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HomeMy WebLinkAbout038-1210-20-000 r - Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix 'Sdfdtyand`BuildingDivisiort ' INSPECTION REPORT Sanitary Permit No. 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)i. I Permit Holder's Name: City Village X Township Parcel Tax No: Oeverin , Ken I Star Prairie Township 038 - 1210 -20 -000 CST BM Elev: / Insp. BM Elev: BM Description: �^ Section/Town /Range /Map No: I oo. o 100,4) 9 ajr PvC- 13.31.18.1140 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark }�- - - .. Dosing i Alt. BM I Aeration Bldg. Sewer 6` 33;r r 7- Holding ~ - •- ..._..,_- St/Ht Inlet d TANK SETBACK INFORMATION St/Ht Outlet 7 2 5- ++ TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic , Ot Bottom Dosing Header /Man. Aeration Dist. Pipe Holding Bot. System PUMP /SIPHON INFORMATION Final Grade `� ��` s Manufatcturer Demand St'Cover p� GPM y ll Model Number Y TDH Lift 1 7 7 Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS a. SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHING Manuf ct rer INFORMATION CHAMBER Type Of System: f . I, r i D ModRI Number: i LC DISTRIBUTION SYSTEM Header /Manifold Distribution i x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Lengtli "`°�.�___._ Dia " Spacng SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil ` Yes f ] No Ji Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1> : t t I �::,t' Inspection #2: - - / Location: 1354 212th Avenue New Richmond, WI 54017 (NE 1/4 SW 1/4 13 T31N -R18W) Northgate Lot 50 Parcel No: 13.31.18.1140 / 0 1.) Alt BM Description = + r' ���( y� Ul 2.) Bldg sewer length = - � / - amount of cover Plan revision Required? ° Yes J Use other side for additional niormatio'n. No I Date Insepptor's Signahwe Cert. No. SBD -6710 (R.3/97) !Y /J / l �6 RECEIVED Wisconsin Department Com p g 2006 OIL EVALUATION REPORT Page of 3 0:wision of Safety and Bu dings in accordance wi h Comm 85, Wis. Adm. Code ST. CRO!X COUNTY County��� Attach complete site pi kn on paper not less than 81/2 x 1 I inches in size. Plan must include, but not limited point (BM), direction and Parcel I.D, p percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 0 '3 0 I a ICJ — 6 - 66 Please print all information. I Re vi ed by Date Personal information ou p rovide may be used for seconds u (Privacy — L Y Pr Y second purposes (Privy Law, s. 15.04 tt) (m)). Property Owner Property Location hel %,, 0 4 ! - J r / Govt. Lot 1„ j 1 /45)51 /4 S 3 T3 I N R 6 E (o ( W Property Owne s Mailing Address Lot # Block # I Subd. Name or CSM# State . Zip Code Ph a umber ❑ City ❑ Village wn Nearest Road 101 ) r ew Construction ential / Number of bedrooms Code derived design flow rate GPD ❑ Replacement �❑ Public or com erclal - Describe: Parent material JrJA--A �✓ Flood Plain elevation if applicable General comments and recommendations: System Type System Elevation Boiling # El ring � / Rit Ground surface elev. ! ' ft. Depth to limiting factor /02 b in. Soil Appl ication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 I •Eff#2 s I 3 F-1 Boring ° Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 •Eff#2 • Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 ' Effluent #2 = BOD 130 mg/L and TSS < 30 mglL CST Name (Please Print) CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address 4�� Dt. Evalua ion Conduc d Telephone Number 1008 192nd Ave, New Richmond, WI 5401 i 715 - 246 -4516 -12� I r , Property Owner _ Parcel ID # Page of 1 Boring # [] Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil — Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ❑ Boring # E] Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring F Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil ication Rate Horizon 'depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg& and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. SBD -8330 (RAW) OT PLAN * PROJECT Ken Overina ADDRESS 838 Summer Pines Circle Hudson Wi 54016 NW 1/4 SE 1 /4S 13 /T N/R 1 W TOWN Star Prairie COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 6/29/06 BEDROOM 3 CONVENTIONAL XXX IN -GROU PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 650 # of chambers 26 IL BENCHMARK V.R.P. Top of 1" pvc pipe ASSUME ELEVATION 100' Filter Zabel A -100 ❑ BOREHOLE O WELL *H. R. P. Same as Benchmark B.M. * Alt.B.M. SYSTEM ELEVATION 93.1/93.0 6' below qrade 38' 26' 158' 06� 15' 10' Plans Designed Using Conventional Powts B -1 35 B -4 Manual Version 2.0 2 -3' X 65' Cells with 42' B -3 >3' spacing Vents 2 B -4 20' B -5 B -6 20' ST Well is to meet all setbacks required