HomeMy WebLinkAbout030-2102-00-000 Safety and Buildings Division County
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V isloons i n 201 7162 Madi (6f315T p6 2 Sanitary Permit Number ( to be filled in by Co.)
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1 Department of Commerce 3 ? 5 ?b
Sanitary Permit A pli&&W 2006 State Plan I.D. Numb
In accord with Comm 83.2 1, Wis. Adm. Code, al information you provide
may be used for secondary purposes Lav W40UNTY Project Address (if different than maih address)
I. Application Information - Please Print All Information ��� �r y� /a✓t V I et„�
i
Property Owner's Name / Parcel # Lot # Block #
Property Owner' ain Address - - d
� li g Property Location
City, S
L Zip Code Phone Number Section ---- • ,�aincley� -'Z� T 36 N; - e II. Type of Building (c all that apply) �(,, 3 � R E
'9I or2 Family Dwelling - Number ofBedrooms Ay- r, V Subdivision Name
❑ Public /Commercial - Describe Use 'lA
❑ State Owned - Describe Use Z U - ��� Q� , . 9 :1J✓ / S� / S r ❑City ❑ Vill "ship of
s'
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A.
New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
B. - E Permit Renewal Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type 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 ❑ D ' m ravel -less Pipe Oth (explain)
V. Dis ersaUTreatmentArea Information: _
Design Flow (gpd) Design Soil Application Rate(gpdsf) Dis equ Area Proposed System Elevation
— ,/ °! 3b 1 /
VI. Tank Info Capacity in Total Number Manufacturer P Site Steel Fiber Plastic
Gallons Gallons of Units Concrete Constructed Glass
New F.)osting
Tanks Tanks
Septic or Holding Tank
Aerobic Treatment Unit / ✓
Dosing Chamber
VII. Responsibility Statement- I, the undersigned, ass . responsibility for installation of the POWTS shown on the attached plans.
Plumber's e ht) Plumb 's Si MP/MPRS Number Business Phone Number
P1 ber'!§ Address (Street, City, State, Zip ode)
VIII. Coun /De art Use On
Approved ❑ isapproved Sanitary Permit Fee (includes Groundwater Date u Issuin gent Sign o
Surcharge Fee)
Ow n Reason for Denial 75
. Ob Z
IX. Conditions of Approval/Reasons for Disapproval
SYSTEM OWNER:
1. Septic tank, ef&wnt filter and
dispersal cell must all be servit:es / maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained
as per appIC" Code / ardKWIM.
Attach complete plans (to the County only),for the system on paper not kss than 812 x I1 inches in size
SBD -6398 (R. 01/03)
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Safety and Buildings Division county
201 W. Washington Ave., P.O. Box 7162
IIsloonsin Madison, WI 53707 - 7162 S
Dep artment of Commerce _ ' >>
Sanitary Permit Application Address �� 3i r
In accord with Comm 83.21, Wis. Adm. Code, petsoml i�o vide ❑ Check if Revision
ma be used for secondary Privacy Law; s1�5, 1 rti
I. Application Information - Please Print All Information r State Plan I.D. Number
Property Owner's Name ";') - Parcel Number
Property s A s Property Location 4.
City, Sfate Zip Code Pirsne.Number Lot N r Block N ber
SubdivW n Name CSM Number
�AAL S
H. Type of Building (check all that apply) ws y , t „ ❑City
1 or 2 Family Dwelling - Number of Bedrooms --75 ❑Village
❑ Public/Cotnmercial - Describe Use owmhip
❑ State Owned Nearest Road
2 ) 3 r G&. fis , �
III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable)
A. 1, New 2 ❑Replacement System 3 ❑Replacement of 6 ❑ Addition w jFor C ounty use
Sy stem Tank Only Existing sum
B. 11 Check if Sanitary Permit Previously Issued
Permit Number Date Issued
IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) �tE 14" loo
44 0 Non - Pressurized In- Ground 21❑ Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland
22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line
45 ❑ At -Grade 46 ❑ Aerobic T=tment Unit 4 ❑ Reciicula ' 30 11 Other
V. D' rsaUTYeatment Area Information: -
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rau System Elevation Final Grade
Required
Proposed Rate(Gals./Days/Sq.Ft.) (Min. ) Elevation
\ � r Total Number Manufacturer Prefab �� D
Capacity VI. Tank Info tY m Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank
Dosing Chamber
VII. Fe 'bility Statement- I, the undersigned, a responsibility for installation of the POWTS shown on the attached plans.
