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008-1059-30-000
F • Wisconsin Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM County: INSPECTION REPORT St. Croix GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No -: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)1. 353156 Permit Holder's Name: ❑ City ❑ Village [R Town of: State Plan ID No.: VanSomeren Dan I Town of Eau Galle CST BM Elev.:- In BM Elev.: BM Description: Parcel Tax No.: 1 11. ctO , 0 ` 008- 1059 -30 -000 TANK INFORMATION ELEV TION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic . wo (pD Benchmark �i `r Id2,z ro0 ,d' Dosing Alt. BM Aeration Bldg. Sewer ( Holding St/ Ht Inlet (� � (p ,�°� q(�, e6 r TANK SETBACK INFORMATION TANK TO P/ L WELL BLDG. Air I to ntake ROAD Elt In A Septic asp' 1 NA Dt Bottom Dosing - 1-0 t NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand St cover �r 0.83 O[, 1 Model Number GPM TDH Lift Friction System TDH Ft oss Forcemain Length Dia. me Dist. To well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SYSTEM TO P / L BLDG WELL LAKE / STREAM LEACHING Manufacturer: SETBACK INFORMATION Type O CHAMBER � Model Number: System: v OR UNIT DISTRIBUTION SYST M Header/Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges Topsoil El Yes El No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Inspection #1: / / Inspection #2: / ! Location: 232 222nd Street, aldwin, WI (NW1 /4, SWIA, Section 20 T28N -R16W) - 20.28.16.298 e 6 t£ s �!�'�� '" e 7 Uj / r � Plan revision required? ❑ Yes N No I 6 Use other side for additional information. I to q SBD -6710 (R.3/97) Date Inspector's Signature Cert. No ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: } E € e e « I 5 } € « € } 1 } C e k. 3 } t �c z � i J rl � a .N } e } } «- e a.,.m... e .. ,...m e a w.� .. w, e s, »,. d.a ....._..,.} 9 e E e t } { k 5 f e s � g . e : E t a F e � } E � 3 e i k E ee k x } 3 3 y H 0 . e. „. .., .. .. ...« .gym e e� .a ....€, } E S a. 1 � e }e s 9 y f g S °_ e i e � € .. ., i t � gggggg a �3 2 _ - A r Safety and Buildings Division * 6consin SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue Department of Commerce In accord with ILHR 83.05, Wis. A . n'��.., Madison, WI 53707 -7302 • Attach complete plans (to the count co o for the s st �yoSaper not ies- P p Y c Y Y r� � y ._" _ oust y than 8 1/2 x 11 inches in size. ,.;%' �► �% �-� .�/ZO / �- • See reverse side for instructions for completing this appli atipn REFIVE0 ` Sta Sanitary Permit Number L ± 353 15b Personal information you provide may be used for secondary purposes (^ 7 0q Q' It if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. _ ST GIRrAJ xat Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT AL OR Pro rty Owner Name atibn ..� .t % '; /4 A) 1 a, r ' � 0 T � �3 , N, R l� E n (or� Property Owner's Mailing A dr s of Number Block N umbe r City, St r Zip Code Phone Number Subdivision Name or CSM Number n (� is DO ( y E F B 1 DIN : (check one) ❑ State Owned Ity Nearest Road Public 1 or 2 Family Dwelling - No. of bedrooms Vll wn OF III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) I to 1 ❑ Apartment/ Condo a s ` 3, © ea 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 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43�/ault 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.) Propos (sq. ft.) (Gals day /sq. ft.) (Min. /inch) Elevation — - _____�eet — feet VIL Capacit TANK in a llo s Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank or Holding Tank 1:1 El 1:1 11 1-1 Lift Pump Tank /Siphon Chamber ❑ 1 ❑ I ❑ 1 ❑ ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plu ber's Na e: (Print) Plumber's Signature: (No Sta s) MP /MPRSW No.: Business Phone Number: c- s: �S 10" 6 Plumber's Address (Street, Cit , State Zi Code): / - IX. COUNTY / DEPARTMENT USE ONLY ❑Disapproved Sani ary Permit Fee (Includes Groundwater e Issued Issuing Agent Signa re(NoStamps) ` Approved [I Owner Given Initial Adverse Determination �s Surcharge Fee) at —/1— X. CONDIT ONS OF APPROVAL / REASONS FOR DISAPPROV 0 is 46 t3✓ • i B $ ) p DI TRIBUTION: Ori i unty, One copy To: Safety & Buildings Division, Owner, plumber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at 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. 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 81/2 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. OCT -05 -99 TUE 02'11 PM NELSEN WEBER SURVEYING,M 1 715 425 6864 P.05 Own e.''s name Sari. Permit No. H63.05 PLOT PLAN Show. �- Location of building served 1 VoWiq chamber n' Septic tank ® vertical/horizontal reference point Building sewer Q System elevation is S - �&, Oo Effluent system 1 'tay CD Well Replacement system area tap property lines wjin 50 • of system �-�-� sa' Distribution boxes L.�r! Scale = !! � , or dimensLoned ttiA Pump and controls: • Mfr. &Model No. Vertical, Lift Size Force Main Friction Loss T. D. H. Vol. Dist. 'Pape Gal Min. Gal per Cycle Place check mark in appropriate box, indicating item is shown on plot -plan m � • aq i -d s� X .GA Ptuv`f e.� N o L D S cAmi3 rr r T ��'-� QX4 �rettt�v7 O ��"5E• TSC..p1�s r'1ovk.,,J �p- it�lut� � N �5#�, ��: kti+•S ` Off By the granring or appxoving of the above plan, or upon the event of a' subsequent permit being issued,St.Croixcounty and theSt.CroixCounty zoning Administrator, does not assume or hold itself liable for any defects in plans or specifications, plan omission, examination oversight, construction, or any damage that may result in or after instal anon r s s gna uYe License o. a e OCT-05-99 TUE 02:12 PM NELSEN WEBER SURVEYIMG,M 1 715 425 6864 P.06 a w►.�� rU�+n� S�C4`E EIS "��7,/w+�.+0uw I 1 •�S`i�Lti.. V 1��-f tn,Y Pl�g1= 11.aS�cT 1 -qoF" �V-0 2 i��SS Gt Alne t ill • �• t7 0 � � �-�*�� *���v�tc�v�;� ; �.:.