HomeMy WebLinkAbout020-1437-12-000oisconsin Departr,~ent of Commerce PRIVATE SEWAGE SYSTEM
Safa~;and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township
Peters, Jeff Hudson Townshi
CST BM Elev: Insp. BM Elev: BM Description:
TANK INFORMATION
TYPE MANUFACTURER CAPACITY
Septic
Dosing
Aeration
Holding
,crh-~r~. --10 (~
TANK SETBACK INFORMATION
TANK TO PiL WELL BLDG. Vent to Air Intake ROAD
Septic ?
~ ~~ ( ~ ~~ ^.
Dosing ___~
Aeration
L
Holdin
PUMP/SIPHON INFORMATION
Manu cturer Demand
PM
Model Nu
TD Lift Fn Loss System Head TDH ~ Ft
orcemain Length Dia. ' t. to Well
SOIL ABSORPTION SYSTEM
ELEVATION DATA
County: St. CrDiX
Sanitary Permit No:
453356 0
State Plan ID No:
Parcel Tax No:
020-1437-12-000
Section/Town/Range/Map No:
22.29.19.2717
STATION BS HI FS ELEV.
Benchmark / ,~~y
1!. (.C~ I~~
/mod°0.'i
AIt.BM _, J~ ~~1.(r7
Bldg. Sewer
SUHt Inlet
/G. `f
7oG . G.~
SUHt Outlet
/a.`~
rocs. ru
Dt Inlet
Dt Bottom ~~
Header/Man. ~' ~~ qc3 q~
~"is ~ / Z.
/Z.7F
48.
Bet:.-s~~t--
S-~ R~ t t - 3g
j .7 q4 . °7 v
`'4 -
Final Grade
St Cover
S• ~ ~~ S. Y
BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS ~ lo$ ? ~ Z-
SETBACK SYSTEM TO P/L BLDG WEL E/STREAM LEACHING Manufacturer:
~ ~
INFORMATION CHAMBER OR -
Type Of System:
Cu ~~ V ~~ ' v ~
~ !
~/ / 5
~
7 ~pG
~ / N
UNIT _
Model Number: ~{
~
DISTRIBUTION SYSTEM
Header/Manifold Distribution x Hole Size x Ho a Spac g
cl
~~ Pipe(s) _i 1 ~
/ G'
Length
Dia Length Dia Spacing
SOIL COVER x Pressure Systems Onlv xx Mound Or At-Grade Svstems Onlv
Depth Over ~ Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bed/Trench Center .-~ ~-~ Bed/Trench Edges Topsoil
~_,', Yes 0 No
L~ Yes [~ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Q / 1~ /~
.`'CLt, ~
Location: 687 Heritage Way Hudson, WI 54016 (SE 1/4 SE 1/4 22 T29N R19W) Kelly Estates Lot 12
1.) Alt BM Description = ,~ u ~ c ~ r ~+.r.N o~ ~ .,.~,e-~ b~ ~}- ~..r
2.) Bldg sewer length = '`-/S
-amount of cover = %-~ Q ~SU `t
Plan revision Required? ~~ Yes No
Use other side for additional informati
SBD-6710 (R.3/97)
Inspection #2: / /
Parcel No: 22.29.19.2717
- - -
- -
~ ,~ J
~ ~ ~ ~~
Date Insepctor's Signature Cert. No.
~ f \ c-h • ~ 'flit ~ 1~ r/1-_-. Y~' +~ "~ v~_S ~ ~
I in Vent to Air Intake
[--~ Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 y- ~~o~X
~
' ~
,~~OJ~~,~ Madison, WI 53707 - 7162
1
Sanitary Permit Number (to be filled in by Co.)
'
(608) 266-315 S
335
De artment of Commerce
State Sanitary Permit Application State Plan I.D. Number
in accord with Comm 83.21, Wis. Adm. Code, personal information you provide project Address (if ditl'erent than mailing address)
maybe used for secondary purposes Privacy Law, s15.04(1)(m)
I. Application Information -Please Print All Information -,,._..._...-~.--. ----~
~-
~/~/rat! !/.bY
Property Owner's Name Parcel # Lot # Block #
T/~ /
1/ L ~/- L~ j~/r f ~ ~ i e ~ ~ • ,
Property Owner's Mailing Address operty Location
~/O hL~n/ ,OwL der ~ ~ ; SE '/y Section old
sE '/.
City, State Zip Code _
P~bri ,
SS// L
il/lEn/ CL S /V circle gee)
T a g N; R/ 7 E o
(check ali that apply)
ildin
f B
I
g
u
. Type o
I Subdivision Name CSM Number
~I or 2 Family Dwelling -Number of Bedrooms _
ib
U
l
D
i
^ ~EL rr Esr rers
se
escr
e
-
a
Public/Commerc
~ K ' ~ ~'iry_~iHage ®`fownship of ,pSo./
^ State Owned -Describe Use
III. Type of Permit: (Check only one box on line A. omplete line B if applicable) OZo - 3 - Z- , 02
A' New System ^ Replacement System ^ TreatmenUHolding Tank Replacement Only ^ Other Modification to Existing System
B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Pemut Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
1(V. T e of POWTS S stem: Check all that a 1
Non -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^
Constructed Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^
Recirculating Synthetic Media Filter aching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) r
V. Dis ersaUTrea ent Area Inf rmation: ' X
Design Flow (gpd) Design Soi] Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed sf) System Elevation
= so . 7 ~y3 c~yZ ~~~ ~--- 9~~3
VI. TaIIk Info Capacity in
Gallons Total
Gallons Number
of Units ct
r
u1re
~~Manu~fa
w( y
~p) Prefab
Concrete Site
Constntcted Steel Fiber
Glass Plastic
i
i
E ~
'
_
~
New ng
x
st ` r'K
't"~ 1'F~
Tanks Tanks .
