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040-1169-40-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: • (ATTACH TO PERMIT) 488173 0 GENERA4'INkORMATION 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: Eubank, William I Troy, Town of 040- 1169 -40 -000 CST BM Elev: Insp. BM Elev: BM Description: I Section/Town /Range /Map No: Ofl • O' 36.28.20.645A TANK INFORMATION U ELEV ON DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. W n Pe ?- Septic w (�3C�2 ( /�� Benchmark •Qg I 0(. 2 1 1C Dosing U Alt. BM A eration Bldg. ewer, , 2 Jib H olding t/ t n et f ID .90 .o$ St/H Outle TANKSETBACK INFORMATION TANK TO P/L. WELL BLDG. Vent o Air Intake ROAD Dt Inlet S eptic .5D (aa r Z 3 r u., • S 6 sm9 Z 3 � ea er an. l�.e� ��► era fl On IS • 1 lope A 40 o Ing o . ys em F inal Urade PUMP /SIPHON INFORMATION m anufacturer Demairia over ^' C q�} GPM F , s/� �t pl 3.2 / a' m odel um er 0 ;I NFORMATION rlc io LOSS Syst ea 41YUN 4 3 �_V K3 .17 3 g. Z e 35 f 12 to vven CHA MB OR Ivid � • > So 35, > IaD� � �k y Pipes) 4s r Length 5 Dia Len Dia Spacing �' x Pressure Systems Only xx Mound Or At -Grade Systems Only Bed/Trench Center Bed/Trench Edges Topsoil j Yes No 1 j Yes j No C T Loc 276 N. Ilwaco Ro Incl de scr encie 54022 (S rs s esent, etc. Ins ection #1: Inspection #2: atio Falls, 1/4 NW 1/4 36 T28N R20W) NA Lot P rcel o: 36.28.20.645A 1.) Alt BM Description 2.) Bldg sewer length d r = ti e� ' s�' "`� - amount of cover = ? � (.•gB . 95,40 J S ic > / Plan revision Required? Yes No izz Use other side for additional information. – -- _J _ p SBD -6710 (R.3/97) 2(� �6 Safety and Buildings Division County MV 201 W. Washington Ave. (D -1"2 ST C ✓2 d ( �( M ad i - Sanitary Permit Number (to be filled in by Co.) c0ns,n Department of Commerce 608) 1 $' 7 fate Plan I.D. Number Sanitary Permit App ' ti AY $ In accord with Comm 83.21, Wis. Adm. Code, personal i ati JY may be used for secondary purposes Privacy La 4(1)� GROIX U oject Address (if different than mailing address) I. Application Information - Please Print All Information SA Yo C Property Owner's Name J Parcel # Lot # Block # It'_L / 134 IL 090 — �-16 Property Owner's Mailing Address Property Location AJ a - 7 /GwpC_ v /2D cr / / (-4j l Zip Code Phone Number ��° � �' Section City, State �l/L% id�f S j I S (J� TO-TN: R (� K II. Type of Building (check all that apply) r ^C l B / G Subdivision Name CSM Number 1 or 2 Family Dwelling - Number of Bedrooms �"� /J � .LJ , � ❑ Public/Commercial - Describe Use �� ❑ State Owned - Describe Use 3 tr-' 6a CZ�V5 t.✓ I S IS } 15 ❑City_ ❑Village Township of �(�y III. Type of Permit: (Check only one box on line A. Complete line B if applicable) / A. New System Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Plumber Owner i - 1 i ` IV. Type of POWTS System: Check all that appl ❑ Non - Pressurized In- Ground ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass Sand Filter ❑ Constructed Wetland - 1y Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter ❑ Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain) V. Dispersal/T Area Information: t' Design Flow ( Design Soil Application Rate(gpdsf) Dispersal.Area Required (sf) Dispersal Area Proposed (sf) tystem Elevation / VV o.1 `b57. 1�{ �5�' S y �d �/.5 b s ,5 VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons of Units Concrete Constructed Glass New I Existing Tanks Tanks Septic or Holding Tank O50 W I t5 t 2 (UY✓) Aerobic Treatment Unit Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name (Print) Plu er's E:tu MP/MPRS Number Business Phone Number �)�t �,a✓u � /33 '70 9 7i e1q7 Plumber's Address (Street, City, State, Zip Code) VIII. Coun /De artment Use Onl Approved El Di prove Sanitary Permit Fee includes Groundwater Date ssu Issuing ent Signa re o Stamp Surcharge Fee) D A /z Q � ❑Owner Reason for Denial U IX. Conditions of Approval/Reasons for Disapproval I I / SYSTEM OWNER: QC lj �/ S0�✓� 1. Septic tank, effluent fitter and ✓ J , dispersal cell must all be. services / maintained C-0 as per management plan provided by plumber. 2 AN sed ack requirements must be maintained as per sppk" Code / ordinances. Attach complete plans (to the County only) for the system on paper not less than 81/2 x 11 inches in size SBD -6398 (R. 01/03) cs VI to 1 4 (D Sc cl -j co 0 CL O 0 Chi W l9 L1 7T cia CL 5 - Wisconsin Department ofCommerce SOIL EVALUATION REPORT Page —j—of3 Division of Safety and Buildingsunk in rd n_ce wit q� Pra� 9 n coon Attach complete site plan on paper not le x 11 nches i n E include, but not limited to: v horizontal reference int (BM), direction and Pare I.D. percent slope, scale or dimensions, nort d locati n andPiMcZtven %road. CM0 — t I ( 4 4 — oco Please print all informati . C Re e,ved by Date Personal information you provide may be used for secondary pure es (Pk 1rf 19QlX QQUNTZfn)). , 2' , Pr Owner (�a� c v� f'ry k . -, f -I— V t ' Cx�— CJ b� �1 Govt. Lot —'S 1/4 ! E 1/4 S � T N R Property Owner's Mailing Address � Lot # Block # Subd. Name or CS!A# 0 0. 