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040-1188-90-009
c 1 o u o O WW 0 M m o c o rn �C • N 7 �' l' ? N 7 W co �_ K N Q ICI O -4 CL O� y owl COa� O m Nom o W p, OD CD 0 CL Q N O 0017 c A C C l � C N = O N O A� rn y 3 go H m w m cn CD c c 3 a IW oc°oo ° aaa`z' N N a CL !� y W W N co CD CO) M c lr ° S. 3 000 000 Z �' ° a4 v m m e co � CO m N eo a 0 p m w v, a to o CD cr CD CD N 3 m' N 3 m D n CL Z rr N I I Z y N D W o D a 0 O a s @ O a 0 c) C 1:3 CD CD p m y �• !►1 CD C c m 3 CL c m w o w m Z m N z m (,6 c ° o A ? n N c �_ m v m 0 w 0 0 O, C N rn e CD co � m ao CL CL A z m C � N D N C4 �' w �O a m m a cz a �_ a O — O C _ 0 d p d N N N O O I I w w CD fD a I I m b A a O ON N � N I I o CL CD 0 0 °p m o 0 9 N c„ CD a 1 AS BUILT SANITARY SYSTEM REPORT OWNER UA-w TY Sy1c T . .,p s TOWNSHIP d SECTION_ T Z U N -R__ W ADDRESS — ..—R e X ST. CROIX COUNTY, WISCONSIN � SUBDIVISION 1 6C LOT 6 ? LOT SIZE PLAN VIEW a -1' co+ EVERYTHING WITHIN 100 P E O F SYSTE i i i 7 I i I raJ° e�c TE��c Cs y ,c u 1 �•� �tl+ I Lai CJ� � ✓E INDICATE NORTH ARROW / BENCHKARK:Elevation and description: 4fn Alternate benchmark SEPTIC TANK: Manufacturer: Liquid Cap. r�.J �� qq _ z__� r Rings used: Manhole cover elev: 77, �6inal grade elev: 14914A 3 Tank inlet elev.:_ b� Tank outlet elev.: �7`•3/ No. of feet from nearest road:Front Side , Rear Ft. r From nearest,prop. line:Front Side , Rear Ft. No. of feet from: Well Building* 7,5- (Include this information in the above plot plan) (2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CI*MBER Manufa ture Liquid Capacity: Pump ode Pump /Siphon Manufact.: Pump Size Elevat on of inlet: Bottom of tank elevation Pump o elev.: Pump off elev.: Gallons /cycle: Alarq: an.: Switch Type: Location Dis ance from nearest prop. line: Front_, Side, Rear_Ft. D' tance om: Well Building SOIL ABSORPTION SYSTEM Bed: Trench: Seepage Pit: Width: Length Number of Lines : 3—Area Built Exist. Grade Elev. Proposed Final Grade Elev. Fill depth to to of pipe: P P s No. feet from nearest prop. line:Front , Side, Rear Ft. s No. feet from well: N' � No. feet from building HOLDI T Manuf ctur r: Capacity: No. of r'ngs used: Elevation of bottom tank: Elevat' n of inlet: No. f et from nearest prop. line:Front , Side , Rear Ft. No. eet rom: Well building nearest road Alarm Manufacturer: INSPECTOR• p DATE: Z 92- PLUMBER ON JOB: LICENSE NUMBER: /W 7 9 6 /9Q:cj i LOC QN: TROY 36.28.19.822,SE,NE,36,WOOD RIDGE DR,.LOT #69 Wisconsin Department of Industry PRIVATE SEWAGE SYSTEM C nty: ` Labor ind Human Relations INSPECTION REPORT Safety and Buildings Division ST. CROIX ' (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION QUALITY BUILT HOM S, Permit Holder's Name: ❑ City ❑ Village)] Town of: State Plan ID No.: UALITY BUILT HOMES DON KRUG RTROY CST BM Elev.: A- Insp. BM Elev.: ! BM Description: Parcel Tax No.: 040118890009 TANK INFORMATION ELEVATION DATA A9200128 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic f� S p� .' Benchmark 97 /d r Aeration Bldg. Sewer t>- 5z I O f Holding St /�K Inlet TANK SETBACK INFORMATION St /)A Outlet TANKTO P/L WELL BLDG. Ventto ROAD D Air Intake Septic �a / NA Dt _.. Dos' NA Header hhftm Headed Aeration NA Dist. Pipe QZ Holding Bot. System 9 ,5-./,2 ' PUMP/ SIPHON INFORMATION Final Grade 99 t cjD 6. S, *A 2 "5 7,94 Manufacturer Demand C Model Number E GPM TDH Lift Friction S em TDH Ft oss ea Forcemain Length Dia. Dist. SOIL ABSORPTION SYSTEM BED/TRENCH Width 1 1 LengtS No. Of Trenches p Of Pits Inside Dia. Liquid Depth DIMENSIONS DIM N I N SYSTEM TO P/L BLDG WELL LAKE /STREAM LEACHI Manufacturer: SETBACK CHAMBER INFORMATION Type of n dw , Cmu i System: e,4 OR UNIT DISTRIBUTION SYSTEM Header 1fAaP4QW— „ Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length 5 Dia, Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over „ „ xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center — 2 / Bed /Trench Edges 36 — 4Z Topsoil ❑ Yes ❑ No ❑ Yes E] No sons present, etc.) COMMENTS: (Include code discrepancies, per I f Plan revision required? ❑ Yes No Use other side for additional information. 9� SBD- 6710(R 05191) Date Inspector's Signature Cert.No. e ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: r e s I =jZ - 0ff1LHR SANITARY PERMIT APPLICATION In accord with ILHR 83.05, Wis. Adm. Code COUNTY 5� Ckoe r STATE SANITARY PERMIT # -Attach complete plans (to the county copy only) for the system, on paper not less than a �o 8% x 14 inches in size. El l Check i rev sion to previo us 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 & c_AL t -ry tc<G ddAJ 10114f4 5 & '/a ,V e /a, S 31 T ZAN, R E (or PR ERTY OWNER'S MAILIN ADDRESS LOT # G BLOCK # A< CI ` STATE ZIP �QdE S PH M SUBDIVISION NAME OR �CSM� MBE n C J*K 11. TYPE OF OF BUILDING Check G ate Owned I CI LL AGE � '1 ] NEAREST J ROAD ( ) ❑ State VLL O v (� ❑ Public [.1 or 2 Fam. Dwelling -#� of bedrooms � IC 111. BUILDING USE: (if building type is public, check all that apply) v �� — � _ Q0 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 P heck only one in line A. Check line B if a pplicable ) IV. TYPE OF ERM (C y pp ) A Replacement 3. ❑ P Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an ) 1. � New 2. ❑ Re P Existing System System s System System Tank Only Existing g y Y Y Y Y B) ❑ A Sanitary Permit was previousl issued. Permit ## — Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 9 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System -In -Fill PTI N SYSTEM INFORMATION: I. ABSOR O S S O 1. GALLONS PER DAY 1 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE •6. SYSTEM ELEV. 7. FINAL GRADE q V REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals /da /sq. ft.) (Min. /inch) EELEVATION IV OD / ?� i Z Feet 4 � 77 Feet VII. TANK CAPACITY Site in oallons Total # of Prefab. Fiber- Exper. INFORMATION New istin Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass App App Tanks Tanks structed Septic Tank or Holdina Tank w F u r ank/ o Vlll. