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012-1031-30-050 (2)
Wisconsin Department of Commerce Safety and Budding Division GENERAL INFORMATION Personal information you provide may be used for secondary purposes Properties LLC TANK INFORMATION PRIVATE SEWAGE SYSTEM INSPECTION REPORT (ATTACH TO PERMIT) [Privacy Law. s 15 oa (1)(m11 TOWN OF ERIN PRAIRIE TYPE MANUFACTURER CAPACITY Septic W O Dosing 545 Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG Vent to Au Intake ROAD Septic 5 ?SO 37r Dosing Aeration Holding INFORMATION to SYSTEM ELEVATION DATA County St. Croix Sanitary Permit Nc 645496 Staie Plan 10 No. Parcel Tax No 012-1031-30-050 Section[Town/RangeiMap No 12.30 . 17.182B STATION BS HI FS ELEV Benchmark �c1 r 1'T � ��, rD® 1 Alt BMkilwoww �. � . Bldg. Se�vter,� r� G SI/Ht Inlet SI/Ht Outlet —1 . 1 Inlet Dt tom Header/Man ( M Dist. Pipe Bot. System �es Final Grade Q`Z•Lr(�d - '�d'7 Cover V 2 a � D —LS lI I'llr— BEDlTRENCH DIMENSION9 Width /� ` //w Len s No. a Trenche PIT DIMENSIONS No OI Pits Inside Dia. Liquid Depth SETBACK INFORMATION SYSTEM TO IP/LW BLDG WELL LAKE/STREAM LEACHING CHAMBER OR UNIT Me c ror Ty Of System: n b . 3� /j � I `� M Number: a UIS I KIlfU I IVN 5T5I tM - Header/Manddd t' q'f 51 Distribution Pipets) �Hole ue �Jenlu I ntake Length t Oia Length Dia Spaotng OU111- I,LIV tK . - -- u......w n. A._r.-a- n-i.. Depth Over . I r Bedrrrench Center2�1 Dapth Over f Bed/Trench Edges r `� xx De of Topsoil xx Mulched ,-i yes _ No _ yes No COMMENTS: (Include code discrepancies, persons present. etc.) Inspection #1 1nspeclyon Q -A A. J P%YICs rerib wM})EI'9 Edc� .Ltd t/cK' Location: 1645 200TH ST ��e. 1.) All BM Description =f1 COX/ ! `' 6t 2.) Bldg sewer length = IS - amount of cove - > .l� �e �t°fldL Awlra: ia"nlC.� wl Plan revision Required? , Yes No Use other side for additional information. L�_ SBD-6710 (R.31g7) Date . A 41ct, *-g'atwe l�lg Cen No «W'aoA, L — �0 2.A Industry Services Division Coemty 4822 Madison Yards Way St. Croix Sanitary Permit Number (to be filled in by Co. ) Madison. W1 53705 X COuloPment P.O. Box 7162 Madison , WI 53 CIO" Will csE, ttarjr Permit Applicati State Transaction Number In accordance with SPS 183.21(2). Wis. Adm. Code, submission of this form w the�Soffmunit Project Address (if different than mailing address) is required prior to obtaining a sanitary permit Note: Application forms for state-owned POWTS are submitted to the Department of Safety and Professions Services. Personal information you provide may be used for secondary 1645 200th Street purposes in accordance with the Privacy law, s. 15." 1 xm), Stets. L Application loformation — Please Print All Information Property Owner's Name Parcel H Double S. Ridge Properties LLC 012-1031-30-050 Property Owner's Mailing Address Property Location 1670 200th St. Govt. Let City, Sane Zip Code Phone Number New Richmond, Wi. 154017 651-270-4854 N`" % SW Section 12 T 30 N R 17 For W IL Type of Building (cheep all that apply) Lot g ✓ OI or 2 Fanily levelling -Number of Bedrooms 3 ' Subdivision Name EJ1ubl tc/Commercial - Describe Use Block JI � aCiry, of Elstate Owned -Describe Use illageof CSMNumher(plit„ )0( 12_ 27-61 21 IZIfown of Erin Prarie IIL Type of POWTS Permit: (Chan either "Nero" or "Replecemeat" and other applicable on line A. Cheek one box oat Bee B. Colmpide line C i appamw) A. System 'placement System D)111er Modification to Existing System (explain) Additional Pretreatment Unit (explain) B. Dlolding Tank In -Ground at -Grade Individual Site Design Other Type (explain) (lxmventionel C. ❑ Renewal Before Revision e of Plur n .ist Previous Permi[ Number and Dale Issued Ej Expiration IV. Dispersalffirestment Area atsd Tank Information: Design Flow(gpd) Design Soil Application Rate(gpdhf) Dispersal Area Required (sf) Disperse Area Proposed (t) System Elevation 450 0.6 750 770. 91.3 / 90.5 Tank Information Capacity in Gallons foal Gallons g of Units )Manufacturer �O �( 0 8 .Y �L7L New Tasks Existing Tutu V in K rn eL U 6. Sepae or Bowwg Taal` 1000 1000 1 Wieser ✓ nosing Clamber V. Rpponudbilily Stattment- L the oderdped, monme respemillifty for insulation of the POWTS shown oa the attached plan. Plumber's Name (Print) PI 's Si MP/MPRS Number Business Phone Number Keith Knudtson 1648443 651-470-1737 Plumber's Address (Street City, Sate, Zip Code) 927 15M St. Roberts, Wi. 54023 VL C000ty/Deportatent Use Only Approved ❑ Permit Fee Date Issued 1 ins Agent S� IJJ9wVGivenRea9on or Denial $ Conditions o Appmv 1 SYSTEM OWNER: \ i"SC ptic tank, effluent filter and dispersal Cd ) Cr %�2_ tt K Gye,Q..,r 3�`( Ljs.0 >— must be serviced / maintained as per-Z w• t,o�e atlaouL c�ed1�,►C e.+ . anagement plan provided by plumber "�' `"`T `�.>� setback requirements must be maintained P � s wnaa-r�nt►�.tt.2. -- r—• —rrw - to dw-cstualy only_ a� eager not leas tkan 8 112 c 11 incaea in sae SBD-6399 (R. 03l21) O�� Mm p.7 4folr+ %jOq:9 e. R f/D t- 4``5vr Al Dmr✓110 1`4L 'L .57- IV GJ w 1/ s R TADA /7sv Sev-- CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Double S. Properties Owners Name: Double S. Properties LLC Owners Address: 1670 200th St New Richmond, Wi. 54017 Legal Description: Township: County: Subdivision Name: NW 1/4 SW 1/4 S. 12 T. 30 R. 17W Elkin Prairie St. Croix Lot Number: I Parcel ID Number 012-1031-30-050 Page 1 Index and title Page 2 Plot Plan Page 3 System Sizing & Cross -Section Page 4 Filter Specs Page 5 Maintenance Information Page 6 Management Plan Page 7 St. Croix Cty Septic Tank Maintenance Form Page 8 Warranty Deed Page 9 CSM or Plat Attachments: Soil Test & House Plans Designer/Plumber. Keith Knudtson Date: 12/27/2022 License Number. Phone Number 648443 (651)470-1737 Signature Designed pursuant to Me In -Ground Sol Absorption Component Manual for POWTS Version 2.0 SBD-10705-P IN.01/01). Page 1 y �jperq e ,Fe IA .op&rw« _ 98 Z ko Jo:o l Dm(.j62a S:,P.a) LLc /«S seoYGS7' IV l.