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004-1041-90-100
St. Croix County Planning and Zoning N%dnesday, A~rril 04, 200' at 8:58:30 AM Detail Sanitary Information Page 1 of 1 Computer #: 004-1041-90-100 Sub/Plat: >35 acres Section: 18 Parcel #: 18.28.15.283A Lot: TN/RNG: T28N R15W Municipality: Cady, Town of CSM: 1/4 114: NE 1/4 SW 1/4 Owner: Nelson, Robert 2744 County Road N Wilson, WI 54027 State Permit: Issued: 04/25/2005 POWTS Dispersal: Mound 24" or more suitable soi Permit: Reconnection County Permit: 84 Installed: 04/25/2005 POWTS Detail: NA Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Issuer/Inspector As Built Plumber Other Reouirements Additional Notes Money Owed Kevin Grabau NA Helgeson, Bennie see CSM; this house is on remaining acres not lot $0.00 None ' ~ "- No 1 of CSM 21/5235 Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 4/25/2008 Owner: Nelson, Robert 2744 County Road N Wilson, WI 54027 State Permit: 453247 Issued: 05/28/2004 POWTS Dispersal: Mound 24" or more suitable soi Permit: Replacement County Permit: 0 Installed: 06/15/2004 POWTS Detail: NA Bedrooms: 3 WI Fund: yes POWTS Pretreatment: NA NLlteS Issuer/Inspector As Built Plumber Other Requirements Additional Notes Money Owed Pam Quinn >4/1/00 -Not Required Helgeson, Bennie $0.00 Mark Iverson (contr ~:=~r,t-d Oft: Yes Parcel #: 004-1041-90-100 04/04/2007 08:48 AM PAGE 1 OF 1 Alt. Parcel #: 18.28.15.283A 004 -TOWN OF CADY Current X ST. CROIX COUNTY, WISCONSIN Creation Date Historical Date Map # Sales Area Application # Permit # Permit Type 08/09/2006 00 0 Tax Address: Owner(s): O =Current Owner, C =Current Co-Owner O -NELSON, ROBERT D & DONNA K ROBERT D & DONNA K NELSON 2744 CTY RD N WILSON WI 54027 Districts: SC =School SP =Special Property Address(es): ' =Primary Type Dist # Description SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 0.000 Plat: N/A-NOT AVAILABLE SEC 18 T28N R15W PT NE SW EXC CSM Block/Condo Bldg: 21-5235 (EZ-U-1107/576) Tract(s): (Sec-Twn-Rng 401/4 1601/4) 18-28N-15W NE SW Notes: Parcel History: Date Doc # Vol/Page Type 07/10/2006 CSM 21/5235 CSM 07/23/ 1997 813/582 07/23/1997 806/19 ~nn7 CI iMMeRV Bill #: Fair Market Value: Assessed with: Valuations: Description Totals for 2007: General Property 0.000 0 0 0 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: Batch #: 0 Class Acres Land Improve Last Changed: 08/09/2006 Total State Reason Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 Parcel #: 004-1041-80-000 04/04/2007 08:48 AM PAGE 1 OF 1 Alt. Parcel #: 18.28.15.282 004 -TOWN OF CADY 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 -NELSON, ROBERT D & DONNA K ROBERT D & DONNA K NELSON 2744 CTY RD N WILSON WI 54027 Districts: SC =School SP =Special Property Address(es): " =Primary Type Dist # Description SC 0231 BALDWIN-WOODVILLE AREA SP 1700 WITC Legal Description: Acres: 40.000 Plat: N/A-NOT AVAILABLE SEC 18 T28N R15W 40A SE NW Block/Condo Bldg: Tract(s): (Sec-Twn-Rng 401/4 1601/4) 18-28N-15W Notes: Parcel History: Date Doc # Vol/Page Type 07/23/1997 813/582 07/23/1997 806/19 2007 SUMMARY Bill #: Fair Market Value: Assessed with: Use Value Assessment Valuations: Last Changed: 04/17/2006 Description Class Acres Land Improve Total State Reason AGRICULTURAL G4 40.000 7,600 0 7,600 NO Totals for 2007: General Property 40.000 7,600 0 7,600 Woodland 0.000 0 0 Totals for 2006: General Property 40.000 7,600 0 7,600 Woodland 0.000 0 0 Lottery Credit: Claim Count: 0 Certification Date: 04/17/2001 Batch #: PRGRM Specials: User Special Code Category Amount Special Assessments Special Charges Delinquent Charges Total 0.00 0.00 0.00 /;3 e`er i ~6 VOL 22 PAGE 235 KATETCi~ H. W REGISTER OF DEEDS ST. CROI7C CO. , MI RECEIVED FOR RECORD 07/10/200b 08:15AM CERTIFIED SURVEY IIAP CERTIFIED SURVEY M~'!~'FEE2 3.00 LOCATED IN PART OF THE NORTHEAST 1/4 OF THE SOUTHWEST 1/4 OF SECTION 18, TOWNSHIP 28 NORTH, RANGE 15 WEST, TOWN OF CADY, ST. CROIX COUNTY, wlscoNSIN. RECEIVED N 1/4 CORNER SECTON 18~ l I C (5/8~ IRON ROD) NOTE: BEARINGS ARE REFERENCED TO N ~ AUG ~ 32006 THE EAST LINE OF THE O0n o NORTHEAST 1/4 OF THE 'r.~i c~i~ UNPI.ATTED LANDS SOUTHWEST } f4, BEARING SOO'08'59"E. (ST. CROIX COUNTY N 89'1746" E 392.02 "' i COORDINATE SYSTEM) OWNER: SURVEY CONDUCTED AT THE REQUEST OF THE OWNER: 808 NELSON 2744 CTH N WILSON, WI 54027 SETBACK NOTE: FRONT SETBACK = 50' ref '' ~. ,z ,~ . ~, ~~~, ~~ tP/a7 ° ~'~ _ N ~ ~~ s iso LEGEND: ~ SET 3/4" SY 18"I ON pIN WT. 1.50 LBS. / T. ~ • FOUND 3/4 IRON PI ~ -~ COUNTY SECTION MONUMENT ti (FOUND AS NOTED) r - - BUILDING SETBACK LINE ~` O PROPOSED DRIVEWAY LOCATION ST. CROIX COUMY SURVEYOR'S RECORD LOT 1 I~ Z 382148 S.F. I~ I~ O 8.77 Ac. ID ~y O O WITH R-O-W ~--yy -i* jo ~ 371521 S.F. r j~ r ~ 8.53 Ac. z ~o a IvZ ~ WITHOUT R-O-W Iw ~cn W v w ~ H S 89'17'46" W O ''' 70.00' ~ ~ ~ m c0 z s m .. - - .~ m A ~, (I ~ ' .~ O ~ O ~ O m Z f ~ ~ f p n ~^ CIl N 1c ~ O ~ ~ S 8 p ~~ I~ , to ~ co I_ V I I -~ ~' N I I r IQ ~ cUn ID In I ~ W ° ~ "' I l IZV W ~ I I~ ~. Ivy O N (cn I`O ~ N 89'17'46" E 322.02' -- -- -r-•------ - ~ - LOUTH LINE OF THE NE ~ ~ ~ ~ t/4 OF THE SW 1/4 8 Si; UNPLATTED LANDS ~;I$ ~N ~ S 1/4 CORNER SEC110N 18 THIS INSTRUMENT DRAFTED BY JEFF M1KLA (3" ALUMINUM MONUMENT) €i Vol 21 Page 5235 w 1of2 SHEET 1 OF 2 OQ N OCR 1 ... .~consin Department of Commerce PRIVATE SEWAGE SYSTEM oafety and Building Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provide may be used for secondaN Purposes fPrivacv Law, s.15.04 (1)(m)l. Permit Holder's Name: Nelson, Robert City Village X Township Cad ,Town of CST BM Elev: Insp. BM Elev: BM Description: TANK IN FORMATION TYPE MANUFACTURER CAPACITY Septic Dosing Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic Dosing Aeration Holding PUMP/SIPHON INFORMATION Manufacturer Demand GPM Model Number TDH Lift Friction Loss System Head TDH Ft Forcemain Length Dia. Dist. to Well SOIL ABSORPTION SYSTEM ELEVATION DATA County: St. Croix Sanitary Permit No: 84 State Plan ID No: Parcel Tax No'. 004-1041-90-000 Section/Town/Range/Map No: 18.28.15.283 STATION BS HI FS ELEV. Benchmark Alt. BM Bldg. Sewer SUHt Inlet SUHt Outlet Dt Inlet Dt Bottom Header/Man. Dist. Pipe Bot. System Final Grade St Cover BED/TRENCH Width Length No. Of Trenches PIT DIMENSIONS No. Of Pits Inside Dia. Liquid Depth DIMENSIONS SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacturer: INFORMATION CHAMBER OR Type Of System: UNIT Model Number. DISTRIBUTION SYSTEM Header/Manifold Distribution x Hole Size x Hole Spacing Vent to Air Intake Pipe(s) Length Dia Length Dia Spacing SOIL COVER Y Praee~~ra Rvetame only YY Mnunrl nr At-Grade SVStemS ~nIV Depth Over Depth Over xx Depth of xx SeededlSodded xx Mulched Bed/Trench Center Bed/Trench Edges Topsoil Yes No Yes No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: / / Location: 2744 County Road N Wilson, WI 54027 (NE 1/4 SW 1/4 18 T28N R15W) 40 acres Lot 1.) Alt BM Description= 2.) Bldg sewer length = - amount of cover = Plan revision Required? ~ ~j Yes ~ ~ No ~ I ', Use other side for additional information. Date Insepctors Signature SBD-6710 (R.3i97) Inspection #2: / /_ Parcel No: 18.28.15.283 -~ --- Cert. No. :r~ 02. of xu\ 12: ~5 Fa1 715 38d ~ld5d ST c:Rl LO ZU^:I,tiG f~l u u l County Sanitary Permit A 1 ' ST. GRQ4X000NTY MfISGONSIIV !n accora wiut 15.04 St Cr u ~~~yV~~a+ c~ zONING OFFICE GROIX COVNTI' C;OVERNMENT CEfJTER 9T Parsonai information you p•uvide r ay ~e s c)fsewnje~' P'~rPose . fF'rlva . ;. i',.u~t(luirr)i G71) 18 s ~ ~ O 2 1 2005 40113-7 0 W1 Hud cn, pPR (7t~)38ti-4ti80 Fax 1715 39t3-4ti85 Attach COm lets tans for the s tem on a ~i~tS-4/2 x 11 inCh66 in size. CCUn Sa ' P li # 17 C trek 1 ~~61~'s~ n t. A IlcaUon Information • Please Print 11 Information Location: Property Owner Name IV E 114 SW 1/4, Sec 1 ~ ROBERT NELSON E (or W R 15 T Lti N~ .