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Home My WebLink About002-1074-80-000Wisconsin.Department of Commerce Safety and Building Division PRIVATE SEWAGE SYSTEM INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. Permit Holder's Name: City Village X Township Holle, Frederick Baldwin, Town of CST BM Elev: Insp. BM Elev: BM Description: ov (3 -n~ ~ LS-t- TANK INFORMATION TYPE MANUFACTURER . ,r'S i CAPACITY Septic .lw 3 j F'- f DOb Dosing ~~4 ~ ~,,,,~ s,s~ ~~ F. - n F'd 1 b ~, sZ 5 Holding TANK SETBACK INFORMATION TANK TO / ~P~L Gd.Y` WELL BLDG. Vent to Air Intake ROAD Septic ~~ 7 ~~ ~ / ~~~ Dosing ~5 ~ > /~ I l~ ~ ~l~ , -..- Aeration Holding ``" PUMP/SIPHON INFORMATION , ~ Manufacturer ~ ('. Demand D v d1 GPM Model Number ~.~~~ 3~ ~ / TDH LifJ,,, ~ ~~ Friction Lo System [iea~ TDH t t I ~ /l ,0 r ~ (/ V Forcemain length ~ Dia. ~ , Dist. to well 7 ~~ / 2 SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: 515004 0 State Plan ID No: Parcel Tax No: 002-1074-80-000 Section(TownlRangelMap No: 29.29.16.4430 STATION BS HI FS ELEV. Benchmark 3. ~ f U3 • ,~~ Alt BM ~ Loy ~., Z •7`~ / ~ . 9/ Bldg. Sew r ', ~ q`, Z. SUHt Inlet 5.Z$ 91f ~ ~ SUHt Outlet ` Dt Inlet Dt Bottom ~z.g5 70 .~ Header/Man. /eb ~ / Dist. Pipe ~.~~ ~~.~ Boty 15 m ~"~ ~ ~ , ~ ' S Final Grade St C~i(er Y GG.xc.t~ Z .7 / /~ BEDITRENCH DIMENSIONS Width / Q V Length i ~~ ~ ~ No. Of Trenc s ~~ PIT DIMENSIONS ~` No. Of Pits ~- Inside Dia. ~~-- Liquid Depth ~ SETBACK RMATION SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING ER OR CHA Manufacturer: _\ INFO Type f System: a .,i ~. 7 30 ,Z3 ` / / /d~ N ~ MIN Model Number: ~ DISTRIBUTION SYSTEM F.~'!'-` Header/Manifo~~ I 11 5 Length_~ Dia Distribution / .3 ~ ~ f Fipe(s) ~ 3Z Length ~ Dia /~ Spacing x Hole Siz d ~ / I D x Hole Spacing ~~ ~~ Ve(i~to Air Intak~~ `r) SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Bed/Trench Center ~ ~p~ Depth Over Bed/Trench Edges xx Depth of Topsoil j ~ xx 5eeded/Sodded xx Mulched ~ , ~ l , ,.-~ ;Yes [] No 1`es Q No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~6 / Zy/ ~Y Inspection #2: / /_ Location: 2272 Hwy 12 q~ldwin, WI 54 02 (SW 1/4 SE 1/4 29 T29N R16W) metes & bounds Lot ~'~iti}~~~P cel NQ:~29.29.16.~3C J ~ ~ pJ.~„~, Q ~ cli, S y ~'C.~. ¢. ba, r.~M.G ~ (L-) O t/ L11fC. 1.) Alt BM Description = `1 2.) Bldg sewer length = s!~ / - amount of cover = ~ / Cam ow -~,_ _, Plan revision Required? [] Yes No ,~ n ~ I~~ ~ Use other side for additional information. ~ I L__~ _ __._ _ _ _ --__ SBD-6710 (R.3/97) Date Insepctor' Signatur 1 !- z ~ 6 <3 5 -~ ;- Cert. No. / commerce.wi.gov Safety and Build' Division County ~ 201 W. Washington ., P.O. Box 7162 St. Croix ' ~~~ ns' ~ Madison, 53 162 Sanitary Permit Number (to be filled in by Co.) Department of Commerce 5 ~5~ Sanitary Permit Application action Number 159242$ In accordance with s. Comm. 83.21(2), Wis. Adm. Code, submission of this form to appropriate governmental unit is required prior to obtaining a sanitary permit. Note: Application forms for to-owned project Address (if different than mailing address) POWTS are submitted to the Department of Commerce. Personal inform ' secondary purposes in accordance with the Privacy Law, s. 15.04(1)(m), Sta ~ ~/y. Z ~7Z ~(.~' ~ Z I. A lication Informat' -Plea se Print All Information -r/ V Property Owner's Name ! UCI ~ 6 2008 Parcel N 002-1074-80-000 Frederick Holle Property Owner's Mailing Address Property Location ~/ ~ 2272 Hwy 12 ST. CROIX COUNTY ~ 7 (~ ZONING OFFICE Govt. Lot City, State Zip Code Phone Number SW ~/o,SE ~/a, eStion 2,9 Baldwin, WI 54002 715-684-2608 (circle one) W II. Type of Building (check all that apply) Lot ~ T 29 N; R 16 ®1 or 2 Famil Dwellin - Number of Bedroo s 3 Subdivision Name y g N/A N/A 1 ~p~ ^ ~""' Block 1/ Public/Commercial - Describe Use I ^ city of N/A ^ State Owned - Describese ~ CSM Number ^ Village of ~ s ~ Z5 Ov~ N/A ®Town oaf Baldwin III. Type of Permit: (Check only one box on Gne A. Complete li ne B if applicable) A' ^ New System ®Replacement ^ Treatment/Holding Tank Replacement Only ^ Other Modification to Existing System (explain) System ~' .