HomeMy WebLinkAbout018-2019-40-000Wisconsin 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)!m)]
Permit Holder's Name. City Village Township
Tome Welke & Gina Vento TOWN OF HAMMOND
CST BM Elev. Insp. BM Elev: IBM Description
TANK INFORMATION
TYPE
MANUFACTU R
CAPACITY
Septic
Dosing
Aeration
Holding
TANK SETBACK INFORMATION
TANK TO
E P/L
WELL
BLDG.
Vent to Air Intake
ROAD
Septic
19,
1
Dosing
Aeration
Holding
PUMP/SIPHON INFORMATION
Manufacturer Demand
GPM
Model Number
TDH Lift Friction Loss ystem Head TDH Ft
Forcemain Len Dia. Dist to Well
JUIL At3SURPTION SYSTEM
ELEVATION DATA
County:
St. Croix
Sanitary Permit No
641951
State Plan ID Noa.
Parcel Tax No-
018-2019-40-000
Section/TownlRange/Map No.
29.29.17.1240
St/Ht Outlet
UT bollorn
:.
m--_
BEDlTRENCH
DIMENSIONS
Width Length
No. Of Trenches
PIT DIMENSIONS
No. Of Pits
Inside Dia.
Liquid Depth
SETBACK
INFORMATION
S
E 11V V I UL
LDG
IWELL
LAKElSTREAM
LEACHING
CHAMBER OR
UNIT
Manufacturer:
Type Of System.
Model Number:
Header/Manifold
Distribution
x Hole Size
Hole Spacing
Vent to Air Intake
Pipe(s)
Ix
Length Dia
Length Dia Spacing
uvr� vVV ter\ V Praceure Rwefnmc n.1- w RA -.. -A n. Al c... d., c..-I-_-
Depth Over
Depth Over
xx Depth of
roc Seeded/Sodded
xx Mulched
Bed/Trench Center
Bed/Trench Edges
Topsoil
❑ Yes ❑ No
❑ Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2
Location: 728 161ST ST
1.) Alt BM Description=ryCCMV
2.) Bldg sewer length �� t
- amount of cover =Y Y(}'I
-Now o 1' �o� t
' IrU�,/d�(�VV(&(1� DA (&r ( IOI\4,506
/'^/y1�G'�/1�/q/
Uli l` FV"lraV hfVtid� J�"'1 tylf WV
i
Plan revision Required? ❑Yes No
A4sMp,*rSgnat.,e---
other side for additional information.
'' jJV
JUse
SBO-6710 (R.3'97)
i
Cert o
54N-24LL- l(q
Industry Services Division
County
4822 Madison Yards Way
St. Croix
Sanitary Permit Number (to be filled in by Co.)
'
_ '.
APR 11 2022
Madison.W153705-
P.O. Box 7162
Madison, WI5370 2
J�
/ , l' ��I
D
eDn�aniit el f[ i Application o Ok
State Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropri a governmental unit
��
is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to
Project Address (if different than mailing address)
the Department of Safety and Professional Services. Personal information you provide may he used for secondary
728 161 st St.
purposes in accordance with the Privacy Law, s. 15.04(1 xm), Slats.
I. Application Information - Please Print All Information
Property Owner's Name
Parcel #
Tom Welke & Gina Vento
018-2019-40-000
Property Owner's Mailing Address
Property Location
1148 132nd Ave
Govt. Lot
City, State Zip
Code
Phone Number
New Richmond 54017
NWS`" %, Section 29
T 29 N R 17 E or W
11. Type of Building (check all that apply) /
✓f
Lot #
Subdivision Name
Zlor2Family Dwelling-Numberof rooms
S Ili
O
fOG!
Rolling Rolling Hills Farm
Opublic/Commercial - Describe Use
)Block
^_
❑City of
fate Owned - Describe Use
Ovillage of
CSM Number
OTown of Hammond
III. Type of POWTS Permit: (Check either "New" or "Replacement" and other applicable on line A. Check one box on line B. Complete line C i
appl'cable.)
A.[:]New
System
Y
I IK P y
[]Replacement System
L❑Jln-Ground
� g y ( p )
Elmer Modification to Existing System (explain)
✓Additional Pretreatment Unit (explain) Arai 1
B'
�iolding Tank
Dkt-Grade
u
R:oj
Individual Site Design
Other Type (explain)
(conventional)
�-) 2
C.
