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020-1395-67-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety art Building Divispn ~' *~ INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. "f~ ~~ Permit Holder's Name: City Village X Township Lifest le Homes Hudson Townshi CST BM Elev: Insp. BM Elev: BM Description: ~ a ~ ~5 TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~~S R~: ~ I Z 6l~ F; ~ Pa l ~. s zS Aeration Holding TANK SETBACK INFORMATION ELEVATION DATA county: St. Croix S nitary Permit No: 3 /~{ 4 tale Plan IDtate Plan ID No: Parcel Tax No: 020-1395-67-000 Section/Town/Range/Map No: 25.29.19.2461 STATION BS HI FS ELEV. Benchmark 7. o ~ /07 , cal ~ UZ~ Alt. BM Bldg. Sewer 3.8 (.o /a 3 , / s SUHt Inlet X83 ioZ , ~$ SUHt Outlet s, 0~ fib/ r q~ Dt Inlet ~ ~_ Dt Bottom ~ O Header/Man. Dist. Pipe B ~ 2. ~ ~ Bot. System 9 ~ ~ c(7 ~ ~ ~ Final Grade St Cover 1~ Go J O 9$ ~~ ~ D~ TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic ~ / I ~ / ' 7 ! „! Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer _- - ~- -___ Demand Model Numb TDH Lift Friction Loss System TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width ® Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS Z g~ Z ~~G~~ ` ~. ~_ ~~ SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR Manufacturer: ~I-r L~/1A-~ ~~CW"0'~ T e Of S stem: / . - yp y C t ~ ~~ ~( lQ A//I ~1/rj~ ,~ I~ 'v UNIT Model Number: ~ ~ t- J~ C J~- 6 D . DISTRIBUTION SYSTEM l.J,.~k- Header/Manifold , f Distribution x Hole Size x Hole acing / ~ 5 Pipe(s) \ \ h 1 i ~ ~ ,3f~ ~vv~-~ Length Dia Lengt Dia Spac ng SOIL COVER x Pressure Systems Onlv xx Mound Or At-Grade Svstems Onlv Depth Over / Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center ? ~C J J Bed/Trench Edges ~ Topsoil Yes ~ No Yes I No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / /_ Location: 718 Regal Ridge Hudson, WI 54016 (NW 1/ SW 1/4 25 T29N 19W) Scenic Hills Lot 67 1.) Alt BM Description = ~ ~'~`" ~~ ~~ ~~~ 2.) Bldg sewer length = , 7/ Inspection #2: / /_ Parcel No: 25.29.19.2461 Z 3 tZ3 = `I co t~d-~. Vent to it I take ~~ ~ ~~ Safety and to ings County ! ` 201 W. W e. P.O. Box 7162 ,~~O~~i,~ ~ Madiso WI 5 g 26 1JED nary Permit Number (to be filled in by Co.) Department of Commerce > ( y$ ~] ~ ~f Sanitary Permit Applic 'onNQi~ ,~ ~ ? ~ ~1 ~ S to PIanLD.Numb~ In acwrd with Comm 83.21, Wis. Adm. Code, personal info ation you provide ~ V may be used for s~ondary purposes Privacy Law, s .04(1 ) ~. CROIX COUNTY jest Addtess (if different than mailing address} I. Application Information -Please Print All Informatan CE I ~~+ I l a ~ $~/ // r + ~ v (G ~ Property Owner's Name I Parcel # Lot Block # ,3 Property Owner s M [ling Address Property Location ~ Eton ~ ~~~~' Zi d C Ph N b ' City, Sta p e o um er one /// ~ircle grt~ / G~ / _ (~'~ Type of Building (check all that apply) I ~ . ~. OCtGI Oo ( ~ um bdi i i N S , `~-.(( II f Bedrooms ~ y lli N b il D 2 F ( ~ ame u v on s er o _ ~ .. ng - um we i or am y ` ^ PublidCommercial -Describe Use - G t _ ^StateOwned-Describe Use 2 ~~ CQ.\\5 t.J Z~rLsZ~ ,1 ^City ^Vii eownshipof ~ 5 a III. T ype of Permit: (Check only one box on line A. Complete line B if applicable) '~' ^ New System ^ Replacement System ^ TratmenthIolding Tank Replacement Only ^ Other Modification to Existing System B. ^ Permit Renewal ®Permit Revision hange of i~Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration ~~ Plumber Owner ~~ /J C '] J IV. T of POWTS S stem: Check all that a Non -Pressurized In-Ground ^ Mound >_ 24 in. of suitable soil ^ Mound < 24 in. of suitable soil ^ At-Grade ^ Single Pass Sand Filter ^ Constntcted Wetland ^ Pressurized In-Ground ^ Holding Tank ^ Pat Filter ^ Aerobic Treatment Unit ^ Recirculating Sand Filter ^ Recirculating Synthetic Media Filter hing Chamber the v - Pipe ^ Other (explain) V. Dis rsal/Treatment Area Information: Ara Proposed (sf) System Elevatio% ~ r sal spe a (gpd) Design Soil Application RattXgpdsf) Di n Fl o w _ I Desig w p - 7 G / ~ / ~ / ~ l7'z l!/t.ti/ ~ ~~ rI O /O ' ~ Tank Info VI Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic . Galkms Gallons of Units Ctxtcrabe Corrsitrt+"ted GJass New Existing [~ ~- ~l. _ / NOl 1~ I„ t' C2l_ I l Tanks Tanks t n rL. Septic or Holding Tank ._ ~ / [ ~, Aerobic Treatment Unit Dosing Chamber VII. Resp nsibility Statement- ]y the undersign ,assume responsibility for installation of the POWT'S shown on the attached plans. Plum r' ame Print) ~ ~ Plum 's 'gna _ MP/MPRS Number Business Phone Number - - Address (Street, City, State, Zip ode) ber ' PI ~ ~ r VIII. Coun / De artment Use Onl Approved Disapprov Sanitary Permit (includes Groundwater Surcharge Fee) ~l Date Is 'I~$~S Issuing Si S ~ (J /// iven Reason for Dent IX. Conditions of Approval/Reasons for Disapproval 3~ tiJQ~„ ~ ~p ; ~ ~ e5 t~-.C~e~. SYSTEM OWNER: 1. 'Septic tank, effluent filter and dispersal cell must ali be services /maintained ss P~ management plan provided by plumber. 2. AN tlti~dc rrgttirerr-ertts must bs maintaittad ~ PM aPP~ 9i3dr 1 ordilanc~s. Attach Wmplete pure tro me •,ounq omyr mr Luc syn,c,o u . papo.......G,....e......- .............. .......- cRri_~~clu rIZ nl in~t~ ~~~~~ ~~/ /~~~~ I 4~` ~~~o~ i`~/ ~ ~5G ~-/g~z~ ~~~~~ -~~, t~z~~~ ~~ `~/ ~ ~~w /r~l,~~ ~~~~' ~~1~a,,~ t~4~, -ri~~~ ~ !~ ~ Sce ~~/// //' //~~ ~~ 1 ~.:f--~ ~.a..' i 0 G~~~ /~ ~~ ~%~,~ ~~~ ~tii ~~ ~~ ~k / i i ~ vP /. _ ~ ~ ^^( ~~ >~~\ u~~t ~ ~~~~,~ /l ~-~l a `/J ~`~.97~.E~° / ~~ose.J 6~ ~ s,~6/~ / ~~ ~~ ~~~ ~ ~~~ ~~ ~tii ~sG~ ~~ ~ ,1 ~,~rs//~~l /~a~ /sue/~~~ -,~cioa, o ',~ ~ 9~/w(~ /iu/~ TOT ~~OuJ ~i2u,Yi1~'~v -~i/O~.~d~ ~~ SLR ~" G>~ ~/,/~~~~ G% -~ ~! j~Y~ .~ ~, \ ~ ~o i~ ~~k ~ G~~~ a3 / ~ ~/ vP _ ~ o~ r3 .