HomeMy WebLinkAbout032-2092-50-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix
Safety and Building Division
INSPECTION REPORT Sanitary Permit No:
556375 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)].
Parcel Tax No:
Permit Holder's Name. City Village X Township
Woulfe, Robin R. Somerset, Town of 032-2092-50-000
CST BM Elev:
1 11141 Insp. BM Elev: BM Description: SectionTrown/Range/Map No:
(o~ 13/yl
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark
►5~-1` 14aKt tf m-- /d X 53 le~,~1 ~o~. ~
r~llw Alt. BM
a a Ic, Z~ l'-F'/1....
Aeration Bldg. Sewer f
Holding St/Ht Inlet
St/Ht Outlet
~7.
TANK SETBACK INFORMATION -7-39
TANK TO P/L WELL BLDG. Vent to Air Intake ROAD ts 1:
Septic QW30" 7-
-7) Z7 - 0 ~7 ° & X, 6 q7- 1
Dosing ~t Header/Ma .
Aeration Dist. Pipe Qe
Holding Bot. System '
Final Grade
PUMP/SIPHON INFORMATION ~o • =b c7
Manufacturer Demand St Cover
GPM T•S3 z) . G
Model Num 5 f 9 4 YS .-7 Z
TDH Lift Friction Loss System Head - TDH Ft A. 57 O~
Forcemain Length _ to Well
P. lop
-Y 4
SOIL ABSORPTION SYSTEM 9~, 3
BEDITRENCH Width Length No. Of Trenches PIT DIMENSION f Pits Inside Dia. Liquid Depth
DIMENSIONS 75 4
SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION CHAMBER OR Ez ~l6
Type Of System: UNIT Model Number:
Y3 7_21) /to S 4,
DISTRIBUTION SYSTEM LJ~S -7 S =,3 IS 4-a
Header/Manifdd II Distribution x Hole Size x Hole Spacing tent t i~Inta
Pipe(s) d Length G Dia Length Dia acing
SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only oJ+.~ s 4 0:Z7
Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched
Bedrrrench Center 3. JT Bed/Trench Edges Topsoil Yes No es 0 No
COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: Inspection #2:
Location: 781 205th Avenue Somerset, WI 54025 (SW 1/4 SE 1/4 24 T31 N R1 9W) Hansen's Turtle Lake Hills 1 st Add L Parcel No: 24.31.19.904
1.) Alt BM Description = a~ 15, 4' ~ 01~
2.) Bldg sewer length C4,)4-,
- amount of cover =
~l
Plan revi Required? Yes )
_ 3'-__-
Use othesls de for additional information. No _f] E4~
Date Insepct Cert. No.
SBD-6710 (R.3/97)
J EIV Safe and Buildings Division County
201 W. Washington Ave., P.Ox 7162 Sanitary Permit Number (to be filled in by Co.)
OCT C Madison, WI 53707-7
t.Il,t .
4 3 7 S
Sanitary Permit Application Transaction Number
In accordance with SPS 383.21(2), Wis. Adm. Code, submission of this form to the appropriate governmental unit
/v
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 Servies. Personal information you provide may be used for secondary
LL
purposes in accordance with the Privacy Law, s. 15.04 1 m , Slats. t 79 1 26 5
1. Application Information - Please Print All Information
Property Owner's Name Parcel #
1+1 oTH V +JtJ 1J bdl n1 tA)oUe-k;- 03Z- Zo Z - -000
Property Owner's Mailing Address Property Location 90~
70) Z051' y r Govt. Lot r
City, State Zip Code Phone Number° ye, Section Z L
JOi ~ Cl15~ / ircleone
T N; REotGV
II. Type of Building (check all that apply) Lot #
KI I or 2 Family Dwelling - Number of Bedrooms Subdivision Name r} A NS Af N 'S
Tub rcc 4A KF r+)Lts Ise
R ock #
❑ Public/Commercial - Describe Use ate- ❑ City of
Z
❑ State Owned - Describe Use CSM Number ❑ Village of C
® Town of c!O /~l C1~5 T
III. Type of Permit: (Check only o box on line A. Complete line B if applicable)
A.
❑ New System
®Re ment System ❑ Treatment/Holding Tank Replacement Only er Modification to Existing System (explain)
B. ❑ Permit Renewal ❑ Permit Revision ❑ Change of Plumber ❑ Permit Transfer to New List Previous Permit Number and Date Issued
Before Expiration Owner 3 il L 0 7 o0
IV. Type of POWTS System/Component/Device: Check all that apply)
9 Non-Pressurized In-Ground ❑ Pressurized In-Ground ❑ At-Grade ❑ Mound > 24 in. of suitable soil ❑ Mound < 24 in. of suitable soil
❑ Holding Tank ❑ Other Dispersal Component (explain) ❑ Pretreatment Device (explain
V. Dispersal/Treatment Area Information:
Design Flow (gpd) Design Soil Application Rate(g f) Dispersal Area Required (sf) Dispersal Area Propo (sf) System Elevation
.76 y~'o 0. -z ZZ o ZZ o CC_
VI. Tank Info Capacity in Total # of Man uf Curer
Gallons Gallons Units L 0 PV o 0 0
New Tanks Existing Tanks s Z S 0 0/ ' r e
a. U inn y on P. E5 a
pD~
Septic or Holding Tank /000
Dosing Clamber
VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of the POWTS shown on the attached plans.
