Loading...
HomeMy WebLinkAbout040-1266-50-000 Wisconsin Department of Commerce ° PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division + INSPECTION REPORT Sanitary Permit No: 463411 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'. Paulson, David I Troy, Town of 040 - 1266 -50 -000 CST BM Elev: ` l Insp. SM Elev: BM D ription: Section/Town /Range /Map No: /Q � • o/ /W. � �} m 2� 16.28.19.1447 TANK INFORMATION ELEVATION DATA LI .C74 0 py. 9( .116b TYPE MANUFACTURER CAPACITY STATION BS HI FS EL V f 0 .v Septic Benchmar CGW �, • /., D �Uv �Yt /0zo l da b Dosing` Alt. BM jj-- 2 m4,d i I -9�- �b Aeration Bldg. Sewer / 2 � �Ifo / Holding SUHt Inlet St/Ht Outlet TANK SETBACK INFORMATION - � - TANK TO P� WELL BL3� Vent to Air ` In ROAD Dt Inlet Septic > / 7 Dt Bottom I Dosing Headera2 l / O 2. G ex Aeratio Dist. Pipe 2.18 0 Z. ( Holding Bot. System (Z .9 2. d� / ©/, r 2 d Y ,j Final Grade 6Z PUMP /SIPHON INFORMATION Manufacturer Dema t C ver GPM C �/ (�` jyt �i • yZ S Model Number W Q� q f a 3 TDH Lift / Friction Loss S ste�Hea� T 7 Ft 6y, co Ai�a `7 . Z SS . Forcemain Len Dia. ii Dist. to Well J 11 9 f l SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Tre PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTE TO P/ BLDG WEL LAKE fs /STREAM L CHI u ,,, „ INFORMATION CHA OR U r/ `� Type/Q�f,System: � � � �� � .� T Model Number. 1"1l/ r DISTRJBtqtqN SYSTEM "� U Header anifold l� Distribution f / 1 x Hole Size x Hole Spacing Vent t Air Intake f ` Pipe(s) �' L� f 2 �,./( CO, C / Length Dia v Length_ Dia �' Spacing / `yea _ SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only S U Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed /Trench Center i t Bed/Trench Edges Topsoil Yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1:_ _/ I ns ection #2: /- _ 7 C�5 �r T - Location: 324 Empire Buil ders Drive Hudson, WI 54016 (NW 1/4 SE 1/4 16 T28N R1 6W) Glover Station eil Lot WNo: 16.28.19.1447 1.) Alt BM Description = 101 bf P ." �I a� Le- 1/I. � S(/(,0� 4- }�vrc C r'l ���`' -- 2.) Bldg sewer length = qb -2q / ✓(,v ScS Ul< �+ Gl/ & , fLtMjr AtU R'l - amount of cover = f 3 f L h _ Yes P Plan 3 af��d�f•��- ,� � �i - - - -- d Y - �7 ion' Use others de for additional information. o � � Date - - - - - -I l _ ___- _. �� G�!►1 - - - - -- u _ __ Re Insepctor's ignature Cert. No. SBD -6710 (R.3/97) Safety aW Built ags Division Ctwtuy ` ! 20l W 'Wssfaagton Ave., P.O. Ilm 7162 MAdWM Wl 53707 - 7 162 Preterit Number��ed in by Co.) De artment of Commerce - . (606) 26Cr315! Sanitary Sttgc Plan L D. Rumba i I 2, 03 In word wMa Call= 83.21. Wis. A m Code ` _ � IT r 6.* I provide may be woad for sa:ortdsr) pwp Privacy w, sl lXm) ti0�� Project ( than mailing atkiress) L AptpIllu es Infwmati - pkatae prW AI! Itdtatretieu p� � � � P _ $utl�ss �. Owner's Na me t�V a Parcel d Block +► t wn (7 _ 1 So 6 1 44 7 O M atlarg Address {� PmPxrty s gS� �ut � or rh^ Ko �� �,� City. stm zip Code pip : - J� 0 'A S V 1. - 7 t {CirGIC U. Type o f klhaek am that apply) _ T N; R E or K or 2 Family Dwelling - Number of Bedrooms S Subdivision Name CSM Numbes PubliclCommerciai - Describe Use ` '( V1 AI [ State Owned - Describe Uso i 1Gity [t ownship of Of Pertttdt: (C>KCk sally else boat an Moe A. Ceaaptlete I m B 9 apple) A. New system Q RepiaaxnXU System Q Treatment/Holding Tank Replacement Only U Other Modifx ation to