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Wis %,or *n DepartmentofCommerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and building Division
INSPECTION REPORT Sanitary Permit No:
506261 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:
Weyer, Shawn I Springfield, Town of
CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No:
l 0b - 6 be 146A 31.29.15.
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic � Benchmark
(i(f �a•� /a� s �oa� a
Dosing / Alt. BM ej /
ll! I to(o.
Aeration Bldg. Sewer
films U V 7 4 6 S 103 r
Holding 01-It Inlet,,, • /S
/
TANK SETBACK INFORMATION SL'Ht Outlet
TANK TO P/L WELL BLDG. Vent to Air �/ Intake ROAD Dt Inlet /
4 2
Septic / 5 ! Dt B t m
Dosing He de Ma S S. / d /D O S- 7 V
s T
Aeration TM ry Dist. Pipe
Holding U Bot. System
Final Grade
PUMP /SIPHON INFORMATION 1
Manufacturer Demand St Cover �,� t� Q o�
GPM 71 T`
Model Number J5, ry 36L.'75' Q S-"s /f
TDH Lifj,. Friction Loss System ? ad TDH Ft
Forcemain engtlL / Dia. /y Dist. to Well 1 / / '.✓ , 3 0- f/ Z
SOIL ABSORPTION M k C#
BEDITRENCH Width f Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth
DIMENSIONS
SETBACK SYSTEM TO tBLDG WE LAKE /STRE G Manufacturer
INFORMATION
OR
:(05 — *BEZ
Type stem: UNIT 44QOel Number
e�l -* I 6ol
DISTRIBUTION SYSTEM _ (r( I a 5411 S
Header anifold istribution �� x Hole Size fr x Hole Spacing �. Veneto L Air I take
Pipes) / l G T f
L Dia Length_ Dia / "' Spacing 2
SOIL COVER x Pressure Systems Only xx Mound - Grade Systems Only Kit. G(/' ear
Depth Over TBed/ Over of xx Se ded /Sodd xx Mulched
Bed/Trench Center rench Edges Topsoil 1 ���t. Yes 'f to J Yes
1: !9No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection / O/� Inspection #2: /�/ 0 7
Location: 673 270th Street Woodville, WI 540288 (( SW 1/4 NW 1/4 31 T29N R15W) NA Lot 1 ' -` w Parcel No: 31.29.15.
1.) Alt BM Description = / ' d� y� `"4�"d !J��
2.) Bldg sewer length = - Arvkj1J
- amount of cover = > 5 0
Plan revision Required? Yes " No
Use other side for additional information. !
Date Insepctor's ature Cert. No.
SBD -6710 (R.3/97)
1
I
I '
commerce Safety and Buildings Division County
Washington Ave., P.O. Box 7162 St. Croix
scons Madison, WI 53707-7 162 Sanitary Permit Number (to be filled in by Co.) �
Department of Commerce 56 Z(p
Sanitary Permit Application S ta te Transaction Number
In accordance with s. Comm. 83.21(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 Project Address (if different than mailing address)
POWTS are submitted to the Department of Commerce. Personal information you provide may be used for
secondary purposes in accordance with the Privacy Law, s. 15.04(1)(m), Stats. , / 7 3 2 70
I. Application Informatio Plea se Print All Information W
Property Owner's Name Parcel N - - - -
Shawn Weyer I i �
Property Owner's Mailing Address Property Location
666 270th Street � 0 y-1Ol�9 7
Govt. Lot
City, State Zip Code Phone Number SW %,NW -Aa 31
Woodville, WI 54028 715- 977 -0184 (circle one)
T29N; R15 W
II. Type of Building (check all that apply RE Lot ;f
®1 or 2 Family Dwelling - Number of Bedro 3 Subdivision Name
UL 13 200 1 N/A
ock
❑ Public /Commercial - Describe Use
��� ST. CROIX COUN YN /A � City of
❑ State Owned - Describe Use f umber Village of
k 5( • ZS 853002 ® Town of Springfield
III. Type of Permit: (Check only one box on line A. Complete line B if appli
A. ® New System ❑ Replacement Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain)
System
B. ❑ Permit ❑ Permit Revision ❑ Change of Permit Transfer to List Previous Permit Number and Date Issued
Renewal Before Plumber New Owner
Expiration
IV. Type of POWTS System/Component/Device: (Check all that appl n I , or go
❑ Non - Pressurized In- Ground ❑ Pressurized In- Ground ❑ At -Grade ❑ Mound > 24 in. of suitable soil ® Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain) /
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil Ap ation Rate(gpdsf) Dispersal Area Required (sf) Dispersal Are Proposed (sf) System Elevation
450 1 450 75t� 450 1 105,
VI. Tank Info Capacity in Total N of Manufacturer w A
Gallons Gallons Units 0 a H
a
New Tanks Existing Tanks k,' Q / L F 4 w Q H F W ^�
Septic or Holding Tank 1 000 1000 1 Wieser toncrete ® ❑ ❑ ❑ ❑
Dosing Chamber C00 600 1 Wieser Concrete ® ❑ ❑ ❑ ❑
VII. Responsibility Statement- I, the undersigned, assume responsibility for ingallation of the POWTS shown on the attached plans.