Plumber's Name (Print) P=mi rec MP/MPRS Number Business Phone Number
0HAAJ cNrAl 4-~ 2!Z376 O 7`76d Otl4g
Plumber's Address (Street, City, State, Zip Code)
X16 ~sQ~ N /4ut`
VIII. un /De artment Use On
Approved Permit Fee Date Issued Issuing Agent S, lure
~~~VenReason for De
$ 40
IR. ConditftWM&teasons for Disapproval
, n
fe,niLi r O(~i i ~dsr Ga
3)
1. Septic tank, effluent finer and A.
,
dispersal ce# must all be services / maintained o ~ ~ ~l^et ~jP~ . lure- !'ro`w 8
oo per management plan provided by plumber. t ' ~dlw~G! ~JO~ ~e`~` ' .7
3. +4p setback requirements must be maintained Sd , ~ Ljo rk t A,1 r ta,
.
coda
Attach to complete plans for the system and submk to the County only on paper not leas than 8 1/2 x l l inches in size
r
(a[~j~_ !s, L,+ f~ J i f'L5
SBD-6398 (R. 11/11) clp
CONVENTIONAL COMPONENT DESIGN
Residential Application
INDEX AND TITLE PAGE
Project Name: Woulfe 3 Bedroom Septic System
Owners Name: Timothy & Robin Woulfe
Owner's Address 781 205th Ave.
Somerset, WI 54025
Legal Description: NE1/4, SE1/4, S24, T31N, R19W
Township Somerset
County: St. Croix
Subdivision Name: Hansen's Turtle Lake Hills 1 st Addition
Lot Number: 2 Block Number 2
Parcel I.D. Number 032-2092-50-000
Plan Transaction No.
Page 1 Index and title
Page 2 Plot Plan
Page 3 System Sizing & Cross Section
Page 4 & 5 Septic Tank Specifications
Page 6 Effluent Filter Information
Page 7 & 8 Management and contingency plan
Page 9 Septic Tank Maintenance Agreement
Page 10 EZ Flow Information
Page 11 Warranty Deed
Page 12 CSM
Page 13-15 Soil Evaluation Report
Designer: John Schmitt Licnese Number: MPRS 223760
Date: 10/26/2012 Phone Number: 715-760-0486
Signature: 7 Vzx~
In-Ground Soil Absorption Component Manual Version 2.0 SBD-10705-P (N. 01/01)
Page 1 of 15
PLOT PLAN N
Project Name: Timothy & Robin Woulfe
Legal Description: NE114, NE1/4, S24 T31N, R19W P.I.D: 032-2092-50-000
Hansen's Turtle Hill 1st Add. Lot M 2 SCALE- Township: SOMERSET Parcel Size: 2.99 Acres 7^ 6 4W
County: ST. CROIX
System Elevation: T1=96.00' Existing 75' Hi-Ca INFILTRATOR Trench
Slope: 10% T2=95.35' Existing 75' Hi-Ca INFILTRATOR Trench
A BM1 Elevation: 100.00' To of 2" PVC Pie T3=95.35' Proposed 75' EZ Flow Trench
BM2 Elevation: 100.66' To of existing septic tank cover T4=95.35' Proposed 75' EZ Flow Trench
Alt. BM 101.85 Basement floor T5=94.80' Proposed 75' EZ Flow Trench
Backhoe Pits: T5=94.00' Proposed 75' EZ Flow Trench
7-1*':- 4 inch Sch 40 -ASTM 02665
TANK SCHEDULE 4 inch 3034 - ASTM D3034
A Existing 1000 gallon S.T. w/ Po lok 525 installed Geotextile fabrics to meet requirementsof Table
384.30-12
NOTE: See page 12 for a complete plot of the parcel.
K/ W 7 O s'-'' AV E
3 B Ed QooM
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SOIL ABSORPTION SYSTEM DETAIL / GRAVELLESS LEACHING UNIT
Project Name: Timothy & Robin Woulfe
4 No. of Cells 7.5 Per Cell
3 ft Cell Width 30 Total No of 1203H
75 ft Cell Length 375 sq ft EISA Per Cell
3 ft Cell Spacing 1500 sy It Total EISA
Manufacturer Model Laying Length EISA Rating
Infiltrator EZ1203H-5ft 5.0' 25.0
EZ1203H-10ft 10.0' 50.0
Gravelless Leaching Unit Manufacturer: to Infiltator
Gravelless Leaching Unit Model: 1203H
Typical Cross Section
Finished Grade 97 ft
Observation Pipe with
approved cap or vent
Soil Backfill
36 in
■ Geotextile Fabric
•
94 ft Infiltrative Surface
86.6 ft Limiting Factor
12 in O I 7"
y
>36 in Slotted and Anchored Vent/
Observation Pipe with Cap
■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ . ■ ■ . ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■
Plumber/Designer Signature:
License MPRS 223760 Date: 26-Oct-12
i
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PROJECT: HUFFCUTT 4154 rd STREET w _ N.P.C.A. CE1(TiEO PLANT
CHIPPEVA FALLS, VI 54729 1 &
q 1,000 GAL. LOW PROFILE R
N PUMP, SEPTIC, C 0 A C R E T E. A C (715) 723-7446 ■ (600) 924-1516 ~ ~ i x MEMBER OF:
OR HOLDING TANK FAX (715) 723-7111 ■ ■ww.huffcutt.com X ~ d s NATOK & MSCOIISSI PRECAST C%XXTE ASSOgATM
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PROJECT, 4154 123rd STREET o N.P.C.A. CERTM PLANT
1,000 GAL. LOW PROFILE HUFFCUTT pRPPEVA FANS, NI 54729 9 Sam ~
PUMP, SEPTIC, C 0 A C R E T C. I A C 1715) 723-7446 a (800) 924-1516 MEMBER OF:
OR HOLDING TANK FAX (715) 723-7111 ■ wwrhuffcutt.con 25 NATXMIAL R Ms01m PRECAST cmaTw ASSOQAIIONS
Filters
PL-525 EFFLUENT FILTER (COMMERCIAL)
Polylok, Inc is pleased to add its
new commercial filter to its existing
line of quality effluent filters.The
PL-525 is rated for over 10,000 GPD
Alarm ~Ir Accepts PVC
(gallons per day) making it one of accessibility 1
the largest commercial filters in its extension handle
class. It has 525 linear feet of 1/16"
filtration slots. Like the Polylok
PL-122, the new Polylok PL-525 has `R-
an automatic shut off ball installed 525 linear feet € ` F ,J
with every filter. When the filter is of 1/16"
