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032-1061-60-120 (2)
r PRIVATE ONSITE WASTE TREATMENT SYSTEMS County /1S►if (POWTS) oepmsnt of commerce INSPECTION REPORT St. Croix 5*rety and r0dings Diw"asion (ATTACH TO PERMIT Sanitary Permit No: GENERAL INFORMATION 515239 Personal information you provide may be used for secondary purposes [ Privacy Law, s. 15.04 (1)(m) ] State Plan Transaction ID #: Permit Holder's Name: City Village Town of: Lloyd Peterson Somerset, Town of Parcel Tax No: CST BM Elev: Insp BM Elev: BM Description: q r j �f > m. - 2) r^ 032- 1061 -60 -120 TANK INFORMATION ; A46 ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV Septic Wieser W1000/600 $ Benchmark 2 Z Cie) 77 97 53 Dosing Wieser W1000/600 /Q Bldg. Sewer Holding St/Ht Inlet /Z , W 37 � � (1 TANK SETBACK INFORMATION �,� St/Ht Outlet Tank TO P/L WELL BLDG VENT TO ROAD Dt Inlet AIR r INTAKE Dt Bottom �, 73 �� 0 Septic /6a Z4 NA Installation Dosing 150 9 2,4 NA Contour Header /Man. Aeration NA Dist. Pipe Holding Infiltrative PUMP / SIPHON INFORMATION Surface Manufacturer I Qemand Final Grade Model Number G 1 3 1 Zz icj GPM --' TDH Li Friction Loss System H 2g TDH Ft Forcemain Length Dia Z Dist. To Well DISPERSAL CELL INFORMATION DIMENSIONS Width Length No of Cells Type of System Manufactuer SETBACK P/L Bldg Well OHWN of Nav L EACHING INFORMATION Waters ` CHAMBER Model Number: CELL TO ?C1 6d'tti DISTRIBUTION SYSTEM X Pressure Systems Only Header / Manifold Distribution Pipe(s) X Hole Size X Hole Spacing Observation Pipes Length Dia Length Dia Spac Yes _ No SOIL COVER Depth Over Depth Over Depth of Seeded / Sodded Mulched Cell Center Cell Edges Topsoil — Yes _ No — Yes — No COMMENTS: (InZr de discrepancies, persons present, etrc.)� G6 f'1r-�. Err "-,J Plan revision required? _ Yes No T Fz- F p 1 �[ 5 Use other side for additional information. Date POW IS Inspe or's ignature D Cert. No. Bureau of Field Operations, PO Box 7302, Madison, WI 53701 -7302 it • t4 SBO -6710 (R 3101) commerce.wi.gov Safety and Buildings Division County 0 /� 201 W. Washington Ave., P.O. Box 7162 � C vol i sco n s n Madison, WI 53707 -716 Sanitary Permit Number (to be filled in by Co.) Department of Commerce 5/-5Z3 Sanitary Permit Application tate Transaction Num er In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to the appropriate govenunen a unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are Proje t Addre (if different than ai n addres submitted to the Department of Commerce. Personal information you provide may be used for secondary �� 2O oses in accordance with the Privacy Law, s. 15.04 1 m , Stats. 5A /NJ�� I. Application Information - Please Print All Jdfo hpAVq Property Owner's Name Parcel # E64bG��- cREn Qy vre, fl=s 6�2 - 1861 -100- 12D Property ( Owner's Maili Address Property Location (,, (o 4 l ( Zn�� N ST Govt. Lot City, State Zip Code one Number N V0 14, S 14 1114, Section 23 ST. CROIX COUNTY q(circle on E IZSET W S' L�d2 e OFFICE T ( N; R / E or� H. Type of Building (check all that apply) 2 j. W1 or 2 Family Dwelling - Number of Bedrooms v DI 2 Subdivision Name Sv; Block # D Public /Commercial - Describe Use r D City of D State Owned - Describe Use CSM Number ❑ Village of VoL I hh 19 P Town of sr)M6lZSE'T' S SZZ III. Type of Permit: (Chick only one box on line A. Colpoiplete line B if applicable) A ' ❑ New System ❑ Replacement System XTreatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. Permit Renewal Permit Revision ❑ Chan ge of Plumber D Permit Transfer to New List Previous Permit Number and Date Issued ❑ ❑ Before Expiration Owner 24J 9 752— & //,y IV. Type of POWTS System/Component/Device: Check all that a 1 D Non - Pressurized In-GroAmd ❑PTs In- Ground D At -Grade ound > 24 in. of suitable soil D Mound < 24 in. of suitable soil D Holding Tank ❑ r9af Compo ent (explain) ❑ Pretreatment Device (explain) V. Dispersal/Treatment Area Informa ion: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation ysv tt3 r- : VI. Tank Info apacity in Total # of Manufacturer Gallons Gallons Units o New Tanks Existing Tanks c « r✓ �� G / o, U cn v, Septic or Holding Tank / DID /s n � Dosing Chamber J^ OQ YU VII. Responsibility Statement - 11 I, the undersigned, assume respo nsibility for in stallation of the PO show he attached plans. Plumber's Name (Print) umber's i ature MP RS mber Business Phone Number �£F X �c �,, �- -zz3292_ 715- 7f6- -2L4 h1 Plumber's Address (Street, City, State, Zip Code) P.G. B(3�4 V III. Court /De artment Use Only roved a Permit Fee Date Is ued Issuing A ignature iven Re Denial $ Z 6 0. IX. Condit!$M casons for Disapproval 3 \ O �.'� `t eV 1. Septic tank, effluent filter and d �✓�� O dispersal cell must all be services / maintained Ta w� / / ,�/� AR I �Aje/"gA��, as per management plan provided by plumber'. 2. All setback requiremwft must be maintained Cep e as pit applicable code/ mss. A ll C e It f �r ^ 1—, c q N'r Attach to complete plans for the system and submit to thi Counyy oW o pa of l s than 1/2 x 11 inches in s" e yJ 6[ /d � /1� C0.0 , SBD -6398 (R. 02/09) Valid thru 02/11 w 'AIV,1•'r:, M332Y2 i Lc�v berg ?S�tU z V 1 Au\ -Z7_ 3z"/Z Zns Wei NSW l DDo Ih�c� WE- LSce — rRt�lC 1 or Ali T�.N1.( L = C1 7,S3 4.0%?D6 Lo\4b EzSaiV VJ / AIL eck r ar r tz()(V" weu- MX + !� NE1�1 /DD�Ih� l�� -rA 1C Al E, N1 d� lr.-IJ [. = 911? Page Of COMBINATION SEPTIC TANK /PUMP CHAMBER (No Scale) 4" Ct Vent.Pipe with ,Approved Locking Manhole Cover APProved Cap, +25' With Warning Label Attached From Buildings Weatherproof Ap proved _ Warning Label Junction Box. Vent Cap 12" Minimum _ ► 1 Final Grade 6° Mi mm' umm 4 Mi of mmum 6" Maximum f Quick 4" C.I.. Minimum - . Insp. Pipe .._ Disconnect - i r 1 /4" Weep Baffles , Bole d Joint t ni p 3' - + A Ala.:: , lid Soil B Approved :Joint On `. w /C.I. Pipe Extending 3' Off d� Onto Solid Soil Conc. Block 3" of Bedding Under Tank --/ Pump and Alarm Are On Soarate Circuits Number of-Doses - 1 Per Day - h ' Gallons Per Daley /f o r�Doses: Volume of Backflow:.......