HomeMy WebLinkAbout034-1011-40-000 I D
commerce.wl.gov., COV Wisconsin Fund -
iscon s i n ' ! O er Private Onsite Wastewater
_ Treatment System
Department of commerce A I o 209�p� I ation Replacement or Rehabilitation
safety and Buildings Divisio Financial Assistance Program
Instructions For Property Owne S CROIX TO BE COMPLETED' BY COMIVIEPFGE
You may apply for a grant award for up to three ' F ICE received a
determination of failure and after you h e o tained a sanitary permit. Complete Part A of
this form, attach evidence of your annual income explained in Section #7, and return those
items to the sanitation or health department office in the county where the property is
located.
PART A. TO BE COMPLETED BY THE PROPERTY OWNER Please print.
O w
Owner* Oner Owner
p (C il e S
Owner Owner Owner
b e..l
Address City, State, Zip Code Telephone Number
*Grant awards will be issued in the name and address of this If there are additional owners, attach documentation listing all
owner.
owners.
1. Is this application for a principal residence or a small commercial establishment? Principal Residence
(Complete both if applicable.) Small Commercial
Establishment
If applying as a principal residence, do you occupy this residence 51 % of the year? es No NA
If applying as a small commercial establishment, do you own and occupy the small
commercial establishment? Yes NA
2. If applying as a small commercial establishment,
what is the name of the small commercial establishment?
Description of Small Commercial Establishment (farm, restaurant, etc.):
3. Has there been a change in ownership of the principal residence or small commercial
establishment served by the failing system within the last three years? Yes No
If yes, please explain:
4. As the owner, are you a licensed plumber or contractor engaged in the business of
installing private onsite wastewater treatment systems? Yes
5. Will a portion of the replacement system be funded by another program? Yes No
If yes, explain:
6. How did you hear about the Wisconsin Fund - Private Onsite Wastewater Treatment System Replacement or Rehabilitation Program?
7. Evidence of income. If you are applying as a principal residence, attach a copy of your federal income tax return for the year of or
prior to the determination of failure. If you were married and filed separate forms, you must also include your spouse's return for the
same year. You must include evidence of income for each owner and for each owner's spouse. If you are applying as a small
commercial establishment, submit a copy of your federal profit and loss form for the year of or prior to the order or determination of failure.
If you or any owner listed above did not file an income tax return, contact your governmental unit for further instructions. Evidence of
income will be kept on file at the governmental unit and is subject to verification by the Department of Commerce.
Property Owner's Certification. I certify that, to the best of my knowledge and belief, the information I have provided on this
form and all attachments are true and correct.
Owner's Signature Date Signed Co- Owner's Signature Date Signed
r r-
�t
4) --G _nom oo / / _7 08-
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)].
SBD -9163 (R. 02/2005)
i
PART B. TO BE COMPLETED BY T 00VERNMENTAL UNIT
1. VERIFICATION OF OWNERSHIP
On the document used to verify ownership, do the names match those on Part A of this
application? If no, please attach additional documentation explaining. Yes No
If the applicant answered yes to question 3 on Part A of this application, did the applicant(s)
own the property when the order or verification of failure was issued or the system installed Yes No
and incur the cost of replacement?
(� v� /� n Document or Page
Document used to verify ownership: l faA5�.. o kJ tr '0 e�lC Number:
2. Is a public sewer available to this property? Yes No
3. Has a previous grant been awarded for this property under this program? Yes C
4. Principal Residence evidence of income. Please indicate applicable annual family income: $ L
Federal income tax form IND Line 37 , Year 7M7 OR Affidavit of Year
Small Commercial Establishment evidence of income. Please indicate applicable annual gross revenue: $
Profit & loss form used: Line Year
5. Date of the Order or Determination of Failure: 16 r t i o$
When was the existing failing system installed? Prior to 12 -1 -1969
12 -1 -1969 to 7 -1 -1978
f the existing infiltrative surface to a limiting Vertical distance from the bottom o g 9 condition: 0 to Less tha
24 to Less than 36"
Equal to or greater than 36"
6. Private onsite wastewater treatment system failure caused by discharge of sewage to (check all that apply):
Suwater roundwater ................................................................................ ...............................
( 2EDA zone of saturation ........................................................................................... ...............................
Adrain the or zone of bedrock ............................................................................... ...............................
Category2 The surface of the ground ...................................................................................... ...............................
Category 3 Back -up of sewage into the structure served ........................................................ ...............................
At -grade
7. This request is for what type of replacement system:
Conventional
If this request is for a system not listed at the right, please explain: Experimental
Holding Tank
In d Pressure
Mound
8. Uniform Sanitary Permit Number 5/50/2 Date Issued 16 �d8
Plan Approval Number J � c l 7 4 1 &A Date Approved X0 /1 7 b �
Exp eriment App roval Number Date Approved
9. After reviewing this application, I have determined the applicant to be: Eligible
Ineligible
If ineligible, reason ineligible:
10. Governmental Unit Representative's Certification. I certify that I have reviewed and verified all information provided on this
form and attachments and that they are true and correct to the best of m knowledge and belief.
Si ure of rized Govern tal Unit Representative Title Date Signed
Z ,106�
commerce.wi.gov Wisconsin Fund -
Private Onsite Wastewater
i s c o n s i n Grant Treatment System
Department of Commerce Worksheet Replacement or Rehabilitation
Safety and Building Division Financial Assistance Program
Owner's Name: Governmental Unit:
4r �: A. e
In Sections B -F, the number of bedrooms determine the grant award To use the grant funding 'de the
estimated daily wastewater flow rate in gallons per day b 150, round off to the next highest whole number, and use the e resu t for the i number of bedrooms.