Septtcorilaie+eg~etilt ~DOO "-~ /'00O l f/l6SEic GOnJLRdr~ /
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, assume responsib' ty for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plum r' na/, MP/SNumber Business Phone Number
Plumber's Address (Street, City, State, Zip Code)
.~ Gm?96' fir. wt: .~.5 ~iir o ~/~ Y7.~C
VIII. Coun /De artment Use Onl
Approved ^ Disa
' Sanitary Permit Fee (includes Groundwater Date Issued Issuing Ag gnature o s)
Surcharge Fee) ~~
er Given Reason o enial
IX. Conditions of Approval/Reasons for Disapproval ~,
~ S ~ ~ '~`"^ 2
3~ "
SYSTEM OW
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NER:
1 Se
tic tank
` o~1
ffl
t f
lt
~
p
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uen
c,..~
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er and
dispersal cell must all be serviced /maintain ^ ~~ ~_ n
~ //~~~
as per management
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e
y p
umber. t
2. All setback requirements must be maintained
as per applicable code/ordinances.
Attach complete plans (to tue l:ounry omy) for the syscem oa paper oor less rnan au~ x ii mcues m sue
SBD-6398 (R. 01/03)
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Wisconsin Departm!?nt of Commerce SOIL EVALUATION REPORT page 1 of 3
Division of Safety and Buildings in accordance with Comm 85. Wis. Adm. Cede . Steel's Soil Service Inc.
Attach complete site plan on paper not les~~an ~ w..,. I~S~i~ ~LPlan mus a e
~
~
' „County
St. Croix
include, but not limited to: vertical and horikoMal pc~r+t
,dp~eCtion a
percentslope, scale or dimemsions, north grow, and location and distance to nea t road. ~
~ --
~,
arcel I.D.
Pending
Please print a-- information. ~ a,
• ~ - ~ 2 C~ ~~ ~* t
ewed By
-
Date
Persons information you provide may be us for secondary purposes (Privacy Law, s. 15. (1) (m)).
Properiy Owner ~ `~' '~ ~ Pr erty Location
Reliant Developers LTD ,' ~p"'~~' t~rriC,~ .Lot na SE 1/4 SE 1!4 S 22 T 29 N R 19 W
Property Owner's Mailing Address Lot # Blodc # Subd. Name or CSM#
9900 Valley Creek Rd. Suite 135 12 na Kelly Estates
Ciiy State Zip Code Phone Number ~ City J Village ~f Town Nearest Road
Saint Paul ~ MN 55125 651-731-3174 Hudson Heritage Way
4
Boring # ~ Boring ~~ 1 ~
i~ Pit Ground Surface elev. 105.40 ft. Depth to limiting factor 110 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft'
in. Munsell Qu. Sz. Cont. Cocos Gr. Sz. Sh. *Eft#1 *Eff#2
1 0-10 10yr3/1 none sil 2msbk mfr cs 1f .6 .8
2 10-24 10yr4/4 none sicl 2msbk mfr cs na .4 .6
3 24-60 7.5yr4/4 none sl 2msbk mfr gw na .6 1.0
4 60-110 7.5yr4l6 none ms osg ml na na .7 1.6
lens starting at 24"depth ending at 40" aproximatly 18" in Diameter
* Effluent #1 = 80D5> 30 <_ 220 g/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) 'nature: CST Number
David J. Steel 248956
Address Steel's Soil Service In . ~ Date Evaluation Conducted Telephone Number
1564 CR GG, New Richmond, WI 54017 6/14/2004 715-246-6200
New Construction Use: ~ Residential / Number of bedrooms
~( Replacement ~ Public or commercial -Describe:
Parent material Outwash Plain and Stream Terraces
General comments
and recommen tions: Conventional system, system eleva/tion 100.40
~no~t~ /) c«n-aQ ~~ c~ X129 t7 / 4 Code derived design flow rate 600 GPD
Flood plain elevation, if applicable na
Trenches spaced and depth to code 5.OOft below gr;~de.
Boring # Boring
Pit Ground Surface elev. 105.40 ft.
Depth to limiting factor 110 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0-10 10yr3/2 none sil 2msbk mfr cs 1f .6 .8
2 10-26 10yr4/4 none scl 2msbk mfr gw na .4 .6
~ ~52 7.5yr4/4 c2d 7.5yr5/6 sl/Is 2msbk mfr gw na .6 1.0
4 52-110 7.5yr4/6 none Is osg mvfr na na .7 1.6
g ~•~/
Property owner Reliant Developers LTD Parcel ID # Pending Page 2 of 3
Boring # Boring
Pit Ground Surface elev. 99.10 ft. Depth to limiting factor 110 in. Sod Application Rate
Horizon Depth
in. Dominant Color
Munsell Redox Description
Qu. Sz. CoM. Color Texture Structure
Gr. Sz. Sh. Consistence Boundary Roots
*Eff#1 *Eff#2
1 0-29 10yr3/1 none sil 2msbk mfr gw 1f .6 .8
2 29-44 10yr4/4 none sicl 2msbk mfr cs 1vf .4 .6
3 44-110 7.5yr4/4 none ms osg ml na na .7 1.6
^ Boring # I Boring
~ Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon De
th Dominant Color Redox Description Texture Structure Consistence Boundary Roots P
p
in. Munsell Qu. Sz. CoM. Color Gr. Sz. Sh. *Eff#1 *Eff#2
^ Boring # -~ Boring
J Pit Ground Surface elev. ff. Depth to limiting factor in. Soif Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD 5> 30 < 220 mg/Land TSS >30 < 150 mg/L * Effluent #2 = BODS <30 mg/L and TSS < 30 mglL
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.