~ / \~ ~~\ 1\ ®~'' -~~ti ~o~ I Wisconsin Department of Commerce S L E~1L[JO~A~EP RT Page, of .-3 Division of Safety and Buildings in accordance with C mm >~~T• m,,~gde_ Attach complete site plan on paper not less than 81/2 x 11 in es in si~'OLAi~r®fsfl~E indude, but not limited to: vertical and horizontal reference poi re on a roel LD. peroent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all ir~fonnation. Revie by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ~ ~ ~ s Property Owner Property Location ~ Govt. Lot jJ 1!~ 114 S T N R ~oi~ Property Owner's aili g Address Lot # Blo Sutxt. Name or~roklr ~ ~' City 'p Code Phone Number ^ City ^ village ~ Town Nea Road ( ) _ ~. New Construction Use:, Residential / Number of bedrooms Code derived design flow rate ~f~f3 GPD ^ Replacement ^ Public or commerdal -Describe: Parent material ~~>~ Flood Plain elevation if applicable ft. General comments Q and recommendations: ~ ~~~,, ~, q8 a C7 -~ ~a~~ ~- Boring # ~ Boring f ® Pit Ground surface elev.~ft. Depth to limiting fador~_ in. Soil licafion Rate Horizon Depth Dominant Color Redox Description Texture Sttudure Consistence Boundary Roots GP D/fP in. Munsell pu. Sz. Cont. Color Gr. Sz. Sh. *Ef(#1 "Eff#2 , J s ~ - 4 Q a 4 n n ,~ ~~' Boring # ~ Boring ® Pit Ground surface elev. ~ ft. Depth to limiting fadorl» in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Strudure Consistence Boundary Roots GP D/ft° in. Munsell pu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 "Etf#2 ~ ~ _ a 4 .~ 9 Il (! ~ ~ " Eftlue #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ftiuent #2 = BOD < 30 mg/L and T55 < 30 mg/L CST Name 1 P ') , ~ ). Signature ~, CST Nun~er ,~ Address Date Evaluation Conduded Telephone Number ne~e~ nwnn Tn7 MAl Property OHmer~e~*! ~ Parcel ID # ~b f. 3~--SSG 7F~~ Page Q~ of ~ ^ Boring ~ Boring # Pit Ground surface elev. , ~5°S- ft. Deptl'- to limiiting factor ,1~ in. Soil lic~tion Rate Horizon Depth Dominant Color Redox Descripfion Texture Structure Consistence Boundary Roots GP D/flR in. Munsell Qu. Sz. nt. Color Gr. 5z. Sh. *Eff#1 "'Eff#2 -~ ~ /~ / _ ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP DIff' in. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ^ Boring # ^ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. Soii lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fF in. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = 8ODfi > 30 a 220 mg!!. and TSS >30 < 150 mg/L * Effluent #2 =BODE < 30 mg/L and TSS < 30 mglL The Department of Commerce is an equal opportunity service provider and employer, If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-$777. sso-s3so (RO~ioo) .+` .~ - Property Owner~eh,J ~, ,~ E,~° Parrret ID # (0~6 /. 3~-~'~'G 7f~'XJ Page ~~ of ~_ ® Boring # ^ .Boring ~~~ n~ pit Ground surface elev. 1~ ft. Depth to fimifing factor ~" ~n• Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP DffP in. MunseU Qu. Sz. nt Color . Gr. Sz. Sh. 'Eff#1 *Eif#2 _ '< -~ _ hs _ - a 9 i6 / - ^ Boring # ^ Boring ^ pit Ground surface elev. ft. Depth to limiting factor in . Soil ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fF in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 ^ Boring # ^ ~~ ^ Pit Ground surface elev. ft. Depth to limiting factor in. SoU lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP DlIt= in. Munseil Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 "Eff#2 * Etffuent #1 = BODfi > 30 < 220 mgll. and TSS >30 a 150 mglL * Effluent #2 =BODE < 30 mg/~ and TSS < 30 mg1L 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-$777. sen-s~o rx.mroor Vii/ t/1~.~'~ ~ . w~~ ~~i~ ~! -/o~as / \ / io~~~s ,~~ ~. ~,~;~~ ~`~j ~~~~ / / ,x ~ ~'a~5 1~~~ . $, 90 , ~. 3a ~\, ~~/y =S~J~y.s,~c~2.~ ~~,V- ~Pi~~ ~ fit, ~ ~,~©.~ -~ \ ~~ ~~ ~- \, ~~, A~,J,2 Gn~G ~u~~ / ~b~~ ~,~-: /V /~~7 ~t,~ ~~ ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM " OwnerBuyer ~,~`,,~ ~ /~ Mailing Address Property Address City/State Parcel Identification Number ~ ~~;/_~ 5-~ 7~~ LEGAL DESCRIPTION Property Location ~'/4 ~~_'/4 , Sect, T, ~N R~_W, Town of - Subdivision Certified Survey Map # Volume ,Page # Lot # ~. Warranty Deed # ~(°'e{3~~ ,Volume - ~ ,Page # 3 Spec house yes Lot lines identifiable ~ 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 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 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. 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 Planning & Zoning Department within 30 days of the three year expiration date. 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 above, by virtue of a warranty deed recorded in Register of Deeds Office. Num er o bedrooms _~ SIGNATURE OF APPLICANT(S) ~~ / ~ / v~~ DATE ***Any information 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 Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) u, ~esiP sss STATE BAR OF WISCONSIN FORM 1 - 1998 WARRANTY DEED Document Number ~~ This Deed, made between Cameron Homes. Inc.. a Corporation Grantor, and John P. Maher and Beckv Maher, husband and wife Grantee. Grantor, for a valuable consideration conveys to Grantee the following described real estate in St. Croix County State of Wisconsin (the "Property"): 65398 KATHLEEN H. wALSH REGISTER OF DEEDS ST. CROIX CO. , WI RECEIVED FOR RECORD 09/02/2005 02:15P![ fdARRANTY DEED EXEMPT A REC FEE: 11.00 TRANS FEE: 321.00 COPY FEE: CC FEE: PAl3ES : 1 Area RETURN T0: METRO LEGAL SERVICES, tNC. 330 SOIlTt; ZI.O RVFNUE, SUITE 150 MihNEAPOLIS, MN 55401-2217 Metro Legai Services 020139567000 EDIItET 478814 A Pareel Identification Number (PIN) 493792 Vk1~ 380381 This is homestead property. (is) (is not) Lot 67, Scenic Hills, St. Croix County, Wisconsin. Together with alt appurtenant