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HomeMy WebLinkAbout006-1008-30-000 (2)Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM 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: I City Village Township Jim Williams :ST BM Elev: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic DosltiJ � ) Asplh.cr` H [ding TANK SETBACK INFORMATION E f I. - TANK TO P/L WELL BL G. Vent to Air Intake ROAD Septic Aeration Holding PIMP/SIPHON INFORM —AT- IbN a ufacturer emand PM Mod I Number TDH Lift Fiction Loss Sy ern Hea TD Ft Forcem in Len th Dia. ist. to ell SOIL ABSORPTION SYSTEM BED=NCH Width jt Length N re�Z s DIMENSIONS �� INFORMATION MM AIA DISTRIBUTION TOWN OF CYLON ELEVATION DATA County: St. Croix Sanitary Permit No: 644719 State Plan ID No: Parcel Tax No: 006-1008-30-000 Section/Town/Range/Map No: 04.31.16.59E Map " === ,9 51.71}'M1=-M� CHAMBER OR UNIT Header/Manifold IDistribution ole Size x Hole Spacing Vent to Air Intake 1 itPipe(s) T Length Dia Length Dia Spacing SOIL MVER x Pressure Svstems Only xx Mound Or At -Grade Svstems Orilv��� Depth Over , Bedlrrench Center %, . 3 Depth Over A Bed/Trench Edges � %� xx D of IT096oilJS xx Seede odded ulched l[A Yes [:] No 0 COMMENTS: (Include code discrepancies, persons present, etc.) Location: 2301 220TH ST 1.) Alt BM Description=�j}{y/ (p(.(li 2.) Bldg sewer length - amount of cover = JI Plan revision Required? Yes �..No Use other side for additional information. -Date SBD-6710 (R.3/97) Inspection #1: Inspection #2: �I lS �rt�i� �' •S locaiu� I'C� � ion �vosI 1Gts�lrld �i*lnlsepcor'stSignature Cert. No. it F0 1.T119YU SY! 1.: 23 VeriaLiFk�- ^ Industry Services Division County �. 4822 Madison Yards Way Madison, WI 53705 (of filled in s 2022 P.O. Box 7162 Sanitary Permit Number (to be by Co.) a Madison, WI 3707 162 J / l ll 11 ll Spa lit o 't Applicatio State Transaction Number ,�— S In accordance wi SPS 383 q�t ''' . Code, submission of this form to the appro mental unit Project Address (if different than mailing address) is required prior t ob�ia5 nary permit. Note: Application forms for state-o OWTS are submitted to the Department of and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(1)(m), Slats. I. Application Information - Please Print All Information Property Owner's Name �11wW � 1 � 1 � w•6(; s Parcel # 00 -93D- Property Owner's Mailing Address Property Location � "� �- rei.>:7 Govt. Lot City, State Zip Code Phone Number ' -De e V< L % SectikW T 31 N R E 11. Type of Building (check all that apply) Lot # �- I or 2 Family Dwelling -Number of Bedrooms Subdivision Nam et DPublic/Commercial - Describe Use Block # ems— City of ❑State Owned - Describe Use Elvillage of CSM Number Town of III. Type of POWTS Permttr(Che either "New" or "Replacement' and other applicable on line k Check one bax on line B. Complete line C if applicable.) A. New System ement System []Other Modification to Existing System (explain) ❑Additional Pretreatment Unit (explain) B' ❑Holding Tank In -Ground []At -Grade ❑Mound Individual Site Design Other Type (explain) C. ❑ Renewal Before Revision Ohange of Plumber amnsfer to New Owne List Previous Pe tel Expiration IV. Dispersal/TreatmentArea and .Tank Information. Design Flow (gpd) Design Soil Application Rate(gpd/st) Dispusal Area Required (sf) Dispersal Area Proposed (sf) &stem Elev �7J 1 - 1 L9V 1 P3S f!' r Capacity in Total # of Manufacturer u o Tank Information Gallons Gallons Units- /J l y B v c d � u a w m New Tanks Existing Tanks `�':, p y Septic or Holding Tank SeaiagChamber V. Responsibility Statement- &4e undersigned, a e responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plu Signature MP/MPRS Number Business Phone Nu her Plumbbe�r'ss Address (Street , Ciity State, Zip L C J � ! -(; ' VI. County/Department Use Only - Approved ❑ Disa Permit Fee $ �Z5'-- Dale Issued �slZo22 Issuin Agent Signature c ❑ rvenReaso for Denial Conditions Approv / 3\ � _ v�2 _ /1 TEM OWN 1 J?