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HomeMy WebLinkAbout040-1297-20-000 i "V(sconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division: •� INSPECTION REPORT Sanitary Permit No: (ATCH TO PERMIT) 429976 0 GENERAL INFORMATION 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: Klancke, Scott I Troy Township 040 - 1297 -20 -000 CST BM Elev: Insp. BM Elev: I BM Description: Section/Town /Range /Map No: 03 . 2t 03.2$ P UC, a CST Qrw Z — 19.28.19. � i TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark %I AFA Dosing v! Alt. BM Aeration vJ Bldg. Sewer t . 13 93• V Holding St/Ht Inlet ,� � • � � TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL BLDG. Vent to it Intake ROAD Dt Inlet Septic ? S '+ f Dt Bott � + 1 , / , • /7 Dosing Oh H T 7 ct� -!• �o2.itb Aeration Dist. Pipe d �� I•t ,•(,� 0�•q l Holding Bot. System PUMP /SIPHON INFORMATION Final �d�; u 14 Manufacturer Demand St over �' GPM LAdr \ � . odel Number q C`j /L(Q. • Q,i>tll �i �. � `C Ok � D � 0 Lift Friction Loss System Head TDH �Ft dr► P,>> 107•Q 2• t b O, to l I ( • SO i 9. Z , A, �1r Forcemain Length D4 r .69 ia., f( Dist. to Well ` 1011 SOIL ABSORPTION SYSTEM -7C1 ('RER40MCH Width Length No. Of T.wael,es PIT DIMENSIONS No, Of Pits Inside Dia. i i Dep IMENSIONS / CID Im I =� SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LE HING anufacturer: INFORMATION CHAM O Type Of System: �� _ j UNIT Model Number: System `0 t (V DISTRIBUTION SYSTEM _ P/L •j,. r•c He anifold DCee ution x Hole ize x Hole Spacing Vent to Air Intake ) Length L Dia Spacing k jy` OVER x Pressure Systems Only xx Mound Or At -Grade SystemK Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil `] Yes L] No i'`J Yes Ll No C$ IV�M� (Incltyd code dis epencies, Person pre pre Inspection,#;: �`t n eetion #2: Location itchel a Hudson, WI 54016 (SE 1/4 SE 1/4 19 8 R19W) Treb ( Va a l y Es tes o � arcel o: 1 .2���— ����{�e� 1.) Alt BM Description 2.) Bldg sewer length = aj v� _► �L - amount of cover = l- •�'•SN6( C Ali, _ y• AFL {1l. PI'a revise equired� Yes �� Use other side for additional information. SBD -6710 (R.3/97) Date Ins t is Signatur Cert. No. CI IfAl� Sanitary Permit Application Safety & Buildings Division In accord with Comm 83.21, Wis. Adm. Code 201 W Washington Ave. PO Box 7302 See reverse side for instructions for completing this application N4 1 sc onsin Personal information you provide may be used for secondary purposes Madison, W[ 53707 -7302 Department of Commerce (Privacy Law, s. 15.04(l)(m)) (Submit completed form to county if not state owned. Attach co m p lete plans to the county copy only) for the er stem, on a s than 8 -1/2 x 11 inches in size. county , State S hazy Permit Number ❑ Check if paws app 'cation ' ta t nl / VT 3 � 9T H G� a r I. Application Information - Please Print all Information Location: Property Owner Name g 200 3 Property Location 5 (��{ 114- 4 -16 1/4, S T-M ,N, R/ Property owner's Mailing A L��1NTY Lot Number Block Number 5A G W mG OFFICE o?� City, S to Zip Code Ph Subdivision Name or CSM Number /9107 7'►''�usdQ.�e '.5z. 3 II. 'hype of Building: (check one) c , Par S w•� S. ❑ City ❑ Vi 1 or 2 Family Dwelling - No. of Bedrooms: own of � ❑ Public/Commercial (describe use):_ / , C) ❑ State -Owned � _ I cZt� • � �N:earest ad Number(s) III. Type of Pe t: Check only one box on line A. Check box on line B if a livable . A) 1. ew- 2. ❑ Replacement 3. L3 5 Replacement of 4. 6 E ❑ dition to El Addition System System System Tank Only Date Issued B) Permit Number ❑ A Sanitary Permit was previously issued IV. Type of POWT System: (Check all that apply) ��� ❑Sand Filter 11 Constructed Wetland • Non - pressurized, ,In- ground 21 ound • pressurized In -ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line • At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other: V. Dis ersal/Treatmeut Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. So il "Ze tion Rate 6. System Elevation pPlastic rade Required Proposed Rate () F' 6 -A: /. v / D /. ,3 (� /S . VII. Tank Capa ty in Total # of efab Site Steel Fiber- Information Gallons Gallons Tanks Con - Con- glass New I Existing crete strutted Tanks Tanks L ❑ ❑ ❑ ❑ 01 0 --;7 � Cl PLro VIII. R ponsibility Statement i, the undersigned, assume respon sibili for installation of the POWTS shown on the attached plans. Business phone Number Plumbe a (print) a Plum s �Sjgeaturo o slam s): MP/MPRS O �� 3 � I R ^ - / ✓ / y / j � p �,s - ��/ s to7o` Plumber's Address ( t, City, St / ate, Ze) �n 14 1 L' � / � o IX. County/Department Use Only C3 Disapproved Sanitary Permit Fee (Inclundwater Date I gin �AgeTntlignatum(NOstamPs) ),Approved ❑ Owner Given Initial Adverse Surcharge Fee) ' 7 l M Determination A X. onditions of Approval /Relsons for isappr al: 1 Ad ac�- r-;e __'Vv"t � h.'o vin % I , er r• , � 50;/ QdQ /ua� "orb / A EledQ�iori w Road / �"� ■ N ok , ioo.