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032-2156-20-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 574346 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: Torrey, Todd &Sandra I Somerset, Town of 032-2156-20-000 CST BM Elev: Insp.BM Elev: BM Description: // Section/Town/Range/Map No: `r?. cr p �To�. 12.30.19.1344 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ' �a0d Benchmark � �•�/ �, g t W Alt.BM 9 7 . Aeration Bldg.Sewer Holding SUHt Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. en Air Intake ROAD Dt Inlet OR.r.. Septic 7 7 SIB / Z 1 &J 41 Dt Bottom Dosing Header/Man. 1.14 `3 1.-77 Aeration Dist. Pipe q Holding Bot. System /,Q 76``71 / Final Grade I PUMP/SIPHON INFORMATION S.-7 91,21 Manufacturer Demand St Cover GPM Z.• 'LS Z7 .`r � Mod tuber 7. 48 cyZ. 3 TD ift Friction Loss S ste TDH Ft a 0e_ 7.57 17- .3q Forcemain Length Dia. Dist.to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No.Of Trench PIT DIMENSIONS No.Of Pits Inside Dia. Liquid Depth DIMENSIONS �2 q6 7e� �_ SETBACK SYSTEM TO (J P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR 45-M �Ip c.l Type Of System: / / UNIT Model Number � /] DISTRIBUTION SYSTEM l� t-g= Header/Manifold / Distribution x Hole Size x Hole Spacing Vent to Air Intake Pi e(s) Length_Di Length �� Dia ` Spacing \_ �� Ab SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only If Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Z -3 Bed/Trench Edges Topsoil _� .J. Yes a No '—S�,Yes 0 No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: Location: 1687 89th Street New Richmond,WI 54017(NE 1/4 NE 1/4 12 T30N R19W) Highlands,The Lot 2 Parcel No: 12.30.19.1344 1.)Alt BM Description= Ve er 2.)Bldg sewer length -amount of cover= Plan revision Required? Yes No Use other side for additional information. SBD-6710(R.3/97) Date Insepctor's i ture Cert.No. PLOT PLAN N Project Name: Todd &Sandra Torre Legal Description: NEI/4,NE1/4,S24 T31 N,RI 9W P.I.D: 032-2156-20-000 Plat Name: The Highlands Lot#: 2 Township: SOMERSET Parcel Size: 3.02 Acres SCALE:1"=40' County: ST.CROIX System Elevatio :7J=91,56' Existing 68.30'Bio Diffuser Trench Slope: 5% T 91.56' Existing 62.10'Bio Diffuser Trench A BM1 Elevation: 100.00' Top of walkout wall T3=91.00 Proposed 80'EZ Flow Trench BM2 Elevation: T4=91.00 Proposed 80'EZ Flow Trench Backhoe Pits: 4 inch Sch 40-ASTM D2665 TANK SCHEDULE 4 inch 3034 - ASTM D3034 A Existing 1000 gallon S.T.w/Zabel A-100 installed Geotextile fabrics to meet requirementsof Table NOTE:See page 10 for a complete plot of the parcel. 384.30-12 VAL✓c 7g 3 _ \ — ..TZ T, B L w"1 z���3rz r1•lo� i L XISTit JG f-IUL/sl; 1)P,1V c iNctL Page 2 County f� Safety and Buildings Division -57. C,Q©/X 201 W.Was ' o Ave.,P.O. Box 7162 Sanitary Permit Number(to be filled in by Co.) 45101P11162 N State Transaction Number ` - Aitary Permit Application �� 1 !� In accordance with$'$3.21(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitted to Project Addre s(if different bran mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law,s.15, t (m),Stats. � „tA I. Application Information-Please Print All Information II' Property Owner's Name Parcel# T0,60 tv,j S,4A)QR l /0ko 2 y/ 03Z - 7/ 576 —Z0 �b© v Property Owner's Mailing Address Property Location 3 Y I /A ( 7 L / ( TJ 7 89"" 57,8 Lf C T Govt.Lot (/ City,State /� ,' 9 Zip Code Phone Number y, �f 6 %, Section I z Ne K 1 C)4 41 O lu d W, L�(�/7 ircle one T 3 0 N; R 1� E or� U.Type of Building(check all that apply) Lot# 1 or 2 Family Dwelling-Number of Bedrooms �� L Subdivision Name (S 1/l� �24,Q0 Block# ❑Public/Commercial-Describe Use El city of ❑State Owned-Describe Use CSM Number ❑Village of Town of 5OX4.E.c 5e T III,Type of Permit: (Check onhi an box ne A. Complete line B if applicable) A. ❑New System R ep lacement Sys ❑Treatment/Holding Tank Replacement Only El Other Modification to Existing System(explain) B. ❑Permit Renewal ❑Permit Revision ❑Change of Plumber ❑Permit Transfer to New List Previous Permit Number and Date Issued ^� Before Expiration Owner ' -1 Z a — -7 / L� IV.Type of POWTS System/Component/Device: Check all that apply) WNon-Pressurized In-Ground ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil ❑Holding Tank ❑Other Dispersal Component 1 ❑Pretreatment Device(explain) V.Dis ersAlTreatment Area Information: -Q - Design Flow(gpd) Design Soil Application Rate(gpdsf) Dispersal Area Requir (sf) Dispersal Area Proposed(sf) S s m E evation Aso ©s 7 V (y3 ✓ Qa 9 ' 00 � � VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units o o $ New Tanks Existing Tanks c y n Ji C. U Septic or Holding Tank 1©0© Q� / eE�S C P Dosing Chamber / C. VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumbe' Si tune MP/MPRS Number F-7 siness Phone Number ©N n1 C M Wt 1-r r 2 Z3 7(o 0 S-7kD -C��{8 Plumber's Address(Street,City,State,Zip Code) 4116, lSOTM ve Sv meess,T VQI.Conn !De artment Use Only Approved El Disapproved Permit Fee �1!2- Issuing Agent Si tur ^7 / ❑Owner Given Reason for Denial S T / l IX.Conditions of Approval/Reasons for Disapproval G „ SYSTEM OWNER; 1.Septic tank,effluent filter and dispersal cell must leti5*d!-m ►n " as per management plan provided by plumber. -r-(�� ✓' `G 2 All sathaCk requirements must be as per applicable GbW@ f-'glaaa for the system and submit to the tounty only on paper not less than S in x 11 Inches in size SBD-6398(R. I1/11) r CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Torrey 3 Bedroom Replacement Septic System Owners Name: Todd &Sandra Torrey Owner's Address 1687 89th Street New Richmond, WI 54017 Legal Description: NE1/4, NE1/4, S12, T30N, R19W Township Somerset County: St. Croix Subdivision Name: 3.02 Acre Parcel Lot Number: 2 Block Number Parcel I.D. Number 032-2156-20-000 Plan Transaction No. Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing &Cross Section Page 4 Effluent Filter Information Page 5 EZ Flow Information Page 6& 7 Management and contingency plan Page 8 Septic Tank Maintenance Agreement Page 9 Warranty Deed Page 10 CSM Page 11-13 Soil Evaluation Report Designer: John Schmitt Licnese Number: MPRS 223760 Date: 8/18/2014 Phone Number: 715-760-0486 Signature: - In-Ground Soil Absorption Component Manual Version 2.0 SBD-10705-P(N. 01/01) Page 1 PLOT PLAN N Project Name: Todd &Sandra Torre Legal Description: NE1 14,NE1 14,S24 T31 N,R1 9W P.I.D: 032-2156-20-000 Plat Name: The Highlands Lot#: 2 SCALE 1"a 40' Township: SOMERSET Parcel Size: 3.02 Acres County: ST.CROIX System Elevatio : T =91.56' Existing 68.30'Bio Diffuser Trench Slope: 5% T 91.56' Existing 62.10'Bio Diffuser Trench A BM1 Elevation: 100.00' Top of walkout wall T3=91.00 Pro osed 80'EZ Flow Trench BM2 Elevation: T4=91.00 Proposed 80'EZ Flow Trench ■ Backhoe Pits: 4 inch Sch 40-ASTM D2665 TANK SCHEDULE 4 inch 3034 - ASTM D3034 A I Existing 1000 gallon S.T.w/Zabel A-100 installed Geotextile fabrics to meet requirementsof Table NOTE:See page 10 for a complete plot of the parcel. 384.30-12 Tq 9� 1/AL vr_` _ T3 tom' Ti _ T, �13 L _ 40 _ _ W i 4gtrL A-loe QC _ CXlSTI NG rloL1Sr Ga/a�2 r1CrF 1NLL[ Page 2 SOIL ABSORPTION SYSTEM DETAIL/GRAVELLESS LEACHING UNIT Project Name: Todd &Sandra Torrey 2 No.of Cells 8 Per Cell 3 ft Cell Width 16 Total No of EZ1203h 80 ft Cell Length 400 sq ft EISA Per Cell 3 ft Cell Spacing 800 sq ft Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ12031-1-5ft 5.0' 25.0 EZ1203H-10ft 10.0' 50.0 Gravelless Leaching Unit Manufacturer: Infiltrator Gravelless Leaching Unit Model: EZ1203H 3 gZ -`f ` 2 q';-.`7 3 Typical Cross Section Finished Grade 89.9 ft C1 i5- �'�� _ Observation Pipe with approved cap or vent .�e..■e■■.>♦■0000;.■■■■■�■■�■.��.■ ■■e.■=e.■.■■0000.■0000..■0000.■.■..i Soil Backfill 36 in ■ Geotextile Fabric 9 1.00 ft Infiltrative Surface 12 in � ©1(- 86.84 ft+' Limiting Factor >36 in Slotted and Anchored Ventl j -----__---__ Observation Pipe with Cap .........................................................0.0x.0.......... Plumber/Designer Signature: License#: 223760 Date: 08/18/14 Page 3 Page 3 • Wisconsin Department of Commerce,Safety and Buildings Division, 5. The Absorption area (SF) necessary for a given site shall be has reviewed the specifications and/or plans for this product and sized based on maximum daily sewage Now(GPD)and the determined it to be in compliance with chapters Comm 82 through Permeability for the site. If certain criteria is met, the EISA 84,Wisconsin Admin.Code,and Chapters 145 and 160,Wisconsin sizing can be used in Wisconsin, resulting in a 40%smaller Statutes. All sites must meet the Site&Soil Conditions&Locations distances as noted in local regulations. drainfield. &Isolation g The approved products are 1203H(3-12"bundles with pipe in cen- 6. Place EZflow bundle(s)in the EZjlow configuration approved ter bundle in 5'or 10'lengths)and 1203HP(3-12"bundles with pipe by system design permit specified for the articular site.The in each bundle in 5'or 10'len ths. y P P 9 top or cente r-most bundles containing in i n 9 pipe a r e joined end to A single pipe bundle contains a four inch perforated pipe surround- end with an internal pipe coupler.Any additional aggregate 9 PP P PP ed by EPS aggregate and is held together with polyehtylene net- only bundles that may be required,should be butted against ting.A single aggregate bundle contains aggregate only and is held the other aggregate-only bundles and do not require any together with polyethylene netting, type of connection. Materials and Equipment Needed 7. The top of each GEO cylinder contains a filter fabric pre-manu- • EZflow@a Bundles factured in between the netting and aggregate. The fabric • EZflow Geotextile Fabric is inserted to prevent soil intrusion. The installer shall make • EZjlrru,Internal Pipe Couplers sure the the GEO is positioned upward and is in contact with • Pipe for Header and Inlet the fabric contained in the adjacent cylinder before backfill- • Backhoe/Excavator ing Installation Instructions 8. The EZflow Drainfield Systems should be installed in a level The instructions for installation of EZflow®products are given be- trench in all directions (both across and along the trench low. This product must be installed in accordance with state rules bottom)and should follow the contour of the ground surface defined in chapters Comm 82 through 84,Wisconsin Administrative elevation (uniform depth), with all continuous adjoining Code,and Chapters 145 and 160,Wisconsin Statutes,as well as the 10-foot cylindrical bundles placed end to end, with central local health department's current design manual. bundle distribution pipe interconnected without an dams PP Y stepdowns or other water stops. I , 1. After the local health department has determined sizing,con- figuration,and layout for the EZflow systems,stake or mark 9.The trench top shall be graded such that water will not pond. with paint the location of trenches and lines.Be careful to set Back-fill should be seeded or sodded immediately after correct tank, invert pipe,header line or distribution box and completion to reduce erosion. trench bottom elevations before installation of pipe bundles. 10.EZflow EPS bundles are flexible and can fit in curved trenches 2. Remove plastic Wow shipping bags prior to placing bundles as may be necessary to avoid trees, boulders, or other in the trench(es). Remove any plastic bags in the trench be- obstacles. fore system is covered. 11. EPS aggregate is lighter than water, therefore, it might be 3. This product must have geotextile fabric that meets require- expected that natural buoyancy forces would tend to cause ments of s. Comm 84.30 (6) (g), Wis. Adm. Code, installed EZflow assemblies to float out of ground when ponding oc- directly on top of the product and extending down along the curs. Field experience has shown, however,that this is not a sides of the product to a point at least six inches from the problem when systems have a minimum of 6"of soil cover as bottom of product. recommended by manufacturer. 