Existing System j i f g. ❑ Permit Renewal ❑ Permit Revisiort ❑ List Previous Permit Number and Daft Issued � Change of [� Permit Transfer ro New Before Eapitailon Plumber Owner r � N. of I'OW`t8 tt'heck ail that } 0 — � g Q Non iaed irrGrourrd 19 Mormd > 24 in. of suitable soil [) Mound < 24 in. of suitable soil U At- Grade ❑ Single Pass Sand Filter FJ Constructed Welland U Prsastrriaed la Grouml U Ftotdmg Tank i. I Peat Finer 0 Aerobic Treatment Unit f l Recirculating Sand Filter Q Reciratla ' S yiatbecic Media Filter ❑ Lcacfuag Chamber El Drip Linn 11 Gravel -less Pipe ❑Other (expiai) I V. DWpftyWTn Aura lutbro atiota: = 161 O Deign Plow (pa) Design S W Application Raa{aAdsn Dispersal Area Required (sf) Dispasat Area Proposed (SKI System Elevation � o t (p> �� /O�� VI.. Took Info Capacity in Total Plumber Maratfacfarrer Prefab Site Steel Fiber Plaztic�� Canons Galbrts of Units Conacte Coastrucmd Glass New Ea istina Tanks Took, j Nofdirtg Teak — t -- -- -- Aerobic Treaunere Unit V �? C t? r + ^ i' CAssibet CIP Va. Rapowibillily Stott 1, tae respeRaiblYty far ' or the 110W" +own an the attae#ed pass. Pi' 's Si lure JMPRS Strsirtess Phone Number ! Abider . State. Zip Code) -� VIM Liar {V e v , t Approved ❑ Disapy Sanitary Permit F ) Fee t' Groundwater Dube Issued I Agent Si (No Stamps) Q Sumbaw Given Reason for D y�2S— 19 2G�S UL C ti A for nbapproval - SYSTE 1 Septic tank, effluent filter and dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code /ordinances. Amcb qn tie Cawnt� wyr) ear t4 tyato M payer wM i� tt+rn s1/2 X 11 iodres its size — __' 1 r i ® AJ - - I � 1� Q' _c.�' i '1�+ T��4�� fi„�:a1'ki fy'f��7 '4 t I t Av i j A { t i • ' j ' f f , , Y t _ A t E i { I s _ ) s �i } I , d ` i t + s 1 i I _1 t� I i � _. pp s I Safety and Buildings C0111111 @I'Ce.WI. OV 4003 N KINNEY COULEE RD g LA CROSSE WI 54601 -1831 TDD #: (608) 264 -8777 isconsin www.w www.commer isco govsb, Department of Commerce isconsin.gov Jim Doyle, Governor Mary P. Burke, Secretary March 29, 2005 CUST ID No.220537 ATTN: POWTS Inspector CALVIN W POWERS ZONING OFFICE POWERS EXCAVATING, INC ST CROIX COUNTY SPIA 1969 185TH AVE 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 03/29/2007 Identification Numbers Transaction ID No. 1122057 SITE: Site ID No. 696251 Derrick Construction Co Inc Please refer to both identification numbers, Empire Builder Dr L above, in all correspondence with the a enc . Town of Troy St Croix County NW1 /4, SE1/4, S16, T28N, R19W Lot: 86, Subdivision: Glover Station 5th Addn. FOR: Description: Proposed Four Bedroom Mound System Object Type: POWTS Component Manual Regulated Object ID No.: 1010314 Maintenance required; 600 GPD Flow rate; 27 in Soil minimum depth to limiting factor from original grade System(s): EZflow Mound Component Manual, (N.6/03), Pressure Distribution Component Manual - Version 2.0, SBD- 10706 -P (N.01 /01); Biofilter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: • This system is to be constructed and located in accordance with the enclosed approved plans and with the EZ Flow Mound Component Manual (June 6, 2003). • The pressure network is to be constructed and located in accordance with the approved plans and with the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems Version 2.0" SBD- 10706 -P (N.01 /01). • The distribution pipe being inserted into the 4" corrugated