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumbe Name (Print): Plumber'ZSiature: (No S p T MP Z o.: Business Phone Number: Plumber's r dress (Str6ret, City, State, Zip Code): &Im W I �0 t IX. COUNTY /DEPARTMENT USE ONLY Disapproved Hilary Permit Fee (Includes Groundwater jDate Issued Issuing ent Signature (No S ) Surcharge Fee) Approved ❑ Owner Given initial a/ - Adverse De terminatio n C0 �= X. CONDITI OF APPROVAL /REASONS FOR DISAPPROVAL: dr to � c1,Z SBD -8318 rmerly Plb-67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber 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. 1 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. 11. Type of building being served. Check only one and complete ## of bedrooms if 1 or 2 Family Dwelling. 111. 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. Rosponsibility 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; sirearns 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 required by the county; E) soil test data on a 115 form; and F) all si- ing information. ------------------ . - ---------- - - - - -- ------------------ ------ - - - - -- --------------- - - - - -- --------------------------------- GROUNDWATER SURCHARGE A. Wisconsin Act 410 included the creation of surcharges (fees) for a number of regp,jilated practices which can effect groundwater. .� p a 9 Th( !)w- ccii;ected through these: surcharges are used for ` on€ oring groundwater, ground- water contamination investigations and establishment of standards. SBD -6398 (R.1V88) STC -100 This application form is to be completed in full and sig ned b' Y the oc, ncr (s ) of the property been de Y q loped. Any inadequacies wil only result In delays of the permit Issuance. Should this development p be Intended for resale by owner /contractor,(spec Douse), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property 1` S a)69--1'/ Location of property _ 1/4 9F section" , T2 N -R W fg .Township 6 Hailing address _ g 32 1c1(/ - n 2 c 1 �cf� Z2 Address of site cl)Do0 ID I?, Subdivision nam frC 12fp c. F / -C -S Lot no other homes on property? yes Previous owner of property _ - i t-- D ` Z5— P z� Total size of parcel f A- Cle€ Date parcel was created _ I q 7";- p Are all corners and lot lines identifiable? Yes No Is thin property being developed for (spec house) ?,Yes No Volume and page Number _ d as recorded. with the Register of Deeds. ------------------------------------------------------------------------ INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARIWITY DEED which includes a DOCUMENT NUIWER, VOLUME AND PAGE. NURDI R & THE SEAL OF THE REGISTGIt OF DEEDS. In addition, a certified survey, if available, ;would be helpful so as to avoid delays of the reviewing process. If the deed description referencar. to a certified survey Map, the certified survey Map shall also be required. PROPERTY OWNER CERTIFICATION I 0 , !e ) certify that all statements on this form are true to the best of ny (our) knowledge that I (we) am (are) the owner(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 110. Lf :� 1Ob f , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of County Register of deeds as Document No. l signature of 'a �l cant Co- Date of Signature Date of Signature DOCUMENT NO. STATE BAR OF WISCONSIN FORM 2 -1982 THIS SPACE RESERVED FOR RECORDING DATA WARRANTY DEED 431006 n F " I n 's voi 9,41 Rolling Hills Development, Inc_, a Wisconsin_ REGISTEWS OFFICE corporation ST. CROIX CO... WI Recd for Record conveys and warrants to Eugene 0. Larson, Don D. Kruger, at MA 2o 1992 and Lawrence M. Johnson Jr. doing business AA as Quality Built Homes 0 "`` Register of Deeds RETURN TO the following described real estate in St. Cro ix County, State of Wisconsin: Tax Parcel No: Lot Sixty -Nine (69), Oak Ridge Acres, to the Town of Troy. tT ` n UaR J I I This is not homestead property. (is) (is not) Exception to Warranties: easements, restrictions, and rights -of -way of record, if any. Dated this 25th day of March D N RU,LJ�ING KILLS VE (SEAL) E - . By: Richard N. Fox, Presid (SEAL) �—� (SEAL) • By: Frances J. Fox, Secret AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN SS. County. � authenticated this —day of 1 Personal) came bofr -re me this 25th d of Y 9 Y Y March 19 the above named Richar N. Fox and Franc e _,q__ J . Fox TITLE: MEMBER STATE BAR OF WISCONSIN .u.ua (If not, to,c>?e'k n {ii•bq the person who executed the authorized by § 706.06, Wis. Stats.) ,fdl�I S #*,� " acknowledge the same. THIS INSTRUMENT WAS DRAFTED BY �'L C. L. Gaylord, Attorney T� y River Falls, WI Ii (Si 54022 IotaFy u County, Wis. natures may be authenticated d r acknowledged. h e �' Commission i 'm 9 Y a e o ac ow ed ed. Bot '. Commisslon s et anent. If not state expiration g� . �� P are not necessary.) daQb O ' /D 1g Names of persons signing in any capacity should be typed or printed below their signatures. S82 NTF 0021 WARRANTY DEED STATE BAR OF WISCONSIN Nelco Tax Forms, P.O. Box 10208, Green Bay, Wt 54307 -0208 '� Form No.2 — 1982 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER [ VJ ADDRESS: /3 t x 3 q Ri0jr1olt ai S FIRE NO: LOCATION: -5 f , �L 1/4, SEC. 3 f,--. N-R 1 r'( W, TOWN OF: ST.•CROIX COUNTY SUBDIVISION: /a„t 2t v 6A `�e�Z S LOT NO. - G q 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 septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system: St. Croix County residents may be eligible to receive a grant to help with the cost of the 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 the St. Croix County Zoning 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 (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. Certification from will be sent approximately 30 days prior to three year expiration. I /WE, the undersigned have read the above requirements and agree to maintain the private sewage disposal system-in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification form must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: l DATE: 2� St. Croix County Zoning Office 911 4th St. Hudson, WI 54016 ' rt O a -' 0 0 u '] Vf p� 3 ' to (� �+ j :3 p D Z 0 > N - n N y ob b Q 7 v N /D c m C l I m - . 