HomeMy WebLinkAbout042-1031-10-200 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
ti 488212 0
GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No:
Perso; oal information ygu provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)].
PeAnit Hold 's Name: City Village X Township Parcel Tax No:
Conley, Mike I Warren, Town of 042 - 1031 -10 -200
CST BM Elev: Insp. BM Elev: P Description: Section/Town /Range /Map No:
b p z 100,D - 8t u ( 11 12.29.18.177a20
TANK IN ORMATION ELEVATION DATA
TYPE cr.. / �MA�IUFA� U�R�ER�,,, � CAPACITY STATION BS HI FS ELEV.
Septic ! w G �C, --r Z� Benchmark I � `Q F
Dosing 1 � �, Alt. BM
Aeration Bldg. Sewer
Holding St/Ht Inlet / q b I
SVHt Outlet ( /
TANK SETBACK INFORMATION
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet v pip
Septic > I S � ' '� Dt Bottom 15-,53 �z. 0 I 1
Dosing 1 Lt �, �p t Header /Man. D S �
u ..� 0
Aeration Dist. Pipe Z , Z- 1 /
2.5' c9S.�
Holding Bot. System 3 �L p
T
Fin
PUMP /SIPHON INFORMATION l sd
Manufacturer Demand St Cover O r
GPM , ( `� D a 3 • Z
Model Number 0 . J IS �
Lift Friction Los System Head TDH Ft D f
o' ,64' p3.
2. 3.2� i' • 9f ,ra : 5 �.� a
Forcemain Length t Dia. 2 u Dist. to Well V
N J
SOIL ABSORPTION SYSTEM ( $ --,>
Width Length No. Of T PIT DIMENSIONS No. Of its In ' ia. Liquid Depth
DIMENSIONS C f �I f
SETBACK SYSTEM TO L P/L BLDG IWELL LAKE /STREAM LE H Manufacturer:
INFORMATION f1 C MBER O
Type Of System t I -` UNIT umber:
,PnVAf System,
L,11C1 �� k 'S u
DISTRIBUTION SYSTEM Iii 4 L " cis pp' Z; �a IKSp.
Header /Manifold r v Distribution f f fl f ole Size /� I x Hole Spacing Vent to Air Intake
�/ Pipe(s) 3 8b Length , Dia I /7 Length Spacing /��'J
SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only
Depth Over Depth Over xx Depth of xx Seeded /Sodded xx Mulched
Bed/Trench Center Bed/Trench Edges Topsoil Yes f ?] No Yes No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Od r - I�js ct; 2. /
I cry
Location: 1485 110th Ave Hammond, WI 54015 (NE 1/4 NE 1/4 12 T29N RI 8W) NA Lot 2 Parcel No: 12.29.18.177a20
1.) Alt BM Description
2.) Bldg sewer length = 2 �
3> amo nt of cover= �{�? 54,3 t +�
Plan revision Required? Yes ' No
Use other side for additional Informa it"on.___Ui_— — -- - - - - -- - -
Date Insepctor's Signature Cart. No.
) -6710 (R.3/97)
r
Safety and Buildings Division County _.
201 W. Washington Ave., P.O. Box 7162 S-r- t`e x
Madison, WI 53707-7162 Sanity
(608) 266 - 151 Sanitary P emlit Number (to be filled in by Co.)
Pne 9'2 t Z.
C ni Permit Application State Plan LD. Number
1n accord wit 83.21, Wis. Adm. Code, personal information you provide Z : - = TP-4AJ5 /,6
} ypu oses Privacy Law,
may 1 used o secondar rp , s15.04 (11 ",{ m ) Project Address (if different than mailing address)
{ 1. Applicat ` "ati - Please Print All Information
P roperty Ow
Parcel # Lot # 2 Block #
Property Owner's Mailing Addres _ Property Location
y --
j Cit •. State Phone Number e" , -'& V,, Section
Zip Code
j M7 Mlf9�I d �� S' /5'
� ` crrcle
j II. Type of Building (check all that apply)
S v>ti t
N; R1�E o
l or 2 Family Dwelling - Number of Bedrooms s Sobdiroisitm3dame M Number j
I ❑ Public /Commercial - Describe Use _— V A6
❑ State Owned - Describe Use []City ❑Village &ownship of
III. Type of Permit: (Check only one box on line A. Complete litre B if applicable) 2 -/O 3 - -� _ /D - JCJi� • /� -
A- �7.
i 11 New System ❑ Replacement System ❑ Treatment/Holding Tank Replacement Only ❑ Other Modification to Existing System
I u. ❑ Permit Renewal ❑ Permit Revision ❑ Change of ❑ Permit Transfer to New List Previous Permit Number and Date Issued
f Before Expiration Plumber Owner
IV. T e of POWTS S stem: Check all that a I 2 - 2
❑ Non - Pressurized In- Ground R Mound > 24 in. of suitable sot ❑ Mound < 24 in. of suitable soil ❑ At -Grade ❑ Single Pass and Filter ❑
Constructed Wetland ❑ Pressurized In- Ground ❑ Holding Tank ❑ Peat Filter ❑ Aerobic 'Treatment Unit ❑ Recirculating Sand Filter ❑
Recirculating Synthetic Media Filter ❑ Leaching Chamber ❑ Drip Line ❑ Gravel -less Pipe ❑ Other (explain)
V. Dispersal/Treatment Area Information:
Desi Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal ca Required (sf) Disposal Area Proposed (sf) 'System Elevation
�� ra9 C(.0SZ wo 6do /0 V,
VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic
i Gallons Gallons of Units Concrete Constructed Glass
I New Existing
Tanks Tanks
Septic or Bolding Tank K
Aerobic Treatment Unit a u
j
Dosing Chamber ,
I
VIL .Responsibility Statement - I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) Plumber;, Si natur MP /MPRS Number Business Phone Number
A I ke, (�C->Qes' � d '*� a ^3X -
Plumber's Address (Str City, State, Zip Code)
/1
VIII. Conn /De artment U On I
Approved ❑ Das Sanitary Permit Fee (' lodes Groundwater Date Issued Issuing Ag t Signature (N Stamps)
Surcharge Fee)
Reason for 'al
E]
IX. Conditions at
SYSTEM OWNER:
1 Septic tank, effluent filter and
dispersal cell must all be serviced / maintained
as per management plan provided by plumber.
