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HomeMy WebLinkAbout022-1025-50-000 r �► ST. CROIX COUNTY ZONING DEPARTMENT 7 AS BUILT SANITARY REPORT Owner Property Address 2 City /State Legal Description: Lot Block -- - - Subdivision/CSM # , l ' /4 S� 1 / a, Sec. T2,0 N- R_Z9.0Town of PIN # SEPTIC TANK -- DOSE CHAMBER -- HOL ING TANK INFORMATION: G 7 1a, t -57 7- - Tank manufacturer AUAXK, Size ST/PC Metback from: House I IV Well P/L Pump manufacturer Model M E A/ Alarm location (HOLDING TANKS ONLY) Setbacks: Service`road Vent to fresh air intake Water Line 4 Meter location Alarm location. SOIL ABSORPTION SYSTEM Type of system: Width S Length —�� Number of Trenches Setback from: House 6.3 Well /11 P/L 12 Vent to fresh air intake ELEVATIONS Description of benchmark r - J Elevation /40 Description of alternate benchmark Elevation ed Building Sewer S s$ e ST/HT Inlet 95 - 00 / ST Outlet O r PC Inlet 93 , 7 I Header/Manifold To of SD/PC Manhole Cover /DB , . l 9 PC Bottom �_ p ' Distribution Lines O 90, 1 S {) ( ) Bottom of System ( ) O ( ) Final Grade () () ( ) Date of installation Permit number 3 S_ & State plan number y Plumber's signature License number Dat Inspector Complete plot plan * NOTICE Please provide the following: • A plan view sketch showing everything within 100 feet of the system. • Two horizontal reference points to center of septic tank manhole cover. • Show alternate benchmark, if applicable. PLAN VIEW o 57'� T w R� -Op � E E 1 1�cL 0 i L- �.� INDICATE NORTH ARROW d o 5 I'Wisconsin'Department of Commerce Safety and Buildings Division PRIVATE SEWAGE SYSTEM County: INSPECTION REPORT St C 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)]. Permit Holder's Name: ❑ City ❑ Village [I X T of: State P an ID No.: Tnw-n of Kinnickin 0? T6 v.: Insp. BM Elev.: BM Description: Parcel Tax No.: God (Op TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV_ 't Septic tro Benchmar / Dosing, Aeration Bldg. Sewer r Holding St/Ht Inlet TANK SETBACK wwmmoN St/ Ht Outlet . ga' TANKTO P/L WELL BLDG. Air I ntake ROAD Dt Inlet t(•� q3•�� Air Septic - ?-,r� f �/ - — NA Dt Bottom Dosing 9 q q NA Header /Man. Aeration NA Dist. Pipe } ,31 Holding Bot. System �— PUMP / SIPHON INFORMATION Final Grade S Manufacturer WQ Demand DDS (9 fDp. Iq r '.qt enver Model Number Q 40 6 #5, S, q � TD H Lift'�,D Friction ��q Systema� T D H ``,"'Ft Forcemain Length Q Dia. H �� Dist. To Well > SOIL ABSORPTION SYSTEM -T BED/TRENCH Width I Len t / No. f enches PIT No. Of Pits Inside Dia. Liquid Depth D IMENSIONS ` DIM SETBACK SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION Type O � �� � �� CHAMBER Mod Number: System: OR UNIT DISTRIBUTION SYSTEM Header / M o Distribution Pipe(s) ( t �� x Hole Size x Hole Spacing Vent To Air Intake -� ' e / �/ Length Dia. Length _ :1'2. Dia. Spacing 7 �$ 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/Tr nch Center Bed /Trench Edges Topsoil I ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) v° """ p Inspection #1: lC / /9 /4'9jInspection #2: ! 12 oc 'o 1102 Coulee Trail, Roberts, WI (NW 1/4, SW 1/4 Section 9 T28N - R18W) - 9.28.18. 38B ' f Y i -T be. Id "s�2 � an revls on required? ❑ Yes NO ' Use other side for additional information. 