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HomeMy WebLinkAbout020-1439-43-000 (3) \Nis~onsin Department of Commerce PRIVATE SEWAGE SYSTEM SafE~y 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 Rosam~i LLC Hudson, Town of CST BM Elev: Insp. BM Elev: BM Description: ~~ a~ , SST TANK INFORMATION TYPE MANUFACTURER ~ "' CAPACITY / Septic =" ,` ~- ~,~ti... 1 1 ZS O Dosing Za ~ n ~ $~ /~~- Aeration i 5 11 . e..l Holding TANK SETBACK INFORMATION TANK TO P/L A~~ WELL BLDG. Vent to Air Intake ROAD Septic 7 /Q7 ~ ~rT' / s Z 1 "`_ Dosing "----~__ Aeration Holding ~, PUMPISIPHON INFORMATION Manufacturer ,_,,,.- Demand GPM Model Numb TDH Lif Friction Loss System H TDH Ft Forcemain Le - --- ~ a. Dist. to Well 'Call ARSnRPTi(~N SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: 506191 0 State Plan ID No: Parcel Tax No: 020-1439-43-000 Section/Town/Range/Map No: 25.29.19.2769 STATION BS HI FS ELEV. Benchmark b7 X04 • ~? ~ as Alt. BM P ~C~ ~; t~ 3. 39 ~ a ~ , Z4~ Bldg. Sew,~er ~,,n. o ~- o~C ~ t~' ~d3. z ~ St/Ht Inlet (e,l~ 9 $ . 5 SbHt Outlet (P, ~ Z, ~~ , Z'S Dt Inlet ~ ~ Dt Bottom ~, Header/Man. /l ~ 3'f N• 37 `~3 •.3~ 73 3 Dist. Pipe //~ $ / //. t ?'-1• ~~ 1 3 Bot. System o~~ l11 Ot i-t.. /Z• 53 qZ ' ~ Final Grade ~ ' ~ ~ b .~ St Coverer \ n r: ~'~e... Id' 3. 35 ~~ ~ BEDITRENCH Width / Length / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia._ Liquid Depth DIMENSIONS 3 ~?, `` Z ~.tic.~4.X.) '`~'`-_ "'_- _ \ SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: ((~~ ~ ~ CHAMBER OR .J-d~.e"i , °'• INFORMATION / ~ Type Of System: + , •}, ZS Z ` )~ ~V N ~ • 1 UNIT Model Number Q J; L , t CsL. T r0 6~hJ2,J~ i nICTRIRi ITInAI CYCTFM t t~,<]-- L.3 tt'7.S ~ ~F In ~CS~". Header/Manifold ~~ ~ Distribution x Hole Size ~ x Hole Sp`ci`g Ve'~n~t touir^Intaljg j l ~ ~ Di ~ pipe(s) ~ ~^\, acin th Dia ~ S L '~-,-` u•a.,. a Length p g eng Cnll ('n\/FR ., o.....~.•.., c.,~•e..,~ n.,i.. .... Mnnnrl nr Af_C:rarle Systems Only Depth Over Depth Over xx. Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges \ Topsoil ~ Yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) inspection #1:_____/ / Inspection #2: / /_ Location: 895 Highlander Trail Hudson, WI 54016 (NE 1/4 NE 1/4 5 T29N R1 )Indigo Ponds Lot 43 Parcel No: 25.29.19.2769 1.) Alt BM Description = t 2.) Bldg sewer length = zb - amount of cover = 1 ~ ~ e.J~-' r t"s.. / Plan revision Required? Yes No Use other side for additional information. SBD-6710 (R-3/97) Date Insepctor's Signature Cert. No. ~ ~ ~ ~ commerce.wi.gov S ivision County /'Od / ~~ ~ C IC- tiu v ., .O. Box 7162 ~ s e o n s ~ n Madison, ~~7-7162 Sanitary PermSt Number (to be filled i by Co.) Department of Cotnrrteroe ~ a~ Sanitary Permit plication State Transaction Number sub fission orm to the appropriate governmental 21(2) Wis Adm Code In accordance with s Comm 83 . , . , . . . state-owned POWTS are unit is required prior to obtaining a sanitary permit. Not : Appl Project