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006-1039-95-075 (3)
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No 644736 Personal information you provide may be used for secondary purposes (Privacy Law. s 15 0e (1)iml] Permit Holder's Name C,ty Village Township Parcel Tax No Douglas & Tamera Belisle TOWN OF CYLON 1 006-1039-95-075 CST BM Elev Insp BM Elev BM Description Section lrown/RangelMap No 18.31.16.269B TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic t Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO PIL WELL BLDG Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM odel Number T H Lift Friction Los Syste Head TDH Ft Fo ema Length Dia Dist to Well SOIL ABSORPTION SYSTEW ELEVATION DATA ANOMMHeade-i-IM an BEDITRENCH DIMENSIONS Width /J� 5 Leng 1 No CI Tren5;v 'aL PIT DIMENSIONS No. Of Pits Inside Dia Liquid Depth SETBACK INFORMATION SYSTEM TO JPIL IBLDG WELL LAKE/STREAM LEACHING CHAMBER OR UNIT Ty CIS ystem n I 7 �) 7 56 DISTRIBUTION SYSTEM ` VI HeadedMandold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipes) Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Gr ysT§taF Only -� Depth Over 1 Depth Over /yti xx Depth of xx Seeded S d xx Mulched Bed/Trench Center Bed/Trench Edges I /J (/ 7it Yes No - Yes No COMMENTS: (Include code disc pencies, persons presen etc) Inspeclinn re+ ��� ✓ Inspection #2 Location: 2046 215TH AVE ��!�� ���� LV� VG Q�� • t�� r ' tyro fflti� 1.) All BM Description = 1" ���V/ Y xr� 2.) Bldg sewer length`S�t -amount of cover� Plan revision Required? Yes No Use other side for additional information. Di. sepclor ature -- - Cert No f SBD•6710 (R 3/97) Q 8 2�22 Indus ervices Division 4822 Madison Yards Wit County St. Croix JUL %I �i'`'' Madison, WI 53705 Sanitary Permit Number (to be filled in by Co.) ,� St. Croix County P.O. Box 7162/ Madison, WI 537 -7l r "r31P Sanitary Permit Applicatio State Transaction Number In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the app ovemmrntaI unit Project Address (if different than mailing address) is required prior to obtaining a sanitary permit. Note: Application forms for staleow WTS are submitted to the Department of Safety and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.64(I Xm), Stars. L Applicadem lsformadeat - Pravate Prlat AN Ietbrmaden Property Owner's Name Parcel ft DOUGLAS & TAMERA TR BELISLE 006-1039-95-075 Property Owner's Mailing Address Property Location 2046 215TH AVE Govt Lot City, State Zip Code Phone Number DEER PARK, WI 54007 SE ,, Nw section 18 T 31 N R 16 E or W II. Type of Balkiing (check all that apply) Lot it Subdivision Name aIor2Family Dwelling -Number ofBedrooms 3 � �ublic/Commercial - Describe Use t Block a `� ❑City of ❑State Owned - Describe Use illage of CSM Number ❑'Town or CYLON III. Type of 11OW'1'S Permit: (Check either "New" or "PAphilcialincialls atad ether applicable on ■ne A. Cheek am box an Yae B. Complete Yaa C A. IDNkw System a/ eplacement System ❑Other Modification to Existing System (explain) ❑Additional Pretreatment Unit (explain) B' ❑Holdin Tank g ✓ In -Ground �• Lr't-Grade Mound Individual Site Design Other Type (explain) conventional C. ❑ Renewal Before ❑Revision hange of Plumber ❑Transfer to New Owner List Prc%ious Permit Number and Date Issued Expiration IV. D eat Area and Tank laforeandoo: Design Flow (gpd) Design Soil Application Rate(gpd/sf) Dis 1 Area Required (sf) Dispersal Area P System Elevation 450 0.7 642.86 651.6 4 9'3 . Z 91.4 Capacity in Total p of Manufac ter 8 Tank Information Gallons Gallons Units L /n� J�1n �l,L�y 2V a A .041r+ z Luc New Tanks Existing Tanks I w e Septic or Hokling Tank 1000 1000 WIES ✓ Dosing Chamber O V. Reapoaem9Ny statement- L the aadani<aW, name resins py 11r hulaBatNa of die POWTS dews this the atnehed plash Plumber's Name (Print) Plumber's Si re MP,MPRS Number Business Phone Number Joel Myers 1918453 1715-418-1272 Plumber's Address (Street, City, State, Zip Code) P.O. Box 64 Chetek, WI 547 8 VL CeinaityMepartmetat Use Only Approved ❑ Disapproved Permit Fee s Date Issued I Issuing Agent Signs re or Denial S2 S— ZoZZ Conditions A rove acfc�Dieepppetial t . 3) � a Ill S �"`" -tl�t -� Pra *S YSTEM OW `^'` � &W o t. Septic tank, effluent filter and p` 3� 'Lc+�DuQad rSd dispersal cell must be serviced / malntairtIld S+—kk'ltr a++—� as per management plan provided by plumber, All setback requirements must be maintained P I � w+'`iti J2tirt as per applicable code/ordinances. Cf1a��t_fo j 1 j Attach to complete plans for the system a�nd�,.nhm, lt�top�a Lonm y only on papeerrnm9less than a 112 x 11 Inches in size' SB0.6398 (R. 03/21) 1- - Vr t`r��rtti,�t ron � Plr fifm�6">.tor ;a CHECKBOXAS APPUCABLE. Scale: 1" =40' e� © SYSTEM PAGE 2 OF 0 40 e0 eo PLOT PLAN 10' DESIGN FLOW: 171s0 DPD Attach design flow calculations for commercial plane. PROJECT ADDRESS: 2046 215th Ave Deer Park, WI 54007 Pipe Matedal ! ASTM Standard (Tables 384.3Q0.3�&/�/8�4�.345) am 9) mb A:® BM sevoon: 100 FT N BenRory Sewer' l��/ am Dncd Top of concrete (dock) post NE comer of house Face Mdn N ! P� 8fo�aGndWA(%ti� _ Indlcabnarmby IMPORTANT d ntadA: wMl Symbd (If oppllable): Q drnMrp an anov Show ground elevation Contours at suitable Intervals. "en oppro" Ina. CHECK BOIL AS APPLICABLE. C] SOIL EVALUATION SITE MAP PROJECT NAME: Belisle ppY Lt5to V06( � l e5a s � `^� yys � w CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Belisle Conventional Owners Name: Douglas & Tamara Belisle Owners Address: 2046 215th Ave Deer Park, WI 54007 Legal Description: SE 1/4 NW 1/4 S 18 T 31 N R 16 W Township: Cylon County: St. Croix Subdivision Name: Lot Number. Parcel ID Number: 006-1039-95-075 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross -Section Page 4 E;r{, 4�73 Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber. Joel Myers License Number: 918453 Date: 07/07/2022 Phone Number (715) 418-1272 Signature c— Designed pursuant to thi In Ground Soil Absorption Component Manual for POWiS Version 2.0 SBD-10705-P (N.01/01). Page 1 CHECK BOX AS APPLICABLE. CHECK BOX" APPLICABLE. U SOIL EVALUATION Scale: ,• =40' 0 SYSTEM PAGE 2 OF ° SITE MAP 40 80 B0 PLOT PLAN PROJECT NAME: DESIGN FLOW: ysD GM 10, Belisle Attach design flow calculations for commercial plane. PROJECT ADDRESS: 2046 215th Ave Deer Park, WI 54007 N Pipe Material / ASTM Standard (Tables 384.30.33 & 388/4...330.55) Pic Sanitary Sewer /�� �� .7� BM 9ymbd: BM Elevation: 100 FT � Face Main N � T of concrete (deck) SM Daaerl op ( ) poet NE comer of house Slope Graftni N C' of Tested Area: sZ _ W«I Syff" Is appMuda): O Indices names dir"Ins an r on dw appaprhe Ina IMPORTANT: Show ground elevation Contours at suitable Intervals. V' JJr fA �"`,cp— �tja<rA II��C�sa�l�I�f�c. 42 5ysk m a 1s' hAv�- F.. L _i_� fS,0 11 97.50 ft 4' Sdrodula 40 Final Grade PVC Vent Pipe Wth Verrt Cap ft Leaching 91.40 Chamber ft ♦- System Elevation Soll Absomtlon 8vstem Plan View 1 (06 ft 3.00 ft 1 Leaching Trench 1 Vent Or Observation Pipe Chambers Leachina Chamber Saeclflcatlons Manufacturer And Model Infiltrator Water Technologies, Q4 2000 0 70 EISA Rating sq ft per chamber Soil Application Rate gpd/sq ft 450.00 gpd