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HomeMy WebLinkAbout042-1076-90-250 Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 563823 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Lightner, Brenda Warren, Town of 042-1076-90-250 CST BM Elev: Insp. BM Elev: BM Descript; Section/Town/Range/Map No: d D 47VI D~_ T ! iJW ~ 28.29.18.437610 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic & d~ 124 /0 e) -D Ben m r ,L Er" ~7 7L /D~.2 ~G 'S Dosing Alt. BM 8a Aeration Bldg. Sewer Holding SVHt Inlet TANK SETBACK INFORMATION St/Ht Outlet d TANK TO WELL BLDG. Vi to Air In Take ROAD Dt Inlet Septic Dt Bottom Puny Pa l KS e Jy l~° Z Y Dosing ~ e an Aeratio Dist. Pie ` b 5- ~Q s Holding Bot. System f 3 / Final Grade PUMP/SIPHON INFORMATION 66~ S~'T Manufacturer e St Cover GPM Model Number Ft TDH Lift Friction Los S/ stem H T511 21 • -f 2~ 2 Forcemai Length Dia. 211 Dist. to well SOIL ABSORPTION SYSTEM BED/TRENCH Width Lengt / No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS _I V SETBACK SYSTEM TO P/L BLDG WELL LAK /S REAM EACHING Manufacturer: INFORMATION CH OR Type Of System: } 5 `j f ♦ / Model Number: DISTRIBUTION SYSTEM ecesS t/ eAv'en 0 1 piipestribution ole Size x Hole Spacing Ve t to it Intake U~ Header/Manif D / (s) o~t/. 1 Length Dia G Length Dia 26 x H Spacing 3 T' i~ a 1-1 14 SOIL COVER x Pressure Systems Only xx JoMd Or At-Grade Systems Only Depth Over Depth Over Depth o xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil es ® No g Yes 0 No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: 7 / to / nspection #2: Location: 747 112th Street Roberts, WI 54023 (NW 1/4 SW 1/4 28 T29N R1 8W) NA Lot 2 Sy~~Q~7ti Parcel No: 28.29.18.437610 1.) Alt BM Description = ,v u ,OQ ,r;1, /14 At,J 2.) Bldg sewer length - amount of cover lv1.2 C.s(~crvv Gt/,1//2~ . Plan revision Required? ❑ Yes /No Use other side for additional information. L-7 SBD-6710 (R.3/97) Date Insepctor's ignature Cert. No. SOLI. f ^ ( hrn ` ~ ~ 2 o~ ~ ~ Qy A p x G ~ c eqb rr a.g~ b I s op co ~ f O R `9J ,A v~a~1` to 1T`1 4~, G ~ ,r. Co 4 vv COPY / rt 1 Count}' ` ~.~6 l Safety and Buildings Qivision X r! 201 W. Washington Ave., P.O. Box 7162 Sanitary Permit Number (to be filled.in by Co.) 1 Madison, W1 53707-7162 70 Sanitary Permit Application State Transaction Number in accordance with SPS 383.21(2), Wis. Adm. Code, submission o tthhis form to the appropriate gov9I I unit J ! i is required prior to obtaining a sanitary permit. Note; Application forms for state-owned P are su5to Project Address (if different than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be Q}~}or secon ary purposes in accordance with the Privaey.LalCk 15.04 1 m), Stats. 1. Application Inform ' le t All Information ~Y v 1-7 Parcel # PropertK Owner's a o ~a ~a ~6 0 ~ o Property Owner's MailiGovt. Property Lot Location l { /53 413 78/O) Ci 7 R~~b) Zip Code Phone Number ~ ~-VO ~.1 QQ J Sly section 11. Type of Building (check all that apply) Lot4 I or2 Family Dwelling-Number of Bedrooms 2 Subdivision Name S7► n~G~ Block (__Y1 D Public/Comittercial - Describe Use ❑ City of ' CSM Number ❑ Village of 4 ❑ State Owned -Describe Use Q L~Y P , / l'own of 111. Type of Permit: (Check only one box on line A. Complete line B if a plicable) D ®to E is tin S's 1 A. ❑ New System Replacement System D Treatment/Holding Tank Replacement Only Other Modification ) m (exPlai) B. D Permit Renewal D Permit Revision D Change of Plumber O Permit Transfer to New List Previous Permit Number Pd Date Issued- O Before Expiration Owner 19 STE S71 IV. Type of POWTS System/Component/Device.- Check all that a l D Non-Pressurized Iri-Ground D Pressurized In-Ground D At-Grade ,R-Mound _>24 in. of suitable soil D Mound < 24 in. of suitable soil i ❑ Holding Tank D Other Dispersal Component (explain) D Pretrea nt Device (explain) / V. Dis ersal/Treatme.ntArea Information: Design Flow (gpd) Design Soil Application Rate(gpdsf) Dispersal Area Required (s#) Dispersal Area Propo d (sI) System Elevation S 900 Joao 100.6' VI. Tank Info Capacity in Total #1 of Manufacturer Gallons Gallons Units fl ? New Tanks Existing Tanks ~ o v ~ ~ ~ = s Septic or Holding Tank r = x Dosing Chamber VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans. Plumbe ' Name (Print) Plumber' nature MP/MPR Number Business Phone Nwnb r Plumber's Address (Street ity, State, Zip Code) Ijb ~4~ ~9~v<~0~~ 1ls J oar VII oun /De partment Use Only Approved D Disapproved Permit Fee Date I su suing Agent igna X2l25 -'o -7/3 D Owner Given Reason for Denial 1X. Coe*§9S#lF R1at/Reasons for Disapprova, 7 3 r cry-~`~-/ J x a 1. Septic tank, effluent filter and dispersal cell must p,s_$g viced / maintained ~0 as per management pli#n provided by plumber. / 2. All Setback requirements must be maintained ~ 7D' / ~I k as er applicabig Attach to wmptete plans for the,system nd b to t my on pert less than Et 12 x I1 inches in size „ Ct f r_ SGT W2~ rw , dYl SBD•6398 (R. 11/11) ~a p~T NT DIVISION OF INDUSTRY SERVICES 2715 POST ROAD v STEVENS POINT WI ~3 S Contact Through Relay yt P U www.dsps.vA.gov/sb/ www.vAsconsin.gov Ro ION ~s~4 P S Scott Walker, r p , Governo RECEms, Dave Roar, Secretary June 19, 2013 JUN 2 6 2013 CUST ID No. 220673 sT CRp►X CpA77W. POW7S Inspector CHARLES L WEBSTER ZONING OFFICE WEBSTER SOIL TESTING & DESIGN ST CROIX COUNTY SPIA N5815 770TH ST 1101 CARMICHAEL RD ELLSWORTH WI 54011 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 06/19/2015 Identification Numbers Transaction ID No. 2253973 SITE: Site ID No. 791298 Brenda Lightner Pleas refer to both identification numbers, 747 112TH St above, in all coffespondence with the agency. Town of Warren, St Croix County NWIA, SWIA, S28, T29N, R19W FOR: Object Type: POWTS Component Manual Regulated Object ID No.: 1430845 Maintenance required; Replacement system; 450 GPD Flow rate; System(s): Mound Component Manual - Ver. 2.0, SBD -10691-P (N.01/01, R. 10/12), Pressure Distribution Component Manual - Ver. 2.0, SBD-10706-P (N.01/01, R. 10/12); Effluent Filter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. 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, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: • This system is to be constructed and located in accordance with the approved plans and with the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems Version 2.0" SBD-10706-P (N.01/O1). • This system is to be constructed and located in accordance with the approved plans, and the "Mound Component Manual for Private Onsite Wastewater Systems Version 2.0" SBD- 1069 1 -P(N.0 1 /0 1). • The pressure network is to be constructed in accordance with publications SBD-10706-P(NO1/01) "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems - Version 2.0" and/or the sizing methods of publication "SSWMP Publication 9.6 Design of Pressure Distribution Networks for ST-SAS (01/81)" A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits 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 Industry Services 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. CHARLES L WEBSTER Page 2 6/19/2013 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 and the POWTS management plan to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, Fee Required $ 250.00 This Amount Will Be Invoiced. When You Receive That Invoice Matthew Allen 7anzen Please Include a Copy With Your POWTS Lead, Integrated Services Payment Submittal. (715)340-0407, WWAIART code: 7633 matthew.janzen@wisconsin.gov