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W iscons i n SOIL EVALUATION REPORT #1691
Department of Commerce in accordance with Comm 85, Wis. Adm. Code Page 1 of 3
Division of Safety and Buildings Steel's Soil Service, Inc.
Attach complete site plan on paper not less than 8'/2 County x 11 inches in size. 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.
028 - 1025 -95 -000
Please print all information. Reviewed By Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location
Clyde Jacobson Govt. Lot na SW1 /4, NW1 /4, S22, T28N, R17W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
257 Cty Rd T na na 80 Acres
City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road
Hammond WI 1 54015 1 715 - 796 -5254 Rush River I Cty Rd T
❑ New Construction Use: ® Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
® Replacement ❑ Public or commercial - Describe na
Parent material Ridges and foot slopes of ground moraines, pitted glacial drift Flood plain elevation, if applicable na ft.
General comments Mound Design, system elevation 101.70ft based on contour line elevation 100.45ft.
and recommendations:
Boring # Z Ground surface elev. 101.15 ft. Depth to limiting factor 40 in. Soil Application ® Ppcation 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
1 0 -14 10yr 3/1 none sil 2msbk mfr cs if .6 .8
2 14 -24 10yr4/4 none sil 2msbk mfr cs na .6 .8
3 24 -40 10yr4 /4 none scl 2msb mfr cs na .4 .6
4 40 -60 5yr4/4 c2d 7.5yr5/6 sl /scl om mfr na na .0 .0
Boring # ❑ Ground surface elev. 101.15 ft. Depth to limiting factor 21 in.
® p 9 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
1 0 -5 10yr 3/1 none sil 2msbk mfr cs if .6 .8
2 5 -21 10yr4 /4 none scl 2msbk mfr cs ivf .4 .6
3 21 -47 5yr4/4 cid 7.5yr5/6 scl 2pl mfr cs na .0 .2
4 47 -53 7.5yr4/4 cid 7.5yr5/6 Ifs osg mvfr cs na .5 1.0
5 53 -60 7.5 yr4 /4 none cos osg ml na na .7 1.6
* Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 m /L * Effluent #2 = BOD s30 mg /L and TSS s mg /L
CST Name (Please Print) Signat r �— --� CST Number
David J. Steel 248956
Address Steel's Soil Service, Date Evaluation Conducted Telephone Number
994 200th St. Baldwin, WI 54002 6/7/2005 715 - 760 -0347
SBD -8330 (R.07 /00)
Property Owner Clyde Jacobson Parcel ID # 028- 1025 -95 -000 Page 2 of 3
F3 ] Boring # ❑ 98.95 ft. Depth to limiting factor
® Ground surface elev. 9 33 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
1 0 -12 10yr 3/1 none sil 2msbk mfr Cs if .6 .8
2 12 -24 10yr4 /4 none Sid 2msbk mfr Cs na .4 .6
3 24 -33 7.5yr4/4 none sl 2msb mfr cs na .6 1.0
4 33 -60 5yr4/4 c2d 7.5yr5/6 sl om mfr na na .2 .6
❑Boring # El Ground surface elev. ft. Depth to limiting factor in.
El Ground Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPOM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff #2
F-1 Boring # ❑ 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 I *Eff#2
* Effluent #1 = BOD 30 < 220 mg /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.07 /00) Steel's Soil Service, Inc.
STEEL'S SOIL SERVICE INC. 3 of 3
Da vid J. Steel Clyde Jacobson , 994 200` St
CS - POWTSM SWl /4,NW1 /4,S22,T28N,R17W Baldwin, WI 54002.
Li c. #248956 Town of Rash River, St Croix Co. Direct 715 -760 -0347
80 Acres Fax 715- 6843449
Legend N
I" 40v
♦ = Benchmark Ele. 100.00 ft
Top of 3/4" pvc pipe
• = Alt Benchmark Ele. 9516 ft
Top of 3/4" pvc pipe
= Borings
(� Boring Elevations
Bl = 101.15 ft
B2 = 101.15 ft
B3 = 98.95 ft
0.00 ft
� C/ 't3l s ��
yl gZ
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1 s
ST. CROIX COUNTY
WISCONSIN
ZONING OFFICE
N ti w � o k- I ST. CROIX COUNTY GOVERNMENT CENTER
101 Carmichael Road
Hudson, WI 54016 -7710
_--` (715) 386 -4680 FAX (715) 386 -4686
Page _ I of I
COUNTY ON -SITE VERIFICATION FORM
Inspector: 912 Date: 'T� k5h 5
Parc el ID Number p Z $ - 16? - 7 5 - a c)
ropertyOymar r periy oca on
G 4A- J a crotoSo /\ Govt. Lot S w 19 P) W 114 a 22 T 18 N R 17 E (nr
Property er'sMailing Address lot # Block; S.W. Name or CSM#
ZS /
c ity State Zip a Phone umber ❑ Cdy ❑ Villa a own Nearest Road
aw%wk W 54015 ( 715) 695- 505q j9 lti -Z--
❑ New ConsWcd()n User Residential f Number of hadrnoms .._..__.__.,.._ _._._ Code derived design flow rate ., _ _ _..... _._ _ _ GPD
placement ❑ Public orcommerdal - Describe : . ............. _ ...... . ...... _.._.._ ........ ....... .. ........