STEEL'S SOIL SERVICE INC.
Page 3 of 3
David J. Steel 994 200 Th St
CST-POWYS Reliant Developers LTD Baldwin,WI 54002
L1C. #248956 SE1/4,SEI/4,S20,T29N,R19W Bus.(715) 684- 5680
Town of Hudson, St. Croix Co. Fax (715) 684-3449
Kelly Estates Lot , 12 Legend
1" = 40'
N • = Benchm k Fle,. 100s1f1$
Top of 3/4" ~~C ~~ ~~
• =Alt Benchmark Ele. 99.65ft
Top of 3/4" f~yfG Wipe "'-'
^ =Borings
Boring Elevations
B 1 = 105.40ft
B2 = 105.40ft
B3 = 99.1Oft
B4 = OO.OOft
(-C1 p ~~ Q
h, nQ
~, ~~ ~ ~-0~
~`~. /o,T,~~
-----
~-~~< ~~ ,
c.~N ~O
~~ ~
~~
Zabe] A 100 Residential and
Commercial Effluent F~ter
SPECIFICATIONS
APPLICATIQAIS: The A100 is rued In raidentIal and commercial optic systems. It
is effective to mulcIfamilyhotuing, rental prolxny, schools, offices
and everywhere wastewater has high suspended solids content.
FLOW RATE: 3,OOOgpd pufilttr.lnst~Il twoormore filters Ina PVCorconcnce
d
00
h
fl
f 6
to ac
ieve
ows o
,0
manif~o1l
gpd o: more. Checkwich•Zabel
for details.
FILTRATION: The 26 Disc Dams ~ 1!lb:nch provide 198 lineal feet of
flltrarion.
INSTALLATION: ~lte filter may be Installed inside the tank or installed to a Zabel
C ntainer Auembly anltiide the acetic tank.
SERVICE: Service ruidcnttal installations whenever you pump the tank.
o
6.0.0. 4-iR' I.D. ... ... Qo
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• x--11-3/S' DIA --• •
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• Matlrrisl Spcctflcations
Cases, Lids, Reducers ~ Rigid Vinyl PVC 87371
Discs Hlgh Impact Polysryrcnc
Rod, Nuts High Ucnsity Polyethylene
U.S. Patent No. 4,710,295
r/all 1-800-ZZI -5?4Z or Fax (SOZ) Z67-8801 for further information.
~~~ `r t ~ it ~Iit 1 `~.4~[!rf'jr~rple
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Maintenance
The interval for servicing septic tanks is set by state and Igcal code. Throughout the United States there is a
wide difference of opinion on what this interval should be, but most regulatory agencies suggest two to five years.
The Zabel'" filter, which does not increase the frequency of servicing for the tank, should be cleaned when the
septic tank is normally Inspected and pumpped. However, our filter is vlrtuallysalf-cleaning. The continued action
of the anaerobic organisms on the Zabei filter causes lodged particles to disintegrate and fall to the bottom of
the tank. If your f'slter contains a SmartFilter" alarm, you will be notified by an alarm when the filter needs servicing.
To service the filter:
`Servicing any zabel filler should only be done by a certified septic tank pumper or installer.
Locate the
outlet of the
septic tank.
While holding tl
the. access open
cartridge with tr
careful to rinse all
'Note: !t /s not nece
'spotless'. me dom
aides b- the prebeatn
be tell on the litter. (It
maybe disa;
Remove the tank
and pump the '
necessary to pl
any solid;
escaping to th'.
when the f
Insert t
back in
sure the
pro
complet
Repla
,~;~~~~
'~t .1~
~;:
"~:'...~~'t
Firmly pull the fitter handle
and slide the cartrldgA:out
of the c~l3gt~~,
'Nola: A tee
fo be used /t
below nroun
he fxiter ir~'rtrta~a~•,
the'caSt3'ftti~Wn~.' ;~
rlt . ~ ~'
pert
elyi:: .• ~ `.
,,
C9 t ~~~
.~ . w
.tirl , ~?~ ~ u~eE w vs+~
The product(s) shown are covered by one or more of the /ollowing patents:
U.S. 5,762,793, 5,580,453, 5,591,331, 5,759,393, 5,683,577, 5,582,716, 5,779,896, 5,593,584,5,795,472,5,736,035, 4,710,295, 5,382.357. S,a82.621
U.S. Des. 386,241, 349067, 4605501,5098568, Des. 309007, Australia: 134440; Canada: 2,135,937; Israel: 111574; New Zealand: 26a824,
Other Patents Pending
Call for a free ZABEL ZONE An Onsite Wastewater Magazine 1-800-221-5742 • Website hitp://www.zabel.com
A100~300.1•M•61e99
APR-19•-2004 16:19 FROM:ALLINA HOSPICE & PC 6516262959
~~_ 02/09/2894 12:,41 ?153814232 NIELSEN
• ~ "~fE6, 9.2D04 10:38A~- ED1NA REALIY HUDSOP!
