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HomeMy WebLinkAbout030-2024-60-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Cr oix Safety-and Building Division INSPECTION REPORT Sanitary Permit No: 483968 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: Kurima , Rowan G. & Bonnie I St. Joseph, Town of 030 - 2024 -60 -000 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: /cb rA I CdS 1 12.29.20.436131 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURE CAPACITY STATION BS HI FS ELEV. �`> Septic ` Benchmark AkLi P -6 d�c. S ZS F 1; Z.5 , A1t.13 Aeration Bldg. Sewer. t Holding St/Ht Inlet .� St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL *DG. Vent to Air Intake ROAD Dt Inlet a c 6A ! X71 . Z Septic Ji Dt Bottom C?-.. Dosing AJ,� — Header /Man. , 7 Aeration Dist. Pipe Holding Bot. System ,' �� ✓ PUMP /SIPHON INFORMATION Final Grade 3 g5 c ✓7 - 5 '2 Manufacturer Demand St Cover GPM L G ib 75. Modpldrer TDH Friction Loss Head Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length / No. Of Tren / PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 73 7� =1 ..a A --- SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR .lI i �M Type Of System: 2 � �/I jj � C G 2-1 S T /3� f l UNIT Model Number: 4 Uc , G1� r W DISTRIBUTION SYSTEM ZX A Header /Manifold IDIstribution x Hole Size x Hole Spacing Vent to I 1 D Pipe(s) 1 '5 J Length "� Dia Length Dia \ Spacing \ �� —^ A. SOIL COVER j x Pressure Systems Only xx Mound Or At - Grade Systems Only 0 4S N 11 2- (J tL Depth Over Depth Over I xx Depth of xx Seeded /Sodded xx Mutc e�i d Bed/Trench Center Bed /Trench Edges Topsoil V v ` Yes tJ No Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: Location: 221 River Heights Trail Hudson, WI 54016 (Gov't Lot 1 12 T29N R20W) NA Lot 1 Parcel No: 12.29.20.43661 1.) Alt BM Description= �� �OJ ?.� 6 /� W i ese.. A " �X 2.) Bldg sewer length J "' ff - amount of cover =�5�. ✓� �5 �-- �aC O Plan revision Required? ] Yes No Z l ]� l i `� �6 Use other side for additional information. - - -- -- - - Date Insep or's Sig ure Cart. No. SBD -6710 (R.3/97) Safety and Buildings Division County _ ,p 201 W. Washington Ave., P.O. Box 7162 1 *is cOnsIn Madison, WI 53707 — 7162 Sanitary Permit Number (to be filled in by Co.) 608 266 -3151 ( ) 4 1 -3 Department of Commerce (s? Sanitary PP Permit Application State Plan I.D. Number ,� /� In accord with Comm 83.2 1, Wis. Adm. Code, personal information you p 'Ai. / JA may be used for secondary purposes Privacy Law, s15.04(1 xm) � Project Addressrf if different than mailing address) I. Application Information — Please Print All Information - .; n +� /" d to Propert Owner's Name Parcel # Lot # lock # ©W CA) ANO olvly t r- kLc Ae l m q1 3 e z0! - f ) - (Irk Property Owner's Mailing Address Property Location / 2 Z /2/ Vt a2 14t 16. 7�!.411- r Y3 (3 ,� /,, /., tion City, State Zip Phone Number R LV E o y,{circle off) II. Type of Building (check all that apply) 0 1 or 2 Family Dwelling -Number of Bedrooms 4 Subdivi on Name CSM Number ❑ Public /Commercial - Describe Use AUG 0 3c`J7�3 ❑ State Owned — Describe Use COUN ❑City Village 97ro wnship of 5 % .J III. Type of Permit: (Chec only one box on line A. Complet line B i A. ❑ New System Cll Replacement System y p y ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System B. El Permit Renewal ❑Permit Revision El Change of El Permit Transfer to New / List Previous Permit Number and Date Issued Before Expiration Plumber Owner >1 h t l - D� J ! 7 i IV. Type of POWTS System: Check all that ap I Non -Pressurized In- Ground ❑ Mound Z4 in. of suitable soil ❑ Mound <24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In -G *nd El Hold* * Ta k ❑ Peat Filter El Aerobic Trc m Unit El Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter 11Kefti g t aMb�r r rip Line ❑ Gravel -less Pipe YOther (explain) V. Dis ersaVl'reatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (so Dispersal Area oposed (s Syste Elevation VI. Tank Info Capacity in Total Number Manufacturer I`Wab' Site Steel Fiber Plastic Gallons Gallons of Units Contirete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank 1000 /ODD 2 Z_ ) 6 S6 ie C o N C e /L Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- 1, the undersigned, assume responsibility fo installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plum S store MP/MPRS Number Business Phone Number �a 14,u �5c Wry (� Z 2 76 d 7/ s ?� o ~ D x'8 Plumber's Address (Street, City, State, Zip e) VII Coun /De artment Use Only— Sanitary Permit Fee (includes Groundwater Date Issued Issuing Age t Si atu Stamps) IV Approved ❑ Disapproved , I {j Surcharge Fee) ❑ Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapproval -i %. � .G'rt:� -.