Plumber's ame ) Plum is Si cure MP/MPRS Number Business Phone Number
S
Plumber's Address (Street, City, tate, Zip Code
VIII. County /De artment Use Onl
Approved ❑Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Surcharge Fee)
❑ Owner Given Initial Adverse I/
Determination �-
EX. Conditions of ApprovaUR ,-& for Disapproval -b 4-- e6` _ Imo` ( -6 S l
y�„ � tv�S ..G- -w Au-, tb' & Se+�S 0• �8 f'.Q �•� z"
D
�-- plebe Elam (to the County only) for the em on not E z Il inches in size Qp
��tl is CIMaf -�
SBD -6398 (R. 05101)
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�arllil'N�111an b,, SOIL AND SITE EVALUATION REPORT Pape„ a
°f in accord w%h ILHR 83A5, Wis. Adm. Code
L ,
Attach ails Plan on PaPW nc¢ 119" than 8 112 r t t inches in size. plan nwst include. but St. goda
tact limited vwfical end horizorMal reierenoe Point (BM, direction and % of slop*. seals or PARCEL I.D. t
dtnensran . - north arrow, and location and datarsse b nearest road.
APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION
r+'riC1PERTYO1MWEf�' ZZ a�O
PROPERTY LOCATION
J 40VT, LOT S fq SW t14,$ 2g T ,N.R W
PROPERTY OWNER:$ IYM UNG ADORESB LOT f &=4 t3U90. NAME OR CSM of
Carr. STATE at coop P�roNE NUIMgEp 29 a-- INUMTROAD
Wt- M401-L ! ILUIGE LNCWM
rid New Consbucion Lett Pc I Reefd.MM / Nun+eer of ttedranms 3
L 11 4"Aw oaten! I j Public of W MWdd deecxibe — (1 Addil�dt to •>tls<rrq bupdnq
Code 6#4d.d* Now 450 Wd R==Wnded d*n lading rate _.7 bo,
AbsorPlion area M*Arsd 643 bed. a 56 3 tench, 4 Wa* m design 1006V rob __.7 bed. 8pdnf . � trench. V Reaom►nended Y»ElrWpn av4a slwaNan(e} 99,...0 al area=
97.65 ft in rowed le aNe plan bendwa k)
Additional deeipn aNa maidwa`ons na -
Pannl mWerial _ pitted glacial drift Flood pain elemishon, Mapploabis na R
S s S{t u b � Cat111811 ?dtAl �IOWD P1 Csf10tJN0l�PIESSt1RE AT-OE t{YSTQI IN FLL ►IOLDArO TAW
13U ®s ❑ � D IES ou ®S aU ®$ 13U L Gi
• SOIL DESCRIPTION REPORT
g oring d Horizon Depth Dominant Color ' Mottles Texture structure � �Y Boob GPD/ft
In. Muriseil tau. sz. Cora Color Gr. Sz. Sh. ;`
1 b
Z 9 Y r 4 norms sicl lcsbk mfr 9v if .2 .3
Ground
elev. { 4 - mvfr na na .7 .8
)2,L f t.
Depth to
OrNfi 5
fi ,bZa
Remarks: 14
Boring a
2
e atvfr if .5. .6 :�
Ground 4 la i 0 mvfr na na .7 .8
elev, � ,
L4� --
�
Do* lo
ter Ila .
