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HomeMy WebLinkAbout020-1395-60-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERA~..I3JFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: Ctty Village X Township Carria a Homes Inc. Hudson Townshi CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~a 5--v Dosing Aeration Holding TANK SETBACK INFORMATION ELEVA ON DATA ' county: St. Croix Sanitary Permit No: 420611 State Plan ID No: Parce! Tax No: 020-1395-60-000 STATION BS HI FS ELEV. Benchmark /~ ~ • ~ /oy, ltd- z~ Alt. BM ~~ Bldg. Se D 3 ~ S~ ` v (p Q p p L / 0 , S Ht Inlet ~.~ ~~ 4 Od ~ DI 3 / SUHt Outlet 7 9~- ~/ Dt Inlet ~~ Dt Bottom ~~ ~- Head~'er~/Man~~ Dist. P' v~ ' ~ s~ 8: S ) v °l S' Bot. System 1 , ~' 9 - Final Grade ,~ 7S7ZJR ~ '7`` I~iIY~I~ L • ~ ~ Z St Co er 3. va TANK TO P/L WE BLDG. Vent to Air Intake ROAD Septic ~~ ~ ` ~ ~ Dosing Aeration Holding PUMP/SIPHON INFORMATION Dia. SOIL ABSORPTION SYSTEM /c.! C~Gtllir,,l.~t~a//~( ems, ~r~ - .~ -~o-fz~ BED/TRENCH DIMENSIONS Width~t Lengt ~ No. Of Trenches v'C1.~ PIT DIMENSIOAFB •/~ No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM EACHING HAMBER OR Manuf ur~r j ^-j-~ L- t TT f S - -. i Type ystem: / ~~ ~ ~ ~ ~ ~ / _. UNIT Model Number: / ,Z ~, D IBUTION SYSTEM y~o,r-3-~.~ Header/ anif old Distribution x Hole Size x Hole Spacing ~- C / ~ Pipe9 s) 7 k~ / / ~~ nth Dia 9 J ` ,L g Len th Dia m SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only 1~-3 4vl Vi.6M~T''v-~~ Depth Over i Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center ~ •~~ Bed/Trench Edges Topsoil ®Yes [~ No ~] Yes j~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:~/~/~ Inspection #2: / / Location: 755 Highlander C/t+.~H,u~d-~spon, WI 5~4,0/16 (SE NW 1/4 25 T29N R19W) Scgnic Hills Lot 0 Parcel~No:~25~.29.19.24~54 1.) Alt BM Description =JI %~~/G~ ,N ~~ ~~ ~~ ~ ~~~ ~~s~'U~~~,/°r /~~'~~F'` 2.) Bldg sewer length = ~~ ~ /Z~~inu~ - 't~~'~2~~~~ ~~j~'~'~~L~~ - amount of cover = -- ~ ~ S / ^~~~ ' ~s,~~ ~/~ola3~ L..c-ice S/~~ ~ ~ - Plan revisio quired? n Yes ~ o Use other side for additional information. ~ ~ _~~ ____ L ~' `S~ SBD-6710 (R.3/97) ~(/i/ ~ tor' S/~~ ~+ '`vim r `~' " ' Cert. No. Vent to Airlntake ,S D~ ~`~ ~~ Safety and Building, Uiviston County .r ~ ~ 201 W. Wastungton Ave., P.U. Box 7162 ~ ~a~a r x s ~~~~~~,~ Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.j De artment of Commerce (~$) 266-3`51 ,p ~ f 2 6 ! / ~~;~1~/1QL~ i Sanitary Permit Apphcat~on State Plan I.D. Number ~ i In accord with Comm 53,21, Wis. Adm. Code, persona! information you provide ~ may be creed for secondary purposes Privacy Law, s15.04(1)(,m) Pro~'ect Address {if di Brent than mailing address) f I. Application Information -Please Print All Information RECEIVE D _~ ~e ~ ~ SS -~/ 2 y ~ ~~ e , PropertyOwtter's Na me P rcel ft Lot;Y ~O Block ~ ~ ~. c ~ s ~ ~.- MAY 0 S 2003 ~9~ c, ~ 3~ s =~~- oil Property Owt~r's ailing Address ST. CROIX COUNTI P perty Location '' `` ~ Z7~ ~ ~ ~ ~ ZONING OFFICE C ~ r ~ lL Y cL.- . . Y H- '~ „// °,6 , Socdon a J City, State Zip Code Phone Number ~ / e ~~7`~t=0e ~A /~ .~ y~l(O , T v7 `lr N; R ~ ~ (cB or~) II. Type of Braiding (check all that apply) ° 'S~- ~ ~u ~ Subdivision Name CSM Number ~ ' 1 or 2 Family Dwelling -Number of Bedrooms I ^ ,Public/Commercial -Describe Use ~ ~~z~~ i llS i ^ State Owned -Describe Use '- ~ ^City!^Village~!'awnship ofL~~~ III. Type of Permit: (Check only one boa on line A, Complete line 13 if applicable) A' ~ New System ^ Replacement System C TreaunendHolding Tank Replacement On?y ^ Ocher Modification to Existing System B. ^ Permit Renewal Permit Revision ^ Change of ^ Perr :it Transfer ro New List Previous Permit Number and Dace Issued Before Expiration ~ Plumber Owner C~6 Z /, /_ `~ / ~/~ 3/O'?j V (O IV. T of POWTS S stem: (Check all that a 1) Avon -Pressurized In-Ground ^ Mound > 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Sittgle Pass Sand Filter ter ^ Constructed Weiland ^ Pressurized In-Ground ^ Holding Tank ^ Peat Fitter i_! Aerobic Treatment Unit ^ Recirculatia Sand Fil // j ^ Rec;irculating Synthetic Media Filter ~j.eaching Chamber ^ Drip Line J Gravel-less Pipe ^ Other (explain) ,Sf-+~G~~T~w~6YJ~ ' V. Dis ersai/Treatment Area Information: Design Ftow {gpd) Design Soil Application Rate(gpdst} i Dispersal Area Required (sf} Dispersal Area o osed (s System Elevation / F ~ VI. Tank Info Capacity in + Toral Number ' lvlanufacturer Prefab Site t d t C Steel ~ Fiber ~ Glass Plastic Gallons i GaUons New Existing of L rits ~ ~ ~ _ /~ // w`2'~~''~tX~C /'~ ~6~ Concrete ons ruc e r Tanks Tanks Septic or Holding Tank ~! /`+ I ~ ' ~ ~.'rG°Y i Aerobic Treatment Unit i Closing Chambrr ~ I i ~ VII'. Responsibility Statement- I, the undersigned, assume responsibility For ' taUation of the POWTS shown nn the attached plans. Plumber's Na me (Print) Plumber's Si gnature hl /MPRS Number Business Phone Number ~'r!l«t la'r ~SC~iu. ~~Ls~Y ~ /'~2 '7 l d 7 l S --.3~~'~/~ l Plumber's Addre ss (Street, City, State, Zip Code) ~ l ~ ill .~ ~u ~,~/, ~ 5 Z f~ V Count /De artment Use Qni Approved ^ Disapproved Sanitary Permit Fee {' eludes Groundwater Surcharge Fee) ~ ~"/~ ~ Dam 1ss ~ suing ent Si e ~ Stamps) e.- ~ , ~ (/ / Q G {/y'Yn ^ Owner Given Reason for Denial , iX. Conditions of ApprovaliReasotts for Disapproval ~~ ~ ~~Gu-~~, v~._~bl ~ Z ti ~~ ~,cc.C ~ /GPimU.fih.~t ~ /~ ~i .~7.n•, n ~ 6.4,I.A.GYt.Ci.(/ at%~/~~ ~- /d'~cXX ~~ `~A~t Attach complete plans the County only} r rho system a paper sot less than 8112 x 11 Inches is size SBD-6398 (R. 01/03) • otcommerce SOIL EVALUATION REPORT (%~ ~'`f~ Page 1 of Wisconsin Department Dnrisioq of Safety~nd Bindings in aoiordartce wHh Comm 85, Wis. Adm. Code Co~Y C ~t - C(C~~Zc Attach cotnplete site pin on paper not less tttart 81x2 x 11s~~ch.}espst~size. Dien must incN,de, but not limited b: veNcal and horitaMal reference Y"°•• (~~^Ir d~vn and Peroel i.D. /y ~ 6~~ ~ y r / , _d~ ~ percent dope, scale or dirrtensbr~, north snow, and bcatior- and distance to nearest road. V (~ R by Date P/e~ase psrfnt a~ hitormatton. ~ ~ 6- Personaiinformationyou provide may be used for aewrbaq't (PAY Law. s.15.0I (1) (mN• PropertyOwner propertyLocation l.-l>1~YY C`lCa'S Govt t of ,S'~ 1r4 /(~L/1/4 S ~ T Z N R E (or)6 Property Owner's Mt~-g Address Lot # Bbdc 8 Subd. Name ix CSM~k n . ~c ' ~e ~~ ~~~~ tea,. Z State ~ Phone Nurttber ^ City ^ ~~ ®TO`"^ Nit axoad . Gctk•t ~ rmo {YYI~^I ~5~'~'~(U5(i`IJ`7'777U~ t-rr~u.~~.. - ~ New Constrrrctiori Use: Cl~ Residenttai I Nrunber o1 bedrooms 3 - Code derived design flow ram h ^ Replacement ^ Pitbtic or cantnerrlal - Detxxibe: Patent material _ ~~~J a `~I~ r---- Food/,Plain elevatlon a a(~IiCable - General oorrmtems S ~e~ 2%~ v , y'S~ `/~ ~~t ~ O~- v`~?~4,C,~~ and n;c;ornmiardatitxts: Y MAY 0 8 2003 G OFFICE GPD ft. u ~9 Q ~9 # Pit Grtwnd surface elev. / 9 ft. Fbr¢on Depth Daninartt Color Redox Description Texture in. Mtmsell 11u. Sz. Cont Cobr ~ C'-I ICS ~ 3 3 `- S i~ St ~I ~ (4 - /O ~ 3 y .I r~ / _.. s Depth to ~tnitlng factlor -~- in• SkttcPubre Consistent%e Boundary Gr. Sz. Sh. » -fir C 5 2-~~~sbk r CS ~~ n~ - Roots ~ V -~ - - ~ Rate GPDrff 'Ettffl 'EfiJl:2 ~ 5 - ~' . ~ /. Z a Boring fl c^f Baring O )) ~/~/~l t~ Pit Grotutd surface elev, [ ~ U fl. Depth ib firrdtang tailor ~ in• SW Rate D~ Domirtarrt Rt~x Description Texttu~e Struchrte Cortsister-ce Boundary .Roots GPDrfg 'Ef~1 'EffIf2 in. Mutsu Qu. Sz. Copt Color Gr. Sz. Sh. 5 ~ 1 - g IU 3 -___ 5 ; ! 2rr~s rr~-~ r. c s . I , 2 -I r ~ /~ Si^ c l 1 rn rr-,-~'~r c` _ . Y 3 ~ -I ~l S ~ l - ~ .7 /:2 ~~ ~L, ~`~ • EtlkterN ~ _ BOD . > 3p < ~Q ~ aril TSS >30 c 1 50 mglL ' Eflktertt ty2. = BOD < 30 rrtgrL.artd TSS <_ 30 rngA. CST Name (Please Print) CST Number ~.3 Address nation Cadttt~ed. Date Eval phone Number le Te ~~h /` /` / 1 I ~ Ci .~1 Y+ ~ ~ \..e i l a .L . ~ ~Un 7 C-- / .~ "'G( ~ ~ ~ G ~ G7 / ~J ~.