~.--~ B. ^ Permit ^ Permit Revision ^ Change of ^ Permit Transfer to List Previous Permit Number and Date Issued Renewal Before Plumber New Owner Ex iration // IV. T e of POWTS S stem/Com onent/Device: (Check all that a 1) ~ ^ Non-Pressurized In-Ground ^ Pressurized In-Ground ^ At-Grade ^ Mound > 24 in. of suitable soil ®Mound < 24 in. of suitable soil ^ Holding Tank ^ Other Dispersal Component (explain) ^ Pretreatment Device (explain) V. Dis ersal/Treatment Area Information: J Design Fly' (gpd) Design Soil Ap ation Rate(gpdst) Dispersal Area Required (sf) Dispersal Area roposed (st) System Elevation 450 / 1.00 450 450 99.50 ./ VI. Tank Info Capacity in Total i/ of Manufacturer H z Q Gallons Gallons Units ///~~~ ~- ro ~ o ~ ~ ~ New Tanks Existing Tanks ~ ~~ L,'~ ~'" ,~Z H a w ~ a ~ ~ septic or Holding Tank 1000 1000 1 ieser C ncrete ® ^ ^ ^ ^ Dosing Chamber 600 600 1 Wieser Concrete ® ^ ^ ^ ^ VII. Responsibility Statement- I, the undersigned, assume responsibility for installation of he POWTS shown on the attached plans. Plumber's Name (Print) Plumber's Signa P/MPRS Number Business Phone Number Bennie Hel eson 220292 715-772-3278 Plumber's Address (Street, City, State, Zip Code) W1229 770th Avenue, S rin Valle , WI 54767 VI .Count /De artment Use Onl Approved isapprove Permit Fee Date I ued Issuing ent Signa e _ ven Reason fo Denial $ Q~ ~ ~ Dom[ IX. Condi~rpg~~Rl/Reasons for Disapproval // n ~ 5~... ~ ~~~~ ~~ (' ~ ~ ~ a ~ C. ~~ 3' fi L.6~,CIGt 0 1. Septic tank, effluent fitter and ' dispersal cell must alt be service;/ maintained ~~,~, ~~ ~ r~,~, ~ ~- ~ as per management plan provided by plumber. 2. All setback requirements must be maintained as per appNcaWe code / oMinances. ~ ~ (~ Attach to complete plans for the system and submit to the Count ly on paper not ss than S 1~1 in sin size / s~ ~~. ,, ~ ~'r SBD-6398 (R. 01/07) Valid thru 01/09 ~~~ ~-- ~ uaet~ S~" c'RDiX Cary sc.~-~ S ~-~ Se4 ~ 9 `fi.~9.;U R 1~w ~~ 1.~ f',= y ~ ~, ,;.., Ex~s~K 9 3'R~~ Na~er Glean o~-_ pro F047/boa 6-~t, --- SQPf~~`lbse ran~C. w ~~-~ ~Pb1y ! o k s..zs- ~~ 1 f-~er GQ~ (~~ M< < o~+, ~' ~fi-o,k. o ~ 1-I~s-Q S~`dt ~a5 EX~sfih9 ~s.-r,~ ~- ~) ate. c~. F (lam B~ D ~ L~ `~ c~ Q ~ .a ~~• ! Qo-~ ~ ( 2'.U tb'' l~ia , ,4Si~ Ta-e.~ a ~6 S/o~,o ~ ~ d3 i ~~ ~' ~ . V j i~ _~n. 1 \~~ ~-- C~ J/ ~ ~oUeh Fl~u~ ~~ ~C®P .,,._ _ . K5"~~'~ 5 ~--- ~+ ~ 1 f ~u~,u a ~ 8~ ~b~~ 1J 3 ~`~ ~ No~•-.~ Sw-~ S F-~ Se4 ~ 9 `r~9.~1 R t'b c.v -~--~~-~----- ~.!-~ l'' t... ~~~~~ ~roPoSe~ ~,~, t'ocX~/ GoQ 6-~ 1, -----~- ~QP t"~ ~ / ~s~. 7cth ~c. ~~D w ~~~ ~6[y l o (~ s-zs- F~ 1 f-e~ (~, M~ l b~+. ~ r3o+1-a,.~ o ~ Fl~.s-~ S~ ~ ~aS Ex~SfiN9 ~s.r~ ~- ~) Yo b4- ~~ a~. c!L F~ I t~ ~ ~. T ~ .~ S/o~o~ / r q~ i s flyai ~ ~•U lb`~ IJio. ~- ~ ~QSIt TI-e-~ '`_ ~- 5 C~, 9l u - y ar~ ~~UL° {"' ~[~ll~ commerce.wi.gov ^ isconsin Department of Commerce Safety and Buildings 3824 N CREEKSIDE LA HOLMEN WI 54636 TDD #: (608) 264-8777 www.commerce.wi. gov/sb/ www.wisconsin.gov Jim Doyle, Governor Jack L. Fischer, A.I.A., Secretary September 25, 2008 CUST ID No. 220292 BENNIE W HELGESON HELGESON EXCAVATING W1229 770TH AVE SPRING VALLEY WI 54767 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 09/25/2010 SITE: Frederick Holle 2272 U.S. Hwy 12 Town of Baldwin St Croix County SWll4, SE1/4, 529, T29N, R16W ATTN.