� 1 ��� C.t�J �. ��►av �w�pc��tUdo� �t S 17� � � � b � G frt... •- Wisconsin Department of industry SOIL AND SITE EVALUATION REPORT Kn Page of 3 Labor and Human Relations r Division o4Safety & auilkings in accord with ILHR 83.05, Wis. Adm. Code ' COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but ST • x-20 �X not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. Dos S9 - 30 APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION R EWE BY DATE Z PROPERTY OWNER: Gtr NQW'r } W PROPERTY LOCATION SUKJ Z.(„31V £A1F� -L� NW 1/4 SW 1 /4,SZQ T ZP► ,N,R j b E (a O PROPERTY OWNER'.S MAILING ADDRESS. LOT # I BLOCK # SUBD. NAME OR CSM # eao SPR.ve.�_ ST , CITY, STATE ZIP CODE PHONE NUMBER E]CITY OVILLAGE QrOWN NEAREST ROAD B L�jwf/u /.vt S -Lwz_ ( _)tS) 69q_ \4 l.SO �U G�Lia - z ZZ h 5T'. �C] New Construction Use Residential /Number of bedrooms 3 (] AdditiQn to existing building j } Replacement (] Public or commercial describe Code derived daily flow tAS0 gpd Recommended design loading rate - bed, gpd/ft - trench, gpdA Absorption area required - bed, ft - trench, ft Maximum design loading rate — bed, gpd/ft trench, gpd/ft Recommended infiltration surface elevation(s) - It (as referred to site plan benchmark) / Additional design /site considerations VMO"Miz*j D U 1''Nt- Ti_CPL.ACk I evT r la%JK _ t/ Parent material Low py tie e 1 'tz� L Flood plain elevation, if applicable K A It S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem 0 S IK U ❑ S ®U ❑ S O U 0S O U 0S ®U [is ® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon in. Munsell Cu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trerx�t 1 . , • z S , b VL Y / y - s t` 1 2 `P S b>z to t � s - • 5 , � Ground 3 19 -3t Lry Y% 0 -n-3- Z S1S C S 1 CS61T v�t'�h • 3 elev. q q."1 It y+ Depth to I `, r C limiting -; fac �, sr '999 t Remarks: -�- \ \ `` v►n/c OF Boring # lo1-1li V/y — s>0_.) z °LS •� '� 3 �Z Z9 l0`1 R (1 e •S Tz S /g L° e Sb1 z m Ft- - : Z . 3 s Ground elev. ° t4.o ft Depth to limiting factor tZh Remarks: T Name:- Please Print " ' Phone: Arthur L. - We erer 715 - 425-0165_: Add ress: _ egerer.;Soil.,Testing & Design Service -P.O. Box 74:River'Falls,WI. 54022 ' *nature: Date: CST Number. 0, 5 4 .-� ! PROPERTYOWNER VfVry S���, SOIL DESCRIPTION REPORT Page ?of ° PAR CEL1A bob- MS9- � Boring # Horizon Depth Dominant Color Mottles Texture Structure GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence Bouncbry Roots Bed 7rerxt� r a Z °i -tS l ;Ground 3 1S'M La y/6 a 7•SyR s!g C l e S \P k m `elev. b -5 tt. Depth to limiting factor 1 S i . i i Remarks: y Boring # l 4' } 3 Ground elev. ft. Depth to i • limiting i factor Remarks: Boring # .�w� i Ground i elev. ft. Depth to limiting factor Remarks: Boring # Ground i elev. ft. Depth to limiting factor: Remarks: • PLOT PLAN Pa 3 of SCALE 1 "= y,0 ' tm s 6.1 N 1 1 1 �j t--t. q 6 s 1 - t 1 e0r1P 1 - --3.2 w1u�n� Viett'pu� 0 N t %Y) *� - �. J%O W V- ft�L g f�%U csv- " I MiEsC - -Pa � 715 ) 4 — CST Signature Date Signed Telephone No. CST # Wiisconsin Department oflndushy, SOIL AND SITE EVALUATION REPORT I s !of Labor and Human Relations Division of safety & BuikSngs in accord with ILHR 83.05, Wis. Adm. Code . COUNTY Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but S�' C a O W not limited to vertical and horizontal reference point (84, direction and % of slope, scale or PARCEL I.D. e dimensioned, north arrow, and location and distance to nearest road. C)oS - l0 S9 _ 30 APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION ff DATE 't 1 PROPERTY OWNER: C- ZE T NQWTE}e1jtjQ LKAvsTRLe-5 PROPERTY LOCATION �F NW 1/4 SW 1 /4,S 2A T Z£'j ,N,R ) 6 E ( W PROPERTY OWNERS MAILING ADDRESS. LOT # I BLOCK# SUBD. NAME OR CSM# 880 SpRvC -- S' — CITY, STATE ZIP CODE PHONE NUMBER []CITY []VILLAGE MOWN NEAREST ROAQ BP��w11u,Gvt S4,t,oZ ()ts) 68q -4g3c3 ST. pC) New Construction Use P). Residential /Number of bedrooms 3 [ ] Addition to existing building j) Replacement O Public or commercial describe Code derived daily flow USO gpd Recommended design loading rate - bed, gpd/ft : trertctl, gpd$ Absorption area required - bed, ft - trench, ft Maximum design loading rate — bed, gpd/ft trench, gpd /ft Recommended infiltration surface elevation(s) - ft (as referred to site plan benchmark) Additional design/ site considerations RqM�t>heoj D % fNk- - r w/ 2ePLA t"to �r Parent material Lows (3v 1 z 3 -)t el 'nk-l_ Flood plain elevation, if applicable N A It S = Suitable for system CONVENTIONAL I MOUND W- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem ❑ S M U [I S ®U [] S Q U [] S ®U ❑ S ®U I ❑ S ® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botchy Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr .Sz. Sh. Bed Tfflnch 2 S l Z`F Sbh WI�1^ a, S t��z y! _ S ,'1 z`Psbk ►nil- �s - • •L Ground 3 lo1 - 31 lo`'f YI b ��_sH� sit; e 1 1 csbk wt`Ft� • Z- • 3 elev. o n. - I ft. Depth to smiting fac ti 1 Remarks: Boring # Z Z 6 -k7L to-.cZ- ycy W, o.s �.S s ag Ground elev. `1 It Depth to limiting factor \2 � Remarks: T Name:- Please Print Phone: Arthur L4i erer 7.15 - 425 -016.5 egerer:;Soil Testing . &:Design Service -P.O Box .74 River.Falls,WL 54022 Date: CST Number: . *nature: ', ® R� =6$ A -1 ��� 220254 , IROPERTYOWNER - \)iw Sw-1e!kZta:N SOIL DESCRIPTION REPORT Page Z' 3 PARCEL(D.# 00� �pS9 30 3oring # Horizon Depth Dominant Color Mottles Texture Structure GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Consistence BwXlUy Roots ed Trerxh § B ti h st 1 z `� soh l� `F►- a.,g • S •.!. Ground 3 ZS'M LO`12 y/6 c 7•S�1R S!g C 1 e -S�'lt yn .