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020-1395-01-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT sanitary Permit No: 572845 0 GENERAL INFORMATION (ATTACH TO PERMIT) 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: Matuke, Sherri M. I Hudson, Town of 020-1395-01-000 CST BM Elev: Insp.BM Elev BM Description: ^ Section/Town/Range/Map No: C /(({J� — 25.29.19.2395 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER ,',n y CAPACITY STATION BS HI FS ELEV. e Septic � /�� '�. 3 3zo B�on'..chmark 97, lg 93, 7 per. W Alt. BM gyp$4 Aeration Bldg.Sewer !�9Z 9Z . z(. Holding St/Ht Inlet (0,fZ 91d- -;P Ca y TANK SETBACK INFORMATION St/Ht Outlet pfd 7 Z.G TANK TO P/L WELL BLDG. a to Air Intake ROAD Dt Inlet �\ Septic 9 / Dt Bottom Dosing o� heJKi Header/Man. .7 ft, a 7 Aeration Dist. Pipe .6.6 li,.7% 90 Holding Bot.S stem C•(�,G $ O 97, T�6 O Final Grade 3 ,fo 73. 7 PUMP/SIPHON INFORMATION �d Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System TDH Forcemain Length Dia. Dist.to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width 1 Length No.Of Trenches PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS 5c� SETBACK SYSTEM TO v P/L BLDG IWELL LAKE/STREAM LEACHING Manufacturer: EZ /o�J INFORMATION CHAMBER OR Type Of System: la UNIT Model Number: IJA DISTRIBUTION SYSTEM Jost S Header/Manifold Distribution 1 ap J Ole Size x Hole Spacing Vent to/Air Inta Pipe(s) �- �S �Z `'—� �._ WZ>5 t . Length Dia Length Dia Spacing d� 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 L n - Bedrrrench Edges Topsoil � No 0 No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: Location: 802 Prairie Meg ow Drive Hudson,WI 54016(NW 1/4 NW 1/4 25 T29N R19W) Scenic Hills Lot 1 Parcel No: 25.29.19.2395 1.)Alt BM Description= r` J ��r"�-- �— /Q G h-- Cam, 2.)Bldg sewer length= SO -amount of cover= /� Plan revision Required? Yes )<No C Use other side for additional information. Date Inse tot's Si ure Cert.No. SBD-6710(R.3/97) Page 3 of 3 0 ft. 24 ft. 40 ft. 80 ft. N (,i}a gcY 3205,1 Scq-Y G -group orth of pos Property Line St�S�� �_. jYfGVr rp 3.6 B-2 Si C'7 p vpa 94'--- Y s °m Cn ose o � COUTOUR s C pOO� BM#1-top of well 100.0' Garage � j Y • =Ground Surface Elevation BM#&Descriptiorr = Bench Mark B 1 Elevation 100, =Boring Location&Elevation Owner: Sherri Matuke Site Information: Completed By: Mark Iverson, PSS#197 802 Prairie Meadow NW1/4, NW1/4, S25, T29N, R19W 680 Larcom Street Hudson, WI 54016 Town of Hudson Hammond, WI 54015 St. Croix County 715-796-5664 Phone: CST#46672 County Safety and Buildings Division ST. CROIX ,.t11� 201 W.Washington Ave., P.O. BOX 7162 Sanitary Permit Number(to be filled in by Co.) C' � v Madisonz WI 537 762 r 2, W* ff' r_y Permit Application State Transac tio NumbeIn accordance with SP (2), Wis. Adm. Code, submission of this form to the appropriate governmental /�� unit is required prior Vr obtaining a sanitary permit. Note: Application forms for state-owned POWTS are Project Addre s(if different than mailing address) submitted to the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s. 15.04(1)(m),Stats. I. Application Information-Please Print All Information Property Owner's Name Parcel# SHERRI MATUKE 020139501000 Property Owner's Mailing Address Property Location 802 PRAIRIE MEADOWS DRIVE Govt. Lot 1 _ City,State Zip Code Phone Number NW y4,NW '/4, Section HUDSON, WI 54016 N/A T N; R (E orQV e 29 II.Type of Building(check all that apply) Lot# — — `5_JW_ Pdv� Subdivision Name �G 1 !C(.[S� Ek1 or 2 Family Dwelling, umber of Bedrooms N/A POOL HOUSE ��� Block# --_-_---- -------._S ❑Public/Commercial-Describe Use ❑ City of ❑State Owned-Describe Use CSM Number ❑ Village of q Town of jjj_jp2C)N III.Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New SysteT ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System(explain) B List Previous Permit Number and Date Issued ❑ Permit Renewal El Revision El Change of El Transfer to New Before Expiration Plumber Owner IV ii S System/Component/Device: (Check all that apply) Non-Pressurized In-Ground) ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in.of suitable soil ❑ Mound < 24 in.of suitable soil ❑ Holding"TdlSrc0'6ther Dispersal Component(explain) i,C M LtEl pretreatment D vice(explain) t V. Dispersal/Treatment Area Information: ` Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required(sf) Dispersal Area Proposed(sf) System Elevation L'' 4 175 1" �w VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units o New Tanks Existing Tanks c v ro a U v, iw c7 a. Septic or Holding Tank 320 0 320 1 WIESER 1 X Dosing Chamber N/A 1 i,,. VII.Responsibility Statement- I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's Signature MP/MPRS Number Business Phone Number PAUL KOEHLER / /�_._ 225410 715-246-2660 Plumber's Address(Street,City,State,Zip Code) 321 WISCONSIN DRIVE NEW RICHMOND WI VI11. County/Department Use Only Permit Fee Date Issu Issuing Agent Si to e;y Approved ❑ Disapproved $ L" El Owner Given Reason for Denial 7� � L� � 1 i'�2 �...- IX. Conditions of Approval/Reasons for Disapproval SYSTEM OWNER: 1.Septic tank,effluent filter and f k 'i ..1 a � +>'n dispersal cell must be_;eruiced/maintained as per management plan provided by�lu��rker. 2.All setback requirements must be maintained as per applicableAdl9*jt8r i1*"ans for the system and submit to the County only on paper not less than 8 112 x 11 inches in size SBD-6398(R. 11/11) CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: SHERRI MATUKE Owner's Name: _ SHERRI MATUKE Owner's Address: 802 PRAIRIE MEADOWS DRIVE 14IMSON, WT 54016 - Legal Description: NW 1/4 NW 1/4 SEC 25 T 29 R 19 W Township: HUDSON County: ST. CROIX Subdivision Name: PRAIRIE MEADOWS Lot Number: 1 Parcel ID Number: 020139501000 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing &Cross-Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test&House Plans Designer/Plumber.- PAUL KOEHLER License Number: 225410 Date: 11/5/14 Phone Number 715-246-2660 Signature Designed pursuant to the In-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P(N.01/01). Page 1 Page 3 of 3 0 ft. 24 ft. 40 ft. 80 ft. N (,�,�S�Y 3zogAl sit, c -group orth of post Property Line B-3 93. S'Scl 'lD 4`"Ppe- s�QSp��vti �W�t'�rp 93.6 'S�I,�fib y'pvc, 94'--- 94.0 0 c o a Uf`� 0 m h A o�se�/ COUTOUR Apo BM#1 -top of well 100.0' Garage �I • =Ground Surface Elevation BM#& vaRn g rfptiort = Elevatio Bench Mark B 1 — Boring Location&Elevabon 100' Owner: Sherri Matuke Site Information: Completed By: Mark Iverson, PSS#197 802 Prairie Meadow NW1/4, NW1/4, S25, T29N,R19W 680 Larcom Street Hudson,WI 54016 Town of Hudson Hammond, WI 54015 St. Croix County 715-796-5664 Phone: CST#46672 SOIL ABSORPTION SYSTEM DETAIL/GRAVELLESS LEACHING UNIT Page_of Project Name: No. of Cells 450 Per Cell _J—ft Cell Width Total No of ft Cell Length 50 sq ft EISA Per Cell 0 ft Cell Spacing —aJ-0 sq ft Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ1203H-5ft 5.0' 25.0 EZ1203H-10ft 10.0' 50.0 Gravelless Leaching Unit Manufacturer: /) J /I a Gravelless Leaching Unit Model: ou Typical Cross Section Finished Grade ft Observation Pipe with approved cap or vent a.. a a.e eeeae.