1 11 . SBD -6710 (R.3197) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: R # m u..,. a ...m,....,�.. m »...me......n _.:�e.� ._m�. .......,w.,��. a _ _ s C c r a t � ° — 4 t ^ 00 „ E, Safety and Buildings Division e-• ■■..r>.i SANITARY PERMIT APPL#C-A-T1gN Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.45 Wis 4dm ( od r� ~ ,� P.O. Box 7969 Madison, WI 53707 -7969 Attach complete plans (to the county copy only for the y tem oppape) t less; , unty than 8 112 x 11 inches in size. `~ ° � t • See reverse side for instructions for com letin this a lk do St to Sanitary Permit Number p 9 P� ►A rr e?r 353 166 _, The information you provide may be used by other government agency p 6 ��ims )T rti, ; l heck it revision to previous application [Privacy Law, s. 15.04 (1) (m)). ' 'A 00UN Y 0 - � N N - 0Fr1C State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT AL I 1131APO Propert Owne r� Name h � r Pr '4oc 1 5 Q T e 2 N R W / 8 r ! 8 fir) Property Owner's Mailing Address Lot Number Block Number City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE F BUILDING: (check one) ❑State Owned o V i ll age Ner — , C] VI age C�,etitV Public C& 1 or 2 Family Dwelling - No. of bedrooms W Town OF Ill. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo C o;e2 . -10,P 2 . S_ _ 60 I F. / 38 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 g&Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an _____System -------- ------------- _____________ Tank Only_________,____ Existing System _________Ex --- System B) ❑ A Sanitary Permit was previously issued. Permit Number )V....9, Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 OdMound 30 ❑ Specify Type 41 ❑ Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure X t A 42 ❑ Pit Privy 13 ❑ Seepage Pit / cJ � 43 ❑ Vault Privy 14 ❑ System- In -Fil l o:*-" 42 VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev_ 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation ! If oz$_ If Y 4 4 Al , 4 7 4 7— Feet 9 Feet Capacit VII. TANK in allons Total # Of Prefab. Site. Fiber - Exper. INFORMATION g Gallons Tanks Manufacturer's Name Concrete Con- Steel glass Plastic App New Existin strutted Tanks Tanks Septic Tank or Holding Tank 1 0007 Do c7 c /* El ❑ ❑ El 1:1 Pump Tank /Siphon Chamber z SV "t$� P 01 ❑ ❑ ❑ ❑ VI11. RESPONSIBILITY STATEMENT - I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) t Plumber's Si nature: (No Stamps) MP /MPRSW No.: Business Phone Number: Plumber's Address (Street, Cit , State, Zip Code): 96l I S Q L0.1 IX. COUNTY / OEPARTMENT USE ONLY ❑ Disapproved Sa nary Permit Fee (Includes Groundwater ate Issue Issuing Agent Signature (No Stamps) �j roved Surcharge MkgLe A � Ap proved ❑ Owner Given Initial 2 I'D Adverse Determination - �b 79 X. COND TIONS OF APPROVAL FOR DISAPPROVAL: F( PIS C SBD - 6398 (R. 05/94) DISTRIBUTION: original to County, One copy To: Safety & Buildings Division, Owner, Plumber i INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD -6399) to be submitted to the county prior cou y p o to installation 5. Onsite sewage systems must be properly maintained. The septic tank must be pumped licensed g y p p y p (s ) p p d by a tensed 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 -3815. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. Ill. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one 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 a// 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 isto 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 I sconsin www.commerce.state.wi.us Department of Commerce Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary September 22, 1999 CUST ID No.226375 ATTN: POWTS INSPECTOR ZONING OFFICE ROBERT W ULBRICHT ST CROIX COUNTY SPIA 655 O'NEIL RD 1101 CARMICHAEL RD HUDSON WI 54016 HUDSON WI 54016 RE: CONDITIONAL APPROVAL APPROVAL EXPIRES: 09/22/2001 Identification Numbers Transaction ID No. 248004 Site ID No. 180875 SITE: Please refer to both identification numbers, Site ID: 180875 above, in all correspondence, ith the'Agency ST CROIX County, Town of KINNICKINNIC; 1102 COULEE TR, ROBERTS 54023 NW1 /4, SWIA, S9, T28N, R18W Facility: ROMAN LUBICH 1102 COULEE TR, ROBERTS 54023 FOR: Object Type: POWT System, MOUND, Regulated Object ID No.: 491405 The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(10), Wisconsin Statutes, is responsible for compliance with all code requirements. a The following conditions shall be met during construction or installation and prior to occupancy or use: • Deep and thorough chisel plowing must be done to the absorption area to break up any compaction which may exist. 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 09/13/1999 A , FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 DUANE R STEINER , WASTEWATER SPECIALIST BALANCE DUE $ 0.00 Field Operations (608)355-3159, W 7:15 -4 :00 PM DSTEINER @COMMERCE.STATE.WI.US WhIT . cc: ROMAN LUBICH ORGNAL _ - T lJLBRICHT & ASSOCIATES CO. 655 O'Neil Road -Hudson, Wl 5401 Reg. Designers of Engineering Systems 715- 386 -8185 Private Sewage Consultants PROJECT INDEX DIL.IIR Plan I.U. # Date Sept. 8, 1999 Owner Roman Lubich Phone 715 42 5 -6349 Address 1102 Coulee Trail, Roberts, Wis. 54023 Legal Description 1.5 acre meets /bounds lot. PIN 022 - 1025 -50. NW 1/4, SW 1/4, Sec.9, T28N, R18W. Town of Kinnickinnic County St- -G-r x - -_. C.S.T. Robert Ulbricht 226375 Installer Local Authority/ Supervision St. Cr oix County Zoning Dept. PROJECT DESCRIPTION Replacement sy stem for a 3 bedroom sized home. Estimated daily wasteflow: 450 gals. The failing drywell (sited in seasonally saturated soils) shall be abandoned per code, also the existing trench will be abandoned. Soils are fairly permiable in upper 12 (.4/.5 GPD /ft2) but seasonally saturated at 24 (in very dense massive till). A long narrow mound system using 12" sand fill is proposed. Highly g ly recommended: install a Zabel filter in the new precast 1000 gal. septic tank (Midwestern Precast Co. Menomonie, Wis.). An approved locking above ground manhole cover should be provided P for sere' ft .0 C ON rp r�h 4o w 2 R OBEm W. ULBRICHT G� HUDSON, WI I Gtk �.