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020-1309-00-000
Wisconsin Department of Commerce PRIVATE SEWAGE SYSTEM county: St. Croix Safety and Building Division INSPECTION REPORT Sanitary Permit No: 569548 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: Wilcox, Rae Ann William Hudson, Town of 020-1309-00-000) L CST BM Elev: Insp.BM Elev: BM Descri tion: Section/Town/Range/Map N. .q7 OS�� le. 2 4-e 16.29.19.1549 TANK INFORMATION / ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark �S 34 lay•3 g9.9� Dosing Alt. BM ro0a f I rJ Aeration Bldg.Sewer Holding l; /,l St/Ht Inlet St/Ht Outlet TANK SETBACK INFORMATION TANK TO P/L WELL B o Air Intake ROAD Dt Inlet t Dt Bottom 1 1 z $/. 97 Septic Dosing W Header/Man. J�L ✓ L .0 t w 2 Aeration Dist. Pipe 1, !S 7' q ' ZV Holding Bot.System G Ve 1I •447 Final Grade PUMP/SIPHON INFORMATION J Manufacturer Demand St Cover L f l 3 GPM Model Number 32' TDH Lift 04e Friction Lo System Head tD,00 TDH D Ft Forcemain Length 7/ DYi a. a•I Dist.to well 7 1 � � SOIL ABSORPTION SYSTEM BED/TRENCH Width / Length No.Of Trenches PIT DIMENSIONS No.Of Pit _ Inside Dia. Liquid Q�pth DIMENSIONS D '— �_ � 7 a 2 �e SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM CHAMBEIR OR Manufacturer: /4 P-6 IF _INFORMATION Type Of System: a �j r � � � UNIT Model Number: A��• .,,..�. 1 l J DISTRIBUTION SYSTEM it j Header/Man Distribution x Hole Size x Hole Spacing Vent to Air)ntake Pipe(s) 1 /0 Length Length Dia Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only e er- ' S Depth Over Depth Over xx Depth of xx Seeded/Sodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil �� Yes No es G-aJ No COMMENTS: (Include code discrepencies,persons present,etc.) Inspection#1: / / Inspection#2: Location: 942 Waxon Lan Hudson,WI 54 /o:le 40016(W1/2 SE1/4 16 T29N R19W) Pleasant View Lot 10 Parcel N 16. 9.1549 1.)Alt BM Description= �J 4 2.)Bldg sewer length= t -amount of cover Plan revision Required? ❑ Yes No 63 5 Use other side for additional information. ' L p — _ - Cert.No. Date Insectoes nature SBD-6710(R.3/97) PLOT PLAN N Project Name: Rae Ann Wilcox Legal Description: W1 12,SE1 14,S16 T29N,R19W RIB: 020-1309-00-000 Subdivision Name: Pleasant view Lot#: 10 SCALE:I"=40' Township: HUDSON Parcel Size: 2 Acres County: ST.CROIX System Elevation: T1=98.50' Existing 56'Rock Trench Slope: 2% T2=98.50' Existing 56'Rock Trench A BM1 Elevation: 89.97' Bottom of Dose Tank T3=98.00' Proposed 65'EZ Flow Trench A BM2 Elevation: 98.50 Bottom of Existing System T4=98.00' Prop osed 65'EZ Flow Trench M Backhoe Pits: TANK SCHEDULE 2 inch Sch 40-ASTM D1785 A Existing 1000 al Septic tank 4 inch Sch 40-ASTM D2665 B Existing 600 gal Dose tank+Sim/Tech STF-100 4 inch 3034 - ASTM D3034 C Proposed Distribution Box NOTE:See page 12 for a complete plot of the parcel. ALL 3 B EUCOM 0 e00 M eLtSc ,4, 83 , v \ r�Rtv 1Ew��Y IN 6PrQl4i�F � x v 6i Pr W/ . A00ft S)M/reclh 4 S;F-MO ��t rz T� �' rfrxiy ,, co I to Safety and Buildings Division T, t�© ;t3 P 201 W.Washington Ave., P.O.BOX 7162 Sanitary Permit Number(to be filled in by Co.) *� pS 'W'; Madison,WI 53707-7162 �_ -_ Y 3t anitary Permit Application aetion In accordance with S 383.21(2),Wis.Adm.Code,submission of this form to the appropriate govemme is required prior to obtaining a sanitary permit. Note:Application forms for state-owned POWTS are submitte 'Y/h yt d ess tf d erent than mailing address) the Department of Safety and Professional Servies. Personal information you provide may be used for secondary Q T- purp oses in accordance with the Privacy Law,s.15.04 1 m,Stats. QF�� I. Application Information—Please Print All Information P Property Owner's Name ', , gq Parcel# T RA E W C cc k Z®/.3017-0D -a®O Property Owner's Mailing Address p Property Location U7 WAX®I" /7' f� Govt.Lot City,State Zip Code Phone Number y4 Section L& 4a ce ` I T 6_1101& ircle one N T N; R f Eo-O H.Type of Building(check all that apply) Lot# 1 or 2 Family Dwelling—Number�of/Bedrooms / © Subdivision Name ' 9 L/� _�n 1'J Block# ❑Public/Commercial—Describe Use ❑City of ❑State Owned—Describe Use CSM Number ❑Village of Town of H0,65(9/y III.Type of Permit: (Check only one box on line A. Complete line B if applicable) A. ❑New System Replacement System ❑Treatment/Holding Tank R ep lacement Onl y Othe�M/odifi cation to Existin g y t eru-(e P lain) C//t ' B. El Permit Renewal El Permit Revision El Change of Plumber El Permit Transfer to New List Previous Permit et d Date Issued Before Expiration Owner IV-1f9 7 IV.T OWT stem/Component/Device: Check all that apply) lZ Non-Pressurized In-Gro ❑Pressurized In-Ground ❑At-Grade ❑Mound>24 in.of suitable soil ❑Mound<24 in.of suitable soil Ho mg ank Other Dispersal Component(ex in) ❑Pretreatment Device(explain) V.Dis ersaVrreatment Area Information: _G Design Flow(gpd) Design Soil Applicatio Rate f) Dispersa Area Requi d(sf) Dis ersal Area Pro sed(sf) System Elevation 17C y� V. 7 �� 6 Y 3 f ��3 �s© �- 7d 9r. O , VI.Tank Info Capacity in Total #of Manufacturer Gallons Gallons Units /� J� p U New Tanks Existing Tanks o a� yVl�Q (N- (i t Q 1l �C(� r U in Septic or Holding Tank /000 Dosing Chamber �?©® ap r C ct T VII.Responsibility Statement-I,the undersigned,assume responsibility for installation of the POWTS shown on the attached plans. Plumber's Name(Print) Plumber's gna e r MP/MPRS Number Business Phone Number :YO"ry _5Q#V1 T 27376C� Plumber's Address(Street,City,StateXec de) �/ 1J D 7 -" ���n ��5�'T LV ' s 4 ?s VIIIXounty/De artment Use Only Approved ❑Disapproved Permit Fee Z/ Date Issued I uing Agent Si afar ❑Owner Given Reason for Denial ' IX.Conditions of Approval/Reasons for Disapproval �� /I`� '. v i, , . mac✓ C 1 SYSTEM OWNER: J /V ` 1.Septic tank,effluent filter and � �/y C S / 1- 9/0 �D /U� l dispersal cell must be serviced/_maintained r as per management plan provided by plumber. ( � requirements must be maintained v as per applicabl lL9/M"P%1d&V.for the system and submit to I e / !Z SBD-6398(R. 11/11) i t CONVENTIONAL COMPONENT DESIGN Residential Application INDEX AND TITLE PAGE Project Name: Wilcox Replacement Soil Absorption Area Owners Name: Rae Ann Wilcox Owner's Address 942 Waxon Lane Hudson, WI 54016 Legal Description: W1/2, SE1/4, S16,T29N, R19W Township Hudson County: St. Croix Subdivision Name: 2 Acre parcel Lot Number: 10 Block Number Parcel I.D. Number 020-1309-00-000 Plan Transaction No. Page 1 Index and Title Page 2 Plot Plan Page 3 System Sizing &Cross Section Page 4 Dose Tank Cross Section Page 5 &6 Pump Curve Page 7 Filter Information Page 8 &9 Management and contingency plan Page10 Septic Tank Maintenance Agreement Page 11 Warranty Deed Page 12 CSM or Plat Attachment Soil Evaluation Report Designer: John Schmitt Licnese Number: MPRS 223760 Date: 4/22/2014 Phone Number: 715-760-0486 Signature: ::Z� In-Ground Soil Absorption Component Manual Version 2.0 SBD-10705-P(N. 01/01) PLOT PLAN N Project Name: Rae Ann Wilcox Legal Description: W112,SE1 14,S16 T29N,R10W P.I.D: 020-1309-00-000 Subdivision Name: Pleasant view Lot#: 10 SCALE:V:40' Township: HUDSON Parcel Size: 2 Acres County: ST.CROIX System Elevation: T1=98.50' Existing 56'Rock Trench Slope: 2% T2=98.50' Existing 56'Rock Trench A BM1 Elevation: 89.97' Bottom of Dose Tank T3--98.00' Proposed 65'EZ Flow Trench BM2 Elevation: 98.50 Bottom of Existing System T4--98.00' Proposed 65'EZ Flow Trench Backhoe Pits: TANK SCHEDULE 2 inch Sch 40-ASTM D1785 A Existing 1000 gal Septic tank 4 inch Sch 40-ASTM D2665 B Existing 600 gal Dose tank+Sim/Tech STF-100 4 inch 3034 - ASTM D3034 C Proposed Distribution Box NOTE:See page 12 for a complete plot of the parcel. L L. 3 B E1'eooM o «o I4 cc) I IV Ct 63 � v 41e4 � [—%15TfN<, gpt� ►'� )000/(,00 B I�D r'r ff s r r�1 l'!