~p Q "~ Oz ~ / Z 3 5 Paroel ro# ~ I d d k i~ Page ~ ~ a er w,ar o~ _~ar GP DIif ane ~ Consi~ence Boundary Roots Horimn Dep7h Domirrar~t Color Retlox Descr~ior- Cant Cobr Sz t]u Teadure ruc Gr. Sz. ~. •EffA'1 'Ei<#2 ~,. . . 5 - 5 i l ~~,~ ~- c s I u -~ - _ g I O- (a IU 3 - 2 3 ~i-~ati tbv 1 -- s Os . ~ r. ^ ~'8 # ^ Pit ='Ground,s~uface elev. it Depth to tinlr-p in. SoN ~, Horizon Dept Dominant Color Redox Desc~ptioc Texture ~rucUue Consistence Ba~uy Roots GPDlitt in. Munse9 Qu. Sz. Cant. Color Pr. Sz Sh. "EtT#1 "Et~2 ~9 # ~ ~8 Csround surface dev. R Depth b ~-9 factor in. ^ Pit Sot Rate Horizon Depth Dominant Color Radox Description Texture StrucWre Coru~tnnce Boundary Roofs C~D1fP ~. Mansell Qu. Sz Cont Color (3r. Sz. Sh. "Etf~1 •Etf~2 • F ~ = BODS> 30 < 220 mgll oral TSS >30 <_ 1 s0 mgf L " Effluerd #2 =GODS <_ 30 mglL and TSS <_ 30 mglt. The Deparanent of Commerco is an egaal opportwtity service Provider and employer. If you Hoed assistance to access services or need materisi is an altercate format, Please contact the depattcret-t at 608-266-3151 or TTY 60&264-8777. sec-easo~amrom PAGE 3 OF 3 NAME: G~~ntaY,L LOT# CP 0 LEGAL DESCRIPTION:_1/4_I/4,S_T_,N,R, E(or)W SCALE: 1"= ~~ / Br+~ ELEVATION: /D~ • a BM 1 DESCRIPTION: ~o~ o.~ Pa~1i'y 1~ o r S'~~ BM 2 ELEVATION: -' _ ,f °~ BM 2 DESCRIPTION: SYSTEM ELEVATION: ~ ~ ' ~ '" SYSTEM TYPE: ~~~'/t,~"~~/lcc( ~~~ ~~~ ~~ b 2 ~ ~' ~- 3 SIGNA ?~ _ DATE: s G-~~ FROM Schumaker Plumbing FAX N0. 7153863121 May. 08 2003 06:35AM P2 v ~~ ~~ V~\ L ~~ ~~ _..~.. ~w~ ,~ M~ ~~f~'~' '' ,~;5 r~y~~/~~+a•~' 1 ,~r~ ~~ yid ~~~ ~ ,''l~~i-. i~ ;{ ~ ~p~ ~g, ~ ?3w~d c ~.~,,~ Cto~ ~~s r~~ ~i~ ,lea ~ ~-~` / ~~ lfra, ~ y .,. ~`~~ ~ «~ ~ G+~~ ~~1~ ~~ ~ ~~ ~~ ~"~~'~~. ~ c 1~0 ~ -e s ~ .v ~- ~ Cr7- ~' Cf SC ~~ v` ~' /~r /l ~f~- ~sv r ~` v ~~ ~ ~" \ ~~~ ~~ \~ ~c~~ ~. ~~ °~ ~ ~~~ .X~ ~ .~ ~~ .~.~ FROM Schumaker Plumbinq FAX N0. 7153863121 May. 08 2003 06:35AM P1 Salbt)• and 8ua4irtga li;•~isiurt ~ ,~,r 201 W, WasL•iugton Ave., P.G. Box 7!ti2 ~ - C,uunry 1 I .,i ~~ ~trd r' l'C ,~c~~~'~~ ~+ladison, W I 53707 - 7162 _ Sanitary Pertait Number taut be F.II in t`y Co, ~ DPAclf~i11t3ht Df COtT1Rt@t'C@ (1508)266-iiSi ( ~~©~//~ A/J :~ CY Sanitar Permit A lieatY State Plan l.D. Number y pp Qn ~ eccprd vwidt Comm 83.21, Wis. Adrrt. Cade, •persottal lttformapan you provide ! 1 /v ~'1 ~y ~ yacd for secondary purFw~ses Privacy I,aw, s15.04(l)(m) i Projcat Address f different bran mailing atldreas) 1. Appllt:atlon Inforawcioa - Pleatto Print All Infoc7Qatlon ~ ~ ~ ~~S ~i ' f ~ cr..u Z ~Y G Pwperty Owner's >va me i parcel >y i.ot N ~ ~ IilocJc ii ~ • ~ e~ t~ G ohs .5 ~ d ~ C.• - 3 S ~ mod- O'4 Propcrry Owaer'p ailing Address Propgty l.ocatioe City, State + Zip Code I Phorc Number .-L ~ `t X R ! ~ B T YY. Type of $tcilding (check al! that apply) ~~'~' ~'~ ~'L' e ; o ~ or 2 Pamily Dwelling - Number of Bedrooms ~ _ i 5ubdivisioa Vame CSh2 humbnr ~ .©•Public/Commercial -Describe Use ~ ~t~ 6ir/iC ~: !!S -~•~-{ Slate Owned -Deecribe Use - ~ C1City_L~Villags~I'ownship ofd III. Type oI Permit: (Check on[y one bor on ]loo A. Complete line B if sppiYcabLe) '~' ~ New System ',~~ Replacement 3ysrem C TreatmentlHelctir•g Truk Replacement On?y ' ~! Qthtr Modification to $rcisting System ~_ B. ^ Pcrnut Renewal Permit ]2erision ; ^ Ch9:~ge of List Previous Persnic Dumber anti Dare Issued ~ L'crr..ir Tretrs-'er ro New liefote Bxpiration ~---'~' ~ Plnmyat' Owner I ~-L ~~ J_ /l ~ i3 ~•~ TV, T pe of PQWTS 5ystecn: (Check all t_hstt alpplp) t~Von -Preasurixed In•Ground G l-3ound > 24 in. of suitable soil i~ Mooed < 24 in, of suitable sou ^ At-Grade (.,1 Sii>EIe Pasd Sand Filtar Q Cenrvuettiu Wetland ^ Presstrrizuei StrC,rouaCi ~ Lioldiar TsNi Q Peat Filter i_ Aerobic Treatment Unit C Resireulsong Sand Fitter j L liecirculatitrs Synthetic 112edis Fitter ~j.est;iring Chamber ~ Drip Lint r' Gravel-less Pipe L7 Other (explain) ' V. Die erral/Treatcnent Areta Inforcnaeiog: ""'~ Aealgo Ftow (gpd) Aealgn Soil Application Rare(gpdst;~ ~ Dispersal Area Required (sn Dispersal Area Proposed (%~ System Elevation 6"ot~ ~ .gS 7 gam- ~ 93. ~L . 