filtration slots•~ Rated for over
removed for cleaning, the ball will ~tl t_ 10,000 GPD
float up and temporarily shut off
VV,
the system so the effluent won't - a
leave the tank. No other filter on
the market can make that claim! Accepts 4" & 6"`.,.-
SCHD. 40 Pipe-,,",,-~
The PL-525 Effluent Filter should
operate efficiently for several years
under normal conditions before
requiring cleaning. It is recom-
mended that the filter be cleaned
every time the tank is pumped or
at least every three years. If the
installed filter contains an optional
alarm, the owner will be notified
by an alarm when the filter needs
servicing. Servicing should be Gas deflector
done by a certified septic tank Automatic shut-off
pumper or installer. ball when filter
is removed
1. Locate the outlet of the U.S. Patent No# 6,015,488
septic tank. 5,871,640
2. Remove tank cover and pump
tank if necessary. 1. Locate the outlet of the
3. Do not use plumbing when septic tank.
filter is removed. Ideal for residential and com- 2. Remove the tank cover and
4. Pull PL-525 out of the housing. mercial waste flows up to pump tank if necessary.
5. Hose off filter over the septic 10,000 Gallons Per Day (GPD). 3. Glue the filter housing to the
tank. Make sure all solids fall 4 or 6 outlet pipe. If the
filter is not centered under the
back into septic tank. access opening use a Polylok
6. Insert the filter cartridge back Extend & Lok or piece of pipe
into the housing making sure to center filter.
the filter is properly aligned and 4. Insert the PL-525 filter into
completely inserted. its housing.
7. Replace septic tank cover. 5. Replace the septic tank cover.
POWTS OWNER'S MANUAL & MANAGEMENT PLAN
FILE INFORMATION SYSTEM SPECIFICATIONS
Owner: Timothy & Robin Woulfe Tank Manufacturer: Huffcutt F NA
Permit # Septic is Dose Holding Volume: 1000 gal
DESIGN PARAMETERS Tank Manufacturer: It NA
Number of Bedrooms: 3 r NA E: Septic _ff Dose Holding Volume: al
Number of Public Facility Units: d NA Vertical Distance Tank Bottom (s) to Service Pad: ft
Estimated (average) Flow: 300 gal/day Horizontal Distance Tank(s) to Serivice Pad: ft
Design (peak) Flow = estimated x 1.5: 450 gal/day Specific servicing mechanics must be provide if vertical is>15 feet or if
In Situ Soil Application Rate: 0.2 gal/da /ft2 horizontal is > 150 feet. Specific instructions to be provided on back.
Standard Domestic Influent/Effluent Monthly average Effluent Filter Manufacturer: Polylok F NA
Fats, Oils & Grease (FOG) !530 mg/L Effluent Filter Model: 525
Biochemical Oxygen Demand (BOD5) 5220mg/L r NA Pump Manufacturer: 10 NA
Total Suspended Solids (TSS) 5150mg/L Pump Model:
High Strength InfluenVEffluent Monthly average Petreatment Unit
Fats, Oils & Grease (FOG) 530 mg/L Manufacturer:
Biochemical Oxygen Demand (BOD5) 5220mg/L NA F_ Mechanical Aeration r Peat Filter 1W NA
Total Suspended Solids (TSS) 5150mg/L r Disinfection r wetland
Petreated Effluent Monthly average r Sand/Gravel Filter I- Other.
Biochemical Oxygen Demand (BODs) 530mg/L Soil Absorption System
Total Suspended Solids (TSS) 530mg/L ® NA It In-Ground (gravity) r In-Ground (pressure) r NA
Fecal Coliform (geometric mean) 5104cfu/100m1 r At-Grade r Mound
Maximum Effluent Particle Size: % in dia. f N r Ddp-Line r Other.
Other: I- Other: F NA
MAINTENANCE SCHEDULE
Service Event Service Frequency
When combined with sludge and scum equals one-third of tank volume
Pump out contents of tank(s) When the high water alarm is activated
Inspect condition of tank(s) At least once eve : 3 r year(s) (Maximum 3 ears) NA
r month(s)
Inspect dispersal cell(s) At least once eve : 3 r year(s) (Maximum 3 ears) r NA
r month(s)
Clean effluent filter At least once eve : 1.5 r year(s) r NA
r --"S)
Inspect pump, pump controls & alarm At least once eve : r year(s) r NA
Flush laterals and pressure test At least once eve : r- year(s) r NA
month(s)
Other: At least once eve : r year(s) F NA
Alternate drainfields Rest old drainfield for 5 years, then alternate drainfields annually
MAINTENANCE INSTRUCTIONS
Inspections of tanks and dispersal cells shall be made by an individual carrying one of the following licenses or certifications: Master
Plumber; Master Plumber Restricted Sewer; POWTS Insepector; POWTS Maintainer; Septage Servicing Operator (pumper). Tank
inspections must include a visual inspeciton of the tank(s) to identify any missing or broken hardware, identify any cracks or leaks,
measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on ground surface. The
dispersal cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent
on the ground surface. The ponding of effluent on the ground surface may indicated a failing condition and requires the immediate
notification of the local regulatory authority.
When the combined accumualtion of sludge and scum in any treatment tank equals one-third or more of the tank volume, the entire
contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113, Wisconsin
Admininistrative Code.
All other services, including but not limited to the servicing of effluent filters, mechanical or pressurized components, petreatment units,
and any servicing at intervals of 512 months, shall be performed by a certified POWTS Maintainer.
A service report shall be provided to the local regulatory authority within 30 days of completion of any service event.
(Rev.2/05)
Page of
START UP AND OPERATION
For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products, solvents or other
chemicals or sediment that may impede the treatment process and/or damage the soil dispersal cell(s). If high concentrations are
detected have the contents of the tank(s) removed by a septage servicing operator prior to use.
System start up shall not occur when soil conditions are frozen at the infiltrative surface.
During extended power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will
be discharged to the dispersal cell(s) in one large dose and may overload them resulting in the backup or surface discharge of effluent.
To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the
effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels
within the pump tank.
Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise disturb or compact, the area within
15 feet down slope of any mound or at-grade soil absorption area.
Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS:
antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain
(sump pump) discharge; fruit and vegetable peelings; gasoline; grease; herbicides; meat scraps; medications; oil; painting products;
pesticides; sanitary napkins; tampons; and water softener brine.
ABANDONMENT
When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely
abandoned in compliance with chapter Comm 83.33, Wisconsin Administrative Code:
• All piping to tanks, pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed.
• The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator.
• After pumping, all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil,
gravel or another inert solid material.
CONTINGENCY PLAN
If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide the opportunity to obtain a sanitary permit for
a code compliant replacement system:
❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system.
The replacement area should be protected from disturbance and compaction and should not be infringed upon by required
setbacks from existing and proposed structure, lot lines and wells. Failure to protect the replacement area will result in the need for a new soil
and site evaluation to establish a suitable replacement area. Replacement systems must comply with the rules in effect at the time of their
permit issuance.
❑ A suitable replacement area is not available due to setback and/or soil limitations. If the soil absorption system cannot be
rehabilitated and barring advances in POWTS technology, a holding tank may be installed as a last resort.
❑ The site has not been evaluated to identify a suitable replacement area. Upon failure of the POWTS a soil and site evaluation
must be performed to locate a suitable replacement area. If no replacement area is available a holding tank may be installed as a last resort to
replace the failed POWTS.
❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative
surface. Reconstructions of such systems must comply with the rules in effect at that time.
WARNING: TREATMENT TANKS AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES AND LACK SUFFICIENT
OXYGEN TO SUPPORT LIFE. NEVER ENTER A TREATMENT TANK OR HOLDING TANK UNDER ANY
CIRCUMSTANCE. DEATH MAY RESULT. ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK IS VERY DIFFICULT.
ADDITIONAL INFORMATION:
POWTS INSTALLER POWTS MAINTAINER
Name: John Schmitt Name: John Schmitt
Phone: 715-760-0486 Phone: 715-760-0486
SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY
Name: Owners Choice Name: St Croix County Zoning
Phone: Phone: 715-386-4680
I
This document is intended to meet minimum requirements of Ch. Comm 83.22(2)(b)(1)(d)&(f) and 83.54(1), (2) & (3), Wisconsin Administrative Code.
Use of this document does not guarantee the performance of the POWTS.
(Rev. 2/05)
Installation Instructions for EZ OZU'"
EZflow Systems in Wisconsin flbylFILTRwTOR
.
Wisconsin Department of Commerce, Safety and Buildings 5. The Absorption area (SF) necessary for a given site shall
Division, has reviewed the specifications and/or plans for this be sized based on maximum daily sewage flow (GPD) and
product and determined it to be in compliance with chapters the Permeability for the site. If certain criteria is met, the
Comm 82 through 84, Wisconsin Admin. Code, and Chapters EISA sizing can be used in Wisconsin, resulting in a 40%
145 and 160, Wisconsin Statutes. All sites must meet the Site smaller drainfield.
& Soil Conditions & Locations & Isolation distances as noted in
local regulations. 6. Place EZflow bundle(s) in the EZflow configuration ap-
proved by system design permit specified for the particu-
The approved products are 1203H (3-12" bundles with pipe in lar site. The top or center-most bundles containing pipe
center bundle in 5' or 10' lengths) and 1203HP (3-12" bundles are joined end to end with an internal pipe coupler. Any
with pipe in each bundle in 5' or 10' lengths. additional aggregate only bundles that may be required,
should be butted against the other aggregate-only bun-
A single pipe bundle contains a four inch perforated pipe sur- dles and do not require any type of connection.
rounded by EPS aggregate and is held together with poly-
ehtylene netting. A single aggregate bundle contains aggregate 7. The top of each GEO cylinder contains a filter fabric pre-
only and is held together with polyethylene netting. manufactured in between the netting and aggregate. The
fabric is inserted to prevent soil intrusion. The installer
Materials and Equipment Needed shall make sure the the GEO is positioned upward and is
• EZflow Bundles in contact with the fabric contained in the adjacent cylin-
• EZflow Geotextile Fabric der before backfilling.
• EZflow Internal Pipe Couplers
• Pipe for Header and Inlet 8. The EZflow Drainfield Systems should be installed in a
• Backhoe/Excavator level trench in all directions (both across and along the
trench bottom) and should follow the contour of the ground
Installation Instructions surface elevation (uniform depth), with all continuous
The instructions for installation of EZflow products are given ; adjoining 10-foot cylindrical bundles placed end to end,
below. This product must be installed in accordance with state ; with central bundle distribution pipe interconnected,
rules defined in chapters Comm 82 through 84, Wisconsin Ad- without any dams, stepdowns or other water stops.
ministrative Code, and Chapters 145 and 160, Wisconsin Stat-
utes, as well as the local health department's current design 9. The trench top shall be graded such that water will not
manual. pond. Backfill should be seeded or sodded immediately
after completion to reduce erosion.
1. After the local health department has determined sizing,
configuration, and layout for the EZflow systems, stake 10. EZflow EPS bundles are flexible and can fit in curved
or mark with paint the location of trenches and lines. Be ; trenches as may be necessary to avoid trees, boulders, or
careful to set correct tank, invert pipe, header line or dis- other obstacles.
tribution box and trench bottom elevations before instal-
lation of pipe bundles. 11. EPS aggregate is lighter than water, therefore, it might
be expected that natural buoyancy forces would tend to
2. Remove plastic EZflow shipping bags prior to placing cause EZflow assemblies to float out of ground when
bundles in the trench(es). Remove any plastic bags in the ponding occurs. Field experience has shown, however,
trench before system is covered. that this is not a problem when systems have a minimum
of 6" of soil cover as recommended by manufacturer.
3. This product must have geotextile fabric that meets re-
quirements of s. Comm 84.30 (6) (g), Wis. Adm. Code, ;
installed directly on top of the product and extending 1203H-GEO
down along the sides of the product to a point at least six ;
inches from the bottom of product. Geotextile
• Barrier Material
4. When installed in a trench, the trench should be dug to ;
• 12'
.o
a width of 36 inches. This not only saves labor in excava-
,
tion, but also provides better load-bearing capacity after
backfilling is complete.