rights, title and interests. Grantor warrants that the title to the Properties good, indefeasible in simple fee and free and clear of encumbrances except Dated this 19th day of Au ust, 2005. (SEAL) (SEAL) ~2~- Mike Dockendorf, President Cameron Homes, Inc. (SEAL} (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signatures ) SV`~~TZ~NA a ~; v authenticated thi~*1~T F`~y ,-, ~- n ~y Icy, N _, ST ATE) ; - ~ `--~°s~ State of Wisconsin, St. Croix County } ss. Personally came before me this 19th day of August, 2005 the above named Mike Dockendorf as President of 0ameron.Homes. Inc, TITLE: MEMBER STATE BAR OF WISCONSIN (if not, authorized by §706.06, Wis. Stats) THIS INSTRUMENT WAS DRAFTED BY Coldwell Banker Burnet/Robert Nicholson 1301 Coulee Road Hudson, WI 54016 53239 (Signatures may be authenticated or acknowledged. Both are not necessary.) Names of persons signing in anv capacity must be tvoed c STATE BAR OF WISCONSIN to me known to be the perso who executed the fore ing ' st ment and acknowledge a same. ~~ l~ ~ St:.~.l a~ 1 i'~- Notary Public, State of )IVisconsin My commission is perma~gt~~lfOn~state expiration date: Wisconsin Legal Blank Co, Inc. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of FILE INFORMATION Owner ~-- Permit # DESIGN PARAMETERS Number of Bedrooms ^ NA Number of Public Facility Units )~NA Estimated flow (average) ~' gal/day Design flow (peak-, (Estimated x 1.5) gallday Soil Application Rate a gallday/ftZ Standard Influent/Effluent Quality Monthly average* Fats, Oil 81 Grease (FOG) <_30 mg/L Biochemical Oxygen Demand (BOD5) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality __ Monthly .average Biochemical Oxygen Demand IBOD5) 530 mg/C Total Suspended Solids ITSS) <_30 mg/L ~ NA Fecal Coliform (geometric mean) <_104 cfu/100m1 Maximum Effluent Particle Size %8 in dia. ^ NA Other: ^ NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity gal ^ NA Septic Tank Manufacturer ~ ~ S ^ NA Effluent Filter Manufacturer / ^ NA Effluent Filter Model ^ NA Pump Tank Capacity gal ;APIA Pump Tank Manufacturer ANA Pump. Manufacturer ,~ NA Pump Model JB. NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ~ NA t)ispe[sal Celllsl_ ~In-Ground (gravity) ^ At-Grade ^ Drip-Line _ __ ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA nn nlwrr~wlnwlnC Cf`4Cf1111 G ~ni+n~ a v~r~,. v.. v Service Event Service Frequency Inspect condition of tanks} At least once every: ~ ^ yea~(s)Is} (Maximum 3 years) ^ NA Pump out contents of tank{s) When combined sludge and scum equals one-third IY31 of tank volume ^ NA Inspect dispersal cells} At least once every: ~Yea~lsjls) (Maximum 3 years- ~ ^ NA Clean effluent filter At least once every: ^ month(s) ,~ ~-year(s) ^ NA Ins ect um pump controls & alarm P p P~ At least once ever Y' ^ month(s) ^ year(s) ~ NA Flush laterals and pressure test At least once every: ^ monthlsl ^ year(s) ®',NA Other: At least once every: ^ month(s) ^ year(s) ~ 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 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 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 (Y3) or more of the tank volume, the entire contents of the tank shaft 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 <_12 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 ~ of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting. products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s!. If high concentrations are detected have the contents of the tanks! 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 cells! 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 and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following 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 wilt 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. ^ 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. If 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 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 PnWTS INSTALLERI Name Phone - .. ~ s POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ~~ ' ~ Phone Phone `~ This document was drafted in compliance with chapter Comm 83.22(2)(bl(1-(dl&(fl and 83.54(11, l2) & (3), Wisconsin Administrative Code_ } Page ~ of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting. products or other chemicals that may impede the treatment process and/or damage the dispersal cell{s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal 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 and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN It 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. ^ 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. If 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 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 ANDlOR 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. ADDITIQNAL COMMENTS POWTS INSTALLER ~ Name Phone '' POWTS MAINTAINER Name Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name ~ ~ i Phone Phone `7ic~-~ 74t _ -~l/_ cs,~c This document was drafted in compliance with chapter Comm 83.22(21(bl(t )Idl&(fl and 83.54111, (21 & 13), Wisconsin Administrative Code. 20' DRAINAGE SEMENT 10' EACH . SIDE OF LOAF LINE _~ t5 : ~_ sQ Ft ~~ ACRES : I4 I ' --~ i ' ~ ~ ~-l 2.259 ACRES ~ N87°OT56'E 468.08' I ' I f ~ 65 $~ 93,959 SQ FT Ni 2.157 ACRES o~ ~ ~ ~~ 5"E 295.80' . • ~- ~ ~ 120,091 SQ FT 2.757 ACRES 14.65'. . co ~~~°E 250.00' . ~ ~ co • , i ~ `~ / ~ S84°36'O6"E 639.26' =T . ~ ~ 6 ~,~ ~ ~~ 444.26' .S ~ ~ ~ . ~ / .' ZpC~ 175.00' .' ~ ~ ~~ .• ~~ ~ ~ s7 / / e~,~ • ' 96,775 SQ FT • 2.222 ACRES ' .• k~1~ ~ • , 1~` ' . ~ 0 ". }`~~" ~ ~ ' , 98,886 SQ Ff~ s~ . , . t ~ 1 ~ • .. 2.270 ACRES ~ 90,281 SQ FT ~; . ' ,-• ~, 2.073 ACRES ~ _~, . ~~ ~ ~ /~i- ~`` Jam- 11 ~ .