1 ° x ° ? Ri X � 3 -a J r r v : r' t� A G 3 ? O O� 3 K ' (D o J P OP On ft N 7 r+ N. V n t O n O V I,- ( 0 " r `� O ti G 9 - �Xd cp "K 'P b to I I I C .c G► z O A �� �O f co S � J yf c a N O' O N G ~ ` C O ' �° 4 U) Q O � r -- m '� o e N c a to 0 N A w c�! N N c, j r N (D 3 t^` n m � . . s c O oj n v O 3 3 `, . 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C b 3 O 1 dN D 0 OrQ� O V r Q M C lP 1 �' �toc tQ to Q- r Cl r- V to O V w v+ J f-+ j �1 -^ < r O D = o b r 3 Q l!1 ° 0 o o t' 4� C3 �+ 0n o rb ��1 M d� -, e d !q I W CL:) lTa- ( .. I C N f r v (W an M v G U1 N °P /�! �( t ;p3 i vi 0 � � (A fi it G w N - o � o 6` o N � G Q L Q o ✓ or' a . J R I I o^ ° �, >na Mi a O P o ✓J Lp x ° D N m m � N 0 rj K m La V' N O x l< l< � —i A N Cl 1 p to CD 9D 00 al CL W - 0 b c I �. N O r -a W Lo N Q PR Lb CL v r - o �m r•? O ro �o f _(D e3 cJ 3 C m LA In d N p 3 QQ� 0. D P -0 j G •� N � ' U tip CA 4m -- V/ I 5 I.1 W o r o D O p o a "/ ° i to o N � V'► V) o a � °, U N �' < 7- I �. 0 D Z o =: en C 0 rf n N tO r+ 3 Z O �. T fG C. d d7 oo G v �•� ; W 3 Ma ID J O 01 9D gyp' 3 N r . .. tij o ° ^0 �.. O o G 3 -1 G m d C. o N� G S Q z a OX kA CA -{ IV 1p b ^� If1 � o co (A 0 o u O � ° — N d ,- -0 0 O m 1 ' o� ro N .. w.r0 N Q m A N� z m LoO IV O V 0 . OL N ro N T T°i d A �' CL cl A a D 0 to O v a eo U1 CA �7 O SJ^ ° C IF so fD � 0 N N ' r ri W ` N O< 4-0 qA (> � �, f IA W LA a tG 1 J a a r � 0 0 t ]C v '• �D m H d CA Z d jr O D m°+ N � �� (n n n 'f M C _ o 1 0 © o F 0 O O N °' -j CD � 4m �-- o i U:) d a o > un � � <_ .(�; ° Q o 3 ; I ,. O O �� (D a N o r d:�`G, 3 �,CA � °o b d3 O d tD ? ^ r^ A C � C f Z ' r 0i 3 � ;o � s Q d p o O ter. (A c N n b in V) � � o N� ~ K - P N O d U �^ (P O N O co ~ C C r N ...5 N ` n 00 N ° m N .- �� .�• A A N O � � A 0 (D 3 r_ 4. �, z m d- NM o ell M m ^ A O p �3 D 3 G N rl O_A OD Z» to cD o ro Q4p '° o ` a D O b IF (D � N 0 g N *m� � A t � 0 A � i� P C T. J cn u 'A C �. 43 • • S 0 00 A �° cD 3 C, b -► fD fD N d C b up b Z jr O D m r� A Lh C< p - 0 d 0 d w + c q& �N g ;X90 r U1 '� a o �^. a -. s y Lo Nt° I� - V c to � to a� _ 3 L p o_ r D. in zoo' N w i - �w r a o Q 3 ( - �� cl ° rrayy L o � y A �"_ ° W z C/ 1 W cc 17 r V c 0 - -j — tpo Lo 'D r A v w "sp - C� t p zoo. o N� J v w 67 1 �Z of A n Id- �nl?° ll Pip P LC)T AAJ AN r,eT 0. ri IV J ,v t' cvz r o g ,� sE l "-DUB I I I L L D R e ,r Y .e• I .Z I QuA, t L -C ff _ CS � � l r M t j p p d - Al o IV v\ s X05 CPO J Q ZS O I pn� t Arp 1V �W crrC+2 o g p - s E o� c Ec �o x REPT131 TROY o ST. CROIX COUNTY ZONING PAGE 1 09/3b/92 oa a63 REQUESTS FOR INSPECTION WORK SHEETS FOR: 9/30/92 AREA: JT Activity: A9200128 9/30/92 Type: CONVSEPT Status: PENDING Constr: Address: TROY 36.28.19.822,SE,NE,36,WOOD RIDGE DR,.LOT #69 Parcel: 040- 1188 -90 -009 Occ: Use: Description: QUALITY BUILT HOMES, DON KRUGER Applicant: QUALITY BUILT HOMES,DON KRUGER Phone: 425 -5358 Owner: QUALITY BUILT HOMES,DON KRUGER Phone: 425 -5358 Contractor: NELSON, ROGER Phone: 273 -4444 -------------------------------------------------------------------------------- Inspection Request Information..... Requestor: ROGER NELSON Phone: Req Time: 15:09 Comments: Items requested to be Inspected... Action Comments Time Exp 00012 FINAL INSPECTION -------------------------------------------------------------------------------- Inspection History..... Item: 00012 FINAL INSPECTION -rent of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix livision V' INSPECTION REPORT Sanitary Permit No: 430403 0 INFORMATION (ATTACH TO PERMIT) State PI I No: T aormation you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)). S = 1 �YI/��j• �. .solder's Name: City Village X Township 'Parcel ax No: 'tbertson, Gerald I Troy Township 040 - 1188 -90 -009 ,ST BM Elev: Insp. BM Elev BM Description: Section/Town /Range /Map No: yofl.� rya .8a1: J w.o , BUA 2 � 36.28.19.822 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark � � q �y I O � g � ' � • � � Dosing Alt. BM ya Aeration r Bldg. Sewer t ` f c Holding St/Ht Inlet St/Ht Outlet / TANK SETBACK INFORMATION 43 s:sZ TANK TO P/L WELL BLDG. Vent to Air Intake ROAD �� w� �•Sa s Septic 7 2S 1 �p D , 2. / ^em u!( 4 . ( -P .29 r i Dosing 2 s / $1 33 �o i / Header /Man. > �' x S•6 Aeration Dist. Pipe W 5 3 / Holding Bot. System Ca •, 0 F inal Grade �t PUMP /SIPHON INFORMATION y ,�Lk IZ f 56IQ COW -- Manufacturer Demand St Cover �� 6 GPM t Model Number PM& -/{n 3 2-0 4 9g•1) TDH Lift r Friction Loss System Head TDH Ft � 1.2. 3 S Forcemain Length Dia. Dist. to Well 2- " _ i' C fl 1 3 2 - 1%46 SOIL ABSORPTION SYSTEM D (2• BED/TRENCH Width f Length ' No. Of Ttm es Plf DIMENSION No. Of Pits I side Dia. Liquid Depth DIMENSIONS It37 SETBACK SYSTEM TO (/ P/L BLDG WELL LAKE /STREAM LEACH nufacturer. INFORMATION Type Of System: I � / � r � � CHAMBER IV, 1 � Number: '� —fir DISTRIBUTION SYSTEM b. - 6L -j-e st /L Header /Manifold Distribution t t x Hole Size x Hole Spacing Vent to Air Intake flp. D Pipe(s) 2 1 �.O -7. 6 3 ! ?