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020-1288-80-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety 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)]. Permit Holder's Name: City Village X Township Fors he, Thomas Hudson, Town of CST BM Elev: ~ Insp. BM Elev: BM Description: TANK INFORMATION `" ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic c~J C--~~.s' ~ 's ! ~ Dosing ~_~,~~s Z 6~ Aeration ~~ ~~ Q ~~. ~~ `/a - ` J Holding t TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD eptic ~,, , , so ~ , ~-s 3 3 ~~" > Sa ' y ~,~' ~ ' --. Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift riction s System Head TDH Ft Forcemain Lengt o well County: St. Croix Sanitary Permit No: 499268 0 State Plan ID No: "'_' -~~. Parcel Tax No: 020-1288-80-000 Section/Town/Range/Map No: 21.29.19.1414 STATION BS Hi FS ELEV. Benchmark (. (7 ~ OD,p Alt. BM Bldg. Sewer ~' SUHt Inlet ~~\ J s- 3~ .sfa f St/Ht Outlet ~~ ~,~ ~ ~~. 2~ ~ Dt Inlet /~ Dt Bottom Header/Man. / U. C ~ ` p / l C Dist. Pipe 5 N `D.' ~ ID.tt ~ f• } l ~ Bot. System 1 ~~ ~3 ~ ~ S.~ i Final Grade ~. ~ ~~. ~D/ St Cover ~~ ~,~~ ~~/~ ~ ST' cQ s•3 9,~~ S(v' o-wt- L. o ~ `IS. p l SOIL ABSORPTION SYSTEM ~ /Lt' +- ~) S ~ 3S E Width ~ Length ~ No. Of renches PIT DIMENSIONS ~ O ~ SETBACK SYSTEM TO P/L BLDG WELL LAI INFORMATION Type Of System: { ~ r -~-bp ' So ~ ~ ~ , 111STRIRIITI(~N SYSTEM -~ (Jo~"~P// \ Pits (Inside Dia. (Liquid Depth CHAMBER OR J`~J/~ UNIT Model Nt~n~rG ~~ Header/Manifold I ~ Distribution ~ x Hole Size x H ing Vent to Air Intake LtJ/ Pipe(s) Q ! ~' Length Dia Length Dia Spacing Sf711 CnVFR Y Dre~cnro Quc4cmc Mt.. YY Mnimrl nr At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed(irench Center 8ed/Trench Edges Topsoil j Yes I ~ No Yes No dl/, COMMENjS: llnclud co a discrepencies, persons present, etc.) Inspection #1:~. /S/~~ Inspection #2: Location. /850~Zane Gray Circle Hudson, WI 54016 (NE 1/4 NE 1/4 21 T29N R19W) Wells Fargo Station Lot 18 Parcel No: 21.29.19.1414 1.) Alt BM Description = ~++~ ~7' ~~~ ~~ r 2.) Bldg sewer length = ^~ 33 -amount of cover = ? ~ s.-~••`5' ' ~~~+'~°' Plan revision Required? Yes No ~.C /~" - ~/ S'~ t,~ ) Use other side for additional information. ~I _ ____y __ _ _ _ _ __. _. ___ _ ''~'~__ _ ~- ~-/-- Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) Safcty and Buildings Division Cam' ~ , ,~ 201 W. Washington Ave., P.O. Box 7162 D ,S'CO~s,~ Madison, WI 53707 - 7162 ice Address De artment of Commerce ,5~0 C Sanitary Permit Application Sanitary Permit Number ~ 9 26 ~ In arxotd with Comm E321, Wis. Adm. Code, personal information you ide Check if vision rna be used for seco Privac Law s15. 1 m I. Application Information - Please Print Au Iaformati n RECEIVED state Phtn I.D. Number Property Owner's Name Parcel Number 1~Om l4 S ~D,~'~'r~ i l~ E DEC 1 3 2006 ~ (~/~{ Property Owner's Mailing Address Property Location ~~ ~~~~G, ~ ~~ ~ ~/~C G ST. CROIXCOUNTY ~ ~ ~ ~~~: S T N, R ~ ~ City, State Zip Code one um er Lot N~ber Block Number Subdivision Name CSM Number 1~ FYI 5 ~ ti~ ~t1-~ _ J ~/~~ ~ ~~ i S - 3 ~~ ..7~~~ ~/ ~ ~- ~~ r f +~ ,~ , ~ sT,~ s II. Type of Building (check all that apply) ^City 1 or 2 Family Dwelling -Number of Bedrooms ~l ~~ge ^ Publtc/Commercial -Describe Use Township Z{ Q S 4 /l~ ^ Sate Owned Nearest Road Z/~/lJr ,~'E C ~~'C ~ r III. Type of Permit: (Check only one box on line A (numbering scheme for internal ttse). Complete line B if applicable) A' 1 ^ New 2 ~ Rephuxment System 3 ^ Replacement of 6 ^ Addition to For Count? use S stem Tank Onl Exis ' S stem B. ^ Check if Sanitary Permit Previously Iswed Permit Number Date Issued TV.1y+pe of Permit: (Check ali that apply)(numbering scheme is for internal use) 44 ~ Noa -Presauized Ice-Ground. 21^ Moues 47 ^ Sand Filter SO ^ Constructed Wetland 22 ^ Pressurized Ia~Grouad 41 ^ Holding Tank 48 ^ Single Pus S1 ^ Drip Line 45 ^ At-Grade 46 ^ Aerobic Treatment Unit 49 ^ Recirculating 30 Ocher L.Q.a V. D' rsal/'IYeatment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Gnde Required Proposed Rate(Gals./Days/Sq.FtJ (Min./Inch) Elevaion VI.,Tank Info Capacity in Total Number Manufacturer vrr Prcfab Site Steel Fiber plastic Gallons Gallons of Tanks tw1/~'T' ~ (~'(r Coacrcte Constructed Glass New F.xistiaj ~~ 1 Tanks Tuilcs e+M~a. Septic or Haldin~ Tank ~6 ~ ~ ~B~ latD ~ o''Z. ~')(/5/at~(~ %O~~ ->< Ul G E~s VII. Responsibility Statement- I, the undersigned, an„n,. respoadb[lity for installation of the POWTS shown on the attached places. Plumber's Name (Print) P 's cure MP/IvIPRS Number Business Phone Number .J a I-E ~ SC. rf N1 c ~ c ~.