�J � S ru 414 pnari8. 1 9$/ tlo <, V`i�djy GNP �� 9y.y P�� Z . ,py `'`''ice 7- L Soil Absorption SYsiem Cross Section 94.00 4' Schedule 40 Final Grade PVC Vent Pipe 4.00 With Vent Cap Comber --�� 91.30 ft 4— System Elevation ` 3.010 4.0 ft ft Soll Absorption &atom Plan View ft 1'1 i 4.00 Leaching Trench 1 ft Vent Or Observation Pipe Chambers !I �Illl�i �IIIIII �' � Leschina Chamber Speciflcatfons Manufacturer And Model Infiltrator EISA Rating10.00 ` sq ft per chamber Soil Application Rate 0.60 gpd/s9 ft 450.00 .60 020 38.00 gpd Design Flow + Soil Application Rate + EISA = Chambers 18.00 2 rows of chambers each. Page of POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page I of 2 FILE INFORMATION Owner Permit # DESIGN PARAMETERS Number of Bedrooms ❑ NA Number of Public Facility Units IAA Estimated flow leverage) 300gal/day Design flow (peak), (Estimated x 1.5) gal/day Soil Application Rate • 6 gaildaytW Standard Influent/Effluent Quality Monthly average' Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODE) :=0 mg/L ❑ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOD6) 530 mg/L Total Suspended Solids (TSS) 530 mg/L f? NA Fecal Colifomn (geometric mean) 510' cfu/100ml Maximum Effluent Particle Size Ys in dia. ❑ NA Other ❑ NA -Values typical for domestic wastewater and septic tank effluent. MAINTENANCE SCHEDULE SYSTEM SPECIFICATIONS Septic Tank Capacity al ❑ NA Septic Tank Manufacturer ❑ NA Effluent Filter Manufacturer ❑ NA Effluent Fitter Model _ ❑ NA Pump Tank Capacity al NA Pump Tank Manufacturer 14NA Pump Manufacturer NA Pump Model NA Pretreatment Unit ❑ Sand/Gravel Filter ❑ Mechanical Aeration ❑ Disinfection ❑ Peat Filter ❑ Wetland ❑ Other: lh NA Dispersal Cells) ❑ In -Ground (gravity) ❑ At -Grade ❑ Drip -Line ❑ NA ❑ In -Ground (pressurized) ❑ Mound ❑ Other: Other: ❑ NA Other ❑ NA Other: ❑ NA Service Event Service Frequency Inspect condition of tank(s) At least once every: ❑ monUsmlls) (Maximum 3 years) ❑ NA Pump out contents of tankisl When combined sludge and scum equals one-third (Y.) of tank volume ❑ NA Inspect dispersal tasllls) At least once every: E month(s) (Maximum 3 years) ❑ NA Clean effluent filter At least once every: ❑smonthl / LVeeIsl DNA Inspect pump, pump controls &alarm At least once every: ❑ month(s) year(sl "A❑ Flush laterals and pressure test At least once every: ❑ month(sl ❑ year(s) U-NA Ot1°r At least once every: D month(sl ❑ year(s) IAA Other. ,la'NA 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 Inspector; POWTS Maintainer; Septage Servicing Operator. Tank inspections must include a visual inspection of the tanks) to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and to check for any back up or ponding of effluent on the ground surface. The dispersal cellis) 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 indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third (Y3) 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 Administrative Code. All other services, including but not limited to the servicing of effluent fitters, mechanical or pressurized components, pretreatment 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 10 days of completion of any service event. Page Z of 7/ START UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the dispersal cell(s). If high concentrations are detected have the contents of the tanks) 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 power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cells) in one large dose, overloading the call(s) and may result 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 calls. 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) water; 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 and pits shall be disconnected and the abandoned pipe openings sealed. • The contents of all tanks and pits shall be removed and property 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 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 that time. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. 0Tweytarm alua ' o mt g ank be ' e ai FR D+418 nEZ�!', �D /.% COh157R C1 D ❑ 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> > SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR IMPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAINER Name S,�7 Name f 5p< Phone _ _ 1j — Phone SEPTAGE SERVICING OPERATOR (PUMPER) LOCAL REGULATORY AUTHORITY Name n t� .�r� S Name ST. C ( /ij Phone _ !� `� Phone —](S— 3�Co— i0 This document was drafted in compliance with chapter Comm 83.Z2(2)(b)(1)ld)&(fl and 83.54(1), (2) & (3), Wisconsin Administrative Code. • E4 ( 1�0 Fitters FL 525 EFFLUENT RLTER T.,Ae'i-525 Filter is rated for lws 10,000 GPD (gallons per day) *c aic ng it one of the largest fitters .r -m class. It has 525 linear feet of . "6" filtration slots. Like the anti-,ok PL-122, the Polylok P =25 has an automatic shut d= Bali installed with every fitter. O'hen the.fitter is removed for osantng, the ball will float up and *er Aporanly shut off the system so tic- effluent won't leave the tank. No other.fiiter on the market can make that claim. PL-525 Maintenance: to PL-M Effluent Rtiter should operate efficiently for several years finder normal conditions before i requiring cleaning. It is recom- mended that the fitter 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 sem►icing. Servicing should be done by a certified septic tank pumper or installer. 