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HomeMy WebLinkAbout022-1080-80-050 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 515076 0 GENERAL INFORMATION (ATTACH TO PERMIT) 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 X Township Parcel Tax No: King, Nolan D. I Kinnickinnic, Town of 022 - 1080 -80 -050 CST BM Elev: Insp BM Elev: BM Description. , , Section/Town/Range/Map No: 28.28.18.439C20 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER — w CAPACITY STATION BS HI FS ELEV. Septic , L .�•, Z. f Benchmark (y g- .7- lG Dosing pi Alt. BM � .., f .. Aeration , Bldg. Sew er Holding = ... St/Ht Inlet � > 1 - 1 I •t A TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Inj6ke ROAD Dt Inlet Septic Dt Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover PM Model Number 77, , / / ri ,! , / f '7 IL ( F2 TDH Lift Friction Loss System Head TDH Ft Forcemain Length 'a: Dist. to well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO ' ` P. 18 LIYG I IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipes) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded j xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes @ No 0 Yes 0 No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / hinspection #2: Location: 1119 Pine Ridge Drive River Falls, WI 54022 (SW 1/4 NW 1/4 28 T28N R18W) NA Lot 4 Parcel No: 28.28.18.439C20 1.) Alt BM Description 2.) Bldg sewer length = - amount of cover = Plan revision Required? Yes No ___ET Use other side for additional information. Date Insepctor's Signature Cert. No. SBD -6710 (R.3/97) e Safety and Buildings Division County � 201 W. Washington Ave., P.O. Box 7162 S'r, CY Madison, WI 53707 - 7162 (608) 266 -3151 Sanitary Permit N be filled in by Co.) �o Number (to Department of Commerce _57 / Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privacy law, sl5.04(bvaCF Project Addres (if different than mailing address) I. Application Information - Please Print All Informati n Property Owner's Name vvV ii, �1 b Parcel # Lo Block # / a - ��"��'T CFZOIX COUNOFFIC ll Property Owner's Mailing Address PL Property � r� c �� k Vt /., � /<, Section City, State n / � � ^�— ]] Zi p C Number (/ q� li QSL W_ 5"0�� �.%��I� T Zt7 N; R , I _ I , . T / yne of Building (check all that apply) � ,y `" a^ n bdivisi jExi stin g Y or 2 Family Dwelling - Number of Bedrooms 12.Q/ t 4 �(� Suon Name mber El Pub] ic /Commercial - Describe Use v, -7 l State Owned - Describe Use ❑City_ ❑Village o � NIC III. Type of Permit: (Check only one box on line A. Complete line B if applicable) El New System El Replacement System El TreatmentJHolding Tank Replacement Only Other Modification to " ►- B• 11 rm Peit Renewal en ❑ Change of ❑ Permit Transfer to New nit Revision List Previous Pennit Nuued Before Expiration Plumber Owner Gam') /2 / - 7 S_ 7 J vv t(w� IV. T e of POWTS S stem: Check all that apply) T7 - f/S 5 / 0 on - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade h Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In -Grow ❑ Holding Tank El Peat Filter El Aerobic Treatment Unit El Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter thing Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation D.S /200 /Z /Z. f VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons ofUnits Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank 2 / / n ^ , Aerobic Treatment Unit CJ� 5 DosingChaotber VII. Responsibility Statement- I, the undersigned, assume responsibility for install POWTS shown on the attached plans. Plum is Name (Print) lumber' Signature M PRS Nu Business Phone Number P Plumber's Address (Street, City, State, Zip Code) 6 7 . Gf .S �fQ rppro ,ount /De artme it Use O El Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing A Si azamps) Surcharge Fee} er en / L ❑Owner Given Reason for Denial `' ..