~ `~ d. • ~ ~ H.W.L. =991.9 ~ ~"' ,~ ~-~ • \ \ a~ ~. ` ~•• ~x ~ • ' ~ ~ ...... . H.W.Lr=~ .'~. 1'' ~ 1002.0 \~ C~9 100.13' ~ - - - - _ - _ 1 ,~ \ ~ ~ ` S86°58'14"E 336.83' `~ C `~ • . \ \' ' ~ Regal Ridge _ _____ . ~ N86°58'14"W 336.83' i~ v _ _4 • ~~ // - -- -- 129.99' °~ 41 ~,y ~ i .............. z 138,779 SQ FT 3.186 ACRES ~P~~ / /~ ~ / `~' ~ ~ ~~~~ r H M "'~' M O M o' W ~a } H a z N a s ~ ~~ ~~:~ ~~ ~ ~ ~ ~ ~ h ~ ' ~ .~ ~, g B ~ ~~~ ~ ~~ ~~~~~ ~ ~ ,~ ~~ ~ ~ ~.~ '~ ~~~~~ ~ ~ ~ ~~Yss E~~ Z a Q w y Z w o ~N o .~ ~ Z do Z abed W 2 3 0 z 0 d m H ~o~ ~~ ~~ "~ °~ ~ mzt~o ~~mo ~pw~ a ~- Q Wd Z1~90~6 ;iwl ~OOZI£Z!£ :elea 0 W V O z H W 0 4_ 0 H 0 m W a H W Z N N w a W Z Q J a Z F- O a O ~. U z U c~ Z 0 I- 0 w z c~ Z 2 0 Q O W z 0 m g e~ riv30 ;off, ;wad --__ - Sai'ety aad Buildings I}ivision Conrrty I ' 201 W. Washington Ave., P.O. Ikrx 7082 ST. CROIX _ ~~~~~~~~ Madisrtts, W 153707 - 7082 Sanitary P~ennit Number (to be filled in by Cd.) eP ment of Commerce (~~g)z~l~~~ -y~3v 3 ,.~ Sanattalry Permit Application ~ state Plan r.n. N„r~~r I ~J ~ In ac«rrd with Ccxmn 83.21. Wis. Aden Code, personal irlfolmatiar you provide ~ may be et~il tilt seiwndary purposes Privacy lxw, s15.04(k xm) Project Address }t"differentthan mailing addr~) - _- L Application Information- PEerse Frtnt AEI lnt+rrma ' -- ~~~ ~~ ~~~ L ~/ , -- Pri~xrtg° ()Natar'x ~ ~ ~E~T~LCi ~l m ~, I~G• Par ~ l.ot iI _ ~ _odc p ' ' 4 ~ 67~ -- .. ~• 1'rCl~lelly VYYlItT'S 1~18111ng e~ -- ~~~' ~~ ~/~ 6750 STILLWATER VD. ST. CF'.u!X 000I~I I ~Y NW v~ SW ~r~ Sediar 25 • 2~~~ City, State 7.rp Code ' f- ~_R~._.~.~.- . , (~ ~ ) NO. STILLWATER, MN 55082 651-439-2414 _ - --- - r; T 29 N; R19 Type of Bniltling (check al! th ppn') d k ~Pi}/ II . ~ 7'i 1 or 2 Family Ihvalling - Nurni~ d' 4 /l /,,.•, ~ ~, p __-__ V Ku~ '-- 1~ f SYtncnrnsiorr Nattae CSM 1Vwnl+ea' ~ : ~~ p ( J ~~2 ~ /IS ^ Putrlicf;oarunercial -lkaaaibet~se SCENIC HILLS , ' ~_ ~n /n , ^ stare U.v,~~! t~ Cry _3 /,~ _p7 ~ .J L.~~ l~/~_q ~_~ (atv-C.lv-page 1WI'<nm~lrip of HUDSON ~~----------- III. T ype ntPermit: (Check only nne bolt ox a A. Complete line B if; plicable) A- ~ New System ~~ Rgrlaeaneeri System ^ Trealneetnfllddint;, Replareenen! Only ~..~ Qtltex Modification W Existing Svslem ---~. ~¢~ ~• ^ Yarmii Renewal ^ Pemrit Revision -surge of ~'t U Permit Tran~erin New Taal PrcwHws Permit Number and Date Issue) I~ktixe Expiration P afi. ~x IV. T of 1f~W"IrS S . fain: ('6etk all that a i ~` , , Mormd < z9 in of suitable soil ^ At-Grade 1, Single Pass Sid Filtbx 1. ~ ~ Ncm -I's~surized In-(irvuad U ~lrwnd % 2d is oi':aiitan-e soil ~ / Cnnsttttcxed Werlar>,l ^ Preaseerizcxt Io-C;rawW I.1 Holding'i'anlc ~ w Nil! a i I rierotric'1~aalrtw~Ki7nit ^ R Brunel Fdtcr LI /~L Recitvaelatirtg Syrrthetie Tvledia Fiher [,eadttstgClranrber ^ `` lane ^ Grdvel-less Pipe ^ (>ttui' (exP~) ~ lJ~a !/ ~w'G~- V. Dis rsxilTreattnent Atea intarnnat[on: - cN` f~ .3_ o r -~ Ieesi,®n Flow {gpd) Ih•s<ign Suit Apglicatio» rtate(~dct) nispereal Men iirct) (c Ta- J Area Prvgxaoerl (xf) fiystem F.levari / = ,~ ~ g 7b~ ~- ~ - ~r ~,;..~ ~ ~. 600 , ? VL 1'anlt Into ~'+rY ~ 'rou! hiz>mbcz M aaur~e r Prefab site steel Fiber- PlnsLiC Galioets f:alkxee fiinits ~,, // '' L~~ ~V i] Concrete (:onslruciai (ilaxs ~ New T:u,iss Facestuq>, TaRk., ~ / - n ~ / X '~'~~`~'Qle,~~s„~ 1 1250 ;•~ - 1 WIESER YES Aernbie TnrotrneaN tloi! .._ pm ._,.__._ __._._..-. rk,~~ ~~~,t,~ a°~~ VII. I2esplmsibilily Statetmnt-1, tLe ntlie 5 ~ ~ tt4r odd t~• Plunelxr's Nana (Print) PI s 1'j 'Number 1Aniescaa WenneNnenber TODD FEATHERSTONE 242514 ~ _-_-- _ . 715-381-1704 Plumtrer's Addre~ (Street, city, Stare, zip C 1 P. . 130X 467 - 368 TOWEROAD -HUDSON, WI 54016 ~ V Coug 4)e xrtment tJse Sanitary Fermi[ fee (iacltedes Gronrrdevater IYale suit>LR Aly SiFreatrtre ,, rps) j .3prsresv~Yl i~ Disaptxvvea 9w ~lw~5o Noel 0 U l ~ ~ ~ h / Z~ V Y ^ Ovwnar Givar R far Derria! ~ ~ - IX. Condrtrons of Approva sons.for I?isap~ ~~ / r' SYSTEM OWNER: ~{,~-~ ~ ~~ ep Ic tank, effluen filter and . ~_ -~ ~ dispersal cell mus II be serviced /maintained 3 j ~. ~j,(/}u~~ ~ ~ as per management plan provided by plumber. ~~~~ 2 tb k i All ~~~° ~ / ~ S~~ C' . se ac requ rements must be maintained 3 ~ . - y as per applicable code/ordinances. ~~ ~~ (~ G~~d ~ !~ ~ l0 7-od~ ~,~ 4,S °~~s ;~~~ Attas9 abseeplete plain (lathe Camly ~) fw tla: rystcim ~ep paW;Ye1r wd less tYn 82rL i~,i/t names ~ s(me ~ ~~ Cam' ,~/j~ ,Lc~ - /ae . ~ Tm~ o F L~~ yr ~H~~ . `1 yid B/ -- 9~ moo- ~ . • ~ ~ .Q~ - 97. ~ o - . , .. ~ ~ ~~ - ~ ~. _ _ ~ .~ . ~ ~ ~.~ . ~~,,~ ~ - ~ C A'~ ~ .. ~ ~ ~ ~. ~ - ~ _ j- ~' ~ . ~ '~ - r - ' ~ - - ~ ~o L,~vFi ~. ~ . ~ ~ - ~ ~ ~ ,~~ .- ~ ~ -_..~ . ~. .. ~ ~ ~~ ~ -- ~ '. ~~ , ~ ~,. Y .. •~ "~ r ~ `~ Fi.MI/~L ~ = Sa COPY From: To: PAM QUINN Date: 3/22/2004 Time: 3:50:34 PM Page 2 of 2 --. .- ._. SC~~r .r ` iii _Sv ~~ V ~J .EL /do ~ p ~ . ~ ti~~ • 1' ~~ - 97. ~ o . - . .. - ~ ~~,' . ~ ~ ~ ~~~ ~/iCJE - ~ ,~ 1 - . . - , . ~ ~ ~ ~ ~ ~ r~,.. - . s . ~ ~~,. ~* ... ~.CA~ / - + ~ ~% . ,. ~ ~~ _ _• - ~ . .-. o ~-~ ~ .~ .~ ~' ~ ~ ~ d i ~ ~- ~ - - . ~ Dv" z' _~ _ - . ~ ~ ~ ~ ~ ~~ / `~ .. ~ .~ - ~` ,~ ,~ .~ ~ s ~- -- c Wisconsin Department of Commerce - ~ 'SOIL EVALUATION REPORT page I of .f Divisica of Saiery and Buildings in accordance with Comm 85, Wis. Adm. Code county 5 C o Attach complete site plan on paper not less than 81/2 x 11 irxmes in see. Plan must include, but not limited to: vertical and hori¢ontal , dRedion and Parcel I.D.. I percent slope, scale w dimensions, north arrow, a rid tl ' to nearest road. GIB d - ( cJ:S _~ ~ -CX' ~' Please print all ~ ~• anon. , ~ % , by Date ... Personal iMorrnation you provide may bs used dory pu~oY Laiitr, s., .04 (1) (m)). , ~j7./r'c-Q ~ ~~(, jjj/Vy~;` ( ~ (j '7 P~~ ~r 1 ..,• ~ ~ LOCa . Zy ~ T ._; ' .XJ ~ .