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1 O c ci h p Iz Q U N O O O Z C D Y p N Co N c C O C \r 0 O -0 � I y O O N E 3 E CD h co ! 0 7 f9 U 0- OL c6 O co N co O C z N a Z O O ci LL o 3 o Er <1 iz E ¢ = co U 3 ro Q v z cr �i I a) w E E z = ° o = ° o � N N W a m a m N O 2 zt c Q I co N H it Y' o �__ o ` N N E O 0 cy N C Q Q N • N 0 o a) Q Q Q Q z in z 2 z z IL N c y E 2 s. .. L c - O ! N - N 3 N C w .i N C w (6 I $ °ooa °'a o0oa ac J v) c) F N - H H di cn - IN- F- d� m o 0 0 o 0 0 • ry N a a a N a a. a a ccLO LL (mil o y M M cn m Opi CD ! O O } N N to c N N c N 0� a0 O N N C p O O J v to Co o cD E M @ p o _ o o c p m N c 0 m c d 00 Q Z m � m w U) m «° ° o � w c � N c _ `o `o -o E o a) 0 op p ca °° o ID '', -� c v i s 0 o o rn a; u c E m c 5 M a m M 11 E 0 0 _ z C3 as r.l p N �. N CD a 4) 0 �' y 0 ,+; 0 '0 C a) CO • ya O N z N Z 0� It O z z d U) \ w = E = E V d E a E a m m at a L a m y a w • CL d ,� y c o y c ( > 'Mv E v c ''.' c o c .. f L 7 R ! O o A U a 2 0 0) v O N v r Wisconsin Department %f Comrgerce PRIVATE SEWAGE SYSTEM County: St. Cr oix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 430045 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)J. 6 - 1 3 Permit Holder's Name: City Village X Township Parcel Tax No: Rosenthal, Jeff Troy Township O 0- CST BM Elev: Insp. BM Elev: B 2 644n,% scriptiion 1 / Secti n/Town /Range /Map No: 0 ' / U 0 • S tc� f 5 w c&/t _ 28.28.19. C TANK INFORMATION EVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. s •L, Septic Bench rk_ _ .� 611 Dosing X'00 Alt. BM Aeration Bldpo Sewer qs 3 Holding S t Inlet TANK SETBACK INFORMATION StfHt outlet TANK TO P/L WELL BLDG. Vent Air Intake ROAD Dt I nlet �Y- 6. Sep I / loV 1 n ^ � n/ _ Dt Bottom �y►'1� . Z / 0 `J Dosing S , �3t Heade�r/_Man H 3 3 r �1 Aeration Di6t. Pipe �• n � U Holding Bot. ystem f S ` 9 7 G Final Grade 7 PUMP /SIPHON INFORMATION 1 S 6 Manufacturer Demand GPM /. Model Number � a 1 / �-� (� � �D�Q TDH Lift ► Frictp` Loss System ea� TDH Ft ( f �( V � � Fdrcemain Le t Dia. // Dist. to Well d 1 �� 2 SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS / � SETBACK SYSTEM TO I P/L JBLDG WELL LAKE /STREAM L Manufacturer: INFORMATION CHAftWbR Typ f ystem: -7 Model Number: DISTRI TION SYSTEM S i Head r /Manifold stribution x Hole Size x Hole Spacing V Air tak Ps) '] h Z Length Dia Z Length r A Dia Spacing —` n �h 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 S/ J Yes ] No Yes No COMMENTS: (Include code discrepencies persons present, etc.) Inspection #1: / � Inspection #2: / Location: 590 Sykora Lane River Falls, WI 54022 (SE 1/4 NE 1/4 28 T28 Sundown Hills Lot P6 Parcel No: 28.28.1 . 1.) Alt BM Description = i� ( AAQ,� (- 61d)yt-/ G UpY ' n a l i p " �6�1bhJi -_'A.W I- b f 2.) Bldg sewer length = �S f- )�� -�► 3&t m(m, — Sv , lQ�. �p• - amount of cover = J 1 i ,� �S �G� / �dG /� _ — PAkk h�S Plan revision Required? Yes ` o 11 Z Use other side for additional information. 1 l ______.__ _ .____ _ ___ __ _ SBD -6710 (R.3/97) Date Insepctor's Sign ure Cert. No. Safety and Buildings Division County ^ cx I { Aw 201 W. Washington Ave., P.O. Box 7162 T C rp l ISC����� Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) (608) 266 3151 - T� Department of Commerce O O Sanitary Permit Application State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal information you provide 3 S�SS= " Tests, frD may be used for secondary purposes Privacy Law, s15.04(1)(m) Project Address (if different than mailing address) I. Application Information - Please Print All Information Property Owner's Na me Parcel # Lot N Block k k4w� - - IJ N 3 Property Owner's M ailing dress Property Location ' J 1_ City, State Zip Code 6 f / P(circl on ) II. Type of Building (check all that apply) T O` N; R E W �l or 2 Family Dwelling '- Number of drooms Subdivision Name CSM Number ❑ Y m ublic/Comercial — Describe Use ��' _ � .r tl_� It Slate Owned - Describe Use x Y� u " S D I L UCity UVillag wnship of III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A. New System placement System ❑ Treatment/ Holding Tank Replacement Only ❑Other Modification to Existing System i 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) ❑ 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 Chan1ber ❑ Drip Line ❑ Gravel -less e Other (explain) V. Dispersal/ reatment Area Information: CO Desi� Flow (gpd) Design Soil App ation Rate(gpdsf) ispersal Area Required (st) Dis ersa] Area Pr osed (sf) Syst�EFn �'� VI.. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existin s Septic or Holding Tank .� Aerobic Treatment Unit I Dosing Chamber Ix VII. Responsibility Statement- T, the undersigned tune responsibility for installation of the POW"TS shown on the attached plans. Plumber's me (Print) Plumber's S� ture MP /MPRS Number Business Phone Nu bet of Plumber's Addre ss (Street, City, State, Zip ) VIII. Count /Department Use Onl ,Approved ❑ Disapproved Satitary Permit Fee (includes Groundwater Date Issued Iss ing gent Signature (No Stamps) Surcharge Fee) \ I ❑ Owner Given Reason for Denial 0 IX. Conditions of Approval /Reasons for Disap oval y , PAr lnA&A*tatw.. 4"44,1 yy J .n ► I Attach comps plans (to the Co µ ty only) for tpe s E>6on pa not less than 81/2 x 11 inches in size C .,vw. --- b-e tM 11��t'l�i'd SBD -6398 (R. 01/03 PLOT PLAN 4" Jeff Rosenthal ADDRESS 590 Svkora Lane River Falls Wi 54022 t 1/4 NE 1/4s 28 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 5 BEDROOM 4 CONVENTIONAL AT -GRADE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1000/261 LIFT TANK SIZE DOSE TANK SIZE 848 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 600 # of chambers none BENCHMARK V.R.P. Bottom of Siding ASSUME ELEVATION 100° Filter Zabel A -100 ❑ BOREHOLE O WELL - H.R.P. Same as Benchmark SYSTEM ELEVATION 98.4' 0 w Scale = 1/4 = 10' Tanks are to be properly bedded and Well provided with lockdown covers with 0 approved warning labels Existing 4 Weiser X` Weeks Bedroom 1000 eeks 261 