•�,C I F QG $;F—mO P/t rZ T SOIL ABSORPTION SYSTEM DETAIL/GRAVELLESS LEACHING UNIT Project Name: Rae Ann Wilcox 2 No.of Cells 6.5 Per Cell 3 ft Cell Width 13 Total No of 1203H 65 ft Cell Length 325 sq ft EISA Per Cell 3 ft Cell Spacing 650 sq ft Total EISA Manufacturer Model Laying Length EISA Rating Infiltrator EZ1203H-5ft 5.0' 25.0 EZ1203H-10ft 10.0' 50.0 Gravelless Leaching Unit Manufacturer: to Infiltator Gravelless Leaching Unit Model: 1203H Typical Cross Section Finished Grade 102 ft Observation Pipe with approved cap or vent Soil Backfill 30 in ' • Geotextile Fabric 98 ft Infiltrative Surface 12 in 0 I I <94.2 ft Limiting Factor >36 in Slotted and Anchored Ventl Observation Pipe with Cap ...............: :::::: .-................................................ Plumber/Designer Signature: Llelleil I" License#: MPRS 223760 7Date:' 4/22/2014 �? p SECTION:2.20.010 rJUVTY I 'UMP6�)YCE 19,7 FM0311 0311 12e %. Supersedes Product information presented 0810 here reflecLs conditions at PUMP time of publication.Consult factory regarding disaepan- visit our web site: ores a inconsistencies. MAIL T0: P.O.BOX 16347•Loursvile,KY 40256-0347 SHIP TO: 3649 Cane Run Road•Louisville,KY 40211-1961 www-Zoeiier com (502)778-2731.1(800)928-PUMP•FAX(502)774-3624 COMPARE THESE FEATURES 53 - 57 Cast Iron Series • Non-Clogging vortex impeller • Float operated,submersible(NEMA 6)2-pole mechanical 55 - 59 Bronze Series switch&variable level long cycle systems available • UL Listed 3-wire cord plug;9 ft.standard for automatic, 15 ft.standard for nonautomatic For Pump Prefix Identcation see News& Views 0052) • Corrosion resistant powder coated epoxy finish • No sheet metal parts to rust or corrode i' M I G H TY-MATE" • Stainless steel screws,switch arm,guard and handle • No screens to clog SUBMERSIBLE PUMP • Watertight neoprene"0'ring between motor and pump UL FOR �. housing DEWATERING (SUMP) UL • Solid buoyant polypropylene float SWTefOed to�mrd kx77 ne. OR • Motor-60 Hz,1550 IPM,oil-filled,hermetically sealed, automatic reset thermal overload protected EFFLUENT (SEPTIC TANK SYSTEMS) • Upper and lower sleeve bearings running in bath of oil o SSP►f 1 • Entire unit pressure tested after assembly 0 ca us PASSES'/2"SOLIDS • Carbon and ceramic shaft seal (TesWtoUL778XW 1%"NPT DISCHARGE • Maximum temperature for effluent or CUM 108 Sladx&) dewatering-130°F (540C) AUTOMATIC • Passes Y:"inch spherical solids MODEL • 1'Y2 NPT Discharge. • On point-7'/; • Off point-3" _ r. • Major width-10 3/32" • Height-101/16' F# - SPECIAL MODEL FEATURES: MODEL 53 MODEL 55 •Cast iron switch case,motor& •Bronze switch case,motor& pump housing pump housing •Engineered thermoplastic base •Engineered thermoplastic base VORTEX TYPE •Engineered,glass-filled,plastic •Engineered,glass-filled,plastic IMPELLER impeller with metal insert impeller with metal insert •Stainless steel guard&handle •Stainless steel guard&handle •Bearing-lower&upper oil fed •Bearing-lower&upper oil fed cast iron bronze MODEL 57 MODEL 59 •All cast iron construclion •All bronze construction •Stainless steel guard&handle •Stainless steel guard&handle •Bearing-lower&upper oil fed •Bearing.lower&upper oil fed cast iron bronze •Cast iron impeller •Bronze impeller ALL MODELS ARE POWDER � i BN MODEL COMPLETELY SUBMERSIBLE COATED HERMETICALLY SEALED TOUGH- Watertight-dust tight.Permanently oiled bearings. MODELS AVAILABLE VARIABLE LEVEL CONTROL Automatic or Nonautomatic SYSTEMS AVAILABLE '53-57"-.3 HP,115Vor 230V • "55-59"-.3 HP,115V or 230V Note: The sizing of effluent systems normally requires variable level BE531BE57&BN53IBN57 available packaged floats)controls and properly sized basins to achieve required with Piggyback Variable Level Float Switch pumping cycles or dosing timers with nonautomatic pumps. ®Copyright 2011 Zoeller Co.All rights reserved. DOSE TANK DETAIL Owner's Name: Rae Ann Wilcox 93.93 ft Inlet Elevation Weatherproof Manhole with Locking Device -- Junction and Waming Label ..., ......2uick disconnect fitting n Alternate forcemain outlet 0o Sim/Tech Filter Dimensions Inches Gallons res (a) --------------- ------- L 23.28 347.33 se ara n b) 2 29 84 alarm on dose Vol a(c) 6 90 pump on 10.72 160 ------ ------- 42 627.17 d (d) 92.18 Intake Elevation �v4 Tank Manufacturer Huffcutt Pump Manufacturer Zoeller Tank Model 1000/600 Pump Model 53 ✓(�� Tank Capacity 600 gal Alarm Manufacturer Existing Tank Volume 14.92 gal/in Alarm Model Existing Filter Manufacturer Sim/tech 0,'> Filter Model STF-100 w TD H DOSE VOLUME CALCULATIONS TOTAL DYNAMIC HEAD CALCULATIONS Design Flow(DWF) 450 gal/day Min Network Supply na ft Number of Doses 5 /day Passive Vertical Lift 9.37 ft—(Header/D.Box elev.-Pump intake elev.) —(Forcemain Length x Friction Loss Max.Dose Volume 96.52 gal Friction Loss 0.44 It Factor)/1 00+Filter Friction Loss Drain Back 6.52 gal Total Dynamic Head 9.81 ft Design Dose Volume 90 gal Min Discharge Rate 20 gpm NOTE: Pump and alarm are to be installed on separate circuits. INTERNAL DIMENSIONS OF TANK Diameter in Liquid Depth 42 Plumber/Designer Signature: C���A License#: 223760 Date: 4/22/2014 TOTAL DYNAMIC HEAD/FLOW UJ W PER MINUTE UJ 2 PUMP PERFORMANCE CURVE EFFLUENT AND DEWATERING MODELS 53/55/57/59 MODEL 53/55/57/59 6 zo Feet Meters Gal. Liters = 5 1.5 43 163 v 15 10 3.0 34 129 4 15 4.6 19 72 0 Shut-off Head: 1 19.25 ft.(5.9m) 0 2 889887 3718 sans 5 ase t to-tt trzNar 3 718 0 10 20 30 40 50 i + GALLONS a LITERS 0 80 160 FLOW PER MINUTE i i ! i CONSULT FACTORY FOR SPECIAL APPLICATIONS • Variable level float switches available i • Variable level long cycle systems available i • Available with special cord lengths of 15',25',35',(50'230V only) 101/16 i i • Alarm systems available • Duplex systems available i 3 3f32 I � eK858 SELECTION GUIDE 1.Integral float operated mechanical switch,no extemal control required. 2.Single piggyback variable level float switch or double piggyback variable level float switch.Refer to FM0477. 