❑ Renewal Before
❑Revision
hang a of Plumber
Efransfer to New Owner
ist Previous Permit Number and Vae Issued
Expiration
615460 9/3/19 3q- q2
IV.
DispersaVP tment Area and Tank Information:
Design Flow (994Design
Soil Application Ra ( sf)
Dispersal Area Required (sf)
Dispersal Area Proposed (sf)
System evation
Existing
t
Capacity in
Total
# of
Manufacturer
Tank Information
Gallons
Gallons
Units
c '�
o
New Tanks
Existing TanksOwQ
ti
v1==
i u
in
a
Septic or Holding Tank
400/975
Hoot Wieser
✓
Dosing Chamber
V. Responsibility Statement- 1, the undersigned, assume responsibility for' stallation of 9F POWTS shown on the attached plans.
Plumber's Name (Print)
Plum C ignatu
MP/MPRS Number
Business Phone Number
Keith Knudtson
�648443
651-470-1737
Plumber's Address (Street, City, State, Zip Code)
927 150th St, Roberts,Wi.
VI. County/Department Use Only
Pf Approved
❑Disapproved
Permit Fee
Dale issued
Issuin Agent Signat ure
[STEM
❑ Owner Given Reason for Denial
$
p
/p ZZ
Conditions o e �^ . \ 1 —
OWNER: R: 3— / `-t Cu 1 4 ,
Septic tank, effluent Fllter and
_r�7
dispersal cell c-.usl be serviced / ma(nt i VLLO✓U "U
�-
as per many )ement plan provided by plumW. ($�---kAro c
,-t
All setback r, Iren enls must be maintained, 7 -}
as per apphoocl� code/ordinances. tr0
l /
l_
Attach to complete plans for the system and submit to the Couo only on,,ppbeLooei n 1/2x 1l y�hes 'n sat
^Tf 5 �� -I` s I `vTT Gefit.►teaa
SBD-6398 (R. 03/21) %s p_ �IS�f 60) l v 34- T-A-e
,(c1Copl
_F—� �Ce--Vter .4xAa&
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: Welke ATU
Owners Name: Tom Welke Gina Vento
Owners Address: 1148 132nd Ave
New Richmond Wi 54017
Legal Description:
Township:
County:
Subdivision Name:
Lot Number:
Parcel ID Number.
DesignerlPlumber.
Date:
NW 1/4 SW 1/4 S29 T29 R 17 W
Hammond
St. Croix
Rolling Hills Farm
40
018-2019-40-000
Page 1
Index and title
Page 2
Plot Plan
Page 3
System Sizing & Cross -Section
Page 4
Filter Specs
Page 5
Maintenance Information
Page 6
Management Plan
Page 7
St. Croix Cty Septic Tank Maintenance Form
Page 8
Warranty Deed
Page 9
CSM or Plat
Attachments: Soil Test & House Plans
Keith Knudtson
04/06/2022
License Number: 648443
Phone Number (651) 470-1737
Signature zz=
Designed pursuant to the In -Ground Soil Absorption Component Manual for POWTS Version 2.0 SBD-10705-P (N.01101).
Page 1
Contractor Guidelines for ATU Septic Homes
The septic system for this home will depend on the proper functioning of the Aerobic Treatment Unit
(ATU), which is designed to treat and degrade solids prior to discharge into the shared septic system. As
I contractor/builder, please observe the following construction guidelines:
• As part of design and construction, arrange for water from sump pumps to go to an external
discharge. Backwash from water softeners should also be discharged externally, as doing so will
extend the life of the septic system. Note: Regulations prohibit furnace condensate from being
discharged externally.
• Garbage disposals are not recommended.
• Avoid allowing any inert construction materials such as plastic, rubber, cigarette filters, bandages,
rags, cloth and towels to enter the system. Likewise, prevent construction chemicals and toxins
such as paint and paint thinners, solvents, etc., from entering the system.
• Contact Knudtson Plumbing and Contracting prior to siting house grade in order to confirm that
adequate fall will exist to allow gravity flow between the house, the ATU and the shared septic
line (which may be as shallow as 42 inches). Incorrect siting may require an additional pumping
station and incur significantly higher costs.
• The ATU manufacturer does not recommend tank installation in frozen ground, and it will be
done only at the contractor/bui(der's request and risk. Installation under these conditions will
likely also incur added costs related to requirements such as snow removal, frost ripping, etc.