•�' 11,.111 Pg.l PLOT PLAN VIEWS Pg.2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEWS Pg.3 PIPE LATERAL LAYOUT Pg.n DOSING CHAMF;FR CROSS SECTION Pg.5 PUMP PERFORMANCE SPECS 11lis design for installation is based entirely on measurements, elevations, laildscape conditions (Slopes etc.) and soil suitability provided b f 711 t accuracy of Ilis specs, as reported, shall remain the sole resp f he CSiT1. p ili.ty o Any use of this POWTS design by any licensed plumber, or any related unlicensed parties or persons (excavaters, laborers) shall not be construed as an assumption of responsibility by the designer for the workmanship, construction, placement, substitution or selection of any components not specified, or any assumptions by the plumt that any unspecified components are state approved or proper, or the effects of poor judgement if working under adverse damaging weather conditions (wet /frozen soils) by any such parties or persons. l P�•rs MbOA.) n s �I6U w i a l' S A kj D Ft L (• w Top Of ALL NON - CONFORMING L o 0 E 67 STf p- TREATMENT TANKS SHALL BE ABANDONED PROPERLY FOR ILHR 83.03(2). - o a 3 � � s'i R/15 � NaN v �avoa 1� , l49 A w i N N 'b w ESTER , .j e2l� I� PR E /ts T 40 SUPT IC T. �, �2-- p/ �oNT v SGT 4'0 f}i�✓�l —�3 the area 25 0. below the 10801 edleo $nil 011 011 10 m mes! Idi 1 a. W& DD Po S, 7 e4u 40-r ele <? c CL /3 ° 4x4" — C� h�S / •• � /,� U � �� O • SO CR055 SECTIOU o f M OOOD wi Tti f3 eD Otv aF %'' ro . Di STRi(3uTIeN A33ec Cr, Tkicl; o Es 9 pip IN G - • or TopSOiL sysrr~M e levA rioo •u l i µ E 3 I. ` c ►/i � RAT MEo. o i l Mtn p . • . . 1 Plowr, o T o p So r , Z *7v 51 opE FORCE" M AW 1= t rWATAoa UX MR /' 0 Fr. ELEVAT'lo►-) -s --• " E, A r. INVERT of 2 1A TER/4 (s 97 1 2 - gy FT. ► F To o f R o ck f , ZCy G , _ /'0 FT /O H 01 "5- T. • TOP O F IATERAIS — F PLA VI OF MouojD - wi r ff 13E o FvRcE MAi&) A FT K /o Fr IT I1V ' ------- - - - - -- ___� 1 9 FT �a w � F 1' (v o w 2 F T .9 m 0 F Puc. cAppED To I 0135E R VArI00 A 93PEI ATE Pipes PE RMAAjENT MARLERS REC.2umeD BASAL, hReA 'D Ait_y whST'E'Fl 50 c /1 ►�c il 't)0E- =1 S F y y a, r, PRvposed BA SAI APeA = B X A t 1 & 04k24 80 04 +� C 1 s q. FT, „u t u v V'STRt UOT�pti . Plpt~ k) ETwoR k TO VvLu E d F LATj'lkA 0” r 9t5�Rlt3uTl °tit• .� LATERAI 1r"v CAP X x X Y Pvc FORCE i Td /I�ow M AW LAST V,olE s HA II 13E NE1�T TO tRr,p CAP VOID WuMt FOR 1NVERr 1; IEVAr10 d� FoRcE MAW J , PERFORATED PIPE DETai L. Q HOIEg IOCATFO 6A3 G vl'rOM SH All BE (' Y `I VARiAMLE y IR(Roh y S PACED. Ut 5 t�NcE p HOIE Di Htr E R Y7 IN. � T R N /A- L ATERA L Z tN , MAM FOLD " IN . Y I�cl 5 ot` I}olES/ P i P EF' / DISTRi t3uTIU�U DtSCH/\R&E RATE' PER L NTE-RAL, GAI TO TAL - Di5 GkAR vE BATE E�-tuO k / N GA L M ,• , ,� 1 A s 1 I A-74 a/ l t 248004 PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS P141E If OF 5 -VEMT CAP 4 "C.I. VIUT PIPE WEATHER PROOF APPROVED LOCKIIIIG JUAICTIOAI BOX MANHOLE ,COVER 25' FROM DOOR, I, /gAIAJ/N(r 12 "M11J. WINDOW OR FRESH I AIR INTAKE I / ("I9inni GRADE I I 4" MIAJ. — ' CONDUIT ` -- f /EV <v IP PROVIDE l -y INLET AIRTIGHT SEAL I III V I I R,FPROVED JOINT A y�D,Gf1C I I APPROVED JOINTS tJ /C.I. PIPE IN �V� I I I I I W /GI. PIPE IJDING 3' _ {�0� o I I I ALARM ONTO SOLID S 01JTO SOLID SOIL B v Q.