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HomeMy WebLinkAbout032-2099-90-000 I C) N Q 0 Cn Q T O d 0 r 0 V I ~ O k .C. �.' co m A I I 3 o m 00 °' as << m° c0 X N C ' cD A� -' CD_ - - C Rs G7 O ~ 3 cn o s c G) G) W N � O O ^ 0 cl) N 0 � o o� "4 d w C07 > o a O 2 O ° _ (D i A 3 a N 7 N O) 3 O O tD CO N O C N C o f w C O !r cr D a rn m r v y A a c CD a m u w o n ci N ( o o C/) I w O W ! (� o - h } 00 CD OD O L (T N (n II z (!� A O CO CO O M o O 3 n r N I ° c-0 �3 l w CD D o m ';� N o c CD l a C c CD N j O O O m l o z a O O O �• p r2 A o O D �c r L 2 Ul o 6 0 N N N n O� N N N o CD 7 g o N ^� 3 Q 'C fl V7 n A N U O O� (D . y �: N I � 4) nN+ CL 3 z 3 Z z co z ° D m z O O ° ° n CD O o s r+t • CD m m m CD � N N I m I ° y C (D » a C N ( D C (D a W c a 3 O 7 O z O A ? C1 O N C N C X .' n m a z 3 I 0 Cn -i N W m I W m 0 3 c 3 A z 3 I 3 * co z co y �! 7U CD o W A pj CD co � a 3 CD C 0 m v T I m a v c 0 n a C N CD 7 a o a I w o a ° F (D (D 0 I fD o o 3 °_ r CD m s I o_ 3M a aw I s a Z I a CD w w I o o w I F o v 0 0 CD w as O sn O o 0 o m o CD �? a o o a I Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 399573 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: LeRo , John I Somerset Township 032 - 2099 -90 -000 CST BM Elev: f Insp. BM Elev: BM Description: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Bench rk �� Cis t Pr bµ-4 &C . (� 9 3 -�• B!osir ` Z � � Alt. B Aeration (� Bldg. Sewer S'E'A Holding St/Ht Inlet *- 1 .38 I,o� TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic I=WMA *,o I A , r ` Dt Bottom ENV Doeft S Header /Man. L D� >tOV, 3� Aeration Dist. Pipe 9 x`31 O. Holding Bot. System •.S PUMP /SIPHON INFORMATION Final Grade Manufacturer Zemand St Cover G Model Numb i yr}- '�.,3q p( 1Z TDH Lift riction Loss System Head TDH Ft t*+ t Force Length ��Dlstll SOI L B PTION SYSTE is B (TRENCH wMth Length , No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DI s 2- SETBACK SYSTEM TO P/L JBLDG IWELL LAKE/STREAM LEACHING Manufacturer. INFORMATION CHAMBER OR -SA w "IL- Type Of System: �' �r y � s • ✓ UNIT M Number. µ e DISTRIBUTION SYSTEM p' Header /M ifold u Distribution x x Hole Spacing Vent to Air Intake Pip „ 2 1 1-angt Dia Length Dia pacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded Mulched Bed/Trench Center Bed/Trench Edges Topsoil [in] Yes [] No T ❑ Yes ❑ No COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: D ( Inspection Location: 1962 62nd St Somerset, WI 5402 (Unknown 26 T31 N R19W) Pinecliff Lot 9 Parcel No: 26.31.19.954 1.) Alt BM Description 2.) Bldg sewer length = O - amount of cover = ' Plan revision Required? ❑ Yes No S� Use other side for additional information.• Zl fiD Date Insepctoes Signature Cert. No. SBD -6710 (R.3197) ------ - ^ safc(y and 13uildin6s Divisi County 201 W. Washington A P.O. Box 7162 4, Madison, W1 53707 - 7162 site Address Nvi sconsin De ent of Commerce Sanitary Permit Application Sani _ t mbe 7�3 In accord with Comm 83,21, Wis. Adm, Code, personal information you provide ❑ Check if Revision may be used for secondary purNses Phy cy Law, 05,04(1 m) 1, Application Information - Please Print All Information State Plan I.D. Number Property Owner's Nam Parcel Number Property Owner's Mailing A&rrss REM t U Property Location 91,V 42 A) 14 'A; T ?J N. R jq City, SLJLC zip CWC r Wi QWuMbcr,/IjUj Lot Number Block Number ST GROI rn X 7 4§__ Subdivision Name CSM NuLcr COUN' ZONING OFFICE U. Type of Building (check all that apply) Dory ,0 1 or 2 Family Dwelling - Number of Bedrooms . ...... ❑valage ❑ Public/Comincrcia) - Describe Use 0TOWTIShip ❑ State Owned Nearest Road _ �,40 M. Type of Permit: (Check only ox on line A (numbering scheme for internal use). Complete line B if applicable) A. 1 ❑ New For County use xni 3 ❑ Replacement o System f 6 ❑ Addition to System ��T�j Tank OnJy [ElxisLiag System B Permit Number Date Issued . Chock if Sauitaxy Permit Pmyiously Iswed IV. Type of Permit: (Check all that apply)(numbering scheme is for internal use)-t: A­f . 