�- -- ■ ,.. Soil Backfill in ■ Geotextile Fabric ft Infiltrative Surface 12 in it o/y-ft,- Limiting Factor (/tin Slotted and Anchored Vent[ Observation Pipe with Cap eeee•■aaaae•■aaaa■■ee•■a••.e•■e.e■eae■■eaa ee aer•■ae ea■■a■ea■e■.a■a■aew.■■ Plumber/Designer Signature: License#: /� `.��6 Date: /mow of 2O1! IV Wisconsin Department of commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings A► /G 4 In accordance with Comm 85,Wis.Adm.Code � ^_l! County St.complete site Ian �gNtll l�l 8`/z x 11 inches in size. Plan must St. Cro1X Include but not limit �o: It cc point(BM),direction and Parcel I.D. 020139501000 11 Percent slope,sg®$udklla�i 61 i ttdrtli-snow,and BM referenced to nearest road. view Please print all information i Re ed by Date i Personal information you provide may be used for secondary purposes(Privacy,s'.13 II4�t} } �. 'Tt�►-t ' C' Li Property Owner Pro}38rty-lieeation_____ Sherri Matuke Govt.Lot NW v, NW s 25 T 29 N R 19 W Property Owner's Mailing Address Lot# Block# Subd.Name or CSM# 802 Prairie Meadows Dr. 1 I Scenic Hills Z 7 `I City State Zip Code Phone ❑City ❑Village 0 Town Nearest Road Hudson WI 54016 Hudson Prairie Meadows EI New Construction Use: 0 Residential/Number of Bedrooms other Code derived design flow rate ? GPD ❑Replacement ❑Public or Commercial-Describe: Parent Material Loess over outwash Flood Plain elevation if applicable N/A ft. General comments and recommendations: System is a new pool house with bathroom and sink. EIBoring 1 Boring# 0 pit Ground Surface Elevation 93.7 ft. Depth to Limiting factor >104 in. Soil ADDlication 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 0-10 10YR2/1 - SIL 3-m-gr dsh as 3f 0.6 0.8 2 10-17 1OYR2/1 - SIL 1-f-pl dsh cs 2f-m 0.4 0.6 3 17-24 jr OYR4/3 - SIL 1-f-pl dsh cs 1 f-co 0.4 0.6 4 24-38 1 1OYR3/4 - SIL 2-m-bk dsh gs 1f 0.6 0.8 5 38-49 10YR5/4 - SIL 2-co-bk dsh gs 1f 0.6 0.8 6 49-59 10YR4/6 - FS 0-m dh cs - 0.5 1.0 7 59-104+ 10YR4/6 �`f' �- -- S j 0-sg ml - - 0.7 1.6 ._ b Boring -' Boring# ®pit Ground Surface Elevation 94.0 ft. Depth to Limiting factor >112 in. Soil ADolication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fe in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 1 0-10 10YR2/1 - SIL 2-m-gr dsh cs 2f 0.6 0.8 2 10-18 1OYR2/1 - SIL 2-m-pl dsh gs 2f 0.0 0.2 3 _ 18-24 10YR4%3 - SIL 2-m-pt dsh cs 1 f 0.0 0.2 4 24-34 1 1OYR3/4 - SIL 3-m-bk dh cs if 0.6 0.8 5 34-46 10YR4/6 - SIL 3-m-bk mfr as - 0.6 0.8 6 46-56 1OYR4/6 - FS 0-m mfi cs - 0.5 1.0 7 >'56-112+ 10YR4/6 ! - S 0-sg ml - - J0.7 1.6 *Efflue #1=BOD5>30:5 220 mg/L and TSS>30:5 150 In •-- *Effluent#2=BOD5<_30 mg/L and TSS<_30 m CST Name(Please Print) Sign a CST Number Mark Iverson 46672 Address Date Evaluation Conducted Telephone Number P.O. Box 155 Hammond, WI 54015 November 3, 2014 715-796-5664 ILr 1L V1l1LUlU 0U114UG rIUViMLlllll lt. 1jupul LV Llllllllllg 1aGWr 1VG M. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PD/fe in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Ef1#1 *Eff#2 1 0-12 1OYR2/1 - SIL 2-m-bk dsh cs 3f-co 0.6 0.8 2 12-24 1OYR4/6 - SICL 1-co-bk dh cs 1f-co 0.2 0.3 3 24-31 10YR4/6 - FS 0-m dh cs 1f 0.5 1.0 4 31-47 7.5YR4/6 - VGRS 0-sg ml cs 2f 0.7 1.6 5 47-102+ 10YR4/6 - S 0-sg ml - - 0.7 1.6 Boring Boring# EIPit Ground Surface Elevation ft. Depth to Limiting factor in. Soil Aoolication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDHe in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 a Boring# 13 Boring OPit Ground Surface Elevation ft. Depth to Limiting factor in. Soil Application Ra e Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fe in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 *Eff#2 *Effluent#1=BOD5>30:5 220 mg/L and TSS>30:5 150 mg/L *Effluent#2=1301)5 5 30 mg/L and TSS:S 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. - round north of pos Pro Line B-3 93.1' B-1 93.6 g3,7 94'--- B-2 - --- 9a.o COUTOUR "bo/ BM#1-top of well 100.0' /Garage • =Ground Surface Elevation BM#&Description = Bench Mark (B- - Borin Location& Elevation Elevation - 9 Owner: Sherri Matuke Site Information: Completed By: Mark Iverson, PSS#197 802 Prairie Meadow NW1/4, NW1/4, S25, T29N, R19W 680 Larcom Street Hudson, WI 54016 Town of Hudson Hammond, WI 54015 St. Croix County 715-796-5664 Phone: CST#46672 S INSTALLATION INSTRUCTIONS �catorn PrF:a.�8raanag° A b.o.n PL-525/PL-625 FILTER Warewafir Proc�.�C,s oyiek tnc PL-525/PL-625 FEATURES & BENEFITS Features & Benefits: *Rated for 10,000 GPD .PL-525 = 525 Linear Feet of 1/18" Filtration PL-625 = 625 Linear Feet of 1/32" Filtration PL-525- PL-625 *Accepts 4" and 6" SCHD. 40 pipe The PL-525/625 Effluent Filter should operate efficiently * Built in Gas Deflector for several years under normal conditions before *Automatic Shut-Off Ball when Filter is Removed requiring cleaning. It is recommended that the filter be cleaned every time the tank is pumped or at least every *Alarm Accessibility three years. If the installed filter contains an optional alarm, the owner will be notified by an alarm when the *Accepts PVC Extension Handle filter needs servicing. Servicing should be done by a certified septic tank pumper or installer. RECOMMENDED PRODUCTS Polytok PVC .Filter Extension Handle x r . ib K" d Risers&Riser Covers Extend& Lok- Riser Safety Screens Filter Alarm Panel and Polylok risers bring your Polylok Extend&Lok7m Polylok safety screens SmartFllterTM Control septic tank cover to grade. is a simple, easy to use prevent tragic accidents Switch This allows locating and solution that can extend: from happening by children Potylok filter alarm panels servicing your filter easier the inlet or outlet pipe and and pets falling,into open and switchs provid a visual and time saving by etimi- make filter and/or baffle septic tank entrances. and audible notification of n'ating digging to find tank installation a snap. impending filter and tank entrance. Fits 3"and 4"pipe_ servicing. For a full list of Polylok products please visit our web site at: www.pol`yl'ok.com POWTS OWNER'S MANUAL St MANAGEMENT PLAN Page I of�! FILE INFORMATION SYSTEM SPECIFICATIONS Owner SHERRI MATUKE Septic Tank Capacity qal 11 NA Permit # — Septic Tank Manufacturer WIESER O NA DESIGN PARAMETERS Effluent Filter Manufacturer POLYLOK d NA Number of Bedrooms p IR NA Effluent Filter Model 525 ❑ NA Number of Public Facility Units C!NA Pump Tank Capacity gal 11 N 4 Estimated flow(average) 1j7 gal/day Pump Tank Manufacturer A7 NA Design flow (peak), (Estimated x 1.51 17 5 _91yday Pump Manufacturer %i NA Soil Application Rate .7 al/day/ft2 Pump Model ] N.a Standard Influent/Effluent Qualltv Monthly average* Pretreatment Unit ] N,a Fats, Oil & Grease (FO 530 mg/L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODS) 5220 mg/L ® NA 1 ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) :;ISO mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) O N,k Biochemical Oxygen Demand (HODS) SSO mg/L M In-Ground (gravityl ❑ In-Ground (pressurized) Total Suspended Solids (TSSJ 530 mg/L (t NA ❑ At-Grade ❑ Mound Fecal Coliform (geometric mean) 510' o"00ml O Drip-Line ❑ Other: Maximum Effluent Particle Size Y in dia. 13 NA Other: 0 NA Other: ❑ NA Other: ❑ NA *Values typical for domestic wastewater and septic tank effluent, Other: ❑ N7It MAINTENANCE SCHEDULE Service Event