pipe located in the EZflow product shall also have one out of every five orifices installed at the 6 o'clock position. The remaining four orifices shall be installed at the 12 o'clock position. All pipes must drain fully after every dose. • The manifold and lateral turn -up ends shall extend out past the exterior end of the cells at both ends. The observation pipes shall also be located in between where bundle(s) come together. These requirements must be followed so that the aggregate bundles will not be damaged during the installation process. • A sanitary permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 14 G2 j;, , Stats. Conditi0 (Illy APPROV —r..orzAFNT Of COMRIERCE _ CALVIN W POWERS JR Page 2 3/29/2005 • The area within 15 feet horizontally below the system shall remain undisturbed. Vehicular traffic or soil compaction in this area is prohibited. • A state approved effluent filter is required. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided per Comm 84 product approval conditions. • Comm 83.22(7) - A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. Owner Responsibilities: • The current owner, and each subsequent owner, shall receive a copy of this letter including instructions relating to proper use and maintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or owner's manual for the POWTS described in this approval. • Comm 83.52(1)(a) - The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). • Comm 83.52(2) - A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 Gerard M. Swim POWTS Plan Reviewer - Integrated Services (608)- 789 -7892, Mon. - Fri. 7:30 am to 4:15 pm WiSMART code: 7633 jswirn@commerce.state.wi.us cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 �+`' oArr*rY AND BU14U�try TITLE SHEET DATE: PAGEIOF_S_ MOUND SYSTEM FOR A BEDROOM RESIDENCE This plan has been prepared in accordance with the EZFLOW Mound Component Manual VERSION 2.0 (N. 06 /03)and the Pressure Distnbution Manual VERSSION 2.0 SBD- 10706 -P. (N. 01/01) LOCATED IN THE A)0 /4 OF THE 1 /4 OF SECTION jj,,TA.&N, RJ!J-W, TOWN OF , ST. CROIX COUNTY, WISCONSIN. INDEX PAGE I OF 8 TITLE SHEET PAGE 2 OF 8 PLOT PLAN PAGE 3 OF 8 PLANVIEW CROSS SECTION PAGE 4 OF 8 DISTRIBUTION PIPE LAYOUT PAGE 5 OF 8 PUMP CHAMBER CROSS SECTION PAGE 6 OF 8 SYSTEM MANAGEMENT PLAN PAGE 7 OF 8 PUMP CURVE PAGE 8 OF 8 CROSS SECTION OF E Z FLOW PREPARED FOR 15 s �„ Ir1S P $cv, -9 ,i t..5 P D BY POWERS EXCAVATING INC. 1969 185 AVE. NEW RICHMOND, WIS. 54017 PHONE: 715 -246 -5135 FAX: 715 -246 -5135 CELL: 715 -381 -9920 p1V151GT► �r F(ECEIVED GoRRE ONpEN�E MAR 2 5 2005 sEE SAFETY 8L BUILDINGS l 4 _ P u �- _ z a ` f A S w : 1 t f : t : : 1� : : : d ` Ma Al • . • �. Page 3 Of r . Synthetic Covering Distribution Pipe AS1'M -G33 Medium Sand G Topsail _ F 3 E D % Slaps Bed Of ( Force Main Plowed 0 0 Layer D E Cross Section Of A Mound System Using F E Z FIDU)5For The Absorption Area G nom zo EZFLo W 621 N P 1500Vt.65 P401005ED N A Cv Ft. .ia ear T B 140 Ft. Y Nm r'?J/ 3 K Ft L 1 Ft. j Ft. Position T fir Ft. of W Ft . L Force Main da t + Observation Pipe J K Distribution, Of r Pi 1 Observation Pipe Pion View Of Mound Using A Bed For The Absorption Area y.ry�ucioe. 'ape LOYQUL c�.:. c 3a lr 3 ati vxEf? y � 3.I 3i a U pipe and every .