44 R Non -Pressurized In-Ground 21 Mound 47 ❑ Sand Filter 50 ❑ Constructed Wetland 22 ❑ Pressurized In- Ground 41 ❑ Holding Tank 48 ❑ S41C Pass 51 ❑ Drip Line 45 ❑ At-Grade 46 ❑ Aerobic Treatment Unit 49 ❑ Recirculating 30 C3 other V, Dispersal)Treat ent Area Information: Design Flow (gpd) Dispersal Area Dispersal Area Soil Application Percolation Rate System Elevation Final Gr2dc Required Proposed KAtc(Gals-/Days/Sq.F(.) (Min./Inch) Elevation '42 V1. Tank 111170 Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Tanks Concrete Constructed Glass New Existing Tucks Tanks Septic or Holding Tank ==gk I�J VII. Responsibility Statement 1, the undersigned, e responsibility for installation of the POVM shown on the attached plans. Plumber' Name (print) Plumber' Si NQIMPRS Number 7 , Business Phone Number / I 3 _ (Street, F_PT&bc_f City, State. Zip Code) a VIII, County epartment Use Only Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued AgoaL Signature (No Stamps) Surcharge Fee) O Owner Given Initial Adverse _L2clerminaiion 10 IV Conditions of Approval/Reasoms for Disapproval 0-4 Attach complete plant (w the County only) ror the rmew oa paper no( kw U&aa 814 X 11 1"hes in dac SBD-6398 (R, 05/01) lj r ,L2, / r 6" r 9-� � A 6 V l 14 J //, iCJ KJ�/'� /i If IC .S �i�J'7C � ,Y - ,E".r .s�i✓� /ZdOd�q,� � �/z,t �S b��xr , 9 � Q 6 ,?x17,18 Wisco;isin Department of Industry SOIL AND SITE EVALUATION W or acid Human Relations Page of 1 %6ion of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # / APPLICANT INFORMATION - Please print all information. Reviewed by P 6 7 ersonal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). S- r Property Owner Property Location*+ i - + Govt. Lot `. 1/4 1 /4,S T ;f0 ^;(br)� i Property Owners Mailing Ad re Lot # Block# Subd. Name or CS vi / ' 7 ; � v i City State Zip Code Phone Number Nearest Road ( ) El city �❑ Village Town fi 5� a7 New Construction Use: ® Residential / Number of bedrooms .4_ Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 4Z— gpd Recommended design loading rate 2 bed, gpd* _L 2 trench, gpd/ft Absorption► area required R S k_ bed, ft 20 trench, ft 2 Maximum design loading rate _ bed, gpd/ —,f — trench, gpd/ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design/site considerations Parent material A-/j tI fs.l 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❑ u m S❑ u ® S u ® S u ❑ s O U ❑ S® u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench C1 6, --- S s-. '- t S Ground s elev. S 8 -ft• Alf - 2 A _ Depth to limiting factor Remarks: Boring # Al - 3 Ground 7 , S' elev. 5S•Sv !•S Depth to limiting factor 5�; in. Remarks: CST Name (Please Print) ' Signature Telephone No. J 7 7 s_ Address Date CST Number i . t Dominant Color Mottles Structure • �M AW- 1 . MM ; Dominant Color Mottles .y �� -yQ ship- •� 1 � t � , � // I , ; AM IiF,7 �,�•c,� x, f POWTS OWNER'S MANUAL at MANAGEMENT PLAN Page _„[_ of,-2 FILE INFORMATION SYSTEM SPECIFICATIONS Owner Septic Tank Capacity al ❑ NA Permit # Septic Tank Manufacturer ,� ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer / ❑ NA Number of Bedrooms 0 NA. Effluent Filter Model _ ❑ NA Number of Commercial Units J9 NA " Tank Capacity gal ❑ NA Estimated flow (average) gal /day Tank Manufacturer _ ❑ NA Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer 2f-NA Soil Application Rate gal/day Pump Model 2� NA Influent/Effluent Quality Monthly average* Pretreatment Unit NA Fats, Oil 8z Grease (FOG) _ <30 mg/L ❑ Sand /Gravel Filter ❑ Peat Filter <_220 mg/L ❑ Mechanical Aeration ❑ Wetland Biochemical Oxygen Demand (BODs) ❑ Disinfection ❑Other: Total Susp Solids ( TSS) <_ 150 mg/L Manufacturer Pretreated Effluent Quality ANA Monthly average ** Dispersal Cell(s) Biochemical Oxygen Demand (BODs) :530 mg /L D� In- ground (gravity) ❑ In- ground (pressurized) Total Suspended Solids (TSS) 530 mg/L ❑ At -grade ❑ Mound Fecal Coliform (geometric mean) <_10' cfu /100ml ❑ Drip -line ❑ Other: Maximum Effluent Particle Size k inch diameter * Values typical for domestic (non - commercial) wastewater and septic tank effluent. * * Values typical for pretreated wastewater. MAINTENANCE SCHEDULE Service Event Service Frequency Inspe condition of tank(s) At least once every ❑ months 0 year(s) (Maximum 3 yrs. ) Pump out contents of tank(s) When combined sludge and scum equals one -third ()i) of tank volume Inspect dispersal cell(s) At least once every _.:F ❑ months 19 year(s) (Maximum 3 yrs. ) Clean effluent niter At least once every ❑ months 0 year(s) Inspect pump, pump controls &alarm At least once every ❑ months ❑ year(s) .0 NA Flush laterals and pressure test At least once every ❑ months ❑ year(s) 0 NA Other At least once every ❑ months ❑ year(s) S NA Other At least once every ❑ months ❑ year(s) Z NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Mastc Plumber; Master Plumber Restricted Sewer, POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspectior must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure th 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 (A) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with ch. NR 113, Wisconsii Administrative Code. The servicing of effluent fliters, 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 certified 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 of the POWTS check treatment tank(s) for the presence of painting products or other chemica that may Impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the content of the tank(s) removed by a senWe servicing operator prior to use, • Pig( of System 4urt up shall not occur when soil con=Qm are frown at the InfllVatave surfWt. During power outages pump tanks may fill above normal higbwater levels, When power is restored the excess wastkw;,trr will t1r discharged to the dispersal cell(s) In one large dose, overloading the cell($) and may result in the backup or surface discharge u effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servking Operator prior to resto power to the effluent pump or contact a Plumber or POWTS Malntalner to assist In manually operacJng the pump controls to restore ncrmal levels within the pump lank, Do not drive or park vehicles over tanks and dispersal cells, Do not drive or park vvvr, or otherwlw diswrb or compact, the area within 15 Net down slope of any mound or at-grade soil absorption arra, Reduction or elimination of the following from the wastewater stream may Improve the performance and prolong the life of c POWTS; antibiotics; ba'vy wipes; clgarettx butts; condoms; cotton swats; degreasers; dental floss; diapers; dWnfecunu; tat; foundation drain (sump pump) water; fruit and vegetable peelings; gasohrw; grease; herbicides; meat scraps; medications; of , Painting Products: oemcldes; sanitary nookins: tampons; and water soMner brine, ARANDONEMENT When the POW75 fails and /or Is permanently taken out of service the following steps shall be taken to Insure that the system j5 properly and safely abandoned In compliance with ch, Comm 83,33, Wiscoruln Admintstradve Codte • All piping to sinks and pits shall be disconnected and the abandoned plpe openings sealed. • The contents of all tanks and plu shall be removed and property disposed of by a Sepuge Servicing Operator. • Aher pumping, all tanks