Plumber's Name (Print) Pl 's Signature MP /MPRS Number Business Phone Number
Bennie Hel eson 220292 715/772 -3278
Plumber's Address (Street, City, State, Zip Code
W1229 770th Avenue, Spring Valley, WI 54767
VI U. County/Department Use Onl
Approved _ 1nc� Permit Fee Date Issu Issuing A nt Signatur
caner G n Reas for Denial $ l0D , Dt� . / 6-7
IX. Cond�UReasons for Disapproval
1. Saptic tank, et"8uertt fester and
dispersal ce0 must all be serttes I maintalW
as per management plan provided by plumber.
2..A# setback re9tikaments must be maintained
a per appkable 0ode! ordhvK% es.
Attach to complete plans for the system and submit to the County only on paper not less than 8 1n x 11 inches in size
SBD -6398 (R. 01/07) Valid thru 01/09
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Safety and Buildings
4003 N KINNEY COULEE RD
commerce.wi.gov LA CROSSE WI 54601 -1831
isconsin TDD #: (608) 264 -8777
www.commerce.wi.gov /sb/
Department merce www.wisconsin.gov
Com
Jim Doyle, Governor
Mary P. Burke, Secretary
July 09, 2007
CUST ID No. 220292 ATTN.• POWTS Inspector
BENNIE W HELGESON ZONING OFFICE
HELGESON EXCAVATING ST CROIX COUNTY SPIA
W 1229 770TH AVE 1101 CARMICHAEL RD
SPRING VALLEY WI 54767 HUDSON WI 54016
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 07/09/2009 Identification Numbers
Transaction ID No. 1412869
SITE: Site ID No. 727247
Shawn Weyer Please refer to both identification numbers,
270 Street -above, in all corres onlence with the a enc .
Town of Springfield
St Croix County
SWIA, NWI /4, S31, T29N, R15W
FOR:
Description: Mound / Three Bedroom ! Sloping Site
Object Type: POWTS Component Manual Regulated Object ID No.: 1139140
Maintenance required; 450 GPD Flow rate; 20 in Soil minimum depth to limiting factor from original grade;
System: Mound Component Manual, SBD- 10572 -P (8.6/99),
Pressure Distribution Component Manual, SBD- 10573 -P (8.6/99); Biofilter
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.
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
• This system is to be constructed and located in accordance with the enclosed approved plans and with the
component manuals listed above.
• Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area.
Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and
dispersal are prohibited.
Core
• The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption
area. chs. NR 811 & 812c
• A Sanitary Permit must be obtained from the county where this project is located in accordance with the OF
requirements of Sec. 145.135 and 145.19, Wis. Stats.
SEE COIF
• Inspection of the POWTS installation is required. Arrangements for inspection shall be made with the designated
county official in accordance with the provisions of See. 145.20(2)(d), Wis. Stat
BENNIE W HELGESON Page 2 7/9/2007
• Comm 83.22(7) A covy of the approved plans specifications this letter shall be on -site during construction
and open to inspection by authorized representatives of the Department, which may include local inspectors.
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.
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.
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.