3.Mechanical alternator"M-Pak"10-0072 or 10-0075. 4.See FW712 for correct model of Electrical Alternator, "Easy assembly" 5.Viable level control switch 10.0225 used as a control activator,with (prp&discharge Pipe Electrical Alternator(3)or(4)float system. not •) single Soel control Selection Model Voles Phase I Mode Amps Simplex Duplex JCSAJ UL M53/55&M57/59 115 1 UAutD4.8 1 — Y Y N53/55&N57/59 115 1 2 3 or 4&5 Y Y BN53 115 1 — Y Y BN57 115 1 — N Y `BE53/57 230 1 — Y Y OPTIONAL PUMP STAND P/N 10.2421 1 Y AY Reduces potential dogging by debris E53/55&E57/59 230 1 2 3 or 4&5 Y Replaces rocks or bricks under the pump Single piggyback switch i"d"led. Made of durable,notxxxrosive ABS • • Raises pump 2'off bottom of basin All installation of controls,protection devices and wiring should be done by a qualified Provides the ability to raise intake by adding sections of 1%i licensed electrician. All electrical and safety codes should be followed including the 2•PVC n most recent National Electrical Code(NEC)and the Occupational Safety and Health piping Act(OSHA). • Attaches securely to pump For intonation on additional Zoeller products refer to catalog on Piggyback Variable level Accommodates sump,dewatering and effluent applications Float Swkhes,FM0477;ElecbicalAltemator,FMD486;MechanicalAltemator,FM0495;Surnp/ NOTE:Make sure ft at is free from obstrudlon. Sewage Basins,FMOM;and Single Phase Simplex Pump Ca"Alarm Systems,FM0732, RESERVE POWERED DESIGN For unusual conditions a reserve safety factor is engineered into the design of every Zoeller pump. 0 Copyright 2011 Zoeller Co.All rights reserved. MA re PRESSURE FILTER INSTALLATION & SERVICE INSTRUCTIONS 1455 Lexamar Drive Toll Free 888-999-3290 Office 231-582-1020 Boyne City,MI 49712 Fax 231-582-7324 Email s i!a4r.�aa-simtech.com Web www.14ag-simtech.com INSTALLATION: When installing an STF-100, screw filter into discharge port of any pump that has a 2" National Pipe Thread. Pumps with a smaller discharge port may be adapted to fit. When installing an STF-100A2 a tailpiece and male adapter will need to be added to the inlet end of the filter(end opposite of the cap)to the desired height and a 2"union will need to be added to the outlet end (the end closest to the cap&on the side of the filter). Always install the filters in a position where they can be easily serviced. **Always use caution when starting threads to avoid cross threading**. Plumb force main into the 2"sch 80 PVC union. **We recommend that the union remain together during gluing to insure that glue or cleaner does not ruin O-ring or sealing surface**. For best performance, if a check valve is installed it should only be after the outlet of the filter. SERVICE: Service of filter screen is dependent on usage as every system is unique. For most residential systems we recommend inspecting the filter within the first year to determine the necessary service intervals for the filter. In high volume systems we recommend inspection within the first 6 months to determine necessary service intervals for the filter. Once the service interval is determined it should be consistent unless something changes in the system. Always inspect the filter screen for any damage or corrosion and replace if necessary. If our STF-101 service alarm switch has been installed and adjusted properly it will alarm when the filter requires service. It should be serviced no less than when periodic pumping of the septic tank and pump chamber is performed. Servicing will be more frequent if using any one of our optional filter socks(600 micron, 150-190 micron,and 100 micron). Check your local health department for septic system servicing recommendations. If the screen becomes clogged before the periodic pumping requirements,a high level alarm or light will indicate the need for service. If system is equipped with a"pump on light"that stays on longer than normal,this also may indicate a need to service filter. To service filter screen, unscrew the 4"cap. Pull filter screen from canister and wash out thoroughly in appropriate location with proper protection. In some cases an additional filter screen allows quicker service allowing the dirty filter to be washed later at the shop. Note t/W in Gold GOrtdMM gte tFKer cap may be dMkx&to removes Keep Me OW In s Norm SM or pour rim war over the cap before netri Unce the>�IS�In the tank it�s stsbes temper�uv+e and removing the cap wfN rW be a probIbm. If the system is equipped with our Service Alarm Switch, the filter screen does not need service until the Service Alarm Switch activates a light or audio alarm. We still recommend that the filter be inspected once a year for damage or corrosion. NOTE: The total dynamic head loss of the system must be increased by 0.5 feet of head to overcome friction loss through the filter. SERVICE ALARM SWITCH The alarm switch is available in three pressure ranges, low head, medium head, and high head. Installation is simple,on SIM/TECH FILTER systems, remove 1/4"plug from base of filter chamber and connect tube fitting. Next, run the tube up into the tank riser and connect to service alarm switch. The alarm switch is fastened to the side of the riser via the nylon strap provided. Run alarm wire to alarm box. The service alarm switch can be wired with its own alarm or with the high water alarm. Pressure adjustment is made by removing the end plug, and inserting the 7/32 alien. Clockwise increases pressure. One turn equals approximately 3 PSI. The low head alarm switch comes factory preset at 8 PSI and is completely field adjustable within it's range(3 to 24 PSI). We recommend the use of a ball valve when using an alarm switch. Once you have installed the filter and alarm switch, the ball valve can be closed off to simulate a plugged filter so that you can make sure the alarm switch is working correctly. ****TRY OUR LID/SCREEN REMOVAL WRENCH. Our wrench holds filter lid firmly and hooks screen for easy removal and installation. Made of PVC plastic. WARRANTY All products are warranted against defects in material and workmanship for a period of two years from the date of purchase. In no event shall GAG SIM/TECH FILTER, INC. be liable for any consequential damages or any labor, material,freight or expenses required to replace, correct or reinstall the product. GAG SIM/TECH FILTER, INC.'s liability is limited to repair or replacement of the part. All warranties are void if the product has been improperly modified, applied or installed,subjected to misuse or abuse. Except as stated herein,there are no warranties expressed or implied, including the warranty of merchantability or warranty of fitness for a specific purpose. EFFECTIVE September 13, 2005 POWTS OWNER'S MANUAL & MANAGEMENT PLAN page—of FILE INFORMATION SYSTEM SPECIFICATIONS Owner: Rae Ann Wilcox Tank Manufacturer: Huffcutt r NA