( 8f Length Dia Length Dia Spacing �j ✓ SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only 372 Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched BedlTrench Center Bed/Trench Edges Topsoil Yes No Yes No O MENTS: djs� e es, persons present, etc.) Inspection #1:1 / Inspe lion #2: 0 • I �' G�0 T oca ion. 3 E. Woodridge Drive River alls, WI 54022 (SE 1/4 NE 1/4 36 T28N R19W) O L 69 Par el o 1.) Alt BM Description = M124 ea) 2.) Bldg sewer length= t2. / ' -amount of cover =U) (4 - -> / 3 -/orb has h. C � 60 .1 72 _ Pan revision Requlr ? Yes No Use other side for additional Information. L L - -- e ctor's Si nature Cert Date p g . No SBD -6710 (R.3/97) Safety and Buildings Division County 201 W. Washington Ave., P.O. Box 7162 isconsI n Madison, WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce 1 (608) 266 -3151 3 3 Sanitary Permit Applic State Plan I.D. Number In accord with Comm 83.21, Wis. Adm. Code, personal infratfiionRCMoV �� �� may be used for secondary purposes Privacy Law, 1)(m) Project Address (if different than mailing address) I. Application Information - Please Print All Information [ 9 n �p 2 0_ Property Owner's Na me � ST. CR )IX CUUNiv" Parcel # ot# Block # G-�Pi f r - 1,3&1v,9+ rr� /,6e2 oFF�cE o o Property 1,0000 Owner's M ailing Address Property Location / t� . Q0� /� � A�� k,Section C'ty, StaatQte�� / Zip Code Phone Number /1 ., fJ �/, iiv j ail. ,5 j *V Z� y�J Sy7 1A /? (circle one) II. Type of Building (check all that apply) �j T N; R # or W K 1 or 2 Family Dwelling - Number of B ooms ! Subdivisioonn Name CSM Number ❑ Public /Commercial - Describe Use ��• 0 ,4K " � s A W / 11 State Owned - Describe Use 3 X S ❑City _ ❑Village Township of 7/C 1 1, =( my one box on line A. Complete line B if applicable) placement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System rntit Revision El change of El Permit Transfer to New List Previous Permit Number and Date Issued Plumber Owner Check all that apply) <, Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter _ u Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -le s Pipe ❑ OthelLexplai V. Dispersal/Treatment Area Information: A 6v"404 Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (sf) Dispersal Area Proposed (so System Elevation 1 / 9 0 1 . 5 1 ys ? 7 70 VI. Tank Info , Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New Existing Tanks Tanks Septic or Holding Tank Aerobic Treatment Unit Dosing Chamber - .7< / i E t 15 /� n _�/ _ / HIE VII. Responsibility St. (� issume responsibility for installation of the POWTS shown on the attached plans. Plumber's Na me (Print) re .MP /MPRS Number Business Phone Number 3 � X0 � e 7 ?,r (� �� 77a y Z Plumber's Addre ss (Stre B/ o %2 • S��i�G� 1114 l/ ZV/ 5 y7c VIII. Count /De ark X Approved ❑Dis Sanitary Permit Fee (includes Groundwater Date Issued I su' g Agent Signature (No Stamps) 36. ?X3 4 Surcharge Fee) $350 �_ ' ❑ Ov ' IX. Conditions of Al royal 3 1 _ � n $R!( /�_ SYSTEM OWNER; 1 Septic tank, effluent filter and dispersal cell must all bg §grviced j maintained as per management plan provided by plumber. p 2. All setback requirements must be maintained I as era applicable code/ordinances. tom - p pp Attach complete plans (to the County only) for the � paper not less th 81/2 x 11 inches ' size SBD -6398 (R. 01/03) u/ ALL �-- pp W� / G S N pRppE IN 44 121c ,�` # • f b g3 MOO f� p11.'�E � R p r � � 3 az g ��MS I z8 S N mew � ,, �� Cc 1 , O F � ►N jA) Tor of Fi�a,�., y. 30.9 I AV C5 Co•� �e .4 /IjM `5 S y y r& - F 3. S Q i Cd �/ C GAp /06• i - - - - -- -- - - - - -- oT� e 13 i o 97 SC MA d I 'M vAj ' GDS fo v 5 g 7 0 M�NiHV � � � s '� o y�•so E 13 0 9*1 5 0 i'E Ted M, v ,O D -SYSTEM / VihTipv �0 -CJ � 'fi 7 The area 15 ft. below the downslope edge of the Soil Absorption System must remain undisturbed. zo 13.4 �,- Pi T-S r Safety and Buildings PO BOX 7162 MADISON WI 53707 -7162 TDD #: (608) 264 -8777 vi, �O��In www.commercestate.wi.us/sb Department of Commerce www.wisoonsin.gov Jim Doyle, Governor Cory L. Nettles, Secretary September 26, 2003 CUST ID No.226375 ATTN.- POWTS Inspector ROBERT W ULBRICHT ZONING OFFICE ULBRICHT & ASSOCIATES CO ST CROIX COUNTY SPIA 2812 10TH AVE 1101 CARMICHAEL RD SPRING VALLEY WI 54767 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 09/26/2005 Identification Numbers Transaction ID No. 924531 SITE• Site ID No. 665705 Gerald Gilbertson - Dwelling Please refer to both identification numbers, 93 E Woodridge Dr above, in all correspondence with the agency. Town of Troy, 54022 St Croix County SE1 /4, NEIA, S36, T28N, R19W Lot: 69, Subdivision: Oak Ridge Acres FOR: Description: Replacement Mound System / 450 gpd Object Type: POWT System Regulated Object ID No.: 922761 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. 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. All permits +. C required by the state or the local municipality shall be obtained prior to commencement of cozid construction /installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should A P conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review DEP 7 shall relieve the designer of the responsibility for designing a safe building, structure, or component. DIVISJ 1 O Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the addre�5'�� on this letterhead. cc)i ''�Ey 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. iragel Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 n R wer II , Integrated Services WiSMART code: 7633 (608)266-2889, M - F, 0630 - 1500 Hrs pepagel@commerce.state.wi.us cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544 i * U,LBBICHT & ASSOCIATES CO. 651 O'Neil Road - Hudson, W1 54016 Reg. Designers of Engineering Systems 715- 386-8185 Private Sewage Consultants RECEIVED PROJECT INDEX Plan I.D. # _ Date S j 2-r G 3 Owner 6 E - Rw o t� Phone 7/ • y 2 5 S yyY Address y3 G t!v 00l� 2� l� � E" !