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Home My WebLink About006-1061-10-000'Vlliscons+n Department of Commerce PRIVATE SEWAGE SYSTEM Safety and Buildings Division INSPECTION REPORT GENERAL INFORMATION (ATTACH TO PERMIT) Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)j. Permit Holder's Name: ^ City ^ Village ^ Tdlwn of: Bos, George Cylon Township CST BM Elev.:. Insp. BM Elev.: BM Description: TANK INFORMATION TYPE MANUFACTURER CAPACITY Septic ~ Dosing t:~J.e..c.~Ls Aeration Holding TANK SETBACK INFORMATION TANK TO P/L WELL BLDG. vent to Air Intake ROAD Septic asp' ~S'p r ~ S ~ NA Dosing ~ ~0 ? S~ r 2 3~ 2 Co ~ NA Aeration NA Holding PUMP /SIPHON INFORMATION Manufacturer Model Number ~ p a~ TDH Lift ~0-33 Lriction ` 3 ~ Syste \Q Fi Forcemain Length ,~0 ~ Dia. Z " SOIL ABSORPTION SYSTEM Demand '1j~'~ G PM TDH I~}•I'1Ft Dist. To Well ~ sp ` ELEVATION DATA county: St. Croix Sanitary Permit No.' 363916 ate Plan ID No.: S /D~ 3Z`f arcel Tax No.: 006-1061-10-000 STATION BS HI FS ELEV. Benchmark .~ o. 0 ~' r /DO.t~ Alt. BM ~.~ c/S-,Zoe Bldg. Sewer ~,84 Q3.9D` St/ Ht Inlet $• 3 3 3.3i~ St/ Ht Outlet $ •~-2 q2.'$ r Dt Inlet $., ~ ~z,~3 ` Dt Bottom Z•/ 8~.52~ Header /Man. ~"2 ~ Dist. Pipe I ~ ~• 1 •SZ s 1 a~ • 18 Bot. System L ' l ~ /Z `~' `j'.SQj Final Grade et- ~ ~ St cover D Width ~ Length t No.Of PIT No.O its Inside Dia. Liquid De h EN I N S DIMEN I N SYSTEM TO P / L BLDG WELL LAKE /STREAM LEACHING nufacturer~ SETBACK INFORMATION Type O , ~ r CHAMBER odel Numbe . System: ~ $0 ''' ,3(v ~ $~ OR UNIT DISTRIBUTION SYSTEM ~y~° 5~'4°~- ~ v~-wk~ Header / Mani old rr Distribution Pipe(s) ,~~ ' ~~ ~ ~ x Hole 4ize x Hole Spacing Vent To Air Intake Length .O Dia. 2 Length ~~ Dia. ~ /2 Spacing S •~ r/.f ~j6 SOIL COVER x Pressure Systems Only xx Mound Or At-Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded /Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ^ Yes ^ No ^ Yes ^ No COMMENTS: (Intl deco ediscrepa ~~les, rs~o~}present,etc.) '~' `~`F 1.,~,~ Inspection #l: D`~/ 2//vv Ins ection #2: / / ~~ Location: 2299 200th Avenue, Deer Park, WI 54007 (NE 1/4 NE 1/4 26 T31N R W - 283116422 1.) Alt BM Description = $a~~^^.e~ I~,o~-se-s:~ °.~eue_- 6~'~."ev-• ' 20 ` ~-o'"'~,a r.5~ 2.) Bldg sewer length = IS ' ~~ _ ~ zn / -amount of coven. _ > 2 'f ~-- I C~Ct~e-,~` ~_P~~~ '~ 3.) contour = cl $, Sv ` l.. " a* ~•ZD' a~- H-~ z I o 1• ~~ ~~~ Plan revision required? ^ Yes ~ No ~2 0 oa 'p Us other ide fQQr additio I in~~ matio ~ /~ ~-- b SB 6710 (R.3/97) ~ Q L__~,,, Date ~r ~ ~ ,~~ect r'sSi na r~~~~ D~__ __ ~.,a C~rt. No. i „„_.. S fl ~ F r ' ... __~~~~~ _ _ ~_~ ~"~~s `~~- -fi``'n:' ~wrV ~ y ~ ,. ~visconsin Department of Commerce SANITARY PERMIT APPLICATION In accord with Comm 83.05, Wis. . Ceid _nt ~ L_...,._ _/~. ~_ a e uildings Division 201 W. Washington Avenue POBox7162 Madison, WI 53707-7162 • Attach tom lete tans (to the count co onl )for the s st `V ~~"a er of p p Y pY Y Y ~ p~ unt C ~ Y S~~ ~- than 8 tiz x 11 inches in size. ~~ D O ~ r1m,~ ~C~`~ t~ it mber P it N • See reverse side for instructions for completing this appli trgn ary an erm u Personal information ou rovide ma be used for seconds ,~~ ~j ~ S ~ y p y ry purposes p~ ~ 3 6 3 `t ~ ~ k if revision to previous application [Privacy Law, s. 15.04 (1) (m)]. ST Cox to an Review Transaction Number I. APPLICATI N INF RM TION -PLEASE PRINT ALL R ~ S /Q~ . 3a Property Owner Na a i' ~ p o a R ~ E N i4 5 T ~ e ® y, ,~ , , Property Owner's Mailing Ad ress ~ ~ ~ Block Number Cit a Zip Co a Phone Number Subdivision Name or CSM Number e ~~'' r X00 ( ) ~_ IL PE F B ILDING: (check one) . ^ State Owned ^ it~ ~ Vilage ~' O Nearest Road ~ ' ~~~ Public 1 or 2 Famil Dwellin - No. of bedrooms / ~ Town of f 04/ ' III. BUILDING USE: (Ifbuildin t eis ublic,checkallthata 1) Parcel Tax Number(s) 9 YP P PP Y ~ ~ ~, / ~ . ~ AJlJ G4 ®~ ~ ~~~/~ l~ ^ 1 ^ Apartment /Condo 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 online B, if applicable) A) 1. ^ New 2~teptacement 3, ^ Replacement of 4_ ^ Reconnection of 5_ ^ Repair of an -_____System ________System_____________TankOnly-_____________ Existing System ________ Existin~S~stem 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 2,,~Mound 0 ^ Specify Type 41 ^ Holding Tank r ~ n 42 ^ Pit Privy . 