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W.L.H.R.
Leroy Jansky O.W.S. Wisconsin Department of industry,
PLB -1 INSPECTION REPORT 13 E. Spruce Street Labor & Human Relations
Chippewa Falls, WI 54729 Safety & Buildings Division
(715) 723 -8786 Bureau of Plumbing
N ame of remises Date Plan I.D. No.
b - 2.t -8
-str eet - oun y Sanitary Permit r
SF- 56 q N is
TW 5P
Rta FIELD S k -C41
Master Plumber & IrirM Name AaaYVSS
Qrk- S ML -k-Z C�l woc� CCs ttil�
Journeyman Plumb Adaress
O wner n ( ress
T BWDM
ib
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A-T lo" 1► TbkE 16"MR 14) s
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IV IV
Discussed with Fignature
( )See Attached.
DILHR -SBD -6192 (R.10/82) Signature of is n- a Was
Inspector Local Inspector Plumber or Responsibl Party �Oer
r -
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County' St. Croix
Safety and Building Division
11 INSPECTION REPORT Sanitary Permit No:
399650 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:
Seim, Leroy Springfield Townshi 034 - 1012 -80 -000
CST BM Elev: Insp. BM Eley: BM Description:
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STAT ON BS HI FS ELEV.
. 3a o v
Septic Benc mark '
W ao7,v •a o
Dosing Alt. BM
r= Co 3.1 gohf 9
Aeration /,�// Bldg. Sewer t' Y-6 3
Holding St/Ht Inlet T
a $. 1 7
TANK SETBACK INFORMATION St/Ht Outlet It 1. / • 3
TANK TO P/L WELL BLDG. Vent Air Intake ROAD Dt Inlet
Septic u o Dt Bottom
Ion
Dosing / Header/ an. /� q
l 1 r O /Do
�
Aeration Dist. Pipe I �Z c, A
Holding B t. S stem
_-- 97.Y- 2 z. s Z• C19 •y
al G de
PUMP /SIPHON INFORMATION / / &%,, _ 9q. 3
Manufacturer Demand St Cover d^
`�
` GPM / IVC r' -"'� 3 (p ,
Model Number ti � G #
TDH Lift f rtt Friction Loss �q System Head S TDH t
u IAW 1 3 1 1
l ForcernalnLeny Dia. // Dist. tow ell
Z0
SOIL ABSORPTION SYSTEM
BEDITRENCH Width �� Length / No. Of Tien h PIT DIMENSIONS No. Of Pits Inside Dia. Liquid epth
DIMENSIONS 22 f
SETBACK SYSTEM TO P/L JBLDG LL LAKE/STREAM L CH G Manufacturer.
INFORMATION CHAM R OR
Type f System: p r- I* � N Model Number.
I I 26 d 22 1) . DISTRIBUTION SYSTEM / a''
Header/Manifold l/ Distribution Y x Hole Size x Hole Spacing t to Air Intake
�„ L� Pipe(s) 3 ' , .� ' I _ 4' h j JQ'P
Length is - , Length Dia �' Spacing l! // , • ,
S OIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only -� t5-(rn' Yt
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched`
Bed/Trench Center t / oy t r Bed/Trench Edges Topsoil > Yes * no Yes [SIKo
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection / Z �- Inspection #2: /0/ 61—
Location: 1128 280th St Glenwood City, WI 4013 NE 1/4 SE 1/4 6 29N R15 NA L o a' -? t ,��- Parcel No: 06.
6.29.15.93
1.) Alt BM Description =' �� �V S� - -k�h- r2G2 d �l �`a `'ry ✓�S G�l
2.) Bldg sewer length = 5Z/ �C��' ti - 'C' i Se✓�
- amount of cover
3.) Contour = S•eL
Plan revision Required? _; Yes [
Use other side for additional information. ' f ]
3L U r!O s
Date Insepctor's S nature Cart. No.