Dose tank Existing 12 year House gallon #C old system failed - ABANDo#J PEC <oMM 65.33 W IS . ADtA . C-006 Alt. B.M. B M B 3 Vent 98' ! X47.4 97' B -2 B -1 95' 9% Area 15' below Slo Grading is to be done to system is to remain divert run -off away from undisturbed system Property Line 270' Safety and Buildings 4003 N KINNEY COULEE RD LACROSSE WI 54601 -1831 TDD #: (608) 264 -8777 Visconsin www.commerc .wis ons Department of Commerce www.wisconsin.gov Jim Doyle, Governor Cory L. Nettles, Secretary June 04, 2003 CUST ID No.226900 ATTN. POWTS Inspector SHAUN R BIRD ZONING OFFICE BIRD PLUMBING, INC ST CROIX COUNTY SPIA 1008 192 ND AVE 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 06/04/2005 Identification Numbers Transaction ID No. 873555 SITE: Site ID No. 659732 Jeff Rosenthal Please refer to both identification numbers, 590 Sykora Lane above, in all correspondence with the agency. Town of Troy St Croix County SE1 /4, NEIA, S28, T28N, R19W Subdivision: Sundown Hills Troy — lot 3 FOR: Description: Four Bedroom Replacement Mound System Object Type: POWT System Regulated Object ID No.: 905347 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: Conditions of Approval: • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Private Onsite Wastewater Systems VERSION 2.0" SBD- 10691 -P (N.01 /01) and the 'Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems VERSION 2.0" SBD- 10706 -P (N.01 /01). • 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. • A state approved effluent filter is required. Maintenance information must be given to the owner of the tank explaining that periodic cleaning of the filter is required. Access to the filter for cleaning must be provided per Comm 84 product approval conditions. • 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. Stats. • The existing septic tank must be inspected for structural soundness, size and baffles where required and must be brought into conformance with the requirements of ch. Comm 83, Wis. Adm. Code. If it does not conform, a state approved tank must be installed. PQ r �. k . � R Con zzl�kr, 7 c A P Pl� - % I` SHAUN R BIRD Page 2 6/4/03 Conditions of Approval Continued: • Comm 83.22(7) - A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. Owner Responsibilities: • Comm 83.52(1)(a) - The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). • Comm 83.52(2) - A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. In the event this soil absorption system or any of its component parts malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. • The owner is responsible for submitting a maintenance verification report per Comm 83.55, that is acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 175.00 Fee Received $ 175.00 Gerard M. Swim Balance Due $ 0.00 POWTS Plan Reviewer - Integrated Services (608)- 789 -7892, Mon. - Fri. 7:30 am to 4:15 pm jswim @commerce.state.wi.us WiSMART code: 7633 cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 Cover Page Shaun Bird Bird Plumbing Inc. 1008 192nd Ave New Richmond Wi 54017 715- 246 -4516 Date: 5/21/03 Owner: Jeff Rosenthal Location: SE 1/4 NE 1/4 S 28 T28 N,R 19W Lot 3 Sundown Hills Troy System type: Mound System Manuals Used: Mound Component Manual version 2.0 (01/31) Pressure Distribution Manual version 2.0 (01/31) Page# 1. Cover Page 2. Mound Plot Plan 3. Mound Cross Section 4. Pipe Cross Section /Pipe Layout 5. Pump Chamber Cross Section 6. Pump Curve 7 -9. Maintance and Contigency plan 10 -12 Soil test Signature License nu er 226900 ` RECEIVED MAY 2 2 2003 SAFETY & BLDGS DIV. PLOT PLAN PROJECT Jeff Rosenthal ADDRESS 590 Svkora Lane River Falls Wi 54022 SE 1/4 NE 1/4S 28 /T 28 N/R 19 W TOWN Troy COUNTY ST. CROIX MPRS Shaun Bird 226900 DATE 5/21/03 BEDROOM 4 CONVENTIONAL AT -GRADE CONVENTIONAL LIFT HOLDING TANK MOUND XXX SEPTIC TANK SIZE 1000/261 LIFT TANK SIZE DOSE TANK SIZE 848 HOLDING TANK SIZE LOAD RATE 1.0 ABSORPTION AREA 600 # of chambers none IL BENCHMARK V.R.P. Bottom of Siding ASSUME ELEVATION 100° Filter Zabel A -100 ❑ BOREHOLE O WELL sH.R.P. Same as Benchmark SYSTEM ELEVATION 98.4' 0 AL w Scale = 1 /4" = 10' Tanks are to be properly bedded and Well provided with lockdown covers with 0 approved warning labels Existing 4 Weiser Weeks Bedroom 1000 Weeks 261 Dose tank Existing 12 year House gallon old system failed - ABANDva PEF. <oMM $3.33 W 15. A bm . C.906 Alt. B.M. B M Vent B -3 98 , 97.4' 97' 96' -2 B -1 95' 9% Area 15' below Slope Grading is to be done to system is to remain divert run -off away from undisturbed system Property Line 270' Designer NO Date Non -Woven Filter Fabric 4 Observation Pipe Perforated .,Distribution Pipe Below Filter Fabric ASTK C -33 S a n d 1 }H G " Topsoil _ = = =_- - - -- c % Slope Bed Of #,- 2 %2 Force Main \�FIowed Drain Rock From Pump Layer } !1 f E /• z3 C r e ss Section Of A Mou - Sys tem Using F A Bed For The Absorption Area C A Ft. 6 I �. Ft.- Ft. K Ft.. __ ..... L�'/ 6Ft- j` Ft. L 4'Observation Pipe - A °- 1 Force Moin K: W `n (° _.. --- - -- ----- .._ _� - - -T - - - - -- From Pump L -..– — I 0 Distribution Bed Of %Z� Pipe Drain RocK 4 0bservation Pipe Permanent Marker Pipe or Rods - Plan View Of Mound Using A Bed For The Absorption Area PAGF-_,r„OF Perforated Pips Oef*i3 End View {RertorateC i' RJC R -De a� s Ho es t_OCaied On 8oliom. o � Are Equal Sooeea e Q Y t 4 P v C Force Main / 1' I FtRaT - A*Lf. mr.% va Cannec }lot PVC Manifold Pipe /r- S�X a l tZiSiriDVdfan Pipe Disfribution Pipe Layout / 4 Ft. R. R. X47-1 Inches Y Inches Signed: Hole Diameter 3 i Inch License Number: Lateral Inch( es ) Manifold Inches Force Main - Inches # of holes /pipe. Invert ElevAtion of Lateral s ?f Ft. * 'r•' ,1010...... i3�' �..�� r� P C tj it 4� VCS i CA • C. ;, vr�R ABM ~� ' WtATt.{C,�rROAr ; w t■CiGN�A }{�, L� lAOiw ppOR, _+4u A} CTIOM box MAM04<~' Cttivtot - biaow OR rot CA GRAOSi down { h Mt�, CMWDufr --" +a "IRtsa. a .r. w .w A WWI lN4t T �tRTi$kT $CAA. ( I w A "APPROV60 OAr i APPROVED JO NTS OIT" cv. f Y PIPE 3' ONTO pump —�,. � aft 0 SO410 SOIL G4►1cRtT9 f►>,ac1c K"CR CX 1T RC1Rl�4iy!">j�f Q/JL`i t♦ T�t�K �tsufir:A+t:TL►RCR t�Ai •1if.M A!