HomeMy WebLinkAbout014-1027-60-000Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM
Safety and Building Division
INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT)
Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(nl
Permit Holder's Name: City Village Township
Michael Zamzow & Lorene Young I TOWN OF FOREST
CST BM Elev Insp. BM Elev. IBM Description.
TANK INFORMATION ELEVATION DATA
TYPE
TANK SETBACK INFORMATION
TANK TO
P/L
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer Demand
GPM
Model Number
TDH Lift Friction Loss System Head TDH Ft
Forcemain Length DO.—. Dist. to Well
JUIL At5bl I IUN SYSTEM
STATION BS HI FS ELEV.
Benchmark
Alt BM
Bldg. Sewer
SVHt Inlet
St/Ht Outlet
Dt Inlet
Dt Bottom
Header/Man.
Dist. Pipe
Bot. System
Final Grade
St Cover
BED/TRENCH
DIMENSIONS
Width
Length
No. Of Trenches
PIT DIMENSIONS
No. Of Pits
Inside Dia.
Liquid Depth
SETBACK
INFORMATION
SYSTEM TO
JPIL
JBLDG
IWELL
LAKE/STREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer:
Type Of System.
Model Number.
Header/Manifold
IDistribution
x Hole Size
x Hale Spacing
Vent to Air Intake
Pipets)
Length Dia
Length Dia Spacing
vvr� vvr il—rA v Vroeeurn cuetnme n..i.. -- Re..—. n_ •. I _ �
Depth Over
Depth Over
xx Depth of
xx Seeded/Sodded
xx Mulched
Bed/Trench Center
Bed/Trench Edges
Topsoil
❑ Yes a No
❑ Yes n No
t,UnnMtN I S: (Include code discrepencies. persons present, etc.) Inspection #1: Inspection #2:
Location: 3138 CTY RD O
1.) Alt BM Description =
2.) Bldg sewer length =
- amount of cover
Plan revision Required? ❑ Yes ] No I
Use other side for additional information. .1 I_J L-
SBD-6710 (R.3197)
Date Insepctor's Signature Cart. No.
�—� dt e- . -1\ r -:Vp4hl —,20a2 —d 7 R•
- r
D
Safety and Buildings vision
County
•�a
_` 0$ �-
201 W. Washington Ave., P.O. Box 7162
Sanitary Permit Number(to be filled in by Co.)
~ PS Z 1I 2p22
Madison, WI 53707-7162
MAR
,,.., .
C,,TL dr e AppllCatl
tare Transaction Number
In accordance with SPS is. Adm. Code, submission of this form to the appropriate govern mental unitt
PJ5T5 ���L90 2 �C
Project
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to
the Department of Safety and Professional Services. Personal information you provide may be used for secondary
Address (if different than mailing address)
purposes in accordance with the Privacy Law, s. l 5.04 1 m Stars.
I. Application Information — Please Print All Information
Property Ow er'
Nam
cG L ZAwt
Parcel #
aH -- 2 0 - 40
OU.J
Property Owne ' )Tling dress
11
Property Location
5v of
5 '/. sC 1/4 Section IZ
City, State
Zip Code
Phone Number
u /yip
`2 '• g -t �✓O`
(circle one)
T 3 L N; R 157 West
II. Type of Building (check all that a ply)
1 or 2 Family Dwelling — Num Q� oo
Lot #
`
Subdivision
Block #
Public / commercial — Descr use is
❑ City of
Village of
State owned — Described use
Na
CSM Numter
Town of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A.
ew ystem
Replacement System
Treatment/Holding Tank Replacement Only
❑ Other Modification to Existing System (explain)
B.
❑ Permit Renewal
❑ Permit Revision
❑ Change of Plumber
❑ Permit Transfer to New
List Previous Permit Number and Date Issued
Before Expiration
(Tuner
IV. Type of POWTS System/Component/Device: (Check all that apply)
Non -Pressurized In -Ground ❑ Pressurized ln-Ground At- Mound > 24 in. of suitable sod Mound < 24 in. of suitable soil
Holding Tank ❑ Other Dispersal Component (explain) ❑ Pre tr t Device explain)
V. DispersaU'IYeatmentArea Information: X
o xbS
Design Flow (gpd)
Design Soil Application Rate(gpdsf)
Dispersal Area Required (sf)