` ti nj f- DOttW —,j .)f` toe pipe F=Rud Eft and at each Ian aP wrah dw use of Ims cum or 43' fut to a gomz *►xtlua fix =Ch" oftbe ftM1 VS& Twousin dw cube(** U9010 W"h a VM1v%'d` ied oap or Onadedplog PwvJ&w=ft &a god R* for &e tale. 1 06ea 1 ed a■p ar &madod pkW r j LAW" r - LAST ORtFfGX 1� FRoM Elyp pF' Gilt. FoK ALL VATCRALS, Ft. F 11L►lt Diameter � InGh S Ft. Lateral ' �� ch4ss x .' l In manifold 4 a Inches Force Me In " Inches t of fro l e3 /D i ps--Oq5 Invert Elevation of Laterals Ft. 4" CI VENT PIPE 12 MIN. ABOVE GRADE E WEATHER PROOF ? 25' FROM.DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR ViTAKE � WITH CONDUIT MANHOLE COV £R Wl PADLOCK E WARNING LABEL MIN . 18" Itt _ . 14LET i WATER TIGHT SEALS GAS- TIGHTi „ A SEAL APPROVED JOINTS W/ CI ;I PIPE B i ALM PIPE 3' ONTO 3' ONTO E , N SOLID SOIL SOIL C + *st RISER EXIT PUMP OFF ELEV . �FT. ♦- _+_ Off PERMITTED ONLY D IF.TANK MANUFACTURER HAS APPROVAL 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE TANX MANUFACTURER: c�z. NUMBER 'DOSES PER DAY: _ TA14K SIZES SEPTIC lap g2 GAL. DOSE VOLUME INCLUDING GAL. DOSE GAL. F LOWBAC K: ALARM MANUFACTURER: CAPACITIES: A = 19,5 INCHES = GAL. MODEL NUMBER: 149.* 1& Arn dom B 2 INCHES = 7/ 2 GGAL. SWITCH TYPE: ut PUMP MANUFACTURER: C = _ z _ ,/ r INCHES = Ar3 GAL. MODEL NUMBER: �5l SWITCH TYPE: D = 9, INCHES 3 GAL, REQUIRED DISCHARGE RATE GPM PUMP 6 ALARM WIRING AS PER ILHR 16.23 WA( VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE g FEET + MINIMUM NETWORK SUPPLY PRESSURE. . . . . .t. g.5 FEET + J &D FEET FORCEMAIN X 3f_ FT /100 FT. FRICTION FACTOR --- S,-3 FEET TOTAL DYNAMIC HEAD = / 9, FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH ; WIDTH , DIAMETER LIQUID DEPTH pOWTS OWNER'S MANUAL & MANAGEMENT PLAN Papa of ,eC 'C 'e- cS 0 NA E RANDIVILAIPM— Dwrw Y Tank 1�Aani �< ° ' SapIft 0' DOW O Holding vd. f exrrdt # 4 J ( n fr? (� S - q3 NA Tang MwwMC t PAMWA IM (3 NA 13 Septic " t1 Holdi V N iumbew of Bedrooms D NA ❑ NA Effluent Filter Manuf r of pt*ft FOGS" Units EffluNt FOW Model 4� CT NA cstirriated ( } fbw PUMP l- Design 1pedd flow (Estimated x t <Sl poop Modal th Q NA Soil AppOcatlon Rata Unit Starndar'd to �dit!! t♦Aorrd�y � O Sar d xi/Crav O peat Filtfar Fats. Oil & Grease lFOta) 530 mgn O Meamucal Aeration O Wetland Wmchamical OxVW Demand MOD.) Sm m O NA glt- Q Disinfa0dix+ O Other: Total Suspended Solids OMS) SI so rii L awereKie pretreated Effluent oUAW Mond* Dwparsd Caws) DNA Biochemical oxygen Demand (BOD.) 130 m g' L O NA p in- Graund (f ) 13 lr'a<ound ) Total Suspended Sd� tTSS) S30 +ng/L Q At -Grade Mound Fecal Coliiform ! � mean) 51 f)" ek,11 t�tkni O Drip a O 000. Y in die. 0 NA D NA Modmon Effluent Particle Size s O NA Zp t%o3 H V tarp effkter+t r; CI NA Othe •Vskos typi� for � wastewater and septic Se"EM" Service 6teq l► Etta) p ws 3 Vows) O NA condition of taaikls) At UNW once every- of tank g Scum one -third artnids iY O NA Wh c op*kwd sludge, and Pea out c+srteda of tank(s) When 4the s lam W ac*d*W � O NA menfln! 