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HomeMy WebLinkAbout020-1395-21-000Wisconsin, Cwepartment cf Cotnmerce S'yfe~ arid Building Division PRIVATE SEWAGE SYSTEM 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 Na City Village X Township Kretschme ,~im & Mark Hudson, Town of SST BM Elev: Insp. BM Elev: BM Des ription: R ~ -r l , ~- reNk Inl~nanne•rfntu ~i ~vnr~nti Here TYPE MANUFACTURER CAPACITY Septic ~ _ f f ZJ v Dosing „! W I f `'/l~/ CJv Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic , ~ ~ ~~ ~ ZS Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Friction Loss item Head n SOIL A6SORPTION SYSTEM 7_ ~ -I'' L ~ ~- ~ S county: St. Croix Sanitary Permit 463494 0 State Plan ID No: ~ Parcel Tax No: 020-1395-21-000 Section/Town/Range/Map No: 25.29.19.2415 STAT~ N BS HI FS ELEV. Benchmark ~' ~~ /D3. Alt. BM L J ~/ Bldg. Sewer ~ / I ,~ f{W~ ~. d 0,'1 St/ t Ir,]Et. ~•°- q3. z~ St/Ht Outlet ,~ ~~ lo.2f qZ-89 Dt Inlet .~--. Dt Bott ~" q Dist. Pipe ~ ~~, ~ ~~ / Final Gr e /~ y ~ ,Z ' ~ , S Cover / /~'_"~ i L'S I ~-C,C~X Ca2cLR/~ BED/TRENCH Width Length ~ / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Ligwd Depth DIMENSIONS '2 ~ L 'T SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Ma a er + /~ r ~ INFORMATION CHAMB T /~ Ty Of System. ~~~i7sN. / 3a ~ / >25 (~S / Model Number: RLRTR16l1TION SYSTEM .ter-- ~ Header anifold / G length ~ Dia istri uti QQ v / Pipe(s) "1 Length ~ Dia Spacing x Hole Size ~""--_ x Hole Spacir~ /~ Vent Air Intake Sell CnVFR ~ .. ~ (l ., ore~~~~re c..~•e..,~ n.,i.. ,.,. Mn~~nrl nr At_r;rade Systems Clnly Depth Over Depth Over xx Depth of xx Seeded/Sodded Bed/Trench Ce t ~ / BedlTrench Edges Topsoil Yes L] No ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection#1: ~ al ~7 i~ In p n ~ _ _ ~ Location: 876 Highlander-Trail .Hudson, WI 54016 (NE 1/4 NW 1/4 25 T29N R19W) Scenic Hills Lot 21 ,. Parcel No: 25.29.-19.2415' ~ 1.) Alt BM Description = ~/ ~- pW`~ ~ `'~ ~ """'- n+',"~`.1^,-~.,4,d ~ X"' ~~"w~ ""~~ 2.) Bldg sewer length = ZS /07'~~I I~ wrwl ~!~'L ~~~~~y;~ ~ (M~S~2~~ cv n. '" " - ~UUUs~ h~ -amount of cover =' J - / ~~ ., ~ ~/r~~ / 1~ V -. --- --- Plan revision Required? ~ -+] Yes ~ No ~ „~~O,~r ~ ~ ~ ~~ Use other side for additional information. ~-__~ ~ __~ I` __ L - SBD-6710 (R.3/97) Date Insepctors Si nature ~~ Cert. No. ~- ~ 3rd ~ xx Mulched ~' ~~ ~~ !M- H 0 /~,~ L ~rr- l..iT Vf..'~ Safety arld Buildings Division ~ Box 7162 201 W. Washington Ave. P.O County s~ -G 'Vd r k- , . , ~~~Ons,~ De artrnent_ afi Commerce P __ Madison, WI 53707 - 7162 _ (6U8) 26f+-3151 ~_ Sanitary Pe//r~"mit Num to be filled i y Co.) 'y1o 3 ~~ Sanitary Permit Applicati n State Plan [.D. Number , ) In ucor~t with Comm 83.21, Wis. Adm. Code, persanaP i at o fde ( v ~ may be used for secondary purprrses Privacy L 5 Project Address (if di Brent than mailing address) I. Application Information -Please Print All Information ~~~ ~.9,~~ow~~v, Property Owner's Name ~t ~ Parcel # of # Block # s yy~ ~' ~~~',rvi Y _ v ~ ~ ProperW 0 er' M if~ng Address ~~ ~QI-~~~~~~ ZONING OFFICE Property Location > ~•~ ir6S ~'~~] ,, ~ /~ -_-._-- ~~ ,~~'/.,/U~.'/.. Section ~~ City, State Zip Code Phane Number ~ ,~ d0.~ I ~.{~ ~ N; R (cEc~e o ) ~" r ~ T-2 ~ II. Type of Building (check al} that apply) - , ~ or 2 Family Dwelling - Nurnber of Bedrooms Subdivision Name CSM Number ^ PubliclCommercial -Describe Use ~ ~ ~ ~ ~ < < s _ _ __ ^ State Owned -Describe Llse __._~ ~, ,.. A .. __ _ _`-_, ClCity_^Village ~wnship ot~~~~" ,./t~ III. T ype of Permit: (Check only one box on line A. Complete tintine B if applicable) `~' ~iew System ^ Replacement System ^ TreatmentlHelding'Fank Replacement Only ^ Other Modification to Existing System B. ^ Permit Renewal Pernrit Revision List Previous Permit Number and Date Issu ^ Change of ^ Permit'Fransfer to New ~~ ~ ~~~ ~/ 3~ S~ Before Expiration 1 Plumber Owner ~/T. [V. T yQe of POWT_S Svstem: (('.heck alt that a l ~~+ S Non -Pressurized ln-Ground ^ Maund > 24 in. of suitable soil ^ Mouitd < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ~ Constructfd Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter Leaching G e I;rip Line ravel-les ~ ~i e ^ O et(exp ' V. Dis ersaUTreatment Area Information. ~~ Design Flow (gpcl} Design Soi{ App4icatian gpdsf) Disperse; Area e aired (st? ispersa sed {sf) r G a I.~ ~ ~ Cl '~~ ~ ~_/ ~~ / ~ ' ~ .~~~' C VI. Tank Info Capacity in Gallons Total Gatlens Nurribcr of Units ( Manufacturer Prefab Concrete Site Constructed Steel Fiber Glass i Plastic New Existing T'anlcs TRnks _~ Septic or Holding Tank i Aerobic Treatment Unit Uasing Chamber VII. Responsibility Statement- I, the undersigned, assuntc responsibility for i lion at the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature PRS Number Business Phone Number Plumber's Address (Street, City, State, Zip Code J VIII. un /De artment Ilse Only pproved ^ Disapproved Sanitary Permit Fee (includes C,rot}pdwater Surttrwrge Fee) ~- /_ D fT'v / ! Date Issued )Q' d D~ 0 Iss ' g Ago Sig ps) 1 ~ 1 ^ Owner Given Reason for Aenial ~ __ IX. Conditions of ApprovaUReasons for llisapproval- ___._~ ~ // ~~ / 2 ~e~~ ~ ~ ~~ :-C.!'KLiI ~~~ _. ,..