3s,
♦ YI
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM y:
Count
Safety and Buildings Division INSPECTION REPORT
GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary Permit No.: X
Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. 3 4 4 6 4 0
Permit Holder's Name: ❑ Cit ❑ Village Town of: State Plan ID No.:
WOULFE, ROBIN R. SOMERSET
CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.:
032-2092-50-000
TANK INFORMATION ELEVATION DATA
TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV.
Septic Benchmark dk 60
- D p e6,~
Aeration Bldg. Sewer
Halding~ St/ Ht Inlet, -
TANK SETBACK INFORMATION St/ Ht Outlet H. f 2- 7
Vent
TANK TO P / L WELL BLDG. A
ir Ito ntake ROAD
Septic D Z 9 Z 9 NA
N Header / Man.
tion NA Dist. Pipe
L. / 2, 33
Holding Bot. System L /z; -1.$- ~6'
:rl PUMP/ SIPHON INFORMATION Final Grade _ 3
anufacturer Demand S 66. 66
Model Numbe PM
TDH Lift— Fricti S stem TDH I
Loss e
Forcemain Length Dia. I
SOIL ABSORPTION SYSTEM /Z
T No. Of Pits Inside Dia. Liquid Depth
BED / REN width Len th i No. Of renches 111MENSIONS
DIME
NstaNs 3 S 2 SETBACK
SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer:
INFORMATION Type Of A B Mbde N'mber.
System: of f h- 7 S /fl~¢ NIT
DISTRIBUTION SYSTEM
Header/Manifold i/ Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake
Length l/ Dia. Length _ ' Dia. _A14 Spacing ltl 7 r~
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.) t~ y U 7 S
LOCATION: {SOMERSET 24. 31.19.904, SW, SE 781 /205TH AVENUE - LOT 2
~ l ~ b / ~ ~ ~l Gt/~/ 7 /1 ~ ~CfJ l(rf GG,~✓~r Ct .
O Gov~✓
Plan revision required? ❑ Yes [ No
Use other side for additional information. Qp
k SBD-6710 (8.3/97) Da Inspector's Si e Cert No
Safety and Buildings Division
SANITARY PERMIT~►~P 1CAT[ON 201 W. Washington Avenue
Visconsin P O Box 7302 44 Department of Commerce In accord with ILHR 8 ~,VV4s Adm. Code '
' Madison, WI 53707-7302
• Attach complete plans (to the county copy only) for th s m, pra p r,-not less _ County
than 8 1/2 x 11 inches in size. Q0
• See reverse side for instructions for completing this a ation .,arm. 3 ate Sanitary ccP,,ermiitNumber
71L-1
Personal information you provide may be used for secondary purppses r`•. S ( ✓RCtx Check if revision to previous application
(Privacy law, s. 15.04 (1) (m)]. GOotjY tate Plan I.D. Number
GUJ Y ~;FFIGf
1. APPLI ATIO ORMATION -PLEASE PRIN A AI I~TION,.'
Prope w r Npme L60 ion
s Pv,w 1/4, S a T 3 , N, R l E (or~
Prope oOwner's Mailing Address 5- Lot Num~r Block Number
16od
City, State Zip Code Phone Number Subdivision Nam%or CSM Numb r
4~
sYaaS~ (7i51 iRV7 8
t . PE B II DING: (check one) ❑ State Owned ityy Nearest Road
Vlltage
Public 1 or 2 Family Dwelling - No. of bedrooms Town of .S (rte
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax2Number(s) . ~I Iq 04-
1 ❑ Apartment/Condo -0 ;1 - OZ ~Q
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/ Factory 13 ❑ Other: specify
IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. (New 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5_ ❑ Repair of an
"_`_System System Tank Only______________ Existing System Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
110 Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 Holding Tank
12 Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit S 43 ❑ Vault Privy
14 ❑ System-In-Fill a - q - 57R,
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/da q. ft (Min./inch) Elevation
7 s'~ l 7 ( o --r Feet - Feet
VII. TANK Capacity gallonTotal # of Prefab. Site Fiber- Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete con- steel glass Plastic App
New Existing structed
Tanks Tanks
eptic T rtgTRTrk a 6 G /00a
/ ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber, ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber' Na : (P int) Ptu a 's Sig ture: ( o S16 s MP/MPRSW No.: Business Phone Number:
Plumber' Address (Slreet, City, State, ip ode):
IX. CODUNTY(/JDEPARTMENT USE ONLY T-- 7
❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued I wing ent Signature (No Stamps)
Owner Given Initial ao~ Surcharge Fee
Approved ❑ )
Adverse Determination te /4.,6
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
I)TirrrJ~ro~• .~a~~2 I~-k,w>#- tt S~~ cs~ oti. w~r+%~'-e~Q. .
.RRn- R3QR !R 11 1471 DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
Aug-OV-99 11:07A P.01
r
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer hl ~Q't~
Mailing Address 1" • ~ ~ C 14 Cos -6m ~(Se , W\ sm OZS
Property Adress
(Verification required from Planning Department for new construction)
City/StateD~~~ a Parcel Identification Number
LEGAL DESC ON
Property Location._ Y., 61~_ Sec. &'1~4, T,--~LN-Rj-~._W, Town of'~N~~
Subdivision 1`1 ~S \t 1. %l a Lot #
CertUied Survey Map # lV - A Volume. Page #
Warranty Deed # S 7 2 (o volume 31 7 Page # < g
Spec house ❑ yes K no Lot lines identifiable 0 yes ❑ no
SiXS= MAINTENANCE
Improper use and maintenance of your septic system could result in its premature failure to haadlc wastes. Proper maintenance
consists of pumping out the septic tank every three years or sooner, if needed by a licensed ptmVer. What you put into flu 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
masterplumber, joumaymanplumber, restrictedplumberor a licensedpumper 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 113 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. Cettiftcation
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
ys f the tlrte exp" lion date.
