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HomeMy WebLinkAbout040-1088-60-000 I Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 453417 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: Albert, Dean I Troy, Town of 040 - 1088 -60 -000 CST BM Elev: Insp. BM Elev: BM Descriptio Section/Town /Range /Map No: UO 0 /00. o � j 23.28.19.357D TANK INFORMATION U ELEVA ION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark �o �L /� Alt. BM Po �v Aeration h� �/ Bldg. Sewer q ` I 7dz<, to ✓ �. Holdin r R _ St/Ht Inlet Y TANK SETBACK INFORMATION Ht Outlet 7.16 TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt I t SCf-( Septic l 5-n _ ( Dt Bottom ��1 N r� in -2 /� 'Ad_ ader /Man. ^ I � CA Aeration � q� Dist. Pipe ' 1 f (� m jot d /— -i J Holding 13 S l em � � C n 3• l'S PUMP /SIPHON INFORMATION Manufacturer Demand St Cover r7 / GPM 2 2 Vl too- Model Number TDH Lift Friction Loss tem Head TDH Ft Forcemain Length ia. Dist, to We SOIL ABSORPTION SYSTEM BED /TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L JBLDG 1WELL LAKE /STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header /Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth of 1 xx Seeded /Sodded Mulched Bed/Trench Center Bed/ Trench Edges Topsoil Yes 0 r No 0 Yes E] No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / s O / Inspection #2: Location: 296 Old Hwy 35 River Falls, WI 54022 (NW 1/4 NW 1/4 23 T28N R19W) >35 acres Lot Parcel No: 23.28.19.357D 1.) Alt BM Description = (� 2. r �r7bY c� t (� - C� {02 : L? 2.) Bldg sewer length = 25" ,/ - - amount of cover = �' y am, {�Q,(.0�Gt /1 Plan revision Required? ❑ Yes No Use other side for additional information. SBD -6710 (R.3/97) Date Insepctor's Sign ure Cert. No. , cov w e County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN `0 � In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT Personal information you provide may be used for se ary rpos s ST. CROIX COUNTY GOVERNMENT CENTER [Privacy Law. S. 15.04(1)(m)) 1101 Carmichael Road $O Hudson, WI 54016-7710 (715)386 -4680 Fax (715)386 -4666 Attach complete plans for the system on paper not less an es in size. County Sanitary Permit If ❑ Check if revision to previous application —5 TC — 1. Application Information - Please Print all Information Loc tion : Property O Namep `J— W 1/4 ti 1/4, Sec a3 b_EA y + 1 �\( LLIS L.` r �N, R E(or Property Owner's Mailing Address tj L UUU Lot mber Block Number C OUNT City, City, State Zip Code Phone Nu er ZONING OFFICE ision Name or CSM Number i�c vk_R F�CCS �r 5Y ©2a 7lS = a 5 ` II Type of Building: (check one) City ❑ Village Town of 7 1 or 2 Family Dwelling - No. of Bedrooms: ❑ Public /Commercial (describe use): ❑ State -owned Nearest oad II. Type of Permit: (Check only one box on line A. Check box on line B if applicable) S 9 , 6 3 Pa Tax Number(s) A) 1 Repair 2.< Reconnection 3. ❑Non-plumbing 4. E] Rejuvenation L Sanitation 0 (o � 60 ' 0 B) Permit Number Date Issued State Sanitary Permit was previously issued JUL a aid IV. Type of POWT System: (Check all that apply) K Non - pressurized In -grow d ❑ Mound ? 24 in. suitable soil ❑ Mounds 24 in. suitable soil ❑ Mound A +0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Other ❑ At -grade ❑ Aerobic Treatment Unit ❑ Recirculating . Dispersal/Treatment Area Information: 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System Elevation 7. Final Grade Required Proposed (Gals. /day /sq.ft.) (Min. /inch) Elevation L 1 d 010 - `''� r ' 5 q31 s f 3, C-3 I. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete structed glass Tanks Tanks c so i �S ra' ❑ ❑ ❑ ❑ t loo/ W IF_S > g ❑ ❑ ❑ ❑ ❑ II. Responsibility Statement I, the undersigned, assume responsibility for repair / reconnenction /rejuvenation/installation of non- plumbing for the POWTS shown on the attached plans. A license is not required for terralift repair or the installation of non-plumbing sanitation system. Plumber's Name (print) PI 's Si atu (no mps): MP /MPRS No. B giness Phone Number Plumber's Address (Street, City, State, Zip Code) r;W '106 a v w y to M4a;D8AJ 1�_yal 6 VIII. County Use Only Disapproved Sanita Permit Fee ate Issued ISS ' g Agent ignature Approved Owner Given Initial Adverse 2�_ q Determination IX. Conditions of Approval/Reasons for Disapp� val: 2 U - 0y Coo ..kxG Cow- �~'.�. D�� n�i►� -tea' ��.d�;�:f � - 7 4 0 44"zAt tt :r C V, Q 0 n V IM A 0 3 ?7 -4. O C� t o M s- 2 d �. }/ a r: w 0 D z m z z m �y 0 O m p n X X m ,— x O C/) C/) m"'► O m. m m cn 0� ~. O r - � r m - ° C - n 0 p X ° 'N , r O m -� �� O D 0 c D r G) D� _ n m 0 X m zD m z o C/) Z z 4 p r � c0 ;U O ;u -n U) c Q to C 0 z z < — m o cn � U` C7 o z -n p Z z m Z '`� �Q m m . 0 3 Er r m% 3 E1 3 m° v o w m v c�� ��-� ��� a n o o m o' m� o m o D N 3 flt SU N O N o y . m S N (� n n b CD < � (D t ^n Z _ fn CD m �� lD o- o 3 3 C r :3 0 X X y N SU y y 7 co y g - (D 'm 0, 0 :3 �; :3 : m v, m o o _oa n 42 0 N' o v n 3 �' g N m m m d 3 m 3 3 = co v v o D tD < FA vi m C ° v o C �,° m v, o �v (j) m s ? D3 co 0 �° =3 ` .. `� - p � C7. r . 