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Home My WebLink About020-1395-49-000 (2)Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Wert, Brian Hudson, Town of CST BM Elev: r Insp. BM Elev: BM Description: TANK INFORMATION u ELEVATION DATA County: St. CroiX Sanitary Permit No: 453453 0 State Plan ID No: ~ ~~ Parcel Tax No: 020-1395-49-000 Section/Town/Range/Map No: 25.29.19.2443 TYPE MANUFACTURER~+1 CAPACITY Septic t~ ~~5~2 12so Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic , > I~ ~ >i~ ~ 23 Dosing Aeration Holding PUMP/SIPHON INFORMATION n SOIL ABSORPTION SYSTEM / ~ E C Width ~ Length I DIM S 3 OT-~ SETBACK SYSTEM TO u J INFORMATION Type Of System: DISTRIBUTION SYSTEM STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer 3.9z I 1os29 SUHt Inlet ~.~~ / ~o~(-sy SUHt Outlet 5•o`f o~•t~' Dt Inlet Dt Bottom Header/Man. ~ Z~'j 19 q 2 r Dist. Pipe q•L} I(•Z~ 9g,cj~ / Bot. System lo.(} IZ.zI ,o . oO Final Grade acl~ , ' St Cover 2.25 06 q ~ Of Pits I Inside Dia. 2) /L BLDG WELL LAKE/STREAM LEACHING Manu urer: CHAMBER OR ~ - ~ ,~i ~1 , (~/ ~ L~f UNIT ModelNumber:l ~ C7 u d Header/Manifold Distribution x Hole ize x Hole Spacing Vent to Air Intake ~I ~ Pi e(s) r ~ ~O Lengt Q~ Dia Len i Spacinq SOIL COVER v Proec~~ro Cvc4amc Plniv xy Mnund Ar At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center BedlTrench Edges Topsoil 0 Yes ~ No ~~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:.~~~ ~SL~- Inspection #2: `-T-T" Location: 739 Regal Ridge Circle Hudson, WI 54016 (NE 1/4DS~W--11/4 25 T29N R19W) Scenic Hills Lot 49 arcel No:, 25.29. 9.2443 1.) Alt BM Description = 5 T ~°'"~~ ~~'~ ~~" " J ~ ~ ~~~ ~~ ~ ~~~ ~~~~~~~ 2.) Bldg sewer length = - 2 S 3) W unto oss„~ct. S•cQ.s>, ~~°'`~~"/no S~~ 3s"t2-S -~ s~ G~~^ Plan revision Required? ~ Yes No A~ OS ~ 2, /_ Use other side for additional information. ! _ +[~ SBD-6710 (R.3/97) Date Insepctors Signature Cert. No. / Wisconsin Department of Commerce ' PRIVATE SEWAGE SYSTEM Safety and Building Division , INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holders Name: Wert, Brian City Village X Township Hudson Townshi CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~Z- 2 'S"U Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic , ~ ~ ~ ~3( 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/ l tl 1 ~~ ~.,. ~.,y /~.,..L ELEVATION DATA County: St. C.roiX Sanitary Permit No: 453453 0 State Plan ID No: Parcel Tax No: 020-1395-49-000 Section/Town/Range/Map No: 25.29.19.2443 STATION BS HI FS ELEV. Benchmark (2 t/ (Z ~ ~- 2 Alt. BM Bldg. Sewer ~ lu1 ~ ~' I I ~~ ~.~~ SUHt Inlet ~/t~ rl (T , (o SUHt Outlet ~ IfZ ~ /C~ S Dt Inlet Dt Bottom Header(Man. ~ ~ 24 Dist. Pipe l ~ ~ ~ l R ~2 ( ~ 1 J ~ 3 c~ ~ 1~ Z~... l Bot. System . «~~ o i `L ' ,. -~`Z Iz.z, Final Grade St Cover ' ~ ~ ~ ( t f 2.25 BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS z SETBACK SYSTEM TO P/L BLDG WELL L E/ST M LEACHING ManylpFtur INFORMATION ~„ CHAMBER OR ((~~ Type Of System: r p~ i UNIT Model Number: n } , s ~ , ~~ ~ 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 PI'PCRIIfP Svwtc±mc Only xx Mound Or At-Grade SVStemS OnIV Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ~ Yes a No ~~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / / Location: 739 Regal Ridge circle Hudson, WI 54016 (NE 1/4 SW 1/4 5 T2'~9nN^R19W) Scenic Hills Lot 49 Parcel No: 25.29.19.2443 V • " `t 4 1.) Alt BM Description = ~ ~.Q~~S 2.) Bldg sewer length = -~ -amount of cover = l ~- C --- Plan revision Required? [] Yes ~~ No ~ ~ I i -- Use other side for additional information. ___ `___ _ ~ L____ _ _._ Date SBD-6710 (R.3/97) Insepctor's Signature ~- ~__ Cert. No. Safety and Buildings Division Washington Ave., P.O. Box 7162 201 W t-a'"~' ,,pp ~~,~,, ~?'~ ~Kl /'~ . m ~ Madison, WI 53707 - 7162 Sanitary Permit Number (ta be filled in by Co.) ,~~~~~~~ (608} 266-315 4 S De artment of Commerce lication it A P State plan 1. Nu ber pp erm Sanitary rovide ou tion l i f p y orma n In accord with Comm 83.21, Wis. Adm. Code, persona may be used for secondary purposes Privacy Law, s15.04(1 xm) Pro' Addr (if different than mailing address) 1~ t. Application Information -Please Print All Information 7 ~ C( 2g Co>~- 210 ~~ ~ ~ Property Owner's Name ' -1 - ~- ~ 2,t ~z Parcel !l Lot N Block # . ~yK3 'fig dam-- 13~ -y~-c + It1 ~ perry Owner's Mailing Address Property Lora ion 4 z3 ~~~~~~ ~ t,,z . ~ ~- ~.,. s ~ ~.., Sect;an .~ s City, State Zip Cade Phone Number ~OSd~ (^/-i. SyD/(~ as 97 /J '700" circle o T~N; R~ C Eor _ ) II. Type of Building (check all that apply) ~ /~ ~Q/~ 6~~~~-/ ~ Subdivision Name CSM Number ~ or 2 Family Dwelling - Number of Bedrooms 7 ,, f ~~' '' $C,f~r~ ~'~lr-eS ^ publiclCCommercial - Destxibe use ~ A / ~ ~Z-C ~ w ly ^Cm! QVillage ~Fownship of{l, -~ ^ State Owned -Describe Use 1[I. T ype of Permit: (Check only one box oa line A. Complete line B if applicable) A' ~;jdew System ^ Replacement System ^ TreatmettdHolding Tank Replacement Only ^ Other Modification to Existing System List Pn;vious Permit Number and Date Issued B. ^ Permit Renevvel ^ Permit Revision ^ Change of ^ Permit Transfer to New Btforo Expiratfon Plumbs Owner 1[V. T of POW'fS S em: Cbeck all that a ~1~uttis~ in.Ground ^ Mamd >_ 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Crrade ^ Single Pass Sand Filcer ^ Non - Cmtstructed Waland~^ Pressurized In nd ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filly ^ Recirculating Synthetic Media Filter hing Chamber ^ Drip Line ^ Gravel-less Pipe ^ Othu explain) / G V, Di4 rsal/I'reattnent Area Infot'nuttiott: 1 O ~ r ~ ~ Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed {~ System Elevation ~ ~ ~ fi ~t7 v ~ .7 ~ ~5~.~ 87Ur~ Vl. Tank info Capacity in Total Number Manufacturer Con~rete Constrtnrcted Steel Glass. Plastic Gallons Gallons of Units New Existing Tanks Tanks S~ ~ Hording Tani: AerobicTteutttem Unk ~' Dorins Chamber VIi. Responsibility Statement- 1" the nadetaigned, assnme srslwas[bility for lnstttttation of the POWTS shown oa the attached plans Bttsiness Phoru Nutnbu Plum s Name (Print) ~ Plumber's Signature MP/M~~Ntunber 22 ~5 z 7/ ~7~z~- 321 Plumber's ddresc (Street, Ciry, State, Zip e) h ~ ~ ~ ~~U 3f2 ~¢ ~ 1'itl. nun !De artment Use Onl Sanitary Pumit Fee {'ncludes Groundw~ Da Issued Iswin t Si at Stamps) roved d ^ Disa A ~ pp pprove Surcharge Foe) ~ a ~ / `d Q ``~~ ~ ^ Owner Given Reason for Denial IX. Con lions of Approv Reasons for Disapproval 4~ / ,~~e ~~~~ l~ )'1 l ~ Q Sa~c~ ? ~ ~ ~~~ .