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030-2106-40-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 579024 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No: Blanchard, Dennie & Ma St. Joseph, Town of 030-2106-40-000 CST BM Elev: Insp. BM Elev: BM Description:( Section/Town/Range/Map No: Ida Si ofl .t 06.29.19.888 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Li e Amfs Dosing J 1/)81...E 6. 4e .4 6 Ov AIt~BM~ Z J 7.1/" Aeration Bldg. Sewer 5 t Holding St/Ht Inlet TANK SETBACK INFORMATION St/Ht Outlet TANK TO P/L WELL , BLDG. Vent to Air Intake ROAD Dt Inlet Septic Dt Bottom Z. Z!J Dosing Header/Man. Aeration Dist. Pipe 9 • G• 1,41 Holding Bot. System st3 73. 12-6k- PUMP/SIPHON INFORMATION Final Grade 9f, g Manufacturer Demand St Cover GPM ,r ~ COJ G • toll 9T 3 Model Number 32 a~ Eo TDH Lift Friction Lo System Hap, TDH t 17. -1541 Forcemain Length 9a. Dist. to Well SOIL ABSORPTION YSTEM BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS J'I G(_ Z `12~L 1- SETBACK SYSTEM TO VV P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System:ra~ l_yx /L UNIT Model Number. oK~ + V ;l 1~ DISTRIBUTION SYSTEM / (0'x'1(0 = 3 Z ~S Header/Manifop i t Distribution x Hole Size x Hole Spacing Vent t Air Intake s Pipe(s) Pc7 r Length Dia Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over d Depth Over xx Depth of xx Seeded/Sodded 1xxMuIched Bed/Trench Center p Bedlrrench Ed s Topsoil Yes Fin] No `I Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2: Location: 376 117th Avenue Hudson, WI 54016 (SW 1/4 NE 1/4 6 T29N R1 9W) Evergreen Ridge Lot 4 Parcel No: 06.229.19.888 1.) Alt BM Description X e"O✓AA_ Lj/ Z..; n.,G~ 2.) Bldg sewer length W/ J rA too -'e - amount of cover = Plan revision Required? E Yes No FiT, .Q `CJ 7 Use other side for additional information. 0 6 SBD-6710 (R.3/97) Date Insepcto Signat Cert. No. ■ ~,i eda/c~a~U-,P~'E rL"~~~~ ~t`0~1f~ US C- D : G f r-i-/ 9 8 ~ S -r I ~ ~ E~~ s fl ny) ~ ra.L✓e Q (e+f: b I A-s c. u 01-0, k.d,r i -~-E,w~nCo,J~er,ce(rtlt~dt'/:ne ~ ~OLIf~1FT5 Y~L-I~1EL7 J:~`a~n t~~~n ' U W Score:/= r i 37G 117t'14,4- A, ~'~-pL 'ri ~%/k ~ o~ E(/F.ry'tQC~ K10~9 e~ L~~ S`~i~lf yd/Q ~C✓ C4 Kt ,I«I ~ Scc; ~s~/9E/'y See. ~v T. Z9 /l. ,P/9uw. drsprr C'a//, Tr<.io(z) -~,c,7,Q/s i ~ it it II P 7n.a~S ~ose/4~ Sf.Cto;xCo./~jl, xSG.ZS~/ - 030 --2 /off" s~o-tom l tF'~~rmfos fs~rs 5} Sf~•, ~ ~ } 3. l7 acres Gleam ` 92. /S• 1 > ~"ndt~ t/tom ot~'s.~'/J'tiyi 1" ~Xr S~nq 2` ~lD ~ ` ~ ~rccwtd,n = B~S~ ~n3Yde 8!r. 93' Syrr/7eaSrF/~c I~r /ua,t iSG~arAL . L "zone r~ UU 9.~5~ ProPalco/L~.~:t5rr-11 \ ~r; K ses~o 6ecdc%c/r'-S,T d;3f r 6uti~ ° ~~/e~ in~i /i a/e • ~ Crn,crt,~e ib 1 a7'- '3 ~ a E Xi S~J•n q / t7 L 1(,1~ ~ / OfJ. r.;j~ i ~,"d; ny, ~ lug = 9S 3~ /J~ \ j i' II O t' S~.54/Ge to eon S,SEo><` two(zj~r-ene~esa•~3X67'S/oe'ced~z`~~ I CnCLrIEu! /(D rn o, "C.J,ambvs ~ i _'S. C- P ly b County z, EC Safety and Buildings Division St. Croix k°/ t 201 W. Washington A P.O. Box 7162 Sanitary Permit Number (to be filled in by Co.) SP 1Q~ Madison, WI 5 7- 2 S JUG S~1~D2~ )UNTY 10MMUNI i ary Permit Application State Transaction Number in accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit Na _ is required prior to obtaining a sanitary permit. Note: Application forms for state-owned POWTS are submitted to Project Address (if different than mailing address) the Department of Safety and Professional Services. Personal information you provide may be used for secondary purposes in accordance with the Privacy Law, s. 15.04(1 m , Stats. ~tl 6 117'b Ave., Hudson, WI 54016 1. Application Information - E lease Print All Information Property Owner's Name Parcel # Dennis & Ma Blanchard I 030-2106-40-000 ✓ Property Owner's Mailing Address Property Location 376 117'h Ave. Govt. Lot City, State Zip Code Phone Number SW v., _NESection _6_ (circle one) Hudson, WI 54 (612) 309 - 7981 T 29 N; R 19 W II. Ty~ef Building (check all that apply) Lot # ~~lJ 4 ✓ Subdivision Name or 2 Family Dwelling -Number of Bedrooms (3, I Block # Evergreen Ridge ❑ Public/Commercial - Describe Use Na ❑ City of ❑ Sta Owned - Describe Use CSM Number ❑ Vill of I ' Town of St. Jose h III. Type of Permit: (C (Jh/ ox o A. Corn lete line B if applicable) A. ❑ New System Replacement system Treatment/Holding Tank Replacement Only [I Other Modification to xisting System (explain) I ik V!t Change of Plumber [I Permit Transfer to New List Previous Permit her and Date Issued B. El Permit Renewal El Permit Revision El Before Expiration Owner # 324759 2 9 9 IV. /Component/Device: (Check all that apply) on-Pressurized In-Ground Pressurized In-Ground 11 At-Grade El Mound > 24 in. of suitable soil ❑ Mound < 24 ' f 'table 11 Holding Tank ❑ Other Dispersal Component (explain) El Pretreatment Device (explain) V. Dis ersaVrre ment Area Information: 32 Infiltrator Quick 4 Standard Plus ambers & 4 end caps, S mTe STF100 effluent filter Design Flow (gp Design Soil Application Rate( st) Dispersal Area Required (s Dispersal Area Proposed System Elevation 450.0 d 0.7 Gpd/Sq. Ft. 642.86 sq. ft 651.60 sq. 93.0' & 9 ' VI. Tank Info Capacity in Total # of Man Gallons Gallons U ' ~j y New Tanks Existing Tanks I .C ~,1rr o & AD 7 Tt /1 7 G o a U in vz w C7 G. Septic or Holding Tank Na 00 1,000 1 cast X Dosing Chamber Na 600 600 1 Combination ST/PC VII. Responsibility Statement- I, the and igned, ass me responsibility for in n of the POWTS shown on the attached plans. Plumber's Name (Print) Plumber' Signatu MP/MPRS Number Business one Number James K. Thompson MPRS 30021 715) 248-7767 Plumber's Address (Street, City, State, Zip C 340 Paulson Lake Lane, Osceola, WI 54020 VIII. un /De artment Use Only Approved Disapprov Permuit Fee Date Issued Issuing Age Si re r Given Reason for Dent $ { S , 1 I Zb, IX. Cond Me tw.wasons for Disapproval 1. Septic tank, effluent filter and dispersal cell must be serviced / maintained as per management plan provided by g!,_ nber. 2. All setback requirements must be maintained as pPr;;pplFt1;i Attach to complete plans for the system and submit to the County only on paper not less than 8 1/2 x 11 inches in size SBD-6398 (R. 11/11) Dose-Conventional POWTS Index & Tilte Sheet Project Name: Blanchard 3 Bedroom Replacement Dose-Conventional POWTS Owners Name: Dennis & Mary Blanchard Owner's adress: 376 117th Ave., Hudson, WI 54016 Site address: Same Project Location: Subdivision: Lot 4, Plat of Evergreen Ridge Legal Description: SWii4, NEll4, Sec. 6, T.29N., R. 19W., Tn of St. Joseph, St. Croix Co., WI. Parcel ID 030-2106-40-000 Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Dispersal Cell Sizing Page 4 System Cross Section Page 5 Existing Septic/PumpTank Cross-section Page 6 SymTech Effluent Filter Specifications Page 7 Distribution Box Cross section Page 8 Infiltrator Quick 4 Standard Chamber Cross section Page 9 Septic Tank Maintenance Agreement Page 10 Certification for Utilization of Existing Septic Tank Page 11 System Management Plan Page 12 Waranty Deed Attachments: Soil Evaluation Report Mater PI ber )Restrict d Service: James K. Thom on, De 't. of SPS Cr dential 0021 Signature: Date: Page 1 Of 12 Design pursuant to In-Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD-10705-P (N.01/01) 850,/ ¢ daAai6,1 rE A~n:~ ~C ~41 ()SLD: 'Ia GST ♦ E",r, s-~,-ny~ ~ ~xde ~J: b y /QCs ~ k u r••.o, ro..r .