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HomeMy WebLinkAbout026-1149-00-010 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division ' INSPECTION REPORT Sanitary Permit No: 430227 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: Green, Steve Richmond Township 026- 1149 -00 -010 CST BM Elev: Insp. BM Elev: BM Description: e� Section/Town /Range /Map No: r .,-t 4 Z C S 1 1 15.30.18.1115 TANK INFORMATION j ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. 1 Septic r `y Benchmark L 1.75 �G Dosing Alt. BM Aeration Bldg. Sewer t'q0 Holding St/Ht Inlet (0 93 t O 1, • L, TANK SETBACK INFORMATION St(Ht Outlet ,, TANK TO P/L WELL BLDG. EVento Air Intake ROAD Dt Inlet Septic S� t�U Dt Bottom Dosing Header /Man. Aeration Dist. Pipe r J�� o 1 A_ Holding �_- Bot. System Final Grade p PUMP /SIPHON INFORMATION L lo•� lD ?.AS Manufacturer Demand St Cover Model mber TDH Lift Friction Loss System Head TDH Ft. rcemain Length IDist.toWell SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 2 t ✓1 •?� -- -.- SETBACK SYSTEM TO l P/L 1131 IWELL LAKE /STREAM LEACHING Manufacturer: �� r.1 • s INFORMATION CHAMBER OR , Type Of System: 1 1$ ( N UNIT Model Number: r♦ DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Lengt J Dia Length Dia " - 5[S8L1tig _. __. _. . SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only 7Q Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center J.. ( Bed/Trench Edges Topsoil a / Yes J No F,1 Yes ! ?: No COMMENTS: (Inc, de code discre ties, ersons present, etc.) Inspection #1: /0 !4 / 3 Inspection #2: Location: 1525 127th Street New Richmond, WI 54017 (SW 1/4 SE 1/4 15 T30N R1 8W) Cherry Knolls Lot 10 Parcel No: 15.30.18.1115 1.) Alt BM Description c,v d� ♦o 2.) Bldg sewer length = a - 7 1 �, t3 r5•M � f� '� - amount of cover = < (Q," dc..w, f� n s l �t C Ole I.v C a -- Plan revision Required? Yes I No / Use other side for additional information. /0 . ��.G SBD -6710 (R.3/97) Date l Inse s Signature Cert. No. 1 L • z, 0/7 3( LA X>Ih L- I J" , ` � 9 C•` -r-.t� Ss h( ` Safety and Buildings Division County W ME 201 W. Washington Ave., P.O. Box 7082 Sl a C_U I)( Madison, WI 53707 - 7082 Sari Permit Number (to be filled in by Co.) ,S'COn�',n Department of Commerce (608) 261 - 6546 3C7 • State Plan I.D. Number Sanitary Permit Application in accord with Comm 83.21, Wis. Adm. Code, personal how.-A-tryqu provide may be used for secondary purposes Priv+cy LAW, s' B.040)(m) Project Address (if different than mailing address) I. Application Information — Please Print All Informs ion ! SZS Property Owner's Name Parcel # Lot # Block # 6u 6- C-1, ( r Property Owner's Mailing Address — "' - ° °"" Property Location 4 R,LOC,(L ( 5.s J`^' %., ' /., Section � S City, State Zip Code Phone Number K 0 t 1011 �.CA -Y Ctry ( .3%1 / 5 +3— S f 4f4lZ T 30 N; R I� (c �o e J.) i II. Type of Building (check all that apply) S� t - Subdivision Nam der ❑ 1 or 2 Family Dwelling -Number of Bedrooms S• f ❑ Public/Commercial - Describe Use Ctfe__ee -Y tAo(t ❑ State Owned - Describe Use ❑City ❑Village orownship of (_ A16 III. Type of Permit: (Check only one box on line A. Complete line B if applicable) 2 — ( —coo O O , It/ 5 A. ❑ New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B - ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. T of POWTS System: Check all that appl ❑ Non - Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching 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 (st) System Elevation VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New I Existing Tanks Tanks pt or Holding Tank Aerobic Treatment Unit lY R J Dosing Chamber VII. Responsibility Statement- 1, the unde ned, assum sponsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plum 's Signature MP/MPRS Number Business Phone Number L � A G 2- 2,3 Plumber's Address (Street, City, State, Zip e) v g 8x 2-G VIII. Coun /De artment Use Onl Approved ❑ Disapproved Sanitary Permit Fee f includes Groundwater te Issued Issuing ent Signatur (No Stamps) Da Surcharge Fee) --�-�``�� ❑ Owner Given Reason for Denial 25 /- . S LE?