1:11wrXca City State Zip Code Phone Number ❑ City ❑ Village � Town Nearest Rcad roA -5 W I 54o 2.Z 1 (7 IS- )q2 - (ob I ( �ro� = =Ivaco ❑ New Construction Use: Residential / Number of bedrooms Code derived design flow rate &00 GPD (Replacement a s ❑ Public or commercial - Describe: Parent material .� ' d'LS Flood Plain el vation if app: amble ft General comments and recommendations: 's �sq/ Systems, ca>'r.'s �s °{ gu•c°� IV rya t a�P•3 c�C� T - 4 &Y' `�U to 9 4 ii�c� �cG /o�Y �rade. See ske t� I Boring # Boring ® Pit Ground surface elev. 9 � , ? ft. Depth to limiting factor I (DO, t in. Sc�! A Iication Rate Horizon Depth Dominant Color Redox Description Texture Stricture Consistence Bouncary Roots GPD /ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'cff#1 'Eff#2 0 - !D �ovR Sl I S I -F O, (o D . � °E IwR St j ),"k rnv�r �s (� . D.(, S Boring # Boring Pit Ground surface elev. C O30 ft. Depth :o limiting factor /0 f it .. Sod Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Bouncary Roots GPD /ff in: Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. `Eff#1 'Eff#2 o 10Yel a 6 1� /Q y y �-- 6i ( r I d • (f, C7.zS L l PO 40 /0 yK s �� 5'., i a li+'tabK ff\ T D1(0 /�•2 c " . --- q7 -it ' Effluent #1 = BOD > 30 220 mg/l- and TSS >30 < 150 mg /L ' Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L N ame (Please Print) Signature -�—y� CST Number Address Date Evaluation Conducted Telephone Number A 0 Ef ( �' �! pis - 7Z SO Droperty Owner W - M -, � be CL.e F-1) 60-f)K Parce! ID # O q o - j � �, q Page a of 3 Boring # ❑ Boring pit Ground surface elev. 't y 8' ( 0 ft. Depth to limiting factor �b� in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ff in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 l I -F o 7 7 -� �J �OVF,JIa st at cn� Fr cis " LID iv y : 'e`� os m1 -- — 0,1 /- ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor (n Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fF in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ❑ Pit Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /fg in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 ' Effluent #1 = > 30 < 220 mg/L and TSS >30 < 150 mg/L ' Effluent #2 = BOD, < 30 mg/L and TSS < 30 mg/L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608- 266 -3151 or TTY 608 -264 -8777. SBD -8330 (R.07 /00) H/ /l ►•a �I` lac 6c � �� .r"w 61� � P� 3 a� -� IGOV /ot-vn SLy r`p - �f- �La /X �ofcJ�'fS/' 0 > loc"rf to p"Op kh e q trop /�hC aP � el urCfrauw.C�.' 98.9 I t , /tichck_ .5c4 s�s`tc� e% @ 4P+- E x istr��' 4 home IA e/ Ic s_r .v e, ct1 a a7S P�ti.P aes ale, �� l�rJev kcL ".2o j'-r) N 44 °s� 44 °�- x_103• 4"s� -/9�' ArcIMS Viewer Page 1 of 1 `y 3s 4 http: //72.21. 230.178/ website /LRPortal /ARCIMS/MapFrame.asp ?PIN= 2/24/2006 Uri -fj 1 0 7 44 'ci C4 vj 7z- Qz 7 1 C- lQD C/3 cts P m 0 cc LU M. R AMMS Viewer Page 1 of 1 T a cs M http://72.21.230.178/ website /LRPortal /ARCIMS/MapFrame.asp ?PIN= 2/24/2006 x � ��_. _1 sJ ' � �cl 3A IC_ Page 4 CIS j46ef - NO ScaIe) 1 _A rzved Locking Manhole Covers 9 rni ng LabelS Attached Weatherproof Approved Junction Box Vent Cap • / • f w.+Y. ? �fk 18" Minimum Baffle 'Pul 1,#Aszr e Iwe+�f A s, , A i e � Al arm jr► B O n t '� B...►� p p e ; C *APPROVED Off 6 o�'caysr to JOINTS WITH , e , Vw a. APPROVED PIPE 3 ONTO 'ta i SOLID SOIL Cc�rar_ 3" of Bedding Under Tank --/ ik Manufacturer: !4/:esr• ta.tr� 7 .ZAe• ik Size-Septic/Pump: _ t 3,5 p 1-7 _� Gallons rm Manufacturer: 4e rep �lao,►, el Number: j>L V tch Type: ___rrezll��t p Manufacturer: Sr &" el Number: imum Discharge Rat Betxeen Pump Off and Distribu i Pipe: _l `eet imum Required Supply, Pressure:. _ . X: d X17 , _ _ _ _+ _3 5'Feet of Force Main x Friction F eet: +eet = Inch Diameter Forcp-Main Total Dynamic H ad:__. =• Feet rnal Tank Dimensions: Length 5i 4 Width d D epth . - « �� 146P SFPr)cr CIJA F2 cAF� [qGOULDS PUMPS Submersible Effluent Pump A& EPO4 & EP05 Series APPLICATIONS • Fully submerged in high ■ EP05 Impeller: Thermo- ■ Bearings: Upper and lower Specifically designed for the grade turbine oil for plastic enclosed design for heavy duty ball bearing con - following uses: lubrication and efficient improved performance. struction. • Effluent systems heat transfer. ■ Casing and Base: Rugged • Homes Available for automatic and thermoplastic design provides AGENCY LISTING • Farms manual operation. Automatic superior strength and corrosion Canadian standards • Heavy duty sump resistance. • Association •Water transfer models include Mechanical Float Switch assembled and ■ Motor Housing: Cast iron for O p us File # LR38549 • Dewatering preset at the factory. efficient heat transfer, strength, and durability. Goulds Pumps is ISO 9001 Registered. SPECIFICATIONS FEATURES ■ Motor Cover: Thermoplastic • Solids handling capability: cover with integral handle and 3 /4 ' maximum. ■ EPO4 Impeller: Thermo- float switch attachment points. • Capacities: up to 60 GPM. plastic semi -open design with 0 Power Cable: Severe duty • Total heads: up to 31 feet. pump out vanes for mechanical rated oil and water resistant. • Discharge size: 1 1 /2' NPT. seal protection. • Mechanical seal: carbon- rotary/ceramic-stationary, BUNA -N elastomers. • Temperature: METERS FEET 104° F (40° C) continuous 10 140° F (60 Q intermittent. • Fasteners: 300 series 9 30 —► 5GPM stainless steel. • Capable of running 8 2 5 dry without damage to 25._ _ components. °a 7 w = 6 20. _ Motor: " -. • EPO4 Single phase: 0.4 HP, Z s 115 or 230 V, 60 Hz, 1550 } RPM, built in overload with a 4 15 I EPOS automatic reset. o • EP05 Single phase: 0.5 HP, ~ 3 10 115 V or 230V, 60 Hz, 1550 g`•Z EPO4 RPM, built in overload with 10. 2 5 _ automatic reset. • Power cord: 10 foot 1 standard length, 16/3 SJTW with three prong ° ° 10 20 30 40 50 GPM grounding plug. Optional 20 foot length, 16/3 SJTW with 0 2 4 6 8 10 1 12 3 h three prong grounding plug CAPACITY (standard on EP05). Goulds Pumps ©2005117 Water Technology, Inc. ITT Industries Effective January, 2005 B3871 To STATE BAR OF WISCONSIN FORM 3 - 1982 627226 QUIZ CLAIM DEED KATHLEEN H. WALSH REGISTER OF DEEDS DOCUMENT NO. VOL .153ONA6C 162 62 ST., CROIX CO., WI RECEIVED FOR RECORD WILLIAM R. EUBANK, SR. AND WILLIAM R. E!:BA�K, JR. TRUSTEES 07 - 28 - 2000 1:00 PM OF THE HOLLY -R OD TRUST ' —- - — - -- — - - -- QUIT CLAIM DEED EY,EMPT q 17 quwt claims to WILLIAM R. EUBANK, JR. AND REBEC M. EUBANK CERT COPY FEE: HUSBAND AND WIF COPY FEE: TRANSFER FEE: _. RECORDING FEE: 10.00 PAGES: 1 the following described real estate to - ST. CROIX _ - County, State of Wisconsin' THIS SPACE RESERVED FOR RECORDING DATA CONVEYS THE SE - OF THE NW- AND THE NEB OF SECTION 36, NAME AND RETURN ADDRESS TOWNSHIP 28 NORTH, RANGE 20 WEST EXCEPT THAT PART THEREOF DESCRIBED AS FOLLOWS: COMMENCING AT THE HEYWOOD & CARI, S.C. SOUTHEAST CORNER OF NE`,, THENCE RUNNING NORTH 32 RODS, BOX 125 THENCE RUNNING WEST 65 RODS, THENCE RUNNING SOUTH 32 RODS, HUDSON, WI 54016 THENCE RUNNING EAST 65 RODS TO THE PLACE OF BEGINNING. THE ABOVE DESCRIBED PREMISES CONTAIN 187 ACRES, MORE OR LESS. 040 - 1169 -10 040- 1169 -20 040 - 1169 -30 PARCEL. IDENTIFICATION NUMBER THIS DEED IS GIVEN IN SATISFACTION OF A CERTAIN LAND CONTRACT BETWEEN THE PARTIES DATED SEPTEMBER 24, 1981, RECORDED APRIL 6, 1932, IN VOLUME 645, PAGE 40, DOCUMENT NUMBER 376969. This-- Is homestead property. (Is) lX,]N4t1 Dated this `3'L. -_ day of AUGUS A D.. 19 99 SE - (SEAL) (SEAL) (SEAL) 7 ULT , IAM R -FZM Z; SR; TRUSTEE WILLI - AM - . "EUBANK, JR., TRUSTEE AUTHENTICATION ACKNOWLEDGMENT F1 ors C1 c- Slgnature(s) State of i4isecsla, lI i \ q � ss authenticated this _ day of __, 19_ Personally came before me this _.g� 1 U` day of - - - - - -- ^ -- -- - - -- - -- - �� - 19C4 q, the above named TITLE NIINIBER MATE BAR OF WISCONSIN k If n(it, - _ _ authurizcd by ` i)o o( Wi, St:u >' to me known to he the person who executed the foregoing strument and acknowledge the same.SflC` vlain zr. THIS INSTRUMENT WAS DRAFTED BY �R' W��.�"�S�C+1 QI^ ( HEYWOOD & CARD S.C. BOX 125 __- HUDSON, WI 54016 - - - -- -- -- ---- - - - - -- - -- - Nntarp Puhllc, ounty, delis F�_ (Shnattlres may be authentt-ited or ackno�eIcdgcd Both arc nut N9y commission is permanent (If not, state expiration date �-.I�,, II Ix I „d d h,•I, d,< t[� 1 Doris S. Sw ft y I ��til�ll :,.p... p - c - MY COMMISSION t CC665709 EXPIRES QLII _AIM urt:o s LCrP BtRt>rwtscuNtit j. October !0, 2001wscors L.eyalBlakCo.Inc II,rm Nu. 3 - 1982 fi r;rn�;: Mtwa�kee, W's. POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page of FILE INFORMATION SYSTEM SPECIFICATIONS Owner WILL p✓V &N Septic Tank Capacity a 50 gal ❑ NA Permit # Septic Tank Manufacturer ❑ NA CJ) G3C 2 DESIGN PARAMETERS Effluent Filter Manufacturer A L ❑ NA Number of Bedrooms 4 4 ❑ NA Effluent Filter Model -- i p ❑ NA Number of Public Facility Units ❑ NA Pump Tank Capacity Sb gal ❑ NA Estimated flow (average) 00 gal /day Pump Tank Manufacturer �� L-5 2 ❑ NA Design flow (peak), (Estimated x 1.5) gal /day Pump Manufacturer /X'y45/Z 5 ❑ NA Soil Application Rate gal/day/ft' Pump Model 0 'c VU ❑ NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit ❑ NA Fats, Oil & Grease (FOG) 5_30 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (BOD 5_220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) 5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA ! Biochemical Oxygen Demand (BOD 5_30 mg /L ❑ In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) <_30 mg /L ❑ NA ❑ At -Grade ❑ Mound Fecal Coliform (geometric mean) 5_10' cfu /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y. in dia. ❑ NA Other: ❑ NA Other: ❑ NA Other: ❑ NA * Values typical for domestic wastewater and septic tank effluent. Other: ❑ NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ year) 1(s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (% of tank volume ❑ NA Inspect dispersal cell(s) At least once every: 3 ❑ month(s) (Maximum 3 years) ❑ NA year(s) Clean effluent filter At least once every: ❑ m ) l�year (s) ❑ NA �� � ls) Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ NA ❑ year(s) Flush laterals and ressure test At least once ever ❑ month(s) ❑ NA P Y' ❑ year(s) Other: ❑ month(s) [I NA At least once every: ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third W or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION Pa 9 a of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other "chemicals that may impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS i POWTS INSTALLER POWTS MAINTAINER Name Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name -}., C I'• >f �r..• Phone Phone 7 A 9 S b This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. START UP AND OPERATION Page of For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may'impede the treatment process and /or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed b a se to e y p g servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWT antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name Name Phone Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name -5+. Gr• C i...• - �,�,�' Phone Phone 15 _ 3$ 80 This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d) &(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code. �uu• 08/11/00 FRI 13:12 FAX 715 386 4686 ST CRX CO ZUN1NG . S'1' CROIX lC�� AAGREEMENT SEPTIC TANK AND OWgERSjU CERTIFICATION FORM L .� c - t owner/Buyer _ Y � Z Z Mailing Address Property Address �° !✓1 to (Verification required from Planning Department for new construction) ova CitylStatc �� UCfj r4LC_5 GV,_ Parcel Identification Number �r� , - _ � I � EGAY• DESCRIPTION , Scc. �+ T� --� -R � yd� Town of Property Location +• L Subdivision Volume .Page # Certified Survey Map IN , Volume v Page # Warranty Deed # Spec house O yes El no Lot lines identifiable C3 yes ❑ no ' tern, S YSTEM AiNTEN� ce of your t eptie "em mould =mdt is its pru� failure to haadl y s- Proper mata into the sy step, Improper use and maintcuaa if needed b a licensed pumPc • you put consists of pumping out the septic tank every tltree Yom or sooaR.f, can affect the function of the septic talc as a treatment stage in the waste disposa sy teuL t a �iflcation forth, signed by the owner and by a �Ihe property owner agrees to submit to St. Croix Zoning Deps� , that l/3 f io the oa site wastewaterdisposal system mastcr pluutbcr,]°�ymap1umbc4= ictedplumberoraficeusedP�Pa � the septio tank is less than � of fudg (if necessary)• Lion and pupnpin8 (i is in proper operating condition and/or (2) slier inspec � em with vwe the standards to mai�ia the private scvtage disposal system cation , the undersigned have read the above and agree eni of Natural g esources, State of Wisconsin Certiii► of Commerce and the Dept to the so Croix County Zoning Office within 30 set forth, herein, as set by the Department leted and returned dating that your septic system bas been haintained must be comp days of the three year expiration date. J � DA'L'E SIC,NAT[1RB OF APPLICANT pWNER CERTIFICATION our lmowledge. I (we) am (arc) the owne r(s) of I (we) certify that all statements on this form are true to the best of needs Office. the property descr above, by virtue of a warranty deed recorded in Reg ister a DATE SI Y A ' OF APPLICANT « « « «•• ... «., A. information that is mis- ropresentcdmax result in ilia sanitary p being revoked by the Zoning Department. ............ . on: a stamped wamnty deed from the Register of Deeds o�u decd a copy of the eertifred nuvey UMP if reference is made in the wa=WY •• Include with this appticati Parcel #: 040 - 1169 -40 -000 05/12/2006 11:50 AM PAGE 1 OF 1 Alf. Pdr6el M 36.28.20.645A 040 - TOWN OF TROY Current U ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner O - EUBANK, WILLIAM R JR & REBECCA M WILLIAM R JR & REBECCA M EUBANK 276 N ILWACO RD RIVER FALLS WI 54022 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description ` 276 N ILWACO RD SC 4893 SCH D OF RIVER FALLS SP 0100 CHIP VALLEY VOTECH Legal Description: Acres: 27.000 Plat: N/A -NOT AVAILABLE SEC 36 T28N R20W 27A SE NE EXC S 32 RDS Block/Condo Bldg: OF E 65 RDS & EXC HWY Tract(s): (Sec- Twn -Rng 401/4 1601/4) 36- 28N -20W Notes: Parcel History: Date Doc # Vol /Page Type 07/28/2000 627227 1530/163 QC 07/28/2000 627226 1530/162 QC 07/23/1997 879/143 07/23/1997 878/49 more 2006 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Changed: 07/21/2004 Last Chan Valuations: g Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.000 44,000 230,400 274,400 NO ENTERED BEFORE 2005 OPE W7 25.000 131,300 0 131,300 NO Totals for 2006: General Property 2.000 44,000 230,400 274,400 Woodland 25.000 131,300 131,300 Totals for 2005: General Property 2.000 44,000 230,400 274,400 Woodland 25.000 131,300 131,300 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 313 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 n Cl) v 0 a O o r p C 3 �m� ;�► v n m o* c v `�° C D m I 3 3 c N N n d O A M rn ° Ill o W O `t . C C a A <� a < a c 00 O O y O 0 3 3 c m cr < N ° (D "" 3 O O :U N (n Z Z (D ip a) co O O 7 p A O .D (D n a 7 c 7 7 (D c O (n O o ° O ° c c o ai fli D o ^; o N C v N = to V ° �• (� Cf O d (D O a r, v D ( a Z D m a Z q o 07 CTJ 0 N N O O O O a Z O (D N o I U1 (D .Z1 O O a O w co a O c m rn rn m (fl 3 Fr a' CD m C m 'I O- O O O O O O v !�1 z _ _ C N N f A N m " �I �E M v S '0 v v N - N r", ? T '� i C1 A 90 � (D (D o o m= m o a t►i .. d N N cr w N C j (D — Q cn „ N °. z z Z :� z `© D + O I D j 0 v 0 N 0 O CD O y (A i N m Cn N CD O CD CD M C N. 'O N w ro' 77 o. (o a A (D Er O o a o � p Z n cn c U C A z ° O .. O N m N 0) rA rA v w a 3 a a z ° o °o z M ° N N Z CD CD O C A A N W n CD O o C (D (D Q C CD cr m 00 a T y v T a`aa a_ c R' a c v 3 z a a z a m o to N-01 m 7 S O N 0 N (D CD m o a3 >_ = 3 CD $ J o co 3 r a (O O 3 =r C N O N = O fll (D 0 3 ti p S 'D '0 o N O CD ? m 0 CN z c cn m =3 0 . o a o 3 O `J I � � 0 � 0 I � � b o <D m do p m v+ O O w o f °o . `' a Form -STC- 104 AS BUILT SANITARY SYSTEM REPORT p OWNER P / /1 / U � J / TOWNSHIP 0 1 SEC. T N -R W 0 12d ADDRESS 7 �. �446W T CROIX COUNTY, WISCONSIN 1�9 5-1720 SUBDIVISION LOT LOT SIZE PLAN VIEW Distances and dimensions to meet requirements of I•IHR 83 SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM �� 11 �P INDICATE NORTH ARROW BENCHMARK: Describe the vertical reference point used ,✓ IT CE yy�� r Elevation of vertical reference point: / 60 , Q Proposed slope at site: Co uZA� - /0 SEPTIC TANK: Manufacturer: Liquid Capacity: 1 Number of rings used:l Tank manhole cover elevation: / 7e �d ' Tank Inlet Elevation: /W��L Tank Outlet Elevation: �`N ' Z Number of feet from nearest Road: Front,u Side 0 Rear, O } 2 'd 0 feet From nearest property line Front 0 Side,0 Rear, O �� d feet Number of feet from: well 0 building: (Include this information of the above plot plan)( 2 reference dimensions to septic tank) SEE REVERSE SIDE PUMP CHAMBER Manufacturer: Liqu Capacity: Pump Model: Pump /Siph Manufacturer: Pump Size Elevation of inlet: Bottom of tank elevation: Pump off switch elevat n: Gallons per cycle: Alarm Manufactur Alarm Switch Type: t Number of f t from nearest property line: Front, O Side, O Rear, 0 Ft. Number of feet from well: Number of feet from building: (Include distances on plot plan). SOIL ABSORPTION SYSTEM Bed: Trench: X` ,/ y , Width: S Length : _ Number of Lines: Area Built: ry �/ Fill depth to top of pipe: 2-0 A Z 5� r Number of feet from nearest property line: Front, © Side, O Rear,0 pt� 00 Number of feet from well: 7 2-^ (7 r Number of feet from building: �U (Include distances on plot plan). SEEPAGE PIT Size: Number of pits: Diameter: li Liquid depth: Bottom of seepage pi evation: Area Built: Has either a drop box O or distrib on box O been used on any of the above soil absorbtion sytems? (Check one). HOLDING TANK Manufacturer: Capacity: Number o rings used: Elevation of bottom of tank: Ele tion of inlet: Number of feet from nearest property line: Front, O Side, O Rear, O Ft. Number of feet from well: Number of feet from building: Number of feet from nearest road: Alarm Manufacturer: Inspector Dated: 6) Plumber on job: License Number: NOMESITE SEPTIC PLUMBINU CO- 65 C'NEIL RD., hAJDSON, WIS. 5401 ROBEPT U US MAeTER PLUMBER LIC, NO. 3307 M.P.R.S. 3/84:mj MINN. i '!TALLER d DESIGNER LIC. NO. 00663 I _ S- B PLOT PLAJ 5y f30.Pi:v h S 33 r -� 3. of .� Gs 1-0 f z� yf � ,� Col 5 CGS pip of ce pit Ny IQ � 3 • q 3 • .S�/ST COV�£�17 M sg 10 0 o " y a" r PRCA 'to QE 'P0001Oep VUT• tiff pf -. 96W OH C-OW w/ LVATE79- SFreu"car 6r )AbT4Ll Poly la►I . 