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HomeMy WebLinkAbout030-2001-60-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 578913 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 O1(m )1. Permit Holder's Name: City Village X Township Parcel Tax No: Lacy, Michael & Heather St. Joseph, Town of 030-2001-60-000 CST BM Elev: Insp. M lev: IBM Description: SectionlTown/Range/Map No: 6j CT ~ 33.30.19.361 K TANK INFORMATION ' ELEVATION DATA TYPE MANUFACTURER C PACITY STATION BS HI FS ELEV. Septic /1 l- /ti~"I!1 Benchmark ~ O (~c V 'IL • /1 _ i ~A A Alt. BM 4V coo, AereEiea Bldg. Sewer SW" Inlet GV -l(J I `t q~,~~ J ~P TANK SETBACK MA I~0 O1r`s~ s utlet to / _ 104 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD N6 t~i'~ l (,~G~ tow Septic Dosing Heade an. N "F 'O 1-t Aeration Dist. Pipe I t . Bot. System Holding 9.3 8.b 97. s.9 t±:d - . , - PUMP/SIPHON INFORMATION Final Grade ,b It`s zct Manufacturer Dem nd St Cover 116-* L- 1. I 108. Mode umber TDH Lift Friction Loss System He TDH Ft lForcema Length Dia. Dist. to well SOIL ABSORPTION SYSTEM BEDITRENCH Width ~ Length t No. Of Trenches PIT DIMENSI NS No. Of Pits/ Inside Dia/ Liquid Depth> DIMENSIONS ?Pits/ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: f n~ INFORMATION Typ Of Sy a CHAMBER OR Ira O ini rj' UNIT Model Number: IL S DISTRIBUTION SYSTEM yC16r- Header/Manifold Distribution x Hole Size / x Hole Spaci Vent to Air Intake t✓' Pipe(s) (~~/~O r~/ Length Dia_ Length a Spacing I ~ O SOIL COVER ressure Systems Only xx Mound Or At-Grade Systems Only Depth Over epth Over / xx Depth of xx Seeded/Sodded xx Mulched BedlTrench Center Bed/Trench Edges Topsoil Yes 0 No "f~ Yes E No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 1285 Arrowood Trail Hudson, WI 54016 (NW 1/4 W,1/433 T30N R1 9W) metes & bounds Lot / Parcel No: 33.30.19.361K 1.) Alt BM Description= ~'1'VV C"/t 2.) Bldg sewer length = C~G Y - amount of cover = Ak ` ~2'I DA Plan revision Required? Fv~ Yes No - Use other side for additional information. 4 ~~orq ' Date Insepc or's Signature Cert. No. SBD-6710 (R.3/97) - Co»t~ A. ' Safety'and Buildings Divisio_._ 1 _2QL1fj1.1Ctzaungton Ave., P 2 Sanitary Permit Number (to be filled in by Co.} JQ, -01 ~10~ r Madison, W 573913 Transaction N tkr Sanitary Permit Application pQ oU QM lf - this In accordance wddt SPS 383 ~i (2), Wis. Adm. Code, submission of this form to the approp mined to Project Address (if different than mailing addrt ) is required prior to obtaining a sanitary permit. Note: Application fOrtns for state -o dd for SeL-mdary the Department of Safety and Professional Servies. Personal information you provi ~I t b l purposes to accordance with the Privac Law', s. 15.04(1)L Stars. 1 (t I. Application Information - lease Print Ap form_a-ti 11,111 rk fo~n- _ Parcel # Property Owner's Name ji G. `4t - V u V 1(l~ ~ `(l ~ CA_ Property Location Property Owners Mailing Address Govt. Lot i Zip Code Phone Number 14, Section City, State " - / rde one) n T V N. R ( Ele V ) 1 Y) Lot # II. Type of Building (check all that aPP1 - Subdivision Name ; or 2 Family Dwelling-Number of Bedrooms ----1 Block v El Public/Commercial - Describe LJse ED] City ~P CSM Number ❑ Village of ❑ State Owned - Describe Use f own of J~-s ^ Z fJ:~ ~'t G i III. Type of Permit: (Check only one b ix on line A. Complete line B if applicable) A. 1 ❑ 11 Treatment/Holding Tank Replacement Chtly Other Modification to Existing System (explain) blew System ❑ Replacement System List Previous Permit Number and Date Issued ❑ B. ❑ Permit Renewal ❑ Permit Revision Change of Plumber El Permit Transfer to New t Owncx J~ Before Expiration ~ / L,5 IV. P!, of POWTS System/Component/Device: Check all that apply) n-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil l . ' ❑ Pretreatment Device (explain] - Holding Tank El Other Dispersal