(Of A I t. 6. T p 0 I 2" P. ✓. e. e� c 83 11 �_____ Pro posed r4v,,nd a.t I j 0 0 0. / /10.0/ `t / 9. P9 X � ', �' spa ccd at 3. I8' ( /bP`''• k�cn./ . Q 4. j1 / 00. 9' %. C 3 /B`reb4� Elev _ �a7.m: 8 Proposed 1,20 S.T. /A.C• /bel.4- /coo eFF /ue / 4,/c. �I 'Lfa/ 5.T. out/tt. 4rcc l"o n 3 /e4 '1 B 0 4"t o { -t�.�o"�ti � "s�•sf0 ",4. .1. 3031 P ✓,C. T o be Co.,, 5.6 ' c- d z�- co —PIIr t C"nW, 3.2.30(j,)(e,��rosf P�ot`ec�;o"1 uir'e-me(l 6:5, /��o posed / /, o /, 9r do �� bu. %d, �� S. � _ /01.810' P �.7e1 l T o y btdroo.•+ /eesi der�R 0 0 P�. 8 e {g Safety and Buildings j 4003 N KINNEY COULEE RD LACROSSE WI 54601 -1831 TDD #: (608) 264 -8777 iscons www.�mmerc wissb www.wisc isconsnsin.gov Department of Commerce Jim Doyle, Governor Cory L. Nettles, Secretary April 22, 2003 CUST ID No.225036 ATTN: POWTS Inspector MICHAEL P MC DONELL ZONING OFFICE A.C.E. SOIL & SITE EVALUATIONS ST CROIX COUNTY SPIA 340 PAULSON LAKE LANE 1101 CARMICHAEL RD OSCEOLA WI 54020 HUDSON WI 54016 CONDITIONAL APPROVAL Identification Numbers PLAN APPROVAL EXPIRES: 04/22/2005 Transaction ID No. 861853 SITE• Site ID No. 658081 Scott & Angela Klancke Please refer to both identification numbers, 361 Mitchell Rd above, in all correspondence with the agency. Town of Troy, 54022 St Croix County SETA, SETA, 519, T28N, R19W Lot: 22, Subdivision: Trebus Valley Estates FOR: Description: Proposed Four Bedroom Mound System Object Type: POWT System Regulated Object ID No.: 900116 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 Con did chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. APPI R The following conditions shall be met during construction or installation and prior to occupancy or use: DEPARTMENT 0 General Approval Requirements: , Of E • This system is to be constructed and located in accordance with the enclosed approved plans and with the SEE CORRES "Mound Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD- 10691 -P (N.01 101) and the SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST SAS (01/81) • Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area. Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal are prohibited. • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption area. chs. NR 811 & 812c • 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. 145.20(2)(d), Wis. Stat • 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. MICHAEL P MC DONELL Page 2 4/22/03 Owner Responsibilities: • Comm 83.52 Responsibilities. 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. • Comm 83.55 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. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation /operation. 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 Charles L Bratz POWTS Reviewer II , Integrated Services WiSMARTcode: 7633 (608)789 -7893 , 7:45 am - 4 :30 pm Monday - Friday cbratz @commerce.state.wi.us cc: Leroy G Jansky, , Wastewater Specialist, (715) 726 -2544 MOUND AND PRESSURE DISTRIBUTION COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Scott & Angela Klancke 4 bedroom residential mound Owner's Name: Scott & Angela Klancke Owner's Address: 8302 174th St. West Lakeville, MN 55044 Pcl. Add.: 361 Mitchell Road Legal Description: SE1 /4SE1/4, Sec.19, T.28N., R.19W. Township: Troy County: St. Croix Subdivision Name: Trebus Valley Estates Lot Number: 22 Block Number: na Parcel I.D. Number: 040- 1297 - 20-000 Plan Transaction No,: -11 My Page 1 Index and title )Vt® Page 2 Data entry :COMMERCE RECEIVED Page 3 Mound drawings OINGS r p Page 4 Lateral and dose tank Page 5 System maintenances ifications P / APR 21 2003 Page 6 Management and contingency plan ONDENC Page 7 Pump curve and specifications SAFETY & BLDGS DI'V. Page 8 Site Plan Page 9 Soil Evaluation Report Designer: Mike McDonell License Number: 225036 Date: 03/26/03 Phone Number: 715 - 386 -8692 Signature: Z& / ' ! Designed Pursuant to the Mound Component Manual for POWTS Version 2.0 SDB- 10691 -P (N. 01/01), and SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST -SAS (01/81) Version 3.0 (03/01/01) Page 1 of 9 Mound and Pressure Distribution Component Design Design Worksheet Site Information (r or c) R! Residential or Commercial Design Note: Sand fill (D) calculations assume a — Table 83 -44-3 in -situ soil treatment for fecal 400.00 Estimated Wastewater Flow (gpd) coliform of <= 36 inches. 1.501 Peaking Factor (e.g. 1.5 = 150 %) 600.00 Design Flow (gpd) 7.001 Site Slope ( %) 100.69! Contour Line Elevation (ft) 28.001 Depth to Limiting Factor (in) — - - -1 2 0.401 In -situ Soil Application Rate (gpd /ft ) Distribution Cell Information -- _ 0 6.00 Cell Width (ft) 1. .. 