4. When installed in a trench, the trench should be dug to a 1203H-GEO width of 36 inches. This not only saves labor in excavation, -- - Geotextile but also provides better load-bearing capacity after backfill- Barrier Material ing is complete. �r JO@+CFNM1FYfAINIIFS MiTH Q."IPYNAL P&E C4IJPt@!(i 3W 1p V_- 401 U low. Ring Industrial Group P: 1-800-649-0253 30 Industrial Park PERFORMANCE. Q DOES IT. F: 1-866-279-9203 Oakland,TN 38060 Ringlndustrial.conn 1044-101008 ®2006 Ring Industrial Group,LP Page 5 ; MAINTENANCE A100'", A300', A600"-12 Series Filters TM The mtervval for wffi-ag septic tanks is set by state and heal code. Throughout the United States there is a wide difference of opstion on what this should be,but most regtiatary agencies two m Pere years.The Zaber fifer.which does not tnuease the tret2uertcy d servicing far the tank sftould be cleaned wt�en�ie sep�oc taNc rs nonn3ly inspected and pumped Howewier,our flaw is viol►self-cbamg. The cartavred action of the anaerobic agarwms on the Zabel f leer causes bilged particles to disintegrate and fall to the bottom of fie tank. t yotr filter cmiams,a SmarttAW alarm.you A be notified by an alarm when the MW needs servicing.. To smix dre Mar 'Servicing anymbel fire sftarfd only be darw byj ceMW squ tank punW ormstak r Locate the STEP STEP STEP , septic tank Rem d*tank cam F"piA Me Mw and prep the tarn I harde and side the ���essaryr w Prevent am canwge out d the sdids from escapim to case. ttv' few When the VMFV is removed. r• 1 STEP STEP Inseft ft filer cartridge back While hoWV the canndge over the in the case making sure the access opergng rww dff tie ca vidge filter cartridge is fresh wiater. came m mse a and ai septage matenal�be*irtb ttte tart asserted in the case. Replace die septic tank cover Notes: •H you have a%mad wpr%a<"y Wdel Faker.be an and Spray dean the outlet opening bore g the Flter. sr.�daa Copyl Tt M3.1aba rtLzMjrnw=xnxL MJUI,5flk6 C R-31=m mined n are v mac US xr to Yea, F4-11 Wor Lis un rnzne t"pawn M"to P"IV Call for a free ZABEL ZONE -1-800-221-5742.Or Order Online:www.zabeizone.com Page�` POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page_of FILE INFORMATION SYSTEM SPECIFICATIONS Owner: Todd&Sandra Torrey Tank Manufacturer: Week's C. P.oncrete r NA Permit# 1 Ir Septic t- Dose Holding Volume: 1000 gal DESIGN PARAMETERS Tank Manufacturer: r✓ NA Number of Bedrooms: 3 r NA E Septic E Dose Holding Volume: gal Number of Public Facility Units: rv/NA Vertical Distance Tank Bottom(s)to Service Pad: ft Estimated(average) Flow: 300 gal/day Horizontal Distance Tank(s)to Serivice Pad: ft Design(peak) Flow=estimated x 1.5: 450 gal/day Specific servicing mechanics must be provide if vertical is>15 feet or if In Situ Soil Application Rate: 0.7 gal/day/ft2 horizontal is>150 feet.Specific instructions to be provided on back. Standard Domestic Influent/Effluent Monthly average Effluent Filter Manufacturer: Zabel r NA Fats,Oils&Grease(FOG) s30 mg/L Effluent Filter Model: A-100 Biochemical Oxygen Demand(60135) 5220mg/L r NA Pump Manufacturer: r✓NA Total Suspended Solids(TSS) 5150mg/L Pump Model: High Strength Influent/Effluent Monthly average Petreatment Unit Fats,Oils&Grease(FOG) 530 mg/L Manufacturer: Biochemical Oxygen Demand(BOD5) 5220mg/L V NA r Mechanical Aeration r Peat Filter P✓NA Total Suspended Solids(TSS) 5150mg/L r' Disinfection r- wetland Petreated Effluent Monthly average r- Sand/Gravel Filter r Other: Biochemical Oxygen Demand(BOD5) 530mg/L Soil Absorption System Total Suspended Solids(TSS) 530mg/L ry NA rV'ln-Ground(gravity) r In-Ground(pressure) F NA Fecal Coliform(geometric mean) 5104cfu/100m1 r At-Grade 17' Mound Maximum Effluent Particle Size: %in dia. NJ Drip-Line f` Other: Other: F I Other: F NA MAINTENANCE SCHEDULE Service Event Service Frequency When combined with sludge and scum equals one-third(%)of tank volume Pump out contents of tank(s) When the high water alarm is activated maihm Inspect condition of tank(s) At least once every: 3 Yearm Maximum 3 ears) r NA r ($) Inspect dispersal cell(s) At least once every: 1.5 IV Yew(s) Maximum 3 ears r NA Clean effluent filter At least once eve : 1.5 W Y—(S) r NA -($) Inspect pump, pump controls&alarm At least on eve r Y—(S) r1_4 NA S Flush laterals and pressure test At least once every. r Y—(S) R' NA Other: Cap trenches T1 &T2 Use T3&T4 for 5 t"✓ Ye-m r NA i Other:Alternate Trenches Alternate Trenches every 1.5 years 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 Insepector; POWTS Maintainer;Septage Servicing Operator(pumper).Tank inspections must include a visual inspeciton of the tank(s)to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on 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 indicated a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumualtion of sludge and scum in any treatment tank equals one-third(%)or more of the tank volume,the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,Wisconsin Admininistrative Code. All other services,including ut not limited to the servicing of effluent fillers mechanical or pressurized components, treatment units 9 9 P P ,Pe , and any servicing at intervals of 512 months,shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. (Rev.2/05) Page 6 Page of START UP AND OPERATION For new construction,prior to use of the POWTS check treatment tank(s)for the presence of painting products,solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil dispersal cell(s). If high concentrations are detected have the contents of the tank(s)removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During extended power outages pump tanks may fill above normal highwater levels.When power is restored the excess wastewater will be discharged to the dispersal cell(s)in one large dose and may overload them resulting in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or Contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells.Do not drive or park over,or otherwise disturb or compact,the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics;baby wipes;cigarette butts;condoms;cotton swabs;degreasers;dental floss;diapers;disinfectants;fat;foundation drain (sump pump)discharge;fruit and vegetable peelings;gasoline;grease;herbicides;meat scraps;medications;oil;painting products; pesticides;sanitary napkins;tampons;and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33,Wisconsin Administrative Code: •All piping to tanks,pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. •The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. •After pumping,all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been,or must be taken,to provide the opportunity to obtain a sanitary permit for a code compliant replacement system: ER A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure,lot lines and wells.Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area.Replacement systems must comply with the rules in effect at the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations.If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology,a holding tank may be installed as a last resort. ❑ The site has not been evaluated to identify a suitable replacement area.Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area.If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface.Reconstructions of such systems must comply with the rules in effect at that time. WARNING: TREATMENT TANKS AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES AND LACK SUFFICIENT OXYGEN TO SUPPORT LIFE.NEVER ENTER A TREATMENT TANK OR HOLDING TANK UNDER ANY CIRCUMSTANCE.DEATH MAY RESULT.ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK IS VERY DIFFICULT. ADDITIONAL INFORMATION: POWTS INSTALLER POWTS MAINTAINER Name:John Schmitt Name:John Schmitt Phone:715-760-0486 Phone:715-760-0486 SEPTAGE SERVICING OPERATOR(PUMPER) LOCAL REGULATORY AUTHORITY Name: Owners Choice Name:St Croix County Zoning Phone: Phone:715-386.4680 This document is intended to meet minimum requirements of Ch.Comm 83.22(2)(b)(1)(d)&(f)and 83.54(1),(2)&(3),Wisconsin Administrative Code. Use of this document does not guarantee the performance of the POWTS. Ppaft75) ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Todd & Sandra Torrey Mailing Address 1687 89th Street Property Address Same (Verification required from Planning&Zoning Department for new construction.) City/State New Richmond, WI Parcel Identification Number 032-21 56-20-660 LEGAL DESCRIPTION Property Location NE '/a , `NE /4 , Sec. 12 , T 30 N R 19 W,Town of Somerset Subdivision Plat: The Highlands , Lot# 2 Certified Survey Map# , Volume ,Page# Warranty Deed# 7Z �j (before 2007)Volume �2 Page# Spec house OyesEho Lot lines identifiable Dyes[]no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner,if needed,by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in§SPS.383.52(1)and in Chapter 12-St.Croix County Sanitary Ordinance. The property owner agrees to submit to St.Croix County Planning&Zoning Department a certification form,signed by the owner and by a master plumber,journeyman plumber,restricted plumber or a licensed pumper verifying that(1)the on-site wastewater disposal system is in proper operating condition and/or 2 after inspection and pumping(if necessary),the septic tank is less than 1/3 full of sludge. I/we,the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth,herein,as set by the Department of Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St.Croix County Planning&Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s)of the property described above,by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 3 08/18/14 SIGNATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning&Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV.04/12) Page 8 1138 Wisconsin Dot of Co vww SOIL EVALUATION REPORT Page 1 of 3 Dh►Wm of Salely and Udings in accordance with Comm 85,Wm.Adm.Code Tom Schmitt Atedh cw0sl a ste plan on paper not less than 8%x t t kw hes in size. Plan must County kick*but not Wried ID:vertices and horizo M retewce point(BM),dsedion and St.Croix rtice povent slope,NO or dimernsive,raid►arrow,and Well rt and distance to nearest road. Parcel I.D. -2044-10.000 032-204-40-000 Please print all Infonnatdon. e . By Date Pamcnal ftmasm yw pm"may to , . 5.04(i)(m)). GLLyN.` 9 L;11,16 Property Ovrner roperty Loca Grand Properties,LP Govt Lot NE 114 NE 114 S 12 T 30 N R 19 W Property Owner's Mailing Address �;; . '' J Lot# Block# Subd.Name or CSfhA# 712 Rivard Streeet,Suite 300 2 Highlands City State rip Code +htiras Number City Village k/ Town Nearest Road Somerset WI p99A9-° Somerset 89Th St. t New Construction Use: e; Residential!Number of bedrooms 3 Code derived design flow rate 450 GPD Yid Replacement Public or commercial-Describe: Parent material Outwash Plain Flood plain elevation,It applicable no General comments and suitable for a conventional system with a 0.7 gpolsqft rating. Possible system elevation for Area i is 91.50'. Tope is 5%. Boring# Bming >108 in. Pit Ground Surface elev. 94.56 ft. Depth to limiting factor Sol Application Rate Horizon Depth Domkhent Cdor Red"Des*ft Texkme Shdure COn8i8ten s Boundary Roofs III. Munsel tau.Sz.Cont.Cokx Gr.Sz.Sh 1 0-11 10yr313 none 1 2mgr mfr cs 2f .5 .8 2 11-28 1 414 none W 2msbk mfr gw If .5 .9 3 10 j 10yr5m none ms 0sg ml — ---- 7 1.2 r Z Boring# x� Ong ❑ 00 Pit Ground Surface elev. 94.42 ft limit actor >110 In. Sol Rcte Depth to trig f Avptcadon Horizon Depth Dominent Cdor Raft Desarlp m Texture Struchre Co visisnoe Boundary Rook kh. Munsel Qu.Sz.Cord.Color Gr.Sz.Sh. 1 - 0-11 10yr313 none sl 2mgr mfr Cs 2f .5 .9 2 11-27 10yr4/6 none Is 1msbk mfr gw --- .7 1.2 3 7-110 10yr516 none ms Osg ml — 7 1.2 35 .o " Er,F. 76 "Effluent#1=BODS>30<220 mg/t.and TSS>30<150 moll. •Effluent#2=B(n<_30 not and TSS<_30 ng1L CST Name(Please Print) Signature: r CST Number Thomas J.Schmitt 227429 Address Tom Schmitt Date Evaluation Conducted Telephone Number 586 Valley View Trall Somerset M 54025 &23102 715-549-0851 Property Owner Grand Properfles,LP Paroei ID# 032-204410-000 032-2044-40- Page 2 of 3 F 3 1 Boring# Boring K Pit Ground Surface elev. 95.93 ft. Depth to limiting factor >109 in. Sol Applicallm p Horizon Depth Dm*w t Color Retbot Description Texture StnuCtIme Carrsieeertse Boundary Roots GPDW irt. Mixed Qu.Sz.Cont.Color Gr.Sz.Sh. 