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H!i rsin °DepartmentofCommerce PRIVATE SEWAGE SYSTEM County -
Safb and Buildings Division INSPECTION REPORT St. Croix
GENERAL INFORMATION (ATTACH TO PERMIT) SanitamPormit No.:
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 37036
Permit Holder's Name: ty ❑ Village JD 'Dowrx of State Pan ID No.:
❑Ci
Glamm, Robert Somerset Township
CST BM Elev7 r Insp. BM Elev.: BM Description: Parcel Tax Nn
t?D•D (Sp,�' –� Quc. m I 032 - 2111 -10 -000
TANK INFORMATION ELEVATION DATA S •� f g, io39
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic W 65*— Opel Benchmark ,
f
Dosing Alt. BM •'30 � 3 ° �.O
Aeration Bldg. Sewer /p t
Holding St/ Ht Inlet
TANK SETBACK INFORMATION St/ Ht Outlet
TANKTO P/L WELL BLDG. Ventto ROAD Ot Inlet —
Air Intake
Septic > I p — NA Dt Bottom
Dosing NA Header/Man. ���n5h S .o 4 30 /
Aeration - NA tFinal ipe ` (05
g . roo
Holding stem ��� 30 ,Z -ml
PUMP / SIPHON INFORMATION rade to q$ of
M nu er emand a�crc
a St cover
Model Number GPM NQ�,(� , 6wt i30.
TDH Lift coon tem TDH Ft
Forcemain Length Dia. Dist. To
SOIL ABSORPTION SYSTEM S .
BED /TRENCH Width Le h I No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS �✓ Q .2S .ea. DIMEN I N
Manu N ur r.
SETBACK SYSTEM TO P/ L BLDG WELL LAKE / STREAM LEACHING — �r r <n
INFORMATION Type O I CHAMBER M e Number:
System: l�V� A J, S� —'—' OR UNIT - C
DISTRIBUTION SYSTEM
Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
j
Length Dia. acin
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
CO MENTS: (Include code discrepanc'es, persons present, etc.)
LOW : rts* CbVG"Etit 0- t QO& ! Inspection #1: � 1 Inspection #2:-- -1 -- -i
Location: 1765 46th Street, Somerset, WI 54025 ( NW 1/4 NE 1/ 5 T30 R19W) - 0530191039 Cedar Val Estates -Lot
21 �,ri ( lIC C"� t'DV ✓L�d2 i3 a�f ` a `P��
1.) Alt BM Description = /lf C 1
2.) Bldg sewer length = Z 0
3 -a o t of cover , = 6i'/��� O�� %-T 0/-J°
Plan revision required? No
Use other side for additio r
Date inspector's Signature Cert, No.
SBD -6 (R. 7) � /
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9
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Safety &Buildings Division
Sanitary Permit Application
In accord with Comm 83.21, Wis. Adm. Code 201 W. Washington Ave.
See reverse side for instructions for completing this application PO Box 7302
lV isconsin Personal information you provide ma y be used for second purposes p Madison, WI 53707 -7302
Department of Commerce (Submit completed form to county if not
[Privacy Law, s. 15.04(1)(m)] state owned.)
Attach complete plans (to the county copy only) for the system, on paper not less than 8 -1/2 x 11 inches in size.
County State Sanitary Permit Number ❑ Check if revision to previous application State Plan I. D. Num ber
3 T0 3(0
I. Application Information - Please Print all Information Location:
Proper70w Name Property Location
4 �2z�
1/4 1/4, Ss UeN, 49E (or
Prope Owners Mailing Address Lot Number Block Number
_4,14'� _
City, State Zip Code Phone Number Subdivision T n Name or C M Number
II. Type of Building: (check one) ❑ City
1 or 2 Family Dwelling - No. of Bedrooms : 0 Town of
❑ Public /Commercial (describe use):_
❑ State -Owned
Nearest Road
3 3 X $ S - (-r dA. M U 5 Parcel T u ber(s
III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) 30 ! 0
A) 1. P New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to
System System Tank Only Existing System
B) Permit Number Date Issued
❑ A Sanitary Permit was previously issued
IV. Type of POWT System: (Check all that apply) 77c7c -
W Non - pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland
❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line
❑ At -grade ❑ Aerobic Treatment Unit 0 Recirculating ❑ Other:
V. Dispersal/Treatment Area Information:
1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade
Required Proposed Rate (Gals./ ay/ Xt (Min. /inch) Elevation
VII. Tank Capacity in Total ManufaCtur Prefab Site Steel Fiber- Plastic
Information Gallons Gallons Tanks Con- Con- glass
New Existing crete structed
Tanks Tanks
❑ ❑ ❑ ❑
X ✓ - ❑ ❑ ❑ ❑ ❑
VIII. Responsibility S a em
I, the un rsigned, assume responsibility for installa ' n of the POWTS shown on the attached plans.