-~-E.Y,~:n(~lFer-~celirtt//at/:ne OJOG►NkIS Y~I~IED J~1° ^ I Scn e: _ ~0 ~ ~ ` I C~en~is~~i' Q/a~uro/ l \ ~u ds o-; w/ s X016 t /v/a~ o~ Evu~~ee~ ~d~e Esti%i(~f ')tydiau/c4 d;s derfs~ Cre ?~..io(z) (~nc des l I ~ , II r a See ` ~s /JEy9 See . ~v T. 19 W. ,P19&()- D 7',r. o SE 7ase/o~ Sf. C/o~rCo./tel. a63xSG..t5- 67' ~ I 030 -,:z /061' s/O-cC , n,~`/L`~s,~Os 1 I ` 6e;/jj 3. i7 acres Gle `9,2.~s 1111 EXi 3~w' /Y(~ a(WfS~h /"~'CCGt 5 ~ ~ S~~ '~1 t I`a \ ~ I ~ Q` ~ a4l6; CueK bilXT6 in 5.rlAC - ~'Adt e/ea of s~~~j 2`! S~^y 2' scd. /C ~~•-uwta.,'n=8F1.S~~Sii~Yde {c?J.C./ceMa.~~~~ r 'l~r b c.,, o~ P.~ . = BS. 33 ' i 9s u d S L~ C, .DH2 J~ldc \ 6ecco%/ec/L~oS.T. 9S Propas~o/LJ:cSir Q Crr~crv~e C/~S~ri6c~~ior-, ~ i i / / ~ rN. ~ ~='b~f~nr of ~ E X/`Sf1 g / ~S? L l ems' ~ ~ v£1• QtS.ele,gc~ J ~~G 0 I~~cPo se ~J e1,554~~'e //o ion sSEof ~wo(z~~~enekesat3X67"31oaced4•~~j~ E n Can //o z n /Era z<or "q- el ,C;A„ bus EiLV 'J fy 62 = 93.o'l9~D~ d I 4 ~I U /7~•4✓e• t~ . 20.E lZ BLANCHARD DISPERSAL CELL SIZING CALCULATIONS 1. (3bedrooms)(100 gallons estimated flow)(1.5 design factor) = 450.00 Gpd design flow 2. Infiltrative capacity of native soil = 0.7 gpd/sq. ft. 3. Absorption area required: 642.86 sq_ ft. 4. Absorption area as proposed: 651.60 sq. ft. (32 chambers total) Infiltrator "Quick 4 Plus" = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4 Plus" end cap = 5.80 sq.ft. EISA /pair 642.86 sq. ft. - (2 pair end caps)(5.80) = 631.26 sq. ft. 631.26 sq. ft./20.00 = 31.57 chambers required Number of trenches: 2 @ 16 chambers per trench Trench width: 2.83' Trench length: 67.00' Trench spacing: 9.00' on center Total system area w/ 9' center spacing: 12.00'x 67.00' 'I Pg. 3 of 11 Soil Absorption System Cross Section 9s 7,5 ft 4" Schedule 40 Final Grade fir O je PVC Vent Pipe , With Vent Cap LSD ft Leaching Chamber 9 yd, ft System Elevation 3 ft ~(~ft Soil Absorption System Plan View 67 ft ft { I Leaching Trench 1 Vent Or Observation Pipe Chambers 4" Dia. Trench 2 Header Leachina Chamber Specifications Manufacturer And Model EISA Rating ~O.y sq ft per chamber Soil Application Rate O, gpd/sq ft ,vs-() gpd Design Flow+ av Soil Application Rate + ~2- Q_ EIS = .3~ Chambers 22 rows of ~G chambers each. Page of Blanchard 3 bedroom Dose Conventional Pump Chamber Calculations I . Force Main: 2. Total dynamic head: Diameter 2" Min. supply pressure 0.00' Length 115' Vertical lift 9.50' Flow rate 40.00 gal./min.± Friction loss 3.80' Friction loss 3.80' (115')(3.30ft./100ft.) = 3.795 ft. SymTech filter loss: 0.50' Total dynamic head = 13.80' 3. Pump selection: Manufacturer: Existing Goul Model number: EP04 Pump will discharge approx. 38.0 gpm @ 13.80' TDH or 3.88 ft. sec. flow rate 4. Dose chamber: Existing Midwestern 1,000/650 Comb. ST/PC - 38.00" @ 17.00 pal./inch (646.00 gal actual) A) One day holding capacity: 18.500" = 314.50 gal. 13) Alarm setting: 2.00" = 34.00 gal. C) Dose volume: 5.50" = 93.50 gal. (450gal.)(20% Design flow) + (.164)(115') = 108.86 gal. Max. Dose D) Reserve storage: 12.00" = 204.00 gal. I TOTAL 38.0" = 646.00 gal. Dose Tank Information Locking cover with warning label and locking device and sealed watertight Electrical as per NEC 300 and Comm 16.28 WAC 4 in, min. Disconnect Tank component is properly vented F-- Alternate outlet location Forcemain diameter Midwestern 1000/650 Manufacturer 2 in. Capacityl 646.00 Gallons Volume 17.00 gal/inch A Weep hole or anti- Dimension Inches Gallons g siphon device A 18.50 314.44 B 2.00 34.00 C Pump off elevation (ft) C 5.50 93.56 -t 83.25 D 12.00 204.00 D Total 38.00 646.00 1 11 -d Dose tank elevation (ft) 3" Bedding un er tank. 82.25 Alarm Manuafacturer Existing Alarm Model Number Pump Manufacturer Existing Goulds Pump Model Number EP04 Pg. 5 of 12 [qGOULDS PUMPS Submersible Effluent Pump MODEL 3871 EPO & EP05 ~i _ Series APPLICATIONS • Fully submerged in high ■ EP05 Impeller. Thermo- ■ Bearings: Upper and lower Specifically designed for the grade turbine oil for plastic enclosed design for heavy duty ball bearing con- following uses: lubrication and efficient improved performance. struction. • Effluent systems heat transfer. ■ Casing and Base: Rugged • Homes Available for automatic and thermoplastic design provides AGENCY LISTING • Farms superior strength and corrosion manual operation. Automatic Canadian Standards • Heavy duty sump resistance. • Water transfer models include Mechanical GO • association Float Switch assembled and ■ Motor Housing: Cast iron for us File # LR38549 • Dewatering preset at the factory. efficient heat transfer, strength, and durability. Goulds Pumps is ISO 9001 Registered. SPECIFICATIONS FEATURES ■ Motor Cover: Thermoplastic • Solids handling capability: E EP04 Impeller: Thermo- cover with integral handle and 3/d' maximum. float switch attachment points. • Capacities: up to 60 GPM. plastic semi-open design with N Power Cable: Severe duty • Total heads: up to 31 feet. pump out vanes for mechanical rated oil and water resistant. • Discharge size: 1'/2° NPT. seal protection. • Mechanical seal: carbon- rotary/ceramic-stationary, BUNA-N elastomers. •Temperature: METERS FEET 1040 F (401 C) continuous 10 1400 F (600 Q intermittent. • Fasteners: 300 series 9- 30; -►~-4--5GPM stainless steel. • Capable of running 8 ! X2.5 FT dry without damage to 25 - - components. °a 7 w x 6 20; . Motor _ • EP04 Single phase: 0.4 HP Z 5 ` 115 or 230 V, 60 Hz, 1550 0 1 s -----._r..