12 ^ Seepage Trench 22 ^ In-Ground Pressure g r } X ~ 13 ^ Seepage Pit , t~t.~C 43 ^ Vault Privy 14 ^ System-In-Fill 8 .~ VI. ABSORPTIONS TEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Pert. Rate 6. System Elev. 7. Final Grade v Require (s .) Proposed (s ft.) (Gals/day/s ft.) (Min./inch) !y Elevation ~ ~ ~ ,~ > - ~-- / ~ ~ Feet ,: Feet VII. TANK INFORMATION Capacft in allots g Total l # of Manufacturer s Name Prefab. Site Con- l St Fiber- Plastic Exper. N E i i lons Ga Tanks Concrete ee glass App ew x n st strutted Tanks Tanks Septic Tank or Holding Tank « ^ ^ ^ ^ ^ Lift Pump Tank/Siphon Chamber ~ ~ ^ ^ ^ ^ ^ VIII. RESPONSIBILITY ATEMENT I, the undersigned, assume responsibility for installation of the onsite sewage system shown on the attached plans. Plumber's e: (Print) ~, ~~ Plumb i ature: (No Sta ) MP/MPRSW No.: Business Phone Number: Plu r' dd ss (Street, City, ate Z" Code): ~ ~- / IX. COUNTY /DEPARTMENT USE ONLY ^ Disapproved sanitary Permit Fee fi^dudes Groundwater ate ssue Issuing Agent Signature (NO Stamps) A roved pp ^ Owner Given Initial Surcharge Fee) s- ~ '"~' Adverse Determination X. CONDITIONS OF APPROVAL /REASONS FOR DISAPPROVAL: . ~ ~~S w.k~~-c~ `-x., ~ ~ ~tol~-s . ~9' NJ~.-~ ,^^r"~s~-1,~ ~ as px- ~~~~'al~llntio~rc-~.~.~.- SBD-6398 (R.12199) DISTMBUTION: Original to County, One copy To: Safety & Buildings Division, Owner, Plumber INSTRUCTIONS ' ; ,. ~ , ~ , 1. A sanitary permit is valid for two (~j"~yearr. ,~- . 2. Your sanitary permit may be renewed be~~id~t~~expiratio-i date, and at a time of renewal any new criteria in the Wisconsin Administrative Codeivtiin be applicable. 3. All revisions to this permit must be,app~`dV.ed~by_th~ permit issuing authority. ;> 4. Charges in ownership or plu~mler requires e:Sar~~t~ry PerrritT'ransfer /Renewal Form (SBD-6399) to be submitted to the county prior to installatiori ~ - ;. 5. Onsite sewage systems must be properly,inaintained. 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: I. Property owner's name and mailing address. Provide the legal description and parcel tax number(s) of where the system is to oe 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 af! 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. PFumber 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: Aj 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 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) a!I sizing information. GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included thecreation 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. ,, P. isconsin Department of Commerce June 22, 2000 CUST ID No.220527 BYRON BIRD JR 896 68TH AVE AMERY WI 54001 RE: CONDITIONAL APPROVAL Safety and Buildings 1340 E GREEN BAY ST STE 300 SHAWANO WI 54166 TDD #: (608) 264-8777 www.commerce.state.wi. us Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary ATTN: POWTS INSPECTOR ZONING OFFICE ST CROIX COUNTY SPIA 1101 CARMICHAEL RD HUDSON WI 54016 PLAN APPROVAL EXPIRES: 06!22/2002 Identificatio ers Transaction ID No. 240 6 Site ID No. 194530 SITE: Please refer to both identification numbers, Site ID: 194530, GEORGE BOS above, in all corres ondence with the a enc . ST CROIX County, Town of CYLON; 2299 200TH AV, DEER PARK 54007 NE1/4, NE1/4, S28, T31N, R16W FOR: Description: MOUND SYSTEM FOR GEORGE BOS Object Type: POWT System Regulated Object ID No.: 669347 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. CAUTION: Wis. Stats. 145.135(2)(b) indicates that the approval of a sanitary permit is based on regulations in force on the date of approval. The effective date of COMM 83 revisions is expected to be July 1, 2000. Thus depending on the type of system and your design, this plan approval may not be eligible for sanitary permit approval if submitted to the issuing agency on or after July 1, 2000. Note: There is a otn ential for a lawsuit that may delay the effective date of the code so this status may or may not change. 