'V 1. 'l'ank Info Capacity in ~ Total i Number tilanufac;urer Prefab j Site , Sutcl Fiber ' P145tiC Gallol)•4 Gallons oP L'nits Concrete Constructed I (41ass New 13detin~ l Tanks ranks $~uk. or Holulag Tank ~e /`~ S i . 'G~~~y~.,'Y I I Aerobic Trcatrnerrt Uri: i I i posing Chamber ~ i I __ _V IT. l;a~iponsLbility Statesnenc- I, the uaderstYaed, mcvWne re:pansibitit far :allation al the )POWYS Shown on tlso attached pisrns. - Plumber's Na me (Pr1nrJ Pluetber'a Si plratur e 141 i?viFTtS Numoer Business Phorrs: Numl+er ! p ~~t'lF~t.y'r .5"~Ciastw~:~cyf ~/.~~,~~~~ ~ ,Z? 7t~d 7 r5 -3~G~ 3/v~ l ~ _ , Plumber's Addre ss (Street. Ciry, State, Zip Codz) ~~~ VIII_ Count /De artment Use O ~ l~ Approved ~ Disapproved Sanitary Permi: Fee (includes Groundwater I Date Sssucd lasuiaF Agent Signature (Nn StampR) Surcharge Fce) i C Owner Given Hasson for I~anial , IX. Cottdltlocts of Apptroral/Remoras foi ir:a ptoral `• kY,-,;~.tt, s s~~ ~t~Za~, , _ ~i~d - a~~/ 1,tt~.d . ~'S/d/~ 3, ~.._ Attach cprnpleie glans (to rho Couaty ugly) for Ute syatent oa paler not leas than Slrt k 12 tp~lrer in aloe SBD-6398 (~. 01/03) Safety and Buildings Division County ~ ~ ` ~ ~ 201 W. Washington Ave., P.O. Box 7162 i ~ j ~ ~~eons~n Madison, WI 53707 - 7162 Site A dd ress . D~ artment of Commerce 3 ~I / ` l /7 ~l ~~.~~~+~~- CT Sanitary Permit Ap lication Salutary ` t Ntttnber~' / ( In accord wilt Comm 83.21, Wis. Adm. Code, personal information you provide p~ ^ ~~ ~ Revisil o ma be used for seco ses Privac Law, a15. 1 m I. Application Information -Please Print All Information State Plan I.D. Number Property Owoer's Name R - , ` . - X~-~ ~ CR Parcel Number ~ _ OO~ ~ s ~ ~ ~,~~ ~-~~. ~ o o -i. s ss DE(~ Property Owner's Addr e t, roperty Location ~,/~ ~ 7` ~ j ~Y ~o? ~~ YTI J~~LL ~-Gc'U -~' p ~v Sf 54: S o~- To7~ N R City, State Zip Code Phony C pFFICE t Number /~ Block Number ZO Subdivision Name CSM Number II. Type of Building (check at aPPIY) ~ ~ ^Ciry ~1 or 2 Family Dwelling - Number o ootns _ w // ^Village ^ PublidCommercial -Describe Use o 'p Li f/~ ^ Stau Owned n Z ') ~ ~ t N st Road ~ GC~+ e S k -3U eM. III. Type of Permit: (Check only one box line A (numbering scheme for internal use). C plete line B II ap A' 1 New 2 ^ Replacement System 3 Replaccmem of 6 ^ Addition to For only stem T Onl Eris ' sum B. ^ Check if Sanitary Permit Previously Issued P 't Number Date Issued 5 y1 IV. Type of Permit: (Check all that apply)(nttmberin heme is for internal us 44~Non -Pressurized In-Ground 21^ Moues 47 ^ Sam Fil 50 Cons Wetland ~ 22 ^ Pressurized In-Groin 41 ^ Holding Tank 48 ^ Singl ass 51 ^ Drip Line nn _ p 45 ^ At-Grade 46 ^ Aerobic Trea ent U 49 ^ R acing 30 ^ Other ~' , I V. D' rsal/'llreatment Area Informati on: d'' rr s v+,ti -B L Design Flow (gpd) Dispersal Area Dispersal oil li on Percolation Rate System E vation Final Grade Required Propost ~~ u( ays/Sq.Ft.) (Min./Ittch) Elevation Goa gS ~ ~, ~~ ~~ ~ ~a~ ~y ~ . VI. Tank Info Capacity in Total Number ufacturer Prefa Steel Fiber plastic Gallons Gallons of Tanks Concreu Constructed Glass New FxistinY Tanks Tanks septic or HokiittQ Tank - ~'.?S~ I ~~ s ~ ~' OC ~~ VII. Responsibility Statement- I, the undersigned, a responsibility for ti of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signs RS ber Business Phone Number s Address (Street, Ciry, Stau, Zip Code) Plumb e i ~ l - 1 v 76 S .~ ^ 4 S VIII. Coon /De artment Use Onl Approved ^ Disapproved ~~Y Permit Fee (includes Groundwaur Surchar e Fee) ate Issued Issuing em Signature (No Stamps) ^ Owner Given Initial erne g ~ ~~~_ ~" 3~Z t Deurmination IX. Conditions of ApprovaUReas for Disapproval - ~ Attach cqm ete cto the Couaq oal,> fur the emou~°per not l~ 81Ci x 11 loch m me. ,. w.4,Q_~ G~1 ~G ®d\ .---~ @~ ~~a ~ ~ ~~ ~`' ~~ . G~ ~~ y ~ ~ u BAY ti ~ ~! CL~S ~~~~ ~~ G~` ~G ~- ~~ ~~~a ~ ~~ ~ ti v ~8~ y ~ /3` CL~~ ~~~~ ®d .