Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
008-2000-20-000 (2)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] Permit Holder's Name: Jerome Baumann City Village Township TOWN OF EAU GALLE CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: .St. CrOIX Sanitary Permit No: 624851 State Plan ID No: Parcel Tax No: 008-2000-20-000 Section/Town/Range/Map 36.28.16.537B&540C No: STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer St/Ht Inlet SUHt Outlet Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover BEDITRENCH DIMENSIONS Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING CHAMBER OR UNtT Manufacturer: Type Of System: Model Numtrer: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipes) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil � Yes � No � Yes � No COMMENTS: (Include code discrepencies, persons present, etc.) Location: 2686 BOSTON RD 1.) Alt BM Description = 2.) Bldg sewer length = - amount of cover = Inspection #1: Inspection #2: Plan revision Required? � Yes 0 No Use other side for additional information. Date Insepctor's Signature Cert. No. nl r *I . r� _ 0 t 1J ��•�t 'vat� 'd 610 " `= ""`': Industry Se ices Division '' County0. -- l7 1400 E Washington Ave Sj' �/zdlX R O 2020 O. Box 7162 1 Sanitary Permit Number (to be filled in by Co.) JUN Madi WI 707- 162 62Lf �I st ro p it AppE C - — State Transaction K mber — --- - in accordance w _ _ , Wis. Adm. Code, submission of this fomuo the appropri. a go t nta unit Q/'ls �01 zw (pu `cw is required prior to obtaining a sanitary pemrit. Note: Application forms for state-owned POWTS are submittty( to Project Address (if different than mailing address) the Department of Safcty and Professional Services. Personal information y provide may be used for secondary purposes in accordance with the PrivacyLaw, s. I5.0�1(i)(m),Slats. �d� � ��-- I. Application Information — Please Print All Information 4�r bogUX Property Owner's Name Parcel V 60 8 - - a6 - aob Property Owner's Mailing Address a7060 Property Location aG 8G lies rdr %?Q Govt. Lat City, State Zip Code Phone Number .S�✓ V4, /t/E 'A, Section 4 Q6QU/CedC4)� ,'r'y6 $ 7/S SeS- Y177 - (circle one II. Type of Building (cheL t all that apply) Lott N; R C e�8 __ o �r i or 2 Family Dwelling—Numbcr of Bedrooms 7 Subdivision Name 0 ` Block r ❑ Public/Commercial -Describe Use gmcity of__ ❑ State Owned - Describe Use ___ - - - - - i^i v llage of CSM Number - Town of EAa 17.4146 III. Type of Permit: (Che sly one box on line A. Complete line B if applicable) A. ❑ New System 9placcment System ❑ Treatment/Holding Tank Replacement Only ❑ Other Mudifrcation to Existing System (explain) B• ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber=E01PcrmitTrmansfcrtoNeNV List Previous Permit Nuurner dDate issued Before Expiratiear IV. Type of POWTS System/Component/Device: Cheep all that apply) / ❑ Non -Pressurized In -Ground ❑ Pressurized in -Ground ❑ At -Grade 9 Mound > 24 in. of suitable soil ❑ Mound < 24 In. ofsuitab(e soil ❑ Holding Tank ❑ Other Dispersal Component x laijr)^ ❑ Pretreatment Device (explain)_ _- V. Dis ersaUTreatment Area information: Design Flow (gpd) Design Soil Application Rat gpdsf) Dispersal Area Require (sf) Dispersal Area Proposed (sf) System Elevation Ada rdv*L Gea 1 /. 1 Goo 600 9/.a? po.7 � VI. Tanis Info Capacity in Gallons Total Gallons 11 or Units Manuractu PC to o u New Tanks Existing Tank % •- ufj n L U yr s ... m r2 '7 t= 0 W 0. Septic or ttaldiag luk / Dosing Chamber 750 756 l Ld %y/7 tJ v VII. Responsibility Statement- I, the undersigned, assume res r rsibility for installation of the PONN'TS shown on the attached plans. Plumber's Name brit Plumber's Si MPPrk£ Number Business Phone Number /��'—�T d3/3YG 7/5 G77-5o7G4 Plumber's Address (Street, City, State, zip Code) /V ea a? 98 fir. //&Js g' �u/tAvo W.i S1173. VIFH. Colin /De artment Use Only 1�Approved ❑ZDiirove Permit Fee Date Issued sst�n�g�Aznt Signatur ( $4 410,4* ❑Giv Reason for Denial iX. Conditions of Approval/Reasons for Disapproval 3� `MQ �k— O•I��"i�> TEMOWNER: 1.YIS eptic tank, effluent filter and SL- nn ispersal cell must be serviced / maintained C,�,nn � LOSql� Cgr►rt MAX cc s per management plan provided by plumber. ,� V �t2 setback tO3 -requirements m}pC�� i vb2.All m orecen ,ayeSl:ennal less (Mali N`i/ t tl to siT� as per applicable code/ordinances. Set, S Pr+= Lle twl�1444 L04-0-6 a June 4, 2020 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 2022-06-04 Plan Review: PWTS-062001026-C JOHN PELKE N6298 State Highway 25 Durand WI 54736 SITE: Jerome Baumann 2686 Boston Town of Eau Galle Saint Croix County Total Amount: $250.00 FOR: nescrint%or � 60P ('PD Maintenance Required DIVISION OF INDUSTRY SERVICES 2331 SAN LUIS PL GREEN BAY WI 54304-5211 Contact Through Relay http://dsps.wi.gov/programs/industry-services www.wisconsin.gov Tony Evers -Governor Dawn Crim - Secretary Conditionally APPROVED DEPT. OF SAFETY AND PROFESSIONAL SERVICES DIVISION OF INDUSTRY SERVICES SEE CORRESPONDENCE Mound Component Manual —Ver. 2.0, 5BD-10691-P (N.O1/O1, R 10/12) Pressure Distribution Component Manual — Ver. 2.0, SBD-10706-P (N.01 /01, R 10/12) The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do on by the Department per s.145.06, stats. The following conditions