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HomeMy WebLinkAbout040-1132-70-100 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Building Division St. Croix INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) 578946 0 Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: VanderVorst, Dustin & Alissa Troy, Town of 040-1132-70-100 CST BM Elev: Insp. BM Elev: BM Description: ~b ~ G Jr Section/Town/Range/Map No: TANK INFORMATION 35.28.19.552D01 ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic W" Tn Benchmark ' Lam- F'~ a' lzSO Al. (14, JL_ /D ~f / od / Ad ~ p ~ Sz.S Alt. BM 1 "1 3,717 /dS. "I - Aeration Bldg. Sewer /6y Holding St/Ht Inlet s s.L3,~3,3] S TANK SETBACK INFORMATION St/Ht Outlet S~ TANK TO P/L WELL BLDG. ent o Air Intake ROAD Dt Inlet !j f e Septic 5U 7 51 /Z6 / Dt Bottom ` Dosing Header/Man. Aeration 4` ~ 162 • 5 cj Dist. Pipe is Holding -1 -.q ~de 4 Bot. System Z P Final Grade UMP/SIPHON INFORMATION A ~ $ . L 143. Manufacturer Demand St Cover GPM CpJ Z. 7 J16(a • L.$ Model er TDH Friction Loss System TDH Ft =z, g.~{L loo. sg Forcemain Length Dia. Dist. to Well 9. ~ g9 s SOIL ABSORPTION SYSTEM t,) , 6 . y -'ii. s BED/TRENCH Width Length / No. f Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: / INFORMATION CHAMBER OR G rla'-, 5VV ~t4 Type Of System E!' ~1~ UNIT Model Number: _ 1672, DISTRIBUTION SYSTEM WeSf- Header/Manifold I Distribution Pipe(s) x Hole Ix Hole Spacing Vent to Air Intake Length Dia 4 Length ` Dia Spacing C q I'e SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over ( Depth Over e Bed/Trench Center Depth o~ xx Seeded/Sodded xx Mulched -Z7 Bed/Trench Ed Topsoil Topsoil Yes 1 No es H No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection Inspection #2: Location: 10 Dry Run Rd River F 1111s, W1 54022 (NE 1/4 SW 1/4 35 T(2~8(N~ R19W) Lot 3 Parcel o: 35.28.19.552D01 1.) Alt BM Description = J V ro 2.) Bldg sewer length = CoJek 44- 1 - amount of cover 7 32. 4: e Plan revision Required? ❑ Yes No q C Use other side for additional information. I J SBD-6710 (R.3/97) Date epct s Signa re Cert. No. - fe4 County GR~~X Safety and B.ul ng§ Division !W G 201 W. Washington Ave., P.O. BOX 7162 Sanitary Permit Number (to be filled in by Co.) Madison, WI 53707-7162 oiI' 100UNTY O State Transaction Number Sanitary Permit Application QUA In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04 1 m , Stats. DRY K(W FWD L Application Information - Please Print All Information / Property Owner's Name Parcel # ~ ks-r( W, Lis6~A G. Ufl t)te ortsf a ~4 C - 70 - / Property Owner's Mailing Address Property Location ~ Io3(a N ig-0 P~ RD" Govt. Lot - SSZ l City, State AipCode~, Phone Number ~y, :TV /4, Section 35- ~/iJl 715 $2-1- $bg' T Zf N, R ,,(circlEon II. Type of Building (check all that apply) Lo I or 2 Family Dwelling - Number of Bedrooms Subdivision Name L Block # ❑ Public/Commercial - Describe Use A) A ah \ ❑ J 01", 1 City of 5 CSM Number ❑ Village of El State Owned -Describe Use 14 gU Town of 'rt4~ III. Type of Permit: (Check only one box online A. Complete line B if applicable) 2-6 A/ 0 _ A. ^)Klqew System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only Other Modification to Existing System (explain) List Previous Permit B. and Date Issued B. 11 Permit Renewal El Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New ~ Before Expiration Owner IV. Type of POWTS System/Component/Device: Check all that apply) )(Non-Pressurized In-Ground El Pressurized In-Ground 11 At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound <24 in. of sortable soil ❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) 11 V. Dis ersal/Treat ent Area Information: Design Flow (gpd) Design Soil Application Rate(gpds Dispersal Area Required (sf) Dispersal Area Proposed (s System Elevation q 60D 0.6 Iz00 1 znv 10z ID /00 9 J VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units i, New Tanks Existing Tanks G 7 d Y • v / („1 /U Imo" V G. U Cn N rn W 0"1 3 Septic or Holding Tank Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) um is Signat MP PRS umber Business Phone Number ,e~ u ELL eta C o 7 3 (7/5 3D7-I~t3d Plumber's Address (Street, City, State, Zip Code) 7 S Rao` ST&ST~r 'Z\VUi__FAUs Ws fl~z VIII. Coun /De artment Use Only Approved ❑ D Permit Fee Date Issued Iss3uing nt Signature X75 i~ i~ Owner n Reason for Denial IX. Condit easons for Disapproval 1 Septic tank, efflusrlt filter and dispersal cell "must all be servlces /'maintained y t t4-~ 6C1~L t G O as per management plan provided by plumber. J 2. llsetbeckrequim'Mont must ;be•maintained ss per spplica~bfe code / ordinances. Attach to complete plans for the system and submit to the County only on paper of less than 81/2 x 11 inches in size SBD-6398 (R. 11 /11) - Plot Plan Page a of Property Owner Pt 11 u P .6. c--*Lc- M. Kosl•~IER- Zky-ex:.bk,-TIN w. AL-1ss G 4o ft. Legal Description ~ )N -r-Hg N =){y s ~ (except where noted} Backhoe- pit yi tscm.s, N ' LOT- -3, CAM Z • 9~~ C ~ ° C> North movosz-n o I Q o ~s iob j 31 sc q oa 40 Og fv~W VJ~ CSIgCi P-V-5 ) 0 1 ~'IDS' 55 N S c o a o ~ J 9 ~ ftl7•~ ~ t1 JJ Mi34 ~ 0 0 o a~$Z aP ` 1100 SA'L-TflP OF-s P. @ F~~c gaST"-~4ssunn'et~ 1a0.~o ` N N1 Site Location: P 'Y 1 c C"GFY CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE 1 Project Name: DUSTIN ►W. YhAmVoRST V~~1~~R Q~ST Owners Name: ( ~S4NW) Owner's Address: &3b /4 L H- RI ty F RDAD R►VEx FA U5, WT 54o2z s*X Legal Description: _ JxT~ r NL~ pr t4M SWI 4LSW, 36; Tz Township: TI~y County: ST, C ni K Subdivision Name: ni A- Lot Number. Parcel ID Number. Page 1 Index and title i Page 2 Plot Plan //V/ V/ Page 3 System Sizing & Cross-Section Page 4 Filter Specs • MARY JO : Page 5 Maintenance Information HUPPERT s Page 6 Management Plan D 1859 R FALLS Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed %V 4&j * Page 9 CSM or Plat uiirymn+tttiia~a~~~ti~r`Attachments: Soil Test & House Plans TA SPECS Designer/ lumber. MAKY 30W w0~Fr-T License Number. 1 K59-a07 Date: Phone Number IS qzb-1775 Signature 0 LK6e~n~ Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD.10705-P (N.0,101). Page 1 • Plot Plan Page a of Property Owner :Pt JUF A6 GAUE- M. Ko~~ Bkyex :.bUsTim w, 4~ AL 1ssR c. . VAr4tep go#z5T I f~ = 40 ft Legal Description zeA-{ b. 1N -r,4 f= N rz '/y z) r- ~i (except where noted) _5w, TnA, RlavJ, -rowA C9-'b,'( rovtat , = Backhoepit Wtscr A]. Lord North taco ~ wec~ ~ _ 3 L ~ Q tQU w 3► x"' S ~ 00 Y I- IDT 90-5 o_ 5 b3 115D GA~• 9~a 9. x si 4. i ` C 5 ur ~u (Gaa ss~ ) $z- pit- ? Zt0.67 . %,A-- Ttp OFT.Q @ F~~ paSt'-,~}ssunn'~v N to Site Location: r C.r. SOIL. ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT PaP.?3' .of,_7_ Project Name: b ysTi m W. U SSA . VAA bQK Vms'T zoo z_,1 X /D.o . 1000 • 2~ No Tk'EA1Gfi'L~s ; 60 f4. -&t of Cells Per Coll _ y ft Cell Width Total No of _6,0- ft Cell Length _'o■ 0 sq it EISA Per Cell ft Cell Spacing sq n Total EISA Manufacturer Model Laying Length EISA Rating infi@rator EZ1203H-5fl 5.0' Z5.0 EZ1203H-10ft 10.0' 50.0 - Gravelless Leaching Unit Manufacturer: GLD14 Gravelless Leaching Unit Model: 1 Z03 t1 ~II?~fi Typical Cross Section Finished Grade ft Observation Pik a with approved cap or vent s■ ■ ■ ■ e ■ e ! s:'.'.:;:-::.:•:r:o-:::---::;::;::•:o-:' its ' ` ; :it. is Soil Backfill Geotaxtile Fabric ■::~r R,;;v,v,';•; its>: v-~ it Infiltradve Surface 12 to 0 I ft Limiting Factor 7 310 in Slotted and Anchored Vent/ Observation Pli*with Cap ~~~------aa-s_ seasr■sssas■ssK■r~s■r■asar■saswas* mean ■owns ■■ssss■s■■■ssan•■ TKH 1 sys~M ~c.~Y77DNs /oz, asp/ 4t Z Plum.igner ignature: License Date: S 1 S i 0 0o>3>o -4 -Ir -I~r D Dom -I < r z D O m C: -0 X M 0 Q N A Cr M Z w -n m X Is Q' w m D o coo"M z O m pM- S T> m~ q~ p n 0 Fn s T ~ ~ ~o a a+ A ~ Vf Z ~ Nv O N CO I rr n n ^ 8 m O V IV ~ - Of y ' l OWW A S w n, A co O co tO A 0 3 N O ~ ni N ~ N u U~ u O "N pOp ST ~ ~ W V N _ O ~ O ~ u O O' O p 0 SIMON l0 win VA/VDaZ-VO 1 DWSTW 01- Fe6.26.2013 01;22 AM St. Croix County Plan/Zoning 715-386-4686 POWTS OWNS RT MANUAL & MANAGNMENT PU►N raga - of FILM ATiON Sy" M SPECIFICATIONS Owner Permit # /q vr'- A1Z1 01, O Septic Tank Capacity al O NA Septic Tank Manufacturer W ~Sr;KK Cl NA 0Ed3101 PARAN(EMN Effluent Filter Manufacturer 19OCYLOK D NA Number of Bsdrooms 11 NA Effluent Miter Model z S 17 NA Number of Public Facility Undue WNA Pump Tank Capacity al 1,?'NA Estimated flow leverage) y00 aVday Pump Tank Manufacturer 5t NA Design flow (peak), (Estimated x 1.5) (orb allda Pump Manufacturer 16 NA Sall Appkoation Rate 101 aUd /ft' Pump Model Vr NA Standard influent/Effluent Quality Monthly averago Pretreatment Unit 7NA Fate, 011 & Grasso IFOG) !930 trig/L D Sand/Gravel Filtar 1:1 Peat Filter Biochemical Oxygen Demand (000e) 9220 mg/L Cl NA 13 Mechanical Aeration Cl Wetland Total Suspended Solids ITSS) 51 So mex 0 Disinfection Cl Other: Pretreated Effluent Quality Monthly everage Dispersal Cella) C1 NA Biochemical Oxygen Demand (BODE) 530 mg/L In-Ground (gravity) C In-Ground !pressurized) Total Suspended Solids (TSS) S80 mg/L P NA D At-Grade C Mound Fecal Callform igeomatrio mean) 5104 cfu/100ml D Drip-Une C Other. Maximum Effluent Particle Size Y In dla. C1 NA oti»r. D Na ocher: D NA Other. D NA "Values typical for domeetko W"Isweter and Septic tank effluent, °d»r. D NA MAINTENANCE SCHEDULE service Event Service Frequency inspect condition of tank(s) At least once every. 