3 v o' o v y m C? p o v, = c < D o Z o •• C > >ov o; m� i , ' m Z r Z mo o i� WZ - c m a v, :5 d o = , D D C) m M I ID -o a m 3 v m y :- m m SR =r 9 o m v a c o '- Z Z 0 Z x 3 d 3 to n s CD v m v m o m ❑ ❑ N ❑ m a Document Number Document Title * 8 8 1 7 4 6 2 St. Croix County KATHLEEN H. WALSH REGISTER OF DEEDS Occupancy Affidavit for Common POWTS serving ST. CROIX CO., WI RECEIVED FOR RECORD Multiple Dwellings 09/23/2008 09:45AM AA AFFIDAVIT ✓� N T' EXEMPT # Name — (Owner) Typed or printed REC FEE: 13.00 being duly sworn , states, under oath, that: COPY FEE: 3.00 PAGES: 2 1. He /she is the owner /part owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume Page O s Document Number St. Croix County Register of Deeds Office: Recording Area A parcel of land located in the W % a of thePW % a of Section a, Name and Retu A dress T_ N — R W, Town of b'OQ of /. , 4 P A e Q � � C- act (a S St. Croix County, isconsin, being duly descri ed as follows (include lot A Ue2 F /Is cart 6 D ZZ no. and subdivision/CSM or detailed legal description): 0 -- O- MOO A -TUCR � Parcel Identification Number (PIN) 2. As owner of the above described property , I ackn ledge that the common private onsite wastewater treatment system ( POWTS) serving this residence is sized for bedrooms, or a design wastewater flow ofGPD /dwelling. The design flow is calculated by assuming 150 GPD with 2 persons per bedroom. There are currently _ occupants living in this residence; the maximum permitted occupants /dwelling is i � based on the design wastewater flow. Therefore the POWTS serving multiple dwellings is currently code compliant. However, I understand that if the number of occupants /dwelling exceeds the design flow, the POWTS will need to be modified to accommodate increased wastewater flows and/or contaminant loads. I also acknowledge that I will make this information available to any future parties interested i p chasing this property. Dated this `Z 3 day of 5 , 2 00 W r AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )ss. St. Croix County. ) authenticated this day of Per Wally came before me this � day of th b amed A ILI TITLE: MEMBER STATE BAR OF WISCONSIN to me rntown tg l' , (If not, the person(s) who executed the foregoing instrument and acknowledge� h\ authorized by § 706.06, Wis. Stats.) same' THI INSTRU WAS DRAFTED BY+, G w- i � k rs. /* A� � u rN C_ Notary Public, State of Wisconsin 1 (Signatures may be authenticated or acknowledged. Both are not My Commission is4Pvrffm=nt. If not, u lei '11a'Te: 4 necessary.) Date: "THIS PAGE IS PART OF THIS LEGAL DOCUMENT — DO NOT REMOVE" This information must be completed by submitter: document title name & return address. and PIN (if required). Other information such as the granting clauses, legal description, etc. may be placed on this first page of the document or may be placed on additional pages of the document. Note: Use of this cover page,adds one page to your document and $2.00 to the recording fee. Wisconsin Statutes, 59.517. The NEB- � 4 of the NE of Section 22 -28 -19 except for that portion of the parcel of land described In Volume "2" of Certified Survey Maps page 304 as lies in said Forty, and except for a parcel of approximately .37 acre in the SE corner of said Forty, said parcel being described in Volume "302 ", page 233. The NW4 of the NE4 of Section 22 -28 -1 That part of the NW,L, of the NW4 o Section 23- 29 - 19, lying W of STH "35" except for that portion of the parcel of land described in Volume "2" of Certified survey Maps page 304 as lies in said Forty and except for a parcel of approximately 1.18 acres in she S side of said Forty, said parcel being described in Volume "302 ", 283. A w> ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND (� OWNERSHIP CERTIFICATION FORM Owner/Buyer OW hOb POL LI � Lt3EJt Mailing Address � - l � S 4 T f E Pdftb 3: Property Address 91 � I , I -r L Ro A-b 3 (Verification required from Planning & Zoning Department for new construction.) City /StaJ F 5 WZ- Parcel Identification Number 93. a K. (1, 3 S - 7.Q alb logf- 6o -o LEGAL DESCRIPTION Property Location " /4 '/a , Sec. ? , T N RA—W, Town of ;� 1 � Subdivision , Lot # Certified Survey Map # , Volume , Page # c� Warranty Deed # yAqq , Volume 77 , Page # Spec house yes ( no ) Lot lines identifiable (:Y� no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & 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. I/we, 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 Planning & Zoning Department within 30 days of the three year expiration date. 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 N er of bedrooms + fc La-6? SIGNATURE OF APPLICANTS) DATE ** *Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. * ** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) Doc;u WIEN NOe, ii ST A TE B OF WISCONSIN FORM 3- 1.82%t� TRIS SPAGR RESERV£O FOR RECORU{NG ORTw 1 I QUIT CLAIM VEEiD 429963 -- II eou 790 PACE 405 13 OFHOE 4! Production Credit Association of Noe thwest S7iscox -�sin E �` �•+ I -------------- --- ••- - --- --- •-----------•--- _ former ty knower as a rG.