__ ___ F+ropem Cwner's Ma!ling Addrtacs _ ~ . _ Lot Number 81ocJc NumboP '1744 CO RD N N/A N/A Ciy, State Zip Code Phone Ntrmer Subdlvlsron Name or CSM Number WILSON WI 54027 715/698-2866 N/A II Type o 8ttildinQ: (oheok one) Mq,~- . e), 3 I U ^%ity ^ vulage ~7Town of ~ t or 2 Family Dwelling - No. of Bedrooms: 3 ~~.,,~. ~D1apQ., CADY merrral (describe use): G P blidt, .om u C' 3tdte•owrred Nearest kaad N Check box on line E if applicable) li l A b COUNTY KD ne y one ox on . II. Type of Permit: (Check on Parcel Tax Number(s) 1•^ Repair . ® Reconnection 3.^Non•plumbing 4. ^Rejuvenation Up4-1041-9U-ODU A} Sanltatlon Perrrdl Number Date Issued e) ® State Sanlia Permit was rewousr issued 453247 - - N. Type of POWT System: (Check all that apply) Non-pressurized In-ground (~ Mound ^ Sand Flktrr p Construoted We'.18nd =' Pressurized In~rounc ^ Holding Tank ^ Singltz Pass ^ Drip Line r At- tads ^ Aerobic Treatment Unit ^ RACIrcWadng ^ Other V. Dis ersallTreatmentA t. Design Row (gvd) rea Information: 2. Dispersal Area 3, Dispersal Area _ _ __ 4. Soil Application Rafe 5, Perodatlon Rats E. System Elevation T, Fin 0 RegWred ?roposed (Gals.lday/sq.ft) (Min~nch) Elevation 450 450 450 1 N/A 94.5 96.3 an n ormat On pa fin a ons ~ o # of ManufdCttJ~ 6r' Prefab Site Con- Ste61 Flbor~ R~stIC New Existing Gallons Tanks Concrete structed glass Tanks Tanks 1000 ^ O ^ C 6(70 600 1 WIESER CONCRET ^ ^ ^ ~ VII. Responsibility Statement I, the undvrzignod, aSLtAtto rpzponslbiUty for repair/teconnencbonlrejuvenaGon/installatlon of non plumbing for the POWTS shown ort the atiattred pldn8. A license is not re wired for terralitt re air or the Installation ofnon-plumb) sanitation s z:tom~ Plumbar5 Name (prlnl) Plu s Signature s~ s): MPlMPRS No. 9uslness Phone Number BENNIE HELGESON 220292 715 772- 278 Plumber's Address (Street. City, State, Zip Code) [x1229 770TH AVENUE, SPRING VALLEY, WI 54767 VIII. County Use Onl Dior roved Sgnitary' Permit Fee Dats Issued Istuing t Signaturo sCtmDS) ADPrOvetl Owner Giv itial AdverEe ~ ~ ~...~- ~' Zs ~ anon ~ IX. Coe+dltb fAp ro / 3\-t-t. ~ ~ p, ~f2 - Cane ~ '~ ""` ~~~ ~ S ~~- ~~.re1~ ~ SYSTEM OWNER: / t0.. 1 S ~ ~~ eptic tank, effluent filter and dispersal cell must all be serviced /maintained ~ ~~Of JSIO~ • as per management plan provided by plumber. 2. All setback requirements must be maintained as per applicable code/ordinances. ~^~~ - - e U- O i +- 0 4 v ~ ~ 1 U L. '--s v S J a_ / M b 0 ~~~V Z 1.~~`/ oQ-t, _, G ' °~ 'I ~~I j+. ti~ ~I ~ti c~i '1 ._ ._._-~ 7 ,-. . ~0 :~ ~ J ~ \~ alp ~~ j ,~ ~ ~~ ~ 4-- vI ~ ,~,, / '"1 j, O ~J - t~ v_-' .~~ ~ 0 J ~ V7 / / '- / `~ // / ~v ~ ~~ ,~, / ~ ~ ! ~l ~ ~~ ~~ ~ -~ ~ ~ ~~~ n ~ ~~ ~ ~~~ ~ J ,s ~ ~ ~ x a u! ~ z J s~ ~ ~ a ~ ~ ~a a i ~ ..Q ~, J ~ ~ ~ --s - U ~ ^' ' 7 N c U ~ , O --C ~ i S S ~ .~ ~) M ~ v -n d -- ~ ~ ~ vl ' .i ~ S' _ L U ~ ~ ~J1 ~ ~ v a ~ J ` 1~I ~ ~ ~ •L vt ~~~ ~ -~ a 0. ~~ ~~ 0 ,~1 Y ~ ~ L `r~ ~ ~~ ~ ~~ ~ ~ ~ ~ ~~ _ i ,~ ~ ~ 3~ ~ ~ ~~ ~~~ q ~~~ r~ .~ ~~ V .^ S~ vl ~ y ~ ~ ~~ ~ ~ ~ ~ ~ _' ~ ~ .~ :~, ~ ~~ ~~ /~~ --- -- ~~ ~~ 'I ~~ ti -_ __-~ l T ~~ ~a I i' ItJ 'o ~ ~ I i ,,,, `~ ~_ ~ ~ vi ~ ! ~~ I RPR-25-05 11:09 F1M FAX COVER SHEET NELGESON E7fCAVAT/ON INC W1229 770TH AVENUE SPRING VALLEY, W/ 54767' PHONE.• 715/x72-3275 FAx.• r,srrrz-33e~ SEND TO Company name Flom 7T . ~ ~ ~ K f ,,f~ ,•1 BENNIE HELGESON / Atlenfion Date , OMcs cation OMce location Fax numbor Phone number ~ / `~ ~ ''~ ~ . y c~ ~ 715x772-3279 ^ Urgent ^ Rop/y asAr ^ Ploasa eolllmenr ^ Ploase review ^ po- yourlnlbrmst/on P.@1 WisconsinDapartmentofCommerce PRIVATE SEWAGE SYSTEM Safety and Building Division . INSPECTION REPORT (AITP:~~I TCI~PERMIT) GENERAL INFORMATION Personal information you provide maybe used for secondary purposes [Privacy Law, s.15.04 (1)(m)]. permit Holder's Name: City Village X Township Nelson, Robert Cad Townshi SST BM Elev: Insp. BM Elev: BM Descriptio /d0 ~ ,,,,,._ o 1 GST SANK INFORMATION ELEV ION DATA TYPE MANUFACTURER CAPACITY Septic loon tbo~ Dosing Aeration Holding ~ A~g~~ A- yob TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. Vent to Air Intake ROAD Septic '7' /00 ,,,, 90 -c----- Dosing ~ boo -~ 95 ti 50 -~, 50 .--, Aeration Holding PUMP/SIPHON INFORMATION Manufacturer / Demand f L3 t~v t s GPM Model Number ~G , ~O~ TDH Lift Friction Loss:lo~ Stem Head TDH F Forc m i ~ Lengt 5 ~ Dia. ~ ,I~ t Dist. to Well ~ /Q~ ~ Z. ' SOIL ABSORPTION SYSTEM County: St. Croix Sanitary Permit No: 453247 0 State Plan ID No: Parcel Tax No: 004-1041-90-000 SectionlTown/Range/Map No: 18.28.15.283 STATION BS HI FS ELEV. Benchmark . o z /~ ~-° Boa Alt. BM Bldg. Sewer ~ II' ~? wit ~,~ St/Ht Inlet /3 ~ Flo F~; -~J~ SUHt Outlet Dt Inlet Dt Bottom ~ ~~ Header/Man. 7. 9s. /~ Dist. Pipe SG '~ . 7~ ~ ~ - t'~ Bot. System ~~ 5 ~' ~ ~f S-O Final Grade St Cover /~ •67 ~~ .~~ ~~a~ q•5Z 93.5 c, BED/TRENCH DIMENSIONS Width ~ ~ Length y G! • Z~ J~p No. Of Trenches I PI~DIMENSIONS No. Of Pits ide Dia. L' Depth SETBACK SYSTEM TO P/L BLDG WELL LAKE/STREAM LEACHING Manufacture. INFORMATION CHAMBER OR ~ T f stem: YPe~Y ~ ~, ,v 7 /~ ~ \ ` ~~ / . r ~ N UNIT Model N DISTRIBUTION SYSTEM Header/Manifold ~ I1 Length ~ Dia Z 5 Distribution ] d Length ~ ~ Dia Spacing Pipe(s) ~Z x Hole Size ~,.$z, x Hole Spacing a7 ~, Vent to Air Intake SOIL COVER x Pressure Systems Onlv xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth of I xx Seeded/Sodded xx Mulched Bed/Trench Center ~ (~ Bed/Trench Ed es g ,~ ~-~ To soil I p ~ Yes ~ No ~ Yes ~ No COMMENTS: (Include code discrepencies, persons present, etc.) Inspection #1: ~0 / ~ 5 / d Inspection #2:_~/ IS /~`~ Pte- ~: /(o.~F? Location: 2744 Cty. Rd. N Wilson, WI 54027 (NE 1/4 SW 1/4 18 T28N R15W) 40 acres Lot ~ /fi ~IQ~Parcel No: 18.28.15.283 -~ r / y 1 J Alt BM Description = 10~ 2+Y ~~'"'G- ~~...,.k~.. ~OJeJ`- 2.) Bldg sewer length = r (e ~ e~ ~~~ ~ Pl~v~-~^- ~~~` ~6~ ~^'~~ - amount of cover = JC T~ ~ ~ C ('~ Q(~ ~ ,~~ T J 11d- Y ~ Use otherls de for additional in Yes No ~ formation. ~ ~' _ _ ___ _ . _ 'D-6710 (R.3/97) Date Insepc~s Signature Cert. No. ~ ~ ' ~~ ~ 5 x ~ 7s ~ 1'r' ~ r4- Ft' ~ ~ ~ ~ O T . -" ~- F--~' ~ Q 1° ~ Q ~ ~ ~ T _ ~ o ~ Q _ ~ ~ O a o ~ ~ ~ ~o p ~ s~ ~-~' m o F ~. ~~ ~. /~ ~. JIFF U n~ V ~~ _~ W 3 N /y n ~M a s r z ZP ~ ~, ~ ~ ~~ ..b Q~ ~ ~' r ~ ~--~ ~ ~~ m ~~ ~~ o n / ~ r ~ ~ ~ / ~ ~~ 0 6 ~ / P y 0 a w 0 00 . D ~ Saftay and Buildings Division ~ 201 W. Washington Ave., P.O. Box 7162 ISCOnsI'~ Madison, 16!I ~ 53707 F 716 ~artment of Commerce (608) 266-3151 Sanitary Permit Application in accord with Comm 83.21, Wis. Adm. Cade, personal inforrtution you provide may be used for secondary purposes Pr ~~TT. I. Application Information - Please Prittt All Inforn Property Owner's Na me kUBERT D NELSUN ~ ~j Property Owner's M ailing Ad ess 1744 CUUNTY ROAD 1V I acy a s`I~g~ ~ ` `_ i (°- I~-tion `~ F ?y' I rt~r~ :;u(~: - ~,.~,, City, State Zip Ctxie Phone Number ~ WILSUN, wI 54027 715/ ~~_ II. Type of Btulding (check all that apply) / ~] 1 or 2 Family Dwelling -Number of Bedrooms • 3 ~S ~{ ^ Public/Commercial -Describe Use ^ State Owrted -Describe Usc `pIST~ CAL $~C S~p, ?i~ tm C''dn' _._ .. ~ ~ County ST CROIX Sattitary Permit umber (to be QUed in by Co.) ~~~~~_. Sate~~Ptah I.D. Ntimbcr ~ ~ ~ g 3 3 Project Address (if different that mailing d ~~N~ c~.1 Parcelr Lotr Bloch, UU4-1041-9U-U00 N/A Iv/A Yropcny Location ~ p • 0 NE ~k, S~~{ bG,Section li3 (CifCIC Qjlt) ~U~~ 'I' 1~ N; R 15 E or W Subdivision Name CSM Number i`;/a N/A ^Ciry~^Village $XI'owrtship of ' CADY - III. Type of Permit: (Che only one box on line A. Complete lice B if applicable) A' ^ New System ®Re acement System ^ Treamient/Holding Tartk Replacement Oltly ^ Othct Modification to Existing System I B. ^ Permit Renewal ^ Permit Revision ^ Change of ^ Permit Transfer to New List Previous Permit Number tu>d Date Issued Before Expiration Plumber Owner ~/ i IV. T of POWTS S stem: (Check all that a 1 ) ^ Non -Pressurized in-Ground Mound > 24 in. of suitable soil L~ Moulin < 24 in. of ^ At-Grade ^ Sittgle Pass Sand Filter i ^ Corsswctcd Wetland ^ Pressurized In-Ground ^ Holding Talilc . ^ Peat Filer ^ Aerobic Treaunen[ Unit ^ Recirculating Sand Filter ~ ^ Recirculating Synthetic Media Filter ^ Leaching Chamber ^ llrip Line ^ Grrvel•less Pita ^ OIIICf (CXPIaII]) s ~/ i .. a.o ... v...... ~.... ~; Duign Flow (gpd) 450 ..