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HomeMy WebLinkAbout020-1395-51-000?~'~sconsirx ~:partment of Commerce PRIVATE SEWAGE SYSTEM ~ $i~rety and gilding 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: City Village X Township Carria a Homes Inc. Hudson Townshi CST BM Elev: Insp. BM Elev: BM Desc ' tip~~ rum. ,~.~ ~~1~, ~.l l cs~ 0;;:-.-~-r w~-~._~~ Ct7u r ~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing ~~, ~., _ ~~ Aeration ~.~ Holding "'~---.._ ~~~.~-~~ I~7 ~ c~•~ - TAWK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ } ____ G_~ Dosing Aeration Holding "'-- PUMP/SIPHON INFORMATION l~. Manufacturer __ ___. _ _ r- Demand GPM Model Number 1 TDH Lift Friction Loss System Head TDH t Forcemain Length Dia. - Dist. to Well - SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: 430435 0 State Plan ID No: Parcel Tax No: 020-1395-51-000 Section/Town/Range/Map No: 25.29.19.2445 STATION BS HI FS ELEV. Benchmark ~ ~~~~.~ c ~, , G Alt. BM Bldg. Sewer °~-~ ~/ ~ f, rc~ SUHt Inlet - c.-- St/Ht Outlet ~ . ti/ S r G .'S" Dt Inlet Dt Bottom Header/Man. ~ ~ i~-~ Dist. Pipe Bot. System ~ `~ '~ n • Final Grade St Cover 3~2~ ~~.~ 3ED/TRENCH Width ~ ~Leng~l l INo.OfTrenc~es I IPIT DIMENSIONS t:< ~ ~~ INFORMATION L~ ~ _ ~' CHAMBER OR Type Of System: / //~ // rr// j UNIT DISTRIBUTION SYSTEM ~- :: L ~' -- Header/Manifold Distribution - L~ Hole Size e K Pipe(s) -° ,= ..__- ___- - -- --- Length ~ Dia `~ " Length Dia -SPacin9..---- - SOIL COVER x Pressure Systems Onlv xx Mound Or At-Grade Systems Onlv Dia. -_ Liquid Depth 3cturer: Number. it r y1~~Y ~_ , 4 _ Vent to Air Intake Depth Over ~ B lT h v <-% Depth Over xx Depth of xx Seeded/Sodded xx Mulched renc Center ed (1; Bed/Trench Edges Topsoil L] Yes ~ No ~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~ /_~/~ Inspection #2: / / Location: 741 Regal Ridge Hudson, WI 54016 (NE 1/4 SW 114 25 T29N R19W) Scenic Hills~ot 51 ,~,~ ) Paljcol No: 25.29.19.2445 1. Alt BM Descri tion = _' ~ - C'r "' ~ ,l p ,a~ ~S ti's-. ~la'S ~_~.v fv }~.~ : r- '~i~.~ ~~lC~ ~ ~ G~~ 2.) Bldg sewer length = ';2~ . 7 5 t.~i c_ c ~~i/ ~ '/ -amount of cover = Le ,~,:r ~ ~ ~~~~/~., ~~ 'F' I ~ C 1.~,ti,. ~, U.,,,,,~,L, ~~ Plan revision Required? L Yes No ~, Use (ither side for additional information. ~ ~_ I ~ -~ SBD-6710 R.3/97 / ~ Date qq ~ Insepctor's ature f, 11 Cert. No. f SaYnty and Buildings l~aivisiun I ~~~ , 201 W. Washitt~ton Ave., P.O. Sox 7162 WI S37QT - 711;2 ~ ® ~ I Madiaon L~+nty „~ ~ G Y~~ .. K -- Sanitary Permit Number (m be tlilad in by Co.) , ~~~a~~ ~ S (boa) 266-3151 ~3 Dt: artment of Commerce . . AID ~ State Plan Z.D. ;umber rcatlon Sanitary F~rm>lt App ersonal information you proyi Coda Wi Adm 83 21 i h C i d , p . w . , s. t omm n accor may be used for secondary purpnses Privacy I.aw, a1S.04(1)(m) I. Application Intortaation - Please i'PrLat Ali Infocmatiot: Q ~ C`- F ! Ol ~ F° ` . ~ , Pmject Address {if different than mailing addrassl -~ ~~ ~~ ~ / _-,r` 9~ 1_ Property Owner's Na me h ~ an ~ s r' ~~I~~ i ~ ~ 2.~0~ Dicxk ~` j Parcel ~ Lot N ~l I Y ~ c Property Owner's M Address ~ ,;; i/f;vli:CUui~,' Properry location ~~ r ~.Sd S ~ fi~~ ~ iNG Of FICE i ~'~,~~ G~ ~, ~~~,i,5ection 2S k City, S Phone Number Zip Cade ~ C v 15.~G) ~~- ~ (circle or) t Il. Type of BuildinS (check all that apply) ~1 or 2 Family Dwellrng - Number of Bodrooms _,,,_,~ v Subdivision Name C5M Number ^ PublieJCommercial _ Describe Use .~ c ~ fs ^ State fJwned -Describe Use ~ ~ ___ ~. ~ CCity~l~Viliage ~1'ownship of ~ SG III. Type of Permltt (Check. only one box on line A, Complete Una B if applicable) A' i ~ New 5y:tern ^ Replacement System ^ TreatmenilHolding Tank Replsu:ement Only ^ Other Modification w Existing System $. ^ permit Renewal ~ermit Revision ^ Change of List Previous Permit Number and Date Issued ^ Permit Transfer to Naw Before Expiration ~ Plumber Owner ~ ~ i ~ I_V• TY.pe of POW'PS System: Check all that ap ps) Non -Prouuriaed in-Ground ^ Mound > 24 in. of suitable soil ^ Mound < ?rl in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ~ ^ Peat Filter ~'i Aerobic Treatment Unit ^ Recirculatins Sand Filter ^ Constructed Wetland ^ Pressurized in-C3rounC ^ Holding Tanis ^ Recirculatin S nthetic Media Filter eachin Chamber ~ Dri Line ^ Grave!-less Pipe ^ Other (explain) V, Dls rsaUTreatment Area Infarmatlon: Design Flow (gpd) Daslgn Soil Application Rata(gpdsf} Dispersal Area Required (sfj Dispersal Area Proposed (af) System Eicvarian VI. Tank Info Capacity in Total Number Marntfacturer Prefab Site Steel 'Fiber Plastic Galiona Gallons of Units Concrete Cott:ttucted Glass Now iadns Tanks Tanks Septic ar Ho14lnQ Tank Aerobic Treatment Unit r ` tSosint Chamber VII. Rea rtalbwty Statement- I, the tiindersi d, aaaurne res onsibWty for tailation of the POWTS shown en the attached Pfutn[.