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Parcel #: 034 - 1000 -30 -000 11/17/2006 09:12 AM
PAGE 1OF1
Alt. Parcel #: 01.29.15.3 034 - TOWN OF SPRINGFIELD
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
VIRGINIA L YORK O - YORK, VIRGINIA L
1158 CTY RD W
DOWNING WI 54734
Districts: SC = School SP = Special Property Address(es): " = Primary
Type Dist # Description " 1158 CTY RD W
SC 2198 GLENWOOD CITY
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A -NOT AVAILABLE
SEC 1 T29N R1 5W SW NE (WD- 1043/57) Block/Condo Bldg:
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
01- 29N -15W
Notes: Parcel History:
Date Doc # Vol /Page Type
07/23/1997 1043/57 WD
07/23/1997 870/480
07/23/1997 816/605
07/23/1997 816/602
2006 SUMMARY Bill #: Fair Market Value: Assessed with:
Use Value Assessment
Valuations:
Last Changed: 04/14/2006
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 26.000 2,300 0 2,300 NO
UNDEVELOPED G5 12.000 500 0 500 NO
OTHER G7 2.000 9,550 117,000 126,550 NO
Totals for 2006:
General Property 40.000 12,350 117,000 129,350
Woodland 0.000 0 0
Totals for 2005:
General Property 40.000 12,700 117,000 129,700
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch M 113
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00
SPRINGFIELD R.29N -R.15W 37
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SEE PAGE 23 .Sf Cro:X Co�.n ty,W s.
j STEINER SALES & SERVICE, INC.
We can
make your
DAIRY EQUIPMENT (�� _ -,cows WATER SOFTENERS
SURSE
Phone: 684 -3261 Baldwin, Wisconsin
z
REPORT OF INSPECTION_ INDIVIDUAL S SYSTEM
San.i-taAy Petcm.it
k ,its State S
NAME (I/c<<.OS rownbhip St. Cno ix Count y j
Locat.iaw -561 61 section `Z__ I
SEPTIC: TANK
Size ga.Cton.6. Numb en as Campan.tmen.t,6
D.iztance FAam: Wet t ,Z- 12% aA gAeateA Atope
:.' Bu.itd.ing 6t. Wettand.6
H.ighwateA it. _.
DISPOSAL SYSTEM
D.iatance FAom: Wett� st. 12% an gAeateA ztope - it.
Bu.itd.ing it. Wettand,6 '" F t.
H.ighwateA " St.
FIELD DIMENSIONS: ��•
Width a4 tAench it. Depth ab Aock below t.ite _4-��in.
Length o4 each tine it. Depth as kock oveA t.ite 2-1 in.
Numb o4 t.ine6 Depth o6 t.ite below gAade
Total length o4 tinis it. Stope a6 trench ' in pen 100 it.
Distance b eture en tines /" {� t. Depth to b edtca cft fit.
Totat absoAbt.ion anea6t Depth to gtroundwatetc fit.
o
2 Type o Covc&: Pa tc tc Straw
- Requ.�.Aed area �t yp � e
p
PIT DIMENSIONS:
Numb et o6 pith G avet atcound p it�5 yea no
Outz ide d.iameteA epth b etow intet St.
Totat ab3oAbtion f` it2 A
all"
2
AAea Aequ.d fig` �t n '
INSP BY TITL
�,: ,
APPROVED DATE 1977.
E'D at�' ,
REJECTED ,DATE 197
7 V �
"r
efo/S
P L B 6 7 S tate and County State Permit # s
Permit Application County Permit
for Private Domestic Sewage Systems County !"ol
* DENOTES STATE APPROVAL REQUIRED
Date Approval Received from State if Required State Plan I.D. #
A. OWNER OF PROPERTY Mailing Address:
v o
LOCATION: 5L41_ %, Section TnN, R E (or) W Lot# City
Subdivision Name, nearest road, lake or landmark Blk# Village
Township
C. TYPE OF OCCUPANCY: Commercial *Industrial *Other (specify) * Variance
Single family r/ Duplex No. of Bedrooms 3 No. of Persons
D. SEPTIC TANK CAPACITY J O 0 Q Total gallons No. of tanks /
HOLDING TANK CAPACITY Total gallons No. of tanks
Prefab concrete Poured -in -Place Steel Fiberglass Other (specify)
New Installation Replacement
Lift Pump Tank or Siphon Chamber Total gallons Prefab concrete Poured -in -Place Other (Specify)
E. EFFLUENT DISPOSAL SYSTEM: Percolation Rate Total Absorb Area sq. ft.
New ✓ Replacement Alternate (Specify)
Seepage Trench: No. of Lineal Ft. Width Depth Tile depth (top) No. of Tra ches
Seepage Bed: 0'L-- ' Length S _ Width--/- 5L� _Depth Tile depth (top :2 5 " No. of Lines.
Seepage Pit: Inside diam r Liquid Depth No. of Seepage Pits
Percent slope of land _ /_T— Distance from critical slope
WATER SUPPLY: Private ❑ Joint Community ❑ Municipal ❑
Owners name as listed on EH 115 if other than pr owner:
I, the undersigned, do hereby certify that the information I have reported is in accord with Section H62.20,
Wisconsin Administrative Code, and that 1 have sized the effluent disposal system from the EH -115 prepared
by the tried Soil Tester, /f
NAME C.S.T. # '5.5 ,0 a 2 (0 and other information
obtained from (owner/builder).