Di sal Area Pfoposed 00
System Elev i
VI. Tank Info
Capacity in
Total
# of
Manufacturer
u
6
Gallons
Gallons
Units
0
New Tanks
Existing Tanks�1
C6
Septic Tank
SkAul
X
Lift Tank
1
1 \ •r
I X
VII. Res onsibili went- I, th u ersigned, a me resnsibliftfTdNostallption of the POWTS shown on the attached plans.
Plumber's Name ( t)
--
P re
MP/MPRS Number
Business Phone Number
Lewis B'o k •
253976
715-231-7375
Plumber's Address et, City, State, Z' ode)
E7818 Count o enomo
'e, W 751
VIII. County/Department Use Only
pproved
❑ Di s
Permit Fee
Date Issued
Iss ' g ent \ignatur
❑ Ow n e for DenialZ-
����
YSTEMndit W' rov 3? A4 ,� • OS PS
,
Septic tank, effluent flllar and c. t �111�D .�—r_. S PA i�
dispersal cell must b�tervieed I Inalntolnad
as per management plan provided by plumber. �j1
.All setback requirements must be maintained
dLSC
^7 -
At> :��i t
.:a,
0-al
O—fi
CHECK BOX AS APPLICABLE, CHECK BOX AS APPLICABLE,
❑ SOIL EVALUATION o(- 7P.I=40' so YSTEM PAGE 2 OF�o
SITE MAP eo XI'LOT
PLAN
PROJECT _N.A�M�E,:_l
.�it�s� I GiLi�'�sNw 1D° DESIGN FLOW. 3CO GPD
Atta91L
h design flow calculations for commercial plans.
PROJECT ADDRESS: �- %I 3$ ut, ig M Q NSTM Standard (Tables /3a4.�&38 .30-5)
Symbol BM Elevation: er.
8M ac�1 Ion:
91opeGrodarnt°6) Well Symbol(Itappllcable): 0 °"O"hIMPORTANT:
of Tested Anea ewinp an nd elevation contours at suitable intervals.
o
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Z.S3�'7fa .
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5 blOe 9, AliS 1 �troo
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Wt�l y`
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Arcs
40 acre parcel per St. Croix -- /
County CIS
Qlb 065P5e1� NACU- FS__ Section
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March 10, 2022
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 2024-03-10
Plan Review: PWTS-032200382-C
LEWIS C BJORK
E7818 County Rd E
Menomonie WI 54751
SITE:
Micheal Zamzow
3138 County Q
Town of Forest
St. Croix County
Sec. 12, T31N, R15W
Total Amount: $250.00
DIVISION OF INDUSTRY SERVICES
2331 SAN LUIS PL
GREEN BAY WI 54304-5211
Contact Through Relay
http://dsps.wi.gov/programs/industry-services
www.wisconsin.gov
Tony Evers • Governor
Dawn Crim - Secretary
Conditionally
APPROVED
DEPT. OF SAFETY AND PROFESSIONAL
SERVICES
DIV SIGN OJISTRY SERVICES
SEECORRESPOND CE
FOR:
Description: Two Bedroom At -Grade system 1 Sloped Site
Pressure Distribution Component Manual — Ver. 2.0, SBD-10706-P (N.01/01, R 10/12)
At -Grade Component Manual - Ver. 2.0, S13D-10854 (N.03/07, R. V12), 300 gpd, 36 inches to limiting
factor from original grade, Maintenance required, effluent filter, New construction
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:
Reminders
• A sanitary permit must be obtained from the county where this project is located in accordance with
the requirements of Sec. 145.19, Wis. Stats.
• Prior to construction of the dispersal area, check the moisture content of the soil to a depth of 8
inches. Proper soil moisture content can be determined by rolling a soil sample between the hands. If
it rolls into a 1/4- inch wire, the site is too wet to prepare. If it crumbles, site preparation can proceed.
If the site is too wet to prepare, do not proceed until it dries.
• 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 state approved effluent filter is required. Maintenance information must be given to the owner of the
tank explaining that periodic: cleaning of the filter is required.
Owner Responsibilities
The current owner, and each subsequent owner, shall receive a copy of this letter. Owners shall also
receive a copy of the appropriate operation and maintenance manual(s) and be responsible for
ensuring that POWTS is operated and maintained in accordance with this chapter and the approved
management plan under s. SPS 383.54(l).
• 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.
• 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.
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.
In granting this approval the Division of Industry Services 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.
The above left addressee shall provide a copy of this letter and the POWTS management plan to the
owner and any others who are responsible for the installation, operation or maintenance of the POWTS.
Sincerely,
<,oMG 'PFI-5q
POWTS Plan Reviewer — Wastewater Specialist
Department of Safety & Professional Services I Division of Industry Services
email: Katie.Petzel<a)wisconsin.gcv
Cell: 608-574-1189
At -Grade Plan PAGE 1 OF 6
Index & Cover Sheet
Component Manual Design References:
Version 2.0, SBD-10854-P (N.03/07, R. 01/12) & Version 2.0, SBD-10706-P (N.01/01, R. 10/12)
Pg 1 of 6 Index & Cover Sheet
Pg 2 of 6 Plot Plan
Pg 3 of 6 Dispersal Area Cross -Section & Plan View
Pg 4 of 6 Distribution Network Specifications
Pg 5 of 6 Pump Tank Specifications
Pg 6 of 6 Management Plan
Attachments: � Enclosures:
Pump Curve I POWTS Application for Review
Tank (s) ( Soil Evaluation Report & Site Map
Project Name I Description
NJ Z *tz bw CoNbi . - M -Gr"
Owner Name(s): `"';L�qt l ZAM,1001 Phone: (11Z- _ -S40-MR I_
Owner Address: 3138 G+y Qd Q Zip:
Project Address: Jf VA4.
