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HomeMy WebLinkAbout032-2146-90-000 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Divisioie INSPECTION REPORT Sanitary Permit No: 405044 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)]. 4 Permit Holder's Name: City Village X Township Parcel Tax No: Iverson, Rodney Somerset Township 032- 2146 - 90-000 CST BM Elev: Insp. BM Elev: I BM escription: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark /aZ 10 6 . Dosing Alt. BM GtJ s� 7l 7 ,7 DD• d� Aeration > Bldg. Sewer Holding St/Ht Inlet 9 S4 TANK SETBACK INFORMATION St/Ht Outlet 1 - 0 -1(o 17 TANK TO P L LL I BLDG. pVentt Int a ROAD Dt Inlet Septic > 6 — b / Dt Bottom Dosing Hea¢grlMa� Aeration Dist. Pipe y ,D� D o T 7• Holding Bot. S tem (` 1 , 2 70,07 PUMP /SIPHON INFORMATION Final Grade 3 0 .2•j/ Manufacturer M 9er Qand St C er GP Model Numbe TDH L' ion Loss System Head TDH Ft Forcemain Length Dia. Dist. to well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSI S No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG IWELL LA E /STREAM LEACHING podeiNumber: reyn, INFORMATION : CHAMBER OR T Of S stem tTi'�L TG`f �;p� � I � � I � 7 � UNIT DISTRIBUTION SYSTEM Header /M if old Distribution r x Hole Size x Hole Spacing Ven=Intak / P�pe(s) Length Dia Length q I ' Dia 1 ' k ( kA g SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only y Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bedrrrench Center Bed/Trench Edges Topsoil j Yes jai No IgI Yes tl No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 1,0 '7 D Inspection #2: ! 1 Location: 2137 54TH St Somerset, WI 54025 (NE 114 SW 1/415 T31 R1 9W) Oak Haven Lot 9 Parcel No: 15.31.19.1280 1.) Alt BM Description SIl ► f V1 S he" of 3• 2.) Bldg sewer length =�� OZ440r -. amount of cover = � ��� �� / � ��� , ar '� (� ID- � f - f IGn. ntd � Plan revision Required? lw Yes No Use other side for additional information. i Date Insepctor's Signature Cert. No. SBD -6710 (R.3/97) m sf.�:c'srr?'� �3 Ze /22)v I' 3 1 Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 l N visconsinMadison, WI 53707 - 7162 Site Address De ailment of Commerce �/_ 3G' -c'Z- // Y�-& Sanitary Permit Application Permit Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide ❑ Check if Revision��� way be used for secondary pulposq Privacy Law, sl5. 1 in I. Application Information - Please Print All Information State Plan I.D. Number Property is Name RECEIVED Parcel Number,_�� 4 Property Owner's Address Property Location APR 2 9 2002 1 'A ,5 T N,R C„ city" tax Zip Code ST. C 4rf Y Lot N r Block umber l �` Z N ING OFFICE - Subdivision Name CSM- Ntmtber II. Type of Building (check all that apply) e JUV7"W ?W_ All ❑City J�(1 or 2 Family Dwelling - Number of Bedrooms �u a N ❑village ❑ Pubhc/CommercW - Describe Use A- 1 11 e t �lca2J mot �� - QTownship ❑ State Owned YX (0 2.25- Nearest Road M. Type of Permit: (Check only one box on line A (numbering scheme for mternal use). Complete line B if applicable) ____t_ A. 1 New 2 ❑ Replacement System 3 11 Replace of 6 ❑Addition to For County use S stem I Tank Only F.xis g system 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) 44 5( Non - Pressurized In- Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ pressurized In- Ground 41 ❑ Holding Tank 48 ❑ Single Pass 51 ❑ Drip Line 45 ❑ At -Grade 46 ❑ Aerobic Treatment ling ❑ Other V. D' rsalPTreatment Area Information: r i ; % ` - �' ` Design Flow (gpd) Dispersal Area Dispersal Area hcanon Percolation Rate System Elevation Final Grade Required Proposed Rate(Gals./Days/Sq.Ft.) (Min -Anch) Elevation S VI. Tank Info Capacity in Total Number Manufacturer Prefab site Steel Fiber Plastic Concrete Cons Gallons Gallons of Tanks Constructed Glass New Existing Tanks Tanks Septic or Holdift Tank Dosing Chamber r f - VII. Responsibility Statement - I, the undetsigned, 9�.m responsibility for installation of the POWTS shown on the attached plans. Plumber' ame ), Plumber' s S' MP/MPRS Number Business Phone Number t gr Plumber's Address (Street, City, State, Zip Code) c' VIII, tm !De artment Use Onl Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Approved ❑Disapproved Suro ge Fee) ' ❑ Owner Given Initial Adverse Determination IX. Conditions of Approval/Reasons for Disapproval z IF15 0h i Attach comOlde Plana 06 the Coast? onl7) for the gstem oa Paper not 1— than 8112 111 inches in size SBD -6398 (R. 05101) I _ i /-=Ws x/.37 AIJO -36 SfyJnJryl Pq .