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014-1027-30-000
Wisconsin Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village Township Ian Hewitt TOWN OF FOREST CST BM Elev: Insp. BM Elev: BM Description: 6crner- r t(\ rotMA4%on TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic Dosing CI��� 1� Aeration ing TANK SETBACK INFORMATION) TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic 7 \ t 2 150\ Dosing Aeration Holding PUMP/SIPHON INFORMATION %A,.cv LVII&.J W Manufacturer 000, Demand GPM _1 Model Number TDH L Friction o s Syste He d TD . sSFt Forcemain 1 Len th` 6 Dia. 1 it Dist. to Well ST SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: 651358 State Plan ID No: ?W-T, - gno2.147 Parcel Tax No: 014-1027-30-000 Section/Town/Range/Map No: 12.31.15.188 STATION BS HI� FS ELEV. Benchmark . BM Noun I Ib l Bldg. Sewer St/Ht Inlet I OM St/Ht Outlet Dt Inlet Dt Bottom y Header/Man. Dist. Pipe Bot. System J Final Grade Co r . e .3 .� C,0 . o BED/TRENCH DIMENSIONS Width Length / 7S No. Of Trenches i IA �/ 2 �a}.5L�� PIT DIMENSIONS Of Pi Inside Dia. SETBACK INFORMATION SYSTEM TO P/L BLDG WELL .W LAK ST EAM LEACHING CHAMBER O UNI ufacturer: 1._� Type Of System: n � � �Q j J 50 el Nu & DISTRIBUTION SYSTEM Header/Manifold Distribution N 2I Pipe(s) »»»»»«s)� t❑ ` x Hole Size x Hole Spacing if Vent to Air Intake Length Dia Length_ �� Dia Spacing J SOIL COVER x Pres ure Systems Only xx Mound Or At -Grade Systems Only �er p6hkor Depth Over S Depth Over xx Depth of �t xx Seeded/Sodded xx Mulched Bed/Tre Center Bed/Tr Edges Topsoil Yes ❑ No ®Yes ❑ No COMMENTS: (Include code discrepencies, persons present, etc.) Insp ction #1: 1214/23 Inspection #2:!?�l''II2� i ��-I �l X ` 11- a'' � -is+ • .A s�� - i 46+ b"11& mow* � t Location: � 3136 CTY RD Q a,1 SIM�+�O(� Kra. SptlS i�'ltl�.�vp�i' �kw� Te *N 1.) Alt BM Description = � �'�GVV414 ,�thM�.k. for '�•'n'thv< <r►y'�'r►� 2.) Bldg sewer length - 44V Nna ,%iYe 4;�e& 1d �,A ;,rl( au,6 rerio v4\ - amount of cover ='�` Ma 12411i3 •� No �cb l Plan revision Required? ❑ Yes No 00 Use other side for additional informatio14c1 6 000" 1 Date epctor's Signature Cer . No. SBD-6710 (R.3/97) C ounty FFz, kvfR xw-Of j Fj -' fety and Buildings Division Sa 201 W Watihington Ave., P.O. Box 7162 OCT 202 M adlson,'Wl 53707-7162 an iuwy gatt N urnbc r I to N fi I led is i by Co AIN ______7§jwTrxLsa6,on Number TdOn t A Sanitary- I pplication In acwrdancc witli SPS 383.21 (2). Wis. Adni, k'odc% submisislion of this timm to the appropnate govemnunwl unit EWTS 0723 02. 14 ct C, Ls rcquitM prior jo obainlinga sanitary pennit- Note -,,�1,ppl is PA ion fwms fix.statc-owiled an submited to Project the Depwuwt of Safety and Prokmsk)nal Sct-vices. Pmsonal intloffution you pivvide mp- bc ustd for sccowtarN Ad•rtss (O'differnt than mailing. addrc".) at gxtscs In scoofda—ax Nvfth LrbC PriM Low s. 15 j141. 1) St s- 1. Application Information — Please Print All I it (cir m atiort ------- . . . . ................. Pr(vl;jnv 5wncr's Nam pawe 10 '07 rk It 4 211A0 4Trol,wriv 0wncr'5_Mai1i,,i.Addtess Zip Code Phonc Numixf SLAJ 114 Sec,,di.-.)n W_ jZ- LA wimp olliz, #4 i. _L54 45 W es. t I I I. rvpe (of building (check 911 that j4pply) Lot 0 T,24 N� R I T' _Fam, iDI ng- NumtoBedrom Public :'coinmercial - Dcscribe use—, D ao D 1:11Y or State owned - Descnibed use 'F Nuwtr lage. of -C)92 ( . CSM �c_A211111 vin of W Imp, its T�pe of —Permit: (Check only one box on line A. Complete line 8 if OPPI' Me) A. Nvw sysical Rc heement Sy�Iclll 1Frcainxnt/Ho14dirtSTsnk Replaccnvnt Only U Oeicr Modification to Evisling Syste-m (explain) ® mxsNXI Datelis"ed a� 'mof Putg Evr"nit Trmfer toNONIt. PernitReric?nni(RM.MaC IV. Type of FOWTS Svstem/ComponenVDevice: (CheCk Sit that aPPIY) MoufW 2:24 in,, ol"suitable it Mound 2 -1 111 01 -4111 (xj_prcqSutjzcd JTi-GrourW 0 PTCS S U I ti C'd I is -j ground At-kirad jidding Itulk D other Dispem, a1l Component x 11 111) 1 PT0Fq:r!l`l11C1!! 