A. Site evaluation and soil testing. Grant amount $250. $ [$�
B. Installation of a replacement anaerobic treatment component.
Number of Bedrooms Grant Amount
1 or 2 .................................................................... ............................... ...........................$500
550
........................................................................................... ............................... 650
.....:....................................................... ............................... 725
... ...............................
6 750
7 875
.......
8 or more-, .......................... ........................ .......950 $
........... ...............................
C. Installation of a dosing component, lift pump or siphon:
Number of Bedrooms Grant Amount
........................................................................... ...... .... ......................... $1,100
...........
l3 ste ......................................... ............................... ...............1 200
. ... ........... ...........
...................... . $
.................. ............................... ........................1,250 Z
D. Installation of a non - pressurized and in- ground pressure POWTS treatment or dispersal component.
Percolation Rate Design Loading
When Properly Filed Rate in Gallons
with the Governmental Per Square Each Additional
Unit Before 7 -2 -94 Foot Per Day 1 2 3 4 5 Bedroom:
Minutes Per Inch
0 to less than 10 0.7 or more $ 1,400 $1,450 $1,925 $2,100 $2,100 $250
10 to less than 30 0.60 to 0.69 1,475 1,475 2,100 2,200 2,250 250
30 to less than 45 0.50 to 0.59 1,475 1,475 2,100 2,400 2,450 300 A
45 to less than 60 0.49 or less 1,475 1,550 2,325 2,725 2,750 300 $ A
E. Installation of an at -grade or mound POWTS treatment or dispersal component.
Each Additional
Tvpe of Design 1 2 3 4 5 Bedroom:
At -Grade $2,050 $2,350 $2,600 $3,200 $3,800 $275
High Groundwater Mound 2,550 3,500 4,100 4,750 4,775 300
High Bedrock Mound 4,000 4,600 4,675 , 4,775 350
* Slowly Permeable Mound 3,250 3,600 4,400 4,750 4,750 375
Mound with less than 24" of suitable c
Soil or reciter than 12% slope. 3,050 4,175 4,400 4,775 4,775 375 $ q 75 0
0
* A slowly permeable mound may be designed using percolation test results property filed with the county before 7/2194. A slowly permeable mound is
defined in s. Comm 83.23(1)(b) as having a percolation rate of greater than 60 minutes per inch and less than or equal to 120 minutes per inch, or having a
soil loading rate of 0.3 or less.
F. Installation of a POWTS Holding Component.
Each Additional
1, 2 or 3 4 5 6 7 8 Bedroom: /^�
Grant Amount: $2,800 3,200 3,850 4,400 4,775 4,775 $400 $
Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)]. /(>ti'4
SBD -9167 (R. 10/08)
RAFT 1 GRANT Fl1ND:iN,G TALE9 continues!
G. Installation of a Replacement Exterior Grease Interceptor by Gallon Capacity.
Gallons: Up to 1,249 1,250 -1,499 1,500 -1,749 1,750 -1,999 2,000 or more
Grant Amount: $550 $650 $750 $800 $900 $ /V
Amount Requested
H. Installation of an Experimental System. For Installation:
If you are requesting funding for an experimental system, please submit a copy of the Wisconsin Fund $ , I�
pre - approval letter along with a copy of the plan approval letter and experimental approval letter N
containing corresponding identification numbers. Amount Requested
For Monitoring:
List the total cost of the experimental system and monitoring that is being requested separately at the $ N t_
right. Copies of paid invoices must be submitted with this request.
I. Installations not Covered by the Grant Funding Tables.
The Department on a case -by -case basis reviews installations not covered by the Grant Funding
Tables. If you are requesting funding for an installation not covered by the grant funding tables or listed
in Sections A -H, please explain your request here, attach a copy of the paid invoice showing the cost of
the item, and request 60% of the cost of the installation at the right.
$ NA,
TOTAL PART 1. $ tP 5O
O U R T�AT 'A'[ I >fIVS
A. Enter the total from Part 1. $
B. Is the applicant a licensed plumber or contractor that installs private onsite wastewater treatment
systems? If yes, enter 2/3 of the amount from section A in this section or $4,667, whichever amount
is less. if the applicant is not an installer, carry the amount forward from Section A to Section B. $ v
C. If this application is for a small commercial establishment and the annual gross income of
the business that owns the small commercial establishment is less than $362,500, the amount
listed in Section B is the total grant award. Carry the amount in Section B forward to Section F.
If this application is for a principal residence and the annual family income of the owner(s) is
1 ss than $32,001, the amount listed in Section B is the total grant award. Carry the amount in
Section orw rd to Section F.
If this application is for a principal residence and the annual family income of the owner(s) is N�
between $32,001 and $44,999, list the amount in Section B here and go on to Section D. $
D. Calculate 30% of the amount by which the applicants annual family income exceeds
$32,000 here and then continue to Section E.
