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042-1102-50-100
Wisconsin Depy.rtment of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety cjid Building Division INSPECTION REPORT sanitary Permit No: 121 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: Mansell, David I Warren, Town of 042 - 1102 -50 -100 CST BM Elev: r77 BM Description: Section/Town /Range /Map No: 36.29.18.267a10 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing X` ` /\ Alt. BM e O J./ Bldg. Se er -7 79 qZ Holdi St/Ht Inlet /0-6 9� TANK SETBACK INFORMATION St/Ht Outlet /G.'7� 1dD� '� 9 • 4 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 Co er L + GPM S c. 7 • , Model Number W NGt� Z TDH Lift Friction Loss Sys ead TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM BEDITRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO (L BLDG WELL LAKE /STREAM LEAQJING Manufacturer: INFORMATION — CHAMBER Type Of System: U, 3S1 UNIT Model Num b)�- DISTRIBUTION SYSTEM Header /Manifold Distribution �— --_� x Hole Size y x Hole Spacing Vent to Air Intake Length is Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over IDepth Over Ixx Depth of xx Seeded /Sodded xMulched Bed/Trench Center Bed/T E dges__ — psoi -- - -' -- -- s No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: ! / Location: 609 140th Avenue Roberts, WI 54023 (SW 1/4 SW 1/4 36 T29N R118W) NA Lot 1 r� ACA-.J , , / Par \ o: 36.29.18.267a10 1.) Alt BM Description = I ' tiJ� `_''� /j �EIC,..��'/J O / 2.) Bldg sewer length = Z I A)Q.K 1O `.. � 1'�Ow� JL4 45 CAS - amount of cover = 1 7 2 Plan revision Required? Yes No Use other side for additional information. E 4� Date Insep or's Sig ure Cert. No. SBD -6710 (R.3/97) le rl;9 Sanitary Permit Application ST. CROIX COUNTY WISCONSIN In accord with Chapert 12 St. Croix County Sanitary Ordinance PLANNING & ZONING DEPARTMENT f� Personal information you provide may be used for secondary purposes ST. CROIX COUNTY GOVERNMENT CENTER 0 rf [Privacy Law. S. 15.04(1)(m)] 1101 Carmichael Road Hudson, WI 54016 -7710 715)386 -4680 Fax (715)386 -4686 Attach complete plans for the system on paper not less than B -1/2 x 11 inches in size. County Sanitary Per J# ❑ ck if revision to previous application C I. Application I - Please Print all Information Location: Property Owner Name D �� yt S (--� 1 /4 S � 1 /4, Sec (p D M OCT aJ N, R 1a Property Owner's Mailing Address Lot Numb r Block Number o (? 0 7 1 10 ST. CROIX COUtVTY City, State Zip Code Subdivision Name o CSM Number �� c ��da- , T7 iS - Q - 361 ��' ✓ / I L3 3,43 II Type of Building: (check one) � , Mity El Village own of 1 or 2 Family Dwelling - No. of BedroorOs:, _ 1� a/ l: J 1 / ?J / U " , "�'� ❑ Public /Commercial (describe use): /ZOT �yt�C> q/1A ❑ State -owned 1T 0. _T ma Nearest Road I.Type of Permit: (Check only one box on line A. ChUck box on line B if applicable) (Do 0 ,- . Parcel Tax Number(s) A) 1.0 Repair 2.� Reconnection ❑Non- plumbing 4. ❑ Rejuvenation 0,q Z _ 0 —SQ / Sanitation , G(p I 0 g) Permit Number / Date Issued IF State Sanitary Permit was previously issued f 0 10 j q98 IV. Type of POWT System: (Check all that apply) ❑ Non - pressurized In- ground I, Mound z 24 in. suitable soil ❑ Mound :5 24 in. suitable soil ❑ Mound A +0 ❑ Sand Filter ❑ Constructed Wetland ❑ Peat Filter ❑ Drip Line ❑ Pressurized In- ground ❑ Holding Tank ❑ Single Pass ❑ Other a At -grade ❑ A robic Treatment UniV ❑ Recirculati . Dispersal /Treatment Area Informatio U` - 1. Design Flow (gpd) 2. Dispersal Area 3. Dispersal Area *Soil A lication Rate S. Percolatio to 6. System Elevation 7. Final Grade Required Proposed (Gals. /day /sq.ft.) (Min. /inch) _ Elevation VI. Tank Information Capaicty in Gallons Total # of Manufacturer Prefab Site Con- Steel Fiber- Plastic New Existing Gallons Tanks Concrete strutted glass Tanks Tanks 5 1000 G-1 ❑ ❑ ❑ �---- O crs�t e•�r (,S.��z + K El 11 11 0 11. Responsibility Statement - 1 the undersigned, assume responsibility for repair /rec nnenction /rejuvenatio, i f non aIIat- plumbing the POWTS sh non the attached plans. A license is not required for terralift repair or the installation of non - plumbing sanitation system. Plumber's Name (print) Plumber's Signature (nos mps�: MP /MPRS No. Business Phone Number 3��,ia Plumber's Address (Street, City, State, Zip Code) 96� VIII. Count Use Only Disapproved Sanitary Permit Fee Date Is ued wing ent Signat (No stamps) Approved Owner Given Initial Adverse Determination IX. Conditions of Approval /Reasons for Disapproval: �, �� SYSTEM OWNER: �— 0 1 Septic tank, effluent filter and 7,bp,� 'Lv - YLp , dispersal cell must all be serviced / maintained Q as per management plan provided by plumber. r. 7 Jr4Z'T�r , 2. All setback requirements must be main at e r as per applicable code /ordinances. � 0k G( 7�?.