~ ~- Ste. f 5~t `1 ~f~ l amt,, I~G~r,~ ..~n~'~ r C~'/u-~ ~ S G~a~`.e- l ~ y ,, Areach COmrykte plans {f0 the COpnly Only) roe the aysleM on paper nor lps man aus x r ~ mcnes ~n sou '~ `~ ~~ ttih ?~.~ ,, SBD-639 (R. Oli~3) /O~, a ~~ `~ ` ~ y~5 ,~. mow- ;' 7-~ :~ "~~~i _ ~ ~ : ~'q~,~~ .~ ~ u,~ 9~~~~N/y`~ ~~ ~ ~ ~`' 6~~6 ~~ VD° J~ ~~'' sib' ' ~,~• ~~ ~ ~~~ ~~~ ~ . ~~ ~ ~ ~, ~ s~~ h ~~~~o ~3 r___. e.v ~~ ~d~~ !,~ ~ ~~ ~~ f s~~ ,~ :J \S x"'21 S'c,'~,u , ~G, ~ ° 11.s- /6~. a r J ~~ 1' ' ~^~' v V n\1~, ' ~Y ~; , ~~~~~~~~ ~~T ~ '~ 2.05 S7. CRpIX COUN Y nt7apertrnanxafC rsa ZONINGOFFIC~~~~ VAl.l1AT N RE PQRT ~~ ~~ DlvfNgn o! SaFaty and 6uisdtngs _ . isa aRVOdaltioe whh Gomm 85, WI6. ndm. Coda - - Acnch mmp~ete aua pan on f rat Ies~. than 8,r~ x t, inches in sits Plan must rr ' ~ ~ ~ . krcfrtde, b1,4 ftot limited <Q: vwtlCBt and t`or~pn;e! r+ffatatrce f (9M), directicrt artd .. ... Psroet E D ~ ~- .-•_.._ AefneM Sbpe, scale w dimenslon8, rmrlh rifforv, andlpRatian Mitt dlstancs to naAreef road. . . i P~t)Ga'! prlR! itfl tAlb!'r11~t/DA. ~ ~Y • ?~~!! ptpeOnaNen ypy rwrme n,ey b~ 1ls+od for NcOnON7 P~PRM ttM,lriCy tar. 6. 79.W t r3 (l'AtJ. ~ ~ ~rarJ4rt~l t?wf1d1 Property lo6itlgn ~ ' { , r &+ ~ ~ nevi. E.O~t ,~ ~:, 11d .t/W 214 7 ~ N R ~ E (tx~ +~Owrle$ ~e9 ~vt # i~iadt it Slbd. ltaRls a CSiM17 „ sir. )! -•••,•• *+r.....A r~nwgrwaran ~~ ~MaAEi I~YOYY11 (NY~f '~A09d ~~ d.Sa~ ~' ~ uaa ® Rasidevldal l nlurnper of eadroomc rose dorived dear now rate W ~Q~~d4 ~.._ GPa © RapisoMnera (~~ Pubic«oorrnnarc~at • Deatsiba• __ __ Parentdkeleriai G>(~z.-~c .~ Waoti Plain ehvatian iibfa ~ ..~i/f~..~_.,...,...._.~ !L ~~ ~ jC~ ~Q~ (~. t~~ •`712 na ~ a~ ~r -~~~. ~~/ ~ a (~.{nr,rtC~ .~,~-~ ~ ~~` ~! j ~`~ Q ~+~ t~ J 8°~"'°' ~7! Wt surfaae aiav. ~~7 ~ tt_ dry, rn iui,~,n ~.~ ) ~/". .. -- S~ ~rfJ Z r~ s ~Ic. mfr c 1 v. . if , ~ " EtlMltxrt ff1 ~ t3Q0 ! 30, ~ ~ and'F;~S ?3Q K 19G ~ > ~ ~ < 30 ~ r~i. ~' tlfiQlTla (P~9alB Q!Y't~ ~,Sy`7' C~111~9f ~t!'!L'K /Y1 ~C' ~1 trr r'-'1Ch~ *'1`, c. .. .. -~ ---• - ~ .. ~~r- ~ f ]J ~~) 9 ~- l (_s ~1 ~r `~q i ~, ,~.d _ IU r ~ r t h r ~~ Cr"rr . r, {,? r '~ "~ C r 7 7 ~ F v Zd WHb~ : Z t SOC~~ ZZ "~~0 'Ohd Xb~ WOti~ y U # ~ ~~ Pit t3rotmd surface elev. ,~~ ft, Oeptti to Gr~ting fader ~ T 1 tn. ~ ~P~ Claminanf Got Redo!! pasafp~rt T t~ttttsre s-ae Boundary Roofs OPp/!p u1. t,Aunsatl ou sz ne.~! ['~,. .,. r1_ a.. ~ -_-,.. ~ ..~_-- r ' s c~ ~ ~~ ~~~ ~- ~. -.Pit Grdp+d atateo6 s1ev.1 ~.=5~ R, Qepm to iaRu'~'~s fa~a _ ~'" Ra tiaiao n itepth pgrNnaM Ca1ar M RbOii Radaoe twsscfipdas tiu~ 8L Cont. Coiar Taxturo 3aucbre Gr. Sa, 9h. l~I7rt6istentat i3auadg+y Raons 'E~R1 ~F~2 ~ in. v--~t0 U iD .~~ -.~ 5a ZmSb~- ~ C 2 i(} -1 ~' ~D r'~ 3 S' 2m GS i ~' • '~ - In .~ i ~ p ~-y /y ~. 1 r c 5 ~' .'-t ' lc ~ ~l~i.. o., ~~11~ r S ~s ~ i -- . 7 r . z (""~ i ~ Q LJ l7 pn o~o,ur*~c..ia~...~_._n. -t«izon peptl+ tyotNnattt Redaos oe~puoR testate k ~.~x i1u. ~. Cora Cobr ___ . . ~ -- _~,. ~ ~>~ ~ 13ori<g ~ ~ (~ruutkl aurieob elev. „_.~...._ fi. Cfe~th tc B 9aua' _..-__-_ --- in. Fkxfaort CePlh pottrkw~ ttedoot ~. TerAu~ ~atenca BourdAryr ~ - -._ ..__., .b. ti r~..,,r c~ fit', St. &h. - ~,rprp ~ ~ ppp~ r ~0 <_ ?Zt) ~ and 798 y28! ~ l Gb ~ ' ~~ p! , 6ClD~ k 3Q mDIL And TSS , a0 ~+~R. 'Elf~2 'moo gcp~tent of C.At~tetce to AA nqusl opportunity aervico prgvidat and cnrplayer_ lCyou nced Assistance to Atce~a services or aecd rnater9af In en altanpte format, planes cat+sset tha dept~etment at bdB-266~3lS1 4r TTY (Q8-164-8777. awa~~t~ ~d ~ibs~ : ~ z seoz zti ~~-~o •aN xd~ wo~~ ~ _ ~~_ ''22 r PAQC ~ p~ NAM ~6-- LOT# tT { Lr~c~wL D~S+Cp1i~TlaN.li~?/aGW ~/a.'37~ "1' G~ N,R (r E(pit _ SCALE: i ~~ =_~~ BM 1 D~aCRlPT'!ON {r(¢t, ~ ~~ ~ Gj. ~~ (v t~C't~ C3M 2 EL~erArtont ---- 8M 2 DescRlPt'!oN '~"'- SYSTEM E: n dd r/'' p /, 4,~VATION ..[/ {~~C(}c/1% ~y-Ti.'~ ~~'~ 7 yC~J O:rY~ SYSTEM TYPE c~vt 1~, ~~ slaNa~ru~F ~. . ro~~ os c.d Wdb~ : ~ Z 560 LZ '~°0 'ON ~k~'J : WO~~ ... ~ _ f..._- _...----~" t `~ t/sconsln f Detaartmr3nt of Commerce .~--~-------~-".' ---~- County ____ r Safety afl~ Buildings Division ~~- G yam, y~ - zp) W, Washington Ave., P.n, &3x 7162 3?07 - 7162 Salutary P It 1`tUtn Er (~e filled in br Co.) Madison. ~~ ~ 3 i 60~ t/~61f-'Q 151 _ _ ~ _ ~ _~-_.-.----- Sanitary Permit Applicat -de Ir, accord with Comm 83.21, Wis. Adm. Code, personal information y MAY may be usod far secondary purposes Privacy Law, s1S,Od(l)( ,~- -- L.R j T. Application Information - Plezse Print A!i Ltformation -~ t' ~'~lX OUNTY ~ ~~~ ~~ ~t ~ ~ ------_. p~cr Lot N BlocR q rroperty Owner's Na me .r---- Property Owner's M ailing Address i Property La:ation f ~.