I
i I
SI ATURE OF APPLICANT
DATE
O-F„R CERTIFICATION
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
d a ve, by vof a warranty deed recorded in Register of Deeds Office. rr\\ 1-1
PLICANT ATE
Any information that is tray 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 cagy of the certified survey map if reference is made in the warranty deed
Safety and Buildings Division
NNAISCOnSin SANITARY PERMIT APPLICATION 201 W. Washington Avenue
P O Box 7162
Department of Commerce In accord with Comm 83.05, Wis. Adm. Code Madison, WI 53707-7162
• Attach complete plans (to the county copy only) for the system, on paper not less County
than 8 1/2 x 11 inches in size.
• . See reverse side for instructions for completing this application State Sanitary PPeermmiit Number
Personal information you provide may be used for secondary purposes Check if revision to ®ous application
[Privacy Law, s. 15.04 (1) (m)].
State Plan Review Transaction Number
1. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION
Properliv Owneii Name Property Location
,fUV /4 F 1 /4, 5 T 3 1, N, R q
l (orO
Pro
try Own 's Mailing Add Z's Lot Number Block Number
pt 1 I P,
Cit , state Zip Code Phone Number Subdi i 'on Name or CSM N tuber
G,t O (7/Sb'2 gaz
II. PE F BUILDING: (check one) ❑ State Owned ❑ City Nearest Road
Village
Public 16 1 or 2 Family Dwelling - No. of bedrooms own OF
III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) Z✓ 31l9 / d Y
1 ❑ Apartment/ Condo 7 0 D l / _ 5-C
2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility
3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/Bar/Dining
4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station/ Car Wash
5 ❑ Hotel/ Motel 9 ❑ Office/Factory 13 ❑ Other: specify
IV. TYPE ,OF PERMIT: (Check only one box on line A. Check box on line B, if applicable)
A) 1. New 2_ ❑ Replacement 3. ❑ Replacement of 4, ❑ Reconnection of 5. ❑ Repair of an
System System___, Tank Only ______________Existing System _ Existing System
B) A Sanitary Permit was previously issued. Permit Number 3 Date Issued Edzzo fl
V. TYP OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 410 Holding Tank
12 Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit S' 3 ❑ Vault Privy
14 ❑ System-In-Fill L~ -
VI. ABSORPTION SYSTEM INFORMATION:
1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. Final Grade
~Q equired (sq. Proposed (sq. ft.) (Gals/d /sq. ft.) in./inch) `ltd / Elevation
Feet Feet
-7-5-0 76x 7 (94-,3 VII. TANK Capacity Total # of Prefab . site
INFORMATION in g Gallons Tanks Manufacturer's Name Concrete con- steel Fiberglass- Plastic ExAppper.
New Existing struded
Tanks Tanks
Septic Tan ink ❑ ❑ ❑ ❑ ❑ '1060 AT ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
1, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's e' P n Plumber' igna re: No MPRSW No.: Business Phone Number:
on a_5
Plumber
I /W- ~idress (S r t, Ci State, de): Pao lzz~l
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued lissui gent Signature (No Stamps)
T Approved ❑ Owner Given initial surcharge Fee)
/ ` Adverse Determination ~0 00
X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL:
Rt1/r av. 4M4 -e6arreol ieCJIG4se 44e wSoje/4s1r GALS /Lt tOr e At~iK~{ ~oarl~i~
A, *esf iA.Sel k a.f Glom ~y Uortnot, ~{av~ er $/Z _~/f9 (Oh/y 3 borart,f~e due_., rCGOrn(
1 a T L
SBD-6398 (R.12/99) DISTRIBU ION: Original to County. One copy To: Safety & Buildings Div ion, 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 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 thaR8 1/2 x 11 inches must be submitted to the county. The plans must
include the following:: A) plot plan, drawn to state 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;
6) 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'investigati'ons
and establishment of standards.
and SANITARY PERMITAPP TAT ON 201eW. Wahingt nAvenuen
Visconsin P O Box 7302
Department of Commerce In accord with ILHR 8 ~V~i ,4dm: Code ' .
' Madison, WI 53707-7302
• Attach complete plans (to the county copy only) forth s m, I(Y1ot less" , ,count
i~ @*~l?~"
than 8 112 x 11 inches in size.
• See reverse side for instructions for completing this a ation .C;, n I -State Sanitary Permit Number
Olt-
Personal information you provide may be used for secondary purepses ST GFlO1X check i~f~revision to previous application
[Privacy Law, s. 15.04 (1) (m)]. UNN
7q g , ` pFFIG~ r.tate Plan Number
1. APPLICATIO ORMATION -PLEASE PRIN A RXTI
Prope Ow r Npme -property Lo ion
I v4 1/4, S 'a(/ T3/ 3 . N, R l E
Prope OOwner's Maili ng Address Lot Num~r Block Number
~3 a
City, State Zip Code Phone Number Subdivision Namvr CSM Numb r r
ya R 6-- (7/31 y1V7 -3/8/
11. TYPE F BUILDING: (check one) ❑ State Owned E] City Nearest Road
Public 1 or 2 Family Dwelling -No. of bedrooms 3 Towan of cad
111. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) ,1, 3t - Iq . q D 1+
1 ❑ Apartment/ Condo -0 3 a - O-Z 0 _ 1~ lQ
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. WNew 2. ❑ Replacement 3. ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an
_______ystem System Tank Only ___Existing System ________Existing System
B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued
V. TYPE OF SYSTEM: (Check only one)
Non-Pressurized Distribution Pressurized Distribution Experimental Other
11 ❑ Seepage Bed 21 ❑ Mound 30 ❑ Specify Type 41 ❑ Holding Tank
12 (Seepage Trench 22 ❑ In-Ground Pressure 42 ❑ Pit Privy
13 ❑ Seepage Pit S,t.~la,wl.t 43 ❑ Vault Privy
14 ❑ System-In-Fill - q ~ s n.