•�ROV�►1. i b p v mgt . � �.1��- :LiU MAAILtKA►CTi�R . ......,..... *AWMOKR Opp Docks; #ZR OAS; TAWK fit . bAt.1.0i►3>i 0049 Y06WMC ' +�+�+•�TarRlcle�� �i � �,- ����'- .•....�.....�.. �wcs,.uo}At±b �Aefc�2 ' s "' Ct{ QR 0 435 �2 MOpi1. 1 JYtiwir�.' � • .w......,.,.,�..,.,.. _ CArAUTtE ;s A ■ - ..�....... M►fC#i Mtt.k0ittl swift" a • °` tNCw96 OR '�4rR0Yl ► AAAiYrAt'r61Ri . e- lt� t» s 1%11.11&0 Oil ' �o % *us MOD96 mumost� - S D rw 11+ c 1498 OR O At6ftt SwtTtK Tt1It: 4 9E: PU MP AWC A6AKM AMR TO H rh +atiswWM DISC KARA RAT- GP I NSTAW-90 010J UPA AATi MOWN VLRTttA� pIPPOINCi ftTM/ 6N FUM Otr ^&A O}; - ring lnow Pt /C.. 1pt'c-'r * (4 + 10 MWM NLTW*IkK SUPP61 P10tg$$WRt 10 10..10 OP /C1tC9 AWN Xl— ..�.:/fo. ;t ateT +e►t sACTURli pttT 37 1010 � TbTA1., G'�IA+MItG IItAD �w �wi.:.�•. �'!.!T �/ WTCRWA6 01140 410Aji OF TAIJOU LgAl6Ta - TOTAL DYNAMIC HEAD /CAPACITY PER MINUTE HEAD CAPACITY CURVE EFFLUENT AND DEWATERING MODEL 152 MODEL 152 153 UJ W� :2 U_ 50 Feet Meters Gal. Liters Gal- Liters 5 1 69 261 77 291 153 I 10 3.1 61 231 70 265 12 40 152 15 4.6 53 201 61 231 0 20 6.1 44 167 52 197 w _ 30 25 7.6 34 129 42 159 1 23 87 33 125 9. a 8 30 z 22 85 r 35 10.7 -- 0 a 20 40 12.2 -- -- 11 42 0 0 Ft, 11.6m) 44.0 Ft. (i3.4m) Lock Valve: 38 4 Gi4503 10 D 20 60 80 100 GALLONS s 1/4 LITERS 0 80 60 240 320 3 27/32 FLOW PER MINUTE l 3 27/32 ' I I CONSULT FACTORY FOR SPECIAL APPLICATIONS ON S - - ® 3 27/32 • Timed dosing panels available. " systems, are available and supplied with • Electrical a l t ern at ors, for d y an alarm_ • Variable level control switches are available for controlling single phase 1 systems. • Double piggyback variable level float switches are available for variable level long and short cycle controls. • Sealed Qwik -Box available for outdoor installations. See FM1420. • Over 130 °F. (54 °C.) special quotation required. i 12 1/s 150153 Series 1571153 MODELS control 5elecuon 5 1/8 L Nadel VWtsPh Node Am M Duplex N152 115 1 Non 8.5 2 or 3 I _� sxzoes BN152 115 1 Auto 8.5 2 or 3 E152 230 1 Non 4.3 2 BE152 230 1 Auto 4.3 2 or 3 N153 115 1 Auto 10.5 Included Non to.5 2 SELECTION GUIDE . 115 1 2 or 3 l float E153 230 1 Non 5.3 1 2 or 3 1. Single piggyback variable level float switch or double piggy back variable level BE153 230 1 Auto 5.3 Included 2 or 3 switch. Refer to FM0477. 2. See FMO712 for correct model of Electrical Alternator E-Pak. n CAUTION 3 AU insW A011 of controls, protection devices and w should be done by a qualified . Variable level control switch 10 -0225 used as a control activator, specify duplex (3) or (4) float system. licensed electrician. Afl electrical and safety codes should be followed including he most recent National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA)- 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 Manufadi ersof - . Louisvile, KY 40256.0347 SHIP T0: 3649 Cane Run Road E Louisville, KY 40211 -1961 r=17 1CAW 9 S /ACE �i93c� L r ® (502) 778-2731. 928 -PUMP S f 7U "rT aG 0 FAX (504 774 -3624 h0:t1www.zoer1er com _..� �. �nnn 7nPller . Co_ All rights reserved Maintenance and Contingency Plan for a Mound System Maintenance Plan 1 Septic Tank is to be pumped once every 3 years. 2. Dose Chamber is to be pumped at the same time as the septic tank. 3. Effluent filter is to be cleaned once a year. Please note: a larger filter is being installed in order to extend the maintenance interval of the filter. 4. Once every 3 years the mound is to be inspected via the inspections pipes in the at- grade. The laterals are to be inspected via the cleanouts. 5. Owner agrees to limit greases, garbage, and water conditioner discharge into the system. 6. Pump and electrical components are to be checked at the time of the pumping. 7. Owner agrees to leave the area 15' below mound undisturbed. 8. The owner agrees to save this plan. 9. Trees, shrubs, and other similiar vegitation are not be planted on system. The system is not be driven over. 10. Effluent Quality is not to excede the requirements found in Comm. 83 Contingency Plan 1. Pump alarm goes off, call pumper and pump out dose chamber and septic tank if needed, then bypass pump float and try pump without float. If this works, float is bad, replace float. If pump still does not work, check power at the pump with a electrical device such as a hair dryer. If no power, check breaker inside house and call a electrician. If there is power, then pump is bad and needs to be replaced by a plumber. 2. If mound fails, determine cause of failure, test another area or remove pipe and sewer rock, retill soil, install new mound system. 3. Replace any other failing components as needed. Important Phone Numbers Plumber: Shaun Bird 715 - 246 -4516 Pumper: Tom Mondor 715 - 246 -5148 St. Croix County Zoning 715 - 386 -4680 t - pOWTS OWNER MANUAL & MANAGEMENT PLAN Page of SYSTEM SPECIFICATIONS FILE INFORMATION owner Septic Tank Capacity 20 o7G al 13 NA Permit �. Sepik Tank Manufacttrrer DNA Effluent Fltet Manufacturer , e l 13 NA DESIGN P,pRgly(ETERS Number of Bedrooms O NA Effluent Filter Model �a Cl NA Number of Commeraal Units Z4NA Pump -Tank Capacity gal 0 NA Estimated now ( ai/d Pump Tank Manufacturer 4& O NA Pump Manufacturer (3 NA' Design flow (peak), (Estimated x 1.5) aVd -) ❑ NA Solt Application Rate U aVda ffi Pump Model f- Unit Monthly average' Pretreatment Peat Fitter lnfiuent/EfflcrerrtQuslity 0 Sand/Gravel Filter Fats,. 