~ ~GJ~ ~~h J ~~~ ~ ~ ~ Ik,~~k,SeCtion ~~ C y, State Zip Code Phone N ber i a~ ` ~_ h t° _~ ~j DO ~ „~. _ T cam! ~ N; R 1 ~E or (~ - -~ II. Type of Suf1 t heck elf that apply) ~ 5 _ ~ ~ ~ .-._--- ~ (~i or 2 Family Dwelling - ember of Bedronnts ~~_ _~S Subdivision Name C'SM Humbrr f r /, ~ I ~~ Q N, .G I , ~~S' ' ._ Public Commercial - laeseribe se __ ~~. _____,_,-_~F__ ` - -L/.~ -- ~/ ~~_ '.~ State Owned - Describe Use __ _ ~_ __~ ~~~ 1 L~City_i~~'il4age'uwnship ot~/a~SG./t/ III, Type of Permit: (Check only on ox on lino A. Complete ~irte B if applicable} Zp - i39S = Z~Qt7b~, ~ ~S 1 A. New System ~ Replacement stom rJ Trrauztend oldiug 7attk Repia~rment Only 1~1 Other Modi'icaaon to Existinc System g• ^ Permit Renewal !~ Permit Revision r' { gist P ous Permit Number Issued ~ U Change o ~ Permir Transfer [o New ~ Before F.xpiratiae ~ Plumber Uwner ~ -1----,_.~.~_... _ ~~ _ _____ Ti~'. T of POWTS S stem: (Chock all that a ~~ __ __ _ __ Non -Pressurized !n-Ground ^ Mound > 24 in. of su ble oil ~ M:wnd < 2a in. of suitable soil '~ t-Grade i~ Single Fass Sand Filter j ^ Cottstruc:ed Watlatxl ^ Pressurized In-Ground ^ Hot g'Tank C..~ Peat Filter ~~~' Aerobic 'treatment Unit ^ Recirculatin ~ il Piper ~: Rec-rctslatieg Synthruc Media Pillar _~~l.tact;ing Chantbrr ' np Line Li tiravtF(rss Pipe ^ Odier (explains I ; V. Dispersal/Treatment Area Irrf'orrnation: •~_~~-~j -~,~ Design Flow (gpd) Design Soil Application 1Lte(gpdsf}~I isper a raa Re~t:iret! (sf) Drspt:rsa! Arta Proposed (sf) ys _ evanon ~vd ~ _ , 3 ~~~<e~1 ~e,~7" Vi, Tank Info Ca at:it ui ~~• ~ `-~ `~~~ ~ ~ -"~.. p y i Totaf I Num r anufaetuter Prefab Site ,Steele Filar j plastic I t"sallons Gallons ! of U 't<c ~~~Q ~ ~~ Concrete Constructed ~ Glass New Existing !I / i Tanks` Tanks --~1~ I rSeptiC or Holding lank x / // ~~ nerobtc Treattreru Uni[ ~~'~"`-'~'-`~ ___ _ Dosing Chamber ~d0 ~ ~"""` -~--~-~~~~~~ -L~ ~ ~~ __. !.___._- VII. Respon5ibiiity Statement- I, tht undersi~ied, ' •ttnte respattsibility for ins ~ llation of the P TS sho_wu on the attached plans. _ f Plumber`s Na me (Print) Plumber's Si gn° re -MFRS Numtxr M ~ Business Ftwrte Numtier~ . ~~sam Sc~u m dX~ rr ~ ~? ?Q9' ~ h !S ~~~-glzl i Plumber's Addre ss (Srreet, L'iry. State, Zip Cade) ~-~.~~'~.~~ u-~ _ ~ ~ -~y~_~,_________________________.____---_.__~__..____ VIII. Count /De artment Use Only T _ _ ~ ~.Approvtxt ^ I)~sapprov ,Sanitary Permit Fee '1 tchtdes Groundwater Date Issued suing ent Signature ?ro Stamps) `Surcharge Fee) ~ ~~~ __„i ^ Ow tven Reason for Dt al , ~~--- ~QM Z ~ 2eJ~~~i~~iil,._ ~(`f'1 e9.,Q 1~,--~.- } ix. t;ontyitiorts Approv ke~en~8it=~vs} SYSTEM ER: J 1 Septic tank, effluent filter and I dispersal cell must all be serviced / maintained ` as per management plan provided by plumber. 1 2. All setback requirements must be maintained as per applicable code/ordinances. 7 tto the County only) for the system oa paper not lass thRq 81/Z x It inches in size s (if di?ferent than mai'•ing address) ~ i ~~~~L~~~ S'Ga~~- l ` %~ y~ '~ (,!1 ~%J,y~ir.~l i;0 l6 Gene r' /G~ ~-- ~^ °W~ ~,~. e ~.- `~`~- .c I~6~ ~~'~ ~ ~~ ~~ '~ ~,~r~s~fi ~ ~r :,,4 ,, ~l ~~ a oK ~ ~ ~~~ ~~ ~. ~ ~~ .~ pp~ C ~~ ti ~~•d-- ~1~~'t ~~~ ~i ~ ~~ ,~~ ~" .z ~ .sc ~,.~~ `~ ,tom` /ls ffu ~~-v -- ~~ .Z qua, l i,~/~ ' ~ ~~iv~ /e ~~ ~ ~-- -~, :~.: e W~ ~°`~' B ~ '?`'e~'- ~~~~~ G /~60~ ~~~~ ~~~~ ~,~~ti a o~ D~ ~~ z~ v 'Q.. ~~ ~~ ,~~ .~ ,~ `~ tNsoornsin Department of Commerce ' Division of Safely and Buildings SOIL EVALUATION REPORT Page ! of~ m aoooroance wim Comm ~, ulna. pwm. woe st m Pl 81/2 l qty ~+. c ro ~' an u x . ei than ~ Attach complete site plan on paper not indude, but not Itinited to: vertical and horizontal p t~ di , and ` p~ l,D. ~/- DZv ' 3 9S - Ova and distarr6elo crest road. percent slope, scale or dimensions, north arrow, / ,Please print alt i "~ ,- .~ ? by Date Personal information you provide may be used for ry Pu Law. s. 04 ) (m)).. Properly Owner - _: a ~ ~ ~~~~ ~ Prnpe,_ Location ~ _~X L N t 1/4 Nw1/4 S ZS T 29 N R I°I E(o Property Owners Mailing Address ~ COt1~N ' ~ L #~ -Block # Subd. Name w CSIU~ >= CO ~ Z ~ S -!• i ~ ~ lvU-'~'-e rc"/' . ~1t~G O S ~ , . City State Zp Code Phon@ ~ -r- ; . , Cdy ^ Ydlage [~ Town Nearest Road . . , ~Srti I l t~1a.}tr rh ~.. f'S'o ~Z ( ~~ j ~ U s n ~. . ® New Construdbn Use: ® Resider-tial / Number of bedrooms 3,=`/r Code derived design flow rate DSO l (o O O GPD ^ Replacement ^ Public w commercial - Descrl~e: Pai'errtmaterial OUfca.JaS ~ _ - l=loodPla~elevationiFappricable q^19. ?y ft. General comments ~ S S ~ rYL e.. t c Ja f •b N6~ - sys~rn `'~ s-~u Glli~i,~~,, ,~¢~ yr 8 3 and recommendations: ~ ~ ~ ~ e, l ~.