3 (Maximum S "wa) D NA 1a eater S)°) Pump out contents of tank(s) When combined sludge and scum equals one third (M) of tank volume D NA Inspect dispersal osil(s) At least once every: 3 me~ ° r;M imum 3 years) 0 NA Clean effluent filter At least once every: 4 month e) ar s DNA Inspect pump, pump controls & alarm At least once every: month(s) C) ear(s) NA Flush laterals and pressure teat At least once ovary: month(s) 110 NA Other: O ear(s) At least once every: month(s) ❑ NA Other. CI Yowls) 13 NA MAINTENNANcE INsTRucTloNs Inspections of tanks and dispersal cells shall be made by an individual carrying one of the follow, ng licenses or eartiflcationsi Master Plumber; Master Plumber Restricted Sewer; POWT5 Inspector, POWTS Maititelnar; Septaa,e Servicing Operator. lank Inepactions must include a visual inspection of the tsnkIs) to Identify any missing or broken hardware, Identify any cracks or leeks, measure the volume of combined sludge and scum and to check for any back up or pending of effluent on the ground surface. The dispersal collie) shall be visually inspected to check the effluent levels In the observation pipes i1nd to check for any pending of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a fairrig condition and requires the Immediate notification of the local regulatory authority. When the combined secumulation of sludge and scum in any tank equals oneAWrd OS) or more of the tank volume, the entire contents of the tank shelf be removed by a Ssptage Servicing Operator and disposed of in accordance with chapter NR 119, Wisconsin Administrative Code. All other ofrvices, including but not limited to the servicing of effluent filters, mechanical or pressurize#d components, pretreatment units, and any aervloing at intervals of S12 months, shall be performed by a certlfled POWTS Maintainer. A service report shall be provided to the local regulaatory authority withln 10 days of completion of ant, service event. Feb-26-2013 01:22 PM St. Croix County Plan/Zoning 715.386.4686 START UP AND OPERATION utee ~O or, For new oonstruction, prior to use of the POWTS check treatment tank(s) for the presence of pekMng products or other chemicals that may Impede the treatment process and/or damage the dispersal cell(s). If high concentrations ,'tie detected have the contents of the tank(s) removed by a eeptage servicing operator prior to use. System start up shell not occur when moll 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 call(a) in one large dose, overloading the call(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the oontents of the pump tank removed by a Septage Serv)ring Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Malntalner to assist in manually o "rating 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 16 feet down slope of any mound or n4rade soli 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; clgarette butts; condoms; cotton swabs; degreasers; dental fk as; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; neat scraps; medications; all; painting products; pesticides; sanitary napkins; tampons; and water softener brine, ABANDONMENT When the POWTS fails and/or is permanently taken out of servlos the following steps shall tie taktm to Insure that the system in properly and safely abandoned in compliance with chapter Comm 83.33. Wisconsin Administrative Code: e All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. e The contents of all tanks and pits shall be removed and property disposed of by a Septage servicing Operator. e 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 falls and cannot be repaired the following measures have been, or must be taken, to provide a cods comppeut replacement system; A suitable replacement area has