shall be met during cons tnict;nn or ;natanar;nn and�rior to essuP�nsTer us�• • Any tall grasses, leaves and shrubs shall be cut short and removed prior to tilling the surface for installation to prevent matting under the dispersal area. Prior to construction of the dispersal area, check the moisture content of the soil to a depth of 8 inches. Smearing and compacting of wet soil will result in reducing the infiltration capacity of the soil. Proper soil moisture content can be determined by rolling a soil sample between the hands. If it rolls into a 1/4- inch wire, the site is too wet to prepare. If it crumbles, site preparation can proceed. If the site is too wet to prepare, do not proceed until it dries. • It is recommended to cut as short as possible and remove ground cover prior to tilling the ground surface for the dispersal area. • Remove and maintain woody vegetation on or near the dispersal component to minimize root infiltration into the dispersal cells A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtaincd prior to commencement of construction/installation/operation. In granting this approval the Division of Industry Services reserves the right to require changes or additions should conditions arise malting them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, dir,��.a UU.eo�rzeir Travis Wagner POWTS Wastewater Specialist, Division of Industry Services (608)59&0715 travis.wagner@wi.gov i'ruje�t 'vat�te: 'rivate Onsite Wastewater Treatment System indox and Title Page. mar 77 J if �iprY� /�AtJ �Y.�n1 J ^ _': �!i'� - /av,10 / a tS Conditionally P RQVE-Q- sPJ5@T. OF SAFETY AND PROFESSIONAL SERVICES _DIVISION- OF INDUSTRY SERVICES Lc�l�! T7� criptit�n: _ .SlJ,� N �_3� 'i8 N, ia:[ I Ift:fn.�r' _. :,t-,:�._f• SEE C_O;,RR; ,§,QQNDENCE tiubdiviSion tial)tcr 02Gco,yion ^d. 'at1e I Inllrx and '!'illl: PaIl,% "lf,c 1'i<t;I l�ltl1,';-SIaCCiltiy p r; 1_,alLl':3i Liyout �lIit4C T,-tAl: � Pump (ittt?i t�tUllt; P�fir,rm;ttf�c �11ii)CnT.ltl[)!i ;ItiaCtCllltnt S11t Pl)1'��'I`5 OLvncr s :vlaua,�t! cv, MOtt lit ocrnent Plate Tiltcr 111 Uri17rl(l0;2 l - ) );all` `;i;i)- if}f;<II 1' (��l.;iiic i � •';i3�1i)strj � ,;•�i,-�Ft. U 1atltt,tf4' %ut`, !' 11 11s;III ) I Il'k'.).)II i-h;IIiIII1111liI t I)II)tiinLai i Alanua) '' 11 itt.nl,rutttl- 5ui1 (:t,lieaatifJ!, c � o i ' K a �n 1 ` LN a1 L A b � EZ flow kit, slotted to Pq ca H W D�I pipe w/water closet o II It II II II II it collar, or 3/8" die. bar C a V 0 _ � v �O . rat (t r�`i rt fi fi (t > O O X X o X \ rn C V, W Q D C N. 0 a _ C (D N N 7 03 (D N to N \Cr �n 3 m fD 0 N (D C� (D m su cl \ m � Cr 0 a a � Q 0 rn 0 u r. C�7 1 � m i 4J Ui]l W u II II II 11 II N t"h hj hit Ftt rfi ('t' ci• ro" cr rt O m / G) s m � c5 v w r (n W m O z D l 0 A mn n r 00 a < I z D � n r D 0 r I` m c� Cn v \ 0 o o N > > X X b < n C� Sll � (D _m m_ m o C) o � o R x m 4 ] ƒ / § m m K § / o > o e & \ / It / It Hi � FINAL GRADE {slope ground surface away front manholes) for proper drainage) BUILDING SEWER r (per SPS 382.30(11)) MANHOLE s 6" covzr MANHOLE RISER &COVER (per SPS 384.25(7) & (8). approved tockIng device, & yarning label; Extend manhole riser as necessary.) 4" h9in. Sch. 40 PVC Tank Vent located 12' above grade or 24" above Regional Flood Elevation OOTTOP.i OF INLET (oven elevation} (svaslec�ater Ar G F io 4' ICIL°T Plc APProved Effluent Eller ttco o, uarnrt s'/, PartiUe Sze Required On Oullel Pepe 5 Of 9 4' Min. Sch. d0 PVC Tank Vent ELECTRICAL located 12" above grade or 24" JUNCTION BOX above Regional Flood Elevation {comply with SPS 316 and NEC 300) i r12' FORCE MAIN �tl t�� (>4. OPTIONS Fl oal Trza— ' B A �> 18' -- Force 1 I Idain 1 Wezp I I Hota I ! MINIMUM OF 3" OF SUITABLE BEDDING BENEATH TANK &MAXIMUM BURY DEPTH OF OR Anchoring of tank may be required per SPS 383.43(8)(g} Tank Manufacturer: �/ESE2 �O�ccErE Septic/Pump Size: /.?.SO / 750 gallons Alarm Manufacturer: ,e„r E, flhVow6vs Mode( Number Z"A�K AZZAr / LAL Effluent Pump Manufacturer: x2 Model i�lumber: /S 1 Minimum Discharge Rate: 33 GPM Vertical lift (pump off to lateral invert)............ G.,? ft System head (distal pressure ?. S X 1.3 fit): 3.3 ft o?O ft Force main X f;??� 7" /100 friction factor . S ft Filter friction loss .........:............................ — ft Total Dynamic Head (TDH): _/o . 4 ft vhen CIO usesd -Alarm Float On FIO41 Ofl Float Elev. = BSSft Daily Wastewater Fiow (DWF): �db GILD (Number of daily doses: S. /p G rcteurnotsr.7:auutuwnricii�.r%t���>tca iri�ant (total dose volume - �©5� TANS CAAACi71E5: Reserve above alarm .�0, S in = Yp/.7 gal (D) Alarm float above On/Off float measurement 75 in = /14. 9 gal (B) Oft above tank bottom $ in gal (A) DOSE TAN6T DIMENSIONS: Length /SS in Width &G in butiet height z8 in Geilons/inch _ FLOW PER MINUTE GSLF'r37_1 CONSULT IrACTORY I°OR SPECIAL APPLICATIONS • Timed dosing panels available. • Electrical alternators, for duplex systems, are available and supplied with an alarm. • Variable level control switches are available for controlling single phase systems. • Double piggyback variable level float switches are available for variable level long and short cycle controls. • Sealed Qwik-Box available for outdoor installations. See FM1420. • Over 1307 (54°C) special quotation required. 