Parent material _—.__„—_ — ,._.._._,_, � — - - Rood Plain ale°� vn 'rf applicable _ _ _ — ft.
Ge nera l comments c) 5:1�. 4
and recommendations: c 5
r l U
Baring tt ❑ Boring
Pit Ground siuface elev. �B$ Z ft. Depth to limilr ig fbcDrir _ in. Shc Applicatien Rate
Horizon Depth Dominant Color Redox Description Texture Structure ConslMnce Boundary Roots GPDIP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eif#1 "0#2
6- 0 C 3 1 A o -- 5.' 1 Z C-r 65 1 �' • fo S
Zo l bwcql 4 M i^ G Art. ID • 8
46 ier 4L4. CZ 7.5 rP n^ mfiC na • O
Conditions: Poo(' 60: � 6 fa weQQ, 5,yed -ems
Soil Survey description:
Notes:
FEE:
I
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
479382 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal infonnalion you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit HoldBr's Name: City Village X Township Parcel Tax No:
Jacobson, Clyde I Rush River, Town of 028 - 1025 -95 -000
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
/ bb 0A ) T 1 22.28.17.151
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
g• /tom
Septic ` . � 52• /&)C) Benchmark S, 16 S. 5
I
Dosing 5 Alt. BM
Bldg. Sewer � � • � f � � . z
Holding St/Ht Inlet
TANK SETBACK INFORMATION St/Ht Outlet
TANK TO P/ WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic /51 } 206 ,53 '33 Dt Bottom 13.9Z q 74
Dosing ZQ 7 7 z� I 7-, I Header /Man.
Aeration /L, ` Dist. Pipe�5 �az
Holding /�� Bot. System L
Final Grade P
PUMP /SIPHON INFORMATION 35 3.3/
Manufacturer �� Demand St Cover
GPM t + A7• �S
Model Number
TDH
j. 14 3 Li. :5 1 Friction / Loss System HeadFt T z.
(p 62 f 7 1 1 1 ,15 +'4326 Z3
Forcemain Length Dia. / j I Dist. to Well 7 �
Z
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length No. Of ench PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
y.�1 `' 16
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG IWELL LAKE /STREAM LEACHING Manufacturer.
INFORMATION CHAMBER OR
Type S ystem: 1 I UNIT Model Numbed
d v it , :3 �(� 7 7d� /)4-
DISTRIBUTION SYSTEM
Header /Manifold ( l Fistribution f x Hole Size I f I x Hole Spacing Vent to Air Intake ,
I i e s �} —6 7 I P Length Z Length 4a •5 Dia r A Spacing /� a
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over I Depth Over xx Depth of xx Seeded /So ded xx Mulched
Bed/Trench Center CCp Bed/Trench Edges Topsoil
1 J O t �• Yes I: % N J No
COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: — 6 / Z3 / d5 spection
Location: 257 County Road T`am I X15 (SW 1/4 NW 1/4 22 T28N R17W) 40 acres Lot el o: 8.17.151
�x� t%'5 F 22.2
,,� F P
1.) Alt BM Description = C60A,- �,(t6S :5 -J_ G�� �-)— u a -
2.) Bldg sewer length = 34' / 4. ` �' d
- amount of cover = Ins hhhhc)� KKKSSS
l
P)
Plan revision Required? Yes XNo Zr Z� z
Use other side for additional information. �� _ __ - -- ✓
Date Insepctor's Sign a Cert. No.
SBD -6710 (R.3/97)
201 W. VV Ate. P.O. Boot 7162
_ Madieor` VYI
MW-7162
x-79 S? 2_
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STEM OWNER:
1 Septic tank, effluent filter and Q Aa
dispersal cell must all be serviced / maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per applicable coderordinasnc s
AMrdieerMYleM fbtie Novo" aePraet - all itMeindw
SBD -6398 (R. 0 1 /03 �'� �A /Aj = �� C.
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7
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.1110 f�Ap%l
Safety and Buildings
4003 N KINNEY COULEE RD
commerce .Wl.gov LA CROSSE WI 54601 -1831
TDD #: (608) 264 -8777
www.commerce.wLgov /sb/
ent of C
www.wisconsin.gov
isconsin
Departmommerce
Jim Doyle, Governor
Mary P. Burke, Secretary
August 04, 2005
CUST ID No.223475 ATTN. POWTS Inspector
JOE STANG ZONING OFFICE
STANG PLUMBING & ELECTRIC ST CROIX COUNTY SPIA
PO BOX 263 1101 CARMICHAEL RD
WOODVILLE WI 54028 HUDSON WI 54016
CONDITIONAL APPROVAL Identification Numbers
PLAN APPROVAL EXPIRES: 08/04/2007
Transaction ID No. 1159952
SITE: Site ID No. 702137
Clyde Jacobson Please refer to both; identification numbers,
257 County Road T above, in all correspondence with the -agency.
Town of Rush River,
St Croix County
SWl /4, NWI /4, S22, T28N, R17W
FOR:
Description: Three Bedroom Mound System
Object Type: POWTS Component Manual Regulated Object ID No.: 1030732
Maintenance required; Replacement system; 450 GPD Flow rate; 21 in Soil minimum depth to limiting factor from
original grade;
System: Mound Component Manual - Version 2.0, SBD- 10691 -P (N.01 101); Biofilter
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. Cond
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06,
stats.
