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040-1242-10-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM County: St. Croix Safety and Building Division Sanitary Permit No: INSPECTION REPORT 538798 0 GENERAL INFORMATION (ATTACH TO PERMIT) State Plan ID No: Personal information you provide may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Parcel Tax No. 040 - 1242 -10 -000 Genson, Leslie & Sharon I Troy, Town of ' CST BM Elev: Insp. BM Elev: BM Description: Section/Town /Range /Map No 03.28.19.1230 TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark ZL r ( C 7 Dosing Aeration Bldg. Sewer Holding St /Ht Inlet St /Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Dt Inlet i Septic Dt Bottom f 9t 3 Dosing n Header/Man. I ,��) o5 77 f 1 � 1v `/"zs Aeration Dist. Pipe Holding Bot. System 7,75 /03 � Final Grade PUMP /SIPHON INFORMATION 4 Manufacturer Demand St Cover 5 � S �r g , GPM 4- P� ,1 Model Number �^� , f - 35 TDH Lift, Friction System Hea TDH. Ft� IS • b Forcemain Le i gth� Dia. %� Dist. to Well y _ SOIL ABSORPTION SYSTEM BED /TRENCH Width f Length / f . No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 3 / ti /�� Al � — SETBACK SYSTEM TO IDS' P/L JBLDG WELL LAKE /STREAM LEACHING Manufacturer: CHAMBER OR INFORMATION Type Of System: 16O j g UNIT Model Number: DISTRIBUTION SYSTEM 5�� $�°"" /� /S� Header /Manifold ) ri,p tribution x Hole Size x Hole Spacing Vent t�� Air In ke es) 1 ` ` �� Length DiaA__ gth \ D ia � Spacing SOIL COVER x Pressure Systems Only xx Mound Or At - Grade Systems Only Depth Over 7 Depth Over xx Depth of xx Seeded /Sodded xx Muic` ed Bed/Trench Center 47 1 Bed/Trench Edges \ Topsoil ` Yes -i No Yes Nc COMMENTS (Include code discrepencies, persons present, etc.) Inspection #1: / / Inspection #2: / Location: 500 Trillium Lane Hudson, Wi 54016 (NE 1/4 SE 1/4 3 T28N R1 9W) Country Wood 2nd Add Lot 72 Parcel No: 03.28.19.1230 Pi ""F GaJ �'.. So l � t/� ��v.ti. -54 ioa,. -..S 4b 1.) Alt BM Description = U 2.) Bldg sewer length = 11�=Xi S G - amount of cover G - - - - -— G Plan revision Required? g Yes No Use other side for additional information. Date Insepc s Signat ,en W SBD -6710 (R.3/97) ■ � �jcr'S Made e • Loca�ecd�Or�o..s��f'e 5 ca-k: rr i ,�.,• � l�udso►�, mil. 7,2 17Cg6'N,, Sec. 3,7 -), . o�Tro s f . craX C�,., r• o y o- /zy ? - /o -COO ,be,'� 2.03 acres EXis Ltr�g 8C 1, : i o �w,a/a �ibh. /Qesr rcp� /e "Itw 4ec,e. be C /C!J Q S �G/* G/iRiilQ f�rSf�+y eerl s,*Oe "c. {o., : n S G�'an /'t S io5.9S:' �� � �r.�r'eL balm o�'dteX� o� sfS `� ,�.tP``,��� ,2'i5�i h- j rorcJGS�L/n Prt e41 � C'o»c nc�e Scab c - EwK. 2 f 3 X 3 "W; < /� �,��t�a �— 4' -�' Ex.sE.' n1, �wea .'n PecaSE 5 ) , m TQ .SrF 160 e %uen ,\ o \ LcJti,{�. P ;ne'b'CQ.S �, � Ei�.S•�r a'TS�vc�sa/ Cc // Q t/g i �V 'E 6e1rco.-7 n`c?4;3/ / 0 7 00, \ io7.5° CortErlw 2- arl2 /G B• aU � CO a Safety and Buildings Divisi County 1 !3ZO 201 W. Washington Ave St. Croix 's � � Madison, WI 53 itary Permit Number (to be filled in by Co.) 53 7 9 e s.. ®1 Application State Transaction N In accordance with s. C ode, submission of this form to the appropriate governmental Project Address (if different than mailing address) unit is required prior to obtaining a sanitary permit. Note: Application forms for state -owned POWTS are submitted to the Department of Commerce. Personal information you provide may be used for secondary Same purp oses in accordance with the Privacy Law, s. 15.04 1 m , Slats. I. Application Information - Please Print All Information Property Owner's Name Parcel # Les & Sharon Genson 040 1242 - 10 - 000 Property Owner's Mailing Address Property Location 500 Trillium Lane Govt. Lot City, State Zip Code Phone Number ' Hudson, W1. 54016 715 - 386 - 6766 NE / <, SE /., Section 3 (circle one) II. Tie of Building (check all that apply) Lot # T 28 N; R 19 E or W 1 or 2 Family Dwelling - Number of Bedrooms 4 72 Subdivision Name Block # Country Wood 2nd Addition El Public /Commercial - Describe Use Na El city of ❑ State Owned - Describe Use CSM Number ❑ vin, e of Na %i Own of Troy III. Type of Permit: (Check only one box on line A. Complete line B if applicable) A- ❑ New System P System ❑ Tmatment/Holding Tank Replacement Only ❑ Other Modification to Existing System (explain) B. El Permit Renewal El Permit Revision El Change of Plumber El Permit Transfer to New List Previous Permit Number and Date Issued Before Expiration Owner ?- r 9 a ' q — l b q 7 IV. T f POWTS System/Component/Device: Check all that appl R on-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. Dispersalirf'reatq A rea Information: 60 Infiltrator "Q - 4" Standard Plus chambers & 8 endca s, S - Tech STF - 100 effluent filter Design Flow (gpd) Desigp Soil Applic ion Rate(gpdsf) Dispersal Area Required (sfj Dispersal Area Proposed (sf) System Elevation 600 gpd 0.50 ! d/sq. ft. 1,200.00 sq. ft. ✓ 1,240.80 sq. ft. 103.50' OK VI. Tank Info Capacity in Total # of Manufacturer Gallons Gallons Units A, `� I N �/ U y 0 New Tanks Existing Tanks / i d/*^ / 0 Y y Q v Septic or Holding Tank Na ,20 1,200 1 Midwestern Precast X Dosing Chamber Na 750 750 1 Midwestern Precast X VII. Responsibility Statement- I, the unde igned, ass 4e responsibility for inst f the POWTS shown on the attached plans. Plumber's Name (Print) Niumbe s Signature [ MP/MPRS Number Business Phone Number James K. Thompson I MPRS 30021 (715) 248 -7767 Plumber's Address (Street, City, State, Zip Cod 340 Pa son Lake Lane, Osceola, WI 54020 VII oun /De artment Use Onl / � Approved 11 Disapproved Pe[r�miit7Fee Date Issued uing AX_ nt Si 11 Owner Given Reason for Denial $ -! / Si 1-/ �. 20 �l IX. Conditions of Approval/Reasons for Disapproval V At 4o �1� SYSTEM OWNER: Vk t GC/}�(C Y •5'L 1 Septic tank, effluent filter and (/ dispersal cell must all be serviced / maintained as per management plan provided by plumber. 