� I I II ONTO SOLID SOIL • — � v/ r1 � � I I ow C L E V. � F T. -' J Pump OFF Z/SE 3 4iQ �10�PE' eF ?, PPIA G _ SitNl� 0 1 ) k BLOCK f it vA ( t0 RISER EXIT PERMITTED OIJI_'J IF TANK MANUFACTURER HAS SUCH APPROVAL SEPTIC E SPECIFICATIOUS DOSE / 1 ' ,P4)tj'7t AJ ✓ - TANKS MAIJUFACTURER: VJUMBER OF DOSES: PER DA3 TAX1K SIZE: _75�9 GALLOAIS DOSE VOLUME 10 n ALARM MA1.IUFACTURER: L4otz, �-( INCLUDING BACKFLOW: /� fJ GALt ONS _ MODEL 1JUMBER: �` L CAPACITIES: A= INCHES OR GALLONS SWITCH TYPE: OAT SCI t `"'�/ � _ IIJCHES OR ' s GALLONS PUMP MANUFACTURER: C = �+ S INCHES OR D GALLOIJS MODEL NUMBER: ME / O / Y D= /`� ' INCHES OR � GALLONS r SWITCH TYPE: �JJI V 1 /OA 1 50 11(4 NOTE: PUMP AND ALARM ARE TO BE MIIJIMUM DISCHARGE RATE $© GPM Q INSTALLED OIJ SEPARATE CIRCUITS VERTICAL DIFFEREMCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE.. FEET fiAA,) L 19PEG5 MIIJIMUM NETWORK SUPPLY 5Y joo R , , • • . , • • // z• 5 FEET EAC.G� 7 c + _✓o FEET OF FORCE MAIM X FAGYOR.l� FEET lt_ , 0 75 - J r TOTAL DYNAMIC. HEAD = FEET MTERNAL DIME."SIONS OF TANK: LLNGTH ;W16TH ;LIQUID DEPTH 8004 ME40 Series M ®. 4/10 HP Effluent and Drain Water Pumps Performance Curve MODEL ME40 EFFLUENT PUMP CAPACITY LITERS PER MINUTE 0 50 100 150 200 250 300 350 40 12 35 10 tn It W 30 LL W 8 N 25 Z O 20 6 0 J H 15 Q Fes- 4 O H 10 2 5 O 0 0 10 20 30 40 5 60 70 80 90 100 CAPACITY GALLONS PER MINUTE F.E. Myers, A Pentair Company • 1101 Myers Parkway, Ashland, Ohio 44805 -1923 419/289 -1144 FAX 419/289 -6658 Telex 98 -7443 K3326 7/91 Printed in U.S.A. ME40 SERIES 4/10 HP Effluent and Drain Water Pumps POWER & FLOAT CORDS PLUG DIMENSIONS Quick- connect, watertight Replaces switch assembly fittings are interchange- for manual operation. 11 able, replaceable from `- 1 Npr (38.1 mm) pump exterior. <" Discharge MECHANICAL FLOAT SWITCH C r Mercury-free, 90 angle operation. _ 5.66 �...... (144mm) -_.J 1168 (296.5mm) "ON" MOTOR HOUSING 1 Cast iron for efficient heat transfer. — -- _ OVERLOAD SWITCH �--� E Built -in to protect against overload conditions. �. 8 } 4/10 HP MOTOR ; air "OFT., 1600 rpm, n 60 phase. z, 11 or 230 } ~ _ g cooled and lubricated. i ROTARY SHAFT SEAL — - -- - rr Carbon, ceramic faces. l I i -- - PERFORMANCE CURVE —�— CAPACITY LITERS PER MINUTE O 50 100 150 200 250 300 350 40 12 H ' VOLUTE/IMPELLER SEAL 35 RING 10 Maintains high efficiency 30 m and reduces recirculation e replaceable. zs � yi. SV ISA � � 4�. 2 ENCLOSED TWO VANE 20 6 IMPELLERk - High efficiency, passes HIGH EFFICIENCY ABS o 15 4 '/4" spherical solids, with VOLUTE stainless steel wear ring. Corrosion resistant. Passes ° - spherical solids. 1 W x ° ` 2 TEMUST WASHER. SLEEVE NPT discharge. 5 3 A, 0" BEARINGS ° s,�, t o )Rule smooth operation 0 10 20 30 40 50 60 70 e0 90 100 and extend pump life. CAPACITY GALLONS PER MINUTE K3319 n U U S ® F. E. Myers, A Pentair Company Printed in .S .A. � 1101 Myers Parkway Ashland, Ohio 44805 -1923 419/289 -1144 FAX: 419/289- 6658,TLX: 98 -7443 I ~' V'vitz�;.� . +, Department of Industry, Labor end Human Relations SOIL AND SITE EVALUATION Page of - pi vision of Safety and Buildings in accordance with s ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County �•• Include, but not limited to: vertical and horizontal reference point (BM), direction and •5/ • C/PO / percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # APPLICANT INFORMATION - Please print all information Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). I Property Owner Property Location l T 4,V Z&Sick, Govt. Lot NW 1/4 S� 1/4,S � T M ,N,R !4 E (or� Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# //D Z Covc.E& 7�% i- / !i �lS /"+.Gets l3ov -v1PS City State Zip Code Phone Number ��,/ Nearest Road CI RAG& - Rrs W /. XV0 2.3 ( 7/5 ) 4t LC •(034/ ❑ C{ , ❑;ills e L7 T� C�IIL+EE' Tif ❑ New Construction Use: X1 Residential/ Number of bedrooms Addition to existing building Replacement �/ El Public or commercial - Describe: Code derived daily flow 7 gpd Recommended design loading rate ` bed, gpdfft ' s, trench, gpdff1 Absorption area required 3 7S bed, ft 37 S trench, ft ,/ Maximum design loading rate 7 bed, gpdffl • s trench, gpd/ft Recommended Infiltration surface elevation(s) rye P� • 3 ! g 7• y Z ' ft (as referred to site plan benchmark) Additional design /site considerations Parent material 4WK PeV rE� (�,! W E! •s Flood plain elevation, if applicable ft S = Suitable for system Conventional J Mound In- Ground Pressure AT -Grade System In Fill is: Tank U = Unsuitable for system ❑ S U S U E S M U ❑ Ia U [:Is X1 U �.0 SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD /ft In. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed , Trench /. ! iz 104e 313 •�� /o ye 373 SiL �sh,� �► �.� �� S • 4 Ground lT 3! /4Y�P Ylsl S/L. �fSd� n� A,' CGS •S' . !�• elev 0 1 1 0- B k 1 0Y�7 A/ �EH b U,�SG !f />~ W z Q S - N N Depth to ,/ limiting 5 7 ' �d /O 6 C l f f o t ;* vr l /� M r '! C / • — -- r �- factor - S. Y..< Y ,cam , Remarks: 1*1eJ'ZeA-o1,.s /5 •s;'7VXWrZ- 7 �►` Boring # 0 _f royiQ 3!3 — L ?,,� �s W /1 . S . lo•3 l i0Y/e f — 51L 2,w Ae dA 4'S - .s : .6 . Ground ioY/Z Yl� R I f A tO ! S L *,fi ff7W dP 4 C S ).5 ' N elev. S 'S7 �©YA Y` i � f Cl i fs k /r VA I C N ; N 9!v•�3 -ft- s 7• !� /o C� c z �•tofiS v S /,Q s , G Depth to 5 Y oe S Co limiting ' c or 24 — In. Remarks: CST Name (Please Print) Signature Telephone N . ,pose, r ?��,8 647 c 71S 3 P • 0 Address Date CST Number S� e i • q • Lq j 5 2 Private Sewage Consultants 655 O'Neil Rd. Hudson, Wis. 54018 i t �1 �� / v• T a ,� 3. S-;!!5) l R• LUf3 G SOIL DESCRIPTION REPORT PROPERTY OWNER Page Z of PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Structure 2 Texture Consistence Boundary Roots In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed I Trench 3 •/ ioy 3/3 — a shk a's�, cw 2, . S ; . 4 2 3 io V e . 313 -- s/� Z,,.,, ,Jri d A, CS s .� Ground 3 .J T S 4 71 — J L 4"14SaMIF j . `s 0. 3 I O. zlev. ft. ` • �0 /! �6 sG(� �T S U �,• _ D.2 O 3 �yz Depth to o • !D f/ G Z eQ �•ca tS U ^ I Limiting factor ALM. Remarks: Boring # 9w, Y12 31.3 G /�' SGT dSLi 2. a •17 /O VA 3l — 5 "G /�Sh� C�SLc C Gr� 11 YiZ .2 Ground LIZ 1 /o ca d% 40 s " GL �.sSiv /yh PYC et N elev. tt.� 16 Y (lL.. T ; Depth to S 7•S Y t Kot5 11 5 1 )c 4w �++ _ S • . Co limiting factor �P Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ In. Munsell Qu. Sz. Cont. Color Gr. Sz. Bed , Trench Boring # ; � I Ground elev. ft. ' Depth to limiting factor in. Remarks: Boring # �j I Ground elev. ft. Depth to limiting factor — in. Remarks: SBDW -8330 (R. 08/95) • a I I 1 3 P�' Ts l�b0 SyST �'►cu �( w / ►a S� u� �� LL BM 4f w L00EEST ST p• O N y� P d our1 . r MS ' v 1� r 0 �oNTav/e I P3 — 33 S L C OV ,u D $ (C7bZ) p Po S T P Sw /-e-r POS / • � / /D O • Sd ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND a OWNERSHIP CERTIFICATION FORM Owner/Buyer _ AaW.6-r.. a a kl-& � �- Mailing Address Co—Z-x- Property Address S CL "'-Q (Verification required from Planning Department for new construction) A" � City/State Q a- Cs�^ -� Parcel Identification Number a LEGAL DESCRIPTION Property Location N '/4, s �"� ' /s, Sec. �, T E$ N -R I g W, Town of k,.