�� �NGG vw �'J Al fj " rrt. MA,,�. T t�09 1Na 'tA sT' 0 3 St , � 3 S� 9 y5 ,5 PC. f �, Sh 4 S T 3, A U , o r > K Z z y m C O m %t7 • - n 0 :::i Q X lo" m -� r rV X No d U) C/) x �� O w *S4 0 10 w - o v , m m � O C 3: O cn o vo w r z o c m >Q O X r C 0 i Q --� c D r z = Cl) G)m Z o m n ;u m x Q z> z 0 C z o —I r &5 'v N C U) c 0 v C/) z G) J C7 i z m o cn zz zz) m Q O —'� —• m m x °vim m=° ma 3 B31 3 EF �mv v �a� �`v = o , m o m m n d D �' ' - ' y , � °m ID 10 om o m r -� = C p � (D 7 C = (D - 0 CD �1 O =r m OM � Cl N N p m O `� v N (D �o v�(b -c ° ° 3 -m c7 n w o 3 3 x' x ^ w m to O m = 0 (D n D o m � (D , m o m °n a ^ (0 1Q rT °— v w 3 to w D w m (D < r g or pN (D to v m m Q a o a CD = ° m m °' ° ` n m' ° °—' m O n CD � �c ° v 3� n o'o m (0 :? C D o ° m v m ' m w (p I Z r Z o j o. > > o m o to Z C m U) �M gym° =3 �� D DK o m - m a m a n ' m m n Co 1 D D o m m c o a o O O G) O ;U - v m m - 3 E m= 0 ° 6 m c m S 0 m _ m (D N N m m = ❑ ❑ ❑ 0 Q 7 J 0 CD _ POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page / of FILE INFORMATION SYSTEM SPECIFICATIONS Owner OLq �Q Septic Tank Capacity /000 gal ❑ NA Permit # S O/ 2 Septic Tank Manufacturer ❑ NA DESIGN PARAMETERS fluent Filter Manufacturer ❑ NA Number of Bedrooms ❑ NA Effluent Filter Model 8 L ❑ NA Number of Public Facility Units DENA Pump Tank Capacity la p © a l ❑ NA Estimated flow (average) al /day Pump Tank Manufacturer (,� °° ❑ NA Design flow (peak), (Estimated x 1.5) �j'D gal /day Pump Manufacturer ❑ NA Soil Application Rate al /day /ftz Pump Model ❑ NA Standard Influent /Effluent Quality Monthly average* Pretreatment Unit KNA Fats, Oil & Grease (FOG) 530 mg /L ❑ Sand /Gravel Filter ❑ Peat Filter Biochemical Oxygen Demand (B0D :5220 mg /L ❑ NA ❑ Mechanical Aeration ❑ Wetland Total Suspended Solids (TSS) :5150 mg /L ❑ Disinfection ❑ Other: Pretreated Effluent Quality Monthly average Dispersal Cell(s) ❑ NA Biochemical Oxygen Demand (BOD 530 mg /L ❑ In- Ground (gravity) ❑ In- Ground (pressurized) Total Suspended Solids (TSS) 530 mg /L 044A ❑ At -Grade $( Mound Fecal Coliform (geometric mean) :510 u /100ml ❑ Drip -Line ❑ Other: Maximum Effluent Particle Size Y in dia. ❑ NA Other: ® NA Other: ❑ NA Other: 10 NA *Values typical for domestic wastewater and septic tank effluent. Other: 0 NA MAINTENANCE SCHEDULE Service Event Service Frequency Inspect condition of tank(s) At least once every: 0 month(s) (Maximum 3 years) ❑ NA Pump out contents of tank(s) When combined sludge and scum equals one -third (Y of tank volume ❑ NA Inspect dispersal cell(s) At least once every: ❑ month(s) (Maximum 3 years) 13 NA j I- year(s) Clean effluent filter At least once every: 11 month(s) an wR.... ' �' year(s) ❑ NA Inspect pump, pump controls & alarm At least once every: CI month ®' ye() ars 1 ❑ NA Flush laterals and pressure test At least once every: 13 month(s) ❑ NA OF year(s) Other: At least once every: 13 month(s) ❑ NA ❑ year(s) Other: ❑ NA MAINTENANCE INSTRUCTIONS Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master Plumber; Master Plumber Restricted Sewer; POWTS Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one -third (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 filters, mechanical or pressurized components, pretreatment units, and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 10 days of completion of any service event. GMW (4/01) Page 2 of 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 cell(s). If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cell(s) in one large dose, overloading the cell(s) and may result in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at -grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) water; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener brine. ABANDONMENT When the POWTS fails and /or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. • After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: • A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at that time. • A suitable replacement area is not available due to setback and /or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. • The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. Mound and at -grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. < <WARNING> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND /OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name UJA.L-Tt_V- _ I- /1/jf.