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HomeMy WebLinkAbout040-1312-05-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: Safety and Building Division St. Croix INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) 579012 0 State Plan ID No: 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: Delta Construction, Inc. Troy, Town of 040-1312-05-000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town/Range/Map No: 65T 04.28.19.2035 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 4, 4 Alt. BM / Aeration Bldg. Sewer qT. 31 Holding St/Ht Inlet (a97.7/ TANK SETBACK INFORMATION St/Ht Outlet G. $5 q7. fq, TANK TO P/L WELL BLDG. a it Intake ROAD Dt Inlet Septic / ' DQ /1 a ~b Dt Bottom \ Dosing O / Header/Man. 7. a 9S. 3 ~ Aeration Dist. Pipe 9 . C> 9"S. jf - 1-1, 19 Holding 9' ' Bot. System /o' r> 3 6.- 9 3. sir ~k PUMP/SIPHON INFORMATION Final Grade 4, 1197. g Manufacturer Demand St Cover GPM 3.6 6• 7 Model Numb TDH ift Friction Loss System Head TDH Ft Forcemain Dist. to Well , rn:= SOIL ABSORPTION SYSTEM BEDITRENCH Width J Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 p y~ C~ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacture INFORMATION CHAMBER OR ,L .A Type Of System:t / Die l$ Z UNIT Model Num r. . DISTRIBUTION SYSTEM L)25~_ qb , `J'j~ d-a nee ~ ecs west zZxZ = -544 P ~"Js Header/Manifold' Distribution x Hoe Size x Hoe Spacing Vent to Airy Intake Pipe(s) ` \ 7 t~ 1~ S Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded 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: Location: 517 Edie Ct Hudson, WI 54016 (NW 1/4 SW 1/4 4 T28N R1 9W) Cottage Meadows Lot 5 Parcel No: 04.28.19.2035 1.) Alt BM Description = (:;,I '::~bJ4~"-- 2.) Bldg sewer length - amount of cover = 1 i 32 Plan revision Required? ❑ Yes No Eu fi~f SBDUse other side for additional information-6710 (R.3/97) Date Insepctor's Si lure Cert. No. PLOT PLAN PROJECT Delta Construction ADDRESS 202 2nd St. Hudson Wi 54016 NE 1/4 SW 1/4S 4 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX SYSTEM ELEVATION 95.3/95.2 47 below grade 7/6/15 4 DATE BEDROOM CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891 # of chambers 44 ,BENCHMARK V.R.P. top of 1/2" pipe ❑ ASSUME ELEVATION 100' Filter Lifetime Filter BOREHOLE O WELL *H.R. P. same as benchmark Edie Court Pro 4 Bedroom Gale = 1/4" = 10' House r► J~'~~ Q d 30' ~"0- All piping shall be ASTM SDR 30/34, within B.M.#1 T 10' of tank, piping shall be ASTM F891 10' 20' B-1 -y/ 't j ZIlr 5T' 100' Z~ 0% Slope Vent >6" Quick4 Standard of Cover Leaching Chamber 30' -3 with 20.0 ft2 of Area B 4 12 5.6ft^2/pair of end caps 10 Vents 4' Long 3 4" Grade at System Elevation 2-3' X 90' cells with 2' B.M.#2 >3' spacing 34' ]COPY 32' 79' _r X11 M ~Qwata~,r ~ ~ County ~ = 4M1 And A Division X10 JUL lb 201 W. Washington Ave., P.O. Box 71b2 Sanitary Permit Number (to be filled in by Co.) P lwwlrrNA-iis,on AAI7 7162 ~a 5 l ROIX COUNW q '7 yip UNITY I) Vi LOMENT 901 2~, Sanitary Permit Application State Traction N e I ! 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 (if ifferew than mailing address) l the Department of Safety and Professional Servies. Personal information you provide may be used for secondary ) purposes in accordance with the Privac , Law, s. 15.04(1) m), Stats.5/ ~C(~ C C fi 11 1. Application Information - Please Print All Information Property Owner's Name Parcel #i ! Property Owner's Mailin , Address Property Location /v ~ ~ . I Gotrt. Lot C Zip Code Phone Number ~_'4, Section City, Stn o' > rcleo nn (/lJ 1 T Z N: R E r W II. ype of Building (check all that apply) ~ Lot r 2 Family Dwelling -Number of Bedrooms Subdivision N' e i-B10Ck 1! as ~ ❑ Public/Commercial -Describe Use V ~~pdtn City of CSM Number ❑ Village of i ❑ State Owned - Describe Use III- Type of Permit: (Check only one box on line