by WDNR 20' 10' Pro 3 Bedroom House 250' Property Line Vent >6 " ARC 36 Standard Bi diffuser Leaching g of Cover Chamber with 25.0 ft2 of Area 5' Long 1191 Grade at System Elevation 36" Safety and Buildingp.Division tY L �(to 201 W. Washington .: S IN J,��O1��� Madison, 537 y 6 Sanit ry Permit Nu be filled in b Co.) ;f (608) 66 -3T5l Department of Commerce i; 'State Ian LD. Numper. Sanitary Permit n l ia In accord with Comm 83.21, Wis. Adm. Code, pers It rr'.you provide G pUN Y may be used for secondary purposes Privacy L 15 I(m)p CR�1X �FFIG Projec ddress (if different than mailing address) NING I. Application Information - Please Print All Information l Property Owner's Name / Parcel # �j 0 Block # ,r✓ ��� Je f Z r i � Il J Property Owner's Mailing Address Property Locate l b ? 6 - <, 'fie, Section � Ci' ,State Zip Code Phone Number (� i ! 7bti— (circ) T N. R E rW II. Type of Building (check all that apply) � p� � � �""' "_ Subdivision Name � CSM�er r 2 Family Dwelling -Number of Bedrooms V L 1` EI ❑ Public/Commercial - Describe Use ❑City_ ❑Village wnship o f , - El State Owned - Describe Use III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A' a System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only El Other Modification to Existing System List Previous Permit Number and Date Issue B. ermit Renewal Permit Revision Change of El Pen-nit Transfer to New / Before Expiration Plu er Owner IV. Type of POWTS System: Check all that apply) 0 El - Pressurized In- Ground L1 Mound > 24 in. of suitable soil El Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ ❑ Pipe ) .� • S I p t/J Recirculating Synthetic Media Filter eaching C amber Dri Line ❑ r vel -less El Other V. Dis ersaVrrreatment Area Information: S stem Elev ion Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area (sf) Y � Gf 9(.� VI. Tank Info Capacity in Total Number Manufacturer Prefab Site teel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank x XX� (� Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- 1, the undersigned, ass a esponsibility for installation of the POWTS shown on the attached plans Plumber's Name (Print) Plumber's S" MP/MPRS Number Business Phone Number / Plumber's Address (Street, City, State, Zip VIII. oun /De artment Use Onl Sanitary Permit Fee Alncludes Groundwater Dat Issued Is mg Agent igna (N ps) Approved El Disapproved Surcharge Fee) �C/ FFF fff (� ❑ Owner Given Reason for Denial IX. Conditions of Approval/Reasons for Disapprgval QW 0 D Attach complete plans (to t e C my onlykfor the system on pa r not less than 8112 x 11 inches in size SBD -6398 (R. 01 3) PLO PLAN PROJECT Ken Overino DDRESS 838 Summer Pines Circle Hudson Wi 54016 NW X 1 /4 SE 1 /4S 13 /T 31 1 W TOWN Star Prairie COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 8/8/05 BEDROOM 3 CONVENTIONAL XXX IN- GROUND ESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22 IL BENCHMARK V.R.P. Top of 1" pvc pipe ASSUME ELEVATION 100' Filter Zabel A -100 ❑ BOREHOLE O WELL *H. R. P. Same as Benchmark B.M. * A1t.B.M. SYSTEM ELEVATION 96.5/96.4 3.5' below qrade 38' 26' 158' 06 15' 10 , Plans Designed Using t ' o-r— J 35' B -4 Conventional Powts B -1 Manual Version 2.0 42' B -3 Vents 2' B -4 2 -3' X 69' Cells with B -5 >3' spacing Well is to meet all 40' setbacks required by WDNR, y ST 30' Pro 3 Bedroom House 250' Prope . Line Vent >6„ Standard Biodiffuser of Cover Leaching. Chamber with 3 1. 1 ft2 of Area 6' Long 11 " " Grade at System Elevation 3 4 PLO PLAN PROJECT Ken Overina DDRESS 838 Summer Pines Circle Hudson Wi 54016 NW '1/4 SE 1 /4S 13 /T 31 i01 W TOWN Star Prairie COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE8 /8/05 BEDROOM 3 r CONVENTIONAL XXX IN- GROUND ESSURE CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22 kL BENCHMARK V.R.P. Top of 1" pvc pipe ASSUME ELEVATION 100' Filter Zabel A -100 ❑ BOREHOLE O WELL *H. R. P. Same as Benchmark B.M. * A1t.B.M. SYSTEM ELEVATION 96.5/96.4 3.5' below grade 38' 26' 158' L-0-r— 06, 1 15' , Plans Designed Using 35' Conventional Powts B -1 Manual Version 2.0 42' B -3 Vents 2' B -4 2-3' X 69' Cells with B -5 >3' spacing Well is to meet all 40' 1 setbacks required by WDNR ST 30' Pro 3 Bedroom House 250' Property Line Vent ALo Standard Biodiffuser Leaching _Chamber with 31.1 ft2 of Area " 34" Grade at System Elevation Maintenance and Contingency Plan for a Septic System Maintenance Plan 1. Septic Tank is to be pumped once every 3 years. 2. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 3. Once every 3 years, cells are to be inspected via the inspections pipes at the ends of the cells. 4. Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 5. The owner agrees to save this plan. 6. Do not plant trees nor park nor drive over system. 7. Watershed is to be diverted away from system. 8. Discharge into system is not exceed those required as per Comm. 83 ncy Plan Option #1. system fails, determine cause of failure, use alternate area and install new system in tested replacement area. Option #2. Install system at a lower elevation, by removing chambers, removing biomat, and install new system. Option#3. No adequate area is suitable for replacement area an q p d system elevation cannont be lowered. Install holding tank as last resort. 3. Replace any other failing components as needed. Plumber: Shaun Bird 715 - 246 -4516 St. Croix County Zoning 715 - 386 -4680 Pumper Tom Mondor 715 - 246 -5148 Shaun Bird #226900 La - do Departm Hurrli;� Relations g ent of Industry SOIL AND SITE EVALUATION REPORT Pag 1 — of 3 L,t+bor� Division'of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attaclicompiele site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. Crnix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 038- 1055 -95 APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION N 'aill*q WE DBY DATE h• 8 /9 PROPERTY OWNER: PROPERTY LOCATION Greenwood Enterprises, Inc. GOVT. LOT NW 114 SE 1/4,S13 T31 ,N,R 18 f (or) W PROPERTY OWNER':S MAILING ADDRESS LOT # I BLOCK # I SUBD. NAME OR CSM # 1416 Third St. 50 na Nor to CITY, STATE ZIP CODE PHONE NUMBER (]CITY []VILLAGE SOWN I NEAREST ROAD Hudson WI. 54016 (7j St [xJ New Construction Use[ J Residential/ Number of bedrooms 4 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd /ft .8 trench, gpd/ft Absorption area required 858 bed, ft2 750 trench, ft Maximum design loading rate bed, gpd /ft _ trench, gpd/ft Recommended infiltration surface elevation(s) 95.60 ft (as referred to site plan benchmark) Additional design / site considerations nA Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE 7 AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem RI S❑ U RI S ❑ U f] S❑ U IBS ❑ U ® S O U ❑ S 1R U SOIL DESCRIPTION REPORT Boring# Horizon Depth Dominant Color Mottles Texture Structure Consistence Botxxlary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench h iii:: 1 0 -12 10 r 3/3 none 1 2msbk mfr QIw if .5 .6 2 12 -33 10 r 4 4 none sicl 2msbk mfr qw if .4 .5 Ground 3 1 33-84 7.5 r 4/6 none ms OSCF ml na na .7 .8 elev. 9 - 6 ft. Depth to limiting factor +84" Remarks: Boring # 1 0 -12 10 r 3/3 none 1 2msbk mfr ciw if .5 .6 2 12 -26 10 r 4/4 n one sici 2msbk mfr Qw if Ground 3 26 -84 7.5 r 4/6 none ms OSQ ml na na .7 .8 elev. 9 9.0 ft. Depth to ` limiting factor ` +84" �. B � "� s Remarks: ZONI [ Add ress: Name: -- Please Print G L. Steel Phone: 715 - 246 -6200 1554 200th. e. New Ri hmond WI 54017 ature: ty Date: 11 -6 -98 CST Number: m02298 PROPERTYOWNER Greenwood Enterprise SOIL DESCRIPTION REPORT Page 2 _wf 3, PARCEL I.D. # 038 - 1055 -95 Depth Dominant Color Mottles Structure Gp[Xft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed TW& .................. ................. .................. .................. ................. ... ............... 3 1 0 -12 10yr 3Z3 n ie 1 2msbk mfr 2 12 -26 10 r 4/4 none sicl 2msbk mfr Ground 3 26 -84 7.5 r 4 ms 0sa M1 na na elev. 99 ft. Depth to limiting factor + 8 4 �n Remarks: Boring # ... 1 0 -12 10 r 3 3 none 1 2msbk mfr qw if .5 .6 4 2 12 -29 10 r 4/4 none sicl 2msbk mfr gw if .4' .5 Ground 3 29-84 7. 4 /6 none ms 0SQ ml na _ na .7 .8 elev. 99.3 ft. — Depth to -- limiting factor +84 Remarks: Boring # 1 0 -12 10 r 3/3 none 1 2msbk mfr if .5 .6 `.< ......... 2 12 -30 10 r 4 4 none sicl 2msbk mfr if .4 .5 Ground 30 -84 7.5yr 4/6 none ms osa ml na na .7' .8 elev. 9 8.9 ft. Depth to limiting factor +84" Remarks: Boring # Ground elev. j ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) Wiscorcin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of ' 3 L,aborzn� Human Relations Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Aftacifcompis'le site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but St. rrnix not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 038 - 1055 -95 APPLICANT INFORMATION— PLEASE PRINT ALL INFORMATION N al i - k.