Plum is ame rint Plumb s Si MP/MPRS No. Business Phone Number
lum ees dress (Street ity, S Zip ode)
�� a
IX. County/Department Use Only [j 7
❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Ztent Si ature o.
Approved ❑ Owner Given Initial Adverse Su Fee)
Determination -R a� S, CM o -3o - 2tn
X. Conditions fAp�pr for Disapprov
� : '.�ta,C s� co
k4S
�.0 Cl>
SBD -6398 (R. 07/00)
• �(/iJ� ;,�/�� s�cS T�D�yC /I'LL
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-raJA,ftnsin Department of Commerce SOIL AND SITE EVALUATION
Division of Safety and Buildings Page —L of
Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code
Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must County
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. #
APPLICANT INFORMATION - Please print all information. R pate
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
PrNr"', r Property Location
GovL Lot 11/4 1/4,S T ,N,R �'(orlff
P rs Mailing Address Lot # Block Subd. or CSMff
1
,rS
City / State Zip Code Phone Number ❑ �y ❑village Town Road
1 1
New Construction Use: Residential / Number of bedrooms Addition to existing building
❑ Replacement ❑ Public or commercial - Describe:
Code derived daily flow gpd Recommended design loading rate L bed, gpd/fl
Absorption area required bed, ft trench, ft Maximum design loading rate — , - 6 — bed, gpd* Z—Vench,
Recommended infiltration surface elevation(s) 9/. 95" ft ( referred to site plan berdvnark)
Additional design/sit siderations '
Parent material r Flood plain elevation, if appik" ft
S = Suitable for system Conventional Mound In -Ground Pressure AT -Grade System in Fill Holdutg Tank
u= Unsuitable for system s❑ u ® s ❑ u ( s❑ U R s❑ u ❑ s(A u [Is fK U
SOIL DESCRIPTION REPORT
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/f12
13 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench
r r
Ground _ olv
elev. _ 1 /
Depth to
limiting
factor
S,L:in.
Remarks:
Boring #
d
Ground
ICON pFF► `�
elev. ;
Depth to
limiting
factor
>e-- Rem rks:
CST Name I e Pri Signature �,� Telephone No.
Address yY/J 1 Date CST Number
_ SOIL DESCRIPTION REPORT ••r-
PROPERTYOWNER '�'- Page. of
PARCEL I.D.#
Boring Horizon Depth Dominant Color Mottles Structure 2
g in. 'Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed ,Trench
1
Ground
elev. r
Depth to
limiting
factor
> c in.
Remarks:
Boring #
r s_
Ground
elev.
Depth to
limiting
factor
?g
Remarks:
Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench
Boring # /
'< Y c
Ground
elev.
Depth to
limiting
factor
: �t-' n • Remarks:
Boring #
Ground
elev.
ft. ,
Depth to
limiting
factor
in. Remarks:
SBD -8330 (R. 07/96)
m4 Al
e
3
Private Onsite Wastewater Treatment System Management Plan
or
Septic Tank And Gravity In- Ground Soil Absorption Component
Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment
System (POWTS) shall include information and procedures for maintaining the system within
the parameters of Comm 83 and 84, and the conditions of approval by the department, agent,
or 9 overnmental unit. The approved plans and permits for system are on file at the county
zoning or health department.
This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground
Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD-
.10567 -P (R.6/99).