��, . Z„ • 3 elev t -5 ft. 1 4 Depth to limiting i factor • i t Remarks: t Boring # • i Mound I i elev. ft. i depth to l !imlting factor Remarks: 3oring # t . y,ko:Yr.2 7 i (round 'iev. ft, )epth to Inviting actor Remarks: L3oring # t �'irourid ft. ,apth to siting EE ctor,: Remarks: PLOT PLAN Page 3 of SCALE 1"= QL96 1 S 5 0 8.1 N —'1 1 c ol , 5 l � 1 w`�,oZ� `►�wT f 0 w�u�n� l�eefio� { 0 N ti a�'1�1 - �,l�v. 1�0 , p' oo� ���- 8'+�8 UvC GRc� t►U ��c- po � , 8►^1w> tELEX) tw-s' a1 �Ul� (JF 3Z``HIGI� 1 1'E1vuE -OFD, I � �/� Z - zc jz s f ( 715 ? 42q CST Signature Date Signed Telephone No. CST # OCT -05 -99 TUE 02:10 PM NELSEN WEBER SURVEYING,M 1 715 425 6864 P.09 STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER RXh�, C 1, Kj Wf fWj �i M MAIL411iG ADDRESS 'Q Q 6 AUt 1�t?tt_.bt-J bly , K1 ) S vUO Z PROPERTY ADDRESS Z-3 -zz.Z 4a S T . �3#`�l Q►n.i) t�J� 1 � l S q U Q z (location of septic system) Please obtain froze the Planning Dept. CITY /STATE PROPERTY LOCATION NIA3 114, S W 114, Sectiou _� O , T N -R b W TOWN OF fit.] C� t'e'a , ST. CROIX COUNTY, WI SUBI)MSION '--� -- , LOT NUMBER CERTIFIED SURVEY MAP -- , VOLUME _ — PAGE ' , LOT NUMBE 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to 5t. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on - site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 113 full of sludge and scum_ Me, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: DATE: St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11193 OCT -05 -99 TUE 02:10 PM NELSEN WEBER SURVEYING,M 1 715 425 6864 P.02 S T C - loll This application form is to be complated in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, (spec house), then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. Owner of property a� 1 )N, BUNION \1 $t J �4yl _ Location of property tiU Z/q Sly] 1/4, Section Z ,`x z8 N--R 1 (O ~ W Township �� GfrtS -L Mailingaddress - I �sO k -N A Q 1 . , 1 -i t SL,I D O Z Address of site 23Z ST, W}Aj 1-.11 svoo ,. Subdivision name Lot no. -� Other homes on property? Yes '� No Previous owner of property Gi b' X-�OSz�,1 }1v5�yST )AjC . Total size of property pro.'t Total size of parcel 1 3 � Date parcel was created Are all corners and lot lines identifiable? �'` Yes No Is this property being developed for (spec house)? Yes < L— No Volume L4—S and page Number 6:�8 as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATXON THE FOLLOWING: A, WARPJkNTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGXSTER OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. It the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the Property described in this information fprm, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. 6) oq �7 , and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No, Signature of Applicant 1 pp Co -App t li Date of Signature Date of Signature t= VOL 1461FAGE 226 /] 611554 ' r'eC- - KATHLEEN N. MALSH Dowmart Number ! Docameat Title REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD 10-05 -1939 11:00 AN AGREEMENT �T COPY FEE: COPY FEE: TRANSFER FEE: RECORDING FEES 12.00 PAGES: 2 R- ordiag A. Name aad ReWm Address ��lCir� {f8,r,,sam�.r� 730 (a A,se- n lt) l 5`00 Z DO $- 10S9- 3a -cwo Parcd IdmtiificMim Nmaber aPINI - "THIS PAGE IS PART OF THIS LEGAL DOCUMENT - DO NOT REMOVE" T hi. iofomutim mud Ue eompldM by mbiaitter: Aoaenou dk, � do noon m7drrlr. mid !N ev ie roalin claraa, k � fV regwa). Other %tdora.ada. P;M d r I f d A`04 .. ex- awry be placed am ddi f&u pine of Ae doarana ar may be placed ea addUa d pa ;a of d. doaanpic tl—i Ure of dde coin pare ad& aae pare m yaa- doc rnear mid SZ.Ib m di, rcmn ft 4e Wireauv. SramrrJ. Sp.Sl7. WRDA 21% i _ STC - 106 L VOL 1461 PAGE 22'7 PRIVY INSTALLATION AGREEMENT St, Croix County, Wisconsin PRIVY IN STALLATiON AGREEMENT -COPY TO BE ATTACHED TO THE SANITARY PERMIT APPLICATION. Pr rty owner(0: Rexrved Fo, Re<ordwe Oat& �_A W. O N A a -43nts_F w Ma. nq Addreu: r. toutwn: w � `� NE }•$� },S�Q TAN R1 EorW Gty, vdtage avnsh,p �: Ept Q 6 frLL�, ..reel Tax Number: C - 10;5 000 Legal Oewipt,on; Tf W - t <<k CAF Ai-e, 5 W - 1 (4 au rc, 1. No plumbing will be installed in the privy. 2. No plumbing will be installed in the premises served by the privy unless a code compliant soil absorption system or holding tank exists, or a valid sanitary permh to install such a system has been issued. 3. A privy vault /pit shall maintain minimum setbacks as specified in Table 1. Tablet Well Building Lake /Stream Additional County Setbacks Open Pit 50 Ft 25 Ft Min. 75 Ft Sealed Vault 25 Ft 25 Ft Min. 75 Ft 0. Privies for public buildings shall c0mplywithlLHR52 .63,WisAdm.Code.. S. Privies used for one -and two-family purposes shall be constructed in such a manner so as to exclude flies, rats and other vermin. Doorsshould be Self-closing and vault ventilators should terminate at least one foot above the roof. 6. A privy vault shall be constructed of watertight plastic. fiberglass. coated steel or monolithic concrete. Materialsshall comply the intent with ILHR 83.20, WIS. Adm. Code. Counties may, by ordinance, establish minimum sealed vault sizes and type or construction within the guidelines of ILHR 83.20, Wis. Adm. Code. 7. The privy shall be kept clean and sanitary. The contents of the pit or vault shall be disposed in accordance with NR 113. Wis. Adm. Code. B. This agreement shall be binding on the owner, their heirs and assignees. This document shall be recorded by the register of deeds in a manner which allows its existence to be determined by reference to the prope ny where the privy is installed. ^nt ner s Nam t �' fl la @ Subscribed and sworn to before me on this date: •j t r N e r J y commission expires on � NOTE: This document was drafted by the State Department of Industry. Labor and Human ela'tions. Bureau of Building Water Systems. OCT -05 -99 TUE 02:11 PM NELSEN WEBER SURVEYING,M 1 715 425 6564 P.04 ,. 