< ::.,,�°v►,� �7,(,.1.`� s:{A,�a,p�[/�°�'Gt�2 - r(i.i SYSTEM OWNER: _. 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained+' " C _ y)� as per applicable code /ordinances. " ' `'""` `" r � Attach complete plans (to the County only) for the system on paper not less than 81/22 xx 11 inches iin p ) { SBD -6398 (R. 01/03) I Page 2 of 11 PLOT PLAN (Kurimay_Property) ♦ BM1 Elevation = 100.00' Top of 2 PVC pipe A BM2 Elevation = 99.20' Top of brick wanes coating in front of house. ■ Backhoe pits Slope =5% System Elevation = 89.60' 3.10 Acre Parcel New 1000 gallon septic tank with Polylok 525 effluent filter to be N added to the existing 1000 gallon septic tank. Scale: V= 40' 54 -ePC '� NX /�TiIJ(y �G'O(:(taIIL y cLL t� !7t /)/1OeIri '+' 2 t 0P-A riz 83 I. PRIvEWAY GH`� 41� I r � CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Kurimay Conventional Gravity Septic System Owners Name: Rowen and Bonnie Kurimay Owners Address: 221 River Heights Trail Hudson, Wl 54016 Legal Description: NE %, NW' /., S12, T29N, R20W Township: St. Joseph Subdivision Name: 3.10 Acre Parcel Lot Number: 1 Parcel ID Number: 030 - 2024 -60 -000 Page 1 Index and Title Page 2 Plot Plan Page 3 System Cross Section and Sizing Page 4 Existing ank Certification g Page 5 Septic Tank Specifications Page 6 Filter Information Page 7 &8 Maintenance & Management Plan Page 9 Septic Tank Maintenance Form Pagel0 Warranty Deed Pagel 1 CSM or Plat Attachment: Soil Evaluation Report Designer /Plumber: John Schmitt License Number: 223760 Date: August 18, 2010 Phone Number: 715- 760 - 0486 Signature / C Designed pursuant to the In- Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD- 110705 -P (N.01 /01). I Page 2 of 11 PLOT PLAT (Kurimay Property) ♦ BM1 Elevation = 100.00' Top of 2 PVC pipe 0 BM2 Elevation = 99.20' Top of brick wanes coating in front of house. - _ ■ Backhoe pits Slope =5 °!o - System Elevation = 89.60' _- 3.10 Acre Parcel - Now 1000 gallon septic tank with Polylok 525 effluent filter to be - - -' N added to the existing -1000 gallon septic tank. -_ Scale : 1 40' - - 5«.lE - t ML J � - -- � GinsT�rv& I n , � .SJ: /Jod�r� 83 h - DRivrWA► - - a 5�i:9� Page 3 of it Soll Absorption System Cross Section , 96.50 ft 40 FUtal Grade nt Pipe 90.60 t Cap �^ ft 89 60 ♦_ 89.60 ft. Trench Elevation _ Trench Elevation 3 ft >3 ft Soll Absorption System Plan View 64 ft 3 ft 3 ft Leaching Trench 1 Vent Or Observation Pipe Chambers 4' DUi Trench 2 Header Leaching Chamber Specifications Manufactuer and Model INFILTRATOR Quik 4 ESIA Rating 20 sq. ft per chamber ESIA Rating 5.8 sq. ft per 2 endcaps DWF 450 gpd Soil Aplication Rate 0.7 gpd /sq. ft 450 gpd DWF + 0.7 Soil Aplication Rate = 20 ESIA= 32 Chambers 2 rows of 16 chambers each. i Page 4 of 11 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to cert ify that I have inspected the existing septic and/or dose tank presently serving the followin residence: (Street address) Z ) v e %`Z ice! 7TS .IIC located at: ' /a, '/4, Section z , Town�N, Range Z © W, Town of S TT ,% D S w l� , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service Z - ZL 0 Did flow back occur from absorption system? Yes No k (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity l e9O 0 Construction: Prefab Concrete C Steel Other Manufacturer (if known): ro - Age of Tank (if known): _ 207 e qpc Permit number (if known) 5 7 j ( eased Plumber Signature) (Print Name) ZZ3 (Title) (License Number) MP/MPRS (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9 /2008 Page 5of11 D z x rA D A A 61. 86" a 42" _ 8 z m :0 N 4 rn O r^ UP 41" a 1 N 4" CAS / -° �, \ x — A Ln m 3" 36" 4" � o S s I D I r ED rn UP 38" l D � ) ° m 1 4" CAS \m � / N N v � m rn g -° D C �D= ° 39" ° < ° y °rD N rrn > r O (n r 0 D Fa mO r m� x� n x D Z a m n n -i C D 2 O 2 r' z z -Ni x� x D g m m m--I y z z o -� z s > z OO Omer xr° mfrn ^+ry ;x_ MZ. Z - O nC0 A O�z D�z DrO-IZ my0 O Z C° ° �W Or�1 t � D > i A �A 2pOS �SA OrN G -iD SL>m \m CD r x n :0z2 r1r,>,g C m S Z _ fir° ; _ w N r x �N =C F� Z DO 02 id °Dr'�*1 Vmm�'p� ' = mom C D oo D m N M I+1 O 1 N p r - ° rn - l". N ' O < o m o c u x D 0� R1 m p C W V10 -- n D r � O; n i °° O a A m 00 03 0 NO \ � z C O O mmr I O Q � c ' v m a -4m �rj Z o v v $ O C M c N ov 0A D ° L" M D > 00 m< v m a Z D �r Z o N 2 DSO 07� w�D C - n O _� D D �o� °o� � v O X m ,1 W) z g p r r�* �� Ov � o N -4 m n v p M � z ° o - Q �' f* � D r z X r g m O z r N v m Z m m r m I \ (A WLP1000 -MR m DRAWN BY: SME SCALE: 1 4' =1' -0' PRE -POUR: ° m SEPTIC MANUAL CODCAETE REV. \ z W3716 US HWY 10 MAIDEN ROCK, WI 54750 DATE: JANUARY 2010 DATE:. POST -POUR: ° REVISED JAN. 2010 800- 325 -8456 FILE: KMOOD -1111 !Wast aw!hodum � °` INSTALLATION INSTRUCTIONS °°� °��°`�°°° '' °fP PL- 525 /PL -625 FILTER INSTALLATION INSTRUCTIONS Center filter with opening c� W N J � M = e e Additional pipe or Polylok Extend & Lok- Glue for centering. Step 1: Step 2: Step 3: (A) Locate the outlet of the septic tank. (A) Before installation, place the (A) Glue the filter housing on the (B) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe. if necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the is positioned so the filter can be housing, making sure the filter removed from the tank for cartridge is properly aligned and maintenance and service. completely inserted in the housing. MAINTENANCE INSTRUCTIONS i i � e Step 1: Step 2: Step 3: Locate the outlet of the septic tank. (A) Remove tank cover and pump (A) Insert the filter cartridge back if necessary. into the the housing making sure • NOT FILTE R EM O VE D the filter is p roperly ali (B) Pull the filter out of the housing. p p y hed WHEN g (C) Hose off the filter over the septic tank. and completely inserted. USKI RVII11M OLO a Make sure all solids fall back into the (B) Replace septic tank cover IAI M CL INA , 11 111 111110 FLTM septic tank. PAI ` *SCO -- WIL EVALUATION REPORT #1635 Department of Commerce in accordance with Comm 85, Wis. Adm. Code Page 1 of 4 Division of Safety and Buildings Schmitt Soil Testing, Inc. Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County 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. 030 - 2024 -60 -000 Please print eviewed Dat Personal information you provide may be u for seR�RA�E f l cy L , s. 15.04 (1) (m)). U Property Owner oparty Location Kurimay, Rowen & Bonnie vt. Lot 1 NE1 /4, NW1 /4, S12, T29N, R20W I NK Property Owner's Mailing Address t # Block # Subd. Name or CSM# 221 River Heights Trail ST. CROIX COUNTY 1 CSM 2/396 City State A ❑City ❑ Village ❑ Town Nearest Road Hudson WI 54016 1 651 - 214 -1758 St.Joseph I River Heights Trail ❑ New Construction Use: ❑ Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD_ ❑ Replacement ❑ Public or commercial - Describe: Z Cjl�, i CAAC Parent material OutWash Plain (Go6 Gotham Flood plain elevation, if applicable General comments and recommendations: Replacement area is suitable for conventional system with a 0.7 gpd /sgft rate. Possible system elevation is 89.6 ' F-11 Boring # [] Boring ❑ Pit Ground surface elev. 97.60 ft. Depth to limiting factor 136+ 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 'EfW 1 0 -12 10yr3/4 none vfsl 2mgr mvfr cs 2f lvf .4 .8 2 12 -28 10yr6 /4 none Ivfs Osg ml cs 2vf .4 .6 3 28 -37 7.5yr5/6 none sl lmsbk mfr gw - - - - -- .4 .7 4 37 -65 10yr6 /3 none vfsl imsbk mfr gw - - - - -- .2 .6 5 65 -74 10yr6 /4 c1d 7.5yr6/8 sil imsbk mfr cs - - - - -- 4c 6 7.5yr6/2 6 74 -80 10yr5 /6 none grcos Osg ml cs - - - - -- .7 1.6 7 80 -136 10yr6/4 none s Osg ml - - -- - - - - -- 7 1.6 ( O S -- 1� 03 otr3 C40w oy Cvl$edN 5 of yyc�-��w�fIfv%CMed -, o� � Ra. t Boring # Boring ❑ Pit Ground surface elev. 96.22 ft. Depth to limiting factor 118+ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Effn 1 0 -17 10yr3/3 none vfsl 2mgr mvfr as 2f,2vf .4 .8 2 17 -32 10yr6 /4 none Ivfs imsbk mvfr as 2f lvf .4 .6 3 32-48 7.5yr5/6 none vfsl imsbk mfr gw lvf .2 .6 4 48 -64 7.5yr6/3 none vfsl imsbk mfr gw - - - - -- .2 .6 5 64 -97 10yr5 /6 none grcos Osg ml cs - - - - -- .7 1.6 6 97 -118 10yr5 /6 none s Osg ml - - -- - - - -- .7 1.6 " Effluent #1 = BOD 5 > 30 < 220 mg /L and TSS >30 < 150 mg /L " Effluent #2 = BOD s30 mg /L and TSS S mg /L CST Name (Please Print) Signature: CST Number Thomas J. Schmitt ` . - 227429 Address Schmitt Soil Testing, Inc. Date Evaluation Conducted Telephone Number 1595 72nd Street New Richmond, WI 54017 8/12/2010 715- 247 -2941 SBD -8330 (R.07 /00) ,Property Owner Kurimay, Rowen & Bonnie Parcel ID # 030 - 2024 -60 -000 Page 2 of 4 1 Boring # El Boring pit Ground surface elev. 94.15 ft. Depth to limiting factor 110+ 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 10yr3/3 none vfSl 2mgr mvfr Cs 2m,2f .4 .8 2 12 -18 10yr4/3 none vfsl 2msbk mvfr CS if .4 .8 3 18 -32 10yr6/3 none vfsl lmsbk mfr Cs if .2 .6 4 32-44 7.5yr5/6 none vfsl imsbk mfr CS - - - - -- . 2 .6 5 44 -64 7.5yr5/6 none grls lcsbk mvfr CS - - - - -- . 7 1.6 6 64 -84 10yr5 /6 none gricos Osg ml Cs - - - - -- . 