�� ((,,// IX. Conditions of Approval /Reasons for Disapproval , I. - p Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) C C Z p O ML CO s� ° w V O �p Q U) E "» @gym �. lb i O = W p O O .Yf W E Cf H V g� efa c r a w w O v > m ° no ° aZ' ie'� Z Z L w L LL �L r a Q O = I.- O1-.e1- aV a � � Z I OWO � Z W w w O (o L Z J W N > c� w w N Q Z _ W � ~ D cn _ � C.) � � Z C.) Z � J J w V w Z Z � o " J oC z O m O w st _ I — LL I-- N ti in► z ., O z (� O W w v � _ FM w W co j � N FL Z �O� W w u -j — � L. OWO O'eo w ❑ w ZZNO a m� :) �: Z JQwz = >A N C,-/ l 1 q �G 0 96 a' s7B_ 4 7! I 7t&( ` tf r n N O y T n C d f c o d fD m a m v T a C I fn T .Z1 N O 0 N O eI • C7 ,rp d `< N i:b j O N .... 3 N c f0 7 N Ul Z x o o m w p cn O O � ° 3 :3 ! o N 0 ' 3 y m ',i f 0 0 p c � o t ° Z D m CD D ca N a � I 1�► o W d c0\n corm lot CD ° y O. z N zt N N " O O O .Z1 '.,.. N p c !1 o � Z '0 * * `2 I < p Z c O O to \ 2 y T A N CD .. W * z � Z o0 0 O ' R ° � j N C N N• N N I l l V q CD r - N CD o►q O fn � T *_ O Q O C Z m N � Il k 'OQV vc� E ; D / ^ 3 �m N o o cl CD o ?con p a c �D a C OF �p N A 7 O_ O ? 7 7 N C O O 3 m v ( y N CD A N N 0 N � 7 n O ( d j a r I fD 7 N N N= N =3 n �. n o CD n CD y 0 O O a � N _ O C N A N DD O A tv O'C V EA 0 O O CD , a I • Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT sanitary Permit No: (ATTACH TO PERMIT) 506175 0 GENERAL INFORMATION 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 X Township Parcel Tax No King, Nolan I Kinnickinnic, Town of 022- 1080 -80 -050 CST BM Elev: Insp. BM Elev: BM Des ription: , r Section/Town /Range /Map No 0 of S 28.28.18.439C20 TANK INFORMATION ELEVATION ATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. l Beachmark •rr /, 3 9g 1 /0 L d Alt. BM H 1— 2 2't1 � � •� �Qd - I� Aeration der Sc q v Holding SUHt Inl f, �t✓ yid 6 ✓ G3 TANK SETBACK INFORMATION &tt Outlet 6 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD t !Aeration tic Dt Bottom i i g a Header /Man. • 3 12. Dist. Pipet^ p r. L ding Bot. System jo 2 t 7l- zy ce .2 Final de G PUMP /SIPHON INFORMATION RiV-1 7 � �� Q g17 �7 9/ e' 23 Manufacturer Demand St Cover 2 l 00. 7 GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Len Dia. Dist. ll SOIL ABSORPTION SYSTEM BED /TRENCH Width i Length No. Of Trenches PIT DIMENS No. Of Pits Inside Dia Liquid Depth DIMENSIONS 3 SETBACK SYSTEM TO P/ BLDG WELL LAKE /STREAM LEACHING Manuf c r INFORMATION CHAMBER O It O Type 91 System: L *> t� l Model Numb I D IBUTIO S STEM 7 ////-- Header/ anifold < C f A t o Distribution i x Hole Size FHole p acing Vent to it Intake Pipe(s) 1 — Lengt Dia Length I Dia � Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded j xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil I 1 Yes No I I Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: J 1— / ' / Inspection #2: / / Location: 1119 Pine Ridge Drive River Falls, WI 5_4022 (SW 1/4 NW 1/4 28 T28N R1 8W) NA�L�otLp4 ..f���439GZ[) 1.) Alt BM Description = i� l�'t�M1hQK' .�" "`(�/}+- /�-� !