2. All setback requirements must be maintained as per app ica eL QIi FO& for the system and submit to the County only on paper not less than 8 to x It inches in size SBD -6398 (R. 02/09) Valid thru 02/11 Dose - Conventional POWTS Index & Tilte Sheet Project Name: Genson 4 bedroom Replacement Conventional POWTS Owners Name: Les & Sharon Genson Owner's adress: 500 Trillium Lane, Hudson, WI 54016 Site address: Same Project Location: Subdivision: Lot 72, Country Wood 2nd Additio Legal Description: NEIA SETA, Sec. 3, T.28N., R. 19W., Town of Troy, St. Croix Co., WI. Parcel ID #: 040 - 1242 -10 -000 Page 1 Index and Title Sheet Page 2 Site Plan Page 3 Dispersal Cell Sizing Calcualtions Page 4 System Cross Section Page 5 Pump Chamber calculations & Cross section Page 6 Valve Specifications Page 7 Filter Specifications Page 8 System Management Plan Page 9 Certification for Utilization of existing septic tank Page 10 Septic Tank Maintenance Agreement Page 11 Parcel map Page 12 Waranty Deed Attachments: Soil Evaluaiton Report Mater Pl ber Restric ed Service: James K. Thompson, De 't. of Comm. redentt l #30021 s Date: 9 ,Z O// Signature: Page 1 Of 12 Design pursuant to In- Ground Soil Absorption Component Manual for POWTS, version 2.0 SBD- 10705 -P (N.01101) / Lo�edoro�..5�� _ 1?,F Oyasz U• S� Tr,' / /aml�ena �•" /,"dr7, Lo /. 550 /G O ,C.,.e T2, cw try " 2,03 acres pu.s� EXi.s-d'r� F /elf ci.S ,iOCr* ���i .Sy3fa+h be�een S�i�'c �a., h� m�i(a /e 'l /A 5,oz &66on 4 E ,3 X 63 , W %� /� T_.,�'Yt�a•67r "d'- �' EX.sE.' �. �wesEu'r PeeaSE ��m/� c� > -; ber, rfu4e Odd _ 2 ° �o[ /ls. dam rJo�dC •/� � �XiS�i'k4' 1 4y ' rCeo Ww�e /one �i ces '� cc lr of /8 Eo be n co�n�c7�c„� �'wce Mari,. vi � CorrEow' /'� t' •L. � QA ��i GENSON DISPERSAL CELL SIZING CALCULATIONS 1. (4 bedrooms )(100 gallons estimated flow)(1.5 design factor) = 600.00 Gpd design flow 2. Infiltrative capacity of native soil = 0.5 gpd/sq. ft. 3. Absorption area required: 1,200.00 sq. ft. 4. Absorption area as proposed: 1,240.80 sq. ft. (60 chambers total) Infiltrator "Quick 4" Plus = 20.00 sq.ft. EISA per chamber, Infiltrator "Quick 4" Plus end cap = 5.10 sq.ft, EISA 1,200.00 sq. ft. — (8 endcaps)(5.10) = 1,159.20 sq. ft. 1,159.20 sq. 1/20.00 = 57.96 chambers required Number of trenches: 4 @ 15 chambers per trench (60 chambers total) Trench width: 2.83' Trench length: 63.00' Trench spacing: 9.00' on center Total system area w/ 5' trench spacing: 30.00'x 63.00' Pg. 3 of 12 Soil Absorption System Cross Section / 2/ o�� ft 4" Schedule 40 Final Grade PVC Vent Pipe With Vent Cap 1O s� ft Leaching --► Chamber ft �- System Elevation ,2.63 ft �o. (� ft Soil Absorption System Plan View ft 6.0 ft Vent Or Observation Pipe Leaching Trenc 1 Chambers I i 4" Dia. Trench 2 Header Leaching Chamber Specifications —� i I Manufacturer And Model I EISA Rating 26, 0 sq ft per chamber Soil Application Rate _ 6. S gpd /sq ft j _ gpd Design Flow -; y. 5 Soil Application Rate 2-0 d EISA = (oO Chambers I i //,'V of �� cham each. Page �` of l•Z Dose Tank Information Locking cover with warning label and locking device and sealed watertight Electrical as per NEC 300 and Comm 16.28 WAC Disconnect in. min. connect .�_ y Tank component is properly vented F- Alternate outlet location Forcemain diameter Midwestern Precast Manufacturer 2 in. - Cap acityl 740.63 Gallons Volume 18.75 gal /inch A Weep hole or anti - Dimension Inches Gallons B siphon device A 21.50 403.07 C B 2.00 37.50 P = ump off elevation (ft) C 6.00 112.56 97,13 D 10 .0_0' 187.50 D Total 39.50 740.63 L Dose tank elevation (ft) 3" Bedding uncTer tank. 96.30 Alarm Manuafacturer LevelArm Alarm Model Number !DLV - -� Pump Manufacturer Goulds _ Pump Model Number 1EPO4 Pump Chamber Calculations 1. Force Main: Diameter: 2" Length: 140' Estimated Flow rate: 40.0 gal. /min. Friction loss: 4.62' (140' forcemain)(3.30ft. /100ft.) 2. Total dynamic head: 12.82' Min. supply pressure: 0.00' (0 Vertical lift: 7.70' Forcemain friction loss: 4.62' Effluent filter friction loss: 0.50' (Sim/Tech STF 100A) 3. Existing Pump specifications: Manufacturer: Goulds Model number: EPO4 Pump will discharge approx. 40.0 gpm @ 12.82' TDH (Flow Velocity 4.08 ft. /second) 4. Existing Dose chamber: Midwestern Precast - 39.5" @ 18.75 gal. /inch ( 740.63 gal. actual) A) One day holding capacity: 21.50" 21.50" = 403.13 gal. B) Alarm setting: 2.00" =2.00" = 37.50 gal. C) Dose volume: 6.00" =6.00" = 112.50 gal. (600ga1.)(20 %) + (.164)(140 = 142.96 max. dose D) Reserve storage: 10.00" 10.00" = 187.50ga1. TOTAL 39.50" 39.50" = 760.36 gal. Pg. 5 of 12 NGOULDS PUMPS Submersible Effluent Pump 3871 EPO4 EP05 APPLICATIONS • Fully submerged in high ■ EP05 Impeller: Thermoplas- ■ Bearings: Upper and lower grade turbine oil for tic enclosed design for heavy duty ball bearing Specifically designed for the lubrication and efficient improved performance. construction. following uses: heat transfer. ■ Casing and Base: Rugged • Effluent systems thermoplastic design provides AGENCY LISTING ' Homes Available for automatic and Farms manual operation. Auto superior strength and corrosion • Q Canadian Standards Association • Heavy duty sump matic models include resistance. $P • Water transfer Mechanical Float Switch ■ Motor Housing: Cast iron Goulds Pumps is ISO 9001 Registered. • Dewatering assembled and preset at the for efficient heat transfer, factory. strength, and durability. SPECIFICATIONS ■ Motor Cover: Thermoplastic FEATURES cover with integral handle and • Solids handling capability: float switch attachment points. ' /4" maximum. ■ EPO4 Impeller: Thermoplas- N Power Cable: Severe duty • Capacities: up to 60 GPM. tic Semi -open design with rated oil and water resistant. • Total heads: up to 31 feet. pump out vanes for mechanical • Discharge size: 1 NPT. seal protection. • Mechanical seal: carbon - rotary/ceramic - stationary, BUNA -N elastomers. • Temperature: 104 "F (40 °C) continuous METERS FEET 140 0 F (60 o C) intermittent. • Fasteners: 300 series 10 � —` -+ — stainless steel. •Capable of running 9 30 � dry without damage to $ — ' 2 F GPM components. 25 0 7 Motor: _ • EPO4 Single phase: 0.4 HP, U 6 20 A 115 or 230 V, 60 Hz, 1550 RPM, built in overload with > 5 automatic reset. /.?,BlQ 4 • EP05 Single phase: 0.5 HP, T/o EP05 115 V or 230V, 60 Hz, 1550 ~ 3 10 ;. RPM, built in overload with - .- EPO4 - - automatic reset. 2 • Power cord: 10 foot 5, standard length, 16/3 1 SJTOW with three prong grounding plug Optional 20 0 ° 0 10 20 * 30 50 GPM foot length, 16/3 SJTW with three prong grounding plug — (standard on EP05). 