The following conditions shall be met during construction or installation and prior to occupancy or use: E ARTMEW
N OE
� y
Approval Requirements:
��
SEE CORRI
• This system is to be constructed and located in accordance with the enclosed approved plans and with the
"Mound Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD- 10691 -P (N.01 /01)
and the SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST SAS (0 1/8 1)
• Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area.
Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal
are prohibited.
• The existing POWTS must be properly abandoned per Comm 83.33 Wisc.Adm. Code.
• A Sanitary Permit must be obtained from the county where this project is located in accordance with the
requirements of Sec. 145.135 and 145.19, Wis. Stats.
• Inspection of the POWTS installation is required. Arrangements for inspection shall be made with the designated
county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stat
I
JOE STANG Page 2 8/4/2005
• Comm 83.22(7) A copy of the approved plans specifications and this letter shall be on -site during construction
and open to inspection by authorized representatives of the Department which may include local inspectors
Owner Responsibilities:
• Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and
maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s.
Comm 83.54(1).
• Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as
required under s. Comm 83.54(4) shall be considered a human health hazard.
• Comm 83.55 The owner is responsible for submitting a maintenance verification report acceptable to the county
for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s)
utilized in the POWTS.
All permits required by the state or the local municipality shall be obtained prior to commencement of
construction/installation /operation.
In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should
conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review
shall relieve the designer of the responsibility for designing a safe building, structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above left addressee shall provide a copy of this letter to the owner and any others who are responsible
for the installation, operation or maintenance of the POWTS.
Sincerely, Fee Required $ 175.00
6X/vZ Fee Received $ 175.00
Balance Due $ 0.00
Charles L Bratz
POWTS Reviewer it , Integrated Services WiSMART code: 7633
(608)789 -7893 , 7:45 am - 4:30 pm Monday -Friday
cbratz @commerce. state. wi.us
cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544
.0
MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: Clyde Jacobson 3 Bedroom Replacement Mound
Owners Name: Clyde Jacobson
Owners Address: 257 Cty Rd. T
RECEIVED Hammond, Wisc 54015
JUL 2 12005
SAFETY 8 e aUT g ,. SW 1/4, NW 1/4, S22 T28N, RI 7W
Township: ilVl7i Rush River
County: St.Croix
Subdivision Name: 80 Acres
Lot Number Block Number.
Parcel I.D. Number
Plan Transaction No.:
Page 1 Index and title
Page 2 Data entry
Page 3 Mound drawings
����1� r
Page 4 Lateral and dose tank j at y
Page 5 System maintenance specifications
Page 6 Management and contingency plan °
Page 7 Pump curve and specifications ;�r c-,WAf RCE
Page 8 Plot Plan &' iwc
Page 9 Soil Evaluation Report
'
NCF,
Designer Joe Stang License Number 223475
Date: 07/1 ADS Phone Number: (715) 684 -5166
Signature: D -L
DesOW to the
Mound Component Manual for POWTS Version 2.0 SDB- 10691 -P (N. 01/01), and
SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01181)
Version 4.01 (R. 09/04) Page 1 of 9
� 1
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4,
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a.� .:
;,
` *..'..
Mound and Pressure Distribution Component Design
Design Worksheet
Site Information
(r or c) R residential or Commercial Design Nate: sand ail (0) calcU00na risers a
300.00 Estimated Wastewater Flow (gild) Table $344'3 In-sit sou beetivent for fecal
1.50 Peaking. Factor (e.g. 1.5 = 15096) colifomn of <= 36 hv&m.
450.00 Design Flow (gpd)
6.00 $ite Slope (%) .
100AS Contour Line Elevation (ft)