(,:11 Name Phone - 7/ S— 7 — 3 3 2'i Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name Name Phone Phone 7 (5- This document was drafted in compliance with chapter Comm 83.22(2)(b)(1)(d)&(f) and 83.5411), (2) & (3), Wisconsin Administrative Code. 1 Parcel #: 042 - 1102 -50 -100 10/08/2007 04:11 PM PAGE I Alt. Parcel #: 3629A8.567A -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): O = Current Owner, C = Current Co -Owner O - MANSELL, DAVID & KELLY JO DAVID & KELLY JO MANSELL 609 140TH ST ROBERTS WI 54023 Districts: SC = School SP = Special Property Address(es): ' = Primary Type Dist # Description * 609 140TH ST SC 2422 ST CROIX CENTRAL SP 1700 WITC Legal Description: Acres: 5.448 Plat: 3303 -CSM 12 -3303 SEC 36 T29N R18W PT SW SW BEING LOT 1 Block/Condo Bldg: LOT 1 CSM 12/3303 Tract(s): (Sec- Twn -Rng 401/4 1601/4) 36- 29N -18W Notes: Parcel History: Date Doc # Vol /Page Type 11/15/2004 779905 2695/311 WD 11/20/1997 568781 1278/077 WD 07/23/1997 721/220 07/23/1997 389/312 2007 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 05/31/2006 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.448 60,000 195,500 255,500 NO Totals for 2007: General Property 5.448 60,000 195,500 255,500 Woodland 0.000 0 0 Totals for 2006: General Property 5.448 60,000 195,500 255,500 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: Batch #: 314 Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 .. ._. _ n U) o ■ 2 0 c � k � ) \ _■ X z/ z / e< » m 2 Q �• 0 E k «§ Q M _ \ [ ƒ n - f ) f § 2 \ / k k \ ] CD a / 0 / § § ) S ƒ ; m - $ ! 3 $ m O I ® E E\ a\ k / ƒ 2 S CD / / E % \ } \ _ - / io o \ § 7 ° C ® $2 / k_ § g E a OD � § I 2\ 0 0 0 /. §/ / f j j j/ f§ § k R o v q I Ln � § \ ) Cl) / C) 0 3 � k � \ { .. oa ƒ(f § \ / _ . � I / Oro I a { C z _ a R - � ■ � / § $ I 0 � -0 \ § m 0 k $ 7 § \ \ .. z $ w I k 0 § � -n / % C 5 IF � § � \ � \ I $ � 2 I % I � 0 / _ o t CD [ / • Y � NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW t 135 6 r / a yD sco i INDICATE NORTH ARROW ST. CROIX COUNTY ZONING DEPARTMEN AS BUILT SANITARY REPORT / R EC EIVED Owner r� , o� ?�t° SE 3 Q 1998 Address sr caolx City /Stat s COUNTY :✓�r '� — ZONiNOOFRCE S Legal Description: Z Lot _� Block Subdivision/CSM # See—, L, T',-25_�N -Ra W, Town of i JWeZAI PIN SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer P Size ST/PC /�/ Setback from: House /�_ Well P/L �� Pump manufacturer Model / Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM Type of system: /IJAv,,1n Width _6 Length Number of Trenches Setback from: House -Y— Weil P/L _ Vent to fresh air intake ELEVATIONS Description of benchmark Elevation _ /M. Description of alternate benchmark Elevation 16z.?3 Building Sewer ST/HT Inlet 9o, i ST Outlet- ;g9; ,gl PC Inlet 6� PC Bottom _ Header/Manifold 9? _f Top of ST/PC Manhole Cover Distribution Lines () 22 ,2 () ( ) Bottom of System( ) <Zg,S () ( ) Final Grade ( ) 9 7 3 ( ) ( ) Date of installation ermit�nu er State plan number Plumber's signature License number 5/?l Date i Inspector ('ompictc plot plan � Wisconsin Department of Commerce SEWAGE SYSTEM Safety"and Buildings Division PRIVATE Count tT . CROIX INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) SanitarjjeSrgt.: Personal information you provice may be used for secondary purposes [Privacy Lq s.15. (1)(m)]. _PW E1Qjc rSNam 4)� *illage []Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: dO t oa r-• I w S+OJ t TANK INFORMATION ELEVATION DATA A9800294 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. S ti tv •t2_A 4000 Bench �•� ( 'D 3- 4ao 2 --I ZJ 400,2 Aeration Bldg. Sewer /0? 23 I I ( may , ? Holding t E Inlet 1 34 1 71 0 f 710 - 3 TANK SETBACK INFORMATION Outlet �Z �1 -v TANK TO P/ L WELL BLDG. vent o t ROAD Dt Inlet `3 7 l • ��/ Air Intake ptic s (� ✓ C4 NA Dt Bottom 17, �� • Q osin S j� ��j ZG) NA Header /Man. 01 -2S R5 Aeration NA Dist. Pipe !�3•ZS °D 9 f . �-- Holding Bot. System /a3,2 -&G 12 . 5f PUMP/ SIPHON INFORMATION l Final Grade Manufacturer man Ded 1 03.2 --? oc,fcCS S� ����� /r•gr 47i- Z Model Number 7j 1 ?j GPM q 1 1 - 7 1 4 S 3 - /03-2 / eD TDH Lift �j, Friction Z System ZS TDHr t Lwvlr�- 2'�� /03.2 (OO. 8 V ead Forcemain Length Dia. H Dist. To Well 1 1 03.731 Z •3f' /ob•2Y SOIL ABSORPTION SYSTEM ENCH Width Length / No. Of Trenches PIT No. Of P Inside Dia. id Depth DIMENSIONS �� DIMENSION SETBACK SYSTEM TO P/ L LD WELL LAKE/STREAM LEA RING Manufacturer: INFORMATION Type of i t CHA R Moe Number: System I Ao 13 OR UNIT DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length _.� Dia. Z Length _4Q Dia. 1_4� 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 (Fj Bed/ Trench Edges (Z f Topsoil 6 ,Yes ❑ No Fj Yes E] No COMMENTS: (Include code discrepancies, persons present, etc.) G. 3 - �� 0on �c ? /jry LOCATION: WARREN 36.29.18,SW,SW 609 140TH AVENUE 5ewZA -kv" l l loc l x s�(wko�. Plan revision required? []Yes ,fit No Use other side for additional information. 