been evaluated and may be utilised for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and a iould 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, 13 A suitable replacement area Is not available due to setback and/or soli limitations. Earring advances in POWTS technology a holding tank may be installed as a fact resort to replace the failed POWTS. C] The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soli and alts ,,evaluation must be performed to locate a suitable replacement area. If no replacement was In available a holding tank may be Installed as a last resort to replace the failed POWTS. 0 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 TRgATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH `VIAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTia INSTALLER POWTS MAINTAINER _ WAAE%LL Name bA-ARGLL L _ L Name EtI175) )AMF-1.-L- Phone X2-163D !'hope L?IS p - I6 3a SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Noma ! Name CRbI 'OkrUTV ZbNI& Phone .C ?I5 ul z~ /Oz~S Phone ~jls) 3gb - 14 17) ST. CROix COUNTY SEPTIC TANK AIAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owoeo"r DU;STIAI ~31o H(C~t RI i~~ RaRD Property Address Ill ~0 flD a (fit " requited fiam Planning & Zoning for newaonshuction.) City/State RIWW, FALLS, Pare el Iden LFGAL DESCRIP't'IM hopes y Location C- n/4 , -5 1A _ V4, Sec. ,-:~5, T Z9 N R 19 W. Town of 120 Subdivision Plat. Lot # 3 I Ca'ti6ed Stnrvey m2p Z, 7 , Volume 12-UK , Page # 1113 W=Tawty Deed # 55 ZO 71 (before 2t onvoiume , Page # Spec house ll yes/Kno Lot lines identi6sbleyyez tt no SYSTEM MAl KWNANCE AND OWNER C RTZF[CATYON Imptoper use and mantenance of your septic system could, result m its premature: fanlue to handle wastes. Proper maintenancie- ohs of pumping out the septic tank every three years or sooner, if nmdetl. by a licensed puugw VAW ym-v pent into the system can affect the function of the septic tar k as a treatment stage in the waste disposal system. Owner mamicUmm responsibilities ate specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sank" OVdinance. 1"he property owner agrees to submit to SL Croix County Manning & ! omng Department a cetihcabon torm, signed by the owner and by a master plumber, journeyman plumber reskiciod plumbs or a incensed pumpcr verifying that (1) the on--sine wastewater disposal system is in proper operating condign and/or (2) after mspedwn and pumping (if necessary), the septic task is less am In full of An dw - l/wre, the undersigned have lead the above axpirements and ague to maintain the privale sewage disposal system wild the standards set fords, herein, as set by Ste Department of Commerce and the Depa stmt of Natural Resources, State of Rrisicoffiin. Lomficauou sag that your septic sya n ins been mamamed mum be compietedt and renawd to the s. Croix County gianun g & Zoning DVarboent win 30 days of the fine year ' . date. Uwe rert fv that all statements on this are true to the best of my/ow knowledge. Uwe amlate dw ownu(s) of dw property described above, by virtue of a deed recorded m R of Deeds 0ffic.. N S_ ATURE (W APPLICANT(S) DATE ***Any information that is misrepresented. may result in the sanndany permit being rev©lmd by dw Flaming & Zonmg Department. sss a ce is made is the warmuty