• 55 ` Ql9C t n r per tank, effluent and se spersal cell must be serviced /maintained !� 'CM per management plan provided by plumber.` setback requirements must be maintained ' I. per applicable code/ordinances. Attach to complete plans for The system ands ma to me Llounly only on paper nor jqL z ,...is ..'7 e SBD-6398 (R. 03/21) J aA System PLOT PLAN PROJECT Jim Williams ADDRESS 2301 220th st. Deer Park Wi 54007 SW 1/4 SW 1/4S 4 /T 31 N/R 16 W TOWN Cylon COUNTY ST.CROIX SYSTEM ELEVATION 91.2/90.7 4' below grade DATE 6/30/22 BEDROOM 3 CONVENTIONAL %00< CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE OLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 46 BENCHMARK V.R.P. Bottom of siding ASSUME ELEVATION 100' Filter Lifetime Filter r ❑ BOREHOLE O WELL *H.R.P. same as benchmark ^ 220th St. >6" of Cover 4Lon Cty Rd H Scale = 1/4" = 1,0 coel 200' Existing 3 Bedroom House M . * Huffcutt Filter Tank —4.. 2-3' x 94' cells with >3' spacing Q11 WAR Well IN )Vent Quick4 Standard Leaching Chamber with 20.0 ft2 of Area 35' 6.6f A2/pair of end caps 2" 4„ Grade at System Elevation 70, 0 9% Slope 5' 2c Bird Plumbing Inc. Shaun R. Bird 1432 120th St. New Richmond Wi 54017 715-246-4516 6/30/22 Subject: Jim Williams @ 2301 220th st. Cylon To whom it may concern: CO-- JUG 5 r%22 My name is Shaun Bird, and this letter is to serve as verification that the septic system at the above property has failed and needs immediate replacement. The sytem is overflowing onto the ground and is causing the toilets to flush slowing and the concern is needing more servicing and cleaning out the clogged building sewer line as a result fo the tanks being over filled. Sincerely, shaun bird MPRS #226900 Cover Page Shaun Bird Bird Plumbing Inc. 1432 120th St. New Richmond Wi 54017 715-246-4516 Date: 06/30/22 Owner:Jim Williams Location:SW1/4 SW1/4 S 4 T31 N,R 16W 2301 220th st. Cylon Used: In -ground absorbtion system (version 2.0) Page# 1. Cover Page 2. Plot Plan 3. Chamber Cross Section 4-6. Maintance and Contigency Plan 7. Filter Cross Section Signature License numbpf #,Q26900 System PLOT PLAN PROJECT Jim Williams ADDRESS 2301 220th st. Deer Park Wi 54007 SW 1/4 SW 1/45 4 /T 31 N/R 16 W TOWN Cylon COUNTY ST.CROIX SYSTEM ELEVATION 91.2/90.7 4' below grade DATE 6/30/22 BEDROOM 3 CONVENTIONAL XXX CONVENTIONAL LIFT HOLDING TANK MOUND SEPTIC TANK SIZE 1000 gallons LIFT TANK SIZE DOSE TANK SIZE OLDING TANK SIZE LOAD RATE .5 ABSORPTION AREA 933 # of chambers 46 BENCHMARK V.R.P. Bottom of siding ASSUME ELEVATION loo° Filter Lifetime Filter ❑ BOREHOLE O WELL *H.R.P. same as benchmark 220th St. Scale = 1 /4" = 10' 200' Vent >6" Ar of Cover 4' Long 12 34" Cty Rd H Existing 3 Bedroom House M.* 20 Huffcutt Filter Tank —po, (71 5 M 2-3' x 94' cells with >3' spacing 4 * B-1 Quick4 Standard Leaching Chamber with 20.0 ft2 of Area \6.6f A2/pair of end caps .