0 2 4 6 8 10 12 m3 /h CAPACITY G Pumps 2002 Goulds Pumps ITT Industries Effective September, 2002 C {�Z 83871 belkpvjtv4rrfi- ILZI51322.2: 72 VgebLf C C LARUS- 475: IDbof ISvo!S P Vgebtf e11321 qi pof ;12.988.355.: 4511loy;12. 988.525.5427 Tvqf st f of t IAf x ENVI RONMENTAL x x x /drbsvt f owjspon f oibrtdpn Zoeller Family of Wafer Solutions ZpvslCf bdf IpjNjoeIjt lPvs1Upg1Csjpsjtzb B dLm • • • • 1 Drbsvt Fowjspon f oLbrt[ pof !V\brwf t ! ZONE gspwjef !bo!f dpopn jdbrtn f d pe!pd { pojoh!rbshf !f �pf otlejt Lsjcvypo! VALVES of LDC psl t /!U f !wbrwf t !bsf !f bt jrn! bvLpn bLf e!x jd !d f !beejtjpolpd Li f !n pLps!bdwbLO!DpoLbdd Drbsvt 1gps!dvt Lpn j {f e!dpoLsprh tztLfn t/ VALVE ACTUATOR � `� � . TM,.�€ �dlN bl -`e�1 Of1:1N�r;,t"I�AA1 ta:1�P "j b; �... >,. v p .RQX� C.f s , .`'A 4, �/�''� . y ti 8 ? �': t" MS. 7y� : 2$fi,1.fi5$ (a P 4t Y. stlld�06z, brif'1t)tR 28fi.fi5: " k a 3. sukboez!�brwf'tbt n.TM13#1JBa BdUitips lvabrtW.tbt.rl.135V1f± gisUld�dt3zl4 tirflttn = 1216#A.IE!''3#pF� 3 (ps lldiQezl i4biwf lot 6`42L60Xl j3#1,,F, Dpgzlhi tl' !3121!Bn%hi ut!sftf Illlllllllllfllllll(III III!! I! I11I! IIIIIIII (II11!I1111((ji(IIIIII11111111 �. biz SIM/TECH FILTER S rw 14 FILTER Sim/Tech Filter ;.;. _ The GAG Sim[rech Filter is unique to the industry, engineered to pr maximum protection for your sanitary pressure system. The Sim /Tech Filter has been designed as an effluent filtering assure small holes in the distribution piping remain unclogged Pr ess ,re distribution systems are very effective in treating effluent, but only �:❑er holes remain open. Many of these systems only partially fail causin 'rj contamination of ground water long before the system shows any signs of distress. Placing a filter just before entering the forced main is a simple solution The filtering device installs by simply screwing onto the discharge any effluent pump, thereby filtering out contaminants before they ei•'-( r-, distribution system. Thus, maintaining even distribution of effluent The GAG Sim/Tech Filter protects any pressurized system incluaina S- y Filters - Spray Irrigation Systems - Pressurized Chambered Systeri; Recirculation Sand Filters - Mound Systems tcfr� {� t, �2cdC)t�ic��j �ilrt��7oUc'S � �c<ditt ��ttd�cft( 6t riS�r- <2c�rj cvc;r y. � (r. <eyrr J'u6Y�t�zs'i6Cc ccy s - Lrlh 6e t(gM irr 6017d1 '�esid�lrci�t( :trr.� f; Order # Model Description List Prig: STF- 'COA�� STF -100 GAG Sim /Tech Filter (field assembly) r: �J /- J. � J �f�� ;,. D[e ST 10 has .vyell over 1;2 mile of filtration media with over 319 cuoic inches ji open area to eliminate clogging. The 2,215 square inches of filtering surface snow a flow rate of over 1200 GPD filtering to 1/16 inch diameter. This incredible :mount of filtering surface is achieved through the unique shape of each !.nangular bristle, which more than doubles the filtering surface, with no uniform poles or slots to plug. i % Order # M odel Description List Price STF 1 c STF -1 10 D!stposable Septic Tank Filter f ypllow bristle; - 6 -5 Dose - Conventional Septic System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code General The conventional septic system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall be maintained in accordance with component manual SBD- 10705 -P (N.01 /01). All local and/or state rules pertaining to system maintenance and maintenance reporting shall be complied with. Septic Tank Septic tank servicing mechanics comply with Comm. 83.54(1)(e). Septic tank to be located within 150' of service pad, with bottom of tank to be <_ 15' below service pad elevation. The operating condition of the septic tank and outlet filter shall be assessed at least once every two years by inspection. The septic tank contents shall be removed when the sludge and scum in the tank exceed 1/3 the liquid volume of the tank. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code, by an individual certified to service septic tanks under s. 281.48, Stats. If the contents of the tank are not removed at the time of a biannual assessment, maintenance personnel shall advise the owner of when service will be needed to maintain less than 1/3 scum and sludge accumulation in the tank. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated. Septic tank manholes risers, access risers, and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8 inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into the tank. No individual should ever enter the septic tank as dangerous gases may be present that could cause death. Septic tank abandonment shall be in accordance with Comm83.33, Wis. Adm. Code when the tank is no longer used as a POWTS component. The addition of biological or chemical additives to enhance septic tank performance is generally not required. If such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Pump Tank The pump (dosing) tank shall be inspected at least once every two years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed at the pump discharge, it shall be inspected and serviced as necessary. Soil Absorption Cell Trees or shrubs should not be planted directly on the soil absorption system. The area above and around the system should be seeded and mulched as necessary to prevent erosion and provide some degree of frost protection. Traffic (other than for vegetative maintenance) over the system is to be avoided. Soil compaction may hinder aeration of the infiltrative surface within and above the system and will promote frost penetration during cold weather months. Cold weather installations (October - March) dictate that the system be heavily mulched for frost protection. Influent quality into the system may not exceed 220mg/L BOD5, 150 MG/L TSS, and 30 mg/L FOG. Influent flow may not exceed maximum design flow specified in the permit for the installation. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner. Levels above 4 inches indicate an impending hydraulic failure requiring additional, more frequent monitoring. Effluent flow shall be alternated between dispersal cells on a two -year schedule by use of diversion valve. Effluent to be diverted from new dispersal cell to old cell at 4 year anniversary of new system installation. Old cell to be utilized for a 1 year period. Afterwards, effluent dispersal to be alternated between cells to allow use of each cell for a two year period. Contingency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. Excessive ponding within the dispersal cell will be eliminated by installing a new soil absorption cell to bring the system into proper operating condition. Questions on the operation or maintenance of the system should be directed to the installing plumber, Jim Thompson at (715) 248 -7767 or the St Croix County Zoning Department at (715) 3864680. Pg. 8 of 12 ST. CROIX COUNTY ZONING OFFICE CERTIFICATION STATEMENT FOR UTILIZATION OF EXISTING SEPTIC TANK(S) This is to certify that I have inspected the existing septic and/or dose tank presently serving the following residence: (Street address) , � ,, , u Dl. located at: n L - 1 / 4 , 5� 1 /a, Section 3 , Tow � N, Range l�? W, Town of , St. Croix County Wisconsin. Upon inspectio{, I certify that I have found the tank(s), to the best of my knowledge, will conform to the requirements of Comm. 84.25, and it (they) appear(s) to be functioning properly. Most recent date of inspection or service rw A- �S�i� 2 o // ) T Did flow back occur from absorption system? Yes . —T (if no, skip next line.) Approximate volume or length of time: - gallons minutes Tank Capacity: Construction: Prefab Concrete f eel Other Manufacturer (if known): �. Tank (if known):_ 7 er � mit mber (if known) p icensed Plumber Signature) (Print Name) ( (License Number) tdP/MPRS ate) Form to be completed by licensed plumber (Dept of Commerce Chapter 5 and s. 145.06, Wisconsin Statutes) or licensed disposer (NR 113 Wisconsin Administrative Code) Rev. 9/2008 Jun -30 -2011 07:45 AM St. Croix County Plan /Zoning 715- 386 -4686 16/16 STC - SEPTIC TANK MAINTENANCE AGREEMENT SL Croix County OWP ERMUM o, A - c rM ac,- a ro q MAII RG .AUDRYISS �5-0 PROPERTY ADDRESS (location of septic, system) plain obtain from the Planning Dnpt. CITYISTATE PROPERTY LOCATION _ I/ #, 114 Sedfaik . �S — • T � N- R _,Z, — W TONW OF -01 ST. cROLx COUNTY, W , RUBD114SION ,r a A dal n• . LOT NUM33ER „ – CEN TUPIBD B URRWY MAP 4 VOLUMM PAGE LOT NUMBER Improper un and nutin%nauee of your septic system could - result in its premature failure to hwWle wastes. PTWW tit &durance consists of pumping out do septic tank every throe ymrrra or sooner, if needed by lic Kmad septic tank pumper. What you put into the system can tit the function of the septic tank as a traotment stage in the waste disposal sue. St. Crok County rmideau may bo eligible to t We a grant for a maximum o 60% of the cost of replaoGarRtent of m failing s Ysk u , 6 which w= in operation Prior to July 1, 1975. St. Croix County accepted this program in August of 1980, with thk requirement that owners of all new systems agree; to keep their system pt01W1Y maintained. The propedy o"er to shit to St. Croix Zoning a certification form. signed by the owner and by a mater plumber. ,jounreyman plumber, rested plumber or a licensed pumper verifying that (1) the on -site wastewater disposal systans is in proper operating condition and (2) after inspection and pumping (if nccessary)� the septic tank is lass than 1/3 bill of sludge end scorn. I/We, the.undem4ped line read the above a quiramarts artd agrac to m*ihta " tore privsw sewage disposal system In acoordanae with the standards set forth. herchk as set by the Wisconsin DNR. Cc tificajon stw erg that your septic has been maintained must be completed and r4umod to the St. Croix County Zoning 0111cer within 30 clays of the Gm year expiration date, Slt31VW. DATE: ` St. Croix COUR y Zoning Office 0overnmew Center 1101 Cartnicheal Road Hudson, WI 54016 II/93 �� SS 0 73 2 72 _ _ j J-j F - E,) I lk e . ------------- )L ------ 7 74 4 D ACRES FT 0 7 5' .4 C i7'40"V� j , 4 75, d Jun -30 -2011 07:45 AM 5t. Croix County Plan /Zoning 715 - 386 -4686 12/16 Fs. ' v STATF BAR OF WISCONSIN "%A I - 19$2 Wr1RUNNTY DEED r N=MFENT NO W!L 1 •J.� W 44� This Deed, madebetuern Richard O. st REGISTER'S OFFICE ST. CROM CO.. W1 , _ GCAnt1r. A UG } 7 1 997 at ,d Lei 4 On D an k hdr n huatx? and _;a1}1d•_1N� �S. - _ .. - -- 4:56 A Geantre, ` � -4k U)..1.., Wltne ssetb, Tt>itt ttK =W Granux. far a valuable `. sMxs SPACE RESERVED FOR RECOROwG WTI conveys to Grantee the following described teal estate In Et ta :. . . CxKmly, State of Wisconsin; "" .W� -T'rRN wflpFai99 Lot 72, Plat of Country Wood Second 3 ANddi.tion, Town of Troy. st. Croix County, a l Q� a Wisconsin. This lot is included in protective - covenants and there are no outbuildings allowed on this lot. ; cs% mENTWiam»a mmeaft F This In not homestead property (1s) 01 not) Together with all acid singular the kereditamentc and appurwna wxs dwmuuo belonging A Richa AtOut --- warrams that the tit is good, indefeasible in fee simple and free a=ad ck-Ar of encumi3ran-" et"Tt easements, restrictions, righte - of - way an d co v e na nts of record, if any, and will warrant and defend the sauce. Dated this 1 _ (SEAL) _ _. — (SFAL) �l Rich Q . St�it t - — ' - — —�--- - t ` ---- --- - (SEAL) _ _ - (SLW y el s L CEIVED JUL 12 2011 � 2252 Wisconsin Departm SOIL EVALUATI & I M " COUNTY Page 1 of 3 Division of Safety a G & ZONING QF &( nce with Comm 85, Wis. Adm. Coe A.C.E. Soil & Site Evaluations Attach complete site an on County pl pl paper not less than 8'/: x 11 inches in size. Plan must St. Croix include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. Please print all information. 04 1242 -10 -000 Revie d B ` Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). 