• POWTS Inspector ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 Identification Numbers Transaction lD No. 1592428 Site ID No. 742742 Please refer to both identification numbers, above, in all corres ondence with the a enc . FOR: Description: 1Vlound /Three Bedroom /Sloping Site Object Type: POWTS Component Manual Regulated Object ID No.: 1201709 Maintenance required; Replacement system; 450 GPD Flow rate; 18 in Soil minimum depth to limiting factor from original grade; System: Mound Component Manual, SBD-10572-P (R.6/99), Pressure Distribution Component Manual, SBD-10573-P (R.6/99); Biofilter The submittal described above has been reviewed for conformance with applicable Wisconsin Administrative Codes and Wisconsin Statutes. The submittal has been CONDITIONALLY APPROVED. The owner, as defined in chapter 101.01(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.145.06, stats. The following conditions shall be met during construction or installation and prior to occupancy or use: Reminders • This system is to be constructed and located in accordance with the enclosed approved plans and with the component manuals listed above. • The existing POWTS must be properly abandoned per Comm 83.33 Wisc.Adm. Code. • Per manual cited above, limited activities are allowed in the area 15 feet down slope of the component area. Soil compaction, excavation, vehicular traffic and other similar activities that impact the treatment and dispersal (.'Ol'd ~1~~' are prohibited. • The well must be a minimum of 25 feet from any POWTS tank, and a minimum of 50 feet from the absorption ~ area. chs. NR 811 & 812c ~ ~ E • A Sanitary Permit must be obtained from the county where this project is located in accordance with the SEE CORRE requirements of Sec. 145.135 and 145.19, Wis. Stats. BENNIE W HELGESON Page 2 9/25/2008 • Inspection of the POWTS installation is required. Arrangements for inspection shall bemade with the designated county official in accordance with the provisions ofSec. 145.20(2)(d), Wis. Stat • Comm 83.22(7) A copy of the approved plans, specifications and this letter shall be on-site during construction and open to inspection by authorized representatives of the Department, which may include local inspectors. Owner Responsibilities: • Comm 83.52 Responsibilities. The owner of a POWTS shall be responsible for ensuring that the operation and maintenance of the POWTS occurs in accordance with this chapter and the approved management plan under s. Comm 83.54(1). • Comm 83.52(2) A POWTS that is not maintained in accordance with the approved management plan or as required under s. Comm 83.54(4) shall be considered a human health hazard. • Comm 83.55 The owner is responsible for submitting a maintenance verification report acceptable to the county for maintenance tracking purposes. Reports shall be submitted at intervals appropriate for the component(s) utilized in the POWTS. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. In granting this approval the Division of Safety & Buildings reserves the right to require changes or additions should conditions arise making them necessary for code compliance. As per state stats 101.12(2), nothing in this review shall relieve the designer of the responsibility for designing a safe building, structure, or component. Inquiries concerning this correspondence may be nude to me at the telephone number listed below, or at the address on this letterhead. The above left addressee shall provide a copy of this letter to the owner and any others who are responsible for the installation, operation or maintenance of the POWTS. Sincerely, ~~~~~~ ~ Charles