~...... -- ~... -- .--__- .. - Design Soil Applic• •o a gpdsl) ' ~l 1 ~~~ ~ Dispersal Arc• Re~luircJ (sQ 45U 7~ Uispersal Area rupuse~ (st) 45U ~S'7p System Elevation 94.5 VI. Tank Info Capacit in Gallons Tutal Galloru Numlxr of Unlu Manufacturer Prefab Cont.rete Site (rotLSWCted Stael Fiber Glasi Plastic New Talcs Existing TalO:s ! Septic or Holding Tank 1000 1000 I WIESEK CUiVCRETE X Aerobic Treatlnelu Unit I 1f ~ ~ /~ oOS1"e ~" 600 6UU 1 6vIE5Ek CONCRETE X VII. Responsibility Statement- I, the ulldersiglled, assuuse respottslbility for uutallatlou of the POWTS shown at the attached iaa4. Plumber's Na me (Print) Plum Si gnature MP/MP12S Number Busitless Phone Number iHEIvNIE fiELCESUN 11U2y2 715/771-317i~ Plumber's Addre ss (Street, City, State, Zip Code) ~ '~ l a-~ Wl'L'L ~77UTH AVENUE, SPRING VALLEY, WI 54767 VII .County/Department Use Only Approved ^ Disapproved Sanitary Permit Fce includes Grou~ ter Da issued issuing A Stg tw q , Surcharge Fee) ~ ~ ~jt ,~ ^ Owner Given Reason for Denial `~(J IX. Conditlons of ApprovaUReasoris t'or Disapproval 3 ~ 4/f~(,^ I~Yt S~~ '"(%~'~~/~~~ STEM OWNER: ~~~t,~~,~ ~~~r'r~vn ~ 1 )Septic tank, efflue t filter is d (iy,, l ~(~•(~ -;~l~t~ /~~~ ' l~ dispersal cell must all be serviced /maintained 1 _~~ U~/ ~ GAG as per management plan provided by plumber. ~ YYtQii~tC~ ~~~ "! ~'`~ S 2. All setback requirements must be maintained ~„~~i~~. J~/J~ "' ~G~~'1 d~~" as per applicable code/ordinances. ~~m- ~3, 4~3 ~~ ~~~~~ G~~~- fin- ~jois~in~ i rs~~ h~ WT. Attach complete ylaus (to We Couuty ouly) for the systetu ou payer not less W:ul 81/2 1'11 Iuches to size C`T)T1 ~~OQ !D n~ln~i ~. /%~e_ ,~ I Safety and Buildings 4003 N KINNEY COULEE RD commerce.wl.gov • ` ~ ' LA CROSSE WI 54601-1831 ~ ~ TDD #: (608) 264-8777 www•commerce.state.wi.us/sb i sco n s i n Department of Commerce www.wisconsin.gov Jim Doyle, Governor Cory L. Nettles, Secretary May 12, 2004 CUST ID No.220292 ATTN: POWTS Inspector BENNIE W HELGESON ZONING OFFICE HELGESON EXCAVATING ST CROIX COUNTY SPIA W 1229 770TH AVE 1101 CARMICHAEL RD SPRING VALLEY. WI 54767 HUDSON WI 54016 CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 05/12/2006 Identification Numbers Transaction ID No. 996833 SITE: Site ID No. 683224 Robert Nelson Please refer to both identification numbers, 2744 County Hwy N above, in all corres ondence with the a enc . Town of Cady St Croix County NE1/4, SW1/4, S18, T28N, R15W FOR: Description: Three Bedroom Mound System Object Type: POWTS Component Manual Regulated Object ID No.: 957181 Maintenance required; 450 GPD Flow rate; 24 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, COll[~1h0 stats. ~-PPF~C The following conditions shall be met during construction or installation and prior to occupancy or use: RTMENT OF ~ ,81p1 N General Approval Requirements: ._s/...~_ "~ SEE CORRESP • This system is to be constructed and located in accordance with the enclosed approved plans and with the "Mound Component Manual for Septic Tank Effluent for Private Onsite Wastewater Systems" SBD-10572-P (R.6/99) and the "Pressure Distribution Component Manual for Private Onsite Wastewater Treatment Systems" ~~ SBD-10573-P (R.6/99). ( • )The changes made to,~t is plan on 05/12/04 by this reviewer were acknowledged and approved by the system ~~ designer. /~'t Q/Yl/1~ `~ lp ~f y ~ ~ Z~~' ~ , • The existing POWTS must be pcoperly abandoned per Comm 83.33 Wisc.Adm. Code. t/ • 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 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 BENNIE W HELGESON Page 2 5/12/04 • A Sanitary Permit must be obtained from the county where this project is located in accordance with the requirements of Sec. 145.135 and 145.19, Wis. Stats. • Inspection of the private sewage system installation is required. Arrangements for inspection shall be made with the designated county official in accordance with the provisions of Sec. 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 made 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 cbratz@commerce. state.wi.us Fee Required $ 175.00 Fee Received $ 175.00 Balance Due $ 0.00 WiSMART code:. 7633 cc: Leroy G Jansky, Wastewater Specialist, (715) 726-2544 4 ; PROJECT NAME INDEX S,~IEET ROBERT NELSON 2744 COUNTY ROAD N WILSON, WI 54027 ROBERT NELSON sq,~F 9FcF~~Fp ry&e~oGSO iv. PROJECT LOCATION: NE 1/4, SW 1/4 , S 18 T 28 N, R 15W MUNICIPALITY: TOWN OF CADY COUNTY: ST CROIX DESIGN: PRESSURE DISTRIBUTION MANUAL SBD-10573-P(R/99) MOUND COMPONENT MANUAL SBD-10572-P (R 6/99) PROPERTY OWNER: CONTENTS: Page 1; Plot Plan Page 2: Cross Section and Plan View of Mound Page 3: Distribution Pipe Layout Page 4: Septic Tank & Pump Chamber Cross Section & Specifications Page 5: WLP 1000/600-MR Zable Tank Specifications Page 6: Pump Specifications r~~fy, Page 7: POWTS Owner's Manual & Management Plan - Pg. 1 ~{~,~ Page 8: POWTS Owner's Manual & Management Plan - Pg. 2 N ~~fERCE ILQIN JND EN Name: Bennie Helgeson r Signed .,_,_ Address: W 1229 770th Avenue Spring Valley, WI 54767 Credential Number: 220292 Date: May 5, 2004 Vi.A~ln'e r~. ~obef-~ /1~e 1So(~ _~~~.w~lq~cir. elny~lf ~l~e Sc~ ~~0~`/~ ~~. 1~- ~©t+aw. o~ Noc~s~ s~~,~~ ~.~1 ~~ g7.15- s~,~k.~ f~br . G~ ~ bbb n ~ A5 ~ ~~ ~ ~l ~~~I~ 1"= yo' ,~x~~~~ ~}s S~to~~ T c I° A ~(o t P(a~, ~ t,~EIL (~ I o ~ €3 ~D~12 ~ L out .5 ~ -rte bt. P~~,~ t F. t ~ Q ~ ~ '~~ d ~ ~So ~ / , o Q3 c .7TH ``,~/ -' Page a Of S Synthetic Covering ,~STM C 3 -~ Medium Sand ~ Topsoil Slope !J i ~ 3 1` ~ t ~.~.0 f 2M- 2 '2 Aggregate _ Cross Section Of A Mound Distribution Pipe ~le~ . 9~ ~ 3 ~ SyslP.~-~ F 9 ,S 0 / ` ~~rrnu i;1~V. q.3•S Force Main From Pump q ~ Ft. Signed: (3 ~~.?~Ft. License Number: K ~. Ft. L 7`/©SFt. Date: d (~.~ Ft. T ~- F t . W~,~Ft. Plowed Lover D / Ft. E /. 3~ Ft . F , ~U Ft. ~ , s' Ft . H / Ft. L -- Observation Pipe a -.,.._--- ~ J ~ ------ --- K A !. ~ __---- ---------------------------------- w G ~ _ ~ l ------------------ ~ Distribution ~`=L'1' Of z - 2 a Pipe Aggregate 1 Observation Pipe Plan View Of Mound C )ea~~o~ A-<<rs` ' .C ~'~ELC+INo~-~ PorrorolnA r'IP• Onloll ~ ~ ,/ End VIEW P~rforolao ~ _ , P Holes Located on Bottom are Equally Spaced ~~~n'1.cs.1t1L e ~, .. r+ tt ,A n ~- ~e ~ ~ x T -E- ~ /"/ d vi 6Y~_t 9~- ~ i~~l f'Ip~ Distribution I'i a La out Signed: License Number: Dace: P ~~ , ~j~'~Y`' S a`~ '` x ~?" Y 1 Hole Diameter g Inch Lateral ~ Inch (es) Manifold " ~/~ Inches force Main " _ ~ Inches ~~ ~I~e~. ~.,t,~VE 9'S; O I ' -rr-6 = ~ S~ rfOIQ$ 1 e~ ~G~e L ~cJ~~letr- e~ ~-0.~era.~ S= )C ©~Q~ /~lo/eS - - ~ oWY1P,r ; ~o~P,~+ ~ e,~ So h Page y Of$ SEPTIC TANK E PUMP CHAMBER CROSS SECTION AND SPECIFICATIONS v .~IK.VENT PIPE 12" MIN. ABOVE GRADE E ~~ >_ 25' FROM DOOR, WINDOW OR FRESH AIR II~T~~E~, 93. ~ . 9 ~ r© u,~ ~~{11 18" 'MI INLET T - ~ WATER TIGHT SEALS ~FILtER A APPROVED to"x ~~~, B PIPE 3' ~ ONTO SO110 C SOIL PUMP OFF ELEV . ~(o. D FT . -~ D NEATNERPROOF JUNCTION BOX WITH CONDUIT APPROVED MANHOLE COVER W/ PADLOCK E WARNING LABEL -4" MIN. MIN• ~8u JOINTS WITH ALM APPROVED PIPE ON 3' ONTO sol.IO soli FF S.O ~~ 1 ~~ I' GAS- ~ 1~ TIGHTS SEAL ~ r I 3~~ gppROVED BEDDING UNDER TANK CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE /~, 3 `/ X S. %~ Sl , g S- GPI. TANK MANUFACTURER: ~~ SEA TANK SIZES: SEPTIC `_ D07 1 G~l M--~FLO BACKG ~ GAL. DOSE , GAL. j_ = ~/ g' INCHES = 6/. ~ GAL. ALARM MANUFACTURER: f // .~, F ~e f~-o ~jSrew.S pACITIES: A AL ~~ -MODEL NUMBER: 1 DI H ~ ~ g = 2 ~~ INCHES ' G = 3-.3•_ SWITCH TYPE: 6~ ~ INCHES = )00.5 GAL. PUMP MANUFACTURER: F ~ OS(I C = , ~ ~ CHES = I6`~~ ~O ~L' MODEL NUMBER: I ~ ~ D = IN SWITCH TYPE: ~- - ARM WIRING AS PER I LHR 16.23 WAC D S- GpM pUMp E AL REQUIRED DISCHARGE RATE ~_,L FEET VERTICA L DIFFERENCE BETWEEN PUMP OFF•AND•DISTRIBUTION PIPE.