� %may -�=� as� y I _ - " /e -Ana r' ►VIsconsilt Department of Commerce SOIL EVALUATION REPORT Li- Page _ of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code CO11 "h' St. Croix 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. din Please print all information. Review d by Dat Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location Ger ald J. Smith Govt. Lot NE 1/4 $W 114 S15, T 31 1 N R 1 f (or) W Property Owner's Mailing Address L Block It Subd. Name or CSM# 11160 190th. Ave. 10 na Oak Haven City State Zip Code Phone Number City ❑ Village ® Town Nearest Road Elk River I MN 1 55330 ( 612)441 -8888 Somerset I 210th. Ave. [3 New Construction Use: (3 Residential / Number of bedrooms 4 Code derived design flow rate 600-- GPD ❑ Replacement ❑ Public or commercial - Describe: - -- Parent material outwash Flood Plain elevation if applicable ffia M ft• r£�'cfrrr'�7 General comments and recommendations: trenches @ el. 98.00', spaced to code 3.50' below grad2'_�t 1,f 1 ` 1 ._... 14 3 — P ,k'V, - 1 . G. ,'7( I t Boring # ❑Boring u' \ ZONiNG OFFICE F I Pit Ground surface elev. 101 .50 ft. Depth to limiting factor in. 8vii lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence I S, Ha (Jt�o GPD / ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 1 0 -14 10yr3/3 none sl 2csbk mvfr gw 2m .5 .9 2 14 -30 7.5 4 4 none is osq mvfr ClW 1m .7 11.2 F- Borin # Boring 21 g pit Ground surface elev. 00 ft Depth to limiting factor 90 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 1 0 -10 10 3 3 none sl ZTqr mvfr QW 2m 5 9 2 10-20 7-Svr4/4 none Is OSQ mvfr QW 1M -7 1-2 Effluent #1 = BOD > 30 5 220 mg/L and TSS >30 < 150 mg/L ' uent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) Signature . CST Number Gary L. Steel 02298 Address Date valuation ducte Telephone Number 1554 200th. Ave., New Richmond, WI. 54017 6 -6 -2001 715- 246 -6200 h Property Owner C,r?M d J Smi i h Parcel ID # r)wd i n T Page _ 2 of 3, ❑ Boring # ❑ Boring 90 3 ❑ pit Ground surface elev. 104.50 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 1 0-8 1 2 8 -30 7.5yr4/4 non S1 2csbk mvfr qw 1m .5 9 3 30 -90 7.5 4/6 none ms os 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 GPDlft= in. Munsell Qu. Sz, Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 F-1 Boring # ❑ Boring Depth t limiting factor in El Pit Ground surface elev. ft. o mng . SoilA lication 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 = 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 -6330 (R.6100) " STEEL'S SOIL SERVICE Gary L. Steel Gerald J. Smith 1554 200th Ave. CSTM2298 NE4SWJ S15- T31N - R19W New Richmond, WI 54017 MPRSW -3254 f _ (715) 246 -6200 lot #10 -Oak Have �t�c n k? i _e + ` This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of the test may may not be as shown as permanent lot lines were not established at the time the test was conducted. N 1 " =40' BM.= top of SE lot stake @ e Inn nn' alt. BM.= top of 1" pvc pipe @ el. 105.10' J c A 0 t Gary L. Ste_ e1 �5 , u. 6C( sc r l '�� I 6 -6 -2001 re. (� ✓� . ber 1. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer e Mailing Address /37 �s- y Property Address f .0 (Verification req fired from Planning Department for new construction) City/State As <�,e� lam // Parcel Identification Number BOG LE DESCRIPTION S ' 03)--!0413, 90 -cam Property Location ' /,, S-W. r ' /,, Sec. , T LN -R�W, Town of Q� Subdivision -Z '-a� tZ �,.,� , Lot # Cerd fled ,Survey Map # Volume , Page # Warranty Deed # (a_ �� , Volume . ? , Page # Spec house O yes 19 no Lot lines identifiable 18 yes O no MUM 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 piumberor a licensed pumper verifying that (1) the on -site wastewaterdisposat 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, a set s c by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that our septic t Y p s y s tem has been maintained must be completed and returned to the St: Croix County Zoning Office within 30 days three r piration date. a 9 oa SIGNA F APPLICANT DATE .. 9M=R CERTIFICATION weI ccrtif that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the de i d above, by virtue of a warranty deed recorded in Register of Deeds Office. 