21.00 Depth to Limiting Factor (in)
0.40 In-situ Soil Application Bate (gpdtft
Distribution Cell Information
95.00 Dispersal Cell Length Along Contour (ft) W 4.74 Cell Width (ft)
1.00 Dispersal Cell Design Loading Rate (gpd/f't)
1 Influent Wastewater Quality (1 or 2) Are the laterals the higEly
in the distribution
Pressure Disribution Information network? Enter Y or N
(c or e) c Center or End Manifold
1 i9 lateral Spacing (ft) If N above, enter the elevation ft
4 Number of Laterals of the highest point.
0.168 Orifice Diameter (in) (e.g. 0.25)
3.00 Estimated Orifice Spacing (ft) = 7.04 ft
2.00 Forcemain Diameter {in)
50.00 Forcemain Length (ft) Does the forcemain drain back? Y
�
A92.00 Pump Tank Elevation (ft) Enter Y or N
3.25 System Head (ft) x 1.3 8.16 Forcemain Orainback (gal)
fi
- 9.20 Vertical. Lift (ft) 61.63 5x Void Volume (gal)
1.80 Friction Lass (ft) 69.78 Minimum Dose Volume (gal)
14.25 Total Dynamic Head (ft) 41.94 System Demand (gpm)
Lateral Diame Selection Manifold Diameter Selection
in. dia. o ions choice In. dig. options choice
0.75 1.25 x
410 1.50 x x
1.25 x x 2,00 x
1,50 x 3.00
2.00 x
3.00 x
Gallons/lnch Calculator (optional)
Treatment Tank Information 750.00 Total Tank Capacity (gal)
1000.00 -Septic Tank Capacity (gal) 37.00 Total Working Liquid Depth (in)
Wieser Manufacturer 20.27 gal/in (enter result in cell 849)
Dose Tank Information Effluent Filter Information
750.001 Dose Tank Capacity (gal) 12awl Filter Manufacturer
20,271 Dose Tank Volume (gal /in) JAIOO Filter Model Number
Wieser Manufacturer
Project: Clyde Jacobson 3 Bedroom Replacement Mound Page 2 of 9
Z6d =GI 90:LI S0 -8Z -L0
Found Plan View
1/L�94�B. • obaerponpipe ;C J
1� ,
.� 4Y• +�YRY• M S'.. Y�
+S•S S S^ r S + S
i . S
� .�Yd',J', rr1'••r•�r.•Y ^ "MY"11: n r. �w•�, ,�n�.r" Y ^n ,.r „�"r- 1'Y�'.lY "•rnr• r -,'. •
,� ”. ^'�Srti ^b• +�y, " Yrr, Y• �f, F ^,5..�,.l�n� ^r.•r.,,. ,.,,:tin w.4• A
rrrr. a•r � "�, .r,••�.r.rYfY�rrr, Yf.rr
lai
L 1 i
. J: r,%'_ n .,�Y; Y•IY:YJan": r; �f �`r.,+' "J�.� -Yr� fr e' �, d', 1' %�';.ir�r� r.rnr� a"•�'•,r r
. , ",
, •.• •, . . ' •'• �i
� .:.
•� • f .•
,•
.,•
Mound Component Dimensions
A 4.74 ft E 18.41 in H 1.00 ft K 9.48 ft
B 55.00 ft F 9.25 in . 1 10.26 ft L 113.98 ft
D� 15.00 M G 0.50 ft J 6.41 ft w 21.41 ft
450.30 (ft) Dispersal Cell Area 1425.78 (11 Basal Area Available
4.74 (gpd/ft) Linear Loading Rate 9.50 (ft) 1/10 B 4bs. Pipe Placement
Mound Crass Section View
Aggregate Dispersal Area
Finished Grade 103.47 (ft) ►
rr H
rrrrrirr 2 rrrr^rrr G
P 0tspersar Cgn 102.20 (ft) Lateral
101.70 (ft) Invert
04etsal Cell c ; [3 1
Elevation E D ::
_ 4
100.45 (ft) Contour Elevation
6.0 % Site Slope
Geotexdle Fabric Cover
Shading Key pispersal Cell See lateral details on
Topsoil Cap 1.5 ft ^ .�. �. w^ .,. Page 4 for number, size,
Subsoil Cap 0 e . s a; r: ",�" : ''" and spacing of laterals.
ASTM C33 Sand; �j�. ;ti r'.� f fir^ F Laterals are equally
EM Tilled Layer � 0.5 ft ��.1Y cal lateral 7rt spaced from the
Y y1+
} tiryY Y t'..•;rYl 1 d' Yd's.' : " I
L31 r•r "r" Aggr"ate v
distribution cells
"• A — �_1 o b uti fne to the
. distr cell (AxE3).
Project: Clyde Jacobson 3 Bedroom Replacement Mound Page 3 of 9
E0d =QI LO: LT SO -SZ -LO
Center Connection Lateral Layout Daigram
Face nWn oonneotran Via too nr nrasx manftl(l at ang Poht Lstwa4s are identbaaf
IFm7urn gplMlbelrra4ve �E i t2�� . f.ataat9�ft�me main of PVC Soh�40
�1 ®gnoutplu� per COMM Tabic.% -W-6
Holes drilled on the bottom of the lateral.
Number of Laterals 4 Orifice Diameter 0.188 in
Lateral Diameter 1.25 In Orifice Spacing pQ 3.12 ft
Lateral Length (P) 48.36 ft Orifices per Lateral 18
Lateral Spacing ($) 1.19 ft Orifice tensity 7.04 tt ce
Lateral Flow Rate 10.49 gpm Manifold Length 1.19 ft
System Flow hate 4i.94 orn Manifold Diameter 1.50 in
Total Dynamic Head 14.25 ft Forcemain Velocity 4,28 ft/sec
Dose Tank Infonmdon Dover wrm wsrNn
lam and Eocl" device and
seared w orfight
E t l as per NEC 300 and .. No
corratt eas w.aa oiacr a in. min. Tw* c ompot�ent I8 p up" v ented = — Alternate oUW ir rar:aaon
Famermin dierWer
Wieser Manufacturer 2 In.