~ ; Govt. Lot W 1/4 ~ 1/4 S Z,s'T Z Q N R / ~ E (or)d~ PnapertyOwrier'sMaiCmgAddn3ss 7 - ,` G-, r'Ra,, .~, got Btodc# Subd. Name,wCSM~ ~j~ ~ State Zip Code N ~i;, Yd Town Nearest Road ~STi: I L w«..~--~r rh r` . ~So ~Z. c '~"~): ~ ~ - z ~~1~ ,, ,~ , ~„ ~. a • , , .. ~~ ® New Construction l1se: ® Residential / Number of bedrooms _3 _ ~{ Code derived design flow retie ~SD~~o O O GPD ^ Replacement ^ Public w commerpial -Describe: . Parent material OU fc,Ja.s (.. Food Plain elevation if applicable ~//!4 R General comments S ~ S ~ rrl e.. I e. J0.f•b n /~~' • s ° w~ ~; / - 3 ~,~~=~'o"x/ ~'-~,~~ `~,~?~' ,a' ~'~ and recommendations: a, ~ o ri ~ --- _ Apr Pit Ground surface elev. q8.8 ~ ft. Depth to limiting factor ~ ~ 3 in. Soil Rate Horizon Depth Dominant Cobr Redox Description Texture Structure Consistence Boundary Roots GP D/f~ . in. Mansell Ru. Sz. Cont. Cobr Gr. Sz. Sh. •[-~ ~~ 1 U-Ja I(~ 31 - Sri 2mabk -fir ~ Ivy' .5 :~ 2 IU -~~d JD 4~`{ -- Si P 2 mczbk mfr ~~ - : 5 . ~ 3 ~~-ii ~D • r~l(~ m 5 ~~~ ~ - - . ~ l . Z 9 ~. v = ~ h ~~~ # . ^ . ®Pit Ground surface elev. 9 ~ z ~ tt. Depth to limiting factor ~ O in.. ~ Raba Horizon Depth Dominant Color Redox Description Textun: Structure Consistence Boundary Roots GP D/f~ in. Mansell Qu. Sz. Cont Cobr Gr. Sz. Sh. ~ •EtT#1 •Eff#2 2 i Z - 3~. jp : ~:I ~ S ~ .j 2 rrab ~ .~~ c S - . 5 .g ~~~ ~ ~ ' Etfluerrt #1 = Bt]D_ > 30 < 220 moll and TSS >30 < 1 50 mNL ' F,Iluent #2 = BOD. < 30 mglL end TSS < 30 mglL CST Name (Please ..Print) ,,s~gnature CST Number _ i~GtG INS. ~~ ~~~ wok e. ~ ~~---~ ~ ~' -- Z g 3 30~ Address Date Evaluation Conduc0ed Telephaie Numbec ZiJ 3 BCC ~'-' S~ - ~ymer-~-},, C.~>i ~~oZ~ - l U l ~~~s~ 2 X17- ~ot~8~ Property Owner A.r' ~~ ~ _ I 1 ~ \-. ParoellD# ~-~'~ ~~ Page Z ~~ Borng # U ~~ d ® Pit Ground surface elev: ~_ ft. Depth t'o limiting factor ~ in. Soil Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP in. Mansell Qu. Sz. Cont Color Gr. Sz. Sh: "E~ "Eff#2 ~ a--1 i o I" - Si ~ Zmabk m ~r c s _ v~ . 5' , 8 ~ ~~-~9 I~, yi~I - Sig 2 U.bk rn~ c - _ ,~ _ ~ 5~ i ~P~/. - ~ _. i 37'2 . Vii. ^ Boring # ~ Boring ^ Pit Ground surface elev. ft. Depth to limiting factor in. ~~ ication Rate Horizon th De Dominant Color Redox Description Texture Strudrrne Consistence Boundary Roots GP D/itt p in. Mansell _ ~ Qu. Sz. Cont Cobr Gr. Sz Sh. "Eff#1 "Eff#2 Bonng # ^ Bormg . ^ Pit Ground surface elev. R Depth b limiting factor in. Soil icatbn Rate Horizon Depth Dominant Cob Redox Description Texture Siruc~e Consistence Boundary Roots GP D/f~ in. Mansell Qu. Sz. Cont Cobr Gr. Sz. Sh. "Eff#1 "Eff#2 "Effluent #1 =- BODE > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 =GODS < 30 rrglL 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. SBp-8330 (ROT/00) ~- .- PAGE ~ OF~_ NAME 14 Y` K-e- ~ LOT# (~ ~ LEGAL DESCRIPTIONAIW `/45w `~<,S 25 T z q N,R /q E (or) SCALE: 1"= yU BM 1 ELEVATION l0 U . O ~ BM 1 DESCRIPTION I-n p o~ ~u~~ y ~' ~•~ l.. -' + BM 2 ELEVATION 9`/ /g x ~ Sec. 2 ~ BM 2 DESCRIPTION+op o ~ l uth ~ ~ ~ ~~ h_ SYSTEM ELEVATION 9y ~U ALTERNATE ELEVATION Q 3. SO CONTOUR ELEVATION q7. a ~, 48 •o ~ , ~I9• o y ZS'"` , C ~ ,~) ~l ,~QrnL / 0 a b ~~. i SIGNATURE ,r_~~C~- - ~~ ~ DATE G -G -O/ I `'+ J \ I ~ \ ~ _ ~ ~ U , ~ 9 e ' , x P -. w I w n N ~ ~ ~/ X 3 o ~ ~ ~ ~ i / 1 ~ i f ~ I ~ 1--~ [~ x ''~ti X u D ~. ~ J Iyw , N al 'at^ O G x ~ OD m X 'v ~,.~. y i- y .+....... ..` ... ~ ... tp ~ ~. ~\~ V fG ~a I V ~! ~ ' OX ~; + V •~ ~ ~ ~ h . ''' l J X i r O ~ ~ ~~ ~ ~ it \` ~~~ `~\ O `' V N • ~ X ~V./ A ~ \ \ • V ~, ~~ x ~ ~ \ _ X \\ ~ 4'~ \tp i ~ x ~ 4 ~` 8 ~ ~ .. "„_ r_' , -:i ~ . _ -- _ -,~ e 12/09~p3 TUE 15: p3 FA% 715 388 4686 5T CRX Cp ZONING ~ p01 rar..- ~ cr PUMP CF{AMBf;fi, CRASS SEC+i01.! AA1G SPECIFI~q-r'IQ~]S H"C.S. VCAJT PIpC ? 4~' FROr1 DOOR W;AInOW aR FRESH AIR Ii~tTAKE INLET */ A 13 ---v~uT cAP WCA'YHERPROOF JUAIC7IOA1 8r1X I z"Nt i i.i. ( GRADE ~ I f co-JOUIT '--_ /+aPROVEO lOCKiAlt. MAA1Hat-E caVEf~ 4~ MiA1, G ~ I~~b 18" MIAs, Pko~~pE I AIRTIGHT 5£A L. I III ~ *APPRDYED JOINTS WITH ELEV. ~ FT, ~ APPROVED PIPE 3' ONTO 0 50LI0 SOIL I III I IIR I I III ALARM I 11 I I . I I oN l i I PUMP --~r ~ ft' 1 OFF GbE1CRETE t3lbtH ~~ R15ER EX3T PLR!'11TrCp OAJLy IF TA-JiC MAtJLiFAGT1,JRER NAS SL1GFi APPROVAL. sEPTtc ,< ~EG~~AY~S DOS£ ` TAl1K5 /NAAyVFACTURER_ ~ie~SE~ E1LtMBER QF DOS[S: ~~pER OA'y TA1~K SIZE: ~©~ G GALLONS DOSE VOLUME i ALARM MAAtUFACTUR.Ek' /~/L~G _ 1NCLUDIiJG BACICfI.pW: ~ // ~UGAtlDN4 MODAL IJUMl6CR:~~ ~ CAPACITIES: A,~IUt'gf<50R GALLOAIS 8WITCH TyPC:~~ G< ~-~_It3G1i£S OR _ GALl01J5 pu/NP !"~ARIUFAGTUREI~; LL t-~ ~ LMES pR GALtO-J: I MDDEL A1L1MbER: 0 = ~ SuGHfS OR GALLb1Ji i SWITCH TypE: ~/ ~~~~ ~>l~ l TCfi( Np-=E; p~y~{p ,q*yp ALARM ARE TO 8[ MIAlIMUM 015CHr1RGE QA7ES"1_L.~SLGPM I~NS,~T/ALLED r~u SEPARATE CIRCUITS VERTICAL pIFFfRENtt: D£TWfiEA1 PUMP OFF AA1p htgT;IbUT14~.1 PIP6...r! a!D FECT ~- M~tUlMUM ~ETWbFItC SUPPi.'~ Pk>•5 tJkE ~ ~ ~ ~ _ 2.5 FEET + ~ FEE7 OF' 1'ORGE MAtll ?E ~~~ F~ioorcFRlc'skv-1 FACTOR-.~~~ FELT "' TOTAL. Qyi,JAMIC HEAD = r FEET ~/ ii i~ IAITERAIAL, DlM[1.151 R!A TAIJK: I..EAjGTM~~_;1,/IpTH.~l.~,~.,~Lli~U1D OEP74-1~,~.,~ 9tGIVE LICEAlSsE IvUMBER~~~~ DATE; 1 W V V a a v 0 a w x o ~ a ~ o a V _ _ = M O V~ ~ ~ ~ r q q ~ 1 1 1 1 1 1 1 1 1 ~ ~ F R~~=~~ i i i i i i i i i N ~ S "~3 13 rO ~ e i i i i i i i i i i N _ Y S '" gg 3 X~ i- i i i i i i i i i ~' p O~ ~~ n A FS ~~~ i i i i 1 i 1 i I ~^ ~ c~ °~ n° i S S~ i i i i i i i i i ,~' M ,~ ~~~~ ?~ R i i i l i i i i i i l c c~ "~ ~' ~ S° i i i i i i i i i i i ~' n a'3 ~ '~ i i i i i i i i i i i i rn G c~ ~' e S ki i i i i i i i i i i i i In ~~ ~~ ~~ ~_ U ~ d ~ a v c~ w ? > VI N ~ J Q 7 U ~ a O p U ~ J J aZ~ o U ~ ~ ~ ~J.