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HomeMy WebLinkAbout032-2163-04-000 (2) Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) 600363 State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village Township Parcel Tax No: Darin & Jill Anderson TOWN OF SOMERSET 032-2163-04-000 CST BM Elev: Insp. B I~: BM Description: 11; Section/Town/Range/Map No: 14.31.19.1396 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER r CAPACITY STATION BS HI FS ELEV. Septic t ?K..- 3 Z Benchm rk .I / SO E ►`c. a Z.35 /ax •3 / Alt. BM - i 7 g~ , t I p ~C. 7 Aeration Bldg. Sewer Holding ~g ~ St/Ht Inlet , 9g CIZ .37 TANK SETBACK INFORMATION St/Ht Outlet TANK TO P~I~ ' WELL BLDG. Ve Air I take ROAD Dt Inlet P Septic 44 Dt Bottom Dosing Header/Man. Aeration Dist. Pipe \ ~ 9/.75 Holding Bot. System PUMP/SIPHON INFORMATION Final Grade y, Lrj 9S. Manufacturer De and St Cover GPM Model Number TDH Li Friction Loss I ystem =TDHFt Forcemain I Le la. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches r IT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 13 ((Q °i SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufactt INFORMATION CHAMBER OR Type Of System: , 34 UNIT l yy~er:, GQ O Mode e A4 43 r.( DISTRIBUTION SYSTEM ( Z,Z,~ Z Z Header/Manifold / Distribution ix Hole Size Ix Hole Spacing Vent to Air Intake Dia Pipe(s) _ _ _ N____ LLength Dia Spacing r7' SOIL COVER / x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of Seeded/Sodded xx Mulched Bed/Trench Center )ev5 Bed /Trench Edges Topsoil xx ~s No Ye ^p E] s jNo COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspectio #2: Location: 2124 62ND ST GOaL~ G, r..S S eve 1.) Alt BM Description 1 2.) Bldg sewer length = - amount of cover = if n n qZ. 06 Plan revision Required? ❑ Yes No V Use other side for additional information. V T J7 SBD-6710 (R.3/97) Date Inse or's Sign a Cert. No. Tltl l(I " - n r41 County Industry Services Division 1400 E Washington Ave Sanitary Permit Number (to be filled in by Co.) P P.O. Box 7162 zj - Madison, WI 53707-7162 r,, stn Sanitary Permit Applicat " - state Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code,,spbmission of this form to the appropriate 1 unit ~A- is required prior to obtaining a sanitary permit. Note; Application forms for stataesalR'>, PINTS are submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary Project Address (if different than mailing address) purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. 1. Application Information -Please Print All Inform ' ~Jm Property Owner's Name / Parcel # 1 I _ 6~ z~, Property Owner's Mailing Address Property Location 9 Govt. Lot City, State Zip Code Phone Number Section (circle Ong) T,_-.i / N R E 0(V~-: II. Type of Building (check all that apply) Lot # I or 2 Family Dwelling - Number of Bedrooms Subdivision Name D it q~j F-1 Public/Commercial-Describe Use lw,ti Block# ❑ State Owned - Describe Use ❑ City of t r ISM Number ❑ Village of c7~ ~►~il2Z '}_ZZ r".rY.ld~ Town of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) :7-0, ,,_~L_ A. New System ❑ Replacement System ❑ Treatnlent/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New ist Pr vt us Permit Numbe ,n Date ssued Before Expiration Plumber Owner r Y l Cr T IV. Type of POWTS System/Component/Device: (Check all that apply) I t 4-4 L. a) 10 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil Ho ding Tank Other Dispersal Component (explain) ❑ Pretreatment Device (explain) ~C V. Dis ersal/Treatme Area Information: Design Flow (gpd) Design Soil Application Dispersal Area Required (sf) Dispersal Area Proposed (s System Elevation Rate(gpdsf) Z VI. Tank Info Capacity in c Gallons Total # of j ° Manu acturer v Gallons Units Mo New Tanks Existing Tanks 6~, Septic or Holding Tank ❑ ❑ ❑ ❑ Dosing Chamber ❑ ❑ ❑ ❑ ❑ VII. Res,po ibility Statement- 1, the undersigned, assume responsi i{rty fq~stallation of the POWTS shown on the attached plans. Plumb Name ri Plumber'- t re MP/MPRS Number Business Phone Number i Plumber's Address (Street, City, State, Zip Code) /4 Z,_ VIII. ount /De artment Use Only Approved tsapprove Permit Fee Dat Issue Issuin ent Signatur to, en Reason foal $ ?O~ ` IX. Condil!Reasons for Disapproval C*# kAtAH LM 111W* 2L ee>F per i :agemeM. plan pia 4ded by plumbeF. 