+ f8 Ga'Yoirs C Manufacturer: W GSE K Total Dose Volume......... j a 1oas r, S:i ae- Septic /Pump : b a 1 ons - M Manufacturer: S_ el Number: Capacities: A I inches or WIons tch Type: O + B ittcfies or % Gallons p Manufacturer: -Z E (L + Cinches or. 6a1oAS- lel - Number : + p -- inches a , - '6a 1 timum Discharge ate: Total....._ +y inches or TTons rtical Difference Between Pump Off and Distribution Pipe: - Feet -- nimum Required Supply Pressure: .......................... 1 Feet Feet of Force Main x Friction Factor/100 Feet: + ... - Inch Diameter Force Main T Total Dynamic #lead :... = . P dL 1 IlkS P o f % M ternal Tank Dimensions: length ; Width Liquid Deptt 3�_ &.I,ii-P-tl Signature License Number Date i TOTAL DYNAMIC HEAD /CAPACIT`' HEAD CAPACITY CURVE PER MINUTE EFFLUENT AND DEWATERtNG it MODEL 152/153 W w MODEL 152 153 50 Feet Meters Gal. Liters Gal. Liters 153 5 1.5 69 261 77 291 12 40 152 10 3.1 61 231 70 265 15 4.6 53 201 61 231 30 20 6.1 44 167 197 M 8 � 25 7.6 34 129 159 Z 30 9.1 23 87 33 125 a 20 35 10.7 -- -- 22 85 0 '— 40 12.2 — -- 11 42 4 10 �� Lock Valve: 38.0 Ft. (11.6m) 44.0 Ft. (13.4m) 01 4soa AT aa.s " r&4 Pum? s�wLh 20 40 60 80 100 m to GALLONS LITERS 0 80 160 240 320 6 1/4 3 27/32 4 5/8 FLOW PER MINUTE e F^u��rS 1 , ;� C R Y FOR SP P I 9 3 2727 /32 • �3y .� k � `� t"s � � ��P�t��� � � � 1t_x L- <;; , �� i — Timed dosing panels available. •Electrical alternators, for duplex systems, are available and supplied with 3 27/32 an alarm. • Variable level control switches are available for controlling single phase systems. • Double piggyback variable Level float switches are available for variable I { level long and short cycle controls. • Sealed Qwik -Box available for outdoor installations. See FM1420. i • Over 130 °F. (54 °C.) special quotation required. I t 1521153 Series 12 1/8 1521153 MODELS Control Selection Model Volts -Ph Mode Amps Simplex DuNex 5 t/8 N152 115 1 Non 8.5 1 2 or 3 BN152 115 1 Auto 8.5 Included 2 or 3 srkzzoaa E152 230 1 Non 4.3 1 2 or 3 BE152 230 1 Au(o 4.3 ln*K ed 2 or 3 N153 1`15 1 Non 10.5 1 2or3 BN11531 115 1 t Auto 10.5 Included 2 or3 SELEG F ION GUIDE E 230 1 Non 5.3 1 2 or 3 E1 53 230 1 Auto 5.3 Included 2 or 3 1. Single piggyback variable level float switch or double piggyback variable level float BE1 switch. Refer to FM0477. o CAlTr10N 2. See FM0712 for correct model of Electrical Altemator E-Pak. All installation of controls, protection devices and vairing should be done by a qualified 3. Variable level control switch 10-0225 used as a control acMtor, specify duplex (3) 'licensed electrician. All electrical and safety codes should be follovred including the most recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA). or (4) float system. RESERVE POWERED DES2 �-'J For unusual conditions a reserve safety factor is e ngineered i the design of every Zoeller pump. MAIL T0: P.O. BOX 16347 �. Louisville, KY 40256.0347 Manufachms of. , 0� SF8P is v 3649 Cane Run Road Lowsvide, KY 40211 -1961 rLwIrrP�Pe SAME /9S9 http://www-- iter.com PUMP !O_ (502) 778- FA X (800} 24 PUMP FAX (502) 774 © Copyright 2001 Zoeller Co. All rights reserved. :.� � � Illllllllllllllllllllllllllllllllllfllllllllllllll ' * 9 1 3 6 4 4 2 913644 BETH PABST REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD SPECIAL WARRANTY 03/24/2010 10:55AM SPECIAL WARRANTY DEED Document Number DEED EXEMPT t 2 1D 5 7 71 7- REC FEE: 13.00 THIS DEED, made between FEDERAL OME LOAN PAGES 2 MORTGAGE CORPORATION, with a business address of 5000 Plano Parkway Carrollton, Texas 75010, Grantor and LLOYD PETERSON and BONNIE PETERSON, husband and wife, as tenants by the entirety, residing at lnu l 2JCG -k-� ± Vt. y}tlXrJfr - +; W 1 26a ,� Grantees. Grantor for a valuable consideration, conveys to Grantees the following described real estate, together with the rents, profits, fixtures Recording Area J 3 and other appurtenant interests, in the following described real estate in After Recording Return to: St. Croix County, State of Wisconsin: LOT 2 OF CERTIFIED SURVEY MAP RECORDED IN Rsturn to: VOLUME 11, PAGE 2971, DOCUMENT NO. 532271, BEING R ORDING OANTITLEIPlSI)RA 410 E RECORD O PART OF NORTHEAST QUARTER OF THE SOUTHWEST ISlRN 2606 ENTiRPR{BB ROAD 11111000 QUARTER (NE 1/4 OF SW 1/4), OF SECTION 23, TOWNSHIP 31 CLEARWAT111 PL �#'MMr�lM NORTH, RANGE 19 WEST, TOWN OF SOMERSET, ST. CROIX COUNTY, WISCONSIN. Mail Tax Statements To: Lloyd Peterson BEING THE SAME PROPERTY CONVEYED TO FEDERAL Bonnie Peterson HOME LOAN MORTGAGE CORPORATION BY SHERIFF'S ( t{ l DEED RECORDED 03/2512009 AS DOCUMENT NO. 891664, ST. W CROIX COUNTY, WISCONSIN. PROPERTY ADDRESS: 641 205' Avenue, Somerset, Wisconsin 54025 The legal description was obtained from a previously recorded instrument. PARCEL ID NO. (PIN) —) This property %,/ is is not homestead property. Dated this �— day of , � , 2010. Grantor hereby warrants with special warranty covenants with said Grantees that the Grantor is lawfully seized of said title to Property is good, indefeasible, and in fee simple. Said title held with the exception of, but not limited to encumbrances as noted in: Municipal and Zoning Ordinances and Agreements entered under them, Recorded Easements for the distribution of Utility and Municipal Services, Recorded Building and Use Restrictions and Covenants, General Taxes levied in the year of closing, other easements of record. This deed warrants title only against claims held by, through, or under the grantor, or against encumbrances made or suffered by the grantor, and it cannot be held to warrant title generally against all persons. Grantor does further covenant and bind itself, and its successors and assigns to warrant and forever defend the title to the property to the said Grantee against the lawful claims of all persons claiming by, through or under the Grantor, but no further or otherwise. Pagel of 2 1 of 2 a ° 0 y oc 0. 0 ° o a 00 0 0 0 O ! 