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. All permits required by the state or the local municipality shall be obtained prior to commencement of construction/installation/operation. Inquiries concerning this correspondence maybe made to me at the telephone number listed below, or at the address on this letterhead. Sincerely, ~ ~. -~ vJ' KEIT A WILKINSON , POWTS PLAN REVIEWER Integrated Services (715) 524-3630, FAX: (715) 524-3633 , M-F 7 AM - 3:45 PM KWILKINSON@COMMERCE. STATE. WI.US DATE RECEIVED 06/14/2000 FEE REQUIRED $ 180.00 FEE RECEIVED $ 180.00 BALANCE DUE $ 0.00 WiSMART code: 7633 cc: GEORGE BOS t • PLOT PLAN PROJECT Georae Bos ADDRESS 2299 200th Ave Deer Park Wi 54007 NE 1 / 4 NE i /4 S 28 /T 31 N/R16 W TOWN Cylon COUNTY ST. CROIX MFRS BYRON BIRD JR. 22052 / DATE6/9/00 BEDROOM 3 CONVENTIONAL IN-GRO D PRESSURE CONVENTIONAL LIFT HOLDING TANK MOUND ~~ SEPTIC TANK SIZE1000 Gallons LIFT TANK SIZE DOSE TANK SI7,E 800 HOLDING TANK SIZE LOAD RATE t •2 ABSORPTION AREA 375 BED SIZE 8' X 47' BENCHMARK V.R.P. One block up from barn grade ASSUME ELEVATION 100° ^ BOREHOLE O WELL *H.R.P. Same as Benchmark SYSTEM ELEVATION qq ~ 0 m r m >500' System is to be installed along the ./98.2 Contour Line Area 25' below system is to remain undisturbed . f ,~ 7 a ~`-~t ,, - ,;~ ` ~~ ~,~.e ~fi~~:, ~ ~E~~ a~~~ ~. ~ ,~ ,~i <y'~C)C1v~ ~, Barn ^ It. ~/ 4% Slope B-4 ~ r-- DW r' /~ /l aE ~• Overflow .~ ~G~ ~ OFRESPON~tc ~ ~ ~O Otd System is to be 3 ~ pumped and buried Tanks are to be properly bedded and provided with approved warning labels, dose tank is to have a lockdown cover >500' J Milk House E~,1 0 c~ DT Weeks ST ST Pro 3 ~ Bedroom House ~ o~ Old House to be W e I I torn down 200th Ave Scale ~ 1 /4" = 10' ~y ~~ -f.. _ ~ ,~~ q ; .~ ~' ~ 1: ^ Y ~ ~r•l~~ al'' ~G~.G~ \.l ~` arn- c5 ~w,.• J3 ~.c..~ • ~ • ~ ~ Qerformance Data ruim~ cn ~ 4racter~st~cs / aroror uelr s~eurslbk tAeeeal tV~1ti: SiiEi~01tU SNENONt2 Autaawai ~i~~~}, ~ sNFr~aoai siia~aatz Hor qua, 4 14 Nip load Aa~s ~ !4 A.5 Nkta ~ ~ ~ tidJa. iS3Q i'I~e 1$ Y °~t I1S 130 !~ b0 ~ ~ a1Yf~ _ 12e° ! 1Nos. Ft~i ttaria oo~ ~~ +- Insebtioe Chet A Siu 1 1 T" NPT ( SaNds Headlie , 4" ~, W r ~ ~. Pawtr Cord i d/ii, Sl1W, S4' sti. {~' N llAaterials of Construction phchoM~ol ~ Sad FaaK: ~~ Shah Saat i sib t ~ 40 i , 30 , t ~ ` ___ i - ~ -- 10 i ~ 0 l0 2(} 30 GP 40 50 b0 70 I Toroi Nsad {fast) 10 ! ] 4 17 3 t 25 x8 30 3b (ies} ~ 3.0 4.3 . '•S.Z~ " 6'.1 _ 7.6 ~ _ ~.5,... .$.~~ 1 .7 GPM {U5 GPMy •, 70 ; b0 so ~ ao so zo j 1 a o t)i~ sionat Data {` t~'et. at a''~ r186 z7--., ' ~ 1. AO dintenslons I~ inches. (Mattk for inietnatanal use}. tt2T;--~ a aare• 2. Compenmt dinunsimfs moy (oa.4~ vary t i/S fnch. 3. Not for cortstraction purpou 3•Tte' DtSCY.AfILAE (eQsY} r+. -'."1" NPT ~' UII~ISS W[tifi~, `svv°si:k 4.0ltnvnsions nt-d weights are opprox}mate. ~_{; ~...--,--,~-.------~- l t l i 1 5. We reserve the right to moke revisions so our product aad their specifkoiions without notke. (~2a8~ 78; LttyS ~~ Nyrppp~f,~pTrC ~- ~4}} ~ ~ • • ~ • 1.~ . splo».d Ofiia ~4E~`. kh.414.285.344'I fox: x`,9.2$1 ks$7 Wab jive „wrw lronlni;pusnu.tot", . , , .A n st1R C11tFS ANQ tOt1t3TR1ES` , .,r.F.,r.o. ~~ I. i :, ~~~ • (2.07; 2" (50.8; ~..L---i- _3.. 1 iS8 Krdrorw,;c" Pumps, As'nkr,w, Oh;c• Aft Rigtith i - Your Aott~c*jted~~ f D'~Uiburor .. ~~~asZ? ~41~ ~•' .1 !~' ,/ ___----~ ,, ~ t ~~,~ i ~, ~1"'`~~C.HA:!~~EGP~ C~.^.55 SCC"!C+~.; At~l~ .5 °t:i.fFl~'Rt'fC~iS --`~.._.--- -- V E +~Jt C A P " ~T ~{ c.i. JE-JT PIPE .._._.~...~.,.~ WEArkERPllooF ~ 2S F 0.0 M DOO R-~ ~ ~IJIJGT (DN H O X 1w~Naow oR F'I~ESH ~ 13~'MI-J 111 tt ~ N r/A!6 E i GRADE R ....-. Id°~hIN. !A1LCT ~ ~ ,i ~ A i I ~ a I j C ~-, 11 ~ 1 D I ""1 r----. l ~ F + I ``~ ; n ' • ..._.. _.. _1-PPROVEtD LOG KING '~ MI41Jl1pt_E CovtR W~rl+ wk2N~~ly ~~~ t ' 4"MIE1I. ~ .•1-----~--.... _ i ~ i 18'~M'l;~i ~\`,~ PRGv;C=_ _~~ kIR7!!,HT SEAL ~ I Qy,,~P--~. __~. t~(-.-`L *APPROVFD JOINTS WITH A,PPRQVED PIPE 3' DNTO SOLID SOIL. ~~ I_.~.__ _~______~~ -~I ~ f ~}~ '!~Ai.^RM ~ ~ [,~ Il Ch1 j a<< ` '~' "!SEFC ~XiT a~R±'!'?rF ak!Ly IF '?'t+,-JKvMAI.yl1FA.GTJR~R HA,S SUC.t~. APPRG~~AL ~ ~~e a~~~r~,-~ o Eicf ~~~ ~,.~~ _„SsP~~,i_FICAT-Oi~JS ~ ^ ,; ;-~s~i 5 MA~tJF,~CT:JRttR=-~^~~~~~~ TAIJK SIZE; ~'~U GALl.0U5 ALARM MA-.lUfACT{,fI~CR: _ ~~`~~~t~ S~,/ b ~ ~__. PUMP f+~A-.iUFAC'TUR£R' ~ -~~~^ -~•"7 ~.- ~; a n 1.