Address (if different than mailing address) / submitted to the Department of Commerce. Personal in nnation yo f~' for secondary ' C ~pS"~1L6/vGv~in6/L TRAZL u ses in accordance with the Privac Law, s. I5.0 1 m Stats. ~ S 1. A lication Information -Please Print All [nf mati ~~ - Property Owner's Name ,~ s `~~' Parcel # " e ~-~y ~~~~3-0 ~~ ~ ~ - Property Owner's Mailing Address UNrY Property Location ^ ~~ ( p~s~ Govt. Lot ~ ~ Ciry, State Zip Code Phone N r ~~ y., /y,~e /, Section °v~S- ~ (circle o ~` m ~ ~`~ ~N; R~Q_Eo~W T~3 II. Type of Building (ch ck aU that apply) Lot # , 'Ir~}t or 2 Family Dwetting mberof Bedroom ~~ Subdivision Name ~ ~ - ~ j ~ji(~.~ Block # ^ Public/Commercial -Describe Udte -'~ ^ City of ^ State Owned -Describe Use CSM Number ^ Village of /~ lfl. Type of Permit: (Check only one box online A. Complete Gne B if applicable) A. ® New Replacement System ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System (explain) B. ^ Permit Renewal ^ Permit Revision ^ Change of Plumber ^ Permit Transfer to New List Previous Permit Number and Dace Issued Before Expiration Owner IV. T e of POW'CS S stem/Com onent/Device: Check aU that a 1 ~ ® Non-Pressurized In-Ground ^ Pressurized ln-Ground At-Grade ^ M jt > 24 in. f uitable it /~Mo d 4 m. of suitable ~ ~ / ~~ ~ ~~~~ r 8 t t L 2~% treatmen ev c e a ^ Holding Tank ^ Other Dispersal Component (explai 2?n ~ V. Dis ersal/I'reatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdst) Dispersal Area Required (st) Dispersal Area Proposed (sf) System Elevation ~o o / ~ r~l'3- o ~ 9~, s V[. Tank Info Capacity in Total # of Manufacturer d ~ " Gallons Gallons Units ~ ~ -, New Tanks Existing Tanks d c $ ~ II °~ ~ ~ G`~i Pi? a U rn m in w V a. Septic or Holding Taok a~.s _ _ / Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the atGtched plans. Plumber's Name (Print) Plumber's Signature MPlMPRS Number Business Phone Number /~/~~ ~ ~ ~/S ~~'d ` d Plumber' Ad dl •ess (Street, City, State, Zip Code) ~ + ~1 G! !~ VIII. unt /De artment Use Onl Approved ^ Disapproved Permit Fee $ [Ja ~ J Date is ued ~ Issuing Agent ignature ~ L ^ Owner Given Reason for Denial / ~ 7/ U / ~~~~" u' 1'~/ IX. Conditions of Approval/Iteasons for Disapproval ~~ _/ „ , ~ „ /~„ ~~~ ~~~ ~ n[G~2i7~~f~/Z~ - . SYSTEM OWNER: n~~~ ~j (/~~ ~L ;v,~~~-y,Qj~_ 1 Septic tank, effluent filter and ~" ~~J~ ~ /~ _ /,Cr~.~ ~' dispersal cell must all be serviced /maintained ~~~ ,' ~~~~ .~'~'"/ _~L~,C~,~.~ (~ Alta h f0 com Ito plam,l6 7pe 3y em and ubmit to thX.[;ounty only on pap n t ItSS to n a lrz x I I mcnes m sae 2. All setback requirements musg~ie mam{alne ~/~~ -~ ~~ ',~Z,L{,~~- as per applicable code/ordinances.. CX-~/ ;~ ~ / SBD-6398 (R. 01/07) Valid thru 01/09 /i/~ ,, Q.~ /~~ ~~GLC~-,-,// _,.._ _ _ _ ..... _ avP./t /so' To /Vaitri+ /-/lvP.E/17'y /~-ivE LT, /j/'f 7oP of ~~~P/G FS/°E J~/v+AostO X B~'r 7oP oil __. _.,,,~- 4 /3aeR.,.m ~ i°YG P1'PE RE~aNCf~GNI(flGf E~LE/.: /oo.oo~ 3 ~ r --~ 1 ' /0/ta/°aJ'BO ~itzVew~oY /y9a ScoPti ~ F"""~ Y:o/C .!'civ[=~ yr~ ,(~,~OG .,(~~7-rrR .D,t Q! p E~--~- /~S~O ~iAC hCll:!'fR ~EPnG YANK J~,tZ7N 2A[!t`L /ir /~00 QQI ~ fL7F/L rvr/o .