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HomeMy WebLinkAbout020-1395-17-000~~ Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buitding Division ' INSPECTION REPORT GENERAL INFC¢1RMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.~4 (1)(m)]. 'ermit Holder's Name: City Village X Township Carria a Homes Inc. Hudson Townshi :ST BM Elev: Insp. BM Elev: BM Description: ` ~~ ~ t t~fl . ;J I ~et.t ~ ~ S 'ANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY Septic ~C ~ J 2~ Dosing ,~ ~~ Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ ~ rl J ~~ ! Z ~ ~ ~_ Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer 6-~•tl~(X ~ ~ errand ~ Model Number ~PO, ( y "'( J(~ ~ .r. y TDH Lift ..'~.O Friction Lo I . o~ System Head ~--' TDH Ft .off Forcemain Length ( Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches DIMENSIONS ~ ~ .~+~.. u ~i_ \ l -. ~ county: St. Croix Sanitary Permit No: 430005 0 State Plan ID No: ~ ~_~ Parcel Tax No: 020-1395-17-000 Section/Town/Range/Map No: 25.29.19. ~ STATION BS HI FS ELEV. B nchmark ~ n,/iSTo~nS ~ ~ ~. ~ ~~'~ Alt. BM ~_ Bldg. SeAwer~ -- ~n1 l~-~*~c.~ ~ ~ ~/ ( I St/Ht Inlet . 3 ~ $9.10 SUHt Outlet Dt Inlet Dt Bottom • rr ~`` Sp/ Header/Man. 8 (o p l~•~ Dist. Pipe (~. 9/. ya ~ . g(o ~ Bot. System Q, ~ 1 b • (o S r •gb Final Grade I c+w. •{- Z~ ~3 ~ ZS ~ StSt Cover PIT DIMENSIONS INo. Of Pits Inside Dia. (Liquid SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING M~pyfactpr~r: ~ _~ INFORMATION CHAMBER OR v~hltTr~tN Type Of System: t 1 I `_~ UNIT ~v• 'S + ~Q ~' Model Number: (~ l~ DISTRIBUTION SYSTEM k~E`e!- P/4) Header/ anifold l~ ~ Distribution Pipe( x Hole Size x Hole S Vent to Air Intake 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 Bedlrrench Center Bed/Trench Edges Topsoil r~ Yes ~ ~~ No i :,:j Yes «~,~ No COMNJIENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~~%'~/~w_,3 Inspection #2: Locat'on: 829 Prairie Meadows Dr Hudson, WI 54016 (NE 1/4 NW 1/4 25 T29N R19W)lSceni Hill of 7 / rcel No: .19. 1.) Alt BM Description = N~f{' ~/ ~~ ~ _ ~ C~ ~~ 2.) Bldg sewer length = 30 - amount of cgver = /8 'r~-~ `N - _ A' „ `~ 3~ n ~~ ~~s . 0~5drJt~a. ~tK~"~~'0 S~•IiAtdJ Un0 Plan revision Required? Yes `, I No i~~ ~`~ I~ ., Use other side for additional information. __-_J~ _ t I ___ i ~_ ~- SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. Safety and Buildings Division County A~-~ o „ 201 W. Washington Ave., P.O. Box 7162 ~~r~y~ ; ' X r~~~®~„S,n Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) De artment of Commerce (~8) 266-3151 t/30005 Sanitary Permit Application state Plan LD. Number i In accord with Comm 83.21, Wis. Adm. Code, personal information you provide I I may be usod for secondary purposes Privacy Law, s)5.04(1)(m) Project Address (if different than mailing address) I. Application Information -Please Print All ](nPormatio p i Property Owner's Na me 1 ~ i ~f.~ fG~C ~ G ~'~J~ :~~. i r~ n ,~ i Parcel J/ C,o J/ ~f Block A~ Property Owner's ailing Address Property Location / CO s~` City, State ~ ' Section ~ `~ ~'ti Zip Code ~~ , !l/ Y t° ~ .!~ ~' S~ 2 ~~ 6 .... ,r?%~~/~ circle ) II. Type of Building (check all that apply) T ~~ N; R~E o W~' ~l or 2 Family Dwelling -Number of Bedrooms _~ ~ Subdivision Name CSM Number _^.Public/Commercial -Describe Use ~ ~ ~~e~ ~ ~~ J~S. _ J State Owned -Describe Use , ~~City_^Viliageownship of III, Type of Permit: (Check only one box on line A. Complete line B if applicable) ~A D2p - S- ~~' ~D Z`f // i ^ New System ^ Replacement System ^ Treatment/Holding Tank Replacement Unly ~- _ _ B • ^ Permit Renewal Permit Revision ^ Change of^~-[~ PertYtir Transfer to New ^ Other Modification to Existing System List Previous Permit Number and Date Issued Before Expiration Plumber Owner _ IV. T e of POWTS S 'stem: (Check all that apply) ~{3ooro 5- s/z~-~3 Nan -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ A[-Grade ^ Single Pass Sand Filter '~ ~ ^ Constructed Wetland ^ Pressunzed In-Ground ^ Holding Tank ^ Peat Filter ~J Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter Leaching Chamber ^ Drip Line ^ Gravel-less Pipe ^ Other (explain) V, Dis rsaUTreatment Area Information: Design Fiow (gpd) Design Soil Application Rate(gpdsfl Dispers~alyArea Required (sf) Dispersal Are P(~s (~ System ElGevation I Vi Tank Info Capacity in Towl Number Manufacturer Prefab Site Steel Fiber Plastic r s Gallons Gallons of Unit Concrete Constructed Glass New Existing Tanks Tanks f , Septic or Holding Tank X a.~D i , ~~-~,~ , Aerobic 'treatment Unit - Dosing Chamber •~ - VII, Responsibility Statement- I, the undersigned, assume responsib i lity for installation of the POWTS shown on the attached plans. _ I ' _ _ Plumber s Na me (Print) Plumber's Si gnature /MPRS Number _~ Business Phone Number -I . / ~•, ~,., s-. 