1. Locate the outlet of the Septic tank. 2. Remove tank cover and pump tank if necessary. 3. Do not use plumbing when filter is removed. 4. Pull PL-525 out of the housing. S. Hose off fitter over the septic tank. Make sure all solids fall back into septic tank. 6. Insert the fitter cartridge back into the housing making sure the fitter is property aligned and completely inserted. 7. Replace septic tank cover. 1116" Filtration Slots _1-0 1 000'6P SE lover R al vw rAmim Shah U.S. Patera No# 6,015,488 5,871,640 F-L-525 ljnstafiiallon: Ideal for residential and com- mercial waste flows up to 10,000 Gallons Per Day (GPD). 1. Locate the outlet of the septic tank 2 Remove the tank cover and pump tank if necessary. x 111WWk lYwl.ew. w Ws !..,-0 cee Oernor �c-� wwr.rara - Ilrna 3. Glue the fitter housing to the 4" or 6e outlet pipe. If the filter is not centered under the access opening use a Polylok Extend & Lok or piece of pipe to center filter. See page 19-21 for Extend & Lok information. 4. Insert the PL-525 fitter into its housing. 5. Replace and secure the septic tank cover. I vftowsh mom 2 SOIL EVALUATION REPORT ,i>i� 2 5 202 - In l000rdbnoe with tips aes, N+ite. Adm. cod. ANOM mopYO. plan on pbper pot W. Al x 11 Incha In eloe. PYn mustInclude, twt not NOW to: bet het�lD K d , eteoUon end percent elope, btt.le or rf�Qp brlo t in nerd d hum to aunt roes. pun print #A tntom"on. CST.aoat a - 651 pop -_ of County � Croce P.roN I.D. nIZ-lo31- 35'e5t7 Property Loaetlan ❑ OovL Lot if l)Y• S W Y. S l Z T 3 O N R 1-1 E Lot # Bb& # Subd. Nam or MW / 7-7./-171 Ckv Slab ZIP Code . Phone Number N��* /1�6•l.) CP�w.., 1Nt J 10/'J �. �Ar �Itlepe `•�Tov i /Lvr fps.- I pNwOontmm UerjPwomensmimunowarbedto,=Z—Cod.denvedd*Wgnlownete_Y_f_tGPD 6 R4.pl. m fit Pubic or aotn.rckd - Docribr. P+trerrtmWrlel ti /- to t1lFbadPianWmWnNopppabletp'tt zoJ�(Q t7MINe1 eomrrwrla fe0alanlelld♦epn: (�ertt�v+•o,,�. o��7i ��,,Q�,...,. So-S� (on.lorlJ�+^ od.p �Ot� 4�or��"-55 lc,I _ UU Ar ©soft pvPitOraund eurlace elev. -�j L . De* to IYnl&v Motor L°I I well I -Rmdft= ° °& I T.. I arm. ^o � - -- t2 &A V M Pj 8orinp PR Ground eurfeaelev.1ri—Y-9 topnAplptro0orl�ti, �� E�MAI'.��L����il�> I�*� r-� ��l �1 /l �l t�►�/ FrMff i7/is ��:?'.'?���;�Jt�..F3r=5T^,�"rir' I � . .. • ��=�,�*r,.r:-a r.�.�-.�_��-li �gt•r;t � ,.. P: mu(71 vv" , -.95H� v onl+�aUmMnW /06-aoo S4- Batop Wn0 Dow to JmRtnglo0or ISM-h ! / Pl Ground aurtsae sift. 17. AL i Flolmatt i Os00► i OornU�nt Color i Rsdou DISOrk w. Tawr. 8wetyn Consmmm : Boundw Rood F I in M1d►MR Ou Ai. Cone Co{u or. Sc Sir. - "PA P11 ems- --•---- �• . , ��. ism%� �' I ; M dw S ] P? Groura surfaos a+ay. _7.••�" — . — • — —� Nadaan Domloant Comr Radox 7as ��:•.: TO=rs Stn.ctum Cars:m-cm Boundary Roola Ia. ; M�Fusll Cu. Ax. Cart. Cc;:- Gr. St P. Pit Gmura surface a:sv. _'_ DsP Lo ltrnilr� ` r. a Mort7Dn Dspd► Oomimot Color Ra3oK QacnphM Tormle SLvCu n conslaw:a Soundsq Rots In. l MLMNI C6. Az Cont. Co;;r Gr. Sz 3.1. LJML 1 i i • dldt I#1 a B00, 2,30 S 22D M.WL 00 -W > 30 SIN !rgL ' ltr6@nta2 =BOO: = 305220 my: and 7SE = 3o s 160 rtsyL i r� 39ax-f^- k OLL� eye 1-/dit &4( f�?a A 4 aa:!- Ne,a ,Uom r�jwa:7 Syd7 f 0, Palo M"q� m Will Heidt Soil testing YQc W3503 Hemlock Road �Aondovi, WI 54755 (715) 579-9584 "1NVr 9, 20 ZJL ST. CRo NTY SANITARY SYSTEM File #: Office Use O OWNERSHIP/ADDRESS FORM CreaW Z,02021nly Community Development Department will utilize this information to provide the property owner with information regarding operation and maintenance of your new or replacement sanitary system! This information will be provided as part of our ongoing efforts to protect public health, your well, groundwater, surface water, property values, and county resources. Once approved, this completed form and educational information will be sent to you by email. OWNER/BUYER INFORMATION Owner/Buyer Double S. Ridge Properties LLC Mailing Address 1670 200th St. City/State/Zip New Richmond Wi. 54017 Phone Number (required) 651-270-4854 Email Address (required) stitchm58@gmail.com Parcel Identification Number 012-1031-30-050 (found on the property tax bill) NEW SYSTEM: LEGAL DESCRIPTION Property Location NW �/. SW t/4 , Sec. 12 , T 30 N R 17 W, Town of Erin Prarie Subdivision Plat: Lot # 1 Certified Survey Map # Volume 27 Page # 6121 Warranty Deed # ISR (before 2006)Volume . Page # Number of bedrooms 3 Spec house O yes ■ no Lot lines identifiable ■ yes O no OF. FKX USE ONLY New Property Address (Verification of new address required from Community Development Department for new construction.) (Z-7,9 1#9 zZ (Staff Initials) (Date) This farm must be submitted with all Private Onsite Water Treatment System (POWTS) applications. New System: Include with this form 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 Community Development Department - Land Use Division 715-386-4680 St. Croix County Government Center cdd@sccwi.gov 1101 Carmichael Road, Hudson, WI 54016 715-245-4250 Fax www.sccwt.gav C 57.a da a ♦ WlaconsJn M {� al somoss `� Pape of DlvWon of I 5 Z022 SOIL EVALUATION REPORT pPR In rdanoewlth8P8366,11YI& Adm. Code county Cro Attach cacnpNOa plan on ppyypp gtbeWf ih1 x 11 Inches In size. Plan must include, but not Urtdted to scale or dimenel aetl.ho (t3M), direction and percent slope, n cation and distance to nearest road Parcel l D Z - .3 J — J2 ' �z7 Please print all Iwormation. Personal Information You orovtde may be used for secondery ouromed (Pdvaav Law. a. 181WIlrmll Revsl�lWed by I /- I I C� h hW fi- / ( Date V 6 / 7h riaZymer Property Location Q ' oovL Lot lJWY. S w Y, S 17, T 3 D N R 11 E {or Property O er's Maglnp Addres� f Lot # Black # Subd. Name or CSMS Z7- ZI City State Zip Code . Phone Number ❑ pity Clmilvp 4,Town N rest Road u•.o..,.