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HomeMy WebLinkAbout006-1079-50-000 \ ° ® § e 0 / ±a) \�E m \-_-) � ^ cn 0 / fEf0o* % E2)//© , mccg o % r_ a 0 _, =f i) o ƒ 4 2 3 83 72{52 ea�- c- 1 0 � / «2kE � < $ 2 �§f 7 © ) CL z 'o LLL cm co -3 /#�mlm30 Q df \E& E <eES32) ; n / \ w / �_, § z�; §a G § 7 a � . k 2 ® 2 $ � D or § 'Z-- s r ' 2 r \ K 3 I\ ) z z } z \ ° Q ! , ® r (D k & i 2 0 B o a " \ k k k a- CL - t f a a a ` \ \ \ 0) a LO 00 � z-_ § £ 2 o o \ ) § ( I 2 $ $ I $ g » e 2 7 - ] 4 7 8 2% k ) �§ CO z e m @ _ ° _ _ _ § \ CO / = m & & @ \ \ j \ .� % e ) ) ; \) 3 ) D a + ¥ 6 m/ ƒ\ o z 0), ) / � ® � f / 2 7 i « - .. } » CL w k U)) ka§ ƒ 0 a 2 0 o) J ST. CROIX COUNTY WISCONSIN ZONING OFFICE 4 ■ ■ ■ " "■ ■ ■ ■ �...i ST. CROIX COUNTY GOVERNMENT CENTER •.,. �` -- 1101 Carmichael Road Hudson, WI 54016 -7710 - (715) 386 -4680 Fax (715) 386 -4686 August 31, 2000 Bernard Francis 1850 235' Street New Richmond, WI 54017 RE: WISCONSIN FUND GRANT AWARD Dear Mr. Francis: Enclosed is your Wisconsin Fund Grant Award check. This is the amount you have been awarded for the replacement/rehabilitation of your septic system. If you have any questions, please feel free to contact our office. Sincerely, Kevin Grabau Zoning Technician Enclosure NOTICE TO CASHIER BE SURE WATERMARK 15 ON REVERSE SIDE EFORE NORWEST BANK OF HUDSON, N.A. COUNTY OF ST. CROIX STATE OF WISCONSIN - - VOID AFTER SIX MONTHS i Check Dxte _ iCliecFr Nv �14un'C 08/31/00 00510099: $3,822.00 PAY THREE THOUSAND EIGHT HUNDRED;TWENTY TWO DOLLARS AND 00 :CENTS TO THE FRANCIS, BERNARD ORDER 1850 235TH STREET , NEW RIC -HMOND WI 54017 Od1C,f,►r/tfsC. OF:- AutlwrUW Signatures (( L`0099 1:09 L8 1 L13004:: 000 LO 10 230 COUNTY OF ST. CROIX STATE OF WISCONSIN DATE::::: CHC1.f: >NO VNftOR NO "; VENDOR: FRANCIS BERNARD 08/31/00 00510099 999999 iNV1GE DESCRIPTION VOUCHER NO. I1MOU(VT �'A(D 08 -30 -2000 PRIVATE SEWAGE SYSTEM REPLACEMT G0005068 3,822.00 NEW 1999 BENEFIT AMOUNT NAME: BEOLA B FRANCIS SOCIAL SECURITY NUMBER: 472 -36 -7110 B We are writing to tell you that your Social Security benefits will increase by 1.3 percent starting in January. We based the increase in your benefits on a rise in the cost of living. If you are paying for Medicare medical insurance, we have deducted your premium amount as shown below. Your New Benefit Amount s These amounts are based on your record as of 11/20/98. • Amount Before Deductions. (This is the figure organizations need when they ask for proof of your benefit amount.) $ 292.00 • Amount We Deducted For Medicare If You Pay A Premium. (If you do not have Medicare or your state pays for your Medicare, we show $0.00.) S0,00 0 Amount After We Deducted Medicare and Any Other Deductions. (This is the amount we will deposit into your bank account starting with your January payment date.) For those receiving benefits on the third of the month, this amount will be deposited on December 31, 1998. $ 292.00 If you disagree with any of these amounts, you should let us know within 60 days from the date you receive this notice. Use this notice when you need proof of your benefit amount to receive food stamps, rent subsidies, energy assistance, bank loans or for other business. If You Have Any Questions If you have any questions, call us at 1- 800 - 772 -1213. The field office serving you is located at: 4120 OAKWOOD HILLS PKY EAU CLAIRE, WI We can answer questions by phone between 7 a.m. and 7 p.m. on business days. We are busiest early in the week and early in the month. If your business can wait, it's best to call at other times. Please Tell Us If Your Address Changes We need your correct mailing address to tell you about Social Security changes that may affect your benefits. Please check your mailing address on this form. If it is correcit, you do not have to do anything. If it is incorrect, call us at 1- 800 - 772 -1213 with your correct address. Do Not Call If The Only Change Is To Your Zip Code. This Will Be Changed Automatically. NEW 1999 BENEFIT AMOUNT NAME: BERNARD