4 <u ~` ~--~--.~-~ .~.~C"Y~• ~~~ • ~~~~,- as ~ 94 Plumber s Addre ss (Street, Cuy, State, Zip Code) -346-•31.2 ~~ ~ c~~/~ ~r~o~/ ~~. r S~ id~ VIIh Count JD t -' e ar ment Use Onl Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued I t ~ Agent Signature {No Stamps) Surcharge Fee) ^ Owner Given Reason for Denial ~ .--- IX. Condarinna of A...,r.,.,~troe,.~,...~ e.._ r~__._____. - ~-~!-~ ~.---........., ......woyrs vrw SYSTEM OWNER: 1 Septic tank, effluent filter and dispersal cell must all be serviced / rpalntained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances. complete plans (to the Couury only) For the system oa paper not less than 8112 x I1 inches in size ~ y~ SBD-638 (R. OX/03) ~ ~: ~y ° ° c~a ~.- ~~ e. ~',G,tiG .Zo "7~ l7 s~cv ~` ~ c~~' Cls ~w~ af' ~ds~i.,/ ' ' ~~ a,-d,oo /~ ~.~ ~° f 1 ~~~~ ,~ S' '~" ~ /'// .. ..~ G ~, s~~ed~ ,re,~.t i Si t9~v~ , ,ti ~ ~ ~~ ~~~ ~ ~ r ~ ~~~ ~ ~,, ~L ~ ~~~ ~~ ~'~ A~ ,~w d ~$ ~r 0 ~ I ~'~~~ ~~ /~~ ~1~~ Wisconsin Department of Commerce Divisbrt of Safety and Bufldings SOIL EVALUATION REPORT Page ~ of ~_ m accoroance vvrrrt wmm oa, vns. ream. ~.ooe in ize Pl n ust 11 i h fi 1/2 County ~ /• . ~ C. . nc es s a m an 8 x Attach complete site plan on paper not less t include, but not limited to: vertigl and horfzontai reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. parcel ID. Please print aff fnformatfort. Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Re ' ed by Date ~ I I~ Property Owner ~q ~.~ ~~~ ~~~ Property Location Govt Lot ti F 1/4Z/(nJ 1/4 S 2ST Z N R ~ E (or tM1~ Property Owner's ailing Address CP z o -~ ~" 1(w~r ,t3~ ~ Lot # 1 ~-~ Block # Subd. Name or CSM# ~` (' ~~ e ~ r ~-- City State Zip Code Phone Number ^ City ^ Vllage ®Town Nearest Road [~ New ConsVudion Use: ~ Residential / Number of bedrooms _~ _ Code derived design flow rate ~D (1 ~ _ GPD ^ Replacement ^ Pubfic or commeroial -Describe: _ __ -__ Parent material __ d U ~_ a S (~~ ______ _ Flood Plain elevation if applicable __ General comments S ys~-C rYt ~ ~ ~ v ~ ~ n 90~ (~~J - G-aw Gir `j Oro 4 and recommendations: f' oc; + 1 s zoo3 ' a Boring _ ZONING OFf=1CE Boring # G o d ~ 2 pit Ground surface elev. l S ~ ft. Depth to limiting factor _ In• So8 lication Rate fior¢on Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/Ff= in. Munself Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'Eff#1 ! 'Eff#2 Q I ~~ ( I ( y-~ 0.95 .6 ~s ~ Boring # ~ Boring pit Ground surface elev.~iz~ _ ft. Depth to limiting factor-~F-~- in. - Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIit= in. Mansell Qu. Sz. Cont Cobr Gr. Sz. Sh. ~ 'Eff#1 ~ 'Eff#2 o~~ fo / -- L Z .s~ Yh f , ~S 1v~ r ~ ii, 2 Z ~ l- ~ t~ ~U - a s m l I- - r~ ' lr ~ ~ I Effluent k1 = BODS> 30 < 220 mg(L and TSS >30 < 150 mg/L 'Effluent #2 = BOD, < 30 mg1L and TSS < 30 mg/L CST Name (Please Printy ~ Signature ~,. CST Number ~u ay'~ ~c. Gtvof-rtc ~ ~ i ,,,~ °"~ ~~:,~<~~ zS3.3 09 .. ,~~ Address Date Evaluation~onduded Telephone Number ~-!1 ~ ~ SarY.c~Se-l call. ~'yOZS" lG-z -~'~ 7~_s`- 7(o~-4z~9 ~3 Property Owner _ ~G / /.~3•~db~~ Parcel ID # ~f! t' ~ i _ _ Page z of _~ Boring # ^ Boring ~ ~ 3 ®Pit Ground surface elev. ~~ ft. Horizon Depth Dominant Color Redox Description in. Munsell Qu. Sz. Cont Cobr Z 2 ~1- ~ Depth w limiting factor ~_ in. Texture Structure Consistence Boundary Roots Gr. Sz. Sh. ~ l ~ SoA A lion Rate GPDlf~ 'Eff#1 'Eff#2 ~ ~ ^ Boring # ~ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil A lication Rate tion i D d Texture Structure Consistence Boundary Roots GPD/fP Horizon Depth (n. Dominant Color Munsell p escr ox Re Du. Sz. Cant Cobr Gr. Sz Sh. 'Eff#1 'Eff#2 I I I Boring ^ Boring # Ground surface elev. ft. Depth to limiting factor _ in. ^ Pit Sod A lication Rate Horizon Depth Dominant Caior Redox Description Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Du. Sz. Cont Cobr Gr. Sz Sh. 'Eff#1 'Eff#2 4 ~ I I i I I j l i ' Effluent #1 = BODS> 30 < 220 mglL and TSS >30 < 150 mglL `Effluent #2 = BODS < 30 mg/L and TSS < 30 mgiL 7-he Department of Commerce is an equal opportunity service provider and employer. if you need assistance to access servrces or need material in an alternate format, please contact the department at 608-26b-3151 oc• TTY 608-264-8777. SBD-81J0IR.07/00) 1 PAGE ~ OF NAME; CR ~('~`~ ~.2 LOT# ~ ~- LEGAL. DESCRIPTION:Nf=1/4!Uwl/4,S~SI'7~,N,R,~E(or~ SCALE: 1"= ~U ~ M. ~; ~jM~ELEVATION: IDU ~ C7 ,~~~~ - ~ --r ~ ~, .;-,>,; ~ BM 1 DESCRIPTION: (~ rti~ ~-rn !i-~ St cf c \R ~ , BM 2 ELEVATION: ~ ~ BM Z DESCRIPTION: SYSTEM ELEVATION: ~o P 90~ KO -lbw-~.rQd._ a ~% SYSTEM TYPE: (~"CU n v -~ /~ ~I ~'u v~ of - (l~ ~c c `` 8 /~ ;. ~I {~~Z ' / SIGNATURE: ~ \ ,~.~~ ,,-~~'"'" .~.~ ,,~~~," DATE: ~~ _y ~ ~3 ~~~~°~^ TAANK ~ rL`;.,p Cr~AM~£R Ck~SS SEc~TZL'i~' Atha C?