Design Flow + 0.70 Soil Application Rate + 20 EISA = 32.00 Chambers 16.00 2 rows of chambers each. Page 3 of 9 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residency: (Streetaddress) O located at: j� �/,, k) '/., Section / , Town 3/ N, Range16W, Town of , St. Croix County Wisconsin. Upon inspectio , I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of ins ection or service *�2�.... Did flow back occur from absorption system? Yes No (if no, skip next line.) Approximate volume or length of time: gallons minutes Tank Capacity: llye Construction: Prefab Concrete Steel Other Manufacturer (if known): � Age of Tank (if known): '`S _ .'ems aX&- Permit number (if known) (Licensed Plumber Signature) (Print Name) (Title) (Date) (License Number) MPRMP'RS Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 j POWTS OWNER'S MANUAL & MANAGEMENT PLAN Pegs of FILE INFORMATION Owner d M Permit i DESIGN PARAMETERS Number of Bedrooms 3 ❑ NA Number of Public Facility Units Z1 NA Estimated flow (avenge) 360 gal/day Design flow (peak), (Estimated x 1.5) gal/day Soil Application Rate al/da /ft' Standard influent/Effluent Quality Monthly average* Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BOD`) 5220 mg/L ❑ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOD`) 00 mg/L Total Suspended Solids (TSS) 530 mg/L ❑ NA Fecal Coliform (geometric mean) 510' cfu/100ml Maximum Effluent Particle Size Ye in dia, ❑ NA Other ❑ NA Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE c SYSTEM SPECIFICATIONS /t/1/�t1— Septic Tank Capacity,,ZM al ❑ NA Septic Tank Manufacturer ❑ NA Effluent Filter Manufacturer Z o 6 a- ❑ NA Effluent Filter Model /1 /00 ❑ NA Pump Tank Capacity al NA Pump Tank Manufacturer NA Pump Manufacturer NA Pump Model gNA Pretreatment Unit NA ❑ Send/Gravel Filter ❑ Peat Filter ❑ Mechanical Aeration ❑ Wetland ❑ Disinfection ❑ Other: Dispersal Cells) ❑ NA In -Ground (gravtty) ❑ In -Ground (pressurized) ❑ At -Grade ❑ Mound ❑ Drip -Line ❑ Other: Other: ❑ NA Other: ❑ NA Other: ❑ NA Service Event Service Frequency Inspect condition of tank(s) At least once every: 3 13 ear(sl monthie) (Maxlnnim 3 years) ❑ NA Pump out contents of tankisl When combined sludge and scum equals one-third (Y7) of tank volume ❑ NA Inspect dispersal cell At least once every: 3 month aldls) l (Maximum 3 years) earls)s) ❑ NA Clean effluent filter At least once every: / / l ❑ m ) ear(al al ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ aw($) ❑ NA Flush laterals and pressure test At bast once every: ❑ month(s) ❑ year(s) ❑ NA ahor: At least once every: ❑ month(s) ❑ aerial ❑ NA Other: O NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal calls shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector, POWTS Maintainer; Septage Servicing Operator. Tank inspections must Include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal call(s) shell be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a falling condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY3) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of S12 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. 6 9 Page _ if 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 chemicals that may impede the treatment process and/or damage the dispersal cattle). If high concentrations are detected have the contents of the tank(si removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cattle) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned In compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and property disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS falls and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area Is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. T ovs lu o ng tank e ei a �ZD}!1� n� ��- I•l CorVST?Z(i�L n ❑ 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. POWTS INSTALLER POWTS MAINTAINER Name I C Name Phone -7 _ Phone �i%i SEPTAGE SERVICING OPERATOR (PUMPER) Name v Phone , C LOCAL REGULATORY AUTHORITY Name S . ( 20liw Phone %l;> — 3F(P— (o This document was drafted in compliance with chapter Comm 83.22(2)Ib)(1)IdWfl and 83.5411), (2) S (3), Wisconsin Administrative Code. ST. CRo UNTY SANITARY SYSTEM File #: ! Office Use Only OWNERSHIP/ADDRESS FORM Created 212021 Community Development Department will utilize this information to provide the property owner with information regarding operation and maintenance of your new or replacement sanitary system! This information will be provided as part of our ongoing efforts to protect public health, your well, groundwater, surface water, property values, and county resources. Once approved, this completed form and educational information will be sent to you by email. If you would like to view your issued sanitary permit online, you can do so by using the Pro e�rty Files Scanned weblink. OWNER/BUYER INFORMATION Owner/Buyer 0Y)A -0 4 r2-1 L 5, 'e— Mailing Address i �,1(� (p `��� ) City/State/Zip t✓ZC- -C VL f Phone Number (required) Is- - S 7 ( { Email Address (required) bZI S l e_ l_ ctry\ tkM - c •�" Parcel Identification Number no(J - /C> 39 -a5 - U %.S (found on the property tax bill) Property Location Subdivision Plat: NEW SYSTEM: LEGAL DESCRIPTION t/4 , _ Ye , Sec. J_�., T 3,N R-IjaW, Town of (s, Lot # Certified Survey Map # Volume . Page # Warranty Deed # :: 1 4`43 (before 2006)Volume Page # 093_. Number of bedrooms - Spec house 0 yes O no Lot lines identifiable 1#4es O no OFFICE USE ONLY New Property Address (Verification of new address required from Community Development Department for new construction.) (Staff Initials) (Date) This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications. New System: Include with this form 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. Community Development Department — Land Use Division 715-386-4680 St. Croix County Government Center 715-245-4250 Fax cdd@sccwi..ov 1101 Carmichael Road, Hudson, WI 54016 www.sccwi.aov 0 '-sat V9 wsn ��f an Professional Services 5 Page of entices I,\�. ,J ®_: UL Og JAll OIL EVALUATION REPORT ecco ante with SPS 385, Wis. Adm. Code County untJn Attach complete site n on pagprbal 9 " inches in size. Plan must include, St. Croix but not limited to: verti I and r{ptital point (BM), direction and percent slope, Parcel I.D. scale or dimensions, h ocation and distance to nearest road. 006-1039-95-075 Please print all Information. Reviewed by Date Personal information you provide may be used for secondary purposes (Prtvacy Law, s. 15.04(txm)). I Property Owner Property Location Q DOUGLAS & TAMERA TR BELISLE Govt. Lot SE Y. NW s 18 T 31 N R 16 E (or) W Property Owner's Mailing Address Site Address or CSM and Lot #: 2046 215TH AVE City State Zip Code 15400754733 Phone Number ❑ City ❑ Village ® Town Nearest Road DEER PARK WI ( ) CYLON 215th Ave ❑New Construction Use: ❑Residential /Number of bedrooms Code deriveddesignflowrate450 GPD QReplacement ❑ Public or commercial - Desyrlbe: Flood Plan elevation it applicable Parent material _ft. n+✓ % SerZas .. a+esl•' General comments and recommendation �`t�lS 5�1� % ...Q V+�r �s S w. a Being # Boring 96.87 112 87.53 N]Pft Ground surface elev. ft. Depth to limiting factor in. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft= •Eff#1 'Eff#2 1 0-8 7.5YR2.5/2 sil 21 ds Cw 3vf 0.6 0.8 2 - 36 7.5YR4/3 sil 21 dsh Cs 1vf 0.6 0.8 3 - 51 7.5YR4/4 s Ori dl Cs 0.7 1.6 4 - 92 7.5YR3/4 s Omsg dl Cs 0.7 1.6 5 lip , 112 7.5YR5/3 s Omsg dl - 0.7 1.6 9. e f.b 7 Boring # []Boring 97.52 110 88.35 ®Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/FF 'Eff#1 'Eff#2 1 10 7.5YR3/3 sil 2mabk ds Cw 3f 0.6 0.8 2 27 7.5YR3/4 Sid lmabk mfi Cs 2m 0.2 0.3 3 4 7.5YR4/4 Is Omsg dsh Cs - 0.7 1.6 4 110 7.5YR4/6 s Omsg dl - 0.7 1.6 3• oq.y CST Name (Please Print) Signa ure CST Number Joel Myers 918453 Address Date Evall0lon Conducted Telephone Number P.O. Box 64 Chetek, WI 54728 06/28/20 2 715-418-1272 Effluent #1 = BOO > 30 5 220 mg/L and TSS > 30 s 150 mg/L ' Effluent #2 = BOD, 5 30 mg/L and TSS 5 30 mg/L SBD-8330 (R04/21) Page 2 of 3 ❑3 Boring # ❑ Boring 96.07 ®Pit Ground surface elev. ft. Depth to limiting (actor 112 in. I elev. 86.73ft. Soil Application Rate Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft= 'Eff#1 'EH#2 1 - 13 7.5YR2.5/3 sil 2mabk ds Cw 3f 0.6 0.8 2 - 32 7.5YR3/4 sil 2mabk dsh Cs 21' 0.6 0.8 3 - 46 7.5YR4/4 sl 2mabk dsh CS - 0.6 1.0 4 _ 112 7.5YR4/6 s Omsg di - - 0.7 1.6 D ❑ Boring # ❑ Boring ❑ Pit Ground surface elev. ft. Depth to limiting factor in. / elev. ft. Sal Annlir fim Rafw Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft' 'EM 'Efl#2 ❑ Boring # ❑ Boring ❑ Ph Ground surface elev. ft. Depth to limiting factor in. / elev. fl. .4` ,ll Arnllr�fim Rafa Horizon Depth In. Dominant Color Munsell Redox Description Qu. Az. Cont. Color Texture Structure Gr. Sz. Sh. Consistence Boundary Roots GPD/Ft2 'Eif#1 'Eff#2 Effluent #1 = BOD > 30 s 220 mg/L and TSS > 30 s 150 mg/L ' Effluent #2 = BOD, s 30 mg/L and TSS s 30 mg/L CHECK BOX AS APPLICABLE ❑✓ SOIL EVALUATION SITE MAP PROJECT NAME: Belisle CHECK BOX AS APPLICAM. Scale: 1"=40' ❑ SYSTEM PAGE 2 OF D 40 eo eo PLOT PLAN 10' DESIGN FLOW: Gpo Attach design flow calculations for Commercial plans. pRC,IECT ADORESS: 2046 2151h Ave Deer Park, WI 54007 Pipe Material / ASTM Standard (Tables 384.30-3 A 384.30,5) BM Synbd: + BM Elwetbn: 1()1) FT NSanitary Sewer / SM OMMpow TOP of conCrste (dea) post NE comer of house Faros M.In / &o aradl«x(xi Indlcetenorth by IMPORTANT: w w«I 9ymbd (If applicable): p drawkV an arrow Show ground elevation contours at suitable Intervals. on dr appv o W& SAVE F"eI° 7r 0 Revel < 4 5T CbR counry Lam' - Np. 644736 STATE SANITARY PERMIT PREVIOUS qA OWNER>w,L1kS %'1�,�,(.�B&�,Ti•��' PLUMBER SoH- MYIzU LIC.#�S3 TOWN OF 1.0 SEC_9T_31 N, R Jb AND/OR LOT 01-�LOCK SUBDIVISION o. q??ozz57 CHAPTER 145.135 (2) WISCONSIN STATUTES (a) The purpose of the sanitary permit is to allow installation of the private sewage system described in the permit. (b) The approval of the sanitary permit Is based on regulations In force on the date of approval. (c) The sanitary permit is valid and may be renewed for a specified period. (d) Changed regulations will not Impair the validity of a sanitary permit (e) Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. (f) The sanitary permit is transferable. History: 1977 c. 168; 1979 c. 34,221; 1981 c. 314 Note: If you wish to ienew the permit, or transfer ownership of the permit, please contact the county authority. 090V%. VKhAU RIZ D ISSUING OFFICER - DATE '/ZZ ZOZZ PERMIT EXPIRES ZZ UNLESS RENEWED BEFORE THAT DATE POST IN PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (R11/20) Wisconsin Departmenl of Commerce Safety and Building Division GENERAL INFORMATION Personal information you provide may he used for l Permit Hollers Name: Belisle, D6u las 3 Tamera CST BM Elev: Insp. BM Elev: TANK INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) Purposes [Privacy Law, s.15.04 (1pm)I. City Village X Township Colon, Town of TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Hdding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic r f Dosing Aeration Holding PUMP/SIPHON INFORMATION SOIL ARSORPTIOIJ 3VQT9rlUI` 2d-I4., ,. L (__, r.,-- f_. ELEVATION DATA STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer 3� SVHt Inlet St/Ht Outlet , 3 9u 53' /, Dt Inlet Dt Bottom Header/Man. 9 •� ! �y 31 ! Dist. Pipe Bot. System [ �. T5. 32' Final Grade St Cover 4 :'you s • 5W/ g-2f�9S6S` BP9KRENCW Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Da. Liquid Depth DIME 'v. �_4• -. . SETBACK SYSTEM TO P/L JBLDG WELL LAKE/STREAM LEACHING Manufayurer: INFORMATION CHAMBER OR ..l- Type Of System: Model N .4 t t ,� .-� 4- • _ UNIT �. , DISTRIBUTION SYSTEM HeaderfManifold it J Diktrihutiors- - -. .. .. Pipes) _ ■ Hole Size s Hole. Spacing Vent to Air Intake ii- Length¢" Dial ' length Dia Spacing ' Gr 0WIL. V V vrr% x Pmael" Cv:/..ne nnly v- alin,,..w n jh#--� C,...- n..r.. Depth Over Depth Over roc Depth of xx Seeded Sodded xx Mulched Bed/Trench Center Bed(Tranch Edges Topsoil -_ I Yes j No ._ J Yes wk eACI IIMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: r Inspection #2: Location: 2046 215th Avenue Deer Park, WI 5.1 07 (SE 1/4 NW 1 /4 18 T31 N R16W) NA Lot _ { Parcel No: 18.3I1.118.26/9B /1 1.) Alt BM Description = A,f . i •? . ^ o , {x- OK j Lily„ 3 Qm.,r/�+0./ L /jam ¢IC fi� 2.) Bldg sewer length f. -amount of Covert Plan revision Required? Yes No t:. * IL Q /1 Use other side for additional Information. ___ /-�11 ''� r 11_'.', �t 1.-;1.•_, �/�L��i SBD-6710 (R.3197) Date Insepctors Signature Can. No. Safety and Buildings Division County 4isconsin 201 W. Washington Ave., P.O. Box 7162 S7- G r M 4 WI 53707 - 7162 Sanitary Permit Number (to be filled in by Co 1 ` )266 3151 y�'�' �Zr— Department of Commerce Sat(IOII State Plan 1D. Number _ In accord with Comm 8121. Wis. Adm. Code, personal information you provide Project Address (if different than mailing addressl �L may be used for secondary purposes Privacy Lew, s 15.G4(1 xm) L Application Information- Please Print All Information Property Otma'sName JUN 0 9 2006 P reel 1-0"f Blocked t o 44.r JL ..•• c•- lSeL; C ©6- - 40L-A§0'_ Property 's Mailing Address ST. CROIX COUN I Y P y Location 7-0 y 6 z!f r1 *✓� _. C v., A!L/Q%, section City, State Zip Code Phone Number Q P4 4( (✓ _s-yf 0 1U 6lcircle Duel T N: R �_ H. Type of Building check all that apply) SnSdivisionN=nle bc+ SSA4DMna R+or2Family Dwelling - Number ofBedrooms Public/Commercial - Describe Use QCity QJillage wtowmhip of C1_ :as.. am ❑ State Owned - Deaersbe Use III. Type of Permit: (Check only one box on line A. Complete line B If applicable) r, ' - r _ j .. C ' c, ;2�- y g A. 13 New System t System ❑ Treatment/Holding Tank Replacement Only 17 Other Modification m Existing System B. 11 Permit Renewal 17 Permit Revision El Change of a Permit Transfer to New List Previous Permit Number and Dale Issued Before Expiration Plumber owner izk , IV. Type of POWTS stem: Check all that a Gct t'.; . ; w qq �Nm -Pressurized InXm ..it 13 Mound > 24 in. of suitable snit LJ Mood < 24`in. of suitable sod ❑ At -Grade 13 Single Pass Sand Filer U Constructed Welland ❑ Pressurized to -Ground 13 Holding Tank 13 Peat Filter ❑ Aerobic Treatment Unit ❑ Recirculating Sand Filter 11 RecirculatingSynthetic Media Filter Leachi Chamber 0 Dri Line 13Gravel-less Pi oo r Pipe ❑ Other lax lain) V. Dis rsaVTreatment Area information: ` Design Flow(gpd) Design Soil Application Rale(gpdsf) Dispersal Area Required Dispersal Area Proposed (sf) ystem Elevation r s-a • i VP 6 v z, $r' is Y4. S a . 