L FRANCIS SOCIAL SECURITY NUMBER: 472 -36 -7110 A We are writing to tell you that your Social Security benefits will increase by 1.3 percent starting in January. We based the increase in your benefits on a rise in the cost of living. If you are paying for Medicare medical insurance, we have deducted your premium amount as shown below. Your New Benefit Amount These amounts are based on your record as of 11/20/98. • Amount Before Deductions. (This is the figure organizations need when they ask for proof of your benefit amount.) $ 726.00 • Amount We Deducted For Medicare If You Pay A Premium. (If you do not have Medicare or your state pays for your Medicare, we show $0.00.) $ 0.00 • Amount After We Deducted Medicare and Any Other Deductions. (This is the amount we will deposit into your bank account starting with your January payment date.) For those receiving benefits on the third of the month, this amount will be deposited on December 31, 1998. $ 726.00 If you disagree with any of these amounts, you should let us know within 60 days from the date you receive this notice. Use this notice when you need proof of your benefit amount to receive food stamps, rent subsidies, energy assistance, bank loans or for other business. If You Have Any Questions If you have any questions, call us at 1 -1213. The field office serving you is located at: 4120 OAKWOOD HILLS PKY EAU CLAIRE, WI We can answer questions by phone between 7 a-m. and 7 p.m. on business days. We are busiest early in the week and early in the month. If your business can wait, it's best to call at other times. Please Tell Us If Your Address Changes We need your correct mailing address to tell you about Social Security changes that may affect your benefits. Please check your mailing address on this form. If it is correct, you do not have to do anything. If it is incorrect, call us at 1-800 -772 -1213 with your correct address. Do Not Call If The Only Change Is To Your Zip Code. This Will Be Changed Automatically. POWERS EX INC. I Invoice Number: 1969 185th AVE 5373 NEW RICHMOND, WI 54017 ST CROIX Invoice Date: ' Jul 15, 1995 'i Voice: 715- 246 -5135 Page: Fax: 1 Sold To: Ship to: BERNARD FRANCIS 1850 235th ST NEW RICHMOND, WI 54017 Customer ID Customer PO Payment Terms FRANCIS Net 30 Days Sales Rep ID Shipping Method Ship Date Due Date Courier 8/14/99 Quantity Item Description Unit Price Extension D JULY 15 INSTALL MOUND FOR 3 BEDROOM HOME 1.00 MOUND 3 MOUND 3 BEDROOM 8,700.00 8,700.00 1.00 PERK TEST PERK TEST 400.00 400.00 I Subtotal 9,100.00 Sales Tax Total Invoice Amount 9,100.00 Check No: Payment Received 0.00 TOTAL 9,100.00 We will add finance charges on invoices more than 30 days overdue. Illlllilllll11111 illIIIIII 11l IIII111111IIIIIIII 2 Document Number Document Title 884459 KATHLEEN H, WALSH REGISTER OF DEEDS St. Croix County ST. CROIX CO., WI RECEIVED FOR RECORD Occupancy Affidavit for a single POWTS 11/18/2008 02:30PM servicing Two Dwellings EXE PD IT t'C� rt L�1`/ �: nc S REC FEE: 13.00 PAGES: 2 Name — (Owner) Typed or printed being duly sworn , states, under oath, that: 1. He /she is the owner /co -owner of the following parcel of land located in St. Croix County, Wisconsin, recorded in Volume ys Z Page 5 j, i Document Number. Y9rS St. Croix County Register of Deeds Office: Recording Area A parcel of land located in the / _'/,*-of the se:,) ' /4 of Section33 V Na. a and Returq.Address T N — R / [r W, Town of t. „ , St. Croix County, �S f� .Z_3 S > T r' -e ° r Wisconsin, being duly described as follows (include lot number and L' ��� fZ ,'c (mot, t t:..c� i,;� Sc/y" subdivision/CSM or detailed legal description): t �`� ��, _ 0C,#0 Parcel Identification Number (PIN) As owner of the above described property, I acknowledge that a single Private On -site Wastewater Treatment System (POWTS) is servicing two dwellings and is sized for 3, bedroom(s) with a design wastewater flow of >gallons /day. (DWF calculation based on 150 gpd /bedroom @ 2 persons/bedroom). A maximum of L, occupants