7 / 2 I / Property Owner Property Location Leslie G. & Sharon A. Genson Govt. Lot NE 19 SE 19 S 3 T 28 NR 19 W Property Owner's Mailing Address Lot # Block # Subd. Name or CSM# 500 Trillium Lane 72 1 1 Country Wood 2Nd Addition City State Zip Code Phone Number I City _j Village J Town Nearest Road Hudson I WI 1 54016 1 715 - 386 -6766 Troy Trillium Lane J New Construction Use: 6� Residential / Number of bedrooms 4 Code derived design flow rate 600 GPD Replacement —J Public or commercial - Describe: Parent material Glacial drift Flood plain elevation, if applicable Na General comments and recommendations: Site suitable for conventional POWTS dispersal cell with 0.5 gpd /sq.ft. /day loading rate. Proposed trench elevations to be 103.50'. Pump needed to reach system elevation. Boring # I Boring 0 Pit Ground Surface elev. 108.17 ft. Depth to limiting factor >98 in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD/ft' in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I *Eff#1 *Eff#2 1 0 -11 1Oyr3/3 none sil 2fgr ds cs 2fm na na 2 11 -18 1Oyr4/3 none sil 2fsbk mvfr cs 2f,11m 0.6 0.8 3 18 -36 1Oyr4/4 none sil 2msbk mvfr cw 1vf,f 0.6 0.8 4 36 -62 7.5yr4/4 none sl 2msbk mfr cw 1vf 0.6 1.0 5 62-98 7.5yr4/4 none slAs mix 1msbk/Osg mvfr /ml - 1vf 0. 0.9 /o3'S Loading rate of Horizon # 5 renects reduced permeability of horizon associated with textural changes. Boring # I Boring V1 Pit Ground Surface elev. 107.78 ft. Depth to limiting factor >95" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GPD /ftz in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. I *Eff#1 *Eff#2 1 0-12 1 Oyr3 /3 none sil 2fgr ds cs 2fm,1 c na na 2 12 -28 1 Oyr4 /3 none sil 2fsbk dsh cs 2fm,1 c 0.6 0.8 3 28-38 1Oyr4/4 none sl /Is mix 2msbk/Osg dsh /dl cw 1vf,f 0.6 0.8 4 38 -95 7.5yr4/4 none s Osg dl - - 0.5 1.0 Horizon #4 contains 1/2" - 2" horizontal ds of 1 4/4 IN at 8" - 16" spacing. Loading rate reflects most restrictive permeability rate within horizon. * Effluent #1 = BOD? 30 < 220 mg /L and TSS >30 < 150 g/L * fflue 2 = BOD < 30 mg /L and TSS < 30 mg/L CST Name (Please Print) ture: CST Number James K. Thompson �- 3602 Address A.C.E. Soil & Site Evaluations ate Evaluation Conducted Telephone Number 340 Paulson Lake Lane, Osceola, Wl 54020 7/4/2011 715- 248 -7767 Property Owner Leslie G. & Sharon A. Genson Parcel ID # 040- 1242 -10 -000 Page 2 of 3 a Boring # J Boring rl Pit Ground Surface elev. 107.21 ft. Depth to limiting factor >92" in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 1 0 -14 10yr3/3 none sil 2fgr ds cs 2fm na na 2 14 -23 10yr4/3 none sil 2fsbk mvfr gs 2f,11m 0.6 0.8 3 23 -38 10yr4/4 none sil 2msbk mvfr cs 1 vf,f 0.6 0.8 4 38 -48 7.5yr4/4 none sl 2msbk mfr gw 1vf 0.6 1.0 5 48 -92 7.5yr4/4 none slAs mix Imsbk/Osg mvfr /ml - 1vf 0.5 0.9 Loading rate of Horizon #5 reflects reduced permeability of horizon associated with textural changes. ❑ Boring # Boring Pit Ground Surface elev. ft. Depth to limiting factor in. F Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 F-1 Boring # - Boring _j Pit Ground Surface elev. ft. Depth to limiting factor in. Soil Application Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots P in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 * Effluent #1 = BOD 30 < 220 mg /L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg /L and TSS <30 mg /L The Department of Commerce is an equal opportunity service provider and employer. If you need assistance to access services or need material in an alternate format, please contact the department at 608 - 266 -3151 or TTY 608- 264 -8777. SBD -8330 (R.07 /00) A.C.E. Soil &Site Evaluations t EXi (�'nc� �iaa(e e %r� • La�e�✓ -fcz� ._� RW "z-zsz LGS � .5 �an �o.amSo� 0 ,Cod 72 �JEYpSE`S; .Sec, 3, 7 /9cJ, 7`.t . air 1K, S .ciaX 6o., uJ) pl. Ooyo- 12y2 -10 -COO heil.7 Z. acres EXisG'r� -1 ,6 , C(y�Xr leac4 (ec e. 5�3 "C/e F /ev` et s /per� a/;�.;a fsy3feM be�wee,, SepZ-'c 6- A-� rna ikdle `� w pa,c /'i'/.al�xu�sr., Pre cas E C'ar,e nc6e Se c �..K. �' EX /sfs' ✓ �" J �'(, �wesba'/1 /'recaSE �� c -l�.ri &�,-, . a E rBEI �Ea 6P l2 can,?efZ4ci' 6 .2 156 e/k. -Z el uz/ve. ci4 \ \ \ /b B• oU' �� .3 0{ 3 4 S . CROIX COUNTY ZONINNT�r ST G DEPARTME , R ECEIVED AS BUILT SANITARY REPORT i ....,,/ ,a JA At 1 6 1998 ST CROIX COUNTY ress ZONINGOFFICE d '` -� ty /State •� �° egal Description: T t �_ Block Subdivision/CSM # PIN # 'j, y Sec. 3 ' , T� N -R2 Town of 7 . a8 • I�. �a3 0 SEPTIC TANK -- DOSE CHAMBER -- HOLDING TANK INFORMATION: Size ST/PC d' / 4J Setback from: House Z0 Well �� P/- 1L Tank manufacturer LN I 4--/ - Model Pump manufacturer j, kel go Alarm location L4 (HOLDING TANKS ONLY) Water Line Setbacks: Service road Vent to fresh air intake Meter location Alarm location SOIL ABSORPTION SYSTEM: Trenches Number of Trenc °Yt his Type of system: T 11,4,/ Width Length n._ SGI �u l� L -- Setback from: House so =� Well ,t/ P/L Ze Vent to fresh air intake 4*7 ELEVATIONS: Elevation OCR, o Description of benchmark .SSo " -e- Elevation Description of alternate benchmark �� "' `�` S . c c a � � � e7 ° PC Inlet Building Sewer I DO • ST/HT Inlet - U • o S' ST Outlet PC Bottom __ geader/Manifold 01 • Top of ST/PC Manhole Cover D3 Distribution Lines( ) l D I • �7 () r' b(• ( ) Bottom of System () G 0 0 . 3 � �) ( ) Final Grade ( ) D Date of installation /2 / //`?. Permit number �q State p lan number Plumber's signature v `' '� =� License number Date Inspector Complete plot plan or L Department atioIndustry, PRIVATE SEWAGE SYSTEM Count �;I, CROIX "Labor and Human Relations INSPECTION REPORT , Safety and Buildings Division GENERAL INFORMATION (ATTACH TO PERMIT) Sanita orajyo.: Permit Holder's Name: ❑ Cit Village Town of: State Plan ID No.: ENSON, LESLIE Ti& CST BM Elev.: / Insp. BM Elev.: BM Descriptio S 8W5G tC «T'g Parcel d c � l g1 242-10-000 /�0 To o-F Surde ors er e. TANK INFORMATION ELEVATION DATA A9700408 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic \A/ P 12 00 Benchmark 9 t ai> Dosing P -b Aeration Bldg. Sewer .Z /00.9' Holding (P* Inlet 05' /00 -05 — TANK SETBACK INFORMATION St Outlet % -2D 1 7 , 7-c? TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet p Air Intake g•2� -/ 9. 