2. All setback requirements must be maintained
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)
Mike Conte and M Ho
y � ex y
NE 1 /4,NE 1 /4, S 12, T29 N, R 18 W
Town of Warren, St Croix Co.
CSM Lot .A.
Le
r / �-; A kvb: I$$g e nd
40' N
♦ - Benchmark Ele. 100.00 ft
Top of 3/4" pvc pipe
• - Alt Benchmark Ele. 100.05 ft
Top of 3/4" pvc pipe
Borings
1 Boring Elevations Z
U
Inca 131= 103.65 ft
132 = 103.65 ft
\
133- 102.05 ft
B4 - 0.00 ft
o.
4 (( �
s k I Lk-'
\ q I
- I
G � 1
o $Ili 'v -
PO
bSIS
Safety and Buildings
4003 N KINNEY COULEE RD
�ommerce.wi.gov LA CROSSE WI 54601 -1831
TDD #: (608) 264 -8777
i sco ns i n www.commerce.wi.gov /sb/
Department of Commerce
www.wisconsin.gov
Jim Doyle, Governor
Mary P. Burke, Secretary
May 26, 2006
CUST ID No. 225094 ATTN.• POWTS Inspector
MICHAEL P ROGERS ZONING OFFICE
ROGERS PLUMBING ST CROIX COUNTY SPIA
E4457 HWY 12 1101 CARMICHAEL RD
MENOMONIE WI 54751 HUDSON WI 54016
CONDITIONAL APPROVAL
PLAN APPROVAL EXPIRES: 05/26/2008 Identification Numbers
Transaction ID No. 1275641
SITE: Site ID No. 713406
Mike Conley & Mary Hoyer Please refer to both identification numbers,
1 l 0 Ave above, ;in all corres ondence with the agenc
Town of Warren
St Croix County
,NE1 /4, NE1 /4, S12, T29N, R18W
Lot: A,
FOR:
Description: Four Bedroom Mound System
Object Type: POWTS Component Manual Regulated Object ID No.: 1077721
Maintenance required; 600 GPD Flow rate; 17 in Soil minimum depth to limiting factor from original grade;
System: Mound Component Manual - Version 2.0, SBD- 10691 -P (N.01 101),
Pressure Distribution Component Manual - Version 2.0, SBD- 10706 -P (N.01101); Filter
The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes
and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in
chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements.
No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.145.06, CO, #'A
stats.
The follow_ ing conditions shall be met during construction or installation and prior to occupancy or use: AWN
DER R YENI
Reminders ,1� N OF RAF
• This system is to be constructed and located in accordance with the enclosed approved plans and with the SEE CORRE
component manuals listed above.
• Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area.
Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and
dispersal are prohibited.
• The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption
area. chs. NR 811 & 812c
• A Sanitary Permit must be obtained from the county where this project is located in accordance with the
requirements of Sec. 145.135 and 145.19, Wis. Stats.
• Inspection of the POWTS installation is required. Arrangements for inspection shall be made with the designated
county official in accordance with the provisions of Sec. 145.20(2)(d), Wis. Stat
MICHAEL P ROGERS Page 2 5/26/2006
• Comm 83.22(7) A copy of the approved plans specifications and this letter shall be on -site during construction
and open to inspection by authorized representatives of the Department, which may include local inspectors.
Owner Responsibilities:
• Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and
maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s.
Comm 83.54(1).
• Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as
required under s. Comm 83.54(4) shall be considered a human health hazard.
• Comm 83.55 The owner is responsible for submitting a maintenance verification report acceptable to the county
for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s)
utilized in the POWTS.
All permits required by the state or the local municipality shall be obtained prior to commencement of
construction /installation/operation.
In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should
conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review
shall relieve the designer of the responsibility for designing a safe building, structure, or component.
Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address
on this letterhead.
The above left addressee shall provide a copy of this letter to the owner and any others who are responsible
for the installation, operation or maintenance of the POWTS.
Sincerely, Fee Required $ 175.00
7 Fee Received $ 175.00
Balance Due $ 0.00
_1
Charles L Bratz
POWTS Reviewer II , Integrated Services WiSMARTcode: 7633
(608)789-7893, 7:45 am - 4:30 pm Monday - Friday
charlie.bratz@wisconsin.gov
cc: Leroy G Jansky, Wastewater Specialist, (715) 726 -2544
Henry F Grote , Certified Soil Testing
i
I i
Conley & Hoyer - Mound
Construction Materials and Techniques
All materials must comply with Comm 84 and be installed in accordance with manufacturer's
specifications. Construction methods must comply with the following Component Manuals:
Mound, SBD - 10691 -P (01/01)
Pressure Distribution, SBD - 10706 -P (01
Location: Lot A, CSM, from NE ' /4, NE '/4, Sec. 12, T 29 N, R 18W
Town: Warren
County: St. Croix
Date: May 16 2006
Owner: Mike Conley & Mary Hoyer
Address: 1485 110 Ave.
Hammond, WI 54015
Plumber: Mike r
Signature:
License: MP 225094
Attachments: SBD -10577 - Plan Approval Application `'onallp
SBD -8330
OF Cod',
1iFRCE
Page 1: cover EYANL) U -
G s
2: design criteria & calculations��,
3: plot plan SP ON�ENCE
4: system cross section
5: plan view, lateral detail
6: pump tank exit detail
7: pump curve
8: system management
I
1 f8
page o
Design Criteria
Residential Wastewater Contaminant Load: 30 mg/L < BOD5 < 220 mg/L
Anticipated septic tank effluent 30 mg/L < TSS < 150mg/L
Fecal Coliform > 10,000 cfu/100 mL
Fats, oils, grease < 30 mg/L
Bedrooms x 100 gal/bedroom/day x 1.5 �' "'0 gallons /day hydraulic load
Design Calculations
In situ designed loading rate O.Z g gallons /sq. ft. per day
Depth to estimated high ground water - in.
Depth to bedrock in.
Cross slope at system �' �� %
Force main length In ft. of in. Z�,��
Manifold/header length 2 ,T ft. of Vt4- in. 0, `�
Drain -back Z� �S' gallons
y' o ft. of V/4 in.
Lateral length @ o,
Lateral elevation "S 1 ft. @ bottom of lateral
Lateral hole size " Y b in. @ S in. ( `� ft.) Spacing
l 3 holes /lateral S Z holes total
Lateral volume S ,3 gallons
Total lateral discharge rate gallons /minute @ 2 ' ft. head
Network pressure compensation losses ���� ft.