[er's Na ma (Print) Plumber's Si gne~re M MPRS Numbar `-- Business Phone Number f Plumber's Adtlre ys (Street. City, State, Zip Code) / /f / q VIII. Gount !De arttnent Use Onl , ^ Apprav~d ^ Disapproved Sanitary Permit Fae {includes Groundwater Aate Issued Issuing Agent Signature {Na Stamps) ; Surcharge Fae} Ci Owner Given Reason for Denial i ~ IX. Gondlttons of Approval/Reasons for Dlsapprovai 1 ~"' ~ i -- Atho- eoaspbit plain (to tAe Couaty Daly} far tht~ syitwt oa paper avt toss ttwa ill2 x ti Luhn la sly SBD-398 (R. O1/~3) Z~~'. ~~~ ~~/~~G 5 .~~1~'G ,Co Z` Jrf .SC~'G..ri ~ ~r IIS ~~GG~so.~/ ~ . Wisconsin DeparbneM of Commerce Division of Safety and tiulidings SOiL EVALUATVON' REP f~-«) Page ~ of m aucorpancx3 wrtn Comm ao, rvis. twm. ~.ove County Attach complete site plan on paper not less than 8112 x 1 ~ include, but not Urrdted tx vertical and horizontal reference -. int ( ~ ~ ~ Parcel I.D. percent slope, scale or dimensions, north arrow, and bcati and d neart3s toad. ri Please print all lMormati n. Reviewed by Date Penronel bsformation you provide may be used for secondary pu ~/ ~ 1 ~ ~, } sea {Pr law~• ~S.u9 ~{my~n)). Property OHmer ~ Property location i~~ . ~ ~ ,.~Q, .J~ Vii' ZOi~JI i~~,U~i: , (~d}lt.F~E,~!/~ 11ASLClI14 S~5' T.?q' N R/~ E(or~ Ptopetty ONrtter's Mailing Address Lot # 8lodc # Subd. Name a CSM# 7.5"O' Si ,"l ,rev ~~v~ .t/~ ~/ rt•~ ~' City State ~ City ^ llilfage ~ Town Nearest ad [~ New Canstrudior- Use: ~ Residential / Number of bedrooms.,~.:~_„-. Code derived design flow rate ~~, O d GPD ^ RepiaCement ^ Pub6c or oofrknercia! - Descxflae: _-~_.~ __ ._.._.~ _~ Parent material ~ c ,~~ ~,JCx C In Food Plain elevation if apptlcable ~li~i~ #. a Pit Ground surface elev. it. Dean to Amiting factor - J 1 ~ in. # ° ~~ F ~- = - - - -- Soft Rate Horizon Depth Dominant Cot Redox Description Texture Struchxe Consistence Boundary Roots in. Mansell qu. Sz. Corrt. Cobr (3r. Sz. Sh. 'Eff#1 'Eft#2 I Q-l~ 3/ - sL mS.~IG G ~ ~ ~ 5 ~/ ~ r~ -z io - ~~ lc ~ s -- , 5 r 3 25J~ ~ -- s ~ - ,z ~ - ' L1J Y{i v+vtsw otn law vrev. r c~ -...~ - n. ueput rA urruung racapr ..1. i _ !n. .SOY ication Race Horizon Depth Dominant Color Redox Description Texture Structure Gatsistence Boundary Roota t3P DffF in. Munsefl Qu. Sz. Cont. Color Gr. Sz Sh. "E1T#1 "Etf#2 3 - ~ % -- vY- l -- - . ~ , Z " Effluent .#1 = BOD > 3il < 220 mglL and TSS >30 < 150 rt)gIL ' Effluent #2 = $t)D < 30 mg1L and TSS < 30 ttgR. CST Name (Please Print] tore CST Number ~ S" c3 Address tote Evaluation Conducted Telephone N P~~ a"'r~ --- Parcel iD # Pit Grotmdsurfaoeelev. lj~",~, a~ ~ ~~ Depth to IirnltN~g factor /%S ~n Page ~ Z of ~_ Horizon bepth i Dominant Color M N Redox Description Texture - Struc#ure Consistence - Boundary Roots soi --+ C3P caHon Rate DI-f n. unae Qu. Sz. Cont. Color Gr. Sz, Sh. "Etf#1 •Eff#2 3 z~ -~ls ~~ l(o `~ o s ~- ,~ '~ , Z e°r"'° # ^ ~''~ n eu Ground surfarA alev rb.,w.... is..,:~;..,. ~..,,. Horizon . Depth ~. ... Dominant Cola - -- --- - - _~r. ..............y .o... u.. Redox De9piptlon Textre Strex~ure Cor>sislence Bourxlary Roots SON Rate GPD/fF in. MurraeN Qu. Sz Cork. Color Gr. Sz. Sh. 'Effftt •Eff#2 LJ ~~ # ^ 8orkg ^ Pit Ground sutieoe elev. ~ ft. Depth to Nmiting factor in. Soft Rate Hortmn Depth Dominant Color Redox Desaiptlon. Texture Stnxture Corraistence Boixrdary Roots P in. MunseM thr. Sz. Cork. Cobr Gr. Sz. Sh. •Eif~1 'Eff112 • Eilluent !F1 = BOOS > 30 ~ 224 mglL and TSS >30 _< 150 mgJL • Effluent #2 * Btx?s = 30 mgiL and TSS _< 30 rngtL The Department of Corrsmerae is an equal opportunity service provider and employer. If you nced assistance to access services or nced material in an alternate format, please contact the department at 6Q8-266-3151 or TTY b(18.2b4-8777. SBD-1330 (R.d00) 1 ~' ~-3 ~ i~~. sa 2' ~`. V~ ~~J~" SIGNATLIKE: ' pAGE„~OF~ NAME: rv~~~~~~~ LOT#.~ ~ LEGAL DESCRIPI'ION:_?l4_I/4,S T_,N,R, E(or)W SCALE: 1"=,~~' U~ ~,,n( ELEVATION: 1 O d BM 1 DESCRIPTION: -~c7 O a -~ Pa~ y ~6~ f S.' / / BM 2 ELEVATION: ___~. BM 2 DESCRIPTIC}N:_ SYSTEM ELEVATION: 9 ~/. D y SYSTEM TYPE: Cc~,~, c/ye. n ~ ~' ' /~ ~ -~ TE: ~ z/ ~ ~`~~`. ~~ , ~ FROM :SCHUMAKER PLUMBING FAX N0. :7153863121 May. 06 2004 08:13AM P2 ~a-r'Yg`a.~'~ r~017~ ~ Z~c. ,Lv~ 41 S ~~~ ~ ,~z"/ /_s ... f~udC.s_~- i _ I I X r~ "" i ~ d~~ ~~,~ I ~~J ~~ ~;~~Jr~~ s~ ll/~ ~ ~ ~ ~ ~ ~ ~~ ~~ ~l P~ ~~ ~~ 4 ~ S ~~ G ~ ~~ Vr. -~ i l-L-~ ~ ` w %Y'~ ~<b~~ ~~~ ®G~ ~~ ~~[ -~-~~ ~~ sJ ~ ~~ _ ~~s FROM :SCHUMAKER PLUMBING FAX N0. :7153863121 May. 06 2004 08:12AM P1 ~~ ..~. ~ -..._ _ - Satoty and SuiWings Vi~iafun• 7162 S I , Ccx;nty T G Ya k ax zol w. washirrptonAve., P.O. ~~ ! Madiaaffl, i~Vl S37t77 - 7162 r ~O~ ,.