----~ ~~ d~ Wisconsin Department of Commerce ~ - SOIL EVALUATION REPORT page I of ~„ Division of Safety and Buildings m accoroanoe wrm c:omm ~, vvrs. r+~n. woe ~~ - 1 r0 5 C m st i Pl 11 i i 811 d m r - ze. an u 2 x rr res n s plete site plan on paper not lei than Attach co inducts, but not limited to: vertical and horizontal reference point (Burn, direction and Parcel I.D.. . percent slope, scale or dimensions, north arrow, and ~ ~ b nearest road. P/ease pri»t aN f ° i-:: _` ~ ~ , ; .~, by Dated ( Peroonai information you provide may be used for ~ r ~ivaaY Law.:: .oa (a) (m>).. /' 3I0 .. Property Owner - ~)~ ~~= !. ~; P rly Location ~. ~;, r ~~'Itr : ~ ~ 1/ ~Gt1114 SzST Z`t N R /~ E(~)~ r . (~©j property owners Mai~ig Address L Lath Block # subs. Nine or CSN~ piX (.t!JJ ~ Z .O S~ i ~ ~ W ;- ._ ~o ~ e ~ i. City StaUe Zp Code , _> FFiCE . /• • .City []Pillage (,~ Town Nearest Road ~STi' I L wa.~-cr f'i1 r\.. fSo XZ.. ( ,a ~~~ 4 - '~` ~~•~n s ® New Construction Use: ® Residential / Number of r ' S'~ Code derived design flow note ~Sd l (o O r7 GPD ^ Replacement ^ PubFc or commercial - Describe: Pai+ent material OU fc~a.S (.. Food Plain elevation if applicable ,~/~- tt General oxriments S ~ S ~ i11 G l C v0. f .b /~ _ ~ o Z. and recommendations: ~ Ui~ e?. I ~e.~ a- ~-,`o r~ - !Uo • d ~~ # ^ Borng Pit Ground surhaceelev. ~~' ~ R Depth to limiting factor 7 I ~ in. Soil icsttition Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fF . in. Muns~l Gki. Sz. Cont. Color Gr. Sz Sh. •EtT#1 •Etf#2 I 6-I 2 IG r .313 Sr 2mabK m-~- c S ) v-~ , S , g Z 12-yb I~~ y~~I ~,~~I 2mab -~~r' c5 _ •`~ -(o 3 40-u3 Ip~ ~-l/~ -- mS ~~ mI - - 1 I.2 /~•0~ .fo llt . _ ~~ # . ^ Boring ._ ®Pit Ground surface elev. / U 3- $ y ft. Depth tD limiting factor 1 i 3 in. Sod ~~ Horizon DepBi Dominant Cobr Redox Description Texture Sure Consistence Boundary Roots GP D/li? in. MunseU Qu. Sz. Cont. t;olor Gr. Sz. Sh. - 'Eff#'t *Eff#2 r b-l`I 1D ~3~~ ~ - .°~~~ Zrr?c~'. ~r cs (v~ •5 •8 z ry-y4. gip; ~y 1~-1 -_ i ~l Z>~b ~ ~-~- ~ s - . ti . ~ • EtAuent #t = 60D_ > 3fl < 220 moll and TSS >30 < 1 50 mdL ' Eftiuent #2 = BOD . < 30 nx.11L and TSS < 30 mglL CST Name (Please Print) S' n re CST Number e. r" ~-~--~ 25 330 Adder Date Evaluation Conduced Telephone Number 2i Tom`+. ~~ e+ ~r `"~I~~S ~-1-~ ~ "7f5-2y7-yvc~ Property Owner ~.-^ k~- ~ ~ Parcel ID # Page Z ~ of_~. Boring # ^ Borimg 3 ®Pit Ground surface elev. ./ ~~ 3 o ft. Depth to limiting factor 1 C~ ~ in. mil ication Rate Horizon Depth Dominant Color Redox Description Texhrre Structure Consistence Boundary Roots GPDlfi? in. Munsell Qu. Sz. Cont Color Gr. Sz Sh: "E~ "Eff#2 Z Ip - 3 I L ~ ~-f ~~4 --- s i c.l 2mc1b~~ rn ~ c - , y ~ ~ 3 -~0 ID ~y~lo ~. mS . Lj~c. mI ~ -.. .^1 1.2 •4 t' 1..60 ~~ # ^ Boring ^ Pit Ground surface elev. R. Depth to limiting factor in. ~ ~~ Rath Horizon Depth Dominant Cobr Redox Description Texture Struc~rre Consistence Boundary Roots GPD/lf in. Munsell Qu. Sz. Coat Cobr Gr. Sz Sh. 'Eff#1 "Eff#2 ^ Pit Ground surface elev. eft Depth m limiting factor in. Borg # ^ ~~ Soil ication Rate Horizon Depth Dominant Cobr Redox Description Texture S6vdtae Consisfienoe Boundary Roots GP D/fl? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. "EfitY1 "Eft#2 "Effluent #1 = BODS > 30 _< 220 mglL and TSS >30 <_ 150 mglL " Effluent #2 = BODS < 30 mg/l. and. TSS < ~ mg/!. 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. SBp-8330 (807/00) PAGE ~ OF~_ NAME ~ Y` K.e, ~ I LOT#(o 6 LEGAL DESCRIPTION 5 t `/,Uw ~/o S z.s~T ZQ N,R [R E (or)~ SCALE: I"= yU BM 1 ELEVATION ~Q~- O BM 1 DESCRIPTION -fap o -~ ~ z p v~ - D~'v e , BM 2 ELEVATION 9 ~ ~-~ BM 2 DESCRIPTION f op a~ [ ~ ~ ~u ~ p ~'/~_ SYSTEM ELEVATION ~ ~ Z • ~ ALTERNATE ELEVATION !Uo • o ~ONTOURELEVATION /oy ~~ /6<~ • O 1 fi K 1 ~ee.zS U a ~o v `o i3-Z 3-3 ~ QmZ 8-l -l -O( Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In-Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWYS} shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the {n-Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- Table 7: System Design Specifications -,----- Sanitary Permit Number ZU Number of Bedrooms Design Flow -Peak (gpd} Estimated Fiow - Avera a (gpd) Septic Tank Capacity ( al) Soil Absorption Component Size } T pe of Wastewater D estic Tahla 2~ Sell AbAert~tien Comnsnent -Limits of Bailable Operation Septic Tank Component Soil Abso ti n Component Desi n Flow -Peak ( pd) ZS ~ °d Maximum Influent Particle Size (in) /8 Maximum BODE (m /L) 220 Maximum TSS (mg/L) 150 Ta61a 3~ Mafntanance SchedUl@ ~~ Septic Tank ^~ Inspect and/or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 ears Soil Absorption Com onent Ins act once every 3 ears Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms}. The opera#ing condition of the se tic tank and outlet filter shall be assessed at least once every 3 years by inspection. Th ou et filte shall be cleaned as necessary to ensure pro .The filter cartridge shoo d no be removed unless provisions are ma a to retain solids in the tank that may slough off the filter when removed from its enclosure. If the Managem®nt Pi$n ft~r a Septic ~'a~x arc Sai; A~sorption Com,par~er~t _.., . fUt+e-r'fe equipped with are alarm, the finer abets bo serviced if the alarm is activated rantinuousiy• Intetmitter~t filter alarms may indicate sure flows or an impending continuous alan~n. Ths aeptie tank shall haw its oontenta romoved when the volume of arum and sludge in the tame exaeeda 413 the liquid volume of the tank. It the oonter+ts of the tank aro not nmov+~d at the time of an aeeeasment, rt~lrttenance penonnei abets advise thi r of when the next service needy to b1- parforrned t4 rria#ntatn leas then tYwcirnum scum end sludge accumulation in the tank, dWanhote rlaa-ra, aaceas risers and covers should be Inapeated !or water tightn®aa and soundness. Access openings used for aerolce and arsessrnent shad be asa}ed watht upon the aornpietbn oP eenrice. Any opening deemed unaound~ dafacilva, ar aubj~t to itilu:e- rr~ust be rrpleced. , Exposed aocaas opantn~s greeter than B-inches to diameter shall be secured by an e!!fective locxWnq dwioe to prevent aoeldentai or unautttori~d or~try iota the lank. 1rEo one ahoufd enbr a aspNa or other tnttmeA! or hofdM~ bok br soy rsraaon wlrhou! befog In fait oomaltrna moldy attnai4trdi for ~t~ a ~~+~d ate, the ilmatph~nt wlthfi the ear olha~ b~wtiGtnorllt ~ h~ataNr~- taalk,~y ~~e i aid raeaua of s peon from the Io~a'1or of ato tu~r »~ybt ~rlt or ~r~poaa~bl~. Tank abandonrnertt shell be !n aooordanas with Comm 83.33 Wis. Adm. Code wf,en tree tonic Is no iongs~r used as a leOWt"8 component. The soli absorption component serving this atru~un is daelQnsd tri accept domestic wsstswater fnsm a rostdentla2 lacl~ty. The limits of operation of this component era sht'own in Tape ~, longevity of a eo-! absorption oornponent depends greedy on proper and time4y rt~in#ertanos, and system use within or bebw the Limits of rotlsbla operation, Oood water cortaarvatton prsotices by ai! o~tPanta and the inataga#ion of water aonser+rir>g plumbing fixtures era key fitota-rs in extending the uaaiu111fs o1 t!'tia oarnporrsn~ The soot abso~tlon oompor3ent's operafian must be asNe~sad by inaon apt asst or-ce every three year=, Thf Inspection shaft lrtaiucis rrcording this levels of pondin or d achy ~$ the observiti0n pi{~s, and s visual inspioti4n for my evidence of aurfic~ seepage from th+s component. On steeply aioptr~ alias, areal o< eroslr,M should t» Iderstl~ed and reported to thsr owner for t+epalr. The eurtaa discharge of domeetie wastewater or sewsq~s from the oysterNt h prohibited and considered a human health haterd~ Traffic around or over the soil absorption component ah~ld ire avoided ParaiCUla~•ly during winter rr+or:ths, The compaction or removal of sow cove p~~ u~?