Elevation difference T ft.
Friction loss 3 35� ft. @ 3 �/ gallons /minute
Total dynamic head Z �' Z ft.
Pump /slpbon A gpm @ Z 2 - ft. of head
Manufacturer Model # I z
Dose volume gallons
Lift/sip''on tank JS� gallons
Septic tank , gallons
Effluent filter C� -�� / O a. � r` i �� ii- 14 R
Measurement pump on and off to -s� in.
Height alarm from tank bottom in.
Reserve capacity
specs.calcs.res
Page Z of
Mike Conley and Mazy Hoyer
NE1 /4,NE1 /4,S 12,T29N,R18W
Town of Warren, St Croix Co.
CSM Lot A
Legend N
♦ - Benchmark file. 100.00 ft
Top of 3/4" pvc pipe
• - Alt Benchmark Ele. 100.05 ft
Top of 3/4" pvc pipe
d - Borings
1 Boring Elevations Z
1 131 = 103.65 ft
Inca }:Jv 13 = 103.65 ft
133 - 102.05 ft
B4 — 0.00 ft
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WEATHERPROOF
LOCKING�GOVER JUNCT►o►+
6cnc
CtJA�N MJG � f1BE� .
GWtcK C►�GO�ur<CT -1
� 12
A PI v e 3' n�
twm No1STuR8ED
SOIL. 2 4u T. D.
YENT
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pp►�acvtD A 4.5 4, PQ(-
4to
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PVrIP
SEPTIC F _S
DOSE
TAWKS MAWUFACTUP CK: QUMSER OF DOSES: PER OA.:j
TAWK SIZE: \'*r GALLOWS DOSE VOLUME
ALARM MAUUFACTUKER' S� F INCLUDING OACKF{.OW: (,ALLONS
MODEL IJUMb'EK: CAPACITIES: A= zG I OR GALLOWS
SWITCH TYPE: � "�� a e Z WCHES OK � Z (,ALL0u5
PUMP MAQU FACT URC>R: � -``�� C. 6 '� INCHES OR 104 } �' GALLOUS
MODEL QUMDER: 1J Z' D■ 9 " INCHES OR GA�L0JS
SWITCH TYPE; 6 '`' 0 '"`'� `"`�� IJOTE' PUMP AWD ALARM ARC TO DC
MINIMUM DISCKAR" RATE 4' _GPM INSTALLED ON SEPARATE CIRCUITS
VERTICAL DIFFERENCE bETWEEU PUMP OFF AUO 013TRIbUTIOW PIPE.. 10 FEET I I
+ MIAJ METWORK SUPPLY FREtsuKc.. . , .. . FCCTI�
+ «O FEET OF FORCE 1AAIW X z, � g F / _ ' 11< FEET
loo rtFKICTIOW FACTOR.
TOTAL DyWAMIC. HEAD = 21 FEET
IIJTERIJAL DIMEIJStOWS 01 TAWK: LE►J67H `YY
;WIDTH 9 ;LIQUID DEPTH
�' • x ILI PUMP PERFORMANCE CURVE
• MODEL 1511152!153 TOTAL DYNAMIC HEAD/FLOW
PER MINUTE
14 45 153, EFFLUENT AND DEWATERING
�} MODEL 151 152 153
35 f
= 10 r Feet Meters Gal. Liars Gal. titers Gal. Liters
5 1.5 50 189 69 261 77 291
'c 6 26 151 10 3.0 45 170 61 231 70 265
15 4.6 38 144 53 201 61 231
0
20 6.1
29 110 44 187 52 197
8
20
25 7.6 .18 81 34 129 42 159
15
30 9.1 •- 23 33 125
4 35 10.7 _ _ 22 85
10 40. 12.2 - - 11 42 Shut-off Head: 30 R. (9.tm) 38 n. (1�
. 44 tl (13.am)
5
01451786
0
10 20 30 40 50 60 70 80 90 100
GALLONS
LITERS 0 40 80 120 160 200 240 280 320 360
LOW PER MINUTE 014508A Model 151 Models 152/153
- 3`f•Y
;ONSULT FACTORY FOR 6 7,32
SPECIAL APPLICATIONS 6
3 7/8- a 5/8 3 27/3 6 5/
,-
• Timed dosing panels available. � 3 7/6
• Electrical alternators, for duplex systems, are available and `
supplied with an alarm, e • Variable level control switches are available for controlling ® 3 7/e
single phase systems. j
• Double piggyback variable level float switches are available I
for variable level Ion and short cycle controls.
.
9 Y
s
• Sealed Qwik -Box available for outdoor installations. See j
FM 1420.
• Over 130 °F. (54 °C.) special quotation required.
I
1
151/ ?x21 11 I1 /16 12 /8 .153 Series
151/152/153 MODELS Control Selection I �.
Model ' Volta -Ph Mode Am s Slm lex I Du lex N151 115 '1 1 Non 6.0 1 2or3 1
BN151 115 1 1 Auto 6.0 Included 2 or 3
E151 230 1 1 Non J 3.2 1 2 or 3
BE151 230 1 Auto 3.2 Included 2 or 3 151 SK2064
N152 115 1 14on 8.5 1 2 or 3
6N152 115 1 Auto 8.5 Included 2 or 3
EI52 230 1 Non 4.3 1 2 or 3
BE152 230 1 to 4.3 Included 2 or 3
N753 115 1 Non 10.5 1 2or3
BN153 115 1 Auto 10.5 Included 2 or 3
E153 230 1 Non 5.3 1 2or3 SELECTION GUIDE
BE153 230 1 Auto 5.3 Included 20,3 1. Single piggyback variable level float switch or double piggyback variable level float
switch. Refer to FMO477.
A CAUTION 2. See FM0712 for correct model of Electrical Alternator E -Pak.
All insiailation of controls, protection devices and wiring should be done by a qualified 3. Variable level control switch 10 -M5 used as a control activator, specify duplex
(3)
licensed electrician. All electrical and safety codes should be followed including the most
rzcenl National Electric Code (NEC) and the Occupational Safety and Health Act (OSHA). or (4) float system.
RESERVE POWERED DESIGN
For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump.
MAIL T0: P.O. BOX 16347
5 Louisvi, lle KY 40256.0347
SHIP
Manufacturers o/. .