~ a ~-.`o r~ - . q p . vie, ~- ~-o~~ '~'L'~ s' -~ l a -~- r ~'//yw/n~ __ ,, z 1 d 5 bow ,~~~ I ~ cam- ~ ys~,, _ . , . a ,,, , _ _ tpi Pit Ground surface elev. C1_ `JSQ R Depth to limiting factor 1 C~ ~ in. ~~ # r^a ~g Sod ication Rate Horizon Depth Dominant Cob Redox Description Texture Stnidur+e Consistence Boundary Roots GP D/f~ . in. Mansell Qu. Sz. Copt Color Gr. Sz Sh. •F_ff#1 •EffiR2 I o-~S /D ,-3~Z ~ mil ~mS It m~'r c ~ I v~ . 5 , ~' 2 ~5 -l ~3 %L ~r~ `f lc~ - m.S ~ U ~ ~ nn l - - ti ~ (, 2 ~- ~~• 1 > i 'Serino # ~ ~~ _ n - -'~. I i~ Q I ~-'i L~0 Pit Ground surtaoeelev. -l c. - ~ tt. [leptn to irtrimng tac[w ~ v ~ m. ~ ~~ Horizon Depth Dominant Cob Redox Description Texture SWdure Consistence Boundary Roots GP D/t~ in. Mansell Qu. Sz. Cont Color Gr. Sz Sh. - 'Eft#1 •Eff#2 1 - lU ~~2 ~ ~i~1 ZmS~ k. Vii- c ~v~ .5 ..~ 2 26--~o~i l0 ~~f1~ m5 bs I - -. ~ (. Z ~ .o = ~~ * Etfluert #1 = BOD_ > 30 < 220 rro/L and TSS >30 < 1 50 mall ' FJfluent #2 =SOD. < 30 mglL and TSS < 30 mglL CST Name (Please Prrtrtj ,~,a~~re CST Number. Address Date Evaluation Conducted Telephone Number ~-- ~ 3 `~~ s+ . ~mer~.~e~, ~ ~ 5uoZ5 ~-/ -a / C~115~2~11- yC~U g' Property Owner Qr ~~ l f! ParcellD # . ~ / Page z of , 3 Bonrrg # ^ ~~ Pit Ground surface elev ''~ • 1D ft. Depth to limiting factor ~ I ~ in. Sal lication Race Horizon Depth Dominant Color Redox Description Texture StrucWre Consistence Boundary t2oois GPDlft? in. Munseil Qu. Sz. Cont Color Gr. Sz Sh: *Eff#1 *Eft#2 1 a-IZ ~0 2 _ Z i2.-3 I ~ ~ s. 1 k ,~,~r- c, - 5 , ~ ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil. lication Rate Horizon Depth Dominant Color Redox Description Texuun: Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont Cobr Gr. Sz Sh. *E8#f '"`B Bonng # ^ B~9 ^ Pit Ground surface elev. _ __ ft. Depth ~ limiting factor in. Sal licatbn Rate Horizon De th Dominant Cobr Redox Desatption Texture Struchu Consistence Boundary Roots GP D/ft? p in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#'1 "Eff#2 "Effluent #1 = BODb > 30 < 220 mg/l. and TSS >30 <_ 150 mglt. * EfNuent #2 = BODS a 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 department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07l00) PAGE ~ OF~_ NAME 14 r ~-e-~ L LOT# Z ~ LEGAL DESCRIPTION,U E`/4,UGP/< SZST29 N R l q E (or~ SCALE: 1"= yO BM 1 ELEVATION /OU • y ~ x BM 1 DESCRIlTION n a ,' I ,' ,~ I D ' ~ C1t-c~ c ~' -' f' BM 2 ELEVATION / )O. O l S eC . ZS BM 2 DESCRIPTION ha; l ,' ~ (~ "~ ~ v~ • SYSTEM ELEVATION ~ ~. O U ALTERNATE ELEVATION `~0. O ~ CONTOUR ELEVATION 43. a v - 9G• U o Waocl4cl~ ~}rec~ 7 bC~ ~,/. ~i ~` y, y. 3 rr ,M' `~ ~6 ~ W" 11.1/Y.. ~~1 \ ~~ ~h JV ~ 1, 1 ~ ~, (3'Z ~~''~ ~ ~ ~5 ~~. ~ ~ C v ~~ ' , ~.o d"Q ~cf S `~ ~l ~ w~'~' ~ t, ~ ,1. i ~ r ~, ~'~ ` ~ y,0 ~b RF. ~~ /fkL~ -__ Flo L ~7q• ~~ -~ -a/ i ~ h ~ " X ` ~~ ~ ; • ..r .3 A 1.0 9~ 9. b~ R, ~ / 1 / A~ ~~~ _~ ~- a~., ~~ ~~ ., ,oo ~ ~~ 94.~~1~X~~~ ~ J ~ ~ //_' `~',J ~~~ -i F1~ Y - ~ \~ ~~ 98.1 ~~~~~~~1111 \~,----- X X ,x,78 1 ~~~ A 1 + ~/ ~\ ro 1~1 w ./ 7 ~_ 981. Fit ~1 ~/, X 997. .~ A ~~ / 991 _- ~ ~! X \--~ ," , ~ o `>',r.7 ~d~ : ~ ~ .~ ~ ~ X 995.9 ~; p I (Y Q' _ .J ~ ~'- 0 i ~: ~i r' ~. SEPTZr ':°ANK E FLJMP cHr'~J':BF_Fi cRGS SCCT~ON Ar1D SPEC7F'~CATZO:~ti 4" CI VEIr'T PIPE 12" MIN. ABOVE GRADE ~ ? 25' FROM DOOR, WINDOW OR FRESH AIR INTAKE FINISHED GRADE 4" GI RISER --~~ 18" SN. 6" MAX. L 1Y LI L 1 f WATER TIGHT SEALS _~ A PPRGVED ---~- 'IPE 3' ~, INTQ SOLIO ~ C 'OIL PUMP OFF ELEV . FT . --~--- I _~___ ~ D ~tEA3HERPROOF JUNCTION BOX WITH CONDUIT .'11 ~ 3 1 '~ t vAS- ~ ` TiGHT~ '~ SEAL r ~ti r ~ I ~ 3" APPR44'ED BEDDING UNDER TANK APPkOV £D~ MANEiOLE CCV E.R W/ PADLOCK WARNING LABEL r; ,~ `JAPPROVED JOINTS WITH A LM APPROVED PIPE aN soL~nrsoiL OFF ~~ RISER EXIT PERMITTED ONLY IF TANK M.4NUFACfiURER HAS APPROVAL CONCRETE; PAD SPEvIFICATIONS SEPTIC / DOSE TANK MANUFACTURER ; ~ 1~:.~a~-R. TAtdK SIDES: SEPTIC 1`'Jt,~'~ GAL. ...__._ DOSE $b~ GAL. ALARM MANUUFACTURER: ~ ~ti~_~.~.Ttt~ MODEL NUMBER: 'p L~( SWITCH TYPE: ~ 'c`~e.as, PUMP MANUFACTURER : ~~ M:?nEL NUMBER : p d SWITCH T'tFE : ~~~, REQUIRED DISCfyARGE RATE L~~ GPM NUMBER DJSES ?ER DAY: DOSE VOLUME INCLUD:.NG F I,OWBAC K : I ~ ~ GAL . CAPACITIES: A = ~~ INCHES =`GAL. 8 ~ 2 INCHES = ~~ GAL. C = ~ INCHES = ~,-$ _GAL. D ~ INCHES = ~~ GAL. PUMP 8 ALARM WIRING AS PER ItLHR 16.23' WAC `IERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE 10~ FEET }MINIMUM NETWORK SUPPLY PRESSURE .~ FEET + (,~© E'E£T FpItCEMA2N X ~,6~FT/lOQ FT. FRICTION FACTOR ~,~-' FEET TOTAL DYNAMIC HEAD = _1~~~,~~'I FEET iNTERNAu DIMENSIONS OF FUMP TANK: LENGTH ,.,.- ; WIDTH r-~'' ; DIAM TER -'-r'" LIQUID s~ t3 ~ " ~ 1 ~~l p~.2 1 :SIGNED: _~~~---ter LICENSE NIIMBDR: ~.'