Annual Family Income
Subtract $32,000
Subtotal X .30 = $ VA
E. Subtract section D from section C. This is the maximum grant amount for this applicant.
Carry this amount forward to section F. $ /V
F. Total grant award requested for this applicant up to the maximum of $7,000.
(The amount in this section must be at least $100 for the applicant to be eligible for a grant award. ¢ ��
K the amount calculated is less than $100, the applicant is not eligible.) $ v
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT sanitary Permit No:
515019 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
Permit Holder's Name: City Village X Township Parcel Tax No:
Haines, Richard B. & Donna J. I S rin field, Town of 034 - 1011 -40 -000
CST BM Elev Insp. BM Elev: IBM Description: ten,, Section/Town /Range /Map No:
- _97 9 / v l Z 06.29.15.84
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic /� Benctyna 7i
Dosing -7� /4f4- Bflfl —
Aeration B Sewer
Holding
St/Ht Ins
St/Ht Outlet
TANK SETBACK INFORMATION
TANK TO P/L WEL BLDG. Vent to Air Intake ROAD Dt Inlet
Se tic. I i Dt - X010 Botto
I ) 6D Ct 3. -R
Dosing `/I(� Header /Ma
Aeration Dist. Pipe c�
Holding BIZ-By-stem
Final Grade / (9
PUMP /SIPHON INFORMATION k�
Manufacturer Ll�y GPM at Cov er �I k via q I ,
Model Number i%� qq I
A UJ11-
TDH l l-i4 m FrictiI Loss SysteGHe TDF O 3 Ft
. 9 ;
Forcemain Length Dia. 1 Dist. to Well
10 �-
SOIL ABSORPTION SYSTEM a �.
BEDITRENCH Width Length No. Of Trenches PIT IM IONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS / 0 / �
SETBACK SYSTEM TO CJ P/ BLDG WELL LAKE /STR M _ CHING Manufacturer:
INFORMATION CHA ER
Type Qf�System: r � � � � br U Model Number:
DISTRI TION SYSTEM i - SCH �
Header/ anifol Distribution q x Hole Size x Hole Spacing Ve o Air intake
rr Pipe(s) 1 � S 3 / o.1 2S / r � TYlJ
Length Dia Length Dia Spacing
SOIL COVER x Pressure Systems Only ound Or Systems Only
Depth Over Depth Over xx Depth of xx Se ded/ dded xx Mulched
'I
Bed/Trench Center Bed/Trench Edges Topsoil
� [] 2 mm Yes No E] Yes E] No
COMMENTS: (Include code discrepencies persons present, etc.) spection #1: � / 3� / V Inspection #2: I /
Location: 1160 280th Street Glenwood Ci y, WI 54013 (SE 1/4 NE 1/4 6 TN R15W) 40 acres Lot Parcel No: 06.29.15.84
1.) Alt BM Description = I
2.) Bldg sewer length = 98
- amount of cover _ Cl�jt (�ee� /,(r
= I litif ` b d� a. a,
5 � 4- a4a
Plan revision Required? � Yes o C
Use other side for additional information. ®_ 3 _ C -
Date L Insepctor's ure Cert. No.
SBD -6710 (R3/97)
commerce.wi.gov Safety and Buildings Division County
201 W. Washington Ave., P.O. Box 7162 �f
S C O S ' n Madison, WI 53707-7162 Sanity ry Permit Number 1 17 filled in by Co.)
Department of Commerce
Sanitary Permit Applicati State Transaction Number
- tal
In accordance with s. Comm. 81.21(2), Wis. Adm. Code, submission of this form to the !•;;�CTISm
unit is required prior to obtaining a sanitary permit. Note: Application forms or state -owned POWTS are Project Address (ifdifferent than mailing address)
submitted to the Department of Commerce. Personal information you provide may be used for secondary
u uses in accordance with the Privacy Law, s. 15 040)(m), Stats.
1. Application Information - Please Print Ali Information
Property Owner's Name Parcel #
f� i tc _ - Dl - 0 -Z1
Property Owner's Mailing Address Property Location
//4 Zb?d?"—.-SY- ST. CROIX COUNTY Govt. Lot
City, State Zip Code Phe1Q1N Qie0FFICE S E y, fi y,, Section _
`5Y61 '7 /S" 2' y 5 " 'y � T �_ N; R irclE o" W
I1. Type of Building (check all that apply) Lot #
1 or 2 Family Dwelling - Number of Bedrooms --- Subdivision Name
�sIl ti Block #
❑ Public /Commercial - Describe Use / � 1
11� �jl , "' ❑ C i h. of
❑ State Owned - Describe Use CSM Number ❑ Village of
Town of :5? /rJ6F eZA
111. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A.
❑ New System eplacement System ❑ Treatment /Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
Date Issued
B. ❑Permit Renewal Permit Revision ❑ Change of Plumber ❑ Peit Transfer to N w e ���� mn � Previous Permit Number and '/�1
Before Expiration Owner V'l
IV. Type of POWTS System/Component/Device: Check all that apply) (�
❑ Non - Pressurized In- Ground ❑ Pressurized In- Ground 11 At-Grade El Mound > 24 in. 0fsuitable soil Mound < 24 in of suitabl i
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil Application Ra e(gpdst) Dispersal Area Required ( f) Dispersal Area Pro sed (st) System Elevation
(le a0 i ns , z �� o t3 �o-� e e, Boa `�!� . 39
VI. Tank Info C acity in Total # of Manufacturer
Gallons Gallons Units a v u
U �
New Tanks Existing Tanks y v 0
Septic or Holding Tank /QUO A R M-
Dosing Chamber < ��
VII. Responsibility Statement- 1, the undersigns , atsume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) PI er's Signature MP /MPRS Number Business Phone Number
210 ? /s'
Plumber's, Address (Street, City. State. Zip Code)
z f Y3 /3d'V AA-e
VIII. ount y /De artment Use Only
Approved ❑ Disapproved Per /miit fee Date Issued p Iss g Agent Sig Lure
El Owner Given Reason for Denial $ lS� �' / aa7
IX. Conditions of Approval/Reasons for Disapproval
SYSTEM OWNER: �j 3
9 Septic tank, effluent filter and
dispersal cell must all be serviced / maintained • � 44-x.
a5 pel c I . r em ant submit to the County only on paper not less than 8 IR x I 1 inches I n size
2. All setback requirements must be maintained
as per applicable code /ordinances.