Govt. Lot: 1/4 of _1A Section1, T 3 ( N-R I E❑ or WE
Township: 1:o' rCounty:•
Project Parcel ID #: GPI°{ "Ib'=7 — 60 -" Cad
Designer Information
Designer Name: Lewis Blork Phone: 715 -231 -7375
Designer Address: E7818 County E Menomonie WI zip: 54751
E-mail: IewisbiorkCcwahoo.com _ I . ,
License Number: 253976
Remarks:
Signatu
Conditionally
APPROVED
DEPT. OF SAFETY AND PROFESSIONAL
SERVICES
DIV SION OF I STRY SERVICES
SEE CORRESPOND CE
Date: '"19 -ZZ.
Original signature required on each submitted copy.
CHECK BOX ASAafMJCABLE. CHECK BOX
❑ SYSTEM
SOIL EVALUATION Scale' 1" =40' PAGE 2 OF
SITE MAP eD B0 LOT PLAN
t PROJECT NAME:
DESIGN FLOW. 3�
tic I to K" design
h' ,, I Attach des n flow calculations for commercial plans.
PROJECT ADDRESS: '5L 3139 4444 IV[ Q Pipe Material ! ASTM Standard (Tables 384.30.3 & 384.30-5)
N Sanitary Sewer_
Symba � BM Elevetbn. F7
BM aclglon:
SPi w Men: 2 !3�b3"
Stope Gradlerli WeuSymbW(dappucatwel. katewrt"� �� IMPORTANT:
of Tesled Area: e1'^^o a"'+ nd elevation contours at suitable intervals.
h0 approprite k e.
MNS': ,Lit 0 G ?w f 99
7� 0, 0
Z53q• icy
III S V�G M x��S \ •,�
1 .
r +•
S• �
z tr TAy�- --
�•WM4 ^1
IrAQP l swi6
-- NtA ^ G1�►�1
40 acre parcel per St. Croix
County GIS
p55 5(t `I�Acu- F!b Section, T 3 N-R E[] or WE—
PAGE 3OF6
CROSS SECTION VIEW
(No Scale)
0.5' TO 2.5" WASHED AGGREGATE
(covered with approved synthetic fabric) MIN. 6.0" OF TOPSOIL COVER
99
PLAN VIEW
(No Scale)
2 •ewdao
Surface Contour SLOPING sne
Elevation = ft
L=15L
AT -GRADE DISPERSAL AREA
(Show force main and flush valve locations on plan view.)
�r �5 L)/— — —/ �R7 1-
---------------------_-----
W- ft� — — -- — -- — I 2.0 ft� -- — — — AGGREGATE BED ( /) $ T �
nvaa�) / I A f&- ft
1 — y9 — — — — — — `Observation Pipe 7-7-7-7-7—
J
B-1—ft — — — — — —
Prohibit disturbance and vehicular
traffic within 15 ft of downslope toe.
z
m
Bend as necessary to follow contours.
Resat Pave
DISTRIBUTION NETWORK SPECIFICATIONS
(No Scale)
fids r2"
Laterals to be level First Orifice -"0 Schd140
Schdl 40 PVC Lateral 0 = in (typical) low :' /PVC Force Main
FLUSH (too VALVE QDETAIL (typical)\ `� (riser
ptlo �/ (slope rdra -back)
nk
\ .,
Orifice in �--
— Valve Box
Center of Threaded Cap
(insulation optional)
for Head Testing
(optional)
I
, \
I
Ball Valve
I \
(optional)
\
i
Orifices equally spaced:
a) OR b) below)
a)1al_
along bottom of lateral
-
b)
n along top of lateral
Flush Valve
with every th tole
Assembly
Shield orifices for
graveness applications
facing down (typical - see detall) Last Orifice
(typical)
LATERAL INVERT ELEVATION = S' ft
(typical)
OBSERVATION PIPE DETAIL
(No Scale)
Screw -Type or •� :� .
Slip cap (loose) v
Finished Grade
(mulched & seeded)
4"PJ PVC Pipe
Topsoll Cover
Top of pipe to terminate
(min. 1 foot)
at or above finished grade
(4)1/4"-l/2" X 6" Slots
®4b apart
Anchoring Device ...
