Loading...
HomeMy WebLinkAbout020-1395-61-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Davies, Todd & Julie Hudson, Town of SST BM Elev: Insp. BM Elev: BM Description: TANK IN FORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. CI.OIX Sanitary Permit No: 145 State Plan ID No: Parcel Tax No: 020-1395-61-000 Sectiontrown/Range/Map No: 25.29.19.2455 STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer ~, ~Z SUHt Inlet ~ ~~ SUHt Outlet Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover /o o~c' ~ ~, 9. k-roar' ~ I!~ J~ w~., ~• ~5 BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: IIISTRIBIITInN SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SAIL COVER v Drnc~~~ro c..~rom~ new YY Mn~~nrl nr O}_r~radP SVStEmS Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center BedlTrench Edges Topsoil itti Yes ~ No ~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / /. Location: 756 Highlander Ct. Hudson, WI 54016 (SE 1/4 NW 1/4 25 T29N R19W) Scenic Hills Lot 61 1.) Alt BM Description = 2.) Bldg sewer length = ~! /~ - amount of cover = ~.J 4~- ~' o ~` Plan revision Required? 0 Yes ~ No Use other side for additional information. SBD-6710 (R.3197) Coy ~- o~- ~ z~ o~ Date Inspection #2: / / ~,e5 ~OI nn__ Parcel No: 25.29.19.24 5 /~GCA,A~ OJ\. ~v~ 35 ~ ie<x~ ~-+`-r~ ~~ f~ o-~„ dew b~~ e~,-ICS. Insep is Sign Cert. No. County anitary Permit App In accord with Chapert 12 St. Croix County Sanitary O[djpance ST• CROlX COUNTY WISCONSIN ` Personal information you provide may be used for seconda u s ~~~~ ~ ZONING' DEPARTMENT [Privacy Law. S. 15.04(f)(m)) ry P ~ ~ ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-Ti 10 Attach com fete ens for the s stem on (715 366-4660 Fax (715)386-4686 County Sanitary Permi~/ ~ n 11 inches in size. ^ Check if revision t viaus applicatlon Ilcatloa Information -Please Print aH Infor roperty Owner Name oration ovation: O ~NNit~ ~ NING F ~ 1/4 Iv ~/4, Sec aS roperty Owner's Mailing Address N, R E (r W J[` -~^-~ of Number Block Number ity, Stale v~~ ~t? N l.. o "~ r l ' Zp Code Phone Nmmer ~~ ~ Oh W~ ~~ / bdivision Name S umber Type of Buf- ng: (check one) (O SG Cr\ ~ t` ~ 1~~ 1 or 2 Family Dwelling - No. of Bedrooms: ~/ Ok ~~ ^ Public/Comme~al (describe use): --.~L~~ ~lY ^t Village 1~{Town of ^ State-owned ~1 G,~ ~ / l ©/~ !• Type of Permit: (Check only ane box an line A. Check box on line B if applicable} ~~e~t Roa A) 1.^ Repatr ~ Reconnection FJ ~ -^Non umbin Parcel Tax N tuber(s) 1~ g . ^ Rejuvenation ~~~ Sanitation ,,,, `~ QS' _~1 ~ 00 8) ^ State Sanitary permit was previously issued Permit Nwnber Date Issued ~ Z ~5S IV. Type of POW7' Sys~n; (Check all that apply) Non-pressurized Irnground ^ San filter ^ Mound Z 24 in. suitable soil p Mounds 24 in. suitable soil ^ Mound A+0 Pressurized In-ground ^ Constructed Wetland At reds ^ Holding Tank ^ Peat Filter ^ Drip Line © ~ ^ Single Pass ~ Aerobic Treatment Unit ^ Other ' Di rsaUT-eat-nent ea Inoormation: ^ Recirculating 1 • Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soli Application Rate 5. Percolation Rate 6. System Elev lion 7. Final Grade lI/~~ Required ~ , ~ Proposed ~ ~ (Gals./day/sq.ttJ X00/ ~.? ~ (Min./inch} ~j (r'} Elevation 1. Tank Information Capaicty in Gallons Total ' .la, # of Manufacturer Prefab Site Con- Steel Fiber- New Existing Gallons Tanks ""'API' astir Tanks Tanks Concrete structed glass `~ ~ ~ ~ ^ ^ ^ ^ t. Responsibility Statement ^ ^ ^ ^ the undersigned, assume responsibility for repair/recon ^ icense is not r uired for terrdtitt r ~ rejuvenafioMinstallation of non-plumbing for the POWTS shown on the attached plans. A I tuber's Nam ~rn) eparr °f ~ mstaHatio of non umbing sanitation system. Plu is Signatu fames): ~ /MPR o. lumber's Address (Street, Ci Business Phone Number ~ ~' stale, zp N ) s3 7 `7!S s'13.5 Nt. Coun Use On ~~ "`-"~- S C7 ~,.,/ Disapproved Sanitary Permit Fee JaC Approved py„ner i 'tiai Adverse D to iss Issui c , .,(~ z2 5 , o~ $ 1 ~ ent Sign ure stamp Det .ion Y - ~ ~ Conclltions of APProvaUReasons for Disapproval: SYS?~M ^V~iNER~ 'main ~' tank, effluent filter end 2. rJ • ~Y PipttibK, dispersal cell must all n~ ; jtlta >ia per management pi~n~ as pr. uY,:4i;;,,, ,,, ....,.e ; ordm ~ ~'k•[lqujfements ; a ~ ~ ~pPNatble epde / arMd~, ~1~ ~~ v-r-C,.lVi~'~o S N ~Q~lu/~dvr ~c9ur'f' ~~,~s©~,, ~z syo tt~ Plor fl,.,. S~.y ~~,'I S~~ as raq u ~ ~~ ~ ~~ o ~ s7' C` ~o ~~C 5e~n~c, ~~1~ ~ort~ ~f p;,, ~ c~~p-~~gs_Col-oo~ f /~~rf ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT . AND ''~ OWNERSHIP CERTIFICATION FORM OwnerB uyer _ ~~ o ~ ®P'v ~ ~S Mailing Address `~ S Ca ~t ~ +-ti ~-L~-t-t-~~ ~-'J ~u O So ~.1 ~ ~tc~ f, ~ 4 a L to Property Address ~ ~~-M'~~ ~ ~ ~ ~-~-t ~-t+-t lA~~~~ ~". ri ergcation required from Planning & Zonir-g Deportment for new construction.) City/State ~OSa ~--t ~ ~t ,. Parcel Identification Number Ch Z4 --- l~`~ S - Cv 1 - ©~ ~ -- L- E~AL-DESCRIPTION Property Location ~ ~/a , ~~! 