�LC "1 L_ cu • Rr awd this 8th reeve" i�_l 13 quit- claims to _Dezn __W,._ Allier* ,and . Phy_llis _ °,__Albert,__ hus�anc� 'i 8: 30 At& j and w - -- --- and_ eacn__in__their -. own - • right : _ ---------- __ ____________________ • q is �l -- f' 1 r --- --- -- - - -- - •-•---- - -•-•--• -------------------------- ( lcykfor 0 --- •-•---- ----------- - ---- --- --•- ------ -•---° --•-.._- ....- - - ---• �! .,.rti _ailoa ^ne da =crihvd real estate in ----------------- 5 VL- zt ....... ----- State of Wisconsin: Tax Parcel No: .............................. i 4 The NE4- of the NEE* of Section 22- 28 -19, except ^ nv nl of land described In Volume "2 °C of certl d Sur ey Mere Page - as lies In said Forty, and except for a parcel of approximately 37 acre in the SE corner of said Forty, said parcel being described in Volume "302 Page 283. The NW of the NE4 of Section 22 - 28 - 1 That part of the AW o•f the NW of Section 23 29 -19, lying W of STH 1t 35"' except for that portion of the parcel of land described in Volume "2" of Certified survey Maps page 304 as lies in said Forty -and except j; for a parcel of approximately 1.18 acres in the S side of said Forty, said parcel being described in Volume "302 ", page 283. I This ...__1 not..- _- ._. -.. homestead property. - ( (is slot) (Dated thie -- --_---- 4th Se tember , 19. 8! -- ---- - --' -- ------ - - - - -- day of ... ....... -' - -. -�. _- E -- ------- (SEAL) - �t9 ?"� Y,".------- ,-.---' ....... (SEAL) - - ---- - Paul Moe, Regional Manager ----------------------------------- (SEAL.) ------------------------------------ .. ... ....---------- ----._...(SEAL) " - ---•------- --------•-----•- - ......... - - ----- ---------- - ------- - -. ......... .._....... --- .... AUTHENTICATION ACKNOWLEDGMENT Signature(s) ------------ ----------------- ----------- ........ ........... STATE OF WISC0 - - -- --- -----• ) - ------- -- ...- _'S t,___CrQi�i___..County. authenticated this __- ---- day of --- ------ -- -- ---- - --- - -- --- 19 ------ Personal came before me this --- -4tai- ...... day of _ -_ September ___ - - , ,p_87 - __ the above named � ----•-- --------------• Paul_ 2:ce�__Regiopa .._Manager............... TITLE: MEMBER STATE BAR OF WISCONSIN -------------------------------------------------------------- (If not, __ - - -- authorized by § 706.36, Wis. Stats.) to me known to be the person ..- ......... who executed the forexoing instrument and ackrowledgn the same. -i a n. ..0 %F1 i r"C nv i, '/ CSGIVI 1 n. ._. ,... _.. ,...� .tee , v^ vrod,irtinn Credit Assn of Nta WL Rer.ita A. i -li teG ,• - - - Ui = �'•� i'- _ Secretary Pierce Notary Ptiblio +tourer r, iv s. .... . -... -_ ..- , .. -r.r, r.n �.. ,,:.::�'--'-- • ., _... rr is r rt �_ r i" 'ti grrtn. n. • C... r., o:R r.i ��, n ♦ .n. n [ .:.1 1.. r.. e. -.i 1.. ,.. v. , 1,. ,: - C .., .r a >+Y ra, .,.r r..r..r „ny rrt .., , r�t,Kn ' fir.. • i _ -�t „rev' .... �:,;�!; N.. Y Z()n3 1813 Wisconsin Department of Commence SOIL EVALUATION REPORT Page 1 of 3 Division of Safety and Buildings in axordance 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 include, but riot limited to: ve and horizontal reference point (BM}, drcection and St Cfouc r" percent slope, scale or dimemsionns, north arrow, and location and distance to nearest road. Parcel I.D. 040-10e8- 60-000 , w4wed By Date Personal intonrra6an you may he l.ew, s. 15.04 (1) (m) ?. za Property Owner Property Location Dean Albert JUN 2 3 2004 Govt Lot NW 1f4 NW19 S 23 T 28 NR 19 W Property Owners Mailing A Lot # Block# I Subd. Name or CSWf# 296 Old Hwy 35 ST. CROIX COUN i City CrTy A Vloage 1I Town N Road River Falls i WI 1 54022 715. 425 -7907 Troy I Old Hwy 35 A New Con*uction Use: Residential i Number of bedrooms 3 Code derived design flow rate 450 GPD Jd Replacement Pubic or coninierc ial - Describe: Parent material Glacial outvvash Flood plain elevation, if applicable na General comments and nxorrunendatbns: Install three trenches at elevation = 93.50' or higher, using 30 leaching chambers. Dose chamber may be needed to reach system elevation. BorbV Pit Ground Surface dev. 98.05 ft. Depth to 6rgft factor — in. Sol Application Rale Horizon Depth Dominant Color Redact Descriprion Tertiure Structure Consistence Boundary Rails GP )ff �j in. Mmrsel Qu. Sz. Coot Color Or. Sz. Sh. `Eff#1 1 0-12 10yr2/1 none 1 2fgr mvfr gs 21' 0.6 0.8 jpD I f 2 12 -21 10yr414 none sl 2rsbk mvfr CW 20m 0.6 1.0 3 21-30 7.5yr416 noire sl 2msbk mvfr CW 1fm 0.6 1.0 4 30-62 7.5yr4115 none we 0 sg mvfr aw 1vff 0.5 1.0 5 6292 10yr5a none strat gr s 0 sg ml gi - 0.5 1.0 6 92 -105 10yr5M Y2f 7.5yr518,, gr s 0 sg ml - - 0.7 1.6 Mcz_ & 5 IM - T Writgular discontlnuous bands of 10yr4f4 #s. Loading rate of H#5 reduced to. pernreebiitY ree#uiction aat+ocialed wRh banding- Q # So" PR Ground Surface elev. 98.67 IL Depth 10 knbV far-b >W in. 3ad Apps Rob Hlmm Depth Worwd Color Reft Description Taxtiae Structure CoMmience Boundary Roots GPQ P in. Mursei Qu. SL Call. Color Gr. Sz. Sh — TM I TIM k p 1 0_15 10yr2l1 none all 2fsbk mvfr gs 2f 0.6 0.8 2 15-25 10yr414 none so 21sbk mvrr CW 2f,1 0.6 0.8 3 25-38 10yrW4 none a 2fsbk mvfr CW 1fm 0.6 0.8 4 38 §9L 7.5yr4J6 none FS 0 ag mvfr aw l of f 0.5 1.0 5 66-98 10yr5f6 name strat gr s 0 sg rill - - 0.5 1.0 5 oontaeu 1/4" - T Rfagular, Of 10yr414 IF& Loading tale of M5 neduced b 1~ pemreabtlRy reebidion aesociaied rnitln banding. • 131luent #1= WD W < 22D mg& TSS >W < 1 "WL ' OW" = BOD < W not and M <-0 wa& CST Name (Please ft" CST Number James K Thompson 3602 AddrWS A.C.E. Sort & Site Evaluations Dee Evaluation Conducted Telephone Nna im 340 Paulson Labe Lane, WI 54020 6/1$!2004 715- 248 -7767 r Property Owner Dean Albert Parcel IDS 040-1088-60 -000 Page -- L - d 3 BorkV EE jm # A Boring Pit Ground Surface elev. 98.65 ft. Depth to W&V factor >10r in. Sol APpketim Rate Horizon Depth Doinkied Color Redox Desaiptim Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz Cont cola Gr. Sz. Sh. 