Infiltration
Surface
Lateral Length (P) = c7 It
Q 33
Number of Orifices per Lateral =
Orifice Discharge Rate = • `�� gpm
Orifice Spacing (X) _ in
(typical)
Orifice Diameter = in
Number of Laterals =
Lateral Discharge Rate = Z • W gpm
TOTAL DISCHARGE RATE = 24 • K47 GPM
(typical) First Odfice
(typical)
x
END MANIFOLD
Check
(typical) 191 CONNECTION
applicable box. Manifold
First Orifice (riser pipe optional) D
(types) Q
m
I-- xw2 x162 x
(types) (typical) 0
CENTER MANIFOLD 'TI
Manifold ❑ CONNECTION cr)
(riser pipe optional)
PAGE 5 OF 6
SEPTIC / PUMP TANK SPECIFICATIONS
4"0 Vent Pipe (No Scale)
>10 ft from
Building Eectrical must oomoly with
12' Min. or 2.0 A above SPS 316 and NEC 300
Established Flood Elevation Weatherproof Extend manhole riser as necessary.
(typical) AppovedJunction Box
Vent Cap Approved Locking Manhole
IMPORTANT: p with Warning Label Attached
Anchor tank(s) as necessary I (typical)
pursuant to SPS 383.43 8' `—cone°'t
( 4" Min. or ft above
Established Flood Elevation
Itg)
T(typical)
Finished Grade
CAPACITIES @ L(ogal/in
18.25
4.5
Depth (in)
Volume (gal)
A
B
2.0
32.94
[c]
D
I
.
300.58
74.12
*Pump Tank Liquid Level = '9 in
Force Main Diameter = �•� in
e
Force Main Length = ZS ft 3"Approved Bed`
20.375
Force Main Void Volume gal �*.1
6
74.12
[C] Total Dose Volume TDh� _ :—� gal/dose
(5X total lateral void volume < TDV < 0.2X design flow)
+ (force main drainbacc volume)
MIN. PUMP DISCHARGE RATE = ZI • NS gpm
PUMP TANK:
Volume = 2. gal
Manufacturer: V4173
Pump Manufacturer: 70L�I[A ".
Pump Model: I52.
(See attached pump curve.)
Controls/Alarm Manufacturer: vy�,bV 5
Controls/Alarm Model:
Float switches containing mercury are prohibited.
/_Airtight Seal
Quick Disconnect
18" Min.
(typical) t `o -5,
Weep I � Approved Joints with
Approved Pipe 3 ft onto
Solid Ground
Hole
(tYPlraq
Alarm
—On PUMP -OFF
_oa ELEVATION = 8 . Z5_�ft
Concrete INSIDE BOTTOM
Block ELEVATION = �� ft
Material Beneath Tank _
Vertical Head = t `rr,a" ZdT ft
+ Min. Supply Head = Z�'S ._ft
0
f
+ FM Friction Loss = ft1.32
+ Fitting Loss* = -S ft
*(min. supply head x 0.3)
= TOTAL DYNAMIC HEAD=�ft21.6;
SEPTIC TANKS 1.
Total Volume = gal
Manufacturer(s):
Install approved effluent filter at the septic tank outlet
immediately upstream of the Bump tank inlet.
Filter Manufacturer: _tV7_.F N(p
Filter Model: �T— 0RZ Z — t
Page 6 of 6
At -Grade Management Plan
IMPORTANT:
The owner of this at -grade system shall be responsible for its perpetual operation and maintenance pursuant to
requirements of SPS 382-384, Wise. Admin. Code. Pursuant to SPS 383.52 (2), Wisc. Admin. Code, this system shall be
considered a human health hazard if not maintained in accordance with this approved management plan. Furthermore,
all inspection and maintenance activities shall be performed by a registered POWTS Maintainer in accordance with SPS
383.52 (3), Wisc. Admin. Code.
Maximum Dispersal Area Operatina Limits:
Design Flow = 3M_ gpd; BODE 5 220 mgL`; TSS 5 150 mgL''; FOGS 30 mgL"
Inspection Checklist INSPECT EVERY 3 YEARS
o type of use ,
o age of system
o nuisance factors (i.e. odors, user complaints, etc.)
o mechanical malfunction (i.e., pumps, valves, switches, floats, etc.)
o material fatigue (i.e.. leaks, breaks, corrosion, etc.)
o solids volume in anaerobic treatment tank(s) and any distribution appurtenance(s) (i.e., distribution / drop boxes)
o neglect or improper use (i.e., exceeding design capacities, prohibited activities, etc.)
o extent of ponding in distribution cell prior to dosing
o dosing irregularities (i.e., pump re -cycling, float switch settings, etc.)
o electrical components (i.e., wiring, connections, switches, controls, timers, alarms, etc.)
o distribution lateral or lateral orifice plugging (measure lateral distal pressure — compare to design specification)
o surface discharge of effluent or sewage back-up into structure served
Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when necessary)
o Septic and dose tank(* i shall be pumped by a certified septage servicing operator licensed under s. 281.48 Wis.
Stats. when the volume of solids in the tank(s) exceeds one-third (113) the liquid volume of the tank(s) or
as required by local ordinance. Disposal of contents shall be pursuant to NR 113. Wisc. Admin. Code.
o Effluent filterlsl shall be inspected every 3 years and shall be cleaned when necessary to remove any
accumulated solids according to manufacturer's specifications. A servicing period will always be greater than 12
months.
c Distribution laterals shall be flushed once every 3 years or when necessary.