1/4 ,Sec. Z~ , T 2°! N R ~ ~ Town of ~ O S ~ ~t-i Subdivision ~ C~EPl [ v ~'~ ~ 5 Loi # ~ ~ Certified. Snrvey Map # Volume ,Page # Warranty Deed # _ ~~ ~'D-~.1VL~ , Volumc , Pagc # Spec house yes no Lot lines identifiabl yes ` no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists ~f 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 are 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 Planning & 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. I/we, 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 Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that alt statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Ofi"ice. Number of bedrooms __ _ _ . S NATURE OF APPLICANT(S) ~S ~ ld ~ 09 DATE _ ***Any inforrnation'that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Ofl~ice and a copy of the certified survey map if reference_is made- in the warranty deed. (REV. 08/05) 05/03/06 9YED 07:28 FAS 715 386 4686 ST CR7[ CO ZONING f~J001 ST, CItOIX COUNTY ZONXNG OFFICE CERTIFICAT'TON STATEMENT rOYt UTILIZA'T'ION OF AN .~.~ISTINC: SE:QTIC TANS This is to certify that i Dave inspected the septic tank presently serving the 7~ ~ ,- ,os _ residence located at: s~ t/~, ~U tu'/4, Section ~, 'I'own~N, ~Ratlgc~W, Town o.f , St, Croix County Wisconsin. Upon inspection, I eertifiy that I have found the tank(s), to the best of my knowledge, will confonxl to the requirements of Comm. $4,25, and it (they) appear(s) to be functioning properly. Most recent date of service a o os I7id flow back occur from absorption system? Yes No~ (iFno, skip next line.) Approximate volume ar :length of time: _ gallons _ txlinutes Capacity: i~ ©~ Constxuction: Prefab Cancrete ~_ Steel ~.~ (7thcr Manufacturer (if known): __~/R Age of. Tank (if known): T~-. ca ~ ~ ~~ ~w ~.~s (Licensed Plumber Signature) (Print Name) -~~ ~ ~ 1n ~~ s ~a x.53 7 {'Citle) (License Number)II'RS ~ ~® (.Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wiscau.sin .Adntinistrative Code) POWTS OWNER'S MANUAL & MANAGEMENT PLAN FILE INFORMATION Owner ~ ~ i ~ S Permit # DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ^ NA Estimated flow (average} Q ~ of/da Design flow (peak), (Estimated x 1.5) ~~ allda Soil Application Rate al/da /tta Standard lnfluent/Effluent Quality Monthly average* Fats, Oil & Grease {FOG) 530 mglL Biochemical Oxygen Demand (RODS) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mglL :P[e3'r_eated_Efflueni.IIuality----- ,~~1,~,-~ra9e Biochemical Oxygen Demand (BODE} 530 mglL Total Suspended Solids (TSS} 530 mg/L ^ NA Fecal Cotifiorm igeometric mean) 57 04 cfu/i OOmI Maximum Effluent Particle Size YB in dia. ^ NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Page ~ of Septic Tank Capacity ~a Cro al ^ NA Septic Tank Manufacturer ^ NA Effluent Filter Manufacturer e ~ ^ NA • Effluent fitter Model ^ NA Pump Tank Capacity al ,~ NA Pump Tank Manufacturer J~ NA Pump. Manufacturer I~NA Pump Model NA Pretreatment Unit ~ NA ^ SandlGravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other; -!)ispessal-Gei4ts)--- -- - - - - --- - ~In-Ground (gravity! ^ In-Ground (pressurized} ^ At Grade ^ Mound ^ Drip-Line ^ Other: Other. PS} NA Other: ,~ NA Other. NA Service Event Service Frequency inspect condition of tank(s) At least once every: ^ month(s) saris} {M¢~ximtim 3 yearsf ^ NA Pump out contents of tanks} When combined sludge and scum equals one-third iY3} of tank volume ^ NA Inspect dispersal cell{s} At least once every: ^ monthis) (Ma~amum 3 years} yearis}. ^ NA Clean effluent fitter At least once. every: ^ month(s), ~,f year(s) ^ NA Inspect pump, pump controls & alarm At least once every: ^ month(s) ^ year{s} ^ NA Flush laterals and pressure test At least once every:. ^ month(s) ^yearis} ^ NA Other: At least once every:. ^ month{s} ^:yearis) ^ NA Other: ^ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certfications: Master Plumber, Master Plumber Restricted Sewer; POWTS inspector; POWTS Maintainer, Septage Servicing Operator. Tank inspections must include a visual inspection of the tanks} 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 cell{s} 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 effluem 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 iY3} 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. Atl other services, including but not limited to the. servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of <12 months, shall be performed by a certified POWTS Maintainer. A service report shah be provided to the local regulatory authority within 10 days of completion of any service event. Page ~of o~, START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of .painting products or otherchem~als that may impede the treatment process and/or damage the dispersal ceN(s-. If high concentrations are detected have the contents of the tanktsl 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 shave norms! highwater levels. When power is restored the excess wastewater wilt be discharged to the dispersal cell(s- in one large dose, overloading. the cell(s- 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 Plturrber 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 taroks ~d dispersal