1 kt11CAT.4' ill) 7 I rrr: c-sailTestmient Area InfomationUk12 x L Li- 0 iar a� .; I � ��� n tp<Lsl) DiWTsal Ams ReqAred Isf) Flom i gpkl 1 Dv, i I I C141. 5-D 50 7_3 IL acof 1 otal V 1. Tank Info Capity 1j) 01111ons Units U F.. U Xi MITI 4TW"h s .� _�.,. 11 .!S,ePtlCT,,ank I., i ft Tank abilii (or in-Oa1aflon of the RAVTS shown oo Ole attachtd pions. n m b i I i ty $tgte.m evi t- I., i h t sunder s ed -s U, t s MP(NIPR NkLfllbell Busine. s Phow Numk,r er'. Nwilic (Mnt) J 7 15 1'1 2�3976 LeNvi"; 13'lork V1 L1 i n be r"� A d d re i,, tree t. IN I k, le 71 E t R 1 �R VVI 51-1751 I I I. Cou n qiDepadni v lk t I -;e 0111Y two [-cc Date Issued hosvilin ANgeni. %iqA1jrUTC A pr I "' 7 9�� I F1 m Reason IN t K LV c . con(lit i 0 it S n� �Iv �rv, AbM*j6,,C4 SYSTEIA OWN- 1 Se plir, 1;:r-.-k. �fflueni filler and i err..@I cell must be serviced.frnaintain,r-d aper LAA, mansaerri:.:Jari pro-oded �y plumber. 2, 11 � 11) a c, � r--- q LiTmc-nis must be mainta-Med C ItAZS 8.5 PEI adpi'fzbk� orjdE� 'ordin,99ces ------ lip lZ�l2Z23 11 D-67 98 (R. I 1 I D, 0jv_ SS C6 C CHECK BOX AS APpll A" XLOT OX AS APPLICAME. SOIL E ALUAL' N Scale: 1" r- 40' STEM PAGE I OF(o 0 4o w ao '' SiTE MA PLAN PROJECT NAME- „ DESI O14 FLOW:�tm - -mm ON .....,. oPD v Attach design flow cicufstoru for oommerdei plane. PROJECT ADDRESst *-- N am "bol.- SM EWvW0m FT 8Mxiptivn; slope c;rwwd�} of 10S d Anw: WWI symbol (if appk.*.): "gan i1f. 253q74, ltutS j 0r� Pipe MelWal 1 AST'M (Tablm . 3.& .30-5) Fove Maier Show ground elevalo 1 conimat sui '�% a InWolsa MW lbgo':�o�t 1p� �,� (1, "N j SC ( I n i j 11 [)t 7pmiment of Safety and PTMICSSIonal Servi"s Division of Industry Services 4922 Madison Ysrds Way PO Box 7302 Madi,sori. W1 53707 Septem Der 26. 202 3 C U S7 ID N 0.: 2 5.3976 LEWIS C BJ0RK E78 IS COUN T fir" R 1) 1-' MENOMONIE, Nk] 547S1 q PLAN,APPROVAL EXPIRES: 04,26-20225 �11LISICJPALITV; FONVN 01-J`0REST 'ST. GROLX COUNTY SITE- HEW11T 3136 COUNTY Q CLEAR. L.ILKE-, Wl 54005 SE12 31 15 FOR: Design Wastexs a ter Fl ow %Ift [me: 4,50 Bedrooms: 3 Lifnifing Factor(s): 24 Inches Is Maintenance Required: ElTuent Filter Phone-. 609-266-2112 Web- htT -L Email; &1p.. cl, NOr", CC 11 IR V Ov Tony Evers, Governor Dan Hereth, Secretary Identification Numbers -IWTS-092302149..0 Plan Rex lew N o. - .1 Application No.: D] S-092 3 30917 'T-8 Site ID No.: �) I_ 1 1 115 i - Please ro'er toy all identifieat ioii niiinbers in each corre-;pondence with the Deparviicrat , r. ondirianally APPROVED REFIT, OF SAFETY AND PROf7ESSIONAL SERVICES C IV SION OF I qT R Y SE RV I CIES '0 ITS SEE CORRESPONED) CIE : V" Mound (_'ompmient Manual - VeF-s 611 2.1 (May 2022-202 7) Pre sure DistrihutK-n C0JT1jL10nL'A1 N'411ILK11 - Version 2.1 (M ay 2022 -27 0 217) 0 SITE REQUIREMENTS 0 A full size copy of the approved phins. %pe�:jfi,ttioiis, and, this letter sliall be on -site during construct-loii and open to fflq)tction by �,uthoriled representartives oftlic Dcj-,Pawmw, which may ire ClUdelocal inspectors. A Department eiecti-onic stanij) inn be on the plans whicli are tised tt the.ji-lb site for construction. ,rfie fonowing condili4ms shall be met during construction or'woall-.ai iri:9 tid prior to occupancy or use: A