• Freeze warning: Water from furnace condensate lines or other sources. including sinks and
toilets, entering the system during winter construction can cause the tank and components to
freeze and fail, as there is no bacterial action at this stage to -generate heat Use a salt sump to treat
this water prior to entering drain lines. Contact Knudtson Plumbing and Contracting for a
description. Builders failing to observe this precaution may be liable for system repair and/or
replacement due to freezing. Whenever possible, keep interior water lines turned off during
winter until the time of occupancy.
• Tanks must be pumped prior to homeowner occupancy.
For questions regarding these construction guidelines, call:
Knudtson Plumbing and Contracting
651-470-1737
I have reviewed and understand the above guidelines:
Date
7o?P� - 1 s1 sfga-et HAmmb x) Lug 6yolc; L.af 4 qo
Roiling Hills Lot #
Private On -Site Waste Treatment
The correct operation of the equipment noted below
Periodic Inspections will help extend the life of the sy
authorizes access to your POWTS equipment by a trai
provide regular Inspections and routine maintenance
It Is hereby agreed by and between Purchaser and Knui
payments provided for herein, Knudtson Plumbing and
representative to perform periodic Inspections of the e
Contracting will prepare a written report after each ins
This report will contain recommendations for any open
Inspector.
This agreement does not assume any responsibilities for
Purchaser and does not extend to cover any costs that n
this agreement. in no event shall Knudtson Plumbing an
consequential damages, Including but not limited to loss
economic loss due to equipment failure or for any other
may supply additional services, parts or labor only after
This agreement shall remain in force for a period of---t
automatically renew each year thereafter for one year
notice. This agreement may be canceled by the Purcha
authorized service provider for the equipment listed bE
cancel future inspections if payment becomes at least:
Periodic Inspections: Purchaser agrees to pay Knudtson
inspection. Any additional testing or services required v
Equipment Covered
(POWTS) Inspection Agreement
nlflcantly Influences the life of the wastewater system,
m and prevent the need for costly repairs. The agreement
i and authorized technician, during daylight hours, to
help assure the equipment is working properly.
Plumbing and Contracting that in consideration of the
racting will provide the services of a factory -trained
nent described below. Knudtson Plumbing and
m and provide a copy of the report to the Purchaser.
and maintenance deemed appropriate by the
obligations that are normally the responsibilities of
ay be associate with any recommendations made under
Contracting be responsible for any special or
of time, injury to person or property or incidental
'eason whatsoever. Knudtson Plumbing and Contracting
uthonzation by Purchaser.
years, beginning . 202 2.and will
ess canceled by either party with at least 30 days written
only If replaced by a service agreement with an
u. Knudtson Plumbing and Contracting may delay or ,
lays past due, 1^t Y of ^e_ 1 p e; 6etdc
tmbing and Contracting $J4P romper each annual
be billed on time and material amounts.
This Agreement
Description
Model No.
Serial
No,
install Date
Location if different
from system owner
" zf
�D
Knudtson Plumbing and Contracting
927 IS& St., Roberts, WI 54023
651470-1737
System Owner
Signed: Date:
77
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i
Signature:
Date:
Print Name: ''/I ''
lve vzc-
Street:
'Phone:
city, state & ZIP
ZU) ac iOAOVIJ ")-r- 52k < %
Fax:
; Email: co e l k-e--e
7Z Cry l (o s r 5771,e-e r 14,a31 ✓ VLS--
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TOM WELKE s
GINA VENTO
LANDBUILDERS
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Homeowner Guidelines for homes equipped with Aerobic Treatment Units
The septic system for your home depends on the proper functioning of the Aerobic Treatment
Unit (ATU), which is designed to treat and degrade solids prior to discharge into the shared
septic system. To avoid breakdowns and costly repairs, please observe the following guidelines:
• Avoid allowing any inert materials such as plastic, rubber, scouring pads, dental floss,
cigarette filters, bandages, hair, mop strings, lint, rags, cloth and towels to enter the
system. These materials can build up in the tank, resulting in system malfunction,
clogging and premature pump failure.
• Do not flush or drain chemicals and toxins into the system, as they kill the microbes
necessary for treatment. These include paint and paint thinners, solvents, drain cleaners,
automotive fluids, fuels, pesticides, herbicides, fertilizers, metals, disinfectants and
sanitizers.