�3 IX. Conditions of Approval/Reasons for Disapproval Attack c mplete plans (to dynanty only) for #ke system anipaper not less than al : l hilches In size -�(__ SBD -6398 (R_._d8/02) R L F —Y _­Y raz,una a I-..l vrrasam n re�raranr av pre�rvua apNrn.aennr I. Application Information - Please Print all Information Location: Property Owner Name e y r 7 SW 1/4 SE 1/4, Sec 15 Steve Greene 30 N, R 113 r W Property Owner's Mailing Address a Lot Number Block Number 49 Block Lane 10 C ity, State Zip Code hone Nupier Subdivision Name or CSM Number Mont City 63361 573 - 564- 24T2 - Cherry Knolls II FS1 Building: check one) ity Village ■ own of or 2 Family Dwelling - No. of Bedrooms: 4 ublic/Commercial (describe use): Richmond tate -owned Nearest Road 11. Type of Permit: (Check only one box on line A. Check box on line B if applicable) Cth G Parcel Tax Numbs s) 1 Repair Reconnedlon [ Rejuvenation A / © ©I ?i Sanitation p (O L 1 V V B) Permit Number Date Issued State Sanitary Permit was previously issued V. Type of POWr System: (Check all that apply) ❑✓ Non- pressurized ["round � Mound � Sand Filter � Constructed Wetland Pressurized In -ground ❑ Holding Tank Single Pass Drip Line At -grade ❑ Aerobic Treatment Unit Recirculating ® Other V. Dispersaln'reatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals. /day /sq.ft.) (Min.Anch) Elevation 600 1,200.00 1,200.00 0.5 106.30 108.80 I. Tank Information Capaccty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks 1 0 1,250 1 Wieser ■ ■ II. Responsibility Statement I, the undersigned, assume responsibility for repair/ reconnenction /rejuvenationlinstallation of non- plumbing for the POWTS shown on the attached plans. A license Is not required for terralift repair or the igotallation of no"Iqmbing sanitation system. Plumber's Name (print) PIumb4 Signature (n (f s ): PRS No. IBusiness Phone Number Joe Stang ,,� 2.3`/ 75 715 - 684 - 5166 Plumber's Address (Street, City, State, Zi e) PO Box 263, Woodville, Wisconsin, 54'028 Ill. County Use Onl Disapproved Sanitary Permit Fee Date Issued Issuing Agent Signature (No stamps) ❑ Approved Owner Given Initial Adverse Determination [X. Conditions of Approval /Reasons for Disapproval: oi19sitep1n001a.jpg -Steve IGreefte to( 10 ,op Ofierry Kstoees qO ° WA / � Sol } s 4r, k O �S a wtA ( 1 a ga RUi VOp or COW IAOA 1.00' BM3 'F Or MWEEL VOPI,UIT 903.17 B1 103.9.1 A3 108.60 �. B3 909.73 ,� soi1ssitep1n001a.jp9 St eve lGre 1 lop h� Nodh ofierry Kotoee W A ch"L- Ice RO `�. be, I G� 6 wtA 1 ¢�► So /0 . HPA3 'wOP O3; i,ow ]ROA 1.00' EM2 "FOI' OF MWEEL tONJDV1T 103.37 R1 10i.9t �►s Mas�au BI 109.72 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page l of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County St. Croix Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Rev' ed by �D Date Personal information you provide may be used for secondary purposes jeii s. 15.04 (1) (m)). �L I Property Owner I I _ i ,. 6 Property Location Steve Greene �,d, Lot SW 1/4 SE 1/4 S 15 T 30 N R 18 ®®W Property Owner's Mailing Address Lot # Bbck M# # Subd. Name or CS 49 Block Lane 10 - Cherry Knowls City State Zip Code Phone Number 03ity QVillage •!, own Nearest Road Montgomery City I MO 1 63361 (. 