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HomeMy WebLinkAbout040-1064-70-110 ST. CROIX COUNTY WISCONSIN ' PLANNING & ZONING DEPARTMENT ST. CROIX COUNTY GOVERNMENT CENTER 0 1 M Y M 111 H■ 1 101 Carmichael Road Hudson, WI 54016 -7710 Phone: 715 386 -4680 Fax 715 386 -4686 August 27, 2008 Kerry Geurkink 383 North Glover Road Hudson, WI 54016 RE: POWTs Installation Inspection for 383 North Glover Road, Sanitary Permit #514967 Location of Property: St. Croix County, Wisconsin Municipality: Troy Township Subdivision or Plat: in NW 1/4 of NE 1/4 Certified Survey Map: #853736, Section 16, T28N, R19W Lot Number: 5 Address: 383 North Glover Road Dear Applicant: A septic inspection of the above referenced property was conducted on August 27, 2008. This property is located in the NW 1/4 of NE' /4 of Section 16, T28N, R19W, also known as lot 5 of CSM 853736. At the time of the installation inspection, this replacement Private On -site Wastewater Treatment System ( POWTS) was found to be code compliant for a three (3) bedroom home. An effluent filter has been included to improve wastewater quality discharged into the drainfield. A valve has also been installed to alternate between the new drainfield and the existing drainfield as needed. The inspection report and related documentation of this POWTS is on file at the Zoning Department. If you have any question regarding this system, please contact our office at 715.386.4680. Sincerely, Ryan Yarrington Zoning Technician Cc: Jim Boumeester, POWTS Installer file I T - Wisconsin 11 Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 514967 0 GENERAL, INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Geurkink, Kerr (Lynn) Troy, Town of 040- 1064 -70 -110 CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No: MO -6 /a 0. o �� � _ 16.28.19.2411315 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Se Benchmark �j � / vo C� � o2 lod • a Dosing , Alt. BM Aeration Bldg. Se er Holding v SUHt Inlet St/Ht Outle Jo TANK SETBACK INFORMATION A � f 36 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Sept Dt Bottom Dosing Head 5 — Aeration Dist. pe (�.R (� G Holdin Bot. S s 7 PUMP /SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss e.Lrt Head TDH Ft Forcemain Length Dia. Dist. t Well SOIL ABSORPTION SYSTEM 2 3 BED /TRENCH Width / Length No. Of Trenches PIT DIME IONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 9 '�/ SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM EACHING Maryst INFORMATION T OfS tem: C AMBER J/ �'' T� ATV YP Ys ) ^ / J� UNIT Model Number: z DIS UTION SYSTEM m 4 1 Header! ifoid Distribution / x Hole Size I x Hole Spacing Vent to Air Intake / Pi `r Length Dia Lengt Dia Spacing �— 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 2 ? Bed/Trench Edges Topsoil a �7 Ye�sl No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / d /V Inspection #2: Location: 383 N. Glover Rd. Hudson, WI 54016 (N 1/2 NE 1/4 16 T28N R19W) NA Lot 5 '� Parcel No: 16.28.19.241615 1.) Alt BM Description = B �lX V l r 2.) Bldg sewer length = - amount of cover = Plan revision Required? ❑Yes �o 1� i^1 1 ,Q d "© C U (Y J Use other side for additional information. Date Insepctor's Signature Cart. No. SBD -6710 (R.3/97) Safety and Buildings Div on County � m 201 W. Washington Ave., P.O. 716 S I"n U V scon w Madison, W 1 53707 — 7162 O h7nkafy Permit Number (to be DIM in by Co.) (608) 266-315 S P Department of Commerce Sanitary Permit Application s Ian I.D. N umber In accord with Comm 83.21, Wis. Adm. Code, personal vide pgd ® Pro Address if different than mailing address) may be used for secondary purposes Privacy , s I S. 4 ` 1. Application Information - Please Print All Info anon x d r 1 1 Property Owner's Name Pam Block N Property Owner's Malling Address ZOMNG OFFICE Property Location r r° N low in. 1--a 0 W ki.,IQj�_k,.. section � City, State II __ Zip Code r _ Phone Number 1 pS D U V") J v v �P T� N; R�E W \ II. hype of Building (check all that apply) 53 1 or 2 Family Dwelling - Number of Bedrooms Subdivision Name ^ CSM Number v �' ^ ❑ PublWommercial - Describe Use G /6* X S 1 p ❑ State Owned - Describe Use r Z ity ❑Village Township of 2 i) Ill. Type of Permit: (Check only one box on line A. Complete line B if applicable) -► A ' ❑New System 1 System ❑ Tratmertt/Hoiding Tank Replacement Only ❑Other Modification to Existing System g• ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiradim Plumber Owner IV. Type of POWfS System: Check all that apply) " Non - Pressurized In -Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pau Sand Filter ❑ W a ❑ Pressurized In -Ground ❑ Holding Tank ❑ Pat Filter 11 Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑' Caatrueted tU net B Roci Synthetic Media Filter OLeochingChunber ❑ Dri Line ❑ Gravel -Ias Pi ❑ Other (explain) V. Disrowsal/Treat9mut Area Information: Design Flow (MA Design Soil Appiirxtion Re gpdsf) Dispersal Area Required 1) Dispersal Ares Proposed ( System ion S to 910-u I Capacity in Total Number Manufactu er Prefab Site Steel Fiber Plastic VI. Tank Info Wct tY Gallons Gallons of Units crete Constructed Glass ZG New Existing �/ �J f Tucks Tanks Septic or Holding Tank 1 000 Actable Treatment Unit Dosing (:timber t w Vii. Responsibility Statement - 1, the anderskelul, awanre ralso usiblilty for Installation of the POWTS shown on the stun Plumber's Name (Print) PI •s S MPIMPRS W '� ten Kok Plumber's Address (Street, City, State, Zip Code D7u N � Vlll. County/Departnient Use Onl pproved Disapprov Sanitary Permit Fee (inciud Groundwater Dal Issued Issui Sett Si Surcharge Fee) �G,� . 