/�. _� /•U Legal Description Lp T #�, 6,f z 4,t /�j� - E - 4415 ?,('n.? o rh o 11ek• fo - oo� S�, Nom, S-ec. 36 rLam, � /sr w Town of County C.S.T. �• �l�G�� /lGr 2 Z -7 S Installer P Local Authority/ Supervision f . ; Cam � - PROJECT DESCRIPTION �Az4, /N S X49 7W ��„•� S l7 � l� /� �y�3 �ti o,v� Y7 P T�,Ao Ulbricht & Associates �� • Private Sewage Consultants 2812 1 dth Ave. Spring Valley, WI 54767 A0, ��cs F Pg.1 PLOT PLAN VIEWS Pg.2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEWS (REVERSE SIDE DETAILS INSPECTION PIPES & FABRIC /TOP FILL DETAILS) Pg.3 PIPE LATERAL LAYOUT (REVERSE SIDE SHOWS DETAILS OF LATERAL CLEAN OU ) Pg.4 DOSING CHAMBER CROSS SECTION & SPECS. Pg.5 PUMP PERFORMANCE SPECS (REVERSE SIDE SHOWS PUMP DETAILS) Pg.6.OPERATION, MAINTENANCE REQUIREMENTS (REVERSE SIDE SHOWS SITE & SPECIFIC PROJECT DETAILED INFORMATION,UNIQUE TO LOCALE AND GOVERNMENTAL UNIT AREA) The attached plans and specifications are based on the following approved manuals: "Mound Component Manual For Private Onsite Wastewater Treatment Systems " (Version 2.0 SBD- 10691- P(N.O1 /Oi) and "Pressure Distribution Component Manual For Private Onsite Wastewater Treatment Systems" (version2.0) SBD- 10706- P(NO1 /01). r o G 1NC� �� a3 441 0 00p I F1 � -�Ea z� • l ` ,0 3 0 S Y * O o N 5 v 's -r; u � 5� s c Nom' P r To F I _ i o � � FiP y• 30.9 N w �5�'e Cow 't 't To P F� y6r�M � co r �� G eAp 106•b 9�S'c 5 7o�fi a 13 u lr � 53 fo v Mi' N u M 70 � � r 13 3 20 S U E rea r� o v a S�/ STE M ' / -, + k . W r /s1 es 44A- C ltll P� U The area 15 ft. below the downslope edge of the Soil Absorption System must remain undisturbed. _ • / „` 5 C,4 • r3 ���� P�� rs � - z P of CPOSS S E GT10h) W MouoE> wi Tti B eD B ev O " 0 F ro Alliec -5ATE �iSTRi(3t�T�o� G , T'kt C, k fs E•s s pi to Cr OF T ap sort rv/ Tahlx sysreM elevA rio,v 70 If UfJ 1 FoR M To E' 9� �Ir r� H ' _ - t-i'" E artT�o , MEv.. e i ►' • SAND . T o P Sol u F F 2 '7-o S I o P E F ORCE - u E t WATIoa c» OE R Mhi� Bee 7 D 1) , c�1 F r. --- ELE v h rI O N 5 5 -- ff E Fr. iuvERT' OF if IATERA ( g qo• 2l1 F .1S FT• • Top of Rack qg• a G 05 FY• cr N • p F • TOP O I ATER A I S 1�• 30 �i PLAN VIEW vF MOULD -- W rri 13E D e 6vO & FvRcE MAW A / FT. I 4 d F.r Fr a - -- IT L. S w t ---- - - - - -- -- - - -yam' 1 FT Fr N 3 Fr B e r7 a F ! Pvc cADn n To IL qq 4 QEG-A)TE- d (3SE R VATS O AJ A4 f�viV PERMAnjEuT MARkERS PPS Of GICAA9 7 00% S REG2uiRED BASAL %QeA 'D A�'�y lUhsi'E'F1 - Jj�"o Soil, 80 ITRATIOE S C APAci ry S4. Pr. PRopoSEV S3ASA1 AReN = X ( A 0go ( 0 v� ) - 6r x ( / 1 S. 1, I=T, T TP1 h U Q oo LA Yo61 T f CEO R A MA 1 p P • ST `� Z Z Fr R 3.0 rr 6EO - tR A L- P O R c e MA X = luC. y J�o rr. PUL ---- 1 C 1 PARr To �CA L V (9 1 D V a I v M E N d i f~ D %�'-t E TE 3 �"o r44L ll0 /U.y� R IN4 N �s iNc HAS ,.7 • C" -rRAL M AMI r oLD 2 a . INCF{f;S MAIN -Z tucµEs �� •�� °� NoIE g L u V E R T E CE V AT t C of LATE! SEA Utz PSE SIDE ro '� C� Q• '. c/o D E T f L pp R Fo R Aye P P P E DIQ� �i cLe- -F4. U R� Mou� - X411 DRill 1 ` \ t R � i � f3 uRR5 Y Kot�S ldc�T�b o,J {3oT1'oM 6� Q V A11 Y S.pAc& D . �ISTR�`[3uT'tn� 1��5chAQGE RATE PAR �a R, eAch LArP-RA L GA 1'oTAI 'O - Di5cH,&%R6E ATE ror N�rwoR K 3 I. g G 4 �4 �1�►tiu. � a•5 Maui MVM t . PUMP CHAMBER CROSS SECTIOM AMD SPECIFICATIONS P,4 E `f of �o 7 Pvc -VENT CAP I PI WEATHER PROOF VENT PIPE APPROVED LOCKING JUNCTION BOX MAWHOLE COVER yg. to/ W,4, 01,06- IAAk 0 12'MIU. � I pr ��� t rt - /O n/ GRADE ` 4" MIN. / COWDUIT - - -- -- - -- - -- 5 0 ---- - - - - -- 1114 P (I /L/ PROVIDE I - - -- ,, -i•- INLET AIRTIGHT SEAL I I I I r� APPROVED JOINT A `�jy K I III APPROVED JOINTS k\// PIPE IVI�� I I I EXTENDIMG 3' �0 I ` ALARM EXTrM 3' ONTO soL� s�� j �� � 3 y0 i I . DNS SO LID � °BUG 5C14 ' -� P oN yo I- LEV. FT. oM _.J vs; e 3 o P UMP OFF D ` ,( PINK A - e� vim N `g�p �( k BLOCK cc l[- V A f i 0,J � c I RISER EXIT PERMITTED GQL9 IF TANK MANUFACTURER HAS SUCH APPROVAL .-jr, SEPTIC E SPEC IFIGATIOI�IS DOSE j TANKS MA NUFACTURER: IJUMBER OF DOSES: �•� PER DAS t TAMK SIZE: / 7 0 GALLOMS DOSE VOLUM11- It ALARM MANUFACTURER: INCLUDING BACK LOW: 90 GALLONS MODEL 1.1UMBER: D y ��" ' CAPACITIES: A� / IMCNES OR � GALLONS y SWITCH TYPE: . B = 2 - INCHES OR 8 GALLONS PUMP MANUFACTURER: Z / / �� /� ��• P • C = WCNES OR - GALLONS MODEL NUMBER: 13 D =LL' - 2- INCHES OR GALLONS SWITCH TYPE: i ji ✓A r &� MOTE: PUMP AND ALARM ARE TO BE MINIMUM DISCHARGE RATE. GPM 7 INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE 15ETWF-EU PUMP OFF AND DISTRIBUTION PIPE.. / FEET - rAA)k S) fC S -I- MINIMUM NETWORK SUPPLY PRESSURE . . .. . . . 3' FEET: EAGGL I Of .Y{ W it + --19L FEET OF FORCE MAIN X 2.2 100FT.FRICTIOO FACY /. ? FEET /, S �•15 / TOTAL D9QAMIC. HEAD J FEET `C Y 4IS• - go Vjp INTERNAL DIMEMSIONS OF TANK: LENGTH ;WIDTH ;LIQUID DEPTH n THIS POWT SYSTEM SHALL JOUJ,v.$'PEAM of �x� INCORPORATE PER COMM pR ��s T-- S" Fie 83.44(2)c A PROPER ZABEL / /��}� FILTER MODEL # ri4N� . �Q� �Q �C1 I SEPTIC TANK, per Comm.83.44 (2) (c) shall be equipped with an outlet attached approved filter device (Zabel fliter). Tank shall have an approved above ground locking manhole cover for regular (every 12 months or less) inspection & servicing by a licensdd service pumper. �.S o�Co� H EADI LL CAPACITY 1S 34 „o 32 ,OS lQ tic 38 ME40 Series M "M 4/10 HP Effluent and Drain Water Pumps Performance Curve i MODEL ME40 EFFLUENT PUMP CAPACITY LITERS PER MINUTE 0 50 100 150 200 250 300 350 40 12 35 10 (J) 30 O Z 25 8 Z N 20 s 15 It -�9 4 a T o 14. 10 2 � 5 0 0 0 10 20 310 40 50 60 70 80 90 100 CAP ITY GALLONS PER MINUTE 32,0 rv"_� F.E. Myers, A Pentair Company a 1101 Myers Parkway, Ashland, Ohio 44805 -1923 419/289 -1144 FAX 419/289 -6658 Telex 98 -7443 K3328 7/91 Printed in U.S.A. • Stainless steel screws, bolts, guard, handle and / ,r""/ 138 Series SB -1115 137 Series SC -2225 arm and seal assembly. 'Bronze motor and pump housing, switch NOTE: No UL listing for 200- 208V/1 Ph. case, base and impeller. pumps. Mercury float switches are available for non - automatic models. r Wisconsin Department of conmienc SOIL EVALUATION REPORT P age � Of 3 Division of Safety and Buildings in accordanoe with Comm 85, Wis. Adm. Code Attach complete site plan on paper not less than 81/2 x 11 inches in e. include. but not limited to: vertical and horizontal reference point (BM), ir E IV uu f �j Q a percent slope, scale or dimensions, north arrow, and location and dis ce to nearest road. arW I. o • f�a d / o • 0 0 / Please print all information. S t P 2 y D by Date Persona( blfb -mtmn t"au Pw may W used Tar secmWafy Wpm Mdvy w s. 15.04 (1) (m)). Prnpertyowner v Gj5RALD I�,P ,�,u9�- Cy; 1, 85 T' So n" N G ! t, T � i S � o . T ? 