Permit# t i✓ Septic 1= Dose (_Holding Volume:_1000 gal DESIGN PARAMETERS Tank Manufacturer: Huffcutt r NA Number of Bedrooms: 3 r N l' Septic 11: Dose E�Holding Volume: 600 gal Number of Public Facility Units: r NA Vertical Distance Tank Bottom(s)to Service Pad: ft Estimated(average)Flow: 300 gal/ Horizontal Distance Tank(s)to Serivice Pad: ft Design(peak)Flow=estimated x 1.5: 450 gal/4 Specific servicing mechanics must be provide if vertical is>15 feet or if In Situ Soil Application Rate: 0.7 gal/day/ horizontal is>150 feet.Specific instructions to be provided on bads. Standard Domestic Influent/Effluent Monthly average Effluent Filter Manufacturer: SIM/TECH r NA Fats,Oils&Grease(FOG) 530 mg/L Effluent Filter Model: STF-100 Biochemical Oxygen Demand(BOD5) 5220mg/L r NA Pump Manufacturer: Zoeller r NA Total Suspended Solids(TSS) 5150mg/L Pump Model: 53 High Strength Influent/Effluent Monthly average Petreatment Unit Fats,Oils&Grease(FOG) 530 mg/L Manufacturer: Biochemical Oxygen Demand(BOD5) 5220mg/L (7/ NA r Mechanical Aeration r Peat Fitter r NA Total Suspended Solids(TSS) 5150mg/L r Disinfection r- wetland Petreated Effluent Monthly average r Sand/Gravel Filter r Other. Biochemical Oxygen Demand(BOD5) 530mg/L Soil Absorption System Total Suspended Solids(TSS) 530mg/L r NA W In-Ground(gravity) r In-Ground(pressure) r NA Fecal Coliform(geometric mean) 5104cfu 1100m1 I– At-Grade r Mound Maximum Effluent Particle Size: Ye in dia. r N r Drip Line r Other. Other: r Other: FW NA MAINTENANCE SCHEDULE Service Event Service Frequency When combined with sludge and scum equals one-third('/)of tank volume Pump out contents of tank(s) When the high water alarm is activated (s) Inspect condition of tank(s) At least once every: 3 IN Y—(s) Maximum 3 ears NA montn(s) Inspect dispersal cell(s) At least once every: 1.1 a Year(s) Maximum 3 ears r NA F mort"O Clean effluent filter At least once every: 1.1 Y—(s) r N months) Inspect pump, pump controls&alarm At least once every: 1.1 #f year(s) r N Flush laterals and pressure test At least once every: r Yea(s) R NA r rtwrnh(s) Other: At least once every: r years) r NA r 10ther: At least once every: r years) r 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 Insepector;POWTS Maintainer;Septage Servicing Operator(pumper).Tank inspections must include a visual inspeciton of the tank(s)to identify any missing or broken hardware,identify any cracks or leaks, measure the volume of combined sludge and scum and a check for any back up or ponding of effluent on ground surface.The dispersal cell(s)shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface.The ponding of effluent on the ground surface may indicated a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumualtion of sludge and scum in any treatment tank equals one-third('/)or more of the tank volume,the entire contents of the tank shall be removed by a Septage Servicing Operator and disposed of in accordance with chapter NR 113,Wisconsin Admininistrative Code. All other services,including but not limited to the servicing of effluent filters,mechanical or pressurized components,petreatment units, and any servicing at intervals of 512 months,shall be performed by a certified POWTS Maintainer. A service report shall be provided to the local regulatory authority within 30 days of completion of any service event. (Rev.2/05) START UP AND OPERATION Page of For new construction,prior to use of the POWTS check treatment tank(s)for the presence of painting products,solvents or other chemicals or sediment that may impede the treatment process and/or damage the soil dispersal cell(s).If high concentrations are detected have the contents of the tank(s)removed by a septage servicing operator prior to use. System start up shall not occur when soil conditions are frozen at the infiltrative surface. During extended power outages pump tanks may fill above normal highwater levels.When power is restored the excess wastewater will be discharged to the dispersal cell(s)in one large dose and may overload them resulting in the backup or surface discharge of effluent. To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells.Do not drive or park over,or otherwise disturb or compact,the area within 15 feet down slope of any mound or at-grade soil absorption area. Reduction or elimination of the following from the wastewater stream may improve the performance and prolong the life of the POWTS: antibiotics;baby wipes;cigarette butts;condoms;cotton swabs;degreasers;dental floss;diapers;disinfectants;fat;foundation drain (sump pump)discharge;fruit and vegetable peelings;gasoline;grease;herbicides;meat scraps;medications;oil;painting products; pesticides;sanitary napkins;tampons;and water softener brine. ABANDONMENT When the POWTS fails and/or is permanently taken out of service the following steps shall be taken to insure that the system is properly and safely abandoned in compliance with chapter Comm 83.33,Wisconsin Administrative Code: •All piping to tanks,pits and other soil absorption systems shall be disconnected and the abandoned pipe openings sealed. •The contents of all tanks and pits shall be removed and properly disposed of by a Septage Servicing Operator. •After pumping,all tanks and pits shall be excavated and removed or their covers removed and the void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS fails and cannot be repaired the following measures have been,or must be taken,to provide the opportunity to obtain a sanitary permit for a code compliant replacement system: ❑ A suitable replacement area has been evaluated and may be utilized for the location of a replacement soil absorption system. The replacement area should be protected from disturbance and compaction and should not be infringed upon by required setbacks from existing and proposed structure,lot lines and wells.Failure to protect the replacement area will result in the need for a new soil and site evaluation to establish a suitable replacement area.Replacement systems must comply with the rules in effect at the time of their permit issuance. ❑ A suitable replacement area is not available due to setback and/or soil limitations.If the soil absorption system cannot be rehabilitated and barring advances in POWTS technology,a holding tank may be installed as a last resort. ® The site has not been evaluated to identify a suitable replacement area.Upon failure of the POWTS a soil and site evaluation must be performed to locate a suitable replacement area.If no replacement area is available a holding tank may be installed as a last resort to replace the failed POWTS. ❑ Mound and at-grade soil absorption systems may be reconstructed in place following removal of the biomat at the infiltrative surface. Reconstructions of such systems must comply with the rules in effect at that time. WARNING: TREATMENT TANKS AND HOLDING TANKS MAY CONTAIN POISONOUS GASSES AND LACK SUFFICIENT r 11 OXYGEN TO SUPPORT LIFE.NEVER ENTER A TREATMENT TANK OR HOLDING TANK UNDER ANY CIRCUMSTANCE.DEATH MAY RESULT.ESCAPE OR RESCUE FROM THE INTERIOR OF A TANK IS VERY DIFFICULT. ADDITIONAL INFORMATION: POWTS INSTALLER POWTS MAINTAINER Name:John Schmitt Name:John Schmitt Phone:715-760-0486 Phone:715-760-0486 SEPTAGE SERVICING OPERATOR(PUMPER) LOCAL REGULATORY AUTHORITY Name: Owners Choice Name:St.Croix County Zoning Phone: Phone:715-3864680 This document is intended to meet minimum requirements of Ch.Comm 83.22(2)(b)(1)(d)&(f)and 83.54(1),(2)&(3),Wisconsin Administrative Code. Use of this document does not guarantee the performance of the POWTS. (Rev.2/05) STC - 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER MAILING ADDRESS , L�CI rd A lL4j5j) oo.1_ L JLIO AR PROPERTY ADDRESS ;W -a !