SBD -6398 (R. 01/07) Valid thtu 01/09
� o h
G p N
S .l'a �• C
y
w
� � w
0 w
�A
280 A4 .�JL
Safety and Buildings
141 NW BARSTOW ST FL 4TH
lt commerce .Wi.gov WAUKESHA WI 53188 -3789
i Contact Through Relay
! ov
sco n s' n www.wisconsin
e of Commerce g
Jim Doyle, Governor
Richard J. Leinenkugel, Secretary
October 17, 2008
CUST ID No. 267985 ATTN.- POWTS Inspector
MICHAEL J MYERS ZONING OFFICE
NORTHLAND PLUMBING INC ST CROIX COUNTY SPIA
2943 130TH AVE 1101 CARMICHAEL RD
GLENWOOD CITY WI 54013 HUDSON WI 54016
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 10/17/2010 Identification Numbers
Transaction ID No. 1597400
SITE: Site ID No. 743346
Richard Haines Please refer to both identification numbers,
1160 280TH St above, in all correspondence with the agency.
Town of Springfield, 54013
St Croix County
SETA, NEIA, S6, T29N, R15W
FOR:
Description: Mound, 4 bedroom
Object Type: POWTS Component Manual Regulated Object ID No.: 1204116
Maintenance required; Replacement system; 600 GPD Flow rate; 17 in Soil minimum depth to limiting factor from
original grade; System(s): Mound Component Manual - Version 2.0, SBD- 10691 -P (N.01 /01), Pressure Distribution
Component Manual - Version 2.0, S13D- 10706 -P (N.01 /O1)
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed
and located in accordance with the enclosed approved plans and with any component manual(s) referenced above.
The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code
requirements.
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06,
stats.
The following conditions shall be met during construction or installation and prior to occupancy or use:
This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound
Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD- 10691 -P (N.01 /01) and the
"Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems VERSION 2.0" SBD -
10706 -P (N.01 /01).
In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the
property owner must follow the contingency plan as described in the approved plans. In addition, the owner must
comply with the operation, maintenance and monitoring duties as described in section VIII of the m�nd & onent
manual. A copy of this information must be given to the owner upon completion of the pro
jec �j ? �.•
All holding/treatment tanks are to comply with Comm. 84.25(7)(a). 4 1.. p
wi Rry
Maintenance information must be given to the owner of the tank explaining that perio ' cleaningm the filter is
required. Access to the filter for cleaning must be provided per Comm 84 product apprs� ditions.
A Sanitary Permit must be obtained from the county where this project is located in accordance with the
requirements of Sec. 145.135 and 145.19, Wis. Stats.
MICHAEL J MYERS Page 2 10/17/2008
Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the
designated county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stats.
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.
Owner Responsibilities:
• Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and
maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s.
Comm 83.54(1).
• Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as
required under s. Comm 83.54(4) shall be considered a human health hazard.
• Comm 83.55 The owner is responsible for submitting a maintenance verification report acceptable to the county
for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s)
utilized in the POWTS.
In
granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should
conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review
shall relieve the designer of the responsibility for designing a safe building, structure, or component.
Beginning October 1", 2008, small wastewater holding tanks with estimated flows less than 3,000 gpd that are based
completely on approved POWTS component manuals must be submitted to the appropriate governmental unit and
will no longer be accepted by the Safety and Buildings Division for review. Please refer to s. Comm 83.22, Wis.
Adm. Code for further information.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the
installation, operation or maintenance of the POWTS.
S' rely, Fee Required $ 175.00
Fee Received $ 175.00
Balance Due $ 0.00
Julia Lewis - Osborne
POWTS Reviewer 2, Integrated Services WiSMART code: 7633
(262) 397 -6005, Fax: (608) 283 -7481
julia.lewis@wisconsin.gov
Mound System Cover Page as I of 6
WIENER eannETE
Project Name: Haines -Mound
Owner's Name Richard Haines
Owners Address 1160 280th St
Glenwood City,Wl 54013
Legal Description SE NE %. SeC(�� T 29 N, R 15 w1
Township Springfield RECEIV
County �r>tcl x • OCT - 9 2008
Subdivision S A FETY & BUILDINGS
Lot#
Parcel ID#
Table of Contents
pg-
1 Cover page
2 Mound Sizing Calculations
3 Pressure Distribution Layout and Dynamics
4 Dose Tank
5 Management and Contingency Plan
6 Plot Map
total # of pages: 6
Designer Name: Michael J. Myers
MP /License #: 267985
Date: 1016/08
Ph. #: 715-265-4115
Signature: TS'
Mound System Design Methods Used
per "Mound Component Manual For Private Onsite WestewraW TreaWw4 Systems" (Version 2.0) SBD- 10691 -P (N.01101) N
r
per "Pressure Distribution Composer manual for Private Ortsite wastewater T reatrnent Systemg' (Version 2.0) SBD- 10706 -P (N 01101) � tiny
Spreadsheet provkled by: 3bAdvisement N12486 220th St, Boyeaville, Wl 54725 Ph: 715443 -8068 emall: O Com HG
NQ��C�
Mound System Pap z of s
Mound Sizing Calculations
Project Name: Haines -Mound
Site Conditions Design of Entire Fill
Project Type: 1 or 2 Family Dwelling 7w Cell depth at upslope edge (D): 19.0 in.
