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HomeMy WebLinkAbout032-2118-10-000 0 / (M T ■ 2 E 0 0f o °% 0§ S 7 Z # t 2 e 4 § / / E m o � ■ 7 C & # e f_ CD CD R3 , ■ 8 8 8 2 8 (D \ 0 2 w § Q. E ® c S: a o E 3 > \ CL OD \ o $ i \ CD 9 0 ) ) 3 2 E . � cr z o o o Z g / m ` ■ CO) ■ c ; \ $ E ~� 0 «: o � CD u j E - & Q � ƒ rr z E z \ D7\0\ }% { _ \ =o =m $� �- - 2 A , ƒ \ k CLD =r k z k§ §) / �� E G E( q k§ / EC 0 § 9 \ a % f � „ . e ° (I[ g' = _ ° § k 2 CD (/ k z@ , z ,» a— % k L moo± CL c CL -0 0. mom: \\/ \J o % §6 / mE c b ƒ/ 2 CL . § ( �( 7 k ( 0 � < § § _o �§ P« o = G` � �% `Wisconsin Department of Commerce y: PRIVATE SEWAGE SYSTEM Safety and Buildings Division Count INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). 374925 Permit Holder's Name: ❑ City ❑ Village ❑ TVwn of: State Plan ID No.: Emerson, Jeff Somerset Township CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 032 - 2118 -10 -000 TANK INFORMATION ELEVATION DATA /S , Z/' /? /08 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Air I ntake ROAD Dt Inlet Air Septic NA Dt Bottom Dosing NA Header/ Man. Aeration NA Dist. Pipe I Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand St cover Model Number GPM TDH Lift Friction System TDH Ft oss Forcemain Length Dia. H Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING manu INFORMATION Typeo CHAMB Mo Number: System: OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1• / / Inspection #2• / / Location: 2163 59th Street, Somerset, WI 54025 (SW 1/4 NE 1/4 15 T3 IN R19W) - 1531191081 Shadow Pines -Lot 24 1.) Alt BM Description= 2.) Bldg sewer length= / - amount of cover = ? N a ;vac e r Cs✓�S `S I "�S� R � r / Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 9 d Q 5 4 € ( e a g } d m. °a�lrn i E & 4 s ° � a � f I g e qq j# gR E #j 3 PP s ?£ 9 5 zt 1 i p � 66 3 1 £ 3 0 3 ° L lstq'h "Z I6 3 Sanitary Permit Application Safety & Buildings Division IVA In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave. INfisconsin See reverse side for instructions for completing this application PO Box 7302 Personal information you provide may be used for secondary purposes Madison, WI 53707 -7302 Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned. Attach complete plans to the county copy only) for *Ks 4n ess than 8 -1/2 x I 1 inches in size. County State Sanitary Permit Number e, sion to O tt lion State Plan I. D. Number I. Application Information - Please Print all Information 1 Location: Property Owner Name c.� Property Location �' G� , — V' /4 /4, S T ,N, o Proptrty Owner's Mailing Address - Lot Number Block Number S? CROIX COON7Y City, State Zip Code ne / Subdivision Name or CSM Number r a U. Type of Building: (check one) `�'; _ � -_ ❑ City I or 2 Family Dwelling - No. of Bedrooms: ❑Village Public /Commercial (describe use):_ Town of ❑ State -Owned 1 r � a Nearest Ro 3 3 ' X lOz� Cam) 3ac� Paz u be 9' .. III. T ype of Permit: Check only one box on line A. Check box on line B if applicable) l 3 l . V9. log A) 1. B New 2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to System System Tank Only Existing System B) Permit N be Date Issued A Sanitary Permit was previously issued 1 3 _2 IV. T pe of POWT System: (Check all that apply) U Non - pressurized In- ground ❑ Mound ❑ Sand Filter ❑ Constructed Wetland Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line ❑ At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (GalsJday /sq. ft.) (Min. /inch) Elevation y VII. Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks Tanks t �v ,� r ❑ ❑ ❑ ❑ ❑ VIII. Responsibility Statement I, the undersigned, assume res on ibility for installation of POWTS shown on the attached plans. Plumber's Name (print) PI mbeesAignetme (no ps): -hffY PRS No. Business Phone Number F O e) 28288 McKenzie Rd. IX. 60"WR eMn3jolUse Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) Approved 0 Owner Given Initial Adverse S�{cha- Fee) Determination 5 6 b O - 2`Zb6o X. Conditions of Approval /Reaso s for Disapproval: 1 A•tl sysl��• ,,,,,�.�- ,nnw,mt�v` �P {�� a i�l�C!J �a . N � x 1 1 I \ I t � I 1 v► ' ' y y I 00 o ; � oa I y 1'1 tq At Wisconsin Department of Commerce SOIL EVALUATION REPORT Page �of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code _ County �, Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must , include, but 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 ail information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Govt. Lot S 114 1A S T y N R E (a® --- P r rty Owners Mailing Address Lot # Block # Subd. Name or CSM# City State Zip Code Phone Number ❑ City ❑ Village Town Nearest Road ,E (2 97 - o 7 1 S Zf sT Ip New Construction Use: Residential ! Number of bedrooms Code derived design flow rate GPD ❑ Replacement ❑ Public or commercial - Describe: // Parent material C�0 Flood Plain elevation if applicable ft. General comments and recommendations: 7�s- �E,c/C wrtS 1,)0.1,6 7b r.44o�— 7,4r,— -4177— S/ a Boring # ❑ Boring 57,*Ar T - 2 X47' B -3 >►� woiQ /� k' ffsGL Pit Ground surface elev. /Oy J ft. Depth to limiting factor >f02 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 Z — 5L S. `F 7 . 5D ,3 F Boring # Boring Pit Ground surface elev. l ey ft. Depth to limiting factor 7 1 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 L - 7- - 57 - t S c S IF A 1 •1' Z 2- U 3 0 rz i L — 7 4 -� - Z . 2 - M: AAA5A /11 d Effluent #1 = BOD, > 30 _< 220 mg/L and TSS >30 _< 150 mg/L ' #2 = BOD, < 30 mg/L and TSS < 30 mg/L- - CST Name (Please Print) Signa CST Number / d Address Fogerty Plumbing & Perk Testing ate Evaluation Conducted Telephone Number 28288 McKenzie R J , 9 6 F A 7 /-T — 3 r '9WV Spooner, WI 54801 Property OWne F F/rrE,� Parcel ID # J6.72 Page 2 of F3 ] _ Boring # Boring .. . Pit Ground surface elev. -16 ) 3.,k ft. Depth to limiting factor > •Z 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 •Etf#2 .57 9 S 17 �- ]C)/, 0 ��L 33•��bg•f� F-1 Boring # E] 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/i0 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 F-1 Boring # ❑ Boring ❑ Pit Ground surface eiev. ft. Depth to limiting factor 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 Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg/L • Effluent #2 = BOD, < 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 material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608- 264 -8777. SBD -8330 (KWOO) N 1 Iw � I y y / N ► 0 N CA) 1 N : (V . � Ln N 0 0 0 3 tR o �1 o w w Safety & Buildings Division Sanitary Permit Application 201 W. Washington Av e. In accord %%ith Comm 93 '_' I. Wis Adm. Code PO Box 7302 See re%erw side 10r mstruc•tions six completing this application Madison. WI 53707 -730' IvI seonsin Personal inti0t mation you provide may he used for secondar% purposes . (Submit completed form to county if no Department of CnmmercP II'ri%ac) Lac%. s. 15.04(1)(rn)l state owned. t Attach complete plans (u, the County Co V ()"IN) lur the s\stcm, on paper not less than 8-1/2 x I I inches in sire. County State S:uut: r��nNumhcr ❑ ( heel, it rccicton to precuws apptretiuon State Plan I U Number ear- C" t L Application infor ' tion - Please Pint all Information Location: Property Owner Name I'mpert) l.ocauon _ S 1/4 A1414, -S T N, rty Owner's Mailing Address of Number Block Number A na ` Phone Numher Subdivision Name or CSM Number City. State tp ode m w r II Type of Building: (check one) O Vi llage yp g� O Village 1 or 2 Family Dwelling - No. of Bedrex ns �/ _ rown of O Public/Commercial (describe use): O State -owned III Type of Permit: (Check only one box on line A. Check box on line B if'ap icable) Nearest Roa A) 1. C New System 2 ❑ Replaccnun 3. ❑ Replacement of ❑ Addition to Para a- Numher(s) 5vstem 'Tank Only Existing System � l B) Permit Number Ua�r,..