4 y VI. Tank Info Capacity in Total Number Manufacturer Prefab Site Steel Fiber Plastic Gallons Gallons ofunits, ,tea; �� ,j �, ,r - Concrete Constructed Glass New•V'ra".- Tanks Tadu <20 err Holding Tads 00 % � Gf•! r 1'� Aarobic Trvataent Usti VoinatiCliazaba VII. Raponsibility Statement- 1, the aadenigned, assase responsibility for fastallatioa of the POWTS slsowa a the attached plans. Plumber's Name (Print) Plumber's Signature MP/MPRS Nunber Business Phone Number Michael E. Wilson r (�� 225150 715-268-6626 Plumber's Address (Street, City, State, Zip Code) 894 State Rd 46 PO Box 232 Amery, WI 54001 VIi7. Couny/Depertmeist Use Only Ty Approved F' Diappvvwtd Suriary Permit Fee (include GroundwaterDate Issued Issuing�tgent Signureato Stempel r Surcharge Fee)0 ven Reason for Dertial DC. Conditions of App al - 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 as per applicable codelordinances AYti Comprele parr la se ceaaq awry) air tat syares s paper caw s ass ears s r r o u — SBD-6398 (R. 01/03) IAI - 4.?V-O !1A AV-P pi iD imp GS O -.1-- - . -- f AV RECEIVED UvWonmsftyand JUN 0 9 2006SO1 EVALM"A -MOM REPORT Page —/— of n i Aaad1 aomplele site Plan on per neTk JYin size. Plan must LXT04M, �ybut Paod I.D. — not WTftd $D: I end Ilertca dfrodion and Percent slope. scale or dlrrw I arrow, and WOW and distance to nearest road. . Please print all Inform tfon. Radewed by Dam Personel Momubw you proMW may be used for asanMry purposes (MVICY law, a. 13.04 (1) (m)). sty Owner Property Locallon GovL Lot 1/4 114 S T j N R Properly t]wfters Mating Address Lot • a Subd. Name or CSILAAR Zlp Code Phone Number O City O yyage M Town Nearest Road Q New Coretnalfon Use: Reeldentlal / Number of bedrooms �_ Code derW design Now rate GPO Pq Replecarnamt ❑ Pubic or commardal - Dwaft: Parent materiel Flood Plait elevation tf applicable R General comaneria and I'ecDmrnendabona: NMI MMUMM EAM� WAW O r■ .: r :..,,rGQ IF 0 w Property owner Pafam 100 Pepe L;22— d 111 Bake• ❑ Bake Pit Orourd acafaca elev. , �9 t Deplh to Nnov fagot lf� in. S„t amlnmum, Raw �Ppl E4MMMAIMM ' Mart V = BODE a 30 :5 22D rnWL and TSS >M :5 150 ng1L • Eftw t i2 = BOD< 130 ffK l& and TSS c 30 nWL 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. seaano rnmiom • SauQN6 � %J'NIEU-/ KJ�/SAC ,4 �nicA �� • �yyo e{ [bJcl� !An h� / � - .c�.lkl^.D z2,l Reef /laKaw 4 3v-'3 sF/- Nrv'%/- SZC /3 --T..Fi tl -,t°/G eJ 4�44 E�ca�•a� �iS'�11JG Cross Section of a Two Cell In Ground Component Using Leaching Chambers �2 — T-,L,, c Observation/Vent Pipes Fir -',shed Grade Ceti slope % Top of Chamber = System Bev. reot4mytent"pnd' plsperedi .doge • ' • 4 `. r R; rmished Grade = �' •_i J , ,v'original Grade Top of Chamber = �� System Elev. = 7 3, c y Limiting Factor. Observation/Vent pipes to be constucted and capped with approved materials for the particular use. Not to Scde i POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of?' FILE INFORMATION Owner vc:�4gjt .S i A MGt y1 1-15c {, rWziS'l Permit Sb •5 DESIGN PARAMETERS Number of Bedrooms A(NA Number of Public Facility Units t$ NA Estimated flow (average) 3C;; allda Design flow (peak), (Estimated x 1.51 al/da Soil Application Rate C• t -7 al/da /ft2 Standard Influent/Effluent Quality Monthly average' Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BOD51 5220 mg/L ❑ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODs) S30 mg/L Total Suspended Solids (TSS) 530 mg/L ❑ NA Fecal Coliform (geometric mean) 5104 cfu/100m1 Maximum Effluent Particle Size Ye in dia. ❑ NA Other. ❑ NA Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity CDC gal ❑ NA Septic Tank Manufacturer tN ❑ NA Effluent Filter Manufacturer ❑ NA Effluent Filter Model ❑ NA Pump Tank Capacity al Pump Tank Manufacturer A Pump Manufacturer "A Pump Model OWA Pretreatment Unit ❑ Sand/Gravel Filter ❑ Mechanical Aeration C3 Disinfection ❑ Peat Filter ❑ Wetland ❑ Other: YkNA Dispersal Collis) Oq In -Ground (gravity) ❑ At -Grade ❑ Drip -Line ❑ NA ❑ In -Ground (pressurtzedl ❑ Mound ❑ Other: Other: ❑ NA Other: ❑ NA outer ❑ NA Service Event Service Frequency Inspect condition of tankls) At least once every: 2 monthisl (Maximum 3 years) >13 year(f;) ❑ NA Pump out contents of tankls) When combined sludge and scum equals one-third (Y31 of tank volume ❑ NA Inspect dispersal cell(s) At least once every: . 3 ❑ monthis► (Maximum 3 years) 12-year(s) ❑ NA Clean effluent filter At least once every: 1 ❑ monthls) years) ❑ NA Inspect pump, pump controls & alarm At least once every: ❑ month(s) ❑ yearls) NA Flush laterals and pressure test At least once every: ❑ month(s) ❑ earls) VVINA Other: At least once every: ❑ monthisl ❑ year(s) NA Other: A MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y.) or more of the tank volume, the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin Administrative Code. All other services, including but not limited to the servicing of effluent fitters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. START UP AND OPERATION Page -21 of v For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cells) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, ormust be taken, to provide a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS AA // technology a holding tank may be installed as a last resort to replace the failed POWTS. Iv� T alua ' a ale Pf2�N18rT� �oAl&%J C&is ❑ 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. COMMENTS POWTS INSTALLER POWTS MAINTAINER Name '04 'H U- 11 �frn Phone Y-'5. .,. .. Name 1 a Phones SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name .v Phone 61, t Name s'r, C ( 20rt11�(l Phone -7/S— 3g�- q&lefo This document was drafted in compliance with chapter Comm 83.22(2)(b)11101&(f) and 83.54111, (2) & (3), Wisconsin Administrative Code. Owner%Buyei Mailing Addi Property Address ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM (Verification required from Planning & Zoning Department for new City/State �/s �„ Parcel Identification Number LEGAL DESCRIPTION Property Location S Cr '/. , Wc,/ '/. , Sec. / 8" , T J / N R / t: W, Town of C , !- a y Subdivision - w1 a `... y� c, 1' r b n ti Lot # Certified Survey Map # Volume , Page # Warranty Deed # 79 L y Y 3 , Volume 2707 , Page # 0 5-3� Spec house yes C�nj Lot lines identifiable ® no SYSTEM MAINTENANCE AND OWNER CERTIFICATION 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 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsm. 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 amlam the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedro 3 SIGNX7ME OF APPLICANTS) 6/ 8•laL DATE .:.Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department ••* :aClude with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if -tference is trade in the warranty deed REV. 08105) ArcIMS Viewer Page 1 of 1 fSb http://72.21.230.178/website/LRPortal/ARCIMS/MapFrame.asp?PIN= 6/12/2006 vll =kpJn Department of Commerce Dlblaion of Qety and Buildings Bureau of Integrated Services in i Attach complete site plan on paper not less titan S 1/2 Include. but not limited to: vertical and horizontal retwi percent elope, scale or dimensions, north arrow, anq+ia (<') i - APPLICANT INFORMATION - Plans& prfrq Perearol NAonnahon e p s me e use ordar�,pe1 Property Owner - - SOIL AND SITE EVALUATION Page ( of 3 �rda s ILHR 83.t)<J, Wis. Adm. Code 3 1.,4 Q and (i11�(ildFd`�eare�t noel. ., J 10�1/4 ' 1/4,S T N,R IG E Progeny Owners Mating Address C l # Block# I Subd. Name or GSM# city /State Zip Code Phone Number ❑ City ❑ 7ge Town Nearest Road I uc� r / iwv &Ir 1 4:s49i71(W s�) � SK9'3196 G�/, _ I 7 V„ -jr�/4 '41� - - 5d New Construction Use: ® Residential / Number of bedrooms dW to existing building El Replacement ❑ Pubic or comrtrercial - Describe: Code derived daly 1IoW4! � gpd Recommended design loading rate bed, 9pdAt2' Absorption area required - bed, ftz _trench, 0 2 Maximum design loading rate —12—bed, gpdfW.� Recommended Inf itration surface elevatlon(S? ' r ft (as referred to site plan benchmark) Addit&W desipVsite considerations o Parent material Flood plain elevation, If applicable f� I S - Suitable for system Conventional Mouuxl In -Grand From" AT -(trade System In RI U = Unsuftsbfe for system �j s❑ u 4 S❑ u s❑ u 'K S❑ u ❑ S IOU S[]Il_ nFcrPIPTinu DFonoT Boring # 13 Ground Oft. Depth to Inning factor 712LLin. ❑s QU ©o M - ==OEM 42 e ICY/,'l�if� 0 AR Mi 1FA _/lam S. i Remarks: Boring # 1 Ground yl��ft rl b limiting faaor in. Remarks: CST Name (Please Print) Signature Telephone No. Ada`. � � � . Date _ / � CST NumberQ ML PROPERTY OWNER Gz4��-- DESCRIPTION REPORT FIVW a PAFAXL I.D.0 Boring # 13 Gmud ,R Depth to kniting factor 7AIO"- y.s Boring 9 0 Ground P� k Boring # 13 Ground R Depth to Urniting Bonng # [3 �, �el . MM i rr� r�il��ra Remarks: r ILjM P,I MINN. ' MF�Me M®MMw Remarks: r■■rr�r r�rrF�rrrrrrrrr rrr ■rrrrr�rrrr rrrr r�rrrrrrrra rr�rrir■ rrrrrrrrrrr Remarks: Ground at". _R Depth to Wfft9 factor —h'' Remarks: SBO-e330 (R. 07M) Y S00 o o II � I • � i ° � .. r\ �i%�,�� I` l 0 �. -' gam, C I� a - t ---- 44 OY • - -11 I i C?p { —Nj 4 I) jOJi 105 CZ)19 so _ 1 I ry _ yy 032 1069 ,- �I '1.�` i \`\ � ` �[`1I/�.j1/1+ O 'y" .ate � "'" •w' OAP - _. -"'.- -"- may, �� • I/ ° I °1 Piw -H,4 12 )1 DO N c6c1�7— Soil Test Plot Plan Project Name Steve Halleen Byron ird Jr. Address 2162 170th Ave New Richmond Wi 54017 CS #220527 t - -- Subdivision ----------- Date 8/30/98 NW 1 /4 NE /4S 18 T 31 N/R 16 W TownshipCylon Ci y Na r' Well PL Property Line County • CROIX BM or VRP Assume Elevation 100 ft.Top of Wood Stake with Orange Ribbon System Elevation 91.4/90.9 *HRpSame as Benchmark Alternate Benchmark Top of Wood Stake with Orange Ribbon @ 98.0 ttr-Aae��i-urn Nw+o Sinl Cr,� �,-? 1320 l lope V11.1 15' B-1 C S T _a i erty Line Alt. 1B.MJep B.M 5' -4 Pri A % lope 18% Slope 18% Slope Parcel #: 006-1039-30-050 03/28/2007 11:49 AM PAGE 1 OF 1 Alt. Parcel M 18.31.16.263A-5 006 - TOWN OF CYLON Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O = Current Owner, C = Current Co -Owner DOUGLAS & TAMERA TR BELISLE O - BELISLE, DOUGLAS & TAMERA TR 2046 215TH AVE DEER PARK Wl54007 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description SC 0119 AMERY SP 8020 UPPER WILLOW REHAB DIST SP 1700 WITC Legal Description: Acres: 59.000 Plat: N/A -NOT AVAILABLE SEC 18 T31N R16W NW NE & PT NE NW LYING Block/Condo Bldg: E OF THE FOLLOWING DESCRIBED LINE; COMM Tract(s): (Sec-Twn-Rng 40 1/4 160 1/4) N LN OF NE NW & W LN CSM 1012879; TH OVE TO S LN NE NW AND THERE 18-31N-16W NE NW TERMINATING; EXC CSM 1012879 Notes: Parcel History: Date Doc # Vol/Page Type 12/02/2004 781444 2707/094 QC 05/15/2003 721259 2239/513 QC 05/13/2003 721258 2239/552 QC 10/24/2000 632346 1553/243 QC 2007 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last changed: 09/09/2004 Description Class Acres Land Improve Total State Reason UNDEVELOPED G5 39.000 39.000 0 39.000 NO PRODUCTIVE FORST LANDS G6 20.000 40,000 0 40,000 NO Totals for 2007: General Property 59.000 79,000 0 79,000 Woodland 0.000 0 0 Totals for 2006: General Property 59,000 79,000 0 79.000 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 CYLON p .� T.31N. - R.16W. 9 •°w1Or°�-°-"'••�•r'^a"" °' Polk County 1s1.31 n.r.nnk[away needy i•a. 126.75 yy L' 2 Herbert a j Ilween 92.05 s""" 97 4 1,Y ° In.94 Nomw Reed . •... 1061s Y —a it7.N Stnl$5 � wv e4.os Ged.aMk F Whdd (.ethvt W'..ni 193 ♦ to 160 7 Wfla�en�oe$ P.".. M« xatl.leen K.o6h o xPed` Henke �aoM d. •' N Fam Tr U-w CB 16634 p M�, Vernon 0.� Kemu.k �i� TtM Group C.T. Y D Ive* yyg i 7. °" Ovi. �� B l5t 97 8 •°•"• Esdwr ' I.Th ; o.... v b Sr i kldro wM+e Y •° _ � ll.m.p.on m µ,. w °,-... 1"nw pia.n �� � w 40 Imn Sww. hlw.mrm g n. frw N Ji 114.99 °a , p ao ]Hu t20 tl IN H7$5 PARK 74sj R Arthur&Florence Moore p >a11" oL.n o° IRlnOyne Evetlson 40 140 Kati....DEER Derrick & ; des&Barbara .. . >.. 19e I.s te/heY C�oreanew.�a7�S p Cod Y kk 40 41 Om Kevin Luke& ter Waide id. l.nni 139.48 Ra..ld & Rila 120m ....u1 FIJSb 1 aos IN 5ydrw• tl°•d• G.a Sble d 1Vlm.it. DNR s0 0." ri '^'. S4ee a1elmanDared& Wboo.Yn Yvorum Kuhn 4D l.ay r.. 160 do �. DNR 160Y160 bvidey ane h a 940 Erie k Krv*1,,Sft"a°'�. Sd 7791 57922 560 . 1)SevFF. 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Serving Western Wisconsin and Eastern Minnesota Bohn Peterson (715) 246-5650 Steve Peterson (800) 657-7050 IMsomsin Department of Coinmeme PRIVATE SEWAGE SYSTEM Salaly NW BulOfnp Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) PWOO W information you provide may be used for secondary purposes (Privacy Law. a.15.04 (1Kmp TANK INFORMATION ELEVATION DATA TANK SETBACK INFORMATION PUMP/SIPHON INFORMATION Manufadtaer Demand GPM Model Nxflber H Lot Friction Loss System Head TDH —Ft Forcerain Length Dia. Clot bWON BEOrrREIICH 0111AS lSgNS VWM LengM No. Of Trartehes PIT DWENWO No. Of Pet Inside DY. Depet SETBACK INFORMATION SYSTEM TO Type Of Systam. PA- BLDG LL LAKEISTREAN LEACHINGopt C~UNIT momitagttrer. Wool Number. olsTwau'"ON 5Y5TE lB MaadMAlart%aW Dleaitiution • Hole Sao s HOW Spedng Venl to Air Intam Ptpe(y Lerio Dios Lrglh Dta Spaanq SOIL COVER . nr.a.,rr. Qv trn. ell. .. Mti.. d nr At1:r.A. Qv.trtt. Art, DoW Over Depin Over = Depth of >« SeededrSodded = MukAad Bed?rim'Kh Cantor Bed(Tronch Edpas Topsoil `J Yas L so D Yea U No COMMENTS: (Include code diaaependes, persons present. eta) Inspection et, Location: 2046 215TH AVE 1.) Alt BM Description 2.) 91dg sewer lerpth • - amount of cover Irsspedion 02: Plan refRequired? Yes YsS n. No I I I I L I J Use other er side for additional hformabon. IL_IL_JI JI _ _ J SW-6710(R.LS7) 0461 Insepctor's Signature Cart. No. Wisconsin` Sat` and Buildings St. Cix :00i�m�'j Q 2��1b W. W inylon Ave.. P.O. Box 7162 it umber (b be filled in by Co.) Department Safety and r�Qi [ Mad WI 7 6z Professional Services (02`F$Og AIL State Sa ' r � '` ppIR >< $11e Plan LD. Nustber In accord with SPS 383.21 (2) Wis. Adm. Code submission of this form to to appmpriatc amemmenW Project Address (if different than mailin a test unit is required prior to obtaining a sanitary permit. Now application forms for state-owned POW TS we submitted to the Department of Safety and Professional Services. Paso" information you provide may be used for in s000rdswe with the privacy law, s15. 