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HomeMy WebLinkAbout032-2076-95-000 u -7 Ap ostle S Service 1483 24th Street - Houlton, WI 54082 715.497.5929 �f PHONE ANSWERED 24 HOURS A DAY "PLEASE KEEP THE ENVIRONMENT SAFE, PUMP YOUR TANK" SERVICE PERFORMED �,..r --''� (- - L Tank (� Open Manhole Depth % `� %� ' "; CHECK (-T' Ta�evel C,�c`ep� table - yroblem: (-- 3' 3cum Depth ce tableyroblem: (-- )' a Depth cc 1$ Problem: affle Integrity ZQGR l Troblem: INLET (, ! FILTER (Yj NO TYPE: (- )--- a�ntegrity �Accceptable,Problem: ( �' emgve Content C -Ac j. bl Problem: Flush ce table,, )Problem: ce table ,Problem: T Inspect Pipes Ac ee ta Problem: O Cie Manhole r j Clean -up .'"��'.� /7 . fr1 ,'fit �' _../�.�� t� (L - r `I� _ � -r �� L -tf �� �d Your system has been properly maintained and should be serviced again this will assure the proper operation and treatment of the waste water at our site. If you have any questions or problems please feel free to contact APOSTLE SEPTIC SERVICE at 715.4975929 TOTAL AMOUNT OF WASTE COLLECTED: METHOD OF DISPOSAL: Apostle Septic Servi ADDITIONAL WORK NECESSARY: - =' 1069192nd Avenue New Richmond, WI 54017 TOTAL AMOUNT PAID: Wisconsin Department of Commerce N Safety and '3uildings Division PRIVATE SEWAGE SYSTEM Count T, CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) San itar Personal information you provice may be used for secondary purposes [Privacy L)(w, s.15.04 (1)(m)). PP999 loldt6ha fe: [S(§M MgEq§e ❑ Town of: State Plan ID No.: CST BM Elev. Insp. BM Elev.: BM Description: Parcel thidwa 0 7 6 5 I cx_� t oo 4tr` TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. e ti pcMt_ L LSa Be 3. L a3• leb Dosing 90A 9 3 I II /03.q 1 pU Aeration Bldg. Sewer Holding - P* Inlet (� 4x - �7 U TANK SETBACK INFORMATION St/ Ht Outlet TA__ TO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Se tic 4 icj NA Dt Bottom Dosing y ���C L*_ °C _' NA Header/ Man. Aeration NA Dist. Pipe ob . r/ Holding Bot. System PUMP/ SIPHON INFORMATION ..Final Grade Manufacturer Demand Q p A c • Irwir 6,13 17 • Z Model Number r s S� ' GPM ; r�;,, 44f V; 44- t,� TDH Lift Friction System �(� TDH Ft K ,� 9 C& H Forcemai n Length 7O' 1 Dia., ' Dist. To well 041 L SOIL ABSORPTION SYSTEM te r., of ' /�� �� 4 *✓C 9246 e ED - ENCH Width Length No. Of Trenches PIT No. Of Pits side Dia. Liquid Depth MEN I N �� ZGa, DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manuf SETBACK CHAMBE INFORMATION Type O � �/ �,� ► ,j-� OR UNIT M Syste DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) J x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. 3 / Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded! Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: SOMERSET 14.30.20.793B,NW,SE 1535 ANDERSON SCOUT CAMP ROAD 3+ 0 4 41 ~_ 3/� ++ (t q 9�AYt G rGG�- 4 `" .."/ Y� . n , �, �,� � „� ►t t vvcun cwt t Ac k f o v* y h - Ai t . Plan revision required? ❑ Ye ❑ No Use other side for additional information. SBD -6710 (R.3/97) Date Inspector's Signature Cert. No f - Safety and Buildings Division • `� - SANITARY PERMIT APPLICATION 201 W. Washington Avenue �scons�n In accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on paper not less County than 112 x 11 inches in size. St. Croix • See reverse side for instructions for completing this application State Sanitary Permit Number tN mb I Personal information you provide may be used for secondary purposes ❑ Check previous'application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INFORMATION 163636 Property Owner Name Property Location Lori Passe NW 114 SE 114, S 14 T 30 , N, R 20 M(or) W Property Owner's Mailing Address Lot Number Block Number 1535 Anderson Scout Camp Rd City, State Zip Code Phone Number Subdivision Name or CSM Number Houlton, WI 54082 (715)549 -6292 IL TYPE OF ILDING: (check one) ❑ State Owned Q ity Nearest Road Anderson Public 1 or 2 Family Dwelling - No. of bedrooms 3 Q Tow of Somer Scout Camp Road III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) I L[. '3 se. - 1 93 b 032- 2076.95 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 online B, if applicable) A) 1. ❑ New 2. ❑ Replacement 3, ❑ Replacement of 4. ❑ Reconnection of 5. ® Repair of an ------ System ________System _ __ Tank Only______________ Existing System ________�ExlstlnoSvstem 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 wl sand filter pre - treatment ZO x Is VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 17 . Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation 450 existing sys em, exact site unknown Feet Feet Cap acit y VII. TANK in Ca allon Total # of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks ` Ta Septic Tank - - -- ® ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ I ❑ I ❑ 1 ❑ 1 ❑ ❑ VIII. RESPONSIBILITY STATEMENT ], the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumbe 's Signatur :(NoStamps) r2 25826 RSWNo.: Business Phone Number: Halverson Plumbing, Inc ° (715)284 -2556 Plumber's Address (Street, City, State, Zip Code): 180 Gebhardt Road Black River Falls, WI 54615 IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps) ® Approved f Owner Given Initial �� / Surcharge Fee) po �� Adverse Determination oe O° � ' I r t eL — X. T.0 MJC,1 NDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: / essy - j6 -14th *,� *e �- W be °4rl AG G415'>" S I L o r-'1A la h SBD- 6398 (R.11/97) 1 RIBUTION: Original to county. One copy To: Safety & Buildings D' ision, 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. 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 -3151. To be complete and accurate this sanitary permit application must include: 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. 11. 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. d 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 G 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 i of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- f GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practiceswhich can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. v 5. Wisconsin Department of Indust �� N Labor and Human Relations Industr SOIL AND SITE EVALUATION � i �'a �+�• 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 1/2 x 11 inches In size. Plan must County Include, but not limited to: vertical and horizontal reference point (BM), direction and 5 C. R 0 k X percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. A D3Z� z0 7C�'gS APPLICANT INFORMATION - Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner A QA q Property Location / �' 1 y : / IT � Govt. Lot ftj 1/457 ( l T 30 ,N,R 7 - E (or)(@ Property Owner's Mailing Address Lot ff BloC fl Subd. Name or CSM# City Slate Zip Code Phone Number Nearest Road Z City ❑ Villag M SO,J H d t) I To rJ (.c,1: S yO�L (7/5 )$`�j (0 4 L 9 o Town C] New Construction Use: L'7 Residential / Number of bedrooms Addition -to existing building [.4<placement ❑ Public or commercial - Describe: Code derived daily flow f5 gpd Recommended design loading rate bed, gpd/(t trench, gpd /11 Absorption area required 315 bed, ft 2 37 - 5 —trenc h , it 2 Maximum design loading rate 3 bed, gpd/flz ' S trench, gpd/ft Recommended infiltration surface elevation(s) S 14 �P— • 3 it (as referred to site plan benchmark) 43 - , e Additional design /site considerations S let- ti`O S T Qzc� �'~ EXiSTi'J W SY$7Ztt 61"-- ' ` t J Patent material 1 0 aA�4 ��ld� - t� — Flood plain elevation, if applicable �J' / 4 — it S = Suitable for system I Conventional rM�,ou/nd In- Ground �Prresss AT -Grade System in Fill Holding Tank U = Unsuitable for system ❑ S B U l� 5❑ U ❑ S [E U ❑ S U El S Q U El S U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /fl Texture Consistence Boundary Roots d in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 1 i 0.1 lo 31 1 - 04 1y slik rka-r2 c 5 3Vi . S Ground • S/ 10 Y cP 7 J AUTX C 5 ^ •�� • 5 elev. R 7 --3 ft. ( / -� lo y 64 tORAtTeo SC L Pf s hk Av f 4 a.i . _ . z : • 3 Depth to L =� =- R1d limiting OF `�' D D/-fe' E`S' factor — d / n c� Remarks: �7 4'C RA be2� 7�&,At Z r~ C( {�j,�0 S 4 v i 2f Cr - Boring # i �� /& 3/2- — �- 1 +, 5k k M-4R c-s 3uf •q :.5 2., 2 z /0YX 3i3 S'i z f S6k � CrY /,f S' 3 .