100.0 Dispersal Cell Length Along Contour (ft) _ 1._0 Dispersal Cell Design Loading Rate (gpd /ft 1 Influent Wastewater Quality (1 or 2) Are the laterals the highest point in the distribution Y Pre_ ssure Disribution Information network? Enter Y or N (c or e) c1 Center or End Manifold 7 ­ 3 _ 0 ' 0 Lateral Spacing (ft) If N above, enter the elevation (ft) 4 Number of Laterals of the highest point. 0.1261 Orifice Diameter (in) (e.g. 0.25) 3.001 Estimated Orifice Spacing (ft) = 9.38 ft /orifice 2 OO Forcemain Diameter (in) 40.00; Forcemain Length (ft) Does the forcemain drain back? Y 90.00; Pump Tank Elevation (ft) Enter Y or N 6.50 System Head (ft) x 1.3 6.52 Forcemain Drainback (gal) 10.98 Vertical Lift (ft) 90.45 5x Void Volume (gal) 0.61 Friction Loss (ft) 96.98 Minimum Dose Volume (gal) 18.09 Total Dynamic Head (ft) 26.36 System Demand (gpm) Lateral Diameter Selection Manifold Diameter Selection in. dia. options choice in. dia. options choice 0.75 _ _ 1.25 x 1.00 x 1.50 x x 1.25 x 2.00 1.50 x x 3.00 2.00 x L 3.00 x Gallons /Inch Calculator (optional) Treatment Tank Information . 800.64i Total Tank Capacity (gal) 1200 001 Septic Tank Capacity (gal) 36.001 Total Working Liquid Depth (in) -- - -- -- -- - - -- Wieser Concrete Manufacturer 22.24 gal /in (enter result in cell 649) Dose Tank Information Effluent Filter Information 800.64; Dose Tank Capacity (gal) Zabel ;Filter Manufacturer -_ 22.24' ose an _ k Volume (gal /in) A100 Filter Model Number Wieser Concrete Manufacturer Project: Scott & Angela Klancke 4 bedroom residential mound Page 2 of 9 1 Mound Plan View T r . . .. J 1 /F _10 B : • Observation Pipe �J Q 5 A W I ..... �.... . B ... ... ...: .... .............. ... ..... ' I ............... L Mound Component Dimensions A 6.00 ft E 13.04 in H 1.00 ft K gift ft B 100.00 ft F 9.50 in 1 9.03 ft L ft D 8.00 in G 0.50 ft J 4.86 ft W 600.00 (ft Dispersal Cell Area 1 1503.16 (ft Basal Area Available 6.00 (gpd /ft) Linear Loading Rate 1 10.00 (ft) 1/10 B Obs. Pipe Placement Mound Cross Section View Aggregate Dispersal Area Finished Grade 103.15 (ft) —♦ F Dispersal Cell 101.86 (ft) Lateral 101.36 (ft)- - ► — Invert Dispersal Cell •• Elevation E . D A. 100.69 (ft) Contour Elevation 7.0 % Site Slope Geotextile Fabric Cover Shading Key T Dispersal Cell See lateral details on 1❑ Topsoil Cap c = 1.5 ft ;,•, ; Page 4 for number, !lr,r Subsoil Cap ; size, and spacing of ©[ ASTM C33 Sand :� . `'' F laterals. Laterals are m 0.5 ft Typical Lateral equally spaced from ® Tilled Layer y ❑5 0 Aggregate o __l__ the distribution cell's -- A --* centerline in the distribution cell (AxB). Project: Scott & Angela Klancke 4 bedroom residential mound Page 3 of 9 Center Connection Lateral Layout Daigram Force main connection via tee or cross to manifold at any point. Laterals are identical P 5 •= Turn -up m ba II valve or IE X 11<- x12 1 Px1241 La terals & force main of PVC Sch 40 cf ee n out plu g per COMM Table 84.30 -5 Holes drilled on the bottom of the lateral. Number of Laterals 4 Orifice Diameter 0.125 in Lateral Diameter 1.50 in Orifice Spacing (X) 3.18 ft Lateral Length (P) 49.29 ft Orifices per Lateral 16 Lateral Spacing (S) 3.00 ft Orifice Density 9.38 ft /orifice Lateral Flow Rate 6.59 gpm Manifold Length 3.00 ft System Flow Rate 26.36 gpm Manifold Diameter 1.50 in Total Dynamic Head 18.09 ft Forcemain Velocity 2.69 ft/sec Dose Tank Information Locking cover with warning label and locking device and sealed watertight Electrical as per NEC 300 and -► Comm 16.28 WAC 4 in. min. Disconnect _ y Tank component is properly vented Alternate outlet location Forcemain diameter Wieser Concrete Manufacturer 2 in. Cap acityl 800.64 Gallons Volume 22.24 gal /inch A Weep hole or anti - Dimension Inches Gallons B siphon device A 18.05 401.34 B 2.00 44.48 C P� um off e levation (ft) C 5.45 121.30 90.88 D 10.50 233.52 D Total M.00[ 6.00 800.64 Do se tank elevation (ft) 3" Bedding un er tank. 90.00 Alarm Manuafacturer LevelArm Alarm Model Number DLV Pump Manufacturer Zoeller Pump Model Number 98 Pump Must Deliver 26.36 gpm at 18.09 ft TDH Project: Scott & Angela Klancke 4 bedroom residential mound Page 4 of 9 � ` . . . ` � Service Providers Name J. Thompson, PDVVT@|N8P.#481Q | Phone ,---------------'----------- Phone! 715 15-38G'48 O i POVVTSRogu|oto�mNanne i_ G�Cn/k�{�ounty�onmg � nne_' System Flow and Load Parameters � gpd �o�mum|nOu�tPod�eGbe in Design Maximum mg� Estimated F| Average gpo Septic Tank Capacity 1200 gal Maximum TGG 150 mg/L � Soil Absorption Component Size 600 *e Maximum FOG 30 nno/L Maximum mn Facg| Co|ifonn ofu/100 m TypeofVVast�wmter o�nnu � � Septic and Pump Tank Inspect and/or service once every 3 years Eff|umFd Filter Should inspect and clean at least once every 3 years Pump and Controls Test once every 3 ears A|omn � Pressure System � Mound ct for ponding and seepage �once every (3 years - ' | Miscellaneous Construction and Materials Standards � 1. Observation pipes are eJodeU and materials conform to Table Comm 84.30-1. have a watertight cap, and are secured inao shown in the mound component manual. 