Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
006-1073-20-000
*Wisconsin Department of Commerce Sai&y and Buildings Division PRIVATE SEWAGE SYSTEM Count y INSPECTION REPORT S cJZ.or.t GENERAL INFORMATION (ATTACH TO PERMIT) Sanitary r"6 Personal information you provice may be used for secondary purposes [Privacy Law, s.15.04 (1)(m)1. 1 Permit Holder's Name: ❑ City ❑ Village ❑ Torn of: tate Plan ID No.: Jarosch, Jerry C lon To wnshi p S /L* = l96 CST BM Elev.:- Insp. BM Elev.: BM Desscription: „ -Parcel Tax No.: rn0 • �` 1 Qo a rT .. s , cs i I� - - - TANK INFORMATION ELEVATION DATA TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV_ Septic ��dr'r csvv (�Sa Benchmark Dosing `` Alt. BM 1C17.q S 3 - -tom Aeration Bldg. Sewer t, 3(, Holding St/ Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANKTO P/L WELL BLDG. Air to I ntake ROAD Dt Inlet _ Air Septic $ 7Sb ' / NA Dt Bottom �( .S -`CID r Dosing u }�' Uk ` A Header / Man. S • 6 Aeration �A� Dist. Pipe �j6 • �-�- Holding Bot. System iO ' p ` PUMP/ SIPHON INFORMATION Final Grade 8 `' Manufacturer l � 5 Demand St cover Q .� Model Number — ' f0 S GPM �� � 2 � f 1(yo .6 / rA Ivy TDH Lift (,.5� �riction ti p System TDH j[,SZFt i . Forcemain Length qD Dia. FZ N Dist. To Well *( S SOIL ABSORPTION SYSTEM B Width `� Len th No.'Of Twe PIT No. Of Inside Dia. Liquid Depth DIMENSION DIMENSION SYSTEM TO P/ L BLDG WELL LAKE/STREAM LEACHING Manu rer: SETBACK - CHAMBER r ' o e Num er: System: >? { oZ 'r 1 ,j� INFORMATION Type O O DISTRIBUTION SYSTEM Header/Manifold Distribution Pipe(s) U u x Hole Size x Hole Spacing Vent To Air Intake Length %( Dia. �� t Length ( Dia. Spacing _X 3 �[ Z tl It L SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over FBd h Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Tren ch Edges Topsoil ❑ Yes ❑ No Yes El COMMENTS: (Include code discrepancies, persons present, etc.) C,.T.w �i� a 0-- Ins ection # 10`41 Csb inspection #2: / a Lo . j ob Location: 1823 215th Street, New Richmond WI 54017 (NW 1/4 SE 1/4 32 T3 IN R1 6W) - 323116499A 1.) Alt BM Description= -r4� 2.) Bldg sewer length= `� ? - amount of cover = 3.) contour = 4"4 Plan revision required? ❑ Yes ®, No �-- l 3 6 Z Use othe s for additional i Date Inspector's Sign ture Cert. No. 41 SBDI 0 (R.3197) < F � 3 F � I � F (0 :839vgnN lINV83d AHVlINVS Ha13)IS aNV S1N3WWOO IVNO111aaV Safet & Buildin Sanitary Permit App ication Y � gs Division In accord with Comm 83.21. Wis. Adm. Code 201 W. Washington Ave. See reverse side for instructions for completing this application PO Box 7302 `�SCOnSJF Personal information you provide may be used for secondan purposes Madison. WI 53707 -730.^ Department of Commerce [Privacy Law, s. 15.04(1)(m)] (Submit completed form to county if r - state owne( Attach complete plans (to the county cop) only) `fit e s s n . o er not less than 8 -1/2 x 11 inches in size. County State Sanitary Permit Number eck if revisio q$ Vi us application State Plan 1. D. N mber t o , , < '` S = I. Application Information - Please Print all InformaAaw ma1 qtAl Location: Property Owner Name �__._. Property Location /J C afjj $ tJ J j5 AA Y C. c p '� (; ^ �UUU ;� j xtol /4 $Fl/4. S 42J3 J,N, R W Property Owners Mailing Address �( (; Lot Number Block Number City, State Zip Code / one Number Subdivision Name or CSM Number /14t'c3 R1'e-h mo h d 4 �'Yd 7 hG< °' Yb .2778 ' II Type of Building: (check one) ❑ City Qk I or 2 Family Dwelling — No. of Bedrooms: ❑ village ❑ Public/Commercial (describe use): Wrown of Y /_ e N ❑ State -owned III Type of Permit: (Check only one be Check box on line B if applicable) Nearest Road o215- tom. Sf A) I. ❑ New System 2. Rep acement ❑ Replacement of 4. ❑ Addition to Parcel Tax Number(s) e o 0 0 System Tank Only Existing System 0 6 , 40 /07' A0 QDO B) Permit Number Bate-19Yffed a A Sanitary Permit was previously issued N AIR. 3 2 • ) le IV. Type of POWT System: (Check all that apply — (aO ❑ Non - pressurized In -gr�nd _, Mound ❑ Sand Filter ❑ Constructed Wetland ❑ Pressurized - ground 6 1 X ❑ Holding Tank ❑ Single Pass ❑Drip Line ❑ At -grade t l erobic T atmen Uni O circulating ❑ Other: V Dis ersa reatment Area Information: 1. Design Flow (gpd) 2. DispersalArea 3. Dispersal Area 4. Soil Application 5. Percolation Rate 6. System Elevation 7. Final Grade 5V Required Proposed Rate (Gals. /day /sq. ft.) (Min. /inch) Elevation /1as' /5 ..4 /Vjg4 �TL,• l o Q `tY VI Tank Capacity in Total # of Manufacturer Prefab Site Steel Fiber- Plastic Information Gallons Gallons Tanks Con- Con- glas New Existing crete structed Tanks Tanks /000 EL ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ VII Responsibility Statement I, the undersigned, assume res on ibility for installation of the POWTS shown on the attached plans. Plumber's Name (print) Plumber's Signature (no stamps): MP/MPRS No. Business Phone Number t�4L +e r Nec k v ti � J��e44_ t �� t�.Z? ? ro 1 -71 s - JI— Plumber's Address (Street, City, State, Zip Code) 94? i &c ; A S' ;Z.3 VIII County/Department Use Only ❑ Disapproved Sanitary Permit Fee (Includes Groundwater Date Issued Issuing Agent Signature (No stamps) J, Approved ❑ Owner Given Initial Adverse §Vcharge Fee) Determination 4P - 3;ZS- CO O- Z- IX. Conditions of Approval /Reasons for Disapproval: "D QLt410 = ?oNE C. aE Ate 4, r, - `x�� o pQA- C64- SBD -6398 (R. 07/00) Safety and Buildings r PO BOX 7162 MADISON WI 53707 -7162 TDD #: (608) 264 -8777 hscons,rn www.commerce.state.wi.us Department of Commerce Tommy G. Thompson, Governor Brenda J. Blanchard, Secretary August 31, 2000 CUST ID No.226375 ATIN: POWTS INSPECTOR ZONING OFFICE ROBERT W ULBRICHT ST CROIX COUNTY SPIA 655 O'NEIL RD 1101 CARMICHAEL RD HUDSON WI 54016 HUDSON WI 54016 RE: CONDITIONAL APPROVAL PLAN APPROVAL EXPIRES: 08/31/2002 Identi atro hers Transaction ID o. 414196 Site ID No. 1970 SITE: Please, refer to both identification numbers, JERRY JAROSCH - RESIDENCE above, in all correspondence with the agenc ST CROIX County, Town of CYLON 1823 215TH ST, NEW RICHMOND 54017 NW1 /4, SE1/4, S32, T31N, R16W FOR: Description: MOUND SYSTEM Object Type: POWT System Regulated Object ID No.: 755920 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. 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 may be made to me at the telephone number listed below, or at the address on this letterpead. Sincerely, / DATE RECEIVED 08/07/2000 i FEE REQUIRED $ 175.00 FEE RECEIVED $ 180.00 P ESL E PAGEL , PO TS PLAN REVIEWER Il REFUND AMT $ 5.00 Integrated Services (608)266-2889, M - F, 0745 - 1630 HRS Refunds of $25 or less will be PEPAGEL @COMMERCE.STATE.WI.US made only on written request. �t��de.�763 cc: JERRY JAROSCH ORIGINAL �.. ULBRICHT & ASSOCIATES CO. 655 O'Neil Road • Hudson, WI 54016 Reg. Designers of Engineering Systems 715- 386 -8185 Private Sewage Consultants llle��Gr��� S PROJECT INDEX Plan I.D. # y�y'i X 2- Date /�U� 0 Owner Tee y TA K0 Sc , ,Phone 7 /,s.• 2 y� • 2. SST Address /9 - ffl ST. ��f . ClV !4 /ait'0qDiv Legal Descri ption P/N n 0 6 — 40 7-), - 70 - CNn'V 'S 00 G - 10'7 3 0. 00 410F10 , sc, vc . 3 2, T 3 I, R I C* w Town of Cy 0A) County S T. CC R 0 �• A- C.S.T. Installer olow F j % / /L� Local Authority/ Supervision ST• epos x CT Y . Zoa; aG- PROJECT DESCRIPTION Re?LAc E'neaT — 'F A 3 QED,12rt. He" DeS /44 piv R�rf' � y's'D � • � • eQe� wA sTt- law. y . 5 � f� , z � s � �- sE,�sa << y ��T �T �� �� T. C`ojz di�iolic�ll y �tis............,.