1511152i153 Serir::> 15111b2/153 MODELS Control Soloclion ------ -- — Volt_s•Ph Mode_ Amps Simplex ---- Du 1Llex._ _Model N151 115 1 Non _ 6.0 1 �__ 2or3 _ Auto --6.0 _ Included 1 2or3 - BN151 115 t -i E151 230 1 Non 3.2 1 { 200 BE151 230 1 Auto 3-2 Included , 2or3 N152 115 1 Non �8.5 i ) 2or3 SN152 116 1 Auto 8.5 Incuded_ 2 or 3 E162 230 1 Non 4.3 1 2 or 3 BE152 230 1 Auld 4.3 Induderl 2 or 3 4153 115 1 Non 10.6 1 2 or 3 -- — _ u o Included 2 or 3 E163 230 1 Non 5.3 1 BE153 230 1 Auto 5.3 Included I 2 or 3 Ci �'i j.=+�rir are t;iri81[: TOTAL DYNAMIC HEAD/FLOW PER MINUTE EFFLUENT AND DEWATERING ifG Gat- 4 MODEL Feet Meters 151 Gal. UtersLA 152 . Liters 153 Gal. Liters 5 1.5 50 189 261 77 291 10 3.0 5 170 231 70 15 4.6 38 144 201 61 _265 231 20 6A 29 110 167 52 197 25 T6 16 61 34 129 42 159 30 9.1 - - 23 87 33 125 35 10.7 - - - 22 85 40 12.2 - - 11 42 Shut-off Head: 30 tl (9.tm) 38 fl. (it.6m) 44 ft. (13.4m) Model 151 07132 371B -.��_---�� 4510 -' I nu16 1. Single piggyback variable level float switch or double piggyback variable level float switch. Refer io FAd0477. 2. See FM0712 for correct model of Electrical Alternator E-Pak, 3. Variable level control switch 10-0743 used as a control activator, specify duplex (3) or (4) float system. hf_o.. ,. a .:�i1n - qYi I I �:��'+IY;•t1a..,,ionc6' '.li .16-�d ...� 1 t' ...Jia .I. ra t.' `.:I a��,il ,c; ,., .unjr� {:,. r Ilc. rr�:i it u...l•-I'ha ❑:` . _: J� i' �I 1 .-,: !- t: b'I.' i1 - r.illi t I �+urtlP".I tl tl ','?c; A:.f I 1p.1i�1 3 7t8 d 15 16 I (SK24M Models 1521153 "Easy assembly" (pump 8 discharge pipe not included.) Reduces potential clogging by debris. Replaces rocks or bricks under the pump. Made of durable, noncorrosive ABS. Raises pump 2" off bottom of basin. Provides the ability to raise intake by adding sections of 1%0 or 2" PVC piping. Attaches securely to pump. Accommodates sump, dewatering and effluent applications. NdTE: Make sure float Is free from obstruction. RESEftVL Pt7VVERE� flESIGN f-ar unusual condlflaris a reserve safety factor is engineered into the design of every Moeller putilp. SK206S 0 Copyright 2008 7oeller Co, All rights reservpd. Page / OT 9 (DINTS S 0 ,%t/PIER'S 1IA-fAT UA.1f; AND hCkA +IAGEME TT Pr.,.ANT Owner Permit r \umber of Bedrooms (100 gpd/bedroor Ncumber of Commercial Units Estimated flow (average) Design flow (DWF) = estimated :: 1.5 Soil .+\pplicati0n Raie Septic Tank Caoacitv ' Se tic Tanl: Nfanufrcun•er Effluent Filter h4anuracturer Effluent Filter Model Pump Tank Capacity > gal/day Pump Tank Nlanufacturer 9 gal/day Pump .Manufacturer influent/Eirluent Quality (L Nr\) Nlonthfy.\verage Cats. Oil & Grease (FOG) <30 in /L Biochemical Oxygen Demand (BOD;) <220 m_JL Total Suspended Solids (TSS) < 150 mg/L Prcu•catcd Effluent Quality (($ NA} l(vlouthly Areraec Biochemical Oxygen Demand (BOD;) <30 mit%L TOIal Suspended Solids (TSS) < 3 0 me/L Fecal Coliform (geometric mean) < 10 cht/100mL Off t'ump \•iodel Pretreatment Unit (RI` SandlGravel Filter G Mechanical Aeration Disinfection Nlanufacturer: Soil Absorption Comp In -ground (gravity) r I At -grade t Drip -line /,lSD gal C� Nf1 /ES 6A Co,aGR i�i �J EST r �Iv\ 0 l� A 7506 gal 0 NA Zo drc 1.,rR: G NT A C Pearl=titer C Weiland© Other: Model: IA) C In-_round(pressurized) f iviound :1 O`dter: Vettical Distance Tank Bottom to Service Pad: 9 —11 Maximum Effluent Particle Siza 11/13 inch diameter Horizontal Distance Tank(s)toService Pad• 740 ft DrsperSal chit ie•�fg,/N.odel plumber: \r1 CaleuLrtions: --- Soil Dispersal End Cap (Dispersal Unit EISA) D\\wF — AL - oolication Rate = Area Required - A or (Trench Width) _ ;Units or Total Lenath afTrench(s) 7s' ('I. "Design Of Pressure Distribution Networks forSeptic Tank -Soil absorption Systems" Publication 9.6 (SS\t1blP \=lanual) Q "ICC Flo«4ech Nlound Component ivianual" \version 1.2 G "EZ Clore tNlound Component ivianual" Version 8/20/2007 SBD - 1085 ".-P (R_ 1 / f 2) "At -Grade Component )Manual Usin, Pressure Distribution" Version 2.0 Li SBD-10705-P (NfOl/01)"In Ground Soil Absorption Component Manual" Version 2.0 Zd'SBD - 10691-P 0%1.01101) "ivlound Component ivianual" Version 2.0 C SBD - 10657-3? (R.6/99) "Drip -line Effluent Disposal Component Manual" iL(SBD - 10706-P (N.01/0I) "Pressure Distribution Component Manual" Version 2.0 7 Other•_ cell(s), clean filter - rYifi�tH 1 2;�it:i 10E �i!''t�? 1•/: At least once eve �,' 13 months Other: !1 rusnano pnsstuL test la(crais _ -- _ ..."...'.' f' � �•`•"'° u rv:t At te'tst once e� erg • 0 months ST AR t i1P Ai�IF FJr'ER� 1 It3\: For nett' constnrcuon, poor to using the PO11vTS checl: treatment tanks) Tor the presence of painlin�� products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). )thigh convent concentrations are detected hay; Cite contents of the tank(s) removed b} a septage servicing operator prior to use. System start upshall notoceur tvnen soil eonditians fire ;cozen at tite infiltrative surface. "the property owner is responsible l'or the operation and ntaimenance of the 1'011-TS and submission or required reports. The quantity and qualify of the wastewater stream will affect the performance attd longevity o!' your PO\\vTS. •the installation of rater -saving appliances and tisttrres along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water softeners. iron removal