04> n Rason ial " IX. Conditions of Approval /Reasons for Digapproval SYSTEM OWNER: 1. Septic tank, effluent filter and dispersal cell must all be services maintained as per management plan provided by plumber. 2. AN ammiek rer eiiteMs ttw�* ba nV* t Lood Pct txide / ordhV# Attach complete plains (tin the Comely only) for On system on paper not less also $1 t 11 tacbes in site SBD -6398 (R. 01/03) s� e `wr.r,);.tt •eu'i:.• -r'�.ri.ip3tli?�G�l� , c, IF _.i}t�t!!t NQ of r 00 o z M a p A4 me inn ���.�. 1� ri � mees� � C ' Oc& G I ov-.rz G��e�se �f( ry) boa S;11 � C f i 4�•SV ,� T neti �� 7� I t V LecoPY a a A4 md Vouzlt 1"m LQca4 on G i mg(Z cha � To (y � O"N 501 - i�v- ►uu 0 Jam' 3�g Irk s , �o ?� c� Tneh► ��, 1- � � V- � 1 t 2140 Wisconsin Department of Commerce SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Soil & Site Evaluations Attach complete site plan on paper not less than 8% x 11 inches in size. Plan must County St. Croix include, but not limited to: vertical and horizontal reference point (B Ct10 nd Parcel I.D. percent slope, scale or dimemsions, north arrow, and location and d' 040- 1064 -70 -110 Please print all information. evie y Da r/ Personal information you provide maybe 5.04 (1) (m)). / d X Property Owner roperty Location I UUU Kerry Gurkink rovt. Lot NW 1/4 NE 1/4 S 16 T 28 N R 19 W Property Owner's Mailing Address AUG of # Block # Subd. Name or CSM# 383 N. Glover Road 8 2008 5 CSM Vol. 22, Pg. 5413 City State ip Co1q dl pp�y City Village ✓ Town Nearest Road Hudson WI Troy I N. Glover New Construction Use: t/( Residential / Number of bedrooms Code derived design flow rate GPD 1/ Replacement Public or commercial - Describe: ��h tc&s Parent material Glacial Outwash Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for conventional dispersal c with 0.5 gpd /sq.ft loadin ra e. Recommended installing upper trench at 94.50', lower trench at 93.5 . Boring # Boring ✓' Pit Ground Surface elev. 99.84 ft. Depth to limiting factor >107" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDK1 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 1 0 -11 10yr3/2 none sil 2fsbk dsh cs 3fm.2c 0.6 0.8 2 11 -15 10yr4/3 none sil 2fsbk dsh cw 3fmc 0.6 0.8 3 15 - 32 10yr4 /6 none Is 0 sg dl gw 2fm,1c 0.7 1.6 4 32 -61 10yr4/6 none Is /s 0 sg dl cw 1fm 0.7 1.6 5 61 -107 10yr5/6 strat s&gi 0sg ml - - 0.7 1.6 yj, s :;2 #4 consiS,tS of an unsorted mixture of Osg Is & s. 1 4 Boring # Boring ✓, Pit Ground Surf elev. 98.42 ft. Depth to limiting factor >98" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 I *Eff#2 1 0 -8 10yr3/2 none sil 2fsbk dsh cs 2fm,1c 0.6 0.8 2 8 -20 10yr3/4 none sil 2msbk dsh cs 2fm,lc 0.6 0.8 3 20 -30 1 10yr4/4 none sil 2msbk dsh cw 1fmc 0.6 0.8 4 30 -54 7.5yr4/6 none Is /sl 1msbk dl /dsh cw 1vf,f 0.5 07 5 55 -98 10yr4/6 none s 0sg dl - - 0.5 0.7 Cl ' H#4 consists of an unsorted mixture of Os s ( minant texture) and lmsbk 10yr4/4 sl. H #5 contains 1/8" - 2" bands of 10ry4/4 Ifs. * Effluent #1 = BOD? 30 < 220 mg /L nd TSS >30 < 1 0 mg /L * Effluent #2 = BOD < 30 mg/L and TSS < mg /L CST Name (Please Print) Signatur CST Number James K. Thompson :.2Lr 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 8/13/2008 715 - 248 -7767 Property Owner Kerry Gurkink Parcel ID # 040- 1064 -70 -110 Page 2 of 3 3] Boring # Boring ✓! Pit Ground Surface elev. 97.26 ft. Depth to limiting factor >103" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -5 1Oyr3/2 none sil fill 2fsbk dsh cs 2fm,1c 0.0 0.0 2 5 -13 1Oyr3 /4 none Is &s frl Osg dl as 2fm,1c 0.0 0.0 3 - 8 1 Oyr4 /4 none sil 2msbk dsh cw 2fm,1 c 0.6 0.8 4 - 46 7.5yr4/6 none Is /s On dl cw 1vf,f 0.7 1.6 5 10yr4/6 none s Osg dl gw - 0.7 1.6 6 76 1Oyr5/6 none s Osg dl - - 0.7 1.6 #4 consists of an unsorted mixture of Osg Is & s. c� F-1 Boring # Boring - " Pit Grou d Surface elev. ft. Depth to Limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 ❑ 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 QPD in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg/L * Effluent #2 = BOD <30 mg/L and TSS - 30 mg /L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 -266 -3151 or TTY 608 -264 -8777. SBD -8330 (R.07 /00) A.C.E. SON & Ste Evaluabons • Soi / eta /ua.•Fion %t ' • � - r ,s6� y,•�w�a ere! /ot Sfa.E� ina d br T -,Dort �P zinc �c�ry,C. Gurv 38 3 /j. 6 /ovri ,rd •, 77 -211 /et C sgv'e 2a, 1.5W.3, nEy�rli 5¢e. /G, T. Z64 /9u1,, T • of Tioy, X. Crotx uA ,4 A' o s -✓06 4�'- 70 -110 S E,Yi3'� cabal �J�• fi b_ �ou'� rod L.y /aco.�do►.� MccS� Q t,.i ed ✓ e/ f'ed ,artar -6o sysl6c*n i� Caner 3 ;c took. Pines V � G � , aa ,�, <<`�/ � � � ��,,• acs bare eie e: ,x A li n ),Ba �e� F /tda•�bn s : /�; yes 8.�rj. = Top �Ser ae dco� s.'r /�o /a E,{'isY`.'n� 4%'s�oei,s,Q ce // Q /e v` = 9,?•TS' r /lo✓� 6 /over goad 3 a•F3 r RECEIVED IllII' "" Illll !11!1111! Illlil !!II 1111 AUG '" L KATHLEEN r LSH REGISTER OF DEEDS ST. CROIX CO., WI ST. CROIX COUNTY RECEIVED FOR RECORD SURVEYOR'S RECORD 06/20/2007 12 :40PM CERTIFIED SURVEY MAP CERTIFIED SURVEY MAP LOCATED IN THE SW 1/4 OF THE SE 1/4 AND THE SE 1/4 OF THE "°` - F A ' 4 tie SE 1/4 OF SECTION 9, AND THE NW 1/4 OF THE NE 1/4 AND THE NE 1 ? I'O�E 1/4 OF SECTION 16, ALL IN T28N. R19W. TOWN OF TROY, ST. CROIX COUNTY W� INCLUDING ALL OF LOT 1 OF THE CERTIFIED SURVEY MAP RECORDED IN VOL �, AGE 796. DOCUMENT NUMBER 356581. LEGEND COUNTY SECTION CORNER MONUMENT. ALUMINUM CAP. FOUND. i NOTE' ALL IRON 1 1/4ON PIPE. FOUND. 