•..•...•..•••...•• �.R�I.■urea.naw�rvumuvrorwarvomsL_uaaeaenveoaesrpnnowraw -7-T-yuPD of ,t Replacement Public or corn arolal — Dssc ibe: , Parent material — Flood Plan elevation It applicable &Lft Fok't c General comments vrecommendations: llecawu-moo o^3L�1-XI •J�..,,. SaS3`� 60 (or��^ p r!acd—O�or fQ55 i l.4oef— r��ti �LcLo a Boring # ❑ Boring Pit Ground surface elev. fil,tPl. Depth to Iunitinp factor _ �n. ®®®®�o nn �_� 99119.111•!11.Yd1 1 M �'�����rcis��...�r,.�r�r��■ Bodno Bo # 4Pti around surface slev.(YA r �I']ioth yreQnp�otorl } ln, ..• . •lip ffi*ZAMWMOM MAI i� - -- —�—L/J ��MMM4T =F IN MWWA ���P";i�i�T•I■F37rFT1,� ��•1 �;��-% . .. „•!_ „�TrT�''%L7a.7. :•• ....., r7igZ�.�i Monauvi, v 584 V Cfm-oaau(nwl,o) (715) 579-9 /05-e;2oa Ste" I 5 ( Borino # Hatton Baring Depth to ,fmhing factor Pit Ground eurfaae el@No 2 L i Sail kdDn Rat rsce ; Boundary Rants t3pme Depth C= tjo Dolor Redox Deacrlp•,Ion Tin' ; Gr. Sz Sh. mcwm Coneiata i 'E14lF2 tM1 MYngA Cu. Az Conti COW I BorinQ # Sortng 1] pit Ground surface elev. _ P.• Depth to 1lmltfig factor ----% Im Horizon Depth oanantColor WOMDeacrlpLicn 1 Terdttro Stru�ue i oonataterrae Boundary Rants mi In. j Munaell i Gu. As. Cont Color Gr. Sz St. i Boring # I H� or zon Pit Ground auAaoe elev. _ R Depth to ilmlting `actor_ in, Depth I DaraLnard Coicr j Redox Desuiptlol Texture Bmictune i t',onalsterrce i Boundary i �� In, ! Muntell ; GLi. Az Cont. Color i ! Gr. Sz Sh. i I - Effluent 01 = BDD, ;p 305 220 rn41L end -SS > 30 5110 rngOt ' EfriLent #2 = Boo, > 30 s 22C mgrL and TSs > 30 5160 MWL MI M.A t t, rie-,o014" Will Heidt Soil Testing W3503 Hemlock Road Mondow, WI 54755 (715) 579-9584 1o?o'Za- a fr,6w 4r 9'I O did f � ja �a� ` 5�•�a�.s— 'farL,--p 4- e-r, 4 (lv, floe- . 1 Olk couNnr No. 645496 STATE E= ��ANIT�t��ERMIT 1645 2eo see rxevtoysNO. bYY / OWNER PLUMBER4X46P,6W_LIC* TOWN OF � SEC,T N, R� AND/OR LOT�_BLOCK � Ai- SUBDIVISION CHAPTER 145.115 (2) WISCONSIN STATUTES (a) The purpose of the sanitary permit is to allow installation of the private sewage system described in the permit (b) The approval of the sanitary permit Is based on regulations In force on the date of approval. (c) The unitary permit is valld and may be renewed for a specified period. (d) Changed regulations Will not Impair the validity of a sanitary permit (e) Renewal of the unitary permit will be based on regulations In force at the time renewal is sought, and that changed regulations may impede renewal. (f) The unitary permit is transferable. History: 1977 c. 168; 1979 c. 34,221; 1981 c. 314 Note: If you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. AU� RI D ISSUING OFFICER - DATE Z't EXPIRES fth RF UNLESS RENEWED BEFORE THAT DATE POST IN PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (R11/20) Wsconsin Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s 15 Oa (1)(mll TANK INFORMATION ELEVATION DATA TYPE TArJI[ CCTGA,` 1W IWCYf0IUATIlla1 M®m e a e MMMM► mmmlm "& .r . MMWWIF�r PUMP/SIPHON INFORMATION Number to Well tiYa1lIV_1=1,Ya1:1iI[*]:IE41Y&'11:3 , BEDITRENCH Wdth Length No Of Trenches PIT DIMENSIONS No Of Pits Inside D,a Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer INFORMATION CHAMBER OR Type Of System. Model Number UNIT V W I r\I&PU I IVla Q I J I MITI Header/Mangold Distnbution x Hole Size z Hole Spacing Vent to Au Intake PiPa(s) Length D,a Length D,e Spacing JVIL s+VYGIS a Prasaura Svatarna nnla v Ua ...A A. A•_l:.arin C..e •n...e A..h. Depth Over Depth Over xx Depth of xx SeedediSodded xx Mulched Bedlrrench Center Bed/Trench Edges Topsoil Yes No Yes No COMMENTS: (Include code discrepencies. persons present. etc) Location: 1645 200TH ST 1.) Aft BM Description 2.) Bldg sewer length = - amounl of cover Plan revision Required? I - Yes , 'I No Use other side for additional information. -- Date --- SBD-6710 (R.3197) Inspection 01 Insepctors Signature Inspection #2 Cen No Is P!a' P Z-AIW , Division _ ` arfisaa Y (C�l county.... S T. CiQo,X M M5 I f SmiaryPermit Numbber (to be filled m by Co.) O. Box 522 707 Madison rv153707-7162 ` l / Sanity Pe it Application stake Transaction Number In with swffiIIl'e2) submission of this form to the appropriate governmental unit is rcquired 'or to Pmjax Addrm (f different therm mailing addmn) AppGotion f«tm f« snteowned POWTS are submitted to the t ional Services. Personal information you provide may be used it secondary purposes in with the Pdvwy Law. s. 15.04(1 xm). Sara ✓ /6Y5 J00�� Sr 1. Applicadn Inforesodm— Man Peat ANafarmMon Prvpony oa'mcc's Namc Parcel a I ` / - 30- o to �? Property owmeh Mailing A Prop41.2.o-c1.d3 Q/ Govt. Lot City, Sate Zip Code Phone Number IVZW 114VOle.rl I 5Vo/7 Nt✓uti rld fat., section 47 - n. Type of BaUding (cbeck an that &") La a T 30 N R 7 e « ©1«2Family Dwelling - Number ofBedrooms 3 subdivIst ablidCommercid - Desrn'beUx Block a • iry of Ilk ate Owned - Describe Use ant i � �/ Nk 00kLE 7— 2� of EX/'j 01'e E M. Type of POWI'S Petrstait Wilber "New" or "Replaeen bk on saK B CaaapWe Ise C III Mopliesible.) A. Pe, System System �OOtiter Mod' 'og S ( ) Unit (ekpaun) B oWi ng Tank X �%.Gmtmd •G and Site Other Type (gepaim) (conventional) , b u PreviousgtIand Dare Issued C• ❑ Renewal Before Expinition [:]Revislon ge of Plumber y� IV. fast Area and Tank Info Design Flow (Ppd)'Design Sal Appli i Raluited Mspersd Aj (sQ Elevation 9 i 3 90.5 Tank taiormauon Capaciy im GaMomas f of Units t(aw Tadu Tula ai ran kr t7 a Sepac Or o00 — /000 !