Service(Frequency inspect condition of tank(s) At least once every: O months) (Maximum 3 years) -❑ Nit 3 El year(s) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y3) of tank volume ❑ N/� Inspect dispersal cell(s) At least once every: 3 ❑yeads)s! (Maximum 3 years) ❑ NA �year(s! Clean effluent filter At least once every: 1 0 month(s) Q Nit Inspect pump, pump controls & alarm At least once every: ❑ month(s) ki W, ❑year(s) Flush laterals and pressure test At least once every: O month(s) ® N<. ❑ year(s) Other: At least once every: © month(s) ❑ NA O years! Other: ❑ W, - MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tanks) 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 back up or ponding of effluent on the ground surface. The dispersal cell(s) 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 tlie immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) 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 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 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION Page 71 of 71 For new construction,t n, prior to use of the POWYS check treatment tankls) for the presence of painting products or other chemic 3 that may impede the treatment roces P sand/or damage a age the dispersal cell(s). If high concentrations are detected have the contern of the tank(s) removed by a septa a servicing g c ng operator prior to 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 b discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge c effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restorin Power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls t 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 are 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 thi POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; tat foundation drain (sump pump) water; fruit.and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; coil, 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 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: C� A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorptkm 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 limes and wells- Failure to protect the replacement area %ill 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 A, technology a holding tank may be installed as a last resort to replace the failed POWTS. site slue � - - be" ear - Rai-�i$)'TL�(� i>�1�-J�/�✓ �NSTRl1��'l ►k ❑ 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 tine. <<WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NCT 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 DIFRCULT OR IMPOSSIBLE. ADDITIONAL COMMENTS r POWTS INSTALLER POWTS MAINTAINER Name COUNTRYSIDE PLUMBING & HEATING INC Name PAUL KOEHLER Phonia 715-246-2660 Phone 715-246-2660 SEPTAGE SERVICING OPERATOR(PUMPER) LOCAL REGULATORY AUTHORITY Name POWERS LIQUID WASTE MANAGEMENT Name �-j- Gip( ?p�ll(J Phone 715-246-5738 phone 7 39(p (p . D This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.64(11. (21 & (3), Wisconsin Administrative Code. 0 P, vu/vl/vu "zL) X0;V0 rAA Ila JOO 4000 al kKA W 4VINIAIi WJ vul ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer SHERRI MATUKE Mailing Address 802 PRAIRIE MEADOWS DRIVE, HUDSON, WI 54016 Property Address SAME (Verification required from Planning&Zoning Department for new construction.) City/State HUDSON, WI Parcel Identification Number 020139501000 LEGAL DESCRIECTON Property Location NW I/. NW '/4 , Sec. 25 T 29 N R 19 W,Town of HUDSON Subdivision PR=TE—?MIADOWS �CENIC Certified Survey Map# Volume Page it Warranty Deed # lq l 40 -2-- Volume Page# Spec house❑yes Zrio Lot lines identifiable r' yes❑no SYSTEM MAINTEN A NCE AND OWNER C RRTIFICATION improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of purnping out the septic tank every three years or sooner,if needed,by a licensed pumpor. 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 arc 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 Departniwit 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 staterneno,on this form are true to the best of my/our knowledge. I/wc am/are the owner(s)of the property described above,by virtue of a warranty deed recorded in Register of Deeds Office. Num1ber of bedroomSVdA �Ro t- WdLl-!�E 11 /5 14 SIGNATORE OF 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 trap if reference is made in the warranty deed. (REV.08/05) i 111111 II III IIIIIIIII IIIIIIII I 8247242 Tx:4202176 RIVER VALLEY ABSTRACT&TITLE 999402 1200 HOSFORD STREET,SUITE 201 BETH PABST HUDSON,WI 54016 REGISTER OF DEEDS ST. CROIX CO., WI :ICY 07/31/20140' 9:17 AM EXEMPT#: NA REC FEE: 30.00 TRANS FEE: 1425.00 PAGES: 2 DOCUMENT NO WARRANTY DEED Name&Return Address This Deed,made between Kevin James Buscher and Donna Jill Buscher,husband and wife,Grantor,and Sherri M Matuke of Grantee, Witnesseth,that the said Grantor,for$1.00 and other good and valuable consideration conveys,to Grantee the following described real. estate in St.Croix County,State of Wisconsin: PIN 020-1395-01-000 Lot 1,P1 of Scenic Hills in thee Town of Hudson,St.Croix County,Wisconsin. This....................1S.............................homestead property. (is) (is not) Together with all and singular the hereditaments and appurtenances thereunto belonging; and Kevin James Buscher and Donna Jill Buscher warrants that the title is good,indefeasible in fee simple and free and clear of encumbrances except: Municipal and zoning ordinances and agreements entered under them, recorded easements for the distribution of utility and municipal services,recorded building and use restrictions and covenants,and general taxes levied in the year of closing. and will warrant and defend the same. \ St. Croix County 999402 Page 1 of 2 tY tz ^'1 w OEt6E M.t t 7�68 SW°35VTE 4MI7. u2 r L. ----16- NNM a'� a �W -f4 004 i m i 9�9� i Q zC° -� ----� --- >lnANaNij03NR1S3M1, ---ZQ IL�7ZF'J3 t 33 �. z N Ld I l -241 Datedthis.............911k......................day of...... ....................................................................... ... ....... . ... .. .... .... er :iiiu .... ... ............. Ke .................. D.--oia�iisc ACKNOWLEDGMENT S -W. On7r.".I.County. Personally came before me this ....... ....... day of.:S& .. the above named Kevin James Buscher —,(,f*iI1 in marital status)to me known to be the person who executed the foregoing instrument and acknowledge the sal ne. KIM A. MATTHEWS .............................................................................. ...........7.... 1$QT0)gF4BLIC-STATE OF MICHIGAN COUNTY OF GENESEE My Commission Expi 20117111 4, 1c1n,in the Co W—L I .... . .. .. .... .............................. u*Of -0 . - -a I . ............County,)h Nola Public.. ... ........ My commission is permanent. (If not, state expiration date:..... .....Lb........................................ *Names of persons signing in any capacity should be typed of printed below their signatures. ACKNOWLEDGMENT S4� OF.WISCONSIN rqW....................county. Personally came before me this ...).Q..........day of...;:SAY,.............................d the above named Donna Jill Buscher (fill in marital status)to me known to be the person who executed the foregoing instrument and acknowledge the same. ......P. C, &11.040 FELICIA BAILLARGEON .................................. Nota Seal Notary Public State of Wisconsin County, is. Mycommission is permanent. (If not, state expiration date:..... ........................................... ........ *Names of persons'signing in any capacity should be type-y-o-',printed below their signatures. THIS INSTRUMENT WAS DRAFTED BY F.R.S. 900 Wilshire Drive Suite 107 Troy,MI 48084 Ellen Ludorf 728689 10100-20904 St.Croix County 999402 Page 2 of 2• Parcel #: 020-1395-01-000 11/10/20P AGE E1 AM P 1 OF 1 Alt. Parcel#: 25.29.19.2395 020-TOWN OF HUDSON Current ❑X ST. CROIX COUNTY,WISCONSIN Creation Date Historical Date Map# Sales Area Application# Permit# Permit Type #of Units 00 0 Tax Address: Owner(s): 0=Current Owner, C=Current Co-Owner 0-MATUKE, SHERRI M SHERRI M MATUKE 802 PRAIRIE MEADOW DR HUDSON WI 54016 Property Address(es): *=Primary *802 PRAIRIE MEADOW DR Districts: SC=School SP=Special Type Dist# Description SC 2611 SCH DIST OF HUDSON SP 1700 WITC Notes: Legal Description: Acres: 2.329 SEC 25 T29N R19W PT NW NW SCENIC HILLS LOT 1 Parcel History: Date Doc# Vol/Page Type 07/31/2014 999402 WD 06/13/2011 937441 WD 05/05/2011 935822 QC 01/27/2004 752780 2498/624 WD more... Plat: *=Primary Tract: (S-T-R 40'%160%GQ Block/Condo Bldg: *08-076-SCENIC HILLS 1/72 020-01 25-29N-19W NW NW LOT 001 2014 SUMMARY Bill#: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/18/2012 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.329 51,200 322,500 373,700 NO Totals for 2014: General Property 2.329 51,200 322,500 373,700 Woodland 0.000 0 0 Totals for 2013: General Property 2.329 51,200 322,500 373,7000 Woodland 0.000 0 i Lottery Credit: Claim Count: 1 Certification Date: 09/07/2006 Batch#: 06-08 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page I of 3 Division of Safety and Buildings In accordance with Comm 85,Wis.Adm.Code County Attach complete site plan on paper not less than 8%x 1 l inches in size. Plan must St. CrO1X Include but not limited to:vertical and horizontal reference point(BM),direction and Parcel I.D. 020139501000 Percent slope,scale or dimensions,north arrow,and BM referenced to nearest road. Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes(Privacy Law,s.15.04(1)(m)) Property Owner Property Location Sherri Matuke Govt.Lot NW v. NW %, s 25 T 29 N R 19 w Property Owner's Mailing Address Lot# Block# I Subd.Name or CSM# 802 Prairie Meadows Dr. 1 Scenic Hills City State Zip Code Phone ❑ City ❑Village 0 Town Nearest Road Hudson WI 54016 Hudson Prairie Meadows 0 New Construction Use: 2 Residential/Number of Bedrooms other Code derived design flow rate 9 GPD ❑Replacement ❑Public or Commercial-Describe: Parent Material Loess over outwash Flood Plain elevation if applicable N/A ft. General comments and recommendations: System is for a new pool house with bathroom and sink. Boring 1 Boring# p pit Ground Surface Elevation 93.7 ft. Depth to Limiting factor >104 in. Soil Application Rate Roots GPD/ftz Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. *Eff#1 'Eff#2 1 0-10 10YR2/1 - SIL 3-m-gr dsh as 3f 0.6 0.8 2 10-17 10YR2/1 - SIL 1-f-pl dsh cs 2f-m 0.4 0.6 3 17-24 10YR4/3 - SIL 1-f-pl dsh cs 1f-co 0.4 0.6 4 24-38 10YR3/4 - SIL 2-m-bk dsh gs if 0.6 0.8 5 38-49 10YR5/4 - SIL 2-co-bk dsh gs 1f 0.6 0.8 6 49-59 10YR4/6 - FS 0-m dh cs - 0.5 1.0 7 59-104+ 10YR4/6 - S 0-sg ml - - 0.7 1.6 ❑Boring Fq Boring# ppit Ground Surface Elevation 94.0 ft. Depth to Limiting factor >112 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. 'Eff#1 `Eff#2 1 0-10 10YR2/1 - SIL 2-m-gr dsh cs 2f 0.6 0.8 2 10-18 10YR2/1 - SIL 2-m-pl dsh gs 2f 0.0 0.2 3 18-24 10YR4/3 - SIL 2-m-pl dsh cs 1f 0.0 0.2 4 24-34 10YR3/4 - SIL 3-m-bk dh cs 1f 0.6 0.8 5 34-46 10YR4/6 - SIL 3-m-bk mfr as - 0.6 0.8 6 46-56 10YR4/6 - FS 0-m mfi cs - 0.5 1.0 7 56-112+ 10YR4/6 - S 0-sg ml - - 0.7 1.6 *Effluent#1=BOD5>30:5 220 mg/L and TSS>30<150 m;/L #2=BOD5 <_30 mg/L and TSS<_30 mg/L CST Name(Please Print) Signature CST Number . �Mark Iverson 46672 i Address ate Ev luation Conducted Telephone Number P.O. Box 155 Hammond,WI 54015 November 3, 2014 715-796-5664 Property Owner Sherri Matuke Parcel ID# 020139501000 Page 2 of 3 ❑Boring Fq Boring# ppit Ground Surface Elevation 93.6 ft. Depth to Limiting factor >102 in. Soil ADPlication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. 'Eff#1 'Eff#2 1 0-12 10YR2/1 - SIL 2-m-bk dsh cs 3f-co 0.6 0.8 2 12-24 10YR4/6 - SICL 1-co-bk dh cs 1f-co 0.2 0.3 3 24-31 10YR4/6 - FS 0-m d cs 1f 0.5 1.0 4 31-47 7.5YR4/6 - VGRS 0-Sg ml cs 2f 0.7 1.6 5 47-102+ 10YR4/6 - S 0-sg ml - - 0.7 1.6 ❑Boring 4 Boring# Elpit Ground Surface Elevation ft. Depth to Limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. 'Eff#1 -Eff#2 ❑Boring [7]Boring# Elpit Ground Surface Elevation ft. Depth to Limiting factor in. Soil APD11cation Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. 'Eff#1 -Eff#2 * Effluent#1=BODS>30<220 mg/L and TSS>30<150 mg/L *Effluent#2=BOD5<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 Need material in an alternate format,please contact the department at 608-266-3151 or TTY 608-264-8777. Page 3 of 3 Oft. 24 ft. 40 ft. 80 ft. t-� � N -ground north of pos Pro ert Line B-3 93.1' B-1 93.6 93.7 B-2 94'--- 94.0 --- o m ho ,o ose oo/ COUTOUR Apo/ BM#1 -top of well 100.0' Garage • =Ground Surface Elevation BM#&Descriptio Elevation g n = Bench Mark B 1 — Boring Location& Elevation 100' Owner: Sherri Matuke Site Information: Completed By: Mark Iverson, PSS#197 802 Prairie Meadow NW1/4, NW1/4, S25, T29N, R19W 680 Larcom Street Hudson, WI 54016 Town of Hudson Hammond,WI 54015 St. Croix County 715-796-5664 Phone: CST#46672 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)]. Perrnit Holder's Name: City Village X Township Carria a Homes Inc. /l'llf/l2C~rA~G ~ Hudso Townshi CST BM Elev: nsp. BM Elev: BM Description: / (,[~ rc~~' gas ~ ~~i ~ ~J TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic a 5~ Dosing _/Qv Aeration Holding TANK SETBACK INFORMATION TANK TO P!L WELL BLDG. Vent to Air Intake ROAD Septic ~~~ ~ 7s,' ,~ ~/ 3 ~ ~ Dosing Aeration - Holding - PUMP/SIPHON INFORMATION Manufacturer d i GPM Model umber ~~- TDH Lift F ' ion Loss System Head TDH Ft Forcemain Length Dia. Dist. to well s SOII ABSORPTION SYSTEM / /} ,.iv__ /. nn „ ~~-may. ~~- zsys STATION BS HI FS ELEV. Benchma~ T •G d .6 ~• ~ 00 Alt. BM ST. O •b*~ Bldg. Sewer /_ Cv. ~p ~d /' ~~ SUHt Inlet ~, 76 /06. ~o SUHt Outlet o: ~~3 Dt Inlet ~ i- Dt Bottom / .~ Header/Man. Dist. Pip v ,~ ~ 6 ~- ~-y ~~-~- Bot. System '1 o[• ~~' ~ Finai Grade /p/. Z. S~ Cov r ~ 3 .73- /b _ ~~ //.~ BED/TRENCH DIMENSIONS Width ~ ~ Length (~/ No. Of Trenches. PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK SYSTEM TO P/L ~ BLDG WELL ~ LAKE/STREAM LEACHING Manufac re ~ /~~ N CHAMBER OR / ~ INFORMATIO Typ f System: ~ \~~ ~ ~~ ~ ~ j ~ UNIT odel Number. DISTRIBUTION SYSTEM n , _ ~ r / 1... „ __ - ~ Header/Manifold Distribution ~ x Hole Size x Hole Spacing V~ to Air Intake ~ Pipe(s) ~ /, 1 Di ~~ ~~ g ~~ ~ / Length Dia i n Length a _ SOIL COVER z Pressure Systems Only xx Mound Or At-Grade Systems Only .~ (rte G~2GG~i2,(JQJ?