SBD -6710 (R.3197)
SANITARY PERMIT A TION 0 Safety and 1 E. Washington
NV isconsin P.O. Box 7969
s
In r i h 1! is t �l_S d
Department of Commerce acco w t 8 � Qav t92� Madison, WI 53747 -7969
• Attach complete plans (to the county copy only) fort on not County
than 8 1/2 x 11 inches in size. RECEIIPE O/IC
• See reverse side for instructions for completing this q ' tate Sanitary Permit Number
EC ?_ 0 2001 Q46�a
The information you provide may be used by other government agen �- ❑ Check it revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. OOLOTY �_.i State Plan I.D. Number
I. APPLICATI N INFORMATI N - PLEASE PRIN #
Property Owner Name Pro . i y Lb tion
°y 1/4,5 �j T, N, R/,3 W
Property Owner's Mailing A' dre '_ ye er Block Number
City, State Zip Code Phone Number Subdivision Name or CSM Number
0/3
11. TYPE OF BUILDING: (check one) ❑ State Owned ❑ Cit Nearest Road
❑ Village ^
Public 9 1 or 2 Family Dwelling -No. of bedrooms rer Town OF 1e'1d �` ✓��`
111. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s)
1 ❑ Apartment/ Condo d-� ep
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant /Bar /Dining
4 ❑ Church / School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. ❑ New 2. X Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an
System -------- System ------------- Tank Only______________ Existing System ________ - Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE, OF SYSTEM: (Check only one)
Non - Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 Mound ( Q 9) 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 S 3
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 1 7. Final Grade
7 Required (sq. ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min. /inch) q Elevation
Q 0 - p , / �s Feet , Feet
VII. TANK Capacit g allons Total # Of Prefab. Site Fiber- Exper
INFORMATION New Existin Gallons Tanks Manufacturers Name Concrete strutted Steel glass Plastic App
Tanks Tank
Septic Tank orb OBE e ® ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber X rQ DO 77 tqi ❑ ❑ ❑ ❑ 1 ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Name: (Print) Plumber's Signatur : (No Stamps) MRIIMMMI -No.: Business Phone N
Plumber's Ac dress (Street, City, State, Zip Code):
IX. COUNTY / DrEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate ssued Issuing Agent Signature (No Stamps)
Appro Surcharge Fee)
pp []Owner Given Initial � ,�
Adverse Determination 3L S L
X. CONDITIONS OF APPROVAL
/ � QMOX
/ REASONS FOR DIS
-�-�� 41frr' 3 b %KSTt / 1-_4 g ikccf h&AK(ti -taJt eer ' 5 yCW01."0 �
ltr � � SY s��w., �S ie 044^,dacjea /o C a�ytw� 0
SBD-6M (R.11/96) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, 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-
it. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling.
111. 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. .
Vill- Responsibility statement. Installing lumber isto fill in name, license number with appropriate prefix (e.g. MP, etc.),
P Y 9p
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.
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<. Safety and Buildings
10541N RANCH ROAD
1 HAYWARD WI 54843
TDD #: (608) 264 -8777
Mir ,�c0ns n www.w
www.commerce.s s i n.gov
isconin.gov
Department of Commerce
Sc4tt Governor
Brenda n�l@pAd So
May 09, 2001
CUST ID No.222234 AM. POWTS Inspector
ZONING OFFICE ?,`'_.. Sf CPO)(
GALE W SMITH ST CROIX COUNTY SPIA COUNT`;
3228 HWY 170 1101 CARMICHAEL RD 2200 OFmi
GLENWOOD CITY WI 54013 HUDSON WI 54016
RE: CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 05/09/2003 Identification Numbers
Transaction ID No. 639544
Site ID No. 629009
SITE: Please refer to both identification numbers,
SITE ID: 629009, LEROY SEIM above, in all correspondence with the a enc
ST CROIX COUNTY, TOWN OF SPRINGFIELD; 1128 280TH ST, GLENWOOD CITY 54013 Cpi� ttla� , i
NEl/4, SETA, S6, T29N, R15W S
FOR: REPLACEMENT MOUND, 900 GPD
OBJECT TYPE: POWT SYSTEM REGULATED OBJECT ID NO.: 790145
p�ETY�
➢ This approval is for a mound that serves a 4 bedroom dwelling and a 2 bedroom dwelling (common sy emt�_ .—
no employment or self employment taking place in either building. — \ ��RF
� — ..