3, oa SIGNA 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 POWTS OWNER'S MANUAL at MANAGEMENT PLAN Page _j of FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity al 13 NA Permit # Z r' Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA, Effluent Filter Model ❑ NA Number of Commercial Units 0 NA Pump Tank Capacity gal Iff NA Estimated flow (average) gal /day Pump Tank Manufacturer r Z NA Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer E5 NA Soil Application Rate gal /day /ft' Pump Model 2-NA Influent/Effluent Quality Monthly average* Pretreatment Unit ;. NA Fats, Oil at Grease (FOG) 530 mg/L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BODs) :5220 mg/L ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality ❑ NA Monthly average**- Manufacturer Dispersal Cell(s) Biochemical Oxygen Demand (BODs) :530 mg/L AIn- ground (gravity) ❑ in- ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ At -grade ❑ Mound Fecal Coliform (geometric mean) 510' cfu/ 100ml ❑Drip -line ❑ Other: Maximum Effluent Particle Size Yo inch diameter * Values typical for domestic (non - commercial) wastewater and septic tank effluent. * * Values typical for pretreated wastewater, MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every ❑months g9 year(s) (Maximum 3 yrs. Pump out contents of tank(s) When combined sludge and scum equals one -third (h) of tank volume Inspect dispersal cell(s) At least once every ❑ months ® year(s) (Maximum 3 yrs.) Clean effluent fllter At least once every ❑ months J W year(s) Inspect pump, pump controls ez.alarm At least once every ❑ months ❑ year(s) J2 NA Flush laterals and pressure test At least once every ❑ months ❑ year(s) 2 NA Other: At least once every ❑ months ❑ year(s) ® NA Other: At least once every ❑ months ❑ year(s) 0 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. 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 to check for any back up or ponding of effluent on the 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 indicate a failing condition and requires the Immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Yi) 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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent fllters, mechanical or pressurized POWTS components, pretreatement components, and any other maintenance or monitoring at intervals of 12 months or less shall be performed by a cerdfled POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION For new construction, prior to use 3f the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents �F the 1,nlefct r- rrovad by a sentpse servicinp operptor prior to use, Page ,vf System start up shall not occur when soil conditlom are frozen at the inflttradve surface. During power outages pump tanks may fill above normal hlghwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) In one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the um tank removed b a Septage Servicing Operator prior to restoring; p p Y power to the effluent pump or contact a Plumber or POWTS Malntalner 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 sott absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; bany wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain Isump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting >rroducts: pesticides: sanitary navkins: tamponsi and water softener brine. ARANDONEMENT When the POWTS fails andlor 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 ch. Comm 83.33, Msconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of of tanks and pits shall be removed and property; 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 rewired setbacks from existing and proposed svwcwre, lot flnes 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 loll 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 reeptacernentarea. if no replacement area Is available a holding tank may be installed as a last resort to replace the failed POWTS. O Mound and at-grade soft absorption systems may be reconstructed in place following removal of the biomat at the Infiitracive surface. Reconstructlons 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 THT INTER10R OF A TANK MAY BE DIFFICULT OR IMpnVICURI F. ADDITIONAL COMMENTS POWTS INSTAL R ' POWTS MAINTAINER Name _ Narne T^ Phone — Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Na Agency Phone Phone `- unt � 217 STATE BAR OF WISCONSIN FORM 2 - 1999 KATHLEEN H WALSH Document Number WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI This Deed, made between Forest Oaks Condos, Inc., a Minnesota RECEIVED FOR RECORD Corporation 01 -04 72002 9:35 AM WARRANTY DEED Grantor, a d Rodney . Iverson and Cheryl D. Iverson, husband and CERT EXEMPT 11 Y rY CERT COPY .FEE: wife TRANSFER FEE: 145.50 RECORDING FEE: 11.00 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 of 10 ak Haven. St. Croix County, Wisconsin. Name and RIMISMA OGLAND ESTREEN & OGL.AND 304 Locust y �-t Hudson, WI 54016 - 032- 1043 -80- 000;032- 1043 -90 -000 Parcel Identification Number (PIN) This is not homestead property. (9) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this , day of December , 2001 Forest Oaks Condos, Inc. * ; Gerald Smith, resident * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) ) ss. 15+ Cr-0 t X County ) authenticated this day of ' Personally came before me til*' a � J day of • December , 20 .