✓/Esde Lo..rc e. nomg Chmnb« 0 V. RespaOeibility satement-1. the • aaw.a mrera rovers obowa on the av gibed pWz. Plumber's Name (Print) Knows S. MP/IntM Number Business I ham Number :ArNr A14�r _a.I'✓/ 99 7iS 942- Y/SS Plumber's Add= (StrM City. Sate, Zip Code) P.D. 4ox O A SF730 YL Comtymqmrtniont Use Approved I Cl Disapproved Permit Fla• 55Ti, Dam Issued Issuing igrotun: ❑ Owner Given Rasom for Denial ov $ �i Conditions of ApprovaVReasons for /� SYSTEM OtNNER: t+t(3 Q'U�CPV`t• Q P L((�%t-L CY1T Q✓1'h filler and (l yH r i t A . S / 1), J. 1. S Ver tank. l must dispersal cNl muse n 2'I> k_V a)e r ( �'Lt of i[E-fCe as per management plan provkled by ptumbft 2. An setback milw"o ents must be maintained i� yCi A(�pQ C(' ri y m wf.�er u per applicable (odc/ordnrNnces ACarb b osarpba pane it ft 1600Co ay only /lYnot Iw Nat t u1: 11 loeke In a:e SBD-6398 (IL 0301) G04% 'ns[ ✓) 3 1/ t l /1- 1401,4 1,4 I M /lfs-ano� Sr. Opt&' r / b.H - M4.o '64rrDN of I H roc _ Sc .sr 3 y i P� E ffa Rr. M /o.7 A r. \� ' lAceCof a�9vy` FiF�d t / eeOff'k ►-gdstnk:rd Nw/ Sal, /,?,, 30.vt 1741 , , a F F ti., 141CIFX Jf/ Sr. G[dY 4. P" h f. T 0 AA'sC )r U£�rLsn(]J 4yd, ?13, asf Et flow /AoJ hl 4ma),Itrs C'/ +'d'f /Jd')w Ay i,/`yf`X J'' � /S Qua OccJ x SD.O it a %Sao f.0' /14K /JSrtc[. OE/rNs " 3y ,6FY*AJ tcl/r �— 75� —+ " 3` 0 y'uc o,6. IA A. Pi/cs ll) 30J! G , 0 3 / L./.a 1//E!d 4,6 Se.4M) N A�—1 _ //"rs/ SAc.ts [or AU S/S 383. V.; frr4,rus roEr EX. /rou rs ro 6c AB,wl".,r/, 14,,+dt/ oar it FlCtcd /� Page I of 6 Private Onsite Wastewater Treatment System Index and Title Page Project Name: Owner's Name: Owner's Address: ,we Sr. Nei, �icyro.ro, L.II Sfo/7 Legal Description: _ /Y[��i�/��,7� J04 1741 Municipality. Town, Village, City of E,civ /�iui eiE County: Sr e,Aa/X Lot Number. / Block Number: CSM Number: 6/,7/ Subdivision Name: /Lys ,/� d S.- Parcel I.D. Number: D/.T - /03/- do- 05;0 Page I Index and Title Page Page 2 Plot Plan with Cross -Section & Plan View Page 3 Septic Tank Specifications Page 4 POWTS Owner's Manual & Management Plan Page 5 POWTS Owner's Manual & Management Plan Page 6 Filter Information Name of Designer. License #: Signature: Date: Desi®ed p1m= to the following PO)M Component Manual and 13SPS 381-385: SBD-10705-P (N.01101, R.10/12) "In -ground Soil Absorption Component Manual" Version 2.0 Attachment: Soil Evaluation Report pv i S r. --?aa& Sr, ft" ®u �opr s.r. r / b.N. - /oo. o f. 1 .64rro,v aL Nst: CAxsff H y Prrt spa. ro aaw S, Fs 9� � ✓' 9xa • fiF�o . / V0DCt('f 1�YgCUnl" /Li'S,roarNSr, N'j1 S/,lr A7, 3oIV, /76/ l', of E,t/r I'J.CA/rrrl Sr, CwY Ce, Pt 0 & p. ?-A Ao rrsr/r 9Yo L.40S UGurljnl?) >/]"Pot Scv. ''a S.Ek. 3r �r 9bS t�itOSS- JfLT/W LJO oejdr) CIS! Et f[ou /poi H 6u.lOtls / xJ i /a')A C/"t Jos' =07 CS 6u 1--5 x Se7,0 Fr : 7Saa ��• /yox. //SrAte. "IrNe 3Y r--- 75r 3r 3dy G UEvr lih-sel) r a o 3 SL.n!) It N N r �m a= lr"rS, SALnE [or Att 5/5 381. VJ Ser4Aeos ,rt r EX. /rou rS re 64- .I{S.olaa.rlJ, /y.v/!/ or,r Fi[t to /,J v� 0 4" CAST - INLET - A"In I M • ~ V I ,' n n v j v I v I I TO MEET OR " CAST -A -SEAL 07 I 1 AS o Q 1 � l PUMP PAD WLP1000-MR TANK SPECIFICATIONS DIMENSIONS: WALL: 2 1 /2' BOTTOM: 3' COVER: 5' MANHOLE: 24' I.D. PRECAST CONCRETE RISER HEIGHT: 53 1 /4' LENGTH: W-8' WIDTH: 7 -2' BELOW INLET: 42' LIQUID LEVEL: 36' WEIGHT: 6,790 LEIS. INLET AND OUTLET: 4" CAST -A -SEAL BOOT OR EQUAL GASKET INLET AND OUTLET BAFFLE AND FILTER: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 27.83 GAL/IN HOLDING TANK: OUTLET HOLE PLUGGED ACTUAL CAPACITY: 1,085 GALLONS LOADING DESIGN: E'-0" UNSATURATED SOIL TANK CAN BE USED AS: SEPTIC / HOLDING / PUMP OR SIPHON COVER: MIX DESIGN /8 (NO FIBER) TANK: MIX DESIGN #10 (STRUCTURAL FIBER) CUSTOMIZED TANKS - FOR CUSTOM TANKS CONTACT WIESER CONCRETE REVIEW DATE DRAWINGS SUBMITTED FOR APPROVAL APPROVED BY: APPROVAL DATE: PRODUCTS NEEDED BY: !w a 1 OF POWTS OWNER'S MANUAL AND MANAGEMENT PLAN FILE INFORMATION Owner 1(1�i�y} F dp V1 �1 �KC1 Permit # DESIGN PARAMETERS Number of Bedrooms 1 Number of Commercial Units ^gal/day Estimated flow (average) jzio Design flow (DWF), estimated x 1.5 ySogal/day Soil Application Rate i fi? influent/Effluent Quality (❑ NA) Monthly Average Fats. Oil & Grease (FOG) 5 30 mg/L Biochemical Oxygen Demand (BODs) 5 220 mg/L Total Suspended Solids (TSS) 5 150 ang/L Ptetreated Effluent Quality (® NA) Monthly Average Biochemical Oxygen Demand (BODO 5 30 mg/L Total Suspended Solids (I SS) 5 30 mg/L Fail Coliform (geometric mean) 510 cfu/100tn1 Maximum Effluent Particle Size 1 1/8 inch diameter Ualcuunoos: SVSTRM SPRCiFICATiONS Septic Tank Capacity 1400 gal 0 NA Septic Tank Manufacturer 404- £.l 0 NA Effluent Filter Manufacturer 0.4fAJ6 o El NA Effluent Filter Model fro S,i]-/ 6 E3 