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(10), Wisconsin Statutes, is responsible for compliance with all code requirements.
The following conditions shall be met during construction or installation and prior to occupancy or use:
General Approval Conditions:
• This system is to be constructed and located in accordance with the enclosed approved plans and with the
"Mound Component Manual for Septic Tank Effluent for Private Onsite Wastewater Systems" SBD- 10691 -P
( N.01 /01) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment
Systems" SBD - 10706 -P (N.01 101).
• 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 insure that the operation, maintenance and monitoring duties as described in section VIII of
the mound component manual are complied with. A copy of this information must be given to the owner upon
completion of the project.
• 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.
• 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.
• The maintenance plan for this system must be given to the owner of the POWTS.
Site Specific Conditions:
• This mound is designed to be installed on a level site.
r'
GALE W SMITH Page 2 5/9/01
• This approval does not include plans for the general plumbing systems or sewer piping leading to the
septic/holding tank that may be required for this project. See section COMM 82.20, Wis. Adm. Code, to
determine if plan submittal and approval is required.
• The designer proposes to install an outlet filter to achieve the requirement of wastewater particle size.
Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the septic
tank outlet filter will be required. The outlet filter shall be installed per product approval stipulations.
• Insulate building sewer per COMM 82.30(11)(c).
• Abandon ikilm system per COMM 83.33.
• The designer proposes to install a 2000 gallon septic tank manufactured by Wieser Concrete.
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.
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.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
Sincere DATE RECEIVED 04/23/2001
FEE REQUIRED $ 175.00
et-t- ^ c `- FEE RECEIVED $ 175.00
PATRICIA L SHANDORF BALANCE DUE $ 0.00
POWTS PLAN REVIEWER, INTEGRATED SERVICES
(715) 634 -7810, FAX: (715) 634-5150, M -F 7:45 AM - 4:30 PM
PSHANDORF @COMMERCE.STATE. WI.US WiSMART'code: 7633
cc: LEROY SEIM
Goo y Arty�� / �F
MOUND SYSTEM DESIGN
Residential Application
INDEX AND TITLE SHEET
Project d �/�/� I'll e 61/1
Owner ,L /'q e" A'1-
Address
11y
Legal Description � SL s� J` 9/j/ /��Gc.J_
Township County ,�f 4� / 6 2 p
Subdivision Name Lot No. � N D Et � CE
Parcel ID Number ' �l> /� - �0 - -ODD 3 7 5 q y
- T
Plan Transaction Number
J�q SC a n 0
Index and title sheet Page 1
Mound calculations Page 2
Mound drawings Page 3
Pres. dist. calcs. and laterals Page 4
TDH and pump tank drawing Page 5
Pump curve , Page 6
Site plan Page 7
Soil test (a,b,& c of page 8) Page 8
14 ,* i N tr'N A k e a ' li ' ,ye 9
Designer e '�J S 1 License Number �2 G�
Signature Phone No.
y
Date
Notice: Tampering with this file by unauthorized persons is prohibited.
Deliberate modification will result in disciplinary action under s. 145.10, Wis. Stats.
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)).
Page -
Strow, Morsh Hoy, Or
Synthetic Covering
Distribution Pipe
Medium Sand _�--
G
Topsoil F 11-12
J ► E o
b
n % Slope
Bed Of 2 "— 2 %2 Force Main i'�owed
Aggregate From F'ump l oy�r
Cross Section Of A Mound System Using J/{
F J ;/
A Bed f - or the Absorption Arta G
A /7 Ft. H
Srgncd: S �- Ft.
License [lumber: I Ft.
J Ft.