Sincerely, Fee Required $ 175.00
Fee Received $ 175.00
Balance Due $ 0.00
Charles L Bratz
POWTS Reviewer II , Integrated Services WiSMART- code:: 7633
(608)789-7893, 7:45 am - 4:30 pm Monday - Friday
charles.bratz@wisconsin.gov
cc: Leroy G Jansky, POWTS Wastewater Specialist, (715) 726-2544, Friday, 7:00 A.M. To 3:30 P.M.
INDEX SHEET
PROPERTY OWNER: SHAWN WEYER
666 270TH STREET
WOODVILLE. WI 54028
PROJECT NAME: SHAWN WEYER
PROJECT LOCATION: SW 1/4, NW 1/4, S 31, T 29 N, R 15 W
G MUNICIPALITY: TOWN OF SPRINGFIELD
cl�j
ED ,.. COUNTY: ST CROIX
DESIGN: PRESSURE DISTRIBUTION MANUAL SBD- 10573- P(R/99)
cc
MOUND COMPONENT MANUAL SBD- 10572 -P (R 6/99)
g
CONTENTS:
Page 1: Plot Plan
Page 2: Cross Section and Plan View of Mound
Page 3: Distribution Pipe Layout
Page 4: Septic Tank & Pump Chamber Cross Section and Specifications
Page 5: WLP 1000 /600 -MR ZABLE Tank Specifications
Page 6: Pump Specifications
Page 7: POWTS Owner's Manual & Management Plan - Pg. 1
Page 8: POWTS Owner's Manual & Management Plan - Pg. 2
Name: Bennie Helgeson Signed c ��
Address: W1229 770th Avenue
Spring Valley, WI 54767
Credential Number: 220292 Date: June 20, 2007 lionally
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Topsoil p
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Slope Plowed
�E�f �•_ 2 , Force Main
z From Pump Lcyer
Aggregole
D /• 3Y- Ft .
E /. 98 Ft.
Cross :iecti >n Of A hlound F PC) Ft
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F t . H �_ Ft.
Signed: - --
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License Number: � 220 — Ft.
Date: J Ft.
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-- _ Observation Pipe �K
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% Distribution
Pipe Aggregate
I
Observation Pipe C3aSa,� A r,e
Plan View Of Mound
Perforated Pipe Detail
Cleanout
Access j -7
Threaded L j V16w
Cleanout
C
End Manifold
0 01-
Holes Located on Bottom
Are Equally Spaced
Force Main From Pump
First Hole Next to Manifold
Y
Cleanouts Distribution Pioe Layout
R
S
X
Y
Hole Diameter Inch
Lateral Inch (es)
Manifold Inches
Signed:
Force Main Inches
License Number: Invert Elevation
0 5
Date: Holes Per Lateral
Number of Laterals
Total Holes
(1)n 2�r` < c 7�►CUJ/1 ll)e_y g r Page 4 OF-
SEPTIC TANK 6 PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS
PV(-. V ENT PIPE 12" MIN. ABOVE GRADE L WEATHE OF APPROVED
?:25 FROM DOOR, WINDOW OR
FRESH AIR INTAKE WITH CONDUIT MANHOLE COVER
W1 PADLOCK E
Y-OU&I & E F WARNING LABEL
a ==%- _ 4 " MIN.
2y �,
INLET �
WATER TIGHT SEALS GAS-
TIGHT \/APPROVED
FINER A SEAL JOINTS WITH
�o� ALM APPROVED PIPE
APPROVED B O N 3' ONTO
PIPE 3' — F — SOLID SOIL
ONTO SOLID C I '
SOIL PUMP OFF ELEV -FT. —i-- OFF
t — i—
D
3" APPROVED BEDDING UNDER TANK
CONCRETE PAD
SPECIFICATIONS
c.l ,. I r. L �Ltm rsl.,S
SEPTIC / DOSE X S" _ 5 - j 8S G ctl.
TANK MANUFACTURER:
TANK SIZES: SEPTIC 0C GAL. DOSE VOLUME INCLUDING _
DOSE ( c GAL. 7_ 3 (4 Gr l , FLOWBACK: S 9•��/ GAL.
AL MANUFACTURER: S E('-, '-u • CAPACITIES: A = /9 INCHES = C� :fig GAL.