10 SBD -6710 (R.3/97) Date Inspecto s Signature No: ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: I * sconsi n Safety and Buildings Division SANITARY PERMIT APPLICATION 200 Box796 ngtonAve: Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less county than 8 1/2 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number an � The information you provide may be used by other government agency programs ❑ Check i revision evision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Prope y Owner NarTle Property Location va pt ) 1 /4, S T , N, R l (orM/ Prop rtyy Owners M iling gddres Lot Number Block Nu ber C% pt ,'mot' Zip C0 Phone Number Subdivision Name or CSM Number IUTYPE OF BUILDING: (check one) ❑ State Owned ❑ It Nearest oad ❑ Village Public N 1 or 2 Family Dwelling No. of bedrooms a Lown OF 14),-iLZkZA1 III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(,) 1 ❑ Apartment/ Condo 1 Li'3 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 box on line A. Check box on line B, if applicable) A) 1. ,® 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 Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 J4 Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 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 -' ch) Elevation 7 ,•C, Feet Feet Cap VII. I NFORMATION in gallons Total # of Manufacturer's Name Prefab. Con- steel Fiber- Plastic Exper. New Existin Gallons Tanks Concrete strutted glass App. Tanks Tanks Septic Tank or Molding Tank �7 ❑ El ❑ 1:1 Lift Pump Tank /Siphon Chamber 0 ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for inst ation of the onsite sewage system shown on the attached plans. Plum , r' Name Pri f ' Plumbe s Si Zr95"mps) MP /MPRSW No.: Business Phone Number: C � Plumber's hcTdress (Strqpt Cit , State, Zip C e): IX. COUNTY / DEPARTMEN USE ONLY ❑Disapproved Mary Permit Fee (Includ Groundwater ate Issued Issuing A nt Si ature (No S ps Approved ❑ Owner Given Initial l�� Surcharge Fee) Adverse Determination �—� X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL' SBD-6M (R t tom) DISTRIBUTION: Ork_&W to County. One copy To: Safety & Buildings Division, Owner, Plumber I INSTRUCTIONS ' 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a 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 and Buildings Division, 608- 266 -3151. To be complete and accurate this sanitary permit application must include: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. n stem type. k appropriate box depending o s V. Type of system. Check y yp VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /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. VIII. 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 8 112 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 contamination investigations and establishment of standards. Safety and Buildings 15837 USH 63 HAYWARD WI 54843 -8107 ' \Visconsin Tommy G. Thompson, Governor Depart of Commerce William J. McCoshen, Secretary July 09, 1998 CUST ID No.224263 KIM A O'CONNELL 504 3RD AVE OSCEOLA WI 54020 RE: CONDITIONAL APPROVAL APPROVAL EXPIRES: 07/09/2000 TdentificatianNutnbers Transaction ID No. 102849 Site ID No. 13132 SITE: Please refer to both identifie t on nut ; Site ID: 13132 above, ip, all correspq deuce w1, the agency. ST CROIX County, Town of WARREN SWIA, SWIA, S36, T29N, R18W JEFF MUNDINGER RES SEPTIC SYSTEM FOR: Description: NEW MOUND Object Type: POWT System Regulated Object ID No.: 27517 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. This plan approval is for a 450gpd mound. The following conditions shall be met during construction or installation and prior to occupancy or use: • This plan action is subject to designer comments on the plan • Correspondence Note: • Per Comm. 83.23(3)(b)2, the area 25 feet below the downslope edge of the soil absorption system must remain undisturbed. P O N • The orientation of the mound system must be such that the mound's longest dimension is perpendicular to the Condit of maximum slope. A copy of the approved plans, specifications and this letter shall be on -site during construction and open to APPR inspection by authorized representatives of the Department, which may include local inspectors. All permits DEP RTMENTI required by the state or the local municipality shall be obtained prior to commencement of DIVIPIgh OF SAFEI construction/installation /operation. G Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address SEE CORRE on this letter d. Sincerely, DATE RECEIVED 06/26/1998 FEE REQUIRED $ 180.00 TO B UN , LAN REVIEWER FEE RECEIVED $ 180.00 Integrated Services BALANCE DUE $ 0.00 (715)634-3026, M - F 7:45 AM TO 4:30 PM TBRAUN @COMMERCE. STATE. WLUS RESIDENTIAL MOUND DESIGN INDEX AND TITLE SHEET Project JEFF MUNDINGER Owner JEFF MUNDINGER Address 609 60TH AVE ROBERTS WI 54023 Legal Description SW -SW 36- T29N -R18W Township WARREN County ST. CROIX Subdivision Name CSM 5627 Lot No. 1 Parcel ID Number Plan ID Number 102849 I.T.S. INDEX SHEET PAGE ONE tonally MOUND CALCULATIONS PAGE TWO OVED MOUND DRAWINGS PAGE THREE -F COMMERCE