£CZFZCRTZCrs4~ .~ . a 1 ~' 4" CI VENT PIPE tit" MTN. ABOVE GRADE ~ W~ATH£iIPROf}F >_ 25' FROM DOOR, WINDOW QR JUNCTION BOX APFRCV£D FRES~i AIR INTAKE WITH CONDUIT ~INPADLOCKV~n FINISHED GP.ADE --WARNING LA3F.L ~ ~. ~ l8" . 1N. 6" MAX. ;~ i ~ •t Y ~ ~ 11 INLET }'' j ' ' ~f, + '~ _ WATER TIGHT SEALS ~ GAS` t ' ~~ ~ ~' T.GHT ~ ~ ~ ~APPROV~D A SEP.L JGINTS WIT;{ tiPPRCVEp --3--- ~ ; AiM 1~PPROVEp PIPE 'iPE 3' ~-- ~ ~' Ora 3' UNTO 3NTp 5f~LIB ~ SOS.Ip SaI~. ifllL PUMP OFF ELE'V . ~'T. --~--- ~ s DOFF ~''~ RISER EXIT D PERMITTED QP3LY IF TANK MANUFACTURER _~_ HAS APPROVAL 3" APPROVED BEDDING UNDER TANK CONCRETE FAD PECIFICATiONS SEPTIC ! DQSE TANK MANUFACTUREk: ~~'e~~~ NI;MBER DOSES PER DAY: ~ Tr'~NK SIZES: SEPTIC !o?Sd GAL. ~" DOSE 8____,__~ _.__ GAL . A i.~.RM MANUFACTURER : ~~ ~e 1 c~=rry_~?___ ~""""' MODEL NUMBER : d7~ U SWITCH TYT'E: ~~~~- _ PfIMP MANUFACTURER : ~"v_c~/.,~~" .,.,_,_ MODEL NUP~I3ER : ~~`~ SWITCH TYPE: - ~~--.,s:~-__-- RE~41iRED DISCHARGE RATE ~~1 GPM DOSE VOLUM£ IHCL'JDTNG FL©WBAGK. l ~r~/ GAL. CAPACITIES: A = ~~ INCH£a = ,-„ ~C,~__~? ___GAL. $ = Z INCHES =.GAL. C = ~ INCHES = t!'8 SAL D - ~o INCHES - _._.._GA ~ , , PUMP ~ ALARM WIRING AS PaR ILHR 16.23' WA VERTICAL DIFFERENCE BETWEEN PUMP OFF APJD DiSTRIBUT:ION PIPE l~ FEET + MINIMUM NETWORK SUPPLY PRESSURE FEET + ~_~~ FEET FGRCEMAZN ?~ ~.6C F'lip0 FT. FRICTION FACTOR ~ F'EE''-' TOTAL DYNAMIC HEAD - .~.3:.~7 FFET iNTERNAI, Di~lENSI'ONS OF PUMP TANS{: LENGTH ~~ y WIDTH ~` DIAME'"ER `-` LIQUID ~~` 3~ "~ ~r~~~/~~y l -; I G N v D : ~~6i~f -9.~a~~:~-,.~.• ---=~~, L I C E N SX,' NUMBER : ~,~ 99 E AT E : .~ cS ~ d~ •_- 1.185 ~,~ t • ~aStBRerS: 3ti0 Series stainless steal. • Capable of running dry without damage to companents. Mater: • EP04 Single phase: O.Q ttiz, t i 5 or 230 V, GO Hr,155g RPM, built in overload with automatic resat • EP05 Single phase: 0,5 NP, I15 V, 80 Hz, 1550 RPM, built in overload witfi automatic reset. • Power cord:l0 foot standard length,16f3 S,tTC wi#h three prang grounding plug. Optiartal 20 foe: length, 15/3 SJ7W with three prong grounding plug ;standard an EPt35). APPii,tlCATifl~tS Speei~icaify dasign~t for th® foilowit~g uses: • E#fiuent systems . • Names • FarrRs Heavy duty sump llyater txansfer • pewatering S1'Ef;i~tCATt01fS Pomp: EP04 * Saps handling capability: 9/a' moXimUn1. • Capacitia~: up io 55 GPM. Totaf heads: uA to 2~ feet. Disatarge size: f'la" hPT. fJiechaniaal seat. carbon- ratarylcaerarnic-statlcnary, BIJNA-A! elastamers. • Temperature: 1{~4°t" (4Q°C; corttinuaus i4€i°F;6fl°G; intermittent. • Fas#eners: 300 series stainless steel. • Capable Of running dry without damage to camp~opne~nets. Primp: f~5 • Solids handling capability: Ali" malclftluffl. • Capaclt~s: up to 60 GPM. • Total heads: up to 31 feet. , • Cisc>f~arge size: #'~" (VPT. • iirlechanicat seat: cartrorr- Cflffiry~{~rarllrC'&#at9onary, i~t~i~iA-iV @i35t0~8r3. • Temperature: 10Q~F (4f3•Cy a-rttinuous i44°F tom? internlittenx. c1~j ~ 1•i~ tlauk~ Pins, Ina FILTERS FF.E'i' 10 s ao a~ ~GrJ ~ ~ z ~, s ~o 5 q t5 < m 3 1G E~y ~1UU~C~~ Submersible Effluent Pump ~~~ 3871 EP05 ~^ * Fttiiy submerged in high QrddB turb~r!e ail for lubrication Arid efficient heat transfer. Arailahie for automatic and manaal cperetioa. Autamatis models lnalude Nllechanica! lrfoa# gwl#ah assembled and pre~t at the factory. Cr~ATtIREf; ^ EPfJ4 impelier~ Th~rmo- plastic Semi-open design with p;rmp aut vanes far mechanical seal protection. ^ 5P05 Impeller: Therma- piastic enclosieddesign far improved performance. r Casing and tee; Rugged thermoplastic design protrides superior strength and carrostwi~ res'~tar~e. ^ Motar t~aueing: Cast iron far effscient heat transfer, strength,. and durabi~ty. ^ Mater Carter. Thermop~as- tic oaverwith integral handle and float switch attachment pants. ^ Poarer Cable: Severe duty rated ail end water resistant ^ Gearfngs: Upper and lower heavy duty bail bearing construction. Ar~~t1CY 1!S'i'ING Cant<dien 8t~atds RssoclaiPan (CSA iistied model numbers end In "F" ar "AC".) I ~ { i . ~ i ~ »...~ i ( ~ ~ T i ~ l j it .._._ i _____.