MODEL NUMBER: I B = 2 INCHES = 33.5 GAL.
SWITCH TYPE: 79
PUMP MANUFACTURER: (TQc�Ic � ✓ C = �� INCHES = jC GAL.
MODEL NUMBER: p = 10 INCHES
SWITCH TYPE: _ /�? � �� ��c"
REQUIRED DISCHARGE RATE PUMP E ALARM WIRING AS PER ILHR 16.23 WAC
6. R l FEET -7
ERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE FEET
+ MINIMUM NETWORK SUPPLY PRESSURE . . • • • • ' . . G. SL. FEET
FEET FORCEMAIN X �.C�') FT /100 FT. FRICTION FACTOR _ FEET
TOTAL DYNAMIC HEAD
INTERNAL. DIMENSIONS OF PUMP TANK: LENGTH WIDTH DIAMETF
LIQUID b -rPTA
r/ 7
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- 'V. - 1 -�,nC
IGNED: LICENSE NUMBER: DATE: _
1/88
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MODEL: 3871
SIZE: 3/4" SOLIDS.
Submersible
RPM: 1550
PumP Effluent HP: 0.4
METERS FEET
8
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CAPACITY
GOULDS PUMPS, INC.
5"<E , PALLS t f--W WW GWa;
Effective October, t M
r •+ Tn C14 a me K wrTNOUT NOTICE PRINTED W U.SA.'
POWTS OWNER'S MANUAL 8t MANAGEMENT PLAN Page 7 of 8
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner Sttawn Weyer Septic Tank Capacity 1000 al ❑ NA
Permit # Septic Tank Manufacturer ❑ NA
Wieser Concrete
DESIGN PARAMETERS Effluent Filter Manufacturer Pol lok ❑ NA
Number of Bedrooms 3 ❑ NA Effluent Filter Model PL - 525 O NA
Number of Public Facility Units Q NA Pump Tank Capacity 600 ga l ❑ NA
Estimated flow (average) 300 al /day Pump Tank Manufacturer W ieser Concrete ❑ NA
Design flow (peak), (Estimated x 1 .5) 450 gal /day Pump Manufacturer Goulds Pumps, Inc ❑ NA
Soil Application Rate 0. al /day /ft' Pump Model 3871 EPO4 ❑ NA
Standard Influent /Effluent Quality Monthly average' Pretreatment Unit W NA
Fats, Oil & Grease (FOG) :530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter
Biochemical Oxygen Demand (B0D,J 5_220 mg /L W NA ❑ Mechanical Aeration ❑ Wetland
Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other:
�' " reated trfiuent Quality Monthly average Dispersal Cell(s) ❑ NA I
j Biochemical Oxygen Demand (BOD 5530 mg /L ❑ In- Ground (gravity) ❑ In- Ground (pressurized)
` Total Suspended Solids (TSS) :530 mg /L ® NA ❑ At -Grade 12 Mound
Fecal Coliform (geometric mean) 5_10' cfu /100ml ❑ Drip -Line ❑ Other:
Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA
Other. ❑ NA Other: ❑ NA
V;ilues tvpical for domestic: wastewater and septic tank effluent. Other: ❑ NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
Inspect condition of tank(s) At least once every: 2 12 ea�lsl(s) (Maximum 3 years) ❑ NA i
Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA
Inspect dispersal cell(s) At least once every: 2 Q year(s) month( (Maximum 3 years) ❑ NA
_- — 12 month(s) ❑ NA
Clean effluent filter At least once every 13 ❑ year(s)
- Q month(s)
Inspect pump, pump controls & alarm At least once every: 13 ❑ year(s) ❑ NA
❑ month(s) ❑ NA .
Flush laterals and pressure test At least once every: 3 year(s)
Other' At least once every: ❑ month(s) ❑ NA
_ ❑ year(s)
Other: ❑ NA
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications:
Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank
inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface.
The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding
of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the
immediate notification of the local regulatory authority.
When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,
Wisconsin Administrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment
units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 10 days of completion of any service event.
OWNER: Shawn Weyer Page 8 of 8
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals
that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the c ootents
of the tank(s) removed by a septage servicing operator prior to use.