• Paper products including disposable diapers, paper towels, baby wipes, facial tissues and
moist toilet paper are not designed to dissolve in your on -site treatment systems. Neither
will excessive amounts of toilet tissue decompose.
• Limit garbage disposal use to food waste that cannot be scooped and thrown in the trash.
Do not put animal fats and bones, grease, coffee grounds, citrus and melon rinds, corn
cobs, egg shells, etc. down the sink. Also avoid putting spoiled dairy products and yeasts
from baking into the system.
• Do not put medicinal materials, automatic disinfection tablets and similar items into the
system. Also, septic tank additives generally do more harm than good.
• If possible, spread laundry practices out over several days, rather than one "wash day," so
the ATU can more efficiently process the water as it enters the system. Liquid detergents
are recommended over powder; fabric softener sheets are preferred over liquid softeners.
Use bleach sparingly, at half the recommended rate.
• Clear water waste from dehumidifiers, HVAC units, gutters, whole house treatment
systems and sump pumps can increase the flow to both your on -site system and the
shared system, leading to shorter life. Both clear water and backwash from water softener
regeneration should be discharged to an alternate outlet. Talk to your contractor.
Do not disconnect power from the unit!
Your ATU is equipped with an alarm that will notify you of a malfunction. If the alarm does
sound, for diagnostics, service and repair call:
Knudtson Plumbing and Contracting
651470-1737
_H
1
ksie9A&dDO PoL9e
H-Series Gravity Treatment System
Green Choice Applications:
Single and Multi -Family
Dwellings, light commercial,
Churches, and other similar
Residential strength uses.
Performance:
98% Reduction CBODs
99% Reduction TSS
99% Conversion of Ammonia (NH3)
Co��l i1 nnn,,,rn,iicinfn.-+inn
Range of Sizes:
500, 600, 750 & 1000 GPD
High performance, low cost, energy efficient treatment system
The H-Series Gravity Treatment System provides high performance at a price comparable to most entry level ATU's.
Producing effluent of less than 3 mg/L on CBOD5 and 2 mg/L on TSS, it far exceeds the secondary standards of 25 mg/L on
CBODs and 30 mg/L on TSS. With these results, many locations allow reductions in disposal areas between 25 and 40%.
Because the H-Series completely transforms ammonia into nitrate, it is best suited for applications with rich organic soil
content, surface plant growth and depth to groundwater to prevent nitrogen pollution of the water table.
Simple installation, reliable performance, low cost of ownership
This level of performance is enhanced by its simple installation, energy efficient performance and low cost long term
maintenance and ownership. The systems components are assembled at controlled manufacturing facilities, rather than in
the field, to ensure reliable performance with local support.
Energy efficient, environmental protection
Made of locally available and manufactured concrete, the H-Series features an energy efficient linear compressor that
uses less power than an average light bulb. Its polyethylene clarifier hopper is made of recycled milkjugs. Choose Hoot,
and you make a sensible, decision to protect the environment as you protect our most precious resource, our water
Drainfield and Vertical Separation Reductions
With gravity flow discharge, the H-Series allows you to choose your disposal application from conventional lateral lines,
leeching chambers, other alternative drainfield materials. In some areas direct discharge is an option as well. Reductions
of vertical separations to groundwater and impermeable layers such as rock range from 1 to 2 feet.
Make the green choice for wastewater treatment
Your wastewater system is the most expensive and important appliance you will ever purchase. Don't settle forjust any
system. Protect your family and the environment with a Hoot H-Series System,
Wieser Concrete Products Inc. 1-800-3ZS43456 www-wieserconcrete.com
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4" CAS
4" CAS
POLYLOK 12" ACCESS LID (TYP)
Z SET RISER (TYP)
. "3
SIDE VIEW
TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS
800 GPD GRAVITSJHARGE SYSTEM
H--600 A
TANK SPECIFICATIONS
DIMENSIONS:.
WAL• L:. 3"
BOTTOM: 3"
COVERT 4"
MANHOLE: 12" & 24" I.D. PLASTIC RISER
HEIGHT: 70" O.D.
LENOTH 108" O.D.
WIDTH: 74 1 2" O.D.
BELOW INLET: 87" 0,0.
LIQUID LEVEL: 81"
WEIGHT: 11,138 LEIS.