i I~ Webster Soil Testing & Sewer System Design Charlie Webster, Owner N5815 770th Street Ellsworth, WI 54011 WI Licenses: MP220673, ST220673, PE18803 Telephoni(715) 273-3430 POWTS Index Sheet Page 1 of 9 Mound System for a 3 Bedroom Residence Property Owner/Project: Brenda Lightner NW 1 /4 of SW S28 T29N RI 9W 747112Th St., Roberts, WI 54023 Town of Warren, St Croix County Parcel I. D. 042-1076-90-250 Page 1 Of 9 Index Sheet Page 2 of 9 Situation Report & Construction Considerations Page 3 of 8 Plot Plan Page 4 of 9 System Cross Section Page 5 of 9 Distribution Pipe Layout Page 6 of 9 Pump Chamber Layout Page 7 of 9 Pump Performance Curve Page 8&9 of 9 Management Plan \5 C o s GHAl1LES L S}iiorlly s WEBSTER t E-18803 : Z p FLLSWORTM sue", ulvtu q% % W15. DEPARTMENT OF COMMERCE DIVISION OF SAFETY AND BU INa8 Component Manual Used: Name: Mound Component Manual for POWTS Version: 2.0 SBD-10691-P Dated. January 30, 2001 Name: Pressure Distribution Manual for POWTS Version: 2.0 SBD-10706-P Dated: January 20, 2001 REPLACEMENT MOUND FOR BRENDA LIGHTNER PG oZ,0 F WARREN TWNP - ST CROIX CTY SITUATION REPORT This mound was installed in 1993 in accordance with the code that was in effect at that time. The mound was designed for a three bedroom home. The system has formed a clogging biomat at the interface of the dispersal cell and the sand lift, which is the reason for this replacement. The soil test was done in 1993 with an actual percolation test done. The slowest percolation rate was 9 minutes per inch. Per Table 83.441, we can use a soil infiltrative rate for the basil area of 0.7gpd per sq. ft. if there is less that 12 inches of sand lift, or 1.2gpd per sq. ft. if the sand lift is 12 inches or greater in depth. The depth to the limiting factor on the soil test is 28 inches. Therefore, a minimum sand lift of 8 inches is required. All four ends of the distribution laterals were exposed at the time of a visit to the site by this designer on May 12`x, 2013. Using the top of the NW property pin as an elevation of 100 ft., as was done in the original design, the top of the distribution pipes average elevation was 101.4 ft. This matches the elevation of these pipes given in the original inspection report done in 1993. Elevations taken in the bottom of the inspection pipes were 100.5 and 100.8, which would correspond to the elevations of the top of the distribution laterals. The top of well and bottom of siding of the garage elevations shown on t he sketch were established based on these observations. The elevation of the pump pad of 80.2 ft. was taken on this visit. The contour elevation as shown seems about correct. EXISTING SYSEM DESIGN The existing system was designed with the following values corresponding to the plan view cross section; A=8ft., B=48ft., K=10ft., L=68 ft., J=8ft., 1=12ft., W=28ft., D=1ft., E=1.3ft., F=0.8ft., G=1.Oft., and H=1.5ft. CHANGES This design makes the following changes from the old design to meet current code requirements. A=9 ft., 13=50ft., 1=11 ft., K=9ft., D=0.8ft., E=1.2ft., G=0.8ft., and H=1.Oft.All other dimensions remain the same. These changes increase the size of the rock bed while keeping the basil area and overall length and width of the mound the same. The distribution cell (rock bed) is 2 ft longer and one ft. wider than the original distribution cell. This should be accomplished by increasing the length 1 ft. on each end and increasing the width 1 ft. to the east. The system elevation has been lowered 0.2 ft., which still provides for more sand lift (about 0.15 ft.), than is the minimum required under the current code. OTHER DESIGN CONSIDERATIONS A filter is needed to bring this system to current code. This design calls for the addition of a Simtech STF 100 filter to the existing pump discharge. CONSTRUCTION CONSIDERATIONS 1. Remove excess /overgrown vegetation from the mound, mow and remove clippings. 2. Pump out any standing wastewater through observation pipes. 3. Permit dispersal area to dry out. 4. Pump out septic and dose tanks. 5. Remove and stockpile topsoil from mound system. 6. Remove aggregate from absorption area and dispose of in approved manner. It cannot be reused. 7. Remove distribution pipes and observation pipes. Dispose of properly. 8. Remove clogged sand plus an additional 3 inches of clean sand and dispose of properly. This sand cannot be reused. 9. Inspect remaining sand for particle size to see if it meets ASTM Specification C-33. 10. Install replacement mound system using procedure outlined in the approved mound component manual. k n o Ah, Vc way if 0 o 41- S Q v ~ 4.: !1 a q~ b If Cb •~0 ~ v v IT, r u , i, (a k' e YY 0 G 0 ~ 1cs A r 6 A n ~ Q x 3 2 ~0 r n 0 Q ° W o ooh 1'ar ~c~(Vq -~~h l7 t- PageOf J~ ld n 1/: Eci Crag.: sec t ~ q,-1 Approved Synthetic Covering lps-r" c 33 Distribution Pipe Medium Sand Topsoil u - H G F Elev z -1a d " 3 E \ - ~ C a °7 ~Q be f" % Slope C- - Bed Of !?,-_2 Force Main Plowed Aggregate From Pump Layer ,sec p,p~dafa./ Fora He, Nd tc Po ► C. e D g Ft . Cross Section Of A Mound System Using E 02 Ft. A Bed For The Absorption Area Ft. G 4,S Ft. A Ft. H d Ft. Linear Loading Rate= /M °G D/LN FT B Ft. Design Loading Rate= t3~D/SQ FT I J / Ft. J Ft. K Ft. L Ft. W g Ft. 'Observation Pipe ~ K - ° i Distribution Bed Of 2 - 2 2 Pise I$ ~3 /stha Aggregate Its Observation Pipe %1 a`cef Boic. a` (Anchbr securely) CSC n - u p ~ L ` - - /rjJ/ 0 1. 1-07 9/:10 A.e•*-,V ej- 6c pd w; yk .t a- 01fek- r, j St ~d p;, 4>t~a r6c b.-+► ef', rG~cr r/. fz'e G Page ~ Of Perforated Pipe Oetatl n Ead V!- Perforated PVC Pipe o tox, / .1 ati / Holes Located On Bottom, J 3- d C Are Equally SPaced t~ r vti( t Qistri'd ion / Pi4e Sce d c~'d. l P~ Ft. O i r~ c ~t. Distribution Pipe, Layout S Ft. h7i I7~/+r~e nv I- l•h.~G,y ,'~rcC C,. S7-+q O~» ep y X Inches Hole Diameter 3c;tdnch Lateral t4 Inch(es) Manifold t: Inches Force Main Inches # of holes/pipe r ~ otceess b~X I tl,rod Ad PAL I Invert Elevation of Laterals /o`/`/ Ft. ~r/ps Cry d a G~7 1/~~ Place lst holeo7.0;ra/cs C,p,», with succeeding holes at ©4. intervals. ' /~'l v u y o/ P /1-7 li Yool- PAr t c; F PUMP CHAMBER CR055 SECT IOW ARID SPECIFICATIOKJS -tip VEUT CAP v~~/~K~,~Le Gpy~ytoprrv+ dcccsS y.. C. I. r~hsc~ied•'Sr~ .o/dJ'!7C 1!E~TI% a WEATHERPROOF APPROVED LOCKINIG ~JOfi. rROM DOOR, JUUCTIOU BOX MANHOLE C WINDOW OR FRESH IZ"MW. .t~hs x/HTFC AIR INTAKE r/L7ZCA? GRADE ItvpFL S jF !o I> CONDUIT - WAIN. l IAILET PROVIDE AIRTIGHT SEAL 17 * A I' }I ALARM iN c 8 o A ec~ /k w C *APPROVED ON . JOINTS WITH I ELEV. FT. APPROVED PIPE 3' ONTO PUMP-~ OFF D SOLID SOIL CONCRETE BLOCK RISER EXIT PERMITTED OIJLy IF TANK MAIJUFACTURCR HAS SUCH APPROVAL ;,s~l,e s t"l,oh w e`as~7 s~~,r-x-, c t.+ ,f is va.~ t //ten duo ~/ee/~' CGh ~►-ta+r~ SPECIFICAtIOM1 DOSE r 1,3 TANKS MANUFACTURER: GVee ~s ~6i'r~~'' IJUMBER OF DOSES' PER DAB TANK SIZE: - ~ d GALLONS DOSE VOLUME S-dC /ow ` 170 C./4t> 2 7 T f'.a/ ALARM MANUFACTURER: bW--F INCLUDING 6ACKFLOW: J/0- GALLONS MODEL IJUMBEK: s`r~ api,. h~ 574e_ CAPACITIES: A= 'S ~0 GAILOtiJs INCHES OR SWITCH TYPE: g INCHES OR - f_/ GALLOWS PUMP MANUFACTURER: INCHES OR Z/12- GALLOWS MODEL NUMBER: W s t~ Ds LZ_.IMCHES OR !3L~ GALLONS SWITCH TYPE: -l LChan r Q NOTE: PUMP AND ALARM ARE TO BC MINIMUM DISCHARGE RATE X41-GPM INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFERENCE BETWEEN PUMP OFF ARID OISTRi UTION P E..