units. other clear water treatment devices and foundation drains should be discharged to the ground surface whenever possible. Note: this does not include laundry waste, shower. dishwater. etc. This system is designed to handle domestic strength waste��mter however,. the disposal of Food based grease;, oils, vegetable/fruit pceis0 seeds, bones, and food solids, such as those produced by a garbage disposal should be minimized. Toilet tissue is the only paper that should br` dischar ed iiitb rite sy rem, l7tNor rion-biodcnraclable irons, 5UVly US buli�v 'wipes, tampons, Sanitary napkits condurils, Cigarette bulls. denial Boss, and cotton swabs, should not enter (he system. Chemicals, such as itehvlcum products, (iainl, disinfectants, pesticides: antibiotics, solvents, etc., should not be flushed into the system tvraumm they can seriously dtlhlagc ;your 1'Ot/tvTS and collitintiiltate Y'bEli' Page $ of q drinking water supply. Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components. Compaction ofsnow over the dispersal unit may cause it to freeze up. INSYLCTIONS &c MAINT�NANCI : Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer, or Septage Servicing Operator (per the attached Maintenance Schedule). Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware. identify any cracks or leaks, measure the volume of combined sludge and scum and check for any backup or ponding of effluent to the a.round surface and test all electrical equipment such as pumps and alarms. Any defects shall be promptly corrected. Exposed openincy greater than 8 inches in diameter shall be secured with effective locking devices to prevent accidental or unauthorized entry the tankst tVhen the combination of'sludge and scum in any tank exceeds one-third (1/3} ormore 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 11 3, Wisconsin Admin. Code. Specific set icing mechanics must be provided if vertical is > 15 feet or if horizontal is > 150 feet and instructions to be provided below. 'I•hc outlet iilter(s) shall be inspected and cleaned to remove any accumulated solids according to manufactw•er'sspecificatiats. Solids washed fi•om the filter shall be retained in the tank. Filter cleaning may be necessary at more frequent intervals than stated in the maintenance schedule to keep the system operating, Alarms should be tested on a regular basis by the home Owner. !fan alarm sounds; contact an individual licensed tO service 1'01�1�TS. there is normally a I day reserve under regular operating conditions, however water should be conserved until any problems with the system are corrected to prevent back-up of sewage into the dwelling or surfacing. ABANDONMENT: When the POWTS fails and/or is permanently taken out ofservice the fallowing steps shall be taken to ensure that the system is property and safely abandoned in compliance with Ch. SPS 383.33, Wisconsin Admin. Code: All piping to tanks and pits shall be disconnected and the abandoned pipe openings scaled. ° The contents ofall tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. Alter pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space tilled with soil, gravel, or other inert solid material. CONTiNGhNC`! PI•,A\: 11•the PO\\ITS fails and cannot be r•cpaired the following measures have been; Or must be tatcen, to provide a code compliant replacement system: 0 A suitable replacement area has been evaluated and may be utilized for the location or it 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 renders it unusable. Replacement systems must comply Nvith the rules in cFfect at the time of replacement. . ® A suitable replacement area is not available due to setback and/or soil limitations. f3arring advances in POWTS technology it holding tank may be installed as a last resort to replace the failed POWTS. 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 lank may be installed as a last resort to replace the failed POWTS. 11 Mound and at -grade soil absorption systems may he 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. 1i+.112NINC!!!! SEPTIC, Ptlii4P, AND OT€i'GI2 'I'REA'I'NIE\'I' T:-t.NW.S li:li' CO\TI:1N 1.[:TIL+iI. GASSES AND/OR INSIiPFICiL'\7' O\YGEN. DO NOT ENTER A SEPTIC, PI1iYII', OR O0f1fER 'I'REATi\'II;NT "TANK I3NI)LsR ANY CIRCU\'IS"fANCLS_ DI:ATII MAY . ADD[TIONf\L CO\4IviF.t\l'fS: _ Y----_-_----- •---_ I'OWTS INS'I:�LL1;12 Vdd Rhone: SERVICING OPERATOR (Pumper) 1Vamc: _ Phone: YOW'FS 1YIr1[N1'AINBR aT 3(3y4 1 I Name Phone: t LOCAL REGUL. Name: �r Phone 7/S I TORY AUTHORITY to/x �or�aru,✓iTY ��u6to?Nd�I 3gd - y6 80 mm to ro to to ,4L, fool b� 11 awl cc 7 1 m to3 to5:� a to!! p 7 O Vcn m`'° o^ 30 � � =, m 3to to i^ MaLA n a n p n V tom .. M[ ro N tr H C ro n U m on o I 3 m D 77 0 `� T .. p• U1 �, p !D It"tn 7 I :L > uj ro to to N O N v a n n 3 r, to oa o a$ 4 1 o4wc n ro 3 C C 1 rIt u Q 0— 0 0 _ It M Dh,0 _ __ �_.._. _ N 7' 3 to-O r p; to a v a - ot to to GL SSitte— (I mn?a0o w .. T = ^ �, ID N am Q. Ottoo, 1. o ^ ro c. p G: o cni V1 to �' m 7 .,o.ot t III—IfS OI'r p. nM toot Q. 0.0 T N ,pfifi ra _ ...�. - . _ ._.__ .. -_ nM p o to O o- ci i 1 V' --7 t0 U d p N at'S� toot O N ro to too C n O tot p C3A y �78lot to O S C p 3 to to - - - ..__._.,.-- AM N 0 7'�n G< cry (D m 13 3 0 3 ^ ? a {` c ro c N ro 3 a zta ^� I' � 7"0 ro i w 0 n n �„ ! — — o =h o =s f � tot m > .c 3 3 0 to o. /o f. d I 3 2 fD b O -^ T H n .' 