8 N. R ` 7 (t (or) W Props � Owners Maims Address Lot # Block # Subd Nam M# e or CS � . �,vaoDRiDG -�' G ask / ?in �9-Gc.L3 y State Zip Code Phone Number ❑ city. ❑ village ICI Town Nearest Road syoz firs ( Yes•'Yoe �-,_A0.0 y 0 New Construcbm Use: -Residential / Number of bedrooms _ _ code derived design Raw rate d GPD Replacement 0 Public or cornmercial - .r e: �1 Parent material DAS S OI>L,V DBt tQ- Flood Plain elevation if applicable A i° . A Y pg�-;eY 'P&'E-p sl-•t'�rs d s�G SrcL N10 G� Gc F/I# a �7 f� t zR Pit Ground surface elev. Depth to limiting factor i _ n. Sob Applicallm Rate Horton Depth Dartkiant Red= Description Texdre Structure Consk tenoe Boundary d GPON in. Mumll am Sz, Coral Color Gr. Sz. Sh. 'E(F#1 'Eff#2 iko S!L S6k �t-F cw 0YR y SrL 1 fs6K I,C s y Boring Q # Pi d � Ground surface elev. � ft. Depth to limiting factor 3 0 y in. Soli Applicabon Rate Horton Depth Dominant Color Redod Description Texture Shi Lure Consistence Boundary Roots GPDflf In. Munsd Qu. S7- Con Color Gr. Sz. Sh. •Eff#1 'Eff#2 o• 2 o y,� .StL z�Fsh� •wt�r2 w 3 f . s • o /4 ----� SQL's L oll z M o C L f,5 bK nm-F i a s 2 - • 3 dsA f-7 • Eflfuent #1 = BOD > 30 1220 mglL and TSS >30 < 150 mgil. ' Effluent #2 = BO _< 30 mgll and TSS < 30 rnglL CST Norm aP,��f� Zrlb c � T _ Si g nat ure z 4f ,, S- Address Date Evaluation Conducted Telephone Number �4 v . - 7-,;Z003 71S • 77a• 3 yyZ t1lb riont & Associates Private Sewage Consultants 2812 10th Ave. Spring Valley, WI 54767 ORIGINAL Cr • �i G/3�2TSo� /� /Q� y Y Owner Paroe110 # Y� • /` v 0 • � • a �" Page or S 131 # ❑ t3orin9 2 ,l ` sss Pit Ground surface elev. �> 3 (J ft. Depth to +g tads 3o in. Sod Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Rods GPVff In. Munsed Qu. Sz. Cont. Color Gr. Sz. Sh. •Eff#1 Tim a• 2v �a yR --- s iL fs b e /m f 2 w 3 s � o YA - F k Cw ! ..Z . 3 cZ rl o TS / L fShK nt�`FI q,S F Bor in g ❑ Borin ❑ Pit Ground surface elev. ft. Depth to knifing factor In. SWA ppl icadon Rate Horizon Depth Dominant Cdor 'Redox Description - Texture Structure Consistence Boundary Rods GPM in. Mussed Qu. Sz. Cont Color Gr. Sz Sh. •Efo1 'Eff#2 � 0 7" .Pti U �.0 C• -- �,P amt v N U t o e- s i �'aN � rna.c� • e �v c� : ` DAY -OF # ❑ Pit Ground surface elev. ft. Depth to Uniting factor kn. ❑ Sdf ApOcallon Rate Horizon Depth Dominant Color Redox Description_ Texture Structure Boundary Rods 9M In. Muusell Qu. Sz Court. Color Gr. Sz. Sh. •Eif#1 T02 w F] # ° Bori 11 Pit Ground surface elev. ft. / to Uniting factor in. Sol Rye Horizon Depth Dominant Color Redox Desaiption. Texture Structure Consistence Boundary Roots GPON in. Mursed Qu. Sz. Cont. Color Gr. Sz. Sh. 'Etf#i •01102 • Effluent #1 = BOD, > 30 220 n & and TSS >30 150 mglL ' Eftent #2 = BOD, 130 mglL and TSS 130 mgiL 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. �4,v Ak TP- 5 T TEST wi// 7 I OS -1,01 1 4- o t) i¢- f 00. ,9,;fT /oAu' 4 Gi���v/"SE 1�,4U " TU ,dam �Io UPL� i z AR 3 13 fl�i c r � j b----.. _,.___ � ► �a ► 7i O t -- -- ! e / r — S � - -- -- - - - - -- e Q 13 f 6�6 �57 9 d OV)oD ? 53 20 L.fJJ� l CA 4 f B A cam' P°' �� S'1' CiMIX COUN'T'Y SEPTIC •TANK MAINTENANCE AGREEMENT' AND OWNERSIIIP CERTIFICA'T'ION FORM Uwtter /I31.1yer lf'"/�� ? ���iV�/¢ ISO ,e> Mailing Address f3 tF• 4�2009 .� i. i Property Address (Verification required from Planning Depattmenl for new construction) City /Stab ���'�t//�l�f Parcel Identifi Number dy � • �� 6 '� • �'� M Ai VESCRIrTION Pturct,y Loci lion S t '/, °i� 5ec 3 T' N -R W Town of T��1 Subdivision _0400 �f� �f , Lot # Cerlilied Survey Ajnp # 0 , Volume 1 117f- Page # wflrrnnly Deed # _Z_1 S� J , Volume ! g/— Page # �O Spec house U yesx no Lot lines identiftableX yes U no SY91EM IMNIENANCL Inirtoper ttse and ntainfenanceof your septic system could result in its pretnalute failure to handle wastes. Proper maintenance consists of f out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affed the function of the septic tank as a`lieatnment ststage in the waste disposal system. The properly owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master l+EUntber, lotttneyntan plumber, testticted phr►nbet or a licensed pumper vetifying that (1) the on -site wastewater disposal system Is in pe pct operating condition atid/ot (2) after inspection and pumping (if necessary), the septic tank is less than 113 full of sludge. 1 /we, the undersigned have read (lie above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Deparintcnt of Commerce and the Department of Natural Resources, Slate of Wisconsin. Certification atntit p, I11a1 ymur septic gygletn Iraq been maintained roust be completed and returned to flue St. Croix County Zoning Office within 30 days of file three year expiration date. 9 SIONAmpu Ur APPLICANT DATH U1�'N !�ER' _ IC A1]0N 1 (we) certify Ilrat all statements on this form are lnte to the best of my (our) knowledge. I (we) Ain (ate) (lie ownet(s) of fire vInperly described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIMA ; JRLr OC APPLICANT DATE Any information That is mis- represented stay result in the sanitary permit being revoked by the Zoning Department. * * * * ** *� Inrlutle tclfh Iluls Applicafion: n stamped warranfy deed from the Register of Deeds office R copy of the certified survey map if reference is made in the warranty deed `r OWNER's MAINTAINCE OF S 1 x (J jlI i EPTIC SYSTEM . POWTS (landowner maintenance of this rePonsible for proper operation and servicin g s ystem. Regular is Periodic inspections and necessary for the system, The owner safe health maintena is required by code u operation of. this /inspection reports to the o submit all necessary controlling ,authorities. SPECIFIC CONTACT AGENTS * Governmental authority/ ST eAa1 x Cp l ' �l,c.l1 A_) Y/ inspectors: DO 7— his- Y� ,nO * Licensed installer ma intenance r esponsibl e Users mprovidin anual: for prov 7/S • - 7 7� 3 yyz an operation/ * Licensed servdree / inspeCtion agent other TIPI �T j s��r' than installer: f3L-�,v NoleC� 3 S6• , 130 * Electrician, for pump, electric controls, wirin g units: IMPORTANT OWNER MAINTENANCE RE UIREMENTS X• Winter traffic area shall not (sledding, shovetin be permitted, or g' etc.) across the the cell, freezing up frost can /will winter.