°z FEET + MIUIMUM NETWORK SUPPLY PKESSURE3 ` _6 0 5' FEET + L'70 FEET OF FORCE MAIM X F/ppFEFRICTION FACTOR. FEET 2$,21. pl I ~Q✓ TOTAL DyNAMIG HEAD FEET D t S T~' ~V ~ ~ IIJTERtJAL DIME 1 MS OF TA 1J S O N K: bp6kk6wTwH • ..ter.; LIQUID DEPTH 7 P o Goa d / u,.•~p M° d e u o FEET 90 SERII SIZE: 80 VIE1 RPM: 5 Gpm 70 V40 5 FT 60 } t wi 2 I J € f t 3 1 1 2 = 50 40E i 30 s 1 20 016- 0 10 20 30 40 50 W 70 8o w 1o0 11o 6 PAI CAPACITY 0-5 POWTS OWNER'S MANUAL & MANAGEMENT, PLAN Page 00 ot-j- FILE INFORMATION SYSTEM SPECIFICATIONS Owner } e h c✓a L. i " Li f h e Tank Permit* Septic Capacity ©U O al O NA Septic Tank Manufacturer (i(!Q e K5' O NA DESIGN PARAMETERS Effluent Filter Manufacturer 5, a► 7ec A- O NA Number of Bedrooffm D NA Efllwd Ffter Model STF too 13 NA Number of Commercial Units NA Pump T sirk Capacity ~ G O gal ❑ NA Estimated flow (average) o d Pump Tank Manufacturer L1'✓e c kX O NA Design flow (Peak), (ESUrnated x 1.5) ,Sol . Pump Maufufa tLuw w qL O NA Soil Application Rate olds, a tact Pump Model 388-3` 1V€6-- NA Influeft/Eftent Quatihv 4,~/o c /77/c~ Mond* awage' P'nl nt Unit Fats, Oti S Grease (F0t3) 0 mgIL 0 SwxVQmvet Filter 0 Peat Filter -W-NA Mechan Biochemical Oxygen Demand (®OD.) 5200 mglL O ical Aeration O Wetland malL O Disirdection OQtltierTotal Suspended Solids (TSS) 5160 Pretr led Effluent Quality " DNA Mw" avwqp- Dispersal Cati(s) Biochemist OMW Dernand (BODs) s30 nV& 0 InVvund (gravity) O In-ground (pressurized) Total Suspended Solids (M) 53o mg/L O A4rade O Mound Fecal CoWbffn (geometric afeatf 5104 du/100mi 0 O Other: Maximum Effluent Particles Size Ya inch diameter VWww 4v" fordarnodic (non- m mcbQ meter and aPtia t" rfuuit • Vatua t~yloal flat ptrbMtrd wwgw~niK. MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every 3 0 months year(s) (Maximum 3 yrs.) Pump out contents of bunk(s) When ootbined sludge and scum squab or*4hitd (I(,) of tank volume Inspect dispersal rates) At Bost once every O months 0 year(s) (Maximum 3 yrs.) r A.,, ~ a H ~ s Clean effluent fiber At bast once every 3 0 months Xyaws) "k ost- inspect pump, pump controls & alarm At bast arms every 13 months O year(s) 0 NA~j.~(/ac. oCe Flush laterals and pressure test At best once every D months 0 year(s) O NA A S Illee W,- yl Otl~er At best once every ❑ months 0 year(s) O NA At best onus every 0-months O year(s) 0 NA t„ ~c 4« t ~F•r t°. fir. MAINTENANCE INSTRUCTIONS s. tic... of 4.yc c 17, ow */w 6 c o• c c e...r Owe'#& a•?tsq, q s aA lei, g4 rice I~C~ ear. d i t i•• roc A a14 Inspections of tanks and dispersal cob shave be made by an individual catrft ore tithe toao h loanses or certifications: Master Plumber, Master PlWnber tt *ialed S9wAr; POWTS Mepoclr c POWTS Malhillrw Salts" Servtcing Operator. Tank inspections must Inpiude a visual Inspection of the tank(s) to IderWy any missing or broken hardnre, won* any cracks or leaks, measure the volutne of combined sludge and scrum and to c ww* for any back up or pondinp of effluent on the ground surface. The dispersal oat(s) shall be visually irispOeted Io check the a kwd Weis in the observation pipes and to check for any ponding of effluent on the wound aaurkm- The pcxrding of effluent on the ground surface may Irxhcete a fdtirg ooriditior and rroquirss the Inanedieft noMication of rte local regulatory authority. When the combined aaxun jWbon of sludge and scum in any tw* eQuads aw#" (1j or more of the tank volume, the entire contents of the tank shall be removed by a SephW ServkSfg OWISIOr and disposed of it accordance with ch. NR 113, Wisconsin Administrative Code. The servicing of effluent filters, mem =*W or preesurtaed POWTS components. pretrse "tit components, and any other maintenance or monitoring at interval of 12 rriandw or less shaal be PwfOmn*d by a owWwd POWTS Maintainer. A service report shell be provided to the local rsgulf>#iry audhority wstrot 10 days of completion of any service event. START UP AND OPERATION. For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other dmffucsts afar may impede the treatment process w War damage the dispersal ce*s). If high concentrations are detected have the contents of the tank(s) renmved by a septage servk*V operator prior to use. / o a< 4j / /a.s Tar- s~-' c -e of~ L ~y H~ GY Page J of System start up shall not occur when soil conditions are frozen at the InfI traA five surface. During power outages pump tanks may fill above normal h%Or**W levels. When power is restored the excess wastewater will be dlStitmar+gW to the ditspersat cull(s) in one 1111W dog, overkmadirg the cell(s) and may result in the backup or surface discharge of effluent To avoid this si{bon have the ooritents of the pump tank removed by a Septage ServkxV Operator prior to restoring power to the effluent pump or contact a Plember 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 cob. 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 r r stream may kygxw a the performance and prolong the life of the POWTS: antibiotics; baby wipes; c%Ww a butts; cwKloms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundabo n drain (sump pump) water ffluk and vegetable pe i, gasoline; grease; herbicides; meat soaps; medications; oil; painting product; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONN ENT When the POWTS faits and/or is permanently taken out of service the followft ste~s stmt be taken to Insure that the system is properly and sefaly abandoned in oomplience 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 dbposed of bye Septage Servicing Operator. • After pumping, all tanks and pits shall be excavailed and removed or their covers removed and the void space filled with soli, 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 mW proposed strucWre, let lines and wells. Failure to protect the reptsCement area will result In the need for a new soil and Me evskadon to establish a suitable replacement aces. Replacement systems must comply with the miss in exec at that time. ❑ A suitable replacement area Is not available due to setback and/or soil limitations. Barring advances in POW T'S 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 replacernent 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 r holding tank may be installed as a last resort to replace the faded 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 MAIITAINER Name To.., 4t,~ Name v ~ ~ ~~S S'c ~ "c Phone S` - "Phone SEPTAGE SERWMG OPERATOR PUMPER LOCAL REGULATORY AUTHORITY Name S'c Agency 1S CA- Phone Phone 1 /-7 E Phone 1„S"_ - S' - aZ o~ r5' 6 ibis document was drsftd by taco staffs or the Green lake, Margwrse sari Wseshsa Count)r Zcudtp and Sstrifstlort agencies. This document meets the minimum requkements of ch. Comm 83.=)(bxlxd)&M w 8&54(1).