~i-Lgnr Al.,o~¢irJ ~. ~ k___,------p,2,s~ =--------~ Q l33 Jo.lE- Y,/6ST /RuPt/CTY L2~/c Lo~~/~eYi~' y ~iOVG tr~zvr.~n- LrNE /3p" ~~ ovfR i3v" Yo sari PiWPfltrY LZNB S ..~ Q~.s~K 5'`rr,,tioA~n (. ~,~~~ - o~..sr.-rt~•9rr,~v ~~~ a~eo: . t~,T ~,~~ AQS~t~ilr~or~//VEivr..~7ACkTv T~vtt~rvr,~ /A i~ov~' Hof LiCRNN~; ...,.,,,..,,.. .MAxz~,a~+~r A6 "~ Cr9t~d"R ---------~ '~i°Yt:.11tidL ~+ /g;~e' --._ .~ ~ ..~... ~.,....,.,... .Tivvka7" f., .t two vtwtw Y T/ZENt:N .$Coc~.t ~LE1~r9i.,Tv~v .~~ _ toawr"w Snrc ysT :r .., ~/YF1LTii~iV.Tt~ fJJT~ ..Z+vG MuttiP'ott end Cap .itAoNtvrftw.. r ove/t iso' ro Naas /~i1vPt~r~'r LzvE 1 E- LT, /,S1'1 ToP of ~~~P/4 P1Y°E P/~riAoSrO ELEY,. =99.55" ri/r-rt NI~c,+n~art T/L4zc. WNA lilfai• tiXCACYA~TIN1~ It~ICN~Ki 1JNM1' .~ P/to~areo ,O.uve,,~Ar X i°VG .~1'PE /iFS-4iNCF~G/1RAG£ 1 E'LE/. r/DD.ao ~! i ~~ ~ ,y~o s~oat~~.~ F----- y'%~vc ,rcHr•~ Yv /.BLDG .I"~W~ .Q.~ Q~ O E--- /.~S"O rs.14 h~L7P CFR ~SEi°TYG JrANK Y.~Z ~/3/ ~ ~ fL7FR i'9N0 ~G'~.•'9/t'l iVLAiQ/~7 ~F" ~-----.y,26~'----~1 Q /33 ~o +E- y H.~v~ t~LVr~rr L,rv~' --- ovfa i3o" Yo ~~ P/WPfRTY L,~~/B /3v" h/6sT /"RuPtI9TY Ls"/E' P,~,,~r~, .h~ru~dA'~° . ~«sCK y`rr~ti~~n ~~~~ - o,~.r,~-r~,~.~rrav r~F ~„r ~,~-.---~.. OZdS~t~Artar//v~NS»ri.~cK Td 7~t~o~o~,~ /A :&to~~+ ~wdE .MAxZ/'Jt/r'1 9eS'` Cc~i~6'R ~--`•'~~ '~''~`ioYG ol'~a°L f~ .~:~C _..__ ttrrrarvt wwn+~ ~.II ~~N NWt vKw tNt~weo: uce,r~: M~~i 0~//II//~ / ~ rrr~w.~rtwww.r. ~~Y~ FYI .Oryu ~ ~~~~'~i - ~ fRFNCN .rCuwt ~L~`vrorsviv .~'R ?op vllW ~GIX"4 7~'1T .,ZNF1LTi~TN.''AR ..~jJT~.C .ZNC IlAuitii~+ori end Cap . -~iii~ vii' Wisconsin Department of Commerce Division of Safety and Buildings SOIL EVALUATION REPORT in arrrrrlanra with Rnmm R~ Wis Arlm Cnrle 1253 Page 1 of 3 Steel Soil Service County Attach complete site plan on paper not less than 8%: x 11 inches in s¢e. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. ~ 2 p _ ~~,~'i q - Cj3 - Ofd ~~dip g- Please p n a ~ ~~ ~ Date eviewed Personal information you provide may used for sewn ary purposes "(Privacy Law s. 15.04 (1) (m)). ~~ ~~ Property Owner MAY 1 3 2003 Property Location ROSAMJI, L.L.C Govt. Lot na NE 1/4 NE 1/4 S 25 T 29 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 2141 Cty Rd. C ST. CI~UIX COUNTY ,,, - 43 na Indigo Ponds City State rp _f City ~ Village 1I' Town Nearest Road New Richmond ~ WI 54017 715-248-7071 Hudson Highlander Trail /~ New Construction Use: ~ Residential /Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement ~ Public or commercial -Describe: Parent material Sream terraces and pitted outwash plains Flood plain elevation, if applicable na General comments ~{'~' ~'~ -SR/~G~ ~ O ti ~,p~ and recommendations: system elevation 95.15 ft, trenches spaced and depth to code ~3~00 ft below grade , U'' / Boring # J Boring Pit Ground Surface elev. 98.15 ff. Depth to limiting factor 120 in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-4 10yt2/1 none I 2msbk mfr cs 2c .5 .8 2 4-9 10yr4/4 none sicl 2msbk mfr gw 1 c .4 .6 3 9-21 7.5yr4/4 none scl 2msbk mfr gw na .4 .6 4 21-32 7.5yr4/4 none Is osg mvfr cs na ,rJ 1.2 5 32-120 7.5yr4/6 none cos osg mvfr na na .7 1.6 ri ^ Boring # J Boring 1/ Pit Ground Surface elev. 98.15 ft. Depth to limiting factor 120 in. Sod Application Rate Horizon Depth Dominant Color Redox Description Textun: Structure Consistence Boundary Roots GP D/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-7 10yr2/1 none sil 2msbk mfr gw 2c .5 .8 2 7-21 10yr4/4 none scl 2msbk mfr gw 1 c .4 .6 3 21-36 7.5yr4/4 none sl 2msbk mfr cs na .5 .9 4 36-120 7.5yr4/4 none cos osg mvfr na na .7 1.6 o / ~I N~ Z-Q(7~ ~~ C~G~ ~~ \ COS <35% coarse fragments = 36" & >3 " 5% - <60% = 60 below system * Effluent #1 = BODS> 30 <_ 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TS5 <30 mg/L CST Name (Please Print) 'gnatur ~ ~ CST Number David J. Steel 248956 Address Steel Soil Service Date Evaluation Conducted Telephone Number 1564 CR GG, New Richmond, WI 54017 4/28/2003 715-246-5085 Property Owner ROSAM]I, L.L.C Parcel ID # pending Page 2 of 3 Boring # J Boring 1/ Pit Ground Surface elev. 92.65 ft. Depth to limiting factor 120 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-3 10yr2/1 none I 2msbk mfr cs 2c .5 .8 2 3-6 10yr3/4 none sil 2msbk mfr cs 1 c .5 .8 3 6-28 10yr4/4 none sicl 2msbk mfr gw na .4 .6 4 28-36 7.5yr4/4 none s{ 2msbk mfr cs na .5 .9 5 36-120 7.5yr4/6 none cos osg mvfr na na .7 1.6 c~ ^ Boring # ~ Boring J Pit Ground Surtace elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ^ Boring # -~ Boring -J Pit Ground Surface elev. ft. Depth to limiting factor in. ~~ Appl~atan Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Murrsell Qu. Sz. Cont. Color Gr. Sz. Sh. "Eff#1 *Eff#2 'Effluent #1 = BODS> 30 < 220 mg/L and TSS >30 < 150 mg/L 'Effluent #2 = BODS < 30 mg/L and TSS <30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608-264-8777. Page 3 of 3 STEEL'S SOIL SERVICE INC. David J. Steel 1564 Cty Rd GG CST-POWTSM ROSAMJI, L.L.C. New Richmond,WI 54017 L1C. #248956 NE1/4,NE1/4,S25,T29N,R19W Bus.(715) 246-6200 Town of Hudson, St. Croix Co. Fax.(715) 246-9372 Indigo Ponds Lot 43 This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for yow use. The location of this test may or may not be as shown, as permanent lot lines were not established at the time the soil test was conducted. Legend 1"=40' ~~ • =Benchmark Ele. 100.00Ft Top of 1/2" pvc pipe • =Alt Benchmark Ele. 99.SSFt Top of 1/2" pvc pipe ^ =Borings Boring Elevations .' (2.01 AC.) ,,.' ~~ f ~ ~Ij f" ~ ! r / i f ! / ! ~ ~. .456. AC. N.S.P.A.) r~/ .~'~ / ~ r e~ ~ f ' I ~; 5.0T t ~ ' ~ d ~ J l ~ R=80~ ' . ~ ' s ! ~ ~~ $7 29 S.~. f `<< ~ -r'• ~,, 29.- y0~ ''r ~ ~ . ~' / ~ ; ~/ l ~ (2000 AC.) ~ • , 8 P.A,) ~~ .. t g~ ~ /93~ f / j f 18$ .13' !