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HomeMy WebLinkAbout040-1157-70-000 O N O £i f $ d G —1 I 3 I T n v n CD o d N y O O N N fl v O O W d Q A A `C �rxOy- • '-' Q A n N W d o N Cn O N OD M C 3 C p (b N O p 0 0� O Cn a CD 3 j 7 07 7 V \ 1 C O Q O O O 3 p ~" N N N N N N p (n v N A O. b U? N ( D n F a c CD m O. m O. m IW ' = to W 7 CD Z 0 \ 0 O O N O Co 000 N 0 O 0 il. Co .r o N N l c O 0 1 lD O! Cp m N I CD m N W N 3 3 - O. 7 •• p •• CA \ ` Z M O Z N O O D D s 7 a � o, o 0 CD m @ !r • CD X c cD V, N C C CD 7 N CD W a a a a 3 a 3 3 o CD c6 A z C .. in c c -• .� �� a n ±' C/) N W T < 00 A I C 3 C 3 a Z O O " C C y I y Z v fD a �O $ CL a CL Cl 0 c 3° w c CD m °3x o a o a 0 C D p w 3 c' N N p� N CD (D a ma S 7 co' I O CL 0 > m a CD w I O N ~ y I N I S I A W 0 0 A CD I m C A 0 c 0 r A C, y I O O i ti Y r '1 AS BUILT SANITARY SYSTEM REPORT OWNER �Q�K�,� TOWNSHIP SECI ADDRESS �,,� Gc/� ST. CROIX COUNTY, WISCONSIN. SUBDIVISION �;a��,e LOT LOT SIZE PLAN VIEW AV-11 SHOW and dimensions to meet requirements of H63 . O SHOW EVERYTHING WITHIN 1.00 FEET OF SYSTEM A /A440 1 / c B/N ' r x it a .. I di at N r h krr w 1 BEN HMARK: (Permanent reference Point) Describe: � �'s✓v -�i�c� V��5`/x�;t A in 1-fee li%re• /Pa..* 4AfA Elevation of vertical reference point: �p ©,fJ Slope at site: j SEPTIC TANK: Manufacturer: a/e Liquid Capacity: / Number of rings on cover : /VU,& Tank manhole cover elevation: Tank Inlet Elevation: /pm ��' Tank Outlet Elevation: `00.39' PUMP CHAMBER A)` Manufacture /' Number of gallons Number of gal. pump semi fur a cy-le gallons; Total capacity of distribution lines gallon: siz& of pump head; gallon per minute horsepower ;brand name of pump and model number ; Type of-warning device HOLDING TANK: Manufacturer Number of gallons Elevation of manhole cover ; Type of warning device SEEPAGE PIT SIZE; &/,* Number of pits feet diameter feet liquid depth pit inlet pipe - elevation bottom of seepage pit elevation feet. SEEPAGE BED SIZE: number of lines 3 width /j ' length J,77 the depth SEEPAGE TRENCH: width ,�/� length PERCOLATION RATE J� AREA REQUIRED r�� AREA AS BUILT ' INSPECTOR DATED_ PLUMBER ON JOB LICENSE NUMBER r J f'9 DEPARTMENT OF INDUSTRY, INSPECTION REPORT FOR SAFETY & BUILDINGS LABOR4 HI)MAN RELATIONS PRIVATE SEWAGE SYSTEMS DIVISION P.O. BOX 7969 e BUREAU OF PLUMBING MADISON; WI 53707 DiCONVENTIONAL ❑ALTERNATIVE State Plan l.D.Number: O Holding Tank O In- Ground Pressure O Mound (If assigned) NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Gary Halverson Croix Ridge, Hudson, WI �:3� 0-4 93 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV. SW SW, Sec. 24, T28N —R20W, Croix Ridge, Town of Troy Name of Plumber MP /MPRSW N. County Sanitary Permit Number: D. B. Fogerty 3289 St. Croix 43635 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV TANK OUTLET ELEV.' WARNING LABEL LOCKING COVER j ]j LI PROVIDED'. PROVIDED: •� 004 DYES ONO DYES ONO BEDDING: V D .: VENT M L.. HIGH WATER �" ROAD: PROPERTY WELL UILDING: VENT O E e / ALARM FEET- �FR LIN OYES ONO t/ OYES ONO NEAREST Q / DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY. PUMP MODEL. 1 PUMPISIPHON MANUFACTURER. WARNING LABEL LOCKING COVER PROVIDED'. PROVIDED: ❑YES ❑NO OYES ONO ❑YES ONO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER O PROPERTY WELL BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE AIR INLET: PUMP ON AND OFF) DYES ONO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing LENGTH DIAMETER MATERIAL AND MARKING or excavation. (If soil can be rolled into a wire, construction shall cease until FORCE the soil is dry enough to continue.) �# CONVENTIONAL SYSTEM: WIDTH LENGTH. NO. OF DISTR. PIPE PACING. COVER INSIDE CIA.. #PITS. LIQUID 1 E f 1 N "4 2 TRENCH E& I PIT H: ho. GRAVEL DEPTH FILL DEPTH IDIST11 . PIPE. DISTR. PIPE DISTR. PIPE MA IAL: 7N. ! G1F PROPERTY WELL: BUILDING. V NT TO FRE BELOW PIPES. ABOVE COVER. EV INLET E V. EN AIR LET' 'f _o$ <o . 4 NEARESM 40 50 MOUN SYSTEM: Mound site plowed perpendicular to slope Check the texture of the I aterial for /'IONS I E A DIAGRAM OFSYSTEM and furrows thrown upslope: mound systems to make ce tain that it ERSE SIDE. SHOW ELEVA- meets the criteria for me um and. EASURED. DYES El NO ,SOIL COVER TEXTURE: PERMANENT MARK OBSERVATION WELLS MARKERS ❑YES I OYES 1:1 NO DEPTH OVER TRENCH/BED DEPTH OVER TRENCH /BED DEPTH OF TOPSOIL S SEEDED. MULCHED: CENTER: EDGES. YES ON �SONO DYES ❑NO PRESSURIZED DISTRIBUTION SYSTEM: WIDTH. LENGTH: NO.OF LATERAL 7G. JGRAVE/DEPTH BELOW PI FILL DEPTH ABOVE COVER: TRENCHES: MANIFOLD PUMP MANIFOLD DIST . PlPf M MATERIAL IW. DISTR. DISTR. PPE DISTRIBUTION PIPE MATERIAL & MARKING `. ELEV.: ELEV.. DIA.