~+
s
.~
TC:715 672 5057 P.3~'S
PAGE 13
fi1U. U~U ~• I t~ i ~ .
v Page 3 of 3
STEEL'S S~~L SE~tVX~E
David J 8tee1 ~ - - t S 64 Cty Rd GG
CST-POWTSM Reliant Dev~bpers LTD New R3cl~tnond. WI 54017
Lic. X1248956 S61l4~SB1/i,S 20.7~9,1Z19W X715) 246-b200
~'a~- v~H-~rao, 9t C~+o~ Ca (715} 246r508S
1Cdb- TssBtes !r~ ~
Tfa ~ eral~iw wN ~ooibelei ~ ratbi~ w s~te~ rpdreraeet, it mllr Or my o01 be sidh~k l~
y0Q dR. '1'be rOC~b10~ Or til! pit p~ Ot py~ o0,t !ie AMA 160wD a! pe~quacat lOt Wier ~n ~Ot
tall~ltl>ted at 1~ tioe Ike 10~7'tell rrb casd~li. ~d
1"40'
1 ~ ,8mdir!~tk Bt. tO0.00P't
Tap of ~S"p+nc O=Pe
A = Aat ~ E199.6SFt
Ibp o[!6" pMc pipe
d ~ HoriOgs
Ht~ag ~Ice~tians
_ $3 ~105.35Ft
• B2 a305.93Ft
B3.301.65'~!
~4 =O~.OOPt
~~
~~
ra~Y~;,. ~ c.~ 5 -~ e
~~
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.~~_~ey~~aaa 12:,41 715381aa32 NIEI.SEN
~ PAGE 12
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~,~;, otSdsty send W~dirtga In a~erdaeosvcllh Carnfri 95, Wla, Aetrn. Cass steel son Sen+los
' ~..1 Cocmt/
Aliztt+ oomphts artr Dian ?^ i~ trot loss iM 8~i u t i Inches fi Nea Plan nwct St. Cfvbc
ielute, but notonNed to: wAnai and Aa'a+o+aal wtaeroe Doh ~}. dtroc4on+r~d Parcel t.tt,
,~ pgoars>k~ ecsla a 4in+snolons, fYOfitf ~fIQM. and lam and d~ ia~fernl mad. Peffdtny
p'la3ase' prht+t erA Mfonrtt>slat. Re~raea ~ bad
-aaa~ idansi~ yeu D~ ~a awd br Maa~detY vuipoou 1~1 ~ % ~ f6 01(>? ~*U.
p~'~ C1r~ rty 4ee+ldort
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ProOa~lr Ormer'. htadrfg.IoQdiars t..d A 010 ~ 8ukd. Nateaa or CBMMf
9i100~~~ Ftd. Sulpe~ 135 12 n~i Kely ~stBWa
C;a st>ia Zlp Cade ptterv NvmbQ ~ cby ~ Vtlq~ff ~ To+s^ Naareat Road
MN 661?S @54 731-3174 .ttudson Kecitspe W
t~1aw Censtnmtlen Use ~ t~sidaMlal ! iJyrnfber at tMdronmt a Coda det9rad e~sipn rlow rate 6b0 fyPD
Pvt~rc d eonener4ti - tksonba:
Pateed ttfabectal vultn~h pgdh! and stream ta~oas Fitsse plain eieretton, K applicable f1a
paflslat eernnMMNa .
ana neonreNxldoAiene: 3yslatn abaabon 98.858, baafehes spaced and dapth to cede 5.508 below Made
f
~~ A
~ 8~
«
~
~~ L._i. Pit lprol~rld 9wfaos etaY
' 105.35 A, DeP1h M 1aYltfp l~toc
Cen
M
5h 105
Gowrls ~
Rood Sop Apolloedow+ t1~s
UIlM
~laireosr.. ~ ~9niltl0elar altMe oaont enx
l ry ~
~ ~
O
. 1 0.10 ICyr3~J nonr s1 Znfsbk mfr ~ ti' S ',8
2 t0.$9 10yrV4 e2d 7r.5yr516 soi 2msbk mi'r gw na .4 .8
3 2952 7.~t4l4 noes o1As 2entbk 8th gw na .S .t#
i 52-105 7.5yre/e Honer la asp mvtr na ha , r 1.2
Z ! goe4q t t9aMo
1..:.x.+1 ~'!i v~sntd surhrar s?Ie~r. 905.35 R bopia tr, braie+o tatter 10S d~
1 1k12 90yr3f3 none sA 2fttabk mfr ea 1f .S _A
Z 129 1 Qy1d19 c2d 7.5yr516 slci Zm~lc ntfr fs< nm .~ .8
~ 3 29-A8 7SprtiJt non9 al Ztnabk mfr dl na .d ..9.• •
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1 ~.