Component (explain r /3C V. Dis ersaVTreatment Area Information: Dis ersal Area Required (sfl Dispersal Area Proposed (sf) System Elev n - Design Flow' (gpd)~✓ Design SOiI Application Rate( dsf} P~ Y ; I •v~ Total # of Manufacturer V1. Tank Info Capacity in v Gallons Gallons Units - o m er v i `n ~ New Tanks Existing Tanks I ' W 1 / y' `J on I V / I Septic or Holding Tani: L/ Dosing Chamber VII. Responsibility Statement- I, the undersigned, assu es onsibility for installation of the POWTSivshown o the attached Business Phone Nqgi er P/MPRS Number Plum er's Name Plumber e (Print) 7 06 7 t lJ Q` Plumber's Address (Street, City: State, Zip Co Z Z~ VIII. untv/De partment use Only Permit Fee Date tied lssuing . t Signature Approved rsappro 5 175 eason for Deni ✓ IX. Conditii$ sons for Disapproval tartlt, lflhent ow V4 dispersal ce"'Must all be aer+t"A! Ftiainw`u~ d j as per management plan pr64ided by plumber. 2.. AA 5010, k r>wquil mt ! + stained 1 P apb Attach to complete plaas for tho system and submit to the County only on paper not less Wao A rrz 111 inches in size SBD-6398 (R 11/11) PLOT PLAN PROJECT Mike Lacv ADDRESS 1835 Northwestern Ave Stillwater Mn 55082 NW 1/4 NW 1/4S 33 /T 30 N/R 19 W TOWN St. Joseph COUNTY ST. CROIX SYSTEM ELEVATION 99.9/98.5 4.5' below grade DATE 4/10/15 BEDROOM 3 CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32 BENCHMARK V.R.P. Top of 3/4" pipe ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark All piping shall be SDR 30/34, within 10' Scale - of tank, piping shall be Schedule 40. 130' Scale is 1" = 40' unless otherwise 5' noted 103 105' 101' 99' B-1 45 Pro 3 17% Slope 45' Bedroom House 50' B-3 ST 2-3' x 66' cells 40' with >3' spacing 25' B-2 Arrowood Drive 30' B.M.* Area of soils not suitable for a conventional system. Shift system as far north as possible Vent >6„ Quick4 Standard of Cover Leaching Chamber with 20.0 ft2 of Area 5.6f A2/pair of end caps Long 12" 3 41' Grade at System Elevation Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 4/10/15 Owner: Mike Lacy Location: NW1/4 NW1/4 S33 T30N,R19 Arrowwood St. Joseph Manuals Used: In-ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Section 4-6. Maintanance and Contingency Plan 7. Filter Specification S eet Signature License nu e7#226900 PLOT PLAN PROJECT Mike Lacv ADDRESS 1835 Northwestern Ave Stillwater Mn 55082 NW 1/4 NW 1/4S 33 /T 30 N/R 19 W TOWN St. Joseph COUNTY ST. CROIX SYSTEM ELEVATION 99.9/98.5 4.5' below grade DATE 4/10/15 BEDROOM 3 CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK 1000 gallons LIFT TANK SIZE DOSE TANK SIZE MOUND SEPTIC TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 651 # of chambers 32 BENCHMARK V.R.P. Top of 3/4" pipe ASSUME ELEVATION 100' Filter BEAR Filter ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark All piping shall be SDR 30/34, within 10' of tank, piping shall be Schedule 40. Cale = 1/4" = 10' 130' Scale is 1" = 40' unless otherwise 5' noted 103' 105' 101' 99' B-1 45 Pro 3 17% Slope 45' Bedroom House 50' B-3 ST 2-3' x 66' cells 40' with >3' spacing , 25' B-2 Arrowood Drive 30' B.M.* Area of soils not suitable for a conventional system. Shift system as far north as possible Vent >691 Quick4 Standard of Cover Leaching Chamber with 20.0 ft2 of Area 5.6ft^2/pair of end caps 4' Long 12" 34" Grade at System Elevation Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber 5.6ft^2 pair of end plates To be >1' above grade Finish grade elevation Typical Installation A(I 104.5' Vent Grade Vent 3' 4" 3' X30/34 ::fic Tank 1" Long 5' S' Long 1 Grade at System Elevation 36" Grade at System Elevation Spacing 5' 2-3' X 66' ' Cells Same on other end Observation tubeNent At end of cell A B 16 chambers per cell System elevations: A 99.5' B 98.5' ST. CROtX COUNTY SEPTIC TANK MAINT1 N ANCE) ~GRFFMENT AND OWNERS141P