- ELE IPES. OIA.: N Ti HOLE SIZE HOLE SPACING DRILLED CORRECT Y COVER ATERIAL VERTICAL LIFT CORRESPONDS TO APPROVED HOLE v,v , ❑YES ONO OYES ONO COMMENTS: PERMANENT M LINE: ARKER S: OBSERVATI WE 5: N 13ES OF PROPERTY WELL: BUILDING: 5 . OYES ❑NO ❑YES ❑NO NE oM Sketch System on Ret ' county file for audit. Reverse Side. SIGN TITLE - , DILHR SBD 6710 (R. 01/82) DEPARTMENT OF A& AL APPLICATION S AFETY & BUILDINGS INDUSTRY, y FOR SANITARY DIVISION LABOR AND PERMIT P.O. BOX 7969 HUMAN RELATIONS (PLB 67) MADISON, WI 53707 Attach plans for the system on paper not less than 8' /z x 11 inches in size. Include a plot plan that is dimensioned or drawn to scale. Horizontal and vertical elevation reference points must be shown. All appropriate separating distances and physical characteristics as specified in chapter H -63, Wis. Adm. Code, must be shown. An index page or each page must be signed, sealed and dated by the designer. If designed by a Master Plumber, t be , he date, signature and license number must be shown. A legible reproduction of the soil test report or the owner's copy must be included. Property Owner: Mailing Address: Property L cation: City, Village or Township: County: st4) % Sw' /aS ,,? 4,TZf NCR %40 E for T,-,p Lot Number: Blk No.: Subdivision Name: Nearest Road, Lake or Landmark: State Plan I.D. Number: �_ v . (If assigned) - TYPE OF BUILDING Number of ❑ Public ❑ Variance* ❑ Other (specify) Bedrooms: Q 1 or 2 Family * State Approval Required. TOTAL NUMBER PREFAB POURED -IN STEEL FIBERGLASS NEW REPLACE- OTHER AS GALLONS OF TANKS CONCRETE PLACE INSTALLAT40N MENT (Specify) SEPTIC TANK CAPACITY HOLDING TANK CAPACITY LIFT PUMP TANK /SIPHON CHAMBER MANUFACTURER: Zf EFFLUENT DISPOSAL SYSTEM PERCOLATION RATE ABSORPTION AREA (Minutes per inch): PROPOSED (Square feet): New ❑ Replacement ❑ Experimental Seepage Bed ❑ Seepage Pit ❑ Alternative (specify) ❑ Seepage Trench e Wa Owner's Name as Listed on Soil Test Report (If other than present owner): N? Private ❑ Joint ❑ Public I, the undersigned, hereby assume responsibility for installation of the private sewage system shown on the attached plans. Name of Plum ber• Si tur MP /MPRSW No.: Phone Number: Z,P I (7 6 Plumber's Addre Name of Designer: COUNTY /DEPARTMENT USE ONLY Signature of Issuing A ent: / e: Da e: Sanitary Perm Number: APPROVED ? it �Q �� &Y /� �� ❑ DISAPPROVED Js Reason for Disapproval: i • Alternate course(s) of Action Available: Change of ownership, building use or plumber requires a Sanitary Permit Transfer Form (67 -T) to be submitted to the county prior to in- stallation. Failure to comply will void the sanitary permit. DISTRIBUTION: White- County, Canary- Bureau of Plumbing, Pink- Owner, Goldenrod - Plumber DILHR -SBD -6398 (R.07/81) I Form - S T C 100 Owner of Property Location of Property Section 2 y T N R Township Mailing Address � a ,,, / - ,t' - c Subdivision Name �I-L Lot Number Previous Owner of Property ��' o ✓�.�� >,,,� Total Size of Parcel Date Parcel Was Created Are all corners identifiable? Yes No Include with this application one of the following .Certified Survey Map .Deed .Land Contract, or .Other Iaegal Document which describes the property PROPERTY OWNER CERTIFICATION I (We) certify that all statements on this form are true to the best of my (our) knowledge; that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warranty deed ecorded in the Office of the County Register of Deeds as.Document No.. 701 -J- ; and that I (we) presently own the proposed site for the sewage disposal system (or I (we) have obtained an easement, to run with the above described property, for the construction of said system, and the same has been duly recorded in the Office of the County Register of Deeds, as Document No. KA! SiGNATURt OF OWNER SIGNATURE OF CO-OWNER (IF APPLICABLE) KZ16 hx DATE S aNED DATE SIGNED � j • , - 7 � � v '�^� v•-� . s �� �"y` t3 z 3 ��� gs.� �. � �� �` P • �'�'� 3d Y .� � 0�; 1 1$1& SAFETY � BUILDING", .liSTIfy, DIVI REPORT ON SOIL BORINGS 1 SRY, .10fi AND PERCOU�Tj JON 7ESTS (11-5) LIOX PJUJ ..IAN RFLAT.IONS r_ 0 MADISON. WI 5:1701 Chapter 145-045) 'C _Y_15`N O f mTuLK NAME . 4fl"614, .