� 10V 3 7 sy S/L bf6 1*41 4�• . z. • 3 Ground b VA qzZ elev ft. A �D /l G� I �S� le AY Depth to, --� limiting factor 2.�fn. Remarks: CST Name (Please Print) Signature Telephone No. �(s � oCiEI�T' 7.��8 KickT 3 �'� • � 8,s Address ate CST Number . Zd • �- C'S rA-r zq p Z pehrate Sewage Consultants So�IS � O Gh a (/ �/t, S 77 1.v�7 WS O'NsN Rd. Hudson, Wis. 54018 s I \ Gv �� 9� D 7 � o � b vh fv�tED R 57 cko I`X c.T'y zo,� tN 9 Befo & CeI*0 * -Q— A B l A5 . ��I'� 10 l2 6 Oi t O ore local �pMnE permits pD be _ ko�-t -t (2lq DQ! S -r P-,0 Yt--Z) THIS PROJECT WILL �S / i REQUI ` ^,- - . RE STATE .�'G.l�- f✓ X. C ,5 T f1— :5 KS T• GI �^^- CO,v29EM,(IETi PLAN APPROVAL.. Plans /3 Y '4 AW /,V G— • 2�- � 5 TE / S will need to � we by a quallfbd desi8lne sv�'Ti�B�fG DN�-t/ /i' �" �jOU ?YY P er L.N.R. 1. 83.08 (2) S SOIL DESCRIPTION REPORT Page Z • ot .3 ' PROPERTY OWNER PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots Qe in. Munseli Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3 ' t p.( �o VQ 3/�- �- l �S6K /VAA C 3 f . �{ • S - - • IS /oI/R 3 SIL zfS k A-- cS •S '• � Ground 3 15 . Z - / R 3 1 L If S b k �'-F I' c s.. — ��; 3 C L k i►M� f li 4 4 , ^ to N n. s •i �.s y R Y! "" s« Depth to . OU G limiting s/ tac or -� - -- y In. S Remarks: Boring # 1 Ground elev. -- - -- _ - i — Depth to - limiting factor In. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G E It2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. - - ft. Depth to , limiting factor - - -In. Remarks: Boring # Ground _ - — elev. It. I Depth to limitirg factor In ' Remarks: . SBDW -8330 (R. 08/95) ,. '' . ;:i 6 0�y- . R E FL��t-i ,uC� tiA- /o U y ► u ti 0 c � y C ' b � I �► i ; I N _ o Zk Z � � N )3 w 5 m o � C Cl al vi 01111/1999 14:41 608 -785 -9330 PAGE 05/05 r SAFETY $ BUILDINGS DIVISION INSPECTION SUPPORT UNIT iScOnSI PO Box M2 Madison WI 53707 -71302 Department of Commerce Tommy G. Thompson, Governor Philip Edw. Albert, Acting Secretary ys em bmpletioK Report The System Completion Report must be filed by the county within 15 business days after the final system inspection is performed for all systems approved under s. Comm 83.09 (2) (b), Wisconsin Administrative Code. Systems approved pursuant to this section include alternative technologies not specifically recognized in Comm 83. These systems are generally subject to a shorter maintenance cycle than standard technologies to ensure proper system performance. The System Completion Report serves to notify the department when the maintenance cycle should begin. Please provide the following information: 1. 189680 Department of Commerce Transaction Identification Number 2, 445031 Department of Commerce Regulated Object Identification Number 3. / / Final Inspection Date 4. Current Owner Information Name a ' <r _ 4!w � •4 : �+, :j, F , Ti �`Y '••.:� §r ,l.: ^. Mailing address N k . R..Y !r ' • .i'. Mailing address c ity Slate Zip code 5. POWTS Maintainer Information Name Mailing address city State Zip code ( _ Mail or FAX This Report To: telephone number Credential number Department of Commerce 6. County Inspector Information PO Box 7302 Madison, WI 53707 -7302 Name FAX (608) 267-0592 Signature, Data Credential number SBD -10627 (N.8198) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)] I Safety and Buildings 2226 ROSE ST LACROSSE WI 54603 -1905 isconsin G. Thompson, Governor Department of Commerce Philip Edw. Albert, Acting Secretary January 20, 1999 CUST ID No.225826 ATTN.- POWTS INSPECTOR ZONING OFFICE RICHARD C HALVERSON ST CROIX COUNTY 180 GEBHARDT RD 1101 CARMICHAEL RD BLACK RIVER FALLS WI 54615 HUDSON WI 54016 RE: CONDITIONAL APPROVAL APPROVAL EXPIRES: 01/07/2001 Identification Numbers Transaction ID No. 189680 Site ID No. 163636 SITE: Please refer to both identification numbers, Site ID: 163636 above, in all correspondence with the agency. St. Croix County, Town of Somerset NW1 /4, SE1 /4, S14, T30N, R20W Lori Passe FOR: Description: Sand filter - 450 gpd Object Type: POWT Sand Filter System Regulated Object ID No.: 445031 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The following conditions shall be met during construction or installation and prior to occupancy or use: • This system is to be located and installed in accordance with chs. Comm 82, 83, and 84, Wisconsin Administrative Code, except where the approved plans grant exception to these rules. • A manufacturer's technician or other authorized factory trained individual shall be present during all phases of the installation process. All system components requiring calibration shall be completed by the manufacturer's technician or under the direct supervision of the technician assigned to the project. • Prior to transfer of this property, the new owner shall be given notice that a POWTS exists that requires maintenance on a more frequent schedule than a standard system, and that said maintenance events must be reported to the department's maintenance reporting system pursuant to this approval. • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operations and maintenance manual and/or manufacturer's owner's manual for the POWTS described in this approval. • A valid maintenance /servicing contract is required for the life of the system. A copy of the initial warranty or contract must be submitted to the county prior to issuance of the sanitary permit by the permit issuing agent. • The owner shall report to the county authority any changes in maintenance /service contract providers or conditions of service within 30 days of such changes. (R. 2/98) File Ref: S:\APPS \REG_OBJ \PLAN \CUSTOM \87046.DOC i RICHARD C HALVERSON Page 2 1/20/99 • The owner is responsible for submitting the Maintenance Verification Report (SBD- 10626) to the department for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. A filing fee will be assessed for each transaction processed. • An inspection report on the condition of the existing septic tank must submitted to the District Wastewater Specialist for review and approval prior to issue of the sanitary permit. The report must include comments regarding structural soundness, size, baffles and water tightness of the tank. In order to be used the tank must be brought into conformance with the requirements of ch. Comm 83, Wis. Adm. Code. If it does not conform, a state approved tank must be installed. • Appropriate county officials and division employees, as well as employees of the University of Wisconsin Small Scale Waste Management Project, shall be permitted access to the property at any reasonable time of the day for purposes of inspecting and monitoring the system. Monitoring and inspection includes, but is not limited to, constructing soil borings, or other physical examinations of the system or site, and collection of soil, groundwater, or wastewater samples for testing off site. • In event that this system malfunctions so as to create a human health hazard by discharging wastewater of unsuitable quality to another POWTS component, the ground surface or the waters of the state — including zones of seasonal soil saturation, the owner agrees to employ properly licensed personnel to repair, modify or replace the system (including the possibility of utilizing a holding tank with off site disposal) with such action approved by the department and appropriate local officials. If compliance with the conditions of this approval or chs. Comm 83 or 84 is not maintained, the owner may be subject to an enforcement action by the department or county to ensure compliance. Pursuant to s. 101.02 (13) (a), Wisconsin Statutes, penalties for noncompliance with an order of the department include forfeitures of $10.00 to $100.00 per day of the continued violation. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, DATE RECEIVED 11/03/1998 t FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 Gerard M. Swim BALANCE DUE $ 0.00 POWTS Plan Reviewer - Integrated Services (608)785-9348, Mon - Fri, 7:15 AM - 4:00 PM jswim @commerce.state,wi,us WiSMAI ;� 763 cc: Leroy Jansky - Wastewater Specialist - Chippewa Falls Rod Eslinger - St. Croix County Zoning Office - Hudson Lori Passe - Owner 1 AdL% SAFETY AND BUILDINGS DIVISION Field Operations Bureau 13 East Spruce Street \ Visconsin Chippewa Falls, WI 54729 Tommy Q nmvson, Governor Depa o f C 4 William J. McCoshen, Secretary Date of Inspection: April 21, 1998 Plumber Name and Address: Project Name: Passe Residence Use: Replacement - Residential Legal Description: NW, SE, 14, 30, 20 � Certified Soil Tester Name and Address: Lot Number: �?5 ,` Bob Uibdcht, CST 226375 Subdivision: 655 O'Neil Road Municipality: Town of Somerset / f Hudson, WI 54018 County: St. Criox ~ � ' � � � ", , . -,� `.. Owner ame and Address: Plan Identification Number: d a ' on Passe r * "ry` `1 535 Anderson Scout Camp Road Sanitary Permit Number: ! � t , � ,', � Houlton, WI 54082 Wastewater Flow: 450 gpd Persons Present: L. Passe, R. ii'l of B. Ulbricht Onsite consultation and soils verification at the request of the soil tester and owner. The owner has approval for a replacement mound system for the residence, but she does not want trees and other landscaping disturbed. Such disturbance is impossible to avoid for this type of project. Mrs. Passe prefers to use the old below grade conventional system that apparently served them well in the past. The soil Investigation centered on the possible use of the old existing conventional soil absorption system rather than Installing a mound system. The county had previously determined that the existing system did not have the appropriate (3 feet) vertical separation to limestone bedrock. Introduction of untreated sewage effluent too dose to or into fractured bedrock such as limestone can be a serious threat to groundwater quality and public health. NRCS soil survey maps for this area indicate that limestone bedrock is prevalent at 34 inches depth (Whalen sift loam). This onsite investigation revealed that the depth to bedrock Is somewhat variable, and is insufficient for the type of system installed based on current environmental and code standards. Two soil pits were evaluated and revealed the following results: T -1 00-11" 10YR 3/2 sit, 2f -msbk, mfr, as. 11 -30" 10 YR 3/4 sil, 2msbk, mfr, c.v. 30-41" 10YR 4/4 sit, 2msbk, mfr, cw, with 7.5YR 3/3 cutans, and f2d 5YR 416 high chroma mot. on ped surfaces. 41 -72" 7.5YR 4/4 gr sl till, Osg when disturbed, ml. 72 "+ LS BR >50% consolidated weathered -in- place. T -2 52"+ LS BR >50% consolidated weathered -in- place. The relative elevation of the soil absorption system's Infiltrative surface (aggregate /soil interface) was approximately 35 inches below grade, and the ground surface is relatively level. Therefore, the minimum depth of'suitable soil from the surface is 71 to 72 inches. T -1 appears to meet the vertical requirement for separation to bedrock, but T -2 falls far short. Suitable soil conditions must be present across the entire area the soil absorption system occupies to meet minimum code requirements. In the system's present state there is insufficient soil media available below it for wastewater purification of sewage effluent before it reaches bedrock and groundwater. 1 • r ti Lori Passe - Residence April 21, 1998 Page 2 of 2 Options that may be available for this site include: • Installation of the mound system currently approved. • Installation of some type of experimental system to treat and disperse wastewater,, • Petition for variance to use the existing system provided a treatment equivalency can be shown that takes the place of soil for treatment. • Petition for variance to downsize a mound for use on this site using highly treated wastewater. • Petition for variance to install a holding tank in lieu of a mound system or some other alternative. I informed the owner that I am more than willing to work with her to resolve any issues that require attention, but that any resolution must meet code standards. If there are any questions regarding this repo:;, please contact me. defoy'G . nsky Wastewa r Specialist, Seni r Ljansky@commerce.state.wi.us E -mail 715/726 -2549 Fax 715/726 -2544 Voice cc: St. Croix County Zoning Bob Ulbricht — Private Sewage Consultants Owner Q1/11/1999 14:41 608- 785 -9330 PAGE 03105 Satety and t3waings 2 "-6 ROSE ST _ LA CROSSE WI 54603 -1905 1 \ *1Sd:honsin Tommy G, Thompson, Governor Philip Edw_ Albert, Acting Secretary Department of Commerce January 11, 1999 CUST ID No.225826 ATTN.' POW7S INSPECTOR ZONING OFFICE RICHARD C HALVERSON ST CROIX COUNTY 180 GEBHARDT RD 1101 CARMICHAEL RD BLACK RIVER FALLS WI 54615 HUDSON WI 54016 RE; CONDITIONAL APPROVAL Nwhbets APPROVAL EXPIRES: 01/06/2001 Transaction ID No. 189684 Site ID No. 163636 SITE: PT®se` fef�;tLfa ?ientificiitxoR �itimbers;; " above in-�a lqq of nee viti .trio; ag cy' Site ID: 163636 St Croix County, Town of Somerset NW1 /4, SEl /4, S14, T3014, R20W Lori Passe FOR: Petition for Variance to code section(s): Comm 83.10(2), Wis. Adm. Code. Comm 83.12(3), Wis. Adm. Code. Your Petition for Variance of code section(s) noted above has been reviewed, The code sections petitioned require that there shall be a minimum of three feet of suitable soil below the bottom of a soil absorption system and that the sizing for a residential absorption system shall be based on the guidelines listed in Comm 83.12(3), Wis. Adm. Code. The variance requested was to allow an intermittent sand filter unit to be installed for a three bedroom residence. The sand filter will discharge the effluent by gravity to an existing non- pressurized In- ground system that is undersized by approximately 34 percent. It is also located on a site that has 1$ inches of suitable soil above bedrock. The intent of the code section petitioned is to protect groundwater by providing an adequate treatment zone for typical residential strength wastewater prior to discharge to the environment. The petitioner submitted a notarized. SB -9$94 application form including ten additional page(s) of supporting documents and/or plans. Reviewer's Con=ents: 1. Sand filters are proven to provide to provide highly pretreated effluent that will minimize the danger of contaminating the groundwater at the site when it is released back into the local environment at the site. 2. The proposal is one of the options. suggested by the Wastewatcr Specialist performing the onsite. 3. The undersized absorption system is.'an existing one that will be receiving highly pretreated effluent from the sand filter. As a result, the request for its' continued use is valid and should cause no danger to the local environment. 4. The depth of suitable soil above the limiting factor is 42 inches when the depth of the sand filter and existing soil available at the site are added together. Q1/11/1999 14:41 Goe -7e5 -9330 PAGE 04/05 RICHARD C HALVERSON Page 2 1/11199 Departmental Action: CONDITIONAL APPRO'V'AL Conditions of Approval: 1. All of the petitioner's statements included on the variance application form, any other documents submitted to the Department, and all conditions of approval, if any, listed below shall be carried out, This variance is specific to the subject petition and ca:anot be used for any additional modifications. 