INLET AND OUTLETs
4" CAST —A —SEAL (CAS) BOOT OR EQUAL
COVER: MIX DESIGNS (NO FIBER)
TANK: MIX DESIGN(SMALL FBER)
CUSTOMIZED TANKS:
FOR CUSTOMNTANKS CONTACT WIESER CONCRETE
,
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8
DRAWINGS SUBMITTED
FOR APPROVAL
APPROVED BY:
SHEET
APPROVAL DATE:
PRODUCTS NEEDED BY;
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IB
—11 DEUNAT
sanitary Site Plan L �
For. sp TysePcertie+s LLC f �_ - tos3m r`
Rolling Hilts Farm Ootbt 2 V249.w 10S2t12'
Lott 39.42 Part of the SWIM
Sea Z! T29"17W b1 N�06 g
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�WtP12504M wt D1� Puff" � B,tl - eo rt.
NWVr37'W 2ti2 W t06206 a! Sintbch STF-100 Film
AleYthi t WaN end Weenane SeoerLs per SPS 3tt8.43(tl►Q)
M13T °KLL MO•[NeD '
M - LC R ��, '� WErJ= t1113AiE AT JW
MI LOT 42 °N'F_°009p0 $ Y �acw"s� ta5o.t1'', �A�TE ORVAIM of 104
ID J
21,781 SO. FT. Lr aa.o rrc *~aoaww '`'M•w.L 1045,E
SBB 56WZM 257.7T 1 Ptvpoeed DupMK r Sat 40
M III N� « e . PVC For oe Main
__' •11 °3
10
S DWF - tan Wd
LOT 41 •.�
2t,78t SO. FT. •
' SBWZ o2°W 2M.3T roem 1a54.Ai ,A •:i �I
Mob t-6 We/ end WOuMrte Se"Cft • WE" _ rw ~
per SPS 3tt3.amm --�-' DrOrw CAN Lola 43�t
Naec Nr6 S Plopoeed 9 tc 1ffi tburtd Ctepueel t�e1
DWF ` 900 aPd I w'a" 0 loafed done ft 1053 aQ MrAmw We
LOT 40 L___ Sydarn Bev. d 1054.44Y
21,
$!8'1t 1S W 287.81� -eC,
ji-AkIOMLW
.,
LOT 39 Pr *000d r 90 40 PMC , Gwoe ® now to* = 105& tar PYopoeed
or Awn DaM NCdepth d doee ertk Ytbt 1047.0
21.M SO. F7. Corn Ourlm Pipe B •i. °e
_ t 257.57 SOUTH UEOFTHE NIROFTHE SW114
u .Vawwwe " NORTH LNE OF THE SIR OF THE SWIH
i iw. - 16N.N
P.
C Cooncreft
P.OpOred Duple r Soh. 40 wLP1 wnw 01pi[ �w
N PVC Force Main _ — I B • 3 ' vd SY/erit STF-100 Flue
mnw
V - i�a �:r DMIF d 2400 tiPWt at SAR - 1465 eq R
tea
—. L0b 3Y42
m oy..Nra.
,
,y B •2 .79
Proposed &a x I Gr Mound oMprw CAN i
e • 1, ra loc"d WoN the t M7.7S MM" v#A
9yMue Bev. of I me25'
j
1
H-W-L. 103&6
\\ $TORMWATER
MAMAOEMMT
Install A Hoot Dool Pollute AiNk
January 1, 2022
RE: Service Provider/Installer Certification
Wisconsin Hoot Systems
Hoot Systems, LLC
(Service Provider/Installer)
Keith Knudtson
927 150th Street
Roberts, WI 54023
This letter is to serve as your official certification as a "Hoot Certified Service Provider/Installer"
for its Advanced Treatment Units. Keith Knudtson has been listed as an approved
service provider/Installer on our listing for the state of Wisconsin.
They have successfully completed onsite training on multiple sites and engaged in trouble shooting
methods and solutions. Service Technicians have been trained to service and inspect the functionality of
our products along with proper installation guidelines. As a "Hoot Service Provider/Installer" we have
agreed to continually educate Keith Knudtson on all aspects of our product line.
Respectfully Submitted,
OAKd'n+#-T—
Aaron Yonts
Regional Manager
Hoot Systems, LLC.