Ca bi 750.00 Gallons �—
Volume 20.27 galrihch A
Weep hole or anti -
I�I artsl n inches Gallons B syphon device
A 19.56 39614
B . 2.00 40.54 PwV aff_e lwavon
C 3.44 .89.78 93.00
D 12.00 243.24 D
Total $7.00 750.00 il -�� Dose tm* ereva >Y
3" Bedding und er WK 1 92.�
Alarm Manuafactumr SJERhombus Controls
Alarm Model Number Enk Alert 1
Pump Manufiacturer Goulds
Pump Model Number 13871 EPO4
Pump Must Deliver 41.94 gpm at 14.25 ft TDH
Prpjed: Clyde Jacobson 3 E3edroom Replacement Mound Page 4 of 8
t0d =QI LO:LT SO -8Z —Le
A„ oou„pd S"-t*M Maintenalce and PRersdon Specifications
Service Provider's Name Joe Stang �� Phone 715- 6845166
POWTS Regulator's Name St. Criox County Zoning Phone 715- 386 -4680
System F-19N and Load Parameters
Design Flow - Peak 450 gpd Maximum Influent Particle Size 118 in
Estimated Flow - Average 300 gpd Maximum BOD5 220 mg/L
Septic Tank Capacity 1000 gal Maximum TSS 150 mg/L
Soil Absorption Component Size 450 ft' Maximum FOG 30 mg/L
Type of Wastewater Domestic Maximum Fecal Coliform >10E4 cfu/100 mL
Service Freauencv
Septic and Pump Tank Inspect and/or service once every 3 years
Effluent Filter Should inspect and clean at least once every 3 years
Pump and Controls Test once every 3 years
Alarm Should test month)
Pressure System Laterals should be flushed and re tested every 1.5 ears
Mound Inspect for ponding and seepage once every 3 ears
Other
Miscellaneous Construction and Materials Ste}, .ndards
1. Observation pipes are slotted and materials conform to Table Comm 84.30 -1, have a watertight cap,
and are secured in as shown in the mound component manual.
2. Dispersal cell aggregate conforms to Comm 84.30 (6)(1), Wis. Adm. Code.
3. All gravity and pressure piping materials conform to the requirements in Comm 84, Wis. Adm. Code.
4. Tillage of the basal area is accomplished with a mold board or chisel plow.
5. The mound structure and other disturbed areas will be seeded and mulched to prevent soil erosion
and help reduce frost penetration.
Lateral Turn -up Detail
Finished • ............. ,.�... ...............
Grade
6-8" Diameter Lawn —� Threaded Cleanout
Sprinkler Valve Box Plug or Ball Valve
Distribution
Lateral
Long Sweep 90 or Two
45 Degree Bends Same
Diameter as Lateral
Project: Clyde Jacobson 3 Bedroom Replacement Mound Page 5 of 9
Mound System Management Plan
Pursuant to Comm 83.54, Ms. Adm. Code
Sal
Cam This system shall be operated in accordance with Co 82-84 Wis. Adm. Code, and shall maintained in accordance with Its! component
manuals )SBO- 10691 -P (N.01/01) and SSWMP Publication 9.6 (01/81)) and local or state rules pertaining to system maintenance and
maintenance reporting.
No one should ever enter a septic or pump tank since dangerous gases maybe present that could cause death.
Septic and Pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no layer used as
POWTS components.
Septic or push tank manhole risers, access risers and covers should be Inspected for water tightness and soundness. Access gw*Vs
used for service and assessment shag be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject
to failure must be replaced. Ehrpow d access openings grWer than 8- inches in diametsr shall be sacred by an effective locking device to
prevent accidental or unauthorized entry into a tank or component.
Septic Tank
The septic tank *0 be mairtalned by an individual certiried to service septic tanks under s. 281.48, Stab. The contents of the septic tank
shell be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet filter shall be assessed at
least once every 3 years by inspection.
The outlet kilter shall be cleaned as nary to ensure proper operation. The titter cartridge should not be removed unless provisions are
male to retain solids In the tank that may slough off the niter when removed from its enclosure. If the fitter is equipped with an alarm, the filter
shall be serviced 9 the alarm is activated continuously Intermittent filter dwrns may kdk*e surge flows or an knpwx*V continuous alarm.
The septic tank shal have its contents removed when the volume of sludge and scum in the tarts owesds 1/3 the liquid volume of the tarts. If
the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the r od
service needs to be perfornred to maintain less than maximum scum and sludge accumulation in the tarts.
The addition of biologic'sl or chemical additives to stance septic tank performance is generally not required. However, 9 such products we
used they shall be approved for septic tank use by the Departs t of Commerce.
mpg Tank
The pump (doekmg) tanks shall be Inspected at least orce every 3 years. AA switches, alarms, and pumps shall be tested to verify proper
operation. If an effluent finer Is installed within the tank it shall be inspected and serviced as necessary.
Mound arid Press" Dishlitiulke
No tram or shrubs should be planted on the mound. Plantings may be mark around the mounds perimeter, and the mound shall be seeded
and mulched as necessary to prevent erosion and to provide some protection from frost penetratiam. Traffk (other then for vegetative
nuftenanoe) on the mound is not recommended since soil compaction may hinder aeration of the Wiltrative surface within in the mound and $now
compaction in the winter will promote frost penetration. Colt weather Insbitations ( October - February) dictate that the mound be heavily mulched
as protection from freezing.
Influent quality Into the mound system may not exceed 220 mgll. BOD mg/L TSS, and 30 mg/L FOG for septic tank effluent or 30 mg/L
BOD 30 mg/L TSS, 10 mg/L FOG, and 10 4 cu/100 mL for highly trued effluent. Influent flow may not exceed maximum design flow specified
in the permit for this Installation.