�f, ',�ijW� UNICIVALITY: l�N AJ Y 2A-A�WR I I lij 'jtielF )V\j f�jj:S7tIUYrH*S NAME: OAR UtASl: IWA r IONS MADE NCIAIFOAMS,: CONIMER iAL ES FIROYf6r4 PHOFiLE TESTS: laudis(K O]Navv DI'lopco A ld ce U- Site "mmlabla for 3,vitum bil 1��$ a fi�ZU�Alv) NOW SYSI EM luptional) S u U EJU [�]U EIS E1U I r_,t "colation T is I, 4"d Nu'r foclulrod 0L5i6&T4ATE, 114ny jum1QA 00 Ind lbbfed v. alv,i In Intl LF Indicate: Floacipi int Flootlsildm vidvaijon: J PROFILE DESCRIPTIONS Nr. i a I A )L P(H P =UNDWATF- OF — SOIL WITH _ THICKWESS-, COLOR. TEXTUHE, AND DEPTH .'I _ W, ELEVATION - W 0 IF QkjSE,`lVL0 1St. c Abb"V. ON DACK I C 0. tj a hi C m6j 4. b"i C 0.70' L; I I L o v I'. I - U S 4-4 &.j Woo._ L t A 7 J 10 b.4 L rA Ll .4 30' �,, C Q' , - P: 67 8r4 L 0, - S p S -, s.'5.1 MeaS -ew 8,jt. a *j 45 iri cp. z r_.j 1- 6. SW 43-� L i w b;& a , :j 4 C 13ij A $'I PERCOLATION TESTS WAT ERIN 7 P L — TEST TIME _5116p IN WAT9A L5VEL-INCHES RATE MIN U ES' I-IN I 1E IN AFTER Srj�LaLIN` PITERVAL-MIN. T 6 PFR 1!4cm Z b_ I'PLANI Show 10imiclils of pa(cala(lon't soil borings sad the dimensions of suitable soil areas. Indicate scald or distances. Describe his i we /he hori• and v#nIcal.010lilition r4forenoo p9lall and show their 10calidn on the plot p1da. Sho she surface elevation at all borings a rid the dir ection and percent VC) S C�k • f; . ac 'STEM, ELEVATION __ ' - - -- - O ' F'�E W�-qt_ o nl L e G? a ................. 7 T 1L'rl !X C,4 N 6 t__ MAA� t4 J:4 .F _ _, C ��I. � S 0 ' NE( 42 2S O 1 0 AN A OA) dy T 1� t r - F14 undo(sioned, hsfOhV certify that t, v so twits reported on this 10(m were madd bV'mv in accord with the pro me L i I soil edures and methods so-ocilma I t h e W'sconsim MisufiYV COdb, stud that the data fist i "I'll "Ad the In" twits Otis CO(Wil to this best of my knovilodga ancl 001181� TESTS WERE CQ ON: r) CERTI FICA (ION NUMBER: PHONE NUMBER (opict"j. 4( (—.4 oil C L5I-, i& N A Y U H E 111 NUTION: Q(ArJifkl) 4140 nowro-hpV to l.tur;ok Ajjjhb(j(v. PfcbP*ftv Owner and Sail Tester,- i j r ZI ^ O ' j f I _ - a { i l � - f X I i � I i ti � 4 r r i fir, , `1 i ` ddd . i J ! 1 l , , i - I i :i i • (( I z I , : : I : i a : : I , i i r I : i Wisconsin Department of Commerce PRIVATE, SEWAGE SYSTEM County: St. Croix Safety and Building Division ' INSPEICTION REPORT Sanitary Permit No: 420538 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Halverson, Gary Troy Township 040 - 1157 -70 -000 CST BM Elev: Insp. BM Elev: BM Descnp w TANK INFORMATION ELEVATION DA T ok QjytS' TYPE MANUFACTURER CAPACITY STATIDN. t FS V. Septic Benchmark ` Dosing /000 Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet t TANK SETBACK INFORMATION SUHt Outle S TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet I d Slid m d t tlT.f� -e- 9 �t LZ S� C q y Z Septic Dt o s al Dosing Aeration Dist. Pip i Holding Bot. Sy $ 7 Final Grade PUMP /SIPHON INFORMATION Manufacturer Demand St CoveX/ GPM 4" ' Model Num r TDH Lift ction Loss System Head TDH Ft Forcemain . - Length Dist. to Well SOIL ABSORPTION SYSTEM _0d I j�G� BEDITRENCH Width I Length f No. Of Trenches PIT DIMENSIONS No.- Inside Dia. Liquid Depth DIMENSIONS 3 1 SETBACK SYSTEM TO P/L JBLDG WELL LAKE/STREA LEACHING anufactur . / ✓ INFORMATION T f Sy CHAMBER OR y �� �' D %> 7r Z) t Model Number: j � DISTRIBUTION SYSTEM / JL� C.) Header /Manifold 1 Distribution x Hole Size I x Hole Spacing lVent ir Intake �• Ppes) rr nn 9 Lengthj is f Length Dia rJ U fif ,, r s SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over { h Depth Over xx Depth of xx Seeded /Sodded xx Mulched Bed/Trench Center -Z'h Q,l Bed/french Edges Topsoil - 3 r1 Yes (1 No Yes j No COMMENTS: (include code discrepencies persons present, etc.) Inspection #1: y Inspection #2: i ! Location: 218 Plainvie Drive River Falls, WI 54022 (SW 1/4 SW 1/4 24 T28N R20W) NA Lot 1 Parcel No: 24.28.20.615b i W 1. Alt BM Descri p tion -gyp ��ug - .� A, !V �t�Gvr� ,�- vrn� 4AIMd� , 01 = ��� 2.) Bldg sewer length = - Q�C fs �r ` vb , ` ; Y � - amount of cover = J Plan revision Required? 11 Yes je No Use other side for additional information. / t _ _ _ Gam____ SBD -6710 (R.3/97) Date Insepctor's Signature Cart. No. t - Sanitary Permit Application safety W Buildings Division In accord with Comm 83.2 1, Wis. Adm. Code 201 W. Washington Ave. PO Box 7302 See reverse side for instructions for completing this application Madison, WI 53707 -7302 NVIsconsin Personal information you provide may be used for secondary purposes Submit completed form to county if 1101 Department of Commerce Ijvacy Lays, S. 15.W(1)( «O �- 3 � State owned.,' Attach complete plans (to the county copy only) for the system, on not less tW& 8-1/2 x 11 inches in size. Pem* �, C umber Check if revision to previous appticatiaa Static Plan I. D. Nu mber L Application Information - Please Print all 111forma tion x Location: Pmpetty Owner Name periy Location V w , 114, SZ N, Br; ftopetty owners Mail A ddress Lot Nwnber Block Number i ty & Zip Code _ Subdivision Name or CSM Nutn II. of Buiitim • check one) El City i �� g' ( O Village 1 or 2 Fami Dwelli No. of Bedrooms: ..3 13 Y B — �� ` 1 C!'