commerce {s en egos need material is sn attecnste ! awe»ta.s+ao, S}30_950tr~ll. 'tiC2=80D,<3Q~andlSS_30mg11. tuoity service provider aad employe: ff you need assiatattce to ermss serVitxs or IPA cotuacx the d~hcncnt az 60E-266-slst ar rflr 6os„2ta-am. Q~ru~ 5 y '~ S / ~ /"~/"" ~ /D~~ d yi 0 ~ D r• ~Z s`~~, ~,~_30~ e = ,~,9~l~~e. P~. r~ • ----- ~o a .= lea -{v~~S ~ ~~ ~~~ a`~ ~~~ a~y~ cyJ~~ a ~ ~o ~~~ V~ ~~~~~~~ -~~J~~ ~~aQ Q ~`~ ~w or ~~~ ti V°Q~o~~ti ~~~~04` ti~ ~~ ~1 ~~ 3 ~ ~!~ o i -~. ga ~ _______ ~~ ~ ~ ., , a~ ~ ~- y yV ~~~~u~ `a ~~ vv'~,~ ~ B~ y~~~ ,n ~ d 5~ i ~' I ~, P t3 ~' 5~ oo-D 1~0 I OL+aa3dw s3;ivwva aodwroprol no..l~3rB11S ~~ ~/~ Avn ax a3uewOad slNOllonalsa~a~ssrd~r awao~N ~ \ ~+J lO NasslNa3d N3111tlM 3N11ngLLIM N13tl31103111Y1N W sld3araoaNV S~NIMVao 3s3N1 do 3srtNal~musrw~ '7'^~ NISNOOSIM NH'Id ~g''I~QOY~I N`d'Id QYg assvn~rnmaoxr io 3sn 3NSmo><33N1ao3 ,~ j((~L- : l~3road D ~ \` 03elOtdM130YK111~lW615N]~71SbYi7 WJwIW9N.iOAla3dOad i:w: ~{31.~51 ~`~ :NOLLYJOl1~3fOad :1~3fOad i d ONN 1JMOtld WWMAatl13MWad 3N13atl SJNMtla0353N1 . ~y.~V w 0 a ao z? o~ ow mQ ~U O~ LL ~ d'~ Q Z g a w w F- .~ t~ O1H'JItl1dOJ'SS`JtlW00lgi wivavol llOA 1J319(IS °i~Q~~~ AYN OM'03119HOtld SIlgll?'i•WSIq~~ISStl1~NJYWN(A'PW dO N01SSIWYSd N311MM 31LL 1f1pLLIM N131p110311V1NOJ /~~ ~~{(~A~ r~ ~~~r~ /~}(} r(r~/~ }~) A~{~} T /{{ 61d3~Np~ONV SE]NIMtlW 353X1 dD 3811'NOIIJIILISNOJ ~ I. (~/ 1 LV1 JlY0J~ 1V V ld ll1 Q~ 1.111 ~YY y~y yQ lll~ :UOd 1~3fOtld 03dO13/d0'NOLL~IWB ~i53VYJ M~tNItlOJ~W~ tl3dOMi ~`-~~ :Ng1YJOl 1~3fONd :1~3fOMd UNV I~fgOtld lltlOMAW131tldOMd 3X13W S5NIMMIO 3S3H1 •...Il..l. J Z O W N O a a~ z? . - o~ ~. .> x., ~ , o w ,. m Q ~~ O LL= d'~ - Z p.- m g w t w ~ ~~ G p n. E ___ __ .___ ____ ~ k R ~ i I 7 ~, r'I/. eAs _~ g - ~ K R __~_n,T .y I I , I I rN i i i I I I i ~ Q ~ / I I 3a ~ I ~ I I I I I I i I I i I I i i I I I R i i I ~ I I ~ i i