T0: 3649 Cane Run Road !T
(502) 778.2731 - 1(800) 928-PUMP
Q!/4L/TY P4t/P8 S v CE I,9��
htip //wwwzoeller.com PUMP !O. FAX (502) 774 -3624
® Copyright 2003 Zoeller Co. All rights reserved.
System Management
Management of this system is critical. As a condition of approval of these plans this system management section must be
reviewed with the owner, and the owner must be provided with a complete set of plans including this management section. If
problems develop with the adsorption system or any other system components, the installing plumber, Rogers Plumbing, 715 -235-
1132, or the St. Croix County Zoning Office, 715- 386 -4680, should be contacted for assistance.
General
Proper functioning of an on -site disposal system, "septic system," is significantly dependent on the volume of water which
flows into the system and the level of contaminants in that volume. The lower the volume of water and the lower the level of
contaminants, the better and longer the system will function. Typical system components include a septic tank or compartment to
settle out solids and contain greases and oils, a filter on the outlet of the septic tank to retain small particles of the same density as
water, a dose tank or compartment to allow a dose to be accumulated, a pump and controls or automatic siphon, and finally some type
of soil adsorption cell to recycle the water in a manner to protect ground water quality and public health.
1. If the septic tank is installed prior to sheet -rock and /or painting, pump the septic tank before normal use begins to ensure
adherence to contaminant load design criteria.
2. Install water-saving appliances whenever and wherever possible.
g PP P
3. Repair even small water leaks as soon as possible.
4. Never pour grease or oil down any drain or stool.
5. Garbage disposals are not recommended; if you must have one, use it sparingly
6. No paper products other than tissue should go into the system.
7. No chemicals should go into the system.
8. Avoid surge flows of water; try to spread laundry throughout the week.
9. Septic tank effluent must be less than or equal to the design criteria specified in page 2 of these plans.
10. If septic or dose tanks are no longer used, they must be properly abandoned.
11. If construction timing and weather could create a frozen infiltration system, weather - proofing with plastic sheeting and
heavy mulching may be required to maintain a functional system at start-up.
12. The upslope toe of the mound system must be landscaped with additional fill to blend this area into the
upslope natural grade; this will minimize the possibility of the system trapping surface run -off; final settled slope should
be 2 -3% over the system or 2 -3% diverting surface run -off around the ends of the system.
Maintenance
1. The septic tank must be inspected every three years by a properly licensed person.
2. If necessary, the septic tank must be pumped to remove solids and scum; pumping is required if the combined scum and solids
volume equals one third of the tank volume.
3. When the septic tank is pumped, any solids in the bottom of the dose tank must be pumped, and the filter must be back - washed
into the septic tank to remove accumulated material. System use may require more frequent filter cleaning; initial inspections of the
filter should be made every 6 months until a minimum time sequence is determined.
4. Periodic observation pipe inspections should be made by the owner to examine the state of the in -situ soil adsorption cell.
Quarterly inspections are recommended; a licensed plumber should be notified if effluent is consistently ponded in the adsorption
cell.
5. If this system contains specific treatment components other than those mentioned here, maintenance requirements will accompany
their specifications.
6. The pumping components for this system include an alarm which must be installed and remain on a separate circuit from the
pump. If the alarm is activated, minimize water use and notify a licensed plumber for service as soon as possible. The system allows
reserve capacity to accumulate some necessary flow until normal service can be restored; this volume is minimal, and no more than
one or two days should pass before any necessary repairs can be made.
7. Avoid compaction such as vehicle traffic within 15' down -slope of the adsorption system.
8. Avoid disturbing the system itself such that might encourage erosion or disturb the required seeding of the system.
9. Particularly avoid winter traffic such as sliding or snowmobiling which might compact snow and lead to increased frost depth.
10. Surface drainage must be diverted around the system; avoid landscape changes which might send surface run -off into the system
area.
11. Warning: Do not enter septic, dose or other treatment tanks; death may result because they may contain lethal gases or
insufficient oxygen.
Contingency Plan
Wastewater monitoring of volume and quality is not a normal requirement for low effluent strength systems; such monitoring
may become necessary if problems develop. Any necessary monitoring shal I be done in accord with the requirements of Comm 83.54
(2). Pumping and hauling of wastewater may be necessary while analysis and repairs are implemented. Additional testing, designing,
and /or installation of additional treatment components or conversion to a holding tank may be necessary.
Page 8 of 8
G
Wi scons i n S IL fC� ORT #1849
Department of Commerce in ccordance with Comm 8 , Wis. dm. Code Page 1 of 3
Division of Safety and B ' 'ngs M Steel's Soil Service
Attach ple 'te er not less than 8'% 11 inches in size. PI 0 must County St. Croix
includ a to: vertical and horizontal refe nce gain cc�rection and
percent slope, s cale or dim _Et]s s, north arrow, and ocation an��4 WW4*c)6 rest ad. Parcel I.D.
� eW�"" — ° 040- 031 0 -000
Please print all information. Review By Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 5 d (p
Property Owner Property Location
Mike Conley And Mary Hoyer Govt. Lot na E114, E1 /4, S12, T29N, R18W
Property Owner's Mailing Address Lot # Block # Subd. Name or CSM#
1485 110th Ave A na CSM
City State Zip Code Phone Number ❑ City [ ❑ Town Nearest Road
Hammond WI 1 54015 1 651 - 402 - 8392 Warren I 110Th Ave
❑ New Construction Use: ❑ Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD
❑ Replacement ❑ Public or commercial - Describe na
Parent material Loess over Glacial Till Flood plain elevation, if applicable na ft.
General comments Mound Design, system elevation 1 04.73ft b ased on contour line elevation 103.15ft. Minimum of 1 inch
and recommendations: class 33 mound sand.