•~
•
" ~i T6+bR IM •000 70 .c ~O n~@A. +if1t1 ~TS9 ~O ~ 100
!fasts tl"111be Psitlt)
Dauld J, Stall _ ~j
1594 GR GG Flew Rtc WI SfOtT
~ ~~
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748~ai8
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1 gR22002 Ti S,Zd6-5085
' ~ POWTS OWNER'S MANUAL AND MANAGEMENT PLAN
FILE INFORMATION
Owner JEfs' B~r~tiS
Permit # 3 3
DESIGN PARAMETERS
Number of Bedrooms 100 d/bedroom „ 3 ^ NA
Number of Commercial Units NA
Estimated flow (average)* moo al/da
Design flow (peak), estimated x 1.5* y.'s'o aUda
Soil Application Rate , 7 al/da
Influent/Effluent Quality (NAp) Monthly Average**
Fats. Oil & Grease (FOG) < 30 mg/L
Biochemical Oxygen Demand (BODS) < 220 mg/L
Total Suspended Solids (TSS)
<_ 150 m
Pretreated Effluent Quality ^ Monthly Average***
Biochemical Oxygen Demand (BODS) < 30 mg/L
Total Suspended Solids (TSS) ~ 30 mg/L
Fecal Coliform (geometric mean) _<10 cfu/100m1
Maximum Effluent Particle Size 1/8 inch diameter
*Wastewater Flow Verification and Calculations:
(Other than bedroom based)
** Values typical for domestic (non-commercial wastewater
and septic tank effluent.
***Values ical for retreated wastewater.
SYSTEM SPECIFICATIONS
Se tic Tank Ca aci /ooo al ^ NA
Se tic Tank Manufacturer ,c%e-Ser,~ ^ NA
Effluent Filter Manufacturer z~QEL ^ NA
Effluent Filter Model - oo ^ NA
Pum Tank Ca aci al NA
Pum Tank Manufacturer ^ NA
Pum Manufacturer ^ NA
Pum Model ^ NA
Pretreatment Unit ANA
^ Sand/Gravel Filter ^ Peat Filter
^ Mechanical Aeration ^ Wetland
^ Disinfection ^ Other:
Manufacturer: Model:
Dispersal Cell(s)
~'In-ground (gravity) ^ In-ground (pressurized)
^ At-grade ^ Mound
^ Dri -line ^ Other:
'Leaching Chamber Manufacturer
~.dfiz ~-.t,~rac
^
Model ~j'.ac•~o~~a .6~/o Laying Length/Chamber L. 2.f
Soil Application Rate . 7 gpd/ftz Area Req. G y3 ft~
Infiltrative Surface/Chamber-ES]A Rating .~/, / ftZ
Minimum Number of Chambers
^ A e ate Desi Flow/Loadin Rate= ft min
Materials: all materials must comply with WI Adm. Code
COMM84 and be installed per manufacturers specifications
and a royal letters.
llE51GN C:K11'EK1A
^ "Wisconsin At-grade Soil Absorption System, Siting, Design & Construction Manual" (Converse et.a1.1990)
^ "Wisconsin Mound Soil Absorption System: Siting, Design & Construction Manual" Converse, J.C. and E.J. Tyler.
Publication 15.22
^ "Design of Pressure Distribution Networks for Septic Tank-Soil Absorption Systems" Publications 9.6
^ "Design of Conventional Soil Absorption Trenches and Beds". R.J. Otis - ASAE Publications 5-77 and "Design Manual -
Onsite Wastewater Treatment and Disposal Systems". EPA 625/1-80-012 October 1980
^ SBD - 10570-P (8.6/99) "At-Grade Component Manual Using Pressure Distribution"
$'SBD - 10567 P (8.6/99) "In Ground Absorption Component Manual"
^SBD - 10705 P (N.O1/O1) "In Ground Soil Absorption Component Manual" Version 2.0
^ SBD -10628-P (N.6/99) "Recirculating Sand Filter System Component Manual"
^ SBD -10656-P (N.6/99) "Split Bed Recirculating Sand Filter System Component Manual"
^ SBD - 10572 P (8.6/99) "Mound Component Manual"
^ SBD - 10691 P (N.O1/O1) "Mound Component Manual" Version 2.0
^ SBD - 10595 P (8.6/99) "Single Pass Sand Filter Component Manual"
^ SBD - 10657 P (8.6/99) "Drip-line Effluent Disposal Component Manual"
^ SBD - 10573 P (R 6/99) "Pressure Distribution Component Manual"
^ SBD - 10706-P (N.O1/O1) "Pressure Distribution Component Manual" Version 2.0
p Drip-line Effluent Dispersal Component Manual for Multi-flo Onsite Wastewater Treatment Units
MAIN'1'ENAN(rE ANll MANAC:EMEN'1
McTNTFNeN!'F. M(1NTT(IRTNC;' CrNF.T)TTT.F.
Service Event Service Fre uenc
Ins ect condition of tank s At least once eve ^ months ,3 ear s) aximum 3 s.)
Pum out contents of tank s When combined stud a and scum a uals one-third 1/3 of tank volume
Ins ect dis ersal cells At least once eve ^ months -3 ~ ears Maximum 3 s.
Clean effluent filter At least once eve months ^ earls
Ins ect um , um controls & alarm At Ieast once ever ^ months ^ earls NA
Flush laterals and ressure test At least once eve ^ months ^ ear s) ^ NA
Valves At least once eve ^ months ^ earls ^ NA
Other: At least once eve ^ months ^ earls ^ NA
Pagel of S
START UP '
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products os other chemicals that ,
may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents df the ,
tank(s) removed by a septage servicing operator prior to use. '
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
OPERATION
The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity
and quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation ofwater-saving
appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water
softeners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface
whenever possible. Note: this does not include laundry waste, showers, dishwater, etc.