0 G N ry -p N p n N� n mot to 7 `C .7c � roil n rr 0 o EGe S rD o a 0 c ij j (D _Itoot r-h _ N _ toot n 9' � �dzo] at c - ... v ro g�� u W :' m look It"o* N = O ro e O a n n m N °- n m S� Q c Ior ti ro � N — lL] .. too cL rv., o �, a ro 3 f m (C� v no fo L y/ o. LPI 7 ro roO \ 2 ot N W O paj W '� v !' 4 3� 1,.Ir 3• N .�-. � ^ — r`o N N N [ � � � d n N � oMoot A Q y to ry E If tow \ »> y m «\1. I \. \\\ \ ? \ar , ±: it It /\\ �/}/> «. le,. v v - - 2 `m: .IV\§il,4 I. \�- �.: - �?? 3«2:§' \ \\\d\\��� ƒ % \<:/... \\ :1Al /\V 'I-�\����� ® ` \ \ y7 &I 2 r%�- w i w w \ � 117— w,w� \\y . tot Wisconsin Department of Safety and Professional Services Division of Industry Services SOIL EVALUATION REPORT in accordance with Comm 85, Wis, Adm, Cade Page of,3 ,5 l . C R01X Attach complete site plan on paper not less than 8112 x 11 inches in size. Plan must County 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. ()Q 8 - Z OO O _ ZO - 040O Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Lave, s. 15.04 (1) (m)). Property Owner Property Location El N IeraMe 0a /36L&LIPYrg,fl/1 GovL Lot Sbf 1/4 /VE IX S 36 T a8 N R !'6 E (or) W Property Owner's Mailing Address Lot # Blocl(# Subd. Name or CSM# a 686 45o,3fol) Aid Q New Construction Replacement Parent material L o General comments and recommendations: Boring # none rvumoer City Q Village �f Town Nearest Road Rd Ll Use Residential ! Number of bedrooms Code derived design flow rate 0 Public or commercial - Describe: _ 55 1 Flood Plain elevation if appiicable /V/Q ft. Re coMmPrloO� her fVja Lapn� . 6 go 5D i Area'I1 % LSIoPe y 50ry) Free.3 40 r� 0geejo R'("mm nde>^d 5. 15L — g�,�r oA 90S Gon}otir, 10i U01 LenoA Avall,ble, Boring Pit Ground surface elev. 11, 6 ft. Depth to limiting factor 38 in. Horizon Depth in. Dominant Color Munsell Redox Description Qu_ Sz, Cont Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/fl? 4Eff#1 'EW2 I o-W lUY9 3/,Z SQL 2 rr` gr rl'r O.S a ni G S �Z Gl -20 ►DYR Y/3 5 ilw z n, SbK rn�r 5 /ram 6 $ zD 38 I��R ply SiL a. M 516K fy\fr y 38 0YA k/y Goa IOYR5/2356 S,L I 5b1A mfrful ® Boring # Boring id Pit Ground surface efev. $ 3 y 9. G I ft Dep01 to limiting factor in. Sail Annliratinn Rota ep Effluent #1 = BOD, > 30 r 220 mg/L and TSS >30 < 150 mglL "Effluent #2 = BODE �i 30 mgR.. and TSS < 30 mg/L CAT N»arc. (Please Print) ,! VI , ti55(:ir Sign»tur» CST Nirmtipr Address Eeatt (hi1i'e, '1r1/1 64701 Date Evelu lion Conducted Telephone! Number (H) 715-t134&&8010 (0 7.15-577-4383 MVINS474974, IM i38ll t)33ti(ltfi7/ij Property Olaner Jero m P� /J. ljrti u.m c' n n 3 Borina # Boring Pit Ground surface elev. Parcel ID # aO$ ZOUo- ,ZU- pUU 8• it, Depth to limiting factor 35 In. Page os' of .7 Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz, Cont. Color Texture Structure Gr, Sz. Sh. Consistence Boundary Roots GPD/fR 'Eff#1 'Effil2 rn toMrr �S o2rr�m b 8 a 3 6-15 IS-JJr lOYR 5/3 GoYR "A - SiL SQL a m,gbK 2M Sb15 mir in, r S Im b g 35'5.2 IoYRS/z3,6/b ►< mfrrl 8oring # Boring pit Ground surface elev ft, Horizon Depth In, Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/fi? 'Eff#1 'Eff#12 Boring It Boring ® Pit Ground surface elev. ft. Depth to tin?fang factor in. Horizon Depth in. Dominant or Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. 5z. Sh. Consistence Boundary Roots GPDIfP„ 'Eff#1 'Eif#2 ' Effluent #1 = BOD, > 30 < 220 mglL and TS5 >30 < •150 mgrL "Effluent #2 = BOU, !� 30 mglL and 7SS < 30 mg1L TI?c Department of Commerce is an equal opportunity service provider and employer. if you ncud assistance to uccusaservices or need material in an alternate formal, please contact the depatlment at G08-2GG-3151 nr 'I't'Y Gf)ti-2G4-tS777. snn.R»nr.0 of m/rnl �y. 3oF3 �ro 4°STd/ViQO, ; �Q 6 m I y 3 C 0 Cry I 1 W \q�v% Ae �\yyv .✓ � o 409z W 0 ST. CROIX COUNTI' SEPTIC TANK MAINTENANCE AGREFMENT AND O.WNERSNIP CERTWICATION FORM Owner/Buyer 73"�e roriP Sic t.> A n !n Mauling Address 1 t/P 1! -f l�Wn ��yto y _ L -�- . SC/< Property Address lr+/e��u�- G._ Svoc ( Verification required from I'lanning & Zoning Depamnent for new construction.) City/State o U r Le LJ-J� Parcel Identification Number ...Q-_,�flc�l C� LEGAL DESCItIP')t 10N Property Locstion ___'/a , ';', , S(;c. , I N R N•'. To«�n of P Volume �—,1'�►ge # . _. Warranty Deed # I . ___ ___ _ _ _. �g �3 , Volume - Puge H Spec house yes no Lot tines identifiable yes no Improper use ar+d maintenance of your septic systcnn could result to its prrunature failure to handlr wastes. Proper maintenance consists of pumping nut the septic tank every three years or stwner, if needed, by a licensed pt►mper. What ynu put urns the system can affect the function of the septic (auk ns a treatment st:nge in the waste disposal system. Owner maintenance responsibilities are specified in §COmm. 83 520) and in Chapter 12. St. Croix County Sanitary Ordinance. The property owner agrees to suhmn to St, Grotx t:ounty i'lannrng & Zoning Department a certrftcatuur forth. signed by the (J%vner and by a toaster plumber, joumey'nwn plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition andlor (2) after inspection and purnprng (if necessary), the septic tarn: is less than 113 full of sludgy Uwe, the