1Ka �I IQ O PEE (FOUND •' IRON k I G� / O SE ARE S X 2 3/8" IRON PIPE. FOUND. OUTSIDE DIAMETER. 1 1/4" x 18" IRON PIPE WEIGHING + — — — — -\ ` '�J O 1.68 LBS./LNEAR FOOT. SET. \ \� !J/ LPL A TTED pl MAGNETIC SURVEY NAIL. SET. g LAND \ t G 4f (R) PREVIOUSLY RECORDED INFORMATION. or L O 1 2` 4 — GVO p 1 Ar 9 ETh S�/ of ..'.'.. CENTERLINE OF EASTING DRIVEWAY. C.S.M �, SE 1� 7w SE 1/4 — BUILDING SETBACK LINE. 50' f� 0R — * - UNLESS OTHERWISE SHOWN. V. 7 1 �a" ti 5� NQRTH LAME OF TAE' AC 1/4 OF -- E 1ST FENCE. NE CORNER SECTXIN 16 SECTION 16 � . M # 1- 4� 4 N 8 2645 .84' , E - - _ T28N. R 19 W // v' 599.33 � --� _ _ _ �a - 2046.51' 0 > S 89.04' 24" W N 1/4 CORNERS / /V`� a a i DRAINAGE k s�ti .>4g Os'� SECTION 16 - EASEMENT `' 3.� ( POINT OF T28N. R19W Y `� HIGH WATER 3g1 I BEGINNING L o T 1 3 ELEV.-901.17 AE Z 5 /N 3 C^ LBO - 903.17 .. '1 n 1 . 2 1. a S C , UNPLA TTED V 17/A� As % I - 3a7 -7g' b �.o ° �y� I�"� LARD 460 / S Ir. / J j ry .�! % , OF T L E NNW 1/4 LOT 7 — _ — - / ryy % , TI,L� V4 13.131 ACRES y� (o / SEP77C 571,993 S.F. • � I BM �2 VA ;£. TYPICAL -3 c DRAINAGE 3� \� \ t �q� 5� $ EASEMENT \•; � N HIGH WATER / C+~ rcpt % S 89-55'31 E 352.10' ELEV.- 903.41 / y 3• �\ b X9.S / 1 113.78_ 238.32 C-4 LBO 905.41 SOL 2 \ . e� ,�°i, ORNGS. W al 1> ` �' \ / ^� W l LOT s y TYP .- ^ iI 1j 1 R ?� B2 O+ 1� 'h N 9 S 9 )► '�' c'I' 6.926 ACRES '�� •r (6 1 lal �\•'� � S y �l 301,699 S.F. K5 301,699 GL0jTL? � � �l L�j / & O. 66'WIDESHARED t I�I�I�I 5TA T /OA/ fVEW. �j� �•� (CR ATCHED) I N QI -I WELL ��_'� ' �� ��p� �� ? ti Ens 6 �� 9• ' �°a. I �^ BENCH MARKS: ° ` g,� M B 1 -J` S 6. �� 3 �3 F �� T OP OF 2 3/8• xm /\ gL \ (R -N ��,i S' \` 1� 1-1 IRON PIPE , O• � ELEVATION-910.38 L 2 .L & l (NGVD 29) = V E LOT 5 IS NOT A NEW LOT AND IS ONLY INCLUDED IN ORDER -CZ , EL i P ON- 905.00 �- TO ACCOMMODATE AN EXCHANGE OF LAND BETWEEN �.Da, (NGVD 29) ADJOINING OWNERS. IT IS NOT SUBJECT TO SUBDIVISION ORDINANCES, LOT STANDARDS, OR FEES. \ SCALE IN FEET T Q LO 3 A A " I LUND KERRY L. GEURKINK 0 100 200 400 393 NO RTH GLOVER ROAD 383 NORTH GLOVER ROAD 7'I S� INSTRUMENT GRAFTED BY H UDS ON . A IN WI SCONSIN 54016 HUDSON, W ISCONSIN 54016 PAGE 1 OF 3 ��,., 2Z. �� 96Z 928d C @mnTOA 83W3V8A 31inr AG o31db8o: M61 b c N8Z1 19IINW05 014INO2 OW `91 N01103S A hH o O= V '07, 01 43438 A ! ^.'� � X flHINNVId S B AISN3 AISN3H38dW0D '1S 1 yn0trddb 63N800 t 3 Od 1 c�s Jr1d3S ao 911S ONIa7rna , ' oo'zz£ �i 08 LL l ='b NV9w 1ON S30v 6M 9 dd ,00 'L9l= )4OlSr^raenS SON 1114 d0 7y^O�ddb ,00'££ M„Ob °L8N 9 °9 ' ,1£9SWN ,c's. auir M/ �j ONINN1039 a3AOSddd Alaat4}a0N 1NIOd s'O� 9UII M /2i Apalseat4lJON ;p y� d LO, AdM3A I WI c� \ NOWWOO 3NO 01 Q310I IS38 A93212H OSIV 388 � QNV S10] ' AVM3n I 2I CI NOWWOO 3NO 01 0�, y am' Q310I a1S32! 1�S32i3H � \�� o. \ 3NV Z QNd j S10l CP ,'d L : 310k c aN n03 `1N3VYnNOW 83N800 N011035 AINn00 / :1003 - 1t13NI - VA' 89'1 1� O� 3� i �3► !JNIHJI3M 3dld N081 bZ X,,1 0 °06 3, O o GN393 O \ _ �� �' ` 3N 32 3N — MS 7A � °�� 3 N - 33N—MN \ DLO id c,'��Z \' S� -f >�� AUG. 22. 2008 ' 9: 44AM" `'MINNESOTA L I f E °°° "" war " " `NO, 708 " P, 2i ST. CROIX COUNTX SEPTIC TANK M- AAINTENANCE .AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owrtel•Buyer >w l.. `r�tl.�2 Mailing Address can; AV. eT cy+r e Property Address 3%++C- (Verification required (rout planning & Zoning Impntment for new construction.) City /State tldS&J .._ Pmei Identification Number - [ ,.9,J 1/o LE� GAL DE5CWPT,LQN Property Location N W t/, , NF, t/, , Sec., r (e , T . �j_ N R 19 W, T own of 1 k o, Snbdiv'ision v ,,Lot # Certified Survey Map # .3�� ��� , Volume 3 , Page # Warranty Deed # Yk Volume �� �, Page # Spec home no Lot litres idenitialnle yes no XST C AND QWNJd& C RTIFTCA1M Inwropet tree and maintenance of your septib ays test could result in its p lure faibm to handle wastes. Proper tnainteeance consists of pumping out the septic tank, every three years or sooner, if needed, by a licensed pumper, 'What you put into the syatant can orect the function of the septic tank a a treatment sage i the waste disposal system Owner maintenance reap0ttstV1i&s are specified in §Cmmp. 93.52(1) and in Chapter 13 • St. Croix County Sanitary Ordinance. The prop" owner agrees to submit to St. Croix Cwmty Planniog & Zoning pepattmant a ocrtiftcation form, signed by the owner and by a Waster plutnbm, im meyman plumber, restricted plumber or a licensed pumper verifying that (1) the cur -site wastewater disposal system is in ptoper operating condition andlor (2) after iospect ion and pornping (if necesa%KA the septic tank, is leas than 1/3 full of sludge. Uwe, the undersigned have read ft,Above rd aventents and agree to maintain tine private sewage dispooal sysL with the M ndatds set forth, herein, as set by the Department pf eowneret and the Department of Natural Resources, State of Wiscx min Cettif"11On Aldl yg that grout $eptic system has been Maintained mutt be completed and tetoroad to the St. Croix County Planting & Zonitcg'Depamnent within 30 daps of the three year - expiration date. That certify that all statements on this fanO true to the best of tnyfour kAOWW&e. Vwe amlaue the owner(j) of the Property desaibed above, by virtue of a warranty deed recorded in Register of Deeds Offi Number of bedrootas �. IGNaTURE OF LICANTCs? DA TE '"Any information that is misw4wesestted may rwWt'in tine sanitary permit bring revoked by the Planning & Zenatng Depert pant. Include with this application a recorded warranty deed ftm the