% Slope: 5% Cell depth at downslope edge (E): 22.6 in.
# of Bedrooms: 4 Distribution cell depth (F): 9.5 in.
Depth to limiting factor. 17 in. Cover thickness over edge (G): 6 in.
Absorbtion rate of fill material: 1 gavif /day Cover thickness over center (H): 12 in.
Absorbtion rate of in -situ soil: 0.2 gaW /day End slope width (I): 10.6 ft.
Effluent quality Eff #1 w Fill length (L): 121.2 ft.
Max BOD effluent value: 220 mg/I Upslope width (J): 7.5 ft.
Max TSS effluent value: 150 mg/I Downslope width (Toe) (1): 24.0 ft.
Fill Width (W): 37.5 ft.
Design of the Distribution Cell Basal Area
System Design Flow: 600.0 gal/day Basal area required: 3000 fe
Distribution cell width (A): 6.00 ft Basal area available: 3000 fe
Distribution cell length (B): F 100.0 ft
Area of Distribution Cell: 600.0 fe Observation Pipes
Contour Elevation of Mound: F 9 4 ft Location from end of cell (Z): 16.67 ft
System Elevation of Mound: 96.39 ft
Final Grade of Mound: 98.19 ft
Mound Plan View
J Observation Pipes
W Distribution Cell A
T B k—K
I Tilled Area/Fill Material
L '
Mound Cross Section
Fine) Grade bserwa ion Pipe
Synthetic Fabric
Distribution Cell
a
System Elevation ° 6 n �A•�. F 1
Cover Material Lateral p 3
Fill Material Invert
Tilled Area
—Slope �Forcemain nto ur
Notes:
Fill material to consist of ASTM C33 Sand
Distribution cell aggregate to comply with Comm 84.30(6)(1)
Synthetic Fabric covering on cell per Comm 84.30(6)(9)
Distribution Cell to have minimum 6" aggregate below lateral and 2" above.
Mound System Page 3 of 6
Pressure Distribution Calculations
Project Name: Haines -Mound
Lateral Layout Lateral /Manifold Design
Lateral elevation: 96.9 ft Lateral diameter: In.
Rows of Laterals: 2 Lateral spacing (S): ft
Manifold type: center Lateral to cell edge: 1.5 ft
Orifice diameter: o.izs • In. Lateral discharge rate: 12.36 gpm
# of Laterals: 4 System discharge rate: 49.43 gpm
Distal Pressure: 5 ft Manifold diameter: 2 , In.
Lateral Length: 49.5 ft Manifold length: 3 ft
Orifice Spacing /Distribution Forcemain Friction Loss
Orifice spacing (X): 20.14 Inches Forcemain length: 1 80 ft
Orifices per lateral: 30 Forcemain diameter: 2 In.
Avg. ft /Orifice: 5.00 ft Friction loss in forcemain: 3.906 ft
Lateral Side View
Manifold
Lateral Lateral
X x x x x x x x x x
2
Lateral Length Lateral Length
Lateral Plan View
Lateral Length I Turn -up w /ball valve or cleanout plug
o --
S I
o a !—
Orifices on bottom of
lateral equally spaced PVC laterals and forcemain to comply with
specifications per Comm 84.30(2ne)
Forcemain connection via tee or cross to manifold at any point
Clean Out Detail Observation Pipes
Clean -out plug
Final Grade or ball valve Water tight cap
or plug
Lawn
Sprinkler
Box
Slot
Note: Closet Collar
6" Minimum
T Lon ray be used n
Long Sweep 90 pn lace of 3/8" bar
or two 45's L 3J8' Bar
Latera
I I
Mound System Pp 4 of 6
Septic, Pump and Dose Tank
Project. Haines -Mound
Tank Information Dosage Volume
Pump tank manufacturer. Wieser Concrete Forcemain drains back to tank? Q Yes O No
Pump tank size/model: W1250/750 -MR Lateral void volume: 20.9 gal
Pump tank gaVinch: 16.12 Dosage to absorbtion Celt: 104.6 gal
Actual Pump Tank Volume: 758 gal Forcemain volume: 13.9 gal
Tank bottom elevation (inside): 91.5 ft Total dosage: 118.6 gal
Septic tank size/model: W1250/750 -MR n
Pump and Filter Total Dynamic Head
Pump Manufacturer. Gouolds Are laterals highest point? y
Pump Model: PE51 1f if not, enter highest elevation: 0 ft
Effluent Filter. Polylock 525 System head (distal x 1.3) 6.50 ft
Vertical Lift ( "D" to lateral) 4.73 ft
We Access opening of suffldent size to be provided to allow Friction loss in forcemain: 3.91 ft
removal of filter: Opening to terminate at or above grade. r
Pressure loss from filter. ft
Total dynamic head (TDH): 15.13 ft
Pump Tank Diagram Dose Tank Levels
Watertight Locking Cover In. Gal
4 Inch Y th Warning Label
Minimum mished A Reserve 29.7 478.2
rode B Pump off to Alarm 2.0 32.2
Alternate C Total Dosage 7.4 118.6
Outlet
7
Location Elea. per Comm D Effluent depth for pump 8.0 129.0
i s.2e end Total Capacity: 47.0 758.0
NEC 300 _
METERS FEET
40
Weep Hole A PESt 1MMLS! PE31. PEn, vrsr
orAnti- B "...33,.40..50
Siphon 3s 1— – - - --
Device to zGPM
C 30 1 FT - -- - - --
c
w 25.
o —
8 15 --- --- __._.