(2) & (3). Wleasnsin Adndnbfr dw Code. Use of this document does not guarantee the performance of the POWTS. GMW (2/01) ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND 1 O RSHIP CERTIFICATION FORM (~~uyer L w 'fl~l t° Mailing Address Property Address (Verificatio)n required from Planning & Zoning Department for new construction.) City/State 10G~ ~5 Parcel Identification Number 9Ld^ LEGAL DESCRIPTION 1 ~y /J Property Location ) % 4) Sec. 0 b , T 0, 9 N R2~7 W, Town of Subdivision , Lot # Certified Survey Map # , Volume Page # 04 ~nty- Deed # ~ -7 Volume , Page # Spec house yes 0 0' lines identifiable no SYSTEM MAINTENANCE AND OWNER CERTIFICATION v Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department 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/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 fiill of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Naturaf Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms 2 SIGNA F APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) Parcel 042-1076-90-250 07/02/2013 09:53 AM PAGE 1 OF 1 Alt. Parcel M 28.29.18.437B-10 042 - TOWN OF WARREN Current ❑ ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type # of Units 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co-Owner BRENDA J LIGHTNER 0 - LIGHTNER, BRENDA J 747 112TH ST ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): * = Primary Type Dist # Description * 747 112TH ST SC 2422 SCH D ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 2.001 Plat: N/A-NOT AVAILABLE SEC 28 T29N R18W PT GL 1 BEING LOT 2 OF Block/Condo Bldg: CSM 9/2691 (2.27AC) EXC PT DESC IN AFF 1952/624 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 28-29N-18W Notes: Parcel History: Vol/Page Type 08/08/2 961357 ) QC 2005 -799422- 2836/376 WD 05/03/2004 761407 2563/025 QC 01/26/2004 752600 2497/512 QC more... 2013 SUMMARY Bill M Fair Market Value: Assessed with: 0 Valuations: Last Changed: 08/06/2010 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.001 80,000 166,000 246,000 NO Totals for 2013: General Property 2.001 80,000 166,000 246,000 Woodland 0.000 0 0 Totals for 2012: General Property 2.001 80,000 166,000 246,000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 554 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 hoc (D <D # ' L p O L N 3 Z p Z C n N O N O O CD 3 N O (Cpp 7 N N CD CD co m 00 U) CD D C) ID (D p C co V N N (D O 3 i 00 03 0 0 0 co O -4 CO .7 O N COO c V V 7 N M 7 V! 4 N Co -4 O O Q ~1 0 d d (D K) lY m v~ Z D cp a s cn C D 4 (D 60 > CL CD (n CL 0) 03 1.0 0 -a co ::z - I CD C: CD CD -4 3 CL CL 8 CD co (D =4 iz~ § C.0 v 3 0 ti z CD Co Co CD O N N y W W N C !mil 3 Q M M M M v v z o 0 o p 0 0 0 m cS CS CS CS Cc < N Z (}n 1 y W O T E ~Nj O ~ W to Ul fA m N y o D 3 v o v CD Q T v q K ID (D ' Ot •0 0 'O ° io = (D ° ~o = CD (o ` m m d N z N ° o D D K D D o v O o CL 3 CL N C ( CD (D C .0 .0 C C 3 z CD CD 1 N p CD _ in cn , ~ n ~ I A Z ~ CZ N ONO -0 co CL CL z O O A y A y Z CD (D w d W oaocc a N a m D R(D a C a O n OM S. CD 3 m c y v c CC , 'a (D (D z S2 O O Q pz O. CO (D n CL V! N Cft cn O CD N O N O ~N 0 CL y =r CL O) N N C a '0 A G(D' co CD C) CD O N A =04 j CD ~00 C M C S O O » O O O (D (D p0 O o 0 I o ~0 ~ N CD (D a, Op L O L Z Parcel 042-1076-90-250 03/08/2005 01:42 PM PAGE 1 OF 1 Alt. Parcel M 28.29.18.4376-10 042 - TOWN OF WARREN Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): Current Owner JERI ROSE JENSEN ' JENSEN, JERI ROSE 747 112TH ST ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): Primary Type Dist # Description " 747 112TH ST SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 2.001 Plat: N/A-NOT AVAILABLE SEC 28 T29N R18W PT GL 1 BEING LOT 2 OF Block/Condo Bldg: CSM 9/2691 (2.27AC) EXC PT DESC IN AFF 1952/624 Tract(s): (Sec-Twn-Rng 401/4 1601/4) 28-29N-18W Notes: Parcel History: Date Doc # Vol/Page Type 05/03/2004 761407 2563/025 QC 01/26/2004 752600 2497/512 QC 08/20/2002 687545 1952/624 AFF 05/26/2000 623768 1514/193 mor 2004 SUMMARY Bill M Fair Market Value: Assessed with: 38490 233,700 Valuations: Last Changed: 07/11/2003 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 2.001 35,000 170,600 205,600 NO Totals for 2004: General Property 2.001 35,000 170,600 205,600 Woodland 0.000 0 0 Totals for 2003: General Property 2.001 35,000 170,600 205,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch 554 Specials: User Special Code Category Amount 018-RECYCLING SPECIAL ASSESSMENT 15.00 Special Assessments Special Charges Delinquent Charges Total 15.00 0.00 0.00 W,iscoi0n DSpartment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 50 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Jensen, Jeri Warren Township 042-1076-90-200 CST BM Elev: Insp. BM Elev: BM Description: TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Alt. BM Aeration Bldg. Sewer Holding St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Dosing Header/Man. Aeration Dist. Pipe Holding Bot. System Final Grade PUMP/SIPHON INFORMATION Manufacturer Demand St Cover GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM uid BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liq Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number: DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil 1 [2 Yes 0 No 0 Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 747 112th St. Roberts, WI 54023 (NW 1/4 SW 1/4 28 T29N RR19W) NA Lot 2 Parcel No: 28.29.18.437B 1.) Alt BM Description = y~ ~ W" 6vW at"YB~ 0- t'~11/d Z_ &X 2.) Bldg sewer length _ " - - amount of cover = 1/t 3.) Contour = 61141 at-, &f& ~ Plan revision Required? F Yes 0 No Use other side for additional information. SBD-6710 (R.3/97) Date Insepctor's Signature Cert. No. Nov 29 02 11:38p FOGERTY PLUMBING 171SG3552BG P-2 ' County Sanitary Permit Application ST. CROIX COUNTY WISCONSIN In accord with 15,04 SI, Croix County Sanitary Ordinance ZONING OFFICE . Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER (Privacy Law. S, 15.04(1)(m)] Carmichael 1101 Hudson, WI 54016.77 0 -0 ~-D z 9 f ~3) (715)386-4680 Fax (715)366-4886 Attach complete plans for the system on paper not less than a-112 x 11 inches in site. County Sanitary Purmil # t] Check if revision to previous application 1. Application Information - Please Print all Information Location: Property Owner Name 114 jsd 114, Sec a l r T 2 N, R E (qM Pro rty Owner ailing Address Lot Number Block Number - 2 City, Stale Zip Code Phone Number b orIRS~NU7r3-/ a E ~Yo~ 7 9- o s" - 20 Ill. 1 Type of 9uilding: (chock one) amity ❑villa o Town of ly 1 or 2 Family Dwelling - No, of Bedrooms: 3 _ O Public/Commercial (describe use): O Stale-owned NearestRoadgf_ Typo of Permit: (Check only one box on line A_ Check box on line 8 if applicable) Z f Parcul Tart Number(s) A) 1,"pair 2. ❑ Reconnection 3.❑Non-plumbing C QRejuvenation Q y Z to q-4:_ QU - 1co Sanitation 6) /lr~• Permit Number rlDato Issued State Sanitary Permit was previously issued 3 70 /~Y~ IV. Type of POWT System: (Check all that apply) r~~` 11 or ❑ Non-pressurized In-ground vtound ❑ Sand Filter C3 Constructed Wetland ❑ Pressurized In-ground ❑ Holding Tank ' ' ' ' ❑ Singlo Pass CI Drip Line 0 At-grade ❑ Aerobic Treatment Unit O Recirculating- ❑ Other V. Disperse( reaUnent Area Information: 1. Design Flow (gpd) 2, Dispersal Area 3. Dispersal Area 4. Soil Application Rate 5. Percolation Rate 6. System. Elevation 7. Final Grade Required Proposed (Gals./day/sq.ft.) (Min,liinch) Elevation y5-6 Tank Information Capaicty in Cations Total a of Manufacturer Prefab Site Con- Steel Fiber- Plasuc New Existing Gallons Tanks Concrete strucled glass Tanks Tanks ❑ ❑ O ❑ VII. Responsibility Statement I, the undersigned, assume responsibility for repairlreconnonctionlrejuve liordinslallation or non-plumbing for the POWTS shown on the attached plans. A license is not required for tetralift repair or the installation of non-plurn ' sanitation system. Plu rs Na~41)rint) Plumber ignalur 'la "-mFliMPRS NO. Business Phono Number '020 A lplu`mQees Add ss (Steee , City, Stales, Z10 Code) 7 L/0.2 VIII. County Uso Only Disapproved Sanitary Permit Fee Date Issued Issuing Agent Signature (No stamps) Approved Ownur Givun Initial Adverse / 2 c2f) 1 Dutormination 1 Z CZ IX. Conditions of Approval/Reasons for Disapproval:. ' . jai ~ ~ 4 STC - 104 AS BUILT SANITARY SYSTEM REPOR; Irv Tom. ! 