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032-2056-95-100
Wisconsjn Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix S<fety and Building Division INSPECTION REPORT Sanitary Permit No: 515267 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: M.L. Johnson Develop ment, c/o Michael L. Jo I Somerset, Town of 032 - 2056 -95 -100 CST BM Elev: Insp. BM Elev: BM Description: nn Section/Town /Range /Map No: 01. - 7 1 Ar 0,- 8 N 16.30.19.721610 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic ��.; Benc mark '� / 4 W QM Z 7 5 /del• id1, 7/ Dosing Ki.Zf Alt. BM Ae►Atien Bldg. Sewer Holding ` � � St/Ht Inlet 1 . TANK SETBACK INFORMATION J St/Ht Outlet 6 U a4lo TANK TO �P /L 1 WELL BLDG. Vent to Air Intake ROAD Ptirtlet `•�� . es.... Se tic / / 7 — � �e, �7Z 33 !.p l.J, ems, t5 L. y7 , Header /Man. 71 ZO 9L, 11 O 7 Aelation Dist. Pipe 9.3 95• I(� Holding Bot. System 163 PUMP /SIPHON INFORMATION Final Grade Gl • Manufacturer GPM nd St Co�gG 7.4 Model Numb 1.J TDH Lift Friction Loss ISystem TD Ft aloe.. 6A 7-To %P �5 Forcemain Length Dia. Dist. to Well '7 77 ' 1(,. , ?/ SOIL ABSORPTION SYSTEM p�� 5 Q. y�/. S( BED/TRENCH Width I Length No. Of Trenches IT DIMENSIONS Of Pits Inside Dia. Liquid Depth DIMENSIONS z yZ " Z 7lee VA-96 I I-,— `1 ` SETBACK SYSTEM TO P/L JBLDG IWELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: b l'` _ �� UNIT Model NuC>,., , r y DISTRIBUTION SYSTEM 23 +• Z3 = j-0 2 Header /Manifold �� Mistr x Hole Siz x Hole g lVelifir ake �r '� Spa n t^' Lengt Dia T Dia �. Spacing ayp,M, SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only xx Dept xx Seeded /Sodded xx Mulched Bed/Trench Over Center �. 3 Depth Over Edges Topsoil \ Yes 0 , Depth Over Depth Over h of No es E No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / / Inspection #2: Location: 570 155th Ave Somerset, WI 55440025 (NW 1/4 SE 1/4 16 T30N R19W) NA Lot 1 Parcel No: 16.30.19 1.) Alt BM Description = W l e 2.) Bldg sewer length = 4,no�S - amount of cover = 6W Plan revision Required? Yes Nc =6 � Use other side for additional information. ( p Y J SBD -6710 (R.3/97) Date I#Sigure Cent. No. Safety and Buildings Division Co un : w§ §hiBN Avg: : ®: ®# 11Q N1 W • sconsln Madison'll 53767 — 7162 Dep artment of Co mmeroe � l 5 ) Z Sanitary Permit Application State Plan I.D. Nu r In accord with Comm 83.21, Wis. Adm. Code, personal informatio u provi may be used for secondary purposes Privacy Law, sl5.04(1 xm t A Project Add ss (if different than mailing address) �7 d 15 -N, I. Application Information - Please Print A Information, Property Owner's Name 174 , Parcel # Lot # Block # �. v � c A,) p S/- � 03 Z - Z ©S" - ? V Property Owner's Mailing Address / NG Ik( Property Location f S 7 T f! S ,6 %, Section l0 City State Zip Code P ne NuJp� C �/ S c'/ 1/ C j T ��C7 Z DtJ�I o�► N; R i ot� II. Type of Building (check all that apply) r v Subdivision Name 1 or 2 Family Dwelling - Number of Bedrooms CSM Number ❑ Public/Commercial - Describe Use IOUSc� A.) `�1�1�/O o cl El state Owned -Describe Use 2 6, --,4- t✓eAA,5 t�..1 Z� �- L�Nn ( 5 ❑City_ ❑Village [gTownship of Spi �l �/?S E III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑ New System uy Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. El Permit Renewal El Permit Revision El Change of El Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. of POWTS System: Check all that a ' y' on - Pressurized ht- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application te(gpd f) Dispersal Area Required ( Dispersal Area Proposed System Elevation 4/5_C) o. 900 3 I �� - - VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New I Existing } Tanks Tanks W r C S C Septic or Holding Tank ) CO / co o 200 W / os J Ce 6 AJ t 1! `' Aerobic Treatment Unit W Dosing Chamber ' r VII. Responsibility Stateme I, the undersigned, assume respon tbility f installation of the POWTS shown on the attached plans Pl Name (Print) Plumber's S1 afore MP/MPRS Number Business Phone Number J ©�N Sc� lwfT Z,, 2 Z 3 7i(c 0 - 7t -760 - CY�� Plumber's Address (Street, City, State, Zip e) 10 6 /S9r ©7 - o 5oittoews�;; PVT VIII. ty /De artment Use Onl pproved ❑ Sanitary Permit Fee (includes Groundwater Date I sued Issuing t Signa tamps) Surcharge Fee) C / T ❑ er Gi eason for ial J [/ IX. Conditions of Approval/Reasons for Disa roval t� VFW 3, ✓d . �� e/1�► � l2 d. tie 1. Septic tank, effluent filter and r l dispersal celf must all be services / maintained ` 764" as per management plan provided by plumber. 2. A# setback requirements must be maintained \ as per applicable code / ordinances. LI/✓ 0 W.A.. $� tti �^• G o„ Attach coaapkh planq (to the Comfy Daly) for the system as paper not "81/2 in size le� SBD -6398 (R. 01/03) ff Y PLOT PLAN Page 2 of 13 (Tim & Laura Green) ♦ BM1 Elevation = 105.69 Window sill on west side of house. - cover. � BM2 Elevation - 101. ?1 Septic tank r. e ■ Backhoe pits Slope= 3.0 Elevation Trenches 00 2 - 3'x 92' INFILTRATOR Quik 4 Trenches NOTE: 2n 1000 gallon septic tank added to system with Polylok 625 filter N Bull Run Valve added to alternate between new and old system Scale: 1 "= 50' Pete 3� `I Z � QL41/ y cl4lmieee,S K EW 1000 GIR 5 -7. W rrN (oZ /000 GAL 5,7, W17 L A -IoC �0 ; i5 Ex�ST�n1Co f31�D�r�uSE� Q1ti1 Z _ Tk ou C �� _r'S E X /3 T1 k, L of t - 3 X - 7 S K �tLL J I -- COPY Page 1 of 13 CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Green Conventional Gravity Septic System Owners Name: Tim and Laura Green Owners Address: 1570155' Avenue Somerset, W154025 Legal Description: NW /a, SE' /., S16, T30N, R19W Township: Somerset Subdivision Name: 3.08 Acre Parcel Lot Number: 1 Parcel ID Number: 032- 2056 - 95-100 Page 1 Index and Title Page 2 Plot Plan Page 3 System Cross Section and Sizing Page 4 Tank Specifications Page 586 Filter Information Page 7 Bull Run Valve Information Page 889 Maintenance & Management Plan Pagel o Septic Tank Maintenance Form Page 11 Existing Tank Certification Page 12 Warranty Deed Page 13 CSM or Plat Attachment: Soil Evaluation Report Designer/Plumber.