Plumber's Signature MP /MPRSW# �` Phone #
4e 3 o7oZ_
Plumber's Address
PLAN VIEW: Provide sketch below of system (include direction of slope and all distances in accord with H62.20. Well loca-
tion shall be included on the sketch. Indicate or dimension location of all wells on the property or neighbors
property. If well has not been drilled please indicate.
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Do Not Write in Space Be w FOR COUN A ST E DEPARTMENT U ONLY
Date of Application _ O F b / County Date li'3a' 7
Permit Issued /Rejecte (date) Issuing Agent Name
Inspection Yes No State Valid# Date Recd
1. county (white copy) 3. owner (green copy) DIVISION OF HEALTH, P.O. BOX 309, MADISON, WI 53701
2. state (pink copy) 4. plumber (canary copy) Revised Date 7 /1/78
EH 115
WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF HEALTH, BUREAU OF ENVIRONMENTAL HEALTH
` P.O. BOX 309
' MADISON, WISCONSIN 53701
REPORT ON SOIL BORINGS AND PERCOLATION TE TS
LOCATION: Section J, T %, R L2 E (or) Q Township or Municipality a
•
Lot No. , Block No County
-rXbdivision Name
Owner's Name:
Mailing Address: R
TYPE OF OCCUPANCY: Residence No. of Bedrooms � Other
EFFLUENT DISPOSAL SYSTEM: NEW ✓ ADDITION REPLACEMENT
DATES OBSERVATIONS MADE: SOIL BORINGS y ?—PER CO ATION TESTS any
SOIL MAP SHEET SOIL TYPE
PERCOLATION TESTS
TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE
NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTER INTERVAL MIN /IN
BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3
/' 3Ca see Gar o 0 c�
30 ,. 3
, 3 n �� 0 l�, 7,
3o * � y C-A t o
SOIL BORING TESTS
TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, INCHES
NUMBER INCHES OBSERVED ESTIMATED HIGHEST (DEPTH TO BEDROCK IF OBSERVED)
B _ D > 4 0 s� , s s a S
S7_5
3'Ir
qty > 7 °'T.5 " s, I s3' S 0
B-
qb >q(p tiT St r1
�.+ q 7 q t. S" 5 S i S L, "S
PLAN VIEW (Locate percolation tests,soil bore holes and suitable soil areas.)
Indicate on the plan the locationand square feet of suitable areas. In irate number of square feet of absorption area
needed for building type and occupancy. ,,, hoo.
� ,la Indicate scale
or distances. Give horizontal and vertical reference p ints. Indicate slope.
r6 n
S 1
0
W
I
e to
I V Nc
ZS
d
G 1 E
q
c c D
�4
I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures
and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct
to the best of my knowledge and _be r lief.
°Q
Name (print) no i�- Ic+P� e— Certification No. G�5
Address qR oQ e.e,vi
Ile—
Name of installer if known
.g::�_�
COPY A —LOCAL AUTHORITY CST Signature
r 6
Wisconsin Department of Commerce Count
PRIVATE SEWAGE SYSTEM St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No: 430225 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 4Par Tax No:
York, Virginia Springfield 034- 1000 - 30-000
CST BM Elev: Insp. BM Elev: BM Description: �_ - ('� n/Town /Range /Map No:
% • J"7 46 / cj! IMAw L S 01.29.15.3
TANK INFORMATION EL ATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic �. , Benchmark �y
Bening � � Alt. BM 1, I
Aeration Bldg. Sewer 1 2
r
Holding St/Ht Inlet 37-
T SETBACK INFORMATION St/Ht outlet t
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD onl le ` �. �
Z
Septic / r r �R84tilem
AAA. > J, S D > J CC
S-�* LSD y(bpf (05 ! Header /Man.
Aeration Dist. Pipe
Holding Bot. System
Final Grade
P MP /SIPHON INFORMATION
Manufacturer Demand St-Cover
GPM
Model Numter
TDH Lift riction Loss System Head TD Ft
Forc ain Length Di
OIL ABSORPTION SYSTEM
BED/TRENCH Width Length o. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO P/L BLDG LL LAKE /STREAM LEACHING urer:
INFORMATION CH
Type Of System: UNIT Model Number:
DISTRIBUTION SYSTEM
Header /Manifold Distribution x Hole Si x Hole Spacing Vent to Air Intake
Pipe(s)
Length Di L ength Dia sing
SOIL COVER x Pressur stems Only xx Mound Or At - Grade Systems
Depth Over iDejatWOver xx Depth of xx Seeded /Sodded xx I
Edges Topsoil Bed/Trench Center ed/Trench Ed soil
g p Yes i] No [� Yes J �No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: } .� t `3 Inspection #2:
Location: 1158 County Road W Downing, WI 54734 (SW 114 NE 1/4 1 T29N R15yv) 40 acres Lot Parcel No: 01.29.15.3
1.) Alt BM Description =
2.) Bldg sewer length
- amount of cover = $14,
Plan revison Use other de for addition Yes l oll No —� - — -- L - —1— d --
Re
SBD -6710 (R.3/97) Insepctorsature Cert. No.
TWA w� r (/is—
\` County
St. Croix
3
Sanitary Permit Number (to be filled in by Co.)