~{. ~f'Y 'c' ~ U'a--Q GE ~2 r9' YWU'~- Q ~~rytAJ?J SYST R ~ ~ c i 1 Septic tank, effluent filter and U ~0 ~( ~ L~ rQ,~irL~ ~ ~ , dispersal cell must all be serviced / m~ntained ®.S S-{~/1~ G-a ~ OHGUm !ln Gi-.,~ ~ ~ ~' as per mono ement Ian rovided b lumber.~ ' ~~~ ~ ~ _ /~ 2. setback requirements mus L ~„ .~~,,.-~ o~ //vi .tV<-~iN-~ -~X1.Ll as per ap ncable code/ordin `" ~w '" """ ~ - Attaea ewapfeee plain (to tha c .~ for ~e syskm •ot :ta:11 ~ sloe ~ ~r SBD-6398 (R. 01/03) ~k%~ S~ls~rn ' ~~'~ ~~~~ ~ 6 '~ / 3 ~~~o%~ Q,ud ~Q~ ~.~ ~sy~'t ~ rte.. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ~l ~/ Mailing Address ~Z3 ~~~ L~.I~F ~°~ruc-f ~/v~osc-~, L.~z ~~/oiL Property Address 4 ~ ~~ (Verification required from Planning Department for new construction.) City/State `~,os ~,~„ l..cJ= Parcel Identification Number G 2 a - l 3 9 ~ ' `~ ~1 - o ~ ~ LEGAL DESCRIPTION Property Location ~ %4 , 5~ '/< , Sec.:2, S , T ,~2~ N R~W, Town of `~os o ~~ Subdivision $ ~ w ~ t- l-~ic,L s ,Lot # `l g . Certified Survey Map # ,Volume ,Page # Warranty Deed # ~ ~~~ 2~' ,Volume o?S d Page # ~ 7~_. Spec house yes no Lot lines identifiable ~ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities aze 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 Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Department within 30 days of the three year expiration date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION Uwe certify that all statements on this form aze true to the best of my/our knowledge. Uwe am/are the owner(s) of the propscribtbove,~by virtue of a warranty deed recorded in Register of Deeds Office ~ $/'?a-~ SIGNATURE OF APPLICANT DATE ****** Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department. ****** Include with this application a stamped warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. , TIMM EXCAVATING Route 1 Box 192 WILSON, WISCONSIN 54027 (715) 772-3214 MPRS #3224 WI X06 ~~-~ic,a. (tile. ~' SHEET NO. OF ~ ,~ ..JZ~a~/ CALCULATED BY e / DATE CHECKED BY DATE ~« SCALE = v~ ' PRODUCT?OS1~Ix.,Orolon,Mats.Oi/71. TO OMer PHONE TOLL FREE I-800-7ESSiBO / ' , ,//~ ~ '~..~c - 1 ~ 9,a r ~1- d o ca ryti~ c e ~ zss~~ z --~ C. ~~~ l\ ` ~\ I SI O7y ~° S c o,,(~ 1 ~~ 1 ~, 1S•0°J~ ~9~~ __- - _ , IS,.~aly tS,L r __ -__m.. •• ---._._._ __.__._____~. ~_____ ~ Q ~j Q. ~! 9"" .~" ~ ~. °~ r .~ ~ - " ~ h_ ___ _. ___~ f ~ ~~~ ~ ~ b ..---- -- --- - ~ s : `~ ~~ w ~~~ ; ~ ~ ~y~ey~ 1' cad f q p~ahT t w.~, ~.~ S: 4a `, w g a~.,.:~~ s'~S'~ ~Qo~ ~~~ ~~ ~~ ~ V ~~ ~~, s~-(~~ S~~t Z.KEH IJ~ `1~~r;~ (Q` Qom, /6v~ ~s-` ° hR \ 1 ~ ~ ZH i-~r Q-Q H' k7 Q 1/'e_ ~(Y~1/t^'~ SUn(.~CJ~~ ~~ ~0 0.C~~.~.e e a ~ ~ ~ ~.e: ~ ~L Q.v ~. '~ ~ g -~ sa~-~ •-~l~ ~~td~ 1 gl~os zgs~ N I , ~..~ d Zo ~`~ Lod ~ ~ ~~.-~ ~5--~~5 ~~' Spa-~S-zq-~4 ~ ~---, U ~ a ~ ~ / ~ ~ 1 V '~ ~ ~ f i i i \ / ll. ~ ~ _ _ ,~ ~ ~q~ _ __ ~ ~., ., .~ ~ ~ f ~ ~~ _ ~~ ~ ~ ~, ,, Y ., r _ -- __ .- i \ / - _ f ~, ~ . -~ - l'~ ~r ~~ , ~. ~~ `~~ {A ~,_ , f ~, -~ _ - - .-___~ _, ~ ~. ~,: ~ _ ~~ .. i ~- ~. ~, ~ ~~ -. ....- ter, ~. ~ ~/ ~ r ~ .~ _. ~.. _- .. ' . `~ - - ~~ -. _ - ... -, \` ~~.,,, /' - - - >. -• l j . ~ _~-~~._ _ _ ._ 4 / i Y i ~, ~__, . --' ,_ __- f .~. _.