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
~s~ Required (sq. ft.) Proposed (sq. (Gals/da q. ft.) (Min./inch) Elevation
S6 7.?, o 03 8Feet Feet
VII. TANK capacity gallons Total # of Prefab- Site Fiber- Plastic Exper.
INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel glass App.
New Existing structed
Tank Tanks
< -17 epticT rtk b66 ❑ ❑ ❑ ❑ ❑
Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑
VIII. RESPONSIBILITY STATEMENT
I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans.
Plumber's Na : (P int)O~ Plu e 's Sig ture: ( o S sidni) MyP~/MPRSW No.: Businesss Phone Number:
Plumber' Address (Street, City, State, ip ode):
IX. COUNTY / DEPARTMENT USE ONLY
❑ Disapproved Sanitary Permit Fee (Includes Groundwater ate Issued I uing ent Signature (No Stamps)
Approved ❑ Owner Given Initial Surcharge Fee)
a~ g Z3 99
Adverse Determination aa,4 /cb
X. CONDITIONS OF APPROVAL / REASONS FOR DISA~P OVAL:
S.ou- euaQr 01.
SBD- 6398 (R.11/97) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber
r
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 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 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.
v , v.• vv av - -
r ~I of fi - ,Mgt
a..
C, I Y 16
r 'rte 5 l V t..
,
1 '
thin LN
4C 4AP
0
4
-
Ill A i e _
i q1)
i
4C.. _ i _ - - - .
_ _ _ _ . ) TT . I..-.
t Q sx~+ o v-N 'Vi`a r . « ( +s j sy lec rB.,~
Wisobn o omm e ~ Jc OIL D SITE EVALUATION
Division of Safety and Buildingp" c,~( « U~ Page of
Bureau of Integrated Services( t4'ft~4 i~ 3 - t n accordance with Comm 83.09, Wis. Adm. Code
'1'" `
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 S-I , C R 0 ,
percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. #
63 a -Do 9.2-50-400P
APPLICANT INFORMATION - Please prfn blrmation. R Mewed by Date
Personal information you provide may be used for secon Iqu?poses (Privacy Law, s. 1.5.04 (1) (m)). ~f g _Z~p
q
"OL Property Location
Property Owner ~~jj
v F7 Qh ` a Govt. Lot 1/4 5F 1/4,SQ4j T 31 'N'R r g E (or)(
R -
Property Owner's Mailing Address Lof4 Block# Subd. Name or CSM#
City State Zip Cod$ Phone N€imbAi);r Nearest Road
"'UN? r City ❑ Village 59 Town
N 5.511'3. ( - t S om er ID* ~ #W e- ,
E> i, 0 r. -t'O r , o v j3Cr C.,
New Construction Use: ~Residentiaj`/ Number of Fp"Pr" Addition to existing building
E4 Replacement ❑ Public or commercial =`bescribe:
Code derived daily flow V5 D gpd Recommended design loading rate • S bed, gpd/ft2±-Lo_trench, gpd/ft2
Absorption area required 90 D bed, ft2 trench, ft2 Maximum design loading rate S bed, gpdHt2 • to trench, gpd/ft2
Recommended infiltration surface elevation(s) C 1:5 .60 _r, g $ . db It (as referred to site plan benchmark)
Additional design/site` considerations
Parent material _4s'. r 4_j ' 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 S❑ U G~ S❑ U [AS ❑ U C S E] u ❑ s ®u El 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
0-13 Ioy 3l - S Fsb k hof, 46 a F . 5
13-a9 s Y2 s1 S L M S 6 W- M F'- G ii'v FG , S ;
Ground 9-3$ 59 R V1 Y L_ c YV'1f 44,W (01 45
94~ft. 38-95 5 `f R91 L r~~
Depth to
limiting 9S. 3
factor
tin. yl• ~6/~~.~L ~Z,
Remarks:
Boring #
C) $ IQ f 5 L I+tv a ,
a a S -I n A Sly L s b k IrIn F v- G w ► F ,
3 /43 ?.5`((zy! - S 1. IIF5bk r w Ce...a ~uF
Ground - ? . tJ ti fssf Q - ra { L Q 4V .
9 9 elev. S
Depth to aG G z
limiting R `FI'ily~ ate f
ctor ~
in. Remarks: 'rfv+
CST Name (Please Print) Signature Telephone No.
T Q I'll V1 A W- -7 15 4M q - 36 504
Address Q Date CST `Number
re to DIb ID ~~acl
s Day
PROPERTY OWNER 9-IC-INOLY-1 04(h59'h SOIL DESCRIPTION REPORT Page a of
PARCEL I.D.# n3a- alga - so-ovo v
Boring # Horizon Depth Dominant Color Mottles Structure 2
g in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots
Bed Trench
3 0 -9 10 -f o/ s t- :56v-- r q5 F. y S
of -2-10 7, 54 I?s/ S L a ^ S%av, M F•-
Ground 3 b-a 754 9011 S ` ' F 5.6 k- r- Fr-
elev.
9$ 0p ft. b_y 7, 5'1 (2, -519 Depth to S 8- 61 S H R ` j/ SL R rv%SbW- hr► F. C ~S► :.6
limiting 43 6~ - s Y R yJy s L. A e-% ~C.. 1v, F., • 5 ,
Vin. 36~~-i cr ~3 3(•e
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
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 # ;
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
in. Remarks:
SBD-8330 (R.9/98)
• ~ icy` S ~ '~y S t c . y~ 3 c n~~ R ~ 9 w s+~ kW
N cc,\ 1 gyp/ Ca ~9q
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Wfc?gsin Department of Industry, SOIL A N VALUATION REPORT Page of
=tabor and Human Relations
Division of Safety & Buildings a 5, Wis. Adm. Code
COUNTY
Attach complete site plan on paper not les a 1/2 x VQ in siz must include, but
not limited to vertical and horizontal refere int , dir nd % pe, scale or PARCEL I.D. #
dimensioned, north arrow, and location a ance t61 *``arest road.