~ Saniury Permit Number (m be fliled in Dy Co.) , ~ $ Ct30S) 366.3151 I N,~,~ De artme~c of CoMmer~e .., ~"'° ~"'° ~' ' ~`"~~" Sanitary Permit Application ' ou Drw•icle d iutarrtutGon rlo A9 21 C04C I i h C Wi Ad p y . , pe t , m. omm a. n sCcvrd W II rpriy 6e uaed for iecoaduy pt~rot~a Prirscy Lw. c13,M(1ktN PtQ~tct Midrtas (if di~hreut thin mew sddf'tssl ~t. ApptiepRlols ite[ortmcim - leteue Melett Ali rlttomeatian -? ~~ i~y r~'~ /L H'operey Owew's Ns the --• 8:ock y ; PtirON P Lsl N ~ r- i G 6+ i*7'1 e s l lropet~y Owner's >K Addreat Ptoperw location ' S~ / ' ~~~ ~ i/~ Se¢tion ' ~S ~~ ~ Ci S s v . ~ f~ ty, re ( iaoae t wltber Z ~' ~ ~ ~ s d Pte- R~B o T ~ N A, 'fyise o[ SWltiist~ tehectc sell l>bat rrpplY) - ' ~ _- ~1 or 2 Family I~valtiag - Nwnbse of Bedroorats SwhtUvtalon IWsne CSM Nuanber I __ ^ Public/Cosnmereial - Deaacrttx Use ~ r ~ ~ ~ ~~ Sratr Uwtxd - Dattctthe t)se .... ' li~~Ciry CVilittye: ~1'owntMip of IIT. 'lip. of il~eraltte (CbeClc o-lIy arse bou an tine A. Colnylets line H It applicable) _ '~ ' ; ~A ioW Sy attn C Reptacemeoe Syrseta ^ 1~Ntmenl~}loldinS lank Rspla+~enront ody ^ Odtlr Alodifjcation to Eteisting SysNm - -- ~ ~ ~ - ~'- @. ~ ~ Permit Renewsl ~Pertnk Aevsion L cha>yle nr !~ Permit TranRtmr to N.~ Llsr Previeus~erdtii Nwnber ie-d~ite Issued 8ebte Prtplruion ~ Pltunbor Owttet t i IV~t' ~e of POWTS 9ystetn: (Check Ail that Op p! 1 _ 1~+ 1Von •4tsetwttred ir-d3round ~ Mouud ~ Z4 in. of suitable Boll ~ lttougd < 1d in. of luinble ooi! ~ Atlittida ~ Sitl(tle 1+ret Send Pilur 1 r ^ Corattvcted ~etlana Q Pnswrlaad in•Orourt t~ Ho;direr Tank ^ Peas Fatter C Aerobic Troettnent Ualr ~ )teeircu:etlnt Send Ftltcr ltrclreuLue S nrlsatu Media pptar eaotsin Citrsnber C Drs Line C ciravol-I~gs Pipe [~ OdUV (espltiit~ I TiQUTti'eWls;i®t Arsq I111!4a~lAti4110 i -- Aesigta Plo. (px~ i Da(yt Sotl Appiltartan Attd`pdefl Duperral Area Required (et) f t)ispernl Area Propnaed Ufl Syttstn P,levadon i 'VI. Temk Info Capacity iA Total Number MatraFacturer Prebs Sits Steel ~ giber ?lasde I Gelloes Gallons of L'uia Gnncrae Corrat3uctad Gran Ncw Isdeti I T Teaits SMtIc or Noltllne Truk s Ae~ c rCt•IrHerK Uslt ~ ; pwieY i ~ VII. R lylbWt 5tlltemeat- I, rho lrsdatyl , eKatuae Brat onytbWty for eilatloa o[ the P0VY'T9 s6owa on tLe atfeclred ' Plunuer'; Ne rt>r (print) Plumber's 5i jreiture M MPRS >t'utnber BWirtew phone N•.ttnber PWroter'a Adtba w (s'Reer, city. tisate, ZIP Cade) sc - ~J, • ~-~1~~ ~ VIII, Cougt / __ De tutolegt Use 0t11 "-""~'~ Q APPro~Qd LJ Digpprovod Seniury Permit Fee (includes aroundvuf<ter D,*.e ltistled ;aeulre ASeat $iSriature (!tie ~tntrpi) i Surcharge Fro) ^ Owner Otvan Jittasoe 1br laenlet + ~~ CCOdtilAR a ai[ Ahnmvsl/te.~...~ e~~ n._--.-.-----.~"'~' T'-/-h'~)- , _-.. ) I "T 7" Y Ut;~ V ~"~ ~~ - /yt~ 1'1G1,~-~ ~_ > ACS ~, D - ~-- .- ••~. -...~..y ~Merur sw~ ynas~a paper poi 1~ titee iUJ >r 11 leeJtes !s eHe CRT1~sG9oa iv nr .nom. / FROM :SCHUMAKER PLUMBING FAX N0. :7153863121 May. 06 2004 08:13AM P3 Olviaion of 8aUa~y and BtaNdlt~gsrnar~ SOIL EVALUATION REPORT L~ e.w...In..w..aJr. /~~~ sr ue_ ..~ .._~_ Paps ~ of Attaoh aomplsk, Nto pltln on paper not Iw 1F)en ®112 Y 11 inctws in size. Pisn nK~st `~"~ p7 incaude, but no! MMted q: v+e~cal ans, herizonW refaranee point (BM), drrc4ion snd peroent sops, fascia or dU~ensbn9 rwAh snow o w+d l t{ nd di t Pard I.D. , , e s o on a s ances ro nsaest nsaal. P/ea~w pNnf a!/ /~fbr~at/oA. Itartare4 ~Y Data P«rond Inlawrt~ien feu proWaq gas h w•4 for Moq~y vWi~oevs (P'rNaey taw, •. ~ S-o1(S) lm!)• ~p'0+1Y ~' PrepaAy loestlon ~. ~ S Qort. Lol ~/~ 1/O.Sl~j1N S?S T9Q N R/Q E (or~ F'n~petty Otwrtefa MiOf~g Address lot ar 81ack ~ Stud. ar CSAM- ?,S® .5 der B.[ra1 .dd ~/ .~ . ~" City lAKape Town tWs,~est ~ Nswcorseuralort uee:6] Raddends~! Number~r~a,~_ 3 ;,y coda a.~.e aos~n noW rata yS'o%rQ c~ o oPo ~ Repla~nlbnt ^ Pubic a aon)rtlardsl - pesot~e• ______., Parentrtieitedsl Dc r ~J ~ .C1.~ Fbod Plak~ ekvetion Mapnllcabls __ ~j~ ..,..., _ ~ ©ep~° ~ p pti~D Grand surfaos ekv. ~q,'~ s, t~aplFt to NrNgnp rt~r I15~' in. seas t'tO~^ ~f Oa~r+In~rt< Redas Desatipdora Tertnxr Seucaur+e t:araststann epurdary Roots in. Munwtl (~1U. Sx. Cann Cdor .ttr. 8z. 5h. 'tEifp1 '(r11~ z r~ - ~ ~ -- ~~ k. c. S -- , . 3 zs-! ~ - ~ -- -- , Z L~ .1 ~"0 ~ ~ t~ c~rour,aw~aoe.lo~-. 9g 5~~. . °'°Mr b ts,rv~,~ ~ ~_ ~ ~ Rata t-tortzan ~ flolnlnant fbedaec Deseiption Ts~rv 81rYd4-e Gormitter~oe 6amdary Rats CsPGA~E ~ ~~ Qu. Sz Cont. Cate. Or. et. ~. '211181 •Ehtli2 Addax ~N3 -I2.0~ IOVr ~~(o ~ `- S16a~ . ~ 90 a ?20 ~ find TSB >3p < 160 G , ~~ Et>wera ~' ~~ ~ 90 tr1yl, orld T$S _< 90 - ~ ~-- F;OM :SCHUMAKER PLUMBING FAX N0. :7153863121 May. 06 2004 08:14AM P4 PAGB~OF NAME: r~a~LOT~~l LEGA.r. DFSCRiI'Tl4N:{__I14TI/4,S 1__,,,,,N,R, Etar)W /' \ SCALE: 1 '~ U „~ „ ~„n~ Er,EVATION:~O Q ~ y _.~....._ ~'`'', BM 1 l~r~SCR1P7'ION:~,~ o •~ ~~ ` ~ S.' J / I3M 2 ELEVATION: ~~ SYSTEM ELEVATION: 9y a ~..-.. _-, SYSTEM TYPL':~s211 ~•~~ /"' /... ~'.