~ 3 ~7 d 7/s - SY9 -l 6 Plumber's Address (Street, City. State, ) rf9 / (o / S C~ . N ~U~ S~~ vet E/~5t` i ~~f~'~1 S ~lC~~-~ VIII. Count /De artment Use Onl Approved ^ Disapproved ~~' Permit Fee (' lodes Groundwater S h F Date Issued Issuing Agent Signature (No Stamps) ^ ven Initial urc arge ee) , /,,~ may{) (~ ./ /3 ~ Q Dete lion ((' """ ~ ~ IX. Conditions pprov al 3~ ~ 4 ~ G-~.w~, k ' (~ 1~t4,e, (~ drv ~. 45 ~ 9-' 'f' ~Z + ~~ ~t SYSTEM OWNER: ~ ` ~~$ ~ ~q ~ ~ 1 Septic tank, effluent filter and U . J dispersal cell must all be serviced /maintained ' aS t1P.r mananamont nhn nrrniirlorl h., .,i...,.w,._ . setback requireme~4)1t9~Plhd4fl~fli¢~rS~f - _ _ as per applicable code/ordinances. ~ ~ "'~ ,~ ~nr ~s,~ ~ ,.,~,o- ... SBD=b398 (R. OS/Ol) L ~~ ~ C Q C r ~~~'~ ~,.. ~ ~ _U a .p U ~ ~ ~ y C ~ y Q ~ G Ea m .o m `~ o` "= Qca~i ~ ~ a~i ~ ° ~~ ~ ~3 a~ W ~ . a~ o~.o Zy U (II ~.U ~ U C Q .~, cfl ~ U Q UGay a~i ti ~ y ~ ~a mQ h ~ ^ co N w¢~~ , ~Y ~.. w~~ _ ~ b ~Ec _c ~ 'm a~ ~ 'co N ~ ~ N ~ U ~ ~ C C ~ a ~ C `~° ~ a ~' .o co .~ o _ c -a~a~ ca .., a ~ h ~ ~ U W ~ ~ ~ ~~ Z.y N ~ ~ U L U N Y Q 0 ~ ~ ~ ~ ~ .'J. a. a ~ ~ ~ Q C6 ~ ~ ~ ~ ~ ~ ~ `- N /'' = ya ~~ v ~~ O v ~\ l 3 X 9Q~ p.Rc 3~ J-3x8S Aec3~ ~~ T,~.~~uc~iES ~,-- ` ~- 3 .~ 3 ja ~~crr ~. ~ ~ ~ \ ~ ~ ~i ~ ~ ~j'1 ~ ~ ~ i ~. r \7L ~ B/11 cL. >Q~,~ 7eP e~ Z' ScVT~C r~fw'~ rk+fru~~~LT C~u~r~ ~ ~}LT Bid tl. ~! $ - 31 ~ ~~'TT~-'Yt ~ E S~di/L-~ ~,ti y'~4~ ~ S/~c b9 ® ~p~~ NfJL ES ~~~~t~%1~U'~ job %~orn~S ~©k'$ ~f % fir " a,~ .. ~ ~tds©,~.~ Lti~ 1 ~y c~ ~ ~o `(" l~ C ~ I L 1 ~ ~~~ 5 ~~A ~u, Bm STAB ~ c~i~c: H ~ p 1~'-hs~ D~j~~ C~~A`~ Ci~2c~~ F /~ /.SO%t~ ~TU~' .S~~~nc,~s%~ ~'I" s"vo~s ~/1 ~~S ~~.37(oG /'~ - ~/© ~~ v !~ O V I~ ,~ 3 l 3 X 90~µRc 3~ .r.-axes Aec~~ T,L' ~ n:CHES ~,-_ ~3 ~'~ ~ ~~ 3ej, S~ePw_ ~xiSr~Nb fleA~~r~~cQ 1 ^ '~ 2lvo Gac s. r. ~ w'% PRA m c~~ ~, ~ ~o ~ ~ tl ~ F;+ 0 ~ ~~uE ez~sr,uo iooo6a~, ~ B 5. r. ~~ B~ ~ y6 1 S \ ~' ~ ~' Yy p~Tgcµe ~ ~ a~~16E ZA~~ CiQcu ~ae~~ ~ ® [ Xur~ cXES%!n!6 W r! H ou5~ ~ ~Z ° B/Y1 c~. >O~.t~~ 7eP o~ Z' sc,~r~c r~F~~ r1r«4~~~E cove. ° t4L~ B~~t CL. 98 ~ 3l ' $d77or~ ©!' s~r~in,-l, oN ~'~4~ ~ sic ~ ® Bo,~r N~c ES ST~~ r c~a~cl~ ~ ~ J~`~4~~,~'~ ~'d~ %l~or~l~5 ~0~'.Sy'i wF ~ ~tdso~ v~ 1 ~y~ / ~ y~~~ s ~+~~ R~r~ Bm s~ ~( /SO i r~ ~U~ 1y1 ~,~ s ~a.3 7l0 0 ~risconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT in accordance ~omm 85, Wis. Adm. Code #1558 Page 1 of 3 Schmitt Soil Testing, Inc. ' County Attach complete site plan on paper not less than 8% x 11 inches r e. m St. Croix include, but not limited to: vertical and horizontal reference point (B irectio d percent slope, scale or dimensions, north arrow, and location and distan o nea parcel I.D. (J~?C~- /old- S'O-Oo0 Please print ev' Btt Date Personal information you provide may be u for L , s. 15.04 (1 (m)). /Z,~ 3/Q ~~ ~~ Properly Owner DEC 13 2006 operty Logtion Forsythe, Thomas & Kristin vt. Lot SE1/4, NW1/4, S21, T29N, R19W Property Owners Mailing Address L t # Block # Subd. Name or CSM# 850 Zane Grey Circe ST. CROIX COUNTY 18 Weels Fargo Station City State Zi ~ City ^ Village ~ Town Nearest Road Hudson WI 54016 715-386-7208 Hudson Zane Gre Circle ^ New Construction Use: ~ Residential / Number of bedrooms 3 Code derived design flow rate 450 ^ Replacement ^ Public or commercial -Describe: Parent material OutWash Flood plain elevation, if applicable na General comments and recommendations: Area is suitable for a conven 'onal system with a 0.7 gpd/sgft rate. Possible system elevation for replacement area is ~. glue to be installed between the new and old GPD ft. a Boring # ~ Boring ^ Pit Ground surface elev. 96.60 ft. Depth to limiting factor 96+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consisten Boundary Roots GP D/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-16 10yr3/2 fill ------ -- --- ----- ----- 2 16-32 10yr3/2 none sil 2fsbk mfr gw ----- .6 .8 3 32-40 10yr4/3 none sil 2fsbk mfr gw ----- .6 .8 4 40-64 10yr4/6 none scl 2msbk mfr gw ----- .4 .6 5 64-88 10yr5/6 none scl 2msbk mfr cs ------ .4 .6 6 88-96 10yr5/6 none s Osg ml ---- ------ 7 1.6 ~- 9o.Go 2 Boring ~'2'~/0~ Boring # ® Pit Ground surface elev. 94.03 ft. Depth to limiting factor 98+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consisten Boundary Roots GP D/ft~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eft/~1 *Eff#2 1 0-12 10yr3/2 none sl 2fsbk mfr gw 2vf .6 1.0 2 12-22 IOyr4/4 none grsl 2csbk mfr gw lvf .6 1.0 3 22-27 10yr5/4 none Is Osg ml gw ----- .7 1.6 4 27~ 10yr6/4 none s Osg ml a ----- .7 1.6 5 55-65 7.5yr5/6 none grins Osg ml gw ----- .7 1.6 6 65-98 i0yr5/4 none cos Osg ml ---- ----- .7 1.6 ~fn'GD ~ ~` .