~~ ..--- -~- /' , / .' ~ ,. 508 02' '1~ . . f ~ ...- :~ ~,-, ~ _ ~ " *~ 1 102593 S.F. e , :~ ' ~',~ .-- "~_.. ~. - •/ ~-. ; ~ __,,p~~= / ` (2355 AC.) it ! ;' •. ~': ~--~ 611 f~ ` ' !_ -~ ! \ (1.023 AC. N.B,P.A. ~ a ,~,.:,. '`:~? _n/ /~ / ` ~ /, ~ . _ ~, , ,•' ff / ~ ~ r ~ i ` ~ U ' r„ is ~. ` ~' f ~ ~ .-`~ :~ ' ~ 2.266 AC. '` -- _ /~ ~ ~ ~ ;::.i _w~_,. ~ (1.635 AC. N.B.P.A.'~ (II' i j r ' `~ ~, _ " ~ ~ r .:: :~ • ` •~ ~:. '" ~ ~ l~r" „~ ' / l /~ _ ,. __. 44 ~ _ ~' --•-87181 , S ~ 1 ~ ~ ~~ ~~ ~~ . 1 ~ ~ r ~~ ~ ~ ~ ~ ~ _.(2.004 AC.) ~-~'? t ~, ` c -x(1.581 AC. N.B.P.A) '•• ~ ,~~ _~. ~ ~~ ~ ~ ~ t f,h t~' t _ ~ .` .. , ._ .. w ,. ,• ~` ._ s„ ,. ~, " , ~ f ~3r - _J. a /~ ~ , - C J ., 1' .. . , ~, ~~~-- j - ~ 2 ~60 ; _ ~ - ~-- ''~., ' ~, 109074 .F..k ~, _ __4~ ......_ "~ j _. • ~, •, (2.504 AC.) , ", --1 ~ r '~ A N.B.P.A. r w Io C _ ry - __- 062 ,_ -. y ~ l,..~ . ~~ 2 001 AC ~ _ _ cO ~ t' ~{ t S ' '• !,: ~ '~ - , ~ ,> ,r ', fl 0 l ./~ / ~1y t ,~! ,~ t - o _ r ' ~ ' f, ~ ~ .' aNi / ;.• ,~ . 41 `' ~` - ~,,r ~ j X109800 S.F. ~ ~' ~,``~~` / _ - f ~ `(2,521 AC.) '' ~ ~ / ~' -.i ` ..,.. ~' ~' . ~-$7.537 S.F,``°~ i r`. (2.010 AC.) l~`. (_1087 AC. N.B.P.A.) / /` 59.57 ~ / 1 ~ ~ /. .~\6`e. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer Mailing Address Property Address ~ ~ SG Gln 2;a 85~ ~I, ~e CaV~c~ cS1l~ee. Q Z ~ IM~tnc (Verification requir~d from Planning Department for new construction.) (,~ 1 City/State I' IuG~~ w ~ Parcel Identification Number f~ 26 -~~~ - ~ 3 -6~~ LEGAL DESCRIPTION Property Location N 1~ '/a , ~'/a , Sec.2-~ , T Z ~ N R ~ l W, Town of ~t~ GI~~~V Subdivision Certified Survey Map Volume ,Page # Warranty Deed # 1 ~ ~ 3 C7 ~ ,Volume ,Page # Spec house ~ yes ^ no Lot lines identifiable ~ yes ^ no Lot#~ 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. The property owner agrees to submit to St. Croix County Zoning Deparhnent 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 De ent within 30 da of the three year expiration date. /~/ n SIGNATURE OF LICANT DATE OWNER CERTIFICATION I/we certify that all statements on this form are true to the best of my/our knowledge. I/we am/are the owner(s) of the pro described above, by virtue of a warranty deed recorded in Register of Deeds Office. s l~i~ SIGNATURE OF APPLICANT DATE ****** Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department. ****** Include with this application a stamped warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page ~ of ~. FILE INFORMATION Owner Permit # d-~ DESIGN PARAMETERS Number of Bedrooms ~/ ^ NA Number of Public Facility Units ^ NA Estimated flow (average) ~ gal/day Design flow (peakl, (Estimated x 1.51 gal/da Soil Application Rate ~ r gal/day/ft2 Standard Influent/Effluent Quality Monthly average` Fats, Oil & Grease (FOG) <_30 mg/L Biochemical Oxygen Demand IBOD5) <_220 mg/L ~1 NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOD5) <_30 