~ \ ~w M x ~ N M _~ ~ n s x ~s ~ ° a s - „ ~ g i i i i t ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~ ~s ~ ~ $ ~ i i ~ ~ ~'* ~ at at at ~t ar at ~t x at a n ~ tl i f # ~ ~ i i i i i ~ ~ a = x i i i i i i ~ ~ ~ i i i l i ~ R n ~ i l i i l i ~, ~ a a a p ~ ~ 3~ $ ~ s ~t i i i i i ~ ^ ^ ~ ~ e ~ S R ~l ~3 A ei R ~ 1 i i l i 1•1M ~ "~ "~ ~ ~ r .~ ~ t` ~ ~ n i i i i i i i ~ ~ ~ ~ O O Op O s Y! h yy~~ 111 o S yy ~ ~1 1 1 1 1 i i i j~ s ~ ~ ~ ~ ~ ~ ~ ~ R ~ i i i i i l l l -f ~ / ,. ~ ~ $ a g ~ ~ a s a f I I I i i I t m~ o n ~ o o rn rn m a0 133! f .- _ _. .- ~ ~ ~ n m 521313Y1 r n n n n n° ~., ,., ,., N N OV3H OIYIYNI.O 1V101 °a n o ~ e°v 1. n ~^ ~. ~I ~ ~ --'~ ---- "'-rt iFA1NEA81O1dFIGVSmswrc. 38e iowER RO ~ ~ ,_ .- 1 t ~ .~ - I ~ .. f _1. .^,. ~ -- '-~ i ; ~ ~ ' ao HUD80N M7. 6/018 851-138.1987 OR 715361-1701 ~ I 1 I 11 ~ - , I i ~ -rt - _ FAX LINE 715388-8885 _- _~ -i _ - _ _ _. _. I _ ~ ~ ~ , ' ~_~I ~ ~I ~_f ._._ I f ~ If .I i ~ ~L ~~ ~ i ~ ~ • I i ~i ' ~ 1 ~ - ~ i / ' `I ' ~ ~ ~ ~ - +' i - _}.._ -+---- ?- ~ _. - ~ , - --4 - ~ -- - l~~ I i - ~ I -- -- 1 - ~` - ~ ~ I` S °S fi _ -~ ~ ~ - I I fif -T ~ ~ ; ~ ~ . ~ - . -_ - ~~ ~ O ~ j ~ ~ - I ~ -- ---1-- -- .LL - _. ~~ ~.__. ' ~ -- ~ 1. .. _. i ~ ~ I I I . f I ' ~ I I I~ -- Y - ~- ~ I ` i ` i I i - I ~-- ~ ~ - ~ ~ ~ ~ [ __. - - ~ ~ ' - ~ . ~ - ' ~ I ---- ~ ~ i I ~ ~ ~ ~ j ~ i , ~ ~ ~ ~ i I i I I i ~ i _ _ _~ t~ f ~ i __ I - I ~~ ~ + I I ~ - - ~ - ~- - I ' I i i ~- i ~ --- ~ - I - ~ s--- --- ~--- ~ ~ i~ ~~ ~ I ~ - ~ j , ~ t j ' ! ; ~ : I ~ , i +-- -- ~ I - ~ i --i---_ ; i -- ~--- i t-- ~--- ~- ~ ~ i ~- - ~ 1- t-- 1 ,-~- i_ - - T " i ~ ~ ,~ POWTS OWNER'S MANUAL & MANAGEMENT PLAN FILE INFORMATION Owner 6YYi ~ ,~" e, Permit # ~ [ O DESIGN PAfiAMETERS Number of Bedrooms 4 ^ NA Number of Public Facility Units ifi NA Estimated flow )average) ~ al/da Design flow (peak), (Estimated x 1.5) 600 gal/da Soil Application Rate 7 al/da /ft2 Starxj~d Influent/Effluent Quality Monthly average' Fats, Oil & Grease (FOG) 530 mglL Biochemical Oxygen Demand (BOD5) 5220 mg/L ^ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand IBOD51 Total Suspended Solids (TSS) <_30 mg/L 530 mglL y~ NA /// ~~\ Fecal Coliform (geometric mean! ° OOmI Maximum Effluent Particle Size Ye in dia. ^ NA Other. )ANA "Ya(ues typical for dornest~ wastewater and septic tank eftk~enL sennunuewr•c cr•ucnrnc SYSTEM SPECIFICATIONS Page 1 of 2 Septic Tank Capacity1250 al ^ NA Septic Tank Manufacture~IVIESER ^ NA Effluent Filter Manufacturer Z~.~~Z ^ NA Effluent Filter Mode! ~-~(~~ ^ NA Pump Tank Capacity ~QQ(~ al ^ NA Pump Tank Manufacturer ^ NA Pump Manufacturer ~ ^ NA Pump Model ~S ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Mechanical Aeration ^ Disinfection ^ Peat Filter ^ Wetland ^ Other: ~JA Dispersal Cell(s) O In-Ground {gravity) ^ At-Grade ^ Drip-Line ^ NA ^ In-Ground (pressurized) ^ Mound ^ Other: Other: ~A Other: .f~ NA Other: ~ Nq Service Event Service Frequency Inspect condition of tank(s) At least once every: ^monthls) (Maximum 3 years) ,~ ~ earls) ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third 1Y31 of tank volume ^ NA Inspect dispersal ceII1s) At least once every: ~ yearlsl}1s) lMaxlmum 3 years) ^ NA Clean effluent filter At least once every: ^monthls- ~ear{s) ^ NA Inspect pump, pump controls & alarm At least once every: ~ Ba~~ /1s) Y ^ NA Flush laterals and pressure test At least once every: ^monthls) ^ year(s) ^ NA ether; At least once every: ^monthls- ^ yearls) i'~,NA Other: ~.NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tankls) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal celllsl 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 IY,1 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 1 i3, 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. t A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW 14!01) 'r Y ~ Page 2 of 2 STAR`f UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal ceNls). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cellls) in one large dose, overloading the cellls) and may resuh 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 vehic{es 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 and/or is permanently taken out of service the following steps shalt be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • Atl piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shalt 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. CONT)NGENCY 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 ble re ement area is n t available due to ck and/or soil limitat' Barring vances in POWTS to nol holdi tank m e insta resort to re ce the fat TS. (~ T e ite not been evalu ted to identify a suitable replace rea. Upo ailur of the P TS soil and site lIX>ev 1 do ust b rfor d o {oc a su rep{aceme area. nor acement a vailable a Iding tank m st Iled s a l s esort epla a fail OWT . ^ 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 {NSTALLER Name ~~ Phone ~~ _ r ~~(~ POWTS MAINTAINER Name o~ ~oniv ~r,~ iniTV SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was drafted in compliance with chapter Comm 63.221211b1111id1&If) and 83.54(t?, (2) & (3), Wisconsin Administrative Code. w ~ - sT CRa~ co~lrrrx `' ~ SI?1ri'rC 'TANK MA.INTENANCA AGREEMENT . AND ORTII~RS'HIP t~RTiPTCATION FORM OvrmerBuyer ~~-/ rES7'yL.~ ~m~ /~JC . Mailing Address C~ 7S0 S •~-~ ~ /wti..~„ ~ v 1t/~ . S~ !/Cuz~. ~ !~h SS'Efi~`.2 Propcuty Address L ! (Vctification required from Planning Department for tttw construction) dZD--/39 _ `7-C~c~ CitylSttatc 6V ~ s d_ Parcel Identification Number ~c~Ai, nESC~eTra~r ~, ~ 2~~ / s'FZl' ~-•~f~ltcr~ L ,19.4-/ vac/ t~ r<<: ,. / property I,ocation~~ 'l+,s~ SG, Sec. ~-S. T~_N-Rr~~' S~, Tawn of ~'ryos'~ Subtiivisian .5 e ~ N ' ,!