7 1.6 7 84 -110 10yr6 /4 none s Osg MI - - -- - - - - -- .7 1.6 e = ga, F-1 Boring # Boring El 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 # 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 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) Schmitt Soil Testing, Inc. Page 3 of 4 Conducted by: Conducted For: Schmitt Soil Testing Inc Name: Rowen & Bonnie Kurimay ` Thomas J. Schmitt, CST 227429 Address: 221 River Heights Trail 1595 72nd St. City, State, Zip: Hudson, W154016 New Richmond, Wl. 54017 Phone: 715- 247 -2941 Subd .Name: NA CSM 2/396 si9nam,re Lot No.: 1 Date !c� %L� Legal Description: NE1 /4 NWl /4 S12 T29N R20W ■ Backhoe pit Township, County: St. Joseph, St Coix County ♦ Bench Mark 1 El. 100.00' Top of 2" PVC pipe 0 Bench Mark 2 El. 99.20' Top of brick wanes coating on front of house Slope= 5% Scale 1" = 40' bin t�V ' L PTIC V L'� +� �r O � �v S c'� �k - p r .. a c A l tom. OW j5 Si it V A& [4# J ;1 1 y r Y! r y a - au Ak t Page 7 of 11 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner: Row Tank Manufacturer: ❑ NA n & Por�r.'�e Kurima Concrete e Wieser C oncre Permit # ® Septic ❑ Dose ❑ Holding Volume: 10 0 0 gal DESIGN PARAMETERS Tank Manufacturer: Wieser Concrete ❑ NA Number of Bedrooms: 3 ❑ NA ® Septic ❑ Dose ❑ Holding Volume: 1000 gal Number of Public Facility Units: 0 NA Vertical Distance Tank Bottom(s) to Service Pad: ft Estimated (average) Flow: 300 gal /day Horizontal Distance Tank(s) to Service Pad: ft Specific servicing mechanics must be provide if vertical is >15 feet or if Design (peak) Flow = estimated x 1.5: 4 S n gal /day horizontal is >150 feet. Specific instructions to be provided on back. In Situ Soil Application Rate: C.7 gal /day/fe Effluent Filter Manufacturer: Polylok ❑ NA Standard Domestic InfluentlEfftuent Monthly average Effluent Filter Model: 5 Fats, Oil & Grease (FOG) :30 mg /L Pump Manufacturer: Biochemical Oxygen Demand (BOD :220 mg/L ❑ NA ® NA Total Suspended Solids (TSS) :150 m /L Pump Model: High Strength Influent/Effluent Monthly average Pretreatment Unit Fats, Oil & Grease (FOG) >30 mg /L Manufacturer: Biochemical Oxygen Demand (BOD >220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Peat Filter ® NA Total Suspended Solids (TSS) >150 m /L ❑ Disinfection ❑ wetland Pretreated Effluent Monthly average ❑ Sand /Gravel Filter ❑ Other: Biochemical Oxygen Demand (BODs) s30 mg /L Soil Absorption System Total Suspended Solids (TSS) :30 mg /L NA Fecal Coliform (geometric mean) :10 /100m1 ❑ In- Ground (gravity) ❑ In- Ground (pressure) ❑ NA Maximum Effluent Particle Size: Y8 in dia. ❑ At - Grade El Mound ❑ NA ❑Drip - Line ❑Other: Other: ❑ NA Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Pump out contents of tank(s) ❑ When combined sludge and scum equals one -third (35) of tank volume ❑ When the high water alarm is activated Inspect condition of tank(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA 3 ® year(s) ❑ Inspect dispersal cell month(s) s) At least once every: (Maximum 3 years) ❑ NA 3 UN year(s) Clean effluent filter At least once every: ❑ month(s) ❑ NA 3 ® year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA ❑ year(s) Flush laterals and pressure test At least once every: C3 [I yea ) m [I NA Other: At least once every: ❑ month(s) ❑ NA ❑year(s) Other: ❑ NA I 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 (pumper). Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The 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 treatment tank equals one -third (36) 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 s12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. (Rev.2/05) Page 8 of 11 Page of START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals or sediment that may impede the treatment process and /or damage the soil dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. n it conditions re frozen at the infiltrative surface. System start up shalt not occur when soi co s a During extended 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 and may overload them resulting 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 r n a Plumber or POWTS Maintainer to assist in manual) operating the um effluent um o contact Y P 9 pump controls to restore normal levels pump 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) discharge; 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 sys tem is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: i • All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • 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 the opportunity to obtain a sanitary permit for a code compliant replacement system: suitable replacement rah en evaluated an may be utilized for the location of a replacement soil absorption stem. ❑ A su le a e as be d y P P Y The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and /or soil limitations. If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort. The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING: TREATMENT TANKS AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES AND LACK SUFFICIENT OXYGEN TO SUPPORT LIFE. NEVER ENTER A TREATMENT TANK OR HOLDING TANK UNDER ANY CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK IS VERY DIFFICULT. ADDITIONAL INFORMATION: POWTS INSTALLER POWTS MAINTAINER Name: John Schmitt Name: J ohn Schmitt Phone: 715-760 Phone: 7 15-760-0486 SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name: Apostle Septic Service Name: St. Croix Count Zonin Phone: 71, Phone: 715- 386 -4680 This document is intended to meet minimum requirements of Ch. Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Use of this document does not guarantee the performance of the POWTS. (Rev. 2/05) I Page 9 of 11 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner /Buyer Rowen & Bonnie Kurimay Mailing Address 221 River Heights Trail ' Same Property Address (Verification required from Planning & Zoning Department for new construction.) Hudson ' WI 030 - 2024 -60 -000 City/State Parcel Identification Number LEGAL DESCRIPTION NE NW 12 2 9 20 St. Joseph Property Location ' / 4 , ' /4 , Sec. , T N R W, Town of Subdivision Plat: , Lot # 1 Certified Survey Map # 02 om 3 d Volume'" , Page # Warranty Deed # 3 - 7 (before 2007)Volume 7(o ,Page # . Spec house : i 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. 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 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. I /we am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. N e of bedrooms ?Qid SIGNATURE OF APPLICAN (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) r 5'1'ATE BAR OF tFt$CONSJtt —FORM ti a . !... A 3 -. SVARAAhITt':DEED:''• $. C� - ._ THts'spAce RESERVED 00 RECORDMG DATr v 341 t il REQ4S.TERS OfFI�E Rudolf Ferruarm and Maria -El sorbet Hermann, -- ' s hez - own — ' harlf, ST. G._Ci`; CO:; WIS. a -- - Recd. i~cr R c-ir:� 27t ` -" d caav ra and war . ards:to - Forle n . 'G Kurimay- an e ms a.y onn] — Q f .o urie A D 19 7� e Y. Kurim . - sl artd and wife as _ 3 o nor enants , opbta►� H of as , � _ - e. C u_ ma _ to `� i _� f St Croix x Y the fcltom'n� described ' u .� ,. ! r a.! estate in Co n[ e [ _ g y �i Store a( Wiscansin_._' c8� Pl d3.2e 1 A'p 209 �t , x aul.,. M 55119 A Parcel ' of land. located in C overnment : Lot 1, Tait Key No N Section 1.2 , :Township 29 N6rth.,. Range ,20 West, �• described as: Lot 1 on the rtif ed_ Surve Ma filed June :2Q 1977 , C.:.. - the off_ice .'of th`e Reg ister of. Dseds for. St. Ce a ..: Re `i y p .i n . Wiscoin ' 1. . _ - d.roi -x county ns in Voluttte . 2 , page : 395 , document 3 together with an easement 'for. an ' access road .over the parce'1 °Of land mar}ced' "pub�ic.:road" as shown on. .`the r "f. ceitiried uxvvPv_,Maps.recorced,:in Volume:_2, p:ages.-'396 .and_ 388 and:. over the road described_ in "paragraph` numbered;l on page 3 of the: Road4ray - Agreement recorded in .the office ..of the said Register of •Deeds in" Volume . 5?4 ,' :pages: 92 -101, document 348583 Supplement Volume 574, pages 102 105, 348584 E F 'T'RANSFER � 33, • f a IM I} - r This not: homelteed propert y l� (is) (is not)..: 1' Exception to warranties Subject to :the Declaration of Covenants to be recorded in the of fice.:of the Register of Deeds for said .County prior -.to or at the. •..t me`0f recording, this deed: + Dra 7 8 __ 6 b Dated this _:_ day _ , 19._.: U li _._.. (SEAL) �w'' (SEAL) 4 . . _. _ _.. ...... z2udo> - Hermann _ • . (SEAL) Marla– Elisabet Hermann AUTHENTICATION ACKNOWLEDGMENT Signatures authenticated.-this _ �1 ay of STATE OF t�la ' ss. �. Madison County. Personally came before me, this day of k May, 1978 _ the above named_ _ TITLE': MEMSER STATE BAR OF WISCONSIN Rudolf.- . Hermann and Maria Elisabet_ )f not, �'. ( Hermann, his wife 3` authorized by § 706.06, Wis. Stars:) ,E - +; l . This instrument was drafted b v John .D. .Heywood,. Attorney at - Ht1d Wisconsin — to me known. to be the person who executed the fore - going to trument and a cknowledged the same.' (Signatures may be authenticated or a Linnie H. Cronin cknowledged. Both C are not necessar Notr.r Public Madison - 1a. Y) Y you 7glS�i A � . nCY. T v C {_. My Commission is permanent. (]f rtbve stat x nation P %- - dale - - -- P.iove�rr tEs�r 17 °. WARRANTY DEED-STATE DAR OF WISCONSIN. PORN NO. 2-1977 ' .... --•-- ' Page 11 of 11 Met ti S� i _.: r w �} 4 rr r w� _ 6 w k rt cq tot Jr 0 Jir .O V �Q Nvisc onsin SOIL EVALUATION REPORT #9635 Department of Commerce in accordance with Comm 85, Wis. Adm. Code Page 1 of 4 Division of Safety and Buildings Schmitt Soil Testing, Inc. Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. Please print all informadon. 