cells. Do not drnre ar 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 ths wastewater stream may improve the performance and prolong the Bfe of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat, foundation drain (sump pump- water': 'Fran 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 andlor is permanently taken out et service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33,1NiscAnsm Administrative Code: • Ali piping to tanks and pits shall 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, all tanks and p"its 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 measures have been, or must be taken, to provide a code compliant replacyement system: G~, A sortable replacemenrt area has been evaluated and may be utilized for the location of a replacem~t .soil .absorption / _ system. The repiacernent area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot (inesand wells. Failure to protect the replac~nent area will result in the need for a new soil and site evaluation to establish a su"",table replacement area. Replacement systems must. comply with the rules in effect at that tone. A suitable replacement area is not available due to setback and/or soil limitations. t3arring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ^ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. ff no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ^ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the btomat at the infihrattve 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 INSUFFlCIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. i3ESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE.. ADDR70NAL COMMENTS PrftAITC lNSTAI I FR Name ~ ~p r~ Phone "~' (S ~` POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Phone Name S~- C ro ~ Zpn ; rt Phone `(l S 3~(~ ~o~C~ This document was drafted in compliance with chapter Comm 83.22t2lIbl11 itdl&(f) and 83.54{1), (2) & (31, Wisconsin Administrative Code. . Page ~af START UP AND OPERATION For new construction, prior to use of the-POWYS check treatment tanks} for the presence of .painting products or other chemicals that may impede the treatment process and/or damage the dispersal celNs?. If high concentrations are detected have the contents of the tank(s). removed by a septage-servicing operator prior to use. System start up shalt not occur when soil conditrons are frozen at the infiltrative .surface. During power outages pump tanks Wray fip above normal highwater revels. When power is restored the excess wastewater wilt be discharged to the dispersal -cell(s) in one Large doss, overloading.-the cents) 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 FOWTS Maintainer to assist in manually operating the pump controls to restore normal tevets 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 soli absorption area. Reduction or elimination of the following from the wastewater .stream may improve the performance and prolong the Bfe of the POWYS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; faE; foundation drain (sump pump} water; fruit and vegetable peelings; gasoime grease; herbicides; meat scraps; medications; ail; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWYS fails andlor is permanently taken out, of service the ~foiiowing steps sha[I be taken to .insure that the system is properly and safety abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: e Ail piping to tanksand pits shall be disconnected and the abandoned pipe openings seated. ~ The contents of all tanks and pits shall be removed. and properly disposed of by a Septage Servicing Operator. • After pumping, alt tanks and pits shall be excavated and removed or their covers removed and the void space filled with sail, gravel or another inert solid material, CONTINQENCY PLAN if the POWYS faits and cannot be repaired the fo0awing measures have been, or must by tak-err, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement -sail .absorption system. The replacement.area should be protected from disturbance and compaction and should not be infr"rnged upon by requited setbacks #rom existing and proposed structure,. lot lines and wails. Failure to protect the replacement area wilt result in the. need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rotes in effect at that time. A suitable .replacement area is not available due to setback and/or soil Gm.'ttations. Barring advances in POWYS technology .a holding tank may be installed as a last resort to replace the failed POWYS. ^ The site has not been .evaluated to identify a suitable replacement area. Upon failure of the POWYS a soil and site evaluation must be performed to Locate a suitable replacement area. ff no replacement area is available aholding-tank may be installed as a last resort to replace the failed POWYS. ^ Mound and at-grade soli.. absorption systems may be reconstructed in place following removal of the biomat at the ' infiltrative:surface. Reconstructions of such systems mWst~coniply wtth.the rules in effect:at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. ~iESCUE