0225
ermit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provid _
may be used for secondary purposes Privacy Law, s ii y Pr ject Address (if different than mailing address)
C EIV t
I. Application Information — Please Print All Information
S
Property Owner's Name t', P cel N Lot ( (,o ck 4
Virginia York
Property Owner's Mailing Address i ) r= C -? Pr erty Location (,j ru O y3
1158 CTHW W �- SW NE 1
City, Stale Zip Code Phone Number h, /., Section
Downing, WI 54734 715 265 - 7266 T 29 N: R 15 (c ir c le W e)
II. Type of Building (check all that apply)
3 Subdivision Name CSM Number
I or 2 Family Dwelling — Number of Bedrooms
❑ Public /Commercial — Describe Use
❑ State Owned — Describe Use ❑Ciry_ ❑Village ) BTownship of Springfiel
III. Type of Permit: (Check only one box on line ete lin App t1 cabTej°
A. ❑ New System p y g p g y JD ❑ Replacement S m reatinen oldin T ank Rep Only Other Modification [o Existing System
B - ❑Permit Renewal 11 Permit Revision ange o Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration Plumber Owner
IV. Type of POWTS System: Check all that appl
Non —pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑
-- Co nstructed Wetland ❑ Pressurized In-Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter
Recirculating Synthetic Media Filter ❑ Leaching Chamber"
hambe ❑ Drip Line ❑ Gravel less Pie Q P4er (expl in)
V. Dispersal/Treat - ent Area Information: l
Design Flow (gpd) Design Soil Application Rate(gpd Dispersal Area Required (so Dispersal Area Proposed (so System Elevation
450 0.7 643 existing 95.25
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
Gallons Gallons of Units. Concrete Constructed Glass
New I Existing
Tanks Tanks
Septic or Holding Tank 1000 1000 2000 2 HuffCutt X
Aerobic Treatment Unit
Dosing Chamber
VII. Responsibility Statemen a under) ned, assume esponsibility installation of the POWTS shown on the attached plans.
Plumber's Name (Print) lumber's tigliature /MPRS Number Business Phone Number
Tim Mittlestadt MPRS 227548 715- 665 -2112
Plumber's Address (Street, City, S te, p Code)
E. 742 HW 12, Knapp, WI 54749
VIII. County/ e artment Use Onl
Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date Issued Issuin gent Signature Stamps)
Surcharge Fee) 1
❑ Owner Given Reason for Denial
IX. Conditions of Approval/Reasons for Disapproval r .
4 � i i i
Atta� III to plans (to thl /e,1(County only) for �the �system �on paper not less than 8 112 X 1 1 l
SBD -6398 (R. 01 /0
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POWTS OWNER'S`MANUAL MANAGEMENT PLAN Page of
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner V Z� - N �{ ,,,(� Septic Tank Capacity I gal ❑ NA
Permit # Septic Tank Manufacturer d ❑ NA
DESIGN PARAMETERS Effluent Filter Manufacturer «. r_I N
Number of Bedrooms 100 d/bedroom ❑ NA Effluent Filter Model (a. two E] N a,
Number of Commercial Units y Pump Tank Capacity (9 V-%0 gal ❑ NA
Estimated flow (average)* 3 al/da Pump Tank Manufacturer ❑ NA l
Design flow (peak), estimated x 5* 4Yb al /da
Manufacturer w »� ❑ NA
Pump Model r❑ N,q
Soil Application Rate Oil �al /da ft Pretreatment Unit
Influent/Effluent Quality (NA❑) Monthly Average ** ❑ Sand/Gravel Filter ❑ Peat Filter
Fats. Oil & Grease (FOG) < 30 mg /L ❑ Mechanical Aeration ❑ %Vetlartd
Biochemical Oxygen Demand (BODs) < 220 mg /L C3 Disinfection ❑Other:
Total Suspended Solids (TSS) Manufacturer: Model:
_< 250 m L ✓* Dispersal Cell(s)
Pretreated Effluent Quality ❑ Monthly Average In- round
Biochemical Oxygen Demand (BODs) S 30 m /L g (gravity) C] In-ground (pressurized)
Total Suspended Solids (TSS) g ❑ At -grade ❑Mound
Fecal Coliform (geometric mean) 30 mg /L ❑ Drip-line ❑ Other: ^_
IO + cfu/100m1 ❑ Leaching Chamber Manufacturer _
Maximum Effluent Particle Size 1/8 inch diameter ve Model Approval Stipula! ion____
*Wastewater Flow Verification on and calculations: Soil Application Rate gpd/ft Area Req.
(Other than bedroom based) Absorption Area Credit per unit
Minimum Number of Chambers
❑ Aggregate Desi n Flow/Loading Rate= It' in i
** Values typical for domestic (non - commercial wastewater Materials: all materials must comply with WI Adm. Code
and septic tank effluent. COMM84 and be installed per manufacturers specificatio is
** *Values typical for prerreated wastewater. and approval letters.
DESIGN CRITERIA
❑ "Wisconsin At -grade Soil Absorption System, Siting, Design & Construction Manual" (Converse et.al.1990)
❑ "Wisconsin Mound Soil Absorption System: Siting, Design & Construction Manual" Converse, J.C. and E.J. Tyler.