Ciatc: K FE
L I
}---
z
,
OBScrvafi "on pipe
J '� force Moin
W
J From Pump
Distribution Bed Of c _ 2 i"
Pipe Aggregate
I
Observation Pipe Permanent Morkcrs
Pion View Of Mound Using A Bed For The Absorpilon Areo
Page/-
,
Perforated Pipe Detail
End View
P e A1
p PiPe
Ile- CP �Pe/10% �°� y�
o N 7"44 A/
' Q �S �yPlC�4
.
kN�
Holes located on bottom, of force
0 y main are equally ,spaced
Force twain
._ .. ,.
PVC
Distributation pipe layout
y � F t x z
\ HInches
Invert Elevation of Laterals � t Bo w.
P i �� S�Inches
ce-
X
Signed i
Y — Inches
Liae nse o
Hole Diameter 9/WInches
Dates
u
Lateral / L LInches
Manifold " Inches
Force 1 " Inches
# of holes/pipe
i
PAGE � OF .
PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS'
' VEAIT CAP
4 C.I. VEIJT PIPE
WEATHER PROOF APPROVED LOCKING
25' FROM DOOR
JUAICTIOU BOX f MANHOLE COVER
� ,
4"11111
WitiDOW OR FRESH 12 "MID.
AIR INTAKE
GRADE
I .
18 "MID.
COIJDUIT
IA1L_ET PROVIDE I - - - -- —.
AIRTIGHT SEAL
AFFROVED JOINT A I I APPRDVED
C.I. FIFE I III VI/C,I. PIFE
ExTCHDIQ(:9 3' _ _ I II ALARM EXTE�JOIN'.
C)�TO SOLID SOIL, B I I OQT0 501.Ip < ;I
C
0u
� I
I
PUMP OFF
D
CONCRETE BLOCK
"sa /v
RISER EXIT PCP./"07ED G1JL'J IF TANK MAUUFACTURE.R HAS SUCH APPROVAL. tied
7 Nlt
SEPTIC#► °O 5PECIFICATIOUS
LOSE -/ 1? /a--G
TAIJKS MANUFACTURER : -- V" e� DUMBER OF DOSES:
PER DAy
TANK SIZE : / D GALLONS DOSE VOLUME //z �
ALARM MANUFACTURER: _S�/ �� e� rgo IMCLUDING BACKFLOW: 01-e4 GALLON S
MODEL A1UM6ER: - /V 4t; CAPACITIES: A = /, OR GALLOk; i
SWITCH TYPE: M 2g - al? (/ B = 2 INCHES OR J_:�_ W,LLO�' S
PUMP MANUFACTURER: - C D Gf L S C =_� IWCHES OR t2 ® GALLOl:i
MODEL MUMBER: -G D= INCHES OR _[ 1_42 GALLOP'S
SWITCH TYPE: '1 eq C!,. R � 0 E: PUMP AMD ALARM ARE TO BE
MMIMUM DISCHARGE RATE -67e �, GPM INSTALLED OM SEPARATE CIRCUITS
VERTICAL DIFFEREMCC BETWECW PUMP OFF ARID DISTRIBUTIOW'PIPE.. ��' FEET � f
+ MIN IMUM NETWORK SUPPLY PRESSLIK � , , .�' • � r
� mT
+ FEET O F FOR M X -`-Z_ gq _� F /ppF;FRICTIOIJ FACTOR. `Z FEET
TOTAL 09MAMIC. HEAD = �� FEET
IUTERNAL. DIMEWSIONS Of TAA1K: LENCsTH % � •
,WIDTH • ; DEPTH
SIGUE D: LICEMSE DUMBER: DATE:_
WESTBURNE SUPPLY INC.
12 DUS`i"RIAL RD. Goulds
ON, WI 54016 Submersible
Effluent Pump
3871 EPO4
1 EP05
APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron
Specifically designed for the stainless steel. grade turbine oil for for efficient heat transfer,
following uses: • Capable of running lubrication and efficient strength, and durability.
• Effluent systems dry without damage to heat transfer. Is Motor Cover: Thermoplas-
• Homes components. tic cover with integral handle
•Farms
Motor: Available for automatic and and float switch attachment • Heavy duty sump • EPO4 Single please: 0.4 HP, manual operation. Automatic models include Mechanical
• Dewatering RPM, built It in ovv erloa Points.