5440 4 All 41 04A)kk a TO /ET 3 ';j , i7 . �' /�y•9rioa = /d 0, O fi > 75 HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., IfJOSON, WIS. 54016 ROBEITt ULBRIGHT CS r 7 S WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. mINN. OISTALLER & DESIGNER LIC. NO.00663 Ute* u & ov-� DEPARTMENT OF INDUSTRY INSPECTION REPORT FOR SAFETY & BUILDING LABOR & HUMAN RELATIONS DIVISION P.O. Box 7969 ON -SITE SEWAGE SYSTEMS OFFICE OF DIVISION CODES & APPLICATION MADISON, WI 53707 r ��+�� State Plan I.D. Number: SE 4,NE 4 36, 28, 20W KK CONVENTIONAL ❑ ALTERATIVE (If assigned) 9 q ---- - - - - -- Ilwaco Road' ❑ Holding Tank ❑ In- Ground Pressure ❑ Mound NAME OF PERMIT HOLDER: ADDRESS OF PERMIT HOLDER: INSPECTION DATE: Bill Eubanks 276 N. Ilwaco Rd River Falls WI 54022 BENCH MARK (Permanent reference point) DESCRIBE IF DIFFERENT FROM PLAN: REF. PT. ELEV.: CST REF. PT. ELEV.: Name of Plumber: MP /MPRSW No.: County: Sanitary Permit Number: Robert Ulbricht 3307 St. Croix 119523 SEPTIC TANK /HOLDING TANK: MANUFACTURER: LIQUID CAPACITY: TANK INLET ELEV.: TANK OUTLET ELEV: WARNING LABEL LOCKING COVER '?U b q � ' a I PROV IDED. ❑ NO P ROVIDED: ❑ YES 54NO BEDDING: ( �VENT DIA.: VENT MATL.: HIGH WATER NUMBER OF ROAD: PROPERTY WELL: BUILDING: VENT TO FRESH ALARM: FEET FROM LINE: AIR INLET: ❑ YES KNO I G Z ❑ YES YLNO NEAREST aOv Go p I I oZ -- DOSING CHAMBER: MANUFACTURER: BEDDING: LIQUID CAPACITY: PUMP MODEL: PUMP /SIPHON MANUFACTURER: WARNING LABEL LOCKING COVER PROVIDED: PROVIDED: ❑ YES ❑ NO ❑ YES ❑ NO ❑ YES ❑ NO GALLONS PER CYCLE: PUMP AND CONTROLS OPERATIONAL: NUMBER OF PROPERTY WELL: BUILDING: VENT TO FRESH (DIFFERENCE BETWEEN FEET FROM LINE: AIR INLET: PUMP ON AND OFF ) ❑ YES ❑ NO NEAREST SOIL ABSORPTION SYSTEM. Check the soil moisture at the depth of plowing FORCE LENGTH: DIAMETER: MATERIAL AND MARKING: or excavation. (If soil can be rolled into a wire, construction shall cease until MAIN the soil is dry enough to continue.) CONVENTIONAL SYSTEM: BED /TRENCH WIDTH: LENG �_� H: NO. OF DISTR. PIPE SPACING: COVER INSIDE DIA.: #PITS: LIQUID TRENCHES: MAT : PIT DEPTH: DIMENSIONS I GRAVEL DEPTH FILL DEPTH DISTR. PI E DISTR. PIPE I DISTR. PIPE MATERIAL: NO. TR. NUMBER OF I PROPERTY WELL: BUILDING: VENT TO FRESH BELOW PIPES: ABOVE COVER: ELEV. INLET ELEV. END: ^ PIP : FEET FROM LINE: AIR INLET: to a 4 .t '440 35 a CI NEAREST + MOUND SYSTEM: Mound site plowed perpendicular to Check the texture of the fill material for PROVIDE A DIAGRAM OF SYSTEM slope and furrows thrown unslope: mound systems to make certain that it ON REVERSE SIDE. SHOW ❑ YES ❑ NO meets the criteria for medium sand. ELEVATIONS MEASURED. SOIL COVER TEXTURE: PERMANENT MARKERS: OBSERVATION WELLS; ❑ YES ❑ NO ❑ YES ❑ NO DEPTH OVER TRENCH /BED DEPTH OVER TRENCH /BED OF TOPSOIL: SODDED: SEEDED: MULCHED: CENTER: EDGES: DEPTHS ❑ YES ❑ NO ❑ YES [_1 NO ❑ YES ❑ NO PRESSURIZED DISTRIBUTION SYSTEM: BED /TRENCH WIDTH: LENGTH: NO. OF LATERAL SPACING: GRAVEL DEPTH BELOW PIPE: FILL DEPTH ABOVE COVER: TRENCHES: DIMENSIONS MANIFOLD PUMP MANIFOLD DISTR. PIPE MANIFOLD MATERIAL: NO DISTR. I D PIPE DISTRIBUTION PIPE MATERIAL & MARKING: ELEV.: ELEV.: DIA.: ELEV.: PIPES: DA. ELEVATION AND DISTRIBUTION HOLE SIZE: HOLE SPACING: DRILLED CORRECTLY: COVER MATERIAL: VERTICAL LIFT CORRESPONDS TO INFORMATION APPROVED PLANS E] YES ❑ NO ❑ YES ❑ NO COMMENT PERMANENT MARKERS: OBSERVATION WELLS: NUMBER OF PROPERTY WELL: BUILDING: FEET FROM El YES ❑ NO [__1 YES ❑ NO NEAREST - Aek Sketch System on Retain in county file for audit. Reverse Side. "GNATURE TITLE: Zoning Administrator SBD -6710 (R. 06/88) Thomas G. Ne son Z ®ILHR S ANITARY PERMIT APPLICATION CO TY E=mmmmmmm=w In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERM -Attach complete plans (to the county copy only) for the system, on paper not less than ii4? 5.9- 8% x 11 inches in size. ❑ Check if revision to previous application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION – PLEASE PRINT ALL INFORMATION. PRQPER OWNER PROPERTY LOCATION �, _r) 25i �1J�1 ` A.4 S rjtr 1 /a Nc /a, S 36 T LS, N, R 20 E (o CW PROPERTY 2, 07 (.t OWNER'S MAILING4 CO V la - LOT # D � / B�Q j �- / 7 -L � 7 �- CITY, STATE ��f ZIP CODE PHONE NUMBER SUBDIVISION NAME OR CS I U MBER �c Uk�x ���f `(/� S9� 1( 4L 5)6 01 1 1. TYPE OF BUILDING (Check one CITY Q NEAREST ROAD 0 1 ) ❑State Owned VILLAGE 404(N OF: ❑ P ❑ 1 or 2 Fam. Dwelling -# of bedrooms — PAR TAX NUMBER() 3 / ' 2 9 Z a /: /1 III. BUILDING . If building type is public, check all that apply) l0 (Q Z i e J c6 _ / 1 El 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 A Other: Specify fE£ e ld d �- IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. X New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit ## — Date Issued V. TYPE OF SYSTEM: (Check only on Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 � Seepage Trench 22 El In-Ground 42 ❑ Pit Privy 13 Seepage Pit Pressure S Y57 43 ❑ Vault Privy 14 ❑System - In - Fill Td, 4C S "Z.FD 5 �i� Tv Z- & Pkl r VI. ABSORPTION ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/ y /sq. ft.) (Min./inch) ^� ELEVATION . 