The pressure won system Is provided with a flushing poled at the end of each lateral, and it is r000mmeded that each lateral be fleshed
of accumulated solds at least once every 18 months. When a pressure testis performed t should be compered to the bills test when the
system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to naltaln equal distribution within the
cell.
Observation pipes within the disperse! cell shall be checked for efthrent ponclkhg. Ponalng levefs shall be reported to the owner, and any levels
above 6 inches considered as an knpadkmg hydraulic failure requiring additional, more frequent monitorkhg.
QggNMNM Pion
If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the systern In proper
operating condition.
If the dosing tank, pump, pump controls, alarm or related wking becomes defective the detective components) shall be k mixilsbly repaired
or replaced with a component of the some or equal performance.
If the mound component falls to accept wastewater or begins to discharge vvastewater to the ground surface, it will be repaired or replaced in
Its! present location by increasing basal area 9 too leekage occurs or by removing biologically dMed absorption and dispersel, and related
piping, and replacing said components as deemed necessary to bring the system into proper operating condition.
See Page 6 of this plan for the name and telephone number of your kx ud POWTS regulator and service provkler.
Project: Clyde Jacobson 3 Bedroom Replacement Mound Page 6 of 9
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W isconsin SOIL EVALUATION REPORT #1691
Depart rent of COmm8m in accordance with Comm 85, Mlia. Adm. Code Page 1 of 3
Division of Safety and Buildings Steers soil service, inc.
Attach complete ails plan on paper not less than a% x 11 inches In size. Plan must County St. Croix
include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.O.
percent slope. scab or dimenimns, north arrow, and location and dletance to nearest road. 02 8-1025 - 95-000
Please print all informstlon. Reviewed By Date
Personal inlomuation you wovide may be used for secondary Wpom (Privacy tom, s. 15.04 (1) (m))•
Pin owner Property Location
Clyde Jacobson Govt. Lot na SW1 14, NW1 /4, S22, 728N, R17W
Property Owner's Mailing Address Lot #i j Block 8 Subd. Name or CSW "
257 Cty Rd T • nil nil 80 Acres
City State Zip Code Phone Number ❑ City ❑ Village [ Town Nearest Road
Hammond WI 1 54015 1 715 -796 -5254 Rush River Cty Rd T
t ,I Now Construction Use: ❑ Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
Replacement ❑ Pubic or commercial - Describe nil
Parent material Ridges and foot slopes of ground moraines, Pitted glacial drift Flood plain elevation, if applicable na ft.
General comments Mound Design, system elevation 101.70ft based on contour line elevation 100.458.
and recommendations:
r r Boring e ❑ Ground surface elev. 101.15 ft. Depth to limiting factor 40 in. Soti Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure ! Consistence Boundary Roots GPD/it=
in. MunseO Qu. Sz Cont. Color Gr. Sz Sh. I `01*1 -gi
1 0-14 10yr 3/1 none sil 2msbk mfr cs if .6 .8
2 14-24 10yr4/4 tone sit 2msbk mfr CS na .6 .8
3 24-40 10yr4 /4 none sd 2msb mfr CS na .4 .6
4 40-60 5yr4/4 c2d 7.5yr5/6 SI /Sd om mfr na na .0 .0
Borft o * Ground surface elev. 101.15 ft. Deoh to limiting factor 21 in. Sort Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDIR'
in. Munsell Qu. Sz. Cont Color Gr. Sz Sh. 'E
1 0-5 10yr 3/1 none sit 2msbk mfr Cs if .6 .8
2 5 -21 10yr4 /4 none sd 2msbk mfr CS ivf .4 .6
3 21-47 J Syr4 /4 c1d 7.5yr5/6 Sd 2pi mfr CS na .0 .2
4 47 -53 7.5yr4/4 dd 7.5yr5/6 Ifs os9 mvfr CS na .5 1.0
5 53-60 7.5 yr4 /4 none cos 099 ml na na .7 1.6
' Efllttlent #1= BM? 30 < 220 mglL and TSS >30 < 1 mglL ' Effluent #2 = 801 s <_30 mglL and TSS <_30 mg&
CST Name (Please - - CST Number
David J. Steel 248956
Address Sleets Soti Service. Inc. Date Evaluation Conducted Telephone Number
W4 200th St. Baldwin, Wl 54002 647/2005 715-760-0347
Pun, I C
` Property Owem CMde bcobson per{ m g 028-102545-M Pegs __ j _ of 3
F. sod" # C
® ter Duna Aurbu a am MM tt NOW +In 10 g fum 33 _ im Aavpcaflcn
Hannon DWO Domlwd COW Redcoc OeecdlpYon Taftm Shudue S=Wwy Root War
flu. MAlurwa/ Cltl. SL Cont. Color (3r. !3Z fin. I'm 'ERa
1 0-12 10yr 3/1 Hate d 2rnsbk mfr cs if .6 .8
2 12-24 10yt4 /4 none sid 2msbk mfr cs na .4 .6
3 24-33 7.Syr4 /4 none sf 2msb mfr cs na .6 1.0
4 33-60 "/4 c2d 7SyrS/6 $i om mfr na na .2 .6
❑ t3ouirg ❑ Ground eudaa ebv. tk Depth b fedar in. SoN App lication Role
MaAron Ooplh DouninAnt Color f:edouc Daecxlpflour Taxquua Shucgw BoeridAry Root GPD IF
In. Munnil Cu. SL Cont Color Gr. SL Stu. 'tweet 'awe
❑ t< ❑ Ground tuu bm ft 040 to factor
❑ elev. �MKf in.