~ , * Effluent iFT'= BoD 5> 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS <30 mglL and TSS <_30 mg/L CST Name (Please Print) Signature: CST Number Thomas J. Schmitt ~ 227429 Address Schmitt Soil Testing, Inc. Date Evaluation Conducted Telephone Number 1595 72nd Street New Richmond, WI 54017 12/11/2006 715-247-2941 SBD-8330 (8.07/00) Property Owner Forsythe, Thomas & Kristin parcel ID # Page 2 of 3 Boring # ^ Boring pit Ground surface elev. 93.83 ft. Depth to limiting factor 100+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 1 0-11 10yr3/4 none sl 2msbk mfr as 2vf .6 1.0 2 11-17 10yr4/4 none grsl 2msbk mfr gw 1vf .6 1.0 3 17-22 10yr5/4 none gris lrsbk mvfr gw ------ .7 1.6 4 22-57 10yr6/4 none s Osg ml cs --- .7 1.6 5 57-82 7.Syr5/4 none grcos Osg ml cs --- .7 1.6 6 82-100 10yr5/4 none cos Osg ml ---- --- .7 1.6 ^ Boring # ^ Boring ~ ^ pit Ground surface elev. 95.12 ft. Depth to limiting factor 100+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Etf#1 'EtF#2 1 0-24 10yr3/3 none sil 2fsbk mfr cs 2vf .6 .8 2 24-34 10yr4/4 none sl 2csbk mfi gw --- .6 1.0 3 34-43 10yr4/6 none grsl 2msbk mfr gw -- .6 1.0 4 43-100 10yr6/4 none s Osg ml --- --- .7 1.6 ^ 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/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Etf#1 *Eff#2 * Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 <150 mg/L * Effluent #2 = BODS < 30 mg/Land 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 (8.07/00) Shcrt~t SoY Testing, InC. ' Conducted by: Conducted For: SG~11Tllt1: SOI~ Z'@Sting Illc. Name: Thomas J. Sehmitt, CST 227429 Address: 1595 72nd St. City, State,. Zip: New Richmond, WI. 54017 Phone: 715-247-2941 Subd.Name: s,~t~ , >~ Lot 1~0.: Date l-Z ~ l ~~~? Lega1 Description: ® Backhoe pit _ Township, County: ® Bench Marls E1. 100.00' Tog of 2' septic tank manhole cover a Alternate Bench l4~ark 11.1.9831 ` bottom of siding on yard. shed Slope= 3% Scale 1" = 40' /~fe,-}t- L~~ L~tii ~~ ~~ ~~~ ~~~ l,C' Page 3 of 3 Thomas & Kristin Forsythe 860 Zane Grey Circle Hudson, WI 54016 Week Fargo Station 18 SEl/4 NWl/4 S21 T29N R19W Hudson, St. Croix --5~~~. BIODIFFUSER CROS5 SECTION Approximate Grade III. f~.. E 1 . _ ~, ~ . _ I -~ i~----- ? 3 ~. 1. ad a veroge OpM AfCQ Wi0[h 4"PVC Inspection + Vent Pipe t'1 '_. 1=1 ------._ . __ I I i ~~ E 1._ ~~rC 2. Qd a veroge Dnen area Widfn POWTS OWNER'S MANUAL & MIANAGEMENT PLAN PeO. o, FILE !Nr-ORMAT]ON Owner Thomas Fors the Permit ! '~/ DESIGN PARAMETERS Ntunber o! bedrooms - O lyq: Number of Public Faticlllry UrtIU q NA Estimated flow (average) Q allda Oesign tbw (peak), (Estimated x 1.5) allda SoA Appiicatlon Rate 0 . 7 aflda /ft' Standard Influant/Etiluani Duality Monthly average• Fats, OU b Graeae (FOG) S30 mg/L Biochemical Oxyflen Demand (BODa 5220 mg/L O NA Total Suapendod Solkfs (TSSI 5150 mp/L Preveated Effluent Ottality Monthly average Biochemical Oxygetl Demand (BOD~1 S30 mg/L Total Suspended SoUds (TSS) 530 mglL ®NA Fecal Coliform (gaometrlc moan) S10' ctu/1 OOmI Maximum Effluent Particle Size Ye in die. ~ r r ^ NA Otiw: O NA •Valwa typlul for domeatla wastewater and septle tank ellluent. SYSTFJN SPECIFlCATIONS ~yT~Nt, • Septic Tank Capacity 1000 + 260 al O NA Saptlc Tank Manufacturer Week ' s C . P . O ~~ Effluent Flltor Manufacturer Pr •NA Efifluent Flltor Model GF10 • ^ NA Pump Tank Capacity al 0 NA Pump Tank Manufacturer ^ NA Pump Manufacturer ~ NA Pump Model n NA Pretreatment Unit {~ Nq O Sand/Gravel Flltor O Peat Flltor D Mechanical Aeration O Wetland O Disinfection O Other: Dispersal Cell(s) O NA O In-Ground (gravity) ' b In-Ground (pressurized) O At-Grade O Mound ^ Drip-Lino D Other: Other: l7 NA Other: ^ NA Other: DNA MAINTENANCE SCF(EDULE Servke Event Sorvlce Frequency Inspect condition of tank(s) At least once every: 3 O month(s) (Maximum 3 years) a ear(s) ^ NA Pump out contents of tank(s) Whon combined sludge and scum oquals ono-third (Y,) of tank volume ^ NA inspect dispsrsal ceUls) At least once eve ry' O month(s) (Maximum 3 ears) 3 8 ear(s) y O PIA' Clean effluent filter At least once every: 1 ~ ( ~ 08f1s1(s) O,NA Inspect pump. pump•cantrols & alarm At feast once every: O month(s) O ear(s) d NA~. Flush laterals and pressure test At least once every: ' O month(s) O oar(s) O"Nti - Other. At least once every: O month(s) O oar(s) p NA; • - Otter: ^ NA~ MAINTENANCE WSTRUCTIONS :i:•;`~ • ;~~<.