2. 'ANallellds'i^ tiirixm~ms muut toll mair ti u -e-! ✓I1R 11 Cfy:i! /,•#dim1r,Sx, Attach to complete plans for the system and submit to the County only on paper not less than S 1/2 x I1 inches in size SBD-6398 (R03/14) a - - n~~--- Wit-:, \ ~ k~--- , - - , - - - - - - - j a \ i v~ - - Ai- N Gpdoo Nz- - - ---may ~ o ti 5c - - - - - - - - - I CO P Y- CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Owner's Name: t~ Owner's Address: ~ 141 / ~ "1~"> f / Legal Description: Township: County: / Subdivision Name: s' Lot Number_ Parcel ID Number Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Gross-Section Page 4 Filter Specs Page b Maintenance Information Page 6 Management Plan Page 7 St_ Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page g CSM or Plat j Attachments: Soil Test & House Plans Designer/Plumber. License Number. r-=-~=----- Phone Number 7 ` f 7 Date: 1% Signature f' Designed pursuant to the in-Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-1 70 (N.01101). Page 1 a i - f / i \ w v x _ A stom O (--r,e vent Pipe Leaching s~ Chamber r ~ I ~-Vabon 7J r it y~ M rm Gf~~sers - , c Veni or obsenon Pipe } 47 s } fl = ~Ii~ Ef Reader t r sq ft Pei- chamber S.H Appticaffon R-de 90" ~ EtSa Ra-QrIg god Design Fines - 1 2 Mgrs -~nae tea. # wage ~r pL 525 EFFLUENT FILER ( CMAfZE~j srv -y ».4u j..e,:..:, ..tea Polylok, Inc is pleased to add its new commercial fitter to its existing line of quality effluent filters. The f ry, PL--525 is rated for over 10,000 GPD warm Accept5 PVC l accessibility (gallons per dayi making it one of r lion 6ancHe the largest commercial filters in its class. It has 525 linear feet of 1.16° filtration slots. Like the Polylok n PL 122, the new Polylok PL~25 has u 4~ 4 , 11 an automatic shut off half installed 525 GttearFeet i of 1116" with every filter. When the filter is j r ' Rated for over } filtration slots removed for cleaning, the ball will 10,000' float up and temporarily shut off y a the system so the effl uent won't leave the tank, alto other fAer On the market can mare that ddaim# & s, " e ~ - - SCHD_ 40 Pipe PL-5z,: Maiintenance: The PL-625 Eflfuent Filter should operate efficiently for several years 3 under normal conditions before V requiring cleaning- It is reccrn- r mended that the filter be cleaned a every time the tank is pumped or j _ at least every three years. If the, installed filter contains an optional a i~1 r alarm, the,pwner will be notified - z by an alarm when the fitter needs e f Gas deflector c servicing. -servicing should be done by a certified septic tank s automatic shut off i ball when filter pumper or installer. is removed 1. Locate the outlet of the 5 u_~ Patent Moi= s~isaas septic tank. 5o^T1,640 Z.-Remove tank cover and pump tank if necessary- PL r z ins-ailatioll': 1- Locate the outlet of the septic tank. Do not use plumbing when filter n is removed- ideal for residential and com- 2. Remove the tank cover and 4. Pull PL~25 out of the housing. merciat waste flows up to pump tank if necessary. 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the 5- (-lose off fitter over the septic 4° or 6° outlet pipe. If the tank. Make sure all solids fall filter is not centered under the bade into septic tank. access opening use a Polylok Extend & Lok or piece of pipe 6. Insert the fitter cartridge bade fitter. - into the housing-making sure to center 4. Insert the (ter. filter into the fitter is property aligned and its housing. compleEely inserted. 5- Replace the septic tank cover. 7_ Replace septic tank cover. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Tank Manufacturer: ❑ NA Permit # Septic ❑ Dose ❑ Holding Volume: al DESIGN PARAMETERS Tank Manufacturer: J9 NA Number of Bedrooms: ❑ NA ❑ Septic ❑ Dose ❑Holdin9 Volume. (gal) Number of Public Facility Units: E3 NA Vertical Distance Tank Bottom(s) to Service Pad: (ft) Estimated (average) Flow : y (gal/day) Horizontal Distance Tank(s) to Service Pad: (ft) Design (peak) Flow = (estimated x 1.5): (gal/day) Specific servicing mechanics must be provided if vertical is >15 feet or if horizontal is >150 feet. Specific inst cti ns to be provided on back. In Situ Soil Application Rate: (gauday1ft2) Effluent Filter Manufacturer: ❑ NA Standard (Domestic) Influent/Effluent Monthly average Effluent Filter Model: Fats, Oil & Grease (FOG) <_30 mg/L Pump Manufacturer: Biochemical Oxygen Demand (BOD5) <_220 mg/L ❑ NA B NA Total Suspended Solids (TSS) <150 mg/L Pump Model: High Strength Influent/Effluent Monthly average Pretreatment Unit (FOG) >30 mg/L Manufacturer: (BODS) >220 mg/L f NA 9 NA (TSS) >150 mg/L ❑ Mechanical Aeration ❑ Peat Filter Pretreated Effluent ❑ Disinfection ❑ Wetland Monthly average ❑ Sand/Gravel Filter ❑ Other: (BODE) 530 mg/L Soil Absorption System (TSS) <30 mg/L [~f NA Fecal Coliform (geometric mean) s104 Ij In-Ground (gravity) ❑ In-Ground (pressure) ❑ NA At- riri [I Grade El Mound Maximum Effluent Particle Size X in dia. ❑ NA ❑ Drip-Grade D p-Line ❑ Other: Other: ❑ NA Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) J21 When combined sludge and scum equals one-third (k) of tank volume ❑ When the high water alarm is activated 1. El Inspect condition of tank(s) At least once every: month(s) year(s) (Maximum 3 years) ❑ NA Inspect dispersal cell(s) At least once every: month(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: _71 ❑ month(s) ❑ NA _ ) © year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) NA ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and soil absorption systems shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Inspector, POWTS Maintainer or Septage Servicing Operator (pumper). 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 a check for any back up or ponding of effluent on the ground surface. The soil absorption system 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 treatment tank equals one-third or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator (pumper) 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 30 days of completion of anv service event. GMW-005 (02/05) ~ START UP AND OPERATION Page of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. 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 treatment tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge. 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 s. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks, pits and other soil absorption systems 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 (pumper). • 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: J?~J 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 the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. ❑ 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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK *-1 SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ADDITIONAL INSTRUCTIONS: POWTS INSTA LER POWTS MAINTAINER Name LName Phone - - e SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone - _ l- , This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (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, solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil absorption system. If high concentrations are detected have the contents of the tank(s) removed by a Septage Servicing Operator (pumper) prior to use. Pump tanks may fill above normal highwater levels prior to startup or due to pump failures. Start up or restoration of power under these conditions is not recommended, as the excess wastewater will be discharged to the soil absorption system in one large dose causing an overload that may result in the backup or surface discharge of effluent and damage to the system. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator (pumper) prior to restoring power to the pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls until normal effluent levels are restored within the pump tank. System start up shall not occur when soil conditions are frozen at the infiltrative surface. Do not drive or park vehicles over tanks or the soil absorption system. 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 treatment tanks and soil absorption system: acids, antibiotics, baby wipes, cigarette butts, condoms, cotton swabs, degreasers, dental floss, diapers, disinfectants, fats, foundation drain (sump pump) discharge, fruit and vegetable peelings, gasoline, greases, herbicides, meat scraps, medications, oils, painting products, pesticides, sanitary napkins, solvents, tampons, and water softener brine discharge. ABANDONMENT When the POWTS fails and/or is oermanentiv taken out of service the follnwnng stops shall be taken to insure that the system is p"rope..Y and safely abandoned in compliance with s. Comm 83.33, Wisconsin Administrative Code: • All piping to tanks, pits and other soil absorption systems 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 (pumper). • 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 the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. ❑ 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 TREATMENT TANKS, PUMP TANKS, AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES OR LACK SUFFICIENT OXYGEN TO SUSTAIN LIFE. NEVER ENTER ANY TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK MAY NOT BE POSSIBLE. ADDITIONAL INSTRUCTIONS: POWTS INSTA LER POWTS MAINTAINER Name 1 z Name Phone - C Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone This document was drafted by the staffs of the Green Lake, Marquette and Waushara County POWTS regulatory agencies in compliance with sections Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM 11 n ONAmer/Buyer CCC LLL ,p 41 Mailing Address !'/ale'Ii~ S ~D/ Property Address o~ (o d (Verification required from Plauning & Zon' g epartment for new, construction City/State 5;,,m er Se l Parcel Identificatt n Number LEGAL DESCRIPTION l CL Property Location,1 11 11 ; Sec. ; T ~~N R~' T, Town of Subdivision Plat'. Lot it Certified Survey Map # , Volume , Page Warranty Deed # (before 2007)Volume , Page Spec house n ye~no Lot lines identifiable yes D no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper I 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 ASPS. 383.52(l) 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 pItunber 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. l/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the i standards set forth, herein, as set by the Department of Safety And Professional Services 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 m ithin 30 days of the three year expiration date. l/we certify that all statements on th' form are true to the best of my/our knowledge. Vwe am/are the owner(s) of the { property described above, by virtue of a w anty deed recorded in Register of Deeds Office. Now jr of bedrooms SIGNATURE . F APPLICANT(S) 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. i (REV. 04112) . y.. y.- ...y t of mr 1 yam.,,.,• vyy..