10 Ij STATE BAR OF WISCDNSIN FORM I - 1999 ir:p JL CS-4L6 WARRANTY DECD RECISTEK H. DEEDS pgCt"r+onr lw�mbar 41,E 1 /a 56 Phu G38 ST. CROI CD. WI RECEIVED FOR RECORD This Deed, made between GREAT NORTHERN INDUSTRIES, INC. , 49 -16 -1999 3:00 PM attiinnet} corp _ WARRANTY DEED -- EXEMPT A (;rantor. CERT COPY FEE; and _DANN J . VAN SOME and CINDY L . _ COPY F(£: nd hustia eDd wife as suY Vvoki TRANSFER FEE: 533.50 ma �� 1�pQpxty .__ RECORDING FEE: 10.00 PAGES: I Grantor, for a valuable consideration. conveys to Grantce the following described real estate to St. Croix County, Slate of W)scomiin (the 'Property'), ..,,"' Name and Aeturn Addrass F1AV IUMONLI BAR OF BALDW111 %10 MOM rhea! 008-1059 -30 - 000 Parcel tdentificaUen Numbs iiRtNl --- -_ - -__ Thia - n� o pt homestead property ( 03 not) NW -1/4 of the S14-1/4 of Section 20, Township 28 North, Range 16 West, St. Croix County, Wisconsin. Together with all appurtenant rights, title and imtcresls. Grantor warrants that the title to the Property Is good, Indefeasible in rev simple and free and clear of encumbrances exrgpt - none Dated this 157-+' day of 33sU ° je - -,�gqy GREA NORTHERN 1NrPSTRIES, INC. (SEAL) (SEAL} " • BYs Douglas D. Slack„ l Presi (SEAL) (SEAL) AUTHENTICATION ACKNOWLEDGMENT 51�rtatura {c) Stott of Wisconsin. _ as. St. C ro ix County. authenticated this day of —_ Personally carne before mo this ��_* day or 2r- g9+fAM , -12D— the r named TITLE- MEMBER STATE BAR OF WISCONSlh( — _ � to (If not, me known to be the person who executed the foregottt8 authorimol by 5706 06, Wis. Scats.) instrurnont Bnd acknowledge the same. THIS INSTRUMf~NT WAS t]RAfTEO tav Attorne Lgrr C. Lundeen MUDGE, PORTER, LUNDEEN & SEQUIN, S.C. Notary Public. State or Wisconsin ~� 10 52 Street, Hudson, W isco nsin 540 16 My commission is permanent. (I[ nol. state expfrmjon date: (S)$ natures may be authenticated ar atknowlct)ged. Both are not — Np y�ubAC btel+e d W*Q~ } necessary) pyiip 1,Irti�Mt'17, ice _— Nnn., nt prv.n,•..,p„mp v. ...r rgiariq mqa r. rprA m prinaef r ✓rnw m »Ir SVR�nw:r Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Coup y: . ♦ Safety and Buildings Division Croix INSPECTION REPORT J GENERAL INFORMATION (ATTACH TO PERMIT) San35�Perm No.: Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)1. Permit Holder's Name: ❑ City p Villa e Town of: State Plan ID No.: Van Someren, Dan & Cindy Eau Gal e CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: l 008- 1059 -30 -000 TANK INFORMATION EL VATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic �•� /duo Benchmark Z. S� Z, Dosin Alt. BM Bldg. Sewer j H g St/ Ht Inlet TANK SETBACK INFORMATION TANK TO P/ L WELL BLDG. Air I ntake ROAD Air Septic 7 -rU r ! Zv NA Dt Bottom Dosing �Sd ` �� t f NA Header/ Man. w � 3,3� !o z A n A Dist. Pipe 7� 3 Holdi Bot. System e UMP / SIPHON INFORMATION (;t Final Grade Manufacturer Dem nd St cover Model Number 'ZP'OGPM W -. N Z- U lOd TDH Lift Friction SystemZ. TDHZp 3 t ead oss Forcemain Length f? Q Dia. " Dist. To Well SOI ORPTION SYSTEM r S EN C Width i length No. Of Trenches PIT No. Of Pits Inside Dia. N I y7 Z I N SYSTEM TO P / L BLDG WELL LAKE /STREAM ING nufacturer: SETBACK CHAM INFORMATION Type Of j r Mo er: System: l0 j ± 5�5 - - ---- _ OR U IT DISTRIBUTION SYSTEM Header / Manipld r� Distribution Pipes ,Z,% ' , x Hole Size x Hole Spacing Vent To Air Intake Length 1-1 Dia. Length Dia. L y 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 Q I nspection : /1 %lo I f q in spection : i/ G Pr f COMMENTS: Include code di5cr W1 ll�i��w��'' n ,,p 1j4 J % W) - 20.28.16.298 U< /o 9, o Location: 232 2 2nd St., Baldwin, 1.) Alt BM Description = boy,, 6o+r(r S�r/I� SrG�.a� 1 6 •� c�><t�t 2.) Bldg sewer length = s�,a✓ 4 rock- - amount of co = 3, q 5- b U1140JAr r- all " i , l� fG�io/QCC YD Q��'r v y ? an revlslorfregtlired. Yes ❑ No Use other side for additional information. Z Z SBD -6710 (R.3/97) Date( Inspe is Signature Cert No i ADDITIONAL COMMENTS AND SKETCH 4 F SANITARY PERMIT NUMBER: i o I Safety and Buildings Division Visconsin SANITARY PERMIT APPLICATION 2201 B Wa 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 paper not less County than 81/2 x 11 inches in size. ST ep • See reverse side for instructions for completing this application State Sanitary Permit Number 353 ,P-31 Personal information you provide may be used for secondary purposes ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. LL State Plan I.D: Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N Pronerty Owner Nam L cation rope o V � y1 �t i4' Y � la �? 0 va, S d T 2 , N, R I.6 E =(0 rq,Pei Maili7Ad iriess Lot Number B ►ock Number Cit StatQ Zip Code Phone Number ubdivision Name or CSM Number II. TYPE OF BLTI LDIN : (check one) ❑ State Owned ❑ it Nearest Road �,, Public 1 or 2 Famil Dwelling - N o. of bedrooms ° row OF Ge� LC.� 2 .Z� S III BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) — O 30 QM 1 ❑ Apartment/ Condo Ca - 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 SA 0510 - ermit was previously issued. Permit Number 3S3 Date Issued lo 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 i 42 ❑ Pit Privy 13 ❑ Seepage Pit / Q ) q x 43 ❑ Vault Privy 14 ❑ System -In -Fill e V ABSORPT SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Require s .) Pro osed (sq. ft.) (Gafs/da /sq. ft.) (Min Inch) Elevation 7 i 2-- D eet Capacity VII. TANK in Ca allo g Total # of r Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed Tanks Tanks Septic Tank or Holding Tank oG�D� ❑ ❑ ❑ 1 ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ 1 • ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber Name: (Print) Ptum er's nat re: (N Stamps) MP /MPRSW No.: Business Phone Number: Plumber's Addre Street, Cit State, ipLQd i 'Y7 --.3�� IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sa - tar)r Permit Fee (includes Groundwater D ate Issued Issuing Agent Si ict re (No Stamps) P Approved Surcharge Fee) [:]Owner Given Initial � Adverse Determination a5-. X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD- 6398 (R.11/97) DISTRIBUTION: original to county, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS ° 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at 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 of 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: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. 