OF A PERSON FROM. THE INTERIOR OF A TANK MAY BE.DIFFICULT OR IMPOSSIBLE.. ADDITIONAL Ct?MMENTS POWYS INSTALLER Name ~ .o r-s Phone 7 (S c~- `~~ POWYS MAINTAINER Name Phone SEPTAGE SERVICING OPERATfJR !PUMPER) LOCAL REt3ULATORY AUTHORITY Name Phone - Name S~ C ~©~ ~©n ` -'~ Phone "~ (S 3~(p ~pg~ This document was drafted in compliance with chapter Comm 83.22t2)(b}t1)(dl&(f) and 83.54{1), f2} & (3l, Wisconsin Administrative Code. U, 2870P y81 State Bar of Wisconsin Form 1-2003 WARRANTY DEED Document Number A Document Name THIS DEED, made between Midwest Vinyl Systems, Inc., a Wisconsin Corporation ("Grantor," whether one or more), and Todd Davies and Julie Davies ("Grantee," whether one or more). Grantor, for a valuable consideration, conveys to Grantee the following described real estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Croix County, State of Wisconsin ("Property"} (if more space is needed, please attach addendum): Lot 61, Plat of Scenic Hills in the Town of Hudson, St. Croix County, Wisconsin. 839 1 1 KATHLEEN H. NALSH REGISTER OF DEEDS ST. CROIX CO.. NI RECEIVED FOR REGORD 08/19/2085 09:SSAlt iIARRAHTY DEED E?iE)4~' p REC FEE: 11.00 TRANS FEE: 1770.00 CLIPY FEE CC FEE: PAGES: 1 Recording Atea Name and Return Address Te+~nsenpe-~t{e 'a.v-es 40Z~1 ~~ /~ ~Oyhft~'S I ttl~ !8D 9 A/ov~y wesilPvn /i~ve ~ i - ~ Sfi~~Vvdf-~r, -1'1~ 5>OgZ 020-1395-61-000 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except: Dated August 15, 2005 Z * Luke Panek, President of Midwest Vinyl Systems, (SEAL) (SEAL) (SEAL) * AUTHENTICATION Signature(s) authenticated ,„..~ uy Commission Expires Jan. 31.2010 * TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by Wis. Stat. § 706.06) THIS INSTRUMENT DRAFTED BY: Townscape Title Services, LLC 1835 Northwestern Ave Stillwater, Minnesota 55082 ACKNOWLEDGMENT STATE OF WISCONSIN ) ss. Washington COUNTY ) Personally came before me on August 15, 2005 the above-named Luke Panek, president of Midwest Vinyl Svtems. Inc. to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. * Notary Pu lie, State of /Yt;-intsoT'4 My Commission (is permanent) (expires: ) (Signatures may be tatheuticated or acknowledged. Both are not necessary.) NOTE: THIS IS A STANDARD FORRt. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED ®2003 STATE BAR OF WISCONSIN FORM NO.1-2003 • Type name below signatures. W isconsiR Depar`,ment of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM 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 Midwest Vin I S stems Hudson Townshi SST BM Elev: Insp. BM Elev: BM Description: ~~~ y5 (~ rte, ~~- (~ - ~ TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ Z ~~O Dosing ~ ~~ /( J~- Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic 4 ~ ~ , ^ ~ /V ~ ~, i ~ G / I Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufac Demand GPM M el Number T Lift Friction Loss S s ad TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. CrDIX Sanitary Permit No: 453472 0 State Plan ID No: Parcel Tax No: 020-1395-61-000 Section/Town/Range/Map No: 25.29.19.2455 STATION BS HI FS ELEV. Benchmark ~~ /~ ~ 5. s~ 95 Alt. BM ~~'- ~bV L.~ . ~/ ~ 9s ~ Z Bldg. Sewer -7 7 "/ Z SUHt Inlet OL y . 5~ SUHt Outlet $ Z?j y~, 3Z Dt Inlet Dt Bottom .~ HeaderlMan. ''T. 3 q• s7 ~ J , /4 qp .9g Dist. Pipe 9 '~~ / , / (, ~ 9g Bot. System ~G2. ~O c,~,/ Final Grade 5. `ar7 q~ St Cover ~ 5 ~ ~S ~ 7 Gr rt /O,k ~•~ j Z t a , ~ 9U . /~ BEDITRENCH DIMENSIONS Width ~ Length ~ No. Of Trenches \ PIT DIMENSIONS No. Of P'ts ~ Inside Dia. Liquid Depth ~ ~ ~ ~ ; ~,~ t, \ ` \ ` SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufactu~e~ •, ~ INFORMATION CHAMBER OR ~ ~ Type Of System: ~ ~ / J ,7 f • ~ /~ . (^ UNIT Model Number: ~~ DISTRIBUTION SYSTEM ?A ~e~, /~ p..~ I ,. i ~",o .~~ 1.1 Header/Manifold ~ Length ~ Dia `l !/ T Distribution Pipe(s) Length \ Dia ~ Spacing \ x Hole Size \ x Hole Spacing \ Vent to Ai Inta 3r~ IL v ..-a,rc SOIL COVER x Pressure Systems Onlv xx Mound Or At-Grade Systems Only Depth Over ~ Bed/Trench Center ~' ~~ Depth Over Bed/Trench Ed es g xx Depth of To soil p ` xx Seeded/Sodded xx Mulched N - i Yes ~ No _- Yes C] o COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2; / / Location: 756 Highlander Ct. Hudson, WI 54016 (SE 1/4 NW 1/4 25(~T29N R19W) Scenic Hills Lot 61 i ~ p Parcel No: 25.29.19.2455 1.) Alt BM Description = 5~~`~" ~ Piv ~~., GJ~~ ~oad~.~ `-, d ~ / 2.) Bldg sewer length = ~ ~ y ~('; ,r..q S ~.o~t-' -amount of cover = ~g +'~ ~ bl~ , ~ ~ 5~ ~vh ~03~- ~.~+~~ f 4tJv~at~- ~we~5v f_ -- Plan revision Required? [] Yes No ~ j Use other side for additional information. _~ ~z~_i~~ ~ L . _. __ -___ . _ ___ - _._. _ -_-_ ._._-_-_____ J !.~ ___ ___ Date Ins ctor's nature Cert. No. SBD-6710 (R.3/97) l% Safety and Buildings Division 201 W. Washington Ave., P.O. Box 7162 County /~ S ` Madison, WI 53707 - 7162 i i Sanitary Permit Number (to be filled ' by Co ) n seons (608)266-3151 y Department of Commerce State Plan I.D. Number Sanitary Permit Application ~---- rovide ou mation l i f Ad C d Wi p y or e, persona n m. o s. In accord with Comm 83.21, may be used for secondary purposes Privacy Law, s15.04(1 xm) Project Address (if different than mailing address) ` ' v ~~~ ~S~ ~~ -Please Print All Information ti I f i ~G/ t / on orma on n 1. Applicat Property Owyner~'~s Nf ame e ~ A~ ~ Parcel q N Block # ing Address il ner's Ma Property Ow Property Location ~ 7 n l 30 / 2~ (~~ .