~~ N procue by the St Croix County Board of t ysep t00 R Adjustment, ( 1 OF 3) S ONSgy I LOT 1Y t lrr LOT 5 s4o° oa -Tt7WN f91O.4D - -~r- g `9N0 S > 0~ N88 28'41'E 420.00' 1 1 ~c N88 ZOO1*E 410.72' - - CSM VOL. 11 PAGE 236 n j I 57fl p•coyr~~ LOT 4 t. LOT 1s x w .101 AQ~ff~ CCR -jog if 1J1,040 Sa Fr. N x is 'TiY 10J ACRES !g i Pl g 8 naa0 I TZ000 SYi k Fr. lispp aa•a45te N6828'41'E O 9 34*E 420.00' 3.85' LOr 5 CSM VOL.9, PAGE 2454 LOT 9 T 14 JOYA04ES Lri 1J1,0I0 St2 Fr. ACRES 17 Sa FT ~ l Ig N88'28.41 •E m n ~y - - - - - - - - 420.00' I I N84 23' 8'E ^1 412.97' 1 fJ it + ; ONC ~J 3dSyT/p'( 1 LOT 2 lnr a S01 ACRES .I. ~ ~t3 ~4 N$ I ICI Parcel 032-2163-04-000 Valid as of 03/28/2018 08:28 AM Alt. Parcel #:14.31.19.1396 TOWN OF SOMERSET ST. CROIX COUNTY, WISCONSIN Owner and Mailing Address: Co-Owner(s): DARIN ANDERSEN ANDERSEN, JILL JILL ANDERSEN 4816 105TH LN NE Physical Property CIRCLE PINES MN 55014 Address(es): 2124 62ND ST Districts: Dist# Description Parcel History: 5432 SCH DIST OF SOMERSET Date Doc # Vol/Page Type 1700 WITC 10/18/2017 1055741 / WD 05/26/2004 763903 2581/385 WD Legal Description: Acres: 3.010 05/19/2003 721974 2245/509 EZ-U SEC 14 T31 N RI 9W PT SW SW GAVIN'S ACRES 03/09/2003 714143 9/54 PLAT LOT 4 (3.010AC) more... Plat Tract (S-T-R 40'/41601/4 GL) Block/Condo Bldg 09-054-GAVIN'S ACRES LTS 1/16 032-03 14-31N-19W SW SW LOT 04 2017 Valuations: Values Last Changed on 09/06/2017 Class and Description Acres Land Improvement Total G1-RESIDENTIAL 3.010 45,100.00 0.00 45,100.00 Totals for 2017 General Property 3.010 45,100.00 0.00 45,100.00 Woodland 0.000 0.00 0.00 0.00 Totals for 2016 General Property 3.010 25,000.00 0.00 25,000.00 Woodland 0.000 0.00 0.00 0.00 2017 Taxes Bill # Fair Market Value: Assessment Ratio: 430565 45,400.00 0.9924 Amt Due Amt Paid Balance Installments Net Tax 636.00 636.00 0.00 End Date Total Special Assessments 0.00 0.00 0.00 I 318.00 1 01/31/2018 Special Charges 0.00 0.00 0.00 " 2 07/31/2018 318.00 Delinquent Charges 0.00 0.00 0.00 Private Forest Crop 0.00 0.00 0.00 Net Mill Rate 0.014101854 Woodland Tax 0.00 0.00 0.00 Managed Forest Land 0.00 0.00 0.00 Gross Tax 713.31 Prop Tax Interest 0.00 0.00 School Credit 77.31 Spec Tax Interest 0.00 0.00 Total 636.00 Prop Tax Penalty 0.00 0.00 First Dollar Credit 0.00 Spec Tax Penalty 0.00 0.00 Lottery Credit 0 Claims 0.00 Other Charges 0.00 0.00 0.00 Net Tax 636.00 TOTAL 636.00 636.00 0.00 Interest Calculated For 0312812018 (Posted Payment Payments) Date Receipt # Type Amount Note 02/06/2018 40256; T 636.00 ANDERSEN CHK#6418 HL Key I I IM '13S2BWOS _ I mm 3Z)N3GIS38 N3SH(3NV llif 8 NIUV0 +~aPIIP4aimna~'rn,xx. 9088'bE8'SlL _ _ 6ZL6S IM'SlWA VM36dINJ £S AMH SS3NIS(IB MIL I w c ;:aa r i II ®~a I o ®D°~J z 0 ® }o ®~a ®~a ® Q W WQ z 0 t_ ow LL IM'13S213WOS w r° 6 N 33114341SH N3S83GNV lllf 8 N18VU u ~ s° Q 'vePllnyaz~nMa~'iuvn 90BB '6M'S LL S F 6LL65 IM 'SlIVA VMMZMa ES AMH SS3NISO80SLL I o I n ------------=-=-----------1 z :Oo I: ®I w ::mow w~ :am ® I rTT_T z 0 ® > o u1 . w~ ❑O ~ w l~ Q U 1 ~ IM '13S213WOS ~ --a ~ ~ Q N aslapllncpaz Mml~voea-dfBslL 3JN341S38N3S830NV111f8NIMV4 dZLYS IM'Slltli tlMdddIHJ LS AMH SS8NIS880SLI ~ - - 7,7 ~ so ,ro , - - LU.Y z EE .~L L I.L o ~ m rc p of m P ~ m ' m of-zl . b ~ ti4 m~ ~ A P lF m J. m m ly) 0 5 r< .~-eL a ~ O 9 a o o~ ~~a ~ z U i O Q LL U- 'D 1 IM "13S213W0S 9 " 3ONNISH N3S834NV nr 8 NIHV4 Q n.xx, 9088'dfB'SlL T I I I q dLGYS 1M MI VM3ddIHJ I f AMH su.H,sf oszi - o~? 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Lot 1/ 1/4 T N R E (or Property Owner's Mailing Address Lot # ' Block # Subd. Na or M# City State Zip Code Phone Number City ❑ Vdage .Town Nearest Road 7' J ® New Construction Use. I Residential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement Public or commercial - Describe: Parent materialy Flood Plain elevation if applicable ft. General comments J~ and recommendations: F TP~~-5~_C) ~1S'~ " l I Boring # ❑ Boring pit Ground surface elev. ft. Depth to limiting factory in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure nsistence Boundary Roots GPD/ft s in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. tf#1 * ff#2 J C1. q S i Boring # ❑ Boring Pit Ground surface elev. ft. Depth to limiting factor /5- in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure sistence Boundary Roots GPD/ft 2 in. Munsell Qu. Si. Cont. Color Gr. Sz. Sh. * ff#1 ff#2 3~ s . 