L Bratz POWTS Reviewer II ,Integrated Services (608)789-7893 , 7:45 am - 4:30 pm Monday -Friday charles.bratz@wisconsin. gov Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 WiSMART code: 7633 cc: Leroy G Jansky, POWTS Wastewater Specialist, (715) 726-2544 ,Friday, 7:00 A.M. To 3:30 P.M. INDEX SHEET PROPERTY OWNER: FREDERICK HOLLE 2272 HWY 12 BALDWIN, WI 54002 PROJECT NAME: FREDERICK HOLLE PROJECT LOCATION: SW 1/4, SE 1/4, S 29 T 29 N, R 16 W MUNICIPALITY: TOWNSHIP OF BALDWIN COUNTY: ST. CROIX DESIGN: PRESSURE DISTRIBUTION MANUAL SBD-10573-P(R/99) MOUND COMPONENT MANUAL SBD-10572-P (R 6/99) CONTENTS: Page 1: Page 2: Page 3: RECEIVED Page 4: SAP ~ 2 LQ~$ ++ Page 5: ~~1.~IF.~~ ~: ~~.1l~.QING~7 Page 6: Page 7: Page 8: Plot Plan Cross Section and Plan View of Mound Perforated Pipe Detail Septic Tank & Pump Chamber Cross Section and Specifications WLP 1000/600- NIR ZABLE Tank Specifications Pump Specifications POWTS Owner's Manual & Management Plan - Pg. 1 POWTS Owner's Manual & Management Plan - Pg. 2 Name: Bennie Helgeson Address: W 1229 770th Avenue Spring Valley, WI 54767 Credential Number: 220292 `/ Signed Date: September 17, 2008 ';,~, P t~t~ly ~~ )F COMMFRC~ ~~ DNNGS .~PONDENr/ Signed: Pa e ~T istribution Pipe •~.,. , i~ /. 3 ~ t, A , ~i'9', ~` Con License Number: Cross Section Of A Mound ~r-c~ ~a~~ `~ Date: --- l_ --_- Synthetic Covering Medium Sand -~.. Topsoil ~-~ s a % Slope C: Et-.~LO f 2y- 2 i Aggregate - U Plowed Layer p ~ Ft. E /.fib Ft. F , S~ Ft. ~ ,S'OFt. q ~ Ft: H _ 1.D Ft. e 5~..?s"F t . K ~ Ft. L ~Ft. ~ ~q Ft. I ~ Ft. W ~ Ft. Observation Pipe ~K ~ -------------------------------_ o -- i --- -----------~-•--•------~ g -- -T------_--- --------_®:J Distribution ~~~'~' Of i - 2'2 Pipe Aggregate Observation Pipe [3a5~~ ~}r~o..~ 9Sy.3`1 Force Main From Pump Plan View Of Mound Cleanout Access Perforated Pipe Detail Manifold r ~ ~~ End VCcw Perlorol<e PVG Pipt PO Holes Located on Bottom \ Are Equally Spaced Force Main From Pump First Hole Next to Manifold Signed: License Number: Date: P 5y° /'_ [ / ~l R ~o 'f S ~~ '~ X ~7 ~ ~ Y ~r Hole Diameter ~ .Inch Lateral " ~ Inch (es) Manifold " _~ Inches Force Main " c~ Inches Invert Elevation /60, CJ Holes Per Lateral ~ ~ Number of Laterals 3 Total Holes 7 . Cis n ~y ; ~ir' _rlrc+ r ~ ck (1 D 61 cL Pd~e~Of SEPTIC TANK.E PUMP:CHAM6ER CROSS SECTION AND SPECIFICATION$ 4 " RUC. V ENT PIPE 12" MIN . ABOVE GRADE E W£ATNERPROOF > 25' FROM DOOR, WINDOW OR' JUNCTION BOX APAREJVED FRESH AIR INTAKE----- WITH CONDUIT MANHOLE COVER W / PADLOCK 8 ~~J• ~ WARNING LABEL R Q'; , ~,.,_,~..._ v " MIN . Zy" 18" IN. ~ s.a. ~ u , INLET ~ ~~ WATER TIGHT SEALS T GAS- , '~ TIGHT ~ ~IA PROVLfl FILTER ---~a- A SEAL ~ P JO:IN~$ ~IITM APPROVEO po.]~./[o`l~ .-k-- , ; ALM APPROVED PAP; PIPE 3' ~/~~~_ • • -.~.- ~ ~ ~ ON 3' ON'1'0 SOLID S4tl ONTO SOLID- - ~ ~ SOIL PUMP OFF ELEV . ,(~~FT. --~-- ~ OFF • D 1. 3" APPROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE TANK MANUFACTURER : <<~ 1 eSC-y- f ,3 7 X S. = S / gs Gc~ ~ . TANK SIZES: SEPTIC~^ GAL. DOSE VOLUME INCLUDING • DOSE ~'~ GAL. ~ ~,`] (~I•-~FLOWBACK: `~7,~ GAL. ALARM MANUFACTURER: ~,T, EIe~~~~ CAPACITIES: A = /~ INCHES = ~~ GAL.. •MODEL NUMBER : (o { (-i• L~ t SWITCH TYPE: ~ .a~~~, r~~ 'Flp~,~{- ~ B = 2 INCHES = 3_~. ~ GAL• PUMP MANUFACTURER; ®~ S ~~j C = ~} INCHES = JC>O~ G~ GAL. MODEL .NUMBER : 3g 71 E O SWITCH TYPE:. ~t .Prc ~lo~.'~ D = I C'~ INCHES = ~~7. b GAL• R>gUIRED DISCHARGE RATE 3C4 7,~ GPM PUMP E ALARM WIRING AS PER ILNR 16.23;':WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE ~ ~ FEET + MINIMUM NET~JORK SUPPLY PRESSURE ~ FEET + ~$'~ FEET FORCEMAIN X.