Complete ine B if applicable) /jA U/ System ❑ Replacement System El i ❑ Other Modification to Existing System ('explain) A- ( I Treatment/Holding Tank Replacement Only List Previous Permit Number and Date issued ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit T ransfer to New R Befrlre E ions U t e of POAlTS Svste om onent/Device: (Check all that apply) V (I r Vi) j n-Pressurized In-Ground Pressurized In-Ground 0 At-Grade ❑ Mound 24 in. of suitable soil ! Mound < A in. table sor Holding Tank ❑ Other Dispersal Component (explain)! ❑ Pretreatment Device (explain] V. Dis ersaVTrea ent Area Information: Design Flow (gpd) Design Soil Applicati Rate(gpdsf) Dispersal Area Req ed (sf) Pyt~i)sed (st) Svste_m Elev on - ` M J Vl_ Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units / l o a i New Tanks Existing Tanks I I I~~ VVV ~ Septic or Holding Tani: Dosing Chamber VII, Responsibility Statement- 1, the un r igned, assum risibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's ure MMPP//MPRS Number Business Phone N Plumber's Address (Street, City; State, Zip de) 1,2 W7 7VIII,Countv/De artment Use Only _ _ _ Truing Agent Signature p ved proved l q S wnerGiven enial IX- Conditions of App easons for Disapproval SYSTEM OWNER: NER: n'I A4V- ^A s`- e , ~ C IV`7 U 1. Septic tank, effluent filter and I I 1 dispersal cell must b-e served /maint in as per management plan provided by plumber. A^~ "v Ail setback requirements .,must be maintained q) W 61S as per applic6~dtode4ofoipl$M(:Me system and submit to he County Only on paper' not less than 8 is i 11 inch CS 1 lZC W s iv$IkAn JOY7 1) -F 14641W( Al l~` e #00 SBD-6395 (R hill) !/W' d vW/ s g0dtL1w10evel -h P~✓~ l Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 7/6/15 Owner: Delta Construction Location: NE /4 SW1A S4 T28 N,R19 Lot 5 Cottage Meadows Troy 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 Specificatio Sheet Signature License num r #226900 PLOT PLAN PROJECT Delta Construction ADDRESS 202 2nd St. Hudson Wi 54016 NE 1/4 SW 1/4S 4 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX SYSTEM ELEVATION 95.3/95.2 4.7' below grade 7/6/15 BEDROOM 4 DATE CONVENTIONAL XXX IN-GROUND PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1255 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 891 # of chambers 44 BENCHMARK V.R.P. top of 1/2" pipe ASSUME ELEVATION 100' Filter Lifetime Filter ❑ BOREHOLE O WELL * H. R. P. same as benchmark Edie Court Pro 4 Bedroom Scab' = 1 /4° = 10' ` House Vj~ ' 30' All piping shall be ASTM SDR 30/34, within B.M.#1 T 10' of tank, piping shall be ASTM F891 10' 20' B-1 100' 0% Slope Vent >6" Quick4 Standard of Cover Leaching Chamber 30' -3 with 20.0 ft2 of Area B- B-4 Vents g 12„ 5.6ft^2/pair of end caps 4' Lon 10' 34 Grade at System Elevation 2-3' X 90' cells with 2' B.M.#2 >3' spacing 34 32' 79' 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 100.0' Vent Grade Vent 417 X 30/34 Septic Tank\~ ~1" 'Long 5' 'Long l Grade at System Elevation )0-- Grade at System Elevation Spacing 5' 2-3' X 90' Cells Same on other end Observation tubeNent At end of cell A B 22 chambers per cell System elevations: A-95.3' B 95.2' ST CRO IX CC) UNT S_E TH7 TV& ( 1 i 7Y77 Fi. !y1.) 2 a1~~jvt'1\ .tltly ~,~`,1 Y Cf'W'i 11!._ N f'1. pIM OmmmqllltJ - Mailin E1cldress 2 h _l Property A(Wicss Ed f 2 C-+ HuosL* (t elificatlon Fcclinled flolu ~QQ0(:Jmlt Jul uclA ntlslrttcun :'iLV(StateV_ U~! ~~0(`,(;l~fticttt,ft(afion NUM CT ©y0 13.1Z I1EC L 1}1.SCItiP l'>tON c Pro pc i-t Lmation "nfW i J Subdivision Certified Survey Map `4 C~ Warranty Deed Pad, Spat IMMISe no or ideuniinh bCs M SYSTEM I /A.A.I N'I'Yt'.NANCE M41) a:rNAINIA CEU'l'Y 11CAMON tLnproper usr. anct mainitunaIlGC Of VOLU Sljl(tl, SyStCIn coia(j is tilt 111 its pinmiatme ralluin M biDdir wanes. Ilagw.1 tnairtteuance consists 01 