�,� AP DE ;' UL BEACH W. DIVI t ENT 0M 01160 E AND CE HUDSON. W1 tl IN s V- E CORRESPON NCB ' ,I Pg. 1 PLOT PLAN VIEWS 7 Pg. 2 SYSTEM CROSS SECTIONS & SYSTEM PLAN VIEWS Pg. 3 PIPE LATERAL LAYOUT Pg. 4 DOSING CHAMBER CROSS SECTION & SPECS. Pg. 5 PUMP PERFORMANCE SPECS Pg. 6 OPERATION, MAINTENANCE, AND PERFORMANCE REQUIREMENTS This design for installation is based entirely on measurements, elevations, landscape conditions (slopes etc.) and soil suitability provided by CSTM L The accuracy of his specs, as reported, shall remain the sole responsibility of the CSTM. Any use of this POWTS design by any licensed plumber, or any related unlicensed parties or persons (excavaters, laborers) shall not be construed as an assumption of responsibility by the designer for the workmanship, construction, placement, substitution or selection of any components not specified, or any assumptions by the plumt•er that any unspecified components are state approved or proper, or the effects of poor judgement , i if working under adverse damaging weather conditions (wet /frozen soils) by any such parties or persons. P . I Of C� — r TS �� � \��� � �: pop oy �►_ tv hl\ ,( v , Ci yoy �� �'.ris Ti N Cr SfpTi T y U � os TaT'fG I 6 �' � P/C, 14�Idb The area � �, below the Iowa aP � sill lhol loo VIN Nisi Noll aifte YS 7 8 ► �' � I � h i � i I � LL >i o ox.) n s y s. 6,(-e o. ' D w `' -5 4A)o i l I - - - �_ _ 83 i8 f 1761, 10 ' �,v� rDp" �4 Co�7Ovp q� 45 C vi vci T --, — o -93, g° 6 CROSS SECT100 o f MouAjD " wi rti B eD Oeo OF % " ro 1' A33et-SATE 'Di STRit3uT�o,V G , rA; cka F S S pi p to 6- °F TdP SOiL Gv/ l2FAeAi,U4L sysr c/p's• elevA (W i FO To H D' E uu F d RM aJ 51opE FORCE ° MAW � t eVAT%oa UN oat R f3ED �7• � O _V Fr. — F-LeVhrlorJ s -- , E. 5 Fr. WVERr OF Z- IAT£RA(S S Top OF P ock G Fr. <o H / D F T. T or- 2' IATERA IS 9 .7 PLA VIEW OF MoutjD - w rti 13E v ; F r• • I f3 75 Fr -- -- � k l 2 F r �._ - - - -- a— -- w FT i F r 3z Fr B ev of Appep T° i OSSF R AVATIOO A.99Re5ATE Pipes /oe,47-1 : 12• ' /cePAf Xm/ o f ee !/ RRG?uiReD B ASAL AReh �_ � A'•t �RSi'e'F / ow _ ��Q /lLS s o 1 � �,�f. I rrtnTlu E • C APAci ry PRopo5 BASM APeN = B X ( A + z 75 >< G t I s 15,75 H S d2. FT. -- �• 3 0�5 P T � M Aa1F ono -� P 1� Fr R 3 Fr 3 Jr Fr. Z Z of P V G y VARi'A(3LE T OTAL. V(glE) UOIuME S'� GA15, �iSTA)o H OI D�i4 - ,� ToT�L Vo /U�y . R / Iuc4{ES HOIE5/ Pi pE 39 z, z DR i cam' � ,A)S� j 1/ D� C�'L L._ �. `1 �-�� • OVERT E L E V AT j o o J or- LATE !; SEE IpLolapS15 SIDE Fok �� CP • Cl d T"- PM i NA L C/o b L"( -- - 7E -FAA i1 PER FOR /4TE D • Re"outF- All Rill f3 u RR5 y . No� s I ocA TEa o,v BoTTOM ECG AIIY SpAcED . V� STRi [3uTIbN DISChAR (rE RATE• PoR eAch LArERq L o8 GAL�Mi�1. TOTAL 1 ' 7 i 5 TRtQUTio0 V5cHRR6E R NET woR k 50. / (� GA'L/MrI). � -2•5 MI*Ni'MUM b ETA t L 6 F L ATL� A I C L Ff, �;�i:SffLv �1oU,vD 9�P��� i 1 UG /.3.4 , 1—►-9 y` �^ 'O � P I SEPT TA NK UM r SEPTI - -. -. P CHAMBER CROSS SECTION AND .SPECIFICATIONS P sN�� 4" CI VENT PIPE 12" MIN. ABOVE GRADE & WEATHER PROOF Z• a ?l0' FROM DOOR, WINDOW OR JUNCTION BOX APPROVED FRESH AI D INTAKE WITH CONDUIT MANHOLE COVE] Se,4 40 W / PADLOCK 6 Pv c - WARNING LABE1 4 " MIN y p 1 /wLET - e 75 NLET � � GAS- ' .I T __ �� - - -__ -, �� (TIG �I ZASEL __ -_. _ A I SEAL APPROVED ScD. 4n F �- - - (�UG pi pt # ALM JOINTS W/ • NI 0(� C /q 1 001 3 00 ► -} 3 i ON PIPE 3' ONTO 3 SOLID - 3. SOIL � 3y C i SOLID SOIL PUMP OFF ELEV . _FT. +- i _ OFF '�'� RISER EXIZ a Cis' D ( PERMITTED ONL 13 a rrs %�V IF TANK MANUFACTURER 3" APPROVED BEDDING UNDER 'TANK HAS APPROVAL CONCRETE PAD SPECIFICATIONS SEPTIC / DOSE Ripocs TANK MANUFACTURER: ) S7_ � NUMBER DOSES PER DAY : TANK SIZE SEPTIC �� 150 - - - -- _ GAL. DOSE VOLUME INCLUDING / DOSE - GAL, Cp FLOWBACK: GAL. ' ALARM MANUFACTURER: ! A� S CAPACITIES: A = �a'S INCHES = 3U MODEL NUMBER: 5 GAL. -WITCH TYPE: f/ohT B = 2 INCHES = 3Z'sd G GAL. PUMP MANUFACTURER: C = /•� INCHES = 15(0 MODEL NUMBER: M p GAL. SWITCH TYPE: IvAT D = 0 INCHES = ( (0 Z ,,[['' GAL. REQUIRED DISCHARGE RATE ✓ GPM PUMP & ALARM WIRING AS PER ILHR 16.23 WAC VERTICAL DIFFERENCE BETWEEN PUMP OFF AND DISTRIBUTION PIPE . . 0.15 + MINIMUM NETWORK SUPPLY PRESSURE . FEET +� FEET FORCEMAIN X� FT / 100 FT • 2 5 FEET 9 . FRICTION FACTOR . �. FEET TOTAL DYNAMIC HEAD = ,2.55 FEET INTERNAL DIMENSIONS OF PUMP 'TANK: LENGTH �/ _7' 0 WIDT 7 o DIAMETE LIQUID DEPTH 7 0 SIGNED: LICENSE NUMBER: - • DATE: P/C specs EA C& IV Of De pl& IC�•z5 � -Q SEPTIC TANK, per Comm.83.44 (2) (c) shall be equipped With an outlet attached approved filter device (Zabel fllter). Tank shall have an approved above ground locking manhole cover for regular (every 12 months or less) inspection & servicing by a licensdd service pumper. ME40 Series 4/10 HP Effluent and Drain Water Pumps Performance Curve MODEL ME40 EFFLUENT PUMP CAPACITY LITERS PER MINUTE 0 50 100 150 200 250 300 350 40 12 35 10 N W 30 il LL H 25 Z 0 20 6 15 Q O 4 H 2 5 O O 0 10 20 30 40 EO 60 70 60 90 100 CAPACITY GAL ONS PER MINUTE F.E. Myers, A Pentair Company • 1101 Myers Parkway, Ashland, Ohio 44805 -1923 419/289 -1144 FAX 419/289 -6658 Telex 98 -7443 K3326 7/91 Printed in U.S.A. ME40 SERIES 4/10 HP Effluent and Drain Water Pumps POWER & FLOAT CORDS PLUG DIMENSIONS Quick -connect, watertight Replaces switch assembly fittings are interchange- for manual operation. - - -- -- able, replaceable from 1 1 rrPr pump exterior. /< o�l>arge MECHANICAL FLOAT I Mercury-free, 90 angle operation. fln i � • I _� _ _.---- _ - - - - -- 5.66 f- -- (144mm) -- -� 11.68 (296.5mm) - -- MOTOR HOUSING Cast iron for efficient heat transfer. �1 j OVERLOAD SWLTCH Built -in to protect against overload conditions. 4/10 HP MOTOR 11 " O FT 8 R 1600 rpm, 60 Hz, 115 or N cI 230V, single phase. Oil- cooled and lubricated. ROTARY SHAFT SEAL s -� Carbon, ceramic faces.. PERFORMANCE CURVE CAPACITY LITERS PER MINUTE .. 1 O 50 100 150 200 250 300 350 40 VOLUTE/IMPELLER SEAL 35° RING 10 Maintains high efficiency 30 and reduces recirculation H r° e replaceable. 25 Z ENCLOSED TWO VANE 20 e IMPELLER High efficiency, passes WGH EFFICIENCY AILS 15 3 A" spherical solids, with VOLUTE 4 0 stainless steel wear ring. Corrosion resistant. Passes 10 r THRUST WASHER, SLEEVE 3 /" spherical solids. I' V 5 2 DEARINGS NPT discharge. 0 Enhmoe smooth operation 0 10 20 30 40 50 60 70 e0 so 100 0 and extend pump life. CAPACITY GALLONS PER MINUTE K3319 5/92 Ash F. E. Myers, A Pentair Company Printed in U.S.A. mw Myers Parkway Ashland, Ohio 44805 -1923 419/289 -1144 FAX: 419/289 -6658, TLX: 98 -7443 Pg. 6 of 6 Mound System Management Plan Pursuant to Comm 83.54, Wis. Adm. Code Septic Tank The septic tank shall be maintained by an individual certified to service septic tanks under s. 281.48, Slats. The contents of the septic tank shall be disposed of in accordance with NR 113, Wis. Adm. Code. The operating condition of the septic tank and outlet filter shall be assessed at least once every 3 years by inspection. The outlet filter shall be cleaned as necessary to ensure proper operation. The filter cartridge should not be removed unless provisions are made to retain solids in the tank that may slough off the filter when removed from its enclosure. If the filter is equipped with an alarm, the filter shall be serviced if the alarm is activated continuously. Intermittent filter alarms may indicate surge flows or an impending continuous alarm. The septic tank shall have its contents removed when the volume of sludge and scum in the tank exceeds 1/3 the liquid volume of the tank. If the contents of the tank are not removed at the time of a triennial assessment, maintenance personnel shall advise the owner of when the next service needs to be performed to maintain less than maximum scum and sludge accumulation in the tank. The addition of biological or chemical additives to enhance septic tank performance is generally not required. However, if such products are used they shall be approved for septic tank use by the Department of Commerce, Safety and Buildings Division. Pump Tank The pump (dosing) tank shall be inspected at least once every 3 years. All switches, alarms, and pumps shall be tested to verify proper operation. If an effluent filter is installed within the tank it shall be inspected and serviced as necessary. Mound and Pressure Distribution System No trees