2. Dispersal cell aggregate conforms to Comm 84.30 (6)(i). Wis. Adm. Code. 3. All gravity and pressure piping materials conform tothe requirements in Comm 84, Wis. Adm. Code. 4. Tillage of the basal area in accomplished with o mold board or chisel plow. 5. The mound structure and other disturbed areas will be seeded and mulched to prevent soil erosion and help reduce frost penetration. Lateral Turn-up Detail � Finished " " °°°°°°" °°°"""° mn*oe O'B''Di et L Threaded �� � —' — ---� Ball Valve Sprinkler Valve Box Distribution Lodeno| Long Sweep 8OorTwo 45 Degree Bends Same Diameter as Lateral Project: Scott &Angela K]oncko4 bedroom residential mound Page 5 o S � Mound System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General This system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall maintained in accordance with its' component manuals [SBD- 10691 -P (N.01/01) and SSWMP Publication 9.6 (01/81)] and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Slats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet fitter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the next service needs to tie performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Department of Commerce. Puma Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Mound and Pressure Distribution System No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October- February) dictate that the mound be heavily mulched as protection from freezing. Influent quality into the mound system may not exceed 220 mg /L BOD 150 mg /L TSS, and 30 mg /L FOG for septic tank effluent or 30 mg/L BOD 30 mg /L TSS, 10 mg /L FOG, and 10 cfu/100 mL for highly treated effluent. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system is provided with a flushing point at the end of each lateral, and it is recommended that each lateral be flushed of accumulated solids at least once every 18 months. When a pressure test is performed it should be compared to the initial test when the system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution within the dispersal cell. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 6 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component(s) shall be immediately repaired or replaced with a component of the same or equal performance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or by removing biologically clogged absorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. See Page)S of this plan for the name and telephone number of your local POWTS regulator and service provider. Project: Scott & Angela Klancke 4 bedroom residential mound Page 6 of 9 1K w HEAD /CAPACITY CURVE S W LL HEAD CAPACITY CURVE EFFLUENT MODELS 1 3. TOTAL DYNAMIC HEAD /CAPACITY PER MINUTE a EFFLUENT AND DEWATERING 32 ,os 6336 SERIES 6738 97 96 IVA 39 161 163 186 185 168 1M t68 l FT M. Gal LIr# Gal. Ure GaL Lts Gal. L.1'1 C1aL 1° Ur* Gal Lae Gal L9a. Gal L6't 04 us. GaL L41, Gal Lv$. 95 — 6 1.62: 43 163.. 56 012 72 '.273 1104 .394 108 .401. 61 231 61 231. 64 210 166 68) 166 697 28 10 106.: 34 128 e6 171 81 - 231 79 300 100 378 61 231 ' : 61 gal 68 230 148 - 600 15t 672 90 15 4.6)' 19 T2 36 f�7 IS/70 64 242 91 3M.. 80 277' 00 227. 68 .'220 142 '637 t4S 549 26 BS 20 410.; 16 ?a 98 38 1 38 82 310 69 223. 00 68 220 136 '816 140 630 26 8 a0 74 250: 67 216 60 4?3:.. 68 7dD Ib '4M 133 603 i+ f60— 30 A14 66 216 08 °' . 55 2 6/ 22D'.. 90 310: 6B 220 of .464 127 Yt 40 27 t86 60 1621 21 BD:: 3J 126'' 61 181 W iN B. 68 2Z0 W 311 100 37p 60 10.2867,. u io 70 2LJf 36 130 61 '210 71 - IIM 96 165 30 114 10 34 62 197. 61 '.193 70 256 '"'_ 14 63 15 170 24 :106 61 204 16 90 27.43 32 121 2 • 37 f40 55 100 30.48 111 SS 21 79 ,5—t— 163 110 3200 50 7 ?e. is 1 30 Lock VaN4: 1826'_ 2176' 1 26' 6a' 66' 97' 73' 116' 91' 112' a5 2 40 EFFLUENT & DEWATERING 35 165 Warning: Model 185 should not be subjected to less 0 30 than 30 feet TDH. b i5 _ 169 Note: For Head Capacity on Model 112, industrial o 6 120 column - explosion proof pump, see FM 219. T. d.f1 _5 0 97 1B8 i — 98 S— ,55, 7,59 13 ,39 SEWAGE & DEWATERING GALLONS 10 20 30 40 50 60 70 8° 90 1°° 110 120 130 140 1 1 1 50 160 WARNING: Model 293 should not be subjected LITERS 80 160 240 0 320 400 480 560 640 to less than 15 feet TDH. N , Q r u g-exl --- LL 24 so TOTAL DYNAMIC HEAD /CAPACITY PER MINUTE 75 SEWAGE AND DEWATERING 22 SERIES 262 2% 387 26B 262 294 292 293 294 295 70 FT. M