~ din uit may lead to hydre-utlc tallun by freetinp. This type of !assure s Y trapossipie t0 repair antis weather corfditions improve. in penerat, s~~~+l homey loadl to ~pnlppnent wits reduce diffusion Cf oxY4sr+ into the soil and di:pars c~nora intsz~se, erld eeriier, organic Glogylrt~ of fhb soil, Management Pian fora 5sptic Tank and sal Absorption Compansnt Plantings of deep-rooted trees and shrubs directly aver of within ten feet of the component should ba svoided since root intrusion iota the camponeM may obstruct wastewater flow. Contingency Pian In the avant of system failure, a new system could be installed in an alternate area. With the lnatallatian aP a diverter vain®, the existing system could also be reused after a period of three to four yeas. $ is the property owners responsibility to maintain the alternate area free from any planting of trees, shrubs, etc. in ease of failure of the original system, the alt~amate area will be needed. if any trees, shrulas, etc. Nava been planted on the altemste area, they will have to ba removed at propertt oMmsrs expen:a. if aitamata area is destroyed, there are other attemativs systems that can ba used, in which, aouid result In added expense to the property owner. Any tank abandonment shall bs done in accordance with Wlsc. Cods 83,33. Any questions regarding this Dods, please contact your local Zoning Qtfiw ar contact the instal3ing plumper. ZdN~~vc~ 'D~s~ce. ~'1tS~3g ~ --><.{ ~o8q 5crk,~,.~a-1~~-~ t~1.u,-eY,1p~H~ ('t~S~ 3~~,3 f ~ ~ s~r Cfrofx cOuN~rY SEPTIC TA1~fK MAINTENANCE AGP.EEMENT AND ` OWNERSHIP CERTIFICATION FORM Owner/Buyer L ! !''l'K,~_ ! ~ -r' Mailing Address ~~.~"~ ~Y~',S' uY ~ar,U-~ .Ca~f~ ,~!~d~0 ~'''~ Property Address City/State T,FGAL DESCRIP'I'~ON Parcel Identification Number Property Location -~~ %.,~ ~/~, Scc. a?~ . T R 9 tit-R~.W, Town of ~,~~1r~- Sttl~divisian ,~~-~ ~ i ~ ~i ~~G' _ .Lot # .~,~. Cetrtif'ied Sarvey Map # _ _ ,Volume .Page # warty n~a # 6 yg 6° `~ . volurat: I~~z- .Page # 2~7 Spec horse 'yes ^ na I.ot Imes identifiable ,[yes ^ no S~S~M MAINTENANCE Improper use sad ~ of your septic xystem could result dm its prLmattutfailurn to handle wastes. Proper arainieaan,ce consists of pumping oai the eeptie tank every tlmce y~ or sooner if needed by a licensed pmaper. What you put into die system . can affect the firrzctiaa of the septic taalc as a lizataxnt stage is !!yc Este disposal spstcm. Ttse pmpcxty oRmcr a8~ Lo stihmit to St (~oix Zoning Ducat: eatificcx~tioafotm, signed 6y the owacr~ and by a az~crpl~ber, joumoYautaPtumbez,:+e.~idodplumberor t liacasodvaifYing tbai (I) the oa-silo wastewaierdispasalsysum is der proper operating eonditioaand/or (2) after inspection nerd psauping.(if necessary), the tcptie tank is less than l!3 full of sludge. IVwe„ the nad~ed have r~cad the above rngrrirrmeats and agree bo ruasutaia 4~c private sewage disposal systcat wig the standards ter forth, herein, as let by t4u Departzaent ofCotamctnc and the Dcgattmeat of 2laturaf Resources; State of Wisconsin. Gectificatioa staling that year septic systcaz has been maintained must be coiupldod and returned to the SL Croix County Zoning Offix within 30 days o year ezpiratioa date. ~ a ~2~ ~~ l t G p~ DATE OWNER CEItTIFICA'ITON I (we) cetbify statements on this form arc true to the best of my (oar) lmowlcdgc. l (we) am (are) the ownc:(s) of rho , by virtue of a warranty decd recorded in ~egistcr of Dads Office. .- ! /C~~ SI APPI:ICA21T DATE ss«sss t be' revoicod b the Zoai DC artment. s•+•s• Any iaforrriatioa that is tail icd tray result do the sanitary pctau uzg y ~ P •s Iaelude with this apptitatdon: a stn warranty decd from the Register of Duds office a copy of the certified s+arvoy rnap if reference is trade in the warranty decd 7v' ~ ~',~~~/ (VctiScation required from Planning Department for new construction) k Document Number t,,Ja r r-~-r~~ 17ccd ~~ , 1GG2PA~: 289 i C.t 64$6,Q4 Y,ATHLEEM H. WALSH ~tnms'ISa~ hEGISTER OF DEEDS 5'i. CFOIX CQ., WI H.ECEIUED fOR RECDkD 06-18-2001 12:45 PM WAkkAHTY DEED EXEMPT k CERT COPY FEE; COPY FEE: TkANSFEk FEE: 9900.00 