sanitar�perms it must be AmMed from the .1"ouTM wljej-�. ljjj� J)rn 'IT 'IT) acc(,)r(J-mce with the %quirements ol Sec. 1, 45, 19, W is. sta Is. It Pi-i(ir tt) Ilie, con,,tr(icii("M oCthu dispersal area, cht,ck the 601`.L%1111t Of . the soil to a &pth ifl"8 inches. Proper isail nioistar-C Lument car; '11),e deteFT11i i'i cd by roll i a so i I sian ple lwtween the hwids. If it ro I Is into a, 1/4-inch lire, the site is too wet to prepare. I i i can i ti-i h I � s, it to p reparat 10 1 C4A I I F. roceed. I fthe ; ite i s too wet is prepare, do not proceed Lint i I I i dri L:1 Inspection of the s'Nstem ffl�a�ill;itiun is reqUired. AiTaiiaemefits for inspection shall be madewifli the (it. Si (Tn ated COLInt-k �'j J'f I C i'Ll I i 11 3C Cord;ince m, i t ii i [i e pro - i sion s of" Sec. 145.2 0(2)(d), Wis. S t, i �, s. ID, A state-approv e c f 11 ue ti t J1 I te r is req Lj it cd. Mai ii.t e r,,ance in fl0rm at i on must be given to the weer of the tank ex p I a I ji in k, drat pe, ri od to c I e-an i rim, i,-) I" t h e ri 11 e r is req, i i I rc d All vipiinj, )}gall contonn to SPS Table 384.1'0-3 and SPS Ta-ble 184.0--i • I 11S U lame 1) L1 i Id i n g st-.wer beyond 3 ) 0 fOct per SPS 3 82.30 ( I I )(ic) & WO I set backs to ni eel chi. N R 811 & 812 6 Tank Instaltatian to 1,-0110k' -111 1'11rVlUfac-Laror`s reconiritendatIMIS & N"erill), prolwa% ltnc-(s) prioT, Lo iliA111,9tioll. 0 pUrIlli Floa(stcl he yet and %,erified per the aliprove d plan, OWNER RESPONSIBILITIES 1 he current owner, and each subsequent owner, shah receive a copy of this letter including instructions relating to proper use and taintenance of the system. Owners shall receive a copy of the appropriate operation and maintenance manual and/or • owner's manual for the PO`VVTS described in this approval and Wis. A.dmin. Code § 5PS-383.54ffl1h • Ili tlh.e event this soil absorption system or any of its component pans malfunctions so as to create a health hazard, the property owner must follow the contingency plan as described in the approved plans. The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. This system is to be constructed and located in accordance with the enclosed approved plans and with any component manual(s) referenced above. The owner, as defined in chapter 10 1.0 I (10), Wisconsin Statutes, is responsible for compliance with, all code requirements. No person may engage in or work at plumbing in the state unless licensed to do so by the Department per s.I45.06, stats. All permits required by the state or the local municipality shall be obtained prior to commencement of con struction/installati onloper�ion. In granting this approval, the Division of Industry Services reserves the right to require changes or additions, should conditions arise making them necessary for code compliance. As per state stats I o I.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. The Division does not take responsibility for the design or construction of the reviewed items. Inquiries concerning this correspondence may be made to me at the contact information listed below, or at the address on this letterhead. Sincerely < V-P r4 peprA 61 Katie I'etzel Division of Industry Services Phone: 608-574- 1189 Email: katie.petzel wisconsin,gov Fee Required: $250.00 Fee Received: $250.00 Balance Due: $0.00 Refund cted: $0.00 Mound Plan Index & Cover Sheet Component Manual Desfgn References: Mound Version 2.1 (May 2022-2027) & Pressure Distribution Version 2.1 (May 2022-2027) Pg 1 of 6 Index & Cover Page Pg 2 of 6 Plot Plan Pg 3 of 6 Mound Cross -Section & Plan