j)tntlpul,? (1111 dl(' se[:tic idnl( evvirv direr vCa)s c(r stoker, , deeded„ by it licensed L~uulpl~r What ~'ou pn1 lair, ltie syste2I1Gild of uct'div function of dtc ',CT)11C tank as a trCaiui(m Siaiy & Ac "You (1I5(1')sal :mum- (-)wfl(n Ina mutwir,-t'. responsibilities aie specified in on-im. 8 _:j 1) alx! in Wpm 1 ' bt_ C"Ux ( b In y ;_I tnitnrv ( hdiunncc The property owns r 1 pre , to subm to Sc tmx s :(niun i'l nmio r. /on ji; i ii'panl wm d cclufl(:aticul saw qn~ iv ;1« owner and by a Il ster plttntbe.r, iooi lit'.yrnan plunibcr, rtstlJ ;i~~a{ phinlhur a Itcv sect purnpci vc i d-ving that ( I j iht 0 1 ,tn ewasteawalm disposal Sysmin is 111 ymnpcr operajug ciandition alabol (2) aiicl ngkn fort mid pulriplmt, (if II_ c.essaa?, the '.(.pile mni' less dean lli f til of Sh.ldgC. Owc, the uaduisymd Wo c "ad dw 1lhmv lCtIti n(:"ilu'uts ami zi)irc(- 'lo mail tt1111 ill,, ilrivan maudaids set Jbidt, Mehl, as set Uy ttlc [.icpaimicin of i_.i)inlnel(-r and i)x ,)rprlrttncni cti Natural 1tc,~~on1((.~- ;;tine of \x'15( -,~i-;t2, c'eititication stating that yottl septic system has bet,Ii Tnanvanicd unlit he. cojnpicw° anti •cnuned to the St, (_'rol'- i `oruu 1'ianlut ~E. %onulg Depart111;(nt within W days of HIC tare ~c~ar cvpirati(Irt bate LWO cerndyb at al! statements on dus na arc 1im, it) the hest of un': (an 1, nk u=.'Icd''> li~.vr x1111 tur thk-' rte ,l; 1(" property described above, by vWmi of a vas= ran y i.lecd recorded ill itctrswi of Doi N (Ahc-e. Nlillab .r of; edrooln5 f . **Any infhrlnaMion that is Inisrejlu~st;nti~d rUay result in the Saunaiv lot mil bi'-mg a SQ-t-li bl- the i tan n nl ati- 7onin)~- { pin ttl,u ` MAW with this applicalmn a inumded anamv cNe'd himl Ill(' INgw -1 01111 't1; 'HOC dmi a copy of dic Ccttili(d sU1va% Blip i~ reicrcnce is made in the warranty (REV, 081115) POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page__ of FILE INFORMATION SYSTEM SPECIFICATIONS Owner L Tank Manufacturer ❑ NA Permit # eptic ❑ Dose ❑ Holding Volume: (gal) DESIGN PARAMETERS Tank Manufacturer; ❑ NA Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑ Holding Volume: (gai) Number of Public Facility Units: NA Vertical Distance Tank Bottom(s) to Service (ft) low : (gal/day) Horizontal Distance Tank(s) to Service Pad: P(ft) Estimated (averaga) . Specific servicing mechanics must be provided if vertical is 515 feet or Design (peak) Flow = (estimated x 1.5): 6 Q (gallday) if horizontal is > 150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: - (gal/day/fe) Effluent Filter Manufacturer- si~ !2-ems ❑ NA ~J t Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: Fats, Oil & Grease (FOG) 530 mg/L Pump Manufacturer: A Biochemical Oxygen Demand (BOD5) s220 mg/L ❑ NA ' Pump Model: Total Suspended Solids (TSS) 5150 mg/L High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer. (BODs) >220 mg/L NA ❑ Mechanical Aeration ❑ Peat Filter (TSS) >150 mg/L ❑ Disinfection ❑ Wetland Pretreated Effluent Monthly average ❑ Sand/Gravel Filter ❑ Other: (BODs) 530 mg/L Soil Abs0 on System JSS) 530 Fecal Coliform (geometric mean) <10`mg/L A ound (gravity) ❑ In-Ground (pressure) ❑ NA ❑ At-Gra ❑ Mound Maximum Effluent Particle Size 'la in dia. ❑ NA ❑ Drip-Line ❑ Other: Other. NA [Other- ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) When combined sludge and scum equals one-third ('h) of tank volume ❑ V-Tften the high water alarm is activated Inspect condition of tank(s) At feast once every: month(ear(s)s) (Maximum 3 years) C3 NA Inspect dispersal cell(s) At least once every: Li onth(s) Maximum 3 years) [3 NA ear(s) Clean effluent filter At least once every: month(s) C3 NA ear(s) Inspect pump, pump controls & alarm At least once every: ❑ mon (s) ❑ NA ❑ year(s) Flush laterals and pressure test At least once every:. C1 ❑ year(s) month(s) (\M NA Other: At least once every: ❑ month(s) NA ❑ year(s) Other: NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifi 'ons: Master Plumber, Master Plumber 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. When the combined accumulation of sludge and scum in any treatment tank equals one-third (X) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of <_12 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 (02/05) Page of START UP AND OPERATION products, solvents or other For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting p 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. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be=discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber or POWTS 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. Do not drive or park vehicles over tanks or the soil absorption system. 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 treatment tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette' butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanifs ,y napkins, solvents, tampons,'and water softener brine discharge. 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 If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. 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 the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING 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. ~r ADDITIONAL INSTRUCTIONS: POWTS INSTALLER POWTS MAINTAINER. Name Phone ~Name hone r SEPTAGE SERVICING OPERATOR UMPER LOCAL REGULATORY AUTHORITY Name Name~ 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. ii cv 4 t Ik ~ s l e O TO E LO Q Q / N `C) S ' b o m % 3 a w f C..J i a I. L Property Owner _ Parcel ID # Page of F-1 Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Appli 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 F-1 ❑ 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/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 ication 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 = BODS > 30 < 220 mg/l, and TSS >30 < 150 mgA- ' Effluent #2 = BOD3 < 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 608-264-8777. SOD-8330 (8.6/00) m'NOacnn F~ F, ~a j! o c 0 N n: 3`f~lE ! 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RECEIVED FOR RECORD 08/16/2005 02:00Pt( WARRANTY DEED This Deed made between CORNERSTONE EXEMPT # PARTNERS, a Minnesota limited liabil' company, REC FEE: 11.00 Grantor, and DELTA CONSTRUC N, INC., a TRANS FEE: 3120.00 COPY FEE: Wisconsin corporation, CC FEE: PAGES: i Witnesseth, That the said Grantor conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin: RETURN TO: Ty q-' oU0a3 t/0(0 Lots 1-13, inclusive, Plat of Cottage Meadows in the Town of Troy, St. Croix County, Wisconsin. This is not homestead property. TaxID# 040-1014-20-000; Together with all and singular the hereditaments and 040-1014-50-000 and 040-1015-80-000. appurtenances thereunto belonging; and Cornerstone Partners, LLC warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except easements, restrictions and reservations, if any, of record. Dat th day of August 2005. CO TONE PA TNERS, LLC (SEAL) Its: AUTHENTICATION ACKNOWLEDGMENT Signature of as STATE OF WISCONSIN ) ofCor 7&rtners, ) SS LLC authenticated this day of August I ,,~COUNTY OF ST. CROIX ) Personally ve named came before me this 15 t lacy of August 2005, the TITLE: MEMBER STATE BAR OF WG'ep ,SI1f A• f. OZ abo CC~~_y of Cornerstone Partners, LLC, to me (Signatures may be authenticated or ackiS edged. B*Ate not known to the person who executed the foregoing instrument and necessary) '~~CC G acknow d d the same. THIS INSTRUMENT DRAFTEI A-* ' • G0 D. Peter Seguin i,,F OF W%S``o~ MUDGE, PORTER, LUNDEEN & SEZ7 td!15.V. JLU M. UUj__Uq-;~Wj 110 Second Street, Post Office Box 469 Notary Public, State of wilco M-11-2005 My Commission (expires): ' Hudson, Wisconsin 54016 RECEIVED Wisconsin Department of roe SO EVALUATION REPORT Pa e ~ of 3 Division of Safety and Buis JUN 9 1_ 2005 g in accordance with mss , Adm. Code S-r. CR01` C TY County S i C- Attach complete site plan Paper 11 as in include. but not lim to: O 4 O percent slope, sca eo dimensions, north arrow, and location and distance to ne l d Parcel I.D. Please print all Information. f " by Date Revie# Personal informetion You provide may be used for secondary purposes (Privacy Law, a. 15.04 (1) (m)). 