° tnspsctions of tanks and dispersal calla shall be made by an .Individual carrying ono of the following ))tenses or coltJtlcatlons:: Master Plumber; Muter Piuistber Restricted Sewer; POWTS Inspector; POWTS biaintalnor; Soptaga •Servieing Operator. ,;.Tank lnapectlona must Jnciude a Vlitlal Inspection of the tank(s) to ldentlfy any misaing or broken hardware, ldoridfy any cracks or:lonlc~s~ measure the volume of Combined sludge and scum and to check for any back up or pending of effluent on the ground~surfrioe. ,...,... The dupersaJ call(s) shall be vtwauy Inspactsd to check the effluent levels ir1 the observation pipoa and to chock for eny,..pondin' .o/ efflusnt on the Around surface. The porufing of effluent on the Around surface may indicate a failing condition and roquiros'tho • r Immediate notifIcatIon df the local regulatory authority. ~ '% 'a when the combinad accumulation of sludge .and scum In any tank oquals ono-third ()~1 or morn of the tank volun•~o,• trie~an-tice~ contents of •the tank'iltaJl be removed by a Soptape Ssrvicing Operator and disposed of in accordanes with chapter. NR•1 13; Wlsconsln AdlstinlsiJatiYl COde. •,.,F, All other services, Includlnp but not Welted to the servicing of effluent filters, mechanical or pressurized components, provoatment unlta, end any servkir-p at Intorvals•ot t12.months, shall be performed by a certlfled POWTS Maintainer. ~ ''`t A sarvko report shaD be provided to the local regulatory authorhy wlthln 10 days of completion of•any service event. , Pape of START UP AND OPERATION For new construction. 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 and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicktg operator prioj ~o 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(s) in one large dose, overloading the ce(lls) 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 Septaga Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do.not drive or park over, or otherwise disturb or compact, the area within 16 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;' toundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and 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 covors removed and the void space filled with soil, gravel or another inert solid material ~ CONTWGENCY PLAN - ' It the POWTS fails and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing 'and proposed structure, lot lines and wells. Failure to protect the replacement. area will result in the need for a new soil and site evaluation to establish a suitable roplacontent 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 sitehas not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank '~ may be installed as a last resort to replace the failed POWTS. ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the,. infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER Name John Schmitt Phone t - 51 POWTS MAINTAINER Name Owners choice Phone ' SEPTAGE SERVICING OPERATOR (PUMPER) Name w rs choice Phone LOCAL REGULATORY AUTHORITY Name St. Croix Ct Zonin Phone (715 386-4680 Th)s document was draped in compliance with chapter Comm 83.22(2)(b)11)(d)&If) and 83.54(1), (2) & (3), Wisconsin Administrative Code ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~/ ff~l"lA S ~' O R.S'1~ %f~~ Mailing Address ~~~~~ G~~ /~ ~~~~~~~~ ~'(~~ Property Address (Verification required from Planning & Zoning Department for new construction.) City/State ~/~S~~G' l~ ` ,S'tlp~ (~ Parcel Identification Number lOZQ= Q2 ~'A' --~'CJ-t~D~ LEGAL DESCRIPTION Property Location ,$E '/4 , ~~'/4 ,Sec. ~~, T ~_N R~W, Town of ~~`~~ r~y~ Subdivision Ll~~L.c S T~~ ~/~ ~' ~~ ~/~~1, ,Lot # ~~. Certified Survey Map # Volume ,Page # Warranty Deed # ~`jQ yp.Sp ,Volume /Od2$ ,Page # ~f Spec house yes no Lot lines identifiable ye no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms _~_ .-- SIG AT F APPLICANT(S) ~~/~/~~ DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) Ii is . ~ Ik DOCUMENT NG. ~ STATE BAR OF WISCONSIN FOBId 1-3988 tN~s s~AC[ Ru.RV[D row RccoRDiND DATA - ' ~ WARRANTY DEED ', ,' ;, - ~~ REGi~TER'S (JFFlCE This Deed, made between --Sam-•E.--Miller, a•.single•man-• !~ ST.CRpIxcQ,,{iy~ ~~ i R~c'd ibr Reoo~d _ i~ .. _ . .......... ............ ......... ......... ... _.........------ ......-. -. Grantor, ~~ AUG 17 1993 I' and -an~mwi e~'••Forsythe-•an-Kristin-~•e--Forsythe., -husLand--- ~ 1.30 - P,M ~~ ~j _ ,~ f ~~ ~~ ~ ---• - ................................................... ..........•.........---.. Grantee ;, Dew'.'. !, Witnesseth, That the said Crantor, for a valuable consideration...--. I' _-__ _ i ---- _ ___-_ _ _ ----- -1 • I RtTURN t0 , conveys to Grantee the following described real estate in ......