01 & Grease (FOG) s30 mg/L p Mechanical Aeration D Wetland Biochemical Oxygen Demand (BOD x220 mg/L [3 Disinfection ❑ Other Total Suspended Solids (TSS) 5150 m /L Manufac Curer Pretreated Effluent Quality A Monthly average" Dispersal Cell(s) S30 mg1L ❑ In -ground (gravity) + o nd (P ressurized ) Biochemical Oxygen Demand (BODS) 530 mg1L Q eV At -grade ; Total Suspended Solids (TSS) ❑ Other Fecal Coliform (geometric mean) 51 W cfu 1100m( D Dri ire Y inch diameter values types for domestic (non - con —rcian vast —ater and Maximum Effluent Particle Size septic tank eHiuenL values typical for pretreated wastewater_ MAINTENANCE SCHEDULE Service Frequency Service Event Inspect condition of tank(s) At least once every ❑ months ,Kyear(s) (Maximum 3 yrs.) When combined sludge and scum equals one -third (Y,) of tank volume Pump out contents of tank(s) months ;�year(s) (Maximum 3 yrs.) Inspect dispersal cell(s) At least once every At least once every D months . ear(s) Clean effluent filter o months , ear(s) O NA At feast once every Inspect pump. pump controls & alarm p months2il!;4ear(s) 0 NA Flush laterals and pressure test At least once every ther. At least once every ❑months O year(s) ❑ NA O other At least once every Cl months ❑years) DNA MAINTENANCE INSTRUCTIONS one of the following licenses or inspections of tanks and dis ssai cells shall be made b y an individual carrying . POWTS Maintainer. Septa9e certifications. Master Plumber, Master Plumber Restricted Sewer; POV TS Servicing Operator. Tank inspections must include a visual inspection of the tank and scum a d to check for any% up hardware, Identify any cracks or leaks, measure the volume of combined sludge i to effluent levels or poding of effluent on the ground surface_ The dispersal sett (s) shat( g ro un d su rface . The ponding of effluent on the in the observation pipes and to check for any ponding of effluent on the g reg ulatory authority - ground surface may indicate a failing condition and requires the immediate notification loca f the tank volume, the or When the combined accumulation of sludge and scum g any tank equals e Servicing opera and or and ( Y,) disposed of in accordance with ch. NR entire contents of the tank shalt be removed by a Septag 113, Wisconsin Administrative Code onents, pre�tgment components and any The servicing of effluent filters, mechan ics! or pressurized POWTS come a certified POWTS Maintainer. other maintenance or monitoring at intervals vals of 12 months or less shall days perfo of any service event - A ser report shall be provided to the local regulatory authority within 10 days START UP AND OPERATION s ) for the presence of painting products or other For new construction, prior to use of the POWTS check treatment tank( 1 cells if Nigh concentrations are chemicals that may impede the treatment process and/or damage the dispersa for cell( s). to use_ detected have the contents of the tanks) removed by a septage servicing ope i R . Page of System start up shall not occur when soli conditions are frozen at the infiltrative surface. C) uing 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 celi(s) and may result in the backup or surface discharge of effluent To avoid this situation have the contents of the primp tank removed by a Septage $ervidn$ Operator pcior.to power to the effluent pump or contact a Plumber or POWTS Maintainer to r assist in manually operating the pump'conbds to restore normal levels within the pump tank Do not drive or park vehides 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 absorptiion area. Reduction orefintination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics: baby wipes. cigarette b�; moms; cotton swabs: degreasers; dental flow, drapers; fruit and vegetable pee disinfectants; fat; foundation drain (sump pump) water, rrng - a d wa grease; herbicides; meat scraps; medications; og; painting products; pesticides; sanitary napkins: tampons; water softener brine_ ABANDONNMENT When the POWTS falls and/or is permanentiy.taken out of service the following steps shag ripe taken to insure that the system is property and safely abandoned in compliance with ch. Comm 83.33, Wisconsin Administrative Code: • AN piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of an tanks and pits shall be removed and property disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shag 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 fads and cannot be repaired the following measures have been, or must be taken, #o provide a code compliant replacement system: valuated and may be utilized for the location of a replacement so • A suitable replacement - area has been e li absorption system. The replacement area should be protected from disturbance and compaction and shook( not be infringed upon by required setbacks from existing and proposed structure, lot lines and welts. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area- Replacement systems must comply with the rules in effect at that time. • A suitable replacement area is not available due to setback and/or soil limitations. 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 sod 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 POWT'S. eAound and at -grade soil absorption systems may be reconstructed in place f removal of the biomat at f the rnfiitrative 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 A TANK MAY BE DIFFICULT OR IMPOSSIBLE RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER E �e Name ��. ; c ..