2. An inspection report onk the present condition of the existing septic tank must submitted to the District Wastewater Specialist for review and approval prior to issue of the sanitary permit. The report must include comments regarding structmtal soundness, size, baffles and water tightness of the tank In order to be used the tank must be brought into conformance with the requirements of eh. Comm 83, Wis. Adm. Code. If it does not conform, a state approved tank must be installed. This decision will become final unless the department within 30 days from the date of this letter receives a written request for a hearing. A request for hearing should be sent to the address shown on this letterhead. A copy of this letter must be included with the request for a bearing. The request for hearing should state the reasons for objecting to the department's decision, because a request for hearing may be denied if it does not present a significant question in fact, law or policy. This approval does not include review of the design and size of the system(s). All other criteria in chapter Comm 83, Wis. Admin. Code, must be met prior to issuance of the sanitary permits by the local authority. A copy of the approved plans, specifications =4 this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of constitution /installation/operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely DATE RECEIVED 11/03/3998 • FEE REQUIRED $ 225.00 FEE RECEIVED $ 225.00 erard M, Swim BALANCE DUE $ 0.00 POWTS Plan Reviewer - Integrated Services (608)795-9348, Mon - Fri, 7:15 AM - 4:00 PM jswimQeommerce.state.wi . us Ise „�`+�.... cc: Leroy Jansky - Wastewater Specialist - Chippewa Falls Rod Eslinger - St. Croix County Zoning Office - Hudson I 01/11/1999 14:41 608 -785 -9330 PAGE 01/05 Safety and Suiidinga 2226 ROSE ST LA CROSSE WI 54603 -1905 Tommy N *isconstn lip Edw. !3. Thompson, Secretary + Philip Edw. Albert, ecting Secretary Department of Commerce January 11 1999 CUST ID No.225826 ATI'1V. POWTS INSPECTOR ZONING OFFICE RICHARD C HALVERSON ST CROIX COUNTY 180 GEBHARDT RD 1101 CARMICHAEL RD BLACK RIVER FALLS WI 54615 HUDSON WI 54016 RE: CONDITIONAL APPROVAL I APPROVAL EXPIRES; 01/07/200X " IR es> eaticinNuznbeis Transaction ID No. 189680 Site ID No. 163636 SITE: Please i- *r'to ;bell: ideatif cation numbers,; Site ID: 163636 above, in :a11 corrtsponYleaee with the agency. St. Croix County, Town of Somerset NW114, SE1 /4, S14, T30N, R20W Lori Passe FOR Description: Sand filter - 450 gpd Object Type; POWT Sand Filter System Regulated Object ID No.: 445031 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The following conditions shall be met during construction or installation and prior to occupancy or use: • This system is to be located and installed in accordance with ohs. Comm 82, 83, and 84, Wisconsin Administrative Code, except where the approved plans grant exception to these rules_ • A manufacturer's technician or other authorized factory trained individual shall be present during all phases of the installation process. All system components requiring calibration shall be completed by the manufacturer's technician or under the direct supervision of the technician assigned to the project. • Prior to transfer of this property, the new owner shall be given notice that a POWTS exists that requires maintenance on a more frequent schedule than a standard system, and that said maintenance events must be reported to the department's maintenance reporting system pursuant to this approval. • The current owner, and each subsequent owner, "I receive a copy of this letter including.instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operations and maintenance manual and/or manufacturer's owner's manual for the POWTS described in this approval. • A valid maintenance /servicing contract is required for the life of the system. A copy of the initial warranty or contract must be submitted to the county prior to issuance of the sanity erwit by the permit issuing agent. riP rYP • The owner sha11 report to the county authority any changes in maintenance /service contract providers or conditions of service within 30 days of such changes. (R, M) nie Ref: CnTEMMORI PASSE SAND FII,TER.DOc 81/11/1999 14:41 608 -785 -9330 PAGE 02/05 0 RICHARD C HALVERSON Page 2 1/11/99 • The owner is responsible for submitting the Maintenance Verification Report (SBD- 10626) to the department for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. A filing fee will be assessed for each transaction processed. • An inspection report on the condition of the existing septic tank must submitted to the District Wastewater Specialist for review and approval prior to issue of the sanitary permit. The report must include comments regarding structural soundness, size, baffles and water tightness of the tank. In order to be used the tank must be brought into conformance with the requirements of ch. Comm 83, Wis. Adm. Code. If it does not conform, a state approved tank must be installed. • Appropriate county officials and division employees, as well as employees of the University of Wisconsin Small Scale Waste Management Project, shall be permitted access to the property at any reasonable time of the day for purposes of inspecting and monitoring the system. Monitoring and inspection includes, but is not limited to, constructing soil borings, or other physical examinations of the system or site, and collection of soil, groundwater, or wastewater samples for testing off' site. • In event that this system malfunctions so as to create a human health hazard by discharging• wastewater of unsuitable quality to another POWTS component, the ground surface or the waters of the state - including zones of seasonal soil saturation, the owner agrees to employ properly licensed personnel to repair, modify or replace the system (including the possibility of utilizing a holding tank with off site disposal) with such action approved by. the department and appropriate local officials. If compliance with the conditions of this approval or chs. Comm 83 or 84 is not maintained, the owner may be subject to an enforcement action by the department or county to ensure compliance. Pursuant to s. 101.02 (13) (a), Wisconsin Statutes, penalties for noncompliance with an order of the department include forfeitures of $10.00 to $100.00 per day of the continued violation. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencoment of construction /installation/operation. loquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, DATE RECEIVED 11/03/1998 FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 erard M. Swim BALANCE DUE $ 0.00 POWTS Plan Reviewer - Integrated Services (608)785-9348, Mon - Fri, 7:15 AM -4:00 PM jswim commerce.state,wi,us cc: Leroy Jansky - Wastewater Specialist - Chippewa Falls Rod Eslinger - St. Croix County Zoning Office - Hudson Lori Passe - Owner TM1, NAGt A� 1011 IILGO.DINO DATA DOCUMENT NO. STATE BARIWI _—'� 4� X485 11A.1.t►.. .. lkl...�tu�ll�..lkt �xst_. ,t �l�??a�t?! .............. IV IV NNW ...._ - ---- •------ - - - - -- p+ * .---... . ........................ ...._.................._....... SEP 831992 ...................... -- --- pnit- etsima t . A p ................._ ____ ...................... 9:40 A. _ d ........ ............................... .......................... .- •--- .....�........__......... ........................... tbo too0wins dnerm d real estate State of Wes: Part of the W 1/4 of the SE 1/4 of Section 14, Township 30 north, hands 24 West, described as follows s O mpenciag at the sW corner of said NW 1/4 of SE 1/4, _ thence Nortberly� along Westerly line of said W 1/4 of ?'