Publication 15.22
❑ "Design of Pressure Distribution Networks for Septic Tank -Soil Absorption Systems" Publications 9.6
❑ "Design of Conventional Soil Absorption Trenches and Beds ". R.J. Otis — ASAE Publications 5 -77 and "Design ManuaI -
Onsite Wastewater Treatment and Disposal Systems ". EPA 625/1 -80 -012 October 1980
❑ SBD — 10570 —P (R.6/99) "At -Grade Component Manual Using Pressure Distribution"
❑ SBD — 10567 —P (R.6/99) "In Ground Absorption Component Manual"
❑ SBD — 10705 —P (N.01 101) "In Ground Soil Absorption Component Manual" Version 2.0
❑ SBD — 10628 —P (N.6/99) "Recirculating Sand Filter System Component Manual"
❑ SBD — 10656 —P (N.6/99) "Split Bed Recirculating Sand Filter System Component Manual"
❑ SBD - 10572 —P (R.6/99) "Mound Component Manual"
❑ SBD - 10691 —P (N.01 /01) "Mound Component Manual" Version 2.0
❑ SBD - 10595 —P (R.6/99) "Single Pass Sand Filter Component Manual"
❑ SBD 10657 —P (R.6/99) "Drip -line Effluent Disposal Component Manual"
• SBD - 10573 —P (R 6/99) "Pressure Distribution Component Manual"
• SBD - 10706 —P (N.01 101) "Pressure Distribution Component Manual" Version 2.0
• Drip -line Effluent Dispersal Component Manual for Multi -flo Onsite Wastewater Treatment Units
MAINTENANCE AND MANAGEMENT
MAINTENANCE MONITORING SCHEDULE
Service Event Service Frequenc
Inspect condition of tanks At least once every 7 ❑ months ears Max 3 yrs
Pump out contents of tanks When combined sludge and scum equals one -third 1/3 of tank volu ✓'
Inspect dispersal cells At least once every ❑ months C8 ears Maxi 3 vTs _
Clean effluent filter At least once every ❑ months :R year (s
Inspect pump, pump controls & alarm At least once every ❑ months ❑ year(s) ❑
Flush laterals and pressure test At least once every ❑months ❑ ears E3 NA
Valve --
al es At least once ever ❑ months ❑ ears
III ❑ N
Other: At least once ever ❑ months [] ❑ \A
I
i Page Z of 3
START UP ta'
For new construction, prior to use of the POWTS check tre ent to ) for the presence of painting products or other chemicals that
may impede the treatment process and/or damage the dispersal 1 . If high concentrations are detected have the'contents of the
tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are zen at the infiltrative surface.
OPERATION
The property owner is responsible for the operation'arid rhAiritenance of the'POWTS and submission of required reports. The quantity
and quality of the wastewater stream will affecrthe performance'atid longevity of your POWTS. The installation of water- saving
appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water
softeners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface
whenever possible. Note: this does not include laundry waste, showers, dishwater, etc. ✓
This system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetable /fn.it
peels and seeds, bones, and food solids such as those produced by a garbage disposal should be minimized. Toilet tissue is the on!\
paper that should be discharged into the system. Other non - biodegradable items such as baby wipes, tampons, sanitary napkins
condoms, cigarette butts, dental floss, and cotton swabs should not enter the system. Chemicals such as petroleum products, paint,
disinfectants, pesticides, antibiotics, solvents, etc,, should not be flushed into the system as they can seriously damage your POWTS
and contaminate your drinking water supply.
Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components.
Compaction of snow over the dispersal unit may cause it to freeze up.
0 Valves
Valves shall be operated in the following ma er:
O Alarms
Alarms should be tested on a regular basis by the Aown If a n alarm sounds, contact an individual licensed to service
POWTS, There is normally a 1 day reserve and regular operating conditions, however water should be conserved until any
problems with the system are corrected to pr entback -up of sewage into'the dwelling or surfacing.
INSPECTIONS
Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Mast"!.-
Plumber Restricted Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule).
(Septic Tanks Component
/J� Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks
or leaks, measure the volume of combined sludge and scum and to check for any backup or surfacing of effluent .
Access openings used for service or assessment shall be sealed and/or locked upon completion of service. Any
defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with an effective
locking device to prevent accidental or unauthorized entry into the tank.
When the combination of sludge and scum in any tank exceeds one -third (1/3) or more of the tank volume, the entire coa:ents
of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with Chapter NR1 13, Wisconsin
Administrative Code.
Th (ou�filte ) shall be insp ected and cleaned to remove an accumulat in the t tlt rding to o manufact�Ir
specs I ovistons are o e made to retain solids o er cleaning may be necessary at more
frequent intervals than stated in the maintenance schedule to keep the system operating.
CD Pump Chamber /Treatment Tanks Component
The inspection must include a test of all electrical equipment such as pumps, alarms and floats. A visual check must be
made for leaks, backups, surfacirig;'missing or bioken security devices and other hardware and the condition of the filter.
Any service needs or repairs shall be promptly taken care of.
ln- Ground Gravity Component Dispersal Cells r
Page_ of 3
The inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for an\
evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulator
authority. Ponding at depths greater than 75% of the height of the component may indicate overloading or impending
hydraulic failure necessitating more frequent monitoring.
C3 Mound, At- Grade, In- Ground Pressure
The inspection shall include recording the 16 els of ponding, if any in the observation tubes and a visual inspection for anN
evidence of surface seepage or discharge. An ischarge to th round surface must be promptly reported to the regulato
authority. Ponding greater than 75% of the heig of the c ponent may indicate overloading or impending hydraulic fail.ire
necessitating more frequent monitoring.
The pressure distribution system is provided wi an opens at the end of each lateral to be used for flushing. The laterals
should be flushed at least once every three years. Pressure checks of systems with multiple laterals should be done to
ensure that equal distribution of effluent ' occurring to promote the longevity of the system.
REPORTS
Reports for maintenance, inspection, and monitoring shall be submitted in accordance with COMM 83.55 Wisconsin Administrati\ e�
Code. ✓
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure that the system is
properly and safely abandoned in compliance with Ch. COMM 83.33, Wisconsin Administrative Code.
All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. ✓
The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled x:ln
soil, gravel or other inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
replace ent system:
replace
suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption syste:r.