• ~~ FEET + MINIMUM NETWORK SUPPLY PRESSURE FEET + ~/~ FEET FORCEMAIN X 2:0~7FT/100 FTOTALIDYNAMICAHEAD •_• FEET WIDTH DIAMETER INTERNAL DIMENSIONS OF PUMP TANK: LIQUID 6E"P'I`A- ~~ C LICENSE NUMBER: DATE: SIGNED: 1/88 150' ao -rnp ~n~w SCALE: 1 /4' = 1' OUTLET rn ~inF viFw SCALE: 1/4" = I ~~ s ~F~ - WLP1000/600-MR ZABLE TANK SPEt~FlCAl10NS DIMENSIONS: WALL: 3' BOTTOM: 3' LAVER: 5" MANHOLE: ~4' I.D. HEIGHT: 56 O.D. LENGTH: 150' O.D. WIDTH: 84' O.D. BELOW INLET: 42' O.D. UQUIO LEVEL: 38' WEIGHT: 14.795 LBS. INLET AND OUTLET: - 4" BORE WITH STOP FOR QUIK-T1TE, FERNCO' GASKET, CAST-A-SEAL 800T OR EQUAL INLET AND OUTLET BAFFLES: - WISCONSIN, SEE DETAIL X10 (OTHER STATES SEE CHART) LIQUID CAPACITY: 27.88 GAL/IN (SEPTIC) 16.76 GAL/IN (PUMP) LOADING DESIGN: 7' 0" UNSATURATED SOIL ~~C~~~Q ~o~c~~~~~ WJ716 US HWY 10, MAIDEN ROCK, WI 54750 800-325-8456 MODEL WLP1000/600-MR ZABLE SEPTIC/SEPTIC, SEPTIC/PUMP OR SEPTIC/SIPHON JANUARY, 2000 FILE: w1.n1000 600-MR ..~.,r~ ul.l"' =~=-_ „ ~ Pump Specifications '/3 H P Up to 40 GPM ~ Discharge size 1'/." NPT Solids:'/e" maximum Motor Single phase: 115V Materials of Construction Brass/thermoplastic Features and Benefits •Top suction eliminates impeller clogging. •Corrosion resistant ~ construction. - •Float actuated switch. MFTER$ FEET ___. 2 ,. _.__. _. _. ' ; ! MODEL DVP03 Q ~ I = 5. I ~ v ,5 ~ .. _.1 ..... . "L 4 i a > 3 10 I o 2 I 0 5 ~, of u 1. _. ..._~. _ ... _ .. I 0 5 10 15 20 25 30 35 a0 U.S.GPM o z 4 6 e lomlAlr CAPACITY MEIEOS FEET .. , to ~ . i MODEL: 3871 l 9- 30 J/._ 6 _I. I ..I_ I_. (.rCs~. , ._. II` ' _. . _ _ _. o ,; i c=.1 5 ._.__-_. _-___ .._._ ........ ...... _.. _. i .. 1 .__ _... e 15 ~'-- EPOS, , ' i ~, o _ _ I .... i ,._.. --- ~ 3 10 ~ +__.__ i _ _ , 2 --- I ' _I ; 1 ~ '------ ._ _. L_._ _ .. i_. _ _- 0 00 10 20 30 40 50 US. GPM 0 2 4 6 6 10 12 ~Ar Pump Specifications 'ho and'/: HP Up to 60 GPM Maximum head to 32' Discharge size 1'/2"NPT Solids:'/<" maximum Molor All motors feature ball bearing construction. Single phase: 115V Materials of Construction Cast iron Thermoplastic Stainless steel CAS AOItiYr Features and Benefits • EP04 impeller- semi-open design with pump out vanes to protect mechanical seal. • EP05 impeller -enclosed design for improved performance. •Rugged glass-filled thermoplastic casing and base design provides superior strength and corrosion resistance. • Cast iron motor housing for efficient heat transfer, strength, and durability. •Corrosion resistant threaded stainless steel shaft. •Available for automatic and manual operation. • CSA listed models available. All Models are designed for continuous operation and feature stainless steel hardware. ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM OwnerBuyer ~° ~- ess -4 ¢ Cow /e b, !V W ~ZSo~ ~" ~ s~Z'7- Z~l-1`? Mztltng A~~.r Property Address (Verification required from Pla~uiing Department for ne City/State Vy /~S° ~ ~ ~ 1 Parcel Identification Number U~ 4 I ~~ ~ - ~ ° -~'° °- LEGAL DESCRIPTION ~.3 1 N-R ~ ~ W, Town of ~~ Property Location N~ /+, ~,~ /+, Sec. _!~ , T-~_ ~- Subdivision Certified Survey Map # Volume ,Page # Lot # Volume 81 ,Page # Ra Warranty Deed # ~'~J ~6 °~ ~'7 Spec house O yes ~1 no Lot lines identifiable lid yes D no SYSTEM MAINTENANCE 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. The property owner agrees to submit to St. Croix 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 wastewaterdisposal 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 s °^ set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of WisconsO~CCe~fi~a30 stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning days of a three ye expir ion date. ~ / l r/ O DATE SIGNATURE OF APPLICANT OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (otu) knowledge. I (we) am (are) the owaer(s) of the pr erty de c ' ed above, by virtue of a warranty deed recorded in Register of Deeds Office. qq /l1 /O'i- ~ DATE SIGNATURE OF gpPL;ICANT Any infotznation that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** W-iYiWt •• Include with this application: a stamped warranty deed from the Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed ' POWTS OWNER'S MANUAL & MANAGEMENT PLAN Page 7 of ~ FILE INFORMATION Owner ROBERT NELSON Permit # `~~ ~/ L/f DESIGN PARAMETERS Number of Bedrooms 3 ^ NA Number of Public Facility Units ~ NA Estimated flow (average) al/da Design flow (peak), (Estimated x 1.5) 450 al/day Soil Application Rate al/day/ft2 Standard Influent/Effluent Quality Monthly average " Fats, Oil & Grease (FOG) 530 mg/L Biochemical Oxygen Demand (BODS) 5220 mg/L ~ NA Total Suspended Solids (TSS) 5150 mg/L Pretreated Effluent Quality Monthly average Biochemical Oxygen Demand (BODS) 530 mg/L Total Suspended Solids (TSS) 530 mg/L ^ NA Fecal Coliform (geometric mean) 510° cfu/100m1 Maximum Effluent Particle Size Y8 in dia. ^ NA Other: ^ NA "Values typical for domestic wastewater and septic tank effluent. SYSTEM SPECIFICATIONS Septic Tank Capacity 0 al ^ NA Septic Tank Manufacturer WIESER CONCRETE ^ NA Effluent Filter Manufacturer ZABLE ^ NA Effluent Filter Model A-100 12"x20" ^ NA Pump Tank Capacity 600 al ^ NA Pump Tank Manufacturer WIESER CONCRETE ^ NA Pump Manufacturer GOULDS PU iPS INC ^ NA Pump Model 3871 EP0511F ^ NA Pretreatment Unit ^ Sand/Gravel Filter ^ Peat Filter ^ Mechanical Aeration ^ Wetland ^ Disinfection ^ Other: ®NA Dispersal Cellls) ^ NA ^ In-Ground (gravity) ^ In-Ground (pressurized! ^ At-Grade ~ Mound ^ Drip-Line ^ Other: Other: ^ NA Other: ^ NA Other: ^ NA nnerNTCNeNr`F C(_HFt1111 F Service Event Service Frequency Inspect condition of tankls) At least once every: 2 ^ ea~lsjlsl (Maximum 3 years) ^ NA Pump out contents of tankls) When combined sludge and scum equals one-third IY3) of tank volume ^ NA Inspect dispersal cellls) At least once every: 2 ~ yearl Ils) (Maximum 3 years) ^ NA Clean effluent filter At least once every: 13 44 monthls) ^ year(s) ^ NA Inspect pump, pump controls & alarm At least once every: 13 ^ yearl )Is) ^ NA Flush laterals and pressure test At least once every: 3 ^ year(sjls) ^ NA Other: At least once every: ^monthls) ^ year(s) ^ NA other: ^ 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 tankls) to identify any missing or broken hardware, identify any cracks or {oaks, 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 cellls) shall be visually inspected to check the effluent levels in the observation pipes and to check for any ponding of effluent on the ground surface. The ponding of effluent on the ground surface may indicate a failing condition and requires the immediate notification of the local regulatory authority. When the combined accumulation of sludge and scum in any tank equals one-third IY3) 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. GMW (4/01) OWNER:, ROBERT NELSON ' ~ Pape ~_ of ~. ,~ , ' START UP AND OPERATION. For new construction, prior to use of the POWTS check treatment tank(s) for the presence of painting products or other chemicals that may Impede the treatment process and/or damage the dispersal Celt(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 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.targe dose, ovenoading the Cell(s) and may result in the backup or surface discharge of effluent To avoid this situation have the contents of the pump tank removed by a Septage Servicing Operator prior to restoring power to the effluent pump or contact a Plumber or POWTS Maintainer to assist in manually operating the pump controls to restore normal levels within the pump tank. Do not drive or park vehicles over tanks and dispersal cells. Do not drive or park over, or otherwise d(sttub 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; degreasefs; dental tlaoss;'d(apers; disinfectants; fate foundation drain (sump pump) water, fruit and vegetable peelings; gasoltrte; grease; herblddes; meat scraps; medications; oil; painting products; pesticides; sanitary napkins; tampons; and water softener txine. ABANDON«l1AENT ' When the POVYTS fails and/or is pennanentiy taken out of service the following steps shall be taken to Insure that the system is properly and safely abandoned in compliance with ch. Comm 83:33, Wisconsln'Administratlve Code: • All piping to tanks and pits shall be disconnected and the abandoned pipe openings sealed.