or shrubs should be planted on the mound. Plantings may be made around the mound's perimeter, and the mound shall be seeded and mulched as necessary to prevent erosion and to provide some protection from frost penetration. Traffic (other than for vegetative maintenance) on the mound is not recommended since soil compaction may hinder aeration of the infiltrative surface within the mound and snow compaction in the winter will promote frost penetration. Cold weather installations (October- February) dictate that the mound be heavily mulched for frost protection. Influent quality into the mound system may not exceed 220 mg /L BOD5, 150 mg /L TSS, and 30 mg /L FOG. Influent flow may not exceed maximum design flow specified in the permit for this installation. The pressure distribution system is provided with a flushing point at the end of each lateral, and it is recommended that each lateral be flushed of accumulated solids at least once every 18 months. When a pressure test is performed it should be compared to the initial test when the system was installed to determine if orifice clogging has occurred and if orifice cleaning is required to maintain equal distribution within the dispersal cell. Observation pipes within the dispersal cell shall be checked for effluent ponding. Ponding levels shall be reported to the owner, and any levels above 4 inches considered as an impending hydraulic failure requiring additional, more frequent monitoring. General This system shall be operated in accordance with Comm 82 -84 Wis. Adm. Code, and shall maintained in accordance with its' component manual [SBD- 10572 -P (R. 6/99)] and local or state rules pertaining to system maintenance and maintenance reporting. No one should ever enter a septic or pump tank since dangerous gases may be present that could cause death. Septic and pump tank abandonment shall be in accordance with Comm 83.33, Wis. Adm. Code when the tanks are no longer used as POWTS components. Septic or pump tank manhole risers, access risers and covers should be inspected for water tightness and soundness. Access openings used for service and assessment shall be sealed watertight upon the completion of service. Any opening deemed unsound, defective, or subject to failure must be replaced. Exposed access openings greater than 8- inches in diameter shall be secured by an effective locking device to prevent accidental or unauthorized entry into a tank or component. Continciency Plan If the septic tank or any of its components become defective the tank or component shall be repaired or replaced to keep the system in proper operating condition. If the dosing tank, pump, pump controls, alarm or related wiring becomes defective the defective component shall be immediately repaired or replaced with a component of the same or equal performance. If the mound component fails to accept wastewater or begins to discharge wastewater to the ground surface, it will be repaired or replaced in its' present location by increasing basal area if toe leakage occurs or by removing biologically clogged adsorption and dispersal media, and related piping, and replacing said components as deemed necessary to bring the system into proper operating condition. Questions on the operation or maintenance of this system should be directed to your county zoning or health inspector. SEE REVERSE SIDE Pg.6 FOR MAINTENANCE REQUIREMENTS SPECIFIC TO THIS SITE, DESIGN, AND COMPONENTS Pg. 6 Continued. POWTS (landowner) is reponsible for proper operation and maintenance of this system. Regular periodic inspections and servicing is necessary for the safe healthy operation of this system. The owner is required by code to submit all necessary maintenance /inspection reports to the controlling authorities. SPECIFIC CONTACT AGENTS 5 C/P��)( L��/ Zp,3I 'A.) -' * Governmental authority/ inspectors: . ' OEpT - 14o Ps -o w� * Licensed installer, responsible for providing an operation/ maintenance "Users" manual: � �' /�l�,V�Q�/ �fe 7/S • 7 yy 33 2 - o 1E , Ofi Ee TS , cZ CS . s L{ z 3 * Licensed service / inspection agent other than installer: 13EV 11oRSjAJ - 7-0/ c T y Sr4N1' r.4 rl" t� u D So.o , to i. S 4 o t 4 - 7/5 • 3 QNh • 31 z o * Electrician, for pump, electric controls, wiring units: IMPORTANT OWNER MAINTENANCE REQUIREMENTS 1. Winter traffic (sledding, shoveling, etc.) across the mound area shall not be permitted, or frost can /will penetrate into the cell, freezing up the system. Discontinuos use in the winter (a vacaction trip, resulting in no water use) can also lead to freeze ups. 2. Water conservation needs to be exercised! Or system can be hydrolically overloaded and destroyed. This system was designed for a maximum wastewater flow of L15D gals. daily. 3. POWTS are not designed to accomodate wastes from a garbage disposal unit, or any other unnatural sources of waste. Any introduction of such waste materials will overload and destroy this system. 4. If a power outage occurs, or a pump fails, it may result in a temporary overload of effluent being pumped into the ' cell, which may adversely impact the cell (leakkge). It is recommended that a licensed pumper empty the dosing tank, allowing the pump to return to dosing the correct amounts. Consult your installer immediately for advice. 5. Neglect of the vegetative cover (the cells insulation & erosion preventive) can lead to failure. Compaction or heavy traffic also can destroy t he system. It IS NECESSARY TO REGULARLY WATER THE VEGETATION OVER A SYSTEM!! Effluent in the system beneath IS NOT sufficient alone tO maintain a grass cover. 6. Periodic inspections by the owner, or his agents, is necessary. Inspection pipes and ports have been incorporated into the system: on the mound basal area (effluent level inspection pipes), cleanout terminals on the pressurized laterals, at each tip - for flushing and cleaning the laterals out. The filter system in the tanks (via a locked above ground cover /manhole). Only a licensed properly qualibied person should be performing this work which involves health & seve safety risks. Evidence of effluent ponding in the system treatment cell shall also be regularly inspected. • Wisconsin Department of Industry SOIL AND SITE EVALUATION / 3 Labor and Human Relations Page of Division of Safety and Buildings in accordance with s. ILHR 83.09, Wis. Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must County ST: ee0 X. Include, but not limited to: vertical and horizontal reference point (BM), direction and percent slope, scale or dimensions, north arrow, and location and distance to nearest road. Parcel I.D. # 006 • /07 2 - • 7 O . &VV0 00& - /O 73 • 2-0 • 6V APPLICANT INFORMATION - Please print all information. R ewes by Date Personal information you provide may be used for secondary purposes (Privacy Law, s. 15.04 (1) (m)). ;�^^ Property Owner Property Location �— �ERRy T OSC Govt. Lot 11MI 1/4 1/4,S 3 T ,N,R /(, E(or )(D Property OVmer's Mailing Address Lot # Block # Subd. Name or CSM# /823 215 ti, sr. Nl,+ City / � State Zip Code Phone Number 7/ ,.,/ Nearest Road /VV /tl�j/�ID v �/ (1yGP) 7 -770 ❑City El LJ Town 2 t Ste. ❑ New Construction Use: Residential / Number of bedrooms 3 Addition to existing building Replacement N P Iic or commercial - Descri e Code derived daily flow gpd f'' ` — 1 - 7 1 mb*ndeO dais gn loading rate bed, gpdffl J trench, gpolft a Absorption area required ySy bed, ft ysd ire cR A6 um de, l@64oading rate bed, gpd/ft S trench, gpd/ft Recommended infiltration surface elevation(s) Ste- Get (as referred to site plan benchmark) r- Additional design/site considerations dd Parent material 1,0 4AI 4911 A S L = f� - , 18gd plain elevation, if applicable N 'r ft S = Suitable for system Conventional Mou tN �re e/ A T- Grad / System i Fil Holding Tank U - Unsuitable for system El S 2 U S ❑ S L ]'U ❑ S L'1 u ❑ S U SOIL D PT dN PORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft2 in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench /o y 3111 sL 2fs hk Ib & .