__ --- -- - '- ' ~ ~. --~ 'i~,J `~ ~ ,~~ ~~~~ ~ ~ J ~~' c ~~ ~~ ~~ J ~ ~~~~~ \ `tea , \ ~Nt ~~ ~ ' i i ~~ r. ~ ~ J ~ .~~ ~ ~ .~A ~ _ ` ~ ~ - f~ ~ ~ -- ~u , ~ ~ ' A ~ ~ ~'~~ v ~~ ~ . ,~~, ~ ~ '~;~ ~- `\` `\\t'~`MC~,`~\~ , r' ~ `~ \ ~ i 1 r ~~ >>~. ~~ r r ~ I / - ~ ,~ ~ - ~ ~~'GIN~k~Y HI~~H WATER LINE .', ,' ,~ . „ ~ , ~, .~ / ' , .. ~ ~ ~~. ~ WATEP. LINE /, p, ~ ~~ f`j ~ ',FplNARY~ Hl~i X - ~ ~ ~~ . TIMM EXCAVATING Route 1 Box 192 WILSON, WISCONSIN 54 27 (715) 772-3214 MPRS #3224 WI roe ~~l'-~c~a~ (~t~ SHEET NO. OF ~ ~ - 16~ CALCULATED BY ~ e / DATE CHECKED BY DATE ~ « _ SCALE yb / PRODUCT 20St~lnc., Groton, Mass. 01471. To Order PHONE TOLL FREE 1.800-225-8380 r~RIG~1~~A~ Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings in accnrrlance with Cnmm A5 Wis. Adm Code 2o7s Page 1 of 3 Certified Soil Testing County Attach complete site plan on paper not less than 8'/: x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I D percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. . . 20-1395-49-000 Please print all information. view Dat Persona! information you provi may for aeeendary parposea (Privacy t.avr, a. 15.04 (1) (m~). ~ ~ ~p Property Owner y' ~ ~ ~ ~ YM Property Location Wert, Brian & JoAnn Govt. Lot NE 1/4 SW 114 S 25 T 29 N R t9 W Property Owner's Mailing Addre$ Lot # B-ock # Subd. Name or CSM# 923 Cloverleaf Circle 49 Senic HiNs City State Zip Code Phone Number City Village Town Nearest Road Hudson ~ WI 5401.6 715.386-5278 Hudson Regal Ridge Circle ~%' New Construction Use: Residential / Number of bedrooms 4 Code derived design flow rate 600 Replacement Public or commercial -Describe: ` - Parent material sandy/loamy outwash Flood plain elevation, if applicable NA General comments and recommendations: install "conventional" in-ground trench system @ system elevations 2.5-3.0' below nominal surface contours as trench center lines w/ 0.7 gpd/sq ft loading GPD Boring # -Boring }~ Pit Ground Surface elev. 100.0 ft. Depth to limiting factor 72 in~ Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP DIft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 1 0-33 7.5YR 3/3 - is 1 f-m sbk mvfr gs 1 m .7 1.6 2 33-72 7.5YR 4/4 - s 0 sg ml cs 1 m .7 1.6 3 72- 7.5YR 4/4 f2d 7.5YR 4/6 s as - .7 1.6 4 77-79 10YR 6/4 c1 p 7.5YR 4/6 scl 0 m mfr - - 0 0 ti ^ Boring # _' Boring t!I Pit Ground Surface elev. 100.0 ft. Depth to limiting factor ~ 83 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP DIft' in. Munsell t]u. Sz. Cont. Color Gr. Sz. Sh. ~Eff#1 'Eff#2 1 0-7 7.5YR 3/2 - Is 1 f sbk ds gs 1 m .7 1.6 2 7-48 7.5YR 4/4 - s 0 sg ml gs 1 m .7 1.6 3 48-83 7.5YR 5/3 - s 0 sg ml - - .7 1.6 ~< <r 'Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mglL _ "Effluent #2 = BODS < 30 mg/L and TSS < 30 mglL CST Name (Please Print) Signatu e: {~^' ~"' "`J CST Number Henry F. Grote ~ 222774 Address Certified Soil Testing a Evalua n nducted Telephone Number E. 4366 353rd Ave., Menomonie, WI 54751 8/5/2004 715-233-0398 w Property Owner Wert, Brian & ]oAnn Parcel ID # 20-1395-49-Q00 Page ' 2 of 3 Boring # Boring /' Pit Ground Surface elev. 102.3 ft. Depth to limiting factor > 78 in. Soii Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P ' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-5 7.5YR 3/2 - Is 1 f