•th` apyVe named Forest Oaks Condos, Inc., a MinnesA tioir, y Gerald * i q f Smith, its President TITLE: MEMBER STATE BAR OF WISCONSIN - to me known to be the persons d thg (If not, instrument and acknowled ed the. authorized by § 706.06, Wis. Stars.) THIS INSTRUMENT WAS DRAFTED BY Attorney Kristina Ogland Notary Public, diate of Wisconsin Hudson, WI 54016 My Commission ' . (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 arofessionais company, Fond du Lac, WI STATE BAR OF WISCONSIN SOD-655 WARRANTY DEED FORM No. 2 -1999 f - 04/19l02 FRI 10:22 FAX 1 715 386 6560 ESTMEMOGLAND Z002 SCRIVENER'S AFFIDA-�IT V6-,/ (S-73 (�9 (4; 14 73 Document Number: 2- M m Address: Parcel (.D. Number: Pt 032- 1043 -80 -000; 032. 1043 -90 -000 KRISTINA OGLAND, being first duly sworn, on oath, deposes and says as follows: 1. That I am an Attorney at Law duly licensed and qualified to practice in the State of Wisconsin; 2. That I drafted Warranty Deed from Forest Oaks Condos, Inc., a Minnesota Corporation, to Rodney J. Iverson and Cheryl D. Iverson, dated December 13,200 1, recorded January 4, 2002, in Vol. 1808, page 217, as Document No. 667309, covering the following described real property: Lot 1 0, Oak Haven, St. Croix 'n. 3. t the legal description in the Warranty Deed referred to in P aph 2 herein contained and error and the correct legal d escription is as follows: Lot 9, Oak Haven, St. Croix County, Wiscons d. That this Affidavit is made for the purpose of correcting the legal description of the Warranty Deed referenced in Paragraph 2 herein. Dated this f ay of April, 2002. Krist 0sland Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 �SC�nS,rn Madison, WI 53707 - 7162 Site Addre s j3 Department of Commerce Sanitary Permit Ap licMQEIVED Sanitary Permit Number In accord with Comm 83.21. Wis. Adm. Code, perso information purpo ode, Privac w, s 1 you provide ❑ Check if Revision ma be used for seco I. Application Information - Please Print All Informal State Plan I.D. Number Parcel Number Property Owner's Name ZONING OFFICE - d Property Owner'd ang Address Property Location ili e.J �~< -A A; S N, R City, State Zip Code Phone Number Lot Ntun Bier C'�YY� - GK Subdivisi ame CSM- Number II. Type of Building (check all that apply) �'z, ❑City 1 or 2 Family Dwelling - Number of Bedrooms 1 ru a -�� ' B�'¢' ❑village ❑ Public /Commercial - Describe Use uP_S ❑ State �� Owned ��� � � `�`lc` Nearest Road III. Type of Permit: (Check only one box on line A (numbering scheme for internal use). Complete line B if applicable) A For County use 1 j X New 2 ❑ Replace ment System 3 ❑ Replacement of 6 ❑ Addition to S 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) ti �L' �f �� ��>�ii /� �hr A xn d 44 14 Non - Pressurized In- Ground 210 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wedand 11 2- 3I. 22 Pressurized In -Ground 41 ❑ El ' Y Holding Tank 48 ❑ Single Pass 51 Drip Line '.! -0 45 ❑ At -Grade 46 El Aerobic Treatme 30 ❑Other SictilGUii� V. Dispenalfrreatment Area Information: 61 2 ,t/ Design Flow (gpd) Dispersal Area Dispersal A rea Percolation Rate System Elevation Final Grade Required Proposed -2, Rate(Gals./Days /Sq.Ft.) (Min./Imb) Elevation �X 5 jq f� (ol o s' VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constricted Glass New Existing Tanks Tanks Septic or Holding Tank Y -- Dosing Chamber VII. Resppasibility Statement- I, the undersigned, aspnne responsibility for installation of the POVVTS shown on the attached plans. Plumber' Name (Print) Plumbe 's Si MP/MPRS Number Business Phone Number f _ r 1/t P umber's Address (Street, City, State, Zip Code) VIII. county /De artment Use Only ❑ Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuing Agent Signature (No Stamps) Surcharge Fee). ❑ Owner Given Initial Adverse 1Y - Determination / °� IX. Conditions of Approval/Reasons for Disapproval /c Attach complete plans (to the County only) for the system on paper not less than 8112 x 11 inches in size SBD -6398 (R. 05101) - es�ew IV4 1 7 - - ._�® / /,e�Slef' d ,� �C�.�S� C�Z�`J�( ! 8 '4�. _t� �.1 �r f /'GCd'y�.�? r'1 � �j A 2 I-e l It - / ISO 166 d 71 r OAK H4 WN lip; I Located In the Northeast Quarter of the Southwest Quarter and the Southeast Quarter of the Southwest Quarter of Section 15, Township 31 North, Range 19 West, Town of Somerset, St. Croix County, Wisconsin. 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