mg/L Total Suspended Solids (TSS) <_30 mg/L 8 NA Fecal Cotiform (geometric mean) 510° cfu/100m1 Maximum Effluent Particle Size Ye in da. ^ NA Other: ®NA *Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS •Septic Tank Capacity (S 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 ` N ^ In-Ca~ol~nd (pressurized) ^ Mound ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA rrll w •1/+c (~/+ucnl 11 C IVIHIIY 1 CIYNIYVC JVI7ClJY LG Service Event Service Frequency Inspect condition of tankls) At least once every: ^ month(s) (Maximum 3 years) ® earls) ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third IY31 of tank volume ^ NA 1s) Maximum 3 years) ^ NA Inspect dispersal cell(s) At least once ever y' ^ yearls) ~ Clean effluent filter At least once every: ® month(s) ~~ ^ yearlsl ^ NA ^ month(s) ®NA Inspect pump, pump controls & alarm At least once every: ^ year(s) ^ monthlsl ®NA Flush laterals and pressure test At least once every: ^ year(s) Other: At least once every: ^ month(s) ^ year(s) ®NA Other: 9 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 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 IY31 or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed'by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW 14/011 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 cellls-. 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 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 tie 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. ^ 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 POWTS INSTALLER Name r ,, ~p Phone _ J POWTS MAINTAINER ' Name /~f'o Phone ~~s- _ SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name ~ u~4 Phone „ ~/~U Name ,tr,c? Phone S- _ This document was drafted in compliance with chapter Comm 83.22(2)(b111)(d-&If1 and 83.54111, (21 & (31, Wisconsin Administrative Code. J 2223f' 306 • STATE BAR OF WISCONSIN FORM S - 2000 PERSONAL REPRESENTATIVE'S Dc~:ument Number DEED Ju_ dv iViccum.asPersonalRepresentativeofthecstateofFlorenceK.Polen ("Decedent"), for valuable consideration conveys, without warranty, to Rosamii. LLC Grantee, the following described real estate in St. Croix County, State of Wisconsin (the "Property) (if more space is needed, please attach addendum): - _. Please see the attached Legal description. , . 7 1 ~3~9 KATHLEEN H. WALSH . REGISTER OF DEED$ ST. CROIX CQ: , WI RECEIVED FOR RECORD 04/2/2003 03:00PM PERSOHAL.REPRESEHTATIV :. tXE14;7 # .. REC . FEE : 13:00 . TRABS FEE: 3448:80 C©PY FEE: CC FEE: .PAGES:, 2 Recording Area Personal Representative by this deed does convey to Grantee all of the estate and ~ ~ - ' `7P~ ~~~ ' ~ • interest in the Property which the Decedent had immediately prior to Decedent's death, Parcel Idennficehon Number (Plt~ . and ell of the estate and interest in the Property which the Personal Representative has This Is not ~'• homestead property. • since acquired. .. ~ .. .. .