~ f l ~ ~ ~ l _ _ ~ ~ ~ ; C ~ n (SOLI ~~ 20 3U Au av urm Q ~ ~ 8 8. :10 t~~ Ri'rh CAFJICRY , ~.,~ ~< ~; . .. ~4ia~tive ~ay,14p5 Wisconsin Department of Commerce. ; PRIVATE SEWAGE SYSTEM Safety and Building Division ° INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: Carria a Homes Inc. City Village X Township Hudson Townshi CST BM Elev: Insp. BM Elev: BM Description: TANK IN FORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA county: St. Croix Sanitary Permit No: 430005 0 State Plan ID No Parcel Tax No: 020-1395-17-000 SectionlTOwn/Range/Map No: 25.29.19.2411 STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer SUHt Inlet SUHt Outlet Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Fina! Grade St Cover BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems ~nlv xx Mound Or At-Grade Systems ~nlv Depth Over Depth Over xx Depth of xx 5eeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes ~~ No i I Yes ', No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / /_ Location: 829 Prairie Meadows Dr Hudson, WI 54016 (NE 1/4 NW 1/4 25 T29N R19W) Scenic Hills Lot 17 Parcel No: 25.29.19.2411 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Plan revision Required? [J Yes ~ No Use other side for additional information. _. _. C_ L- -- SBD-6710 (R.3197) Date Insepctor's Signature Cert. No. fr= y .• ~a.,.t ~ ansl E3u?Id:n~~ Uivi.,i~n ~ ~ _-__ _ , Caunt4 / 201 i~'. Wask,in tun Ave., P.O. Box'162 .r ~ & ~ tl ~~f''~~r~ '~'~'~On~,n ?viadison, WI 53707 - 7162 ~ ` -nary Fermit Number {to be filled in by Co.) San Department of Commt:rce ~ (608} 256-3151 L~ ©~ Sanitary P'ernlit .~.pplieati~n - Mate Plan I. .Number ~ ~ In accord with Comm 83.21, VVis. Adm. Cade, ersonal information you rovide P P d f IS 04 P _ _ __~ e -- address) t tha ili t Add f di f P (1}(m} ~ may be use or secondary purposes rivacy Law, s . ~ __._ ~ eren ng rojec ess (t . n~~:Hnna / ~ ~"'~ ~°~ ~ ~~~ I. Application Information -Please Print Alt Informatian 7 l _ _ _ Property Owner's Na me ~ ` ~ mo ~hbJ Parcel 11 Block l/ /7 ~~ s __ _ _ __ m ~. A~ d. ,~ , ~ _ ~.~~._._ Property Owner's 1V't ailing Address Property Location 111 - ?,S~ STrlliJ~~ 7~-e ~~ ~ , ~~~ f , ~~ ~ Section ~ '" ~'w Y ~ , '•~ I City, State Zip Code Phene Nutrber l ~~~~( lJa t~ ~ Jn ,SSQ~ t ~~ _ _._.~_ ~ (circle o i T 82~ Iv`. R~E o>~ II. Type of Building (check all that apply) ~ S~w. ~~ or 2 FamPly Dwelling -Number of 13edroarns _~,~„~, _..__ Subdivision Name CSM Number r MAY 0 8 200' T 7 ~ f,!~ l~s' e - _ _ PubliclCammercial -Describe Use i ~ ,- ~ __,y~-~_ - ^ State Owned - Describe Use ^Cir,}' ^V' age l~ownship of t/!-tolS'0...~ ----~~1~6t~~~TY- ~ III. Type of Permit: (Check only one b n ltne A . C o m _ ^ te ' ` "~ A' ~, New System ^ Repiat;ement Systen[ ~:i Treaimei~u'Flolding Tank Repla;:ement Only ' ther Tdadificatian to Existing System 1 iti. iJ Permit Renewal 1 ^ Permit Revision ^ nge of ^ Pertrit Transfer ea N List Previou errtju be. a s Before Expiration Plumbe Owner / _ ' ~. Ty a of PUWTS S stem: (Check all that a 1 } R^ Y _ _ __ _ ~~ Nan -Pressurized ln-Ground ^ Mound > 24 in. of suitable soil ound < 24 i. of suitable soil ^ At-Grade ^ Single Pass Sand Filter i rJ Constructed Wetland ^ Pressurized In-Ground Q Hal3fng Tank ^ t Filt ^ Aerobi i c Treatment Unie ^ Recirculating Sand Filter V I ^ Recirculating Synthetic Medza Filter i Leacbirag CYtamber ~] I7ri Line Grave!-less Pipr v. I?ur ' persalJTreatment Area Information: 3 ~c 3 ~ • ~ ^ Ottaer {ex;?lain) J~ r -~7~rr7a r , _ ~ _ i-- . ~ ~ ~ Design Flow (gpd} Design Soil Application Rate(gpdst~ Dispersal Area e iced (sf} Dispersal Area Proposed f) System Elevation ~ ~ ~ ~ ~3~ y~- dd ~ , ~ ~ , ~ VI. Tank Info ~ Capacity iar Total I~ Number Manvf ct rer Gallons Gallons of Units ~ y,/ ~~~ ~~~ N E i i Prefab ~ Site ~ Steel Fiber TPlastic ~ Concrete 1 Constructed ~ Glass I ~ xis[ ew ng ~ ~ ~/ ------ Tanks T'aaks I r ` Septic or bolding Tank r,~~'1 ` ~~ ~ °~ ~,,t, rf+ ••+ ~ ~ I ~ ,,I ------- I .._. J ~ _ ~ ~ '. Aerobic 'rreatnun[ Unit ~ ~osing Chamber ~ ~ - -~- ~ ^^ ' VII. Responsibility Statement- I, the undersigne asstutte responsibility for ' allation of the POW'I'S shown an the attached plans. Plumber's Na me (Print) Plumber's gnature ~ P PRS NurnL~er ` Business Phone N~;:mber f Plumber's Addre ss (Street, City, State, Zip ode'} r - ~ Cr ,lea Sc ~"T'~ !~ /'~ ~~~ ~~ ~~ VIII ouzo /Department tise Oni~ Approved ~ __ ^ Disapproved _ Sanitary Per.ni[ Fee chides rGroundwater Surchar, a Fee) Z7iJ • DvI g Date lssu d is Agent S' not e a S /a.7~0 ~ ^ Owner Given Rea san for Denial ' _ _ onditions of AppravalJReasons fo:~ Disappra al ~ ~.,1 ~, lo'Tr •.avK- ao~- n.0-~ ruutx.. X1c.trL.t.w R. ~G„J~-t.c.v ,...~.,~,,,rc..v-.i ..,. ..__. ~. ,,..-.,i,~.~~.p. ..~--/~~~ ~ - _ - ntiu~~ wafi.,P~z,~.o~-rrn. A ate, ~.~c . Sys .~ 6.~ ~•,,'s-fi~ r~~ ems.' ~ mod- ate., aot> . ,~w rf~- r ~~'(`(~ f~(,{~y~ ~/ us ( i u t~r~ollt;±e system on papas :iut less than $112 z I i incites 'n size sBD-~3ss ~R. 0~~03) ~ Qcc~/a.~ ~~~~~`r-~ ~ ~/~~r,~ ,~1~-,`t- ~~~ Gam h~---~-~. ~( -~i}1-~- I~'~P~ ~,`,~2•• U~~~, ~'" ~2~ 03 ~ ~r ~~' // s 1 ~ ~ ~~ ~'°l~lr ~j2 ~(B 3 ~- a,~ ~~ 2 ~=~?~-~" S~.f-~?r~`- I~-~-Q (~e._ (NiS-~~-mod ~~~ / c ~~.Z~ ~s ~, ~ ~~ ~~ ~ ~~"' . ~~ ~~ N~,Q,~. ~- d,u,~.~ ~.~- ~C - ~,~-. ~~ '~`~ ~ ~' ~~~~ .~ ~~0 ,~ ~~~'~ ~ d~' ay ~a 6t s ~ n~~G a ,~a > ~ j~~ ~ ~ ~ ~ `~jo as ~~r~ ~~~~~~ 6 ~~~y Z'~xYj'r`~-!1~ ~/ y.-, ,° S~ ,f-,v G ~ t T % 7 ~<ed' ~'G 7~/-" l~s ~!