� Pared Ito :.............. S1 1/4 550 feet to point of beginning, tbenee EasterlY at right angles to said Westerly Line of the Nit 1/4 of SE 1/4 a distance of 261.71 feet, thence Wortberly at right angle ..to -the *fore described litre a distance of 208.71 feet, thence Westerly at right angles to the &fora described line, a distance of 261.71 feet to said Westerly line of the U4t 114 of SE 1/4, thence Southerly along iiestesly line of the Nli 1/4 of SE 1/4, a distance of 208.71 feet to point of begimins. IHIS.'D1ED GIV!!N III F(iLL SATISFACTION AM e=* tM OF TEAT CERTAIN „'i►'MENT CW DIVORCS WHICH WAS GRANTED ON JULY 2, 1984. "SM. 83FA41, IN THE cIBQ)IT COURT IM ST. CRDIX COUNTT, VISOONSIIq, AMD GRAY= SPECIFICALLY RELEASES MY LIEN 09 THE ADM— DIS"ED MPERT11 Ir is , �.3 This boawtead propeety. j Dst.. . ........... 1 4th............................ of Se tember il.._92.. u�e'r!!, ,,c ......... CasAL) '� ........ .....- • .... ........... ....... - -• is • Csvtoley,......... ......................... • . ............ ........ ............. ............. (SEAL) (SEAL) .............---•-................ .._..._........_._........._... - S • ............................•..--.. ..._........................... ' • - AIITalMTie! ♦TIOIt ACKNOWLSOGURNT BrATN OF WISCONSIN 1 SiEnstax�( :) - --° -----------------° •--•--------------------- •• -•-- } SS. ass anitsd ibis .... asy oi___ _ .................. , 19. °- _ Iiesooaily eamo bd .r1�4h_ :.day of EfY1,ti1yG!C_.. itA&. the abm named . .............. ..._� .. ----- ------ - ........ � iA..•..1. -r m.. ..... ............ TMLE: i[ZMBEB� STATE EAR OF WISCONSIN - •► ~' YY� .....-.... -.» - ... - a----- ------------- -- be ft �o •&tad the THIS t MMUNEW WAS DRAFrto n ' ................. ......... .. ...... Robert W. Mudge Attorney ___ .............. ?1111 L�; 1 b lt? w $:C: - __ ........................ Ce4a its tri n it_..._�...�__..r........................... _ Niseary Pnbiie i 006hIn ialm - - - -- - -- tieated or ad moT.led¢ed. Both YT (7oanmfasion In p (It ask state SiQ (Signatures may be sntben are not necessary.) its {rATIL 00' UAa: O p1ilnit 1N./ qvn CLAIM Dow f?aasf fin a -19O O 4c O. rn ii a o �� y� o •�► ta y x P ozoc �m� u i M i x m m x m m m cn > x U>) a, > > > > > r > v � �i u rri o 0 c) (7) G) o � C) v > C) > m "' rn rn rn rrn rn rn m x rn to -b. W N �. •._• 1 1 1 t t t > m &> m m� 0 , t , 1 1 1 CD z N z z z U) m an 1 1 1 1 1 1 1 1 1 1 1 1 0 0 m 0 < ° > b-4 -> -i — 0 (A co -1 0 z m> n Fn w o m t 1 { { t t z -4 ° N -1 1 > O _0 0 n - u -- i -< r c 0" C X X r O r- r 3 0 0 0 -1 0 Z mr m >n- 0 r 0 Z rn U) to rn z -n o z > c u) tor to � 0 w x> z cn ;o rn >> z o °m m0�0 Fnn > r i { 0 z M Z c m w n "n O r O CD � n� � �� SD M �. o ® p . `� Z Z w to m m (D ; 4 R -4 U) o Q r� r m 1 ;u Ch M 1 0 9 N X N > � a � C Uf n C) .� fl > > 7R N m ro m w o CD m tn � O a+. �a t_ E3 4 � ro to rn 1 x �- t o w CR x ts -� rir hi _� m a -U G�1 W `O V V , 1 r 9u i ST CROIX COUNTY w SEPTIC TANK MAINTENANCE AGREEMENT AND • 1 OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Address C v� Property Address s (Verification required from Planning Department for new construction) City /State S city, e, Parcel Identification Number 0 3 Z 7 , � 1 LEGAL DESCRIPTION Property Location QL 4, S <, Sec. I , T 3 C N -R W, Town of Subdivision — Lot # Certified Survey Map # . Volume , Page # Warranty Deed # ! o B q 1L Volume _ 1949 Page # Spec house ❑ yes J no Lot lines identifiable W yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of th three r expiration date. A) SI F APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the properW described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIG TORE 6F APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed I `� O mZ w uj ,_ 1 1 < w Y Z � I j 2 ; x vi x �u U . u x a m w �i km2 �Z . c>. V �� P* Rx ..�w� O 73 < �O� ���s Z d 0 0 z CO LU Y ��'�j F J(��' Nom. °'• 0t N w v l 2 a LG �> �' C. <� 0 t• ® i <• i t : i r : : v G 3 � • • a tu �� < < •E: td Z ..4 Ci Q z . rsa a O 3 � en w R <•. t a ar .<•. ID tE •t : • 6 O u<••<••< :sdx a s { <' ., 3 2 o 06 R 0 CA V <•. .t •<•.<••<••t••<•.t••<•. <•. <• t•.e•.t•.t•. •E•Ea' E • • ♦E: i a 1 < °Z � < J F Z VI JAN -13 -99 WED 14 00 HALVERSON PLUMBING FAX NO. 17152844979 P.02 OD w 20 O 1 2 1 rte '' , ,fi .A" !` . <• .R R• ♦ V N i q a ' r - .i f, aC x' �, ,,, 5' •.� '.y ME — i,; 'i'' ;'Wig { " y 'i„ Y �9 "!.� I•M�;�� "+ �{' -- ( 1�J 1 ' � ,)'��, i � <��Q� ;k. � .� ni't .'� • � V 4 r., � i ". , � • � ', �� � � I tt yJ� � � � .:'t��r ��' - ; �'�'iyy 9`' : 1 M3 5� • k ; . f►d V st �' • rill Pik -.. ��'=7b�1'y�,xi�S „S' • ♦ I. a' { ' y.- ' � .r ,i. ♦ • ..Nab(• • i i I OCT-23'-98 08:03 AM AI.MCDERMOTT CO 715 355 5193 P.01 160 _ Effluent UMPS - ig Hp to 1/2 Hp single Phase. W Hertz P501512, 23OV- 6 stage 115 1230 Volt 4 — 7— Curve PC4 � _.-. � ,, �•........... — ; - Orenco ftsftme T ..... ... ..... .. . . ...... Incorporated 140 T 4 Ajpwky AVENUE 97479-9012 .. . . . . ........ P501012. 23OV- 4 stage TELEF)IONP ..... ...... (541) 459- ..... .. .... FACSTMILE; 455-2864 .. . ..... ... 100 P500712.23OV- 3 stag T — 7 V A3 Cm + L ... ..... ... . stage so . . .. ........ 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W 9 o U N z< ul O � C { Z � a YI K m Z z t9 W N a a m N a L °E N 3 Z'� cu _ aE Ewa c cm w N� vE x � g 7 >O ~ O a ��> > a vi Y Y °m mod J c N` ' =W LV fir. C mm I s � z1o) v •-� m I � � � 3 m to o 0 • Q Q t = a5•E > L J t m m Y � 4 'n V \ i c W ... � : • p W NJ 1 p Q LL C 3 J z Lu LUa W Q w Lo 'v u7cc �^ �— cu r J a) D W X 0 9 a � N RT N W g — w O U im J V) k ; p yy E3 k �c g o y co .;<< co in cu r W CD c p p p g Ij' ���� Qb�` 3��7C� o I 180 Gebhardt Road Black River Falls, WI 54615 1 -715- 284 -2556 FAX # 1 -715- 284 -4979 Lori Passe July 26, 2001 1535 Anderson Scout Camp Rd !1•,3U Houlton, WI 54082 SAND FILTER ANNUAL INSPECTION The sand filter system appears to be working properly. I checked the septic tank for solids with my "sludge judge" and found there to be approx 20% solids in the tank. I would anticipate the need for you to have your tank pumped next year. The two laterals on the outside edge of the sand filter were clogged. I could not get effluent to come out the outside flushing valves. I backflushed the laterals and got them flowing properly. This is a normal problem for a lateral configuration such as yours. The effluent enters manifold supplying effluent to the laterals in the center. The force of the pump tends to move any solids in the wastewater and force main to the outside laterals causing them to clog. Counter readings and squirt heights are on accompanying drawing. Sincerely, CC: St Croix County Zoning s� �N r. , 4 N IL m 0) m m m cm m cri cv m c� m m m F C W m Z � H � w 2 to W B i AI I t III - -- r Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM County: INSPECTION REPORT 00 r GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 3 7 - 4- 7 7 ? Permit Holder' ame: [I City E] Village [9} Town of: State Plan ID No.: Lov' i u-;r d 7oW vS r CST BM Elev.:- Insp. BM Elev.: BM Description: Parcel Tax No.: laa R, o t�orv� S- d�c-GC - 0 37- 2 -mot S-a TANK INFORMATION ELEVATION DATA A9 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Se tic t Bench a - 4 3 1a3 43 jab Dosing IZv 61 ,o Do -t �4 /o / lcSo Aeration Bldg. Sewer Holding St/ Inlet O 3 , &,Ib 97,ol TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake e tic ( ( �� NA Dt Bottom Dosing �,, ,,,� A Header / Man. 3, �� /C1�1• Aeration T �"�^ L NA D i d Pipe Zly 1 Holding 3• / (.+Q Of G, PUMP/ SIPHON INFORMATION -// '/ 9 Manufacturer Gn . Demand Model Number �tbp SI I S (� GPM r " + � "% a �s TDH Lift Lriction� /- System TDH Ft C ` tr G iM + 4O '9 . w "25 Forcemain Length ga Dia. P r Dist. To Well ¢. 