The replacement area should be protected from disturbance and compaction and should not be infringed upon by required
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in th-
need for a new soil from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must
comply with the rules in effect at that time.
p A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POD TS technolo a
holding tank may be installed as a last resort to replace the failed POWTS.
p The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluai , n
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installe i
as a last resort to replace the failed POWTS.
p Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infilrrat:%e
surface. Reconstructions of such systems must comply with the rules in effect at that time.
<<WARNING>>
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASES 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 THE INTERIOR OF A TANK MAY BE DIFFICULT OR
IMPOSSIBLE.
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER _
Name % Name
Phone vlu I Phone
SEPTAGE SERVICING OPERATOR (Pumper) LOCAL REGULATORY AUTHORITY
Name A enc C."' ": x U-- -:(-*—*.% --
Phone Phone 3.16 4-6Y0
,
w 1809
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings in accordance . ode Certified Soil Testing
�'"1
Attach complete site plan on paper not less than 8' %x 11 inch a t • County St. Croix
include, but not limited to: vertical and horizontal reference poin dl
percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. Parcel I.D.
034 - 1000 -30 -000
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 Property Location
York, Virginia Govt. Lot SW 1/4 NE 1/4 S I T 29 N R 15 W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
1158 CTHW W
City State Zip Code Phone Number City Village yJ Town Nearest Road
Downing I WI 1 54734 715 - 265 -7266 Springfield CTHW W
New Construction Use: Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
V Replacement Public or commercial - Describe
Parent material sandy /loamy outwash Flood plain elevation, if applicable NA
General comments
and recommendations: Install –750 effective sq ft leaching chamber trench @ system elevation of 95.2 in B -1 - B -2 - B -3 area or
900 sq ft @ 95.2 in B -2 - B -3 - B -4 area
a Boring # - Boring
r/j Pit Ground Surface elev. 99.4 ft. Depth to limiting factor ' 104 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -11 10YR 2/2 - sil 2 f sbk mvfr cs 1f /m .5 .8
2 11 -18 10YR 4/3 - sil 2 m sbk mvfr gs 1m .5 .8
3 18 -28 10YR 4/3 - sl 2 m sbk mvfr cs 1 m .5 1 .9
I
4 28 -56 10YR 4/6 - s 0 sg ml gs 1m .7 1.2
_AS 5 56 -75 10YR 4/4 - s 0 sg ml cs .7 1.2
6 75 -104 10YR 4/3 - sl 1 m sbk mvfr - 4 .6
to horizon 5 has some thin (-1/8 ") stratified 10YR 3/4 Is bands
M e Boring # _j Boring
Pit Ground Surface elev. 98.7 ft. Depth to limiting factor 7 8 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -8 10YR 2/2 - sil 2 f sbk mvfr cs 1f /m .5 .8
2 8 -24 10YR 4/3 - sl 2 m sbk mvfr cs if .5 .9
3 24 -32 7.5YR 4/4 - s 0 sg ml gs if .7 1.2
4 32 78 10YR 4/6 - s 0 sg ml cs 1M .7 1.2
5 78 -84 10YR 3/4 f2f 7.5YR 5/3 Is 0 s ml -
g .7 1 1.2
i
stratified 10YR 3/4 Is bands: 1" @ 51" + 58 -60, 64 -66, & 78 -84
* Effluent #1 = BOD 30 < 220 mg /L and TSP >30 < 150 /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mgr
CST Name (Please Print) CST Number
V��
Henry F. Grote 222774
Address Certified Soil Testing Date Evaluation Conducted Telephone Number
E. 4366 353rd Ave., Menomonie, WI 54751 6/26/2003 715 - 233 -0398
Property Owner York, Virginia Parcel ID # 034 - 1000 -30 -000 Page 2 of 3 Y
a Boring # j Boring
Pit Ground Surface elev. 98.1 ft. Depth to limiting factor > 86 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P '
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0 -12 10YR 2/2 - sil 2 f sbk mvfr cs 1f /m .5 .8
2 12 -20 10YR 4/3 - sl 2 m sbk clsh gs if .5 .9
3 1 20 -30 7.5YR 4/4 - si 2 m sbk mvfr Cs if .5 .9
4 30 -40 7.5YR 4/4 - s 0 sg ml gs if .7 1.2
5 40 -86 10YR 4/6 - s 0 sg ml - - .7 1.2
10YR 3/4 sl band (0, m, mfr) @ 60-62; oversize nominal 0.7 loading to about 0.6 to account for textural variations @ depth (24 leaching chamber
shells => 746.4 sq ft w/ 31.1 ElSA/shell = >0.603 gpd /sq ft) if use B -1 - B -2 - B -3 area
47 Boring # j Boring
16 Pit Ground Surface elev. 97.4 ft. Depth to limiting factor > 95 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots QPDW
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0 -12 10YR 2/2 - sil 2 f sbk mvfr cs 1f /m .5 .8
2 12 -20 10YR 4/3 - sl 2 m sbk mvfr cs 1M .5 .9
3 j 20 -31 7.5YR 4/4 - sl 2 m sbk mvfr Cs if .5 .9
4 31 -44 7.5YR 4/4 - s 0 sg ml gs 1M .7 1.2
5 44 -95 10YR 4/6 - s 0 sg ml - .7 1.2
stratified 10YR 3/4 sl bands: 1/2" @ 43, 35 -36, 48 -49, 54 -58, 61 -62, 66 -67, & 75 -77'
❑ Boring # _j Boring
_j Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots '
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
I
I �
Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L " Effluent #2 = BOD :i 30 mg /L and TSS < 30 mg /L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 -266 -3 151 or TTY 608 - 264 -8777.