Remarks:
CST Name: - Please FcW Gary L. Steel Ptx m: 715 - 246 - 62M
Address 1554 2 N ow Rich W1 NO_l7
Signature: Darr:
" - 1I -12 -96 csr Nvmtber. uronns
iOP9MOWNjA Joanne Persico
SOIL DESCRIPTION REPORT Page 2 of
,RC.ELLD.#
Ang I # Horizon Depth Dominant Color Mottles Texture Structure consiew" emxdny Roots! apo/ftZ
In, Muns9l ,U Sz, Cont. C010C 11r. Sz, Sh. Bed JTMnCh
3 1Qvr4Z3 none OU 2mabk Inf r —2f-
1 0-15
2 15-34 Ift r4 4 none sicl 1 mfr I ay .2 .3
•ound 3 34-89 7.5 r4/4 none is Osa zvfr na na .7
N -
?Plh to
tar
Remarks:
)ring #
nme gil 7MMhk fflfr 2f
.4 2 10-28 _1 Oyr4
14 —none _A_ic,1 lcsb-k mfr aw If
28-84 7.5yr4/4 none la Oaa ffwfr
CUM[ .7 R
:I)Lh ID
ng
.tor
+84 11
Remarks:
ling #
10yr4 3 none S1 2=r CS 2f .5
N I iO-12_,
4 .6
1 4' ,
2 12-26 7.5 r4/4 none 2mor mvfr
M if .5 .6
3 26-84 7.5 r4 4 none
iund 1S Os mvfr na na .7 .8
pth to
iting
+84 11
Remarks:
ring #
v.
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Dth to
; fing
.or
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STEEL'S SOIL SERVICE
Gary L. Steel Joanne Persico 1554 200th Ave.
CSTM2298 SEkSWk S29- T30N -R19W New Richmond, Wi 54017
MPRSW 3254 town of St. Joseph (715) 246 -6200
lot #29- Highland Dills Second Addn.
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EM-= top of E lot stake el. 100'
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' County:
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM St. Croix
Safety and Building Division
' INSPECTION REPORT sanitary Permit No:
395290 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:
Bishop, Terry St. Joseph, Town of 030 - 2102 -00 -000
CST BM Elev: Insp. BM Elev: BM Description: Sectionfrown /Range /Map No:
29.30.19.829
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Dosing Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic Dt Bottom
Dosing Header /Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
PUMP /SIPHON INFORMATION
Manufacturer Demand St Cover
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length Dia. Dist. to Well
SOIL ABSORPTION SYSTEM
BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR
Type Of System: UNIT Model Number:
DISTRIBUTION SYSTEM
Header /Manifold IDistribution x Hole Size x Hole Spacing Vent to Air Intake
Pipe(s)
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed /Trench Edges Topsoil Yes I No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: 1 /
Location: 466 Highland View Hudson, WI 54016 (SE 1/4 SW 1/4 29 T30N R19W) Highland Hills 2nd Addition Lot 29 Parcel No: 29.30.19.829
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover =
Use revision
de for additional information. Yes i 1 No
Re
- -- - -- i - --
Date Insepctors Signature Cert. No.
SBD -6710 (R.3/97)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
11 INSPECTION REPORT Sanitary Permit No:
395290
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information ou provide may be used for seconds purposes [Privacy Law, s.15.04 1 m - �
Y P Y secondary P rP I Y O( )1.
Permit Holder's Name: City Village X Township Parcel Tax No:
Bishop, Ter St. Jose Township 030 - 2102 -00 -000
CST BM Elev:� O Insp. BM E BM Descriptipn: , � FS � �, 1p, o7.7, q
Ilh1L 7
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
Z �o b 2 • q Gz -d
Dosing U Alt. BM r v /0`1.9{/
Aeration Bldg. Sewer S /
�.y
Hold' SVHt Inlet
/
TANK SETBACK INFORMATION SVHt Outlet 0 •
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet
Septic ' 53 1 Dt Bottom
Dosing Header /Man. ' Z ID• IIDy /
Aeration Dist. Pipe ' 9 - Y
Holdin I Bot. System
PUMP /SIPHON INFORMATION Final Grade
J2. CO.
Manufacturer Demand St Cover
GPM
Mode umber
TDH Lift Friction Loss System Head I T Ft
For
in Length Dia. Dist. to well
SOIL ABSORPTION SYSTE
BEDITRENCH Width Leng No. O� es PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS 6 93 'I>, y I t�01
SETBACK SYSTEM TO P/L 19LDG IWELL LAKE /STREAM LEACHING nu . cuter:
INFORMATION Ty Of System: CHAMBER OR 11,,77 �l
YP Y ! UNIT Moqq Numbe r
DISTRIBUTION SYSTEM
Header /Ma fold y Distribution x Hole Size x Hole Spacing Vent to Air Intake
eQ Pipe I
Lengt Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bedrrrench Edges Topsoil I inn Yes (] No I Yes ❑ No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 1 Z / 2 D / L Inspection #2: 4 /
Location: 466 Highland View Hudson, WI 54016 (SE 1/4 SW 1/4 29 T30N R19W) Highland Hills I Lot Parcel N,p: 29.30.19.829
1.) Alt BM Description
2.) Bldg sewer length = �v�w• f'i't -
3� �- amoynt of cover
I �I
Plan revision Required? es No `-p
Use other side for additiona o a
D Inse ctoes Signature / 5 ,1
� Br S td CjZ o.