~G ~Hizl' ~~ ~'~GGEL }JUMDCR: - ~ - J • 5 w ~ TC H T P ~ ~ ~c. ~~ ~ ' ,~ ;LIMBER OF D4SE5. "".PER DAb DOSC VOLt~ME ; -. Ff~i ,~ rAICLU01AiG S/1CKFt.OW: (sAl'.pys CAPACITIES: A =~v~.. iuCNES OR-lam ~' G ~',.tl ~l~j 3 Cm~IU:KES ORl~:~A:.~~tj?. . `J C. ~1_!__ Y. l1~r~,iL~t-? ~rE. PL}MkP A!JO ALARM ARE TO pC M1A11F'1Uf~ DISCF4ARdbE~~ ~ `r GIM INSTAt.LGO OIJ SEPP.'RA7'E C4RC!~t;5 VCRTICA~ DIFFgREtJCF 6ETWC1tiAi PtSMP GFf AAIU Q1'TRIDU'~";Q3.1 PIPE.. /~ FE>:"' ~ ,i ~'(i'c.._/ ', , t r++~;;nu!~, -UETWOR+c 5JPPt.~ PRCSSURE 2.5 t` ~C +ot ~ FEET OF PQRCC I'1AJiJ X°?- F-~,~T~artiRRtG~!OAl•FACTGR..,.~.Z, FEET ""' '"'O T"~, L. O' ~ 4.1A. M t C. HEAD ~ ~ ~ t^'f~ f:.. _.__ _ - ~,y/ 11 !AJTERA~:AL Di,"lEl„$1 'C :7F TA,A„)i(; LE!~JCsTh - `~, ;W}Q~F{ r~ ~L1QUip Ci;PTH -w~~(( ~~f ~ :.o>JOU} T CoucRe*>~ Ot.OGK r; ~ ~oca~ed On Qaiiom. 't Equa~}y Spocec ~tRST t4o1.L f1tXT ro GenMG}~a~1 ~o:i rye WSlripul~p~ P,pe LOyOUt Signed: License N ~` ~`~ -~~ er: ~ ~lCJS ~ ~ Oats: - '"~^ ---~-----r ~~.. P ~~ Ft. ~' R ~ Ff. X ~~~ Inches Y ~_ Inches 1/. Noie Diameter _ ," '`~ Inch Laterai M f ,~„ Inches) Manifold ~ Inches Force Mein ~L~~ Inches ~'of holes/pipe Invert Elevation of Laterals ~~-~'~'~ Ft, 9y.~o PerforotaC ~~0! 4etoti . Designer _~~ ~ S 2 ~ . Date -~--~v 1 4" Observation Pipe Perforated Below Filter Fabric A51?t C-33 San d ~~ Topso!! --~ r Non-Woven Filter Fabric j~0~siriDuf ion pipe t H .,. _. r G 1~. \\ 1 7. Scope 6~d of;j"- 7 : Forte Ma=r, ~~F~iowed t Droin Rock Fram Pump Loyer ,D ~ ~ Cress Section Of A Mound System Usino , E ~'~ / A Bed For The Absorption Arco F G A Ft. h -! S ~ 6 ~ 7 Ft. I ~ t"t.~ ~ . J ~ Ft. K . ~,,,.~f t . ~! . L~$ Ft. N ~S' Ft. ~ ~¢~~Observotian Pipe ~---- ~ - - -------~--- K `r`----_ _... _. _-__ -----_ _-_-_-----_ ~i °' a I - ~ i W N c ____ -------------------___------------- I Force Moin 3 ~ • -- -- -- . ~ ._...,...._ ~ .~ ..,., .~ . _,., -.. From Pump p Distribution Bed Of %2~-- 2 ~Z. Pipe Or•oin Rock i 4 Obtervotian Pipe, Permor-ent Morket• Pipe or Rods _Pion View Of Mound Utinfl A Bed for The Abaorplion Areo P~- G E ,-.,,,,,,0 F,.,_,r, Wiscfonsin Department of Commerce SOIL AND SITE EVALUATION Division of Safety and Buildings Page __ of • Bureau of,lnteyrated Services in accordance with Comm 83.09, Wis. Adm. Code Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County .~ include, but not limited to: vertical and horizontal reference point (BM), direction and ~~ ~~1~ G [7 . percent slope, scale or dimensions, north arrow, and location and distance to nearest road. p,,,,e, , ~ ~ APPLICANT INFORMATION -Please print all information. Reviewed by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). Property Owner Property Location -~-•~~~^ .~ ~~ ~ T- ~ ~ Govt. Lot ~L- 1/4~/~ 1/4,SpZg T ,N,R ~'6 E (~ Property Owner's Mai ' g Address Lot # Block# Subd. Name or CSM# o~ ~~_ Ci ` State Zip Code Phone Number ^ City ^ Village [Town Nearest Road ~ ^ New Construction Use: Residential /Number of bedrooms y,~ ,Addition to existing building __ 'Replacement Public or commercial -Describe: Code derived daily flow `~~- gpd Recommended design loading rate •5' bed, gpd/ft2 •~ ~ trench, 9Pd/ft2 Absorption area required ~,~bed, ft2 ~i r~S_trench, ft~ Maximum design loading rate ~_bed, gpd/fit ~. trench, gpd/ft2 Recommended infiltration surface elevations ~~ s referred to site plan benchmark) Additional design/site considerations • ~~ ' lv, ~ ~ ~'/~'-! ~-? Parent material ~ / Flood plain elevation, if applicable - ~'~ __ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system [~S ^ U ~ S ^ U ,~ S ^ U ~ S ^ U ^ S ~ U ^ S [.~'-U SOIL DESCRIPTION REPORT Boring # G~bund ~~ Depth to limiting f to ,~C/ in. Boring # G~rou~~nd ft. e%'~-f- Depth to limiting Horizon Depth Dominant Color Mottles T Structure si t C B d Roots GPD/fit in. Munsell Qu. Sz. Cont. Color exture Gr. S z. Sh . on s ence oun ary Bed , Tr ench fJ ` /~ ~ ~r}.~- f ~ r ` , ~ ~/ FAN i^ ~/ ~/ e . ~J'~' - Tom' Remarks: /B/ ~ llil`~ ~ ~ ~~-~ , c., ~J~ ~;~~ C:.5^ c \ ~ r ~'` tacto in. Remarks: CST Na (Please Print) ,~- ,~ Signature ~ Telephone No. i Addre "" Date CST Number G - ~.. do ~ ~ SOIL DESCRIPTION REPORT PROPERTY OWNER 9-L~~r ~- ~ O PARCEL I.D.