sbk ds cs 1f/m .7 1.6 2 5-58 7.5YR 4/4 - s 0 sg ml cs 1 m .7 1.6 3 58-78 7.5YR 5/3 - s 0 sg ml - - .7 1.6 1 m roots to 44" Boring # ~~ 1 Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 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 Application Rate Horzon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots 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 = BODS <_ 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R.07/00) Certified SOiI TeStlng `-_ ( p C ~1.L S~-2.5-xq-1g~ ~---, 1 O w.1'~ \~ ti ~,O ~. f (~ b._- ~ ~---- `v 2 C'~ z.zz-~~1 ~ ~_ d Z o 4-0 ' \ ~f d~esu.:~a ~L `~ / ~Qa, r ~~ ~ ~~ 2°~~ ~~~~~- ~g ~ t . Z ~~~~~I ~ 5• off,. ~ ~ ~ 3s, l6 g -t ~s~~~r (S•3 ~~ \ <1 rot , ~~ .3.5%0 + / k ~' /. ~ , 1~~~ ~ g,o°~d ' ~3-'~ f i Y 1~•oq~ ~ .r ,. / ~ ~S ~~3~~t ~ ~~. L ~p Z ~ l A t11~ jp ~ b1~ ~ Q ^~ / ~! C~ ~+•o) u...~, ~~..Q., ~K ~ ~~ ~ rs K (~ a~ , o~ ~.Qi c~ .. e ~ ~-(a ~~ 1 a ~ z'' ~ ~. we r n -~ ~ ~ ~ l q i . ~os~ ? Vitas f - tNlsconsin Department of Commerce ' - SOIL EVALUATION REPORT Page I of `Division of Safeiyand BuiMings In 8000rGance 1NIR1 Wnlm ifs, YYIS. /'Wm. Woe S-f- ~ t l i . . C o I an mus n s¢e. P Attach complete site plan on paper not lei than 81 d'cec~ion and b~lt ( d h i i l d • zon p or an e, but not limited to: vert ca indu p~oei I.D. ~1 /// Q ~ ' 13 ~ ~ - ~ ~ ~`~ percent slope, scale or dimensions, north a ~cJ. and distance ro neared road. 7 o< .Please print i~rm , ~` ..I 1 by Date '~5.04 (1) (m)).. cy Law, s. Personal informaf)on you provide maybe ndary d~~ ~ Z Q P~dyOwner o, , ~1~~~ ~ P rlyLocation ~~ ''ww 2 '~ ~~(~' _ .XJ ~. . Lot ^/ 114 114 S Z S T Z Y N R~ E (or) Properly Owner's Mai~ng Address r~ ~. ~'QUM~rI' # •1 13todc # Subd. Nine or CSNII~ ~' Z 0 S'~ i ~ ~ W i^ ICE ~ -;t ~/ 1f, '`[`"~ S ~ ~ e ~ City Stairs T.rp Code umber ~~ ^ City ^ Ydlage (~ Town Nearest Road stl: I l wa.•~-tr 1~11-~.. ~'S~0 ~Z t ~~ ~ `~ .. c~ ~ n n ® New Carlstt Use: ® Resider-tial / Number of bedrooms _3 - ~{ Code dernred design flow rate ~Sd ~~ O O GPD ^ Replacement ^ Public or commercial -, Descnbe: Parent material Oyfc~Ja.B (.. Flood Plain elevation if apprx~ble 9'Sy D R General comments S A S >4 rv~ e_ l e J a f. b n - `l /• Z~ and recommendations: ~,1.,,~ e. I -e.J a ~1~-.`0 ~ -- .9 Z • ~~ ! t Boring # r~~ ~n9 _ Lpl Pit Ground surface elev. ~ y' ~' ~ R Depth to limiting fadnr ~ l b in. Sod licafion Rate Horizon Depth Dominanf Cobr Redox Description Texture Structure Consistence Boundary Roots GP D/fi? , in. Mansell t~,l. Sz. Coat Color Gr. Sz. Sh. 'Eff#'I 'Eff#2 I b-I~ 1~ lZ -- 5L l l •~ . ~ ~ ~ ~~ # ^ Boring ® Pit Ground surface elev. ~ ~' U ft. Depth to limiting factor l) in. Sod Rate Horizon Depth Dominant Cobr Redox Description Texture SWdure Consistence Boundary Roots GP D/[P in. Mansell Qu. Sz. Cont Cobr Gr. Sz. Sh. ~~ 'Eff#9 'Eff#2 o l Iz - s~ ~ ~- -~ ~. ' Efliuent #1 = BOD_ > 30 < 220 ma/l_ and TSS >30 < 1 50 mcr//L ' F~fluent #2 = BOD . < 30 mgll. and TSS < 30 mglL CST Name (Please PrrHSSt) - -. r' S'~re ~~ CST Nuni~el' Address Date Evaluation Conducted Telephone Number Z,ll 3 ~~' ~. `Sprn r~ a>1 S`{~25 ~ - ~-G/ 7lS-Z`~7-~fcaDfj r ~ property Owner ~-Y' k~ ~ ~ ParcellD # Page Z of 3 Boring # U Boring ® Pit Ground surface elev. q • Z d ft. Depth to limiting factor' i z-~ in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consister-oe Boundary Roots GPD/f~ in. Munsell Qu. Sz. Cont. Color Gr. Sz Sh: "Eff#1 "Eff#2 i ~-~ ~o Iz sl_ ~ -~ ~ I.