are permitted. There are currently a total of occupants in these two residences, therefore the POWTS can be considered code - compliant at this time. However, I understand that if the number of occupants exceeds the maximum for POWTS design, the system will be undersized to accommodate any increased wastewater flows and/or contaminant loads and may be subject to premature failure. I also acknowledge that I will disclose this information to any parties interested in purchasing this property in the future. Dated this J_ day of / t i r * AUTHENTICATION ACKNOWLEDGMENT Signature(s) STATE OF WISCONSIN ) )ss. St. Croix County. ) authenticated this day of Personally came before me this _ I'g' day of nln U e rnlxr , OtOO F( the above named *:zInnanr i c' &_" el bo c TITLE: MEMBER STATE BAR OF WISCONSIN to me known (If not, to be the person(s) who executed the foregoing instrument and acknowledge the same. authorized by § 706.06, Wis. Stats.) THIS INS//T,,R//UNI NT WAS DRAFTED BY Notary Publi , State of Wisconsin �.�.r unrt (Signatures may be authenticated or acknowledged. My Commission is permanent. If not, s�ta�t��paplatltSh,,� Both are not necessary.) date: s _ s Date: "THIS PAGE IS PART OF THIS LEGAL DOCUMENT —DO NOT REMOVE' '•••••' " ` This i� /or g(ion tnucl be completed by submitter: document title. name & return address and P/N (ifreyuired). Other information such as the granting cluusc r. de, etc. may be placed on this first page gjthe document or may be placed on additional pages ofthe document. of Use gjthis cover scription page adds one page to your document and $2 00 to the recording lee Wisconsin Slatutes, 59.517. ST: CIZOIX COUNTY ZONING DEPARTMEN _L10 . - AS BUILT SANITARY REPORT RECEIVED Owner Lq h t a,r% e is Address 9 S � �� X 1 5 1999 �= City /State �-c�d �. s7 GROX omwy Z'CINt 010 /I, Legal Description: S , Lot •— Block — Subdivision/CSM # '/, AN '/, ,�, Sec., `S4N -R,ZLW, Town of C PIN # n o/ • l07 9= SEPTIC 'WANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Tank manufacturer t 1 tag,, Size STJPC !(off? Setback rom: House 'yd Well P/L, Pump manufacturer _ t��lt Model L_ Alarm location (HOLDING TANKS ONLY) Setbacks: Service road V t to fresh air intake Water Li Meter location Alarm location SOIL ABSORPTIONS STEM: Type of system: __ )Y Width S Length 3 7,V Number of Trenches_ Setback from: House o Well 0 P/L ,9 Vent to fresh air intake 9 a ELEVATIONS Description . nofb benchmark rn�.�' P bmark 3- Elevation try Description of alternate benchmark ~'– hmark Elevation Building Sewer ST/HT Inlet 93, Z ST Outlet • Q� PC Inlet PC Bottom Header/Manifold 9 ° L Top of ST/PC Manhole Cover 9 Se Distribution Lines ( ) _ 4�, b 2 () 9� t a ., L- Bottom of System 9 O Final Grade Date of installation 11 - 1 Permit number State plan number a 7 7 Plumber's signature ` , g ��ber Date 77�5'J Inspector _ Ikif 2k complete plot plan ,* I NOTICE: Please provide the following: : g • 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 i8 �J 4 s' 6 Z> INDICATE NORTH ARROW Wisconsin Department of Commerce Count PRIVATE SEWAGE SYSTEM y: Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No-: ST CRO X Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 338967 Permit Holder's Name: ❑ City ❑ Village N Town of: State Plan ID No.: FRANCIS, BERNARD CYLON CST BM Elev.: / Insp. BM Ele' .: BM Description: Parcel Tax No.: 0-0 610 k%"* 006- 1079 -50 -000 TANK INFORMATION ELEVATION DATA A9900221 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic n Benc mark '�- 106. Dosing �S'�99 G 1 9 44 -o•� qq 8 Aeration Bldg. Sewer Holding t Ht Inlet 02- TANK SETBACK INFORMATION 5t+ * 9W�l st TANKTO P/L WELL BLDG. Air to I ntake ROAD 9#-4 4e1• ir Septic �S kf L 44t' NA Dt Bottom /�•Z ��(, IFS` Dosing " " y� i NA Header /Man. 9I. S'}- Z. Aeration NA Dist. Pipe C .2 2S % 7 S �- Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand � 4 3.33 of 6. VT Model Number w 7 If j_ .4GPM TDH Lift Q, f2 Friction , Zs � System Z TDH [B.Ot ead Forcemain Length Dia. Ff `� Dist. To Well T SOIL ABSORPTION SYSTEM B$/ R Width , Length No. Of PIT No. Of Pits Inside Dia. Liquid Depth DIMENSION '� f DIMEN I N SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O f CHAMBER Model Number: System: M ?Z > L S OR UNIT DISTRIBUTION SYSTEM Header / Manifold W Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length�ePi Dia. 3 Length Dia. �.� Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) _ s. s• L OCATION: CYLON 34.31.16.528B tp 529B,NW,SW 1850 235THSTREE' ®19 0 , 9>s. T Plan revision required? C] Yes ❑ No � f �� c .� � � � 6 Q Use other side for additional information. SBD -6710 (R.3/97) Date Inspe r' i nat eert No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: m m� _ 4 S i e } 8 � � a e E a 3 3 ' e s = E 4.e t i t t ,...� l e 3 F q ...d e,. a j € ( e a p { B 3 ' 3 s e r .. es. e m- f s � � 0 i a z 7 - -,.. i. z .mf E� @ d t ,e S Safety and Buildings Division ��SCO/1S %/1 SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, WI 53707 -7302 • Attach complete plans (to the county copy only) for the system, on pap County than 8 112 x 11 inches in size. • See reverse side for instructions for completing this applica 'on r4 4 State Sanitary Permit Number Personal information y ou p rovide may be use f or ( U J l y p y d o secondary purposes n [Privacy Law, s. 15.04 (1) (m)]. ❑ Check � P �i State Plan I.D. N ber 1. APPLICATION INFORMATION - PLEASE PRINT ALL 1 ORMA N 5q Propert y wner Name I Property Location 14 S 114,S T - 31 , N, R ( E (or) is sc> Property Owner's Mailing Address ST' Lot Number Block Number !� " h City, Stays Zip Code Phone Number Subdivision Name or CSM Number 11. TYPE OF BUILDING: (check one) ❑ State Owned o it age Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms ❑ Vll Town of 3v��` aS III. BUILDING USE (If building type is public, check all that apply} Parcel Tax Numb (s) 2q, . 16 . S�Ze 6 4 52A ]g 1 ❑ Apartment/ Condo — SO _00 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. E:] 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 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 5� Required (s q, ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min. /inch) Elevation 3 ? - 7 ----� �� �� Feet W, 6. Feet VII. TANK in Capacit Total # Of Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App_ New Existin structed Tanks Tanks Septic Tank or Holding Tank ❑ ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber t L7001 ❑ 1 ❑ 1 ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for instpffalikn of the onsite sewage system shown on the attached plans. Plumber's Name: (D't)) P er' Signa re: (No to ps) TiMP/MPRSW No.: Business Phone Number: S i s a s r Plumber's Address (treet, City, State, Zip ode): O 19 c IX. COUNTY / DEPARTMENT USE ONLY Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued ssue Issui A nt Signature (No Stamps) Surchargeree) [fApproved ❑ Owner Given Initial Adverse Determination X - INDITIONS OF APPROVAL/ REASONS FOR DISAPPROVA . &bh 177) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber 1 INSTRUCTIONS s 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 ar -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. V. Type of system. Check appropriate box depending on system type. 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 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- 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. it a , Safety and Buildings 2226 ROSE ST LA CROSSE WI 54603 -1905 *iscons'in TDD #: (608) 264 -8777 www.commerce.state.wi.us Department of Commerce Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary May 20, 1999 CUST ID No.273085 ATTN: Jim Thompson CALVIN POWERS ZONING OFFICE POWERS EXCAVATING INC ST CROIX COUNTY SPIA 1969 185TH AVE 1101 CARMICHAEL RD NEW RICHMOND WI 54017 HUDSON WI 54016 RE: CONDITIONAL APPROVAL APPROVAL EXPIRES: 05120!2001 Identification Numbers Transaction ID No. 225754 Site ID No. 172381 SITE• Please refer to both identification numbers, Site ID: 172381 above, in all correspondence with the agency. St Croix County, Town of Cylon NW1 /4, SWIA, S34, T31N, R16W Facility: Bernard Francis FOR: Object Type: Mound System Regulated Object ID No.: 468263 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The following conditions shall be met during construction or installation and prior to occupancy or use: • A Sanitary ermit must be obtained from the county where this project is located in accordance with the rY ty P J requirements of Sec. 145.135 and 145.19, Wis. Adm. Code. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the county designated official in accordance with the provisions of Sec. 145.20(d), Wis. Stats. g tY A copy of the approved plans, specifications and this letter shall be on -site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. All permits required by the state or the local municipality shall be obtained prior to commencement of construction /installation/operation. Inquiries concerning this correspondence may be made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, DATE RECEIVED 05/07/1999 FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 4ehf on BALANCE DUE $ 0.00 Wastewater Specialist (608) 785 -9336 dsorenson @commerce.state.wi.us WSMART;code: 7633 r . l ., APPLICATION FOR REVIEW pOWTS rsconsin - Complete all pages - Department of Commerce Safety & Buildings Division This page may be utilized for fax appointment requests Bureau of Integrated Services Complete and indicate date plans will be in our office NOTE: Personal information you provide may be used for secondary Complete for confirmed appointments * : purposes (Privacy Law s. 15.04(1)(m)). Not available for POWTS at this time. 1. Private Sewage Submittal 2. Type of Submittal: Transaction ID: System Type New ( ) Groundwater Monitoring Replacement Previous Related Trans. ID: ( Site Evaluation POWTS System ( ) Petition (attach form SBD -9890) Appointment Date: MAY X 99_ At Grade ( ) Experimental Review Assigned Reviewer: ( ) Holding Tank ( ) Engineered System ( ) Nonpressureized In- Assigned Office: EN & F11 nar ru i r Ground - conventional 'Plans must be received in the office of the app t later than ( ) Pressurized In- 1 2 working days before the confirmed aepointment. Ground 3. Project Site Information - Fill in all known information. ( ound Site Number ( ) Xlerbbic System ( ) Sand Filter Number & Street: 5� � � S r () Constructed Wetland Legal Description W ( ) Other: County k ( ) Ci ( ) VIllage ( Town of 0 - 42 XS Gallons per Day: Facility Na e: (individual a d /or b siness name of project) Building Type (check one): C` Dwelling, 1 or 2 family Public Building Facility Address: (project address) Zip Code ( ) State -owned Building S 0 J w -�_ o / 4. After plans are reviewed, please: (check all that apply) _ Call when completed. Mail plans to customeel )2, 3, 4 Requesting party will pick up Circle customer number from below. Other: 5. Complete the following designer /owner /requesting Information. Utilize the check boxes when designer, owner or requesting party is the same to avoid. repeating information. l Qe ;�rfb50#597M , afit3 fts,ir>?artjrfffrerittsddefig , Ctt _; First Name Last Name Customer Number First Name Last Name Customer Number ' t c9 rS Co any Name Company Name ZV%. C Address Address City State Zip +4 (9digits) City State Zip +4 (9digits) NJ c� Phone Number (area code) Fax or Internet Phone Number (area code) Fax or Internet 715 - 1 SJ S_( Check others if applicable Check others if applicable ( ) Owner ('y<) Payer { Requesting party ( Owner ( ) Payer First Name last Name Customer Number First Name Last Name Customer Number POWERS _EXCAVATINd 1N 9364839 CALVIN POWERS, JR - .~ p ) pTl State Zip +4 (9digits) LIC 062-119 0 ^� ti 1' (9digits) 1969 165TH AVE PH 715 246 5135 �, EW RICH, MOND WI 17 '• 4s . i, [DE .. •' - s - r - . Fax or Internet w THE FIRST ^, .. .01- rv►zzorw. $�►ria -,. NEW, RICHMOND (7151 248090 .,��,,, r ".�I 'r.V.' 1. '`� .•„`j IN NEW PlpiMfYJO AN0 SOMERSET '`„'� ^ "• ^.. Review Code 7633 .ne. yX °C_� S ^*.. M � 80.9980ii n ■g3 7.i�- _.