� Ground 3 S /D Y161 Y161 S/ - -- L Z tilt iy4-6e G uy • S ; s elev. Depth to s flu T z " limiting l. S factor X S • Remarks: Boring # O /0 5•1- 2-,yr+ shle im t/rge e5 /f . S ' • .s 3 OY/? Y! 5 L !- h!c I*-6e cw Ground /� L l / ^4 2 P JL( OTS 51(- l T she PT . Z. Of 00 4044 4. oe- �y el , ft. 7• S S(R 5/ fo Depth to limiting fa for / n. Remarks: CST Name (Please Print) [ Telephone No. Ro(3ERT' 2( ie[ j 715' .386 • $1 5 Address Date CST Number Ulbricht 8 Associates Private Sewage Consultants 655 O'Neil Rd. Hudson, Wis. 54016 ORIGINAL PROPERTY OWNER 7. 10R Page osck SOIL DESCRIPTION REPORT of 3 PARCEL I.D.# Boring Horizon Depth Dominant Color Mottles Structure 2 9 Texture Structure Boundary Roots in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench 3. I D•& ioyk 31 2f . . s q •� , y,� Y16 S iL 2- f she /; ew Ground fA (P SI L -/—/ • C S • • 2 , • 3 .2. elev. e ft. •50 YR r►+,, YIL /-� �C �� • u o &( — Depth to limiting factor S Remarks: Boring # Elm Ground elev. ft. Depth to limiting factor In. Remarks: Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots G D in. Munsell Qu. Sz. Cont. Color Gr. Sz. Sh. Bed , Trench Boring # ; Ground elev. ft. Depth to limiting factor ' Remarks: Boring # Ground elev. ft. Depth to limiting factor In. Remarks: SBDW -8330 (R. 08M) i P � ���0$3 �CQ` PBP,�P �/ ►1 f op ef w ) � COflE coMP - Trl�i /ir : � S , p T/ 7 zlr 1 t , 0 -Op v�� • o . z8 - ..�_ 30 f h lltvt . fo f� /0 J s ys ,� H o OA-1 p Sys . 9,(-e o . 33 f l 6 Co �, T °v2 j 45 Cv� vt T - } -t ST CROIX COUNTY ' SEPTIC TANK MAINTENANCE AGREEMENT AND a . OWNERSHIP CERTIFICATION FORM 6� Buyer ruk g Address Y .rxJtl, y� qr iroperty Address r r (Verification required from Planning Department for new construction) p ©fa 161 ;t tatp Lj , Parcel Identification Number ao� !o13 -ao - o 00 Y h EAL DESCRIPTION N 4 e( �•+� erty Location N %., S %., Sec. 3V . T 3 / N - / b W, Town of F — Sttb4ivision Lot # A Gelr##ed Survey Map # Volume , Page # f M M s KY aIT*uty Deed # t / ? Volume Page # 9 t Y. " S 'house ❑ yes %no Lot lines identifiable Q yes ❑ no MTE MAINTENANCE Improper use and maintenance of your septic system could result in its premature failure to handle wastes. Proper maintenance corrs#ts of pumping out the septic tank every three years or sooner, if needed by a licensed pumper. What you put into the system affect the function of the septic tank as a treatment stage in the waste disposal system. 9 A n The property owner agrees to submit to St. Croix Zoning Department a certification form, signed by the owner and by a mastorplumber, joumneymanplumber, restricted plumber or a licensed pumper verifying that (1) the on -site wastewaterdisposal system # i proper operating condition and/or (2) after inspection and m if necessary), septic tank is less than 1/3 full of pumping ( rY)� p sludge. tl ;`tthe undersigned have read the above requirements and agree to maintain the private sewage system with the standards rA Forth, herein, as set by the Department of Commerce and the Department of Natural Resources, State of Wisconsin. Certification static that your septic system has been maintained must be completed and returned to the St. Croix County Zoning Office within 30, da o the three xp' date. A DATE r ON MR CERTIFICATION 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 k he Sto pFrty desc ' abov , virtue of a warranty deed recorded in Register of Deeds Office. Z / 0 L DATE ' Any info . on that is mis- represented may result in the sanitary pe:mit being revoked by the Zoning Department. « «s *** ** siude with this application: a stamped warranty deed from fhe Register of Deeds office a copy of the certified survey map if reference is made in the warranty deed t. YQl 1461n% Is ]. 1574 STATE BAR OF WISCONSIN FORM 2.1998 KATHLEEN H. WALSH REGISTER OF DEEDS ST. CROIX CO., WI This Deed, made between Timothy W. Glenn and Mary Elizabeth RECEIVED FOR RECORD Glenn, husband and wife. 10 -05 -1999 2:00 PR Grantor, conveys and warrants to VARRPMTTM DEED Jerome J. Jarosch, CERT COPY FEE: COPY FEE: Grantee. TRANSFER FEE: 555.00 Grantor, for a valuable consideration, conveys and warrants to Grantee RECORDING FEE: 10.00 the following described real estate in St. Croix County, State of Wisconsin PAGES: 1 (The "Property "): Recording Area Name and Return Address ��tno- t1E0. 'T l i O7'I$ 00e.1072- 70000 WG_j M20_W - 3(. . Parcel Identificatioe Number (PIN) This Is homestead property, All that part of the Northeast Quarter (NEI14) of the Southwest Quarter (SW I/4) lying Easterly of the Town Road-, and all of the Northwest Quarter (NW I /4) of the Southeast Quarter (SE 1/4) EXCEPT one rod squj m the Nor rn theast comer thereof, all in Section Thirty-two (32), Township Thirty -one (3 1) North, Range Sixteen (16) West FxCE �PT any portion of the above described premises conveyed by Deeds dated April 19, 1884, and recorded April 30, b in olume 24 of Deeds, page 180 and in Volume 24 of Deeds, page 192, both respectively, St. Croix County, Wisconsin. Exceptions to warranties: Easements, restrictions and rights -of -way of record, if any. Dated this _ day of October, 1999. « *Thlot, W. ^.! Tan �JL 1` * * Mary E , abelh G& AUTHENTICATION ACKNOWLEDGMENT Signature(s) Timothy W. Glenn and Mary Elizabeth STATE OF WISCONSIN ) Glenn. husband and wife, authenticated this County ) day of October, 1999. Perso Personally n amebeforemethis _ dayof 1999, the above named * Kri Ogla to me known to be the persons) who executed the TITLE: MEMBER STATE BAR OF WISCONSIN foregoing instrument and acknowledge the same. (If not, authorized by $ 706.06, Wis. Stats.) THIS INSTRUMENT WAS DRAFTED BY Notary Public, State of Wisconsin Attorney Kristine Ogbmd My Commission is permanent. (If not, state expiration date: Hudson, WI 54016 --- ) (Signatures may be authenticated or acknowledged. Both are not tacesaary -) -Names of persons signlnlg in any capacity should be typed or printed below their signatures WARRANTY DE= STATE BAR OF WISCONSIN FORM W 2 - 1998 INFORMATION PROFESSIONALS COMPANY FOND DU LAC. W I 800.8 ' Wisconsin Department of Industry, PRIVATE SEWAGE SYSTEM County: Labor and Human Relations INSPECTION REPORT ST . CROIX Safety and Buildings Division (ATTACH TO PERMIT) Sanitary Permit No.: GENERAL INFORMATION 284178 Permit Holder's Name: ❑ City ❑ Village Rj Town of: State Plan ID No.: GLENN, TIM CYLON CST BM Elev.: Insp. BM Elev.: BM Description: Parcel Tax No.: TANK INFORMATION ELEVATION DATA A9600429 TYPE MANUFACTURER CAPACITY STATION BS HI FS ELEV. Septic Benchmark Dosing Aeration Bldg. Sewer Holding St /Ht Inlet TANK SETBACK INFORMATION St/ Ht Outlet TANK TO P/ L WELL BLDG. Ventto ROAD Dt Inlet Air Intake Septic NA Dt Bottom Dosing NA Header / Man. Aeration NA Dist. Pipe Holding Bot. System PUMP/ SIPHON INFORMATION Final Grade Manufacturer Demand Model Number GPM TDH Lift Friction System TDH Ft H ead Forcemain Length Dia. Dist. To Well SOIL ABSORPTION SYSTEM BED/TRENCH Width Length No. Of Trenches PIT No. Of Pits Inside Dia. Liquid Depth DIMENSIONS DIMENSION SETBACK SYSTEM TO P/ L BLDG WELL LAKE /STREAM LEACHING manufacturer: INFORMATION Type Of CHAMBER Model Number: System: OR UNIT DISTRIBUTION SYSTEM Header / Manifold Distribution Pipe(s) x Hole Size x Hole Spacing Vent To Air Intake Length Dia. Length Dia. Spacing SOIL COVER x Pressure Systems Only xx Mound Or At -Grade Systems Only Depth Over Depth Over xx Depth Of xx Seeded/ Sodded xx Mulched Bed /Trench Center Bed /Trench Edges Topsoil ❑ Yes ❑ No ❑ Yes ❑ No COMMENTS: (Include code discrepancies, persons present, etc.) LOCATION: CYLON.32.31.16W, NE, SW, 215TH STREET I Plan revision required? 