undersigned have read the above requirenwnts and agree to maunta►n the private se++age disposal system mth the stwWards set forth, herein, as set by the: Department of Commerce and the Department of Natural Resmttces, State of Wiscousut. Certification stating that your septic systeln has been maintained must be completed and returned to the St. Croix County Plannt ig R Zoning Department wiUun 30 days of the three year expiration as I/wr ccttify that all statcrnents on this form an 4uc to the best of my/our knowledge. flue arniare the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms SIGNATURE OF AI'P1�ILAN'C(S) U.4TF.' '*•Any nartmcnt. "' infnrntation that is misrepresented may result a) I. sanitary pettnit briny, revoked by the Platuring �. Zoning Del tnciude with thin aptrlicatuw a recorded wanTanty deed from the Rcgistar of Decds UfGce and a copy of the certified survey map (t referent; is made in the warranty deed. (lltEV. 08/05) ;STATE BAR OF WISCONSIN FORM 2 - 2000 Document Number � _____ WARRANTY DEED THIS DEED, made between Catherine McKim Olyphant and Bart J. Hoekstra, married to each other, Grantor, and Jerome D. Baumann and Abby R. Baumann aka Abby Rose Baumann, husband and wife, as Survivorship Marital Property, Grantee. Grantor for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County, Wisconsin: SEE EXHIBIT "A" ATTACHED HERETO AND MADE A PART HEREOF Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this June 14, 2019 �.0 rtil �Jwf1� I tG�+'� Catherine McKim Olyphant ,�J STATE BAR OF WISCONSIN 1083349 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 06/ 20/ 2019 08:24 AM EXEMPTrM: REC FEE 30.00 TRANS FEE 975.00 PAGES: 4 * *The above recording information verities that this document has been electronically recorded !k returned to the submltter Recording Area Name and Return Address: Edina Realty Title, Inc. 400 South Second Street, Suite 130 Hudson, WI 54016 1312204 008-2000-20-000 Parcel Identification Number (PIN) This is homestead property. FORM No. 2.2000 WARRANTY DEED �t C:roix County 1083349 Pape 1 of 4 AUTHENTICATION ACKNOWL�E�D�G�MENT Signatures) _-- STATE OF ___WtS�(�b�!`-'J-Y- `-- authenticated this June 14, 2019 TITLE: MEMBER STATE BAR OF WISCONSIN (If not, authorized by §706.06, Wis. Slats.} THIS INSTRUMENT WAS DRAFTED BY Edina Realty Title, Inc. Cheri Brown 400 South Second Street, Suite 130 Hudson, W 154016 (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. COUNTY OF Personally came before me this the above Catherine McKim Olyphant and art J. Hoekstra, married to each other to me known to be the person or persons who executed the foregoing instrument and acknowledged the same. Notary Public, State of VYisconsin My commission is perm n nt. (If not, state the expiration date: ) CHERI BROWN NOTAFlY PUBLIC STATE OF WISCONSIN STATE BAR OF WISCONSIN FORM No. 2.2000 WARRANTY DEED St. Croix County 1083349 Pape 2 of 4 �.xhibit n Legal Description Part of the East Half of the Northeast Quarter (E 1/2 of NE 1/4) of Section Thirty-six �36}, Township Twenty-eight (28) North, Range Sixteen �16) West, described as follows: Commencing at the Northeast corner of Section 36, Township 28, Range Sixteen, Town of Eau Galle; thence on an assumed bearing of North 86 degrees 30 minutes 41 seconds West along the North line of the Northeast Quarter of said Section 36, a distance of 661.17 feet to an iron pipe for the point of beginning of the parcel herein described; thence South 00 degrees 31 minutes 00 seconds West, 1659.91 feet to the Northerly right-of-way line of Coulee Road; thence South 61 degrees 25 minutes 07 seconds West along said right-of-way line 137.51 feet; thence South 68 degrees 10 minutes 15 seconds West along said right-of-way line 341.51 feet; thence South 63 degrees 11 minutes 23 seconds West along said right-of-way line 251.56 feet to the west line of the East 1/2 of the Northeast 114 of said Section 36; thence North 00 degrees 29 minutes 39 seconds East along said East line 2006.38 feet to the North line of the Northeast 1/4 of said Section 36; thence South 86 degrees 30 minutes 41 seconds East along said North line 661.17 feet to the point of beginning. Together with a 66 foot wide easement for ingress and egress for Richard Lambert and Barbara Lambert, their heirs and assigns over and across part of the franctionaf W 1l2 of the NW 1/4 of Section 31, Township 28, Range 15, Town of Cady and across part of the Northeast 114 of the Northeast 114 of Section 26, Township 28, Range 16, Town of Eau Galle, the centerline of said easemen eing escri e . Commencing at the Northeast corner of Section 36, Township 28, Range 16, Town on Eau Galle; thence on an assumed bearing of South 33 degrees 19 minutes 02 seconds East, 1980.52 feet to a point in the centerline of Coulee Road for the point of beginning of the centerline to be described; thence North 42 degrees 21 minutes 05 seconds West, 299.74 feet to a railroad spike; thence North 33 degrees 21 minutes 15 seconds West, 402.53 feet to a railroad spike; thence North 43 degrees 39 minutes 30 seconds West, 156.07 feet to a railroad spike; thence WARRANTY DEED STATE 8AR Uf� WISCONSIN FORM No. 2•'1000 St. Croix County 1083349 Page 3 of 4 Wisconsin Department of Division of InduobV $eNk 357 I ervicesLimil