~~~~'~ DATE: _ 1/88 (~ GOULDS PUMPS Submersible EfFtuent Pump 3871 EP05 APPLICATIONS Specifically designed for the following uses: • Effluent systems • Homes • Fanns • Heavy duty sump • Water transfer • Dewatering SPECIFICATIONS • Solids handling capability: '/.° maximum. • Capacities: up to 60 GPM. • Total heads: up to 31 feet. • Discharge size: 1'!s" NPT. • Mechanical seal: carbon- rotary/ceramic-stationary, BUNA-N elastomers. • Temperature: 104°F (4OgC} continuous t40°F (tiOyC} intermittent. • fasteners: 300 series stainless steel. • Capable of running dry without damage to components. Motor: • EP04 Single phase: 0.4 HP, 115 or 230 V, 50 Hz, 1550 RPM, bulb in overload with automatk reset. •EP05 Singgle phase: 0.5 HP, 115 V, 60 Hz, 1550 RPM, bulb in overload with automatic reset. • Power cord: t 0 foot standard length, t 6/3 SJTOW with three prong grounding plug. Optional 20 foot length, t1i/3 51T1N with three prong grounding plug (standard on EPOS}. • Fully submerged in hfgh grade turbine oil for lubrication and efficient heat transfer. Available for automatic and manual operation: Auto- matic models include Mechanical float Switch assembled and .preset at the factory. FEATURES ^ EP041mpeller: Therm~aplas- tic Semi-open design with pump out vanes for mechanical seal protection. EP05 Impeller: Thermoplas- tic Qnclased design for impioved performance. t Caging and Base: Rugged thermoplastic design provides supersar strength and corrosion resistance; ^ Motor Housing: Cast iron foreffiaent heat transfer, strength, and durability. ^ Motor Cover: Thermoplastic covisr with integral handle and float switch attachment points. ^ Power Cable. Severe duty rated oil and water resistant. rNETERS FEET , .. . . _ ....,. 10 i .. _.. ............... _ i a 25 ;.... ....,, ty 6 20 m ` _, +_ . 5 0 15' , .. ... _. ~ a , o ~ 3 10 _ _.. __. S ^ Bearings: Upperand lower heavy duty ball bearing construction. AGfeNCY USTiNG ~' Canadian standards Assodation (CSA listed model numbers end m "F" ar "CI'.~ Goulds Pumps is ISO 9009 Registered. .. _. EP05 ® 2000 Goulds Pumps ~ !TT IrlduStrieS Effective February, 2900 V~~~lll 63871 uic~r4~ Q STANDARD CHAMBER Quick4 Standard Chamber MuitiPort End Cap _~y- ~ r-- 12" ,l ~ 1 _,I ~, I~ ~ __~__..__-~ 3q"_ - -.•1 SIDE VIEW SIRE VIEW TOP VIEW FRONT VIEW Cuick4 Standard`Chamber Nomirfal Specifications Size {W x L x H) 34' x 52° x 12" Effective Length 48" invert Heigh 8" 'Size (W x L'x H) '"' '` 3A" x 16" x i2" :Invert H2ight 8'` or 1.25" i FIN. LTRATOR SYSTEMS, INC. STANDAR4 ~I !M TED WARRANTY lal The s-tructurai unagnly ul each clamber, end plater, weCigo arxY oliwr accessory manulaclur9d Ly Inlihra:cx ("Units"1, when nrstallod artd oPeratexJ in a leacnkald nr an rnrsae septic system in accordanoa with ;niihrator's insUUCtions, is warranted to thu original purrAtaser j"Hofdor') a(dainsl dl:leclrva mataua?s ar.~d workmansl"p for one year born the date Ihat Iha septic pemlil Is issued for the sdpliu system sadaining 1ha Uni!c; provided, how9veC !hat it a senrir. parmil is nu rerluired nY applicabye law. the warranty f»nai will bogie Upon fllo data that ir.•stallafxr of the sePtk' sy5lem cxxnmences, To oxyrcisn as warranty rights, Holder must notify Infrhratnr in rxiL:xg at Its Corporate Heaegsarters in O!rJ :,ayCrank. Connectictd within tiflean (I S) days of Iho aibgid doIEMX. IrlrllLater will supply replacement DnMS kx U!I,IS dalmmined by tnLhla!c+ In tra c<n+erc~r3 by Ibis LimiLad Warranty. InfilLatorb liability s(aclidaly exck!c!es the cost of remOVal anlfor inslallaliU: of the Units. 1141 TI1E LIMITLU WARRANII' AND HEAAFDIEA IN vl1HPARA[3RAPH Sn1 AHE F_RGLl1RIVF ' IiIiRF ARE NO p1FA IR W.ARRAMIFG 1MTH FlFFpFCT TO Ti iL UNI(5. VNCLI,DING hiQ IMf'LIEU WARRANTi'c5 - ~ hkERCHAN flBI~ITY OR nTNr• FC!!1 A AR7,L:J1NP I'IRiPCSE. t1 J 111,5 I.mlite7 Waunnty sna'I !>e veld d arry pan tY inn n'+w leer _,ystem i,; rranufaGluretl ~/ ~r.yo~lr. _.her trap mall alor. The iJmited VY;.nanN does nut extnnrl In In: inanlat. ,:nns(r, Pfanti3l, snaC~a1 rx h',dlract damages. InlAlrarcx shah rbt ha liat;le Ipr pan6lrfes or I~qudatcxJ der rlagas. innludiny IeSe of W~xsuclion and profits, labor and materials. overhead roses, a other lo5se.; a expenses incurred by the H„Ider or any th~,n1 na'ly SrhY!YCal;y eMCI!:dod Iran Liln?ad Wa!ranly oovarage are damaya to Itl9 IJIAIS dUy 10 (+rdlnafy W9ar and tear, alfaraliorr. accloort4, rn15uSC, Abrl`iC'. or naS]lall of Ih9 UaAS; tho Units being subjected ;c vedcle t+eNe pr Dthgr canditrons wMeh are nor patmurrl by Lie innlataJon instr+,+ctkris; failure Id rnanfaht the ltnimum ground covers sot !od11 in iha lnslallallon inslructk~nS~, iM placement of mpr~er ma19r4NS into the system cordainng iha Units; lailore ill ilia Llnifs or the septic system due id improper siting or improper sizing, excessive water us:.gc:, rmproprr grease disposal, a