and ulu shalt be excavated and removed or thtlr covers removed and the void space fllied w„r soil, grave( or another Inert solid material. CONTINGENCY PLAN If the POWTS falls And cannot be repaired the following measures have been, or must be taken, W provide a Code compllant replacement system; v A sulubie replacement area has been evaluated and may be utilized for the locadon of a replacement soil absorption system. The replacement area should be proU:cud from disturbance and compaction and should not be Infringed upon required setbacks from existing and proposed strvcwr*, lot (Ines and wells. Faliure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable mp)actment ana, Replacement systems rnust comply with the rules In effect at that time, D A sultabie replacement area (s not available due W setback and /or soil Ilmltatioru. Barring advances in POWTS technology a holding tank may be Installed as a last resort to replace the failed POWTS. ;X The site has not been evaluated to Identify a Suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be prrformcd to locate a suluNe replacement area. If no replacement area is available a holding tank rn be installed as a last resort to replace the failed POWTS, CD Mound and it-grade soil absorption systems may be reconstructed In place following removal of the biomat at the Inflluaclve surface. Rieeonswctloru or such systems nwst 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 TKE INTERIOR Of A TANK MAY BE DIFFICULT OR IMPC1MRI i ADDITIONAL COMMENTS POWTS INSTALL VP, POWTS MAINTAINER Name z c, Z Na me Phone Phone SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORY AUTHOPJTY Name Agency 4 Phnnr r ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the residence located at : � 1/, Sec. , T N, R _1_7 W, Town of _J�i.�er°sET St. Croix County, Wisconsin. Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? Yes�G No (if no, skip next line. Approximate volume or length of time: gallons minutes Capacity: Construction: Prefab Concrete _-A Steel Other Manufacturer ( if known) : Age of Tank ( if known) : - 1/ 9 q7 (Signa IEd re) (Name lease Print (Title) (License Number) (Date) Form to be completed by licensed plumber (s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except fo inspection o ening over outlet baff ) . Name V Signature MP /MFRS < I 10!30 /:U1 TUE 12:47 FAX 7152474225 JOHN A LEROY SE MC TANK r AND a3 owmwi p TM ;A-=?4 F41w �>rop�Y (tira atioa =gWrad � D o ae°'tzwcdao} �y i��' Pared Id+aadfwatiou r4umbar nss A) Lc) Z6 T - I,W� Tvwa . /�, y,, Sac. �. .:a.t,.1`� r7 �f�'�^� G Lot .�.r�.n w Samy Map 0 v0bA a — .,_ - .Par � WKInal #� vob=a a y " , Lot u a a Y a tss'lvtn to box&" e+ 0 o ats anamt3�aaamaeot tyga�QOnWrenaltla.lt: i�� � a aaaaee. itnaod�b7 a UoeoaadPtmoAes: �7�� oaosi� p aad t a ae or t U u a i 0 a yatrt 1a rho wait 4� "Gum � fbt A a t a * +� taakss s t stare a aatdba p wit Eft (m , ai�sd by go awaw sue) by a Papa orates mesa m G"u to St. Q*k z oubw 8sa ar • rioeq�ed P W f 4�+•r •f v `�.i . /1 0 wn G'fr /� ..s,, MM uw4k fo bals as Pdvw $v"P doom 19, systen► Us ban ms1n' taaodt. �` ma a�a� ba oarapiAld sad to ow 8t, t�oix � 0 .rithin o t Ytrac aoptic dop Of tbraeo 7w axpbxdos date• a�Ts A pffc - AM (we) mft a that oa oo this f m are j= to fire bat of aty (cur) lcwW194 0- 1(rvo} so I m) the o. WKS) of Y 4zsar4W vWV%. by VMW of x *=MW decd x MaWd is RCOW at Dealt tllioa. DATE /PPL1t,J►N'r •••••• •••••r My Wfarawti n that is =b4sp =$Ated MSS rssult ea tba sltailaY Oedeelt bhp rsvoked trJr the T�oAia6 T� ° deed � tlro 8 of DeaSs ova +0 WAS ttW appliawtbsx' oo of 60 o oftd MWO taaP sntda itt t6s F►stzaat,► deed I v S8-30 1 83 001 50 ,� Y 14 i 3 /Q O` 00 � G O Co 1 - y a T. " ' OD •� �' 3 3.07 ACRE$ cn •'•, • 133,608 SO. FT. O 33' AF 0 1 33 :S MT. — T. O 0 _ •. tb w 2.36 AC. EXC. ESMT. o O N 102,987 SO. FT. AG • '•,O W • ti v 00 "W 528.53' U Rj 39' 293:61 U� Al 247.27' ee i A' Ir , ' Wiscon$in Department of Commerce p Safety and'Buildings Division PRIVATE SEWAGE SYSTEM County ST . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitarKP�flnjtJUo.: Personal information you provice may be used for secondary purposes [Privacy U s.15.04 (1)(m) er�iL pjdQis Nam } [�814ag e [] Town of: State Plan ID No.: CST BM Elev.: ' 1 P�111111�� Insp. BM Elev.: BM Description: VP�1 b Parcel T )OL 2099 90-0_0 �,.,� ct: > <_. 9- (p. b I . I CI C? '-2 � I TANK INFORMATION ELEVATION DATA A9700226 -7 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic w�� s ��h L . �vU ' Benchmark Dosi U ir,rn , JA No Aeration Bldg. Sewer ' Holding St/ Inlet TANK SETBACK INFORMATION St / Outlet TANKTO P/L WELL BLDG. Aenttake ROAD Dt Inlet 7 Septic +4- NA Dt Bottom Dosing NA Header. Aeration NA Dist. Pipe Holding: Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand r . Model Number GPM TDH Lift F ' ion System TDH Ft H ead Force m Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length i No. Of Trenches pl No. Of Pits inside Dia. Liquid Depth DIM N 1 N 7 DIM SYSTEM TO P / L BLDG WELL LAKE/STREAM LEA rNIT anu acturer: SETBACK CH INFORMATION Type 17T. r I/- , Mod Number: System: Ar C/ .dSS �, o2�p yI O DISTRIBUTION SYSTEM Header /Manifold ,, Distribution Pipes) , ! � x Hole Size x Hole S ntake Length G � Dia. Length Sr- Dia. X / Spacing SOIL COVER x Pressure Systems Only xx Mound O -Grade Syste nl Depth Over Depth Over xx Dept f xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Tops ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) LOCATION: SOMERSET 26.31.19,SW,NW 1962 62ND STREET LOT 9 �� r, f 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: I I I I :o Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems ) 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 Count than 8 112 x 11 inches in size. ' • See reverse side for instructions for completing this application State Sanitary Per it Number CqL <( The information you provide may be used by other government agency programs 0 Check if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Prope y wner Na a Property Location o ti4 ✓ 1/4, S T3 , N, R ,Z(ortg Property Owner's Mailing Address Lot Number Block Num er ,Na City, statE7 I Zip Code Phone Number Subdivision N me or C M Number ( > ,P II. TYPE F BUILDING:. (check one) E] State Owned El it Nearest Road Vilae Public 1 or 2 Family Dwelling - No. of bedrooms E Town OF III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) /� p 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- jg New 2, ❑ Replacement 3_ ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ 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 E0 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage e Pit 43 E] Vault Privy p 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perfh) Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min Elevation Feet Feet Capacity VII. TANK in allons Total # of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank or Holding Tank — ( r El El El E] 1:1 Lift Pump Tank /Siphon Chamberil I ❑ ❑ I ❑ ❑ ❑ 1 ❑ Vlll. RESPONSIBILITY STATEMENT I, the undersigned,. assume responsibility for ins Ilatioo of e o9eite sewage system shown on the attached plans. Plumber' am : (P ) / Plumb r'sSi to s) MP /MPRSW No.: Business Phone Number: Plumber's Address (Street, ity, State Zip Code): J cJ IX. COUNTY /DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issue Issuing Age t Signa re (No St ps X Ap p roved Surcharge Fee) F] Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 05194) DISTRIBUTION: original to eounly. One copy To: Safety 8 Ruildings Dive ion, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 1 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: L Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. 