4ls i w r OWNER ADDRESS !A ! v SUBDIVISION / CSM# UT SECTION T_,ay N-R /g W, Town of i6 ~rR CA ST. CROIX C T W CONSIN PLAN VIEW SHOW EVERYTHING WITHIN 100 FEET OF SYSTEM poe, 7s o a ^ /~eo a IT CI S ~ a-f•G _ IV 12 4 INDICATE NORTH ARROW Provide setback and elevation information on reverse of this form. Provide 2 dimensions to center of septic tank manhole cover. I BENCHMARK: ALTERNATE BM: SEPTIC TANK / PUMP CHAMBER / HOLDING.TANK INFORMATION \ Manufacturer: G(~«(C Liquid Capacity: / e-ow Setback from: Well > Say House ?o Other Pump: Manufacturer ,,U Model# Gvroe-* Size Float seperation 2 ~Gallons/cycle: Alarm Location A ;SOIL ABSORPTION SYSTEM Width: Length y? Number of trenches z Distance & Direction to nearest prop. line: /S Setback from: well: > so House > ~e Other i ELEVATIONS Building Sewer ST Inlet; ST outlet PC inlet PC bottom Pump Off Header/Manifold Bottom of system Existing Grade Final grade DATE OF INSTALLATION: ^-~C PLUMBER ON JOB: LICENSE NUMBER: ) a-f 7 INSPECTOR: ~~ww 3/93:jt ~,p p21f ) j~ .29.19 WATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) SanitaryPermitNo.: Permit Holder's Name: ❑ City ❑ Village Town of: State Plan ID No.: `c WARREN v.: Insp. BM Elev.: BM Description: Parcel Tax No.: '5 16 no Paz/ TANK INFORMATION ELEVATION DATA A9300309 a ,3- TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark uJ eels ~e_ a. J 9. /OZJ Dosing Aer Ion Bldg. Sewer H~J St/ Z, Inlet TANK SETBACK INFORMATION St/ t Outlet TANK TO P / L WELL BLDG. Ventto ROAD Dt Inlet ~i Air Intake ,-a Septic NA Dt Bottom 1 1,33 72, - Dosing NA Ueacke"Man. Aerat' n Dist. Pipe Holding Bot. System PUMP 45AtUMFORMATIONO Final Grade Manufacturer Demand 33~ ~'C, C~ Z% r!a Cam, , i Model Number Cor GPM TDH Lift Lrictio5 3l' Systems ' TDH , (+Ft Forcemain Length Sv ° Dia. 1A" Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length ? No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMEN I SYSTEM TO P / L BLDG WELL LAKE LEAC Manufacturer: SETBACK CHAMBER INFORMATION Type Of UN1L Mode er: System: zxo OR dYlntw.crYc~ DISTRIBUTION SYSTEM /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length ff/ Dia. Length ` Dia. Spacing 111K I i 6 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only g Depth Over , Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Ij!!Kb,Center 1- ` Bed / TeQ it Edges /G - ~J Topsoil co es' El No [9-i'gs E] No COMMENTS: (Include code discrepancies, persons present, etc.) e9- W ' ~a~ LOCATT ON : ARR7. 2 8.2 9.19 LO 2 k." C al 0 w Plan revision required? ❑ Yes j;~NN Q Use other side for additional information. 3 7 SBD-6710 (R 05/91) Date r, Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 74- ~i-,,~!'~-~~~~rYJv.~ GC,r/L~~~II~ L2~ C.l.✓i.~ p~''~~~-~~4: x''~ ~30 G'.~i~ 7. . 9X II L T DILHR SANITARY PERMIT APPLICATION COUNTY In accord with ILHR 83.05, Wis. Adm. Code STATE SANITARY PERMIT`W -Attach complete plans (to the county copy only) for the system, on paper not less than ❑ 8% x 11 inches in size. Check if v o to p v s application -See reverse side for instructions for completing this application. STATE PLAN I.D. NUMBER 1. APPLICANT INFORMATION - PLEASE PRINT ALL INFORMATION. PROPERTY OWNER PROPERTY LOCATION .rYtS %4 S~Q T N,R /91 E o P PERTY O R'S MAILING ADDRESS LOT # BLOCK # 17 Z CITY STATE ZIP CODE PHONE NUMBER E OR CSM NUMBER i'►+ ®L * , vo . /mod 3 O y 7-/ 11. TYPE OF BUILDING: (Check one CITY NEAREST R7 ) El State owned VILLAGE w / y ❑ Public 211 or 2 Fam. Dwelling-#~ of bedrooms L TAX N 111. BUILDING USE: (If building type is public, check all that apply) _ O 26 - _ X06 zo V)- 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 ❑ Other: Specify IV. TYPE OF PERMIT: (Check only one in line A. Check line B if applicable) A) 1. 0 New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Existing System B) ❑ A Sanitary Permit was previously issued. Permit # - Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 Z Mound 30 ❑ Specity Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit Pressure 43 ❑ Vault Privy 14 ❑ System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. GALLONS PER DAY 2. ABSORP. AREA 3. ABSORP. AREA 4. LOADING RATE 5. PERC. RATE 6. SYSTEM ELEV. 7. FINAL GRADE REQUIRED (sq. ft.) PROPOSED (sq. ft.) (Gals/day/sq. ft.) (Min./inch) ELEVATION $'D 37 r 37r f''. J%0 Feet Feet VII. TANK CAPACITY in gallons Total #of Prefab. Site Fiber- Exper. INFORMATION Manufacturer's Name Con- Steel Plastic New istin Gallons Tanks oncret strutted glass App. Tanks Tanks Septic Tank or Holdin Tank W ! Gf Lift Pump Tank/Si hon Chamber X00 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 Stam MP/MPRSW No.: Business Phone Number: v/1V {r) 3'9 3C~t: Plumber's Address (Street, CRY, State, ZIP Code): IX. CO TY/DEPARTMENT USE ONLY ❑ Disapproved S tary Permit Fee (Includes Groundwater Date Issued Issuing A m Si No S ps) Approved ❑ Owner Given Initial n fl!y (,0 rcharge Fee) a Adverse Determin tin t'((~~ 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: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. IL Type of building being served. Check only one and complete of bedrooms if 1 or 2 Family Dwelling. Ill. 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% 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. 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. SBO-8398 (R.11/88) 1 SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations August 30, 1993 201 East Washington Avenue P. 0. Box 7969 Madison WI 53707 ROBERT ULBRICHT 655 O'NEILL ROAD HUDSON WI 54016 RE: PLAN S93-02706 FEE RECEIVED: 180.00 JENSON, GERRY GOVT LOTI,SEC28,29,18W TOWN OF WARREN COUNTY OF ST CROIX MOUND SYSTEM The Department has reviewed the above-referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter ILHR 82 or in chapters ILHR 50-64, Wisconsin Administrative Code. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be made. All permits required by the city, village, township or county shall be obtained prior to installation. Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. lame erely, s Quinlan Plan Reviewer Section of Private Sewage (608) 266-3937 sBD 7997 iR.OMI) i i I 11~ `YE K 1. L . r1. 1% J • Ud PROJECT INDEX SHis'FT OWNER : ADDRESS: 1,4'-IX S%, SITE LOCATION: Z6 Go f J~6 .Z - CS.y ~F.c•p<%vlr, n'f "IC C"p(~'T, Lo f SFC o PROJECT DESCRIPTION: ST C,eoiX Ct,tr a rY 461.s7-al-r-low PAY. f~v T- y PAGE 1. PL')`l' VI7,,WS PAGE 2. MOUND CROSS S BGTI('N & SYSTLT"M PLAN VTE';`iS PAGE 3. PIPE LATU AL LAYOUT PAGE 4. DOSING OR SIPITG'J CIL"IMBER CROSS SECTIOTTS RECEIVED PAGE 5. PUI'tr PERFORMANC : SPECS OR SIPHON SPE CS A U G 3 01993 OFFICE OF DIVISION CODES AND APPLICATION • PLUMBER: DESIGNER DATE : ~``~•~~•`''~~'''~'I~ FMMTW. S IGNATTJRE : uLmc HT 01160 Wis. y,~~II~N1i1N~~~ t } IIFFT. rP INDUSTRY, t~.~ IVISIOV OF SA"`E"TY A EiI'. ,~It . r`E E C;ORAE:rUP()Nit=N L 4.