'EfWI 'EN#2 1 0-7 10yr3/3 none sl 2mgr mir cs 2f .5 .9 2 7-19 10yr4/6 none Is 1msbk mvfr gw -- .7 1.2 3 19- 09 10yr5/6 none ms 039 ml --- --- .7 1.2 F1 Boring# Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soi gpplcation Rob Horizon Depth Domirertt Color Redox Deepip m Texlum Stnx*rre Ca nisienoe Boundery Root GPIM In. Mtutsell Qu.Sz.Cont.Color Gr.Sz.Sh. 'Efftitl "Ef1N2 F—I �# t; Boring ? Pit Ground Surface elev. ft. Depth limiting facto in. �p p Role Horizon NO Dominant Color Raft Description TO&" Strtrckwe Corteletence Boundary Roots GPOAP in. Munsell Qu.Sz.Cont.Color Gr.Sz.Sh. 'E111101 'EfF#2 I ' Effluent#1=SOD?30<220 gpiL and TSS>30<150 mgA. "Effluent#2=6005<_30 mgt.and TSS<_30 mglt. 11m Department of ' is an equal opportunity service provider and.employer. If you need assistance to access services or • .. -•oe�olfo'nwM Fnra�wt �b.woo N�MoM tr�n A�.oa...w.t of!.!1!t_7f.1._Z rtl nw TTV fJ1R_'fful_fi'r19 f 1 • b3 , E k t : : : _ • i 16U, off? _ np r o -fs. L maw co a�.d P� r r t171J) ,�V5'-6 6 �..J v41 tz T. o�r, rg1 i s a; O V N `c !t S1tA✓�1�X6171019, Q' Q U + i MLwtwurOS«��sv� co)U2 � i `'}'y 1 .tt'trst of NEI je 1 i W ZX it co ` t &r ji 1 f it T- all e� t 1 � � y 1� !i�!El '�A 7>A60p'tlpp s ir✓►aN Al NN 1 � �I t I t� ��10fC70yLA0bA191A 1 1 � Page �i 2 2 i 5 i' ti 6 2 7;2 1 'E96Z3 KATHLEEN H. WALSH STATE BAR OF WISCONSIN FORM 2- 1999 REGISTER OF DEEDS Document Number WARRANTY DEED ST. CROIX GO., W1 RECEIVED FOR RECORD This Deed,made between Grand Properties,LP, 05/19/2003 11:45AN WARRANTY DEED EXEMPT # Grantor, and Todd A.Torrey and Sandra L.Torrey,husband and REC FEE: 11.00 wife, TRANS FEE: 737.70 COPY FEE: CC FEE: PAGES: 1 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 2,Plat of the Highlands in the Town of Somerset,St.Croix County, Name and Return Address Wisconsin. cm 032-2156-20-000 Parcel Identification Number(PIN) This is not homestead property. CK) (is not) Exceptions to warranties: Easements,restrictions and rights-of-way of record,if any. Dated this Lay of May 2003 Grand P operties,LP, * * By' MJpagement,LLC by Michael J.Germain s * AUTHENTICATION ACKNOWLEDGMENT Signature(s) Grand Properties,LP,MMG Management,LLC, SIAJE OF WISCONSIN ) by Michael J.Germain )ss. County ) authenticated this day of May 2003 Personally came before me this day of Tracy L. Tumor the above named s Kristina Ogland Notary Public State of isconsm TITLE: MEMBER STATE BAR OF WISCONSIN a known to a rson(s)who executed the foregoing (If not, i st d k e the same. authorized by §706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Ogland Notary Public, tate of Wisconsin Hudson,WI 54016 My Com ission is permanent. (If not,state expiration date: (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. Information Professionals company,Fond du Lac,Vw STATE BAR OF WISCONSIN 8001555-2021 WARRANTY DEED FORM No.2-1999 Wlpconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division ` INSPECTION REPORT Sanitary Permit No: 408229 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: Grand Properties L.P. Somerset Township CST BM Elev: Insp. BM Elev: • BM Description: dmog, TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmar .gM Dosing Alt. BM i Aeration Bldg. Sewer lv • bo 46 •o l Holding St/Ht Inlet P. cly. ?:K I TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic 7so f Dt Bottom Dosing Header/Man. Aeration Dist. Pipe 10. ! V 2 la • I 92 • ~ Holding Bot. System • Final Grade PUMP/ SIPHON INFORMATION %6 Ate OI,~ Manufacturer Demand St Cover / t GPM ~•'~Ip 53 !Z Model Numb TDH Lift ction Loss System Head TDH Ft Force n Length Dist. to Well SOIL ABSORPTION SYSTEM RE C Width f Length No. Of Tenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIME S ~7 SETBACK SYSTEM TO P/L LDG WELL LAKE/STREAM LEACHING Manuf~ `ure~t A^ INFORMATION Type Of System: f CHAMBER OR s. r ' t~/ UNIT Model Number: V. DISTRIBUTION SYSTEM Header/Manifold it Distribution THole Size x Hole Spacing Vent to Air Intake Length Dia Pipe(s) Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded T Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes ~ No Yes I No COMMENTS: (Incjade cede discr a ies, pe sons pr ent, etj4) Ins ection #1:Ld1Z3 Inspection #2: Location: 1687 891h Street Somerset, WI 54025 (NE 1/4 NE 1/4 12 T30N R19W) Highlands Lot 2 Parcel No, 1.) Alt BM Description = -5-z0.z%T, f, A/t~/~N~( 2.) Bldg sewer length = (J.01.5 J -t0 -~^t hG~n ,Q amount of cover Z~f 1c ;,.L.,Q, Plan revision Required? A Yes XNo 1 _4~ Use other side for additional information. C _ Date Insepctor's Signature Cert. No. SBD-6710 (R.3/97) E Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 NVIsconsin Madison, WI 53707 - 7162 Site Address Department of Commerce 6-OZ 3fWs D /4 87 P 9~ 7" s/ . Sanitary Permit Application Sanitary Permit Nu g~z 9 In accord with Comm 83.21, Wis. Adm. Code, personal information you provide Check if Revision may be used for secondary purposes Privacy Law, sl5. i m - 1. Application Information -Please Print All Information W State Plan I.D. Number Nh Property Owner's Name Parcel Number c~~Z 03,;t -~oyy /D -000 A' t 3 o q11 - 41D- O 06 Property Owner's Mailing Address Property Location 714 / A A 1^ Iffg- -A 5!4;S T30 N,R - 12 City, state Zip Code ne umber Lot Number Block Number Subdivision Name CSM Number 5 v 6 7/s" y-2 %5LH'1_14nr s U. Type of Building (check all that apply) ❑City 1 or 2 Family Dwelling - Number of Bedrooms ❑vinage ❑ Public/Commercial - Describe Use township Q e ❑ State Owned ~ jl_ Lpyl,6 L - V X (P 2 3' x (o t Nearest Road Tti S 7-, M. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) A. 1 A New 2 ❑ Replacement System 3 ❑ Replacement of 6 ❑ Addition to For County use stem Tank Only Existing stem B. Check if Sanitary Permit Previously Issued Permit Number Date Issued L ✓ _ IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use) 02 L J3/ / (/S L C f~A7h ~s 44 19 Non -Pressurized In-Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland st 2_1 22 ❑ Pressurized in-Ground 4111 Holding Tank 48 ❑ Single Pass 510 Drip Line 45 ❑ At-Grade 46 ❑ Aerobic Treatment unit 49 ❑ Recirculating 3o ❑ Other V. tment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Grade / Required / Proposed / Rate(Gals./Days/Sq.Ft.) (Min.Anch) Elevation d 6 Y3 &S3 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tanks Tanks aXJ`t Septic or Holding Tank ©o Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached phms. Plumber's Name (Print) P is Signature RS Number Business Phone Number &)Af,441/A1' Z. a= 1 .2.: 1, 1 Z! / Plumber's Address (Street, City, State, Zip Code) LG F /ECU 22, O - 5-?0.2 s- VIII. /De artment Use Only Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Is ent Signature (No Stamps) ❑ Owner Given Initial Adverse Su"! ~ Fee) ✓ ~ ~ ~ 0 ~ ~G4~ ~^✓ys~ Determination v IR. Conditions of Approval/Reasons for Disapproval .Po CaO'~^./" Curti Ln` 6 0 ~ plsos (to tha Cow only) for the system on paper not less than SM x U inches In size -7 Aundu0misplete f SBD-6398 (R. 05101) ' EUiSio/v 9y 5 3` /-,5'(,p '3' A"Al-A-C-4- - : WC, 7,1 i I I l : - Z _ QOPOWD Y,Rn 7o off 10 ALI X21US Ay E~- 9S~06 L o', T ,2 /yi c~fc~05 GRA~rO ~/lo~~~i mss- - - - v'►~•o.~,~= . ~1a2 IZ/yea ~ _ - SBG UAc c ~ y !/~~u~ _T2_ - cS0/'f~ /2 fET CCU/` S~~Z S / ) Eut5`rolV yr` p vc, /Ori6 NT' ,rNSEc 3 - 3' - - - - r=C i - v z X1 v/`t t~ _ Dv4 C. 4 /0 - _ _ - pRvPosr-n 3 ~3F0 _ ~'C~9« yO r c/czL ffdu5 ran %op- WAart' Oui LUAct !Y7 pop s ~ f0~ k s - L I3Q2z 5 p~fuu~n~G-_ FoR' ~-~0-02 _ l~ u~~NU ~3y 1_ ?102 :~r`~~~a~ si, _ ~8G UAcct~ dl~cv T2 _ _ _ _ _ _ - _ _ _ _ _ _ _ - - 1138 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Tom Schmitt Attach complete site plan on paper not less than 8'/: x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. 32-2044-10-000 032-2044-40-000 Please print all information. evie By Date Personal information you provide may be TW61ff8MVp1W F 5.04 (1) (m)). Gl -~),~1 Property Owner Property Locatio Grand Properties, LP Govt. Lot NE 1/4 NE 19 S 12 T 30 N R 19 W Property Owner's Mailing Address , iu _ Lot # Block # Subd. Name or CSM# 712 Rivard Streeet, Suite 300 2 Highlands City State tip Code Phone idumber City Village le Town Nearest Road Somerset WI t. "M715=2*7--5966--• Somerset 89Th St. New Construction Use: Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD Replacement Public or commercial - Describe: Parent material Outwash Plain Flood plain elevation, if applicable na General comments and recommendations: i suitable for a conventional system with a 0.7 gpd/sgft rating. Possible system elevation for Area I is 91.50'. lope is 5%. FT] Boring # Boring ie, Pit Ground Surface elev. 94.56 ft. Depth to limiting factor >108 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-11 1Oyr3/3 none I 2mgr mfr cs 2f .5 .8 2 11-28 1Oyr4/4 none sl 2msbk mfr gw 1f .5 .9 3 -108 10yr5/6 none ms Osg ml 7 1.2 ❑ Boring # Boring Y Pit Ground Surface elev. 94.42 ft. Depth to limiting factor >110 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-11 1Oyr3/3 none sl 2mgr mfr cs 2f .5 .9 2 11-27 1Oyr4/6 none Is 1msbk mfr gw .7 1.2 3 27-110 1Oyr5/6 none ms Osg ml .7 1.2 35 . U <l /•D * Effluent #1 = BOD? 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD5 < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature: , CST Number Thomas J. Schmitt 227429 Address Tom Schmitt Date Evaluation Conducted Telephone Number 586 Valle View Trail, Somerset, Wl 54025 8123/02 715-549-6651 Property Owner Grand Properties, LP Parcel ID # 032-2044-10-000 032-2044-40- Page 2 of 3 / 1 Boring # Boring Pit Ground Surface elev. 95.93 ft. Depth to limiting factor > 109 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fe in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-7 10yr3/3 none sl 2mgr mfr cs 2f .5 .9 2 7-19 10yr4/6 none Is 1 msbk mvfr gw 7 1.2 .7 1.2 3 19-109 10yr5/6 none ms Osg ml ❑ Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ❑ Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5> 30 < 220 " and TSS >30 < 150 mg/L * Effluent #2 = BOD5 < 30 mg/- and TSS <30 mg/L The Department of E e is an equal opportunity service provider and employer. If you need assistance to access services or .]#-ta f- f -1-- -t-t the ,1a„o,4--l of lnQ-')AAA 14 1 - TTV An4_7AA_Q'7'1'7 3 P I I I S' y ` 75 ' t3 B ~ S1 o C4, `6-0.0-0 r 4r: Profae-4,-ei-I Z14 /it", Su ~e /off IS -Fr 7.2,o cZ S - 47,T) &IS-1 Aj,- /V & 1 MY 54 7'3 c) Y el?4 ) / vt e So- , sue Safety and Buildings Division C1,i-. NVIsconsin 201 W. Washington Ave., P.O. Box 7162 CJ" Ix Madison, WI 53707 - 7162 Site Address Cam, Department of Commerce 5-5--3 0 ~5'* 16n O Sanitary Permit Application Sanitary Permit Number In accord with Comm 83.21, Wis. Adm. Code, personal info yon ~ / may be used for secondary purposes Privacy Law, s15. 1 m i , k i.vision 1. Application Information - Please Print All Information Stad Plan I.D. Number Property Owner's Name / P I r Q~~_2,oryy-/O•- 0 00 #4, E C - x Y - o Y~ SIa ~d Cr3 Property Owner's Mailing Addiess ^=i'ri iG OFFICE rty Location 5T -NE % -A; S 12 T N, R Nu City, State Zip Code Pbone Number Lot r Block Number Subdivision Name CSM Number U. Type of Building (check all that apply) e ❑City Z~t ".4" -1 I or 2 Family Dwelling - Number of Bedrooms t~t~t.w► ❑Village ❑ Public/Commercial - Describe Use *ownsbip (J - - ❑State owned Nearest Road --=)(-*Z 40~ 126 r ,4t, 2 t M. Type of Permit: (Check only a box on line A (numbering sch a for internal use). Complete lime B if applicable) al~ ~ For Co A. 11 Replacement of 6 ❑ Addition to use New 2 ❑ Replacement stem 3 1 K New Sy stem Tank Only Existing 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) wz (oO 44 ;4 Non -Pressurized In-Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In-Ground 410 Holding Tank 48 ❑ Single Pass 510 Drip Line 45 ❑ At-Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other V. tment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area il Application Percolation Rate % System Elevation Final Grade Required Proposed Rate(Gals./Days/Sq.Ft.) (Min./Inch) q Elevation lap. ~i ~ !