~ d ~ l~ ~~c~s:-v ~.~ ~ ~ '" UG y,DG LoT ~~v v1,of ~e ~~~ ~ ~~ ~ ' U~ T ~y ~ / \ 3~° ,,~'~'° ~V ~~ ~ ~ ~ W"_ ` ~~ ~ ~' ,~ ~ ti°~~' ~ ~~ .~~ o~ ~ r~ ~3 ~d~ s ~~ ~~~(~ ~ ~~o ~ ~~ ~~ ~~. ~° ~, n ~ ~~ ~ ~3 ~,~ 0 !`~'a~j~ s, "~~ ~~ I was-~~~~~ ~ jao ~, ,, '"~ z o-,t~ -- ~~, not sG~ Kw~ ~ ~( ~a " ~~~ "~ ~ ~ ~a~'~ ~ ~s~~~L~ ~.. ~ ~~ ~~ ~~-~.,~ ~'y Qhtiu~ nub ~~~~ac,~- 0'2- sys~ a~~. ~~~y `~jo as ~~r'd ~~~~~.~ ~ <~ FROM Schur~sker P l ~arnb i nq FA}: 1 a0. 71°s~353121 '~cp. 1 ~ 2901 0~: ~55F't'I P4 sr C~a~ cauN•rx SEPTIC 'LANK MAiNTBNANCB AC}RLEMENT AND . OWNizRSHIP CERTIFICATION FARM j~~ s X~ x .~ iN QwnerlBuyar r9~?Q i~r~ Mailing Address 4 7S0 5 ~~-~ / /wK.~v ~ v J~O~, ~~ !/e~.rz~. -v~ vuh .55'©-x'.2 pfoparty Address t {Verification toquirod From Planning Department for flew ~y D~e 61Jc S C- Parcel Identification Number G ~~(r p (Xry/State 3~ - -O~S1~ dz o -/ qs~" I ~ ~ FOAL DES „ TICIl~i property Location / ~''/., ~'/•, Sec. ~2.5~ . TAN-R,~-w, Town of ~~ ~_ ~'~ Subdivision „~,S C F/y i ~~ l /.S Lot # ~ ~ .. Certified Survey Map # , Votumc .Page # Warranty Deed # ~ ~(~ Ct ©,~ .Volume , ~ ~ (2-~ Page # Spec house ^ yes ~ no Prot lines identifiable ~ yes ^ no SYS~'E1VI MAYNTENANC~ r utaintetrawce lmprorpcr use and maintenarxx of your septic system could result in its premature failure to handle wastes. Pmpe consists of pumphi$ out the :optic tank every three years or sooner. if needed by a licensed pumper. What You put into the systttn can affect the function of fhe septic tank as a treatment stage in fife wasto disposal system. 'i~u pmperty owner agues to submit to St. Croix Zoning Deparmunt a eeitiRcation form, aignfld by the owner sad by a ph,~, ~~uymarr plumber, t0edplumber ar a llcansed proaprr ~~-m8 that (i) the on-site wa:rawaterdispob~al sperm is fa proper vpcrating condition and/or (2) after aupection and puo~ing C~ necessary), ~ septic tank is less tbaa 1/3 fsr1l of sludge. ~/we, the undersigned have read the above requirements and agroe W resamtaia the private acwage disposal system with flu standards set forth, hecei4 as set by the Department of Commerce and the Departmerrt of 1Qatural Resources, State of Wisconsla. f~ertificadon gating that your septk system has bars maintained must be completed and returned to the St. Croix County Zoning Of&t:e within 30 days of the throe year lcatioai date. Y`°~ SIG ATt1R$rQF APPT,dCANI' DATA O R CERTII`ICA,TIOPI that all statemenu on this form are taste to the best of my (our) knowledge. I (we) am (ate) the owner(s) of 1(wc) certify the pro descn d above, by virtue of a warranty deed rceorded in Register of Deeds Office. y _ ~ y~ O~ f/lEtf ~~, --- - SI A OF APPLICANT pAT'E •~+•;` Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. •s'*'`'` a" Iaa[ude with this :ppl(cz<tion: a stamped warranty deed from the legister of Aeecis off-ee . a capY of the certified sarvey map if reference is made in the warranty decd PQWTS OWNER'S MANUAL & MANAGEMENT PLAN P~~s 1 0, v FIi.E MIFORMATWN Owner ~ a-c~ca~ cX. -~ g permit d 3f~0 ~ DESIGN PARAMETERS Number of t3edroams ~{ d NA Number of PubNc Faciucy Units ^ NA Estimated flow leverage) ~ Q'Q al/da Design flaw ipsak), {Estimated x 1.5) ~p GT d al/da SioS App Rate a1/da /its 5tandarol infiuent/tffluent QuaUty Monthly average' Fats, Oil & t3rease iFCiG) S30 mgil, Bioohemical Oxygen Demand {BODE) 5220 mglL l~ NA Total Suspended 8oiida tTSSI 5150 mg/L Pretreated Effluent Quality Monthly average Blochemkal Oxygen Demand 48flQe) 530 mg/l Total Suspended SaSsis {TSS) 530 mg/L O NA Fecal Coliform {geometric mean) 5104 afu/i00m1 Maximum Effluent Pargte Sixe Ys in dia. ^ NA ~~ ^ NA "'Values typical for domestic wastewater and septic tank afrlusnt. SYSTEM SPECtfiCATWNB Septic Tank Capacity ~~J al DNA Septic Tank Manufacturer O NA Efflugni Filter Manufacturer ' ~'.~ ^ NA Effluent Fllter Made{ ~~t' d NA Pump Tank Capacity al ANA Pump Tank Manufacturer i ~'9 ~,~. d NA Pump Manufacturer GE.~~ ^ NA Pump Modal ~ ^ NA Pretreatment unit ^ SandlCuaval Filter t3 Maohankai Aeration ^ Disinfection f~ Peat Fitter 1!l Wetland ^ Other: Q NA Diapsraal Ca1Nsl ^ in-Ground {gravity! O At-tirade ^ Orip•Llna O NA Q 1n-Ground {pressurized) ^ Mound ^ Other: tither: ^ NA Other: ^ NA Other: ^ NA MAINTENANCE BCFMDI;fLE Service Event Service Frequeaoy Inapeat condkian of tank{a) At least ones every: 3 s tliAaxMtum 3 Yaws) a ^ NA Pump out contents of rankle) When combined sludge and scum equals one-tFtard tYr,) of tank volume ^ NA inspect disperse! cei!{s1 At least onoa every: 3 ~~ s) tMaxltnurn 3 years) DNA Clean effluent iEter At least once every: ( month s) ~ setts) ^ NA inspect pump, pump controls b. alarm At least once every: ~.._.- mon~ts) D earls) p NA Flush isrtarats and pressure tsar At least ones every: -- mo a) ^ sorts! ^ NA _____ _ ~ Od''~' At !asst once every: .