/�`rfi 126e SGI��r�arr 2.) Bldg sewer length =/ ow � amount of cover = . _ails Z Plan revision Required? Yes , No /� ©–� Use other side for additional information. Date Insepctor's Signature Cert. No. SBD -6710 (R.3/97) =and gs Division Count 20., P.O. Box 7162 CO�SI 07 - 7162 Sanitary Permit Number (to he tilled in by Co.) 151 Im 5 in (P 1 7 5 Department of Commerce e Plan LDpNmber Sanitary Permit Application A In accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Address (if different than p mailing address) 1. Application Information - Please Print All Informa ' R Property Owner's Name Parcel # Lot # Block # 10-Al �. / / MAY 0 1 2007 ©;, 2 -Soso - 46 49 50 At Property Owner's Mailing Address Property Location . 13 _ 2,6 / ST. CROIX COUNTY m 7 /7 l 7 �O crz rt _57c (1) y., W'/., Section 2 City, State Zip Code urr >er r e, i' Fa �S W� y0� 6 71 7; (circle one) T � N; R1�E o �1 11. Tyse of Building (check all that apply) ak � L' Subdivision Name CSM Number I or 2 Family Dwelling - Number of Bedrooms 7 ©� /s� S` �' G S r ❑ Public /Commercial - Describe Use �to- �'""�- // ❑ State Owned - Describe Use 7 Qa5� � " j�5 L,) / 9 Z6 G 1 wv1 er-, ❑City_ ❑Village 91 of i AI N r c ({ ) ( III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑Permit Renewal El Permit Revision ❑Change of 11 Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Ow IV. Type of POWTS System: (Check all that apply) — a i I 7 , i;; 7 t_ 5Z 4 o ❑ Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 ut. o surta a soil ❑ At -Grade ❑Single Pass Sand Filter El Constructed Wetland ❑ Pressurized In-Ground El Holding Tank ❑ Peat Filter El Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter L7 Leaching Chamber El Drip Li ravel -less Pipe explain) V. Dispersal/Treatment Area Information: 9 Design Flow (gpd) Design Soil Application Rate(gpdsf) Disperse rea Proposed (sf) System Elevation 600 - ©, 5' '2 0 0 / � 1,-2-9 ✓ ?/, 5 NIL Tank Info Capacity in Total Number Manutacturer Prefab Site Steel Fiber Plastic - Gallons Gallons of Units 9 Concrete Constructed Glass New Existing I Tanks Tanks Septic. or I-loldinc lank (l Om� Aerobic TreanncntI.'ml Dosing Chamber N Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signature MP /MPRS Number Business Phone Number �8/ 7171/ 3 32 z Plumber's Address (Street, Cily, State, Zip Code) /7' W VIII. Counhh/De artment Use Only }r3/ phrovcd Disap d Sanitary Permit ee (includes Groundwater Date IZ d Issuit gent Signatur (N s) Surcharge Fee) 7L/ . ^� C � r Given Reason enial C � c � J IX. Conditions of Approval /Reasons for Disapproval SYSTEM OWNER: 3, "` �e 1. Septic tank, effluent fitter and E r C a �� t P l w 4-C. dispersal call! ser must all be vices I makdkyw og r e as per management plan provided by Ounber. 2. AN sa tech requirements must be maNt einrd CO- as pair aPPNC*b oode / mdNgnces. Attach complete plans (to the County only) for the system on paper not less than 81/2 x I t inches in size SBD -6398 (R. 01/03) • I+ � VIII i IIIIII IIIIVIIIIIII I IIII (IIIIIIII IIIIII I * 8 4 9 7 9 2 1* Document Number Document Title 849792 KATHLEEN H. WALSH St. Croix Count REGISTER OF DEEDS Y ST. CROIX CO., WI RECEIVED FOR RECORD Occupancy Affidavit for a single POWTS 05/04/2007 08:OOAM servicing Two Dwellings via PIMS AFFIDAVIT EXEMPT N REC FEE: 11.00 Name — (Owner) Typfi or printed COPY FEE: 2.00 being duly sworn , states, under oath, that: PAGES: 1 1. He /she is the owner /co -owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume 2— Page 3 4/4' Document Number _7-3y- St. Croix County Register of Deeds Office: Recording Area A parcel of land located in the (a t /4 of the �^ t /4 of Section 2 , Name and Retur , caress T N — R /R W, Town of 11 1'N N , L k i N /q I G Na /0'V ' _ ' h7� , o` St. Croix County, Wisconsin, being duly