Pump must be capable of 49.4 GPM 10
and head pressure of 15.2 F
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0 0 0 10 20 30 40 0 60� 70 GPM
0 5 10 15 MIA
CAPACITY
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Mound System Management Plan pursuant to comm 83.54 W. A. C. page 5 of 6
Owner's Responsibility:
The component owner is responsible for the operation and maintenance of the component. The county,
department or POWTS service contractor may make periodic inspections of the components, checking for
surface discharge, treated effluent levels, etc. The owner or owner's agent is required to submit necessary
maintenance reports to the appropriate jurisdiction and/or the department.
Septic Tank:
Septic tank(s) are to be inspected routinely and maintained by department approved individuals when
necessary in accordance with their approvals. The use of chemical/biological "treatments" is not required or
recommended. If such additives are used, make sure they are approved by Department of Commerce,
Safety and Buildings Div.. Effluent filters are to be removed & cleaned as necessary, with provisions to keep
solids from passing the septic during removal. No more than 1/3 of the usable tank volume may be occupied
by sludge /scum. 3 year inspection: If tank has greater than 1/3 volume sludge, tank contents must be
emptied and disposed of in accordance with NR 113 Wisconsin Administrative Code by an approved
individual. If the inspector does not recommend pumping of the septic tank, then the owner must be notified
of when pumping should be done as to not exceed 1/3 sludge volume. Septic tank should be routinely
inspected to be watertight and of good repair.
Pump/Dose Tank
If an effluent filter has been installed in the pump /dose tank, it must be removed & cleaned as
necessary, with provisions to keep solids from passing to the mound component during removal.
The pump, float switches and alarms must be inspected at least every three years for proper
operation. Pump /dose tank should be routinely inspected to be watertight and of good repair.
Mound and Lateral System
The mound system component must remain free of ponded surface water prior to pump operation. If 4
inches or more water level is detected in the observation pipes, the owner must be notified of possible
problems/failure. The designed daily flow capabilities of the component should never be exceeded. Trees
and any other deep rooted vegetation should never be planted, or allowed to grow anywhere on the
component. Activities OTHER than mowing /maintenance (i.e. excessive walking, pets, vehicles, etc...) could
compress the component and reduce it's absorbtion capabilities and /or possibly cause it to freeze in winter
conditions. Lateral distribution pipes should be flushed out/tested every 18 months using the cleanout points
at each end of the component to remove scum that may clog orifices.
Perfonnance Monitoring:
Performance monitoring must be done at least once every three years following the installation or at the time
of a problem, complaint, or failure.
Contingency Plan:
If the septic tank, pump tank or any of their components therein (including floats, alarms, pumps, etc)
become defective, the defective tank or component must be replaced immediately to ensure that the system
can operate as designed. If the mound component cannot accept wastewater or ponds wastewater to the
surface, the component must be repaired or replaced in it's current location by either: extending basal toe to
provide added absorbtion area; or by removing the clogged bacterial mat,aggregate cell, and distribution
piping within the mound and replacing said components in order to return system to proper working order as
required.
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
OwnerBuyer
Mailing Address / le d Z 8'y tG• r� � ',�/ �' `7 , u' (' S�a / j
Property Address .Sca,►��
(Verification required from Planning Department for new construction)
City/State Cif eA w" Parcel Identification Number 03y �dii - d oG�
LEGAL DESCRIPTION
Property Location .5 'l., J t /., Sec. �P , T 2 7 N - R 5 W, Town of _ SP4v , J
Subdivision Lot #�
Certified Survey Map # , Volume , Page #
Warranty Deed # � Volume $2 , Page #
Spec house ❑ yes 2"no Lot lines identifiable Oyes ❑ no
SYSTEM MAINTENANCE Be
Improper use and maintenance ofyour 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.
Uwe, 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 the three ,y ar expiration date.
X �v / 2 4-'i f-r
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DAT
SIGNA F APPLICANT
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 property desc ' ed above, by virtue of a warranty deed recorded in Register of Deeds Office.
SIGNATURE OF APPLICANT DATE
•••••' Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Dep
artnlent. �•• «•«
•• Include with this application: a stamped warranty de6d from the Register of Deeds office
a copy of the certified survey reap if reference is made in the warranty deed
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gcpnsin SOIL EVALU TION REPORT #56
Department of Commerce
in accordance wit m 85 P 1 of 3 , Wis. Adm. Code 9
Division of Safety and Buildings Northland Plumbing, Inc.
Attach complete site plan on paper not less than 8'/: County x 11 inches i\distano St. Croix
include, but not limited to: vertical and horizontal reference point (
percent slope, scale or dimensions, north arrow, and location and st d. Parcel I.D. / Lr � Plea se p Re 'wed By Date
Personal information you provide may be sed for secondary purposes (Pn 1) (m)). — / � Q
Property Owner L 7 2 008 Properly Location
Richard Haines OCT t 1- Govt. Lot SE1 /4, NE1 /4, S6, T29N, R15W
Property Owner's Mailing Address S -F. CROIX COUNTY Lot # Block # Subd. Name or CSM#
1160 280th St OFFICE
City State LZip e lig PnFff ITu E] City [:] Village ❑ Town Nearest Road
Glenwood City WI 1 54013 1 715 - 265 -4443 Springfield 1 280Th St
❑ New Construction Use: ❑ Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
® Replacement ❑ Public or commercial - Describe
Parent material Glacial Till Flood plain elevation, if applicable ft.