`,~-----,--, ~~ ~~d~ ~~~ ~•~ ='•?. T w- r:. ~,~' 1 S-~ dl \1~' ~~ ~ r 7 t«_; ~ ~ i :.<t .~ q .Z ~ ~- -, ,, n z ~:r -r ~z `'--~ r ; 5~~~-~ IC. `r- ~Z f:\ ~ ~-t~,, e, ~ ^t• S'~~~ s~:r~ `~`titfi T4~ Y~G~ \5' J C.~ y( J ~~ ` ~ ~ ~~ ~, ~ ~~ L7~ 1 ~ ' Safety and Buildings Division 20I W. Washington Ave., P.O. Box 7162 County ~ -~ S7r~YG~X ,~ CO~~',n Madison, WI 53707 - 7162 Sanitary Perm it Number (to be filled in by Co.)~ De artment of Commerce (608) 266-3151 '~ // ~30 '-t'3 Sanitary Permit Application State Plan LD. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used for d ..._---- secon ary purposes Privacy Law, s15.Q4(1)(m) Project Address (if different than mailing address) I. Application Information -Please Print All Informati ~~C~1~~~ ' ~ ~~~ ~~ ~ L ~' I D~C Property Owner s Na me `~ ---(---• ' Parcel iY Lot !I Block d ~ Property Owner s M ailing Address ~ ~ r G'~~'d sT c ~ of ~. ' i operty Location City, State Lip Code Phone Number ~=`=-'k'sfi/'~ Section ,s'T llu.~ot-1~-GY ,~ ~ tJ J ~ ~ circle o II. Type of Building (check all that apply) T ~~ N; R~Eflr~ ~ ,5 ~~ j ~ 1 or 2 Family Dwelling -Number of B rooms Subdivision Name CSM Number ^ Public/Commercial -Describe Use _ ~ ~~ ~~~ ~~'/lS i~ State Owned -Describe Use ~ - ~. I ^City_^Village ~ownship of ~~u,,GJ III. Type of Permit: (Check only one box on a A. Complete line B if appli le) ~ 2D - J3`1~- S/'- oZR7 2 S A. New System ^ Replacement System ~ TreatmentiHolding rank R lacement Uttly I . ^ Other Modification to Existing System B• ^ Permit Renewal Before Expiration ^ Permit Revision ^ ange of ^ P it Transfer to New Plwn O evious P u ate Issued i w r JV. T ype of POWTS System: (Check all that a~piy} Non -Pressurized !n-Ground ^ Mound > 24 in. of suitable soil ^ and < 24 in. of suitable soil t-Grade ^ Single Pass Sand Filter ^ Constructed Wetiattd ^ Pressurized In-Ground ^ Holding Tank Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter Leaching Chamber ^ Dri ine ^ Gravet-less Pipe ^ Other 4explain) V. Dis ersallTreatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsO~Dispersa Area quired (stl Dispersal Area osed is System Elevation ~dD i r ~ 5 s~ ~4 , ~ 4 _ . VI. Tank Info Capacity in Total Number ;via acturer Pre Site Steel Fiber Pl:i tiC Gallons Gallons of Ututs Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank ~S.Q f ~ 1 - LJt ~~5''el~ Aerobic Treatment Unit Dosing Chamber pQ - VII. Responsibility Statement- I, the tindersigrted, same responsibility for installation of th OWTS shows on the attached plans. Plurber's Na me (Print} Plumber's Si store P PRS N umber Business Phone Number Plumber's Addre ss (Street, City, State, Zip Code) - d ~~ ~C ~~ L ~ /~/, ` ~~DOG` 1 VIII. Count IDe artment Use Onl Approved ^ Disapproved Sanitary Permit Fee (includes Groundwater --~ Date Issued I su' Agent Signature (No Stamps) Surchargt: Fee) ~ ^ Ownec Giv R f 2 ~ -" ~~_ en eason or Denis! , ~Q IX. Conditions of Approval{Reasons for Disapproval .~ I~- ~ ~) SYSTEM OWNER; ~ !~ ~" ' I cn ~ o~ 1 Septic tank, effluent Biter and .~. c~-.2aS . dispersal cell must all be serviced ! maintained C ~~ ~- as per management plan provided by plumber. ~ # l /_ /- 2. All setback requirements must be maintained ~~ ~-t, U h2 0~((L. l`a as per applicable code/ordinances. J „ e ~ wx~'^'~- I !1 i Attach complete plans (to the County only) for the system SBD-6398 (R. 01/03) d ~,~ ~ ~ t ~` ,q ~ . ~ ~ I 1 ~ t '~ O ~ ~ ~ _c .. ~~ ,~ _ "~ ~r ~. O Q\ / moo, ~- s -s a. "' a ~~kr_~ -.l r ~/p/-~ a.Y9''~ ~ ,,ra ~--/, ~ s~,qr V 3 ~~ i. \ ~~ ~ ~ X ~~ ~~~~ -~~~~ Wisconsin •Departrrrerrt of Commerce - SOIL EVALUATION REPORT ~ Page I of Division of Safely and Buildings m acooraanoe vnmi ~orrnn ~, rvis. r+arri. was st a Pla m 11 i i 8112 d l th ~n~ 5 c ra ~~ e. n u an x n ~es n s ess Attach complete site plan on paper not inducts, but not limited to: vertical and horizontal percent slope, scale or dimensions, north arrow, a ~ and d nearest road. pal I.D. Z p - / ~ 9 ~- Jr/ - ~b v .Please prfnt all f n. :., by Date ~. Personal information you provide may be used for purpoa~ ~, , . s 1504`(1) (m)).. ~.(;fiyyy~" /~- ol-b 0 Property Owner - ~;'.; f ~ l ' ProPe_.__, ocatron . ~ ~ . .~ i u ~ to~ ~ 1/4~J 1l4 SZ ST Z 9 N R l q E ~~) Property Owners Mailing Address '~\ ~~iOiX Lot #- Bbdc # Subd. Name or CSMI/ C~J ~ L O S-~ i I ~ Wa-~-e r...~'~ , UFUTy r. S G ti i City Stele Tp Code Ph dy ^ Village (~ Town Nearest Road ® New Construction l1se: ® Residential / Number of bedrooms 3 _ `/~ Code derived design lbw rate DSO l (o O O GPD ^ Replacement ^ Public or commerdal - Descnbe: Parent material Oc>+crJG+`S (.~ Fbod Plain elevation if applicable 4 7 Z . ~ tt. General comments s S f-~ rrl e. t e i1 a+•~' /~ - QO • SU .