• Water transfer 115 or 2 V, Hz 1550
with 1550 Float Switch assembled and ■ Power Cable: Severe duty automatic reset, preset at the factory. rated oil and water resistant.
• EP05 Single phase: 0.5 HP. ■ Bearings: Upper and lower
SPECIFICATIONS 115 V, 60 f1z, 1550 RPM, FEATURES heavy duty ball bearing
Pump: EPO4 built in overload with ■ EPO4 Impeller: Thermo- construction.
• Solids handling ca,=abili,y: automatic reset. plastic Semi -open design
/4 maximum. • Power cord: 10 foot AGENCY LISTING
e:ith pump out vanes for
• Capacities: up to 55 GPM standard longth, 16/3 SJTO mechanical seal protection. SP Canadian Standards Association
• Total heads: up to 21 feel. with three ptong grounding
• Discharge size: 1 :` NPf. plug. Optional 20 toot ■ EP05 Impeller: Thermo
g plastic enclosed design for (CSA listed model numbers
• Mechanical seal: carbon- length, 16/3 SJTW with improved performance. end in "F" or "AC ".)
rotary/ceramic- st,i!:onary, three prong grounding plug
BUNA -N elastomers (standard on EP05) ■ Casing and Base: Rugged
• Temperature: thermoplastic design provides
104 T (40'C) continuous superior strength and
140" F (60 intermittent, corrosion resistance.
• Fasteners: 300 series METERS FEEL
stainless steel. 10 ! 1
• Capable of running +
dry without damage to 9 30
components.
Pump: EP05 e 25
I F
• Solids handling capability: 0 25
/4
'" maximum. a 7
• Capacities: up to 60 GP _
M. '
• Total heads: up to 31 feet.
s 20 - -- — — —_
• Discharge size: 1'12' NPT. Z 5 i I
• Mechanical seal:
carbon-0 1 ! i
rotary/ceramic - stationary, 4
BUNA N elastomers. ;_ i EP05
• Temperature: 3 10 - _ - - -- _ - -- --
104 °F (40 ^C) continuous EPO4
140 ^F (60 "C) intermittent. 2
5
i
OL 0� — 10 20 30 40 50 GPM
0 2 4 6 8 10 12 ml /h
CAPACITY
n 1995 Goulds Pumps. Inc. Effective May, 1995
83671
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Mound System Management Plan
Pursuant to Comm 83.54, Wis. Adm. Code
Septic Tank
The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Slats. The contents of the
septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and
outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to
ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that
may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if
the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The
septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of
the tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise
the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in
the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required.
However, if such products are used they shall approved for septic tank use by the Department of Commerce, Safety and
Buildings Division.
Pump Tank
The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to
verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary.
Mound and Pressure Distribution System
No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound
shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic
(other than for vegetative maintenance) on the mound is not recommended since soil conpaction may hinder aeration of he
infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather
installations (October- February) dictate that the mound be heavily mulched for frost protection.
Influent quality into the mound system may not exceed 220 mg /L BOD5, 150 mg /LTSS, and 30 mg /L FOG. Influent flow may
not exceed maximum design flow specified in the permit for this installation.
The pressure distribution system is provided with a flushing point at the end of each lateral, and it is recommended that each
lateral be flushed of accumulated solids at least once every 18 months. When a pressure testis peformed it should be
compared to the initial test when the system was installed to determine if orifice clogging has occurred and if orifice cleaning is
required to maintain equal distribution within the dispersal cell.
Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner.
and any levels above 4 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring.
General
This system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall maintained in accordance with its'
component manual [SBD- 10572 -P (R. 6/99)] and local or state rules pertaining to system maintence and maintenance
reporting.
l
No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and
pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as
POWTS components.
Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access
openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed
unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall
be secured by an effective locking device to prevent accidental or unauthorized entry into the tank.