~O'~ FT/100 FT. FRxCTION FACTOR . `~~ FEET ~U TOTAL DYNAMIC HEAD = ern. a3 FEET INTERNAL DIMENSIONS OF PUMP TANK: LENGTH WIDTH DIAMETER LIQUID b~~- ~~ SIGNED: LICENSE NUMBER: DATE: 1/88 5oP TOP VfE1fV SCALE: 1 /4° = 1' `t VGIV i J ~ - in OUTLET INLET ~ ~ N M ~ 3" M ~Ir~~- v~r-~~r JI,HLt: 1 / 4 = 1 WLP1 a40~600=MR ZABk.E :TANK SPECIFICAl1ONS DIMENSIONS: WALL: 3" BOTTOM: 3" COVER: 5" MANHOLE: 24" hD, HEIGHT: 56" O.D. LENGTH: 150' O.D. WIDTH.: 84" O.D. BELOW INLET: 42° O.D. LIQUID LEVEL; 36" WEIGHT: 14,795 LBS. INLET AND OUTLET: 4° BORE WITH STOP FOR QUIK-TITE, FERNCO GASKET, CAST-A-SEAL BOOT OR EQUAL INLET AND OUTLET BAFFLES: WISCONSIN, SEE DETAIL #10 (OTHER STATES SEE CHART) L10UID CAPACITY: 27.88 GAL/IN (SEPTIC) 16.76 GAL/IN (PUMP) LOADING DESIGN: T 0" UNSATURATED SOIL ~C~~C~Q ~o~~~~~~ W3716 US HWY 10, MAIDEN ROCK, Wt 54750 800-325-8456 MODEL WLP1000/600-MR ZABLE SEPTIC/SEPTIC, SEPTIC/PUMP OR SEPTIC/SIPHON JANUARY, 2000 FILE: WLP10D0 600-MR ------ °/~o and'/= HP - ~~-w~vv M~• vV~~V~~{V •EP04 impeller- semi-open design Up to 60 GPM with pump out vanes to protect Maximum head to 32' mechanical seal. Discharge size 1'/=" NPT • EP05 impeller -enclosed design Solids:'/<" maximum for improved performance. Motor • Rugged glass-filled thermoplastic All motors feature ball casing and base design provides bearing construction. superior strength and corrosion Single phase: 115V resistance. Materials of Construction 'Cast iron motor housing for Cast iron efficient heat transfer, strength, Thermoplastic and durability. Stainless steel •Corrosion resistant threaded stainless steel shaft. •Available for automatic and manual operation. • CSA listed models available. operation and feature stainless steel hardware. • POWTS OWNER'S MANUAL & MANAGEMENT PLAN . a FILE INFORMATION SYSTEM SPECIFICATIONS Owner FREDERICK HO • ~ , Permit # DESIGN PARAMETERS Number of Bedrooms 3 ^ NA Number of Public Facility Units NA Estimated flow (average) 300 al/day Design flow (peak), (Estimated x 1.5- 450 al/day Soil Application Rate 0~( al/day/ftZ Standard Influent/Effluent Quality Monthly average• Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BOD51 5220 mg/L C~NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BOD5) 530 mg/L Total Suspended Solids (TSS) <_30 mg/L ~ NA Fecal Coliform (geometric mean) 510' cfu/100m1 Maximum Effluent Particle Size Ye in dia. ^ NA Other: ^ NA "values typical for domestic wastewater and septic tank effluent. ~AAINTFNANr`F !.r`HFf)111 F Page 7 of 8 Septic Tank Capacity al ^ NA Septic Tank Manufacturer WIESER CONCRETE 0' NA Effluent Filter Manufacturer pOLYLOK ^ NA Effluent Filter Model pL~S~~~.,. ~ NA Pump Tank Capacity 60U a~ ~' NA Pump Tank Manufacturer ^ NA Pump Manufacturer GOULDS ^ NA Pump Model 3871 Ep04 I~ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: C~ NA " Dispersal Cell(s) ^ NA ^ In-Ground (gravity) ^ In-Ground Ipressurizedl ^ At-Grade ~ Mound ^ Drip-Line ^ Other: Other: ^ NA Other: ^ NA Other. ^ NA Service Event Service Frequency Inspect condition of tank(s) At feast once every: 2 ^ month(s) (Maximum 3 ears! [~ earls) y ^ NA Pump out contents of tank(s) When combined sludge and scum equals one-third IY31 of tank volume ^ NA Ins ect dispersal cell(s) p At least once ever y~ 2 ^ month(s) (Maximum 3 ears) [~ year(s) y ^ NA Clean effluent filter Ai least once every: 13 Gt month(s) ^ year(s) ^ NA, Inspect pump, pump controls & alarm At least once every: 13 p y arj j1s1 ^ NA Flush laterals and pressure test At least. once every: 3 ^ month(s) l$ yearlsl ^ NA Other: At least once every: ^ month(s) ^ year(s) 0 NA Other: 0 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 tank(s) 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 cell(s) shall be visually inspected