111. 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. Safety and Buildings PO BOX 7162 MADISON WI 53707 -7162 _ TDD #: (608) 264 -8777 N *isconsin www.cornmerce.statemi.us Department of Commerce Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary November 04, 1999 CUST ID No.267341 ATTN.• POWTS INSPECTOR WEGERER SOIL TESTING & DESIGN ZONING OFFICE 421 N MAIN ST ST CROIX COUNTY SPIA PO BOX 74 1101 CARMICHAEL RD RIVER FALLS WI 54022 HUDSON WI 54016 RE: CONDITIONAL APPROVAL APPROVAL EXPIRES: 11/04/2001 Identification Numbers Transaction ID No. 274190 Site ID No. 183730 SITE: Please refer to both identification numbers, Site ID: 183730 above, in all correspondence with the agency. ST CROIX County, Town of EAU GALLE 1 NW1 /4, SW1 /4, S20, T28N, R16W r. Facility: DAN & CINDY VANSOMEREN 232 22ND ST, BALDWIN 54002 C6: ,:.. FOR:' Description: REPLACEMENT MOUND DWELLING 450 GPD`� Object Type: POWT System Regulated Object ID No.: 499991 ptViS1QN L''e' SAI n, The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Code and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in SE CURE chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. The following conditions shall be met during construction or installation and prior to occupancy or use: • 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 11/02/1999 FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 ?AMESQUINLAN , POWTS PLAN REVIEWER BALANCE DUE $ 0.00 Integrated Services (608)266 -3937 , JQUINLAN @COMMERCE.STATE.WI.US WSMART code: 7633 cc: DAN & CINDY VANSOMEREN I Page of 6 MOUND SYSTEM FOR A 3 BEDROOM RESIDENCE LOCATED IN THE tiW 1/4 OF THE SW 1/4 OF SECTION 113 ,T "-b N, R lJo W, TOWN OF ) 6 .� , S'T. <%_" X COUNTY , WISCONSIN. INDEX PAGE 1 'of 6 TITLE SHEET PAGE 2 of 6 PLOT PLAN PAGE 3 of 6 PLAN VIEW -CROSS SECTION PAGE 4 of 6 DISTRIBUTION PIPE LAYOUT -PAGE 5 of 6 PUMPING CHAMBER�, PA GE 6 of 6 PUMP PERFORMANCE CURVE v D PREPARED FOR ' 0r" i®r�r'z: ETY At11iU1LL,n•�S Ze j ��'CN 1�'!W C ll�h>�{ V ipU Sd"1�'RLN 3l� 6 AVE)%,jUp \ESPONDENCE $twL1v , w� s tj o Z RE'CEI'1IED NOV - 21999 PREPARED BY Wm & BLD86. DIV. WE3 EEREF2 SO I L - TEST I NG AND . ������4es�HN � DES = CN SERV = CE F.0. BOX 74 421 K. KAIK ST. RIVED. FAILS. KI 54022 , = ARr41rR L 11S- 4L.r -OI6J � � w'er;FiER pa ELLO S�N,�RTN, wr . a+ c .. '. S'ICV' JOB NO. —� �' PLOT PLAN - Page 2- of � Scale 1 "= 40' QL�6 8M 1F•2 �'sy CCOSCSR�c - TU wl.o' 8rti �S rj •�`"'t 9q? N I 5 a.� N z$Pue F.ra . z5 3 9D 18.3 V1_ �1j - 1C ti'1, R 6 S ' i. oR 1 ale f— SC � lS`1ti2B 'Ttt�SN tC'1Z�S` z s^ g+^�� - 2 _— L�U � 1 W:S ` a►�J �Ol� OF 3Z" l� _T�LN�? ►�� NOTES •1. Elevations shown are existing ground elevations unless otherwise noted. 2. Install permanent markers at end of each lateral. ( y required) 3. Install 4" observation pipes with approved caps. ( 7 7 — required) 4. - Septic tank to be 1.000 /be gallon capacity manufactured by u)'j I -i L-\ L boa 5. Bench Marks SIZE "Utip 6. Divert surface water around system to prevent.ponding at the uphill side. Page 3 of Approved Synthetic Covering rtsTm C 33 Distribution Pipe Medium Sand H — G , Topsoil F Elev. Vz t.- �l) H - , D 3 E Slope Trench Of 2 2 2 Force Main Plowed Aggregate From Pump Layer Undisturbed D Z -O Ft. Soil E Z . a Ft. Cross Section Of A Mound System Using F b-8 Ft. 2 Trenches For The Absorption Area G 1. .0 Ft. A y Ft. H 1.5 Ft. B W1 Ft. C Ft. Linear Loading Rate= 4.19 GPD /LN FT I i Ft. Design Loading Rate= _ GPD /SQ FT J `O Ft. uPsQVI pk TSZ Ct} � 0.3 k , bl twvu SLOPE ?R0vCN ; a .'z-q K , K 1 Ft. A! te i ion o L 1S Ft. W Ft. L J B K O bservation Perm C I ►— - - - Pipes Markers i) S PIT (Anchor securely) _ _ _ _ _ _ Force L= -_ - - -- — — — — — — — — — — -� Main W � Distribution Trench Of 2 2 2 Pipe Aggregate I Mound Using 2 Trenches For Absorption Area Page q Of b Perforated Pipe Detail / 0 End View Perforated End Cap PVC Pipe `ob oe `e Install permanent - marker at end of each lateral Holes located On Bottom, Are Equally Spaced S PVC Force Main T PVC Manifold Pipe r Disiri I uTion pipe Lost Hole Should Be Next To End Cap End Cap . P Z Z. Ft. Distribution Pipe Layout S Ft. X LiB Inches Y V8 Inches Hole Diameter 1 I 1 f Inch Lateral 11Y Inch(es) Manifold Z Inches Force Main Z Inches # of holes /pipe b Invert Elevation of Laterals l0k•,S Ft. Place lst hole from center of manifold with succeeding holes at V$` 'intervals. Last hole to be next to the end cap. Combination Septic;Tank and PUMP CHAMBER CRO55 SECTION AND SPECIFICATIONS' PAGE S OF Io VEAIT CAP WEATHER PROOF I JW.IC BOX 'i - C.1. VENT PIPE APPROVED LOCKING x.10' FROM DOOR„ MkWHOLE COVER rv11l - ,,%IUDOW OR FRESH wARrJI>JG LA6EL A R IWTAKE Co saDU1T r 5u N FX t2:1 Ot y " I�JSV`nn►a PI?t l � l - - - -- PROVIDE I I AJ LET -- • AIRTIGHT SEAL APPROVED JOI �gFFL� A I i APPROVED JOIIJT:' W /C.I. PI PE OK Tank construction i I'I wiC.I. PIPE�f'�O ALARM shall comply with "I II ILHP I >3.15 and 33.20- s I I I { ON � I I 85. sy i CLEV. FT. PUMP, __J � OFF D COWCRETE BLOCK 1 3" AVPRo?e RISER EXIT PERmiTrcD OIJLy IF TAWK MA WUFACTURER HAS SUCH APPIkOVAL B>~flOIN SEPTIC E _ 5PEC,IFICAT10US DOSE TA W Kj MALI UFACTURC R: NUMBER OF DOSES: 3 15 PLK 0" TAWK SIZC : 1OO6 60t' GALLOQS DOSE VOLUME z ALARM MANUFACTURER: S.S. TnO ��IS`t-�1'tS INCLUDING BACKFLOW: X a GALLOti: MODEL ►JUMBCK CAPACITIES: A= IWCHE50R 301 GALLONS hLTccz.Y SWITCH T�PC: B = IWCHES''OR G�LLOWS FRUMP MANUFACTURER: ZU C= IULHES OR �� GALLOWS MODEL ►DUMBER: D= S INCHES OR 'GJ GALLOWS SWITCH TYPE: �ZL MOTE: PUMP AND ALARM ARC TO 5L MIIJIMUM DISCHARGE RATE Z&'q% GPM IN5TALLED ON SEPARATC CIRCUITS vEKTICAL DIFFERENCE DETWEEW PUMP OFF ALID 0I5TRIBUTIOW PIPE ` `FEET + MItiJIMUM METWORK SUPPLY PRESSURE , , . , , . , , , . . 