0 Yes No 71 F Use other side for additional information. SBD -6710 (R 05/91) Date Inspector's Signature Cert. No. Safety and Buildings Division SANITARY PERMIT APPLICATION Bureau of Building Water Systems 201 E. Washington Ave. In accord with ILHR 83.05, Wis. Adm. Code P.O. Box 7969 Madison, WI 53707 -7969 • Attach complete plans (to the county copy only) for the system, on paper not less County - S) — , I than 8112 x 11 inches in size. • See reverse side for instructions for completing this application State sanitary Permit Numb y ou p rovide may be used b other g overnment agency p rograms ��� �� The information y p y y g g y p g ❑Check It revision to previous application [Privacy Law, s. 15.04 (1) (m)]. State Plan I.D. Number I. APPLICATION INFORMATION - PLEASE PRINT ALL INFORMATION Property Owner me Property Location All _ 114 ' 114; S T , N, R (or Property Owner's Mailing Add r ss Lot Number Block Nu ber Ci ,State Zip Code Phone Number Subdivision Name or CSM Number II. TY E OF BUILDING: (check one) ❑ State Owned ❑ cit Nearest Road ❑ Village Public 1 or 2 Family Dwelling - No. of bedrooms Town OF Ill. BUILDING USE (If building type is public, check all that apply) Parcel Tax Num (s) 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 on line B, if applicable) A) 1. ❑ New 2. Ig Replacement 3_ ❑ Replacement of 4. ❑ Reconnection of 5. ❑ Repair of an System System Tank Only -------------- Existing System - --------- Existing System B) ❑ A Sanitary Permit was previously issued. Permit Number Date Issued V. TYPE OF SYSTEM: (Check only one) Non- Pressurized Distribution Pressurized Distribution Experimental Other 11 ❑ Seepage Bed 21 [g Mound 30 ❑ Specify Type 41 []Holding Tank 12 ❑ Seepage Trench 22 ❑ In- Ground Pressure 42 ❑ Pit Privy 13 ❑ Seepage Pit 43 ❑ Vault Privy 14 ❑ System -In -Fill VI. ABSORPTION SYSTEM INFORMATION: 1. Gallons Per Day 2. Absorp. Area 3. Absorp. Area 4. Loading Rate 5. Perc. Rate 6. System Elev. 7. Final Grade Required (sq. ft.) Proposed (sq. ft.) (Gals/day /sq. ft.) (Min /'rich) Elevation Feet Feet Capacity VII. TANK in g allon s Total # of r Prefab. Site Fiber- Exper. INFORMATION g Gallons Tanks manufacturer Name Concrete Con- Steel glass Plastic App New Existing strutted Tanks Tanks Septic Tank or Holding Tank — jW6 400 � ' ' ® ❑ ❑ ❑ ❑ 1:1 Lift Pump Tank /Siphon Chamber I 1:1 ❑ El El E] VIII. RESPONSIBILITY STATEMENT I, the yndersigned assume responsibility for in a atio(i of a nsit sewage system shown on the attached plans. Plumb r' 7 (Pri Plu erZgrnyr mps I MP /MPRSW No.: Business Phone Number: Plumber's dress tree , City, State Zip Code) O _ �- IX. COUNTY / DEPARTMENT USE ONLY ❑ Disapproved S nitary Permit Fee (Includes Groundwater D ate I uey Issuing Agent Signature (No Stamp)) Surcharge Fee) X Approved ❑ Owner Given Initial �� Q Adverse Determination 7 X. CONDITIONS OF APPROVAL / REASONS FOR DISAPPROVAL: SBD -6398 (R. 05194) DISTRIBUTION: Original to Counly, One copy To: Safety & Buildings Dim:ion, Owner, Plumber T INSTRUCTIONS 1. A sanitary permit is valid for two (2) years. 2. Your sanitary permit maybe renewed before the expiration date, and at a time of renewal any new criteria in the Wisconsin Administrative Code will be applicable. 3. All revisions to this permit must be approved by the permit issuing authority. 4. Changes in ownership or plumber requires a Sanitary Permit Transfer/ Renewal Form (SBD -6399) to be submitted to the county prior to installation 5. Onsite sewage systems must be properly maintained. The septic tank(s) must be pumped by a licensed pumper whenever necessary, usually every 2 to 3 years. 6. If you have questions concerning your onsite sewage system, contact your local code administrator or the State of Wisconsin, Safety and Buildings Division, 608 - 266 -3815. 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 be installed. II. Type of building being served. Check only one and complete # of bedrooms if 1 or 2 Family Dwelling. III. Building use. If building type is public, check all appropriate boxes that apply. IV. Type of permit. Check only one on line A. Complete line B if permit is for tank replacement, reconnection, or repair. V. Type of system. Check appropriate box depending on system type. VI. Absorption system information. Provide all information requested for numbers 1 through 7. VII. Tank information. Fill in the capacity of every new /or existing tank, list the total gallons, number of tanks and manufacturer's name, indicate prefab or site constructed and tank material. Complete for all septic, pump /siphon and holding tanks for this system. Check experimental approval only if tanks received experimental product approval from DILHR. VIII. Responsibility statement. Installing plumber is to fill in name, license number with appropriate prefix (e.g. MP, etc.), address and phone number. Plumber must sign application form. IX. County/ Department Use Only. X. County/ Department Use Only. Complete plans and specifications not smaller than 8 1/2 x 11 inches must be submitted to the county. The plans must include the following: A) plot plan, drawn to scale or with complete dimensions, Location of holding tank(s),-septic tank(s) or other treatment tanks; building sewers; wells; water mains/water service; streams and lakes; pump or siphon tanks; distribution boxes; soil absorption systems; replacement system areas; and the location of the building served; B) horizontal and vertical elevation reference points; C) complete specifications for pumps and controls; dose volume; elevation differences; friction loss; pump performance curve; pump model and pump manufacturer; D) cross section of the soil absorption system if required by the county, E) soil test data on a 115 form; and F) all sizing information. ---------------------------------------------------------------------------------------------------- GROUNDWATER SURCHARGE 1983 Wisconsin Act 410 included the creation of surcharges (fees) for a number of regulated practices which can effect groundwater. The monies collected through these surcharges are used for monitoring groundwater contamination investigations and establishment of standards. 1 SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations October 23, 1996 2226 Rose Street La Crosse WI 54603 K 0 CONSTRUCTION KIM 0 CONNELL 504 THIRD AVE OSCEOLA WI 54020 RE: PLAN S96 -41272 FEE RECEIVED: 180.00 GLENN, TIM NE,SW,32,31,16W TOWN OF CYLON COUNTY OF ST CROIX MOUND SYSTEM The Department has reviewed the above - referenced submittal. Conditional approval is hereby granted for the system plan submittal. All noted items must be corrected. The review and approval of the system is based on chapter 145, Wisconsin Statutes, and chapters ILHR 83 and 84, Wisconsin Administrative Code, and is contingent upon compliance with any stipulations shown on the plans. This system has not been reviewed for the code requirements set forth in chapter ILHR 82 or in chapters ILHR 50 -64, Wisconsin Administrative Code. - The existing septic tank must be inspected for structural soundness, size and baffles, and must be brought into conformance with the requirements of chapter ILHR 83, Wis. Adm. Code. If it does not comply, a state approved septic tank shall be installed. This plan submittal approval will expire two years from the approval date, or if a sanitary permit is obtained, plan approval will expire on the day the initial sanitary permit expires. The licensed plumber responsible for this installation shall keep one set of plans with the Department's stamp of approval at the construction site. The installer shall notify the appropriate inspector when inspections can be made. All permits required by the city, village, township or county shall be obtained prior to installation. SHDA- 79871x. 10/94, I SAFETY & BUILDINGS DIVISION State of Wisconsin Department of Industry, Labor and Human Relations K 0 