�vr,.i c�-c, Subdivision , Lot # Certified Survey Map # , Volume . Page # Warranty Deed # AS q 7 0 , Volume 4 1cR 4 1 Page # l a Spec house ❑ yes [&no Lot lines identifiable 0 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 rnasterplumber, 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. I/we, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days the three year expiration date. SIGNATURE OF APPLICANT DATE OWNER CERTIFICATION we I (we) certify that all statements on this form are true to the best of my (our) knowledge. I am (are) the owner(s) of the roperty described above, by virtue of a warranty de recorded in Register of Deeds Office. 7 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 . 2 10101 AW N'ARRAN11' nFEn 3b JOINI' TE \'A\ "I'S. i,Sectlon 230.45 Wlnconnin Statuteel ,, .,�w ,....•„ ) �) -t y `+ t t This Indenture, Made this Y/ AW da of May A. D., 1066 between Mary Iverson, a single woman, part y of the first part, and Roman Lubich and Ursula Lubich, husband and wife, , as joint tenants, parties of the second part. Witnesseth, That the said part_ y of the first part, for and in consideration of the sum of Four Hundred Fifty and N01100 Dollars ($450.OD) t her in hand paid by the said parties of the second part, the receipt whereof is hereby confe,sed and acknowledged, has given, granted, bargained, sold, remised, released, aliened, conveyed and confirmed, and by these presents do es give, grant, bargain, sell, remise, release, alien, convey and confirm unhr the said parties of the second part, in joint tenancy, their heirs and assigns forever, the following described real estate, situated in the County of _ ; >t. Croix and State of Wisconsin, to -Tit: A parcel of land located in the , °J,' of OW of ection 9, Twp. 28 P;orth, R. 18 (vest, rnore fully described as follows: Peginning at the intersection of the Center of the Tovm road and the west line of said 40 thence easterly 165 feet along the center of the road, thence North 396 feet parallel with the west line, thence 'nesterly parallel with the town road 165 feet, thence south on the west line 396 feet to point of beE,inning. I i Together, ,vith all and singular the hereditaments and appurtenances thereunto belonging or in any wise appertaining; and all the estate, right, title, interest, claim or demand whatsoever, of the said party of the first part, either in laa- or equity, either in possession or expectancy of, in and to the above bargained premises, and their hereditaments and appurtenances. To have and to hold the said premises as above described with the hereditaments and appurtenances, unto the said parties of the second part, in joint tenancy, and not as tenants in common, and to their respective heirs and assigns FOREVER. VOL r ` Ph`,_F 117 t � � O !✓ O CL ,n N D O C: r `r TT O N 3s " r; C'1 .^.. zD c — *.t�' Z ry * ? ^� o ? O m Z z b 9 ,, D 41 w o U z _. _... r? Q n -1 m C c+ ✓ In m 9 TQ o a o Z 0 6. 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