PRES. DIST. CALCS. & LATERALS PAGE FOUR N UILDINCS PUMP TANK DRAWINGS PAGE FIVE PUMP CURVE PAGE SIX PLOT PLAN PAGE SEVEN 3PONDENCE Designer KIM A OC NNELL License Number Signature-,- , , Phone No. 715 - 755 -3145 Date 6 -21 -98 Notice: Tampering with this Hie by unauthorized persons is prohibited. Deliberate modification viii result in disciplinary action under s. 145.10, Wis. Stats. SBD- 10482E (R.04197) Pagel of 7 i RESIDENTIAL MOUND DESIGN Eight Bedroom Maximum Complete information in red framed boxes as necessary. (y or n) n Is the s rstem over creviced bedrock? Slope 5 % Number of bedrooms 3 Wastewater flow rate F_ 121�jin gpd 1703.3 Lpd Depth to limiting factor 66.0 cm In situ soil infiltration rate (code) 1 0.5 lgww 20.4 Um I Contour line below the upslope edge of absorption cell EK ft 29.69 m Use standard fill depths? x OR Designer speed depth I _ in �� cm Place X In boor to use standard depths (1$ 24, A+4 Inclusive) OR specify design fill depth. C enter or end manifold e (c or e) Estimated hole space 5 ft Not a final calculation Lateral spacing 3 ft Minimum dose >= 10 times void volume Use a o lateral spacing for trenches. Pump tank elevation 84.4 ft Outside bottom of tank Number of laterals 2 Force main diameter 2 in Force main length 80 ft Force main actual dia. 1 2.067 lin SYSTEM SOLUTIONS Inch- pounds Metric Cell media "x" One only. Estimated daily flow ®gpd 1703 Lpd x Aggregate and pipe Chamber and pipe Absorption cell Design load rate & area 1.2 gVW 375.0 fe 34.84 m Linear load rate 7.1 gpd/ft 88.0 Lpd /m Design width (A) 6 ft 1.83 m Cell length (B) 63.0 ft 1920 . m Depth of cell (F) 9.9 in 25.1 cm Sand filter Upslope fill depth (D) 12.0 in 30.5 cm Downslope fill depth (E) 15.6 in 39.6 cm Basal area required (gpd/infiltration rate) 900 ft 83.61 m Supporting components Topsoil depth 6.0 in 15.2 cm Subsoil depth at center 12.0 in 30.4 cm Subsoil depth at cell wall 6.0 in 15.2 cm End slope toe length (K) 10.4 ft 3.17 m Upslope toe length (J) 7.4 ft 2.26 m Downslope toe length (1) 11.0 ft 3.35 m Total mound length (L) 83.8 ft 25.54 m Total mound width (W) 24.4 ft 7.44 m Project: JEFF MUNDINGER Plan I.D. 102849 Page 2 of 7 MOUND PLAN VIEW observation pipes (typical) J W= 24.4ft A A= 6.Oft 1.83m 7.44m — O — B= 63ft 19.2m B - ____ __ K J= 7.4 ft 2.26m I 1 = .0 ft 3.35m y; K = 10.4 ft 3.17 m L = 83.8 ft 25.5 m typ. obS. pipe A X B refers to absorption cell width and length (anchored securely) J = upslope width I = dowrislope width K = end slope dimension 6, (150 mm) MOUND CROSS SECTION T subsoil cap D = 12.0 in 30.5 cm lateral topsoil G H E = 15.6 in 39.6 cm invert 98.9 ft _ F = 9.9 in 25.1 cm elev. 130.14 m see note F G = 12.0 in 30.4 cm H= 18.0in 45.6 cm D E ASTM C33 Sys. F 9 - 41 ft Sand Fill elev. 29.99 m 97.4 ft contour 5% 29.69 m slope Note: Absorption cell media will D = upslope fill depth plowed layer consist of aggregate and pipe E = dowrislope fill depth or leaching chambers and pipe F = absorption cell depth as specified eAggregate G = subsoil + topsoil depth at cell wall at right. Chamber H = subsoil + topsoil depth at cell center Designer notes: If aggregate is used, it is covered with code compliant material. Project: JEFF MUNDINGER Plan I. D. ### Page 3 of 7 PRESSURE DISTRIBUTION CALCULATIONS Absorption cell Inch- pounds Metric Width (A) 6 ft 1.83 Im Length (B) 63.0 ft 1 19.2 m Lateral specifications Number laterals 2 Holes/lateral 13 holes Lateral length 60.0 ft 18.3 m Perforation dia. 0.25 in 6.4 mm Lat. dis. rate 15.15 gpm 1.0 Us Sys. dis. rate 30.30 gpm 1.9 us Hole spacing 60 in 152.4 cm Lateral diameter Pipe diameter Design option= De=ign choice Designer must 1 in25 mm _ Place X in red "Xe one choice 1 1 /4inr32 mm box of chosen from the options 1 1 ran/4o mm X x diameter. provided. 2!in50 mm X 3inf75 mm I X Manifold diameter Pipe diameter Design options Design choice Designer must 1 in25 mm NX" one choice 1 1/4nr32 mm Place X in red from the options 1 1 an/40 mm x box of chosen provided. 2in50 mm x x diamete 3in175 mm I X 4n/100 mm I X Distribution system contains 2 lateral(s). LATERAL DIAGRAM - END CONNECTION Place correct lateral diagram by clicking in one of the drawings at tight and dragging the diagram into this area. Laterals oentere over the &rnenston Last hole dt ed nextto e�iiaR P AM laterals are idenlri" If- x —jl Holes drilled on the bottom of the lateral equally spaced S • Force main connection Via tee or cross to mankid at aN point. Laterals & force main of PVC sch 40 • = permanent end marker (per COMM Table 84.30 -5) Inch-pounds Metric Lateral length (P) 60.0 ft 18.29 m Lateral spacing (S) 3 ft 0.91 m Manifold length 3 ft 0.91 m Hole diameter 0.25 in 6.35 mm Lateral diameter 1.5 in 40 mm Number of holes per pipe 13 Invert elevation of laterals 98.9 I ft 30.05 