CFRTI- ICA`I'1t-iN FORM Owner/Btu er Mailing .Address I t f/X /c - '14.5 S Q ' Property Address 17-' 9,5 (Verification required from Planning louurh Depart Went tirr new co "a uorr.) City/State I',trcel Idelititication i~1m il)er 0 3o -,:2 tip l 6- Try LEGAL DESCRIPTION Property 1,ocation/✓ ,Sec 5 , I L~ N C: VV Town of Subdivision ['of 41 Certified Survey Map # ltuttt; Page # #r Warranty Deed # Wluti)c - Page Spec . house yes 01.1 Leif. HIIA~~- identifiable 6~110 SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its pr..rmatu.re faihue to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, u needed, by a licensed pumper. What you put into the systern can affect the function of die septic tank as a treatment stage in the wasic disposal system. Owner maintenance; responsibilities are specified in §Couun. 83.52(l) and ire Chapter 12 - C uoix County Sanitary Oidinancc. The property owner agrees to submit to St. Croix County Plarnung & Lon ing Department a certification form, signed by the owner and by a master plurnber, journeyman plnrrtber, restricted plumber or it licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspecc:ion and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned havu read the above requirements and agrue to rnair; twin the private sewage disposal systern with the standards sct firth, herein, as set by the Department of(:onunerce; and the L)cpartrr-crn ol'Natural Resotuces, State of Wiscousia. Certification stating that your septic system has been inaintairred must he complete,[ and reuuned to the tit. Croix County Planning & Zoning Department within 30 days of the three. .year expiration date. I/we certify that all statements on t form are true to the; hest of my/our k nowledga. 1/we ant/are the ownrer(s) of the property described above, by virtue of a wa -anty deed recorded in Repister of Deep Is Office. Numb r of droo - 141 SIC. ATU. 'PLICANI(S) - DAT1-, ":**Any information that is misrepresented may result in the satritaly permit being o-woked by the Planning & Zoning Department. Y** Include with tlus application a recorded warranty deed 'from the Register of Deeds C,ffice and a copy of the certified survey map if reference is made: in the warranty dr,:ed. (REV. 08/05) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of , FILE INFORMATION SYSTEM SPECIFICATIONS Tank Manufacturer, / ❑ NA Owner Permit # Septic ❑ Dose ❑ Holding Volume: (gal} Tank Manufacturer: ,dNA DESIGN PARAMETERS Number of Bedrooms: ❑ Nptic ❑ Dose ❑ Holding Volume: (gal) Number of Public Facility Units: Al Vertical Distance Tank Bottom(s) to Service Pad, (ft) allday) Horizontal Distance Tank(s) to Service Pad: (ft) Estimated (average) Flow : (9 Srizo servicing mechanics must be provided rf vertical is >15 feet or Design (peak) Flow = (estimated x 1.5): (gallday) if horizontal is >150 feet. Specific instructions to be provided on back. In Situ Soil Applcation Rate: /-7 (gaudaytw) Effluent Filter Manufacturer: p NA Effluent Fitter Model: Standard (Domestic) Influent/Effluent Monthly average Fats, Oil & Grease (FOG) 530 mg/L Pump Manufacturer: A BlochemlcaI Oxygen Demand (BODs) 5220 mg/L ❑ NA Total Suspended Pump Model: Solids (TSS} s150 m L High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer. (BODs) >220 mg/L A (TSS) > 150 mg/L C3 Mechanical Aeration ❑ Peat Filter (:1 Disinfection ❑ Wetland Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other. (BODs) 530 mg/L Soil Absorption System 'NA (TSS) s30 mg/L ~ Ground (gravity) ❑ In-Ground (pressure) ❑ NA Fecal Coliform (geometric mean) <_10' /`0 At--Grade C3 Mound ❑ At Other: Maximum Effluent Particle Size 'a in dia. ❑ NA ❑ Drip-Line NA Other: ❑ NA Other: MAINTENANCE SCHEDULE Service Event Service Frequency When combined sludge and scum equals one-third ('h) of tank volume Pump out contents of tank(s) ❑ en the high water