described as follows S O - 4 $ r n o �3. (include lot number and subdivision /CSM or detailed legal 2 _ /e p µ h CCr7"; �1 Eta S ct N d� /r!a descrip L..af" / y o Y P � ` � Parcel Identification Number (PIN) �N Yo 4 am ' -5 et rev t- g -EX0'7) o CEl -`, - f E'd s i VEy 177W PA 461F / '4 S DOC'CN, XP'f /11 arms &/- 7 :2 As owner of the above described property, I acknowledge that a Private On -site Wastewater Treatment System ( POWTS) serving the primary residence is sized for _6 bedroom(s) with a design wastewater flow of t9, gallons /day. (DWF calculation based on 150 gpd /bedroom @ 2 personsibedroom). Two dwellings will be connected to the POWTS via Private Interceptor Main Sewer (PIMS) in compliance with Comm 82.30(12). A maximum of )Y occupants are permitted. There are currently a total of __*_ occupants in these residences, therefore the POWTS can be considered code - compliant at this time. However, I understand that if the number of occupants exceeds the maximum for POWTS design, the system will be undersized to accommodate any increased wastewater flows and /or contaminant loads and may be subject to premature failure. I also acknowledge that i will disclose this information to any partie purchasing this property in the future. <``� •'�'� R Dated this 1 - 7 day of : S OS A * * � , AU 0 �� sustsg� AUTHENTICATION AAeICNOW NT Signature(s) STATE OF WISCONSIN ) k�e&i )ss. St. Croix County. ) authenticated this day of Personally came efore me this � day of �- '; the above named a f TITLE: MEMBER STATE BAR OF WISCONSIN to me known (If not, to be the person(s) who executed the foregoing instrument and acknowledge the same. � i S'65 'saptlnl.S ul.cruiosl� as ulp.roao.r arpatlt oy 0� pun ruaurn:�op .rno�i of a8nd auo sppn aYnd 4 .ranoo .clyl fo dsn :: atop/ ludtunaop p fo sa2nd lnuop!ppn uo paon ay nntu .ro ruaunroop ayl a8nd is rff s ! yi uo paoald dq Kour 'old 'uolJdl.rosap 1n4al 'sdsnnlo 8u S ayl sn yans uollntu ro il! ,raylp '(pa.nnbar ft1 �'jd pill) 'ssa.rppn u.rnla7 g alums 'ajl!7 ludianoop :.ronpvgns aq pala/durod aq lsntu uo!nnu.rofir! S!µll { AAtotv3m - IVD l SIN1 do.L2lVd SI 99Vd SIN11, { J� _ al>?Q :31up ('X'L'Ssaoau IOU ;)lu 4102 uoljuiidxa ajs ;s `;ou - Iuauuuuad sl uoissiuiwo /Cyr - pa2polmouxap. ao pajeaijuagjne aq / C m sa.znjuui�is) f uisuoas►A jo ojejS `oilgnd X-IMoN t Ni N17 oY '�� / AS GUTAVdQ SVM IN3MI'd SNI Slxi CSIMS •S1 `90'90L § Xq pazuogjm,, / A/j AlolaN����� , --Ad p Dec JA G /1 e�w rxA Guzs o U sir I WO o � 0 s \lN 9 'T- 2068 Wisconsin Department of Commerce SOIL EVALUATION REPORT page 1 of 3 Division of Safety and Buildings in accordance with Co4Plan 5, Wis. m. County A.C.E. Soil & Site Evaluations Attach complete site plan on paper not less than 8% x 11 inches in sizem St. Cr oix include, but not limited to: vertical and horizontal reference point (BM), a percent slope, scale or dimemsiors, north arrow, and location and dfst t road. Parcel I.D. 0 - 108 0 -050 Please print all information. Rev' By Date Personal information you provide may be .1 .04 (1) (m)). S 7 D 7 Property Owner operty Location Nolan King .l.ot SW 1/4 NW S 28 T 28 NR 18 W Property Owner's Mailing Address t # Block # Subd. Namb or CSM# 817 South Main Street 4 CSM Vol. 17, Pg. 4619 City Stat hone umber City _J Village ✓J Town Nearest Road River Falls W- 23 Kinnickinnic I Pine Ridge Drive 0 New Construction Use: !