�ssued G / ❑ A Sanitary Permit was re% iousl� issued yy o o� IV. Type of POWT System: (('heck all that appl) ) a"` ( V Wetland In- ground ❑ and lat ❑ Sand Filter ❑ Constructe Wttland t^ AO Pressurized In- ground ❑ 1 l ing ❑ Single Pass ❑ Drip line ❑ At -grade Aero 'c ❑ Recirculating ❑ Other: f 3? V Dispersal/Treatment Area Information: I. Design Flow (gpd) 2. DtspersalArea 3 Dispersal Area 4 S I Application 5. PercotatrorrRate• 6 System ka 7. Final Grade Rcc cared Pn osed Rate( i:ds /day /sy t1) (Min /inch) v Elevation 1 ,0 � ?X40 VI Tank Capacity in Total # of Ma facturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con - Con- glass New I {xisting Crete structed Tanks I I•anks ❑ a D ❑ � ❑ p ❑ D O VII Responsibility Statement I, the uu nders � i g ned, assume res onsihilit nstallation of the POW'I'S own on the attach tans. Business Phone Number 10 Plumber' P1tJft'1Din Perk Tes inl Signature (no slam s): i.4PlMPRS No. ame gerty Plumbers dress trees, ity, . iate. !i 'ode) Spooner, WI 541;,. VIII County/Department U e Only ❑ Uisappro cd Sanitary Permit Fee (Includes Groundwater Date Issue Issuing Agent Signat re (No stamps) �l Approved ❑Owner iven Initial Adverse Surch a Fee) Determin tion IX- Conditions of Ap roval /Reasons for Disapproval: 8 X�,�S = 87•S !47/1L can_�zott ru mmm Fogerty Plumbing #221180 28288 McKenzie Rd. $pooner9 WI 54801 (715) 635 -9609 710 r ✓ �sT�y scAA4-9 / Yo TmjP ,61444 XA/ /31 ACW w�.�r�BO�, /Ga 0 ' y i'v/, o f WAX4 APV C01MA �-/ /trJ3da� undo ' = w EGL - T r/ /O = !,1 OlJ Z r G T 471 /�jcf eS C� 3 Q'T Y ,pN1� f� A #y� S" ' C*,4 z 7-Q9,V fly �d�� w isco`hsin•Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page I of 3 Bureau of integrated Services in accordance with S. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Xf n must 'County include, but not limited to: vertical and horizontal reference point (BM), di'eqtion and �¢, � St . Croix percent slope, scale or dimensions, north arrow, and location and distanceto nearer ;.[pfd.. parcel • D. # APPLICANT INFORMATION - Please print all information ,, �, •,� Reviewe" by Date Personal information you provide may be used for secondary purposes (Privacy I aw 8. 15.04 (1) gym)),, Property Owner PropeWftbiWtion Richard Stout Go 1J4`;NE 1 /4,s1 5 T31 N,R19 (o Property Owner's Mailing Address 'L'qt , t ck#', rz d. Name or CSM# 1353 Awatukee Trail `L' Shadow Pines City State Zip Code Phone Number ❑ City ❑ Village ❑ Town Nearest Road Hudson Wi 54016 (715)549 -6731 1 Somerset 60th Street New Construction Use: ® Residential / Number of bedrooms 4 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 600 gpd Recommended design loading rate • 7 bed, gpd /ft2 ' 8 trench, gpd /ft Absorption area required $5 R bed, ft 75 0 trench, ft 2 Maximum design loading rate • 7 bed, gpd /ft • 8 trench, gpd /ft Recommended infiltration surface elevation(s) See plot plan ft (as referred to site plan benchmark) Additional design /site considerations Parent material COC2 Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = unsuitable for system [s El S ❑ U [ s El [ S El U ❑ S [ u ❑ s [ U SOIL DESCRIPTION REPORT Boring Horizon Depth Dominant Color Mottles Structure GPD /ft g Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 1 1 0 -1 1 0 r2 1 -- is 1 mvfr cs 1 f .7 .8 2 10-24 10yr3/4 -- is 1 W A DT, mvfr cs -- .7 .8 � Ground 3 24-89 10yr4/6 -- ms osg ml cs -- .7 .8 elev. -- 91 -0— ft. Depth to limiting �. p factor Remarks: Boring # , 2 2 10- -- -- } Ground elev. 90 ft. Depth to limiting factor 8 9 in. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number 1 PROPERTY OWNER Ri eharr3 Strn"t SOIL DESCRIPTION REPORT " Page 2 of 3 PARCEL I.D.# r Boris # Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench 3 1 0-10 10 r2 1 -- sil 2 mfr CS if 6 2 10-38 10yr3/4 -- sil 2 P PrOK mfr Cs ` Ground' 3 1 38-86 1 0 r 4 6 MS elev. - - 90 Depth to limiting factor 86 in. Remarks: Boring # m 1 } 4 2 24 -48 10 r3 4 1 2 m� mfr 5 6 •� ........... 3 48 -96 10yr4/6 TIS osq ml Cs -- .7 '.8 Ground 9 O 0 ft. Depth to limiting factor Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 1 0- 5 "° 2 6-941 10 r4 6 TIS osa ml .� Ground elev. 9 2 . AD L _ ft. Depth to limiting .8. factor 9 4 in. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD -8330 (R. 07/96) 2 Y /PQ - 1q, - _.�'c : ti t I l 09 InI Private Onsite Wastewater Treatment System Management Plan Septic Tank And Gravity In- Ground Soil Absorption Component Pursuant to Comm 83.54 Wis. Adm. Code each Private Onsite Wastewater Treatment System (POWTS) shall include information and procedures for maintaining the system within the parameters of Comm 83 and 84, and the conditions of approval by the department, agent, or governmental unit. The approved plans and permits for system are on file at the county zoning or health department. This management plan complies with Comm 83.54, Wis. Adm. Code, and the In- Ground Soil Absorption Component Manual for Private Onsite Wastewater Treatment Systems SBD- 10567-P (R.6/99). Table 1: System Design Specifications Sanitary Permit Number 3j' _qS Number of Bedrooms Design Flow - Peak d i 9 (gpd) ao-0 Estimated Flow - Average (gpd) Septic Tank Capacity (gal) Soil Absorption Component Size (ft Type of Wastewater Domestic Table 2: Soil Absorption Component - Limits of Reliable Operation Septic Tank Component Soil Absorption Component Design Flow - Peak (gpd) ZSo Z Maximum Influent Particle Size (in) 1/8 Maximum BOD (mg /L) 220 Maximum TSS (mg /L) 150 Table 3: Maintenance Schedule Septic Tank Inspect and /or service once every 3 years Outlet Filter Inspect once a year and clean at least once every 3 years Soil Absorption Component Inspect once every 3 years Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Stats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code (Servicing Septic or Holding Tanks, Pumping Chambers, Grease Interceptors, Seepage Beds, Seepage Pits, Seepage Trenches, Privies, or Portable Restrooms). The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the a Management Plan for a Septic Tank and Soil Absorption Component filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of scum and sludge in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of an assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. Manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No one should enter a septic or other treatment or holding tank for any reason without being in full compliance with OSHA standards for entering a confined space. The atmosphere within the septic or other treatment of holding tank may contain lethal gases, and rescue of a person from the interior of the tank may be difficult or impossible. Tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. Soil Absorption Component The soil absorption component serving this structure is designed to accept domestic wastewater from a residential facility. The limits of operation of this component are shown in Table 2. The longevity of a soil absorption component depends greatly on proper and timely maintenance, and system use within or below the limits