&q WED BY DATE -avl • 8 /9 PROPERTY OWNER: PROPERTY LOCATION Greenwood Enterprises, Inc. GOVT. LOT NW 1/4 SE 1/4,813 T31 N,R 18 ]E(or) W PROPERTY OWNER':S MAILING ADDRESS LOT # I BLOCK # SUBD. NAME OR CSM # 1416 Third St. 50 na NorthGate CITY, STATE ZIP CODE PHONE NUMBER []CITY [ fWOWN NEAREST ROAD Hudson WI. 54016 (7A 386 - 3674 Star r 1 [ New Construction Use [ ] Residential / Number of bedrooms 4 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 600 gpd Recommended design loading rate .7 bed, gpd /ft .8 trench, gpd /ft Absorption area required 858 bed, ft 750 trench, ft Maximum design loading rate _ .7 bed, gpd /ft gpd/ft Recommended infiltration surface elevation(s) 95.60 ft (as referred to site plan benchmark) Additional design / site considerations nA Parent material outwash Flood plain elevation, if applicable na ft S = Suitable for system CONVENTIONAL I MOUND IN- GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem ® S ❑ U :k] S ❑ U ® S ❑ U (a6 ❑ U ® S 1: U ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Clu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench 1... -. 1 0 -12 10 r 3/3 none 1 2msbk mfr if .5 I .6 2 12 -33 10 r 4/4 none sicl 2msbk mfr qw if .4 .5 Ground 3 33 -84 7.5 r 4/ 6 none ms osq m1 na na .7 .8 elev. 99. ft. Depth to limiting factor +84" ts it Remarks: Boring # 1 0 -12 10 r 3/3 none 1 2msbk mfr ciw if .5 .6 2 2 12 -26 10 r 4/4 none s' .4 i. 5 Ground 3 26 -84 7.5 r 4/6 none ms osq I m1 na na .7 .8 9 9.0 ft. Depth to limiting _. factor r +84" Remarks: ZONiN FF CST Name: -- Please Print G2a L. Steel Phone: 715- 246 -6200 Address: 1554 200th. e. New Ri hmond WI 54017 Signature: Date: 11 -6 -98 CST Number: m02298 STEEL'S SOIL SERVICE Gary L. Steel Greenwood Enterprises, Inc. 1554 200th Ave. CSTM2298 NW4SE4 S13- T31N -R18W New Richmond, WI 54017 MPRSW -3254 town of Star Prarie (715) 246 -6200 lot #50- NorthGate This soil evaluation was conducted to satisfy a zoning requirement, it may or may not be suitable for your use. The location of the test may or may not be as shown as permanent lot lines were not established at the time the test was conducted. , "N " - 40 ' !A�Il op of 1" pvc pipe C el. 100 B t = top of 1" pvc pipe @ el 99.10' P� fOA t 2, r �- a� Gary L. Steel 11 -6 -98 Safety and Buildings Division County /SCO/tSl/f 201 w. w Ave., P.O. Box 7162 Madison, WI 53707 - 7162 sanitary Permit Number (to be fined in by co.) Department of Commerce ( 266 - 3151 Sanitary Permit Application Q S� Plan `M Number In accord with Comm 83.21, 'Wis. Adm. Code. personal iafamavou YOU Provide may be used for se000dary purposes Privacy Law, sl5.01(1Xm) "etx Address (if different than mailing address) I. Application Informatim - PI -.4 P PeW An Irtforma ion �� - 1 Property-Owner's Nun me Parcel 0 Lot Block i Se Property ownees M Wing Address Prouty Location S �S / city, state WIYE lf, reO %.Sectim 1,3 7/S7 '0 — 4MV/ IL Type of BWb&g (dttwk all that apply) T .7 / N: R E G( w� w� • 0 1 or 2 Family Dwelling -Number of Bedrooms Q Subdivision Name CSM Number ❑ Public/Commercial - Descr ft Use WE Ma ❑ Stare Owned - Describe Use 2 ) 5 2 ❑city Ovate ge gTownship of III. Type of Permit: ((beck a dy we box on roe A. C Itle B if applicable) A. Q'fYew System O Re- I - t System O T Tank Rat Only ❑ Other Modifxxtan to Fmumg System B. O Permit Renewal ❑ Permit Rawsion ❑ of Permit T to New Last Permit Number Lssued Before Expiration e m b 4 rv of POwTS • ((bunk an the 920 x t7 Non - Prcwm,iwd In -Grooms ❑ Mamd > 2a in. suiuMe sal ❑ Mound 24 Is,crob itable wet ❑ At -Grade O Sine Pass Sard Fiber ❑ Coosuucted wtlbmd ❑ Presatriaed b "kaund Homing Tank ❑ Peat ic Tirnanait Uni t O Recirculating Sand Fiber R- -dating synthetic Mdia FVver ❑ ❑Drip Line ❑ Pipe O Other (explain) V. DbpetvaMeahund Area Information: r - - L1 •.� / - S Desigo How 4po Design Sod ApPiira__ a Area Rcqabmd (d) Dispersal Am rv% S • (sfl Sysmeta Elevation Sr/ / S.3 VI. Tank Info in T Number aP�tY Maoufaahhrer Prefab site Stud Fiber Plastic CAB= GWI&M ofUn� ��_�`� Caaaeoe Commute Glass New Eis T_ Tanks Tacks ZAaa� G �j2 Septic orilelerr�aoit Aerobic Tmato mt Unit Dosing C]h "" VII. Respondulity I, (lie assume for ikon of the PO shown as the attached Plato�fl11Y(�(IQ1i nai s Si R3 Nurser Business Number #221180 2R988 MCKPn7 RE[ za po �r- — 'Srd see. Zib a" (715) 635 -9609 , VIII• Use Only /- m2— I. Approved O Disapproved S an it ory Perms (Jdudes Grohmdw er Daft lamed Agcat S' Stamps) O Owner Given Reason for Demal SD �- I7C. CatatGtiaw of AppsvvaUReasoo for 13-e- � �iM a��'�� �-✓�/ oto Att wtmd► easp4te Flow go the County ooW for tie ti w 00 poper 001 tess dm a1r2 x 11 inches in sine Fogerty Plumbing #221180 28288 McKenzie Rd. Spooner, WI 54801 (715) 635 -960 r* /or 9 �' Jot Lo 1 r •3 x x a� c= L - R x 3B�/eij'I r t X = ,d0,er��� _ ps. 3 fix• • = Fiuwp 1-07 coOe 2 Z Lam: c- � 3'x Lp7s� Awl Fogerty Plumbing #221180 28288 McKenzie Rd. Spooner, WI 54801 (715) 635 -960 -J* dfi �Z % x x a3 C -L - C L x � x 3MAI"- 4AL 4 X= ,de'e.MOx 3 ` J� -- .max. c -2- i� t -*V.