#1 Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD J Replacement J Public or commercial - Describe: Parent material Glacial Outwash Flood plain elevation, if applicable na General comments and recommendations: Site suitable for conventional dispersal cell at 0.5 gpd loading rate. Recommended system elevation to be 91.25'. E Boring # J Boring Pit Ground Surface elev. 93.08 ft. Depth to limiting factor 76" in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P in. Munsel Qu. Sz. Cont. Color Gr. Sz. Sh. -Eff#7 - Eff #2 1 0 -8 10yr4/3 none Ifs 0 sg ml cw 2fmc 0.5 1.0 2 8 -17 10yr3/3 none Ifs 0 sg ml cw 2f,1mc 0.5 1.0 3 17 -33 10yr4/3 none Ifs 0 sg ml gw 2f,1 me 0.5 1.0 4 33-51 10yr4/6 none Ifs 0 sg ml gs lfmc 0.5 1.0 5 51 -76 10yr5/4 none Ifs 0 sg dl aw 1fm 0.5 1.0 6 76 -86 10yr5/4 m2p 7.5yr5/8 fs 0 sg dl - - 0.5 1.0 all, It Boring # -. Boring 10 Z Pit Ground Surface elev. 94.01 ft. 90 in. Depth to limiting factor Application Rate Horizon Depth Dominant Color Redox Description Texture Stnnctuure Consistence Boundary Roots In. Munsell Qu. Sz. Cont. Coke Gr. Sz. Sh - Eff#1 - E 1 0 -16 10yr4/3 none mixed fill na mvfr as 2fmc 0.0 0.0 2 16-43 10yr3/3 none Ifs 0 sg ml cw 2f,lmc 0.5 1.0 3 43-57 10yr4/6 none Ifs 0 sg ml cw 2f,1 m 0.5 1.0 4 57 -86 10yr5/6 none s 0 sg ml cw - 0.7 1.6 5 86 -102 10yr5/6 c2d 7.5yr5/8 s 0 sg dl - - 0.7 1.6 z5 . 3 r - Effluent #1 =BOO? 30 < 220 mg/L a TSS >30< 150 M #2 = BOD < 30 mg/L and TSS a 30 mg/L CST Name (Please Print) Signature: CST Number James K. Thompson 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceol , 154020 4/6/2007 715- 248 -7767 Property Owner Nolan King Parcel ID # 022- 1080 -80 -050 Page 2 of 3 F3 ] Boring # J Boring V1 Pit Ground Surface elev. 94.39 ft. Depth to limiting factor 74" in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Mansell Qu. Sz. Cont. Color Gr. Sz. Sh. I *Eff#1 *Eff#2 1 0 -14 10yr3/3 none Ifs 0 Sg ml Cw 2fmc 0.5 1.0 2 14 -33 10yr4 /3 none Ifs 0 Sg ml Cw 20mc 0.5 1.0 3 33 -49 10yr4/4 none Ifs 0 Sg ml gw 2f,1 me 0.5 1.0 4 49 -74 10yr5 /4 none fs 0 Sg ml gs 1 f 0.5 1.0 5 74 -82 10yr5/4 c2d 7.5yr5/8 fs 0 Sg dl - - 0.5 1.0 F-1 Boring # I Boring _J Pit Ground Surface elev. ft. Depth to limiting factor in. SoN Application Rate Horizon Depth Dominant Color Redox Description Texture Stn dure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # I Boring J Pk Ground Surface elev. ft. Depth to limiting factor in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Ef1#1 *Eff#2 ' Effluent #1 = BOq > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 m and TSS <30 mg/L s _ _ g/L s The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608-266-3151 or TTY 608- 264.8777. SBD -8330 (R.07 /00) A.C.E. SOU & Site Evalueflom l v • �ocG��flroyO. S Sate c/al"a • EXis,�iT de e 4e Es le "A "`w6d v "0-ap" /o t 5/ Cs m dal /7 , y6✓9 (� S W, yV/7 J� Sec. lzBrt, /Bu) 7n. o��n.r�.� 'Od OZA /0,0 ! -bc cwx :a .h I� �;ooded �r 8 ti &e . T o4'drip e l e ct -7 h S ;d .4ssapndc/ / y bl o dr; dLuJay �u� /d�M N � • U � `� cvcDded 9G x' � 1 i i �d lop� I � � I � f uow vadv ' all a�iS �' /.'n9 � ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer o � t4 _ �i /V 9 Mailing Address 01 &.2 " ee� Property Address ///9 (Verification required from Panning & Zoning Department for new c 20G�ation.) City /State �; d sy 0 Parcel Identification Number d _-z 2 _ X V& — 0 - 6,5 LEGAL DESCRIPTION Property Location S IN '/4 , N W '/4 , Sec. ;2$ , T 24 N R lS Q Town of �/ NN I C I'C Subdivision , Lot # Certified Survey Map # 7 2 , Volume 17 ,Page # y 6 (9 Warranty Deed # YO S 7 IF , Volume 2 g 8 , Page # �y2 Spec house yes no Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists 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. I /we 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. Number of bedrooms SIGNAT OF ANT(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. (REV. 08/05) 7 4 1 2 1 1 VOL 7 PAGE 4619 KATHLEEN H. WWLSH _ - REGISTER OF DEEDS ST. CROIX CO.. MI RECEIVED FOR RECORD 09/25/2003 08:00AM CERTIFIED SURVEY MAP REe FEE. 11:3.00 COPY FEE: 3.00 CERTIFIED SURVEY MAP PAGES: 2 LOCA I N THE SW I i4 OF THE NW 1 i4 OF SECTION 28, T28N, R 18W, TOWN OF K I NN I CK I NN I C, ST. CRO I X COUNTY, WISCONSIN. (BEING LOT I OF C.S.M. VOLUME 6, PAGE 1746). eREEAR£D FOR: mnTF: BEARINGS ARE STEVEN CUDD APPROVED REFERENCED TO THE WEST ST. CROIX COUNTY L A j � I NE OF THE NW I e4. Planning Zoning and Parks Committi ECORD BEAR 1 NG ). S E P 2 5 2003 NW CORNER OF SECTION T \ - 28, T28N, R t 8W. if not recorded within 30 days of ( FOUND ALUMINUM CAP approval date approval shall be MONUMENT ). null and void P.. l NE - P..G-f, I. � G �. -•' Q,.• pg.: 33 - � i 33' 5.? 33 33' ' \ N88' 47' 20" E 657.63' p • ....................... o moo• N88.47' 20'E ! 33. 00': 6 HIGHWAY SETBACK LINE --"... 100. LOT 3 ;� „ l "' 'n n 6. 16 ACRES n gl MANMADE 268, 309 SO. FT. y 1 5. 74 AC. EXC. Ri1VO g =y �� a : POND 250, 032 SO. FT. -c : CA :nl m I + N LOT �I 4 N, x: 4a \1 5.15 ACRES ca ! I 224,239 SO. FT. 5.14 AC. EXC. RiW 223, 862 SO. FT. ! I v Z 1B' ............................ 3 I 33. 4". N90 00' 00' W 891. 18' n r n ! ! I C E R T I F I E D SURVEY "MAP VOLUME 2 :a 4 {{ zl PAGE 345: J- 0.T...� ulc" W 1,e4 OF SECTION T2 R18W. (FOUND ALUMINUM \SC / ti CAP MONUMENT). JAMES M. O SET I' O.D. X IS' IRON PIPE WEBER HIE / GH ! NG I . 1 3L BS PER L 1 NEAR FOOT. 8-1804 82RW10 V � c Y. • - 1' IRON PIPE FOUND. �' Vol O Q` 1 " -200' �O v�••L JAMES M. WEBER S -1804 O 100 200 400 SHEET I OF 2 LANDMARK SURVEYING, INC. 2003046 THIS INSTRUMENT DRAFTED BY JIM WEBER DATED Vol 17 Page 4619 80574'3 U, 2883 P 542 KATHLEEN H. WALSH STATE BAR OF WISCONSIN FORM 2 - 2000 REGISTER OF DEEDS ST. CROIx CO. MI Document Number WARRANTY DEED RECEIVED FOR RECORD This Deed, made between Steven G. Cudd and Gail L. Cudd 09/08/2005 08:00AN husband and wife Grantor, and Nolan D. King Grantee. WARRANTY DEED Grantor, for a valuable consideration, conveys and warrants to Grantee EXERT # the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): REC FEE: 11.80 LOT FOUR (4) OF CERTIFIED SURVEY MAP IN VOLUME TRANS FEE: 435.00 COPY FEE: SEVENTEEN (17) OF CERTIFIED SURVEY MAPS, PAGE 4619, AS CC FEE: DOCUMENT NUMBER 741211, /FILED IN ST. CROIX COUNTY PAGES: 1 REGISTER OF DEEDS OFFICE ON SEPTEMBER 25, 2003, BEING LOCATED IN THE SOUTHWEST QUARTER OF THE NORTHWEST QUARTER (SW 1/4 OF NW 1/4) OF SECTION TWENTY EIGHT (28), TOWNSHIP TWENTY EIGHT (28) NORTH, RANGE EIGHTEEN (18) WEST, TOWN OF KINNICKINNIC, FORMERLY PART OF LOT 1 OF CERTIFIED SURVEY MAP IN VOLUME 6, PAGE 1746, AS Recording Area DOCUMENT NUMBER 419476, FORMERLY KNOWN AS LOT 3 OF CERTIFIED SURVEY MAP IN VOLUME 2, PAGE 345, AS Name and Return Address DOCUMENT NUMBER 338318. Subject to Liberty Road right of way. NoIQn lam. Kin Q� g1 h �D • /Y�Ei� �" (plo FkA. W/ ?46 022-1080-8"50 Parcel Identification Number (PIN) This jLMg homestead property. (is) (is not) Exce ptions to warranties: easements, restrictions and rights of way of record, if any. Dated this Im day of September, 2005 * * Steven G. Cudd Al * * Gail L. Cudd AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) ss. ,. PIERCE Countv. ) ,a�entii4 ailig day of tf? . .......... Personally came before me this day of CHARLM A. LARSON September 2005 the above named tl Notary Publ Steven G. Cudd and Gail L. Cudd .