of reliable operation. Good water conservation practices by all occupants and the installation of water conserving plumbing fixtures are key factors in extending the useful life of this component. The soil absorption component's operation must be assessed by inspection at least once every three years. The inspection shall include recording the levels of ponding, if any, in the observation pipes, and a visual inspection for any evidence of surface seepage or discharge from the component. On steeply sloping sites, areas of erosion should be identified and reported to the owner for repair. The surface discharge of domestic wastewater or sewage from the system is prohibited and considered a human health hazard. Traffic around or over the soil absorption component should be avoided particularly during winter months. The compaction or removal of snow cover over the component may lead to hydraulic failure by freezing. This type of failure is usually temporary, but is difficult or impossible to repair until weather conditions improve. In general, soil compaction over this component will reduce diffusion of oxygen into the soil and dispersal cell, which may lead to more intense, and earlier, organic clogging of the soil. 2 s a ' Management Plan for a Septic Tank and Soil Absorption Component Plantings of deep- rooted trees and shrubs directly over or within ten feet of the component should be avoided since root intrusion into the component may obstruct wastewater flow. 3 ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer I Mailing Address `6 , �" -1 L 6 2 )" Property Address -& a" 5f *51 S'1 Verification required from Pl ( q arming Department for new construction) City /State Parcel Identification Number LEGAL DESCRIPTION Property Location S;5 %4, %4, Sec. / , T om% N- R_Z9_W, Town of Subdivision �'/��G'b4/l� ,t F , Lot # Certified Survey Map # , Volume , Page # -- Warranty Deed # _ v/.2 7 P,?k - Volume /S7 3 3 , Page # Spec house O yes no Lot lines identifiable yes 0 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 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 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 Zoning Office within 30 days of the three year expiration date. 2 /a / SIGNATURE OF APPLICANT 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 described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNATURE 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 a w.1533PAA20 (o STATE BAR OF WISCONSIN FORM 2 - 1998 627835 WARRANTY DEED KATHLEEN H WALSH REGISTER OF DEEDS DocumentNtmber ST. CROIX CO., WI RECEIVED FOR RECORD This Deed, made between 08 -08 -2000 10:45 AN RICHARD O STOUT and JANET P STOUT, husband and wife, WARRAkTY DEED Grantor. EXENPI N - - - - -- - -- CERT COPY FEE: and JEFF P EMERSON and DARLENE T EMERSON, COPY FEE: h lahand and w; fa, TRANSFER FEE: 149.70 -- — ftECORDI96 FEE: 10.00 PAGES: I Grantee. Grantor, for a valuable consideration, conveys and warrants to Grantee the following described real estate in St. Croix County. State of Wisconsin: Reco,or,O Are,', Lot 24, Plat of Shadow Pines, Town of - Somerset, St. Croix County, Wisconsin Name and Return Address Return To: Edina Realty Title m 400 South 2nd Street Suite #115 Hudson, WI 54016 0 32- 1042 -10; 032 - 1042 -30; O P,gr{iel ldentificAti Vd7ber•tP,I1V). — 0 4 2 - 5 0 T his 1 is nnn t , hom property (is) (is not) Exceptions to warranties: easements. restrictions, rights -of -way and covenants of record. + 1 4- 4 e 2000 Dated this 5 day of W CI Ai hl, QSA (SEAL) &o ��Y - (SEAL) • Richard O_ Stout * Janet P Stout (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, ss. St. Croix County authenticated this day of Personally c e before se this i � day of T . 