!'own of ❑ Public/Commercial (describe use):_ ❑ State - Owned T Road III. Type of Permit: (Check only one box on line A. Check box on line B if applicable) A) 1. New 2. eplacement 3. Rep acement of 4. 5. 6. Addition to System System Tank Only Dane Ex System d B) it Num W/A Sanitary Permit was previously issued _ IV. WT System: (Check all that apply) Xrsy G . r yfs' "o pressurized In - ground ❑ Mound - ❑ Sand Filter (3 Con�tucted Wet • Pressurized In- ground ❑ Holding Tank ❑ Single Pass . ❑ Drip Line • At-grade ❑ Aerobic Treatment Unit ❑ Recirculating ❑ Other. zMen c V. Dis rsaUTreatment Area Information: I. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area 4. il Application 5. Percol Rabe le 7. Final Gntdo Required Proposed Rate (Galslday /sq. R) `OfmJinch) �' -1 � Elevown Q 03 S/ / Y . 7 VII. Tank Capacity in Total # of Manufacturer Prefab St Steel F' Plastic Information Gallons Gallons Tanks Con- Con- glass New Existing crete structed Tanks I Tanks ❑ ❑ ❑ Q .t'. i s' VIII. Responsibility Statement 1, the undersigned, assume tespamsibility for installation of the PO down on the attached plans. P! s N (print) plumbers Signature (no lumpits No. Business Phone Ni plumbers A City. State, Zip w w r DL County/Department Use Only Disapproved Sanitary Permit Fee (lncludes Groundwater Date Issued g Agar Sag ro Maps) (Approved 13 Owner Given Initial Adverse Serge Fee) ` Deterrninatio11 L-� X. Conditions of Approv /Reasons for Disapproval: AAA- 7�n alert [ "t' t4 -a Black Creek Bison ✓ Dave Fogerty 28288 McKenzie Rd. Spooner, WI 54801 (715) 635- 1 1N f� � r 1 4I� SKr- A pp ,Or jJ 4NO x4fw 1 � c 1 � . _ j faLt vet ✓E ;es G � Ej�c�R•t/NL FsGT� -,�t /Li�t1�T I ` y e 1 I c -3. c-3 X7.6 y3�s BOW I Black Creek Bism ✓ Dave Fogerty 28288 McKenzie Rd. Spooner, Vi/i 54801 (715) 635- . 1� r X �-► r f t 1 J A- -lGSr� yam ®f �. ' 1 1 �ff� �a `-� � /off oL' 1 o = Frr413 vrAT 1 � • = RaLt YALdE i , � d r E1c�7GtlI►� flLT�yC /Gtrf37�'�T � � ` w •r- iov � f f�crrrz 1 i90, D � Syfr�. = Eck: ��•v�T� t e #1 c -r 9q.c c - 3 �7.L y �S 1 �laT t,tvc t IAO b rso = r �� .::. r . N �. rA IL toll •'�' .,�: .• � / ^�� VON rz 00 Ol- n N OD O OD � O 2: • g W N I� 0 AW vftwmin DaPartrnen of Cort►rnerce SOIL EVALUATION REPORT Pa / of _ 3 Division of Safety end Bulldogs in acomxWm with Comm 85, Wis. Adm. Code County Attach compleW site phm on paper not less then 81n x 11 inches in size. Plan must include, but not limited to: vabcai and horizontal reference Point (BM), direction and fl. Percent slope, scale or dmensions, north arrow. and location and distance to nearest road. �— " 74 d+ J ✓J by owe 3 D� 7 ° l please print all in forrnaHon. j j 4 (( l Peraor M inFmrn d" you P�� mar be used taw. S. 5.04 (1) (m)). = , , M 404 Pmpert yowrw locatiot► 2u Lot 1M 114 S2 T2 N R �Q E ( cr? 0 �... # Bloctr # Subd. Name or CSMN Roperty0yo . �!9 Address 4 �' F CR State Zip Code Phor�i r [ i (. F- _ . City ❑ T t Road V p Now Construction use: Residential / Number of bedrooms Code derived design Now rate GPD 2Aeplacernent (] Pubic or eorrrnemal - Describe ain N R Parent material Flood Pl elevation if applicable end M=M'fWeWm: Boring # p tonne I / I ICI Pit Ground surface elev. l7 ft --— �' Soil Rate 1 i r 4� Texture Structure Consistence Bo�defl� Roots, G Horizon Depth Dominant Redox Descripti 'Eff#1 'Etffn in. Mu>ser Qu. Sz. Cont. Color Gr. Sz. Sh. c Awfif e 3 ' ^ .3 , . . ou ' --_ Boring El # pi Ground surface W. Q` • / f 10 factor in. S Rate Texture Structure Consistence Boundary Roots GPDRP Horizon Depth pomrrant Redox Descrip •Etf#1 'Etffi2 in. Muisei Qu. Sz. Cont. Color Gr. Sz Sh. 3� L c s A S G .