RECDkDING FEE: 14.00 RAGES: 3 Rtratdiag Area Name aad Retarc Address 1900 S~Ivor L.nke '~OC~d lilt w B r~H~n ~ M N SS'/l z OZo- 10bq-'7o _qoo Pastel Ideng6ctiaa Ntmsber (PIN) C7ZC~-IC~(aS'-~{O -vUp Oho - I X6`1 -`1D - uvo ~ 2v - 1070 ~- cao - Cep 020 - ~o~Q .. ~ ~ - ~,Uv v2v - l0-7~ -zo ~-~ "THIS PAGE I5 PART OF THIS LEGAL D(>CIIMEN'p - DO NOT RElIO9E" Thir io[atmad0a ttwit bo eo~Iaed 6y wbtaitsar; docvmotr ede. ar iltc ~rtmdn j elaurv, k Ccsert tLmne & retunt addrvr mtd ~ (~ rcqutre6J. Othrr ,brfortnaNOn ruelt FaI Pte. ue. may be ploeed on dtir~Crrr Pote of she doeionertr or ~ ~~ Vrc of dtlr amr jwtc addr ate Pafe ro Ya'k doc*onw and SY W ro rAe rccwrdu,~r ~ placed on adddona! parv oJKe -~._, iPucovuin Swaecr, J-.S17. WRD,s Z/yd DOCUMENT NO, WAl11LANTY DEED ~(1 h~.E BTATE OF WISCgN61N-FORM B 1 t<I)! Uo(%P~~ TNI^ apI,CE R[aFgvF.D FOR RBI OROINO OAi• THIS INDEN'I'i.JRE, Made by.RICHARD N. PEARSON and JEAN M. PEAR50N~ .husband and wife, ...................................... ........... grantor.s_...of...:St.~..Croix....._ ................................................Count Wisconsin hereby conveys and warrants to ...CARRIAGE HC~IES XXI, INC., a Minnesota corporataon, ........._ ................................._. Washin -£o]i---°-- .............................................................~1~n..~~gg~~ rautee........ of ......._.:..._._ ........................ . ................................Count , ~"]E'c~liY+1S~~ Qne Dollar and._no 100_ ..1,00), and.. other ood and valuable +)SEi,~I/~ /y~~ S 1~ ..~ L<rl(~ I~cG. G4?ns ide,ra tin,-_. ~ . « -Y..---~...... or the sum -of I gEr~RR ro [ i; h. tl T r f ~ t st zL'~, ! r the following tract of land in.. SC......G.ro1x '~ t ~Si/Z .........................................County. W;sconsin: .A~.~..4~...kh~...Northw~$-1.:--Qyartec-,-iNW;) and.-,forth--Half (N~) of the Southwest Quarter (541;) of Section Twenty-Five (25), Township twenty-Nine (29) North, Range Nineteen (19) west, St. Croix County, Wisconsin, except Lqt One of Certified Survey D7ap filed June 29, 1999, recorded in Volume 10, Page 2782, St. Croix County Register of Deeds, as Document No. 518944. See Attached Exhibit A Parcel Identification Number This is not homestead property In Witness Whereof the said grantors.. haVe...... hereunto set......... their hands... and seals.... this .................. day of...... aY..._.._............................., A. D., Y`lC..Z-QOJ- 610NF,D AND SEALED IN PRESENCE OP ~ ...................... ..........................-..............................-..(SEAL) .................. (SEAL) yy~~ ~ -- ~ ~ Oil ~ -~..c'L_~!'.~"f"'.-'~._._.....(srnc) p,N M: ~EAFtSON -- _~pri~spta - -- - St~te of `~dr~~ ..................... WaShlnytOn --County, Personally came before me, this..~~':,`n`.. day of.. ~.`:.} ............... A. D., t`~..2.Q01 the above named ..RICHARD- N.,, EAI2SON and JEAN M. PEARSON, husband and wife ............................... ..................... _._.t _. to me known to be the persons.... who executed the foregoing instrument and acknowledged the same. ............................ ~ti ~ ............... _... THIS INSTRUMENT Aq DRAFTED v ~.AA.~y_N10UNTAIN __^_ ' Richard J. Ga~r>eJ, #3264 ,° . NcrrAar Notar Public, _ i~~~'SNOTARY.PL;gUG-MINNESOTA Count W;s. 880 Sibley Memorial Fiwy., #114 SEAL Y ~; y, My Comni. Expires Jan, 31, 2(x15 -1736 my commission (ex ' ^ (Section Sy.yl (t) of the Wiscomin S<atutcs Provides that all instruments to he recorded shall have plaiDly printed or typewritten th<r<on the nano of the ~rantvrf, grantees, witnesses and aaty. Section y9.S13 sinillarly requires chat the name of the person who, r govern mental agency whuh. drall<d mch instrum<nt, shall Ise p i red, typ mn, Bumped or writt<n thereon in a legible mann<r,) WARRANTY DEED STATE OP WISCONSIN Wlaconatn Lego! Blank Comosoy FgRRI No. 9 Mnwaukee, WIe. (Job 3JF.11 ) ~~~ 1G62PA~~~ 291 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 b .. r ~~