--- - - - i - - - - - - RPM, built in overload with a a EPOS I automatic reset. ~ 3 o~------- - - • EP05 Single phase: 0.5 HP 1 -6 115 V or 230V, 60 Hz, 1550 ! I EP04 RPM, built in overload with 2 automatic reset. • Power cord: 10 foot 1 i standard length, 16/3 L____-_ S1TW with three prong o 10 20 30 40 50 GPM grounding plug. Optional 20 foot length, 16/3 S1TW with 0 2 4 6 l 0 12 m3/h three prong grounding plug (standard on EP05). caPaclTv Goulds Pumps ®2005 ITT Water Technology, Inc. ITT Industries Effective January, 2005 B3871 SIM/TECH 1 FILTER SIMITECA FILT -Ell Sim/Tech Filter t The GAG Sim/Tech Filter is unique to the industry, engineered to provice maximum protection for your sanitary pressure system. x t ~ The Sim/Tech Filter has been designed as an effluent filtering device ;o •h' assure small holes in the distribution piping remain unclogged. Pressure distribution systems are very effective in treating effluent, but only r:hen holes remain open. Many of these systems only partially fail, causing rf contamination of ground water long before the system shows any visible signs of distress. Placing a filter just before entering the forced main is a simple solution. The filtering device installs by simply screwing onto the discharge port of any effluent pump, thereby filtering out contaminants before they enter the distribution system. Thus, maintaining even distribution of effluent. The GAG SimlTech Filter protects any pressurized system including: S a* Filters - Spray Irrigation Systems - Pressurized Chambered Systerns Recirculation Sand Filters - Mound Systems S~ciSt~ ~YtStct~~citivyt - /~.vlV ~(c1(Ytt`eYtlirtCe - ~~CVrtv3+ttvci~ - ~~,1'teltl~~ ~i~c' v ~2A£Yt~(e(t-(' ~fYl~~7vUeS ~ ~~(lteYlC CG(Gt~LI`l~ btf liS3G(7fYl~ el/eYl ~CSt7(6Gtt(oll - ~)~~~':it i~vi 7 S'~ Lccertt ~c<6rrte~s~ble urrt~s - (ZnYt 6e used trt 6ot)i `%egMe)trict( roiA `_yj ~oY,v~tezci~tl ~pp~ic'~trioYts 3 tJ . Order Model Description gist Price STF•t00A2 STF-100 GAG Sim/Tech Filter (field assembly) I J J v M The STF-110 has well over 1/2 mile of filtration media with over 319 cubic inches of open area to eliminate clogging. The 2,215 square inches of filtering surface allow a flow rate of over 1200 GPD, filtering to 1/16 inch diameter. This incredible r,'.. amount of filtering surface is achieved through the unique shape of each triangular bristle, which more than doubles the filtering surface, with no uniform -~r holes or slots to plug. r Order # Model Description List Price STF-110 STF-110 Disposable Septic Tank Filter (yellow bristle) 3.3c 6-s ~q (P v~'!2 =i6 14: ''1 : 155475181 WIESER CONCRETE E I I 0O rn - ~ < r7", m 0 L N®R ~ \a,, m Z ~ZNROM&"\, D p -ziz Q ~ N ~Ch e b m ~ 0 O Z I ~ Q I 1 WoNO O p ~ Q N O O O y C D w 0 x \ 6 HOLE DISTRIBUTION BOX SGIF-3' - 1' REV No. DA7F U NEW DRAWN BY:SWT o~\o SEPTIC MANUAL X18 LtS F{WY10. wuoF71 RoM YIi 54750 DA7E: 4MIUARY 2005 REV. JAN. 2005 800-325-8456 FILE:B HOLE CAMMUMN Box ~5.7 o-/,Z Quick4TM STANDARD CHAMBER - - Quick4 Standard Chamber 48° (EFFECTIVE LENGTH) 2 / I I I~',,a =Ia II 8 'I I I I ~i = _ ~ = II ~ j / awls 34" SIDE VIEW SECTION VIEW MultiPort End Cap - 12" 34" _ SIDE VIEW TOP VIEW FRONT VIEW Quick4 Standard Chamber Nominal Specifications MultiPort End Cap Nominal Specifications Size (WxLxH) 34"x521 x12 Size (WxLxH) 34"x16"x12" Effective Length 48" Invert Height 8" or 1.25" Invert Height 89 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer Dennis & Mary Blanchard Mailing Addres 376 117th St. -it Property Address Same 117 5_0 (Verification required from Planning & Zoning Department for new construction.) City/State Hudson, W1 Parcel Identification Number 030-2106-40-000 LEGAL DESCRIPTION Property Location SW '/4 NE '/4 , Sec. 06 , T 29 N R 19 W, Town of St. Joseph Subdivision Plat: Evergreen Ridge Lot # 4 Certified Survey Map # Na , Volume Na , Page # Na Warranty Deed # 929556 (before 2007)Volume Na , Page # Na Spec house Oyes[ao Lot lines identifiable Elyes[] no SYSTEM MAINTENANCE AND OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §SPS. 383.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. 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 Safety And Professional Services and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Planning & Zoning Department within 30 days of the three year expiration date. I/we certify that all statementfs on thi orm are true to the best of my/our knowledge. I/we am/are the owner(s) of the property described above, by virtue o a w anty deed recorded in Register of Deeds Office. Number of bedrooms 3 ? 7 /d9 IGNATURE OF APPLICAN S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 04/12) Dose Conventional Septic System Managemei~t lan Pursuant to SPS 383.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with SPS 382-384 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD-10705-P (N.01/01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715) 248-7767 or the St. Croix County Zoning Department at (715) 386-4680. Septic Tank Septic tank servicing mechanics comply with SPS 383.54(l)(e). Septic tank to be located within 150' of service pad, with bottom of tank to be 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1 /3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Pump Tank The pump (dosing) tank shall be inspected at least once every two years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed at the pump discharge, it shall be inspected and serviced as necessary. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October-March) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L, TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a vo-year schedule by use of diversion valve. Effluent to be diverted from new cell to old Drainfield at 4 year anniversary of new system costa anon. ie d to be utilized for a 2 year period. Effluent dispersal to be alternated between systems on a two year rotating basis thereafter or as needed to prevent ponding of effluent within dispersal cell. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Pg. 11 of 12 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) 376 117th St., Hudson, WI 54016 located at: Sw 1/4, NE 1/4, Section 6 , Town 29 N, Range 19 W, Town of St. Joseph , St. Croix County Wisconsin. Upon inspection, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of SPS. 384.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service June 10, 2015 V Did flow back occur from absorption system? Yes No X (if no, skip next line.) Approximate volume or length of time: Na gallons Na minutes Tank Capacity: 1,000 gallon Construction: Prefab Concrete X Steel Other Manufacturer (if known): Midwestern Precast Concrete ge Tank (if known): 16 years, installed 1999 P umber (if known '5 Jam s K. Thompson icensed Plumber S' ature) rint Name) MPRS MPRS #30021 (Title) (License Number) MP/MPRS July 13, 2015 (Date) Form to be completed by licensed plumber (Dept of Safety and Professional Services Chapter 305 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 2/2012 . ~0 ! JVr.7L'rll~ ►.71 t~1bV111 i.