it j SOIL EVALUATION � UATION REPORT ` �UN 20?In accordance with Comm 85, Wis. Adm. Code Attach complete site plan on papergt tress than 8 1/2 x 11 inches in size. Plan must include, but not limited tomc�: ver 4 FahtY ,h, Rt�;�!ntat reference point (BM), direction and percent slope, s aleCoord%fli ; w, and location and distance to nearest road. Please print a&9 information. Personal Information you provide may be used for secondary purposes (Privacy Law, S. 15.04 (1) (m)). Property Owner .JErdn1C � �a.a,Ma,/1� Property Owner's Mailing Address a 6s6 Bo6fo1) Rof. Woo✓%��� I In/Z I Sy0at3 I (1/S county Page / of 3 S i . C ROIX Parcel I.D. 008p good- 20-000 Reviewed by Date Property Location Gour Lot 5 fin% 1/4 f Vt 114 S 3 6 Lot # Block # Subd. Name or GSM# Village New Construction Use Residential / Number of bedrooms �� Code derived design flow rate Replacement [] Public or commercial - Describe: Parent material Loess Flood Plain elevation tfapplicable All General comments �2coMm�ndCt� 6" Mo,,,n � / (, e)o go.i Pret1� / /I%Sloes / and recommendations: ('P�mvve-d. Reco,, me„de) S. 6L v 91.1 on 90. b` con } ockr, aBoring # Boring v Pit Ground surface elev. q I * 6 ft. Depth to limiting factor 3�_ in. T oZ g N R Nearest Road 6 (or) r r� GPD o 5 M 2-4-r2es -�o be qU' L611 L6,10A AvAiigble, Soil Annlication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f� in. Munsell Qu, Sz, ConL Color Gr. Sz. Sh. "Eff#1 �Eff#2 I a- W i 0 YR 34Z s i L I rh 3r rl A r o 5 7 rrl 6 $ a cl-ZO 10Y/1 S/3 a Sit ;I.M Sbg mfr es S /M 6 g j a0 38 I�`lf�i `A o Sit �. M 5bK P'\ Fr y 38-510YA q/y o;L0 soya5/.LI'Y 51L I f sbVA Mfi` ,1 . 6 ® Boring # Boring Pit Ground surface elev. $ 9. t ft. � � Depth to limiting factor �, in. Snil Annliratinn Rata 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- 6 10VR 3/z r Mir S F-m 6 8 d. 01 10YR5/3 0 Jul. Z 3 (41-311 ►()yR 11K siL 2 M gbk (rr=Fr cs q 39w500 loyR q/q C�.O 10 A5/z 5/6 Sit I 610R rnfr Effluent #1 = B0DrZ > 30:< 220 mg/L and TSS >30 < 150 mg/L �ffi�� =BODE < 30 mo/L and TSS < 30 mg/L CST Name (Please Print) , . 1htSSES t Signature CST Number Address Eau Clahve5 W1 54701 Date Evalu lion Conduoted Telephone Number (lL) 7154314-8610 (C) 715-5774353 a /S-aeao 3 9 V -� 7, -1152 SBD-8330(R07113) ® Boring # Boring Pit Ground surface elev. $ 9. t ft. � � Depth to limiting factor �, in. Snil Annliratinn Rata 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- 6 10VR 3/z r Mir S F-m 6 8 d. 01 10YR5/3 0 Jul. Z 3 (41-311 ►()yR 11K siL 2 M gbk (rr=Fr cs q 39w500 loyR q/q C�.O 10 A5/z 5/6 Sit I 610R rnfr Effluent #1 = B0DrZ > 30:< 220 mg/L and TSS >30 < 150 mg/L �ffi�� =BODE < 30 mo/L and TSS < 30 mg/L CST Name (Please Print) , . 1htSSES t Signature CST Number Address Eau Clahve5 W1 54701 Date Evalu lion Conduoted Telephone Number (lL) 7154314-8610 (C) 715-5774353 a /S-aeao 3 9 V -� 7, -1152 SBD-8330(R07113) Effluent #1 = B0DrZ > 30:< 220 mg/L and TSS >30 < 150 mg/L �ffi�� =BODE < 30 mo/L and TSS < 30 mg/L CST Name (Please Print) , . 1htSSES t Signature CST Number Address Eau Clahve5 W1 54701 Date Evalu lion Conduoted Telephone Number (lL) 7154314-8610 (C) 715-5774353 a /S-aeao 3 9 V -� 7, -1152 SBD-8330(R07113) Q, Property Owner Je✓ro m C� /J. (ja u n� v" Parcel ID # 008 Zd00- a 0- Od0 7J Boring Ell Boring /5 Pit GroundsurfaceelevY a ft. Depth to limiting factor in. Page of Soil Aaolicalion Rate I Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/ffi °Eff#1 0E02 O� 6 IaY� 3b, SiL M t~ n .Yr- a5 rA b .� b'Is I0Vv\ 5/3 SiL a m Stet; mrr S t m 6 j !s-3� IoYR rl�y �' SiL n� 5bK nitr 35-5ml 10YA H/y yap ioYA6A 9/e rr .y mg a Boring # n Boring Pit Ground surface elev. fl. Depth to limiting factor ln• Soii Apolicalion Rale Horizon Depth In. Dominant or Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/fP "Eff#1 °Eff;12 Boring # � Boring Pit Ground surface etev. ft. Depth to I(miting factor in. Snll Annliralinn Rata Horizon Depth in. Dominant or Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPDIff "Eff#1 °Eff#2 I i " Effluent #1 = BODE > 30 < 220 mg1L and TSS >30 < 150 mg1L " Effluent #2 =GODS < 30 mgR and 7SS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. if you nccd assistance to aceess.services or need material in an alternate format, please contact the department at 608-266-315I or TT'Y 608-264-8777. SDD•3730I'cst (R07100) �9.3oF3 �n/APRoX,1 ro /"ri✓q�e 4OSTpn,RO. \ �o O t -o �7 N cl 11. \ o 0 40,Z Ca 0 n � o U' m v�N AS BUILT SANITARY SYSTEM REPORT �!' i `'• r OWNER ����� �jl/� �h T�rI�SEC �/� �� ice- TOWNSHIP ADDRESS .. %/�-�l��j•!, �l ��bL; �L•� -E COUNTY, WISCOi�SS�I�` i ./��,� � ��t�h S �"�l i. SUBDIVISION LOT �.DT SI.��� PLAN VIEW Distances and dimensions to meet requirements of H63 i �_ �F�� ;• �', cc" � .-,�> 9a11�i� p� ■ ■■ �JlGe�Id��■\�������������� ■�����av��C�o����i ■ ■ ■��NHIN`�,i������� ■O �r��■ ■�0���������■ ___ Elevation of vertical reference point: /(.