�.' 0. c Q h L.d n e (location of septic system) Please obtain from the Planning Dept. CITY/STATES "}7-� PROPERTY LOCATION UY-ZA 1/4, yL. 1/4, Section Ro T_ 2c N-R {_y w TOWN OF_J-L d:Snn ST. CROIX COUNTY, WI SUBDMSION Pka wmi__I I j�_dt} LOT NUMBER �D CERTIFIED SURVEY 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 1/3 full of sludge and scum. I/We, 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 (lie 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: -�G -- ----- St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson. \VI 54016 11193 90&W7,94KWW-49t9RV-;4K JAM WARRANTY DEED 1 t)oc°"'e°t Nunber REGISTER'S OFFICE ST. CROIX CO.. WI rq hW M >asW SEP 0 8 1997 ! ttecurn Address KRISTINA OGLAND 1:40 P M Zilz, Estreen & Ogland P.O. Box 359 Hudson, WI 54016 Parcel I.D.Number: a Vern an Waxoa, ailda Veraoa E Waxoa, and Iresre Wuoa, a/Wa Irene S. Waxen. kasband and wife, conveys and warrants to William L. Wilcox and Rae Ann Wilcox, t�asbaad and wife, as sarvivorship msrital property, the following described real estabc in St. Croix County, State of Wisconsin: Town of Hudson, SL Croix County, Wisconsin. Lot 10, Pleasant View in the This is not homestead property Exception to warranties: Easements, restriction and rights-of-way of record, if any. Dated this day of September, 1997. - (SEAL) Q�L,�t K/ SEAL) /k/a ernon E. Waxon Irene Waxon, a/h/a ene S_ Waxon - ,_ Y'- AUTHENTICATION b, a/Wa Vernon E. Waxen, $ TR "ER Signature(s) Vernon Waxen, and Irene Waxen, a/Wa Irene S. Waxen, hasba" and ii wife, authenticated this C*1-_ day of Sgaember, 1997. Kristin Ogland TITLE: MEMBER STATE BAR OF WISCOC'-MN " THIS INSTRUMENT WAS DRAFTED BY: � Attorney Kristin Ogland Hudson, WI 54016 i g a-. 8 i 1' 00 f • r `oqs4l��P 0 oZ 04 6/o oZ pE G / ( ti h •N1/ 6 /< N p hR W CON / W lb / r 1-0' 60 log A O 1A V6 6 os Q • `, r ` N~ / ey WU. lb4 Op N / i / 00/N Q 0 o A ti°° M % W W WW{L l N �. a1 . U OWN W co cm lb to to 01OL t ` O CL W W I �/. Va I . 001 1 cm I ~ • , O t ' O O 391' 0`6, f 'a� VO \ C; 77e03, OW- y� (n^ to i a _ 3M 00 00006 N— V a -Jviu O W 0 1 0 °° oAM : ea 00j/ �/ 0 a � N e0 i w LIL O0fB1nDeP"0"1°"`Otl"d'�t' SOIL AND SITE EVALUATION REPORT _ tabor and t*xnm Relations Pap-Lim 3 Dnran+�Satsry a in accord with ILHR 83.05.Wis.Adm.Code GOIJNTY Attach complete site an on 61 . G R O I• � plan Paper not less than 81/2 x 11 inches in size.Plan waist include,but not limited to vertical and horizontal reference Point(SM),direction and%of slope,scale or PARCEL IA.# dinwn$kwW,north arrow,and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATIONS DATE PROPERTY E. G!/fX oiV PROPERTY LOCATION GM.LOT�� SE 'U4,S 1 T 2 9 .NA I q E W c T R RESS - O T MOIX i sum.Iox OR CSM 0 t e, TY,STATE �1+S V E ZIP COOS PHONE NUMBER OWN NEAREgr v o.� t . S o oS 4� S Y /` (7i51 t:•3 U cr . v H DSo,J �� 1-f New Consbuction use[ Residential/Nut Im of bedrooms 3 'Foy [ j Addition ID 04"kftq I 1 t Yso- [ 1 Ptft or aommeraal describe - Code derived daly llow tb0 flp Reno nwled design Iceding tale , Absciption — _ 9 fr6ttdt,WdIR2 aa required bed,ft2 trench,ft2 Maramum design loading►ant �? bed,gpdAl� . B tt�ettch, Reoonmended in�bratiort sttrfaoe elevations) S,act P e .3 It (as relented to site pan bendlmara Additional dtlsigrt/site aortsidera6ons ZIS4` S - eV-"D •.� ,S'/d,nE. Parent malarial ScS f t 15A—I T/4- _70 Flood pain elevation,d applic" ,t a+. R S=Un�e�W��stem CrS o '° a U [31 ❑u EssuRE AT-r,S►oO u LA'S 0 u Q TMK SOIL DESCRIPTION REPORT 1133SS y Boring i Horizon Depth Dominant Color mottles Texture Structure Boutdbry GPD/ft� in. Munsell tau.Sz.Cont Color Gr.Sz. Sh. R0018 o`� �o r Bed IFT tertdt W1 ( /2 3/z Si' . 2,w► S4K .t?s C's 3 rt- . S •G amill L •�7 is vif f/4 ------ 5W. /f XAX WSA s if elev. . OU- Depth Remarks: 1 L a Zo..3 .3 /0Y�f 312 5,'/ 2,, sit dsA es 3 f .57 .` z 9-�jf /0 YR s/ x•30 �0 ye s/S/ -- SXe �,scwd �s ♦ , y ,s elev. 7. S yr s/� c s o, s 7 Depth lo bnbq Af E Remarks: T Name:—Plea Print Ro 6E Q r 1A L(3R i c h T Pho"'I 7IS- 3 86- F 185 55 0' Nl:i L 'lip. t+U0S,0A3 W tS . 5yorG =2� CSrti a4 ML Date: , PROPERrYOtiYNER VeQtJ w�Xo�J SOIL DESCRIPTION REPORT POP 2 d PARC9.IA.t /4' /0 Stnxture GPD/tfld Boring Horizon Depth Dominant Color Mottles Texture Gr.Sz.Sh• Floots Bed Wendt In. Munsell au.Sz.Cont Cflbr �+►. a� • y . S ZAft L ^iy /oye y lesz4F7; Growl 3 y. /o i/e 5-1f: s./ /•f M& ds A Q s �f • Y .S ,00. �. 1- /oY/ Depth to /a g./o.ri3 n g# Remarks: '//Co ` S 2 o, S yS c 5 s 3-2A%—. , o- /0 Y93/2— $r y S +2 7-!S io y Y 4 I•S ve n. �S - O, S .`5 S� •.-�G C g /o ne s/ Worm lector LA Remarks: (�- I?v l E A ptP t e o IQ Boring# veer y 4,�u /S /,c, 5 /y 2 7.S V R y ------- i 24 1 /o ,Q s/y -------- c•s O, s �•� d� Gwd elev. /00.9 Depth ID 1a ry Remarks: Boring# GfwW elev.. K DepthID 9 IBM Remarks: '. woov LE7" LOT !O oL i f L7 y � �s 0 �y BS 71 to �SuR ugyoR s .4ar ,o �- yo' � q - 9 A• Lor L(As E Ry S•�• l� coR� �lev�.NoN = too• b SCALE t 30 ' • _ �hckti o� p�'Ts su 5 �ES'tEU -T�2ea ct�. 61 wVAW"S w ArZ eh j3?t-f3Y- (35 o ! a~i o 3 0 ° O Go y a ~ I o op 0 N I n N ti ~ I y O N Z N O Z C C LL Q Cl) N z N w ! o ! cn ZNI' E O 01 d N u. Co O Z d Z a ~ c ' fn F- r ii,, ~ N N ~ 22 CL J N N 0 0 0. U U N O N Z F- Z 0 Z N (ID E V CD IQ T 16 D 12 v C A y m m " 0 D 0 d L _rn = 3 3 3 a~ I • a a a N~ a J 6 i } (n J U j 0iQO O O I N j N - O N N a) o O O 'o E O V O C 5 w a N N N O o o ots N c v O od 3 m v v m 00 o m V c ~aoooo O !P F > 'y C 'p N N N N v (D -q co t„w C ~p ,y 3 N N N N a! U o N_ o rZ Lo N t=y~,l in O y C N O ~ ! Y E 7 u L: n. E ` •C C w A U a ! 0 cn U NOTICE: Please provide the following: • A plan view sketch showing everything within 100 feet of the syste..- ' r Two horizontal reference points to center of septic tank manhole cove ``~NsryG Q~ r • Show alternate benchmark, if applicable. PLAN VIEW 0 ~O INDICATE NORTH ARROW ST. CROIX COUNTY ZONING DEPARTMENT i AS BUILT SANITARY REPORT Owner I CJ~.