Register of Deeds Office and a copy of 60 certified covey map if refatlow i6 Rude in the warranty cited, FILE INFORMATION POWTS OWNER'S MANUAL tit MANAGEMENT PLAN rase _ of Owner SYSTEM SPECIFICATIONS Permit Ar -- - - 530 mg /L F Tank Capacit p V 1VU� of ONA Tank Manufacturer DESIGN PARAMETERS __. ___ - - - -_ }� y�L O NA Filter Man ��)Uli F mber of Bedrooms O NA __ Cl NA mber of Public FacfNty Units - Effluent Filter Modal - -- O NA 9 Pump Tank CApac ity NA mated flow (avers e) _. - al Design flow --lial /dam Purnp lank Manufacturer g (peak!, (Estimated x 1, 51 y V -- - - - NA - -- .._. /dy Pump Manufacturer Soil Appflcatlon R ____ NA Standard Influent /Effluent oualit _ day! /t' Pump Moclel y Monthly averag - - - -- _ - NA Fats, Oil & Grease (FOG) < g Pretreatment Unit 30 tttpJL Il Satrrf /Glavol Fill NA Biochemical Oxygen Demand (1106 1.1 Peat Filter Total Suspended Solids TSS) 72c.) r „p /t 1 1 NA 1.1 M "r ;hnnical nr•rarinn (.I W"tland 1 1 5150 mg /L Pretreated Effluent QuAlit -- y — C1 Disinlection -- -- - - -- IJ Other: " —_ _ . __.... -_ - -. Biochemical Ox ( p (Dispersal cell(4) ygen Mor►thly AverA Demand BODRI O NA H ( Total Suspended Solids (TSS) 530 ni /L "-Gr"a"d (gravity! ❑ I olind nd (pressurized) Fecal Coliforrn g O NA Cl At Glade (geometric_ mean) 510' cfu /100m1 C1 Mound Maximum Effluent Particle Size IJ Drip -Line .. _ O Other: fa in ells. __ I7 NA O NA O NA Other: ... ....... ...... _ "Values typical for domestic wastewater and e"pNc tnnk "Ilinent- — O NA Other, -- MAINTENANCE SCHEDULE O NA Service Event rInspect condition oCtank(s) Service Frequency At least once every: 3 months► ut contents of tanks) -- - earls) IMaxmmum 3 years) O NA Wlten combined sludge And scum equals one -third (Y.) of tank volume -- -- _ Inspect dispersal cells) O NA At least once every: O nronth(s) Clean effluent filter -'�— year(s) (Maximum 3 years) O NA �- At least once "very: O monthis) Inspect pump, p, pump controls 8r alarm -- +- i � Year(s) O NA _ At least once every; L7 monthis! lush laterls e y __ ___.____. O yearis) F a and prssure test NA Other: — - - - -- At least once every: O months) _ ye aris) NA 0 m Other. At least once every: - onthis) - - ------------- O year(s) C NA MAINTENANCE INSTRUCTIONS 1 NA Inspections of tanks and dispersal cells shall be made by an individual carrying one of the Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer, following licens inspections must include a visual inspection of the tartk(SI to identity any missing or broken hardware, S er vi c i ng e vi or certifications: measure the volume of combined sludge and scum and to check for any back o or ondi Septage etify 811 Operator. Tank The dispersal cell(sl Shall be visually inspected Y cracks or (sake. to check the effluent levels in the observation ation pipes ef fluent and to check for anndy surface. Of effluent on the ground surface. The pondMg of effluent on ttre g round surface ma immediate notification of the local regulatory authority. Y indicate a tailing condition and requires the When the combined accumulation of sludge and scum in contents of the tank shell be removed any tank equals one-third (Y Wisconsin Administrative Code. ► or more of the by a Septage Servicing Operator and disposed of in accordance ankh tank volume, entire me, the All other services, including but not limited to the servicing of effluent filters, mechanical or p ressuri ch apter NR 113, units, and any servicing at intervals of 512 months, shelf be performed by a certified POWTS Maintainer. zed components, pretreatment A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. I START UP AND OPERATION Page of For new construction, prior to use of the POWTS check treatment tanks) for the presence of painting products or other chsrktlode that may Irnpede the treatment process and /cr damage the dispersal celi(ei• if high concentrations are detected have the contents of the tankfa) 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 hlghwater levels. When power is restored the excess wastewater will be ;. discharged to the dispersal cepls) in one large dose, overloading the cells) and may result M the backup or smfaoe d6dw pe of effluent. `ro avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring.- power to the effluent pump or contact a Plumber or POWTS Maintalner to assist In manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact. the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: - antibiotics; baby wipes; cigarette butte: condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fetf foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is 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. S pool wdhf Nitl.wr Ali iti 61 tilwiil »trlt Maim Iris WMA446 ON* WrdilA"s MIMMNAi ll 06 It; as errwtwNir MoiiliilhM "0046411 • 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: A suitable replacement area has been evaluated and .may be utilized for the location of a replacement soil absorption';,',: system. The replacement area should be protected from disturbance and compaction and should not 60 Anfrktged upon by required setbacks from existing and • proposed structure, lot Ines and wells. Failure to protect the replacement area will result M the need for a new soil and site evaluation to establish a suitable replacement area. Replaoentertt systeaa must comply with the rules In effect at that .time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site hss'not been, evaluated to Identify a suitable replacement area. Upon failure of the POWTS a soil and 440 r� A evaluation' must be performed to locate a suitable replacement area. If no replacement area is available a holding tanl� may be Installed as a last resort to rep a thpffailltl.POWTS, �oU tO Mound and at -grade soil absorpt be reconstructed In place following removsl? bktmst at tin Infiltrative surface. Aeconstructi must comply with the rules In effect at the <WARNING> > SWM. PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATmW :T K UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A' PERSON FROM THE INTERIOR OF A TANK MAIf# 41t.T OR IMPOSSIBLE. ADDITIONAL COMMENTS. A , X41 It Y'!',. ; , , i► zp ���� �� , . , � h� ♦�1 lit; � •t POWTS iNSTALLLE POWTS MAINTAINER ' Name J - j Y* Ugh lh�t t V :.,f. r r ;rrk Norte Phone . 