Boring # ❑ Boring
❑ Pit Ground surface elev. 103.65 ft. Depth to limiting factor 32 ' m in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -9 10yr2/2 none sil 2msbk mfr cs if .6 .8
2 9 -14 10yr3 /4 none Sid 2msbk mfr gw 1vf .4 .6
3 14 -32 5yr3/4 none sl om na cs na .2 .6
4 32 -48 5yr3/4 c2d 7.5yr5/6 sl 0 na na na .2 .6
Fi-I Boring # ❑ Boring
❑ Pit Ground surface elev. 103.65 ft. Depth to limiting factor 20 / in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -12 10yr2 /2 none sil 2msbk mfr cs 2f .6 .8
2 12 -20 10yr4 /4 none sicl 2msbk mfr cs ivf .4 .6
3 20 -36 7.5yr4/4 m3p 7.5yr5/6 sc om na na na .0 .0
* Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg/ , * Effluent #2 = BOD S30 mg /L and TSS < 30 mg /L
CST Name (Please Print) Signature: c CST Number
David J. Steel 248956
Address Steel's Soil Service Date Evaluation Conducted Telephone Number
994 200th St. Baldwin, WI 54002 4/25/2006 715- 760 -0347
SBD -8330 (R.07 /00)
Property Owner Mike Conley And Mary Hoyer Parcel ID # 040 - 1031 -10 -000 Page 2 of 3
' ❑ Boring # [_] Boring /
❑ Pit Ground surface elev. 102.05 ft. Depth to limiting factor 17 ✓ in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
1 0 -12 10yr2 /2 none A 2msbk mfr CS 1vf .6 .8
2 12 -17 10yr4/4 none Sid 2msbk mfr gw na .4 .6
3 17 -24 5yr4/4 c2d 7.5yr5/6 Scl om na na na .0 .0
F-1 Boring # E] Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft'
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
F-1 Boring # ❑ Boring
❑ Pit Ground surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft
in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2
* Effluent #1 = BOD 30 < 220 mg /L and TSS >30 <150 mg /L * Effluent #2 = BOD < 30 mg /L and TSS <30 mg /L
The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or
need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608 - 264 -8777.
SBD -8330 (R.07 /00) Steel's Soil Service
STEEL'S SOIL SERVICE 3 of 3
David J. Steel Mike Conley and Mary Hoyer 994200 th St.
CST - POWTSM NE1 /4,NE1 /4,S12,T29N,R18W Baldwin, WI 54002
Lic. #248956 Town of Warren, St Croix Co. Direct 715- 760 -0347
CSM Lot A Fax 715- 684 -3449
Legend N
4uf:
1" = 40'
♦ = Benchmark Ele. 100.00 ft f
Top of 3/4" pvc pipe
• = Alt Benchmark Ele. 100.05 ft
Top of 3/4" pvc pipe
d = Borings
Boring Elevations
BI = 103.65 ft
B2 = 103.65 ft
B3 = 102.05 ft
B4 = 0.00 ft
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RECEIVED
1542
Wisconsin Departmerit of Commerce SOIL EVALUATION REPORT p 1 of 3
Division of Safety and Buildings MAY 1 4 2,Q &site Evaluations
in accordance with Comm 85, Wis. Adm. Code
Attach complete site plan on paper not less than 8'% x 11 inches in size. Plan must C r'y ST. CR01X Dc
include, but not limited to: vertical and horizontal reference point (BM), direction and Par
percent slope, scale or dimensions, north arrow, and location and distance to nearest road.
- 1031 -10-8 /,�,�
Please print all informairion. R B Date
Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 4. l
Property Owner Property Location J V
RHK Farm, INC. - Mike Kamm Govt. Lot NE 1/4 NE 1/4 S 12 T 29 N R 18 W
Property Owners Mailing Address Lot # Block # �Subd- m e or CSW
JE
1382 110th Ave. epeced CSM (p
City State Zip Code Phone Number r j City Village Town Nit Road / (,tJ�
Roberts I WI 1 54023 715 - 749 -3597 Warren V
New Construction Use: 10 Residential / Number of bedrooms 4 Code derived !;00ff6w rate 600 GIRD
; Replacement Public or commercial - Describe:
Parent material loess over glacial till /Flood levation, if applicable na
General comments
and recommendations: Install mound system at elev. 100.00' at 18" above 98.5
FT] Boring # Boring r
ft Ground Surface elev. 98.63 ft. Afting jfjL in. Sal Application Rate
Horizon Depth D nt Color Redox Description Texture ctu Roots GPDIft=
*Eff#1 'Eff#2
1 0 -9 10yr3/ none sil vfr s • 2f,1 m 0.5 0.8
2 9 -18 10 r4 /4 none it 2 sb r cs 2f,1m 0.5 0.8
3 18 -24 10yr4 /6 N437. sl 1 msbk cw 1 fm 0.4 0.6
4 24 - 5yr5/6 sl c - - .04 0.6
i
❑ Boring # j Boring
0 Pit G nd Surface elev. 98.17 ft. Depth •miting factor 24 in. Sal Application Rate
Horizon Depth Dominant Ca Redox Description Texture Structure Consistence Boundary Roots GPDtft
'Eff#1 *Eff#2
1 0 -8 10y none sil 2fsbk m as 2f,1m 0.5 0.8
2 8 -16 1 r4/4 none sil 2msbk mvfr aw 2f,1m 0.5 0.8
3 16 -24 .5yr4 /6 none Is 0 sg ml c 1 f 0.7 1.2
4 24 -30 7.5yr4/6 f2f7.5yr5/8 Is 0 s ml cw if 0.7 1.2
5 30-4 7.5yr4/6 m rrr�d 10yyr6 /2 L sl 1 msbk mfr - - 0.4 0.6
* Effluent #1 = BOD ? 30 < 220 mg/L and TSS > <_150 ' < uent #2 = BOD 30 mg/L and TSS <�0 mg(L
Nam CST Na (Please Print) Signat : CST Number
Z�� James K. Thompson 3602
Address A.C.E. Sal & Site Evaluations Date Evaluation Conducted Telephone Number
340 Paulson take Lane, Osceola, WI 54020 5/2/02 715- 248 -7767
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property owner RHK Farm, INC. - Mike Kamm Parcel ID # 040- 1031 -10 -000 Page 2 of 3
# Boring
jo Pit Ground Surface elev. 97.72 ft. Depth to limiting factor 24" in. Sod Appin Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots
*Eff#1 *Eff#2
1 0 -9 10yr3/2 none sil 2fsbk mvfr as 2f,1m 0.5 0.8
2 9 -19 10yr4/4 none sil 2msbk mvfr cw 2f,1m 0.5 0.8
3 19 -24 7.5yr4/4 none gr. sl 2msbk mfr cw If 0.5 0.9
4 24 -30 7.5yr4/4 f2f7.5yr5/8 gr.sl 2 msbk mfr cw if 0.5 0.9
5 30 -38 10yr4/4 m3p 7.5yr5/8 & m 10yr6/2 scl 1 csbk mfi - - 0.2 0.3
F Ong # Boring
Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPDHV
*Eff#1 *Eff#2
F-1 Boring # � y Boring g
� j Pit Ground Surface elm. ft. Depth to limiting factor in. F Application Rate
Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/W
*Eff#1 *Eff#2
* Effluent #1 = BOD 5 > 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 altemate format, please contact the department at 608- 266 -3151 or TTY 608- 264 -8777.