SBD -6710 (R.3/97) ! ,
I
Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162
N *Asconsln Madison, WI 53707 - 7162 S'
De artment of Commerce _
Sanitary Permit Application �3gsz90
In accord with Comm 83.21, Wis. Adm. Code, 77 vide ❑ Check if Revision
may be used for secondary Purposes Pr I. Application Information - Please Print All Infor, State Plan I.D. Number
Property Owner's Name Parcel Number
elea i
Property Ownd Mailing A s > ,., Property Location I
li:
N. R
Ci ty, Ste 1 Zip Code ° 1 e.Number Lot Nuniber Block N be
Subdivis' nName CSM Number
r
' ,q S
�J
II. Type of Building (check all that apply) at ev ❑City
JP 1 or 2 Family Dwelling - Number of Bedrooms lien— - e e ❑Village
❑ Public/Commercial - Describe Use ownship
❑ State Owned Nearest Road
2) 3 �x 6�•�sr 034 - a J0,Z -00�0 0 C)
III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable)
A. For County use •
IN New 2 oZ
❑ Replacement System 3 ❑ Replacement of 6 ❑Addition to �a •
- Sv stem Tank Only ' E ds stem
B. ❑ Check if Sanitary Permit Previously Issued
Permit Number Date Issued
IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) V -&" lab
44 0 Non - Pressurized In- Ground 2111 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland
22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line
45 ❑ At -Grade 46 ❑ Aerobic T mznt Unit 49 ❑ Recitcula " 30 ❑ Other
V. Dispe rsalPi'reatment Area Information: - S
Percolation Rate System Elevation Final Grade
Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Per
Required Proposed Rate(Gals./Days/Sq.Ft.) (Min. ) Elevation
377 S An" 8
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Tanks Concrete Constructed Glass
New Existing
Tanks Tanks
Septic or Holding Tank _
Dosing Chamber
VII. Respoj Statement- I, the undersigned, #mine responsibility for installation of the POWTS shown on the attached plans.
Plumber's ame ) Plum. ore MP/MPItS Number Business Phone Number
Plumber's Address (Street, City, tate, Zip Code
—""o A& 61Z G
VIII. Count /De artment Use Onl
Approved C1 Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps)
Surcharge Fee) dD �•.�
❑ Owner Given Initial Adverse �.• +' �v�
Determination X11
IX. Conditions of Approval/Reasons for Disapproval -b 14e e . n L S l
- 60_tAL�, *&Jku�14 1644, -4w
0
pWe elans (to the County only) for the em on not S[u�l x 11 inches In size / p -
,�
SBD -6398 (R. 05101)
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Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of
Labor arso Human Relations
+ Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but C
not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PA
dimensioned, north arrow, and location and distance to nearest road. N.`° Pend' g
APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION WED B
PROPERTY OWNER: PROPERTY LOCATION -
Joanne Persico GOVT. LOT SE 1/4 col ,S 29 � ,; I 19 ) W
PROPERTY OWNER':S MAILING ADDRESS LOT # I BLOCK # SUBD.