~.L....G><S2xX.......... ;! County, State of W iaconain : ~ ~~ If ~`_-_ _== ---ii of 18, Wells Fargo Station in the Towr. of Hudson. - - `------- -- - -„ ~' ~- ~ Taz Parcel No: _-..---•--•-•°------•-------•- ' ..._ i I f ~~ TSia 18 not homestead property, i ~1tj[ (is not) Together with all sad singular the hereditamenta and appurtenances thereunto belonging; And...---SBm.-E.-- hiller--------•-----•---- warranta that the title is good, indefeasible in fee simple and free and clear of encumbrances except warranties, easements, covenants and restrictions of record and will warrant and defend the same. Dated this .,----•-13th•~ - --•------•-•--------------- day of ..- ---• - -August.--- - ...-.----...-...-....--------•--..-. -, 19 93.... - --- -- ---------••-- • -------------- ~ ~ e ------•-----•-----••--------(SEAL) \~~~---•--•------ -- ---------------------------------(SEAL) ' _ Sam E. Mil --• ......................•-----•------------•---•----------•----- ler AIITHSNTICATION 3iQnatnre(a) -----•-----------------•-------••---------•----------------- ..- - ---•-•--• ----------------•-----------••----•--•--------•---(SEAL) ACiSNOWLSDLI<i1SSNT STATE OF WISCONSIN as. ... , sTC - io4 AS BUILT SANITARY SYSTEM REPORT OWNER ~ ~~ /I~I,~/~~u-t~''"~ S~ ;~ ~~ C~'~„~~ ADDRESS ~mx~ ~ 8' 2_.. SUBDIVISION / CSM# Li/~ // s ~~.. ,~ o LOT # ~~ SECTION L / T_~N-R~ Town of /-~k..~s c~rr 1~1~ ST. CROIX COUNTY, WISCONSIN SHOW PLAN VIER EVERYTHING WITHIN 100 FEET OF SYSTEM ~~ ~~~- °----- lrllf we+~ f c SS ~ :. S C ... ~ e !~y_. J d ~f, I /~ k~U ~__ ~ ~ ie o ~~ i __ - _ ~ ~ \ ~~ ~ ~ i t ~ ~ ~ ~ ~ 1 ~ ~~ \ \ ~ ' \~~ I ~ I Ito' ~~! • \ f \ ( ~ ' .~ ~ d 33 90 . 6an)~~ Al~Va 2 i 3 s ~ ~~ I 3 r ,~ ~ti r . , w A w ~ ~~ ~ b ~.s ` `~ - INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. BENCHMARR : /D~ O ~` / ~~ ~.~/t.- ~' ~~ lr~~earN dr ,~ ~~ /~JC9 D~ ~ _ ~ 1 , l~a ALTERNATE BM: ~°f~~T ~~b-t`~- Toe~~ ~/~~0~ ~~ ~~ EPTIC TA % PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer:~~a~'S e~ Liquid Capacity: Odc~ Setback from: Well 9y ~ House `~Z~ Other ~ 3 ~~o,,,, GQ~,,t~ Pump: Manufacturer Float seperation~-- Alarm Location ~- Model# - Size ~ Gallons/cycle• _ ;SOIL ABSORPTION SYSTEM Width : ~ ~ ~ Length ~ d ~ Number of trenches Distance & Direction to nearest prop. line:-- s'S" ~ Tn ~/e~~L /eT /,'o, Setback from: well : /zO" House 73 ~ Other 6 3 ~ ~•~oa.. 64~~ 9 .~ ELEVATIONS Building Sewer= PC inlets--~" Pump O f f ~--~ Header/Manifold /~~4 y Bottom of system /(~ /~ ~o N°'" ~~, po Existing Grade Final grade DATE OF INSTALLATI~OtN~: ~"~ PLUMBER ON JOB: vim' G''z'~'~"' ~ `"~~'7 LICENSE NUMBER: ~ I~ `~ ~ ~ / 2 INSPECTOR: ST Inlet : ~~ ~?j ST outlet ~ ~ ~ PC bottom ------- 3/93:jt LOCATION : HUD~SO~TT 21.2 9.19 , N~~SinTa=,p~'E.18 G ESST'~'~E M Wisconsin Department o In ustry, IV TE WA OUCH ' Labor and Human Relations INSPECTION REPORT Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Permit Holder's Name: ^ City ^ Village fl_Town of: ~X UNDELL,ERIC & MILLER SAM CST BM Elev.: Insp. B E lev.: / M' BM Description: ~ ~ J ; / TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic i 5, ~ l i' Do ' g Aeration Holding TANK SETBACK INFORMATION TANK TO P/ L WELL BLDG. vent to Airlntake ROAD Septic ~/~Z;' ESL} z = NA Dosi n ~~ -~,, NA Aeration Holding PUMP /SIPHON INFORMATION Manu cturer Demand Model Number GPM TDH Lift Lriction tem ' TDH F Forcemain Length Dia. Dist. o SOIL ABSORPTION SYSTEM ELEVATION DATA AA~nni ~ti ~/~~ /9~' STATION BS HI FS ELEV. Benchmark ~', G~ ~~,~ ~ /-~' ~ ;~ y7 G~ /O b~. G~~ Bldg. Sewer St/~ Inlet ,J / St / WE Outlet ? /7 ' d~. ~7 Dt Inlet Dt Bottom y ; Headers <: / ' , 33 Dist. Pipe y ~ ~j~ Bot. System ~ 35 Grade:.-..;-, ~.s9 ~ 0~,~ BED /TRENCH Width /~ / Length''// ~ No. Of Trenches PIT Inside Dia. Liquid Depth DIMEN I N Y 1 N SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING Ma facturer: SETBACK INFORMATION Type O ,' ~_ ,'; ; -.;; ' ~ , - ~ ~ CHAMBER Mode Nu r: System: t=;~ ,~ . ~--,~ ~o („ ~ > SG OR UNIT DISTRIBUTION SYSTEM Header / ReiF}. „ ~ Distribution Pipe(s) //, , ~ ~ x Hole Size x Hole Spacing Vent To Air Intake Length ~ Dia- Length 37 Dia. Y Spacing ' - - - ------ SOiL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over ~~ ~~ - ~ Depth Over ~ ii '- ` ~ xx Depth Of xx Seeded /Sodded xx Mulched Bed /tee Center ' Bed /h Edges T Topsoil-_. _ ~ COMMENTS: (Include code discrepancies, persons present, etc.) LOCATIU~d: HUDSON.21.29.19,NE,SW,LOT 18, STAGE COUCH TRAIL ~~ ~ ~ i .. -. _ ~~ , -, ' . ~- ~~ ~- , _ ' ~. Plan revision required? ^ Yes 0' Il~o g /, 'Q~ / Use other side for additional information. !