Svstern start up shall not occur when soil conditions are frozen at the infiltrative surface.
During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be
discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface dischmge of
effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring
power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls: to
restore normal levels within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area
Within 15 feet down slope of any mound or at -grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life Of.the
POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat;
foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil;
painting products; pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is
oroperly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with
soil, gravel or another inert solid material.
•,ONTINGENCY PLAN
r the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant
rt: placement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption
system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by
required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will
result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systern4jPILIst
comply with the rules in effect at that time.
11 A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS
technology a holding tank may be installed as a last resort to replace the failed POWTS.
❑ The Site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site
evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank
may be installed as a last resort to replace the failed POWTS.
M Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the
infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time.
<WARNING> >
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. 00 NOT
ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A
PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. °-
ADDITIONAL COMMENTS
POWTS INSTALLER POWTS MAINTAINER
Name
Helgeson Excavation Inc Name Johnson Sani tation
Phone 715/772 -3278 Phone 715/273 -5811
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name Johnson Sanitation Name St. Croix County Zonin
1 Phone 715/273 -5811 Phone 715/386-4
tr,is document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
RECEIVED C 7 5
Wisconsin Department fCo�gr SOIL EVALUATION REPORT Page of
Division of Safety and 6 ildingiJtt 0 4 2006
in accordance h Comm 85, Wis. Adm. Code
C UNTY County ` jt L
Attach complete site plan on� gt ss an 8 1/2 x 1 inches in size. Plan must �c
include, but not limited to: vertical and horizo point (BM), direction and Parcel I.D. // ll
percent slope, scale or imensions, north arrow, and location and distance to nearest road. 3 — evj 7'
Please print all information. Review by Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)).
Property Owner Property Location `�
Govt. Lot SO 1/4, )Q ) 1/4 S N R �$� E ( W
Property Owner's Mailing Address j Lot # Block # Subd. Name r CSM# t
G Ys *(1 c> I k . S T�r*e�_ {� — vL rn
City State Zip Code Phone Number ❑ City ❑ Village own earest Road
W 04011 11 W SVoa ( ) - y f^ 'rj' )j i a70 L 5 E�
New Construction Use: esidential / Number of bedrooms 3 Code derived design flow rate Z 15 -0 GPD
❑ Replacement ❑ Public or commercial -Describe: r
Parent material L n,rSS cc r '7 // Flood Plain elevation if applicable /V A ft.
General comments , /, 3 `/,
and recommends ions: (� 5�: �lO Sa— � C.A n cker cppei- rce5-e- ® F
c m _ Duv�� /
F1__1 Boring # ❑ Boring
� _
Lld Pit Ground surface elev. /by' S ft. Depth to limiting factor C;� Q in.
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 I *Eff#2
/ 0- /Oy 3 L :i w• sb� r w I o • 8
LA-) r r
CV.n s
S_1 b /o \ } 6 (i
Boring # ❑ Boring f
❑ Pit Ground surface elev. ft. Depth to limiting factor a 6 in.
Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fe
in. /� Mun ss ell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff##2
b 7' r` S 1 U
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* Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD, < 30 mg /L and TSS < 30 mg/L
CST N (Please Print) H CST Number
Levt h 14 2 P w 2) D2
Address r ate aluation Conducted Telephone Number
1et)I X01 % f 1 / In 00, e
r
Property Owner rI.L�C cY` i�t� -�a� Parcel ID # Page of
a Boring # ❑ �Bo 'ng /
Pit Ground surface elev./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. Cora. Color Gr. Sz. Sh. *Eff #1 *Eff#2
LJ j , 1�
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil A plication Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fP
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in.
Soil A ption Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff #2
* Effluent #1 = BOD > 30 < 220 mg /L and TSS >30 < 150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS < 30 mg/L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 264 -8777.