0 ;. �� �-25 C/g• I c� SOIL ABSORPTION SYSTEM - To? �ct Cd r" 103.f - .CT a B TRENCH Width ( Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIM EN 1 N 1a to DIMENSION SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING Manufacturer: SETBACK INFORMATION Type Of Model Number: / - System: ' 5 r + 0 ' CHAMBER OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing I Vent To Air Intake Length Dia. Length Dia. Spacing —3 o I /8 SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) /y'� �},����,� � `ov -1 L'a». Itafta /$' ' I Zd' 5 "o( t+ R• a -, is ,� �• ✓avc/ . /� �� " ltna�G ✓IIIK f �ITYI'iA tS /'� n ' JO f Ge�•1. {ir/c Tp,� o i t �j /U - � 3 /y./ h 01 �4*4 A /2�t k5 tn(aal r ra t = F'0 !cc-1 /991.L 6 ('rih u o v UA, D' 4 x wn.ti � y1 kj4p, (cis �ku, • Illo(/w will 40(0( t '4 ' 0 1 1 511 6 - Plan revision required? ❑ Yes r J 0 Use other side for additional information. 1 ,? y SBD -6710 (R.3/97) Date Inspector's Sign ture e t No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: i . ....... . f t -h- V-P m _ a voto 2 a i A ] { { em � O } x F § i i 3 T E 1 € t t t E t � F p ;t- 7117,1 O d { a A ll: _.w..� 9 f # i 3 # C _ Off' 1\ tt—El • a 3 2 t ' g - 0 0 -1 _ _� ,�mme� _ s I? El 4 e5. d ..e..„ V tee. E b.� S a 6 .,.,....... � € .,.a „ . ,�..... .me ... (h' .e.... � \ •A NT vee .�-� ., m y d "' s # 2 t ( € k ..e y 2 .... ..«....� , i { pn i { n. All, . .. . ... f r E f a , f tA ' i f { 1 ( �._. _.;. ! :H39vm llW83d J UVIINdS HOIMIS (INV S1N3WWO3 - IVNOIlICIGV Wisconsifi Department of Commerce PRIVATE SEWAGE SYSTEM County: Safefy and Buildings Division ST. CROI X INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryNgpi2l�q,; ' Perso nformation you provice may be used for secondary purposes [Privacy La s.15.04 (1)(m)). L yy 11 y7 GG P ASS er's e:& LORI ❑� &J'gI Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tv1Iel: 076-95-000 TANK INFOR ION ELEVATION DATA 00509 TYPE UFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark 40 F Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outl TANK TO P/ L WELL BLDG. Air j ROAD Dt Inlet Septic 1 k, NA Dt B m Dosing H er /Man. Aeration NA st. Pipe Holding ot. System PUMP/ SIPHON INFORMATION I Grade Manufacturer Dem Model Number PM TDH Lift Friction System T D Ft L oss Forcemain Length Dia. H Dist- T ell SOIL ABSORPTION SYSTEM if BED/TRENCH width Length No. Of Trenches PIT No. O Inside Dia. Liquid Depth D IMENSIONS DIMENSION SYSTEM TO L BLDG WELL LAKE/STREAM LEACH Manufacturer: SETBACK CHABE INFORMATION Type O Al Model Number: System: OR UNIT kk DI STRIBUTION SYSTEM Header / Manifold Di ution Pipe(s) x Hole Size x Hole SpaN Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx ed Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Ye ❑ No COMMENTS nclude code discrepancies, persons present, etc.) LOCATION: OMERSET 14.30.20.793B,NW,SE 1535 ANDERSON SCOUT CAMP ROAD I 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: • 1 s 3 3 Safety and Buildings Division 201 E. Washington Ave. SANITARY PERMIT APPLICATION Vis P.O. Box 7969 Department of Commerce In accord with ILHR 83.05 , Wis. Ad m. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County / than 8 v �,6 ,. �/, i x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number "1 The information you provide may be used by other government agency programs ❑ Check if revision to previous application (Privacy Law, s. 15.04 (1) (m)]. State f Ian I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATI N 7"- /'n' Pro P rty Owner me /1 Propert L cation Lids/ �4S5;er_ NA)1i4 � 1/ 4, 5 T ,3a , N, R Z0 E (o W P rope rt Owner's Mailing Address �t� n Lot Number Block Number Cit , State Zi Code Phone Nu a Subdivision Name o�SM Number vG/v 4 / ' s I (�/ S) 4I'r�l I. TYPE I NG: (check one) ❑ State Owned It Nea ' rest R ad Public or 2 Family Dwelling - No. of bedrooms 3 o vlllag of S'o�.4je �� SST ��t Agi 111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) J� 1 E] Apartment/ Condo 7Z — 2.0 76 " , 2 EjAssembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 Q Restaurant /Bar /Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/Factory 13 Q Other: specify IV. TYPE OF PERMIT: (Check onl ne box online A. Check box online B, if applicable) A) 1. Q New 2 acement 3 Q Replacement of 4. Q 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 istribution Experimental Other 11 ❑ Seepage Bed 21 ound 30 Q Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 Q In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SY STEM INFORMATION: /02.0 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade J/ Required (sq_ ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) G� Elevation -` � 1Q v �� J� ` r ' Feet Feet Capacit VII. TA ORMATION in gallon Total # of Manufacturer's Name Prefab. con Steel Fiber Plastic Exper. New Existin Gallons Tanks Concrete structed glass App - Tanks Tanks It 1 Septic Tank or Holding Tank L=j❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamberl 00 " O ❑ ❑ I ❑ ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans_ PI tier's Name; (Print) m Plu (NO Stamps Phone Numb A 2r 1 � /GLt� PRSW No.: Business Number: 3307 •71 - Plumber's Address (Street, City, State, Zip Code): 57 IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater D ate Issued ISSUIn Agent Signature (No Stamps) 1 Surcharge Fee) + Approved []Owner Given Initial �� Z� Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBO-6M (R.1 tom) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division. Owner, plumber it r _ 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. 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 -3151. To be complete and accurate this sanitary permit application must include: 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. 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 oallons, 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 witn 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 regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. SAFETY AND BUILDINGS DIVISION 15837 USH 63 N Visconsin Hayward, WI 54843 Department of Commerce Tommy G. Thompson, Govemor 23- Sep -97 William J. McCoshen, Secretary Ulbricht & Assoc Robert Ulbricht 655 O'Neil Rd Hudson WI 54016 Ray Passe Plan ID 9710416 NW,SE,14,30,20W Municipality of Somerset Inspector: Leroy G. Jansky County of St Croix (715) 726 -2544 Private Sewage plans including the following element(s): MOUND 450 gpd The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(2)(e), Wisconsin Statutes, is responsible for compliance with! all code requirements. This plan action Is subject to no additional conditions. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department. All permits required by the state or local municipality shall be obtained prior to commencement of construction /installation /operation. This project is under the supervision of a state inspector. As inspection concerns arise feel free to contact the state inspector at the number listed. The inspector for this project is listed above. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Please refer to Plan ID number listed at the top of this page when making an inquiry or submitting additional information. Sincerely, Carl Lippert Wastewater Specialist (715) 634 -3484 t � , t ULRRICHT & ASSOCIATES CO. 655 O'Neil Road - Hudson, WI 54016 Reg. Designers of Engineering Systems 715 -3$6 -8185 Private Sewage Consultants PROJECT INDEX DILHR Plan I.D. # S97- 21088 Date Sept. 22, 1 1997 Owner Ray Passe `.Phone 715- 549 -6292 Address 1535 Anderson Scout Camp Rd. Houlton, Wis. 54082 Legal Description ^ Approx. 2 acres. Tax Parcel # 032- 2076-95.