~ ~ St y, N~/., Section Z ~ / 2 5' City, State Zip Code Phone Number ~A G!W - ~- ~ (circle T ~ N; RI~E o W ' „Jl/Z~ ding (check al that apply) II. Ty of Bu Subdivision Name CSM Number ~ or 2 Family Dwelling -Number of Bodrooms S(~t".1"' lG•... t ^ PubliclCommeroial -Describe Use^^ G p~Tt ~ ~~ (S ^City_^Village ownship of p.~ ^ State Owned -Describe Use ~. III. Type of Permit: (Check only one box on line A. Complete line B itapplicable) '4' New System ~~ ^ Replacement System ^ TreatmentlHolding Tank Replacement Only ^ Other Modification to Existing System B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number and Date Issued Before Expitatfon Plumber Owner ~. IV. T of POWTS S stem: Check all that a 1 Non -Pressurized In-Ground ^ Mound ? 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constructed Wetland ^ Pressurized n-Ground ^ Holding Tank ^ Peat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter thing Chamber ^ Drip Line ^ Gravel-less Pipe explain) V. Dis etsal/I'reatment Area I ormation: 0 ~ S Design Flow (gpd) Design Soil Applicatio gpdst) Dispersal Area Required (st) Dt Proposed (sf) S m Elevati Cevv o~ 7 3 YS'7• ~ ~ ( I.3 . o VI. Tank Info Capacity in oral Number Manufacturer Prefab Site feel fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank 2 0 AerobicTreatntentUnit ~ -~~~ ~` Dosi~ Chamber VII. Responsibility Statement- >G the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Business Phone Number Plumber' me (Print) ~, P tuber's Si P/MPRS Number .~ r" Plumber' ddress (Street, City, State, ip ode) w ~/`/- m ~ ~ VIII. oun ~/De artment Use Onl Sanitary Permit Fee (includes Groundwat Dat Issued 1 uin Age Sign re tamps) Approved ^ Disapproved Surcharge Fa) ~ ~~ ~ g ~"6 U ^ Owner Given Reason for Denial IX. Cond' ions of pp •avaUReason.s• for~ tsapprova~ ~ ~~w'~ ~~ ~ ~Q~ ~~ ry ~~ ' z SYS M OWNER: ~ `-~~'~ . S eptic tank, effluent filter and ~'~f ~~- dispersal cell must all be serviced /maintained( `~~~~,C/'C/ (~ GSA as per management plan provided by plumber. X33, ~f t `viS~-Q ~ ~ aS 2. All setback requirements must be maintained ~ ~ ~ ~2 ~ ~~ as per a licable code/or ' S ~~-y ~O • ~t..CQ ~C.;~~~ Attach complete plain (to the County only) for systaa on paper aot las than 812 :1 6a in` ajtt ~ . _ _ ,~j / / tee, ~/~~ ~ (~, I~j I SBD-6398 (R. 01/03 ~~., ~ ~ Zh ~ s7 ~ ~y4.- S Y ._ ' ~r `~r''~`s~ ~~ nY~ PLOT PLAN ,y~ .,r ~~o~~ PROJECT Sys~~ ADDRESS ~ ~ ~J ~ ~ O `d 6 7 ,~f ~~.. `rD~ x ~Gcl r ijJ~) 1/4 ~~ 1/45 ~' /T~ N/R~ W TORN /~l~dy/ COUNTY ~'~ G`,~ ~ ~ ~- 1 MFRS Byron Bird Jr. 2205 DATE - ~ BEDROOM CONVENTIONAL ~ t-Grade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE /~-~ LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE O LOAD RATE ~ ~ ABSORPTION AREA X5--7 # of chambers ~' lE'~ BENCHMARK V.R.P. .f~~ Q~ ~ ~ ~~ ASSUME ELEVATION 208' ^ BOREHOLE O R'ELL *g,g,p, .L~` d!„ ~yf~ Vent SYSTEM ELEVATION ~"' ~ ~~ ~ >12" ~r ~f ~^~~•~^ of Standard Leaching ---~ Chamber with 31.1 Cov ft^2 per chamber ~ ~~ 6~, ' _ ~- ...~ .- T_ rn - °° ox ~ o ~ -~ r- o X X~ U Q 'o ~ ~ o M `~ \ 0 ~ \~' " X° Q o ~~ ~ P ~- ~+ `T Q 'x 0- ~` a. _ , .... j ,, ~~ . ' _~ ~., ~ o Xa ~1~ R `~ ~° -~ .1 ~ ~ °~ ~~ x M ~ E ~~G ~ .2 o ~ ~ ~ i~ d ' 32 ~;~ ~ ~- ~' ~ :-_.- L ~ o ~`^x _ ~\ ~- , ~~ .~ •, Q - -~--- X ~ '` .--~ o `~~ ~ ~ ~ ~ \ ~ ~~ ~ ,~ ~~ -~ i r , ,~ -_ _~ i ~ \~ • 4 1 N ~ ~ ~~ ~ ~~ ~ v T\ ~ ~ ~ N ~ ~~~ T V~ i A• O ~ ~ V ~ <, •- o ~ ~ ~ 1J. '~-=~ -. (U , l 3 /;~r `~"~d ` s~ G~'> nyY~ PLOT PLAN .y / .,r ~~ D~~ PROJECT Sysf~ ADDRESS J 3 f9 j v2.~~~1j ~l ./~~ ~rB~~ ~Gc(`~ `j jf' 1/4 ~~~/ 1J4S ~ ,~' /T ~. N!R ~q' W TOWN /~~C~~a~ COUNTY ~' f G~„~ ~ MFRS Byron Bird Jr. 2205 DATE _.. - ~ ~ BEDROOM CONVENTIONAL _~ t-Grade CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE /~-~ LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE 0 LOAD RATE ~ ~ ABSORPTION AREA X5,7 # of chambers ,BENCHMARK V.R.P. ,/ C It ~.(.f ~~~ ~,~ ASSUME ELEVATION 100' ^ BOREHOLE O WELL *g,R,p, 5-~-~--_ ~~s- ~~ >12" of Long Vent SYSTEM ELEVATION ~ r ~ ~ ~ " ~~ ~ ~~, _ ~ _. ~~ ~ Standard Leaching Chamber with 3 1. l ft^2 per chamber 6" 4„ Elevation /,' ~,n ~ ~ ~~ O ~L ~.~o, /~ ~ ~.~ l~luS ~- s1 ~ ~ T ~i County Sanitary Permit Application ST. CROIx COUNTY WISCONSIN In accord with 15.04 St. Croix County Sanitary Ordinance ZONING OFFICE Personal infomwtion you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Law. S. 15.04(1 xm)) 1101 Carmichael Road ! Hudson, WI 54016-7710 (715)386-4680 Fax 15)386-4686 Attach complete plans for Uie system on paper not less than 8-1/2 x 11 inches in size. County Sanitary Permit # ^ Check if revision to previous application icatlon Information -Please Print all Information '+W' "- "`" ` ' "° Locatlon• roperty Owner Name • __„, ,~ ~ _ ;~ ~..