•r -� =,�- PAGE jLOF_j MOUND SYSTEM FOR A,_BEDROOM RESIDENCE LOCATED IN THE AIW 1 /40F THE 1/40F SECTION 33,T3LN,Rj�kW, TOWN OF C n w , ST C "j,$ COUNTY, WISCONSIN. INDEX PAGE IA OF 9 TITLE SHEET PAGE 1 OF 9 WORK SHEET PAGE 2 OF 9 WORK SHEET` PAGE 3 OF 9 WORK SHEET PAGE 4 OF 9 WORK SHEET PAGE 5 OF 9 PLOT PLAN PAGE 6 OF 9 PLANVIEW CROSS SECTION PAGE 7 OF 9 DISTRIBUTION PIPE LAYOUT PAGE 8 OF 9 PUMP CHAMBER PAGE 9 OF 9 PUMP PERFORMANCE CURVE PREPARED FOR &� � (l yNcxt — c � C,S PREPARED BY POWER CAVATIINGG�INC. 1969 185th AVE NEW RICHMOND, WISC. 54017 715- 246 -5135 • 3 mvA� (A)tL 'T V017 NWy�SwV� y 7 NQI(oc,J WORKSHEET - MOUND SYSTEM DESIGN C yy(oV" PROBLEM: nn Design a mound system fora C� P� ctbo The site characteristics are: Depth to groundwater or bedrock -3 in ' Landsl ope -� % K.y �,in. Percolation rate -- Distance from dose chamber to distribution system .&0 ft. Elevation difference between pump and distribution system S ft. Step 1. WASTEWATER LOAD gal. Step 2. SIZE 'THE ABSORPTION AREA A) Area required 45 ; 2' 3 7.5 sq. ft. 7.5 B) Bed or trench length (B) = 3 37 -5 - S ft. � C) Bed or trench width (A) --5 -- ft. -0) Trench spicing. (C) ".; Wastewa er load , .24 gal/ft /day 3 ft. tre:) ems+ s Step 3. MOUND HEIGHT A) Fill depth (D) Q L ft. B) Fill depth (E) - D + 6 slope (AJf�� -� a ft' C 9x 5,, C) Bed or trench depth (F) �$ 3 ft. D) Cap and topsoil depth (G):= j ft. E) Cap and topsoil depth (H) _ ft. B Y _ .. % D0 S N e - a Me AA, 6.7`E S cup /� Nw`fySu''k Sa T3! Av J2 ((pW Step 4. MOUND LENGTH i (- , - r coo t� A) End slope (K) D + E 1 + F + H x 3 = �a. ,. ft. fia -x,83 -• 1,5 J p B) Total mound lent3t (L = B + 2(K) r ft, Step 5. MOUND WIDTH Al) Upslope correction factor = .g A2) Upslope width (J) R (D + F + G)(3)(factor) _ 7.1a ft. (/ -4.0 -4 B1) Downslope correction factor B2) Downslope width (I) ■ (E + F + G)(3)(factor) _ 1 Cl) Total mound width (W) for bed ■ J + A + I ; Z3 ft. C2) Total wound width (W) for trenches J + � + (no. trenches -1)(c) + A + I = ft. Step 6. BASAL AREA A) Infiltrative capacity of natural soil gal. /ft /day r B) Basal area required ■ wastewater flow natural soil infiltrative-capacity = 7�0 sq. ft. 4s0 C1) Basal area available for bed for sloping sites = B x (A + I) _ sq.. ft. C2) as are avail le for trench for sloping sites = B W �J + A 1 7, = 6 sq. ft. 75x a3 ( � � 9� C3) Basal area available for trench or bed for level sites = B x W = sq. ft. Liconse V`Q rVIQ� • Y ` C l� � , l�5o a-�S►' Step 7. DISTRIBUTION SYSTEM u ,ti N kSwy Sa 3 k)(0 � 7A) SIZE DISTRIBUTION SYSTEM C tdr, 1) Hole size = in. 2) Hole spacing = in. i 3) Distribution pipe length 37 in. 4) Distribution pipe diameter Q in. s. 5) Spacing between distribution pipes R —'' in. 6) Distance from sidewall to distribution pipe = _,30 in. 7B) DISTRIBUTION PIPE DISCHARGE RATE ft. 1) Number of holes per pipe 2) Flow per pipe GPM 7C) SIZE MANIFOLD 1) Manifold is central/ end i 2) Manifold length n *K 3 a lee D ft. 3) Number of distribution lines = 4) Manifold diameter = -3 in. 7D) SIZE FORCE MAIN 1) Minimum dosing rate =,GPM 2) Force main diameter = �a 3� in. 3) Friction loss ft. 7E) TOTAL, DYNAMIC HEAD 1) Vertical lift = ft. 2) Friction loss = ft. 3) System head 2.5 ft.._ ft. 4) Total dynamic head ft. ,ice; 9 e:�c2S3.'._ C FSso nn aSNA sT / u yew: tC: L� mo n b. w�-5k o 1�• . W S l y T 31 N R Cy�o� ste r�,jC 7F) PUMP SELECTION 1) Pump selected will discharge GPM at J5 ft. total dynamic head. 2) Pump model and manufacturer 7G) DOSE VOLUME 1) 10 times void volume of distribution lines =' �8�� gal. /cycle 2) Daily wastewater volume . 4 doses /24 hrs. gal. /cycle 3) Minimum dose volume 5 z. - S / 7,5 gal. /cycle a 7H) DOSE CHAMBER 1) Minimum capacity required R (off gal. Ucu .:to• oZ p.537_ Date: Pau s N U-) `�� S 3 Y T 31 N P, ! (o Lo /per /� 6th q� CtJl��.ei�- C�a 0 2 ' a X Y'O o - ' Spa ' 0 � �i �1. SEPTIC TANK E PUMP CHAMBE CROSS SECTION AND SPECIFICATIONS -- - 4" CI VENT PIPE 12" MIN. ABOVE GRADE £ k ;?T ER PKOOF 2S' FROM.DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AIR I - NTAKE WITH CONDUIT MANHOLE COVER FINISHED GRADE 4" Cl RISER W/ PADLOCK & WARNING LABEL 6 MIN. y ABOVE GRADE - ; — __--4" MIN. ! 