+L- - J , 7 Phone - L;_ �' SEPTAGE SERVICING OPERATOR (PUMPER LOCAL. REGULATORY AUTHORITY Name� f EPhone �' Phone --Ley . ^ document This do meets This doannentwas diafted by the stairs of the Green take. Marquette and Waushara County Zoning and SalAaWn agendes. the minimum requirements of ch. COMM 83.2=(b)tt)(d)&(f) and 83.54(1). ( 8. (3), Wisconsin AdmrnisUratjve Code. Use of this d does not GMw (fit) guarantee the performance of the POWfS. Wisconsin Department of Commerce SOIL EVALUATION REPORT Page of Division of Safety and Buildings in accordance with Comm 85, Wis. Adm. Code County (7 J Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must 6 ' 4 include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Please print all information. Re 'ewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner —5 Property Location �.J r� s 4G�✓ Govt. Lot ,��114A /4 S N Rd E ( W Property Owners Mailing Address Lot # Block # S Name or cl 13 city Stale Zip Code hone Number El City E] village Town Nearest Road ❑ New Construction Us?9 Residential / Number of bedrooms Code derived design flo rate _ v GPD JIS�Replacernent C] Public or co - Describe: Parent material b—" � d&!jZ /�, /% –;IZ4 Flood Plain el vation if applicable ft. Gener MAY 200 5 f. 01X 000N i Y ZONING OFFICE F I Boring # O Boring 5� pit Ground surface elev. ` �t J ft. Depth to limiting factor � in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 •Eff#2 AO a Boring # Boring .i Pit Grounds elev. Depth to limiting factor S in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff #2 1, 3 Effluent #1 = BOD > 30 220 mg/L and TSS >30 < 1 ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name (Please Print) CST Number Bird Plumbing, Inc. Shaun Bird 226900 Address Date Evaluation Conducted Telephone Number 1008 192nd Ave, New Richmond, WI 54017 �? /�— 0 3 715- 246 -4516 Property Owner _ Parcel ID # Page of Boring # C] Boring Q pit Ground surface elev y ft. Depth to limiting factor Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDM in. Munsell // Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 I 'Eff#2 z -3o F-1 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 GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 F-1 Boring # E] Boring pit Boring Ground surface elev. ft. Depth to limiting factor in. Soil ication Rate Horizon Depth Dominant Color Redox Description. Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Effluent #1 = BOD. > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. SBD -8330 (RAM) Soil Test Plot Plan Project Name Jeff Rosenthal Shaun Address 590 Sykora Lane River Falls Wi 54022 CS #226900 Lot 3 Subdivision Sundown Hills Date 5/21/03 SE 1/4 NE 1/4S 2 8 T 2 8 N /14 W Township Troy n Boring 0 Well PL Property Line County ST. CROIX BM or VRP Assume Elevation 100 ft. = Bottom of Siding System Elevation 98.4' *HRPSame as Benchmark ,/A'lt. BM Top of Walkout @ 96.0' 0 m kale = 1/4 = 10' CD Well 0 Existing 4 Weiser Bedroom 1000 Existing 12 year House gallon olds stem failed Alt. B.M. B Vent IS — B -3 � 98 97' 96' -2 ❑ ❑ B -1 �- 9 5 9 % Slop Property Line 270' ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify th t I have insApected the septic tank presently serving the resi 4fnce located at: Xction Cz'_- a - , TN, W, Town of Upon inspection, I certify that I have found the tank arg baffles to be in good condition, and it appears to be functioning properly. Last time serviced: Did flow back occur from absorption system? Yes _ No (If no, skip next line) Approximate volume or length of time: gallons minutes Capacity: 11L4r0 Construction: Prefab Concrete_ Steel Other _ Manufacturer: (If known): Age of Tank f known).: (Sign e) ( ame) Please print (Title) (License Number) Date Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 113 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: In accepting the above statement regarding existing septic tank condition, I certify that the tank to the be of my knowledge will conform to the requirements of ILHR 83, Wis Adm. Code (except for inspection openiTV2 over outlet baffle). Name ✓C Signature MP /MPRS ST CROIX COUNTY SEPTIC - TANK MAINTENANCE AGRELMENT` OWNERSHIP CERTIFICATION FORM i Owner/Buyer Mailing Addresses Property Address (Verification required from Planning Department for new construction) City /State Parcel Identification Number O `f O 30 - 0 �• �l °� i LEGAL DESCRIPTION Property Location SE 1 /a, r/,, Sec. TLN -RILW, Town of th Subdivision . Lot # 3 Certified Survey Map # Volume Page # Warranty Deed # qTl � Volume , Page # I �� Spec house ❑ ye no Lot lines identifiable yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure handle wastes. Proper maintenance consists of pumping septic every Y in out the s tic tank eve three ears or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restrictedplumberor a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. 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 operty described above, by virtue of a warranty deed recorded in Register of Deeds Office. 7: /Z1/ 03 I ATURE bF APPLICANT DATE Any information that is mis- represented 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 a copy of the certified survey map if reference is made in the warranty deed r DOC U MENT No. STATIC BAIZ OT WISCONSIN FORK >t -1m THIS NAet Rt uayse �oR RtCORD1NB IsafA�� WARRANTY DEED 45 v;; 87 4PA4178 R EGISTER ' S �� / OFFFICE C r ST. IX W., 1 This Deed, made between ..&ykora.. Land. - Company., ....... Reed for Record ....Incorporated., .a..Wisconaia. .corporation .................. MAY 99 ............................................................................... ............................... at 0 � �' M Grantor. V - and .... J ray...Roa entha-1 .wad ... Ann ... ........... husband and wife•..as..survi.vorship „marital ►� - l prope�x.tY....... .... I .... ............................... ............................... ...... Grantee. Witnesseth, That the said Grantor, for a valuable consideration...... ..............•.................................................................. ............................... R[TUIIN. TO conveys to Grantee the following described real estate in ... s t'....Ciralx -......._ County, StAo of W onsin: Lot Thre (3 S undown Hi1 1s Subdivision of the Town o Troy Tax Parcel No: P 4 I� i �1 � { i' ! This ......is ..nOt........ homestead property. { (is) (is not) Together with all and singular the hereditament• and appurtenances thereunto belonging; And.....Sy.kora . .Land- .Company. Incorporated .................. .............. .................. ................... {j warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except ,.,,.4'Uni, NY 1�` �' {I easements and rights -of -way of record, if any, ;�,.•••Y and wili warrant and defend the same. ' Dated this day of .... MAY ..... .... .......