-Grade at System Elevation Well Ell 70 90' 95' Vents 9% Slope 93' Cross Section of Infiltrator Quick 4 Leaching Chamber Typical cross section for 2 of 2 cells Quick 4 Standard Leaching Chamber with 20.0 ft2 of Area per Chamber 6.6ft^2 pair of end plates Typical Installation vent � Grade 4„ 3' A/30/34 Septic Tank _ �I„ 5' Long Spacing 5' q.0' System elevations: A 91.2' B 90.7' 5' Grade at System Elevation To be >1' above grade Finish grade elevation 95.0' )Vent 5' Lone 1 at System Elevation 2-3' X 94' Cells Same on other end Observation tubeNent At end of cell A 713 23 chambers per cell POWTS OWNER'S MANUAL & MANAGEMENT PLAN page .of FILEINFORMATION Owner Permit # nFSIGN PARAMETERS Number of Bedrooms ❑ NA Number of Commercial Units NA Estimated flow (average) gal/day Design flow (peak), (Estimated x 1.5) i/jt7 gal/day Soli Application Rate aida /ft2 Influent/Effluent Quality Monthly average' Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BOD5) -=0 mg/L Total Suspended Solids (TSS) 5150 m /L Pretreated Effluent Quality ',�E41A Monthly average" Biochemical Oxygen Demand (BOD5) s30 mg/L Total Suspended Solids (TSS) 530 mg/L Fecal Coliform (geometric mean) 510' cfu/100ml Maximum Effluent Particle Size Y.inch diameter MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity gal ❑ NA Septic Tank Manufacturer NA Effluent Filter Manufacturer ❑ NA Effluent Filter Model ❑ NA Pump Tank Capacity al NA Pump Tank Manufacturer NA .Pump Manufacturer NA Pump Model NA Pretreatment Unit NA ❑ Sand/Gmvel Filter ❑ Peat Filter ❑ Mechanical Aeration ❑ Wetland ❑ Disinfection ❑ Other. Manufacturer Dispersal Cell(s) (gravity) ❑ In -ground (pressurized) 7_ground rade ❑ Mound Drip -line ❑ Other. • Values typical for domestic (non-eommerdat) wastewater and septic tank effluent. �• Values typical for pretreated wastewater. Service Event Service Frequency Inspect condition of tank(s) At least once every ❑ months R year(s) (Maximum 3 yrs.) Pump out contents of tank(s) When combined sludge and scum equals one-third (Y,) of tank volume Inspect dispersal cell(s) At least once every ❑ months,� ye r(s) (Maximum 3 yrs.) Clean effluent filter At least once every ❑ months ar(s) Inspect pump, pump controls & alarm At least once every ❑ months ❑ year(s) ❑ NA Flush laterals and pressure test At least once every ❑ months ❑ year(s) ❑ NA Other At least once every ❑ months ❑ year(s) ❑ NA Other At least once every ❑ months ❑ year(s) ❑ 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 ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mech nical or pressurized POWTS components, pretreatfinent components, and any other maintenance or monitoring at iritervals of 12 months or less 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. 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 ceel(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. Page of START UP AND OPERATION newFor construction, thetreatmentprocess and/or dmagehthe dispersal rsaltS) cell(s)n If high concentrations at tions for the presence of rare deteednting thave then contents s oftt I'- tank(s) removed by a septage servicing 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 highwater levels. When power is restored the excess wastewater will he discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result In the backup or surface discharge of effluent cing to thle effluent pump orucointa taaePlumber the for POWTS Maintainer ents of the pump t to assist din manually operating the pump ocontrols to resttore normal r prior to restorig rlevels 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 POWI"i: antibiotics: baby wipes; cigarette butts; condoms,; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundationrM (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting p d 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 property 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, ail 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 falls and cannot be repaired the following measures have been, or must be taken, to provide a code compl4lint replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption systorn. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, tot lines and wells. Failure to protect the replacement area will result in the neled for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the ruler{ in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances In POWTS technologi/ 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 iailure of the POWTS a soil and site evaluation 2 must be performed to locate a suitable replacement area. if no replacement area is available a holding tank may be installedl as a last resort to replace the failed POWTS. ❑ 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 ANDA)R INSUFFICIENT OXYGEN. DO NIOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE Ok A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS -,— OnUUTQ IkIQTAI 1 PP /1 Name `' ,12 Phone ' - r SEPTAGE SERVICING OPERATOR (PLIMPER) Name �ZI Phone POWTS MAINTAINER Name t Phone LOCAL REGULATORY AUTHORITY _ Name Phone This document was drafted In compliance with chapter SPS 383.22(2)(b)(1)(d)&(f) and 383.54(1), (2) & (3), Wisconsin Administrative Code. J;4 SECTION A -A S�'• CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently :'10rVing the ,,� , l residence located at: Section � T�N, K / �j W, gbwr, c,f Upon inspection, I certify that I have Laund the tank and baffles to be in good condition, and it appears to be functioning properly. i_-ast time serviced: _�� ^_ Did flow back occur i`rom absorption system? YeS__- No (If no, skip next Line). Approximate volume or length of time: gallons !.'apacity: /0&..0 - Construction: Il:anufacture.r Prefab Concrete_ Steel (if known )4a i1 ! "C"/%_'/ e known).: 4% flPdl'� Other _' �s'� _ 2;12; (Name) Please print mi.nuteEA — - --- -.---._..._..--.__. (License N Number) fo nn to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) certification: Cn accepting the above statement regarding existing septic tank condition, I certify that the tank to he best of my knowledge will conform to the requirements of ILHR , Wis. Adm. Code (except for inspection opening OVer outlet baf e). Name ^`a.-� Sign e MP/MPRS ZZ�fV S-T. CRo NTY SANITARY SYSTEM File#: Office Use Only OWNERSHIP/ADDRESS FORM t:reated212021 Community Development Department will utilize this information to provide the property owner with information regarding operation and maintenance of your new or replacement sanitary system! This information will be provided as part of our ongoing efforts to protect public health, your well, groundwater, surface water, property values, and county resources. Once approved, this completed form and educational information will be sent to you by email. If you would like to view your issued sanitary permit online, you can do so by using the Property Files Scanned weblink. Owner/Buyer Mailing Address 2- sU City/State/Zip Phone Number (required)_ Email Address (required)y Parcel Identification Num (found on the property tax bill) OWNER/BUYER INFORMATION NEW SYSTEM: LEGAL; DESCRIPTION Property Location,g& /4.5 W '/4 , Seb , T -�ekN W, Town Subdivision Plat: `—� , Lot # Certified Survey Map # Volume Page Warranty Deed # �15 (before 2006)Volume Page #�. Number of bedrooms Spec house 0 ye�ho Lot