9L Septic $ CX- AZ 7-1 ` NA Dt Bottom / / -FSd 9G- �_> Dosing g �� 35 r L'Q NA Header / Man. /0/-3g- Aeration NA Dist. Pipe - 70 / o/. C/ e> . Holding Bot. System T-77 ) 00,2,-S �•9 PUMP/ SIPHON INFORMATION 5 mar Final Grade 3.7� loe 3S Manufacturer J oA5Demand Al f. 9 M ►n a c 2•ly lOS9s' Model Number (; F04 �O GPM Sf /0 B' TDH I Lift 5 p 'd Friction p System` TDH6 Ft Forcemain Length L(0' Dia. If L Dist. To well �2 SOIL ABSORPTION SYSTEM E RENCH Width Length / No. Of Trenches PIT No. Of Pits Inside Dia. Li id Depth DIMENSIONS t I l DIMENSION SETBACK SYSTEM TO P/L BLDG WELL LAKE /STREAM HING nufacturer: INFORMATION Type Of t CH o e Num m Syste i �� n b OR UNIT DISTRIBUTION SYSTEM ST," t-tZ Header / Manifold r � Distribution Pipe(s) x Hole S e x Hole S pal ng Vent To Air Intake Length Dia. �, { Length �96K Dia. ALP Spacing �t =� 7S SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over x De xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edge opsoil s ❑ No E] Yes ❑ No COMMENTS (Include code discrepancies, persons present, etc.) LOCATION: TROY 3 .2 8.19 , NE , SE 500 TRILLION , LANE COUNTRY WOO LOT 72 L 0 ,�,� � i o ttt IOD.33 becau� G•'� o i ; l tonal %�,ryj s iA Aar;,I -w3 of Bo^'A , sec so;l {si c Plan revision required? ❑ Yes No 1 1 - 71 1 Use other side for additional infor ation. IZ ?j Or11 SBD -6710 (R 05/91) Date Inspector's SiciWature Cert No *i sconsin ITARY PERMIT APPLICATION 2 01 e E.W and ashn sion SAN In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 vi x 11 inches in size. S7 y a a • See reverse side for instructions for completing this application State Sanitary. Permit Number The information you provide may be used by other government agency programs heck if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INF RMATION Pro erty Owner Name Pfpperty Lo Cation /� , X/�114,s 1/4, S T 4 , N, R E (orl Property Owner's Mailing Address Lot Number- Block Number 10, 10 1 —,&.4/ - 7 City, State Zip Code Phone Number Subdivision Name or CSM Number II. TYPE F B ILDING: (check one) ❑ State Owned ❑ I Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms � Town OF Vo III. BUILDING USE (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo I is 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 S ❑ 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. R1 New 2 E] 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 29 9497 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 43 ❑ Vault Privy 14 ❑ System-In-Fi I I VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min. /inch) Elevation �i o j.SQ /S /a r Sr �c/� /Q ®� Feet /0`6 " Feet VII. TANK Capacity INFORMATION in gallons Total # of Manufacturer's Name Prefab. Con- steel Fiber- Plastic Exper. G New Exist in Gallons Tanks concrete strutted glass App. Tanks Tanks Septic Tank or Holding Tank X /.V 4 I jh , d A) - jr I w ®, ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber Fk7T 1 7,52 . 1 ❑ 1 ❑ 1 ❑ 1 ❑ 1 ❑ VIII'. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plumber's Signature: (No Stamps) ` MPRSW No.: Business Phone Number: fry Pl r V 1 Y Plumber's Ac dress (Street, City, State, Zip Code): IX. COUNTY/ DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No Stamps) n Approved []owner Fee) .Owner Given Initial �� Adverse Determination //{6 - X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R.11/96) DISTRIBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber 1 PAGI GF PUMP CHAMBER CROSS SEC T ICIld AND SPECIFICAT10k15 VEUT CAP `"C.I. VENT PIPE WEATHERPROOF APPROVED LOCKINUG - Z5' FROM DOOR, JUIJCTIOU BOX MAIJHOLE COVER WIUDOW OR FRESH I2 "MIU. AIR I►JTAKE I GRADE I I COAIDUIT � -- \ 111 INLET PROVIDE I = _T AIRTIGHT SEAL *� A I III � I I I I ALARM B I II I I o *APPROVED I oN JOINTS WITH I I CLEV FT. APPROVED PIPE I OFF 3' ONTO PUMP--- - -� D SOLID SOIL COAICRETE BLOCK ,� RISER EXIT PERMITTED OIJL'J IF TAWK MAULIFACTURE:R HAS SUCH APPROVAL SEPTIC f SPEGIFICATIOUS DOSE y� TAIJKS MAIJUFACTURER /� : jVt-y IJUMBER OF DOSES: PER DA- TANK SIZE : _ GALLOIJS DOSE VOLUME /-{� ALARM MAMUFACTLIKER: .4 'C 6 1 rwL INCLUDING BACKFLOW: A -7 GALLONS MODEL NUMBER: � -?Y 3 .5' w1a � CAPACITIES: A = IAICHE5 OR � GALLONS SWITCH TyPC: PY L° FA B 2 IIJCHES OR Ti S GALLOIIS i PUMP MAMUFACTURER: ld;s� 1Q,� _ C - IMCHES OR l� GALLO MODEL NUMBER: . o 4 `Y D= FICHES OR GALLO{JS j SWITCH TYPE: vL IJOTE: PUMP AMD ALARM ARE TO BE MINI DISCHARGE RATE GpM INSTALLED OW SEPARATE CIRCUITS VERTICAL DIFFEKE BETWEEW PUMP OFF ARID DISTRIBUTION PIPE.. FEET + MIIJIMUM NETWORK SUPPLY PRESSURE . • . • `" FEET i + 4 FEET OF FORCE MAIN X �'G F JpOfLFRICTIO&J FACTOR. - FEET TOTAL DYNAMIC. HEAD FEET IF, Ilew i IMTERMAL DIMEIJSIONZ OF TANK: LENGTH ----- .; W IDTH ;LIQUID DEPTH � slGI,lEn: Goulds 3871 EPO4 EP05 APPLICATIONS • Fasteners: 300 series • Fully submerged in high ■ Motor Housing: Cast iron stainless steel. grade turbine oil for for efficient heat transfer, Specifically designed for the .Capable of running lubrication and efficient strength, and durability. following uses: dry without damage to heat transfer. a Motor Cover: Thermoplas- • Effluent systems components. tic cover with integral handle Homes Available for automatic and and float switch attachment • Farms Motor: manual operation. Automatic points. • Heavy duty sump • EPO4 Single phase: 0.4 HP, models include Mechanical • transfer 115 or 230 V, 60 Hz, 1550 Float Switch assembled and ■ Power Cable: Severe duty Water t • Water ring RPM, built in overload with preset at the factory. rated oil and water resistant. automatic reset. ■ Bearings: Upper and lower S PECIFICATIONS • EP05 Single phase: 0.5 HP, FEATURES heavy duty ball bearing 115 V, 60 Hz, 1550 RPM, construction. Pump: EPO4 built in overload with ■ EPO4 Impeller: Thermo - automatic reset. plastic Semi -open design • Solids handling capability: p AGENCY LISTING 3 /4 ". maximum. • Power cord: 10 foot with pump out vanes for * .Capacities: up to 55 GPM. standard length, 16/3 SJTO mechanical seal protection. 05. Canadian standards Association p with three prong grounding . EP05 Impeder: Thermo- _ • Total heads: u to 24 feet. CSA listed model numbers • Discharge size: 1 NPT. plug. Optional 20 foot plastic enclosed design for "F length, l 6/3 SJTW with end in " or "AC ".) • Mechanical seal: carbon- improved performance. rotary/ceramic- stationary, three prong grounding plug ■Casing and Base: Rugged BUNA -N elastomers. ( standard on EP05). thermoplastic design provides • Temperature: superior strength and 104 °F (40 °C) continuous corrosion resistance. 140 °F (60 °C) intermittent. • Fasteners: 300 series METERS FEET stainless steel. 