030 - 2024 - 60-000 Personal information you provide may be used for seconds N purposes (Privacy Law, s. 15.04 (1) (m)). Reviewed By Data Property Owner Property Location Kurimay, Rowen & Bonnie Govt. Lot 1 NE1 /4, NW1 /4, 812, T29N, R20W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 221 River Heights Trail 1 CSM 2/396 City State Zip Code Phone Number C dy L] Village ® Town Nearest Road Hudson WI 54016 651 - 214 -1758 St.Jose h p River Heights Trail N L] New Construction Use: []_ Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement 1- 1 Public or commercial - Describe; Parent material Outwash Plain (GoB Gotham General comments Flood plain elevation, if applicable na ft. and recommendations: Replacement area is suitable for conventional system with a 0.7 gpd/sgft rate. Possible system elevation is 89.60'. Boring # ❑ Boring (] Pit Ground surface elev. 97.60 ft. Depth to limiting factor 136+ in. Horizon Depth Dominant Color Redox Description Texture Structure Soil Application Rate in. Munsell Qu. Sz. Cont. Color Consisten Boundary Roots GPD/ftx Gr. Sz. Sh. 'Efr#1 - EfW 1 0-12 10yr3 /4 none vPsl 2mgr mvfr Cs 2f,lvf .4 .8 2 12 -28 10yr6 /4 none lvfs 05g ml Cs 2vf .4 .6 3 28-37 7.5yr5/6 none sl imsbk mfr gw - -- .4 .7 4 37 -65 10yr6 /3 none vfsl imsbk mfr 9w ,2 .6 5 65 -74 10yr6 /4 c1d 7.5yr6 /8 �I imsbk rnfj (S 7.5yr6/2 .4C .6 6 74-80 1 r5 6 OY / none grcos Osg ml a - .7 1.6 7 80 -136 10yr6 /4 none s Osg ml �� ❑ — .7 1.6 Boring # [ -� Boring 2 Ej Pit Ground surface elev. 96.22 ft. Depth to limiting factor 118+ in. Horizon Depth Dominant Color Redox Oescri lion Soil Application Rate p Texture Structure Consistenc Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Efl#1 'EM 1 0 -17 10yr3 /3 none vfsl 2mgr mvfr as 2f,2vf .4 .8 2 17 -32 10yr6 /4 none Ivfs imsbk mvfr as 2f,1vf .4 .6 3 32-48 7.5yr5/6 none vfsl imsbk mfr gw ivf .2 .6 4 48-64 7.5yr6/3 none vfsl imsbk mfr gw 5 6497 10yr5/6 none grcos Osg ml cs - - - - -- .7 1.6 6 97 -118 10yr5 /6 none s Osg ml ' Effluent #1 = BOD 5> 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 Thomas J. Schmitt CST Number 227429 Address Schmitt Soil Testing, Inc. Date Evaluation Conducted Telephone Number 1595 72nd Street New Richmond, WI 54017 8/12/2010 715 - 247 -2941 • Propgrty Owner Kurimay, Rowen & Bonnie Parcel ID # 030 - 2024 -60 -000 Page 2 of 4 • El Boring # El Boring Pit Ground surface elev. 94.15 ft. Depth to limiting factor 110+ in. Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots Soil �IDt Rate in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Etf1t1 T 1 0 -12 10yr3 /3 none vfsl 2mgr mvfr Cs 2m,2f .4 .8 2 12 -18 10yr4/3 none vfsl 2msbk mvfr cs if .4 .8 3 18 -32 10yr6/3 none vfsl imsbk mfr cs if .2 .6 4 32-44 7.5yr5/6 none vfsl imsbk mfr Cs ---- -- .2 .6 5 44-64 7.5yr5/6 none grls icsbk mvfr is .7 1.6 6 6484 10yr5 /6 none grlcos Osg ml Cs - - - -_ .7 1.6 7 84 -110 10yr6 /4 none s Osg ml .7 1.6 F —I Boring # ❑ Boring Pit Ground surface elev. ft. Depth to limiting factor in GP2 Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Soil App Rate �' oots in. Munseli Qu. Sz. Cont. Color App licatio n DlftD/ft Gr. Sz. Sh. •Eft#1 'Eff#2 ❑ Boring # r Boring Pit Ground surface elev. ft. Depth to limiting factor Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary - in Roots Soil App D /ft2 Rate in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Etf#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 SBD -8330 (R.07/OD) need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608- 264 -8777. • Page 3 of 4 Conducted by: Conducted For • Schmitt Soil Testing Inc Name: Rowen & Bonnie Kurimay Thomas J. Schmitt, CST 227429 Address 221 River Heights Trail 1595 72nd St. City, State, Zip: Hudson, Wl 54016 New Richmond, WI. 54017 Phone: 715- 247 -2941 Subd.Name: NA CSM 2/396 Si gncftro , . U-- J Lot No.: 1 Dcft ��c�,�0 Legal Description: NE1 /4 NWl /4 S12 T29N R20W ■ Bockhoe pit Township, County: St. Joseph, St Coix County ♦ Bench Mark 1 El. 100.00 Top of 2" PVC pipe 0 Bench Mark 2 El. 99.20 Top of brick wanes coating on front of house Slope= 5% Scale 1" = 40 4i� 07 G W ri _. — 1 ok' 1' roll d ali m w 4 M e m n m va P q � I N 0 F r C 3_ (�� 0 �G a 96 # o o 3' 0 2 t!i Z '(('�� N C N CS • = Ot. 3 C . A Ul M. L IV O F.