This system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetable/fruit
peels and seeds, bones, and food solids such as those produced by a garbage disposal should be minimized. Toilet tissue is the only
paper that should be discharged into the system. Other non-biodegradable items such as baby wipes, tampons, sanitary napkins
condoms, cigarette butts, dental floss, and cotton swabs should not enter the system. Chemicals such as petroleum products, paint,
disinfectants, pesticides, antibiotics, solvents, etc., should not be flushed into the system as they can seriously damage your POWTS
and contaminate your drinking water supply.
Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components.
Compaction of snow over the dispersal unit may cause it to freeze up.
^ Valves
Valves shall be operated in the following manner:
^ Alarms
Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service
POWTS, There is normally a 1 day reserve under regular operating conditions, however water should be conserved until any
problems with the system are corrected to prevent back-up of sewage into the dwelling or surfacing.
INSPECTIONS
Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master
Plumber Restricted Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule):
Septic Tanks Component
Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks
or leaks, measure the volume of combined sludge and scum and to check for any backup or ponding of effluent to the ground
surface. Access openings used for service or assessment shall be sealed and/or locked upon completion of service. Any
defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with an effective
locking device to prevent accidental or unauthorized entry into the tank.
When the combination of sludge and scum in any tank exceeds one-third (113) or more of the tank volume, the entire contents
of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with Chapter NR113, Wisconsin
Administrative Code.
The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's
specifications. Provisions are to be made to retain solids in the tank. Filter cleaning maybe necessary at more
frequent intervals than stated in the maintenance schedule to keep the system operating.
p Pump Chamber/Treatment Tanks Component
The inspection must include a test of all electrical equipment such as pumps, alarms and floats. A visual check must be
made for leaks, backups, surfacing, missing or broken security devices and other hazdwaze and the condition of any filters.
Any service needs or repairs shall be promptly taken care of.
~In-Ground Gravity Component Dispersal Cells
The inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any
evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory
authority. Ponding at depths greater than 75% of the height of the component may indicate overloading or impending
hydraulic failure necessitating more frequent monitoring.
Page y ofS
L Mound,;At=Grade, Tn-Ground Pressure
The inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any
evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory
authority. Ponding greater than 75% of the height of the component may indicate overloading or impending hydraulic failure
necessitating more frequent monitoring.
The pressure distribution system is provided with an opening at the end of each lateral to be used for flushing. The laterals
should be flushed at least once every three (3) years. Pressure checks of systems with multiple laterals should be done to
ensure that equal distribution of effluent is occurring to promote the longevity of the system.
REPORTS
Reports for maintenance, inspection, and monitoring shall be submitted in accordance with COMM 83.55 Wisconsin Administrative
Code.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure that the system is
properly and safely abandoned in compliance with Ch. COMM 83.33, Wisconsin Administrative Code.
- All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
- The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
- After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or other 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 maybe 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 from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a
holding tank may be installed as a last resort to replace the failed POWTS.
^ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank maybe 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 CONTIAN 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 E"•tB E[,e~ /yip- 3y/z I
Phone ~/., L7-~ -.5-.? ~ L
SEPTAGE SERVICING OPERATOR um er - G/./.Cnlow,J
Name
Phone
K:\WPDATA\EH\POWTS OWNER'S MANUAL.doc
POWTS MAINTAINER
Name E.IB ~6L,CB' ~< ~ ~Lury~/.~~
Phone ~YS G7•? - .~~ L
LOCAL REGULATORY AUTHORITY
A enc mss; L.ro~x L"s. Zo.~i.rc Of'fic~
Phone 7i.~ ~Bl - X80
Page .r of -r
ST CROIX COUNTY
y _ SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer
.~~,1~ ) ~ 20Q4
r r~sr,r~u rn~~rl ~r
zotiirJ~ or~!c
Mailing Address 11~ l a G ~ ~ ~~ ~ y .~-'~ ~ (`"~-S W~-~ s~~77~'~~~~
Property Address ~ ~ ~~ ~`' ~ G ~ ~ ~
(Verification required from Planning Department for new construction)
City/State 1"fud~'1 , ~ I ~ Parcel Identification Number Off'' !~3} ~ ~ 2~ °~ • 2 ~~~)
T EGAL DESCRIPTION
property Location ~'/., ~ `/., Sec. ZZ. T Z°j N-R ~~ W, Town of
Subdivision ~ 1.~. `~ C"~TI4~'~ .Lot # ~ L-
Certified Survey Map # ~'-. Volume ~ . ,Page #
Warranty Deed # ~~ 4~ Z ,Volume ~~ Page # ~ 3
Spec house ^ yes ^ no Lot lines identifiable ^ yes ^ no
SYSTEM MAINTENANCE
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 throe 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 is the waste disposal system.
The properly owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
mastCr plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on site wastewater disposal system
is is proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than I/3 full of sludge.
Uwe, 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 Zoning Office within 30
clays of the throe y piratioa date.
1_~~~~~
SI PLICANT Q txrwQr 1 DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the p rty described above, virtue of a warranty deed recorded in Register of Deeds Office.
/~/~
DATE
SIGN F PLICANT (}~-~'^Q~
~, pe artment. ««*«««
«««««« pny information that is mis-represented may result in the rani rnut being revoked by the Zoning Dep
«« include with this application: a stamped warranty deed from the Register of Deeds ofEce
a copy of the certified survey map if reference is made in the warranty deed
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer ~ ~~ ~C--.