~ SBD-6710 (R 05/91) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: ~~ - _ SONITARV DFRMIT ODPI 1[_OTIIflN L o1Ls,MR in accord with ILHR 83.05, Wis. Adm. Code cout~Y /Jw .. - ') STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than ' ~J'~/~ ^ 8 /z x 11 inches in size. Check re soon opreviousapplication wee reVerSe Slde fOr InStrUCtIOnS for COmpleting thlS appllCatlOn. STATE PLAN LD. NUMBER I. APPLICANT INFORMATION -PLEASE PRINT ALL INFORMATION. PROPERTY OWNER ~~/ ~ L E/ Sf= /L6 PROPERTY LOCATION E %a Ste'/a, S Z/ T1~ , N, R /9 E (ol~ PROPERTY OWNER'S MAILING A RESS LOT # BLOCK # y, ~ ~ / ~ i CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER 11. TYPE OF BUILDING: (Check one) ^ State Owned p VILLAGE ~ ~[ /J ~NEAREST ROAD ~ ' ^ Public ®1 or 2 Fam ~# of bedrooms 3 AR ELTAX NUM ER( ) Dwellin . g III. BUILDING USE: (If building type is public, check all that apply) _ ~ a~ - /~ ~~- ~~ 1 ^ Apt/Condo 2 ^ Assembly Hall 6 ^ Medical Facility/Nursing Home 10 ^ Outdoor Recreational Facility 3 ^ Campground 7 ^ Merchandise: Sales/Repairs 11 ^ RestauranUBar/Dining 4 ^ Church/School 8 ^ Mobile Home Park 12 ^ Service Station/Car Wash 5 ^ Hotel/Motel 9 ^ Office/Factory 13 ^ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. ~ -New 2. ^ Replacement 3. ^ Replacement of 4. ^ Reconnection of 5. ^ flepair of an System System Tank Only Existing System Existing System B) ^ A Sanitary.Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ®Seepage Bed 21 ^ Mound 30 ^ Specify Type 41 ^ Holding Tank 12 ^Seepage Trench 22 ^ In-Ground 42 ^ Pit Privy 13 ^Seepage Pit Pressure 43 ^-Vault Privy 14 ^ System-In-Fill. VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA. 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE g. SYSTEM ELEV. 7. FINAL GRADE ~ „ELEVATION REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) q" qg. zs //~~ / ro/ i' ~ s ~ • ' V 7 z o 7 ZO O. 7 $ • JRG .So Feet ." ~lf.p Feet VII. TANK CAPACITY in allons Total # of ' Prefab. Site C l St Fiber- ti Pl Exper. INFORMATION New istin Gallons Tanks Manufacturer s Name oncret on- ee glass c as App Tanks Tanks strutted Se tic Tank orHoidin Tank OOd / (it/~ ' F~ Lift Pum Tank/Si hon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumb is Signature: (No Stam s) MPlMPRSW No.: Business Phone Number: o t~ oh 6~ °~ ~~~-~~ M ~°~ ~ 9- 3 2- z 3 2 3 3 Plumber' Address (Street, City, S te, Zip Code): IX. C LINTY/DEPARTMENT USE ONLY ^ Disapproved Sa 'tary Permit Fee (Includes Groundwater a e ssu Issuing gent Signa a (No mps) Surcharge Fee] Approved ^ Owner Given Initial Adverse D t rmination X. CONDITIONS OF APPROVAL/REASONS FOR DISAPPROVAL: SBD-6398 (formerly Pib-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1.. A sanitary permit is valid for two (2) years. 2. ~ Y©a~•sanitar~r permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/Renewal Form (SBD 6399) to' be .submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintairied. The septic farik(sj must be pumped 6y a~licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety 8~ Buildings Division, 608-266-3815. To be complete and accor~ate this sanitary permit application must include: t I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. . IL Type of building be'fng sefvd'd.~Clieck ohly one and complete # of bedrooms if 1 or 2 Family Dwelling. III. .Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1-7. VII. Tank information. Fill in the capacity of every new and/or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for a// septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8%z x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if ... required by the county; E) soil test data on a 11,5 form; and F) all sizin8 information. GROUNDWAtER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- _ water contamination investigations and establishment of standards. -~ LL ~~- ~ - ~ " ,~ ,_ _ ~ ... SBD-6398 (R.11/88) S T C - 100 T}~is application form is to be completed in full and signed by the owner(s) of the property being.. developed. Any inadequacies will only rESUlt ~n delays of the psrmit issuance. ,Should this development be intended for resale by owner/contractor,(spec house), then~~a second form should~be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property ~ii\~ ~~ s~ ~•_,~~ ,~54 i~~ ~-~~ ~~cr.-~ Location of 'property NE 1/4 Sw 1/4 , Section Z ~ , T z 9 N-R~~ Township Mailing address ~OX ~F2~ ~. a Address of site ~s.3 Z,4NE ~,ep j' C/RCL E Subdivision name ~~~s ~a~~d S"1`~T~~o~r Lot no._ /g• other homes on property? _.