YJisu"wri Depan�*w D+ Co^+=r,etce v�— E SYSTEIM
Satery End 6ui4ira D ow,
INSPECTION REPORT
GENERAL INFORMATION ,ATTACH TO PERWTj
Fe'a=ra . ^'d`^.+' t-_ C'=.s —2. LI4 .SC: '_' S[CG'. d'y T✓:-YS •".a:) .3n 5 .:j
TANK INFORMATION
TYPE
MANUFACTURER
CAPACITY
Septic
Dosing
1
/Z 56
Aefaltor
TANK SETBACK INFORMATION
TANK TO
P'L
WELL
BLDG
ie I s; A, i^taM.e
ROAD
Septic
Dosing
y25
NA-
,va
NA-
--
Aeration
Holding
ay
PUMPISIPHON INFORMATION A N yr ,
Ma*u!aaure' l %� Der'a^c
Model ",,rr", E P S 33 �f
TDH 1011 Fr coon Loss System He I TD
IS.t9 y.cS dS 3
Foreemain Lis It" 7 Dia 1 1 Oral to Weil _ /�
e.e�u .sIennnr.nu cVQTGaE N A
ELEVATION DATA
Dt Irle!
Dt Bottom
HeaderWan
Dist Pipe
Bo! System
Final Giaoe
6OE�i7jr
;d�my St. Croix
/.
1.
Q(0•
'.
i
�
S
fp
1
q.BS
I
iS
El
3. to D
/843.3
i o 51. 7
s• c
ros6.
17• $5
/Q�3.
5•)(0
!
s,
ies9•
tP.114
/ass -
.3
A%d.t
5 b
/aSc. '7
f.S1
i+s-r �
BEDITRENCH
DIMENSIONS
w::nr
8
Le-ptn
I
Nu '•rn�.•
PIT DIM SIGNS
N, pr p,•s
ra:oe Oa
LKIWI DtPlr•
SETBACK
WFORMA"DN
SYSTEM TO P
18LDG
Lh'EIL
LAK&STREAM
I►EACHntG
CHAMBER OR
UNIT
Ma^u'acteer
`
I�
y
NR
�/A1
MpOC' N..!^Dr.•' �.
rTrs J-rrarr. a r.n�.a-[.a r y i �.
- - -- - --- --- ----
HaaaerA'a�•
aJ
O5t. won 61%(
G:e 'itr.tcng
?r Hare Sral 1 t
• �;.,:e SDac,ng
Ver Apt yitaoa
Lengr' _._Cha
_/"`
1_e,gm__
Depth Over - -" -
eed�Travct, Gflnlrn
Drol- Ovr' -•�--- -- -
BedJoench Cdpes
is Dept^. �r �.,,!
Topsoil ' y�
xd Srcded.�rddeA
No
vx MW led
a No
I I
'
es
COMMENTS. (Include code discrepences persons wesem etc l Inspection $1 9 R ( 19 lnspectig1)02
Location 776 16!ST ST j�1 ✓` j iIO lbL.J
I I AM BM DeSVVa Dr = CG�.ws '�'" 5. 4+.. ► •'b�.JC.r
2 ; Slag W*re iengti,
. a m4nl of cave, =
Plan revision Required' Yes kNd 7 f_ J q G�34
Use other side for addfional nformatior �Y ( _
IIdIe _ i^:aer ee% a1o•r Celt No
' St Croix
f
I t ..'•�• - �7 3 rv,1, l ., i i _ : $A1pf1/ AM) t3tllklglg8 pivlbitlll
"i
207 W WluMngton Ave. P.O Box 7162 xend.n Pcemn Nlmtl.ct (be be raw m by ra )
. Madlsm, 37 -11
• 4/ � 2��g (, / & V
Sailit it Application
Numbers
pK�
law rtaexx Ntlh SP- 4bi71(*{ Wli A hn (',Mk Mth elts'pm Uf Ihta Itral Is, the At"'ree t.IC we, m aersuldal met
081901450-C
u tegldrad pnlx 1,> n6lalmng r s.mtwS• pamd Nick Apphcal.m from (IV •I.Ie-,„.•ttd 14 N6'I"ti evc .ulrmtted tit
('mina A,Wre.• ti(dtl)lcrcM tMn ttwdlnK .dJrcxt)
Ike Depeatmrnl nl'sakty end ler .1"Wirwl tie%lc• ('rn.l.l ud.rtaatrstt yaw (v,N I,l,t Itw} f+ .wwl t:st •nr.,ttdev
in am%w,eaa+c Aide the par • I.w. % I S IM(1>(ml. Mou
I� 15 V S4_
/
4 Applicolika (efprwitatim - Matter Print AN lufarwslke