'E-m 'f-2 1 0-22 10yr2/1 none so 2fsbk mvfr gs 2f,1 me 0.6 0.8 2 22-29 10yr4/4 none 81 2fsbk fftvfr cw 2fmc 0.6 0.8 3 29-39 10yr5/4 none 81 2fsbk mvfr Cw lfmc 0.6 0.8 4 39-7Q. 7.5yr416 none ifs 0 sg mvfr aw l of f 0.5 1.0 5 70-101 10yr516 none strat gr s 0 sg ml - - 0.7 1.6 BorkV A Pd Ground Surface elev. R. Depth to knbV factor in. Sol AWcWm Rate, Horizon Depth Domirm" color RedOK Desaip m Texture St wbxe Consistence Boundary Roots GPDNF in. Wad QU. Sz Cont. Color Gr. Sz. Sh. 'EfM '01*2 B Pit Ground Surface elev. ft. Depth to lk,dk factor in. Sol AWcdm Rate Horizon Depth Dominant Color RedoxDesaip m Texture Structure Cons'steme Boundary Roob GPM in. Qu. Sz Card. Color Gr. SL Sh. *M 'EM2 ' Effluent #1= BOD 30 < 220 mglL and TSS >30 < 150 mq& ' Effluent #2 = BW 30 rnWL and TSS -_3D mWL The Department of Commaac is an equd opportamihy service provider and employer. If you need asmstom to scc= wrvwm or nwd maUmW in an shmnste format Dleew contact the department at 608- 266-3151 or TTY 608- 264 -8777. ® Eteda� ion ' lee (ihe tieare -5 / Orap /,; - n . N 71.7 7 "old,lwy. 3s �Pe P /3 4.; 79f o ost. �b Sy.34� B3 � Proposed rg4item nb 61 d is peridJ cell. -- ---�►- ,' 4 17 5 1- pe t�iroc�( ' 5r.S;6e, -7 area. BZ Af C 7m o F i �4,oprer. /Oc- d:&Ohor Assuoin4- c✓.eleV: _ I da 60 :FX F'�tis•L�� Ted Ord. elegy = 98.x' o EXlsf:n reStd��+ce czlsZW ww a_ EXis�E." 6 - -- as�vcodt. e drtdey /. 3 o�3 r Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: (ATTAC)11 TO PERMIT) 453417 0 GENERAL INFORMATION State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. Permit Holder's Name: City Village X Township Parcel Tax No: Albert, Dean I Troy Township 040 - 1088 -60 -000 CST BM EIS: Insp. BM Elev: BM Description: Section/Town /Range /Map No: 23.28.19.357D TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark /0 O ` Dosing Alt. BM Aeration / S Zy B ldg Sewer Holding St/ Inlets �� �S St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic � /� ` Dt Bottom SGk 5 Z _ Dosing z ��/ h Hea lyjan. t sr ( g 2A 1 Aeration Dist. Pipe Q y OS (4'ri Holding Bot. System 3 C_O S Z '( 1D•U q 3. / . n ,� PUMP /SIPHON INFORMATION Final Grade �%�"" A d S — �• I cj ,�. 3 Manufacturer Demand St Cover Z YT!5 q ` GPM Model Number Z, e� o N f e s al-\, f TDH Liter Fricliono$s System Hoac� ,/� TDH F Forcemain Le gth , Dia., , Dist. to Well SOIL ABSORPTION SYSTEM BED /TRENCH Width Length / No. Of Trenches PIT DIMENSI No. Of Pits Inside Dia. Liquid Depth DIMENSIONS J 7 J 7, SETBACK SYSTEM TO lR � P/L BLDG W LAKE /BYRE LEAING M of INFORMATION : CHAM:BER OR /� D 1 12- Ch Type Of System: / UT O / odel Number G T _� OTt �y 8 tfJ t t�.� .d DISTRIBUTI SYSTEM < o - )Z D pz ym eii ti — V�.- o A Intake Header nifolN IDistribution x Hole Size x Hole Spacing Vent t Length / Dia P ipe ngth Dia _ Sp� g ' SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center / � Bed/Trench Edges Topsoil (lI g p / L Yes I j No f� Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / ` 7 Inspection #2: Location: 296 Old Hwy 35 River Falls, WI 54022 (NW 1/4 NW 1/4 23 T28N R19W) NA Lot P� L Parcel No: 23.28.19.357D 1.) Alt BM Description = J 35( ' � �x Z ' 2.) Bldg sewer length - amount of cover - ---- Plan revision Required? ; l Yes No 112- Q 1 � 4 - � I Use other side for additional information. �_--- - -1- - � 1 !j3ll!� I L Date Signature Cert. No. SBD -6710 (R.3/97) Safety and Buildings Division ounry 201 W. Washington Ave., P.O. Box 7162 ��� \ *isconsin Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) (608)266 -3151 Department of Commerce �3 Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide may be used for secondary purposes Privacy Law, sl5.04(1)(m) Project Address (if different than mailing address) I. Application Information - Please Print All Information _. r, h:_ _ : �,' Property Owner's Na me Parcel N •tret_#_ $leek# -� Dca►,In �A15ae,�� _ _ %O0 040 - loft -&0- coo r Property Owner's M ailing Address Property Location zci (o old Rwv •�+- �W 4, I't YU %,Section 473 City, State 476-us 1��^� Zip Code? ^7 -P7hofne Number —7p� wer W.L o7 L�4- f q Z� - / !v� p (circle owe) ' II. Type of Building (check all that apply) T t O N; R_LE o � 1 or 2 Family Dwelling - Number of Bedrooms 3 Name •C ++amber ❑ Public /Commercial - Describe Use / E) State Owned - Describe Use K 6,? -SD S ❑City_ ❑Village lXownship of TyQ(,/ 8625 R �tD _" �_ —_ III. Type of Permit: (Check only one box on line A- Complete line B if applicable) A• ❑ New System Y� Replacement System y p y ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner IV. Type of POWTS System: (Check all that apply) 9 Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dispersal/Treatment Area Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (sf) System Elevation y 1 , 5 gQ'� 9 3 .3 9 3, � VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel FiL•er Plastic Gallons Gallons of Units 64F oncrete Constructed Glass New Existing �'�� -/ Tanks Tanks l` Septic or44ekling -arik 000 101 Aerobic Treatment Unit Dosing Chamber e9r�i no It VII. Responsibility Statement- I, the ut rsigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) Ktumbfth Si g lure MPA4A2& - Nwrrber Business Phone Number POAL Steiner 55- Plumber's Addre ss (Street, City, State, Yip Code) N '�a 5o 5 w- ) &-• F u s , w- 5407-2 VIII. County Department Use Onl Approved ❑ Disapproved Sanitary Permit Fee (includes Groundwater Date rs* \ Issuing ent Signatur ( o Stamps) Surcharge Fee) r `�J , ❑ Owner Given Reason for Denial ��.;•-. G d IX. Conditions of Approval /Reasons for Disapproval SYSTEM OWNER, > , 1 Septic tank, effluent filter and dispersal cell must all be iced I Maintained �_-- -- as per management plan provided by plumber. 2, All setback requirements must be maintained as per applicable code /ordinances. Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) 0 1813 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 (BM), direction and parcel I.D. percent slope, scale or dimemsions, north arrow, and location and distance to nearest road. 040- 1088 -60 -000 P/easp-PAiweffinforn a�tim.. _ ....' awed B Date Personal information you p Wcq may be b�Ceabndar)ipiii$im Y (Privacy Lew, s. 15.04 (1) (m)). Property Owner Property Location Dean Albert Govt. Lot NW 1!4 NW1/4 S 23 T 28 N R 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 296 Old Hwy 35 city i di 14� iVuulk7er _j City _f Village iOl Town Nearest Road River Falls ( WI 54022 1 715 - 425 - 7907 Troy I Old Hwy 35 1 New Construction Use: Residential / Number of bedrooms 3 Code derived design flow rate 450 GIRD iiM Replacement _ ( Public or commercial - Describe: Parent material Glacial outwash Flood plain elevation, if applicable na General comments and recommendations: Install three trenches at elevation = 93.50' or higher, using 30 leaching chambers. Dose chamber may be needed to reach system elevation. Boring # Boring sel Pit Ground Surface elev. 98.05 ft. 9 in. Soil Application Rate Depth to limiting factor Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 a 1 1 0 -12 10yr2/1 none I 2fgr mvfr gs 2f 0.6 0.8 J&PO 2 12 -21 10yr4/4 none sl 2fsbk mvfr cw 2f,1 m 0.6 1.0 3 21 -30 7.5yr4/6 none sl 2msbk mvfr cvv 1fm 0.6 1.0 4 30-62 7.5yr4/6 none Ifs 0 sg mvfr aw 1vii 0.5 1.0 5 62 -92 10yr5/6 none strat gr s 0 sg ml gi - 0.5 1.0 6 92 -105 10yr5/6 f2f 7.5yr5/8 strat gr s 0 sg ml - - 0.7 1.6 #4 & 5 co tain 1/4 - 2" irregular, discontinuous bands of 10yr4/4 Ifs. Loading rate of H#5 reduced to reflect permeability restriction associated with banding. Boring # I Boring Pit Ground Surface elev. 98.67 ft. >98" in. Soil iii pit to limiting factor App lication 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 0 1 0 -15 10yr2/1 none sil 2fsbk ni gs 2f 0.6 0.8 bZ 2 15 -25 10yr4/4 none sil 2fsbk mvfr cw 2f,lmc 0.6 0.8 n tf 0 1 U 3 25 -38 10yr5/4 none sil 2fsbk mvfr cw 1fm 0.6 0.8 4 38� 7.5yr4/6 none Ifs 0 sg mvfr aw 1vii 0.5 1.0 5 66 -98 10yr5/6 none strat gr s 0 sg ml - - 0.5 1.0 11#4 & 5 contain 1/4" - 2" irregular, disc on n of 10yr414 Ifs. Loading rate of H #5 reduced to reflect permeability restriction associated with banding. * Effluent #1 = BOD ? 30 < 220 mg /L an TSS >30 < 1 mg/L * Effluent #2 = BOD < 30 mg/L and TSS <30 mg/L CST Name (Please Print) Signatu : CST Number James K. Thompson 3602 Address A.C.E. Soil & Site Evaluations Date Evaluation Conducted Telephone Number 340 Paulson Lake Lane, , WI 54020 6/182004 715 - 248 -7767 Property Owner Dean Albert Parcel ID # 040- 1088 -60 -000 Page 2 of 3 3] Boring # J Boring 1/ Pit Ground Surface elev. 98.65 ft. Depth to limiting factor >101" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDW in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -22 10yr2/1 none sil 2fsbk mvfr gs 2f,1mc 0.6 0.8 2 22 -29 10yr4/4 none sil 2fsbk mvfr cw 2fmc 0.6 0.8 3 29 -39 10yr5/4 none sil 2fsbk mvfr cw 1fmc 0.6 0.8 4 39 -7Q 7.5yr4/6 none Ifs 0 sg mvfr aw 1vf,f 0.5 1.0 5 70 -101 10yr5/6 none strat gr s 0 sg ml - - 0.7 1.6 F—I 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 P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F—I Boring # I 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 QP 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. • E /eda -lion ' ', �t1c�.ics� �prap. lane rye $ Z. 3 q 83 ■ �ropesed /�laccrr,cn� �— 61 c 1;sp�rsa/ tell. — ■ i * SyS��r - c2,reA. 8Z A ,a pax /, o i 8 r /sCa • As5L, cc✓ /0 0 . tA ,� EX� S �' n � App ox � — � O O e S�u'n 3 bt�fao. re s lds�ce EX - 5 - 6 - we ll /0 C= CW � M o • o uN���• ��" ash �. 