~- monthts) D ear{a) ^ NA ~ Other: ^ NA MAIN'~#IANCE IN8TRUCTlONS inspections of tanks and dispersal cells shall be made by an individual carrying vne of the following pcenaes or certifications: Master Plumber; Master Plumber Fiastrieted Sevt~er, PQWTS inspector; PQWTS Maintainer; Septaga Serviaing operator. Tanis inspections must inolude a visual inspection of the tank{a) 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 w pending of affluent an the ground surface. 'The dispersal cell{e) shall be visually inspected to aback the affluent levels in the observation pipes and to check for any pending of affluent an the ground surfsca. The pending of affluent on the ground surface may indicate a failing condign and requires the immediate notification of the local regulatory autharRy. When the oombinad accumulation of sludge and scum in any tank squats one-third tY~l ar more of the tank voiuma, the entire contents of the tank sha11 be removed by a 8eptaga Servicing Operator and diaposad of in accordance with chapter NR 113, WieconaM Adminktrath+e Code. Ali other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatmem unite, and any servicing at intervals of 51 Z months. shah ba performed by a certified PQWTS Maintainer. A service report shall be provided eci the loco! regulatory authority within 10 days at completkin of any service event. Paget l/qf ~~ START OF ANQ OP@FiATlON ' For new construction, prior to use of the POWTS check treatment tanks} for the presence of painting praducts.or other oherrricals that may impede the treatment process andlar damage the dispersal cell(si. If high concentrations are detected have ttie contents of the tank(s1 removed by a septage servicing operator prior to use. System start up shall not occur when sail aanditians era frozen at the infiltrative surface. i?urtng power outages pump tanks may #ill above normal highwater levels. When power is restored the excess wastewater wail be discharged to the dispersal ceiltsi in one large dose, overiaading the califs} and may result in the baokup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septege Servicing Operator prior to restoring power to the effluent pump ar contact a Plumber ar POWYS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. t)o not drive or park veniclea over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slaps of any mound or at-grade soil absorption area. Reduction or eiirtsination of the following from the wastewater stream may improve the perforntance and prolong the life of the POWYS: antibiotics; baby wipes; cigarette butts; condoms; ootton swabs; daflreasars; dents( floss; diapers; disinfectants; fat; foundation drain (sump pumps water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; ail; painting produ+Cts; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWYS 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 Gomm 83.33, Wisconsin Administrative Code: • Aii 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. ail tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or anatt~er inert solid material. CnNTINt3f:NCY PLAN If the POWTS fails and cannot be repaired thb fioitowing measures have bean, or.must ba taken, to provide a coda compliant replacement system: ~~A A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The repiacemont area should be protected from disturbance and compaction and ahouid not be infringed upon by required setbacks from existing and proposed structure, lot lines and walla. Failure to protest the replacement area will result in the Head for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must oomply with the rules in affect at that time. D A suitable replacement area is Hat avaliaflle due to setback andlor aoi! limitations. Barring advances in PUtNTS teohnology a holding tank may ba installed as a last raaort to replace the failed POWYS. D ^ Mound and at-grade soli absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFF[CIENT OXYGEN. DO NOT ENTER A SEPTIC, PtlMP OR OTHER TREATMENT 'TANK UNDER ANY CIRCUMSTANCES. DF.ATti MAY RESULT. RESCUE OF A PERSON ifRGM THE iNTER{OR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS P01N'f$ INSTALLER Name ~!~'rf~r~d( s„-~ s.~(~.!''~ Phone 7 C ~` ~ SY -- ..5'l'~' POWTS MAINTAINER Name Phone SEPTAt3E SERVICINQ OPERATOR {PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This doaumant was drafted in compliance with chapter Comm 83.Z4t2i(bli;itdl&ifi and 83.54111, t2l d~ (31, Wisconsin Administrative Code. ~, ST. CROIX COUNTY WISCONSIN ZONING DEPARTMENT ST. CRO1X COUNTY GOVERNMENT CENTER 1101 CaRnidiael Road Hudson, WI 54016-7710 Phone: (715)386-4680 Fax (715)386.4686 ~ ~ ~J Fa~c 3 ~ (~ - 3 ~ Z t Pages: Phone; Date: 5' ~- ~3 Urgent For Review ~ Please Comment ^ Please Reply ^ Please Recycle ~ Comments: `~ / ~ ~ 1 ~ i'~~ lC.