'K d N CU U y O O'D q °o e E (D n r ax a 3 ° I c Z lL c (D � N O f0 NO Q C m c+) a m N F- z T i l l y O z U ir d Z c to F- N o T CY 0 0 C c N N O O O • "6 -= t6 c6 N 7 0 U w O II I O < Q _ '.' N N �zz zzo N R E E I L �i N D 0 a s c h w z o v) to N U 51 I w� z N > a 0 M � fn J U O � � O co M N 00 O c o- 0 E N III j O 7 N N cc 0 CD N 7 w O - C fp C ►y p 3 (0 o c o rn O O II O) " N O O V O I - N N C N U d m 0 N ' o C N N C W O `- N N M N -) t y -O L7 r O N f C N co • "� � O N U) 2 N O z N (n O r w V � � N • • C� a N .0 N , A U a 0 0 0 1 9 1p 2 4L l� STC - 104 C4.1',i� AS BUILT SANITARY SYSTEM REPORT N OWNER i45 �w cD ST GNlt &G ' z ADDRESS � GF r SUBDIVISION / CSM # _� 7 ? LOT # SECTION -R W, Town of - �- ST. CROIX COUNTY, WISCONSIN I PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM &A essc 97D ys s' INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. 1 BENCHMARK: z -z ALTERNATE BM: c o` .� SEPTIC TANK J PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Wel ' House �Z Other Pump: Manufacturer Model# 2� Size Float seperation Gallons /cycle: /_-�;]; Alarm Location SOIL ABSORPTION SYSTEM Width: Length 7 �_ Number of trenches Distance & Direction to nearest prop. line: -may Setback from: well: - House _ 1 Q Other ELEVATIONS Building Sewer ST Inlet. ST outlet PC inlet PC botto Pump Off Header /Manifold ��_ Bottom of system 5�5 Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: LICENSE NUMBER: INSPECTOR: 3/93:jt r P � f BENCHMARK: T ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: Setback from: Wel House ,Z2' _ Other Pump: Manufacturer � s Model # Size Float seperation Gallons /cycle: / Alarm Location ;SOIL ABSORPTION SYSTEM Width: Length Number of trenches Distance & Direction to nearest prop. line: ,, Setback from: well: Other ELEVATIONS Building Sewer ST Inlet ST outlet PC inlet PC bottom , Pump Off He ader/Manifold ,/ Bo ttom Bottom of system 5 Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB: - 2 LICENSE NUMBER: INSPECTOR: 3/93:jt wisccnsin q " of Industry PRIVATE SEWAGE SYSTEM County: Labor an3uman Relations INSPECTION REPORT ST. CROIX •Safiety grid Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION P ermTS H older ' s N ame: ❑ City E] Village © Town of: State Plan o.: R CST BM Elev.: , Insp. BM Elev.: BM Description: n Parcel Tax No.: 7� _ TANK INFORMATION ELEVATION DATA -.�s� TYPE MANUFACTURER CAPACITY STATION BS HI FS tLEV. Septic J �G c.,u Benchmark ? Dosing Aeration Bldg. Sewer Holdin St /,�Yt Inlet g TANK SETBACK INFORMATION St /fit Outlet S 7 3y' TANK TO P / L • WELL BLDG. Ve Intake ROAD Dt Inlet a/' 87 68 Septic , 93. `� NA Dt Bottom 7S Sc/ Dosing >a� 7� > 7 7 NA ' Man. G3 Aeration _. NA Dist. Pipe Holdig'� �� Bot. System PUMP/ 5J INFORMATION Final Grade P Manufacturer Model Number , G L P�I v 1(I d TDH Lift I(� ((nr Friction �' Systen TDH ;;4t Loss ea .50 2 Forcemain Length // () ` Dia. 2 Dist. To Well > b, SOIL ABSORPTION SYSTEM BED /i Width Length No. Of renches P No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHIN anufacturer: SETBACK CHA ER INFORMATION Type O yl /�� 3 1 O IT Model Number. — System: y>A.cun ,cl N a j' DISTRIBUTION SYSTEM Fr /Manifold „ I Distribution Pipe(s) �� 2n , I x Hole Size I x Hole Spacing I Vent To Air Intake Length y Dia. Length 7o Dia. Spacing 30 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only i Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No `s COMMENTS: (Include code discrepancies, persons present, etc.) -4- LOCATION: Somerset-23.31.19W, NW, SW Lot 2, 205th Avenue , l Plan revision required? ❑ Yes No Use other side for additional information. �-- SBD -6710 (R 05/91) Date Inspector's Signature Cert No. °^"` I�° Safety and Buildings Division :�� =a.�rs : SANITARY PERMIT APPLICATION Bureau of Building Water System: 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 Attach complete plans (to the county copy only) for the system, on paper not less County than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sa�nitTq Per N umber y ou p rovide may be used b other g overnment agency programs Z— Th e information Y P Y Y 9 9 Y P 9 ❑Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)). State PI n .D N um p, I. APPLICATION INFORMATION -PLEASE PRINT ALLINF RMATION S q — tTj Z) J Prope Owner Name Property Location t /4� 1 /4, S T , N, R (Oro Prope y wrier' Mailing Address Lot Num er Block Numbe Ci t to Zip Code Phone Number Subdivisi n Name or CSM Number 44 ,�' ( > II. TYPE F BUILDING: (check one) ❑ State Owned ❑ !t Nearest Road Public R 1 or 2 Family Dwelling - No. of bedrooms Io w a n OF 111 BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. g New 2. E] Replacement 3 E] Replacement of 4_ [] Reconnection of 5 E] Repair of an System ___,__ ________ System _ _� Tank Only _____�_______ Existing System ____�___ Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 %Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min /' ch) Elevation Feet ff Feet VII. TANK Capacity gallons Total # of Site in INFORMATION g Manufacturer's Name Prefab. Con- Steel Fiber- plastic App G Tanks p - New Existing Gallons ans concrete glass App- strutted Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber Rw — ❑ 1 ❑ ❑ 1 ❑ 1 ❑ VIII. RESPONSIBILITY STATEMENT I, thq undersigned, assume responsibility or i to ti t onsite sewage system shown on the attached plans. Plumbe Na in Plum er' Ign o Sta s) MP /MPRSW No.: Business Phone Number: -� P umber's Address reet, Citu , State, Zip Co i IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved SAvitary Permit Fee (Includes Groundwater D ate Issued Issuing Agent Signature ! Stamps) Approved E] Owner Given Initial Surcharge Fee) I &/ Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 05/94) DISTRI81LITION: Original to County, One copy To: Safety 6 Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6_ If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3815. To be complete and accurate this sanitary permit application must include: I I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. IL Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. Ill. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and l holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number-with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX_ County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic . tank(s) oi• other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on.a 115 form; and F) all sizing information_ ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees),for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations October 6, 1995 2226 Rose Street. La Crosse WI 54603 K 0 CONSTRUCTION KIM 0 CONNELL 308 MIDPINE CT STAR PRAIRIE WI 54026 RE: PLAN S95 -41219 FEE RECEIVED: 180.00 HUSTAD, GREG NW,SW,23,31,19W TOWN OF SOMERSET COUNTY OF ST CROIX MOUND SYSTEM The Department has reviewed the above- referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Sta.t,utes, and chapters TLHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system bass not been reviewed for the code requirements set forth in chapter TLHR. 82 or in chapters TLHR 50 -64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or if a sanitary permit, is obtained, plan approval will. expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be. made. All permits required b. the city, village, township or county shall be obtained prior to Installation. Iizquiries should be directed to me al the number listed below. Please refer to the plan number shown above. Sincerely, enn-Is gorenSon Wastewater Specla.list. Section of Private Sewage ( 608 ) 785-9336 SHOA.7e97 (K. 14M) i Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM Safety and Buildings Division t`a'bor and Human Relations REVIEW APPLICATION Bureau of Building Water Systems Hayward Office La Crosse Office Madison Office Shawano Office Waukesha Office 209 W 1 st Street 2226 Rose Street 201 E. Washington Ave. 1340 E. Green Bay Street 401 Pilot Court, Suite C Rt 8, Box 8072 LaCrosse, WI 54603 P.O. Box 7969 Suite 300 Waukesha, WI 53188 Hayward, WI 54843 Phone (608) 785 -9334 Madison, Wf 53707 Shawano, WI 54166 Phone (414) 548 -8606 Phone(715)634 -4804 Fax(608)785 -9330 Phone(608)267 -5119 Phone(715)524 -3626 Fax(414)548 -8614 Fax(71 - Fax(60 - Fax(715)524 -3633 INSTRUCTIONS: To save time, schedule your review with one of the offices listed above prior to submittal. Fill in all applicable data and submit this form together with fees and plans /information. Your submittal must be received at least one working day prior to the appointment at the office where your review was scheduled. Please call any of the listed offices if you need help filling out the form or v u ons on what information to submit. PLEASE PRINT VERY CLEARLY. A sample of a completed form is on the reverse side for your refere V t A 4 1 9 1. APPOINTMENT INFORMA - If you have scheduled an appointment, fill in the information requested below to save time: Appointment Date Reviewer Name Plan Identification Number 2. PROD CT INFORMATION If this review is a revision or extension to your existing plan identification number, provide that number here: Project Name City Village ® Town Of: County Project Location GOVT LOT 1/4 114,5 T N R E or 7> / 3. APPLICATION FOR 4. FEE COMPUTATIONS FEE SUBMITTED System Type (check one): System Type 1 (include new and existing tanks) Up To 1,500 gallon septic tank $110.00 ........ IJ6 —_ A El At -Grade 1,501 -2,500 gallon septic tank .................. $120.00 ........ _ H Holding Tank 2,501 - 5,000 gallon septic tank .................. $160.00 ...... . M Mound 5,001 - 9,000 gallon septic tank ...... .. ........ $200.00 ........ N El Non - Pressurized In Ground ((onvenclondil 9,001 - 15,000 gallon septic tank .................. $ 300.00 ....... . I P Pressurized In- Ground Over 15,000 gallon septic tank .................. $ 500.00 ........ O Other: Up To 1,000 gallon dose chamber ............... $ 70.00 ........ 1,001 - 2,000 gallon dose chamber .......... .... $ 80.00 ........ Building Type (check one): 2,001 - 4,000 gallon dose chamber .......... _ ... $100.00 ........ 4,001 - 8,000 gallon dose chamber ............... $120.00 ........ D ® Dwelling, 1 or 2 Family 8,001 - 12,000 gallon dose chamber ............... $140.00 P Public Building Over 12,000 gallon dose chamber ............... $160.00 ........ S State -Owned Building Up To 5,000 gallon,holding tank ................ $ 60.00 5,001 - 10,000 gallon holding tank ................ $100.00 ....... . Code Derived Daily Flow :V_S ) 9pd Over 10,000 gallon holdinQtank $150.00 Check If Replacing Existing System Experimental System (additie fee) .... $ 300.00 ........ Revisions ToA proved N1;Z" .. .. . S 60.00 ........ Petition For Vari146Setbacc S . ............... $100.00 ........ El Petition For Variance Y�Sva ati�C...... .... $225.00 ........ Plu �/............ $ 225.00 ........ ReS .. .......... ... $ 75.00 ........ Groundwater Monitoring roundwater Monitoring - Per Site .. �............ $ 60.00 ........ g (other than a proposed subdivision) Site Evaluation in Lieu of Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring $ 60.00 ........ Subtotal: ......... �o Priority Review: Enter same amount as Subtotal: ........ Afd ` MAKE ALL CHECKS PAYABLE TO: SAFETY AND BUILDINGS DIVISION Total Fee: ...... �p 5. SUBMITTI PARTY INFORMA Telephone No (include area code & extension) Compa Name Con ct ers t� f /S r No & Street Address Or P O. Box _ City, T wn or age, State, lip C de I Aerobic or prepackaged treatment system fees are calculated based on equivalent size septic tanks and dose chambers. 2 Revision fees are not applicable to temporary holding tanks or extensions to existing approvals NOTE: Fees are pursuant to Wis Adm Code, Chapter ILHR 2, and are subject to change annually. The information you provide maybe used by other government agency programs (Privacy Law, s. 15.04 (1) (m)). SBDW -6748 (R. 09/94) OVER ��► / f 9 WORKSHEET - MOUND SYSTEM DESIGN PROBLEM: Design a mound system fora The site characteristics are. Depth to groundwater or bedrock —_27 in. Landslope .� % Percolation rate . �� ✓�'� n. Distance from dose chamber to distribution system ft. Elevation difference between Dump and distribution systern - J0 ft. Step 1. WASTEWATER LOAD s • /S�,gd — Sal. Step 2. SIZE THE ABSO VTION AREA -? 