3 W3 i Prot Sca I " a /O' \ co 14 n � e� 1 Yom" ) ;oo Aid 4„-,400 T" k �o }e ,� ��dt _ B,•vt �,;��� � 5 �'d,.;� £Iev. l oo, o' lip a &ed voom Dyt ve Way ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM (6 Mailing Address S'o Property Address (Verification required from Planning Department for new construction.) City /State ��,J"2- Fvk-t-LS Parcel Identification Number o�o - I d • 3 �) LEGAL DESCRIPTION Property Location S,� '/4 , � /4 , Sec. , T N R W, Town of Subdivision , Lot # Certified Survey Map # — — ,Volume , Page # Warranty Deed # `-Cz Volume , Page # Spec house yes no Lot lines identifiable yes 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. Owner maintenance responsibilities are specified in § Comm 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The roP e rtY owner agrees to submit to St. Croix County Zoning Department a certification form, signed by the owner and P � 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 Department within 30 days of the three year expiration date. /3 /o -- SIGNATURE � OF APPLICANT DATE OWNER CERTIFICATION I/we certify that all statements on this form are true to the best of my /our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office SIGNATURE OF APPLICANT DATE * * * * ** Any information that is misrepresented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** Include with this application a stamped warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. I'UHP CIIAMIIF.It CROSS SECTION AND SPECIFICATIONS Vent Cap Weather Proof Approved Locking Junction Box Manhole Cover 4 C.I.-- -- 12" Min Vent Pipe Final 4" Min Grade ' Conduit 18 Min 18" Min l� Approved Inlet Joints u/ C . I . P i p e I FApproved � Extending; Joint w/ 3' Onto C.I. Pipe I ,,; Solid Extending A Ground S ' Onto ' Solid Alarm � , ,round ' '� B_ - C Pump --__ _ l Off - Concrete Block 4 D S1 TANK . PUFI1' 'lanufac turer : Q 15 O Manufacturer: glee rank Macerial: ,uA Hod a1 ldumt,cc: / lank Size: 4 Gallons Switch' Type : C /o Olt Total Dynamic Ilead: - — F t. CAPACITIrS Pump Discharge Rate: GPM Total Daily Effluent: `/✓r0 Gallons or Callons Number of I)o!j cs : `Y Per Day or / Cal loll!) Dose Volume:' 1. Gallons or YZO Gallons 140 tes: 1. See pump curve for or ,�3a — Gallons additional performance total Tank information. rapacity Required Callona 2. Pump and alarm are to be inatalled on ueparat ? circuit ALAItH au per 1LIIK 16.19 NAC . 4nn►if ncturer: 4-eue �lQ4h� lode Number: Q Iv 1 t ch Type f� f page of • TOTAL DYNAMIC HEAD /CAPACITY HEAD CAPACITY CURVE PER MINUTE- EFFLUENT AND DEWATERING MODEL 152/153 Li - w � MODEL 152 153 50 - - Feet Meters Gal, Liters Gal. Liters 153 5 1.5 69 261 77 291 12 40 152 10 3.1 61 231 70 265 N 15 4.6 53 201 61 231_ _ 20 6.1 44 167 52 197 30 z 8 25F 7.6 34 129 42 159 0 30 9.1 23 87 33 125 a 20 35 10.7 -- 22 85 �°- 40 12.2 -- -- 11 42 4 10 Lock Valve: 38.0 Ft. (11.6m) 44.0 Ft. ( 1 3. 4m) 014508 0 20 0 60 80 100 GALLONS LITERS 0 g0 60 240 320 6 1/4 3 27132 4 5/8 FLOW PER MINUTE ® 1 CONSULT FACTORY FOR SPECIAL APPLICATIONS 3 77 a • Timed dosing panels available. 3 27/32 Electrical alternators, for duplex systems, are available and supplied with an alarm. • Variable level control switches are available for controlling single phase systems. Double piggyback variable level float switches are available for variable level long and short cycle controls. • Sealed Owik -Box available for outdoor installations. See FM 1420. { • Over 130 °F. (54 °C) special quotation required. -- 1521153 Series 12 1/8 T 1521153 MODELS Control Selection Model Volts -Ph Mode Amps Simplex Duplex _- - - 5 1/8 N152 115 1 Non 8.5 1 2 or 3 `- BN152 115 1 Auto 8.5 Included 2 or 3 - E152 230 1 Non 4.3 1 2 or 3 - - - -- sKZOS4 SE152 230 1 Auto 4.3 Included 2 or 3 N153 115 1 Non 10.5 1 2 or 3 8N153 115 1 Auto 10.5 Included 2 or 3 SELECTION GUIDE E153 1 230 ' 1 Non 1 5.3 1 2 or 3 1. Single variable level float switch or double p ig gy back variable level float BE153 230 1 Auto 5.3 Included 2 or 3 9 p iggyback p 99Y switch. Refer to FM0477. o Cnu71oN 2. See FM0712 for correct model of Electrical Alternator E -Pak. All installation of controls, protection devices and wiring should be done by a qualified 3. Variable level control switch 10 -0225 used as a control activator, specify duplex (3) licensed electrician. All electrical and safety codes should be followed Including the most recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA). or (4) float system. RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL TO. P.O. BOX 16347 ` Louisville, KY 40256-0347 Manufacturers of.. O SHIP T0: 3649 Cane Run Road Louisville, KY (800) 928-PUMP QMAI/TY P MMP6 S HCE /,939 httpMAvww.zoelleccom F` PUMP !O. ® (502) 778 -27 2 774 -3 928 -PUMP FAX (502) 774 -3624 © Copyright 2000 Zoeller Co. All rights reserved. Fr___ 1 2-- POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION ; SYSTEM SPECIFICATIONS Owner 7eQn Septic Tank Capacity a1 �Q al ❑ NA Permit # T5_3 q I Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS Effluent Filter Manufacturer zc,e ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model