improper cJlararton: ar any miler avant nor caused by Infiltrator. This Limited Wanaray sisal: be verb d the Hofdar !aVs !o comply with all of the larms se! forth in this LlmVled Wanar,ly runher, m no avant Shag Inrili+alrr be responsible for aty loss or damage to the dad91; the Units, or arty third party resulting frd:n inslailalion or shlp- n+enl or ."pm any product liability claims of Holder or arty third party. Fa ihLs Finned VYananCr to appry, the Uru15 must be installed iq accordance with ail ails ronditlons r9quired by slate and local Cpaea; all other apptlcablo laws; and Infiltrami ; iista!lahm~ insiruciions Itl) NO repfeSP.nlal'Ne dl Infillra{or has iha atRhnnly to chonue Ur exiaix7 true Lirilitdtl Wnnm dy Nn warnnty aPPiias to any party utlw' than the prigi- nai Holder f he alxwe renrascx,ta the Standard l ieuted Warcardy uRar>3d by Inllllralor A 4mitoU number nl status and soun[ws haw di}rurant warranty rep!!ini• r110n1S. Any L~Inchaaar o! Unlt3 should ronlacl InIllUalor'S %aporale Headttuane°s N OdJ Saybrook, roruxtctk:uL Vrbr to SuU+ puuha2a, t0 oLlein a cnpy of Iha applicabW war: any, and should Carelulty read that wananly prior b the purchase u' Units. ' • 0 SYSTEMS I N C Environmental gristle Wasfewater Solutions'" 6 Business Park Raad • F! 0. Etox 768 C71d Saybrook, CT 06475 860-577-7000 • FAX 860-577-7001 800-221-4436 U.S. Patents. 4,769,661; 5,017,041; 5,156,488; 5,338,1)17; 5,401,1 1G, 5,40t,d59; 5,L•i 1,908; 5,716,163; 5,588,?78; 5,~39,&1d ter,,, Canadian Patents: 1.329.959; 2,604,564 Other patents pending. \N~r+~/ Infiltrator Cq;a!+zer aril SideWinuer arc registered trademarks of lnlillraEOr Syslenls inc Infiltrator is a registered iradomdrk in Fr©nce. Inf~irator Systems Inc. is a reyistered trademark iii Mexico. Contour, lAntour Swivel Connection, MicroLaaching, Pulyiutf, SnapLock, Chamb©rSpacer, PosiLCCk, OuickCut puickPlay eECrciearwa:n^ SECTION VIEW . , ' ~ POWTS OWNER'$ iV~ANU!#!. & MANAGEMENT PLAN Pace of - FIi.E INRORNWTtON ..--._ caner - ~1 c~.lcZ_ ~ k . ~... k .- Wit- _ o 'Number of t3edrooms ~ Q NA Number of Pubtio Faciihy Units, NA Estimated fbw taveragei ~Q'd si a pesign flow speak}, {Estimated x 1.&1 G~~ al/d Soil Application Rate .:. _ . 5tanderd MffuentlEffiuent Quality Monthly avara~~r• Fats, Oil b t3rease tFOG} S30 mglL Biochemical Oxygen Demand tBOt)a} s220 mg/L p NA Total Suspended SoNds 1T&SI 5150 mg/l Pretreated Effluent t],uatity Monthly average Biochemioai Oxygen Demand tBODsi S30 mg/i. Total 5t,spended Somas tTSSi a30 rng/L Q Nq Fecal Cofiform tgeometric means 510` ofu/10Drnl Maximum Effluent Particle t3ise Y` to dla. ©NA Other: Q N A "Values typic+d for domestic wastewater and septic tank affluent. SY TSM 8PECFfICATIONS Slip;io Tank Capaolty ,~ ~ a~ DNA Saptlc Tank Manufacturer DNA ~~ ~ff{urnt Filter Manufacturer ~ DN ~ ~ A Effluent FNter Model ~~ p NA Purltp Tank Capacity al O NA Pump Tank Arlanufaoturer r ^ NA ~ S ~ Pump Manufacturer ~,~..~ / DNA Pt~srlp Model ~O NA Pretreatment Unit ~A' Q Sand/Gravel Filter d Peat Fliter 0 Msohanicai Aeration D Wetlm~d Q Disinfection L3 Other: Diaprrsai Ceg(si DNA '. ~n•~Sround tgravityi i:7 En-Gro~d {preseurixedl 0 At•Cirade D Mound q Orip•Line D Other: ~~~' ~ NA fir' ~.iVA ~~: 1~NA lM 8CMRDtItE 8srviee Ewrrt Service Frsquenoy Inspect condition of tank{s} ~ At least once curry: ,3 ear s s lMaxfrrwrn 3 years) O NA Pump out contents of rankle; When combined si4ldge and scum equals one-third tY~ of tank volume DNA inspect dispersal cell{s} At least ones every: ~ ttlon ~ s} tMaxMwm S yearst O NA Clean effluent finer At least once every. ~ rrl0ntt14e1 ~ carts} 0 NA InaQect pump, pump controls ~ a{arm At teat once every: ~--- ~ wont its} Flush lateraia and prsasurs tese At least Anod every: ©mO al s) ~A Other: At le#tY Race ev ~' y moatthtai © carts! NA Other: ANA MAgVTENANCt MISTRUCTIONS inspections of tanks end dispersal cells shall be made by en individual carrying one of the fallowing licenses or osrtifioatlons: Master Plumber; Master Plarr~ber l4tstrictad Sewer; PQWT9 Inspector; PQWTS Makstsinar; Septage &erv~clnp Operator. Tank Inspections moat include a visual inspection of the tsnkU! t4 identify any missing or broken hardware, identify any cracks or leaks, measure ~+e volume of combined stodge and scum atld to chsuk for sny back up or ponding of effluent on the ground surface. The dispersal ceN(s} shall be viauaily inspected to check the effluent levels in the observation pipes and to check for any pondinq of effluent on the ground aurfsce. The ponding of s#fiuent on the Around eurftlce may indicate a falling cottdltion ~d requires the immediate notification of the k~cat regulatory authority. When the combined accumulation of sludge and arum in any tank equals one-third (Ya? or more of the tank volume, the