lines identifiabl es 0 no OFFICE E ONLY New Property Address >o,4 Q /Q (Verification of new address r ired frdrn Com nity Development Department for new construction.) (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 cdd0sccwi.gov 1101 Carmichael Road, Hudson, WI S4016 www.sccwi.aov p 5 2022 !:V2! Msconsrn Depa. . . of C r„e SOIL EVALUATION REPORT Page — o�— Dnns+or of Sateh, a ^ B:ticdinas county 5,. cf o1 pe�21a ' - xr Ca^±m 86 h+ts 4d^:. Cade /J unity AttaC: cemplete si , not less #yan E .,`z x : inches ir- size. Plan nust .51. inc�ude, buf not limR tc vetica: and haizontat reference pint sv.-•„ direcbor and paw ! D `6 J� ^ /�n L percent slope, stake or dimensions. north arrow, and location and distance tc nearest road. f (f ( 6X�� Z�IiLL U FFease print a01 information. Re #wed by Date Pawns'. +Morrnat o rou prov+ae may be used fa secanoary purposes (Privacy Law', s `E.Ot '1 ) (ml`. Property owner t P*opeKy LOcat on �) L� L4 Lot T RZ E f hG Property Ovrte?s Meiling Address I Lot# Block # I Subd. Name or CSM# i City State Zip Cade Pnane Number ❑City C Village Town, Nearest Road ''` , i?3� ©:✓ 2� Sal � ; Nit Constructian use ' Residen5a r Number o` .. c Cade derived design flow rate y2L'J GPD Replacement Pubii m-nrteaai • Describe: ---------_—,-- — Paent. material 671 Rood Plain eievation `applicable f Genera wxrrnents So and recommendations: E I System Type n 5ysfem Elevafion r Z_ Q tAA e6tti`e4 i � I # ❑ �n Z i fyl5��+ Pit Ground surface eiev. R. Depth to limiting factor f��` - in. r $oil Application Rate Horizon Depth in. Dominant Cotorl Munseff Reddx Description Ou, Sz. Corn. Color Texh re i Structure Gr. Sz Sh. Consistence Boundary Roots GPDNP -Eff#1 •Efr#2 / i ,ir r—Mta:L 191.z Sor1ro # Q Boift ® S iC Pit Ground surface elev.� r ZDepth to limiting factor //2%) it. car e...Jr.yw.,., owe �M �II � �, iLa'� i�I IM_�_3� Etliuent #1 = BOD. > 30 5 220 mgrL and TSS >30 < 150 'Effluent #2 = BOD, < 30 mg/L and l55 < 3t! mgrL CST Name (Please Print) n CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address - / Date Evaluation Conducted Telephone Number 1432 120th St, New Richmond, WI 54017 O C/ I' . '� 715 246 4516 Property Owner _ 37 Boeing # ❑t Boring t� Pit Parcel10 # Ground surface elev. ft. Depth to limiting factor -, in. Page of Redox Description Qu. Sz. Cont- Color Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Sail ADDlication Rate Redox Description Qu. Sz. Cont. Color Bonn0 # ❑ Boring ❑ Pit C'�^d surface elev. ft. Depth to limiting factor irt. Sail ADDlication Rate Qu. Sz. Cont. Color Effluent #1 = BOD, > 30 < 220 mg(. and TSS >30 < 150 mgfl ' Effluent #2 = BOD, 130 mgiL 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. seae330 (e.6=) Property Owner _ Boring # ❑Boring Pit Parcel ID # Ground surface elev. �� ft. Depth to limiting factor . -14— in. Page of _ Rnil Annfir tin. Gore ❑ Boring # ❑ Boring ❑ pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth in. Dominant Color Munsell Redox Description Qu. Sz. Cont. Color Texture Structure Gr, Sz. Sh. Consistence Boundary Roots GPDM 'Eff#1 I 'Eff#2 ❑ Boring Boring # ❑ Ground surface elev. ft. Depth to limiting factor in. Pit - Soil Aodiration Rate Qu. Sz. Cont. Color MUFAMMM i Effluent #1 = BODS > 30 < 220 mg/L and TSS >30 < 150 mg/L Y Effluent #2 = BODS < 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. sao-s»o (it_cmo) Soil Test Plot PI Project Name Jim Williams Address 2301 220th st. Deer Park Wi 54016 Lot ---- Subdivision S W 1/4 S W 1/4S 4 T 31 iTM #226900 6/30/22 Township Cylon Boring