9 Q t> Mit il7'.1`N. Phone , .• �;:, .� t;I� A ' w SEPTAGE SERVICING OPERATOR I PUMPER) ' i ', LOCAL REGULATORY AUTHORITY �Il ..'' ! Name QD Ili ; 1/InU , :; . , Nems (, j.> . ;► " V��N) Al Phone - #� x " .j��' Phone This docurnent was drafted in compliance with chapter Comm $&22l2)(b)11)Id)d(Q and 83.64(11,12) b 131, Wisconsin AdnilMhMtiw Code. BART UP AND OPERATION Page of ;w new construction, prior to use of the POWTS check treatment tanklsi for the presence of painting products or other chemicals chat may Impede the treatment process and /or damage the dispersal cell(a). if high concentrations are detected have the contents A the tankls) removed by a septage servicing operator prior to use System start up shall not occur when soil conditions are frozen at the infiltrative surface. Arring power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be f Recharged to the dispersal collie) in one large dose, overloading the collie) and may result in the backup or surface discharge of rffluent. 'To 'avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring. rower to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to estore normal levels within the pump tank. )o not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the arse vithin 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 pro" the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; Sainting products; pesticides; sanitary napkins; tampons; and water softener brine. IANDONMENT Vhen the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is Koperly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: e All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. w 0 40 411111111610141 of fill injowl limb 0,44 w4wil 046 4A#0 46006 M140 *0004ris d1011111149 & 44 M oftpi ooi1 ii wi4liilhM 0004 e After pumping, all tanks and pits shell be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. )NTINdENCY PLAN f the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant *placement system: A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption{'' system. The replacement area should be protected from disturbance and compaction and should not be ;tnfrirged upon by ' required setbacks from existing and proposed structure, lot tines and welts. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules In effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. earring 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 tegtk," r may be installed as a lest resort to rep s this 4 fallltl•POWTS. O Mound and at -grade soil absorpt Abe reconstructed in place following removals biomot at the Infiltrative Surface. -Reconstruction must comply with the rules in effect at the ' : < WARNING> > SEPTIC. PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT Tf K UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A: PERSON FROM THE INTERIOR OF A TANK MAY;LT OR IMPOSSIBLE. �-• WOITIONAL COMMENTS ►u fite�� �� ,kths 'slt1 r r POWTS INSTALLER =>rr�irt`e1 POWTS MAINTAINER a,l.;• ��` : ' Name f r rfth e' Nam „�,. J� � �u h lti.A.a: cl � Fa���� ,�;�� �S� e � � �- ��tia,. Phone J iJJ i ° ".! Phone ry � y „ •' 0i , .. IMAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY rit3 Name (Jpnrr� N `� ;+ Name Phone " ��►� „, 3 ear Phone This doctrrnent was drafted In oomplisnce with chapter Comm 83421211b11111ft(f) and 83.64111, 121 & (3), Wisconsin AdrrANIttrattive Code. ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank pre sently serving the �+� �L�11,ILja, residence located at: N W W, U W, Sec. �Q �, N, R W, Town of _ l 72V St. Croix County, Wisconsin. Upon inspection, I certify th t I have found the tank and baffles to be in good cond't it appears to be functioning properly. Last time serviced Did flow back occur from absorption system? Yes No line. P Y � (if no, skip next Approximate volume or length of time- gallons minutes Capacity: Construction: Prefab Concrete Steel Other Manufacturer (if known) : tnlQt�cL Age of Tank (if known) (Signat e) (Name)- Please Print (Title) (License Number) (Date) Form 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: In accepting the above statement regarding existing septic tank condition, , I certify that the tank, to the best of my knowledge, will conform to the requirements of ILHR 83, Wis. Adm. Code (except or inspection opening over outlet baffle). Name J �� 1 >blr�ln^{�Q Signature MP f MPRS �aa 9 �y ?74465 P 1 9 ]. U Z s S KATHLEEN H. NALSH REGISTER OF DEEDS ST. CROIX CO., NI STATE BAR OF WISCONSIN FORM 3 - 2000 RECEIVED FOR RECORD QUIT CLAIM DEED Document Number 09/15/2004 03 :15PN This Deed, made between Lynn D. Geurkink Grantor, and Kerry L. QUIT CLAMS DEED Geurkink Grantee. EXWT # 8M Grantor quit claims to Grantee the following described real estate in St. REC FEE: 11.00 Croix County, State of Wisconsin (if more space is needed, please attach TRANS FEE: addendum): COPY FEE: CC FEE: Part of N 1/2 of NE 114 of Section 16, Township 28 North, Range PAGES 1 19 West, St. Croix County, Wisconsin, described as follows: L 1 of Certified Survey Map filed May 2, 1979 in Volume 3 at Page 796 as Document No. 356581. Recording Area Name and Return Address Kerr L. Geurkink 383 North Glover Road THIS CONVEYANCE IS MADE PURSUANT TO A JUDGMENT Hudson, wl saolb OF DIVORCE RENDERED IN THE CIRCUIT COURT FOR ST. CROIX COUNTY, WISCONSIN, CASE NO. 04 FA 133. 