. - _ - - _
pnupcm ty flev 'r Nevac
1-a l r
Rolling HIls Fame Owners Association Inc
M-201
P(ttpeny t}Imer'. kWnv l Addtca -- -
t'nl(tt"s I. wavo 25.21 IT
3435 Labore Rd STE 150
t„„t lest
S'. StIN .., yet'h.e. 29
cily.'%We
/,p t''.k
IMsme Nuww
Vtxinals Heights Mn
In/ck . wit t
f 29 N a
R. Typr of Beim" tcbck an tbat apply 1.4 e
i
Q I ar 2 Flealh th eltalp NtanM or (tcdr 16 + +
x"vesun+ Newsier
weer«
Rolling Hds Farm
-- - — _ . _ _
0 wlitc�ratarr.c(.1 f)esclhe u.e f�
fJJ�di— Z
- . _ - ------
0rn..r
t %M N.ant.ct
tWt Owed i?ncrtle 1'� '•
� I
❑ Vdl►i
HR1111na1d
•
®1.mw t4
/ gyp. f
j
Wbeelt oak aft bei ea lies A. t'orplek War B If applimbkl
NeA Symcm ❑ Rcplacemlca ti> teem ❑ 1 ma ustrati I, 4drye 1 evil, ltgd.ono .O 1 lid, ❑ (Meer, M.tdd•eslrm r, F-awrE System tvapk t)
a. 0 prnm( Raw" ❑ paed itcva•wm 0 4 %W4c .4 PWmba I ❑ (`amd f rrw(v Mr NeA 1 n114c,wsu Pbma Nteabcs evd Dent he.lod
6e4re i--Apir",it {l Its--
IV.T a/leON1J5�ate--I a—peweallikirlow. Itlw kwNew7a
❑ NulTlerwrtea! breinw W ❑ E9estated tn[in.aat ❑ A(,[natk ht..e"I - :'i mrr,yyd "94k Alwl,t.,eaw - 74 m .d uatattIc Wa
❑ Hoidery I.** ❑ (Rho Ihglmemd t",o(ti.1Ct1 rccptaul) iJ {'IWcdAcrA lit+wc I<gdrm) L.V'4r—Z0
V. erect Area bibrretloe:
t)"W FlnA(fjem4pti AW AaWrj%slt thgrtvi Arcs dill) Ihq•ttrd Attar (•(1 t}fcu F7nbm�
2400 1.65 P 11200 1455 1058.25
leave
�9. Tank (efo +-.tad, u. La.l n.d i�enrt(.clutc+
traillra (:dl.rw Irma SMII leC fdl8r5
i]T'
sapnc sit M4t6ee Twk _._ ._.... - -- ..
D"" oia1"' 1250 1250 Conaata x
-----
still. Respowi .. Stalettteat- 6 der ae/nripnb r Hr "satesr W n 11 lbw • w W etaebN plae►
riueehee's N.mr 1pnaff IM Iptw,ur � -. - etpletYR.0 N.rnhcr Nlr..er. Pbwle Nate><trr
Keith Knudtson t• 3 ae"Mine
ri.nvelva'. Addles (%tteet_ City. tilde.7lp Vede l
927 ISM St Roberts Wf 54023
. C rtseet Ilse
ppmccd
J
eatm
1m9„Il1r5x
1 !t,yraae
kill0e
t
❑ m
IX. C
l%
CM `MnIII, DgA^!A,.3�L•Awfir
as per .,nW3g men, pun qo •wrl tiv 0kr>Ilw Qf4 : n G4 f1it.R sf-
�Jl
2 AO "Ark eegt�aro-en,mW w r. cr.KN i i
M pw oppkrus ctr5: , ct4m&""
.S.I.ce M tempMM tie.. 6r Ht.ykm aed.aMae w Ate 17taly ad!' .. pre tw M..le.a a Irt ■ 1 t litres r rw
SIiD.6398(R 1111)
DWF - e1)0 goIB
NEunwT
� N..eKaoowae.* �
Sanitary Site Plan
-For. `t'Tmr Prwpertie:, i.1 C 3 �i4arw Y 1063er
Roiling F#iHs Farm Oudot 2 241MW 1062.e7 i
i,ots39-42 P°rt of the SW iM
Sec.2?T29N4U7W
Town of Axmmwnd - 5t. Croix County
DWFFL -w r d10 �D r Lm ae •.c MRPwpowd M R WWOO G piwPUmM
iaM� 4a•.� Scw (r..+1
m Jrr P x r_
MWVr3TW 252.m, 102 04 w' 9nutri STT 100 FOW lob,?