__.___yes~X No Previous owner of property _ ~n'~ ~ ~ 6 . llJ~ ~ ( ~ Total size of parcel _ 2. Z ~ /4-~c~G 3 Date parcel •was created /L'' 30- ~!/ ,'Areall corners and lot lines identifiable? ~_yes __No Is this property being developed for (spec house)?,,Yes No Volume 9L8' and. Page Number 3~9 as recorded with the Register of Deeds. INCLUDE WITIi THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & THE SEAL OF THE REGISTER OF DEEDS. :In addition, a certified survey, ~.f available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I(we) certify that all statements on this form are true to the best of my ( our ) knowledge that I ( we ) am ( are ) the owner (s ) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No . y'7'~ z7/ , and that I ( we ) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the oPFice oP County Register of deeds as Document N o,~~7 >..z 4/ . ~ , ~ ii DOCUMENT NO. I~ WARRk~ITY DEED STATE BAR OF WISCONSIN FORM 2 -1982 r 4'T7291 v ~ 9~~ -x:.319 - - - - ~-- - Anita- G,-- Wells-..a-.single woman conveys and warrants to .. John- A.-.-Elbert-.and._Eric-.J. -_Lundell,~--- ..aa..Tenants..ia .Oamaan,--an.-undixided..ane-half..intezes.t....... each--------------------------•--------- ------ --.......................-..-- ----------------........ the following described real estate in .....$t,•-CtOix ...County, State of Wisconsin: All that part of the Northeast Quarter of the Northwest Quarter (NE}NW}) lying Southerly (Sly) of the Railroad Right-of-way; The Southeast Quarter of the Northwest Quarter (.°E}NW}); The East Half of the Southwest Quarter (E}SW}), EXCEPT part to Alfred L. Ekblad in Volume 498, page 484; part to Leslie L. Swenson in Volume 498, page X04; part to Donald F. Johnsin, in Volume 500, page 525; and part to Donald L. Jordan, in Volume 580, page 354, all in Section Twenty-Onr (21), Township Twenty-Nine (29) North, Range Nineteen (19) West. TNIS SPACE RESERVED IOR RECORDING DATA REGlST~R'S OFFICE sr. cROUt eo., w~ Recd for Record DcC3p1991 ~_.2:4Q P: M 0 Repb~e-Of DMus aeruRN ro Taz Parcel No: ~~~ This Warranty Deed is given in full and final satisfaction of that original Land Contract between the parties, dated December 4, 1989, recorded December 13, 1989, at 11:30 A.M., in Vol. 858 of Records, on page b33-634, as Document No.454203, Office of Register of Deeds for St. Croix Co., WI. ~~ iS not : homestead prt;erty. (is) (is not) Ezception to warranties: Easements, restrictions and rights-oE-way of record. Dated this _ _..- --....._..---....-ZZt.h.. ---.----. day of ...._--.._ December _ 19. 91 . •~i~~t~.~L-/.._ .. -........(SEAL) ..Anita. G....Wells.....__... .... - -..._.. - - - --- ---- ---- ------•--- .--- --... ------ • (SEAL) AUTHENTICATION Signs (s) OF Anita G. We11s, a si ~1 woman • 27t December 1 apt a d t' a of---••--- •-•--...----•-•-~ 1 -•---- Leo A. Beskar TITLE: MEMBER STATE BAR OF WISCONSIN (If not, ---••-------•---------- ---------•--------•--•-•-------- -- authorized by § 706.06, Wis. Stats.) 7Hi5 INSTRUMENT WAS DRAFTED BY Leo A. Beskar, Attorney • - --- I~odli; Beskar.-~..Boles;'-'~:C:•--------••----•--- -T19..DTarth.Ma_iu-S -f-~ -3-----------------••-----•---------- (~,~~ur~sa~n~a~'he a~t~e~t~iited or acknowledti*ed. Both are not necessary.) .. _.- -- ~ _._.-(SEAL) ACiHNOWLELdMENT STATE OF WISCONSIN ss. ---•--•---•--••-- • ---••--•---•------County. Personally came before me this ................day of ----•---•-------------------------------- • -lg---•- -- the above named to ma knocvn to be the person ..-._....... who executed the foret:oint! instrum^nt and acknowledge the same. Notary Public .. County, Wis. 3T}• Commission is permanent. (If not, state expiration date: _ . -. ._ ................___----- - -- 19.. .) . Q ~ . ~ Qi J o~ W ~4~, 7 7 . 9.3p'1q~.__ ~' ~ m a. ( Z~ Z ~ _ __ 6g8~02' ~ OI ' ® N I• - 304 ~-_ ~ W ~' 155.92 "W ' ' ~ 00 . 648.02 , 60 ~ `` N 00 28 51 - ~ 3 -- -~_ - - _ " ' 1 ~Q E 28 20. 2p. _- S 0051 ®155.83' N a ~ 9 .~ m ~~ 087 Square Feet Q1 ~ m 8 N. 2.09 Acres c u' 90 041 S uare Feet ~ °D 2.07 Acres ~ Z r r r m ~m ~i 06'11'02"W 374.79• m 3 ~- '9.39' ~ ~ 96.90.- ~=I WI N ~, m m 362. 4g . N ~ aJ.,I o^ U = w }~ Feet Z Q m~ u 14 0 ~ of 93, 126 Square Feet N Z~ 2.14 Acres ~` ~ 1 3 ~ I pl • ~ \ II j ~_ ~ j ~I - Zq NE N ~ 4 °I J _ ~ ~-_ 347 >6, n 1r. _ CI J J 13 ~ s 13 ~36 5g, R~~ E_ ~ ,/ 320 45 4j. 76 . ``_ ~ - _ t ~ _ N -~~ ~ 3 __' t 3 s _ '' _ 17 r LINE ~ tD. i i. o ~ ~• ~ 1 8 ~ ^ ti ~ LINE BEARI v 92, 015 Square Feet q8, 390 Square Feet ~ ~ ~ 1 S 89' i0' =~v 2.11 Acres w~ 2 N 12'24' ~ ~ 2.26 Acres ~ 2 ~ 3 S 77'35' P ~ t 4 N 86'50' ~ - - - - - -'~ 2 WI 5 N 76'23' 6 S 89'10' - m , O 5 ~I 7 N 52'06' \ j I Q~ 8 N 89'08' \• ~ ~ ~a,ge 1 ~~ 9 S 89'08' ' .t2~~' 10 S 52'06' / a,~~~ 8 6 ~~ 11 N 76'23' 1 •~'e \ Y ota~a e °o J ~ o J, 318.00' ~ ~ 262.00' 6 00 __ .. ., ..