• • The contents of all tanks and pits shatPbe removed and properly disposed of by a Septage Servicing Operetor.~ • After pumping, all tanks and pits shall be excavated and removed or their covers removed end the Void space filled with soil, gravel or another inert solid material. CONTINGENCY PLAN If the POWTS falls 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 soU absorption system. The replacement area should be protected from disturbance and compactlon,and should trot be infringed upon by required setbacks from existing and proposed structure, lot Uses and wells. FaUure to protect the replacement area will result in the need for a new soil and site evaluation to estebUsh a 'suitable replacement area. Replacement systems must comply with the rules In effect at that time. O A suitable replacement area is not available due to setback and/or soil limitations. Barring advances (n POVYTS technology a holding tank maybe Installed as a last resort to replace the felled POWTS. O The site has not been evaluated to Identify a suitable replacement area Upon failure of the POtM'S a soU and site evaluation must be performed to locate a suitable replacement area. If no replacement area IS evallable 8 ~ holding tank may be installed as a last resort to replace the failed POWTS. ~ Mound and at-grade soli absorption systems may be reconstructed in place following removal of the bkunat at the inflVative surface. Reconstructions of such systems must comply with the Ntes in effect at that time. <WARNING» SEPTIC, PUMP AND OTHER TREATMENT TANKS MAY CONTAIN LETHAL GASSES ANDlOR INSUFFICIENT OXYGEN. RESUOLT.ERESCUE OF AI PERSON FROM THE NTERIOR OF A TANK MAY BE D F,FICULT OR IMPOSSIBLE. MAY ADDITIONAL COMMENTS POWTS INSTALLER POVifTS MAINTAINER Name HELGESON EXCAVATI N Name JOHNSON SANITATI N Phone 715/772-3278 •Phone 715/273-5811 SEPTAGE SERVICING OPERATOR PUMPER LOCAL REGULATORYAUTHORITlY Name JOHNSON SANITATION Agency ST CROIX COUNTY ZONING Phone 715/273-5811 Phone 715/38b-4680 This document was dnlRad by the staffs of the Graon l.ako, pAarquatta and Waushara County Zonlnp and Sanitation sytuld¢s: Thla docurtlant mNti u,e minimum requirements of ch. Comm 83.22(2)(b)(1)(d)S(f) and 83.54(1), (2) b (3), Wisconsin AdminlsUat(w Coda Uas of thlt; doCUmORtdo~i AOt guarantee rho perforrnanes of the POWTS. G1AUIl(?pt) DacUMeN7 NO. WARRANTY DEED STATE BAIL OF WISCONSIN FORM 2- 43840'7 •.•-. eoo~ , _. Marcia..l~.-.Pe.tersomA.- f/k/.a .Marc.ia...A.....D.'.Rcurke~~... .a- aiggle..person ................ .......................... conveys and «arrastts to ... Robert-, D.. Nelsoq- and ........................ Aolnma...K.... N~aisaa...husband..ansi...xi.~e.,...boiding............ e.a...muxY~Ya~ceh.i.~...me~ri. E.d~...p>E'.opeJF~y ..................................... a St. Croix .-Cauntp. the follovein described real estate in ..............-. .............................. State of Wisconsin: TNI! !-AC[ R[itRV[D /OIT R[CORDINO DATA REGISTER'S OFFICE sr. caoix co., wi Reed fo- Ree~xd ,111N 1 S 1988 of 9t6s A M ~M e! Daed~ RETURN t0 Menalanie Farmers Credit Uhion 860 Cedar 9aldlrirt, NI 54002 was Parcel No: Southeast Quarter of Northwest Quarter (SEA of NWT) and Northeast Quarter of Southwest Quarter (NEB of SW~) of Section Eighteen (18), Township Twenty-eight North (T28N)r Range Fifteen West (R15W). This ..- ..is ................ homestead prope:-ts. Exception to warranties: Easements and restrictions of record. Dated this ......:.....13 ............................ day of .....-- ....-.IUII@......-....--- ..........._............ 19.88 . --•-- ---------- ........................(SEAL) . ~LL' LZSl,- ~.~ .(~ Ct~~.r.Ii.~ .... -... (S EAL3 • Marcia A. Peterson --• . ..................... .....................................(SEAL) AIIT'SENT:CATIST2i ACBNaWLRBGt~C33NT Signatnre(s) ............................................................ STATE OF WISCONSIN --•-------------------------------•---._.....__.._..---.._._._........-------••- st. Croix ..................... _.......---..-County. $a. fy, authenticated this ...._._.day of ........................... 18._.... Personall came before me this Y ` .___ . g.._...-day et --------_S'~ _'~.~ .....................• 19..~~._ the show's name) •. ---..Marcia..A.._.Pete>;som.--• . .. ... .........:...~....-:__ ~. ITLE: ~2EMBE13 STATE BAR OF WISCONSIN •~ ' ...... i ~ - -• t • ~~ ....................•--...-•--•---•---•--...._...._......_ :..G • - .,,: ; (If net.. ................ . . ~ ` ~ .. .................... .-..... -•---•--•--- - authorized by ~ 706.Mt, Wia. Stats.) •-----.......--•---------..._...----•--•--•------• - to me known to be the person ....-.-..... ----~_•- t '~---~--' ¢• ~ wh xet~ t ~. THIS INSTRUMENT WAS ORARTCO eY foregoi 'nat:-u and acknowledge ~ - /~/ L tree ~~~ ~ a n3+~...•~ \'' \ R M ~ ' .•th~ V y ..-. ....------T~Ama S...A.r...-AS:CrQ~Ina4'A-•--•---•-•---•---- ... .. . i .... -~--~~•-• - .......... .... ..........Haldl~i~l~. .W ~ . 549Q2 •. Eieubea.~oornink------------ - -- X St CrOi --------- ----- --- -- . . . ... ................ ....... . .- Meta-v Public -•-- -- - - ---....Counts, Wia. (SlRnatares may be authenticated or acknowledged. Rath rfy Commis:ion is permanent. ([f not, state exniratien are not neeesaary.) date:......Augunt..2T .......... . ..._..-. ...--..... 1s.8R....1 ~NAR!!! Ot Dersnro sitninf 1^ ARC uDAelt1 .Mould hs tined or prinUrl below their silnaturell. w-11R>R/11r'r! DIiT,D 8TATti AAR OT 1NISC0li3iV ,wisrmlein L«tal fllar,k t•.., inr YOftdl 170. •-~ IyNS .H.;w.a sec. Wb. -, . Wisconsin Department of Commerce SOIL EVALUATION REPORT Division of Safety and Buildings in accordance with Comm 85, 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 not Umited to: vertical and horizontal reference point (BMj, direction and Parcel I.O. D percent slope, scale or dimens(ons, north arrow, and IocaUon and distance to nearest road. o_ ~ .~~ ~ '! Personal InforrnaUon you provide m+~ be Law. s. 15.04 (1) (m)). Page ~ of ~~ oa PropertyO(w~~ner R AA `` P < ~ GovLLot /1!~ 1/4~~1/4 S (~ E( R i'g T~~ N p~Y' <S t2 /V~ # Block # L Subd. Name or CSM# Property owners Mail ing Address ~ ot ~-__ /~(/ u`"`' ~~ /J U a ~ ,~ Y ~ , T ~ ~ N ;~;-, . ~;; ~u;x ccur~-~~~~ r . ^ City ^ VlNage 't'own Nearest Road ~ C~, ~ State Code - 5'~oa~ (7~ s ! -a g 6 CA.~ y C'. T_ H iv r ~ So~ use GPD ^ New Construction Use: (,~'f'2esidential / Number of bedrooms 3 Code derived design flow rate [~'~eplacement ^ Pubiic or commeraal - Desaibe: ~~ R ' Flood Plain elevatlon if applicable Parent material ~ ©~S-S General comments ~r~ ~ ~ ~ - X $-~ . ~~' r _ G FLL W ~ ~~ %~ ~~ ~" c~ c.~nc~er- u~O p-pr and recommendations : Edg ~ © ~ CO ~t'f'oul~ q 3 $- ~ M d u.N,D Sy s ~~ ,,,.. F~eU. 4 v, s / [' Boring a 7 In. ^ Boring # ,-.,~ ~ fj h, Depth ra limiting factor L1 P(t Ground surface elev. Texture Structure Consistence Bound Horizon Depth in. Dominant Color Mansell Redox Description t]u. Sz. Conl Color ~ 2 ~---~ a4 -~ ~~ 7,S' I 'I/ I Boring # ~ Bo g 11 ~~' II pit Ground surface elev. ~-? • 3 tt• Horizon Depth in. Dominant Color Mansell Redox Description Qu. Sz. Cont. Color Tey - vY~- '3 - -t 9 ©~t2 s~ 3 _ p ~ v~ - {2 . s- ~~ S~/~6 Depth to IimlUng factor ~ ~• lure Structure Consistence Bound. Property Owner ~o ~ ~--~ 4~~ ? w Parcel ID # Boring # ~~ Boring _ . • _ / QQ~~ ..~~ De th to limiting factor .