75 A) Area required B) Bed or trench length (B) ft. C) Bed or trench width (A) ft. -D) Trench spicing (C) WasteNa ter load .24 coal /ft /day B ft ` �t re � c ems Step 3. MOUND HEIGHT A) Fill depth (D) - ft. B) Fill depth (E) - D + slope (A -��%' ft. / "/ ) --= /,J C) Bed or trench depth (F) a �t. D) Cap and topsoil depth (G) - 1 ft. E Capq top depth (H) - � ft. 12 l r of Jd Step 4. MOUND LENGTH 8 ' 95 - 41219 A) End slope (K) ■ �D,+ E \ + F + H x 3 = ft. B) Total mound length (L) B + 2(x) _ ft. Step 5. MOUND WIDTH Al) Upslope correction factor ■ _� A2) Upslope width (J) (D + F + G)(3)(factor) _ , ft. I J 831- /) �3) 6 gel) yss� B1) Downslope correction factor 82) Downslope width (I) _ (E + F+ G )(3)(factor) ft. (i,-,2 t, Y -?�-�)f3j « �O,3 � Cl) Total mound width (W) for bed = J + A + I ■ ft. X30 C2) Total mound width (W) for trenches ■ (no. trenches -1)(c) + A + I = �- ft. Step 6. BASAL AREA A) Infiltrative capacity of natural soil gal. /ft 2 /day B) Basal area required ■ wastewater flow = natural soil infiltrative- capacity = sq. ft. 2, C1) Basal area available for bed for sloping sites ■ sq. ft. C2) Bas are avail le for trench for sloping sites ■ B W �J +A = �) sq. ft. C3 Basal area available for trench or bed for level Sign: �s f ■ x W ■ sq. ft. Liconse Wu: Date: - 2-- —2 ` r 895 ®41219 Step 7. DISTRIBUTION SYSTEM 7A) SIZE DISTRIBUTION SYSTEM 1) Hole size = in. 2) Hole spacing = in, 3) Distribution pipe length y ':tk 4) Distribution pipe diameter ._ in. 5) Spacing between distribution pipes , ) in. 6) Distance from sidewall to distribution pipe in. 76) DISTRIBUTION PIPE DISCHARGE RATE ,,6_ ft. 1) Number of holes per pipe 2) Flow per pipe GPM 7C) SIZE MANIFOLD 1) Manifold is central / _ end 2) Manifold length 3 ) Numbl er of distribution lines a � ? 4) Manifold diameter ? in. 7D) SIZE FORCE MAIN 1) Minimum dosing rate GPM 2) Force main diameter = in. 3) Friction loss 3 3,27 ft. 7E) TOTAh DYNAMIC HEAD 1) Vertical lift = , 6 ft. 2) Friction loss 3"-7 ft. 3) System head 2.5 ft. s �- ft. 4) Total dynamic head /S; ft. n:_/ 1,icer8 qsr- of S%'95 7F) PUMP SELECTION 1) Pump selected will discharge 1e GPM at 1 ft. total dynamic head. 2) Pump model and manufacturer 7G) DOSE VOLUME 1) 10 times void volume of distribution lines gal. /cycle /�4'Y( -2) /,2, 81 //a ; h?�: 2) Daily wast water volume = 4 doses /24 hrs. _ /1 ," gal. /cycle 3) Minimum dose volume ��-;2 gal. /cycle 7H) DOSE CHAMBER 1) Minimum capacity required = szo- nog, l gso gal , Lici;nzo I;u:_ ? __ Date: 9 5"41219 0 i I h A! J_Z9 i l . Page / Of . r Straw, Marsh Hay, Or S95 "41219 \� Synthetic Covering Distribution Pipe Me um Sand H G � ~ - -- a NI Topsoil – _� 1 D $ Slope Force Main Plowed Layer Bed of Aggregate Cross Section of a Mound System Using A Bed For The Absorption Area D E /, Ft. F sjs Ft. A Ft. G /,p Ft. B _ Ft. i - : H Signed: K /l},s Ft. L 9 Ft. License #: J 7 _ Ft. I _ Ft. Ft. Date: r Alternate Position of . Force Main ....� .. ., ...... 1 :1. I L I J Observation Pipe _ B Imo--- K - -► -------- -- - --- - -- 1 I� ----- ------ - - ---- ---- - - - - -- A I , Forc Main W 47 ----------- — Distribution Pipe Bed of h " -2� Aggregate Observation I Pipe Permanent Marker Plan View of Mound Using a Bed For the Absorption Area PA9e Of .1. S95" 41219 Perforated Pipe Detail n nd View Perforated End Cop PVC Pipe a�e`opa Holes Located On Bottom. s Are Equally Spaced R S Q PVC Force Main 7 Alternate Position Of Dislrib lion Force Main Pipe Lost Hole Should Be Neat To Eno Cap End Cap Distribution Pipe Layout p,_ Ft. R -?e /' S 36 „ X : Z Z ' Inches Y.. 7` Inches Si ned: Hole Diameter Inch 9 Lateral is Inches) License Nuraber, Manifold " ' Inches Date: 9'�,,_ ;,�.;� Force Main 11 r _Inches L # of holes /pipe �.: Ft Invert Elevation of Laterals -93 . b b t c w Y � O=j A J'. q ; q 44 ` a j C: w W aw - ,\4 o 1� N � 4 w O = . V1 '� C U d N N � y C � d V 0 + U J b E a a ? AGE • PUMP CHAMBE CA055 SECTION AND SPECIFICAT(ONS 5 - 412 19 VENT CAP `I VENT PIPE i,( EATHERPROaF' - APPROVED LOCKING 1 MANHOLE COVER 'VITA � 25' FROM DOOR, JUKICT O 80X W14DOW OR FR ESN IL*MIU. WAA►JING L.AML AIR INTAKE GRADE 18'MIU. COKIDUIT - ---- MILE 7 ., r.'�;1 PROVIDE' - -- ! AIRTIGHT SEAL APPROVED JOIfJT I ':' i (( APPROVED JOIWTS ' 3 " `, y I ( W/ ' PIPE ',J/ PIp '�J - ';' ( (� I E%TEIJDIIJG 3' EXTENDI'f,SG 3 N O: ^ ALARM a ;� v� I ONTO SOLID SOIL OUTO SOLID S OIL . - (�,� s Om r � PUMP —� � OFF r z[' CO►JCRETC DLOCK - RISER EXIT PERMITTED OIJLy IF TAQI( MMlUFACTURE.R HAS SUCH APPROVAL. 3" /}pPRoVFcZi 6EDDItvG ur�dcr Trti�K SEPTIC E SPEC. IF) CATIOUS .Al DOSE TAIJKS MAWUFACTURE:R: �LL WMBER OF DOSES: PER DAU TA UK SIZE: ` � GALLOWS DOSE VOLUME _ ALARM MAIJUFACTUREK: IMCLUDINCG DACKFLOW: �� -� GALLONS MODEL IJUMDER: Z/2 CAPACITIES: A= _ INCHES OK GALLOWS SWITCH TyPf: —!.l �? u e a _ INCHES OR , GALLOWS PUMP MAIJUFACTUREK: J r -- JUCHES OR Lys . GALLOU MODEL MUMDEK: ? �V� I � s� /I-� �i�� D- INCHES OR _11sa— GAlLO1J5 SWITCH TYPE: L_.,L MOTE: PUMP AMD ALARM ARE TO OE MI►JIMUM DISCHARGE RATC. Gi , ! - �2? rrm INSTALLED OW SEPARATE CIRCUITS VERTICAL DIFFEKENCE 6ETWEEJJ PUMP OFF AKIO DISTRIBUTIOM PIPE.. 1 4" ) FEET + MIJ,JIMUM KIETWORK SUPPLY PRESSURE . . . . . . . . . 2.5 FLET3 .} z0 FEET OF FORCE MAIN X Z c2lL!