to check the effluent levels in the observation pipes and to check for any .ponding of effluent on the ground surface. The ponding. of effluent on the ground surface may indicate a failing condition and r®quires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY31 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 filters, 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. • OWNER: FREDERICK HULLE Page 8 of 8 3T~RT UP AND OPERATION For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or otherchemicals that may impede the treatment process and/or damage the dispersal cellls-. If high concentrations are detected have the contents of the tank(s) removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During power outages pump tanks may fill above normal highwater levels. When power is restored the excess wastewater will be discharged to the dispersal cellls) in one large dose, overloading the cellls) 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 cells. Do not drive or park over, or otherwise disturb or compact, the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics; baby wipes; cigarette butts; condoms; cotton swabs; degreasers; dental floss; diapers; disinfectants; fat; foundation drain (sump pump) 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: • AI! 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, 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 PCIWTS 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 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 pnWTS INSTALLER Narne HELGESUN EXCAVATION INC Phone 715-772-3278 cFOTArE SERVICING. OPERATOR (PUMPERI Name JOHNSON SANITATION Phone 715-273-5811 anwrc MAINTAINER Name JUHNSUN ANIT T Phone 715-273-5811 LOCAL REGULATORY AUTHORITY Name ST CROIX CUUNTY ZUNING Phone 7..15-38.6-4680 This document was drafted in compliance with chapter Comm 83.22(2i1b1(111d1&(f) and 83.54(1), 121 & (31, Wisconsin Administrative Code. E , WsconsinDepartmentofCommerce ,..,.._._S6f1_ EVALUATION REPORT Division of Safety and Buildings ~"""~~ Page ~ of m accoraance wim ~.omm oa, vv~s. ram. ~.vae ~ ~ a County ~ ~a/ __ er not less than 81/2 x 11 inches in size Plan must Attach com lete site lan on a . p p p p include, but not limited to: vertical and horizontal reference point (BM), direction and Parcel I.D. /J//~ percent slope, scale or dimensions, north arrow, and location and distance to nearest road. 00 --~v'7'f o -d6o • 7 7 Please print all information. R wed Date ~ / Personal information you provide may be used for ec n 04 (1) (m)). / ~~~',,,, ,~,, ~~ G~4/r ~w /~ j ~ ~ ~ V Property Ownnner r_ ~ ~ ~ ~ 't ~ Pro erty Location t ~ r T~ ~ N 1/45 1/4 S~ E (o W R ~ ~ CX~ r t L \ y 6 ~ Go .Lo V 1 I (,~ Property Owner's Mailing Address Lot Block # Subd. Name or CSM# Cily State Zip Code ^ rr''11 c ~ ~ Pho N ZONING OFF CE City ^ Village own Nearest R 1 oad , L~ I h 1d~ ~ ~ T ~../ ' ^ New Construction Use: ^ Residential / Number of bedrooms 3 Code derived design flow rate y~0 GPD [~'~eplacement ^ Public orcommercial -Describe: Parent material 2.. ~ ¢SS ~UPr, ~~ ~ Flood Plain elevation if applicable _ ft. General comments . ' ~ g ''sa" Cy u h G~e~- c-~ -ed- ~c~5 ~ - o'~ e'~ l and recommendations: (,C S~ /~ ~//~ Ort COKfolcr 9'G+O f Boring Boring # Pit Ground surface elev. ~7 s ft. Depth to limiting factor ~~ in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fl= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Etf#1 *Eff#2 ~ a ~~ c, _' '~ w, ~ ~ t ~ I ~~ . 8 ~ .~ ~. ~ F d~ , 3 ® Boring # ~ Boring 2~ Pit Ground surface elev. U~ ft. Depth to limting factor ~ in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/ft= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 L ~` r 6 T l (~(, u 3M I fU ~ ~ -~~ c R '' S!