alarm is activated ❑ month(s) (Maximum 3 years) ❑ NA Inspect condition of tank(s) At least once every: 3 (Kyear(s) ❑,month(s) (Maximum 3 years) [3 NA Inspect dispersal cell(s) At least once every: J ears) month(s) NA Clean effluent filter At least once every: ear(s) ❑ month(s) 4NNAA .Inspect pump, pump controls alarm At least once 'every: ❑ year(s) ❑ month(s) Flush laterals and pressure test At least once every:. year(s) month(s) Other: At least once every: ❑ year(s) ❑ NA Other: MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Piumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). 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 a check for any back up or ponding of effluent on the ground surface. The soil absorption system 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. more of the lume, the tank enti When the combined accumulation a Septage treatment disposed )ofrin accordance wthochapter NR 113, shall contents of the tank 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 30 days of completion of any service event. GMW 005 (02105) Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. . Start up or und Pump tanks may fill above normal he eater levels prior to wastewater will be-discharged to the soil absorption systemtnone la ge dose casingean conditions is not recommended, as the excess s have the overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this s~tad a Plumber contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or POINTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. compact, Do not drive or park vehicles over tanks or the soil absorption system. Do not drive or park over, or otherwise disturb or comp area within 15 feet down slope of any mound or at-grade soil absorption area. nce and the Reduction or elimination of the oaciid, atib oticst baby wastream may stewater cigarettebutts, hcondoms acotton s abs ndeg easers,t dental floss tanks and soil absorption system: fruit and vegetable peelings, gasoline, greases, herbicides, meat diapers, disinfectants, fats, foundation drain (sump pump) discharge, napkins, solvents, tampons, and water softener brine discharge. scraps, medications, oils, painting products, pesticides, sanitary p 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 s. Comm 83.33, Wisconsin Administrative Code`. • All piping to tanks, pits and other soil absorption systems 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 (pumper). • 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 provide a code compliant If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to p replacement system: -j9L__Asuitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. O Th_e 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 tin the he uleeed for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with in effect at the time of their permit issuance. system cannot be ❑ A suitable replacement 'area is not available due to setback and/or soil limitations. If the soil absorption rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. ure of site and soil POWTS evaluation ❑ The site has not been suitable replacement rrea replacement no replacement arrea islavail ble a holding tank may be installed as a locate a evaluated must be performed to last resort to replace the failed POWTS. place f ❑ Mound and at -grade soil a such systemsemust comply reconstructed in effect atollo time.emoval of the biomat at the infiltrative surface. Reconstructions WARNING TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ADDITIONAL INSTRUCTIONS: POINTS INSTALLER POWYS MAINTAINER. Name u rt/ / Name LZ k___1 -S / Phone LOCAL REGULATORY AUTHORITY Phone -71 SEPTAGE SERVICING OPERATO PUMPER Name . ZBert Name f 77 Phone Phone This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. J_ 01V Ilk" FILTER CARTRIDGE INSTRUCTIONS i,r " Installation STEP 1 Dry fit the filter case onto the end of the outlet pipe to ensure it is centered under the access opening. If not, then either insert more pipe into the tank through the outlet or solvent weld (glue) additional pipe onto the outlet s pipe. STEP Z While the case is still dry fitted on the outlet pipe, measure the length of 3/4-inch pipe needed to brace the filter to the tank end wall if utilizing the optional supplemental side support. If side support method is not utilized, proceed to step four. STEP 3 For installations utilizing the optional supplemental side support: ; solvent weld the 3/4-inch pipe onto the filter case. If side support method is not a utilized, proceed to step four. ` >a. tt STEP 4 Solvent weld the filter case onto the outlet pipe. Insert the filter cartridge into the case, pressing down until the filter locks into the bottom of . the case. STEP 5 If a VRS switch is utilized: insert into the filter and lock by turning clockwise 90°. Maintenance 1. The effluent filter should be cleaned every time the septic tank is serviced. s~ a v 2. Open the outlet access opening to inspect the tank and filter. 3. Pump the septic tank completely, making sure to remove the sludge layer on the bottom of the tank and not just the scum and effluent. 4. Once the effluent level has been lowered below the invert of the outlet pipe, firmly pull up on the filter handle to dislodge the cartridge from the case. S. Slide the cartridge up and out of the case for cleaning. 6. If a VRS switch connected to an alarm is present, the switch should be removed by turning counterclockwise 900 and cleaned 4 with water only. d. 7. While holding the cartridge on its side (large flat surface facing down) over the access opening, rinse off the cartridge with water only, making sure all septage material is rinsed back into the tank. 8. If VRS switch is utilized, replace by inserting into filter and V turning clockwise 90°. 9. Insert the filter cartridge back into the case, pressing down until the filter locks into the bottom of the case. 10. Replace and secure the access opening on the tank. BEAR ONSITE" FILTEP, CARTRIDGE - FIVE-YEAR LIMITED WARRANTY J h - _ BEAR ONSITE" Fitter Case -Lifetime Limited Warrantv ':cll n:~ 11 I r4 c' E' 'I 0! "n vvww, , 877-MLFHXERS (653A5 ) 998188 BETH PABST REGISTER OF DEEDS STATE BAR OF WISCONSIN FORM 2 - 2000 ST. CROIX CO., WI Document Number WARRANTY DEED RECEIVED FOR. RECORD 07/03/2014 11:55 AM THIS DEED, made between Marian Herwig Berglund, a/k/a EXEMPT NA Marian A. Berglund fka Marian A. Nerving, a single person, REC FEE: 30.00 Grantor, and Michael G. Lacy and Heather A. Lacy, husband TRANS FEE: 186.00 and wife, as survivorship marital property, Grantee. PAGES: 4 Grantor for a valuable consideration, conveys and warrants to **The above recording information Grantee the following described real estate in St. Croix County, verifies that this document has Wisconsin: been electronically recorded i returned to the submitter SEEEXHIBIT "A" ATTACHED HERETO AND MADE A PART HEREOF Recording Area Name and Return Address: Edina Fealty Tie, Inc. 400 South Second Street, Suite 115 Hudson, Wl 54016 1125671 Exceptions to warranties: 030-.2001-60-000 Easements, restrictions and rights-of-way of record, if any. Parcel identification Number (PIN) This is not homestead rty, Bated this June 30, 2014 Manan Herwig Berglun a Maria A. Berglund, flk a Marian A. Herwg WARRANTY DEED STATE BAR OF WISCONSIN FORAM No. 2-21*0 St. Croix County 998188 Page 1 of 4 Exhibit A Legal Descdption Part of NW-1/4 of NW-1/4 of Section 33-30-19, St. Croix County, Wisconsin, described as follows- A tract of land in the N-1/4 of NW-1/4 of Sec. 33, T30N, R1 9W, Town of St. Joseph, consisting of two adjoining parcels described as follows: A parcel described as fellows: Commencing at