400 S. Second St. 29 na Hi
CITY, STATE ZIP CODE PHONE NUMBER ❑CITY ❑VILLAGE [3rOWN NEAR
Hudson WI. 54016 f r f
[ New Construction Use Pc ] Residential ! Number of bedrooms 3 [ ] Addition to'existing building
j] Replacement [ ] Public or commercial describe
Code derived daily flow 450 gpd Recommended design loading rate .7 bed, gpd /ft .8 trench, gpd /ft
Absorption area required 643 bed, ft 563 trench, ft Maximum design loading rate .7 bed, gpd /ft .87 trench, gpd /ft
Recommended infiltration surface elevation(s) 99.0 alt. area= 97.65 It (as referred to site plan benchmark)
Additional design / site considerations na
Parent material pitted glacial drift Flood plain elevation, if applicable na ft
S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem ® S El ®S ❑ U ® S El ®S ❑ U ® S ❑ U E] S ® U
SOIL DESCRIPTION REPORT >��
Depth Dominant Color Mottles Structure GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Bo Roots Bed Trench
`' ..1._.. 1 0 -9 10 r mfr cs 2f .5 .6 .5
2 9 -19 10 r4/4 none sicl lcsbk mfr gW if .2 .3 . Z
Ground 3 19 -84 7.5 r4 4 none cos OSQ mvfr na na .7 .8 . �-
elev.
10 ft.
Depth to
limiting
fact +84 p ,
Remarks:
Boring #
none sil 2msbk mfr Cfw 2f .5 .6 • S
2 r4 4 none si 2m r mvfr CfW if .5 .6 . S'
Ground 3 30 -90 7.5 r4 4 none is os mvfr na na .7 .8 . }
elev.
1
Depth to
limiting
factor
+90
Remarks:
CST Name: -- Please Print Gary L. Steel Phone: 715- 246 -6200
Address: 1554 200th. A)pe., New Rich nd WI 54017
Signature: Date: 11 -11 -96 CST Number: m02298
I .
PROPERTYOWNER Joanne Persico SOIL DESCRIPTION REPORT Page 2 of 3
PARCEL I.D. # pending
Depth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
ti 3 1 0 -15 10 r4 3 none • S'
2 15 -34 10 r4/4 none sici lcsbk mfr qw if .2 .3 •Z-
Ground 3 34 -89 7.5yr4/4 none is oscf mvfr na na .7 .8
elev.
10 00 1t.
Depth to
limiting
factor
+89
Remarks:
Boring #
1 0 -10 10 r3 3 none • r
4 2 10 -28 10 r4/4 none sicl lcsbk mfr qw if .2 .3 •Z
Ground
3 28 -84 7.5 r4 4 none is o r n na .7 .8 •�"
elev.
100 .4
Depth to
limiting
factor
+84
Remarks:
Boring #
1 0 -12 10 r4 3 none sl 2m r mfr cs 2f .5 .6 i
2 12 - 7.5 r4/4 none sl 2m r mvfr 9w if .5 .6 • S
Ground 3 26 -84 7.5 r4/4 none is osq mvfr na na .7 .8
elev.
10 ft.
Depth to
limiting
factor
+84
Remarks:
Boring #
LMA
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD- 8330(8.05/92)
STEEL'S SOIL SERVICE
Gary L. Steel Joanne Persico 1554 200th Ave.
CSTM2298 SE4SW4 S29- T30N -R19W New Richmond, WI 54017
MPRSW 3254 town of St. Joseph (715) 246 -6200
lot #29- Highland Hills Second Addn.
N
1" =40'
/ BM.= top of E lot stake C el. 100'
V
Y
A Garyv. Steel
11 -11 -96
POWTS OWNER'S MANUAL aL MANAGEME N f PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Septic Tank Capacity ga l ❑ NA
Permit # Septic Tank Manufacturer 1 — ❑ NA
DESIGN PARAMETERS
Effluent Filter Manufacturer ❑ NA
Number of Bedrooms DNA. Effluent Filter Model
❑ NA
Number of Commercial Units ONA
Pump Tank Capacity gal 0 NA
gal/day Estimated flow (average) g Y Pump Tank Manufacturer J9 NA
Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer 21' NA
Soli Application Rate ,gal/day/ft Pump Model
J'NA
Influent/ Effluent Quality Monthly average* Pretreatment Unit NA
❑ Sand /Gravel Filter
❑Peat Filter
Fats, Oil 8z Grease (FOG) 530 mg/L ❑Mechanical Aeration ❑Wetland
Biochemical Oxygen Demand (BODs) :5220 mg /L ❑Disinfection ❑Other:
Total Suspended Solids (TSS) x150 mg /L Manufacturer
Pretreated Effluent Quality ❑ NA Monthly average ** Dispersal Cell(s)
Biochemical Oxygen Demand (BODs) 1530 mg /L ,W In- ground (gravity) ❑ In- ground (pressurized)
Total Suspended Solids (TSS) s30 mg/L ❑ At -grade ❑ Mound
Fecal Coliform (geometric mean) s10 cfu /100mi 1 ❑ Drip -line ❑ Other:
Maximum Effluent Particle Size % inch diameter
* Values typical for domestic (non - commercial) wastewater and septic
tank effluent.