/p�rT.FRICTIOU FACTOR.. -2-27 FEET TOTAL Dy►JAMIC. HEAP — - FEET IUTF -RUAL DIMEWSI qui OF TA : LEWGTH J iWIDTH •LIQUID DEPTH i `' LICiJSE NUMR: s�% SIGWE D: E - BE DATE: . • . �'erformance u ! n P u mps �- el" CU rV es METERS FEET S `-' 5" 41219 90 MODEL 3885 25 SIZE 3 14" Solids w WE15H u7y 70 = 20 WE10H i 60 1 -11 1 O WE07H F- 15 50 40 WEOSH �I���SkJ ?2S� 10 WE03M 20 WE031 5 10 0 0 0 10 20 30 40 70 80 90 100 110 120 GPM I I 0 10 20 30 m'/h CAPACITY �GOULDS PUMPS, INC, 58rECJ+ X115 r�ttiv tiO�c :)�a�. METERS FEET 120 MODEL 3885 35 SIZE 3 /4 " Solids 110 WE15HH I i 100 30 90 25 80 70 S 20 60 O F- 15 50 WE05HH ' 40 tp 30 20 5 I 10 0 0 0 10 20 30 40 50 60 70 80 90 100 110 120 GPM I. t 0 10 20 30 m'/h CAPACITY 6 1985 Goulds Pumps, Inc. EltectivwJuly, 1985 C)8R� Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page -4 of Labor and Human Relations givi0ora of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inc in size. Plan must include, but not limited to vertical and horizontal reference point (B i n f slope, scale or PARC dimensioned, north arrow, and location and distanc h APPLICANT INFORMATION PLEASE PRI INRRM�10 REVIEWED BY DATE PROPERTY OWNER: t ,� P TY LOCATION s I , � ` -A � °� G OT Ij 11 1/4,S T 3f N,R E (or) W PROPERTY OWNERS MAILING ADDRESS U L B CK # SUBD. NAME OR CSM # 1 ' :t, G2Q_, i�, CITY, STATE ZIP CODE ( N � BER 0% � [:]VILLAGE „MOWN NEAREST ROAD New Construction Use Residential / Number [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow - > gpd Recommended design loading rate /, bed, gpd /0 -- trench, gpd/ft Absorption area required a >; bed, ft -� ` trench, ft Maximum design loading rate Z bed, gpd /ft Z _.2 trench, gpd/ft Recommended infiltration surface elevation(s) L ft (as referred to site plan benchmark) Additional design / site considerations Parent material , , & �n4 h,& Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ❑ S R U 0S ❑ U ❑ S W U 1 ❑ S O U ❑ S ® U [I S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Ground elev. ft. Depth to limiting factor Remarks: Boring # .0 \:•} 1,C AIP 1 0 Ground elev. �,Qft. Depth to limiting factor Remarks: CST Name: — Please Print Phone: A ddress: Signature: Date: CST Number: PROPERTY OWNER �J SOIL DESCRIPTION REPORT Pageof 3 PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench \... `4 Ground ssc'G � elev. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) Wisconsin Department of Industry, SOIL AND SITE EVALUATION REPORT Page of fib& and Human Relations Division of Safety 8 Buildings in acgrC�,ltvlt�,ILHR 83.05, Wis. Adm. Code ll 55 - 4121 COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must inc ude, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARC I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION– PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION s GOVT. LOT A l j j 114 1/4,S T N,R E (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # B CK # SUBD. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER ❑CITY []VILLAGE „MOWN NEAREST ROAD MA New Construction Use Residential / Number of bedrooms [ ] Addition to existing building j J Replacement [ J Public or commercial describe Code derived daily flow °) gpd Recommended design loading rate ' bed, gpd/ft gpd /ft Absorption area required li bed, ft2. ?7-1– trench, ft Maximum design loading rate ,r� bed, gpd /ft trench, gpd /ft Recommended infiltration surface elevations);. ft (as referred to site plan benchmark) Additional design / site considerations Parent material lr;;2 ,,,ate. l A� „�,�/ Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem El R U 0 S ❑ U El WU ❑ S O U ❑ S O U ❑ S O U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed I Tmr& Ground 8 -- elev. it. Depth to limiting factor 4 27 i Remarks: Boring # Ground elev. / a ft. Depth to limiting factor Remarks: CST Name:— Please Print Phone: Address: Signature: Date: CST Number: / 731 4x2xs � r 312 3iy r i l3O r PROPERTYOWNER �J - - _ SOIL DESCRIPTION REPORT Page 2 O 'PARc'EL I.D. # S95"4121 Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell Qu: Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench \lA�i \iiiiii<k� Ground s5C'G elev. ' 9 ft. Depth to limiting factor Remarks: Boring # ............... ................ Ground elev. ft. Depth to limiting factor Remarks: Boring # ................ I Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(R.05/92) a r �3 z Ll 3� 9g IIWO / l I T . t STC -105 SEPTIC TANK MAINTENANCE AGREEMENT ,^ St. Croix County OWNER/BUYER 1 =� I'C c � ✓ / /7 Is MAILING ADDRESS �/� /_ PROPERTY ADDRESS CD �( �� S 0L -eu ) v f f ;fz )" G �7 (location of septic system) Please obtain from the Planning Dept. CITY /STATE S . , e e f PROPERTY LOCATION �L� 1/4, 1/4, Section ` T — _�2:/ N -R j2 W TOWN OF S�� o f,;c ST. CROIX COUNTY, WI SUBDIVISION ✓ LOT NUMBER _ CERTIFIED SURVEY MAP L a VOLUME PAG , LOT NUMBE 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. I/We, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: lJ St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 T 4 v S T C - 100 r • This application form is to be completed in full and signed by the " owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. ---------------------------------------------/---------------------- Owner of property �j'�L% ev 1/ L�ciz Location of property 1 1 /4 1/4, Sectio ,T N - R _,& W Township S rnt�'��` Mailing address Address of site ��� o C , i k� j of Subdivision name Lot no. Other homes on property? ,,rr�� Yes � No Previous owner of property AQ6xy Q J4C4 . Total size of property Grc' {.S Total size of parcel Date parcel was created e - 6 1- 9 J5 Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes No Volume k and Page Number as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. S"� z99 " -, and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. Signat e f Applicant Co- Applicant 1 ,)9's Date of Signature Date of Signature FILED g AUG 8 1995 R 2 KATHLEEN H. WALSH L sL JX / CERTIFIED SURVEY MAP Located in part of the NE4 of the SW4 of Section 23, T31N, R19W, Town of Somerset, St. Croix County, Wisconsin. 