~ in. l1 Pit Ground surface elev. ~ h• P G..: Page ~ of ~ • 8ortng ~. a Boring # Ground surface elev. ft. Depth to limiting factor ~ ^ Pit Texture SWcture Consistence Boundary Roots Horizon Depth Dominant Color Radox Description Gr. Sz. Sh. 'EfF#1 in. MunseA Qu. Sz. Cont. Color , • Effluent #1 =GODS > 30 _< 220 mglL and TSS >30 _< 150 mglL `Effluent #2 = 80Da, 30 mg/t. and 7SS S 30 mglL 'The Department of Commerce is an equal opportunity service provider and employer. tf 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. sen-a»o rx.doo) [] Boring ~ Boring # _ h, Depth to limiting !actor ~ tlon Rate Pit Ground surface elev. Texture SWcture Consistence Boundary Roots GPD/ff Horizon Depth Dominant Color Redox Description Gr. Sz. Sh. •Etf#1 in. Munsell Qu. Sz. Cont. Color . :,, 0 M d a +- S `b o~ 0 ~d 0 i~ r7 Y ~~ v~ ~` ~ b ~- - . > 4' ~~ ~ -o ~~ t p r ~ ~ c. ~ ~y ~ o ~.'f, fi . N ---~ s ~ ~ ~ _ ~~ ~ d ~ Q ~ ~, s or ~ ~-- ~ ~ 3~ ~ ~ ~ ~ ~~ ~~ ~ cn c~' ~ cn ~ 3 r~ ~_I~ u1 E-- _S// ~l .S~- -+- l 0 a ~~-- "v ~~ v 1 ''• a !' ~ ' LUATION REPORT Page of SOIL EVA Wisconsin Department of Co a ,. r ~ - ' Division of Safety and Buildin ~ City i ccord ce with Comm 85, Wis. Adm. Code f, ~ Rai Attach complete site plan on Paper not less than 8 1/2 x 11 Inches In size. Plan must include, but not Ilrttlted to: vertical and horizontal reference point (BM), direction and Parcel I.D. percent slope, scale or dimensions, north arrow, and location end distance to nearest road. vie y Date Please print all information. • Personal InforrnaUon you provide may ba used for saoondary Purpotaa (Privacy t.aw, ~. iS.W (t) (m)). party pwner PropartY Location rr-- ~ 2 <<S ~ c 2 Govt. Lot /U E 114 S~ 1/4 S I S T~ S N R I S E R p ~''- Lot # Block # Subd. Name or CSM# pro o ~ ~ ers Mailing Address \~ N ~~ .~ --~~ y c . r. N City ^ Village CA.4 Nearest Road ~~ ~~ _ y c. r. H use GPI 3 Code derived design flow rate ^ New Construction Use: (H'~esldential / Number of bedrooms - ~teplacement ^ Public or commercial -Describe: ~l~ - R ~ ., rs' ~, Flood Plain elevation If applicable Parent material General comments ~ W ~ r ~ %.~ ~ • ,~ n ~ u„c.~ ~ r ulo P pr and recommendations: ~ ~~ 3 . S Ed9 z C~ ~~ C v .. o«~- r~ n u.N.~ sy s ~{ ~v~ r r~~. ~ v, S- / ^ Boring Boring # Pit Ground surface elev. ~ tt• Ground surface elev. 9~, -~ _ h• ~~/%L,% ;, Depth to limiting factor o2 7 In• Depth to I1miUng factor ~-•-- ~• a ~ ~. • ~ . ~{ ff f- ~ ~ ~ ~~ U p rT L~ `-? ~ ~' r Parcel ID # Page ~ of Property -- ~ c7 Owner Boring # ^ Boring ~ r~ > ft. Plt Ground surface elev. ~ Depth to limiting factor ,~ ~, ,n, ._ ~ Soil Iicatlon Ra P . LK Horizon Depth Dominant Color Redox Description Texture SWcture Consistence Sz Sh. Gr Boundary Roots GPD/f 'Eff#1 'EfF#2 ~. Munsell t1u. Sz. Cont. Color . - d ~ C ~ c J ~ ! G - I ~ R ~ ~' , ~ ~ ~ ~ to :3 ly-~~ ~ - ~ 5~ ~ ~l S ~ ~. ,, _ , tr , ~ y ~r_-s~ ~n~~ s .. [] Boring ~, a Boring # __ n, Depth to IimiUng factor SoU Icatlon Ra ^ PIt Ground surface elev. GPD/if Horizon Oepth Dominant Color Redox Description Texture SWcture Consistence Boundary Roots Gr. Sz. Sh. •Effa'i1 'E~ in, Munsell Du. Sz. Cont. Color Boring ~ in. Boring # Ground surface elev. _ h• Depth to IimiGng factor ^ Plt ~~ Texture SWcture Consistence Boundary Horizon Depth pominant Cdor Redox Oes(Yiptlon Gr. Sz. Sh. In, Munsell Qu. Sz. Cont. Color . • Effluent #2 = BOD < 30 mg/L and TSS _< 30 tnglL 'Effluent #1 = BODE > 30 _< 220 mg/L and TSS >30 < 150 mg1L ~- The Department of Commerce alternate format, pleasescontactpthe departmentlat 608-2 6y3151 ord aT'fY 608-264-8777. sorvtces or need material to an SUD•t))0 (0..6N0) `s A I e ~~ ~ fa i ~ .~~ ~ ~~ ' ~ ~ / 4 ~ ~ ~ ~ ~`y ~/ ~~C~, P~ 4 ~ ~ ~~ ~ ~ ,d .J --~_ v1 ~ Q ~ ~ ~ ~ ) ~ ~~i7 3 °S ~ ~ d ~ ~ ~ ~ ~i _1 ~ ..,~ ~` ~ S. l', ,~~'a I s O~ c~ 0 a v ~~ c.1~ ,j^ ~~ cv. ~ . .~ ~ _ .~ M S `~ l.n ~ _.1 I __.L ~7 ~ 1 -- i~ ~ - -- . 7 - - - _ - _----___ s ~~ ~ ~ ~ ~ _ ~~ ~ ~ ~ - ~ O ?'- cT7 s ~ o #~~ ~~ ~-~ ~~ ~ ~ ~ .s 0 a` `~-- N 4 ~~ _~ 1 3 ~s r ~ ~`I~ ~ f v ~ w ~~ I~_ HELGES N ~~~~ EXCAVATI N, Inc. ~'~~- ~~ ~~~ v>oo~ ~~ ~. SEWER AND WATER SPECIALISTS ~`-„-~-~'~..- ' r'~~ ~._ Plumber/CST Cert. #220292 BEN HELGESON Office (715) 772-3278 W. 1229 770th Ave. Home (715) 772-3127 Spring Valley, WI 54767 Fax (715) 772-3387 July 20, 2004 St. Croix County Zoning Office ATTN: Pam Quinn 1101 Carmichael Road Hudson, WI 54016 RE: BOB NELSON WISCONSIN FUND Dear Pam: Bob Nelson would like to apply for the Wisconsin Fund. I have added ahand-dug pit to the soil evaluation report. (B4) is located next to the old septic tank that was pumped and filled when the new system was installed. When we removed the freezer panel off the old steel septic tank I could see the top had caved in and the sides were rusted through. I believe septic waste had to be leaching into saturated soils. Sincerely, yz-z~-~~ ennie Helgeson President ~_~~~ ~~ BH:cb Enc 1 " ~ ~' • `' SOIL EVALUATION REPORT Page ~ or ~ Wisconsin Department of Commerce Division of Safety and Buildings in accordance with Comm 85, ws. Adm. Code ~~ t RO/ Attach complete site plan on paper not less than 81/2 x 11 Inches in size. Plan must ~7 include, but not Ilmtted to: vertical and horizontal reference point (BM), direction and Parcel I.D. lO ~ _ ~0 percent scope, scale or dimensions, north arrow, and location and distance to nearest road. evie ~~ Please print all lntormatlon. ~ -~ ~ Q Id ma bs used for secondary Purpose (Privacy Law, s. 15.04 (1) (m)). (,~.f/!/Y~'~- Personal Inlorma0on you p-ov e y PropaRy LOcafl Property Otw~ner ~,1 ~2 < GovL Lot /1I ~ 1/4 S w1/4 S (g T `~ ~ N R I S E ~-_.. p r ~ <S~ c1 Lot # Block # Subd Narrw or CSM# property Owner's Mailing Address `~ ~~ N r ___, ~-- a~~ Cm, c. .H State Zip Code Phone Number T Had ~N a ° Clty A ~ Y e own N C ,U~ l so ~ti Syo~`i c 7i s ~ -~ s 6 • c ^ New Conswdion Use: ~esldenUal / Number of bedrooms 3 Code derived design flow rate DSO GPD (replacement ^ Public or commerdal -Describe: ' ~~_ _ ~ levation t(applicabte e lood Platn F ~~ 4 Parent material " General comments ~ e, J C t lJ~ C - ~j ~ X J ~ • ~~' ~ O /] / l l Cam' F~'L.- W L T n ~e7 ~~ ~n !J~ ~n~'et' u~p~r - and recommendations : Edg z o h ~ 0 l ~.,0~ y 3. $ M d U.N~D 5y s ~~ ~ F (~•~. 9 v, s / ^ 6onng /} q Q a 7 In. a Boring # l~ Pit Ground surface elev. _"~ ft• Depth to limiting factor __ Horizon Depth L~J Penal nt Color Redox Description Texture Stn.-cture Consfstertce 8oundatN Room in. Mansell Qu. Sz. Cont. Cdor Gr. Sz. Sh. /~ •t r l ~ f C L~ r f n f. ,S' ^ Bo~t9 a Boring # ~/ ~~ ft. pit Ground surtace elev. 5 ~/%E S ~~ Depth io limiting factor ~ ~• ;; . ~° , Property Owner ~oGe'"'T ~~ow Parcel ID # Boring # r~-~~~nng t~ Plt Ground surface elev. ~ h• ' Effluent #1 = BODE > 30 _< 220 m9lt-and T55'30 _< 150 mgll. Oepth to limiting factor .~J~-- in. Page ~ ~ 3 • Efluent #2 = BODE < 30 ~ and TSS < 30 mglt. The Department of Commerce is an equal op a`rt leas scontactpthe depaartrnenttat 608-266-3151 oa aTTY 608-264-8777. services or need material in an alternate form , p SUD•lJJO (R.M70) Boring Depth to limiting factor ~• Boring # ~ Pit Ground surface elev. _.__.__-- h• Sop i~tbn Rete Texture SWcture Consistence Bou~rY Roots Horizon Depth Dominant Color Redox DesaipUon •E(f#1 '~ Gr. Sz. Sh. in. Munsetl Qu. Sz. Cont. Color , • n Y ... ' , ~ ~ ~ ~ cW ~ ~-~ ~~ ~~ ~ ~ ~. ~ .~ U m `~ ~~~ ~ ~ o .._.(G ^0 ,.fi r, ~ ~' ~ ~ ~ ~ Q r = ~ ~ ~ ~, ~ ~ ,1 0 G S , o ~; ~ A 0 rn r r C_ ~:. ~• ,~ ~l I!.` ---r I^ R 1 --t- ~f ~~ =w ~ o ~ .., T (~ r~ ~ ~' f .----~.__ V''` ~ ~ ~ jft O 1. ~ ~ ~- ~' ~ q ~ ~ • ; -" ~? / ~u /~~ / ~ s ' .~ F~ / ~ ~. Px ~ rd ~..-~, /~' ~~' ~ N~ ~ ;~ ., ,w . r ~ ~~ ~ w !