~m~0'Y Depth Over ~-j"b ~ O Depth Over xx Depth of xx Seeded/Sodded xx Mulched _ Bed/Trench Center ~ ~/-~ Bed/Trench Edges Topsoil ~~ =:i Yes No 'Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/ 7i~1 67/ Inspection #2: / / Location: 802 Prairie Meadow~snD/rinv~e,Hudson, WI 54016 (NW 1/4 NW 1/4 25 T29N R19W) Scenic/Hills Lot~1 Parcel No: 25.29.1(9.2395 1.) Alt BM Description = ST ~'^'~ '"' ~'~ ~ ~~~~ 2 ` ~ ~~"`""~'~~ Vlt(~`~ ~S~~rs~ , 2.) Bldg sewer length = ~ 5 `~k7~tJLt`~ ~' sy~-(stn' }~t97t~K.-- ~(I' -amount of cover = , ` Z ii Est ~ •Eia~r~ l c1~ ,11~ " "~ ~a-~' 7 `l Plan revision Required? ~ ;Yes i No _- -/~ J ~ (p ~~ Use other side for additional information. ! ~ ~ ~'' ~ ~ ~, GZ!`~ ~ --- ~-~~-,~ _ ~ i . Insepctor's Signature Cert. No. SBD-6710 (R.3/97) County: St. Croix Sanitary Permit No: 404900 0 State Plan ID No: Parcel Tax No: 020-1395-01-000 ~'!` e ~ 1 Safety and Buildings Division COtnry i Y f.' ~ ~, 201 W. Washitt~ton Ave., P.O. Box 7162 ~~C~l ~S~n Madison. wI 53707 - 7162 Sits At~Z ~ ~~ De artment of Commerce ~ Q °; ~ Ovv Sanitary permit Naunbe~~~ ~ iD, Sanitary i'ermit Application ~,~ av~ Comm 83.21, VVts. Adm• Code, penoaal infartastion you provide ^ Cluck if Revtscan tea ~ used for seco es Privac law s13. 1 ttt Plan I.D. Number I. Application Informat3oa - Plwse Print All informwtiou ~ Property t3waer's N 8 W ~ -.--''~- err 1" OZo -13gS~ol -a~'p rty t]wsber's MaiUnS Addrssa '".r ~ ~ party ,. lion ~~ II ~j a'T ,, ., ,rJC~~ if =" ~ ~ i4 • S S T N. R f ~ ,~ '" • ~ !l ~ ~ Gr ~~ t N ~ Black Number City. Slue Zip Code PhD um if~~M~F...x . «" ~~.,~ Subdiva ~ Name CSM Nattnber ~~~./C~J~. `~'t%,k ~.~ 3~5`6~~ 4!"" ~~'7 ~ ~3C9f1: ` ~ c~ ~~ is u Type ai sttitatn~ {check aIf that apply) as ~" ^"^ ~_._ Ocity 1nw~ ^viuage J~ 1 or 2 Family Dwelling -Number of Bedronms ^ Pubiic/Commercial -Describe Use awttahip a~ .~ Nearest Road ^ state oxned z 3 t K q3.~'~ i ~- C~XJLS „v III. Type of Psrrrttt: (Check Daly one box on tine A (numbering scheaue far internal use}. Complete line B if applicable) ~ For Carat) tree 1 New 2 ^ Repltceaaeat System 3 ^ Replacenneat of 6 ^ Addition to ~n Tank t)nl P.xis . S went Date Issued Permit Number Ii. ^ Check ieSanitary Permit Previously Issued IV. Type of Perratlt: (Check aII that apply)(aumberFagseheme is for internal use) 21^ Mound 47 ^ Sand Filter SO ^ Constructed Wetland 44,~ Non -Freaatuized Tn-Dr~ 51 ^ Drip Line 22 ^ presa.ria3d ItrGmund 41 ©Holdiag Tank dg ^ Single Pass 45 ^ At-Grads 4b ^ Aerobic Ttratmrnt Unit 49 ^ Recircula ' 3Q ^ ~ V. D ant Area Ia[ormatioil: Petrolation Rste System Elevation Fiaai Grade Design Flow (~ I)iapertcel ~ ~ Soli Application Eievadon ~~ ,ooh Sl~f~ Ram(Gals.~DayslSq.Fc.) ~,~,} qC~ G~ ~4l ~v ~~d0 ~5? X57 ,~~ (~.Z~;~ ,~«- ~~ ~ ~~ /ao~ 50 i to .Total Number Mrutufactttrer Prefab Site Steel Fiber Plastic VI. Tank Infa ~ ~'' ' Concrete Canatntctod Glass ~loas CraIloaa of Teaks lYew >3~at raalu '~ or lloMist~ Tack - ~'0 f ` basing f'hantber of the FawTS ebowtt oa We attaches ~, otesihili Statt.meut- I, the uuserd~aes, aesttme reapoasibtilty for Number Business Phase Number Fhmtber's Name {Print) FSucnber'a Sigstaarro r ~~ ~ rs-3e''6--- ~J ~ l !~J/Il ~s~h1 sC- Lt 1u 'v pjttn717er'd Atldrestt ($ti'eet, city, State, Zip Code) VIII. Count /De artment U`se Sanitary Permit Fee (includes Groundwater Dax Issued Issuing Agent Signature eZlo Stamps) Approved ^ Disapproved S>irClSargE Fee) Qp ^ Avvaer Given Initial Adverse '~ ` Detorminatioa ~ 225. ~ • t iX. Ca~ititxts of rov easons Par Disapproval i~p,,, ~~~ ~ ~~,~,~,,,~ ~ ~:wc~ ~ S~ dttz. tou+u~uto .~.:r-~- ° ' ~'t~ " ~ l~tr a,~ r--, T,e tf~,• N/atl~d~a.~t~ . ~ gllZ:ll lt>~es in tie ~, ple~plao. (to eee c«mtr eal7) rar tluirt~ ~ ~. s~sn-~39s . oSio ' ~~Y ~ fir. ~ ,s .t D~ / Sc edi G "' y~ ' ~ ,. /~ . n, ,.r.c f1 ./ ~~~~~ ,~ ~~ y,~z ~e "~ ff~ ,~" ~ ~~ Q `V ~~~ ,~. ~~~L a ~~~ b~ ai ,gyp/ =~ w Ov ~ % ~~ ~ ~ ~ ,~~ 1,., t .. ~f/J ,~- .~ ©~'" l sc erg: c' !~/ ; v ~ b ~ ~ ~~J~~~~~ a~~~ ~• '" 3`~ w' ~3~G~- .3 'r J _~. ~f ~ ~~ ~~~ ~~~1/ //'ice/~'-2 Wisconsin Department of Commerce Division of 5afeiy and Buildings SOfL EVALUATION REPORT Page ~ of m accoroance wrtn Comm rso, vns. Ham. was _ County Pl mu t 11 i h i i 8 1/2 ~' ze. an s nc es n s x Attach complete site plan on paper not less than include, but not limited to: vertical and horizontal reference point (BM), direction and I .~,+,._. ~,~~' percent slope, scale or dimensions, north arrow, and location and distance to nearest road. .' , ---=~-~ Please print ail information. /~ 04 (1) m)) 15 P L ~$"'~"`?'~;~,~ °~^ii !~~ ( ., aw. s. . rnacy Personal information you provide may be used for secondary purposes ( Property Owner Property Lo 'on •. ~ ` .` p ~~ - f ~ry .~ // ~ ri C~ Gl~ ~ i1~C.-~ ~ Govt. Lot 21M1(~ . 1 /4 il~~'B i Z . ~ _.-' R % (or) Property Ow~ s Mailing Ads/ ~ ~ ~ ~ Lot ~ Blocli;# ; S M# ~' . City StaUe Zip Code Phone Number ^ City ^ v ~ [Town, -_, ~ \ Barest Road [~ New Construction Use: ~ Residential / Number of bedrooms ~ Code denved design flow rate ysd - ~~ a GPD ^ Replacement ^ Public or commercial - Descrit~: Parent material f~ U ~w ~~ 5 h~ Flood Plain elevation if apgplicable ~C/ /,(~ _ __ ft. Genera! comments s'ys /-P~ ~il•~ v~ ~u n 9~• l~ C3 ~"~ ~ / ~D ' ~ ~ and recommendations: 7 ~L~. -e~{v~ ys t'v~~ ^ Boring Boring # [~ pit Ground surface elev. G • ZO ft. Depth to limiting factor ~ 2 C) in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P D/fP in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. #1 *Eft *Eff#2 ,p r C 30- ~ r G _ S Z~ ,~ yrt~r GS f . S Ste-! /G ~ -- Y~25 6 S .~ -` r ~, w~-' 96 •b~~ .Z 7 C-- ^ Boring ~ Boring # ~~ ~~ ~ pit Ground surface elev. ~ ft. Depth to Limiting factor 11 ~ in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP DNf in. Munself Qu. Sz. Cont. Cobr . Gr. Sz. Sh *Eff#1 *Eff #2 j d -l3 l~yr 3/Z ~ ~~ l / Z/na.~C Y~'~'.-~ C .~ ~ r.S u ~ U Z i3--~ ~ /0 /~ `~ is zm.sb YY~-~ ~ ~ - , ,~ ~ -S~ / i - s G 2n~- Sb ~r ~ S -- , .~ a-/~ /G~ r // - m5 U S ~1 -- ~ ~ . Z .Z ~.' * Effluent #1 = BODS > 30 < 220 mglL and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TS5 < 30 mg/L CST Name (Please Print} Si ature CST Number r~ a -~. ~ rwt ~ ~- zS.3 3 ~ Address Date Evaluation Conducted Te~phone Number Z-l ,~~ ~S~ ~ v~ ~ ~ ~~4--, cy / .S~UzS~ / -lam - Q Z Ez~~sJz y~-~~a~S o~o~~~ Property Owner m a~ ~u ~7`f' T Parcel ID # Page ~ of ~ _ Boring # ^ Boring Pit Ground surface elev. 0 • Sv ft. Depth to limiting factor ~ z / in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP O/ff in. Munseit Qu. Sz. Cont Color Gr. Sz. Sh. "Eff#1 'Eff#2 Z i 3 2 /~ y~ / - S, '~ Z,rtse n'l ,- ~ S - . y . ~ 9 ~~ ~a. - mS 65 ( - - ~~ /Z ^ Boring # ^ Boring ^ pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP Olfg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 Boring # ^ Boring ^ Pit Ground surface elev. ft Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP Dlftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 `Effluent #1 = BODS > 30 < 220 mglL and TSS >30 < 150 mglL 'Effluent #2 = BODS < 30 mg1L and 7SS < 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 608-2G6-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) property Owner /Yt u~ ~,~ ~~ ~ Parcel ID # Page ~ of ~_ Boring # ~ Boring [~ pit Ground surface elev. O • SU ft. Depth to limiting factor ~ z ~ in. Soil lication Rate Horizon Depth Dominant Cobr Redox Description Texture Structure Consistence Boundary Raots GP O/tf in. Munsell Qu. Sz. Cont Cobr Gr_ Sz. Sh. 