Table 1: System Design Specifications
Sanitary Permit Number 3(, g
Number of Bedrooms
Design Flow - Peak (gpd)
Estimated Flow - Average (gpd) 4
Septic Tank Capacity (gal) c) .
Soil Absorption Component Size (ft to -+
Type of Wastewater Domestic
Table 2: Soil Absorption Component - Limits of Reliable Operation
Septic Tank Component Soil Absorption Component
Design Flow - Peak (gpd) TTL
Maximum Influent Particle Size (in) 1/8
Maximum BOD (mg /L) 220
Maximum TSS (mg /L) 150
Table 3: Maintenance Schedule
Septic Tank Inspect and /or service once every 3 years
Outlet Filter Inspect once a year and clean at least once every 3 years
Soil Absorption Component Inspect once every 3 years
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks
under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with
NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease
Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable
Restrooms).
The operating condition of the septic tank and outlet filter shall be assessed at least
once every 3 years by inspection. The outlet filter hall be cleaned as necessary to ensure
proper operates The filter cartridge should not be removed unless provisions are made to
retain solids in the tank that may slough off the filter when removed from its enclosure. If the
Management Plan for a Septic Tank and Soil Absorption Component
filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously.
Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of scum and sludge in the tank
exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the
time of an assessment, maintenance personnel shall advise the owner of when the next service
needs to be performed to maintain less than maximum scum and sludge accumulation in the
tank.
Manhole risers, access risers and covers should be inspected for water tightness and
soundness. Access openings used for service and assessment shall be sealed watertight upon
the completion of service. Any opening deemed unsound, defective, or subject to failure must
be replaced. Exposed access openings greater than 8- inches -in diameter. shall be secured by
an effective locking device to prevent accidental or unauthorized entry into the tank.
No one should enter a septic or other treatment or holding tank for
any reason without being in full compliance with OSHA standards for
entering a confined space. The atmosphere within the septic or other
treatment of holding tank may contain lethal gases, and rescue of a
person from the interior of tank may - be difficult orimpossible.
Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the
tank is no longer used as a POWTS component.
Soil Absorption Component
The soil absorption component serving this structure is designed to accept domestic
wastewater from a residential facility. The limits of operation of this component are shown in
Table 2.
The longevity of a soil absorption component depends greatly on proper and timely
maintenance, and system use within or below the limits of reliable operation. Good water
conservation practices by all occupants and the installation of water conserving plumbing
fixtures are key factors in extending the useful life of this component.
The soil absorption component's operation must be assessed by inspection at least
once every three years. The inspection shall include recording the levels of ponding, if any, in
the observation pipes, and a visual inspection for any evidence of surface seepage or discharge
from the component. On steeply sloping sites, areas of erosion should be identified and
reported to the owner for repair. The surface discharge of domestic wastewater or sewage
from the system is prohibited and considered a human health hazard.
Traffic around or over the soil absorption component should be avoided particularly
during winter months. The compaction or removal of snow cover over the component may lead
to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or
impossible to repair until weather conditions improve. In general, soil compaction over this
component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to
more intense, and earlier, organic clogging of the soil.
2
Management Plan for a Septic Tank and Soil Absorption Component
Plantings of deep- rooted trees and shrubs directly over or within ten feet of the
component should be avoided since root intrusion into the component may obstruct wastewater
flow.
3
10/25/00 WED 16:48 FAX 651 6282701 SECURE COMPUTING CORP 001
19/25/2980 14:21 512- 4368761 _,_ PPAC 0282
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer �
Maims Address L P s'�#
Property Address �� ----
(Verification required from Pla,atting Depanmcm for nrw curulnicl an)
C ib4tate _:!��_I I !U1 Parcel Identification Number 1 a
r
Property Location ..k � ri.. Y. sm. s . T -2 4& o,• own 4,r
Subdivision , Lot N
Certified Survey Map # # �i JAV'0 . , Volume
WAnmaty Deed 3 � 14I ...._. Volume
Spec house ❑ Yet �Ao Lot lines identitiab)c 0 ycs D flo
use and
ImprOpCr mattnftsAa»ceof your septic system could result sit ttx prrruawrr wtlurc t )ir:jdlr wustes.l't:operrnaiutentutrx
contttists of PNV4* Out the septic tank every dutc years or soolur. it urede.i by , ti-oeu;,ed pun►pey Wlt.►t you nut info the system
can affect flee Auction of the ataptie tank as b fMUMCat Stage is the waste disposal rys tem.