18' IN. 6" MAX. INLET +� WATER HT SEALS GAS- TIGHT: 4 " BAFFLE A SEAL APPROVED CI PIPE —}-- + ALM JOINTS W/ CI B PIPE 3' ONTO SOLID TO WAGeS"S _Teta -f^ + , ON SOLID SOIL S� ��jjj C ' ic�t RISER EXIT SOIL t .. {fit'' *LEV . FT. - --- r` OfF 4 (�t D PERMITTED ONLY IF . TANK . MANUFACTURER HAS APPROVAL 0i Spy'" OVED BEDDING UNDER TANK 1V0 CONCRETE PAD R �S P � N pENGE SPECIFICATIONS SEPTIC D CAE ppR TANK MANUFACTURER: ON Zk 00 WW2jaA NUMBER 'DOSES PER DAY: '7 TANK SIZES SEPTIC �„ GAL. DOSE VOLUME INCLUDING DOSE GAL. FLOWBACK: /59' GAL. ALARM MANUFACTURER: $ "�'� G`I¢�`f CAPACITIES: A = INCHES = 3CY GAL. MODEL NUMBER: SWITCH TYPE: /a�-Y B = 2 INCHES = 33 GAL. PUMP MANUFACTURER: (�, �,� \� g C = 9,,3 INCHES = 13� GAL. MODEL NUMBER: 3f� w �.0 3 I I L SWITCH TYPE: ��a� D = �i 7 INCHES = Ay, GAL. REQUIRED DISCHARGE .RATE GPM PUMP 6 ALARM WIRING AS PER ILHR 16. 23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE s FEET + MINIMUM NETWORK SUPPLY PRESSURE . . . ... . . . . . 2.5 FEET + FEET FORCEMAIN X FT /100 FT. FRICTION FACTOR , j j FEET TOTAL DYNAMIC HEAD = _ 7, lo. FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH '� ; WIDTH '� ; DIAMETER _______• LIQUID DEPTH ( , (oo /lA` LICENSE NUMBER: DATE: .S - -q2 1/88 Y S Page SOIL DESCRIPTION REPORT o2 of -- PROPERTY OWNEA 61 ►' f� —a1-� T 1 U PARCEL I.D.# neo 7 9 50- OGb Boris # Horizon Depth. Dominant Color Mottles Structure 2 Boring Texture Consistence Boundary Roots q; in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench 5 L rA e 0Z / ab r 5/ m Sbk M i s l r UJ 1,►. , 5 ; , 6 Ground 3 p (,-.36 A x, r /`( .�-�"' S Q IYI 6 M U T P 5 U'_ lev. S �s,o 6•y s X r s .z, r s l r sbk. m Depth to _ l LIE] imiting factor in. Remarks: Boring # l a - / r 512 m SW w.-T r C LJ YA �• 3o S 0M ms Ground .�.36 I S elev. Depth to limiting factor � in. Remarks: Horizon Depth Dominant Color Mottles Structure Consistence Boundary Roots GPD /ft Texture in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed . Trench Boring # Ground elev. ft. Depth to limiting factor ' Remarks: Boring # Ground elev. it. Depth to limiting factor in ' Remarks: SBD -8330 (R. 07/96) BQc�na,c'd rar.C�s Nw�{� ZWY� Sm 7'.31 NO I & IS S0 CY., c-�rvmo ^d, 0 [7 BA Ceram S�'a`'Lt. loc.', Me b �i e r - ► n,y h v A J o • W. -)nsli. ep'�ime'dt of'Commerce SOIL A EVALUATION 3 Division of Safety and Buildings -* Page of Bureau of Integrated Services in accord JLHR 83:68, Wis. Adm. Code Attach complete site plan on paper not less than 81/2 x 11 in size lrrrulsft, � County include, but not limited to: vertical and horizontal referenc 'poirA (BM), direction ehd. � Cwo f k percent slope, scale or dimensions, north arrow, and locatibn and di �e tp nearest road. _ i Parcel I. D. # APPLICANT INFORMATION - Please print all infOrmat►ax►�, t+. Revi d by Date Personal information you provide may be used for secondary purpose9,(Priyacy Lew, v§ S)PPI m)). 7 . Property Owner Property,_* tion A v� Cl S `J. - 'Go�1t. f A IW1 /4 S W 1 /4,S 3 Y T 3 l N,R �� IS(or) W Property Owner's Mailing Addre Lot # Block# Subd. Name or CSM# ss l + / ST N N/* A k City State Zip Code Phone Number Nearest Ro ❑ City ❑ ad Village ,�] Town � mt> W- 5 017 (7S s ❑ New Construction Use: Residential/ Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow 7- gpd Recommended design loading rate bed, gpd /ft Jo trench, gpd /ft Absorption area required 3 75 bed, ft 31 trench, t2 Maximum des ig loading rate s bed, gpd /ft I r. trench, gpd /ft Recommended infiltration surface elevation(s) E?s +e 95� ft (as referred to site plan benchmark) Additional design /site considerations Parent material Flood plain elevation, if applicable A/A ft S = Suitable for system Conventional Mound In- Ground Pressure AT -Grade System in Fill Holding Tank U = Unsuitable for system El 5a U S❑ U F S [U ❑ S ? U ❑ S & U EIS o U SOIL DESCRIPTION REPORT 5 Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed ,Trench y M Yr1 . . G Ground 0 t s1t, s O S . — , b elev C ,. Depth to I f II g. C '- a.S r k s, / ! I r S6K limiting factor Remarks: Boring # d -ty Aiy S a �.S l k ,� 7r J 2 �• OZ y'3y /p r S a Vti#_ S i K M 1 Ground elev. Depth to limiting factor in. Remarks: CST Name (Please Prin S' nat re Telephone No. C Z ' ^1 r ? r r - . 