~ Gz~"~c~YYi D ~~~G~ V v / ~ ~/ 1' ~ - ~~~`~~'~ ~~~ - p~ ~ ~ V C b~ J~ `iV 2 _ UU-c.~ ~- ~ ,~~~ ~ ~~~ _,~ ~,~~. ~~~ ~~ ~~ ~/~ ~ °~ ~~ . ,, wlsconsin D~artment of Commerce - SOIL EVALUATION REPORT Division of Saieiy and Buadings Page I of ~. m acooroanoe wmr ~:omm tsa, rns. rwm. t.aoe ' i i 8112 11 i d Plan must 5 c ro ~ res ze. n n s x Attach complete site plan on paper not less than indude, but not limited to: vertical and horimntat refierenoe d percent slope, scale or dimensions, north arrow, and ni~rid d mectiorr and nearest road. Parcel l.D. . U Z O- / 3 9S - / ~ - 0~ U \~. Please print all i ~ a. - •~ by Date ~ Personal irdormation you prpvide may ba used ~ibr , d@ pu a 15.FM~'~1) (m)). , ~~ Q Z G~L..~ 1 ~ Property Owner - ~ - property - n I ~ ~. k, 7 Lot 1/4NW1/4 S 25T Zq N R ~ q E(or Property Owners Maikng Address ~ "Nx ' ___ L Biodc # Subd. Name or CSMtf ~, v~ Co ~ Z o S~ ~ l l wa+~ ~ t::~ ,. S '. City State Zip Code Ph ^ Yllage (~ Tawn Nearest Road ~STi' I l wu.~-cr Vh~, f'So ~Z ( b'1`)~:'Y~ ~~~ ~~ ; v s Rd ®New Construction Use: ® Residential /Number of bedrooms ' `{ Code derived design flaw rate ~Sd l (o O O GPD ^ Repiaca:rrrent ^ Public or oornmerdal - Descxibe: Parent material Oy f caJ0.s ~. Flood Plain elevation iF apptiCeble 9 3 2 . ~ R G~eral c«nments S S ~ rrt e. ! e ll a f , b n - ~ 5 - p 0 I-~~t~t~a-e- tc cw~v-' ~.. =d '.''d° and recomrrrendations: ~ L,,~ er l ~e..~ a ; r7 ~. - 9 3.5d `~ 1 tv s~ lam- - d -{a -~Zs-l- ~~ y+vY~. o f-~JI r~~ Uv 4~. d~c-t~.r,~ -I~ Kw C, ~v~ ~ ~ Apr Pit Ground surface elev. 9 5 . eft Depth to limiting tailor 1+~,~,. in. Sor7 ' n Rate Horizon Depth Dominant Cobr Redox Description Texture Strudure Consistence Boundary Roots GP D/tF . in. Mansell f]u. Sz. Coat Color Gr. Sz. Sh. •Eff#1 •Etf#2 I b-ii (~ ~ I t_5 I m m-~r c s 1.r ~ 'I I. 2 Z t! -u l 0 y( ~ m S OS m l _ - .1 1. 2 ~-c ~ a~ 0 ® Pit Ground surface elev. q ~ . ~0 fL Depth to limiting factor / b0 in. Soli Rate ~"~# ~' Horizon Depth Dominant Cob Redox Descriptbn Texture Structure Consistence Boundary Roots GP Dlttz in. Mansell flu. Sz. Cont Cobr Gr. Sz Sh. - 'EIT#1 •Eff#2 Z 8-~ . 1 ms ~- - . ~ I.2 ~r ii ' Ef fluent #1 = i9oDb > 30 < 220 mg/L and TSS >30 < 150 mg/l. ` Etnuent ~z = tic~og < sa mgt ana t ~ < 3u mg2 CST Name {Please Prart) _ S" re CST Number ~r^ ~--- -zs33o Address Date Evaluation Condur~ed Telephone Number Z I t ~ ~lJ'-'' Sf Scsmcr-s~ L.c11 SyozS ~i - I - c~ i ~ l s-Z4 7-`fc~ L Property Owner A.r ~~• ~ Parcel ID # -- Page Z of 3 Boring # [,f Boring ® Pit Ground surfaceelev. 9~~• I C~ ft. Depth to limiting factor 1 C~ ~ in. Soil licabon Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDlfi: in. Munsell Qu. Sz. Cont Color Gr. Sz Sh: *Eff#1 *Eff#2 _ Z I~-lolo y -'_ mS v5 m l _-- _ : ~ I • Z ~,37.Z ~ ~3.Z~~ ^ Boring # ^ Boring ^ pit Ground surface elev. ft. Depth m limiting factor in. ~~ ication Rate rizon H th De Dominant Color Redox Descriptbn Texture Structure Consistence Boundary Roots GP DAf o p in. Munseil ~ Qu. Sz. Cont. Color Gr. Sz Sh. 'Etl#1 *Eff#Z Boring # ^ Bonng ^ Pit Ground surfaceelev.,~ft. .Depth to limiting factor in. Soii licatbn Rate Horizon th De Dominant Cob ~ Redox Description Texture .Structure Consistence Boundary Roots GP D/fP p in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Ef!#2 " Effluent #1 =- BODE > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = GODS < 30 mglt. and. TSS _< ~ mglL The Department of Commerce is an equal opportunity service provider and employer. If you need as§istance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. 580.8330 (807/00) 1 ~ PAGE J? OF~_ NAME 14 Y` K~-~ ~ LOT# /~- LEGALDESCRIPTION,vE `~4uw'~<,SzsTz4 ,N,RIq E (or)b SCALE: 1 "= y U , BM I ELEVATION /00 • o ~ X BM 1 DESCRIPTION •fa p o~ 2° P v ~- P ~' p c ~ ~ BM 2 ELEVATION 99.9 ~ ~ S c., z5 ~ BM 2 DESCRIPTION ~foP o ~' Z " Pyc.- ~Q,~~QL° SYSTEM ELEVATION' QS ° ~ AI,~'ERNATEELEVATION 93•sd ~ ~ ~ CONTOUR ELEVATION 9S. a~ - lod • d ~' ~~~~ J / ~ ~ ~ ~ ~ cr° i \` ` Zo ~ . b~ O °6 ~ ,; lJ ~ p~ a b ~~~, a -a °` o; ~ °` q 3 2 • ~ o, g4 0 4 h ~ a ~ o~~a Rd• ,~ s l}G~ a. ( La L v+ ,r SKaQ<. •Q . ' ~ 1,0 Z~ 2 ~S ~ -~- C>/ ' iI DOCUMENT NO. ~~~ ~~ ~ ~. ~. 'T'HIS INDENTURE, Made b RICHARD .N: _ PEARSON and : SEAN M.._..»...__.. I?EARSON, husband and ~ife, granter. S.. of....St.:.»Croix...» ................................•--.............. Count ~ Wisconsin, hFreb conveys and warrants to.._»CARRIAGE»HOMES . XXI , - INC ~, »a_.».»~ Minn~sota corporation, WAItilANTY DEDD BTATE OF WISCONSIN-FORM 9 THIS 6PACt R[9[RY[D FOR R[CORDIN6 DATA GilasTiiiig£Ori .................................».............---...... ----- . ~i .