~ -~ . 4-~ • ~ 2 ~,~Zv I S mi _ _ 1 ), 2 ^ Boring # [-~ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil. ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPO/f~ in. Munsell Qu. Sz. Cont Color Gr. Sz Sh. `Eff#1 "Eff#2 Boring # ^ Boring ^ Pit Ground surface elev. eft. .Depth fo limiting factor in. Soil lication Rate Horizon De th Dominanrt Co Redox Description Texture .Structure Consistence Boundary Roots GP D/fl? p in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. 'Eff#1 *Eff#2 " Effluent #1 =. BODE > 30 < 720 mglL and TSS >30 < 150 mgll ` Effluent #2 = BODS < 30 mglL and. 7SS _< 30 mgll. The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. SBD-8330 (R07Po0) PAGE ~ OF~_ NAME 14 Y` K -~ ~ ~ LOT# `/ Q LEGAL DESCRIPTION/ E '/esw'/4 S z5 T29 N,R f`(E (or~ » v y ~~~~ a~ • .. ~P~ i,,,~ d r j h qw ,t~,~ .T~ C ' ~ i ~ SCALE: 1 = BM I ELEVATION /OU ~ O BM 1 DESCRIPTION h Iy ~O~_ BM 2 ELEVATION j0 ~ • U BM 2 DESCRIPTION ylu; ~ ~' ~ 10'` Dale SYSTEM ELEVATION q j. z U ALTERNATE ELEVATION RZ ~ ~ U CONTOUR ELEVATION 4y Sv q§' So ~~ ~~.~~ ~~U X ~s G\ , _, < ~.-Q , q a w ~ ~~ ~ b~~ ~~ / ~..ca d r Uv r-' ~r 0 ~ ~,~- ,,11 ~~ O q ~~ a / n app ~~ ~~' °~ k~ ~.~ ~~ ~._-- DATE ~ - G - O/ . ~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of 2 FILE INFORMATION Owner ~ Permit # ,~5~ (/ DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units A Estimated flow (ave~agel ~f Q (' al/day Design flow (peakl, (Estimated x 1.5) (~ gal/day Soil Application Rate Q al/day/ft2 Standard Influent/Effluent Quality Monthly ave rage* Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODE) <_220 mg/L ^ NA Total Suspended Solids (TSS) <_150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand IBOD51 Total Suspended Solids (TSS) <_30 mg/L S30 mg/L ~ NA Fecal Coliform (geometric mean) 51 100m1 Maximum Effluent Particle Size Ya in dia. ^ NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity ~ 2 ~~ al ^ NA Septic Tank Manufacturer S ^ NA Effluent Filter Manufacturer ^ NA Effluent Filter Model ~ ~ ) Q ~ ^ NA Pump Tank Capacity al ^ NA Pump Tank Manufacturer ^ NA Pump Manufacturer ^ NA Pump Model ~ ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: A Dispersal Cellls) ~'In-Ground (9ravi 1 /^\ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA MAINTFN~NCF SCHFI]I11 F Service Event Service Frequency Inspect condition of tankls) At least once every: ^ monthls- (Maximum 3 years) Z ^ 3 earls) ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third IY31 of tank volume ^ NA Inspect dispersal Cellls) At least once ever y: 3 ^ year(sllsl (Maximum 3 years) 2- ^ NA Clean effluent filter ~~~~~ At least once every: / ^monthls) ~ ear(s) ^ NA Inspect pump, pump controls & alarm At least once every: ^monthls) ^ year(s) ^ NA Flush laterals and pressure test At least once every: ' ^monthls) ^ yearls- ^ NA Other: At least once ever y' ^monthls) ^yearls- ^ NA Other: ^ NA 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 tankls) 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 