System maintenance reports shall be submitted to the proper local government unit in accordance with SPS
383.55 Wis. Admin. Code. Report any component failure or malfunction to:
Name of individual or company: Lewis Biork Family Septic SerPhone
Local government unit:
Local government unit;
� � r
Any defective part of this system shall be repaired, replaced, or removed pursuant to SPS 383.51 (1), Wisc. Admin. Code,
Repair or replacement of failed or malfunctioning components shall comply with SPS 383, Wis. Admin. Code. No product
for chemical or physical restoration of the POWTS may be used unless approved by the department in accordance with
SPS 384, Wis. Admin. Code.
Continaency Plan
In the event that any failed treatment component of this POWTS cannot be repaired, it shall be replaced pursuant to
plan submitted to the appropriate agency for review and approval. A failed at -grade dispersal component may be re-
constructed within the originally approved area after removal of all failed components.
System Abandonment
If use of this POWTS is discontinued, it shall be abandoned in accordance with SPS 383.33, Wis. Admin. Code.
150 Series lal cent Pumps AwIler Pump Company
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40 80
120
160 200 240
280 320 360
FLOW PER MINUTE
2'21^_018, I0:05 A\t
a0WARNING DEATH A4AY OCCUR tF TANK IS ENTERED
Q WITHOUT PROPER EQUIPMENT
NOTE. SEE INNER WALL PHOTO ON THE'FXCLUSIVELY AT SKA WS' PAGE.
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24.00 N.00 71'00
S00 1--.1do0 � 1.00
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SEAL GASKET
L— BAFFLE FILTER
100 J SECTION VIEW OF TANK AND COVER
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1000 OUTLET
4 OUCH
PRESS
SEAL
GASKET
Model Number: 10001600 SKAW PRE -CAST Phone: (715) 967-2277
Approved for SEPTI=EPTIC.SEPTIC/PUAIRSEPTIGSIPHON OR HOLDING 26255 105th Street, New Aubum Toll Free: 1-800-924-8625
Weight a aim. nT Liq. Depth Gel. / In. Nom. Cap. Wisconsin 54757 Fax: (715) 967-2707
13,050lbs. 44' 42' 39' 16.47 642.33 gal, www.skawpre",w.c=
Wisconsin Department of Commerce SOIL EVALUATION REPORT
Division of Safety and Buildings
in accordance with Comm 85 Wis Adm Code
Page! of 3
County Gz} • LQ Q qv
Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must 7
Include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel LD�n-7 �n
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. O 114N I v `-a /Dv ' �0
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
fi4,1li A tiI Z/Jivr1ZOW GovL Lot 1/4 1/4 S IZ T a t N R 124 E (or} W
Prooertv Owner's Mailino Address I Lot # I Block # I Subd. Name or CSNW
Nearest Road�
El New Construction LlseQ Residential / Number of bedrooms �_ Code derived design flow rate 3!�10 GPD
Replacement Public or commercial - Describe:
Parent material 10to'5 W (L T14 Flood Plainelevationif applicable 0 A ft.
General comments ZVAI( M • Grrd k C)N 98 •
and recommendations:
B-1
Boring # 11 Boring p
Q Pit Ground surface elev. 1$ ft. Depth to limiting favor in.
Soil Application Rate
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/ff
•EH#1
•Eff#2
y
c�N
i
2.4a
Cg
7F
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• 8
j
t 5!
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-
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I & I B�� # M o "� Ground surface elev. q ) ft. Depth to limiting factor _ " in. 0- r ���r �,N� 0�,e
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr, Sz. Sh.
Consistence
Boundary
Roots
GPDNF
'Eff#1
40#2
Q'
104 3 -Z-
g
10*
N
5 •
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(M.
Cs
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4 Effluent #1 = BOO n 30 <ZZU mg/L and IS:i < l L cmm�m x< - nvv _ ,y,.. �, ,., , _ •••yam
CST Name (Please Print) ure CST Number
Lewis Bork
s Bjork 253976
Address Date Evaluation Conducted Telephone Number
E7818 County E Menomonie WI '�, 6-0 %jZZ 715-231-7375
Property Owner 7,4m L.w Parcel lD # (fY(~ tbZ7 — X-= Pago
❑B-3 Boring # rr��� Boring u
LJ Pit Ground surface elev. ft. Depth to limiting factor - `0 in.
2 3
of -__
1 Cni� nn.Jirsr�nn F2�ta,
a . Sz.o DescriptionColor
I W.".
maral
I
VMWM="�-
Boring # Boring
• Pit Ground surface elev. ft. Depth to limiting factor in.
Sod Application Rate
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
Ou. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/fF
'Eff#1
'Eff#2
❑
Boring # Boring Ground surface elev. ft. Depth to limiting tailor in.
• Pit Soil Application Rate
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPD/W
'Eff#1
'Eff#2
' Effluent #1 = BOD5 > 30 < 220 mg& 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.