~VVlI►1 1 ~ /11,.7C~VL~~7llr. 1---OF CERTIFIED SURVEY MAP REWORDED IN CR OIX COUNTY REGISTER OF DEEDS OFFICE C S. M i SURVEYOR'S VOL. 7, PG. 2025 E 1, Douglas J. i I UNPLATTED LANDS that full c I 1 1 Statutes, an / i Weckworth, I 14 NE1 4 i plat correct) IW g .18 1 -6.0'+/- _ the land sur 306.00' 311.88' the NE1 /4 c L3.0'+/- / I Joseph, St. r Survey Map 3 County Regis c I Commencinc the north - N88'20'38"E M 1305.50 fee 3.096 ACRES f 3.170 ACRES ` section, 8F 3 134,874 SQ. FT. 3 ' 138,079 SQ. FT. ` 481.84 feet, feet to the STORM WATER \ ( along said r Q RETENSION AREA to the point o J Z Z r J H. W.L. = 931.2 .001 / i j 1. l. 1 ~.i.• ~.i.~ Y T S 89'52'23" E 79992' _ ,!y! TEMPOR REMOVE( DEDICATED TO THE FPUBUC C• O z w C4 C14 z _.AUUT------ w N 89'52'23" W 799.92' 0 n.. . 00 ( 5 \„J 1 CY N I N , tO z I 3.016 ACRES 3.127 ACRES M ` 131,391 SQ. FT. 136,206 SQ. FT. I a 1 17 4, s9' C° STORM WATER RETENSION AREA 0., I 265.00' ' H . W. L. = 919.2 ; i Wisconsin Department of Commerce NO SITE EVALUATION ~Divisim of safety and Buimings ti Page of Bureau of Integrated Services s. ILHR 83.09, Wis. Adm. Code ' `:i.. Attach complete site plan on paper not 8 ! in ssiz4, must county include, but not limited to: vertical and ref r and f • C r~ l percent slope, scale or dimensions, and caiion and distance iarest road Parcel I.D. # ' J U 0 '998 APPLICANT INFORMATION - P print E R~(prmador. ` Reviewed by Dab Personal inforrnation you provide may be used for ry . s 1 .04 (1) (m)). x. • 7 / Property Owner ^._1- ` \ f Property location Flo r V-.- (A J.,- r k. jr ~-e- ~~a Govt Lot ..S W 19 VC-1/4,S (p TZQ. N,R1rf~p(j E (w)69 Property Owner's Mailing Address Lot`s~f Blocks Subd. Name or CSM# /r' G It n - Ev-e r-e -e n City State Zp Code Phone Number City 171 Town Nearest San ( Sy/la (7i~>3"S'9-Y~/q ose ff Nevv Construction Use: [gResidential / Number of bedrooms Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: Code derived daily flow 6 QU gpd Reowmrwbded design loading rate ~ bed. gpd*.~_trench. gpoltlz Absorption area required jtr7 , it2 7,5-G _V9noh, ft2 Maximum design loading rate _~-7bed. gpolllz_! 1--trench. gpdHl2 Recommended infiltration surface elevalon(s) 'Y 517. ISS day'r • /S ` ft (as referred to site plan benchmark) Additional designisite considerations Parent material cc C rcL / Q S )-f! t. .S Flood plain elevation, if applicable ft r Suitable for System Cormentional Mound In-Ground Pressure AT-Grade , System in Fill Holding Tank u = unsuitable for system ® S ❑ u COs Cl u ®s O u 6~s I u ❑ s ®u ❑ s W flu SOIL DESCRIPTION REPORT ` Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPDM2 In. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench o- d z- 51 C i 13 Z 9 --/z / r. 5 yn c Ground 3 NL~+ /.n G~ yyf l C . ; . elev. 9Y~ft. , Depth to limiting factor [O 1 in. Remarks: Boring # -L s,~/ labs r^ c , 02 Z y 2, y/Z r►~-~ ; l--~ Ground elev. Depth to `O limiting factor (ZCY in. Remarks: CST Name (Please Print) Signs re Telephone No. Sc v,MC~ ~c e 7iS-- -r"7- 2'60 2 Address Date CST Number 70 .eaPe/S sGr+~t/S"Q t G/! 2S'330 PROPERTY OWNER SOIL DESCRIPTION REPORT Page PARCEL LD.#I Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GapAt2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 13 0-0 /Oy,- V& 511/ , C-S I Ground y~Ip /O YJt ✓sr C.S p~elev. C~w Depth to limiting [vin. ' Remarks: Boring # oao A, r 3/z .5l m49 `n.rrr S 13 z o 0 3///5/ LS l m/ L 5 M-5 1 n-3 .-n c 57 Ground elev. Q7, 7.f"ft. Depth to limiting factor Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # G-3l l0 /"3l S~ /rrob l'~-~'/' G • Mrt Us l C-5 7, 3F led Ground elev. ft. i Depth to limiting factor j622LIn. Remarks: Boring # Ground elev. ft. Depth to limiting factor in. Remarks: SBD-8330 (R. 07/96) SOIL DESCRIPTION REPORT PROPERTYOWNER fytc,~ - r,~'~~-~, Page PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots in. Munsell Ou. Sz. Cont Color Or. Sz. Sh. Bed , Trench Ground yrij/~ /G f/~P y1t 5 ✓n CS i elev. Q fL Depth to ` limiting actor ~ . ~7-in. Remarks: Boring # o->a /o 3/~ l rr4 ` xI- 3 C 57 Ground elev. Q 7 -7 - Depth tD limiting factor Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots in. Munsell Ou. Sz. Cont Color Or. Sz. Sh. Bed , Trench Boring # -3l ~o r3l S' ~rrGb :4--.Vf- G to ~5~/ m5 US Ground Q elev.~ ft Depth to limiting $ factor /09 In. Remarks: Boring # 13 Ground elev. ft Depth to limiting factor `n' Remarks: SBD-8330 (R. 07/96) rCt h e r -e l•c~ lam'' /ica " _ ~,/0 ` r S 3G Sw SUE ~Q 3u, 19-CO-1 41 rn e leu. ,Vc% as- /o 0-1- SAZe ,6A 3,3z c~ in G/tV. foe lowtr r4 h !a 1 r' n L 'Its a J a e_ Y' n ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer rub 4- -zJ "J Mailing Address i t uq ~c G C f} l~z~nvq 4V1 r _ SSA 3 Property Address 17 ALI (Verification requited from Planning Department for new construction) City/State Parcel Identification Number 030 -;Z/06 --YO LEGAL DESCRIPTION Property Location r/,, A Lt!-- Sec. T 7 LN-R,J~_W, Town of d .6 5._ p k.. . Subdivision J , Lot # Certified Survey Map # D-~ me b . Pa e # 2 / G 3 Warranty Deed # J``~3 02 S~oZ Volume l 35- 3 . Page # 5 lO Spec house O yes loo Lot lines identifiable Oyes 0 no SYSTEM MAINTENANCE Improper use and mainteosuceof 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, journeymanplumber, restrictedplumber or a licensedpumperverif*g 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, her+eia,•as act by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification sb that your septic has been maintained must be completed and returned to the St. Croix County Zoning Office within 3Q the year on date. d CiNAliFM OtKAPPLICANT DATE OWNER C r' I twe) certify that a to ents on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of a e, by'virtua of a warranty deed recorded in Register of Deeds Office. A 017 APILICANT DATE «•ss.« Any information that is mis-represented may ~lt in the sanitary permit being revoked by the Zoning Department. ssss~s 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 ~ o ; o I M ti O ° ° 0. 