• ..,. ..a~.~ z7o nn•, I S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County owNER/BUYER- Vii,"~ ~~,,~~// ~s/t'/y1 /~l,'f/~~' ADDRESS .~m,~ '~ ~- ~ '~- FIRE NUMBER CITY/STATE- ~~.. ~_, a rt L!J ~ ZIP- S-Sld /.~, PROPERTY LOCATION : G 1/4 , S lJ 1/4 , SECTION Z ~ , T z~N-R~~ TOWN OF~~-p S o.~ , St. Croix •County, ' SUSDIVISION_~~~ ~.r /gd `,~a~%'a`r , LOT NUMBER. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60~ of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, -with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1). the on-site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/~~Te, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin ONR. certification stating that your septic has been maintained must be completed and returned to the St. Croi Zoning Officer within 3o days of the three year expiratio ate. SIGNED: q DATE• 1 St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 ' Wisconsin Department of Industry, Laoorand Fluman Relations Division of Safety 8 Buildings SOIL AND SITE EVALUATION REPORT Q ~, Page ~ of3 . ..J :aL 11 111.1 A tAI.~ 11J~ l~_J_ ... wvvv.~ •,.,.. .~~ .. • vv.v , •~v. . •v.... vVVV COUNTY ~~ ~~ 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 % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION o 96V~t9T /~~ 1/45W 1/4,S21 T Z 7 ,N,R ~ 9 E (or) W PROPERTY OWN ':S MAILIN ADDRESS LOT # BLOCK # S UBq. NAME CSM # ~ CITY, STAT~ ODE (HON; NUMBER ~ ^CITY ^VI~ GE OWN NEB ~S~ OAD~ ~ ~~ - S4~ I u ~ New Construction Use p(J Residential / Number of bedrooms [ ]Addition to existing building j J Replacement [ ] Public or commercial describe Code derived daily flow ~~ gpd Recommended design loading rate ~.7 bed, gpd/ft2 O,~ trench, gpd/ft2 Absorption area required ~ bed, ft2 S6S trench, ft2 Maximum design loading rate O.-1 bed, gpd/ft2 [~.g trench, gpd/ft2 Recommended infiltration surface elevation(s) AREA A'ID ~- qQ , Z~ ft (as referred to site plan benchmark) Additional design /site considerations ~~~ ~ - 9~• SO Parent materialSo~~~K P ~ - BxCi - ~c,q.~rt+~-i2~r Flood plain elevation, if applicable ft S =Suitable for system U=Unsuitable for s stem CONVENTIONAL ~I S O U M UND ~ S ^ U IN-GROUND PRESSURE f~] S^ U AT-GRADE ~ S ,~U SYSTEM IN FILL S^ U HOLDING~K ^ S U SOIL DESCRIPTION REPORT Boring # F ::; :.: ,:.: :.::;.:.: ::; x:<:: r ~ .... :::::: ~` Ground elev. /aq z,6ft. Depth to limiting f,~cto~.r.., >7~/ Boring # :~.: }: Z Ground elev. /dz.osft. Depth to limiting factor 9 ftA4~ Horizon Depth Dominant COlor Mottles Texture Structure Consistence Bour~la Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed. Trench p-Za '7.SY ~ -- L I Cr ~' Z 0.3 Remarks: ~ o-~~ ~o - t, 1 cr ~' Z o.Z 43 l-3L io 3 - L 3 c c f M ~+ C I 0.3 ~.4 $ -IZo i 4 4 -- S 1 .~ Remarks: CST Name:-Please Print r j~~YEy ,~N NSW Phone: ~/, A D~a ress: Q~ ~a i rvumoer:~~~~ PRQI?~RTY0INNER~M~i4~R SOIL DESCRIPTION REPORT Page?of PARCEL I.D. # ~T ~ ~ W~~ ~~~-~ Boryi~n.~g # Ground elev. /pZ.~1 ft. Depth to limiting ~cto~r Boring # ;:~~: Ground elev. /OZ. ~7 ft. Depth. to limiting >9~~ Boring # l ~:~.:.:::.:::.; >.<::>> Ground elev. 101. S ft. Depth to limiting ' f~ct~ Boring # Ground elev. ft. Depth to limiting factor Horizon Depth Dominant Color Mottles Texture Structure Consistence Bcurxtar Roots GPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. y Bed Trench Q - l4 3 - 1, ~ ,' ~ Z N ? ~ t4 3 /oy+e - ~ z ~, r Mv~i C ~ 3 0,4 ~Z ~-1/s is 4~ -~ s ~, rn 1 1 Z .~s Remarks: O-~6 /OY 1 -' L- 3 m ~ ~'t't' ~~ ~ ~' N .~ 0 Z ~~ a 3 ~ ~, 3 C ~- r rk 1~ C. ~ ~ O Z. 4-II g d X2.4 4 -` S m M I ~ d.? 0,~6 Remarks: A - i ~ - ~ 3 ~ rn ~ ~ ~ N: P. X0.2 ~1-29 by 3 '-' n, c r MY i C ~ 0.3 0.4 Remarks: Remarks: SBD-8330(8.05/92) ' ~ LoT ~, Pte, f 3 a~ 3 --_ ~;d' - - _~. __ _ - - ,_ X03'- - - ~_ --'-' -3S'--'~' ~i' ~ ~ - ' _ --~ - - z ,_ 1 ~ ~\ .~ ~ ~~ °g_4 ~ . ~, ~v~a~ ~~ ~~'s ~~ rtw Loy- Co~~ . \. E1sJ~'c"I~N = l~.~~. Scald / N 3O' ~~ I oT 1 ~o 4_ ---- ~~y~, ~~?~~, ~ ~~ J S- ~iG~COAc.N i ~R,4~ 1, ERIC LUN Eli S~tM /~I/LL~,$ WELLS ~~Rbo STHT/ON Lor~O`!8 ~~~ til /~ , h 3 ~ Sy3t~„~ F{V. ARER A'" q8-zS ~ AREA ~13~~ 9~.SO' ' ~ ~ 2 /~' / ~ ~ Sc.a~ta, ~/y~'= lO' CI 13o~~s~8aek Aod~ RM ToP of 2"~/i'E /ET NW Lao' Corn.. E1.= /OO,oo~ ~.__... 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