* * Values typical for pretreated wastewater.
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every ❑ months 0 years) (Maximum 3 yrs. )
Pump out contents of tank(s) When combined sludge and scum equals one -third (fs) of tank volume
Inspect dispersal cell(s) At least once every ❑ months 125 year(s) (Maximum 3 yrs.)
Clean effluent filter At least once every ❑ months Oyear(s)
Inspect pump, pump controls ez.alarm At least once every ❑ months ❑ year(s) JZ NA
Flush laterals and pressure test At least once every ❑ months ❑ year(s) -1 NA
Other: At least once every ❑ months ❑ year(s) Z7 NA
Other: At least once every ❑ months ❑ year(s) 0 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 (Ys) 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 ch. NR 113, Wisconsin
Administrative Code.
urized POWTS components, pretreatement components, and any other
The servicing of effluent filters, mechanical or press
maintenance or monitoring at Intervals of 12 months or less shall be performed by a certified POWTS Maintainer.
A se rvice re
local regulatory authority within 10 days of completion of any service event.
p ort sh all be p rovided to the I gu rY
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 trr}k_(sj removed by a senwe servidng operator nrior to w> o-_
f
Past — of .—
System start up shall not occur when soil condlwm are frown at Ow Inflitrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will t e
discharged to the dispersal cell(%) In one large dose, overloading the cell(s) and may result In the baclwp or surface discharge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servking Operator Prior to restorl%
power to the effluent pump or contact a Plumber or POWTS Malntalner to assist In manually operating the pump controls to
restore normal levels within the pump lank.
Do not drive or park vehicles over sinks and dispersal cells. Po not drive or park over, or otherwise diswrb or compact, the are;
within 15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater %gran, may Improve the performance and prolong the life of the
POWTS. antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; (at;
foundation drain (sump pump) water; fruit and vegetable peellrsgs; gasollne; grease; herbicldes; meat scraps; medications; oil;
paindnR rmclucts. aesticldes, sanitary naokins; tampons; and water softener brine.
A$ANDONEMENT
When the POWTS falls and /or Is pemianently taken out of servlce the following steps shall be taken to Insure that the system is
properly and safely abandoned In compliance with ch. Comm 83.33, Wisconsin AdminlsvaUve Code:
• All piping to monks and plu shall be disconnected and the abandoned pipe openings sealed.
• The contents of aft tanks and pits shad be removed and property disposed of by a Septage Servicing Operator.
• Aher pumping, all tanks and plu shall be excavaud and removed or their covers removed and the void space filled with
soil, gravel or another Inert solid materlal.
CONTINGENCY PLAN
If the POWTS falls anti cannot be repaired the following measures have been, or must be taken, to prov(de a code compliant
n g
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 sultaWe replacement ana, Replacement systems trust
comply with the rules In effect at that Ume.
O A suitable replacement area Is not available due to setback and /or soli limitations. Barring advances In POWTS technology
a holding tank may be Installed as a last resort to reptace the failed POWTS.
o 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 sultabie mplacement area. if no replacement area Is available a holding tank may
be Installed as a last resort to replace the failed POWTS.
Q Mound and at-grade soil absorption systems may be reconstructed In place following removal of the biomat at the
Infiluative surface. Ritconstructloiu of such systems must.comply with the rules In effect at that Ume.