View Pg 4 of fi Distribution Network Specifications Pg 5 of 6 Pump Tank Specifications Pg 6 of 6 Management Plan chm � � Enclosures: PumR.Curve Tank Pages Effluent Filter POWTS Application for Review Soil Evaluation Regq-q-& Site Ma Project Name / Description Owner Name(s):_�� '�U1►� Phone- Owner Address: 7Z2 �' �.,,�Zip: Proje+ct Address: �� .A lL LAvr, 1 �� Govt. Lot: �"�,, _ 1 /4 of W .1 /4, Section_, T-3 N-RG_E Q or W Township: �TOD9L',��.,, County: Sal • !Q&t1t� (Project Parcel 1D #: Designer Name: Lewis Bjork Designer Address: Designer Information E7818 County E Menomonie WI E-mail: lew'l'sbjork@yahoo.com... ...... ..... . .. .. .. License Number: Master Plumber # 253976 Remarks: 4' signature: ` Original signMwe fequired on each subr Med copy. Phone: 715 _231 .7375 Zip: 54751 Condivonarly APPROVED DEPT. OF SAFETY AND PROFESSIONAL SERVICES ,DIVISION OF I TRY SERVICES SEE CORRESPOND CE Date:�' . CHECK BOX AS APpll A" XLOT OX AS APPLICAME. SOIL E ALUAL' N Scale: 1" r- 40' STEM PAGE I OF(o 0 4o w ao '' SiTE MA PLAN PROJECT NAME- „ DESI O14 FLOW:�tm - -mm ON .....,. oPD v Attach design flow cicufstoru for oommerdei plane. PROJECT ADDRESst *-- N am "bol.- SM EWvW0m FT 8Mxiptivn; slope c;rwwd�} of 10S d Anw: WWI symbol (if appk.*.): "gan i1f. 253q74, ltutS j 0r� Pipe MelWal 1 AST'M (Tablm . 3.& .30-5) Fove Maier Show ground elevalo 1 conimat sui '�% a InWolsa MW lbgo':�o�t 4x 1p� �,� (1, 0.6' TO 2.W WASHED AGGREGATE (min, 6.0" beneath distrtion pipe - n►in.2.0" over dkMbuti©n pipe and covered wfh approved synthetic ftbdc) ASTM C-33 SAND FILL 1 r r \ft Y P+kwed Surface --�-� SINGA `.nFls I MOUND DISPER%0*03"AL AREA MIN. 6.0" OF TOPSOIL COVER min_ 1.0 tt rrdrt. 0.5 tt0-11 �- — — o o L A F A ft �111,o 11f Surface Contour Elevation = :144• 5 R (Show force maw manifold and flush valve locations on plan vsew. 1 D- ft E = ft System Elevation = i Lail Invert Elevation = 96 mom ft CROSS SECTION VIEW (No Scale) .�. ■• ��• •• YAK ••• •. i f' I III" a ,. ■ % slope �� PLAN VIEW (No scats) A 0 Schdl 40 S ft PVC Lateral '� (typical) Ob sel L J B 1=ft K ft ftypkai) Bend as necessary to follow contour DOWNSLOPE TOE Prohibit disturbance and vehicular traft within 15 feet of downstope toe. i Reset Page 41 if8 1.3 DISTRIBUTION NETWORK SPECIFICATIONS (No Scale) FLUSH VALVE DETAIL (No sm1e) Orifice in ,r. - - *,% , Valve Box Lateral Center of Threaded Crap ` (insulation optional) S A ft for dead Testing (optional) � Sherd ortfoon for gravelle33 aWmatJons Safi Valve � • (optional) Lateral Length (P) ft 'f Ohm PON V Schdi 40 PVC Manitoid _ .. el. i'0 Schd140 PVC Force Main (slope to iwmP tank r— for drain-)asic) l" First Odle e (typical) LateraLs to be kwel Schdl 40 PVC Lateral 0 in Mew) Number of Orifices per Latex = etas equaNy spemd: —` [d"Kk a; OR b) below] ❑� � spaced jifWong bottom of Were)Mish Vahpa akxV both of lateral b) Wong top of lakwai Asaeff"y th hf" (typal - see detal) facing down LATERAL INVERT ELEVATION (typical) Last Orifice � Orifice Spacing (X) = i � in 90 (typical)ttYPica? Orifice D+ameter = (� in OBSERVATION RIPE DETAIL (No Some) Screw -Type or Firistted Grade SNP Cap (Wes) (rnulched & seeded) 4 � PVC Ripe .. Topsoil Cover Top of pipe to tem*wte '�• �.1 } at or above Bred ode • • • •. (4) 114"-'l12" X 6* SkAs ., @ st aw AnchodN Duce : ' •� • • : :. • ' Infiltration • •.. = A r SuErfaoe Cw fioe Discharge Rate = Qpm Number of Lateralsam lateral Discharge Rate = �� gpm TOTAL DISCHARGE RATE... �. %0*0 G (typkal} First Orfte END MANIFOLDCheck ('y�l) � CONNECTION applicable box. I Man gdd First oritbe �� pipe ° ) (typlcal)—\�. G) AIL (ty�iicat} ttypic�+> CENTER MANIFOLD � Ma"#°�a Q CONNECTION � ow pie optbna!) SEPTIC / PUMP TANK SPECIFICATIONS (No Scale) 4V Vent Pipe >1❑ ft from Buiwg 1 r Min. or 2.0 #! atww Estsblshed Flood Flew oon # Arad ve►nt r's. Anchor tank(s) as necessary pursuant to SPS 383.43($Xg) FiNshed grads CAPACITIES i@ �t� I gaUin EkOnce€ must wrnply with SPS 316 and NEC 3W wowwwwad Extend rrranhWe riser as necessary. Jurcoon BOX ;T Approved Loddnq Manhole with vliaming Label Attwhed (typk*) Depth (in) Volume (gal) A A B 2.o �,� [C] Cor►du k 4" Min. or 2.0 ft above • E lishad Fkxrd Elsvadon �. (WOW)Ok A . . Quick 01 1 Ir min. (tyPlcw) We" Approved Joints w1h Hale Approved Piper 31t onto Solid around Alarm . On * Purr�lr Purmp Tank Liquid Level- In N D Force Main Diameter = l�n Force Main Length = 0-20 �ft FRUGJ Canwsle 3" Appmved W Beneath Tank 'Pfioo�� 0 Force Main Void Volume ga l [Cj Total Dose Vaiurne DV 3p gal/dose (5X total lateral void volume 7 TDV s 0_2X design flow) + �lome main dralnbemok volurre) MIN. PUMP DISCHARGE RATE gpm PUMP TANK,: .wwr ► plume Chocnnl gal M a n ufactu rer•. Pump Manufacturer. Zoeller PumpModel: 152 (see attached pump curvv.) (: ontrols/Alarm Manufacturer. SJ R.ombus Controls/Alarm Model: AB FI t switches opntaini.ng m u r geed. PUMP -OFF E LEVATl ON = ft y INSIDE BOTTOM ELEVATION C1 o ft �nob � Vertical Head = ��ft + ' l = ��� f# Min. Supply � n Dead + FM Friction lass - - �-�------------ ---------ft + Fitting Loss* = 1 5 ft (rdr.i. supply lid x 0.3) T TAL DYNAW9 H.9,61 = ft SEPTIC TAN s : .a.��r �.rrrnrr�rrw�rw� Total Volume gal Manufacturer(s): Install a raved effluent filter at the se tic tank outlet j[0Mgd'1gWy Uot[egffl gf 1ho lau tJ131 Filter Manufacturer: Orenco Filter Model: FT-0822-14B - - _U 7 1, %w4p " N.ZT----w - Mound Management Plan INIK')RTANT: -111.1-1 The (der of this mound systern shall be resjxmsibk� for its pe'�r *tual operation and maintenance pursuant to MqUirenients of 5-PS 382-384, ftsc, ACrT'Jri (--'.Cde Purs. uant to SPS 383.52 (2), Wi-c. )'dmin. Code: this system all be cc-ns dered a hurran fiealth hazard if no,,, rmc-iritalned in accardanc* vAth th[s approved ag eM Lent plan. Furthermore. .-Pection and maintenance activjfie�JS h.Irrmed %, a registered POWTS Midiiintainer in accordanoe Yvith ',';PS 1, z-%l be pefob, 0"83.-152 (3), Wisc. Admin, Code- MaximD i er l Area Operatirig Limits: I thl-Q"% Design Flow gpd; SOD#, 5 220 nxil", TSS 5. 150 mjjL,.`1 FOG < 30 i`ngl.-' 11 1 -OW ection Cho i IN,415PECT EVERY � YEARS 0 type of use o age of syk-3terr- 0 n u isa ice fa c i, ors (i. e. odors, deer corn pi a I rats, etc+) mechanical malfunction (ie,, pumps, valves, switches, floats, etc.) o material fatigue (i.e., leaks, breaks, corrosion, etc.) solids volurrie in anaerobic treatment tank(s) and any distribution appurtenance(s) (i e-, distr :Dution /ctop boxes) 1 neglect or improper use (i, e,, exceeding design capacities, prohibited activibes. 6.4c, o extent of n d i n g i n d i stri buti on cel r prier to do n 9 0 dosing irregularities (i.e., pump re-cvcling, float Witch settings, etc.) o eiectricall components (ie., wiring, c:onnectlons, swtches, ccntrols timers, alamis, etc,) i 0 distribution liateral or lateral onifioe ipfiuqqinq k'measUre!ateral distal pressure — compare to design specific�ation) s .