3 ) At iaaast once evercY: C] a Inspect dispersal 011018) CLriioeita) O NA At feast once eveay: C7 NA Cleen effluent filter 13 ntoid }la) inspect Pump. Pip coi►ti'ois S alarm At least once evey- 0 NA At 100M once every: 3 ys�iria)) O NA Rush laterals and test O C3 At lest antis every: 13 NA or certifications: MgWTENANCE WSTRUCT' be made by an OeHs shad � canYa►8 one of the following l Servicing o 1purnpo* one of tanks and , POWTS Mai nteineri Septa" Servicingi an v cracks of Master ti f'lurnbar; Master Pluinber p�cted sewer pOWTS e � or broken hardware on the ground Tank inspections must include a viwal e of nd the ! a any for any for any beck up or ponding o f e ffluent # obearvation keeks. measure the "hum of .0 beard � The check the aryl the levels a" surface may' indicate a fan i ng coif so lace. Then d%Persd ce0t snail po of afflu�erit on the ground r oad the irnrteadistm rwdficasdr�n of Uie local ragulrr� V authority- one-third !Ys) or more of the tank volume. tw When the combiner! accumulation of sludge end scion � � Op9wor disposed of in accordance with c hapter NR 113 a Ssptaga entire contents of the tank aha0 be removed by pressurized components, Rrstreatmen Wisconsin Ad"Alw ratwe Code i Sters, rnec ha n AN other aeivices, lnduding but net limited to the swvk*o of effluent certified pOW Maintainer- units, and any servicing at intervals of 5 12 months. shall be perf�withi n1 e vent- o do" of co mpletion of any ssrwr" a A service report sha0 be provided to the local regulatory airtltoritY GMW i2102 . Page START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other chemicals that may impede the tit process and/Or damage the sod cKspersal Collis). If high concentrations we detected he" the contents of the tankis) removed by a SWUGe servicing operator prior to use. System start up shall not occur when sou) conditions are frozen at the infiltrative surface. Ucw{ng extended power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal collie) in one farpe does and may overload them rea<dting in the backup or surface discharge of effhuarnt. To avoid " situation have the contwft of the pump tank removed by a Septage Servicing Operator prior to rasmring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist lo manually operating the pump controls to restore normal levels within the pump tank. tO not drive or park vehicles over tanks and dispersal calls. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade =0 absorption area. Reduction or elimination of the following from the wastewater stream may improve the perform and prolong the life of the POWTS: antibiotics; baby wipes: cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; dsiriectants; fat; M undation drain (sump Pump) discharge; fruit and vegebabla postings; gsaoih'na; gnassa; herbicides; most scraps; medications; oil; P aintin g Products; Pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS tads and/or is permanently taken out of service the following steps shall be taken to insure that the system is Property and safety abandoned in compliance with diaptar Comm 831.33. Wrsaansin Admi gWrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all trunks aid pits shall be removed and property disposed of by a Septage Servicing Operator. • Atter Pumping, all tanks and pits she" be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid materiel. CONTINGENCY PLAN If the POWTS fells and, cannot be repaired the following measures have been. or must be taken, to provide s 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 replatwrrwnt area should be protected from disturbance and cormpacbm and should not be infringed upon by MWJWed "docks from a *dk* and proposed strucrma, lot tunas and waft. Failure to protect the replacement area will raavft in the rod for a new sag