entire contents of the tank shalt be removed by a 5eptaga Servicing Qperetor and disposed of in accordance with chapter NR 113, Wisconsin Admintstratiw Coda. All other services, including but not limited to the aervlcing of rffiuent filters, mechanical or pressurized Components, pretreatment uttiits:, end any servicing at intervals of 512 months, Ghat( be prrfor!'nsd by a certif'~ed POWT8 Maintainer. A serviw report shall be provided to the locst regulatory authority with 1 C dsys of completion of any service event. Page _ ®t i START UP ANI~ OPERATION Far new construction, prior to use pf the POWTS check t<eatment tanklsi for the presence of painting products ar other chemie~is that may impede the treatment process andlor damage the dhtPeraal ceNl>a!, if high concentrations are detected have the oantents ' of the tank{s3 removed by a ssptage servicing operator pile[ tQ use. - .. System start up ahati not occur when soil condition$ era frozen at tits infiltrative surface. poring power outages pump tanks may fill alloys normal highwatsr levels. When power is restored the excess wastewater will be discharged to the dispersal cellls} in one large dose. gverloadin~ the collie} and may result in the backup or surface discharge of effluent. To avoid this situation have the contents ctf the pump tank removed by a Septage Servicing Operator prior to teetering power to the effluent pump or contact a Plumber or PQWTS !Mairttafner to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles aver tanks and dispersal calla. pp not drive or park aver, or otherwiao disturb or compact, the area within 15 feet down slope of any mound or at-grade sail absorption arRa. Reduction or elimination of the foNowing from the. wastewater stream may improve the performance and prolong the life of tits POW7S: antibiotics; baby wipes; cigarette butts; condans; cott~pn swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump? water; fruit and ve~etaple peelings; gasoline; grease; herbicides; meat scraps; medications; ail; painting products; pesticides; sanitary napkins; tampons; and avatar softener brine, ABANDONMENT When the POWTS fails andlor is permanently taken out of apryics the following steps shall be taken to insure that the system is properly and safely abandoned in compliance uvith chapter Comm 83.33, Vllisconaln Administrative Code: * All piping to tanks and pies shall be discannacted and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removeii and prgpefly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be exoau'atsd and removed or their covers removed and the void space filled with soil, grove! or another inert solid material. CONTINENCY PLAN if the POWTS fei{s and cannot be repaired the fofiownp measures have been, or~must be taken, to provide a code compliant replacement system: ~/a A suitable replacement area has been evaluated and may ba ut'ttized for the location of a replacement soil absorption system. The repfacsmant area should bt3 protected frarri disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed mtrueture, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site svalua;ion to eatabfisi+ a suitable replacement area. Replacement systems must comply with the rules in effect at that time. p A suitable replacement area is not av~pllable due to setback andlor soil limitations. technology a holding tank may be installed as a 6aat teeort to roplaos the faitod POWTS. n i11Q ~n k O Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the: infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND UTHER TREATMENT TANK8 MAY CONTAIfY LE1'HAI. QASSES AND/OR INSUFFiC1ENT OXY13EN. DO NOT ENTER A SEPTIC, PUMP OR OTHf.R TREATMENT TANK UNf~R ANY CIRCUMSTANCES. OF.ATI~i MAY RESUtT. RESCi3E pF A PERSON FROM THE INTERIOR OF A TANK MAY ~ pllYFICIILT QR {MPO$81BLE. ADDITIONAL COMMfENTS IsOWT'S INSTALLER POWT8 MAINTANVER Name l./'r ~~1,'~c ~~ ~hrC3 >" Phone ~ r _ a• ~ ~ Name Phone S6PTAdE 6ERVICINa OPERATOR (PUMPER) LOC L REGULATORY AUTHORITY ntame Nairla T_ C (Zo UC Cc~tA~ l Z~_-J / fJ phone Phone ~~Se 3~(~,, ~~ This document was drafted in eortspiiance with chapter Comm $3.2~1211b}lilld}&i'f} and 83,54{tl, (Z- S {3I, Wisconsin Administrative Code. Batting advsnces in POWTS FRQM,:SCHUMAKER PLUMBING FAX Nl). :7153863121 May. 06 2005 04:49PM P2 sr cRan~c covhn~t SEPTIC TANK MAINTSNANCB AGRBBMBNT AND QVITNERSHIP/CERTIFICATION FORM OtNtlaJBtryer ~ r ylZ _~ L~ /?~~ „r ~ /~ Y ~ "T ~s'e ~i 1~'~ e / Mailing Address ~.~ ~1~,5~ 7~~ .5'~.~~ ~a s~ ,/.~etl~ e~ ~~ Propaety Address .