0 o ~ I ' o N ti d I a ~ I I ~ I I O Z (D o z c U. C O a I ' I Z W E z o cc E 04 H d m m ~ o Z c m z N H r rn 0) 4 c rn 3 7 O a) (V li N IZ C O O O •N d L L R 'M N = G O w O N z y ~ z - z6 4 c0 Z o c LO a> a r m ~ O a1 a) m d o d U) U) E Jew > ° rn W v a 'c O O O • ~ M M a a G L O O li to J U iz rn rn ° M I-- O ~V O N y o o o r- a M fV -q - O N N N a) O O 'O E M C m C a ^ O N (n o °r t 'C m Q Z U) as ►Z' C ° ca y v y C C) :c C) 0 1~ c 0 ° co H ° a o N O v O oO o 0 W t '•7 y m m •O N N N V 0 00 N c ` C N_ 7 N C2 0 0) G N O O c n 2 (D W W • H co O? O N O O O U O O C/) M O Z- d~ fn O l C ~ E V ` O a a ` a • eet a m .2 m c `IV E 0 c c C) (L 2 0 U) Co) WiscoAsir) Department of Commerce SOIL AND SITE EVALUATION • D'ivfsf3n of Safety and Buildings Page of Bureau of Integrated Services in acv"fnn syILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 iPla 1 include, but not limited to: vertical and horizontal reference point (BM), direc ' n lkli r` r percent slope, scale or dimensions, north arrow, and location and distance.0eiEfest roa FPa&?f . # rt,r- f `o UE; F t V. APPLICANT INFORMATION - Please print all informati tLl Reviev*d-b Date R is 3 111 Personal information you provide may be used for secondary purposes (Privacy La f , 5 j 5.04 (3(#. 2 Property Owner Propelrtyr oC is_, t c ,,n --t"l`-„- ;~Pov~t7'iilA i/4,S Gf T C N,R E (or)@) Properfy Owner's Mailing Address 191 # Block# Sql ame or CSM# j.~ City State Zip Code Phone Number ❑ City ❑ Village [7 Town Nearest Roa s~ G cS > y C'~. - do-5 New Construction Use: ❑ Residential / Number of bedrooms Addition to existing building Replacement ❑ Public or commercial - Describe: Code derived daily flow Crtf gpd Recommended design loading rate 7bed, gpd/ft2J-trench, gpd/ft2 Absorption area required Z_bed, ft2 ?<'(2 trench, ft2 Maximum design loading rate . ? bed, gpd/ft2 trench, gpd/ft2 Recommended infiltration surface elevation(s) 'toy ft (as referred to site plan benchmark) Additional design/site considerations / f-,r ~c, ~Pwr '3S. 6~ Parent material h , / ~k~J Ck S Flood plain elevation, if applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system E~ S ❑ U S ❑ U Dfl S ❑ U [)is ❑ U ❑ S E' U ❑ S ~A'U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell ou. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Z it, v - ; ~1~ yr C 7/ 17 7 -5~ Ground L " t !v y s} 5 elev 641 Depth to ' limiting factor Remarks: Boring # c-7-14 cy #I' k4 i- Ground / !yl Lf) a elev. qU:Lft. Depth to limiting factor /&,-in. Remarks: CST Name (Please Print) Signature Telephone No. Address Date CST Number ' F S°v. Y 4-1,__3 302 PROPERTY OWNER A/ ell k-lw(' SOIL DESCRIPTION REPORT Pa e , • ' g , 2- of ` PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench . t d Ground elev. ' eft. Depth to limiting factor Remarks: Boring # 6-1v 2!. A, q r Ground elev~ Depth to limiting factor fC~ in. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed Trench Boring # C _3t /O r ir- r -1 Ground elev. Depth to limiting factor in. Remarks: Boring # Ground elev. ft. ' Depth to limiting factor in. Remarks: SBD-8330 (R. 07/96) , onsin Department of Commerce PRIVATE SEWAGE SYSTEM Count .K k, ,ety.and Buildings Division INSPECTION REPORT • CRO~X GENERAL INFORMATION (ATTACH TO PERMIT) Sanita7 f%TV#,-: Personal information you provice may be used for secondary purposes [Privacy w, s.15.04 (1)(m)]. Permit Holder's Na g f ity [gCyghVjF Town o : State Plan ID No.: JOHNSON, CST BM Elev.: Insp. BM Elev.: BM Description: Parce]da_2 146 X40-000 LGv /ov 2t .ry TANK INFORMATION ELEVATION DATA A9900026 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. ,0,4 oF' Septic (i1,~7GQ OUn Benchmark s- c ~t7 16r Dosing < l~ I~. / , f 0►0 D ^ 6 a-- Aeration Bldg. Sewer / a t'7 96 . a Holding St/ Ht Inlet SZ ~o TANK SETBACK INFORMATION St/ Ht Outlet verit irito ntake ROAD Dt Inlet T, O P/L WELL BLDG. A Ar Sept. `7S a `Ov' 0 1 1.> T 14, NA Dt Bottom D in 78' NA Header/Man. Lq,/5 7(0~ 93• S/ Aeration Dist. Pipe 7•g~ 93./7 Holding - Bot. System o/ a1'1' 6 7 PUMP/ SIPHON INFORMATION Final Grade J~'•~~ (p';3 9Y.$/ Manufacturer s Demand 54, yy; Model Number p 5 aSGPM TDH Lftg.l 4e FrictiorV~ System TDH?,/~ Ft Loss Forcemain Length I Diaa•' Dist.ToVvell SOIL ABS PTION SYSTEM BED Width Length No. Of Trenches PIT No. Of Pits inside Dia. Li pth DI I N 15-6. DIMENSIONS SETBACK SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING M`nnu rt INFORMATION Type 2 /o~~ CHAMBER gel u er: Syste r N OR UNIT DISTRIBUTION SYSTEM Header/ Mari old Distribution Pie(s) W7 x Hole Size x Hole Spacing Vent To Aic Intake Length - IL Dia. ~ Length J_~V p+a. Spacing 77 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.) LOCATIgN: ST: JQSgPH 6.29 r 19, SWtIS 376, 3_1' -'AVE - EVEMR=4 RDG LOT 4 .7 Plan revision required? ❑ Yes ❑ No 7_1 I Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature Cert. No. ADDITIONAL COMMENTS AND SKETCH 4 SANITARY PERMIT NUMBER: 10 s 1.&1 7,00 (,.35 Six S rS y °o qo,~. ~ 2 Zg Soy ? 6f. ~n o_ Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division CountY INSPECTION REPORT 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 ❑ Town of: State Plan ID No.: ,Jac 17~ tin 5~ ~5 . Jo h CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 1 TANK INFORMATION ELEVATION DATA /7Ob TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Se~ pic i , ;L enchm k Z c p pro qa 103'5a MN B Dosing &A_ Al 17,!, C7 101; bo Aeration Bldg. Sewer 7-57 Holding &/lllf Inlet 4424 614, TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Se ti ~CVZ, L)CSI LJIA NA Dt Bottom p S^ osin V4 I NA Header/Man. &:sklt 93.s-I eration NA Dist. Pipe !3/ 7 off Holding Bot. System b i•'~ PUMP/ SIPHON INFORMATION Final Grade g Manufacturer IOv 1 Demand I VIOL "Is 0-T. (1-14- Model Number ~)~GPM VVo-661, ~g.38- TDH Lift%. Friction ,)q System . TDHq. [a Ft oss Head Forcemain Length. Y~_ Dia. 9!' Dist. To Well SOIL ABSORPTION SYSTEM BED / Width 2 Length No. Of Trenches PIT No. Of Pits Inside Liquid Depth DIMEN °DIMENSIONS SYSTEM TO P / L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK 1 ~lr I' INFORMATION Type O CHAMBER Mo el Num er: Systeme_. (QZ j OR UNIT DISTRIBUTION SYSTEM C~m Header/Manifold c~ Distribution Pipe(s) x Hole Size Xf Hole Spacing Vent To Air Intake Length ~ Dia Length~~~ia' ~ Spacing y7 ~ke 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 E] Yes E] No ❑ Yes El No COMMENTS: (Include code discrepancies, persons present, etc.) 54.fose-fh /q, !Wl Afe 37( 1171ti vs, - Ct/,eYy ✓ l~Td~e c e tf' 1f, do 6~ c~ S telq Plan revision required? ❑ Yes &INo Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature Cert No. ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: 13 gvBi 3 t a F r, x 3 Q f F S r c } E E a { g i T c E s a Sri Q3 ~3 9~•7\ 9 q~13 46 13y~s i ham' ` I ~ I qo sT J1 ,aoo-~ 1 6 5-0 a-y ~ `too 7-f S ~s a-Y l i 1 Do° ~r 3-~ r►-}•h ~ t a&&',+i0h -t*o ar<'15'em4l f erc._ dons tae- FIor', 0,r% Qt-aKwIL Wisconsin Department of Commerce SOIL AND SITE EVALUATION Q0 !I'7- 9%) Division of Safety and Buildings Page~ of 3 Bureau of integrated Services in accordance with s. ILHR 83.09, Wis. Adm. Code 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 J 1 . percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 030- alb(,o_ VO APPLICANT INFORMATION.