-�Xge of effluent or sew -age back-up -nto structure served urface dlsrl� Maintenance Checklist MAINTAIN EVERY 3 YEARS (or when nec-%essary) o 6901g and. Stan K, (s) sh a II be p -j -iip E,%d by a c e rt i fi ad se pt aa e s e, rvii c, I, n c ns-e iced under s. ")81.48 Wis, j c, p .. r: Stats. when the volume of solids in the tank(s) exceeds ot)e-thllird (V3) the. I iq u id volume of the lank(s) or as requixi-td t-,,/ local ordinance. Ds-)ocall of wntents shaP be pursuant to NP 1 13. V11i'sc, Admin. Jr .Effluent hall be nspected every 3 years and shall be cleaned whon necewwry to remove ny accumulated solids according to rre-inufacturer's specifkcatin s, A servicing period W11 a1ways be grealer than 12 months. DistrIbut ion laterals shall be fusheld once every 3 years or when necessary System maintenance reports shall bo submitted to the proper lor,:all government uinit in accordance wilth SPS 383b55 Wisc. A ji-nin. Gods. Report 3ny component failure or malfunction to: Name of inn IV] d0all C11, C,,T,,,,,, Blork'FC-unily Septic Service 715-231-7375 Locr'.-'ll governmert unit Phcne P A li Li%A Local government unit address: Z I P. -UA*- k . - Any deceive pail of this systern shail be repaired replaced, or removed pursuant t--) 'SPS 3813,51 Wisc rain Cod S 383 VVisc. Admin. r-,ode. g components shall ornply �mth 1A, ei r ep Rpa or r[acerne, n f falr I I t o ied omal t n I n 'I No product for &erri,,cal or physical restoral-Illon of 'L!-led POWTS mcay be used tjn[ess '31-epirovE."d by the departrilent in anc%orri<-inci-,, with SP.S '184, Wigt-- Admin. Crria C orAi n la n I n the e,,ie n t that ary lead tre atment c om p',me rit of t h i s POWTS :'. annot, be repalrec , it �-ha I' be replaced p u r-�� o,a n tc a or 'eview and apj-)ro�--.TjL A fa ic-.,d mount diaper sal component rn,-)y be p I -C'i r. sub mi tted to V'i e a ppra pria te a g P. n qi- f I Trp 1 1 -irea after rernoval o-f all faillecl components -, --cor!.structed wiO) ir, 11',e original ly appi ov�. . -C I.- tem Abandoni-tient 1, '-1 q ff Use of ties Poko'v- L'�k I' ---% discor-it, n ued, it shall be abaf-doned in aa.'-ordaice wr1h S PS 1'� 3 33, Vvisc. Admin. Code, 154) S+:i ies Effluent mumps Awfiler Puntp Compwy https:.'"W%.,W.Zoeiterpum�-cDiet,�eii-nalproducts,.'suriipreilluent-pumps ef.. N a: W I-- W � ui 50 14 45 40 12 � 6 2-C 1 44 80 120 160 200 240 zoo 320 36v FLOW PER MINUTE 0 WARNING DEA P4 MAY IF TAW IS E01'47EPED WITHOUT PROPER EQUIPMENT NoTE -EA iNNER WALL PHOTO ON THE -EXCLUSIVELYAT SKAWS* PAGE, pia i7 nn 27.X 2tOC J. ou - - - - - - - - - - - - - - - - 0 U TLL T END VIEW OF TANK' RECEIVED 11/29/2023 ST CRo NTY SANITARY SYSTEM File #: Di ce Use Only „``"'"�' OWNERSHIPIAl3DRESS FORM createdv2w, 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. If you would like to view your issued sanitary permit online., you can do so by using the Property Files Scanned weblink. OWNER/BUYER INFORMATION Own,er/Buyer ge �j I Mailing Address G)t)dt`FLf ("1""' 0 City/State/Zip C e- 0( 5 q 610 5 Phone Number required) 16-70q— IL2!1 Email Address (required). 16 1 It X 0 0 C, rg e, k 0, iea,�r`�c. A C VPV' Parcel Identification Number 0 - -000 (found on the property tax bill) 11L -5 F i/4PF 60114 Sec. / 2 T N I. W Town of roreSt Property Location t I I Subdivision Plat: e'�� 1, Lot # Certified Survey Map # Volume.Page # Warranty Deed # /I 100 q 0 (before 2006)Volume Page -ff Number of bedrooms 3 Spec house 0 yes Wno Lot lines identifiable Wyes 0 no New Property Address "Staff Initials) M a a 11541:9944*01 Z I VA �Verificatiuri of Tiew address required from Cornmuni�y Devc-1cpment Departrne-i-r for new construction.) ----------------------- 1. 