~ ~ + 'YL't- 1 ~ ~aCO / c ~o p O 1- l ~ ~ ~' ~~ ~ ~ b w~ u ~ . ~ * Effluent #1 = BOD > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BOD < 30 mg/L and TSS < 30 mg/L CST Name P ase Print Si , ture CST Number 9 Address ~ Da a Evaluation Conducted Telephone Number sv~~ ~ Property Owner ~r" ~d(~ (f'< < ~ ~ +~ I ~ ~-- Parcel lD # Page o~ of j 3 Boring # ^~ Boring ~' Pit Ground surface elev. 9 7 7 ft. Depth to limiting factor ~~ in. Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP DlfP in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 *Eff#2 oy ~ L v~ ~~ ~ ~ t~ io~- ^ Boring Boring # Ground surface elev. ~ ft. Depth to limiting factor ~ in. Soil Ap lication Rate Horizon Depth Dominant Cobr Redox Description Texture Structure Consistence Boundary Roots GPD/fl~ in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. *Eff#1 *Eff#2 /'~'- ~ 3 ---- ~ ~ ~- L W /~ /~F / w. c o ~ tso . 8 3 -~ a oY ca ~ s o~ -~ c L vc s t v f- ~~ ^ Boring Boring # Ground surface elev. ft. Depth to limiting factor in. ^ Pit Soil A lication Rate Horizon Depth Dominant Color Redox Description Texture Structure Consistence Boundary Roots GP D/fl= in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. 'Eff#1 'Eff#2 'Effluent #1 =BODE > 30 < 220 mg/L and TSS >30 < 150 mg/L * Effluent #2 = BODS < 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) I ~q,s' /-~C2CS ~~v~~ev-`. ~~e~er ~c k ~o~ P S7; CRo r,~,r ~~'~YY ~~~~ ~ F G~ A [.p (,~r.~I ~w~ sE y ~~2g~.~y.,~ ~ ~~ ~ ~~ ~~la~~ S~.:er ~vt~erfil~leu, G~".S ~ ~,t?~Ll_ ~a~~ 3 d~ 3 ~3.~n Io4.s L3o}I o„,~ o F Notes ~ S.d,nq a0 ~~s~~"~`i q . ~.t ~ CA~ ~,~ q~,3s E~eu. Q~ e~fl-ow. a wr_u_ ~ ~~i 1 i~ ~~`~i ~~,~. ~~ ,~ ~0 0 ea,- '~ ar w ~~~~ ,- ~~~y L ~-~ cveF-c~) ov.~ i ~_ r 7 Parcel #: 002-1074-80-000 Category ___ Alt. Parcel #: 29.29.16.4430 002 -TOWN OF BALDWIN Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 00 0 Tax Address: Owner(s): O =Current Owner, C =Current Co-Owner O - HOLLE, FREDERICK H &WANDA J FREDERICK H & WANDA J HOLLE 2272 HWY 12 BALDWIN WI 54002 Districts: SC =School SP =Special Property Address(es): ' =Primary Type Dist # Description ' 2272 HWY 12 SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 5.000 Plat: N/A-NOT AVAILABLE SEC 29 T29N R16W E 1/2 OF E1/2 SW SE N Block/Condo Bldg: OF RWY Tract(s): (Sec-Twn-Rng 401/4 1601/4) 29-29N-16W Notes: Parcel History: Date Doc # Vol/Page Type 06/14/1991 470402 905/475 QC 2008 SUMMARY Bill #: Fair Market Value: Assessed with: 0 Valuations: Last Changed: 10/27/2006 Description Class Acres Land Improve Total State Reason RESIDENTIAL G1 5.000 35,800 167,500 203,300 NO Totals for 2008: General Property 5.000 35,800 167,500 203,300 Woodland 0.000 0 0 Totals for 2007: General Property 5.000 35,800 167,500 203,300 Woodland 0.000 0 0 Lottery Credit: Claim Count: 1 Certification Date: 04/1712001 Batch #: 510 Specials: User Special Code 09/25/2008 07:57 AM PAGE 1 OF 1 Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 ST. CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~ ,e ~ ,~ ,,r ~ (~ O ~ ~ .Mailing Address a ~ 7 a, l~ to ~.~,, l ~. Property Address Q (Verification required from Planning & Zoning Department for new construction.) City/State /0,1~.10~ ct.~ ~ v1 Parcel Identification Number ~; a ~ _ /~ 7 ~ - ~~ _DGa LEGAL DESCRIPTION Property Location SI.~J '/ , S~ % ,Sec. ~, T _~N R !