m Project: JEFF MUNDINGER Plan I.D. 102849 Page 4 of 7 Total dynamic head ! K �l = I • zr°�l oa� System head = 3.25 ft 0.99 m j o O o k= tie 8 Vertical lift = 13.60 ft 4.15 m Are laterals the �tgFj5oirk in the �• Friction loss = 1.26 ft Z 13 0.38 m system? Yes "x' here. L� Total dynamic head = 18.11 F If no, what is the highest elevation Dose Volume downstream of pump? Lateral void volume = 12.7 gal 48.1 L Force main drain Minimum dose = 127.0 gal 480.7 L back to tank? ( ")e' one) Drain back = 13.9 gal 52.6 L x Yes Dose volume = 140.9 gal 533.4 L No Typical Pump Chamber Layout In combination with state approved treatment tank. Tank construction as per Comm 83.20(3) WAC. approved manhole cover weather proof w/warning label and padlock grade levels junction box 300 — grade levels Fquic k disconect alternate 'a' 4' vent pipe electric as per NEC 300 and - - outlet Comm 16.28 WAC loc ation 18!'(46 cm) min. wall of pump approved chamber or outlet combination joint tank A 7 1/4° weep Grade levels alarm on hole as pump tank martxAe = 4' min. above finished grade pump on B necessary pump tank nun. =100 mm min above finished grade vent = 12' min. above firdshed grade pump 85.3 ft C y vent = 300 mm min. above finished grads Off elev. 26.0 m D 7 3 " (75 mm) of bedding under tank and anchor tank as necessary 84.4 ft Pump tank elevation 25.7 m bottom of tank Tank specifications: WEEKS Pump tank = 19.04 gallln Pump tank volume = 800 gal Capacities: Inches Gallons A= 24.6 468.7 Pump manufacturer: 1GOULDS B = 2 38.1 Pump model number: IW E0311L C = 7.4 140.9 D = 8 152.3 Project: JEFF MUNDINGER Plan I.D. 102849 Page 5 of 7 venormance curves s P Um p METERS FEET 25 w — -- - --'MODEL 3885 - -� -- SIZE 1 /4" Solids WE15H — 20 WE10H — — -- — 60- 0 WE07H — -- — -- —� - -- zz 40 10 30 WE03M -� -I - - -� WE03L 10 0 0 - 0 10 20 30 50 60 70 80 90 1w 110 120 GPM L L 0 10 20 30 MI/h CAPACITY ;K• 3 ►Ih'� 4, h'k � iP` l''�'.+. `�::(I r✓ 1 ,�, ;,+ GOULDS PUMPS. INC. ►- Softy F-ya5 rt�n rtiw .p�.. METERS FEET 120 M ODEL 3885 35 - rt - SIZE 3 /4 " Solids, 110 WE15HH 100 - 30 i 1i0 25 60 70 20 0 - - -- ~ WE05MH - - - —j -- - - t5 �— 40 10 30 20 - 10 - oL 0 0 10 20 30 40 50 60 70 tiA .W 110 1w GPM L 10 - - -- :� - - 30 m4h 0 CAPACITY • 1 WI O,oulds Pumps. Inc. E01-1 duly. IV" C)111° - 1 1 4 ; E I I 0/ I I j j I � I l � I I j I I � I � i I i i i T y I / r i f I I Wiscor3sin Department of Commerce SOIL AND SITE EVALUATION Division'of Safety and Buildings Page o Bureau of Integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code comp lete site Ian on paper not less than 1�/2 x 11 i he4 County Attach com p p p p � size. Plan must include, but not limited to: vertical and cW horizontal reference off" irection and percent slope, scale or dimensions, north arrow;r4nd location and disf ce to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all , o 9 ►Y Rey�ewed by Date Personal information you provide may be used for sec' da' -purp s s'•( T! Caw, s. 15.04 (1) (m)). y 5 ! c? Prope Owner "perry Location �� ,' Govt. Lot 1/4 1/4,S T C� ,N,R ,�(o(0 Property Owner's Mailing Address Lot # Bloc Subd. Name or CS M# City Sta Zip Code Phone Number ❑ City ❑ village C. Town Nearest Road f New Construction Use: Residential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow gpd Recommended design loading rate bed, gpd/ft trench, gpd/ft Absorption area required „�7S bed, ft �y5 trench, ft Maximum design loading rate _ bed, gpd /ft2 4,2 trench, gpd/ft Recommended infiltration surface elevation(s) 9 ft (as referred to site plan benchmark) Additional design /site considerations Parent material l �� Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system I ❑ S E U [OS ❑ U [Is R U ❑ S m U ❑ S E` U [Is M U SOIL DESCRIPTION REPORT Boren # Horizon Depth Dominant Color Mottles Structure GPD /ft 9 Texture Consistence Boundary Roots in. Munsell Ou. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench rw r Ground 3 � elect r ft' <'o - Depth to limiting factor in. Remarks: Boring # Ground — — - 1 elev. Depth to limiting factor —?L— Remarks: CST Nam (P ase Pr' t) Signature Telephone No. K Address Date CST Number _ SOIL DESCRIPTION REPORT PROPERTY OWNER — Page of. PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Al /r Ground .� elev. ft• s` — Depth to limiting factor = ,2/__in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft ! in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # Ground elev. ft. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. Depth to limiting factor in ' Remarks: SBD -8330 (R. 07/96) l � COL e aya J O GQ //cOk Wisconsin Department of Industry SOIL TE EVALUATION / 3 Labor and Human Relations Page of r 1 9 g Division of Safety and Buildings in a�rcAC# llft R 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 `��1.1 inches must :� County Include, but not limited to: vertical and horizontal refe4nce point (� and Sr' 6 o/ X P ercent slope, scale or dimensions, ons north arrow, and ocation a d distance to nearest r I , Parcel I.D. # au�e�t L Y r1'� Z 1897 E O 2 — - APPLICANT INFORMATION - Please rf ' all /nformROlx Jr' oi P f�'NiY � Reviewed by Date Personal Inforrnation you provide may be used for secondary pu ses (Pd4WW.g��(1 ) ' Property Owner Pr6 Location q/ vt. Lot �W 1145 1/4,S J 6 T 2 / ,N,R /8 E (ot W Property Owner's Mailing Address 1170 CQu,&_,2 Lot If Block# Subd. Name or CSM# �'o w i . SV v� y,' oS / CS 6--- City State Zip Code Phone Number �/ Nearest Road �tA3 ?T wj. Syo �3 1i� ) , Y,2.4- & 73a [:1 city village LYJ Town Lg rvew Construction Use: 1 / Number of bedrooms Addition to existing building ❑ Replacement Y 3'6 _ ❑ Public or commercial - Describe: Code derived daily flow &OD pd Recommended design loading rate bed, gpd4 trench, gpd/ft Absorption area required 3 fj bed, 11 2 375 - S oa trench, ft2 Maximum design loading rate y bed, gpd/ft trench, gpd/ft Recommended n .s 2. i filtration surface elevation(s) 3 It (as referred to site plan enchmark) i'TE" E i .vii ,,�� S'! Additional design / + site considerations S � � a e4 -S � -���� ���2' "' �sT Parent material Wit` wi �t A 5 AN Ti Mro 56;/S — f Flood plain elevation, if applicable /V / * — ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade A System in Fill Holding Tank U = Unsuitable for system ❑ S 0'6 [9 ❑ U El S [9 ss 0 [Is U I ❑ S a ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /112 In. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed ,Trench l 1 0 -13 /Doe 3/3 L, 2 -Fs he cs 3 -e . s : •Ca Z-- /3.3 i0 Vie 3/ — 5/L. 2f IW4 C s /v-F • S ' Ground `3 3 - .1d R �/ SL / f yle '�'' C S • N ; . S �• elev. r — ft . s 7 s F e 3( /6 2. P sc L f cSl7/e Depth to limiting factor 33—In SSS' Remarks: Boring # l 6 -12- 10 313 L d,S 3 -f • S' :2. Z j -/ 9 io ie 31 S/L 2 f Sie A .-,AA CS /f • S: 3 Iff'- 10YA 31e s L 7d 4 0 — . 4: -_5 Ground . S .s C- SGL If f 4 -MVfi' � — N A_7 �S Depth to , limiting factor Z5—in. Remarks: CST Name (Please Print) Signature Telephone No. Rof3LRT 2tL6Ri"T 7i5. 3gCo - 81135 Address D to CST Number Private Sewage Consultants 855 O'Neil Rd. Hudson, Wis. 54016 ORIGINAL l i 3 ", SOIL DESCRIPTION REPORT PROPERTY OWNER Page of PARCEL 11.131 Boring # Horizon Depth Dominant Color Mottles Structure 2 Texture Consistence Boundary Roots r : in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench 3 � / /d 3 G s s S .� R 3 z i3 a J/ / / y/� � - ,S etevund 3 -3 /OI /e 1 li /jV`�/Q C ./ . y G a Depth to limiting factor , 3 - 5 -1n. Remarks: Boring # g , , �G Ground elev. LH Depth to limiting factor in. Remarks: I lotizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G D /11 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # F Ground elev. ft. Depth to limiting factor In. Remarks: Boring # Ground elev. ft. Depth to limiting factor In. Remarks: SBDW -8330 (R. 08/95) r G y �a 3 q I 1 ",9 7W �- s� r y 70 49 5 70 7- 3�y ASS OC18 169 s Ulbrlcht & V ' private Sewage consultant 855 O'Neil $d- 54016 Nudson, 011,0000' sw L o o �T ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer �CfF MLLMn,Nraffie + Tipup 1V12( Mailing Address Property Address fo04 i hile S WX (Verification required from Planning Department for new construction)_ City /State Parcel Identification Number LEGAL DESCRIPTION Property Location S tJ '/4, __S_jiJ /4, Sec. , T 29 _N- R Town of UWj4AX EN Subdivision , Lot Certified Survey Map # 54 24 a I , Volume , Page # Warranty Deed # , Volume , Page # Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑ no SYSTEM MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a 1 wastewaterdis disposal system master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that O the on -site P is in eratin ro er o 2 if necessary), the septic tank is less than 1/3 full of sludge. P P operating condition and/or () after inspection and p umping in g( P I /we, the undersigned leave read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Conunerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Oftce within 30 days of the three year expiration date. __ 06/6$/ S N • APPLI NT DATE OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. 0 6 i0/l Q$ S F APPL NT DATE * * * * ** Any information that is mis- represented may result in the sanitary permit being revoked by the Zoning Department. * * * * ** ** Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed P� .• �':' � . F;. ...