~ f_~=~ Q~~ 1/4 1/4, Sec ~- In ~ ~ ~ .. T N, R l E (or Property Owners Mailing Address , `" ~ Lot umber / Bkx~c Number ~~ O ~® ~~ t ~ l •ty, State Zip Code :.:,.,,.~_, .,~,-,, ~~, Subdivision Name or CSM Number -~~~~ ~ ~ ~ ~ as ~ /~ "~1`~~`f~~ s~ ~h - ~ ~ . / ~ G 1 Type of Building: (check one) ~ ~ 1 or 2 Family Dwelling - No of Bedrooms: p:,'ity ^ Villa/ge Town of . ^ f ~"T c ~ Public/Commeraai (describe use): .~ C/ j O /~ ^ Stated Nearest Road 11 T f P it Ch c l ~ . ype o erm : ( e k on y one box on line A. Check box om line B if applicable) r l Parcel ax Numbe ~ 1.^ Repair 2. ^ Reconnection 3.^Non-plumbing . ^RejwenaUon ~7 sanitation pl d -' / ~ - 6 6) Pemnit Number Date Issued ^ State Sanitary Permit was previously issued N. Type of POWT System: (Check all that apply) Nom-pressurized In-ground ^ Mound ^ Sand Filter ^ ConsUucted Wetland Pressurized In-ground ^ Holding Tank ^ Single Pass ^ Drip Line ^ ~-9~e ^ Aerobic Treatment Unit ^ Recirculating ^ Other . Oispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Shc Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min.lnch) ~'y.. ~ = ~/~ Elevation . Tank information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete strutted glass Tanks Tanks e ~ ~ ^ o a ^ ^ ^ ^ ^ ^ 1. Responsibility Statement I, the undersigned, assume responsibility for repair/reconnenction/rejuvenationfinstallaUon of norrplumbing for the POWTS shown on the attached plans. A ioense is not required for terralift repair or the ins tion of non-plumbing sanitation system. PI Name (print) ~ lum S' ature (nos s):* MP/MPRS No. Business Phone Number :s~ /s"-a2G~ s Address (Street, City, State, Zip e) J ~ ~ / r Li e •~ ~ ~ II. County Use Only Disapproved Sanitary Permit Fee Date Issued Issuing Agent Signature (No stamps) ^ Approved Owner Given Initial Adverse Detemunation IX. Conditions of Approval/Reasons for Disapproval: Vir~oonsin Department of Commerce - SOIL EVALUATION REPORT Page I of Division of Safely and Buildings m acooroanoe wrm r.:orrrm ~, vvrs. rwm. woe - ~"'' S -f- ' i i 81/2 ~ must Pl . C o c ze x n s h ooleplete side plan on paper not less than Att an i~idude, but Halt limited to: vertical and hori¢orrtal ire ction and parwl I.D.. . ' ^^ '' ~~'' \\ - 1 3 ~ S li / -C~J 2 percent slope, scale or dimensions, north arrow m neared road. O O ,~~ ' Please print al ,f-t~ti->r . ,~ by ~~ . Personal information you provide may bs used sa~ndary ~~~~,- Law, s..a 04 (1) (m)). , . ~ 3 D P~rb Ovrner _ ~` ~i`' ~ P rty Location . ~ ~ . _ ~3 .~. ,~ _ Lot .Sc.J 1 /4 i(/c~,~ 114 S Z,S T L ~l' N R f E (or) i~ Property Owner's Mailing Address ~ z cps -X 4.oE Bbdc # Subd Name or CSMf~ ~o ~' Z O s-~ i ~ ~ wa-f-~ r ry_ ; ~. I S e ' Number - `,, ''' City Sta13e Zlp Code .City ^ Y~lage (~ Town Nearest Road , . <STi.I~wa.+-ct^ YK~, fSO~Z ( b^~~- y1~3~7,7~/l s K.'n~'1`~ ® New Construction Use: ® Residential / Number of bedrooms _3 ' ~{ Code derived design flow rate ~Sd ~~ O d GPD ^ RRepllaaoenrent Q Public or cornmeroial -. Descnbe: Parent material OU fc~.ta.8 (~ Flood Plain elevation if applicable _Lo z ~. 7 U ft. General comments S~S~i11 tlGilaf.bn - Q/ 30 -~,.~.9a h,y.l,~s•~-• mil- .gi ~'~ 8"v `J Sw and rec~nmerxtations: ~ (~ ~ e, l •e.r1 a. ~-, o >~ - . i' ° /o.~~ J -~ 9D • S ~ ~-r, s-{u~~ L,~ Cl I Boring # i~~i ~9 i:pi Pit Ground surface elev. ~R Depfti to limiting factor ~ ~ y in. Sort ication Rate Hor¢on Depth Dominant Cob Redox Description Texture Structure Consistienoe Boundary Roots GP D/f~ . in. MunseU c]u. Sz. Cont. Cobr Gr. Sz. Sh. •F~1 'Eft#2 1 0- ~2 1 h .313 s ~ I 2 k rY-i-~r- ~s - v~ , `~ ~ g 2 j2-2~ ~ 4~`j Si~j Zmc~b~~ rn~~ c S - .'~ 3 2~f_~_Ig IU ~Sl`~ CZP~1.`~: r LI -~o _ cl 3msbk m-~~ cis - , 2 , 3 y yg-li ~ r y~L~ ~ m S ~5 ml ~ - . -1 I , 2 ~I 1 D ~ ~ s 3 - Z `, 0 ® Pit Ground surface elev. ~ ~ /U ft. Depth to limiting factor in. Sod Rate ~°~ # ~ ~~ Horizon Depth Dominant Cobr Redox Description Texture Structure Consistence Boundary Roots GP D/fta in. Mansell Qu. Sz. Cont. Cobr Gr. Sz Sh. ~ 'Eti~1 •Etf#2 ~ p-I`f 10 r~ ~ i~ ZmC_bK .~~ << lv~ Fj q 3 ~-`-F la ~S ~ C2P~•5 `-1~c~ ca 3~nsbk rn-~ ~ cs - , 3 O`' q2.~ ~ • Effluent #1 = ~ > 3D < 220 nwlL and TSS >30 < 1 50 mall ' Effluent #2 = BOD. < 30 mglL and TSS < 30 mglL CST Name (Please Print) Signature CST Nun~er ~G VV~. ~ ~~~ vttioc..k e. r' ,~~~ --~~.. ~ ~ Zs 33a`~ Address Datie Evaluatan Conducted Telephone Number ', ,Zl l ~ 8'b"'-`' S--~_ ~m~r' -e-~, Lc~ I ~~1o2s- ~ ~zJ,~ `1~~--2y7-Yowl Property Owner IQ. r k~• 1 ~ Panx~l ID # Page. z of""-r•. a ~rin9 # ° ~~ -~ ®Pit Ground surface slay: 9S D d ft. Depth to laniting factor ) ~ 0 in. Soil ic~tion Rate th D t Color D i Redox Description Texture Structure Consistence boundary Roots GP D/fti Horizon ep in. nan om Mansell Qu. Sz. Cont Cobr Gr. Sz Sh: *~ 'E~ I o_i ,p~ r 3I3 siI r~k m~~ ~~.. ~ ~vt .5' c~ 3 ~g-yz to ,-s1~1 Cz~~~,5, y I ~l 3~-,~bk ,~~; Gs _ ,,Z . 3 yZ-IIB la ~ y -- mS b I ~ J ~ __. )..Z . ~ o- _ ~~, _ ~~ . ~ ~~ # ^ Bonng ^ Pit Ground surface elev. ft. Depth to limiting factor in. ~~ ication Rate i H th De Dominant Cobr Redox Description Texture Structune Consistence Boundary Roots GP D/fit zon or p in. Mansell Qu. Sz. Cont. Cobr Gr. Sz Sh. 