~ rautee......... of I( ...».._:. __~.».-» .. .....................................County, ^~i~ ~or the sum of I _ - Qri~„~pllar:,and,.no1100,,,_(~1; 00),.and__other,.good.»and,valuable.,:IRETURN To the following tract of land in._..~tt ~..»C1:4?:g.» ..........................................County ~'_.. , ._ ... .. _ ... , Wisconsin: .~1~],»4~..~1~~..N4~~(lWe~~.,Q~~riier,,.~~~_,and,._[vor~h ,half (N~) of the Southwest ' Quarter (SW's) of Section Twenty-Five (25), Township Twenty-Nine (29) .North, Range Nineteen (19) West, St. Croix County, Wisconsin, except Lot 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. ~~,~ 1(i62PA~289 648604 ocument Numbc~ DO°'~m TStte KATHLEEN H. WALSH hEGISTER OF' DEEDS Warr~.r~'~ ~ccc1 Si. CROIX CQ., WI kECEIVED FDR RECORD ,. - 06-18-2001 12:45 PM } . ;' ' WAkkflkTY DEED - EXEMPT q CERT COPT FEE: COPY FEE: TkANSFEk FEE: 9900.40 RECOHpING FEE: 14.00 ' PAGES: 3 Recording Area I ~ . Name ami Rctarn Addrsst -'- l~a,.1 T ~ -i ~,~ ~ ~ n c . ,900 ~p'~lvcr L~.k~ IZo~.d /l~tw Ori,yk,ly~ ~ MN S~/I Z dZo ~ tObq- ~70 -oov Pact$ IdmtiGntioc Nembv a'iN) C~Zp-1U64'-~p~-r~Up 02 n ~ 106`f -°1D - v0v (~ 2v - 1070 - too - ~~ 020 - 1070 ~ iv -nckJ v z v ~- ) o -76 - z o-~ "THIS PAGE IS PART OF THIS LEGAL DOCOlIENT - DO NOT REMOVE" 7LG infarmatiaa mwt be oompkrod 6j~ rubmirtc; tlo~+eaerv drfe. ~mn~ & rcnun addrcrr. and ar dir trmdnj daruw, kcal rksutpatan, rra +~' yrP~'~ on Arty ~ Nrc4drrdJ. Odw ~yfwnarion rueh Qoe.aiak loo ;Use of rMr omr pate addr one e ro 1~+Pata 4l r~ mar or ~ be plaerd on ad~doal pates oJde p'at Y°'~ dac*enent and SI.W W die rccy~ « 1Pucaarin Sraoee~, Sp.S17. WFDA 7r9d «- 117-M-CO rstiotl Minnesota Uniform Conveyancing Blanks (1978) __ Miller/Davls Co. ° St. Paul, MN 6bt-642-1.988 ----------~---. _~------ ----• ------_... ------------ _._. _... -------.A.-------._-_- _. _ ___ i 1. ('They are) (____ he is) the _._ _~-.---_--~.-___-.. --_____-----~--___---- and the ___- ------ respectively, of ._ __.__`-~ _._._.._~ Carriage~iomesXXI,_~nc~ ------ -= a __ ._Minnesota___ _ corporation, the corporation named as ---- ------- ----- in the document dated _-__ _ _ __ ____ ___ , and filed for record _- _` - ---.- STATE OF MINNESOTA ss, Affidavit Regarding Corporation COUNTY OF -----------_._ -------_._ _--- ------__ .-- _ an - -----_. being first duly sworn on oath says(s} that: as Document No. Page ._-_ _._ of ---- __ ... - - _ __ ---- _ .-___-_- -.__St.-.Croix __-. _. _ _ _ _. (or•in Book _ of ____ _--_..- ~~~~ __~) in the Office of the (County Recorder) (~~ --_- --_._.._.._.. County, Minnesota. 2. Said corporation's principal place of business is at . _ _.__ _.____ __.____._ __--_ ____~._____.... and said corporation's previous principal place(s) of business during the past ten years (has) (have een at: 3. There have been no: a. Bankruptcy or dissolution proceedings involving said corporation during the time said corporation has had any interest in the premises described in the above document ("Premises"); b. Unsatisfied judgments of record against said corporation nor any actions pending in any courts which affect the Premises; c. Tax liens filed against said corporation; except as herein stated: 4. Any bankruptcy or dissolution proceedings of record against corporations with the same or similaz names, during the time period in which the above named corporation had any interest in the Premises, are not against the above named corporation. iv~ m Y'o ~2I~ ~" ~/ /~~~/ i/ 1 ~~ w ~~ ~ ~, ~ ~~ ~` ~` ~ ~~ ~ ~~ ` s ~ \ ~ ~, ~''o ~ /~ ~~+~ ~~iw~i9 <,e ~~~ ~\ ~__ ~ ~~>_ 20_ ~ . _ N ~ •• i ~ m ~~ ~; cn ~ ~. „~ ~ , r • ~W3Sd3 ~Aili ~fc _ . ~ .r ..~ •~•~ QO -'~'~'~• ~ ~. ~~ ~ ` ~ \ ~~ ~ d'{ o ~ ~ _~, ~9~ ~''F 4 ?~~j, N ~ v O ~ ~~ w ~D ~~ 2~~~Oq_ ~r c ~~ ~~~FMti F .~ ~a~ ~~ N • $L d w$ j j v -~ i n~~y ~~~ ~~~~~~~• ~~~ `4~` ~~ ~~ ~~ 8 ~ ~ r u ~ ~~` \ ~~ 1 ~~ ~~ _ ~~ / t0 ~~.~~'~ '1v c~ N ~ N ~ v~ i n~ ~ m~ ~~ Spp°p9'OTE 444.7 N s N ~j W ~ Q ~~ N j C~J1 i ~ D ~v" i $ m~ ~ ~~ T ' / ,- - 1 ~l,~ ~q2 (1 X~/~z ~5' tiv ~~~ ~~ ~Nf l v/ L N.u wo nluv~. _ -OEI- ~~ r II ' AL'444 3d0~60oA0S ~~ w ~ ~U ~Q ~ r' N Y l17 T Y N ~6Z'088 w z N AL'44ti ~ ((( ~ \ ~~ `~ J ~iJb~h, \ _ ~ ~ ~ ` O \ \ // w • ~v 0 4 N ~ ~ .~ T ' r N r W ~ ~a r ~N ~ ~' r N ,, S ~~ ~ `. \ ~ \ II -i g \ _ \ ~ •\ ~~` ~~ \ .mob rn 1 ,(~, ~~b ~~ ~'~! 1ti `\ ~eJbN~s'6~` O II ~ J ~ 2~ ~w ~ h~~ a J *' r I~ ~~ ~V ~ N ~ ~ ~i i~ ~1~~~t ~ ~1~ o ~ 3 a,~ ~,~ ~,,~ ~~ o ~ /~ ~~ ~ -~\ N r . . L o° ~ _.~•- .~•~• \ • . ~ ~ Np4a31'37"W 353.98' _•_._•_._.J • Z~ 66 JOINT DRIVE EASEMENT ~ _.- ,.- • ,,;~ ..~ . -- , '~ • ' ~ 1,57 ~ ~ . ~ •~ ~~ w ~w r oQ N ~~ ~ °' r N ~~ ~~ N `~ ~ N ~~ ~~ ~ N ~~ ~ ~ /~ :I ~ u •` J •` _ ~ `\ ~- • ' \ gg928 •~. J~ ~w ~~ ~ ~Q N °; rn T O Cp N ~~, ~b o/S~^' _ `~~ / ~,~ i ~~b~~~~\ ~, ~ ~ ~ ~o ~ ~~