and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that tbna. D A suitable rapiacenrsm area Is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a hot resort to replace the failed POWTS. D The site has not been evaluated to identify a suitable repfarximernt area. Upon failure of the POWTS a soil and site evaivatior moot be performed to locate a suitable replacement area If no replacement area is avalable a holding tank may be installed as a last resort to replace the failed POWTS. O Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. of such systems must comply with the rules in effect at that tinge. < < WARMNG> > Sii?Ync, PUMP AND OTHER TREATMENT TANKS MAY Comm LETHAL d3ASSEs AND/OR I CIENT OXYGEN. DO NOT E M A SERM. PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE WTBKOR OF A TANK MAY BE Do I CULT OR MWOSSIKE. ADDITIONAL COMMENTS f'OMiTS INSTALLER POWTS MAWTAfNER Ep", ame Nome S a & Phone sEPTAGE OPERATOR (t" UMPE R) LOCAL REQU1IATORY AUTHORITY Name Name Phone r Vl This doo"em was dratted by the staffs of the Green Wes. Maousits acid Waue#iars County Zoning and Saiitatiori agsriiaies in compliance with cmpter Comm 83.22f2)(b)(1)(d)eff) and 83.54(1). (2) A M. Wisc"win Adrnirticiarative Code. 1 i ! - ' 1 f. - •1 1 { f -'1 1 11 Y II t �i 1 II r lr 1 1 I _ f. f - s f II•. ALO an wwwww a. wwwww ! warwwwuwwwwwwwww r � + � 11+1l �wwwwwwwwwwwwwlw4 lwcrwww iwwwwwwwwr w w- llww�w Nauman l I- I!"'Itz "Mwwwwwwwwww� •wwwwwwwww ww o o f•:- ww Nunes ==sun �s ww �r w wwww■ aawwwwwww�wwwwwwwwww w+�+�ww�r�.;mrwwwewi_,_� _�wwwwwwwwww +�►�� 2:0 ii now as ZZ .' •, O N 0 • i ►`�lwwwsiwwwbowwwwwwwwwwwwwwww *'°'-:•wwwi..ww.7wwww &Nwwwwwww w w w owww lam ww w{ ,,;,Rew,rwww==00 s �I• +:fww► wili�i� lwwwww"Nowwwwwwwwww ��www`�www� f�lswwww. wwwwwwwwww Eggsww� man www asaw►•rw�rwwa•�w,.�. l - -! wwwwww r►wr w►- �ww�►"swww�`swwwwww noftji I"f`.wooft- ww "muw.t. •ww\"wwwwws "= ••�__- -- `••��ws� sw!a,• +ww.�waiwwwww �!►�•:_ w wwwIWMW .�rwws �.�rr wwwww no, was. _- +. \w..�wwwa -�,'rr wwwwa�e ►sww w • ° "am l wwwws.--- l.:awr1.`wiwwwwN►� "ww�w r man =was • � s .. to (� O cm v i CD > cc co 5 Q cm cc C:) ea cr. > CID 18 0 Cq ' o Z * R o' COD "T cl c E .2.4 4 OR At, 4� rA 7 1 E 7E E 0 0 j= ai r I O U 4 1 V1 =n 4. '5 42 w E ZI ta 2 0 4 o 7a 'a L t E rA +01 RS J 0 CJ 0. 0 42 -0 cn Q o C-i W U z w LLJ g:d ts >m z Iw o lu*i 21. _�. _ o $ r y I > 0 T Human bons stry Labor SOIL AND SITE EVALUATION REPORT P 1 of 3 bor and n Relations g Oivisipn of Safety & Buildings - , - T in accord with ILHR 83-05, d(ri" Cpd� COUNTY Attach complete site plan on paper not less than 8112 x 11 inches in size' Plan "must i hde,`but not limited to vertical and horizontal reference point (BM), direction and ef scats or '� P EL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION— PLEASE PRINT ALL INFORMATION R D BY DAT , r I PROPERTY OWNER � 5 f ROP Fs, tON r1 e $ fl�A �1J}�l \ S S C tiU l.j Z i SC J ,S !T ? ,N R tq E ( CW PROPERTY OWNER' MAILING ADDRESS. : 0CITY BLOCK # SUBE) AME OR CSM # Z. S8 lz1l��2S tDE U21uE S'CYt�1ok1 S 1t1b CITY, STATE ZIP CODE PHONE NUMBER ❑ GE ®TOWN ' NEAREST ROAD 1�•lU�(L �PCLL -S w1 Sy,oZZhLS) H.