040 - 1064 -20 -000 Parcel Identification Number (PIN) Together with all appurtenant rights, title and interests. This is homestead property. Dated this 9 day of September 2004. 8 -D *L D. Geur ink # t AUTHENTICATION ACKNOWLEDGMENT b STATE OF WISCONSIN ) Signature(s) Lynn D. Geurkink authenticated this day of ) ss. Sept , 2004. ,� 0 County ' ; m �jJ ) ln ' �" t� "` � _ Personally came before me this — _ day of u el , * v ew. C i y the above named to me known to be the person _ who executed TITLE: MEMBER STATE BAR OF WISCONSIN the foregoing instrument and acknowledged the same. (If not, authorized by § 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Barbara K. Miller. Miller Law Office, S.C. Notary Public, State of Wisconsin 615 1/2 2' St., P.O. Box 377, Hudson, WI 54016 My Commission is permanent. (If not, state expiration date: (Signatures may be authenticated or acknowledged. Both are not necessary.) ) *Names of persons signing in any capacity must be typed or printed below their signature. QUITCLAIM DEED STATE BAR OF WISCONSIN FORM No. 3 — 2000 " Parcel #: 040 - 1064 -70 -110 08/18/2008 03:58 PM P AGE 1 O 1 Alt. Parcel #: 16.28.19.241 B -15 040 - TOWN OF TROY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 06/20/2007 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co - Owner O - GEURKINK, KERRY L KERRY L GEURKINK 383 N GLOVER RD HUDSON WI 54016 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description ' 383 N GLOVER RD SC 4893 RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 2.001 Plat: 5413 -CSM 22 -5413 040 -07 SEC 16 T28N R19W PT NE NE & PT NW NE FKA _ Block/Condo Bldg: LOT 05 LOT 1 OF - 6�EING CSM 22 -5413 LOT Tract(s): (Sec- Twn -Rng 401/4 1601/4) 16- 28N -19W NE NE 16- 28N -19W NW NE Notes: Parcel History: Date Doc # Vol /Page Type 06/20/2007 853736 22/5413 CSM 09/15/2004 774465 2657/191 QC 2008 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations Last Changed: 08/14/2008 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.001 50,800 181,100 231,900 NO 05 Totals for 2008: General Property 2.001 50,800 181,100 231,900 Woodland 0.000 0 0 Lottery Credit Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 0 Cl) 0 0 c_n 0 m y O d 1 0 CD M T @ �: ° 3 r; cn -I m v z o w G) z x m z o cn 0! s sy 3 N C- OD C ° m c o A c ° o rLl O M C CD K N h�l CD M x° m 0) 4 ^ O O ' U = N 0 CCDD CC] n CD n• O N 3 N Cn O •' T m n D A a v�l z D m a C m i w N C w D G w Z oo O CD ;-n Cn rn m co 00 o N° o y C c N W Ca Q co a 0 0 0 0 0 0 �/1J�[ • - NO OW Em O Cn Z - �f N N y C fA N N? O D N . N CD M w N ° N ' CD p A Ln !'y 3 CD G CCD CD 7 N O - N O w CA N CA ! j i7 CD W 1111 O D co 0 O D =r °•: !V CD N o CA �• N CD N c ( CDC c CD N `L CD CD n - a Cp Ca CD N (6 �' -{ CA .`p Z A U C n n n p C Z -1 03 'U w T N rn G r N T z 1 3 0 z j ° $ m 0 O N Z N CD CD W O N N Q (D d CD cc p .. T co N C Su C G '.. N v N N N co �. y CD O y N O A A 00 6 W a N CD CD 3 ? a CD tv O A A O O A w CD CD i b I � 0 C) o 0 N r { O b I O i O L ti n C2 o ■ t 0 / ± E 0 \ CD / 7 § ' •g§ , 5® - \ e , (D z } / � \ / K CL \ E / % / t ) 8 S 2 Q /$ 7 a 2\ ■ ° 3 - E F/ S E 0 §_C\ © R //� w \ i \ I § 3 o $ � z 10 � \ \ \ / / / CO U o r / � i 0 0 3 7 § < z % > Or o 1 �3 v v \ o 3 �k�\ / (A & / z = z I 0 > \ q 7 ƒ ƒ . ch 10 10 / N Oro @ ° / 2 / 2 CD I : { z [ = Q , � .. j 2 / _ CL z \ k to 7 2 / » I � 2 � ± 0 § ; n 0 % ƒ � ) I ` I � I A I % I 2 I 0 / < § I \ � / k «. ~ AS BUILT SANITARY SYSTEM REPORT OWNER OWNSHIP SEC TjW -R / ADDRESS ST. CROIX COUN , WISCONSIN. M I I , C'sr� 317 ` SUBDIVISION (�-� LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of H63 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM i t 1 f I di at N r h rr w T LI; BENCHMARK: (Permanent reference Point) Describe: Elevation of vertical reference point: Slope at site: SEPTIC TANK: Manufacturer: _ \ Liquid Capacity: OC/ Number of rings on cover Tank manhole cover elevation: Tank Inlet Elevation: Tank Outlet Elevation: PUMP CHAMBER Manufacturer: Number of gallons Number of gal. pump set for a cycle gallons; Total capacity of distribution lines gallon: size of pump _ head; gallon per minute horsepower ;brand name of pump and model number ; Type of warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover ; Type of warning device SEEPAGE PIT SIZE; Number of pits feet diameter feet liquid depth seepage pit inlet pipe - elevation bottom of seepage pit elevation _ feet. I I SEEPAGE BED SIZE: number of line width I lengt tile depth SEEPAGE TRENCH: width length PERCOLATION RATE 6 L ILE AREA REQUIRED AREA AS BUILT INSPECTOR DATED Q PLUMBER ON JOB LICENSE NUMBER F _� DEPARTMENTbF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR &HUMAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.Qz BOX -469 BUREAU OF PLUMBING MADISON, WI 53707 CONVENTIONAL El ALTERNATIVE S f assigned) State Plan l.D.Number: 1 (I ❑ H ding Tank ❑ In- Ground Pressure ❑ Mound ` c NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTIC DATE f q0 R. R. 5, River Falls, WI �7� BE A anem reference polnH r SCRIBE IF DIFFERENT FROM PLAN: REF. PT. E' EV.: CST REF. PT. ELEV.: SE t 1 Troy Name of Plumber MP /MPRSW No.. County: Sanitary Permit Number: a , ei§e =ems 9 S t . Croix J SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLE ELEV.: TANK OUTL T ELEV.: WARNING LABEL LOCKIN COV 1 {IS 7 P OVI ED: PROVI D: 1 1( .