� as ti5 ' EMUKA #1 = BW > 30 220 mglL and TSS >30 _< 150 ngA. • Mot #2 = BOD _< m9� T (S�T < Number ^' r i rung & Perk TOWNS Z�l/ Address c erwe Date Evaduatx n Conducted Telephone rf9d Spooner, WI 54801 2 /— /3' -�33 Property Owner Parcel ID # Z Page -;—Z— of # o 3� Bonng [ Pit Ground surface elev. _ [L_ i _ __ if. Depth to Ding facer > Q in. Rob Horizon Depth Dominant Color Redox Desa"m Texture Stnxtxe Consistenoe Boundary Roots GPDJI! in. Munsell Ou. Sz. Cord. Color Gr. Sz. Sh. 7AME 'Eff#1 l 94 S !?X L --- L T t :hft7 F-I� #� Boft pit Ground surface elev. ft. Depth to GrrNtin9 factor in. Sail Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Boundary Roots GPM in. Munsell tau. Sz. Cont color Gr. Sz. Sh. '001 'Efr#2 Boring # o Boriry Ground surface elev. it. D to trmitirg factor lo. V Pit Rate Horizon Depth Dominant Color Redox Descry ion Texture Structure Consistence Boundary Roots GPDM in. Munsell Ou. Sz. Cont. Color Gr. Sz Sh. 'E.ff#1 'Eff#2 �J�G�iLrik" Pt - •L !� Effluent #1 = 600 > 30 1 220 mgJL and •TSS >30 < 150 mg& ' Effluent ill - 800 _< 30 rrg& and TSS < 30 mgft. 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, 3141 or TfiY 608 - 264 - 8777. sw -U30O W00) - Black Creak Bison Dave Fogerty 28288 McKenzie Rd. Spooner, Wl 54801 (715) 635 - .,� x ate_ A;sr- ,ro —p2 r�m�,b PwAzr, l &AD l �z x = =�rrrax /,os��irG_ t T. o ' O 0 4 O 1 O AA1 two AMC Nov 20 02 10:13p FOGERTY PLUMBING 17156355286 P - FOGERTY P & P ERK TESTING t.nr 7�6— y6Sl 28288 McKonzie Rd. Spooner, WI 54801 (715) 635 -9609 (715) 749.3656 Fax (715) 635.5286 S;p= jCa.gr ZBi ,��istr 400 Fip/z �f1'E K tcls[pxr roA rALT / � ,cr ,fdrd SrfT.Lc 77.1-wtr CEGr -�rcn nv,r �y�rT Nov 20 02 10:13p FOGERTY PLUMBING 17156355286 p -2 POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of Z 1 nON srsYEIYI sPFCIFICATIO NS Owner V A� Septic Tank Capacity a DNA Permit Septic Tank Manufacturer Cl NA DESIGN PAi1AMtsTfRS Effluent Filter Manufacturer odr,[ 0 NA Number of Bedrooms 3 O NA Effluent Filter Model _ ,g o O NA Number of Public Facility Units XNA Pump Tank Capacity gal bjWA Estimated flow (average) ,S� got/d Pump Tank Manufacturer gf�o- Q NA pesipn flow (peak), (Estiriated x 1.5) g allday Pump Manufacturer ,t/ D NA Soil Application Rate _ 61 1der /te Pump Model ,l/ i7 ► Standard Influent/Effluent Quality Monthly average' Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 530 mg/L O Sand /Gravel Filter ❑ Peat Filter biochemical Oxygen Demand (BOD 5220 mg/L O NA ❑ Mechanical Aeration O Wetland Total Suspended Solids (TSS) %f SO mg /L O Disinfection O Otlw Ptetreated Effluent Quality Monthly average Dispersal Cells) 0 NA Biochemical Oxygen Demand (BOD S30 mg/L )q In- Ground (gravity) O In- Ground (pressurized) Total Suspended Solids ITSS) 530 mg/L O NA O At -Grade E3 Mound Focal Coliform (geometric mean) 51W efWl00ml ❑ Drip -Lino 0 Other: Maximum Effluent Particle Size Y. in dia. O NA 0 NA Other; O NA Other: 0 NA 'vaiuee typical for dorna"c .vanewwor and septic tank effluent. Other: O NA MAINTENANCE SCHEDUL Service Event Service Frequency Inspect s condition of tank s) At least once every: s (Maximum 3 years) 17 NA n pest c 1 ear( ) Pump out contents of tank(s) When combined sludge and scum oQuals one-third (1#) of tank volume 13 NA Inspect dispersal Collis) At least once every: 7> E3 morttttlsl (Yla><imtrtn 3 years! 13 NA Clean effluent filter At least once ovary; E3 month!') ❑ NA " Z - A year S) Inspect pump, pump controls ere alarm At least once every: ❑ month(s) • �A ❑ yewfal Flush at laterals and pressure tow At least once every: (7 0 mo earls) year(s) l Q NA Other: ❑ rnonth(s) rl NA At least once every: O earls) Wlar: a HA MNNTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells %hall be made by an individual carrying one of the following licenses or certifications. Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer, Septago Servicing Operator_ Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or pending of effluent on the ground surface. The dispersal cellist shall be visually inspected to check the effluent levels in tho observation pipes and to check for any pending of effluent on the ground surface. The ponding of of fluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When tho combined accumulation of sludge and scum in any tank equals one -third (Y or more of the tank volume, the entire contents of tho tank shell be removed by a Septage Servicing Operator and disposed of in accordanco with chapter NR 113, Wisconsin Administrative Code, All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreaRmen' units, and any servicing at intervals of S12 months, shall be performed by a certified POWTS Maintsiner. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. Nov 20 02 10:13p FOGERTY PLUMBING 17156355286 p -3 papa � of KT 6V A140 OPERATION For new construction. Prior to use of the POWTS check vestment tank(sl for the presence of painting products or other chemicals that may impede the treatment process and /or demage the dispersal call(s). If high concentrations are detected have the contents of the tank removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface, During power outages pump tanks may fill above normal highwater levels, When power is restored the excess wastewater will be discharged to the dispersal call(s) in one large dose, overloading the cell(sl and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Saplings Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the Puma tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; Oigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline: gross* herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: + All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed, The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their Covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN if the POWTS fails and cannot be repaired the following measures have been, or. must be taken, to provide a code compliant replacement system: E3 A suitable replacement area has been evaluated and may be utirwmd for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells- Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable roplacement area. Replacement systems must comply with the rules in effect at that time. O 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 boon evaluated to identify a Suitable replacement; area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may bo installed as a last resort co replace the failed POWTS. Q Mound and at -grade soil absorption systems may be reconstructed in place following removal of who biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that tirne- < < WARNING > > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT '.ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TAME MAY BE OIFWULT OR IMPOSSIBLE. Fa�s►tjr-Plae+bil� -�-- 0221180 -- zlwaw 10 e e Sdoone _ Wl 5 e(fiA1 POTS INSTA LEA PG%VM MANNT (715) 635 -9609 , W I E e ( ( � Name e S'. — ' Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name �" ,C Name 1 C." 00,,_ V� / "_ij Phone �� �� Phone I(s This doturnunt was drafted in compliance with chapter Comm 133.22(2)(b)(UldiAb(f) and 133.54111, (21 b (31, Wucaonain Administrative Code. Fogerty Plumbing #221180 28288 McKenzie Rd. Spooner, WI 54801 ST. CROIX COUNTY ZONING OFFICE (715) 635 -9609 CERTIFICATION STATEMENT FOR UTILIZATION OF AN EXISTING SEPTIC TANK This is to certify that I have inspected the septic tank presently serving the 6Z Alve tiro - ZS'mA ,) residence located at: -5 :, s_ ;, Section --W , T R 2d W, Town of Upon inspection, I certify that I have found the ank and baffles to be in good condition, and it appears to be functioning properly. I II Last time serviced: Did flow back occur f m absorption system? j Yes No (If no, skip next line) I I Approximate volume or length of time: gallons minutes Capacity: temo Construction: Prefab Concrete Steel Other Manufacturer: (If known): uv,64;xs' Age of Tank (If known): (Signature) (Name) Please p int 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 best of my knowledge will conform to the requ�er ements of ILHR 83, Wis. Adm. de (except for inspection opening outlet baffle). Name Signature MP /MPRS 2 - 11Z 7XZ: 4maA7V ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Ownerffiuyer Mailing Address .2 S -�- Property Address (Verification required from Planning Department for new construction) City/State Parcel Identification Number 4 YQ — AL 5 - 7 — L49 LEGAL DESCRIPTION Property Location ,�_ '/4, jvAw '/,, See. .1 y , T a,,P N -R 1 A', Town of 7'R'0 Subdivision <7,ggD� &gUgRIZ , Lot # Certified Survey Map # , Volume . Page # Warranty Deed # ? Z , Volume & 7 Page # Spec house O yes LR no Lot lines identifiable lames 0 no SYSTEM MAI Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensedpumper 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 Resourcet, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 day the tivyr vrar rrn� t+..•• 7 _•_ AedAwe SIONATUP,06F APPLICANT *f— DATE OWNER CERTIFICATION I (we) certify that all statements on this Corm are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of t i o perty dy;cribe ab ve, by virtue of a warranty deed recorded in Register of Deeds Office. - SIGNATUR#4F APPLICANT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Depa ** 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 DOCUMENT NO. STATE BAR OF W ISCONSIN FORM 1 -1Sft THIS srA{.