-' State of Wisconsin ;TIT TATE BAR OF WISCONSIN t • • no t„•' �.� to me known to be the verson(s) who executed the foregoing 4 4 4.( ' Mtjt+ialr3 'v 5706.06, Wis. Stats.) ins nt and ack ged the same. T)-IIS INSTRUMENT WAS DRAFTED BY (l Joseoh D. Boles - Attorney at Law River Falls, WI 54022 Notary Public, State of W1 My Commissio is ve anent. (If not state exviration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) � / &0q ) * Names of persons signing in any capacity must be typed or printed below their signature. INFO -PRO (800 )655 -2021 w Jnfoproforms.com STATE BAR OF WISCONSIN WARRANTY DEED FORK/ No. 2 - 2000 1 CURVE DATA TABLE Curve No. Radius Central Angle Arc Length Chord Length Chord Bearing 1 -2 80.00' 124 173.71' 141.54' S63 "E Lot 3 80.00' 57 16" 79.85' 76.58' S29 0 48' 18 "E Lot 4 80.00' 67 93.86' 88.57' N87 0 59'25 "E Tangent Bearings: At 1 =SO1 0 12'40 "E At 2= N54 "E DESCRIPTION A parcel of land located in the SW '/4 of the NW '/4 of Section 28, T28N, RI 8W Town of Kinnickinnic, St.Croix County, Wisconsin, being Lot 1 of Certified Survey Map recorded in Volume 6 of Certified Survey Maps, Page 1746, more fully described as follows: Commencing at the NW corner of Section 28, T28N, RI 8W: Thence SO0 °57'00 "E along the west line of the NW '' /,, 1428.73' to the POINT OF BEGINNING: Thence N88 ° 47'20 "E 657.63'; Thence southeasterly 173.71' along the right -of -way line of Pine Ridge Drive, also being the arc of a 80.00' radius curve concave northerly and having a long chord that bears S63 "E 141.54'; Thence N88 °47'20 "E 106.25'; Thence SO 1'08'14"E 514.14'; Thence N90 °00'00 "W 891.18' to a point on the west line of the NW '/, of said Section 28; Thence N00 °57'00 "W along said line, 561.31' to the point of beginning. Contains 11.31 acres subject to Liberty Road right -of -way and any and all additional easements, right -of -ways or conveyances of record. SURVEYOR'S CERTIFICATE 1, James M. Weber, registered land surveyor, hereby certify: That in full compliance with the provisions of Chapter 236.34 of the Wisconsin Statutes and the provisions of the St.Croix County Subdivision Ordinance and under the direction of Steven Cudd, owner, I have surveyed, divided and mapped the hereon described parcel of land and that this map is a correct representation of the boundary thereof. Dated this Z day of , .► \ ,2003. _�, 18 JAMES M. James M. Weber 5 -04 WEBER Landmark Surveying, Inc. Note: The parcels shown on this map are subject to State, County an own laws, rules and regulations (i.e. wetlands, minimum lot size, access to parcel, etc.). Before purchasing or developing any lot, contact the St.Croix County Zoning Office and the Town of Kinnickinnic for advice. Sheet 2 of 2 2003046 This instrument drafted by Jim Weber Vol 17 Page 4619 :�kp S f oN L PU4n1 "@'c IQ.6o Eonsin Department of Commerce S ILUATION X REPORT I Page of sion of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County r��'. CZO15C Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan m include, but not limited to: vertical and horizontal reference point (BM), direction Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance ton Please print all informati 4 Rev' a Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner p Property Location l v t ? yJ 114 YJ1 /4 S T N R E(or)W� Property Owner's Mailing Address of # Block # Subd. Name or CSM# City State Zip Code PhoAe°Number City ❑ Village R Town Nearest Road TLWf �Z F(�US IvY1 I S ` (7LS) 14RS- °Z.0'1 1 �I ►.