Q Well PL Property Line County ST. CROIX )13 1� M or VRP Assume Elevation 100 ft. Bottom of siding System Elevation 91.2/90.7' *HRPSame as Benchmark N/R16 W No. 644719 STATE SANITARY PERMIT OWNE PLUMBER TOWN k SEC ,T 3 N, AND/OR LOT PERMIT EXPIRES PREVIOUS NO. 14f K2 wI wwm0a- BLOCK F SUBDIVISION ISSUING OFFICER CHAPTER 145.135 (2) WISCONSIN STATUTES (a) The purpose of the sanitary permit is to allow installation of the private sewage system described in the permit. (b) The approval of the sanitary permit is based on regulations in force on the date of approval. (c) The sanitary permit is valid and may be renewed for a specified period. (d) Changed regulations will not impair the validity of a sanitary permit. (e) Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. (f) The sanitary permit is transferable. History: 1977 c.168; 1979 c. 34,221; 1981 c. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. - DATE SS RENEWED BEFORE THAT DATE POST IN PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (R11/20) St. Croix County Planning and Zoning Detail Sanilary Information Computer #: 006-1008-30-000 Sub/Plat: metes & hounds Section: 4 Parcel #: 04.31.16.59B Lot: TN/RNG: T31N R16W Municipality: Cylon, Town of CSM: 114 114: SW 114 SW 114 Owner: Jones, Vernon W. Sr. 2301 220th Street Deer Park, WI 54007 State Permit: 14162 Issued: 12109/1970 POWTS Dispersal: Non -Pressurized In -ground Permit: New County Permit: 0 Installed: 1211711970 POWTS Detail• Seepage Pit Bedrooms: 3 WI Fund: POWTS Pretreatment: NA I[ edneaday, April 25, 2007 at 4:28:47 PM Page l of 1 Notes Issuer/Inspector As Built Plumber Other Reeuiremeots Additional Notes Money Owed Harold Barber NA Bird, Byron Jr. penult notes occupancy at 3 persons, 1 BR and $0.00 Not determined 5 n ,; . rft No Byron Senior was plumber l_. Plb. #67 3/70 TYPE or USE BLACK INX Wisconsin Department of Health and Social Services Division of Health SEPTIC TANK PERMIT APPLICATION t A. OWNER 0! PROPERTY Name �' a �� Address (Street,, Y. Tipp Code) I g.LMTICK OF PROPERTY WHERE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTLvDED COUNTY Check Ones CITY VILLAGE LEGAL DESCRIPTION/sue k w`s ✓1�} '—r"" (� 1-7 7Z11 X J /TOWNSHIP S S V1% // �C %D 1✓ to wP C. IS LOCAL PERMIT REQUIRED FOR THIS WORK? YES NO PERMIT3ER �L>� � D. SEPTIC TANK CAPACITY �7 % , Gallons NEW INSTALLATION REPLACEMENT ADDITION / �Other MATERIALSt prefab Concrete Poured in Place Steel _ j V"r6R OF TANKS TO BE INSTALLEDs E. TYPE OF OCCUPANCY Chook Ones One or Two Family Residence, Commercial Industrial Other speeiry Number of Parsons to be Accommodated Number of Bedroosm i F. APPLIANCES, ETCs Food Waste Grinder YES i� NO Automatic Clothes Washer YES No _ Dishwasher YES D- NO Autoeatie Potato Peeler YI.V No Other (Specify) G. MASTER PLUMB MAKING INSTALW�'ION ��✓� Names �J S;:✓ra,� Addresst ��%'�.e�� a Liesnse Mmbert ' Signature of Applicants :`'^/ "'i�� MP RSW 'i• Addresse L H. (To be Completed by Issuing Agent) Date of Application /1?t--' Fee Paid Permit Issued (date) ' �L Permit Number Agent (Nape) lees Town, Village, City, County, etc. (Specify) dotot The application cannot be, considered for filing until all of the above questions are answered and the too paid. Agents will forward application, the fee of $1.00 :or each septic tsna and the tnird copy of the permit (canary) to the Division of Health. Checks and money seders should be made Payable to the Divicion of Heaath. Do not write in space below - FOR DEPARTMENT USE ONLY I. DATE RECEIVED % b ACCEPTED BY sky RETURNED (Initials) Z (Date) Se"a�C'orres.) �� i� FEE RECEIVED VALID. No. PERMIT NO. es or No)TT"-- REVIEWED BY APPROVED DATE (Initials) Yes or No COMPIATt: &PW.R cmr i .