(a vacaction P system D iscontinuos useetrate into lead to freeze ups. resulti in the Ps• resulting s no water use) can also Water conserva tin needs to be exercised! Water licall 2 • designed y overloaded and destroyed• Z•hi�r s y s tem can be for a maximum wastewater flow o f svS�em was ,. 3 - POWTS a O gals. daily. nvt desi disposal unit fined to accomodate or any other unnaturalwas rc from a destroy this of waste garbage, such sources of waste. Y this system, materials will overload and 4' If a Power ; in a outage occurs, or a cell temporary overload of effluent being s, it may result which may adversely p the cell Pum into the recommended that y im act allowing the a licensed pumper empty (leaksing It , Consult Pump to return P Y the dosing tank Your installer to dosing the correct 5• immediately for advice. amounts. Neglect of the v erosion pre the vegetative cover traff ) can lead (the cells insulation is also can destr o to failure. REGULARLY WATER Y t he compaction or heavy the THE V EGETATION system. It IS NECESSARY TO ystem beneath IS NOT s OVER A SYSTEM!! Effluent fir cover. ufficienL t0 in alone maintain a 6. Periodic ins p ec tions Pections by the owner n ecessary . I nspection • or his the system. Pi p e s and ports agents, is Into inspection Pipes), mound basal have been i le laterals Pi es pout area (effluent Incor porated at each terminals on level out. The filter sy tip - for flushin the Pressurized ground cove le). in the g and cleaning the Person o nly cover/manhole). O tanks (via a locked laterals & severe safety be performing a licensed ick above ystem safety risks. Evidence this w which p quali6ied s 's idence work involves health treatment Cell °f effluent 1� shall also be Ponding In the regularly inspected. Pg. 6 of 6 Mound System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Slats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The fitter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the fitter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Puma Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Mound and Pressure Distribution System No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October - February) dictate that the mound be heavily mulched for frost protection. Influent quality into the mound system may not exceed 220 mg /L BOD5, 150 mg /L TSS, and 30 mg /L FOG. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system is provided with a flushing point at the end of each lateral, and it is recommended that each lateral be flushed of accumulated solids at least once every 18 months. When a pressure test is performed it should be compared to the initial test when the system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution within the dispersal cell. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 4 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. General = This system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall maintained in accordance with its' component manual [SBD- 10572 -P (R. 6/99)] and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. if the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component shall be immediately repaired or replaced with a component of the same or equal performance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or by removing biologically clogged adsorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. Questions on the operation or maintenance of this system should be directed to your county zoning or health inspector. SF.F REVERSE SIDE Pg.6 FOR MAINTENANCE REQUIREMENTS SPECIFIC TO TIIIS SITE, DESIGN, AND COMPONENTS � 7 - S - // DOCUMENT N O, WARRANTY DEED Tp S a►�Ca srstavao post R[CopolNO DATA ii STATE BAR OF WISCONSIN FORK 2 -1982 ;i 5 1575 ',O! 981PAGE 180 REGISTR'S QFRI Eugene O. Larson Don D. Kruger and �rE ... ............................... ST. CROIX C Lawrence M. Johnson Jr , doing business as W Qualit Built Homes a Partnershi . R!�'d fey Record conveys and warrants to Gerald L. Gilbertson and B renda NOV ;'; 5. :.,_G.ilbez.�son .....hus. an• ,..... . -s - -•- 1 Q ••and - wife with 0 11 g;�g A survivQrshiP .............. ............................... .. ......:::::.............:............................_................... I.............................: a- isii .... ....................... ................. •--- ........•. - •...................... to j ....................................................................... ............................... . ... . . the ioflow .. .... des ...... ribe .. d .. real ...es t a.i.... !n ....... ..- . ...... THE FIRST NATIONAL BANK followicd estate ........ St_. ... Croix ......... County, BOX 166 State of Wisconsin: RIPER FALLS WISCONSIN 540271 Tax Parcel No: Lot 69 t Oak Ridge Acres in the Town of Troy, St. Croix County, 92 RAN l o / ©! i Z � FEH This ..... not homestead property. (is) (is not) �I Exception to warranties: easements, reservations, and restrictions, if any, of record. ;I ;► Dated this .............1 . .... 'November ..... ............... day o! ...- ......`.... -..- ......, 19..92... _ ....... ............................... QUALI BUILT HO e / C .. .• (SEAL) (SEAL) 4: f1 :. * /'E g �C . -; ene O. Lars n Lawrence M. Johnson,Jr c ...... SEAL .... (SEAL) • .Don - D. - -- Kruger AUTHENTICATION ACHNOWLSDGURNT j Sicnature(s) of Eugene O. Larson, Don STATE OF WISCONSIN D. Kruger & L .. . aw ren...ce ... M. Johnson, Jr. Pierce �ss. ... . .. .. ....... .• ---- •- ...-- •-- •• - - -• 1 County. authenticated this ........ day of._NOVember . 19 92 personally came before me this ..12t1l day of November .. 