1~1~ " 1 Z Property Owner Property Location i D D D SJ e1Q s-rer->?'- Govt Lot NE 114S1rr 114 S T Z& N R E (or) 4g> Property owners Maifing Address W_ F # Subd Name or CSW -59 Z-- O M1} H GT 5 GOTTq, <-a c- A4c9D o~ 5 ow State Zip Code Phone Number O City ❑ Village Toxin Nearest Road b-56 WI Arlo ( ) -TRO 0i.aeRa &I ® New Construction tJse: W Residential / Number of bedrooms 3 _ 5 Code derived design flwu rate -15 b - 7$0 GPD ❑ Replacement Q Public or commerdal - Describe: Parent material I r~.~ oK.. o tJTW !qS Flood Plain elevation if applicable rJ it General comments and samninendations: Area x Spot Tested suitable for a Conventional Inground system (P.O.W.T.S.) CJ ~'7 L"d~ Q-Tl;, • ' e # ® Pit Ground surface elev. 99 , 9/ ft Depth to tinting factor > 9'S in. U a~ Soo Application Rate Horizon Depth Dominant Color' Redox Description Texdxe Structure Consistence Boundary Roots GPD/ff im Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 `Efl#2 1 o-23 lvrR zlz C 2 C5bX &7f r 3V-F &0 .8 2 23-3,9 1 v Ya 13 - SC l 2 c sbK Mfr q w 2-,1-( y- 3 31h-9~ 1 u Yf2 5/~t s 0 s C1 ! - - •7 f Boring # 0~ii BMW F2-1 Bo El Pit Ground surface elev. • Z8 ft Depth to bmiting factor > 98 in. Sol Application Rate Horimn Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff° in. Murrell Qu. Sz Court color Gr. Sz. Sk 'Etf#1 'Eff#2 I 0-9-g 1v f',e 2/1 - 1Z 31 sbK m -f r ,S 3 v-{ .10 • S L 48-70 1vYR413 - siCl 2rh5bA m* ow - .y 3 70'q I b YRs/~ - S 0 s C/ / - ,-7 E I Effluent #1= BOD > 30 < 720 mg& and TSS >30 < 150 m9& ` Effluent #2 = BoD 5 30 mg1L and TSS < 30 mg& CST Name Tiesse Prim Signature CST Number C-N) -3 7 U L R-e le-H-r k59935.L Address Date Evaluation Conducted Telephone Number 24312- 10- -Ft A VE: SPRf^fh V*t LVIVY W/ MAV /o-zoa.f 6715-) -772--3-9-9-2- For issuance of permits and designing Ulbricht & Associates Contact; Ulbricht & Associates Private Sewage Consultants 2812 Registered private wastewater consultant and PIAMIS SpringVVa ley, VVl 54767 2812 10th Ave. Spring Valley, WI 54767 715-772-3442 ORIGINAL I i S yo-T Property Owner Pancei lD # 6 40 014 -16ooo& Page L of 3 -31 F Babg # ❑ ears ® Pic Gmu d surbw Nev. qq• & & oep& to > 93 im se Awkeson e Haim Dep& Dowk rrt Calou Redox oesm"m Texture 5bucWm Camidence Boundary- Roots GPW Im Munseli Qu. Sz. Cart. Cola Gr. Sz. Sh. *EM -EW 0-12- toyRYI - .9 2M-5,bK fh -Fr CS 2 12- ?5 10 -(R 4/ _ C l 2 bK Yn f-i OL W 2<V 6 3 25U 1Vtot 5i~} S 0 59 ®S ~Jf 2 I'6 VAV F-1 # ❑ so*v U O Pit Grand scxface ela►. it DaO to &nRiV baOr in Horiaon Depth Don*wt Calm Redorc Des u"m Texture Sh x*m Consistence Barudary Roots GPDff in. Murrell Qu. Sz. cont. Color Gr. Sz. sh. •EW 'Elf ❑ &nv F-1B,bv# ❑ Pit Grand surface elev. >t Deo to rrrrBrug Motor in. Sol Rate Horiaon Depdr Darrinara CO&N Redox Desa"on. Ta tre Sbucwm commence Boundary Rawls GPO/ in. Murrsd Qu. Sz. Cant Color Gr. Sz Sh. 'EA#1 •EW E Batts # ❑ Baits ❑ Pit Groutricl srrfaoe elev oepr► to M s f or Sol Application Rate Horiaon Deplh Domkwd Color RedcK Dssc pGon. Ta dm Struct" Coristslenoe Botndwy Roots GPDIF im Musser Qu. SL Cant. Color er. Sz. Sh. OE ' T3112 • Etlpt "#1 = BW, > M < =0 ngA. OW Mm >W:5 150 WQ& • Elruent #2 = BM,j 8a n MA. and M:5 M wq& Ue DeMbneM of Commerce is an equal opportunity service provider and empioM. 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