Mailing Address I 1 l o Cn 1. ~ ~ L IQ~v ~ ~- t1~ ~ l ~~ S ~ S 5- I / Z
Pmperly Address ~ ~ ~~ ~` ~4 G ~ ~ f 4-
(Verification required from Planning Department for new construction)
City/State Parcel Identification Number O ~ ~ l ~3 } ` C 2- ~ 2 ~l ~~
LEGAL DESCRIPTION
property Location ~`/., ~ '/., Sec. 2-2. T Z°t N-R ~~ W, Town of
Subdivision ~ ll., `~ C~T1~~~ -. Lot # ~ ~-
Certified Survey Map # ~~ . Volume r .Page #
Warranty Deed # ~'~ 0~ 2 ,Volume ~~ Page # ~ 3
Spec house ^ yes ^ no Lot lines identifiable ^ yes ^ no
SYSTEM MAINTENANCE
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 nceded 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.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
mastorplumber, journeymanplumber, restrictedplumber or a licensedpumper verifying that (1) the on-site wastewaterdisposal system
is is 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, heroin, 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 Zoning Office within 30
days of the three year expiration date.
SIGNATURE OF APPLICANT
/ /
DATE
OWNER CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
the property descn'bed above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE OF APPLICANT
/ /
DATE
«««««« Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ««««««
«« Include with this application: a stamped warranty deed firm the Register of Deeds office
a copy of the certified survey map if reference is made in the warranty deed
Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 ~~' Cit oiX
-~v
'fit „ 1218
Wisconsin Department of Commerce SOIL EVALUATION REPO ;Yr ~~ ~ ~ ~ ; ~.~ P 1 of 3
Division of uafety and Sui!dings in accordance with Comm 85, Wis. Adm. Code Steer Soil Service
~ _~ ~ ~ i ~r
Atiach complete site plan on paper not less than 8l z 11 inches in s¢e. Plan must C £ _n~ ~''~tS Croix
ir~lude, but not limited to: vertical and harizonta! reference point (BM}, direction and - ° _., °'
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D.
Pending
Please print all information. R ~ gy Date
Persorai information You pro,~ide maybe used for sacondary purposes (Privacy L.aw, s. iS.Cy (tj (mj). 3/~
Property Owner Property Location
Reliant Developers LTD Govt. Lot SE 1/4 SE 114 S 22 T 29 N R 19 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
9900 Valley Creek Rd_ Suite 135 12 na Kelly Estates
CiN (,~66CP~u~ State Zip Code Phone Number City Village Town Nearest Road
MN 55125 651-731-3174 Hudson Heritage Way
~ /I ri
`( ~~
~/~ New Construction Use: fir, Residential /Number of bedrooms 4 Code derived design fla~nv rate 600 GPD
Replacement Fublic or commercial -Describe:
Parent material outwash plains and stream terraces Flood plain elevation, if applicable na
General comments
and recanmendations: System elevation 98.85ft, trenches spaced and depth to code 5.50ft bebw grade
~ 7 f Boxing # .:_. i Boring
105
u ~; Pit Ground Surface elev. 105.35 ft. Depth to limiting factor
in. Sal Application Rate
Horzon Depth Dominant Color Redox Descrption Texture Structure Consstence boundary Roots GPDIftz
*Eff#1 *Eff#2
1 0-10 10yr3/3 none sil 2msbk mfr cs 1f .5 .8
2 10-26 10yr4/4 c2d 7.5yr5/6 sc! 2msbk mft gw na .4 .6
3 26-52 7.5yr4l4 none sVls 2msbk mfr gw na .5 .9
4 52-105 7.5yr4/6 none is osg mvfr na na .7 1.2
~ `/~dy
Boring # Boring
~ Pit Ground Surface elev. 105.35 ft. Depth to limiting factor 105 in.
Horizon Depth Dominant Color Redoz Description Texture Structure Consistence boundary Roots
1 0-12 10yr3/3 none sil 2msbk mfr cs 1f
u
(~')
2
12-29
10yr4/6
c2d 7.5yr5/6 sicl
2msbk
mfr cs na
3 29-48 7.5yr4/4 none sl 2msbk mfr di na
4 48-105 7.5yr4/6 none Is osg mvfr na na
~oZ
Sat Applicatan Rate
GFDNt'
*Eff#1 ~ *E1i#2
.5 .8
.4 .6
.5 .9
.7 1.2
trriueni aF'I = oUU 5> 3t) < 220 mglL ono TS8 >30 < 1 bt) mgtL `Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print} ySi nature: ~~ CST Number
David J. Steel M X ~'-~J 248956
Address Steer Soit Service % Date Evaluation Conducted Telephone Number
1564 CR GG, New Richmond, WI 54017 10/22/2002 715-246-5085
p~peE{y ovrneT Rel"sang Developers LTD Parcel 1D #
a Boring # Boring
:/ Pit Ground Surtace env. 101.65 Pending
ft. Depth to limiting factor
105
in. Page 2 of 3
~~ gpplication Rate
Hortron Depth Dominant Dolor Redox Descriptron Texture Structure Consistence Boundary Roots GPD/it'
'Eff#1 'Eff#2
1 0-9 10yr3/3 none sil 2msbk mfr cs 1f .5 .8
2 9-24 10yr4/4 none scl 2msbk mfr di na .4 .6
3 248 10yr4/4 none sl 2msbk mfr gw na .5 .9
4 48-56 7.5yr4/4 none sUls 2msbk mfr gw na .5 .9
5 56-105 7.5yr4/6 none Is osg mvfr na na .7 1.2
Rnrinn # Boring
'Effluent #1 = BOD ~ 30 ~ 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BODS <30 mg/L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
Boring # Boring - -
• ~ ,. ~ ~ Page 3 of 3
STEEL'S SOIL SERVICE
David J. Steel 1564 Cty Rd GG
CST-POWTSM Reliant Developers LTD New Richmond, WI 54017
Lic. # 248956 SE1/4,SE1/4,S 20,T29,R19W (715) 246-6200
Town of Hudson, St. Croix Co. (715) 246-5085
Kelly Estates lot 12
This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for
your use. The location of the test may or may not be as shown as permanent lot lines were not
established at the time the soil test was conducted. Legend
i" = 40' /
/ ~ ~ Benchmark El. 100.00Ft
/ op of %i"pvc pipe -+
~= Alt Benchmark EI.99.65Ft
Top of %2" pvc pipe '--
=Borings
Boring Elevations
B1 =105.35Ft
B2 =105.35Ft
B3 =101.65Ft
B4 =OO.OOFt
Jo ~~°~
~ ~'l~i~
~ Kl``
` /05.~~
~'~ ro 1. G; ~-~
~~5~~
A~ 1 '__----~
l`ib` l~b`~~ 2`~`
s~
/~ z~~~Z
7 ~"~
~~
~~/
21 `f.