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 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) or 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 reouIated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment f standards- o Wisconsin Department of Industry SOIL AND SITE EVALUATION - Labor and Human Relations Page of 3 Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 112 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I. D. ,r APPLICANT INFORMATION - Please print all information. Reviewed by _ P we Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). S. _ Y Property Owner Property Location r - a Govt. Lot �. 1/4 1/4,S T '73 ' J r)5 Property Owner's Mailing Ad re s Lot # I Block# Subd. Name or CSW Wl i City State Zip Code Phone Number Nearest Road El Ci �' Y' Town New Construction Use: ® Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 9Pd Recommended design loading rate 1 _ 2 bed, gpd/tP L2 trench, gpd/ft � Absorption area required bed, ft �Sr'� trench, ft Maximum design loading rate _ bed, gpd/ft gpd/ft Recommended infiltration surface elevation(s) 2n ft (as referred to site plan benchmark) Additional design /site considerations Parent material 5%!7 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 ❑ U ❑ S ❑ U ® S ❑ U 1 ® S ❑ U I ❑ S 2 U [I ® U SOIL DESCRIPTION REPORT Borin g # Horizon Texture Consistence Boundary Roots Depth Dominant Color Mottles Structure GPD /fl K in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench ! - S `., '- j S Ground AP elev ft. �_ F — , Depth to limiting factor Z 9 _ 1n. Remarks: Boring # - (� - A l Ground S' elev. 9 Depth to limiting factor �2 in. Remarks: T m Please Print ' Telephone No. CS Name ( ) , Signature Address Date CST Number I SOIL DESCRIPTION REPORT ' PROPERTY OWNER Page of PARCEL I.D.# dC Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda ry Roots 2 .; in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench w 7 Ground a , el 7 Depth to limiting factor ; /v in. Remarks: Boring # 3 c r7 / Ground elev.G� WP Depth to limiting facto l: 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 # 4 1 1 v+ Ground elev. Depth to limiting factor 3 7 In. Remarks: Boring # 3. ;.... Ground elev. ft. , Depth to limiting factor ' Remarks: SBDW -8330 (R. 08/95) 9`W le ? 33 i I -Ile G 6 0 _1 STC - 104 F AS BUILT SANITARY SYSTEM REPORT OWNER � 1997 ADDRESS ,da �� �lfiS C'RpIX �� , pw Q /1 201`1tiNa ��' SUBDIVISION / CSM # 1 .�� LOT # SECTIONT W, Town of ST. ROIX COUNTY, WISCO SIN PLAN. VIEW HOW EVERY T NG WITHIN 100 FEET OF SYSTEM 4 �y J INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. I ENCHMARK: ALTERNATE BM: � � �, f` 9� l� l 9 2,7:7 :SEPTIC TANK / PUMP CHAMBER / HOLDING TANK INFORMATION Manufacturer: Liquid Capacity: p Setback from: Well �� House Other Pump: Manufacturer :Model# Size Float seperation Gallons /cycle: Alarm Location SOIL ABSORPTION SYSTEM Width: /, Length CL - Number of trenches Distance & Direction to nearest prop. line: Setback from: well: - -� House Other ELEVATIONS -_ Building Sewer ST Inlet: ST outlet: PC inlet PC bottom Pump Off Header /Manifold Bottom of system y Existing Grade Final grade DATE OF INSTALLATION: PLUMBER ON JOB:� LICENSE NUMBER: 5� INSPECTOR: 3/93:jt 7 9 9 33' i d a87,l� c'A LE 1 WreL4 !" A p f or Unve� X33 �iAkAF -- F�Poar +�i21 M R - 32 1 x `1 7. /a RE PL XCaME.Nr Gil � s � I8o 7tiP a 13, I r i , S 83 50. ' Y }' 14 i W ` Co I i T ao '•• 1 8 1 3 / 3.07 ACRE$ 133, 608 SO. FT. o 33' AF o 33 =s MT. T. -�� v — ' co o w 2.36 AC. EXC. ESMT. •,� o O N 102,987 