C ontingency Plan
If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the
system in proper operating condition.
If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component shall be repaired
or replaced immediately with a component of the same or equal performance.
If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired
or replaced in its' present location by increasing basal area if toe leakage occurs or removing biologically clogged adsorption
and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper
operating condition.
Questions on the operation or maintence of this system should be directed to your county zoning or health inspector.
I
Wisconsin Department of Commerce SOIL -SVALUATION REPORT Page of 3
Division of Safety and Buildings
in accordance wjtt►'�dmis►Bs WYs: Abp ,fie dun
Attach complete site plan on paper not less than 8 1/ 1'4,inches siz*Plan must County C "'T'o �
x
include, but not limited to: vertical and horizontal ref , point (�i and R parcel I.D.
percent slope, scale or dimensions, north arrow, and 140ion and dis tb Barest read. t, �� —'-'20a
' Reviewed by Date
Please print all inforrttajtion &!? E i r� i , _
Personal information you provide may be used for secondly purposes (Priv cy egd (1) (0g. - Z
Property Owner COUN party L ko ft o n
Re * ZONING FoW
/°f 1/4 4 1/4 S T N R 41r) W
i
Property Owner's Mailing Address r - _ 40 odc # Subd. Name or CSM#
City State Zip Code Phone Number ❑ City ❑ Village XTown Nearest Road
o7h S 2
❑ New Construction Use: Residential / Number of bedrooms Code derived design flow rate 90 O GPD
14 Replacement ❑ Public or commercial - Describe:
Parent material Flood Plain elevation if applicable fE ft.
General comments
and recommendations:
I
1 Boring # Boring /
pit Ground surface elev. �.�J, o ft. Depth to limiting factor 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
6 / o - r/ 3 S/J- d A S m
�k �Z q -13 1 jo sic A b
,5 �?- SC I MA
s oz`s
® Boring # Boring
�( pit Ground surface elev. 9Y W ft. Depth to limiting factor _ in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2
o l e ,4 h Dh I e S IF
5 M;2 6K I v
S a 7''S
Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L
CST Name (Please Print) Sig CST Number
Address Date Evaluation Conducted Telephone Number
Sao /3
Property Owner y S e/ /Vi Parcel ID # �✓ y' / l� �d " 000 Page oZ of
— T
❑ 3 Ong # Boring p
pit Ground surface elev. /S ft. Depth to limiting facto in.
I Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff #2
l 0 - Io S// M
kkk S /'1A6 S � ✓' dz
S o S
F -1 Boring # ❑ Boring
❑ pit Ground surface eiev. ft. Depth to limiting factor in. Soil Appli cabon Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2
F - 1 E] Boring
Boring # Ground surface elev. ft. Depth to limiting factor in.
1:1 pit Soil Application Rate
Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 I •Eff#2
Effluent #1 = BOD, > 30 < 220 mg/L and TSS >30 < 150 mgll_ • Effluent #2 = BOD, < 30 mg/- 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.
seD -8330 (rt.a(0o)
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ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/
Mailing Address # .. 7 -S�
Property Address
(Verification required from Planning Department for new construction)
r Syo /3
City/State ��e/X A-, o e d G l f� Parcel Identification Number D.��/ "
LEGAL DESCRIPTION
Property Location &4L r /4,�� r /4, Sec.
6 , T,�N -R --. W, Town of
Subdivision . Lot #
Certified Survey Map # , Volume , Page #
Warranty Deed # " ' Z-:Lo G , Volume Page #
Spec house ❑ yes q no Lot lines identifiable ❑ yes 9 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
mastprplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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 o the three year expiration date.
SIGNATURE OF 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
e erty descn �ve, 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 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
P PF-
f Slate Bar (If Wiuonsin Vo,m 1 1982
r, 50 QUIT CLAIM DEED
DOCUMENT NO V L A '� .t i .�. �•,y��
1
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Susan J. Seim, a siagle person
APR L 2 1996
9:
quit - claims to Leroy 4. Seim, a single person -_ -- _
THIS SPACE REGERVED FOR RE, '?RDiNC, ^A *A
the follow; g described real estate in SC. Croix _ __ C. only,
NAME AND RE TURN ADDPE$S
State of Wisconsin:
! �p. /3?