SBD -8330 (R.07 /00)
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State Bar of Wisconsin Form 3 -2003 * 8 5 4 0 0 7 1
QUIT CLAIM DEED 854007
KATHLEEN H. WALSH
Document Number Document Name REGISTER OF DEEDS
ST. CROIX CO., WI
RECEIVED FOR RECORD
THIS DEED, made between Bruce L. Achterhof and Sharon M. Achterhof, 06/21/2007 10 :50AM
husband and,wife QUIT CLAIM DEED
EXEMPT ll
( "Grantor," whether one or more), and Shawn D. Weyer and Holly M. Weyer, REC FEE: 11.00
husband and wife holding as survivorship marital property TRANS FEE: 45.00
PAGES: 1
( "Grantee," whether one or more).
Grantor quit claims to Grantee the following described real estate, together with the
rents, profits, fixtures and other appurtenant interests, in St. Croix Recording Area
County, State of Wisconsin ( "Property") (if more space is needed, please attach addendum): Name and Return Address ► l
Part of the South Half of the Northwest Quarter (S 1/2 of NW 1/4), Section Shawn Weyer
Thirty-one (31), Township Twenty -nine (29) North, Range Fifteen (15) West, 666 2 7 0th St.
Town of Springfield, St. Croix County, Wisconsin, more particularly described as Woodvi WI 54028
follows:
Lot 1 of Certified Survey Map filed June 15, 2007, in Volume 22 of Certified
Survey Maps, at Page 5410, as Document No. 853002, office of the Register of 034 - 1069 -70, 034 - 1069 -80
Deeds for St. Croix County, Wisconsin.
Parcel Identification Number (PIN)
This is not homestead property.
Os) (is not)
Dated
f f (�
(SEAL) mac. t— / T(1iy` - V (SEAL)
* * Bruce L. Achterhof
1 .
- - -- —
(SEAL) (SEAL)
_ tt %� 5� _ (SEAL)
* * Sharon M. Achterhof
AUTHENTICATION ACKNOWLEDGMENT
Signature(s) STATE OF Wisconsin )
) ss.
authenticated on St. Croix COUNTY)
Personally came before me on
* the above -named Bruce L. Achterhof and Sharon M.
TITLE: MEMBER STATE BAR OF WISCONSIN Achterhof
(If not, to a known to be e person(s) who executed the foregoing
authorized by Wis. Stat. § 706.06) ent and ac I d the same.
THIS INSTRUMENT DRAFTED BY:
Thomas A. McCormack Notary Public, State of Wisconsin
Baldwin, WI 54002 My commission (is permanent) (expires:
(Signatures may be authenticated or acknowledged. Both are not necessary.)
NOTE: THIS IS A STANDARD FORM. ANY MODIFICATION TO THIS FORM SHOULD BE CLEARLY IDENTIFIED.
QUIT CLAIM DEED 02003 STATE BAR OF WISCONSIN FORM NO. 3-2003
*Type name below signatures. INFO -PRO Legal Forms . (800)655 -2021 • nr
^' oprofortns.com
ST. CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner /Buyer 51 A . W d- ) ��
Mailing Address w,6 2 7p `k
Property Address (o75 P-70 �� \
(Ver
\ required from Planning & Zoning Department for new construction.)
City /State �CZ� �� �\ Parcel Identification Number ) 0 (9
LEGAL DESCRIPTION
Property Location 5 i4J '/ , ki Uj t /a , Sec. 3/ , T �7q N R 15 W, Town of l a)pr► MC , e_1
Subdivision f / (.\ , Lot #
Certified Survey Map # 0� � 0 O Z , Volume � , Page # �� 10
Warranty Deed # L160 7 , Volume , Page #
Spec house 0 yesno Lot lines identifiable yes 0 no
SYSTEM MAINTENANCE AND OWNER CERTIFICATION
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. Owner maintenance
responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance.
The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the
owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site
wastewater disposal system is in proper operating condition and /or (2) after inspection and pumping (if necessary), the septic tank is
less than 1/3 full of sludge.
I /we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the
standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin.
Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning &
Zoning Department within 30 days of the three year expiration date.
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 described above, by virtue of a warranty deed recorded in Register of Deeds Office.
Numb of bedrooms 5
k/6/ 0
L >--91 GNATURE c5FAPPLI A T(S) DATE
** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * **
Include with this application 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.