# / Boring # Ground el~. ~ /• ~,SIt. Depth to limiting facto ~~in. Boring # Ground elev. ~, ' ~-ft. Depth to limiting f~tor ~n. Boring # Ground elev. ft. Depth to limiting factor in. Boring # Ground elev. ft. Page _ of ,_ Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench i -~ ,/p r rzf ~ / ~J~ ~ /~''~ - I Remarks: GO j~ .. ~' a'J~ s~ ,,t- _ . t .? Y- 7 , rs- Gam- /bt'~ ` ~ ~ ~ - Remarks: ~ ~ =~ C-'~S!~t/ ~~~ s~ Gc~~ C Horizon Depth Dominant Color Mottles TeMure Structure Consistence Bounda Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench 4 Remarks: Depth to t limiting factor in. Remarks: SBD-8330 (R.9/98) } ~ 1 ~~ ~ a r Soil Test Plot Plan Project Name George Bos Byro ird Jr. Address 2299 200th ave. DeerPark Wi. 54007 CS #220527 Lot ----- Subdivision --°-- Date 6/7/0 NE 114 NE 1 /4S 28 T 31 N/R16 W Township~Ylone Boring Q Well PL Property Line County ST. CROIX ,BM or VRP Assume Elevation 100 ft.one block up from barn grade System Elevation 99.2 H.R.P. same as BM Alternate B.M. 102.1 inn of rnn~rP at mj]j{hnL~Se ,w 200th ave. ,Vlljsconsin Department of COmmeroe SOIL AND SIT~~f~~61~-TION Division of 6afety and Buildings ,- , Page of i t Bureau of Integrated Services in accordance with,~omrrt83:09; ~fiS .Code ~,r pp 1 Attach complete site plan on paper not less than 8 1/2 x 11 inches in si e.`~n mustf>;~CE'~r~[ C / !_~ ~ include, but not limited to: vertical and horizontal reference point (BM) di-r..1 ion and l ~jf ~/ ~~ Cp . percent slope, scale or dimensions, north arrow, and location and dis aa~to negfi~ro .; Z~ Parc , -,D, # ~r ~ cl, ~U ~ /~'6~ ~4- a~o~ APPLICANT INFORMATION -Please print all informa "d~~ CC.at~ntrv Rev by Date Personal intom~ation you provide may be used for secondary purposes (Privacy La , s. 1 4 1~7r~fi' U~cl4 ~ .~ ' ` ~ b -30 -2 Property Owner ~ :, C®/" ,~ ~p -_:~- L ~ Lot' ~ '1/4~ 1/4,Sp~ T ,N,R ~6 E (~ Property Owner's Mai g Address Lot # Block# Subd. Name or CSM# Ci State Zip Code Phone Number Nearest Road ^ City ^ Village (Town ^ New Construction Use: Residential / Number of bedrooms ~~ Addition to existing building Replacement Public or commercial -Describe: Code derived daily flow gpd Recommended design loading rate •~ bed, gpd/ft2~trench, gpd/ft2 i Absorption area required _,~Z,~bed, ft2 ~3 ~s trench, ft 2 Maximum design loading rate ~_bed, gpd/ft2~_trench, gpd/ft2 Recommended infiltration surtace elevations ~~ ~ ft (as referred to site plan benchmark) Additional design/site considerations ~. ' w. Te'l'? /~/ Parent material "~ ~ Flood plain elevation, if applicable ,, ~~,~ft S = Suitable for system Conventional Mound In-Ground Pressure AT-Grade System in Fill Holding Tank U = Unsuitable for system [~S ^ U ~ S ^ U ,~ S ^ U ~ S ^ U ^ S ~ U ^ S SOIL DESCRIPTION REPORT Boring # Ground v. ~ ft. Depth to limiting i. f~ Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots GPD/ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench / 6 ~ 2 ate- ~ ~ ~~~~ ,.. G ~ ~ S- ~ Remarks: Boring # Ground Ye~l of i~``." f-ft. Depth to limiting ~ ~ ~~ ~~ G-ac ~ ~ .~ f i~ i~~ facto in. Remarks: CST Na (Please Print) /. Signature Telephone No. Addr CST Number PROPERTY OWNER ~~!' °c- ~ PARCEL I.D.# Boring # Ground ele~ c,, ~~~c' `. Depth to limiting f cto~ ei~in. Boring # Ground elev. q~-tt. Depth to limiting factor C%~n Boring # SOIL DESCRIPTION REPORT • ,r ~ , . Page ~ of 4 Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots 2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench /B ~2 D~~-` r / ~~H G F , yy ~~ Remarks: s ~ ~ ~ ~ ~~ e ti _ ~ r' •-~ o /L ~-~- ~ G ~-~ Remarks: J7 ~rL~'J ~y ~~ c ®(O L v Horizon Depth Dominant Color Mottles Texture Structure Consistence Bounda Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. ry Bed ,Trench Ground elev. ft. Depth to limiting factor in. Boring # Ground elev. ft. Remarks: Depth to I~ limiting factor in. Remarks: SBD-8330 (R.9/98) .. ~ Soil Test Plot Plan Protect Name George Bos Byro Bird Jr. Address 2299 200th ave. DeerPark Wi. 54007 CS #220527 Lot ----- Subdivision ------ Date 6/7/00 NE 1/4 NE 1/4S28 T 31 N/R16 W TownshipGYlon~ Boring Q Well PL Property Line COUnty ST. CROIX ,BM or VRP Assume Elevation 100 ft.one block up from barn grade System Elevation 99.2 H.R.P. same as BM Alternate B.M. 102.1 tT of.