3 O 33 a 1 33 0 l 7 Feet (p IJ Feet VII. TANK CAPACITY Site in allons Total Ill! of Prefab. Fiber- Exper. INFORMATION New is Gallons Tanks Manufacturer's Name C oncrete Con- Steel glass Plastic App Tanks Tanks strutted Septic Tank or Holding Tank God '� Lift Pump ber Tank/S hon Ch am Q; VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name (Print): Plumber's Signature: (No Stamps) P /MPRSW No.: Business Phone Number: 4 a/. 7 7f 3o - SI' Plumber's Address (Street, City, State, Zip Code): IX. COUNTY /DEPARTMENT USE ONLY Disapproved Sani ry Per it Fee (includes Groundwater a e ssue , Iss 'nip Agent Signature (No Stamps) • f J Surcharge Fee) Approved ❑Owner Given Initial �`J v Determin tin A- X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: SBD -6398 (formerly Pib -67) (R. 11/88) DISTRIBUTION: Original to County, One Copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at the time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer /Renewal Form (SBD 6399) to be submitted to the county prior to installation. 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety & Buildings Division, 608- 266 -3815. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type` of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is Public, check all appropriate boxes that apply. IV. Type of permit. Check only one in line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested in #1 -7. VII. Tank information. Fill in the capacity of every new and /or existing tank, list the total gallons, number of tanks and manufacturer's name. Indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. Vlll. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/Department Use Only. X. County/Department Use Only. Complete plans and specifications not smaller than 8 1 /2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains /water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. r i GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater, ground- water contamination investigations and establishment of standards. SBD -6388 (R.11/88) A • f J Q Z P Z Q H Z r-+ V w P 4L i r-+ z z 0 � � 3 a � w C/I W 1� + w mo d' z w ` + d c� ! 1 l A 0o a a ac I d ~ (� I APPLICATION FOR SANITARY PERMIT STC -100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor,(spec house), 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 propert 4/� /J��� (:5 0,d 4 A Location of property S e l/9 NJF_ 1/4, Section 36 , T ` N -R 1 W Township :2 Mailing address ew Address of site Subdivision name Lot number Previous owner of property -- Tom# s <ft Vercel ( gkcm �. Date parcel was created Are all corners and lot lines identifiable? A- Yes No Is this property being developed for resale (spec house)? Yes _ N0 Volume 111 and Page Number 7 Q as recorded with the Register of Deeds. 9 9 ------------------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER, and the SEAL OF THE REGISTER 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 references to a Certified Survey Map, the Certified Survey Map shall also be required. ------------------------------------------------------------------------------- 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 r ecorded in the Office of the County Register of Deeds as Document No. 3 � F6o Y ; 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. ). Signature of Owner Sign ure of Co ex (If Applicable) Date of Signature Da of Signa e l T r• s,,�`x;,r�, •mil es s�Nli Pik wtb is Pard r OrAki a . '_!-.o 4'xW�'� � iSwti fry . d as K � aiMill al�ge �ei>air{ , • � _ , , y Cara 974 ; n tJrs snt+eSet� , ill erwaliSr�rliaua a/ !kc pru, �e� , . or Sapp �rwfi�, fihll ate* "of ,_1'hllli.:�. ; IiirwMi� s�sLtini �, tom► Prowstf at *0 sawal rate or IIIiFA_Owert* 06arti ft femm"r lat a IL =ai 0 IV and bald,, MW rrtus that said, preprW r+� n la tow ar t!r jr fr Vw erilip►tien or this bqrorsr a r., iN .lmd &iV"d that thw miler doll p i� 1 ' sad *w is 1902•. Tt►r+art*r thw "re dMI w . . � r of Uwe and insurmse'o SIN 1 tarthee �. Sad app as tail to P". Wore penalpt:aeit N qtr loss »-- Said ft n�hSpeeet mss, sad aY aaeeeemeuta 3 Oi~ OVA jmpr& reme *tr ate► e ft so km4k or wrier X11 bawlfRr 1e �1 M tM111ed Erb[ tom. tort e" Iw and Ismaia. tM lro/SK7 09 the 1 7 of IM I 1 1 i polAilM b us "rum of tips " Wei" paoa. and at !bete own e:peale. to bee► Mi reNabk Insweaee sImwww tee oewpml^ to be app "d b tre Mlfl of-, _ l d at>ld wummwm ter at leis[ as awe 49�. - - nft eat Part. #0 wiessomm et ani�ae. apd, is eair at ten. e�wtt �, 4 a MMIt e�Irlit ajM party K an &M D&O. Me antra oe a dr a edxb4 WO °; riY Ira- .n.ild '"� r their iafeaa! exalt appear. Sad to i� MM" dapoadt wlth'etile !nom ,aai -pll ee. * the Noah Mrt� 4Y M Mr #ralr lh to he Pall by is Slot lurta tent shah be latlrwit V&VWft VMA hNnat !M "s- as as be. Ruff In the , mu"Ot St pdodpd or i t wat daK heteuaMt. u tbw teat is sw 00 4r aaaere.eesM rNa ,twos atoll, no rla. terra 4w eobdl"l torch pww et me wet am at no spio% b wrote. aogae titte and MrroMb # eMM „ S one” pMtl�ilt PSYW t =a" wfiMrtnew htr hear a * de "MA M SW st rem+ i re It STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER /BUYER If ROUTE /BOX NUMBER l ' l ' �7 /'� FIRE NO. CITY /STATE ��� �d /O ��- ZIP s y PROPERTY LOCATION: SF 1/4 Pb 1/4, Section � & , T )X N, R Z® W, Town of �� Y , St. Croix County, Subdivision , Lot No. Improper use and maintenance of your septic system could result in its premature failGre 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 for a MAXIMUM of $3000 of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of ALL NEW SYSTEMS agree to keep their systems properly maintained. The property owner agrees to submit to 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 form 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 Department of Natural Resources. Certification form must be completed and returned to the St.Croix County Zoning Office within 30 days of the three year expiration date. SIGNED l p� --- DATE St. Croix County Zoning Office St. Croix County Courthouse 911 4th Street Hudson, WI 54016 (715) 386 -4680 Sign, Date, and Return to above address i DEPARTMENT OF RE PORT ON SOIL BORINGS AN D SAFETY & BUILDINGS INDUSTRY, 1 c DIVISION HUMAN NDLATIONS PERCOLATION TESTS (115) MADISON W BOX 769 I 3707 (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: TOWNSHIP/ LOT NO.:BLK. NO.: SUBDIVISION NAME: 5e 1 /4 NE 1 /4 3 (e 1T 2,' N /RwE woo y - - -- COUNTY: OWNER'S NAME: MAILING ADDRESS: S/ Gco l X &J0, ef-ZC BR.ve 27G 1( T koAcc o RD - I? % 0 2 FA I S Gv IS Soot i_ USE li 2 - Co o DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRIPTION: PR F L DESCRIPTIONS: A TESTES: Residence New ❑Replace I p Rj l 2 - �y �y /+P 'ei ) 1 s - / fey ON S .SewF.�e -1 PRo0 i��l> RATING: S= Site suitable for system U= Site unsuitab for system ONVENTIONAL: MOUND: IN- GROUND - PRESSURE: SYSTEM- IN- FILLHOLDING TANK: RECOMMENDED SYSTEM: (optional) ®S ❑U SS ❑U ©S ❑U ❑S BU I ❑S DU I C_OZ'Ve"o71'e -y"tL If Percolation Tests are NOT required DESIGN RATE: 4 GL SS S If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate: 1} Floodplain, indicate Floodplain elevation: PROFILE DESCRIPTIONS $CS 3 ' a BORING TOTAL DEPTH TO GROUNDWATER- INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER D IN, ELEVATION OBSERVED EST. H HES TO BEDROCK IF OBSERVED (SEE ABBRV. ON BACK.) 6 -/ /�r� ����� > � ` /,o Y SC S , /s ee,e5� 6,0 `Tru • .7S' B L). S .7 o S, /. O'o.C 6,d ' zf'.' B- go 9y y >9.d v 'rs B- 3 �• 1 G•70 f )40 �,� ' ,62' 8,0 _ Sl ,S'3' o,P. S, S' o�P.cS, �,� r1,v v E"e C S B- �5� a 1,K y� ' ?�, ' o 3w S i, � , 7• .6 , ?',� v€R es B- PERCOLATION TESTS /w dER f/ C'S 5"?Wf74 S TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL - INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL -MIN. PERT D 1 PER OD 2 PERIOD PER INCH P_ / 2, 2 P- P- P- P- P- PLOT PLAN: Show locations of percolation tests, soil borings and the dimensions of suitable soil areas. Indicate scale or distances. Describe what are the hori- zontal and vertical elevation reference points and show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. �a J t� � SYSTEM ELEVATION /N 3 y s SSE / 00 0 1.,f.✓ __... , i I , I, the undersigned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and methods specified in the Wisconsin Administrative Code, and that the data recorded and the location of the tests are correct to the best of my knowledge and belief. NAME (print): TESTS WERE COMPLETED ON: HOMESITE SEPTIC PLUMBING CO. 655 O'NEIL RD., MkSON, WIS. 54016 ADDRESS: ROBERT. ULBRIUH I ICERTIFICATION NUMBER: PHONE NUMBER (optional): NIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. 7'/ 'r2_ 3�� Q l� r- a c CST SIGNATURE: 7,�/ M 2 w " V DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR- SBD-6395 (R. 10/83) - OVER - L - - -- P LO T PL x fn�0 3z 3s =Zp n � / �'o � X = ERG S�TFS i d T r { Qv a0 / t � eoATEk "yptA,) r pRopos�u � il , J PR£ 'J o RE pQov�Oep !� U EPT• IREf /�1 30170 -t EI�6E W ATEP- SF- Pv" 4P H tT�L POD t3)� . 51'PI'AJ6- 4 7-- ME e0AAW C &V A - 000 = /00, 0 -BAPO hb14 t � v/3kaK > 75 HOMESITE SEPTIC PLUMBING CO. 656 O'NEIL RD., MJDSON WIS. 54016 ROBER i ULBW4 6.5 r- 2 NP Z WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. riINrl. 013TALLER & DESIGNER LIC. NO. 00663 LA i 31 ' /3p.Pi%v (r S K = EiRG SiTEs y� <� i \ •� � GS \ \ c \ ` 0 \ t M � M � o fit" t otae 2 # ya "r I � R � poS �v Ii' PREP 'to 4E PQou�O�o !—'�- VEQr• I�Ef Pf = 13olto� -+ EI�bE w/ w ATE - R SE �pu�'t� 6 ACT4 PoIr t 1 P5 . - - - - - - - - 51'oiAufi Al" Al S ( C,/r- yAr loa = /00,0 � vpkaK fi > 75 t HOMESITE SEPTIC PLUMBING CO. W O'NEIL RD., I*JpSON. WIS. 54016 2 NP Z ROBER i ULBRIGHT C5 f WIS. MASTER PLUMBER LIC. NO. 3307 M.P.R.S. A9INNi. jISTALLER & DESIGNER LIC. 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