~ I, - Ct S cl~ \n \A v „ ,,t~„ ,n era 4,13jvs AO NOIS Al 3 W 1. o ~r,A N`a'rilm 8 ucl;141 °AdisS}a 4 A 'id*- a ~r~ tE t~ V go l-~ N rn M ~ ` C 3 0 7 fo,~C6 puG I~ O Al. \r`, a v r~ . V) ~w o, 4 ~ o dl ~ (U ~rIC t \i1 f c^,. n in ` r!1 i U~ F j V) -A R J J 0 4 SIl o v ~ -Z •9d uo pue uTaaaq urogs axe (saaXaem agIUT gITM 93TS uo paxeIs suoTIenaTe palsaMS •aTgTssod se uiao3Tun se a:as adoTs ssoaoe 9uoT3enaj8 -Z nTmoi? os (ai0aaa~g paq aapun eaae pue ~ 3 o auiT aol 1 uozITsod puno 3uaTao ao IJTgs \1\ J ATTn3aaea TTTM aaTTelsuI -?u1AOTd os aotad /JV~R 7- off- /S /OD a 5GEV,t7'i0A1.5 170OF -lZD_C.K._ . /d40 f P Page Z Of rv P °F Synthetic Covering _ Distribution Pipe Medium Sand _ H G s y trEM Topsoil F E1607100 u % Slope uNt?t 81E~ `-Bed Of ? Force Main Plowed Aggregate _ Layer UtilropM Tom- Gave- D 1 Ft. Cross Section Of A Mound System Using E 3 Ft' A Bed For The Absorption Area F 80 Ft. G O Ft. • A . $ Ft. H A Ft. B y8 Ft. K /O Ft. L ~g Ft. e;~WSTRYI Wo a ~.ara ,Ea~,;a,: 8 Ft. Ft. / MiIf9N OF SAFETY API f/ fsUtiGti~~: W 2 S Ft. fdiE'CE /~'1/9~iV SEE CORRESPONDENCE Observation Pipe - 8 K 10--)--------------------------------------- W - Distribution Bed Of Pipe Aggregate Observation Pipe Permanent Markers Ale CAoPED s~E~~ ,PooS Plan View. Of Mound Using A Bed For The Absorption Area ~~Qc9iip~'a /3ffS~4 L, /f'7PE = QAi~ 6vf1 S TE F/ckJ _ y~D . soy i ~,v ir~~r~•vE ~~~'~`~'x~' ~ ' - SILL sa.~r ARE/- (S/O~pi,VCr S~'TE - ,(3 x < A ,j Z/,9 77 76 12- Page 3 Of / 411A•t t7 /off 130 Fr of- z ~UC ~ORc fl"le'r AST /!(ale- Perforated Pipo Oetoll ~ A R~'r--~ T U~RI ~'•~E t1AC u4 e'oA-) End Yiew )Perforaltd End Cop PVC Pipe 4oi C'S Holes Located On Bottom, Are Equally Spaced R s A Q~ PVC t Mordlold Pipe OivribIttion Isr• Pipe Hole Should Be C.. Next To Cnd ~Ulti+e4olp/ ~l9 E 7 Distribution Pipe Layout P Ft R 2- , ./?O of 2- f UG X /7/0 Inches _ - Y inches Mule Diameter Inc-, Lateral r Manifold " Z- Inches 1 Force Main 2- Inches j of" holes/pipe 12- -l t Elevation of Lateralslc~U•~~ Ft. ~I'S rfziGo1-10,J T1 e-' H^ QCGE RATE PAR E~c~ ~ L, ATE R A L_ , h A/r o T i-s rP z -7 /y O TOTAL- ""D►STRi13urloAl VISGMAP G E RArE FOR NaeTWORK 29 Mio ~•5 ~IAJI'MUM l't gh D OF 30. ~ ~ G w C. . AMBER CROSS SECTION AND SPECIFICATIONS pf} yE' ~ OF S PUMP CH VEIJT CAP 4"C.I. VENT PIPE WEATHER PROOF APPROVED LOCKING I JUNCTION BOX MANHOLE COVER 25' FROM POOR, l.~/ ~jAR,UI,p(,r /AA3 WINDOW OR FRESH 12"MIN. I AIR INTAKE 1 'r10 Al I GRADE I 4"MIN. IB" MIN. X3.0 Co1JDUIT-_ f/EU~n oil/ PROVIDE I INLET AIRTIGHT SEAL I III I III D , D E I III APPROVED JOINTS APPROVED JOINT f A IN I III W/C.I. PIPE w/C.T. PIPE KV ( II ALARM EXTENDING 3' EXTENDIIJG 3' O I II ONTO SOLID SOIL QA1T0 SOLID SOIL 13 n J_ I I . 0 tY 3' 25 i °i.' A_0FF ELEV. FT. PUMP-o I, 3 ~i 'jfjpw BLOCK OP SD RISET{ EXIT PERMI'TT'ED OJLy IF TANK MANUFACTURER HAS SUCH ArPROVAL SEPTIC E SPECIFI'CATI0KJS DOSE vC~~ZL 59 WMBER OF DOSES: "PER DAS TAlJKS MAIJUFACT:JRER:112.5 TANK SIZE: GALLONS DOSE VOLUME yZ /3S INCLUDING BACKFLOW: GALLONS ALARM MANUFACTURER: MODEL ►JUMBER: L V CAPACITIES: A= ~.G IAICNES OR 30~. GALLONS 4.ffpW Ry f7-_loA7- B= L INCHES oR y~ GALLONS SWITCH TYPE: PUMP MANUFACTURER: C INCHES OR 135 GALLONS MODEL MUMBER1 //a U ,:a D = /5, " INCHES OR GALLONS SWITCH TI lPE: r'JAK 1"cory /p~qr MOTE: PUMP AND ALARM ARE TO BE INSTALLED ON SEPARATE CIRCUITS MINIMUM DISCHARGE RATE -L 3 (f) -GPM 121. 5 --A~k 5•P~CS, I VERTICAL DIFFEREMCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. FEET L ^t, P " LET EAR. -I- MIIJIMUM NETWORK SUPPLY PRESSURE . . . . . - F Of + ~3o FEET OF FORCE MAIN X 1,-5',111 F y" ,FRICTIOU FACTOR.' ~ FEET fr4oAjS 1015 AL TOTAL D't3WAMIC. HEAD = 17 / FEET • ~'O UFO IIJTERAIAL DIME IJSIOLJl WATTiglt~~ ;WIDTH ll_~iLi4UID DEPTH VYAl~ff' dorditionally , t A yj aft a rv Ruv E3f DEPT. F INDUSTRY, LABOR $ HUMAN RELATMUS _ IVISION OF SAFETY Al BUILDIidGS ' fit. SEE +CORRIESPON01=IVCE 0 N HEAD CAPACITY CURVE • 3 7/86 1/4 3o MODEL "98" 4 5/8 { e 7,., I F 25 6 3 Sj8 6 2 m ~Cos~ 15 ® 4 3/16 4 10 r-- 1 1/2-11 1/2 NPT 0 U.S. GALLONS 10 20 30 40 50 60 70 80 LITERS 80 160 240 .r 0 FLOW PER MINUTE , U UW y 1 TOTAL DYNAMIC HEAD/FLOW PER MINUTE i EFFLUENT AND DEWAI E11MG 1 CAPACITY 12 HEAD UNITSWIN 1 I FEET METERS GALS LIAS ' 5 - 1.52 72 x•73 a 10 3.05 81 231.,-,* 15 4.57 5 5 ~~3 5 - - 20 6.10 2 25 9 95 - /16 Lock Valve 23' l~ a CONSULT FACTORY FOR SPECIAL APPLICATIONS `d Electrical alternators, for duplex systems, are av i.:able and • Mercury float switches are available for controlling single and ' supplied with an alarm. three phase systems. r + Mechanical alternators, for duplex systems, are available with or • Double piggyback mercury float switches are available for without. alarm switches. variable level long cycle controls. . a SELECTION GUIDE 1. Integral float operated 2 pole mechanical switch, no external control required. Standard all models -Weight 39 lbs. - 'h H.P. 2. Single piggyback mercury float switch or double piggyback mercury. float 98 Series Control Selection switch. Refer to FM0477. Model Volts-Ph Mode Amps Simplex Duplex 3. Mechanical alternator 10-0072 or 10-0075. r M98 115 1 Auto 9.0 , 1 or 1 & 7 - 4. See FM0712. for correct model of Electrical Alternator, "E-Pak". N98 115 1 Non 9.0 2 or 2 & 6 3 or 4 & 5 5. Mercury sensor float switch 10-0225 used as a control activator, specify D98 230 1 Auto 4.5 1 or 1 & 7 - duplex (3) or (4) float system. 6. Four (4) hole "J-Pak", junction box, for watertight connection or wired-in Sim- to 'F98 230 1 Non 4.5 2 or 2 & 6 3 or 4 & 5 Alex or duplex operation, 10-0002. :F 7. Two (2) hole "J-Pak", for watertight connection or splice. CAUTION For information on additional Zoeller products refer to catalog on Combination Starter, FM0514; All installation of controls, protection devices and wiring should he done by a quali- Piggyback Mercury Switches, FM0477; Electrical Alternator, FMC486; Mechanical Alternator, tied licensed electrician. All electrical and safety codes ahoukt be followed includ- FMO495; Alarm Package, FM0513; Sump/Sewage Basins, FMO487; and Simplex Control Box, ing the most recent National Electric Code (NEC) and the Occupational Safety and FM0732. Heafth Act. (OSHA). ALI ,A RESERVE POWERED DESIGN l For'unusual conditions a reserve safety factor is dfigineered into the design of every Zoeller pump. l y MAIL TO: P.U. BOX 16347 Loiusvilt, KY 40256-0347 Manufacturers o1.. . IG zJ~~Lr / 1Q n SHIP TO. 3280 P✓ril'ers Cane 1 Louisvide, KY 45216 ,1UAL/7Y LIMPS /NCF (502) 778-2731 9 FAX (502) 774 3624 . r- , 506451 CERTIFIED SURVEY MAP IV Located in part of Government Lot 1 of Section 28, T29N, R18W, H a Town of Warren, St. Croix County, Wisconsin. rt z N Z ~ N N t0 a U) U) AREAS a " -M / .-r 4- 2.27 Acres (98,844 Sq. Ft.) Including R/W r 3 a o o e FILED 2.00 Acres (87,121 Sq. Ft.) Excluding R/W O `9 0 Note: Areas shown above do not include lands S E P 3 0 1993 ► ~ cn O N O_ lying between the water's edge and the meander JAMES O'CONNELL oo rt line. Ngww Of Deeft 0 M_ o St ow Ca, W1 oo m ^V y L1NP1_HTTEC I_/-\,1`~D E} Corner of N9000010011E I I ' - - N90000100"E 4384.13' - - Section 28 i East-west 1/4 line of Section 28 T900.721 S90°00' 00"W 333.64' 251 . rner of 300.26' N26027' 44"E -33.38- 28 33 33' 7 . 6 0 I W/12S~, Section ' ko 1 cnI SEP 3 X:. o 1-4 I ON wi '931 x IIr~ 1-I - m LOT 2 d1 201± ._JI ComprohenSIV9 P:11" I T~ I= I I w Zoning af~d 1 - I : I~ P~1cao.000~ndt: s I -I Ich I W ; - I M I `_N z 1 If not recoid rci I I-,1 1-{ I N CC) o I I L~ Ill rn - ~M~ within 30 days o€ 1~ I w 00 I o I I app, oral ds'.a IFn I , a6f 3 I Nov 100. vro3d ..,--75' I-33.12' 218: 30' I ~S m / ,4i ICJ '6 N86015' 49"E 251.42+ f ~ AL ENCC. e 23- l \ I I I - i GEN L 1 a S-1407 J. M. vol l . v. 2418 HUDSON, x WIS.