10 -- • Capable of running L - 4-5GPM, dry without damage to 9 30 -- components. - -- - - -- � { Pump: EP05 a 2.5 FT •Solids handling capability: 0 7 25 �� -- - - -- _ - - -- - - 3 /4' maximum. a W • Capacities: up to 60 GPM. s 20 - - -- - - - -- -- • Total heads: up to 31 feet. • Discharge size: 1 NPT. Z 5 15 •Mechanical seal: carbon - '' p r --- rotary/ceramic- stationary a 4 ! >_�,'',1 ; _ ___ - - - - -- - - -- EP05 - BUNA -N elastomers. o - - - -- - • Temperature: '' 3 10 ! --- - -- - - - -- 104 °F 40 °C continuous __ _.. EPO4 . _ _ _ -_ - -_ -- __ _. __ -140 OF (60 intermittent. 2 5 — — - -- -- I -- - — - - — - / ` 1 0 06 - - 10 2 30 40 50� GPM 0 2 4 8 8 10 12 m' /h CAPACITY Effective May, 1995 ©1995 Goulds Pumps, Inc. 83871 0 CO) 0 3 - 0 0 _1 O i :E C O A ;Y 0 ;u z u, z o G) w CD ::r �' O. O C N co = NO FBI CD O N C m (D to V O N R W O N N N CL O N r 7 0 0 0 (D N O U) Q O A N 3 N a o fD p p r+ 7 N! (T p 0 ° �+ (n D I D to a O o i W o O O O cn (a co CD co C co 3 0C 0 C 0 " �• C SS CSS SS J o vy CL 0 y CO) O N C ca 3 Ic v v O 7 N (D N O 3 d a N a rr A_ A p O 3 z W z G O N r i5 D N 0 a O O O _ (D M N O) m 7 O (D 0 y ju co N C (D (D Oro a m c6 to N A (D CL I Z -I w CD M m ^� w CL A z o M co � m co N (D A A I I a I O. O D1 C z O. CD z N O ��.. �C I A I N p o N � V p f N CD ° O. ►� ` �. SANITARY PERMIT APPLICATION Safet eE w sBnilgt onAve Sion i seonsin I n accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Department of Commerce Madison, WI 53707 -7969 • 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. -5 o • See reverse side for instructions for completing this application State sanitary Permit Number dgg0q The information you provide may be used by other government agency programs ❑ Check it revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION Property Owner Name Property Location -eS �� �Di v4 L c - 1 /4, S T „ Z , N, R /�/ E (or)AC Property Owner's Mailing Address Lot Number Block Number do Zif u h2 4 g. City, State Zip Code Phone Number Subdivision Name or CSM Number 11. TYPE OF BUILDING: (check one) ❑ State Owned 't� Nearest Road Public a 1 or 2 Family Dwelling - No. of bedrooms Town OF 7 7" III BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) yam /d 1 ❑ Apartment/ Condo _ 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 E] Outdoor Recreational Facility 3 E] Campground 7 E] Merchandise: Sales/ Repairs / 11 C] Restaurant/ Bar/ Dining 4 11 Church / School 8 ❑ Mobile Home Park 12 El Service Station / Car Wash 5 E] Hotel /Motel 9 E] Office/Factory ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box o line A. Check box on Ii B, if applicable) A) 1. Z New 2 E] Replacement 3 Replacement of 4_ ❑ Reconnection of 5 F] Repair of an - _____System -------- ------ ______ ank9nly___ __________ Existing System ________ ExlstingSystem B) E] A Sanitary Permit was previously issued. Per ' Numb _ Date Issued V. TYPE OF SYSTEM: (Check only one) Non - Pressurized Distribution Pressurized Dis /Prsure SEx ter K 11 Seepage Bed 21 [] Mound ❑ Specify Typ 41 ❑Holding Tank 1 Trench 22 E] In-Ground 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Abs or . Area 4_ Loading Rate 5. Perc: Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Propos (sq. ft.) (Gals/day /sq_ ft.) (Min. /inch) Elevation as G0 Capacity S QLI , cj� Feet /6zy', / Feet VII. TANK in allo s T tal LTank r Prefab. Site Fiber- Exper. INFORMATION Ilons Manufacturers Name concrete Con- Steel glass Plastic App New Existing strutted - Tanks Tanks Septic Tank or Holding Tank f ;, e 7� ✓� ❑ ❑ ❑ ❑ ❑ 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. 7 Plumber's Name: (Print) Plumber's Signature: (No Stamps) PRSW NO.: Business Phone Number: ,Sc Business Plumber's Ar dress (Street, City, State, Zip Code): 4 7 e c 41� IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate Issued Issuing Agent Signature (No Stamps) 1# Approved ❑ Owner Given Initial Surcharge Fee) Adverse Determination �" X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD-8398 (R 11/96) DISTRIBUTION: Original to county. One copy To: Safety & Buildings Division, Owner, Plumber 5 V 0 16 z2 C elf s s ec a a sxl6 rL-- 8TC- 100 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, (spec house), then.a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. --------------------------------------------- Owner of property L e S �i D. �d S/� a �^a✓L / x'15 o t/\ Location of property 1/4, Section _ , T R _1�___ w Township Do Mailing address _ P,'o i (, u �, 4, a .A) Address Of site J 00 Tr r he uq�5 o N GJ r �y�l subdivision name �f oon4vy CJoad Z id a��f(ov\ Lot no -- . Other `homes on property? - Yes P�', Previous owner of property Total size of property Total size of parcel Date parcel was created Are all corners and lot lines identifiable? — —Yes No Is this property being developed for (spec house) ? Yes -,::�_'No Volume iaS Y and Page Number ((,Z as recorded with the Register of Deeds. ----------------------------------- _ ---------------------------- --- INCLUDS.WITH THIS APPLICATION TSB FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMBER, VOLUME AND PAGE NUMBER AND THE SEAL OF THE REGISTER�OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) an (are) the owner(s) of the property described in this information form, by virtue of a warranty deed recorded in the office of the County Register of Deeds as Document No. `Vb 3 and that I (we) presently own the proposed site for the sewage disposal system or I (we) obtained'an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deeds as Document No. Signature of Applicant Co- Applicant (?12 g12g�-t� ADDENDUM TO THE S IURCIIASF AGREEMENT DATED 7 , 19 Q 7 IIFTWFEN RICHARD O. STOUT, SELLE I< AND BUYERS, FOR LOT # 7A OF COUNTRY WOOD, COUNTRY WOOD I s . ADDITION OR COiJN T RY WOOD 2 ADDITION, 1. Buyers acknowledge that preliminary lot # M is final plat lot # 7a•. ✓2, E3uyers acknowledge receipt of recorded subdivision covenants. ✓3. Buyers are aware that driveway locations are noted on their copy of the recorded plat of their lot 11 7K ✓4. Buyers acknowledge that they have received a copy of the final plat of lot 11� V/.5. Buyers are aware that a outbuilding is o n Ilowed on their lot Il_. G. Buyers are aware that no permanent structures are allowed in ponding or water flow easements as noted on their final plat copy. 7. Buyers are aware that setback requirements are designated on the final plat. IC 0'02"7_/ —X 8. Buyers