SBIM330Tnr (l0T100)
CHECK BCX AS APPLICABLE. CHECK BOX AS APPLICABLE
❑ SOIL EVALUATION Scale: 1"=40' ❑ SYSTEM PAGE 2 OF
SITE MAP `° W 80
PLOT PLAN
PROJECT NAME: 30�
— 4 � lo, DESIGN FLOW. — GPD
? 9 C,14 .mil Attach design flow calculations (or commercial plans
PROJECT ADDRESS: �, 31 34 Q
SM Symba, + BM Elevation. .__.',00 FT
SMDespnpNon.
Slope Gradient (°A) Q well Symboi la appllwMe) 0
o1 Tested Area
Z53Q'7�
4nS �
K\O wal
N '
60 cats Moth avnng an ar a
lien ePprwm line
Pipe Material / ASTM Standard (Tables 384.30-3 8 384.30-5)
�(►L Sanhary Sewer AI - �Z%6 5-
Forces Main 2.
1 '
61,00 ` IMPORTANT.
Show SlYwnd elevation contours at suitable intervals.
q(A0e.1 ^
W Z 08
O O Oi
tag
8•a
(2) %--z
v{oMb
a
t )b DSSP Ser 9ACU-
County
Safety and Buildings Division
201 W. Washington Ave., P.O. Box 7162
Madison, WI 53707-7162 Sanitary Permit Numb
(to be filled in by Co.)
Sanitary Permit Application State Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project
the Department of Safety and Professional Services. Personal information you provide may be used for secondary Address (if different than mailing address)
purposes in accordance with the Privacy Law, s. 15. 1 Am), Sm.
1. Application Information — Please Print All Information
City, State
11. Type of Building (check all that apply)
I or 2 Family Dwelling— Number of Bedrooms
Public / commercial — Describe use
State owned — Described use
w"IL I�
or
Phone Number Govt. L
12- 8-I0-0f7j 1/4I!A Section 14
—t (7 (circle one)
Lot a T -6 L N; R i5- West
Subdivision
Block it
Na
CSM Number
❑ City of
Village of JR), f.
Town of
III. Type of Permit: (Check only one box on line A. Complete line B if applicable)
A. Nev, System Replacement System Treatment/Holding "rank Replacement Only ❑ Other Modification to Existing System (explain)
B.
❑ Pemtit Renewal
❑Permit Revision
❑ Change of Plumber
[11P,�ermil Transfer to New
list Previous Permit Number and Date Issued
Before Expiration
Ower
tv. -type or rvw i b bystemrt omponenrr Vevtce: tt,neca an enat apply/
Non -Pressurized In -Ground ❑ Pressurized In-CrrounSYAt-Grade Mound >_ 24 in. of suitable sod Mound < 24 in. of suitable soil
Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain)
V. DispersaMestment Area Information:
Design Flow (gpd) Design Soil Application Rrue(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation
42
V1.
Gal Ions
Exisang
Total I M of
Gallons Units
Septic Tank I 1= I I 1 5 KAQ 7`
Lift Tank l 1 t 4 At
X
'
VII. Responsibility Statement- 1, the undersigned,me res nsibil nstal fion of the POWTS shown on the attached plans.
Plumber's Name (Print) MPJMPRS Number Business Phone Number
Lewis Borkjj��
253976 715-231-7375
Plumber's Address (Street, City, State, Zip Code)(
E7919 County Road E Menomo 'e. W 751
VIII. County/Department Use Only
Permit Fee Date Issued Issuing Agent Signature
❑ Approved El Disapproved
❑ Owner Given Reason for Denial
IX. Conditions of ApprovalitReasons for Disapproval
SBD-6398 (R. 1 Ill1)
Parcel #: 014-1027-60-000
Valid as of 03/22/2022 03:14 PM
Alt. Parcel #: 12.31.15.191
Owner and Mailing Address:
MICHAEL ZAMZOW
YOUNG LORENE
350 150TH AVE
SOMERSET WI 54025
Districts:
Dist# Description
1127 SCH DIST OF CLEAR LAKE
0038 ICLEAR LAKE FIRE DIST
1700 NORTHWOOD TECH
Abbreviated Acres: 40.000
Description:
SEC 12 T31N R15W SW SE
TOWN OF FOREST
ST. CROIX COUNTY, WISCONSIN
Co-Owner(s):
YOUNG LORENE
ress(es):
3138 CTY RD Q
Parcel Histo
Date
Doc # Vol/Page
Type
10/07/2003
742853
2430/558
QC
08/11/2003
734948
2357/359
WD
07/23/1997
1
11226/238
1 PR
Plat Tract (S-T-R 401/4 1601/4 GL) Block/Condo Bldg
* N/A -NOT AVAILABLE 12-31N-15W
2021 Valuations: Values Last Changed on 04/06/2021
Class and Description Acres Land Improvement Total
G4-AGRICULTURAL
20.000
3,300.00
0.001
3,300.00
G5-UNDEVELOPED
0.500
100.00
0.001
100.00
G5M-AGRICULTURAL FOREST
17.500
13,200.00
0.001
13,200.00
G7-OTHER
2.000
9,000.00