an iron pipe stake 617.32 feet South and 623.91 feet East of the NW corner of said Sec. 3, being also the Point of Beginning, thence Nally along the Ely right-of-way of the 66 foot road easement on a curve concave Sally having a radius of 286.16 feet and a chord bearing N46°52'W 193.35 feet; thence along said Ely right-of-way N66034' 75.00 feet; thence along said Ely right-of-way on a curve concave NEly having a radius of 96.98 feet and a chord bearing N39°27"W 88.88 feet; thence N74°38'E 600.00 feet; thence South 300.00 feet; thence S 00° 07'E 81.45 feet; thence N50°37 110.10 feet; thence N73°31'W 62.30 feet; thence S64°25'W 82.30 feet; thence S47058' 98.47 feet to the Point of Beginning. SUBJECT TO a 24 foot wide road easement across the entire Sly 24 feet of said parcel, the Sly right-of-way line of said easement being the Sly line of said parcel. AND A parcel adjoining the Wly side of the above described parcel, being the a abutting portion of the Ely one-half of a 66 foot wide road easement which is the land described in a Warranty deed from Werts to Sables dated July 31, WARRANTY OMD STATE BAR of WISCONSIN FORM No, 2-2000 Cmix County 11981" Page 3 of 4 8 o m ~ O q m R C~ C N 1 i x m [ ~ ~ n i N ♦ ♦ i i A ~ I+Ii:r. =F 'tilla= N N ~ N ` N v A a ~ ~ ~~q $i ~F N N R tP l A ~ N ~ - y t K o 4 h 9 L I O e`~a mq x i i HIl "'MAN TD Ill I ro ~lil~ ~ $ DES*M,SERVICE °~~4~ ~ RESIDENTIAL DESIGN i 5 Y1414~~~21i Y, N0153a ltlllN3'f".3b ~ ixl~;+~a I LAI G °p # ~ d h m a ~ z n 0 d ~ R Y Q It ti Fd !pp a 5 ~a ~ ~ I a c r ! dd! dd -d! ~~F~43fs M. 11.426 ZH d3 N9153~ ~tlI1N30153a~ '~;R+;~$ g L33IAN35~~€~~~ H ~ 9 t0~yy it lit ; if i9 O ~~5 O w ~ Q r 6 ^ ^ w ~ ~ II II I a lg ❑ s i 9i k - - • • 3 99 r _ « 4 i w y ' n } .c.. oO ~ i k I k " w s 3k 4 ~k 2 g 3 a ~ ~ w t A6 ;k '6 } b , 1 ~ p~i0.p~1! ,~,j L3~JAV35 j aIiIA!.Jlj FFI a s 1 Q 2 .wa it o a - - - - 4dm 4dA dZ#~I'~i gay - - Pik @~ k E ~ --+a~- _._e bhp ; . 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CROIX CO., WI Document Number WARRANTY DEED RECEIVED FOR RECORD 07/03/2014 11:55 AM THIS DEED, made between Marian Herwig Berglund, a/k/a EXEMPT # NA Marian A. Berglund fka Marian A. Herwig, a single person, REC FEE: 30.00 Grantor, and Michael G. Lacy and Heather A. Lacy, husband TRANS FEE: 186.00 and wife, as survivorship marital property, Grantee. PAGES: 4 Grantor for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, **The above recording information verifies that this document has Wisconsin: been electronically recorded & returned to the submitter SEE EXHIBIT "A" ATTACHED HERETO AND MADE A PART HEREOF Recording Area Name and Return Address: Edina Realty Title, Inc. 400 South Second Street, Suite 115 Hudson, WI 54016 1125671 Exceptions to warranties: 030-2001-60-000 Easements, restrictions and rights-of-way of record, if any. Parcel Identification Number (PIN) This is not homestead Dated this June 30, 2014 property. Marian Herwig Berglund, a a Maria A. Berglund, f/k/a Marian A. Herwig WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2-2000 St. Croix County 998188 Page 1 of 4 t AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF Wisconsin COUNTY OF St. Croix authenticated this June 30, 2014 Personally came before me this * the above Marian Herwig Berglund, a/k/a Marian A. TITLE: MEMBER STATE BAR OF WISCONSIN Berglund fka Marian A. Herwig, a single person to me (If not, known to be the person or persons who executed the authorized by §706.06, Wis. Stats.) foregoing instrument and acknowledged the same. THIS INSTRUMENT WAS DRAFTED BY Martin D. Henschel ~Yftft7< 6800 France Avenue South, Suite 410 Cheri Brown Edina, MN 55435 Notary Public, State of Wisconsin (Signatures may be authenticated or acknowledged. My commission is permanent. (If not, state the Both are not necessary.) expiration date: 03101/2015) *Names of