5 ~ s~" c~ ' was • • E #1 =130D > 30 < 220 mg/L and TSS >30 < 150 mg/L ;*Elffluent #2600 < 30 mg/L and TSS < 30 mg/L CST Nam ~ Prin( Signa / CST Number Address Date Evaluation Conducted elep one Number SBD-8330 (RI 1/11) Property Owner .LCJ;r __5 Parcel ID Page ~of E - ❑ Boring pit Boring # Ground surface elev. ft. Depth to limiting facEor~ i-- in. Soil RL:a Rate i~ Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPDfft : in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. * ff#1 ff#2 All, 2 ~ 5 , /J ,-7 4 ~ t ❑ Boring Boring # ❑ pit Ground surface elev. ft Depth to iimiring factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Z~onsistence undary Roots GPDIft z in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. * ff# t * i#2 a w El Boring ~a ❑ Bonng # Ground surface elev. R Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture structure onsistence Boundary Roots * ff#1 GPD/ft in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. Effluent #1 = BOD b > 30 1220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD a < 30 mg/L and TSS 30 mg/L The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. S@D8330 (R I Ul 1) Property Owner dJCJi=~s~ > % Parcel ID # Page . ~ of M Baring E] Boring Pit Ground surface elev. 97 ft. Depth to &miting factor in. Sod Application Rate # Horizon Depth Dominant Color Redox Description Texture Structure onsistenc® oundary Roots GPD/ft s in. Munsell Qu. Sz. Cont_ Color Gr. Sz. Sh. ff#1 ~ q O q F-1 Baring # Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Solt Application Rate Horizon Depth Dominant Color Redox Description Texture Structure nsistence Boundary Roots GPDin. Munsell Qu. S z. Cont. Color Gr. Sz. Sh. ff# l r~ Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure onsistence Boundary Roots GPD/ft 2 in. Munsell Qu. Sm Cont. Color Gr. Sz. Sh. * ff#1 * ff#2 * Effluent #1 = BOD 5 > 30:< 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD a < 30 mg/L and TSS < 30 mg/L The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. 5BD-8330(R11111) Iq - -z I ~ F v e f ~ I T X 1 i Ilil fllllll II IIII ii !III State Bar of Wisconsin Form 1-2003 8 4 7 7 1 1 6 WARRANTY DEED Tx :4402400 1055741 Document Number Document Name BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI THIS DEED, made between K°t=., LLC, a Wisconsin Limited Liability Company 10/ 18/ 2017 11:07 AM ("Grantor," whether one or more), EXEMPT#: and Darin AndersatrInd Jill iIlIjMnff, husband and wife REC FEE: 30.00 ("Grantee," whether one or more). TRANS FEE: 129.00 Grantor, for a valuable consideration, conveys to Grantee the following described real PAGES: 1 estate, together with the rents, profits, fixtures and other appurtenant interests, in St. Crois County, State of Wisconsin ("Property") (if more space is needed, please attach Recording Area addendum): Lot 4, Gavin's Acres, a County Plat in the Town of Somerset. Name and Return Address Attorney Kristina Ogland Estreen & Ogland Darin Andersen and Jill Andersen 304 Locust Street Hudson, WI 54016 32-2163-04-0000(PID) 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: easements, restrictions and reservations, if any, of record. Dated K°g, LL , y: * (SEAL) (SEAL) *Mic ael * (SEAL) (SEAL) *Kristina Ogla AUTHENTICATION ACKNOWLEDGMENT Signatures Michael GPT tina Oland authenticated on STATE OF ) ss. COUNTY *Attorne avid s TITLE: MEMBER ST F WISCONSIN Personally came before me on (If not, the above-named authorized by Wis. Stat. § 706.06) to me known to be the person(s) who executed the foregoing instrument and acknowledged the same. THIS INSTRUMENT DRAFTED BY: Attorney Kristina Ogland Estreen & Ogland 304 Locust Street, Hudson, WI 54016 Notary Public, State of My Commission (is permanent) (expires: ) (Signatures may be authenticated or acknowledged. Both are not necessary.) NOTE: THIS 1S A STANDARD FORM. ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED © 2003 STATE BAR OF WISCONSIN FORM NO. 1-2003 » Type name below signatures. INFO-PROT' Legal Forms 800-655-2021 www.infoproforms.com St. Croix County 1055741 Page 1 of 1