< <WARNiNG> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT
OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TRUTMENT TANK UNDER ANY CIRCUMSTANCES,
DEATH MAY RESULT, RESCUE OF A PERSON FROM TKiE INTERIOR OF A TANK MAY SE DIFFICULT OR
IMPMS1R1 V
ADDITIONAL COMMENTS
POWTS INSTALLE POWTS MAINTAI E
Name *
Phone _ Phone
SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY
Name . Agency I ,
Phony
r
FROM :R0_KYMOI_!NTAINHOMES FAX N0. :6514333907 Rug. 27 2001 10:14PM P2
ST CROIX COUN'T'Y
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
O wner/BuyerR
Mailing Address
Property Address , /
verification required from Planning Department for new construction)
City /State � —r Parcel Identification Number 030 - 2102 - zoo
LEG UESCRi,LTION
Property Location Se ' /., St* /, Sec. — ?A , T 30 N - R 1 W, Town of S)tj sc
Subdivis on N L1t.V j , Lot # ?5
Certified Survey Map # Volume , Page #
Warranty Deed # C ��—�
a Volume �_-. Page #
Spec house D yes d no Lot lines identifiable V yes O no
SYSTEM MAINTENANCE
!mproper use and maintenanceof your septic system could result in its premature failure to handle wastes. Proper maintenaact
c of pumping out the scptic tactk every three years or sooner, if needed by a licensed pumper. What you put into the system
can affect the function o.r the septic tank as a treatment stage its the waste disposal system.
TM property owner agrees to submit to St. Croix Zoning Department a cerlifcation form, signed by the owner and by a
master piutr:ber, journeyrnan 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 m5pection and pumping (if necessary), the septic tank is less than 113 full of sludge.
Uwe, the undersigned have road the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, heroin, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that yoar septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
days f the three year expiration date, �}
._
NA OF APPI,I ANT
DATE
1 (we) certify that Ail statements on this form are true to the best of try (our) knowledge. I (we) am (are) the owner(s) of
the p perry describe�,eb t, by virtue of a warranty deed recorded in Register of Deeds Office,
S A G
OF APPL ANT �� ^'
RATE
`••••• Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department.
ssssss
•• Include with thus application a stamped warranty deed from the Register of Deeds office
a copy of the certified survey map if refcrence is made in the warranty deed
1510FACE 282
IJ
STATE BAR Oi WISCONSIN FORM 2
WARRANTYDEED KATHLEEN H. WALSH
• Document Nambcr REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made between Highland Hills, A Partnership RECEIVED FOR RECORD
05-2-2000 t0:15 An
VMNTY DEED
Grantor, and Terry A. Bishop and Jeanine M. Bishop, husband and EXEMPT #
wife, CERT COPY FEE:
COPY FEE;
TRANVER FEE: 150-00
RECO11111116 FEE: 10-00
PAGES- I
Grantee,
Grantor, for a valuable consideration, conveys to Grantee the
following described real estate in St. Croix -- -- County,
State of Wisconsin (if more space is needed, please attach addendum):
Recording Area
Lot 29, Plat of Highland Hills Second Addition in the Town of 154, Joseph, Name and Return Address
St Croix County, Wisconsin
F
Parse: identificat,un N - wn - b - er
- - - --
This is not --- homestead property.
00 (is not)
Exceptions to warranties: Easements, restrictions and rights-of-way of record, if any.
Dated this day of Mly____ 2000
Highland Hills, A Partnership
• JoAna Pmko, individually and as Attorney ist Fact for Roger
Ruelin and Bruce Peterson
AUTHENTICATION ACKNOWLEDGMENT
Signaturc(sj Highiand Hills, A Partnership, byJoAnnPorsico. STATE OF WISCONSIN
individually and as Attorney in Fact for Roger Ruelia and ss.
i§ruce Peterson counly
authenticated this of -- Nlav T , 2000
Personally came before me this day of
4 1 _-- the above named
— kri tine Ofiland ------
TITLE. MEMBER STATE BAR Of WISCONSIN
to me kncwn to be the person(s) who executed the foregoing
(If' not, instrunicrit and acknowledged the same.
authorized by q 706.06, Wis, Stats,
THIS INSTRUMFNT WAS DRAFTED BY
Attorney Kristine Ogland Notary Public, State of Wisconsin
- frw7sWi,VVl1 — 5"16 My Commission is permanent. (If not, state expiration date!
(Signatures may b t i olkilticincd or acknowledged. Both are not necessary.)
Names of persons signing in any capacity Fritist be typed or printed below their signature. namafion kwss4rW C—o" Fora }, L.. W
STATE BAR OF WISCONSIN
WARRANTY DEED
FORM No. 1- 1999
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