Hwh on Dom DoAanseg Color Rwox Dega"on Team Shudin 8oundwy Root GPDIM
in fulro.ea Clu. ft +Coot. Color Gr. SL Sh. test
Effluent 01 + 90D 301_ 220 MV& And TSS }301_160 nV& • S M" 42 _ WO 1_ 30 mgiL and T$S 1.,30 trgit
lire Dgwbvdd ofComma+ee is = eqW ODPW OY service agvider m d emkm w if you ne wl madam , t.,wywe M,wirre.r
3of3
STEEL'S SOIL SERVICE IN •
Da fid J . Steel Clyde Jacobson 994 20& St
C - POWTSM SW1 /4,NW1/4,S22,T28N,R1'7W Bal 71 5- 7 7 6 6 0 -0347
54002
Li 424$956 Town of Rush River St Croix Co. Dire 71
Fax 715- 684 -3449
80 Acres
i.egeard N
l" = 40' I
♦ = Benchmark Eta. 100.00 ft
Top of 3/4" pvc pipe
•
—Alt Benchmark Ele. 99.16 ft
Top of 3/4" pvc pipe
1 = Borings
Boring Elevations
B1= 101.15 ft
B2 = I01.15 ft
B3 = 98.95 ft
B4 = 0.00 ft
/l0 3 3
r 9 i�l s get
�O J
® s �
AI
,�s�S�
.• `2 �' RECEIVED a #1ss1
SCO/Ill�
Department of Commerce SOIL EV N REPORT
ance ith 8 , W
U is. Adm. Code Page 1 of 3
Division of Safety and Buildin s O Steel's Soil Service, Inc.
County
Attach complete site plan on pap r not &ism )I Il*cfles in size. Plan t St. Croix
include, but not limited to: vertica and ho$l(rtl� point ( ), direction and
percent slope, scale or dimensio istance to nearest road. Parcel I.D.
- 1025 -95 -000
Please print all information. Rev' wed B Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). _ /� , _ _ ` Z� I �A_—
Property Owner Property Location GC���
Clyde Jacobson Govt. Lot na SWIM, NW1 /4, S22, T2814, R17W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
257 Cty Rd T na na 80 Acres
City State Zip Code Phone Number City [:]Village ❑ Town Nearest Road
Hammond WI 54015 1 715 - 796 - 5254 Rush River I Cty Rd T
n Use: ❑ Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
Replacement ❑ Public or commercial - Describe na
Pare anal Ridges and foot slopes of ground moraines, pitted glacial drift Flood plain elevation, if applicable na ft.
General comments Mound Design, system elevation 101.70ft based on contour line elevation 100.45ft.
and recommendations:
F 1-1 Boring #
® Ground surface elev. 101.15 ft. Depth to limiting factor 40 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 *01#2
1 0 -14 10yr 3/1 none sil 2msbk mfr cs if .6 .8
2 14 -24 10yr4 /4 none A 2msbk mfr a na .6 .8
3 24-40 10yr4 /4 none scl 2msb mfr cs na .4 .6
4 40 -60 5yr4/4 c2d 7.5yr5/6 si /scl om mfr na na .0 .0
l Boring # ® Ground surface elev. 101.15 ft. Depth to limiting factor 21 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. *Efl#1 *Eff#2
1 0 -5 10yr 3/1 none sil 2msbk mfr a if .6 .8
2 5 - 10yr4/4 none scl 2msbk mfr CS ivf .4 .6
3 2147 5yr4/4 cid 7.5yr5/6 scl 2pl mfr CS na .0 .2
4 47 -53 7.5yr4/4 c1d 7.5yr5/6 Ifs osg mvfr a na .5 1.0
5 53 -60 7.5 yr4 /4 none cos oSg ml na na .7 1.6
* Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD S30 mg/L and TSS <_30 mg/L
CST Name (Please Print) Signature: CST Number
David J. Steel 248956
Address Steel's Soil Service, Inc. Date Evaluation Conducted Telephone Number
994 200th St. Baldwin, WI 54002 6/7/2005 715 -760 -0347
SBD- 8330/R07/001
Property Owner Clyde Jacobson Parcel ID # 028 - 1025 -95 -000 Page 2 of 3
Boring # ❑ Ground surface elev. 98.95 ft. Depth to limiting factor 33 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
1 0 -12 10yr 3/1 none sil 2msbk mfr a if .6 .8
2 12 -24 10yr4/4 none Sid 2msbk mfr cs na .4 .6
3 24 -33 7.5 r4/4 none sl 2msb mfr a na .6 1.0
4 33 -60 5yr4/4 c2d 7.5yr5/6 sl om mfr na na .2 .6
❑Boring # ❑ 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 I - Ef'f#2
F-1 Boring # El Ground surface elev. ft. Depth to limiting factor in.