General comments Mound site using 94.81' contour.
and recommendations:
F-11 Boring # ® Boring
E] Pit Ground surface elev. 95.57 ft. Depth to limiting factor 17 in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/f1
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *011#1 *EfW
1 0-9 10YR3/2 sil 3sbk mvfr Cs 2f .6 .8
I I
ail 2 9 -17 10YR6 /3 A 2sbk mvfr gs if .8
3 17 -28 10YR5/3 7.5YR5/8c2d spots scl lsbk mfi gs if .2 .3
4 28-45 10YR6/8 7.5YR5 /8fif spots sc 0m mfi Cs 0.0
I
F ® Boring
Boring # Pit Ground surface elev. 94.17 ft. Depth to limiting factor 17 in.
El Pit 9 Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff #1 - Eft#2
1 0 -8 10YR3/2 A 3sbk mvfr Cs 2f .6 .8
2 8 -17 10YR6 /3 sil 2sbk mvfr gs if .8
3 17 -26 10YR5 /3 7.5YR5/8c2d spots sd lsbk mfi gs if .2 .3
4 26 -50 10YR6/8 7.5YR5 /8flf spots sc Om mfi Cs 0.0
I
* Effluent #1 = BOD 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD s30 mg/L and TSS s30 mg/L
CST Name (Please Print) Signa re: CST Number
Michael J. Myers 267985
Address Northland Plumbing, Inc. Date Evaluation Conducted Telephone Number
2943 130th Ave Glenwood City, WI 54013 10/6/08 715 - 2654115
SBD -8330 (807/00)
Property Owner Richard Haines Parcel ID # Page 2 of 3
F 3 ®Boring
Boring # Bo Ground su elev. 94.81 ft.. Depth to limiting factor 17 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 -9 10YR3 /2 sil 3sbk mvfr cs 2f .6 .8
2 9 -17 10YR6/3 sil 2sbk mvfr gs if .6 .8
3 17 -26 10YR5/3 7.5YR5 /8c2d spots sd lsbk mfi gs if .2 .3
4 26 -58 10YR6 /8 7.5YR5 /8f1f spots sc Om mfi cs 0.0 0.0
* 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.
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Parcel #: 034 - 1011 -40 -000 10/27/2008 11:10 AM
PAGE 1 OF 1
Alt. Parcel #: 06.29.15.84 034 - 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
O - HAINES, RICHARD B & DONNA J
RICHARD B & DONNA J HAINES
1160 280TH ST
GLENWOOD CITY WI 54013
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description " 1160 280TH ST
SC 2198 GLENWOOD CITY
SP 1700 WITC
Legal Description: Acres: 40.000 Plat: N/A -NOT AVAILABLE
SEC 6 T29N R15W SE NE 40A Block/Condo Bldg:
Tract(s): (Sec- Twn -Rng 401/4 1601/4)
06- 29N -15W
Notes: Parcel History:
Date Doc # ge Type
07/23/1997 822/472
07/23/1997 821/494
07/23/1997 364/615
2008 SUMMARY Bill #: Fair Market Value: Assessed with:
Use Value Assessment
Valuations: Last Changed: 06/15/2007
Description Class Acres Land Improve Total State Reason
AGRICULTURAL G4 36.000 5,350 0 5,350 NO
UNDEVELOPED G5 2.000 350 0 350 NO
OTHER G7 2.000 9,550 123,800 133,350 NO
Totals for 2008:
General Property 40.000 15,250 123,800 139,050
Woodland 0.000 0 0
Totals for 2007:
General Property 40.000 15,250 123,800 139,050
Woodland 0.000 0 0
Lottery Credit: Claim Count: 1 Certification Date: Batch #: 113
Specials:
User Special Code Category Amount
Charges Special Assessments Special C ges Delin uent q Charges
Total 0.00 0.00 0.00
0 tI Nrl L - - - I illlil hill fllll IIIII fllli IIIII Ilil 111111 INI Ilil
* 8 8 2 7 5 8 2
TRANSFER ON DEATH DEED 882768
KATHLEEN H. WALSH
This deed shall constitute a non - probate transfer on death, made REGISTER OF DEEDS
by Richard B. Haines and Donna J. Haines, husband and wife ST. CROIX CO., WI
to Jacqueline R. Boler and Jody M. Graese, as tenants -in- RECEIVED FOR RECORD
"Grantors") 4 Y 10/14/2008 11:45AM
common (`Beneficiaries "), for the purpose of creating a payable on death TRANSFER ON DEATH DEED
provision affectiDg—the following described real estate in St. Croix EXEMPT I loft
County, e- e€�i�[isconsin: See a chedule "A:' REC FEE: 13.00
is directive is not a conveyance 77. a Grantors intend by this PAGES: 2
deed to an 25 (10m) Wis. Stats. and
related statutes, which collectively permit transfer of real estate upon the
death of Grantors in a non - testamentary and non - probate fashion. The
Grantors intend this deed to be deemed a "transfer on death" and "payable
on death" conveyance such that Grantors retain full management and Name and Return Address:
control in fee simple during the rest of Grantors' lives and during the life
of the surviving Grantor. This includes the right to sell and convey said Judith t Remington
real property in any manner or rescind this transfer on death designation. Remington Law Offices, LLC
126 S. Knowles Ave.
This deed is revocable and may be changed by the Grantors at any time. New Richmond, WI 54017
Upon the death of one Grantor, the survivor may alter or revoke the
transfer on death designation. Upon the death of the last Grantor, this real
estate shall immediately pass and vest in the named Beneficiaries. If any PIN: See attached Schedule "A"
of the named Beneficiaries shall not be living the interest of said
Beneficiary shall pass and vest in the Beneficiary's then living This is and is not
descendants, per stirpes. If any of the named Beneficiaries shall not be homestead property.