� YES ONO NO BEDDING VENT CIA.: VENT MAT L.: HIGH WATER ;, ;` ° ROAD: IPRCFPERTY W UILD G: T(J FRESH 1 ALARM. FEE LIN 2-3 l KE ❑Y ES NO ❑YES ❑NO Ne / � DOSING CHAMBER: MANUFACTURER BEDDING: LIQUID CAPACITY. P P DEL: JPUMP/slPHO NUFACTURER. WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: 71 N 1 No ❑YES ONO [DYES ONO GALLONS PER CYCLE: PUMP A D C S ROLS OPERATIONAL UMBER OF PROPERTY WELL BUILDING VENT TO FRESH (DIFFERENCE BETWEEN ET FROM LI AIR INLET. PUMP ON AND OFF) ❑ LINO _ NEAREST SOIL ABSORPTION SYSTEM. Check the soil moistur at the 9(epthpf plowing FORGE LENGTH: DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire rc structio sh cease until MAlN the soil is dry enough to continue.) , CONVENTIONAL SYSTEM: b �,y WIDTH . . DIA. - . #PITS: LIQUID I - RE � �° TRENCHES. M, AL• IT DEPTH: well +*+G►� ° l.% l q GRAVEL DEPTH FILL DEPTH DISTR. PIP . DISTR. PIPE DISTR. PIPE MATERIAL: NO, DI NU BER OF : PROPERTY WELL: BUILDING: V NT TO FRESH BELOW PIPES ABOVE )VER. ELE INLET. EL END: / PIPE FEET FROM LINE: AIR INLET: MOUND YSTEM: Mound site plowed perpendicular to slope Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM and furrows thrown upslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ELEVA- YES meets the criteria for medium sand. TIONS MEASURED. NO ❑ ❑ SOIL COVER TEXTURE MANENT MARKERS OBSERVATION WELLS OYES ONO DYES ❑NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOI' [7� . D: MULCHED: CENTER: EDGES: Y S NO DYES ONO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: yy� WIDTH. LENGTH: NO. OF LA AL SP CING: RAVEL P H BELOW PIPE: FILL DEPTH ABOVE COVER. TRENCHES'. MANIFOLD PUMP MANIFOLD r ISTR. PIP ANIFO LD MA ERIAL NO. DISTR. TISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING. ELEV.: ELEV: DIA.. LE V.. PIPES. A.: `:; HOLE SIZE HOLE SPACING. DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO APPROVED PLANS. ❑YES ONO OYES ONO COMMENTS] PERMANENT MARKERS: OBSERVATION WELLS: e a PROPERTY WELL: BUILDING: FEE LINE: DYES 1:1 NO OYES ONO N0,41 0 Sketch System on Retain in c unty file for audit. Reverse Side. SIGNATURE: TITLE: DILHR SBD 6710 (R. 01/82) A APPLICATION RTMENT OF SAFETY & BUILDINGS DUSTRY, FOR SANITARY DIVISION LABQR AND' PERMIT P.O. BOX 7969 ,N r HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8% x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must bg shown. All appropriate separating distances and physical characteristics as specified in chapter H -63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, the date, signature and license number must be shown. The owners copy or a legible reproduction of the soil test report must be included. Property Owner: Mailing Addres G c � Ol! oe S� d r o ` &&C Property location: City, Village or owns County: �+ , E' /a ,' %S & /To?r_ NCR A E (or � J1. dro ;x Lot Num�]er: Blk No.: Subdivisi Name: ,o Nearest Road, La or Landmark: State Plan I.D. Number: 7 //I d o `)- S� -gnol ,.�� f'6U�or kd. (If assigned) A TYPE OF BUILDING rt /`7 Number of ❑ Public* ❑ Variance* ❑ Other (specify) Ap _�— Bedrooms: CR 1 or 2 Family * State Approval Required. m 3 J 1 TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER GALLONS OF TANKS CONCRETE PLACE INSTALLATION MENT (Specify) SEPTIC TANK CAPACITY 6 HOLDING TANK CAPACITY LIFT PUMP TANK /SIPHON CHAMBER MANUFACTURER: I t 'PS P_ 7 S EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): 1�i New ❑ Replacement ❑ Experimental 5? Seepage Bed ❑ Seepage Pit /O � (, K 36 El Alternative (specify) E3 Seepage Trench l /7 , e Water Supply: Owne 's Name as Lis d on Soil Test Report (If of er than present owner): Private ED Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Nam of Plumber: I 1 Sign Ire M MPRS o.: Phone Number: ►4 Plumber's Add Z Name of Designer: �J / DO ltolna tT �tJ h COUNTY /DEPARTMENT USE ONLY Sig Wtq re of Issuing Agen Fee: Dat a n Sant ar T'b� ❑ SA PROVED 7� /LJ Reason for Disapproval: Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White- County, Canary- Bureau of Plumbing, Pink - Owner, Goldenrod - Plumber DILHR -SBD -6398 (N.03/81) r i } ROB P•� �� `u 'l C O mom Hi VIE zmrmzs �m• mi .2 f1 / j g p s l til C ,p a � • 4j. � �Q � g T � 1 0. fn 9 r a � r I � I I I I Form - S 'f C loo Owner of Property AW1 Location of Property G' 14E '' -G, S4ct .o)I R W Township Mailing Address 06)11 / v Subdivision Name for S-t 04_ _ Lot Number f ` Previous Owner of Property Total Size of Parcel !— Date Parcel Was Created Are all corners identifiable? _Yes No Include with this application one of the follow .Certified Survey Map .Deed .Land Contract, or .Other I:egal Document which describes the property PROPERTY OWNER CERTIFICATION I (We) certify that all statements or of my (our) knowledge; that I (we) am (are) thi ribed in this information form, by virtue of a wi '.4, 'fice of the County Register of Deeds as Docur hat I (we) presently own the proposed site fo r I (we) have obtained an easement, to run with or the construction of said system, and th in the Office of the County Register of Deeds, as Document No. ), 45-ATURVO OWNER , SIGNATURE OF CO-OWNER (IF APPLICAtILE) � 3 DATE IGNED DATE SIGNED e'r- De L � ' i e?i- kink,husband and _ ek a as oint - - - - - -- ' I A aT t 1. . ._..._...... .. - - -- • .Grantor and -- -- -Riv -mood_ _Construction Co. , , ` - - - -- - - - -- - ------- - - - - -- -- -- -- -- ---- - -- - - - - --- - - -- - -- •- • .._ •- -..