Gal. Urs. Gal. Llrs, Gal. Ltrs. Gal. Ltra. Gal. Urs. Gal, Ura. Gal, Urs. I Gal L1r5 Gal Lin Gal. L.trs. 20 Ilt 5 1152 90 341 126 484 128 484 128 484 130 492 180 681 UO 530 196 742 225 852 65 10 3.05 60 227 89 337 _ 89 337 89 337 95 360 158 598 124 469 IBI 665 205 776 15 4.57 22.5 85 50 189 50 189 50 189 63 238 135 511 106 401 130 492 165 625 185 700 18 60 20 6.10 10 38 10 38 10 38 33 125 106 dpl Be 333 119 150 150 568 168 636 25 7.82 76 288 68 257 106 401 136 515 153 5E 55 a0 12.19 ° 30 9.14 43 163 47 178 90 140 121 45B 140 530 16 5 79 so 1524 50 189 94 356 115 435 50 60 1829 58 220 89 337 13 49 59 223 14 70 2t.34 25 95 45 lock Valve 18' 2t.5' 21.5' 21.5' 26' JS' IZ' SO' 62' 1T 12 40 35 10 30 6 293 25 6 + 20 1 15 4 282 10 292 2 5 262 266, 267, 268 284 294 295 0 GALLONS I 10 20 I I 30 40 50 60 I 70 80 I 90 100 110 120 130 140 150 160 170 180 190 200 210 220 230 I I I I I I I ___ _ __ LITERS 0 BO 160 240 320 400 480 560 640 720 600 880 ■ Soil eda/uat;"on �� o 00 .1,y a°�°" A ►t . g.M. � Top o-C z" p. ✓. e. 83 ■ I l �-- Proposed ref at //6.0/ bu/f'8 "oriFus 5Pa cecl 1 b C Qnc.) Mnr o o �,� ■ 3 1 8 ° /eb4� Elev _ /00, co' 8 Proposed 1,,ZC()18C0 yob eel" 5.7: /A.C. u7/6 e/ .4 - /00 e 4/ 4rce , 3 /e4v4/ / B 00- O t4nk. - fir dv� v „ Sc./ 10 P. v e. a� R c, occt /cf S.T rq. 3033 P✓, C. Y be Con 5, c,� /ly d 0 ryuire na 1 &S. Se Proposed L.. ci I - - -� o '/ btdr P roposed N' /+Jr do ,-6 l/ bu,' /d,"•,g S. �G = /a1.8(o.' �si der�Ce 6 0 o 0 1514 Wisconsin Department of Commerce SOIL EVALUATION REPORT hAA-f - o z a sr/ Page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Sal & Site Evaluations Attach complete site plan on paper not less than 8% x 11 inch • County ' . Plan must _ St. C robk include, but not limited to: vertical and horizontal ref p(�M , and Parcel I.D. -- percent slope, scale a dimemsions, north arrow, on and'distaln to es road. 040 - 1078- 50 -000, ID#19.28.303 Please print all l " on. , "\ Reviewed By Date Personal MfOffnabDn you provide may be used ary S. 15.Ot CtjS�))• Property Owner Pral�y Wcation J.T.B. Properties, L.L.P. C/O John W. en pt 6 200 1W SE 1/4 SE 114 S 19 T 28 N R 19 W Property Owner's Mailing Address S? C Lot # --'-_;_ Block # Subd. Name or CSW 1564 West University Avenue COUtdT4;`/ Trebus Valley Estates City State Zap ; ,, city J Village or Torun Nearest Road Saint Paul MN 1 55104 Troy County Highway T" V1 New Constriction Use: 1/ � / Nurrilw rooms 3 Code derived design flow rate 450 GPD Replacement Public or commercial - Describe. Parent material Glacial drift _ Flood plain eWmtion, if applicable na General comments and reconxnendations: Recommend installing mound system at elev. = 101.36' at 8" above 100.69' contour. F -] t3onng # 16 Boring 16 Pit Ground Surface elev. 100.72 ft. Depth to limiting factor 28" in. Soil Application Rate Horizon Depth Dominant Cola Redox Description Texture Structure Consistence Boundary Roots .E GPD 1 0 -9 10yr3 /3 none sl 2fsbk mvfr cs 2fm 0.5 0.9 2 9 -15 10yr4 /3 none sl 2msbk mvfr cw 2f,1m 0.5 0.9 3 15 -28 7.5yr4/4 none sl 2msbk mvfr cw 1f 0.5 0.9 4 28 -36 7.5yr4/4 f2f 7.5yr5/8 sl 2msbk mfr gw 1 f 0.5 0.9 5 36.42 10yr4/4 f2f 7.5yr5/8 Is 1 msbk ds cw 1 f 0.7 1.2 6 42-64 10yr5/6 none s Osg di I - - 0.5 0.9 H#6 contains 1/4 " -1/2" hands or 10yr4/4 Om sl at 3" - 6" intervals. Redox concentrations appear at intertface oll extural changes throughout horizon. Loading rate reduced to reflect penniability restriction assoc. with banding. F-1 Baring # Boring Pit Ground Surface elev. 100.80 ft. Depth to limiting factor 35" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD 1 0 -9 10yr3/2 none sl 2fcr mvfr as 2fm 0.5 0.9 2 9 -27 7. none sc l 2m mfr cw 2f,1m 0.4 0.6 3 27 -35 10yr4/6 none Is Osg ml cw 1f,vf 0.7 1.2 4 35-47 10yr5 /6 f2f 7.5yr 5/8 s Osg ml + aw 1f,vf 0.7 1.2 5 47-83 10yr5 /6 m2p 5yr4/6 s/sil Osg /Om duds - - 0.0 0.2 BARS is primarily Osg s with 1/4" - 2" bands of Om 10yr4/6 sil at 4" -10" ir*wvats. Redox concentrations appear within sil bands. Loading rate reflects permiability within horizon. • Effluent #1 = BOD ? 30 < 220 mg/L and TSS >30 _150 mg/L ` E t #2 = BOD <30 mg/L and TSS <-,0 mg/L CST Name (Please Print) Signatu CST Number James K. Thompson s- 3602 Address A.C.E. Sal 8 Site Evaluations -- -- Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, WI 54020 12/5/01 715- 248 -7767 ' Property owner J.T.B. Properties, L.L.R. C/0 John PSI ID# 040- 1078 -50 -000, ID#19.28.303 Page 2 of 3 a #ng Pit Ground Surface elev. 98.29 ft. Depth to limiting factor 33" in. Sal Application Rye Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPOr `Eff#1 `Eff#2 1 0 -9 1Oyr3/3 none Si 2fsbk mvfr C5 2fm 0.5 0.9 2 9 -20 1Oyr4/3 none SO 2fsbk mvfr Cw 2f,1m 0.5 0.8 3 20 -33 1Oyr4/4 none sl 2f &msbk mfr aw 1f 0.5 0.9 4 33-40 1Oyr5/6 f2f 7.5yr5/8 s Osg ml gw 1f 0.7 1.2 5 40 -58 1 Oyr5/6 f2f 7.5yr5/8 s/sil Osg /Om ds Cw if 0.0 0.2 LIA is stratified 2" - 6" bands of Osg s and 1" - 3" bands of Om 1 Oyr416 sil. Redox. concentrations appear throughout horizon. Loading rate reflects mos restrictive permiability within horizon. Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. Sol ppplica,fm Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GROW 'Eff#1 `042 Boring # Boring Pit Ground Surface elev. ft. Depth to Ixrndr►9 factor in. Sol Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDtr `Eff#1 `Eff#2 i I ` Effluent #1 = SOD ? 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, vlease contact the deaartment at 608 - 266 -3151 or TTY 608- 264 -8777. tl �il eyafiC 7 p o PaS�d ® E /e(/icn 8 (� :Sc ah: /': (0' ��. e.n1. T 04'Z "P. ✓,C, P,pe. 3� fi - 1 63 I 3 N N Q � J fr o U pl S� Q q-o� o-r 3 1 L q'/'e�Ar, �s- A S5u,n ed QI = /eZ.Co i I 1514 Wisconsin Department of Commerce SOIL EVALUATION REPORT /c�c -ems` d 2 d Brl page 1 of 3 Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code A.C.E. Sal & Site Evaluations Attach complete site plan on paper not less than 8' /z County St. Croix include, but not limited to: vertical and horizontal refer ppqq��qq(QM , �r ' and - -- percent slope, state or tiimemsions, north arrow, orl Wd�distai►ch to n est road. pares I.D. 040 - 1078- 50 -000, ID #19.28.303 Please print all i on. — B Date Personal information you provide may be used ary pu y�w, S. 15.bRY(1) „QO) ►. MW Property Owner ' ` � Propdify Location J.T.B. Properties, L.L.P. C/O John W. . n Rl 6 200 o vt. dot ' SE 1/4 SE 1/4 S 19 T 28 NR 19 W Property Owner's Mailing Address ST CFO)( ����`�T=rebus 1564 West University Avenue C;Ot1l Valley Estates City State Zip C ; City J Village Town Nearest Road Saint Paul MN 55104 66� 4 7 °y j Troy County Highway F 01 New Construction Use: 01 Residential / Number 3 Code derived design flow rate 450 GPD Replacement Public or commercial - Describe: Parent material Glacial drift Flood plain elevation, if applicable na General comments and recommendations: Recommend installing mound system at elev. = 101.36' at 8” above 100.69' contour. Boring # 16 Boring 28" in. Soft i F Pit Ground Surface elev. 100.72 ft. Depth to limiting factor Appli Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fN *Eff#1 *Eff#2 1 0 -9 1Oyr3 /3 none sl 2fsbk mvfr cs 2fm 0.5 0.9 2 9 -15 1Oyr4/3 none sl 2msbk mvfr cw 2f,1m 0.5 0.9 3 15 -28 7.5yr4/4 none sl 2msbk mvfr cw 1f 0.5 0.9 4 28 -36 7.5yr4/4 f2 sl 2msbk mfr gw if 0.5 0.9 5 36-42 10yr4/4 f2fr5 /8 Is 1 msbk ds cw 1 f 0.7 1.2 6 42-64 1Oyr5 /6 none s Osg dl - - 0.5 0.9 M#6 contains 1/4 " -1/2" bands of 10yr4/4 Om sl at W- W intervals. Red& concentrations appear at Inter ace of textural changes throughout horizon. Loading rate reduced to reflect permiability restriction assoc. with banding. F-1 Boring # � Boring Pit Ground Surface elev. 100.80 ft. Depth to limiting factor 35" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft' *Eff#1 *Eff#2 1 0_9 1Oyr312 none sl 2fcr mvfr as 2fm 0.5 0.9 2 9 -27 7.5yr4/4 none scl 2msbk mfr cw 2f,1 m 0.4 0.6 3 27 -35 1Oyr4 /6 none Is Osg ml cw 1f,vf 0.7 1.2 4 35 -47 1 Oyr5 /6 f 7.5y 5/8 s Osg ml aw 1 f,vf 0.7 1.2 5 47-83 1Oyr5/6 m2p 5yr4/6 s/sil Osg /Om duds - - 0.0 0.2 H#5 is primarily Osg s with 1/4" - 2" bands of Orn 10yrM6 sit at 4' -10" intervals. Redox. concentratbm appear within sit bands. Loading rate reflects postTe9k permiability within horizon. * Effluent #1 = BOD 5 > 30 < 220 mg/L and TSS >30 150 mg/L * E t #2 = BOD <30 mg/L and TSS <_30 mg/L CST Name (Please Print) Signatu - CST Number James K. Thompson G s 3602 Address A.C.E. Sal & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake lane, Osceola, Wl 54020 12/5/01 715 - 248 -7767 Property Owner 3.T-B. Properties, L -L.P. C/O Sohn ParceI ID # 040 - 1078 -50 -000, ID# 19.28.303 Page 2 of 3 3 ] Boring F # 1d Pi Ground Surface elev. . 98.29 ft. Depth to limiting factor 33" in. Sal Application Rate Horizon Depth Dominant Cola Redox Description Texture Structure Consistence Boundary Rood *Eff#1 *Eff#2 1 0 -9 1Oyr3/3 none sl 2fsbk mvfr Cs 2fm 0.5 0.9 2 9 - 1Oyr4/3 none sil 2fsbk mvfr Cw 2f,1m 0.5 0.8 3 20 -33 1 Oyr4 /4 none sl 2f &msbk mfr aw 1 f 0.5 0.9 4 3340 1Oy f2f7.5yr5 /8 s Osg ml gw if 0.7 1.2 5 40 -58 1 Oyr5 /6 f2f 7.5yr5/8 S /Sil Osg /Om ds Cw if 0.0 0.2 is stratified 2" - 6" bands of Osg s and 1" - 3" bands of Om 10yr416 sil. Redo). concentrations appear throughout horizon. Loading rate reflects mos restrictive permiability within horizon. F Boring # Boring j Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Cola Redox Description Texture Structure Consistence Boundary Roots GPDKP *Eff#1 *Eff#2 F Boring # � Boring - - -- Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Cola Redox Description Texture Structure Consistence Boundary Roots *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 m an alternate format, please contact the department at 608- 266 -3151 or TTY 608-264-8777. L /"ro �Iosed ♦ E1e41a6a,-7 ,�� !