2 0 0 0, the above named Richard 0. Stout and Janet P. Stout TITLE: MEMBER STATE BAR OF WISCONSIN tO Ur not. me known to xecuted the foregoing authorized by §706.06, Wis. Stats.) instrument and :4 2 t nbSBNi�IONSIN ER ON J. BAST THIS INSTRUMENT WAS DRAFTED BY Janet P. Stout 1353 Awatukee Tr. Hudson, WI 54016 Notar ublic, State of nsln My, ommtss n i�p r nent. (If not, state expI lion te (Signatures may be authenticated or acknowledged. Both are not V necessary.) • Names of parsons signing in any opacity must be typed or printed below their signature. _ STATE BAR OF WISCONSIN w,sca,sin Legal sank Co., tno. WARRANTY DEED FORM No. 2 - 1998 Milwaukee. Wis. L to Sanitary P ermit Application Safety & Buildings Division 201 W. Washington Ave. In accord %%ith Comm 83.21. Wis. Adm. Code PO Box 7302 See re%erse side for instructions for completing this application Madison, WI 53707 -730' `� seonsin Department of Commerce Personal inhumation you provide may be used fir secondary purposes . (Submit completed form to county if no I1 Law. s. 15.04(1)(m)I state owned. Attach complete plans (to the count\ co v only) for the system. on . a er not less than 8 -1/2 x I 1 inches in size. Count Stale S.uutar} I'crnw Number ❑ ('hc • revision to previous appCtcition State Plan 1 1) Number I. Application Information - Please Print all Infor Loc n: Property Owner Name [rC�`' * � Prope Location _ L1,C`V 1/4 6 /4. T�/,N, P"fert wner's Mailing Address 20 L Number Block Number City, State Zip Code Simi ber Subdivision Name or CSM Number ,� CAUN c <✓ II T e of Buildin check one) �, 0 Vill YP g b /' Village 1 or 2 Family Dwellin - No. of 13edrooms: ?',own of ❑ Public/Commercial (des 'be use): ❑ State -owned O III Type of Permit: (Check on \one ox on line A. Check :box on line B if applica e ) Nearest Road A) 1. C(New System 2. lacement 3. O Rement of 4. Addition to Parce 'ax Number(s) Tank Existin System B) Permit Number Date Issued O A Sanitary Permit was previoush is IV. Type of POWT System: (Check all that a ly) Non - pressurized In ground ❑ Mound ❑ Sand Filter O Constructed Wetland Pressurized In- ground ❑ Holding Tank 1:1 Single Pass ❑Drip Line O At -grade Aerobic Treatme t Unit ❑ Recirculating O Other: UTr V Dis ersaeatment Area Information: l. Design Flow (gpd) 2. Disper [Area Dispersal Area 4.. • i call 5. Percotatron'Rate• 6. System I vation 7. Final Grade Required( roposcd to (Gals. /day /sq ti) (Min. /inch) + Elevation 1 .O VI Tank Capacity in Total # f ufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons T nks Con- Con- glass New Existing crete structed Tanks I Tanks fjr �r A�lr --- W ❑ ❑ O ❑ ❑ VII Responsibility Statement l 1, the undersigned. assume responsibility fo installation of the POWTS own on the attached tans. Plum mt Plumb is Signature (no stamps �h4f+{MPRS No. Business Phone Number o ger'�y 1 0 & Perk Tes ing alzS Plumbe s dress trees, ity, tale, Zip C de) Spooner, WI 546 ,)1 VIII County/Department Use Prily O Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing ens Signature (No stamps) E3 Approved ❑ Owner Giv Initial Adverse Surcharge Fee) Determinatio IX. Conditions of Appro al /Reasons for Disapproval: l.GL'j��f��t4A. w �.�L4D y.1 3 A27/50`6 Fes I SBD -6398 (R. 07/00) y/,oEXXAg� r X7 �p� Fogerty Plumbing #22118L 28288 McKed. $poone�� WI 1 (715) 635 - 10 /3 ,W, rd? a J'A/ �'/r�t/ w��u'rS6o.�/, oa.o ' � �f AVW I"l� d -�'� o f z'G rrr/ c6/�Af �-/ /erJl o� imev 0 iS O ^ w EC.L _ T � I✓ f b � � �9icr o f �y f l�_�s�► 0 = 11 OU 4/tG S•! • w/ `Z /ErGT�/Z, �/�� = � 5 �G�v.• ZoH' ef c . s` ' gy P7. 