A - l0O ❑ NA Number of Public Facility Units NA Pump Tank Capacity 9 g al ❑ NA Estimated flow (average) gal /day Pump Tank Manufacturer ❑ NA Design flow (peak), (Estimated x 1.5) g al/day Pump Manufacturer ❑ NA Soil Application Rate al /day /ft2 Pump Model 5 ❑ NA Standard Influent /Effluent Quality Monthly average" Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) :530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD _5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) 30 ❑ NA Biochemical Oxygen Demand MOD,) 530 mg /L 'X In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) :510 cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA "Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 3 ❑ month(s) (Maximum 3 years) ❑ NA ear(s) Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: Z ❑ month(s) (Maximum 3 years) 13 NA -�= 19 year(s) Clean effluent filter At least once every: -Z ❑ month(s) ❑ NA NI year(s) Inspect pump, pump controls & alarm At least once every: ❑ m ) ❑ NA � year (s) ls) Flush laterals and pressure test At least once every: ❑ month ❑year(s) ) NA Other' At least once every: ❑ month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) Page a of O_ START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of )iaintihd products or other chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To 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 Maintainer 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 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; 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. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ 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 infringed upon by required setbacks from existing and proposed structure, lot lines and wells. 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 r f 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 has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name P ML C, S ne Name DGt l'VP.('. DUn Phone r 71 15- 4 Z5- S54q- Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY A Name n a.rY e,L O uD n Name Y,-. C-to ( �� [ it Lt&P -- J - N / � (� Phone Phone S. 30(0 , ( This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(0 and 83.5411), (2) & (3), Wisconsin Administrative Code. DOCUMENT NO, ij STATE BAR OF WISCONSIN FOAM 3-1982 SPACE RESERVED fOR RRCOROIno DATA I QUIT CLAIM DEED 4 %9ss3 soot[ ?�0 racE405 -- - 9 (:RS oF;iCzc Production Credit Association of Northwest Wisconsin i jrr oo., WISE ...................... ... ........"........._."...............--. ..._...._........._............ formerly known as Production Credit Association of �;�''d.:tir ?Santa this 8th River Falls ........................... .......... •-- • -_ - - -- °� ______.__ APO. 1987 i Sept. quit claims to Dean W. Alber and" Phyllis • F ; Albert,." husband ! and- wife, and each in, -their own right.,_.. - "_ CA 8 .30 At .. ............ ............................... Ij ............... i lSptsl.t D«1F .. ................................... ........... .................................. ........... the following described real estate in ............... ..5 ............. Count - Y. State of Wisconsin: R[TUnY ,c Tax Parcel No: The NEI of the NE4 of Section 22- 28 -19, except for that portion of the parcel of land described in Volume "2" of Certified Survey Maps page 304 as lies in said Forty, and except for a parcel of approximately .37 acre in the SE corner of sail y. ' Forty, said parcel being described in Volume "302 ", ....t /O page 233• The NW4 of the NE of Section 22- 28 -19. That part of the NW4 of the NW4 of S 23- 28 -19, lying W of STH "35" except for that portion of the parcel of land described in Volume "2" of Certified survey Maps page 304 as lies in said Forty and except for a parcel of approxima'ely 1.18 acres in the S side of said Forty, said parcel being described in Volume "302 page 283. I I This ... js Rot_ _ homestead property. " (Is not) Dated this ._...- .. ... . ....... ....... _. ....... . day of ....... 87 ................ .(SEAL) \.(- _.Y . ". � _ - -- --- ............... .............(SEAL) ' ........................... .. .. ....__..... - - - -- --- .......... . Paul Moe. Regional ;`tanager _ ......... ....... ._ ........... ........... .(SEAL) _._ _.. ..... (SEAL) _ ..... ............ .... _... "_ AUTHENTICATION ACKNOWLEDGMENT Signature(a) ............................. .... .......................... STATE OF WISCONSIN 1 r .............. 51'- CTQiX......County. authenticated this ........ day of ........................... 19 ...... Personal.'y came before me this ... .......day of .- - ...__..__ Septzmber-... 19.87... the above named Pau ltae� Regional Manager ......... .............. ............ .............................. . .................................. -••........................................... TITLE: M iABER STATE BAR OF WISCONSIN ................................................................................ (If not, .. ............. - authorized by § 706.06, Wis. Stata.) to me known to be the person ._.......... who executed the foregoing instrument and acknowledge the same. THIS INSfRUMEN7 W4$ ORAFTEO BY BENITA A. MILES Production Credit Assn of IW WI ``" "� u_. /i .1'_ NtDfARYPV N Benita A. `tiles .........- -- --'" .............. ................ .. ........_.. awn Kanis, Credit Secretary Pierce -. _ -" Notary Public "... _....County, Wis. (Sitrlintures may he authenticated or acknowledged. Both My Commission is permanent. l If not, state expiration n Ire not necessary.) date: .. - `�aY... 19 -- --------- ------ - - - - -- 19 --- 91..) inS in any capacity should be typed er pnntrd below their eignsturrs. STATE U Vt tit' FORM N.. .t _lye: Stock No. 13003 C i O St 3 N O 7 A O 7 0 if � t V to M n Q 9 O 4k C = fT to A y 3 N O (A O O Q O d U) O O tjD a w (;• Q-0 e p m y m a ai CO � C a lo CD _ � �I. - 4 Q o v C y N N �• v b 3 a o g y rn 0 3 i o C CL CD 91 (o D a 8 S (5 o N a s a I c a h o o n IW O, ( 3 0 0o w cn 0 o co w CD Z co CD 0 CD ° P d ° o o ! !°* Q Z 000 000 M . f�D N I N N A CD I z T ` Z lv I =S D o 0 D m 0 O v y m I o c c� CD y y CD C .'.. N N• OIQ a I Q a N ? I 3 C � I -I a) OZ {n cc fb .a N D o N c Z CD C c .a i0 St cl C w W m W m < a a co Z 3 1 A °o o :. Z fN Z7 N Z I w v w A I � I M a ' N m °- m S CD N C A c w C y I (D a o �v o a N N N n N (o I CL 3 a y S2. CD I 3 N I r I 7 •D I � N cn '. A .3 O 7 O 0) 7C O I m CL m N I N O 0 O O �o b A u+ CD N o0 o0 C 00 Wisconsin Department of Health and Sooial Services Plb, #67 3/70 Division of Health SEPTIC TANK ;PERMIT APPLICATION TYPE or USE BLACK INK A. OWNER OF PROPERTY .Name f Addres (Street, City, Zip Code) B. LOCATION OF PROPERTY WN,'• - RE SYSTEM WILL BE CONSTRUCTED ALTERED OR EXTENDED COUNTY IT ti f Check One: _ CITY VILLAGE LEGAL DESCRIPTION � 1 TOWNSHIP C. IS LOCAL PERMIT A UIRED FOR THIS WORK? 1 YES NO / PERMIT NUMBER D. SEPTIC TANK CAPACITY /'rl Gallons NEW INSTALLATION X REPLACEMENT ADDITION MATERIALS: Prefab Concrete Y. Poured in Place Steel Other NUMBER OF TANKS TO BE LiSTALLED: / E. TYPE OF OCCUPANCY Check One: One or Two Family Residence Commercial Industrial Other y (Specify) Number of Persons to be Accommodated - Number of Bedrooms F. APPLIANCES, ETC: Food Waste Grinder YES NO Automatic Clothes Washer YES NO Dishwasher X YES NO Automatic Potato Peeler YES_ NO Other (Specify) G. MASTER PL[jM5XR MAKING INSTALLATION Name: Address: FF License Numbers MP Signature of Applicant: -,.- i` MP RSW Address: H. (To be Completed by Issuing Agent) Date of Application �� X /i Fee Paid ; \� Permit Issued (dat / / // Permit Number /.� 1 ; Agent (Name) Forte Town, Village, City, County, etc. (Specify) Note: The applioation, cannot be considered for filing until all of the above questions are answered and the fee paid. Agents will forward application, the fee of $1.00 for each septic tanK and the third copy of the permit (canary) to the Division of Health. Checks and'aoney orders should be scads payable to the Division of Heaath. Do not write in space below - FOR DEPARTMENT USE ONLY I. DATE RECEIVED - 7 (�. ACCEPTED BY RETURNED . ( initials) LI D n -7 � (Date) Corr• ) FEE RECEIVED � VA No. No. l./ _ PBRMI! N0. es or No REVITWED BY APPROVED DATE (Initials) Yes or NO) COMPLETE OTHER SIDE SEPTIC TANK PERMIT N0. •C I'1 c. s r1 < REP -.0N 01L PIR.00LAT10N TEST AND S01L H0RIN0S TO • DIVISION OF HEALTH - PLUMBING SECT1dK P.O.Box 309, Madison, Wis. 53701 Pursuant to H 62.20, Wis. Administrative Code P E R C 0 L A T 1 0 N T E S T Test Depth Character of Soil Hours Water Test Time Drop in Water Level Inches utss Number Inches Thickness in Inches Since Hole in Hole Interval Second to Next to Last To Fall 1st Wetted OVernight in Minutes Last Period Last Period Period One, Inch Example P - 0 36t To Soil 10" C1 26 25 Yes or No 30 1 2 112 _ Y2 60 RECORD DATA FROM MINIMUM OF 3 TEST HOLES Compute size of absorption area in accord with H 62.20 Wis. Administrative Code. S O I L B O R I N G S- Minimum 36 Below Pro osed Absorption S stem Boring Total Depth Depth to Ground Water De th to Bedrock Number Inches Observed Estimated Observed Estimated Character of Soil with Thickness in Inches - Example B - 0 72" 72 Black To Soil 12 ciM iel Sand 18a Gravel 24 RECORD DATA FROM MLVIMUM OF 3 BORE HOLES T YPE OF OCCUPANCYt RESIDENCEt Number of Bedrooms OTHER (Specify) Number of Persons D WASTE GRINDER: Yes No Dishwashers Yes l No Automatic Clothes Washers Yes `' No E FFLUENT DISPOSAL SYSTEM: NEW �4' EXTENSION ADDITION REPLACEMENT Tile Size No.Lin.Feet Trench Width Depth Number of Lines - Seepage Beds Length Width Depth _ Tile Size �+ No. Lines y � /Seepage Pits Inside Diameter `�� Liquid Depth I, the undersigned, hereby certify that the percolation tests reported on this form were made by me or under my super- vision in accord with the proceaures and method specified in Chapter H 62.20 (13), Wisconsin Administrative Code, and that the data recorded and location of test holes are correct to the best of my knowledge and belief. NAME TITLE J` � (Type or Prints REGISTRATION NO. i1 or MASTER PLUMBER LICENSE NO. r X r.% ADDRESS C i / DATE Ll / `�' - - ( -j SIGNATURE 15 28 No ! 9 W. 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