� ,[1 ��. B.M. TP o� z P. ✓, e. 1 0;pe. ■ `' 8� J 0 a � ■ � AS:5 ¢le% _/40. CO.' I ST CROIX COUNTY S1PTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer SCow`- L ,49610 Kan Mailing Address 83 / 7 5� K :56. La rte it V -A rr+ d . Property Address .3 G/ // 020/ (Verification required from Planning Department for new construction) City/State Parcel Identification Number 00 - ia 97- .20 - 00 0 LEGAL DESCRIPTION Property Location 5 `/4, 5 C_ V4, Sec. - T��11 R Town of Ta V Subdivision T e 6 a.5 1/a //e Lot # 2 Certified Survey Map # 4 A - . Volume h A - . Page # h Warranty Deed # al I 'N 9 , Volume 2t l . Page # 3 �-- Spec house ❑ yes O'no Lot lines identifiable 0 yes ❑ no SYSTEM MAINTENANCE Improper use and maintenanceof your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every time 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 mastorplumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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 maintainednr:s: be completed tad ret'rrned to the St. Croix County Zoning Office within 30 days of the three year expiration date. 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 property described above, by virtue of a warranty deed recorded in Register of Deeds Office. x SIGNATURE OF APPLICANT DATE « « « « «« « « « «« Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Departm ent. �« 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 . Yl • 7 1 1 7 4 9 J 2 1 5 9 P 13 2 X ATHLEEN H. YALSH STATE BAR OF WISCONSIN FORM 2 - 1999 REGISTER OF DEEDS WARRANTY DEED ST. CROIX Co., MI Document Number RECEIVED FOR RECORD This Deed, made between J.T.B. Properties, LLP, a Minnesota 03/03/2003 08:00AM Limited Liability Partnership EXEMPT i REC FEE: 11.00 Grantor, and Scott D Klancke and Angela M. Klancke, husband and TRANS FEE: 344.70 COPY FEE: wife CERT COPY FEE: PAGES: 1 Grantee. Grantor, for a valuable consideration, conveys to Grantee the following described real estate in St. Croix County, State of Wisconsin (if more space is needed, please attach addendum): Recording Area Name and Return Address Lot 22, Plat of Trebus Valle Estates in the Town of Troy, St. Croix County, N�nsin. EAGLE VALLEY BANK, NA 1301 Coulee Rd PO Box 70 040- 1297 -20 -000 Parcel Identification Number (PIN) This is not homestead property. Q$) (is not) Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this mK -y of February _ ' 2003 J.T.B. Properties AJV * * + + AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF ISCONSIN ) ) ss. County ) authenticated this day of Personally came before me this day of February 2003 the above named ' ++ J.T.B. Properties LLP, a Minnesota Limited Liability Partnership 1 ; T cc r.4 TITLE: MEMBER STATE BAR OF WISCO SIN p O g g (If not, = x to me to a erson s who executed the fore oin authorized by § 706.06, Wis. Stats.) in e a cknowledged the same. THIS INSTRUMENT WAS DRAF Attorney Kristine Ogland _ Notary lic, State of Wisconsin Hudson, WI 54016 M C mmissi n is perm ent. (If not, state expir i e: Hudson, may be authenticated or acknowledged. Both are not necessary.) ) * Names of persons signing in any capacity must be typed or printed below their sigrAre. Information P rofessionals company, Fond du Lac, wa WARRANTY DEED STATE BAR OF WISCONSIN 800.555 -2a21 FORM No. 2 - 1999 �"' � 1� . 6- I. - I LOT 1 3 ~ 151952 S.F. I I 3.49 Ac. N I DRAINAGE'-- EASEMENT H%EE = M.F.E. = 890' 887.3' % C P EASEI 3 3 LA �i co W 3 i _� L _ LOT 20 435187 S.F. w L8 9.99 Ac. L7 _ 75 i Lo 1711 o ° 3. � w rn� 1 M.F.I 75 . S 87'30'30" E 1008.34' :ENT S 89'30'; SCAL g ■ , o m g k / \ 0� � 0 ( 0 ° # ) / 2 e k§ 5, E 2; B\ g ' c© Q a o 7 0= k (D k A e § § 2 ; @ t ƒ / 2 ■ ■ § G ƒ Q £ c © E / § (o t " g a / c t 0 J CL / \ § 5 0 r 0) w w 0 g ■ z 0 0 0 .. 2 \ § § § 2 7 k 0 cr § & E E f m . ca g £ N) m E - E @ E 2 ° E § 0 E k 7 § 0 CL $§ q 5 3 2 a _ \ \ CD \ \ z 00 E ; ■ _ 7 f, E # §9 £ &§ , 0. � % f ■ T m § RE a§ 2z 0 Cl) q z $ � f(£ 'D G_ c z )0 % CL � J J E a A $ W G § C $ � B � \ � � � ■ � k �\ . � Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. C rOIX Safety and Building Division INSPECTION REPORT Sanitary Permit No: 429976 0 GENERAL INFORMATION (A�A'CH 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: Klancke, Scott I Troy Township 040 - 1297 -20 -000 CST BM Elev: Insp. BM Elev: , BM Description: Section/Town /Range /Map No: 03.29 ) 03. zz P UCr. a CST %rtv- 2 - 19.28.19. 