SBD -8330 (R.07 /00) Certified Soil Testing
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.-- fie Do" made beftmen WAYNE A- YORK and MARION I. M= C06
YORK, HUSBAND AND WIFE. AND VIRGINIA L YOR A
t •`i� w SINGLE PERSON Grantor, bed for �OOfd
x : OCT2 01993 .
' j " . and 2 INTMEST 11:05 A.
TO VIRGINIA L. YOR AN UNDIVIDED 2[,3
� INTEREST, AS JOINT TENANTS W132 RIGHTS OF
SMVIVORSHIP Grantee, - --
Witmweeth, That said Grantor, for a valuable T LAW R
# `(► +4 y ' consideration conveys to Grantee the following described
,t : real estate in ST. CROIX County, State of Wisconsin: P.O. BOX 3M
jjla 9
The Southwest Quarter (SW's /4) of the Northeast Quarter (list /4) and
the South Half (Si /1) of the Southeast Quarter (SBi /t` of the Northwest Quarter
(MI /4) , of Section One (1) , Township Twenty -nine (29) North, Mange Fifteen (15) ,
West, TOWN OF SPRINGFIELD, ST. CROIX COUNTY, WISCO 81M.
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Shia —ZAL homestead ps+opertp. LytQ!
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w �rk ether with all and sing u lar the bereditaments and �R9 �9 9u a ppurtenances thereunto belonging] And
F Grantor warrants that the title is good, indefeasible in fee simple and free and clear of
4 encumbrances except easements, restrictions and roadways of record, and will warrant and
.•, defend the same.
Dated this / g r7V day of 4>GMBA
1993.
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Wavne A. Yor (SFaw) * (SSaw)
_ Marion 1. York
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(SEAL) * V � (3B71I +)
Vixft L. York LEDGNOM
AUTHMTICAT'ION
STATE OF WISCONSIN
Signature (s) of Dunn County
4kt,, authenticated this day of , personally came before me this day of
�4 A „„ 1993. , 1993, the above named
av-
to me !mown to be the person (a) who
executed the foregoing instrument and acknowledge
TITLE: MMM OF STATE BAR OF WISco=X111 the same.
(If not, authorised by
1706.06, Wis. state.)
TXIB INSTRUlBN1' DRAFTED BY irotary public Dunn County, Wisconsin
r 4� my commission is permanent. (If not, state
expiration date: 1
v; THMXVGA LM FIRX (WHT)
(Signatures may be authenticated or acknowledged, both are not necessary.)
j •DTames of persona signing in any capacity should be typed or printed below their signatures.
4TATZ )m 01 UISCONSIN
VORK NO. 1
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rORIGINAI: 1809
Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3
Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code Certified Soil Testing
Attach complete site plan on paper not less than 8'/: x 11 inches in s¢ County e. Plan m St. Croix
include, but not limited to: vertical and horizontal reference point (BM), direction parcel I.D.
percent slope, scale or dimemsions, north arrow, and location and distance to n - 1000 -30 -000
Please print alb in#o=qt ion Review e y Date 'T
Personal information you provide may bused for jirposirs p (Pd" Law, s 5.04 (t) (m)). / l v
Property Owner Property Location �"ajys�Q pt
York, Virginia Govt. Lot SW 1/4 NE 1/4 S I T 29 N R 15 W
Property Owner's Mailing Address ( J Lot # Block # Subd. Name or CSM# 3
115 CTHW W
City Stat ' Pbone Nlimber ( City Village jje Town Nearest Road
Downing I WI 1 54734 715 Springfield CTHW W
New Construction Use: Residential / Number of bedrooms 3 Code derived design flow rate 450 GPD
✓'; Replacement Public or commercial - Describe
Parent material sandy /loamy outwash Flood plain elevation, if applicable NA
General comments
and recommendations: install —750 effective sq ft leaching chamber trench @ system elevation of 95.2 in B -1 - B -2 - B -3 area or
900 sq ft @ 95.2 in B - 2 - B - 3 - B - 4 area
FTI Boring # Boring
Pit Ground Surface elev. 99.4 ft. Depth to limiting factor > 104 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0 - 11 10YR 2/2 - sil 2 f sbk mvfr cs 1f /m .5 .8
2 11-18 10YR 4/3 - sil 2 m sbk mvfr gs 1 m .5 .8
3 18 -28 10YR 4/3 - sl 2 m sbk mvfr cs 1M .5 i .9
4 28 -56 10YR 4/6 - s 0 sg ml gs 1M .7 1.2
5 56 -75 10YR 4/4 - s 0 sg ml cs - .7 1.2
6 i 75 -104 + 10YR 4/3 - sl 1 m sbk mvfr - I .4 .6
horizon 5 has some thin ( -1/8 ") stratified 10YR 3/4 Is bands
Fil Boring # Boring
Pit Ground Surface elev. 98.7 ft. Depth to limiting factor 78 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0 -8 10YR 2/2 - sil 2 f sbk mvfr cs 1f /m .5 .8