- John Schmitt License Number: 223760 Date: May 28, 2010 Phone Number. 715- 760 -0486 Signature Designed pursuant to the In- Ground soil Ahwrgm Cmwoneffi Manual for POWTS version U SBD- 110705 -P (N.olrol). - PLOT PLAN Page 2 of 13 -- (Tim & Laura Green) ♦ BM1 Elevation = 105.69 Windowsill: on west side of house. -- A BM2 Elevation = 101.71 Septic tank cover. - - a Backhoe pits Slope= 3.0 Elevation Trenches 2 = 3'x 92' INFILTRATOR Quik 4 Trenches - NOTE:- 2 1000 gallon septic tank added to system with Polylok 626 filter -- - ll Run Valve added to alternate between new and' old system Scale . V= 50' L- — - -- - -- NEW 1000 CAL 5 -7. w owco ,,nZg _ - k3 w�z1StL A-f E x 13 - r1sV 13A Z _ �® ` 1 ' 3 -A $�© fill = G [ _ 3 X 3.. `7 S W iE L,L - - - - -Z' - - Page 3 of 13 Soil Absomtion System Cross Section .�.. 98.20 ft 4' Sdoduie 40 Fhal Grade Pyc vast Pipe V 96.00 ft th Vast Cep 95.00 ft. Trench Ekv�an Y 4— Trench Elevation 3 ft . >3 ft §4ll Absorption System Plan Vie�n+ 92 ft 3 ft 3 ft 7VentOrObservationPIPG ChLeacNng ambers Trench 1 4' Dia. Trench 2 Header Leaching Chamber Specifications Manufactuer and Model INFILTRATOR Quik 4 ESIA RatingF sq. ft per chamber ESIA Rating 5.8 sq. ft per 2 endcaps DWF 450 gpd , 4 oil Aplication Rate 0.5 gpolsq. ft 0 450 gpd DWF + Soil Aplication Rate + 20 ESIA= 45 Chambers 2 rows of 23 chambers each. x w �o 61" 86' C n 42" - rn o p � UP 41' N 1 7D 4" CAS v 1 r A I 3" 36" 4" I M A m 1I " r 1 A A- I UP 38 \\ AI . 4" CAS N \ / G 2 9: > C �N$ p ° 39" r1 °v� A r A rnmr A C O C D 1.1 > 0 � ?Dmo M A x� x D Z o gg Fn F A *w rn z z o c 1E �� 20 xx v FN o ij g -+ 0o D c) o 28o�c) 2 9 - 0 $ ch ° rn m 5m 11 Ln it�x H q � �� � -�� ¢ w _0 c � / = ttv c v��ff F A 2 oo x.. �0 o � w r* j 1 .. � � _0 a v ; gv D$ oo D a 2 ND Oo }� gIN O u z o zD r5rn N a o �� w A � 000- z P c� O n 7C ��� o!A a �C W y P Fm � O a � O C) a La Z mm C � C Qv r D D 8 ^ D c m H D A� O a° 2 r -1 z 51 o w .D col X A m 0 Z� � o .Q Z D x o Q v, m� $2 rn `" 2 F Z, 0 Z U P10W -MR SCALE 4 "•r-o" -�ouR rn AMN BY: Siff o - rn 1®®11ETE I� n SEPTIC MANUAL DAM MttAIARY 20M oA� . W371 - a�aeNt s US tnrr to MAIDEN Roar. wt 54750 n onn •inc o � cc Page S of 13 MAINTE NANCE A100'"� A300ry, A600' Series Filters TAIL The interval far servicing se corks is set by state aril kacai code. Throughout die United States there 6 a wide drffenenae d apsaion on what this inler�af 5trnukJ b , taut most ro�p ia�xyr agrenues s t tiro to fim ,years. The Zab er �er< which does rut increase the frt?Iquet�cyr d swifting for dre tank shat lld be cleaned when septic rYc rrornnaly and Honwew, our filter is vii>tal1y self- cleanng. The conomW action of die arlaerobic orgariems on die Zabel filter causes es k4geci particles to disintegrate and to ire b000m of the tarn. r yr~<alr lter fi cof&*s a Smarlf Aer' alarm, you A be notified by an alarm when the ftkr nee& servicirig. To unice the Nis- 5 I "Sovong any m bef fiit'W shouttd mty be done bya wow SfPfk Link purtw or fnswtlbr M 51 �" cttt* STEP L"- Remw a the tank owm F" pLA the tier and WM the rank g handle and side da nee x v to mme aw cartridge out of the solids from esca�g ru cam. tare field when the inter s removed. STEP _ STEM' r Insert the fdw cartridge back While ho the cwtidge am the in the case makmq sire the access ra6e df 9w c arrrklige fifter cart idtje is y Fri �skr aligned and at s+eplage nwff all bad i w Ore ruck Wsemed irr the case. Replace the septic lank Qww Nos: • tf tw home a Fftmd tr ems c - Wdel Rim, be an and WY cbm the outlet opffmV Won replacing the Flter. co"VI M1.1abd hL1SVM1MVrUW.AaL a1AI fKS< 2 Pmemw amw tYf CW or mom u 5. W*W trio MMId patens oero U3.1nd rst.^rt a Cat PMXZ maybe toners} Call for a free► ZABEL ZONE* • 1 -800 -221- 5742.Or Order Online. www.zabehmm.com INSTALLATION INSTRUCTIOI� PA LY�IPX Inc Innovations in Precast Drainage ,, Zabel' & Was PL-525/PL-625 FILTER Wastewater Products A Division of Polylok Mc. INSTALLATION INSTRUCTIONS 1�9 lA14hi& wi Center filter with opening U) Z ~�. M_ e � a fA Additional pipe or Polylok Extend & Lok Glue for centering. Step 1: Step 2: Step 3: (A) Locate the outlet of the septic tank. (A) Before installation, place the (A) Glue the filter housing on the (B) Remove tank cover and pump tank filter housing on to the outlet pipe. outlet pipe. if necessary. (B) Make sure that the housing (B) Insert the filter cartridge in the is positioned so the filter can be housing, making sure the filter removed from the tank for cartridge is properly aligned and maintenance and service. completely inserted in the housing. MAINTENANCE INSTRUCTIONS , 1 Y. Step 1: Step 2: Step 3: Locate the outlet of the septic tank. (A) Remove tank cover and pump (A) Insert the filter cartridge back if necessary. into the the housing making sure WHEN • NOT FILTE • � the filter is properly ali (B) Pull the filter out of the housing. P P Y hed 9 (C) Hose off the filter over the septic tank. and completely inserted. USE RUBBER GLOVES MakR surer all cnlid.q fall hark into the (B) Replace septic tank cover American Manufacturing Company -- Bull Run Valve Page 7 of 13 AM ERICAN O NSITE AMERICAN MANUFACTURING COMPANYp INC. Home About Site Map Products IF— Drip Systems Controls Contact Data Center THE BULL RUN TM VALVE 'WATER-TIGHT ACCESS CAP RISER CAP ! ADAPTER �l RISER TUBE VALVE DIRECTI ONI t*NDLE The Bull Run Valve"" is designed to split flows to septic r OUT PORT fields or systems. In addition to the advantages of longer life and easier installation it is the most public 4' OUT PORT health safe alternating device available for wastewater disposal applications. The use has absolutely no contact with wastewater due to the valve's leak -proof and external operating characteristics. The change over from C IN PORT one drainage field to another can be accomplished in less than a minute by simply turning the valve without The Bull Run Valve is available in 4" sch 40 pvc digging or contact with wastewater. and is suitable wherever septic disposal systems are used - in commercial, industrial, and residential applications. OPERATING THE VALVE The direction control handle should be rotated Field Field VValve periodically to direct effluent to one or the other No I No_ 2 of two septic fields. After removing the screw cap at the top of the riser tube, the valve handle can be turned with the valve key furnished. Valve Positioned ed BULL RUN VALVE on No. i . 2 Complete Valve Kit during during Odd Years Septic Septic Even Years Contains Tank Tank 1. Bull Run Valve body 2. 28" Valve Key 3. Riser Cap Adapter ITEM DESCRIPTION 4. Watertight Access Cap BRV4 BULL RUN VALVE 4" BRVBULK BULL RUN VALVE & KEY ONLY BRVCIRISER BULL RUN VALVE RISER W/ CAST COVER BRVCHUSER - 4" BRVKEY28 BULL RUN VALVE KEY 28" http;// www. wnericanonsite .com /american/catalog/brv.hunl 5/17/2010 Page 8 of 13 POWTS OWNER'S MANUAL & MANAGEMENT PLAN FILE INFORMATION SYSTEM SPECIFICATIONS Owner Tim & Laura Green Tank Manufacturer Week's C. P. 0 N Permit # ® Septic ❑ Dose ❑ Holding Vol. 1000 gal DESIGN PARAMETERS Tank Manufacturer Wieser Concrete ❑ NA Number of Bedrooms 3 ❑ NA IN Septic ❑ Dose ❑ Holding Vol. gal Number of Public Facility Units M NA Effluent Filter Manufacturer Zabel POlylok ❑ NA Estimated (average) flow 300 gal/day Effluent Filter Model A-100 625 Design (peak) flow = (Estimated x 1.5) g al/day Pump Manufacturer 99 NA In Situ Soil Application Rate 0.5 al /da /ft2 Pump Model Standard Influent/Effluent Quality Monthly average' Pretreatment Unit [A NA Fats, Oil & Grease (FOG) 5530 mg /L ❑ Sand/Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD5) 5_220 mg /L fm NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5_150 mg/L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Manufacturer Biochemical Oxygen Demand (BOD5) 530 mg /L Dispersal Cell(s) ❑ NA Total Suspended Solids (TSS) 5_30 mg /L ❑ NA IN In- Ground (gravity) ❑ In- Ground (pressurized) Fecal Coliform (geometric mean) 5_10 cfu /100m1 ❑ At -Grade ❑ Mound Maximum Effluent Particle Size % in dia. ❑ NA ❑ Drip -Line ❑ Other: Other: ❑ NA Other: ❑ NA `Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 2 El mear h(s) 10 Y ( ) (Maximum 3 years) ❑ NA Pump out contents of tank(s) ❑ When combined sludge and scum equals one -third ( of tank volume ❑ NA ❑ When the high water alarm is activated Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) ❑ NA 2 ® year(s) Clean effluent filter At least once every: 1 ❑ month(s) ❑ NA a year(s) Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA ❑ year(s) Flush laterals and pressure test At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator (pumper). Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visuaffy inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any treatment tank equals one -third ('A) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of :512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (12/02) Page 9 of 13 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 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 and pits 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 a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a 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 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>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name John Schmitt Name John Schmitt Phone 715-760 Phone 715- 760 -0486 SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name Apostle is Service Name St, Croix County Zoning Phone 715- 497 -5929 Phone 715- 386 -4680 This document was drafted by the staffs of the Green Lake, Marquette and Waushara County Zoning and Sanitation agencies in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. Page 10 of 13 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND -� OWNERSHIP CERTIFICATION FORM Owner /Buyer / 1 nq #yo L,+ uP_.q G eC & ly Mailing Address Property Address (Verification required from Planning & Zoning Department for new construction.) City /State 50 M E125 E ' ; W ! Parcel Identification Number 0 J Z — Z0 SQp " 9 � �0 0 LEGAL DESCRIPTION Property Location N) 0 /a , 1 /4, Sec., T 3 N RW, Town of J o 01,CO2-5 ET Subdivision J © f4 /'U S O to / / L t- 9400 U) S , Lot # �. Certified Survey Map #_03 Z O O Z , Volume , Page # g 3 3 S . Warranty Deed # 6;? 3 Z Q 6 Z I �J 7 1 , Volume 15-o3 , Page # ^ 1� Spec house yes Q0 Lot lines identifiable yes no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and /or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statements on this form are true to the best of my /our knowledge. I/we am/are the owner(s) of the property described above, by virtue of a warranty deed recor egister of Deeds Office. Number of bedrooms 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. 