=nnrre a+ milkh~i~se 200th ave. ,. ~~ OwnerBuyer ST CROIX COUNTY SEPTIC TANK MAINTENANCE AGREEMENT AND OWNERSHIP CERTIFICATION FORM h,~ d~ ~~ Mailing Address o20~.~,~~~ ~~~~~ Property Address (Verification required from Department for new construction) f~~ ~ `~~` Parcel Identification Number ~ 0 ~ /~~~~~0~ City/State -e ~ r' ~>"' ~. ~ LEGAL DESCRIP 9TION Property Location~~~ `/+, .~ '/<, Sec.. T_1~-R,~~~W, Town 'of ~ Subdivision Lot #~~ Certified Survey Map # _ ,Volume ~~ ,Page # r__,~ _ Warranty Deed # ~~ 6~ 7 ~ ,Volume Page # _i -~'"'-'' Spec house yes ^ no Lot lines identifiablel~, yes ^ 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 masterplumber, journeymanplumber, restrictedplumber or a licensedpumperverifying 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 standards set forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification stating that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30 days/~of thel three year expiration date. ~~~h `~(< ~ ! a~i Oct SIGNATURE OF APPLICANT DATE OWNER CERTIFTCATION I (we) certify that all statements on this form are true to the best of my (our) knowledge. I (we) am (are) the owner(s) of the property described above, by virtue of a warranty deed recorded in Register of Deeds Office. SIGNA OF APPLICANT / 07 ~/ CX~ DATE ****** Any information that is mis-represented may result in the sanitary permit being revoked by the Zoning Department. ****** ** 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 _-~'` I~ +~ COCUytI:Nt' ND. STATE HAS 0)! WISCONSIN FORT[ 1-~ifig w~A~a~r a~~fl 4~s149 ~'. '~~=.153 ~~ This Deed. made between .Harold M.. __Bos,__•a_•-single. ..... 1 ..................g.........•--•.-•-................'...-........................-•-...•.•........ Grantor, i{~ ana....ri.~Qx. e..A....IQs...~~~...$e.L.h...I:.~...Bos.,...h~sband ............. ans..w.i.~e.._.-a~...;?urx.~,x4r~~i~p..>~ax.t~;l-.Pxop~-~:tY~........ i ....................................................................................•-•--.....-._. Grantee, WitneSt;i@th, That the said Grantor, for • valuable consideration...... conveys to Grantee the following described real estate iR .. ~x.....~xQix.......... County, State of Wisconsin: The Northwest 1/4 of the Northwest 1/4 of Section 27; the East 1/2 of the Northeast 1/4 of Sec~ion 28; the West 1/2 of the Northeast 1/4 of Section 28; all in Township 31 North, Range 16 West. Exempt No. 8. This -•-•___.1S ................ homestead property. (is) (is not) { ___ 1 f ~ rn~e e-aes acermrco troy IKCOROIpe ewrs t~ ~~ REGISTER`S OFFS $T. CROIX OQ, WI Reed fa ~,jad FE6 2 6130 ~ 9:00 A. M ! ~~ ~ a ~° ~i~crua~TO ---__ __-~.___---- ; Ta: Parcel No: Together with all snd singular the hereditaments and appurtenances thereunto belonging; Ana.....-----Grantor -•--•-------••-•-----•---------•----•---------------------------•--- warranta that the title is good, indefeasible in fee simple and free and clear of encumbrances except municipal zoning ordinances and easements of record. and will warrant and defend the same. Dated this ...............•--- °~a^~`~---------.... day of .....---February--------......-----------------.......---• 18..90.. '~ .- ~/~~~ ---•--..-.......(SEAL) ..------•---•-----• ................•--•--.....--•-- ---....---.._...(SEAL) Harold M. Bos ...............•-•--•-----•-------•--•--•---•------------••------.._. (SEAL) • AIITSSNTICATION signatnre(~ of _Harold M. Bos authenticated this.day o.._.-uar _ ~ 19 90 .-:____G .___E :___ No rman TITLE: MEDiBEA STATE BAR OF WISCONSIN 7~E~RJ(~~f$~?Q~F,~X~9~4~X7YXt+X1~~I4f~-- ---------- `~ THIS INSTRUMENT WAS CHAFTHD BY ~` BAKKE NORMAN SCHUMACHER, S.C. 1200 He its e D ive .Kew._R.ic}rimon~-~---W-~----.~ 4.Q1.7 -----•-•----•----•---.. (Signatures may be authenticated or acknowledged. Both are not necessary.) --------•----...-• .............••-•-•-----•--...-..--....---••---.. (SEAL) • ACHNOWLEDC4I1EtIiNT STATE OF WISCONSIN as. ............. . ..........•-------...---Coanty. Personally came before me this ________________day of •--°-----•-•--------•--------------------• 19----•--. the above named - ---- ------- ------- ----- to me known to be the person _...-_.-.... Wno executed the foregoing instrument and acknowledge the same. Notary Public..