CONSTRUCTION Page 2 October 23, 1996 PLAN S96 -41272 Inquiries should be directed to me at the number listed below. Please refer to the plan number shown above. Si6ra cerely, M. S Plan Reviewer Section of Private Sewage (608) 785 -9348 SHDA -7887 (ft. 10441 Wisconsin Department of Industry PRIVATE SEWAGE SYSTEM Safety and Buildings Division Labor and Human Relations REVIEW APPLICATION Bureau of Building Water Systems Hayward Office La Crosse Office Madison Office i I Shawano Office Waukesha Office 209 W 1 st Street 2226 Rose Street 201 E. Washington Ave. 1340 E. Green Bay Street 401 Pilot Court, Suite C Rt 8, Box 8072 LaCrosse, WI 54603 P.O. Box 7969 Suite 300 Waukesha, WI 53188 Hayward, WI 54843 Phone (608) 785 - 9334 Madison, WI 53707 Shawano, WI 541 66��yy hone (4144 06 Phone (715) 634 - 4804 Fax (608) 785 - 9330 Phone (608) 267 - 5119 Phone (715) 524 - 3@'i� 9 da>M(� 8 -8 M Fax (715) 634 - 5150 Fax (608) 267 - 0592 Fa (715) 5 24 - 363 INSTRUCTIONS: To save time, schedule your review with one of the offices listed above prior to submittal. Fill in all applicable data and submit this form together with fees and plans /information. Your submittal must be received at least one working day prior to the appointment at the office where your review was scheduled. Please call any of the listed offices if you need help filling out the form or have questions on what information to submit. PLEASE PRINT VERY CLEARLY. A sample of a completed form is on the reverse side for your reference. 1. APPOINTMENT INFORMATION -if you have scheduled an appointment fill in the information requested below to save time: Appointment Date Reviewer Name Plan Identification Number C QUED 2. PROJECT INFORMATION If this review is a revision or extension to your existing plan ide ntification number, provide that number here: Project N me ut ❑ City ❑ Village 0 Town Of: County BLDGS• DIV Project Location ✓� SAFE? & , GOVT. LOT 1/4, 1/4 S'. 7 T N R E or W 3. APPLICATION FOR 4. FEE COMPUTATIONS FEE SUBMITTED System Type (check one): System Type i (include new and existing tanks) Up To 1,500 gallon septic tank .................. $110.00 ........ A ❑ At -Grade 1,501 - 2,500 gallon septic tank $120.00 H ❑ Holding Tank 2,501 - 5,000 gallon septic tank .................. $160.00 M Mound 5,001 - 9,000 gallon septic tank .................. $ 200.00 ........ N ❑ Non - Pressurized In- Ground (conventional) 9,001 - 15,000 gallon septic tank .................. $ 300.00 ....... . P ❑ Pressurized in-Ground Over 15,000 gallon septic tank $500.00 ........ O ❑ Other: Up To 1,000 gallon dose chamber $ 70.00 - --,2-4=- 1,001 - 2,000 gallon dose chamber $ 80A0 ........ Building Type (check one): 2,001 - 4,000 gallon dose chamber $100.00 ........ 4,001 - 8,000 gallon dose chamber ............... $120.00 ........ D " Dwelling, 1 or 2 Family 8,001 - 12,000 gallon dose chamber ............... $140.00 ........ P ❑ Public Building Over 12,000 gallon dose chamber $16( 'V � S ❑ State -Owned Building Up To 5,000 gallon holding tank ................ $ 96 _ __ 6000 5,001 - 10,000 gallon holding tank $10W� T . -..7.. 1 Code Derived Daily Flow gpd Over 10,000 gallon holding tank $150.00 ........ T 9 9 FTy Check If Replacing Existing System Experimental System (additional one time fee) .... S AdUbO &. $-DGS DIV• Revisions To Approved Plan z $ 60.00 ........ Petition For Variance: Setback $100.00 ........ Site Evaluation ....... .... $22500 ....... . Petition For Variance Plumbing ............ .. $ 225.00 ....... . Revision $ 75.00 ........ Groundwater Monitoring - Per Site $ 60.00 ........ ❑ Groundwater Monitoring (other than a proposed subdivision) ❑ Site Evaluation in Lieu of Groundwater Monitoring Site Evaluation in Lieu of Groundwater Monitoring $ 60.00 ....... . Subtotal: ......... Priority Review: Enter same amount as Subtotal: ........ MAKE ALL CHECKS PAYABLE TO: SAFETY AND BUILDINGS DIVISION Total Fee: ...... — Z&—) — S. SUBMITTING PARTY INFORMATION Telephone No. (include area code & extension) Co ContaA Pers n r No. & Street Address Or P Box City own or Vi ge, 9tate, Zip C de —g'D 1 Aerobic or prepackaged treatment system fees are calculated based on equivalent size septic tanks and dose chambers. z Revision fees are not applicable to temporary holding tanks or extensions to existing approvals. NOTE: Fees are pursuant to Wis Adm. Code, Chapter ILHR 2, and are subject to change annually The information you provide maybe used by other government agency programs IPrivacy Law, s. 15.04 (1) (m)I. SBDW -6748 (R. 09/94) OVER � 0111ii- Private Sewage System Plan Index/Checklist All plan sets should be legible and permanent copies, organized into sets, bound with staples and covered by an index sheet such as this sample. No other pages need be signed as long as the index sheet for each set is signed. Your cooperation expedites your plan review and shortens plan entry time. Plan ID # Owner's Name Legal )Description Address kZ 7 City 1Ilag own County S� Contents Comments /Special Instructions Page # Included Two copies needed for all plans 1 Plot Plan 2 Plan View/Lateral Return by Mail 3 Cross Section 4 Tank & Pump/ Q Fax Letter to (County) (Submitter) Siphon Information Circle One and Provide Fax #: (_ ) System Sizing (Public) Call for Pick -Up:.( ) 0 Other I, the undersigned, hereby certify that the Seal (if applicable) plans and specifications submitted herewith were prepared under m RECEIVED direction and control. OC T Plumber signer License/Registration # 7 1996 Address cit state SAFETY & B! pGS. Q► Signature C .- r Office Use Only Attachments: 5� App li c ation PGA ��� Soil Soil &site evaluation Fee t ` �� 5 �, •10� ��S Needed for Holding Tank Submittal: One copy of notarized holding tank ® • �. agreement. (Originals to County) Needed for At - Grade Submittal: �04�' X11► Original signed and notarized Application for "Use of an At- pO �jc 9 Grade" County on -site G One additional set of plans cj SBD -10268 (N.01/96) I I I Y I - - - - id 7> 77 IR C IV -7� e k i t C 7_ Q SAF - TY & LD S. DIV I ( I t � I t I 1 i } K i I X41 4 Id { _ f f I I i Page Of Straw, Marsh Hay, Or Synthetic Covering1 ASrt✓j c- ;53 11 Distribution Pipe Medium Sand Topsoil —J E p 3 b . % Slope Bed Of - 2 %2 Force Main Plowed Aggregate From Pump Layer 1 D� Cross Section Of A Mound System Using E A Bed For The Absorption Area F G 1� A 9 Ft. Signed: B Ft. License Number: I Ft. Dater d 7,9 Ft. K �Z Ft. L Ft. W 2 XI,) Ft. Observation Pipe K A (• - - - -- --------------------------- - - - - -- I Force Main W ° .—— . - - - -_— .__._ - -- From Pump Distribution Bed Of 2 2 Pipe Aggregate Observation Pipe Permanent Markers Plan View Of Mound Using A Bed For The Absorption Area P490 0 7 , Perforated Pip• Detail n nd View ) Perforated Ead Cop ' PVC Pipe Notes Located On Bottom, S Are Equally Spaced R d Q � r PVC F Main ♦7 At r ale Pos�it(p6 Of Oiatrit �Gon Force ain /�` Pipe Last Mote Should Be Neal To End Cop End Cap Distribution Pipe Layout P Ft. R S X f�_ Inches Y Inches Signed: Hole Diameter Inch Lateral Inch(es) License Number: Manifold " ,�_ -Inches Date: Force Main a In # of holes /pipe Invert Elevation of Lateral sFt. Page�of 7 ► ► Cross section of pressure system ► ► ► ► ► Final ► ► ► ► vent ► ► Q ► !1 ► ► ► ► ► Difference in ► Elevation Lift 4" i 4" ► i ► E--- -- Drain back to tank 4" ► ► ► ► ► ► septic tank pump station 1 ► ► S s' ► ► ► ► ► ► Signed: ► ► License #: t PAGE -+.L OF PLItAP CHAMBER CROSS SECTION AND SPECIFICATIONS VE NT CAP y� VENT PIPE WEATHERPROOF APPROVED LOCKING JU NCT IOM 80K MAWHOLE COVC.K WITH ? 