08/05) Page 11 of 13 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) 570 /SS T"' - located at: V) '/4, ' /4 Section Town �_ .� (� - (' N Range 17 W Town of -Sp wj c,t?5E7 , St. Croix County Wisconsin. Upon inspection, I cer that I have . P fy f ound the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service - -'5 -- 2 Z- -- Z 0 / Did flow back occur from absorption system? Yes No X (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: J OOO Construction: Prefab Concrete X Steel Other Manufacturer (if known): W E r S C',. 1 Age of Tank (if known): g t gtz S Permit number (if known) 5 L T 8 A 4 4 4 " J o #,L) .56 14 k1 «/7 V c ' ensed Plumber Signature) (Print Name) z37 (o 0 (Title) (License Number) M PRS (Date) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 �v • STATE BAR OF WISCONSIN FORM 1 - 1998 as21476 WARRANTY DEED KATHLEEN H. WALSH REGISTER OF DEEDS Document Number ter: 1 5 (� 1 FA! 558 ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between RAYMOND P, RAFFEL, 04 -18 -2000 11:30 AN AKA RAYMONT) F._ RAFFFT, WARRANTY DEED _ Grantor. EXEMPT R CERT COPY FEE: and M. L. JOHNSON DEVELOPMENT, INC. — COPY FEE: TRANSFER FEE: 303.60 RECORDING FEE: 12.00 PAGES: 2 Grantee. Grantor, for a valuable consideration. conveys to Grantee the following described real estate in St Croix County, State of Wisconsin (the "Property"): Recording Area Name and Return Address (SEE ATTACHED LEGAL DESCRIPTION) 00 032- 2056 -20 Parcel Identification Number (PIN This is not homestead property. (is) (is not) Together with all appurtenant rights, title and interests. Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except - none. Dated this r day of April 2000 7 (SEAL) EA) O BA ND I'?,. RAFFEL t (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature (s) State of Wisconsin, ss. St. Cr County. authenticated this day of Personally came before me this - 7 " day of April 2000 , the above named Raymond E. Raffel TITLE: MEMBER STATE BAR OF WISCONSIN to (If not, me known to be the person who executed the foregoing authorized by §706.06, Wis. Slats.) instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Attor Barry C. Lundeen MUDGE, PORTER, s • Notary Public, State of Wisconsin 110 Second St ree t, Hudson, Wi sconsin 54016 My c mission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not - 3 -• O a ) necessary.) a, 7C TTUL.Sy 1fi • Names or persons signing In any capacity must be typed or printed below their signature. Not ary Public WARRANTY DEED STA FO R M N F WI 1998 SIN State of Wiscarreiwlr ��Milwa� ee.'ws, VOL 1503PAu 559 Legal Description A parcel of land located in the NE A of SW %. and the NW %. of SE "K of Section 16, Township 30 North, Range 19 West, Town of Somerset, St. Croix County, Wisconsin being further described as follows: Commencing at the SE corner of Section 16; thence N00 "E along the East line of said Section a distance of 1311.72 feet to the North line of the SE %. of SE %.; thence N89 0 53'26 "W along said forty line 2011.86 feet to the point of beginning; thence continuing N89 0 53'26 "W 1863.06 feet to the West line of the NE Y4 of SW Y4; thence N0 3'05"W along said forty line 659.54 feet; thence S89 0 50'10 "E 2588.64 feet to the East line of the NW %. of SE Y4; thence S0 "W along said forty line 278.33 feet to the centerline of a 66 foot wide easement; thence S50 0 19'34 "W along said centerline 84.85 feet; thence S63 0 47'00 "W along said centerline 731.83 feet to the point of beginning. Subject To the SEly 33 feet being reserved for easement purposes. TOGETHER WITH and SUBJECT TO an easement as follows: A 66 foot wide strip of land for ingress and egress purposes located in the NW YA of SE Y4 and the NE Y4 of SE Y4 of Section 16, T30N, R1 9W, Town of Somerset, St. Croix County, Wisconsin being further described as follows: Commencing at the SE corner of said Section 16; thence N0 "E along the section line 1311.72 feet to the North line of the SE Y4 of SE %. of said Section; thence N89 °53'26 "W along the North line of said SE %+ of SE YA 1937.46 feet to the point of beginning; thence continuing N89 11 53'26 "W 148.80 feet; thence N63 0 47'00 "E 794.63 feet; thence N50 0 19'34 "E 973.29 feet; thence N66 °51'34 "E 400.15 feet; thence N47 0 27'34 "E 364.88 feet; thence S0 0 28 1 52 "W 90.28 feet; thence S47 0 27'34 "W 314.56 feet; thence S66 0 51'34 "W 401.85 feet; thence S50 0 19'34 "W 971.49 feet; thence S63 0 47'00 "W 669.03 feet to the point of beginning. 40 1 d i - 3 e v a� r xv �• � ��, a •} a � C now I NIT n N n: 1 c 4 '& H i fiyY€ On m m �� r •�I u AV 1 it! fps J im-, y ill 7 I N a S � 'T q r 4 • i: r Zy, + i li 'ijl •6 f y t Il € ��ir4rj,•° + w ool m ica iri3 �A B E E t / FYI � T, r ANN v M- m RO f a A' mw, 3k' � s ' w On r a I v€ a� v may/ E I i t ' ✓ j r t � �4 �a f 'r ' 9 46 L a x x •���� ¢ di aq ay �f C £Ijb £I Abd 1072 f Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in Tom Schmitt accordance with Comm 85, Wis. Adm. Code 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 etance to nearest road. Parcel I.D. I,� part of: j Please print i i ; Reviewed By Vr Date Personal information you provide may d puma (Privacy 15.04 (1) (m)). L� 1 Property Owner r operty Location Johnson, Michael . Lot na NW 1/4 SE 1/4 S 16 T 30 N R 19 W Property Owner's Mailing Address Y•.1? _ I' t # Block # Subd. Name or CSM# 130 Cty. Rd. E ST , z��� ' 1 na Johnson Meadows City Stat (Z odd R641415mber City A Village !9 Town Nearest Road Saint Joseph WI 11 Somerset 155T Ave New Construction Use: id Reside / b r rooms 3 Code derived design flow rate 450 GPD Replacement Public or commercia - Describe: Parent material Outwash Flood plain elevation, if applicable na General comments and recommendations: Area is suitable for a conventional system w/ a 0.5 gpd /sgft rating . Possible system elevation for Area 1 is 95.82'. System area is on a 3% slope. F Boring # Boring 11d Pit Ground Surface elev. 99.32 ft. Depth to limiting factor >101 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots PD/ft' In. Munsell Qu. Sz. Cont, Color Gr. Sz. Sh. - Eff #1 - Eff# 2 1 0-7 1Oyr3/3 none sit 2mgr mfr cs 2f .5 .8 2 7 - 1Oyr4/4 none ail 2fsbk mfr gw 1f .5 .8 3 35-49 10yr516 none ail 2msbk mfr cw ----- .5 .8 4 49-66 5yr4/6 none at 2msbk mfr cw ---- -- ,5 .9 5 6&101 10yr516 none ms Osg ml ---- -- .7 1.2 Boring # Boring im Pit Ground Surface elev. 98.02 ft. Depth to limiting factor >100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Str Consallence Boundary Roots GP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. N#1 - Eff#2 1 0-12 10yr3/3 none sit 2mgr mfr cs 2f .5 .8 2 12 -29 10yr5/6 none sit 2fsbk mfr gw 1f .5 .8 3 29 7.5yr4/4 none all 2msbk mfr gw -- - -- .5 .9 4 47-61 10yr5/3 none at 2msbk mfr cw .5 .9 5 61 -100 10yr5/6 none ms Osg ml --- .7 1.2 " Effluent #1 = BOD? 30 < 220 mg/L and TSS >30 < 150 mg/L ` Effluent #2 = BOD <_30 mg/L and TSS - 30 mg/L CST Name (Please Print) Signature: CST Number Thomas J. Schmitt �� 227429 Address Tom Schmitt Date Evaluation Conducted Telephone Number 586 Valley View Trait, Somerset, WI 54025 8/22/01 715- 549 -6651 Property Owner ]o_hnSOn, Michael Parcel ID # Part of: Page 2 of 3 } 1 $ I Boring # A Boring F 16 Pit Ground Surface elev. 98.44 ft. Depth to limiting factor >97 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 1 0 -7 10yr3/3 none Sil 2mgr mfr Cs 2f .5 .8 2 7 -18 10yr5/6 none sil 2fsbk mfr gw 1f .5 .8 3 18-41 10yr4/6 none sil 2msbk mfr gw - ---- .5 .8 4 41 -64 5yr4/4 none sl 2msbk mfr gw - -- .5 .9 5 64 -97 10yr5/4 none Is 1 msbk mvfr - - -- ---- -- .5 .9 The 5th horizon has bands of 5yr4/4 2msbk sandy loam making the rating 0.5 gpd /sgft. ❑ Boring # Boring 21 Pit Ground Surface elev. ft. Depth to limiting factor in. FSoll 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 Borin g Boring # � g ft. Depth to limiting factor "'. Pit Ground Surface elev. P 9 in. ,� Soil Application Ra te 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 30 < 220 mg/L and TSS >30 < 150 mgA- * Effluent #2 = BOD s30 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 ncwA motarial in �n oltr+rnota. Fnrmo+ -1P... — +ant tit. A. —t--f of AAR- Ir,4 -11 G1 — T'r'V 4A2-,)AA -8777 jo s VcL�e 3of Ale f o? 9r ' 7hI s re/ooY f G✓aj clr. 7 PUP, �/ - zon,, )o9 re� , ✓rr9e /� 5A 4-,,4 ;q 4 H07 GOr.� �2J�e /a f /).eJ owe /�` �7C/ 7171'! M a/ ar -?gt y /-zof 46e- i 7 0 d Pace j., (-e 14 7�id�.T� P�aCerr O fl`e sue, 7 � /'u,,..� ►ti+ 9 FOP i Mti / --W To" S6h Ar24,U ih , 7;O)-las �• JC��i� /� Csrm �.�7Si19 L OT / ra l�r7sen ea4�Js S� �, 4ol hs A, ?/ /; May 2� 2014 10:02 AM St, Croix County Plan /Zoning 715- 385 -4586 4/5 1072 IMnah Dspsrdnent of Commerce FOIL EVALUATION REPORT p I of 3 DWWw of 80* an DAIrp to accordance with Co ea, VYts. Adm. Code Tom Solft AtttOh 11<t pan en pepernot lea then 814 x 11 Yxl+ae In.tra. MM mutt Gout St. Croix Muda bdmtltnlbd to, va M and fro kmW of mw Point {BIt), dndlon ono parcal I .D. Peat alape, axle ordkntnalau, nosh prow, nd baatlon and ditbnoe m neaaet need. oft Mass paint all Info malfoa. Dabs P�d U.ItloeYrop m ma bLMN tbrMw *y WPM ft" tae. a166040)06 ` G Prop"O colft Johnson Michael Oon Lot na NW 1/4 BE 19 8 16 7 30 hIR 1 9 W Property Ownef'e MaIN n0 Addntao Lot# I Rtodt # I$ubd,Nmw 190 A. Rd. E 1 no Johnson Meadows Chy Slate Zip Code Phone Numbw U City Q 1Allop IM Town Meaner Road estntJoaeph WI I 64082 I 716••649-b47e Somerset 1 156Th Area Yd New Construd an Uw, EI I4eei GMW / Number of bedrvoma _ Code dert W deelpn flow rata 430. _ WD n Replawment 10 Public or wmmarohd . Deecdbw. Pantlt material Outwaah flood plain elwatlon, K appilaahM ��___.._ Gen" oornmbive end tecommandeflorm Aran Is sultab s for a conventlonal sys W/ a 0.6 Wdlsgtt rating . Posai6la system elevation forte I Is 95.82'. System area Is on a 3% slope. FT] Bodng 0 CI ®orinp Pit Ground 8urhaa Mw, 69.32 ft. Depth to Ihnlhp factor AN — Do Dworwilcalff %*DWW Y111114110 In MOM 1M. Cant oolor (k ft IN 1 0-7 10y1913 none sli 2mpr mfr a 2f 2 7.36 10yrRJ4 norle sll 2rebk mfr OW if .5 .6 9 3§069 10yr615 none ail 2mfbk mfr ow 4 ftrW none el 2mabk mfr Cw — .6 .9 5 88.101 10yr515 none ms on ml 1.2 ol N D >sonnp # L7 9odnp jt{ Im a round 9urtaoe e lw. 9e.02_ fl. oepttt to I(mtdnp factor In. Appflgtlon Reb Hatp D" tiou In. a► es. 1 0.12 10yr313 none all 2mpr rw oe 2f .5 .8 2 12-29 10yr6/6 none all 2fabk mfr OW if .6 .8 3 2047 7.5yW4 none W 2ntabk M* ow .6 .9 4 47.81 10yr6/9 none el 2mebk mM ow -- .5 .Q 6 61.100 10yea none 1 ma OaQ ml -- — .7 1.2 ' gAwnt #1'R ow 30!= mplt. and T&S >30 s 150 mA ' t lfknnt 02 = BCD 930 m6A. end TOO ,30 mall COT Nam lease Print) n N umber 227421) Thomas J. 3cltmNt ,M2y - 24.2010 10:02 AM St. Croix County Plan, Zoning 715- 386 -4686 516 p over Johnsm, M' eel Para! ID# Will Page 2 of —�.. 6aring * Gmund SurNm ebv. 98.44 ft. Depth to 11miling factor 0.97 In. pp"Won P112 Pit In. Wa Qu. Se. pool Cow Or, 61% 1 0. r313 7 10y none et1 2mo rv* an 2f • a . 