- _Grantee, Witnesseti2 That the said Grantor for a valuable consideration -- •- •------- - - - - -- ----------------- _------ •-- - - - - -- •- •• -• -•- _= corve;,s to G-ranfee the follov6ng described real estate in __-St• -.0 rQl-?C -_ PETUPN To Count}, State of Wisconsin: Tax Key tits. ! Lot l of Certified Survey AIap filed May 2, 1979 in Vol. "3 ",Page 796 Part of A of b ro of Section 16, Ta7 mship 28 North, Range 19 f West, St. Croix County, Wisconsin j, i I • t � t d s i is not This _•_______ homestead property. (is) (is not) ! Together with all and singular the hereditaments and appurtenances thereunto belongin Me L D_ . Geurkink and d K . G_eurkink husband us - b and and wi_ �' And.._yl?r?_ - err- L warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except ! i and will warrant and defend the same. Dated this - - - -- ---------- 2 0th ............... day of April 19 83- ------- - - - - -- ---------------------- - - - - -- i (SEAL) - - (SEAL) r f i / -------- (SEAL) ------ _ - -• -- (SEAL) ! !� AUTHENTICATION ACKNOWLEDGMENT iI Signatures authenticated this ___ __ ____ _________ y o day STATE OF W jWS0JZfdN Minne to , - - -- 19 ........ 11' ES. I - -- - - -- Ra -•---- - •- - - County. Personally came before me, this _ ........ day of x _ April 1983- -•__•. the above named ________________________ TITLE: �fEhiBEP. STATE BAR OF WISCONSIN _ L ynn D Geurkink and Kerry L. 7eurk _nk, j (1f not, _- husband and wife i ! a u: ?)orized by § ?06.06, Wis. Stats.) — -- ................ -- --• -•- ------ ! •-- -- -- -- -- -- - --- ------­----------------- ------ -- ---- -- 1 TH,S INSTRUMENT WAS DRAFTED BY ..r„ ;! to me known to be the pe son^"` �ka•eX uted the } P'verwood Construct—ion foregoing instrum t and rk {wledge tl.e same Co, f ----------------- - ___ -_ -__ � 1800 Sv�dale f�rive , t Signatures ma} be authenticated or acknowledged. Both No'.a ublic __ __ ____ _ __ __ _ __ __ "�G are not necessan,) hSy mission is permanent. (If not, state eaa>ratior- r.e ^GOnT r ninp in erg cJpzc,t} F^ t?ped ..7 r ^u; tec t.ai ns. their Fit to rt ., i t EH 115 Rev. 9/76 ` REPORT ON SOIL BORINGS AND PERCOLATION TESTS 9A �Fc�A • WISCONSIN DEPARTMENT OF HEALTH AND SOCIAL SERVICES 4 P.O. BOX 309, MADISON, WISCONSIN 53701 O � / y6` j .�` Af t E. LOCATION: 'I, NE %, Section�,T 1 ? E (or) I�l Township or Municipality Lot No. , Block No. County ? ub i ision ame Owner's /Buyers Name: LJh iA in k. K in. Mailing Address: V S t t TYPE OF OCCUPANCY: Residence 2_ NO. of Bedroo s COMMERCIAL EFFLUENT DISPOSAL SYSTEM: NEW — REPLACEM ALTERNATE SYSTEM OTHER DATES OBSERVATIONS MADE: SOIL BORINGS _ PERCOLATION TESTS SOIL MAP SHEET NAME OF SOIL MAP UNIT 8x'1 PERCOLATION TESTS TEST DEPTH CHARACTER OF SOIL HOURS WATER IN TEST TIME DROP IN WATER LEVEL, INCHES RATE NUM- INCHES THICKNESS IN INCHES SINCE HOLE HOLE AFTEF INTERVAL MIN /IN BER 1ST WETTED SWELLING IN MINUTES PERIOD 1 PERIOD 2 PERIOD 3 P— o D s P -a n A o NE e s s P- V Z ` t AI 'V P- t e6` P- It d G S P— r l SOIL BORING TESTS TEST TOTAL DEPTH DEPTH TO GROUNDWATER, INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, NUMBER INCHES OBSERVED ,ESTIMATED HIGHEST IF OBSERVED IN INCHES TEXTURE, MOTTLING AND DEPTH TO BEDROCK B- D 6'� is B_ !� 7 s I ;? " h / Gr 53 6# S y r B- b" > �o„ n s 5 1L r B- '' A5B r S l 9 3 `'$ 5 38'mcd -S h5 B_ PLAN VIEW (Locate percolation tests, soil bore holes and suitable soil areas.) Indicate on the plan the locati n aDd snuare feet of suitable areas. Indicate number of square feet of absorption area needed for building type and occupancy D .Indicate scale or distances. Give h rizontal and vertical reference poirlts. Indicate slope well_. n r . ? q fled ,<, a , E 3 f _L � s E f 3 z 1 a , _ .._....... __.. c._ } D , .. v. �e r �'►� n r � � � � � _ "" � ' s � � 4. _a } t ; I rp Li i e 1, the undersigend, hereby certify that the sail tests reported on this form werekr4a2fel9y'Ffie In j,ccjrd'A9 the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. Name (print) Uf n Certification No. ✓ L_ '_M20 Address 1661 L r 6 41,15 , Lss, " of installer if known ,y A —Local Authority CST Signature Lim d' �- C ur Own 's name San. Permit No. ' H63.05 PLOT PLAN Show: Im Location of building served A posing chamber Septic tank © Vertical reference point Building sewer El Horizontal reference point 1Z Effluent system Well hot palled Replacement system area Property lines w /in 50 of system Distribution boxes Scale = rL` 'yy , or dimensioned Pump and controls: - Mfr. & Model No. Vertical Lift Size Force Main Friction Loss T. D. H. Vol. Dist. Pipe Gal. per Min. Gal. per Cycle Place check mark in appropriate box, indicating item is shown on plot plan below: fer�. Pu y ' 3 I_ 1�� jai Qj I8 x0 -10 V7 40 x C ED C�? a. x �1'eSen�' �r�ue YL By the granting or approving of the above plan, or upon the event of a subsequent permit being issued, Pierce County and the Pierce County Zoning Administrator, does not assume or hold itself liable for any defects in plans or specifications, plan omission, examination oversight, construction, or any damage that may result in or after installation. 1 A 6 0 , Plumber's signature i ___ 1/ 82