'Eff#1 'Eff#2 /~l ~a. - mS ~s ( - ~~ ~z ._____ n Boring # ~ Boring U U Pit ~rouna surface e~ev. r(. uep(n w nmia~y cac:tu' '~~- Soil lication Rate Horizon Depth Dominant Cobr Redox Description Texture Structure Consistence Boundary Roots GP D/fi? in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ~)~ # ~ Boring Pit Ground surface elev. R Depth to linfiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP Dlft? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eft#2 'Effluent #1 =GODS > 30 < 220 mg/L and TS5 >30 < 150 mg/L ' Effluent #2 =GODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employec. If you need assistance to access services or need material in an alternate format, please contact the department at 608-2G6-3151 or TTY 608-264-8777. 58D-f330 (R 07/W ) wlsconsin Depacement of Commeroa - SOIL EVALUATION REPORT Division of safety end Buik4ings Page I of m rx~e vnot wrmn ~, rns. ream. ~ ~ ' 81/2 l Pl st n 5 trot x ess than Attach complete site plan on pier not a mu srze. include, but trot limited to: vertir~ll and horizontal ref p 4l3AAy; di~ectior- and Padoel I.D.. . percent slope, scale or dimensions north arrow, and d~aciine'io nearest road. ~y Y by Date Personal inronnation you provide may be used dory Law, s. ~6.b4 (1) (m)). , ~~tti 1 `~ I S Q Property A+Nrter ~ ---, ~ jj 1 P~~ ~~~ V - ~ ~ . 1 ~ ? , ~~~~ Govt: got ,(j~.~3 114 ,U~ 114 S ZS T Z ~ N R jcj' E (or Praperiy Owner's Mai~g Address .-''. CO+ N7,t, ~ Block # Subd. Name ~ CSMtI ~ lv ~ Z• ~ s'{• i ~ ~ WG~ fin` `., OFFICE '`~ ~ G t ~ State Zlp Code . City : ~ . City ^ Village I~ Tawn Neauest Road _ f _ sTt ~ ~ Wa.~tt^ ~ h.. ~'Sr0 ~Z ( ~ ~- ~ I .r , v S ~ .•n rt ~ aP ® New Conshuction tlse: ® Rat / Number of bedrooms 3 _ y~ Code derived der~ign flow rate ~SQ ~~ O d GPD ^ Replacement ^ Put>Ac or oommerral -Describe: Parent material Ov fc~Ja-S i.. Flood Plain ~ ~ epP ~~~ - - ~ Gernetal comments S ~ S ~ r~ e. ! e iJa f.~ n -~ R ~'• $ a and recommendations: ~ L {.• e. (,e-~ a ~4-: o r - - QN-So Boring . Sys ~~ i ~•-~ ~..- ----- Boring # Pit Ground surface elev. Loo • D $. Depth to limiting factor l I C~ in. ~ Rate Horizon Depth Dominant Color Redox DasrxipQion Texture Stnldure Consstence Boundary Roots P D/ll: . in. Munsep CIu. Sz. Cont Color Gr. Sz. Sh. 'EtilR1 •E{f#2 l o -~ io 1 s~~ Z ~ tvF • 5 - g z ~ -l4 ~ ~~+ Sick Zmsbk rn~r' ~ 3 - • ~-l . Co 3 _ ig rrv t o ~ 41(.0 --, ~ m s l ~ _ 1 (. Z S ~. ~, Z Boring # ~ Boring ®Pit Ground surface elev. • YG ft. Depth to limiting fador ~ ~ 3 in. ~ Rate Horizon Depth Dominant Cobr Redox Description Texture Structure Consisbenoe Boundary Roots GP D!!~ in. Mansell Qu. Sz. Cant. Color Gr. Sz. Sh. _ 'EtT#1 'Etf#2 l o -8 Io 13 ._ - -ti Z cbk r~~ cs } ~ t . 5 . g 2 $ .. ~ . p ~ 14 ~ Si t l 2 rn5bk r,~~ c s - -! . ~ , to r l3 l Q - (I(0 _r~ . ,. ` rr~ a 5 Yr1 ~ '- -7 _ ! { t- Z. ~ Ettiileflt #1 = BOD_ ~ ~ < 220 moll and TSS ~~ < 1 50 ttwiL ' Efliu@nt #2 - BOD . < ~ rrx~IL and TSS ~ .~ mQ~ CST Name (Please.Print) Signature C~I't'' 14~1~w~ ~~ ~^~~ww~.k ~r~ ~~~i~~ ~ ~ 2s 33oq Adder Date Evaluation Conduc~eed Telephone Number !I Z I I ~ ~~' ~'. r~r»Pr~"~ [.yl S~f~ZS ~ -~ ~ -7 r 5 -Zy ~~~IaoFS Property Owner f~.Y' ~~ ~ ~, Patoel tp # Page '~ ~~ ^ Pit Ground surface elev. 9~ft. Depth to limiting factor l ZC~ in. Soil ication Rate ~~ # U ~~ Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIfEt in. Mansell Qu. Sz. Cont. Clot Gr. Sz. Sh: "Et?##1 •Eff#2 I b-12 to ~r31 sal ~ cs . lv~ - ~ -~ . Z r 2- ~f B ~ y l `_._. I s k c5 _ ~ ~ Bonng # ~ ~~ ^ Pit Ground surface elev. ft. Depth to limiting tailor in. ~ ication ~~ Horizon th De Dominant Color Redox Descxiptbn Texture Structure Consistence Boundary Roots GP D/fi? p in. Mansell tZu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 "Et'f#2 ~~ # ^ Bonng ^ Pit Ground surface elev. R .Depth to limiting factor in. Soil icatbn Rate Horizon Depth Dominant Cob Redox Description Texture Structure Consistence Boundary Roots GPWff in. Munseti Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'Eff#'I *Eff#2 • Effluent #1 = BODE > 30 < 220 mg/t_ and TSS >30 <_ 150 mg/L ` Effluent #2 = BODS < 30 mglL and. TSS _< 30 mglt. 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 departmerrt at 6d8-266-3151 or TTY 60&264-8777. S9D-83301807/00) ~~ SCALE: 1 = BM I ELEVATION (C9U • o BM 1 DESCRIPTION ~ D o~ Z~~~ P; Pe BM 2 ELEVATION ~ `~ • `~ ~ BM 2 DESCRIPTION ~fa n o .~ ~ " +0 v L ~=P c SYSTEM ELEVATION 9' S• So PAGE ~ OF~_ NAME 14 r K -e- ! , LOT# ( LEGAL DESCRIPTION n1 v,~'/<,cr~'/< S 3 sT zq ,N,R ! al E (or)~ ~, (.~ ALTERNATE ELEVATION ~y g~ I CONTOUR ELEVATION 94. ay , (ov . ~ r Cpl • O 'ar6~('V gSSu w,~d --1~Gw u ~~1, ~z~~ do c.c:~. ~.y~ .~ ~~ ~t - s.e~_ ~Ia {~ ~~ • 1~5~ ~~ 0 -~ 8 5' I ~~~ ~~~ Q~ p~X ~ ~JZ way I (9 O ~e r- ~ ~ Co r rt,G VS ~~~ ~k . M° `~ i2D ~Q'pCJ (~.v. Z b' \~ ~m1 ~ ~~ QUO. d ~~~,AI L a~ S k a p-e ~i ~ s~ i ~ pow.. SIGNATURE r---~ ~~ DATE G - s - o PAGE .3 OF~ t~, I NAME 1Y1~n e~us ~,~T I~wv~ LOT# / LEGAL DESCRIPTION /I/L.! ~ Nw i4 ,S L S~T L~' N R I ~ E(QrX~ SCALE: 1"= ~O ~ ,~` U 1 BM 1 ELEVATION /aG- o BM 1 DESCRIPTION 't- o ~ , ~ ~ ~~ -~ I3o~ BM 2 ELEVATION - BM 2 DESCRIPTION ~ C . ~ S SYSTEM ELEVATION ~ ~ q~R,~,~ y Lo.,, p r 9~, G G ALTERNATE ELEVATION ~ ~S, (D d CONTOUR ELEVATION jU/, Sv ~- /QO. ~ n .: Z~ °% ~- SIGNATURE -~~_ z --_--- DATE / `~~~- o T~ PSG E --~ ~ F '~ SC' ~'~ i ~~ . a ~ ~y ~ m g~ ~ ~ a _~ ~~ 3 ~~ ~~ ~ ~ ~~ m !~.. r g~ ~ ~ m ~ ~. ~~ ~' $ ~ ~~~ ~ z • ~~ ~ c~ A y w .~! ~~ ??$ iX . ~ ~~ ~ ~ ~, (off nr' Y ~ ^ ~/'~~ s . " ~m ~ a t r- ~ k m '~ _ ~ ~~ ~~ ~m ~.i N ~I ~ ~' C? ~~~ ~~ i ~ ~' ~i W ~ -~ . ~ °: a i t M '. .. . • • • • ~J` Ito QC C ~ ~ ~ ~ C A //~ Wf ~ ` tG ~ ~ `• T ~. ~ ~ ? ~ ~ ~ Q ~ ~ ~o ~ ~~ 1 O y ?`~ aui ~Q~~ ~ ~ •~ ~ °~ c ~ ~:~3a ~^ . ~~~~ • ~ ~ ~~ _ m ~ ~ m v 4 Z a ~" Vs.w'n ~ ~ ~~ ~ ~ ~ ~Il . `` ~, o c~ ".~` ~ ~'~°~ .._ _ . Invert ~ t'-~-~ ~t ~ ^ V Fa n; ~. .f ~.: .... ~ N Private Onslte Wastewater Treatment System Management Plan Septic Tank And Gravity In-Ground .Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWYS) shalt include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the canditians of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In-Ground Soli Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- s,~.~e ,. c.,@+aw. nneinn Seecifications 1 QM1~ 1 . v vro.1• r Sancta Permit Number -- ~ Number of Bedrooms Desi n Flow -Peak { pd} ~ °~ Estimated Flow -Aver a pd} ~ Septic Tank Capaci (ai} Soli Absorption Com onent Size ( ) Type of Wastewater - Do estic ~r~4.ew ~. ~..:~ e~,enrl~tGnn [*_nr~nnnnant . LlmitS of Reliable Operation `~ Se tic Tank Component Sail Absor lion Component Desi n Fiow -Peak d} 2.Sa ` °jd `ks Maximum Influent Particle Size (in t ~$ Maximum BODE (m /L} 220 Maximum TSS {mg/L 150 TwL~lw ?• ^~.~~r1+An'nP0 Qfi~1AC,ll~e 1 RYIO J. I~IO1u rp11w.r+. --- - Ss tic Tank Ins ect andbr service once every 3 ears Outlet Filter Inspect once a ear and clean at least once every 3 ears eve 3 ears Soil Absorption Com onent Ins ect once Y Septic Tartk_ The septic tank shall be maintained by an individual certified to service septic tanks under s. 284.48, Stets. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the sept' and outlet filter shah be assessed at least once every 3 years by inspection. The outlet filte shalt be cleaned as necessa to ensure proper operation. The filter cartridge should not be removed un ess provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. if the Management plan for a Septic Tank and So+ Adsorption Compartien# .-,... ' ' filter is equipped with an alarmf the filter ehali be serviced if the alarm is activated xntinuously. intermitt®nt filter simrms may indicate surge flows or an impending continuous alarm. The septic tank shall have Its cantente removed when the volume of scum end sludge In the tank axoaeds 113 the liquid volume of the tank. (f the contents of the tank are net removed at the time of an aa:essment, maintenance peroonnei shall advise the owner of when the next servsCe needs to be performed to mrintaln less than maximum scum and sludge aa~muiatlan in the tank. Manhole risfiars, access risers and covers should be inspected for water tightness and saundneaa. Actress openings Wed for service end asasssmant shall ba sealed watertight open the completion of ser'vioe. Any opening deemed unsound, defective, or subs to faipNe must be replaced. ,Exposed access opanin~ greeter than 8-inches in diameter shall be secured by an eftsc~ve loakin8 device to prevent eoadental or uneuthorUted entry into the tank. No one ah~ttld enter a septic or ofher trwbnent or holdfn~ tank for asy season wltloaut hslnQ !n tut! comp!lutt» w!!#~h OSHA s~ls~ndtrda ku' ariatin~ a carl~-ned space. The ~lJrrosphenr within the ar other trwttl~nt of ho~dln~ htnk niay ~taln Mth~t/ EassR arn+- ~scr~e of a pantan fk~ the InMrlar of the tnrfk may be dllMh~Crlt a Impoaatbh. Tank abendonmsn# shall be in accardana with Comm 83.33, Wis. Adm. Code when the tank is no monger used as a POWT8 companertt, The soil absorption component serving this atructuro is designed to accept domestic wasteswat®r from a nssidantiai faCiifty. The limits of gperation of the component are shown in Table 2, The bngevlty of a sell absorption a~omponent de~psnds grea#fy an proper and timely maintenance, anal system use within or belew the limits of reliable operation, c3aod water cartsecvation practices by ail acxupanta and the insta~at-on of water c~nserving plumbing fixturee ors key fat~ors Ira extending the useful life of tfiia component. The soft absorption component's aperadon must be assessed by inspection et least once every three years. The inspeafan shaft include nxrording the hveta of pending. if any, in the observadom pipes, and a visual inepeation for any evidence of surface seepage ar discharge Pram the component. ©n steeply sloping sites, areas of erasion should ~ identified and reported to tt~ owner for ropsir. The surface discharge of domsstla wastewater or sewage from the system Is prohibited and considered a human health hazard, Traffic around ar over the soil absorption component ahauid be avoided particularly during winter menthe, The compaction or removal of anew cover aver the component may lead to hydreulfc failure by freezing. This type of luilure is usually temporary, but is difficult or irnpos~fble to repair until weather canditiarts improve. !n genera}, sail oornpaction over this aompanant will reduce dilfualan of oxYBsn lrtto the soil and dispereai cell, which may feed tc chore Intense, and earlier, organic closging of the soil. Management Plan for a Septic Tank and Soii Absorption Component l~iar-tings of tleep-rooted trees end siuubs directly aver of wEthin ten het of t}^re campor~ent should be avoided since root intrusion into the component may obstruct wastewater ftaw. Gontingancy Plan In the event of system failure, a new system could be Installed in an altsmate area. With the installation of a diverter valve, the existing system could also be reused attar a period of three to bur years. It ii the property owner's t198ponsibiilty t0 malntein the aitemate area free fhOm any planting of trees, shrubs, etc. In case of failure of the original system, the aitemata area wait be needed. K any trees, shrubs, etc. Nava been planted on ttw aitemate area, ~y wit{ hew to be removed at Ply oWmwrs ~. If alternate area is destroyed, there aro other altemstlw systems that an be used, in whim, could resuh in added expense to the property ownar• Any ink abandonment shall be done in accordance with Wisc. Gods 83.33• Any questions rsparding this cads, Please contact your local Zoning oxio. ar contact the Installing plumber. .~G®N L nt c~ 'dam rc,~. ~'I i S~ 3 $ L, - µ to g, 4 ~ ck~ u..~ a-k+~~c, t~ l v„ eY,1~ - tv c,~ (Z r; S~ 3 `b ~ ~ 3 ! a 1 ST CROYX COUNTY • SEPTIC TANK MAINTENANCE AGREENiBNT • AND OWNERSHIP CERTIFICATION FORM ~h-Gf'.. ~~~. ~c..~ Owner/Buyer ~~-~~U~- ``~"~"~S Mailing Address Property Address "~ ~ 2 ~~--~~(~ ~~ ~S ~ ~- (Verificationrequired from Planning Deparurtent for new construction) Dz o - r3~'s-~ B r -vim City/State Parcel Identification Number ~`~' z9• l~. 2320 ~r.GAL DESCRIPTION Pro erty Location ~~ I/a. 'M`~ '/,, Sec• 2`~T~N-R ~~ W, Town of `'~S~ P Subdivision ~~ 1 ~ ~ ~s .Lot # Certified Survey Map # , Voltune Page # ~ ~'~ Warranty Deed # ~ y ~ Cl o ~ .Volume 4 ~ Z Page # 02 g C> a9 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 beadle wastes. Proper maintenance ooasists 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 flte septic tank as a treatraeat stage is 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 master Plumber, joumcyraan ph~mbe~ restricted plumber or a licensed pumper verifying that (1) the an-site wastewater disposal system is in proper operating condition and/or (2) aRex 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 Dcpartmeat of Natural Reno State of Wisconsin. Certification stating that your septic system bas been maintain must be Ieted and rettuned to the St oix County Zoning O#'Fice within 30 days of the thre expiration date. l`. ~d ~, . ~~ ~ ~(~~ O l ~- ,/ ~~ " DATE SIaNA O CANT G~~yy'I'~~~ ~~% OW1VFIt CERTIFICATION I (we) c 'fy that alI statcmenu on this form are true to th,e best of my (our) knowledge- operty desc 'bc abov vicwe of a warranty deed recorded in Register of Deeds Office. SIGNATURE L I (we) am (are) the owner(s) of //$~O/ DATE *. «««« Any information that is mis-scpresented may result in the sanitary permit being revoked by the Zoning Department. * ««*«« «' Include with this applicattoa: a stamped warranty decd from the Register of Deeds office a copy of the certified survey asap if reference is made in the warranty decd JAN-18-2002 07 34 P.02ig2 S'r' CROI~ COYJNTY' • SAC TAI1I~ MAIN~'BNAt~C~3 ~4.G~38M~.3NT ,AND CWNSRSHiP C~tTIFYCA'Y'TON FORM Qwnes'Buyer ~~ ~ ~~ [f/jB~IA$ a~ildL~SS Prap~ty ,A,dclress ~~~~ Sr' `r*' (Verification req ' d from Plamia~ Dcpam~sent far acw oz~ - -39~5- o~ -ovv ,C:itylState ~/~ dSa .,y, ~aJ ~' _ Aaxcel Idantifiaa~cn Number ~.. ZS`,2q . ~ 9. 23gS pr~partY n ,~~ Y4, ~'l., Soc. ?~ • T ~9.,~'1.g~W, Tavvn a~,~~` '® ~. vi~oa E' c Ccrlifie~ Snrnry ~P ~ ._.,._, _ . Valunae Fage # ~NatY~nly need # .