deed.. es" C 7 9 4 IE 1IEII afEIIEIa III E III 1I 8 2 8 9 8 7 4 State Bar of Wisconsin Form 3-2003 Tx:4237857 QUIT CLAIM DEED 1009082 Document Number Document Name BETH PABST REGISTER OF DEEDS ST. CROIX CO_ wr 03/ 16/20 15 MP 2:37 PM THIS DEED, made between Philip A. Koehler and Gale M. Koehler, husband EX and wife as joint tenants and survivorship marital property $ REl~ FEE: : 30.00 PAGES: I ("Grantor," whether one or more), and Alissa G. Vander Vorst and Dustin W. Vander Vorst, husband and wife as survivorship marital property ("Grantee," whether one or more). Grantor quit claims to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix Recording Area County, State of Wisconsin ("Property") (if more space is needed, please attach addendum): Name and Return Address - Lot 3 of Certified Survey Map in Volume ?.Lof Certified Survey Maps, page eg Leo A. Beskar as Document No. 1006516 filed January 9, 2015 in the office of the Register of Attorney at Law Deeds for St. Croix County, Wisconsin, being located in the Northeast Quarter of 219 N. Main Street the Southwest Quarter (NE 1/4 of SW 1/4) of Section 35, Township 28 North, River Falls, W154022 Range 19 West, Town of Troy, including all of Lot 1 of Certified Survey Map in Volume 2, page 426 in Document No. 342109, St. Croix County, Wisconsin Part of 040-1132-50-000• Together with easements for ingress and egress as shown on said Certified 040-1132-70-000; 040-1132-40-000 Survey Map. Parcel Identification Number (PIN) This is homestead property. (is) (is not) `````~`t11c{INit!!!!rVIi Q Q' . Z U.1 . Dated G'1 ~~IjZO~ 0 O v co z (SEAL) (SEt4 F * Philip A. Koehle SEAL * • to * Ga.'s &1. Koehler 4. Q' V . V,= AUTHENTICATION ACKNOWLEDGMENT ~ Lu : O ~ _J Signature(s) STATE OF WISCONSIN } 2 Jam.. authenticated on COUNTY) t STA'E," Persona ]y came before me on I ta°ls * the above-named Philip A. Koehler and Gale Koehler, TITLE: MEMBER STATE BAR OF WISCONSIN husband and wife as joint tenants and survivorship marital " (If not, to me known to be the person(s) who executed the foregoing authorized by Wis. Stat. j 706.06) nt and ckn w same. Property THIS INSTRUMENT DRAFTED BY: Leo A. Beskar, Attorney at Law, 219 N. Main Street, River Notary Pub Ic, State , a s, My commission (is permanent) (expires: ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORM. ANY MODIFICATION TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. QUIT CLAIM DEED 02003 STATE BAR OF WISCONSIN FORM NO. 3-2003 `Type name below signatures. INFO-PRO' Legal Forms • (600)655-2021 • inloproforms.com x y 84 52r AS READ D c 41" D z i2 nx~ 8 o \ UP 5" It 4" CAS Pn N 3" 44j" 5" y Rl In N O D 36" ~ i r m D I UP 7" p 4" CAS Fn 0 V ' A LL::E: t _ 4 ° v~ 39" id m n i D I m r n V 0 r = C z z Q -I ~p t~ ~3 D o cD-'>tcC) c~ O~Z DMZ 2 C)z0ZOOf Ao IT1 XX z a C --4 DU Y80 igoo =-tG~ p~p2=~~ ~ U) C o ~m m D m mD 1-tO~.. ~ -i m tp*t n 0 y r z z, C n . -14 .I N S R7 zr0~ - _ -1 Fn N .tea NQ \C o=. 