Maaroan Wd wid Wswewww Semwu par 3ps 3Ki.431e M •�,
IfQV %"� r.s rtKoo P1OpgN0 daPQL i IAR1UiM 1J1f V ME AT AM
�O owF = e00 ap0 u*n0ovr TE at
�Y+ON OF ,a
LOT 42 KW-L. 1 o4"
21 7111 SC FT •--... .r,wJ
z w+ rta� a rm s.r
saasszrw 257 rr w. »4s 10 PrpoDaad DOW 7' sor. 40
PVC Fomc Man
REV.,
Ar �c DWF Q0C QpC AM
•:... •' �.
LOT 41
t..rw.aa.M
21 761 90. FT
SeD"12R2W 26437
l pst➢S ��". �.
Much WN ww WrrTrm semeco a • r:-_ *� ter" - DAI w Car last 4345
par SPS 313.43(*M -- A
pmowe • a Im Mound a7Ypuarl C4rt
nr m OWIr - am scare man aw tomes ooroms wa
LOT 40 - *vWw Bar of 106a 40
21.751 SO FT
' swl t'134W 2v e'*
AA troan?,mC10
LOT 39 P'R1o.w' 40 PVC ,D,t4D Grow 0 Dow ana - 10016 P,opoaed
or Amer D W4 J r ., aao& d does Unk no I Wm
° 21,783 SO FZ yr Gora�yanoa �' souse+ UNE OF THE NJ f2 OF rHE SW 1 A
257
N -- -- .—..- mrom nr r• � ^ NCMH UM CF THE SI 12 OF TTE SW114
Prpppwp pa)lew 2' Scn. 40 W1P12ww wl mOw Puny
3 PV'CFws:Meln►ir1.a —.�-�� �,. l f wlSwrephSTF-100FiYn
h '
Lm of00 GY 74'OPt 85 SAA - 146b siIL.
W ru. • rows � �!
ITLaO3W2
_ � l n�wrr
NOT rl-
'. 50 �\ _ 1 •�../ Propowd EA w 1e7 Mound Dlac C410
loretad abQ eonlan n» 1067 75 Dwja
11 "`_ 9"Jum ar« d 106e25
i
Q p H.W.L. 1036.6
STORMWATER
`, MANAGEMENT
COUNTY
OUNTY
STATrmmmn�F SAND'
3zs 14 1,
OWNER
PLUMBER
TOWN OFVT9
SEC�R
AND/OR LOT 4iL
L
NO. 641951
A �2Y PERMIT
PREVIOUS NO. (olSyiO _y=
GkbgeYya
E/W
BLOCK
SUBDIVISION
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.
(I) 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
the permit, please contact the county authority.
►��y�, U RI D ISSUING OFFICER- DATE LVZZ
PERMIT EXPIRES UNLESS RENEWED BEF(ikOTHAT DATE
POST IN PLAIN VIEW
VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION
SBD-06499 (R11/20)
illftce use Only
OWNERSHIPIAD®RESS FORM Created2/2027
Community Development Department will utilize this information to provide the property owner with
information regarding operation and maintenance of yo6r 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 _0
Mailing Address ( I ij A - 13 Z N6 AV!s .
City/State/Zip NeuJ eiCNN fy-%oi�:) W .
Phone Number (required) _ iv5 � - 3 Al -- Z9 3-7
Email Address (required) fabYl Lo e_l Ky- @y koo • Lo vv-,
Parcel Identification Number_ ®IQ- 2e19 -LfO-C)00
(found on the property tax bill)
NEW SYSTEM: LEGAL DESCRIPTION
Property Location hI %0 1/4 , SW 1/4 , Sec.3.1 . T 7q N R j-i W, Town of IMIn rvl a Nn
Subdivision Plat: 1\1S t✓Aem Lot#fib.
Certified Survey Map # Volume . Page #
Warranty Deed # (before 2006)Volume . Page #
Number of bedrooms_ Spec house ❑ yes 9 no Lot lines identifiable )(yes ❑ no
OFFICE USE ONLY
New Property Address
(Verification of new address required from Community Development Department for newconstruction.)
(Staff Initials) (Date)
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.cov