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Private On -Site Wastewater Treatment System ( POWTS)
Index & Title Sheet
Owner: In e, / N V� - /TO
Project Name and System Type: y iG 1 /'no c"M
Location:
Street Addr ss
Legal Description
C/b l X
Township /County
Contents: Page 1: Sanitary Permit Application
Page 2: Plot Plan
Page 3: Soil Test
Page 4: State Approved Plans
Page 5: Septic Tank Maintenance Agreement
Page 6: Warranty Deed
Page 7: POWTS Owner's Manual Management Plan
Page 8: POWTS Owner's Manual Management Plan.
Page 9: POWTS Owner's Manual Management Plan
Page 10: Certified Survey May
Page 11: Copy of House Plans
Attachments:
Plumber /Designer: Mike Rogers Signed:
Credential Number: 225094 Date:
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POWTS OWNER'S MANUAL MANAGEMENT PLAN
FILE MFORMA.TION SYSTEM SPECIFICATIONS
:3wner AlICe t T Septic Tank Capacity v gal ❑ NA
Permit # Septic Tank Manufacturer we ❑ NA
DESIGN P TERS Effluent Filter Manufachurer ❑ NA
Number of Bedrooms 100gpd/bedroom p NA Effluent Filter Model — /of? ❑ NA
Number of Commercial Units NA Pump Tank Capacity gal O NA
Estimated flow (average)* OV gal/day Pump Tank Pretreatment Man nit ufacturer i. t,G O NA
Design flow, (peak), estimated x 1.5* 6O gal/day Pump Manufacturer ❑ NA
Soil Application Rate � gal/ Pum day p Mode ❑ NA
U
In uentlEfltuent Quality (NA ❑) Monthly Average ** p Sand/Gravel Filter ❑ NA
Fats. Oil & Grease (FOG) ❑ Peat Filter
Biochemical Oxygen Demand (BOD) 30 in ❑Mechanical Aeration ❑ Wetland
j Total Suspended Solids (TSS) < 220 mg/L ❑ Disinfection ❑ Other:
f < 250 mg/L Manufacturer: Model:
rPretreated Effluent all * ** Dispersal Cell(s)
Qn ty ❑ Monthly Average avi
# Biochemical Oxygen Demand (BODs) 5 E3 In- ground mg/L ground (gT ty) 13 In-ground (pressurized)
Total Suspended Solids (TSS) ❑ At grade ArMound
Fecal Coliform (geometric mean) < 30 mg/L ❑ Drip -line M Other.
<10 + cfu/IOOml ❑ Leaching Chamber Manufacturer
Maximum Effluent Particle Size 1/8 inch diameter Model Approval Stipulation____
*Wastewater Flow Verification on and calculations: Soil Application Rat " d& 2 Area Req.
(Other than bedroom based) Absorption Area Credit per unit f 2
Minimum Number of Chambers
❑ Aggregate Design Flow/Loading Rate= min
`* Values typical for domestic (non - commercial wastewater Materi :all materials must comply with WI Adm. Code
and septic tank effluent. COMM84 and be installed per manufacturers specifications
** *Values typical for pretreated wastewater. and approval letters.
DESIGN CRITERIA
p "Wisconsin At -grade Soil Absorption System, Siting, Design & Construction Manual" (Converse et.al.1990)
❑ "Wisconsin Mound Soil Absorption System: Siting, Design & Construction Manual" Converse, J.C. and E.J. Tyler.
Publication 15.22
❑ "Design of Pressure Distribution Networks for Septic Tank -Soil Absorption Systems" Publications 9.6
C3 "Design of Conventional Soil Absorption Trenches and Beds". R.J. Otis — ASAE Publications 5 -77 and "Design Manual —
Onsite Wastewater Treatment and Disposal Systems ". EPA 625 /1 -80 -012 October 1980
O SBD — 10570 —P (R.6/99) "At -Grade Component Manual Using Pressure Distribution"
❑ SBD - 10567. —P (8.6/99) "In Ground Absorption Component Manual"
M SBD — 10705 -P (N.01101) "In Ground Soil Absorption Component Manual" Version 2.0
❑ SBD — 10628 —P (N.6199) "Recirculating Sand Filter System Component Manual"
❑ SBD — 10656 —P (N.6/99) "Split Bed Recirculating Sand Filter System Component Manual"
❑ SBD =10572 P (8.6/99) "Mound Component Manual"
0 SBD - 10691—P (N.01101) "Mound Component Manual" Version 2.0
❑ SBD - 10595 —P (86/99) "Single Pass Sand Filter Component Manual"
❑ SBD - 10657 —P (86/99) "Drip -line Effluent Disposal Component Manual"
n SBD - 10573 —P (R 6/99) "Pressure Distribution Component Manual"
❑ SBD - 10706 —P (N.01101) "Pressure Distribution Component Manual" Version 2.0
❑ Drip -line Effluent Dispersal Component Manual for Multi flo Onsite Wastewater Treatment Units
MAINTENANCE AND MANAGEMENT
MAINTENANCE MONITORING SCHEDULE
Service Event Service Frequency
Inspect condition Of tanks) At least once every ❑ months T years) (Maximum 3 yrs.)
Pump out contents of tanks When combined sludge and scum equals one -third (1/3) of tank volume
Inspect dispersal cell(s) At least once every ❑ months year) (Maximum 3 yrs.)
Clean effluent filter At least once every 13 months years)
Inspect pum , pump controls & alarm At least once every ❑months ears) D NA
Flush laterals and pressure test At least once every ❑ months IV year(s) p NA
Valves At least once every ❑ months ❑ year(s) ❑ NA
Other: At least once every ❑ months p year(s) p NA
Page of
START UP
For new constrµction, 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
tanks) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
OPERATION
The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity
and quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation of water - saving
appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water
softeners, iron removal units, other clear water treatment devices and foundation drains should be discharged to the ground surface
whenever possible. Note: this does not include laundry waste, showers, dishwater, etc.