~ W, Town of ~~/~4~,,,, Subdivision _ Lot # Certified Survey Map # N~A ,Volume ,Page # Warranty Deed # ~ 7s' a ~ ~ ,Volume ~ ~ ! ,Page # ~ S S Spec house ^ yes f~ no Lot lines identifiable ^ yes ^ no SYSTEM MAINTENANCE AND .OWNER CERTIFICATION Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper. ., maintenance consists of pumping out the septic tank every three years or sooner, if needed, by a licensed pumper. What you.put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. Owner maintenance responsibilities are specified in §Comm. 83.52(1) and in Chapter 12 - St. Croix County Sanitary Ordinance. The property owner agrees to submit to St. Croix County Planning & Zoning Department a certification form, signed by the owner and by a master plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (1) the on-site wastewater disposal system is in proper operating condition and/or (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge. Uwe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system with the standards set Earth, herein, as set by thes Department of Cormnerce and the Department of Natural Resaurces, State of Wisconsmr--- Cet`tification stating that your septic system has been maintained must be completed and returned to the St: Croix County Planning & Zoning Department within 30 days of'the three year expiration date. Uwe certify that all statements on this form are true to the best of my/our knowledge. Uwe am/are the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. Number of bedrooms .~~ qq / aGl a _L-~ .SIG ATURE OF APPLICANT(S) DATE ***Any information that is misrepresented may result in the sanitary permit being revoked by the Planning & Zoning Department. *** Include with this application a recorded warranty deed from the Register of Deeds Office and a copy of the certified survey map if reference is made in the warranty deed. (REV. 08/05) ~~( a+ sa. w~rraab D.ei•-#A~re Tern, UT~l1 0>. aleCO» (See.'l81i.18. WIS. 8tataNs) ~ p . Q~ Ks. / ~ PaEIISLed b1-Ma Cie-N Hook 4.Rtat1011fry lA. ~( ea Fri ~1~ ~.~ . ~CC~jc$ ~1~t~~titUxQ, Madab~ Ronald Stone and Shirley Stone, Husband and yiife As Joint Tenants grantor s , of St . Croix County, Wiscansin, hereby conveys and warrantsro FreQerick H, Ho11e and Wanda J. Ho11e, Husband and Wife, , As Joir~ Tenants. grantees , of St . Croix County, .Wisconsin, for the sum of Fifteen Hundred...(;~1~500.00) -----__-- ~ Dollars the following tract of ]and ]n St . Cra i.x. - County, State of Wisconsin: Fast half (x?,.'-;) of L;~;t Half (E~-) of South 'guest ~~uarter (SGu~) of Saut;ri last ~~uartcr (SE4} of Section 2q, Township 2c '?orth, of Range 16 ';vest,, Puor~f;h of Itailwa~r right of way to Chi.ca~;o, St . Yal.z1, ~rlinne,rpolis ar.~:~ Ut;.al~l~z t~ailvaay Co.• 4x .vi:. r ~, r. t~~ ~, . , ~; ._ G~~~'~i tar ~~.., .~, ~~~ a . 11,tl~ • ,: E~ e >ru<~ry ~~,~: ,try of _ , ,~ k ~ri tl2liftttP~~ ~~PLPOE, the said grantor;; ha vHiiereunto set their hander and seals this 10t t1. day of ~~'ebruary , A. D., 19 (;~, . Signed and Sealed in Presenc~e7 of _-~ 1~ ~, r--- t, tich-ar~~ ~'. ~:ivard ..~ ~ _ ~ ~% :,,, ,. '' ~ ~'elr~ia ~~auw ~tatt at ~2tii~can~in, St . Croix ~ ss' -•.-...- -.- County. .. . .:......_..._..~.4~._..~L~~..-..i.:...a....k.~:1_.4-{SEA L) .__._...._ on~1c~,, Stone _ /~ Shirley Stone Personally. came before me, this 10th.. day of Ii'ebruary , A. D., 19 64 the above named ctarraid Stone and Shirley Stone, Husb and Wif to me known to be the persgn ~ whp ,e,~ecuted the fore irume a owledg the same. ~~ ~ =~ Richard P. Rivard . 5 ~ ~ ~ -- ~~,~ ~~~~~~ '~ ``x Notary Public, St . CralX Jaunty, Wis. '.~/~ .~...,, > ~~~' ,• My cammisson~rpires PerTrianBXit,,A+~i},~D- Drafted by ____._..,._............~:~ i,~' ~ ~`'` R.. y~r -»...t~.Y~l~.]..t,.aC.r.~.1GI ~ ._...-..........._... lN.B.--Ch, bf Wis. Btab. ororMss.lhat sU le~trlt~b a M hall had Drinte8 er t~p~wt-tM11 tlxessi-tlis a~nies et f~M'.trafNrs, ;rantces,. ~vitnsxa snd notary.) vnl. ~. FA tM JJ