& Lam: c- I a'x 6p7S f - -Z 3' I e o Eo II #� cLC) rq C N O N N CL v '` co cn "! a 4-, o O� > 14 a� S� W � cd v N yam` cd C d rA i;.•. i W M F-+•�: + LI to Co a.• �. o o CA H � F " POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of , FU 111FOroNATION SYSTEM SPECIFWATOW Owner I�� - Septic Tank Capacity O NA Pam Oa F-5— Septic Tank ManurfactLiffer O NA DESIGN PARAMETERS Effluent Filter Merwfa O NA Number of Bedrooms 3 O NA Effluent Filter Model O NA Number of Public Facility Units NA Pump Tank Capacity g d bj1A Estimated flow (average) ga lklay Pump Tank Manufacturer NA Design flow (Peak), lEstimated x 1.5) ga lid ay Pump Manufacturer NA Sod Application Rate _ aUd He Pump Model 17 NA Standard Influent/Effl Quality Monthly average* Pretreatment Unit O NA Fats. ON & Grease (FOG) 530 mgA- O Sand/Gravel Filter O Peat Flter Biochemical Oxygen Demand (BOD 5220 mgA- O NA O Mechanical Aeration O Wedand Total Suspended Solids (TSS) 5150 mg/ O Disinfection O Other. Pretreated Effluent Quality Monthly average Dispersal Celts) O NA Biochemical Oxygen Demand (BODJ 530 mgA. )q Inn - Ground (gravity) O to -Ground (pressurized) Total Suspended Solids (TSS) 530 mg& O NA O At -Grade O Mound _ Fecal Coliform (geometric mean) 510 cfu/1 OOnd O DrnpAjne O Other. � Maximum Effluent Parried Sze Y in dia. O NA Otter: O NA Odeen O NA oil=; O NA *Vahres typical for domestic wastewater and septic tank effluent ' O NA MAINTENANCE SCHEDULE Service Event Service Fiequency Inspect condition of lank(s) At least once every: - . Q month(s) axinnrm 3 years) O NA Pump out contents of tank(s) When combined sludge and scum equals onne4hud (lj of tank volume O NA Inspect dispersal cell(s) At least once every: 3 O ts) ol, 3 yam) O NA jit Clean effluent filter At least ounce every: — Z O marth(s) O NA s) Inspect pump. pump controls & alarm At least once every: O yenr(s) O mo nth arils) l p Rush laterals and pressure test At least once every: 0 y� (sl Q Nq Other: At least once every: 1] y�al rl NA tither, Q,NA MAKFENAUX p11S'TRUG i70NS Inspections of tanks and dispersal cogs shall be made by an individual carrying one of the following licenses or cert ficationu: Master Plumber; Master Plumber Restricted Sewer, POWTS inspector; POWTS Mainntaner, Septags Servicing Operator. Tank inspections must kx*ude a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks to leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent an the ground surface. The dispersal cell(s) shalt be visually inspected to check the effluent levels in the observation pipes and to check for any pounding of effluent on the ground surface. The pounding 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. Page Z of Z ' ttT 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 da3persal ceN(s). If high are detected have the contents of the tank(s) removed by a septage swvi ing operator prior to use - System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highw&w levels. When Powr is restored the excess wastewater WIN be discharged to the dispersal calls) in one large dose, overloading the ceN(s) and may result in the backup or surface d o Hof efferent. To avoid this situation have the contents of the pump tank removed by a Septags Servicing Operator p rior power to the effkient pump or contact a Plumber or POWTS Maintainer to assist in nmwAY operating the Pump controls to restore normal kovels 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 - Redt)ction or elimination of the following from the wastewater stream may i mprove the performance and prolong the Nfe of the POWTS antibiotics: baby wipes: cigarette butts. condoms% cotton swabs. degreasers; dental floss: drapers, disinfectants: fat, foundation drain (sump pumps water: fruit and vegetable Peerrngs: gam" % herbicides. meat scraps' medications: oil; tampons, and water softener brace. - sanitary Pis: ibis: pesticides; napkins panting P� 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 properly 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. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or.must be taken, to provide a code compliant replacement system: �i A suitable replacement area has been evaluated and may be utilized for the location of a replacementt sod absorption system. The replacement area should be protected from disturbance and coupwbon and abould not be infringed upon required setbacks from existing and proposed structure. lot lines and wells. Failure to protect the replacement area wig result in the need for a new soil and site evaluation to establish a suitable replant area- Replacement systems must comply with the rules in effect at that time. 0 A suitable replacement area is not available due to setback and /or soil ('imitations. 