~FTb qG 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 ma Dosing Chamber I the undersigned, assirme respo~rihty for installation of the POWTS shown on the attached plans- 'tY Statement- VII. R~nsibih Plumber's Name (Print) s Signature RS umber Business Phone Number A ' Plumber's Address (Street, City, State, Zif e) S c 5 a,~ s~ VIII. Coup /De artmen Use Only Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee) ❑ Owner Given Initial Adverse OD Determination J IX. Conditions of ppro. easons for Disapproval r ~ 4UX111 4K_ mr) t N tea de~ownst~ T d~'^LQ- ill,A V~~S1~I~C~ t IMG t. SBD-6398 (R. 05101) ~ P 30 y le Puc vEwr 04, ~N irpecirQ,r Y, 7 _ 0. 93:3 77, 3 L07 /G/fG9~.5_ _<SYSTE77-__EG 93<3, __.Locv2_. y',Z•_ ell P~PcpGS~D ~ ~D - 10 00 G-i s j-/,q -~ao F/~ fe2 Lo 7- L - /A(4-7 G2f3/YO pled El /ES 26Z S'T. S~'G 0,4e-(-EX jhezv cSo/`'l~~S~T j G~~`• cs0/'7E2SFi ~9~fv~ TA, ~ Prue ~ N , 09 lard ' r CL•'933_ 617 7o - / c- tL /Qo- o ►f3r'7~ a~ %Y/-'~~'~' 973 - _Dne Es 93,3 Lo:6- r^~- 7 I ~ 9e / .3 'x 6SQ o ~E~rcN Y- pR v 3 X ( a, s~8 0 , Wei - , /A-you« fee ~t- s rpoo . La / _ f~ A a)ING- F04 G Q27_O /n< r e,41yo ~~C o/>E/~r DES, IYta - Wisconfln DepartmerifofCommerce SOIL EVALUATION REPORT Page of . Divisiofi-of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County ( CM Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must 7 include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information, viewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 1 Zia I ~::J=& 2- Property Owner Property Location kayH Govt. Lot I/C7 1/4S o- 1OF114 S 2 T 30 N R E (or)b t~ Block # Subd. Name or CSM# Property Owners Mailing Address Lot # 353 kee- T. 2 -sr- Ht k t o ncls city State Zip Code Phone Number ❑ City ❑ Village [down Nearest Road n 614, (ls~19-~73/ S mer -e gL New Construction Use: 9 Residential / Number of bedrooms 3 Code derived design flow rate o / to l GPD ❑ Replacement ❑ Public or commercial - Describe: Parent material t-)AoQ h Flood Plain elevation if applicable ft. General comments ' and recommendations: 5 m elev. - -6p 95-30 lRECEIVE0 ard- az .-io L 2.Op Y RI ? E] Boring COLW-y F-1 I Boring # on- ® pit Ground surface elev. Q-1-to ft. Depth to limiting factor r l in. Soil li n to Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary t °v-1- in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#2 1 l2 s~ 1 Zt~, k rrSt- c l„ 5 vr 4f 114 Z l6-`fd 5' Zms c 3 `f~ Vii/ 1 L - ( - - 1. •%f 93 Boring # Boring Z ® pit Ground surface elev. Q-t •(ao ft. Depth to limiting factor l~ in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 a- 12 2waoL Cs '5 Z - 1/ 18 , 14 Se.l s c - 1. yd I& w►s Z~ - -2 i .6 ' Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/- and TSS < 30 mg/L CST Name (Please Print) Signature CST Number Mdaryl sc ke- Z33309 Address lop' Date Evaluation Conducted Telephone Number 2113 2 0'~ S-~ • Some io- -01 671z~ -yoo~ Property Owner S460-~ Parcel ID # Page Z• of 3 Boring # Boring nn p,~ft Ground surface elev. ` 15oU. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 I U- (I r-Al 2- Si I Z+~nab~C CS -'5 l - (L)3'r (44 Sic1 cs - -(4 (Q IDVI, q/& ❑ Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ❑ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need materi4t in an alternate format, please contact the department at 608-266-3151 or TTY 60A7264-8777. SBD-8330 (R.07/00) Property Owner Parcel ID # Page Z of 3 Boring # ❑ Boring FN Pit Ground surface elev. Q 5• o s ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 ( 0-1 I 5" ZA1CLb ~S -5 .9 ID r' Sig) c5 - 5 y -2 1. E Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 `Eff#2 F-1 Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDtff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 `Eff#2 Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = BODS < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need materi4( in an alternate format, please contact the department at 608-266-3151 or TTY 600-2648777. S13D-8330 (R.07/00) it PAGE 3 OF 3 NAME, LOT# Z LEGAL DESCRIPTION y 14 Nf X,S lL T 3 N, R, I q E(or~ SCALE:1"= ABM 1 ELEVATION y BM 1 DESCRIPTION_, 6 T ~ - .,-BM 2 ELEVATION q 7.3 O BM 2 DESCRIPTION _:f a p d 3 H rL ,rQe _ .S PG SYSTEM ELEVATION -/ap 93.30 Go~„i •r `JZ , ~O ALTERNATE ELEVATION ' 77,00 CONTOUR. ELEVATION 76-C0, 75.00 I ~f 00 q.00 •OlAt I SIGNATURE c~ - DATE Page -Lof 2, MANAGEMENT PLAN This Private Onsite Wastewater Treatment System (POWTS) has been designed and is to be installed and maintained in acoordingto Comm 83, Wis. Admin. Code, the in-Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems (SBD-10567-P; June 11,1999), 1. This POWTS has been designed to accommodate a maximum daily flow of O gallons of domestic wastewater-per day. The quality of influent discharged into the POWTS treatment or disposal component shall be equal to or less than all of the following: a monthly average of 30 mg/L fats, oil and grease a monthly average of 220 mg/L BOD 5 a monthly average of 159 mg/L TSS. Wastewater shall not be discharged to the POWTS in quantities or qualities that exceed these limits or that result in exceeding the enforcement standards and preventative action limits specked in ch. NR 140 Tables 1 & 2 at a point of standards application, except as provided in Comm 83.03 (4)m Wis. Admin. Code. 2. The owner of this POWTS is responsible for system operation and maintenance. The following maintenance shall occur within three (3) years of the date of installation and at least once every three years thereafter: 1. The septic tank shall be pumped be a certified septage servicing operator, licensed under s2.81.48, Wis. Stats, unless inspection by a licensed master plumber or other person authorized to make such inspection, finds less than (1/3) of the tank volume occupied be sludge and scum. More frequent pumping may be necessary to prevent solids from exceeding one-third (1/3) if the volume of the tank.. Wastes shall be disposed of by the pumper in accordance with ch. NR 113 Wis. Admin. Code. At each pumping the pumper must visually inspect the condition of the tank, baffles, rizers, and manhole cover and verify that any required locks are present. 