~t~lC
~ [ --
y~>3~ w /« ~a~r~w~U / aa~nwr io y.waW a~ •rw ,s '~•o~ w ~~ 'aw s~ .e•q vwN ec ~1 'se wa•s ~ +• '+u•~o
~ ''~ ~ naa~s .w w wu.•o w~a•ss •w y +nJO•e sr.a•.s ra M +++ro aa.w~•s «e y e~wen
I~~H ~ . S~~~ S~,I,XZS~ ~C'I'I~}I ~~ ~gtd ~~eutiuctasd
~~ ~ W~
a -+ Ny
1 ~ ~~ ~
~ ~~ 1 0~ ~e~~ ~ ~ o ~a <
~I
61 i Val ~~''~~ ~ q pk ~ _1 = aW
0 3 W 'F. CC ~ ~ CV ~ iti f/1Qr' ~ F-
~~{ ~ I W~ ~qxA ~ ~ ~g ~ 4 ~~n O V1N ~ N,U
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ER TITLE HUDSON
~.:Z~44P 413
5TATE.BA,lt t?F WISCONSZI~i ~OItT~f 2_ 2000
WAYtRAtvTY D~;$v
lcifrt; aIopt:rs, LLC, Grantor, Did
ator imberly K. ,Fett:r husband and wife, as
un''ivorship Manta! pI'operty, Grantee,
Grantor, rnr a valuabtt: considcyation, t:onyeys :u~d warrtnts to Grantee
kh towing described teat estate in St. Croix CoUrtry, State of Wlseoasin:
i- ! IatofKeily Estates, St. Croix County, Wisconsin.
Ext:cptiotts to warraoties:
tsaremertts, restrictions and rights-ef-way of reeord, if any,
N0. 69 i ?, 2
7 S 9ttZr 7,~
RE~IS7'Ei~ dE' Olri:OS
ST. CROIJI CQ. ,, k~
RECExVCO FOR RECORD
@4/08/a®04 01:0SPI~f
MARRANY'Y DEEb
~~#pit i
1~6C~ I"iss: ZZ. ~
TRANS F6B; ~, gR
CC.OCAY~FEB c
AAG1sS: ,~
lira Area
mttt Rehrrtr Ad~,
Iteaity Titte, lrusCCitna aealty T(tte
z"d st. - sx,iatQc~ South 2nd Street
4 tiw sao16 Sulte # 115
s '=:!dson, WI ~4t"i16
ozo-ios4-90.000
Patsel tdantltication Numbsx {PIt~
This i n homestead property,
Dated this I l th d4y of March, 20oq•
IZt:liant b dopers, LLC
B ,~
* Rick Tosto» Marya ct forAcliant pevalo ers 1*LC
AUT1Ylty'1VTZCATIp111
5lgnaturc{s)
~- -- autltcrrticetctl this 11th Qay of Match, 2004 . -~ _,
"l7TLB: MEMBER STATE gpR pF WISCONSIN
(if not ,,,_,_
autitorizcd by § 704,06, Wis. Stats.j
Tt1151N~17Rt1M6NT WAS URAFYFD nY
r't:tcrson Ft~utt c~ B ah -Steven N. i3runS
54 fiast Fif3lt Street, St. Raul, 1VIN 551 Q1
(Sigltuur~ maybe Wthathcrtta~t nr oaknowledped, 0„th axe tmt nscesSaty.)
"td~t~ of DenanS aiprin6 in anY Wpuicy xaurt bC tYPrn1 or priwt,.~d below theft sidratute
WAtt4tAlY1'Y bdF.D
STATE DAR OF wISCONS'1,11
----Wai
State Of ISCOhsin
FORM Nv,b2ovD
ACKNOWLEDG1t~NT
STATE l7F WI5CONS7N
~ST. GRODC COUNTY. __ __ .. _ _ ) _ _ -- - .. _
ss.
Personally name before me this MarcG ] t, 2004 the above
r,:trrted Rlck Tostoa;- er for RoJisM Devolopera. LLC to
me knowsi tq be t11e pars n(s} who escecutrd
it~trtunant and aclcnowlGdge ~ e~anur, 'the foregoing
-_...,..... - t
Notary Pub- Rio rn
My ccuzurtission !a
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