/ REVIEWED BY DATE
APPLICANT INFO RMATION-PLEAS INT /4t;;t;IN OFLNfl~T10W
PROP TY OWNER:
ROPERTY LO
vrGOVT. LOT ~TION4 1/4 S T ~ ' N,R or
l
PROPERTY OWNER':S MAI NG ADDR SS OT BLOC # SUED NAME OA CSM #
CI STATE ZIP CODE PHONE NUMBER ❑CITY LLAGE IRTOW NEAREST ROAD
d
b(] New Construction Use Residential / Number of bedrooms [ ] Addition to existing building
Replacement Public or commercial describe
Code derived daily flower gpd Recommended design loading rate S" bed, gpd/ft2_,
_trench, gpd/ft2
Absorption area required 9d0 bed, ft2 , trench, ft2 Maximum design loading rate 1 bed, gpd/ft21L-trench, gpd/ft2
Recommended infiltration surface elevation(s) ,9>27 ft (as referred to site plan benchmark)
Additional design / site con iderations
Parent material - Flood plain elevation, if applicable ft
S = Suitable for system CONVENTIONAL MOUND IN-GROUND PRESSURE AT-GRADE SYSTEM IN FILL HOLDING TANK
U = Unsuitable fors stem R1 S ❑ U ❑ S ❑ U fD S❑ U ®S ❑ U ❑ S R ❑ S IOU
SOIL DESCRIPTION REPORT
Depth Dominant Color Mottles Structure GPD/ft
Boring # Horizon in. Munsell Qu. Sz. Cont. Color Texture Gr. Sz. Sh. Consistence Boundary Roots Bed Trer&
> 1 '
t
Ground , 7
elev.
i,aL ft. d ,
Depth to
ZZ ,14 r I,/ e-LIJ , 7 1.8
limiting / - -
factor
Remarks:
Boring #
(C
~```:..~:•:•::::•::.:5: i i
. lG
Ground
elev.
1AI ft. - S
Depth to
limiting
factor
Remarks:
CST Name:-Please Print Phone:
Address:
Signature: J' Date: CST Numb r.
i
L J
PROPERTY OWNER ' SOIL DESCRIPTION REPORT Page,,,;? of
PARCEL I.D. #
Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounday Roots GPD/ft
in. Munsell Qu. Sz. nt Color Gr. Sz. Sh. Bed Trench
RIM ,s
Ground -3 q/ qe AL, ly2iV f"
elev.
j ft.
Depth to
limiting
factor
? q/
Remarks:
Boring #
-ig > -is 1A
i.J
Ground
elev.
ft.
Depth to
limiting
factor
> --F
Remarks:
Boring # J
{
All
Ground
elev. bs.~t~s
ft. d
Depth to
limiting
factor
Remarks:
Boring #
Ground
elev.
ft.
Depth to
limiting
factor
Remarks:
SBD-8330(8.05/92)
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Aug-09-99 11:07A P.01
ST CROIX COUNTY
SEPTIC TANK MAINTENANCE AGREEMENT
AND
OWNERSHIP CERTIFICATION FORM
Owner/Buyer ~Ovm'n wouj~ - -
Mailing A` ddress Cc~• qtoe
Property Addrea _
(Verification required from Planning Department for new construction) City/State's ~ Parcel Identification Number C73~' C~
LEGAL 2ESCI N
Property Location Sec. 2-4 T,~N-R-J-~-W, Town of~M~ -
Subdivision W ~1~5 T1 e VA jo Lot #
Certified Survey Map # Volume . Page #
Warranty Deed # S 7 Volume 13 l 7 . Page #
Spec house ❑ yes K no Lot lines identifiable § yes ❑ no
SY3MM 1MAIMNANCE
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
masterplumber, journeyman plumber, restrictedplumber or a licensed pumper verifying that (1) the on site wastewaterdisposal system
is in proper operating condition and/or (Z) after inspection and pumping (if necessary), the septic tank is less than 113 full of sludge.
Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards
set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification
stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30
ys f the three expiration date.
*SIAIURJS OF A PI CANT DATE
4YMR CERTIB ATIQN
I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of
~VNAMM erty d a ve, by ism"tedumy warranty deed recorded in Register of Deeds Office.
rr\\
sil/
v
O PPLICANT DATE
Any information that is result in the sanitary permit being revoked by the Zoning Department. ssssss
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
5 77695 STATE BAR OF WISCONSIN FORM 2 - 1982
NVARR.;VTY DEED
DOCUMENT NO..;
;~tG1S7ER'S OFFICE
ekes..__a_single.~PrsnnY----------- ST, 0 R00( WI
- - - - APR 2 2 1998
conveys and
warrants to
~QUl- h t~mothand.I_ fQillfean d_ - 8:00 A M
_ _ _ - - - - 7a !Q i of Ueda
THIS SPACE RESERVED FOR RECC ADING DAtA
NAME AND RETURN ADDRESS
the following described real estate in St - Croi x _ County,
State of Wisconsin:
/Y1 ~t3
PARCEL IDENT,F:CATIGN NUMBER
f
Lot 2, Blom "2", Hansen's Turtle Lake Hills First Addition in the Town of
Somerset, j,.. Croix County, Wisconsin.
TRANSFER
FEE
This -Q -not homestead property.
XX(jft (u trot)
Exception to warranties: Easements, restrictions and rights-of-way of record, if any.
Dated this day of ---April - A D , _98
- - - -(SEAL) IL (SEAL)
Stanle R. Baker -
AUTHENTICATION ACKNON LEDG'vlENT
State e' A'Y-isroirsin,Mnf
,7-, L 45 a Court,
auili,mucated this #4
April is 98 aiv e name, 3W
-
-
*..anl.e" _Baker
i i rl.E. MEMBER STATE BAR OF \\'I~CONv ,IiN
(II not. - -
au!;;cnz, d by §706 06, \\ls Stats !
to mr ~nt%k,T "'!,e trX r:cr~ol; ,t,t ~rr•I;oi±:
Instrunit'n[ ?nd
THIS INSTRUMENT WAS DRAF-.D NV
a
Attorney Kristin P.0gland /
Hudson, WT 54016 P
he .,u :alit"! OF
cor...... c , I
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