2 7 -18 10yr" none ell 2bbk mfr pw 1f 3 98.41 10yra none oil 2mobk mfr aw —�- • 4 41.84 8 1AA none sl fts* n�fr ow 8 6407 10yrs/4 none is lmsbk mvrr -�- �— ,8 .2 h n ha ban • of so loom =111 ratylp 0 0 4 tj r Tm Iodnp # eodnp 0 PR &round Surface else. 1l Depth to llmkinp hetor in, of n RXb W— In, mmiall Qu. Bs. Cant Cola or. IL ft ❑ Ooting 0 goring fl Depth to !immng factor � in, ( i PR Ground Surface elan. �_ NO YMna 1110mr4my ROM M oi, SL Copt. Color or. s:. a. 0 Muent#1 ■ 130D 3C SZZO mplL end T88 *30 t160 itWL • Eflius Y DOD w30 ttlpll. end TO fit) m01L no Department of Comtuorce is era equal oppottuntty savlos provider and employer. If you Reed assirtancs to access services or nam rnwsrdal in en �1f�rn�er A...nar n1wa� r...,iuM Flf/. arnKl�r1 »/ N fJ1A.91tfi.71S7 nw'1TV finA.71U.A'r?7 May- 24.2010 10:02 AM St. Croix County Plan /Zoning 715.386 -4686 6/6 IVo I'� W Le F Lr 11d r� 1 I 3��� L ift h7 �,We ra�Gr 7V A s lvleop( 4Ad.3 OYf" f� 1'v�hr�� ai. �ZH.1►O %��'�rr.�Nirrrt. 4, . s isa O ele / C/s k'l r , �s f 1 Jfr,! n',•C' j� / i a'14 /r. ,�r ��tQ reh►y ert ,m)O / f e f"' & i� tile Cfe3 -, ih t A Cht /n 1y" 7I ew+ai 9 eSro, R.?3YV 9 52Y eo Awpct,A'cw^ .41M CAP 'C,f% Tje it�' /;0 n■ ■�� e � k 7 E� / . ƒ ( 7 E A \ E/ S Q �, £�� @i $ k / = m $ \ ; 2 ) % / ¢� �� .� § § \ § 3 E E\ § r S ƒ o g § q J © g / § � 7 R o & § / $ ® � \ § % ƒ Q ; / \ \ 0 \ o E co) © ©2 \ k �- a \" Z ; M M M % E / k k k Oro 0 / \ [ U ■ U) I 7 \ ®� cr k�� _ 0 9 I , - ; m N) ( \ \ 0 .. & E 03 z / , & o � } _ 0 � \ . } 2 N . 3 E a 3 5 -1 CO) \ 7 .. § $ 0 " z d 2 (D CD CD C, z § q CD , 2 CA) % \ ; \ ± 0 0 i 2 � $ � 2 2 � ■ 0 $ � < § § 0 ? § o m � o CL \ Wisconein Department of Corranerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building`Division INSPECTION REPORT Sanitary Permit No: 405088 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: Johnson, Michael I Somerset Townshi CST BM Elev: Insp. BM Elev: SM Description: �A 1j W.t7 l 'VVr0 V� C CS TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark v a - 3 3 J� Dosing Alt. BM LL_)4 C NO Aeration Bldg. Sewe Ico - Holding St/Ht Inlet � . q W-YZ TANK SETBACK INFORMATION St/Ht outlet �•` �/ TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic S t� t 2 i Dt Bottom Dosing Header/Man. N• 2 9 Aeration Dist. Pipe s 1 o. . 6 Holding Bot. System ll• S /l• Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Numb TDH Lift Pfgtton Loss System Head TDH Ft Forcer"71, Length Dia. SO ABSORPTION SYSTEM Z`t ars H idth t Length L No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS S 3 At -, 2 SETBACK SYSTEM TO P/L 11311DG IWELL LAKE /STREAM LEACHING Manufacturer: J INFORMATION Type Of System: I CHAMBER OR la • 5 i ti UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold ` Distribution x Hole Size x Hole Spacing Vent to Air Intake Pi / p() Lengt Dia en Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Deptii of xx Seeded /Sodded xx Mulched B edlTrench Center Bed/Trench Edges Topsoil Yes X No Ye No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:()(), V Inspection #2: — T / Location: 570 155th Ave Somerset, WI 540 5 (NW 1/4 SE 1/4 16 T30N R19W) NA Lot 1 Parce pNo: 16. 0.19. 1.) Alt BM Description = W 0.�'1� 5141 � 2.) Bldg sewer length = 24, amount of cover r . 3 100 'tom Plan revision Required? L Yes No 1 Use other side for additional information. _ J SBD -6710 (8.3/97) � e4 `� Insepctor's Signature Cert. No. Safety and Buildings Division County nn *6 201 W. Washington Ave., P.O. Box 7162 S T C�K.D( WI 53707 - 7162 Site Address De tment of Commerce 5 J 6 z— 6__ - 0 S Sanitary Permit Application Permit Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ Check if Revision zJ0 may be used for secondary purposes Privacy Law, s15. 1 m I. Application Information - Please Print All Information State Plan I.D. Number / k Property Owner's Name l Number ~/ ® 32 = Ds Property Owner's Mailing A s Pro Location lo ST. CR , 3 0 OIX CO '� Si; S T N, R 19 Z City, State Zip Code tOFFICE Lot N r Block Number Subdivision Name CSM Number (,V ' f Ar, E s l U . Type of Building (check all that apply) / ❑City ,AI 1 or 2 Family Dwelling - Number of Bedrooms 3 ,/ []village ❑ Public/Commercial - Describe Use Wrownship / v' ❑ State Owned 3'x'g - 7 t Q� 3>- Q3' Nearest Road TN a cues 6..Ws �sr � s' A M. Type of Permit: (Check only one box on fine A (numbering scheme for internal use). Complete line B if applicable) A For County use 1 t6 New 2 11 Replacement System 3 ❑ Replacement of 6 11 Addition to 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) /D�li tr 4q on - Pressurized In- Ground 210 Mound 47 ❑ Sand Filter 5 50 U Constructed Wetland 22 0 pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line Z 9 45 ❑ At -Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 ❑ Other yam V. D' eatment Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Applicatio^ Percolation Rate System Elevation Final Grade Required Proposed Rate(Gals./Days/Sq.FL) _ (Min•IL-h) Elevation y�o VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing 2 2Z f� /l1D , Tanks Tanks Septic or Holding Tank Dosing Chamber VII. Responsibility Statement - 1, the ug4 ersigaed, assume responsibility for ' WTS shown on the attached plans. Plumber's Name (Print) is Signature RS Numbe Business Phone Number lumber's Address (Street, City, State, tip Code) sr oz VIII Count ap artment T6 se Onl Sanitary Permit Fee (includes Groundwater Date Issued Issu' ent Signature (No Stamps) Approved ❑ Disapproved Surcharge Fee) ❑ Owner Given Initial Adverse �d � 0 (p Determination . Conditions of App ogys for Disa�ro�'al Z f,,Q 3 CLE'..p- QftA� T+r Attach pkete plum (to the y) for the cyst on p pa not less Er/2 x Winches is she ynJ SBD -6398 (R. 05101) - "fJUG UE'NT' - ,Bio Oro re/7 IFt . 