-M N (D V 3 O co N m Z d N y O N a m O W= O Q N G ID to N Oho 'D n m n O -i O G O 3 CD o O m co y th �• n W CD V 3 O � ' rn m Iw I ~ � o � ? I tQ y � y O c 3 cr M z o o CL M 0 3 c_ 3 _ to rn co N O C Z lv Dmo I cn cn f�D N C M. MA V y } C L i a 3 7 (D N C n n A a 2 O 0 . C c N z w a I s� v e — n. N y I I i I n N I ~ N O a A CD < Q ti Oq O I o O O y • AS BUILT SANITARY SYSTEM REPORT ' WNEA jk4 I i j0 ML9 , TOWNSHIP,��� SEC . T�Z�N, R _ W °.0. ADDR SS- ST. CROIX COUNTY WISCONSIN. hUBDIVISISNI, c_ _ , 4)#/ 1 7 L.cl ts , LOT/ef,4LOT SIZE PLAN VIEW -Distances & dimensions to meet requirements of H62.20 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM 53 rf ,t PTIC TANKS) MFGR. (,J, e S j2 f CONCRETE_ STEEL N07 of rings on cover Depth 10" DRY WELL TENCHES NO. of width length area I D no, of lines width 1$l•' length area / depth to top of pipe �" -- XREGATE t/ ERK RATE ( „ AREA REQUIRED-- 15 AREA AS BUILT__'"`_ sciaimer: The inspection of this system by St. Croix County does not imply complete :mpliance with State Administrative Codes. There are other areas that it is not possible inspect at this point of construction. St. Croix County assumes no liability for 'stem operation. However, if failure is noted the County will make every effort to -termine cause of failure. _EASES AND OILS SHOULD NOT BE DISPOSED THROUGH THIS SYSTEM---- � ~ INSPEC DATED / , 7 PLUMBER/ON JOB /,► t�. 1,�„ —� LICENSE NUMBE I i . .. _ .. ... ......... _ . ..... +wv- �+w.. - +�. ... .. �...1.i`..... .... .v_:4 1 ..:.: YgYw.w' - -..- .... - - .. +*••M�•': REPOR o f IIISPECTION-- INDIVIDUAL SEWAGE DISPOSAL SYSTEM • Sanitary Pernit r� • • ,' r / State Septic f'•A'� _ ' Toi 11SHIP F •, t roi% County - -- • .' r r i Sizev gallons, 'lumber of Connartazents. I Distance From: Well ft, '�r 127 or greater slop 0�Lt Building* 20 ft. Wetlands 0 Iiighwater DISPOSAL SYSTH Tile Field or Seepage Pit(s) Distance From: Well � ft. 12% or greater slope' �' t • ...sue Builcinr �l _ ft, Wetlands O (J f;. FIELD Highwater ft. , Total length of lines -,/�J ft, Humber of lines Length of each Line Oft, Distance between lines ft. Width of the trench eft. Total absorption area sq. ft. Depth of rock below tile min. Depth of rock over tile in., Cover _ -aver. rock., n • 'L fi �. Depth of tide below grade in. Slope of trench � #n per 100 ft. Depth to Bedrock ft. Depth to ground water ft. PITS . Number of pits Outside d ame er,r` - ft, Depth below inlet ft. Gravel around pit: sro, Total absorption area f e Square feet of seepa trench,bottom area required Square feet of se ag k nit ea�,frequired Inspected by: 7 e t Title':. ti € Approved Date 197 _ — T ._______ _..•... Rejected Date 197. • 46 y `' :H 115 WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES ` DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH P.O. BOX 309 MADISON, WISCONSIN 53701 ,�� REPORT ON SOIL BORINGS AND PERCOLATION TESTS LOCATION: 4 ! 0 %4, 4, Section L2—, TAN, R�4)E (or) W, Township or Municipality Lot No. Block No. 4!� 1-07 S dT ,S --GT. �1 - Z County O p �/� ,POk �/ U Subdivision Name Owner's Name:( b MA V _ Mailing Address \ : 0 L SD'l) pr 20 TYPE OF OCCUPANCY: Residence A No. of Bedrooms Other EFFLUENT DISPOSAL SYSTEM: NEW x ADDITION REPLACEMENT DATES OBSERVATIONS MADE: SOIL BORINGS � 2 ' PERCOLATION TESTS J U,t1E � 3 "M SOIL MAP SHEET Z �f 5 ^� SCS SOIL TYPE Ct�D /�� 00 � "0 t �LOf�/�? TYPE PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCISES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN /IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P— 3� R p,�ciiv��� s�iF A-5 ZS o -2- % `` /rte % 3 P— 2 34, T� /3 /3 I � % % 4,✓r P -3 1 3& 4 /3�Z-bcv Z� U .� � //� �(� X� SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED) 72- A/!JA/E > 7j, 0" TS Z(, / �Co " �fipe S , 011 75 0 -2 4 q T r5 Z.2 / PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.) Indicate on the plan the location and square feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy. dFD Indicate scale or distances. Give horizontal and vertical reference points. Indicate slope. Af Y ,470 C, T , 0 cp C i I C L I o °I G 17 U` rn r Q I o w m \ 1' 17 No� I, the undersigned, hereby certify that the soil tests reported on this f rm were made by me in accord with th cedur � and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test _ s 19.S t to the best of my knowledge and belief. (n 1� Name (print) Certification No. Address U F 2'V� Ce ,Q - EL l� U Name of installer if known CST Signature COPY A —LOCAL AUTHORITY State and County State Permit # �� PL B6 7 Permit A PP er Application County P '# ' for Private Domestic Sewage Systems County, * DENOTES STATE APPROVAL REQUIRED Date Approval Received from State if Required State Plan I.D. # A. OWNER OF PROPERTY Mailing Address: jv//-$ a A - A 2,01 Z L im B. LOCATION: ' /4 Y a, Section N, R E (or) Lot # City Subdivision Name, nearest road, lake or landmark Blk# Village Township 3 So EF C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) *Variance Single family Duplex No. of Bedrooms No. of Persons Z D. TYPE OF APPLIANCES: Dishwasher YES NO Food Waste Grinder YES NO # of Bathrooms 9%/ Automatic Washer YES NO Other (specify) E. SEPTIC TANK CAPACITY I Q©n Total gallons No. of tanks *Holding tank capacity Total gallons No. of tanks New Installation Addition _ Replacement _ Prefab Concrete *Poured in Place Steel Other (specify) F. EFFLUENT DISPOSAL SYSTEM: Percolation Rate 1L,� 2)_4.53) Total Absorb Area a I sq. ft. New Addition Replacement *Fill System �p Seepage Trench: No Lin 7 Feet Width Depth Tile Depth No. of Trenches Seepage Bed: Length Width I& Depth Depth No. of Lines _ Seepage Pit: Inside diameter Liquid Depth Tile Size Percent slope of land Distance from critical slope I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20, Wisconsin Administrative Code, and that I have sized the effluent disposal system from the EH -115 prepared by the Certi ied Soil Tester, ° ,1 NAME P_ P, r ( C.S.T. # -0 d other information obtained from N (//C I /44 (o ner /builder). � Plumber's Signature M /MPRSW# Phone 24� d Plumber's Address D O N o f PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20, including well). l h� W 63. Do Not Write in Space low OR DEPAR MENT USE ONLY j p Q _�� Date of Ap lic i Fe P " Stat 0 0 County / f l � D to Permit ssue t ate) – !� Issuing Agent Name Inspection Yes No Valid# Date Recd 1, county (w i copy) 3, owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701 2. state (pink copy) 4. plumber (canary copy) Revised Date 6/1/76 TRANSFER FORM P L 6 I SANITARY PERMIT - State Permit # Z .> Sanitary Permit # County _s Crc��x Sanitary Permit Transfer Date —Original Permit Issuance Date A. Property Location: AILJ %A LkLl, I Section Z2 T —al N,R o?CJ , E (or) Q Lot # City Subdivision Name, Nearest Road, Lake or Landmark BLK # Village Townshi B. TYPE of Occupancy:.Commercial Industrial Other (Specify) Single Family Duplex No. of Bedrooms Variance C. SEPTIC TANK CAPACITY A -706 Total gallons No, of tanks i HOLDING TANK CAPACITY Total gallons No. of tanks ,Prefab Concrete X Poured -in -place Steel Fiberglass Other(Specify) New Installation X Replacement LIFT PUMP TANK /SIPHON CHAMBER Total gallons Prefab Concrete Poured -in -place Other (Specify D. EFFLUENT DISPOSAL SYSTEM: Percolation Rate -Total Absorb Area 4z IS sq. ft. New Replacement Alternate(Specify) Seepage Trench: No.Line I Ft. Width Deptt�h Tile Depth(top) No.'Trenches Seepage Bed: Lengt �� Width �g Depth 2D . Tile Depth(top) No. of Lines Seepage Pit: Inside diameter Liquid Depth No. Seepage Pits Percent slope of land Distance from critical slope E. WATER SUPPLY: ❑ Private ❑Joint ❑Community ❑ Municipal Present Sanitary Permit Holder Phone No. Sanitary Permit Transferred To: Phone No. Irit Name n f1(jAiuZLi Name CAC PA' T / 1 Address Address zip symp I, the undersigned, do hereby certify that I have reported all revisions to the sanitary permit and that all revisions are in accord with section H 62.20., Wisconsin Administrative Code and that I d the effluent disposal system according to the EH -115 prepared by the Certified Soil Tester a or y addition of sts tha ay have been required. Plumber's Signature MP /MPRSW # � j �.3 Phone *-- �- Plumber's Address r I Wl s Z Q Information obtained from (owner or agent) PLAN VIEW: Provide sketch below of any revisions to original sanitary permit. Include direction of slope and all distances in accord with H 62.20. Well location shall be included on the sketch. Indicate or dimension location of all wells, on the property or neigh- bor's DrODert . If well has not been drill ' nd ma Lo TE= 1 _7TT T__ Y I 4 Signature of Issuing Agent 1. County (Yellow copy) 3. Owner (Pink copy) DIVISION OF HEALTH 2. State (White copy) 4. Plumber (Green copy) P.O. BOX 309, MAQISON WI 53701 J Parcel #: 030 - 2024 -60 -000 03/21/2006 03:04 PM PAGE 1 OF 1 Alt. Parcel #: 12.29.20.43661 030 - TOWN OF SAINT JOSEPH Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner ROWAN G &BONNIE KURIMAY O - KURIMAY, ROWAN G & BONNIE PO BOX 385 HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description * 221 RIVER HEIGHTS TR SC 2611 SCH D OF HUDSON SP 1700 WITC Legal Description: Acres: 3.100 Plat: N/A -NOT AVAILABLE SEC 12 T29N R20W GL 1 LOT 1 OF CSM 2/396 Block/Condo Bldg: Tract(s): (Sec- Twn -Rng 401/4 1601/4) 12- 29N -20W Notes: Parcel History: Date Doc # Vol /Page Type 2005 SUMMARY Bill #: Fair Market Value: Assessed with: 84302 675,400 Valuations: Last Changed: 09/07/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 3.100 358,600 255,700 614,300 NO Totals for 2005: General Property 3.100 358,600 255,700 614,300 Woodland 0.000 0 0 Totals for 2004: General Property 3.100 358,600 255,700 614,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 502 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges P P 9 Total 0.00 0.00 600