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. 0 Mound and at -grade soil absorption systems may be reconstructed lo place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that tune. < <WAiN MG> > SEPTIC. PUMP AND OTHER TIiEATMHIIT TANKS MAY CONTANII LETHAL GASSES AND/OR NNSUFFlC7�1T OXYGEN- DO NOT ENT A SEPTIC. PUMP OR OTHER TREATMENT TANK 1 ANY TA -DEATH MAY RTrSUIT. RESCUE OF A ER PERSON FROM THE INTERIOR OF A TANK MAY BE DWMMT OR RAPGSMU- *221180 (715) 63PIP60 j POWTS INSTALLER POWTS tUAWT Name ( (�-( Name Phone S -_ _ Phone _ — O SEPTAGE SERVICa1G OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Si OMO ( rjS-L s Q T Y Phone Phone This documert was drafted ki compliance with chaPter Comm 83.22(2)I1441ldl &M and 83.54171. (21 & (3). Wisconsin A Co"* ST CROIX COUNTY SEPTIC TAW MAINTENANCE AGREEMENT AND r/� r OWNERSHIP CERTIFICATION FORM f OwnOwner/Buyer l2 e 1 .Mailing Address ��� U Gi �'► � � � /�S' l r f G� Property Address 3 vc (Verification required from Planning Department for new construction) City/State Parcel Identification Number D Y - 1,7io - ao --o0e/ LEGAL DESCRIPTION Property Location z, V4, SiV %,, Sec. /_7 . T -R /k W, Town of w,t ,Ati --AAE . Subdivision ��RTif� T.� - - , Lot # _jcc.? Certified Survey Map # _ '— . Volume . Page # Warranty Deed # 11 :� 8� . Volume z 2 _7 � Page # o_o Spec house D yes ano Lot lines identifiable Dyes O no SYSTEM MAINTENANCE hMF%peruseanduakftsimixof yowsepticsystr;mcoddiestdtin ispimmatmefidmto bandlevrastes. PrW= maintenance consists of pumupirg out the septic tank every Gm pews w i . 0 , if needed by a licensed puAer. What you pat into the system can affect the function of the septic tank as a tree brunt stage in die waste disposal system. Tbe lady owner agrees to submit to St. Cion Zoning Deparment a oertfficalim form, =Wd by the owner and by a nuster or a)edpmmpery tLat (I) tLe an -site �vas�ratzrd>spo�l system is m proliei operating con ion andlbr (Z) aver iaspati and pompbg (ifnwessaryl the mgmk task is less dram Iii full of shddge. I/we. the andmiped have read do above roga and agm to maintain the private sewage disposal system with tide standards set forth, bati w sei by the Dgmam at of Cammem and dda Deportment of Kral State of Wimoonsim Catifirxtion stating thi system has bees mod must be candpleoed and vemmod ago St. Croix Camay Zoning Office within 30 days of eq*atim date. SIGNATURE OF APPI,I DATE' OWNER CERTIFICATION I (we) ced* drat all statements an this fawn am rant to the best of my ( our) knowledge. I (we) am (are) the owner(s) of the desc ' a by virtue of a warranty deed reeoided in Register of Deeds Office. SIGNA OF APPLI DATE_ * * * * ** Any information that is mis represented may result in the sanitary pemnit being revoked by the Zoning Depa�ment. ** Include with this application: tt stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed J 222`11 206 719396 x; STATE BAR OF WISCONSIN FORM t - 1998 II KATHLEEN H. WALSH WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI Document Number RECEIVED FOR RECORD 04/30/2003 09t15AM This Deed, made between Gree_rtW�OrDCl_F -Tea a WARRANTY DEED Wi sco si n QDr= t i on —._— EXEMPT N (i _ Grantor, it REC FEE: 11.00 and is th ,T_ Oeyerinn 1lAlrf C i,i TRANS 29 CC FEE: PAGES: 1 Grantee. '1 Grantor, for a valuable consideration, conveys to Grantee the following described real estate in Sf- .__Crgi _ County, State of Wisconsin (the 'Property "): cc rdut9 e t Name and Return / Ad dress Lot 0 of the Plat of NorthGate II , recorded in the et}Ll. �C(! T`e ice of the Register of Deeds for St. Croix County, ��� SuWaF. Wisconsin, on June 20, 2001, in Volume 8 of Plats, at t _osan t.oT Page 55, as Document Number 648882. n311 -121 20 -000 — ii Parcel Identification Number (PIN) This i S not - homestead property. (is) (is not) l tf II i is I I I II i� Together with all appurtenant rights, title and interests. Grantor warrants that the title to the Property is good, indefeasible In fee simple and free and clear of encumbrances except easements, restrictions, and reservations, if any of record. j Dated this &94: day of +� ' - 87r16Z3 i D ENTI INC. (SEAL) (SE AL) l ji 4 (SEAL) (SEAL) j AUTHENTICATION ACKNOWLEDGMENT Signature(s) State of Wisconsin, St. Croix County II authenticated this day of Personally came before me this day of April _2403 _ , the above named 7arrng F._ Riicch ifs Praaident T_ R Rii¢rh, its Spc areas TITLE: MEMBER STATE BAR OF WISCONSIN E.