acknowledge that lot 117.Z has an above grade or below grade soil tes louse location on�' (lie lot may necessitate another soil test which may or may not be the same as that of the soil test for the final plat approval. Any cost associated with a new soil test is the responsibility ofthe buyers. Aj s). Buyers acknowledge that their lot ii has acres. T�uyJ of SIGNED DA'T'E Buyer - - - - J.J S1GNIiD __ HATE Buyer - - -- ---- - - - -_ - - -�._. SIGNFI) j �� @ _ DATE 4_0 7 Seller SIGNED _DATE Seller 1 • - 09 3 STATE BAR OF WISCONSIN Ft*p+� 1 — 1982 `t WARRANTY DEED DOCUMENT NO VOL 1 5 PApf 4 4 This Deed made between Richard O. St FA R'S OFFICE IX CO,. WI fw Recom and Leslie G tensor. and Sharon A Genso n :Grantor , 19 1997 hu band _ mod wife 9:55 A M — irantee, Witnesseth That the said Grantor, for a valuable tw of goods conveys to Grantee the following described real estate in St . Croix County, State of wtsconsin: �N w THIS SPACE RESERVED FOR RECPROG ;4 NA AND RET -IRN ADDRESS _ - Lot 72, Plat of Country Wood Second L Addition, Town of Troy, Wisconsin. St. Croy x County, This lot is included in protective covenants and there are no outbuildings allowed on this lot, PARCEL IDENTIFICATION NUMBER This _ is no t homestead property. (is) (is not) Together with all and singular the hereditaments and apnurtenusces thereunto belonging; And R i c hAX-d-_Q.,._ warrants that the title is good, indefeasible in fee simple and free and dear of encumbrances except easements, restrictions, rights — of — way and covenants of record, if any, and will warrant and defend the same. Dated this day of _ A gust (SEAL) • Richard o. Stout [SEAL) -- -- - - -- — (SEAL) _ ' (SEAL) Ii F"isconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page 1 of 3 Labor and Human Relations Division of Safety & Buildings in accord with ILHR 83.05 r Adft� Qd0e COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in s ;f� Ie St. Croix �q / PARCEL I.D. # not limited to vertical and horizontal reference point (BM), direction a f�lc�le or f' dimensioned, north arrow, and location and distance to nearest road pending EVIEWEDBY DATE APPLICANT INFORMATION- PLEASE PRINT ALL INFORM 1� a. ' PROPERTY OWNER: PF I ATION Richard. Stout ii GOVT 1/4��' °/4,S3 T 28 N,R 19 for) W PROPERTY OWNERS MAILING ADDRESS ;� LQT # BLOCK # , Sr�BD. NAME OR CS M # 1353 Awatukee Trl. to �Coiatztr Wood Second Addn. CITY, STATE ZIP CODE PHONE NUMBER 1Y °_[]VILI ASE"' MOWN NEAREST ROAD Hudson, WI. 54016 (715) 549 -6731 r " Troy , Tower Rd. [ New Construction Use Residential / Number of bedrooms 3 [ ] Addition to existing building j ] Replacement [ ] Public or commercial describe Code derived daily flow 450 gpd Recommended design loading rate • 4 bed, gpd/ft - 5 trench, gpd1ft Absorption area required 1125 bed, ft2 900 trench, ft Maximum design loading rate • 4 bed, gpd /ft - 5 trench, gpd/ft Recommended infiltration surface elevation(s) 100.90 ft (as referred to site plan benchmark) Additional design/ site considerations alt. area system el. - 100.25' Parent material pitted alacial drift Flood plain elevation, if applicable na ft L SE Suitable for system CONVENTIONAL MOUND IN- GROUND PRESSURE AT -GRADE SYSTEM IN FILL HOLDING TANK Unsuitable fors stem CAS ❑ U IB S ❑ U ] S ❑ U D S ❑ U ❑ S ®U [IS O U SOIL DESCRIPTION REPORT Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft Boring # Horizon in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed JTW& < ... 'l .. - `` 1 0 -12 10 r3 3 none sil 2c 1 mfr aw if I no 1.2 2 12 -24 10 r4/4 none sicl lfsbk mfr w if .2 .3 Ground 3 24 -40 7.5 r4/4 none scl lcsbk mfr c if .2 .3 elev. 104 ft. 4 40 -82 7.5yr4/6 none scl 2csbk mvfr na na .4 .5 Depth to limiting factor +82 Remarks: Boring # 1 1 0-11 10 r3 3 none sil 2c 1 mfr cs 2f .5 .6 2 2 11 -30 10 r4/4 none sicl lfsbk mfr cly if .2 .3 3 30 -84 7.5yr4/6 none sl 2csbk mvfr na na .5 i.6 Ground elev. 104 ft. FT Depth to limiting factor +84" Remarks: CST Name: Print Phone: Gary L. Steel 715- 246 -62 A ddress: 1554 20OL123 Ave., New Richmond, WI. 54017 m02298 Signature: Date: 8 -6 -96 CST Number: PROPERTY OWNER Richard Stout SOIL DESCRIPTION REPORT Page 2 of PARCEL I.D.`# ' pending Lot #85 - Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Cont Color Gr. Sz. Sh. Bed ITmnch Li 1 0 -11 1 0zr3/3 none si 1 2epi mfr CS 2f no .2 2 11 -36 10yr4 /4 none sicl 2msbk mfr gw if .2 .3 Ground 3 36 -82 7.5yr4/6 none scl 2csbk mvfr na na .4 .5 elev. . 04.0 ft. Depth to limiting factor Remarks: Boring # 1 0 -10 10 r3 3 none sil 2msbk mfr w 2f .5 .6 4 '# 2 10 -32 10yr4 /4 none sicl 2msbk mfr gw if ,4 .5 3 32 -76 7.5 r4/4 none scl 2csbk mvfr na na .4 '.5 Ground elev. 13 ft, Depth to limiting factor + 76" Remarks: Boring # 1 0 -15 10 r3 3 none sil 2c P1 mfr L4W 2f n .2 5 =' 2 15 -34 10 r4/4 none sicl lfsbk mfr gw if .2 .3 3 34 -76 7.5yr4/4 none scl 2csbk mvfr gw na .4 `:..5 Ground elev. 4 76 -84 2.5y5/6 none cl m na na na np n 0 2.8 ft. Depth to limiting factor 76" Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(R.05/92) STEEL'S SOIL SERVICE Gary L. Steel Richard Stout 1554 200th Ave. CSTM2298 NE4SE4 S3- T28N -R19W New Richmond, WI 54017 MPRSW 3254 town of Troy (715) 246 -6200 lot #85- County Wood Second addn. N 1 " =40' BM.= top ofSE lot stake C el. 100' A 15 3t% O 30` ek 44`` Gary L. Steel 8 -6 -96 STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERJBUYER _. L eS /,, - e Gtv+ �� a ro n MAILING ADDRESS 67 D o PROPERTY ADDRESS ( 5 h o _ v e_ (location of septic system) Please ob tain from the Planning Dept. CiTY1STATE PROPERTY L(?CATION � 1/4, 5' t 114, Section .3� , T N -R f ,� W TOWN OF ST. CROIX COUNTY, WI SUBDIVISION d& �7�r , LOT NUMBER CERTIFIEDSURVEY MAP VOLUME , PAGE , LOT NUMBER 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 licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978. St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 113 full of sludge and scum. UWe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with the standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and returned to the St. Croix County Zoning Officer within 30 days of the three year expiration date. SIGNED: - DATE: Z 411-f St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 1l/93