- Plans print all Information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 16.04 (1) (m)). Property Owner Property Location So @I, F.'4 ~:1~r ^ . t s 1 "J C n S 6 h Govt. Lot sw 1/4 ~Je 1/4,S T ~ 9 N,R ~ E (or Property Owner's Mailing Address Lot # Block# Subd. Name or CSM ~G T I Q V e. L4 150C r r e- r: vN R City State Zip Code Phone Number Village ® Town Nearest R Cihr ❑ Ilk v ..~C>. syo/b (j15) s yg-b❑ `r 13 .-t: S-t OS e k 7 AU L ev . e..~ o ~ : "55 ❑ New Construction Use: El Residential / Number of bedrooms 3 Addition to existing building ❑ Replacement ❑ Public or commercial - Uescribe: Code derived daily flow 0 gpd Recommended design loading rate __LZbed, gpd/ft2-Ly_trench, gpd/ft2 Ab rption area required (0q3 bad, ft2 562.5 trench, ft2 Maximum design loading rate 7 bed, gpolfl2 9 trench, gpd/ft2 rose t 9l. c h C_ h L., ~ infiltration surface elg 0' 14 vation(s) 63 0 (;t 'r r ft (as referred to site plan benchmark) nn Additional design/site considerations r h O>n 'r o e V t~u 1CSe "t Jr4' n~1 e ~d Parent material C:# e- O t,: f t"') G 5 Flood plain elevation, if applicable u r t 4 S Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system ® S ❑ U fAS ❑ U ® S ❑ U [9 S ❑ U ❑ S ®U ❑ S 60 U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/ft2 in. Munsell Ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench oA ,oyP, 5 L_ aM Gr, M Ft- C1 5 a s w. a 9-al 7.-9 31y L ~►'n5 yL Mfr cw I Ground 3 4-A9 7,61ky 1•S p-S L C,,a 1,J , elev. qy oLh• -Yo 7.5 YP,YJV 5 D • S M L - 7 ' Depth to DIK IIto limiting factor `30in. Remarks: Boring # 9 D-11 3/P. ---------b :5 4~ M to P, mFrr Q .1 F . _ 2 9-6 7.644, 64 ~M.6bk mfr Cw l F •5 6-3to -1.610h s o •s L, kw of .9 J , p Ground ~v 4$ I S b -S74 elev. r. ; fr' Depth to .fi limiting t to or ~Ot` Z DL1 a~.~ 1l STC in. Remarks: r' CST Name (Please Print) Signature S /Np~F Tele `d o. %Yg r\ A Address T Date umber a o 5+ax Pf-a; e: 42 Z -as-q a y SocL F, ~ , . . PROPERTY OWNER 4, :Tehr►S0+1 SOIL DESCRIPTION REPORT Page ~ Ot3- PARCEL I.D.# 03D- a!O to - YO • Boring # Horizon Depth Dominant Color Mottles Structure 2 9 In. Munseil Ou. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trench - D I0v1R-3 L- M w • S ' . m-a► l0\1R3/a s L QM (OK m FI - Ground ,3 1.3~ 7.5`1f2.`1 5 L m Sb►~ Mfr. C w 1 F . 5 . (P ele . 9y. ft 32-1-7.91 K'11V t 5 D- M L C w 1 J F (q y,o l 9?'d yb-'19 7 ~ 5 `I IL 5 0 -S M L taw - .7 : • ~ Depth to limiting IOU- AP4, 5 Q- 5 M L . 7: -9 factor 535 in. Remarks: t~ o t a v v. a e Bearing # a-? I v`iQ3)eA bK MFG q0 IuF , 7-14 101(Z G P, Fr- 5 014: , 5 ► 3 18-A )O I R 3/~ C w 1 Ground y -y$ I b K R Y/q CL ~ S bk. MF.- c w I v F r S 93 0 ft S q8-5s Sc L athsbk- U-j - y :.S Depth to limiting factoL n. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots in. Munsell tau. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; Ground elev. ft. Depth to limiting factor In. Remarks: Boring # Ground elev. n. Depth to limiting factor i"' Remarks: SSD-8330 (R. 07/86) + C.►~ris'~;r.c A,To-.soh Page,. $ ~ 3 sw'/ , N E fly,) sex-. (Oj T aQ n) R 19 Q art) 4 S , S'i-it Steal Yo' C strY, a a ►7 y hOrth I0+ I- h`~) -j'o ~ o-~. M a r k call - 5 ~ ~ L Q,S Qr'1 I *o 0 i raM Or~~~r„st~ (~QrL ~ ®t,ae. I N $ ~fc~e rcNCe. P Lo+~~~ Q k m C9 C) y W (9y,p/o~ge► 3 ~ b9 43,90 13.34 5r a.ttC i 1 C~ I-AAe. TI~c. th F;-f-,. a+ a K Sur FA Le- 5 L54h~~ l So; L ' bit, zo r . h cJ L) C, to r- ; a,\_ 1 S r. O 0. t' o. F F< 'T' h,e P S y st~~ 3 Safety and Buildings Division `~SC0115%h SANITARY PERMIT APPLICATION 2 1 Box Washington Avenue 7302 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 Count than 8 1/2 x 11 inches in size. , • See reverse side for instructions for completing this application State Sanitary P'er1mit Number 3R '7 75 Personal information you provide may be used for secondary purposes heck if revision to previous pplication (Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATI N I-- Prop Own Name 51 /4 1 1 /4, Property Location $ C.v T 3L N, R X(or) W Property Owner's Mailing Address Lot Number, Block Number Cit , State Zip Code Phone Number Subdivision Name or CSM Number JV 65-6y.? ( ) II. TYPE BUILDING: (check one) ❑ State Owned 3 0 It~/ Nearest 96a Public 1 or 2 Family Dwelling - No. of bedrooms c Tolwn OF 5'7t T 117 f~ 1 " III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/Condo 03 0 ~ ` / v4 o 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, V New 2. ❑ Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank OnIY_____-________ Existing System t1Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number 75~1 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 p~-q ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit a ~15G t 2.S~ 43 Vault Privy 14 ❑ System-In-Fill . VI. ABSORPTION SYSTEM INFOR ATION. 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade C Required q_ ft.) Proposed (sq. ft.) (Gals/da /sq. ft.) (Min /inch) Elevatio 7 Feet ep Feet VII. TANK Capacity in gallons Total # of Prefab. Site Fiber- Exper. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass Plastic App New Existing structed T nk Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ .1606 1 Lift Pump Tank /Siphon Chamber 6,3-n I _ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumb 's Sig ure: (~ts) PIMPRSW No.: Business Phone Number: ~i 7 Plum is Address (Stfee y, State, Zip O IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee oncludes&oundwater ate ssue Issuing Ayyyent Signature (No Stamps) pproved E] Owner Given Initial Surcharge Fee) A Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: ter ~.vf~~an~ 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 maybe 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: 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. r Safety and Buildings Division SANITARY PERMIT APPLICATION 201 W. Washington Avenue • isconsin in accord with ILHR 83.05, Wis. Adm. Code P O Box 7302 Department of Commerce Madison, WI 53707-7302 • `Attach complete plans (to the county copy only) for the system, on paper not less County than 8112 x 11 inches in size. S?, • See reverse side for instructions for completing this application State Sanitarryy Peerrjmitt mber Personal information you provide may be used for secondary purposes C] Check it revision I oa lication P PP [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Prop Ow r Nam Property Location ,y~N 'T &k s(1 la #j g 1/4, S T aq R/?