-------- -------------------- ......... c, is 4t (SEAL) R ,AN ... MPANY 'I_..' '.,, '�. t .�. SEtkL ,l � - ... - nni,I l�Iuttt t i! • By. ..- fL c`�........_. -• •--(SEAL) li ..................... ...... .........................(SEAL) i By. • M. S kora...... .ec.retar 1 ,._- ..ES.the. y....- .- Y AUTHENTICATION ACKNOWLEDGMENT �I {� STATE OF WISCONSIN ---•-----------------------•-------.--..-.--.----- .---- •-- ----- ----•- ---•- - - - - -- County. authenticated this ..._....day of...-•.---- _....--•._-_-- 19...... Personally came before me this .. _ - day of y •- -- - •-• (� .............. Kay ..... 19.9Q.. the above :tamed -•------....-• ...........................•------- ......_..--- ...._.._.._........ ............ Peter ... T,.._.Syicaxa _.and.................... ( ..................................................... .. . BS.f�1Or...Ns.._Y�4Q_8 .. ............ TITLE: MEMBER STATE BAR OF WISCONSIN •--....••••--•• .................................. ............................... '1 ii (If not . ....................................................... ..... . •-••----------•-•-•-••--•--........------------ •-- ••-......- -•- ••- --......_... �I authorized by 1 708.08, Wis. Stats.) � to me known to be the person _A S ....... who, executed V:e y foregoing instrument and acknowledge t same,; THIS INSTRUMENT WAS DRAFTED BY C,t..i.....Gayiaxd Q�cney.---- _-- •---- --- - - - --- a lt,�..�- -. • TARY . , I RiVer... Ea lla, ... WZ .... S4022 ..... ----- -- - - - - -- ,� faun Nota Public ------ +'f�_._� r,� ty, , (Signatures may be authenticated or acknowledged. Both My Commission Is permanen (If ot, st—t VB�. ale ex it 'o jf I are not necessary.) date: ........1.'.l -- P i} pp I •mamas or persons alraing in any capacity should be typed or printed below their signatures. OF r ” F STAT o. —IOU SIN Stock No. 13001 ORM R111 No. 1 CO 10) 0 "' . Z D p c m 335.00' NO °t2'E OD ° N 175.00' 160.00 co ap o GD y > CD ti� Z N 0 .P 0 rn g m - �ti O N N 0 Ocv �N° C O O rnN = O -i D 4 N V1 Z► CO N -Q O_ rn O �V Z rn V •A N 0 . D n (A O� \ \ ti \� ® 2T924 •00' yeti N N2 °O /g9.24I 0 N N £ O. o N2 p 2) 0 40'' 0) W I CA/ A \ W Ch ro I" b O \ � jC\\ 0 co _ _ D cn -4 IV \ rn N rn O'� cn O tQ �' c� — d' �p o O N o cep_ A p _ (:c of OA CQL . 77.00' 73.00 3 1: 50.00' 0 9 c 96 p p S 0 ° 7' 40 "W rn a� / 1, S o 300.00' V -OD Q 0 96`5 M O c� i �� _ ZL JV9 SOV m N I�. _ Co- .. C _ ..� Form -STC- 104 AS BUILT SA MY SYSTEM REPORT OWNER $eh TOftcl;ililP 7_ _� �1 SEC. 28 T N -R 69 W ADDRESS EWaT!,f C fIr'GIe ST. CROTX COUNTY, WISCONSIN R1 rev^ 1- . rat , SUBDIVISION S- -,J6W1A t�fs _ 1.�'r LOT SIZE 2,7 gC,rk -S PLAN VIEW Distances and dimensions to me(.'- to piirements of I-M 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM di z� 3 9 /o' 2 H • N X � BM ` gyp C' a b • s ow INDICATE NORTH ARROW BENCHMARK: Describe the vertical rc'e enro point used Mail 44 - 7'�ee Elevation of vertical reference poin'.." zlp d Proposed slope at site: G /o SEPTIC TANK: Manufacturer: SkaA 'PJ`eca.s Liquid Capacity: f00o s cd, Number of rings used: 3 Tank run►lhole cover elevation: 93 7 Tank Inlet Elevation: I it T, :ik Outlet Elevation: 89 Number of Feet from nearest Rc a i s Front,w Sideo Rear, O 270 feet From nearest prope = - ty 1Joe. s Front 1 0Side, © Rear, 0 c4M $Z- feet Number of feet fr�: wel L _? 2b , building: $� (Include this infortnrL,lon (, f r' =e :jboire 1-?I of plan) ( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER N/ A Manufacturer: Liquid Capacity: ' pump Model: Pump /Siphon Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevation: Gallons per cycle: Alarm Manufacturer: Alarm Switch Type: Number of feet from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: Width: / Z Length: 104 Number of Lines: Area Built: /Z (D Fill depth to top of pipe: 3o Number of feet from nearest property line: Front, O Side, ® Rear, O Ft. 3 Number of feet from well: Z so Number of feet from building: 37 1 (Include distances on plot plan). ' SEEPAGE PIT A)/A Size: Number of pits: Diameter: Liquid depth: Bottom of seepage pit elevation: Area Built: Has either a drop box O or distribution box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number of rings used: Elevation of bottom of tank: Elevation of inlet: Number of feet from nearest property line: Front, O Side, O Rear, OFt. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector • Dated: Sl« l9 / Plumber on job: y'A License Number: /u O S* 3Z 1 2- 3 84:m / j I DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY &BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. BOX 7969 ON - SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION ,y1,Q Q[�,., State Plan I.D. Number: y1QQI;Q[�j 1�/I 5 ' e 7 C. 2 8 , T 2 8 - R 19 (If assigned) Town of Troy, Lot CONVENTIONAL ❑ALTERATIVE S -kora Rd . Holding Tank ❑ In- Ground Pressure ❑ Mound ,. NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: C lary d; Jeff Rosenthal Circle River Falls WI .r..... BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. EV.: CST REF. PT. ELEV. f / Name of Plumber: PRSW No.: County: Sanitary Perrni, Number: MP /M John Sykora III 3212 St r 1 SEPTIC TANK/ + MANUFACTURER: LIQUID CAPACITY: TANK INLE ANK O EV.: WARNING LA EL LOCKING CO R PROVI PROVIDED: C;��;azj . W YES ❑ NO ❑ YES BEDDING: VC -f>LT DIA.: MATL.: HIGH WATER UMBER OF ROAD: PROPERTY WELD�--,^� BUILDING: VENT TO FR SH a , v . ii m ALARM: r EAREST- EET FROM LINE1 lL AIR 1 T: YES NO � [j YES El NO � D ANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP /SIPHON MANUFACTURER: WARNING LABEL I LOCKING COVER PROVIDED: PROVIDED: S ❑ NO [- ❑ NO ❑YES ❑ N GALLONS PER CYCLE: PUMP AND CONTROLS OPERAT NUMBER OF PROPERTY WELL: BUILDING: VENT TO H (DIFFERENCE BETWEEN FEET FROM LINE: AIR PUMP ON AND OFF ❑YES ❑ NO IVXELARUEST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: D MATERIAL KI NG: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: WIDTH: LENGTH: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: # PITS: I LIQUID BED /TRENCH / TRENCHES: ! MAT L: PIT DIMENSIONS GRAVEL DEPTH FILL DEPTH DISTR. PIPE DISTR. PIPE DISTR. IPE Mp.TE IA O. S R. NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: o ABOV COVE : ELEV. INI ET: ELEV. END: (4 ,i�� . � PIPES: FEET FROM LINE: 1 ZZ AIR INL a� gI S �G� - -.._ �_ NEAREST —� �` -7 � lG6 MOUND YSTEM: Mound site plowed perpen Icular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES [:1 NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER I TEXTURE: PERMANENT MARKERS: RVATION WELLS; ❑ YES E] NO NO YES ❑ NO DEPTH OVER TRENCH /BED I DEPTH OVER TRENCH /BED DEPTHS OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: I — El YES ❑ NO ❑ YES ❑ NO I ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED /TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: =OW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE I MANIFOLD MATERIAL: NO. DISTR. DISTR. PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEVATION AND ELEV.: ELEV.: DIA.: ELEV.: PIPES: DIA.: DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS ❑ YES ❑ NO ❑ YES ❑ NO PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: COMMENTS: FEET FROM LINE: ❑/ YES El NO ❑Y�ES❑ NEAREST —► /11' tain in county file for audit. Sketch System on Reverse Side. SIGNAT E: TITLE: SBD -6710 (R. 06/88) .'!' •l. ~ [ SANITARY PERMIT APPLICATION 1.] . 01LHR In accord with ILHR 83.05, Wis. Adm. Code CouN M STATE SANITARY PER IT # -Attach complete plans (to the county copy only) for the system, on paper not less than / qw `P 8% x 11 inches in size. ❑C hock if revision to previous application —See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER I. APPLICANT INFORMATION – PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION Ro st k + SE '/4 NE ' /a, S ZS T fig, N, R /9 E (o W PROPERTY OWNER'S MAILING ADDRESS LOT # BLOCK # Em4sr CG tr ° l CITY, STATE ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CSM NUMBER �r U).._ 5 � Z 5th owe II. TYPE OF BUILDING (Check one) CITY NEAREST ROAD 1:1 State Owned VILLAGE : ]�� iQd�d El Public Public X 1 or 2 Fam. Dwelling of bedrooms PAR EL AX NUMBER(S) F III. BUILDING USE: (If building type is public, check all that apply) V L/v - / g C) - (> 1 ❑ Apt/Condo 2 ❑ Assembly Hall 6 ❑ Medical Facility /Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales /Repairs 11 ❑ Restaurant/Bar /Dining 4 ❑ Church /School 8 ❑ Mobile Home Park 12 ❑ Service Station /Car Wash 5 ❑ Hotel /Motel 9 ❑ Office /Factory 13 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. N New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # — Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ® Seepage Bed 21 El Mound 30 El SpecifyType 41 [:3 HoldingTank 12 ❑ Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /day /sq. ft.) (Min. /inch) ELEVATION q570 �s viz .� :�z 9n"G`' `'*8611- VII. TANK CAPACITY Site in allons Total # of Prefab. Fiber- Exper. INFORMATION Concrete Manufacturer's Name Con- Steel Plastic New istin Gallons Tanks glass App. Tanks Tanks strutted Septic Tank or Holdin Tank d D /boo ` Lift Pump Tank/Siphon Chamber VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) Mqr SW Business Phone Number: r 2- t Z. Plumber's Address (S et, City, State, Zip Code): Z g 75 A / W , .&,�; 5;k7Z� IX. COUNTY /DEPARTMENT USE ONLY ❑ Disroved Sanitary Permit Fee (Includes Groundwater Date Issued ssuing Agent Sig a Stamps) Surcharge Fee) Approved Ownr Given Initial , / Adverse Determination 6Z 17A, X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Plb -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber r R INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608 -266 -3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in ##1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8% x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if requixed by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD -6398 (R.11/88) APPLICATION FOR SANITARY PERMIT STC -100 This application form Is to be completed In full and signed by the ownez(s) of the property being developed. Any Inadequacies will only result In delays of the potmit iss uance. - Should this development be intended lot tesale by owner /contcactot,(spec house), than a second form should be retained and completed when the property is said and submitted to this office with the appropriate deed recording. ------------------------ --------------------------------------- --------- --------- - - - - -- -------------------------------------- Owner of propert Location of property S &_1/4 �_1/4, Section Zr_.• T � -R Y Township Melling address Address of site Subdivision nase ,�c�..�c�o�� Lot number Previous owner of property �Y' &- +�,��► Total also of parcel Data parcel was created - 7_,,., - A all c otnets and lot lines identifiable? an `.� o Is this property being developed for resale (*spec house) ? as �)N volume nd Page Number as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY D&RD which Includes a DOCUMENT NUM82R, VOLUME; AND PAGE NUMANA, and the BRAL OF THE REGISTER OF DEEDS. In addition, a cectlfled survey, it available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Cestlfled Sucvey Map, the Cartlfled Survey Map shall also be required. ---------------------------------------------------------7--------------------- PROPERTY OWNER CERTIFICATION I(Me1 certify that all statements on this forth are true to the best of my (out) knowledge= that I two) am (ace) the ownec(s) of the property described In this Information form, by virtue of a warranty deed recorded in the Office of the County Register of Deeds as Document No. 1 455 8 s and that I two) presently own the proposed site for the sewage disposal system (at I (we) have obtained an easement, to run with the above described property, tot the construction of sold system, and the same has been duly recorded to the Office of t e un! Reglate f adds, as Document No. _ N /.