living and shall not have living descendants, such interest shall pass and
vest in Grantors other named Beneficiaries. Beneficiaries will receive title
subject to all encumbrances or liens or record on the death of the last
Grantor to die and subject to the option to purchase, if any, as set forth in
my last will and testament.
Nothing contained in this document shall prevent Grantors from conveying or encumbering this real estate
for any purpose and in any manner permitted by applicable law or from exercising any right allowed by applicable
law regarding this real estate. This instrument shall not be an encumbrance upon this real estate or prevent Grantors
from conveying clear title to this real estate. If this instrument is in conflict with any instrument signed by Grantors
prior to the date hereof, then such prior instrument shall be considered null and void and the provisions of this
instrument shall control the disposition of Grantors' interest, if any, in this real estate upon the death of Grantors or
the survivor of them. This document is exempt from fee and return under secs. 77.21(1) and 77.25(10m) Wis.
Stats. because it is a transfer on death deed under sec. 705.15 and at death of Grantors will be exempt under sec.
77.25(1 Iin) Wis. Slats.
Dated this 7 day of October, 2008.
* * RICHARD B. HAINES
* * DONNA J. nAINES
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF WISCONSIN )
authenticated this _ day of 2008. ) ss.
ST. CROIX COUNTY )
• Personally came before me this 7 day of_Qggber, 2098,
TITLE: MEMBER STATE 13AR OF WISCONSIN the above named Richard B. Haines and Do ,a J.'-Hare's
husband and wife, to me known to be t der �it9 wl�oicecnte�t
THIS INSTRUMENT WAS DRAFTED BY: the foregoing instrument and acknowledge the s i
Judith A. Remington #1016706 , J'
REMINGTON LAW OFFICES, LLC
126 S. Knowles Ave. • ith A. Remington Q ,
New Richmond, WI 54017 Notary Public, State of Wisconsin. '
Telephone (715) 246 -3422 My Commission is Permanent.
Attorney for Grantors (If not, state expiration date: )
(signatures may be authenticated or acknowledged.
Both are not necessary.)
.Names of persons signing in any capacity should be typed or printed below their signatures
1 of 2
SCHEDULE "A"
RICHARD B. HAINES AND DONNA J. HAINES-
TRANSFR ON DEATH DEED
LEGAL DESCRIPTION
ST. CROIX COUNTY, WISCONSIN
1. The Southwest Quarter of the Southeast Quarter (SW1 /4 of SE1 /4), Town of Glenwood,
Section 16, Township 30 North, Range 15 West.
(PIN: 016-1036-60-000)
2. The Northeast Quarter (NE1 /4), Section 6, Township 29 North, Range 15 West,
EXCEPTING therefrom a strip of land 100 feet in width across the Northwest Quarter of the
Northeast Quarter (NW1 /4 of NE1 /4) reserved for railroad right -of -way, and ALSO EXCEPTING a
strip of land 50 feet in width off the North side of said Northwest Quarter of the Northeast Quarter
(NWl /4 of NE1 /4), the north line of said land being 33 feet South and parallel with the North line
of said North Half of the Northeast Quarter (N1 /2 of NEl /4), and heretofore conveyed to the
Wisconsin Minnesota Light & Power Company.
(PINS: 034 - 1011 -40 -000 - homestead; 034 - 1011 -30 -000; 034 - 1011 -20 -000; 034 - 1011 -10 -000)
3. A 7 acre tract of land in the Southeast corner of the Northwest Quarter (NW 1/4), Section 6,
Township 29 North, Range 15 West, described as follows: Commencing at a point where the right-
of -way of the Minnesota & Wisconsin Railroad Co. intersects the South line of said Northwest
Quarter (NW1 /4) of said Section 6; thence East to center of Section; thence North to intersection of
easterly line of said right -of -way with the East line of said Northwest Quarter (NWI /4) of said
Section; thence Southwest along the East line of said right -of -way to beginning.
(PIN: 034 - 1012 -10 -000)
4. The Southwest Quarter of the Northeast Quarter (SW 1/4 of NE1 /4), Section 8, Township 29
North, Range 15 West.
(PIN: 034-1017-40-000)
5. The Northwest Quarter of the Southeast Quarter (NW1 /4 of SE1 /4), Section 8, Township 29
North, Range 15 West.
(PIN: 034-1018-60-000)
6. A two rod strip running along the West side of the North Half of the Northeast Quarter
(N 1/2 ofNE1 /4), Section 8, Township 29 North, Range 15 West.
(PIN: 034 - 1017 -30 -000)
7. The Southeast Quarter of the Northeast Quarter (SE1 /4 of NE1 /4), Section 8, Township 29
North, Range 15 West, EXCEPT Lot 1 of Certified Survey Map filed July 15, 1982, in Volume 4,
Page 1182 as Document No. 378825.
(PIN: 034-1017-50-000)
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