`,� --� ✓� �a ;tic, �J X
( Para 1 Idenrtication '.umber)
See attached sheet for legal description.
Said deed is given pursuant to a Judgment of Divirce between the parties.
#
This is homestead property.
(is) (ox �( 96
c
'#tit / ` day of April __ -_ - -_ 19
Dated this _. - - - - - - -- - --
�, Y - _ (SEAL)
_ (SEAL.) ___- �`y,1`^-'u`".'___' -
(SEAL)
(SEAL, - -- -- -- --
AUTHENTICATION ACKNOWLEDGMENT
of Susan J. Seim, STATE OF WISCONSIN 1
- -_ -- County.
- i - - - -- -
�{}t April _ . 96 Personally came before me this day of
authenticated this day of _ _ - - -
-
' 19- the above named
TITLE: MEMBER STATE BAR OF WISCONSIN - - — -
(If not. _- _ — -- - - -.-
authorized by §706.06. Wis. Slats.)
to me known to be the person who executed the
foregoing instrument and acknowledge the same.
THIS INSTRUMENT WAS DRAFTED BY -- -_ - - -- --
Joseph D. Boles - Attorney at Law _ __ ------------ - - - - -- - — -
WI 54022 (715) 425 - 7281__ N otary "Iblic County, Wis.
River Falls, y � ' - -- - -- - -- � -
(Signatures may he authenticated or acknowledged. Both are nct My commission is permanent. (If not state expiration date:
neces,arv.)
' %aau -• .ic.n"V n sn� -...r p,u rc� .h. •. td 'x ��p. -.i � r pnnlrJ Wl,consin Logal Blank Co . Inc
OCI t (1. Slit DE VI) sj,kIF. R,% It OF "IS, ON'AN Mllw3uka?r. W:s
F0P,%1
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s It 1 A • R
�. L 1 IIf F4ir 398
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Part of N 1/2 of NE 1/4 described as follows: Commencing
at N line of said NE 1/4 840.7 feet W of NE corner
there-of; thence SO °05'W ?54.0 feet; thence S89
1815.11 feet to W line of said NE 1/4; thence N0 on
said W line 371.35 feet to NW corner of said NE 1/4, E on
N line of said NE 1/4 1815.0 feet to point of beginning;
ALL of NW 1 and that part of N 1/2 of SW 1/4 lying Nly
of Railroad Right -of -Way EXCEPT commencing at centerline
of Railroad Right -of -Way and H 'ine of W 1/2 of N14 1/4 of
SW 1/4, N 50 feet to point of beginning, SWly parallel
with and 50 feet from said centt -rline to W line of said
N 1/2 of SW 1/4, V to point JOG feet from said
centerline, NEly to point of beginning, ALL in Section
29- 29 -15.
N 1/2 of SW 1/4 and aii of the NW 1/4 of Section 8,
Township 29, Range 15, St. Croix County, Wisconsin.
The Southeast Quarter of Section 6; also, West Half of
Southeast nuarter except `he West Half of West Half of
Southwest Quarter of Southeast Quarter, Section 5; also,
Southeast Quarter of Southeast Quarter of Section 5,
excepc therefrom the East 36 rods, all in Town 29 North,
Range 15 West, Subject to mineral rights of tocord and
easements of record.
Tax parcel numbers:
034 - 1063 -50
034 - 1063 -90
034 - 1064 -30
034 - 1064 -20
034 - 1064 -10
034 - 1063 -95
034 - 1013 -10
034 - 1012 -95
034 - 1012 -90
034 - 1012 -80
034 - 1010 -90
034- 1010 -
034- 1010 -60
034 - 1018 -20
034 - 1018 -10
034 - 1017 -95
034 - 1017 -90
034 - 1017 -80
034 - 1017 -70
034 - 1064 -60
034 - 1063 -40
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