persons signing in any capacity must be typed or printed below their signature. CHER' BROWN NOTARY PUBLIC STATE OF WISCONSIN WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2-2000 St. Croix County 998188 Page 2 of 4 Exhibit A Legal Description Part of NW-1/4 of NW-1/4 of Section 33-30-19, St. Croix County, Wisconsin, described as follows: A tract of land in the NW-1/4 of NW-1/4 of Sec. 33, T30N, R1 9W, Town of St. Joseph, consisting of two adjoining parcels described as follows: A parcel described as follows: Commencing at an iron pipe stake 617.32 feet South and 623.91 feet East of the NW corner of said Sec. 33, being also the Point of Beginning, thence NWly along the Ely right-of-way of the 66 foot road easement on a curve concave SWly having a radius of 286.16 feet and a chord bearing N46°52'W 193.35 feet; thence along said Ely right-of-way N66°34'W 75.00 feet; thence along said Ely right-of-way on a curve concave NEly having a radius of 96.98 feet and a chord bearing N39°27'W 88.88 feet; thence N74°38'E 600.00 feet; thence South 300.00 feet; thence S 00° 07'E 81.45 feet; thence N50°37'W 110.10 feet; thence N73°31'W 82.30 feet; thence S64°25'W 82.30 feet; thence S47°58 W 98.47 feet to the Point of Beginning. SUBJECT TO a 24 foot wide road easement across the entire Sly 24 feet of said parcel, the Sly right-of-way line of said easement being the Sly line of said parcel. AND A parcel adjoining the Wly side of the above described parcel, being the abutting portion of the Ely one-half of a 66 foot wide road easement which is the land described in a Warranty deed from Werts to Sables dated July 31, WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2-2000 St. Croix County 998188 Page 3 of 4 r 1972, recorded August 10, 1972 in Vol. "487"; Page 543, Doc. No. 311747, in the office of the Register of Deeds for St. Croix County, Wisconsin, more fully described as follows: Beginning at the same Point of Beginning as the above described parcel, thence NWly along the Ely right-of way of said 66 foot road easement on a curve concave SWly having a radius of 286.16 feet and a chord bearing N46°52'W 193.35 feet; thence along said Ely right-of-way N66°34'W 75.00 feet; thence along said Ely right-of-way on a curve concave NEly having a radius of 96.98 feet and a chord bearing N39°26'W 88.88 feet, thence S74°38'W 33.00 feet, more or less, to the centerline of said 66 foot wide road easement, thence Sly along said centerline to a point on said centerline that is 37.86 feet due West of the Point of Beginning; thence due East 37.86 feet to the Point of Beginning. TOGETHER WITH AND SUBJECT TO a non-exclusive 66 foot wide road easement running from the NW corner of the above described tract of land Sly to County Trunk Highway "E" which easement is the land described in said Warranty Deed in Vol. "487", Page 543, Doc. No. 311747. WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 2-2000 St. Croix County 998188 Page 4 of 4 Property Owner _ Parcel ID # Page of ❑ Boring Boring # s pit Ground surface elev./t93) ft. Depth to limiting factor 0 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 D -S D - 5 ~ ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring # ❑ Boring F-1 ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon ')epth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD5 > 30 < 220 mg/L and TSS >30 < 150 mg/_ ' Effluent #2 = BOD5 130 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 (8.6100) PAID Wisconsin Department ofCom rc~SOIL EVALUATION REPORT Page of Division of Safety and Buildin ~N( ~,ti C th Comm 85, Wis. Adm. Code \.2, vE~ ' County 'n Attach complete site piar£~n~(r~~ess than 8 1/2 x 11 I ches in size. Plan must 16, include, but not limitec~t~, I and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale, iimensions, north arrow, and location