/S I,at # ~~2.. Certf~ied Survey Map # _ ,Volume ,Page # nt peed # G~~ ~4 °r" 3 (2/7~~3. Volume Z / 3 Page # 50~ ~--- R'arra y Spec house~~ ~ no Lot lines identifiable ~ yes ^ no SYS7.'~M MA~NTTLNArIG~ Tmpraper use and maiatenanceof your septic system canld result in its premature failure to handle wastes. Proper maintenance causisis of pumping out the septic tank every throe years or sooner. if uccded by a licensed pamper. What yon gut unto the system can affect the function of the septic tank as a trcatmcnt stage in the waste disposal system. 'Ihe property owner agrxs to submit to SY. (:coix Zoning Department a cxrtifcatian form, signfld by the owner and by a ma~rplumbtr, ~ ~yenan plumber, zrstrictedplumber or a licensed vccifyimg that (1) the on~ite wastewaterdisposal systctn }s }II F1OPcr opcratius canditiou and/or (2) at3rz imspcction and po~piag Cif nooessarY), the septic tank is Less 6taa 1/3 full of sladgc. I/we, the nnd~igned have trod the above ncquiremcnts and agree to maintain the private sewage disposal system with the staudatds set forth, herein, as set by the Department of CommcrCt and the Department of Natural Resources State of Wisconsin. Ceitificadon stating that your septic system has ban maintained must be completed aAd returned. to the St C~rroix County Zoitiag Office within 30 days of throe ycarsxp date. SIG ATURL QF APPLICANT 4V~N1~E. CERTIFICA.TIOhT I (wc) ocitify that s11 statements oa this form arc tntt to the best of my (our) knowledge. I (we) am (are) rho owner(s) of the pro desc~d abo ; by virtue of a warranty deed recorded in Register of Deeds Office. ~.._- ~ A OF APPLICANT pAT?? • Any information that is mis-represented may result in the sanitary pcrrnit being revoked by the Zoning Departmeut•'~''~'`t +rrr+* •• Iac[udc with this application: a stamped wananty dud from the Register of Uecds office a copy of rho certified sarvcy map if reference is made in. the wan-arty decd From: To: PAM QUINN Date: 3/22/2004 Time: 3:17:18 PM Page 2 of 8 a' 11 ment Number 'J 213yP 522 STATB'BAIR OF WISCONSIN FORM 1- 2000 I ' WARRANTY DEED This Deed, made between carriage Homes XXI, lnc.. a Minnesota corporation GfanWC, and Lifestyle Homes Inc., a Minnesota cort4orarion Grantee, Grantor, for a valuable consideration, conveys bo Grantee the following described real estate in St Croix County, State of Wisconsin (the "Property") (if mqs~-sRace is needed, please attach addendtun): 70, Scenic Hills, St Croix County, Wisconsin ?mB?63 KATNLEEN H. MALSH REGISTER OF DEEDS ST. CROIK CO. , MI RECEIVED FOR RECORD 82/07/2003 89:30AM EXEMPT t REC FEE: 11.08 TRANS FEEa 479.4a COPY FEE: CERT COPY FEE: PAGES: 1 Name andRrtumAddress ~y©Ti7LE, 1MC. 4' Lifcstylc Hom c. SUITE 2GD 129501 t N 1 °DO SILVER LAKE ROAD NEW 6RiGNT01~, titV 55112 Elm, MN 55062 FlLE NO. ~ 1 ~ C q 9 Together with all appurtenant rights, title and interests. 020-1395-67-000 aad 020-1395-?0-000 Parcel ldentificstion Number (P1N) • This is not homestead property. Grantor warrants that the title to the Property is good, indefeasible in fee simple and Gee and clear of encumbrantxs except any easements, restrictions or covenants of record; if any. • Dated this ~~'~day of Novem e , ~.QQ2. •Ca~ria Homes XXI lnc. ellei St Martin Vice i e t AUTHEN'ii ICATiON Signature(s) authenticated this day of , TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by § 706.06, Wis. Stats.) TH1S RJSTRUMENT WA5 DRAFTED BY l,Cellei St Martin. Carriage Homes XXI. Inc.. 1?41 S SS`" St N Suite B Lake Elmo MN 55042 (Signatures may be authenticated or acknowledged. Both ere not necessary.) ACKNOWLEDGMENT STATE OF 1~70N9~i1 Minneso~.a Washinggton )ss. $p~Qp~County ) _ Personally came before me this 13ti1day of November , ~, Kellei St Martin Vice President of Ctrriage Homes XXI. lnc. a Minnesota cornoration the above Darned t>zantor to me )rnvwn to be the person who executed the foregoing instrument and acknowledg re same. ~ i l~ , ""'~ `~lapette D. Theis Notary Public, Srate of ~tltD6linC Minnesota My Commission is permanent_ (If not, state ex~ua~i ~n date: n1 _~1- 'Names of persons signing in any capacity must be typed or printed below their sit;rratutt. NOTARY PUBLIC -MINNESOTA MY Comm. E~dr^s J^n. 91. J006 WARRANTY DEED STATE BAR OF W13CONSTN ^ No. 1 - 2000 ~ --- ~~ OGUMENT N ~~ D R ~7 ~ `r`'~ 7 r r I _~~~_.. .-_ y ............................................................. THIS IIVDENI'URP, Made b .RICHARp_ N. PEAR.SON and JEAN M. PEARSON, husband and c~ife,-...•__..-- ....................._.._..„ grantor. s.- of..._St.... Cro1X ...... .................................................County, Wisconsin, CARRIAGE HOMES XXi, INC., a (~ h~seb conveys and warrants to.-------._.........._ .................................._.._.___-- Minn~so_ta corporation, _ i'i .._.._~----- ------------..._~.._... .................--.._. _........................----.............................-_-__w_ 1j .~..........._.___........._.__ ..................------...__._..............................................-rautee-........ of {~ .. ~ -. LJ'as'F]1ng~on - County, ~ ~ + or the sum of: llar and no.lOC ( 1 00 and-,other_~~_~,~~'. anc~ valuable--. 's1~~a~.iQ~1 ---------- WAIIiIA\TY DEGD fTATL OI WifCOhf:N-fOR-a D TN1~ NACa ~~ ~Oal ~ =~~'. ~ a 1" ~~ T ~~ a~ ~~'-~'~~~ ~~~~ ~ ~~ ~ ~~ ~~ ~ S~ REIUNN TV J ~U t - ~r~~. ..................................... the followin tract of land in- .,$t..-..Cf:QliK .. _ . ~-C' testy, ~ w ar e• _: :.firth -Nal.f :•x ~f ae So.:c::~est Wisconsin .Al-1..Q.~...~h~...N4r kh.. ~S.t...Qy C _: R Quarter ISW:) of Section 'I~enty-Five _~ ~~ 5 .ne ;29) 'ortrt, Nineteen (19) West, St. Croix County, wis~~'a:ri, except Lrt One of Certified St:rve.