7 , (nom r~N~.. \ 14 O O ~(n L~ OO do AZT DD-~ Ana V1 Alm OW Z O nr Nma { Nb 0 TI O z v -1p-~ ~ ~ c1 rm*IvmtFn 0w 'P ob w D a C3 C D NG Sr> O P G' n ? r m H a v v ~m z o mp O n ;;u > 0 ~v p~z 1 frp [~Tp]i, 70 -t o m< r Rl r r 'M n my > C/1 M 3 w -0 N a 2 C A X a 0 r c M O co <3 m r m O rn '-O" RE-POUR: -a WLP1250-µR MIENER C®RCNETE DRAWN BY. WCP REV=14- M SEPTIC MANUAL W3718 US HWY 10 MAIDEN ROCK, Wt 54750 DATE: 00 00 00 DATE:. OST-POUR: 0 800-325-8456 FILE: NPIM-M SAN' of--~T,SZ I V~• ALISSA E? F PAaST REGISTER 0, F DEEDS` ST, CROIX CO,f Wl FOR EIVED015 2:26 PM CERTIFIED SURVEY MAP RE01/0912C Exempt V: LOCATED IN THE -NE 1/4 OF THE MONUMENTED SW 1/4 OF REC FEE' 30.00 SECTION 35, T28N, R19W, TOWN OF TROY, ST, CROIX COUNTY, COPY PEE: 4.00 WISCONSIN, INCLUDING ALL OF LOT 1 OF C.S.M., VOLUME 2, PAGES: 3 PAGE 426, DOCUMENT NO, 342109 CENTER OF SECTION SECTION 35 UAIPLATTED LAND b a T28N, R 19W cv (ALUMINUM CAP) (R--W 87°5P4 1 " W 438.58') `t S 89°46' 1" E S 89°46' 11 " E 438.60' 3 66.01` rte- ~ a 66' IRON PIPE SET T =F-00 4 Qi S 89°46'11" E N I a T 3 3.34' FROM ` N~ p ° .91I ACRES FOUND PIPE. LJ QI azno ZZ w3 12,6,7 $ S.F. ( i wow Par-cei Recorded t~ w = - ¢ 57_8, 4i r u w Pac{e in Vo% 13 1_ p _ +n o' Z jl u_ o cn Q ~I Ln J Ce or 00 . S 8900" W 210.67' M ~J ~n~z n I n' ,a O e., . septh 4. 2 zJ`w vent„ fT t 1 C.b - nt-w 3 CO 140111 N o IRON PIPE SET m w to ¢ N 89°11'51" E 1 ~s M ~clNINtl { W t o - 2.11' FROM SEAL I E T Z FOUND PIPE. ` 0 Q 1 - , ~x UI~ml o ~ ~ U f:6 ao ~INIZI L c+ : ° } l~;lc~t2c~.94' D 60 120 240 o~ V+f c9 (R-N 88°44' 08" W) °o POINT OF T ? BEGINNING I r" OWNERS & SUBDIVIDERS % 2.089 ACRES Z~ w N to I w PHILIP & GALE KOENLER 6 ? i 9I ,02Z 5. ~ = I.? NJ 12 DRY RUN ROAD \ ~R C J. ! `6V F\i•V'~I1 f ALLS~ 98t J'fV22 % tr) ~ (Wiry /'0 ! ° Z `e urn c?yc> tjr I t'- a `r S -26B4 ° PROC=ESSIONAL LAND 'SURVEYOR r0n `N c" n c coyt' G "MP ppNv ..i VL~. ENQI .ELi\iIYLS k11-1 Yl fSi WAz loCA 6 A~:_1 OL9 I Wisconsin Department of Safet / and Professional Services Division of Industry Services SOIL EVALUATION P~ER~R-' Page I of 3 in accordance with SPS 383, Wis. Adm. Code County ST. CROIX Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D ENDING) percent slope, scale or dimensions, north arrow, and location and distance to nearest road. P/Ease print all information. Revi by Date Personal information you provid: may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). S / J Property Owner Property Location PHILIP A. & GALE KOE.HLER (Buyer:Dustin VanderVorst) Govt. Lot NE 1/4 S 1/4 S 5 T 28 N R 19 Property Owner's Mailing Address Lot # Block # Subd. Name or MW 12 . :)ry Run Road 3 CSM City State Zip Code Phone Number ity nvllage ■ own Nearest Road River Falls, WI 54022 ( 715 ) 821 - 8684 Dry Run Road New Construction Use[ ( Residential /Number of bedrooms 4 Code derived design flow rate 600 GPD ® Replacement El Public or commercial - Describe: Parent material sandy Flood Plain elevation if applicable }~1,h ft General comments Conventional In-ground Trenches 0.5 loading rate and recommendations: ITIBoring # 0 Boring Q Gv Pit Ground surface elev. 101.68 ft. Depth to limiting factor 64 in. Soil Application Rate Horizon Depth Dominant 'olor Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsel Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-24 7.5YR2.5/1 - 1 3fabk mvfr cs 2vf-co 0.6 0.8 2 24-32 7.5YR/3 - sil 3fabk mfr cs lvf-m 0.6 0.8 3 32-53 7.5YR2'/4 - sit 3fabk mvfr cs 1vf-m 0.6 0.8 4 53-64 10YR4/6 s Os dl 0.7 1.6 5 64-75 1OYR7/3 c2p 1oYR6/8 fs Om mfr 0.5 1.0 I r 6~' , i 2 Boring # ® Boring ❑ 105.08 71 70 El pit Ground surface elev. ft. Depth to li