NA Pump Tank Capacity gal ® NA Pump Tank Manufacturer ❑ NA Pump Manurfactrurer ❑ NA Pump Model ❑ NA Pretreatment Unit ( ® NA) ❑ Sand/Gravel Filter ❑ Peat Filter ❑ Mechanical Aeration ❑ Wetland ❑ Disinfection ❑ Other. Manufacturer. Model: Soil Absorption Component (❑ NA) R In -ground (gravity) ❑ In -ground (pressurized) ❑ At -grade ❑ Mound Dui ine ❑ Other. ® Dispersal Units — Manufacturer Etilow ❑ Aggregate Cell(s) Model lzoll Soil Dispersal End Cap (Dispersal Unit EISA) or DWF +Application rate = Am Reauked - EISA + (Trench Width) _ # Units or Total Len2tho f1:F19 + 17 /Y3fr` - 5-0dfr1 = /S /34meirs 0-,Wir' ❑ "Design of Pressure Distribution Networks for Septic Tank -Soil Absorption Systems" Publication 9.6 (SSWMP Manual) ❑ "iCC Flowtcch Mound Component Manual" Version 1.2 ❑ "EzFlow Mound Component Manual" Version 12/15/2017 ❑ SBD - 10854-P (RL/12) "At -Grade Component Manual Using Pressure Distribution" Version 2.0 19 SBD - 10705-P (N.01101) "In Ground Soil Absorption Component Manual" Version 2.0 ❑ SBD - 10691-P (N.01/01) "Mound Component Manual" Version 2.0 ❑ SBD - 10657-P (R.6/99) "Drip -line Effluent Disposal Component Manual" ❑ SBD - 10706-P (N.01101) "Pressum Distribution Component Manual" Version 2.0 MAINTENANCE MONiTORYNV- ct-wsnnr.v - MATWIMAIAW-c Axn atANAr`rmrvNT Service Event - Service Frequency Pumplinspect s cells clean filter At least once every- 13 months 83 years 0 Other - Inspect pump & pump controls, unit At least once months C3 3 yews E NA Flush and pressure test laterals At least once months 133 ears NA START UP AND OPERATION: For new construction, prior rouse of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may impede the treatment process and/or damage the 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 we frozert at the infiltrative surface. The property owner is responsible for the operation and maintenance of the POWTS and submission of required reports. The quantity and quality of the wastewater stream will affect the performance and longevity of your POWTS. The installation of water -saving appliances and fixtures along with prompt repair of leaks reduces the wastewater volume. Also the brine or waste from water softeners, iron removal unite, other clear water treatment devices and foundation drains should be discharged to the grand surface whenever possible. Note: this does not include laundry waste, showers, dishwater, etc. This system is designed to handle domestic an gth wastewater, however the disposal of food based greases and oils, vegetable/fruit peels and seeds, bones, and food solids such as those produced by a garbage disposal should be minimized. Toilet tissue is the only paper that should be discharged into the system. Other non -biodegradable items such as baby wipes, tampons, unitary napkins condoms, cigarette butts, dental floss, and cotton swabs should not enter the system. Chemicals such as petroleum products, paint, Page yof 4 disinfectants, pesticides, antibiotics, solvents, etc, should not be flushed into the system as they can seriously damage your POWTS and contaminate your drinking water supply. Maintain a regular steady flow by spreading laundry washing throughout the week. Avoid vehicle traffic over all system components. Compaction of snow over the dispersal unit may cause it to freeze up. INSPECTIONS A 11MAINMANCE: Inspection shall be made by an individual carrying one of the following licenses or certifications: Master Plumber, Master Plumber Restricted Sewer, POWTS Maintainer or Septage Servicing Operator (per the attached Maintenance Schedule). Tank inspections must include a visual inspection of the tank to identify any missing or broken hardware, identify any cracks or leaks, measure the volume of combined sludge and scum and check for any backup or ponding of effluent to the ground surface and test all electrical equipment ipment such as pumps and alarms. Any defects shall be promptly corrected. Exposed openings greater than 8 inches in diameter shall be secured with effective locking devices to prevent accidental or unauthorized entry the tanks. When the combination of sludge and scum in any tank exceeds one-third (1/3) 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 NRI 13, Wisconsin Administrative Code. The outlet filter(s) shall be inspected and cleaned to remove any accumulated solids according to manufacturer's specifications. Solids washed from the filter shall be retained in the tank Filter clearing may be necessary at more frequent intervals than stated in the maintenance schedule to keep the system operating. Alarms should be tested on a regular basis by the home owner. If an alarm sounds, contact an individual licensed to service POWTS, There is normally a I day reserve under regular operating conditions, however water should be conserved until any problems with the system are corrected to prevent back-up of sewage into the dwelling or surfacing. ABANDONMENT: When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to ensure that the system is properly and safety abandoned in compliance with Ch. SPS 383.33, Wisconsin Administrative Code. - All piping to tanks and pits 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, gavel or other inert solid material. CONTINGENCY PLAN: If the POWTS fails and cannot be repaired the following measures have been, or must be taken, to provide a code compliant replacement system: pd 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 