+~pQ logo LEGEND OWNER Aluminum County Section Monument Found David E Carol Coyer 1069 70th Avenue • 1" Iron Pipe Found Roberts, Wi. 54023 O 1" x 24" Iron Pipe Set, weighing 1.68 lbs. per linear foot r_ Existing Water's Edge - - - - Meander Line Roadway Setback Line and Water Setback Line SCALE IN FEET VOLUME 9 PAGE 2691 This instrument drafted by Ed Flanum Job No. 89-33-193 0 50 100 200 SURVEYOR'S CERTIFICATE I, Allen C. Nyhagen, registered Wisconsin Land Surveyor, hereby certify that by the direction of David and Carol Coyer, I have surveyed, mapped and described the land parcel which is represented by this Certified Survey-Map; that the exterior boundary of the land parcel surveyed and mapped is described as follows: A parcel of land located in part of Government Lot 1 of Section 28, T29N, R18W, Town of Warren, St. Croix County, Wisconsin; further described as follows: of Section 28, thence N90o00'00"E, Commencing at the W1/4 Corner along the east-west 1/4 line of said section, 900.72 feet to the centerline of the town road (112th Street); thence S08043'31"E, along said centerline, 37.26 feet to the point of beginning; thence continuing S08o43 31"E, along said centerline, 356.39 feet; thence N86015'49"E, along the north line of Lot 1 of Certified Survey Map recorded in Volume 9, Page 2418 at the St. Croix County Register of Deeds office, 251.42 feet to a point being 23 feet more or less from the water's edge of Twin Lakes being the beginning of a meander line along said lake; thence N01053'23"E, along said meander line, 186.81 feet to a point being 20 feet more or less from the water's edge of said lake; thence N07()39'36"E,,along said meander line, 143.65 feet to a point being 25 feet more or less from the water's edge of said lake; thence N26c27'44"E, along said meander line, 7.60 feet to a point being 25 feet more or less from the water's edge ~of~~said lake being the end of said meander line; thence 590000 00 W, 333.64 feet to the point of beginnina. Including all lands lying between the above described meander line and the water's edge of Twin Lakes lying between the extension of a line bearing N86015'49"E from said beginning of meander line and the extension of a line bearing N90o00'00"E from said end'of meander line. Above described parcel is subject to right-of-way for town road (112th Sttreet) and all easements of record. I, also certify that this Certified Survey Map is a correct representation to scale of the exterior boundary surveyed and described; that I have fully complied with the current provisions of Chapter 236.34 of the Wisconsin Statutes and the Land Subdivision Ordinance of the County of St. Croix in surveying and mapping same. Each parcel shown on this map (plat) is subject to state and county laws, rules and regulations (i.e., wetlands, minimum lot size, access to parcel, etc.). Before purchasing or developing any parcel contact the St. Croix County Zoning Office for advice. VOLUME 9 PAGE 2691 CZ,f INbUS RY, OF REPORT ON SOIL BORINGS AND SAFETY & BUILDINGS INDUSTRY, DIVISION LABOR AND - PERCOLATION TESTS (115) MADISOP.O. BOX 76 N WI 53707 HUMAN RELATIONS (ILHR 83.0911) & Chapter 145) LOCATION: SECTION: TOWNS HIP/MttNtetfA-MY: OT NO.:BLK. NO. SUBDIVISION NAME: c~'/4 sw ~/4 z Je N/R/ E (or cv ,e,P~ COUNTY: OWNER'S/BUYER'S NAME: MAILING ADDRESS: 7 rs► r wr o/ < USEw 89S DATES OBSERVATIONS MADE NO. BEDRMS.: COMMERCIAL DESCRI TION: PROFILEDESCRIPTIONS: JPETESTS: Residence 3 ONew ❑Replace RATING: S= Site suitable for system U= Site unsuitable for system MS ENTIONAL: MOUND: IN-GROUND-PRESSURE: 1SYSTEM-IN-FI LL HOLDI NG TANK: RECOMMENDED SYSTEM: (optional) [ZU ZS❑u - ❑SOU osou osou If Percolation Tests are NOT required DESIGN RATE: I If any portion of the tested area is in the under s. ILHR 83.09(5)(b), indicate N Floodplain, indicate Floodplain elevation: v PROFILE DESCRIPTIONS BORING TOTAL DEPTH TO GROUNDWATER-INCHES CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE, AND DEPTH NUMBER DEPTH IN, ELEVATION OBSERVED EST. HIGHEST TO BEDROCK IF yyOBSERVED (SEE ABBRV. ON BACK.) ii/Rft/•l~L~ I.B~pH/Yt$• . Z 7, i c ' 7s "g/Ix6 n 'Rrn w dro< c ~s cc 2 r/ref y~fr~oH~~iuf~ mass.'ve, /,Acs. B- Gy 8 9 s 3 t u rrr w.- A. h e w e o6 w B- sell cc- B- 3 ;q is z~ s i. M -c pg,,A-e4 Ile B- L L✓ a .-fl e N srr ?-Y ' /Awriha OnS~ /,/'ifs rr/>7m~3o a Pa B- 7,1 97.1 1s w L PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME DROP IN WATER LEVEL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. PERIOD 1 PERIOD2 P R PER INCH P- ( Z3 .f P- > P- 2 ` /C24-C -3 P- P- /1, ~O r8 3 3 1 P 2 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 point//s and /show their location on the plot plan. Show the surface elevation at all borings and the direction and percent of land slope. Puc Yhe- rle&r satkrA~/>ti n a7 G~'a l o~v~ 9,V e AW.07i"ve C01cew .1 L SYSTE ELEVATION - E ~3 0 r n_ . 71 - -43 Sera~l~' as, N-0 lei-,eormer-E 7 3 , { I, the u igned, 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. NAM (printTESTS WERE COMPLETED ON: / ~ o r Zz 9? ADDRESS: CERTIFICATIO114 NUMBER: PHONE NUMBER (optional): 0 0 Z Ar wr s yoi- i3 7 - 6s CST SIGNATURE: DISTRIBUTION: Original and one copy to Local Authority, Property Owner and Soil Tester. DILHR-SBD-6395 (R. 10/83) - OVER - INSTRUCTIONS FOR C' a' _ETING FORM 115 - SB - 5395 To be a cor, ; accurate sail t=est:, ~ report naus. it :e: 1. Complete lega description, 2. The use seclJorr must clea€ly indicate . r this is a residence or commercial pioject; 3. MA>CIMU ' nu€r€ber of beclrooras or ccarn; cial use planned; 4. Is this E r~ ` Fr:ement syste€rs; 5, Co I' , y rating boxes. A SITE IS SUITABLE FOR A HOLDING TANK ONLY IF ALL OTr,, ARE RULED OUT BASED ON SOIL CONDITIONS; 6. PLEASE c, the =bbreviations shown here fear ovr sting profile descriptions and completing the plot plan; 7, MAKE A t diagram accurately locating your test locations. Drawing to scale is prefer€•ed. A separate sl used if desired; 8. Make sure yo ark and vertical elevation reference point are clearly shown, and are permanent; 9. Complete all , date boxes as to dates, names, addresses, flood plain data, percolation test: exemp- tion, if app! rpriate; 10. If the, f< 1~n (such as flood plain, elevation) does not apply, place N.A. in the appropriate box; 11. Sign tlrc u::d place your current address and your certification number; 12. Make legibl copies and distribute as recluiied, ALL SOIL TESTS MUST BE FILED WITH THE LOCAL AUTHORITY WITHIN 30 DAYS OF COMPLETION, ABBREVIATIONS FOR CERTIFIED SOIL TESTERS Soil Separates and Textures Other Symbols s'(: Stone {saver 10"') 131`3 - F c r.,ab Cobble, (3-1B") SS - Sandi>re gr C vet (under 3") LS - Liln "s - I1GVV High ° r cs - C , Sand perc P- on med's i. ir.€r7a Sand Gtr 7 1' is sand Bldg E is sty Sand > C sI ~ Loan) < ~ 8n si Gy C Y scl ly [ U-irn R El ci sicl 1 , C Loam riot- II:7ottles sc - Sar;dy C, ,-l , ~.FU, with sir: - S~l`y Clay "f - few, fine, faint c - common, coarse pt - I iany, medium as d distinct: p prominent- HVVL - High water level, Six gcr€eral s it ts =s surface water for liquid vast' d M - Bench Marl. VRr Vertical Reference Point TO THE OWNER: This soil test report is the first step in securing a sanitary permit. The county or the Department may request verification of this soil test in the field prior to permit issuance. A complete set of plans for the private sewage system and a permit application must be submitted to the appropriate local authority in order to obtain a permit, The sanitary permit must be obtained and posted prior to the start of any construction. S T C - 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 property Location of property.,&it1/4 X1/4, Section 2 S , T2_-r_N-R_ZT6P Township G~/a.0 reft_t~' Mailing address X37 21' S~• -~7 ~.v.