2 FEET T� + �S FEET O F FORCE MA X F �' Y1 FACTOR_. V a-7 FEET TOTAL OtIMAMIC. HEAD = �� FEET Pump chamber DIAMETER IMTERIJAL DIMENSIOWJ OF TANK: LELIGTH ;WIDTH ;LIQU10 DEPTH 36 INCH BOTTOM AREA � 231- GAL /INCH AS PER MANUFACTURER GAL /INCH 7->f�-Gc 6 U= 6 --� 13/16 7 7/16 -� w W HEAD CAPACITY CURVE MODELS 137/139 - 6 1/8 MODELS 1371139 Ft. Meters Gal. Ltrs. s 5 1.52 93 352 0 of 4 13/16 25 10 3.05 79 299 i 20 I I• f 15 4.57 64 242 o as r 6 1q.9 ( 20 6.10 36 136 � 0 1 1 /2" - 11 1/2 Nr'i 0 1s 25 7.62 8 30 4 28.06 137,139 30 9.14 10 Lock Valve: 26 ft. T 2 I jl f s I A I I 13 I 0 i U.S. GALLONS 10 20 30 40 50 60 70 90 90 100 1110 LITERS 80 160 240 320 40o I 4 0 FLOW PER MINUTE / 1 SK373 _ 009921 CONSULT FACTORY FOR SPECIAL APPLICATIONS Three phase pumps are available in 200/208V, 230V or 460V. a Variable level control switches are available for controlling single and three Electrical alternators, for duplex systems, are available and supplied with phase systems. an alarm. a Double piggyback variable level float switches are available for variable Mechanical alternators, for duplex systems, are available with or without level long cycle controls. alarm switches. a Over 130 °F. (54 °C.) special quotation required. Combination starters are available for 3 phase pumps. a Refer to FM0806 for 200° F. applications. e Control alarm systems are available for 1 phase pumps. 137 Series - 47 lbs. 139 Series - 51 lbs. SELECTION GUIDE Single Seal Control Selection Listln s 1. Integral float operated 2 pole mechanical switch, no external control required. Model Volts - Ph Mode Amps Simplex Duplex CSA UL M137/139 115 1 Auto 10.7 1 or 1 & 8 - Y Y 2. Single piggyback variable level float switch or double piggyback variable level N137/139 115 1 Non 10.7 2 or 2 & 7 3 or 5 & 6 Y Y float switch. Refer to FM0447. BN137 115 1 Auto 10.7 Y Y 3. Mechanical alternator M - Pak 10 - 0072 or 10 - 0075. Refer to FMO495 37/139 230 1 Auto 5.8 1 or - 1& E - Y Y E137/139 230 1 Non 5.8 2or2 &7 3or5 &6 Y Y 4. Combination Starter. Refer to FM0514. E7 H1371139 200 -208 1 Auto 6.2 1 1 & s Y N 5. See FM0712 for correct model of Electrical Altemator E -Pak. 1137/139 200.208 1 Non 6.2 2&7 3 or 5 & 6 Y N 6. Variable level control switch 10 - 0225 used as a control activator, specify duplex J137/139 200 -208 3 Non 2.6 2&4 3 &4 or 5 &6 Y Y (3) or (4) float system. F1371139 230 3 Non 2.6 2& 4 3 &4 or 5&6 Y Y G137 460 3 Non 1.4 2 &4 3 &4 or 5&6 N N 7. Four (4) hole J-Pak, junction box, for watertight connection for hardwired simplex 6139 460 3 Non 1.4 2&4 3 &4 or 5 &6 N N operation, 10 -0002. No molded plug **Single piggyback switch included. 8. Two (2) hole J -Pak, for Watertight hardwired Pconnection or splice, 10.0003. Pumps must be operated in upright position. CAUTION Three phase units require a control switch to operate an external magnetic or combination starter. All installation of controls, protection devices and wiring should be done by a qualified licensed electrician. All electrical and safety codes should be PiggybackVariab For information le Level FloalSwitches, FM0477: Ele additional Zoeller products refer tr, catalog calAltem at Combination starter, F llema- followed including the most recent National Electric Code (NEC) and the ledriator, FM0486;Mechanical Alterna- tor, FM0495; Alann Package, FM0732; and Sump/Sewage Basins, FM0487. Occupational Safety and Health Act (OSHA). RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. MAIL TO. P.O. BOX 16347 Louisville, KY 40256 -0347 Manufacturers of. . SHIP v 3 a Run Road Louisisville, , KY KY 40 40211 -1961 %QrrPuuP9svc6 /47JJ p (502) 778- 2731.1(800) 928 -PUMP FAX(502) 774.3624 Wiisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Pa of 3 Labor and Human Relations �— DivWon of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY "Attach complete site plan on paper not less than 81/2 x 11 inches in size. Plan must include, but ST - Z"�ZzLX not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. 00S - 10 S9 - 30 APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION R IEWFDBY DATE PROPERTY OWNER: PROPERTY LOCATION _ L L N W 1/4 SW t /4,S ZA T Z� .N, ) E ( W PROPERTY OWNER':S MAILING ADDRESS. LOT # BLOCK # I SUBD. NAME OR CSM # CITY, STATE ZIP CODE PHONE NUMBER (]CITY EIVILLAGE (MOWN NEAREST ROAg bf�lrl�wtlu,fv s) 68 -yq5 0 )F_4'v Gfr_L_I_ ZZZ ST. [ ] New Construction Use Residential / Number of bedrooms [ J AdditiQn to existing building QQ Replacement [ ] Public or commercial describe Code derived daily flow tASZ gpd Recommended design loading rate - bed, gpd/ft • trench, gpd/ft Absorption area required 115 bed, ft 31S trench, ft Maximum design loading rate ' y bed, gpd /ft • S trench, gpd/ft Recommended infiltration surface elevation(s) l01.O ft (as referred to site plan benchmark) Additional design /site considerations Y1)Q JD l-1 /Z - TR UCtt L1 �l X �1� W/ Zq " of Sf1 ELL, Parent material L.oQ'3s S Gy C1"t e• 1 'n\-L_ Flood plain elevation, if applicable N A It S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSU77 ATHOLDING -GRADE SYSTEM IN ALL H TANK U= Unsuitable fors stem ❑ S ER U [is O U ❑ S o U ❑ S ®U ❑ S ®U [Is ® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon Texture Consistence Bcuxry Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. g� Trer>ch M 1 z s i\ S b>z wl'�t^ a S _ , s 2 8 -1-°t W - Y!y _ s,` \ Z� Sb� >n �I � s - • S , � Ground 3 19 -31 L (,'I Yob e-� -S j 2 S1?, elev. 0 8. 