� .'k ce E t ovnec Signature of Co -Owner III Applicable) ZZ Date of 1819noluirW Date of Signature �yry^ t y R ae 'EfN ,� %t!K 2� ryfr h 5�`b � � i +. � "� r� 1f •: � �! � «"`ter n ..: STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/ UYER J S TS T- H w Fire Numb n�"e �f �^"'s 00 ROUTE / BOX NUMBER w�^ C y -- o a CITY / STATE , UE .. x.1-5 ZIP PROPERTY LOCATION :' k, fil C Section 2 ! T N, R 1 W, Town of `'��- ©� ,,�. St. Croix County, Subdivision 444S Lot number. Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance con- sists of pumping out the septic tank every three years or sooner, if needed, by a licensed 'septic tank pumper What you put into the system can affect t e .unction of the septic tank as a treat - ment stage in the waste disposal system. St. Croix County residents M be eligible to recieve a grant for a maximum of 60% of the cost.of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this.program in August of 1980, with the requirement that owners of all' new 'systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix County Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper veri- fying that (1) the on- site wastewater disposal system is in proper operating condition and .(2).after inspection and pumping (if nec- essary), the septic tank is less than 1/3 full of sludge and scum. Certification form will be sent approximately 30 days prior to three year expiration. H I /WE, the undersigned have read the above requirements and agree o to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin Depart- ment of Natural Resources. Certification form must be completed . and retu to the St. Croix County Zoning Office within 30 days of the three year expiration date. 1 SIGNED s DATE jzZz _ St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 386 -4680 Sign, date and return to the above address. I DEPARTMENT OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, . DIVISION BOX LABOR HUMAN REDLATIONS PERCOLATION TESTS (11J) MADISON W 53707 (ILHR 83.09(1) & Chapter 145) LOCATION: SECTION: TOWNS UNICIPALITY: LOT NO.:BLK. NO.: SUBDIVISION NAME: cE 1 / Nt !/ as /T� N /R /9 L ( r) `3 5� ,►dew tf:`!� COUNTY: Cpit >r �"s f >'as , +��t,t G: rCIC, R.viitAr F4.1k9 USE DATES OBSERVATIONS MADE NO. BEDRMS : COMMER IAL DESCRIPTION: PROFILE TIONS: 1 PERCULATIO N TE STS: Residence •7 N 14 1 xNew ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system rs VENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM -IN -FILL HOLDING TANK: RECOMMENDED SYSTEM: (optional) ou ®s ou ZS EA o s ®u o s au �W ,1#_,,+;6UA W (12'k-9)4i. If Percolation Tests are NOT required DESIGN RATE: 4 If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: Floodplain, indicat Fl elev O/ . li LCl a PROFILE DESCRIPTIONS R� BORING TOTAL 0 DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL H THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSE EST. HIGH EST TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) B- $Cc g3 iD rGwe, '4 +►�3"�'�'M / 3 =74 /a 74 yr, B- 2- 9 i '? in 0 $ � 3 ..�, s / � •- 3 e„ / s -� S �' �' Q 8 3 oN 'y�I si. TL � ayu_�[;��� -s S. /� �,"."(� KPH 5i1�'y�p•I, -fu4�a B- -3 V0 97Z' / /'' n a,1 'e0 �'�.� :y: / &'a= 43o B- 9Zr 80 Ay �z i.s Z spy y a c s� � W r li bo FB_ !!: j . PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERIOD 1 PE PERIOD 3 PER INCH P- �� � 1 , {�0,(. , (. _SZ P_ z z9 v►a*.k'. 30 P- I 93 1 10 11 P- Z Z' '100 P - E 4 7 Z' ' PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. SYSTEM ELEVATION 90 4," r f i I r -.__.. I I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: ADDRESS: CERTIFICATION NUMBER: PHONE NUMBER (optional): CST GNATUR� v' DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR -SBD -6395 (R. 10/83) —OVER — ? J r � INSTRUCTIONS FOR COMPLETING FORM 115 - 880 - 6395 To be a complete and accurate soil test, your report must include: 1. Complete legal description; 2. The use suction must clearly indicate whether this is a residence or commercial project; 3. MAXIMUM number of bedrooms or commercial use planned; 4. Is this a new or replacement system; 5. Complete the suitability rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTHER SYSTEMS ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE use the abbreviations shown here for writing profile descriptions and completing the plot plan; 7. MAKE A LEGIBLE diagram accurately locating your test locations. Drawing scale is prefered. A separate sheet may be used if desired; S. Make sure your benchmark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all apropriate boxes as to dates, names, addresses, flood plain data, percolation test exemption, if appropriate; 10. If the information (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign the form and place your current address and yur certification number; 12. Make legible copies and distribute as required. ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION. ABBREVIATIONS FOR CERTIFIED SOIL TESTERS $of Separates and Textures Other Symbols st — Stone (over 10 ") BR — Bedrock cob — Cobble (3 - 1U') SS — Standstone gr — Gravel (under W) LS — Limestone 's — Sand HGW — High Groundwater cs — Coarse Sand Perc — Peecolation Rate med s — Medium Sand W — Well I's — Fine Sand Bldg — Building Is— Loamy Sand > — Greater Than 'sl — Loamy Sand "C — Less Than '1 — Loam Bn — Brown 'sil — Silt Loam BI — Black si — Slit Gy — Gray cl — Clay Loam Y — Yellow scl — Sandy Clay Loam R — Red sicl — Silty Clay Loam mot — Mottles sc — Sandy Clay w/ — with sic — Silty Clay fff — few, fine, faint 'c — Clay cc — common, coarse pt — Peat mm — Many, Medium m — Muck d — distinct p — prominent HWL — High water level, surface water Six general soil textures BM — Bench Mark for liquid waste disposal VRP — Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit. The sanitary permit must be obtained and posted prior to the start of any construction. 1 s: � A / ci , ,1 - 7 y L s (. 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