� 1.,1 C \ (Zi tJ ry l C �l►J� 1Z1g6 �j Q New Construction Use: 2L Residential / Number of bedrooms -- y Code derived design flow rate _ 6 0 O GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material (_j L.,6 OU'T N Flood Plain elevation if applicable General comments and recommendations: 2 S 1 �i) �.S , 1 l<1 3 l S �- c) ❑ Boring # ❑ Boring ( � Cody ® i4 l pit Ground surface elev. �� A ft. Depth to limiting factor _ ��` �o�� Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft- 1 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 - Eff #2 93•a z � r Boring # ❑ Boring pit Ground surface elev. , y U 3 fL Depth to limiting factcr 7 't ir,. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 3 3- q5 l U-1 2SA Effluent #1 = BOD, > 30 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD, < 30 mglL and TSS _< 30 mg/L CST Name (Please Print) Signatyre CST Number Arthur L Wegerer oC 03 -1Z e "y 220254 Address W e g e r e r Soil Testing & Design Service Date Evaluation Conducted Telephone Number 421 N. Alain St. River Falls, HI 54022 715 - 425 -0165 Property Owner U�� Ircei ID # nl� l 1tJ G page of Boring # ❑Boring p ® Pit Ground surface elev. L Depth to limiting factor 7 � in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 D —11 ,S 2 313 33 69 ❑ Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon' Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 F-1 Boring # E] Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD > 30 < 220 m 9 /L and TSS >30 < 150 mg /L ' Effluent #2 = BOD, < 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. SBD -8330 (R.N00) + �• PLOT PLAN Page of f Scale 1' =50' L) hJL— s ' z('. wo I Oil t 34 I I i I 3°Iu LET s r - ;4 OL 715-42 220254 U3_ CST Signature Date Telephone No. CST No. Job '10. - 7 4 VOL 1.7 PAGE 4619 KATHLEEN H. MTiL$H� - - -- REGISTER OF DEEDS ST. CROIX CO., MI RECEIVED FOR RECORD 09/25/2003 08:00AM CERTIFIED SURVEY MAP COPY FEE: 3.00 CERTIFIED SURVEY MAP PAGES: 2 LOCATED IN THE SW 1. OF THE NW 1, OF SECTION 28, T28N, R / 8W, TOWN OF K I NN I CK I NN I C, ST. CRO I X COUNTY, WISCONSIN. (BEING LOT l OF C.S.M. VOL 6, PAGE 1746). PREPARED FOR NOTE: BEARINGS ARE STEVEN CUDD APPROVED REFERENCED TO THE WEST ST. CROIX COUN W t ( LI NE OF THE NW 1- Pla . nMng Zoning and Parka Committi R rt ECORD BEARING). S E P 2 5 2003 NW CORNER OF SECTION T\_ 28, T28N, R I BW. If not recorded within 30 days of I ( FOUND ALUMINUM CAP aPProval data approval shall be MONUMENT). null and void �.P.IpI�. � R.G.& J � �P fgl'►' � °° I 5�`.``J' PG • I I �� `� \�ao I � - I t\L�`� �\��• �.'R, QT... � 33' ! � 33' 0(,`� 33'1 33' N88 20" E 857. 63' \ ....•.... 1 .......... � '624. a o• Na8.47.20" E y I 33.00': HIGHWAY SETBACK L I N ; / 106.25' z z I LOT m I d to I gl z MANMADE 268, 309 SO. FT. 0. 74 AC. EXC. RiM'� • POND 250, 052 so. FT. x �; :D g4• W LOT 4 m ip ICI �' •� .1q \' 5.15 ACRES w 224. SQ. FT. A W - • y \ T o 4 ' S. 14 AC. EXC. Ri1Y 223,962 SO. FT. I I v _5 I 33. 00' NSO.00' 00'W 891. 18 ............. n I C E R T I F I E D D SURVEY' VOLUME 2 . ........... ......................._....... 4.Q.T. ... Z PAGE 345: W /i4 OF SECTION 28. T28N, R I8W. � y Go (FOUND ALUMINUM CAP MONUMENT). JAMES M. O" SET I' O.D. X !8' IRON PIPE WEBER WE 1 GH I NG I. 13L BS PER LINEAR FOOT. 8 ' 10 " • " I* IRON PIPE FOUND. 1'-200' JAMES M. WEBER S -1804 O 100 200 400 SHEET I OF 2 LANDMARK SURVEYING, INC. 2003046 THIS INSTRUMENT DRAFTED BY JIM WEBER DATED 1 7 -°\ A� Vol 17 Page 4619