El Ground Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'E t "ER#2
Effluent #1 = BOD 30 < 220 mg /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 07 /00) stws SON service. irX•
s
STEEL'S SOIL SERVICE INC 3 of 3
David J. Steel Clyde Jacobson 994 200'' St.
CS - POWTSM SWl /4,NW1 /4,S22,T28N,R17W Baldwin, WI 54002
Li c. #248956 Town of Rush River, St Croix Co. Direct 715- 760 -0347
80 Acres Fax 715- 684 -3449
` Legend N
1" = 40'
♦ = Benchmark Ele. 100.00 ft
Top of 3/4" pvc pipe
• = Alt Benchmark Ele. 99.16 ft
Top of 3/4" pvc pipe
i = Borings
Boring Elevations
B1 = 101.15 ft
B2 = 101,15 ft
B3 = 98.95 ft
C n6% B4 = 0.00 ft
CI `C /c� sys --�-
- �6'�
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bu 6-
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer �� s e /} e- ej S�
Mailing Address �Z S� Lz�y /? J-
Property Address )- 7 0, b- y /? ( C
/ (Verification required from Planning Department for new construction)
City /State f�� �� Parcel Identification Number - 4 /9 -G 06
62,k U -�r - GGv
LEGAL DESCRIPTION
Property Location '/4, '/., Sec. �. T L K N -R / { W, Town of
Subdivision Ct� Lot # - -
Certified Survey Map # , Volume Page #
Warranty Deed # % �(� 1 , Volume 2- Page it d 'Z—
Spec house ❑ yes L9 no Lot lines identifiable ❑ yes ❑ no
SYSTEM MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function of the septic tank as a treatment stage in the waste disposal system.
The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a
mastorplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewaterdisposal system
is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 113 full of sludge.
I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days of the three year expiration date.
I VA W4 APPLICANT 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office.
WA5
APPLICANT DATE
* * * * ** Any information that is mis- represented 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
a copy of the certified survey map if reference is made in the warranty deed
768 1 77
2 6 12 P 0 6 2 KATHLEEN H. WALSH
REGISTER OF DEEDS
ST. CROIX CO.. VI
STATE BAR OF WISCONSIN FORM 3 - 2000
RECEIVED FOR RECORD
QUIT CLAIM DEED 07/08/2004 09:15AN
Document Number
QUIT CLAI?f DEED
This Deed made between CLYDE S. JACOBSON AND EXEMPT # 16
JO ANNE E. JACOBSON HUSBAND AND WIFE AS JOINT TENANTS. REC FEE: 11.00
TRANS FEE:
Grantor, COPY FEE:
and CLYDE S. JACOBSON AND J AND THEIR CC FEE:
PAGES: 1
SUCCESSORS, AS TRUSTEES OF THE JACOBSON FAMILY _
REVOCABLE LIVING TRUST
Grantee.
Grantor quit claims to Grantee the following described real estate in
ST. CROIX County, State of Wisconsin (if more space is needed,
please attach addendum):
W est H alf of Northwest Quarter (W 1/2 NW 1/4) of Section 22, Recording Area
Township 26 North, Range 17 West, St. Croix County, Wisconsin Name and Return Address
CLYDE S. AND JO ANNE E. JACOBSON
257 CTY ROAD T
HAMMOND, WI 64015
—/O C 4 0_= t 0& 8 - • 10 as -
1^ . ^ iC 6 "1.
Together with all appurtenant rights, title and interests. 947
GRANTOR SUPPLIED THIS LEGAL DESCRIPTION, DRAFTER Parcel Identification Number (PIN)
MAKES NO WARRANTY OR REPRESENTATION AS TO This is homestead property.
WHETHER THE SAME IS CORRECT, ACCURATE OR (is) (is not)
WITHOUT ERROR. EXEMPT FROM TRANSFER FEE
UNDER IMIS. STAT. 77.25(16)
Dated this ( day of O
« •
Ve - AI
* JO ANNE E. JACOB MN
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN )
Signature(s) ) ss.
ST. CROIX County )
authenticated this _day of
PqrsonaUv came before me this r ? day of
2..00 ,( the above named
�ttttttttti CLYDE S.-AAr-AgRo N AND JO ANNE E. JACOBSON,
w �`•��,�pq —� HUSBAND AND WIFE
TITLE: MEMBER STATE BAR OF WISC�t�ISJN ` .�?�''. tome known to be the person &_ who executed the foregoing
(If not, ti • "�' - -instrument and acknowledged the same.
authorized by § 706.06, Wis. Stats.i; -� ',
THIS INSTRUMENT WAS DRt�pv,I# : ro ToAi✓ L , vrn!� f .e G _
Peter J. Walsh, Walsh lip Keating, S.C. " "111 - li ' , �•`�` Notary Public, State of Wisconsin
5 Wauwatosa Ave., Wauwatosa, WI 53213
gnnn My Commission is permanent. (If not, state e iration date:
150 �O •- 7 - O 7 ,
(Signatures may be authenticated or acknowledged. Both are not necessary.) )
"Names of persons signing in any capacity must be typed or primed below their signature.
QUIT CLAIM DEED STATE BAR OF WISCONSIN FORM No. 3 - 2000