This system is designed to handle domestic strength wastewater, however the disposal of food based greases and oils, vegetablelfruit
peels and seeds, bones, and food solids such as those produced by a garbage disposal should be minimized. Toilet tissue is the only
paper that should be discharged into the system. Other non - biodegradable items such as baby wipes, tampons, sanitary napkins
condoms, cigarette butts, dental floss, and cotton swabs should not enter the system. Chemicals such as petroleum products, paint,
disinfectants, pesticides, antibiotics, solvents, etc., should not be flushed into the system as they can seriously damage your POWTS
and contaminate your drinking water supply.
Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components.
Compaction of snow over the dispersal unit may cause it to freeze up.
❑ 'Valves
Valves shall be operated in the following manner:
Ad Alarms
Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service
POWTS, There is normally a 1 day reserve under regular operating conditions, however water should be conserved until any
problems with the system are corrected to prevent back -up of sewage into the dwelling or surfacing.
INPECTIONS
Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master
Plumber Restricted Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule).
Septic Tanks Component
Tank inspections must include a visual inspection of the tank 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 backup or ponding of effluent to the ground
surface. Access openings used for service or assessment shall be sealed and/or locked upon completion of service. Any
defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with an effective
locking device to prevent accidental or unauthorized entry into the tank.
When the combination of sludge and scum in any tank exceeds one -third (1/3) 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 NRI 13, Wisconsin
Administrative Code.
The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's
specifications. Provisions are to be made to retain solids in the tank. Filter cleaning may be necessary at more
frequent intervals than stated in the maintenance schedule to keep the system operating.
Pump Chamber/Treatment Tanks Component
The inspection must include a test of all electrical equipment such as pumps, alarms and floats. A visual check must be
made for leaks, backups, surfacing, missing or broken security devices and other hardware and the condition of the filter.
Any service needs or repairs shall be promptly taken care of.
p In- Ground Gravity Component Dispersal Cells
The inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any
evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory
authority. Ponding at depths greater than 75% of the height of the component may indicate overloading or impending
hydraulic failure necessitating more frequent monitoring.
Page of
§(Mound, At- Grade, In- Ground Pressure
The inspection shall include recording the levels of ponding, if any in the observation tubes and a visual inspection for any
evidence of surface seepage or discharge. Any discharge to the ground surface must be promptly reported to the regulatory
authority. Poniding greater than 75% of the height of the component may indicate overloading or impending hydraulic failure
necessitating more frequent monitoring.
The pressure distribution system is provided with an opening at the end of each lateral to be used for flushing. The laterals
should be flushed at least once every three (3) years. Pressure checks of systems with multiple laterals should be done to
ensure that equal distribution of effluent is occurring to promote the longevity of the system.
REPORTS
Reports for maintenance, inspection, and monitoring shall be submitted in accordance with COMM 83.55 Wisconsin Administrative
Code.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure that the system is
properly and safely abandoned in compliance with Ch. 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 other 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:
0 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 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.
0 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.
at 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.
4 4 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 tune.
< <WARNING>>
SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTIAN 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
IMIPOSSIBLE.
I
ADDITIONAL COMMENTS
POWTS INST POWTS TAIIVER `
Name Name
Phone a ?S f //:7 a I Phone
SEPTAGE SERVICING OPERATOR {Pumper) LOCAL REGULATORY AUTHORITY
Name I Agency X Cal t
Phone Phone
1{:\WPDATATHTOWTS OWNER'S MANUAL.doe
Page of
05/1512006 09:28 7152350867 ROGERS PLUMBING PAGE 05/05
• � IPTIC TANK xv( =EN ANCE AGREEM2NT
AND
OWNERSMP CERTIFICATION FORM
rrmaar NoyF
b /V rs / !D r# /10-9 .� /Y I".0Q. 4 ivt S d/S
i����alis2 Andress
I ves 1 /o r# qor, gaa'?Mo z S ors
( , 0rification required from Plauaing Depar�nent for new coasauction)
'/ Parezl ldentificadon Number
C'1•c�F /�r�.�L �1R�, 4J.�
nJ
iJc'itj Y QCL7tiYl % _�� rl, Sec. _/.2 , T .29 N -R / W, Town of : 1 AIQQ EAJ —
Y " ¢,
R N. � Fa R TNT Lot # a2.
t xe Ssxrvey map # g / 7 y Voliune 6 Page # 7q
L
���,� /6 Wage #
# 4 � g y P 5 ..� � Volume
S��c l�ous yeS as Lot lines ic�entif�able 01 yes O no
S`x S ' EM �'x`E NANC
Improper use and maintcnamceof your septic system could result in its przrulature failure to l�and].e wastes. Proper tnaialteJa:�.ace
a licensed pumper. What you put into the systetn
.QaasiSts of pumping out the septic tank every tbcee yoazs or sooner, if aeedcdby
,;:Lu affcct nc�: function of the septic tank as a treaj cnt stage in the waste disposal system,
The property owner agrces to submit to St. Croix Zoning Departtxient a ccrtif`icatiou form, signed by the owner and by a
,0 f4�,rplumber, joumeymanplumber, restricted plumber Ora licensed pumper verifying that ( the on -site wastewater disposal sysfcf7;
i in propel operating condition andlor (2) after inspection and. pumping (if iacccssary), - alc septic tank is less than 113 full of stud -2c.
D-,;c tha undersigned have read the above requirements and agree to maintain the private sewage disposal systerit with the ataa,dards
set forth, horcin, as sot b the Department of Commerce and the Departmaiat of Natural Resources, State of Wis Cenificatior
stating that your septic sysiem has been tna.intainedmu9t be completed and renamed to The St. Croix County Zoning
Office witl•jr 313
0 1.34 A t1tG tfireo yc8r x Sl � OF ICAN PATE
1
(we) ccxtify that all statements on this form are tro -: to the best of my (our) knowledge. 1 (we) am (arc) the QNY'acr(s) of
p des bed abov by v' a of a warranty deed recorded in Register of Deeds Office. rr rr
al � & RB OF ,AP DATE PLICANT
* ** * *0 Any information that is mis- represented may result in the satutary peradt being revoked by the Zotxing Dtpattmco.t.