-R(or) V1% Property Owner's Mailing Address ! Lot Number Block Number J s A Cit , Sta a Zip Code Phone Number Subdivision Name or CSM Number M p ( > II. PE BUILDING: (check one) ❑ State Owned ❑ City Nearest R d villae :5 Uev ..1d Public 1 or 2 Family Dwelling - No. of bedrooms _2 O Town OF 7r 111. BUILDING SE: (If building type is public, check all that apply) Parcel Tax Number(s) 1❑ Apartment/ Condo 0 3 Q- l©~ d 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. rk New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only Existing System Exlstlng 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 410 Holding Tank 12 WLSeepage Trench. o? - 9 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit S' 43 ❑ Vault Privy 14 E] System-In-Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate S. Perc. Rate 6. System Elev. 7. Final Grade c-- Required (sq. ft.) rProposed (sq. ft.) (Gals/day/sq. ft_) (Min./inch) l Ele tion 7 ~.7 Q 5- 5-72- Feet Feet VII. TANK Capacity gallons Total # of Prefab. Site Fiber- Plastic Exper. INFORMATION New Existing Gallons Tanks Manufacturers Name Concrete struCon- tted Steel glass App. Tanks Tanks Septic Tank or Holding Tank ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ VI11. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber' gnat (N m / PRSW No.: Business Phone Number: u~ 3S 7~s a~ Plumber's Address (St *qt, City, Or e, Zi de): a 116 J* •S`~ O IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stam Surcharge Fee) Approved ❑ Owner Given initial -1 -?q Adverse Determination 7 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 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: 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. III. Building use. If building type is public, check all appropriate boxes thatapply. 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 foss; 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. f . Page Ur SEPTIC TANK & ,PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS •4" CI VENT PIPE 12" MIN. ABOVE GRADE 6 WEATHT PR OF APPROVED >_25' FROM DOOR, WINDOW O WITH CONDUIT MANHOLE COVER FRESH AIR INTAKE W/ PADLOCK & 4 WARNING LABEL FINISHED GRADE " CI RISER 4" MIN. 18" IN. 6" MAX. INLET i WATER TIGHT SEALS GAS- TIGHT ~ppPR0VED A SEAL JOINTS WITH ALM APPROVED PIPE APPROVED B ' ON 3' ONTO PIPE 3' t SOLID SOIL ONTO SOLID ~ ~ ID'I~FT. SOIL PUMP OFF ELEV . C OFF RISER EXIT PERMITTED ONLY D IF TANK MANUFACTURER HAS APPROVAL 3" APPROVED BEDDING UNDER TANK J~ CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE TANK MANUFACTURER: NUMBER DOSES PER DAY: /k TANK SIZES: SEPTIC 2Q0 GAL. DOSE VOLUME INCLUDING DOSE l.~C GAL. FLOWBACK: GAL. ALARM MANUFACTURER: CAPACITIES: A = Z~INCHES = 309, AL. MODEL NUMBER: B = 2 INCHES = r GAL. SWITCH TYPE: C = E-7 INCHES = / 66, / GAL. PUMP MANUFACTURER: MODEL NUMBER : D = NCHES = GAL . SWITCH TYPE: j _ REQUIRED DISCHARGE RATE GPM PUMP 8 ALARM WIRI G AS PER VIM& WAC • • 1 FEET VERTICAL DIFFERENCE BETWEEN PUMP OFF .AND •DISTRIBUTI ON PIPE FEET + MINIMUM NETWORK SUPPLY PRESSURE FEET + FEET FORCEMAIN X j, I G FT/ 100 FT.OTALIDYNAMICAHEAD • _ • ~/Q FEET .7 r DIAMETER ~ ` INTERNAL DIMENSIONS OF PUMP TANK: LIQUID WIDTH TH DATE: LICENSE NUMBER: SIGNED: tno n , - Goulds Submersible is Effluent Pump j 3871 EP04 EP05 APPLICATIONS • Fasteners: 300 series • =erged in high ■ Motor Housing: Cast iron Specifically designed for the stainless steel. ne oil for for efficient heat transfer, following uses: • Capable of running lubrication and efficient strength, and durability. • Effluent systems dry without damage to heat transfer. N Motor Cover. Thermoplas- • Homes components. tic cover with integral handle Motor Available for automatic and • Farms manual operation. Automatic and float switch attachment • Heavy duty sump • EP04 Single phase: 0.4 HP, models include Mechanical points. • Water transfer 115 of 230 V, 60 Hz, 1550 Float Switch assembled and ■ Power Cable: Severe duty • Dewatering RPM, , built in n overload with automatic reset. preset at the factory. rated oil and water resistant. SPECIFICATIONS • EP05 Single phase: 0.5 HP, ■ Bearings: Upper and lower 115 V, 60 Hz, 1550 RPM, FEATURES heavy duty ball bearing Pump: EP04 built in overload with construction. • automatic reset. ■ EP04 Impeller: Thermo- Solids handling capability: plastic Semi-open design 3/i maximum. • Power cord: 10 foot with pump out vanes for AGENCY LISTING • Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. C0, Canadian Standards Assoctaft • Total heads: up to 24 feet. with three prong grounding • Discharge size: I1h' NPT. plug. Optional 20 foot ■ EP05 Impeller: Thermo-(CSA • Mechanical seal: carbon- length, 16/3 SJTW with plastic enclosed design for end in model numbers improved performance. end n "P' or "AC".) rotary/ceramic-stationary, three prong grounding plug BUNA-N elastomers. (standard on EP05). ■ Casing and Base: Rugged- * Temperature: thermoplastic design provides 104°F (40°C) continuous superior strength and 140°F (601C) intermittent, corrosion resistance. • Fasteners: 300 series METERS FEET stainless steel. 10- o Capable of running ~$4 dry without damage to s 30 ! ,4 components. GF""' Pump: EP05 a • Solids handling capability: 0 25 3/' maximum. w • Capacities: up to 60 GPM. _ • Total heads: up to 31 feet. 6 20 i i • Discharge size: I1h* NPT. Z 5 • Mechanical seal: carbon- } ! rotary/ceramic-stationary, ° 15 • BUNA-N elastomers. 0 4 Temperature: F' 3 10 , ' 104°F (400C) continuous 140OF(600C) intermittent. 2 - - - po4 5 ~ 1 i 0 00 10 20 30 40 50 GPM 0 2 4 6 8 10 12 ml/h CAPACITY LJ LCw-cY ~ S Z` 1 1 l r .7~r 3` ~1 ,,VII f / p ('crt~ Vii-. Wisconsin Department of Commerce AND SITE EVALUATION biviskon of Safety and Buildings page 41 of Bureau of Integrated Services In', `W s. ILHR 83.09, Wis. Adm. Code Attach complete site plan on paper not 1 {h Y8 1/2 ?j in siz, must County include, but not limited to: vertical and refer? 6; ~ At M), di and ~ 7' . C rC) 1 ~L percent slope, scale or dimensions, no arrc/w, and location and /dfistance to rldarest road. Parcel I.D. # 998 R t ` APPLICANT INFORMATION - P prinf4 X grmatiot~i: Reviewed by Date Personal information you provide may be used for ' ry Vjiip" ( Ey fQk". s 1 .04 (1) (m)). Property Owner ; Property Location Govt Lot _5W 1/4,{/C 1/4,S (0 TZ1?,1jN,R/9)2{ E (or)~o Property Owner's Mailing Address Lot # Block# Subd. Name or CSM# f k - Cve r-e -e 0'\ City State Zip Code Phone Number ❑ City ❑ Village Town Nearest R -1~ L J ( S_Val'G (715- ) 5-qr-6 fiW 91 S- os e 'G Of- /IV f New Construction Use: Residential / Number of bedrooms .5 Addition to existing building ❑ Replacement ❑ Public or commercial - Describe: _ Code derived daily flow 00 gpd Recommended design loading rate ! ~ bed, gp6*_{Ltrerx 1, gpd* Absorption area required &7ZZbed, ft2 .