1992... the above named a D. Peter Sequin LUgef1e_. Q,•. Ar , son. Don__D._ Kruger g--- ... -• -- TITLE: MEMBER STATE BAR OF WISCONSIN a13S1_.baW.?Cen &e... t --- onso hn.. Jr, - '•"""-' ...........................•-•--........--. ........................,...... _.... _ i u t not , horiz ed by ........... ..... . . . .. ......... fo uted 708.08. Wis. Sta4.) to me known to be the person P....... ..............IAM a _ e1 re i trument and no ledge t '• ' ti�� THIS INSTRUMENT WAS DRAFTED BY y ^ l ... `.:......... J �: N ... Peter Sequin, Attornex at Law -• - -• e n " "" a Deborah A. .Hartun 0 ,1 QN River . f Wisconsin 54022 ............................... Falls Wisc.• •--•----..• .... . ............. ........... �!t Notary Public .. Pierce •- _.�'2 *. f (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, ra f�•o rrt ;j are not necessary.) •.• C � ' date: .......... Maxch...J. Z.. ...................:.... 1� _. _. • f •........ ) Names of arsons sbrnlsa Is any Capacity should be typed or printed below their danaiures. i WARRANTT D &ED STATE BAR OF WISCONSIN Wisconsin L.:pal Blank Co.. Inc. - FORM Nn_ 2 — . ... - . _ . — ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the ely' -p residence located at: ✓e I' 1/9, Ng 1/4, Sec. 3 & 1 T a N, R /f W, Town of 7'9 ,* y Upon inspection, I certify that I have found the tank and baffles to be in good condition, and it appears to be functioning properly. Last time serviced f11 3 Did flow back occur from absorption system? Yes X No (if no, skip ext line) Approximate volume or length of time: �� gallons Jd minutes Capacity: ljfj� *d Construction: Prefab Concrete Steel Other Manufacurer (if known) : GUELS' Age of Tank ( if known) : (Signature) (Name) Please Print (Title) (License Number) (Date) Form to be completed by licensed plumber (s.145.06, Wisconsin Statutes) or Licensed Disposer (NR 123 Wisconsin Administrative Code) Plumber (applying for sanitary permit) Certification: in accepting the above statement regarding existing septic tank condition, I certify that the tank to the best of my knowledge will c=onform to the requirements of` ILHR -83, Wis. Adm. Code (except for inspection opening over outlet baffle). Name S i gna t ur e — ____ _ _ - MP- /MPRSS 2 Z COJ � S i UnpOttd land IQ , ° 25 c0 1 N 7 1 N I O N89 °53'ti 396.00` 2 7 0 0 ; ac 1 !00•(30' 100.00 100.00` ° 2 00. 0' °O 0 o 100.00 100.0,0 ° n ,� O 4° 0 I�t O 0 O O 3 O O o Z 1 0 0 72 NI 30 29 28 �, ° 27 26 g o " > f� O 7 N 6� B I I Q— cp 0 O O ri P�► Z V P7 � 1 0 100.00' 1 00.00` 1 00.00` 100.00' 100.00` '°°° 66 1' 0 0 Hillside 89 0 53'E 596.00` '0 N 0 73 M D rive N � 1 O O N S9 °53'W 644.52' ° 150.00` °° O M 0 1 411 99.00' 99.00` 99,00` 99.00` 99.52' 9 °0 200.00 °° 0 � O l�0 4 M O 0 -W O m 1- 3 P>o 0 0 74 0 ° O 0 0 0 6 5 : 66 67 - 6 8 69 " z 0 cn - o 0 °o . o x - ' 0 75 0 9 9.00` 99.00' 99-00' 99-00' 99. 2' 2 S 89°53'E 594.52' U �� to Unplatted land O to . 0 °_ r v ss o_ � O fi o N N '! o 3 0 0 77 O 0 0 g o O O N a , 4° 2 00. 00' 1100 Sheet I s I 3 g Mea 9 °53 E o Lane g Sheet 2 i I o �° (D o ° ° 4° N89 °53 W ?I $ 'p �b° 200.00' A o 0 i — M CO 78 co a? °f $ N N N 66.00' Q O — O W O P- cn O 0 O O ` Z 1 286131 I f *R S SrP`►: 1 Jessie Nye Subject: Ulbricht, Gilbertson, Plowing, Oakridge Acres Lot 69, 430403 Location: Troy Start: Fri 10/3/2003 10:00 AM End: Fri 10/3/2003 11:00 AM Recurrence: (none) 040 - 1188 -90 -009 36.28.19.822 1 �PI,44&At,!��U T � P tV S ysr�i ST. C'IMIX COUN'T'Y 'ZONING DE PAII'I'MCNT AS 13UIL71' SANITARY REPORT owner _G,a� (�' / '/ TSo,eJ y Z 5 • s yyJo RECEIVED ^, ddl ^ss Cityr` ;late I U-t;• �,q-l/ t &11.5. Tz/017 OCT 3.1 2003 L,r. Uescr3lllion; ST. CROIX COUNTY" Lot (9 9 Block Subdivision /CSM # G +L ; ,qc, " 14ca S ZONING OFFICE ,Sec. 3(, T Z$ N -R l `� W, Town of _ T 6 PIN # / • y4 • b0 Sh Ef IC 'TANK -- DOSE CIlAMBE R -- HOLDING TANK INFORMATION: -750 " 1 S 17N C- 20 • ZtAt / ory NEE u VAS T. W i ES d2 6 ' Wank manufacturer Cv�L 5 Size ST/PC / Setback from. House Well P/L Pump manufacturer LA ,6�& 5 Model Alarm location ` c % (110LOING TANKS ONLY) ¢Z S — 7 3 3 Setbacks: Service road Vent to fresh air intake Water Line Meter location Mimi location SO IL A>ZSUItT' I'IUN 5Y C�' mu,vg t cis j Type of system: — Width /� Length omes S Number of T Setback from: (louse - Well x/00' 'P 1 7' Vent to fresh air intake > 3S ' —� C �}-v to ES T K LEVATIUNS : TO 6F �4 lv,�: � �n UEv r- C W a,. Description of benchmark 0 Ly /fA4N 03 .v.d_ f R ',' s Z ' /3 E c> Elevation MoD' D Descripfion of alternate benchmark J'O p OF Y " c• X / P! & - vw Elevation X00 • � �'�isTi�� t � • Building Sewer /'� ST/11T Inlet ' ST Outlet 5.5 .2 PC Inlet 9 3 6 PC; Btatoin �' 3? , lleader /Manifold To p of ST/PC Manhole Cover Distribution Lines ( } () () P [ , +N • PU.4-1 MO UAJO Bottom of Sy � � 7 0 (� T 4r OF / "/ 4,+ ]i5eA-15 _ d F F rl / Final Grade ( ) < (• ( j 3 O / 37 (9 C4. �� ~3 Date of installation / / Permit number y 3 y� State plan number S3 f � zzG3�5 . Plumber's signature License number Date Inspector _ �7/ 6)eM /AjPle S (9 3 O • 03 Complete plot plan /,U C0UN SA N t' rA - T 10 A r� J • t� t�oDJPiD� � Dt o w_-- �y 35 THIS POWT SYSTEM SHALL INCORPORATE PER COMM. 83.44(2)c A PROPER ZABEL V 5 FILTER MODEL # A • goo -ro p 10 21 � T /;v 6- ! off E 6A sT s. T 5 1 .5� � ov•K�T � � `�.�., ' •2215 r l'AA)K �N r ./ 1 5 , X5. c ° 3y ---- 7 33 1 D NS CAS Ulbricht & ASSOCi en ultants Private Sewage 6 Sprang al y W 1 4767 o �A� - �oxcr 50� Pt)m� 4,4MIV-L, 0 /'r 5p-e c S �— -� mp 13o t�M 10• 3 PV 770 y�Povvp 9 7 D sME40 Series P Effluent and Drain Water Pumps Performance Curve Mme.. W40 EFFLUENT PUMP CAPACITY LITERS PER MINUTE 0 50 100 150 200 250 300 350 40 12 35 10 30 H !L 13 H 25 Z 0 20 6 15 Q 0 4 O 10 ~ 2 5 O O 0 10 20 30 40 50 60 70 90 90 100 CAPACITY GALLONS PER MINUTE F-E. Myers, A Pentair Company • 1101 Myers Parkway, Ashland, Ohio 44805 -1923 419/289 -1144 FAX 419/289 -6658 Telex 98 -7443 KR12A 7/Q1 0 n