2�15� WPLA71 TED L^11D- WI /4 CORNER North Line of the SW} of Section 23 ,CENTER OF SECTION 23 _205TH AVE SECTION 23 s90 "w \ S90 W 417.51 ' w 2262.46' w N89 0 51' 40 "W 417 w �— w w W ao 1" Iron Pipe I r i Found I:;0 S00 0 51 1 06 11 E, I —I 0.46' from I < i 1 .. . . . .. ............................... computed IC.) 1 f position. IF" ICn cn J O 0 C) r L I ICi) �'1 I Ti .. LOT 2 '� .P I G rr I —I I N I OD 6.00 Acres Inc. R/W 0 „ I� +l 74 11�) Ln 261,434 Sq. Ft. Inc. R/W OD i IC7 �(J'1 cn ••E• 5.63 Acres Exc. R/W 0) 245,155 Sq. Ft. Exc. R/W - I� p I] W O IU Oil Ln co NJ i w r r (p 7 0 p CD 1 n y a v, 0 !tea O O Tree Occupies Corner o LEGEND 6.67' Aluminum County 410.48' N Section Monument Found S89 "E 417.15' N o0 w � m � d • 1" Iron Pipe Found „ s -. UNIDLAT T ED LAN[) - CA 0 1 x 24” Iron Pipe Set, weighing 1.68 lbs. per a " o linear foot �* o rt - 100' Roadway Setback Line OWNER o CD (0 s M +- ---� Existing Fence Line David M. and Debra L. Helget y � 0 637 205th Street o o a Somerset, Wi. 54025 0 --h rt O N O O SCALE IN FEET o �o O 50 100 200 This instrument drafted by Ed Flanum Job No. 94 -07 VOL. 11 PAGE 2971 _ 1 r State &tr of Wis -nsin Form 2 — 1982 y WAkR,.NTY DEED f� DOCUMENT NO, Val. 1137PA -E 298 1 ! �) to David t 14. Hel and Debra L. Hel get, husband A AL� 2 8 1995 - r — I' 10:00 A. i '? conveys and warrants to _ GreQOry J. Hustad { # THIS SPACE RESERVED FOR RECORDING DATA it NAME AND RETURN ADDRESS �CPC:, CtA-1,o the following described real estate in SC Croi t S O t-r- (ems County, State of Wisconsin: !! CCU M li (Parcel Identification Number) Part of NE1 /4 of the SWl/4 of Section 23, Township 31 North, Range 19 West, , Town of Somerset, St. Croix County, Wisconsin, described as follows: Lot 2 of Certified Survey Map filed August 8, 1995, in Volume 11 of Certified Survey ; Maps, Page 2971, as Doc. No. 532271. (1 �i ? w ,� r it This is not homestead property. X)= (is not) Exception to warranties: Easements, restrictions and rights -of -way of record, if any. I I, Dated this 5 day of August 19 95 (SEAL) r (SEAL) . David M. Helget f �t (SEAL) (SEAL) �f Debra L. Helget AUTHENTICATION ACKNOWLEDGMENT l SignatRre(s) STATE OF WISCONSIN ss. ?( St. Croix County. I authenticated this day of ' 19— Personally came before me this day of 1 95 the e n med Davi Helget )ra Oe - L. gel husband aw wire, TITLE: MEMBER STATE BAR OF WISCONSIN !f f (If not, i? a•nhorized by §706.06. Wis. Stats.) to me known to be the person S who executed the �{ Connie M . C] i ru ent and acknowled.e t same. l THIS INSTRUMENT WAS DRAFTED BY Nota Public ` � •..� � Krist Ogland Stat of Wi sconsi n _ at Law Notary Public t _ county. Wis. i (Signatures may be authenticated or acknowledged. Both are not My commission is permanent. (If not, state expiration date: �J ;1 necessary.) co 199.) �I •Names of persons signing in any capacity shtwld be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSL`t Wisconsin legal Blank Co.. Inc- , FORM No. 2 —1992 Milwaukee. Wis. j'� ,\ \ / o & \ o \ ( \ G . \ � 00 � � S k \0 / '[ io / 0. x j g\\ ; \ \ /\\ � 2 a ; k \)o < @ \ � z ; j \ \ \ A } § IL c � ) � . \ k A F- { 2 ° & \ \ \ / / / \ D 3 \j\ § z z ) z i « � 04 k k ƒ I ®' °- � I « $ 7 t ° § B o a ` § b Z N > E o - w i� \ E / a E � o j \ § \ \ \ \ r = Z ƒ . / Q \ \ /_ \ < ° \ / $ c § 0 g # » e ] or- ~ 2 § \ \ a 7 ] m S a CL 9 6 a o c §; 7= e (o f « a n \ \ ° 2 ¥ 2 \ ] 8/ f 0§± c e® - k@ 3 2 C o z/ k\ \ « � ® ( \ L E 7 {\ k a k /\ a 2\ d k 3 N 0 � s� �o � U1 N I LLn `U] •�p� N 4J U1 Z t x� a z 0 § 01 ■ ' 0 c CD k - ) \ 2A r M m - \ k } =r \ E -4 E . m • o \ z k d ) o$\ 2 el § k J k ` In a o « g m ® e _ / f / / % .. _ \ co _ ƒ � ' 0 kk§ � ® @ e % / § ) § § o c � � CJ' � 2 z 0 \ a % ' < z Oro 4 ■ ■ ■ I % > § j / ° \ c. ` a 7 2; 1 - ; to § 7 � \ / § 7 I a c } CD ' � \ . } $ _ ■ , z $ { ■ § q � � E § / 2 0 ® co z % k kG\ 0 § i CD n /k/ C &k/ � k2 � \/ / 2 % §» 1 t CL CD \f % D $ 7 / % \ o / CD \ -0 �tj � \i � �\ Parcel #: 032 - 1061 -60 -120 05/11/2005 09:43 AM PAGE 1 OF 1 Alt. Parcel #: 23.31.19.311 D 032 - TOWN OF SOMERSET Current Xi ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): " = Current Owner JAMES J & DEBORAH SAIKO " SAIKO, JAMES J & DEBORAH 641 205TH AVE S SOMERSET WI 54025 Districts: SC = School SP = Spe ial Property Address(es): ' = Primary Type Dist # Description " 641 205TH AVE SC 5432 SCH D OF SOMERSET SP 1700 WITC Legal Description: Acres: 6.000 Plat: N/A -NOT AVAILABLE SEC 23 T31 R1 9W PT NE SW BEING LOT 2 Block/Condo Bldg: CSM 11/2971 6.00AC EZU- 1163/213 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 23-31N-19W Notes: Parcel History: Date Doc # Vol /Page Type 09/29/2000 630846 1546/550 WD 07/23/1997 1137/298 WD 2005 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 07/14/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 6.000 63,000 171,300 234,300 NO Totals for 2005: General Property 6.000 63,000 171,300 234,300 Woodland 0.000 0 0 Totals for 2004: General Property 6.000 63,000 171,300 234,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 134 Specials: User Special Code Category Amount i Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code ' COUNTY • Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but St. Croix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 032- 1060 -60 -120 APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPERTY OWNER: PROPERTY LOCATION Merrill G. Oestreich T SE 1/4 NE 1/4,S23 T31 N,R 19 XXor)W PROPERTY OWNER':S MAILING ADDRESS LOT # BLOCK # SUBD. NAME OR CSM # 8861 Ideal Ave. N. 3 na 3 06A- csm W148 CITY STATE IP Cp PHONE NUMBER []VILLAGE MOWN NEAREST ROAD Mafttomedi, MN. 5 115- 10 512 )426 -5320 So 205th. Ave. New Construction Use ix Residential / Number of bedrooms 3 to existing building Replacement Public or commercial describe `� i 1 p [ l ., Code derived daily flow 450 g pd Recommended d loadir bed, ` 2 • trench, gpd/ft Absorption area required 900 bed, ft2 750 trench, ft Maximum d � loading rate • led, gpd • 8 trench, gptift Recommended infiltration surface eievation(s) 105.18 " ft (as referred to site plan ben ark) Additional design / site considerations na - Parent material outwash ; plain elevation, if pp li]g6 na it S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem ®S 0 I ®S OU ®S ❑U I ®S []U []S ®U I ❑S ®U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bouncl3ry Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench h 1 0 -10 10yr3 /3 none sl 2msbk mfr cs if .5 .6 4< ° 2 10 -21 10yr4/4 none sl lmsbk mvfr gw if .4 .5 Ground 3 21 -45 7.5yr4/4 none co s Osg ml gw na .7 .8 l i 10 4 45 -84 10yr5 /4 none f s Osg ml na na .5 :.6 Depth to limiting factor +8 Remarks: Boring # 1 0 -10 10yr3 /3 none sl 2mgr mfr cs if .5 '•..6 2 2 10 -30 10yr4 /4 none 9 lmsbk riir na MEAN, 3 20 -90 7.5yr4/6 none f s Osg rnvfr na na .5 .6 Ground elev. 1 Depth to limiting factor +9 Remarks: CST Name :—Please Print Phone: Gary L. Steel 715- 246 -6200 Address: 1554 200 . Ave. , New R' hmond, WI. 54017 Signature: p� t� T": 6 -9 - 94 cs m PROPERTY OWNER Merrill G. Oestreich SOIL DESCRIPTION REPORT Page 3, PARCEL I.D. # 032 - 1060 -60 -120 ' Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundery Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ITrench 1 0 -10 10 r3/3 none 1 2m r mfr cs if .5 .6 03 <` � . 