3 Sl Address V Date CST Number 9 9 -A,.� L s3 T ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer r-h 4 4;]=V,c` 5 Mailing Address a 8 4 -L Property Address Scr- L,,,2 (Verification required from Planning Department for new construction) City /State Parcel Identification Number 00( — O - 29 —'se —C)O LEGAL DESCRIPTION Property Location /V w ' / -c- 1 4-) '/,, Sec. 3 TAN -R-_L(eW, Town of o _ Subdivision Lot # Certified Survey Map # , Volume , Page # 9 Warranty Deed # oVI $ q � ,Volume 5 ,Page # Spec house ❑ yes I` i 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 master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal 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 Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days of the three year expiration date. SIGNATURE OF A PLICANT 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. SIGNATURE OF APPLICANT 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 L DI CUMENT NO, WAEEAETT EEE/ t � { (� STATE OF WISCOMIN— FORD! 9 7 3 a7 cJ UN frAa RlQM !0[ SAO pill TS INDENPURR Made b Orvell if. Andersen and s nderson hu s:�an an wi e C: _of St. Cro'.x Count . Wisconsin hers oon L , : December by veys warrants to 3ernard L Franc and Count B. Francis and hus- band and wife as joint tenants, S �ET��■ TO of St Croix F �a�Thcusard Five Hundred t 4, SCC. C�mr*� atrhesanmof the following tract of land in St. Croix County, State of Wisconsin; A parcel of land located in the North Half of the Southwest Quarter ( ?'? of SW,) of Section Thirty -four (34), Tot Thirty -one (31) Pdorth, nanrc Sixteen (1(,) guest, Town of Cylon,St. Croix Count;, Wisconsin, more fulls described as follows Co=.�mence at t:.e Ncrthea_ >t corner of said Uouthwest Quarter (S' ) (being; the center of said Sect Thirty -four (34) as the POINT OF EE- for r.xrcel to to described • *' — , ,,r.ence proceed r�crth �'� °27' West alonrr the North line of sal d S euth Quarter (C4 a distance of 82' to an iron Nipo stake; thence South h2 °33' 'pest alon,6 Northerly line of a private road 155'.50 l to an iron pipe stake; thence South 67 °37 West to an iron pipe stake; thence South � °45' West 66 feet to an iron pipe stake, thence South 1 024' Last 99.50 feet to an iron pipe stake; thence South 1 °261 Jest 256.30 feet to an iron pipe stake; thence A?orth 74 °15' East � -1.50 feet to an iron pipe stake; thence North 7 °42 Ea t 360.50 feet to an iron pi -e stake set on Southerly line of said private road; thence ' 62 133' Fast along said Southerly line of road 1584.44 feet to an iron pipe stake set on West line of Town Road; thence North 3� 0 2 ° t East 54.56 feat to thepoint of beginning. IN WITNESS WHEREOF, the said grantor S ha y e hereunto set t 1h e 1 r han S S 10th this day of Decembe (c. ° "dam — , A. D., 19 SIGNED AND SEALED IN PRESENCE OF Orvell N. Anderson (SEAL) ,Oa,� >n — F rances L. And Pr on (SEAL) Frances Van Nevel (SEAL) STATE OF WISCONSIN, St Croix ss County. Personally came before me, this 10th day of Decemb 6 a theabovenamed Orvell M. Ander and '�D•.I9• Frances L. Anderson, husband and wife, to me known to be the person S who executed the foregoing instrument and edged the same. ugh _ This instrument drafted by = `• J S t .Croix C,.,, W;s oseph W. Hughes =+rw ' �, Ne y C.mmt.lon (8><pirm"1a) Permanent eS.eetsn Z PAI '(1) of th■ wi■e■nttn satwtss ,{{ ,; • a► ariess of th■ St own, a*snas, wltat+t■■■ aaA r• • nt■■eAse scull be" OWay /rlepe sr q e nea thy, WARRANTY DBHD- -STATE OF WISCONSIN, FORM NO. 0 4 auE549 X. 6. sau■ a.. ■n■�■ra r n D I �6s �o N 256.30' Ul N �. I a J i OD \ a s I D � � S � ,Q CD _ _ sr. _ �,