� NW, SE, Sec.14, T30N, R20 W. Town of Somerset ( south part) County St. Croix C.S.T. Robert Ulbricht CSTM2482 Installer Local Authority/ Supervision St. Croix County Zoning Dept. PROJECT DESCRIPTION The Passe's existing 3 bedroom home was destr yed by-fire from a lightening strike in the summer 1997. A new home (3 bedrms.) shall be built over the old site. However, the new home shall be expanded 15 -20' further east. The old septic tank, 22 years old, shall be abandoned per state code. A new septic tank (1000 gals) shall be installed, from Weeks Concerete Products, New Richmond Wis. The old existing drainfield is sited in non- compliant soils (seasonally saturated, with dolomite beneath). The old system shall be disconnected and abandoned. Soils are fairly permiable (.4/.5 GPD /FT2) in the tested replacement area, but seasonally saturated at 25" as evidenced by mottling. This is the most restrictive immediate soil problem: , seasonal saturation, and a long narrow mound system has been designed, using 12" of approved sand fill. Highly recommended: the precast Septic tank should be p provided with a Zabel Filter. This will provide the ultimate in pretreatment and effluent clarity, and will prolong the life i of the new system. Pg.l PLOT PLAN VIEWS p 2 UVICht 8 ' AS Conaui g. SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEWS p�I to , Sewag 6 O�neWisd 54018 , Pg . 3 PIPE LATERAL LAYOUT Nudso , 2 P .4 J 9 DOSING CHAMBER CROSS SECTION /"/�^ P .5 "f 9 PUMP PERFORMANCE /(p ORMANCE SPECS This design fof Installation ion landscape conditions is based entirely on measurements, elevations, The accuracy (slopes etc.) and soil suitabilit of the cs of his specs, as reported, shall remain the soledresby CSTM ` ponsibility Any use of this POWTS design ty any licensed plumber, or any related unlicensed parties or persons (excavaters, laborers) shall not be construed as an assumption of responsibility by the designer for the workmanship, construction, placement, substitution or selection of any components not specified, or any assumptions by the plumber that any unspecified components are state approved or proper, or the effects of poor judgement' If working under adverse damaging weather conditions (wet /frozen soils) by any such parties or persons. 7 ...,U 4 16 1 U� � u ti � o N o Rte• o T at MIM sma K� O v a _ • e�o C I� wm all A w ? . am y 0M:vr- i X Z Zp I 0 zz O to O m S3 m�z p I Ot , �4 1 b rb o � �? P.O.W.T.S Fri c o Conditions 6� Ii y s © \O o - tI DEp Of SA T OF C ND BUILDINGS � O � � pl N OF SAFE o ' SEE Co ESPONDENCE P5 Z o� 5 CROSS S EGT100 of M ouA-) D -- wi rm f3ED Bev a ro A 9 ��'�S'�T�' I WO7 - c-7-6zZ:> A 59e s �/� 'D 1 ST R i (3t� T % o,V THi Gk'nS ES 9 PI P IN G- OF T °P soil , sysrEM e(EVA rio&3 UOi FORM TO E >< 99 0 E �- Mao. fe PIowEc> ToPSot' �— 1 UW1Fb RM 2 010 SIoPE FORCE- EIEVA'000 BEV 9�• a FT. ELEVhTIa S E A( FT. l"VE,Rr O 2 1AT£'RMS F . FT• • .T.op OF R OCk lr yo G /- FT. *Z. ' '1 Y. 7 /. To °F N S FT. IATERAIS PLAN VIEW vF ' MouAjD wlrti 13Eo FoRm MAW A ✓ �- FT'. Fr Fr I � - - -- - -_ - a--- _----- - -_ =�� Fr w ,;o - - - - - -- - -- S 9 F F� N o W Zg Be E7 of PPEd To I PV _PVC. <A ti nt3SERVhrkoa A 99RE` Pipes PE RMA,J e,uT MARKERS 'D p.O.W.T.S. lfPr pnditionally S. REG2UiREP (3ASAL hRE/t = Ait_y tvhSr _ �� SCIL- t1J•filrRATME APAci Tr DEPARTMENT OF CbMMERCE FT', , pry OF SAFETY ND BUILDINGS PRopoSEV BASM AiReN = '� + z SEE '0 SPONDENCE ro C S q. FT. F�LD D PIPE NE rwoR k IO V ( O F L A P ��5�tR1w'3uTlo►� LATERAI EN CA Y Z PUG FORGE MAW L ASr FiniE s IlA ll f3F- IJE�r Ta t Pt) CAP 1/01 D M w E Vo R u�ER�J 1>= vA1 -�o� dr- 2- PoRtE MA Z TOTAL Volo - PER FoFAVCD. PIPE DETAi L Q HOIES log AT OX-) �) G OTrOM SH A11 Be I" y VARin(3LE y G gONIIy 5PACeD. dtsr�,NcE P 7 9 rr N o1 E DiNKP - Tr- R L AT ERA t- qv MANI FnLo 11 �. �" . X _ 1Jut S �� -- Up ropct MMk) Z l b 10. Y 1 N c I, E s � o� (col E 5� p i P : .. D151 Ri t3uTic�N D�gcIIARv� RATE PER LgTER14l.. 2y s7 �'al /Miu. _ ol'At~ "Di5ctAAR 6 L= - HATE Z S7 p.O.W.T.S- N E y w o R IC y c o te lly AP P COMMERCE DE D� N OF SAFETY AND BUILDING SEE C ESPONDENCE p . 3 s PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS Pf14E �{ OF S — J i -VENT CAP 4"C.I. VEUT PIPE APPROVED LOCKING WEATHER PROOF JUNCT'IOA1 BOX MANHOLE COVER P_5' FROM DOOR„ w � w , 1 , 0 4)6-i�►13EI WINDOW OR FRESH 12 "M11]. I AIR INTAKE tr1E U,17/0ty L GRADE- I 4" MIM. g CONDUIT 3& !E V,4 T7 11 4.1 11� o f PROVIDE I - - - -- �INLET AIRTIGHT SEAL I I E OI y I V E ( III APPROVED JOI APPROV D J IJ7 W1GI. PIPE �(vMf I II EXTEND{NG 3 EXTEtJDING 3' �} O�,�f , \ ALARM ONTO SOLID 5014 01IT0 SOLID SOIL. (3. ZS J I I ON I I 9z•g I ELEV. FT. PUMP -�_ __j OFF �SE 3 oe Z WOiPE sF 'TANK o� BLOCK !E VA n� RISER EXIT PERMITTED ONLY IF TANK MANUFACTURER HAS SUCH APPROVAL SEPTIC E SPEC IFI'CATIOUS 3 DOSE � (� • L R TANKS MANUFACTURER: IUMBE DOSES: PER DAB TA,MK SIZE : o do 4.10. LLOO y� G�A��NS DOSE VOLUME 1° ALARM MANUFACTU �U �1 `"U INCLUDING BACKFL /OW: GALLONS /�OV UL = * . 6 y CHES OR 36b GALLOUS MODEL IJUMBER: 7) U L A IN SWITCH TYPE: �1F�,p�v�Y "�r B = 2 INCHES OR GALLONS PUMP /AAMUFACTURER. "-"` v C= 7• / IAICHES OR �j GALLONS MODEL ►DUMBER: • c l tf - -- D- t' • & INCHES OR _ 2 ff GALLONS SWITCH T`.JPE: f R- lt)(4eC* !_�[ NOTE: PUMP AUD ALARM ARE TO BE Q INSTALLED ON 5EPARATE CIRCUITS MINIMUM DISCHARGE RATE GPM r" CC L VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. &. S FEET -r AA ) k 4- MINIMUM NETWORK SUPPLY PRE S SSURE . . . . . . . . . 2 .. 5 FEET 6AC,(A, I t) () - FEET OF FORCE MAIN X /` FyoFT.FRICTION FACTOR.. ' 7g' / g FEET t7qo IS 2 -0._r7Q TOTAL 091JAMIC HEAD = . FEET lPbuvv D�/ K 3 n TANK: LENGTH INTERNAL DIMEMSIONS OF ;WIDTH d 7 • ;LIGIUID DEPTH n �� p o.w.T.s. Conditionally APPROVED DEPARTMENT OF COMMERCE "rSPO D BUILDINGS NDENCE HEAD CAPACITY CURVE 3 7/8 5 1/4 30 MODEL "9)3" 4 5/8 e I 3 S/8 5 m - + + 15 4— 4 3/15 A 10 2 1 1/2 -11 1/2 NPT s 0 ' U.S. GALLONS 10 20 30 40 50 50 70 80 LITERS I k) 1 240 0 FLOW PER MINUTE TOTAL DYNAMIC HEAO/FLOW PER Mrr1UTE EFFLUENT ANO DEwATEFANG CAPAC17Y 12 HEAD UNITS/MIN • .J FEET METERS GALS L'rRS p 1 t.52 72 ^73 A I O 3.05 e1 15 4.57 45 17 170 20 8.t0 25 as 3 5/16 �•. I LoekValw 23 nh y '.I. C ONSULT FACTORY FOR SPECIAL APPLICATIONS • Electrical alternators, for duplex systems, are available and • Mercury float switches are available for controlling supplled with an alarm. three phase systems. single and 9 Mechanical alternators, for duplex systems, are available with or • Double piggyback mercury float switches are available for : without. alarm switches. variable level long Cycle controls. 1 i V, , i. SELECTION GUIDE Standard all mod - Weight 39 Ibs, - +/a H.P. , 1. 1411 ralfloatope rate d2polernschanicalswitch .noexternalcontrolrequired. 