1 m . Stop �O I. Application Information - Pkae Print AN Information Property Owner's New Parcel e 1 amera Belisle Illlh-IIli0.9saft''lliS� Hybl Property Owners Mailing Address �y wrp on .3I. w. Z W 6 2046 215'h AN e. oovt la _ti V 1A' K. Section 18 city, State Zip Code Plnosme Number Deer Park . WI 54007 715%2-2-5711 T 3lwR 16 w tl. Type of Reilding (cheek all that apply) Lot s s.hdivi9ion Nwne 1 or 2 Family Dwelling - Nuaba of t o Bla Block City PublidComrnerciel - Desmbe Use 7 State Owned - Describe the r -- — V inw of X Tom or , hs CSM Nu fiber III. Ty of Permit: (Check only see box oe Net A. Compktt line 8 if Applicable) A. X System Repkttn ant System ❑ Tramamwlokift Took Replaomtenl Only ❑ Other Modilkrim so f3aa4ng Systm R. ❑ Permit Renewal ❑ Permit Revision _ CMge of El permit Transfer to New LAN permitDale 4srRd Before Expirs6orm Plumber Owner N of P0WT3 Cheek all that a Xjlion -Pressurized In-Orotmd _ Pressuraad In-0toand _ Al-Ckade Mouad>24 in of suitable soil _ Maned Q4in ofamaah1c soil Flouring Tank Otter Dope" Cottponat (Mown) _Preuabnent Device V. VTramtmcut Area Ieformatioe: Design Flow (gpd) Design Soil Appliation Ratc(apth0l otspersel Area Required (s Dispersal Area Proposed (sit) 300 0.7 428.6sq.ft. 450Asq.tt. 92.08' hru 89.3' V1. Tack Info Capacity in TOW Number Martutwxurer �s4 Preisb S'ne Seed Fiber Plastic Gallons Oalbmn of Units O Carman Corotruceed Ohm l� New a Trkr TO,. .,1A� 22* Wit 1 750 750 1 Weiser Concrete X Tank �C7anea =4 VII. Responsibility, Statemewt- 1, the madersiped. wasme responsibility for Iaaalledes of tht POWTIS shown as the attached plass. Plumber's Name (Print) bees Si MPJMPRS Number Business Phone Number Loretta Larrabee MPR5 224580 71 5/661-81 S4 Plumber's Address (Street, City. Code) N2089 Count\ Road Y. Menomonie. WI 54751 VIIL Gee eat Use Only Approved ❑Disapproved Permit Fee Daft Issued Issuing Agent Sipmaeac DNmial �LOjp t MekApprovsVRasess for Disapproval I. septic tank effluent filter and dispersal cell must seniad I 41M Irtd wOrrk'f3 �nµlt. as per management plan provided by plumber. 4 trwa�ta� itar �f 4aAAyt�Q , 2. Ali setback requirements must be maintained �( as applicable codelordinanew S) J. ,A -it S k,�,n per I Awaea ewlele psn. (r. r4 GsHy *My) fir er 9ySftM r Mare ad ksn.04W Ill bean n � M SBD-6398 (R. 01103) Tames Belisle 141 SE'/.NW'/.,S18T31N/RI6W A Cylon township `, St. Croix county LEGEND , I BM : 100.0' bottom of siding of lofting shed 2BM: 100.8' top of orange paint steel post X—bacclkho^elpits .1 -- Wt1WW �\ Y No SPS 393 set back problems t Scale 1'% 40' / I r Al t 4 r r LI I project: BELESLE Site Plan 4,StSl a 6-I IV , 3.k 6* RoJ. r S yam' �LV 4 s s(,k 4o ZM MAO) ISO p'�Aa's" %51Avk, W AA.YT�' 1� .� Lion Q K page 8 o ' 10 1 1 �c N LX it, PRIVATE, ON -SITE WASTEWATER TREATMENT SYSTEM (POWTS) New construction site Index and Title Sheet OWNER: Ms. Tamera Belisle PROJECT NAME AND SYSTEM TYPE: BELISLE/ Conventional system LOCATION: Street Address 2046 215ei Ave. Legal Description SE1/4,NW1/4,S18,T31N/R16W Township/County Cylon township, St. Croix county CONTENTS: PLUMBER: Loretta Larrabee L an L Testing CREDENTIAL NUMBER: MPRS224580 page 1: title page page 2: owner's manual page 3: start up page 4: reports page 5: tank detail page 6: filter information page 7: cross section page 8: site plan Attachment: Soil Test Septic tank agreement Warrenty deed Barn floor plan SIGNED 6/ DATE: May 5, 2020 Designed pursuant to the In -Ground Absorption Component Mantal for POWTS SBD-10705-P (N.01/01� page 1 of 8 POWTS OWNER'S MANUAL MANAGEMENT PLAN OWNER Ms. Tamera Belisle POWTS MAINTAINER L an L Testing LOCAL REGULATORY AUTHORITY: St Croix County Zoning ph 715I222-5711 ph. 715/664-8184 ph. 715/38"UO DESIGN PARAMETERS Influent/effluent quality (values typical for domestic (non-commercial wastewater and septic tank effluent) fats, oil and greases (FOG)<iOmg/L, Biochemical Oxygen Demand (BOD)<220mn/L, total suspended solids (TSS)Q5Omg/L SYSTEM SPECIFICATIONS Two bedroom (300-GPD) Proposing 750gal Weiser Concrete septic tank Proposing Best effluent septic tank filter One distribution cells, 3R X 90R. with &Z Flow soil application rate 0.7gpd/f12, area required 428.6sq.8. absorption area credit 50.0 per chamber, proposed area 450.0 sq.ft (components must comply with DSPS 384 code and be installed per mamrfacturm specifications) DESIGN CRITERIA SBD-10705-P (N.OI/Ol) "In Ground soil absorption component manual" Version 2.0 MAINTENANCE MONITORMG SCHEDULE Inspect condition of tanks) at least once every year (maximum 3yrs.) Pump out contents of tanks when combined sludge and scum equals 1/3 of tank volume biPect dispersal cells) at least once every year Clean effluent filter, (septic tank) at least once every year project: BELISLE page 2 of 8 POWTS OWNER'S MANUAL MANAGEMENT PLAN OWNER: POWTS MAINTAINER: LOCAL REGULATORY AUTHORITY: Ms. Tamers Belisle L an L Testing St. Croix County Zoning ph 715/222-5711 ph. 715/664-8194 ph. 7151386-4680 DESIGN PARAMETERS Influent/effluent quality (values typical for domestic (non-commercial wastewater and septic tank effluent) fats, oil and greases (FOG)<30mg/L, Biochemical Oxygen Demand (BOD)<220mn/L, total suspended solids (TSS)250mg/L, SYSTEM SPECIFICATIONS Two bedroom (300-GPD) Proposing 750gal Weiser Concrete septic tank Proposing Best effluent septic tank filter One distribution cells, 3ft. X 90ft. with E-Z Flow soil application rate 0.7gpd/ft2, area required 428.6sq.8. absorption area credit 50.0 per chamber, proposed area 450.0 sq.ft (components must comply with DSPS 384 code and be installed per manufacturers specifications) DESIGN CRITERIA SBD-10705-P (N.01/01) "In Ground soil absorption component manual" Version 2.0 MAINTENANCE MONITORING SCHEDULE Inspect condition of tank(s) at least once every year (maximum 3yrs.) Pump out contents of tanks when combined sludge and scum equals 113 of tank volume Inspect dispersal cell(s) at least once every year Clean effluent filter, (septic tank) at least once every year project: BELISLE page 2 of 8 START UP For new construction, prior to use of the POWTS check treahnent tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septic tank pumper 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 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 napkin, condoms, cigarette butts, should not enter the system. Chemicals such as petroleum products, paints, disinfectants, pesticides, etc. should not be flushed into the system as they can seriously damage your POWTS Avoid traffic over all system components. Compaction of snow over the dispersal unit may cause it to freeze up. INSPECTIONS Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer or Septic tank pumper. Septic tank ggMW=t inspection must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks of leaks, measure the vohmte 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 >8" in diameter shall be secured with an effective locking device. When the combination of sludge or scum in any tank exceeds 1/3 or more of the tank volume, the entire contents of tank shall be removed by septic tank pumper. The outlet filta(s) shall be inspected and cleaned to remove any accumulated solids according to manufacture'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. In -Ground GravityCompgnent DiWmW Cells 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 >75% of the height of the component may indicate overloading or impending hydraulic failure necessitating more frequent monitoring. Milts[ cJegDLmSTo be done at septic tank pumping. Remove from tank, hose off filter residue in tank, reinsert filter into canister. project: BELISLE page 3 of 8 REPORTS Reports for maintenance, inspections and monitoring shall be submitted in accordance with Comm83.55 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 DSPS 383.33. 