1 1 ft. Depth to limiting factcLr h Remarks: Boring # %S h \Vvs _. O - 1p`lR 91 Z s� z.' i1- (2,S • S`- Z. �vl9- y y - stc.� Z,`�sbk >h f>_ a..s e� 3 Vz zq 1�`1tz vl6 1•skR S/g r1 Ground elev. ft Depth to limiting factor �Z h Remarks: T Name: - Please Print 'Phone: Arthur L.•We erer 7.15 -425- 0165 ress: - ,egerer, -Soil ;esting & Design Service - P.O. Box :74. River. .Ta11s,WI 54022 Signature g Z (' if Date: -1 O� 4 Q _CST Number 2 20 2 54 1 PROPERTY OWNER Vivti St"1c5ZeN SOIL DESCRIPTION REPORT . Page ? of i PARCELIA# (n :S Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bourxlary Roots GPD /ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trends y S� i Z � sbh ryf �f+-- Q.s 1 • s - L Ground 3 1S 31 LO`/fZ y�6 a 7•SHR. s!g C 1 es�► h1'�� - - z. .3 elev. 0tb -S ft. Depth to limiting �ac i Remarks: I� 6 Boring # a�µ • I Ground ` elev. . ft. I Depth to limiting f factor i Remarks: Boring # i Ground elev. ft. Depth to limiting i factor Remarks: Boring # 1`= Ground eleY, ft. Depth to limiting factor: I Remarks: _ PLOT PLAN Pa of 3 SCALE I"= Ljp ' i R,ri$ 23 QL�6 i V� `J N 8M W W�L LIM Z EL.9. 9.V, 7 $u1Zpl -i aF �s� l �%1\ LaL.p• s �cuvY S -1 N zs'��� S � o' 11 k at 6 S '� I 1 V" 1 l� �� DoT Coh�ner `�"P�ntT O o.t n\s1titiZ N -R`�E �ss14s Wlu� �Ct?VQM Q 715 ) 47.5 —f31 h5 CST S Date Signed Telephone No. CST # Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT page I of 3 Labor and Human Relations 9 — Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY 'Attach complete site plan on paper not less than 8112 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference int BM direction and % of sloe ale r PARCEL I.D. # Po ( ), slope, scale o , dimensioned, north arrow, and location and distance to nearest road. ' (:!,C) S - ZO SC) - � APPLICANT INFORMATION PLEASE PRINT ALL INFORMATION REVIEWEDBY DATE PROPERTY OWNER: - PROPERTY LOCATION �� CL },.t -G 49F NW 1/4 SV3 1/4 � O jU ClZ. -<�V .S T ZPj .N,R ) b E( W PROPERTY OWNER':S MAILING ADDRESS. LOT # BLOCK # SUBD. NAME OR CSM # _ -- CITY, STATE ZIP CODE PHONE NUMBER ❑CITY E]VILLAGE IRTOWN NEAREST ROAD, l�f'�l_C�wl1u LV I S4ouZ f7LS) 6Sy -y�lSp 'R-ti G -t_� ZZ2r to ST. (J New Construction Use Jq Residential / Number of bedrooms 3 [ ] Addition to existing building QQ Replacement [ ] Public or commercial describe Code derived daily flow IAS0 gpd Recommended design loading rate - bed, gpd/ft • trench, gpd/h Absorption area required 31S bed, 11 31S trench, 111 Maximum design loading rate bed, gpd$ • s trench, gpd/9 Recommended infiltration surface elevation(s) y 1.0 ft (as referred to site plan benchmark) Additional design/ site considerations W f Z �.�v ,Ali 4 X U� w 2.,w tom- Sf2� F;LL -- Parent material \ Q EE-7S S ov -t 1Z e l 'n\-L Flood plain elevation, if applicable ti-1 A It S = Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE I AT -GRADE SYSTEM IN FILL HOLDING TANK U= Unsuitable fors stem 11 S E U ❑ S Z U ❑ S 9 U [IS ®U [IS ®U [IS ® U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Structure GPD /ft Boring # Horizon Texture Consistence Bo ndaty Roots Bed Trerldt in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ti a_ 8 to 2 1 z 1 � �t►z yly - S i1 Z�Sblc 1n'�t- �S - -S . i Ground 3 19 -31 lo` -t.2 elev. OL2L It Depth to limiting factor 4 Remarks: Boring # O - 1p` - Z 6 -" y1v _ stc.� Z,'�sUlz >nfF- a.s •� €,5 I 3 �Z z9 to`� t� X16 e �•s �cR s/g e �11-sbk, r►t. Ground elev. c t_o ft. Depth to limiting factor �Zh Remarks: T Name: - Please Print Phone: -Arthur L. -We erer 715- 425 -0165: ress: egerer.- ,Soil esting & Design Service - P.O. Box :74 . River Ya11s 54022 Signature: Date: - CST Number . ��_ �6� 1,)-'1,-C19 22025► PROPERTY OWNER Vt�►v SOIL DESCRIPTION REPORT Page ?of ' Pa bob- S - 3 PA R CEL LD. # I 0 �) p Depth Dominant Color Mottles Boring # Horizon in. P Texture Structure Consistence Roots GPD /ft Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Y ^> : Bed Trench '•Z 3 1 0 -9 1D`1R 3�Z St Z�'sbtz'Fr CL ........... <:< >:::: Z °t o K R V/ L/ Ground 3 1S -31 laLi2 u/�6 a 1•SHR. Slg C l eS PtZ elev. qb -S it. Depth to limiting factor i l 5'` i f l Remarks: 1� Boring # i i Ground i elev. ft. Depth to limiting factor Remarks: Boring # K ;:4i �S411iK iiiY Ground elev. iL Depth to i limiting i factor, Remarks: Boring # i gg Ground elev. ft. Depth to limiting factor,. Remarks: _ IL PLOT PLAN Pa of SCALE 1 "= Lq0 Q1�tj i N 4� tM *' C L9 13 0 F- of TV1ve H IV- Lo 4 i 5 0 z s ---, I �tow1� v ot 6 S Vi u 1 fib' bO NpT COv3�ft ! rn O o�Z U�Shti. -U `� "'PI.Rt�"1L`.►vT -mu N � E ri1ZCrRS LUe u rn p >.uo 8��2� =:��: ipD.S` a►J1U�OF 3 Z 4 HfiGN- - �iL�?HtiIN_���. _9 zzoz s (715 ) 425 -n7 h5 rat CST Signature Date Signed Telephone No. CST # ST C COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM i Owner/Buyer ; 1 17 � -7 -� Mailing Address 7 3 4 Prop /3 Property Address .S (Vuificatioa required from planning Dgmtm=t for new coastructioa) CitYlState Parcel Identification Number L& AL DESCRIPTXON Property Location uJ %, /<, sec. 2 p, T � PN -RAW, Town of Subdivision Lot # Ce Wed Survey Map # Volume _ . Page # Watxaaty Deed # Volume �L rage # Spec house ❑ yes ❑ no Lot lines identifiable ❑ yes ❑. no ANCE T xqwqmnwwdnn oryour eUcineouldmsakiahsp to handlewasteLPwpernmfi& aaoe ofpMapiag out 60 sepac to k CyaY d= yrms or soot if wedod by a Hc=scd prep r What yua pat into the system a�ri x�xt the -,oa of the septic taairss a trcabmeat stage is >be vPaste disposal- systcni„ - . TM pmpcdy- over sgroes to :ubD¢it to St. « +one &dwe Department it oatifcWba form, sigzvod by tlaa own= ud by a ' phm baorali=mcdp=q=vc yinihit(l)thcoa stcWxter&iposatsysCem is Pj'�Pu S eorrditioa sndtm (2) der won and pmrpn Cf==u the septic tmk-is t= d= W full of Budge Ywr,, dw hime.nad &c abm mgairauacau and agree to aaaiaana the privaoc =wage disposal syst= wi& tlu standards set CaA bae°•vs Eby the