~~ S s-~eiy,,, -,,,c.Q~ !3 3 ~ a s j' and recommendations: ~ L,~ 2 I ~e,~ a- ~-,b ri - ga.,sc~ q y Bo~9 # i~~I ~9 -. iii Pit Ground surface elev. q`rO O ft. Depth to limiting factor in. Soil ' n Rate Horizon Depth Dominant Cobr Redox Desaiption Texture Structure Consistienoe Boundary Roots GP DIfP . in. Mansell Qu. Sz Coat Cobr Gr. Sz Sh. 'EtT#1 'C-ff#2 a-$ ~ s~ - ~ ~ l ~ -~ . 5 -~ Z -~ 1 -- _ i z ice- ~ - . 5 . ~ 3 ~ ~ Ip ~~ _ m 0 ~ -- , -1 1. Z 2~~ Bones # ^ ~~ _. ®Pit Ground surface elev. ~/ S'"~ R. Depth to limiting factor ~ ~ ~ in. Soli ic~tion ~~ Horizon Depth Dominant Cob Redox Description Texture Structure Consistence Boundary Roots GP D/ft? in. Mansell t]u. Sz. Cont. (:dor Gr. Sz Sh. 'EtT#f ;Eff#2 ~ 0-12 ~ 3~ Z - .~ 2mG k. m ~S v~ . ~ -8' 3 -I lp - ~~ ~ ~ ~ U5 I • ~? ~ : 2- '~ i ~~ • Effluent #1 = BOD_ > 30 < 220 moll and TSS >30 < 1 50 mdL ' Eft)uent tR2 = BOD, < 30 mg/L and TSS < 30 mglL CST Name (Please Print) S' lure CST Nun~er e.r- ~ 2,S33o~ Address Dale Evaluation Conduc6ed Tele~one Number Z I - 3 ~bT'-' ~'. Somei-~~~'i ~ I S~fpZ~ C ~- o/ -7is-Z`f 7-Lfoa~ Property Owner _~r ~G l ~, Parcel ID # Page z of 3 Boring # U Boring ® Pit Ground surface elev. qy. 3 y ft. Depth to limiting factor ~ 15_ in. Soil ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f~ in. Mansell Gtu. Sz. Cont Cob[ Gr. Sz Sh: "Eff#1 *EtT#2 i s-i Z I I Z ~--- _ 2 12-alb -- Z rn-Fr _ • 5 3 S ~ rr,~ = .~. .~ ~-2 __ ~~ # ^ Boring ^ Pit Ground surface elev. ft. Depth m limiting factor in. ~ ication ~~ Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roofs GPD/tf in. Mansell t2u. Sz. Corit Cobr Gr. Sz Sh. `Ef~1 "'Efl#2 a Bo~ng# ° B~ns . ^ Pit Ground surface elev. ft Depth to limiting factor in. Sal lication Rate Horizon De th Dominant Cob Redox Descr~tbn -Texture Sbudure Consistence Boundary Roots GP D/ft~ p in. Mansell Qu. Sz. Cont Color Gr. Sz. Sh. "Eff#'t 'Eft#2 "Effluent #1 =. BODE > 30 < 220 mglL and TSS >30 <_ 150 mg/L * Effluent #2 = BODS < 30 mgll. and. TSS _< 30 mglt. The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-87'17. SBD-8330 (807/00) ~. PAGE ~ OF~_ NAME 14 Y` K-~ ~ ~ LOT# S ( LEGAL DESCRIPTIONtiE '/.sw'/4,SzsT zq N,R ~a E (or) SCALE: 1 "= y U , BM 1 ELEVATION /00 ~ O BM 1 DESCRIPTION h a ~' ~ ~ '~ ~ ~ ~ ~~ ~'' e t ~ ~ ` BM 2 ELEVATION U v • o BM 2 DESCRIPTION VI a ~' l i' n. ~ "ya (c t~{~ SYSTEM ELEVATION c(O • .S-'~ ALTERNATE ELEVATION ~J'(,1 ~O CONTOUR ELEVATION n( S(oQ~. $~.Z~ :; Yy`~ ~~f~„" ~o ~~ ~~ ~~ a 2 ~ Od ~' ~ _~._- j s '~ ~_--_~~~ \~ ' R~~ I --------- ~~ 4 1 j. ~ti ~. B~ / .,` , Zg`~ ~ f 2`~ ~ DATE ~ -~ 4 ~r - ~ ~ L ~~` ~~_ -, ~\ ~ X / it ~ ,. - ~ 26.87' j~ x t0a7.3 ~' E~j~f - E T ,~~1/4 LINE rte- ^J j 3~ ~~8.2~ o - ,l x .v ~ 10 5.0 C 1043.8 -^ x ~~ 1 ~, `~ ~~ \\ ~ ) f~ I ' ` / z `\ \ f % 'I ~ i ~ i j ~ ~ ~~i ~`~ ~ ~ ,\ '~ 1\ ~~- ~ ~ ` ' ~~ ~i ~, ~ ~ ~ I , ~ ~ ~ \ , ,\ ~ . ~~ ~~ r \ ~~ ~, z ~1 Q ~ ~~ .~ ~~ C~~ ~1 a~) ~~ for the .~ . ~~ ~'~ . Fttrne ~ ~~~ • t~eweterino ~A "' SO~i 1'iA1ll~ltl~ CiW~~d,Y; ~~~ ~. • i~~~ ~~'u~n• t01iylCef iti't~Q~bt+f~~Ci>~PY, BUI~~I eaatcmer:~. 1t~4 {4a'C~ C011dAti4lt8 144'F (64'C) ~~, F~ 3qQ u~t sta~+Mee e~eei. • d~M11~) Y~ d~~t1~/~ tt! p~Cpt'1Ip04~!!b. T llc,~~fy~ e~q ~ ~ ~ capat~i~lgt; ~ ' up to 64 GPM. a~~ twin is ttp to 31 tart, . ~G~~,~a,~erpe e#~~`a~~1~~.',,,N~P~~'~ ~ t i0if, t{iw~Y~1+' Ne~omere. ry~ ~T ±a~ oo~inuoua 140"f.~~j ~erntt, A t 0el4 tinuiAr Pueha. i~a. • ~; 800 aerces ~~~ * t;ep#bh of Nnninp aoatu 14 p •~ O~~V, b~ir~ 3so' RPM, btttlt to oaerto~d with iutorrfaic nut. ~ ~8 Bin !e phase: d.a Np~, 118 V, ~Ht,1560 ~, buses rte. ~ Power cor~d:1 Q toot ateAderd tt~ttr, 7813 SdTb Wit11 S11rre ~flq ground!np piuQ. ODtiOrtai 20 fcaat lenpth,1513 SJTW with t#+r1M prod gtoundinq plug ;start tM 1:PU5~, N~t'~lRs , RlC~S +~F Submersible Effluent Pump ~~~~~ 3871 E ~ idlyy =ubmerQrd In hipil dr~d1 t~tbine oil for ic~~ric~toa uxl ~tidec+t truer. ~ br eiitoahth~ egad m~ opu~oa. Nal~oa~ re<~ Ie~tdi~ 1tili~l lrion ae~un6led and R~ d qN ite~ory. ~Ti ~ ~ ImpNller: Thermo- pia:~s; Serni~apat design utith pump 4t~t Wnes ~ maChenfcel stoi Frot~ttaa. ^ EP06 ~~ Ther1~ plastic eaaload desgn for ima-bved per~ormence. • Caein~ and ire: Ruppi~ tnermoR~iC deei~~ provides superior et~en~ end corroelon.r+~. t i#~At li~l~: Cret iron for ~tai~nt trim tn~ger, tied durablltcy. • M~ior`I"~wr; Tlwrmopiee- ~ Dower vl+~h inter ~fe ~ f ~plt owitoh err~ar~ p ~ Ibenir Cebk; Swera duty nod ae and wooer n>~r~. ^ ; Upper iY1d ieYVer ~~ bal beer~rq on. ~a~xor u~ilr~s ~~ fA~Nt+-A~fauas (wt.~.fA1..i mo•da~i num~~e v~Rt it3 ~ ~ rA1~ ~~ ~ ~ ~~ ~0 + '._.,.... ~ ~ ~_ f ~ ~ i ___. f .~..~ ~0 i i ` ~ i I , _..._s.,_..___ 16 ? - +,. ,o --~- ~ . } j , ~ ~ ' ~ ~ ----i------~ Q r l~UY~ IflSi6 .. - .. t r .:.ta , ~+" CI~ VENT PIPE 12" MIN, A80VE G:~ADE 5 25' FRAM DOOR, WIN; QW Og FRESH ASR SNTAKE - FINISHEi; TRADE :.'LET ~~~~OV~~ -ip~ 3 iN1'0 S~t,TD .OI4 -~ ++" C I R S S ER --~-~+•~~ ~ ~ ~~ M X t 1 ~~ A:£R TIUiiT SEALS ;~`~' PUMP vFF ELEV . .,......,,rT, ..