6t G )vNt) is h'E�D�� • a y a�� ES A #y S f,E�R,K�►T.r°N I� V78 f71 ffd drf Wisconsin Department of Commerce SOIL AND SITE EVALUATION 1 livisior pf Safety and Buildings Page 1 of 3 _ of Integrated Services in accordance with s. ILHR 8309, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size.FOlan must County include, but not limited to: vertical and horizontal reference point (BM), fire and 4` St . Croix percent slope, scale or dimensions, north arrow, and location and dist ce t neargst 0d rrd " ..... ,.., _ :. Parcel 0P. # 1 APPLICANT INFORMATION - Please print all informotion. % z '� Peviewe by Date Personal information you provide may be used for secondary purposes (Privacy liaw, s, 15.04 (1) (Yrf)), , Property Owner t _ Pr �1tR 4WOWE Richard Stout Govt. Lot SW 1/ E 1 /4,s 15 T 31 N,R 19 E (or) W Property Owner's Mailing Address ` y t Block #., bbd. Name or CSM# 1 353 Awatukee Trail City State Zip Code Phone Number ❑ City ❑ Village Town ' - � Neafifst Ro d Hudson Wi 54016 (715)549 -6731 Somerset 60th Street ® New Construction Use: [2 Residential / Number of bedrooms 4 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 6 0 0 g pd Recommended design loading rate 7 bed, gpd /fi __8 trench, gpd /ft Absorption area required R 1 , R bed, ft 73 0 trench, ft 2 Maximum design loading rate • 7 bed, gpd /ft 8 trench, gpd/ft Recommended infiltration surface elevation(s) See plot ]f ft (as referred to site plan benchmark) Additional design /site considerations Parent material CoC 2 Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system U s El Qs El ® S El ®S ❑ u ❑ S ©U ❑ S ® U SOIL DESCRIPTION REPORT Boris # Horizon Depth Dominant Color Mottles Structure GPD /ft Boring Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1 1 0 -8 1 Oyr2 /1 -- is 1 pjp6r mfr cs 1 f .7 .8 2 8 -8 10yr4/6 -- ms osg ml cs -- .7;.8 Ground elev. 9 4 —4-- ft. Depth to limiting factor 8 7 in. Remarks: Boring # 1 0 -8 10yr2/1 -- is 1 M46 mfr cs 1f .7 .8 2 2 8 -4 1 Oyr3 /6 -- is 1 >rp mfr cs -- .7 .8 3 45- 0 1Oyr4/6 -- ms osg ml cs -- .7 .8 Ground elev. 9 1.1 ft. Depth to limiting factor __9.0- Remarks: CST Name (Please Print) Signature lr� Telephone No. Address n Date CST Number z -7 PROPERTY OWNER Richard R oiit -_ SOIL DESCRIPTION REPORT Page 2 0� PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 9 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 3 1 0 -6 1 Oyr2 /1 -- is 1 mAt3k mfr cs 1 f .7 .8 6-85 10yr4/6 MS osg ml cs -- .7 .8 Ground elev. 9 3 Depth to limiting factor 8 n. Remarks: Boring # 1 -1 2 10 r2 1 -- s 1 Ill A mfr cs 4 2 12-85 10yr4/6 -- s osg ml cs -- .7 8 Ground elev. 95 .00 ft. Depth to limiting factor 8 in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 1 -6 10 r2 1 L s 1 MA-(5 K m 5 2 -50 10yr3/6 -- s 1 m ,4/5k mfr cs -- .7 '.8 3 0 -9 10yr4/6 -- ,s osg ml cs -- .7 '.8 Ground elev. 9 2 .40—ft. Depth to limiting factor 9 Remarks: Boring # Ground elev. ft. ' Depth to limiting factor in ' Remarks: SBD -8330 (R. 07/96) PROPEJRTYOWNER -_ Ri chard Stc) it SUILUtSCRIPTION REPORT Page 2 of3 PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3 1 0 -6 10yr2 /1 -- is 1 MA6k mfr Cs if .7 '.8 � 2 6-8E 10yr4/6 MS osg ml Cs -- .7 ;.8 Ground elev. 9 3 -4-0-ft- Depth to limiting factor ; 8 in. Remarks: Boring # 1 -12 10 r2 1 -- s 1 Al2>K mfr 4 2 12-85 10yr4/6 ns osg ml Cs -- .7 ',8 Ground elev. 95 .no ft. Depth to limiting factor § in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # 1 -6 1 0 r2 1 1 MA C - - s 1 2 -50 10yr3/6 -- s 1 mA1sK mfr Cs -- .7 ;.8 5 C" 3 0 -9 10yr4/6 -- ,s os ml Cs g -- .7 .8 Ground elev. 9 2 .AZ-ft- Depth to limiting ; factor 9 q in. Remarks: Boring # Ground elev. ft. Depth to I limiting factor ' Remarks: SBD -8330 (R. 07/96) , zz3f q e2 o� �enel�m e(e� l00' >�f "oaks -ree (�n�,kr�ar•k �e(e�.loo`C;akr�ys�r' / �Yt -P9►' �' iI �ll�l� �� 6 ��B�/ ��. [/' 4 IV 0