(REV. 08/05)
■
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* 8 5 3 0 0 2 2
853002
KATHLEEN H. WALSH
REGISTER OF DEEDS
75 A CROIX CO., WI
V D FOR RECORD
CERTIFIED SURVEY:
SURVEY MAP
VOL: 22 PAGE: 5410
Located in part of the Southwest Quarter of the Nort hwe� QUa &6v
Section 31, Township 29 North, Range 15 West, PAGES: 2
Town of Springfield, St. Croix County, Wisconsin
This Certified Survey Map is subject to a farm land preservation program.
589 0 53'00 "E 2562.72
i � ------- - - - - -� ---- - - - - -- N1 /4 Comer o / Section 31,
NW Comer of Section 31, North Line Section 31, T29N, R15W T29N, R15W
T29N, R15W
6,6 I
I I Scale in Feet o�
i 1 1 0 100 200 400 `. Q
I�
1 Inch = 200 Feet m
Iii I �' • ` ��'� �
w I NI I Notes ;
Distances are in feet and decimals of a foot. ) ` .. / g
_ Wire fence approximately 2 feet north
NW Comer of theS112NW1 /4
of line (scale exagerated for clarity) -- �
Point of Beginning
589 0 46'59 "E 1000.00
--
,
589 ° 46'59 "E i
967.00
1` - ,,- -Found 314 Proposed < {;; North Line of the
` I `33.00 Inch Iron Pipe `.� driveway " S1/2 NW 1/4
, � I c ♦O��cJC'0 /�,e
tl' ` s LOT 1 3 ~ •`� '� JOEL '
i �j M �.
N g 392,000 SQ. FT. Proposed house - N N : = T. M
9.0 ACRES including right of way �/ •- O� "� •
O �i cv� ' 8.7 ACRES excluding right of way `� m y M ° oo + * iNEZ
O , y Slopes greater than 12% -! O :
1
, :291
~
: r - -� eeeei
Proposed septic treatment area � .•
i !
A/ 33 00 ' Parallel with north line of fire S112 NW 1/4 - l I \ St1�
• 967.00 i p pplptttN��
\ I�
N89 0 4659 "W 1000.00
� I � - - - - -- Electric fence approximately 5 feet south a
I y i of line (scale exagerated for clarity) N
N Legend u,
t 0 Denotes 314 Inch Inside alameter by 30 inch
8 i ; `. 1 long Iron pipe monument of no less than 1.13 ,
lbs. /lln.ft, set, unless otherwise noted
I ; ' Denotes found survey marker mag nail
Q Denotes P.K. Nap set in pavement
N ('�
~ i • Denotes 314 inch inside diameter iron pipe
�. monument unless otherwise noted
589 0 40'58 "E
2631.35
W1 14 Corner of Section 31, Center ,
T29N,R15W ------ - - - - -- 589 °40'58 "E 25 66.67 - - -- Section-''
66.67
Replaced bent rerod with 1/2 inch S114 Comer of Section 31, -\ Mc r
i
inside diameter open top Iron pipe T29N, R15W �Z i
monument on April 14, 2007 N
E1M Comer ofSectton3l, - .,,
Each parcel shown on this map is subject to State, Counly 729N, R15W f
and Township laws, rules and regulations (i.e., wetlands, prepared for: Owner:
minimum lot size, access to pat t etc.,) Before purchasing Shawn and Holly Weyer Bruce L. and Sharon M. Achterhof
or developing any parcel conta the St. Croix County 666 270th Street '
zoning office and the Town of Springfield for advice. 645 270th Street
Woodville, WI 54028 Woodville, WI 54028
Poge 1 of 2 This instrument drafted by Don Berry on the 14th day of June, 2007 Job No. 2007 -06
Vo1.22 Page 5410
CERTIFIED SURVEY MAP
Located in part of the Southwest Quarter of the Northwest Quarter,
Section 31, Township 29 North, Range 15 West,
Town. of Springfield, St. Croix County, Wisconsin
This Certified Survey Map is subject to a farm land preservation program.