(is•not) •• Dated this ~ 28th day of __ Anrll ~ ~ ,•2003 ~ ~ ~~ .. • .' ..~ ~ _ ~' ~ ~ .. .. .. • Judy .Niccum .. , Personal Representative ~ .. . • ~ ~ ~• .Personal Representative AUTHENTICATION •• . • ~ - ,' ~~ :ACKNOWLEDGMENT • Signature(s) Judy ..Niccum ~ ~ ~ • _ ~; . STATE OF WISCONSW ~ ~ ) . ST. CRODC County ) authenticated this 28'" day of April ~ 2003 ~ ' . ' - Personally came before me this 28'" day of ' ~ + April ~ 2003 theabove.named ~i K% `Judy . ' Niccum TITLE: MEMBER STATE BAR OF WISCONSIN (If not, ~ to me known to be the person(s) who executed the foregoing authorized by § 706.06, Wis. Stats.) • • . ~ . instrument and acknowledged the same. :. : . THIS INSTRUMENT WAS DRAFTED BY ~ ~ ` Heywood, Cari a4c Anderson, S.C., 1200 Hosford St., Suite 106 ~ • P,O. Box 12~, Hudson, WI 54016 .: Notary Public, State of W75CON5IN - My Commission is pectnancnt. (if not, state expiration date: ;Signatures maybe authenticated or acknowledged. Bath are not necessary,) ) • Names of persons slgnmg In eny capacity must be typed.or printed below their signature. STATE BAR OF ~V[SCONSIN PERSONAL REPRESENTATIVE'S DEED FORM No. S - 2000 (800)6334021 www.tn(oprofortro.com µ 'J 2223f' 307 Parcel A: That parcel located in part of the Northwest Quarter of the Southeast Quarter, the Northeast Quarter of the Southeast Quarter, the Southwest Quarter of-the Southeast Quarter, and•the Sautheast~ Quarter of the Southeast Quarter, all in Section 24, Town 29 North, Range 19 West, and the Northwest Quarter of rho Northeast Quarter, the Northeast Quarter of the Northeast• Quarter, and •tha Southwest Quarter of the Northeast Quarter, and the Southeast Quarter of the Northeast Quarter, all in Section 25, Town 29 North, Range 19 Vilest, TCwn of Hodson, County of St. Croix, State 'of Wisconsin; further descn'bed as follows: Beginning at the south quarter corner of said Section 24; thence North 00 degrees 3 l minutes OS seconds Vi7ost, .(far rho. purposes of this description the south lino of said Souilieast Quarter .assumed`to bear North 89 degrees 53 minutes OS seconds West) along rho Noah-South Quarter line of said Section 24, a distance of 158.37 feet; thence North 89 degrees 56 minutes 47 seconds East a distance of'194:98 feet to the point of beginning of a line hereinafser described as "Lino A"; thence North 00 degrees 16 minutes 57 seconds East, along said "Lino A", a di9tanca of 1049.18 feet to dte point of teanamati,an of said "Line A"; thence North 47 degrees 03 minutes 07 seconds West a distance of 118:06 feet; thence North 27 degrees 46 minutes 10 seconds West a distance of 196.02 feet to the center lino of Badlands Road; thence North 67 degrees 30 minutes ]3 seconds East, along said center line, a distance of 708.39 feet-, thence North 67 degrees 56 minutes 31 seconds East, continuing along said center line, a distance of 674.75 feet to the westerly line of BOUNDARY RIDGE, according to the recorded plat thereof, thence