'Dato) This form must be submitted wi'th all Private Onit e Water Treatment System (PODS) applications. New System: Include with this form a recorded warronty deed from tax e Register of Deeds Office and a copy of the certified survey map if reference is made In the warranty deed. Cornrnunity Developaient -De�.jartrnent — Land Use Division 715-386-4680 St. Croix County Government Center 715-245-4250 Fax Cdd@5(aVi-gQy 1101 Carmichael Road, Hudson, W1 54016 www.scCwi.gov RECEIVED 11/29/2023 1170040 BETH PABST REGISTER OF DEEDS State Bar of Wisconsin F--crm 1-2003 WARRANTYDEED Document Nu:, -,-ibex THIS DEED made betwee:� WAl!en Hochstetler arid Amanda H. Hoch stefler C'Grcantor." vmether one or more), and Ian A Hewitt, t"Grantee," vvhe-ther or Circantar, `--or. a valuable oonsilde7cation, conveys to ti following described real estate. mgethear vMi the re,r--Lts, p,,-o`7rrL_s, f-ixtures aFiLd other appurtenant 'nterests, In St Cro'lx Countyr State of VViscuorsiln ("Property" (if more space is needed, please attach adden,�L]T_)- ST. CROIX CO., WI RECEIVED FOR RECORD 08/15/2023 11:13 AM EXEMPT#3 ICE C FEE 30.00 TRANS FEE 1,0.0 PAGES: I **The above recording information verifies that thi-is document has been electronically recorded & returned to the:submitter Recordinc A-esa N a me ,J F� n-t u rn Az d res s The Southeast Quartenr o' the Scuth%,vest QU3rtel- (S E Y4o f S VV Y4) of SeciL--Q!71 Tw6ve (12), Township Th i rty-o ne (3 11 North, Ra 7iqe Fifteen (Ij 5) West, To,*-1-1 of T't' F Pre m"er Grom_ip, Ins. Fo,rest, St- Croix County, Wisconsin, K-:,"! Kol"or Aver u.=--- NoFLh Am e ry, VA 5 4 --. 01 - L0 C, 113, SUBJECT TO County Road I, I, right of way- PID #014-1027-30-000 0 14-1027-3 0 -0 C D Parcel ldcarit,ificcati�rl Num, bpLr �P[N� Th'is is [,Lom_este-a-_i property- (i S) is not) Grantor warrants that the title to the Property is good, indefeasible in fcc_-, simple and free ard c;ear of encumbrance except: Roadways, Easements and Restrictions of Records, Dated AL,12USt4� : 2023 (SEAL) s EAL) VIJAIler Hochstetler At -handy H. Huchstetler AUTHENTICATION Signature(s) authenticated on day of August, 2023 TITLE: MEMBEER STATE BAR OFVVISCONSIN Of not, authorized by Wis. Stat. § 70&.061j THIS INSTRUMENT DRAFTED BY: MiQhael H. For cki ACKNOWLEDGMENT State of W_1Sr,-,cnSir`? Polk County� Personally came befog e me on day I 0 f Aga cus-� 023, the above named W Alien Hoolisteder and Amanda H. Hochstetler to me known to be the person'�`s`, -%vho execuiLed the foregoing and acknpwledced the- &-=me. Dods -[ S D L a 133 3 d a Ni I --,K nf2i-v Ptjhl'n State of VJr:nnqin XQ7 i My Cam.mission E r-es3: July 22. 2 027 (SiqT)aturc!,ci may � auth-.ntilQawd vr ai;KnQwledglad. Both arc not ncoes6iary.) NOTE: THIS IS A STANDARD FORM- ANY MODIFICATIONS TO THIS FORM SHOULD BE CLEARLY IDENTIFIED. WARRANTY DEED 2003 STATE BAR OF WISCONSIN FORM NO. 1-2003 Typo name- oelow signatures, Hie No.: 39966 Page I of I I L ,) Visminisin m cii r- t c i r,^m meme SOIL EVALUA-1-10N RE -PORT' I* iscon of 5 if c-,, Y zwkj builpirgs L 1. 2 Z023 Mn accofdaroa **1 Coi n.-ri 85. Wis. Adni, CWe C;cy Atach com r I i l-) § ties JPAI air� p3* noi, th#6 1nd)jas in size. F- iai, must iimited t : v&M in(iUde. �10�p uriA�,,bOlnt (B AN; , d i re -non and ParW 1, D perceril - 9 or dime nsion s,, north armw, and location and distance to neare st road. paw —1� of --2-11 JW . 3LO Pka$G pdnt all Information. 