98 Series Control selecllon 2. Single Piggyback mercury float switch or double piggyback mercury, float Model Volts -Ph Mode Am s switch. Refer to FM0477. Sim lax Du lax 3. Mechanical alternator 10.0072 or 10 M98 115 1 uto 9.0 1 or 1 6 7 — 4. See FMO712, lot correct model of Electrical Mlernalor, "E- Pak ". j1 1 Non 9-0 & 4 5. Mercury sensor float switch 10-0225 used as a control activator ,pacify 098 230 1 Auto 4..5 1 or 1 & 7 _ duplex (3) or (4) float system. ; ? EBB 230 1 Non 1.5 2 8. Four,(1) hole "J Psk function box, la IN connection or wired -in sim- OJ.2 3 b 3 or 4 8 5 plax or duplex operation, 10.0. tiva I 7. Two (2) hole "J- Pak ", for watertight connection or splice 1 For Information on additional Zcetier products retar to catalog on Combinntlon Starter. fM0514; CAUTION Piggyback Mercury Switehss, FMO477; Electrical Alternator, FMO48e; Mechanical Altarnata, A8 MetaSa of controls. proleetbn rJelrbn and wirkq should a done by a gwi4 FMO405: Alarm Package, FMO513: Sump/Sawsge Basins, FMO4e7: and gimplex Control Boa, llsd licensed electrician, AN elacNloal and esfety sodas should bs followed Inelud- FMO732. Mg IM most resent National Electric Code (NEC) and the Oooupedonal Safety and Health Act (OSHA), RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is efi into the design of every Zoeller pump. f • MAIL TO. 80X 16347 Louisyiti ;,;KY 40256 -0347 Manufacturers of... 0 Z Z7ZIZZR O SNIP T0: 3280 OFr Millers Lane 1A N c ! . - ; LOCiSVilr. KY 4fi21 s .1 1. e-'14 /T SIAI. - 1AMY (502) 778 -2731 'e fAY 002) 774 -3624 L � I� h �� r y � R► u ti 0 c fi ; Z y � � �� � v� c '� � � G � „��° �� � � z � � � � a N � � � � � �^ � � p H o `- - ' `� � . C i � � � _ �� -c� � �, ,; b i � � d � � I ' � Z � i � __._ � � I � `P� � d � � � � � `,.' , y � �i � N � � � � � � o� '� d � ' - -� � � �' � �' � N � � �� z ( � 1 � � M v U b �_ � � � � O � � � � N N � � � o_ -� � N � _ � - . o� � � - � � Ia � � w � � � �' �� c,� � �� o � � � ' �� '��' _ � o � o �. � s� � �, z � U, � �j � s o Go 7 L. . `� O Wiscerl'ain Department of Industry SOIL AND SITE EVALUATION Page of Labor and Human Relations Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must County include, but not limited to: vertical and horizontal reference point (BM), direction and S T C R 0 �• X percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # L 9 3 - )- 2 - 7 � •qf APPLICANT INFORMATION - Please print all information. Rev wed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). •q'7 'Propery Owner �^ Property Location / ��/ �� VC Govt. Lot *Uj 1/4 SC 1/4,,S iq T 30 ,N,R Z E (or) (@ Pro 73�;­ Owner's Mailing Address Lot # Bloc k# Subd. Name or CSM# ff h loa .ov7�" �,yd ,E�� • N/ City State Zip Code Phone Number Nearest Road M s aJ Mooirp -) 1 t,01. I Sy0 (71s )SVI, (02-fL E , Uity ❑ Village [�Town 0 ❑ New Construction Use: [7 Residential / Number of bedrooms Addition -to existing building [4 e placement ❑ Public or commercial - Describe: Code derived daily flow f0 gpd Recommended design loading rate ' 3 bed, gpd /ft trench, gpd /ft Absorption area required 31 5 bed, ft 3 7 5 trench, ft Maximum design loading rate q bed, gpd /fl S trench, gpd /ft Recommended infiltration surface elevation(s) 3 ft (as referred to site plan benchmark) c Additional design /site considerations � s E / �ST� :g S T e, 6,V• � 3•7J Parent material fo r GAlo ` y - r) � Flood plain elevation, if applicable � ft S = Suitable for system Conventi�ona�l �M,ou/nd In Ground ;�u s AT Grade System in Fill Holding Tank U = Unsuitable for system El '� U u s ❑ U El ❑ S 21 ❑ S B U ❑ S U SOIL DESCRIPTION REPORT Boris # Horizon Depth Dominant Color Mottles Structure GPD /ft 9 Texture Consistence Boundary Roots in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench o•I� /oyl2 317- 1 - 0 4, 4 1 Z-F nM vfiR c S 3 Vi S ; . 6, Ground . s l /oyR y y SL 1/w /f' /)qv,X s •L! ; . s .SG L q7,30--ft. / -(� ( S hk nh I� GC.t . Z • 3 Depth to t- _ limiting ,/ ar 2� e qr s� i P , factor n It �� )e / 6 3 �` �i fl1 s L `� 4G 'Q' a �� 1 .4 � Remarks: Boring # _.:, i o- I d ye 3/z — �- r f sb k �Fk 75 3Uf .q{ . 5 .. 2- . l /oY4C 313 Si 2f She l^ f cs It' - f s .� 3 t0 V 31 syR s/ 5' 1 L •*-f ' 1 ,-e • . Z • 3 Ground I& ! Z elev ! a AM Depth to limiting factor 2-9—in. Remarks: CST Name (Please Print) DO QE T, ? / L8 D; C �� Signature 71 S Te 3 p o C t - o / 9 S Address I� 1/t A ate CST Number 2-0 �- CS rA4 zqp z P[ivate 80wapa Consultants /¢ _ Q ,�J , ( 9N�S �N �/P �.v'7 i &ZD 8136 O'NsN Rd. ! LG(;vJ�" v� � s Hudson. Wis. 54018 ( \ w ERA D DEED TO (� AP P R 2 12S dX . p Y o dL J vh c vr4t�i� Q S 7- c 20 (Y y zD� tN 9 C2►:c A Bl�� . �f� f� l- 0 h gvi P l� R � ,� ko,t.� �' � DQc S T Ro YID Q �{ �' �• l2 R. - X CS Try 6 — S YS T• /44 -5 /0-Q't^- Co,c��E� -t vED S PA S IF SOIL DESCRIPTION REPORT Z, .� PROPERTY OWNER Page of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles structure 2 Texture Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench 3 6 -6 10 0, 3/-L L - F'R Z - /0 VF 3/ — Sic 2fs K nMfR cs ! F .S -•(o Ground 3 - 15 10 R 31 I Sil r.. , f l C S ." -- • L , • 3 elev. c L. ^.Q f l .� - » N ���-ft s•t �•syR Y! "" S/� S k Depth to nn limiting tt �-� . L /�� 001 fa or d �, in. /IC/"i s Remarks: C1— C// �� f�0�,, 'rE Boring # Ground elev. h. Depth to limiting factor Remarks: Horizon Depth Dominant Color Mottles Texture Consistence Structure Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. Depth to , limiting factoe in. Remarks: Boring # Ground elev. / ft. I Depth to limiting factor in. Remarks: SBDW -8330 (R. 08/95) D0if> 6 C,Pd I f4 R E fL � r / � A-) U-- © w i f� ✓ T�' r %vim : �P�T S /060 2 iFi4 /,,7 STC -105 SEPTIC TANK MAINTENANCE AGREEMENT [� St. Croix County /� OWNER/BUYER 4y MAILING ADDRESS S' _ S PROPERTY ADDRESS ��L�j /� " ` �l S • .��d ? (location of septic system) Please obtain from the Planning Dept. CITY /STATE PROPERTY LOCATION 114, s 1/4, Section / , T -2 - 0_ N -R TOWN OF 7DVI AE;t'S7 ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME , PAGE , LOT NUMBER 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 Inas been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date l� SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Cann ichael Road Hudson, WI 54016 11/93 S T c - loo 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. rdin . g ------------------ - - - - -- - - - - -- ----------------------------------- Owner of property AV Goes 4_u' Location of property A141 1/4 56 1/4, Section , T N -R ZO W Township —Mailin address Address of site I S - 35 Subdivision name Lot no. Other homes on property? 1--,' Yes No Previous owner of property Total size of property Z-O f 4Cce j Total size of parcel Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house)? Yes Volume l70 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. yT � I ll 2 --- :-- , 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. S i"ature of Applicant Cnt - 5 j`��7 Date of Signature I ST. CROIX COUNTY ZONING DEPAR AS BUILT SANITARY REPORT' Owner Lc -i pa ssc_ - Property Address 1 535 A h dens o n re. �u i Cc►m P Rd � %,, I 1999 , City/State �lo� I +v� �J t s JNT' dtl Legal Description: 2 ' Lot Block Subdivision/CSM # O W %a -Cf,'/,, Sec. j_4, T N -R W, Town of Somerpd PIN # 03z -2a qX SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: tex l4: "& Tank manufacturer U hkn o &, Size�T PC j Setback from: House IS Well 6 PAL 6z' Pump manufacturer 96- 9-'& Model _ FSoos Alarm location ME' c... t h e o JC g g ra S e (HOLDING TANKS ONLY) n 1q Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM E X ; ,s-•�, Type of system: unka.uK Width Length Number of Trenches Setback from: House .29' Well 77' P/L S•7' Vent to fresh air intake 4 ELEVATIONS Description of benchmark o o . 7 deck- Elevation /00.00 Description of alternate benchmark Elevation '"P Of P r ToP o P�PIr Building Sewer 9 9 1 ST T Inlet 46• -t'd' ST Outlet — PC Inlet PC Bottom — Header/Manifold 0 ' 0 • 3 L Top o6T/PC Manhole Cover 9 t Distribution Lines ( ) _ /00 .512 7bP of Bottom of System O O ( ) Final Grade ( ) ( ) ( ) Date of installation Permit number 3ZY 7 '7 ► State plan number 1 89680 Plumber's signature � 1 oyay (j License number Z'SP Date 61 Inspector R o 3 r f: - S rr- Complete plot plan •+ I 4 , I T NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW See 4 Y4 c4d dralQj- INDICATE NORTH ARROW I { t ' J F- O J w a a. w c 0 O a o t� J a LL U 8 N m O t- a m O to LL O • CD rn a s 4 z O m z C9 2 z Z) O _ le 71� N (� Ln \)v U < m O U 7 40 z m N m J i RO C a W O O H 1- O � Q J � O F- O J i FAX ST. CRODC COUNTY ZONING OFFICE 1101 Carmichael Road Hudson, WI 54016 (715) 386 -4680 DATE: _ -�.� -� J( 9 Ct c TO: Fax Number: 7t 5 — - 7,p-c- - -PS 4 q Name: FROM: Fax Number. 386 -4686 Name: Number of Pages Including Cover Sheet: IF COMPLETE AND LEGIBLE INFORMATION IS NOT RECEIVED, PLEASE CONTACT: NAME TELEPHONE NUMBER: II