~'' Address City/State Legal Description: Lot /6 _ Block Subdivision/CSM # w Sec. L(0, T N-R f 7 W, Town of PIN # SEPTIC TANK DOSE CHAMBER HOLDING TANK INFORMATION: Tank manufacturer Size ST/PC )64WGQ~Setback from: House a,Weli - P/L Pump manufacturer Model Alarm location (HOLDING TANKS ONLY) Setbacks: Service road Vent to fresh air intake Water Line Meter location Alarm location SOIL ABSORPTION SYSTEM: Type of system: Width Length S 7 Number of Trenches Setback from: House &n ! Well P/L Vent to fresh air intake ELEVATIONS: Description of benchmark 7 5 fGb / Elevation /O 7, 3 6 Description of alternate benchmark Elevation Building Sewer _t// ST/HT Inlet 13, 1 ST Outlet 3 /PC Inlet 3, .3 1 PC Bottom 7 / Header/Manifold Top of ST/PC Manhole Cover Distribution Lines 7i { } 9w { } Bottom of System ( } ® { ( } Final Grade ( } ( } ( } Date of installation/0 Permit number ---f-~ 106 State plan number Plumber's signature License number Date Inspector Complete plot plan R Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor er'dHuman Relations INSPECTION REPORT ST. CROIX ,Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 299066 Permit Holder's Name: ❑ Cit ❑ Village 'El Town o : State Plan ID No.: WILCOX, BILL & RAE ANN HUDSON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: 020-1309-00-000 TANK INFORMATION ELEVATION DATA A9700381 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic t Benchmark (Q ~~~„3 /a Dosing Aeration Bldg. Sewer 13d q4/0q, Holding St/Ht inlet .393„93 TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic 3 a9 NA Dt Bottom / 2, $e/ y Dosing NA Header/ Man. q, 84 V C/ Aeration NA Dist. Pipe 7~4 / 94, 3q Holding Bot. System ~p ' 98, S PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction Aq System/ TDHG,s% Ft Loss H Forcemain Length Dia,2l Dist. To Well,,aS SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of renches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS 5Z DIMENSIONS LEACHING Manufacturer: SETBACK SYSTEM TO P / L BLDG WELL LAKE / STREAM INFORMATION Type O ~ CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header /Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia- Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over c~JJ xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed/ Trench Edges 0d- Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: HUDSON 16.29.19,W,SE 942 WAXON LANE LOT 10 G r !lam"' ` W p.~9 Plan revision required? ❑ Yes ❑ No d Z 6 Use other side for additional information. SBD-6710 (R 05/91) Date In p or's Signature Cert. No. 146consin SANITARY PERMIT APPLICATION 201eE.WashnigtonAve'sion 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 CountyS than 8 112 x 11 inches in size. • See reverse side for instructions for completing this application State Sanitary Permit Number a627 0((~ 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 1. APPLICATION INFORMATI N -PLEASE PRINT ALL INF RMATION Prop n ame ~~P~~~ppert Location UJ- 4r 1/4,5,/ Ta N,R . E(OIQ Property Owner's Mailing Address Lot Number Block Number Cit , tate Zip Code Phone Num er Subdivisi n Name or C um e w ' ~r 1r715-)_36;-3W,3~(. TYPE F B ILDING: (check one) ❑ State Owned LZ Nearest Road ge Public 1 or 2 Family Dwelling - No. of bedrooms n of y(1 111. BUILDING E: (If building type is public, check all that apply) Parcel Tax Number(s) oLq. I q 1❑ Apartment/Condo D C-Y O 'OC f 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/ Repairs 11 ❑ Restaurant/ Bar/ Dining 4 ❑ Church/ School 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel / Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2. ❑ Replacement 3. ❑ Replacement of 4_ ❑ Reconnection of 5. ❑ Repair of an stem SystemTank OnlyExisting System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11E] Seepage Bed 21 E] Mound 30E] Specify Type 41 E] Holding Tank 12 Seepage Trench 5 ~S J 22 ❑ In-Ground Pressure 42 ❑ Pit Privy 13 Seepage Pit 43 ❑ Vault Privy 14E] System-In-Fill 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 vs O Required (sq. ft.) Propoed©.) (Gals/da q. ft.) (Min./inch) / Elevation O~5_Feet Feet VII. TANK Capacity in gallons Total # of r Prefab. Site Fiber- Ex er. INFORMATION Gallons Tanks Manufacturers Name Concrete Con- Steel Plastic p glass App. New Existing structed Tanks Tanks Septic Tank or Holding Tank lcbo 1:1 11 Lift Pump Tank /Siphon Chamber ❑ ❑ E1:1 1:1 l ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for instal tion of the onsite se ge system sh n on the attached plans. Plum er' Name: (Prin lumb s ignatu : (No Sta P MPRSW No.: Business Phone Number: ~ Gil' G- f`s G 9 A /RP Aoe~ 21, Plum er' ress (S r t, Citty, State, Zip Code : IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate ssue ISignature (No Stamps) *pproved E] Surcharge Fee) _ Owner Given Initial Adverse Determination X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: S13D-6398 (R.11/96) DISTRIBUTION: Original to County. One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS ' 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit may be renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer / Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3151. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber into fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County / Department Use Only. X. County / Department Use Only. Complete plans and specifications not smaller than 81/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; vrater mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. WHOLESALE DISTRIBUTORS OF: MINNEAPOLIS Pnone: _Space - Gard® LAKE ELMO BRANCH Phone: (612) 738 01 HIGH EFFICIENCY AIR CLEANER FARGO BRANCH Phone: (701) 235-0230 Fax. ST. PAUL BRANCH Phone: (612) 646-6537 Fax: (612) 674M ALBERT LEA BRANCH Phone: (507) 373-6412 Fax: (507) 373-9115 MINOT BRANCH Phone: (701) 852-9400 Fax: (701) 852-0942 MANKATO BRANCH Phone: (507) 345-3012 Fax: (507) 345-6568 MAPLE GROVE BRANCH Phone: (612) 391-7780 Fax: (612) 391-7851 ti t 40 as -_•••__='=^'-'°c.rc L;XOSS SECTION AND SPECIFICATIONS v" CI VENT PIPE Iy" MTN. 2! A80VE 25' FROM DOOR, WINDOW OR GRADE WEATHER PROOF FRESH AIR INTAKE JUNCTION BOX APPROVED FINISHED GRADE Cl RISER WITH CONDUIT MANHOLE t - 60 " MIN. W/ PADLOt ABOVE G AD,: 28" WARNING L i N. 6" MAX. v" M i r INLET oe, Z. WATER TIGHT SEALS 4 ,t GAS- ; f S ; CI PIPE TIGHT BAFFLE A SEAL V 3 ` ONTO -J-_ 1 APPROVED SOLID B ' LM JOINTS W/ SOIL ON PIPE 3 ~ 0 PUMP OFF EL'1/. C SOLID SOI D OFF RISER PERMITTED IF TANK 3" APPROVED BEDDING UNDER TANK MANUFACTUI HAS APPRO SPECIFICATIONS CONCRETE PAL) 'EPTIC / DOSE 'TANK MANUFACTURER : 'D'ANK SIZES: SEPTIC /6C7® NUMBER DOSES PER DAY: DOSE GAL. DOSE VOLUME INCLUDING ALARM MANUFACTURER: ~1tFLOW13ACK: D GAL. MODEL NUMBER : CAPACITIES: A - SWITCH TYPE: ~aINCHES B 2 ~I'UMP MANUFACTURER: INCHL:S - MODEL NUMBER : SWITCH TYPE: C 7o~NCN~:S KEOUIRED DISCHARGE RATE D INCHES ini U GPM WIRING AS PER ILHR 16 VERTICAL DIFFERENCE BETWEEN PUMP PUMP E ALARM M~®UM NETWORK SUPPLY PRESSURE OFF AND DISTRIBUTION PIPE . 