SURVEYOR'S CERTIFICATE
t Joel T. Anez, Registered Wisconsin Land Surveyor, hereby certify that by the direction of Shawn and Holly Weyer, I
have surveyed, divided and mapped part of the South Half of the Northwest Quarter of Section 31, Township 29 North,
Range 15 West Town of Springfield, St Croix County, Wisconsin, described as follows:
Commencing at the northwest comer of said Section 31; thence South 00 degrees 12 minutes 41 seconds West,
bearings are based on the St. Croix County Coordinate System, along the west line of said Section 31, a distance, of
1324,06 feet to the northwest comer of said South Half of the Northwest Quarter of Section 31 and to the point of
beginning of the parcel of land to be described; thence South 89 degrees 46 minutes 59 seconds East along the north line
of said South Half of the Northwest Quarter, a distance of 1000.00 feet; thence South 00 degrees 12 minutes 41 seconds
West, parallel with the west line of said South Half of the Northwest Quarter, a distance of 392.00 feet; thence North 89
degrees 46 minutes 59 seconds West parallel with said north line of the South Half of the Northwest quarter, a distance of
1000.00 feet to its intersection with the west line of the South Half of the Northwest Quarter, thence North 00 degrees 12
minutes 41 seconds East, along said west line of the South Half of the Northwest Quarter, a distance of 392.00 feet to the
point of beginning.
This parcel contains 9.0 acres, more or less, and is subject to the right of way of 270th Street
I also certify that this Certified Survey Map is a correct representation to scale of the exterior boundary surveyed and
described; that I have fully complied with the provisions of Chapter 236.34 of the Wisconsin Statutes and the land
subdivision ordinance of St Croix County and the / Town of Springfield In surveying and mapping same.
Joel T. Anez RLS No. 1291 Date ,� ``� �SCQNS�
Landmark Surveying Inc. ��` � • •� •N••••••• •• ti 'v ��
21150 Ozark Avenue North ��� • f JOB 10.
P.O. Box 65
Scandia, MN 55073 : t T
w,, n
• AN
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COUNTY TREASURERS CERTIFICATE
ST,1 T 1? OF WISCONSL ?J
COUNTY OF ST. CROLY)SS
1, Cheryl Sllnd, being the duly elected, qualified and actingTreasurer of St. Croix County, do hereby certify that the records
In my office show no unredeemed tax sales and no unpaid taxes or special assessments as of j 2= 9j (, affecting
the land included in this Cedfied Survey Map.
Ghb*4� Date
f
APPROVED
ST. CRW COUNW
rkimehig t Zonh a
JUN 1 s 2001
it not remood within 30 days of
appal Ot an void sW be
Page 2 of 2 This instrument drafted by bon Berry on the 14th day of June, 2007 Job No. 2007 -06
Vol.22 Page 5410
01/23/2008 08:00 AM
Parcel #: 034 - 1069-70-100 PAGE 1 OF 1
Alt. Parcel #: 31.29.15.472B 034 - TOWN OF SPRINGFIELD
Current X ST. CROIX COUNTY, WISCONSIN
Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type
06/15/2007 00 0
Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner
O - WEYER, SHAWN D & HOLLY M
SHAWN D & HOLLY M WEYER
666 270TH ST
WOODVILLE WI 54028
Districts: SC = School SP = Special Property Address(es): * = Primary
Type Dist # Description " 673 270TH ST
SC 0231 BALDWIN- WOODVILLE AREA
SP 1700 WITC
Legal Description: Acres: 9.000 Plat: 5410 -CSM 22 -5410 034 -07
SEC 31 T29N R1 5W PT SW NW CSM 22 -5410 Block/Condo Bldg: LOT 01
LOT 1
Tract(s): (Sec- Twn -Rng 40 1/4 160 1/4)
31- 29N -15W SW NW
Notes: Parcel History:
Date Doc # Vol /Page Type
11/21/2007 864505 EZ -U
06/21/2007 854007 QC
06/15/2007 853002 22/5410 CSM
08/21/2002 687595 1953/248 WD
more
2008 SUMMARY Bill #: Fair Market Value: Assessed with:
0
Valuations: Last Changed: 06/26/2007
Description Class Acres Land Improve Total State Reason
Totals for 2008:
General Property 0.000 0 0 0
Woodland 0.000 0 0
Lottery Credit: Claim Count: 0 Certification Date: Batch M
Specials:
User Special Code Category Amount
Special Assessments Special Charges Delinquent Charges
Total 0.00 0.00 0.00