7l TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing `w Alt. BM OJI Aeration v, Bldg. Sewer l • �3 93• �-� Holding St/Ht Inlet y St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic ? S t Dt Bott / Q (• /Z f Dosing Header�� Aeration Dist. Pipe 5•, Iq Holding Bot. System it 5'. � 1 0 f Z Final Grade PUMP /SIPHON INFORMATION q Manufacturer Demand St Cover GPM 3 b M odel Number 0 Lift Friction Loss System Head TDH j Ft yr► .� 2• tP 6601 l� • So 9. V+ UV► I� • cL s � Forcemain Length D t ia. 1( 10ist. to Well , / ` � +S �Oq (D •Z0 6 SOIL ABSORPTION SYSTEM — ED H Width Length No. Of TsawAes PIT DIMENSIONS No. Of Pits Inside Dia. i id Dep D IMENSIONS / ( A SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM LE HING anufacturer. INFORMATION CHAM O Type Of System 1 �/ -3 , / UNIT t y F Model Number. DISTRIBUTION SYSTEM P/L 4 - Header /Manifold Distribution r ole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacin SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of x xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil -f�Yes ["] No j Yes L1 No CO M T : (Incl4d code dis epenoies, person pre tc.) Inspectio 1: ��+v3 Inspection L� � J�[ � nII. L ratio 361 itchel a Hudson, WI 54016 (SE 4� 19 *8N R19W) Treb Val y Es tes , Parcel o: 19.28.19. (n�� 1.) Alt BM Description = •� . A7 Cho 2.) Bldg sewer length = � A 1 _ _ � � ^ 6 4i - amount of cover 3 Ar Ot PIB revlsi equtred. Yes No I - -- — - -- II - -- - -- - - - - -- - -- - -- - - -L�� -- Use other side for additional information. ' -- __ SBD -6710 (R.3/97) Date Insepctor's Signature Cent. No. Sanitary Permit Applicat Safety & Buildings Division 201 W In accord with Comm 83.21, Wis. Adm. Code W. Washington 302 NA See reverse side for instructions for completing this application Box 7302 . 1" Personal information you provide may be used for secondary purposes Madison, WI 1 5 53707 -7302 Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if not state owned. Attach complete tans to the county copy only) for the system, on a er s than 8 -1/2 x 11 inches in size. Co unty :��' State Spnitary Permit Number ❑ Check if us app cation 4tate Plan I. D Number / fy-s-3 I. Ap lication Information - Please Print all Information Location: Property Owner Name �p03 Property Location S (� 1 /4•--rC I /4, S TdS ,N, N fady Property Owners Mailing A lX GQUNTY Lot Number Block Number 3 6 � 2, � d ST CRQ G QFFIG City, S to Zip Code Pho Subdivision Name or CSM Number (o �v- /9107 7'►- '�us�/a,�e �",s�. 3 II. Type of Building: (check one) ❑ Vi a� Per 5 w•: S. ❑ City 1 or 2 Family Dwelling - No. of Bedrooms: own of • Public/Commercial(describe use) :_ rU • State -Owned ' l — I L30. (o Nearest Road3 (o/ ,q/. W�, l'e'u`•� m-� � r Y ' I Parcel Tax Numbers) Q f(Q- „,-J0 III. T e of Pe t: Check only one box on line A. Check box on line B if applicable - r rB)]2. ❑ Replacement 3. ❑ Replacement of 4. 5. 6. ❑ Addition to S stem S stem Tank Onl Date Issued Existin S stem ❑ A Sani Permit was previously issued I Permit Number IV. Type of POWT System: (Check all that apply) • Non - pressurized In- ground ound ❑ Sand Filter , ❑ Constructed Wetland • Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Drip Line • At-grade ❑ Aerobic Treatment Unit ❑ Recirculatin ❑ Other: V. Dispersal/Treatment Area Information: — GD 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed Rate (GaIsJday /sq. ft.) (MinJinch) / Elevation (.�� �s� �. � � 1. r) o. t'1 / a / 2 ( o 103.1,S VII. Tank Capa6ity in Totaiv # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con - Con- glass New I Existing Crete structed Tanks Tanks ❑ ❑ ❑ ❑ Tel Se-/ �' nc - ❑ ❑ ❑ 8ca -- 8'00 ���>k 6;.►�->� �� VIII. Rlsponsibilfty Statement I, the undersi ed, assume responsibility for installation of the POWTS shown on the attached plans. Business P; arc t�urnber Plumber's Name (print) Plum s �ature o stamps): MP/IvIPRS No. �� er �/ �� / 4 /Y re (71s- Plumbees Address (Spbot, City, State, Z' e) 1 L(A" &-� IX. County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued XAgent Signs (No stamps) Approved 0 Owner Given Initial Adverse Surcharge Fee) . 2 2S �- Determination J ZIVE X. /Re of Approval JRe sons for isappr ai: r S L lnna%�vcro t^nxa c'° p-er IM4 'eta �i y l ■ 50 ;/ 2da /ua�'o,� 1 / � EIeJQ fiort w - -xaA:/ mad �� ov �-� ■ >r Top a� z" P. ✓. e. 103 29 B3 ■ 1 .- --- P r o pose d r4c at , j 00.69 /9. P9 'X / /lo.�/ ��/ l0 X /60 I i t o dr"5 &i bu -Eton (a tea FS a t 1X 1'X 4l9. As "or ;F'e.es / 00. 9' %. C Qnc-h Mark : 7 of \ � ■ 3 /B�r'eb4� Elet! _ /G�.CY�: g Proposed S.T. ho 4a6 e l �4 - rte e FF e- t S.T. ou tlr sub 4/0 A/C. P /Y(ai n 3 /ea vecl i n B o u.'t` o f ton �. Y be cons�rk��o' 69 C—P /j' �'�` Coi►'Jn/. 81.30C� �l�Clif GM�I�S. Pao postd N,� P ro posed Loci1 T • y (jtdr ILI � o 0 i i