2 8 -24 10YR 4/3 - sl 2 m sbk mvfr cs if .5 .9
3 24 -32 7.5YR 4/4 - s 0 sg ml gs if .7 1.2
4 32 -78 10YR 4/6 - s 0 sg ml cs 1M .7 1.2
5 78 -84 10YR 3/4 f2f 7.5YR 5/3 Is 0 sg ml - - .7 1.2
stratified 10YR 3/4 Is bands: 1" @ 51" + 58 -60, 64 -66, & 78 -84
' Effluent #1 = BOD 30 < 220 mg /L and TSf >30 < 150 /L Effl ent #2 = BOD < 30 mg /L and TSS < 30 mgr
CST Name (Please Print) S n ure: CST Number
Henry F. Grote 222774
Address Certified Soil Testing Date Evaluation Conducted Telephone Number
E. 4366 353rd Ave., Menomonie, WI 54751 6/26/2003 715- 233 -0398
Property Owner York, Virginia Parcel ID # 034 - 1000 -30 -000 Page 2 of 3
a Boring # Boring
Pit Ground Surface elev. 98.1 ft. Depth to limiting factor > 86 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture, Structure Consistence Boundary Roots '
in. Munsell Qu. Sz. Cont. Color` + Gr. Sz. Sh. 'Eff#1 'Eff#2
'
1 0 -12 10YR 2/2 - sil w 2 f sbk mvfr Cs 1f /m .5 .8
2 12 -20 10YR 4/3 - sl 2 m sbk dsh gs if .5 .9
3 20 -30 7.5YR 4/4 - sl 2 m sbk mvfr cs if .5 .9
4 30 -40 7.5YR 4/4 - s 0 sg ml gs if .7 1.2
5 40 -86 10YR 4/6 - s 0 sg ml - - . 7 12
10YR 3/4 sl band (0, m, mfr 60 -62; oversize nominal 0.7 loading to about 0.6 to account for textural variations @ 9 at ons @depth (24 leaching chamber
shells => 746.4 sq ft w/ 31.1 EISA/shell = >0.603 gpd /sq ft) if use B -1 - B -2 - B -3 area
7 Boring # Boring
Pit Ground Surface elev. 97.4 ft. Depth to limiting factor > 95 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots '
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
1 0 -12 10YR 2/2 _ sil 2 f sbk mvfr CS 1f /m .5 .8
2 12 -20 10YR 4/3 _ sl 2 m sbk mvfr CS 1M .5 .9
3 20 -31 7.5YR 4/4 _ sl 2 m sbk mvfr cs if .5 .9
4 31 -44 7.5YR 4/4 _ s 0 sg ml gs 1m .7 1 1.2
5 44 -95 10YR 4/6 _ s 0 sg ml - - . 7 1.2
stratified 10YR 3/4 sl bands: 1/2" @ 43, 35 -36, 48 -49, 54 -58, 61 -62, 66 -67, & 75 -77"
F-1 Boring # Boring
f Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GpDtft2
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2
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' Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg /L ' Effluent #2 = BOD < 30 mg /L and TSS < 30 mg /L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777.
SBD -8330 (R.07 /00)
Certified Soil Testing
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W'.sconsin Departrnent of Commerce .SOIL AND SITE EVALUATION Page ___L of _. 3 _
-Diq lon of Safety and Buildings in'accord with Comm 83.05, Wis. Adm. Code
Certified Soil Testing
Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County
include, but not limited to: vertical and horizontal reference point (BM), direction and St. Croix
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. — -- - - - -- - - -- - —
Parcell.D.# 034 - 100 -1 -20
APPLICANT INFORMATION - P fornladon. - - - - - -- - -- - -- - -
Perwml information you provide may be ! yacy Law, s. 15.04 (1) (m)). Rev y
i - y - - - --
p operty Location
Pro pert co n" r 1 `E�E�UL `�._ Govt. Lot NW 1/4 SW 1/4 S 1 T 29 N 15 W
P ropert Owners Mailin Addr ' Lot # Block # Subd. Name or CSM#
1134 �ural Road # 4 ___ i � �� fn
City tae Zi (',tom a umt�er ❑ City [� Village ®Town Nearest Road
GI City Springfield Rural Road # 4
7] New Construction Use: ntial � *?aWldescribe bedrooms 2 ❑Addition to existing building
X Replacement ubl' r
Code Derived daily flow 300 gpd Recommended design loading rate .4 bed, gpd/ft' .5 trench, gpolft'
Absorption area required 750 bed, ft' 600 trench, ft' Maximum design loading rate .4 bed, gpd/ft' S tr ench, gpd
Recommended infiltration surface elevation(s) lateral on 105.9 ft (as referred to site plan benchmar
Additional design / site consideration i nstall 9 'x 85' effective (11' x 89' overall) at - grade rock unit on 105.9 contour
Parent material sandstone Flood plain elevation, if ap licable NA ft
rU=Un suitaSuitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank
ble for system ❑ N U N S LO U El S ®U N S❑ U C S N U C-', S x U
Depth Dominant Color Mottles Structure GPD/ft'
Horizon Texture Consistence Boundary Roots - - -
' Boring# m. MunseN Qu. Sz. Cont. Color Gr. Sz. Sh. Bed j Trench
Q ` `" 1 04 10YR 2/1 - A 2 m gr mvfr gs if /m .5 .6
2 4 -12 10YR 2/2 - sl 1 m sbk mvfr cs 1m .4 .5
Ground 3 12 -16 10YR 3/2 - A I m sbk mvfr gs If .4 .5
elev - -1-- — -- .