• r SEPTIC TANK PERMIT MO. REPORT ON SOIL PERCOLATION LIST A N D 3 0 1 L B O R I N G S TO DIVISION OF HEALTH - PLUBINGj SSCTI6M P.O.Box 309, Madison, Nis, 53701 Pursuant to H 62.20, Wis. Administrative Code P I H C 0 L A T 1 0 N T I S T Test Depth Character of Soil Hours Water Test Time Drop in hater Level Inches Minutes Nusbar Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall 1st Wetted Overnight In Minutes EAst Period Last Period Period One, Inch Example P - 0 36" Top Soil 10" Clay 26" 25 Yes or No 30 1 2 1 2 1 2 60 77 !r REOM DATA FROM MINIMUM OF 3 TEST HOLES 1 Compute size of absorption area in accord with H 62.20 Wis. Administrative Code._ S O I L B O R I N G S- Mini.-- 36" Belew Pro ossd Absorotlon System Boring Total Depth Depth to Ground Water Depth to Bedrock Number Inches Character of Soil with Thickness in Inches observed ' Istimated Observed Estimated Exmmpie B - 0 72" 72" Black Top Soil i2l'i CW i8l'i Sand 18" Gravel 24" r RICOPD DATA FROM MINIMUM OF 3 BORE HOLES TYPE OF OCCUPANCY: RESIDENCE: Number of Bedroons OTHFRs (Specify) Number of Persons —' FOOD WASTE GRLYDERt Yes .�_ No Dishwashers Yes _ No Y Automatic Clothes Waahert Yes, t�� No P?LUENT DISPOSAL SYS7EMt NEW !� EXTENSION ADDITION RIPLaCE10fT Tile Size No.Lin.Feet Trench Width Depth Number of Lines Seepage Bed: Length Width_ Depth Tile Size No. Lines Seepage Pitt Inside Diameter -Liquid Depth ^/y- - 5 �- !I, the undersigned, hereby certify that the percolation tests reported on this fora were made by me or under r.1 super•, vision in accord with the procedures and method specified In Chapter H 62.20 (13), Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. /i NAME i Itrr /1 / / %✓ TITLE , r • /' � T' r r - Type or Print 'REGISTRATION NO. or MASTER PLUM9ER LICLySE NO. s ADDRESS Parcel #: 006-1008-30-000 oa/zs/zoo7 04:15 PM PAGE 1 OF 1 Alt. Parcel #: 4.31.16.59B 006 - TOWN OF CYLON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s)' O = Current Owner, C = Current Co -Owner O - WILLIAMS, JAMES F & GERALDINE JAMES F & GERALDINE WILLIAMS 2301 220TH ST DEER PARK WI 54007 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description ' 2301 220TH ST SC 0119 AMERY SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 5.000 Plat: N/A -NOT AVAILABLE SEC 4 T31 N R16W 5A IN SW COR SW SW Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 40114 160114) 04-31N-16W Notes: Parcel History: Date Doc # VoUPage Type 2007 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 09/08/2004 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.000 25,000 126,000 151,000 NO Totals for 2007: General Property 5.000 25,000 126,000 151,000 Woodland 0.000 0 0 Totals for 2006: General Property 5.000 25,000 126,000 151,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch M 512 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 CYLON ./Orin N/ lbw i T 31 N-R. 16 W. 59 v K.o9h� : ,a �n L/u e f" Gam/ h,z>•f 4ffr w.r7 'YG/>w:e 7 s/!+ r ✓ � ,t/eini Than • l �� � H fis'ix� : <y fig. nb Cho mn /Fhf � ifC Fck- s . r0 0 !;Y /vie's• CYak f Vie/<> C 0 6� C C y .�so � � b \ C i.�f <c• • :/i.5' b - �� � C>'"r.•n .S:�.f aF.t! '� �✓/-ib`<ft �y4h �� c /)D C C.Fi.a Ii e/ a. G nn// �j� „n.t 7/v •> ✓i9 T e. u/ems •Heo .fare , e'.t%/• F Q 7 ,zo ✓o ✓ � � N . sS>. r B�rn,G -k s/.iE � ii>:.s N � • .-!-<r p L.