31.500.001
40,500.00
Totals for 2021
General Property
1 40.0001
25,600.001
31,500.001
57,100.00
Woodland
0.0001
0.001
0.001
0.00
Totals for 2020
General Property
40.000
25,400.001
31,500.00
56,900.00
Woodland
1 0.0001
0.001
0.001
0.00
2021 Taxes
Bill #
Fair Market Value:
Assessment Ratio:
10587
Use
Value Assessment
0.7362
Amt Due Amt Paid Balance
Installments
Net Tax
1,136.08 1,136.08
0.00
End Date
Total
Special Assessments
0.00
0.00
0.00
1
01'31/2022
568.04
Special Charges
0.00
0.00
0.00
2
07/31/2022
568.04
Delinquent Charges
0.00
0.00
0.00
Private Forest Crop
0.00
0.00
0.00
Net Mill Rate
0.021140271
Woodland Tax
0.00
0.00
0.00
Managed Forest Land
0.00
0.00
0,00
Gross Tax
1,324.09
Prop Tax Interest
0.00
0.00
School Credit
116.99
Spec Tax Interest
0.00
0.00
Total
1,207.10
Prop Tax Penalty
0.00
0.00
First Dollar Credit
71.02
Spec Tax Penalty
0.00
0.00
Lottery Credit
0 Claims 0.00
Other Charges
0.00
0.00
0.00
Net Tax
1,136.08
TOTAL
1,136.08 1,136.08
0.00
Interest Calculated For 0312212022
Payment (Posted Payments)
Date Receipt # Type Amount Note
01/31/2022 1234 T 1,136.08 1 ZAMZOW CK 2410
Key Payment Type: A - Adjustment, R - Redemption, T - Tax * - Primary
ST. CRo UNTY SANITARY SYSTEM File #:
Office use Only
OWNERSHIP/ADDRESS FORM Cr•oted2a02r
Community Development Department will utilize this information to provide the property owner with
information regarding operation and maintenance of your new or replacement sanitary system! This
information will be provided as part of our ongoing efforts to protect public health, your well, groundwater,
surface water, property values, and county resources. Once approved, this completed form and educational
information will be sent to you by email.
OWNER/BUYER INFORMATION
Owner/Buyer Michael Zamzow
Mailing Address 350 150TH AVE
City/State/zip SOMERSET Wl 54025
Phone Number (required)612-840-0081
Email Address (required) mnlzamzow@gmail.com
Parcel Identification Number 014-1027-60-000
(found on the property tax bill)
NEW SYSTEM: LEGAL DESCRIPTION
Property Location _ 1/4 , _ t/4 , Sec. 12 IT 331 N R 1 W, Town of Forest
Subdivision Plat: , Lot # —
Certified Survey Map # Volume") 30 Page # 551
Warranty Deed # —]H 'DS (before 2006)Volume , Page #
Number of bedrooms 2 Spec house 0 yes ■ no Lot lines identifiable ■ yes 0 no
New Property Address
(ttait Initials)
OFFICE USE ONLY
(Verification of Uw address required from Community DJvelopment Department for new construction.)
3 23 zz
(Dat
This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications.
New System: Include with this form a recorded warranty deed from the Register of Deeds Office and a copy of the certified
survey map if reference is made in the warranty deed.
Community Development Department — Land Use Division
715-386-4680 St. Croix County Government Center 715-245-4250 Fax
cdd(@sccwi.gov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.gov
WCkk uso,.vrr PSG
I
_l f
i
-77
LS i � aka — Dad
Wisconsin Department Comme(glnR 17 2022 OIL EVALUATION REPORT Page 1 of 3
Division of Safety and Bui ings M H
in 7reforenoe
oe wit Comm 85, Wis. Adm. Code `�qi—,.---•
Attach complete silo a on St. CrolX ont ches in size. Plan must
County • GR O jy W a �Att9s�
include, but not limited to v zontapoint (BM), direction and Parcel LD -� ,•
percent slope, scale or dimensions, north arrow, and location and distan nearest road. � iL4w = I•+ 40
Please print all infoppumooses
Reyi ed by `� Date
Personal information you provide may be used for seconda(Priv, ( )j.
Property Owner jj Property Location I •
R{,1 ZAVYliZr W Govt. Lot 1A 114 S TN R IS
Property Owner's Mailing Address Lot # I Block # I Subd. Name or CSM#
♦ E
E] New Construction UseQ Residential I Number of bedrooms _ Code derived design flow rate 31PD GPD
El Replacement Public or commercial - Describe:
Parent malerlal M,55 c0i 2 T I lFlood Plain elevation if applicable Ar ft.