25' FROM DOOR, WA PAING LABEL WINDOW OR FRESH It'MIU. AIR INTAKE GRADE I I N" MIN. I I Mlu. CONDUIT \ 11 , 10.1LET PROVIDE I -- T AIRTIGHT SEAL I I I I v APPROVED JOINT A ( I APPROVED JOINTS W/ PIPE I III W/" ' PIPE EXTENDING 3' I I) ALARM E%TEIJOING 3' ONTO SOLID SOIL p I I I OIJTQ SOLID SOIL I I I I ON C i I CLEV. FT. PUMP — - ' J b OFF 0 CONCRETE BLOCK RISER EXIT PERKI'ITED OWLH IF TANK MAIJUFACTURER HAS SUCH APPROVAL Z" 6PPAOVED BECDING %Andcr 'r^104K SEPTIC E SPECIFICATIOUS DOSE f TANKS MANUFACTURER: 1 4 IJUMBER OF DOSES 7 3 •I� 1 PER DAy TA WK SIZE: �h GALLONS OOSE VOLUME ALARM MANUFACTURER: 15;:- (, C�� i� s���T_.✓�' INCLUDING BACKFLOW: 4S GALLONS MODEL QUMBEK: CAPACITIES: A- . INCHE5 OR GALLONS SWITCH TYPE: ��d'✓ao� �ad�� B _ INCHES OR GALLONS PUMP MANUFACTURER: C9Orl� + C =_INCHES OR 1 _ GALLONS MODEL NUMBER: S;S�' G' J�!"��f Do INCHES OR 7_ GALLONS SWITCH T`JPE: J v L MOTE' PUMP AMD ALARM ARE TO BE M DISCHARGE RATE�GPK INSTALLED ON SEPARATE CIRCUITS VERTICAL DIFFEREAICE BETWEEIJ PUMP OFF AND DISTRIBUTION PIPE.. 4 �4 FEET + MIIJIMUM NETWORK SUPPLY PKESSUR . . . . . . . . . . 2 5 FEET + — � FEET OF FORCE MAIN X F /o rr.FRICTIOU FACTOR 7 � FEET TOTAL Ot JAMIC. HEAD = /,< 7 FEET 1UTERMAL. DIMEWSI01JC OF TAWK: LE WG'TH iWIDTI4 -- jLIQUID DEPTH 5 IGrJE0: _ LICENSE NUMBER: DATE: • 1'1 • , , I X-i ,� ■■■■■■■■■■■■■M■OMEN WA am ■■■■■■ ■■■■■■■■■■ �� WO\■■ \'�� ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■ ■■ mom IRM mm MODEL 3885 SIZE 1 /4" Solidt NOW ' ►■■■■■■■■■■■■■■M■■■MMM■ „■■■■\■■■■■■■■■■■ ■■■■o\■■■■■■■■■■M■M■■ ■M■ ■■ ,■■■■■mm■■■■■■■■■■■■■■■■■■■ ■■MMM■WU ■MM■ ■M ■M■■■■M■■■M■ ■■■■■■■W■■■■■■■■■■MMMMM■ ■■ . ■■■■■■■■o■■ ■M■■ ■M■■■■ ■M■■ ,■■■■■■■■mm■■■■■■■■■■■ ■M ■M M■ ■■ ■M■■ ■M■ \MM■ ■M■ ■ M■■ a■ ■■M■■■MM►\M ■MM■M■�M■MMM ■o\■■■■■■■mm ■M■■■■■■■■■■ ■■ -',MM■■■■■M■M■■■■■■■■ ■M ■M■ ' ■ ■■oo■■■■■■■'�■■■■■■■oomm ,■■■■■,M■■■■■�M■■■■■■■■■ ■M■ _ ■■■■■\m■■■■■o■■■■■■■■■■■■ ■■■■■■\■■■■■■\■■■■■ ■M■ ■■M '■■■■■■■■►\■■■■■\m■ ■M■■■■■ ■■ ■■■■■■■■■a■■■■■o■■■■■■■■■■ '■■■■■■■■■■■■■■■■o■■i■■■■■■ ■■■■■■MMM■mu■■■■ ■■ ■■MMMM ■ ■■MMMM ■M ■ ■ ■ ■ ■ ■■ ■■■ ■M■ ■M■ c. 7 OPT.IOIVAL WORKSHEET I. MOUND SYSTEM 11. IN GROUND PRESSURE SYSTEM-Continued- 1. Wastewater Load, Total Daily Flow = gal. 10. Force Main: Use section H 63.1S (3) (c), Wis. Minimum Dosing Rate = gpm. Adm. Code and PROVIDE A DETAILED Diameter = --- c�.-•- in. LIST OF SIZING ON PLANS. /� 11. Total Dynamic Head: 2. Depth to Limiting Factor = # System Head = 2.5 ft. 3. Landslope = % Vertical Lift = .,r7 ft. 4. Distance from Dose Chamber to Friction Loss = ft. Distribution System = .--�� ft. FDri = ft. 5. Elevation Difference Between 12. Pump Selection: Pump and Distribution System = ft. Pump wit ischarge at least gpm 6. Absorption Area Sizing: at ft. total dynamic head. /J Area Required = sq. ft. Pump model and anufact rer: = =� Bed or Trench Length (B) ft. Fii� Z-2 Bed or Trench Width (A) = ft. 13. Dose Volume: Trench Spacing (C) = ft. 10 Times Void Volume of 7. Mound Height: Distribution Lines = 32 g gal. ft. Daily Wastewater Volume T Fill Depth Do = wnslope (E) ft 4 Doses in 24 hrs. gal. Fill Depth Do _ Bed or Trench Depth (F) ft. Backflow = 91h.; gal. Cap and Topsoil Depth (G) = ft. Minimum Dose = 1' gal. Cap and Topsoil Depth (H) = ft. 14. Dose Chamber: 8. Mound Length: ,, / Volume = ..l:1saL� gal. End Slope (K) = 12� ft. Total Mound Length (L) ft. Ill. CONVENTIONAL PRIVATE SEWAGE SYSTEM 9. Mound Width: 1. Wastewater Load, Total Daily Flow = gal. Upslope Correction Factor Use section H 63.15 (3) (c), Wis. R Upslope Width ()) = ..,Z .__ ft. Adm. Code and PROVIDE DETAILED Downslope Correction Factor 1. 1 d11 LIST OF SIZING ON PLANS. Downslope Width (1) = ft. 2. Required Septic Tank Capacity = gal. Total Mound Width (W) = ft. 3. Percolation Rate = min. /in. 10. Basal Area: 4. Absorption Area Sizing: Infiltrative Capacity of Refer to Table 2 In chapter H 63 Natural Soil = _ gal. /sq.ft. /day and PROVIDE A DETAILED LIST OF Basal Area Required = - sq. ft. SIZING ON PLANS. ��� ,� Basal Area Available = Q sq. ft. Required Area = sq. ft. 11. If Standard Tables from Chapter Length = ft. H 63 are Used, Indicate Table No. Width = ft. 12. For the Distribution Network, Use Numbers 5.14 in Section 11. Number of Trenches Trench Spacing = ft. I1. IN- GROUND PRESSURE SYSTEM 5. Distribution System: 1. Depth to Limiting Factor = i� Lateral Length = ft. 2. Landslope = % Number of Laterals = 3. Percolation Rate = min. /in. Lateral Spacing = in. 4. Proposed System Elevation = t � ft. Distance from Sidewall to Pipe = in. 5. Wastewater Load, Total Daily Flow: gal. System Elevation = ft. Use section H 63.15 (3) (c), Wis. Adm. Code and PROVIDE A DETAILED IV. SYSTEM -IN -FILL LIST OF SIZING ON PLANS. Fill In All Items from Section Ill Required Septic Tank Capacity gal. 6. Absorption Area Sizing: _ f V. SEPTIC TANK Percolation Rate = s 1. Capacity = gal. Area Required = sq. ft. 2. Manufacturer: System Length = ft. 3. Show Site Constructed Tank Details on Plan System Width = 9 __ ft. 7. Distribution Pipe Sizing: VI. DOSING TANK Hole Sire = 9 // in. 1. Capacity = gal. Hole Spacing = fl. 2. Manufacturer: Lateral Length 1't. :1. Pump MrnuLiclurer: L.Iler.d Siie in. 4. Pump Model: Lateral Spacing 1't. 5. Operating Head= ft. DWalwe Il'unl Sidewalldu Pipe in. G. Flow Rate= gpm• K. Distribution Pipe Disch.uge Rale: 7. Show Site Constructed Tank Details on Plans Number of I lulus Per Pipe t tow Per Pipe' Kent. V11. Ii()I.U1NG TANK 4. M anilold Sitina: / I. Capacity = gal. ypc (center or end) JB 2. Manufacturer: Length = ft. 3. Show Site Constructed Tank Details on Plans Diameter = _rte_ in. -SHOW ALL INFORMATION ON PLANS - DILHR SBD -6761 (R.03/82) / C Wisconsin Department of Industry SOIL AND SITE EVALUATION REPORT Page of -_ Labor and Human Relations g Division of Safety & Buildings in accord with ILHR 83.05, Wis. Adm. Code COUNTY Attach complete site plan on paper not less than 8 1/2 x 11 inches in size. Plan must include, but not limited to vertical and horizontal reference point (BM), direction and % of slope, scale or PARCEL I.D. # dimensioned, north arrow, and location and distance to nearest road. APPLICANT INFORMATION- PLEASE PRINT ALL INFORMATION REVIEWED BY DATE PROPER WNE - PROPERTY LOCATION 1 GOVT. LOT - 1/4 s� 1/4,S T N,R E (ore PROPER OWNER':S MA�ILJNG DDRESS LOT # BLOC # SUB . NAME OR CSM # f CITY STATE, ZIP CODE PHONE NUMBER ❑CITY ❑V L G [MOWN NEAREST ROAD [ ] New Construction Use Residential / Number of bedroom [ ] Addition to existing building LA Replacement [ ] Public or commercial describe Code derived daily flow gpd Recommended design loading rate f 1 , bed, gpd/ft 1, trench, gpd/ft Absorption area required bed, ft _ 75� trench, ft Maximum design loading rate bed, gpd/ft trench, gpd/ft Recommended infiltration surface elevation(s) ft (as referred to site plan benchmark) Additional design /sit considerations - L Parent material - Al 22 S19 Flood plain elevation, if applicable ft S = Suitable for system CONVENTIONAL MOUND IN GROUND PRESSURE AT GRADE SYSTEM IN FILL HOLDING TANK U = Unsuitable fors stem ❑ S ® U ®S ❑ U ❑ S 1,2 U ❑ S 0 U ❑ ❑ S ,® U SOIL DESCRIPTION REPORT Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft C4. t. Color Gr. Sz. Sh. in. Munsell Qu. Sz. C Bed Tiench y A 'C rM1r : } Ground elev. ,� 5 ft. Depth to limiting factor Remarks: Boring # Ground Depth to limiting factor_ Remarks: CST Name: — Please Pri Phone: t- Address: ��v Signature: Date CST Number: PROPERTY OWNER % [L SOIL DESCRIPTION REPORT Page PARCEL I.D. # Boring # Horizon Depth Dominant Color Mottles Texture Structure Consistence Boundary Roots GPD /ft in. Munsell Qu. Sz. Co Color Gr. Sz. Sh. Bed Tw& :{;:•�`�,:<iii:•::;•`.•::: is • w s�. . v�. . . : : ' : ' ..F C Av I-A Ar GroundG — elev. ol ft. Depth to limiting factor i Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: Boring # ry \' Ground elev. ft. Depth to limiting factor Remarks: Boring # Ground elev. ft. Depth to limiting factor Remarks: SBD- 8330(8.05/92) xp so f at . I a i .- _ STC -105 SEPTIC TANK MAINTENANCE AGREEMENT St. Croix County OWNERIBUYER a MAILING ADDRESS 1,V,2 -3 _ S ; >r/ i rl> .✓n l , i /�! 