The PmPeeray owner agrees to subtitit to St Croix Zoning DePlI trternt a ctirUficaUun form, olguod, by the owner sod by a
maet6rPh=lber. joutaeyatan Plumbcr. restricted plumber or a licensed pumper vin tym4-. that (1) 'lie un.sitc wrstowatordisposs] spkm
is in POV" OPamtlug Sondition and/or (2) after inspection and pumping (if twt:drssafy), lite scptt` t1rt1: is loss thaws V3 fail of aludgo.
Uwet, the tutdersi,gned Inve read the abova requirerneuts and aVerr to n totntrEU du ) ae watc t,cwagv dlsplusal systun with the sumdards
sat fall:. hertsin , its set by the Department of Coalimeme and the Dcpartnn:rtt of N;j tural 1tc:wu2ces, Stab of W iseottsin. Canianitien
st.,tatg that ytttnr septic system has been maintained must be completed and witimcd its tl►e Si r itu.e county rArlinS Office within .t0
da,; of rbe three year expinfiotn date.
A. O��s�,7 /a aw ge)
SIGNATURE OF APPLICANT DATLt
TI
I (sire) catiffy that an stuamrlts on flux roan: are; Uuc to the best of my (uuw ) I.umAi dge. 1 (we) silt (+re tiso ownnr(s) of
the property described above, by virtue of a warranty dead recorded in Regfstt;r all Deeds Uftia:e.
SIGNATURE OF APPLICANT Ag 11
••,"•• way infomation dual is rnie -rc ..
prtsentad may result in the m ilitary peraut tKUll te•vut.rd ! +y flit lotunj; Dtparunrni. �'►�•
Inaltue with this applleation: a sfangw%j warranty decd tram the Register of I)cellb 1►trls 4
u copy of the ccrtttied suivey mup if rcfcrcau:r ►t. ►t►atpr is Ills, %-.rrtAr+ty ddCd
I
Vol. 1552 PAGE 267
STATE BAR OF WISCONSIN FORM 2 - 1999 6321 O 1
WARRANTY DEED KATHLEEN H. WALSH
Document Number REGISTER OF DEEDS
ST. CROIX CO., WI
This Deed, made between Better Homes Inc., a Wisconsin, : RECEIVED FOR RECORD
Corporation
10- 19-2000 10:00 AM
WARRANTY DEED
Grantor, and Robert P. Glamm and Dawn P. Glamm, husband and EXEMPT N
wife CERT COPY FEE:
COPY FEE:
TRANSFER FEE: 179.70
RECORDING FEE: 10.00
Grantee. PAGES: 1
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
Name and Return Address
Lot 21, Cedar Valley Estates First Addition in the Town of Somerset, St.
Croix County, Wisconsin.
032 - 2110 -10
Parcel Identification Number (PIN)
This is not homestead property.
CK) (is not)
Exceptions to warranties: Easements, restrictions and rights -of -way of record, of any.
Dated this day of October , 2000
Better
* *
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
l ss.
04 44 � 0 - County )
authenticated this day of
Personally came before me this 1 #4 day of
October 2000 the above named
Better Homes In ., a Wisconsin C por tion y
TITLE: MEMBER STATE BAR OF WISCON1",A?0
, .ar, me known to be person(s) who executed the foregoing
(If not, a�V"y^ g ` '
'I strum n c (edged the same.
authorized by § 706.06, Wis. Stats.) f��
THIS INSTRUMENT WAS DRAFTED BY
Attorney Kristina Ogland Notary Public, State of Wisconsin
Hudson, WI 54016 N jk Commission is pe anent. (If not, state ex p' a ion ate:
(Signatures may be authenticated or acknowledged. Both are not necessary.) �.)
* Names of persons signing in any capacity must be typed or printed below their sig tune. Information Professionals Company, Fond du Lac wl
e00-655-2021
WARRANTY DEED STATE BAR OF WISCONSIN
FORM No. 2 - 1999
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