Cellls) 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 the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY31 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. ~P2ge ~ of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal celllsl. If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal celllsl in one large dose, overloading the celllsl and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 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 the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain Isump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS faits 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 measur/e/s have been, or: mus~t,,,be/t~ak/eJn~, two provide a code compliant replacement em: ~_ ~~'",~-~--~~ ~C%G2.L//Y~c~ v` `-C ~ 'mil)-"~'C~ suitable replacement area has be evaluated and may be utilized for the location o a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ^ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. T ~~ alua ' a o ing tank be ' e ai a ~Rf]f-118 T?~ ~C~ /~/Lti/ ~NS7Rt1~Or~! ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLEfi~ Name d~~`7Z ~ ~l'I !'Y~ Phone ~ /s ~ ~ ~ 2~ POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name ST. ~ l d(/N 201J~~ Phone "715- 3g(~_ (0 (~ This document was drafted in compliance with chapter Comm 83.221211b11111d1&If) and 83.54111, 12) & 131, Wisconsin Administrative Code. . ,, , ~~ ~ U 2510P 57y STATE BAR OF WISCONSIN FORM 1 - 2000 Document Number WARRANTY DEED THIS DEED, made between Carriage Homes XXI, Inc., a Minnesota corporation, Grantor, and Brian E. Wert and JoAnn L. Wert 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 Recording Area -75442` KATHLEEN H. 1iALSH REGISTER OF DEED5 ST. CROIx CO. ~ YI RECEIVED FOR RECORD 0i/i?/2004 20:00AM MARRANTY DEED EXEMPT N REC FEE: 13.00 TRANS FEE: 429.00 COPY PEE: CC FEE: PAGES: 2 Together with all appurtenant rights, title and interests. Name and Return Address: land Title Inc. 1900 Silver Lake Rd #200 New Brighton, MN 55112 20-1395-49-000 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 15th day of January, 2004. Carriage omes XXI, Inc. * Kellei St. Martin, Vice President * AUTHENTICATION Signature(s) authenticated this 15th day of January, 2004 * TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY ACKNOWLEDGMENT STATE OF MINNESOTA ) "WASHINGTON COUNTY. ) ss. Personally came before me this 15th day of January, 2004 the above named Kellei St, Martin, Vice President of Carriage Homes XXI, Inc., a Minnesota corporation to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. * Arnette D. Theis Notary Public, State of Minnesota My commission is petTrtanent. (If not, state expiration date Gregory A. Booth, Atty, 1900 Silver Lake Rd #200, New Jan. ) Brighton MN SSl 12 •, ANNETTE D. TF1E!S (Signatures may be authenticated or acknowledged. Both are not necessary.) .tk' NOTARY PUBLIC -MINNESOTA 'Names of persons signing in any capacity must be typed or printed below their signature My Cu~.~m. Explras Jan. 31,2006 WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1-2000 I~f t U. 2510P S75 _ -~.~~. EXHIBIT A Lot 49, in Plat of Scenic Hills, located in the Town of Hudson, St. Croix County, Wisconsin.