2. The soil absorption component(s) shall be visually inspected by a licensed master plumber, certified septage servicing operator or POWTS inspector. Inspection shall check for evidence of discharge of sewage to the ground surface and for ponding of effluent in the distribution cell. 3. The tank filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's specifications. The filter cartridge shall not be removed unless provisions are made to retain solids in the tank. Cleaning of the filter at more frequent intervals may be necessary. 4. Any pump, alarm or related electrical connections shall be visually checked for defects and tested to confirm that they are operating properly. 5. Reports for all system maintenance shall be submitted to St. Croix County Zoning in accordance with Comm 83.55, Wis. Admin. Code. 3. Defects or malfunctions identified during maintenance described in item #2 above shall be repaired in conformance with Comm 83, Wis. Admin. Code. 4. Anytime a failure or malfunction occurs, it shall be reported to the owner of this POWTS. Repair or connection of such failure or malfunction shall comply with Comm 83, Wis. Admin. Code. 5. No one should enter a septic or other treatment tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within these tanks may contain lethal gases and rescue of a person from the interior of the tank may be difficult or impossible. 6. No product for chemical or physical restoration or chemical or physical procedures for POWTS may be used unless approved by the Department of Commerce in accordance with Comm 84, Wis. Admin. Code. 7. In the event that this POWTS or a component of this POWTS fails and cannot be repaired, the following contingency plan is proposed: Z_~ilit~ cotncmnenL;il1s11Ll~r~pl~si.. This may require a new soil evaluation to determine where a new soil absorption c con1I-X)11cnt Call IV. 8. If (his 1110WTS is replaced, or its use is discontinued, it shall be abandoned in accordance wi(h Comm 83.33, Wis. Admin.. Code. 9. Name and number of local health agencyL_S Cr0jX C.4ttillv onit ' -_11_5--3-86-468L) 10. Name of service contractor in case of failure or malfunction:-Scllmitt & SonsF.xcuYafinu 715-549-6651 ST CROIX COUNTY SEPTIC "TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer G2a10D li c S-yGZ•S~ Mailing Address 1 \ jUp&0 _ St&i i C ► v0 <,0:nPrcr_" 40 Property Address 1697 (Verification required from Plannin,~ Department for new construction) 032 - e ovq -v -000 City/State S n -54V Parccl Identification Number -d00 LEGAL DESCRIPTION Property Location ~ ' , ~I Sec. TAN-R W Town of UM'e-f Subi lvtston i L c ~~Lc~ ~v Low 2, Certified Survey Map # , Volume , Page # Warranty Deed # Volume Page # ~O Spec house yes ❑ no Lot lines identifiable A yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the syster- can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days oft three year expiration date. ALP/ Wilfrk- ~ -6 - i2(- lGz. SI ATURE F APPLICANT DATI? OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a \%arranty deed recorded in Register of Deeds Office. - & 0~lzzL SI NA OF APPLICANT DATE « Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed I It U 1915r 9 0 5 STATE BAR OF WISCONSIN FORM 2- 1998 6 8 2 5 1 2 WARRANTY DEED XATHLEEH H. WALSH REGISTER OF DEEDS Document Number ST. CROIX Co., WI RECEIVED FOR RECORD This Deed, made between 06-24-2002 3:00 PM RICHARD O STOUT and TANP.T P- STOUT husband and wife, WARRANTY DEED Grantor, EXEMPT # and ('RAND ROPPRTTES T ,P REC FEE: 11.00 TRANS FEE: 159.60 COPY FEE: CERT COPY FEE: Grantee. PAGES: 1 Grantor, for a valuable consideration, conveys and warrants to Grantee the following i " described real estate in St Croix County, State of Wisconsin: Recording Area Lot lat of The Highlands. Town of omerset, St. Croix County, Wisconsin. Name and Return Addres ~l 1 2 T Vu.i-cyJ~J ,2;t, _ Do 54 o~LS I 032-2044-10-000 012-2044-40-000 Parcel Identification Number (PIN) This is no homestead property. II (is) (is not) n ii I ~I I i I Exceptions to warranties: easements, restrictions, rights-of-way and covenants of record. 4^" Dated this 0 day of June , 2 0 0 2 1~c~J~4t~ C Si6~ (SEAL) (SEAL) * Richard O. Stout Janet P. Stout (SEAL) (SEAL) j - AUTHENTICATION ACKNOWLEDGMENT '~~.t-n~c~ 6 57v u i Signature(s) T State of Wisconsin, J A-P J tar h- s -To u -r ss. St. Croix County. J L) T4 6"; authenticated this Personally came before me this day of June --2-Q- -OZ the above named Richard O Stout and Janet P. • Stout 1 s~ W/'~ 06v-~10 TITLE: MEMBER STATE BAR OF WISCONSIN to (If not, me known to be the person S who executed the foregoing authorized by §706.06, Wis. Stats.) instrument and acknowledg2 the same. THIS INSTRUMENT WAS DRAFTED BY Janet P. Stout -a 5 2Arwa_ urk'ea rr Hudson, WI 54016 Notary Public, State of Wisconsin My commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not ) necessary.) ' Names of persons signing in any capacity must be typed or printed below their signature. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co.. Inc. WARRANTY DEED FORM No. 2 - 1998 Milwaukee. 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