104.5 ft 4 16 -29 1 OYR 4/4 - A 2 m sbk mfr gs 1 m .5 .6
Depth 10 5 29 -37 I OYR 4/6 - sl 2 m sbk mfr cs l m .5 .6
famctorg 6 37 -70 1 OYR 4/6 c2d 7.5YR 4/6,5/3 scl 0 m mfi - - NP 2
37 '
Remarks. Gy si coats on pods 16
i k
2 1 0 -5 10YR 2/1 - sl 2 m gr mvfr + _ cs I f/m 5 ! 6
2 5 -16 10YR 3/2 - sl I m sbk mvfr cs j !m 4 .5
Ground 3 16 -21 10YR 4/4 - sl 2 m sbk mfr gs 1 m .5 i .6
elev — -- -- -- - -- - -- - t
105.9 ft 4 21 -38 IOYR 4/6 - sl 2 m sbk mfr i cs 1 m .5 .6
Depth to 5 38 -58 I OYR 4/6 fld 7.5YR 4/6,5/3 scl 1 m sbk mfr I - - .2 j .3
limiting
factor - -- -
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Remarks:
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CST Name (Please Print) Signature: Telephone No.
Henry F. Grote - 715 -665 -2681
C r of estrng -- - -- ------- - - - - -- - __ --- - - - - -- - -- - .. __ ._
Address D to CST Number Ref #
P.O. Box 57, Knapp, WI -54749 427/1999 222774 1135
PROF -,iTY OWNER Laskin Ja ms SOIL DESCRIPTION REPORT S page 2 of 3
PARCEL LDJ _ 034 -100- 1 -2 0 Certified Soil Testing
Depth Dominant Color Mottles Stru cture GPD/ft
Horizon in M�Insell Du. Sz. Cont. Color Texture Sz Sh nsistenoe Boundary, Roots , -
Bed Trench
1 0-4 10YR 2/1 - sl 2 m gr mvfr cs lf/m .5 .6
2 4 -15 10YR 3/2 - sl 1 m sbk mvfr cs lm .4 .5
Ground 3 15 -20 10YR 4/3 - sl 2 m sbk mvfr gs IM .5
eiev - .6
105.9 ft 4 20 -38 10YR 4/4 - sl 2 m sbk mfr cs lm .5 .6
Depth to 5 38 -72 10YR 4/4,4/6 c p 7.5YR 5/3 scl I m sbk mfr - - .2 .3
limiting - -- -- - -- -
factor
38' - -- - - --
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Remarks: an s w _ TM I U Y K 41b trio bZ - bY
Ground
elev - — I - - - -� -- -
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Depth to { —_ - -- - -- - -- -- - - -
limiting i
factor
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Remarks:
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Ground _ -'
eleV - 4 - -- - -- - i - -- _ - - -
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Depth to 1
limiting
factor
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Remarks:
Ground - -- -
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Remarks _._ _
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Safety and Buildings Division
SANITARY PERMIT APPLICATION Bureau of Building Water System:
201 E. Washington Ave.
In accord with ILHR 83.05, Wis. Ad e 2 P.O. Box 7969
Madison, WI 53707 -7969
• Attach complete plans (to the county copy only) for the syste ��ct peLnot ess O
than 81/2 x 11 inches in size. E e
• See reverse side for instructions for completing this applicat sta a , itary Permit Number
„�14� 3 �3 gs3
The information you provide may be used by other government agency progra �� J [I C etlMl revision to previous application
(Privacy Law, s. 15.04 (1) (m)]. S1 to P n I.D. Number
I. APPLICATION INFORMATION - PLEASE PRINT ALL I MATI e47.2 7
Property Owner Name o y Lo do
N, R E (or
Property Owner's Mailing r Lo Block Number
%J f W/t1
City, State Zip Code Phone Number Subdivision Name or C Number
II. TYPE OF BUILDING: (check one) ❑ State Owned El ity NearestRoad��
Public 1 or 2 Family Dwelling - No. of bedrooms El r9tT own g OF!5 f& lV r2i4t /Go
III. BUILDING USE (if building type is public, check all that apply) Parcel Tax Numbers)
1 ❑ Apartment/ Condo d-3 `per
i Nursing Home 10
2 E] Assembly Hall 6 E] Medical Facility/ g ❑ 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: box on line A. Check box on line B, if applicable)
A) 1 E] New 2 Ce Replacement 3 E] Replacement of 4_ ❑ Reconnection of 5_ E] Repair of an
------ ---- ____ ___System Tank Only______________ Existing System --------- _Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non- Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 []Holding Tank
12 ❑ Seepage Trench 22 ❑ In- Ground Pressur 42 [] Pit Privy
13 []Seepage Pit t r �7 61 43 ❑ Vault Privy
14 ❑ System -In -Fill 8 ift2A
VI. ABSORPTION SY T M INFORMATION: ,
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade
Required (sq. ft -) Proposed (sq. ft.) � I aay /sq. ft_) (Min. /inch) Elevation
lr -o Z ty - �,591� Feet /&47 Feet
Cap
VII. TANK in Ca gallons Total # of Prefab. Site Fiber- plastic Exper.
INFORMATION Gallons Tanks Manufacturer's Name Concrete Con- Steel glass App.
New Existing structed
Tanks Tanks rte
Septic Tank or Holding Tank Q�v If
Lift Pump Tank /Siphon Chamber Ej El Ej EJ
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plum er's Si nature: No Stamps) MP /MPRSW No.: Business Phone Number:
=d — �.z o
Plumb is Address (Street, City, Itate, Zip de
IX. COUNTY / DEPARTMENT USE ONLY
[] Disapproved Sanitary Permit Fee (I Surcha r a Fee) water ate ssue Issuing Agent Signature (NO Stamps)
Surcharge Fee) r
❑ Approved ❑ Owner Given Initial s 00
Adverse Determination
X. CONDITIONS OF AP OVAL/ RE NS FOR D
OVAL
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SRO -6398 (R. ' 117f4)Q DISTRIBUTION: riginal to county, nne copy To: Safely & Buildings Division, Owner, Plumber
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