�, •.. fb (If not, me known to be the persog wha�g�r fgtt:gDtil�e�, authorized b §706.06, Wis. Stats. instru nt and acknowl THIS INSTRUMENT WAS DRAFTED BY ed a the sa S O Y ) g /Y• V o t f y y� j am/ ' y L'V tl rXy -R. Rusch • Sandra Ge Notary Public, State of Wisconsin 4 q TAY ' ,� t p�`� —N Richmond, WT 54017 My commission is permanent. (If not siittp, e> 51R1k2� date (Signatures may be authenticated or acknowledged. Both are not ) necessary.) — SeptembEr I , ` Names of persons signing to any capacity must be typed or printed below there ignamre. STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. WARRANTY DEED FORM No 1- 1998 Mgwaukee. Wis. M.tiE.ZS.O S o to �`�O U N ' g �-- N -, / U) O L • D � • ' ©D• OA s s � n �� � °o j• , �� < ;U ( � s� 2 c + .. y 1 0 0 �i `D t c� 2 s CD �' ` 4 1 p Ln o 1 C) CD z z vi O W CU 10 x CU LAJ W N •r ^' i ` --# N ,9Z't82 3 .ir£,ZS.O N I cu A r 1 `D o ! FF EE r N o 1 r.• CO o � r Arr.11£ 3 .L o c °� In 5 t ,r. f � 0� c`ry C) `r V j p 00 t� Ln �`1 'qt ti o 'OO I z tU "" t p j I LO �,Oor M (V cli LO N ,£9'8bZ 3 vVC*2S.O N % r CD I I M CD �,_ f eft � . . 0ir �, 0��fw 0 / § , § g ; ; ■ z z z 2 ■- z z \+ o m o a a$ o C4 , n, m a o w, w w . CD < _ — i a © & - a a 0 ,, E m w m. , _ . _ @ 'L g ® = m a: » , c ; o c } c , : § E E 9 / i; i }` f / \ { CD � o n @ ° « �. § CD R q ; ¥ \ / ■ _ 2 2 ° R E E a & � c « o ■ @ z> CL \ ` �� \ =' . \ / 7� 3 \ $ 2 ƒ, ® $ c ® ° /2 z § z § § CD o o z o o_ o z: § E « � � � � M -0 -0 o k k k 3 k k k z ` -n -0 0 2 o: Ln z \ § Cl) Cl) co CL 0 R § (n CA (1) a ° \ v ¥� 0 $ m v p\ J 2 , 222 . CD f � N) 4 3 % . z . .. 0 .. . 2 I § ( / = o k CD ƒ CD cn @ I ' § Oro N § J m CL 3 _ . 7 a � f /\ 7 � ' 2 z m r § _ � ■ � » / Q. + q 0 .� w T W / , @ � E§ � E § � f 2 0 @ r / z / m CA) % w i q 0 CL 0 § \ / \ § } a) a —\ 2 % ° d z % / z ( }/ \ c �CD C /) ? CD ƒ % 4 0 0 _ ° t \ e o e o 2 g k P a , k E Z �« Wisconsin Department of Commerce County: °SAfery and'Building Division ' PRIVATE SEWAGE SYSTEM St. Croix INSPECTION REPORT Sanitary Permit No: GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: O Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1 )(m)]. ql 1 3 Permit Holder's Name: City Village X Township Parcel Tax No: Oeverin , Ken Star Prairie Township 038- 1210 -20 -000 CST BM Elev: Insp. BM Elev. BM Description: Section/Town /Range /Map No: 13.31.18.1140 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. eptic — ench r mar . - cp _ , � � � Dosing Alt. BM Aeration Bldg. Sewer r Holding St/Ht Inlet St/Ht Outlet „ TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic a _ ` Dt Bottom ^^^-' •y F Dosing Ii Header /Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP /SIPHON INFORMATION , Manufa turer Demand St'Cover' GPM / n Model N fiber p1 � TDH Lift Friction Loss System Head .TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width ` Length No. 9f Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO JPJL BLDG IWELL LAKE /STREAM LEACHING Manufactu INFORMATION CHAMBER OR Type Of System: f UNIT M I Number. C7 t DISTRIBUTION SYSTEM Lit -Es, L- Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) _ - — �- — per Length Dia Length r. - "' Dia / rng ~` SOIL COVER x Press Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx RAulched Bed/Trench Center Bed/Trench Edges Topsoil l Yes I1 � No (a Yes I :: j No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: �i Inspection #2: Location: 1354 212th Avenue New Richmond, WI 54017 (NE 1/4 SW 1/4 13 T31N•R18W) Northgate Lot 50 Parcel No: 13.31.18.1140 1.) Alt BM Description = 1 2.) Bldg sewer length = - amount of cover — - -- -- - r Plan revision Required? Yes F! No j Use other side for additionalormation. Date Insepctor's Signature Cert. No. SBD -6710 (R.3/97) F , .. RECEIVED w } Wisconsin Department Cam OIL EVALUATION REPORT 04 ision of Safety and Bu dings o ZOOO Page of in accordance wi h Comm 85, Wis. Adm. Code ST. CROIX COUNTY County , 5+ , Attach complete site pl n on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 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 f Q 1 Govt. Lot Lj 114� 114 S 3 T3 J N RZ b E (o W Property Owner's Mailing Address Lot # I Block # Subd. Name or CSM# 1 city State Zip Code P e umber ❑ City ❑ Village wn Nearest Road B : Tqew Construction ' ential / Number of bedrooms Code derived design flow rateq,522 GPD ❑ Replacement ❑ Public or com ercial - Describe: Parent material ` �.J� -�( 2"- Flood Plain elevation if applicable ,jiQ ft. General mati / - and recommendations: System Type .OY►_> -Q.1,✓ System Elevation ® Boring g # ❑ Boring / zit Ground surface elev. ` ' ft. Depth