12- F I ersc n al in ft] rM a 110-:1 Vou providt, may be used F0 r secolld:3, y PU ripaseg (Privafy L aw, S (1 ) (m)) 4Z AA ,q � I /I /z23 F"Poporty Owner Property Locabion .0 T Nil R F (09V(V .,Maiiinq -liddoiss Lot t! Block. # Subid. N w* Trjv.,r Nfiarebt Road �Ay S'Ate Zip Code PhDne Numbeir LP-ity Volaw 11 - -,- 151 "JIM0 NOW U$60 Residential I Nurnlxir o" Wrocims Code derived dn 4mv rate GPID 1;-(P,-oP18*qMW,t 11 Publ is or c o rin m a I - Describe: I-),arent material Ft000 Plain elevation if applicable tL Gpenbral comments ar�d mcommandefions- &x- U EWring N Boring # 010. Ground surtsioe eiev, ft. Dep1h to liffriting faclor in. Fsoil k-plication Rate Horizon A E*th vi� I Mxti -,,-.)nt Cchoe NJU�J--fl RC-00� Descrpllofl aqksz 0-&A. CrAor Texl�jre Siruc.tkire Gr. Sz. Sh, 2 011 Consistence boundery 5 Roots C-34,11D.If i Ef f# I AEff#2 100- �11 1 —41Y C L A LA inieer i.An- MAP arm 00 ic- Boring # evW"M ]z pl� G ro u nd surf a c e r-1 H orizon Depth I Ill IVA Redc,x NSCAPW S-.!. Com- C7'ulor Air N,)rne (ReaSe Pnni) [xm 1,; 11jork k 8 County F Menornon, t, W1 Uet tth to I irni tim 'ractor in. qxtlx-�, 5 1 FLJ,e,%t-L re Gorisister? * `7 'Zoundary F -S z. h V 4k!k ition Rate Rocits. GMW *'E flfg 1 OEff#2 jAA & F. ��° PA=bMb ffluent #2 ;- E Cf) ',0 nig"L L-,ind S',5 '30 Z.- 5 T N k,; i,4�i:, r 00 C()r-7A;C—t,:-1-d Telephone iqurnbet -17 15-23 1 --1' 375 LO 10 4 M& Parcel ID ft Property Owner BC ring F) I I Ground surface clev, _IJ Devto hniiUng faaor I 113-iring Bohng # M Ground surfs c-ea le, v. H or[zcn Depth Dor,71nant CAOr Redo x DesvjPbOn -exture In. Munsell ()u. Sz,, Cr�nt Color 'k Honng # 6 an rig sjrl, ace etev. F I F-, Hot, zon C)E-0 DOIJ i I i Q t' t (T! in. Qu, Sz- Cori. C.44ar Depth to tire" factor -'L.jr, S,z Sh ��-3 '7,Q-,JT1Jar y Roots L, S,A A::-phc�i(ion Rate W . *wo� If *E"" I *Eff. #2 ........... _�_ __�� De,;,ttt(ri limiting fat-tori. S.,.Jil, Appel �ticn Rate 7 t L ry Stmoure Consislerce Roots Gpclff Gr. Sz. Sh, EI1# I 'Eff#2 150 rr,91L ,ient 42 m(IIL andl 71SS) '"0 . I CUM Y�)U t 1'�. (jj:'L: C I L) a�:. C, -'N L"CN 0! 1,1c I I I �r Con) Ir, erce I % an equairtL11 Iti- 1 op, ii.y Sizv [cc , pri.v -Y h2 8 77, 1((,rj,-.[ 'TL ;in lllrt-ial [-)]ease L�ont,act th-., dc��,araiienl A 609-766- or ' Ft N � - 64.7 21 CHECK BOX AS Af+PUCABLE. CHECK BAP O% AS PLICABLE. ---- PAGE �- SOIL EVALUATION Scale: I» s ao ElSYSTEM SITE MAP � � � PLOT PLAN PROJECT NAME �' i0� DESIGN FLOW:� � Attach design ibw caiculsdons for oomrnendM plans. - -------- -- pipe Matadal t ASTM (Tables .30-3 S .305) PFO,1ECTPASS: ICI 1�1 Sankery r � BM BIrnOd: � 81A EleviidOn: FT Farce Ma«n: 10DMa BM DesCtlptlon: _��n �1 %4 �_�'��t i�ORTAWT: Indlau north ht slope erecaw,cN We11 Symbol (ii appNCsbM); O drawing an Show mound eiavetton oontD,rs at suuWie inteNvais. of 1'esmG Frae: q76 1AA5tc,vt 4253 �q a � V%(Ae5 Si. C46()( COUNTY ...... ... . ........ . .. ....... . ........ zN .1 . .......... ... . ... . . c3 / 3 ob &- J1L'%j AV "' NOo jr `V" I q0 J` U ' k1q) VV IVIL R 11 wp- OWNER �� �'E�.e� rfT... ... .............................................. ........ PLUMBER l.Eu1�s gJ o2 k TOWN Vr Fv-oee sT0000' LIC.# 20ct7fo CHAPTER 145.135 (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 sanitary permit is valid and may be renewed for a specified period (d) Changed regulations will not impair the validity of a sanitary permit. (e) Renewal of the sanitary permit will be based on regulations in force at the time renewal is sought, and that changed regulations may impede renewal. (f) The sanitary permit is transferable. History: 1977 c. 168; 1979 c. 34,221; 1981 c. 314 Note: 1f you wish to renew the permit, or transfer ownership of the permit, please contact the county authority. — DATE 121112o23, V, 70 " ;i F F I IF T N L S S R E N 1", W E "" B"VE d - f " U` R E T lux A'I-' 13" A T'", T11-111S EXPff"IRES I • t5. U r-d r_j SBD-06499 (RI 1/20)