-G trench, ft2 Maximum design loading rate bed, gpd/fl?_-,j'_trench, gpd/ft2 Recommended infiltration surface elevation(s) 40#0 97. 4av - , 6' ft (as referred to site plan benchmark) Additional design/site considerations Parent material L/C, C /,Ck ~CJFlood plain elevation, H applicable ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system ® S ❑ U PS ❑ U ® S ❑ U ®s ❑ u ❑ S ® U ❑ S ® u SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 0- 6 r -3 /Z C 13 it 7 Ground 3 yL / C 16v y~~ 5 G5 l 1,7 elev. Depth to , limiting factor OI in. Remarks: Boring # C-S Z v mss- ~~z S• c= / rrt--~ ; I . ~l ; . v5--66 7,S r S m q,64 1-14r- C Ground j &0v /6 ' y ~ m5 Cj~ f~ ~ CS 7 elev. q~ft• , Depth to limiting p factor 17C> in. Remarks: CST Name (Please Print) Signa re Telephone No. g5ja V VV-CL ~c 7.,~ Y~ you Address Date CST Number clot e s r.- so.~.e e f c,r < <~a Sr G - y~ ~S'3 30 SOIL DESCRIPTION REPORT PROPERTY OWNER Page PARCEL I.D.# Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench ( -i7 to r 3/& S,' /M- 64 1-t e - C 2/?-Y6 l0 r 3/G L 5 ! 5 Y" l C 5 7 Ground y~/O /G f gyp Yh 5 'In C,5 • 7 ' i elev. Q y. p~ , Depth to limiting actor !~7-in. Remarks: Boring # I 0-/0 lop- 3/z- 5/ n 41, `no'r C Z 0 3/y LS / m/ L 5 • 7. y~ /Q r `n C S w i Ground elev. Q Depth to limiting factor Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # G -3 f c' r /0 C-5 1/41 x i6s Ground ~ele'v. ??z- 5,f• Depth to limiting factor 02'n. Remarks: Boring # y' Y ~S Ground elev. tt. , Depth to limiting factor 'n' Remarks: SBD-8330 (R. 07/96) C- t, ar« v~, e c k r r r-e-e c << celG '9 q30, 19z u 1y► ~c/ect. /UV, dS~ /{°P4Sam/ ~Sf /fir Z e /eu• /0 3,SZ a :1 Z "e /rn N cis in G/cV_ foe /aunt r rl h Prop ]r`nC-/L 3 I( ~ l ~ ~ 1 by t ~ I 1 t j 10 J J Co c- ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM Owner/Buyer ( C. S-) &t)e Mailing Address ( t L1 ,:F, L ~(l v ~~y l ~An1o ~ SSv4 3 Property Address (f (Verification requited from Planning Department for new construction) City/State Parcel Identification Number 030 -;Z/06 Yo LEGAL DESCRIPTION Property Location 5W _ 1/,, Kt.:- y., Sec. T Z j_N-Rj.~_W, Town of !n' To S._ Subdivision J 12 Ljj=& Lot Certified Survey Map # ~~c✓` !Lo ~olume ~ Page # Z/ G 3 Warranty Deed # SS 6 R SoZ Volume -35-3 . Page # 5-/0- Spec house O yes 21ho Lot lines identifiable Byes 0 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, restrictedplumber 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 sta i that your septic sy has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 the year pi on date. jdays 9f ~ l Z~l S'4 GNATURE APPLICANT DATE OWNER CE ATIFIC TION I (we) certify that a stet ents on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of prop rty desc ' ab e, by'virtue of a warranty deed recorded in Register of Deeds Office. A OF LICANT DATE Any information that is mis-represented may sult in the sanitary permit being revoked by the Zoning Department. -t* 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 V to I!'•~l ••)r' STAI-L BAR OF WISCONSIN FORM - ' ~1S: 55ISIb/raJ#4 W,%RRANTY DEED DOCUMENT NO. Richard W. LaCasse, a married man, R IS'T ST. C R n ! X CO.. s CE P 0 1 1998 a,ceys and uarranu o _7021 F. TOhI1SOn aIlCa _SKristin,.~__jDhnaont_hu_s~>~d-atsWi_f, /D oo A~ - - Ro ;star of Daads - - ,,,,rA - Na A~ AND RET,Jt N a~i`HFSi the following descnhed real estate in _ St. Croix tita[e of Wisconsin. - r Lot 4, Plat of Evergreen Ridge in the Town of St- Joseph. T AV'1gFER FE . This is not XX~QC r. r,~;t~ Exccp[wnlt Amrnitics Easements, restrictions and ri-.;'its-of-way of record, if any. JJ t - y 98 noted tills ~r Richard W. LaCasse >EAJ AU FHENTICATION ACKNON\ UDGMEN I State (If \ViSLonsin, ' St. ' • ; , Croix . 40 f - - urrc:nl.a, dthr> - do „f L i.: r l a 98 •,e Rickard W. LaCass nun. i - - - - - - - --£e, a_ married person, HI I1L \1~Ri13LR (~I [ i3;1R t F l ~r S1ti 'M$C0~`sss //I/II1111111~~ - .uuh,~;i_.'d ht ; tk~ Oh, \'[s ~tat• ' ire;., r, ~,~ttr r~ t'. , TI,, INSiR'i.) liENi 'AAS DRAFTED Cti / << •.~_C Attorney Kris itna-0gia-nd 4~~r ~.1.'? Hudson, WI 54016 1,1:1,M11,*- r.~.:c hC 01 ! d Va7L%1-11~ iJ 1 . l~llrVlA VVUlr 1 1 ~ ►I1,JC.VL~~Jllr• > OF CERTIFIED SURVEY MAP RECORDED IN CROIX COUNTY REGISTER OF DEEDS OFFICE C.S._M_. i SURVEYOR'S VOL. 7, PG. 2025 UNPLATTED LANDS t Douglas J. ~ that in full t I Statutes, an 1 NE1/4 j Weckworth, I 04 ' 6.0'+ 8'+/_ plat correct) IW 8.18 _ _ _ I _ - _ _ _ _ the land sur the NE1 /4 c L3.0'+/- 306.00' 311.88' Joseph, St. r Survey map County Regis 3 Commencinc c the north - r = N88'20'38"E M 1305.50 fee 0 3.096 ACRES 3.170 ACRES ` section, 8F 3 134,874 SQ. FT. 3 I 138,079 SQ. FT. ` 481.84 feet, \ feet to the STORM WATER UD I along said r to RETENSION AREA to the point C, z z r H.W.L. = 931.2 / i 0 01 1000 / i rn I ! j I........ 1.. a• M i I CO ~.I./ 1 Y 3 i.~ i./ o S 89'52'23" E 799 M Y._ 232 25 i w _ TEMPOR - -----0fi6~--- -y---- V- C REMOVEI - - - - DEDICATED TO THE PUBLIC 3 8222 0 1 Z w 04 1 -C Z _.46B.fid.----- 31$ - W N 89'52'23" W 799.92' o l I I i ~ I I I N ~ . ............i.............................. , W ~l cly ~l ~00 6 N 5 N O N W 3.016 ACRES 3.127 ACRES M FT V) ' 136,206 SQ. Q, 131,391 FT a A SQ. = I W w , \ ° STORM WATER ` - - 39' o RETENSION AREA 265.00' 1 a! ` H. W. L. = 919.2 i • ADDITIONAL COMMENTS AND SKETCH SANITARY PERMIT NUMBER: . . _ f f _ k m.; - 9 wm .m P eJ ~7 ~nG~G; 5,1 u'i7 e , e m q ~ ~ I ~ I "`777 , i E . E I mm Y ~®eom nw.e e mom. I fi a i I Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division County INSPECTION REPORT 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 ❑ Town of: State Plan ID No.: CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: I TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet Vent TANK TO P/ L WELL BLDG. A ir ito ntake ROAD Dt Inlet A Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP / SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft Head Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside 67a-7 Liquid Depth DIMENSIONS DIMENSIONS SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: SETBACK CHAMBER INFORMATION TypeO Model Number: System: OR UNIT DISTRIBUTION SYSTEM 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 TDepth Over xx Depth Of xx Seeded / Sodded xx Mulched Bed /Trench Center /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) Plan revision required? ❑ Yes ❑ No Use other side for additional information. SBD-6710 (R.3/97) Date Inspector's Signature Cert. No