SO. FT. AG ••, W 00 w 528.53' U Ch 39' 293.61' H Al 247.27' i !V Ch- STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERMUYER m / LAC MAILING ADDRESS a PROPERTY ADDRESS (location of septic system) Ple a obtain from the Planning Dept. CITY /STATE /_ PROPERTY LOCATION 1/4, 1/4, Section ( T _ N -R C LW TOWN OF ST. CROIX COUNTY, WI SUBDIVISION _ e Gh 7cl LOT NUMBER CERTI IEDSURVEYMAP ,VOLUME , ,PAGE LOTNUMBER 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 sidents 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. SIGNS DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 �I S T C - 100 ,Thi.9 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 Hct y- ky-1 Location of property j 1/4 A N 1/4, Section o ,T _N -R __Lq _ W Township Mailing address T- C . I3U k tin Address of site 07 A Subdivision name _ PrA)& CL /�F Lot no. Other homes on property? _ Yes No Previous owner of property Total size of property Ac e-cE Total size of parcel Ad— 6S Date parcel was created 1:7L� T T Are all corners and lot lines identifiable? X- Yes No Is this property being developed for (spec house) ? x" Yes No Volume and Page Number _14*-- 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. IF aj �O 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. Signature of Applicant Co- Applicant ?-7 - �l Date of Signature Date of Signature S28'739 Stat WARRAN Y DIMD S�fR'S G�1C SE CRM C?., M: i DOCUMENT NO. Reed kv&k..nj MAY 91995 George T. Pem=k, a/k/a George Pennock, — at 11:09 A.J conveys am warrants to Pinecliff Parttlership p� to TNtS SPACE RESERYEO FOR RECORDING DATA �NAME AN RETURN ADDRESS the Ulowing described real state in St Y Como, Stahl or Wiscoadim (hreel Westificatioe Number) W1/2 of Nk /4; SE1/4 of W1/4; NE1 /4 of S911ft all that part of MIA of SWl/4 ny of Apple River and that part of SES /f► of Sail 14 lying Ely of Apple River; Section 26• and all that part of WV4 of SEL/4 lying Ely of the Apple Itiver of Section 17 All in TwaoMp 31 ft rdy Badge 19 West, St. Croix County, sconsin. CE o 497� tim T his is Mt bo.atdd property, Imos not) FaoVom a warranties: Easements, restrictions and rights- of-way of record, if any. aced eh(a b �� ay at (S EAL.) — Z: ze Ptezlnork, Pennock (SEAL-) (SEAL.) AUTHENTICATION ACKNOWLEDGMENT M64 T. Pennock W srwTE OF WISCONSIN _ county day o[ — may — . i9 Personally came before me this day of 19— the above named . Land STATE BAR OF WISCONSIN (K authorized by 1706.06, W is. Ststs.) an, me known to be the person who esecrsed the ireeM irg instrument and acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY — Kristina Og — la nd Attorney at Law Naavy Public Coral. Wis (Signatures may be authenticated or wknowlodged. Both are a& my commission is permanent. (if not, state expiration date: necessary.) 19 .1 "Nantes of penes sipina in any apacisy sboutd be typed or primed bolo. heir siqrnesn. WARRANTY DEED STATE "at OF MAMW45M Wisconsin Legal W kW FO!!a 2— aasrz ST. CROIX COUNTY WISCONSIN I M" "p '"" ■..�f ST. CROIX COU GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016 -7710 �- (715) 386 -4680 October 7, 1997 Hartman Homes, Inc. = Attn: Becky Somerset, WI 54025 RE: Septic Inspection for Mike Hartman located at 1962 62nd Street, Somerset, Wisconsin, St. Croix County Dear Becky: An septic inspection of the above referrenced property was conducted on August 18, 1997. This property is located in the SW of the NW of Section 26, T31N -R19W, Pinecliff Subdivision, Lot 9, Town of Somerset, St. Croix County, Wisconsin. At the time of the inspection, this septic system was found to be code compliant for a three (3 ) bedroom home. If you have any questions regarding this, please contact our office at (715) 386 -4680. Since ely, mes K. Thompson Zoning Specialist sm