• Map filed June 29, 1994, recorded in Volw::e .C, Page 2782, St. Croix Canty Register of peels, as Doctunent 130. 518444. _. In Witness Whueof the said grantor. S.. have-.-... hereunto set:......_their- , hands.., and seal...__. this p ----. daq of... ~!aY ................... A D. Y~C--2.QA1. .. ...............................................»....__._ (SEAL BION7B.D AND f$AL$D IN pR$B$NC$ O!' ---~~y-'' ./ ....-- ................ (SIAL) ...... _~ .. ..... ........_...............................................................Y (SEAL ) ' to ' Stta~,te of ~~~~ o Wdshln ton ....County. ~ Personally [ame befvrr me, this..?4'.~-day of...~.. ~ ............... A. D., ~C..29,01 ......._.__...._......9._....._....... .husband and wi f e the above aamcd itI~;rIAFw N. ~ acnn]~,~n~? ~'F.AN M. PF:ARSON, .. ................................... ~................................ to me known to be the persolrS.-.. who executed the foregoing instrument and acknowledged the same. »ai ryia IN4TRUMENT Aq D RITE er _ ,ASv10UNTAIN >. Richard J. G rie # 2864 NO~t-wttY N., -' ''~'~~~ N TORY PUBLIC-MWNE50TA Count Wis. BEAL - Mary NLL~iiC, - ~t;r° ...Q. ......................... }', 880 Sibley Memor is 1 Hwy . , # 114 My Comm. Expires Jan. 3t, Zoos ea ,ae~a-e~ie~~~.. eSr ""mar-i~.~i~Av-1736 ~1y comrnissi~n (dt _ ........................................'........................ - ~ _ (Section }9.51 (tl of the Wlscon in Statutes provides thst sii r.,~s ro be recorded shall have p{ainly printed or typewritten thereon the nano of Ne ~raMon, grantees, W~tnnses and nutrr.. Src: + t::::aarly requires that she ur•nc u( tine person who. or go~ern~ tnentil a(eney vhKh, dralteJ to<h instrument, the{I be part:+:, :~ ~: "r s~~~i~cd or written lhator. '^ r Wi.con. InnC.c~nl 71;~nir CornnenY STA'I'D' ~1'~~VISCONSIN -~< .~-' < jj' 'r 117-M-Corporation Minnesota Uniform Con~r_ _. ~ ..= ~y'~ •• ~ -+• ~ _ 5: ~a_ :"~ c°_' ~ •r--~C'f - - _ - - -- - - . STATE OF '.1~1I'~1?VESOTA ' Ss. Affid~~'it Regarding Corporation COUNTY OF - -- _ - and being first duly sworn, on oath says(s} that: and Qie 1. (They are) (- he is) the --- -- ---- - -- - - respectively, of _ __ . _--- . _ _ Carriage_HomesXXLlnc- -._-- .-- -- -- -- --- a _Minnesota __--_ corporation, the corporation - ----- - - named as - _ ------------ --------- - -- in the document dated _. - _- _ ___ ,and filed for record ~-__~_ --- - as Document No. _ - (or in Book _-------- -- of --------- ------- ------__..._. _ __ . _-_-- _-- -__-- ) in the Office of the (County Recorder) (~GE~Ot~Gtltd~~~9 Page . _ __ _ __ _ of . _ St. Croix _ County, Minnesota. 2. Said corporation's principal place of business is at - - - - -- - ---- -- ------ - ----~- ~-- -- - - _.. -- and said corporation's previous principal place(s) of business during the past ten years (has) (have) been at: 3. There have been no: a. Bankruptcy or dissolution proceedings involving said corporation during the time said corporation has had any interest in the premises described in the abo~•e document ("Premises"); ~' b. Unsatisfied judgments of record against said corporation nor any actions pending in any courts which affect the Premises; c. Tax liens filed against said corporation; except as herein stated: 4. Any bankruptcy or dissolution proceedings of record against corporations with the same or similar names, during the time period in which the above named corporation had any interest in the Premises, are not against the above named corporation. 5. Any }udgments or tax liens of record against corporations with the same or similar names are not against the above named corporation. 6. There has been na labor or materials furnished to the Premises for which payment has not been made. 7. There are no unrecorded contracts, leases, easements or other agreements or interests relating to the Premises except as stated herein: ~ ' ,~ ~ ' 1 8. .There are no persons in possession of any portion of the Premises other than pursuant to a recorded document except as stated herein: , 4 - 9. There are no encroachments or boundary line questions affecting the Premises for which Affiant(s) (has) (have) knowledge. Affiant(s) know(s) the matters herein stated are true ai3d make{s) this Affdavit for the purpose of inducing the passing of title to the Premises. <~ Subscri d sworn to before me this ~ _. _ . day of u _ _ .2001 (Year? `. . _ _ SIGNATURE OF NOTARY PUBLIC O0. OTHER OFFICIAL NOTARIAL STAM/ OR SEAL IOR OTHER TITI~ OR RANK1 LARRY MOUNTAIN NOTARY P!}auc -1,IINNESOTA y ~rJanr. - __ -- -- Carriage Homes,~7j - 'L' ~"` ' - - ~ ~~ ~.~.e.QQ__~- C~"O __._ . THIS INSTRUMENT WAS DRAFTED BY {NAME AND ADDRESS): Land Title, Inc. 1900 Silver Lake Road Suite 200 New Brighton, MN 55112-1786 WARNINGS UNAUTHORIZED COPYING Oi THIS iORM PROHIBITED. • S 5 GENERAL ST. CROIX COUNTY, WISCONSIN OLD TXSCR01 REAL ESTATE TOWN OF HUDSON COMPUTER NUMBER 020 - 1395-67-000 Parcel Number 25.29.19.2461 Claimed Date Re-certified / / Relate Number: SCENIC H OWNER NAME: First Last LIFESTYLE HOMES INC CO-OWNER Mailing Address 11200 STILLWATER BLVD N City LAKE ELMO State MN Zip 55042 - Type Vol Page Doc # Rec.Date Type Vol Page Doc # Rec.Date HISTORY WD 2134/ 522 708783 02/07/2003 PLAT 8/ 76 658318 10/04/2001 PROPERTY ADDRESS: Hse # 1/2 PD --Street Name- Type SD Apartment Post Office 718 REGAL RIDGE School District: 2611 - SCH D OF HUDSON Special District: (1) 1700 - (2) - (3) - WITC Plat Code: Last Changed on: 09/30/2003 Book Number: 1 SECTION 25 TOWN 29N RANGE 19W '/4160 SW '/<40 NW Map Number: 00 - Sales Area: Parcel Control 0 TAXABLE Number of Units: ZONING: Permit Number: Type: Bank Numbers F4-Prev, F5-Next, F6-Legal, F7-Value, F8-History, F10-Exit, F12-More