render it unusable. Replacement systems must comply with the Hiles in effect at the time of replacement. ❑ A suitable replacement area is not available due to setback and/or soil limitations. Barring advances in POWTS technology a holding tank may be installed as a last resort to replace the failed POWTS. ❑ 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>> SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTIAN LETHAL GASSES AND/OR INSUFFICIENT OXYGEN. DO NOT ENTER A SEPTIC, PUMP OR OTHER TREATMENT TANK UNDER ANY CIRCUMSTANCES. DEATH MAY RESULT. RESCUE OF A PERSON FROM THE INTERIOR OF A TANK MAY BE DIFFICULT OR EWPOSSIBLE. ADDITIONAL COMMENTS POWTS INSTALLER POWTS MAINTAIN R Name ENT OKE IYP lJ /99 Name + LvnCiJ Phone / 961-'i/Ss Phone SEPTAGE SERVICING OPERATOR (Pumper) - LOCAL REGULATORY AUTHORITY Name Agency Sr. Choir &-wowr Et/s . Phone Phone 71d 3 - L O Page 5 of 6 Maintenance Instructions Biotubea Effluent Faker Y r TG ?a-z -1,Y J - How to Clean Your Effluent Fker To ensure your of, filter is functioning properly, it shoula be rispecteo every yeal. Urger normal conditions, your effluent filter will function for several years before clearing is necessary. The filter should be cleaned when it becomes clogged enough to restrict normal Flows out of the septic tank. A: a min;mum, the filter should be cleaned whenever the tank s Dumped. Most people prefer to have a sep.,c tank service provider tare care V. fi:zer me ntenacce and cleaning. You car, f rid a septic tarts service prorder it the Yellow Pages, tinder 'Septic Tanks & Systerrs.' Or you car ccntact your cointy health deparxnent for a f=st. if you wis- to insoect and/or clean your eY,luent'iher yourself, De sure to dress propery. Wear full} -length parts and shoes, gloves, and gaggles or glasses Tr en follow these mrructiors 1. Remove the access lid to your septic tank by unscrew- ing the stainless steel lid bolts with hex head wrench provided. If your lid is above ground, it will be easy to find. If it is buried below ground, find the marker that indicates its location. 2. Renwve the fitter cartridge by grasping the tee handle and lifting it out at its housing (see photo l,! 3. Spray the cartridge tubes with a hose w remove any material sticking to them flee photo 1). Ensure the three orifices in the optional flow modulation plate inside the filter are clear of any debris. Make sure the nnse water runs back into the tank, but do not allow solids material W fag into the open filter housing. 4. Firmly place the cartridge back into the housing. 5. Some effluent filters come with an alarm that activates when the filter needs cleaning. It you have an alarm check to make sure it is working by lifting the float with a stick An audible horn should sound. The alarm pane! is normally mounted on the side of the house or in the garage. Nate: if your efflaent filter doesn't have an alarm system and you would like one, call your local septic system ,ristafer. Record the date that you ir"cted and/or cleaned your filter on the form that follows. ff you checked the alarm or made any other observations about the tank or system, include that information under'Notes. 7. Attach access ka by placing it on the riser, matching the openings in the rid with the bolt catches. insert lid bolts into catches and tighten with hex head wench provided. Photo f. Remove the filter cartridge by Mfing it out of its housing. Photo 2 Spray the carmdge tubes with a hose. [a t. I N Wlawnsln DspuhrialfcO8td* and Profasslcnal SaMCea DMaiOnofIndustrySavt es Page — of SOIL EVALUATION REPORT In amondance with SPS 385, Meta. Adm. Cade County cl J'� Cra AVA t aaroplata a* pion on paper not lan than a 112 x 11 Inches In aloe. Plan must Include, but not arnud to vartlaal and hodrorital retsrenoa point (OR, direction and percent slope, Parcel I.D. soft or dit wolane, north crow, and location mid distance to nearest road. i Ptaaae print all Intw=tion. ' Ravlawad by I Date P Owner Property Looetlon ❑ ❑ GOvL Lot Ya Ys S T N R E (or) W Property are Malang Addreafi Lot # Blatk # Subd. Name or t.BMN r City State tip Code _ Phone Number ❑ city ❑ vw"o 4.Town NP~ Road "aa,.� I �'Yoi'J 1. I /6YSolao f 5r`'v� ❑ NawCoratruOtlon UsCiLftoldentlel/NuMberafbadrOona-Y Cods derived dealin flow rate -Y-T-%PD a� *ReplacsmeM Publicaraommerolal-Describe: �f11� Parentmatertalp(�� Flocd Plan elevation if appticable�R General comments T�ik rsoonmandstlona: look- Odoi ss Boring « Bonny �1 PR Ground surface slev. �,�t. Depth t4ltmalny tmrtor;/-77 WMAMAM WWI � Boring". Bonny Pit Ground surface elay. Depth to Ibniany factory. hi. MMMCm c MAM I ill: 'II�ii�. '.1 ✓.1 f/,•,r . , r-t• 1 • ,1 till . • • ...T. T ?r.'T,•i"r0_L77�3?�y.'Sr'1�t��:1C�' tt^ /_J1�7 _ a a a a . VVi .ram• -- !/ sou-oaavtnvwia) Mon ovl, V (715) 579-958Q /d�s,;200 s - I—, 15 t �OrYgi � Barrg 4 PI Ground surtax ate. b'� paptn ro ;ImrngnctarZ�—�= � ` t � , ; 9 H gotion Rat M s 7extufe i Swduca , terlw l IIatmdoY m Moen Depfi WftWetdCcW Redoz tic SL Sh. +. f � t , 1 t , Y 7 -7 (� II Bar'.np 1 Dams R P2 Gmuna rue cLncv- _!t. Depih to illTdibtg factor _� °• SGii ApGltCttlor Ram IIMiM� �y bL Col� Dewww— Tedol 1r ^sis:nr�e ' aaamw WIL114``��YVWr /R��A_ Y/If>�a�/Y^�y--y�..� 1 b�lb�ije �v�: ; i t 1 ` Gc. AL Oft 1�f '� �� ¢z S- I l ' � I 1 I I ; t « ❑ pit ti C 'L surtsCB eieV. depth to lirnldnp'acmr _ r Sou AWWWOrl Rau modem Dept Deminarr. Color f Redex Desadpdea Texture Shuetun Consbwce ! Scundary ; Roots Im E Mur ell QL Az Cant Cola Gr. sZ Sk +its! ' 'EfGfq 4 i + vJz=>3Df?ZDmplLend IN:03091foragt Ef'�a�:z2=BOD,�3C522�.'