South 00 degrees 25 minutes 17 seconds West, along said westerly line, a distance of 1826.90 feet to the south rest corner of Lot 7, said BOUNDARY RIDGE; thence North 89 degrees 43 minutes 38 seconds West a distance of 66.00 feet to a point 66.00 feet westerly of and perpendicular to said westerly tins and hereinafter described as "Point A"; thence South 89 degrees 56 minutes 47 seconds West a distance of 96l .84 feet to a point 66.00 feet easterly of and perpendicular to said "Line A"; thence North 00 degrees 16 minutes 57 seconds East, parallel with said "Lino A", a distance of 1036.45 feet; thence North 89 degrees 25 minutes 43 seconds East a distance of 82.43 feet; thence North 77 degrees 28 minutes 43 seconds Fast a distance of 343.87 feet; thence North 83 degrees 18 minutes 47 seconds East a distance of 201:86 feet;'thence North 'S$ degrees S3 minutes 32 seconds i~:ast a distance of 263 23 feet;. thence North 54 degrees .I9.minntes 28 seconds East a distance of 112.b9 feet; thence North 42 degrees l 3 minutes 44 seconds East a distance of 46.55 feet to a point 66.00 feet westerly of and perpendicular to said westerly line of BOUNDARY RIDGE; thence South 00 degrees 25 minutes 17 seconds West, parallel with said westerly lino of BOUNDARY RIDGE, a distance of 1370.64 feet to said "Point. A"; thence South 89 degrees 43 minutes 38 seconds East a distance of .66/00 feet to said southwest corner of Lot 7; thence South 00 degrees 2S minutes 17 seconds West along said westerly line of BOUNDARY RIDGE, a distance of 163.55 feet to the North dine of said .Northeast Quarter of Section 25; thence South 89 degrees 53 minutes OS seconds East, along the north line of said•Northeast Quarter and the south line of BC3IJN17ARY. RID~;E, . a distance of 760.75 feet to the northeast corner. of said Northeast Quarter, thence •----- Sont13 00'd ~ ___...___ egrees 29'mtnubes 03 seconds West; along the east line of said Northeast-Quarttr, a~distance of 26]6.18 feet to the southeast comer of said Northeast Quarter; thence South 89 degrees 25 minutes S8 seconds West, along the soutfi line of said Northeast Quarter, distance of 2606.35 feet to the southwest corner of said Northeast Quarter; thence North 00 degrees 24 minutes 10 seconds West, along the west line of said Northeast Quarter, a distance of 2647.29 feet to the point of beginning, St. Croix County, Wisconsin, except that part described as follows: All of the Southwest'/, of the Northeast %. anil"also the West SSO Feet of the Southeast'/. of the Northeast'/. and Also the South 250 feet of the Southeast'/. of the Northeast'/,, except the West SSO Feet, all in Section Z5; Township 29 North, Range 19, Town of Hudson, St. Croix County, Wisconsin. ~f~~ ~D- lol~ - ~~-lea ~~-~~~~ -~v-av~, ~o~ /a~c~ - ~a-~o -- ~O~ ~D~Y f ~ ~(~ rV ~V, ~ IU rD.C 9r ~D~D~o dlr lc ~9 ~a-V~ V/G~(V f~(~~~f /q/ f ~ ~v0-DCY~. ~. 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