>,x�///= r.a • .t Le•,^I ,> r �..fiS b ��� h �> :'7•••• h""'/ � F/i�,n ti FJ SrJ �' ' `��" � y i � ,YnrBn /' 9�, t A RK LDb,> 1l w; : n t � ' � •'� J s w rn 1 ` fn • so ✓'fir e� • / ✓Q• RD ro :i �1 `� •� c'h,/,p /f aa•nc/• C y \ • ^Ji ✓n llaf/C Y./boo rGJ'�%,•„ a,>s�.> <r • /•/o, C . F 1pp'1 Q \ ,� 1� >Tf rl DLd//G//• :z/ ; /SO /: yy0 �'• /z/ .r/ 9 C �•nn/s rE/, 90 • Se'n <J' e'CJ' G6.•4 yp v /f'vXra 70 /Pay /•c_ Yf ri .SC rr w� G✓r/ \ M /ao c • of .d AO • 11 db • / /n0 O,a1 n/y O 1.1.J• i fi/ iw Hbne,' ell .� • M M • fAS' /H b ' e/> HQn507 zeo elN E _nvrc IiiK .fenneth , �/y9 �/J<,. ' /1>C fL•/a S{e a,r c .n /=o i 9 d A a.7p s n///f' JS/nf Ld/ an EsrRT 'PQy � N P `7/n ra2n � Oc,J by f G',BGC /Sn �c'h /nJ � a nv0`� G na. s � � f0 • � r✓c'/> R��/ llhc.ESe/Jd• ZLb C/n• 2 .A.e.?/i • �., /aa /zo �• ,eoy .� /an /00 IO 'iQ.S. e•,>y /5! rb r/Pn..ti(r' //9 �Ow„ \r "Jy Gorton N f /R3 .,ame•J / J. '� :Tack Soq rg HrnSon /Y/6u.. ys<' .'. a. :Fu h•Q// /sio • ___ C �0 � '�°T ^ / i � J • ; fe , ^rn<FDwan .Dif/Hann � < ti `e `� rn " l3aJ ✓� i':'.iOO< /`>a,ce/% 1b4/ha/ ✓ v <�� 6e .� e n'.' .h! �;jrelluc. i �(� aas EI .(•.re`ye� O�Cren lipC\� Win/ a � � �V\ aYahn c eon l,✓w//iG. �: -re ✓a r `` � da'O!!Ja ` rl af>Yw"aJOn � i fisi,a� t7JCQ,• � J• do 'fn E/oo`' yi ' �� >• ® >! 1In • • ,r .f'na• fV SPex<,- fzYseAna 'IT • ?J � • /Sn f>/m,nan • J% N />s � Peb�ncahs G.•d:o5� ena O � ' � 3 '� � 'e "'y • .•O Da ffinan >/noa- /o � ae c"ac.b n� yo aPos! z.s! ">' N 9/.�•G � 't..u` E • �4 n G'o.: !cs Q 17 �� \�yR'�^�lsa �� � � .7/r/swf/ ' �v 0�/f ..a a:, � C ss•cr � 'L !fan of A � •y� y"' • . u ��j IMF MCI% ryi<J • �.. > licnGCJ o . o c',f� d H s/'as cTo »<: < /1"✓" caJ<y :s.'.i 4<n , A✓GG�Fs s '<�. 9'iesJ ♦ � If .n > v a • 3s1 T » . en r-oi_' •asD alto _ PLAT BOOK COMMITTEE SALES COMMITTEE Cont'd. on page 61 Mr. James Ray Mrs. Charles Smith Mr. Jim Ruetnmele Mrs. Gordon Mueller Mrs. Ross Pierson Mrs. Miles Casey Mr. and Mrs. Bob Phillips Mr. Robert Hater Mr. Al Franko Mrs. Guy Wilbur Mr. Don Matysik Mrs. Judy Ferguson Mr. and Mrs. Merton Vricze Mrs. Joe Lohmeirer Mrs. Willard Johnson Mrs. Robert Gardner Mrs. Robert Hanson Mr. and Mrs. John Steele Mrs. Freida Fellin$er Mrs. John Lavelle Mr. Robert Condon Mr. Leon Holle Mrs. John Glassbrenner Mr. Del Polzin Mr. Steve Thompson Mrs. Harlan Johnson Mr. LaVcrne Karastes Parcel#: 006-1008-40-000 04/25/2007 04:04 PM PAGE 1 OF 1 Alt. Parcel #: 4.31.16.60 006 - TOWN OF CYLON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current CO -Owner VERNON W JR & MICHELLE J JONES O - JONES, VERNON W JR & MICHELLE J 2240 CTY RD H DEER PARK WI 54007 Districts: SC = School SP = Special Property Address(es): = Primary Type Dist # Description ` 2240 CTY RD H SC 0119 AMERY SP SP 18020 7700 WI C UPPER WILLOW REHAB DIST -Z �4-1- STD Z3�1 Legal Description: Acres: 40.000 Plat: N/A -NOT AVAILABLE SEC 4 T31N R16W 40A SE SW Block/Condo Bldg: , _ 5_lzn A Tract(s): (Sec-Twn-Rng 401/4 1601/4) 04-31N-16W jL✓�SL� '�D � n-!1�'t ram' `!'% � Notes: i` Parcel History: Date Doc # VoUPage Type Zell Z- 2007 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 07/26/2005 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 15,000 210,000 225,000 NO AGRICULTURAL G4 17.000 2.600 0 2,600 NO UNDEVELOPED G5 2.000 1,400 0 1,400 NO AGRICULTURAL FOREST G5M 19.000 22,800 0 22,800 NO Totals for 2007: General Property 40.000 41,800 210,000 251,800 Woodland 0.000 0 0 Totals for 2006: General Property 40.000 41,800 210,000 251,800 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/17/2001 Batch M 512 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00