[ R[gglrv[D rCR RfCORDINO DATA WAkRANTY DEED 387014 VOL 671 rA:E do R EGWERS OFFIC This Deed, made between _.. Corina Jorgensen, formerly ST. CRviX CO. WI& ..._ . ... .. .. . . . . . .• .......... Recd, for Record this 16th ........ . ....... ......... ...... ... day of A A.D. 19 . ........ - .. ....... Grantor, at 2 : y; P rnd _ Cary A- Halvorson . and. Barbara. -J.- .Halvorson, ............. husband. and wife as ,joint -. tenants,.. - -.... ._ ............................. i•oM� of • - .... .... _ ...... --- ----- ---- - - -- -- - -+ Grantee, Witnesseth Thvt the said Grantcr, for a valuable consideration...... -. .- _ -. - - - - -- - _ . _.. ----- - - - . * ----------- - -------- conveys to Grantee the following described real estate in ....St. -- Croix ---._-----. R[TURN 7'0 County, State of Wisconsin: Part of the Southwest Quarter of the So Quarter Section 24 -28 -20 described as follows: Lot 1 f Certified Survey Map filed in the office of the Reg s er of Deeds Tax Parcel No: ................................... for St. Croix County, Wisconsin on August 9, 1983 in Volume 5, Page 1323, as Document #i3 8 TOGETHER WITH an undivided 1/3 interest in Outlot 2 as shown on said Cert Sucvey Map and TOGETHER WITH a roadway easement as shown oat the Certified Survey Map in Volume 4, Page 946, Document #364348 as recorded in said office of t:te Register of Deeds. Also TOGETHER WITH an easement over that portion of Lot 3 of said Certified Survey Map recorded in Volume 5, Page 1323, Document 0386852 described as follows: Commaencing at the angle point on the South line of said Lot 3; thence Westerly to a point on the West line of said Lot located 19 feet North of the Southwest corner of said Lot; thence Southerly along the West line of said Lot to the Southwest corner of said Lot; thence Easterly along the South line of said Lot to the POB; and then- Easterly to a point on the arc of the culdesac of Outlot 2 of said Certified Survey Map 19 feet. Northerly of point 2 on said Certified Survey Map; thence Southerly along the arc of said culdesac to said point 2; thence Westerly along the South line of said Lot 3 to the POB. Said easement over Lot 3 to be for the purpose of ingress and egress over a driveway providing access to Lot 1 of said Certified Survey Map, as no located. By acceptance of this Deed, the Grantees agree and acknowledge that they are responsible for 1/3 of the maintenance cost of the roadway located on Outlot 2 of the Certified Survey Map recorded in Volume 5, Page 1323, Document 11386852 and * continued on reverse side This _1% 1% n.0t .......... homestead propet ty. W.°X Together with all and singular the hereditaulents and appurtenances thereunto belonging; ` And. _... Corina.. lo. rgensen- , - - fl kla..Go.rn.�.l.ia..Agnes., van. Waasbergen ...... ............................... warrants that the title is good, indefeasible in fee simple and free and clear of encumbrances except y ,- subject to easements, restrictions, reservations and protective covenants , t� `� of record, if any. $ •�00 and will warrant and defend the same. Dated this ....t(`i day of -August.- ......... ... ... ----------- --- -- ---- ----•---........(SEAL) L ...... ) CORINA JOR E EN f/ /a Cornelia Agnes - -------- ------------------------------------ ....... ........... "'wari Waasbergen ...... (SEAL) ---- -- -- - ------­----------- ......... I --- -- - -. (SEAL) a AUTHENTICATION ACKNOWLEDGMENT Signature(s) .---_ ...................... ............................... STATE OF WISCONSIN ss. --•-----.....-•---•°•••••••--•-•••°•••-••....•- ••- ..._•••••••••...••-•-•••.... .....>5.t.._. �rQ •-•-- --- -- --County. I , i authenticated this ........ day of ..........................+ 19...... Personally came before me this ...... .......... day of ................. Augusta............. 19.. U. the above named ................................ ...................................... .. CQrA�a__Jo_rgen_s_en,___f[k _a_Cgrnelia_AgHes YanWaasbergen- -• - - -- ........,,.,... TITLE: MEMBER STATE BAR OF WISCONSIN :' t (If not+ ... .............. ----------- ....................... -- -- - �___ _ _. • authorized by § 706.06, Wis. Stats.) A.. �� �,,, p to me known to be the person ...:_..� �" efecl7 ed. the "• foregoing instrum nt and ackne Ikfge ty.► same. THIS INSTRUMENT WAS DRAFTED BY d a s HEYWOOD, CAR(& MURRAY .......... f`'� _. -•• -- - ...