---.-.-••----•-•----------------•--•--..County, Wis. My Commission is permanent. ([f not, state ezpiratioo date: .----• ........................••-----•------..........., 19----•-•-•) Names of Dezfona .i~ninQ is any capacity should be typed or printed L•~,w their signatures. ~t WARRANT? DEED STATE 8AR OF WISCONSIN wi:-?onsin Leral Blank Co. fnr_ __ _ _ FORD! Na 1-1982 Slilwaukee. Wu. Code Enforcement Tracking Sheet Origination Date: 06/28/2000 Violation #: OWNER NAME: Geor a Bos PROJECT NAME: septic failing PROPERTY 2299 200th Ave. MAILING 2299 200th Ave. ADDRESS: ADDRESS: Deer Park, WI 54007 Deer Park, WI 54007 TOWN: melon COMPUTER #: 006-1061-10-000 PARCEL #:28.31.16.422 ZONED: Agricultural OVERLAY: CODE SECTION 15.04 VIOLATED: ORDINANCE Sewage Disposal (Ch. 15) SUBJECT: HISTORY OF CORRESPONDENCE: Letter of Inquiry Notification Final Notification Citation Letter/Corporation Counsel ^ ^ ^ a ^ o Citation Issued: Forwarded to Corporation Counsel: Compliance Date: Staff Signature: Findings of Resolution: ~,\ f ~~~~ --~ . ~~ ~~ ~ 4 ~NMNNNNN^ -- rrrri' +.;. • - ST. CROIX COUNTY WISCONSIN ZONING OFFICE ST. CROIX COUNTY GOVERNMENT CENTER 1101 Carmichael Road Hudson, WI 54016-7710 (715) 386-4680 Fax (715) 386-4686 NOTICE OF VIOLATION June 12, 2000 GEORGE BOS 2299 200TH AVE. DEER PARK, WI 54007 RE: Failing septic system at 2299 200th Ave. Town of Cylon - St. Croix County, WI Computer # 006-1061-10-000 Parcel # 28.31.16.422 Dear Mr./Mrs. Bos: As required by the ST. CROIX COUNTY ZONING ORDINANCE, notice is hereby given that you are in violation of § 254.59(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 § 145.245(4)(b) Wisconsin Statutes (Category I). This violation was first noted on 5/30/00. The violation noted is sewage failing to saturated zone, and also to the ground surface. An on-site inspection on 5/30/00 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 5/30/00 in accordance with Chapter 145.12(4) Wisconsin Statutes. THE FAILING SANITARY SYSTEM ON THIS PROPERTY POSES IMMEDIATE HEALTH CONCERNS AND NEEDS PROMPT ATTENTION. REQiJII2ED ACTION: You have already contracted with a certified soil tester to have a soil evaluation conducted. The soil evaluation has determined the type of septic system needed and it's location, and has also revealed that the current septic system consisting of a drywell, is discharging to a zone of saturated soils. Contract with a licensed plumber, who will design the septic system and obtain a sanitary permit through this office. The existing septic system must be left open for inspection/verification by St. Croix County personnel prior to system abandonment. The replacement septic system must be installed no later than December 1, 2000. 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. Sincerely, Kevin Grabau Zoning Technician cc: file PART B. TO BE COMPLETED BY THE GOVERNMENTAL UNIT 1. VERIFICATION OF OWNERSHIP Does the owner(s) name(s) as listed on the document used to verify ownership agree with the name(s) of the applicant(s) on Part A of this application? ^ Yes ^ No What document was used VU Document or I ? W ~ rL' Pa e Number to verif ownershi y p g If the applicant answered yes to question 3 on Part A of this application, did the applicant own the property when the ordedverificaton of failure was issued or the s stem installed and incur the cost of replacement? ^ Yes ^~ No 2. Is this application for a replacement structure? ^ Yes ^ No If yes, have all requirements outlined in Comm 87.20 4), Wis. Adm. Code, been met? ^ Yes = No 3. Is a public sewer available to this property? ^ Yes ^ No 4. Has a previous grant been awarded for this grope under this program? ~ Yes ^ No ~" -I r lease indicate applicable annual income: $ ~7 ~ , ~ I !