5.7 - 564 - 2412 CTH G New Construction UseE] Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD 0 Replacement 0 Public or commercial - Describe: Parent material "itwach sand Flood Plain elevation if applicable NA ft. General comments There are massive sandy loams present. During installation the contractor should use exteam care when working and recommendations: on these soils so as not to further compact them. a Boring # 0 Boring El Pit Ground surface elev. 105.91 ft. Depth to limiting factor >94 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -11 10yr2 /2 sil lfpl mfr cw 2f .2 .3 2 11 -27 1 3/3 is lfsbk mvfr cw - .7 1.2 3 27 -94 10 5/6 s Osg ml - - .7 1.2 1 0 ❑ 2 Boring # Boring 108.80 >94 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/ff? in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -10 10yr2 /2 sil lfpl mfr cw 2f .2 .3 2 10 -18 1 3/3 is lfsbk mvfr cw - .7 1.2 3 18-28 10yr4/4 is lfsbk mvr cw - .7 1.2 q A 4 2^ 7.5yr5/8 s Os ml cw - 1 5 - 6 10yr4 /4 is Om mvfi cw - .4 .6 6 66 -94 7.5yr5/8 I , s Osg ml - - .7 1.2 k C 7 0 1� CST N Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 (Please Print) Si 150 mg/L `Effluent #2 = _< 30 mg1L and TSS < 30 mg& gnature CST Number If Thomas C Nelson 227387 1�D Address Date Evaluation Conducted Telephone Number VV 1432 120th Street, New Richmond, Wl 7/16/03 715 -246 -2454 s Property Owner Greene Parcel ID # Page 2 of 3 [-3 Borin # Boring g pit Ground surface elev. 109.72 ft. Depth to limiting factor >98 in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0 -20 10yr2/2 - sil 1fpl mfr cs 2f .2 .3 2 20 -28 1 3/3 - Is Om mfi cs - .4 .6 3 28_55 7.5yr5/8 - cbs Osg ml cw - 2 1.2 4 55 -98 7yr4/6 - sl Om mvfi - - .3 .5 ( 6 .30 t F 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/fP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 'Eff#2 F—I Boring # Boring Pit Ground surface elev. ft. Depth to limiting factor in. Sal Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in, Munsell Qu. Sz. Cont Cola' Gr. Sz. Sh. *Eff#1 'Eff#2 * Effluent #1 = BOD > 30 < 220 mglL and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mgIL and TSS < 30 mg/- 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- 8330Ten (R.07M) Environmental B Y Design a� www.environmentalbydesign.com 1 715 f c HE RRY 1141 w0 LZS 11,0 10 N od b BMI TOP OF ]LOW IBOW 100' BM2 TOP OF 9TEEI. COFDUIT 103.37 BI 103.91 B2 108.90 B3 109.72 Thomas Nelson 227387 r POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2 FILE INFORMATION SYSTEM SPECIFICATIONS Owner C 're�� Septic Tank Capacity V.S�t S g al ❑ NA Permit # Z z fi Septic Tank Manufacturer Z S� ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer z ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model A _ lW ❑ NA Number of Public Facility Units K-NA Pump Tank Capacity a l A Estimated flow (average) CrO al /day Pump Tank Manufacturer A Design flow (peak), (Estimated x 1.5) Ua al /day Pump Manufacturer A Soil Application Rate Q , SO gal /da /ft2 Pump Model ft NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit "A Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD :5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L 0 "In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA At -Grade ❑ Mound Fecal Coliform (geometric mean) :510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ ea�(s'(s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA yearls) ❑ Clean effluent filter At least once every: month(s) ❑ NA &I year(s) Inspect pump, pump controls &alarm At least once every: ❑ month(s) ❑ NA ❑ year(s) pressure test At least once ever ❑ month(s) ❑ NA Flush laterals and P y� ❑year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. I Page Z of Z START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or: must be taken, to provide a code compliant replacement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. A � T Iv� alua ' a o ing ank b e ai ?f1 DW I l51TE1h fb R A16 a"577e clCq o ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER 1 Name Name .0 Phone Z(S �(, j ( � Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY / Name Name ST. G l Le) �QIJI Phone Phone /S— 3�( (p () This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administr @tive Code. gag c 'Z , - OD I l e 0 O 0 91.4 0 .004 Ln 0-4 4c cx p C6 cy coo c Go m #r cc CD Bd[-TAdoo aeqov=oT4o9ex 3 '* + F : r } CL lz r�.r 04 o7w ST CROIX COUNTY SEPTIC TANK MAMENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner _& 't'vl C-Te,, e, 4 � s�; Address M4x�l,,,e c�� °Ztv 6336/ � Ales Q'��•"... Yv 7 Property Address (Verification required from Planning Department for new construction) Ne Parcel Idadficatim Nif *a Property Loc ► r /4, Y+, sec. T--N —W, Town of ,o sit C h l/f o Certified Survey Map # Vohmne Page # Warranty Deed Deed # 7 2-4p 079 Vohmoe Page # U Spec how C1 yes Of no Improper use and maw of your septic system could result in its prtmature failure. to handle wastes. Proper maintenance consists of pumping out the septic task every three years or sooner, if needed by a licensed pumper. What you pit 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 fan, signed by the owner and by a master Plumber, lourneYman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is m Proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 fall 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 Wisconsm. Certification stating that your septic has been maintained must be completed and returned to the St Croix County Zonmg Otfiicc within 30 days a thr+ae Year' e #fion date. UJRE OF APPLICANT DATE IIVVNIFR rr'IF': IMCATION I (we) certify that all statements an this form are true to the best of my (our) knowledge- I (we) am (are) the owner(s) of the pro 'bed a6u by virtue of a warranty deed recorded in Register of Deeds office. 7, u, GNATURE OF APPLICANT DATE sss sus Any mbrmatm that isms -represented may result in the sanitary permit being revoked by the Zoning Department. ssssss ss tneIN& wki! W& OPPOMOM: a stamped. warranty deed 6rom the Register of Deeds office a copy of the certified survey map if reference is made in the warranty decd �(3 J 1 � Iii Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County c� t / _ Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must ••�'7' l.C� include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 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 `fir n Govt. Lot S C- 1/4��� 1/4 S T a p N R I E (or) C Property Owner's Mailing Address Lot V I Block # Subd. Name or CSM# City State Zip Code Phone Number ❑ City ❑ Village ® Town Nearest Road C (V W Z 19" C,L I S 1 (7/ -1 — /Za ���Vt . G New Construction Use:'® Residential / Number of bedrooms - - 4 > - 1 Code derived design flow rate hl.S O tl GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material �� Flood Plain elevation if applicable ?/ ft. General comments C( f✓U • /°e q Q, (p O L , , % Z0 and recommendations: 4-4-4, Ct RECEIVED 4 3g b MAR 1 3 2 s a Boring # ❑ Boring ST. CROIX COUNTY Q Pit Ground surface elev. 166 & C ft. Depth to limiting factor L Z(PNING OFFICE pplication 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 l 6-17 16 / Z e- 3 I V•' Z 12 --24 /n 2 Z Si Askk m4 GS - • 5 3 26 -5 1 0 4r y /3 5•c_l 2ms k nnr cs - • 4 Boring # Boring IITTII $( / L^I Pit Ground surface elev. /(16 V ft. Depth to limiting factor '7 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 6-1Z I(Nv 3114 -~ S i l 2- mab re CS I . T Z 12 10 212 S i ) ,2-ma b Pr- C5 .5 3 22 -5`f 10 413 5 ' 4 - 1 2rnSbk naP CS • 4' * Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L CST Name (Please Print) Signature CST Number SG k.. WI ), z "5 3 - 9 Address Date Evaluation Conducted Telephone Number 0 4/3 S f � - s'- o� 7,s - ay 7-tY� SBD -8330 (R07 /00) r. Property Owner JD e rr i c,l , Parcel ID # Page of 3 Boring # E] Boring F 31 ® Pit Ground surface elev. 99 YO ft. Depth to limiting factor � in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 Vr 4 A s 2nnsbk I Vr .5 .9 Z 16- 10 Z 2 i t Zm5 k ►' G 5 . 