`.~""` A ~~ i~ 'C ~~ ~~ar~~~~RO~~ JUNCTZO:v' H^X WIT~1 CONDUIT .. ,~ ~lti ' ', ~~ GA5- ; , TIGHT ~ `~ SEAL i 3" APFRuVEA BES}DiNC UtiDER TANK PECZFICAT:4~1~8 APPROVER 'L4..'~NOiE CG'J ER W / PAD >rOC K ~ WARNING z•AH£~, ~n ~~~ J ( `JAAPROYE~ J4It+~'S ~tTT~1 AI.M i APP~tQY~fl AtA~ ~ON ~ 3~ ~r~a 1 SQt, ID. SOIL, ~. , ~ ~ OF. , rte RISER EX; .j 1 ~ PERMITTED CNI,Y IF TANK ' ~ MANUFACTURER ~"""" ~iAS AFPROVA? CaNCR~TE PAD >DPTIC E DOSE CANK MAN'~JFAC?"JRER: ~ •c~•r.....,..~. IvuM3ER ,705£S °ER LAY: ~~w "ANX. Ss2E5: SEP:"ZC ~,~d GAL. .r.USr VG:~U?riE IA'C:~~3D.r.NG DOSE d'____ v~ GAL. FLOw6ACK:~ GAu. ;44~ MANUFACTURER: 1~~//~~rL~~ MoaEL NUMBER: _._1?~i u SWITCH TYPE . I?~~erc ~~ MA1VilFACTt1RER MODEL NUMHER: SWITCH TXPE: £QJIRED D1 SCtiARGE RAT ~p GFM CAPACAIES: A ~ ,'d~_ I:vC::ES ~...,~~......GAL. C ~ ,,,~„ INCHES = <~~A:. , D= ~i,,,,, i~ C h E 5~ ..~~,._G~Aa L. P°UMF' f ALAFcM k'iRiNG P.S ER Si,Hit 25.23' Wt;C ER1'iCAL D~FFERE,1iCE BE'~iEF.~~ P-~ Dr !" AND D?'STP?Bl3aZON PIPS ~.,2 TEE? MINIMUM NETWORX SUPPLY PRESSURE ~ FEET ~Q „~,,, FEET FORCEMAi~! X ;Z ~D FT1I00 F:'. FRIMT:ON FACTOR FEw'F TC'.*.4L DYNAM?C KEAD = F £ "' +:EKNAL DZMENSIntiS CF FUM? :'~,?S}:: L£'CGi~I ---~-~-~--; WIDTH '~"' ; ~7 ;ETER '"" LIQU ZD ~ ,, __...._... IGNED: ~.~/'`~~'~ i.1::EN~i. M MEcR: ~,~f>~d _ ~A'i J .. ~'-._ i ---~--~---~ ..,.J 188 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION Owner C}~-Q.GIr{- ~ .~--rtJ ~ Permit ~ S~._ DESIGN PARAMETEIt>; Number of Bedrooms Y O NA Number of Pub~so Facil+`ty Elnita ^ NA Estimated flow tavsrage} ~ a}!da Design flow speak}, (Estimated x t .5) Gd d al/da Soil Application Rats at/da lft' Standard influertt/Effluent Quality Monthly average' i=ota, Oil & Qroaae (FOG} 530 mg/L Biochemical Oxygen Demand tBODeI x220 mq/L ^ NA Iota) Suspended Solids tTSSI 5160 mq/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand iBOD6} 538 mq/l. Total Suspended Solids tTSSI S30 mg/L ^ NA Fecal Coliform igeometric mean! s10• cfu/10om1 Maximum Effluent Particle Size Y. in die. DNA Qthsr: ^ NA »Vatuss typi~ ~' domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity ,'~ ~ al DNA Septic Tank Manufacturer ~~, d NA Effluent Flter Manufacturer ~ ,~ DNA Effluent Filter Model ~'Q' O NA Pump Tank Capacity sl DNA Pump Tank Manufacturer reS s°Y d NA Pump Manufacturer ~,.,u / ^ NA Pump Model ~ ~(.~j t~NA Pretreatment Unit Q Send/Brawl Fllter ©Msahanicai Aeration ^ Dbksfeotion D Peat F41ter ~ Wetland O Other: ~IA Qlspersal Ceiltsl D {n-Ground tgrevltyi O At-Grads O Drip-Lies DNA p In-0round (pressurized} D Mound Q Other: Other: DNA other: ^ NA 0 NA MAINT~NAat:E scl~out~ Sarsiioe Event Service Frequency Inspect condition of tanktsl At least oRCe every: 3 rYton s e tMa~dmum 3 years) O NA Punnp out contents of tanktsl Whon combined sludge and scums squats one-third iYt,l of tank volume ^ NA fnspeot dispersal cell(s1 At least once every: ~ eertrl sl (Maximum 3 Years} O NA Clean sfNuent fiksr At least once every: l ~ trsorst}s el s} O NA inspect pump, pump controls 8c alarm At !asst once every: ---- ~~ts) ^ ai DNA Flush laterals and pressure fast At least once every: •- O mon al s) 0 NA Other: At }east once every: .-- monthis} O earls) DNA Ottssr: o NA MAINTENANCE MISTRUCTlONS {nspeotiona of tanks and dispersal cake shall ba made by sn individual carrying one of the folbwinq licenses or oertificsttons: Master Piumkser; Maaier Plummer Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operetor. Tank inapecttone must include a visual inspection of the tank{s} to identify any missing or broken hardware, identify any cracks or Isaks, measure the volume of cambined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The diaperul cellta) shall bo visually inepsoted to check the effluent levels in the observation pipes and to check for any ponding of affluent on the ground surface. The ponding of affluent an the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined ecctaswlation of sludge and scum in any tank equals ono-third tYs? or more of the tank volume, the entire contents of the tank ahal! be removed by a Septage Servicing Operator and diaposad of in accordance with chapter NR 113, Wisoona~ Administrative Code. AI6 other servloes, 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 tss performed by s certified POWTS Maintstner. A service report shall be provided to the local regulatory authority within 10 days of compietior- of any service event. Page of START UP AND OPERATION roducts or other chemicals For new construction, prior to use of she POWTS check treatment tank(ai' for the prase*tCa of painttng p that may impede the treatment process andlor damage the dispersal cell(al. If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. Systsm start up ahaii not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normve