ing factor in. Soil Application Rate Horizon Depth Dominant :olor Redox Description Texture Structure Consistence Boundary Roots GPDIff' in. Munsel Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Ef1#2 1 0-18 7.5YR2.5/1 - 1 3fabk&gr mvfr cs 3vf-co 0.6 0.8 2 18-29 7.5YR3/3 - 1 2fsbk mvfr cs 2vf-m 0.6 0.8 3 29-54 7.5YR314 sil 2fabk mfr cs 1vf-m 0.6 0.8 4 5464 10YR4,'6 - is Osg dl cs 0.7 1.6 5 6470 10YR7 3 - fs Om mfr - 0.5 1.0 * Effluent #1 = BOE > 30:< 220 mg/L and TSS >30:_< 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) k7~j ne CST Number Mary Jo Huppert (Hollister's Soil Testing & Desi 22 4832 Address Date E a a nducted Telephone Number W9875 690th Avenue, River Falls, WI 54022 03 - 26 - 15 715-426-1775 SBD-8330 (R07/13) Property Owner KOEHLER, P (Buyer: VanderVorst) Parcel ID # (Pending) page 2 of 3 ❑ Boring # Boring pit Ground surface elev. 104.08 ft. Depth to limiting factor 70 in. Soil Application Rate Horizon Depth Dominant +'.olor Redox Description Texture Structure Consistence Boundary Roots GPDIff' in. Munsel; Qu. Sz. Cont. Color Gr. Sz. Sh. *Efl#1 *Eff#2 1 0-13 7.5YR2.5/2 1 2f-ma&sbk mvfr cs 3vf-co 0.6 0.8 2 13-20 7 5YR2 i/2 _ I 2fsbk mvfr cs 2vf-m 0.6 0.8 3 20-36 7.5YR3!3 sit 2fabk mfr cs 2vf-f 0.6 0.8 4 36-54 7.5YR56 - Is Osg ds cs lvf-f 0.7 1.6 5 54-70 10YR5 6 s Osg dl as 0.7 1.6 6 70-75 10YR5, 6 flf 7.5YR4/6 s Om ds 0.5 1.0 I Boring / b -2' F 4~ Boring # 107.93 ;i 66 • Pit Ground surface elev. ft. th to limiting factor in. ~j Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDHF in. Munse Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 1 0-12 7.5YR15/2 I 3fa&sbk mvfr cs 3vf-co 0.6 0.8 2 12-24 y 1 2fsbk mvfr cs 2vf-co 0.6 0.8 3 2438 7.5YRL•/4 sil 2fabk mfr cs 2vf-m 0.6 0.8 4 38-57 10YR5/6 - s Osg dl cs Ivf-f 0.7 1.6 5 57-66 10YRSJ6 s Osg dl 0.7 1.6 Horizon :i has broken bands of sl. [-I I i I I L ❑ Boring # ~ Boring ® Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fft in. MunseI Qu. Sz. Cont. Color Gr. Sz. 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Parcel M 35.28.19.552D-01 040 - TOWN OF TROY Current 1--X1 ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 01/09/2015 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner 0 - VANDER VORST, ALISSA G ALISSA G VANDER VORST C - VANDER VORST, DUSTIN W DUSTIN W VANDER VORST 636 HIGH RIDGE RD RIVER FALLS WI 54022 Property Address(es): * = Primary ~j Districts: SC = School SP = Special L 16 Type Dist # Description 7 SC 4893 SCH DIST RIVER FALLS SP 0100 CHIP VALLEY VOTECH Notes: NEW FOR 2016. CSM TOOK ALL OF 040-1132-50-000 AND 040-1132-70-000 WITH NO REMAINDERS. BOUNDARIES OF UNDERLYING Legal Description: Acres: 2.911 PARCELS RECONFIGURED BY CSM. SEC 35 T28N R19W PT NE SW FKA DEC 578/171 AND PRT CSM 2-426 NKA LO R11 Parcel History: 26-6080 Date Doc # Vol/Page Type 03/16/2015 1009082 QC 01/09/2015 1006516 26/6080 CSM 07/23/1997 578/171 11/13/1996 552071 1208/413 EZ-1 Plat: * = Primary Tract: (S-T-R 40% 160% GL) Block/Condo Bldg: * 6080-CSM 26-6080 040-2015 35-28N-19W NE SW LOT 3 N/A-NOT AVAILABLE 35-28N-19W 2016 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 02/27/2015 Description Class Acres Land Improve Total State Reason Totals for 2016: General Property 0.000 0 0 0 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