General comments . [C
and recommendations: 1A1( A+•6rAAt dui 9a
�A V W A/ )?1I� 2S 7� l« _ / _ Nu,¢ �•rC /CS2 r��G+dFe��/ E x
B- I
❑
Boring # ❑Boring
p ED pit Ground surface elev. _IS ft. Depth to limiting factor 6 in.
Soil licadon Rate
Horizon
Depth
1n.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. $h.
Consistence
Boundary
Roots
GPD/fF
'Eff#1
'Efr#2
2F
. G
• (
t S/
;
2 w�eki
ttk
c5
2 F
(o
(�+•♦yam
4
4 fm
/��
�V
/
IL
c� L-
.770R�
w
•"�
®�°ri"� #
• pit Ground surface elev. qf6 ft. Depth to limiting factor 371_ in.
Rna Annlirm/inn Rutw
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
I
Boundary
Roots
GPD/fF
'Ef#i1
*Eff#2
0-8
10U3 z•
S• i
Z4*(4
M%kc.
cs
ZF
• Q
Effluent #1 = BOD > 30 < 220 mg/L. and T < Efauent 92 = BOD � 30 mg/L and TSS _5 30 mgn.
CST Name (Please Print) ure CST Number
Lewis'Biork s Bjork 253976
Address Date Evaluation Conducted Telephone Number
E7818 County E Menomonie WI `� 1 K d Zb ZZ 715-231-7375
Property Owner _Z4rA ow ParcellD#_aj ^t0Zf ^X^(�Co Page
B-3 Boring# 0 Boring ❑ Pit Ground surface elev. J— ft. Depth to limiting factor_ ` lQ In.
2 of 3
Redox Description
�ei:iBlil
=,
• MI
`�
M
Film
,
�®
®
Boring', H
Boring
Pit Ground surface elev. ft. Depth to limiting factor in.
Horizon
Depth
in.
Dominant Color
Munsell
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GPDlfF
'Eff#1
'Eff#2
Boring # , Boring
• Pit Ground surface elev. ft. Depth to limiting factor In.
Snil Annlicatinn Rate
Horizon
Depth
In.
Dominant Color
Morsel
Redox Description
Qu. Sz. Cont. Color
Texture
Structure
Gr. Sz. Sh.
Consistence
Boundary
Roots
GpDN
'001
'Eff#2
. Effluent #1 = BOD, > 30 < 220 mgA- and TSS >30 < 150 mglL ' Effluent #2 = BOD, < 30 mg/L and TSS _< 30 mgrL
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.
sao-83AOT.1 (R 07:n0)
I
CHECK BOX AS APPLICABLE. CHECK BOX AS APPLICABLE. G•!fi
❑ SOIL EVALUATION Sale: 1' =40' FISYSTEM PAGE 2 OF
SITE MAP 40 60 BD,
PLOT PLAN
•-, PROJECT NAME: 3007
tt ( 2Lw12o� tDs DESIGN FLOW: GPD
{ �A�J .� f ,� I Attach design flow calculations for commercial plans.
PROJECT ADDRESS: � 3138 C-14 14.s�. Q
BM Symbol: Y BM Elevation: 100 0 FT
BM Description: SP l E ' W { •i
Slope Gradient (°h) Well Symbol (it applicable):
of Tested Area.
ZS3ti
5 �IOE » 2lLS 7r�
�. / Pipe Material / AS
N�(►1, Sanitary Sewer
Force Main:
w{/Yigla an `
l ewing e l lilk ne
Show g�punc
he approprlla line. �
l
All
✓` 9tal
Aron
TM Standard (Tables 384.30-3 & 384.30-5)
H � Q- 2665
IMPORTANT:
elevation contours at suitable intervals.
IOM4
0
1Jb 055P 5c. t3ACV- M�JFS
2 000Ahap 04
5171 b Rol C couNn
STATE SA
313
OWNER
NO, 641914
TPERMIT
�
PREVIOUS NO. �^
PLUMBE IS[2j0pje..L2.0IC.#
TOWN OF
SEC�2 ,T�I_N, R
ANp/OR_LOT BLOCM
CHAPTER 145.135 (2) WISCONSIN STATUTES
(a) The purpose of the sanitary permit is to allow installation
of the private sewage system described in the permit.
(b) The approval of the sanitary permit is based on
regulations in force on the date of approval.
(c) The sanitary permit is valid and may be renewed for a
specified period.
(d) Changed regulations will not impair the validity of a
sanitary permit.
(e) Renewal of the sanitary permit will be based on
regulations in force at the time renewal is sought, and that
changed regulations may impede renewal.
(f) The sanitary permit is transferable.
History: 1977 c.168; 1979 c. 34,221; 1981 c. 314
Note: If you wish to renew the permit, or transfer ownership of
SUBDIVISIONthe permit, please contact the county authority.
►ISSUING OFFICER- DATE Wift2Z
SS RENEWED BEFORE THAT DATE
POST IN PLAIN VIEW
VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION
SBD-06499 (RI 1/20)-