� -S - - $tbt '�Zp`�( �►�►c�tR65�i1�D DR. �(] New Construction Use pC] Residential / Number of bedrooms [ ] AdditiQn to existing building [ ] Replacement Public or commercial describe Code derived daily flow btQ gpd Recommended design loading rate • y bed, gpdtft — trench, gpd/ft Absorption area required S I�X�i bed, ft STY) trench, 11 Maximum design loading rate • 5 bed, gpo1ft — * b trench, gpo1ft Recommended infiltration surface elevation(s) M� - t-1 - C) ft (as referred to site plan benchmark) Additional design/ site considerations r'1outJ�) \,3 ' .B t M ! Q . Z.0 4 01= S fl kn Fi Parent material L. t� MS QUA M Lyrmt�zTwgz Flood plain elevation, if applicable N ft S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDWG TANK U = Unsuitable fors stem ❑ S ®U ®' S ❑ U ❑ S ®U ❑ S IOU ❑ S 19 U I ❑ S Jl>� U SOIL DESCRIPTION REPORT �' Boring # Horizon Texture Structure Con Depth Dominant Color Mottles Stt GPD /ft sistence Bar�d2ry ( Roots in. Munsell Qu. Sz. Cont Color ( Gr. Sz. Sh. Bad re zh — 1Z L `12 313 — S l I Z S 10 Si Ground 3 SO tU `1 12. 613 — LS 6 R — — N� l.►p elev. Depth to limiting factor 7 Remarks: Boring # YYI 42 " IQ 'CIO Z- 11 Z�. 1�`-t2 3l� - s� 1 Z`�b�C ►nff �S � �5 `-b cv Ground 3 u � 9 � 31�c si�� 1>nsb� m� Os • .3 2- elev. y Z9 -yb l U`7P, 613 LSBR — — — !uP ` lip � -] ft Depth to _ limiting factor Remarks: CST Name. Please Print Phone: Arthur L. We erer 715 - 425 -0165 egerer Soil Testing & Design Service —P.O. Box 74 River Talls,WI.54022 Signature: Date: S -9 O O CST Number.. ' 00 - 103.9 ! 22025 PROPERTY OWNER Q`/� l S Cl+U LYZ / SOIL DESCRIPTION REPORT Page? of 2) PARCEL 1.13. # C — Boring # Horizon Depth Dominant Color Mottles in. Munsell Qu. Sz. Cont. Color Texture Structure GPD /ft Gr. Sz. Sh. Consistence Boundary Roots 'x`an =ti'`k Bed Trench 1 z 3 s)� k R 316 - si 1 Z`VS\07 yn �►- �s -S -b Ground 3 1$ z S - .S 3 1y k elev. �ft. y zs-Sb l U`t IZ 6L3 � LS3R VJIP. I Np Depth to O TZi�C(� Gp�I��TI - S limiting factor ZS � • I Remarks: Boring # Ground elev. it. Depth to limiting factor Remarks: Boring # A�t :;,::rw� • rti Ground elev. It. Depth to limiting factor Remarks: 3oring # ;round tlev. ft. )eplh to imiting actor Remarks: _ •rl n•r •rnrf� .�.r �.. n PLOT PLAN Pa of SCALE 1 "= 50 ' W /4.p 6�4 PVC 1'1 �PriZtic�2 PIPS CRLpD ° _ r Oj 3 �� zS !� W I I �l I � 0- - d Lo Lt 00 _� 03 -86 ow� Z ZGISy S -0Q _( 715 ) 4 .5 —o1 h5 CST Signature Date Signed Telephone No. CST # ti f - ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer �� A • LAW 1.-S. ® 6./ Mailing Address `�' WAS -00i1 f- Property Address 2 - �� ®t?L ��c ✓ (Verification required from Planning Department for new construction) City /State AJ0S ° t , V / ' Parcel Identification Number 040- 1 2- to b " 93 —4 4 LEGAL DESCRIPTION ( i1 14� --�) Property Location %4, S '/4, Sec. , T '49 N -R W, Town of Subdivision C C.t "roil, Lot # Certified Survey Map # , Volume , Page # - Warranty Deed # - 7 00 4 S q Volume Z- . Page # Spec house O yes >(no Lot lines identifiable Xves 0 no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and' by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 day of the three year expira ' te. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the roperty described above, b irtue a warranty deed recorded in Register of Deeds Office. SIGNATURE OF APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zon Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed l� 7 7 1 P. 12 0 -7 c3 ID Z+ 15 -. KATHLEEN H. WALSH Document Numbar WARRANTY DEED REGISTER OF DEEDS ST. CROIX CO., WI THIS DEED made between Brushy Mound Partners, LLP, a RECEIVED FOR RECORD Wisconsin Limited Liability Partnership ( "Grantor ") and David A. 03/25/2005 08:30AK Paulson and Patricia L. Eastham, a s tenants in common, ( "Grantee "), WITN S� SETH, that the said Grantor, for valuable consideration WARRANTY DEED conveys to Grantee the following described real estate in St. Croix EXEMPT # County, State of Wisconsin: REC FEE: 11.00 TRANS FEE: 345.00 Lot Eighty- ' (86 lat of Glover Station Fifth�d dition in the COPY FEE Recording Area • Township of roy, St. Croix County, Wisconsin Name and ReUVOW ; 1 Brushy Mound Partners PO Box 445 New Richmond, WI 54017 040- 1266 -50 -000 (Parcel Identification Number) This 1s not homestead property. Grantor, Brushy Mound Partners, LLP, a Wisconsin Limited Liability Partnership, is an affiliate of Derrick Homes, LLC, a Wisconsin Limited Liability Corporation. Grantor develops land and Derrick Homes, LLC is a home construction contractor. Grantor agrees to sell this lot to Grantee on the condition that Derrick Homes, LLC Will be the builder of the home for Grantee. If Grantee does not commence construction with Derrick Homes, LLC as the contractor/builder within two (2) years of the date of sale of this lot to Grantee, Grantee gives Grantor the irrevocable right to re- purchase the lot for the same price as Grantee paid Grantor for it when Grantee bought it from Grantor. if Grantee desires to sell the lot to another purchaser before constructing a home upon this lot, Grantee gives Grantor the right of first refusal to re- purchase the lot for the same price as Grantee paid Grantor for it when Grantee bought it from Grantor. Dated this 241h day of March, 200. R LJOernick ichael R. Stev s AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ST. CROIX COUNTY Personally came before me this 24ffi day of March 200, the authenticated this _ day of 20_ above named Michael R. Stevens and Ronald L. Derrick, as partners of Brushy Mound Partners, LLP, a Wisconsin Lim' ed Liability Partnership to me known to be the persons signature o exe ed the ::z ument and acknowledge the type or print name same. TITLE: MEMBER STATE BAR OF WISCONSIN ` PAM J. RUTLEDGE signature N (If not, ry authorized by ' 706.06, Wis. Stats.) type or print name P%ffiela J. Rutiefte Shft i w V VIsomidn Notary Public St. Croix County, Wiscon n. THIS INSTRUMENT WAS DRAFTED BY - My Commission Expires: July 27th 2008 Brushy Mound Partners * Names of persons signing in any capacity should be typed or PO Box 445 printed below their signatures. New Richmond, W 1 54017 ' 1 r t C- 2• CRE Age _ 113 S.F. 0 NMI 0# 36" W }. +i f111. i it +ilk, ►. gliI,a! i,Y i Y...Y�� 85 y11MM1�Mn! IIM. a1M, i i -�.•- c N e 154 W 2.525 AC S. VOW i N 100 +' • a " _ 8 4 � MO e S 1 50 1 2 * s e 109 S.F. +y, f Trial And Road Map For Glover Station 0 N r _ V _.. nn 10 9 ® 7 6 5 4 (1 � 2 19 20 21 22 23 t2 1 24 13 18 17 +30 31 16 14 27 i s 2e 32 40 35 41 43 39 37 ]g 33 42 34 44 47 46 u 46 50 59 52 53 S4 55 69 49 _._.... 67 ,� ~ 69 57 - 92 70 62 Gv _ -- 91 r 7i 63 90 64 72 0$ 66 74 73 87 79 6p ® 93 75 SCALE N FEET 85 94 95 ' 0 200 400 800 64 76 77 T6 at 83 96 97 e2 EN 1c Co. Civira a Caru1 5urve r�ra wF x' h� 7r,?f 103 1t10 ' i(t2 7111E C.Y. ro0 OUYE L. an P.O. am my R. SCW&VZ NO SNYIM C. SMUT? aO( Tit 7D RTVER f11ttS, R7lp011fFY MW ,,�, ��, �2 srsodRSIM s+�r2s tlA7E: 5- 30'-C)C) 99 -2380