23 ` FEET FORCEMAIN X FEET 7 FT/ 100 FT. FRICTION FACTOR FEET INTERNAL DIMENSIONS LENGTH TOTAL DYNAMIC HEAD _ FEET OF PUMP TANK: FEET ~i~ WIDTH DIAMETER LIQUID DEPTH IGNED: LICENSE NUMBER: ~~~~s~ W HEAD CAPACITY CURVE J t5/6 5/32- 4 "53157" - "55159" SERIES a 5/e 25 1 112 -11 112 NPT TOTAL DYNAMIC HEAD/CAPACITY PER MINUTE EFFLUENT AND OEWATERING J 15/76 6 - 50 SERIES - - = Ft. Meters CvI. Ltrs. 4 1/t6 U 1S 5 1.52 03 153 z< 4 tU 3.05 .N 129 0 15 4.57 19 71 11 10 Loch Voh•m 19.25' I 2 5 10 7/16 0 U.S. GALLONS 70 20 JO 0-0 50 LITERS I J 3/J2 0 ~ 760 FLOW PER MINUTE sazoa . artw CONSULT FACTORY FOR SPECIAL APPLICATIONS • Variable level Float Switches available. • Variable level long cycle systems available. :Available with special cord lengths of 15', 25', 35' and 54'. Alarm systems available. • Duplex systems available. Standard cord le SELECTION GUIDE automatic 9 ft. Standard cord lei - non automatic 15 1. Integral float operated mechanical switch, no external control required. 2- Single piggyback variable level float switch or double piggyback variable level float MS and 5715111 colaw switch. Refer to FM0447. t► VaMa e A SI x 3. Mechanical altemator Wak' 10-0072 or 10-0075. N Auto 8.0 tor187 mbdN om8 M57159 175 1 Ph Alollbd Ou x d. See FM0712 for correct model of Electrical Anernator. 'E-Pak". 1 1 5. Variable level control switch 10-0225 3 1 4 used as a control activator, with E-Pak (3) or E53155 d E57159 23p 1 4 1 or 7 (q) Hoak System. 4.0 2 or2 8 8 3 or 4 d S 6. Four (4) hole'.Lf'ak', junction box, for watertght connection or wired-in simplex or 53 Series - Wt. 221bs. 57 Series - 2 pump operation, PIN 10-0002- 55 series - Wt. 24 lbs. %M 27 tbs. 7. Two (2) hole "J-Pak', junction box for watedi ht 59 Series- wt. 30 tbs. 9 connection or spice. PM laooo3- Fa gtblrn9liDn addil9/W Zoeller POW= 'a* CAUTION Level Fhet S ~ ~ Gell~ortlation WrOat, FM0514 All inslaltabnn of controls ~hi+Be, FMD077: Ele~gl Aeemalor, FMIkbB, rrl~dlallir~l ApK PIB9yWrJl variable All nsiaolat nrotec ion de",cesandwiringshouldbedonebya7~absedlm "eddectncian. FM~I~;andSuelplSetayseaena.FA00e7•and nYp, FMQt9S; Alarm p and saferyeodessnouldbelotlowe0 mcludingthemost recentNal,aml Elndnc Cone INFCIand • ~4ba Celled 80x. FM0732 the Occuprponal Safety and Health a~ (OSHA! RESERVE POWERED DESIGN For unusual conditions a reserve safery (actor - is engineered into the design of every Zoeller pump. 7 MAX TO. P.O. 80X 76347 _ L&Asv*. KY 4V56-M7 f SNA°A 0 32 O!d AWa Lgee hw+eisd.. ~J Lrtuisurle, KY 40216 Pl!/LIP « (502)778.2731.1(800) 928.PtlAfP 4aW1n'Pc41011r SINE'.- 19, ` FAX(502) 774,X?4 ingAve. ion N46consin SANITARY PERMIT APPLICATION 201 S8fe1 E. W.WdBu~ashingtonAve. Department of Commerce In accord with ILHR 83.05, Wis. Adm. Code Madison, 7969 Madison, WI WI 53707-7969 • Attach complete plans (to the county copy only) for the system, on paper not less County than 8 112 x 11 inches in size. , • 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 t~~~ [Privacy Law, s. 15.04 (1) (m)). E] Check if revision to previous application 1. APPLICATION INFORMATION -PLEASE PRINT ALL INF RMATION State Plan I.D. Number Pro e r Name .1 Property Location { va 1/4,S T21 , N, R 9 (or) Pro erty Owner's Mailing Address Lot Number /d Block Number Cit , State Zip Code Phone Number Subdivision Name or CSM Nun*er II. PE F IL IN CIt -3 (check one) ❑ State Owned v:2 age Road Public 1 or 2 Family Dwelling - No. of bedrooms village Town OF 17& df~4 III. BUILDING USE: (If building type is public, check all that apply) Parcel Tax Number(s) 1 ❑ Apartment/ Condo OAO - /309 - v D - 060 2 ❑ Assembly Hall 6 ❑ Medical Facility/ Nursing Home 10 ❑ Outdoor Recreational Facility 3 ❑ Campground 7 ❑ Merchandise: Sales/Repairs 4 [1 Church /School 11 C] Restaurant/ Bar/ Dining 8 ❑ Mobile Home Park 12 ❑ Service Station / Car Wash 5 ❑ Hotel /Motel 9 ❑ Office/ Factory 13 ❑ Other: specify IV. TYPE OF PERMIT: (Check only one box on line A. Check box on line B, if applicable) A) 1. New 2. ❑ Replacement 3 Re lacement of System S stem ❑ p 4. E] Reconnection of 5. Repair of an yTank OnlyExisting System Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non-Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed X21 ❑ Mottno 30 ❑ Specify Type 41 ❑ Holding Tank 12 0 Seepage Trench 57' 5 r "x/22 ❑ In-Ground Prefisure 13 ❑ Seepage Pit 42 ❑ Pit Privy 14 ❑ System-In-Fill 43 ❑ Vault Privy VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. rE .Final Grade Required (scl Proposed (sq. ft.) (Gals/day/sq. ft.) (Min./inch) G„- levation . V _f a q7. ® Feet -Feet VII: TANK Capacity INFORMATION in gallons Total # of Prefab. Site New Existin Gallons Tanks Manufacturer's Name Concrete Con- Steel gFiber- lass Plastic App- Tank T nks strurted Septic Tank or Holding Tank / Lo _ ❑ ❑ ❑ ❑ ❑ Lift Pump Tank /Siphon Chamber ❑ ❑ ❑ ❑ ❑ ❑ VIII. RESPONSIBILITY STATEMENT I, the undersigned, assume responsibility for installati n of the onsite sewage system shown on the attached plans. Plumber's Name: (Print) Plu is Signat : (No M PRSW No.: Business Phone Number: dumber s A ress (Str2Z y, State, Zip Code): Viol IX. COUNTY/ DEPARTMENT US LY ❑ Disapproved Sanitary Permit Fee (includes Groundwater ate ssue Issuing Agent Signature (No Stamps) ~Qpproved ❑ Owner Given initial cj' / Surcharge Fee) / Adverse Determination ! ~U X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: S'80-s3W (8.11/96) DIST aunoH: original to county. one copy To: sarsq a Wilms Di.him Owner, Fk,mber INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. Code will be before h applicable. date, and at a time of renewal any new criteria in the 2. Your sanitary permit may be Wisconsin Administrative 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD-6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608-266-3151. To be complete and accurate this sanitary permit application must include: 1. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system isto be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new/or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump/siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County / Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, location of holding tank(s), septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference curve; oppumppmodeaand pump mapufacr~tu~er;rD) ; crdoss sseoct ones elevation differences; friction loss; pump performance of the soil absorption system if required by the county; E) soil test data on a 115 form; and F) all sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. i + i Inv* vow, Are. a X a-i S -~4 -Tai flu 3, ei..J Y.5 Q l~ 9~ ~ y t98L-L6£ (ZL9) :XPJ 08LL-L6£ M9) :8u0yd HONVUS 3AOd°J 3ldVW 8999-9b£ (L09) :XBJ Zt0£"94£ (L09) :eu04d HONVUS OlVNNVW Zt,60-Z99 (LOL) :XBd 0046-Z98 (LOL) :eu0yd HONVd810NIW 9tL6-£L£ (L09) :xBd ZL179-£L£ (L09) :eu014d HONVUB Val IM381V 89bL-9b9 (ZL9) :xBd L£99-9179 (Z L9) :euNd HONVUS invd *is 83NV3l0 8IV AON3101:1 HJIH L9bZ-9£Z (LOL) :xBd 0£ZO-9£Z (LOL) :8UNd HONVU13 ODUVd p~8~ _ a~BdS ZL£L-L£L (ZL9) :xBd £1-LO-8£L (Z L9) :euNd HONVUS OM3 3XV- SZ60-LL8 (Z L9) :xBd LZ£8-U8 (Z L9) :euNd sn0dV3NNIW ::jO SdO1nsldiSIa 31dS3l0HM Labor and Department Relations Industry, Labo and La SOIL AND SITE EVALUATION REPORT Page L of 3 Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but S'-1-•' G R O not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or IPARCELI.D.8 dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION-PLEASE PRINT ALL INFORMATION REVIEWEOBY FATE PROPERTY OWNER: PROPERTY LOCH N v,d~vov W X oN GOVT. LOT • 1/4,S 4 T Z 9 PROPEL ONE T MAILINNGD DREG ,N,R. 19 E (o~ LOT # BLOCK # SUBD. NAME OR CSM ~ . l~IE4S>'1AaT UlEtc9 CITY, STATE 20 11 CODE PHONE NUMBER 'CITY 'VILLAGE OWN NEAREST R/ep O VOSd 4~ ! $ , s y p (7i5) 3% - 3y3 8 NU vsoA, orY [•''New Construction Use[ Residential / Number of bedrooms 3 j) Replacement [)Addition to existing building f50- [ J Public or commercial describe Code derived daily flow &a& gpd Recommended design loading rate -'bed 2 , 91~ trench, gpdi'ft2 Absorption area required bed, ft2 trench, ft2 Maximum design loading rate ' ? bed. Recommended infiltration surface elevation(s) 3 gP try' ft (as referred to site plan benchmark) Additional design /site considerations 2/SC l S cf ,p v E D o.v S/~ E Parent material SCS I)A VoTA- S,• ( . Flood plain elevation, if applicable N ,f • . ~ $ =Suitable for system CON~I QONAL MOUNO ❑ U IN -GROUND U PRESSURE AT ►DE SYST IN FILL HOLDW, TA K U =Unsuitable fors stem L7$ LA'S ❑ LA'S ❑ U Q ❑ U ❑ S SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Structure GPD/fte- in. Munsell Qu. Sz. Cont Color Texture Gr. Sz. Sh.is Roots ( fertfi Bed o-e /o //A 3/z 2 A, S4K 3 ic- . S • G 2- S, •17 /a V/2 yl( s,/. ~le sd,~ Asti s Zf . y i . s^ Ground S yle S/ S~ l f S~~ eeUN a . y -_5 elev. /o.i . 0 ft 7 •S yP- y/G C.S. d , S a(.2 . 1, 0 1 Depth to € limiting ! laClQr ~v Remarks: (L " [ 11,4t,4- a-~ Al-Z - 4-o 401.2 t Z-© -'j 3 Boring # o, /o yR'3/2- s,-/ 2 A4 sk dW es 3 -F .5 ' . C- z /o ye 7/~ a'SX cs z ~ • Y ~ •S Ground 5-11 7C 5k Lr.4 mss' / . .5 ~o zelev. It. 30 • 9 7.5 Yr 5/(v c s o, s r- Depth to limiting factor Remarks: CST Name:-Please Print Ro BEQ L ~R 1 Phone: 715. 3 8G' 8185 ress: &5.5 O' N E i L lk D. t{- U O S'o A9 lit) IS . S y 01(0 5-:- CSrh 2.,q 8L Date: CST Number: SOIL DESCRIPTION REPORT Page? of 3 r PROPERTY OWNER VE7RrJ wRXO~ PARCEL LD. Al' /o Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Botxtc3y RootsGPD/ft in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed tench 3 ioye y s~ f s~~ ds~ s Z. y s Ground 3 3 /o ye S-/ SXiir' ~S 4 s l f . • S elew Ye 51 Depth to limiting = factor Remarks: Boring # 7 lo t/2 3/ $~'I 2 S~ii~ YS C S Z S G 0-L z 2 7-15- /o yR Y - - G s Z iP S c 5 3 'F . 5 . C. -7.5t/,e -//6 a s g Ground c 2 a2 Si ' / / f S.G~ ~7~i ~ S . y' ~ •S elev. z y 3 /o YR s/ s, s /0 tL Depth to 5 y- /o y'e s/ limiting factor 7 • Remarks: 11 Put E .4 W p it c'£ [7 i'2 v'y Boring # v . ly /e ye 3/2- Si Z A. A,4- d SLi -s "2 • S • G F (:5- a, S 26 -y' /o yie sly Ground elev. I /00 -9 -ft. Depth to limiting factor Remarks: Boring # ' Ground elev.. Depth to limiting facto Remarks: WOOF LeT- LOT l0 8-3 l 8 cy es 71 1~LLor /o ILL Sup uev DR'S Lo T yo' =p °u So , zP n, LOT- L f o er ra y E• l` eoRw LcleyAr NoAJ = too.b' . SCALE 3 O . • /3hc~~ a pl'Ts sus ~ES~E~ T~eor-~. ArZeA Z W O v 0 CA 0. co 1000, 0 OZ. Z. AA~• 0 5 6~o0Z DOE G / ( ~ h cm .9 T o OZ / oil A4 jam- W / M 0 0 IC) %A) 9) V6 00 V6 40 4. N / ~Z ( o ~ ~ / ~5 \ 00 M \ - I ff- S6 '11 £-3,1 15 A. 95o69 N _ - r / S6 •1 t £ l y ° o O / A cr. w U. O N 40 r / ti ° N UN / b ti e 00/ OD 0 0 A: Z i ~m O ~ / . 00/ 2 / Z V6 N ODD^ U) w _ AA 0 0.' OOci 1 a ^ l O~~ l ` UOON w b 3 s N a M OD Z ° Apo 24 ( - o s~ x o J / N/~=wco 2 VIo .W (Ope)a - a 2 ~ a ~ w I :d Q N 0 ~M I 01 O / " O ? I = ~g .Q C%i l O C _ 391. 06 oo'51 11 11 Ow? cn ^ to J I+• \ w OX0 C . 3„ 00, OOo06 N- - U a JNU , 04 /yea ° O N ~A9/ \ I y~ N C / a \ Z 0 ' N 0/ o i. I LL 8 T C - 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 Location of property -1/4-~ 1/4, Section f(p T ZGjN-R_ Lg W Township ~yZZ "snn Mailing address 6t!9 n , rd a ~'a ct 5ypIC0 Address of site 4L Subdivision name a c~4~-fit ll L~,~ j Lot no. Other homes on property? Yes_ t~ NO Previous owner of property ULp n w-i a Total size of property 2 , DO 2 Oc) Total size of parcel Z. oz) H-~~~,~, X S'9 -~--ff Date parcel was created Are all corners and lot lines identifiable? ~C Yes No Is this property being developed for (spec house) ? Yes X No Volume JL24)--~and Page Number r,~ 2Z as recorded with the Register of Deeds. INCLUDE WITH THIS APPLICATION THE 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) am (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. , 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. &0,6A 4A Si nature of pplican Co-Applicant q - /B- I gg- Date of Signature Date of Signature STC- 105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNER/BUYER i `n MAILING ADDRESS U q 'C.) 1. j A e d ) n J LIb l P PROPERTY ADDRESS 9 jj Qj V~/ C C B n LrA n e (location of septic system) Please obtain from the Planning Dept. CITY/STATE Lt PROPERTY LOCATION QE 1/4, 1/4, Section Ko T Z-ci N-R (~y W TOWN OF _•Ht.. 0(_-Sn n -1 ST. CROIX COUNTY, WI SUBDIVISION PLi~a nf 1 f L>U LOT NUMBER AD CERTIFIED SURVEY 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 1/3 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: am"x- i DATE: q - i g_-/G St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 1119 WARRANTY DEED Document Number REGISTER'S OfFiCE ST. CROIX CO,. WI .y SEF 0 8 1997 Return Address 1'40 P M KRISTINA OGLAND Zilz, Estreen & Ogland ~-.Sk I). P.O. Box 359 of °idi Hudson, WI 54016 Parcel I.D. Number. a/k/a Irene S. Waxon, husband and wife, . Verran Waxon, aWa Vernon E. Waxon, asd Irs Waxon, P conveys and warrants to William L. Wikox sax' Rae Ann Wilcox, husband and wife, as survivorship marital property, the following described real estate in St. Croix County, State of Wisconsin: Lot 10, Pleasant View in the Town of Hudson, SL Croix County, Wisconsin. This is not homestead property. M Exception to warranties: Easements, restrictions and rights-of-way of record, if any. i Dated this 51'4" day of September, 1997. 3" ffn -(SEAL)_ (SEAL) Vernon Waxo n, a/k/a ernon E. Waxon Irene Waxon, a/kla rene S. Waxon • ~ j AUTHENTICATION TR ~=~R Signature(s) Vernon Waxon, a/Wa Vernon F- Waxon, and Irene Waxon, aWa Irene S. Waxon, husbamd and wife, authenticated this day of Sze, 1997. Kristina Ogland TITLE: MEMBER STATE BAR OF WISCONSIN a. THIS INSTRUMENT WAS DRAFTED BY: Attorney Kristina Ogiand j Hudson, WI 54016 g