.•S'-S-,d FSS�3DS1EDrtfIIll G 1�=fOD•O �6 ow"' Tk5 st�-e, &y5- a001.�� 0 , far "it- s -- e-r 4 (w, 0 ` KPI VVili He,dt So,l festing 1N3503 Hen -)look Road wlondovi, Wl 54755 (715) 579-9584 I � �� ao .zat o 5/27/22, 10:11 AM 20220527_062453.jpg 2OIX-COUNTY File #: _- SANITARY SYSTEM office Use Only OWNERSHIP/ADDRESS FORM ceered212o2' Community Development Department will utilize this information to provide the property owner with information regarding operation and maintenance of your new or replacement sanitary system! Thii information will be provided as part of our ongoing efforts to protect public health, your well, groundwater, surface water, property values, and county resources. Once approved, this completed form and educational information will be sent to you by email. If you would like to view your issued sanitary permit online, you can do so by using theweblink OWNER/BUYER INFORMATION `Owner/Buyer T10b6�lz!Z Mailing Address 1t.46 - 'at_>O '121- STD City/State/Zip96.,) RtCA YY_0_1L>-D-- LJ i -590 Phone Number (required) / -;I71 &__ 115-3-3'S?-�L-7I(n Email Address(required)DC>Imp+)SC 1p 6knaI1 Parcel Identification Number __, ' r �71_;�- -103j 30- 0 -"Q (found on the property tax bill) NEW SYSTEM: LEGAL DESCRIPTION Property Location �� Y, , S0 1A , Sec. A T 30N R (1 W, Town of IC Fhin C LIJ � Subdivision Plat: _&'/ M _ Lot # J; Certified Survey Map # Volume_ Page It Warranty Deed # _ _(before 2006)Volume _ Page # Number of bedrooms 12�— Spec house O yesono Lot lines identifiable JIf yes O no S OFFICE USE SONLY ! v� .� New Property Address f _ - - — - - ;Verification of new ress required from Cammuniiy Devebpment Department for new corutnxtionJ (staff Initials) (Date) This form must be submitted with all Private Onsite Water Treatment System (POWTS) applications. New System: Include with this form 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. ' Community Development Department - Land Use Division 715-386-4680 St. Croix County Government Center 71S-245-42S0 Fax 1101 Carmichael Road, Hudson, WI 54016 https://mail.google.com/mai I/u/0/#inboxlFMfcgzGpGBGPjbrtmDBXZngCjpmfd pdF?projector-18messagePartld=0.1 1/1 4P41tKMAlt- COUNTY No. 644781 STATE SANITARY PERMIT �^_— z�� sf �TliAlv�c / EN � AL PU�d9� OWNER PLUMBF TOWN 0 SECT_3p N, R_L7_E/W) AND/OR LOT I BLOCK r qz m 2'7- /A 17 I SUBDIVISION CHAPTER 145.135 (2) WISCONSIN STATUTES (a) The purpose of the unitary permit is to allow installation of the private sewage system described in the permit (b) The approval of the unitary permit is based on regulations in force on the dace of approval. (c) The unitary permit Is valid and may be renewed for a specified period. (d) Changed regulations will not impair the validity of a unitary permit (e) Renewal of the unitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. (f) The unitary permit is transferable. History: 1977 c.169;1979 c. 34,221; 1981 c. 314 Note: if you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. �� , &T & / AUT ORI D ISSUING OFFICER - DATE 6 THIS PERMIT EXPIRES 8 7,5 UNLESS RENEWED BEfOlk THAT DATE POST &T PLAIN VIEW VISIBLE FROM THE ROAD FRONTING THE LOT DURING CONSTRUCTION SBD-06499 (R11/20) ` •� ' '� Ua a � � J 1 1lvlseonsln D Division of I `l./ al SeNlces 1�+ Page of 301E E1rALUAT10P3 REPORT :an n rdanoewfthSPS3tl6,1Ma. Adm. Code COunblAttach complete pfan on pap 4lel x11 inches In size. Plan must Include,butnotdmltedto: scale or dimanst Rtcarl seal he nt (t'IN�, direction and percent slope, Parcel I.D. n cand distance to nearest road. 3 - 3p -Orja Please print all Inforinagan. Reel by Ds Personal on you provide may be used for seoor� ary Puroose)iP va Law, a.16 Props Owner Property Location Govt. Lot Nlws S W% S 17, T 3 D N R 11 E (orj a) Property D ere MelffngAddreofi ( Lat# Block# Subd. Nj;sm* erCBMRt rr 7- ZI city State ZIP Code _ Phone Number C1 city ❑ M11sp •,Town raet Road ❑NewConstructlon Use:WReeldendalINumber ofbadrooms. Code derived design flow rate ,YC—VoPD 6 Replacement Publioorcom orcleI-Deaalbe: Parent matednl � -A1IXk11Flood Plan elevation If applicable NA-ft General comments racommandations: 0 Baring # ❑ Boring n Pit Ground surface elev. �,LiQt. Depth t4 limiting factorw/�n. Tom — ENNUI gym 1 2 1 Boring #. Boring Ph ' �► elaY,� r �3i1Rth bo)lrwlQrtb factor 1 in. c ■ • c �� c-lmPAPMYrin IL MOM I r- r�� Mwim 5-1 NAM Mo /.� / ' ' MOnuv" I I "' - 84 U ���-e93o (Raai,6y (715) Boring Depth to t JJJJ Borteg i i pft Ground surface elay. ILAIUftftingfsetor LLLLLLLL�---- 1 mom= DMA DamtnerliColor RsdoxDsserlpRI! Texture Structum Conststena Boundary ►blots Ut Munawl C.o. Az. Cone color 1 or. Sz Sh. i 1,1 soriag # Hadmn Dsp9s In aonng Pit Dominontcotor Radox Description Mtmseil Gu. Az. Copt Celnr / Depth to Ilmag �r tn. Ground surface slev. _ ft. P --F' 'n TOWS Btr MM . Conslatence Boundary Raab GP t i . I i i B$ ecrltsg Pit Ground surface slev. _ it Depth to lb tang factor _ In." 1 8oQ Aoako! ! tatw Fimimn Dsper Dommm Uctor I nacox ueacnpoon i I QL +Sw 1 JUUu w . in MwusA ' Otc Az Coat. Color Gr. Sz Sh. I i 1 I I I Melt Ort a BOG,.v30 5 220 mglL and TSS > 30 S In mgil ' Efttuent42 = BOD. > 30 9 220 rniik and TSS > 30 9 150 mpll. 61\�P-- @ lays AcD 416 �,outcv 4- e.r. 4 � rvv, f MI U Will Heidt Soil Testing W35Q3 Hemlock Road Mondovi, WI 54755 (715) 579-9584