5 .$ 3 ❑ 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 /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # F1 Boring Pit 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 /ftz 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) Y a t PAGE 3 OF 3 NA_ j)-er r,'c LOT# ��LEGAL D CRIPTION 5 YS1 ,S T 3a .N.R. 18 E(o SCALE: I"= Z /G BM 1 ELEVATION 4 • a BM 1 DESCRIPTION k, p o I /I e 9 � p,' je BM 2 ELEVATION O BM 2 DESCRIPTION y a -F f P2 s'e c SYSTEM ELEVATION laP Tr, u o I- o ,,, Q r I yZlo 1 ALTERNATE ELEVATION `l g '20 — -1 CONTOUR ELEVATION S w• 2 -3 qq ya • (ao• gd SIGNATURE DATE - "a/ I J 2 2 7 7 P 4 4 8 726076 11 STATE BAR OF WISCONSIN FORM 1 —1998 KATHLEEN H. WALSH REGISTER OF DEEDS WARRANTY DEED ST. CROIX CO., WI RECEIVED FOR RECORD Document Number This Deed, made between Steven J. Derrick, a married person 06/16/2003 12:20PN Grantor, and Steve Greene and Sheryl Greene. husband and wife WARRANTY DEED urantee. EXEMPT II Grantor, for a valuable consideration conveys to Grantee the following REC FEE • 11.00 described real estate in St. Croix County State of TRANS FEE: 164.70 Wisconsin (the "Property "): COPY FEE: CC FEE: PAGES: 1 Recording Area Name and Return Address G Stevwereene ShawWeaerfe �l,(,r� - T eX C1i rty n li Ddve O ewe w MR nnond,- w+- 54o1Ti�h � f l O . m*J 554 / Parcel Identification Nurn:: (PIN) 0Z& ))'i9 -0 0 -0 I 0 Lod ' I no115 This Is not homestead property. (Is) (is not) Together with all appurtenant rights, title and interests. none Grantor warrants that the title to the Properties good, indefeasible in simple fee and free and clear of encumbrances except Dated this 0th day of I, u en , 2003. (SEAL) (SEAL) Steven J. Derrick (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, WENDY SWATZINA ) ss. St. Croix County authenticated thisS WISCONSIN Personally came before me this 9th day of ,(yng, 2403 the above named Steven J. Derrick, a married person to me known to be the person who a cuted the foregoing instrument TITLE: MEMBER STATE BAR OF WISCONSIN a d acknowledge the same. (If not, Aa authorized by §706.06, Wis. Stats) THIS INSTRUMENT WAS DRAFTED BY Notary Public, Statt of Wisconsin Coldwel( Banker Burnet 1301 Coulee Road My commission is p rrn ) (If not, state expiration date: Hudson, WI 54016 n 3 -40159 ) (Signatures may be authenticated or acknowledged. Both are not necessary.) Names of persons signing in any capacity must be typed or printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co, Inc. WARRANTY DEED FORM No. 1 -1998 Milwaukee, Wis. vii`iill 1 1%1W%0 _ocated in part of -the - Northeast Quarter of the Southeast Quarter, part of the Southeast Q Quarter of the Southeast Quarter and part of the Northwest Quarter of the Southeast Quart of Richmond, St. Croix County, Wisconsin, including part of Parcel 1C of - `�fied Survey Map A ST. CROIX COUNTY PLA UNPL A T TED L A ND S �I� OF 25 YEAR HIGH WATER = _ ELEV= 968.70 100 YEAR HIGH WATER ELEV= 971.15 EXIS77NG EDGE OF WATER I BENCH MARK: 9 32 TOP IRON PIPE 1 ELEVATION — 970.49 • ��G o, s � S8 V7'17' o.so E 479.73' \ 379.99' I II \ 99.74' I \ • LOT 9 't m I b 2.01 ACRES_ I 87361 SQ. FT. ,� E A 66.99 MIN. FFE 975.0 '►� N A G ,E) BENCH I NW— SE \ TOP IRO n ELEVATI \v \ SW —SE \ ; • \ Nc \• � � NB2;3g 11 - it � C 582 — e T 10 '� • • 83 ACRES 79704 SQ. FT. '��. O \MIN. FFE 975.0 a LOT 11 �,� • \ \ i' 2.38 ACRES \ h i 103648 SQ. FT. W \• • . • . . . . . . h' MIN. FFE 975.0 LOT , q7. ( /24.76 •� I� I • , . 2. 116455 1'0�/ 52.64' ' MIN. FF 5892617"W \ R LOT 3 • • . \ • 52. sf \ \ �.9Q 1.91 ACRES —� \ 83363 SQ. FT. ao \ \ \ 0 \ N o LOT 2 (b r • • \ \ \ • � 1.72 ACRES N 74711 SQ. FT. 4J LOT 1 1.72 ACRES i 74806 SQ. FT. •