Dqmftcd of ommiertie and tlra Departavcat of Nat ud R,esoarecs. State of Wasoonsia.. O etafmg that yoeu'sRldc sy = bas boca maiataiacd must be aompIctod and rcumcd to tie St. Croix Cotmty Zoning Offce v+n = 30 dayx of tha tlanx year eacpiratiore date. -- 0 i9 SIQ3A. APPI.ICAi!T!' DAYS O'P1rN'R• tCER77PTCATtON I (WC) eectify that all stag on this form am true to the best of my (our) knowledge, I (we) am (are) the owners) of the Property 4=n- cd by virtue of a warranty dcod moorded in Rc&tcr of Dodds Office. SIGNA7UIt8 APPUCANT DATE ssssss Any information that is mis -reps+ Cutedmay result is the tanituy Pumit being revoked by the Zoning Department. ss's ss Include with this application: a CUmpod wamaty dood from tic Register of Donis office A Copy of the ceriifod ttuvcy trap if reference is made in the waaanty decd OCT -05 -99 TUE 02:11 PM NELSEN WEBER SURVEYING.M 1 715 425 6864 P.04 STATE PAR OF WISCONSIN FORM 1 - 1998 J4 aCi �7 WARRANTY DEED KA�H� H H. WALSH �'+ (�f'') Q (� NA I M M K OF DEEMS VoCumcm Number 4(�- ,. a}1JPAGLI�,1 8 9T• Cf: IK Co., WI RECEIVED FOR RECORD This Deed, made between GREAT NORTHERN INDUSTRIE INC.,. 09 -16 -1999 3100 PM a 0RANTT DEED EXEMPT 1 Crantor. CERT COPY FEE; and DANNY J. VAN SOMER and CINDY L . V LS32(2F$v.N _ COPY Ff£s TRANSFER FEE: 133.50 hus tl4nd gad wife as RECORDING FEE: 10,00 _ PAGES 1 �• , � _ -- _ Grantcc- Grantor, for a valuable consideration. conveys to Crantee the following described real estate In St. Croix County, State of Wlaconaln (the 'Property): Name and Rettan Address NASTR00 BANK OF BRIcwto Q010 hiala Sint evid'A ia,'W1 5g aoa- 18 59 -3o -000 Parcel tdevificatian Numbw (PIN) This 19 n,_ o„t homestead proprny. (is) (is not) NW -1/4 of the 914-1/4 of Section 20, Township 28 North, Range 16 West, St. Croix County, W�scons;ln. Together with all appurtenant righls. Eiji* and inlrrests• Grantor Warrants that the title to the Property is good, indefeasible in (cc simple and free and clear of encumbrances except — none Dated this day of 15,27,7 GREAT NORTHERN -IN INC. (SEAL) / (SEAL) • EYs Douglas D. Black / Preeident - - (SEA) (SEAL) AUTHENTICATION ACKNOWLEDGMENT Sl�nalure(S) State of Wisconsin• St, Croix County. 11 authenticated this day of Personally carne before me this day of TITLE! MEMBER STATE BAR OP WISCONSIN to (If not, me known to be the person who executed the foregoing authorized by $706.00, WIS. Slats) ( U'Urrent an¢ act;nowkdge the saint. THt51NSTRUMCNr WAS DRAFTEE) sv t orney B arr C. Lundeen MUDGE, PORTER, LUNDEEN 6 SEGUIN, S.C Notary Public. State of Wisconsin _4,10 SB .Street, Hudson _ isco nsio 540 16 My commission is permanent. (it not. state rxwrauon crate: (Slgnatures may be authenticated or acknowleciged. Eoin am not _"*WvRubk a d wwww" ) necessary.) K, bwkw LA117 n IFfNZiw — -- - -' • Nm,r. of Ivr. rn .nr ryuri,y rfuia ,w , y�n'1t nr pint,.R nnNw,Mfr tytn.t,ar STC - 106 J L 146J PAGE 227 PRIVY INSTALLATION AGREEMENT St, Croix County, Wisconsin PRIVY INSTALLATION AGREEMENT - COPY To RE ATTACHED TO THE SANITARY PERMIT APPUCArIDN. Ry Owner(t). 0.ete�.ed Fw xKWd�ng Oata . U+vo as Sim► M. q g Addren: LOfatg K +,SIiE SIQ T?$N R 1 EorW Oly, vd4ge ownlh, Df: Epl U 6 E}LLL rice) Taa Num- 008 - t175 - 30 000 Legal wiPtgn: iNW - +(A ch � AL�, o,.P,`h4 ale K vdh bt UV Ii. Cry 1 W$Z\ t. No plumbing will be installed in the privy. 2. No plumbing will be installed in the premises served by the privy unless a code compliant soil absorption system or holding tank exists, or a valid sanitary permii to install such a system has been issued. 3. A privy vault /pit shall maintain minimum setbacks as specified in Table I. Table Well Building Lake /Stream Additional County Sellsacks Open Pit 50 Ft 25 Ft Min. 75 Ft Seated Vault 2S Ft 25 Ft Min. 75 Ft 4. Privies for public buildings s haBcomplywithlLHR52 .63.WisAdm. Code. . S. Privies used for one- and two-family purposes shall be constructed in such a manner so as to exclude flies, rats and other vermin. Doors should be self - closing and vault ventilators should terminate at least one foot above the roof. 6. A privy vault shall be constructed of watertight plastic, fiberglass, coated steel or monolithic concrete. Materials shall comply the intent with ILHR 83.20, Wis. Adm. Code. Counties may, by ordinance establish minimum sealed vault sites and type or construction within the guidelines of ILHR 83.20, Wis. Adm. Code. 7. The privy shall be kept clean and sanitary. The contents of the pit or vault shall be disposed in accordance with NR 113, Wis. Adm. Code. B. -this agreement shall be binding on the owner, their heirs and assignees. This document shall be recorded by the register of deeds in a manner which allows its existence to be determined by reference to the property where the privy is installed. r.Al nee am t - s ta 5 Subscribed and Sworn to before me on this date: � ' � C-roA I'�6a1S I'll n �gnatwe: r v iz to y commission expire ; �a 10 It. . NOTE: This document was drafted by the State Department of Industry. Labor and Human efatipns. Bureau of Building Water Systems. v 1461 fAGE 226 611554 nmx C-0 - n 4'i KATHLEEN H. WALSH Numb J REGISTER OF DEEDS ST. CROIX CO., WI RECEIVED FOR RECORD lo-05 -1999 11:OQ AN ROREElENi EXENK I CERT COPY FEE: COPY FEE: TRANSFER FEE: RECORDING FEE: 12.00 PM: 2 Raeorditt Ace. Name •sd Redurs Addmw I 73 (o ** & S e &'Yo,, of Sg a0 8- 1 o59- 30 -000 Panel Idmffmfim Nmsbrr" "THIS PAGE IS PART OF THIS LEGAL DOCplSF.NT — DO NOT REMOVE" This iafoc tine aa.GU wcVlctW by �b.aiaec: ft-& � ft� one Crean -d&-l. end f N ff q d/dX Oder frd.WdM nrch w Ac t er dwttec. ksW A—* .. cw- «gay be Mated e" dd, f,,f rare of &e deaeK,u w.W be pow d en eddidoad paw V dw da,uncwt N--' Um of" — J-Z, add, ane pste m yap d...., and SI M to du ,,,on5nr /e,. Wveoa+in Staae,t.199577. wm 7196 i