juciude 'sr 4th this application - , a staxxaped warxanry deed from the P egister of Dceds office
a copy of tho certified survey map if teferetxcc is made in the warranty deed
�( L y 0 P `i 6 5 799979 k\
SITE 1� OF WISCONSIN FORM 1 - 2000 KATHLEEN H. WALSH
WARRANTY DEED REGISTER OF DEEDS
. Document Number ST. CROI X Co.. W I
This Deed, made between R. H. K. Farms, Inc RECEIVED FOR RECORD
87/11/2005 01:i5PH
Grantor, WARRANTY DEED
and Michael R. Conley, a single person and EXENRT #
Mary L. Hoyer, a single person REC FEE: 11.80
as ioint tenants TRANS FEE: 183.00
Grantee. COPY FEE:
Grantor, for a valuable consideration, conveys to Grantee the following CC FEE
eY � PAGES: 1
described real estate in St. Croix _ County, State of
in (the "Property") (if more space is needed, please attach addendum):
Lot of Certified Survey Map recorded in Volume 16
on page 4379 a Document No. 691974 being a part of
the ortheast Quarter of the Northeast Quarter (NE% Recording Area
of NEIL), Section 12, Township 29 North, Range 18
West, Town of Warren Name and Return Address
Title One Premier Group
706 19th Street South
Hudson, WI 54016
042 - 1031 -10 -200
Parcel Identification Number (PIN)
Together with all appurtenant rights, title and interests. This is not homestead property.
(is) (is not)
Grantor warrants that the title to the Property is good, indefeasible in fee simple and free and clear of encumbrances except
Roadways, Easements, and Restrictions of Record
Dated this 11th day of July , 2005
*
* Richard H. Kamm, President
R.H.K. Farms, Inc.
*
AUTHENTICATION ACKNOWLEDGMENT
STATE OF WISCONSIN )
Signature(s) ) ss.
At. Croix County. )
authenticated this day f Personal came before me this 11th da y of
Y Y Y
Q � July 2005 the above named
* 1
Richard H. Kann
TITLE: MEMBER STATE BAR CO Z►
(If not, l i& 0 to me known to be the person who executed
authorized by §706.06, Wis. S '9j�� OF the f t e same.
THIS INSTRUMENT WAS D
* er' J Sune
Michael H. Forecki, Attorney Notary Public, State of Wisconsin
Eau Claire, Wisconsin My Commission is permanent. (If not, state expiration date:
Si al. may be authenticated or acknowledged. Both are not neeess November 0
( 2 2005 .
'Names of persons signing in any capacity must be typed or printed below thew signature.
WARRANTY DEED STATE BAR OF WISCONSIN FORM No. 1-2000
ttomey Michael H Forecki 3452 Oakwood Hills Pkwy Ste 1, Eau Claire WI 54701 -7928
Phone: (715) 835 -3029 Fax: (715) 835 -4112 Michael H. Forecki 8762Szfx
7 Produced with ZipForm by RE FormsNet, LLC 18025 Fifteen Mile Road, Clinton Township, Michigan 48035, (800) 3839805
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KATHLEEN H. WALSH
SEP 2 202 REGISTER OF DEEDS
ST, CROIX Co.. WI
If not r ecorded wit►+nl 30 ao RECEIVED FOR RECORD
approval dare anPAroval shat be l 09-26 -2002 20:30 A
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CERTIFIED SURVEY MAP
CERTIFIED SURVEY MAP COPY 330
R.H.K. Farms, Inc. PAGES: 2
Located in part of the Northeast %4 of the Northeast 1 / 4 of Section 12,
Township 29 North, Range 18 West, Town of Warren,
St. Croix County , Wisconsin_
OWNER'S ADDRESS
1382 100TH AVENUE
ROBERTS, WI 54023
N LEGEND
BEARINGS ARE RE193U90CM INDICATES 1- 114 x 18° IRON
TO THE EAST LINE OF THE PIPE SET (MIV. WE - 1.13 LBJLF- -)
NORTHEAST 114 OF SECTION 12,
T29 M R 18 W, ASSUMED AS a SOE BORINGS (PROPOSED SEPTIC SYSTEM)
S 01 fi 0 SECTION CORNER MONUMENT (AS NOTED)
PROPOSED DR/VEWAYLOCATION
SCALE IN FEET 1' - 200'
0 160 160 2
-- 1� -- PLATTED
P LATTED LANDS F " " - --
NORTH 114 CORNER t 1 _ NDS
SECTION JZ T 29 N, R f8 W S 90'OD'OOt' E 268S.77 - NORTFEAST CORAER 1 I
(FOUND CONCRETE 'PK° NA&) SECTION 1Z T 29 K R 1S W
�_ 7 7QT H (FOUNn J - W O.D . NRONPS -P I L VENU
1743.1a . -- JQD : - JOO' S 90°00'00" E 945.62' ! 3 S 44 w - -_ - — — —
NORTH IWENEIX t; 9 00. —I 4618
7 • 33. 0(Y 300.0 33.W 613.34' e -
$ - S 90°OD'Or E 913.34 -
COUNTY SUN.DlNG _ _ SETBACK LNE
- - -- - -- •- - LOT - - -- a M
- -, 100, �QT _ LOT Z 148,664 SQ. FT. OR 3.413 AC. e
c 1 < (127,881 SQ. FT. OR eT
CERTIFIED C OR 4.W AC. $ 2.9W AC. EX CLUDING it LOT 4
o o
1 ROAD MGHT
CID (188,100 SQ. FT. 1 OF WAY) 0 144,100 SQ. FT. OR w
w{
St IRVEY MAP W $ EXCL I 1A itG y " 3.308 ac. I F
UD y
g (129,791 SO. FT OR29WAC.1 to
b ROAD RIGHT 1 EXCLUDING ROAD e e Q
VOL!/ME 2, o OFWA)9 8 : RIGHTOFWAr I a Z,
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PAGE 577 °o a CO s 90.00.00- E 655.51'
Z - 822.50 - 1 W.
e LOT 5 e i 33.01'-
138,140 SQ. FT. OR 3.171 AC.
o (131,209 SO, FT. OR 3.012 AC.
EAST LIJE 100
N EXCLUDING ROAD RIGHT OF WAY)
'LOT i _ - 927.11' - _ `� e
300.00' 627.11' - 680.12 - 433.01' - _1
N 90 °00'00" W 960.12' T
UNPLATTFD LAND_ S
LAUREN E
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LU
13
DATED: �-
FA ES. ° ,i g JUNE 14, 2002 0 1�
is W I e fQ
` ° ° . ° , ° ° ° J p t EAST 114 CORWR
@p ° g4 SECTION 1Z T 29 N. R 10 W
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(FOUND COUNTY BERNTSEN
THIS INSTRUMENT DRAFTED BYJERALD L L4RSON SHEET 1 OF 2
Vol. 16 Page 4379