~ ~ St. Croix County Planning and Zonin Detail Sanitary Information Friday, April 22, 2005 at 12:05:55 PM Page 1 of I Computer #: 004-1041-90-000 Sub/Plat: 40 acres Section: 18 Parcel #: 18.28.15.283 Lot: TN/RNG: T28N R15W Municipality: Cady, Town of CSM: 1l4 1/4: NE 1/4 SW 1/4 Owner: Nelson, Robert 2744 County Road N Wilson, WI 54027 State Permit: 453247 Issued: 05/2812004 POWTS Dispersal: Mound 24" or more suitable soi Permit: Replacement County Permit: 0 Installed: 06/15/2004 POWTS Detail: Bed -Seepage Bedrooms: 3 WI Fund: POWTS Pretreatment: NA Notes Inspector As Built Mark Iverson (contr NA Signed Off: Yes Plumber Other Requirements Helgeson, Bennie Additional Notes Monev Owed $0.00 Maintenance Scheduled Pump Date Pumped 1st Notification 2nd Notification 3rd Notification 6/15/2007 `~,~ r-,~,;~\ ST. CROIX COUNTY ~~ ~ --~-~~-~ '~ =- - WISCONSIN r ~' ~ ~ ~, `~ ZONING OFFICE ''~~a -- ST. CROIX COUNTY GOVERNMENT CENTER ~'~~•' _ ~_,~_ R. _~.- 1101 Carmichael Road -.. _ -'' Hudson, WI 54016-7710 (715) 386-4680 • Fax (715) 386-4686 December 28, 2004 Robert D. Nelson 2744 County Road N Wilson, WI 54027 Dear Mr. Nelson: After reviewing your Wisconsin Fund application, I have determined the application to be ineligible to receive the Wisconsin Fund grant. The failing sanitary system must be a complete sanitary system. The Wisconsin Department of Commerce defines a "Private onsite wastewater treatment system under State Statutes Section 145.01 (12), as a sewage treatment and disposal system serving a single structure with a septic tank and soil absorption field located on the same parcel as the structure." Because your system only included a septic tank and had no soil absorption field, it is not considered a legal system. Enclosed you will find a check for reimbursement of the $100 Wisconsin Fund application fee. If you have any questions, please feel free to call me at (715) 386-4680. Sincerely, Kevin Grabau Zoning Specialist Enclosure Cc: file KG/jn ~~ r`~w1A.. NOTICE OF VIOLATION May 27, 2004 ROBERT NELSON 2744 COUNTY ROAD N WILSON, WI 54027 RE: Failing septic system at 2744 County Road N. Town of Cady - St. Croix County, WI Computer # 004-1041-90-000 Parcel # 18.28.15.283 Dear Mr. Nelson: ST. CROIX COUNTY WISCONSIN ZONING OFF=CE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 FAX (715) 386-4686 As required by the ST. CROIX COUNTY ZONING ORDINANCE, notice is hereby given that you are in violation of § 2S4.S9(2) Wisconsin Statutes, COMM 83.32(1) Wisconsin Administrative Code, and Article 15.04 of the St. Croix County Zoning Ordinance. This system has failed under the defmition in § 14S.24S(4)(b) Wisconsin Statutes (Category R). This violation was first noted on May 27, 2004. The violation noted is septic effluent discharging to the ground surface. An on-site inspection on OS/27/2004 did reveal the septic effluent discharging to the ground surface. If fines and or forfeitures become necessary to bring about the abatement of this violation, they will be assessed as of OS/27/2004 in accordance with Chapter 145.12(4) Wisconsin Statutes. THE FAILING SANITARY SYSTEM ON THIS PROPERTY POSES IMMEDIATE HEALTH CONCERNS AND NEEDS PROMPT ATTENTION. REQUIRED ACTION: By July 1, 2004, contract with a certified soil tester to have a soil evaluation conducted. The soil evaluation will determine the type of septic system needed and it's location. Then contract with a licensed plumber, who will design the septic system and obtain a sanitary permit through this office. The septic system must be installed no later than September O1, 2004. If you have any questions or concerns that I can address for you in this matter, please feel free to contact me. I look forward to working together to resolve this matter. Sincere , evin a u Zoning Specialist cc: file - ...« ~' ~~' State of Wisconsin WISCONSIN FUND -PRIVATE SEWAGE SYSTEM Safety and Department of REPLACEMENT OR REHABILITATION PROG ^ Q ~ Buildings Commerce [~ _J~ D Division OWNER'S APPLICATION ~-~' Instructions For Properly Owners: RFf`GIIICn Owner Name* -- // Social Security No." Additional Owner ~ Social Security No: "' ~oB~rzT ~, ~l~csa,~/ 39/--f~--4z39 Ecso ~1 oN~ ~- ll ~ ll 395 -4~ A~ t4 Address Telephone Number (include area code) 2 7 ¢4 C~ ~D ~ ~~ s -~9~ - z8~~ City, State Zip Code If there are additional owners, attach documentation listing all ~ , /~GS~~ ~i ~40Z7- Z ~ 1 ~ o`~ers and their soaai security numbers. 'Grant awards will be issued in the name and address of this "Note: Your Social Security Number may be used to verify your owner. nance pa ments. income and status of support or mainte / 1. Was the failin rivate sewage s stem installed rior to Jul 1, 1978? Yes ^ No 2. is this application for a principal residence or a small commercial establishment? Principal Residence (Complete both if applicable.) ^ Small Commercial Establishment // ff applying as a principal residence, do you occupy this residence 51 % of the year't »Yes ^ No ^ NA If applying as a small commercial establishment, do you own and occupy the small commercial establishment? ^ Yes ^ No ^ NA 3. ff applying as a small commercial establishment, what is the small commercial establishment's name: Descri tion of Small Commercial Establishment (farm, restaurant, etc.): 4. Has there been a change in ownership of the principal residence or small commercial ~ ~~ establishment served by the failing system within the last three years? ^ Yes itfNo If es, please explain: 5. As the owner, are you a licensed plumber or contractor engaged in the business of ~ installing private sewage systems? ^ Yes o 6. Will a portion of the replacement system be funded by another program? ^ Yes No If es, explain: 7.. How did you hear about the wsconsin Fund-Private Sewage System Replacement or Rehabilitation Program? i'~ i~~ . ~ /U~IGt~f3ofL, 8. Evidence of income. If applying as a principal residence, attach a copy of your federal income tax return for the year of or prior to the enforcement order or determination of failure. if you were married and filed separate forms, you must also include your spouse's return fOr the same year. You must include evidence of income for each owner and for each owner's spouse. If you are applying as a small commercial establishment, submit a copy of your federal profit and bss form for the year of or prior to the order or determination of failure. ff you or any owner listed above were apart-year resident or did not file an income tax return, contact your governmental unit for further instructions. Evidence of income will be kept on file at the governmental unit and is subject to ver~cafion b the Department of Commerce. Property Owner's Certification. 1 certify that, to the best of my knowledge and belief, the infomtation 1 ve provided on this form and all attachments are true and correct. Owners na Date Signed Co-OHmers Signature Date Sign 9 ~1a~ ~~;~ q ~a~- Personal Information you provide may be used for secondary purposes [Privacy law, s. 15.04(1 m)). SBD-9163 (R. 11/2002) r PART B. TO BE &D B -- , GOVERNMENTAL UNIT 1. VERIFICATION `,~- On the document used ~to v~ftfy~ownei~ip, do the names match those on Part A of this application? If no, please attach additional documentation explaining. 111~Yes ^ No H the applicant answered yes to question 4 on Part A of this application, did the applicant(s) own the property when the order or verification of failure was issued or the system installed Yes ^ No and incur the cost of replacement? Document or Pag Document used to ve ' ownershi : Number. 2. Will the system serve a structure thaYs being replaced? 