�. ` .: *. a n. w:W yy... - ...... rt - - ?WA"'(077 /D SF�S�S1 STAi E [BAR OF WISCONS44 UORM 1 - 1u82 r. WARRANTY DU DOCUMENI NO. Jo T. S a nd Arlene M. S►�ocyenbos• — li disban and w� Les W. Snoeyenbos, J r. , a nd _ R EG i S T E R' S OFFICE an d_ aret ST. CRGIX CO., WI j� J udith G. Sfwe; ^�i husband and wife , _. - - - - -- avea Ann Cave and William S. Cave, wife and Mis bmid. as — e nnY �att 11 - -- NOV 2 0 1991 J effrey A. [luaiir er- _ and_Tinla-I'AU a�nt - - -- A 1 r�.aAilr3lltG —._— — 11 -00 M Roj of Deaft %I — 71413 SPICE RESERVED FOR RECOROING DATA NAME AND RE TURN ADORES$ the following described real estate in —_ of jX — County; Stao- of Wisconsin: Township THE FIRST NAfIONAL BANK OF HUDSON of the SW 1/4 of SW 1/4 of Section 36, p 0 BOX 187 29 Korth, Range 18 West. St. Croix County, Wisconsin HUDSON W 54016.0187 * described as follows: Lot 1 of Certified Survey Map filed July 23, 1997 in Vol. "12 ", Page 3 Doc. No. 562729. �i PAR :EL ,DENTIFICAIION NUSAPER i' 'I TRA _ASFER r • g1F This is ngt _ —_ homestead property. I Exception to wartamics: Easeme n nts, restrictions and rights – of – way of record, if any. Dated t day of _._ N�L�!v'i = ..: \ -D., i997_. .. _ A rlene M. S hoe e nbos ' i • J T. S — � �. —, (SEAL) Z1 : EAL) !` Lest W. Snoeyenbos Judith ; Snoe _ - - �/ ( SEAL i (SEAL) _ ` - ' rg t AXIUIF11ENiICATION William S. ACKNOWLEDGNIENT Cave I CA State of Wisconsin, x Signature(s) -- jrAin- ! $rleey* nbgs - -Ar-14WIM- M..-- SS. : _ Snoe yenbos, Lester W. Snoey enbos, Judith G. I Snoeyen ois, MargareE - Arai Cave, - WLIZia® S_ Cave— - - -- — County ►v P _ autir_nticate this* a�!`' -'day of -- pELphr —• - �7 - ersonally came lxtalr me this day of 19 the a xxe named �'� •�iSt�na_ land - - - - '- -- - -- __ ` —-------------- f1T1E MENIBER SFAIE B,%ROp %ViSCONSIN - -- � --- - - - - -- ,'- authorized by UiW06, Wis. Stats.) to me known to be the Minn —_ who executed the foregoing inctrunlent and ar knowledge the same. THIS INSTRUMENT WAS DRAFTED BY _ ---_— r.` A ttorn ey Kristina O gland r _Htidson WI 54016 _ _ -- -__ -- - -- -- Notary Public. _ _ _ _ _. - - - - -- - - -- County; �\ is. (Signatures may be authenucated or acknowledged N-4h arc vxs M commission is permanent Of not. state expiration dike f �E`, • Nan;ic pt Irru % dgnog m any caw+y >hould be 1) 1" or r 1r, d'r'..+ T \E411:w1SCONSIN t', <sc:r��nlrv7-JP,n�C,.ir \ \':1RR 1`:1,' nrPf! 1..ca �.• P: ? - I�F2 6i ::.: d•.• Aa g 6 ? 3o, - 5G2729 CERTIFIED SURVEY MAP MARGARET CAVE, etal. Part of the Southwest 1/4 of the Southwest 1/4 of Section 36, Township 29 North, Range 18 West, Town of Warren, St. Croix County, Wisconsin. Note: An erosion control plan must be submitted to the St. Croix County Zoning Office prior to construction on these lots. UNPLATT LANDS 140th STREET WESTLINE-SWI14 SECTION 36 (Wo? WIDE -NO0 2637.44 --- k j 1___Bt7)z89fR-809.2)--- 1829.55'-- ---NO0 741.67'--- 2. C° n 4N (b te t C) %1� C1 .a m wC o CV 1, it to c, 0 -4 o� Zrn lO / `" t-,:0:0 -Z, �� Z i ;t C A 1 M C ---NO0 59705 t 1001-i C cp a 1 70 ° 28 ' / IN ZS700 5 118.83, 1 4 b 1 .0 -1.0 //8.9 1 mo o' I y o,i l � S, W 00 at S 84*34' 53" 0 0 1. n , , 1, 54.06' C) � ' E, 1 84.3) N 0 20'24'6 531.67�-- Owner's Address: a - 44 to 10 _P _. C/O William Snoeyenbos 0 1 - ::E Z, -, C', og�, 0 1170 Coulee Trail ro co Roberts, WI 54023 Ez S! E': . r- 7� A /N BEARINGS REFERENCED TO THE WEST LINE OF THE SW, /4 OF SECTION — RECORDED BEARING N 00 0 12 - 00 " W. �0 0 qri cl) "I-- ---N00 '24"E 453.03'--. 414.23' OD 0(n A (b 14 co 0 N 0 N y C C r P of n tp o O Irv) G) za o:0 -1 LN C, a to �'S42 /5.9.37' A -4 ' 293 M I 1474) q G) .44�—, M k C) JS00-11 I .no 23"E -4- (.11 ;?! .330.94*-- EAST LINE- W112 Z So S W 114 SEC T101y,M11 1 1811 0 . YL)�LATTED LAW 11 %, to \ , S COIV r, to rtl CD io z 't to 20 M C) :b :0 Q LAUREN W ; % RIVER FALLS,..' . WISC, . •....... Laurence W. Murphy `0 C V Dated: March 22, 1997 "Revised this 2nd day of Registered Land Surveyor L A ND o Alois 4'� July, 1997. This Instrument Drafted by Mark W. Peavey SHEET I OF 2 Vol.12 Page 3303 ST. CROIX COUNTY * SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM (Ow�n_e) 3 r7cTQk� L L G( 0 q aW Mailing Address Property Address (Verification required from Planning & Zoning Department for new construction.) City/State L Parcel Identification Number ��� — /�� Z LEGAL DESCRIPTION Property Location J5 W /, -��J 'i4 , Sec. 3b , T �)_ I N R W, Town of /e Subdivision Plat: , Lot # 1 Certified Survey Map # , Volume 12- , Page # 3 363 Warranty Deed # - 7 (before 2007)Volume , Page # 3 Spec house yes Lot lines identifiable o 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 ( I ) 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. I /we, 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 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. I /we am/are the owner(s) of the property ribed above, y virtue of a warranty deed recorded in Register of Deeds Office. Nu er o bedroo s S� _ _ 2 SIGN T OF APPLIC NT(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)