2 10 -50 75 r4/6 none co s Os ml na .7 .8 Y g Ground 3 50 -96 10yr5/4 none f s Osg mvfr na na .5 .6 elev. 10 Depth to limiting factor +96 Remarks: Boring # 1 0 -7 10yr3 /3 none sl 2msbk mfr cs if .5 ':.6 t'= 4 2 7 -48 7.5yr4/6 none co s Osg ml gw na .7 .8 3 48 -80 10yr5 /4 none f s Osg mvfr na na .5 .6 Ground elev. 108 ft. Depth to limiting factor +8 Remarks: Boring # 1 0 -12 10yr3/3 none sl 2mgr mfr cs if .5 ` . 6 v:•ti•.ri \.4: 5 2 12 -80 7.5yr4/6 none 1 fs Osg mvfr na na .5 :.6 ee G l round 10 Depth to limiting factor +80 Remarks: Boring # ..iii \: ?i........ Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(R.05/92) STEEL'S SOIL SERVICE Gary L. Steel Merrill G. Oestreich 1554 200th Ave. CSTM2298 SEQNE4 S23- T31N -R19W New Richmond, WI 54017 MPRSW 3254 town of Somerset (715) 246 -6200 t N 1 " =40' BM= top of SW lot stake at el. 100 CY 1 Q0' All q 7 �v 214 Gary L. Steel 6 -9 -94 ); o . ' ,:ors:, Department of Industry, SOIL AND SITE EVALUATION REPORT Pa / of 3 ,� analuman Relations 0 Division %%'Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY teach =omplete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but IS _/ not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATIO (/h CGtq � EVIE 8Y DATE PROPERTY OWNER. W PRO ��� L GOVT. L T 1/4 S , 4,SZ PROPE TY OWNER':S MAILING A R SS LOT # OCK # SUBD. NA OR ( U�7 CITY, TATE ( E . 4( - ZIP CODE PHONE NUMBER OCITY []VILLAGE ®TOWN AREST MOAD o1'i z W S 9.. ASS S A-r'E Z O S -51 New Construction Use [ Residential / Number of bedrooms Addition to existing bui [ ] Replacement Public or commercial describe Code derived daily flow - ?C0 gpd Recommended design loading rate • S bed, gpd/ft trench, gpd/ft Absorption area required Z s o bed, ft Z 50' trench, ft _ Maximum design loading rate __ L 5 bed, gpd 1ft trench, gpd/ft Recommended infiltration surface eievation(s) l o/ s fl (as Feler, ^cu to site plan be c i„-BT;) Additional design / site considerations . ✓at- Parent material N A Flood plain elevation, if applicable IVY- It S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem i CIS ,®U 9S ❑ U I ❑ S ZU 1 ❑ S rav O S Is'U ❑ S U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed Tmnch : Ground 3 - 3 L 7 - 5" P4 (11 z vvl ,. YK f/4 Co elev.�- s Depth to limiting factor 3L'� Remarks: Boring # s K Ground 45- 32- 7� �,•L � e 5c- z rvl std / VYl `�i2- c� l S elev. 5;�!� 3�- 1 & 7- A/ &4v W 9, (�zpsyrzslz c. Depth to 5 5S 7� S i 2 �l —Via limiting: tF factor e I Remarks: CST Name:—Please Print / I Address: ZDJ'k`= Signature: Date: ^ 19 3 1 CST Nu PROPERTY OWNE fr 61145 6-ti g SOIL DESCRIPTION REPORT Page X-- of PARCEL I.D. # Boring epth Dominant Color Mottles Texture Structure Consistence Roots GPD /ft, g # Horizon Y in. Munsell Cu. Sz. Cont Color I Gr. Sz. Sh. I I ! Bed Mwch �.3... 0 fl q( 0� 2 v✓�S(�4 C Zrn . Ground "7 b � / � d "V6( S ✓ YVl ✓ l I , (� e g �z P SY� s/z 5 V 6 Depth to limiting Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(R.05/92) • STEEL'S SOIL SERVICE ass- j zoo* Avc ,- . Gary L. Steel C.S.T. 2298 � N �/ o A _ I SO m L . New Richmond, WI 54017 MPRSW -3254 / 1 V I ' (715) 246 -6200 ovcy�.5k)Y� W ✓1 o P P 1 A+Ca L. l00' �qo O rA 4 37 , 3 � ^, 2,LFy S E, e FILED � � � k 8 AUG 8 1995 1► ? AUG L 6 VATHLEEN H. WALSH L M I T O M S ST. CR OIX COUNYY c�� SURVEYOR'S RECO 5322'71 CERTIFIED SURVEY MAP Located in part of the NE4 of the SW;a of Section 23, T31N, R19W, Town of Somerset, St. Croix County, Wisconsin. 0-1 ij- I UNPLA T Eu 1 Ar1�� W/4 CORNER North Line of the SW of Section 23 CENTER OF SECTION 23 205TH AVE CSECTION 23 s9000o'oo "W S 90 W 417.51 ' w w ' 2262.46' � — — — (A — N89 ° 51' 40 " W 417 w w W . aD Iron Pipe Ir Found I� S00 ° 51'06 "E, 1 - 1 0.46' from I` i� _ . . ............. computed I j position. I co cn O Z N i� U O I� I L 0 Ir IU IZ LOT 2 I< I_ irri CD 6.00 Acres Inc. R/W Ln � Ir�l 261,434 Sq. Ft. Inc. R/W - co IC7 I 5.63 Acres Exc. R/W 0) 245,155 Sq. Ft. Exc. R/W 1i Ir N ti I> I� p 11 -' I I> W i O Ip OD N Ln CD o m .X 0 ' it y a m p m Ctrs O 4* �_i M O O Tree Occupies Corner o L EG, GEND 6.67' Aluminum County O 410.48' Section Monument Found S89 "E 417. N = m ' w o fe • P Iron Pipe Found UNIDLA I I LD LAN[) y r O 1" x 24" Iron Pipe Set, --- - - - - -- - - - -- : j• fn W Lo weighing 1.68 lbs. per a o linear foot o -� S �f ••••••••• -- 100' Roadway Setback Line OWNER , - Existing Fence Line David M. and Debra L. Helget vs W 637 205th Street '.0 o 0 Somerset, Wi. 54025 0 �" f•r t O to O ft SCALE IN FEET O n ff S �+ s 0 50 100 200 This instrument drafted by Ed Flanum Job No. 94 -07 VOL. 11 PAGE 2971 SEPTIC TANK MAINTENANCE AGREEMENT F T. CROIX COUNTY CEIV® AND OWNERSHIP CERTIFICATION FORM 0 2010 Owner /Buyer L �� d P /� CROV COUNTY Mailing Address f 206 A � Property Address (4 1 265 P (Verification required from Planning"I& Zoning Department for new construction.) City /State S e rAc CSe _k - L Parcel Identification Number 0 Z- /0 (ol - (o - /Z O LEGAL DESCRIPTION Property Location 1) 0 '14, Sec. T 31 N R 19 W, Town of 56mcf5e4 Subdivision Plat: ) Lot # Certified Survey Map # 53 "22 - 71 , Volume , Page # 2 971 Warranty Deed # q1 G'-4 (before 2007)Volume Page # Spec house ! yes no Lot lines identifiable -_' yes i 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 ( 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. 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 arn/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number o b oms :5� SIGNATURE OF APPLICANTS) 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)