'Yes 0 No ff es, have all uirements outlined in Comm 87.20(4 ,Wis. Adm. Code, been met? ^ Yes ^ No ^ NA 3. Is a ublic sewer available to this props ^ Yes 1~No 4. Hasa revious grant been awarded for this props under this rogram? ^ Yes I~No 2 5. Principal Residence evidence of income. Please indicate applicable annual family income: $ / ~ . ~ l0 Federal income tax form ~~ Line, Year -3 OR Affidavit of ,Year Small Commercial Establishment evidence of income. Please indicate applicable annual gross revenue: $ Profit & loss form used: ,line ,Year 6. When was the existing failing system installed? ^ Prior to 12-1-1969 ^ 12-1-1969 to 7-1-1978 Vertical distance from the bottom of the existing infiltrative surface to a limiting condition: ^ 0 to Less than 24" '8.24 to Less than 36" 0 Equal to or greater than 36" Date of the Order or Determination of Failure: 7. Private sewage system failure caused by discharge of sewage to (check all that apply): Surface water or groundwater ............................................................................................................... ^ Category 1 A zone of saturation ............................................................................................................................ ^ A drain file or zone of bedrock ......:....................................................................................................... 0 Category 2 The surface of the ground .......:............................................................................................................. ^ Catego 3 Back-up of sewage into the structure served ....................................................................................... ^ ^ At-grade ' 8. This request is for what type of replacement system: ^ Conventional . ^ Experimental if this request is for a system not listed at the right, please explain; ^ F;olding Tank ^ In-ground Pressure Mound 9. Uniform Sanitary Permit Number ~ ~ O~ `T~ Date Issued~o~ ~ roved ~ f ~ 2 I~ ~ ~ ~ $ ~ ~ Date A l N b Pl A pp um er pprova an riment proval Number Date Approved 10. After reviewing this application, I have determined the applicant to be: ^ Eligible ^ ineligible If ineligible, reason ineligible: 11. Govemmentai Unit Representative's Certification: 1 certify that I have reviewed and verfied all information provided on this form and attachments and that the are true and correct to the best of m knowledge and belief. Signature of Authorized t3ovemmental Unit Representative __ Tifie Date Signed >~ s State of Wisconsin PRIVATE SEWAGE SYSTEM REPLACEMENT Department of OR REHABILITATION GRANT PROGRAM Commerce GRANT WORKSHEET Safety and Buildings Division Owner's Name: Governmental Unit: PART .GRANT FUNDING TABLES °~~ A. Site evaluation and soil testin Grant amount $250. $ B. Installation of a replacement or additional septic tank. Minimum Gallons Required Grant Amount 750 ....................................................................................................................$500 975 ............................................................................................................ .........550 1,200 .....................................................................................................................650 1,425 .....................................................................................................................725 1,650 .....................................................................................................................750 1,875 .....................................................................................................................875 ~ ~~ 2,100 or more ................................................................................................ ........950 i ` $ C. Installation of a pump chamber and lift pump or siphon: Number of Bedrooms Grant Amount 1 or 2 ........................................................................................................... ....$1,100 3 or 4 ........................................................................................................... ......1,200 $ ~ ~~ 5 or more ..........................................................................................................1,250 D. Installation of anon-pressurized or in-ground pressure soil absorption area. 1. The following table shall be used for systems sized according to percolation tests. Grant amounts determined by number of bedrooms. Percolation Rate Design Loadin4 When Proaerly Rate in Gallons Filed with Countv Per Square 1 2 3 4 5 Each Addl Before 7-2-94 Foot Per Dav Bedroom: Minutes Per Inch 0 to less than 10 0.7 or more $ 800 $1,100 $1,225 $1,400 $1,725 $150 10 to less than 30 0.60 to 0.69 900 1,175 1,400 1,800 1,900 250 30 to less than 45 0.50 to 0.59 1,050 1,450 1,650 1,950 1,975 300 45 to less than 60 0.49 or less 1,150 1,900 2,200 2,250 2,275 300 E. Installation of an at-grade or mound soil absorption area. Grant amounts determined by number of bedrooms. Tvpe of Design 1 2 ~ 4 5 Each Addl Bedroom: At-Grade $900 $1,300 $1,475 $1,825 $1,950 $250 High Groundwater CC Mound 2,250 B~ [, 3,400 3,775 250 High Bedrock Mound 2,350 2,950 3,000 3,400 3,525 275 Slowly Permeable Mound 2,900 3,100 3,250 3,400 3,650 300 Mound with less than 24" of suitable soil or greater than 12% slo e. 3,050 3,400 3,475 3,550 4,500 375 $ F. Installation of a holding tank. Each Addl Number of Bedrooms: 1, 2 or 3 4 5 6 7 8 Bedroom: Grant Amount: $2,250 2,925 3,100 4,000 4,200 4,750 $225 $ G. Installation of a Replacement Exterior Grease Interceptor by Gallon Capacity. Gallons: Up to 1,249 1,250-1,499 1,500-1,749 1,750-1,999 2,000 or more Grant Amount: $550 $650 $750 $800 $900 ~ Personal information you provide may be used for secondary purposes [Privacy Law, s. 15.04(1)(m)). SBD-9167 (R. 1/99) PART 1. GRANT FUNDING TABLES continued H. Installation of an Experimental System. Amount Requested For Installation: The Department on a case-by-case basis reviews installations of experimental systems. If you are requesting funding for an experimental system not covered by the grant funding tables, $ please submit a copy of the plan approval letter and experiment approval letter with corresponding identification numbers signifying that the experiment has been accepted by the Amount Requested Department of Commerce. For Monitoring: List the total cost of the experimental system and monitoring that is being requested separately at the ri ht. Co ies of aid invoices must be submitted with this re uest. $ 1. Installations not Covered by the Grant Funding Tables. The Department on a case-by-case basis reviews installations not covered by the Grant Funding Tables. If you are requesting funding for an installation not covered by the grant funding tables or listed in Sections A-H, please explain your request here, attach a copy of the paid invoice, and request 60% of the cost of the installation at the right. TOTAL PART 1. ~ ~~ $ PART 2. GRANT AMOUNT CALCULATIONS A. Enter the total from Part 1. ~ ~lJ $ l B. Is the applicant a licensed plumber or contractor who installs private sewage systems? If yes, enter Z3 of the amount from section A or $4,667, whichever amount is less. C. Enter the smaller amount listed in sections A or B. If this application is for a small commercial establishment and the annual gross income of the business that owns the small commercial establishment is less than $362,500, this is the total grant award. Cany this amount fonivard to section F. If this application is for a principal residence and the annual family income of the owner(s) is less than $32,001, this is the total grant award. Carry this amount forward to section F. If this application is for a principal residence and the annual family income of the owner(s) is greater than $32,000, goes to section D. )~ ~ c~]~ ` - If this a lication is for an ex erimental s stem, ca this amount forward to section F. I~..J -J`/ $ D. Enter 30% of the amount by which the applicant's annual family income exceeds $32,000. ~3-7 Annual Family Income Subtract - 32 000 Subtotal ~ X .30 = $ E. Subtract line D from line C. This is the maximum grant amount for this applicant. Carry this amount forward to section F. (The amount in section E must be at least $100 to be eligible for any grant award. if the amount calculated is less than $100, (~ o~ enter $0.00 in section F. $ ` v F. Total rant award re uested for this a licant. $ ` ~' ~~ _ _ _ _ .csn_ :~--__~-- _C~~~C..