~ o/ Address of site Subdivision name Lot no.Z Other homes on property? yes ✓ No Previous owner of property Total size of parcel Z Date parcel -was created S 3 Are all corners and lot lines identifiable? ---,-Yes No Is this property being developed for (spec house)? Yes =-No Volume Yo and Page Number F ea as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER & 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 recorded in the office of the County Register of Deeds as Document No. 5'0 d 5;T0 , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded i the office of County Register of deeds as Document No. n Sig ature of a licant Co-applicant Date of'Signature Date of Signature f ~ S T C - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER ltt4 OAAIP~ ADDRESS S4 - FIRE NUMBER CITY/STATE .2W2L II ZIP PROPERTY LOCATION: N 01/4, S401/4, SECTION, T-2L9-N-R TOWN OF t "_VW , St. Croix County, SUBDIVISION13) M2.% ( cUU ( ( , LOT NUMBER 7 Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater 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. I/We, the undersigned have read the above requirements and agree to maintain-.the private sewage disposal system in accordance with the standards.`set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix Co. Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: 1d /b St. Croix co. Zoning Office 911 4th St. Hudson, WI 54016 r r + DOCUMENT No. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1992 J~06986 104{~PAGE -err` VOL 310 r. Cf ST~~ S C~....>r ST CC; V1 David D. Coyer and Carol J. Coyer, husband and Read fbr %oord wife, individually and each in their own ra~it " OCT $ 1993 3( 1-50 P. . . Jeri R. Jensen a sin le woman J conveys and warrants to • ~tP~ s!a► d DeeGa I UR TO "dWr Wertheimer, S.C. 430 Second St. P. O. Box 106 s CCount - i the following described real estate in St...... ..PO County, State of Wisconsin: Tax Parcel No_ 042-1076-90-200 Part of Government Lot.1 of Section 28, Township 29 North, Range 18 West, described as follows: -Lot 2 of Certified Survey Map filed on September 30, 1993 in Vol. 9 of Certified Survey Maps at Page 2691, as Document No. 506451. 9 t i TRAN-9M qlay FEB I is not This homestead property. f (is not) Exception to warranties: TO(W1>:•IER WITH AND SUBJJB= TO any other easenpnts, covenants, reservations or restrictions of record, if any, but this shall riot be deemed to extend any such other recorded encumbrances beyond the term established by law therefor. October t th.... day of 19-- ° (SEAL) - -(SEAL) ' Vld I1. f •Y _ (SEAL) - . (SEAL) CaroY • er AUTHENTICATION ACKNOWLEDGMENT G; I Signature(s) STATE OF WISCONSIN ' St. Croix ss. -------------------County. au~henticated this day of___________________________ 19 Persp~l~i1~~ c~ame before me th~y~q - day of ----)l,7er------------ - 19.._. the above named •---------David"~: ""Coyer "arid""Ca"rol--J':""Cooyer, r TITLE: MEMBER STATE BAR OF WISCONSIN - huSbaI]d Arid wlie `r (If not, authorized by § 706.06, Wis. Stats.) to me known to be the persons who executed the forego' strum Ent a cknow ed a the same. THIS INSTRUMENT WAS DRAFTED BY ~j Atty. Hugh H. tlwin - 1f .rC~ ~f 430 2nd St., Hudson, WI 54016 ¢ ~X '`f N Notary a .---..-.St---CrbiX--- County, Wis. (Signatures may be authenticated or acknowledged. Both My Commission is pp/ermanent. (If not, state expiration are not necessary.) date: 3D--------------------- 19.9 M yr sd *Names of peraons signing in any capacity should be typed or printed below their signatures. WARRANTY DEED STATE BAR OF WISCONSIN Wisconsin Legal Blank Co., Inc. FORM No. 2 - 1982 Milwaukee. Wisconsin Nov 29 02 11:39p FOGERTY PLUMBING 17156355296 P-4 -CERTIFIED-SURVEY MAP N Located in part of CovcrnmenL Lot 1 of Section 29, T29N, R18W, Town of Warren, St. Croix County, Wisconsin. N t yJ1,1 it rt AREAS a 2,27 her- (98,844 Sq. Ft.) Including nfV e c v ~°w 2.00 Acres (87,L21 sq. Ft.) Excluding RIM Note; Areas shown above do not include land.( p e lying between the weterls edge and the meander s line. T b l_.~NID ",TTEv L 1" N Corner of N9000100"E N90°OO1optlE 4364.13' Section 26 East-resk i14 line of Saetion 28 goo. 7z' ' S90°00' 00"W 333.64' 25 V} Corner of t 3~_]9' / / . 6D SeeuOn 2B 11 38 ~3 1 ul N O q 1 v)I ~ d '010 r, LA SN' 1 ' YI 1 LOT 2 It( Q1 . ; ~ ~ i hl~~lll LN ` ~ I} M IiT1 w c~ ~;oo'-'rte NN, 139.12' 214:30 , ~;..yam G ~4, ~ 1` Sti°l5' 49"E 2.51-47. 6~ IN ~ altt~~- a. L r T c&WGCH a? S-140r hG. 2-418 ~x tiuDSON, z ~r WLS. < AO ?Nd .iU R1A. \\j T,T°G1 Nn OWNER Aluminum County Section Monument Found Orvid E Carol Coyer • 1" Iron Pipe Found 1069 700 Avenue keberts, 81. 54023 O In x 20 Iron Pipe Set, weighing 1.68 lbs. Per linear foot Exlskipg Voter's Edge Meander Line / ......••.•.Boadeay Setback Line and 06L 4- Ztaq 1 Water Setback Line Yy ~1 - 0. si O SCALE IN FEET ~,~~4? ~~3U~~73 This Instrument drafted by Ed Flanp■ Job go. 89.33.193 0 50 l0d 200 f o ~ ~ 0 d o c c > > n 3 CD Mr V 7! 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BOX 1969 LABOR AND PERCOLATION TESTS (11S) ADISON~53707 HUMAN RELATIONS (ILHR 83.09(1) & Chapter 145) i)f~ COCA' i : SECTION: TOWNSHIP/Mb'MMtrAtITY: r OT NO.: BLK NO,: 5UBD1 IS{ON NAM $ W / Z F - 19, 1 COUNTY: ER S/BUYER'S NAME: NG AU RAILI ESS: 77 17, USEw BATES OBSERVATIONS MADE EDRMS.: COMMERDESCR I PROFILE DESCFi PERC A TESTS: ION [Z Rtxidence New ❑RCplace RATING: S- Site suitable for system U= Site unsuitable for system l) O( NNVVE(~NTIOnNA{L: M(ODUNQD: 1N-GROG D•P(R~ES'SIURE: S S ~+M IN FFILLHOLDI~+NGTANK: RECOMMENDED SYSTEM:(optional) !f Percolation Tests are NOT required DESIGN RATE: if any portion of the tested area is in the under s. ILHR 53:09(5)(b), indicate',? Floodplain, indicate Floodplain elevation: ~V PROFILE DESCRIPTIONS BORING TOTAL D P H T R0Q D ATER•1NCH S CHARACTER OF SOIL WITH THICKNESS, COLOR, TEXTURE. AND DEPTH NUMBER DEPTH IN. ELEVATION OBSERVED EST. V E T TO BEDROCK. IF OBSERVED (SEE ABBRV. ON BACK.) iCraS~"~•Yty I.BrBrA*S• 7,2. / S k Rsr t/ 1 rd z Ct. iC xxCf' ~lrravfid«i a »-,g VC, ! ~GSr g- .f,? 7 y_f7 RP r'nz cv r /.~a e.~ Fe w 13-3 B_ . L cr C - ' `TZes r s an.-3o a.' it l 6rrCf" err ,z~y •/0;V0M 0►t5, PERCOLATION TESTS TEST DEPTH WATER IN HOLE TEST TIME -DROP IN WATER EL-INCHES RATE MINUTES NUMBER INCHES AFTERSWELLING INTERVAL-MIN. RI D t PEfllO PE PER INCH P_ 5 f'- p_ rG 3~d' 3 3~ P- x 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 plain. Show the surface elevation at all /blorings-,an`d/the dir*ctio/n' and percent I ~ 7j' T Y~G ~Gi~ MAr i YC ~'dxal'{-~f J~F4d~ /YPT" b ,riCaid'°' Y.Pr Of {and slope. f/wc y{rr r Sn., so+o . 6*t ir:c are, , ~ ~ x ' ' ~ El~r!rl~C~. SYSTE ELEVATION ' I c r I I • LA e lc 1 I v ti ~.JG tr_ I. l I Imo- I ....-7r I 7,3 I I I ! I 1 I . . I I i I _ _I I ~ I I I I I i f r' I . I I I I i I L" I I i I I ~ _._.Ir..__...~. - 7 _ _ T.. _ ._i._.._.. _................L....._...._1.....- - . _ .--r- -F---I I I I- _I_ I I I J, 17' i 4. I I I iFY':!/i!' AS, #Crf - T 1 ....j,... r.... i 1 i t70 H-_ ~~.....j....-lam _..r_---__.._ ..r, . r_L._._._..~.. • _ _ __..l_.. _ _ _ ,r.'. I _ Opp, 19 1, the igned, hereby certify that the soil tests reported on this form were made by me in accord with the procedures and~na! .4l a 'fib the Wisconsin Administrative Code, and that the data recorded and the location of the test: are correct to the best of my knowledge and belief. NAM print): TESTS WERE COMPLETED ON: r . © . / _ . ADDRESS: CERT{F{CATIQPA NUMBER: PHONE NUMBER(optibna!): r~ rJ~(j ~±r^ GJ ter'. SAO a- Z 7 CST SIGNATURE: T 6S'