1 J All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. 2.) The contents of all tanks and pits shall be removed and properly disposed of by a servicing operator. 3.) 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: { x } 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 are will resuh in the need for a new soil and site evaluation to establish a suitable replacement area. ( } suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank maybe installed as a last resort- ) 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 located a suitable replacement area If no replacement area is available a holding tank maybe installed as a last resort. { } mound and at -grade soil absorption systems maybe reconstructed in place following removal of the biomat at the infiltrative surface. Reconstruction of such systems must comply with the rules in effect at that time. 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 UffERIOR OF A TANK MAYBE DIFFICULT OR IMPOSSIBLE. project: BELISLE pop 4 of 8 r m 4' CAST -A -SEAL P g PUMP PAD TANKS ARE MANUFACTURED TO MEET OR EXCEED ASTM C-1227 REQUIREMENTS WLP750-MR TANK SPECIFICATIONS DBIEMSIONS: o0 MALL: 2 1 f Cg BOTTOM: 3' � COVER: -V MAMHOU-- 24' I.D. PRECAST CONCRETE RISER T AT COVER 54' O.D. FLA OUTSIDE DIAMETER: 64' O.D. BELOW NILET: 42' O.D. LIQUID U:VEL: 3T WEIGHT- 6.150 LBS INLET AND OUTLET: 4' CASTT—A—SEAL BOOT OR EQUAL GASKET. CAST —A —SEAL BOOT OR EQUAL INLET AND OUTLET BAFFLE AND FILTER: YMSCON:9N, SEE DETAIL //10 (OTHER STATES SEE CHART) C 8 LIQUID CAPAC TY: 20.28 GAL/IN < HOLDING TAN1.: ACTUAL CAPACITY: 790 GALLONS OUTLET HOLE PUIOGED W LOADING DES ;N; e' O' UNSATURATED SOIL TANK CAN BE USED AS: YR M'n SEPTIC/ HOLDING/ PUMP OR SIPHON Y ODVER: MIX DESM,� NO F18ER)) A STRUCTURAL FIBER) u7 N TANK: MIX Dl:''IGN M o � CUSTOMIZED T,VaM FOR CUSIDM TANKS CONTACT WIESER CONCRETE `� 5 Go u d r F C DRAWINGS SUBMITTED " FOR APPROVAL j 1 A►MOVED BY: SHEET N0. AVPRWAL DATE: �oF p auvas MUM sY • Installation Instructions for the GF10 Filter Sup 1: Locate and wn aw the septic tank caw, on the outlet delete of tan*. Step C Gkw the AMw 00 onto dw outlet pipe. krsert the ow crtrld0! ktto tM case (Maio stale the Mar ks canpktely No to MW ;e* B T e Step L. Before InstaYtlon. place the Ntr cose on to the Outlet pipe. Mahe nee the case It paltloned so the Nter can be removed rrom the tank for ntalMa- nance and sendca Step S: For Installations that ,oq* ordeskeaddbonal R*gmt (if sdddonal support k not needed goo to step 4) Glue a section of t'Sch.40 pipe to tlw two hubs locaed on the bottom of the case and the hub located on the We of the case f ® J Slops: For Insta4tlons tt/ere n adB be dllkutt to coach the hands, pba 1'Sdwdule 40 pipe Into the Me on the halide and mend M toh ftM that wig wdm M am to remove the Ntr. 9oesOusam emmmoccvv000 a vo olj a Installation of an S"Waaal v�«bytt.lotkenk u existing system. B="=an=era " = = = = M = = M o,n � 1 Maintenance of the GF10 Filter A tine aaaw In arhkh aepk lab aw arcked k w a naeard local oodei AM wt# tMy mw be dram., meet Nr*trya/rrdo ■*Om two to ow yaws. We n.con - mW the GFsealtr be drnsdtdwn the upk tank k norrs* dared and Fm on 4 of r needed WARNING: If the liquid level in the tank is above the top of the filter, pump the tank prior to removing the filter cartridge. OCAUTION: USE RUBBER GLOVES WHEN HANDLING FILTER Soap 1: Remove tlw septic task cover and pwnp the tank It rwceswy 10 pevent any wilds Slum ntapatg M the Sold when the Mw Is wnwvd. 0 sip 2 Pull the Ntr %wK$e and side the filter out of the case. f l 1 C-A sap 7: While holding the Nw cwldge over the access openktg of the tank. rinse the co hmoa off with fresh water. like care to make sure all solid material kde balk keto tie tank J 'BEST ncHMowlav 2 F*%W &KA waMnglord Cl e6492 1417-aa49ae Far. 202-2"14 L'::':: M. step t kwrt n» wwwr back lom the case nnmkft sure that It Is propady ahwed and crnpktt* kerted Ism tha cola Place at connection observation pipe, extend 12"above grade Fabric LKUJJ bt:L I IUN - not to scale One cell aft. by 90ft. "Connect vent at end of lateral w/6" drop piece, extend vent 12" above grade 11 23ft of suitable soil Finish nish grade 963' .05'thru 89.3' System installed using E-Z Flow 1203H 9 bundles per cell = 450.Osq.ft. Bundle credit 50.0 observation/vent at end of cell attached to pipe lateral (6" pipe extended to system elevation end of cell J TOP VIEW - not to scale I E-Z Flow 1203H I 3ft. by 90ft. front of cell 10' ' \ 4" Sch 3034 observation Project: BELISLE page 7 of 8 Tamera Belisle SE'/. NW'/.,S 18T31 N/R 16W Cylon township St. Croix county LEGEND IBM: 100.0' bottom of siding of lofting shed 2BM: 100.8' wp of orange paint steel post X — bacldtoe pits - contour No SPS 393 set back Problem i Scale 1 "- 40' / r , r ;� I� l Site Plan 6-V1%, b, Ro ci 9,i` 05 PAY Ala;\ r, e' 1 6 Stb 4 ° s 4o Zrh Z65N, wZLAAN- 1U�., 4'� Yll1.�•�LL project: BELESLE page 8 of 8 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Mailing Addn Property Address -20 4 (p 2-i � (Verification required from Planning k Zoning Department for new construction.) City/State oLe4- 36 Y. , �,J L Parcel Identification Number o o (o -M39 -95 -o 15 ( 2 bcl 6) LEGAL DESCRIP"I'ION Property Location !S�-- '/4 , Nei '/4 , Sec. � � , T 3 1 I (, W, Town of �U, o t\ Subdivision Certified Survey Map 46J pkr ^) r Volume , Page # Lot # Warranty Deed # '_ I 1 H y3 (before 2007)Volume z7 b � , Page # 000 Spec hoax Oyes�o Lot lines identifiabi0yesono Improper use and maintenance of your septic system could result in its prenwhus failure to handler wastes. Proper maintenance consists of pumping out the septic tank every three years or soave, if needed, by a licensed pumper. Whet you put cab the system can attic[ the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 39332(1) and in Chapter 12 - St Croix County Sanitary Ordinance. The property owner agrees to submit to SL Croix County Planning At Zoning Department a ratification form, signed by the owner and by a master plumber, jounneyaan plumber, restricted plumber or a licensed pumper verifying that (1) the or"tc wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if naxssary), the septic tank is less than 113 full of sludge. 