~ 5. Principal Residence evidence of income. P ~J Federal income tax form 100 ,Line "l~ ,Year 1~ Affidavit of ,Year Other form used '~ ,Line ,Year Small Commercial Establishment evidence of income. Please indicate applicable annual gross income: $ Profit & loss form used: ,Line ,Year 6. Date of Order or , Age of the Determination of Failure: (~ existing failed system: Se aratn Distance from .the bottom of the existn failed s stem to a limitn factor: 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 tle or zone of bedrock ......................................:.....................................................................:. ^ Category 2 The surface of the ground ..................................................................................................................... ^ Category 3 Back-up of sewage into the structure served ....................................................................................... ^ 8. Replacement System Type: ^ Conventional ^ In-ground Pressure ^ At-grade ^ Mound ^ Holding Tank ^ Experimental System ^ Monitoring ^ Other,~explain / ~t I 36 3 ~ ~ ~ ~ ~ ~ ~ Date ssued _ 7 Uniform Sanitary Permit Number Plan Approval Number 3a ~- ~ ~ Date Approved-~ ~- Experiment Approval Number Date Approved 9. EI' ible ^ or Ineli ible ^ Reason ineli ible: 10. Governmental Unit Representative's Certification. I certify that I have reviewed and verified all information provided on this form and attachments and that the are true and correct to the best of knowled a and belief. Signature of Authorized Governmental Unit Representative T'~tle Date Signed - ~ i i -Z State of Wisconsin .PRIVATE SEWAGE SYSTEM REPLACEMENT Safety and Department of OR REHABILITATION GRANT PROGRAM Buildings Commerce Division GRANT WORKSHEET Owner's Name: Governmental Unit: ~ ~ ~- ~ ~ (~s ~+-~ P T:1. GRANT FUNDING TABUS _ _ 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 ~~ $ C. Installation of a pump chamber and lift pump or siphon: Number of Bedrooms G rant Amount 1 or2 ...............................................................................................................$1,100 3 or 4 ........................................................................................................... ......1,200 b , . 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 Loading When Properly Rate in Gallons Filed with County Per Square 1 2 3 4 5 Each Addl Before 7-2-94 Foot Per Day 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 am at-grade or mound soli absorption area. Grant amounts determined by number of bedrooms. Type of Design 1 2 ~ 4 5 Each Addl Bedroom: $900 $1,300 $1,475 $1,825 $1,950 $250 igh Groundwater Mound 2,250 2,325 ,550 3,400 3,775 250 Hig B rock Mound 2,350 2,950 3, 0 3,400 3,525 275 Slowly Pemteable 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. Addl Number of Bedrooms: 1, 2 or 3 4 5 6 7 8 Bedrooms 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 1,750-1,899 2,000 or more Grant Amount: $550 $650 $750 $800 $900 $ Personal infOrrnBtlon you provide may De uses for seoonaary Purposes IPnvacy Law, s. i a.uvli )tm)1• SBD-9167 (R. 1/99) PART:1. GRANT FUNDING TABLES continued _ _ _ __ H. Installation of an E~cperimental 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: Ust 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. $ i. Installations not Covered by the Grant Funding Tables. The Department on acase-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. Enterthe -total from Part 1. $ Sao.. B. Is the applicant a licensed plumber or contractor who installs private sewage systems? If yes, enter 2/3 of the amount from section A or $4,667, whichever amount is less. $ C. Enter the smaller amount listed in sed3ons A or B. ff this application is for a small commercial establishment and the annual gross income of the business that owns the small commerdal establishment is less than $362,500, this is the total grant award. Cany this amount forward tD section F. ff this application is for a prindpal residence and the annual family income of the owner(s) is less than $32,001, this is the total grant award. Carty this amount fonnrard to section F. If this application is for a prindpal residence and the annual family income of the owner(s) is greater than $32,000, goes to section D. ff this a lication is for an ex rimental s stem, ca this amount forward to section F. $ S 5 b D. Enter 30% of the amount by which the applicant's annual family income exceeds $32,000. 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, enter $0.00 in sedion F. $ F. Total rant award requested for this a plicant. $ ~~0