---- •---- -- • - - -- -- ••- • -- --- -- •- - - -... -- �'-- c 7 t Cr oix Hudson, WI 54G16 pds - -- -• -- --- ....... - •- - - - - -• ,, � - -•j1k - - -- -- .................. ....... ............................... - •-- --••........I...... Notary Public ... _ ..... ......- ........ . ''t.,,, puuty, Wis. (Signatures m"y he authenticated or acknowledged. Both My Commission is permanent. (If not, sta� expiration are not necessary.) date: /. � l & -v .................. .. 19.. ....... ) .Namos of persons signing in any espacity should be typed or printed b.•low their signatures. WARRANTY DICED STATE BAR OF WISCONSIN Wisenn.in Leval Blank Co. Inc FORM No. 1 - 1981 mil —ukee, Wis. 'VOL 671 wa 69 F *Legal description continued that upon request by the owner of the property lying South of the above described n property, they will join with said owner in the dedication to the Township as a public road of the roadway located on the easement described on the above referred to Certified Survey Map recorded in Volume 4 Page 946. 6 Acceptance of this Deed shall be indicated by its recording with the Register of Deeds and shall automatically and irrevocably make the Grantees, their successors and assigns a member of a non - profit, non -stock corporation known as CROIXRIDGE HOMEOWNERS ASSOCIATION and entitle them to the benefits and privileges of said Association and n bind them to the terms, conditions and obligations of said Association, subject to approval of said Association by By -Law. R C A i f q� �07- �I -PGixC 386852 4+ • CERTI FI ED p LOCATED IN THE 3W1/4 Of THE 3WI /4 OF SECTION 24, T2BN, R20W. TOWN OF TROY . ? i STC ROIx COUNTY �• UNPLATTED : LANDS ' Wls• N 89°2016 "W - 926.91 . .on A s C 1 N /II 111 R,) Zto £ NORTH LINE OF THE SW V4 OF THE SW V 500.00' IZ f w 426.91' —! y Z I`♦, rA m ; ro _ POINT OF BE OINNIN• y O 1 R p 0m 2 a m R 2 0 I-, m 1m m 0 " iO m 1 1 �� 1 sc, c a OUTLOT I ! Z ' /S N 913 G1 M ±3 8 3 � ry at $� 'A 389 49' to gi 5. 28 ACRE PARK is w w OF CROIXRIDGE 1 a , : ,, al A APPROVED _ 1Z 3 pct ? $ , :41011 IAL Y• AU 6 '0 9 f 14 e.4t'�� '! s •4•s1' 21' w �f •` 1 s� 983 °. K to S` 80° 143.30 / *J S �S �� f f a �' 22 30 8• ,.� sa 0.134.14' ��s« d (/a y T 3 lo ST. CR013C COUNTY A" 4 T OI' �y�• : <Q ��,` 0 1. cOMPRE�iENSlVE PARKS PLANNING ZONING �9e•O Ng4 31 21 E 1 re��i� -T ? a�uy� COMMISE T ` • O UNPLA1: L E . FL LANDS _ FdS. aP <c�,y a� /J�4s•�, I I LEGEND F c'r r T o., 90 'lef.16 I SCALE IN FEET I " 2 00' (R) PREVIOUSLY RECORDED o SECTION CORNER MONUMENT N IS 55 S3� E • O 2" I R �• e. S 5.4 50 ON PIPE �FOUNO IOCf 20d 30C' 0' ee •'� +�. • I "IRON PIPE FOUND Z I �d O 1 "X 24 "IRON,PIPE WEIGHINS 1.68L.8S. /LIN.F,T. sET ' DESCRIPTION A parcel of land lgcated in the SW 1'/4 of the SW 1 /4•of Section 24, T�SN, R20W, Town of Troy, St Croi i y• ix County, Wisconsin, described as follows: Beginning at the NW corner of Outlot 1 of Croixxidge; thence N89 "W 926.91 along the North line of said SW 1/4 of the SW 1/4 to the West line of said SW 1/4; thence S1 "E 437.91 along said West line; thence S80 ° 22 1 30 "E 478.01 thence N84 "E 184.14 thence S60 506.89' to the Westerly right -of -way line of Plainview Drive; thence Northerly 12.48 along said Westerly line on a 26.6.00 radius curve concave Easterly whose chord bears N14 "E 12.48'; thence N15 55..42' along said Westerly line; thence N40 151.91 along the Southwesterly line of said Outlot 1; thence N29 "W 151.45 along said Southwesterly line;,thence N0 "E 464..99 along the Westerly line OT said Outlot 1 to the point of beginning, containing 481158 sq. ft. (11.046 acres), and being subject ,to all easements of r °sprd. I, James E. Rusch, Registered Wisconsin Land Surveyor, hereby certify that I have surveyed and mapped the above described property; that such plat is a true and correct representation of the exterior boundaries of the .land surveyed; and that I have fully complied with the provisions of Chapter 236.34 of the. Wisconsin Statutes., 1 the Town of Troy Subdivision Ordinance, and the St. Croix County Subdivision Ox 'nonce tot f m `� v fessional knowledge, understanding and belief. , Ja s E. Rusch" W' consin Land Surveyor S -13 Sur Y ?6 ed for: Co ' Y rina Jorgenson 4 Second Street genson Hudson,. Wisconsin 54016 This map is a eby approved 'by the To oard of the o n of Troy. �tt6llltgh�, i D to - C0 11►S` own er `r te I�� ♦ JAMES E RUSCH 5.1776 1 48 ,C' NL'4so� Q• 3 -468 ♦ � •'9 ♦ 0 III FIRE