and distance to nearest road. a (f0 030 opv Please print all information. _ Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04(l) (m)). R ' w b 7 Z Property Owner Property Location l1 T ft, Govt. Lot N(,J 114A4,J114 S T D N R E (o w A f Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# city State Zip Code Phone Number ❑ City ❑ Village -~Q Town Nearest Road D tJUZJ/C/ 177" / SS 1? ( ) -3 New Construction Use:5LResidential /Number of bedrooms .3 Code derived design flow rate J2> _~Q_ GPD ❑ Replacement ❑ Public ,or~mm)eraal -Describe: Parent material Flood Plain elevation if applicable General comments yJ %~~llJ c ~~/c~ and recommendations: System Type System Elevation 7 FA T_') aBoring # E] Boring pit Ground surface elev. ft. Depth to limiting factor XIL2 in. I I Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. n 'Eff#1 -Eff#2 Boring # Boring © Pit Ground surface elev. 0 1 7-ft. Depth to limiting factor in Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 Effluent #1 = BOD > 30 < 220 mg1L and TSS >30 < 150 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Narre (per print) Si re CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Co ducted Telephone Number 1008 192nd Ave, New Richmond, WI 54017 6%~ ,-1 715-246-4516 Property Owner Parcel ID # Page of Boring # ❑ Boring -CA pit Ground surface elev./,93). ft. Depth to limiting factor in. Soil lication Rate 131 Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eft#2 o - L r----- ~s ~J JJ r S C_ !a L L 5 ~ T 3 5 f a Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ❑ Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate . Horizon Iepth Dominant Color Redox Description. Texture Structure Consistence. Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 Effluent #1 = BODS > 30 < 220 rng/L and TSS >30 < 150 mg/l_ • Effluent #2 = BODE < 30 mg/_ 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 608-2648777. SBD4330 (8.6100) Soil Test Plot Plan Project Name Marian Berglund Shaun Bird Address 4543 17th Ave S. Minneapolis Mn 55407 CSTM #226900 Lot Subdivision Date 6/26/14 N W 1/4 N W 1/4S 33 T 30 N/1319 W Township St. Joseph Fj Boring Q Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. Top of 3/4" pipe System Elevation TBD *HRPSame as Benchmark 130' 75, Scale is 1" = 40' lol ° 103' 105 unless otherwise 99' noted 5' B-1 17% Slope 45' B-3 30' 25' B-2 Arrowood Drive 3 0' B.M.* Area of soils not suitable for a conventional system. Shift system as far north as possible Parcel 030-2001-60-000 07/02/2014 12:43 PM PAGE 1 OF 1 Alt. Parcel M 33.30.19.361 K 030 - TOWN OF SAINT JOSEPH Current ❑ ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner O - BERGLUND, MARIAN A MARIAN A BERGLUND 3810 ALDER LN APT 327 EAGAN MN 55122 Property Address(es): * = Primary Districts: SC = School SP = Special Type Dist # Description SC 2611 SCH DIST OF HUDSON SP 1700 WITC Notes: Legal Description: Acres: 2.970 SEC 33 T30N R1 9W NW NW COM 617.32'S & 623.91'E NW COR SEC 33 TO POB N 46 DEG Parcel History: W 193.35'N 66 DEG W 75'N 39 DEG W Date Doc # Vol/Page Type 88.88'N 74 DEG E 600'S 381.45'N 50 07/23/1997 814/283 DEG W 110.10' N 73 DEG W 82.30'S 64 DEG 07/23/1997 793/102 W 82.30'S 47 DEG W 98.47'-POB ALSO COM 05/15/1979 356836 593/560 WD 617.32'S & 623.91'E NW COR SEC 33 TO 05/15/1979 356835 593/559 QC POB N 46 DEG W 193.35'N 66 DEG W 75'N more... more... Plat: * = Primary Tract: (S-T-R 40% 160%) Block/Condo Bldg: * N/A-NOT AVAILABLE 33-30N-19W 2014 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 05/12/2011 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.970 78,800 0 78,800 NO Totals for 2014: General Property 2.970 78,800 0 78,800 Woodland 0.000 0 0 Totals for 2013: General Property 2.970 78,800 0 78,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch M Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00