~ 'V'aluxa~e Page # - Span heroes ~ yes ^ no I,,at lines identi$ab1C ~'y~ ^ no aaa tcpd mai~ttenaaeaof yaut c syst~n c~at:ld ~ocsu[t 9a its pre~t~ae fa3Eara to bandlc wasoes. Ptop~c msituea '°~ ~ needadby s 8crased pumper. RJ'6at yeu pnt iaW t'Sa sync of pppopisi~ art the aeptitc tank avcxy' tbscc yaars err soq~s, ass. affoct t3see of tie =apttc task as a 's3 aty{C in ~ testa dispo~ t~talsat. s txttiPicaticn f~ aigaed h7 ~ aa~aes and by a 'L7~ ~ Dwyer agtaes to avbwit to St Cxoiic Zoezsp Dq tbst 1 }°s°p~'IIp~ctF~rsc~dpismbararalieca-sedp:amp~' I) ~ ~ ~~' ~ is > c°sditic+n snd/at (Z) slber i~paati+an. asd pustPiflg (~ aecessati5~). ~ s~ live xead the abava xoquuame~ookS sad. sguo to ~tsu- tt+e p~ta ~~ ~°~~ syat~ ~ ~fwa, das aad~sigaad t of Cam ssd the D~Partmsnt of Natsaal. Ps+ S"tata af'G~Yis- sat farcl~ ~~ ~ ~ ~-' ~ ~d must bo coanp aad rttts:aad to the S't. Croy Couaty 7on~uC lea withia 30 a 19aae yon ~~ ~ ~ ~ mcpustt°~r. , d DA's SiONA. n'tx~'nTtc't~ t''~,~CATfL~N banwiadge- X (wa) am (ara) tbs ovmes{s) of I (war.) a ebat xli s as this foz~a are tcua to tk+e~ of myof Deady Office. ~, abav vistua of a vaartessty did. r~mcandcd Rego _I ~ ~ ~~ v~ L-A't'8 5It31~CI[JttB *°~*a~'• Ar~Y inforanstian 4~at is mis-rcptrsanted may resuk is the aaaitarY Parmit b°''xg rCVnfcdd by the Zoning neptixc~mcn~' "' *r,~ *• Iwetuda with t~ apg~erEioa; a :taacypod warranty dead fc+aza~ ~~ m. ~ ~,anq- doed s SPY of the ca~ad snrvcy P TOTAL P.02 FROM : Schumaker Plumbinq Owner/Buyer Mailing Address Property Address ° 2 (Vezification FAX N0. 7153863121 Jan. 18 2002 10:33AM P1 ST CROTX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND - (, OWNERSHIP CERTIFICATION FORM ~-' ;w ~r,,,~:~ IhG.~ ~ ~~~ CitylState ~~y ~ So v~ EGAL DESCRIPTION Planning Dcpararient for new construction) Identification Number 2 S• 2 ~ - ~ ~ ~'`~ Property Location .~~ '/a, 1~ `'`) `/,, Sec. ~ T 2~ N-R~_W, Town of -~-~'v d Sd ~ _; Subdivision S" P,~V~~`~.- ~"~ l\ 5 .Lot # ,~._.• Certified Survey Map # , 'Voltune Page # a ~-~ Warranty Deed # ~ ~/ ~ ~ G ~ ,Volume / 4 ~' 2 .Page # ~ ~ ~ a~ 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. Propez maintenance ooosists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can atI'cct the function of the septic tank as a treatment stage is 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 master plumber, joumeynran plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is iA proper operating condition aadlor (2) after inspoctioa and Bumping (if necessary), the septic tank is less than 1/3 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 Dcpartmerrt of Natural Resources, Stato of Wisconsin. Corti.cation stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office wrthra 30 days of the thre expiration date. ~(~~~~ SIaNA O CANT DATE OWNFIt CERTIFICATION I (we) c that all statements on this form are true to the best of my (our) lonowiedge. I (we) am (aze) the owner(s) of operty desc 'bc above, virnie of a warranty deed recorded in Register of Deeds Office. ~ / S~ G / SIGNATURE L DATE Any information that is mis-roprescnted may result in the sanitary permit being revoked by the Zoning Department. '~"'`*"'` ~•.«r~« ~' Include with this apglicat[on: a stamped warranty decd from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty doad • 1 ~ a'L r r-c~-~'~ ~cc~ OZo ~ t D6q - '"70 -- oo v Pamei Identi5cation Nmnbet (PIId) p'Z o - I ~6`I -~a - vw C~ zv - 1 ago - coo - ~o 020 - to7o ~ ~~ -nao U 20 - - ) o -76 - zo -~ "THIS PAGE IS PART OF THIS LEGAL DOCIIMENT - DO NOT REMOQE" ~~:~ 1662Pacr 289 Es4860~4 KATHLEEN H. WALSH f~EGISTEFt OF DEEDS ST. CFiGIX CO., WI RECEIVED FOR RECORD 06-18-2001 12:45 PM WARRANTY DEED EXEMPT # CERT COPY FEE: COPY FEE: TRANSFEk FEE: 9944.04 RECORDING FEE: 14.04 PAGES: 3 Recording Area ' ~ i Name and Retrun Adtltrss lVc~ ~r-~~fk-bn ~ MN S~tlz 'Chit iafotaution onutt'be completed by tubtaitta: doctanott ttt4, mm~e ~c rcturn adders. and P!N (tf ngdredJ. Otktr irtforntation suck as tkc jrmttint clauses, kcal tlcsetipdon, cte. tray be placed on tkis~Grst pace of nc~ doetonent oror may be placed on additional padts of tke doctancnt oa: Usc of tkLr cmr pagc adds anc paSc to your doetot~ctK mid S2. ~p to rke ncorr!iiit tcc. Wiscoruin Statute:, S9.S11. WRDA 2A6 + i DOGUMc.NT N`J. ~.waAt.~T'i Dim ' ~_ ,`^~j; ~ STATE OF WISCONSIN-FORM 9 `y •. ~(l I- ,~ V 6~i P„~f F-~/~J~~ _ '~ TNI6 SPACE RESERVED FOR RBCORDINO DATA I, ~ Ii i - __. _. RICHARD N. PEARSON and JEAN M. 'I THIS INDENTURE, Made bY .................................................. .................................. PEARSON, husband and wife, rantor.s.. of._.St. Croix Count Wisconsln g~ y ...__....~ .............•--CARRIAGE HOMES XXI , INC .. a......... ' h rebY conve s and war ants to .................................................... . . . Minnesota corporation, --• ................................. ---------------------------------•--------•-----------------------------•------.._..----------......------•--•----•--........----...._...... ~i Wash-ington ••-----•-•--•---•----•--•-•-•---••--•------•--•-••--• -•-•-•------ ..~ p rautee_...---- of ~' -------- ::...................................................................County, ~fB~2S~2i~~or the sum of" One--Dollar.--and--no1100----(1.00)__and--other good_-and valuable FETURN Toil. ., ( 7~f~~ .....-•-----•-•-- ---• c ~ S. 1 ~ r ~- ~u ~~c l~ . ~°nsideraton- --------- --------- --------- ----------------•----------------- --__-..__...---. ~zro~y~l3 / ~ z 5 UC ~ the following tract of land in__.St-..._~rOix---- County 5S//2. Wisconsin: .All-.of--the-•-IVorthwest_-Quarter---~NWA)_-_•and-,North.-Half (N ~) of the Southwest Quarter (Sh114) of Section Twenty-Five (25), Township Twenty~Nine (29) North, Range Nineteen (19) West, St. Croix County, Wisconsin, except Lpt One of Certified Survey Map filed June 29, 1994, recorded in Volume 10, Page 2782, St. Croix County Register of Deeds, as Document No. 518444. See Attached Exhibit A Parcel Identification Number This is not homestead property In Witness Whereof the said grantor. S._ haVe....., hereunto set._.......their.•••-.,.--, hand.5... and seals.... this ---••------• ................ day of--- ~a~'-•----•-------....--------............., A. D., ~~..2RQ1 .. ........................ ..._..........._...._......_........._....................... (SEAL) SION'E.D AND SEALED IN PRESENCE OI' ... .............•_.._..__.. (SEAL) --• -- ••- -.•-.P~A_ n ~ .:::~'.:V...~:~.Y..~...- ..............(SEAL) ~~ V ~' - .............................................................................................. (SEAL) State of ~ta Washington ~n„nty ~ Permnally rame before me- this_~~:::~`.`. day of...~` ~ ............... A. D., ?~..200~- M . ~ .. 1662 Paf~G 291 yni EXHIBIT A Parcel Identification Numbers 020-1069-70-000 020-1069-80-000 020-1069-90-000 020-1070-00-000 020-1070-10-000 020-1070-20-000 BEARINGS ARE REFERENCED TO THE WEST LINE OF THE NW1/4 OF SECTION 25, ASSUMED TO BEAR S00°00'44"E. m _ i ~ 9 9 z ~ ~ EE I ~G~.~dd 4 _° ~ C~4 ~ ~,~~o WEST LINE OFTHE NW1/4 --------~ _ .~_N ~ ~~ Q - - ~ _ -- Q ~ ~ `\~ rn N ~ \\ ~ ~ ~~ ~ \ O soo~osbiNw \~~~ _25' ~ ~~ pro ~7 _. ~.__. •--•--• ~ ~\O 1 ~~, \~~ I ~ \\C/V/ 66' I '~, ~ ~ ~~ ~ ~~ ~~~p ~ ~ N o i~ ~ ~ ~ ~. m N N D~ ~ W ~ p,~ n ~ ~ Q --~ ~ ~~ ~~ ,Z ~ I i ~ ~ w i ~P soa°s~~~w ~~.so' ~ ~o j .i' ~ • ~s~ ~~ / ~•' J N ~ J _ ~~~ 1 n ~ p ~'~''~ g i ti / m f ~.~ ~. N