loadint this ceillsi andnmaY ~esulteintthebackuPcoas3vrfaCe discha gle of discharged to the dispersal cell(s) in one large dose, o g effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to reatonng 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 aver, 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 sxream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; carton swabs; degr•ssera; dontal floss; diapers; disinfectants; tat; foundation drain )sump 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 fails and/or is permanently taken out of service the ioilowing steps shall be taken to insure that the system ~s property and safety abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Cnde: r AN piping to tanks and pits shaA be disconnected and the abandoned pipe openings sealed. • The contents of ail tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, ail tanks and pits shalt be excavated and removed or their covers removed and the void space filled with soli, gravel ar another inert solid material. CONTINQENCY PLAN if the POWTS faits and cannot be repaired the following measures have been, or-must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement Boil absorption system. The replacement area should be protected from disturbance and compaction and should rent be infringed upon by required setbacks from existing and proposed structure, lot lines and wails. Failure to protect the rspiacement area will reautt in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must oompty with the rules in effect at that time. O A suitable replacement area is not available due to setback and/or soil iimkations. Barring advances in POWTS technology a holding tank may ba installed as a fast resort to replace the failed POWTS. ~~ ~ T ~ site tank O Mound and at-grade call absorption systems may be reconstructed in place following removal of the biomat at the infituativa surface. Reconstructions of such systems must comply with the rules in affect at that time. t <WARNiNQ> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL QASSES ANplOR INSUFFICIENT OXYGEN. DO NQT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCE8. DEATH MAY RESULT. RESCUE OP A PERSON FROM THE INTERIOR Of A TANK MAY BE D{FFICt1LT OR iMpOS8l6LE. ADDITIONAL COMMENTS POWTS INSTALLER Name ~•~l~~u ~~-+ a.~ 1~ Phase 7 r. _ O. w ~, POWT8 MAINTAINER Name Phone SEPTA~E SERVICING OPERATOR dPUMPER} LOCAL Rte~ULATORY AUTHORITY Name Name ~", C.PA/X Cc9~~ ~OAI/N~ Phone Phan. I S. 3~ • ~6~ This document was drafted in compliance with chapter Comm 83.Z2{21tbi(11(dl&(fl and 83.54{tI, (21 3 t31, Wiaconsun Admtnlstrative Gode. sr c~taYx covrrrY sl~rtc rANrc Ma.tx~.~IVwrrca av~$MErrr Arm OWNB~RSHIP CBRTZFICATION FORM. OvvuezlBuyar l '~lI Q r~ ~~' ~' ~' x ~ > u MBiliIIg Address ~ D - 5 ~>~"t / ~wK..{~v _~V', ~7~1 .,t~C~'~-1 /~ ~dg,~ ..~ Property Address _ _ ,~ (Ycdficatlaa ralttlrod t~atn Planning Uapaelmcnt foe ttetav a C~ty/Stato ~~ s ~- Parcel IdetstifiCation Number ~ Yg' (r o - ~. L~E(~A~-~DE~C;luP2TQ~ Propeccty location ~~ '/., ~GJ ; y, Scc. ~S , T,~.,N-1Z,,,~~'W, Iowa of ~~~'~ ~/ ,,,,_; Subdivision 5 ~ ~'N ~ ~ ~i l /.S . Let # ~. Cerff f ied 5 urveq Map # Volume ., Page # warranty need # ,.,~ V ~" 4 0 ~ . _, Volume ,,, j,~ ~ 1' .Page # O Spec house a yes ~. no Y.at lines identifiable ~ yes D no S~'S~M~A.~NA_N~CE ~~ ux and maia~neeof your septic system could result in its prcmatare failure to handle wasteR Proper taaintenanve cousista of puaspiiag out the septic tauic every three years or sooner, !f peedcd by a licensed pamper. What you ptst unto the ry=tun race affect the fitnctioA of tbo tept~c tank xs a treatnttnt atagc in the Waste deposal system. 'Ihe property oWnac agroes to zsibmit to b't. Cmlx Z,azuag Depart:tictnt a oertiRcatien farnt, slgs~d by t#sd aware and by a sus~splurnbar, Jrnuaeyaoaa glumtxr, t~i>vtcQplsunber or a licensed patrspar v+crifyiag that (1) the oa-aite rvaesewsterdispassl cyrtem is hn pmper opcratlns eanditioa sad/or (7) spec iasptctiaa and puaaping (sf nec:e~y), the eeptio tank is lest ~san t/3 fish of sludge. flwe, the nade~igsted have mad the shave x~cquiremeats aced sgrao to tstaisvlain the private sewage dispasat ajrstwn tadtlt tlse dxadarde set forth„ hcreln, as sat by the t of Commerce and the Depactmeat of 1`Tatural Resources, 8tata of Wlecanah~. ~ficaden emoting that year ~ctptk boon maintained snssst be cnutpletlod and returned to the St. (~oix Goumty Zatsl~4g Of&x within 34 days of ~c¢~ date. SICt F LICANT IaATt3 1(wc) oertiFy 1I etatcmcnts oa this form arc tnu to tba best of my (our) I~sowledge. I (we) am (ue) the owncr(s} of the prv do 'bid vc, by viriuc of a warranty deed recorded in Register of Ikcds Office. ~'~` 5' -- "` c r A APPLICANT AA'I'fi ••«••• Aay in£armation that is mis-represented may result is the raaicary permit boiag revokzd by the Zottic-8 Dv~• se+,~c«t '`« include wits tots appllrstlaet: a atasupcd wauranty deed from the Register of L~rrds ofl~iee a creepy of the certified survey map i#'teference is nude in the waaanty decd W a r r~u-ti~ ~cc.