1/we, the undersigned have read the above requirements and agree to maintain the privde sewage disposal system with the standards ant forth, herein, as set by the Department of Safety And Professional Services and tbo Department of Natural 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 Dcpartmerrt within 30 days of the three year expiration date. 1/we certify that all statements on this form are true to the bat of my/our knowledge. 1/we am/are the owners) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Officr Number bedrooms N R SIGNATURE OF APPLICANT(S) DATE ••'My 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. M2) hi�rtaleK it•tilx:, W 1 �Mii i tillllf bar �_ ..A ii Na 1f itlr;on 6C�T9r H'iAa r' ';�LL I CIE ra�u.ir of zea- � .wr- >irlr�k .tea• aR" a Gib-: .inrlCrf� _ � er:.alawrsrf r. ta: r. 4Arr*iri�i6Fx ry �, G■■iVrrlf Orr fi -, � �riiiiLlillllCue` "i �■ rp���\iggf7�ie. �fiEifi r . luiiei�iierfnt<a■L a tun Ic 1!lilafl' • 1 quU dn'ili: t,t�=1�0xfR.3N.RI 9C,. KY .T. Ag xaV ssD•14 fral I:4lf�Y4llxlL __.le�!#SiO�i �'.� IreAlr. E ii�1l■�i��l' i Somalia iio■t�". orbYlrlll* ainr. aW ;ram r } il�i�<.- ■itMGl• 9Y .: 7 f!S iploom,'lp6M .. . idler awls,. irl veri■tcgl L F ■■■ills•. r ilil/lw-, . ii.. ;Wwmowpvw 6lIOAa' TOM r vµ ad9Lt" ■ .waft �., r lx��r n4�rrr. ,�. iiic�� p ra■ fl :. Parcel #: 006-1039-9"75 Valid as of 05/19/2020 11:51 AM AIL Parcel *:18.31.16.269B TOWN OF CYLON ST. CROIX COUNTY, WISCONSIN Owner and Meiling Address: Co-Owner(a): DOUGLAS & TAMERA TR BELISLE 2046 215TH AVE Physical property DEER PARK WI 54007 Address(es): 2046 215TH AVE DisMcts: Dlsv Deawplon Parcel mom: 0119 ISCH DIST OF AMERY Dam Dos# Vdy a Type 1700 WITC _ 12/0212004 78/443 2707/093 OC 8020 1 UPPER WILLOW REHAB DIST 05/13/2003 721258 223MM OC 05/13/2003 721259 fi=dfi 223WS53 15531243 OC C1LC Abbreviated Description: Acres: 24.030 10/24=W SEC 18 T31 N R16W PT SE NW THEE 793 FT OF SE NW Pig Treat (8-T-1140541601A OL) SladdCaWo 111ft • N/A -NOT AVAILABLE 18-31 N-16W SE NW 2020 Valuations: CIs" r4 Dpa"M Asp Lend Values Last Changed on O6/2512018 YwprowsMrn TOW GI -RESIDENTIAL 1 4.0001 30,000.001 209,4W.00 1 239,400.00 G5-UNDEVELOPED 1 20.0301 20,000.001 0.00j 20,000.00 Totaim for 2M General Property 1 24.030 50,000.001 209,4W.001 259.400.00 Woodland 1 0.000 0-001 0.001 0.00 TOWS for 2010 General Property 1 24.0301 50,000.001 209,400.00 1 259,400.00 Woodland 1 0.0001 0.001 0.001 0.00 2020 Taxes Taxes have not yet been calculated. Key •. Primary MAY 08 2020 65T-2ozo- 066 Wls.Dept ofSsk*" SOIL EVALUATION REPORT .0() Pop 1 ot 3 . ■ w• wwwwVP W w•Ir �p Jp.-!, rw�. I{IIR lrWr Adadl rof`kit tlIM18 1/! x 11 trxhn n size. Wul must ndide, lo: m*A and ha tmW mkrwm poke (EPA), drection and perewn dope, sale or darwows, rwlh wrow, and loatan wld 6etwl0e to nearest road. P/Np Pihr! ON k8fomadon. Pweoeer Ylloreleeoll tW pi4l0e" be used for wWwWfy po4oa (Pon7 Lew, a 15.04 (1) (1")). IA P. LD. co/� - (U al -9 S `bY Dala Prop" CMNWProperty I i S l-Dalian CioM lot _�E 114 NVIA S 16 T 31 N 110 k(wo Propft oa rrt Ma64 Address ;ko4 tp L15''- - e. Lot* - Slodr s Subd. Nwrla a CSNe - Ulf NUM ZIPCock N"rbw O e: �a.k 'l 54W .-7IS ZZZ-5•lll O City ElVillette own Now Road C �s file. New Calatrudian Lhw: ® ResidwMiel / Number of', iZ, Code derhsd desipn tow role CCU GPD Repfaownwu ❑ Pubie Dsevbe: ^-� Parent nfalwlel Rood Ploh atva0on it spoloi le Garleral , and c •r 1 �� f Borhp tr,,,4 a i Pit Groud o rlam etv. y (o.3 1l OR,* b knov todor ( 2-0 lr, s Sli L Sol Rob tWine Depth frr. Doi, I wll Cdw Lkrlow Radaa Desolptmf Du Sz. Cont. Color Tbnine Structure Or. SL Sh. Root 1 -% 3 �/ , 7 — 3 o nn tr t #�-OWW2-' of� I "ef 4�0 a• . 9•h or Pit Ground omen elev. _ C{ 5, `i Il Depth to 6n sting from ( Z l i> Sol Apvbcmkn Rat llalzan Depth K Da, iw. Color Murod Radon Deeviplkn DILL Sr_ Cont. Wor Tazlua S1na Mrs Gr. Sz. Sh bormisliwoo 6wWwy Root GPDII 1otm L Ip lk 3/I A. c r S � . so 9�.d 31•s7 >??.t c n.t t • Etlusre ar • t100 > 30 1220 mWL wd TSS >V 1150 nV& • Etllsra 02 BOD < 30 nlpll and TSS < —+ 30 mpiL CST Nn w lPkaee P1Numberhro gly m CST Number * MS \.t av ` l&rt Rta ee— CSTM Address Gab EvakrYon Co dudad Tdephow timber %1c �,-lL sl,sl d3 •-to.L6 kLt 1114A "o) <RmLriYl IN 11/I 11 C • Oh Property Oww XT•. Pc.. Paroal D oob - IC 39- Q 5- o `75 Zby fb, Papa er L LEIBaring a ❑ Boring 00 Pit Ground surface elev. q 5. 3 R Depth to kn&V factor ZS In. — r , ®� _m-w Y _��.a -m��i.mwmm__�In"]bm-_ _ ❑ �gr'�w.�a5`�a.ca�rco an.�v.raa..��� ��rls Ip� n oi. Gmune ...I.o..r„ . n..,r. rn M.Yb.n r.,..., i. © Err*-#- Cm � ... �_ El Borings ❑ B"V ❑ pit Ground eurface elev. R. Uepth a tnrairg factor n. . yiri='.i.Ls Etliierit •1 BM r > 30 1220 mplL and TSS.>30 < 150 mp0. ' Efkxnt Y2 - BOD < 30 rnp1L and TSS 130 nV& The Dept. of Safety and Professional Services is an equal opportunity service provider and employer. If you need auistanee to access smim or need material in an alternate formal, contact the department at 603-266-3151 or TTY through Relay. ceu•Waamin 0� _ 1 Properly Owner ^ er c, r 1 i 4 Parch IDS 006 - LD 39- Si 5- 0'75 Z �13� Page �L of _y�L Borirp Borrlq a_ � Pit COMM surface elev. 95. 3 R Depth to Mr*M hlior—> L� In. CN ' •' - OJT ®�� •• • .� • . ®®�VY.•�iYi.t• ® U • • M��MM II • 1O = imw�®m�10 .� r II •_ I1M.MMM® �•_ f'1 �pL�'^��i��� VLL D. �(>t /Y��L SMZf Pit Grand surface elev. fL Deph to tirri6rlp famr r, sal t� Ho izorj . Qepth . Dux *W* Cabr Redox Deco iptlan Texlue Strtxfiae Rode f3PQ11 ' In.. Muinsel Qu. Sz. Cont. Cojm Gr. Sz Sh. tol •w ■ ' Elluant #1 = SOD • > 30 < 220 n9l and TSS•>30 < 150 mg& ' Etltuert n = SOD �5 30 mg& and TSS < 30 m9k The Dept. ol'Safcty, and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. S804" I• I VI I I ' Elluant #1 = SOD • > 30 < 220 n9l and TSS•>30 < 150 mg& ' Etltuert n = SOD �5 30 mg& and TSS < 30 m9k The Dept. ol'Safcty, and Professional Services is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, contact the department at 608-266-3151 or TTY through Relay. S804" I• I VI I I Tames Belisle 1N�1 SE'/. NW'/.,S 18T31 N/R16W Cylon township St. Croix county \� netts Larrabee CSTM 22458�{r LEGEND i 1� : M& bottom of siding of lofting shed i 2BM: 100.8'topoforange Xt steel post f backhoe pits - contour No SPS 383 set back problems Scale 1'% 40' r Soil Evaluation Site Plan F � � I 4 1 ■ Surface Water Data Viewer Map 110 Legend FIRM Panels Flood Hazard Boundaries awt. UNIN Lk" AM of UndnownW*d nocd mum Hazard 'r i it IdentificationsWedwid • ns I Welland Class Points 0.1 0 0.03 0.1 Mies DW AAER The I Amp wOm sl o on eew mop nee been obderd aom vabrw eaeras. aIM are el raryYiO eqa, rasab�y aM rateailen. Tlrr mtp am m brr�Ate Mae uee to n.NywaWa ae Ueae MWS en a.aomeW abma MO WW awrr I er plse sore► No v No ammaae a , I d is meet niwma soom ey. NAD_IM3_HARN_Waconsin TM 1: �,980 spowbely fora ebsaiar ue. mniebbWeH, or bpft of M I ft w to 0epcbe eW 9* np. For mad bieremft aaa M D t lapl Noeost ae! qpe: hapntre.w0e'raopW WeeeWi m amr ID deaneab Filled Points Wetland Class Areas ❑ Weeend upland Q Filled Areas Notes Tammy Belisle property 2046 215th Ave. Deer Park. WI