~.., ~ ~' t (Vtxification required from City~State LEGAL DESCRIPTION ~~ ~ r DepartrneM for new Parcel Iddttificatian Number D 20 ~ (395 - Z 1 ~ wD l ~ Z~{~S ) Pmpaty Location ~~ %„IJG~ %,, Sec. ~-~. T ~ ~ N- `' W, Town of ~~~d-~ Stabdivision Si ~ ~t ~ ~' 11,5' Lot # _ ~l ~----_ Ctxtitted Survey Map # .Volume ~-. Page # W~ttritnty Dad # 7 ~ ! ~~ Q' .Volume ,~~' ~ Page # Spoc house ~ yes ~no Lot lines idetztifiable~yes D do ~, ~ N CE Improper use sad mainknance of your septic system could result in its premature failure to handle wastes. Propamsiateatanoe ootuittt of pumping otrt the tepbic tank every three y~ or sooner, if needed by a licensed pumper. what guff put irfto ~ trystan can atyect ~ iwtction of the toptIa tank as a t ttago im the waste disposal system. The property owner agrees to submit b St. Croy 7aning Department a certif cation form, signed by the owtra and by a ~Ph+~',J~i'ma° Ids. reshietedplunrber or a liexstsodpumper verifying that (1) the oa-site wastewaaerdisposal system is m proper operating eomdidon tutd/a (~) atttx inspection tmd pumping (if ~~Y)~ ~ septic tack is loss rhea ll3 fill of sludge. m'0. the uadtxsi$nod have read the above regerireavents and agree to tnaiataia the private :orvt-ge disposal system with the standards set tottb, herein, as tot by ~e Departntont of Commerce and rho pepartmetrt of Natural Resotr:ocs, ante of Wiacans>n. Gatifiution aptting that your sa~ic system hat been msimtained must be comph:ted and returned to the St. Ckoix County Zoning Office witbla 30 days of the throe year wrpiratioa date, S"lGNATtIRB O~NT DATB OWNEXt CERTIFICATION ' I (we) certify flat all sbtemoatt on this form are true to the best of my (our) lQwwledge. I (wo) am (are) the owners) of the property desan'bed above. by virtre of a avars~nty deed recorded in Register of Deeds t~tFico. SIGNATURE OIt APP C DATE sssrss ~, information that is rnis-rcpt~tatedmay nxrrlt in the sanitary permit being revok~od by the Zoning Department. s'«sasr sa ltadade Nfth this app4gtlon: a stamped warranty decd tree the Register of Deeds ofi"ioe a evpy of the certified cuzrey map if reSeaenco is made to the waasa+ty deb a . U 2694P 491 STATE BAR OF WISCONSIN FORM I - 2000 WARRANTY DEED THIS DEED, made between Duane G. Livingood and Jodi M. Livingood, husband and wife Grantor, and Kimberly Kretschner and Mark Kretschner, husband and wife survivorship marital property Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real. estate in St. Croix County, State of Wisconsin (the .'Property.,): SEE ATTACHED EXHIBIT A 779789 KATHLEEN H. MALSH REGISTER OF DEEDS ST. CROIR CO., MI REGEIVED FOR RECORD 11/12/200f 10:20A?l tiiARRAHTY DEED EXEMPT If REC FEE: 13.00. TRANS FEE: 363.00 COPY FEE: CC FEE: PAGES: 2 Recording Area Name and Retum Address: Land Title Inc. 1900 Silver Lake Road Suite 200 New Brighton MN 55112 Together with all appurtenant rights, title and interests. 20-1395-21-000 Parcel Identification Number (PIN} This is not homestead property. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Dated this 29th day of October 2004. * D e .Livin * AUTHENTICATION * Jodi Livin ood • ~ t/ ! * Signature(s) authenticated this 29th day of October, 2004 TITLE: MEMBER STATF. BAR OF WISCONSIN (If not, authorized by ?i 706.06, Wis. Stats.) THIS INSTRUMENT ~l%AS DRAfTF.D BY Greg Booth A ttorney l 900 S ilver L ake R oad S uite 2 00 New Brighton Mn 55112 (Signatures may be authenticated or acknowledged. Both are not necessary.) .Names of persons signing in any capacity must be typed or printed below their signature ACKNOWLEDGMENT STATE OF Minnesota ) WASHINGTON COUNTY. ) ss. Personally came before me this 29th day of October 2004 the above named Duane G, Livingood and Jodi M. Livingood Husband and Wife to me lyrtQwn t~ be the person(s) who executed theforegoing instru en and ciyttot~ged the same. *Nanc J Len "~ Notary Public, tale of Mi esota My commission is permanent. (If not, state expiration date: O1-31-05 *,...,,.,...:... ) °, WARRANT)' DEED STATE BAR OF WISCONSIN FORM No. 1-2000 .. .u 2ss~ ~ ~s2 EXHIBIT A Lot 21, ~ Plat of Scenic Hills, located in the Town of Hudson, St. Croix County, Wisconsin. z,, 11~ ~- . ,,..- 2.727 ACRES ~-j. 'J.I~\~ ~~ ~~ / ' ' i~ '~~, /~ `~~, i H.W.L.= 1 ~J ~~ 932.00 ~ I ~ ~9~ / / ~ ~ 1 SQ FT ~ % 'ACRES ~ ~ ~ i ~~y~ ~~ 1 /" ~ 80.95' ~ _ ~ 239.29' ~P~~ ~ o~`~~ -' ~ ~ j~ ^by~ ^~ °R ^~,. ^~,• rH.W.L. _ ~ ~ ^~ a~ ~ ~ r~ ~ ~ ~ 1 e~^~ ~P J~~ '`~/ / ~~ti 23 \ 87,959 SQ FT ~ \\ 2.019 ACRES \ \\ \ \\ \ \\ \\\; \ 4~F \~\\ \ 4s4ss, \\ \ 24 \\ \ 97419SQFT \\ ~~ 2.236 ACRES N \. ~ -~` \~~ ~-~~ y p ~ ~ ~ .~ ; `1 . ~~ J~ H.W.L. =992.2 . . c • ~ ~i' ~ /~ `` . ~ r ~~, . 111,1~'S 2.552 ACRES .~ ~~ ' 250.00' N89°50'S3"E 580.95' 111,175 SQ FT~~ 2.552 ACRES 341.66' 22 (N 108,533 SD Ff ~ 1 , 2.492 ACRES ~ 2.976 ACRES m N ~ a'- H.W.L.= 979.7-~ ~ ,-!~ `/~. I / / ~`, ll' ` r~ ... ,' ~ CENTER _ i ' / / 'i N67°44'09"W 86.54' -7 ~ .• ~ l~ ~ / ~ ~ ... ,~ 1 ^~^~°y ~'' • ~ i 89,233 SQ FT ~g"~ ~y~~~~ H.W.L,=993.5 ~ 2.049 ACRES ~ ~ j ~~ !• 21 sQ Fr