~ j:. ;. ~~. ~~~~ 16G2P~~289 648Es04 . Y,ATHLEEN H. WALSH Darnaomt de REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED fDR RECORD 06-1@-2001 12:5 PM YAkkANTY DEED EXEMPT k CERT COPY FEE: COPY FEE: TRANSFEk FEE: 9900. D0 RECORDING FEE: 1.00 PAGES: 3 ~. Aerardiaa 14ea Nana aad Batacn Addrrst L.a.l T;-lle, 1..~ . igoo S'~lv~r L..Ak~ Zoo.d Al~w vr7p^~t~n , MN SS/(Z OZo- tObq-'7o -ooc~ raced ~amtisa6oo Nmmbv true C~ZU - l 064' - DSO - cJG p O"Zo - ~ ~6`/ -Q/D - vw (~ 2v - 1070 - too - ~p0 020 - 1070 ., iv -nvp v zc~ - ~ a ~~ - zo -~ "THIS PAGE I5 PAF,T OF THIS LEGAL DOCOHENT - DO NOT REMOVE^ This iocomutiaa aaut be oomptxed 6j. cub~ypa. you aGle ar da tit dmera, ktd deseNpBaw ere, ~ Ltmne ~ rsarm adCiat. and ['LN N^r4~~J• Od~er~er.~aetaa iud. doc+moit Ute rWr cv~rr ~' P~~ on +1Jr jirit Pete oJyhr Aoaaanu ar ~ ~°~.i ~ pate oddr ane pate m re..r donanav and SZ.017 re die recar~..~. ploeed on adldenul Pater of de _ 1Pucpyin SYmaa, Jp.Sl7. WFDA 21916 le ' DOCUMENT NO. ` ~ wwanwxxY aEra 1 ((~(~]l pp STATE OF WISCONSIN-FORM B V01 ~V V~yf~7~ TRIB IMO[ Rk~ERVED FOR R[GOROIMD DATA ' TINS INDENTURE, Made b .RICHARD N. PEARSON and JEAN M. PEARSON husband and w}ife, • .......................................................•---• grantor_5..of..._St.,Croix .................................................County, Wisconsin,!: h~rebY conveys and warFants to-.._~~?IAGE HOMES XXI, INC ,~ ., a ...... , Minnesota corporation, ................. ................. . dVaSfiing~ori.._.._.-....-._ ...................••-----...............-.....-...~~ry-~~ppr~~rt rautee........ of .....-._ .:........................------•--...--.....-----........-........County, 1RIflF)6liiftlf ~or the sum of;: pn~ _pollar;, and., no1100---.01:00) --and-_other--good _and-valuable---!~ RETUrrN To L c, ti~~ A T ~'f I t CQD.B~d~Fatlon ......... ......... <1Sfi~ar/t/3 /~jL'G Sr I vr~i Lrtf(c 12c:Q. • S f lcC the following tract of land in....$t-r,,,Qroi;g, - ~~'E`U''~t + J~(-fnA.iNl~•~ _ .. .....................................Coonty, i S"i/ t Wisconsin: .A~.i<-.4~--khe,-plort~we$,t:,-Quarter-,-LNyasa~-and,-,Worth-_Half (N~) of the Southwest Quarter (SF]'~) 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. See Attached Exhibit A Parcel Identification Number This is not homestead property Ia Witness Whereof the said grantor. S.. haVe...... hereuato set........_thelt hand 5... and seals.... this ..............._......_..-. day of...... aY....---.....-.........................., A. D., Y9t..2Q0~ BIDNa:D AND SEALED IN PRESENCE OF ••.........•........... ....................................................._. ($E/1L) ...................... -. ... ..... .. .SEAL M. EAR56N• .............. gip I ...................................°-°--~--..................----..-..........-.....°.-.... ($EAL) St~Ce of ~pOgSpta ` ,,,,,,__Wes -1ngt`On~_br-~h~untq. Personally came before me, this.~.?~-day of.. ~~,`:-~..-.-... 2Q01 RICHARD N EARSON and JEAN M. PEARSON husband and wife, ••"' A. D., >~Y-••, the above named ..............._.---...~....------........-......_...-. ..-..........t................----•-• to me nown to be the Persons-... who executed the foregoing instrument and acknowledged the same. 9 ^ .:.......... . _..................--. TNIB INSTRUMENT A>! DRAFTED sY r l Aopv nnOUNTAIN Richard J. Ga~rLel, #32864 - • °~--^~-•-~ NOTAR7 Notar Public, ~'~' NOTARY.PIfBLIG-MINNESOTA 880 Sibley Memorial Hwy., #114 SEAL Y ~,r,, - ._ ....................... County, Wis. • My Comm. Expires Jan. 31, 2005 -1736 Diy mtnmission (eft ' (Section 79.71 (1) of the wiscwuin Statutes provides that all Instruments to ha recorded shill have plainly printed or typewrittrn th<reon the nataes 0( Ne grantors, Snntees, witneucs ind notary. Section 39.S1j similarly requires that the name of the person who, or govern- mentil aaeney whah, drdted such instroment, shall be printed, tYlx~ntten, stamped ar wntlrn thereon in a IeBiLle manner.) WARRANTY DEED STATE OF WISCQNSIN Wlmcomin LoBal Blsnk Company P`OR11I No. 9 Mllwaukae, Wls, (lob 39S 11 1 Vn!, 1U6~vAG: z9~, EXHIBIT A Parcel Identification Numbers 020-1069-70-000 020-1069-80-000 020-1069-90-000 020-1070-00-000 020-1070-10-000 020-1070-20-000 f =~ ~ ,~-~ '~ _.. ~..~~ ~a~. (g ~ •.4 1 ~~ !~{ #' 24@4. .,~.. 1 1 1 1 f k a` ~ ~ ova _ ,. .......... ®e,..... ,..e 1,. _~ .» Lq~ > f 1 _ .. F 1 pi./ ~ I ~ _ \ ' / ~ ~ ~ ~Y~ h ~ a .~ ~ ~' r`~~ 1 ~ ~- ~_ ~ _ ~ i _ i ~ i ~ i Q ~ ~ i ~m ~ a~ ,. <tts c.} ~ - i i «' i s?~ ~ .r ~ i 3 ~ ~_ ~. ~ . 1 Q ~ ~~ ~ r` ~~ µ 1 4 ` `, kA (}dv3 v ~ i ..: p ~ ..'~ M t 1 a rri ~... Y ti~ t