�F),(� Slope at site: SEPTIC TANK: Manufacturer: � (!r:-.r• �: �• Liquid Capacity: �'�;G%C Number of rings on cover _ ��, Tank manhole cover elevation: fh,.0 Tank Inlet _Elevation: �TSJ �c�, Tank Outlet Elevation: c;�w o•; PUMP C}IAMBER Manufacturer: Number of gallons Number of gal. pump set or a cyc e gallons; tota capacity o distribution lines gallon:.. sized pump head; gallon per minute horsepower ran name of pump and model number Type of warning evice HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover 'Pype of warning device SEEPAGE PIT SIZE: um er o pits eet iameter feet liquid dept seepage pit in et pipe -elevation bottom of seepage pit e evation feet. SEEPAGE BED SIZE: number cf lines wi th length the depth_ SEEPAGE TRENCH: width � length��. -� PERCOLATION RATE_ Lam` REA REQUIRED��ARE AS Bl� �, DATED � ..•e � L _ , 'j iJ (� ,1 �� BER ON JOB �`,E i�i.�� �� r i �Sci LICENSE NUMBER -> .� ; ti— DEPAFiTM��NT OF INDUSTRY, LABOR & IiUMAN RELATIONS P.O. SOX 7969 MADISON, WI 53707 INSPECTION REPORT FOR PRIVATE SEWAGE SYSTEMS i�- 3D_�O2' I�CONVENl-ZONAL ❑ALTERNATIVE � i �b ❑ Holding Tank ❑ In -Ground Pressure ❑Mound SAFETY &BUILDINGS DIVISION BUREAU OF PLUMBING Stem Pmn I D. Nwnber: (II assigned) N E OF PERMIT HOLDER // �� V ADDRESS OF PERMIT HOLDER: INSPECTION DATE BENCH ARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN. REF. PT. ELEV.: CS7 REF. P7. ELE V. �y � � � Q � N me ql Plumber. MPtMPRSW No. Cpunty� Sanitary Permit Number. .... SEPTIC TANK/HOLDING TANK:V MANUFACTURER: ` Q, t/� 4..t,,C..S LIDUIO CAPACITY . I �72.'� TANK INLET ELEV.� 1 r� �_ J - L© TANK OUT � T L V. e WARNING LABEL P OV ED: YES ❑ NO LOCKING CO R PROV D: r NO BEDDING: YES ❑NO VENT UTA VENT MATL. HIGH WAT ALARM � � ❑ E NO NUMBER OF � FEET FROM NEAREST ROAD: �'� PROPERTY LINE WELL: BUILDING. jVENT O FRESH AIR INLET: .. J DOSING CHAMBER: MANUFACTURER BEU G OUID CAPACITY PUMP MODEL PUMPiSIPHON hANUFACTURER WARNIN BEL PROVI IDED' ES O E N YES ❑NO GALLONS PER CYC (DIFFERENCE BET E N PUMP ON AND OF �� PUMP AND CONTROLS OPERATIONAL ❑YES ❑NO NUMBER OF FEET FROM NEAREST � PROPERTY LL LINE ILDING (VENT TO FRESH aw wLEr SOIL ABSORPTIO SYSTEM. C eck the soil moistureat the depth of plowing or excavation, (If soil can be rolled into a wire, construction shall cease until ` the soil is dry enough to continue.) ' FORCE- MAFN Len,cni uiArnrTEF MATERIAL ND MAHKIN(i CONVENTIONAL SYSTEM: _. BED/TRENCH DIMENSIONS 4VIOTH� � LENGTH � � NO. OF TR ENCFi�S L DISTR. PIPE SPA LNG � � �'�, COV EH M AL' -- PIT INSIO I rr PITS LIOU10 DEPTH: GRAVEL. nEPTH BF LOW PIPS � (V� FILL DEPTH ABOVE COVER UISTEi PIPF EIEV_I LE! DISTR PIPE ELE E}(� ND. DISTR. PIPE MATERIAL' NO � R PIPE NUMBER OF FE ET FROM � PROPERTY LINE. YVELL� BUILDING: VENT TO FRESH AIR INLET: 1Jy�j-(t.•/4fm � .NEAREST Mound site plowed perpendicular to slope and furrows thrown upslope: LATER ❑YES ❑NO TE XT(1RE EDGES PRESSURIZED DISTRIBUTION SYSTEM: BED/TRENCH (vIDTH LENGTH DIMENSIONS ELEV.. IELEV ELEVATION ALAI DISTRIBUTION INFORMATION COMMENTS: 2.l`Z.�� �pZ�� Z i► �� I �o-.-GI Sketch System on Reverse Side. of ENCIIES. IA Check the xture of the fill material for mound sYste s to make certain that it meets the criterl for medium sand. �I( !� t 0.2. t"L- g�'"`�� ❑YES l*aT�>!�'SI YES ❑ NO PROVIDE A DIAGRAM OFSYSTEM ON REVERSE SIDE. SHOW ELEVA- TIONS MEASURED. ❑YES ❑NO ❑YES ❑NO � ❑YES ❑ PLANS. ❑YES ❑NO NUMBER OF FEET FROM NEAREST- 1 2 � z �/ (l�s l i - h � Lit' �r.,.i,(� r t a-Ll 3 -1 'v` t! � l .�� �--�.. n county file for audit. I DILHR SBD 6710 (R. 01/82) DEPARTMENT OF INDUSTRY, LABOR AND HUMAN RELATIONS APPLICATION FOR SANITARY PERMIT (PLB 67) Attach plans for the system on paper not less than 81/z x 11 inches in size. Include a plot plan that I tBii VE and vertical elevation reference points must be shown. All appropriate separating distances and ph �e4i H-63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and datedi>W Plumber, the date, signature and license number must be shown. The owners copy or a legible reprodu included. TY \�?� J►Jig, ,- 19b2mA9v & BUILDINGS DIVISION '.O. BOX 7969 <ON, W 1 53707 oncdtcCdrawn.'tp,�cale. Horizontal aracteristics `ecified in chapter eslgrrer:�,�lf esigned by a Master ort—`o soil test report must be Property caner: Mailing Address: DGUC di, =, (i i q J4 t Property ocation:t�11=,e-or Township: ounty: n!l '/aS �T,;) N/R or) W L��1 c0 Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: (if assigned) TYPE OF RI III ri1Nr; Number of ❑ Public* ❑ Variance* ❑ Other (specify)* Bedrooms: 94 'f or 2 Family *State Approval Required, CD TOTAL NUMBER PREFAB POURED -IN NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE STEEL FIBERGLASS INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY coo � x HOLDING TANK CAPACITY LIFT PUMP TANK/SIPHON CHAMBER_ MANUFACTURER: EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): lNew ❑Replacement ❑ Experimental ❑ Seepage Bed ❑ Seepage Pit 5 / v ❑Alternative (specify) 19'&epage Trench Water Supply: Owner's Name as Listed on Soil Test Report (if other than present owner); QJPrivate ❑ Joint ❑ Public I, the undersiyned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Naran of Plumber: f Signat e: MZP/MPRSW No.: Phone Number: 2 t PI ber's Address: e' /r %// / 1 Name o(f�Designer! CJLJ�-' /h .. / I / �A / -//f C Gr �7 c /�'a Issui Disapproval; ci- Alternate courses) of Action Available: COUNTY/DEPARTMENT USE ONLY APPR01/ED �% Sanitary Perm rl.rF ❑DISAPPROVED .'1 i i r: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67-T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White -County, Canary -Bureau of Plumbing, Pink -Owner, Goldenrod -Plumber DILHR-SBD•6398 (N.03/81)