95- aL o 1 � - 99 - /- 3'z g6.9_y_ tic O�FFusn T+P�hrc�f e o s WELL �CAtE �=SO / Q .0Qc L G✓ / �Tati,vson� 1"Icf�/�acuS _ _ - - - s fR AW 1 /ECG Dl� cu��rG _ - - -1 30 C � 12 aw'!P // /FCV rz, __ _. __ __ __ __ __ __ __ ___ __ _. ___ _ __ ___ _ _ _ -_ _ _- - _ -_ � ___ __ ____ _ _ __ _ _ _ _ __ __ ___ _ __ _.._.. ......... r __ _ _ __ __ __ __ __ __ __ __ __ __ ____ _ __ __ _ _ __ _ __ - - _ _ _ __ - __ __ __ __ __. __ _ __ __ - __ ___ _ __. _- __ __ _ _ _ -- - - __ ___ _ __ -- __ _ ___ ___ _.. __ -__ ___ __ __ _ _ __ _. _ _ _ __ __ ___ __. _ __ __ ___ __ _._ __ __ _ -- _ _ _- __ __ __ _ _. __ _____ __ 1072 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. part of: Please print all information. ,ewe Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). D Property Owner Property Location Johnson, Michael Govt. Lot na NW 1/4 SE 114 S 16 T 30 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 130 Cty. Rd. E 1 I na I Johnson Meadows City State Zip Code Phone Number j City Village M Town Nearest Road Saint Joseph WI 1 54082 1 715- 549 -6478 Somerset I 155Th Ave J6 New Construction Use: Lit Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD LAJ Replacement Public or commercial - Describe: Parent material Outwash Flood plain elevation, if applicable na General comments and recommendations: Area is suitable for a conventional system w/ a 0.5 gpd /sgft rating . Possible system elevation for Area I is 95.82'. System area is on a 3% slope. ❑ Boring # A Boring id Pit Ground Surface elev. 99.32 ft. Depth to limiting factor >101 in. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots PDJftZ in. Munseil Qu, Sz. Cont. Color Gr. Sz. Sh. *Eff# *Eff#2 1 0 -7 1Oyr3/3 none sit 2mgr mfr cs 2f .5 .8 2 7 -35 1Oyr4/4 none sit 2fsbk mfr gw 1f .5 .8 3 3 9 1Oyr5/6 none sit 2msbk mfr cw - - -- .5 .8 4 49-66 5yr4/6 none sl 2msbk mfr cw --- --- .5 .9 5 66 -101 1Oyr5/6 none ms Osg ml - - -- - - - -- .7 1.2 Boring # Boring id Pit Ground Surface elev. 98.02 fl. Depth to limiting factor >100 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPD/W in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0-12 1Oyr3/3 none sit 2mgr mfr cs 2f .5 .8 2 12 -29 1 Oyr5/6 none sit 2fsbk mfr gw 1 f .5 .8 3 29-47 7.5yr4/4 none sl 2msbk mfr gw - - - -- .5 .9 4 47-61 10yr5/3 none sl 2msbk mfr cw ---- -- .5 .9 5 61 -100 10yr5/6 none ms Osg ml - -- - - -- .7 1.2 -V * Effluent #1 = BOD? 30 < 220 mg/L and TSS >30 < 150 mg /L * Effluent #2 = BOD < mg/L and TSS < 30 mg/L CST Name (Please Print) Signature: CST Number Thomas J. Schmitt r-- -Y�f 227429 Address Tom Schmitt Date Evaluation Conducted Telephone Number 586 Valley View Trail Somerset, Wl 54025 8/22/01 715 549 - 6651 Property Owner Johnson, Michael Parcel ID # part of: Page 2 of 3 3] Boring # Boring Pit Ground Surface elev. 98.44 ft. Depth to limiting factor >97 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GROW in. Munsell Qu. Sz. Cont. Color Gr. $z. Sh. *Eff#1 *Eff#2 1 0 -7 10yr3 /3 none sil 2mgr mfr cs 2f .5 .8 2 7 -18 10yr5/6 none sil 2fsbk mfr gw 1f .5 .8 3 18-41 10yr4/6 none sil 2msbk mfr gw ---- -- .5 .8 4 41-64 5yr4/4 none st 2msbk mfr gw - - --- . .9 5 64 -97 10yr5/4 none Is 1 msbk mvfr - - -- - - - -- .5 .9 The 58K horizon has bands of 5yr4/4 2msbk sandy loam making the rating 0.5 gpd/sgft, 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 ME in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # j 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 GP in. Munsell Qu, Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOO < 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 n aarl mots+rio) in on oltarnotA fnrmot ntra— —t—t 0— IIPIIATF11lPTt t AAQ -144 -Z 141 — TTV AAQ- ')AA- R'7'7'7 C CA f 3 L aid ! �� y�� A d a-- -- __ 3�`l 4. 7 h r- , , /' elie,- e 7'.o Zen, 1, y re t., ll�' 5;" Ir L L / -,,e �! — / 4 7 .54 j a, c ' elace i re, lo, i6l- X I? t Pre 1,21- e f i iy TO lln5C'\ 4J-7 Av ST. CROIX COUNTY SEPTIC TANK MAINTANANCE AGREEMENT AND OWNERSHIP CERTIFICATE FORM I OwnerBuyer Mailing Address P gn Property Address r1b b 7 - (Verification required from Planning bepartment for new construction) City/State I Parcel Identification Number 0302' :2/9 ,9 0 LEGAL DESCRIPTION Property Location ., _Sj5 ''A Sec._LLT_3 N -R _aW, Town of + e Subdivision ld ffA -rc 1 f?,4-Do ty s Lot# / Certified Survey Map# , Volume Page Warranty Deed# �,91 -26 , Volume /5O3 Page sS� Spec house yes d- Lot lines identifiable d es no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result 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. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and b a mast lumber journeyman t y erp > � ym umber, restricted lumber or a licensed pumper verifying that P P P Pe I ()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 th Department of Commerce and use the Department of Natural Resources, State of Wisconsin Certi ation st4ung that your septic system has been maintained must be completed and returned to the roix un n' g Off within 10 days of the three year expiration date. S/3 -0 2 SIGNATURE OF XPPL91NT DATE 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 d ribed above, by virtue of a warranty deed recorded in Register of 7& ffi 4 ce /' /0� 5-13-0 SIGNA URE OF P LIC V DATE ••"'• Any inibrrrution that is misrepresented may result in the sanitary permit being revoked by the Zoning Department •• Include with this application a stamped warranty deed Itom the Register of Deeds office a copy of the certified survey map if reference is nude in the wanmty deed. . f .l,Fr €are Page of MANAGEMENT PLAN This Private Onsite Wastewater Treatment System (POWTS) has been designed and is to be installed and maintained in accordingto Comm 83, Wis. Admin. Code, the in- Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems (SBD- 10567 -P; June 1 ],1999), 1. This POWTS bas been designed to accommodate a maximum daily flow of 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 specified 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 plaster 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 � z 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 Conan 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 sliall 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 Conan 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: jj&f'tllill"MpMrm"lmll be repLw&d- This may require a new soil evaluation to determine where a new soil absorption c component can IV, 8. If this POW'1'S is replaced, or its use is disconlinued, it shall be abandoned in accordance with Comm 83.33, Wis. Admin_ Code. 9. Name and number of local health agency: —S Croix Co ltn ly Lo llit ' - 5 -3 0. 10. Name of service contractor in case of failure or malfiinction & SQns- ExuYatillg 715 -549 -6651 STATE BAR OF WISCONSIN FORM 1 - 1998 621476 WARRANTY DEED KATHLEEN H. WALSH n REGISTER OF DEEDS Document Number 15�3FA 558 ST CROIX CO., WI RECEIVED FOR RECORD This Deed, made between RAYMOND )Z. RAFFEL, 01 -18 -2000 11:30 AN AKA RAYMOND F._ RAFFFT. WAtRAMTY DEED EXEMPT N _ Grantor. CERT COPY FEE: and M. L. JOHNSON DEVELOPMENT, INC. —_ COPY FEE: TRANSFER FEE: 303.60 RECORDING FEE: 12.00 PAGES: 2 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate In Ste Croix County, State of Wisconsin (the "Property "): Recording Area Name and Return Address (SEE ATTACHED LEGAL DESCRIPTION) 0O 032- 2056 -20 Parcel Identification Number (PIN) This is not homestead property. (is) (is not) Together with all appurtenant rights, title and Interests. i Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except - none. Dated this day of , April 2000 ' (SEAL) 1� EAL) . RA OND K. RAFFEL (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, lI } ss. St. Cr County. JJff 1-74 authenticated this day of Personally came before me this day of April 2000 , the above named Raymond E. Raffel TITLE: MEMBER STATE BAR OF WISCONSIN to (If not, me known to be the person who executed the foregoing authorized by §706.06. Wis. Scats.) instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY Attor Barry C. Lundeen MUDGE, POR , • Notary Public, State of Wisconsin 110 Second St ree t, Huds Wisconsin 54016 M Y / c mission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not� •• �D- necessary.) a l a 11 —) ' Names of persons signing in any capacity must be typed w printed below their signature. No Pu blic E BAR OF WARRANTY DEED sTA FORM No. I - 1 998 SiN State Of W (SCV �� Mattikee, W s. VOL 1503PAr,E 559 Legal Description I A parcel of land located in the NE' /. of SW'/. and the NW %. of SE % of Section 16, Township 30 North, Range 19 West, Town of Somerset, St. Croix County, Wisconsin being further described as follows: Commencing at the SE corner of Section 16; thence N00 0 28'52 "E along the East line of said Section a distance of 1311.72 feet to the North line of the SE %. of SE %; thence N89 0 53'26 "W along said forty line 2011.86 feet to the point of beginning; thence continuing N89 0 53'26 "W 1863.06 feet to the West line of the NE %. of SW %; thence N0 0 13'05 "W along said forty line 659.54 feet; thence S89 0 50'10 "E 2588.64 feet to the East line of the NW % of SE %; thence S0 0 14'49 "W along said forty line 278.33 feet to the centerline of a 66 foot wide easement; thence S50 0 19'34 "W along said centerline 84.85 feet; thence S63 0 47'00 "W along said centerline 731.83 feet to the point of beginning. Subject To the SEIy 33 feet being reserved for easement purposes. TOGETHER WITH and SUBJECT TO an easement as follows: A 66 foot wide strip of land for ingress and egress purposes located in the NW % of SE % and the NE % of SE % of Section 16, T30N, R1 9W, Town of Somerset, St. Croix County, Wisconsin being further described as follows: Commencing at the SE corner of said Section 16; thence N0 "E along the section line 1311.72 feet to the North line of the SE % of SE % of said Section; thence N89 0 53'26 "W along the North line of said SE % of SE % 1937.46 feet to the point of beginning; thence continuing N89 0 53'26 "W 148.80 feet; thence N63 0 47'00 "E 794.63 feet; thence N50 0 19'34 "E 973.29 feet; thence N66 0 51'34 "E 400.15 feet; thence N47 0 27'34 "E 364,88 feet; thence S0 0 28'52 "W 90.28 feet; thence S47 0 27'34 "W 314.56 feet; thence S66 0 51'34 "W 401.85 feet; thence S50 0 19'34 "W 971.49 feet; thence S63 0 47'00 "W 669.03 feet to the point of beginning. 4 IL t y 3 „ZS,Sl.00N 2JV36 01 s73Wf1SSv L '9l N01103S 30_11/L H1f10S—HINON = to ^ �. •�� 1, 3H1 01 030N38333N 3611' SONINV38 cn co %EZ'BLZ M.6b,b LOOS) Li 1 � 11: 3H130 3N! 11St3 w p I U- d cO 11 ,�P. z Ca v Ll.I W Q piN riKi m c 0 ou _ J r .4 1� ' co CL IL in F, r-, � ® w � � N c-� I Ln z w o �-ice o ° o 0- LLJ w 4•blZ ca �, d ., o W +n ? 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