'Eff#1 *Eff#2 Bonng # ^ B~9 ^ Pit Ground surface elev. ft .Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant ~ Redox Description Texture .Structure Consistence Boundary Roots GPD/fF in. Mansell Qu. Sz. Cont. Cobr Gr. Sz. Sh. 'Eff#1 'Eff#2 'Effluent #1 = GODS > 30 < 220 mg/L and TSS >30 <_ 150 mglL ' Effluent #2 =GODS < 30 mglL and TSS _< ~ 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 (R07/00) Property Owner i~.Y' k~ ~ ~ Paroel ID # Page z of_~ Boring # ^ ~~ p ®Pit Ground surface elev. S D d ft. Depth to limitug fiactor ~ ~ 0 in. Soil nation Rate Horan Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fP in. Munsell Qu. Sz. Cont Cobr Gr. Sz Sh: "Ett'#'I •Eff#2 I C-i iD• r 313 S~- ` r,->/.bk m-~< <s Ivt . `~~ 0 . 3 3g-~)z 10 .rSltl C2i~~~.~ y l c1 3m~bk ~,-,~; Gs ~ ~ - ,,Z . 3 yZ-II$ ~D ~ ~i '~ mS ~~` ~ - ~ ~ ). Z / / _ _.__ ~'' 10 . v ^ Boring # ^ Boring . ^ pit Ground surface elev. tt. Depth 14 limiting factor in. Soil. ication Rafle Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP DHf 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 licatbn Rate Horizon Depth Dominant Cob Redox Description Texture Structure Consistence Boundary Roots GP D/fr? in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#'I •Eif#2 ' Efttuent #1 = BODS > 30 < 220 mglL and TSS >30 < 150 mg/L ' Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/l. The Departrnent 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 608-266-31ST or TTY 608-264-8777. SBD-8330 (807/00) PAGE ~ OF~_ NAME 14 Y` K ~- ~ ~ LOT# `o ~ LEGAL DESCRIPTIONrw `/<Alw'/4,S ZST Zit N,R !q E (or~ 1"= ~O SCALE : BM I ELEVATION l0 0 • d I BM 1 DESCRIPTION ~a •, u-~- /1 ~o~~ O•Pe _ BM 2 ELEVATION ~ • ~ S ~ ' 5 ~ See . Z BM 2 SCRIl'TION {o P v~ ~~•~~ AZ c " SYSTEM ELEVATION q 1. 3 O ALTERNATE ELEVATION `l' / • 3 U ~ CONTOUR ELEVATION S. acs Yl • oa . ~ G~-~~ ,B~~ ~,u,rn ~ ~ ~ ~ ~' ~. ~ ~~,' 7 ` Bm Z ~~ n l~ ~ 5~~, ~ ti ~ J~ ~_l ~~ \ ~~ 4~" ~ti~ ~~`~ ~ ~.' t ~ O I~• w ~ ~ /~z~. 70 0~ ~ ~ ~~ -~ ~ 12S S~ '' •°o ~- ~~ o ~ -3 ~ ~ 'o ~p ~ ~ShaP~ TE\ ~-~-oi ~~ OwnerBuyer Mailing Address Property Address City/State Parcel Identification Number v70 --- / 3~'Sr= ~~ LEGAL DESCRIPTION 2~f ~".~ rr~perty L•cati~n~ %4 , ~~~4 , Secl~~5 , T ~N R~W, Town of ~c ~~S ~ ~ Subdivision ~C -c ~ ~ ~- ~, ~ ,Lot # ~~. Certified Survey Map # ~arran e~ed # d v2 U , r~~~~y Ir ~ 7 Volume ,Page # Volume ~~7 ,Page # ~ ~-I- Spec house ~ 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 are 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 of the ee year expiration date. I ATURE OF APPLICANT DATE OWNER CERTIFICATION Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described ve v f a warranty deed recorded in Register of Deeds Office SI i3itE OF APPLICANT DATE ****** Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department. ****** ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM ~/ ~ ~ ~ P ~15~ (Verification required fron~'lamm~g Department for new construction.) 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. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of "li FILE INFORMATION Owner ~~~ ~"7-- `~/ ~ S ~'hS Permit # DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units ~ ^ NA Estimated flow (average) Q~~ gal/day Design flow (peakl, (Estimated x 1.5) gal/day Soil Application Rate gal/day/ft2 Standard Influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) S30 mg/L Biochemical Oxygen Demand (BODE) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (RODS) <_30 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) 510° cfu/100m1 Maximum Effluent Particle Size Y8 in dia. ^ NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity 1p2~ G al ^ NA Septic Tank Manufacturer ~~ ~ ^ NA Effluent Filter Manufacturer ^ NA Effluent Filter Model ^ 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: ^ NA Dispersal Cellls) ~In-Ground (gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA MAINTENONCE SCHEDULE Service Event Service Frequency Inspect condition of tankls) At least once every: ^ yearfs11s1 (Maximum 3 years! ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third IY31 of tank volume ^ NA Inspect dispersal cell(s) At least once every: ^ month(s) (Maximum 3 years) yearls) ^ NA Clean effluent filter At least once every: q.,monthlsl yearls) ^ NA Inspect pump, pump controls & alarm At least once every: p yea~(s11s) ^ NA Flush laterals and ressure test p At least once ever y~ ~ ^ month(s) ^yearlsl ^ NA Other: At least once every: ^ month(s) ^yearlsl ^ 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 tank(s) to identify any missing or broken herdware, 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 cell(s) 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 lY3! 