7 PROPERTY ADDRESS soh (location of septic system) Please obtain from the Planning Dept. CITY /STATE PROPERTY LOCATION 1 /4, 1/4, Section ,=?,-2_ , 4:� w TOWN OF _ /,�A) ST. CROIX COUNTY, WI SUBDIVISION LOT NUMBER CERTIFIED SURVEY MAP , VOLUME , PAGE , LOTNUM13ER Improper use and maintenance of your septic system could result in its premature failure to handle wastes. !'roper maintenance consists of pumping out the septic tank every three years or sooner, if needed by licensed septic tank pumper. What you put into the system can affect the function of the septic tank as a treatment stage in the waste disposal system. St. Croix County residents may be eligible to receive a grant for a maximum of 60% of the cost of replacement of a failing system, which was in operation prior to July 1, 1978, St. Croix County accepted this program in August of 1980, with the requirement that owners of all new systems agree to keep their system properly maintained. The property owner agrees to submit to St. Croix Zoning a certification form, signed by the owner and by a mater plumber, journeyman plumber, restricted plumber or a licensed pumper verifying that (I) the on -site wastewater disposal system is in proper operating condition and (2) after inspection and pumping (if necessary), the septic tank is less than 1/3 full of sludge and scum. UWe, the undersigned have read the above requirements and agree to maintain the private sewage disposal system in accordance with (lie standards set forth, herein, as set by the Wisconsin DNR. Certification stating that your septic has been maintained must be completed and retu ed to the St. Croix County Zoning Officer within 30 days of the three year expiration date. c A SIGNED: , w \ , DATE: 8-q►(O St. Croix County Zoning Office Government Center 1101 Carmichael Road Hudson, WI 54016 11/93 This application form is to be completed in full and signed by the owner(s) of the property being developed. Any inadequacies will only result in delays of the permit issuance. Should this development be intended for resale by owner /contractor, (spec house) , then a second form should be retained and completed when the property is sold and submitted to this office with the appropriate deed recording. --------------------------- - - - - -- -------------------------------- owner of property - >ti., Z ) Location of property /41/4, Section Township �,�,� Maili g address Address of site Subdivision name Lot no. other homes on property? Yes No Previous owner of property d-z ` _ Total size of property '_� / 9 Total size of parcel _56. Date parcel was created Are all corners and lot lines identifiable? Yes No Is this property being developed for (spec house) ? _Yes , <_ No Volume ,�Zg and Page Number ,/ 7,2 as recorded with the Register of Deeds. ------------------------------------------------------------------- INCLUDE WITH THIS APPLICATION THE FOLLOWING: A WARRANTY DEED which includes a DOCUMENT NUMDIat, VOLUME AND PAGE NUMBER AND THE SEAI. OF THE REGISTLR OF DEEDS. In addition, a certified survey, if available, would be helpful so as to avoid delays of the reviewing process. If the deed description references to a Certified Survey Map, the Certified Survey Map shall also be required. PROPERTY OWNER CERTIFICATION I (we) certify that all statements on this form are true to the best of my (our) knowledge that I (we) am (are) the owner(s) of the property described in this information form, by virtue of a warrant: , deed recorded in the office of the County Register of Deeds as Document No. and that I (we) Presently own the proposed site for the sewage disposal system or I (we) obt ained an easement, to run the above described property, for the construction of said system, and the same has been duly recorded in the office of the County Register of Deed: a!; (document No. c ature of plican Co- Applicant: p,ite of Signature Date of Signature ti 5. j M" t Fe u• z �.. k 4 `t F tf ?n� tiy., r' v . -• t rt r� Jl A,rs T L a x r fi ,� �y;v,., �{ • 2 .: a 4� Y � a i.� if i :.. � ' i� �1 �. DOCUMENT N o. WARRANTY DEED THIS SPACE RESERVED FOR RECORDING DATA STATE BAR OF WISCONSIN FORM 2-1982 389623 VOL 67 PA"F 17 2 NOWUS OFRCE Herbert Melby and Arliss A. Melby, husband ST Mix * - -- -- -• -• ..................................................•-•-_._...__ •-- -••-- -- -- -.__......__.._._.. Co. •, and w f " " ". " " " ".- -..._. ", .............. .... Wd. fo Record this 2n d •----"--••---""-""" ..............................."--".........._..._............. ._........_......------ ...... -• day of Dec A.D. 198 •----------•-------""---......"-"""""""-"""..._..""-""-....""-...._._...."-" ...... ........................... . . .. ) gf_ __ 12: 35 P M, cand warrants to . Timothy W. Glenn and - Mary ...� Eli_zabeth._G1_�1�n_._. -hu b?iD_ .aDd..Y ?:f'....a....7o ?� ........... tenants DW 19 ......................................................................... ........................................ RETURN TO' ._._._____________________________________________________________________________ _______________________________ the following described real estate in ..... ::...County, State of Wisconsin: Tax Parcel No: ................ ............. The Northwest Quarter of the Southeast Quarter (NW4 of SE4) of Section Thirty -two (32), Township Thirty -one (31) North, of Range Sixteen (16) West, EXCEPT commencing one (1) rod South of the Northeast corner of said Northwest Quarter of the Southeast Quarter (NW4 of SEh); thence West one (1) rod; thence North one (1) rppd ; thence East one (1) rod; thence TRANSF.FA South one (1) rbd to the place of beginning; AND that part of the Northeast Quarter of the Southwest $ ;?70 U Quarter (NE4 of SW4) of Section Thirty -two (32), FEE Township Thirty -one (31) North, of Range Sixteen (16) West, lying East of the Township Road as it now exists. This ............ . :S__._.___._.. homestead property. (is) (is not) Exception to warranties: Dated this ............................... 30 th........ day of ....... Noye_ ICIbEr.................................. 19__8.3.. ....... -........... _...................... - .......................... (SEAL) - .•��•- R:- •�? -=�( ............................... (SEAL) . Herbert Melb " "--------""""----"""-"""...."-•""-" ............................. .. _ ---""•-""----" .. ........................ • -• -___ ....(SEAL QA� -• 4'. (SEAL) ---""------""----""-•-"-"...""""""•_ _________ _________ ____________ . Arles.. - A. Melba '._....--- "- "- •- "- "--- "- - - - - "" AUTHENTICATION ACKNOWLEDGMENT Signature (s) ------------------------------------------- STATE OF WISCONSIN as. Il i i SiNiy - - - St- C r oix County. 1/ authenticated this -------- day of --------------------------- 19 ------ Personally came before me thif� ---------- - - -Ncv eme_r__• 19 __83 * ore na ecly� Herbert Mb elb - and Ard s P 'I� �,-�}�,'•'" - - - - - ------------ - - - - -- �' ' ----------------------------------•------------------------------------- - - - - -- -------------------------------------------------- TITLE: MEMBER STATE BAR OF WISCONSIN ------ ------------ _.�'• - - - - -- .. ., D t t (If not, . -0.. ---- ---- ---•-- -- -------------•--- - --d► '•c;`•- .; %I. authorized by § 706.06, Wis. Stats.) S to me known to be the person _________.__ whojex'e�c •f�� the foregoin �" u t dac ge the I e: THIS INSTRUMENT WAS DRAFTED BY �•— ' "• "� —__ "-- Reinstra , Van ' Dyk & Needham, S.C. (((��.. r __- _ -••." -------------------------------------•------------------------------------ - - - -•- Hendrik W. Van Dy -- - - - - -- New Richmond, • WI - -• 54017 - - - - - -- - Notary Public _. St. Croix Count Wis. -------------- ------ - - - -- y (Signatures may be authenticated or acknowledged. Both My Commission is permanent. (If not, state expiration are not necessary date: Permanent Commission "_ " " -- 19 .........