to limiting factor 6 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDff in.. Munse Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 'Eff#2 �r � O A L- ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD > 30 < 220 mg/l- and TSS >30 < 150 • Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) — — CST' Number Bird Plumbing, Inc. Shaun Bird 2269 Address Date Evalua ion Conduc d Telephone Number 1008 192nd Ave, New Richmond, WI 5401 i 715- 246 -4516 OT PLAN ,.PROJECT Ken Overi ADDRESS 838 Summer Pines Circle Hudson Wi 54016 - NW 1/4 SE 1 /4S 13 /T N/R 1 W TOWN Star Prairie COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 6/29/06 BEDROOM 3 CONVENTIONAL )00( IN -GROU PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUNT; SEPTIC TANK SIZE 1000 gallons LIFE' TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 650 # of chambers 26 BENCHMARK V.R.P Top of 1" pvc pipe ASSUME ELEVATION 100 Filter Zabel A -100 ❑ BOREHOLE O WELL *H.R.P. Same as Benchmark B M * A1t.B.M. SYSTEM ELEVATION 93.1/93.0 6' below qrade 38' 26' 158' 0 6 15' 10' Plans Designed Using Conventional Powts B -1 35 B-4 Manual Version 2.0 2 -3' X 65' Cells with 42' Vents 2' B -3 >3' spacing � i B -4 20' *20' -5 B -6 ST Well is to meet all setbacks required by WDNR 20' 10' Pro 3 Bedroom House 250' Property Line Vent >6 " ARC 36 Standard of Cover Biodiffuser Leaching Chamber with 25.0 ft2 of Area 5' Long 1191 3611 Grade at System Elevation s Safety and Buildin,�.Division n Ity at /) e f . 201 W. Was in ton ������� Madison, 537 , 6 Sani mber (to be filled in b Co.) (608) 66 -3151 Department of Commerce State Ian I.D. in r Sanitary Per � mit � i �1,1G / pp VV � i In accord with Comm 83.21, Wis. Adm. Code, pers 1 rat you provide CO UN �f may be used for secondary purposes Privacy 15 1 m) GT CRDIXOFFIC Pro'ec ddress (if fferent than mailing address) NltAG I. Application Information — Please Print All Information t t/ ( tL o6t#7 Z 1 Property Owner's Name Parcel # / Block # Property Owner's Mailing Address Property Loc t�3 6, 1-1 1 � Section PZ7 6 0 - 0001 Zip Code / Phone Number I (� ) T N; R! (c E c rW ) II. Type of Building (check all that apply) Subdivision Name CSM Number r 2 Family Dwelling - Number of Bedrooms IV 47 ❑ Public/Commercial - Describe Use El State Owned - Describe Use ❑City_ ❑Village wnship o III. Type of Permit: (Check only one box on line A. Complete line B if applicable) ;Before a ystem ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System List Previous Permit Number and Date Issu rmit Renewal Permit Revision 2Change ❑Permit Transfer to New Expiration Owner T e of POWTS S stem: Check all that a / on - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter eaching Chamber ❑ Djje Line ❑ r vel -less Pipe ❑ Other V. Dis ersaVTreatment Area Information: stem Elev ion Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (st) Dispersal Area Of) Sy f VI. Tank Info Capacity in Total Number Manufacturer Prefab Site feel Fiber Plastic Concrete Constructed Glass Gallons Gallons of Units New Existing Tanks Tanks Septic or Holding Tank x Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, ass a esponsibility for installation of the POW FS shown on the attached plans. Plumber's Name (Print) Plumber's S MPIMPRS Number Business Phone Number Plumber's Address (Street, City, State, Zip e) Vortment Use Onl Sanitary Permit Fee,4mcludes Grou dwater Dat Issued Is 2Agen gna ( visapproved Surcharge F e ee) Owner Given Reason for D enial IX. Conditions of ApprovaUReasons for Disapp�val ' A W 1 0 � 31st` A Attach complete Inns (to C9botyonl system on pa r not less than 81/2 :11 inches* size ' " {mow`— "- _ <�/`�1�/,• SBD -6398 (R. 01 3) U PLO PLAN PROJECT Ken Overina bDRESS 838 Summer Pines Circle Hudson Wi 54016 NW ' 1 1/4 SE 1/4S 13 /T 31 R 1 W TOWN Star Prairie COUNTY ST. CROIX MPRS Shaun Bird 226900 , ' DATE 8/8/05 BEDROOM 3 CONVENTIONAL )00C IN- GROUND SSURE CONVENTIONAL LIFT HOLDING TANK NIOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE HOLDING TANK SIZE LOAD RATE .7 ABSORPTION AREA 684 # of chambers 22 BENCHMARK V.R.P. Top of 1" pvc pipe ASSUME ELEVATION 100' Filter Zabel A -100 ❑ BOREHOLE O WELL *H. R. P. Same as Benchmark B M * Alt.B.M. SYSTEM ELEVATION 96.5/96.4 3 .5' below qrade 38' 26' 158' o6' 15' 10 , Plans Designed Using 5, B-4 Conventional Powts B -1 Manual Version 2.0 42' B -3 Vents 2 B-4 2 -3' X 69' Cells with B -5 >3' spacing Well is to meet all 40' setbacks required by WDNR ST 30' Pro 3 Bedroom House 250' Property Line Vent ALo Standard Biodiffuser Leaching Chamber with 31.1 ft2 of Area 1 " 34" Grade at System Elevation