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. Page ~L of 2 START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tankls) for the presence of painting, products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tankls) 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 cell(s) in one large dose, overloading the cell(s) 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 (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 andJor 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 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 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 b e ai a ~RD+~11817~~ ~'c~2- /~/~b/ CaNS"?7eflc~to~ ^ 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 INSTALLER Name ~~ Phone rv rr ~ v ~ne~m ~ ~ur~n ~~ ~ .-~ i ~ v-~. Name Phone ,_-7 SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name ~ Phone Name ST. ~ l (~(/N ~Il~~~ Phone '~/S- 3g(~_ (p (~ This document was drafted in compliance with chapter Comm 83.221211b11111d-&If- and 83.5411), 12) & 131, Wisconsin Administrative Code. U._ 2627P yy7 STATE BAR OF WISCONSIN FORM I - 2000 CORRECTIVE Document Numbci WARRANTY DEED THIS DEED, made between Carriage Homes XX1, Inc.. a Minnesota Corporation Grantor, and Midwest Vinyl Systems, Inc., a Wisconsin C,I~poration 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 ** This deed is being filed to correct the state status of the Grantee which was an error on deed filed 05-03-04 as document number 761378. Name and ttetum Address: Land Title Inc 1900 Silver Lake Rd. 31200 New Brighton. MN~51 12 Together with all appurtenant rights, title and interests. ~20-1395-b1-000 arcel Identitication Number v This rs n ead property. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except Dated this 27th. day .of July, 2004 Carriage omes XX[, Inc. ~. * Kellei St. Martin, Vice President Signature(s) authenticated this * TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) l-HIS INS"I'RUMENT WAS DRAFTED BY * ~~~~~~ KATHLEEN H. MALSH REGISTER OF DEEDS ST. CROIR CO., NI RECEIVED FOR RECORD X7/30/2084 10:fa8AM MARRANTY DEED EXEIPT # 3 REC FEE: 11. N TRANS FEE: COPY FEE: CC PEE: PAGES: 1 Recording Area ACKNOWLEDGMENT STATE OF Minnesota ) WASHINGTON COUNTY. ) ss. Personally came before me this ;:~ il[lly, 27, 2004 the above named Kellei St. Martin, Vice President of Carriage - Homes XX[, Inc. a Minnesota Corporation to me known to he the person(s) who executed the foregoing instrument and ackn ledg d the same. * Notary Public, State of Minnesota My commission is permanent. (If not, state expiration date: Gregory A. Booth, Atty, 1900 Silver Lake Rd #200, New _ ,,_ ) Brighton, MN 551 l2 "~`r CHRISTINE Ni. t_EN t'`~!.~i (Signatures may he authenticated or acknowledged. Both are not necessary.) tr ~, NOraa~ Put7LtC- MtNNESCYiu *Names of poisons signing in any capacity must be typed or printed below their signature 4~ ~~' MY C71WMtSSIOh EX?IAE°`, ' :j„•~ JAWtJARY 31,2005 WARRANTY DEED STATE BAROF WISCONSIN FORM No. 1-2000 AUTHENTICATION M ` U 2562P '~22 STATE BAR OF WISCONSIN FORM i - 2000 ent Number I WARRANTY DEED THIS DEED, made between Carriage Homes XXI, Inc., a Minnesota Corporation, Grantor, and MidwP~1 Vinyl Svc+emc._ Inc ~ a M~nnesot C~~rantee. i-antor, 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 7'6 1 37g KATHLEEN H. NALSH REGISTER OF DEEDS ST. CROIX CO. , MI RECEIVED FOR REGORD 05/83/2eea 10;30AM NARRANTY DEED EXEIMPT # REC FEE: 13.00 TRAAS FEE: 289.70 COPY FEE: CC FEE: PAGES: 2 Recording Area Name and Return Address: Land Title Inc 1900 Silver Lake Rd. #200 New Brighton, MN 55112 Together with all appurtenant rights, title and interests. 20-1395-6]-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 16th day of April, 2004. Carria 'Homes XXI, Inc. ~`~ * Kellei St. Martin, Vice President * AUTHENTICATION Signature(s) authenticated this 16th day of April, 2004 * TITLE: MEMBER STATE BAR OF WISCONSIN (tf not, authorized by § 706.06, Wis. Stats.) TFIIS INSTRUMENT WAS DRAFTED BY Gregory A, Booth, Atty, 1900 Silver Lake Rd #200, New Brighton, MN 55112 (Signatures may be authenticated or acknowledged. Both are not necessary.) 'Names of persons signing in any capacity must be typed or printed below their signature WARRANT}' DEED STATE BAR OF * ACKNOWLEDGMENT STATE OF Minnesota ) WASHINGTON COUNTY. ) ss. Personally came before me this 16th day of April, 2004 the above named Ke11ei 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. * Annette D. Theis Notary Public, State of Minnesota My commission is permanent. (If not, state expiration date t~31'G5 ) • ;; ANNETTE D. THElS ^ NOTARY PUBLIC -MINNESOTA My Comm. Explras Jan. 31,2006 ~ ~ WISCONSIN FORM No. 1-20110 I~ ., U 2562P ~f23 EXHIBIT A Lot 61, in Plat of Scenic Hills, located in the Town of Hudson, St. Croix County, Wisconsin. ~/ .~' ~~ 5 ~ -'" ~• u 1~' ~ ... 62 92.f193 SO Ft' 2.114 ACRES 95,225 SQ Ff 2.186 ACRES w~ - ~, ~, ~ 1G~~ ~, : ~ '~ ._ ~ ~ -.- -,zT3 38 ~ ~~~ i~ ~ ~ f--~ r, ~ f 1 ~L e- `^ .\ L • , ~ '~$.' N~3`_ ~~~ tjj ~~ ...J ~ ki :Y.L= tC27.© ~ Q ~~~ ~f ~•~./ 2.2.59 ACRES Ng7°OTSE'c 93,958 SC! FT .2.257 ACRES ~.~" _~~- r i ~ ~ j ~ _~ ~ ~~ &3.947 S~ F~~~,` 2.042 r1CRES '`~ 'a ~~ ~} t j/ ~ ~ f `" C~ v _. m ~ ~ 55 12(3.Gx32 S~ ~ ~ s`ti Ci ~ 1 444.26'